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 ets.7 Rabbetts, Ronald B.
RAB Clinical Visual
» Optics

Rabbetts, Ronald B.
Visual }
Clinical

a
THIRD EDITION

Bennett & Rabbetts’

linical
Pe |

Visual Optics
This work is dedicated to
Margery Rabbetts
and to the memory of
Winifred Bennett
our respective wives
 THIRD EDITION

Clinical
Bennett & Rabbetts’

Visual Optics
RONALD B RABBETTS
MSc, SMSA, FCOptom, DCLP
Practising Ophthalmic Optician, Portsmouth,
Clinical Supervisor, Institute of
Optometry, London

ices
ER Braille Institute Library Serv

eRe race
BE Nee MAS IN

OXFORD BOSTON JOHANNESBURG MELBOURNE NEW DELHI SINGAPORE

 3utterworth-Heinemann Ltd
Linacre House, Jordan Hill, Oxford OX2 8DP
225 Wildwood Avenue, Woburn, MA 01801-2041
A division of Reed Educational and Professional Publishing Ltd

R A member of the Reed Elsevier ple group

First published 1984

Reprinted 1987
Second edition 1989
Repmmtedil9 91; 19929938
Third edition 1998

© Ronald B. Rabbetts 1998

All rights reserved. No part of this publication may be reproduced in

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British Library Cataloguing in Publication Data

Clinical visual optics — 3rd edn
1. Man. Eyes, refraction disorders
I. Title II. Rabbetts. Ronald B.
Gila, 55)

ISBN 0 7506 1817 5

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Contents

Preface to third edition ix P The new ISO standards 3

Preface to first edition x Near visual acuity: reading-test types 35
Acknowledgements xi Visual acuity in the peripheral field 36
List of symbols xii Kinetic (or dynamic) visual acuity 3 ih
Objective determination of vision 38
1 General introduction 1 Visual efficiency 39
The visual system ] The development of visual acuity 4]
Visual perception 2 Amblyopia 41
Treatment of optics 2 Poor acuity 43
Relevant standards dnd organizations 3 Blindness and partial sight 45
Definitions in experimental assessment 4 Modulation transfer function and the eye 46
Future developments 5 Contrast sensitivity 5]
Further reading 6 Vision through optical instruments 5D
Exercises DF
References Dw,
2 The eye's optical system 7k
The eye and the camera v
Laws of optical image formation ii Spherical ametropia 62
The cornea 10 Main classification of ametropia 62
The anterior chamber il Myopia 62
The iris and pupil 1] Hypermetropia 62
The crystalline lens 1] Ocular refraction 63
The retina 1 ‘Axial’ and ‘refractive’ ametropia 63
The schematic eye 12 The correcting lens 64
The monocular visual field 14 Hypermetropia and accommodation 66
The reduced eye IRS) Aphakia 66
The retinal image 15 The retinal image in corrected ametropia 67
Exercises Li Blurred retinal imagery 68
References 18 Vision in spherical ametropia HA
The pinhole and Scheiner discs HD
19 Subjective optometers 74
3 Visual acuity and contrast sensitivity
Exercises 76
Introduction ig)
References Hi
An order of visual performance 19
Line discrimination 19
Resolution: receptor theory 20 Astigmatism 78
Resolution: wave theory P| Astigmatism in general 78
Grating resolution and acuity Dap) Ocular astigmatism WY)
Resolution and pupil size 23 Axis notation 80
Resolution and illumination 24 Image formation in the astigmatic eye 80
Pupil size and illumination 25 Classification of astigmatism 82
Vernier acuity 26 The distance correcting lens 82
Vision and visual acuity in clinical practice 26 Astigmatic blurring 83
Other clinical tests of visual acuity 32 Vision in uncorrected astigmatism 84
Iumination and luminance contrast oftest The stenopaeic slit 85
charts 34 Residual errors: obliquely crossed cylinders 86
vi Contents

Irregular astigmatism 90 Introduction 158

Historical notes 90 Positions of rest and fixation 158
Exercises 9] The near point of convergence ISS,
References 92 Units of convergence 19
Convergence, accommodation and refractive
Subjective refraction 93 error 160
Introduction 93 Accommodative convergence and the AC/A
Unaided vision and refractive error 93 ratio 162 -
Basic equipment for refraction 94 Convergence-induced accommodation 163
Measurement of a spherical ametropia 5 Relative accommodation and convergence —
Determination of the astigmatic error D7 accommodative facility 164
Modification of techniques following objective Control of accommodation and
refraction 104 convergence 165
Balancing methods and binocular refraction 105 Exercises 166
The binocular addition 109 References 166
Oculomotor balance and previous
correction 110
The repeatability of refraction 110 10 Anomalies of binocular vision: heterophor
Cycloplegia IA and heterotropia 167
Exercises a: Introduction 167
References 12 Heterophoria and heterotropia 167
Classification of heterophoria and
Accommodation and near vision. heterotropia 168
the inadequate-stimulus myopias 113 Causes of an oculo-motor imbalance 169
Introduction ils} The cover test 169
Spectacle and ocular accommodation 114 Instrumentation for measuring
Measurement of amplitude 116 heterophoria 72
Accommodation and age: presbyopia a7 Fixation disparity 174
The near addition APY) Fusional reserves WHF
The accomodative response 121 Incidence of heterophoria WH #
Near vision and anisometropia 22 Symptoms of heterophoria
Effectivity of the astigmatic correction in near Treatment of heterophoria
vision IWS The dominant eye 180
Near vision effectivity LYS Tonic convergence and heterophoria 181
Effect of forward spectacle shift 126 Cyclophoria 181
The near correction IEG Other oculo-motor defects 183
The intermediate addition 128 Nystagmus 184
Anatomy of accommodation I 2Y) Heterotropia (strabismus) 184
Physiology of accommodation 29 Causes of heterotropia 185
The accommodative stimulus 130 Sensory sequelae to strabismus 185
The inadequate-stimulus myopias — tonic Tests for strabismus and retinal
accommodation 132 correspondence 187
Exercises 13g Motor sequelae to strabismus 189
References 139 Examination and treatment of the strabismic
Further reading 141 patient 189
Exercises 189
Ocular motility and binocular vision 142
References 190
Introduction 142
Directions of ocular movements 142
The eye's centre of rotation 143 11 Stereopsis and the stereoscope 191
The extra-ocular muscles 144 Perception of depth and stereopsis 191
Principal and secondary muscle actions 144 Telestereoscopes, rangefinders and binocular
Muscle actions in binocular movements 146 telescopes 1S
Motility testing 147 Alteration of perspective 194
Torsion and false torsion 149 The stereoscope 194
Requirements for binocular vision 52 Optics of the Brewster—Holmes stereoscope I
Monocular projection 154 Additional methods of producing stereoscopic
Corresponding points and the horopter 154 relief iPQ)y)
The cyclopean eye and physiological Clinical tests for stereopsis 201
diplopia 156 The synoptophore 203
Stereopsis IL Sy The variable prism stereoscope 204
References ey) The stereocomparator 205
Holography 205
9 Convergence 158 Virtual reality 205
 Contents vii

Exercises DOS Aberrations of pseudophakic eyes 287

References 205 Aberrations of contact lens wearing eyes INS
Depth of field 288
12 The schematic eye 207 Bichromatic test filters 289
Schematic eyes in general 207 Chromatic stereopsis 290
The cornea 2O7 Monocular diplopia and polyopia BS
The crystalline lens 208 Irregular refraction 294
The Bennett—Rabbetts schematic eye 209 Scattered light UNS)
Other vertebrates’ eyes 208) Exercises 298
Schematic eyes for research DAS References 298
Paraxial relationships 214
Blurred imagery 214
16 Visual examination of the eye and
The Purkinje images 277
ophthalmoscopy 301
The eye’s optical centration 220
Introduction: focal illumination 301
An ordered range of variants Del
The slit lamp 301
Determination of the equivalent power of the
Gonioscopy 303
eye LAD
Slit-lamp examination of the fundus 305
The aphakic eye DS}
Ocular measurements with the slit lamp 308
Intra-ocular lenses 224
The applanation tonometer 310
Exercises 226
Photography of the anterior segment Sal
References DRY
Photographic recording of a cataract Bile
Further reading 228
Lasers in eye treatment 31
The direct ophthalmoscope al,
13 Subsidiary effects of correcting lenses; Clinical use of the direct ophthalmoscope Dale
magnifying devices 229 The indirect ophthalmoscope 318
Principal subsidiary effects 2 XY) Comparison of methods 343)
Spectacle magnification DYY) Development of the ophthalmoscope 324
Astigmatic line rotation 234 The fundus camera 324
Relative spectacle magnification 236 Exercises Be
Plano prisms Dw: References B27
Prismatic effects of lenses YS)
Binocular vision through spectacle lenses or
prisms 243 17 Retinoscopy (skiascopy) 330
Fields of view 246 Objective refraction 330
Optics of magnifying devices 247 Retinoscopy 330
Helping the partially sighted patient BS?) The self-luminous retinoscope 330
Aberrations of correcting lenses 254 Principles of retinoscopy Bll
Exercises 256 Analysis of the reflex: introduction 33332
References 258 Formation of the fundus image 332)
Formation of the reflex 333
Direction of the reflex movement 333
14 Anisometropia and aniseikonia
Reversal 334
Anisometropia: optical difficulties DSS;
Relative speed of the reflex movement 33335)
Relative prismatic effects YS)
Factors affecting the speed of the reflex
Unequal demand on accommodation 259
movement 335)
Unequal retinal image sizes MNS)
Brightness of the reflex and ametropia DO
Unilateral aphakia 262
Sighthole shadow 338
Prescribing for anisometropia DOS
Retinoscopy in astigmatism 338
Aniseikonia 265
Spot retinoscopy in practice 341
Basis of eikonometry 266
Errors and accuracy of retinoscopy 343
Clinical eikonometry 269
Dynamic retinoscopy 345
The aniseikonic correction DIG,
Streak retinoscopy 347
Incidence and importance of aniseikonia WS) N ir)
Exercises 349
Exercises DES
References 350
References DHT 2)
«

15 Ocular aberrations 47D 18 Objective optometers 351

General considerations DIES Introduction Sill
Chromatic aberration DISS Visual instruments Bil
Spherical aberration 281 Some general considerations BS) i)
Other monochromatic aberrations 284 Electronic optometers 3io2
Wave-front aberrations 285 Autorefractors Soy)
Oblique aberrations 286 Research instruments 359)
vill Contents

Design and calibration of infra-red Incidence of astigmatism 408

optometers 360 Components of refraction 409
Clinical results with autorefractors 361 Co-ordination of components 411
Photorefraction 362 The growing eye 41]
Exercises 366 The adult and ageing eye 413
References 366 Surgery for refractive error 417
Exercises 419
19 Vision screening, new subjective refractors References 419 :
and techniques 368 Further reading 420
Vision screening 368
Imaged refraction systems 37Il
The Humphrey Vision Analyser iP 22 Entoptic phenomena 421
Other methods of measuring astigmatism 374 Introduction 421
Laser-speckle refraction 37D Entoptic phenomena due to opacities or objects in
Exercises 376 the media 42]
References Bay, Physiological entoptic phenomena 428
Exercises 429
20 Measurement of ocular dimensions 378 Reterenees 429
Principal methods of measurement 378
Corneal radii and power 380
The keratometer and ocular astigmatism 390 Appendix A: a suggested routine examination
Corneal topography 39] procedure 430
Keratoscopy and photokeratoscopy 3O3
Angle alpha BOY,
Corneal thickness 397 Appendix B: the Bennett—Rabbetts schematic
Depth of the anterior chamber 397 eye 431

Phakometry 398
Pupillometry 402
General bibliography 432
Exercises 402
References 403
Answers 433
21 Distribution and ocular dioptics of :
ametropia 406
Distribution of ametropia 406 Index 436
Preface to third edition

The reception accorded to the first two editions of this of ocular dimensions has been expanded to include
book has been most gratifying. Although no drastic material on videokeratography, while some recent
changes have been needed in this edition, almost all the ideas of the development of refractive error are included
chapters in the book have been revised to take account in the section on the distribution of ametropia.
of the latest research and instrumentation. Sadly, just as we were about to start this revision, my
The second edition proposed a replacement for the co-author, Arthur Bennett, died (in his early eighties,
Gullstrand—Emsley schematic eye and its fellow reduced having retained his remarkable mental abilities right to
eye. In this edition, the new schematic and reduced the end). Since the previous edition, we had kept in con-
eyes have been adopted throughout, entailing consider- stant touch over optical matters; so I hope that he
able revision, particularly of Chapters 12 and 15. Sev- would have been pleased with the revision, including
eral of the figures on chromatic aberration are now those areas in which he took a special interest.
based on wavenumber rather than wavelength. As the book still, obviously, contains a vast amount of
The treatment of magnifiers now emphasizes the rela- Arthur’s original work, and as it has become generally
tionship with the user’s eye, while the chapter on objec- known as ‘Bennett and Rabbetts’, it continues under
tive refraction describes the optical principles of several the joint authorship.
modern auto-refractors. The chapter on measurement R.B. Rabbetts
Preface to first edition

This book has been written as a successor to H.H. Em- the direction of measurement according to the sign con-
sley’s Visual Optics. Its aim is to provide an up-to-date vention adopted.
text on ocular dioptrics, the various subjective and ob- To supplement the references at the end of each chap-
jective techniques of refraction, and the optical instru- ter to authors cited in the text, a bibliography of works
ments used in the examination of the eye. Other topics suitable for further study has been given at the end of
include the side-effects of spectacle and contact-lens cor- the book. This bibliography is not exhaustive, but in-
rections and the aberrations of the eye. The four chap- cludes texts on related subjects such as orthoptics and
ters on the oculo-motor system and stereopsis are physiology, which are outside the scope of this work.
intended to provide a foundation for further study. References to journals are abbreviated to the form
As indicated by the title, we have emphasized the clin- adopted by the World List of Scientific Periodicals.
ical relevance of the subject matter. At the same time, A set of exercises can be found at the end of most
we have endeavoured to maintain the high standard chapters. These exercises are mainly numerical and an-
set by Emsley in his exposition of underlying principles. swers are given at the end of the book. To economize
While the majority of readers will be students of opto- on space, the exercises include the derivation of some
metry, ophthalmology and ophthalmic dispensing, it is expressions and the extension of certain topics not de-
hoped that this book will also serve as a reference work veloped in the text.
for those already in practice, in addition to optical de- Although each of us prepared the initial draft for half
signers, physicists, psychologists and others engaged in the chapters, we both take responsibility for the entire
visual science. contents, which we have thoroughly discussed.
The great majority of the diagrams have not been
drawn to scale so that certain dimensions, particularly
small angles, are clear enough to be seen. The arrow A.G. Bennett

heads placed at one end only of dimension lines indicate R.B. Rabbetts
Acknowledgements

The authors gratefully express their thanks to all those Information concerning their products was kindly
who have assisted in various ways in the preparation of supplied by the following firms:
this work. In particular, they have greatly profited from American Optical Corporation Inc.
helpful discussions with colleagues, especially Mr J.L. Bausch & Lomb
Francis, for many years a Senior Lecturer at the Insti- Birmingham Optical Group Ltd
tute of Optometry (London), Dr W.N. Charman of the Carl Zeiss Ltd
University of Manchester Institute of Science and Tech- Clement Clarke International Ltd
nology, Dr A.R. Hill of the Visual Science Unit, Radcliffe Coherent Radiation Inc.
Infirmary, Oxford, Dr C.E. Campbell of Humphrey In- Essilor Ltd
struments, Inc., San Leandro, California and Professor Humphrey Instruments Inc.
M. Millodot. [OO Marketing Ltd
Thanks are also due to the authors and publications Keeler Ltd
concerned for permission to reproduce various text Oculus-Optikgerate GmbH
figures or photographs. Most of the numerous other Rodenstock Instrumente GmbH
figures were first drawn by the authors as a basis for Tinsley Instruments Ltd.
the finished diagrams kindly prepared for reproduction The authors are also greatly indebted to Miss J.M.
by Mr R. John. Taylor, Librarian of the British Optical Association
Tables 21.2 to 21.5 were compiled from the data made Foundation, for her valuable assistance and to those
available to A.G. Bennett by the then Ministry of who helped in typing the manuscript, principally Miss
Health and used in his paper of 1965, cited in the refer- Gloria Taylor; also Ronald Rabbetts’ wife, Margery,
ences for Chapter 21. who edited the scanned-in computer file for the third
By kind permission of City University, the exercises in- edition.
clude a large number which have been in use for many Finally, the authors are happy to express their sincere
years in their Department of Optometry and Visual gratitude to their respective families for the tolerance
shown during the many years of work involved in writ-
ScClenGe:
ing and revising this book.
List of symbols

Geometrical optics Astigmatism

Standard symbols are used, excepting L, and L{ (recip- The subscripts « and f denote the two principal merid-
rocal of /,,/4 respectively) which are used to denote ver- ians of an astigmatic eye or lens.
gences with respect to the spectacle plane.
Ast Ocular astigmatism, equal to K, — Kg
Cc Spectacle cylinder in general
Gs Spectacle cylinder for near vision
Static refraction
Note. We have adopted the rule that « denotes the more
1B, Static power of eye in general or power of a powerful ocular meridian. On this basis, Ast becomes
given eye negative in sign, with the B meridian as the axis of the
RS Reference power of lens or eye (in context) minus correcting cylinder.
lids Distance spectacle refraction (reciprocal of fy)
ke Dioptric length of the eye in general or of agiven
eye (related to k’)
Kee Dioptric length of a standard emmetropic eye Miscellaneous
K Distance ocular refraction (reciprocal of k)
d Vertex distance
g Pupil diameter
Near vision and accommodation ji Blur-circle diameter
P Semi intra-ocular distance
PD Interpupillary distance
B Dioptric distance to near point of accommoda-
SM Spectacle magnification
tion, measured from the eye (reciprocal ofb)
A Ocular accommodation in general
RSM Relative spectacle magnification
Ag Spectacle accommodation in general Other symbols are defined where they are used and in-
Amp Maximum amplitude of accommodation evitably may carry different meanings in different chap-
Add Addition for near vision ters.
1
General introduction

The visual system The eye's optical system, its possible focusing and
other defects, and the various means of determining
By universal consent, vision is regarded as the most and correcting them form the main subject matter of
precious of our senses and its loss as catastrophic. It is this book. Other topics include the principles of various
also the most complex, so that its study involves several optical instruments used in the examination and testing
different branches of science. The following brief review of the eyes.
of related aspects is intended to place the scope of the
present work in context.

The eye as a photosensor

The eye as a bodily organ
The formation of an image of the external scene is only
Since the eye is part of the body, it cannot be understood the first step in the visual process. The internal lining,
without some knowledge of general anatomy and physi- the retina, covers the greater part of the eye and forms
ology. It follows, then, that a more detailed study of a sensitive screen on which the optical image should
ocular anatomy and physiology is required. Also, since fall when in sharp focus. No disadvantage arises from
drugs are often used in eye examination, pharmacology the fact that the interior of the eyeball is steeply
is another related study. Moreover, medically prescribed curved: so is the optical image.
drugs may have ocular side-effects with which optical A striking feature of the human eye is that it can oper-
practitioners should be familiar. ate over an enormous range of brightness levels. This is
Since one essential part of a complete eye examina- made possible by the existence of two different sets of
tion is to detect any condition requiring medical atten- retinal receptors, named rods and cones. The rods
tion, an adequate knowledge of general pathology is a become fully active at low (scotopic) and the cones at
necessary basis for a comprehensive study of abnormal high (photopic) levels of luminance. In a single eye
ocular conditions. The presence of various systemic dis- there are an estimated seven million cones and at least
eases, as well as disorders of the eye itself, may be in- ten times that number of rods.
ferred or suspected from a careful eye examination. The rod and cone systems can operate simulta-
neously, but when very low illumination is suddenly en-
countered, it may take several minutes for the eyes to
become ‘dark-adapted’.
The eye as an optical instrument
The next stage in the visual process is a complicated
Given the integrity of the eye as a bodily organ, we can photochemical reaction between the light falling on the
now consider the main stages in the visual process. retina and chemical light absorbing substances within
First is the normal stimulus to vision, generally known it. Rod reaction is mediated by the substance known as
as light. Visible light is radiation within a narrow wave- visual purple. Several different pigments take part in
band of the electromagnetic spectrum, from about 380 cone reaction, resulting in the radiant energy of the in-
to 780 nm. Radiations in the neighbouring spectral re- cident light being transformed into electrical impulses
gions on either side — the ultraviolet and infrared — are which are conveyed to the brain. These impulses are
also important clinically because of their potentially sent either singly or integrated from groups of retinal re-
harmful effects on the eyes. ceptors via the optic nerve. A detailed study of these pro-
The eyes of many creatures incorporate an optical cesses falls within the scope of physiological optics, a
system, even if only a pinhole aperture, capable of form- subject with ill-defined boundaries.
ing an optical image. In the human eye, the perform- The quantity of light entering the eye can be regu-
ance of its optical system has almost reached the limit lated by the iris, which controls the pupil diameter.
imposed by the nature of light itself. Given good illumi- Since this latter also affects the eye’s optical perform-
nation, it should normally be possible to resolve 40 ance in various conditions, a balance may need to be
lines per centimetre at a distance of 40 cm. struck between conflicting desirabilities.
2 General introduction

The eye (and brain) as a data processor tially suppressed, or interpreted so as to conform to pre-
vious experience.
An over-simplified earlier view of the relay from retina There is food for thought in the aphorism of Goethe
to brain suggested a comparison with the arrays of indi- that the mind seeks harmony and totality. This applies
vidually connected light bulbs used to display messages. with particular force to vision. We would find it disturb-
Signals from the retinal receptors of each eye passed to ing if the data from two different senses were contradic-
the visual cortex of the brain where a single ‘ocular’ tory. For example, in some contrived experimental
image was constructed point for point by the ‘fusion’ of situations, the apparent position of a near object Waries
the right and left retinal images. It is now known that according to whether or not it is held in the hand.
the retinal and neural processes are much more com- Some people, too, experience disquiet when viewing a
plex. Interaction takes place between various groups of drawing of an ‘impossible object’. As to totality, a strik-
retinal receptors and there appear to be specialized ing feature of visual perception is our constant assump-
neural channels for the detection of horizontal and ver- tion that every drawing, however crude or simple, is
tical lines, different spatial frequencies and other impor- intended to convey a meaning or represent a likeness.
tant features of the scene viewed. A great deal of Even a very young child, when shown a crudely drawn
current visual research is in this field. circle containing two smaller circles above a vertical
and a horizontal line, will interpret it as a face.
The eyes as a pair The familiar ‘optical illusions’ shed an interesting
light on this subject. Many of them could perhaps be de-
The human frame allows many important organs to scribed as errors of visual judgement, arising from the
occur conveniently in pairs, affording some insurance data processing of the visual system. Other well-known
in the event of injury or disease. A further advantage ac- illusions seem to suggest a visual preference for lines to
crues to the eyes from this arrangement. Thanks to intersect at right-angles. For example, long straight
their slightly different viewpoints, additional informa- lines can be made to appear tilted or curved by a succes-
tion can be extracted about the relative positions of ob- sion of short oblique lines drawn through them. The di-
jects in space. With one eye closed, judgement of rection in which the line appears to be bent is such as
distances becomes unreliable. to reduce its obliquity to the intersecting lines.
Since vision is an integrated sensation, we are seldom One of the most important topics of visual perception
conscious of our separate eyes. Various pathological is colour vision, the mechanism of which figures promi-
conditions may gradually destroy part of the field of nently in physiological optics. The development of
vision of one eye long before the victim notices the loss. colour photography and television has generated con-
Binocular vision, the simultaneous use of both eyes siderable research in colour vision, which has an exten-
working in conjunction, occurs in various stages of de- sive specialized literature of its own.
velopment in different species, but reaches its highest Although what we finally perceive does not depend on
level of refinement in the primates. One of the factors the retinal image alone, this image is still the basis of
making it possible is that the retina is not equally sensi- the visual process. When studying a visual phenomenon
tive over its entire extent. In a very small central area — or problem, the optics of the situation should always be
the fovea centralis — densely packed with cones only, exhausted before considering other and perhaps more
the visual acuity or sharpness of vision reaches a pro- speculative factors.
nounced peak. Two important advantages result. First, Visual perception comes under the heading of psy-
we are enabled to concentrate our visual and mental at-
chology. Most related research is carried out within
tention on a small but adequate field. Secondly, the
this discipline or in collaboration with visual scientists.
fovea is able to play a key role in monitoring the neces-
sary eye movements, which have to be carried out with
great precision. Unless the central object of regard is
imaged on the fovea of each eye, diplopia (double vision) Treatment of optics
results.
A set of six external muscles attached to the eyeball
In this work we have followed the principles, sign con-
enables it to be moved smoothly in any desired direction.
vention and symbols adopted jointly in the United
Faults in the system can occur. A squint is an obvious
Kingdom many years ago by the Applied Optics Depart-
breakdown of co-ordination, but there are other less-
ment of the former Northampton Polytechnic Institute
pronounced anomalies of binocular vision which may
(now the City University) and the Imperial College.
call for relief. The investigation of binocular vision is an
They are also used in Freeman's Optics, first published
important sector of ophthalmic practice.
in 1934 as Fincham’s Optics. The basis of the sign con-
vention is that the direction of the incident light is
always positive. Where possible, diagrams are drawn
Visual perception with the incident light coming from the left, so that the
Cartesian sign convention for the x-axis also applies.
The manner in which the endless stream of data from When the incident light is from right to left, this be-
our sensory organs becomes transmuted into sensations comes the positive direction and the Cartesian conven-
unique to the individual is largely unknown. A great tion ceases to apply.
deal of cerebral editing takes place. In the interests of Though this sign convention is in world-wide use, not
the whole organism, some information is wholly or par- only in the ophthalmic field but in technical optics gen-
 Relevant standards and organizations 3

erally, other conventions unfortunately persist at a In 1978, the ISO decided to set up the Technical Com-
lower level. The great advantage of any convention is mittee ISO/TC 172 to be responsible for international
that it enables collections of rules for different cases to standards over a wide range of technical optics as well
be replaced by a single algebraic relationship. as ophthalmic optics. Manufacturing standards relating
Because of its simplicity in optical calculations, exten- to the broad field of spectacle lenses, spectacle frames
sive use has been made of the ‘step-along’ method asso- and their measurement, contact lenses and materials,
ciated with William Swaine and the layout for it and a number of ophthalmic instruments are among
devised later by Bennett. those in course of preparation or have been published;
In problems involving an eye looking through a lens for example the two dealing with ‘optotypes’ (test
or prism, students will find it helpful to follow the two- charts) are briefly summarized in Chapter 3.
stage approach. First, the eye is ignored and the position In general, even official standards are not mandatory
and size of the image formed by the lens or prism are de- in themselves unless referred to in legal contracts, legis-
termined by the usual method. Next, this image, wher- lation or statutory regulations. In the European Union,
ever it is formed, becomes the object for the eye, real or the general requirements for spectacles, contact lenses
virtual as the case may be. and ophthalmic instruments are covered by the Medical
The value of diagrams, as distinct from thumbnail Devices Directive, published by the European Commis-
sketches, cannot be emphasized too strongly and they sion. The simplest way to satisfy this Directive is usually
seldom need to be drawn to scale. If the diagram is right, to demonstrate that the product complies with the rele-
the problem is already solved in principle. In making vant CEN standard.
scale drawings, it is often essential to choose a very
much larger scale vertically than horizontally. Only the
true values of angles are falsified by this procedure. Scientific units: the CIPM

Under the terms of the Metre Convention of 1875, to

Relevant standards and organizations which forty or so countries are now parties, the Comité
International des Poids et Mesures (CIPM) is the recog-
Official standards organizations nized authority on all scientific matters relating to the
metric system, including the fundamental physical
In all the countries in which optometry is firmly rooted,
units of mass, length and time.
there is an official national standards organization.
In 1960, the CIPM adopted a rationalized restructur-
These bodies are mainly concerned with practical stan-
ing of the metric system known as SI (Systeme Inter-
dards having industrial and consumer applications.
national d’Unités). The metre (m), kilogram (kg) and
Most of them fall into one of the following categories:
second (s) are three of the ‘basic units’, the remaining
(1) dimension standards, four being the ampere (A), the degree Kelvin (Kk), the
(2) standards of quality or performance, candela (cd) and the mole (mol). To these are added the
(3) standard methods oftesting or sampling, radian (rad) and steradian (sr) as ‘supplementary
(4) standard nomenclature and symbols, units’. All other units, called ‘derived’, are defined in
(5) standard codes of practice. terms of the basic units.” Standard symbols are used,
and there is a convention governing the choice of subdi-
A great many national standards have been published
visions and multiples of units.
in the ophthalmic optical field. An official translation into English of the Systeme
International standards are the concern of three
International d’Unités has been prepared jointly by the
bodies working on parallel lines: the International Or- National Bureau of Standards (USA) and the National
ganization for Standardization (ISO), the International Physical Laboratory (UK). It is published independently
Electrotechnical Commission (IEC) and the Comite Eur- by the same body in the USA and by Her Majesty's
opéen de Normalisation (CEN), or European Committee Stationery Office in the United Kingdom.
for Standardization. The main object of the ISO is to
reach international agreement on industrial standards
facilitating commerce. Its membership comprises the of- Other organizations
ficial standards bodies of some 60 countries. To further
its primary objective, the ISO also promotes the inter- There are certain other international bodies concerned
change and dissemination of scientific and technical with technical or ophthalmic optics.
data on standards.
The detailed work of preparing ISO standards is car- Commission Internationale de l’Eclairage
ried out on a voluntary basis by about 160 technical
committees, 500 subcommittees and 600 working The International Commission on Illumination, known
groups, all composed of nominees of the participating in Great Britain by the initials of its French name
national standards organizations. These organizations (CIE) and in the USA as ICI, is the recognized inter-
can either accept a published ISO ophthalmic standard
to which they have assented or incorporate the sub-
* The unit of focal power, the dioptre, which is defined in the
stance of it in a separate national standard. For Europe, next chapter, has the physical dimensions of, and the official
the CEN is generally adopting the relevant ISO ophthal- SI abbreviation, m !. In this text, the symbol D will continue
mic standards as official European standards: these auto- to be employed, partly for historical reasons, partly for brevity,
matically must replace any previous national standard. and partly to distinguish power from curvature.
4 General introduction

national body concerned with photometry and colori- Accuracy: a general term describing the ability of an
metry. It has published many standard tables in these instrument to provide good results. It may be broken
fields and was responsible for the CIE chromaticity down into:
chart and system of colorimetry. In 1929, the CIPM Precision or repeatability: this is the consistency with
decided to extend its competence to photometric stan- which repeated measurements are made, and could be
dards and four years later set up a Consultative Com- related to statistical concepts such as the standard de-
mittee on Photometry with which the CIE has fully co- viation. The official ISO definition is given at the end of
operated. The revised definition of the candela, the unit this section. =
of luminance adopted by the CIPM in 1967, was put for- Comparability or validity: this is the ability to meas-
ward by the CIE. ure correctly what is supposed to be measured.
For example, a focimeter (lensometer) would be giving
valid results if the mean of several measurements of a
International Commission on Optics (ICO)
+6.00 D lens were +6.00 D, even though the standard
This body was set up in 1948 with a number of general deviation was +1.00 D. Conversely, another instrument
aims including that of promoting international agree- would be precise if the standard deviation were
ment on nomenclature, units, symbols, specifications, +0.05 D, even though the mean result of +5.50 D was
methods of control and similar subjects. However, since incorrect (invalid). Neither instrument could be re-
the ISO has entered this field, it is unlikely that the ICO garded as accurate.
would wish to pursue any separate activities within it. In clinical work, criteria have to be adopted to distin-
guish or discriminate between normals and abnormals.
International Federation of Because no instrument or test routine is perfect, some
Ophthalmological Societies subjects will be incorrectly classified. To take a very
simple example, a poor ability to converge the eyes is
At the fourteenth International Ophthalmological Con- likely to cause symptoms in near work. If the percentage
gress, held in 1933, it was decided to set up this Federa- of the sample population is plotted against the near
tion to put future activities on a more organized point of convergence, for both the symptom-free and
footing. Membership is composed of the national symptomatic groups, then one might find a result simi-
ophthalmological societies of some forty or more coun-
lar to that in Figure 1.1. Because of the overlapping of
tries. Though the Federation had recently shown a re-
the two curves, any dividing line D is likely to produce
newed interest in formulating an international test
four subclassifications, set out in Table 1.1.
chart for visual acuity, it may now be content to
If the near point of convergence were a reliable and
pursue this aim through the ISO. Medical bodies are
valid predictor of symptoms in near work, there would
usually well represented on appropriate technical com-
be no misclassifications of false negative and false pos-
mittees of national standards organizations.
itive. In practice, however, these errors in classification
are inevitable.
Photometric units Thus in this example, false negatives are people who
should have been identified as having poor convergence.
Many changes in photometric nomenclature and units
False positives are asymptomatic people that the test
were made in the third (1970) edition of the Inter-
has inappropriately identified as abnormal.
national Electrotechnical Vocabulary, prepared jointly
Moving the dividing line D towards poorer conver-
by the IEC and the CIE. In particular, the unit of lumi-
gence will reduce the number of false positives, but
nance is now the candela per square metre, replacing
the footlambert, millilambert and other former units. at the expense of increasing the number of false nega-
tives.
For this reason, we have added a scale in cd/m? to
those diagrams reproduced from earlier writings, in
which older units of luminance were employed. The Frequency
conversion factors to cd/m? are 3.426 for footlamberts, Asymptomatic
3.183 for millilamberts.
The troland, a special unit of retinal illuminance, is
explained on page 24.
Symptomatic

Definitions in experimental :
Good convergence FN FP Poor convergence
assessment
Near point of convergence
In relation to the performance of equipment and the cri- Figure 1.1. Population frequency of a normal
teria to be adopted for diagnostic purposes, the reader (asymptomatic) and an abnormal (symptomatic) population.
may come across various familiar terms which have ac- The dividing line (D) partitions the asymptomatic group into
true negatives and false positives (shown hatched), and the
quired a specialized meaning in this context. Although
symptomatic into false negatives (shown stippled) and true
little used in this book, some definitions of them are pro- positives. (After Reeves and Hill, 1987, reproduced by kind
vided here as they are not otherwise readily available. permission of the editor of Optician.)
 Future developments 5

the kind permission of the British Standards Institutiont

Table 1.1 Classification of true and false negatives and positives.
(The figures in parentheses are used in a numerical example later) are:
ek
eae a eee
Sample population Test result Precision: The closeness of agreement between inde-
pendent test results obtained under stipulated con-
Negative Positive ditions.
(normal (poor Repeatability: Precision under repeatability con-
convergence ) convergence )
ditions.
Normal (asymptomatic) True (1000) False (15) Repeatability conditions: Conditions where indepen-
Abnormal (symptomatic) False (10) True (40) dent test results are obtained with the same method on
identical test items in the same laboratory by the same
Operator using the same equipment within short inter-
Two terms used to describe the ability of a test to dis- vals of time.
criminate between normals and abnormals are sensitiv- Reproducibility: Precision under reproducibility con-
ity and specificity. ditions.
Sensitivity* is measured by the proportion of abnor- Reproducibility conditions: Conditions where test re-
mals (or true positives) who are identified by the test to sults are obtained with the same method on identical
the total number of abnormals. Mathematically, it is test items in different laboratories with different opera-
the ratio: tors using different equipment.
Reproducibility Standard Deviation, sp: The standard
(true positives)/(true positives + false negatives). deviation of test results obtained under reproducibility
conditions. (This is a measure of the dispersion of the
Specificity’ relates to the proportion of normals (or distribution of test results under repeatability con-
true negatives) who pass the test to the total number of ditions.)
normals. Mathematically, it is the ratio: Reproducibility limit, R: The value less than or equal
to which the absolute difference between two test results
(true negatives) /(true negatives + false positives). obtained under reproducibility conditions may be ex-
pected to lie with a probability of 95%.
False positive error rate is the proportion of false posi-
tives expressed as a percentage of the total number of Some articles with references to this subject are listed
positive classifications obtained on the test. below.
The function (1— specificity) or false alarm rate, indi-
cating the ratio of false positives to all normals, is an al-
ternative concept.
A graph of sensitivity plotted against the false alarm Future developments
rate is termed an ROC (receiver operating characteristic)
curve. An explanation with examples is given by Jenkins Confident predictions are naturally difficult in this era of
et al. (1989). rapid change. Spectacles have now been in existence
False negative error rate is the proportion of false for 700 years and seem likely to retain their popularity
negative results expressed as a proportion of the total indefinitely. Although contact lenses have made enor-
number of negative classifications on the test. mous advances, they are still generally unsuitable for
Using the figures in the table, the sensitivity is 40/50, the young and the elderly and there are fears that pro-
or 80%, while the specificity is 1000/1015, or 98.5%. longed or indiscriminate wear may lead to wide-scale
The false positive error rate is 15/55 or 27.3%, while damage to the cornea. Various surgical methods of cor-
the false negative error rate is 10/1010 or 1.0%. recting focusing errors by modifying the curvature of
An ideal test, whether of an instrument or clinical the cornea have been devised. Although some successes
procedure, will have both high sensitivity and specifi- have been achieved, these methods are at present some-
city. If an instrument is made too sensitive, it is likely what inaccurate as well as too drastic for the majority
to fail an increased proportion of normals. Conversely, of spectacle wearers, while some techniques are appro-
if the specificity is raised, sensitivity usually drops. Hill priate only for short-sighted people.
(1987) demonstrates that two neighbouring dividing As we shall see in Chapters 18 and 19, automation
lines can be used to give reduced numbers of false posi- has already established itself in some of the instruments
tives and false negatives. People whose results lie in the and routines used in eye examination. As a result, cer-
zone of uncertainty between the two cut-off criteria tain parts of the examination may become increasingly
should be further examined by other tests before being delegated to assistants without optometric qualifica-
classified. tions. Plotting of the visual fields, even by traditional
Some official ISO definitions taken from BS ISO 3534- methods, is regarded as one that can be carried out
1:1993 Statistics — Vocabulary and symbols — Part 1: Prob- by auxiliary personnel. The scope for automation in
ability and general statistical terms, and reproduced with the testing of binocular functions is probably limited.

* A possible but somewhat clumsy mnemonic for remember- + Complete editions of the standards can be obtained by post
ing these terms is that seNsitivity is not to do with Negatives, from BSI Customer Services, 389 Chiswick High Road, London
while sPecificity is not to do with Positives. W4 4AL.
6 General introduction

It is unlikely to provide information as quickly and ASPINALL, P.A. and HILL, A.R. (1984) Clinical inferences and
decisions — III. Utility assessment and the Bayesian decision
conveniently as the simple cover test and fixation dis-
model. Ophthal. Physiol. Opt., 4, 251-263
parity test, both described in Chapter 10. GILCHRIST, J. (1992) QROC curves and kappa functions: new
In researches on vision, increasing use is being made methods for evaluating the quality of clinical decisions.
of techniques of gaining information from the electrical Ophthal. Physiol. Opt., 12, 350-360
activity in the visual centres of the brain. Whether HILL, A.R. (1987) Making decisions in ophthalmology, Ch. 8 in
Progress in Retinal Research, Vol. 6 (Osborne, N. and Chader,
these methods will find a use in routine eye examination
G., eds), Oxford: Pergamon
is open to doubt. Houcu, T., Livnat, A.. and KEREN, E. (1996) Inter-laboratory
reproducibility of toric hydrogel lenses using the focimeter
and the moire deflectometer. J. Br. Contact Lens Assoc., 19,
117-127
JENKINS, T.C.A., PICKWELL, L.D. and YEKTA, A.A. (1989) Cri-
Further reading teria for decompensation in binocular vision. Ophthal. Phy-
siol, Opt., 9, 121-125
ASPINALL, P. and HILL, A.R. (1983) Clinical inferences and de- REEVES, B.C. and HILL, A.R. (1987) Practical problems in mea-
cisions — I. Diagnosis and Bayes’ theorem. Ophthal. Physiol. suring contrast sensitivity. Optician, 193(5085), 29-34;
Opt., 3, 295-304 (5086), 30-34
ASPINALL, P. and HILL, A.R. (1984) Clinical inferences and de- REEVES, B.C., HILL, A.R. and ROSS, J.E. (1988) Test-retest reli-
cisions — II. Decision trees, receiver operator curves and sub- ability of the Arden Grating Test: inter-tester variability.
jective probability. Ophthal. Physiol. Opt., 4, 31-38 Ophthal. Physiol. Opt.. 8, 128-138
2
The eye’s optical system

The eye and the camera Symbols

Standard symbols for the most important quantities are
Considered as an optical instrument, the eye has certain as follows:
similarities to a camera, though it would be truer to say
that the camera has been copied from the eye. The Refractive index n
points of difference are worth noting, the eye being Object distance t
superior on almost every count. It is much more com- Image distance ye
pact, has a wider field of view, operates over a much First focal length if
more extensive range of luminance levels and its resolv- Second focal length f
ing power is close to the theoretical limit. Paradoxically Radius of curvature r
—as Helmholtz pointed out — the typical eye nevertheless Object height h
exhibits aberrations and errors of centration that an op- Image height h'
tical designer would consider unacceptable in a high- The presence of a dash (or ‘prime’) shows at once that
grade man-made system. the symbol refers to a quantity after refraction or reflec-
The aberrations of the eye are considered in detail in tion, the same symbol undashed denoting the corre-
Chapter 15 and so here we shall look at the basic sponding quantity before refraction or reflection.
image-forming properties of the eye from the standpoint To denote the reciprocal of a distance, the correspond-
of simple geometrical optics valid for the paraxial ing capital letter is used. Thus L = 1/7, R= 1/r and so
region. Although you are probably familiar with optical
on.
principles, an outline of the notation and methods used Letters used as symbols denoting a quantity are nor-
in this book is given in the following pages. For a more mally printed in italic type. On the other hand, letters
detailed treatment including proofs, the works listed in in Roman capitals denote geometrical points. This helps
the bibliography at the end of the book are useful. to distinguish between F (the power of a lens or surface)
and F (the first principal focus).
Subscript numerals are helpful in identifying one of a
Laws of optical image formation series of successive refractions or reflections. For exam-
ple h5 denotes the image height after the second refrac-
Sign convention tion or reflection.

(1) Distances measured in the same direction as that in

which the incident light is travelling are regarded
as positive in sign; if in the opposite direction, as ‘Real’ and ‘virtual’
negative.
(2) Object and image distances, focal lengths and radii When refraction or reflection takes place at two or more
of curvature are measured from the lens, mirror or surfaces in succession, the image formed at the first,
surface concerned. The sign follows from (1). whatever its nature, becomes the object for the next.
(3) Diagrams are normally drawn so that the incident This gives rise to the possibility of ‘virtual’ objects as
light travels from left to right. well as virtual images. Real and virtual types of object
(4) The vertical distance from the optical axis to a point may give rise to either type of image.
above it is taken as positive, and to a point below it
as negative. Definitions
(5) For some purposes, a sign convention for angles is
needed. In accordance with accepted mathematical (1) A real object is one from which incident rays
convention, angles measured in an anticlockwise diverge.
direction are regarded as positive. The angle (2) A virtual object is one towards which incident rays
between a ray and the optical axis is measured are converging as the result of a previous refraction
from the ray to the axis. or reflection.
8 The eye's optical system

(3) A real image is one towards which refracted or

reflected rays converge and is therefore capable of
being received on a screen.
(4) A virtual image is one from which refracted or
reflected rays appear to emanate.

e’

Refraction at a spherical surface Figure 2.3. Refraction at a converging spherical surface.

Let A be the vertex and C the centre of curvature of a
spherical surface, a line through A and C being taken
For an object at infinity, n// = 0 and /’ = f’. Similarly,
as the ‘axis’ (Figure 2.1).
for an image at infinity n’//’ = 0 and / = f. Hence
If the surface is converging (for example, convex, air
a =< =a
/
to glass) the first principal focus F is the real point on
the axis giving rise to an image at infinity, the refracted lege Rien,
ray being parallel to the axis. The second principal
focus F’ is the real image point on the axis correspond-
ing to an object point at infinity, the incident rays
being parallel to the axis.
The same definitions apply to a diverging surface, Power and vergence
except that in this case F is a virtual object point and F’ For a spherical refracting surface, the power F is given
a virtual image point (Figure 2.2). by the relationship
In both cases, the distance AF is the first focal lengthf
and AF’ the second focal length f’. fi a= Tt eee
F =(n =n)R (a3)
Let B be an axial object point giving rise to the image ee ee
point B’ (Figure 2.3). Then, in all possible cases, where the curvature R is the reciprocal of the radius of
/ = AB curvature in metres. The unit of curvature is the recip-
/' = AB’ rocal metre (m_'). From equation (2.3) the surface
f= ANG power is seen to be proportional to the reciprocal of the
n =refractive index of first medium focal lengths. The unit of focal power is the dioptre (D),
n’ =refractive index of second medium the focal lengths being expressed in metres for this pur-
pose.
and The term ‘reduced distance’ denotes a distance (or
n
/
n
thickness of material) traversed by a pencil of rays,
divided by the refractive index of the given medium. On
ak a 1G
this basis, the reciprocal of a reduced object or image
distance, such as n'//’ in equation (2.1), is traditionally
called the ‘reduced vergence’. For brevity, however, we
shall omit the word ‘reduced’ from this term. In this
work vergence will be used to denote the reciprocal of
an object or image distance (in metres) multiplied by
the refractive index of the corresponding medium.”* Like
focal power, its unit is the dioptre. Accordingly

Object vergence L = n// (in metres)

Image vergence L’ = n'//’ (in metres)
Figure 2.1. Principal foci F and F’ of a converging spherical Equation (2.1) can now be rewritten in the more con-
refracting surface. venient form

Li =L-F (2.4)
in which all quantities are in dioptres.
It is a fundamental rule that a positive value of L or L’
always denotes convergence, while a negative value
always denotes divergence.
Unless otherwise stated, all distances in algebraic for-
mulae throughout this book should be taken to be in
metres. If numerical values in millimetres are substi-

’ The term ‘vergence’ has traditionally been used as a syno-

Figure 2.2. Principal foci F and F’ of a diverging spherical nym for wavefront curvature, the unit of which is the recipro-
refracting surface. cal metre, not the dioptre.
 Laws of optical image formation 9
Mirror

B TB?
ee,

- ce i Z)

£’ (+ve)
€ (—ve) L’ (—ve) Figure 2.5. The cardinal points and conjugate foci of an
L (—ve) unequifocal refracting system.

Figure 2.4. Sign convention for reflection.

tuted in such expressions, a compensating factor of

1000 must be introduced.

The thin lens

A thin lens in air has two principal foci F and F’ and two Figure 2.6. Image construction for an optical system using
focal lengths f and f’, defined exactly as for a spherical the principal and nodal points.
refracting surface. In this case, however, the power F of
the lens is given by
(2) P and P’, the first and second principal points.
F=1/f'=—1/f (2.5) (3) N and N’, the first and second nodal points.

again in dioptres if f’ and f are in metres. The cardinal points are always symmetrically positioned
The conjugate focus relationship (2.4) applies equally such that PP’= NN’ and FP = N'F’.
to a thin lens in air. The system as a whole has an ‘equivalent power’ F
such that
SL
Reflection (2.8)
Se
When light is reflected by a mirror (Figure 2.4), whether where f’ = PF’, f = PF, n, = refractive index of first
plane or spherical, there is a reversal of direction which
medium and n., = refractive index of last medium, the
upsets the usual correspondence between the signs of / system having k surfaces. ,
and L’. The same applies to the focal length of a mirror, If the object distance 7 is measured from P and the
since the focal length is also an image distance. Conse- image distance / is measured from P’, the conjugate
. . Late / .

quently, for reflection only we must put (assuming the focus relationship again takes the form
mirror is in air)
L'=L+F
es ae f= =1/L (2.6)
where L = n,/¢ and L' = ny, /?’.
and Let a ray from an extra-axial object point Q be
=2 directed towards P, making an angle u with the optical
a tasen Se (27)
axis (Figure 2.6). The corresponding emergent ray will
Thereis, however, no change in the relationship
appear to have passed through P’ making an angle w’
with the optical axis such that
ele,
The conjugate focus relationship for reflection then (2.9)
yi
Nyowju =n U
assumes the familiar form
Let another ray from Q be directed towards the first
ieee nodal point N. The corresponding emergent ray will
appear to have passed through the second nodal point
Theoretically, reflection cbeys the same laws as re-
N’ without undergoing a change of direction. As indi-
fraction if —n is substituted for n’.
cated in Figure 2.6, these two pairs of rays can be used
to construct the image BQ’ of an object BQ.
Unequifocal systems The properties of the two principal foci F and F’ can
also be used for this purpose, as shown in Figure 2.5.
The eye is an example of an unequifocal optical system,
one in which the first and last media have different re-
fractive indices. In general, such systems have six car- Transverse magnification
dinal points (Figure 2.5) as follows:
The expression
(1) F and F’, the first and second principal foci, defined
exactly as for a single refracting surface.
i tae (2.10)
10 The eye's optical system

Angles and prism power

Throughout the text, angles will be expressed in ra-
dians, degrees, or prism dioptres (symbol A). This last
measure, which is of great convenience in ophthalmic
optics, was introduced in 1890 by C. F. Prentice (but
not given this name by him). If wis any angle less than
90°, then
*
Figure 2.7. Effectivity: (a) converging bundle, (b) diverging win A = 100 tan u (No pilS))
bundle.
Thus, in Figure 2.6
u = 100(BQ/BP) A
in which m denotes the transverse magnification, ap-
plies equally to refraction and reflection at a single sur- Thus, in terms of SI units, the prism dioptre is expressed
face, as well as to thin lenses and optical systems. as cm/m.
Because this vergence formula for magnification is so A disadvantage of this system is that the tangent of an
general, its use is preferable to the alternative forms, in angle does not increase in proportion to the angle itself
which vergence is expressed in terms of object and when other than small values are concerned. For exam-
image distances. ple, 20 A is equivalent to tan | 0.20 or 11.31°, whereas
40 A is equivalent to tan | 0.40 or 21.80°.
For small angles, the formula
4°=7A (2.14)
Effectivity
is an easily remembered and useful approximation.
Let a pencil of rays (Figure 2.7) be travelling in a It also follows from equation (2.13) that for small
medium of refractive index n and let the distance to the values the prism dioptre is equivalent to one-hundredth
origin (or from the focus) of the pencil be 7, measured of a radian, since both the sine and the tangent of a
at a specific point O. After travelling a distance d metres small angle are very nearly equal to the angle itself in
from O to another specified point X, the wavefront is at radian measure.
a distance /, from its origin or focus. Hence, In the ophthalmic world, the prism dioptre is the ac-
fog hi el cepted unit of prismatic power and deviation. According
to the currrent British Standard* for ophthalmic trial
and case lenses, prisms are to be numbered according to the
NLS weet ing n deviation (in A) undergone by a ray of wavelength
ie re Han a 587.6 nm incident normally at one surface.

— L,
(2a)
anit.

This expresses a general effectivity relationship, ‘effec-

The cornea
tivity’ denoting a change of vergence as light passes
from one surface or reference point to another. With this introduction we can now study the various
If dis relatively small, the above expression can be ex- components of the eye’s optical system, first in sequence
panded by the binomial theorem to give the useful ap- and then the system as a whole.
proximation The cornea (Figure 2.8) is a highly transparent struc-
ture of meniscus form, approximately 12 mm in diam-
eter and slightly smaller vertically than horizontally.

(eae)

The quantity d/n is an example of a reduced distance.

Refractive index

The refractive index of a transparent medium varies

with wavelength, and, to a lesser extent, with tempera-
Aqueous (n, = 1.336)
Ba = 1.000 ng = 1.76
ture. Unless the context indicates otherwise, the term
should be understood as an abbreviation for ‘mean re-
fractive index’, namely, the value for a selected wave- Figure 2.8. Profile of the human cornea (to scale): average
length in the brightest part of the spectrum. The d-line values as adopted in Gullstrand’s schematic eye.
of the helium spectrum (A =587.6 nm) is often chosen
for this purpose. Measurements are normally made at a
temperature in the neighbourhood of 18—20°C. * BS 3162: Ophthalmic trial case lenses.
 The crystalline lens 11

The centre thickness is usually between 0.5 and In normal conditions the pupils react to:
0.6 mm.
A thin layer of lacrimal fluid normally covers the (1) A change in luminance — the ‘direct’ reflex
(2) A change in luminance applied to one eye only, also
anterior surface but it is too thin to affect the power ap-
preciably and may be ignored in this context. producing a ‘consensual’ reflex in the fellow eye,
To a first approximation both surfaces may be re- (3) Near fixation, which is accompanied by pupillary
contraction.
garded as spherical, the radii of curvature having
values in the neighbourhood of +7.7 mm (anterior) Failure or anomaly of one or more of these reflexes
and +6.8 mm (posterior). may be an important pointer to some underlying disor-
The refractive index of the corneal substance may be der.
taken as 1.376 and that of the aqueous humour, in con- The pupil size decreases with age at an approximately
tact with the back surface of the cornea, as 1.336.* By uniform rate which does, however, tend to slow down
applying equation (2.3), the two surface powers of the in later life. Largely because of differences in techniques
cornea may be found as follows: of measurement, there is only a limited measure of
(1) Anterior surface agreement between various published studies. The fol-
lowing diameters can be taken as typical. For the eye in
1000(1.376— 1) total darkness, 7.6mm at age 10, 6.2 mm at age 45,
Power F, =
yy and 5.2mm at age 80. For the light-adapted eye,
= +48.83D 4.8mm at age 10, 4.0mm at age 45, and 3.4mm at
age 80.
(2) Posterior surface Pupil size can be affected by a number of external or
1000(1.336 — 1.376) secondary agencies such as drugs, emotions, and
Rowermt> :—
a +6.8 sudden changes in the state of mind.

= = 5)xex0) |)

The power of the cornea as a whole is therefore about

+43 D, over two-thirds of the total power of the eye. The crystalline lens
When the eyes are unprotected under water, the ante-
rior surface of the cornea has its power greatly reduced, The crystalline lens serves the double purpose of sup-
the retinal image then becoming inordinately blurred. plying the balance of the eye's refractive power and pro-
viding a mechanism for focusing at different distances.
This latter faculty is called accommodation.
Both anatomically and optically, the lens is a highly
The anterior chamber complex structure, composed of layers of fibres laid
down in an essentially radial pattern that is regular
The anterior chamber is the cavity lying behind the enough to allow a symmetrical diffraction halo to be
cornea and in front of the iris and crystalline lens. It is formed (see Chapter 22). The lens continues to grow in
filled with a colourless liquid aptly termed the aqueous bulk throughout life by the formation of fresh layers of
humour, since its water content is 98%. fibres on the exterior. As part of the normal process of
The depth of the anterior chamber, measured along ageing it is susceptible to various changes impairing its
the eye’s optical axis, is strictly the distance from the flexibility and transparency. Its centre thickness is
posterior vertex of the cornea to the anterior surface of thereby increased, while the radii of curvature may
the crystalline, but the term as sometimes used includes become longer.
the corneal thickness. Excluding this latter, an average The lens substance is enclosed in a highly elastic cap-
value would be about 3.0 mm. sule. A structure of suspensory ligaments, called the
From an optical point of view, the depth of the ante- zonule of Zinn, stretches from the periphery of the cap-
rior chamber is important inasmuch as it affects the sule to the surrounding ciliary body, holding the lens in
total power of the eye’s optical system. If all other ele- position and controlling the curvature of its surfaces
ments remained unchanged, a reduction of 1 mm in the through variations in tension produced by the action of
depth of the anterior chamber (through a forward shift the ciliary muscle.
of the crystalline) would increase the eye’s total power The lens has a diameter of approximately 9 mm and is
by about 1.4 D. The reverse effect would result from a biconvex in form, the radius of its anterior surface
shift in the opposite direction. being about 1.7 times that of its posterior surface.
When the lens is in its unaccommodated state, the
centre thickness has traditionally been taken as
3.6mm, a figure appropriate to a young adult. As ac-
The iris and pupil commodation is brought into play, both surfaces, but es-
pecially the anterior, assume a more steeply curved
The amount of light admitted to the eye is regulated by form. The centre thickness thus increases and the
the pupil, an approximately circular opening in the iris. vertex of the anterior surface moves forward, reducing
the depth of the anterior diameter. The profiles of a typi-
cal crystalline in its relaxed and fully accommodated
* The values assumed by Gullstrand in his schematic eye. states are shown superimposed in Figure 2.9 which has
12 The eye's optical system

for convenience only. Careful observation reveals a

marked degree of peripheral flattening, especially of the
anterior surface in its accommodated state. Owing to
this, and to the peripheral flattening of the cornea, the
| eye’s spherical aberration is kept within reasonable
|Nucleus! limits, as we shall see in Chapter 15.

The retina

Anatomically an outgrowth of the brain, the retina is a

Figure 2.9. Profiles of the human crystalline lens in its
thin but enormously intricate structure, its functions
relaxed and fully accommodated states.
being much more extensive than was originally sup-
posed. It lines the posterior portion of the globe, ex-
been drawn to scale. The diagram also indicates the tending functionally up to the ora serrata close to the
range of positions of the two centres of curvature. ciliary body.
The back surface of the crystalline is in contact with A surprising feature of the retina is that the nerve
the vitreous humour, a transparent gel which fills the fibres transmitting impulses from individual or groups
posterior segment of the globe. The vitreous humour of retinal receptors travel across its surface to their exit
has very nearly the same chemical composition as the via the main trunk of the optic nerve. The retina is also
aqueous and its refractive index may be taken as the supplied with blood vessels which are clearly visible
same, 1.336. through an ophthalmoscope. Despite these obstructions
Because of its onion-like structure and the compres- to the incident light, the efficiency of the system does
sion exerted on the innermost layers, the crystalline not appear to suffer. Under certain conditions, however,
lens is far from being optically homogeneous. A slit- retinal blood vessels may be seen entoptically by the
lamp section reveals several bands of discontinuity. In shadows which they cast (see Chapter 22).
particular, it is possible to distinguish a central bi- As described more fully in Chapter 3, the ability of the
convex portion called the nucleus, from the surrounding retina to distinguish detail is not uniform over its entire
portion, called the cortex. In the centre of the nucleus, extent and reaches a maximum in the macular region.
the refractive index reaches its maximum value between This is an approximately circular area of diameter
1.40 and 1.41 but diminishes from the centre outwards, about 1.5mm containing a smaller central area, the
being about 1.385 near the poles and about 1.375 fovea, populated exclusively by retinal cones. It is at
near the equator. the fovea that the eye attains its maximum resolving
It may easily be deduced that a refractive index gradi- power. When an object engages visual attention, the
ent of this pattern, irrespective of any surface curva- two eyes are instinctively turned so that the image lies
tures, must produce a converging effect like a positive on each fovea.
lens. Since the velocity of light in a medium is inversely From an optical point of view, the retina could be de-
proportional to its refractive index, an incident wave- scribed as the screen on which the image is formed. It
front would become progressively less retarded from the can be regarded as part of a concave spherical surface
centre outwards and hence assume a convergent form. with a radius of curvature in the neighbourhood of
By way of confirmation, Ivanoff (1953) crushed a —]2 mm.
rabbit crystalline between parallel glass plates so that In cameras and optical instruments generally, it is
all the surfaces including those of the nucleus were ren- convenient to have images formed on plane surfaces,
dered effectively plane. He then found that the element but the curvature of the retina has two positive advan-
so produced had a power in air of just over +6 D. tages. In the first place, the images formed by optical
In his book Physical Optics, Wood (1911) described a systems tend to have curved surfaces. The curvature of
simple method of making ‘pseudo lenses’ from discs of the retina is of the right order from this point of view
gelatine enclosed between glass plates. Immersion in (see Chapter 15). Secondly, the steeply curved retina is
water, which has a lower refractive index, brings about able to cover a much wider field of view than would
a progressive decline in index towards the periphery, otherwise be possible.
producing positive power up to about +12 D. Both Ivan-
off (following Bouasse) and Wood have given mathe-
matical analyses, while Fowler and Pateras (1990) give
some experimental results.
The schematic eye
As a result of this effect, the crystalline lens has a
greater power than would be the case if its refractive General properties
index were uniform and had the highest value actually The schematic eye is a theoretical optical specification of
found. In fact, it is necessary to assume a fictitious re- an idealized eye, retaining average dimensions but omit-
fractive index of about 1.42 to bring the power of a ting the complications (see Chapter 12 for details). The
homogeneous crystalline lens up to a typical value in equivalent power of the unaccommodated eye as a
the neighbourhood of +21 D. whole is +60 D and its cardinal points are situated as
The assumption that the lens surfaces are spherical is shown in Figure 2.10. The first and second principal
 The schematic eye 13

centre at E. This image is called the ‘entrance pupil’.

Taken as an object for the crystalline lens, the pupil HJ
will give rise to another image, the ‘exit pupil’, with its
centre at E’.
It follows from this that an incident pencil of rays di-
rected towards and filling the entrance pupil would
Figure 2.10. The cardinal points of the unaccommodated
pass through the entire area of the real pupil, after re-
schematic eye (to scale), fraction by the cornea, and on finally emerging into the
vitreous body, would appear to have been limited by
the exit pupil.
points, P and P’, lie in the anterior chamber at distances Further, since a ray directed towards the axial point E
of about 1.5 and 1.8 mm respectively from the front sur- appears after refraction to have passed through the
face of the cornea. The nodal points, N and N’, are also axial point E’, these two points must be conjugate with
separated by 0.3 mm and straddle the back surface of respect to the system as a whole.
the crystalline lens. The anterior focal length PF is On the basis of paraxial theory, it may be shown that
about —16.7mm and the posterior focal length P’F’ the entrance pupil is situated about 3mm behind the
about +22.3 mm. anterior surface of the cornea and is about 13% larger
The general relationships and ray paths indicated in than the real pupil. The exit pupil lies closely behind
Figures 2.5 and 2.6 apply in every particular to the sche- the real pupil and is only 3% larger.
matic eye. . Because E and E’ are conjugate points, another rela-
tionship can be established. If an incident ray directed
towards E makes an angle wu with the optical axis, the
Optical centration
conjugate refracted ray will make an angle u’ with the
In the schematic eye it is assumed that all the refracting axis such that
surfaces are coaxial, the cornea and crystalline having / J .
u /u = aconstant fora given system
a common optical axis. The optical centration of the
typical human eye seems to be defective, the crystalline For the schematic eye the value of this constant is
lens being usually decentred and tilted with respect to about 0.82.
the cornea. For this reason the eye does not possess a
true optical axis. However, as shown in Chapter 12, the
principal points of the cornea very nearly coincide as The visual axis
do those of the schematic crystalline lens. Consequently,
a line drawn as nearly as possible through these two It might be reasonable to expect that the fovea would be
pairs of points would represent a very close approxima- situated on the retina at its intersection with the optical
tion to an optical axis. The use of this term in relation axis, a point termed the ‘posterior pole’. In fact, the
to the eye can be justified on this basis. fovea is normally displaced temporally and downwards
from the expected position. We are therefore led to pos-
tulate a ‘visual axis’ as distinct from the optical axis.
Entrance and exit pupils The visual axis has been taken by many writers to be
the imaginary line directed towards the first nodal
The real pupil HJ is assumed to lie in the plane of the
point N such that a parallel line through N’ would pass
anterior pole of the crystalline lens (Figure 2.11). If its
through the fovea. Apart from a slight displacement
centre at E, is regarded as an object for the cornea, it
due to the separation of the two nodal points, as seen
will give rise to a slightly magnified image with its
in Figure 2.6, an incident ray travelling along this path
would be otherwise undeviated. Indeed, it could be as-
Real pupil sumed without serious error that a mean position of
the two nodal points existed and the visual axis could
ntrance pupil] {1 _ ;
E Veatiase | Exit pupil be defined as the line passing through this mean posi-
tion and the fovea.
However, the present writers share the objection to
this concept already voiced by others. The term ‘visual
axis’ ought to mean the axis or chief ray of the actual
pencil of rays which enters the pupil and is converged
to the fovea. Accordingly, despite the weight of present
contrary opinion, the term ‘visual axis’ will be used
here to denote the incident ray path directed towards
the centre E of the entrance pupil such that the conju-
gate refracted ray falls on the fovea, M’ (Figure 2.12).
The angle between the optical and visual axis is called
the angle alpha, and is considered positive when the
visual axis in object space lies on the nasal side of the
optical axis. A positive value in the neighbourhood of
Figure 2.11. The eye’s real pupil and its images, the
entrance and exit pupils. 5° is commonly found. There seems to be general agree-
14 The eye's optical system

Temporal V

i
= Optical axis

Visual axis
Vv
U

Angle alpha Figure 2.14. Visual projection through the nodal point.
Nasal

perception, one may draw the following inference: a

linear extent of the retina subtending a known angle at
Figure 2.12. The optical and visual axes of the eye. Its
the second nodal point corresponds to an equal angular
second principal focus F% is shown in a position indicating
myopia. extent of object space.
The fovea is about 0.3 mm horizontally by 0.2 mm
vertically, subtending an angle at the second nodal
ment with Donders’ observation that the angle tends to point of about 0.018 by 0.012 rad. At a typical reading
be smaller in myopia and greater in hypermetropia. distance of 350mm, this would cover an area of
As for the vertical plane, the visual axis in object 6.3 x 4.2 mm, wide enough for four letters of the size
space is generally Hh a in an upward direction from commonly used for newsprint.
the optical axis, the figure commonly quoted being
about 2

The blind spot

At the papilla, or optic disc, where the main trunk of the
The monocular visual field optic nerve leaves the eye, there are no retinal receptors.
Consequently there is a corresponding ‘blind spot’ in
The monocular field the monocular field of vision, first noted by Mariotte in
On the temporal side, where there are no obstructions, 1668.
the field of vision extends through more than 90° from The optic disc measures about 2mm vertically by
the optical axis. The extreme ray entering the eye from 1.5 mm horizontally, subtending an angle of some 7° by
this side follows approximately the path indicated in 5° at the second nodal point. This is also the angular
Figure 2.13. This diagram also explains why the retina subtense of the blind region in space. It has been pointed
extends so far forwards. It would not need to do so if out that ten full moons placed side by side could disap-
light could not reach it. pear from view within this space.
The nose, brow and cheek limit the monocular visual The centre of the optic disc lies nasalwards from the
field in other directions, so that its shape is irregular. A fovea and slightly upwards from it. The centre of the
more detailed treatment of the visual fields is given in blind space is accordingly some 15° on the temporal
Chapter 8. side of the visual axis and 2° below it.
One can note here a useful application of the nodal In Figure 2.15, the positions on the retina of the
points. If UN and VN in Figure 2.14 are incident rays en- macula and optic disc are shown in relation to the pos-
closing an angle u, the conjugate refracted rays will di- terior pole. Dimensions given in degrees refer to the
verge as though from N’, still including the same angle angular subtense at the second nodal point.
u. Suppose these rays meet the retina at U’ and V’. Undoubtedly the most surprising feature of the blind
Then, without entering at all into questions of visual spot is that normally its existence is never noticed.
Even if one eye is occluded and the other views a
Extreme temporal ray path

Temporal Nasal

Optical axis
hd
oo
2° (M' \ 1
Posterior
'y,
bole
eee
/ x

1 Optic ‘a
‘ee J |

Figure 2.13. The ray path at the limit of the eye’s field of Figure 2.15. The relative sizes and positions of the macula
view. and optic disc. M’ denotes the fovea.
 The retinal image 15

Hypothetical
pupil

Figure 2.16. The reduced eye and its hypothetical pupil.

strongly patterned or brightly coloured expanse, the ob-

server is still not conscious of any gap. Nevertheless,
the blind spot can easily be mapped if suitable fixation
Figure 2.17. Comparison of the Bennett—Rabbetts schematic
and moving test-objects are used.
eye with the simple reduced eye.
Although the blind areas of the right and left eyes do
not overlap, Bridgman (1964) has pointed out that in
certain oblique directions of gaze part of the blind space If the unaccommodated eye is in focus for distant ob-
of one eye is occluded by the nose from the field of jects it is said to be ‘emmetropic’. In this event its
vision of the other eye. second principal focus F’ coincides with M’.
For convenience, the pupil of the reduced eye is con-
sidered to lie at the refracting surface, as shown in
Figure 2.16. The entrance and exit pupils now coincide
The reduced eye with this hypothetical pupil and the principal point P
fills the additional role of being the centre of the pupil.
For most purposes, the optical imagery of the eye can be Figure 2.17 sets in juxtaposition the reduced and the
adequately studied on the basis of a simple analogue, Bennett—Rabbetts schematic eye with the second princi-
called a ‘reduced eye’. As shown in Figure 2.16 it con- pal focus F’ of each in coincidence.
sists of a single convex surface separating air from a The principal point of the reduced eye is seen to coin-
medium of refractive index n’ similar to that of the vit- cide with the second principal point of the schematic
reous body. eye. Hence, vergence calculations based on the principal
Since convenience and simplicity are basic to the con- points of the schematic eye and the simple reduced eye
cept of a reduced eye, round figures are entirely appro- will give similar results. If the cornea of the schematic
priate. As in Emsley’s (1946) version, we take the eye is taken as the reference point, then in round fig-
power F. to be exactly +60D but the value of n’ as ures, the vertex of the reduced eye lies 1.8 mm behind
1.336. The two focal lengths, derived from equation that of the schematic eye. Hence, if a spectacle lens is as-
(2%3)) rare sumed to be 12 mm from the cornea, its distance from
the reduced eye should be reckoned as 13.8 mm. Exer-
f. = PF, = —1000/F, = —1000/ + 60 cise 2.6 gives a reduced eye due to Davison (pers.
= —16.67 mm comm., 1995), also of power +60 D, but with a similar
overall length to that of the Bennett—Rabbetts schematic
and eye.
fo-= PE. = 1000 1 /F,= 1336/60
= +22.27mm
The retinal image
Equation (2.3) also gives the necessary radius of cur-
vature r of the refracting surface as Algebraic treatment
LOOO(n =) 9336 The retinal image is inverted — a fact first propounded by
t= = -+-5.60 mm
F.e 60 Kepler in the early seventeenth century and later
In the case of a single refracting surface, the two prin- demonstrated by Scheiner.
cipal points coincide with each other and with the A distinction must be drawn between the retinal
vertex of the surface, denoted by P. Similarly, the two image, which may be sharp or blurred according to cir-
nodal points coincide with each other and with the cumstances, and the optical image. This latter term de-
centre of curvature of the surface (now denoted by N). notes the sharp image formed by the refracting system
This is logical, since any ray directed toward this point of the eye as though the retina were absent. The actual
meets the surface normally and is hence undeviated. formation of the optical image is, of course, prevented if
The line passing through P and N constitutes the opti- it lies behind the retina.
cal axis, and the fovea, denoted by M’, is assumed to be Given the necessary data, the position and size of an
on this line which accordingly becomes the visual axis optical image can be determined from the algebraic for-
as well. mulae already given in this chapter.
16 The eye’s optical system

Example 1 In this expression, h’ is in metres and u in radians.

An object 50 mm high is situated on the optical axis of

the standard emmetropic reduced eye at a distance of Example 2
250mm from its principal point. Find the position and A distant object subtending an angle of 5° is viewed by a
size of the optical image. reduced eye with a power of +62 D. Find the position
It is easier to work in terms of vergences. Thus
and size of the optical image.
~ = —250 mm fe =i) = n'/F. = 1336/62 == JOOS wal = i=)i=)P

1000/ — 250 = —4.001D

L=5 ~n/ 1s = 0.087a.rad
ca
i ll+60.00 D
he —0.0873 x 1000 _
L’=L+F, = +56.00D 1.41 mm
tn 62
a HLOOOn Sisst
— = ~ > — 423.86 mm
Ibi! 56
The height h’ of the optical image can be found from Ray-construction methods
equation (2.10)
The image formed by a single refracting surface such as
50 x —4.00 the reduced eye can be found by constructing two or
eats = 325) / MOM:
+56.00 more ray paths from the given object point.
The minus sign denotes inversion of the image. Diagrams of this kind are drawn to scale, but different
Since the image distance in this case (23.86 mm) is scales may be used for horizontal and vertical dimen-
greater than the axial length of the eye (22.27 mm), sions. The refracting surface should be replaced by the
the optical image becomes a theoretical construction tangent to its vertex.
only. The ray paths commonly used in these constructions
are shown in Figure 2.19, in which BQ is an object for
the eye. The image point Q’ is the intersection of any
Object at infinity two (or more) of the following refracted rays originating
from Q.
An object at infinity is imaged in the plane of the second
principal focus. Its size depends on the angular subtense Ray 1 Parallel to the optical axis, passing through F;,
of the object. after refraction.
In Figure 2.18, rays from the extremity Q of a distant Ray 2. Through the first principal focus F, refracted
object inclined at the positive angle u to the optical axis parallel to the axis.
are focused at Q’ in the plane of F,. A ray through the Ray 3. Through the nodal point, undeviated.
nodal point is undeviated. A ray incident at P is deviated Ray 4 Directed towards the principal point P.
towards the axis, the refracted ray making an angle u'
To find the refracted ray path for this last ray, locate
with it such that
the point Y on BQ such that
n’ sinu’ =nsinu
/ . =,

BY =BO/1 =0:75.80
in accordance with the law of refraction.
(strictly, BY = 0.749 BOQ).
In this case n = | and, if the angle u is small, the last
The refracted ray path is YP produced. This construc-
expression can be put in the simpler paraxial form:
tion is justified by equation (2.16) which can be written
nu =nu=u sibs) as
or tan u’ = (tan u)/n’
Tea Vane (2.16) since it has already been assumed that u is small. It can
From the diagram be most useful to carry out constructions of this kind,
verifying the results by calculation. However, it should
hee te be borne in mind that they are subject to the same lim-
and thus
Sat feu i (2a)

Figure 2.18. Image construction in the reduced eye: distant Figure 2.19. Image construction in the reduced eye: near
object. object.
 Exercises 17

itations as the approximate expressions on which they Just as a right-hand glove turned inside out takes the
are based. form of a left-hand glove, so the mirror image of one’s
own right hand appears as a left hand. The same three-
dimensional transformation is shown by the virtual
Magnification in visual optics
images formed by concave and convex mirrors, accom-
In optics, transverse magnification is given by the ratio panied by magnification or its opposite.
of image to object size, as in equation (2.10). In visual Clearly, the term ‘lateral inversion’ does not ade-
optics, however, magnification is frequently taken as quately describe the phenomenon. ‘Mirror metamorpho-
the ratio between any linear dimension of the retinal sis’ is offered as an improvement on the term
image when the optical device, e.g. a spectacle lens, ‘perversion’, which has been suggested in the past with-
magnifier, etc., is in use and the corresponding dimen- out gaining effective support.
sion when the object is viewed without the device.
The object is usually assumed to be in the same posi-
tion for both conditions, but particularly for magnifying
devices, the object is assumed to be positioned initially Exercises
at the reference seeing distance (formerly termed the
‘least distance of distinct vision’) of —250 mm from the 2.1 (a) A pencil of rays emerges from a lens with a vergence
of +6.00 D. What is its vergence after a travel of 10 mm in air?
eye.
(b) A pencil of rays emerges from a lens with a vergence
Jalie (1995) has pointed out that, in all cases, magni- of —8.00 D. What is its vergence after a travel of 15 mm in
fication can be calculated by determining the image size air?
produced by the optical device alone, then calculating 2.2 The macula of an emmetropic reduced eye has a diameter
of 1.5mm. What angle does it subtend at the nodal point and
its angular subtense at the eye’s entrance pupil, and
what is the corresponding linear extent of object space at 10 m
lastly comparing this with the angle the object would from the eye?
subtend without the device. 2.3 A schematic eye has a single-surface cornea of 7.5 mm
radius of curvature, an anterior chamber depth of 3 mm and a
homogeneous crystalline lens of thickness 3.5 mm, refractive
Nature of mirror imagery index 1.4 and back surface radius of curvature —6 mm. Both
aqueous and vitreous have a refractive index of 1.336. Calcu-
The so-called lateral inversion of the image formed by a late the position and magnification of the entrance and exit
plane mirror, notably one’s own reflection, still gives pupils.
rise to perplexity and debate. Arguments from psycho- 2.4 The diagram (not to scale) illustrates the positions P and
P’ of the principal points of a telephoto lens system formed by
logical or related grounds tend to be needlessly invoked. two thin lenses of power +10 D and —5 D at A, and A, respec-
To understand the true nature of mirror imagery de- tively. An object point B and its image B’ are also shown.
mands consideration of an object in three dimensions, From the given measurements, all in mm, determine the fol-
not two. For a plane mirror, any object point and its re- lowing distances, using in each case only distances of stated
length and paying strict attention to signs: A,P, A>F’,
flected image lie on a common normal to the surface
PP’, F’B’ and PB. (Example: FB = FA, + A,B = —(—162.5)+
and are equidistant from it. Consequently, the object (=66275)—— 500 mmm)
shown in Figure 2.20, representing a central vertical
section through the head of an observer, is imaged as 662.5
depicted. The image is formed as though the object had 162.5 | 481.25
been pulled through the mirror, and turned inside out
in the process. The same would take place in any verti-
Beale Pe Peet. a \howt onele:
cal section parallel to the plane of the diagram. As a
result, the left eye of the observer appears as the right 7: | karo
eye ofthe three-dimensional image gazing back at him.

|mage Mirror Object

2.5 The diagram illustrates a diverging meniscus lens of
thickness ¢ with its first principal point P at a distance e from
vertex A, and its second principal point P’ at a distance e!
from vertex Aj. An object point B is at a distance / from P and
its image B’ at a distance /’ from P’. Using only these letter
symbols, express the following distances: P’A,, A,B’, PP’, B’P
and BB’. (Example: A,B = A,;P + PB =e+/.)

Figure 2.20. Vertical section through the centre of an

observer's head and its mirror image. Since imagery of the same
type takes place in every plane parallel to that of the diagram, it
follows that the left eye of the observer becomes the right eye of
the three-dimensional mirror image, and vice versa.
18 The eye’s optical system

2.6 What are the radii of curvature and refractive index of a FOWLER, C.W. and PATERAS, E.S. (1990) A gradient-index
simple reduced eye of power +60.00D and axial length ophthalmic lens based on Wood's convex pseudo-lens.
24.00 mm, which is the overall length of the schematic eye? Ophthal. Physiol. Opt., 10, 262-270
IVANOEF, A. (1953) Les Aberrations de l'Oeil. Paris: Editions de la
Revue d'Optique
JALIE, M. (1995) The Arthur Bennett Memorial lecture (unpub-
References lished in written form)
PRENTICE, C.F. (1890) A metric system of numbering and meas-
BRIDGMAN, C.S. (1964) Viewing conditions under which the uring prisms. Arch. Ophthal., N.Y., 19, 64-75, 128-135
blind spot is not compensated by vision in the other eye. Am. woop, R.W. (1911) Physical Optics, 2nd edn. New York> Mac-
J. Optom., 41, 426-428 millan
EMSLEY, H.H. (1946) Visual Optics, 4th edn. London: Hatton
Press, 34-36
3
Visual acuity and contrast sensitivity

Introduction (6) Higher tasks where the visual system stimulates

other responses, for example, a motor response in
Vision is the process by which an organism sees and in- handling something.
cludes all the stages from the physical stimulus reaching The two most important aspects in clinical work are
the eye to the mental perception. The amount of infor- those of form vision and resolution. If the eye views a
mation needed by an organism varies from species to large letter so that the detail in its retinal image is large
species and the visual system tends to be adapted ac- with respect to the size of the retinal receptors, it is the
cordingly. One of the simplest requirements is in the general shape of the letter which has to be recognized,
earthworm, Lumbricus, where perception of light is all no matter whether the retinal image is sharp or blurred.
that is needed and thus simple, light-sensitive cells in If the size of the letter is progressively decreased with
the epithelium are sufficient. The unicellular aquatic or- the retinal image remaining in focus, then the eye’s abil-
ganism, Euglena gracilis, has the additional requirement ity to resolve detail is used more and more, until the
of needing to identify the direction of the incident light. image becomes so small that the visual system can no
Adjacent to a photosensitive region is a pigment spot longer identify the letter. The terms ‘vision’ and ‘visual
which casts a shadow on this region in certain orienta- acuity’ in clinical work relate to the detail size of letters
tions of the cell, enabling it to swim towards the light. that can just be recognized and will be defined on pages
The compound eye of insects has a series of minute 26-27.
lenses, each focusing light on to receptor cells. Each
individual unit therefore ‘sees’ only a limited region in
space. Although there will be a small amount of overlap
between these input regions for neighbouring units, Line discrimination
some detail in the outside environment can be obtained.
An alternative method of obtaining detailed information The ability of the eye to perceive that an object is sepa-
about the environment is to form an image of the out- rate from its background depends partly upon the rela-
side world on an array of receptor elements, using just tive luminances of object and ground. If the ground is
one lens system or pinhole aperture. The vertebrate eye very dark, the object will be seen, provided that the illu-
is of this type, having but a single lens-system. mination of its retinal image exceeds the luminance
threshold of the eye at that adaptation level. The ability
to see a dark object against an illuminated ground is de-
pendent on a different threshold. In these conditions,
the contrast in the image of a large object is similar to
An order of visual performance the contrast in the object (Figure 3.1). As the object is
reduced in size, so the contrast in the image falls, partly
The human eye is capable of many different tasks, in- due to imperfections in the eye's optical system.
volving many different complexities of vision. These A dark object will be perceived, provided that the var-
tasks may be classified under the following headings: iation in retinal illumination exceeds the luminance dif-
ference threshold, AL/L. This fraction, known as the
(1) Light perception, for example, the threshold of Weber—Fechner fraction, varies with the background lu-
vision in the normal eye or the only response of a minance and reaches a minimum value of about 2% at
diseasedeye. , moderate photopic levels. Thus, provided that the ret-
(2) Discrimination, or the ability of the visual system to inal image of a dark object causes an illumination drop
distinguish an object from its background. on the retina of about 2%, it will probably be seen.
(3) Form vision and recognition, such as the ability to Under good conditions, a line subtending as little as 0.5
identify letters and words. seconds of arc may be seen, provided that it is suffi-
(4) Resolution or the ability to see detail. ciently long (for example, a telephone wire) for its
(5) Localization, for example, realizing that an object is image to cover many receptors. Similarly, a disc of
situated to one side of another object. about 30 seconds subtense may be seen.
20 Visual acuity and contrast sensitivity

Object ie) fo) :

Bacillary layer

i i

& 100 cx) wee

ce pile 777 T~ Cuter limiting
o
mn membrane
Object
Oo .

¢ S *.

a= width Outer nuclear layer

Te)
o2 «0 n

Ss
3
100 SN Sa
(a) (b) (c)
fe
Ay © Image Figure 3.2. Simplified illustration of the retinal receptors,
oF width where o represents the outer segment, i the inner segment and
Es 0 n the nucleus: (a) rod, (b) cone, (c) foveal cone.

Figure 3.1. Contrast transfer in an optical system. The upper

row shows three bar objects of different widths. The middle and varies in different areas of the retina. Only near the pos-
lower rows show the luminance across the width of the object
terior pole do cones predominate; in the fovea there are
and image.
only cones. These are, however, much slimmer than
the peripheral cones and this enables them to be
If the object shows a reduced contrast with the back- packed much closer together.
ground, such as a grey line on a light ground, the varia- The outer limiting membrane divides the photosensi-
tion in retinal illumination must again exceed the tive areas of the rods and cones from their nuclei in the
luminance difference threshold over a sufficient area for outer nuclear layer. The endings on these nerve cells sy-
discrimination to result. napse with relay cells known as bipolar cells. These in
turn synapse with the ganglion cells whose fibres pass
across the surface of the retina to the optic nerve head
and then via the optic nerve to the lateral geniculate
body in the brain. Instead of conducting nerve impulses
Resolution: receptor theory to the brain, some nerve cells in the relay layers make
contact with other cells including rods and cones. Their
A brief introduction to the structure of the retina is function may be concerned with processing the neural
given here as a background to the discussion on resolu-
‘image’ and making up for some of the optical defects of
tion. For a more detailed account, the reader should
the eye. The neural connections in the retina are very
refer to one of the specialized textbooks on ocular
complex and in general each ganglion nerve receives
anatomy or physiology.
impulses from many receptors. Only in the foveal
The retina lies against the pigmented choroid, which
region does the number of cones and ganglion fibres
provides both a nutrient supply to the outer layers of
become approximately equal.
the retina and a black-out. This absorbs light that may
With the exception of the pigment epithelium, the
have passed through the sclera and also reduces the
retina is transparent and the optical image is formed on
amount of light scattered back in a diffuse manner after
the bacillary layer after the light has passed through
its initial passage through the retina. The outermost
the nuclear and synaptic layers. Despite the transpar-
layer of the retina is the pigment epithelium, which
also helps to absorb light and contributes greatly to ret- ency, some degradation of the image occurs, so in the
inal receptor metabolism. Where these layers are defi- foveal region the majority of the neural elements are
cient in pigment, as in albinos and blonds, the vision tilted away (Figure 3.2) so that there is very little tissue
may be reduced because the contrast in the optical in front of the cone layer. Duke-Elder (1958) discusses
image is reduced by stray light. Light passing through Wall's suggestion that the deep foveal pit in some birds
the sclera and iris and light scattered around inside the of prey, taking a cusp-like form, serves the purpose of
eye both contribute to spoiling the quality of the retinal magnifying the image. The argument is that rays of
image. light incident just off the apex of the cusp are deviated
The second layer is the photosensitive or bacillary away from it, thus spreading the image over a greater
layer. This consists of the outer and inner segments of number of retinal cones. Another favourable feature is
two types of cell, the rods and cones, so called because that there are no blood capillaries in this region to
of their shape. The rods provide achromatic vision in reduce contrast.
the scotopic or low range of luminances. The cones pro- In the fovea, the cones have a diameter of about
vide colour vision and work in the photopic or high 1.5 um (microns) and they are separated by an edge to
range of luminances. The luminance range in the edge space of about 0.5 tm. Thus the effective separa-
middle where both types of receptors operate is called tion between cone centres is about 2 um. Suppose the
the mesopic region. Typical receptors are illustrated in eye were viewing two closely adjacent point sources of
Figure 3.2. The population density of the receptors light: if their images fell on two neighbouring cones,
 Resolution: wave theory 21

va i
4um

Figure 3.3. Receptor theory of resolution.

they would be perceived as only a single source. If, how-

ever, there was one unstimulated cone between those il-
luminated by the images, then resolution would
probably occur. Hence, a separation between the
images of 4 um is required (Figure 3.3). Assuming the
nodal point to be 163 mm in front of the retina, this - 100
(c) :
represents a theoretical limit to resolution of about 49
seconds of arc.
This simplified analysis is valid only if each cone can
transmit a separate impulse, which means that there is
at least one nerve fibre to each foveal cone. In the per-
iphery of the retina, each nerve fibre is stimulated by
many receptors and therefore it is the size of the receptor Figure 3.4. Wave theory of resolution: (a) two separated
field corresponding to each nerve fibre that is important, Airy discs, (b) discs too close to be resolved, (c) discs separated
rather than the size of the individual receptors. A by half their width — the Rayleigh criterion.
further complication is that the retina is capable of dis-
tinguishing colour, so that some of the nerve fibres
the eye, its angular subtense @ at the nodal point is
must conduct colour information. There is, however, given by the expression
little variation in resolution with wavelength (see. for
example, Shlaer et al., 1941). 2.44)
C= 14d (S51)
The eye is in constant movement and so any image is g
passed from cone to cone. This prevents the reduction where A is the wavelength of the light in metres and g
of contrast by adaptation in the neural ‘image’ — the the pupil diameter, also in metres.
Troxler or extinction effect — and also provides for an in- IMMIS, toe J Sisson” (Si5)5 $< 10) )andg= 3mm
tegration of information received by the various neural (Gea lO ina)
components, thus contributing to the eye’s good per-
formance. The twinkling of stars, however, is not duc PAA EOS S Sohne
O)— — rad
to the image falling between receptors or stimulating = 10-°
first one receptor and then its neighbour, but to fluctua- = 93 seconds of arc
tions in the light paths through the atmosphere. The
eye has appreciable aberrations (see Chapter 15) and The distribution of light within an Airy disc is
these spread the optical image of a star so that it falls strongly peaked at the centre, as shown by the dashed
over several cones. Even if these geometrical aberrations curves in Figure 3.4, accurately drawn to scale.
were eliminated, the wave nature of light would still If there are two closely adjacent point sources, there
spoil the image. will be two overlapping diffraction patterns, each con-
tributing to the illuminance of the retinal image in the
area of overlap. The dashed lines in Figure 3.4 show the
relative illuminance curves for individual Airy discs,
Resolution: wave theory while the solid lines show the summation across the
area of overlap. For example, at a point O (Figure 3.4a),
The nature of light cannot be explained simply. In terms the illuminance due to the left-hand Airy disc is propor-
of stimulating receptors, light appears to act as if it con- tional to QA while that due to the other Airy disc is pro-
sisted of discrete components or quanta, while image portional to OB. The sum of OA and OB is equal to OC,
and shadow formation suggests that light has a wave which determines the corresponding point on the sum-
structure. mation curve.
The wave theory predicts that, even with a perfect op- If two neighbouring patterns are sufficiently sepa-
tical system, the image of a point object cannot be a rated, the combined illuminance curve will show two
point, but must spread to cover a finite area due to dif- peaks with a dip in between (Figure 3.4a). As the point
fraction of light at the margins of the optical system objects approach each other, so will their images and
For a circular aperture, this image pattern takes the eventually the two peaks will merge together into a
form ofa central bright disc surrounded by much fainter
rings, which can be ignored in this context.
The central disc containing about 84% of the light in “The wavelength corresponding to the brightest (yellow—
the entire diffraction pattern is termed the Airy disc. In green) part of the spectrum.
22. Visual acuity and contrast sensitivity

single bright peak. Under these conditions, the eye 21. It is not necessary to assume a completely unstimu-
cannot possibly see the two objects as separate, that is, lated central cone. There may be some spread of light
they are unresolved (Figure 3.4D) . over it, but discrimination could still occur, provided
Lord Rayleigh suggested that resolution was just ob- that the outer cones were more strongly illuminated. It
tained if the central peak of the second Airy disc fell on mustbe pointed out, however, that the luminance differ-
the extreme edge of the first, so that the separation of ence threshold for relatively large bipartite fields may
the geometric images of the point objects was half the not have the same values as for minute areas of the
diameter of the Airy disc (Figure 3.4c). The depression retina. "
or saddle between the peaks then has a minimum illumi-
nance of about 74% of that of the peaks.
This formulation, known as the Rayleigh criterion, es-
tablishes a value for 0,,;,, the minimum angle of resolu-
tion of the eye. It is half the angle subtended at the
Grating resolution and acuity
nodal point by a single Airy disc. Hence,
The previous section extended the principle of resolution
to the case of two parallel line objects as distinct from
0 min — === ad (3.2)
two points. In turn, the line objects may be considered
The minimum angle of resolution is often referred to as a particular case of the grating which consists of a
as resolving power, but the authors prefer not to use series of parallel black and white lines (Figure 3.5a).
this term because the smaller the value of 0,;,, the Usually, the black lines have the same width as the
better the eye. white lines, and both are of the same width over the
For a 3mm pupil and 4 = 555 nm, the value of 0,,;, is whole area of the test pattern. Such a grating is known
47 seconds of arc. The similarity between this theoret- as a Foucault grating or square-wave grating, since the
ical limiting value and the minimum of 49 seconds contrast alters abruptly at the change from black to
given by receptor theory is most striking. Other factors white and vice versa. Gratings may also be designed
influencing resolution are considered on pages 22-26. where the black line is only half the width, for example,
Under optimum astronomical conditions, Dawes of the white line.
(1867) found that the minimum angle of resolution The grating, especially in its sinusoidal form (see
could be smaller than Rayleigh’s value. The Dawes pages 46-55) is frequently used in psychophysical ex-
limit gives 0,,;, the value of periments on vision. In general, it is presented with the
stripes vertical or horizontal. Even when the eye’s focus-
1.00K
aaa — Tac (3.3) ing is corrected for irregularities such as astigmatism
g (see Chapter 5), the eye’s limit of resolution varies with
the angle of presentation of the test grating. The eye per-
The illuminance in the middle of the trough is then forms better with horizontal or vertical gratings than
only a few per cent lower than at the peaks of the lumin- with oblique gratings (see, for example, Nachmias,
osity curve. For a 3mm pupil and A= 555nm, the 1960; Campbell et al., 1966; Tootle and Berkley, 1983;
Dawes limit is only 38 seconds of arc. A figure of 1 ROSS LoD As
minute of arc is frequently quoted’ as the minimum The Foucault grating is a simple test to use because
angle of resolution of a good eye. Although this is a the apparent width of the grating element may be
lower order of performance than the various theoretical varied by rotating the plane of the grating about an
minima, it appears to be unattainable under indoor ex- axis parallel to the lines (Figure 3.5b). The disadvantage
perimental conditions. The best results obtained by of the grating as a test object is that its streaky nature
Ogle (1951) were in the neighbourhood of 90 seconds may be appreciated before the actual elements are prop-
of arc. Much depends on the relative luminance of the erly resolved. If the grating is rotated so that its elements
point sources and the background. become apparently finer, an angle will be reached at
The cross-section of the diffraction pattern for the which it can no longer be resolved. The rotation being
image of a single line is very similar to that of a single continued a little more, the grating elements may
point but differs slightly in the illuminance of the side again, under some conditions of observation, become
stripes. A strip of the retina is stimulated, giving summa-
tion effects which possibly make resolution easier if no
finer.
This argument is similar to the one involved in line
discrimination (page 19), namely, that a dip in retinal il-
luminance enables a dark object to be perceived, pro-
vided that the variation in illuminance exceeds the
luminance difference threshold. The same idea can be
extended to the receptor theory outlined on pages 20—
Apparent
width

* This is based on a statement by Hooke in about 1680, relat- (a) (b)

ing to astronomical observations. The passage occurs in one of Figure 3.5. Foucault grating and the effect of tilt , on its
his lectures to the Royal Society (Hooke, 1705). apparent width, which is reduced by the factor cos .
 Resolution and pupil size No WW

apparently visible over a short critical range. This is

known as spurious resolution (see also pages 50-51).
The limit of resolution for a square-wave grating is
traditionally expressed as the angular subtense in sec-
onds of arc of the grating element (one black plus white
line). If these are of equal width, the size of the grating
element is the same as the centre-to-centre distance of
neighbouring black or white lines. A typical value of
the limit of resolution of a square-wave grating is 80-
90 seconds of arc.
of
Limit
resolution
In general, visual acuity is inversely related to the
minimum angle of resolution. Hence, if A denotes the
angular subtense of the basic detail of the smallest dis-
cernible test object — for example, the line width of the (reciprocal
minutes)
acuity
width
Line
arc)
of
minutes
grating
in
(subtense
element
test letters or characters on any standard form of test 0 1 2 $) 4
chart — the visual acuity V may be defined as Pupil diameter (mm)

V=k/A (3.4) Figure 3.6. Resolution of Foucault grating as a function of

pupil size.
where k is an arbitrary constant. This is the basis of the
decimal notation for recording visual acuity, in which
A is expressed in minutes of arc and the value given to
k is unity. A more detailed explanation is given on
Stiles-Crawford and Campbell effects
pages 26-31.
Grating acuity can also be expressed in the form of Named after its discoverers in 1933, the Stiles—Crawford
line-width acuity, the unit being reciprocal minutes. effect relates to the directional sensitivity of the fovea.
For example, if a subject's limit of resolution for a grat- Rays of light passing through the centre of the pupil
ing is 90 seconds, the angular subtense A of a single are less oblique to the cones after refraction and stimu-
line is 45 seconds or 0.75 minutes of arc. The line- late them more strongly than rays through peripheral
width acuity is therefore 1/0.75 or 1.33. Expressed in areas of the pupil.
this way, grating acuity can be directly compared with If the Stiles—-Crawford effect did not exist, a pupil of
clinical acuity expressed in decimal notation. smaller size would elicit the same response in terms of
apparent brightness than a given actual size in real con-
ditions. Let the respective diameters of the actual and
equivalent pupils be denoted by d and d, and their re-
spective areas by S and S,. In an extensive treatment of
Resolution and pupil size this subject, Le Grand (1948) derived an expression for
S. which is immediately reducible to
On pages 21-22 we showed that, according to the wave Se = (nd?/4) [1 — 0.0106 d? + 0.0000417
d*|
theory of light, diffraction at the pupil margin gives the
minimum separable visual angle as an inverse function For the actual pupil, S = nd? /4. Since the area of a circle
of pupil diameter (equation 3.2). Thus, at large pupil is proportional to the square of its diameter, it follows
diameters, the Airy disc is small, and the limit of resolu- that
tion should also be small. Conversely, small pupil dia-
S./S = de jd?
meters give a larger threshold angle. While the
relationship is true for an aberration-free optical whence
system, the eye’s aberrations reduce its performance at d. = dy/u (3.5)
larger pupil diameters.
Figure 3.6 shows the mean data obtained by Rabbetts where
from six subjects for grating resolution at constant ret- 1 = 1 — 0.0106 d? + 0.0000417d* (3.6)
inal illumination, the test object luminance being re-
duced as pupil diameter was increased. The straight Table 3.1 has been compiled from this basis.
line represents the performance predicted by the Ray-
leigh criterion (equation 3.5). The actual performance Table 3.1 Stiles—Crawford effect. Relationship between actual
of the eye is seen to depart from that of an aberration- and effective pupil diameters
free system when the pupil diameter approaches
1.5 mm. The best acuity, equivalent to a limit of resolu- Actual pupil diameter (mm) Effective pupil diameter (mm)

tion of 77 seconds of arc occurred at a pupil diameter of 0:99

3mm, but many authors quote figures of 2.0-2.4 mm. 1.96
Above the optimum diameter, resolution becomes 2.86
poorer under photopic conditions, because the effects of 3.67
Oye
Re
WN 4.36
aberrations then begin to predominate. Under normal
6 4.92
scotopic conditions, an increase in pupil size gives great- 7 5.55
er retinal illumination, which improves the acuity.
24 Visual acuity and contrast sensitivity

An associated effect, named after Campbell (1958), since five trolands represents five times as much retinal
refers to the loss in visual acuity when incident rays illuminance as one troland, for the same eye, irrespec-
are restricted to a peripheral area of the pupil. It results tive of whether it is pupil size or object luminance or
not only from the Stiles-Crawford effect, but also from both that have been altered. It should not be overlooked,
the ocular aberrations attendant on oblique incidence however, that the actual retinal illuminance is influ-
(Green, 1967; Walsh and Charman, 1985). enced by the transparency of the eye’s media as well as
As reported by Enoch et al. (1980), it has been found by the Stiles—Crawlord effect.
that the directional sensitivity of the fovea of one eye is Shlaer’s results for the grating show an increase in
significantly reduced if it is occluded by a black patch acuity from 0.8 at 1 troland (log 1 = O) to 1.3 at 10 tro-
for several days. The effect takes 3-6 days to reach its lands.
maximum, and complete recovery after removal of the At higher and lower illumination levels there was a
patch takes a similar time. Other transient and minor smaller rate of variation. Similar variations plotting as
visual effects are described. The bearing of these discov- a sigmoid (S-shaped) curve were found with the Landolt
eries on the general question of the alignment of retinal ring.
receptors is discussed in some detail.

Variable (normal) pupil size

Resolution and illumination
An alternative approach is to allow the pupil to take its
Fixed pupil size natural size as the illumination of the test object is
varied. Although this may give less information about
The retina works more efficiently at higher levels of illu-
the physiology of the retina, it gives a better idea of
mination, making it easier to read in a good light than
what happens in normal conditions.
outside at dusk. However, there are other factors to be
Thus, Foxell and Stevens (1955) measured the ability
considered. The pupil diameter alters with the level of il-
of the eye to resolve the gap in a Landolt ring as a func-
lumination, and so, in scientific measurements, the
tion of background luminance. The acuity improved
pupil size is fixed. The eye's own pupil is usually dilated
steadily with increased luminance up to approximately
with a drug (mydriatic) and an artificial pupil of a size
3400 cd/m”, after which resolution became poorer
smaller than the dilated pupil is placed immediately in
(Figure 3.8). They also studied the influence of surround
front of the cornea.
size at various luminance levels. The acuity was found
The results found by Shlaer (1937) for a grating anda
to improve with increased surround size, the improve-
Landolt ring or C are shown in Figure 3.7. The grating
ment being much less marked for surround sizes over 6°.
acuity results are expressed in terms of line width, as in
Foxell and Stevens also investigated the effect of vary-
equation (3.4). The Landolt ring is a circle with a gap
ing the surround illumination over a 120° field with re-
(for a full description see page 32). The subject has to
spect to that of a small central field of 0.5° forming the
recognize the orientation of the gap; the reciprocal sub-
immediate background to the test object. This experi-
tense of the gap width that is just correctly seen is a
ment was repeated for a range of values of the central
measure of the acuity.
field luminance from 3.4 to 34 000 cd/m?. Their results
Retinal illumination is given in trolands. Because the
are shown in Figure 3.9. It appears that the best acuity
illuminance of the retinal image varies with the square
is obtained when the surround luminance is approxi-
of pupil diameter, it is not sufficient to state the lumi-
nance of the test object. Troland suggested a unit based
upon an eye with a pupillary area of one square milli- (Candelas/metre 2)
metre viewing a surface of luminance one candela per
1 10 102 103 104
square metre. This unit is now named after him, 3.0
though it was originally called the photon. The troland
is a very convenient measure of retinal illuminance
x oO
2. a al Or Sa
Landolt C, subject ELS 2
2.0 Grating, subject AMC 05 5
/ Grating, subject ELS p@ =
Fay ~—

5 15 0.67 8 acuity
Visual
o a
Ye aS,

Shaye TOD.
ee ne)
> a
oO

0.5 2.0 3
=

0.0
x
0.1 1 10 102 107, 104
—3 -2 -1 0 1 25 30 Ala 5 a6
Luminance (foot-lamberts)
Log retinal illuminance (trolands)
Figure 3.8. Visual acuity as a function of luminance for
Figure 3.7. Visual acuity and retinal illuminance. (Reference different diameter surrounds. (Redrawn from Foxell and
from Shlaer, copyright The Rockefeller University Press.) Stevens, by kind permission of the publishers of Br. J. Ophthal.)
 Pupil size and illumination 25

(Candelas/metre 2) 8
10°* 10-8 1 10 102 10° 104 Gia® 7
ae ¢ re
3.0 ® ~S
—e 6 é ~. Reeves
— ~
= me } So
e€ 5 oe e ~<
—— ~ _
Misia \ =
2.5
g “ Se ae, woe
= Crawford BSS
Pa s 3 $ “SN
= ne)
oO = 2
E20 =
oO
a
=a
10
—2 —1 0 1 2 3 4
1.5 Test luminance
Log luminance (Candelas/metre2 )

Figure 3.10. Pupil size and illumination. (Campbell and

1.0 Gregory, 1960. Reproduced by kind permission of the
publishers of Nature.)
Dark 10-2 10-1 1. 10 102 103 104
Surround luminance (foot-lamberts)
. (1960) later investigated this relationship in a slightly
Figure 3.9. Visual acuity as a function of surround
luminance for various background luminances. (Redrawn from
different manner, by determining for a range of artificial
Foxell and Stevens, by kind permission of the publishers of Br. J. pupil diameters the luminance level most favourable for
Ophthal.) resolution of a three-bar grating. Their results are
plotted as the circles in Figure 3.10 and are seen to fall
within the range between Reeves’s and Crawford's re-
mately equal to that of the central field for values of the
sults. This suggests that pupil size is adjusted to give op-
latter up to nearly 3400 cd/m?.
timum visual acuity over a wide range of luminances, a
The results of this and similar studies have important
conclusion supported by Laughlin (1992). He also
clinical implications in, the illumination of test charts. points out that, at any particular illumination level, the
For example, if a single letter is shown illuminated on a optimum diameter is a broad function, so that devia-
dark background, as is possible with some test-type pro- tions from the optimum have only a small effect on per-
jectors, a poorer acuity than with an illuminated sur- formance.
round will be expected for most patients. Stanley and Davies (1995) demonstrated that the
Over the range of possible luminances for test charts area of the adapting stimulus and its luminance were in-
(40-600 cd/m’), Sheedy et al. (1984) found an almost versely proportional. Thus pupil contraction would
linear improvement in logMAR acuity (see pages result from increasing either the area of the field of
30-31) when plotted against luminance, also on a loga- view or its luminance. They suggested that some of the
rithmic scale. For test letters the logMAR acuity was reported differences in pupil size for the same illumi-
found to be —0.085 (V = 1.22) at 46 cd/m”, improving nance might therefore be due to differences in the stimu-
to —0.155 (V = 1.43) at 563 cd/m’. The slope of the re- lus area. The pupil diameters for all their nine subjects
gression line was approximately —0.06, from which a (aged 21-33, mean 27, pers. comm.) could be predicted
simple relationship can be derived between a change in by a single formula which related diameter g to the prod-
test chart luminance and the resulting change in uct p of the square of the angle subtended by the stimu-
logMAR visual acuity. Sheedy and colleagues deduced lus diameter and its luminance:
that if a variation of +0.01 of a logMAR unit is permis-
sible, a standard value L for the luminance could be al- (p/846)°*!
lowed to vary by about 0.17 of a log unit. This would l| NINy WW Me 5
(p/846)°*1 + 2
SS

give a tolerance ranging from 0.68 times to 1.47 times

the nominal value of L. Landolt ring acuity was found The maximum angle they studied was 25°. Since the
to be less affected by luminance changes than letter retina becomes less sensitive towards the periphery, in-
acuity. creasing the adapting field size eventually produces a di-
minishing decrease in pupil size. Thus Stanley and
Davies (pers. comm.) found that for a field of 66 cd/m?,
Pupil size and illumination increasing the field size from 25° to 60° decreased the
pupil diameter by only 6% as opposed to the 20% pre-
The pupil constricts with increasing luminance levels, dicted by the above formula. Similarly, a 1.6° field at
although most of the adaptation occurs in the retina. 8000 cd/m? presented to the fovea produced a pupil
An average pupil size as a function of luminance has diameter of 4.3 mm, which increased to 5.2 mm when
been determined independently by Reeves (1918) and positioned 10° away and 5.55mm when 20° from the
Crawford (1936), whose results are plotted as the fovea.
dashed lines in Figure 3.10. Similar results from De Palmer (1966) has found, however, that where the
Groot and Gebhard (1952) and Flamant (1948) are illu- pupil is unable to affect the illumination of the retinal
strated in Hoover (1987). Campbell and Gregory image, it becomes larger than normal. This situation
26 Visual acuity and contrast sensitivity

can occur when the eye is used with an instrument, level of illumination is not abrupt. It takes the form indi-
such that all the light passes through an exit pupil smal- cated by the two identical curves at (b) in Figure 3.11.
ler than the eye’s own pupil. If the break AB in the line shown at (a) is near the
threshold of discrimination, the blurred image of the
edge of the line will extend over a relatively longer dis-
Pupil diameter and age tance, say from A to A’ above the break and from B to
The pupil diameter decreases with age. Winn et al. B’ below it. The drop in illumination below the level of
(1994) showed that, although there is a large variation the break is represented by the vertical distance between
between people in any age group, pupils of young sub- the curves, which is very nearly constant across the
jects dilated much more at low luminances than those whole width of the blurred fringe. In consequence, the
of older people. They found average results of 8 mm for retinal cones in the fringe below the break are less
20 year olds viewing a 10° diameter adapting field of strongly stimulated. The effects of summation and inhi-
9 cd/m? constricting to 4.5mm at 1100 cd/m? com- bition zones within the retina immediately above and
pared with 5mm and 3.5 mm respectively for 80-year- below the break are the most probable explanation of
old subjects. The reduction in pupil size with age has the extraordinary level of vernier acuity (see, for exam-
the disadvantage of lowering retinal illuminance, hence ple, Williams and Essock, 1986; Wilson, 1986). An al-
reducing vision, but, conversely, reducing the deleter- ternative explanation is that the visual system can
ious effects of aberrations and light scattered by older determine the ‘centre of gravity’ of the light distribution
lenses (Woodhouse, 1975). Winn and colleagues also in each of the two adjacent sections of the retinal
found no significant relationship between pupil size and image (Westheimer and McKee, 1977; Watt et al.,
gender, refractive error or iris colour. 1983; Whitaker and Walker, 1988).
Woods (1991) gives an extensive review of ageing In some cases, however, the observer may perceive
and vision, including pupil diameter. one line consistently to one side of the other, thus
making an alignment error. For a particular observer
such errors tend to be similar, but can vary according
Vernier acuity to whether binocular or right or left monocular viewing
is used (Tomlinson, 1969). Emsley (1946) and Carter
(1958) found setting errors of up to 0.8—0.9 minutes of
An entirely different aspect of vision is involved in ver-
nier acuity, the principle of which is illustrated in arc. At one-third of a metre, this is equivalent to 0.1
mm, a significant error. Even so, the principle of vernier
Figure 3.1la. Two parallel straight lines are displaced
fractionally with respect to each other, giving rise to a alignment is frequently and successfully used in instru-
ments. It derives its name from Pierre Vernier (1580-—
break in contour. The angular subtense of the least de-
tectable break is a measure of vernier acuity. Where 1637), the inventor of the scale that bears his name.
the ends of the lines are close together in the direction A similar type of visual process may be involved in the
of their length, acuity is maximal but discrimination perception of dot alignment; if three dots are placed in
falls as the ends of the lines become separated (French, a row, a slight transverse displacement of the centre
1920). For average observers, vernier acuity ranges dot is readily discernible. Vilar et al. (1995) suggest this
from 10 seconds of arc upwards, but values as remark- arrangement is preferable to the usual vernier acuity
able as 2—5 seconds are not uncommon among skilled display since it avoids judgement of the vertical. Like
observers. Such fine limits are well below the angular others, they found that this test showed no alteration
subtense of a single foveal cone (about 20 seconds) and in performance with the observer’s age over the range
much smaller than the limit of resolution for parallel 20 to over 70 years, while there was little difference
lines. whether the stimuli were sharp or degraded.
Because of diffraction and aberrations, the retinal Even if one of the outer dots is removed, the eye is still
image of a line has somewhat blurred borders. As a able to detect a small lateral offset between two verti-
result, the transition from a low to a relatively high cally separated dots, but the threshold is increased to
20 seconds of arc. The term hyperacuity has been
given by Westheimer (1976) to the eyes’ ability to per-
Retinal
form sensitive tasks of this kind. Hyperacuity tests may
illuminance
also be used to assess retinal function in patients with
cataract (see also page 45), since they are relatively in-
sensitive to blur. A description of some of these hyper-
acuities is given in McKee et al. (1990) and in the refer-
ences for the section relating to cataract.

Vision and visual acuity in

clinical practice
(a) (b)
Introduction
Figure 3.11. (a) Lateral displacement in a line object.
(b) Superimposed graphs of retinal illuminance of one side of In the previous sections, the resolution of the eye has
the retinal image of the two parts of the line. been considered in relation to a pair of point sources,
 Vision and visual acuity in clinical practice bo N

line gratings and Landolt rings. These make useful test

objects for scientific study, but, with the exception of
the Landolt rings, are not satisfactory for clinical work.
Point sources and gratings do not represent the type of
detail that a patient normally views. It is useful to
employ, as test objects, characters with which the
patient is familiar. If symbols of varying size are used, Figure 3.12. Constant angular subtense requires increasing
smaller characters will be seen by people with better size in proportion to distance.
vision, while patients with poor sight will need larger
characters.
The characters most frequently chosen have been ca- chart projectors. In this case, a 6m viewing distance
pital letters, but numbers and other symbols have been may require a 6 m projection distance, the projector illu-
used. Some of the charts with symbols other than letters minating the screen after reflection in a mirror.
will be discussed on page 33. Test charts for literate adults usually present stylized
Letter charts require both recognition of the symbol capital letters designed to fit a grid of unit squares. One
and resolution of the detail within the letter itself, of the first of such charts was introduced by Snellen in
although studies by Coates (1935) and others show 1862. Although different letter designs and symbols
that the overall letter shape is also very important in have since been introduced, charts of letters are often
identification. Thus, instead of the term limit of resolu- called Snellen charts. The term ‘letter chart’ is also com-
tion, clinicians use two other terms as follows: monly used. Snellen’s own term ‘optotypes’ is now used
less frequently, especially in the English-speaking
(1) Visual acuity. This is determined from the size of the world, but has persisted sufficiently elsewhere to be
smallest line of letters or symbols in the test chart adopted by the International Organization for Standar-
that can be read by the patient after any defects of dization (ISO).
focusing, other than aberrations, have been cor- Consider a rectangular letter such as a capital E
rected. (Figure 3.12). It was assumed by Snellen that this letter
(2) Unaided vision (often shortened to Vision). This is could just be seen by the average corrected eye if the
determined from the size of the smallest line of let- thickness of the limbs and of the spaces between them
ters or symbols in the test chart that can be read by each subtended 1] minute of arc at the eye. The angular
the patient with the naked eye. subtense of such a letter would therefore be 5 minutes
vertically and 4-6 minutes horizontally, depending on
On pages 19-26, we have assumed that the eye was
the style of type and the particular letter of the alphabet.
properly focused, the discussion relating to visual
As shown in Figure 3.13, a conventional test chart
acuity rather than vision. Both vision and visual acuity
contains about 10 lines of letters in a progression of
may be taken for the right and left eyes individually
sizes, each designated by the distance at which the over-
and also binocularly. Except in patients where the co-
all height of the letter subtends 5 minutes, the detail
ordinated use of the two eyes is poor, vision and visual
size or limb width then subtending 1 minute of arc.
acuity are usually slightly better when determined bino-
Thus, the overall height of a 6 m letter subtends 5 min-
cularly.
utes at 6m. Its height should be 8.73 mm, which is the
tangent of 5 minutes multiplied by 6000. A 12 m letter
subtends 5 minutes at 12m or 10 minutes at 6m, so
Distance test charts and acuity its height is twice that of a 6 m letter and so on.
Visual acuity can be measured in several different
In tests of distance vision, the testing distance should be
ways and various different notations for recording it
large enough not to stimulate accommodation. The ac-
have been suggested from time to time. The basis of the
cepted value in Britain and many other countries is
generally accepted method is shown in Figure 3.14 in
6m, but 5 m is commonly used in some European coun-
which h is the overall height of the test letter and y the
tries. In the USA the standard distance is 20 ft, a little
width of a single limb. Let d be the standard testing dis-
over 6m. There is, however, a move in that country to
tance, D the distance at which the limb width subtends
institute a reduced testing distance of 4m, compen-
an arbitrary angle A, and A the angular subtense at
sating for it by adding —0.25 D to the refractive findings.
the standard testing distance of the limb width of the
Other associated proposals are outlined in a later section
smallest letters that can be read.
on the logMAR system (see pages 30-31).
The visual acuity V, or ‘visus’ as Snellen called it, can
If the consulting room is not long enough, the usual
then be expressed as the ratio A,/A. That is
solution is to use a ‘reverse’ or ‘indirect’ test chart
mounted over or to the side of the patient’s head, in con-
Bo UP
junction with a mirror at 3m. The mirror must be of
A y/d
good quality and large enough for the patient to see the
whole of the chart and some of its surround without = d/D (3.7)
moving the head.
Test charts mounted on cards need to be externally il- This ratio is known as ‘Snellen’s fraction’ and is the
luminated. They have generally been superseded by in- notation most widely used in ophthalmic practice for re-
ternally illuminated test cabinets in which the charts cording vision and visual acuity. It is written, for exam-
are printed on translucent sheet material, or by test ple, as 6/18, 20/60.
28 Visual acuity and contrast sensitivity

e Clement Clarke international Ltd by

i ie)

y haa ==

sl

PN
Figure 3.14. Derivation of the Snellen fraction d/D.

Because of the variation in legibility of different letters

it is unlikely that most patients will be able to read all
the letters on one line and none on the next smaller
line. They are more likely to be able to read most of the
letters on one line and just one or two on the next. This
is recorded as in the example 6/12 + 3, denoting that
the patient could read the whole of the 12m line and
three letters of the next line. Similarly, if all but two let-

DZU->
ters are read on the 6 m line, the vision is 6/6 — 2.
If, for some reason, a test chart is not used at the stan-
dard distance, the actual distance should be given as
the numerator of the Snellen fraction.
The Snellen fraction may also be expressed as a deci-
mal: thus, 6/12 is equivalent to 0.5, 20/80 to 0.25 and

Pe VE
so on. This method of recording acuity, used in a few
countries, has been called decimal V notation. For
many purposes it is useful to be able to express the
acuity in this way, but from the clinical standpoint the
disappearance of the testing distance is a disadvantage.
Since a 6 m letter subtends 5 minutes at the standard

ZHN UD » testing distance of 6m, the size h’ of its retinal image

in an eye of power +60 D is given by equation (2.17) as

h’ = —u/F, = —0.001454/60 (m)

CEOS A) 0Fy Eo = —0.024 mm

thus extending over about 12 cones. It is not surprising,

PREUHODNZ & therefore, that acuities better than 6/6 — commonly re-
garded as a satisfactory standard — are enjoyed by
many people, especially in good illumination.
UV DH EN F P 5

RUZPNHODF 4 Variation in letter styles and legibility

One of the main distinctions between the different letter
EON 2ZFHPU 3
styles used in test charts is that between serif and non-
Figure 3.13. A complete Snellen letter chart for use at 6 m, serif letters. The term ‘serif’ denotes an ornamental
to the full specification of British Standard BS 4274: 1968. cross-stroke at the end of a limb (Figure 3.15). Although
Additional figures in larger type have been inserted in the right-
serif letters were employed by Snellen and are still in
hand margin to assist identification of the letter sizes.
(Reproduced at about 40% of actual size by courtesy of Clement use, they are giving way to non-serif letters. The latter
Clarke International Ltd.)

The relationship V = A,/A is in line with the general

expression V=k/A, derived previously in equation
(3.4). Following Snellen, the letter sizes on test charts
are based on the arbitrary value of 1 minute for the
angle A,. With this substitution, Snellen’s fraction in
decimal notation becomes equivalent to

Figure 3.15. Letter styles: (a) 5 x 5 serif E, (b) 5 x 5 non-serif

V 1/A (where A is in minutes of arc) (3.8)
E, (c) 5 x 4 non-serif E.
 Vision and visual acuity in clinical practice 29

are more in keeping with bold typefaces of modern Later, the numerals 0, 1, 4 and 7 were used in a stylized
design and appear less cluttered as well as being gener- form for the left-hand half of the ‘International Chart’
ally easier to read than serif letters. adopted by the Eleventh International Congress of
It can be seen from Figure 3.15 that non-serif letters Ophthalmology in 1909. The right-hand half of each
appear better proportioned on a 5 x 4 grid than on a row consisted of Landolt rings, but as the selected nu-
5x5 grid. On a 5 x 5 grid, the letter 0 would have a merals had been found more legible than Landolt rings
line width of one unit, the central space being 3 units of the same size, the dimensions of the numerals were
in diameter. The same letter on a 5 x 4 grid would have made 20% smaller than Landolt rings for the same
a central space of 2 units, which is still greater than acuity grading. Test charts of numerals may be useful
the spaces in a letter E. Because of this variation in the in examining illiterates, most of whom can at least read
structure of different letters, even if all designed to fit figures.
the same grid, their legibility varies. The letters L, T
and U, for example, are easier to read than B or G,
while letters which are similar in shape tend to be con-
Progression of sizes
fused, such asCDGOQandHKMNW.
Many detailed studies of relative legibility have been This is another controversial question. Snellen’s original
made. Hartridge and Owen (1922), using letters of test chart was designed for use at 20 Paris feet (approxi-
5 x4 proportions and probably of non-serif design, mately 6.5 m), the range of sizes being 20, 30, 40, 50,
ranked them in order of increasing difficulty as follows: 70, 100 and 200 ft. The metric equivalent of this pro-
gression is 6, 9, 12; 15, 215 30) and 601m, This range
INN JPNEs | ONS DS12 1874UPD) YVKCBORS
may have been selected intuitively but it is fairly close
selection
to a regular geometrical progression, a mathematical
recommended
series in which each number bears a constant ratio to
A later study by Coates (1935) determined legibility the previous one. To start at any number and end with
scores for 104 different letters copied from four test a tenfold increase in 6 steps requires this ratio to be
charts with letters of different styles or formats. The V10 or 1.468.
tests were conducted in sunlight by four young male ob- There is a strong consensus of opinion in favour of a
servers with good acuity, the score being based on the geometrical progression of letter sizes, but several differ-
greatest distance at which each letter could be recog- ent views as to the best ratio to adopt. Two, in particu-
nized. The figures were then adjusted so as to make the lar, have found some distinguished advocates. One is
overall mean equal to unity. In the 5 x 4 non-serif the square root of 2 (1.414) which would result in an
style, the letters E, Z, F, H, P, N, D, V and R (in decreas- exact doubling of the size at every second line. Unfortu-
ing order of legibility) had scores within the range 1.1] nately, it would not produce a close approximation to a
to 0.9. The easiest letter was L (1.39) and the hardest B 200 ft or 60 m line, both enshrined in many legal enact-
(O67): ments and regulations. The other is the cube root of 2
The selection of letters for test charts has been the (1.260) which would double the size at every third line
subject of much debate. On one hand it is argued that and produce a size close enough to 200 ft or 60 m. The
all the letters used should be of similar legibility, the main objection to this progression is that the intervals
ideal being that the subject should be able to read all or are held to be a little too small for normal clinical use.
none of the letters on any line. On the other hand, it In the British Standard already mentioned, the range
has been contended that the test becomes more reliable of sizes is 3, 4, 5, 6, 9, 12, 18, 24, 36 and 60m. The
if every line contains one of the more difficult letters or omission of a 7.5m line, included in some earlier
a pair of letters easily confused such as C G, F P, HN. charts, was regretted by some practitioners who felt
In fact, the letters F, P, H and N were found in both the that the jump from 6/6 to 6/9 was too great for useful
investigations just summarized to belong to the group clinical distinctions to be made.
of medium legibility. Monoyer, who introduced the 5 x 4 non-serif letter
Grimm et al. (1994), using letters from the Linea- style together with the decimal V notation, was also
Antiqua typeface which have widths 4.5—5.5 times the the originator of an entirely different progression of
limb width, and height 7 times the limb width, selected sizes, ranging from V = |] to V = 0.1 at intervals of 0.1.
C, D, E, K, N, P, U and Z because they presented similar This system still has its adherents but it is not a geomet-
difficulty. This typeface was selected for familiarity, rical progression. Starting from the equivalent of a 6m
being used on road signs in Germany. line, it takes another four lines to arrive at the equiva-
The 1968 version of British Standard BS 4274, en- lent of a 10m line (V = 0.6), yet there is nothing to
titled ‘Test charts for clinically determining distance bridge the gap between 6/30 and 6/60.
visual acuity’, stipulated that letters shall be of 5 x 4 Test charts for ordinary use are inadequate for asses-
non-serif construction, the selection being limited to D, sing the vision of patients with low visual acuity (LVA).
E, F, H, N, P, R, U, Vand Z, which are all of similar leg- To fill this need, Keeler (1956) introduced the A series
ibility. In general, this 5 x 4 format is more difficult to of 20 types sizes ranging from Al (equal to 6/6) to A20
read than 5 x 5, especially in the presence of an uncor- (approximately 6/420 or V = 0.014). This series forms
rected focusing error or poor vision. a strict geometrical progression with a constant ratio of
In addition to or instead of letters, numerals can be .25, very close to o2. The Snellen equivalents just
used in test charts. The last three lines of Snellen’s first quoted are based on the specified viewing distance of
published test chart each ended with a single numeral. Ds) (eho
30 + Visual acuity and contrast sensitivity

Table 3.2. The log MAR scale, corresponding minimum angles

of resolution, and equivalent decimal V and Snellen distance
acuities
See
ee
log MAR Angular size Corresponding distance acuities
steps of detail
(min of arc) Decimal V atom at 20 ft

Ihae3s 20.0 0.050 6/120 20/400

Lo 15.8 0.063 6/95 20/320
1.1 12.6 0.079 6/75 20/250
1.0 10.0 0.100 6/60 20/200

0.9 hoe) 0.126 6/48 20/160

0.8 (6353) 0.158 6/38 20/125
OM 5.0 0.200 6/30 20/100

0.6 4.0 Ooi 6/24 20/80

0.5 ayn IES) 0.316 6/19 20/63
0.4 Ds) 0.398 6/15 20/50

0.3 2.0 0.501 6/12 20/40

0.2 1.6 0.631 6/9.5 20/32
0.1 jas) 0.794 6/75 20/25

O 1.0 1.000 6/6 20/20

Figure 3.16. A Bailey—Lovie letter chart for distance vision
(about 1/10th actual size). (Reproduced from Edwards and —0.1 0.79 WeArSye 6/4.75 20/16
Llewellyn’s Optometry.) —(0.2 0.63 1.585 6/3.75 ZO LS.
—0.3 0.50 W995 6/3 20/10

The logMAR scale: Bailey—Lovie and

Ferris charts starts. This is seen from Table 3.2 to apply almost exactly
In his review of the principles and problems of test chart to the logMAR progression.
design, Bennett (1965) pointed out that in addition to Certain other features of the Bailey—Lovie chart may
other suggested geometrical, progressions of letter sizes, be noted. The letters selected, of 5 x 4 non-serif format,
a constant ratio of '\/10 or 1.2589 had been advocated are the 10 specified in the British Standard BS 4724 on
by Blaskovics (1923, 1924) and Kettesy (1948). In the grounds of similar legibility. There are 5 letters on
1976, this progression was chosen by the Australian op- every line, even the biggest. To equalize the possible ef-
tometrists Bailey and Lovie to express visual acuity in fects of the crowding phenomenon (see page 43), the
terms of the logarithm of the angular limb width (in inter-letter spacing on each line is equal to the letter
minutes of arc) of the smallest letters recognized at 6 m. width, and the inter-row spacing equal to the letter
This notation was termed logMAR, ‘MAR’ standing for height of the lower row.
minimum angle of resolution. Thus, the 6m line with For use in the USA, the Bailey—Lovie chart has been
its limb subtense of 1 minute of arc is denoted by modified by Ferris et al. (1982) to comply with the stipu-
logMAR O and the 60 m line of limb subtense 10 min- lations of the Committee on Vision of the National
utes of arc by logMAR 1. The progression of sizes is in Academy of Sciences — National Research Council. Ac-
0.1 logMAR intervals. In the Bailey—Lovie test charts cordingly, the 10 letters used, C, D, H, K, N, O, R, S, V
(Figure 3.16), it extends downwards from logMAR 1 to and Z, are those recommended by Sloan et al. (1952).
logMAR O, continuing with three lines of smaller size They are of 5 x 5 non-serif format, of similar legibility,
having negative logMAR values (—0.1, —O.2, and and also comparable in legibility to Landolt rings of the
—().3) because the angular subtense is less than 1] same size. Also, the letter dimensions are scaled down
minute of arc. to suit the 4m testing distance laid down by the Com-
The logMAR number, denoted here by L,, can be con- mittee.
verted into Snellen acuity by means of equation (3.8). Used in conjunction with a suitable scoring system,
Since V = 1/A in which A is the angular limb width in the logMAR charts are demonstrably better suited for re-
minutes of arc, it follows that search and statistical analysis than the conventional
letter charts used in refraction. Their large size — the
decimal V = 1/antilog L,, (eso)
Bailey—Lovie chart measures approximately 75 cm high
Table 3.2 gives a comprehensive range of logMAR by 80cm wide — would present problems in clinical
sizes, together with the corresponding angular ‘limb practice. Suitable methods of illumination have been de-
widths, decimal V acuity, and the equivalent Snellen scribed by Ferris and Sperduto (1982).
acuities for testing distances of 6 m and 20 ft. The current draft for revision of BS 4274 Part 1 en-
It so happens that the logMAR progression is virtually titled ‘Specification for test charts for clinical deter-
indistinguishable from the Siro basis advocated by mination of distance visual acuity’ proposes the Bailey—
Green (1868) and others. This gives a constant ratio of Lovie layout from the 12 m size downwards, the typical
1.2599. A feature of this progression is that the letter dimensions of consulting room charts necessitating
size doubles at every third line, from whatever line one fewer letters for the larger lines. The letter selection sug-
 Vision and visual acuity in clinical practice 31

gested is°C; DE FF, H, K, By Ry Uy Vand Zin asx 5 Comparison of acuity notations

format.
As logMAR values decrease with letter size, becoming Figure 3.17 shows the relationship between the various
negative in sign, scoring systems can be complicated, progressions and notations. A horizontal line placed
though not unduly so. The first to be published was
across the chart gives equivalent values on all the dis-
tance acuity scales. Reading test type acuity can be con-
that of Kitchin and Bailey (1981), but several alterna-
verted into a Snellen distance value only on the basis of
tive systems have since been devised. Of these, the sim-
the stated viewing distance. For practical purposes,
plest is to score 0.02 of a logMAR unit for every letter
35cm and 14 in can be regarded as identical.
correctly identified, beginning with the logMAR 1
(6/60 or 20/200) line. Thus, if every letter on each of
the fourteen lines of the Bailey—Lovie or Ferris chart
were correctly read, the score would be 1.40. The nega-
tive values for good acuities can be avoided by subtract- Notations for poor vision
ing the logMAR acuity from 1. In this case, 6/6 If even the largest letter on the test chart cannot be read
(logMAR 0) becomes 1, 6/60 becomes 0, and 6/3.75 or at the normal distance, a measurement of the vision
logMAR —O.2 becomes 1.2. can possibly be made by walking the patient towards
When the vision is poor, the testing distance can be the chart until the largest letter is just recognized. If
decreased. By halving it, another three lines of the this occurs at 2m, for example, the vision is recorded
chart should become legible, and halving it again as 2/60. A separate test card can be moved towards the
should make a further three linés legible. In practice, patient if he is not readily mobile. The Bailey—Lovie
the simplest method would be to choose a reduced dis- chart with its five letters on each line, even for the
tance equal to one-tenth of the denominator D of one of large sizes, lends itself to assessment of poor vision.
the Snellen fractions on the chart, for example, testing Where vision is, say, worse than 0.5/60, an alterna-
at 2.4m. Table 3.2 shows the logMAR equivalent of tive method is to ask the patient to count the number of
6/24 to be 0.6. Since this is equivalent to logMAR 1.0 fingers held up at some specified near distance, say
at the reduced distance of 2.4 m, 0.4 should be added 25cm. This would be recorded as ‘CF at 25 cm’. If the
to the logMAR size read. For example, if the 15 m line vision merely permits the patient to be aware of a hand
is then read, the apparent score of 0.4 becomes 0.8. moved near the eye, it would be recorded as ‘hand

Snellen Decimal Angular Snellen

Distance VA Vv detail Bailey-Lovie Distance VA
Feet Metres size logMAR Feet Metres
20/10 6/3 2-05 20/10 +-—0.3-- 6/3 20/10 — 6/3
Keeler
6/4 20/12.5 +—0.2+ 6/3.8 mete aiaie 6/4
20/15 4— 6/4.5 20/16 +—0.1+-6/4.8 at 25cm Neer toe ace
6/5
20/20 6/6 es ES 20/20 0+ 6/6 Ai Yaeger
at
Roman
at
99/20 + 6/6
20/25 6/7.5 20/25 0.1+ 6/7.5 A 2 ae 35 cm 20/25 6/7.5
20/30 6/9 20/32 0.2+6/9.5 es 4 20/30 6/9

20/40 6/12 0.5 2 20/40 + 0.3+ 6/12 A 4 we12 Nalee 5 20/40 +— 6/12
20/50 0.4 20/50 + 0.4+ 6/15 A5 20/50
20/60 +— 6/18 20/63 + 0.5-+6/19 A6 +S -Ne8 20/60——6/18
20/70 0.3 J8 N10 20/70
20/80 — 6/24 4 20/80 + 0.6-+ 6/24 aes opmegy (sl gor en 10s tI20
20/100 ++— 6/30 0.2 20/100 + 0.7-+ 6/30 I OS ROE
20/120 6/36 Nee 6 20/125 + 08-+ 6/38 AQ Nig 20/120-+- 6/36
Aha 8 20/160 + 0.9-+ 6/48 pl Oyent ls 20/150
All N24
20/200 6/60 0.10 + 10 20/200-- 1.0 6/60 3 20/200 -— 6/60
Al
0.08 A13 N36
0.06 ree nae
20/400 3/60 20 mie 20/400 +— 3/60
0.04 ae
20/600 2/60 30 oe 20/600 2/60

ne A18
0.02 50 ie :
20/1200 1/60 60 we /1200 + 1/60

Figure 3.17. Relationship between different acuity scales.

 32 Visual acuity and contrast sensitivity

movements’ (HM). An even lower category of vision is The checkerboard test

the mere perception of light (PL).
A checkerboard pattern of black and white squares
makes a convenient test of resolution. It is used in some
vision screening instruments, where the test objects
Repeatability of measurement take the form of a diamond divided into four smaller dia-
monds. Three of these are grey or appear grey under
One might expect that the ability to read a few more or
the test conditions, while the fourth is a checkerboard.
fewer letters on the chart would indicate a definite im-
Below resolution, this too appears a neutral grey ahd is
provement or deterioration in vision. Using Bailey—
indistinguishable from the rest of the diamond. In a
Lovie charts, both Lovie-Kitchin (1988, 1989) and
similar test object, the checkerboard is replaced by an
Reeves et al. (1993) found similar mean differences of
array of black circles on a white ground.
about 0.03 £0.09 logMAR for the test-retest visual ac-
Calibration of test objects of this kind in terms of Snel-
uities. Adopting the criterion of a difference of at least
len acuity needs to be determined experimentally.
two standard deviations before a change can be as-
sumed to be statistically significant, an acuity of 6/4.8
would have to drop to around 6/7.5 to be meaningful.
Children’s tests
Thus the impression of an improvement in visual
acuity following an eye examination perhaps should be The illiterate E test
verified by allowing the patient to compare the original
spectacles with the new results.
This test, for which we are again indebted to Snellen,
Brown and Yap (1995), also using Bailey—Lovie uses only the letter E in the normal range of sizes,
charts, compared the visual acuities of the right and drawn on a 5 x 5 grid. The open side, which has to be
left eyes of 72 subjects, finding the standard deviation identified, is presented in the same four settings as the
of the difference to be 0.050 logMAR, or half a line. Landolt ring.
They concluded that a difference in acuity of more than The test is particularly useful for children, who can be
5 letters on such a chart indicated that further investi- given a cut-out letter to hold in the same direction as
gation was needed. the letter on the chart. If confused by a whole line of let-
ters or symbols, some children respond better if shown
only one at a time, especially if it is viewed directly and
not in a mirror. From this point of view, a cube with a
Other clinical tests of visual acuity letter E of a different size on each face is better than a
test chart.
Whenever an acuity is measured by means of a chart or Coates found the illiterate E test to have a legibility as
method not in normal routine use, or with single high as 1.38 in comparison with the mean figure for
letters,” or at a non-standard distance, it is advisable to test letters. A relative legibility score is not available for
enter particulars in the patient's records. the Sjogren hand test which embodies a similar idea.

The Landolt ring (or C) The Sheridan-—Gardiner test

The Landolt ring can be described as a letter Con a5 x 5 This is also useful for children. The examiner has a book
grid, the parallel-sided gap having a width of one grid with a conventional range of Snellen letter sizes with
unit. In clinical practice, this gap is presented in one of one letter on each page. The child is given a reference
four positions: up, down, right, or left. The patient card showing the selection of letters used and has to
merely has to indicate which one it is. Originally, four match the letter shown with one on the reference card
oblique presentations were also included, but are not in (Sheridan, 1970).
general use.
Because it does not demand literacy and avoids the
The Cambridge Crowding Cards
difficulties of unsuitable alphabets, the Landolt ring has
come into widespread use and is the basis for the inter- These cards, providing a test on similar lines to the Sher-
nationally standardized test of visual acuity — see page idan—Gardiner system, were devised at the Visual Devel-
35. Nevertheless, it does have a few minor drawbacks opment Unit of Cambridge University. The main
of its own. If uncorrected astigmatism is present, recog- difference is that the letter to be identified on each card,
nition of the gap is easier in some settings than in at a distance of 3 m, is surrounded by four other letters
others. It is less easy to keep in step with the patient’s re- so that the possible effects of the crowding phenomenon
sponses, especially if he returns without warning to the (see page 43) can be brought into play.
beginning of the line to start again. When uncertain of
the true position of the gap, some patients have been
found to show a guessing bias, often choosing the set-
LogMAR crowded test
ting to the right. Any guess has a one in four or eight These cards,+ originally termed the Glasgow Acuity
chance of being correct. Cards, are bound in a spiral top book for use at 3m.

+ Obtainable from Keeler Ltd, Clewer Hill Road. Windsor,

' Often easier to read than a row of letters (see page 43). Berks SL4 4AA.
 Other clinical tests of visual acuity 33

and present letter sizes in the Bailey—Lovie logMAR pro- Script letters
gression from the 19m to the 1.5m size, i.e. 6/38 to
6/3 equivalent. There are four letters in a line on each Young schoolchildren are more familiar with script or
card, and to ensure identification of crowding difficul- lower case letters than with block capitals. Test charts
ties, the letter spacing is half the letter width, while a of such letters are available.
border is added at a similar distance above and at the
ends of the line. To reduce fatigue or boredom, three Pictorial charts
screening cards showing four letters each of succes-
sively smaller size enable the starting point for measure- These show pictures with which the child is familiar, the
ment to be determined. It is claimed that a maximum of assumption being that they can be recognized if large
three uniformly sized cards needs to be shown to meas- enough. These charts are difficult to quantify and confu-
ure acuity. The reversible letters H, O, U, V, X and Y sion may be caused to the child if two objects of greatly
are used to avoid potential problems with left-right different size, for example, a cat and a car, appear on
orientation. the same line. Tests drawn on Snellen principles are the
The test is described by McGraw and Winn (1993, Allen (1957) and Kay (1983) pictures. Mayer and
1995) in articles providing many useful references. Gross (1990) added eight crowding bars in an octagonal
formation around four of the Allen pictures, and demon-
strated about 0.24 logMAR drop in acuity between the
Stycar tests simple and crowded picture acuities for amblyopic eyes.

Dr Mary Sheridan was also the originator of two tests

known as ‘Stycar’, formed from the initial letters of The Sonksen Picture Guide to Visual
Sheridan Tests for Young Children and Retardates. One Function (SPGVF)
of them, the graded-balls vision test (Sheridan, 1973),
A different approach introduced by Sonksen in 1983 is
is a development of Worth’s ivory-ball test introduced
to employ specified pictures from the Ladybird series of
in 1903. A set of balls is used, ranging in diameter
children’s books. Sonksen and Macrae (1987) calibrated
from 61 to 3 mm. They are rolled across the floor 3 m
these for difficulty in terms of their recognition distance,
in front of the infant, whose response is observed. If the
as determined by children from a primary school who
ball is seen, the child will follow its movement with his
had been given artificially induced refractive errors.
eyes and may even crawl to retrieve it. A ‘static’ varia-
The pictures are generally shown at 3m, but if a child
tion of the test is to use a screen so that any ball from
needs a shorter distance to recognize them, poor vision
the set can be exposed to view and then hidden again.
is indicated. The test is suitable for children from about
It can be argued that this is a visual field or an aware-
21 months. For screening purposes, the six most difficult
ness test rather than an examination of acuity.
pictures from their series were recommended.
The other Stycar test uses test charts of the conven-
tional type, but no line has more than three letters, se-
lectedsinomeAn Gyre Oo Uh \VeandexXe these letters The Cardiff Acuity Test
were chosen because they can be easily copied by
The Cardiff Acuity Test,” described by Woodhouse et al.
young children (Sheridan, 1963). One chart makes use
(1992) and Adoh et al. (1992), is a preferential looking
of only five different letters, another only seven and a
test — see page 38. While these authors recoinmend the
third all nine. A three-year-old child can cope with the
conventional grating preferential looking test for in-
five-letter chart, and a four-year old with the seven- or
fants, the Cardiff test has been developed for the toddler
even nine-letter chart. As with the Sheridan—Gardiner
age group of about 1-23 years. Pictures of a fish, car,
test, the child is given a key card with the appropriate
train, house, boat or duck, selected from Kay’s (1983)
choice of letter. Whereas the Sheridan—Gardiner test de-
work, are used to help keep the child’s attention.
pends on the recognition of isolated letters or symbols,
The picture is positioned at the top or bottom of a grey
the result obtained with this Stycar test is closer to con-
card. The outline of the figure is drawn with a white
ventional Snellen acuity.
line bordered by two black lines of half the width, so
that the overall reflectance matches that of the grey
card. All the pictures are the same size, so that the
Ffooks’s test
acuity test is the perception of the white line; below re-
The illiterate E has been criticized as a test for children solution, the picture merges into the card. The cards
because recognition of orientation is a visual task pre- are presented at the child’s eye level at 1 m, or 50 cm if
senting difficulties to them. Vertical settings of the E a better response is obtained or for poorer acuities,
tend to be correctly indicated more often than hori- while the practitioner observes the child’s direction of
zontal. - gaze from the side of the card.
The test introduced by Ffooks (1965) uses three sym- Three cards are available for each acuity level, 6/60
bols free from directional bias: a square, a circle and an to 6/6 equivalent in 0.1 log steps if employed at 1 m. If
equilateral triangle. The presentation is by means of a the toddler's response is correct for the first two cards
book with two to four symbols on each page or by a
cube with a single symbol on each face. Cut-out symbols
are given to the child. The similar KOLT test, described " Obtainable from Keeler Ltd, Clewer Hill Road, Windsor,
in Grimm et al. (1994), also includes a + symbol. Berks SL4 4AA.
 34 Visual acuity and contrast sensitivity

of any size, those of the next smaller acuity level are showed that the luminance (L) can be estimated with a
tried. If a wrong estimate of picture position is made, or photographic exposure meter or camera metering
no definite fixation is observed, then the previous set of system. With the meter set for a given ASA film speed
cards is again presented using all three cards. The end- rating, the F/no. and exposure (t in seconds) for correct
point is where two of the three cards are consistently exposure are noted. The luminance is then found from
seen correctly. the formula
Geer and Westall (1996) evaluated these cards, to find
13.1 x (F/no.)?
that they were not as good at identifying mild amblyopia Luminance = 5 - cd/m?
exposure (s) x ASA setting +
as a letter chart, presumably because of the lack of
crowding. They found them useful for holding the atten- (3.10)
tion of the toddler age group. They also evaluated tests In this equation, for example, F/4 should be entered
based on the VECR (see page 39). Although these per- as 4. 120 cd/m? is approximately 1/60 s at F/4 for 100
formed better and would be suitable for this age group, ASA speed rating. For externally illuminated charts,
they are too expensive for routine use. the luminance is estimated as above after covering the
chart with a piece of white blotting paper, which acts
Computer presentation of subjective charts as an inexpensive but highly diffusive surface of reflec-
tance p about O.8. The blotting paper must cover the
Some test chart cabinets and projector charts can pro- whole field of the exposure meter. If light of illuminance
vide only a limited range of letter charts, perhaps only E lux falls on a unit area of reflectance p, the flux
one selection of letters of each size. Test charts on re-radiated by that area will be pE lux. Then, if the ap-
visual display units can be provided by the Medmont parent luminance of the surface is L and it acts as a per-
AT20 and the Mentor B-VAT, while Lenne et al. (1995) fect diffuser, the total flux radiated into a surrounding
describe software for measuring visual acuity for re- hemisphere from unit area of the surface is mL lux.
search puposes. Hence,
The UMIST Eye System® can provide a large range of
pl —th
letter charts, with Bailey—Lovie 5 x4 letters, Sloan
5 x 5 letters, Stycar letters, lower-case letters and sym- and
bols. The letters for any line on a particular chart are
18, = qlby/oy Ihbbx (alas)
chosen at random from the selection, so that memoriza-
tion is not possible. These can all be provided at different To avoid glare, the test chart surroundings should be
contrasts. The software can also provide many other illuminated to a similar level. Also, general room light-
charts for refraction, as well as colour vision and field ing should be left on. The patient’s pupil size will then
screening. approximate to that in his normal surroundings; few
In the USA, the TVA system* can provide many simi- patients need a correction specifically for use in low illu-
lar tests. mination. Visual acuity is adversely affected by poor
contrast as well as by poor illumination. If L; denotes
the luminance of the white background of a test chart
and L, the luminance of the black letters, the luminance
Illumination and luminance contrast
contrast is defined as (L, — L3)/L,.
of test charts This fraction is often expressed as a percentage. The
British Standard BS 4274 stipulates a minimum of 0.9
The effects of pupil size and illumination on visual or 90% for all types of test charts. Experience has
acuity were discussed on pages 24-25. It is essential shown that to attain this figure a really dense black of
that test charts should be adequately illuminated at a very low transmittance or reflectance is required. In
level where acuity does not alter greatly with change in general, test chart projectors are unable to reach a 90%
illumination. The 1968 edition of British Standard BS contrast unless the room is made very dark, which is
4274 specified the following levels: undesirable for the reason already mentioned. At least
(1) Externally illuminated charts one manufacturer, however, has succeeded in meeting
Minimum illuminance 480 lux the British Standard while ordinary room lighting is in
For new equipment 600 lux use. The aluminized projection screens required for
(2) Internally illuminated charts tests requiring polarized illumination may, however,
Minimum luminance 120 cd/m? give reduced contrast with good room lighting. VDU dis-
For new equipment 150 cd/m? plays, described above, may also have slightly lower lu-
minance than the original BS recommended levels.
The current draft British Standard adopts the lumi- The variation in grating acuity with luminance con-
nance range of the ISO standard discussed below, trast has been studied by (among others) Shlaer (1937)
namely 80 cd/m? to 320 cd/m. and Arnulf (quoted by Fabry, 1936). In good illumina-
For internally illuminated charts, Smith (1982b) tion they found that there was relatively little change
in the minimum angle of resolution, and hence in
acuity, when the luminance contrast was reduced to
‘ Available from Department of Optometry and Vision 20%. Clinical experience suggests, however, that these
Sciences, UMIST, PO Box 88, Manchester M60 10D and findings would not apply to patients with cloudy ocular
Innomed Corporation, Brea, CA 92621, USA respectively. media or opacities. Poor contrast appears to reduce
 Near visual acuity: reading-test types 35

their acuity much more than in the normal patient with 1/72 of an inch. This dimension refers to the ‘body’ on
clear media — see page 43. which the letter is raised or mounted. Since lower case
letters vary in height, their actual size is best indicated
by the ‘x-height’, that is to say, the height of letters
The new ISO standards such as e, m and x which have the same vertical dimen-
sion, unlike other letters with ascenders or descenders.
Two international standards relating to distance test Unfortunately, typefaces of the same point size but ofdif-
charts were initially published as ISO standards in ferent designs may not have the same x-height, which
1994, and as British and European standards in 1996: can be found only by measurement.
If the x-height of a particular typeface is known, its
BS EN ISO 8596: 1996 BS 4274: Part 2: 1996 Visual angular subtense (in minutes of arc) at a given working
acuity test types — Specification for Landolt ring opto- distance can easily be determined, from which an ap-
type for non-clinical purposes proximation to the corresponding Snellen acuity can be
made. For example, given an x-height of 1.5 mm (typical
BS EN ISO 8597: 1996 BS 4274: Part 3: 1996 Visual
for an 8-point type size) and a reading distance of
acuity test types — Method for correlating optotypes
35cm, the angular subtense is 14.7 minutes, corre-
used for non-clinical purposes.
sponding to a Snellen acuity of very nearly 6/18. This
is the basis on which the scales in Figure 3.17 represent-
The purpose ofthe first of these is to provide a basis for
ing two different reading-test types in current use were
an internationally valid certification of visual acuity to
constructed.
meet official or legal requirements. Understandably, the
The earliest reading types to attain widespread popu-
chosen test characters are Landolt rings, in the logMAR
larity were introduced by Jaeger in 1854 and have still
progression to which three sizes larger than 1.0 (6/60)
survived. They present short passages of continuous
have been added, namely, 1.1, 1.2 and 1.3 logMAR.
reading matter in a range of available print sizes which
As it was not found possible to agree on one standard
are simply numbered for reference with the prefix J, the
testing distance, a minimum of 4m is stipulated, and
smallest size being J1. It can be seen from Figure 3.17
the actual testing distance is always to be recorded.
that Jl (at 35 cm) is roughly the equivalent of 6/9 or
Also, because of the wide diversity of opinion, the per-
20/30. In Britain, the reading types in general current
missible range of test chart luminance is from 80 to
use conform to the recommendations of the Faculty of
320 cd/m?. Other lighting requirements are specified in
Ophthalmologists (Law, 1952). The typeface selected,
detail.
known as Times New Roman, was designed for The
Because many different alphabets and other test char-
Times newspaper but subsequently came into more gen-
acters are in use throughout the world, ISO 8596 is not
eral use. The various sizes are distinguished by a
intended for use in routine ophthalmic practice. Never-
number indicating the point size, prefixed by the letter
theless, it may be desirable to correlate national stan-
N. Thus, N6 denotes the 6-point type size. From the
dard test charts to ISO 8596 by experiment. ISO 8597
scale in Figure 3.17 it can be seen that the smallest size
lays down details of the procedure to be followed when
is N5, the subsequent sizes being 6, 8, 10, 12, 14, 18,
this course is undertaken. Thus Grimm et al. (1994)
24, 36 and 48 point. Some practitioners deplore the
found that their selected letters had to be made 5% smal-
fact that the new series does not include even a near ap-
ler than Landolt rings to give similar acuity scores,
proximation to J1; in fact, J2 is smaller than N5.
with individual letters also needing to be made slightly
The Faculty of Ophthalmologists also recommended
larger or smaller than the average to give equal legibil-
that if these test types are used to record a near visual
ity.
acuity, it should be at a distance of 35 cm.
Conversely, Coates (1935) reported the Landolt ring
was easier to read than the letter styles he investigated,
with the ring having a legibility of 1.13 in relation to
the mean legibility of all his test letters. Sloan and Habel’s M notation
A new notation for indicating the x-height of test letters
and for recording near visual acuity was described by
Near visual acuity: reading-test types Sloan and Habel (1956). The x-height is expressed by a
number M denoting the distance in metres at which it
In general, a separate measurement of visual acuity in subtends an angle of 5 minutes of arc. The M number
near vision is seldom required, but scaled-down versions thus corresponds to the denominator D of the Snellen
of distance letter charts for use in near vision can be ob- fraction V = d/D. Consequently, the height 8.73 mm of
tained for this purpose. Reading-test types are used the 6 m letters on a standard Snellen chart is 6 M. It fol-
mainly to determine the sufficiency of accommodation lows that size 1.0 M is 8.73/6 or approximately
or the near addition required. They can, nevertheless, 1.45 mm, which is very close to the x-height of the
be approximately related to Snellen distance acuity, 8-point type used for the great bulk of newsprint
though the reading of words and sentences probably in- material. The approximate relationship 1.0 M=N8,
volves slightly different perceptual processes than the 2.0 M=N16, and pro rata, applies throughout the main
recognition of single letters. range of sizes.
In the printing industry, the size of a typeface is cur- Before the M number of a type size can be equated to a
rently specified by ‘points’, e.g. 8 point, one point being visual acuity rating, a specific viewing distance must be
36 ~=Visual acuity and contrast sensitivity

assumed, representing d in the Snellen fraction. In terms younger subjects managed the smallest gap, possibly be-
of decimal acuity we can therefore write cause they could hold the test closer than older subjects.

decimal V = d (in metres)/M number

For example, if d = 40 cm (0.4 m) and the smallest type

Visual acuity in the peripheral field
that can be read at this distance is 0.5 M, then
decimal V = 0.4/0.5 = 0.8 The structure of the retina has been discussed briefly on
pages 20-21 in relation to visual acuity. For the reasons
equivalent to 6/7.5 or 20/25.
explained, the high resolution at the fovea is not main-
In general, if a reading chart is designed for use at a
tained in the peripheral parts of the retina. Indeed, it
distance d in cm, the M size corresponding to 6/6 is
would scarcely be possible or even beneficial to do so.
d/ 100.
With a mobile eye, the loss of detail in peripheral vision
As an aid to prescribing magnification in cases of low
is unimportant. Movements in the peripheral field are
visual acuity, a set of test cards was made available
readily detected and the eyes or head can quickly be
with letter sizes of 1 to 10 M. If the ability to read 1.0 M
turned to obtain a direct view. In scotopic conditions of
at a given viewing distance is taken as a reasonable
illumination, the pre-eminence of the fovea is lost and
standard, but the smallest type which a particular
there is then little difference between central and periph-
patient can read at this distance is 3 M, a need is clearly
indicated for magnification in the neighbourhood of 3 x. eral acuities.
Many studies of visual acuity in the peripheral field
A further paper by Sloan and Brown (1963) describes
have been made, those of Low (1951) and Millodot
a large chart of test letters for measuring distance
visual acuity and a reading chart of Snellen letters de- (1966) giving reviews. One of the best known and ear-
liest was by Wertheim (1894) who used a grating as
signed for use at 40 cm.
test object. The acuity was measured centrally, at 2.5°
and 5° from fixation, and at every 5° interval up to
70°. Figure 3.18 shows the results for the nasal side of
The Bailey-—Lovie Word Reading Chart
the retina, expressed in terms of acuity relative to that
Reading charts using the Times Roman typeface and at the fovea, the gap in the graph representing the
based on the principles of their logMAR distance chart blind spot. Apart from this feature, the corresponding
have been designed by Bailey and Lovie (1980). graph for the temporal side of the retina is very similar.
Although it was not found practicable to adhere ex- It was pointed out by Low that the shape of this graph
actly to the strict logarithmic progression, a reasonable with its sharp peak can give a misleading impression.
approximation to it has been achieved. Those sizes for This type of curve is characteristic of a simple reciprocal
which no sufficiently close printers’ types exist were pro- function and Snellen acuity is the reciprocal of the
duced by photographic enlargement or reduction. The angular subtense A of the smallest detail size recognized.
17 sizes in all have x-heights varying from about If the curve of Figure 3.18 is re-plotted in terms of the
14.5mm (N80) to as little as 0.36mm (N2). In angle A instead of visual acuity, as in Figure 3.19, the
logMAR units the range is from 1.6 (6/240) to 0.0 graph becomes very nearly linear over half its extent.
(6/6). The Snellen equivalents in parentheses relate to Studies in the central region up to 85 minutes from
the stipulated reading distance of 25 cm. fixation were made by Weymouth et al. (1928), using a
For reasons fully detailed, unconnected words have grating of 10 minutes overall width. Over this range
been chosen instead of continuous reading matter. the fall in acuity was found to be nearly linear, though
Each line from 1.0 logMAR down to the smallest con- slightly greater in the vertical meridian than in the hor-
tains a selection of six words, two each with 4, 7 and izontal. In his study, which involved three observers,
10 letters. As with the distance chart, the inter-word Millodot (1966) measured the peripheral acuity at 5-
and inter-row spacing have been kept on a uniform
basis in relation to the letter size of each row.
GRRE sie
an ll ee
Extra-fine reading charts
| i sil le a
Jenkins et al. (1995) developed the Bradford Near Vision
Charts for experiments on the effects of fixation disparity
hs[eam fre] Cae Se alin
(see Chapter 10) on binocular near acuity. These six Oo o1

charts showed five lines of five four- or five-letter words

of 3.5 to 1.0 point size to be viewed at 40 cm, giving
angular subtenses of 41 to 16 seconds of arc limb acuity
visual
Relative
width. Their pre-presbyopic subjects managed a mean
result of just under 30 seconds of arc. It could be
argued that these charts could also be employed for se-
|
ee
lecting people for very demanding near vision tasks. 20 30 40 50 60 70
This was the argument of Vos et al. (1994), who investi- Eccentricity (degrees from fixation)

gated the Priegel test, an internally illuminated Landolt Figure 3.18. Visual acuity as a function of eccentricity in the
ring test with gap sizes from 0.12 to 0.04mm. The nasal retina. (Redrawn from Wertheim, 1894.)
 Kinetic (or dynamic) visual acuity 37

points in the field where a stimulus of a particular size

is only just perceived is called an isopter.
Contrast sensitivity (see later in this chapter) as a
function of eccentricity has been studied by Pointer and
Fess SOR 99.0):

arc)
(of
A
minutes

Kinetic (or dynamic) visual acuity

0 10 20
Eccentricity eal ie ine The previous sections of this chapter have been con-
cerned with stationary test objects. When visual acuity
Figure 3.19. Angular detail size A in minutes of arc as a is measured with moving test stimuli, the result is
function of eccentricity.
known as kinetic visual acuity. It is also called ‘dynamic
visual acuity’, but this expression is confusing, since
the term ‘dynamic’ is generally understood by optome-
trists to refer to the state of the eye when accommo-
dating for a near object.
Kinetic visual acuity or KVA may depend upon sev-
eral factors:

(1) The static visual acuity or SVA,

(2) The speed of the tracking movements,
acuity (3) The accuracy of the fixation on the moving object.
Relative
visual
1.0
If the SVA is poor, it is unlikely that the KVA will be
Nasal retina (degrees from fixation)
good. Long and May (1992) found no correlation be-
Figure 3.20. Visual acuity as a function of eccentricity in the tween SVA and KVA for their 60 student subjects
nasal retina. (Redrawn from Millodot, 1966, by kind having binocular SVAs between 6/4 and 6/12.
permission of the publishers of Br. J. Physiol. Optics.)
Westheimer (1954) found that the eyes could main-
tain fixation up to an angular speed of 30°/s. Brown
minute intervals up to 2° and then at 30-minute inter- (1972a), however, found that the eye’s pursuit velocity
vals. A Landolt ring was used as a test object and the re- was lower than that of the object. ‘Saccades’, high-
sults published in the form of the actual acuities, which velocity re-fixation movements, were made to regain ap-
varied at fixation from 0.85 to 1.25. Figure 3.20 shows proximate fixation.
the mean of Millodot’s results for the nasal retina, the This lag of fixation behind the test object means that
original data having first been converted into relative the retinal image falls off the fovea and on to a part of
acuities for this purpose. Weymouth and colleagues’ re- the retina possessing intrinsically lower acuity.
sults up to 85-minute eccentricity are in good agree- KVA was studied first by Ludvigh and Miller (1958)
ment, though slightly higher for eccentricities less than for a test object rotating in a circular path in a plane
20 minutes. parallel to that of the face. Their later survey (Miller
In round figures, taking the foveal acuity as 6/6 (20/ and Ludvigh, 1962) discusses many of the factors relat-
20), the peripheral acuity is 6/9 (20/30) at 1” eccentri- ing to this subject. Brown (1972a) found that the
city, 6/12 (20/40) from 15 to 2°, and 6/18 (20/60 kinetic visual threshold (reciprocal acuity) rose approxi-
from 3° to 5°. These figures have clinical significance mately linearly from the static value of 0.75 minute to
when eccentric fixation is in use; for example, in the 3.5 minutes at a velocity of 90°/s. Similar results were
case of retinal burns, senile macular degeneration and also obtained by Miller and Reeder (1965). For a
600 ms exposure time, Long and May (1992) found the
some forms of amblyopia (see pages 41—43).
When reading print, the eyes do not fixate each word KVA to drop from 3 minutes of arc at 60°/s to around
10 minutes at 120°/s. For a 200 ms exposure time, the
in turn, certainly not each letter, but make only two or
three jumps (saccades) along each line. Cattell, quoted results increased to around 10 and 25 minutes respec-
tively. They suggest that the following response is sac-
by Low (1951), showed that in the near periphery
cade dominated for the shorter time interval, saccade
‘words were three times as recognizable as random
and pursuit for the longer exposure. Interestingly,
series of letters and sentences twice as recognizable as
males had slightly better KVA than females.
random series of words’.
Measurements of KVA appear to be influenced by
The factors responsible for the decline in acuity with
learning, practice increasing the acuity. The luminance
eccentricity also affect the visibility of an isolated stimu-
contrast of the test object is another factor. If it falls
lus imaged away from the fovea. In field plotting, for ex-
below about 23%, Brown (1972b) showed that KVA de-
ample, it is found that the size of the smallest object
teriorates, due to the effect of reduced contrast on static
visible increases with eccentricity. The locus of all
acuity and eye movement control.
38 Visual acuity and contrast sensitivity

that eye is amblyopic. Success rates of over 90% are re-

Objective determination of vision
ported. Normative data for the Teller cards have been
presented by Salomaéo et al. (1995) and Mayer et al.
While the subjective measurement of vision and visual
(1995). Both Friendly et al. (1990) and Sireteanu et al.
acuity using letter or similar charts is usually satisfac-
(1990) caution that the Teller card test appears not to
tory, there are cases where an objective determination
identify the loss in acuity in amblyopes. This may be be-
would be a helpful or even the only method available.
cause the measurement is by a grating rather than
Infants, patients who may be unable to co-operate ade-
letter acuity, since Vernon et al. (1990) found that grat-
quately and malingerers are examples.
ings formed by interferometry (see page 44) were also
Because these tests present simpler visual stimuli than
poor at identifying amblyopes, because seven of their
the traditional letter chart, and may be monitoring a re-
nine subjects had grating acuities within one octave
sponse from lower in the visual/cerebral system than is
(i.e. half the frequency) of their better eye, and six
required for letter recognition, the acuities recorded
showed acuities better than or equal to 6/9 equivalent.
may be optimistic in comparison with those which a
More than half their subject’s amblyopic eyes with Snel-
Snellen chart might give.
len acuity of 6/18 or worse showed grating acuities in-
Reviews of the objective methods of determining
distinguishable from normal. Chandna_ (1991)
visual acuity have been given by Voipio (1961), Pearson
suggested that a Teller card acuity difference greater
(1966) and Dobson and Teller (1978). Methods (2)-(5)
than half an octave between the eyes should be consid-
below follow the classification of Voipio.
ered abnormal, even though the acuities in any age
group varied over +2 octaves.
The Cardiff Acuity Cards have been described on
Methods of determining visual acuity pages 33-34.

(1) Forced choice preferential looking (PL) or

differential fixation
(2) Methods based on evoking an
A young infant in a darkened room is simultaneously oscillatory motion
shown a plain disc and a patterned disc both of the
same size and mean luminance. Provided that the child If a detailed object is swung back and forth across the
can see the pattern, it should be more interested to look field of vision, the eyes will follow it with a pendular
at the patterned rather than the plain disc. The pat- motion, provided that the target detail can be resolved.
terned discs are usually square-wave gratings in a geo- A checkerboard or vertical grating oscillates horizon-
metrical progression of sizes which can be equated to tally against a background of the same mean luminance
Snellen acuity on the basis of equation (3.8). A routine so that the edges of the test object cannot be seen as a
system of examination by this technique has been de- luminance difference. The subject sits close to the appa-
scribed by Gwiazda et al. (1980). When there are no ratus and the pendular motion of his eyes is monitored
complications, the binocular acuity can be determined through a magnifier or microscope. The observation dis-
in less than five minutes. Monocular acuities also can tance is then increased until this motion ceases. The
be measured by this method. greatest distance at which response occurs is used to
The basis of a simpler method of applying the PL tech- calculate the objective acuity.
nique, in the form of ‘acuity cards’, was described by If y is the detail size in millimetres and D the greatest
Teller et al. (1974). An account of this method in its de- observation distance in metres, then the angular sub-
veloped form and of clinical trials with it was given by tense A of the detail size becomes
McDonald et al. (1985). A= y/1000D rad = 3.444y/D minutes of arc
A set of long grey cards has a grating at one end, of
Thus from equation (3.6)
the same mean luminance as the card itself. Depending
on the version used, the grating frequency increases V =1/A=D/3.44y (3.12)
with each successive card by a factor of \/2 or 2. The
Correlation with subjective acuities of up to +0.91
cards are placed behind an aperture in a grey screen.
have been reported. Projectors using zoom magnifica-
Each has a small central spyhole through which the ex-
tion systems may be used instead of altering the obser-
aminer can note the response of the infant, who is held
vation distance.
at a distance of about 36 cm from the card. Successively
finer cards are shown until there is no fixation or point-
ing response from the infant.
(3) Methods based on evoking an opto-kinetic
A number of additional studies — for example, by
nystagmus (OKN)
Dobson et al. (1986) and Thompson and Drasdo (1988)
— have found that although this technique is quicker This method is similar to the previous one, except that
(taking 3-5 min) than the use of twin projectors or the test object moves continuously in one direction in-
visual display units, it is no less accurate. stead of oscillating. Provided that the detail is resolved,
The technique is reported to work well with infants up the eyes follow the moving object for a limited rotation
to about 18 months, binocular acuities being easier to and then rapidly swing back. There is thus a slow fol-
measure than monocular. Some children dislike having lowing phase and a rapid recovery phase and such
either eye covered. If, however, there is no reluctance motion is called nystagmus. Good correlations with sub-
to having one particular eye covered, it may be because jective acuity have again been recorded. The acuity of
 Visual efficiency 39

neonates can be estimated by this method (Gorman et to determine whether the predominantly cone-popu-
Gil, WDS7, WSS). lated fovea is functional in patients whose media are
too opaque to allow a determination of acuity or
ophthalmoscopic examination of the interior of the eye.
(4) Methods based on arresting The ERG gives an indication of the functioning of the
opto-kinetic nystagmus retina, but vision requires satisfactory performance of
Opto-kinetic nystagmus is produced by a coarse grating. the whole visual pathways, which end at the occipital
Superimposed on this is a stationary object of fine detail cortex. By placing electrodes on the scalp at the appro-
on a background of the same mean luminance. The nys- priate rear part of the head, it is possible to pick up
tagmus is halted if the patient’s fixation is transferred neural activity in the brain. This activity will be related
to the test object, which occurs when the detail can be to the visual information, but the electrodes will also
resolved. pick up stray noise and signals from other parts of the
Techniques (2)—(4) require careful choice of stimulus brain. The relevant activity may be extracted by an
and speed of motion. averaging process. If the eye views a checkerboard pat-
tern which reverses in contrast at regular intervals at
about 12 Hz, the cortical response should similarly
(5) Methods based on the galvanic show cyclic potential changes. The responses to each
skin response test object cycle may be added together by electronic re-
cording, while signals due to stray noise and other
This method was devised by Wagner (1950) and utilizes brain activity should average out to zero. The resultant
the galvanic skin response. This is the alteration in resis- mean signal is called the visually evoked cortical re-
tance of the skin to an electrical voltage when the sponse or potential (VECR, VECP or just VEP).
patient reacts to a conditioned stimulus. In this applica- Responses were initially determined for stroboscopic
tion, the patient may be shown a series of Snellen let- flashes of light, but later investigators used patterned
ters, of the same size. Following every demonstration of stimuli of constant mean luminance, such as the check-
one particular letter of the alphabet, the patient is sub- erboard pattern, to enhance foveal response.
jected to a mildly unpleasant stimulus, such as an elec- The VECR may be employed to investigate the per-
tric shock or loud noise. In this way, the patient formance of the visual pathways in amblyopia (see
becomes conditioned tg react to any viewing of this one pages 41-43) and retinal or nerve pathway diseases.
particular letter. Thus, a study by Nawratzki et al. (1966) with flashes of
After the conditioning process, the patient is shown a light showed a difference in latency of the VECR follow-
series of test letters of decreasing size, including the ing the stimulus between normal and amblyopic eyes.
letter to which he has been conditioned. The skin resis- Fishman and Copenhaver (1967) also used flash illumi-
tance response is monitored, and when no response is nation and found little difference in latency, but could
made to the relevant letter, it is assumed that the letter distinguish an altered response in patients with unilat-
is below threshold. The test can be repeated with in- eral macular disease.
creasing letter sizes. Arden et al. (1974) used a checkerboard pattern and
The problems with this technique are the considerable found a depressed VECR when the eye was amblyopic
variation from person to person in normal skin resis- (less than about 6/18), and also measured a meridional
tance and the difficulties in producing a conditioned re- amblyopia in a patient whose eye showed low astigma-
sponse. Pearson (1970) repeated this technique using tism. Ikeda (1976) suggests that the reduced response
an auditory shock, but without obtaining satisfactory indicates an organic lesion or functional suppression of
results. the visual pathway.
Although a supra-threshold grating is used, say 5.5
minutes of arc, the amplitude of the VECR is found to
(6) Methods based on the visually evoked
correlate well with acuity (Douthwaite and Jenkins,
cortical response (VECR) 1987).
All neural activity is accompanied by electrical effects. The visually evoked response has been used by Millo-
Nerve conduction, for example, results from a polarized dot and Riggs (1970) to examine the focusing of the
ionic wave or spike potential passing down the fibre. eye. The amplitudes of the responses (both VECR and
Stimulation of the retina by light similarly results in ERG) were shown to produce a marked peak when the
potential changes. On animal specimens, electrodes image of the checkerboard was in focus on the retina.
may be placed in the retina or optic nerve, enabling
measurements to be taken of the electrical activity in
single relay or ganglion cells and their fibres. An aver-
aged response due to a relatively large portion of the Visual efficiency
retina may be measured at the cornea. A transparent
contact lens bearing an electrode is worn on the A normal visual acuity is about 6/6, often slightly
cornea, while a reference electrode is placed on the better. In terms of the minimum angle of resolution,
cheek. The potential changes, resulting from viewing a this is twice as good as 6/12. However, it can also be
flash of light are recorded as an electroretinogram said that an object only just discernible by a person
(ERG). It is possible to distinguish between the responses with 6/12 vision can be seen more easily by someone
of rod and cone pathways, so that the ERG can be used with better vision. This leads to the concept of visual ef-
40 Visual acuity and contrast sensitivity
AMA ratings
ficiency, according to which an acuity 6 IPF (or10%5)
(%)
does not imply that visual capacity in terms of fitness
100
for employment is reduced to one-half.
In 1925 the American Medical Association (AMA) 90
adopted a visual efficiency scale based on the work of
80
Snell and Scott Sterling. A number of identical ‘obscur-
ant’ glasses were made and the acuity of normal obser- 70
vers measured when looking through first one glass,
60
then two together, three together and so on. Six glasses
were found to reduce the vision from 20/20 to 20/400 50
and each successive glass was considered to reduce the
visual efficiency by one-sixth. For example, three
40
istance vision efficiengy
Visual
glasses, giving an acuity of 20/100 were deemed to 30
ear vision
represent a visual efficiency of 50%.
The experimental results were found to agree reason-
ably well with the mathematical relationship whereby
visual efficiency E decreases logarithmically as the mini-
mum angular detail size A or the letter size D increases
0.4
arithmetically. Accordingly, if log EF is plotted against A
Visual acuity (decimal)
or D, the resulting graph is a straight line. The position
of this line can be determined by two points. One has Figure 3.21. Relationship between AMA visual efficiency
the co-ordinates (A = 1, E = 100%), arising from the de- and Snellen visual acuity in decimal notation.
cision to equate 100% visual efficiency with the
‘normal’ visual standard of 20/20. The other point, visual acuity efficiency scale were proposed. For dis-
whose co-ordinates are (A = 10, E = 20% ), is fixed by tance vision, ratings under 20% were related to lower
the decision to equate 20% visual efficiency to exactly Snellen acuities than before. For example, 10% effi-
20/200, broadly in line with the experimental results. ciency was equated to 20/400 instead of 20/280. At
It then follows that the equation of the line is the same time, a separate scale of ratings for near
log
EH = —0.07774A
+ 2.0777 (mrs)) vision was introduced. Details of the decimal V equiva-
lents of the 1955 acuity ratings are given in Table 3.3
From which and are shown graphically in Figure 3.21. The curved
2.0777 — log E line in this diagram represents the original theoretical
A= alle
OO ie) relationship expressed by equation (3.15), without
and
rounding off.
The big drop in the near vision efficiency ratings be-
0.0777
V=1/A= a G15) tween V=0.5 (90%) and V=0.4 (50%) reflects the
2.0777 log fact that inability to read J4 or its near equivalent N6
In 1955, the AMA adopted a report by its Council on at 14in would be a considerable handicap in many
Industrial Health, in which modifications to the original near visual tasks.

Table 3.3. 1955 AMA visual acuity efficiency ratings and their equivalents

AMA Distance vision Near vision

efficiency
rating Snellen Snellen Angle A Snellen Times Angle A
VA VA VA New Roman*
(%) (feet) (metres) (minutes) (inches) (at 35 cm) (minutes)

100 20/20 6/6 1.0 14/18 - has

95 20/25 6/7.5 125 14/22 N5 1.6
90 20/32 6/10 1.6 14/28 N6 2.0
85 20/40 6/12 2AV)

75 20/50 6/15 We)

65 20/64 6/18 Be)
60 20/80 6/24 4.0
50 20/100 6/30 5.0 14/35 i BSS

40 20/125 6/36 * 6.25 14/45 N9 2

30 20/160 6/48 8.0
20 20/200 6/60 10.0 14/56 N12 4.0
LS 20/300 6/90 15.0 14/70 N14 50)

10 20/400 6/120 20.0 14/87 N18 6.2

5 20/800 6/240 40.0 14/112 N24 8.0
2: 14/140 - 10.0

\pproximate equivalents
 Amblyopia 41

In the 1955 revision, the visual efficiency (VE) of one AMA (1955)
eye was defined quantitatively as the product of three visual efficiency
Decimal V rating (%)
separate ratings: central visual efficiency (distance and
100
near acuities combined), visual field efficiency and moti-
lity efficiency. For example, if the three scores are 70, 90
30 and 80%, the visual efficiency is 0.7 x 0.3 x 0.8,
equal to 0.168 or 16.8%. A score below 10% in any
one function is regarded as a total loss of visual effi-
ciency.
Binocular visual efficiency (BVE) is computed from the
formula

BVE
ee
3B

where B is the visual efficiency of the better (or only) eye

and P the visual efficiency of the poorer (or lost) eye. 0 6 12 18 24 S0Rs6
The BVE is thus equal to at least 75% of the better eye’s Age (months)
VE.
Detailed procedures are laid down for determining the Figure 3.22. Development of visual acuity with age. Curve
A: results of Chavasse (1939). Curve B: mean results of recent
three components of the VE rating. They are here de-
investigations.
scribed only in outline. To assess the central acuity
rating, the mean of the distance and near ratings is
taken, any necessary refractive correction being sup- opment of the very young, even the newly born. With-
plied by conventional ophthalmic lenses. Special rules out exception, they all indicate a much higher level of
apply in aphakia. acuity than had previously been supposed. A compre-
The visual field efficiency is assessed on a perimeter hensive review of experimental results for infants up to
with a 3/330 white stimulus (6/330 for uncorrected six months was given by Dobson and Teller (1978).
aphakia). The field of view is measured in degrees in Although the methods of optokinetic nystagmus (OKN)
the eight principal directions at 45° intervals and the and preferential looking (PL) were shown to produce
total divided by five. This gives the efficiency rating as a findings in fair agreement, the results from the method
percentage of the total possible score of 500°, to which of visually evoked cortical response (VECR) gave appre-
the various meridians contribute appropriately. ciably higher acuities.
In assessing motility efficiency, diplopia within 20° of Curve B in Figure 3.22 represents the mean results
the primary position counts as a 100% loss of efficiency. surveyed by Dobson and Teller, together with the later
If diplopia occurs within 20°—40° from fixation, the loss findings of Gwiazda et al. (1980) for 30 infants ranging
of efficiency is determined by means of a special chart from 2 to 58 weeks of age. At birth, the mean acuity
divided into areas with different ratings. Suppression or given by the scanty data is about 6/240 (20/800). By
loss of binocular vision is regarded as a 50% loss of moti- one month, it is of the order of 6/120 (20/400), rising
lity efficiency in the eye affected. to about 6/30 (20/100) at 6 months and about 6/15
The earlier AMA visual acuity ratings have been dis- (20/50) at 1 year. Chandna (1991), also using Teller
cussed by Hofstetter (1950) and Sloan (1951), while Cards over the 6-month to 4-year age span, found re-
Luckiesh (1945) has described in detail the test chart sults approximately mid-way between curves A and B.
based on equation (3.13). Ryan (1962) has provided a These curves do not include results obtained from the
comprehensive historical review and a commentary on VECR method. Using this technique, Marg et al. (1976)
the 1955 revision and innovations. found an acuity of about 6/18 (20/60) at 3 months,
rising to 6/6 (20/20) by the end of 6 months. Somewhat
lower values were found by Sokol and Dobson (1976),
The development of visual acuity but still much higher than those of curve B.
The high acuities revealed in these various studies
refer to gratings or checkerboards. They do not imply a
In the same way that a baby has to learn to co-ordinate
parallel development of shape perception and analysis
its muscular activity, visual acuity also develops with
as required for the recognition of test symbols or letters,
time. This is partly due to the anatomical development
nor the verbal or motor response.
of the fovea itself, which is not completed until a few
months after birth.
One of the early estimates of visual acuity in the
infant was made by Worth (1903) using a series of five Amblyopia
ivory balls (see page 33). Another well-known study
was made by Chavasse (1939). Curve A in Figure 3.22
Types of amblyopia
is based on his findings, but is re-plotted here in terms
of the useful concept of visual acuity efficiency. An addi- Poor unaided vision may be produced sclely by a refrac-
tional scaling gives the acuity in decimal notation. tive (focusing) error in one or both eyes. In some
Several of the more recent techniques described on patients, the corrected visual acuity is below normal, for
pages 38-39 have thrown new light on the visual devel- example, 6/9 or less, although there is no pathological
42 Visual acuity and contrast sensitivity

cause such as irregularity of the refracting surfaces or astigmatism of relatively marked degree, was first noted
media, non-congenital cataract or disorders at the in 1890 by Martin (cited in the study by Mitchell et al.,
macula or in the optic nerve. Reduced acuity of this 1973). The uncorrected astigmatic eye is able to form
type is known as amblyopia. sharp images only of lines substantially parallel to its
Amblyopia may be classified under many headings two mutually perpendicular meridians. Moreover, lines
but the most important ones are: congenital, occlusion, in these two orientations cannot be focused on the
refractive and strabismic. The various toxic amblyopias, retina simultaneously. If, in addition, the eye is hyper-
such as tobacco amblyopia, are not considered here be- metropic in both principal meridians, one set of ines
cause they are of pathological origin. will be more out of focus in both distance and near
vision. The development of acuity for lines in the fa-
voured meridian will thus be normal, while that for
Congenital amblyopia lines in oblique and out-of-focus directions will be hin-
dered. Even when the astigmatism is subsequently cor-
The visual acuity is usually reduced in both eyes by a
rected, the grating acuity for the out-of-focus meridian,
similar amount and, on examination of the macula
and to a lesser extent oblique meridians, may remain
with an ophthalmoscope, the fovea may appear to be
below that of the favoured meridian. The Snellen letter
ill-developed (no foveal reflex). The refractive error is
acuity may nevertheless be virtually normal. In myopic
not large. The letters on the test chart do not appear to
astigmatism, it may be possible for one meridian to be
jumble and fixation is central.
in focus (or nearly so) for distance vision, the other for
near vision, thus reducing the meridional acuity differ-
Occlusion amblyopia ence.
Although marked astigmatism seems to be common in
Ifa child is born with cloudy media, as in congenital cat- young infants, it is usually outgrown by the end of the
aract, the retina is immediately deprived of a clear second year, apparently without lasting effects.
image and amblyopia results: hence the need for early Meridional amblyopia should not be confused with
diagnosis (Jacobson et al., 1981). Prompt surgical inter- the normal reduction in acuity for gratings in oblique
vention and provision of a refractive correction, usually meridians, as mentioned on page 22. This is probably a
a contact lens, are essential. Occlusion of an eye of a physiological response to the preponderance of vertical
young infant to stimulate development of the fellow and horizontal lines in our environment, though Char-
eye's vision also entails a rapid loss of acuity. For this man and Voisin (1993) postulate that this oblique
reason, the occlusion must be part-time, not constant. effect may indeed result from meridional out-of-focus ef-
fects from the preponderance of even small horizontal
and vertical astigmatic errors in the young eye.
Refractive amblyopia
In general, this arises when there is a large refractive
error in one or both eyes, the retina and nervous path-
Strabismic amblyopia
ways having been deprived of an adequately detailed sti-
mulus for development. When the patient has a unilateral squint, the vision in
Discussion of treatment does not fall within the scope the squinting eye is often poor. Classical ideas suggest
of this text, but if the refractive error is corrected before that the acuity would have developed normally up to
the patient is about 8 years old, there is a good chance the time of onset of the strabismus, but that the develop-
that almost normal acuity will be attained. If the error ment to be expected in subsequent years would not
is in one eye only, it is often necessary for the good eye occur. This was known as amblyopia of arrest. Because
to be covered for a certain length of time in order to the squinting eye does not enter fully into binocular
stimulate development of the poorer eye's acuity (see vision, it was thought that following the onset of the
page 263). squint, the vision might deteriorate: amblyopia of ex-
Refractive amblyopia may be divided into three main tinction. These two are often grouped together as am-
types: anisometropic, bilateral and meridional. blyopia ex anopsia (of disuse).
Anisometropic amblyopia occurs when there is a fo- Although these concepts are useful, current ideas on
cusing error of appreciable magnitude in one eye only, the functioning of the strabismic eye have led to a revi-
in which case vision in the poorer eye is affected. This sion of the nomenclature. Under earlier and somewhat
is less likely to happen if the eye is myopic (short- artificial conditions of examination of the squinting pa-
sighted) only by a moderate amount, enabling it to be tient’s binocular system, the mental image due to the
used for near vision. strabismic eye was found to be suppressed. More recent
Bilateral refractive amblyopia may arise if both eyes and sophisticated tests, for example Bagolini glasses or
have high myopic errors (rare in the young child), high the synoptophore with Stanworth’s semi-reflecting mir-
hypermetropic errors for which the eyes are unable to rors, show suppression is often minimal. The strabismic
accommodate or marked astigmatism.* eye may contribute significantly to the binocular per-
Meridional amblyopia, a legacy of early uncorrected cept. The term ‘strabismic amblyopia’ is preferable to
either amblyopia ex anopsia or suppression amblyopia,
since it does not imply a specific cause of the poor vision.
* These various refractive errors are discussed in Chapters 4 As a matter of insurance in case the good eye should
and 5. be lost or injured, the authors feel that improvement of
 Poor acuity 43

the acuity of the patient's amblyopic eye is more impor- ment is used to project a graticule image on to the pa-
tant than curing the strabismus. Any significant refrac- tient’s retina.
tive error in either or both eyes must be corrected and Regan et al. (1992) have challenged this concept, sug-
followed by occlusion of the good eye to force the child gesting that the amblyope’s poor chart acuity results
to use his less efficient eye. The rate at which the acuity from defective control of gaze, or an inability to select
improves will depend upon the age of the child both the intended direction of gaze. Their evidence came
now and at the onset of the strabismus and the amount from measuring acuities on a chart where the single
of amblyopia present before treatment starts. A red test letter was repeated in a regular array in the centre
filter worn over the poor eye tends to help by stimulat- of the chart, the array being surrounded by other letters.
ing the use of the fovea, especially under relatively low In many cases, the amblyopes showed repeat letter
illumination conditions indoors. A suggested explana- acuity similar to or even better than their chart acuity,
tion is that the red filter absorbs blue and green light to a result opposite to that predicted by the crowding phe-
which the rods are more sensitive than the cones under nomenon. Subjects with nystagmus, a condition usually
mesopic conditions. giving horizontal oscillations of the direction of gaze,
Many readers may find it useful to return to this sec- were shown by Simmers et al. (1996) to perform better
tion after reading Chapter 10 on anomalies of binocular on this test than on Glasgow Acuity Cards logMAR
vision. crowded test, confirming Regan’s original idea.
Amblyopia is discussed further by Mallett (1969),
Schapero (1971), Amos (1977, 1978), Mallett (1988),
* Nelson (1988), Jennings (1993), Grounds (1996) and
The crowding phenomenon in texts on orthoptics.

(separation difficulty)
The crowding phenomenon is a difficulty sometimes
shown in separating the letters on a line of type or of a Poor acuity
test chart. It particularly affects patients with strabismic
amblyopia or macular degeneration . Much of the discussion in this chapter on factors af-
The end letters of the line may be read but those in the fecting visual acuity has assumed a healthy eye. The
centre are jumbled and the order may be confused. The visual acuity may decline with increased years due to
measured acuity may be higher if the test letters are various ageing changes and/or pathological conditions.
shown singly. This may be done by screening the re- The causes may lie in the visual pathways or brain; in
maining letters on the line with white card, by using a the retina, especially in the form of macular degenera-
Maddox chart which has only one letter on each line, tion; or in cloudy media, most commonly in the crystal-
or by using the Sheridan—Gardiner test, a Cube E or line lens. Lens opacities reduce the contrast of the
Ffooks’s symbols (see pages 32-33). retinal image by increasing the amount ofdiffusely scat-
The term ‘angular acuity’ has been used to denote tered light within the eye.
acuity determined by single letters, particularly of the E A simple test to demonstrate the fall in acuity with
or Landolt-ring variety, in which only resolution of the scattered light is to introduce a glare source, for exam-
critical feature is required. In contrast with this, the ple, an Anglepoise light shone into the eye from near
term ‘morphoscopic’, implying recognition of form, has the visual axis while the patient is trying to read the
been applied to acuity measured by recognition of letters test chart. Holladay (1986) introduced a Brightness
on a normal chart or rarely, of single unknown letters Acuity Meter for this purpose. It consists of a brightly il-
or symbols. luminated hemispherical cup, held over the eye, with a
It is found in practice that when acuity is better for 12 mm aperture through which the patient views the
letters or symbols viewed singly, the kind used is imma- chart. This device not only produces scattered light, but
terial. The authors therefore consider the term ‘isolated also induces pupil miosis, thus often restricting the
symbol’ or ‘monotype’ acuity, which also carries its light entering the eye to the densest part of a cataract.
own meaning to be preferable to ‘angular acuity’. Although no longer manufactured, the instrument was
Indeed, all acuities are based on angular subtenses. The claimed to demonstrate the handicap suffered out of
term ‘morphoscopic acuity’ is better expressed as ‘chart doors by a patient with cataract. The Tearscope, an in-
acuity’ or ‘line acuity’. strument intended for viewing the quality of the tear
The crowding phenomenon may arise because the eye film, may serve the same purpose.
is not fixating centrally with the fovea, but is using a Poor contrast in the object is a hindrance in many
region just to one side of it. The reduced acuity is gov- such cases. When a low-contrast test chart is used, the
erned by the amount of eccentricity as shown in Figure authors have found that patients with unclear media
3.18. The precise position in space corresponding to show a_ significant deterioration in acuity. Thus,
the true foveal centre may often be determined by utiliz- although the acuity may seem satisfactory when meas-
ing Haidinger’s brushes, an entoptic phenomenon de- ured with a normal high-contrast test chart, the lower
scribed in Chapter 22. Alternatively, the patient may be luminance contrast of a newspaper and even poorer
asked to fixate the centre of the smallest field of the contrast of many other objects in daily life may cause
ophthalmoscope. The practitioner can then observe the much difficulty. Low-contrast charts are described on
position of the foveal reflex relative to the illuminated pages 53-54.
area. More accurate results are obtained if an instru- It has been reported by Arden (1978) and others that
44 Visual acuity and contrast sensitivity

in certain pathological conditions the contrast sensitiv- contrast of 20% of the original. If the patient can distin-
ity of the eye is measurably reduced, even though in guish the fringes and their orientation, the retinal reso-
some cases the Snellen acuity remains normal. This lution can be determined and expressed in terms of an
topic, together with associated clinical tests, is further equivalent visual acuity. Should this be good, there is
discussed on pages 51 et seq. thought to be a favourable prognosis for vision follow-
Prince (1958, 1959), amongst many other research- ing lens extraction (Rassow and Ratzke, 1978). Halliday
ers, investigated different styles of print for the patient and Ross (1983) found, however, that only 45% of
with poor vision. He recommended a non-serif typeface their patients saw as predicted after operation. Those
with slightly increased spacing between the individual with dense cataracts tended to do better, while others
letters of each word. In Britain, the first large-scale ven- with macular changes or possibly with previous am-
ture in books designed specially for poor acuity was blyopia did worse. The suggestion was made that para-
launched by F. A. Thorpe (Publishing) Ltd of Glenfield, macular acuity falls off with eccentricity more rapidly
Leicester. Their extensive series of ‘Ulverscroft Large for Snellen letters than for fine gratings, which thus
Print Books’ are printed in 18-point type with specially give a more optimistic prediction.
black ink to ensure good contrast even under magnifica- Most instruments of this type use lasers and some
tion. In the USA, a catalogue entitled ‘Large Type form of beam-splitter, as described, among others, by
Books in Print’ has been compiled by the R. R. Bowker Rassow and Ratzke (1978) and Smith et al. (1979).
Company, of 1180 Avenue of the Americas, New York, Lotmar, however, describes an instrument with a tung-
New York 10036. sten light source and moiré fringes, though he shows
Magnification in near vision may be obtained by read- that under conditions of Maxwellian view this is equiva-
ing at a closer than normal distance, or by using hand- lent to an interference system. The fringes are achro-
held or stand magnifiers, spectacle magnifiers or tele- matic and the double images of the source in the pupil
scopic spectacles. The latter may also be designed for are each 0.2mm in diameter. Thorn and Schwartz
distance vision. The optical principles of such devices (1990) showed that grating test objects remained much
are discussed in Chapter 13. more visible in the presence of blur than letter charts,
For near vision, specially designed lenses with magni-
and explained this by the possibility of spurious resolu-
fications up to 8x are readily obtainable, as are com-
tion (see pages 50-51). They consequently questioned
pound systems magnifying up to 20x. A more
whether it was sensible to use gratings for predicting
sophisticated technique uses close-up photography of
postoperative chart acuity. Thibos et al. (1991) point
the reading material with closed-circuit television. The
out that the lateral chromatic aberration of the eye will
screen contrast can readily be increased and may even
blur white light fringes if they are orientated perpen-
be reversed to give white print on a dark background.
dicular to the displacement of the beam paths in the pa-
This is preferred by a high proportion of patients, es-
tient’s pupil. They predict a threefold loss in the acuity
pecially those with opacities in the media, since there is
measurement if the beam is displaced 34-4 mm from
less light from the screen to be scattered in the eye
the pupil centre. This may also affect the results from
(Lowe, 1977; Silver and Fass, 1977). Practical aspects
the next two techniques.
of helping the patient with poor visual acuity are dis-
An alternative approach, devised by Guyton (Boyd
cussed on pages 252-254.
and Guyton, 1983) and termed the Potential Acuity
Meter (PAM — no longer manufactured), projects a Snel-
Retinal function in cataract len chart in Maxwellian view through the pupil. The
It might seem that a patient with moderate or severe aerial image of the pinhole aperture in the pupil is 0.1
cloudiness of the crystalline lens (cataract) would best mm. Thus, most of the light reaching the retina can be
be served by an operation to remove the lens, despite directed through a relatively clear area of a cataractous
the resulting aphakia. The simultaneous presence of de- lens. Hence, a normal acuity task is presented to the
generative retinal changes would make the operation patient instead of the recognition of gratings, which
much less worth while, but the cataract may prevent a may give an optimistic result as already described or
satisfactory view of the retina. The electroretinogram possibly underestimate the acuity through unfamiliar-
discussed previously on page 39 provides a crude meas- ity. Surveys were conducted by Fish et al. (1986) on
ure of the cone and hence the macular response in the patients with macular degeneration but clear media.
eye. Their results showed that the PAM results correlated
A more recent technique is to produce Young's inter- better with Snellen acuities than those obtained with
ference fringes on the retina by imaging two tiny coher- laser interferometry, suggesting a better prediction in
ent sources within the pupil, the fringe spacing being cataract patients. In order to find a reasonably clear
inversely proportional to the source separation. Pro- part of the lens, the pupil should be dilated. An allow-
vided that the beams can pass through relatively clear ance may be necessary for the Campbell effect, whereby
areas in the media, high-contrast interference fringes the visual acuity is less for light entering the eye
will be formed on the retina. Lotmar (1980) points out through a peripheral part of the pupil than through the
that the contrast is not dependent on the intensity of centre. In practice, diffraction at the slide of the Snellen
the coherent beams but on their wave amplitude, chart means that light will enter the eye around the
which is the square root of the intensity. Consequently, imaged pinhole, exactly as in the Abbe theory of the mi-
a reduction of the intensity of one beam to 1% (0.01) re- croscope, where light enters the objective at angles out-
duces the amplitude to only 10% (0.1), giving a fringe side that of the illuminating beam. It is left to the
 Blindness and partial sight 45

reader to calculate the theoretical limit of resolution if three times as many are eligible for registration. About
the real pupil diameter were 0.1 mm. 15% of those registering have no perception of light or
The standard pinhole disc (page 94) provides a sim- perception of light only; the acuity of about 55% varies
pler and much cheaper approach. While the patient from hand movements to 3/60 (20/400), while 30%
views the letter chart, he/she is encouraged to move have an acuity better than 3/60. Blindness is a problem
the head slightly, in order to try to align the pinhole of age in that only 15% of those registered are younger
with a clear zone in the lens, in which case a significant than 50, whereas 25% are between 50 and 69 and
improvement may occur. If the cataract is uniform in 60% are 70 or over. Unfortunately, the younger person
haze, then no clear zone can be found through which has much longer to live with his or her disability. New
to view, so only a small improvement in acuity from registrations show an even greater proportion in the
the reduction in scattered light may result. An objective 70-plus age group.
test is to project an acuity grating on to the retina Patients whose near acuity is N12 or lower and wish
using a direct ophthalmoscope’ (see Chapter 16). Allow- to become members of the Talking Book Service of the
ance for the double passage of light through the media Royal National Institute for the Blind can have their ap-
having been made in the calibration of the grating, the plication form signed by an optometrist. They may
smallest size of detail that can be resolved by the obser- have to pay the annual subscription themselves.
ver should correspond to the patient's present visual In the UK, registered blind people are eligible for var-
acuity if the retina is functioning normally — Brown et ious concessions including an increased tax allowance
al. (1987a). With experience, the clarity of view with and, if necessary, higher rates of supplementary benefit.
the small stop of the ophthalmoscope also gives a similar Braille and Moon embossed-type books and _tape-re-
indication.
corded books are available on loan, while local auth-
The hyperacuity tests (see page 26) have also been
orities can provide welfare services.
used in laboratory investigations (for example, Enoch et
In one of a series of official reports on blindness (De-
al., 1985; Hurst et al., 1995), but have not yet found
partment of Health and Social Security, 1979), the inci-
clinical acceptance.
dence, degree and causes of blindness in England were
Reviews of methods for verifying retinal function in
shown to be broadly similar in the two sexes. Among
the presence of cataract are given by Charman (1987),
children, the major causes are congenital anomalies,
Whitaker and Buckingham (1987), Hurst and Douth-
optic nerve atrophy and cataract. The last two con-
waite (1993), Hurst et al. (1993) and McGraw et al.
ditions, together with choroidal atrophy, glaucoma, dia-
(1996). Recent papers questioning the ability of such
betes, retinitis pigmentosa and other retinal conditions,
tests to predict the postoperative acuity from the pre-
are the main causes of blindness in adults.
operative value include Barrett et al. (1994, 1995) and
A further report by the Department was published in
Bueno and Hurst (1995). To a certain extent, the pre-
1988, presenting statistics for 1976/77 and 1980/81.
sent author feels that, since surgery for cataract is now
Though there has been little change in the annual
undertaken at a much earlier stage when both the
number of new registrations, the increasing life span is
patient’s visual acuity is not severely impaired (around
reflected in the fact that the age group 75 and over con-
6/12) and the retina can be inspected visually (see Chap-
stitutes a growing percentage of the total of the regis-
ter 16), there may not be such a need for these tests,
tered blind. In the four years separating the two periods
though the presence of minor changes in the macular
studied, the percentage rose from 54.1 to 58.6. In this
region can still lead to uncertainty.
most elderly group, retinal degenerative conditions are
the largest single cause of blindness.
Blindness and partial sight Among adults up to 64 years old, diabetic retinopathy
is the largest single cause. A point of particular interest
The British statutory definition for the purpose of regis- is the marked increase in the proportion of women to
tration as a blind person under the National Assistance men who become blind for this reason within the age
Act 1948 is that the person is ‘so blind as to be unable group 55-64.
to perform any work for which eyesight is essential’. A more detailed study of this report has been made by
As a working basis, people have been considered leg- Giltrow-Tyler (1988).
ally blind if: In the USA, a typical definition of blindness is that ‘a
person shall be considered blind who has a visual
(1) the binocular acuity is poorer than 3/60, or acuity of 20/200 or less in the better eye with proper
(2) the binocular acuity is between 3/60 and 6/60 and correction, or limitation in the field of vision such that
there is also considerable contraction of the visual the widest diameter of the visual field subtends an angu-
field, or lar distance no greater than 20°’. This definition may
(3) there are gross field defects, even if the acuity is bet- vary in different States. According to the amended
ter than 6/60. « AMA visual efficiency ratings published in 1955, a
In England and Wales, about 0.2% of the population person would be considered blind if his binocular visual
are on the Blind Register, but it is estimated that two to efficiency was below 10%.
Statistics and clinical data on blindness in the USA are
compiled by a Model Reporting Area on Blindness Statis-
tics. This is a voluntary association of States having uni-
“The Acuity Scope, available from Keeler Ltd, Clewer Hill
Road, Windsor, Berks SL4 4AA. form definitions and procedures for that purpose.
46 Visual acuity and contrast sensitivity

Publication of reports is undertaken by the US Depart- <——- Cycle width >

ment of Health, Education and Welfare.
There is no British legal definition of partial sight, but
registration is normally open to those whose visual
acuity is:

(1) from 3/60 to 6/60 with full visual field,

(2) up to 6/24 with moderate contraction of the field, Luminance
opacities in the media or aphakia,
(3) 6/18 or better if there is a gross field defect. Luminance profile of part of grating

Children with acuities between 3/60 and 6/24 may Figure 3.24. Sinusoidal grating: luminance profile. Curve A
be taught in special schools for the partially sighted, has greater modulation than curve B.

but a child with acuity better than 6/24 will usually be

taught in a normal school.
In England, about 0.1% of the population are regis- assessment is based on the eye’s sensitivity to luminance
tered as partially sighted, but the number eligible for re- contrast. Although ‘square wave’ or Foucault gratings
gistration is thought to be considerably more than this. could be used for this purpose, sinusoidal gratings
The main reason is that registration carries no entitle- (Figure 3.23) are preferred. The name arises from the
ment to the tax and certain other of the concessions fact that a continuous plot of the luminance along a per-
available to the blind. The age distribution of the regis- pendicular to the bars would represent the function
tered partially sighted in England is similar to that of
the registered blind. New registrations account for Yasin) 6
about one-fifth of the total annually.
An important advantage of this type of grating is that
Modulation transfer function and even when defocused or affected by aberrations, its
image generally retains the sinusoidal luminance pat-
the eye
tern.
Basic definitions may be understood by reference to
The sinusoidal grating
Figure 3.24 which shows the luminance curves of two
Conventional clinical assessments of visual acuity are sinusoidal gratings having the same mean luminance
related to the eye's resolving power. Another method of and cycle width.

thant
nN

AN

Se
we
SANT
Wort) we
WN attr atime?
NOAA aattl Ya
SSO \ \
ASS
H Atte cat SA eat ayith Ant
ant SL
eet
agattiaity
HAAN awl WW attAN
RSA
TS
| aww\DSS)

Figure 3.23. (a) A square-wave or Foucault grating. (b) A sinusoidal grating of the same frequency. The upper
drawings show
corresponding three-dimensional representations of the spatial luminance profile (material for this illustration
kindly provided by
Professor J. Barbur).
 Modulation transfer function and the eye 47
Table 3.4 Values for luminance curves A and B in Figure 3.24
eee
e ee ee OA a been at the lower figure of 0.02, the contrast sensitivity
Curve Hes Lier Mean luminance Modulation
would have risen to 50. This higher value indicates a
superior performance.
A 0 80 40 ]
B 30 50 40 0.25

The modulation transfer function

If Lyin is the minimum and L,,,, the maximum lumi- When a sinusoidal grating is imaged by an optical
nance, then system, the contrast of the image is reduced by the ef-
fects of aberrations and diffraction. Nevertheless, it re-
Dwax a Linin
Modulation = (3.16) tains the sinusoidal luminance pattern, though with a
Linaax air lage
lowered modulation. In general, the ratio of the modula-
Table 3.4 gives the values of Linay, Lmin and the modu- tion of the image of a grating of given spatial frequency
lation for the two curves illustrated in Figure 3.24. to that of the object is called the modulation transfer
The modulation can be regarded as the maximum factor. A plot of this transfer factor against spatial fre-
change in luminance from its mean value, expressed as quency depicts the modulation transfer function (MTF).
a ratio of this value. When the minimum luminance is It provides a good indication of the performance of the
zero, as in curve A, the modulation is equal to unity. image-forming system at varying frequencies, not just
In the literature of contrast sensitivity, the term ‘con- the finest.
trast’ has come into general use to denote a numerical Modulation transfer functions for the optical system of
value of modulation as defined by equation (3.16). This the human eye were obtained from a two-stage experi-
is sometimes termed Michaelson contrast, and is usually mental process by Campbell and Green (1965a). In
expressed as a percentage. For purposes of comparison, brief, their method was to form sinusoidal interference
this same definition of contrast is sometimes applied to fringes on the retina by an adaptation of Young's
test charts of both high and low contrast. In other con- double-slit system (see also page 44). In this arrange-
texts including standardization, the contrast of a test ment, the angular separation 9 between successive
chart is defined differently as noted earlier (see page 34 bright fringes is given by
and Exercise 3.16 which derives relationships between
§ (rad)
= (A/a) x 107° (GalZ)
the two expressions).“Occasionally, contrast sensitivity
is expressed in decibels — Verbaken (1987) recommends where 2 is the wavelength (in nm) of the monochro-
that for this purpose the dB scale should be equated to matic light source used (632.8 nm in this experiment)
10 x log Contrast Sensitivity. and a (in mm) the separation of the slits. To vary the
The cycle width of a sinusoidal grating corresponds to contrast of the interference pattern, the source produc-
the ‘grating interval’ of a square grating, but is usually ing it was dimmed. At the same time, the mean retinal
expressed as a spatial frequency. Thus, if the cycle illuminance was kept constant by the addition of a uni-
width subtends an angle of 0° at the observer’s eye, form field of light of the same wavelength. Since the in-
terference fringes are not affected by the eye’s optics,
Spatial frequency v = 1/0 cycles/degree
measurement of the threshold modulation as a function
For example, 60 cycles/degree corresponds to a cycle of spatial frequency gives the contrast sensitivity of the
width subtending 1 minute of arc. Gratings used as test retina and neural system alone.
objects do not necessarily have a uniform spatial fre- To provide a comparable test object viewed directly by
quency. For some purposes it may vary in a definable the entire visual system, including the degrading effects
manner, such as logarithmically. of the ocular dioptrics, a sinusoidal grating was gener-
If a sinusoidal grating is presented to the eye, its ated by means of an oscilloscope with a spectral lumi-
threshold of recognition as a grating is affected both by nance peak at 530 nm. The performance of the eye was
its spatial frequency and its luminance contrast.” As considered not to vary significantly between wave-
the contrast is reduced, recognition becomes harder as lengths of 530 and 632.8 nm if the luminance were the
with other test objects. Moreover, with high spatial fre- same. The contrast sensitivity was determined over the
quencies the loss of contrast in the retinal image is same range of variables as before. For the same observer
greater than with low frequencies, again making recog- with a 2mm pupil, the results are shown by the lower
nition more difficult. curve in Figure 3.25. Since the actual contrast in the
In numerical terms, contrast sensitivity at a given retinal image at the threshold of recognition can be as-
spatial frequency is the reciprocal of the threshold sumed to be the same in both cases, the reduced contrast
value of the modulation as defined by equation (3.16). sensitivity for the grating imaged by the eye can only
It is a measure of the eye's ability to detect small differ- be due to the defects and limitations of the eye’s optical
ences in luminance. system with a pupil diameter of 2mm. The oscilloscope
For example, ifa grating can just be resolved when observations can be repeated with other pupil dia-
the modulation has been reduced to 0.08, the contrast meters.
sensitivity is 12.5. If the threshold modulation had For a spatial frequency of 1 cycle/degree, a sinusoidal
grating viewed at 40 cm would need to have a cycle
width of 7.0mm. As suggested by Figures 3.25 and
*In this context, the term ‘luminance contrast’ has come to
3.26 and confirmed by other results, the spatial fre-
be used as a synonym for modulation in its quantitative sense. quency for which the contrast sensitivity is greatest is
48 Visual acuity and contrast sensitivity

1000 1.0

o fo)
4

100
© rep)
Interference
fringes

Oscilloscope o ‘p
10 display
sensitivity
Contrast 2.8
0.2
factor
transfer
Modulation
2.0

40 50 60 0 10 20 30 40 50
0 10 20 30
Spatial frequency (cycles/degree) Spatial frequency (cycles/degree)

Figure 3.25. Contrast sensitivity of the human eye. Upper Figure 3.27. Modulation transfer function for a human eye
curve: measurements obtained from interference fringes, at various pupil diameters. (Reproduced from Campbell and
assessing retinal/neural function; lower curve: measurements Green, 1965a, by kind permission of the publishers of
obtained from an oscilloscope display, assessing optical as well J. Physiol.)
as retinal/neural factors. (Redrawn from Campbell and Green,
1965a, by kind permission of the publishers of J. Physiol.)
A modulation transfer function can be plotted from
160 the data of Figure 3.25. Because contrast sensitivity is
the reciprocal of modulation, it follows that the modula-
tion transfer factor is the inverse ratio of the sensitivity
for the interference fringes to that for the oscilloscope
80 display. For example, at a spatial frequency of 10
cycles/degree the two values are approximately 206
if and 128, giving a transfer factor of 128/206 or 0.62.
45)
°
At 40 cycles/degree the values are approximately 17.5
at) and 4.9, the transfer factor being 0.28.
~
S The complete graph of the modulation transfer func-
tion for this pupil diameter is shown in Figure 3.27, to-
gether with the curves for pupil diameters of 2.8, 3.8
E
S 20 and 5.8mm, all for the same subject. It can be seen
iG that the curves for 2 and 2.8mm pupils are not only
=
very close together, but actually cross over at about 27
ra cycles/degree. On this evidence, the eye’s performance
3
x 10 changes little within this range of pupil diameters — a
a result confirmed by the lightly curved top of the acuity/
e
fo}
oO pupil diameter graph of Figure 3.6.
Campbell and Green (1965b) showed that the con-
5 trast sensitivity measured binocularly was approxi-
mately 40% better than that found under monocular
conditions over a wide range of frequencies. They attrib-
ee eee eee ee uted this to the summation of signals from the two eyes.
0.0.26 0.44 0.77 1.3 2.3 4.0 6.9 12.0 20.7
Spatial frequency (c/deg)

Figure 3.26. The contrast sensitivity function (mean of

Normalized spatial frequency
measurements on ten normal subjects aged between 18 and 27
If an eye of pupil diameter g had a perfect optical system
years). The bar lines represent +1 standard error. Note that
both scales are logarithmic. (Reproduced from Wright and limited only by diffraction, the minimum angle of resolu-
Drasdo, 1985, by kind permission of the publishers of tion 0,,;, for two point sources would be
Documenta Ophthalmologica and reprinted by permission of
Onin (ead) E22 ig (3.2)
Kluwer Academic Publishers.)
For a sinusoidal grating, with 0,,;, the smallest angu-
about 3 cycles/degree for a typical observer. A limiting lar cycle width which can be resolved, the correspond-
frequency of 30 cycles/degree, corresponding to a cycle ing relationship is
width of 2 minutes, would conventionally be equated
Om in i/g (rad)
to an acuity of 6/6 (20/20), at least for a square-wave
grating. I| 57.3h/g (degrees) (3.18)
 Modulation transfer function and the eye 49

= oO

= co

S ron) Slit pupil

Oo ‘pb
Round pupil
o De)

object)
(image
ratio
Contrast
: oO
0 0.2 0.4 0.6 0.8 1.0 factor
transfer
Modulation
Spatial frequency
ON O22. Se O46 me O/),
Figure 3.28. The modulation transfer function for a Normalized spatial frequency
diffraction-limited eye or system with a slit and a round pupil.
(Reproduced from Westheimer, 1972a, by kind permission of Figure 3.29. The modulation transfer function of a human
the publishers, Springer, Berlin and New York.) eye plotted for a normalized spatial frequency. (Reproduced
from Campbell and Green, 1965a, by kind permission of the
publishers of J. Physiol.)
The maximum spatial frequency (v,,,,) which can be
discerned — the ‘cut-off point’ — is thus
The curves in Figure 3.29 for various pupil diameters
Vmax = 1/98min = 9/57-3A (cycles/degree) (09) of the same eye should not be compared with each
For example, given g = 3mm and A = 560 nm other, but only with the theoretical comparison curve.
The diffraction-limited eye performs better as its pupil
Vn = 3-10 7 /(57:3x 560 x 107") diameter increases and so becomes a harder standard of
= 93.5 cycles/degree comparison.

To facilitate comparison between the MTF of an

actual eye and that of a diffraction-limited eye, the con- The double-pass technique
cept of normalized spatial frequency is used. Irrespective
of pupil diameter and wavelength, the cut-off frequency The double-pass technique requires only one set of ex-
Vmax for the diffraction limited eye is fixed at unity. On perimental results from which to compute the MTF of
this normalized scale, any actual value of v is replaced an eye. It has been used in many investigations. In the
by the normalized value v, such that arrangement described by Campbell and Gubisch
(1966), the image of a narrow illuminated slit is formed
Vn = V/ Vmax
on the fundus. Acting as a diffusing surface, the fundus
From equation (3.19) it follows that reflects a portion of the incident light back through the
pupil. It then passes through a beam-splitter and a con-
Vn = (57.32/9)v (3.20)
verging lens which forms an aerial image of the fundus
with v, and v both in cycles/degree. streak. This can be examined either photographically
In this way a single MTF curve can be used to repre- or photoelectrically, allowance being made for the ef-
sent any diffraction-limited optical system, irrespective fects of the reverse passage through the optical media.
of particular values ofg and 2. Analysis of the light distribution in the streak image en-
The complete MTF for a diffraction-limited eye or opti- ables the line-spread function of the eye’s optical
cal system can be calculated by standard mathematical system to be determined. Its graph resembles a Gaussian
procedures (Westheimer, 1972a). If the pupil were rec- normal distribution curve. By a mathematical process
tangular in shape, with its narrower width g perpen- known as Fourier analysis, the modulation transfer
dicular to the grating bars, the MTF graph would be a function can be computed from the line-spread function.
straight line as shown in Figure 3.28. For a circular In this context, Fourier’s more general theorem shows
pupil, the graph assumes the shape indicated in the dia- that the light distribution across a narrow slit or its
gram. The cut-off point is the same for both. image can be resolved into an infinite series of sine
In Figure 3.29, the MTF curves of Figure 3.27 are waves of increasing frequency.
shown re-plotted on a normalized frequency scale. This The conventional index of the narrowness of a Gaus-
process could have been carried out by using equation sian-type curve is its ‘half-width’ — the width at half the
(3.20). For example, the end-point of the graph for peak value. Graphs of the image line-spread for one of
5.8 mm pupil size in Figure 3.27 occurs at an actual fre- Campbell and Gubisch’s subjects showed the half-width
quency of about 45 cycles/degree, the wavelength to decrease with pupil size: from 6.2 minutes of arc at
being 530 nm. Accordingly, 6.6 mm pupil diameter to 2.2 minutes at 2.4 mm pupil
a, = 2 =9 diameter. For smaller pupil sizes, the half-width in-
EEE SEY Bese creased, reaching 3.2 minutes with a 1.0mm pupil.
Vy=
310) °< LO Over this range, the reduction in the eye’s aberrations
which agrees with Figure 3.29. If continued, the graph becomes increasingly outweighed by the effects of dif-
representing the diffraction-limited system would meet fraction.
the x-axis at the cut-off point where v, = 1. The MTF graphs obtained by Campbell and Gubisch
SO Visual acuity and contrast sensitivity

Table 3.5 Frequency and amplitude of odd-numbered grating of the same spatial frequency but of 1/4 times
harmonics the amplitude. It then follows that the contrast sensitiv-
Harmonic Frequency Amplitude
ity thresholds for square-wave and sinusoidal gratings
of the same frequency and amplitude should in theory
First V 4a/t be in the ratio of 4/n.
Third 3v 4a/3n Since the frequencies of the subsequent harmonics are
Fifth Sv 4a/5n
multiples of the basic frequency (of the first harmonic),
they could all be situated beyond the cut-off point, For
this reason alone it is evident that they can become sig-
nificant only when the basic frequency lies within a re-
stricted range. The limits of this range were explored by
Campbell and Robson (1968) by determining the con-
for their three subjects are broadly similar to the results trast sensitivity thresholds for square and sinusoidal
of Campbell and Green (1965a). For two of their gratings of the same frequency and amplitude. The ex-
subjects the curves for 2.0 and 3.0mm pupils cross pected ratio of 4/m was found to hold good for gratings
over as in Figure 3.27.
2?
of spatial frequency exceeding 0.8 cycles/degree. At
lower frequencies, the ratio increased rapidly, probably
due to selective response by individual neural elements
Square-wave (Foucault) gratings in the visual system to particular frequencies.

Unlike sinusoidal ones, square-wave gratings are easily

produced without special equipment, making them Effects of defocus and spurious resolution
useful experimentally. According to Fourier analysis, a
All the MTF results described above have assumed the
square wave of frequency v and amplitude a, denoting
eye to be in focus for the grating. When it is out of
1 (Linax — Lmin) is equivalent to a sine wave of the same
focus, the theory of both geometrical and physical
frequency v but of amplitude 4a/m plus a series of sine
optics predicts that modulation transfer suffers appreci-
waves of increasing frequency and decreasing ampli-
ably, even for very small errors. This is shown in Figure
tude. Each wave, including the first, is called a har-
3.31 (Charman and Jennings, 1976), which refers to
monic. The nth harmonic has the frequency nv and
the theoretical diffraction-limited eye with a 5mm
amplitude 4a/mn, but in this series only the odd-num-
pupil. Even with an error as small as 0.12 D, the modu-
bered values of n are included, as shown in Table 3.5.
lation falls much more rapidly with increasing spatial
The bold lines in Figure 3.30 show one half of a square
frequency than in the perfect eye. As the image modula-
wave of amplitude a and the corresponding half of the
tion in the defocused eye drops to zero, it falls below the
first harmonic of the equivalent sine-wave series. The
threshold for detection. The grating can no longer be re-
lower part of the diagram shows the third and fifth har-
solved but assumes a uniform grey appearance.
monics. Curves representing the sum of the first and
At spatial frequencies greater than this threshold
third, and the sum of the first, third and fifth harmonics
value, a phenomenon known as spurious resolution
are also displayed. It can be seen that even though
may occur. A simple explanation in general terms can
these curves still oscillate, they steadily approach the
outline of the square wave.
If the third and subsequent harmonics are ignored, a
square-wave grating can be regarded as a sinusoidal

ic
=fey)

S fo.)

transfer
Modulation

0 10 20 30 40
Spatial frequency (cycles/degree)

Figure 3.31. Variation in the modulation transfer function

with defocus for an aberration-free eye with a 5 mm diameter
entrance pupil, according to physical optics. The solid curves
show the MTFs at 450 nm, the broken curves the MTFs at
650 nm, for both positive and negative errors of focus of the
amounts indicated in dioptres. There is very little difference
between the MTFs at the two wavelengths when the errors of
Figure 3.30. Partial generation of a square wave by focus are large. (Reproduced from Charman and Jennings,
compounding sine waves of frequencies of the first, third and 1976, by kind permission of the publishers of Br. J. Physiol.
fifth harmonics. Optics.)
S52 Visual acuity and contrast sensitivity

accompanied by a normal Snellen acuity — hence meas-

urement of low-frequency contrast sensitivity may give
additional information on a patient’s ocular condition.
1000
A review of the role of contrast sensitivity measure-
ments is given by Woods and Wood (1995).
In normal observers, optically corrected if necessary
for the distance of the grating, the difference in contrast
100 sensitivity between the two eyes is usually less than
25%. The variation between individuals, however, can
be much greater (Weatherill and Yap, 1986). As shown
by several studies, age is an important factor (Owsley et
al., 1983: Ross et al., 1985; Wright and Drasdo, 1985;
sensitivity
Contrast—_=oO
Elliott, 1987; and others). Contrast sensitivity declines
with increasing age, particularly in the higher frequen-
cies in the range investigated, 0.5-19 cycles/degree.
Both Owsley and colleagues and Wright and Drasdo
1.0 concluded that the main causes were the reduction in
0.1 1.0 10 100 pupil diameter and increasing absorption by the ocular
Spatial frequency (c/deg) media with advancing age, thus reducing the retinal il-
Figure 3.34. Typical changes in contrast sensitivity function
lumination. Owsley and colleagues found that the fall
with retinal illuminance. The curves are marked with the in contrast sensitivity in the 60 year old could be partly
corresponding retinal illuminance in trolands. In the original reproduced in a younger patient viewing through a neu-
study, the gratings were illuminated with green light (525 nm) tral filter of 0.5 density,” which transmits about one-
and viewed through a 2 mm artificial pupil. (The original data
third of the incident light. They also found that the
are from Van Nes and Bouman, 1967, as replotted by Tucker
and Charman, 1986). (Reproduced by kind permission of the peak of the contrast sensitivity curve shifted from 4 to
publishers of Am. J. Optom.) 2 cycles/degree. Elliott, however, who used interference
fringes to measure the function, concluded that decline
in neural capability was the principal factor. A similar
quency 2 cycles/degree, the modulation transfer would conclusion was reached by Sloane et al. (1988) who
be reduced to about 0.1 by a focusing error of 2.0 D, considered that increased light scatter and absorption
whereas with a frequency of 8 cycles/degree the same by the ageing crystalline lens were important subsidiary
reduction to 0.1 would result from a focusing error of factors.
only 0.5 D. Contrast sensitivity is also impaired by pathological
The contrast sensitivity function (CSF) of the eye is conditions and ocular abnormalities. While its loss from
represented by a graph in which contrast sensitivity — such causes has been well documented, no typical pat-
the reciprocal of the grating modulation at threshold — tern has yet been found in amblyopia. Some amblyopes
is plotted against spatial frequency. Charman (1979) show a loss only at high frequencies, others over the
has investigated this function experimentally for various whole range. This topic will be further discussed on
levels of defocus and pupil diameters. His results confirm page 55.
the greater tolerance of low spatial frequencies to focus-
ing errors. In fact, with normal pupil sizes, extremely ac-
curate focusing was required when the spatial Clinical tests
frequency exceeded about 10 cycles/degree. However,
by using an artificial pupil of 1mm diameter it should For experimental purposes, the contrast sensitivity of
be possible to make reliable measurements for frequen- the eye is usually determined by generating a sinusoidal
cies up to about 25 cycles/degree, given adequate illu- pattern electronically on a TV-type monitor. Simpler
mination. techniques are required for clinical purposes. Those
Whereas clinical tests for contrast sensitivity examine known to the authors will now be briefly described.
the performance of the eye at the lower end of the spatial
frequency spectrum at low contrasts, conventional test Arden Test Gratings*
charts for visual acuity examine it at the high frequency
end and at high contrast. Indeed, the intercept of the The Arden test comprises a set of seven printed plates
contrast sensitivity curve in Figure 3.26 with the spatial covering frequencies from 0.2 to 6.4 cycles/degree
frequency axis should indicate the visual acuity at when viewed at the stipulated distance of 57cm. On
100% contrast. Investigation suggests that the visual each plate the contrast increases from top to bottom,
system has separate channels devoted to interpreting and the patient has to state when he first detects the pat-
specific data, for example, from ranges of different fre- tern as the higher contrast part of the plate is gradually
quencies and orientations. The curve in Figure 3.26 uncovered. The results are compared with the values
could possibly be regarded as the envelope of certain of
these channels. It is also to be noted that the coarser fre-
quencies require functional integration over a much * Optical density is the logarithm to base 10 of the reciprocal
of transmittance (expressed as a ratio, not a percentage).
larger retinal area than the fovea. For these reasons, re-
y+ American Optical Co. Renamed AO Contrast Sensitivity
duced contrast sensitivity at low frequencies can still be Test Plates. :
obtained for normal observers as listed in the instruction Je ||
manual. In a clinical study of this test, Reeves et al.
(1988) found that the significant variation in the results
by different examiners was largely accounted for by dif-
ferences in the technique employed. A similar tendency
E015
had been noted by Yap et al. (1985), who also suggested
that because optometrists’ patients, being mostly ame-
tropic, are not typical population samples, it would be
better for practitioners to compile their own norms for
each age group, than to rely on those in the instruction E=0
manual. This advice applies generally to contrast sensi- Figure 3.35. Cross-sectional profile of the retinal
tivity tests. Elliott and Whitaker (1992) give data for illuminance (£) of the image of a square-wave grating of 100%
the Cambridge gratings and the Pelli-Robson chart, de- object contrast. Gratings of various frequencies have been
superimposed by normalizing, i.e. adjusting the horizontal scale
scribed below.
for each frequency so that one complete cycle is shown for all.
(Reproduced, with new lettering, from Drasdo and Cox, 1987,
by kind permission of the publishers of Clin. Vision Sci.)

The Vistech system*

test chart of square-wave gratings of varying frequency
To utilize the more positive end-point of a forced-choice and contrast, shown to him by Dr J. K. Davis. Although
response, Ginsburg (1984, 1986) introduced his Vistech not intended as a test of contrast sensitivity, it could be
system. A single chart presents five rows of photo- a useful point of departure for such a design. The chart
graphed gratings, each contained within a circle and was subsequently described and illustrated in a joint
with the lines randomly set from a choice of three paper by Davis and Ward (1972).
orientations which the patient is required to identify.
The nine gratings in each row decrease progressively in
contrast by a factor of 1/\/2, while retaining the same Cambridge Low-contrast Gratings*®
spatial frequency. This increases from row to row, cov- This test was designed by Dr A. J. Wilkins and Dr J. G.
ering a range from 1.5 to 18 cycles/degree. Distance Robson and uses square-wave gratings in which the
and near versions of the chart are available, to be used bars are of dot matrix construction. At the testing dis-
at 10 ft and 18 in, respectively. A suitable spectacle cor- tance of 6m, the appearance is that of a bar because
rection needs to be worn. As with the Arden test, the re- the individual dots cannot be discerned. All the gratings
sults can be compared with given norms. have the same spatial frequency of 4 cycles/degree but
Reeves and Hill (1987) and Reeves et al. (1991) have with a different contrast in each of the ten plates in the
presented critical reviews of the test. In particular, they set, varying from 5% to 0.14%.
consider that the large range in contrast covered in The test is relatively inexpensive, simple and quickly
only eight steps means that small changes in sensitivity conducted, and the plates can be placed in any orienta-
cannot be identified. tion, thus allowing the accuracy of the results to be
checked (Wilkins, 1986). Because most pathological
conditions have been shown to cause losses in sensitiv-
Square-wave gratings ity at 4 cycles/degree, or also at this frequency even if
It was pointed out in an earlier section (see page 50) that others are more strongly affected, it is claimed that the
for spatial frequencies greater than 0.8 cycles/degree, a test is effective in detecting such conditions.
square-wave grating should give results for contrast
sensitivity consistently 1.27 times as high as those
A City University test
given by a sinusoidal grating of the same frequency
and amplitude. Provided this is borne in mind, square- Photographically produced square-wave grating plates,
wave gratings offer an attractive alternative to sinu- each of a fixed contrast, are used in this uncomplicated
soidal ones, which are very difficult to produce. apparatus designed at City University (London) and de-
The decrease in the modulation transfer function of scribed by Barbur et al. (1986). The test and its method
the eye with increasing spatial frequency reduces the of use incorporate several novel features including a
contrast in the image of a sine-wave grating but does continuously variable spatial frequency scale. With
not change its form. Drasdo and Cox (1987) have calcu- eight different plates it is possible to determine a com-
lated the image contrast for square-wave gratings of dif- plete contrast sensitivity curve over a frequency range
ferent frequencies. Their results, illustrated in Figure of 1.4-36 cycles/degree. The testing distance is 2 m but
3.35, show an increasing departure from the square- can be reduced to 1m so as to extend the low end of
wave form, together with decreasing amplitude, as the the frequency range to 0.7 cycles/degree.
frequency increases. With this system it is possible to produce absolute sen-
In 1970, the present writer (AGB) was impressed by a sitivity curves comparable to those obtained from elec-

* Obtainable from Keeler Ltd, Clewer Hill Road, Windsor, “Obtainable from Clement Clarke International Ltd, Edin-
Berks SL4 4AA. burgh Way, Harlow, Essex CM20 2TT.
54. Visual acuity and contrast sensitivity

tronically generated gratings. The apparatus is not at velopment from previous work by Regan et al. (1977).
present commercially available but is in use at City Uni- Five specially prepared charts were used, one resem-
versity for research purposes. bling a standard Snellen chart with the same high con-
trast and the other four with decreasing contrasts
covering a wide range. Clinical trials were made with
The Melbourne Edge Test these and also with a sine-wave grating test. From the
results, it was concluded that low-contrast letter charts
Described by Verbaken and Johnston (1986), the Mel- are equally capable of detecting visual loss in patjents
bourne Edge Test is a chart of 20 circular patches of 25 with diabetic retinopathy and Parkinson’s disease, even
mm diameter, spread over four rows. Each is divided
when the visual acuity was normal.
into two semicircular halves by a straight line ‘edge’
A similar study was made by Greeves et al. (1988)
forming a boundary between a darker and a lighter
using specially prepared letter charts of the Bailey—
shade of grey. In this respect, the test has similarities
Lovie design, but at contrasts from 95% to 0.1%. Clini-
with a square-wave grating. The contrast diminishes
cal trials on the control group of 15 normal subjects
with each successive patch. To incorporate the principle
showed the letter charts to give results comparable
of forced-choice response, the edge is set in one of four
with CRT generated square-wave gratings and edge
orientations (0, 45, 90, and 135° in standard axis nota-
tests. Their patients with age-related maculopathy (or
tion) which the patient has to identify. The test is based
senile macular degeneration) showed good agreement
on the principle that the contrast sensitivity measured
in the mid-frequency range. The use of 10% contrast
for a single edge is a reliable indicator of its value at the
charts was recommended to differentiate between
peak of the contrast sensitivity function.
normal patients and those with macular disease.
The utility of low-contrast letter charts in the field of
contact lens practice has been studied by Guillon et al.
Low-contrast test charts
(1988) and Guillon and Sayer (1988). They recommend
Contrast sensitivity testing requires the patient to learn the use of high- and low-contrast charts, the latter at
a new and rather difficult end point criterion. This is 10% possibly supplemented by one at 20% contrast. To
avoided by using a conventional test chart but at much test at scotopic luminances they suggest the use of weld-
lower contrast levels than the normal. ing goggles fitted with neutral filters of density 2, trans-
A notable study of the effects of decreasing luminance mitting 1% of the incident light. Specific luminance
and contrast on Snellen letter acuity was undertaken ranges are indicated. As the result of this procedure, dif-
by Oscar Richards (1977). Eight special test charts ferences in the performance of various types of contact
were prepared, with contrasts ranging from approxi- lenses on the eye can be demonstrated, even if the
mately 90% to 6%. Each was presented at four levels of acuity is similar at high contrast in high illumination.
luminance from about 34 to 0.0034 cd/m? in equal The limb width of a test chart letter can be notionally
logarithmic steps. The 149 subjects were chosen to equated to a spatial frequency by regarding the limb as
represent a typical sample of the general population. half of one complete cycle of a square-wave grating.
With each drop in luminance there was not only the Thus, a limb width of angular subtense 6 minutes of
expected reduction of visual acuity at peak contrast but arc is notionally equivalent to 5 cycles/degree. Conse-
also a marked increase in the rate of decline with de- quently, a low-contrast letter chart is testing sensitivity
creasing levels of contrast. This was especially pro- over a wide range of spatial frequencies. The view was
nounced in the older age groups. At all luminance taken by Pelli et al. (1988) that the main purpose of a
levels and in all age groups the fall in acuity became pre- clinical test is to discover whether subjects with normal
cipitous at contrasts below 20%. Similar results were visual acuity (i.e. at high frequencies) show abnormally
also obtained by Johnson and Casson (1995), whose poor contrast sensitivity at lower spatial frequencies. It
findings in the presence of blur are discussed on page would therefore be preferable to use only one letter size,
Te notionally equivalent to a spatial frequency in the
Using three different test charts with contrasts of neighbourhood of 5 cycles/degree. This is near the peak
88%, 21% and 14%, and a similar range for near, Ho of the normal contrast sensitivity curve.
and Bilton (1986) found that the reduction in visual A similar view has since been expressed by Tunna-
acuity with induced refractive blur up to 2.50 D was cliffe (1989). In the chart which he designed for use in
substantially the same at all three contrast levels. On his own practice, the letters all have a notional spatial
the other hand, ‘diffusive’ blur artificially simulated at frequency of 5 cycles/degree. The drop in contrast be-
four different levels reduced the acuity at a faster rate tween each of the five lines of the chart covers a total
with each drop in contrast. For this reason they advo- range of 0.9 log units, the successive intervals having
cated the use of charts with two different contrast been determined by trial to give good repeatability of re-
levels to help differentiate between causes of visual de- sults on successive days.
gradation.
Low-contrast letter charts designed for clinical use
were described by Regan and Neima (1983, 1984), a de-
The Pelli-Robson chart

Despite their comments on spatial frequency quoted

‘ His figures have been converted here into cd/m~ and (per- above, the Pelli-Robson chart, introduced in 1988,
centage) contrast as now understood in this field. shows 5x5 Sloan letters, of height 49mm to be
 Vision through optical instruments 55

viewed at 1m. This gives a limb width subtense of discrimination in the blue-yellow colour axis. Thus
0.57°, corresponding to about 0.9 cycle/degree. The Arden et al. (1988) developed a computer system for in-
individual limbs of the letters are effectively square- vestigating the loss of contrast sensitivity in ophthal-
wave gratings, and so, however, their third and fifth mologists working with the blue-green light from an
harmonics lie close to the peak of the contrast sensitivity argon laser. Arden (pers. comm.) has suggested the use
function. Zhang et al. (1989) demonstrated that the of a studio-quality TV monitor to present blue gratings
end-point for young observers remained constant de- of frequency 0.6 cycles/degree very briefly exposed on a
spite varying the viewing distance from 0.3m to 3m. yellow background (or vice versa). Loss in colour con-
The chart shows 16 groups of three letters; the contrast trast sensitivity has also been found in ocular hyperten-
of each group decreases from log contrast sensitivity of sives and diabetics.
0.00 (i.e. contrast, not modulation, of 100%) in 0.15
log unit steps to 2.25 — see Exercise 3.17. The subject
Amblyopia
reads down the chart; the faintest group of three letters
for which two letters are correctly identified is generally The ability of the above-described clinical tests to screen
taken as the end-point, though Elliott et al. (1991) sug- successfully for amblyopia is uncertain. Glover et al.
gested giving each letter read correctly a score of 0.05, (1987) concluded that neither the Arden nor the Vis-
the first three 100% contrast letters being ignored. tech tests were satisfactory in this respect because too
Elliott et al. (1990b) found that the letter C was often many false results were given. On the other hand,
misread as the letter O, and recommended that this mis- Brown et al. (1987b) concluded that the Arden gratings
identification should be accepted as being correct. On performed well in revealing interocular differences.
this basis, Elliott et al. (1990a) with young subjects and They thought that if the plates were presented at twice
Reeves et al. (1993) with eye hospital patients selected the prescribed distance so as to double the spatial fre-
for VAs not worse than 6/18, both found a test-retest quency at the high end, the test would become a useful
reliability score around +0.3 or two groups of letters. technique for monitoring amblyopia treatment.
This indicates the change in test score needed to indicate
a change in performance. Because the letters at
Cataract
threshold may take some time to appear, the patient
must be encouraged to continue looking at the chart See the last section in Chapter 15.
for 20 seconds or so to try to see letters in the next
faintest group.
Vision through optical instruments
Rabin and Wicks (1996) report on a similar chart, in
which each successive line of 10 letters decreases in
Optical instruments are used as an aid to vision when
contrast in 0.1 log steps. The 5m letter size is viewed
the angular subtense of the image is too small for resolu-
at 4m, and so is testing at the high frequency end of
tion by the naked or corrected eye, and in astronomy
the CSF. The chart was shown to be very sensitive to
when the luminance is too low.
small amounts (+0.50 DS or +1.00 DC) of blur, early
The minimum angle of resolution of a perfect or aber-
cataract and amblyopia. This is attributed to the shape
ration-free eye is limited by two factors: one is the size
of the CSF curve. As shown in Figure 3.26, a small drop
of the Airy discs formed by diffraction and the other is
in VA from the equivalent of 20.7 cycles/degree to 17
the sensitivity of the retinal/neural system. The latter
cycles/degree would correspond to a drop in contrast
must ultimately set the limit. For example, a perfect eye
sensitivity from about 16 to 35, a factor of more than
with a pupil diameter of 6mm could have a minimum
double.
angle of resolution as small as 25 seconds of arc, if dif-
fraction were the only factor. It does not follow, how-
ever, that the retinal/neural system could distinguish
Use of computer displays detail as fine as this.

While the use of computer displays for laboratory sine-

wave contrast sensitivity testing has already been de- Vision with telescopes and
scribed, the power of modern computers and improve- prism binoculars
ments in the display screen equipment enable them to
Consider an instrument whose objective (object glass) is
provide many charts for subjective examination. The
of aperture d. Its limit of resolution 0 for two neigh-
UMIST Eye Systems and TVA’ provide both grating and
bouring points is given by the standard formula
low-contrast test charts for contrast sensitivity testing.
@ (rad) = 1.22d/d (Sa2aly)

which represents half the angular subtense of the Airy

disc. If the instrument magnification is m, the angular
Colour Contrast Sensitivity
separation 0; of the two points in the image presented
One of the earliest functions to suffer in retinal disease is to the eye is

Q@, = m9 = 1.22mA/d
* Available from Department of Optometry and Vision S22 Wa (3,22)
Sciences, UMIST, PO Box 88, Manchester M60 1QD and
Innomed Corporation, Brea, CA 92621, USA respectively. since d’, the diameter of the exit pupil, is equal to d/m.
56 Visual acuity and contrast sensitivity

The minimum angle of resolution 0. of a hypothetical collect 100 times as much light as an unaided eye with
diffraction-limited eye of entrance pupil diameter g is a 5mm pupil, but will spread it over an area 100 times
given by as large. The image brightness will thus remain the
same, apart from the loss of light by reflection and
scattering.
An accepted basis for assessing the performance of a
binocular in night vision is the ‘twilight efficiency
9; /9. = g/d’ factor’ proposed by Kuhl (cited by Haase, 1952). It
Ifgis smaller than d’, 0; is smaller than 0,. This means takes the general form (md)?, where m is the magnifica-
that the magnification of the instrument is insufficient tion and d is the diameter of the objective. This criterion
for full advantage to be taken of the objective’s aperture. strikes a balance between the two main factors improv-
It should be such that 0; is equal to or greater than 0,, ing the performance of the eye, magnification and
the exit pupil then being no larger than the eye’s pupil. light-gathering power.
Equation (3.24) refers to an optically perfect eye. If we
now turn to a typical human eye, Figure 3.6 shows
that its performance approximates to the ideal only at Vision with microscopes
pupil diameters less than about 2.5 mm. Consequently,
for maximum resolution, the human eye requires the As explained in more detail on pages 247-250, the
magnification to be such that the exit pupil is less than magnification of visual instruments for use with near
2.5mm.
objects is conventionally based on the assumption that
Consider a 10 x 50 prism binocular, the first number the unaided eye would view the object from a distance
denoting the magnification and the second the effective of 250 mm. If the observer's minimum angle of resolu-
diameter of the objective in millimetres. If the user's tion is 0, in radians, the corresponding separation h, in
daytime pupil diameter is 2mm, the magnification millimetres between two object points just resolved is
needed to maximize resolution is 25x. However, even if 2500.. To express 0. in minutes of arc, the conversion
such a specification as 25 x 50 were manufactured, the factor from radians of 1/3437.7 must be applied. Ac-
instrument could not be held steadily in the hands. cordingly,
Indeed, for this reason binoculars for general use are h. (mm) = 0.07270, (S25)
seldom manufactured with magnifications greater than
For a microscope objective of numerical aperture NA,*
12 unless intended for tripod mounting.
the corresponding standard expression is
If the exit pupil is larger than the eye’s pupil, the effec-
tive aperture of the objective is reduced proportionately. h(mm) = 1.22A/2NA
Thus, given a 10x50 binocular with its 5mm exit
Hence, for 4 = 560 nm or 5.6 x 10>? mm,
pupil but a real pupil of only 2 mm diameter, the objec-
tive’s useful aperture would be reduced to mx 2 or h(mm) = 3.416 x 10°-*/NA (3.26)
20mm. The user would be carrying much excess For the eye to take full advantage of the instrument's
weight in daytime. The large exit pupil does, however, superior resolution, its magnification m should equalize
allow more latitude in positioning the binocular in rela- h and h,. From equations (3.25) and (3.26) it follows
tion to the eye. Also, at night, the large objectives give that this condition is satisfied if
a brighter image because of their greater area, provided
of course that the pupil dilates sufficiently. m=h./h
x= 215(NA)6, (Gen)
If aberrations are ignored, a distant source such as a The exit pupil diameter d’ of a microscope is given by
small star is imaged as an Airy disc. According to the the formula
Rayleigh criterion, its angular subtense is twice the
minimum angle of resolution as given by equations
d’ = 500NA/m (6223))
(3.22) and (3.23). Thus, when using a telescope, the ap- It is usually smaller than the eye’s pupil. In this event,
parent angular subtense of the retinal image is diffraction takes place only at the objective of the instru-
2.44//d', whereas with the naked eye it is 2.44/./g. Pro- ment. The size of the eye’s pupil then becomes irrelevant
vided that the exit pupil diameter d’ and the eye’s en- and the value to be assigned to 8, problematical. In gen-
trance pupil g are approximately the same, there is little eral, the conventional value of 1 minute of arc is too
change in the retinal image size, whether the instru- low. Values up to 4 minutes of arc have been generally
ment is used or not. The brightness, however, is in- recognized as more realistic. There is certainly a point
creased by the factor (d/g)?. which is the ratio of the beyond which further magnification becomes ‘empty’.
respective areas of the telescope objective and the eye's
pupil. For the particular case in which the exit pupil
and the eye’s pupil are equal in size, the increase in
“It is extremely dangerous to look through a binocular at
brightness is the square of the magnification. In any very bright objects such as the sun, since the total energy deliv-
event, the illuminance of the retinal image may be ered to the retina is greatly increased and can easily cause a
raised above the threshold, enabling dimmer and serious retinal burn. ;
dimmer stars to be seen by using instruments of increas- + NA = nsin U, where nis the refractive index of the medium
in front of the objective and U is the angle subtended by the
ing objective diameter.
semi-aperture of the objective at the object point on the optical
The image of an extended object is, however, magni- axis. For well-designed objectives, the NA increases with the
fied by the instrument. Thus, a 10 x 50 binocular will power from about 0.1 for a 3x lens to 1.4 for 100».
 References 57

No further detail can then be resolved and a poorer 3.5 A patient claims to be able to discern cars on the skyline
image may result. A similar effect occurs when a news- of a hill 5km away. Is this possible. assuming a minimum
angle of 30 seconds of arc for perception of an isolated object?
paper photograph is viewed under magnification.
3.6 At what distance would you expect an observer with a
As Westheimer (1972b), Charman (1974) and others visual acuity of 6/9 to be able to read a notice with letters
have shown, optimum magnification varies with the 150 mm high?
nature of the object studied. For non-periodic structures 3.7 In the printing of this question how many letters occupy
a print width of 50mm? Use this result to determine the
of low contrast, Westheimer found that the image of
number of letters imaged within: (a) the fovea centralis. and
the Airy disc should subtend at least 5 minutes of arc (b) the macula lutea. taking their horizontal dimensions as 0.3
at the eye. The corresponding value of 6, is 2.5 minutes, and 1.5mm respectively. Assume an eve of normal length
for which equation (3.22) gives the appropriate magnifi- (+60 D image distance) in a suitably accommodated state. the
cation as about 550NA. reading distance being one-third of a metre from the eve’s prin-
cipal point.
Using opaque discs and clear holes in an opaque field. 3.8 Using Figure 3.17. construct a double-sided scale show-
Charman found that measurement of the diameters of ing the relationship between Snellen acuity and Times New
the discs and holes — requiring precise detection of the Roman test letters viewed at 450 mm.
change in illuminance at the boundary — increased in 3.9 From first principles calculate the Sloan and Brown M
number for a letter of x-height 2.2 mm.
accuracy with increasing magnification until it ex-
3.10 Using equation (3.8). calculate the AMA visual effi-
ceeded 1500NA for green light (7.= 530nm). A high ciency rating equivalent to 6/12 (20/40).
level of retinal illuminance was maintained throughout. 3.11 Find the linear misalignment corresponding to 10 sec-
For gratings or periodic structures, the contrast sensi- onds of arc vernier acuity at: (a) 250 mm. (b) 400 mm. (c) 1m.
tivity of the retina was maximal for spatial frequencies 3.12 Express the visual acuities 6/9 (20/30). 6/4.5 (20/13)
and 6/36 (20/120) in decimal notation.
within the range 5-10 cycles/degree. Charman pointed 3.13 Non-standard testing distances are often necessary in
out that optimum magnification for low-contrast objects domiciliary examinations. Convert the following to their ap-
must vary with the spatial frequency. The appropriate proximate 6 m or 20 ft equivalents: 3/6. 53/18. 4/12. 2/9-
value is that which makes the period or cycle width of 3.14 Draw to size the following 18-metre letters in 3 x 4 non-
serif and 5 x 5 serif format: F. R. UC.
the image subtend 6-12 minutes of arc at the eye.
3.15 Show that the relationship between the original AMA
Since 9, then has the same range of values, equation visual efficiency rating (E%) and the corresponding angular
(3.27) shows that the optimum magnification may be detail size (A) as given by equation (3-8) can also be expressed
as high as 2000NA or more. as
At these high magrifications. it will be seen from E% = 100(0.83625*’)
equation (3.28) that the exit pupil becomes very small. 3.16 Show that. if contrast. C. is defined as (L, — L,)/L, (see
Although the effects of ocular aberrations are then mini- page 34) and modulation. M. by equation (3.16). M can be ex-
mal, very small exit pupils can be disturbing. In particu- pressed as C/(2 — C) and C as 2M/(1 + M). Hence. draw up a
lar, specks of dust on the instrument lenses and table of M for C = 1.0 (Le. 100%) to C = 0 in 0.1 steps.
3.17 Draw up a table of actual contrasts for the Pelli-Robson
opacities in the ocular media are rendered visible.
chart. C= 1/10”. where S is the log contrast sensitivity.
3.18 From first principles. derive the relationship Decimal
V = v/30. where v is the grating frequency in cycles/degree.
Exercises

3.1 Construct a graph showing the variation of the eye's

theoretical limit of resolution (in seconds of arc) over the References
range of pupil diameters from 1 to $ mm. Take the wavelength
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+
Spherical ametropia

Main classification of ametropia k. In the myopic eye, the far point is at a finite distance
in front of the eye, the distance k being negative in sign
An unaccommodated eye which brings parallel pencils (Figure 4.2).
of rays from a distant object to a sharp focus on the By means of an effort of accommodation, a myope can
retina is said to be emmetropic. An eye which is not em-
focus objects at a shorter distance than the far point
metropic is termed ametropic. An ametropic eye is said
but not objects beyond it. Vision at such distances
to have a refractive error or an error of refraction. would, on the contrary, be worsened by accommoda-
Since the cause is an optical and not a functional tion. The uncorrected myope is therefore handicapped
defect, it is reasonable to suppose that an optical means by having a very restricted range of clear vision. In ex-
treme cases, this may extend to only a few centimetres
of correcting it could be found.
Ametropia is divided into two main categories: spher- from the eyes. The popular name for this refractive
ical ametropia and astigmatism. In spherical ametropia, state — short-sightedness — is certainly apt.
to which this chapter is devoted, the eye's refractive The myope can, perhaps, console himself with the
system is symmetrical about its optical axis. It is there- thought that since he can focus objects at shorter dis-
fore capable of forming a sharp image, but the retina is tances than is usual, he can obtain larger retinal
not in the right position. In simple terms, the axial images and should hence be able to distinguish more
length of the eye and its focal length are out of step. detail. We may, in fact, be indebted to myopic craftsmen
Since the image on the retina of the unaccommodated for some of the intricate and beautiful works of art
ametropic eye is, by definition, out of focus, vision is ad- which have survived from epochs long before the ap-
versely affected. pearance of optical aids.

Myopia Hypermetropia

If the sharp image is formed in front of the retina (Figure If the pencils within the eye are intercepted by the retina
4.1), the resulting error of refraction is called myopia before reaching their focus (Figure 4.3) the resulting
(from the Greek meaning peering, as through half- error of refraction is hypermetropia. This term is due to
closed eyes). Donders, and means ‘beyond the measure ofthe eye’, re-
The myopic eye can be regarded as having an optical ferring to the position of the eye’s focus relative to the
system too powerful for its axial length. To be focused
on the retina, light must therefore reach it in a state of
divergence. In other words, the object must be at some
finite distance from the eye. The higher the refractive
error, the shorter this object distance must be.
The point conjugate with the fovea of the unaccom-
modated eye is called the far point (or punctum remo-
tum). It is denoted by the symbol Mp and its distance Figure 4.2. The far point of the unaccommodated myopic
from the eye's principal point, the far point distance, by eye.

Figure 4.1. The myopic eye and rays from a distant axial Figure 4.3. The unaccommodated hypermetropic eye and
object point. rays from a distant axial object point.
 ‘Axial’ and ‘refractive’ ametropia 63

or

k= K'=F, (4.3)
The ocular refraction is thus the eye’s dioptric length
minus its power. For emmetropia we must have kK’ = F.
so that K = 0.

Figure 4.4. The far point of the unaccommodated

Example (1)
hypermetropic eye.
A reduced eye has an axial length of 21mm and a
power of +62.00 D. What is the ocular refraction and
retina. Similarly, the term emmetropia means that the
where is the far point situated?
focus is at the retina and ametropia that it is not. The
former term is sometimes shortened to hyperopia, and [ees iit 1336/21 = +63.62D
in lay-person’s language, is the so-called long-sighted- and
ness.
The unaccommodated hypermetropic eye is relatively fh =62 00D
too weak to suit its axial length. As a result, light must Thus
reach it in a state of convergence in order to be focused
K = K' =F, = 41.62 D (hypermetropia)
on the retina. The far point is thus a virtual one, situ-
ated behind the eye (Figure 4.4). Without some form of and
correction, no real object, whatever its distance, can be k = 1/K = 1000/1.62 = +618 mm
sharply focused on the retina. However, if the deficiency
in the eye’s dioptric power can be made up by an effort
of accommodation, distant objects can then be seen
clearly. The young hypermetrope does this quite uncon-
sciously, and since he is then able to obtain a normal
standard of vision he may not even suspect the presence ‘Axial’ and ‘refractive’ ametropia
of a refractive error. o
It is usual to make a distinction between ‘axial’ and ‘re-
fractive’ ametropia. In the former, the eye is assumed to
have its ‘standard’ power +60 D, so that any refractive
Ocular refraction error can be attributed to an ‘error’ in the axial length.
In ‘refractive’ ametropia, the axial length of the reduced
The ocular refraction (or principal point refraction), de- eye is assumed to have its standard value of 22.27 mm,
noted by the symbol K, is the reciprocal of the distance the defect being attributed to an ‘error’ in the power.
k in metres. In words it can be defined as the dioptric dis- In the higher degrees of myopia, there is undoubtedly
tance to the eye’s far point. For example, if a myope’s a tendency for the globe to become elongated, giving
far point is 200 mm from the eye’s principal point, then rise in extreme cases to an abnormal protrusion (propto-
k = —200 mm sis). On the other hand, investigations by Stenstrom,
Tron, Sorsby and others have shown that the important
o— lh OOO 20 Olt 20, On) ocular dimensions, like other bodily measurements,
Since K is a measure of the eye’s ametropia, the term follow a normal distribution law. Sorsby, in particular,
‘ocular refraction’ is not well chosen but is too en- has demonstrated that the growth of the eye is organ-
trenched in the literature and in professional parlance ized in such a way that its focal length tends to keep in
to be easily displaced. step with its axial length. Moreover, as far as the lower
The axial length of the reduced eye is denoted by the degrees of ametropia are concerned, the correlation be-
symbol k’. If k’ is regarded as an image distance, the tween ametropia and axial length is not marked.
corresponding image vergence K’ is given by In short, the distinction between ‘axial’ and ‘refrac-
tive’ ametropia seems devoid of statistical foundation
K' =n'/k' (k’ in metres) and in the opinion of the authors should now be aban-
K' may be called the ‘dioptric length of the eye’. It is doned.
the image vergence needed for sharp retinal imagery. Nevertheless, it is not without point to consider what
For the reduced eye change in ametropia would result from a given change
in axial length, the power of the eye remaining the
Chee Pe (4.1) same. Since K = K' — F,, any change AK’ in the value
in which L’ and Leare image and object vergences re- K’ would produce an identical change AK in the refrac-
spectively. For a sharp retinal image we must have tive error if F. remained constant. We have
L' = K' and the object must be situated at the eye’s far :
Oe ile #)
point, so that “=k and L=K. When these special
values of L’ and L are substituted in expression (4.1), it Differentiating gives
becomes
K'=K+F, (4.2)
64 Spherical ametropia

Thus The ocular refraction therefore indicates the power of

the distance correction needed at the eye's principal
(k’ in metres) (4.4) point.

If +60 D is taken as a mean value for K’, this expression

becomes Spectacle refraction

>f = 3.6 i? dune “VW:

The power of a spectacle lens is universally understood
Ak =———Ak’ (k in millimetres)
n to mean its back vertex power. This is defined as the re-
ciprocal of the distance in metres from the back vertex
= — 2.7 Ak (4.5)
of the lens to its second principal focus.
Thus, an increase of 1 mm in the axial length would From the point of view of ophthalmic prescribing and
produce a change in ametropia of —2.7 D, that is, in dispensing, the numbering of lenses in terms of their
the direction of myopia. Conversely back vertex power has important practical advantages.
For example, if fitted at the same distance from the
Ak = —AK'/2.7 = —0.37 AK’ (4.6)
cornea, any two lenses of the same back vertex power
This relationship is often expressed as ‘a variation of would have the same effect in distance vision, even if
three-eighths of a millimetre in axial length alters the they differed considerably in form and thickness.
refractive state by one dioptre’. As far as distance vision is concerned, and until mag-
Thus, if AK’ is 0.25 D, Ak’ is approximately 0.09 mm, nification properties are considered, we can regard the
which is only slightly greater than the combined length actual lens as being replaced by a thin lens of power
of the inner and outer segments of a foveal cone (about F,,¢ equal to the back vertex power F. of the actual
0.07 mm). lens and situated at its back vertex A, (Figure 4.7). The
position at which A, is placed in relation to the eye
may be termed the spectacle point, denoted by S.
The positive distance d from the back vertex of the
The correcting lens lens to the eye (Figure 4.7) is known as the vertex dis-
tance. Measured to the true cornea, the vertex distance
Principle of distance correction usually falls within the range 10-14 mm, so it can be
The unaccommodated eye is in focus for objects in the taken as 12-16 mm to the principal point of the reduced
plane of its far point. A lens forms images of distant ob- eye.
jects in the plane of its second principal focus. Thus an The power of the spectacle lens needed to correct a
eye is corrected for distance vision by a lens with its given ametropia is called the spectacle refraction and
second principal focus coinciding with the eye’s far presupposes a known value of the vertex distance.
point. Figure 4.8 represents a myopic eye corrected for distance
If the correction takes the form of a contact lens, by a thin lens of power F,, and focal length foes its
represented schematically in Figures 4.5 and 4.6, its second principal focus F’ coinciding with the eye’s far
focal length f, must be the same as the far point distance point Mr. A similar diagram for the corrected hyperme-
k, and so its power’ I’, must be equal to K. tropic eye is provided by Figure 4.9. In each case it is evi-
dent that

k= PMp =PS+SF’ =—d +f,

— fs =a
(od)

yes
a ergy

Figure 4.5. Optical principle of the correction of the myopic

eye by a contact lens for distance vision.

Figure 4.6. Optical principle of the correction of the Figure 4.7. A thick lens of back vertex power F’ replaced by
hypermetropic eye by a contact lens for distance vision. a thin lens of the same power lees

In this context, the ‘power’ of a contact lens denotes its + The symbol F, has been used in preference to F, because
power when on the eye and includes the effect of the liquid- the latter is the standard symbol for sagittal power (in oblique
filled space between the contact lens and the eye. astigmatism).
 The correcting lens 65

which the refraction was determined may also need to

be measured and recorded. This is well understood in
contact-lens practice, where a knowledge of the ocular
refraction K is required.
Where spectacles are concerned, it is not considered
essential to record the vertex distance, provided that
the prescription is of fairly low power, say, 5.00 D or
Figure 4.8. A myopic eye corrected for distance by a thin
spectacle lens. less. If the prescription is of higher power and especially
if close liaison between prescriber and dispenser cannot
be assumed, the vertex distance used in testing should
be recorded in millimetres as in Example (4) below.” In
these circumstances the centration distance should also
be specified.
The report of a Ministry of Health Committee, pub-
lished in 1956, states quite clearly that ‘the onus is on
———— the dispenser to determine whether there will be any
change in the vertex distance, and if so, to modify the
Figure 4.9. A hypermetropic eye corrected for distance by a prescribed power accordingly’.
thin spectacle lens. Since the second principal focus of the correcting lens
should coincide with the eye’s far point (Figures 4.8
and 4.9), the modified prescription can be deduced from
so that
the following rule, namely, if the lens is to be moved
1 1 F, xmm nearer to the eye's far point, reduce its focal
K=~=- =? 4.8
eat af Sd ale die > length by x mm. The converse is also true.

Equation (4.7) can be rewritten as

foo =k+d (4.9) Example (4)

which gives
A prescription reads
— x 4.10) R —8.00 at 16
eek i
Equations (4.8) and (4.10) are useful for analysis, but What lens power would be needed if the vertex distance
numerical calculations are most simply carried out as were reduced to 13 mm?
in the following examples. The lens is to be moved 3mm nearer to the eye,
hence, in this case, 3 mm away from the eye’s far point.
The focal length of the lens must be increased accord-
Example (2) ingly.
An eye with an ocular refraction of +5.00 D is to be cor- Original
f,, = 1000/ —8.00 = —125 mm
rected by a spectacle lens placed at a vertex distance of of
New ff, = (AS =6 33)= Xsan
13 mm. What should be its power?
New F,, = 1000/ —128 = —7.81D
~~ = 1000/ +5.00 = +200 mm
Rounded off to the nearest regular interval, the modified
fso =k+d= 42004 13 =+4+213 mm
prescription would read
= 1000/ +213 = +4.70D
R =7.75 at 13

A useful approximation can be obtained as follows.

Example (3) Let F, be the power of the original lens and let F,, be
the modified power needed when the vertex distance is
An eye is corrected for distance vision by a lens of power
changed by x mm. Then
—15.00 D placed 14 mm from its principal point. What
is the ocular refraction? 1 Fo
—fltxe ltxF,
fp = 1000/ -15.00 = —66.67 mm
= Peeks
?

k = bys —d= —66.67 — 14 = —80.67 mm

K 1000/ —80.67 = —12.40D

The necessary change in power is (F,, — Fo), found from

[Eee a +xF>/1000 (x in millimetres) (4.11)

Change in vertex distance

It should be clear from the above that an ophthalmic 2
“The method recommended in BS 2738 Part 3: Specification
prescription is not strictly complete if it specifies only for the presentation of prescriptions and prescription orders for
the spectacle refraction F,,. The vertex distance d at ophthalmic lenses.
66 Spherical ametropia

The question whether the original power is to be in- Experience has shown that after a first correction for
creased or decreased by this amount follows from the hypermetropia has been worn for some time, a stronger
rule already given on this page. correction may be accepted, part of the latent error
Applied to Example (4), the above approximation having become manifest.
gives As we shall see in more detail in Chapter 7, the ampli-
tude of accommodation (the maximum amount that
F.. —F, =+0.19D
sp
can be exerted) decreases with age at a predictable rate.
which agrees with the answer already obtained. As the amplitude of accommodation declines, so does
Equation (4.11) may also be used to calculate those the proportion of latent to the total hypermetropia. In
powers where a change in vertex distance is important. subjects of primary-school age as much as two-thirds to
On the basis that lens powers are manufactured in three-quarters of the total hypermetropia may be
0.25 D steps, a change of 0.13 D may be regarded as latent, but this proportion will have dwindled to zero
the threshold where a correction for effectivity is neces- by the middle forties, when only about 4 D of accommo-
sary. Thus dation are left.
Hypermetropia, or that part of it which can be cor-
F,,sp —Fy = £0.13 » +xF>/1000
rected by accommodation, is termed facultative. Be-
For contact lens calculations, x will equal the vertex cause of the gradual loss of accommodation with age,
distance, say 15mm, giving F, a value around 3D, hypermetropia of a degree which is unnoticed in youth
while for high-power spectacle lenses, x represents the eventually asserts itself. Any hypermetropia in excess
change in vertex distance requiring a power modifica- of the amplitude of accommodation is termed absolute,
tion. For a +10.00 D lens, x is only 1.3 mm. since it is not correctable by natural means.
The relationship between the various components of
hypermetropia is shown schematically in Figure 4.10.

Hypermetropia and accommodation

Aphakia
There is clearly an intimate link between hypermetropia
and accommodation. The emmetrope needs to accom- Aphakia (from the Greek meaning without a lens) is the
modate only when viewing objects at relatively near dis- condition in which the crystalline lens is either absent,
tances and the uncorrected myope only to see objects or, in very rare cases, displaced from the pupillary area
nearer than his far point. On the other hand, the uncor- so that it plays no part in the eye's optical system. The
rected hypermetrope has to exert a sustained effort of former condition may be congenital, but is usually the
accommodation to see clearly at all and a correspond- result of surgery. With advancing age the crystalline
ingly greater effort in near vision. lens tends to develop opacities — a condition known as
Because ofthis excessive activity, the ciliary muscle of cataract — which would eventually lead to blindness. In
the young hypermetrope acquires some degree of phy- the absence of other pathology, or degenerative
siological ‘tone’, which means that a certain amount of changes, removal of the crystalline restores the possi-
accommodation remains permanently in play and bility of good vision, but a strong plus lens is generally
cannot be relaxed at will. Hypermetropia may therefore needed to make good the deficiency in the eye’s power.
be regarded as consisting of two parts: manifest and Removal of the crystalline lens entails the loss of abil-
latent. The manifest error is measured by the strongest ity to accommodate, so additional positive power is
plus lens ‘accepted’ in distance vision, that is, the stron- needed for near vision.
gest lens with which the visual acuity remains at its Depending upon the operative technique, the after-
maximum level. The latent error is the residue masked effects of surgery on the cornea may leave the aphakic
by involuntary accommodation due to physiological eye needing a correction for astigmatism as well, but
tone. since the major element of the prescription is normally

Total hypermetropia

Latent e pte RD tate amas Lie Manifest

Facultative with age oF Absolute

(ie .

i __) Correctable by lenses

(Tonus) (Purposive)

Corrected by accommodation
Ae Figure 4.10. Classification
of hypermetropia and its
change with age.
 The retinal image in corrected ametropia 67

a high spherical power it is reasonable to consider apha- In this example the eye was previously emmetropic.
kia as primarily a type of spherical ametropia. The aphakic correction needed by any given eye would,
The aphakic eye presents a number of distinctive feat- of course, be affected by any previous error of refraction
ures. In the absence of the lens, the iris tends to recede, and by any significant departure in optical dimensions
giving the anterior chamber an unusually deep and con- from the values assumed in the schematic eye. A com-
ical appearance. The iris also shows a tremulous move- prehensive survey of the range of possibilities has been
ment (iridodonesis) when the eye is turned. Another made by Bennett (1968).
indication is the absence of the third and fourth Pur-
kinje images (see Chapter 12) formed by reflection from
the lens surfaces.
If an operation for cataract is performed on one eye
only, the resulting condition is termed ‘unilateral apha- The retinal image in
kia’. This refractive state presents a number of optical corrected ametropia
problems in an acute form (see pages 262-263).
To study the optics of aphakia one must start with a In studying the formation of retinal images when the
schematic eye in which the crystalline lens is repre- eye is corrected or assisted by a lens, two separate
sented. In the Bennett—Rabbetts schematic eye, treated stages should be distinguished. First, the lens forms a
in detail in Chapter 12, the cornea is represented by a real or virtual image, independently of the eye, in accor-
single spherical surface of radius of curvature dance with the laws of conjugate foci. Secondly, this
+7.8 mm, the refractive index of the humours is taken image becomes an object for the eye. As far as the eye
as 1.336 and the overall axial length in emmetropia is is concerned, the first image becomes a real object if
24.09 mm. After removal of the crystalline lens, this formed in front of the eye and a virtual object if formed
eye has the same construction as a reduced eye
behind it.
although its dimensions are different. Thus we have Figure 4.11 represents an unaccommodated hyperme-
SaaS 36 tropic eye corrected for distance by a lens of power F,,
ee 43080 at a vertex distance d. Parallel rays from the extremity
r 8
O of a distant object make an angle u, with the optical
and axis and are converged by the lens to form a real image
Q', in the plane of its second principal focus F’. The posi-
Pate 1 Sac 9:
K Hi Sage eee tion of Q{ in this plane is determined by the undeviated
ray through the optical centre of the lens, which coin-
which gives K = K’ — F, = +12.38 D. cides with the spectacle point S. The distance F’Q4, de-
This indicates the necessary power of a contact lens in noted by h), represents the image height after the first
situ when used as a distance correction for this aphakic refraction and becomes the object height for the second
eye. refraction, by the eye.
If a spectacle correction were to be fitted at a vertex Ifa line is drawn from QO) through the eye’s principal
distance d of 12 mm, its second focal length ie would point P and continued until it meets the lens at T, then
need to be TQ) represents the path of the ray from Q after refrac-
/
tion by the lens. This ray is incident on the lens at T.
fsp = k+d We can therefore take TP as a ray incident on the eye
= (10007 + 12.38) --12 = 480.78 + 12 at P, making an angle wu with the optical axis. After re-
fraction by the eye, this ray makes a reduced angle w’
= +92.78 mm
with the axis such that u’ = u/n’. The intersection of
from which
this refracted ray with the retina determines the second
image point Q) and its distance h from the optical
F,, = 1000/ +92.78 = +10.78D axis.

Figure 4.11. Formation of

the retinal image in the
corrected hypermetropic eye.
68 Spherical ametropia

Figure 4.12. Formation

of the retinal image in the
corrected myopic eye.

Figure 4.12 shows essentially the same construction Second refraction: Method 2
applied to a myopic eye corrected by a minus lens.
k=fpod==200] 12-212 mm
The retinal image size, hy, can be determined as fol-
lows. First, if u, is considered positive, then —30
“y= hh, /PMep = hy /k= = a 5 (rad)

aioe Upfoyp (Uo in radians) (4.12)

=
uum etna
I eee =a 0.106
.106 (rad
(rad)

a (u, in prism dioptres, A) (4.13) |= —(0. 106 x 24.80 = —2°63 mm

This gives the height of the first image, acting as an

object for the eye.
Next, since this object must lie in the eye’s far point Blurred retinal imagery
plane in order to be conjugate with the retina, the
object and image vergences for the second refraction, Blur-circle diameter
Ly) and L5, must be equal to K and K’ respectively. Thus
The requirements for a sharp retinal image are that after
refraction by the eye, the image-forming pencils are
(4.14)
homocentric (i.e. free from astigmatism) and the image
vergence L’ is equal to K’ (the dioptric length of the
eye). In this chapter, the study of blurred imagery is re-
stricted to eyes with axial symmetry, that is, either em-
metropic or with spherical ametropia. There is thus no
Example (5) defect in the optical image and blurring results only if
An eye of axial length 24.80 mm is corrected for dis- this image does not lie on the retina. In this event, the
tance by a —5.00 D lens placed 12 mm from its principal retinal image is composed of overlapping blur circles
point. Find the size of the retinal image of a distant each corresponding to a point on the sharp optical
image.
object subtending an angle of 15A. (Assume n’ = 1.336)
The size of each individual blur circle is related to the
First refraction degree of focusing error, but is also affected by the pupil
size. In Figure 4.13 the refracting surface of a reduced
fp = 1000/ — 5.00 = —200 mm eye and the retina are each represented by a straight
line perpendicular to the optical axis, the extremities of
UN
the pupil being denoted by H and J. A pencil of rays fill-
—15 >< —200 ing the pupil HJ from an axial object point B is con-
m= M2 100
h! a
verged towards the image point B’, shown in the
diagram as lying behind the retina. If g is the pupil diam-
= +30mm

Second refraction: Method 1

k=fi —d = —200 — 12 = -212 mm

K = 1000/ —212 = —4.72D

Ki = no LESS ae e7'D
"SMe TACO
Dg ke Bi) ea
p= x = Ser 2.63 mm
\ DIC Figure 4.13. Blur-circle formation in the ametropic eye.
 Blurred retinal imagery 69

eter and j the diameter of the blur circle on the retina, L=1000/'=250:= —4,00D
then, from similar triangles
EL =L+ FP, = —4,00 + 62.00 = 58.00 D
ae tee ke
K =K+F, =—6.00+ 62.00 = +56.00D
gv
i ib 56.00
— 58.00
so that a g = Se a
K 56.00

(SF)
fi k’

j=9 ; (4.15) = —8/56 = -1/7 = -—0.14mm

Since, in most real situations, /’ and k’ would differ It will be recalled that due to the wave nature of light
only by a small amount, each would have to be worked the best image of a point source is an Airy disc of finite
out to several decimal places to obtain a value of j in size. The Airy disc should not be confused with the blur
millimetres correct to two decimal places. If, however, circle due to out-of-focus conditions and its effect on
/' and k’ are replaced by the corresponding vergences, the distribution of light in the retinal image should not
the expression assumes a much more convenient form. be overlooked, especially when the blur circle is rela-
Thus tively small. A more detailed treatment is offered by Fry
(USS, WSVAO)),
Safnfl anfk
re 1) Ls

(4.16) Blurred image of an extended object

Since K'=K+F, and L’=L+F,, equation (4.16) Figure 4.14 shows an object BQ situated on the axis of a
could be rewritten as myopic reduced eye. A pencil of rays from Q fills the
pupil HJ, its centre being assumed to coincide with the
= (ie! principal point P. The ray directed toward P is the chief
(4.16a)
a ie ie or central ray of the incident pencil, any cross-section
If the image point B’ lies in front of the retina, expres- of the refracted pencil having its centre on the conjugate
sions (4.16) and (4.16a) still apply, but the result gives refracted ray from P. Consequently, this is the most im-
a negative j. This has no real significance apart from in- portant ray path for the study of blurred imagery. In
dicating a crossing over of the refracted rays before this context, the nodal point has no relevance. For ex-
reaching the retina. ample, in reality a ray aimed at the nodal point N at an
The quantity (K’ — L’) may be regarded as the focus- angle of 30° from the axis could not even enter a 4mm
ing error E in dioptres. In distance vision, L' = F, so that pupil.
The intersection with the retina of the refracted ray
hak =F, =K
through P determines the centre of the retinal blur
in which case circle. Moreover, this ray path is not affected by accom-
modation or by a change in pupil size. Consequently,
jH=gkyKk
even if the size of the blur circle were altered by either
or both of these causes, its centre would not shift. We
may therefore define the basic height hj, of an extended
out-of-focus retinal image as the distance between the
Example (6)
centres of the limiting blur circles.
An unaccommodated eye which has a power of Consider the blurred image of a line of negligible
+62.00 D, an ocular refraction of —6.00 D, and a pupil thickness (Figure 4.15). Its basic height is hj. Every
diameter of 4mm views a point object at a distance of point on the sharp optical image is represented by a
250 mm. Find the diameter of the retinal blur circle. blur circle of diameter j, only a few of which are shown.

Figure 4.14. Basic image

height hj, of an out-of-focus
extended object.
 70 Spherical ametropia

ratio’ defined as

; blur-circle diameter
Blur ratio (BR) = ——H——_—_—__—\
basic height of retinal image

= j/Ny

Experiments by Swaine (1925) showed that some test

letters could be recognized when the blur ratio was as
high as 0.5. .
A theoretical expression for blur ratio in terms of the
unaided vision in various degrees of spherical ametropia
may be derived as follows. From equations (4.17) and
(4.18) we obtain

BR = cegK/K' _—=u
aie
(4.19)
—u/K'
in which wis in milliradians (mrad) if g is in millimetres.
A test letter of size D (denominator of the Snellen frac-
tion) subtends an angle u given by
u = 5D/6 minutes of arc + 0.24D mrad
Hence
BR © gK/0.24D = 4gK/D (4.20)

Figure 4.15. Blurred image of a line object. in which g is in millimetres. The minus sign has been
omitted as irrelevant in this context.
In Figure 4.16, this approximation is represented gra-
The total length of the blurred image is clearly (hj, + j),
phically for pupil diameters of 3 and 4 mm. For example,
while its width is j.
with a 3 mm pupil, the blur ratio of a 12 m (40 ft) letter
From Figure 4.14, we can see that
viewed by a subject with 0.75 D of uncorrected ametro-
pia would be 0.8. The small black circles indicate mean
hp uk at —u/K’ (4.18) corresponding values of letter size D and K as found in

If the object is of height h at a distance /,

200
u = —h/f = —hL

which gives
( wo(o>) sl}
hy = hbk (4.18a) Wwro)| ° oO
24-4 a0% 7 80
The height h’ of the sharp optical image is given by the 184 +-60
familiar expression (metres)
size
Letter (feet)
size
Letter
12 + 40
65 + 20
heh te =k st}

0 0.5 1.0 1.5 2.0

It can be seen that hy, is greater than h’ if the optical Ametropia (D)
image lies in front of the retina. The reverse applies if it
lies behind the retina.
When the summation ofthe overlapping blur circles is
closely examined, it is evident that at the extremities of
60 200
the image the effect of blurring tapers off. Thus, if the 4 mm pupi
image is of a luminous line, the illumination at the
ends falls away. Similarly, if the image is of a black line
on a lighter ground, the contrast is reduced. To some
rs) eS
extent, the effect of blurring on vision is thereby miti-
gated. As with visual acuity in general, a high level of il- co I
‘o\c¢ ioe)oO
eet
lumination could be another mitigating factor. (feet)
size
Letter
COICD
NOI
Sr
(metres)
size
Letter
ONwaHROD

0 0.5 1.0 1.5 2.0

Ametropia (D)
Blur ratio
Figure 4.16. Relationship between unaided vision spherical
Since recognition of the blurred image of a letter de- ametropia. The ordinates represent the denominator D of the
Snellen fraction at 6 m and 20 ft. Black circles: mean of
pends on the relative size of the component blur circles,
experimental results from Figure 4.18: straight lines:
we may conveniently introduce the concept of ‘blur theoretical relationships for stated blur ratios.
 Vision in spherical ametropia 71

clinical practice and shown by the dotted line in Figure and the blurred patch, instead of being uniformly
4.18. It can be seen from Figure 4.16 that Swaine’s cri- bright, has a streaky or structured appearance, no
terion — a limiting blur ratio of 0.5 — is well on the con- doubt the result of diffraction by the fibres of the crystal-
servative side. If the clinical findings are generally valid line lens.
for a 4mm as well as a 3 mm pupil size, recognition of
test letters is possible with blur ratios up to 1.0.
In near vision by the unaccommodated eye at a dioptric
distance L, the blur ratio for an object of height h can Vision in spherical ametropia
be found by dividing equation (4.16a) by equation
(4.18a), which yields
If uncorrected by accommodation, | D of hypermetropia
g(K — L) would produce the same degree of blurring in distance
BR = (4.21) vision as | D of myopia.
hb
The effect on vision of uncorrected spherical ametro-
If, however, the subject exerts A dioptres of accommoda-
pia can be studied by placing a series of plus lenses of
tion while viewing at this distance, the term (K — L)
must be replaced by (K — L— A). known power in front of the emmetropic or corrected
eye. By this means the eye is rendered artificially
myopic and vision cannot be improved by accommoda-
Projected blurs tion.
The results of such experiments are in reasonable
In Figure 4.17 the blurred image of-an object point has a agreement with those of similar studies conducted on
diameter j and subtends an angle 0’ at P, considered as uncorrected myopes. There is some evidence to suggest,
the pupil centre. Corresponding to this angle 0’ is an however, that myopes may, as a result of experience, ac-
angle 0 in object space such that quire some ability to interpret blurred images that may
6 =n’'6@' not be developed in other refractive states.
The mean results of Hirsch (1945), Crawford et al.
This is the angle which the perceived blur could be ex- (1945) and Rubin et al. (1951) are plotted in Figure
pected to subtend at the eye. Its apparent size y when 4.18. In the diagram the abscissa represents dioptres of
projected to a distance x can be calculated from the rela- spherical ametropia S (the minus sign omitted), while
tionship y = x0. An experimental determination can be the ordinate represents the denominator D of the corre-
made by placing a screen at the given distance x and at- sponding Snellen acuity, graduated in a logarithmic
taching two vertical markers to it so as to straddle the scale. The graduations on the right-hand side of the
perceived blur. Their positions are then adjusted so that graph show the value of D in metres when the testing
they appear simultaneously tangential to it. distance d is 6m, those on the left-hand side being the
For a distant object point, the diameter of the retinal values of Din feet when d is 20 ft.
blur circle has been shown to be given by When plotted on this basis the relationship is approxi-
(pee clit Se (417) mately linear, in which case it would be expressed by
an equation of the form
Since
log D=mS+c
ele
a
ea) -S
k’ n!
D (feet) D (metres)
then

6227/0 =jK = 9K (4.22)

in which 0 is in radians and g in metres. Alternatively,
8 (in prism dioptres) = gK (g in centimetres) (4.22a)
The perceived blur of a point source in real or simu-
lated spherical ametropia differs in several respects
from the over-simplified geometrical construction sug-
gested by ray diagrams. The boundary is often ill-defined

© Rubin et a/ (1951)
x Crawford et a/ (1945)
Vv Hirsch (1945)

0 1 2 3
S : Spherical ametropia (dioptres)

Figure 4.18. Relationship between unaided vision and

spherical ametropia as determined by various investigators.
The ordinates are the denominator D of the Snellen fraction at
Figure 4.17. Projection of retinal blur. 6 m and 20 ft.
72. Spherical ametropia

The dotted line in Figure 4.18, representing a reason- the expression relating vision to S for small focusing
able approximation to the mean of all the results plotted, errors should take the form
is in fact the graph of the equation
D = dy/(MAR)? + (p98)? (4.27)
log D (in metres) = 0.58 + 0.73 (4.23)
where MAR is the minimum angle of resolution, i.e. the
or
best acuity expressed for the limb width of the test
log
D (in feet) = 0.58 + 1.25 (4.23a) chart letter. Substituting MAR = 1, p = 0.66 as detailed
in the second work cited, and g = 5 mm gives similar re-
A similar expression can be obtained in terms of deci-
sults to those shown in Figure 4.18 for ametropias up
mal V instead of D. Since V = d/D,
to about 2 D, but predicts better resolution for blurs be-
log V = log d — log D tween 2 D and 3 D.
Because this equation has been derived from a simple
in which d is 6 (metres) or 20 (feet). With the appro-
reduced eye, Smith points out that there are very small
priate substitution, equations (4.23) and (4.23a) both
errors arising from ignoring the separation between the
become
principal points and the entrance pupil of the eye, and
log V = 0.05 — 0.58 (4.24) also of the small changes in their positions with accom-
In general, this gives V a negative value, which needs to modation.
be converted to the standard logarithmic form with a Johnson and Casson’s (1995) four observers also
positive mantissa. For example, if S = 1.00 D, showed a slightly lower drop in acuity than the line in
Figure 4.18, with the rate of deterioration slowing with
log V = 0.05 — 0.5 = —0.45 increasing blur up to the 8D investigated. They also
SS) measured the effects of blur over the range of photopic
and mesopic luminances from 75 to 0.075 cd/m? and
which gives over Michaelson contrasts from 97% to 6%. Roughly si-
V=0.36 milar shaped plots of vision against dioptric blur were
obtained in all cases, the vision deteriorating with both
These expressions should be recognized as approxima- reduced luminance and contrast, particularly when the
tions to a mean about which a certain spread is to be ex- latter fell below 12%. Low-contrast stimuli appeared
pected in practice. Moreover, if myopia of much higher more sensitive to blur than high-contrast letters. The
degree than two or three dioptres is taken into consid- vision dropped by approximately 1 logMAR unit for a re-
eration, the expression relating D and S may take a dif- duction to 1/10 of the previous luminance, and by
ferent form from equations (4.23) and (4.23a). Thus about 0.5 logMAR if the contrast was halved. They con-
Smith (1991, 1996), arguing from an equation similar cluded that the effects of low luminance and contrast
to (4.22a), suggested that vision should be linearly pro- on blur were additive.
portional to gS, giving
D= pgS (4.25)

where p is a constant of proportionality. This might The pinhole and Scheiner discs
depend on the criterion for vision. For example, a clini-
cian might expect a cut-off of 80% correct answers, The pinhole disc
whereas a person undertaking physiological research
might accept a lower proportion of correct answers. The pinhole disc is a useful trial case accessory, its func-
From a clinical point of view, the deterioration in vision tion being to reduce the effective pupil size. This affects
caused by small errors of refraction is more important vision in three different ways. First, if the retinal image
than for very large errors. Very few people have large is in sharp focus and resolution is limited by diffraction,
uncorrected focusing errors, while objective refraction a small pinhole may impair the vision by increasing the
(see Chapters 17 and 18) allows the practitioner to esti- size of the Airy discs. For this reason, the diameter of
mate the required lens power. Depending upon the aber- the pinhole should not be less than 1.0 mm. Secondly,
rations in any particular eye, the drop in vision for any a pinhole reduces the illumination of the retinal image,
given small amount of blur may vary. which again may impair the vision. Thirdly, if the ret-
The results of Smith et al. (1989) can be expressed in a inal image is out of focus, resulting in poor vision, a pin-
slightly different form as: hole will reduce the size of the retinal blur circles and
may bring about a noticeable improvement.
D (in metres) = 5.46gS — 19.14 (4.26)
If poor vision is not improved by a pinhole disc, the in-
where g is in millimetres. dication is that it is not due to a blurred retinal image
The relationship between D and S is sometimes ex- but to some deeper underlying cause.
pressed in the form
log D=mlogS+c The Scheiner disc
Smith (1991, 1996) suggests that this equation was Every point on a retinal blur circle corresponds to a
used to give a more uniform distribution to data where unique ray path from a given object point and hence to
most has been collected for low to medium values of S. a unique point of incidence at the refracting surface.
Because of aberrations and diffraction, he suggests that This is illustrated in Figure 4.19, which shows a pencil
 Triangular obstacle
Common field
of view

Cross-section at U e eS
Figure 4.21. Blurred retinal images and fields of view of the
Cross-section
Scheiner disc pinholes.
at V

Figure 4.19. Point-to-point relationship between an obstacle

and its shadow in the ray bundle. pinholes were set vertically and the upper one occluded,
it is the lower image that would seem to disappear.
In myopia, the doubling is crossed on the retina but
of rays from an object point B filling the aperture of a uncrossed by mental projection. Only the emmetropic
converging lens and brought to a focus at B’. If a small eye, where the common focus of the two pencils lies on
area of the aperture is occluded, say by an opaque tri- the retina, receives an image free from doubling. To dis-
angle, every cross-section of the refracted pencil will tinguish between myopia and hypermetropia it is
show a triangular shadow varying in position and poss- merely necessary to occlude one pinhole and discover
ibly in orientation as shown in the diagram. which of the two images has disappeared.
This basic fact has given rise to a number of different Irrespective of any object viewed through them, the
ways of determining ametropia. For example, if a fine appearance of the pinholes themselves deserves study.
wire is moved across the pupil and the retinal image of For this purpose they can be regarded as luminous
a small distant source is out of focus, the apparent direc- points sources, A and B in Figure 4.21. Since they are
tion in which the shadow moves across the blur indi- close to the eye’s anterior focal plane, they will each
cates whether the eye is myopic or hypermetropic. give rise to an approximately parallel pencil within the
A particularly simple application of the general prin- eye, of the same diameter as the pupil HJ. Provided that
ciple is the disc devised by and named after Scheiner AB is less than HJ, these pencils will illuminate two
(b.1573). It consists of an opaque disc pierced with two overlapping circular areas of the retina, and this is how
holes, each of about 1.0 mm diameter with their centres the pinholes will appear to the subject. The area of over-
2-4mm apart. This separation must always be less lap on the retina, shown shaded in the diagram, corre-
than the pupil diameter. The disc is placed close to the sponds to the common field of view in object space.
eye, carefully centred with respect to the pupil, and the The sensitivity of the device is probably improved by
subject looks at a small distant spotlight. The disc oc- replacing the distant spotlight with a narrow illumi-
cludes the pencil that would otherwise fill the pupil and nated slit. If the holes in the Scheiner disc were set hori-
admits only two narrow separated pencils, as shown in zontally, the slit would need to be vertical. The effect of
Figure 4.20. If the eye is hypermetropic, these pencils such an arrangement is illustrated in Figure 4.22, in
are intercepted by the retina before they unite at their which L and R denote, respectively, the left-hand and
common focus B’. As a result, the subject perceives two right-hand pinholes as seen by the subject; 7 denotes
separated images — an effect known as ‘doubling’. In hy- the perceived slit image seen through the left-hand pin-
permetropia, the illuminated retinal patches are un- hole and r the image seen through the right-hand pin-
crossed in relation to their respective pinholes, but hole. To a myopic subject, the appearance would then
because the retinal image is inverted perceptually, the be as shown in the upper part of the figure in which
doubled images as seen will be crossed. That is, if the

Retina (a) (b) (c)

(d) (e) (f)

Figure 4.22. Subjective appearance of a vertical line seen
through a horizontally orientated Scheiner disc. Upper row:
view seen by a myopic patient; lower row: view seen by a
hypermetropic patient. L indicates the view through the left
pinhole, R the view through the right pinhole; (c) and (f) the
Figure 4.20. Principle of the Scheiner disc test for ametropia. combined view.
74 Spherical ametropia

(a) represents the slit as seen through the left pinhole

and (b) as seen through the right. The combined effect
is illustrated in (c). It could be inferred from Figure
4.22(c) that the doubling is perceived as uncrossed be-
cause it is the left-hand one of the two slit images that
is bounded by the left-hand pinhole. The lower half of
Figure 4.22 represents the corresponding appearances +4 +2 0 —5-—10 —20
to a hypermetropic subject. In this case the doubling is ay
perceived as crossed, the slit image seen on the left at
(f) being bounded by the right-hand pinhole.

Figure 4.23. Principle of the simple optometer.

Subjective optometers
The calibration of the simple optometer can be de-
Optometers in general duced from Figure 4.23. It is assumed that the optometer
lens, of power F, is thin and placed at the spectacle
Methods of estimating errors of refraction are divided
point S. To correct the unaccommodated eye, the test
into two categories: subjective and objective. In the
object must be placed at a dioptric distance L from the
former, reliance is placed on the subject's co-operation
lens such that the image vergence L’ is equal to the
during the test. In objective methods, the examiner
power F,, of the distance correcting lens required.
relies on his own observations and judgement.
Although the term optometer could be applied to any Hence
apparatus for measuring errors of refraction, it is gener- Leelee Fie Ba.
ally confined to devices which obviate or restrict the
need for a set of trial lenses. or
The term was introduced in 1737 by William Porter- L = Fey — Fo
field, a Scottish surgeon (Porterfield, 1737, 1759). He
gave few details of the construction beyond making it and
clear that a Scheiner double-slit aperture was an essen- 1000
tial feature; there was no mention of a lens. / = 4.28
ee Fon EG ( )
During the latter part of the nineteenth century, a
great number of subjective optometers of different types This equation gives the theoretical distance / of the test
were devised, but they have since been superseded in object from the lens, enabling the bar of the optometer
everyday practice by more reliable methods of refrac- to be graduated directly in terms of F.,.
tion. Objective optometers, discussed in Chapter 18, As indicated in Figure 4.23, which has been drawn to
have long been in demand both for clinical use and for scale, the interval of graduation is far from uniform.
research. Another disadvantage of this simple form of opt-
The subjective optometers described below are limited ometer is that the apparent size of the image varies con-
to those of historical or particular technical interest. siderably as the test object is moved along the bar. If Q
is a point on the test object (Figure 4.24), its locus as
the object is moved is the straight line QT parallel to
The simple optometer
the optical axis of the optometer lens. If OT is taken as
The simple optometer consists essentially of a plus lens an incident ray path, the refracted ray path is TF), F)
of power about +8 or +10D, mounted at the end of a being the second principal focus of the optometer lens.
graduated bar along which a test object can be freely Consequently, TF’, or TF’, produced backwards is the
moved. The device is usually held by hand such that image locus on which Q’, the image of Q, is bound to
the lens is close to the eye. The test object, initially lie. If Q4 and Q} are two different positions of Q’, it is evi-
placed at the remote end of the bar, is moved towards dent from the diagram that Q) subtends a greater angle
the eye until it is seen clearly. If the subject has suc- at the eye than Q). The closer Q’ lies to the lens, i.e. the
ceeded in relaxing his accommodation completely, the greater the myopic correction required, the larger the
test object will then be at such a distance from the lens apparent size of the test object becomes.
that its image is formed at the eye’s far point where it is
conjugate with the fovea. Oz

Unfortunately, the subject's knowledge that he is ~ «2 *9cus Of Q’

looking at a physically near test object — no matter
where its image may be — is bound to stimulate an invol-
untary effort of accommodation, especially so in young
subjects. Because of this ‘proximal’ accommodation,
the test object is brought too close to the eye. In conse-
quence, the results recorded err in the direction of
myopia. This is a major disadvantage of all such devices
employing a palpably near test object. Figure 4.24. Varying magnification of the simpie optometer.
 Subjective optometers 75

In his Bakerian lecture to the Royal Society, delivered

in 1800 and published in 1801, Thomas Young de-
So OOK
scribed an improved Porterfield optometer for clinical x= = = 57 (4.30)
use. In Young’s model, a straight line was engraved (0)

along the centre of the bar, appearing as an elongated

X when viewed through a Scheiner double-slit aperture. Since the image of Q must invariably lie on the ray
The apparent point of intersection of the two lines, path TF), or TP produced, the image of the test object
being free from doubling, must be conjugate with the subtends a constant angle u at the eye’s principal point.
fovea and thus mark the position of the eye’s far point. It can also be seen from equation (4.30) that the dis-
Another innovation was the addition of a +4.00 D lens tance through which the test object must be moved
placed close to the eye to enable the instrument to be from its zero position at F, is directly proportional to
used in cases of hypermetropia. It is characteristic of the refractive error.
Young's genius that he noted a general tendency to ac- To determine the spectacle refraction, the optometer
commodate on the part of the subject and advised that must be moved slightly forward from the position
the glasses prescribed (for myopia) should be ‘two or shown in Figure 4.25 so that F’, coincides with the spec-
three degrees [power intervals] lower than that which tacle point S. The distance x’ now becomes SMp which
is thus ascertained’. is equal to the focal length f,, of the correcting spectacle
lens (Figure 4.11). Consequently, the calibration equa-
tion becomes
~1000 Fy,
sleds! ©sein ih (4.31)
The Badal optometer
The improved form of optometer introduced in 1876 by Although the image of the test object continues to
the French ophthalmologist Badal has two important subtend a constant angle u at F,, its angular subtense
advantages: its power scale is uniform and the apparent at P will now vary with the state of adjustment. The var-
size of the test object is not greatly affected by the state iation will nevertheless be small compared with that of
of adjustment. the simple Porterfield~Young construction because of
Only one lens is used, but it is moved forward so that the much greater proximity of F/, and P.
its second principal focus F, lies either at the spectacle The Badal principle is embodied in Schober’s subjec-
point S or at the eye’s principal point P, according to tive optometer (Rodenstock) designed for domiciliary
whether the spectacle refraction or the ocular refraction use and is also used in a number of more elaborate ob-
is the result desired. jective optometers.
In Figure 4.25, the instrument is positioned to deter-
mine the ocular refraction, F’, coinciding with P.
If x is the distance of the test object BQ from the first
Telescopic optometers
principal focus F, of the optometer lens, x’ the distance
of the image B’Q’ from the second principal focus F’, of The optometers described so far have used a fixed lens or
the optometer lens and f’, the second focal length of the lens system in conjunction with an adjustable test
optometer lens, then, from a general relationship discov- object which can be moved through a range of near dis-
ered by Newton and named after him, tances. An alternative arrangement is to use a fixed test
object at a normal testing distance together with an ad-
xx’ = —f? (4.29) justable lens system. By this means, the stimulus to
proximal accommodation is reduced.
so that One possibility, described by Von Graefe in 1863, is to
use a Galilean telescope and to vary the separation be-

x=—
fe tween object glass and eye lens to alter the vergence of
bY the emergent light. Racking the eyepiece towards the
eye produces a convergent (plus) effect, away from the
To be seen distinctly without accommodation, the test eye a divergent (minus) effect. The telescope tube can
object must be positioned so that its image lies in the thus be graduated to show the effective power in diop-
eye’s far-point plane. In this setting of the instrument tres as the eyepiece is moved back and forth. A bin-
ocular version was introduced by Von Graefe in 1865.
~ = PMp
=k Two drawbacks of this type of optometer should be
noted: the dioptric scale is not a uniform one and the
apparent size of the test object varies with the state of
adjustment. These drawbacks are removed in an
ingenious telescopic optometer described in 1951 by
Dudragne. A +20 D lens, fixed in position, is placed so
that its second principal focus lies in the spectacle
plane. In front of this lens is a —20 D lens that is axially
movable. When in contact with the +20 D lens the com-
bined power is zero, but as the minus lens is moved for-
Figure 4.25. Principle of the Badal optometer. ward, the combination produces variable plus power.
76 Spherical ametropia

Measured at the spectacle point, this power is directly axial length corresponds to one dioptre of ametropia? Verify
your result algebraically.
proportional to the movement of the —20D lens at a 4.4 If, in the standard reduced eye of power +60D and
uniform rate of 1D per 2.5 mm of movement. n’ = 1.336, the refractive index were increased by 5%, what
To cope with myopia, a second —20 D lens is placed in would its refractive condition be?
the spectacle plane, its power being effectively reduced 4.5 Calculate the ocular refraction corresponding to a spec-
tacle refraction of: (a) +8.00 DS, (b) —8.00 DS. Assume the
as the first minus lens is moved forward from the zero
spectacle point to be 14 mm from the eye’s principal point.
position. 4.6 A reduced eye (n’ = 1.336) has a corneal radius of
The optometer is used in conjunction with a distant 5.75 mm and an axial length of 21.6mm. What lens placed
test object. It was shown by Dudragne that the lens 15 mm from the principal point of this eye will correct it for dis-
system used produced an image of very nearly the same tance?
4.7 (a) A myope is found to require —12.00 D, the spectacle
size as that which would be given by a single correcting
point being 13 mm from the reduced surface. Determine the dis-
lens placed at the spectacle point. tance correction required if this vertex distance were altered to
(i) 11 mm, (ii) 15 mm. (b) Repeat (a) for an original correction
of +15.00 D, all other values being unchanged.
The cobalt disc 4.8 (a) An eye of axial length 25 mm sees clearly an object
which is distant 500 mm. What is the power of the eye, as-
A simple form of subjective test based on the chromatic suming n’ = 1.336? (b) If the object is 2mm high, what is the
aberration of the eye was introduced many years ago. size of the retinal image?
It made use of a plane filter of cobalt blue glass — the 4.9 Calculate the position and size of an object which forms a
‘cobalt disc’ - which absorbs most of the middle region sharp image 0.1 mm high on the retina of an uncorrected and
unaccommodated hypermetrope of +5.00D, assuming the
of the visible spectrum while transmitting a sufficient static power of the eye to be +60 D and n’ to be 1.336. What
proportion at each end, red and blue. Since the eye is a is the nature of this object?
strong positive system exhibiting marked chromatic 4.10 An eye with axial myopia is corrected for distance by a
aberration, its focal length for the longer (red) wave- —8.00 D sphere placed 14 mm from the reduced surface. Find
the size of the retinal image, in this corrected eye, of an object
lengths is appreciably greater than for the shorter
15m high at a distance of 1.056 km. Also find the size of the
(blue) wavelengths. In general, the retinal image of a image that would be formed in the standard emmetropic re-
small white source will be formed by overlapping red duced eye and hence determine the relative spectacle magnifi-
and blue diffusion circles. If both foci are in front of the cation (first answer divided by second).
retina, as in myopia, the red blur circle will be smaller 4.11 In general, an ametropic eye is corrected for distance by
a lens of power F,, at a distance d from the reduced surface of
than the blue because the red is more nearly in focus.
the eye, which has a power F, and a refractive index n’. Find
The subject should thus perceive a small reddish spot an expression for the size of the retinal image of a distant
surrounded by a blue ring. The reverse applies in hyper- object subtending an angle w.
metropia. It is commonly assumed that the ‘best focus’ 4.12 An object 50 mm high is situated on the optical axis of
would normally correspond to the middle of the visible the standard emmetropic reduced eye at a distance of 200 mm
from its principal point. Calculate: (a) the basic size of the
spectrum,
blurred retinal image (that is the distance between the centres
The object of the test is therefore to find the spherical of the limiting blur circles) and (b) the total extent of retina
correction which causes the red and blue foci to straddle stimulated, assuming a pupil diameter of 4 mm.
the retina, such that the two blur circles are equal in 4.13 A —2.00D myope of reduced eye power of +60 D views
a test chart at a distance of 6 m. Find the diameter of the retinal
size.
blur circle corresponding to each object point, assuming a
The cobalt disc, though once a standard trial case ac- pupil diameter of 5mm and also the basic size of the retinal
cessory, is now obsolete. However it is worthy of men- image of the 6-metre and 60-metre letters.
tion because of the current widespread use of Comment on the legibility of these two letter sizes on the
‘bichromatic’ tests based on a similar principle. A more basis of the figures obtained.
4.14 An eye of standard power and —10.00D of myopia
detailed examination of the rationale of such tests will looks through a Scheiner disc at a bright point of light 6m
be found in Chapters 6 and 15. away. The pinholes are each of 1 mm diameter and their cen-
tres are 3 mm apart on a vertical line. The upper pinhole is cov-
ered with a red filter. Giving dimensions, describe what the
subject will see, projected on a plane at the same distance as
Exercises the luminous point.
4.15 When the eye is under water (n = 1.334), the power of
the cornea is almost abolished and the eye could reasonably be
4.1 Find the position of the far point for each of the following
regarded as a (thin) crystalline lens of power +20 D situated
ocular refractive errors: (a) 2.50 D, (b) +5.00 D, (c) £7.50 D,
18 mm from the retina. Assuming a pupil diameter of 4mm, in-
(d) £10.00 D.
vestigate (on paper) the possibility of distinguishing under
Make a graph of the results, choosing suitable scales for each
variable.
water a 60-metre letter at half a metre from the crystalline
lens of the naked eye.
4.2 Calculate the static refractive error (if any) of each of the
4.16 A simple optometer has a thin lens of power +8.00D,
following reduced eyes, taking n’ as 1.336:
the test object being 2mm high. Find the size of the retinal
corneal radius axial length image when the instrument is focused: (a) for an axial hyper-
(a) 5.58 mm 21.42 mm metrope of +5.00 D spectacle refraction, (b) for an axial myope
(b) 5.30 mm 21.20 mm of —5.00 D spectacle refraction. Assume the optometer lens to
(c) 5.42 mm 25.89 mm be situated in the spectacle plane, 15 mm from the principal
(d) 5.86 mm 22.22 mm point of the reduced eye.
4.17 (a) A Badal-type optometer has a thin lens of power
4.3 Assuming a reduced eye of power +60 D and n' = 1.336, +8.00 D arranged so that its second principal focus coincides
calculate the axial length for values of spherical ametropia at with the principal point of the eye under test. Show that the
2.50 D intervals from —10.00 D to +5.00 D. Draw a graph of scale can be uniformly calibrated to record the ocular refraction
your results. On the basis of this graph, what variation in and find the interval of graduation per dioptre of ametropia.
 References NN

(b) Assuming a test object 2 mm in height, find the size of the

retinal image when the instrument is focused: (i) for an axial References
hypermetrope of +5.00D ocular refraction, (ii) for an axial
myope of —5.00D ocular refraction. (c) Where would the BADAL, J. (1876) Optometre métrique international. Annls Ocu-
second focal plane of the optometer lens need to be placed to list., 75, 101-117
give constant retinal image height irrespective of axial length? BENNETT, A.G. (1968) The corrected aphakic eye: a study of ret-
4.18 An unaccommodated eye views a point source at a finite inal image sizes. Optician, 155, 106-111, 132-135
distance for which it is not in focus. Rays drawn from opposite CRAWEORD, J.S., SHAGASS, C. and PASHBY, 1T.J. (1945) Relation-
extremities of the pupil through the eye's far point intersect a ship between visual acuity and refractive error in myopia.
vertical plane through the source at P and Q. Show that PQ is Am. J. Ophthal., 28, 1220-1225
the apparent size of the blurred image of the source when pro- DUDRAGNE, R.A. (1951) Optometre a variation continue de
jected to this plane. puissance. International Optical Congress 1951, pp. 286-298.
4.19 A +1.00D absolute hypermetrope with a 2 mm pupil London: British Optical Association
and a —3.00 D myope with a 4mm pupil each view a Bjerrum FRY, G.A. (1955) Blur ofthe Retinal Image. Columbus: Ohio State
screen (for testing visual fields) at a distance of 1m. Both University Press
patients are uncorrected. Find the blur ratio for a target sti- FRY, G.A. (1970) The optical performance of the human eye. In
mulus of 1mm diameter and comment qualitatively on the Progress in Optics (Wolf, E., ed.), Vol. 8, pp. 51-131. Amster-
effect of the blur on the fields plotted, taking into account the dam and London: North-Holland Publishing Co.
intensity of retinal illumination, summation areas and visual GRAEFE, A. VON (1863) Optometrie. Annis Oculist., 49, 200—
thresholds. 208
4.20 Equation (4.21) shows the blur ratio for an uncorrected HIRSCH, M.J. (1945) Relation of visual acuity to myopia. Archs
and unaccommodated eye viewing a near object to be propor- Ophthal. N.Y., 34, 418-421
tional to {(K/L) — 1} for given values of g and h. Plot graphs of JOHNSON, C.A, and CASSON, E.J. (1995) Effects of luminance,
{(K/L) — 1} for values of K from —8.00D to +8.00D: (a) contrast and blur on visual acuity. Optom. Vis. Sci., 72,
when L = —2.00D, (b) when L = —4.00 D. From these results, 864-869
discuss the change in the blur ratio on bringing an object PORTERFIELD, W. (1737) Essay concerning the motions of our
closer. eyes. In Medical Essays and Observations, Vols 3, 4. Edinburgh:
4.21 A Dudragne optometer is constructed from plus and ‘A Society in Edinburgh’
minus 16.00 D lenses. Show that the scale for the —16.00 D PORTERFIELD, W. (1759) Treatise on the Eye. Edinburgh: Hamil-
lens movement is linear and calculate its travel for each dioptre ton and Balfour
of the subject’s ametropia. RUBIN, L., SILVERSTEIN, H. and SILVERSTEIN, I. (1951) The sig-
4.22 A myopic reduced eye with a 3 mm pupil views a car at nificance of Snellen acuity in uncorrected myopia. Am. J.
100 m. If the rear lights are 1.5 m apart and the retinal blur cir- Optom., 28, 484-488
cles just touch, what is the ametropia? SMITH, G. (1991) Relation between spherical refractive error
4.23 Use equation (4.11) to evaluate the lens power that and visual acuity. Optom. Vis. Sci., 68, 591-598
gives rise to an effectivity difference +0.13 D for a vertex dis- SMITH, G. (1996) Visual acuity and refractive error. Is there a
tance change of (a) 12 mm, and (b) 2mm. What is the rele- mathematical relationship? Optom. Today, 36(17), 22-27
vance of this to (a) contact lens practice and, for (b), the SMITH, G., JACOBS, R.J. and CHAN, C.D.c. (1989) Effects of defo-
dispensing of high-power lenses? cus on visual acuity as measured by source and observer
methods. Optom. Vis. Sci., 66, 430-435
SWAINE, W. (1925) The relation of visual acuity and accommo-
dation to ametropia. Trans. Opt. Soc., 27, 9-27
YOUNG, T. (1801) On the mechanism of the eye. Phil. Trans. R.
Soc. 1800, 92, 23-88 + plates
5
Astigmatism

Astigmatism in general in the same plane as the arc but not passing through its
centre of curvature C;. In spectacle lens terminology,
Spherical lenses and systems of coaxial spherical sur- the meridian of minimum curvature is known as the
faces possess symmetry about an optical axis. Subject to ‘base meridian’, BB in the diagram. It corresponds to
paraxial limitations, rays diverging from a point on the the axis meridian of a cylindrical surface. The meridian
axis are converged to (or made to diverge from) a conju- of maximum curvature, CC in the diagram, is perpen-
gate axial image point. Pencils of rays having this type dicular to the base meridian and is called the ‘cross
of symmetry are termed stigmatic (from the Greek curve’. In the type of torus illustrated (known as ‘barrel
stigma, denoting the mark made by a pointed object). formation’), the base meridian has the same curvature
There is another class of reflecting and refracting sur- as the generating arc GH, while the curvature in the
faces termed astigmatic which possess a lower order of cross-curve meridian is that of the equator MM of the
symmetry and which do not form point images of axial complete torus.
object points. A property common to all astigmatic sur- An astigmatic lens or system is one which has at least
faces is that they have two mutually perpendicular prin- one astigmatic surface. The simplest lens of this type,
cipal meridians, the curvature of the surface varying having one plane and one cylindrical surface, is called
from a minimum in one of these meridians to a maxi- a ‘plano-cylinder’ or ‘plano-cylindrical lens’. Such a
mum in the other. Corresponding to the curvature in lens may be as, for example,
each of the two principal meridians is a different ‘princi-
pal power’ as given by equation (2.3) on page 8. The as-
tigmatism of the surface may be expressed in dioptres
as the difference between the two principal powers.
The simplest astigmatic surface is the cylindrical,
shown in Figure 5.1. It can be regarded as generated by
the rotation of a straight line LL about an axis of revolu-
tion YY parallel to it. Only a small part of the surface,
such as the circular area shown in the diagram, would
be used. The meridian of minimum curvature, zero in
this case, is AA which is parallel to the axis of revolution
and thus called the ‘axis meridian’ or simply the ‘axis’.
The meridian of maximum curvature is PP, which is
perpendicular to AA and known as the ‘power meri-
dian’. The radius of curvature in this meridian (r.) is
that of the circular cross-section of the complete cylin-
der.
Another form of astigmatic surface, commonly used
in spectacle lenses, is the toroidal, one form of which is
illustrated in Figure 5.2. This surface forms part of the
complete figure known as a ‘torus’, which is generated
by the revolution of a circular arc GH about an axis YY

* For many years, the term ‘base curve’ has meant both the
surface power of the flattest meridian of a toroidal surface and
y.
an identification of the power of the front surface of the lens.
This was sensible when almost all lenses had toroidal front sur- Figure 5.1. The cylindrical astigmatic surface. The circular
faces, but these are now rare. Hence, the author has adopted area denotes the part used: AA its axis meridian and PP its
the term ‘base meridian’ rather than ‘base curve meridian’ in power meridian. Principal powers: zero along AA, +4.00 D
the present text. along PP, equivalent to plano/+4.00 DC axis AA.
 Ocular astigmatism 79

astigmatic lens or system by a correcting cylinder. For

example, a convex plano-cylinder could be neutralized
by a concave plano-cylinder of equal (and opposite)
power. The two lenses would fit together to form a paral-
lel plate of zero power. It is not necessary for the correct-
ing lens to be in contact with the given astigmatic lens
or system. Like a correcting lens for spherical ametropia,
its power can be adjusted to suit the separation between
the two. It is on this basis that the astigmatism of an
eye can be neutralized by a correcting cylinder, the
spherical power of the lens simultaneously correcting
any accompanying spherical ametropia.
For a fuller treatment of astigmatic lenses, the reader
is referred to any modern textbook on ophthalmic
lenses.
Even spherical refracting and reflecting surfaces give
rise to what is termed ‘oblique astigmatism’, unless the
incident pencil is normal to the surface. If the incidence
is oblique, symmetry is lost and the refracted pencil (if
narrow) exhibits characteristics very similar to those of
the axial pencils formed by astigmatic lenses or systems.
Oblique astigmatism is an important geometrical aber-
ration affecting lenses and optical systems in general.
Refraction by astigmatic systems can be studied by
Figure 5.2. A barrel-shaped toroidal surface. The circular
area denotes the part used, BB the base meridian (of shallowest considering each of the two principal meridians sepa-
curvature), CC the cross-curve meridian (of steepest curvature). rately.
Principal powers: +3.00 D along BB, +7.00 D along CC,
equivalent to +3.00 DS/+4.00 DC axis BB. C, is the centre of
curvature of the arc GH

Ocular astigmatism
Plano/ +2.00 DC
Most human eyes show at least a slight degree of astig-
in which +2.00 DC denotes a plus or convex cylindrical
matism. There are two contributory factors. First, the
surface of power +2.00 D. A lens bounded by one spher-
cornea is seldom truly spherical, even in the immediate
ical and one cylindrical surface is termed a ‘sphero-
vicinity of the eye's optical axis. By means of an instru-
cylinder’ or ‘sphero-cylindrical lens’. It is specified as in
ment called a keratometer (see Chapter 20), the curva-
+1.50 DS/ +2.00 DC ture of the front surface of the cornea can readily be
measured to a sufficient degree of accuracy. The evi-
denoting a +1.50D spherical surface combined with a
dence of several large-scale investigations has proved
+2.00 D cylindrical surface. beyond doubt that in early life the cornea tends to be
In general, any astigmatic surface can be regarded as
slightly astigmatic with the meridian of maximum cur-
combining an element of spherical power with an ele-
vature in or near the vertical — see, for example, Figure
ment of cylindrical power. It is optically equivalent to a
21.4. Corneal astigmatism of this type is called ‘with
sphero-cylindrical lens. The cylindrical surface is a lim- the rule’. If the meridian of maximum curvature lies in
iting case in which the spherical element is of zero or near the horizontal, the astigmatism is said to be
power. ‘against the rule’.
The cylindrical element of power is invariably the dif- The curvature of the back surface of the cornea is far
ference between the two principal powers. In the case more difficult to measure, but there is evidence to sug-
of toroidal surfaces, the following rules can be applied: gest that at least in cases of marked corneal astigmatism
(1) spherical power, that of weaker principal meridian, both surfaces have the same general configuration.
(2) cylindrical power, power in stronger principal meri- This would mean that a small fraction — about one-
dian minus power in weaker. tenth — of the corneal astigmatism due to the front sur-
face is neutralized by the back surface. As we shall see
For example, if the principal powers of the toroidal in Chapter 20, the calibration of the keratometer makes
surface illustrated in Figure 5.2 were +3.00D (base an arbitrary allowance for the effects of the back surface
meridian) and +7.00 D (cross-curve meridian), the sur- of the cornea.
face would be optically equivalent to the sphero-cylinder The second possible source of ocular astigmatism is
the crystalline lens. Either or both of its surfaces may
+3.00 DS/ +4.00 DC be astigmatic, though accurate measurements of their
In the same way that a +5.00 D spherical lens, for ex- curvature are difficult to make. Even if both surfaces
ample, could be ‘neutralized’ or reduced to zero by a could be regarded as spherical, any decentration or tilt-
—5.00D spherical lens placed in contact with it, it is ing of the crystalline lens with respect to the cornea
possible to neutralize the cylindrical element of an would give rise to oblique astigmatism. Whatever the
SO Astigmatism

90 90
Image formation in the
NVA 135 45
180
astigmatic eye
180 0 2 180 0
For most purposes, ocular astigmatism can be studied on
CY 35 225 315
90 270 the basis of the reduced eye. The single refracting sur-
face is then supposed to be toroidal in form with different
(a) (b) (c)
curvatures and different powers in two mutually per-
Figure 5.3. Standard axis notation (ISO, Tabo, Axint). pendicular principal meridians. To distinguish between
Observer's view. (a) Preferred upper semi-circle notation, (b) them we will denote the meridian of greater curvature
alternative lower semi-circle notation, (c) complete 360°
by a and the meridian of the lesser curvature by 8. The
protractor.
subscript letters « and f will be used in the same way.
Thus
cause, any astigmatism due to the crystalline lens is
F,, = power of eye in stronger principal meridian
simply known as ‘lenticular astigmatism’. This compo-
nent can conveniently be supposed to account for any and
difference between the corneal astigmatism as given by
the keratometer and the total ocular astigmatism as in- F, = power of eye in weaker principal meridian
dicated by the spectacle lens found necessary to correct
Given an object at a dioptric distance L, the respective
it. due allowance having been made for the vertex dis-
image vergences after refraction by the eye are
tance.
Leake (5.1)
and

Lg =L+Fs (5.2)
Axis notation
Strictly, the ocular astigmatism, Ast, is merely the differ-
Numerous different systems have been in use for speci- ence between F', and Fg, and no plus or minus sign
fying a particular meridian of the eye, the axis direction need be given to it, but since it is sometimes convenient
of a correcting cylinder and the base setting of a pre- to do so, we may write
scribed prism. Although there are alternative methods Ast = F, — Fg or br (633))
for expressing the prism base setting, the International
Standards Organization has adopted the scheme known Figure 5.4 is an isometric drawing (though not to
variously as Standard Notation, Tabo” or Axint? in its scale) showing the main features of the refracted pencil
1986 standard: ISO 8429 Graduated dial scale, repub- within an astigmatic eye. Purely for convenience, the
lished as BS 6903: 1987 Graduated dial scales for principal meridians have been taken as horizontal and
ophthalmic instruments. According to this method, a mer- vertical, the latter being the more powerful one as in as-
idian is specified by the anticlockwise angle which it tigmatism ‘with the rule’.
makes with the horizontal. The viewpoint is that of an Consider an incident pencil of rays from an object
observer looking at the eye or at the lens as worn, and point B on the axis. The rays incident at points on the
the same system is used for the right and left eyes or vertical meridian « will be converged to a focus B, on
lenses. the optical axis. Incident rays contained in other vertical
The notation may be represented graphically on pre- sections of the pencil will be brought to a focus in the
scription forms by either Figure 5.3(a) or (b), but the same plane as B, but at different distances from the
former is preferred because it is consistent with the axis, thus forming a horizontal focal line of which B4, is
‘360° protractor’ shown in Figure 5.3. This protractor the mid-point. Similarly, rays incident at points on the
is used in some countries for specifying the base setting horizontal meridian B will be focused at an axial point
of prescribed prisms. It has the advantage of being a By lying at a greater distance from the surface than B/,
more concise notation for this purpose than any other. because of the lower power in this meridian. As in the
In view of the ISO standard, the protractor is no longer previous case, the axial focus Ba will be extended into a
focal line — this time vertical — by the refracted rays pas-
recommended in BS 2738 Part 3: 1991 Specification for
sing through other horizontal sections of the lens. The
the presentation of prescriptions and prescription orders for
ophthalmic lenses. rear focal line is always parallel to the more powerful
meridian. Assuming that the limiting aperture (in this
In writing prescriptions, the degree sign is deliberately
case, the pupil) is circular, the cross-section of the re-
omitted so that, for example, 15° cannot be mistaken
fracted pencil is, in general, elliptical, its dimensions
for 150 or vice versa. By convention, the horizontal set-
and shape varying with the distance from the lens. As
ting is denoted by 180 and not by 0.
we have seen already, the ellipse degenerated into a
line in each of the two principal image planes. Dioptri-
cally — not geometrically — mid-way between these
From the initial letters of Technisher Ausschuss fiir Brille-
noptik. planes, the cross-section of the pencil is circular. This
+ As adopted in 1950 by the International Federation of ‘circle of least confusion’ is shown in Figure 5.4, its
Ophthalmological Societies. centre being denoted by B}. It is customary for the dis-
 Image formation in the astigmatic eye S81

Figure 5.4. Isometric drawing of a refracted astigmatic

pencil in with-the-rule astigmatism. The first (horizontal) focal
line through B4, is due to the more powerful vertical » meridian.
The second (vertical) focal line through By, is due to the less
powerful horizontal f meridian.

Figure 5.5. Analysis of the refracted

astigmatic pencil by superimposing the
cross-sections in the two principal
meridians.

tance between the two focal lines to be called the ‘in- Then, from the similar triangles in the diagram, the
terval of Sturm’, but Thomas Young was undoubtedly following expressions are readily deducible:
the first to describe the geometrical structure of an astig-
matic pencil.
The lengths of the focal lines and the diameter of the
Length (a) of first focal line
circle of least confusion can readily be found with the
{274} {a1
aid of a diagram such as Figure 5.5, in which cross-sec- Ea I rrr tal fae IN eae
tions of the astigmatic pencil in the two principal meri- t is
dians are superimposed. The rays in the more powerful
meridian converge to the first focal line through BJ, =a (5.4)
while the second focal line passes through 3p. The
lengths of these two lines, denoted by a and b respec-
tively, are each determined by the cross-section of the Length (b) of second focal line
pencil in the other meridian. It is evident that the circle
of least confusion must have its centre at B, where the A Ja—t.
B a7 es |eo iB
two cross-sections of the pencil have the same width, z. b= a = } afim \
Let the distances of B,, By, and B, from the eye's
g Ast pea
principal point P be denoted by /4,/, and /, respec- =eLi, (5.5)
tively, and let g denote the pupil diameter.
S2. Astigmatism

Diameter (z) of circle of least confusion

=a Tee Pe ae
5 Va {ao S| .
(5.6)
ze Ba
Mixed
— CHA CMA —>
oe )
(5.7) SHA SMA
and

:=01 Li,
(Eeeaok
; +L,bY Li,
ae + Li
Ast coe
(5.8)
© O06 © Position of retina

Figure 5.6. Classification ofastigmatic refractive errors

according to position of retina in relation to focal lines. CHA,
compound hypermetropic astigmatism; SHA, simple
Example (1) hypermetropic astigmatism; Mixed, mixed astigmatism; SMA,
An astigmatic reduced eye (n’ = 1.336) with a pupil simple myopic astigmatism; CMA, compound myopic
astigmatism.
diameter of 5mm has a power of +62.00 D in the 30°
meridian and +64.00 D in the 120° meridian.
Determine the main features of the image of an axial the two focal lines is situated at the principal focus of
object point at a distance of 1 m from the eye’s principal the corresponding meridian, F, and F5. There are five
point. different possibilities:
The numerical work can be conveniently set out in
parallel columns. (1) Compound hypermetropic astigmatism (CHA)
The retina is situated in front of the first focal line.
120° Meridian («) 30° Meridian (f) (2) Simple hypermetropic astigmatism (SHA)
The retina is situated at the first focal line.
Ls, —1.00 D —1.00 D
(3) Mixed astigmatism
fie +64.00 D +62.00 D
jee +63.00 D +61.00 D The retina lies between the focal lines.
33 1336 (4) Simple myopic astigmatism (SMA)
o: raee = 21.2 mom. = +21.90 mm The retina is situated at the second focal line.
63 61
(5) Compound myopic astigmatism (CMA)
Length of
_ .f 63-61 es) ceed The retina lies behind the second focal line.
focal lines ne ae ae = eG
= 0), 1/5: 9iminm. = 0.164 mm

Circleof L,=4{63+61} =+62.00D The distance correcting lens

least
confusion // — 1326 = +21.55mm Corresponding to each of the two principal meridians of
62
an unaccommodated astigmatic eye is a separate far
63 — 61
15) ee eae 0.081 mm point. The correcting lens must be astigmatic, its prin-
63+ 61
cipal meridians aligned with those of the eye and its
principal powers such that the second principal focus
These calculations assume that the presence of the
coincides in each case with the eye's far point.
retina may be ignored.
As with spherical ametropia, the ocular refraction K
It should be noted that the first focal line, associated
of an unaccommodated astigmatic eye represents the
in this case with the 120° meridian, will be perpendicu-
power of the correcting lens placed in contact with the
lar to this, i.e. at 30°. The second focal line will be at
eye.
IAW,
This example illustrates a general proposition that
can be inferred from a study of equations (5.4)-(5.8). Example (2)
Since L', and Lg differ only by the amount of the ocular
astigmatism, which is relatively small, the two focal An astigmatic eye has principal powers of +64.00D
lines must be of very nearly the same length, about along 60° and +68.00 D along 150°. Its dioptric length
twice the diameter of the circle of least confusion. K’ is +61.00 D. What is the ocular refraction?

Along 60° Along 150

Ke +61.00 D +61.00 D
Classification of astigmatism ie +64.00 D +68.00 D
K=K'—F, —3.00 D —7.00D

A self-explanatory method of classifying astigmatism in

This result could be expressed in sphero-cylindrical
the unaccommodated eye is based on the position of the
form as
retina in relation to the focal lines of the refracted
pencil (Figure 5.6). Given a distant object point, each of K = —3.00 DS/—4.00 DC axis 60
 Astigmatic blurring 83

To find the spectacle correction needed at a given

vertex distance, for example, 14mm, the procedure is ras
Or.
\O

oe ‘O
exactly as for spherical ametropia. Thus: wa

Along 60° Along 150°

K —3.00D —7.00D (a) (b) (c)

k —333.3 mm —142.9 mm Figure 5.7. The retinal image in uncorrected astigmatism:
d 14 mm 14 mm (a) the blur ellipse due to a point object, (b) the blurred image of
ISSE Cl = figs SS IS).3 satan —128.9 mm a line parallel to the major axis of the blur ellipse, (c) the
ES ore aD) —7.76D blurred image of a line perpendicular to the major axis of the
blur ellipse.
The power of the correcting spectacle lens would thus be
—3.13 DS/—4.63 DC axis 60 cal blur on the retina with its long axis at 30°, as
or, in the abbreviated form commonly used in practice, shown in Figure 5.7(a).
The image of a line of negligible thickness could be
—3.13/—4.63 x 60
constructed simply by considering the line as a number
This procedure could be reversed in a self-evident of points, each separately imaged as an elliptical blur. If
manner (see Example (3) on page 65) to determine the the line were at 30°, that is, parallel to the long axis of
ocular refraction, given the spectacle refraction and the the individual blur ellipses, the image would be formed
vertex distance. ; as indicated in Figure 5.7(b). This is clearly the most fa-
To compensate for a change in the vertex distance, vourable orientation, in which the blurring is least ap-
the method on page 65 should be applied to each princi- parent. It is equally evident that the blurring would be
pal meridian of the lens in turn . worst in the meridian perpendicular to this, as indicated
in Figure 5.7(c).

Example (3)
A prescription reads Images of extended objects
+12.50/+3.50 x 170 at 14 In the case of astigmatism, the blurred retinal image of
What modified power would be needed at 12 mm? an extended object can be constructed by the method
In this case, the spectacle plane is being moved 2 mm previously described in relation to spherical ametropia
nearer to the eye's far points, so the focal lengths of the (see pages 69-70). There are two main steps: one is to
lens must be reduced by this amount. Accordingly: determine the basic size of the retinal image, the other
to calculate the dimensions of the blurred patch on the
Along 170 Along 80° retina corresponding to any point on the given object.

Original power F,,, +12.50D +16.00 D

Jig +80.00 mm +62.50 mm Example (4)
—2 mm —2.00 mm —2.00 mm
New f,, +78.00 mm +60.50 mm An unaccommodated astigmatic eye of axial length
Modified power +12.82D +16.53D 23.00 mm, pupil diameter 4 mm, and ocular refraction
—1.00 DS/—3.00 DC axis 60
These principal powers are given by the lens
views, at a distance of 6m, an 18-metre test letter V of
+12.82/+3.71 x 170
5 <4 format. Find the principal dimensions of the
Rounded off to the nearest 0.25 D, the modified prescrip- blurred retinal image.
tion would be The basic size of the retinal image is found by ignoring
12.75) 3.75 4170 atl2 the effects of out-of-focus blurring, that is, by imagining
the pupil to be indefinitely small. In Figure 5.8, the test
letter is represented by the object BO lying on the eye's
visual axis and subtending an angle u at the eye's princi-
pal point P, which is also taken to be the centre of the
Astigmatic blurring
Qa
Images of straight lines
The intersection of an astigmatic refracted pencil with
the retina may form an ellipse, a circle or a line. In gen-
eral, there is some degree of elongation as a result of
which lines in or close to one particular orientation
will be seen more clearly than any other. This is one of
the main characteristic features of vision in the astig-
matic eye.
Suppose, for example, that with a given eye every
object point at a certain distance gives rise to an ellipti- Figure 5.8. Basic retinal image height ht, of object BQ.
S4 Astigmatism

Myopia Retina Hypermetropia

2.00 1.00 1.00 2.00 3.00 eendegnn
in play

7 ° ' (a) O
- °o | (b) 0.50D
- (Oo | (c) 1.50D
(a) (b) “a ae | (d) 2.500
Figure 5.9. (a) The basic inverted retinal image of test letter Figure 5.10. Effect of accommodation on the position of the
V. (b) The blur ellipse corresponding to a single point of the astigmatic focal lines in relation to the retina.
object, drawn to the same scale.

of least confusion in terms of their ametropic distance

pupil. The upper extremity of the basic retinal image lies from the retina. For example, 1.00D in front of the
at the centre of the fovea, at M’. Its lower extremity R is retina represents the image position corresponding to
determined by the refracted ray PR, conjugate with QP, 1.00D of myopia and so on. The scale in Figure 5.10
making an angle uw’ with the visual axis such that has been numbered on this basis.
ein =\0.75u Consider a case of compound hypermetropic astigma-
tism in which the ocular refraction is
Since the axial length of the eye is 23 mm, the basic
height hi, of the retinal image is given by +0.50 DS/+2.00 DC axis 90

hy, = MW’/R = —23u = —23 x 0.75u with the accommodation fully relaxed. A distant object
point would give rise to a horizontal focal line 0.50 D
Viewed at 6m, an 18-metre test letter subtends an
behind the retina, a circle of least confusion 1.50D
angle three times as large as the 6-metre letter, that is,
behind the retina, and a vertical focal line 2.50D
15 minutes of arc or m/720 rad. Hence,
behind it, as in Figure 5.10(a). In general, the effect of
= tf F220, exerting A dioptres of ocular accommodation is to move
all the features of the refracted pencil towards the eye's
and
principal point by this same dioptric amount. Conse-
OX OV KG he quently, the exertion of first 0.50 D, then 1.50 D and fi-
i= al = =0.075 mm
720 nally 2.50D of accommodation would place, in turn,
Since the letter is of 5 x 4 construction, the width of the the horizontal focal line, the circle of least confusion,
basic image will be four-fifths of hj, or 0.060 mm and and the vertical focal line on the retina, as shown re-
the line thickness 0.015 mm. spectively in Figure 5.10(b), (c) and (d). It should be
To determine the dimensions of the individual retinal noted that the dioptric separations between these var-
blurs of which the image is composed, we need only ious features of the refracted pencil remain unchanged
apply equation (4.16) or (4.17), whichever is appropri- by accommodation.
ate, to each principal meridian in turn. In this case we The best position of focus of an astigmatic pencil evi-
may use equation (4.17) since it is customary to regard dently lies within the region bounded by the two focal
an object at 6 m as lying at infinity. Thus lines. The exact position depends on the nature of the
object viewed. For example, the plane of the circles of
Along 60° Along 150° least confusion would not be the best position of focus
for an object consisting mainly of fine lines parallel to
kK 23.00 mm 23.00 mm
Ki= 1336/k +58.09 D 58.09D one of the eye’s principal meridians.
K —1.00 D —4,00D
g 4mm 4mm
if = I —(0.069 mm —0.275 mm

This shows that each point on the object gives rise to

Vision in uncorrected astigmatism
a retinal blur ellipse measuring approximately
0.28 x 0.07 mm, the long axis parallel to the 150° mer-
Unaided vision in the astigmatic eye is affected by a
idian. In Figure 5.9, which has been drawn to scale, the
number of different factors: the amount of astigmatism,
basic (inverted) retinal image is shown at (a) and the
the type of astigmatism, and the axis direction.
blur ellipse at (b). The retinal image of the test letter
can be visualized by imagining every point on the basic
image (a) to be replaced by an ellipse of the relative "size
and shape indicated at (b). In this instance it is fairly evi- Amount of astigmatism
dent that the letter could not then be recognized.
It follows from equations (5.4)—(5.8) that, all other fac-
tors being equal, the dimensions of the focal lines and
Effect of accommodation of the circle of least confusion of an astigmatic pencil
are directly proportional to the amount of astigmatism
When studying an astigmatic pencil, it is often helpful to in dioptres. This has a direct bearing on the unaided
think of the position of the two focal lines and the circle vision, subject to the other factors involved.
 The stenopaeic slit 8&5

Type of astigmatism; mean mean ocular refraction is on the side of myopia or hy-
ocular refraction permetropia.

Consider a single pencil of rays from a distant object

point. Given the pupil diameter, the retinal blur depends Axis direction
on which cross-section of the astigmatic pencil lies on
Since vertical and horizontal lines predominate in test
the retina and on whether any improvement can be
letters as well as in most of the objects in our environ-
brought about by accommodation.
ment, vision is poorest when the ocular astigmatism is
To simplify the discussion, we shall introduce the
at an oblique axis, all other factors being equal. In
term ‘mean ocular refraction’ to denote the mean of the
printed matter, where lower-case letters predominate,
refractive errors in the two principal meridians of an as-
there is no doubt that the vertical strokes are collec-
tigmatic eye. For example, given an ocular refraction of
tively the most important. One reason is that the as-
—1.00 DS/—2.00 DC, indicating myopia of —1.00D in
cending strokes of letters such as b, d, h and t are
one principal meridian and —3.00D in the other, the
important clues to their recognition, as are the tails of
mean ocular refraction would be —2.00 D. It is evident
letters such as p and y. Another important factor is
that the mean ocular refraction gives the position of
that in printed matter there is usually less space be-
the circle of least confusion in terms of ametropia. In
tween the letters on a line than between the lines them-
terms of the powers needed in the spectacle plane, this
selves. Consequently, if horizontal focal lines or ellipses
is often termed the mean refractive error, the mean
are being formed on the retina, the letters will appear
sphere or the equivalent sphere.
to ‘run together’ and become indistinct or illegible.
In simple and compound myopic astigmatism, the dis-
Although the analogy should not be pushed too far, a
tance vision cannot be improved by accommodation. In
reasonably good idea of the effect of astigmatic blurring
such cases the vision would be expected to be approxi-
can be given by photography. Figure 5.11 shows a por-
mately the same as in spherical ametropia equal to the
tion of a test chart of 5 x 5 test letters photographed
mean ocular refraction.
normally and through a +1.00DC plano-cylinder in
In cases of simple and compound hypermetropic astig-
four different axis settings. The effect of this lens is to
matism, the subject can place the most favourable
simulate the condition of simple myopic astigmatism.
cross-section of the astigmatic pencil on his retina, pro-
Though there is little to choose between the 90° and
vided that sufficient accommodation is available. Sup-
180° directions, the legibility is markedly inferior in the
pose that the circle of least confusion is brought into
oblique directions. For comparison, a photograph with
focus. Equation (5.8) shows its diameter z to be given by
a blur from a +0.50 D spherical lens is included.
Peet Figure 5.12 presents a similar set of photographs of
Lbs, part of a reading test card in Times Roman lettering. In
this case there is a marked difference between the verti-
but the mean of the two image vergences L, and Le. cal and horizontal axis setting, the print being quite legi-
must in this case be equal! to the dioptric length K’ of ble when the vertical lines are in focus but nearly
the eye and so illegible when they are blurred.
Perhaps the best way for the student to study the ef-
g Ast
Z (29) fects of uncorrected astigmatism on vision is by simulat-
Die
ing various astigmatic refractive states with the aid of
In the case of spherical ametropia, however, we found trial lenses. They should be held close to one eye while
the diameter j of the blur circle in the unaccommodated the other is occluded. An illuminated pinhole, an illumi-
eye to be given by nated narrow slit and a Snellen letter chart provide ex-
cellent test objects for this purpose.
j= ak (4.17)
K’
Thus, for the same pupil diameter, the circle of least con-
fusion given by x dioptres of astigmatism is only half The stenopaeic slit
the size of the blur circle given by the same amount of
spherical ametropia. This simple device was once in fairly common use as a
This can be a useful pointer to the amount of astigma- means of testing for astigmatism, sometimes as an ad-
tism: the estimate for a case of spherical ametropia is junct to an optometer. Greatly superior methods have
simply doubled. For example, a vision of 6/18 would in- now taken its place, but there is a certain historical in-
dicate spherical ametropia in the neighbourhood of terest attached to the device, and the principle on
1.00 D or astigmatism of about 2.00 D if it could be as- which it is based may still find occasional applications.
sumed that the most favourable part of the pencil was The stenopaeic slit is a trial case accessory consisting
focused on the retina. of an opaque disc having a central slit aperture about
In the unaccommodated eye with mixed astigmatism, 1 mm in width. Correctly centred, it has the effect of re-
only one focal line is behind the retina. There is thus, ducing the effective pupil diameter in the meridian per-
in general, a more limited scope for the improvement of pendicular to the slit.
vision by accommodation. Much depends on the posi- The first use of the device is to locate the principal
tion of the circle of least confusion, which may be in meridians of the astigmatic eye. Provided that the indi-
front of or behind the retina according to whether the vidual blurs (focal lines or ellipses) composing the ret-
 AL. AL
tN C TNC
OLHA OLHA
eC TEN O —EcTNO
CLOH NA L_ONMNA
AELONHCT .¢€

(a) (b)

AL AL
TNC ™NC
OL IA OLHA
Ro TNS® =cT™
mt bth aA TclLtwee
© 4 it otuacec-
(d)
(c) is)

AL Figure 5.12. Portion of a near test chart photographed (a) in

focus, (b) through a +0.50 DC lens at axis 180, (c) axis 90, (d)
axis 45. Blur ratio for the N14 letters approximately, 0.67
(/ = —540 mm, other details as for Figure 5.11).

TNC with the slit at 180°, the refractive error is approxi-

OLHA mately —0.50 DS/—1.00 DC x 180.
The diagram in Figure 5.13 will help to explain this
“aecrnod rule. The upper part (a) of the diagram shows a typical
4i GUMS astigmatic pencil when the entrance pupil is circular,
or #8 YHA? the principal meridians being horizontal and vertical
Sees wy (f) and the astigmatism with the rule. The lower part (b) of
the diagram illustrates the action of the stenopaeic slit
when it is vertical. The waist of the pencil is accentuated
Figure 5.11. Portion of test chart photographed: (a) in focus,
(b) through a +0.50 DS lens, (c) through a +1.00 DC lens at and is displaced such that the focal plane of the vertical
axis 180, (d) axis 90, (e) axis 135, (f) axis 45. A 5.7 mm rays is in the middle of the region of best focus. It will
aperture and the supplementary lenses were placed near the be seen that there are two different positions, denoted
principal planes of a 135 mm telephoto lens, the 1 D error by Z, and Z, where the cross-section of the pencil is ap-
giving a blur ratio for the 18 m line of approximately 0.54 for
the object distance of —2.5 m.
proximately circular, having the same width in both
principal meridians. A similar diagram would show
that when the slit is turned to the horizontal, the
inal image are sufficiently elongated, rotation of the slit region of best focus then straddles the focal plane of the
will enable a ‘best position’ to be found. This will clearly horizontal rays.
occur when the slit is perpendicular to the major axis
of these blur ellipses or focal lines.
The next step is to carry out a subjective refraction,
using spherical lenses only, first with the slit in the best Residual errors: obliquely
position and then turned through 90°. In each case the crossed cylinders
best sphere should approximate to the spectacle refrac-
tion in the meridian of the slit. For example, if the best Suppose that an eye needs a cylinder correction of
sphere is —1.50 D with the slit along 90° and —0.50 D —1.50 DC x 20 but is given —1.00 DC x 10. There will
 Residual errors: obliquely crossed cylinders 87

Horizontal
Vertical Axis of C
Hori ‘ focal line
zs focal line
Circular Vert. Axis of F.
pupil
Vert:

Axis of F,

Vertical
stenopaeic
slit

Figure 5.13. (a) The refracted astigmatic pencil with its two
principal meridians superimposed. (b) The reduction in width of
the pencil in the horizontal meridian, caused by a stenopaeic
slit with its length vertical. Figure 5.14. Compounding obliquely crossed cylinders: the
positive sign convention for anticlockwise acute angles.

be remaining a ‘residual error’, meaning the power of

the additional lens needed to put matters right. First, the
incorrect lens must be neutralized, in this example by
+1.00 DC x 10 and then the correct lens added, —1.50
DC x 20. The residual error is the sum of these two. To
resolve this combination we must resort to the theory
of obliquely crossed cylinders.
There are two basic theorems. The first is that a com-
bination of any two or more cylinders placed in contact
with their axes at random has the same fundamental
properties as a single sphero-cylinder. This statement
may easily be verified with two trial case cylinders and
a focimeter. Two different power readings in mutually O F, A
perpendicular meridians will invariably be obtained.
Figure 5.15. Graphical construction for compounding two
The second proposition is that the sum of the two
obliquely crossed cylinders of like sign.
given cylinder powers, F, and F3, is equal to the sum of
the two principal powers of the equivalent sphero-cylin-
der. Let the spherical power of this latter be denoted by cylinder C is expressed by the angle 0 measured from
S and its cylindrical power by C. Then its principal the F, cylinder. When the obliquely crossed cylinders
powers are S and (S + C) and are of like sign, the relationship illustrated in Figure
5.14 will invariably hold good. The equivalent sphero-
Pee iy = SSE C)
cylinder having the same sign as F, and F, will have its
which gives axis within the angle a and nearer to the axis of the
S=4(F, + F,—C) (5210) stronger given cylinder.
A distinctive feature of the conventional graphical
This expression enables us to find the spherical power of method is that the angles a and 0 are doubled. Figure
the equivalent sphero-cylinder as soon as its cylindrical 5.15 shows the construction when the two given cylin-
power has been determined. ders are of like sign. On a chosen scale, OA is drawn pro-
portional to F,; and AR proportional to F, making an
angle 2a with OA. The resultant cylinder power C, of
A graphical solution the same sign as F, and Fy, is proportional to OR and
makes a positive angle 20 with OA.
The complete resolution of two obliquely crossed cylin-
If the cylinders are of opposite sign, the construction
ders can be carried out by a well-known graphical con-
is modified as in Figure 5.16. The line AR is drawn
struction. The first step is to set out the given data. To
below OA, and the resultant cylinder is of the same sign
avoid mistakes at this stage, an angle convention must
as F,. In this construction, the angle 20 becomes clock-
be followed. As shown in Figure 5.14, the positive (anti-
wise and therefore negative in sign. Consequently, the
clockwise) angle a between the given cylinder axes is
axis of the resultant cylinder is that of F; minus 0.
the acute angle measured from the axis of the F, cylinder
to the axis of the F', cylinder. It is wise to draw or visua-
lize these axes before deciding which of the cylinders
Mathematical solutions
should be labelled F,. For example, if the two axes are
20° and 140°, F, is the cylinder at axis 140 and the Mathematical solutions for the resultant of two obli-
angle a is 60°. The axis direction of the resultant quely crossed cylinders have been devised in the form
SS Astigmatism

Figure 5.17. Graphical construction based on Figure 5.15

R for the combination of two cylinders Cy and C4; at axes O° and
Figure 5.16. Graphical construction for compounding two 45° respectively to produce an oblique cylinder of power C at
obliquely crossed cylinders of opposite sign. axis 0.

of various sequences of equations. The most convenient represents the cylindrical element of Cp and C4; in com-
of them seems to be the following. First, the resultant cy- bination. Conversely, Cy and Cys; are components into
linder C is found from which a given cylinder of power C can be resolved, its
axis direction (@ in standard notation) being half the
C= \/(F) + Fa)? —4F)F) sin? a (5.11) angle AOR. From Figure 5.17 it is evident that

Next, Cy aGicos20 (6218)

Se are : Cae = Cony (5.14)
= are tan — tana (5.12)
Een C and
Finally, the resultant spherical power S is found from
equation (5.10). Cay Cae Gre (5.15)
There is, however, a much simpler solution which
To deal with the spherical element of power we can
needs no preliminary arrangement of data, dispenses
take advantage of another additive property, the mean
with the angle a altogether, and can cope with any
power M of an astigmatic lens, often termed the ‘mean
number of astigmatic lens or surface powers with the
sphere’. This is the algebraic mean of the two principal
axes at random. It is described in the section immedi-
powers, which are S and (S + C). Hence,
ately following.
M=S+C/2 (5.16)
The new method of calculation is to express each of
Astigmatic decomposition the given lens or surface powers in terms of Co, C45 and
The theory of obliquely crossed cylinders, first pro- M, to find their respective algebraic sums, £Cpy, &C45,
pounded by Stokes (1883), shows that any combination and &M, and then to re-convert these totals into ortho-
of plano-cylinders in contact with their axes at random dox sphero-cylinder notation.
is equivalent, in general, to a single sphero-cylinder. A In the following numerical example there are only
corollary to this theorem is that any given cylinder is re- two astigmatic lens or surface powers to be summed.
placeable by a combination of two separate cylinders This is the usual form in which the problem arises.
with their axes in any specified meridians. On this
basis, Dr W. E. Humphrey was able to incorporate a
new method of refraction in the Humphrey Vision Anal- Example (5)
yser which he designed (Chapter 19). In effect, the cor-
Find the resultant of the combination of
recting cylinder of power C is the resultant of two
components, Cp at axis O° and C4; at axis 45°. As ex- —2.75DS/ + 1.00 DC x 10
plained in Chapter 19, the preliminary step of locating and
the eye’s principal meridians is thereby made unneces-
sary. +4.25 DS/ — 1.50 DC x 20
Humphrey's principle of ‘astigmatic decomposition’
can further be utilized to produce the simplest of all Table 5.1 Worked example ofa method of calculating the
methods of performing calculations involving obliquely resultant of any number of astigmatic lens or surface powers
crossed cylinders. As a first step, each of the given cylin-
ders is decomposed into its Cy and C4; components, Given prescription Required components

which need not be of like sign. When expressed in such Sphere Cylinder Axis Co C45 M
a form, cylinders become additive if due regard is paid S GC 0 Ccos20) 1Gsin 20) VSea Gi
to their signs and to resultant spherical components.
—2.75 +1.00 10 +0.940 +0.342 —2.25
The construction illustrated in Figures 5.15 and 5.16 +4.25 —1.50 20 —1.149 —0.964 +3.50
is followed in Figure 5.17 in which OA represents Cy
and AR represents C45. Since all angles have to be XC XC45 <M
Summation —0.209 —0.622 +1.25
doubled, AR is at right-angles to OA. The length OR
 Residual errors: obliquely crossed cylinders 89

Since equations (5.13) and (5.14) represent additive Table 5.2 Worked example of a method of calculating the
quantities, the resultant cylinder Cp can be found from difference between a pair of astigmatic lenses or values

Cp = yf(BC)? + (ECa5)? (5.17)

Sphere
S
Cylinder
G
Axis
0
Co
Geos 20
C45
(Csin20)
M
(S-C/2

The sign taken must be the same as that for XC). In this +3.75 —3.00 12 —2.74 —1.22 +2.25
case, +3.25 —2.25 10 —2.11 —0.77 +2.125

Cr = —V0.0437
+ 0.3869 ACo AC4s AM
Difference —0.63 —0.45 +0.125
= =().65610)
giving, in conventional form, +0.51 DS/ — 0.77 DC x 18
Next, the axis Og of the resultant cylinder Cr of the
sign specified above is given by
Ox = farc tan (ZC45/ECy) (5.18) first, i.e. reversing the signs of both sphere and cylinder
of the first value.
=35.7>

Alternatively, Cp may be given either sign and 0p evalu-

ated from
Op = arctan {(Cp — XC) /ZCy5} (5.18a) Scalar representation of astigmatism
If 0p emerges from either routine’ with a minus sign, Three values are required to specify a sphero-cylindrical
180° should be added to it. power, namely either the spherical and cylindrical
Finally, the spherical power Sp of the combination powers and cylinder axis, or the two principal meri-
can be found by transposing equation (5.16) into dional powers and the orientation of one of these.
So= =M = Cp/2 (5.19) Although +2.00 DS/—1.00 DC x 20 and +2.00 DS/
—1.00 DC x 50 have the same principal powers, their
oO 32.8 Se SA8 DD orientation is different. For some purposes, it is useful
Rounded off, the resultant is to be able to represent such powers by a single scalar
quantity, u. The Humphrey components may again be
+1.58 DS/—0.66 DCx 36° used, as in equation (5.20):
It is left as an exercise for the student to compare this
result with that obtained from the graphical construc- in) Casigece M2 (5.20)
tion of Figure 5.16.
the positive root, in general, being taken irrespective of
the sign of the components. The value of u for both
Astigmatic analysis these two powers is +1.80. Thus the difference between
two powers cannot be represented by the difference in
Mean of many values
their scalar values, but a scalar value can be found for
The technique of astigmatic decomposition may be ex- the difference. Thus in this example, the difference be-
tended to find the mean of any number of astigmatic tween the two powers is +0.50 DS/—1.00 DCx170,
values. As shown by Bennett (1984), each astigmatic giving a scalar difference of 1.00.
power is expressed as its Humphrey components (Cp, Comparison between a series of retinoscopy (Chapter
Cy; and M), and the individual components summed. 17) or autorefractor (Chapter 18) results and subjective
Proceeding exactly as for the resultant of two obliquely refraction (Chapter 6) values can thus easily be evalu-
crossed cylinders, the subsequent totals may be used to ated — Rabbetts (1996). As pointed out by McCaghrey
find the resultant. If, for example, the sum of six astig- and Matthews (1993), the disadvantage of always
matic values is: XCy = —13.28, 2Cys = —4.13 and taking the positive root for a scalar quantity such as u
xXM=-—-11.50, the resultant sphero-cylinder is is that it is impossible to differentiate between findings
—4.55 DS/—13.91 DC x 8.6. If, however, the mean where, say, the retinoscopy result is always more pos-
value is needed, the subtotals should be divided by the itive than the subjective from results where the findings
number of values before calculating the conventional may be more or less positive. A suggestion here would
power. Table 21.6 gives a further example. be to give u the same sign as that of the mean sphere M
of the difference.
An alternative method for deriving a similar scalar
Subtraction of cylinders value was presented in the series of papers by Harris
The difference between two values may also be deter- and co-workers; for example, Harris (1988, 1994),
mined by the Humphrey method. For example, suppose Harris and Malan (1992). The two methods were
an estimate of a patient's refractive error was brought together by Harris (1996). The properties of
+3.25 DS/—2.25DC x10 and the final prescription the oblique cylinder components of the Humphrey de-
given was +3.75 DS/—3.00 DC x 12, then the difference composition method have been further amplified by
between the two may be given either by subtracting the Thibos, Wheeler and Horner (1996). They also point
components as shown in Table 5.2, or by adding the out that this method of analysis was first developed by
power that neutralizes the second value to that of the Gartner (1965).
90 Astigmatism

The Stokes lens eral resemblance to the neat geometrical structure illu-
strated in Figure 5.4.
The Stokes lens is a variable cylinder named after its in- In 1924, Tscherning suggested that irregular astig-
ventor and described by him in 1849. Sometimes used matism is most conveniently studied by observing, at
as an ophthalmic trial case accessory, it consists of two various distances or through various lenses, an illumi-
plano-cylinders of equal and opposite power (+P) nated pinhole of about 0.2 or 0.3mm _ diameter
mounted in a cell and geared to rotate equally in oppo-
(Tscherning, 1924). From the varying size and shape of
site directions from a zero setting. In this setting, the the blurred image, and by occluding different parts of
two cylinder axes coincide, resulting in neutralization. the pupil in turn, it is possible to make certain deduc-
When the lenses have been rotated so as to make an tions about the nature of the refracted pencils.
angle a between their axes, the resultant cylinder Tscherning stated some useful rules relevant to this
power is equal to 2F sina with its axis always at 45° to interpretation.
the zero setting. There is also a resultant spherical Figure 5.18, reproduced from Chapter 10 of Tscher-
power of —F sina. The mean power of the combination ning’s book, illustrates the appearance of a luminous
is invariably zero. A Stokes lens has been used in a point as seen at different distances by his right eye.
number of ophthalmic instruments. Mounted on a suit- Row A refers to vision through the whole pupil, row B
able handle, it would serve as a cross cylinder (Chapter to vision when the lower half of the pupil was occluded
6) of variable power. and row C to the upper half occluded. The columns (a)
to (d) relate respectively to viewing distances of 60 cm,
lm, 1.5m and ‘infinity’. Tscherning remarks that
‘these figures are, up to a certain point, analogous to
those which are obtained with a lens placed obliquely’.
Irregular astigmatism It will be noted that all the figures show marked symme-
try about a nearly vertical axis. The streaky appearance
Astigmatism of the type discussed so far is termed ‘reg- of some of the figures is produced by the fibrous struc-
ular’ because it possesses a certain symmetry and is cor- ture of the crystalline lens.
rectable by suitable lenses. In cases of marked irregular refraction, a pinhole disc
Irregular astigmatism — a better term for which would will generally improve the best visual acuity otherwise
be irregular refraction — denotes a condition in which obtainable, by isolating a relatively homogeneous por-
poor focusing results from asymmetrical or local varia- tion of the eye's optical system.
tions in the curvature of one or more of the eye's refract-
ing surfaces, notably the cornea. In severe cases only a
contact lens will give satisfactory results. Irregular re-
fraction may also be caused by local variations in the re- Historical notes
fractive index of the crystalline lens.
In reality, no sharp dividing line can be drawn be- The concept of astigmatism originated with Newton,
tween regular and irregular astigmatism. No eye is free who was the first to pay attention to rays in the plane
from some irregularities and some degree of asymmetry now called sagittal, perpendicular to the (tangential)
and it would be a mistake to imagine that the refracted plane of the diagram. Newton discovered that rays in
pencils in a typical astigmatic eye bear more than a gen- these two planes are focused at different distances if the

(b)

tse Nant ANON I aac

smite eceamemanetl >

Figure 5.18. Self-drawn appearances of a

luminous point to Tscherning’s right eye.
Columns (a) to (d): viewing distances of
60cm, 1 m, 1.5 m and infinity respectively.
Row A: view with full pupil; row B: with lower
half of pupil covered: row C with upper half
covered. (Reproduced from Tscherning,
1924.)
 Exercises 91

incident pencil is oblique and he devised elegant gra-

Exercises
phical methods of constructing both foci.
There is nothing in Newton's Opticks or in his Optical 5.1 The principal powers of a reduced astigmatic eye are
Lectures devoted to either axial or ocular astigmatism, +62.00 D in the horizontal and +64.00 D in the vertical meri-
but he did make some interesting speculations as to dian. The eye has the normal emmetropic length, a pupil of
which section of an astigmatic pencil would be selected 6 mm, and it views a distant point source. Calculate: (a) the po-
sition of the two focal lines and the circle of least confusion,
by an eye for focusing on the retina. As pointed out by
(b) the lengths of the two focal lines and the diameter of the
Bennett (1961), the section which he suggested as the circle of least confusion, (c) the dimensions of the blurred
most probable can be shown to be that containing the patch on the retina.
circle of least confusion. 5.2 A 60-metre Landolt ring is viewed at 6 m by an unaccom-
After Newton, the subject seemed to arouse little in- modated uncorrected eye of ocular refraction —1.00 DS/
—4.00 DC axis 90 and of pupil diameter 6 mm. Calculate the
terest until Young turned his attention to it towards
apparent size of the blur ellipse corresponding to a point on
the end of the eighteenth century. In his famous Baker- the object when projected to a distance of 6 m. On a scale one-
ian Lecture to the Royal Society, delivered in 1800, half actual size, draw the projected blur patch alongside the
Young presented the results of a brilliant series of ex- 60-metre ring and discuss the apparent blurred appearance of
the latter. Assume the eye to be of normal length.
periments and theoretical calculations on the dioptric
5.3 An astigmatic chart consisting of four thin lines each
system of the eye. 100 mm long intersecting centrally at 45° intervals is viewed
Incidentally to his main purpose, which was to identi- at 1m by an uncorrected eye whose ocular refraction is
fy the mechanism of accommodation, Young determined —3.00 DS/—3.00 DC axis 45. Draw a careful enlarged diagram
the refraction of one of his own eyes, finding it to be (in of the blurred retinal image, indicating the scale. Assume that
the eye has the normal length and a pupil diameter of 6 mm.
our notation) about 4.00 D myopic in the vertical meri-
5.4 An unaccommodated uncorrected eye with pupil diam-
dian and 5.75 D myopic in the horizontal. This is the eter 10mm has an ocular refraction of +2.00 DS/—4.00 DC
first recorded astigmatic refraction. Since Young also axis 180. The eye views a distant point source of light through
discovered that the same amount of astigmatism re- a centred pinhole disc in which there are two pinholes, A and
mained when his cornea was immersed in water, he B, each of diameter 2 mm and with centres 5 mm apart symme-
trically disposed about the disc centre. From simple geometrical
concluded that his own astigmatism must be due to an
considerations describe the illumination on the retina when
obliquity of the crystalline lens. He remarked that it the line of the pinhole centres is: (a) horizontal with A lying
had never troubled him and that he had been unaware outwards, (b) vertical with A lying upwards, (c) in meridian
of it before he started his experiments. 45° with A lying up and out. If pinhole A is occluded in each
case, describe how the observer looking through the disc
In the same lecture Young expounded his own contri-
would see its apparent eclipse.
bution to the study of oblique astigmatism, and one of 5.5 An eye provided with a centred pinhole disc views a
his diagrams showed various cross-sections of the astig- cross-line with its limbs, each 100 mm long, horizontal and
matic pencil formed by oblique refraction. Another dia- vertical. The cross-line chart is 1 m from the eye and mid-way
gram showed what we would now term the tangential between them is a circular lens of diameter 50 mm and power
+2.00 DS/+2.00 DC axis 90. How will the cross-line appear to
and sagittal image shells formed by the successive re-
the eye viewing through the lens? Give an explanation with
fracting surfaces of the eye, from which Young con- diagrams.
cluded that the curvature of the retina has the required 5.6 An uncorrected and unaccommodated eye sees clearly a
value for optimum focusing over a wide field. vertical line at a distance of 850 mm and a horizontal line at a
It was in 1825 that Airy read his famous paper to the distance of 270 mm from its principal point. What lens fitted at
14 mm from the reduced surface would correct this eye for dis-
Cambridge Philosophical Society describing how he had
tance? What is the ocular refraction?
measured the refraction of his own astigmatic eye and 5.7. An astigmatic reduced eye has an axial length of 26 mm
had had a sphero-cylindrical lens specially made to cor- and principal powers of +62.00D along 30° and +59.50D
rect it. This and subsequent papers by Airy on the same along 120°. What is the power of the distance correcting lens
needed if placed at 13 mm from the reduced surface?
subject evoked a world-wide interest.
5.8 A patient has a spectacle correction of +10.00/
After Airy’s discourse had been given, but before it ap- —4.00 x 90 at 15 mm. Calculate: (a) the ocular refraction and
peared in print in 1827, hints on the use of Young's opt- (b) the spectacle correction required at 12mm (suitably
ometer for determining the ocular refraction in two rounded off).
mutually perpendicular meridians had been published 5.9 A patient has a _ spectacle correction of —6.00/
—4.00 x 180 at 15mm. Calculate: (a) the ocular refraction
by a remarkable English engineer, J. 1. Hawkins (1826).
and (b) the spectacle correction required at 12 mm (suitably
A printed music stave was suggested as a suitable test rounded off).
object. Hawkins described not only how he worked out 5.10 From the results of Exercises 5.8 and 5.9, formulate a
a sphero-cylindrical correction for himself, but also qualitative relationship between ocular astigmatism and the
how he had it made up in trifocal form, each separate necessary spectacle cylinder correction in compound hyperme-
tropia and compound myopia.
portion being correctly centred and angled. His paper is
5.11 A patient with an uncorrected refractive error of
an astonishing tour de force for a layman. +1.00/—5.00 x 180 views a distant spotlight without accom-
Another English contribution to the study of astigma- modating. Draw to scale the blur ellipse when viewed through:
tism is the term itself, attributed to Dr Whewell who (a) the natural 4mm pupil and (b) through a stenopaeic slit
1 mm wide orientated (i) along 180", (ii) along 90° and (iii)
became Master of Trinity College Cambridge in 1841
along 135° (Hint: draw an isometric diagram for this last
and Vice-Chancellor of the University in 1855. orientation. )
A detailed account of progress in the study and cor- 5.12 Find the resultant of three +1.00D_ plano-cylinders
rection of astigmatism from 1800 onwards can be placed in contact with their respective axes at 10°, 40°, and
found in the work by Levene (1977). HO
92 Astigmatism

HAWKINS, J.I. (1826) On the means of ascertaining the true

References state of the eye, and of enabling persons to supply themselves
with spectacles, the best adapted to their sight. Repertory of
AIRY, G.B. (1827) On a peculiar defect in the eye and a mode of Patent Inventions, 3, 347-353, 385-392 + plate VIII
correcting it. Trans. Camb. Phil. Soc. 1825, 2, 267-271 LEVENE, J.R. (1977) Clinical Refraction and Visual Science, pp.
BENNETT, A.G. (1961) Some unfamiliar British contributions to 203-285. London: Butterworths
geometrical optics. International Optical Congress 1961, pp. MCCAGHREY, G.E. and MATTHEWS, F.E. (1993) Matters arising —
274-291. London: British Optical Association residual refraction. Ophthal. Physiol. Opt., 13, 432-433
BENNETT, A.G. (1984) A new approach to the statistical anal- RABBETTS, R.B. (1996) Scalar representation of astigmatism.
ysis of ocular astigmatism and astigmatic prescriptions. In Ophthal. Physiol. Opt., 16, 257-260
Trans. First International Congress, The Frontiers of Optome- STOKES, G.G. (1883) Mathematical and Physical Papers, Vol. 2,
try (W. N. Charman, ed.), Vol 2, pp.35—42, British College of pp. 172-175. Cambridge: Cambridge University Press
Ophthalmic Opticians (Optometrists) THIBOS, L.N., WHEELER, W. and HORNER, D. (1996) Power vec-
GARTNER, W.F. (1965) Astigmatism and optometric vectors. tors, an application of Fourier analysis to the description
Am. J. Optom., 53, 459-463 and statistical analysis of refractive error. Optom. Vision Sci.,
HARRIS, W.F. (1988) Algebra of sphero-cylinders and refractive 74, 367-380
errors, and their means, variance and standard deviation. TSCHERNING, M. (1898) Optique Physiologique. Paris: Carre et
Am. J. Optom., 65, 794-802 Naud
HARRIS, W.F. (1994) Dioptric strength: a scalar representation TSCHERNING, M. (1924) Physiologic Optics, 4th edn (English
of dioptric power. Ophthal. Physiol. Opt., 14, 216-218 translation by C. Weiland). Philadelphia: Keystone Publish-
HARRIS, W.F. (1996) Author's reply to Rabbetts (1996). ing Co.
Ophthal. Physiol. Opt., 16, 261-262 YOUNG, T. (1801) On the mechanism of the eye. Phil. Trans. R.
HARRIS, W.E. and MALAN, D.J. (1992) Meridional profiles of Soc. 1800, 92, 23-88 + plates
variance—covariance of dioptric power. Part 2. Profiles repre-
senting variation in one or more of sphere, cylinder and
axis. Ophthal. Physiol. Opt., 12, 471-477
6
Subjective refraction

Introduction rately and then binocularly. As shown in Chapter 4,

myopia will cause a reduction in distance vision from a
A patient may wish to have an eye examination for one standard which is usually taken as 6/6 or better. A hy-
of many reasons such as poor vision either at distance permetropic error may also cause a reduction in vision,
or in close work, asthenopic symptoms such as head or depending on the ability of the eye to increase its refrac-
eye aches or for a general check on the state of his tive power by accommodation. In a young person there
eyes. An eye examination consists of four main parts: is usually ample accommodation and such a patient
checking the health of the eyes, measuring any optical with a small or medium hypermetropic error will be
errors of focusing, evaluating the efficiency with which able to read the small lines on the test chart. Even so,
the two eyes work together and deciding whether to pre- prolonged use of the eyes for detailed vision may cause
scribe some form of optical correction or treatment discomfort since more than the usual amount of accom-
(such as orthoptic training) to improve the binocular modation is required. The maximum power of accom-
functioning of the eyes. modation declines with age (see Chapter 7), therefore
The patient's refraetive error, or refraction as it is an older person with even a small hypermetropic error
often called, may be estimated by two broad methods: of one or two dioptres will have reduced vision.
objective and subjective. The former requires no help An astigmatic error may be combined with either
from the patient except to look in a certain direction or myopia or hypermetropia. With myopia or high hyper-
into an instrument, the adjustments being made by the metropia, both the astigmatic and spherical components
examiner (see Chapters 17 and 18). Subjective refrac- of the error reduce the unaided vision. When astigma-
tion requires the co-operation of the subject and many tism is combined with a low hypermetropic error in a
of the specific techniques will be discussed in this chap- young patient, accommodation can be brought into
ter. Although it is based on scientific principles, the ex- action so as to place either of the focal lines or the
perienced refractionist realizes that subjective work is circle of least confusion on to the retina. Even so, vision
partly an art; the ability to know which method to use is usually reduced. With a small astigmatic error, the
for a particular patient and the ease with which under- vision may be almost normal, but if either focal line
standing is established with patients can come only may be brought on to the retina, accommodation is
with experience. unstable and asthenopic symptoms often result. Para-
In general, a patient's refractive error is first estimated doxically, a larger astigmatic error may cause less asthe-
objectively. There may be errors involved in an objective nopia, because the vision is too poor to stimulate
measurement, so the refraction is usually checked sub- alternations of the level of accommodation between the
jectively in order to refine it. There are patients, for ex- two astigmatic foci. Moreover, the change in accommo-
ample, young children, with whom it is not possible to dation required may be too great for easy adjustment. If
make a satisfactory subjective examination, in which the axes of the error are approximately horizontal or
case the prescriber relies on the objective results alone. vertical, unaided vision is often reduced less than with
In order to impart a thorough understanding of the an oblique error; this is because most letters are com-
methods of subjective work, it is better, however, to de- posed of vertical and horizontal strokes.
scribe subjective refraction without assuming an initial Table 6.1, which is based on the studies plotted in
objective assessment. The later parts of this chapter will Figure 4.18, gives the approximate relationship between
describe how the various subjective techniques are nor- unaided vision and spherical and astigmatic ametropia.
mally linked with a prior objective refraction. Some of With modern apparatus using non-serif letters and
the more sophisticated methods of balancing the mono- higher luminances, the predicted ametropia may be
cular findings will then be discussed. slightly higher than the figures tabulated. For example,
a score of 6/12 (20/40) is often possible with ametropia
of 1.00 D.
Unaided vision and refractive error The predicted vision in astigmatism is tabulated on
the assumption that the circles of least confusion lie on
The first step in measuring a refractive error is to deter- or close to the retina, either naturally or with the aid of
mine the patient’s unaided vision with each eye sepa- accommodation or trial lenses. The vision with a given
94 Subjective refraction

Table 6.1 Expected vision in various ametropic states

i

Vision Refractive error (D)

Spherical Astigmatic

6/6 (20/20) small small

6/9 (20/30) 0.50 1.00
6/12 (20/40) 0.75 1.50
6/18 (20/60) 1.00 2.00
6/24 (20/80) ESO 3.00
6/36 (20/120) 2.00 4.00
6/60 (20/200) 2.00 to 3.00 high

* Myopia or absolute hypermetropia.

Note: The predicted vision in astigmatism is on the assumption that the

circles of least confusion lie on or close to the retina.

dioptric value of astigmatism is better than for the same

amount of spherical ametropia (compare equations
(4.17) and (5.9)). For a patient already wearing specta-
cles, or halfway through a subjective routine, Table 6.1
can be used to predict the remaining error.
This table is reasonably accurate for a pupil size of
about 4mm. With much larger pupils, which can occur
in young patients or in low illumination, the same dete-
rioration in vision will be caused by a smaller error.
Conversely, a patient with small pupils, about 2mm,
will be able to see better than predicted for the refractive
error. A patient who is used to being undercorrected
may see far better than expected from the size of the
error, because he or she is used to interpreting blurred
images, whereas a person who has recently broken his (b)
spectacles will be more greatly handicapped and may
Figure 6.1. (a) Oculus drop cell and (b) rotating cell trial
accordingly be led to the erroneous conclusion that the frames. Photographs reproduced by kind permission of Oculus
spectacles have made the sight worse. Optikgerate GmbH.
Some people habitually squeeze their eyelids together
in order to see clearer: reducing the effective pupil size
decreases the retinal blurs. This habit or manoeuvre is placed at a greater height convenient for the practi-
sometimes erroneously called ‘squinting’. tioner.
The practitioner can make use of the pinhole disc to It is important that the mirror should be large enough
test whether reduced vision is due to poor focusing or so that the test-chart surroundings are visible even to
to a retinal defect such as amblyopia or macular degen- patients not of average height or tending to sit to one
eration. If the pinhole — about 1 or 1.5 mm diameter — side. If the mirror is framed, the colour of the frame
improves the vision, then in general there is ametropia should merge with the surrounding wall. This reduces
to be corrected. An exception to this rule occurs when any tendency on the patient's part to accommodate for
opacities in the ocular media produce an irregular focus- the distance of the mirror instead of attempting to relax
ing effect. In this case the pinhole may give a better his accommodation as fully as possible.
acuity than a lens alone if it isolates a small region The room illumination should be at a comfortable
which is sufficiently homogeneous to give a good focus. indoor level: pupils dilate in the dark and a refraction
under these conditions will be influenced by the aberra-
tions due to the peripheral parts of the eye’s optical
system. The correction found under these conditions
Basic equipment for refraction may not be the best for use in daylight out of doors
with a normal size pupil. A trial case of separate lenses
The distance test chart has already been discussed in is a necessity, even if a refracting unit (or phoropter) is
Chapter 3. By convention, the normal testing distance normally in use. Trial case lenses are placed in a trial
is 6m or 20 ft but is sometimes varied slightly to stit frame (Figure 6.1) worn by the patient, or, less fre-
the size of the consulting room. To enable the patient to quently, supported by a wall bracket. They may either
adopt a comfortable posture, the chart should be placed be full aperture, about 38 mm diameter, or of a reduced
at an average eye-level. Frequently, a reversed or in- aperture of 20 mm or so in a full-size mount. The larger
direct chart is used, viewed by the patient in a mirror. lenses enable the practitioner to obtain a better view of
In this case, the mirror and image of the chart should the patient's eyes and similarly give the patient a larger
be at the patient's eye level, the mirror being angled if field of view. On the other hand, reduced-aperture
necessary to enable the test chart or cabinet to be lenses are lighter and thinner. They are better protected
 Measurement of a spherical ametropia 95

by the wide rim and less likely to break if dropped. The Finally, the projection of the trial frame should be ad-
wide rim also tends to prevent finger marks on the justed so that the vertex distance, as far as can be
lenses and permits clearer power markings. A further judged, will be little changed if spectacles are subse-
advantage is that the trial sets are available in a more quently worn. Because of effectivity considerations, the
extensive range of fractional powers than full-aperture strongest spherical lens needed should be placed in the
trial sets. rear cell, with any weaker auxiliary lenses in front of it.
In a refracting unit, discs of reduced-aperture lenses When the lens power exceeds about 5 D, the vertex dis-
are so mounted that any sphero-cylinder combination tance should be measured and recorded as part of the
can quickly and easily be placed before the patient’s eye. prescription. At the dispensing stage, when the frame
Such units are large and must be mounted mechani- and lens type have both been chosen, the vertex dis-
cally. As a result, the patient’s head has to be kept tance with these spectacles can then be estimated. If it
pressed against the unit, which can be uncomfortable. differs from that recorded in the prescription, calcula-
Also, in some designs the unit cannot be tilted, which tion as in Chapters 4 and 5 or reference to tables will
means that near vision testing has to be undertaken in show what alteration, if any, to the original prescription
a horizontal plane. Nevertheless, refracting units have should be made to reproduce the same effect at the eyes.
many practical advantages. The vertex distance may be measured with special ca-
The designs oftrial lenses, whether for use with a trial lipers, by placing a stenopaeic slit in the rear cell of the
frame or in a refracting unit, raises several problems trial frame and pushing a thin card scale through it to
arising from effectivity, that is, the effect of lens form, meet the patient’s closed eyelid, or, less accurately, by
thicknesses and separations onsthe vergence of the viewing from the side with a rule held against the side
emergent pencils of light. As far as distance vision is of the head.
concerned, these problems can be overcome by designs Since trial frames are relatively heavy, it is more com-
based on the principle of additive vertex powers, but in fortable for the patient if the frames are removed occa-
near vision the full-aperture symmetrical and reduced- sionally during the refraction, for example, when
aperture curved forms are generally superior (see also writing down the objective findings and later the subjec-
Report of a Ministry of Health Committee, 1956; Ben- tive results for distance.
nett, 1968). The many other items of equipment in general use
The trial frame or refracting unit should carefully be will be described in the relevant places.
centred to the patient’s inter-pupillary distance (abbre-
viated to PD). There are specialized instruments for
measuring the PD (see page 221), but reasonable accu- Measurement of a spherical ametropia
racy may be obtained with a simple ruler or, better still,
a rule with a fixed cursor at the zero of the scale and a
A standard routine
movable cursor. The rule is held in the spectacle plane
and the patient is directed to look at the examiner's Although the possibility of astigmatism should never be
right eye. Using this eye, the examiner lines up the zero excluded, it is simpler initially to assume that any ame-
cursor with the centre of the patient’s left pupil. With tropia present is purely spherical. The first stages in the
the rule still held in this position, the patient's attention routine apply in either case. The unaided vision will
is redirected to the examiner’s left eye, and using this give some guide as to the possible size of any error. If
eye the second cursor is lined up with the centre of the the vision is good, for example 6/9 or better, it indicates
patient's right pupil. This gives the distance PD. The a small amount of myopia, emmetropia or hyperme-
near PD is measured by asking the patient to look at tropia. If hypermetropia, there could be a small absolute
one of the examiner's eyes, the examiner leaning for- error in a middle-aged person or a medium or large
ward so that the distance from patient to practitioner is error in a young patient. While the patient is still obser-
the same as the usual working distance. The cursors ving the distant test chart, with the other eye occluded,
are lined up with this eye alone, the rule again being add +1.00DS. If the vision is made worse, try
held in the spectacle plane. +0.50 DS; if the vision again deteriorates, the patient is
Available trial case accessories include centring discs, emmetropic or myopic. Then try —0.50 DS; if the vision
which can be used in a similar manner to adjust the improves, the patient is myopic. From Table 6.1,
trial frame directly to the patient’s PD. They also facili- —(0.50 DS should improve the vision from 6/9 to 6/6,
tate the vertical adjustment’ which is no less important but some patients with 6/9 vision may need slightly
than the horizontal centration. Another necessary ad- more negative power.
justment, made by angling the sides, is to set the plane If the initial +1.00 DS made a slight improvement or
of the lenses at right-angles to the line of sight. no difference to the vision, hypermetropia is confirmed.
Since accommodation can overcome all or part of a hy-
permetropic error, positive sphere should continue to
a

* Trial frames and many refractor heads cannot be adjusted

be added until the vision no longer continues to im-
to compensate for a marked vertical difference in eye and pupil prove. Initially, the plus power should be increased in
positions. With some patients, the final spectacles may best be whole dioptre steps until the next addition of +1.00 DS
fitted off the horizontal so as to match the brow line, in which causes a reduction in vision. At this stage, half- and
case the trial frame may be similarly tilted. In other cases, the
quarter-dioptre steps should then be used.
spectacles and trial frame or refractor head should remain hor-
Now suppose the patient's unaided vision to be 6/24.
izontal. An allowance for induced prism, such as discussed on
pages 263-265, may then be needed. Table 6.1 predicts an error of about 1.50D, so a
96 Subjective refraction

+1.50 DS lens should be tried initially. If this improves 7). The binocular methods of refraction to be described
vision, continue adding positive spherical power as in later are greatly superior.
the previous example until no more is accepted, that is,
further addition causes blurring. On the other hand, if
the initial positive lens made the vision even worse,
then a minus lens, say —1.00 DS, should be tried next. Bichromatic (duochrome) methods
This should improve the vision to about 6/9, and a
little more negative sphere should then give the best
The human eye is not corrected to focus light of different
VA. The change in minus sphere should be consistent wavelengths at the same image point, that is, it suffers
with the improvement in acuity; for example, it should from both axial and transverse chromatic aberration.
The axial aberration may be used to help determine the
not require —4.00 DS to improve the vision from 6/24
spherical component of the refractive error. If yellow
to 6/6. Over-minusing an eye merely stimulates accom-
light is focused exactly on the percipient layer of the
modation without improving vision and makes the eye
retina, the blue-green focus will lie in front of the
effectively hypermetropic.
It is, however, a familiar fact that if a myopic eye is retina and the red focus behind it.
One of the earliest tests based on this principle and
slightly over-corrected (too much minus power) or a hy-
suitable for clinical use was designed by Clifford Brown
permetropic eye is slightly under-corrected, the test let-
and patented in 1927. It used carefully selected red and
ters or symbols generally appear smaller and blacker.
green glass filters and was marketed under the trade-
The accepted rule is that the highest positive or lowest
name ‘duochrome’. More recently, the word ‘bichro-
negative power that gives the best acuity should be re-
matic’ has become an accepted generic term for tests of
garded as the ametropic error. Other factors have to be
this kind, though ‘dichromatic’ is said to be etymologi-
taken into consideration, and we shall discuss this rule
cally more correct.
later in greater detail.
Although the retina is most sensitive to light of a
In order to verify the refractive findings so far deter-
greenish hue in photopic conditions, Ivanoff (1953)
mined, check tests must be applied. The simplest test is
found that for distance vision the eye tends to select a
to add positive power to the correction, whether the
yellow focus in preference to green. The choice of filters
patient is hypermetropic or myopic. If the patient's
takes this into account, together with the spectral distri-
acuity is 6/6, then addition of +0.25 DS should blur
bution of energy of the typical tungsten-filament light
the line fractionally, but without rendering it illegible.
source and the spectral luminous efficiency curve of the
An addition of +0.50 DS should blur the vision back to
eye. Thus, green filters conforming to the British
6/9, and a +1.00 DS to 6/18, as predicted by Table 6.1.
Standard? have their peak luminosity at wavelength ap-
If the patient can still read 6/9 through an extra
proximately 535mm and the red at approximately
+1.00 DS then either the first result is incorrect or the
620nm. Relative to a best focus in the yellow at
patient has either a smaller pupil or greater ability in in-
570 nm, these filters give a green focus about 0.20 D
terpreting blurred images than average. Normally, this
forward and a red focus at about 0.24 D behind (Ben-
check test is carried out only with a +1.00 DS.
nett, 1963). Another property of these filters is that
A disadvantage of increasing positive power from zero
they appear of approximately equal brightness to the ob-
when refracting a hypermetropic patient is that accom-
server with normal colour vision (see also pages 289-
modation is then brought into play until the ametropia
ZION
is fully corrected. Some patients, however, find it diffi-
Since the red and green foci are equally spaced about
cult to make the accommodation relax once it has been
the yellow, an emmetrope (or corrected ametrope)
exerted. Accordingly, an alternative approach is to
should see black test objects on the two coloured back-
start by obtaining the best spherical lens, as described
grounds equally clearly (Figure 6.2a). Bichromatic test
above. The +1.00 DS check test is then applied. Next,
panels may show a series of Snellen letters on each
this extra lens power is reduced” by a quarter of a diop-
colour, a series of concentric rings (usually in the 4.5,
tre at a time until the best line is again read. Perhaps
12 and possibly 24 m sizes) or a pattern of dots. Since
only half a dioptre need be removed if some relaxation
the ‘white’ focus for a low myope falls a short distance
has taken place. This method is called ‘fogging’.
in front of the retina, a myope will see the pattern on
Unfortunately, some eyes will react to a ‘fogged’
the red background clearer: and, conversely, a hyperme-
image by accommodating, even though this makes the
trope will prefer the green. This means that if the red is
retinal image worse. Ward (1987) showed that this re-
seen clearer a minus lens is required (Figure 6.2b) and a
action does not usually occur unless the eye is fogged
plus lens if the green pattern appears clearer.
by more than +1.5-2.0 D. The resulting vision of about
The bichromatic panel may be used as another check
6/30 is then too blurred to control accommodation
test: the patient is asked whether the pattern appears
which may then drift towards its resting state (see the
clearer (or blacker) on the red or the green background.
discussion on inadequate stimulus myopias in Chapter
It sometimes has to be stressed that no attention must
be paid to any apparent brightness difference. The trial
lenses are adjusted to make both rings equally clear, or
‘ During these lens changes, add the new lower powered lens
before removing the original lens or use the other hand as an
occluder. Accommodation will be stimulated if the patient is
allowed to see the chart with less than the full correction in 1 BS 3668: Red and green filters used in opthalmic dichromatic
the trial frame. and dissociation tests.
 Determination of the astigmatic error 97

Meridians of
patient’s eye
90
135
45
180
90 2 eon
(a) xaminer here
135 45

Figure 6.2. (a) Principle of the bichromatic (duochrome 180

test). G indicates the focus for green light, R the focus for red
light. When yellow light is in focus, these should lie Direct vision fan 0
approximately equidistant from the retina, one in front and one chart (from behind)
behind. (b) In the myopic eye, the red focus lies closer to the
retina. Figure 6.3. Three-dimensional view of fan chart and
meridional notation of a patient’s eye. Viewed from behind, the
direct vision fan chart has the same meridians as the eye.
if this is not possible, clearer just on the red or just on
the green, according to the purpose of the examiner.
focal line is parallel to the more myopic « meridian.
Where the ametropia is considerable, the patterns on This figure illustrates diagrammatically the convergent
both colours will be grossly out of focus and the test astigmatic pencil where the principal meridians are hor-
will be unreliable. (This is probably the reason for the
izontal and vertical.
indecisive findings of O’Connor Davies, 1957, when re- They may, of course, be oblique. Suppose that an eye
cording the bichromatic preference of uncorrected sub- with simple myopic astigmatism has its more powerful
jects.) When the correction is within about 1D of the principal meridian along 45° (Figure 6.3). The axis of
optimum, the bichromatic test does appear to work sa- the minus correcting cylinder is thus at 135°. Since the
tisfactorily. If the best acuity is poorer than the detail focal line on the retina lies along the 45° meridian, this
size of the test pattern, the contrast of the frame sur- must also be the direction of the clearest line seen. Ac-
rounding the test panel can sometimes be used though cording to standard axis notation (Figure 5.3), merid-
the test is generally omitted in these circumstances . ians are numbered anticlockwise from the horizontal.
With older patients, the crystalline lens becomes Nevertheless, from the examiner’s position between the
markedly yellow, blue-green light being partially ab- patient and the fan chart, the line on the chart which is
sorbed and scattered. This gives a marked red bias to parallel to the patient's 45° meridian appears to be 45°
the test and it sometimes becomes impossible to obtain clockwise from the horizontal. A reverse numbering is
apparent equality. Where it is obtained in such cases, thus required for fan charts viewed directly (Figure
too much minus lens power has usually been added 6.44).
and on returning to the black and white Snellen chart, When a mirror is used, this reverse numbering is no
an addition of about +0.50DS may well be preferred, longer required but, despite this, a different system is
improving the acuity. Colour defectiveness should not commonly used for convenience. The principle is to
upset this test too much, since the sharpness of focus is assume each line in turn to be the clearest and to
not affected, only the appearance of the colour. The pro- number it with the axis direction of the minus correct-
tanopic or strongly protanomalous patient has a re- ing cylinder, which is always perpendicular to the
duced sensitivity to the red end of the spectrum and given line. The resulting scheme is shown in outline in
this can cause difficulty, since the red background will Figure 6.4(b).
appear much dimmer than the green. The complete fan chart is illustrated in Figure 6.5.
Radial lines of thickness about the limb width of an 18-
metre letter are spaced at 10° intervals around a central
panel carrying an arrowhead and two sets of mutually
Determination of the astigmatic error perpendicular lines. The arrow or V is due to Maddox
and is used to refine the determination of the axis of the
There are two main methods of determining the astig- astigmatism. Thus, if the patient says the group of lines
matic component of the refraction. The older method, near the top of the chart are the clearest, the arrow is
using a special ‘fan’ chart of radial lines, will be de- rotated to point at the clear group. Suppose that, as in
scribed first since it illustrates the nature of the refrac- Figure 6.5, the right-hand side of the arrowhead appears
tive asymmetry extremely well. The newer method, the clearer: this side is more nearly parallel to fan lines
using a specially mounted cross cylinder, is now used on the left of the arrow tip.” Thus, to find the axis of
more often because of its advantages, but not all the astigmatism more accurately, the arrow is rotated
patients respond satisfactorily and it is useful to be able away from its clearer side until equality is obtained.
to return to the older technique. The patient’s attention is then directed to the two sets
of lines or ‘blocks’ and he is asked which is the clearer:
this should be the set parallel to the clearest line on the
The fan and block method

In Figure 5.4 we can see that the first focal line of an

astigmatic pencil is parallel to the weaker or more hy- * When the patient views the chart in a mirror, his left will be
permetropic B meridian of the eye, while the second the refractionist’s right for both the Maddox V and the blocks.
9S Subjective refraction

90 180 state of simple hypermetropic astigmatism, with the

anterior focal line near the retina. In this case, con-
45 135 45 135 tinue adding positive sphere until this new set of
lines just begins to blur.)
0 (a) 180 90 (b) 90 (5) Direct the attention to the Maddox arrow and rotate
it away from its blacker limb until both limbs appear
Figure 6.4. (a) Direct vision fan chart, giving a reversed
equally blurred. This gives the axis of the astigma-
protractor, being the examiner's view of the chart in Figure 6.3.
(b) Indirect fan chart, numbered to indicate the required minus tism, but care must be taken to ensure that the
trial cylinder axis, for viewing by reflection in a mirror. patient's head is upright. bs
(6) Directing attention now to the blocks, add negative
cylinder at the appropriate axis until the second
fan chart. Negative cylinder power is then brought into becomes as clear as the first. If this is not quite possi-
play, the axis being at right-angles to the lines of the ble, it is better to just under-correct than over-cor-
clearer block, until the two sets of lines are equally rect the astigmatic error, that is, leaving the first
clear. group of lines the clearer or blacker of the two.
Using this method, the refraction of an astigmatic eye (7) Make a second check test by again adding +0.50 DS
may be undertaken as follows: or, if the patient is a critical observer, +0.25 DS.
Both blocks should blur equally, but if the blackest
(1) Occlude the second eye and measure the unaided
lines change over, the astigmatism has been over-
vision of the first eye.
corrected. If the originally darker block again
(2) Determine the sphere giving the best vision obtain-
becomes blacker, the original sphere from step (4)
able with spherical lenses alone by the methods on
was wrong and must be re-checked.
pages 95-97. This lens is called the ‘best vision
(8) Return to the letter chart and determine the sphere
sphere’. If the resulting vision is 6/12 or better, a
giving best acuity, the cylindrical element remain-
bichromatic test may also be used. This new vision
ing as just determined. As usual, a positive lens
is then noted, and from Table 6.1 the amount of
should be tried first, but a weak minus lens will
astigmatism present may be estimated. It is assumed
most frequently be required.
that the best vision sphere puts the circle of least
confusion on the retina. Hence, in order to bring If in step (4) no lines appear blacker than the others,
the eye into a state of simple myopic astigmatism: there may be no astigmatism present, but other possi-
)
Add a positive sphere equal to half the estimated bilities are that the eye is excessively fogged, has the cir-
amount of astigmatism (since the circle of least con- cles of least confusion on the retina or is in a state of
fusion lies dioptrically mid-way between the two compound hypermetropic astigmatism. The +0.50 DS
focal lines) or add +1.00 DS if vision at this stage is check test will show up either of these last two con-
6/9 or better. ditions, by making some lines darker. On the other
(4) Refer the patient to the fan chart and ask which line hand, if the eye is already fogged, extra positive power
or group of lines appear clearest and darkest. This will blur the lines even more, whereas the addition of
gives the approximate direction of the astigmatic minus power will make some lines blacker in the pres-
error. However, a simple check test should be made ence of astigmatism, or all equally black if there is no as-
by temporarily adding an extra +0.50 DS in order tigmatism.
to confirm that the eye is in a state of simple myopic To summarize the technique:
astigmatism. The blackest lines should blur, but if
not, more positive sphere should be added until (1) Obtain sphere giving best vision.
they do. (In some cases the clearest lines will change (2) Estimate power of astigmatic error from the vision at
through 90°, indicating that the eye had been in a this stage.

ee. commen
Figure 6.5. Photograph of a fan and
block chart taken through a plus cylinder
at axis 20°. The unequal clarity of the
limbs of the Maddox V shows that an
: a anticlockwise rotation is needed to give
id equality and identify the axis.
 Determination of the astigmatic error 99

(3) Assuming that the lens found in (1) was that put- 90
ting the circle of least confusion on the retina, add
plus spherical power equal to half the estimated
minus cylinder,
(4) Find the clearest line(s) on the fan. Temporarily add
an extra +0.50 DS to check that the blackest lines (a) (b)
blur.
(5) Refine the cylinder axis using the V. Figure 6.6. The cross cylinder and axis determination. The
(6) Equalize the clarity of the blocks with minus cylin- position of the minus cylinder axis is indicated by the two
ders. minus signs and the numerical value of the axis. In this and the
next three figures, the dashed line is in the position ofthe
(7) Ensure that the eye is not spherically under-cor-
required minus axis, assumed to be at 10°. Hence the minus
rected by adding +0.50DS and checking that the axis of the cross cylinder lies nearer the correct axis in (b) than
blocks are equally blurred or at least not reversed in (a).
in clarity from the original appearance. If necessary,
adjust cylinder power.
(8) Refine sphere with Snellen or bichromatic chart. tinoscopy, but in the routine to be described no such
prior information is assumed.
The present writer’s (RBR’s) redesign of the V and
blocks is described on pages 104-105.
Axis determination

To simplify the following discussion and diagrams, the

The cross cylinder refracted pencil within the eye refers to a single distant
object point. This is sufficient to indicate the nature of
Introduction
any blurring of the complete retinal image.
This is an astigmatic lens in which the two principal The circle of least confusion is put on or slightly
powers are numerically equal but opposite in sign, the behind the percipient elements of the retina by obtain-
mean power thus being zero. According to the relevant ing the best vision with spherical lenses on the test
British Standard,’ the power of a cross cylinder should chart, or, where the bichromatic method is reliable,
be denoted by its meridional power, but some manufac- equalizing the clarity of the rings. For a young patient,
turers label their lenses with the total astigmatic a further —0.25DS may be added to allow accom-
power, which is twice the meridional power. Theoreti- modation to put the circle of least confusion on the
cally, a 0.25 D cross cylinder denotes the lens retina.
If the patient’s vision is good at this stage, such as 6/9
+0.25 DC axis 0/—0.25 DC axis (0 + 90)
or better, his attention should be directed to a circular
but, in manufacture. an equivalent sphero-cylindrical test object of size equivalent to 6/12. This next larger
form is preferred for practical convenience. The recom- size is used because the cross cylinder often reduces the
mended term ‘cross cylinder’ is thus more appropriate vision in one of its positions. Concentric circles, for ex-
than ‘crossed cylinder’. ample 6/12 with 6/4.5, are quite useful because if the
The lens is marked with the position of the axes, pre- vision is good through the cross cylinder, the patient
ferably with plus or minus signs or with coloured dots. will also be helped by the clarity of the smaller ring. If
In the UK, + is usually red and — is usually white or the vision is poor, a larger circle should be used.
black, but the opposite code is generally used elsewhere. The cross cylinder is then placed in front of the trial
If used in conjunction with a trial frame, the lens is lens(es) already before the patient's eye with its axes
mounted in a handle which is at 45° to the axes (Figure vertical and horizontal (Figure 6.6). The lens is then
6.6). By twirling the handle, the positions of the axes twirled about its handle direction, interchanging the
are rapidly interchanged. A similar principle applies to positions of the two axes, and the patient asked whether
cross cylinders incorporated in refracting units. the circle appeared sharper (clearer or blacker) with the
The cross cylinder technique was introduced by Jack- lens in its first or second position. If the patient preferred
son, initially to determine or check the cylinder power the position where the minus axis was horizontal, the
(1887) and later (1907) the cylinder axis. Unlike the minus axis of his astigmatism lies nearer the horizontal
fan and block method, successful use of the cross cylin- than the vertical. The cross cylinder is then turned so
der requires the circle of least confusion to lie on the that its handle is horizontal (or vertical), thus putting
retina. Since the mean power of the lens is zero, it does its axes at 45° and 135° (Figure 6.7). With the patient
not affect the position of this circle relative to the
retina, but does affect its size and resultant blurring by 135 45
altering the interval of Sturm. This is its basic principle _—

when used as a chéck on cylinder power.

In current practice, the cross cylinder is commonly
used to refine the results of an objective test, such as re-
(a) (b)

Figure 6.7. Cross cylinder handle horizontal to give 135

*BS 3521: Glossary of terms relating to ophthalmic lenses and 45°. The minus axis of the cross cylinder lies nearer the correct
spectacle frames. axis in (b) than in (a).
100 Subjective refraction

65 Determination of cylinder power

“42
The next step is to determine the cylinder power re-
quired, its axis direction having been accurately located
at 1 Or.
To do this, the cross cylinder is now held so that its
(a) (b)
axes are respectively parallel and perpendicular to the
Figure 6.8. A trial cylinder of —0.50 D at axis 20° (solid line) axis of the trial cylinder. In one setting, the cross cylin-
has been added and cross cylinder handle orientated along this der will then add minus cylinder power at the same
axis. The resultant (minus) axis of the trial and cross cylinder
axis as the trial cylinder, whereas after twirling, it will
combination is shown as a dotted line and is nearer correct axis
in (b) than in (a). add plus cylinder power at this same axis. The power of
the trial cylinder is thus checked by being increased
and decreased to the same extent, without displacing
the circles of least confusion from the retina.
Reverting to the example being considered, let us sup-
pose that at the end of the axis check procedure there
was a —0.50D trial cylinder in position, but the pa-
tient’s astigmatism was actually 1.00 D. Then, if it is as-
(a) sumed that the circles of least confusion had been
Figure 6.9. The axis of trial cylinder and cross cylinder maintained on the retina by adjustment to the spherical
handle adjusted to 10°. The resultant axis of trial and cross power as described, the residual refractive error will be
cylinder combination is equidistant from axis 10° in both
positions. +0.25 DS/—0.50 DC axis 10

This represents hypermetropia of +0.25 D along the 10°

meridian and myopia of —0.25 D along the 100° merid-
still watching the test circles, the better position of the
ian, the focal lines lying as indicated in Figure 6.10(a).
cross cylinder is determined, say, with the minus axis
A +0.25D cross cylinder is now introduced with its
at 45°.
minus axis at 10°, as shown in Figure 6.10(b). This
These two findings indicate that the patient's minus
adds —0.25D along the 100° meridian and +0.25 D
axis lies between 180° (or 0°) and 45°. A negative trial
along the 10° meridian, thus correcting the residual re-
cylinder is then placed in position, axis about 20°, to-
fractive error. The two focal lines would collapse to
gether with the addition of positive spherical power
form a retinal point image of a distant object point. The
equal to half the cylinder power. This keeps the circle of
second setting in which the axes of the cross cylinder
least confusion near the retina. The power of the cylin-
are interchanged is shown in Figure 6.10(c). In this pos-
der should be chosen as indicated by Table 6.1. (In Fig-
ition, the effect is to increase the residual myopia along
ures 6.8 and 6.9 the power of the cylinder has been
the 100° meridian by —0.25 D and the residual hyper-
taken as —0.50D to provide a numerical example. A
metropia along the 10° meridian by a further +0.25 D.
+0.25 D sphere would have been added as well.) The
As a result, the dioptric interval between the focal lines
cross cylinder is placed with its handle along or perpen-
is doubled, together with the diameter of the circle of
dicular to the axis of the trial cylinder, whichever is the least confusion.
easier position to hold. The cross cylinder axes are then Twirling of the cross cylinder showed that better
at 45° to those of the trial cylinder (Figure 6.8). The re- vision was obtained with its minus axis at 10°, in the
sultant of this combination of cross and trial cylinders same setting as the —0.50D trial cylinder. The power
has its minus axis between the two individual axes. of this cylinder should therefore be increased by, say
Twirling the cross cylinder may therefore, in this situa- —0.50D. At the same time, +0.25 D sphere should be
tion, be regarded as swinging the trial cylinder first in added so as to keep the circles of least confusion on the
one direction, then, by the same amount, in the opposite retina. If the astigmatic error has now been corrected,
one. In this example, if the preferred position of the twirling the cross cylinder will give no advantage in
cross cylinder was the one with the minus axis at 155° either position since half a dioptre of astigmatism results
(that is, clockwise from the trial cylinder position), then in each case.
the preferred resultant axis shift was also clockwise In some cases, the astigmatic power of the cross cylin-
from the initial trial cylinder axis. This indicates that der is greater than the residual astigmatic error of
the trial cylinder should be rotated clockwise, say refraction. Suppose, for example, that the residual astig-
through 10°, so that its new axis is at 10°. matic error is —0.25D axis 10°. With the minus axis
The cross cylinder handle is then placed along 10° set at 10°, an 0.25D cross cylinder will reverse the
and the lens twirled (Figure 6.9). If the ring appears residual astigmatic error, making it +0.25 D axis 10°.
equally clear in these two positions, the vision is the In the other setting it will be increased to —0.75 D axis
same whether the trial cylinder is effectively rotated by 10°. Since the circles of least confusion remain on the
the same amount in one direction or the other. Thus retina, this reversal causes no problems. The first setting
the patient’s astigmatic error lies at axis 10°. with the minus axis at 10° is clearly the better one
The numerical values of the resultant cylinder axes since it results in a smaller residual astigmatism, and it
given in Figures 6.8 and 6.9 assume the cross cylinder indicates that additional minus cylinder power at axis
to be of meridional power £0.25 D. 10° is required. If too much extra power is added, the
 Determination of the astigmatic error 101

Retina (9) Alter cylinder (and sphere) power as indicated, and

repeat until equality is obtained.

Residual As a sequel to objective refraction, the trial cylinder is

Refractive Error (K) left in place and steps (2), (3) and (4) omitted.
When a high astigmatic error is found, say 3D or
Kee 0.25 more, greater accuracy may be obtained by transferring
the trial frame complete with lenses to a focimeter to
measure the axis direction, instead of relying on the en-
10° gravings. This refinement is not possible with a refractor
head, which does not permit the manufacturer’s accu-
racy to be checked.

Cross Cylinder Relevant clinical matters

Position 1 The cross cylinder test is a simple one to use, but its suc-
cess depends on two factors: maintenance of the circle
Power of least confusion on the retina and speed of rotation of
=
the lens. The lens should be held in front of the patient's
eye for two or three seconds, then rapidly twirled and
again held steadily in place. This enables the patient to
— axis make a quick comparison between the two successive
images. The ease of rotation is improved on some cross
+ axis cylinders by having a pair of flats on the handle to be
held between finger and thumb, while the smaller
overall diameter of the lenses due to Freeman also helps.
If the eye is either fogged or excessively under-
Position 2 10° plussed, then the apparent clearest ‘focus’ might occur
Powel ’ when one of the focal lines is nearer the retina, despite
4+ 0.25 100° the total astigmatism being greater under these con-
ditions. Figure 6.11 shows an over-plussed eye with

Retina
+ axis

— axis

Figure 6.10. The cross cylinder and astigmatic power

determination: (a) the residual refractive error of +0.25/
—0.50 x 10 and the position of the astigmatic pencil relative to
retina, (b) a cross cylinder with its minus axis along 10°
corrects the refractive error, as shown by K = 0 in the column
for residual refractive error, (c) when the cross cylinder is
twirled into its second position, the astigmatic refractive error is
doubled.

next trial with the cross cylinder will reveal the over-
correction.
To summarize the technique:

(1) Put the circle of least confusion on or behind retina,

employing bichromatic test or Snellen chart.
(2) With patient observing appropriate test object, twirl
cross cylinder with axes along horizontal and verti-
cal. Note clearer direction.
(3) Twirl with axes along 45° and 135°.
(4) Insert trial cylinder (and appropriate sphere) with
axis as indicated by (2) and (3).
(5) Twirl cross cylinder, with handle along or at right
angles to trial cylinder axis. Note clearer direction.
(6) Rotate trial cylinder in this direction.
Figure 6.11. The cross cylinder and the over-plussed eye: (a)
7) Repeat (5) and (6) until no preference, or mid-point
cross cylinder in its first position, reducing the total astigmatic
of range obtained. error but giving a large blur ellipse on the retina, (b) cross
(8) To measure power, twirl cross cylinder with handle cylinder in second position shows an increased astigmatic error
at 45° to trial cylinder axis. giving a focal line on the retina, a position likely to be preferred.
102 Subjective refraction

Table 6.2 Effective cylinder axis shift by cross cylinders

both focal lines in front of the retina. Both settings of the Lie rn A
cross cylinder leave the circles of least confusion in Power of trial cylinder Axis shift (degrees)
their original position. In setting (a), the astigmatism is (D)
reduced and the focal lines brought nearer together, +0.25 D ae(@), 540) 0)
but there is a large elliptical blur on the retina. In set- cross cyl. cross cyl.
ting (b), the astigmatism is increased and the rear focal 0 +45 +45
line moved backwards to the retina. Depending on the 0.50 DDD Soe)
nature of the test object, the patient might find this set- 1.00 NS) prs
ting the better of the two, thus giving a false indication 1.50 9 17
2.00 7 eS
that a stronger cylinder is needed. It is because of this
2.50 Sy) iil
paradoxical situation that the use of rectangular letters 3.00 4.5 9
should be avoided (Williamson-Noble, 1943), especially 4.00 335 Vi
since letters may often be read more clearly with their 5.00 3 5.5
6.00 BES 4.5
vertical strokes in focus than the horizontal ones. A cir-
cular test object (not a 5 x 4 letter chart O) avoids this
Note: Figures rounded off to the nearest 0.5".
problem and is strongly recommended. Another suitable
test object is a cluster of dots, each of about 2 minutes
this reason, if any change is made in the trial cylinder
angular subtense. The cluster pattern reduces the ap-
power as the test proceeds, it must be balanced by half
parent distortion often noticed with ring test objects.
the amount of spherical power of opposite sign.
An alternative test object frequently used in the USA is
This adjustment is carried out automatically by the
a Maltese cross.
Stokes’ lens, named after its inventor who described it
The size of the test pattern to be used depends on the
in 1849. In its modern form it consists of two plano-cy-
patient’s vision, as discussed on page 99. The power of
linders of equal and opposite power, mounted close to-
the cross cylinder used is chosen in a similar manner.
gether in a carrier cell to fit a standard trial frame. It is
Cross cylinders are commonly available in powers of
used in some optometer systems and could also be built
30), 2, 220.25, 220537 eravel 20) OID, Ware Set0)2S as Wave
into a refractor head. As the cylinders are made to
most useful, provided the patient's vision with spherical
rotate in opposite directions by the control screw, the
lenses has reached 6/12. With poorer vision or small
cylinder power of the unit varies continuously, but the
pupils, one might start with a £0.50 cross cylinder but
mean power remains zero. Hence, in any state of adjust-
switch to +0.25 when making the final check on cylin-
ment, there is a spherical power component of one half
der power. However, since the +0.50 cross cylinder
the cylinder power and opposite to it in sign.
does tend to over-blur, a £0.37 cross cylinder is an ex-
The erroneous results which can occur if the circle of
tremely useful compromise.
least confusion is not maintained on the retina were
If, on rotation of the cross cylinder, an increased cy-
demonstrated graphically by Lindsay (1954).
linder power is indicated, it may be more convenient to
do so by holding up a second cross cylinder than to (2) Effective axis shift. The angle through which a
change the spherical and cylindrical trial lenses. This cross cylinder swings the resultant cylinder axis when
second cross cylinder is held stationary, close to the used as an axis check can be calculated from well-
trial lenses, and the first one twirled again. If this new known formulae relating to obliquely crossed cylinders.
total power is rejected, the extra cross cylinder is mere- It can be seen from Table 6.2 that the axis shift decreases
ly taken away; if accepted, the trial lenses are altered. as the power of the trial cylinder increases. Thus, the
Since the cross cylinder is a lens of symmetrical plus axis shift produced by a 40.25 -D cross cylinder is 22.5°
and minus power and is employed with the circle of when the trial cylinder power is 0.50D but only 7°
least confusion on the retina, the method may equally when the trial cylinder is 2.00 D. This is as it should be,
well be employed with plus cylinders, unlike the fan because strong cylinders require more accurate orienta-
and block where only minus cylinders may be used. tion than weak cylinders.
When determining the axis with plus trial cylinders, (3) Residual error of refraction. The theory of obliquely
the axis of the combination of cross and trial cylinders crossed cylinders can also be applied to calculate resid-
will lie between the cross cylinder’s plus axis and that ual errors of refraction. This term denotes the additional
of the trial cylinder. Hence the trial cylinder’s axis lens power needed to correct any remaining error of re-
should be moved towards the preferred plus cylinder fraction when a spectacle lens or trial lens combination
axis direction of the cross cylinder. When verifying the is already in position. In any such case the following
power, the trial cylinder should be increased or de- rule can be applied: to find the residual error of refrac-
creased, depending on whether the preferred position of tion, cancel the lens(es) in place by a hypothetical lens
the cross cylinder had the plus or minus axis respec- of equal and opposite power and add to this the lens
tively lying along that of the trial cylinder. a that fully corrects the given eye.
If the trial cylinder axis is of the correct power C but
set at an angle ¢ from the true axis direction 9, the resid-
ual error of refraction thus arising can be shown from
Background theory equations (5.10)-(5.12) to be
(1) Spherical power adjustment. The importance of
keeping the circle of least confusion on the retina when (Csin b) DS/(—2C sin ) DC axis(6 + 45 + /2)
using the cross cylinder has already been stressed. For (6.1)
 Determination of the astigmatic error 103

Table 6.3 Residual errors of refraction produced by various and also with the trial cylinder power less than the
incorrect cylinders, the eye requiring —1.00 DC axis 180°
astigmatic error. This is not to suggest, however, that
Trial cylinder Residual error of refraction the trial cylinder should purposely be made weaker.
The present writer occasionally uses a +0.12 D cross cy-
— Ono OrxalO 3 OKO) 33/0),
0. 6) IZA linder with 0.25 D trial cylinders when refracting obser-
(0), 7/5) 5< M0) + O.07/—O39°160
O.
al OR xan 0)
vant patients, while if a much stronger cylinder is
+0.17/—0.35 x 140
S125) S110) +0.36/—0.46OF x 124 found than initially in place, it is sensible to re-confirm
1.50) < KO) +0.58/—0.66 x 116 the axis with this.
Errors can also arise during axis location if the handle
of the cross cylinder is not correctly aligned with the
The usual sign convention applies to the angle 6. If it is trial cylinder axis, but Rabbetts (1972) has shown that
negative (clockwise from 9), sind also becomes nega- the comparative blurring in the two positions of the
tive. As an example, if Cis —1.00 D and @ is —10°, the cross cylinder is scarcely affected until the angular posi-
residual refractive error is tional error is of the order of 15°.

+0.17 sph/—0.35 cyl axis (0 + 40)

At the end of a preliminary objective examination, the Comparison of the fan and block and cross
trial cylinder before the eye may be incorrect as regards cylinder methods
both power and axis direction. Suppose, for example, The cross cylinder method has become the favoured
that the required cylinder is —1.00 D axis 180° but the technique because of the following advantages:
trial cylinder in position is —0.50 D axis 10°. The resid-
ual error of refraction is the sum of +0.50 DC axis 10° (1) It is possibly easier to use after objective refraction.
(to neutralize the incorrect lens) and —1.00 DC axis (2) It may be used with either plus or minus cylinders.
180° which is the cylinder required. The resultant of (3) It gives an average astigmatic ‘focus’ for the whole
this combination is of the pupillary area with the position of best spheri-
cal focus on the retina.
+0.03 sph/—O0.56 cyl axis 171 (4) The cross cylinder is relatively unaffected by any
head tilt by the patient (except when a refractor
A general idea of the magnitude of such errors can be
head is employed). The static eye reflex counter-
seen from Table 6.3, which shows the effect of cylinders rotates the eyes through about one-sixth of the
of different power all set at axis 10°, placed before an initial head rotation, but a 10° head tilt to one side
eye requiring —1.00 DC axis 180°. The figures listed will immediately give an erroneous axis result with
refer to an off-axis error of 10° but, to a reasonable the fan chart.
degree of accuracy, residual errors of refraction are pro- (5) It is convenient for the practitioner not to have to
portional to the off-axis angular error, all other factors keep reaching to the fan chart for adjustments.
being unchanged.
Two points are of particular interest. First, the size of Errors and difficulties can, however, arise with the cross
the residual astigmatic error, even when the trial cylin- cylinder when:
der is of the correct power should be noted. Secondly,
(1) The sphere power is incorrect. It is very easy to
the axis direction of the residual astigmatism is clock-
under-plus the older patient, putting the best focus
wise from the true axis if the angular setting error is anti-
behind the retina.
clockwise and vice versa.
(2) An unsuitable test object is used, especially if the
When a trial cylinder of the correct power is in place
important details are parallel to the principal meri-
during a test, its axis can be moved through an angle —
dians of the eye.
say > degrees — before any change is subjectively dis-
(3) The patient is confused by the apparent distortion of
cernible. Corresponding to this angle is a residual astig-
the test circle.
matic error which can be calculated as already
described. Comparative values of angle and corre- In addition, some patients do not understand the
sponding astigmatic errors with +0.25 D and + 0.50 D ‘first’ or ‘second’ approach. Their first answer, say
cross cylinders in use were determined experimentally ‘second’, biases their subsequent answers so that they
by O'Leary et al. (1987). With the £0.25 D cross cylin- repeat ‘second’ on the following trials since they do not
der in use, the mean results from five subjects showed wish to contradict themselves by replying ‘first’. This
to vary from 4.2° to 1.0° as the trial cylinder power problem may sometimes be overcome by labelling the
was increased from 0.50 to 1.50 D. The corresponding next trials third or fourth, fifth or sixth (or heads or
astigmatic power errors remained reasonably close to a tails) before returning to first-second.
mean value of 0.08 D. With the +0.50 D cross cylinder A useful but much less precise technique for finding
in use, the variation in was from 4.2” to 2.0°, while the the axis is to rotate the trial cylinder slowly away from
astigmatic errors ranged from 0.07 to 0.13 D. This con- the expected position and ask the patient to report
firms the general advice given on an earlier page to use when the letter chart begins to blur. This axis position
the +0.25D cross cylinder in the final stages of the is noted, and the process repeated in the opposite direc-
test. Johnston (1990) confirmed theoretically and ex- tion. The mean of the two end-points is taken as the
perimentally that axis determination is best with a axis. Although this is similar in principle to the action
cross cylinder power less than the trial cylinder power, of the cross cylinder, it has been found helpful to some
104 Subjective refraction

patients. It can also be a useful double check when the / \ fe

/ \ (aoa
subjective axis has changed significantly from the pre- aN / \ |
sent spectacle correction or from an objective finding. / K\ / VX aie
Ta aNG\\ / pais yi
The fan and block method is a well-tried and sound RETIRE, ‘pau\ e
fr / / \ / LE
technique. It may be modified to give a logical continua- ip th \) / A iM eaten
/ / / \ ‘ ple
tion to objective refraction, as will be described on page Ale \ / / Sa as re Uf
105. The blocks especially form a useful check test for \\e
\}\
/
/
/
\ \ ! / Wi
: np \ \ / \
cylinder power. ay ibaa ne ent” eel
Cautious patients may prefer this method because the \ \ ya dh 2 wl
simultaneous display of both sides of the arrow or of (a) (b) (c)
the blocks enables them to look repeatedly from one to
Figure 6.12. The Maddox V in low and high astigmatism. In
the other until they have decided which is better. (a) and (b) the limbs of the V include an angle of 40° and in (c)
There are some disadvantages: 15°. The \ is set in all three figures at 5° from a vertical
astigmatic blur. The bold vertical lines indicate the retinal focal
(1) It may be inconvenient to have to keep reaching to lines determining the apparent width of the blurred limbs of the
the fan chart for adjustments. V, (a) in low astigmatism, (b) and (c) in high astigmatism. The
(2) The blocks occasionally appear coloured and hence narrower V then permits finer discrimination.
confuse the patient. Also, if excess fogging is
applied, spurious resolution may occur, causing the
These considerations have been incorporated in the
blocks perpendicular to those predicted to seem
author's (RBR’s) simplification of the Raubitschek
clearer.
arrow or paraboline chart (Figure 19.9). A tapered V is
(3) If the eye shows irregular refraction due to corneal
used with an angle of 20° between the two lines forming
or lenticular distortion, the symmetry of the
the apex of the arrowhead, and 50° between the extre-
refracted pencils will be disturbed. The astigmatic
mities. The effects of various amounts of astigmatic blur
component is determined in a state of slight fog so
with this chart are shown in Figure 6.13.
that the retina intercepts the beam behind the best
The patient's response to the blocks has also been im-
focus. The cylinder that provides the best balance
proved by reducing the number of lines and increasing
under these conditions may not be the optimum
their separation. The original design (Figure 6.5), with
lens when the spherical component is adjusted to
lines and spaces of equal width, was susceptible to spur-
put the best focus back on to the retina.
ious resolution. When this occurs, the blurred block
Moreover, by concentrating attention on lines in
can sometimes seem clearer than the fogged reference
two meridians only, equality of the blocks may
block. In the new chart the space width is double that
again not give the best average refraction. This is
of the line thickness, subtending 6 and 3 minutes of arc
likely to occur when the crystalline lens is divided
respectively, while it is internally illuminated with
into sectors by localized (spoke-like) cataractous
yellow lamps in order to reduce the fringing from chro-
changes.
matic aberration.
(4) If the patient has had uncorrected astigmatism for
years, the neurological response in the usually
more blurred meridian may be poorer than that in
the better meridian (see page 42). This might affect Modification of techniques following
the blocks more than the test objects in the cross
objective refraction
cylinder method.

Although Walsh et al. (1993) found a high correlation If any form of objective test has been made, it is sensible
between the results of the two techniques, as would be to check the findings subjectively, provided that the
expected, there was a consistent difference between patient is able to co-operate. The cross cylinder method
them. can easily be adapted for this purpose.
With the objective findings (including any cylinder) in
place and the other eye occluded, the patient's vision is
recorded. The spherical power is then adjusted to
A redesigned V and blocks obtain the best vision on the Snellen chart, adding per-
haps —O0.25 DS to ensure that the circle of least confu-
The traditional angle between the limbs of the V has sion can be placed on the retina. If a bichromatic test is
been about 45°-60°, values adopted following experi- used for this step, the rings on the green background
mental work by Maddox (1925) and Verhoeff (1923). should be left just clearer than those on the red, subject
In low to moderate amounts of astigmatism, the blur- to the reservation on page 97.
ring of the lines is such that the difference between the The cross cylinder is now used, as described pre-
two when near correct alignment is readily perceptible viously, to check the cylinder axis. In order to demon-
(Figure 6.12a). In high astigmatism, the lines are both strate the effect of the cross cylinder, it is useful initially
so blurred (Figure 6.12b) that there is little difference be- to rotate the trial cylinder 5°-10° away from the objec-
tween them when slightly off-axis and hence the V is tive axis so that there is a definite preference on twirling.
then of little practical use in refraction. If the angle be- Otherwise, if the objective axis is approximately correct,
tween the lines were reduced, the differential blur there will be little difference in sharpness, which will
would be restored, as in Figure 6.12(c). not help the patient to understand the procedure. The
 Balancing methods and binocular refraction 105

cross cylinder method, the trial cylinder should be left

in position and the best vision obtained by adjusting
the spherical power. The spherical lens thus found is
not the ‘best vision sphere’, since an astigmatic lens is
also in play. If a bichromatic test is used, the preference
should be just towards clarity on the red background.
The eye is then fogged by the addition of a +0.50D
sphere, or stronger if the objective refraction showed
high latent hypermetropia, and the trial cylinder is re-
moved. At this stage the eye should be in a state of
simple or slight compound myopic astigmatism. The
astigmatic axis can then be quickly checked by using
the V, the power by using the blocks. The spherical lens
is finally checked and the visual acuity measured.
To summarize this routine:

(1) With the objective cylinder still in position, obtain

red preference with the bichromatic test or find the
sphere giving best vision on the Snellen chart.
(2) Add +0.50 DS (if objective refraction showed a
large latent hypermetropia, use a higher power),
check that vision is blurred and remove the cylin-
der.
(3) Set the V near the objective axis and confirm. If
there is a large discrepancy, use the fan chart.
(4) Using the blocks, find the cylindrical power needed.
5) Possibly check by adding an extra +0.50 DS so that
the blocks blur equally.
(6) Remove the initial +0.50 DS or other lens from step
(2);
(b)
With some patients, for example those with marked
lens opacities, neither an objective nor a standard sub-
jective test can be used. No routine can be laid down
for these, but various expedients may be tried. The pin-
hole disc or stenopaeic slit may reveal an improvement
in vision. If so, a subjective test with lens changes at
one or two dioptre intervals and cylinders freely rotated
may result in some measure of success. If the vision is
poor, 6/24 or worse, a better response often results
with a standard (6 m) direct test chart placed at 3 m or
even 1m.

Balancing methods and

(c) binocular refraction
Figure 6.13. The modified design of the V and blocks. (a) As
seen in focus. (b) Blurred by a low plus cylinder at axis 10°. It is Choice of methods
the wide section of the V which gives the bigger blur
differential. (c) Blurred by a high plus cylinder at axis 5°. It is When the astigmatic component of the distance refrac-
now the narrow section of the V which gives the bigger tive error has been determined, the next steps are to
differential. (The high contrast required for photographic confirm or adjust the spherical component and, if poss-
reproduction cannot convey exactly the appearance seen by the
ible, to balance the two eyes — a process sometimes
patient.)
known as equalizing the accommodative effort. This
allows both eyes to have the retinal image simulta-
astigmatic power is then confirmed and the spherical neously in focus. An imbalanced correction often leads
component is again’ checked. to asthenopia because of unstable acccommodation, the
If the objective test resulted in only a spherical correc- image in first one eye and then the other being brought
tion, the cross cylinder should be used to make sure into sharp focus. There are many different methods of
that an astigmatic error has not been missed, even if balancing, but a broad division into monocular and bin-
the vision at this stage is 6/6 (20/20). ocular techniques can be made.
The fan and block method may also, with some modi- Binocular methods of balancing can also be used to
fications, be used to check the refraction. As with the carry out a full or partial refractive test with both eyes
106 Subjective refraction

simultaneously in use. This procedure, which goes

beyond a balancing test, is best described as binocular
refraction,
Since bichromatic tests can also be used in conjunc-
tion with binocular as well as monocular balancing
techniques, a few general observations about them may A Be Ca D
be useful at this stage. We have already discussed the ef-
Figure 6.14. The waist or ill-defined depth of focus of the
fects of poor acuity, senile crystalline lens yellowing aberrated pencil within the eye. ‘
and protanopia on the bichromatic test (see page 97).
Depending on whether the patient's symptoms are in
distance or near vision, it may be better not to aim at small, the pencil is reduced in width and the depth of
equalizing the red and green but to aim at a red or focus is increased. In such a case, the patient will
green preference. For example, if the test pattern is left accept more plus power before blurring becomes percep-
just clearer on the red (red preference), it means that tible. As a result, it may be a cross-section at a point
the eye is in a slightly myopic state. This will be benefi- such as C, not at the mid-point B of the depth of focus,
cial if the spectacles are to be worn indoors only, for ex- which lies on the retina when the next +0.25 DS just re-
ample, by a young patient for close work. With the duces the acuity.
older (presbyopic) patient whose accommodation is rela- Another monocular balancing method is the succes-
tively inactive, the red preference often gives better sive comparison test. An occluder is transferred from
acuity on the Snellen chart and more comfortable eye to eye and the patient asked to report which eye
vision, especially in the middle distance at about 2 m. has the better vision. If there is a difference, it indicates
If the green is just clearer, then there is slight hyper- that one eye is relatively over- or under-corrected or
metropia, the yellow focus lying just behind the retina. has inherently lower acuity. Equal plus spherical power,
Chis should give the best acuity for the far distance and say +0.50 or +0.75 D, is then placed before each eye
in the younger patient the reserves of accommodation and the question repeated. The relative spherical power
can easily cope with the extra 0.25 D of effort. It should between the two eyes is then adjusted to give equal
be remembered that a lens giving a bichromatic balance vision. The moderate spherical fogging reduces the
at 6m will give —O.16 D of myopia in the far distance. effect of slight acuity differences and overcomes the un-
Charts projected on to a screen at 3—4m will cause certainty as to whether the eye is over- or under-cor-
even more significant errors, unless an appropriate al- rected. The plus power is then reduced for the two eyes
lowance is made in the prescription. equally until the best binocular acuity is obtained.
Some drawbacks of the method should be noted. One
is that the patient may accommodate while the occluder
is being transferred, thus causing errors. The additional
Monocular balancing methods
plus power should not be used in excess because it can
Where a patient has only one working eye, the spherical induce accommodative spasm and very blurred images
component of the correction may be determined by are difficult to compare. Even moderate degrees of fog-
either of the first two methods below. Where the patient ging may depress the acuity of one eye more than the
has no or poor binocular co-ordination, the sphere level other (Flom and Goodwin, 1964). Unequal pupil sizes
is again obtained under monocular conditions. The aim or ocular aberrations may be contributory causes. In
is to obtain the same response for each eye in turn, everyday practice it is not uncommon to find patients
with the other eye occluded. Since the accommodation having unequal unaided vision in the two eyes despite
level may change during the time required to check the similar refractive errors and final corrected acuities. Hy-
two eyes, these monocular methods should not really permetropic patients with an amblyopic eye frequently
be called balancing techniques, but are included in this prefer less positive power in front of the weaker eye
section on finishing techniques for convenience. monocularly than under the binocular conditions to be
When a bichromatic test is used for balancing, the described.
same preference should be obtained when each eye is al-
ternately occluded.
Another monocular method of checking the sphere is
Binocular balancing methods
to obtain the highest plus or lowest minus spherical
power for each eye which does not impair the acuity. For patients with good binocular vision, these methods
Assuming that 6/6 or better can be obtained, it used to are far superior to those just described because the fixed
be thought that the end result had been obtained when convergence required for viewing the test chart helps to
an added +0.25 DS caused a slight loss of crispness and stabilize the accommodation. They can also be used for
+0.50 DS reduced the acuity by one line. Although this checking the astigmatic component under binocular
may be true for a good proportion of patients, it is not viewing conditions.
always so. Because of the combined effects of spherical
and chromatic aberration, a paraxial pencil within the
eve does not come to a geometrical focus, but converges
Turville’s infinity balance test (TIB)
to an ill-detined ‘depth of focus’, as shown in Figure The infinity balance test was introduced by A.E. Turville
6.14. Within the region A to D the concentration of in 1936. In its current form a mirror is used with a re-
light produces the maximum acuity. When the pupil is movable vertical septum, preferably white (though
 Balancing methods and binocular refraction 107

balancing, a very convenient test object often incorpo-

Image of test rings rated in test charts, panels or slides is two identical sets
of concentric circles, one seen by the right eye and the
other by the left eye only. Alternatively, a line of sui-

© ,»O
Monocular Monocular
table size on a Snellen test chart can be selected.
The spherical power is adjusted to give, if possible,
equal acuity to the two eyes. If there is a difference, it is
[L R generally inadvisable to fog the better eye or over-
minus the poorer eye in pursuit of equality or to leave
the dominant eye with an acuity lower than the poorer
eye. Some practitioners prefer to use the TIB technique
with a slight fog, to about 6/9, when balancing spheres.
This is subject to the remarks on the previous page on
unequal response to equal fogging. The method will in
any case be useless if the eyes are fogged by +1.00 DS
Binocular LLL
LL
VfL
Lea Binocular
and comparison is attempted on the 24m line: +0.25
DS extra will then make little difference.
The bichromatic test and the TIB may be combined,
but in this case the method is too sensitive to allow si-
multaneous comparison between right and left eyes.
For each eye in turn, the clarity of the patterns on the
two colours should be equalized or adjusted to a red or
green preference, as appropriate. Because the two eyes

VLZL.
have been open and the great majority of the visual
field has been seen binocularly, it is unlikely that accom-

L modative effort will alter between viewing with first

one eye and then the other. It is this stability of accom-
modation that is the most important asset of binocular
refraction.
Septum

The Humphriss fogging method

If one eye only is fogged by +0.75 or +1.00 DS, foveal
vision in that eye is suspended, but paracentral and per-
ipheral vision are maintained. This is the principle of
the so-called psychologic septum, introduced as a bal-
ancing test by Humphriss (1961) and Humphriss and
Woodruff (1962). Millodot’s (1972) data would suggest
that a central area about 2—3° diameter — about 20-
30 cm at 6m — would be suspended when vision in the
fogged eye was reduced to 6/12.
Simpson (1991) showed that there was an increasing
R eye
probability of suppression of detailed foveal stimuli
Leye
when the monocular blur was increased from 0.50 D to
1.00 D. This confirms clinical experience that fogging
by +1.00 D can generally be relied upon to ensure that
the patient's attention is transferred to the other eye,
Test rings but if the fogged eye is strongly dominant, transference
of attention to the unfogged eye may not result.
Figure 6.15. Principle of the Turville infinity balance or
septum technique. The test rings at the bottom of the diagram The Humphriss fogging method may be used with the
are imaged by the mirror, but the septum occludes the right bichromatic test. Each eye observes the chart in turn
eye’s view of the left-hand image and vice versa. The shaded while its follow eye is fogged with a +1.00 DS. The
area is invisible to both eyes. (The fields of view as shown vary sphere before the observing eye is then adjusted to give
slightly with the patient's PD.)
equality, red preference or green preference as felt ap-
propriate by the refractionist.
black is sometimes tised) and of width about 30-35 mm
(half the inter-pupillary distance). As shown in Figure
The Humphriss immediate contrast test (HIC)
6.15, the effect of this occluding strip is to divide the
central portion of the test chart image into two separate The immediate contrast test HIC is an additional routine
monocular fields surrounded by a binocular field of introduced by Humphriss. With the monocular refrac-
view. Originally, a special set of test cards was used tive findings in place, a +1.00 DS is placed before the
with the TIB, but they are not essential. For spherical left eye’ (Humphriss recommended a +0.75 DS, but
108 Subjective refraction

with the patient fully corrected for hypermetropia, that Binocular refraction
is, red preference on the bichromatic test. If green pre-
The advantage of refracting under binocular conditions
ference is the aim at this stage, a +1.00 D fogging lens
is that the eyes are in a more normal situation than
is indicated). The patient’s attention is directed to an
when one eye is occluded. If, however, the trial cylinder
end letter on the 9 m line and is shown this first through
before one eye is markedly incorrect in power or axis,
an extra +0.25 DS, then —0.25 DS before the right
the patient may be in an even more unnatural visual
eye.t He is asked to say which lens is the more
state than with one eye occluded. Therefore, unless the
comfortable,{ not necessarily the one which makes the
practitioner is very confident of the accuracy of his-veti-
letters clearer or blacker. To help relax accommodation,
noscopy findings, it may be better to ascertain the astig-
the plus lens should be shown first and left in place for
matic component in the conventional, occluded way
several seconds, the minus lens for only one or two.
and then verify it under binocular conditions. With ex-
If the patient is already looking through a balanced
perience, however, the practitioner will be able to iden-
correction, the +0.25 DS will blur the vision, while the
tify those patients with whom the whole refraction may
—0.25 DS will tend to stimulate accommodation but
be done under binocular conditions, saving the patient
still allow a reasonable view of the test object. The
repetition and himself time. Humphriss (1961) and Rab-
patient will then prefer the second (minus) lens. Accord-
betts (1972), for example, have shown that in unse-
ingly, a —0.25 D lens is placed before the right eye and
lected series of patients, slight but sometimes significant
the +0.25/—0.25 DS choice offered again. This time the
differences in astigmatic power and axis arise on chang-
+0.25DS will not give rise to blurring while the
ing from monocular to binocular refraction.
—0.25 DS will require 0.50D of accommodation. The To determine the astigmatic correction with the Hum-
fogging produced by the +1.00D lens before the left phriss method, the +0.75 or +1.00 DS fogging lens is
eye and the 0.25 D of accommodation already in play placed before one eye and the other eye briefly covered
will inhibit further accommodation or make it uncom- to check that the first eye is fogged. The sphere level for
fortable. The plus lens will be preferred and so the the second eye is then adjusted, using either the bichro-
minus trial lens is removed. matic or the immediate contrast method, to put the
Strictly, when the —0.25 D lens was placed before the circle of least confusion on or just in front of the retina.
right eye, an equal lens should have been placed before The cross cylinder is then used in the normal way to
the left eye. This procedure is certainly advisable when confirm the astigmatic axis and power. The fogging
larger adjustments are required, but is of doubtful neces- lens is then transferred to the second eye and the process
sity when only 0.25 D is involved. repeated for the first eye.
The process is repeated for the left eye, with the The TIB is less suitable for long processes such as the
+1.00 D fogging lens transferred to the right eye. complete determination of the astigmatic correction,
To take a second example, suppose that at the end of since the head has to be kept quite still, but it is good
monocular refraction the findings are for the final confirmation under binocular conditions,
especially where a dominant eye renders the Humphriss
R +1:75Ds L +2.25DS
technique uncomfortable.
An alternative technique for binocular refraction and
The steps in the HIC procedure could then be as set out
balancing uses polarized light and an analysing visor
in Table 6.4. It is strongly recommended that the reader
for the patient. In one method, test characters on dupli-
should try this method on himself, in order to under-
cate panels (side by side) are mounted on polarized back-
stand the appearances of the letters.
grounds. The transmission axes for the right eye’s test
The final choice may depend on other factors: for ex-
background and analyser are parallel and perpendicular
ample, the higher plus findings for the older patient
to those for the left eye. The right eye’s panel thus ap-
(presbyope), esophore or young person who will be
pears black to the left eye and vice versa. This can give
using the correction mostly for close work; the lower
rise to the disconcerting effect of retinal rivalry or inter-
plus for a young person who will be wearing the correc-
mittent suppression.
tion for distance vision.
In another method,” polarized characters are printed
on the projector slide or near-test card. By this means,
the test characters in one field appear black on a clear
“It can be useful to have an extra lens in the trial set with the background to the eye with the crossed analyser, while
handle painted a different colour for identification and as a
reminder when in the trial frame. Pinhole discs and occluders the other sees a uniform light field. The same refracting
could also have painted handles. techniques may then be used as with septum methods,
+ The use of a lens pair mounted on a single handle is recom- for example, a bichromatic balance or the comparison
mended. of acuity between the two eyes (with black on white
t Humphriss’ original article suggested that the patient
symbols). The printed characters for the two fields may
should be told: ‘One of the two lenses put before your eyes may
make the letters blacker but not clearer. Choose the clear lens, overlap to allow tests for stereopsis.
and not the lens that makes the letters blacker.’ The use of the When retinoscopy is followed immediately by bin-
much neater phraseology in the main body of the text has ocular refraction, it is perhaps advisable to measure the
been taught for many years at the Institute of Optometry, and
works very well, despite the departure from the usual criterion
of acuity. The practitioner must use his or her own judgement
should the patient respond that the first lens is more comforta- * Vectograph Project-O-Chart slides and Vectographic Near-
ble, the second sharper. Point Cards (American Optical Co.),
 The binocular addition 109
Table 6.4 Humphriss’ immediate contrast test: example of procedure
(Sa ee ee eee Ee eee eee eee eee ee

Right eye Left eye

Initial spherical correction +1.75 +2.25

Leye fogged by +1.00 D +1.75 +3,25
+0.25 D presented to R eye +2.00 clear +3.25
—0.25 D presented to R eye +1.50 effort required Soe A)
Plus lens preferred: hence add +0.25 D +2.00 oe2)
+0.25 D presented to R eye +2.25 blurred +3.25
—0.25 D presented to R eye +1.75 slight effort required +3.25

The —0.25 Dis preferred. Thus, the indicated correction for the right eye is +2.00 DS or, possibly, +1.75 DS. Repeating the process for
the left eye:

Initial spherical correction +2.00 { T tO

R eye fogged by + 1.00 D +3.00

+0.25 D presented to L eye +3.00
—(0).25 D presented to L eye +3.00
Minus lens preferred: hence add —0.25 D +3.00 +
+0.25 D presented to L eye +3.00
—(0.25 D presented to L eye +3.00 WN
rPNNNN

The +0.25 se
te
Po
Dis preferred. Thus, the indicated correction for the left eye is +2.25 DS or, possibly, +2.00 DS.

Balanced spherical correction +2 OOO 2

or, possibly, . shes
] We a
For purposes of record, the higher plus (or lower minus) choice may be termed the plus option and the other the minus option.

patient’s vision through the objective correction with If one eye is markedly dominant, neither of the Hum-
the other eye occluded. This will ensure that the correc- phriss methods may work. Similarly, determination of
tion is sufficiently exact for binocular refraction to be a the astigmatic correction under binocular conditions
help rather than a hindrance. with the fogging method is unlikely to work for the
An alternative basis for binocular balancing and re- non-dominant eye.
fraction originally used in the USA is to induce double
vision by adding 4A base up before one eye and 4A base
down before the other. The bichromatic test or compari-
son of acuity with or without +0.50 DS of fogging may
then be made. To the present writers, the unnatural The binocular addition
conditions of test would appear to make this method
less precise than the septum, Humphriss or polarizing After a subjective refraction on each eye monocularly, it
methods. In a comparison with vectographic methods, is possible that when binocular vision is in play more
West and Somers (1984), however, conclude that these plus power will be accepted without detriment to bin-
prism dissociation techniques do provide a valid bin- ocular visual acuity.
ocular balance method. This can also happen following the use of balancing
techniques, which establish the relative sphere power
between the two eyes, but not necessarily the absolute
General observations
level. The use of binocular refractive techniques, es-
Balancing ofthe sphere is a complex subject with a large pecially the Humphriss method, does tend to relax the
choice of techniques, none of which works in all cases. patient's accommodation, making the binocular addi-
Where there is a unilateral strabismus or defective tion test less important than when following monocular
acuity in one eye, very careful balancing of the sphere refraction.
levels is not required. The best lens that can be found The method is straightforward: with the distance cor-
monocularly for each eye in turn may be sufficient. rection in place, the patient watches the lowest line of
Where one eye has a slightly poorer acuity, the HIC letters than he can read binocularly. A +0.25 DS lens
method may work better than Turville’s acuity balance, is added simultaneously before each eye, and, if pre-
but the basic Humphriss fogging method and the TIB ferred, is incorporated in the correction. The process is
generally work well in conjunction with the biochro- then repeated. The practitioner should bear in mind
matic test. The TIB is preferable for anisometropic that a test object at 6m is dioptrically at a distance of
patients. —0.16D, so that what is accepted in the consulting
If transference to the non-dominant eye does not room may leave an undesirable blur outdoors. In some
occur, it may be irfdicated by any of the following: inde- cases, especially where the symptoms or objective re-
cisive results with the cross cylinder or HIC tests; red sults suggest more hypermetropia than the subjective
clarity from the fogged dominant eye on the biochro- findings, the binocular addition is better determined by
matic test, irrespective of the lens in front of the eye fogging with +1.00 DS binocularly. The resulting
being tested; or patient discomfort shown by verbal binocular vision is measured and the addition reduced
comment or closing the dominant eye to allow refrac- by 0.25 DS at a time until the best acuity is again ob-
tion of the other eye. tained.
110 Subjective refraction

6.15 that there will then be a narrow central area

Oculo-motor balance and
which can be seen binocularly, thus providing greater
previous correction binocular lock. For this purpose, an extra symbol such
as a letter X or I midway between the right and left con-
The visual axes of the two eyes may not readily intersect centric. rings will be needed.
at the object being viewed, but may show a tendency to The final correction obtained is not necessarily the
deviate, requiring additional adjustments by the nerves one to be prescribed. If there is a large change in correc-
and muscles that rotate the eyes to obtain precise bin- tion from that previously worn, it is often advisable to
ocular fixation. Such a tendency to deviate is called an prescribe a compromise correction and give the Tull
oculo-motor imbalance (see Chapter 10). Provided that amount later. A previously uncorrected hypermetrope
binocular fixation can nevertheless be maintained, the may well be very comfortable with +2.00 DS, even
imbalance is termed a heterophoria. though the correction found was +4.00 DS. Marked
A deviation of one eye up or down relative to the changes in astigmatic power or axis can certainly
other will show as an apparent relative vertical displace- cause initial discomfort with a new correction, but are
ment of the rings on either side of the TIB septum. The usually justified by the improvement in vision obtained.
rings may be levelled with plano prisms, which should An oculo-motor imbalance may also require adjustment
then be considered for incorporation into the patient's to the refractive findings. Only experience can guide the
prescription. The TIB indicates a need for prism more practitioner.
frequently than the fixation disparity test (see Chapter With young children whose vision is in the formative
10). An uncorrected vertical heterophoria will make stage, full astigmatic corrections, if significant, should
the patient less comfortable during a binocular refrac- almost always be given immediately to give the acuity
tion and should be compensated by a prism before the maximum chance to develop. A year’s delay with a
using the Humphriss methods. partial correction can be too long. Small refractive
In near vision, the visual axes converge to intersect at errors may be less significant in children than in adults,
the point of regard. This convergence is normally asso- since their visual tasks are less detailed.
ciated with accommodation. For this reason, a hyperme-
trope who has to accommodate to see clearly in the
distance may tend to develop esophoria (convergent het- The repeatability of refraction
erophoria), though esophoria may be associated with
any refractive error. Because balancing under binocular Three recent surveys on the repeatability of refractions
conditions helps to inhibit the accommodation, a have suggested that refraction may not be as accurate
higher plus correction may be found than under mono- as thought. Adams et al. (1995) found that although
cular conditions. the mean difference in spherical equivalent refraction
Conversely, a person whose eyes tend to drift apart between the results of two different examiners on 86
(an exophore) may tend to accommodate more in bin- subjects aged 10-60 years was 0.12 D, there was a
ocular than monocular refraction, although this occurs wide spread of results, with 95% of the differences
infrequently. With the Turville septum, an exophore’s falling between —0.90 and +0.65 DS. Perrigin et al.
visual axes may diverge enough for each axis to pass si- (1982) each refracted optometry students, aged 20-28
multaneously through the appropriate circle. Fusion years, while McKendrick and Brennan's (1995) stu-
then occurs, giving the appearance of one ring. In this dents were aged 19-26 years. Their results are shown
event, base-in prism will be needed to regain separate in Table 6.5, McKendrick and Brennan’s results being
vision of the two rings before the procedure can be con- printed in italics.
tinued. An alternative but rarely used approach is to The age of the subject or patient may have a bearing
reduce the width of the septum to about 21 mm, as sug- on the repeatability. Accommodation will be more
gested by Banks (1954). It can be deduced from Figure active in younger patients, especially if under-corrected

Table 6.5 Percentage ofsubjective refraction results within the power or axis orientation limits of each other

Power

The same Within £0.25 D Within 0.50 D Within 40.75 D

Spherical equivalent DUG 86 98

Spherical power 48 95 99
88 D7.
Cylindrical power | 93 99
64 100 100
Anisometropia 44 95 100

Axis

Within 5° Within 10° Within 20°

88
78 93
LL
 Exercises 111

hypermetropes, while the smaller pupils and poorer but any error of centration with respect to the visual
media of the elderly again are likely to reduce accuracy. axis could then make the refraction even less accurate.
Conversely, the proportion of presbyopic patients who During the objective technique of retinoscopy (see Chap-
show negligible change in refraction over an interval of er 17), the refractionist must watch the centre of the
a year or more would suggest that the process is indeed pupil rather than the periphery, especially when dilated
repeatable. under cycloplegia.
A cycloplegic examination is also indicated in several
other circumstances:

Cycloplegia (1) when the symptoms appear to be of refractive origin

but are not explained by the change found initially;
Except in the mature patient, there is a normal resting (2) when the accommodation measured is very low for
state of ciliary effort and accommodation known as the age;
tonus. This accommodative tonus does not form part of (3) when the oculo-motor balance is markedly esopho-
the refractive error, since it will not relax even if the ap- GIG:
propriate correcting lens is worn for a long time. In the (4) when the subjective findings are considerably less
young uncorrected or under-corrected hypermetrope, hypermetropic or more myopic than the objective
this tonus may be increased abnormally because of the results.
habitual use of accommodation in distance as well as
near vision. A normal routine examination will not Finally, the emmetrope or low hypermetrope with
reveal the full refractive error because some of the hy- spasm of accommodation may appear to be myopic. Be-
permetropia remains latent — masked by the accommo- cause of proximal accommodation myopia, this fre-
dation. In young children a spasm of accommodation quently occurs when children’s sight is checked on a
may cause excessive fluctuations in refraction, so that vision screener (see Chapter 19). This pseudo-myopia
it is not possible to obtain a reasonable assessment of will be revealed under cycloplegia.
either sphere or cylinder.
Drugs known as cycloplegics, which temporarily pa-
ralyse the ciliary muscle (and also the iris sphincter) fa-
cilitate a truer determination of the refractive error.
Atropine sulphate, usually as a 1% ointment, will abol- Exercises
ish all the accommodative tonus and an allowance of
about 1.00D has usually to be made for the resting 6.1 Compile a third column for Table 6.2, relating to a
+0.37 D cross cylinder.
tonus regained when the effects of the drug have
6.2 Calculate the effective power at the cornea of lenses of
passed. Because it is slow both in taking effect and in power +10.00, +11.00, +19.00 and +20.00 DS, assuming
wearing off, it is now rarely employed. A weaker but 15 mm vertex distance. What is the effective power interval be-
quicker-acting drug, 1% or 0.5% cyclopentolate hydro- tween the neighbouring pairs of lenses? Repeat the calculation
chloride (drops) abolishes most of the tonus and is excel- for negative lenses. What relevance have these figures to the
choice of trial case contents and to refraction?
lent for most patients when a cycloplegic refraction is
6.3 An objective refraction gave +2.50/—1.50 x 170. De-
necessary. scribe the possible steps, using the modified fan and block tech-
No fixed rule can be given for the proportion of the cy- nique, that led to the final prescription of +2.25/—1.25 x 160.
cloplegic refractive error to be prescribed for hyperme- 6.4 A patient's previous prescription is listed in column P, the
current findings in column C. What is the lens power that has
tropes. The fullest possible correction should be given
to be held over P to convert it to C, so that the change in pre-
for young esotropes (‘convergent’ squinters, see Chapter scription can be demonstrated to the patient? Approximate an-
10). A partial correction leaving one or two dioptres un- swers are adequate for (c) and (d).
corrected may be best for other young hypermetropes
of over 3 D; the manifest findings and their influence on P @
(a) +5.00/—2.75 x 180 4-3.75/—2.75 * 180
the binocular co-ordination obtained in the pre-cyclo- (b) +4.00/—2.75 x 180 +4.00/—2.00 x 180
plegic examination will be a guide. If no pre-cycloplegic (Cc) —=212
5) — oO Sa 75 —3.00/—2.00 x 80
examination was undertaken, a post-cycloplegic refrac- (d) +3.00/—0.50 x 180 =o5/5/—0.90) 95
tion will be necessary to evaluate the effects of the full
6.5 (a) A distant point source is viewed by an eye of normal
and partial corrections in both distance and near
length with a pupil diameter of 5mm and principal powers of
vision. In the absence of signs or symptoms, it may be +58.00 Din the horizontal and +59.50 D in the vertical merid-
unnecessary to correct young hypermetropes with an ian. Assuming that the subject accommodates throughout so
error of less than about +3.00 DS under cycloplegia. In as to keep the circles of least confusion on the retina, find the
myopia, cycloplegia will reveal the lowest correction diameters of this circle: (i) in the uncorrected eye, (ii) when an
0.25 D cross cylinder is placed before the eye with its minus
giving the maximum acuity and hence the full findings axis vertical, (iii) when the cross cylinder is twirled to bring its
should normally bé prescribed. minus axis horizontal. (b) Assuming that you had no knowl-
The aberrations associated with the dilated pupil may edge of the powers of this eye, what would you deduce from
result in an astigmatic correction that is inappropriate your results about the cylindrical correction required?
6.6 The lens +4.75 DS/—3.25 DC axis 45 is placed before an
for the normal pupil size. It is therefore preferable to pre-
eye having a spectacle refraction of +5.00 DS/—2.75 DC axis
scribe the cylinder found before cycloplegia if reliance 35. What is the residual error of refraction, referred to the spec-
can be placed on it. In theory, an artificial 3 mm pupil tacle plane (that is, what additional lens is needed to correct
placed before the patient's eye would solve the problem, the eye completely)?
112 Subjective refraction

MADDOX, E.B. (1925) The ‘V’ test for astigmatism. Am. J. Phy-
References siol. Opt., 6, 56-58
MILLODOT, M. (1972) Variation of visual acuity in the central
ADAMS, C.W., BULLIMORE, M.A., FUSARO, R.E., COTTERAL, R.M., region of the retina. Br. J. Physiol. Optics, 27, 24-28
SARVER, J. and GRAHAM, A.D. (1995) The reliability of auto- MINISTRY OF HEALTH (1956) Trial Case lenses, Report of a Com-
mated and clinician refraction. Invest. Ophthalmol. Vis. Sci., mittee appointed by the Minister of Health. London: HMSO
36, S947 O'CONNOR DAVIES, P.H. (1957) A critical analysis of bi-chro-
BANKS, R.F. (1954) A foveal lock for infinity balance. Br. J. Phy- matic tests used in clinical refraction. Br. J. Physiol. Optics,
siol. Optics, 11, 216-225 14, 170-182, 213
BENNETT, A.G. (1963) The theory of bichromatic tests. Optician, O'LEARY, D.J., YANG, P.H. and YEO, C.H. (1987) Effect of cross
146, 291-296 cylinder power on cylinder axis sensitivity. Am. J. Optom.,
BENNETT, A.G. (1968) Emsley and Swaine’s Ophthalmic Lenses, 64, 367-369
pp. 170-180. London: Hatton Press
PERRIGIN, J., PERRIGIN, D. and GROSVENOR, T. (1982) A com-
FLOM, M. and GOODWIN, H.E. (1964) Fogging lenses: differential
parison of clinical refractive data obtained by three exami-
acuity response in the two eyes. Am. J. Optom., 41, 388-392
ners. Am. J. Optom., 59, 515-519
HUMPHRISS, D. (1961) Refraction by immediate contrast. In
RABBETTS, R.B. (1972) A comparison of astigmatism and cyclo-
International Optical Congress 1961, pp. 501-510. London:
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British Optical Association
161-190
HUMPHRISS, D. and WOODRUFF, E.W. (1962) Refraction by im-
SIMPSON, T. (1991) The suppression effect of simulated ani-
mediate contrast. Br. J. Physiol. Optics, 19, 15-20
IVANOFF, A. (1953) Les Aberrations de l'Oeil. Paris: Editions de la sometropia. Ophthal. Physiol. Opt., 11, 350-358
Revue d'Optique TURVILLE, A.E. (1946) Outline of Infinity Balance. London: Ra-
JACKSON, E. (1887) Trial set of small lenses and a modified trial phaels
frame. Trans. Am. Ophthal. Soc., 4, 595-598 VERHOEFF, F.H. (1923) The ‘V’ test for astigmatism, and astig-
JACKSON, E. (1907) The astigmatic lens (crossed cylinder) to de- matic charts in general. Am. J. Ophthal., series 3, 6, 9O8—910
termine the amount and principal meridians of astigmia. WALSH, G., CRAWFORD, M. and DONEGAN, M. (1993) Compari-
Ophthal. Rec., 17, 378-383 son of results from common subjective methods of astigma-
JOHNSTON, A.W. (1990) Verification of accuracy in cross cylin- tism determination. Ophthal. Physiol. Opt., 13, 106
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Vision — 10th Anniversary Conference, p. 26. London: British dation. Optician, 194 (5119), 19-20, 22, 26
College of Optometrists WEST, D. and SOMERS, W.W. (1984) Binocular balance validity:
LINDSAY, J. (1954) A theoretical investigation into the possi- a comparison of five common subjective techniques. Ophthal.
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McKENDRICK, A.M. and BRENNAN, N.A. (1995) Clinical evalua- the cross cylinder. Br. J. Ophthal., 27, 1-12
tion of refractive techniques. J. Am. Optom. Ass., 66, 758-
765
if
Accommodation and near vision.
The inadequate-stimulus myopias

Introduction

The young eye is able to change its refractive power by

alterations in curvature of the crystalline lens (see
pages 11-12). The increase in power is known as ac-
commodation. In the unaccommodated state, the ciliary
muscle is relaxed, the suspensory zonule of Zinn is at its
Figure 7.1. The far point Mp and near point of
greatest tension, the lens takes its flattest curves and accommodation Mp of an emmetropic eye.
the retina is conjugate with the far point Mr. In the ac-
commodated state, the ciliary muscle is constricted in a
sphincter-like mode, relaxing the zonule of Zinn and al-
lowing the lens to take a more convex form. In the fully
accommodated state the retina is conjugate with Mp,
the near point of accommodation’ (in Latin, punctum
proximum). Its linear distance from the eye is denoted
by b and its dioptric distance |/b by B. The maximum ac-
commodative effort is termed the amplitude (Amp).
The above is a brief statement of the classical ap-
proach to accommodation. From this standpoint, the Figure 7.2. The far point Mp and near point of
eye is said to be ‘relaxed’ when no accommodation is in accommodation Mp of a myopic eye.
play. In recent years, however, it has been demonstrated
that under various conditions, including poor illumina-
which gives
tion and insufficient object detail, the accommodation
tends to stabilize involuntarily at a level somewhat Amp = K — B (C75)
higher than zero. This is currently known as the ‘resting
state of accommodation’. The resulting ocular condition and
is termed (by the present authors) inadequate stimulus
myopia and is discussed more fully on pages 132-138. B= K — Amp (7.4)
Although these later discoveries throw important
In emmetropic and myopic eyes, the near point is in-
light on the visual system, they do not invalidate the
variably real (b negative) but, as shown by equation
classical approach as a basis for clinical practice and
(7.4), the hypermetrope’s near point will be real only if
the measurement of accommodation.
his amplitude is greater than his distance refractive
Figure 7.1 shows the far and near points of an emme-
Errol:
tropic eye and Figure 7.2 those of a myopic eye. In the
The range of accommodation is the linear distance
general case we have the following relationships:
from the far point to the near point. Thus, for an emme-
For the relaxed eye
trope with 8 D of accommodation, the near point dis-
K =K-+F, CAL) tance is 1/—8m or ~—125mm, so the range of
accommodation is from infinity to -125 mm.
For the fully accommodated eye

K' = B+(F,
+ Amp) (72)
Example (1)

* Usually abbreviated to ‘near point’, though in the USA this What is the range of accommodation of an uncorrected
term is often used for any near point. myope of —4 D whose amplitude is 10 D?
114 Accommodation and near vision. The inadequate-stimulus myopias

= ke 1 4 = =|0 25 25
0 mm of positive power —L,. This hypothetical lens would ob-
viate the need for accommodation and so its power is a
B= K—Amp=-—4-10=-—14D
measure of the so-called ‘spectacle accommodation’. If
b= —71.4 mm this is denoted by A,, then

The range of accommodation is —250 to —71.4 mm. (7)

Because of the lens-eye separation, the required
Example (2) ocular accommodation A differs in general from the
spectacle accommodation, often by a_ signifitant
What is the range of accommodation of an uncorrected amount. If d is the vertex distance, that is, the positive
hypermetrope of +4 D whose amplitude is 6 D? distance from the spectacle point to the eye's (first) prin-
ey Kom 2 Omm cipal point, then, in the simplest case of the emmetropic
eye
B= K—Amp=4-—-6=-2D (Figure 7.3), the object distance PB measured from the
b= —500 mm eye would be

Thus, in this case, the range of accommodation falls PB = PS+SB=-d+/,

into two parts. By exerting up to 4 D of accommodation, For example, given /, = —250mm and d=14mm we
the hypermetropia can be progressively reduced to zero, should have PB = —264 mm, which gives us
so that the point conjugate with the retina recedes from
the far point to infinity. This is the virtual part of the Spectacle acc A, = 1/0.250 = 4.00 D
range. This is of no use, except when using an optical in- Ocular acc A O264.— 3279 D
strument which can provide a virtual object for the eye. Thus, for the emmetrope, the ocular accommodation is
When the distance ametropia is corrected by 4D of ac- less than the spectacle accommodation.
commodation, the remaining 2 D of amplitude can be When a distance correction is worn, the relationship
used to see clearly from infinity to —5O0 mm from the is complicated by the fact that the effect of the lens—eye
eye. This is the real part of the total range of accommo- separation varies with the vergence of the pencil emer-
dation, sometimes called the range of distinct vision. ging from the spectacle lens. In distance vision, the ver-
gence at the eye's principal point is equal to the ocular
refraction K. In near vision, pencils from the given
Spectacle and ocular accommodation point B reach the eye with a vergence L which is nu-
merically less positive or more negative than K. For
Basic principles sharp retinal imagery, the power of the eye must there-
fore be increased by (K — L). Hence the ocular accommo-
In clinical practice most measurements are referred to
dation required is
the spectacle plane. Thus, in general, it is not ocular
but spectacle refraction which is determined. A=K-L (7.6)
Consider a near object B at a distance /, from the spec- Figure 7.4 illustrates the case of a myopic eye cor-
tacle point S (Figure 7.3). A paraxial pencil from B rected by a thin distance lens of power F,,. The ocular
would have a vergence L, (= 1//,) at the spectacle accommodation required can be calculated by the ‘step-
point, but would be rendered parallel by an added lens along’ method, as in the following examples.

Example (3)
A myope is corrected by a thin —4.00 D lens at a vertex

Ee distance of 14 mm. A near object of regard is —350 mm

from the eye’s principal point. Compare the ocular ac-
Figure 7.3. The distance /, of a near object B measured from commodation with the spectacle accommodation and
the spectacle point S. that required by an emmetrope to focus the same object.

fisn

Figure 7.4. A myopic eye, corrected

by a spectacle lens of power loss
viewing a near object B. The
corresponding diagram for distance
vision is Figure 4.8.
 Spectacle and ocular accommodation 115

The distance 7, = —336mm so that In near vision

Spectacle acc A, = 1000/336 = 2.98 D D mm

In distance vision li —2.98 _ ie —336
+Fp +4.00
D mm
Fyp —4.00 — va —250 we +1.02 oe +980.4
—d —14 —d —14
K —3.79 - k —264 ik +1.03 Ze +966.4

The arrow indicates the conversion from a distance in Oculantace——0—she 1 —— ese)

mm to the dioptric equivalent (or vice versa) by taking
1000 times the reciprocal. In this case, the accommodative unit is 3.21/2.86 or
IY.
In near vision
Although the above examples assume thin lenses, the
jlig —2.98 — Be —336 principle of the method applies equally when the actual
+F 5p —4.00 lens form and thickness are taken into account. In this
iif —6.98 = te —143,27 case, a paraxial pencil would have to be traced through
—d —14 each surface of the lens. The distance /, is now meas-
Ik —6.36 — m —157.27 ured from the front surface of the lens, while 7, becomes
the image distance measured from the back surface.
Ocularacc=4 he) — 7D Figure 7.6 shows the true ocular accommodation re-
quired over a wide range of ametropia corrected by spec-
Since the near object is —350 mm from the eye, the tacle lenses of typical form and thickness. Graphs are
accommodation required by an emmetrope would be given for three different object distances (measured
1000/350=2.86 D. from the corneal vertex).
The ratio of ocular accommodation to that required The circles show, for each of these distances, the value
by an emmetrope has been termed by Pascal (1952) the of F,, at which the ocular accommodation is the same
‘accommodative unit’. In this case it is 2.57/2.86 or as that required by an emmetrope, that is, accommoda-
0.90. tive unit equal to unity. The squares show the value of
F,, at which the ocular accommodation is equal to the
spectacle accommodation.
Example (4) It can be seen that the demand on ocular accommoda-
tion increases rapidly as hypermetropia increases. As
A hypermetrope is corrected by a thin +4.00 D lens at a
will be shown later, contact lenses require about the
vertex distance of 14mm. A near object of regard is
same amount of accommodation that an emmetrope
—350 mm from the eye's principal point. Compare the
would need to exert. Consequently, the advantage en-
ocular accommodation with the spectacle accommoda-
joyed by spectacle-corrected myopes disappears when
tion and that required by an emmetrope to focus the
they turn to contact lenses. Hypermetropes, on the
same object.
other hand, may benefit substantially from the lower
The spectacle accommodation and accommodation
demand on accommodative effort.
required by an emmetrope are as in Example 3. Figure
Figure 7.6 was based on calculations in which the
7.5 illustrates the calculation of ocular accommodation
form and thickness of each lens were taken into ac-
for the hypermetrope.
count. A 14 mm vertex distance was assumed. For com-
parison, corresponding figures for ‘thin’ (zero
In distance vision
thickness) lenses were obtained from equation (7.7)
D mm below. Over the whole range of minus lens powers,
Fp +4.00 — is +250 only negligible differences were found between the two
—d__=14 sets of results. In the case of plus lenses, the thick lens
K +4.24 — k +236 values were up to about 8% greater, depending on
the lens power. In the extreme case with F,, = +8.00 D

Figure 7.5. A hypermetropic eye,

corrected by a spectacle lens of power
Fy,
Ss viewing a near object B. The
corresponding diagram for distance
vision is Figure 4.9.
 116 Accommodation and near vision. The inadequate-stimulus myopias

whereas the accurate figure is 3.21/2.98 = 1.08.

From approximation (7.9) we can deduce that the
ratio becomes unity when F,, = —L,/2, that is, when
the spectacle refraction is in the vicinity of +1.25 to
+2.00 D. Figure 7.6 gives rather lower values ranging
from about +0.50 to +1.00 D.
To obtain an approximate formula for the accommo-
dative unit, we need an expression for A,,,, the accom-
modation required by an emmetrope. The object,
viewed directly, is at a distance (7, —d) from the eye’s
principal point, so that
=I Shs
Ae he = HAO,
eee GE peer h Ee
(D)
accommodation
Ocular
Hence, from equation (7.7)
A 1 — dL, 7
Acc unit = = - (Gall)
Aem (ue dF») {1 = de Fy) }
‘ F i ‘ F 2 ;
Binomial expansion with terms in d~ and _ higher
powers omitted leads to the approximation
—20 —16 Cy see a Cane ©
Acc unit = 1 + 2dF,, (FAD)
Spectacle refraction (D)

Figure 7.6. Graphs showing required ocular accommodation These last two expressions both show that there are
for stated object distances (measured from the corneal vertex) two cases in which the accommodative unit becomes
in ametropia corrected by spectacle lenses of typical form and equal to unity:
thickness. Vertex distance taken as 14 mm. Circles: ocular
accommodation equals that required by an emmetrope; (1) When d = 0. This very nearly applies to the contact
squares: ocular accommodation equals spectacle lens wearer because the distance from the corneal
accommodation.
vertex to the first principal point of the schematic
eye is only about 1.5 mm. In terms of accommoda-
and the object distance —300 mm, the necessary ocular tion, the contact-lens wearer may be regarded as
accommodation was found to be 4.52 D for the actual an emmetrope.
lens and 4.20 D for the thin lens. (2) When F,, = 0. It also follows from equation (7.12)
that the accommodative unit is greater than unity
in the case of hypermetropia and less than unity in
Approximate expressions myopia. However, Figure 7.6 shows that for lenses
of average form and thickness the dividing line is
By using binomial expansions it is possible to arrive at
not emmetropia but myopia of slightly less than
approximate expressions from which useful generaliza-
—1.00 D.
tions can be made.
Given an object distant /, from a thin lens of power As a matter of theoretical interest only, equation
F,, at a distance d from the eye, the vergence L at the (7.11) can also be reduced to unity when |e Batbe
eye is +2/d. This relates to the clinically impossible case in
which myopia of extreme degree is corrected by a pos-
L cps ial oA while K==Psp itive lens forming a real inverted image between the
La Ee) asdi
lens and the eye.
The ocular accommodation, equal to K — L, is Equation (7.12) is a reasonably good approximation
=Ibx when the value of F,, is not high. Applied to Example (3)
A= 7
(ir dF.) {1 a d(L, a Fs5)}
(7.7) Acc unit = 1 + 0.028 (—4.00) = 0.89

If this is expanded by the binomial theorem and terms in whereas the more accurate value was found to be 0.90.
d~ and higher powers are omitted, we obtain For Example (4) it gives
A=-L,{1+d(L,
+ 2F,,)} (7.8) Acc unit = 1 + 0.028 (+4.00) = 1.11
and instead of 1.12. Curiously enough, the approximation
ocular acc A becomes increasingly inaccurate in the range of minus
SE UE Se et). 7.
—= == I
spectacle acc A, le + AFsp) (7.9) lens powers from —8.00 D upwards.

Applying this approximation to Example (3) we obtain

A/A, = 1+ 0.014{—2.98 — 8.00} = 0.85 Measurement of amplitude
The accurate figure is 2.57/2.98 = 0.86.
For Example (4) we obtain The distance correction must be in place before the am-
plitude of accommodation is measured, or else a myope
A/A, = 1+0.014{—2.98 + 8:00} = 107
would give a falsely high reading and a hypermetrope a
 Accommodation and age: presbyopia 117

low one. The amplitude may be ascertained both mono- They also point out that a letter subtending, say 5 min-
cularly and binocularly. utes, at 40 cm for an older patient will subtend a larger
In the usual clinical method, sometimes termed the angle to a child with more than 10 D of accommodation.
push-up test, the patient observes a finely detailed test This suggests that measurements of younger people's
object which is brought closer to the patient’s eye until amplitudes may be over-estimated. Exercise 7.4 also
the detail just begins to blur. For convenience, a near- suggests another reason for the over-estimation of high
point rule graduated in dioptric distances may be used, values of the amplitude.
the reference point being approximately in the spectacle When using a near-point rule to measure the ampli-
plane. Care must be taken to ensure that the test card tude of a patient with low accommodation, a positive
does not fall into shade as it approaches the eye. An op- spherical lens should be placed in the trial frame to
posite method is to start with the card very close to the bring the artificial near point to a convenient distance
patient's eye and to move it away until the detail just be- of about 250 mm. The patient will not be able to judge
comes clear. Fitch (1971) found that except in the age an end-point if the test print is already blurred, and
group 25-40, a higher amplitude was recorded on only large print is legible. Similarly, a minus lens may
moving the stimulus towards the patient than on sliding be placed before the eye of a young patient to push the
it away. The binocular amplitude was slightly greater near point away from the eye. Allowance must be made
than the monocular, especially on moving the test in each case for the supplementary lens power.
object towards the patient. Both these differences, Objectively, dynamic retinoscopy (Chapter 17) may
although statistically significant, were only a fraction be used to measure the amplitude. A test object is
of a dioptre and of little clinical importance. mounted on the retinoscope or held just in front of it
As with the simple subjective optometer (see pages and the examiner approaches the eye while observing
74-75) the angular subtense of the object increases as the movement of the reflex. When a with movement is
it approaches the eye, a factor which makes legibility seen, the eye is under-accommodating for the distance
easier. To prevent this effect, the Badal optometer can of the retinoscope. For research purposes an objective
optometer may be used, the subject observing the test
be adapted (Lindsay, 1954). Somers and Ford (1983)
object through a beam splitter.
found the amplitude in the 32-40 age group to be only
0.6 D less when measured with a Badal optometer than
the figure obtained with the push-up test.
The amplitude may also be measured with the patient Accommodation and age: presbyopia
observing either the distance test chart or a near chart
at a fixed distance from the eye. Minus lenses are added Normal amplitude
until the acuity begins to fall, signifying that the full am-
As explained on pages 1 1—12, the young crystalline lens
plitude of accommodation has already been used to
is capable of being moulded into a steeper shape by its
overcome the artificial hypermetropia produced by the
capsule when the ciliary muscle contracts and the
minus lenses. Because the test object itself remains at a
zonule relaxes. As the crystalline ages, the alteration in
constant distance, there is not the same psychological
curvature becomes less for the same action of the
stimulus to accommodate as with a genuine near
muscle, (see page 129). The decline in focusing ability
object, though the fixed near object may provide a
starts in youth and continues till the age of about 60,
better stimulus than the distance chart because of the after which the small amount that apparently remains
induced proximal accommodation (see page 134). For is probably depth of field (see pages 288). not true ac-
this reason, a slightly lower amplitude is often found, commodation.
as by Kragha (1986) who concluded that the simpler Donders (1864) was one of the first to measure ac-
push-up test was reliable. The method works monocu- commodation as a function of age, but his findings
larly but not binocularly, because it would then disturb have been superseded by the results of Duane (1922),
the normal relationship between accommodation and obtained from over 4000 eyes. Duane measured the am-
convergence of the eyes. plitude both monocularly and binocularly, taking as
Rosenfield and Cohen (1996) also compared these the origin a point 14 mm in front of the cornea, approxi-
three methods for measuring the amplitude. The mean mately 15.5 mm from the eye’s first principal point. In
results for their five 23—29-year-old subjects were am- effect, spectacle accommodation was measured in em-
plitudes of 11.1 D for the push-up method, 9.5 D for the metropes and fully corrected ametropes. Figure 7.7
slide-down and 9.1 D for the negative lens method with shows the results for monocular accommodation. The
a test chart fixed at 0.4 m. They postulated that minifi- binocular results were 1—2 D higher in patients up to
cation of the chart by the negative lenses may have con- 15 years of age, the increase falling to below 1.0 D in
tributed to the lower result with this method — the the 45- to 50-year group, and usually less than 0.5 D
present writer would suggest that the minification may higher in the over-50 group. These differences are far
be caused by micropsia, described on page 119, since greater than those reported by Fitch (1971). Compari-
the angular subtense of the object does not increase in sons of Donders’ and Duane’s results have been made
harmony with the demand on accommodation. Rosen- by Hofstetter (1944) and Turner (1958).
field and Cohen (1995) also measured the amplitude The shape of the curve in the 45—60 year old is deba-
with test letters of various sizes, to find slightly greater table. As these measurements of the amplitude have
subjective amplitude with larger letters. They attribute been done subjectively, they include depth of field.
this to a delayed perception of blur with larger letters. Since the N5 print frequently employed as the stimulus
118 Accommodation and near vision. The inadequate-stimulus myopias

Inches Metres

eo sede ahs
ial Apel g 80 _ = f | 2.0

Mear\ , Max.
se hl = 1.8
70+} One-half ral
5 amplitude 16
I ai ar >
ta Te

60
adele La ona
aa ar
50 §
==) 4% =
J [ ad
Lee) “| —_——+

6
2
30 T af 0.8 g
4 Monocular
(D)
accommodation
2
i 3a Oe
2
20 Full amplitude
ee eee Nee SSS i= — 0.4
SLUBBESEEDAR aR =|
20 60 70 0.2
ao
Je in years 4

Figure 7.7. Variation of amplitude of accommodation with (0 el a _——— 0

age. Monocular values (after Duane, 1922) related to the 0 10 20 30 40 50 60 70 80

spectacle plane. Age in years
Figure 7.8. The shortest linear focusing distances
corresponds to about 6/12 (see Figure 3.17), coupled corresponding to exertion of all and half the available mean
with relatively small pupils in this age group, a high amplitude of accommodation as a function of age.

value for the depth of field or apparent amplitude is

given. Thus, Millodot and Millodot (1989) measured about arm's length. A separate graph shows the in-
the depth of field to be just over 2D, a figure much creased distances when only half the amplitude is in
greater than the 0.3 D cited on page 289. play.
Objective measurements of the amplitude have been Extra focusing power is therefore needed by the older
made. Hofstetter (1965) made studies on two subjects, eye in the form of a ‘near addition’ of positive power to
finding a linear reduction in amplitude, with it falling the distance correction. A person needing such help for
to zero before the age of 50, while Hamasaki et al. close work is said to be presbyopic. Presbyopia (from
(1956) found less than 0.50D of accommodation in Greek roots meaning old eye) cannot be defined in
their subjects who were aged over 48. terms of a specific amplitude of accommodation. The
Charman (1989) argued that the gradual slowing in need for a near addition or correction depends not only
loss of accommodation shown in Figure 7.7 for the on the available amplitude, but also on the habitual
50-55 age group was a statistical consequence of
working distance and nature of the near visual task.
taking the mean of many subjects for each age group. Though sufficient for reading a short article, the ampli-
He postulated that for any particular individual, the am- tude may not serve for a day’s close work.
plitude was a linear function of age which declined to Corrected hypermetropes have a lower spectacle ac-
zero, but the spread of ages at which the zero point was commodation than emmetropes and will tend to need a
reached softened the otherwise abrupt intercept be- near addition at a younger age. The converse applies to
tween the linear decline and the horizontal line corre- myopes. In fact, myopes of less than 4 or 5 D can often
sponding to the depth of field. cope with close work by merely removing their distance
At the other end of the age scale, Sokol et al. (1983) correction.
used the method of visually evoked response to try to de- A hypermetrope’s first distance correction, whether
termine the accommodative response of infants. Most full or partial, will also be helpful to him in near vision
2—4-month-old infants showed some response, while and may postpone the need for a near addition. Even
those +-5 months old could accommodate up to 5—6 D. so, this is likely to be required at an earlier age than
This was confirmed by Howland et al. (1987), who, the emmetrope, because of the greater demand on
using the method of photorefraction, found that all of ocular accommodation imposed on hypermetropes in
their infant subjects aged 2-10 months altered their ‘ac- general.
commodation appropriately for stimuli at distances be-
tween —25 and —100 cm. In Figure 7.8, Duane’s mean
results have been re-plotted in terms of the nearest dis-
tance from the spectacle plane at which an emmetrope
Variations from the normal
can see clearly when the full amplitude of accommoda-
tion has been exerted. While a child of 10 can focus at Figure 7.7 shows not only the mean value but also the
10cm or so, an adult of 50 can just see clearly at only normal spread of amplitude at any particular age.
 The near addition 119

Thus, approximately: face. The lens obviously lies within this region. The
relationship with latitude was not significant.
Age Spread of amplitude
The opposite view was taken by Bergman (1957) who
20-45 +2.00 D
50 +1.00 D found that the Afrikaan group (who had lived in South
50 and over +0.50 D Africa all their life) had similar amplitudes to those
given by Duane and Donders. This view is supported by
This spread was confirmed by Rosentield and Cohen Kragha (1986) in a study of Nigerians, and by Kragha
(1996) in the work already cited. The mean of their five and Hofstetter (1986) who found no significant differ-
subjects’ standard deviations was 0.7 D, which suggests ence in near additions prescribed in a survey covering
that a minimum change of around 1.5 D in a patient's the north to the south of North America.
recorded amplitude is necessary before it is meaningful, Since there is a natural spread of amplitude within
especially as usually only one measurement, not sev- any one age group, it is not surprising if patients need a
eral, are made in the consulting room. first near prescription at both earlier and later ages
Some young patients have reserves of accommodation than normal. The amount of close work undertaken,
which are markedly subnormal (Francis et al. 1979), the habitual working distance (both closer or further
and this is why accommodation should always be meas- than average), pupil size and illumination are all ob-
ured, even in the young. Such deficiency may be due to vious factors. In some countries, the availability of spec-
latent hypermetropia, general poor health, Down's syn- tacles and their expense may also influence the age at
drome (Woodhouse et al. 1993), cerebral palsy (Leat, which a correction is first sought. The patient's pride or
1996), ocular disease, a side-effect*of medical treatment self-consciousness may also be factors.
or lack of normal use. This latter can occur, for example,
in myopes who do not wear their spectacles for close
work. Poor accommodation, sometimes associated with
poor convergence, can also occur idiopathically, that
is, without discoverable cause. On the other hand,
The near addition
some elderly patients have accommodative reserves
There are three ways in which the initial near addition
much greater than normal, possibly because of a large
may be selected. These are based on the measurement
depth of field due to a small pupil.
of the amplitude of accommodation, age or the symp-
If a patient’s amplitude is low, a greater than normal
toms and strength of the present spectacles.
mental effort or neurological stimulus is needed to
obtain the required amount of accommodation. The
brain interprets this excessive effort as the object being From measurement of the amplitude
closer than it really is and hence smaller because a
small object at a short distance subtends the same The first step is to measure the available accommoda-
angle at the eye as a larger object at a greater distance. tion. Table 7.1 gives approximate expected values
which are easy to remember.
The apparent reduction in size is known as micropsia:
The third column gives an approximate addition,
the opposite effect — macropsia — results from a spasm
which may usefully be incorporated in the trial correc-
of accommodation. These effects occur particularly
tion before the amplitude is measured, due allowance
when drugs affecting the ciliary muscle are instilled
being made as already noted. It must be emphasized
into the eye.
that the addition prescribed depends on the patient's
There is a controversy over whether or not different
working distance and actual amplitude and should
ethnic groups or people living in hotter climates have a
never be based solely upon age.
lower accommodation for age than Europeans. Edwards
To use one’s full accommodative power for any length
et al. (1993) found their sample of Hong Kong Chinese
of time is not possible, but a fraction between one-half
to have amplitudes of accommodation between | and
and two-thirds can be sustained. Thus, if L, is the diop-
2D lower than Duane’s findings, with depth of field tric working distance and Amp, the full amplitude meas-
only being reached between the ages of 45 and 50. ured from the spectacle plane,
Coates (1955) found little difference in the variation in
amplitude with age between South Africans of European Add = (=I) —4= LD;
stock who had lived in Africa for at least five years and or = (-L,) — 2 Amp, (7.14)
other ethnic groups — all, however, had amplitudes
below those given by Duane. Hofstetter (1968) obtained Table 7.1 Expected amplitude of accommodation and
studies of typical bifocal additions from Fiji and Ghana, approximate near additions at various ages
suggesting that the Fijians and Ghanaians needed near
additions about 0.50 D stronger in the early presbyopic Age (years) Expected amplitude (D) Near addition (D)
years than Europeans living in the same country. 20 10 _
Weale (1981) plotted the average age at which accom- 30 8 -
modation fell below 3 D against both latitude and aver- 40
45
age ambient temperature. He found a decrease in this
50
age with increasing temperature and attributed this to 55
the fact that the surroundings can influence the tem- 60 Ne
pt
ey
oS

perature of the body to a depth of 10 mm below the sur-

120 Accommodation and near vision. The inadequate-stimulus myopias

As a rule of thumb, the fraction of two-thirds seems The ocular accommodation in use (K—L) is
too high to the present writers, who also demur at the (4.24 — 2.59) or 1.65 D.
common assumption that one-third of a metre To find the full ocular amplitude, since we know that
(L, = —3.00D) is the normal working distance. This the spectacle amplitude is 3.00 D, the test object has to
may apply to people engaged in very fine work, or with be at a dioptric distance of —3.00 D from the spectacle
defective acuity, the shorter working distance making plane with the distance correction in use. Accordingly,
the retinal image larger. Nevertheless, the most tracing the incident pencil to the eye, where its vergence
common working distances are found to range from is the dioptric distance B to the eye’s near point, we have
about 380 to 450 mm, giving a mean value of L, in the
D mm
neighbourhood of —2.50D. Numerically, a higher
Des —3.00
value of L, offsets a higher fraction of the amplitude.
+Fip +4.00
Thus, equation (7.13) with L, taken as —2.50D gives
very similar results (for amplitudes up to 3.00 D) as rah +1.00 — ie +1000
equation (7.14) with L, = —3.00 D. Millodot and Millo- —d —14
dot (1989) also investigated the proportion of amplitude B 1.01 f= b +986
used, to find (50.7 +27)%, the mean figure agreeing
with equation (7.13) above. Both these workers and Hence, from equation (7.3)
Morgan (1960) found that patients adopting a shorter Amp = K — B= 4.24 — 1.01 = 3.23D
working distance appeared to utilize a higher proportion
of their available accommodation. Woo and Yap The ocular accommodation in use with the prescribed
(1995) attributed the need for a presbyopic addition in addition is 1.65 D out of the available total of 3.23 D,
Hong Kong Chinese at an earlier age than in Caucasians the fraction being 1.65/3.23 or 0.51. This is almost
to their shorter arm length. identical with the fraction of the spectacle amplitude
In view of the differences between spectacle and adopted for determining the prescribed addition.
ocular accommodation shown by Figure 7.6, it may be Although thin lenses were used in these calculations,
questioned whether near additions can safely be pre- the end result would have been almost the same with
scribed on the basis of the spectacle accommodation. In real lenses.
fact, no qualms need arise. The following example, Prescribing a near addition on the basis of the meas-
which is typical, shows that an addition based on a par- ured amplitude is not sufficiently reliable, because of
ticular fraction of the spectacle amplitude calls into possible inaccuracies in this measurement. Moreover,
play almost exactly the same fraction of the ocular am- the theoretically assumed demand on accommodation
plitude. may not be the amount readily exerted.

Example (5) From the patient’s age

An eye is corrected for distance vision by +4.00 DS at The last column of Table 7.1 gives approximate near ad-
14 mm from the reduced surface. The spectacle ampli- ditions which can lead directly to refinement as de-
tude is 3.00D and the working distance —400 mm scribed below, rather than as a_ preliminary to
from the spectacle plane. What is the theoretical addi- measurement of the amplitude — this is the present wri-
tion needed if based on one-half of the given amplitude ter’s approach. Alternatively, Bussin (1990) suggests a
and what fraction of the ocular amplitude would then starting point of:
be in use? (patient’s age — 35)/10
Since 7, = —400 mm, L, = —2.50D and from equa-
on the assumption of a near working distance of —4m,
tion (7.13) >}

or
(patient’s age — 40)/10
As in Example (4), we now need to find the ocular re-
for a longer working distance (personal communica-
fraction K:
tion). The steady increase in addition given by such for-
D mm mulae (and some published tables) for patients aged
ae +400 > fi, +250 over their mid-60s should be treated with caution,
=a —14 since many elderly patients still prefer to read at 40 cm
K +4.24 — k +236 or more, thus needing an addition no greater than
+2.50D.
With the +1.00 D addition in use, the near correction
F,, is +5.00 D. Hence, in near vision at —400 mm:
From the present spectacles
D mm
If the patient is relatively happy with his present correc-
Ibe —2.50
tion, then it would be unwise to alter the present mean
+F,, +5.00
sphere by more than a small amount.
lee +2.50 = Ht +400 Whichever approach has been taken, the final addi-
—d —14 tion should be made by one or more of the methods
Je aia) — f +386 about to be described.
 The accommodative response 121

Methods of checking the addition for near

Underplus
vision

Range of clear vision

Correct M
The reading test types are used and, with the estimated
addition in place, the patient is directed to observe the + 0.50D
smallest size of type that he can read. He is then asked Overplus <— Retina
to bring the card closer until the print begins to blur.
The same procedure is repeated with the card moved M
— 0.50D
further away. These two positions should straddle the
preferred position, with the greater part of the range on
the far side where it is likely to be more useful. If neces-
sary, the trial lenses are altered to give this optimum dis-
tribution.

Figure 7.9. The cross cylinder technique for determining the

Trial lens method addition. The isometric drawing shows a grid screen viewed
through a cross cylinder, negative axis vertical. The rear focal
The patient looks at the test card held at his chosen dis- line is vertical and if it appears clearer, indicates too high an
tance — which at this stage may not be the clearest posi- addition, while clearer horizontal lines indicate too low an
addition.
tion — and low-powered spherical lenses are added. If
these are preferred, they are incorporated in the trial
correction; if rejected, lenses of opposite power are patient asked to report immediately whether the hori-
tried. Excess minus power will be rejected because of zontal or vertical lines appear sharper. Because an im-
the increased accommodation required, excess plus mediate response is required, the patient has no time to
power because it upsets the normal relationship be- adjust his accommodation so as to bring one meridian
tween accommodation and convergence (see pages of the test object into focus. If the horizontal lines
160-164). With many patients a state may be reached appear clearer, a low positive sphere may be added to
where both plus and minus quarter-dioptre lenses each eye's correction and the procedure repeated until
either cause equal deterioration in vision or make no dif- both meridians of the grid seem equally clear on intro-
ference. No alteration need then be made. It is inter- duction of the cross cylinders.
esting that the dioptric equivalent of the range is This technique may also be used as a check on the dis-
frequently larger than the +0.25 D lenses that are re- tance correction, but in this case the method of quickly
jected. introducing the cross cylinders must be used with non-
presbyopic patients. If the cross cylinders are left in
place for any length of time, the eye will accommodate
Bichromatic tests to make the vertical lines clearer, but is unable to relax
With the addition in place, the patient holds a near bi- to make the horizontal lines clearer. This would suggest
chromatic test, often a pattern of dots on the two colours incorrectly that the patient needs a weaker plus correc-
(see Figure 7.16). The addition is adjusted to give a tion.
slight clarity preference for the green background or,
perhaps, equality. The detail on the red background
should become clear if the device is moved 10-30 mm The accommodative response
further away. The senile yellowing of the crystalline
lens may be raised as an objection to this test because it When considering the level of accommodative demand
tends to promote a red bias typical in the elderly patient. on the eyes, two well-established facts should be borne
Nevertheless, unless the lenses are very yellow or hazy, in mind. One is that the accommodation actually ex-
the test appears to work well. Moreover, since a red erted is generally less than the amount theoretically
bias tends to give equality with a lower positive power, needed for sharp focusing — see Figure 7.17. Confirma-
the addition prescribed would err on the safe side. tion is provided by the extremely high proportion of
non-presbyopes, wearing any necessary distance correc-
tion, who see the pattern better on the green back-
Cross cylinder method ground in the bichromatic test. Reversal usually occurs
The patient observes a grid and a £0.50 D cross cylinder with the addition of +0.50 DS. This means that a theo-
is added to the trial correction, the minus axis vertical retical demand for, say, 2.50 D of accommodation re-
(Figure 7.9). If the addition is insufficient or the eye sults in an exertion of about 2.00D. As shown on
under-accommodated, the horizontal lines appear pages 288-290, the eye's depth of focus is thus used to
clearer. If the reverse applies, the vertical lines are its best advantage.
clearer. The addition is adjusted to give equal blurring. Rosenfield et al. (1996) compared several techniques,
This method may be used monocularly or binocularly. including an autorefractor (Chapter 18) to assess the ac-
Westheimer (1958) suggested a modification whereby commodative response in a group of 25 year olds. They
the patient is first asked to observe the grid without the found that, for binocular viewing of a —2.50 D stimulus,
cross cylinders. These are then put in position and the the autorefractor and dynamic retinoscopy (Chapter
122 Accommodation and near vision. The inadequate-stimulus myopias

Table 7.2. Examples of demand on ocular accommodation in cases of anisometropia

FN ea ES Se ee ee ee
Thin lenses Real lenses
Spectacle
refraction R Eye L Eye Diff. R Eye L Eye Diff.

With no addition
R —1.00 DS 2.43 OSV 0.14 2.47 Zao) 0.18
L+1.00 DS
With +2.00 D addition ee A
Ora; 0.60 0.03 0.61 0.66 0.05

With bifocal
0.52 0.60 0.08

With no addition
R +6.00DS PME SS 0.18 3.16 35 338) ORS
L+8.00 DS
With +2.00 addition

0.69 0.76 0.04 0.93 Hoda 0.18

With bifocal
0.90 0.82 —0.08

17) measured the response to be about 2.00 D, the bi- odot and Millodot (1989) have suggested that a larger
chromatic test slightly more at 2.17 D, while the cross image is needed to compensate for the clarity as the
cylinder method slightly higher again. They concluded ocular media deteriorates with age. They suggest that
that the nature of the cross cylinder test lead to over- the working distance becomes shorter, possibly aided
active accommodation. Monocularly, the autorefractor by the curving spinal posture.
found a lag of accommodation of about 0.3 D, whereas
the bichromatic test found 0.75 D. This reflects the
author's experience, where monocular (including stra-
bismic) patients usually need more plus than binocular Near vision and anisometropia
patients to obtain reversal to seeing the stimulus on the
red clearer. For a given working distance, the difference between
On the other hand, accommodation termed ‘proximal’ spectacle and ocular accommodation has been shown
is often stimulated by the knowledge that an object of to vary with the distance refractive error. It follows
regard is actually at a near distance, even though it is from this that in cases of anisometropia the two eyes
viewed through a lens or optical system intended and are called upon to exert different amounts of ocular ac-
adjustable to place the image at infinity. For this commodation.
reason, the eyepiece of instruments such as microscopes Table 7.2 summarizes data relating to two different re-
and focimeters should always be racked out towards fractive errors, each with 2.00 D of anisometropia. In
the eye and then moved inwards until the image just each case the object distance was taken as —400 mm
comes into focus. and the vertex distance as 14mm. The ocular accom-
Proximal accommodation is quite marked in young modation required for sharp focusing is shown both for
people and would, for example, introduce serious errors ‘thin’ lenses and for real lenses of typical form and thick-
in measuring their refraction with a simple type of opt- ness. Figures for the latter are seen to be slightly higher.
ometer, and under-estimates of visual acuity with When no reading addition is in use, the difference in
vision screeners. the accommodative demand on the two eyes is 0.18 D
Returning to the fact that the amplitude of accommo- in one case and 0.23D in the other. Though these
dation has declined to just depth of focus by the age of amounts may not be clinically significant, they are prob-
50, the question arises as to why the near addition con- ably nearing the level where discomfort may result.
tinues to increase from this age. Pointer (1995), for ex- When a near addition is in use, less accommodation is
ample, found that up to the 51-55 age group, the needed and so the difference between the right and left
mean near addition was given by the expression amounts required is also reduced. For comparison,
Table 7.2 also gives the ocular accommodation needed
0.252 + 0.0996 (age — 40)
when a +2.00 D near addition is in use, both as single
and for the group older than this, by Vision near correction and as a front surface bifocal ad-
dition.
1.272 + 0.0364 (age — 40)
In the great majority of cases, the innervation to ac-
with the two expressions meeting at around 1.8 D. This commodate is probably the same in each eye and gener-
gives a rise from 1.3 to 1.8 D between ages 50 and 55, ally results in equal accommodative effort. Differences
and a further 0.5 D up to the age of 70. The near bichro- in flexibility of the crystalline lenses or the strength of
matic test would suggest that there is indeed a decline the ciliary muscle can give unequal response between
in accommodation, since an increasing addition is re- the two eyes. Innervation to one eye may also be defec-
quired over these periods of time to give equality. Mill- tive. It is unlikely, however, that purposive differences
 Effectivity of the astigmatic correction in near vision 123

in accommodation can be produced, though such a re- The effective cylinder power at the eye is (6.64—2.60)
sponse is postulated in one of the references cited on or 4.04D, which can be taken as indicating the
page 125. The depth of focus of the eye and fluctuations amount of ocular astigmatism.
in accommodation described on page 130 may serve to Near vision at —400 mm
moderate the effect of any difficulties caused by anisome-
tropia. Moreover, the depth of focus in near vision is 150° meridian 60° meridian
greater than in distance vision because of the smaller jE. —2.50 —2.50
pupil size. RS, 46.00 7250
The older ametrope requires different corrections for Le +3.50 0
distance and near vision, whether in bifocal form or bee +285.7
otherwise. In theory, the younger anisometrope — de- —d —16
spite adequate accommodation — may also need a +269.71
separate near correction designed to equalize the ac- Ie +3.71 O
commodative effort of the two eyes.

The effective cylinder power at the eye is now only

3.71 D, which is 0.33 D less than in distance vision.
For a significant under-correction of 0.50 DC to occur
Effectivity of the astigmatic in near vision, this result suggests that the distance as-
correction in near vision tigmatism must be about 4-5 D. As in anisometropia,
the normal depth of focus of the eye is capable oftolerat-
The difference between spectacle and ocular accommo- ing moderate differences. Where symptoms of astheno-
dation is a consequence of effectivity — a concept re- pia do arise in near vision, it is probably better to
lating to the change in vergence that occurs between measure the astigmatism subjectively (see page 127)
two specified points on the path of a pencil of rays. Over than to rely on theoretical allowances.
a given distance, the change in vergence varies with its There have been many attempts to derive theoretical
initial value, being roughly proportional to the square relationships between the correcting cylinder in dis-
of this quantity. tance and near vision. Fletcher (1951/52) presents a
Another consequenee is that the cylindrical compo- summary of these equations, while an exact expression
nent of a distance correcting lens invariably has a re- due to Swaine is quoted by Rabbetts (1972).
duced astigmatic effect in near vision. The change in cylinder effectivity in near vision can
also be regarded as a meridional difference in the re-
quired ocular accommodation. Numerically they are
Example (6) identical. Reverting to Example (6) it will be see that
The distance correction +6.00/—3.50x150 is worn at the quantity (K — L) expressing the required ocular ac-
16 mm from the reduced surface. What is the effective commodation is 2.93D in the 150° meridian and
cylinder power in near vision at —400 mm from the 2.60 D in the 60° meridian. The difference, 0.33 D, was
lens (assumed thin)? the result obtained for the change in cylinder effectivity
The main stages in the calculation are illustrated in from distance to near vision. A simple approximate ex-
Figure 7.10. pression for this quantity can hence be derived.
Each principal meridian must be dealt with sepa- The first step is to substitute —L, for A, (equation 7.5)
rately, as follows. in equation (7.9) which can then be put in the form

fea 1d ee lg Alice pls (7.155))

Distance vision
in which A is the ocular accommodation.
150° meridian 60° meridian
Let F, and Fs, denote the spectacle refraction in the
Fp +6.00 4550) two principal meridians of the eye and A, and Ag the
Tsp +166.67 +400 ocular accommodation theoretically required in these
=d — ]6 Sere ] 6 two meridians. Then, from equation (7.15),
k 50.67 +384
K +6.64 +2.60 Ay = —{1+d(L, + 2F,)}L,

Spectacle Ocular Vergence at eye

refraction refraction in near vision

+ 6.64 + 3.71
+ 6.00
+ 2.50 + 2.60 0

Ocular astigmatism Meridional difference Figure 7.10. Stages in the calculation of reduced
4.04D 3.7:1D cylinder effectivity in near vision.
 124 Accommodation and near vision, The inadequate-stimulus myopias

and Ratio Cy/C

Ag = —{1 + dL, + 2F5)
tL, T 1.10

which gives | | ae a C1 1} 1.09

| |
Ay = Ay = —2dL,(F, = Fe) (7.16) | - | 1.08
Applied to Example (6), this approximation would
give the answer 0.28 D, the correct result being 0.33 D. No addition | oa | a
A more exact expression relating the required cylin- | ts ih - 1.06
der powers in distance and near vision may be derived. ie ae

Let M denote the mean power (S+ C/2) of an astig- | i | esas 1.05
matic lens. The two principal powers of the lens are
then (M+ C/2) and (M—C/2). Also, let C be the dis-
| i CT 404
tance-correcting cylinder, C’ the effective power of C at foal eal ala T T 1.03
.

the eye, C, the theoretically required near-vision cylin-

der and C’, the effective power of C, at the eye. Then, by il Pecccdeene 1.02
use of the exact effectivity formula, equation (2.11), the +2.00D addition |
relationship in distance vision can be written as
: | a 1.01
ani. M+C/2 M—C/2 eae 1.00
=O —5 0 +5 +10
1—d(M+C/2) 1—d(M—C/2)
C Mean spherical power (D)
a 7.17
(1—dM)2 —@C2/4 rae Figure 7.11. The approximate ratio of required near cylinder
Cy to distance cylindrical correction C as a function of mean
In the general case of near vision at a dioptric dis- spherical power. Vertex distance taken as 14 mm and near
tance L, from the lens, the correction may object vergence as —2.50 D.
incorporate
a near addition of power N. Consequently, the quantity
M in the above expressions must be replaced by
(L, + M +N), leading to
M Plane of regard Q
4
oe Cy
=a Men= pe 4 7.18
can)
If C, has the correct value, C/, will remain the same as C’
in distance vision. Little loss of accuracy will ensue if
the term in d* in the denominators of equations (7.17)
and (7.18) is omitted as being relatively small. The con-
dition that C’ = C/, is then represented by the equation

{1 —d(L,+M-+N)}?
Ce= : (7.19)
n/ (1 — dM)?
Expanded by the binomial theorem with terms up to d?
retained, this becomes

C,/C
= 1 — 2d(L, + N) + d?{(L,
+ N)? — 2M(L,
+ N)}
(7.20)
This ratio, always greater than unity, reduces as the
near addition is increased, becoming unity when
N = —L,. With no addition in use, the expression takes 66 mm
the simpler form
Figure 7.12. Accommodation in asymmetrical convergence.
€,/C= i= 2d a? (2 —21,M) (7.21)
It will be noted that the ratio C,/C as given by these
ing cylinder. With a +2.00 D near addition in use. the
various expressions is independent of the cylinder
difference becomes less than 2%.
power. Since the term in d? is relatively small, especially
for moderate values of M, it can be omitted if only a
reasonable first approximation is sought.
Figure 7.11, plotted from equation (7.19), gives a re- Accommodation in asymmetrical
presentative range of values and also shows the effect convergence
of a +2.00 D near addition. A vertex distance of 14mm
In Figure 7.12, Zp and Z;, are the eyes’ centres
was assumed. For a dioptric working distance of of rota-
tion and AM is a line in the median plane,
—2.50 D the cylinder power in near vision should theo- which is a
vertical plane bisecting ZpZ at right-angles.
retically be some 7-9% higher than the distance correct- So far we
have considered only near objects situate
d in the
 Near vision effectivity 125

median plane, where they are equidistant from both Table 7.3 Effectivity errors of spectacle lenses in near vision
eyes. This is not the case for any fixation point such as C5 0D isle)
Q that is not in the median plane. Front surface Centre thickness oflens (mm)
Referring to Figure 7.12, suppose the distances (taken power of
as positive) to be as follows: ZpZ, = 66mm,MQ = lens (D) D 4 6 8 10
100 mm, and MA = 400 mm. Then
+10 —(0.06 —(.12 —0.18 —0.25 —0.32
(QZ,)* = 1337 + 4007 +15 —0.09 —0.19 —0.29 —0.40 —0.52
+20 —0.13 —0.27 —0.42 —0.58 —0.75
which gives QZ; = 421.5 mm.
Since the centre of rotation lies approximately 12 mm
behind the eye’s principal point, P,, the object distance
P,Q is —409.5mm and the corresponding vergence mately proportional to the square of its initial value.
—2.44D. A similar calculation for the right eye shows One consequence is that the change in vergence under-
the vergence to be —2.54 D, a difference of 0.10 D. If gone between the two surfaces of a lens is not the same
the fixation point Q were 200 mm instead of lOO mm in both distance and near vision.
from the median plane, the difference in vergence Figure 7.13 refers to a lens of front surface power
would become 0.16 D. Both these values are small in re- +15.00D and centre thickness 6mm, the refractive
lation to the eye’s depth of field. index being 1.523. In distance vision (L, = 0), the ver-
The vergence difference also increases as the plane of gence L', after the first refraction is +15.00D and the
fixation MQ approaches the eyes, For example, if MA vergence L, at the second surface is +15.94D. The
were reduced to 200mm, the vergence difference change in vergence is +0.94D. In near vision at
would reach 0.50 D with the fixation point only 70 mm —400 mm (L, = —2.50D), L; becomes +12.50D and
from the median plane . Ly, + 13.15 D. In this case, the change in vergence has
In general, both the head and the eyes are rotated to the lower value +0.65D. Thus, the effective power
view objects to one side. Head movement reduces the change is (0.65 — 0.94) or —0.29 D, the minus sign indi-
asymmetry of the convergence. Unless the object is ex- cating a loss of effective positive power.
tremely close, the difference in object vergence at the A simple approximation for the effective power
two eyes is not significant. There have been several ex- change can be derived from equation (2.12), with the
perimental studies of the accommodation exerted when centre thickness t replacing the distance d.
the eyes are converged asymmetrically. Rosenberg et al.
(1953) found that the eye nearer the object did accom- In distance vision
modate more than its fellow eye, the difference agreeing Vergence change = (t/n)F7
approximately with the calculated theoretical value.
Spencer and Wilson (1954) also measured small differ- In near vision
ences between the accommodation levels in the two Vergence change = (t/n)(L, + F))?
eyes, but the eye exerting the greater amount was not
always the one closer to the fixation object. Subtracting the first of these expressions from the
second we obtain

Near effectivity error = (t/n)(L{ + 2L;F;) (a2)

Near vision effectivity The chief value of this approximation is the light it
throws on the relationship in general. In any specific
The concept of effectivity was briefly explained on page case it is just as easy to obtain an accurate value by the
10. It relates to the change in the vergence of a pencil step-along method used on page 115. The skeleton
of rays from one point to another on its path. As shown Table 7.3, compiled by this accurate method, was de-
by equation (2.12), the change in vergence is approxi- signed to give an overall idea of the magnitude of near
vision effectivity errors. Because of their small centre
thickness and relatively weak front surface power, all
i minus lenses and plus lenses of low power can evidently
+ 15.00
be excluded from consideration.
L,=0 =a ae To a good standard of approximation, the effectivity
1 +15.00 +15.94 errors under discussion are proportional to the value of
L,. Thus, to find approximate values for L; = —3.00 D,
the figures in Table 7.3 should be multiplied by 1.2.
Given the same vertex distance, any two lenses of the
same back vertex power will equally correct a static re-
fractive error. In near vision, however, a similar equiva-
lence may not apply to lenses of moderate and high
plus powers. Ideally, trial lenses should have near effec-
tivity errors of the same order as prescription lenses of
typical form and thickness. This, unfortunately, is not
Figure 7.13. Effectivity changes arising from centre
the case. Lenses of the additive vertex power design
thickness of a spectacle lens in distance vision and in near
vision at 40 cm. have plane front surfaces giving effectivity errors in
 126 Accommodation and near vision. The inadequate-stimulus myopias

—2.50 | + 11.50

ii (ik ¢ c.

~2.56 +11.44 |+12.92°

Figure 7.14. Effect in near vision of a forward
spectacle shift: thin lens power +14 D.

near vision never exceeding +0.02 D. In this respect, In near vision at a dioptric distance L from the lens, the
full-aperture bi-convex trial lenses have the advantage effective addition in the original spectacle plane becomes
since their near effectivity errors (for L,; = —2.50D) approximately —d’(L + F)?.
range from about —0.04D on a +8.00D lens to A typical case is illustrated in Figure 7.14. An object B
—0.22 Don a +20.00 D lens. is situated at a distance of —40 cm (L = —2.50 D) from
For a fuller discussion of effective power losses in trial a thin lens of power +14.00 D. After refraction by the
and prescription lenses, see Rabbetts and Bennett lens, the vergence L’ is +11.50 D. The lower half of the
(1986). diagram represents the situation when the lens has
been moved forward 10 mm from the original spectacle
point S to S’. Since the object distance is now —39 cm,
Effect of forward spectacle shift the vergence L becomes —2.56D and the vergence L’
after refraction is +11.44D. After travelling the dis-
tance 10 mm to the original spectacle plane, the pencil
The loss of the crystalline lens in aphakia deprives the
eye of its accommodative power. Nevertheless, it is well has the increased vergence of +12.92 D. The effective
known that an effective increase in positive power can
addition in this plane is therefore (+12.92 — 11.50) or
+1.42D.
be obtained with high-powered spectacles by pushing
them down the nose. When a real lens is substituted for the imaginary thin
If a thin lens of power F is moved forward by a short lens, the addition is reduced by a near effectivity error
(negative) distance d'(in metres) from the original spec- of the type already described. Nevertheless, there would
tacle plane, its effective power in this plane for parallel still be a net gain with the great majority of corrections
incident light is altered by approximately —d’F*, which for aphakia. In the numerical example just given, the
is always a positive quantity. The effect is as though true addition would be about +1.30 D.
the lens had been left in its original position with an ad- Figure 7.15, compiled by the accurate ‘step-along’
ditional lens of power —d'F> placed in contact with it. method used earlier in this chapter, gives an idea of the
additions available by pushing spectacles down the
nose. Figures have been plotted for a wide range of spec-
tacle refractions and for forward shifts of 10 and
20mm. Lens form and thickness were taken into ac-
count, typical values being assumed, and the initial
object distance was taken as —40 cm from the front
vertex of the lens. Note the loss in power with plus cor-
rections of up to about +6.00 D.

The near correction

Normal routine

The relaxed or unaccommodated state of the eyes is

+0.8 often termed ‘static’ and the accommodated state ‘dy-
|| +0.4 (D)
plane
spectacle
in
addition
Effective
namic’. In routine practice, the correction for
vision is not considered until after the static refractive
near

error has been ascertained. One good reason is that the

ERIRIAELED.—-éATases amplitude of accommodation cannot be measured accu-
aPiade dated beh 4 ddd de Pabeeh dod Shope rately until the distance correction has been deter-
20) —46)-12 =) 4 Oe HAS FER 2A? 216
mined, and this is often required in any case. Even if
the patient desires a near correction only, the practi-
Figure 7.15. The effective addition in the original spectacle
plane when the spectacles are moved forward by 10 and tioner has a duty to determine the corrected visual
20 mm. Typical values assumed for lens form and thickness. acuity. If it is subnormal, for example, 6/18 (20/60). it
Initial object vergence —2.50 D. could be a significant pointer to some pathological or
 The near correction 127

other condition requiring appropriate action to be (4) Inhomogeneities in the lens substance could give
taken. rise to an irregular change in refraction in the
Another reason for this procedure is that in the dy- dynamic state.
namic state, the slight pupillary contraction (miosis) (5) The cornea can change shape slightly upon marked
and fluctuations in accommodation make it more diffi- eye movements from the primary position though
cult to measure astigmatism as accurately as in distance not, perhaps, to any significant extent in normal
vision. This applies especially to the younger patient. positions of the gaze. Both Fairmaid (1959) and
It is also routine practice to obtain the correction for Lopping and Weale (1965) measured the corneal
near vision by giving a ‘near addition’ of plus power to curvature before and after convergence. There was
the distance correction (see pages 119-121), rather a tendency for the horizontal meridian to flatten by
than ascertaining the dynamic refraction. For the great an amount equivalent to 0.25 D with convergence,
majority of patients, this is undoubtedly a satisfactory but accommodation alone caused no appreciable
procedure. The miosis in near vision increases the change.
depths of field and focus, giving a slightly greater toler-
ance to residual errors of refraction. Despite all these possible causes for a difference in as-
When refracting in near vision it should be borne in tigmatism in the eye’s dynamic state, changes in astig-
mind that trial lenses stronger than about 4.00 D can matic power and axis detectable by everyday clinical
give rise to significant amounts of oblique astigmatism, techniques rarely occur. Reviews on this subject have
unless the visual axis is closely aligned with the optical been published by (among others) Bannon (1946) and
axis of the lens (Rabbetts, 1984). From this point of Rabbetts (1972). The latter found only nine power
view, the plano-convex form with the curved surface changes exceeding 0.25 D out of a total of 100 eyes. Sig-
next to the eye is worse than others in current use. If nificant axis changes also occurred in only a low propor-
the lens is reversed for this reason, account must be tion of the eyes examined.
taken of its changed back vertex power. For conveni- Millodot and Thibault (1985), in a study of 122 eyes,
ence, a conversion table could be compiled with the aid used an objective optometer to measure changes in as-
of a focimeter. Careful angling and adjustment of the tigmatism as the subjects accommodated for a range of
trial frame (if used) is a necessary precaution. For trial distances from 4.75 m to 30 cm. They found that those
lenses of medium and high minus powers, the plano- subjects who had either oblique or more than 1.0 D of
concave form is particularly suitable, but careful an- with-the-rule astigmatism tended to show an increase
gling is still required. of about 0.1 D in their astigmatism with increased ac-
To reduce the number of lens surfaces, it is preferable commodation. The greatest change occurred with
to incorporate a reading addition by changing the about 2.0D of accommodation in play. On the other
spherical lenses, rather than by adding supplementary hand, subjects with against-the-rule astigmatism
lenses. The trial frame generally allows the patient to re- showed a typical reduction of about 0.05 D with in-
produce the normal head and body posture better than creased accommodation, the greatest change again oc-
a refractor head, hence allowing a better judgement of curring in the neighbourhood of 2.0 D. These results
the patient's near vision distance. suggest that accommodation tends to produce a greater
increase in power in the vertical than in the horizontal
meridian.
Though these results justify the routine use of the
static findings, they also indicate the occasional need to
Astigmatism in near vision check the cylinder component in near vision. This
The possibility that the eye’s astigmatism might show a would be necessary in cases where the patient is comfor-
significant change in its dynamic state should not be table with his single-vision correction in distance but
overlooked. From his wide-ranging investigations, not in near vision. It might also be advisable if spectacles
Fletcher (1951/52) concluded that astigmatic accom- are prescribed for near vision only.
modation does not exist as a deliberate method of com- For the purpose of such a test, the cross cylinder may
pensating for ocular astigmatism, but may arise as a be used with a letter O or preferably a small circle
random by-product of the ordinary process of accommo- drawn on the test card. The young subject should initi-
dation. He suggested it be termed ‘accidental astigma- ally have the distance correction in place, and the pres-
tism of accommodation’. There are a number of byopic patient an adequate near addition as well. It is
essential that the trial lenses be angled perpendicularly
possible causes:
to, and centred on, the depressed line of sight, because
(1) A tilt of the crystalline lens gives rise to astigma- a relative tilt will introduce oblique astigmatism.
tism, the amount being approximately proportional The near refraction may be undertaken in either
to its power (pages 208-209). The astigmatism will monocular or binocular conditions. If the former, the
accordingly increase with accommodation. eye not under test should be occluded. If binocular con-
(2) The position and angle of tilt of the crystalline lens ditions are chosen, the vision in this eye may be
might also change when the suspensory zonule dimmed by a neutral filter of density 0.6—O.8 (or trans-
relaxes during accommodation. mittance between 25 and 15%). Many tinted ophthal-
(3) If either surface of the lens is astigmatic, the astig- mic glasses are suitable for this purpose. An alternative
matism could conceivably increase when the lens method is to blur the vision with a +1.00 D cross cylin-
becomes more steeply curved upon accommodation. der placed with the axes vertical and horizontal.
128 Accommodation and near vision. The inadequate-stimulus myopias

Polarized for R eye quate luminance to compensate for the light loss from
the polarizing filters and analysing visor. The dots
should be about 0.6—0.7 mm in diameter, subtending
Red Green
about 6 minutes of arc at the eye. A variant of this test
@i@
© ele@ uses two sets of letters instead of dots.
@@ @9o An objective method is to use dynamic retinoscopy
@ 8% @ (see Chapter 17).

The intermediate addition

The range of clear vision through a near addition de-

creases with increasing addition power — see, for ex-
ample Exercises 7.5 and 7.6. Thus an early presbyope
Red Green
with a +1 D addition and 3 D of accommodation has a
dioptric range of clear vision from —1 to —4D, or
Polarized for L eye —1000 to —250mm if depth of field is ignored. An
older patient with a +2 D addition and 1 D of accommo-
Figure 7.16. A polarized bichromatic display for near vision dation can manage only from —500 to —333 mm.
balancing (after Mallett), approximately three times actual size. Consequently, an occupational need for working com-
fortably at distances greater than 500 mm will require
a weaker addition, termed an intermediate addition.
Critical vision is often employed in near work for
much longer periods of time than in distance vision. The practitioner should be careful to ascertain what is
Small uncorrected or residual astigmatic errors of the meant, however, if a patient requests help for an inter-
mediate distance — some consider vision at
order of 0.50D prevent sharp retinal imagery. As a
result, the accommodation tends to fluctuate in search 2-3 m to be intermediate.
of the best focus. This may give rise to asthenopic symp- The required intermediate addition can be determined
toms such as tired eyes and headaches. by any of the methods described earlier in this chapter
for confirming the near addition, but commencing with
a power between one-half and two-thirds of the normal
addition.
Balancing the spherical component Depending upon the patient’s needs, the prescription
In distance vision, the spherical correction can be ba- may be dispensed as a separate correction, a trifocal, a
lanced under binocular conditions by one of the tech- progressive power (progressive addition or varifocal)
niques described on pages 106-108. The septum lens, or, rarely, an intermediate and near or distance
technique can also be applied to near vision, as in the and intermediate bifocal. The majority of trifocals have
Esdaile-Turville equilibrium test (Turville, 1934) and an intermediate addition fixed at 50% ofthe full near ad-
the Turville near balance unit described by Giles dition, though a few employ a 60 or 66% value. Anon-
(1960). The Humphriss method is not adaptable, be- ymous (1980) showed that the 50% value gives a
cause the low-powered positive lens does not fog the better linear overall range.
second eye in near vision but merely reduces the accom-
modative effort required. It is then not possible to tell Visual display unit users
which eye is in focus for the test object.
A technique now in common use is to combine the bi- The presbyope may have difficulty working with VDUs
chromatic method with polarization. The two halves of for two reasons: first, the working distance to the
the bichromatic pattern are polarized in mutually per- screen, typically around 600mm, is further than for
pendicular directions so that, when viewed through a si- conventional close work. Secondly, even when the dis-
milarly polarized visor, one half is visible to the right play unit is placed in the preferred position immediately
eye only and the other half to the left eye only. Figure on the desk, the angle of gaze is too high for comfortable
7.16 shows the pattern used in the Mallett units.~ To use of the bifocal’s near segment, while it is too close to
give viewing conditions as near normal as possible, the view through the distance portion. Burns et al. (1993)
upright lines and the surround are seen binocularly. found that most users positioned their paperwork at a si-
The patient's attention is directed to the upper half of milar distance to the screen, thus suggesting that a
the cluster of dots and the spherical correction for the single vision intermediate correction should perform
appropriate eye is adjusted to give equality of contrast well for most users. He also pointed out that although
on the red and green backgrounds. The process is then the keyboard is positioned closer, it has large characters
repeated for the other eye viewing the lower cluster of and therefore does not need a near correction to view it.
dots. It is essential that this test display should have ade- European employers have a responsibility to provide
special spectacles for their employees whose ordinary
spectacle correction is inadequate for VDU use, for ex-
“Supplied by Institute of Optometry Marketing Ltd, 56-62 ample a single vision intermediate correction supplied
Newington Causeway, London SE] 6DS. to a habitual bifocal wearer. The Association of Optome-
 Physiology of accommodation 129

trists’ recommendations on the visual standards for VDU Subjective amplitude 7

users are given on page 370.
Specialized progressive power lenses have been devel-
oped for those users who also spend a_ significant
W Blur
amount of time working at conventional reading dis- we noticed
tances. For example, the Zeiss RD has a +0.50 D addi-
tion at the fitting cross and a slightly larger near zone
than most progressives, the AO Truvision Technica has
very large near and intermediate zones at the expense
of a small distance zone, while the Essilor Proximal, Ro-
objectively)
(determined
denstock Cosmolit P and Sola Access are effectively in-
(D)
Accommodative
response
termediate—near progressives. Although a conventional
progressive power lens would allow vision with only a
slight head back tilt, the width of the intermediate por-
tion may be too narrow to allow comfortable screen
work for a prolonged time. While it might be expected Accommodative stimulus (D)
that the power increase down the progressive corridor Incident vergence L — ve
might cause visual blur because of the varying power
across the pupil, Burns (1995) showed that this was Figure 7.17. Schematic model of accommodation response
negligible. in a young eye. The straight diagonal line represents
coincidence of stimulus and response.

Anatomy of accommodation will relax when viewing the distance test chart, es-
pecially under binocular conditions.
The fibres of the young crystalline lens form an elastic Researches from about 1940 onwards have led to a
substance which is surrounded by an elastic capsule different view. It is now thought that accommodation is
with its maximum thickness at the equator: this drives exerted in both directions from an intermediate resting
the lens into a more convex shape when the zonular state. Thus, what is conventionally called over-accom-
tension is released by contraction of the ciliary body. modation in distance vision is an incomplete relaxation
Changes in the relative sizes of the lens cortex and nu- from the resting state. The accommodative function is
cleus, and their relative softness, explain the age also economical, departing from its resting state only to
changes in lens shape on accommodation. Thus, in the the extent required to give satisfactory vision. In dis-
child’s eye the whole lens is soft, and upon accommoda- tance vision, for example, a good Snellen acuity is con-
tion adopts a more convex spherical shape. In the sistent with slight accommodative lead (bi-
young adult up to about 30 years of age, the cortex has chromatic test left clearer on the red), while the lag of
grown to a significant thickness, but is less easily de- accommodation in near vision has been known from
formed than the nucleus. On accommodation, the softer the beginning of the century.
nucleus thus forces the central zone of the lens to bulge Accommodation is mediated by parasympathetic
more than the periphery producing an aspherical front stimulation of the ciliary body under the innervation of
surface with peripheral flattening. (See pages 281-283 the IlIrd cranial or oculo-motor nerve, arising in the
for the effect of accommodation on the spherical aberra- mid-brain. In the absence of a definite visual stimulus,
tion of the eye.) After the age of 30 or 40, both the nu- a low degree of neural activity gives rise to some ciliary
cleus and cortex stiffen, though the nucleus does so tonus — hence an alternative description of the resting
faster and eventually becomes harder than the cortex. state as tonic accommodation. A reduction from the
Both the asphericity of the lens and the amplitude of ac- tonic level requires an inhibition of the parasympathetic
commodation continue to decrease with age. The size of effort. As it is unusual for body muscles not to be op-
the anterior portion of the ciliary muscle increases be- posed, a sympathetic innervation to reduce accommoda-
tween the ages of 20 and 45, but then begins to di- tion has often been postulated. Recent evidence
minish (Stieve, 1949). Thus the effort required to showing that the ciliary body contains beta-adrenergic
accommodate at the onset of presbyopia is about 50% sympathetic receptors supports this view.
greater than in youth. For further details, the reader is The similar reaction time (latency) of about 375 ms
referred to the papers by Brown (1973, 1974, 1986) for both reductions and increases in accommodation
and Fisher (1971) and the recent reviews by Atchison would suggest, however, that significant changes in
(1995) and Gilmartin (1995). either direction are mediated by the same neural
system. Gilmartin (1986) gives a comprehensive review
of the evidence for and against sympathetic innervation.
Physiology of accommodation Experimental evidence on the performance of the ac-
commodative system is obtained by plotting the actual
The classical view of accommodation is that it is at rest accommodative response against the dioptric distance
when viewing a distant object and that the ciliary body of the test object (i.e. the vergence of the incident light).
is innervated to greater extent the nearer the object of If these two quantities were equal, the graph would be
regard. Indeed, the basis of subjective refraction is the a straight line through the origin at 45° to both axes.
assumption that with most patients the accommodation As shown in Figure 7.17, the typical response confirms
130 Accommodation and near vision. The inadequate-stimulus myopias

Reaction time

Tucker and Charman (1979) showed by high-speed

infra-red recording that in addition to a reaction time
of about one-third of a second (0.29 +0.07s from far
to near, 0.34+0.14 from near to far), there is a re-
sponse time of about a second (0.75 + 0.31 from far
to near, 1.19 + 0.57s from near to far) to reach the
‘steady’ state. Thus a stimulus needs to be present for
at least a second for full response to occur. Moreover,
even when the eye is observing a static target, infra-red
(D)
Accommodative
response optometers show that the power of the eye is fluctu-
ating. Thus Campbell and Robson (1959) found a
focusing tremor of amplitude 0.2—0.3 D at two superim-
posed frequencies in young subjects viewing a test
Object vergence (D) object at 1m. The low-frequency component of fre-
quency < 0.6 Hz is probably due to the neurological
Figure 7.18. Accommodative response as a function of
control, while the high-frequency component has been
object vergence for a Snellen target (bold line) and for
sinusoidal gratings of various spatial frequencies. (Redrawn shown to be related to the arterial pulse (Winn and
from Charman and Tucker, 1978, by kind permission of the Gilmartin, 1992). van der Heijde et al. (1996), using ul-
publishers of Am. J. Optom.) trasonography, confirmed variations in crystalline lens
thickness (and also anterior and vitreous chamber
the proposition that over-accommodation (or accommo- depths) as being associated with the low-frequency com-
dative lead) is the norm in distance vision and under-ac- ponent.
commodation (or lag) in near vision. It follows that at It is not known whether these fluctuations help in de-
some intermediate distance the response curve must termining the direction of accommodative response to
pass through the equality line at +5°. In a young adult, an out-of-focus image (e.g. Campbell et al., 1958). With
the ‘cross-over point’ would lie within the range their subjects’ accommodation paralysed, Walsh and
1.0-2.5 D. The portion of the curve to the right of the Charman (1988) showed that the visual system could
cross-over point is mediated by the parasympathetic detect changes in focus as small as 0.1 D for a target si-
system, while the portion to the left is sometimes mulating the micro-fluctuations of accommodation by
termed the sympathetic part of the curve. despite the oscillating to and from the eye. Maximal sensitivity oc-
fact that the question is still unresolved. The cross-over curred when the retinal image was slightly out of
point was considered to indicate the tonic accomodation focus. They felt this supported Charman and Tucker's
at the resting state, but recent evidence discussed (1978) hypothesis that the fluctuations were an aid in
below finds a much lower value for the tonic accommo- maintaining the final level of accommodation.
dation.
The proposition that accommodation is exerted eco-
nomically from an intermediate (resting-state) point of Dependence on detail size
departure is supported by results such as those of Char- Figure 7.18 showed that the accommodative response
man and Tucker (1978) reproduced here as Figure for detailed objects in the form of fine gratings or Snellen
7.18. In their experiments, the accommodative response charts was more accurate than that for coarser gratings.
at various viewing distances was measured for high- This might be expected since the fine target offers
contrast 6m Snellen letters and for sinusoidal gratings greater stimulus for accommodation, whereas the
of five different spatial frequencies. As the gratings coarser gratings will still be visible even when out of
become coarser, the smaller the changes in accommoda- focus — Figure 3.31 shows a cut-off frequency of 10
tion become over the range of viewing distances. Com- cycles/degree for 0.5 D error in focus, while a 3 cycle/
parable results had previously been obtained by Heath degree grating is still visible when 1.0 D out of focus.
(1956) using distant test objects blurred by fogging The converse argument is that a grating of frequency
lenses or ground glass plates placed immediately in around 5 cycles/degree at the peak of the contrast sensi-
front of them. The greater the blur, the greater the ac- tivity curve is most readily perceived, and therefore
commodation exerted, that is, the smaller the departure most likely to stimulate accurate accommodation,
from the resting state. whereas a fine grating must be positioned dioptrically
close to the eye’s present focus to make it perceptible
and thus able to control accommodation. This was
shown by Ward (1987b), who measured the accommo-
The accommodative stimulus dative response with an infra-red autorefractor (see
Chapter 18) while his subjects viewed sinusoidal grat-
ings of 25-26% modulation (contrast) at an object ver-
Accommodation is a response to an out-of-focus retinal
gence of —5.00D. The results plotted in Figure 7.19
image, and thus may depend upon such factors as the
(Ward, 1987b) show the most consistent accommoda-
duration of presentation, the contrast of the image, the
tion for the 5.0 cycles/degree grating, and a reasonably
size and type of detail, and its luminance.
consistent result for the 1.67 cycles/degree grating. In
 The accommodative stimulus 131

1:6 c/deg
1:67 c/deg

<AS

(D)
Accommodation
response

SOM Om SUMO 5ON O05 mn OmCumnlO)

(s) Time (min)

5-0 c/deg
Accommodation
(DS)
response

15 c/deg
<AS

(D)
Accommodation
response

E020) s0n 40m DOnCORZ 5456 8) 10

(s) Time (min) Grating modulation (%)
Figure 7.20. The monocular accommodation response to
gratings of 1.6, 5.0 and 15 c/deg with a stimulus vergence of
—5.0D, as a function of object contrast. The individual data
points of all observers are represented by circles. The region to
the left of the solid lines is where the defocus produced by the
accommodative error results in a sub-threshold image.
(Reproduced from Ward, 1987a, by kind permission of
Pergamon Press.)

both cases, the contrast of the image on the retina was

above the contrast sensitivity threshold. The greater tol-
<AS
erance to defocus of the coarser grating was due to the
larger depth of focus. The 15 cycles/degree stimulus
gave widely variable accommodative results. Ward's
calculations showed that the retinal image was then at
the contrast sensitivity threshold and thus gave poor
control over the accommodation.
(D)
Accommodation
response This supported his suggestion (1987a) of an accom-
modation response contrast threshold (ARCT), below
which the eye does not maintain focus. With the same
E 10 20 30 40 50602 4 6 8 10
three frequencies, but at modulation down to 0.5%,
Figure 7.19. The variation with time of the monocular Ward found that accommodation was again maintained
accommodation response of five subjects viewing gratings of more accurately after 1 minute's observation for the
contrast 25-26%. The accommodative stimulus, indicated by 5.0 cycles/degree stimulus than for the 1.6 cycles/ degree
AS, was —5.0 D. Note the change in the time scale at 60s. (a)
1.67 c/deg, (b) 5.0 c/deg, (c) 15 c/deg. (Reproduced from
grating, while the response to the 15 cycles/degree stimu-
Ward, 1987b, by kind permission of Pergamon Press.) lus was poor even at 8% modulation. Figure 7.20
 13 > Accommodation and near vision. The nadequate-stimualus myopias

shows that whereas accommodation maintained the Square-wave gratings

two coarser stimuli in sufficient focus for the retinal
Tucker and Charman (1987) measured the accommoda-
image to be above the contrast sensitivity threshold,
tive response to square- and sine-wave gratings. Their
the tine grating’s image fell below threshold, allowing
findings of better response for the square-wave gratings
accommodation to drift towards that of the field sur-
below 6 cycles/degree were explained by the help given
round (at a dioptric distance of —9.0 D). by the higher frequency harmonics of these gratings. A
Tucker and Charman (1986) postulated that for sti- similar result was found by Dul et al. (1988); their sub-
muli containing a broad range of spatial frequencies, jects gave the most accurate accommodative response
the eye's accommodation response from a very out-of when third and fifth harmonics were added to an 84%
focus level may be governed in turn by increasingly contrast sinusoidal grating of 1 cycle/degree. Tucker
tiner detail. Thus, as the response becomes more accu- and Charman suggested that the lower amplitude of ac-
rate, relatively coarse detail drives the accommodation commodation found in amblyopes, for example, by
to a slightly more accurate level, sufficient for finer Hokoda and Ciufireda (1982), could be caused by the
detail to surmount the accommodation response thresh- lower contrast sensitivity of the amblyopic eye to
old. The apparent disagreement between Ward's results higher frequency gratings.
and those of Charman and Tucker (1978) in Figure
7.18 could be explained by the S0% contrast used in
the latter study whereas in Ward's study it was
25-26%. Importance of luminance
Stone et al, (1993) investigated the accuracy of focus
of subjects observing a stimulus oscillating towards and
As shown by Figure 3.34, the contrast sensitivity of the
eye reduces with decreasing luminance. only lower and
away from the eve. They found the best response for
lower frequencies at higher and higher contrast being
gratings between 3 and 5 cycles/degree. The effects of
visible. Tucker and Charman (1986) investigated the
ocular longitudinal chromatic aberration on accommo-
depth of focus and accommodative response of the eye
dation were examined by Kruger et al. (1993). Com-
to sinusoidal grating stimuli as the luminance was low-
pared with the response in white light. they found the
ered. Under these conditions. the eye's focus tends to-
response fell when the aberration was neutralized by
wards that of the resting state. They concluded that the
an achromatizing lens (see Chapter 15), while it was
reduced ability of the eve to perceive fine detail, com-
less again in monochromatic light and even less when
bined with the large depth of focus of the eye to coarse
the aberration was reversed, while the reaction time in-
detail. resulted in a very inaccurate accommodative re-
creased, Stone and colleagues also tried doubling the
sponse. The relatively myopic state thus caused in sco-
longitudinal chromatic aberration of the eye. but found
topic conditions has been termed night myopia.
little improvement in accommodative accuracy. They
found that about 10% of subjects appeared to be rela-
tively unaffected by changes in chromatic aberration,
suggesting that their accommodation was controlled by
an achromatic directional clue. Conversely, they con-
cluded, like Edgar Fincham, that longitudinal chromatic The inadequate-stimulus myopias —
aberration was a component in the reflex control for
most people.
tonic accommodation

Introduction

Whenever the visual stimulus is insufficient to control

the accommodation accurately, it drifts towards a tonic
Voluntary control of accommodation level. governed by a low degree of parasympathetic
In both the studies last mentioned, the subject was stimulation. This has often been assumed to be equal to
that of the resting state, though Rosenfield et al. (1993)
asked to maintain the best possible focus. Some subjects
argue that they may differ. The relatively myopic refrac-
are able to exert voluntary control over their accommo-
tive state found under the various conditions indicated
dation, so that instructions during an investigation can
has been described as night (or twilight) myopia, dark
make significant differences to the results. Ciuffreda and
field myopia, empty space (or empty field) myopia and
Hokoda (1985) demonstrated a 5 D response to a —6 D
instrument myopia.
stimulus when the subject was instructed to keep the
In the recent literature, the various collective terms
object looking as contrasty as possible, yet the response
used for these myopias include resting state, anomalous,
was only about 2.5D after an instruction to relax
and accommodative myopias. The terms inadequate-sti-
when viewing the grating. (Cornsweet and Crane,
mulus myopia and tonic accommodation are used here
1973, showed that subjects could even learn to control as they give a more accurate description of their
their accommodation in response to an auditory sti-
common basic cause, the drift of accommodation to its
mulus.) This can be demonstrated during the push-up tonic value. Additional subsidiary factors may also con-
test for accommodation, when encouragement (the tribute, as later described.
‘mental effort’ of orthoptists) may result in a higher am- Rosentield et al. (1993, 1994) give a comprehensive
plitude.
review of the subject to which the interested reader is re-
 The inadequate-stimulus myopias — tonic accommodation 133

ferred. The next few pages give an introduction to the

subject.
2 1
ia3 a
E 0 =
= -1 &
i= 5 ales=
: ge:
ue} tes
Night myopia
g 3 =
In low illumination the refractive state of the eye tends £ -3 2
to change in the direction of myopia, irrespective of any a —4 —
°
ametropia at photopic luminances. As Levene (1965) = |

has shown, this ‘night myopia’ was discovered indepen- =P si) 0) ash a2 ae sel ake
dently by several astronomers, the first mention of it Focus setting (D)
having been made in 1789 by Nevil Maskelyne, the As-
tronomer Royal at Greenwich. The discovery had ie
o —
hitherto been attributed to Lord Rayleigh, whose an- a N

nouncement on the subject in 1883 created a lasting in- 5

—
1S.
mo}
terest in it. = &
Night myopia, also called twilight myopia, was E 2
cS 2
studied during and after World War II because of its
possible effects on visual performance, both unaided
23 é
fe
= >
and when using telescopes or binoculars. Investigations
followed two main lines.
3
al
g
In the first, the subject adjusted one eyepiece of the —2 -1 Oo +1 49°43 445
binoculars to give the best subjective quality of vision Focus setting (D)
both in daylight and at scotopic luminances, the other
objective being occluded. The difference between the Figure 7.21. The luminance threshold for recognition of a
target as a function of binocular eyepiece setting for two
two settings was taken to indicate the amount of night subjects. Solid line: normal, dark-adapted eye; broken line: with
myopia. Thus, Wald and Griffin (1947) found night cycloplegia. The two pairs of arrows give the subjects’ own
myopia to average —0.59 D, in 21 inexperienced obser- preferred eyepiece setting for dim D and bright B light. Upper:
vers, the spread being from +1.4 to —3.4D. The results normal eye, lower: with cycloplegia. Note the logarithmic
luminance scales. (Redrawn from Wald and Griffin, 1947, by
for 8 experienced observers out of doors ranged from
kind permission of the publishers of J. Opt. Soc. Am.)
+1.4 to —1.9D, with a mean myopic shift of —0.31 D—-
not a particularly dramatic result. In a similar study
with 28 observers viewing binocularly through field lens power) were again obtained, with values of night
glasses, Schober (1947, cited by Knoll, 1952) found a myopia in the neighbourhood of —1.50 D.
range from —0.50 to —4.00 D, with a mean of —2.00 D.
In the second technique used by Wald and Griffin, the
threshold or minimum illumination required by the sub- Causes of night myopia
ject to resolve a coarse acuity test object was measured
as a function of induced ametropia. The subject viewed The relative weight to be attached to the various factors
the chart through one half of a prism binocular, the eye- contributing to night myopia has been the subject of
piece focusing being adjusted in turn for each of a much previous speculation and discussion. Reviews of
range of dioptric values. Dark adaptation was required the literature at different stages have been given among
for mesopic and scotopic determinations. At low lumi- others by Ball (1951), Knoll (1952) and Borish (1970).
nances a plot of the threshold against induced ametro- Though tonic accommodation is now accepted as the
pia resulted in a U-shaped curve, the lowest point of basic cause, the eye’s chromatic aberration makes a
which was regarded as indicating the optimum focus. fairly constant and spherical aberration a variable con-
When this was compared with the optimum focus at tribution.
photopic luminances, a myopic shift was again found.
For the five subjects concerned it averaged —1.4D,
Involuntary accommodation
with a range from approximately —0.75 to —2.25D.
Figure 7.21 shows Wald and Griffin's experimental re- As shown by Campbell (1954), the minimum quantity
sults for two observers, redrawn from the original of light required to elicit the accommodative reflex is
graphs with the luminance additionally re-scaled in cd/ just greater than the threshold for foveal vision. It is
m7’, the appropriate SI unit. The dotted curve gives the therefore concluded that the stimulus to accommodate
result after instillation of homatropine to paralyse the in the interests of visual acuity is mediated by the
accommodation, while the arrows indicate the subject’s foveal cones. As luminance decreases and rod vision be-
own settings. comes more and more predominant, the accuracy of ac-
With themselves as observers, Koomen et al. (1951) commodation decreases and a small amount of
determined the limits of resolution of a square-wave involuntary accommodation becomes manifest. More-
grating as a function of ametropia introduced by phor- over, the U-shaped curves of Figure 7.21 indicate that
opter lenses at a series of different luminance levels. U- the eye tends towards a fixed focus in low illumination.
shaped curves (of angular resolution threshold against A markedly skewed plot would result if the eyes were
134 Accommodation and near vision. The inadequate-stimulus myopias

able to accommodate normally to overcome hyperme- focus P where the tip of the refracted ray caustic is situ-
tropia induced by minus lenses or equivalent eyepiece ated.
settings. Thus the eye can be regarded as showing ‘noc- At scotopic luminances, vision is dependent on the
turnal presbyopia’, in which the available amplitude re- rod receptors, which do not exhibit the Stiles-Crawford
duces towards a relatively fixed level remaining in play effect. Consequently, the rays through the peripheral
as illumination falls (Duran, 1943, cited by Otero, zone of the dilated pupil exert their full effect and shift
1951). the best focus position to W, the waist or circle of least
aberration of the refracted beam. As a result, the eye be-
comes effectively myopic by an amount possibly ‘up to
—().75 Dina typical eye. However, since spherical aber-
Chromatic aberration
ration shows considerable variation between indivi-
At photopic luminances the eye is most sensitive to light duals, its contribution to night myopia may also vary.
of wavelength 555 nm, as shown by the graph of the Having found similar values for marginal spherical
V(X) function (Figure 15.1). In scotopic vision, however, aberration and night myopia with themselves as sub-
the entire curve is displaced towards the shorter end jects, Koomen et al. (1951) were inclined to regard
of the spectrum, its peak occurring at about 510 nm. spherical aberration as the main cause of night myopia.
This is called the Purkinje shift. Because of chromatic This view was strengthened by the fact that a 3 mm arti-
aberration, the eye's focus for blue light is relatively ficial pupil reduced the myopia to between —0.50 and
more myopic than for green or yellow light. Figure 15.5 —0.75 D, about twice the amount which can be attribu-
shows the Purkinje shift to make the ocular refraction ted to the Purkinje shift.
more myopic by about —0.30 D. It can be seen from Figure 7.22 that spherical aberra-
It should be noted, however, that the standard V(A) tion with a dilated pupil has an unequal effect on the
curves refer to the hypothetical equi-energy spectrum size of the retinal blur circles in uncorrected ametropia.
and are affected by the spectral distribution of energy of Because of the additional deviation of the marginal
the light source. For CIE Standard [luminant D,; repre- rays, the increase in the blur size as the pupil dilates is
sentative of noon sunlight the peak is at 548 nm, but less than it would otherwise have been in hypermetro-
for Standard Illuminant A representative of tungsten-fi- pia, while the converse applies to myopia. This is an ad-
lament lamps it is at 570 nm, as shown in Figure 15.1. ditional reason why myopes in particular are likely to
This wavelength is much closer than 555 nm to that complain of poorer acuity at night.
which tends to be focused on the retina in distance
vision (see pages 288-289). In scotopic vision the peak
of the V(A) curve shifts only slightly with the nature of Measurement errors: proximal and
the source. With all these minor complications borne in cognitive myopia
mind, the contribution made to night myopia by the
There are several techniques employed to evaluate the
Purkinje shift can reasonably be taken as —0.35
refractive state of the eye. The laser speckle technique
ae (0)(0)5) 1D):
(see pages 375-376) may be used in conjunction with
an optometer of the Badal type to make a subjective
measurement of ametropia in, for example, total dark-
Spherical aberration ness. Infra-red optometers, especially the Canon Auto
Ref R1 (see page 354) which allows the subject to view
The positive spherical aberration of the relaxed eye
external fixation stimuli, and retinoscopy (see Chapter
causes a refracted axial pencil of rays to take the form
17) allow objective measurements.
shown in Figure 7.22. At photopic luminances, the re-
As pointed out below, results obtained with the laser
duced pupil diameter and the Stiles—Crawford effect
speckle system show greater amounts of inadequate-sti-
combine to place the effective focus close to the paraxial
mulus myopia than the infra-red optometers. This has
been attributed to various factors affecting the laser re-
Blur with sults:
large pupil
(1) Proximal accommodation is induced by the knowl-
edge that the object of regard is close to the eyes, so
Blur with
the laser’s Badal optometer lens and drum could
O small pupil O
trigger this. A related effect produced by the aware-
ness of, for example, the size of the room in which
the experiments are conducted has been termed
‘surround propinquity’ (Rosenfield and Ciuffreda,
WSN).
(2) Jaschinski-Kruza and Toenies (1988) and others
have shown that mental effort as opposed to passive
observation increases the accommodative response.
Figure 7.22. The aberrated ray bundle: paraxial focus P,
It is thought that the effort of judging the direction
waist W. H and M indicate the positions of the retina in
uncorrected hypermetropia and myopia, while the circles above of speckle motion might also give a falsely myopic
indicate the diameters of the blur circles with small and large refraction. This has been termed ‘cognitive accom-
pupils. modation’.
 The inadequate-stimulus myopias — tonic accommodation 135

figure of between 0.50 and 0.75 D as the typical

YI value

2° for tonic accommodation.

y oO
Empty-field or Ganzfeld myopia
—_ oO Though vision continues to operate in an illuminated
but empty-field (or empty-space or Ganzfeld) myopia,
(2) the absence of all visual detail removes the normal sti-
mulus to accommodation. For this reason, as in night
~ fo) myopia, the accommodation becomes fixed at or near to
its resting state. Typical real conditions can occur in
ee fo) daylight fog or in high-level flight well above the clouds
(D)
Accommodative
response where little detail is visible from the aircraft.
1.0 In early investigations, Luckiesh and Moss (1937)
used their ‘sensitometric’ technique of refraction in
which the accommodation is not stimulated. In effect,
the contrast threshold is measured with a range of lens
0 1.0 Zi) 0) 1) AD) Ye powers before the eye, the luminance contrast being
Accommodative stimulus distance (D) raised from below threshold so as to present initially an
empty visual field. The ‘best’ refraction is indicated by
e© 51.42 cd/m? x 0.51cd/m2
- 6.14 cd/m2 ** 0.051 cd/m? the lens power giving the lowest threshold. Measure-
ments were made on 100 subjects, from which a mean
value of about —0.75D was found for empty-space
Figure 7.23. Accommodative response as a function of object myopia, the range being —0.37 to —1.37 D. Two years
vergence for a graticule target viewed at four luminance levels. later, Reese (cited by Knoll, 1952) found a mean value
Individual values of dark focus refraction are given by the of about —1.00 D with a somewhat larger spread from
arrows. The flat response at the lowest light level demonstrates
a study of 25 subjects.
nocturnal presbyopia. (Reproduced from Johnson, 1976, by
kind permission of the publishers of J. Opt. Soc. Am.) Whiteside (1952, 1957) found involuntary accommo-
dation to fluctuate considerably in an empty visual
field, both in time with a single observer and from one
subject to another. These observations were confirmed
Dark-field myopia by Westheimer (1957) and by Heath (1962, cited by
Heron et al., 1981) who found them to apply to night
To prevent confusion, the refractive error measured in
myopia as well.
darkness should be referred to as the dark-field refrac-
Because of the relatively constant photopic illumina-
tion and the term dark-field myopia reserved for the
tion levels in empty-space situations, neither chromatic
shift towards myopia. For example, if the eye is hyper-
nor spherical aberration contribute to this type of
metropic +2.00 D in photopic conditions but +0.50D
myopia, which can most simply be explained by an in-
hypermetropic in total darkness, the latter is the dark-
adequate-stimulus theory.
field refraction but the dark-field myopia is —1.50 D.
Using 120 college students as subjects, Leibowitz and
Owens (1975) found their dark-field myopia to range
Instrument myopia — use of a pinhole to
from O to —4.00D, with a mean value of —1.72D.
‘open-loop’ accommodation
Their results also showed dark-field myopia to be
strongly correlated to night myopia, both in magnitude Instrument myopia is the well-known tendency to over-
and individual variations. In fact, it can be regarded as accommodate when using instruments such as micro-
a limiting form of night myopia. scopes. It was originally thought to be a form of prox-
The effect of night myopia on the accommodative re- imal accommodation. This is certainly a principal
sponse is shown in Figure 7.23, which plots the results factor because instrument myopia can be reduced by
of Johnson (1976) for 4 observers aged 22-24 at four training and by adjusting the eyepiece from the fully
different illumination levels decreasing by a constant racked-out (hypermetropic) side so that accommodation
factor of 10. As the luminance falls, the response curve during this adjustment does not improve the focus.
is seen to become flatter. At the lowest level of approxi- Nevertheless, it is now the opinion that instrument
mately 0.05 cd/m’, the response for all observers is myopia has a contribution from tonic accommodation.
never less than about 1.50 D or more than 2.25 D over Measurements have generally been made with sub-
the entire range of object distances from 0 to —3 D. jects viewing monocularly through a microscope
Levels of dark-field myopia measured with the Canon having an exit pupil not greater than 2mm. Results
Auto Ref R1 appear significantly lower. Thus, Rosenfield show the same spread of individual values typical of the
(1989a) found 1.28 + 0.48 D with the infrared instru- other myopias under discussion. For example, Hennessy
ment, as opposed to 2.01+1.02D with the laser (1975) using as subjects 15 emmetropes aged 18-25,
speckle. The results for each of their 10 subjects found a mean of —|.91 D, with a range from —0.96 to
showed little correlation between the two methods. The —2.78 D. The results of Leibowitz and Owens for instru-
article by Rosenfield et al. (1993) gives the even lower ment myopia, in the study mentioned previously, are
136 Accommodation and near vision. The inadequate-stimulus myopias

modation again unstimulated. Then, as the focus is ad-

justed, the point where the image becomes sufficiently
c a) in focus to stimulate the accommodation is reached too
Oe
suddenly for the accommodation to respond and so it re-
b =
rates mains at its tonic value.
25?
Exe
—
A key point in this explanation is the assumption ofa
ees
Soe small exit pupil. For this reason, the accepted term ‘in-
strument myopia’ could be misleadingly too general. It
=|
SERS
would be interesting to have data on other monocular
instruments having larger exit pupils, such as foci-
meters and prismatic monocular telescopes.
Because they greatly increase the eye’s depth of focus,
small artificial pupils are used in research into the rela-
tionship between convergence and accommodation
(Chapter 9). Their effect is to remove blurring of the ret-
inal image as a stimulus to accommodation; the blur sti-
mulus reflex is then said to be ‘open-looped’, leaving
the control of accommodation to other factors, for exam-
ple. convergence. Ward and Charman (1987) showed
in (D)
field
empty
Accommodation that an artificial pupil used for this purpose should
have a diameter not greater than 0.5 mm.

Correlations and variability of the

inadequate-stimulus myopias
To investigate relative magnitudes and correlations, Lei-
bowitz and Owens (1975. 1978) determined the night.
dark-field. empty-space and instrument myopia of 30
students aged between 17 and 26, all with vision not
less than 20/25 (6/7.5) and wearing their normal dis-
to (D)
image
microscope
Accommodation tance correction (if any). Their results are shown in
Figure 7.24, in which each point on the various scatter-
3 4 graphs records the value of the particular myopia for
one subject, plotted against his dark-field myopia. The
Dark field myopia (D)
line at 45° represents the condition for equality of these
two quantities.
Figure 7.24. Scatter plots for 30 subjects comparing night.
empty-field, and instrument myopia with dark-field myopia. In these experiments, night myopia was measured in
(Reproduced from Leibowitz and Owens, 1975, by kind daylight, but a neutral density filter was used to attenu-
permission of the publishers of Science © by the AAAS.) ate the ambient illumination by a factor of 16 OOO. It
nevertheless remained within the range of photopic
vision and so the Purkinje effect component was elimi-
shown in one of the scattergraphs included in Figure
nated.
7.24. The mean value, determined from this graph, is
Statistical analysis of the results of this study reveals a
about —2.3D, with a range from —0.7 to —4.0D.
high degree of correlation between the various forms of
Schober et al. (1970) found a similarly extensive range
myopia considered. There is, however, a wide range of
but a somewhat higher mean value. about —3.0D.
inter-subject variation. One of the principal reasons for
They reported that variables such as image configura-
this may well be variations in the amplitude of accom-
tion and contrast, magnification and luminance had
modation within the same age group. Another reason
only a minor influence. Their subjects were aged
may be variations in the level of parasympathetic activ-
25-30, but all had an amplitude of accommodation of
ity. an excess of which would tend to reduce pupil size
Sere
and raise the level of accommodation at the resting
Another possible factor investigated by Hennessy was
state.
that the field stop in the microscope might bias the ac-
There is evidence both for and against a relationship
commodation by virtue of the Mandelbaum effect (see
between the tonic level of accommodation and refractive
below). He found, however, that it had no such effect, error. The natural accommodative tonus would be ex-
unless its normally black surface was covered with a dis- pected to vary in low hypermetropes and myopes, de-
tinctive checkerboard pattern. pending on whether and how much a refractive
Hennessy concluded that because the small exit pupil correction is worn. Myopes whose error develops after
of the microscope increases the depth of field, small the age of about 15 years appear to show tonic accom-
errors of focusing provide little stimulus to accommoda- modation about 0.4 D less than emmetropes (B. Gilmar-
tion. On the other hand, if the instrument is markedly tin, 1989, pers. comm.). McBrien and Millodot (198 6a)
out of focus. the image is badly blurred and the accom- found that hypermetropes had a lower ocular amplitude
 The inadequate-stimulus myopias — tonic accommodation 137

of accommodation than emmetropes, who in turn had a Thus, Owens (1979) monitored the actual accommo-
lower amplitude than myopes, especially those who dative level by means of a laser optometer. Results of
became myopic after the age of 14. These effects might one of the four subjects investigated by Owens are
be explained as follows. If in Figure 7.17, the ‘cross- shown in Figure 7.25. In this diagram, the subject's
over point’ moved to the left in myopes as a result of re- dark-field refraction (approximately —2.25D) is indi-
duced sympathetic tonus, a lower resting state would cated by the arrows. The response R with a distant
result. Also, the parasympathetic part of the curve
matrix stimulus S was found to be raised by the inter-
would be longer, giving a larger amplitude. A similar posed screen and lowered for near vision. Both these ef-
effect was found by McBrien and Millodot (1986b), in fects were found to be greatest when the screen was
that the gradient of the ocular accommodative response placed at the eye’s dark focus. However, when the
to changes in object vergence (i.e. the slope in Figure object was positioned near the dark focus, the accommo-
7.17) was greater for hypermetropes than myopes. Cur-
dative response was scarcely influenced by the position
rent research has investigated the differences in tonic
of the screen whether nearer or further than the stimu-
accommodation in myopes who have been recently dis-
lus. He concluded from these and other results that the
covered and those with long-standing corrections, in
eye's dark-field refraction can also be taken to indicate
an effort to ascertain the causes of the progression of
its resting state of accommodation. A further inference
the condition.
is that the accommodation is most accurate and stable
For practical purposes, the tonic value of accommoda-
when the object of regard is situated at the eye’s dark
tion may be taken as its level in the dark-focus situation.
focus. A better than average performance in distance
Despite the wide inter-person variations, the dark-focus
vision would thus be predicted for low uncorrected hy-
accommodative level is relatively stable (apart from
permetropes — an idea earlier suggested by Whiteside
micro-fluctuations), as several different researchers
(1957).
have shown. The same conclusion was reached by
Rosenfield and Ciuffreda (1991), using a subjective
Heron et al. (1981), who also reported on the slightly
optometer, found a wide variation in their subjects’ re-
different values given by different methods of measure-
sponses to stimuli presented simultaneously at —1 and
ment.
5, -1 and —3 or —3 and —5 D, with only a small cor-
Post et al. (1984) investigated the stability of the rest-
relation with the dark focus. They concluded that when
ing focus when measured on several occasions. A high
the eye views stimuli at various distances, the accom-
correlation of 0.98 was found between measurements
taken a few minutes apart, falling to about 0.75 when modative response is produced ‘primarily from the inter-
the measurements were separated by periods of one day action of proximal, convergent and tonic inputs’.
to two weeks. Bullimore et al. (1986) found that the var- Adams and Johnson (1991) similarly felt proximal ac-
iation in results for any individual tended to be propor- commodation to influence their subjects’ results which
tional to the subject's tonic accommodation. were monitored with an infra-red optometer, though
they found that three of their nine subjects did show a
definite influence of dark focus on the accommodative
The Mandelbaum effect
response to conflicting stimuli, and two more a slight
The Mandelbaum effect refers to the response of the eyes tendency.
when there are two superimposed but conflicting stimuli The present writer (RBR) would also question the in-
to accommodation: for example, when viewing a distant fluence of the normal lead and lag of accommodation.
object through a wire fence or dirty window at some in- Thus, in distance vision, if stimuli are presented at ver-
termediate distance (Mandelbaum, 1960). The hypoth- gences of 0 and —3D, with a dark focus of —1.0D,
esis is that the near stimulus will tend to increase the then the accommodative response would be expected to
accommodative response when viewing the distant be around 1 D when the subject concentrates on the
object, especially if the near stimulus is positioned close further stimulus. Conversly, if the stimuli were pre-
to the eye’s dark focus. Conversely, if the object of sented at —2 and —4D, then the normal lag of accom-
regard is closer than the dark focus, then the presence modation in near vision might predict that the response
of a more distant conflicting stimulus might lower the would be nearer the —2 D than the —4 D stimulus, coin-
accommodative response. There is evidence both for cidentally nearer the dark focus.
and against this effect.
(a) (b)

Figure 7.25. The Mandelbaum

effect: accommodative response (R) as
OO
fF
oO a function of the dioptric distance of
the ‘background’ screen (plotted along
=
the abscissa) for three different
stimulus or test object distances (S).
ro)
The arrow indicates the dark-focus
refraction. The effective position of the
(D)
Accommodative
response a5
0 nD eee eS (0) 2. Bier4e letter matrix (a) at infinity, (b) at dark
Screen distance (D) focus, (c) at 5 D. (Redrawn in part from
Owens, 1979.)
 138 Accommodation and near vision. The inadequate-stimulus myopias

Correction of night myopia retinoscopy (see page 343) may be employed for each
eye in turn, the other eye being occluded to prevent con-
Night and empty-space myopia are important because vergence control of the accommodation. The accommo-
they can affect the ability of the eye to perceive objects dative element of the dark-field myopia takes only a few
near the visual threshold. For example, empty-space seconds to develop, so that an adequate response may
myopia in an emmetrope will give a blurred retinal be measured after a minute. Rosenfield (1989b) felt
image. The image of a distant aircraft, whether seen in that the Canon Auto Ref R1 provided a truer value for
silhouette as a dark speck or relatively bright, may thus tonic accommodation than retinoscopy or fixation of a
be spread over a larger region of the retina than the very low spatial frequency grating (~ 0.1c/deg). In case
ganglion summation area. If so, the resultant variation of doubt, any negative addition suggested by these tech-
in intensity may fall below the luminance contrast niques could be fitted to a clip-over for trial.
threshold. Whiteside (1957) found that empty-space The pupil dilation to its fullest extent and hence the
myopia could reduce the range at which an aircraft spherical aberration component may take a _ few
could be perceived by one-half. He also found that a dot minutes. While a lens change might help compensate
very close to threshold size in an otherwise empty field for spherical aberration, irregular refraction in the
could suddenly disappear because it was an insufficient pupil periphery, for example from early crystalline lens
stimulus to prevent the accommodation assuming its changes, may also affect night driving. Depending on
resting state. This effect can be noted when watching the initial state of retinal light adaptation, retinal adap-
aircraft or birds fly into the distance, especially if high tation to minimal light levels will take much longer,
in the sky. As well as affecting visual acuity, night the Purkinje shift occurring after about 5 minutes.
myopia can also raise the luminance threshold (Wald Tonic accommodation theory predicts that the inade-
and Griffin, 1947). quate-stimulus myopias will become less manifest with
The luminance levels for night driving are in the advancing age because of presbyopia. It would also
range (.35-0.7 cd/m? when the light is from the head- follow that any night myopia in old age must be due to
lamps alone. This level could be raised to about 2 chromatic and spherical aberration. The contribution
cd/m? or more by street lighting (Charman, 1996) and of the latter will also decline with advancing age be-
the spread of light from shop windows. It can be seen cause of the smaller pupil size in low illumination. In a
from Figure 7.23 that for three of the four subjects the study of complete presbyopes and aphakics, Otero
accommodative response varied very little over a lumi- (1951) found only the amount of myopia that could be
nance range from 51 down to 0.51 cd/m’. On this explained by aberrations, though Knoll (1952) quotes
basis, a separate correction for night driving may not Schober as finding two septuagenarians with 1.0 and
be needed. 1.5 D respectively of night myopia.
Richards (1968) found that only some 12% of a group Charman (1996), in a comprehensive review, points
of 315 subjects obtained an improvement in visual out that under conditions of binocular viewing, any
acuity from a negative addition, within the range myopic shift occurring will be less that that found
—0.50 to —1.00 D. On the other hand, Sheard (1976) under monocular conditions. Moreover, an uncorrected
found that 17 out of the 26 subjects examined benefited refractive error which might give relatively insignificant
from a minus addition, though never greater than blur with normal sized pupils under photopic conditions
—1.00 D.
will give increased blur with dilated pupils at night. He
As a general principle, Owens and Leibowitz (1976) therefore suggests that symptoms of poor vision for
suggested that the subject’s dark-field myopia was the night driving are much more likely to be caused by un-
best guide to prescribing. They found that a minus addi- corrected photopic refractive errors than by night
tion of one-half this value gave the best acuity at low lu- myopia. Scattered light from dirty windscreens, specta-
minances. In a bright empty field Post et al. (1979) cles and ocular media will also impair vision.
found detection of distant test objects to be best served
by a full correction of dark-field myopia. This was con-
firmed for empty-space myopia by Luria (1980); for ob-
jects subtending up to 7.5 minutes of arc, correction Adaptation of tonic accommodation
improved their visibility, while there was no improve- There is considerable recent experimental work on the
ment for larger objects. effects of prolonged close work on the accommodative
In clinical practice, patients reporting difficulties in response. While this also relates to the bioengineering
night driving possibly due to night myopia should be re- model of accommodation and convergence presented at
fracted in suitably low illumination. Possible methods the end of Chapter 9, two effects of interest here are
are either for the patient to wear very dark filters (2— possible changes in the level of tonic accommodation
3 ND) or to illuminate the distant test chart only by the and refractive error. If an eye has been accommodating
ambient light from a torch. A couple of minutes should for a long time, the focus does not initially relax comple-
be allowed for the myopia to develop and retina to dark tely when the dioptric stimulus is reduced. Most recent
adapt. Bullimore et al. (1986) suggest that the tonic ac- work confirms that there may be a temporary shift to-
commodation can be estimated objectively by using wards a myopic refractive error and a very short-term
automated infra-red optometers in complete darkness, increase in the level of the tonic accommodation of up
though the present writer would question the influence to 0.75 D lasting 60-90 s. The latter is somewhat con-
of the internal fixation scene employed in current in- troversial, as, if an allowance is made for the change in
struments. Alternatively, the Mohindra technique of the far point, there may be almost no change in tonic ac-
 References 139

commodation. There may also be different amounts of its original position, only when its power F,, satisfies the equa-
adaptation and time courses for the decay in the various tion

types of refractive error. The interested reader is referred : —1(2 — 6L)

to Rosenfield et al. (1994) for a review. Pe 18h
(c) Determine this value of F sp When 6=—6mm and
L=—3.00D.
7.11 The smallest size of print on a near point rule is N5, with
x-height 0.95 mm. Compare its angular subtense at the ‘stan-
Exercises dard’ reading distance of 350 mm from the eye with that when
in the position indicating 12 D of ocular accommodation. To
what type size at 350 mm does the latter subtense correspond
7.1 Find the distance of the near point and the range of ac- (see Exercise 3.8)?
commodation in each of the following cases, assumed to be un- 7.12 Compile a table of decentrations for near vision for the
corrected: following ranges of values: inter-ocular distances 56, 60, 64,
(a) Emmetropia: amplitude of accommodation 7.50 D 68 and 72mm and working distances 25, 30, 35, 40 and
(b) Hypermetropia +2.75D: amplitude of accommodation 45 cm. Assume the centre of rotation distance to be 27 mm.
4.75 D 7.13 Owens’ (1979) investigation of the Mandelbaum effect
(c) Hypermetropia +3.25D: amplitude of accommodation made use of a double (or consecutive) Badal optometer arrange-
Z 25 ment. If this were made of four +5.00 D lenses, positioned at
(d) Myopia —12.00 D: amplitude of accommodation 4.00 D —200, —600, —1000 and —1400 mm from the subject's eye,
7.2 (a) A myope is corrected for distance by —7.00 DS placed with the object and screen stimuli placed respectively between
14 mm from the reduced surface and the nearest point he can the first and second, and third and fourth lenses, show that
then see distinctly is one-third of a metre from the lens. Find the stimulus further from the eye would satisfy the usual
the spectacle and ocular accommodation. (b) Repeat (a) for a linear scaling condition of the Badal optometer.
hypermetrope corrected by +7.00 DS, all other values being
unchanged.
7.3 A subject whose amplitude of (spectacle) accommodation
is 2.50 D is corrected for distance by —5.00 DS fitted at 16 mm
from the eye's principal point. What reading addition would be
prescribed for vision at 250mm from the plane of the lenses References
on the basis of leaving: (a) one-half of the available spectacle
accommodation in reserve; (b) one-half of the ocular accommo- ADAMS, C.W. and JOHNSON, C.A. (1991) Steady-state and dy-
dation in reserve? namic response properties of the Mandelbaum effect. Vision
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8
Ocular motility and binocular vision

Introduction cal plane in the head passing through the centre of rota-
tion of each eye and normal to the visual axis of the eye
In this and the following three chapters we shall be out- in its primary position. It coincides with an equatorial
lining the movements of the eyes, their co-ordination in plane of the eye when in this position. The four second-
binocular vision and some of the failures to achieve this ary positions of gaze (Figure 8.2) result from a cardinal
co-ordination. These chapters should provide an intro- rotation of the eye about either a horizontal or a vertical
duction to specialized textbooks and papers on binocular axis in Listing’s plane, as follows:
vision and orthoptics or the use of eye exercises to im-
prove co-ordination.
Cardinal rotation Movement ofcornea
This chapter deals with the movements of the eyes
(1) Elevation (or supraduction) upwards
and some of the perceptual results of well co-ordinated
(2) Depression (or infraduction) downwards
vision with two eyes.
(3) Abduction away from nose
(4) Adduction towards nose

Directions of ocular movements A tertiary position of regard is an oblique direction of

the gaze, for example, up and to the right.
Monocular rotations

The primary position of the eye is its position when RIGHT EYE LEFT EYE
looking straight ahead at a distant object, the head and Binocular
Position
shoulders being erect. It is from this position that the re-
Primary :
maining positions of the eyes are defined. Rotations of a Primary Primary
single eye are known as ductions.
The frontal or Listing’s plane (Figure 8.1) is the verti-
<@> Elevation ;
Elevation Elevation
cs
Depression
Depression

Dextro-
version
Abduction Adduction

Laevo-
version
Adduction Abduction

Convergence
Adduction Adduction
Tp Ss

Intorsion
|
Extorsion
Figure 8.1. Listing’s plane: a vertical section through the
eye’s centre of rotation Z, perpendicular to the primary line of Figure 8.2. Ocular movements from the examiner's
the eye. viewpoint.
 The eye's centre of rotation 143

Rotations of the eye about its anteroposterior axis are D oT E

called torsions. They cannot be induced by voluntary
effort but can result from certain reflexes, for example,
in partial compensation for a tilt of the head towards
one shoulder.
Extorsion occurs when the upper end of the vertical
meridian of the cornea is rotated away from the median
plane. Rotation in the contrary direction is known as in-
torsion.

Binocular movements

The secondary positions of gaze defined above apply to a

single eye. If both eyes move in a similar direction, as,
for example, when maintaining binocular fixation of an
object moving in a fronto-parallel plane (a vertical
plane parallel to the line joining the eyes’ centres of ro-
tation), the resulting binocular movement is called a
Figure 8.3. A method of determining the position of the
version.
ocular centre of rotation Z.
Elevation of both eyes is called supraversion and de-
pression infraversion. When both eyes look to the right,
the right eye abducts and the left eye adducts: the bin- the similar triangles ZGH and ZTD and regarding all dis-
ocular movement is called dextroversion. Gaze to the tances as positive,
left involves laevoversion.
GZ TZ TA+AZ TA+AZ
A vergence movement occurs when the eyes rotate in
opposite directions. Thus, convergence occurs when ENS Mi ERE | 10D)
fixation is changed from a relatively distant to a nearer If the corneal sag A’G is neglected as being small in rela-
object, while divergence denotes the opposite. tion to TA, this expression may be written
Version movements*may also be made in vertical and
3Z_TA+GZ q+GZ
torsional directions under the stimulus of reflex path-
YR ol ge Na abidllD
ways (see Chapter 10).
from which

GZ (TD — yr) = YR
Similarly
The eye’s centre of rotation
GZ (TE — yy.) = 94
Excluding the cornea, the globe of the eye is approxi- so that, by addition
mately spherical, and its movements resemble those of
a ball and socket joint. Rotation takes places about a
GZ (DE — d) = dq
point approximately at the centre of curvature of the which gives
posterior sclera. Because the extra-ocular muscles alter
dq
shape during an ocular rotation, the shape and position z=AZ= + corneal sag A/G
DE— d
of the orbital socket may well be changed as a result.
Consequently, the centre of rotation does not remain For emmetropic eyes, Donders and Doyer found the
fixed with respect to the head during a large eye move- mean distance z to be approximately 13.5 mm, taking
ment. the corneal sag as 2.6 mm.
Helmholtz and von Kries (Helmholtz, 1924) give a Park and Park (1933) found that in the horizontal
comprehensive survey of many of the early researches plane the motion of the eye could best be described as
into the position of the eye’s centre of rotation, includ- the rolling of a pivot of finite size near the centre of the
ing those of Donders and Doyer (Donders, 1864). The eye on another curved surface. This is analogous to the
method they used may be simplified for use by students. clenched fist rolling in the gently cupped palm of the
First, the corneal diameter is measured with a device other hand. The effective centre of rotation lies on the
such as the Wessely keratometer. The subject’s head is nasal side of the visual axis, which could be predicted
then held firmly in a rest and his eye is observed through from Figure 2.12 since the visual axis and the axis of
a telescope fitted with a hair-line graticule (reticle). symmetry of the eye do not coincide.
Two fixation objects D and E are positioned as in Figure This was confirmed by Fry and Hill (1962), who
8.3, such that when the subject views D, the right- found for 28 of their 33 subjects that the centre of rota-
hand side of his cornea is imaged on the graticule line, tion was at a mean distance of 0.79 mm nasalwards
and similarly for the other side when E is viewed. from the visual axis, and some 14.8 mm behind the cor-
If d is the corneal diameter, yp and y, the semi- neal pole. For three of their subjects, however, the re-
diameters (which are not necessarily equal) and q the sults suggested that they did not have a fixed centre of
distance from corneal vertex A to line DE, then, from rotation.
144 Ocwlar motility and binocular vision

Although a fixed centre of rotation situated on the The levator palpebrae superioris also originates from
visual axis is assumed for purposes such as spectacle- the tendon ring at the orbital apex and controls the pos-
lens design and calculations involving convergence, the ition of the upper lid.
true position is more complicated as the previous discus- This simplified picture of the attachments of the mus-
sion has shown. Experimental evidence also suggests cles is sufficient for deducing the effects of their contrac-
that the centre of rotation is not the same for vertical tions, both from the primary position and also from
as for horizontal movements. (For a review see Alpern, oblique positions of gaze. In extreme positions, the
1969.) normal eye's excursions are also controlled by various
A simple technique for estimating the distance be- check ligaments. which prevent excessive movement.
tween the centres of rotation of the eyes, instead of as- Occasionally, the muscles or check ligaments are incor-
suming it to equal the inter-pupillary distance (PD), is rectly positioned and abnormal ocular movements are
described by Ryland and Lang (1913). produced.
The extra-ocular muscles are innervated by three of
the cranial nerves. The third or oculomotor nerve inner-
vates the superior, inferior and medial recti, and also
the inferior oblique. It also innervates the levator pal-
The extra-ocular muscles pebrae superioris, the ciliary muscle and the iris sphine-
ter. The fourth nerve. the trochlear, innervates the
The human orbit is approximately pyramidal in form. superior oblique. while the abducens or sixth nerve in-
the square base lying open at the front. The nasal walls nervates the lateral rectus.
of the left and right orbits are roughly parallel, while The motor nerves originate in the brain stem at the
the two lateral walls lie approximately at right-angles base of the cerebrum. The third nerve nucleus is subdi-
to each other. The axes of the orbits thus diverge at vided into parts for each muscle it controls; these and
about 22° from the median plane (Figure 8.4). the fourth nerve nucleus lie in the tegmentum on the
The eye is rotated in its socket by six extrinsic or dorsal aspect of the mid-brain. The sixth nerve nucleus
extra-ocular muscles. Five of these originate in a tendi- lies in the pons.
nous ring which surrounds the optic nerve at the apex These nuclei are stimulated by supra-nuclear or inter-
of the orbit. Four of them, the recti muscles, pass for- mediary nuclei. which in turn are stimulated by other
ward and are inserted between 5 and 8 mm from the pathways: for example. an involuntary pathway from
limbus. The fifth ocular muscle originating from the the visual or occipital cortex of the cerebrum and the vo-
ring is the superior oblique, which extends forward to luntary route from the frontal cortex. Thus. if a moving
the superior nasal corner of the orbit. There, its tendon object is watched, the fixation reflex from the occipital
passes through a ring called the trochlea and turns cortex will stimulate the nerve nuclei, and hence the
back to its insertion in the rear portion of the sclera. Its extra-ocular muscles, to maintain the retinal images
effective axis makes an angle of 55° with the primary di- upon the foveae. Head movements may also be pro-
rection, passing behind the centre of rotation of the eye. duced. If the gaze is transferred to some other object,
The sixth extra-ocular muscle, the inferior oblique. the innervation arises from the motor cortex in the fron-
originates in the lower nasal corner of the front of the tal lobe of the cerebrum — Brodmann’s area No.8.
orbit and passes diagonally backwards to its insertion Other stimuli. mostly reflex. arise from the sense of
in the lower rear sclera. Its direction of action is at an balance and bodily position. Thus, a head tilt to the
angle of about 51° to the visual axis when the eye is in right shoulder gives rise to a compensatory reflex tilt of
the primary position. the eyes in the opposite direction. as shown at the
bottom of Figure 8.2. This compensatory tilt is, however.
only about one-sixth of the head tilt. Similarly. a head
Primary f
position Orbital
rotation to the right about a vertical axis will tend to
axis stimulate laevoversion (movement to the left). These
—, static reflexes compensate for changes in head or body
22° position, while stato-kinetic reflexes originate during,
and allow for, accelerations and decelerations in head
Trochlea or body movements.
Nasal wall
of orbit
Superior
oblique Principal and secondary
Medial Temporal wall muscle actions
rectus of orbit
Lateral rectus
Monocular actions
Inferior rectus
In general, co-ordinated contractions and relaxations of
Superior rectus the extra-ocular muscles are required to produce any
Figure 8.4. Diagrammatic representation of right orbit and desired change in direction of the visual axes. Initially,
extra-ocular muscles viewed from above, the inferior oblique it is simplest to consider the actions of the individual
muscle being hidden. Z denotes the ocular centre of rotation. muscles on the eye when in its primary position. Figures
 Principal and secondary muscle actions 145

fej | SR
Rh

LR MR
<< —> <—

Ny
Temporal

<- ->
SOv {IR

Figure 8.6. Marquez diagram: primary and secondary

muscle actions in the two eyes in their primary position. Solid
arrows denote primary, broken arrows secondary actions. Note
that the lengths of the lines are not proportional to the effective
action. Key to muscles as in Figure 8.5.
Figure 8.5. Diagrammatic representation of left orbit and
extra-ocular muscles viewed from in front: SO superior oblique,
SR superior rectus, MR medial rectus, LR lateral rectus, IR
inferior rectus, IO inferior oblique. duction produced by the superior rectus. Consequently,
the lateral and medial recti also come into play to pre-
vent horizontal movement of the eye.
&.4 and 8.5 show how the effects of muscle contractions Adler (1981) gives an extensive survey of muscle ac-
may be deduced. tions and changes in nervous stimulations when ocular
Thus, contraction of the medial rectus produces only movements take place. A highly detailed study of the ki-
adduction, since the plane of action of the muscle is nematics of the extra-ocular muscles has been written
purely horizontal. Similarly, contraction of the lateral by Solomons (1977),
rectus abducts the eye.
The plane of action of the superior rectus is not verti-
cal but slightly tilted. Its contraction produces elevation Muscle failure and diplopia
as the principal effect, and in addition adduction and in-
If one of the extra-ocular muscles should cease to func-
torsion. The direction of action of the superior oblique
tion efficiently because, for example, of a haemorrhage
is defined by the line.of its tendinous portion between
within the muscle or damage to the nerve supply, the
the trochlea and its insertion into the eye. It therefore
eye will tend to deviate from its normal position. More-
gives intorsion, abduction and depression. These results
over, if muscle action is suddenly and severely impaired
are summarized in Table 8.1. It will be noted that both
in an adult, diplopia (double vision) will result. If the
the superior oblique and rectus muscles are intorters,
right lateral rectus were affected, then instead of both
while both inferior muscles are extorters. It is advisable,
eyes looking straight ahead to view a distant object B.
however, to memorize the anatomy of the orbit and
the right eye would adduct because the impaired action
deduce the muscle actions, rather than memorizing of the right lateral rectus would be outweighed by the
them. normal muscle tone of the medial rectus (Figure 8.7).
These results can also be illustrated by a Marquez In such cases, the perceived image is localized in space
diagram (Figure 8.6) in which the arrows show the as though the eye were still in its primary position, as
directions of action when the eye is in its primary pos- in Figure 8.7(c). Since, in fact, the retinal image of the
ition. distant object B lies nasally to the right fovea Mr, the
The necessity for co-ordinated action by the extra- perceived image is incorrectly projected to the temporal
ocular muscles arises even in cardinal rotations of the side. The image from the left eye, however, is perceived
eye. Thus, in a purely horizontal movement from the straight ahead. In general, a diplopic image due to a
primary position, muscle tone in the vertically acting malfunctioning or paretic muscle is displaced in the
muscles must be maintained because their lengths are same direction as the rotation which contraction of
affected by the horizontal movement of the eye. Eleva- that muscle normally produces.
tion directly above the primary position requires the Consider a further example: the right superior rectus.
action of the superior rectus, but this also gives rise to This muscle elevates, adducts and intorts the eye. If it is
intorsion and adduction. Although the inferior oblique paretic, the eye becomes relatively depressed, abducted
also provides elevation, accompanied by extorsion and and extorted. Consequently, the diplopic image will be
abduction, the latter does not counterbalance the ad- displaced in the opposite direction up and in, with the

Table 8.1 Principal and secondary actions of the extra-ocular muscles

———._.—_O__——
OT

Muscle « Principal action(s) Secondary action(s)

Medial rectus Adduction

Lateral rectus Abduction
Superior rectus Elevation Adduction Intorsion
Inferior rectus Depression Adduction Extorsion
Superior oblique Intorsion and depression Abduction
Inferior oblique Extorsion and elevation Abduction
ae
146 Ocular motility and binocular vision

Object point Apparent right eye will correctly fixate the bar light. The falsely
Bato direction projected left eye’s image will be positioned as in a
of B mirror image of Figure 8.8.
This method is rarely used to diagnose faulty muscle
action, since small deficiencies would be difficult to iden-
tify. The technique described on pages 147-149 is
much more sensitive.

Muscle actions in
binocular movements

The individual muscle actions described in the previous

section are for small eye movements from the primary
Pheer ans
eT
Se
ite
es
N,
ma position, but eye movements generally require the com-
/S Lf
i‘es
\/
My
f5 aes
re ae \ ey
eae
fac
SS Ae
\a7
L-loSenn-l--
-a----- bined actions of many ofthe extra-ocular muscles. Diag-
BUM’, B’RM'R B’gM'g nosis of faulty muscle action can be simplified if it can
(a) (b) (c) be shown that particular directions of gaze are pro-
duced, in effect, by one muscle only in each eye.
Figure 8.7. Double vision caused by loss of muscle tone in
Consider the action of the superior rectus muscle
the right lateral rectus: (c) illustrates the perceptual projection
of the image in the deviating eye. when the eye has abducted or turned out through an
angle of 22° (Figures 8.4 and 8.9). The line of action of
RSR the muscle now passes almost exactly above the eye's

RIO

\
| centre of rotation. Its action is now purely elevation. In
the primary position, the inferior oblique also has an
elevating function. Figure 8.9 shows that its elevating
effect is less in the abducted position than in the primary
position. Thus, when the eye is looking up and out, the
muscle principally concerned is the superior rectus. By
a similar analysis, a corresponding position of gaze can
be found for each of the other muscles in turn.

RSO
/ \
Figure 8.10 and Table 8.2 show these positions of
gaze, which may be called the fields of action of the mus-
cles. In the right eye, contraction of the right inferior
RIR
rectus muscle is the most important when looking
Figure 8.8. Position (from examiner's viewpoint) of the down and to the right. In the left eye, the most impor-
diplopic image caused by a named paretic muscle in the tant muscle in this direction of gaze is the left superior
deviating right eye. Left eye is fixating a vertical bar light held oblique. Muscles paired in this way are known as yoke
in the median plane.
muscles or contralateral synergists.
These fields of action are also called the diagnostic
positions of gaze, since they are used to check the opera-
top tilted to the patient’s left (Figure 8.8). Note that be- tion of the extra-ocular muscles. Pure elevation and de-
cause the diplopic image lies to the patient’s left, it pression of the eyes should also be observed in order to
could mistakenly be thought that the image shows ex-
torsion.
Orbital and
If the paresis is only slight, the fusional reserves (see ocular axes
Chapter 9) would hold the two eyes in the correct pos-
ition under normal circumstances. If the patient wears
a red filter over his right eye and a green filter over the
left, the retinal images will be of different colours. This
dissociation technique makes fusion more difficult, so
the right eye (with the paretic muscles) will deviate. If
Inferior
the patient now looks at a white light, the left eye’s oblique
green image will be correctly projected back to the
light, while the red image will be displaced. Figure 8.8
shows the apparent position of the diplopic images,
assuming that each muscle in turn of the right eye is Superior
paretic. rectus
In order to demonstrate torsional effects, an elongated
white light (bar light) is needed.
Figure 8.9. Reduction in elevating power ofthe right inferior
Conversely, if a muscle in the left eye becomes paretic oblique muscle when the eye is abducted: view of orbit from
(the right extra-ocular muscles remaining normal), the above.
 Motility testing 147

might be the result of damage to one or more of the

extra-ocular muscles or their innervation. If the move-
ment of both eyes is equally restricted in the same direc-
tions, the patient is said to have a gaze palsy. This is
the effect of damage to the supra-nuclear pathways. If,
however, the movement of the eyes is unequal, the mal-
RLR RMR
Lure § | > LLR function is either in the nerve nuclei, their subsequent
pathways or the muscle itself. Thus, motility testing is
one method of investigating the functioning of various
regions of the brain.
During motility tests, the patient’s head must be kept
RIR wae RSO
LSO LIR still. A fixation object is initially held directly in front of
the patient at about half a metre, so that the eyes are
Figure 8.10. Yoke muscles: examiner's view of the field of converged slightly from their primary position. The ex-
action of each of the extra-ocular muscles. aminer then watches the relative position of the pa-
tient’s eyes while he moves the fixation object first left
check the operation of the lid muscles, notably the leva- and right and then along the four oblique diagnostic
tor palpebrae superioris. positions of gaze given in Table 8.2. With practice, the
In relation to eye movements, Hering’s law of equal examiner will be able to detect small relative deviations
innervation, formulated in 1868, states that the con- of the eyes, while the patient will report a doubling of
tralateral synergists receive equal stimulation. Sherring- the fixation object if binocular fixation breaks down,
ton’s law of 1894 of reciprocal innervation, when unless the diplopic image from one eye is suppressed. A
interpreted for the eye, states that as the acting muscle vertical movement should also be made to check the
is stimulated, so its antagonist on the same eye relaxes. action of the eyelids.
The lateral and medial recti of either eye are obviously A small torch or an ophthalmoscope makes a con-
antagonists; the superior and inferior recti are also con- venient fixation object, provided that the instrument is
sidered as antagonists since their principal actions in angled so that the field of illumination covers both
the primary position oppose each other, even though eyes. The positions of the corneal reflexes relative to the
both are adductors. Similarly, the two obliques are an- centre of the pupil may be used to assess accuracy of
tagonists. fixation, particularly if the examiner moves so that his
Thus, in a binocular version movement up and to the head stays behind the torch. If motility is normal, the
left, the right inferior oblique and left superior rectus patient's eyes should move steadily in all directions of
should receive equal innervation since they are contra- gaze with no diplopia. If the muscle action is slightly de-
lateral synergists. Their antagonists, the right superior fective in one eye, binocular fixation of the test object
oblique and left inferior rectus, correspondingly relax. will probably be maintained near the central position.
If the left superior rectus should become paretic, the In the field(s) of action of the malfunctioning muscle(s),
left eye will not move as far as the right eye. If the right however, the paretic eye may be seen to lag behind.
eye maintains fixation on the test object, the left eye The diplopic image perceived by this eye will accord-
will lag behind. Conversely, if the paretic left eye fixates, ingly be displaced too far from the primary direction.
the right eye will overshoot. Since excessive stimulus of Consequently, if this eye is covered, it is the farther
the left muscle is required to provide sufficient move- image which will disappear.
ment of the eye, the overaction of the right eye will be Diplopia can be induced in this test more easily by dis-
greater than the underaction of the left eye. The primary sociating the two eyes. A convenient and strongly re-
deviation is the angle of lag when the good eye fixates, commended method is to use a red filter for the right
while the larger secondary deviation occurs when the eye and a green filter for the left eye. The patient can
eye with the paretic muscle fixates. Measurement of then report the relative positions of the two coloured
these deviations is discussed in the following section. lights in the various positions of gaze. Alternatively,
the Maddox rod or the cover test may be used (see Chap-
tere):
Motility testing Observation of the patient's eyes as they follow the
test object is sufficient for initial examination, but more
The clinical need for motility testing is to establish accurate methods are needed for an assessment of com-
whether muscle action is normal. Faulty movement plicated or long-standing cases of paresis.

Table 8.2. Yoke muscles and diagnostic positions of gaze

Muscle pair . Field of action

R medial rectus L lateral rectus Horizontally to the left

R lateral rectus L medial rectus Horizontally to the right
R superior rectus L inferior oblique Up and to the right
R inferior rectus L superior oblique Down and to the right
R inferior oblique L superior rectus Up and to the left
R superior oblique L inferior rectus Down and to the left
Siren
nnn nn LEE EEE
148 Ocular motility and binocular vision

(a) two eyes are similar in size and shape, the deviation is
said to be comitant or concomitant. If the plots are un-
equal in size and irregular in shape, the deviation is
said to be incomitant and is indicative of faulty muscle
action.
The chart showing the smaller figure indicates the eye
with the paretic muscle, since this eye lags behind in
the field of action of this muscle. Thus, Figure 8.11 also
illustrates a paresis of the left superior rectus of recent
onset. The left-eye chart shows a reduced angle of move-
ment up and out, while the right chart shows the exag-
Figure 8.11. Typical plot on the Hess screen charts,
indicating paresis of the left superior rectus. For clarity, only
gerated secondary deviation produced by overaction of
one set of fixation points is shown. (a) Plot for left eye (right-eye the right inferior oblique — the contralateral synergist.
fixation), (b) plot for right eve (left-eve fixation). The Lees screen is a pair of Hess screens mounted at
right-angles, the markings showing only when intern-
ally illuminated. A pair of mirrors mounted back to
The Lancaster and Hess screens are commonly used
back bisects the angle between the screens. The patient
for this purpose. The former consists of a grid of equally
initially faces the unilluminated left screen and views
spaced vertical and horizontal lines. The patient sits
the illuminated right screen with his right eye by retlec-
with his eyes level with the centre of the screen at a dis-
tion in the mirror. The examiner indicates the various
tance of 0.5 or 1m, depending on the linear spacing of
test positions to the patient's right eye and the patient
the lines which should subtend 4° or 7A at the eves.
uses a pointer to demonstrate the projection through
The Hess screen is similar, except that the lines curve
the left fovea of these fixation points. These positions
inwards to the centre as in the recording chart shown
are marked directly on the apparently plain left screen
in part in Figure 8.11. The reason for this is to overcome
with a glass writing pen or pencil. This left screen is
perspective problems: a horizontal line 20 cm above the
then switched on, and the relative positions of the two
central point of a screen used at 1 m corresponds to an
eyes recorded on the chart. The patient then moves to
elevation of 20A immediately above the central point,
view the illuminated left chart with the left eye by reflec-
but only 18.5A at +0 cm to one side of it.
A light grey screen is often used, with torches project- tion in the mirror and the process is repeated for the
ing a red or a green streak of light. The patient wears right eve with the right chart switched off.
red-green goggles to dissociate the eyes, with the red In the presence of anomalous retinal correspondence
filter initially over the right eye. The examiner holds (see Chapter 10) the difference in position of the red
the red torch and directs its projected streak to lie hori- and green streaks may not indicate the actual angle be-
zontally at the centre of the screen. This red streak can tween the visual axes of the two eyes.
be seen only by the patient's right eye. since the green When an extra-ocular muscle paresis has been pre-
filter over the left eve absorbs red light and vice versa. sent for some time, secondary effects may occur in
The patient holds the green torch and is asked to pos- some of the other muscles. Thus, paresis of one muscle
ition its streak to lie apparently superimposed on the may be followed by permanent contraction of the an-
red streak. The actual position of the green streak indi- tagonist of the same eye and the contralateral synergist.
cates the projection of the left fovea. together with a secondary inhibition of the contralateral
The position of the green streak when the red streak is antagonist. For example. paralysis of the left lateral
central is marked on the left-hand chart of Figure 8.11. rectus may be followed by contraction of the left medial
This procedure is repeated for the six diagnostic pos- rectus and right medial rectus together with inhibition
itions of gaze and the fixation points directly above and of the right lateral rectus.
below the centre. The positions corresponding to the A head turn to the side or up or down may reduce
inner ‘square’ are usually used, except when no devia- symptoms by avoiding the field of action of the affected
tion occurs between the red and green torch positions. muscle. Thus, from Figure 8.10 or Table 8.2, a left lateral
The outer ‘square’ may then be brought into use. rectus palsy would give rise to a head turn to the left,
Figure 8.11(a) shows the relative direction of the left while a right superior rectus palsy would give a posture
eye when the right eye is fixing. The muscle positions of chin up and head turn to the right. The principal ac-
shown on the chart represent the patient's (and exami- tions of the obliques are torsional. A slight paresis of
ner’s) viewpoint and are therefore reversed left to right the right superior oblique may give a head tilt or ocular
in comparison with Figure 8.10 in which the examiner torticollis to the left (to replace the intorsion — see Table
is facing the patient. 8.1) together with a chin-down posture. Although the
Either the goggles or the torches are then reversed, so muscle is an abductor, which would suggest a face turn
it is now the patient's left eye which fixates the exami- to the right, its principal field of action or diagnostic pos-
ner’s streak. The position of the patient’s streak is now ition of gaze is down to the left. Hence there may be a
plotted on Figure 8.11(b), indicating the position of the face turn to the left to avoid the muscle having to move
right eye and hence the action of its extra-ocular mus- into that position. Of these three rotations, the head tilt
cles. is likely to be the greatest, but even a small head move-
In general, the two coloured streaks are rarely super- ment may be sufficient to avoid the symptoms that
imposed, but are separated. If the plotted figures for the would otherwise be caused by a paretic muscle. It may
 Torsion and false torsion 149

therefore be necessary to hold the patient's head upright point on the fixation line in the eye’s primary position.
to achieve valid results when motility testing. Adapta- Suppose that fixation is now transferred to the point O
tions in the other extra-ocular muscles will reduce the in the vertical plane through O that is normal to ZO. Of
need for an abnormal head posture, thus lessening its di- the many routes which could be taken, the following
agnostic value. An upwards or downwards head posture three are of particular importance in the study of ob-
may be associated with an A or V pattern of eye move- lique movements:
ments.
A fuller explanation of the results of paresis of the (1) Elevation through the angle ~, bringing the fixation
extra-ocular muscles can be found in texts on strabismus. to the point S immediately above O, followed by an
azimuthal rotation through the angle u in the tilted
plane ZSO. Because of this tilt, the axis about
which the second rotation takes place cannot lie in
Torsion and false torsion Listing’s plane but is tipped backwards through the
angle ~. In the diagram, the two rotations are
True torsion denoted by H1 and H2 because these were the para-
meters used by Helmholtz.
True torsion is a rotation of the eye about its anteropos-
(2) A horizontal rotation (longitude) through the angle
terior axis, considered as a separate degree of freedom.
, bringing fixation to the point T, followed by a ver-
As already noted, it is induced in both eyes as a partial
tical rotation (latitude) through the angle 8. They
compensation for a sideways tilt of the head. In the
are denoted by Fl and F2, being the parameters
normal subject, the torsional actions of the muscles are
used by Fick. Once again, it is only the first of these
well balanced so that little unintentional torsion
rotations which takes place about an axis in
occurs. This is not the case if there is a paresis of one
Listing’s plane.
extra-ocular muscle and over-activity by its contralat-
3) A single rotation through the angle f in the plane
eral synergist. A marked degree of torsion in the affected
OZO, executed about the axis RR in Listing’s plane
field of action may then result, though possibly without
making an angle x with the vertical. Since RR must
causing visual problems. Any torsional imbalance, how-
be perpendicular to the plane OZO, it follows that
ever it occurs, would tend to cause perceptual disorien-
the angle OOT must also be equal to x» — thus defin-
tation of space. The same is true, though, of the
ing the meridian OQ in standard axis notation. This
aberrational distortion produced by spectacles lenses, to
route, defined by Listing’s parameters, is indicated
which most subjects eventually contrive to adapt.
in the diagram by the letter L.

Given that ZO = 100, OS = 50, and OT = 80, the other

Oblique eye movements
dimensions given in the diagram can readily be deter-
In Figure 8.12, Z is the eye’s centre of rotation and O a mined. The various angles can also be calculated, as

Figure 8.12. Schematic three-dimensional representation

(not to scale) of the change in fixation from O in the primary
position to Q in the tertiary position. Helmholtz’s system:
elevation (H1) through 7 followed by azimuth p (H2). Fick’s
system: longitude (F1) through ¢ followed by latitude 9 (F2).
Listing’s system: rotation (L) through B about inclined axis RR.
150 Ocular motility and binocular vision

ible. Even so, it can be shown that (with one exception)

the movement or series of movements by which the eye
assumes a tertiary position would have to involve an in-
cidental rotational displacement as though true torsion
had occurred. A more serious complication is that the
amount of incidental torsion in a given tertiary position
of the eye would vary with the route by which fixation
had been brought to that position. For example, in
Figure 8.12 the torsion incidental to route H would be
Projection of: (a) Helmholtz’s, (b) Fick's,
greater than that accompanying route L, though this
Figure 8.13.
(c) Listing’s system of axes on a fronto-parallel plane. could not be inferred from the diagram alone. On the
other hand, it can readily be visualized that route F is
uniquely free from incidental torsion.
follows: It would, of course, be highly disconcerting to the
dX = arc tan 50/100 = 26.57° (elevation) visual system if different amounts of torsion could
uw = arc tan 80/111.80 = 35.59° (azimuth) occur in the same direction of the gaze. In fact, true tor-
= arc tan 80/100 = 38.66° (longitude) sion is used to adjust the amount of incidental torsion
8= arc tan50/128.06 = 21.33° (latitude) and so bring order into what would otherwise be an in-
% = arc tan 50/80 = 32.00° (meridian) tolerable situation. Experimental studies have shown
B= arc tan 94.34/100 = 43.33° (eccentricity) that the actual amount of torsion peculiar to any direc-
tion of the gaze is the same as if the eye had been
These angles are interrelated in various ways, which
brought to that position by a single rotation from the
may be deduced from Figure 8.12. For example, given A
primary position about an axis in Listing’s plane (route
and ut, @ and 9 can be obtained from
L). Paradoxically, this actual amount of torsion is
tan
@ = tan u/cosA (8.1) termed ‘false torsion’.
The observed behaviour of the eye is defined more pre-
and
cisely in two well-known laws:
sin 8 = sin A cos Lt (8.2)
(1) Donders’ law states that for any given position of the
Similarly, the relationship between « and f and the line of fixation with respect to the head there exists
other two pairs of angles is given by a definite and invariable angle of false torsion,
tana
= tan 0/sin
d = sin A/tan (8.3) which is independent of the will of the subject and
independent of the manner in which the fixation
and
has been brought to that position.
cos B = cos } cos 8 = cos XACOs Lt (8.4) (2) Listing’s law states that when the line of fixation is
Figure 8.13 indicates the form that would be taken by brought from the primary to any other position, the
flat screens or wallcharts constructed for the three dif- angle of false torsion in this second position is the
ferent co-ordinate systems under discussion. The grid same as if the eye had arrived at it by rotation
lines in each chart denote equal intervals of the two about an axis (in Listing’s plane) perpendicular to
angular parameters in use. the plane containing the initial and final positions
In studies of binocular vision, Helmholtz’s system of fixation. (In Figure 8.12, for example, the axis of
offers an advantage over Fick’s and 0; for a given rotation RR is perpendicular to the plane OZQ.)
angle of elevation A, convergence simply becomes the al-
gebraic difference Au between two angles of azimuth.
Listing’s angles x and 8, sometimes called meridian and Calculation of false torsion
eccentricity respectively, lead to the polar chart shown Simple methods of demonstrating and measuring false
at Figure 8.13(c), the concentric circles representing torsion were devised by Maddox (1898). Figure 8.14,
regular intervals of the angle f. which is based on one of his diagrams, represents a
The symmetrically curved grid of the Hess screen schematic model of an eye as viewed by an observer.
(Figure 8.11) plots regular intervals of the angles of azi- The point A is the corneal vertex and ZA the fixation
muth up and latitude 0. line when the eye is in its primary position. The equa-
Eye movements are most easily studied with the aid of torial plane of the eye perpendicular to ZA then coin-
an ophthalmetrope (a model eye mounted on pivots) or cides with Listing’s plane.
by using a solid rubber ball with knitting needles as the The eye now turns through an angle B about an axis
axes of rotation and fixation. RZ (in Listing’s plane) making an angle & with the verti-
cal VZ in this plane. As a result, A moves to A’ along a
False torsion circular path in a tilted plane perpendicular to RZ,
bringing the fixation line to the new position ZA’. This
As would be expected, horizontal and vertical ocular ro- rotation would be upwards and to the subject's right.
tation from the primary to a secondary position are not Simultaneously, the point in the eye’s equatorial plane
normally accompanied by torsion. Complications arise originally situated at V moves through the same angle
in the case of movements to a tertiary position. Suppose B to the new position V’. Its path in this rotation lies on
that true torsion as an independent motion is not poss- a circle with its centre M on RZ at the foot of the perpen-
 Torsion and false torsion 151

tan (@/2) = tan (o/2) tan (0/2) (8.7)

With the help of equations (8.3) and (8.4), Helmholtz’s

expressions can be shown to be mathematically iden-
tical with Maddox’s.
The angle of false torsion is usually quite small, with a
maximum value little more than 10°. You can verify
for yourself that when the relevant numerical quantities
from Figure 8.12 are inserted in any of the above expres-
sions for false torsion, the result obtained is 7.56°.
A mathematical treatment of ocular torsion on the
basis of direction cosines has been given by Solomons
(WO).

Figure 8.14. Diagram for derivation of false torsion. (After

Maddox, 1898.) Experimental verifications
The angle of false torsion implicit in Listing’s law can be
dicular from V. Being the axis of rotation, RZ itself re- measured experimentally in various ways. Objective
mains stationary and therefore continues to lie in the methods require a means of distinguishing one meridian
eye's equatorial plane in its new position. This is now es- of the eye as a reference line. Conjunctival sutures and
tablished because it must contain the lines RZ and V’Z a thread placed on the anaesthetized cornea are among
as well as being perpendicular to the new fixation line the devices known to have been used. The iris pattern
ZA’. Let the perpendicular from V to V'M meet this line has also been used as a less drastic alternative.
at W. WZ is then the intersection of the eye’s equatorial Measurement of the angle of torsion requires great
plane with the vertical plane containing the vertical care because the apparent angle between two non-par-
line VZ and the fixation line ZA’. Viewed along this allel lines in the same plane varies with the viewpoint.
latter line, the appearance would be as shown in Figure If photography is used, the photographic axis must be
&.14(b), WZ being seen in line with VZ. With respect to made to coincide with the fixation line in all the ocular
this true vertical the meridian V’Z, which was vertical positions investigated.
when the eye was in its primary position, has moved
Subjective methods have used either the blind spot or
through an angle w that is clockwise from the subject’s
an after-image as a marker. A suitable object for an
point of view. This is the angle of false torsion.
after-image is an upright cross. The subject's head is
The following method of calculating its value is also
constrained to ensure that his eye is in its primary pos-
derived from Maddox. Let ~ denote the angle WZR in
ition, with the centre of the cross on the fixation line.
the eye’s equatorial plane. Then from Figure 8.14 it can
An electronic flash may be used to produce an after-
be seen that
image of the cross, the limbs of which correspond to the
tan o’ = MW/MZ true horizontal and vertical meridians of the retina.
The orientation of the after-image when the subject
and
now looks in various directions (with his head still
tan o = MV’/MZ fixed) is illustrated in Figure 8.15(a). As predicted by Lis-
so that ting’s law, no torsion occurs in secondary positions of
the gaze, while the rotation of the after-image in tertiary
tan a’ = (MW/MV’) tan o positions is in the expected direction. For example,
From triangle VWM it is also apparent that when the subject looks upwards and to his right, the ro-
tation is clockwise as predicted by Figure 8.14.
MW/MV = MW/MV’ = cos Bh
Hence
tana’ = tanacosB
and
O=a-—o
=a
— arc tan (tana cos f) (8.5)

As shown by Helmholtz, expressions for false torsion

can also be obtained in terms of the angles ¢ and 9, as
follows:
(a) (b)
sin o sin 9
Tanna=— Se ee (8.6) Figure 8.15. Projection of an after-image of a vertical—
cos 6 + cos 0
horizontal cross on to: (a) the inside of a sphere concentric with
and the eye, (b) a fronto-parallel plane.
 sing by the brain of the visual input from the two eyes
in turn, rather than the simultaneous integration of in-
formation. This difference of opinion is not of impor-
tance for the present study.
The requirements for binocular vision can be sum-
marized as follows:

(1) The separate visual fields must overlap in all direc-

tions of gaze. _
(2) The separate fields of fixation must overlap, with co-
ordinated movements of the two eyes.
(3) The neural transmission from the two eyes must
reach the same area of the brain.
(4) Perceptual co-ordination must take place.
Figure 8.16. Photograph of a building, camera pointing up
and to the left to show perspective distortion, opposite to that in
Figure 8.15(b).
Visual fields
The visual field is that extent of space containing all
A complication arises when the apparent position of points which produce perception in the stationary eye,
the after-image is plotted on a screen which is not provided that the stimulus is sufficient. For binocular
normal to the subject's line of sight in the particular di- vision to be possible, the two orbits and the structure of
rection studied. If plotted on a screen perpendicular to the eyes must be arranged so that the visual fields
the fixation line in the eye's primary position, the after- overlap. In a grazing animal, protective vision is of
image takes the various forms shown in Figure 8.15(b). great importance. The rabbit has a visual field for either
The apparent distortion of the cross which occurs in ter- eye alone extending over more than a semi-circle in the
tiary positions of the gaze arises purely from the geom- horizontal plane (Duke-Elder, 1958). The two laterally
etry of oblique projection. A similar effect can be seen placed eyes therefore provide a large area of uniocular
in photography, as in Figure 8.16, which shows a build- field on each side of the head, with a small region of
ing photographed with the camera pointing obliquely overlap in front and behind.
upwards and to the left. In this case the distortion is of The predatory animal, however, requires a good sense
the opposite form to that shown in Figure 8.15(b) be- of distance judgement so that it can capture its prey.
cause the direction of projection has been reversed This necessitates a large area of overlapping vision, re-
(backwards to the camera). sulting in a large blind area behind the head.
The difficulty can be overcome by plotting on the Man’s vision is somewhat similar in its requirements
inside of a sphere concentric with the eye’s centre of ro- to the carnivore’s. The orbits are placed anteriorly,
tation. This was the method adopted by Quereau facing forwards although their axes diverge at about
(1955), who used the blind spot as a marker. 45°. The eyes are nevertheless mounted so that their
In general, the truth of Listing’s law has been verified visual axes are approximately parallel. Figure 8.17
by these various experimental techniques, provided shows the two uniocular visual fields, with the bin-
that the right and left fixation lines remain substantially ocular area doubly shaded.
parallel. The angle of false torsion appears to be affected The uniocular field is bounded by the superior and in-
by convergence, though not in a uniform and accu- ferior margins of the orbit, the nose, and on the tempor-
rately predictable manner. In the usual position of de- al side by the projection of the edge of the retina (the
pression and convergence adopted in near vision there ora serrata); this extends furthest forward in the eye on
appears to be very little torsion. the nasal side. The field extends to about 60° nasally
and 100° temporally, given a sufficient stimulus.
The visual field is measured with a perimeter. This is a
Requirements for binocular vision hollow hemisphere or a rotatable semicircular arc,
usually with radius of curvature of a half or third of a
metre. The subject is positioned so that the eye under
Summary of requirements
test is approximately at the centre of curvature of the
The chameleon has two eyes which are moved indepen- perimeter surface. The second eye is covered while the
dently of each other. Despite its two eyes it does not first steadily fixates an object at the centre of the arc. A
have binocular vision, which may be defined as the use test stimulus, for example a 10mm diameter white
of two eyes in such a co-ordinated manner as to produce disc, is brought in from the edge of the arc until the sub-
a single mental impression of external space. An image ject is just aware of its presence in the periphery of his
of partly the same scene is formed in each eye, the two vision. The stimulus eccentricity is measured directly in
images being transmitted separately to the cerebral degrees and the process repeated for other meridians.
cortex. The final mental percept is the result of the If the fields for the right and left eyes are plotted on
blending or fusing of the two neural representations in the same chart, the area of overlap is the binocular
the higher levels of the brain — the psychological stage visual field, which is approximately pear-shaped. The
of the visual process. Some authors, notably Asher monocular temporal crescents contribute significantly
(1961), favour the idea of a rapid consecutive proces- to our awareness of space.
 Requirements for binocular vision 153

is in use, the eyes no longer being able to follow the

object movement precisely. (The monocular field may
also be examined in this way, but the after-image tech-
nique is more accurate since deviation of the projected
after-image from the marker which the eye is following
is immediately apparent to the subject. The printed
word may still be recognizable even if imaged para-
foveally.)
It is important to distinguish between the fields of
vision and fixation. The visual field relates to the
stationary eye(s), whereas the field of fixation is the
motor field — the solid angle within which the visual
axes can be moved. In life, the visual field is effectively
increased by both head and eye movements. An object
in the peripheral field catches our attention and the
eyes move so that the image falls on the fovea. Co-ordi-
nated response of head and eye movements is required,
the eye movements themselves rarely exceeding 20°.

(b)
Neural transmission

The right hemisphere of the brain is concerned with the

left side of both the body and external space and vice
versa. Thus the visual fibres from the two eyes might be
expected to pass to the opposite side. If, however, all
LLL the fibres crossed, the neural information could not be
integrated to give true binocular vision unless there
Figure 8.17. Monocular visual fields plotted on a chart. The were communicating tracts between the two cerebral
crosses in (a) indicate the.approximate limits of the field of hemispheres. Moreover, since the visual field of each
binocular fixation. (b) Horizontal field as seen from above. The eye extends over both sides of the mid-plane, some
doubly shaded area represents the binocular field.
parts of the visual field would be represented in two
places in the brain.
Fields of fixation The chiasma or crossing of the two optic nerves in the
cranium, behind the orbits, is only partial. Although
The field of fixation is that region of space containing all about one-half of all the fibres (those from the nasal
points which may be fixated by the mobile eye, the retina) pass to the opposite hemisphere of the brain, the
head remaining stationary. The eyes do not have an un- temporal fibres remain on the same side. Figure 8.18
limited range of movement in their orbits, but conjugate shows schematically the path to the cortex, where the
version movements of the eyes over a range of approxi- impulses from the respective parts of the two retinae
mately 45° from the primary position are possible. The are brought into proximity. Damage to one ofthe occipi-
horizontal and vertical limits are indicated by the
crosses in Figure 8.17.
The monocular field of fixation may be determined
with a perimeter by means of an after-image on the
fovea produced by staring at a bright light for a few mo-
ments or at an electronic flash. The head is kept still
and the eye rotated as far as the subject is able to. The
position of the projected after-image on the perimeter
scale gives the limit of fixation in the particular direc-
tion.
In the normal subject, the binocular field of fixation is
similar to the monocular fields, but an oculo-motor par-
esis will reduce it in the fields of action of the affected
muscle(s); compare the right and left ocular movements
in Figure 8.11.
One method of measuring the binocular field of fixa-
tion is to ask the subject to look at a fine test object, for
example, a printed word in small type. With the head
stationary at the centre of the perimeter, the test object
To L hemisphere To R hemisphere
is moved out from the centre. When it appears double,
binocular vision has broken down. In some cases the Figure 8.18. Simplified representation of nerve-fibre paths to
print may begin to blur, showing that parafoveal vision the brain.
154 Ocular motility and binocular vision

tal lobes therefore causes a corresponding defect in the

left or the right visual field of both eyes, not to one eye
alone (except for that part of the cortex corresponding
to the monocular temporal crescents).
In the rabbit chiasma, the great majority of nerve
fibres do cross to reach the opposite hemisphere: this ar-
rangement is suited to the extensive uniocular fields of
view but gives little binocular representation in the
cortex.

Perceptual co-ordination
The partial decussation in the chiasma allows the two
parts of each monocular field to be represented in the
correct side of the brain. To bring these two views into
association in the cortex so that there emerges out of
them a single mental perception, with objects seen in
their correct relative positions in space, further con-
ditions must be satisfied.
There must be an orderly arrangement of receptors in
each retina, together with their connections to the
cortex. This will allow the correct monocular represen-
tation of the field of view in the brain. The terms neural
M ’ Q'

and cortical image are sometimes used to describe the Figure 8.19. Projection of a retinal image point Q’ into space
impulse pattern in the cortex, but this does not imply through the nodal point of a reduced eye.
that there is a true picture in the cortex.
The two monocular representations have to be
In Figure 8.19, the projection axis of a reduced eye is
moulded into a single percept. Because the two eyes are
accordingly shown as the line from the fovea M’
positioned about 54-72 mm apart, they receive slightly
through the nodal point N, which is taken to be the
different views of objects lying in the binocular visual
monocular centre of projection. A retinal element Q’, to
field. A simple superposition of these two images would
the right of the fovea, would be stimulated by light
give rise to double vision and a conflicting sense of direc-
from an object point Q situated anywhere on the line
tion. The two monocular impressions must be brought
Q’N produced. The retinal image at Q’ is said to be pro-
into a corresponding association in the cortex and the
jected towards Q. The direction is constant for a particu-
brain must be capable of fusing or integrating them
lar retinal element so that, when stimulated, each
into a single binocular picture.
element always gives rise to a sensation localized in a
specific direction relative to fixation. Lotze referred to
this as local sign.
The monocular centre of projection should not be
Monocular projection confused with the binocular sighting centre (see pages
156-157).
In the normal eye the most important line of projection
is that defined by the position of the centre of the fovea.
For many purposes the visual axis (the line from the
fovea to the centre of the exit pupil and its counterpart Corresponding points and
in object space) may be considered as the projection the horopter
axis of the eye. The projection and visual axes may
nevertheless differ in some anomalous conditions (see Whenever both foveae are stimulated simultaneously,
Chapter 10). the stimulus is invariably perceived as having a
In the unaccommodated emmetropic eye, subject to common origin in space (except in cases of anomalous
paraxial limitations, all ray paths from the fovea retinal correspondence, see Chapter 10). This law ap-
emerge parallel to one another. Hence, in distance plies even in artificial situations, for example, when the
vision, any of these ray paths would lead back to the eyes have been made to diverge by a base-in prism or
same remote object point. The simplest one to select for prisms.
this purpose would be the undeviated ray through the A similar correspondence exists between a multitude
nodal point(s) of the reduced eye. Provided that the ret- of other pairs of retinal receptors, called corresponding
inal image is in sharp focus, the same simplification can points. When stimulated in binocular vision, they too
be applied to near vision as well. The following discus- give rise to a sensation subjectively localized at a single
sion proceeds on this generally accepted basis, though point. In Figure 8.20 the eyes have converged to fixate
its limitations should be borne in mind. Since the con- the point B which is seen singly, and Q{ and Qk are
cept of nodal points is limited to paraxial rays, the con- corresponding points to the left of each fovea. Since the
struction cannot be regarded as precise. projection lines through the respective nodal points in-
 Corresponding points and the horopter 155

Figure 8.20. The longitudinal horopter. Subscripts L and R

refer to the left and right eyes, C to the imaginary cyclopean
eye. Figure 8.21. Panum’s fusional areas.

tersect at Q, this is another point that will be seen singly Figure 8.21 shows a pair of corresponding points Q{
with the eyes in the same position. It does not follow and Qp (represented by crosses), and the retinal images
that the single percept of Q will necessarily be situated of the fixation object (represented by the small circles).
at this point. Provided that the left image falls on Q} and the right
For a given position of the eyes, the locus of all the within the corresponding area around Qk as in (a) in
object points whose images fall on corresponding points the figure, or vice versa as in (b), a single percept will
is known as a horopter, generally a curved surface. The result. Diplopia will occur if the images fall at the extre-
point O in Figure 8.20 is said to be on the horopter of mities of both corresponding areas, as in (d), though
the fixation point B. The longitudinal horopter is the possibly not if they are only partially displaced, as in
line formed by the intersection of the horopter with the (c), which illustrates a bilateral fixation disparity (see
plane containing the eyes’ centres of rotation and the Chapter 10).
fixation point. In Figure 8.20 it is indicated by the Panum’s areas provide not only the element of toler-
curved line through B and Q. ance or ‘slack’ essential in such an arrangement, but
If perfect ocular symmetry is assumed, each point of a also some latitude in the position of the horopter. The
corresponding pair has the same angular separation two broken lines in Figure 8.20 enclose an area known
from the fovea, measured from the nodal point. Thus as Panum’s fusional space, within which all object
the angles denoted by 0 in Figure 8.20 would be equal. points are seen singly. The increasing width of the
As a result, the longitudinal horopter would form part space from the fixation point outwards arises from the
of the circle passing through the point of fixation and increasing size of the Panum’s areas towards the periph-
the eyes’ nodal points — the Vieth—Miiller circle. It is a ery of the retina.
well-known property of the circle that the angle sub- Points on the two retinae which are not correspond-
tended by a given arc at all points on the circumference ing are said to be disparate, for example, the points Dj
is the same. The cyclopean eye shown in Figure 8.20 is and Dp. Though corresponding points are not neces-
discussed in more detail in the next section. sarily equidistant from the fovea, the difference in the
Despite the term ‘corresponding points’, the corre- case of Dj and Dk is so great that they could not be
spondence is not a precise point-to-point relationship other than disparate. Consequently, the object at D
but rather of a point to an area, named after Panum. which stimulates them simultaneously will be seen in
Near the fovea, Panum’s areas are approximately ellipti- diplopia.
cal with the major axis horizontal and subtending The horopter approximates to the subjective fronto-
about 5 minutes of arc at the nodal point. In the periph- parallel plane, found by asking the subject to place a
ery of the retina they are larger, perhaps subtending as series of vertical needles so that they appear to be equi-
much as 30-40 minutes. distant from him. Their position in the horizontal plane
156 Ocular motility and binocular vision

is the longitudinal horopter. Slightly differing loci will

probably be plotted, depending on the instructions
given to the subject and the experimental technique em-
ployed.
The shape of the horopter generally alters with the
fixation distance. If this is less than about 1 m, the hor-
opter is concave towards the subject, while for an obser-
vation distance of about 2m or more the apparent
fronto-parallel plane tends to be convex towards the
subject. These departures from the theoretical Vieth—
Miiller circle are taken to indicate asymmetry in the lo-
cation of corresponding points, though the eyes’ optical
aberrations may be a contributory factor. The distance
at which the longitudinal horopter is approximately a
straight line is called the abathic distance.

The cyclopean eye and

physiological diplopia

When studying the projection of images in binocular

vision, it is often helpful to use an imaginary single eye
stimulated by the right and left eyes. This imaginary
organ is known as the cyclopean eye or binoculus. If
the longitudinal horopter is assumed to coincide with
the Vieth—Miiller circle, the nodal point Nc of the cyclo-
pean eye should be placed on this circle equidistant
from the real eyes’ nodal points, as in Figure 8.20. The
cyclopean fovea Mc lies on the line from the fixation
point through the nodal point Nc. Thus, when the fixa-
tion point lines in the median plane, the primary line of
the cyclopean eye also lies in this plane. Figure 8.22. Crossed (heteronymous) physiological diplopia
When a point on the left retina is stimulated, it is con- of the nearer point E when fixating the further point B.
ceived as stimulating a point on the cyclopean retina at Projection with cyclopean eye.
the same distance and in the same direction from its
fovea. The same applies to a point on the right retina. If
farther than fixation, crossed diplopia when it is nearer
the right and left receptors under consideration are
corresponding points, they coincide when transferred than fixation.
to the cyclopean eye, as in Figure 8.20. They are then The cyclopean eye is helpful in explaining this phe-
said to give rise to a single percept by projection through nomenon. In Figure 8.22, the fixation object B lies in
the cyclopean nodal point. From the geometry of Figure the median plane. A nearer object E in the same plane
8.20, this line is seen to pass through the point Q stimulates the retinal receptors Eg and E;. These recep-
which stimulated the given pair of corresponding points. tors must be disparate because they are on opposite
If the retinal points considered are disparate, they will sides of the respective foveae and hence, when trans-
not coincide when transferred to the cyclopean eye. ferred to the cyclopean eye, on opposite sides of its
Two separate percepts in different directions then arise, fovea, Mc.
resulting in physiological diplopia. This is so called be- By monocular projection, the image of E is seen in the
cause the apparent doubling is the result of the geom- direction N,E by the left eye and in the direction NrE
etry of vision with two eyes and is not pathological in by the right eye, but the images cannot be fused into a
origin or due to a malfunction. If, when one eye is single percept. In binocular vision, projection through
closed, the diplopic image seen on the same (right or the cyclopean nodal point shows that the retinal image
left) side disappears, the diplopia is called homonymous of E in the left eye would be seen in the direction Ej Nc
or uncrossed. If the opposite occurs, the diplopia is that is, to the right of the image due to the right eye,
called heteronymous or crossed. projected in the direction EpNc. So in this case the diplo-
Though physiological diplopia is seldom noticed in pia is crossed — true in general for objects nearer to the
everyday life, it is readily perceived when attention is eyes than the plane of fixation.
drawn to it. For example, if a pencil is held vertically a The monocular and binocular projections could be re-
short distance in front of the eyes while a more distant conciled by supposing the diplopic images to be subjec-
object is steadily fixated, the pencil will appear in tively located in the positions shown in Figure 8.22.
crossed diplopia. When the pencil is fixated, the more This does not imply that the subject would perceive
distant object will be seen in uncrossed diplopia. Hence them in these locations. In general, the diplopic images
the rule: uncrossed diplopia occurs when the object is are out of focus and insubstantial. Any impression of
 References 157

their distance from the eyes would be greatly influenced right and left retinal images. It is the most highly refined
by prior knowledge of the actual positions of the objects attainment of binocular vision and is discussed more
in question, especially if the nearer one is held in the fully in Chapter 11.
hand.
A diagram similar to Figure 8.22 but with fixation
transferred to the nearer object would show the more
distant one to be seen in uncrossed diplopia.
The perfect symmetry assumed in Figures 8.20 and References
8.22 does not occur in nature. Under binocular viewing
conditions, the origin of projection is seldom mid-way ADLER, F.H. (1981) Physiology of the Eye, 7th edn. St. Louis:
C. V. Mosby Co.
between the two eyes. Just as most people are definitely ALPERN, M. (1969) Part 1: Movements of the eyes. In The Eye
right- or left-handed, so one eye tends to be dominant (Davson, H., ed.), Vol. 3, 2nd edn. New York and London:
over the other. If we wish to line up two objects accu- Academic Press
rately, we tend to close the less dominant eye (either ASHER, H. (1961). The Seeing Eye. London: Duckworth
DONDERS, F.C. (1864) Accommodation and Refraction of the Eye.
physically or by mental suppression of that eye’s
London: The New Sydenham Society
image). An approximate judgement of alignment can be DUKE-ELDER, W.S. (1958) System of Ophthalmology, Vol. 1, The
made binocularly, but the binocular projection centre Eye in Evolution, pp. 672-689. London: Henry Kimpton
will usually be found to lie nearer the dominant eye. FRANCIS, J.L. and HARWOOD, K.A. (1951) The variation of the
projection centre with differential stimulus and its relation
A crude way of finding the position of the cyclopean
to ocular dominance. In International Optical Congress 1951,
eye or the binocular projection or sighting centre is for pp. 75-87. London: British Optical Association
the subject to view a pin placed in“a horizontal drawing FRY, G.A. and HILL, W.W. (1962) The center of rotation of the
board in a plane at eye level at about half a metre from eye. Am. J. Optom., 39, 581-595
the eyes. A second pin held with both hands (to reduce HELMHOLTZ, H. VON (1924) Physiological Optics, Vol. 3, pp. 37—
154. English translation ed. by J.P.C. Southall. New York:
the effect of hand-dominance) is pushed rapidly into the
Optical Society of America. Reprinted by Dover Publications:
drawing board in line with the first pin, a procedure re- New York, 1962
peated several times. A line drawn backwards from the MADDOX, E.E. (1898) Tests and Studies of the Ocular Muscles.
first pin through the mean position of the second pin in- Bristol: John Wright & Co.
PARK, R.S. and PARK, G.E. (1933) The centre of ocular rotation
dicates the projection axis of the cyclopean eye. Its pos-
in the horizontal plane. Am. J. Physiol., 104, 545-552
ition relative to the subject’s head (which must be held QUEREAU, J.V.D. (1955) Rolling of the eye around its visual axis
rigidly in a rest) can thus be plotted. (For a more exten- during normal ocular movements. A.M.A. Archs Ophthal,
sive treatment of this subject, see Francis and Harwood, 53, 807-810
RYLAND, H.S. and LANG, B.T. (1913) An instrument for measur-
ES)
ing the distance between the centres of rotation of the two
eyes. The Optician and Photographic Trade Journal, 44, 277-
278
Stereopsis SOLOMONS, H. (1975) Derivation of the angle of torsion of the
eye. Br. J. Physiol. Optics, 30, 47-55
SOLOMONS, H. (1977) Kinematics of the extra-ocular muscles.
Stereopsis is the ability to perceive space as three-dimen- Ophthal. Optn, 17, 10-14, 46-48, 97-100, 146-156, 175-
sional solely through slight differences between the 180
9
Convergence

Introduction D atco

The term ‘convergence’ has two different meanings. One

describes the relative position of the visual axes when
they intersect at a given near point of regard, the other
denotes the relative movement of the visual axes when
fixation changes from a more distant point D to a
nearer point N (Figure 9.la). Divergence has the two
corresponding opposite meanings. If fixation were to
shift back from N to D or beyond, the visual axes would
diverge but the final position would still be a state of
convergence or parallelism. A state of divergence
cannot occur with precise binocular fixation of a real
(b)
object.
If the distant and near objects are both in the median Figure 9.1. Convergence: (a) convergence from a distant
plane, both eyes adduct equally in convergence and object D to a near object N; (b) fixation of a point away from the
median plane; (c) asymmetric convergence, the two points D
abduct in divergence. When fixating a near object
and N being in line with the right eye.
placed to the right (Figure 9.1b), the right eye abducts
and the left adducts. An interesting special case occurs
when the fixation changes as shown in Figure 9.1c, the When the eyes view a distant object, the visual axes
two object points D and N both lying on the right eye’s are parallel, but they may not take this position in the
visual axis. Only the left eye need move to change fixa- absence of the visual stimuli.
tion from D to N but, in fact, both eyes make a small dex-
Because the foveae in the normal individual are corre-
troversion coupled with convergence. This particular
sponding points, the fusion reflex directs the eyes so
case is described by Alpern (1969) and Pickwell (1973).
that the object of regard is imaged simultaneously on
both foveae. If one eye is covered, it may tend to deviate
from the correct position for fixation (see Chapter 10).
Although in clinical examination one eye maintains
fixation of the test object while the second eye may devi-
Positions of rest and fixation ate behind the cover or dissociating device, a theoretical
position may be defined with both eyes deviating
Position of anatomical rest through approximately half the angle in opposite direc-
As we have already seen (page 144) the orbital axes in- tions. Thus, the fusion-free position (passive or disso-
clude an angle of approximately 45°. In the absence of ciated position) is the position adopted by the eyes
all innervation to the extra-ocular muscles, as in death, when postural and fixation reflexes are active but
the eyes usually adopt a position of moderate divergence fusion is prevented. In the particular case where the
and elevation. fixation object is in the distance, the fusion-free position
is known as the position of functional rest.
The active or functional position of the eyes is their
Position of physiological rest position when the fixation axes intersect at the point of
This is the position assumed in the absence of all stimuli regard and occurs when the eyes are parallel for a dis-
determining orientation and occurs as a result of a tant object and converged for a near object.
minimal and balanced tonus of the extra-ocular mus- Figure 9.2 illustrates these various positions of the
cles, as in deep sleep or under general anaesthesia. It is eyes, together with the angles through which the eyes
again a divergent position, but less so than in the pos- move between them. Using the terms defined by
ition of anatomical rest. Maddox (1886, 1907), the tonic convergence is that
 Units of convergence 159

(cranial III and VI) for both version and vergence move-
ments.
Distance The closest point in the median plane to which the
eyes can converge is the near point of convergence. It
may be determined clinically by asking the patient to ob-
serve, for example, a vertical black line drawn on a
white card. The card is then moved towards the pa-
tient’s eyes and he is asked to report when the line goes
double. The position of the card is then taken to mark
Near the near point of convergence.
Disadvantages of this method are that some patients
Median plane
do not observe the diplopia of the test object when con-
Figure 9.2. The various positions of rest and active positions vergence becomes inaccurate, while others continue to
of the right eye, shown looking towards the left. Zp is the centre converge even though single binocular vision is no
of rotation, 7 the tonic convergence, Fp the fusional
convergence (distance), P the proximal convergence, A the longer present. It is probably better to observe the pa-
accommodative convergence and Fy the fusional convergence tient’s eyes as the test line approaches. At a certain dis-
(near). tance of the test line the patient’s eyes will often be
seen to stop adducting: they remain stationary instead
of continuing to converge. Other patients continue fixat-
bringing the eyes from the anatomical position of rest to
ing the test line with one eye — usually their preferred
the fusion-free position for distanee.
or dominant eye — while the second eye abducts. Some-
Fusional convergence (or divergence) will bring the
times this abduction is equal in amount to the continu-
eyes from the fusion-free position to the active position.
ing adduction of the fixating eye, while in other cases
It is reflexly stimulated by the desire for single binocular
the visual axes become nearly parallel with the second
vision. For a near object, the fusion-free position will
eye turned obviously outwards.
almost certainly be converged relative to the distance
The position of the near point of convergence varies
fusion-free position. Two major factors contribute to from as close as 20 mm from the bridge of the nose to
this difference, proximal convergence and accommoda-
more than 500mm. Normal values would perhaps
tive convergence.
range between 40 and 160 mm from the corneal plane.
Proximal convergence is that convergence induced by
Values much greater, that is, poorer than 160mm,
the knowledge that the object of regard is situated near may well give symptoms in near vision. Orthoptic exer-
the observer, even when viewed through a lens or opti- cises to improve the reserves of convergence and/or pris-
cal instrument which places the image at infinity. matic relief may be needed to reduce these symptoms,
Accommodative convergence is stimulated by the con- although patients with poor convergence often hold
sensual linkage between accommodation and conver- near work at a greater distance than normal patients.
gence (in general). Except in advanced presbyopia, Unlike the decline in accommodative power with age
accommodation and convergence are always exerted to- (as discussed on pages 117-119) there is no systematic
gether in near vision, normal situations never demand- decrease in amplitude of convergence with increasing
ing one without the other. The pupil also constricts age. Convergence is unlikely to be as good in age as in
when fixation is changed to a near object: the near reac- youth, due possibly to lack of use (since the presbyopic
tion. patient can never see very close objects clearly) and to
When proximal and accommodative convergence are loss of accommodative convergence. Some _ patients
in play, the eyes are in the fusion-free position in near manage to maintain good powers of convergence into
vision. As in distance vision, fusional convergence will advanced age while others do not.
then be required to bring the eyes to their correct pos- Convergence is essentially a reflex adjustment to give
ition for single binocular vision. single binocular near vision, but it may also be produced
However, when the eyes are dissociated by being in voluntarily. With practice many people can converge
total darkness, the fusion-free position governed by the (and accommodate) in the absence of a physical stimu-
tonic convergence is usually to an intermediate distance lus as if they were really viewing a near object.
of about 110 cm (see the review in Hogan and Gilmartin,
1985, and Owens and Leibowitz, 1983). This is similar
to, but not identical in value with, the tonic accommo-
dation found in dark-field myopia (Chapter 7). Units of convergence

An ocular rotation about the eye’s anteroposterior axis

The near point of convergence (torsion) is usually measured in degrees. Version move-
ments may also be measured in prism dioptres A, a unit
Each eye individually may be able to adduct through of angle explained on page 10. For convergence alone,
40°, but the maximum effort of convergence may corre- yet another angular measure is sometimes used, the
spond to an angle of much less than 80°. This may metre angle MA, devised by Nagel in 1880 before the
partly be explained by different supra-nuclear innerva- prism dioptre had been introduced.
tion in the brain, even though the final nerve supply to In Figure 9.3 the unaided eyes have rotated to obtain
the medial and lateral recti is by the same nerves binocular fixation of point B in the median plane. The
160. Convergence

Accommodation (D) 8

NaSY

N A

—_—roxy
ke)
f

Convergence
(A)
C

Figure 9.3. The total angle of convergence G:

= 100.9 OB O87 O16 015014" O'S O28 051 a0

Object distance (m)

convergence of each eye is the angle through which it
has rotated from its primary direction. The line joining Figure 9.4. The total angle of convergence Cin prism
dioptres, as a function of object distance for PDs of 60, 65 and
the two rotation centres Z; and Zp may be called the 70 mm.
inter-ocular base line and its length the inter-ocular dis-
tance which is approximately the same as the inter-
pupillary distance PD for distance vision. To simplify the treatment in the ensuing discussion,
The total angle of convergence, denoted by C, is the convergence will be expressed in prism dioptres. For
angle between the visual axes when directed towards simplicity, the fixation point will be taken as lying in
the fixation point. It is the algebraic sum of the separate the median plane and it will be assumed that the given
rotations Op and 0; of the right and left eyes, measured conditions apply equally to both eyes. The total conver-
in the plane containing the fixation point and the eyes’ gence C will hence be twice the inward rotation 6 of the
rotation centres. If 2p is the inter-ocular distance, q the single eye considered. Marked anisometropia is not
distance of the fixation point from the base line and common and the expressions obtained will be suffi-
QO = 1/q (qin metres), then to a sufficiently close approx- ciently accurate for the purpose of providing a broad
imation picture and making comparisons.
The relationship between convergence and accommo-
C = arctan (—2p/q) (p,q in m)
dation is affected by any uncorrected ametropia and
= arc tan (—2pQ) also by any correction in use. To establish a norm we
shall begin with emmetropia.
So that

C (in A) = —2pQ (p in cm)

= —Q x PD (in cm) (9.1)

Emmetropia
For example, given that gq= —250 mm and the PD is
60mm, C = 4 x 6 = 24A. Figure 9.4 illustrates the theoretical demand on accom-
Irrespective of the subject’s PD, convergence in metre modation and convergence as the object of regard ap-
angles is simply the absolute value of the dioptric dis- proaches the emmetropic eye. The required total
tance Q. That is, since q is negative convergence C is plotted in prism dioptres for three dif-
ferent inter-pupillary distances. A separate scale at the
C (in MA) = —O (9.2) top of the graph, to be read directly against the object
and distance, gives the necessary accommodation which is
numerically the same as the convergence in metre
C (in A) = C (in MA) x PD (in cm) angles.
Equation (9.1) shows the total convergence required
to be —2pQ (pin cm), while the accommodation is —Q.
Hence, the ratio of convergence to accommodation in
Convergence, accommodation and emmetropia is given by

refractive error C/A = 2p = PD (in cm) (m5)

When studying accommodation in relation to conver-

gence, it is convenient to use the inter-ocular base line
as the origin of measurement instead of the eye’s prin-
cipal point. The theoretical demand on accommodation
Uncorrected ametropia
in the case of emmetropia is then —QO. Thus, binocular If the distance error of refraction is K, the accommoda-
fixation at a dioptric distance of —3 D would require tion required in near vision at a dioptric distance Q is
3 D of accommodation and 3 MA of convergence. (K — Q), while the convergence is unchanged at —2pQ.
 Convergence, accommodation and refractive error 161

Hence,

x Q
(9.4)
This ratio has a wide range of possible values. For ex-
ample, the hypermetrope will need to accommodate
more than an emmetrope while converging by the
same amount. If, however, the accommodation habi-
tually needed to correct the distance refractive error is Median line
disregarded and only the additional accommodation re-
quired in near vision is considered, the C/A ratio is the
same as for the emmetrope. In myopia the situation is
different: a —3.00 D myope is in focus for objects at 7m
and would not accommodate for this or any longer dis-
tance.

Emmetrope with near spectacle correction Figure 9.5. Accommodation and convergence in the myope
corrected by: (a) a thin spectacle lens, (b) a contact lens.
If the spectacle lenses are optically centred for the given
working distance, the convergence required is unaf-
fected. On the other hand, the accommodative demand The right eye fixates Br, the image of B formed by the
is reduced by the prescribed reading addition. right lens. If the distances HB and H’BR are denoted by
hp (= p) and hz respectively, then

hig ipl = (33 ~ 2.50)

= 6,50) =. sa Lain
Spectacle-corrected ametropia
and the semi-convergence angle 9 (in A) is found from
We shall assume that the spectacles are for constant
wear and the lenses are optically centred for distance
100 hR
0= 100%, /H Zz =—
vision. In near vision, the ocular accommodation re- H’/Sr + SpZp
quired has already been found to differ from the spec- 100 (9.71)
— 117.65 426 == 6: /6VN
tacle accommodation, while the convergence is affected
by the prismatic effect of the lenses. The following ex-
so that
ample is typical.
CEES
Example (1) and

A bilateral myope with a PD of 66 mm is corrected by C/A = 13.52/2.07 = 6.53

lenses (assumed thin) of power —6.00 D at 14 mm from
the eye’s principal point. Calculate the convergence
and accommodation required when viewing an object
in the median plane at a distance of 400 mm from the
spectacle plane. Assume the eye’s centres of rotation to Contact-lens corrected ametropia
be 26 mm from this plane.
Example (2)
Using Figure 9.5(a), in distance vision Retaining all the relevant data from Example (1), calcu-
late the convergence and accommodation that would
mm
D
Sai PAN,
be required with a contact-lens correction in use.
—6.00 = lee
Fp
=a. —14 . Ignoring very small differences, we can take the dis-
K =003 - k Fis0 67 tance of the fixation object B from the contact lens
(Figure 9.5b) as —414 mm, the same as PeH in Figure
9,5(a). The ocular accommodation is therefore 1000/
In near vision 414 or 2.42 D. The convergence (in A) is the same as
D mm that for the emmetropic eye (equation 9.1), that is
1B; =2,.30 C= —2pQ (p in cm)
+F op —6.00
In this case
16S —8.50 — bs —117.65
= =|4 g=Z,H = (%, —2) = —426mm
if —7.60 — ¢ —131.65
so that

Occular acc= A= K —L=+2.07D

O=—2.35D
162 Convergence

and

C=-2.35x6.6=15.51A
which gives

C/A =15.51/2.42 = 6.41

Thus, although the myopic contact-lens wearer in
this example has to converge more and accommodate
more than the spectacle wearer, the ratio of the two
functions is virtually the same for both.

Figure 9.6. Accommodative convergence AC from the

Summary
distant to the near dissociated (fusion-free) position.
The generality of this last result can be demonstrated by
an analysis based on binomial approximations. For the
is 7000/350 or 20A. If the object lies on the primary
spectacle-lens wearer, this gives the ocular accommoda-
line of the right eye, this total convergence would need
tion A as approximately
to be made by the left eye. Suppose that, in such a
Ab dh 2dFe (e7ee5)) situation, the left eye is now covered. Because of the ha-
while the convergence C can be shown to be bitual simultaneous use of accommodation and conver-
gence, some convergence will remain in play, perhaps
C = —2pL,{1 + 2(L, + Fsp)} (9.5) 14A.
from which If, in this same situation, the stimulus to accommoda-
tion were increased by placing a carefully centred
C/A = 2p{1 + (z—a)L, + (z — 2a)F,,} (9.6) minus lens before the right eye, the convergence of the
For the contact-lens wearer, left eye (still under cover) would probably increase, say
to 18A. On removal of the cover, the convergence
A= -L,(1
+ dL,) (9.7) would then be increased by the amount needed to
and regain binocular fixation. As explained on pages 158-
159, this faculty of adjustment to give accurate bin-
C= = phd ao7h.) (9.8) ocular fixation is called fusional convergence.
from which Convergence produced as described above by stimu-
lating the accommodation when the eyes are dissociated
GAS 2p =(2= dk. (9.9) was called accommodative convergence by Maddox. In
Typical values of z range from 25 to 30mm, while clinical practice it can be utilized to modify a patient's
typical values of d range from 12 to 15mm. Conse- refractive correction to provide more comfortable bin-
quently, the value of (z — 2d) in equation (9.6) will in ocular vision. Thus, some patients tend to over-con-
general be very small. If it is ignored as relatively negli- verge in near vision. If reading spectacles incorporating
gible, equations (9.6) and (9.9) become identical. More- a plus spherical addition are prescribed, the demand on
over, the ratio C/A now becomes independent of the accommodation is reduced. As a result, the over-conver-
power of the correcting lens. gence may then be reduced. Conversely, a reduction in
In general, therefore, the biggest change in the con- positive power may be made in order to stimulate con-
vergence/accommodation ratio occurs when a first cor- vergence, provided that the patient has sufficient re-
rection is worn. After this, changes in the correction serves of accommodation.
make virtually no difference until the accommodation The ratio of accommodative convergence to accom-
becomes depleted with the onset of presbyopia. modation, the AC/A ratio, can be used to decide how
much to alter the prescription. Two clinical methods of
measuring it are described below.

Accommodative convergence and the

AC/A ratio Direct measurement

Suppose that, in distance vision, one eye is temporarily

When a near object is fixated, both convergence and ac- covered and abducts through 2A, while in near vision
commodation are normally brought into action by the with an object at -400 mm (from the inter-ocular base
non-presbyopic subject. The convergence has to be ac- line) the covered eye under-converges by 5A. Given
curate to within a few minutes of arc to avoid diplopia, that the subject's PD is 60 mm, the total convergence re-
but the accommodation may not be exact; the eye’s quired for binocular fixation is 6000/400 or 15A. As
depth of focus still gives the observer a sharp percept. shown in Figure 9.6, the angle between the visual axes
The total angle of convergence required by the un- when the eyes are dissociated is 10A, being the stated
aided eyes is the angle subtended by the inter-ocular 5A less than the amount required for binocular fixation.
separation 2p at the fixation point. For example, if However, since there was 2A divergence from paralle-
2p = 70mm and the fixation object is at 350 mm from lism when the accommodation was relaxed, the total
the inter-ocular base line, the total convergence needed amount of accommodative convergence is 12A. If the
 Convergence-induced accommodation 163

small distance from the eye’s principal point to the

centre of rotation is ignored, the accommodation re-
quired in this case is 2.50 D. Hence P.S. (32)
AC/A = 12/2.50= 4.8
This method enables the ratio to be determined from
data that are normally obtained in routine examination
of the oculo-motor balance. It should be noted that the
accommodative convergence measured in this way in-
cludes an element of proximal convergence.

Accommodation
(D)
Gradient tests

This method determines the AC/A ratio for a constant

object distance: the vergence of light reaching the eyes
is altered by means of lenses but since the fixation is
(oo 2, DES 4 Oe Ot p fa ets
stationary, proximal convergence should remain unal-
tered. The gradient test is particularly suited to clinical Convergence (metre angles)
uses where the prescription is to be altered for a specific
Figure 9.7. Relationship between accommodation and
object distance. °
convergence. The open circles show the accommodative
With the eyes dissociated by some means, the relative response with equal stimuli to accommodation and
position of the visual axes in near vision is determined convergence; the crosses the response of both accommodation
with the normal prescription in place. A further +1.00 and convergence, accommodation only being stimulated by the
DS lens is placed before each eye, reducing the stimulus dioptric values indicated and the closed circles show
convergence-induced accommodation. (Reproduced from
to accommodation by 1.00D. If the eyes diverge Fincham and Walton, 1957, by kind permission of the
through 4A, the AC/A ratio is 4A/D. In the young publishers of J. Physiol.)
patient, —1.00 DS lenses could also be used, the eyes
now being expected to converge.
The gradient test may also be used in distant vision, of the response value for accommodation may be due
but only negative lenses can be used since positive merely to inaccurate accommodation.
lenses would blur the fixation object. At either distance, There is a voluminous literature on the subject of AC/
the fixation object should be sufficiently detailed to A ratios. Among others, Alpern (1960) discusses many
stimulate accommodation. Typical results (Morgan, theoretical points, while Flom (1959) surveys many of
1944) show a mean gradient of 4.0 + 2.0. the clinical aspects. A more recent review is given in
Both these methods assume that the eyes accommo- the paper by Ramsdale and Charman (1988). It has
date exactly for the test object, but accommodation is been found that the type of refractive error may also in-
usually under-active: the near bichromatic test shows fluence the accommodative convergence. Rosenfield
that the green focus is more often closer to the retina and Gilmartin (1987) investigated this possible link in
than the red. Inattention will also probably produce a emmetropes and two groups of myopes, those who
lower than normal accommodation level. became myopic before the age of 15 years and those
By measuring the accommodation level objectively, who became myopic later. The early-onset myopes
an AC/A response instead of an AC/A stimulus measure- showed higher accommodative convergence than the
ment is obtained. Using laser speckle refraction (see later-onset myopes and the emmetropes.
Chapter 19), Ramsdale and Charman (1988) confirmed
the earlier results of Fincham and Walton (1957). The
latter’s results for a typical subject are shown in Figure Convergence-induced accommodation
9.7. A Fincham Co-incidence Optometer was used, de-
scribed in previous editions of this book. Just as an alteration in the accommodative demand
The central line shows the subject's accommodation upon the eyes produces a change in their convergence,
when the stimuli to convergence in dioptres and accom- so a change in convergence may induce alterations in
modation in metre angles were equal, as when viewing the level of accommodation. This alteration is known
a real object. The accommodation is seen to lag slightly as convergence-induced accommodation, or sometimes
below the theoretical demand for objects closer than convergence accommodation.
—im. In order that the accommodation may take whatever
The left-hand curve shows the accommodative con- value is induced by the convergence, the mechanisms
vergence, accommedation only being stimulated. As ex- which normally control the accommodation must be
pected, the convergence produced is noticeably less eliminated. Pinhole-sized artificial pupils of about
than that occurring in normal vision, although it 0.5mm diameter are used, reducing the blur-circle
should also be noted that the measured accommodation diameter on the retina even when the image is several
rarely equalled the actual stimulus. Fincham and dioptres out of focus. As a result, the eye makes a negli-
Walton point out that apparent fluctuations in the gible effort to bring the test object into focus. Two simi-
AC/A ratio measured using the stimulus value instead lar test objects are used, one for each eye, in an
164 Convergence

11 23

10
Positive Normal
9

a : 26
= ay/
A)
&
ne) 6
fe)
e 5 32
5
Negative
a 4 41 (D)
Accommodation

ee
46 Peoa(32)
Z

1 50
1 2 3 4 5 6 7 8
0 Convergence (metre angles)
1 2 8 @ & © 7 & We © i) ye
Convergence (metre angles)
Figure 9.9. Positive and negative amplitudes of relative
Figure 9.8. Convergence-induced accommodation: effect of accommodation. (Reproduced in part from Fincham and
age. (Reproduced from Fincham, 1958, by kind permission of Walton, 1957, by kind permission of the publishers of J.
the publishers of Optician.) Physiol.)

instrument similar to a synoptophore (see page 203). non-presbyopic emmetrope (or corrected ametrope) in
Their relative positions control the convergence of the viewing a near object. It is possible, however, to alter
eyes. The dioptric state of the eye is measured, prefer- the stimulus to accommodation by placing additional
ably with an objective optometer (see Chapter 18) or positive or negative lenses before the eyes, the conver-
with a subjective optometer which can be viewed for gence remaining constant. The change in accommoda-
only a fraction of a second at a time, again in order to tion while maintaining clear single vision is called
prevent alterations in the level of accommodation. relative accommodation.
Because of the difficulties in eliminating the dioptric The results obtained by Fincham and Walton (1957)
clues to accommodation, convergence-induced accom- are shown in Figure 9.9. The central line labelled
modation cannot be studied accurately under clinical normal shows the objectively determined level of accom-
conditions. Dynamic retinoscopy (see Chapter 17), with modation under normal conditions. The change in ordi-
a coarsely detailed fixation object such as a luminous nate to reach the upper or lower curves at any
pen torch bulb to reduce the need for exact focusing of particular convergence value gives the subjective
the eyes, could perhaps be used. relative amplitude or accommodation for the particular
Fincham and Walton (1957) measured the conver- convergence value. It was found that accommodation
gence-induced accommodation with an objective opt- continued to change slightly when the light vergence
ometer. Figure 9.7 shows their results for the same was altered beyond the subjective limit. This limit is
subject whose accommodative convergence was meas-
reached when the subject reports that the test object
ured. The right-hand curve shows that less accommoda-
begins to blur.
tion is produced when only convergence provides the
Figure 9.9 shows that the accommodation is most
stimulus than when dioptric clues are also available —
flexible between 3 and 5 MA of convergence. At high
the normal curve. A similar effect occurred when
and low values of convergence, the relative amplitude
measuring accommodative convergence: the conver-
is very much smaller. These amplitudes are useful
gence produced was less than normal for the accommo-
when a patient's refractive correction is altered. An in-
dation.
creasing myope will suddenly have to accommodate
Figure 9.8 shows Fincham’s (1958) results for several
more than before when the spectacles are brought up
subjects of differing ages. The younger subjects have
more accommodation induced by the same amount of to date, while the early presbyope will accommodate
convergence than the older subjects. This is to be ex- less. It is surprising, however, how little the oculo-
pected, since the amplitude of accommodation declines motor balance of low myopes (up to about 2.00 D) is al-
with increased age. tered by intermittent wear of the correction for close
Similar results have been found by Kent (1958) and work. The AC/A ratio does not seem very significant
Balsam and Fry (1959), among others. . with these patients.
Under clinical conditions, the relative amplitude of ac-
commodation may be determined as follows. The patient
Relative accommodation and observes a test object at the required distance, usually
convergence — accommodative facility the N5 or J3 reading test types at his near working dis-
tance, with his distance correction in place. Plus spheres
Approximately equal amounts of accommodation and are then added binocularly until the patient reports
convergence (in D and MA respectively) are used by the that the test types have blurred. These extra lenses are
 Control of accommodation and convergence 165

control of accommodation to overcome the conver-

gence-induced accommodation. The accommodative
changes at both ends of the graph were accordingly
a leen(20) much more rapid. This contrasts with the much more
uniform slope of the convergence-induced accommoda-
tion graph where the accommodation is allowed to
float freely with changes in the convergence stimulus.

(D)
Accommodation Control of accommodation and
convergence

On observing a near object, both accommodation and

1S 2 SiS We A eh iG 87
convergence are stimulated. The response of either can
Convergence (metre angles)
be considered as resulting from three factors. Thus, ac-
Figure 9.10. Accommodation as a function of convergence. commodation may be controlled jointly by a fast reflex
The closed circles show convergence-induced accommodation reaction to the blur caused by the dioptric vergence sti-
through 0.5 mm artificial pupils, the crosses the inhibition of mulus, and secondly by a slower or tonic component
convergence-induced accommodation by a constant light
vergence of —3.00 D through 3 mm artificial pupils. possibly dependent on the amplitude of the reflex action
(Reproduced from Fincham and Walton, 1957, by kind and the stimulus from convergence. A similar hypoth-
permission of the publishers of J. Physiol.) esis has been suggested for convergence. Various
models of stimulus-response and cross-over networks
between accommodation and convergence have been
then removed and the process repeated with negative
proposed by, among others, Schor and Cuiffreda
lenses, thus finding the maximum amount by which
(1983), Schor (1985), Rosenfield and _ Gilmartin
the accommodation may be relaxed and increased for (1987), Cuiffreda (1991), Hung (1992) and Schor et al.
fixed convergence and clarity of the test types. These re- (1992). Arguments for and against a bioengineering ap-
sults will, of course, include the depth of focus of the proach to oculo-motor control, though not specifically
eye. In distance vision, only negative lenses may be dealing with convergence, have been discussed by Ro-
added since positive lenses cause an immediate blur. binson (1986) and Steinman (1986).
Although it is not a measure of relative accommoda- A simplified and slightly modified version of Hung’s
tion, a clinical test that is also of use is to assess the flex- (1992) and Hung et al.’s (1996) accommodation—con-
ibility of the linkage between accommodation and vergence model is given in Figure 9.11. Taking the
convergence. The patient observes N5 type and reports upper pathway for accommodation, the stimulus will
when it becomes clear when viewed binocularly be dependent on the difference between the dioptric ver-
through alternate positive and negative lenses of equal gence incident on the eye and the accommodation re-
power, say 1.00 or 1.50 DS. Specially glazed ‘flippers’ sponse. If this difference is less than the eye’s depth of
are available for this. Some patients will take an appreci- focus, the level of accommodation remains unaltered.
able time to refocus, whilst others will adjust very ra- Any greater difference (towards either an increase or a
pidly. This accommodation-rock technique, sometimes decrease) will cause the accommodation controller to
termed the accommodative facility, may be used as an change its response. The controller is assumed to have
orthoptic exercise to loosen the accommodation—con- two systems, an immediate or transient response com-
vergence relationship. ponent and a sustained element. Thus, on receiving a
The relative power of adjusting convergence of the demand for increased accommodation, the transient
eyes (in artificial situations) at a fixed level of accommo- system stimulates the ciliary muscle. The output from
dation is more properly discussed under the title of fu- the accommodation controller is fed back to the sus-
sional reserves (see Chapter 10) and in texts on tained element so that, providing the requirement re-
orthoptics. The subject views a finely detailed object mains constant, the output is increasingly produced by
through normal-sized pupils while the stimulus to con- the sustained system and less by the transient.
vergence alone is altered. The limits of convergence Moreover, the longer the duration of the stimulus, the
and divergence of the eyes while the test object remains more the feedback increases the time constant of the
clear may then be found. The results of Fincham and sustained controller so that when the accommodative
Walton (1957), who measured objectively the actual demand finally changes, the accommodation response
accommodation in use, are shown in Figure 9.10. continues for a short period of time which is somewhat
When the stimuli for convergence and accommodation proportional to the stimulus duration. Further inputs to
were fairly similar, accommodation varied only slightly the accommodation system are given by proximal fac-
with changes in convergence. Convergence-induced ac- tors (see Instrument myopia, page 135), tonic accommo-
commodation changes were inhibited by the fixed light dation and the convergence-induced accommodation
vergence, giving the nearly horizontal part of the cross-linking from the convergence system.
curve. Once the difference between the actual accommo- A similar system operates for the vergence pathway.
dation and its dioptric stimulus was greater than about When measuring a heterophoria, the vergence pathway
1 D, the retinal blur was too great to allow the normal is effectively cut at the Panum’s area box in the dia-
166 Convergence

Feedback Tonic
giving Accommodation
adaptation

Accommodation Sustained
stimulus > Transient
Depth of
field * Accommodation
Controller Accommodation
response
Proximal
Vergence
Vergence
response
Controller
Panum's
Vergence Areas * Transient
stimulus > Sustained

Feedback Tonic
giving Vergence
adaptation

Figure 9.11. Bio-engineering model of the accommodation—convergence systems, simplified and modified from Hung et al. (1996).
Key: « pathways open-looped here, i.e. cut, by a pinhole or occlusion respectively; AC, accommodative convergence; CIA,
convergence-induced accommodation; APG and VPG, accommodation and vergence proximal controllers.

gram. Similarly, if accommodation is ‘open-looped’ by a FINCHAM, E.E. (1958) The adjustment of the eyes for near vi-
sion. Optician, 136, 471-480
small pinhole aperture, it is the depth of field box that
FINCHAM, E.F. and WALTON, J. (1957) The reciprocal actions of
acts as an opened switch. accommodation and convergence. J. Physiol., Lond., 137,
488-508
FLOM, M.c. (1960) On the relationship between accommoda-
Exercises tion and accommodative convergence. Am. J. Optom., 37,
474-482, 517-523, 619-632
HOGAN, R.E. and GILMARTIN, B. (1985) The relationship be-
9.1 The eye of a patient with a PD of 65 mm adducts through
tween tonic vergence and oculomotor stress induced by alco-
1A under cover in distance vision, while when fixating at
hol. Ophthal. Physiol. Opt., 5, 43-52
- ; m, the eye adducts through 2A. Calculate the AC/A ratio.
HUNG, G.K. (1992) Adaptation model of accommodation and
9.2 (a) A patient shows 10A of divergence under cover (exo-
vergence. Ophthal. Physiol. Opt., 12, 319-326
phoria) in near vision. If the AC/A ratio is 4A/D, what change
HUNG, G.K., CIUFFREDA, K.J. and ROSENFIELD, M. (1996) Proxi-
in lens strength would be expected to reduce the divergence to
4A? (b) Would the same change in lens help if the patient were mal contribution to a linear static model of accommodation
also 10A exophoric in distance vision? and convergence. Ophthal. Physiol. Opt., 16, 31-41
9.3 (a) A patient wearing his distance correction shows 6A of KENT. P.R. (1958) Convergence accommodation. Am. J. Optom.,
over-convergence under cover (esophoria) in near vision. If 35, 393-406
the AC/A ratio is 3A/D, what change in lens strength would MADDOX, E.£. (1886) Investigations on the relation between
be expected to reduce the convergence to 3A? (b) If the patient convergence and accommodation of the eyes. J. Anat. Phy-
were also esophoric in distance vision, would the same change siol., Lond., 20, 565-584
in lens strength help? MADDOX, E.E. (1907) The Clinical Use of Prisms and the Decentring
9.4 A 2D uncorrected myope shows 6A of divergence under of Lenses, 5th edn, pp. 158-177. Bristol: John Wright & Co.
cover in near vision. What might the findings be when the cor- MORGAN, N.W. JR. (1944) The clinical aspects of accommoda-
rection is worn? tion and convergence. Am. J. Optom., 21, 301-313
Note: the present writer (RBR)finds this approach too mechan- OWENS, D. and LEIBOWITZ, H. (1983) Perceptual and motor
istic. Because of proximal effects and the reliance on the diop- consequences of tonic convergence. In Vergence Eye Move-
tric values of accommodation stimuli not response (as used in ments: Basic and Clinical Aspects (Schor, C.M. and Ciuffreda,
Fincham and Walton's experiments), the AC/A ratio measure K., eds), Ch. 3. London: Butterworths
with the gradient test is frequently much less than the ratio PICKWELL, L.D. (1973) Eye movements during the cover test.
found from calculations similar to those in question 1. Results Br, J. Physiol. Optics, 28, 23-25
around 2A/D may be more typical. Low myopes frequently RAMSDALE, C. and CHARMAN, W.N. (1988) Accommodation and
show little change in eye co-ordination with or without the pre- convergence: effects of lenses and prisms in ‘closed-loop’ con-
scription in near vision. The technique of fixation disparity de- ditions. Ophtnal. Physiol. Opt., 8, 43-52
scribed in Chapter 10 may give more definite information for ROBINSON, D.A. (1986) The systems approach to the oculomo-
prescribing. tor system. Vision Res., 26, 91-99
ROSENFIELD, M. and GILMARTIN, B. (1987) Effect of a near-vi-
sion task on the response AC/A of a myopic population.
References Ophthal. Physiol. Opt., 7, 225-234
SCHOR, C.M., (1985) Models of mutual interactions between ac-
ALPERN, M. (1969) Part 1: Movements of the eyes. In The Eye, commodation and convergence. Am. J. Optom., 62, 369-374
2nd edn, Vol. 3 (Davson, H., ed.). New York and London: SCHOR, C.M., ALEXANDER, J., CORMACK, L. and STEVENSON, S.
Academic Press (1992) Negative feedback model of proximal convergence
BALSAM, M.H. and FRY, C.A. (1959) Convergence accommoda- and accommodation. Ophthal. Physiol. Opt., 12, 307-318
tion. Am. J. Optom., 36, 567-575 SCHOR, C.M. and CIUFFREDA, K.J. (1983) Vergence Eye Move-
CIUFFREDA, K.J. (1991) Accommodation and its anomalies. In ments: Basic and Clinical Aspects. London: Butterworths
Visual Optics and Instrumentation, Vol. 1 (Charman, W.N., STEINMAN, R.M. (1986) The need for an eclectic, rather than
ed.). In Vision and Visual Dysfunction (Cronly-Dillon, J.R., systems, approach to the study of the primate oculomotor
ed.). London: Macmillan system. Vision Res., 26, 101-112
10
Anomalies of binocular vision:
heterophoria and heterotropia

Introduction B

‘
Binocular vision in its fullest sense can be achieved only
\
with a well-developed and co-ordinated oculo-motor
\ :
and neural system and with the optical functioning of
each eye in reasonable adjustment. If one eye is mark- ve
edly out of focus through uncorrected anisometropia, Neon
binocular vision must be impaired. Even when such an \ Angle of
eye is corrected, difficulties may arise from unequal
image sizes in the two eyes or different prismatic effects
ra heterophoria

when viewing through peripheral parts of the correcting is\ |

lenses (see Chapter 14). In this chapter we shall be \ \
looking at the various deviations from a perfectly co- \ \
ordinated oculo-motor system. \ |
\ Cover
\

Heterophoria and heterotropia

As we saw in Chapter 8, single binocular vision requires

the retinal images to fall on corresponding points in the
two eyes. In general, the fine adjustments needed to
maintain accurate bifoveal fixation are made by correc-
tive reflex movements of the eyes, the stimulus being Figure 10.1. Exophoria showing divergence or abduction
the avoidance of diplopia. behind the cover.
If, while fixating any stationary point, one of the pa-
tient’s eyes is covered, the covered eye will probably
turn so that its visual axis no longer passes through the Some patients do not achieve bifoveal fixation of any
fixation point (Figure 10.1) (in general, the effect of the object, one eye showing a manifest deviation without
cover is to dissociate the eyes, see pages 169-172). being covered. Such patients are said to possess a
When the cover is removed, bifoveal fixation is rapidly squint,” strabismus or heterotropia. If the strabismic
regained. The anomaly thus revealed is known as het- eye is covered while the patient looks at a fixed test
erophoria. If the visual axis of the covered eye remains object, neither the covered nor the uncovered eye will
exactly in line with the object viewed by the unoccluded move. On the other hand, if the originally fixating eye
eye, the condition is called orthophoria. Binocular is covered (Figure 10.2), the strabismic eye will turn
vision is then maintained without the need for reflex fu- through the angle of squint so that the image of the
sional movements of the eyes. In clinical practice, the test object falls on the fovea (subject to various other
term orthophoria is extended to include all cases where factors to be discussed later in this chapter). At the
the deviation under cover is insignificant, for example, same time the originally fixating eye, now under cover,
less than 1A horizontally and 0.25A vertically. Never- makes a similar version movement.
theless, a patient showing heterophoria of this amount
will still need to use fusional movements to maintain
binocular fixation. Moreover, though clinically ortho- “The term ‘squint’ is often incorrectly used by lay people to
phoric in distance vision, a patient may well be hetero- mean squeezing the eyelids together in order to reduce the ret-
phoric in near vision. inal blurring in uncorrected ametropia.
 168 Anomalies of binocular vision: heterophoria and heterotropia

Table 10.1 Classification of heterophoria

Type Movement of Common

eye under cover abbreviations

Esophoria Adduction SOP. Eso*

Exophoria Abduction MOPREXOn
Hyperphoria Elevation See text
Hypophoria Depression See text
\
|
| \ “The abbreviations Eso and Exo, together with Hyper, are
understood to refer to phorias and not to tropias unless specifi-
| \ cally stated.
/ Angle of \
heterotropia \ \
a
ra Cover
Table 10.2 Classification of heterophoria

\ Type Relative position Common

ofdeviating eye abbreviations

Esotropia Adducted SOT, EsoT

Exotropia Abducted XOT, ExoT
Hypertropia Elevated HyperT, see text
Hypotropia Depressed HypoT, see text

Figure 10.2. Left exotropia, showing adduction ofthe

deviating left eye to take up fixation and corresponding
abduction of the right eye behind the cover. habitual near working distance. This is not necessarily
I
3m, although unfortunately many of the instruments
for measuring near heterophoria are designed for this
The above-described conditions can be briefly distin- distance.
guished as follows:
Table 10.1 shows the classification of heterophoria
(1) Heterophoria. When either eye of a heterophoric with the terminology introduced by Stevens in 1886
patient is dissociated, the eye deviates so that its (Stevens, 1906).
visual axis no longer passes through the object of Consider a patient with hyperphoria of the right eye
regard. Bifoveal fixation is restored on removal of when covered. This means that the right eye tends to
the dissociative device. An orthophoric patient has turn above the direction of regard of the left eye. If the
a negligible deviation under cover or when disso- left eye were covered instead, then the left eye would
ciated. tend to turn below the right giving a left hypophoria. A
(2) Heterotropia. The visual axes do not intersect at the right hyperphoria is the same as a left hypophoria.
object of regard, but the axis of the normally fixing Thus, when specifying a vertical phoria, one must
eye does pass through the object of regard. also state which eye is regarded as deviating. To avoid
confusion, clinical practice normally uses only the term
It is possible, indeed probable, that the angle of het-
hyperphoria. Thus a left hypophoria is recorded as
erophoria varies with the distance of observation. The
right hyperphoria, abbreviated to R Hyper or R(.. The
angle of heterotropia may also depend on the distance
abbreviation Hyp should never be used, since it could
of fixation. Some patients may show a heterotropia for
easily be mistaken by another practitioner for hypo-
objects at one distance, yet only a phoria’ at a different
phoria. The R/, notation is to be preferred since it
distance. The term ‘latent strabismus’ to describe a
phoria is to be deprecated since it is relatively rare for a
shows concisely and unambiguously the direction of
heterophoria to break down into a heterotropia after the phoria. Left hyperphoria is written //g. (Some other
the age of about 6 years. The term oculo-motor (im)bal- heterophorias will be discussed later.)
ance covers both heterophoria and heterotrophia. The heterotropias are classified in Table 10.2. The Rip
abbreviations may be adopted for tropias, a letter T de-
noting the deviating eye: for example, R hypertropia
would be written as RT, and R hypotropia as Lipt.
Classification of heterophoria and
With all the tropias both the angle and the eye that
heterotropia deviates must be recorded. It is also important to note
whether the squint is unilateral or alternating and, if
The angle of heterophoria and heterotropia should be the latter, whether there is a preference for fixation by
measured both in distance vision and at the patient's one eye. Some squinting patients can change fixation
voluntarily from one eye to the other, while other
patients change only if the originally fixating eye is
‘An accepted contraction, like tropia, in common clinical covered. Other patients fixate with one eye in part of
use,
 The cover test 169

the field of view and change to the other eye for the
remainder.

Causes of an oculo-motor imbalance

Refractive

The uncorrected hypermetrope needs to accommodate

in order to see clearly. Because of the close link between
accommodation and convergence, the accommodative
effort tends to induce adduction of the eyes — accommo- Figure 10.3. The cover test.
dative convergence. Thus, under-corrected hyperme-
tropes tend to be esophoric. Conversely, under-
corrected myopia makes a lower demand on accommo-
dation than on convergence in near vision: exophoria
in near vision is to be expected. This may be enough to
give symptoms, even though each eye under monocular
The cover test
conditions would receive a perfectly focused image.
Objective cover test
This test, sometimes termed the cover—uncover test, is
Anatomical
probably the most important of the tests for oculo-
If one of the extra-ocular muscles is incorrectly attached motor imbalance. It may be carried out with fixation at
to the globe, faulty muscle action is to be expected. If any distance and with the patient wearing or not
the medial rectus, for example, were attached too far wearing his correction. If spectacles are habitually
from the limbus, its action might be reduced and an worn, it is pointless to do a cover test without them.
exo-deviation could be expected. The surgical treatment The patient should observe a finely detailed test object,
of strabismus is based on making anatomical corrections so that accommodation is sufficiently stimulated and ac-
to the muscles, even when the strabismus is not pri- curate fixation is required. A good object for distance
marily of muscular origin. Faulty positioning of check vision is a letter on the test chart from the line one size
ligaments may also give rise to a motor anomaly. larger than the patient can just read with the poorer
eye. The ‘muscle spot light’ (a bright illuminated spot
5-10 mm in diameter) should not, in general, be used
Neurological as a fixation point, since it will not stimulate an under-
Some patients appear to have a natural excess of ner- corrected hypermetrope’s accommodation. For near
vous energy — they are said to be highly strung. Simi- vision, a letter or small pattern on a card makes an
larly, some patients appear to have overactive ideal fixation stimulus. The card should be held at the
convergence, and are therefore esophoric. Others may patient's habitual reading or working position and the
have a very poor (remote) near point of convergence, trial lenses must be carefully centred, both horizontally
yet the motiliy test shows full power of adduction by and vertically. Readjustment for near vision is usually
the medial recti. The innervation for convergence is at necessary.
fault, not the muscles themselves. The examiner should first make sure that there is no
strabismus present by placing the cover over the pa-
tient’s right eye while observing the left eye (Figure
Pathological 10,3). If the left eye moves to take up fixation, a left eye
strabismus is demonstrated. The eye will move out or
This type includes both anatomical and neurological
abduct in esotropia and move in or adduct in exotropia.
causes. In some patients, a particular muscle action or
The directions of movement in vertical tropias may simi-
group of muscle actions may be affected by, for example,
haemorrhage or nerve damage. The motility is usually larly be deduced.
incomitant, but in slight cases the resulting oculo- If a strabismus has been revealed, both eyes make a
motor imbalance may be only a phoria. In more severe version movement when the cover is removed, the
cases a tropia will result. The sudden onset of a tropia right eye fixating again. If no movement is seen on re-
in an adult produces diplopia, but in a young child moving the cover, then the left eye remains fixating.
double vision is readily prevented by suppression of one Covering this eye will now produce a version movement,
eye’s image. The gradual breakdown of a heterophoria the right eye resuming fixation. This shows an alternat-
into a manifest deviation in an adult may also be unac- ing strabismus.
companied by diplopia. If, on covering the right eye initially, no movement of
General debility and the side-effects of drugs such as the left eye was seen, the left eye should be covered and
tranquillizers can also cause or aggravate an oculo- the right eye watched. Movement of the right eye then
motor imbalance. demonstrates a tropia of that eye. The initial covering
170 Anomalies of binocular vision: heterophoria and heterotropia

of the right eye had no effect, since the unimpeded left because the pupil size alters on removal of the cover. Be-
eye continued to fixate the test object.” cause the lateral vertical borders of the limbus are
The examiner should then look for the presence of a easily seen between the patient's eyelids, it is much
heterophoria, although with practice it is possible to easier to detect horizontal than vertical movements of
check for a tropia and a phoria with the same few move- the eyes. For this reason it is essential to check instru-
ments of the cover. Thus, suppose that on covering the mentally for vertical oculo-motor imbalances, or their
right eye no movement of the left eye is seen, but on re- resultant fixation disparity — see later in this chapter, es-
moval of the cover the right eye makes a fusional move- pecially as the eyes are much less tolerant of vertical
ment to regain fixation of the test object, this shows errors. ‘
that a heterophoria is present. If the return movement Some writers suggest watching for movement of the
is inwards, then the eye had deviated outwards under eye behind the cover after occluding. This may be
cover, indicating exophoria. Similarly, if the eye moves useful but has disadvantages:
down on removal of the cover, a right hyperphoria is
(1) The movement of deviation in a heterophoria is
revealed.
The left eye should now be covered. On removal of the much slower than the fusional refixation and thus
cover this eye will adduct in exophoria, elevate in right more difficult to see.
(2) The speed of the recovery movement may be an
hyperphoria.
indication of the control of the heterophoria: a
To summarize:
quick movement suggests comfortable vision while
(1) Cover RE while watching LE. a slow or jerky movement suggests discomfort.
Movement indicates an L tropia. (3) To allow observation, the cover must be held at an
(2) Uncover RE angle, so that the eye is less efficiently occluded. It
(a) If movement seen in (1), watch for version is then possible that the retinal image of details
movement of both eyes. seen peripherally by the occluded eye will be men-
Movement indicates an L tropia. tally fused with the image in the uncovered eye,
No movement of either eye: alternating strabis- holding the ‘covered’ eye in its normal position. In
mus. other words, the peripheral details form a ‘binocular
(b) If no movement seen in (1), watch for move- lock’.
ment of RE.
Movement indicates heterophoria. With low phorias, it is sometimes easier to see the re-
(3) Cover LE while watching RE. fixation movement of the eyes if the cover is repeatedly
(a) If no movement seen in (1) but RE now moves, transferred from eye to eye, occluding each eye in turn
R tropia indicated. for about a second. This tends to increase the angle of
(b) If movement seen in (1) but RE now makes a heterophoria in some patients, in which case the larger
return movement: alternating strabismus. angle is probably the more significant. For the same
(4) Uncover LE. reason, if a single rather than a repeated cover test is
(a) If movement seen in (3), watch for version used with a heterophoric patient, it is better to hold the
movement of both eyes. Movement indicates an cover in place for several seconds to allow the hetero-
R tropia. phoria to build up than to record the ‘instantaneous
(b) If no movement seen in (3), watch for move- value’. Barnard and Thomson (1995) showed that the
ment of LE. heterophoria in some subjects was still increasing after
Movement indicates heterophoria. 10s occlusion, so that a single period of 1-2 s occlusion
is most unlikely to elicit the heterophoria. They point
If no movement is seen on any of these four steps, the out that the cover test reveals the movement corre-
patient is orthophoric (within the limits of observational sponding to the fast vergence controller (see Figure
accuracy). 9.11). Both repeated and prolonged cover testing may
The cover test needs practice and a good light on the break a borderline heterophoria down into an apparent
patient’s eyes but is much simpler to do than to describe. heterotropia. Thus in cases of strabismus, it may be ad-
In order to demonstrate any heterophoria, the cover visable to do both a quick (2s) and prolonged (10 s)
must be left in place for several seconds to allow the dis- cover to elicit the habitual and total angles of the
sociated eye to deviate to its passive position. The cover heterotropia (see page 188).
is best removed in a swift vertical movement: a sideways With experience, it is possible to estimate the amount
removal of the cover may give the erroneous impression of movement of the corneal limbus and hence the angle
of an ocular movement in the opposite direction. It is im- of the heterophoria or heterotropia. If you get someone
perative to watch the limbus and not the pupil margin to look from one letter to another on the test chart you
can work out the movement of the eye (in A). This is
given by dividing the distance between the letters in
“The occasional patient with a low-angle strabismus does centimetres by the observation distance in metres. A
not readily fixate with the deviating eye, which remains in the change in fixation from one end to the other of a 6m
rotated position. If, with the normally fixating eye covered, the
line of letters viewed at 6 m is usually about 3A.
patient is asked to look at a different letter, the strabismus may
become apparent because the eye turns through an unexpected Small vertical phorias are more difficult to see, since
angle: for example a diagonal movement when the letters are vertical movements of the nasal and temporal limbi are
separated vertically. much less obvious than a horizontal movement. For
 The cover test 171

wards under cover and abducts when the cover is

removed. Figure 10.5 shows the right eye deviating
behind the cover. A prism of the correct power placed
base-out realigns the fixation axis, so that when the
cover is removed, the image falls immediately on the
fovea. No fusional movement is required. Thus, a more
precise measurement of the deviation may be made
than by estimation. A rotary prism or prism bar (ex-
plained in most texts on orthoptics) may be used to
reduce the time taken.

Subjective cover test

Figure 10.4. Conversion of linear limbus movement to This test was introduced in 1924 by Duane, who called
angular measure.
it the parallax test.
The following remarks apply only to heterophoria.
this reason, the cover test should be supplemented with Sensory adaptations which would affect the results of
an instrumental measure of vertical heterophoria or this test occur in many heterotropias (see pages 185-—
fixation disparity. 189). Figure 10.6 represents a case of esophoria, the
Another method is illustrated in Figure 10.4. If the right eye being covered. The cover is then transferred
limbus is assumed to be 15 mm from the eye’s centre of to the left eye. The image in the now-uncovered right
rotation Z, a movement of 1 mm of the limbus corre- eye will initially fall on the nasal retina and will be pro-
sponds to a rotation 9 of 1/15 rad. Hence jected temporally to the right. The patient therefore
sees the fixation object apparently jump to the right.
ORS The right eye will quickly rotate to return the image to
the fovea, but this does not give rise to a sensation of
since 1 rad is approximately 60°. movement, just as our surroundings are perceived as
In fact, the distance from the limbus to Z would be stationary when we move fixation.
nearer to 12.5 mm in most eyes, in which case a more Thus, in esophoria, the apparent movement is in the
accurate calculation of 8 in the above example would opposite direction to the movement of the cover,
give about 4.6° or 8.0A. Any spectacles worn by the whereas in exophoria the apparent movement is in the
patient may alter the apparent size of the movement, same direction. You can confirm for yourself that the
which will appear larger in high hypermetropia, smaller fixation object appears to jump downwards in R hyper-
in myopia. phoria and upwards in L hyperphoria when the cover is
The deviation may also be measured by putting up a
prism to neutralize the movement, so that with a tropia
Apparent
no movement of the normally deviating eye is seen object movement
when the dominant eye is covered, or, in a heterophoria, SSE
no movement on removing the cover. Consider, for ex- B'p
/
ample, the case of an esophore. The eye deviates in-

Movement of
cover
Cover eo

Prism
oe}
ee

M'R
By B’p M’p
My M'R ML
B E
Figure 10.5. Measurement of an esophoric deviation by
means of a prism behind the cover. Figure 10.6. Principle of the subjective cover test.
172 Anomalies of binocular vision: heterophoria and heterotropia

passed from right to left. In all cases the direction of

movement is opposite to the right eye’s deviation under
cover, which can be measured by adding prisms with
their base in the direction of the recovery movement
until the object appears stationary. It should be noted
that the subjective direction of movement is the same
as that of the refixation.
(a) (b)
This subjective movement is sometimes erroneously
termed the -phenomenon. This term should be re- Figure 10.7. (a) The Maddox rod, giving a vertical streak on
served for the apparent motion when different retinal the retina, (b) the Maddox multiple rod or groove.
elements in one or both eyes are stimulated consecu-
tively by similar images formed from different objects.
It is more logical to describe these tests when classified
Certain advertisements make use of this process: a
according to the distance of fixation.
series of electric lamps light up one after the other to
give the impression of a single moving light. The subjec-
tive cover test is similar, but relies solely on cerebral per- Tests in distance vision
ception and integration between the different layers
representing the two eyes. The -phenomenon could in- The test most commonly used is the Maddox rod, some-
volve retinal processing and certainly need not involve times called the Maddox multiple rod or groove. This
changing representation from one layer to another in gives dissociation by distortion. It originally consisted
the striate cortex, but only from one part to another of a glass rod of diameter about 3 mm forming an extre-
within the same layer. mely powerful cylindrical lens. If placed horizontally, as
shown in cross-section in Figure 10.7(a), rays in a ver-
tical plane from a distant illuminated aperture (the spot
or muscle light) are brought to a focus just behind the
rear surface of the rod and then diverge. Since the rod
is held close to the patient’s eye, the rays remain diver-
Instrumentation for measuring gent on entering the eye and form a vertical streak on
heterophoria the retina. Because the single rod had to be placed very
carefully in front of the patient’s pupil, it has been re-
Dissociation techniques placed by the multiple rod or groove (Figure 10.7b)
which has a similar optical effect but is easier to position
The only method of dissociating the eyes mentioned so
and gives a brighter streak. (This modern form is still
far has been to cover one eye, thus virtually eliminating
generally called a Maddox rod.) The Maddox rod is
any area of overlap of the visual fields and hence redu-
usually made of either red or green material: this both
cing the stimulus to fusion. The covered eye is then free
enhances dissociation and aids recognition of the streak
to deviate from its active to its passive position, in re-
by the patient. The red rod is usually preferred for dis-
sponse to refractive, anatomical and innervational fac-
tance fixation, the green for near, to correspond with
tors. In general, instruments for investigating the
the eye’s usual lead or lag of accommodation at the two
oculo-motor imbalance rely instead on dissociating the
distances.
two visual images. The methods used include:
The patient views the distant muscle light with one
(1) Selective screening. Some parts of the visual field are eye while the rod is in front of the other eye. It is useful
seen by one eye, adjacent parts by the other eye to follow the routine of always placing the rod before
(for example, the Maddox wing and similar tests), one particular eye, say the right. The vertical streak
(2) Distortion. The image in one eye is distorted to such seen by the patient when the rod is horizontal enables
an extent that fusion is virtually eliminated, as by the horizontal deviation of the eye to be measured.
the Maddox rod.
(3) Prismatic dissociation. For example, von Graefe’s
method in which a vertical imbalance of about 4—
6A is induced by a prism. This is too large for the
eyes to overcome, so diplopia is produced. A hori-
zontal phoria may then become manifest. A similar
device is the Maddox biprism, consisting of two
prisms of about 5A placed base to base so as to (a) Ortho (b) Exo (c) Eso
divide the pupil of one eye. Monocular diplopia is Rod axis horizontal
produced and again the eye may deviate. These
techniques have become obsolete.
(4) Tests with independent objects. In effect, different
objects are presented to each eye by means of red/
pe
L
aie A) te :
Jie
Maw Sones
L
(d) Ortho (e) R/L (f) L/R
green dissociation (see page 148), crossed Polaroid
techniques as used in fixation disparity devices (see Rod axis vertical
page 174) or instruments of the synoptophore type Figure 10.8. Various appearances to the patient, with the
(see page 203). Maddox rod before the right eye.
 Instrumentation for measuring heterophoria 173

Figure 10.8 illustrates the various appearances with the to the streak gives the angle of heterophoria. Calibrated
Maddox rod placed horizontal before the right eye. In holders for prism and rod are made.
orthophoria (Figure 10.8a), the streak appears to pass Another method is to use a tangent scale, a technique
through the spot seen by the left eye. In exophoria simplified by Freeman in the 1950s. A green Maddox
(Figure 10.8b), the right eye abducts, so that the image rod is held before the patient’s right eye while the left
of the streak falls on the temporal side of the fovea. By eye views a scale of red transilluminated numbers
projection it is thus seen to the left of the spot. The oppo- (Figure 10.9). The white light at the centre of the scale
site occurs in esophoria (Figure 10.8c). To measure the produces the streak, while the red numbers and green-
deviation, prisms are now placed in front of the same coloured rod eliminate the additional streaks that
eye as the Maddox rod with their base in the same direc- would otherwise have been caused had white numbers
tion as the displaced streak until the streak passes been used. The scale, calibrated in prism dioptres for
through the spot. In general, the results are often the assumed testing distance, is placed obliquely, and
‘bracketed’ by finding the powers which just under- hence may be used to measure both horizontal and ver-
and over-correct the deviation. To measure vertical de- tical deviations. Odd numbers are used on one side of
viations, the rod is then turned through a right angle the spot and even numbers on the other, allowing the
to give a horizontal streak. This will be seen passing practitioner to tell immediately in which direction the
through the spot in orthophoria (Figure 10.8d), below eye has deviated. The patient is asked to say through
the spot in R hyperphoria (Figure 10.8e) and above it in what number, or between what numbers, the spot ap-
L hyperphoria (Figure 10.8f). pears to pass. Otherwise, for example, he may reply ‘3’
instead of ‘between 2 and 4’, thus misleading the exam-
Because a spotlight does not demand the most critical
iner. It is essential that the Maddox rod be accurately
focusing by the eye, the test does not necessarily give a
placed horizontally or vertically to prevent inaccuracies
true indication of the horizontal heterophoria present.
in measurement.
Another possibility, despite the completely different
The symbol © is often used to denote orthophoria in
shape and colour of spot and streak, is that a small
the vertical direction, (—) in the horizontal direction,
element of fusion may exist. The eyes may then not be
and for both. They indicate the positions of spotlight
completely dissociated. As a check, a cover is addition-
and streak.
ally placed in front of one of the patient's eyes and he is
asked to say whether the streak is to the left or right of
(or above or below) the spot immediately the cover is re-
moved. The Maddox rod is then providing a marker Tests in near vision
rather than acting as a dissociating device. Correct centration of the trial lenses is essential before a
There are several devices which can help to determine near heterophoria is measured. A general-purpose cor-
the correct prism power rapidly. A prism bar, Risley rection may be left centred at the distance PD, but a
variable prism or even a single 10A rotating prism may true near correction should be centred to correspond to
be used. The latter is placed with its base-apex line at the near PD. For the presbyopic patient, the reading ad-
right-angles to the rod, in which setting the streak is ap- dition must be in place. If a trial frame is used, it should
parently displaced along itself. The prism may then be be adjusted vertically and the bottom rim angled in to-
rotated until the streak is seen to pass through the spot. wards the face so that the patient can look downwards
The resolved component of prism power at right-angles through the centre of the lenses without obliquity.
Equivalent adjustments, where possible. should be
made if a refractor head is used. Measurement of the
e state of the eyes in near vision taken in a horizontal
6 visual plane through a refractor head may not be rea-
e
L/R 4 listic.
eeee Oe oe oe The Maddox rod may again be used. The Freeman—
2 Eso
Archer oblique tangent scale for distance vision, de-
e
scribed above, has also been scaled down for use at
§ 330mm, but the red figures used perhaps over-stimu-
1
late the accommodation, resulting in a falsely esophoric
Exo bs
| oR (or low exophoric) reading. On the other hand, the use
| e of the Maddox rod with a small spot of light such as a
| 5 torch bulb under-stimulates the accommodation, giving
| e
an over-estimate of exophoria.
e
H A popular test based on selective screening of a test
|
| card is the Maddox wing test (Figure 10.10), introduced
° | in 1912. A vertical arrow is presented to one eye and a
11 # horizontal tangent scale to the other to give the meas-
e
urement of the horizontal phoria. A horizontal arrow
13
e and vertical scale are used to measure the vertical im-
balance. The scales are mounted at the fixed viewing
Figure 10.9. The Freeman—Archer oblique tangent scale
(Birmingham Optical Group Ltd): illustration refers to near distance of 5 m, much closer than most patients read, so
unit. the results obtained are not necessarily significant.
174 Anomalies of binocular vision: heterophoria and heterotropia

*
£90
ea

ee
w18 8 s ONE
euunmeeuet
8?
-3-65
8° 7-9-tte ]
8-8 -g.04-S
4°?
4-12)

Corresponding
points

Figure 10.11. Panum’s areas. The eyes are fixating B. A

neighbouring element Q will be seen singly, provided that its
image in the left eye falls in the area around the point
corresponding to Qk.

tion since it is a departure within physiological limits

from normal bifoveal fixation.
In a case of true heterophoria, advantage may habi-
Figure 10.10. One model of the Maddox wing test. The tually be taken of fixation disparity to give partial relief
lower-right scale is for cyclophoria.
by allowing one eye to deviate slightly from the position
of accurate fixation. The fixation disparity units devel-
Early models used relatively large numbers on the
oped by Mallett (1964, 1983) for distance and near
tangent scale, giving an exophoric bias to the measure-
vision provide a simple method of investigation, the
ments because accommodation and hence accommoda-
principle of which is illustrated in Figure 10.12. The
tive convergence were under-stimulated. Recent models
letter X is seen by both eyes, but the markers above
have much smaller figures.
and below it are polarized at right-angles. Viewing
through the analysing visor, the patient sees the upper
marker only with his left eye and the lower marker
with his right eye.
Fixation disparity Since the right eye of our hypothetical subject is ex-
actly fixating the X, the right eye’s marker will be seen
The cover test and instrumental tests already described
precisely below the X, as illustrated by the projection
for the investigation of the oculo-motor balance give a
from the cyclopean eye. On the other hand, the marker
measure of the total imbalance when the eyes are com-
for the left eye is imaged, like the X, fractionally to the
pletely dissociated. The phenomenon of fixation dis-
temporal side of the visual axis. Unlike the X, which is
parity needs negligible dissociation of the eyes to be
projected as though from the fovea because of fusion
demonstrable, yet helps the practitioner to decide the
within Panum’s area, the left marker is projected to the
significance ofthe total imbalance.
right and appears out of line with the X and lower
Though binocular fixation is based on corresponding
marker.
points, it was shown on pages 154-156 that there is
an element of flexibility in the system. As indicated in The fixation disparity of the object X is demonstrated
Figure 10.11, binocular single vision is possible, pro- by the misalignment of the two markers. The image of
vided that the retinal image Qj in the left eye falls the X may be said to have slipped across the retina of
within Panum’s fusional area surrounding the retinal the left eye — hence the older and less-apt term for fixa-
receptor corresponding to Qk in the right eye. This is as tion disparity: ‘retinal slip’ (Ames and Gliddon, 1928).
true for images in the fovea as in the parafovea or per- The value of the relieving or aligning prism that rea-
ipheral retina. It is therefore possible for one eye to ligns the workers, thus eliminating the fixation disparity
maintain fixation while the second eye deviates through is sometimes termed the ‘associated heterophoria’. This
only a fraction of a degree, up to 15 minutes of arc.
This deviation in binocular vision is called a fixation dis-
parity. It should not be regarded as a heterotropic devia- ‘ Institute of Optometry Marketing Ltd.
 Fixation disparity 175

jective assessment is the speed of the fusional recovery

movement in the cover test: a rapid movement suggests
good control, a slow movement poor control of the
heterophoria.
Aligning prisms for heterophoria should be placed
before the eye showing the disparity with their base in
the direction of the marker’s movement, thus allowing
the eye to deviate while keeping the image on the
fovea. In the example above, the left eye showed an exo-
phoric fixation disparity. Base-in prism should hence be
added before this eye until the two marks are aligned.
This minimum prism may then be prescribed. It is prob-
ably better to divide equally a prism of more than 2A,
thereby avoiding the more noticeable aberrations of a
single stronger prism.
With horizontal heterophorias, partial compensation
is sometimes possible by altering the spherical part of
the correction. In near vision, an esophoric disparity
may be reduced by a positive spherical addition, either
in a separate near correction or conventional bifocals.
An esophoric disparity in distance vision cannot be re-
lieved in the same manner because the extra spherical
power will fog acuity; refraction under cyclopegia
should be considered in case there is significant latent
(b) | (c) hypermetropia. An esophoria which is significantly
greater in near than in distance vision is termed a con-
Oxo or OXxO Oxo
| | | vergence excess. The opposite condition of divergence
uncompensated compensated excess is characterized by greater exophoria (or exotro-
pia) in distance vision than in near vision. An exophoric
Figure 10.12. (a) Diagrammatic representation of fixation
disparity in exophoria. The fixation letter X, foveal lock circles disparity in either or both distance and near vision may
OO and markers are situated in a vertical plane perpendicular be helped by adding equal minus spheres before each
to the plane of the diagram. OXO is seen binocularly, the upper eye. The extra accommodation so stimulated will pro-
marker by the left eye and the lower by the right eye. The
duce accommodative convergence and help reduce the
binoculus projects to the distance of the object plane but is
shortened here for clarity. (b) The appearance in exophoria. The reserves of accommodation must be
uncompensated exophoria and (c) when compensated. more than adequate, so this method must not be re-
garded as universal; each patient must be considered in
the light of the findings. Such a negative addition
term (deprecated by Mallett, pers. comm. 1993) is con- should be regarded as a middle term arrangement to
tradictory, since heterophoria implies dissociation. allow ‘passive’ development of the fusional abilities,
It must be emphasized that the angle of disparity, if both neurological and muscular. The negative addition
any, is small since it is governed by the angular size of is progressively reduced with time. ‘Active’ treatment of
Panum’s fusional areas at the fovea. The Mallett fixation both esophoria and exophoria by orthoptic exercises
disparity units’ contain central detail which may be may also be undertaken, but such treatment falls out-
fused binocularly, whereas the apparatus used by side the scope of this book.
Ogle (1950) presented, in the main, peripheral details Since the Polaroid visor is effectively a neutral density
only. Thus Ogle’s apparatus is likely to demonstrate fixa- filter of luminous transmittance about 25%, similar to a
tion disparity more frequently and of larger angle than typical sunglass, it is essential that extra illumination
the Mallett units. This is also true for some other clinical be provided on the fixation disparity panel and its sur-
tests for fixation disparity (see Pickwell et al., 1988). rounds. The latter are seen binocularly and contribute
Mallett’s apparatus was developed to help the practi- to the binocular lock. In poor illumination, a falsely
tioner decide when relief from heterophoria should be high proportion of patients will appear to need prismatic
prescribed. The magnitude of a heterophoria as demon- help.
strated by dissociation tests is not necessarily an indica- The original design of apparatus for distance vision
tion of the need for help. One patient may be able to could be rotated through 90° in order to check for the
overcome a large angle of heterophoria quite comforta- presence of an uncompensated vertical heterophoria.
bly, while another patient will be given symptoms by a Care should be taken to ensure that the trial frame (if
small heterophoria. A heterophoric patient who is used) is level: a frame containing right and left
symptom-free is said to have a compensated heterophor- +5.00 DS and tilted so that one lens is 2mm higher
ia and is unlikely to show a fixation disparity. Conver- than the other will induce a 1A vertical error. Such a
sely, a patient with symptoms caused by binocular tilt is quite easily obtained should one of the frame sides
vision problems has an uncompensated heterophoria be caught up in the patient’s hair. With a refractor
and will probably show a fixation disparity. The only ob- unit, the patient’s head must be level. The distance
176 Anomalies of binocular vision: heterophoria and heterotropia

unit is available for near-vision examination providing

separate displays for horizontal and vertical disparities,
while somewhat similar devices are produced by other
companies.

020
Some patients with heterophorias only just maintain
fusion, but are symptom-free because fine details in the
image falling near the fovea of one eye are suppressed,
that is, the brain disregards the information. This is

ONO
demonstrated if the marker for one eye constantly
disappears. However, this does not always indicate sup-
pression but in some cases may be due to only retinal
rivalry. If the patient is asked to blink several times, the
line may reappear. Especially in near vision, the practi-
tioner should check by covering the eye seeing the oppo-
site marker that the disappearing marker is not simply
(a) occluded by a badly fitting trial frame.
Sometimes a suppression area is only on one side of
the fovea, so that if the marker’s image falls in this
zone, it will not be seen. Thus in esophoria, the image
of one of the horizontal markers for examining vertical
disparity may be imaged on the nasal retina. Reversing
the analysing visor will now interchange the markers
so that the image falls on the temporal side of the fovea,
in which case it may be seen. The same tactic may be
used if the two markers form a fused strip through the
central X.
If diplopia occurs, the practitioner should use a disso-
ciation test to assess the heterotropia (or ‘broken-down’
heterophoria) and incorporate relieving prisms in the
correction to obtain single binocular vision of the unit
before adding the visor. The prism may then be verified
(either increased or decreased) in the normal manner.
If the patient’s record shows that a prismatic correc-
tion was incorporated in their last spectacles, it is sensi-
(b)
ble to check the fixation disparity through their present
Figure 10.13. (a) The Mallett dual fixation disparity unit. (b)
The Mallett near-vision suppression test. The numbers, which lenses before occluding one eye, whether to check the
are normally blue, indicate the angle subtended at the eye visual acuity or to perform the cover test. This avoids
when the chart is held at 35 cm. The central letters and the two the risk of breaking down an unstable binocularity —
bars are seen binocularly. (Illustration by courtesy of Mr R.F.J.
the actual prismatic correction in the present spectacles
Mallett.)
can then be measured on the focimeter if the lenses are
positioned on the instrument at the patient's PD.
unit, introduced in 1994 and illustrated in Figure Some patients may need prism for distance vision but
10.13(a), demonstrates both horizontal and vertical dis- not near vision, or vice versa. The required prism can
parity simultaneously (Mallet and Radnam-Skibin, be checked at the other distance to see whether or not
1994). adverse fixation disparity is induced. With anisometro-
An alternative test for a vertical imbalance in distance pic bifocal wearers, the need for specialized dispensing
vision is the Turville infinity balance technique de- (see pages 263-265) may be verified by checking for ver-
scribed on pages 106-107. With the pair of concentric tical fixation disparity using lowered gaze through their
circles as test object, the strip is placed so that one set is present spectacles. A more typical angle of depression
seen by each eye. Any vertical imbalance tends to will be obtained with these whether or not they are bifo-
result in an apparent vertical displacement of the circles. cals (or single vision distance or near spectacles) than
Prism is then added to level their appearance. This test with trial lenses.
tends to be more sensitive than the fixation disparity With the demand for larger frames in dispensing, the
units since there is no foveal lock, only a parafoveal unit may also be used to gauge any possible intolerance
lock formed by the surrounding details on the test to poor centration. Equally, the prescriber should con-
chart. Horizontal imbalance cannot be examined by sider whether accurate centration of lenses to the pa-
this technique. In esophoria, the ring spacing appears tient’s PD is necessary for the exophoric myope or the
to increase, while in exophoria the rings may be fused esophoric hypermetrope, but must also bear in mind
into one. Base-in prism may then be added to separate the possible problems of prism distortion (see pages
the rings, but this is little guide to its need in everyday 238-246) and peripheral distortion through large
life. lenses (see page 256).
A scaled-down version of the Mallett fixation disparity An alternative test for suppression is a series of letters
 Incidence of heterophoria 177

or words of graded sizes transilluminated by polarized Table 10.3 Typical values of fusional reserves
light. Some letters of each size are visible to both eyes,
Direction Fixation Pusional reserve (in A)
others to one eye only (Figure 10.13b). All the letters
distance
on the top line may be visible, but on the remaining Blur Break Recovery
smaller lines, the letters for one eye may not be seen. It point point point
is often better not to prescribe prismatic help for such
patients, even though the fixation disparity markers Positive (convergence) Distance 4 20 1p
Near 8 30 20
may not be suppressed and indicate a need for prism.
One useful advantage of the fixation disparity units is Negative (divergence) Distance 8 4
Near 15 8
that binocular vision is maintained, the two visual axes
being correctly aligned or very nearly so. This elimi- Vertical Both 4 2
nates a possible error of tests using complete dissocia-
tion: when a large, slightly paretic heterophoria is
present, the eye may make a secondary movement of when binocular single vision is regained — the ‘recovery
elevation in abducting or adducting. In the fixation dis- point’. These results are known as the positive fusional
parity test, the lateral movement is minimal because of reserves for distance vision.
the binocular lock, so there may now be no tendency In the unusual event of a heterophoria in which
for a vertical deviation. The vertical error shown by full single vision is not possible without prismatic assis-
dissociation is of very much less significance from the tance, the prismatic power at the fusion point is also re-
standpoint of prescribing prisms. corded.
A fixation disparity is best recorded in terms of the The negative fusional reserves of abduction or diver-
prism power and base setting required for alignment, gence are obtained with base-in prism before each eye.
not as the type of causative heterophoria. Thus, 2A In distance vision there is now no blur point since there
base-down L should be recorded, rather than 2A L hy- is no ‘negative’ accommodation, provided that the
perphoric disparity. This reduces the possibility of error patient is fully corrected or hypermetropic.
when incorporating into the final prescription. Since The vertical reserves may be measured by adding se-
the test does not provide complete dissociation, the find- parate prisms or a Risley variable prism before one eye.
ings should not be called a heterophoria, nor should Some variable-prism stereoscopes have special test-card
the usual orthophoric symbol of a line through a circle holders to adjust the relative vertical position of the test
be used to denote no fixation disparity. This condition cards. A synoptophore may also be used.
may be recorded, instead, by a line through an X: for ex- The entire process can be repeated in near vision,
ample, compensation in the horizontal direction would though the vertical reserves are normally the same for
be denoted by a vertical line through an X, or simply re- both. A typical set of values is given in Table 10.3.
corded as comp H or CH. Although the fusional reserves are of great impor-
tance in the orthoptic treatment of heterophoria and
heterotropia, their investigation has several disadvan-
tages in routine examination.
Fusional reserves*
(1) It often gives the patient a headache;
(2) the results may not be repeatable, improving with
Just as there are reserves of accommodation, so the bin-
practice;
ocular system has reserves of fusional movements. Con-
(3) the measurements may be affected by the rate of
sider the two eyes fixating a test stimulus, such as a
change in the prism powers;
letter on the chart, at 6 m. If a 2A prism is placed base-
(4) measurement of the negative fusional reserves made
out before each eye, the image seen by the right eye is
immediately after the positive will be inaccurate
displaced to the left and that by the left eye to the right.
because extreme exertion in one direction will
The eyes will probably make the fusional movement of
leave a neural or muscular tonus, reducing the
relative convergence needed to maintain single vision,
effort in the opposite direction.
accommodation remaining approximately steady. If the
base-out prism is gradually increased, for example, by Despite these disadvantages, techniques for prescrib-
means of refractor-head prisms or a variable prism ing relieving prisms in heterophoria based on fusional
stereoscope, the eyes will continue to converge. This reserves are widely used in some countries (Borish,
convergence will induce accommodation, the patient NO ZAO)e
eventually reporting that the test object has blurred.
The prismatic power in place at this moment is recorded
as the ‘blur point’. The prism power may be increased
still further until fusion is no longer possible and bin- Incidence of heterophoria
ocular fixation breaks down. The patient reports that
the test object has gone double — the ‘break point’. If The great majority of the population in the UK enjoy bi-
the prism power is now reduced, a state will be reached foveal fixation, only some 2-4% having strabismus.
The findings of Tait (1951) on the incidence of hori-
zontal phorias are shown in Figure 10.14. In distance
“These have occasionally been called ductions, but this term vision, about 70% are clinically orthophoric, though
should be reserved for movements of one eye. esophoria and exophoria up to 8A are both fairly
178 Anomalies of binocular vision: heterophoria and heterotropia

70 sponds to the lag shown by the accommodative conver-

gence line, the graph to the left of the normal curve in
60
Figure 9.7.
Freier and Pickwell (1983) found that physiological
50
exophoria (measured with the Maddox rod for distance,
40 and Maddox wing test or rod and tangent scale for near
vision) increased with age from approximately none at
30 ages up to 15 to about 6A at 65 or thereabouts. They
did not find that presbyopic near additions made asig-
20 Percentage
of
cases nificant contribution to this.
A person in the 40-50 age group may be esophoric in
10
near vision because of the declining power of accommo-
ob - |
~o6 0 dation: excessive innervational effort is needed to
(ey WR 4 0 4 si IG eye obtain a satisfactory focus if the correction worn, if
Eso Exo (A) any, is out of date. An increase in near addition may
well cause the patient to become exophoric, even appar-
Figure 10.14. The distribution of horizontal heterophoria in
ently uncompensated on the fixation disparity units. A
ocularly comfortable subjects, redrawn from Tait (1951). (By
kind permission of the publishers of Am. J. Ophthal. ©1951 by near exophoric disparity when the addition has been in-
the Ophthalmological Publishing Co.) creased should be regarded with caution.
The older patient may have declining reserves of con-
vergence. If, because of failing acuity he also needs to
common. Larger angles may well be encountered and
read closer with a higher than normal near addition,
are not necessarily pathological. In near vision, exo- he may then show a high near exophoria needing pris-
phoria is seen to be the typical condition. matic help. A useful guide is the incorporation of one
Vertical heterophorias are much smaller, seldom more prism dioptre base in each eye for every dioptre of near
than 1A and rarely more than 2A. A small vertical het- addition, as in prismatic binocular loupes (see page
erophoria is, however, much more likely to give symp- 250).
toms than the same deviation laterally, because the Convergence insufficiency denotes a very high rela-
vertical fusional reserves are very much smaller than tive exophoria in near vision with a ‘normal’ imbalance
the horizontal. in distance vision. In general, but not always, such
As already noted, convergence is usually the domi- patients have a poor near point of convergence. Diver-
nant function in near vision. It must be highly accurate gence excess denotes a high exophoria or even exotropia
to avoid diplopia, whereas the eye’s depth of focus in distance vision, but a normal imbalance in near
allows some latitude in the accommodation. In the vision.
course of a near muscle balance test, the dominant con-
vergence function is no longer fully stimulated. The ac-
commodation is stimulated partly by the proximal
factor and partly by monocular clues such as the eye’s Symptoms of heterophoria
chromatic aberration.
The ease and accuracy of the accommodation influ- The symptoms produced by heterophoria are not neces-
ence the amount of accommodative convergence. This, sarily related to the size of the angle when the eyes are
taken in conjunction with the proximal convergence dissociated. One patient may be troubled by a small het-
and any distance heterophoria, determines the oculo- erophoria, while another may have good fusional re-
motor imbalance in near vision. serves and be able to cope with a much larger amount.
Vertical heterophoria is much less likely to alter be- Typical symptoms are headaches, a feeling of tired or
tween distance and near vision. Slight incomitancy and ‘pulling’ eyes, intermittent blurred vision, and jumbling
relative vertical prism effects in anisometropia (see of the letters of words. Those relatively rare patients
Chapter 14) may, however, cause differences in the whose heterophoria breaks down into an intermittent
angle of a vertical heterophoria as the gaze depresses heterotropia may experience diplopia. Bright light ap-
for close work. pears to aggravate heterophoric asthenopia.
Many patients are exophoric both in distance and The continual nervous effort required to control a het-
near vision or esophoric in both. The angle of deviation, erophoria may give rise to headaches. The lateral het-
however, may not be the same at the two distances. A erophorias tend to give frontal headaches.
patient under 40 years of age, with adequate refractive In exophoria they occur during periods when critical
correction, often appears to show little difference be- vision is in use, for example, during work. Esophoria
tween the distance and near phoria when estimated by tends to cause apparently unrelated headaches, even
the cover test. The Maddox wing test often shows the the day after concentrated use of the eyes. The hyper-
pointer wandering relative to the scale as accommoda- phorias tend to give occipital headaches. There are
tion and hence accommodative-convergence fluctuate, many possible causes of headaches and it may be that
but the mean reading in near vision is often about an ocular component is one of several, each capable of
6A relatively more exophoric than the distance hetero- triggering a tension headache.
phoria measured with the Maddox rod. This normal The reason for the tired or pulling feeling around the
difference is known as physiological exophoria. It corre- eyes is probably fatigue. Blurred vision may result from
 Treatment of heterophoria 179

inhibition or spasm of convergence-induced accommo- versely, the exophoric may tip his chin up. Head tilts
dation in esophoria and exophoria respectively. Blurred may also occur in version heterophorias (see page 183),
vision can also be caused by very small angles of diplo- ocular muscle paresis or for psychological reasons.
pia, but this is often reported as a jumbling ofthe letters. With many patients, it is difficult to decide whether
In a word such as ‘falling’, it is possible for the left eye their symptoms are refractive or oculo-motor in origin.
to fixate the first letter ‘l’, while the right eye fixates the These two are not exclusive and simultaneous treatment
second. Fusion of these two letters could result, but the of both may be required. Blurring of vision may also be
remainder of the word would appear confused since the caused by pathology anywhere in the visual system,
images in the two eyes are incorrectly superimposed. while headaches, even those immediately around the
As a result, binocular acuity may be somewhat lower eyes, may have a non-ocular cause. It is part of the
than the monocular acuity, whereas in the normal ophthalmic practitioner's duty to consider these many
patient binocular acuity is usually the better. This was other causes and refer for medical investigation when
demonstrated experimentally with induced fixation dis- the ophthalmic findings do not appear an adequate
parity by Jenkins et al. (1992), the expected 11% in- cause.
crease in binocular acuity over the mean monocular
acuity being reduced to the monocular level with 6A
base-out each eye, a 6% reduction with 4A base-in.
Every time a different object is fixated, the eyes have Treatment of heterophoria
to make a fusional movement at the instant of re-
fixation. Symptoms are likely to,be worse when the It is possible to give only a few general guidelines on
visual task requires constant changes of fixation. Dy- when and how to help a heterophoric patient, since the
namic tasks such as reading, when fixation passes from decision has to be based on the experience of the practi-
one line to the next, or looking out of a train or car tioner. Having discovered the patient’s symptoms, the
window to watch the ever-changing scene, are more first step is an accurate refraction and then the measure-
ment of the oculo-motor balance. If an esophoric finding
likely to cause trouble from this source than watching
is obtained in the young patient, it is often advisable to
television, which involves much smaller angular move-
recheck the refraction under cycloplegia to verify that
ments of the eyes. For this reason, the incorporation of
there was no large error of latent hypermetropia or
a small horizontal prism in the prescription for a dys-
pseudo-myopia present.
lexic patient may reduce the jumbling of letters (see Ex-
In general, there should be no need to treat the oculo-
excise ORO):
motor imbalance either by refractive, prismatic or
Similarly, the patient's vision may be disturbed fol-
orthoptic means in the absence of symptoms. Fixation-
lowing changes in the distance of fixation. This is
disparity tests may be used to help decide whether or
perhaps most likely where the oculo-motor balance dif-
not a heterophoria is significant, but no hard and fast
fers significantly between distance and near vision.
rule can be given. The authors’ experience with the Tur-
Since dizziness or vertigo may occur with an incomi-
ville infinity balance and the fixation disparity units is
tant heterophoria, the ocular motility should be tested
that a number of apparently symptom-free patients
in patients with this symptom. In the normal eye, a
show an uncompensated heterophoria, while some
change in the pattern of innervation to the extra-
patients have an apparently compensated heterophoria,
ocular muscles is associated with a particular movement and yet are happier with prismatic help. Pickwell et al.
of the image across the retina. If this relationship is dis- (1991) investigated the fixation disparity in 383
turbed, for example, by a paresis of the right lateral patients. The group was subdivided by age and whether
rectus muscle, the right eye will no longer abduct as far they were symptomatic or asymptomatic for distance
on command as it did before. The resulting imbalance and near vision. In distance vision, horizontal fixation
between innervation and retinal image movement disparity measured with the present spectacles or un-
makes the patient’s surroundings appear to move. If aided, as appropriate, showed a similar distribution in
the paresis is not too great, the patient may still have both symptomatic and asymptomatic people for all age
single binocular vision with an incomitant heterophoria groups, suggesting that fixation disparity was a poor in-
rather than a heterotropia and diplopia. dicator of symptoms. In near vision, they concluded
Other causes of vertigo are variations in the blood that an exophoric fixation disparity requiring 2A or
supply to the brain and middle-ear defects, while some more was indicative of symptoms for the under-40 age
patients are worried initially by the magnification group, 3A for the 40-59 age group, but that for the 60
changes resulting from alterations to their spectacle pre- and over group, many asymptomatic patients showed a
scription, especially to the astigmatic component. need for 4A or more base-in aligning prism. Obviously,
A head tilt may also be produced in a heterophoric some of the symptomatic patient’s symptoms may
patient. Motility testing frequently shows that in de- have been caused by refractive changes or non-ocular
pressed gaze the visual axes tend to converge, while in reasons,
elevation divergence occurs. In pronounced cases, this This confirms the present writer’s (RBR) approach, in
type of motility is termed a V-pattern, while the opposite which indications for vertical aligning prism and base-
type of deviation is an A-pattern. An esophoric patient out prism (or near additions) are nearly always pre-
may then tend to tip his face downwards in order to scribed, while small exophoric deviations, especially in
obtain an elevated plane of regard with respect to the near vision, are ignored unless confirmed empirically
face, thus reducing the tendency for convergence. Con- by increased comfort or clarity viewing the chart or
L180. Anomalies of binocular vision: heterophoria and heterotropia

(a) followed by the word up or down to resolve the ambi-

guity as to the position of the base. For example, the
prism combination specified in the last example could
be compounded into the single prism 3.60A base 34
down (Figure 10.15a). Alternatively, if the 0-360" pro-
tractor is used, the same prism would be completely spe-
90 cified by 3.60A base 214 (Figure 10.15b).
ae ee
(b) 138 45

The dominant eye

180 0
Although the majority of patients have binocular vision,
this must not be interpreted as meaning that the two
225 319
eyes are equally important. Similarly, there are few am-
270 bidextrous people. In most cases, ocular and hand domi-
nance are both right or both left, which is to be
Figure 10.15. (a) Compounding vertical and horizontal
prisms into a single oblique prism. (b) Use of the 360
expected since the dominant side of the body tends to
protractor for specifying prism base setting. be related to the functionally more important, but oppo-
site, cerebral hemisphere. Hughes (1953) found that
some 15% of his sample population were left dominant,
near test types, or better recovery in the cover test. If although about half of these had become right-handed
only a small prism is indicated, it may be worth rever- through education. Genuine crossed dominance of
sing it so as to increase the heterophoria. If comfort is hand and eye does occur.
unimpaired, prismatic help is probably unnecessary. The dominant eye is the one which contributes most
Patients showing deep suppression of one eye are to the visual percept: it is easier in general to suppress
almost certainly best left without prismatic aid. the non-dominant eye. Thus, when lining up two ob-
Orthoptic treatment is best reserved for those patients jects, for example, one relies on the dominant eye even
who are under about 30 years of age. It is particularly if the non-dominant eye is kept open. Again, it is usually
useful for those patients who may thereby avoid the the dominant eye which is used with monocular instru-
need for spectacles (for more details, refer to Evans, ments, such as a camera or focimeter.
1997; Edwards and Llewellyn, 1988, or other texts). Clinically, it is useful to know which is the dominant
Inaccurate optical centration, whether horizontal or eye. Some patients are uncomfortable if their dominant
vertical, is an important possible source of discomfort eye is fractionally blurred, for example over-plussed by
with spectacles. For example, a pair of plus lenses with ().25 DS relative to the other eye. Later on in life, senile
their optical centres several millimetres too wide could lens or macular changes cause more worry if the domi-
give enough base-out prism effect to decompensate an nant eye shows the greater deterioration in acuity. On
exophoria or to create discomfort because of the extra the other hand, a small uncorrected or residual refrac-
convergence needed. This is more likely to happen in tive error in the non-dominant eye only may possibly
near vision because of the greater possibility of centra- not give any discomfort.
tion errors (see Exercise 10.4 on page 189) and higher There are many different methods aimed at identify-
positive lens powers. ing the dominant eye. On pages 156-157, about the cy-
In Great Britain and some other countries, the term
clopean eye, it was shown that our two separate
centration distance CD is used to denote the intended uniocular views are fused unconsciously into a single
distance between the right and left optical centres, or mental percept, which could be regarded as the projec-
between the two points at which prescribed prism is to tion or view from the cyclopean eye. This imaginary
be measured. It is important when ordering spectacles
eye is, in general, not situated midway between the two
always to state the required centration distance (and
eyes but is positioned nearer to the dominant eye. Align-
also the vertex distance if the lens powers are numeric-
ment tests for dominance are based on this displace-
ally over about £5.00 D).
ment. The patient clasps both hands together with the
When a prismatic component is added to a prescrip-
forefingers outstretched together. The patient is then
tion, it is written after the lens power, for example:
asked to swing the hands up to point at a distant
R + 4.00/—2.50 x 140 4A base-in CD 64 object, or perhaps at the practitioner’s eye, the practi-
tioner standing on the opposite side of the room. Be-
The base setting of the prism is specified as up, down, in cause both hands are held together, hand dominance is
(towards the nose) or out, as the case may be. If prism eliminated while the fingers are instinctively lined up
power is needed in both the horizontal and vertical di- with the object and the cyclopean eye. The hands will
rections, it is customary to give the vertical component therefore tend to be placed nearer in line with the domi-
first, as in the example: nant eye and often the patient will then move them
L+ 2.00/—1.00 x 20 2A base-down and 3A base-in CD61 over to give an exact line with the dominant eye. Similar
tests, which are also held in both hands, are Parson's
Oblique prisms can be specified in two different ways. cone or manoptoscope and the Dolman card. They use
One is to state the orientation in standard axis notation, a screening aperture which allows the patient to see
 Cyclophoria 181

the fixation object with only one eye. The aperture is Ehrlich’s results showed that this shift was greater in
lined up instead of the hand. subjects who were exophoric rather than esophoric
Carter (1960) and Mallett (1964) have independently before commencing the near vision task, and in those
found that the eye which shows a fixation disparity is who had to accommodate more from their natural ac-
nearly always the non-dominant eye. Some patients commodative resting state, thus inducing more accom-
show a disparity in both eyes. If no disparity is seen, it modative convergence.
may be induced for this purpose by adding equal prism Yekta et al. (1987) and Pickwell et al. (1987) found an
before each eye until a displacement is shown. The re- increase in exophoria and exophoric fixation disparity
sults of these workers suggests that marked ocular dom- (both in angular amount and aligning prism) after a
inance is less common than alignment tests would day’s study or half an hour’s close reading at 20 cm.
predict. This again was interpreted to indicate fatigue of the
A further and objective method of determining ocular visual system.
dominancy is to investigate either the convergence— Adaptation to prisms and lenses has been studied by
divergence movements of the eyes, or the near point of North and Henson (1981, 1982, 1985) and North et al.
convergence. Two pencils of different colours are held (1986), among others. In general they found that if, for
up in the median plane before the patient's eyes, say at example, base-in prism is placed before the eyes, an im-
150 and 500mm, and the patient is asked to look at mediate shift to esophoria occurs when measured
first one and then the other. The faster moving eye is through the prism. This rapidly declines over a minute,
the dominant eye. In determining the near point of con- the heterophoria returning towards its initial level de-
vergence, at some point the non-dominant eye often spite the presence of the prism. The longer the period of
ceases to adduct and suddenly abducts. In practice, adaptation to the prism, the longer the decay back to
these two tests may be indeterminate because the speed the original phoria on removal of the prism. This con-
of movement in the two eyes may be so similar as to firms the idea of a fast and slow controller of tonic ver-
render judgement impossible. gence (see end of Chapter 9).
Some patients, especially anisometropes, may have Clinically, this might suggest that the patients having
acquired a different ocular dominance in near and dis- an uncompensated heterophoria would obtain no relief
tance vision. Consider an uncorrected unilateral low from a prescribed prism. They point out, however, that
myope: the emmetropic eye is likely to be used for dis- patients with oculo-motor symptoms may be poorer at
tance vision, the myopic eye for near vision. adapting to prisms, though these findings were not sup-
When the dominant eye has been identified, the Tur- ported by Pickwell and Kurtz (1986). In another
ville infinity balance test can be used to ensure that the approach, Tunnacliffe and Williams (1985, 1986)
dominant eye has, if possible, the better acuity. The measured the contrast sensitivity (see pages 51-55)
non-dominant eye should not, however, be deliberately under binocular conditions. They found a significant
fogged. drop in the binocular contrast sensitivity function com-
Some patients, as a result of occupational conditions pared with the monocular in the presence of an un-
or hand dominance, may place close work significantly wanted 0.5 or 1A vertical prism, or a horizontal prism
to one side: this may be worth considering when order- of 2A or more outside the region between the active to
ing the insetting of bifocal segments (see Hughes, 1953 passive position, for example, 6A base-in when there is
for further references on this subject). only 4A of exophoria. They concluded that despite an
adaptation to heterophoria as established by dissocia-
tion tests, the visual system was under-performing.
This in turn may be of significance when sizeable pris-
Tonic convergence and heterophoria matic effect is induced in a spectacle correction because
of poor centration. An excellent review article on prism
Referring to Figure 9.2, tonic convergence is that pro- adaptation is given by Sethie (1986).
duced by the natura! tonus in the extra-ocular motor
system, bringing the eyes from the position of anato-
mical rest to the fusion-free or dissociated position. Be-
cause the position of anatomical rest is unknown, tonic
convergence is measured both clinically and experimen- Cyclophoria
tally from the parallel position for distance fixation. In
the dark, a position of convergence to about 110 cm Types of cyclophoria
occurs (see page 159). The heterophorias so far described have been either lat-
This tonus can be reduced by prolonged occlusion, as
eral, vertical or, when these two coexist, oblique. It is
opposed to the few seconds of the normal dissociation also possible for the eyes to show a torsional hetero-
test. Dowley (1987) found a much wider spread of hori- phoria. Such deviations around the line of sight when
zontal heterophoria in his subjects after 5.5 h of occlu- the eyes are dissociated are called cyclophorias. By ana-
sion, than initially. He postulated, therefore, that there logy with the classification of ocular torsion, the best of
was an adaptive mechanism bringing the oculo-motor several methods of classifying cyclophoria is as follows:
system towards orthophoria.
Conversely, the effect of working at an exceptionally (1) Incyclophoria. The upper vertical meridian of either
close distance (20 cm) was found by Wolf et al. (1987) eye rotates inwards towards the median plane
and Ehrlich (1987) to give a short-lived esophoric shift. when dissociated (Figure 10.16a).
182 Anomalies of binocular vision: heterophoria and heterotropia

the cylinder axis, in this case, with the top inwards. In

order for a line to be imaged on the vertical meridian of
the retina of a newly corrected patient, it would have
to be tilted top outwards, suggesting excyclophoria.
Since real surroundings, as opposed to test objects for
cyclophoria, cannot be tilted so that the retinal images
fall on corresponding meridians, the eyes make a com-
pensatory torsional movement. After a period of time,
this becomes habitual, resulting in a cyclophoria. In
the example shown in Figure 10.17, the compensatory
movement would be an inward rotation of the upper
vertical meridian, resulting in an incyclophoria .
The major fallacy of this argument is that it ignores
the scissors nature of astigmatic distortion in the cor-
rected eye. As shown in Figure 13.8 on page 235, a hor-
izontal line also appears tilted towards the minus
cylinder axis, that is, in the opposite direction to the tilt
of the vertical line. Thus if the patient were tested for cy-
clophoria with horizontal instead of vertical lines, the
opposite results would now be found. The preponder-
Figure 10.16. Examiner's view of (a) incyclophoria and (b)
ance of vertical lines in our surroundings, for example,
excyclophoria.
buildings, trees, the upright limbs of letters, perhaps
gives some slight plausibility to the theory.
(2) Excyclophoria. The upper meridian of either eye
The tilt shown in the diagrams is greatly exaggerated
rotates outwards away from the median plane
for ease of illustration. For example, if the astigmatic
when dissociated (Figure 10.16b).
lens were:
Subjectively, the visual scene will appear to tilt in the plano/ — 4.00 DC x 135
opposite direction to the phoria. In theory, this could be
fitted at 16 mm from the eye’s entrance pupil, it can be
demonstrated by the subjective cover test. Cyclophoria
shown (equation 13.20 on page 235) that the apparent
may frequently coexist with vertical deviations due to
tilt of distant horizontal and vertical lines would be just
the torsional actions of the vertically acting extra-
less than 2° in each case. Other factors being equal, the
ocular muscles. The possible causes of cyclophoria are
tilt is approximately proportional to the cylinder power.
similar to those of the other heterophorias, namely: re-
Assuming that the ocular astigmatism is due to the
fractive, anatomical, neurological and pathological. To
cornea, the tilt in the uncorrected eye is negligible
these we may add proximal, while refractive cyclophoria
since the cornea is so close to the entrance pupil. A full
also needs explanation. The importance of refractive cy-
discussion of astigmatic line rotation will be found on
clophoria has been exaggerated by many authors.
pages 234-236.
Their argument is as follows. In general, a spectacle
To summarize on refractive cyclophoria, the condition
lens produces a magnification of the retinal image,
is induced on correction and depends on the orientation
equal in all directions if the lens is spherical. A cylindri-
of the test lines for cyclophoria relative to the axes of as-
cal component of a lens, however, magnifies only in the
tigmatism. The uncorrected astigmat should not be
direction perpendicular to the cylinder axis.
troubled, but on first correction with spectacle lenses
In general, a line viewed through an astigmatic spec-
and on subsequent changes, difficulties may occur.
tacle lens incorporating a minus cylinder appears tilted
These may not be due to cyclophoria but far more likely
towards the cylinder axis. Figure 10.17 illustrates an ex- to changes in spatial perception arising from distortion
ample in which only the left lens is astigmatic. A vertical of the image (see, for example, Ogle and Madigan,
line is therefore imaged vertically on the right retina, 1945).
whereas the retinal image in the left eye is tilted towards Proximal cyclophoria is the term introduced by Rab-
betts (1972) to describe that cyclophoria produced in
Axis of Object line that is
minus cylinder
near vision as a secondary effect of convergence and de-
imaged vertically
pression of the eyes. Because the eyes are no longer in
N the primary position, some false torsion (see pages 149—
152) is expected, equal and opposite in direction in the
two eyes. Cyclophoria is therefore predicted, but, in gen-
eral, a lesser amount is found experimentally. Hermans
(1944) gives results of a detailed survey of 104 subjects
with no detected visual defect. He determined the cyclo-
\. phoria at angles of elevation and depression up to 40°
Image of a and monocular convergence up to 10°. In the primary
vertical line position there was almost zero cyclophoria. At the pos-
Figure 10.17. Cyclophoria due to an astigmatic correction ition normally used in near vision, a depression of
at an oblique axis. about 20° and convergence of about 4° by each eye,
 Other oculo-motor defects 183

astigmatic distortion, while a tilt in the same direction

a @
confirms that it is due to cyclophoria.
In the presence of a pronounced cyclophoria, a mono-
Figure 10.18. Synoptophore slides for cyclophoria. cular refraction can give incorrect values for the astig-
matic axes. Binocular refraction is therefore preferable,
especially when the astigmatism is marked. Moreover,
less than 0.5° of cyclophoria was found, compared with
the eyes will orientate themselves as they prefer with
0.7° predicted by the standard false torsion equations.
regard to the astigmatic scissors distortion: parallelism
In positions of greater convergence or depression, and
of vertical contours in the field of view may be more im-
especially convergence in elevated gaze, higher amounts
portant than parallelism of horizontal contours. Because
of cyclophoria were found.
of the close relationship between hyperphoria and
cyclophoria, a patient suspected of having cyclophoria
should be very carefully checked for hyperphoria, reliev-
Measurement of cyclophoria
ing prism being prescribed as necessary. This alone
There is no standard clinical test for cyclophoria. This may be enough to relieve symptoms, especially if the
is partly because very few patients have significant astigmatic axes are verified under binocular conditions
amounts of cyclophoria, while fewer still have symp- with the prismatic power in place.
toms. In any case there is very little that can be done to A complicating factor in the measurement of cyclo-
help such patients by direct treatment of the condition, phoria may be that the meridians of the retina which
although the symptoms can perhaps be relieved as de- perceptually relate to horizontal and vertical may not
scribed below. Ames invented a spectacle device for the be truly horizontal and vertical. If so, the corresponding
correction of cyclophoria (Lancaster, 1928) but it was vertical meridians of the retinae will not be parallel,
necessarily complicated and has fallen into disuse. while the horizontal meridians through the foveae may
In theory, Maddox rods may be placed before both not be in a straight line. The zero position for a cyclo-
eyes with their axes accurately vertical, thus giving a phorometer would have to allow for this deviation. One
horizontal line. A vertical prism of about 5A will then method of ascertaining the relationship of the corre-
produce vertical separation of the lines, since it is great- sponding vertical meridians of the two retinae is to com-
er than the comfortable fusional reserve of most pare the true (plumb-line) vertical and the retinal
patients. If one line appears tilted with respect to the images that give a perceptual stereoscopic vertical. Rab-
other, one of the rods may be rotated to give parallelism. betts (1972) found that the objective and stereoscopic
The angle and direction of the required rotation gives verticals coincided with no tilt of the retinal images,
the cyclophoria. In practice, it is not possible to place showing that the perceptually vertical meridians of the
the rods in the trial frame with sufficient accuracy, retinae were truly vertical.
while those mounted in a refractor head are incapable
of rotation.
Test slides (Figure 10.18) are available for mounting Other oculo-motor defects
in a synoptophore, and a similar design could be used
with a hand stereoscope. A horizontal line is seen by Dissociated vertical deviation
one eye, while a pair of lines, one above and one below,
are seen by the other eye. In order to reduce the effects In right hyperphoria, the right eye deviates upwards
of secondary muscle actions, horizontal and vertical het- under cover and the left eye downwards. In dissociated
erophorias are kept under control by the fixation dots vertical divergence, the covered eye always moves up-
seen binocularly. As a result, the parallel lines seen by wards, whichever eye is covered, although the angles
one eye can be positioned close to the central line seen of deviation behind the cover may be different. On re-
by the other eye, increasing the accuracy of the test. If moval of the cover, the eye returns to its normal pos-
the test line(s) for one eye can be rotated about the fixa- ition, the uncovered eye not having moved unless the
tion point, the cyclophoria can be measured, preferably condition is associated with a horizontal heterotropia.
by the bracketing method. Starting from a tilted pos- The cause is probably defective supra-nuclear innerva-
ition, the setting is recorded at which the patient reports tion of the oculo-motor nuclei. This condition has also
that parallelism has been restored and the process is been termed ‘alternating hyperphoria’ or ‘alternating
then repeated from the opposite direction. sursumduction’.
The Maddox wing test incorporates a_ rotatable
marker seen by the right eye which can be set parallel
Version heterophorias
with the horizontal line viewed by the left eye (Figure
LORMONs The heterophorias described earlier in this chapter were
The fixation disparity units can be used to detect the all vergence phorias. If, however, there is defective in-
presence of cyclophoria, which is inferred if one of the nervation to or by the supra-nuclear centres controlling
monocular markers appears tilted. (Some patients erro- version movements, there will be a bilateral limitation
neously call a displacement of one of the markers in a of movement in the affected direction of gaze, hence the
horizontal or vertical disparity a tilt.) If there is high as- term ‘gaze palsy’. These are not shown by the dissocia-
tigmatism at an oblique axis, the test should be repeated tive tests described earlier in this chapter, but will be
with the markers at right angles to their original direc- evident in the motility test. Thus, a patient may be
tion. An opposite tilt confirms that the effect is due to unable to elevate the eyes as far as normal above the
184 Anomalies of binocular vision: heterophoria and heterotropia

horizontal plane, giving a resultant tendency for the Heterotropia (strabismus)

eyes to have a passive position in a plane distinctly de-
pressed below the horizon: kataphoria. The patient will The essential difference between heterophoria and het-
probably develop a head tilt, chin up (compare with erotropia is that in heterophoria, bifoveal fixation of the
pages 148 and 179), so that the eyes are depressed object of regard is maintained, whereas in heterotropia
with respect to the head when the plane of fixation is one eye deviates and the image in that eye does not fall
straight ahead. Even in the normal subject, the range of on the fovea.
elevation of the eyes is less than that of depression The nomenclature of heterotropia according to the di-
(Figure 8.17) and it is possible that the range of eleva- rection of deviation of the eye follows that of hetero-
tion reduces further with increasing age. Conversely, in phoria and has already been discussed. The deviation
anaphoria the eyes will tend to be elevated, depression may be:
being limited.
These unfamiliar terms can be avoided by describing (1) Unilateral. The deviating eye takes up fixation only
the condition as a gaze palsy, with deficiency of gaze up when the normally fixating eye is covered and devi-
or down. Lateral gaze palsies may also occur. ates again immediately the cover is removed.
(2) Alternating. Either eye may fixate. Alternating stra-
bismus is much less common than unilateral.

Some patients with alternating strabismus may

Nystagmus change fixation readily from eye to eye: sometimes this
can be achieved voluntarily and sometimes the direction
Most patients can fixate an object steadily for a long of gaze determines which eye fixates. A few patients
time if the physiological movements of the eye which with a unilateral strabismus retain fixation with the
are too small for direct observation are disregarded. A normally deviating eye when the cover is removed
few patients are unable to maintain fixation, their eyes during the cover test. Immediately the point of fixation
showing perpetual involuntary movements to and fro. is moved or the patient blinks, however, the dominant
The movement is usually similar in direction and eye regains fixation. These tropias should not be classed
amount in the two eyes, but the speed of movement in as alternating.
one direction is frequently slower than the return move- All heterotropic patients may additionally be classified
ment. These oscillations may be lateral, vertical, oblique according to whether the deviation is intermittent or
or torsional and are denoted by the term ‘nystagmus’. continuous. In a similar fashion to the development of
The physiological optokinetic nystagmus induced by visual acuity, the very young infant probably does not
watching a moving object has already been introduced have binocular vision but develops this during the first
on page 38. few months of life. During this period, intermittent de-
In some patients, nystagmus is produced by an ob- viations of the eyes from binocular fixation can often be
vious defect: for example, congenital opacities in the seen. After this first 6 months or so, co-ordinated move-
media prevent a good retinal image. As a result, the ments of the two eyes should be well developed, with
fovea and visual acuity may not develop fully, thus approximate bifoveal fixation. Some children appear
causing a poor fixational reflex. A similar result occurs never to have reached a stage where both visual axes
in an albinotic eye because of light scatter in the eye become parallel in distance vision, but always manifest
and neural misrouting to the brain. Defective visual a deviation. It is probable, however, that most patients
pathways to the cerebral cortex may again cause nys- with heterotropia have at some time attained bifoveal
tagmus if the lesion occurred in infancy or young child- fixation, only to lose it later.
hood. In the early stages of the development of a squint, the
Other patients with nystagmus show no obvious deviation may often be intermittent. Bifoveal vision
cause. Their nystagmus will increase in frequency or may be present most of the time, but when the patient
amplitude on occluding either eye. Vision and refraction is tired, ill, or, in the accommodative type of strabismus,
are therefore best determined by employing a binocular paying critical attention to the object of regard, the de-
method such as the Humphriss fogging method, but viation may then appear.
with a +1.50 or +2.00DS lens chosen in relation to Strabismus may be subdivided yet again according to
the acuity. whether the angle of deviation is constant (comitant or
End-position nystagmus may occur in extreme pos- concomitant) or variable. Particularly if the strabismus
itions of gaze, as in motility testing. Small nystagmoid is of muscular origin or if secondary muscular changes
movements may often be seen, especially in the presence (see page 189) are pronounced, the angle of squint may
of paresis of an extra-ocular muscle. Acquired nystag- vary with the direction of gaze; for example, if there is a
mus may also occur in patients with defective co- paralysed right lateral rectus muscle, there may be a
ordination of the innervation, while miners’ nystagmus marked right esotropia on looking to the right, yet the
was partly caused by spending long periods of time in eyes may be almost straight when looking to the left.
low illumination. (For a further discussion of this defect Such a strabismus is incomitant, described on page
of motility, see for example Lyle and Bridgeman, 1959; 148. Different primary and secondary deviations may
Walsh and Hoyt, 1969.) also be shown, depending on which eye is fixating.
 Sensory sequelae to strabismus 185

Causes of heterotropia it
Q"R
|
In many respects, the causes of a heterotropia are si-
milar to those of heterophoria, but the deficiency or defi-
ciencies may be more pronounced or the ability to
overcome the difficulties may be less well developed.

Refractive

A hypermetropic error may cause esophoria, but should

the patient become ill, much more nervous energy may
be needed to provide sufficient accommodation to cor-
rect the error. There will simultaneously be a greatly in-
creased esophoria which the debilitated person may not
be able to control. The deviation becomes manifest as
an esotropia. Thus, the parents of a strabismic child ~
often say that an illness such as measles caused the ~

squint at an age between 24 and 4 years. The illness ~

was merely the trigger and not the basic cause. If such ~

a child is promptly refracted under cycloplegia and a

full refractive correction worn, the strabismus is rapidly
7
cured. An accommodative squint of this kind is often UNG
called a Donders’ squint. /\ G
Unfortunately, if several months or even years elapse Fi / | ’ "R

before the child is brought for examination, the refrac- ML 2 B R Q'p

tive correction may only reduce the angle of strabismus.

BiL B’R Mp
Secondary sensory and motor sequelae to the deviation ML
(described below) prevent an immediate elimination of
BL
Q’R
the strabismus.
Figure 10.19. The projection through the cyclopean eye of
the retinal images in right esotropia: normal retinal
correspondence.
Anatomical

Any anatomical defect within the orbit can predispose to Sensory sequelae to strabismus
a strabismus. A small obstacle following trauma in an
adult, for example, may cause only a heterophoria, but Suppression and amblyopia
in the infant may prevent binocular vision ever being at-
tained. Figure 10.19 represents the eyes of a patient with right
esotropia viewing a fixation object B. The image of B in
the deviating eye falls on the nasal retina and should
therefore be projected temporally. As a result the patient
Neurological should see B in diplopia; indeed, this is what happens in
In addition to any defects at or below the oculo-motor a strabismus of sudden onset in an adult. It is the image
nuclei, the influence of the higher neural paths must be of object QO which falls on the fovea of the deviating eye
remembered. Defects in the reflex paths such as those of and would therefore be seen superimposed on B, giving
fixation, or those originating in the middle ear or a rise to confusion.
failure of co-ordination between various centres, may Moreover, if normal retinal correspondence (the rela-
all contribute or predispose to a strabismus. Central co- tionship between corresponding points described on
ordination may temporarily be affected during the child- pages 154-157) is maintained, every object in the field
hood infectious diseases, giving yet another difficulty to of view of the left eye that forms an image on the retina
the uncorrected hypermetropic child. of the right eye will be seen in diplopia. This may be in-
ferred from Figure 10.20.
In consequence, in the patient young enough for
changes to occur, the brain will tend to disregard the
Pathological image of the deviating eye — a process known as sup-
Anatomical damage to the lateral walls of the orbit, the pression. Because the central region of the retina has
lateral recti or the sixth cranial nerve may be caused by the highest acuity and largest representation in the occi-
the use of forceps during birth. Transient pathology pital cortex, it is in this area that the most pronounced
such as a haemorrhage in an extra-ocular muscle in or deepest suppression will occur. Suppose two different
childhood may induce a strabismus, even though no objects, such as the letters F and L suggested by Javal,
trace of pathology may be detected later. are presented one to each eye of a heterotropic patient
 186 Anomalies of binocular vision: heterophoria and heterotropia

Diplopia or suppression The area of suppression tends to vary with the type of
strabismus and depends on the nature of the corre-
spondence between the elements of the two retinae. In
R
f Monocular virtually all patients, the fovea of the deviating eye is
L % Area 0
W temporal suppressed, As a result of this active inhibition, the
ee \y,crescent
Monocular acuity in this eye does not develop. It either remains re-
temporal
crescent
Ze tarded at the acuity level reached by the age of onset of
the strabismus or may even deteriorate. This reduced
acuity is known as strabismic amblyopia and has al-
Figure 10.20. Field of diplopia in R esotropia (prior to ready been discussed on pages 42-43. It must be em-
secondary changes). phasized that amblyopia is a monocular condition,
while suppression occurs when both retinae are stimu-
lated. Even under the most artificial conditions, the de-
by means of a synoptophore (an instrument discussed viating eye ceases to be suppressed when the normally
on page 203). The normally fixating eye will see the fixating eye is occluded (the only exception to this may
letter F (Figure 10.21a) but the right eye will not seen be the fovea). Some authorities regard amblyopia not as
the letter L. If the position of the letter L is moved rela- an undeveloped fovea, but as a fovea so greatly inhibited
tive to the eye, it may be possible to plot an area of sup- that the central portion no longer operates even in
pression. This area will be affected by the nature and monocular vision. The reduced acuity then results from
angular subtense of the test objects, but will include a using a parafoveal area (see pages 36-37). Only if the
large region around the macula Mk and the point Hp strabismus is intermittent, alternating or of late onset
on the retina of the deviating eye that would receive will there be no amblyopia. Active treatment by refrac-
the image of the fixation object in normal viewing con- tive correction and occlusion of the better eye are neces-
ditions (Figure 10.21b). sary to reduce the amblyopia in cases of constant
This test is utterly unrealistic in that a patient does unilateral strabismus.
not in normal life have different objects presented to
the two eyes. The results of such tests, commonly de-
scribed in older texts on orthoptics, cannot be used to Anomalous retinal correspondence
predict the state of the patient's binocular vision in In the young patient of less than 3—5 years of age, the
normal surroundings. If suppression is investigated onset of strabismus is followed temporarily by suppres-
under conditions which cause little disturbance to sion. Provided that the angle of deviation remains ap-
normal vision, the large area found with the cruder proximately constant, the retinal correspondence is
techniques will shrink to a minute area at the fovea of shifted, so that the fovea of the deviating eye no longer
the deviating eye and possibly another at Hp (Figure
10.21c). One method that could be used is to project a
spot of polarized light on to a metallic screen with the
patient wearing an analysing visor so arranged that
the fixating eye cannot see the spot. An unpolarized
picture is simultaneously projected on to the screen to
provide detail seen binocularly. Alternatively, the Stan-
worth synoptophore may be used (Mallett, 1970a,b).

(c) Objective angle

and angle of
anomaly

‘Classical’ True
suppression suppression
area areas

M H’p| M R
Anomalous
retinal
correspondence

Figure 10.21. Suppression in strabismus. (a) Presentation of

Javal FL to a patient with right esotropia. (b) ‘Classical’
suppression area on the retina. (c) True suppression areas Figure 10.22. Harmonious anomalous retinal
when measured under conditions of normal vision. correspondence: objective angle equal to angle of anomaly.
 Tests for strabismus and retinal correspondence 187

heterotropia is zero, while the objective angle equals

the angle of anomaly.
Some patients show an unharmonious ARC, in which
the angle of anomaly does not equal the angle of devia-
tion. In Figure 10.23 the left fovea Mj corresponds
with point H’ on the right retina. Object B is imaged na-
sally to H’ at Bg and hence is projected temporally to
Bk. The subjective angle of the strabismus is BpNpH’,
or the angle through which the eye must turn before B
is imaged on H’. The objective angle is the angle be-
tween the visual axis and BB. The angle of anomaly
Angle of could be determined in theory by using a synoptophore
anomaly and asking the patient to superimpose two similar
Subjective
slides. The cover test will then reveal the angle of anom-
angle
Objective aly. In practice, the patient will probably show suppres-
sion to avoid diplopia.
Unharmonious ARC in real life may be due to a
change in angle of deviation of a mature patient’s stra-
bismus after a deeply ingrained harmonious ARC had
been developed. Figure 10.23 represented a patient
whose angle had increased. It is instructive to draw a si-
milar diagram for a patient whose angle has decreased,
perhaps by surgical intervention, to show that the direc-
tion of diplopia is apparently paradoxical, that is,
crossed in an esotropia. The conditions of examination
may produce an apparently unharmonious ARC in a
patient with harmonious ARC. This is discussed below.

Figure 10.23. Unharmonious retinal correspondence:

objective angle equals subjective angle plus angle of anomaly. Tests for strabismus and retinal
correspondence
corresponds to that of the fixating eye. In Figure 10.22,
The only satisfactory test for strabismus is the objective
point Br now corresponds to M; and so on for the re-
cover test, already described on pages 169-171. The
mainder of the retina. A new retinal correspondence
prism recovery test described under the screening of
has been produced so that images in the two eyes again
young children (see page 371) and, to some extent, the
fall on corresponding points. This is called an anoma-
presence or absence of stereopsis (see Chapter 11) may
lous (or abnormal) retinal correspondence (ARC). In
also be employed to evaluate a patient’s binocular
this particular case, the ARC is said to be harmonious
status. A few patients are unable to straighten their de-
because the images fall on the ‘adjusted’ corresponding
viating eye; they may have extremely poor fixation or
points. In such patients, diplopia will not exist in
be too unco-operative to examine with the cover test.
normal conditions so that suppression will be minimal.
The angle of strabismus may be estimated in these
The harmonious ARC acts as a positive factor allowing cases by asking the patient to fixate a small bright
a partial return to binocular vision. light, an instinctive act if this is the only light in a dark
Patients with a consolidated harmonious ARC may room. The relative positions of the corneal reflexes in
have reasonable stereoscopic acuity if, say, the three- the two eyes may then be observed: the Hirschberg test.
needle test is used (see Chapter 11). Since stereoscopic According to Lyle and Bridgeman (1959), the deviation
vision is regarded as the highest grade of binocular is 10-15° (17-27A) when the reflex appears on the
vision, it is not strictly correct to describe the strabismic margin of the pupil (assumed to be 4 mm in diameter);
patient possessing this faculty as not having binocular about 25° (47A) when halfway between pupil margin
vision. For this reason, the authors have preferred to and limbus and 45° when on the limbus. Alternatively,
use the term ‘bifoveal fixation’ to describe the attribute a displacement of 1 mm in the position of the reflex rela-
of the normal, but quite frequently, heterophoric, tive to the centre of the pupil may be equated to a devia-
patient. tion of about 22A in an adult (Brodie, 1987; Eskridge et
The angle through which the retinal correspondence al., 1988), and because of the steeper cornea, to
has been shifted from the normal is called the angle of around 27A in an infant (Eskridge et al., 1990). This
anomaly. test, like the cosmetic appearance of a strabismus, is in-
Because the retinal images fall on corresponding fluenced by the angle 4 between the visual and pupillary
points, the deviating eye projects them in the same di- axes (see page 221).
rection as the fixating eye. When this eye is covered, no Another casual method is to compare the relative
apparent movement of the surroundings will be seen. amounts of sclera seen on either side of the cornea in
Thus, in harmonious ARC, the subjective angle of the each eye. If there is much less nasal sclera than usual
188 Anomalies of binocular vision: heterophoria and heterotropia

Table 10.4 Example of calculation of angles of anomaly

Angle Habitual angle Total angle

in play (A) in play (A)

Objective angle 15 22
Subjective angle Oo ads
Angle of anomaly 5 Sy

(a) (b)

in one eye, an esotropia is suggested. Some children

have a very shallow bridge to the nose, giving an abnor-
mally wide fold of skin on either side of it. This is
termed ‘epicanthus’ and can give a misleading impres-
sion of esotropia, although such patients may indeed
have esotropia as well as the epicanthus.
Whereas the subjective cover test may be used in het-
erophoria to measure the angle of deviation, the pres- (c) (d)
ence of ARC in a heterotropic patient gives a subjective Figure 10.24. Appearance of the streak when the Bagolini
angle different from the objective angle. Only if normal striated glass is placed before the right eye in R esotropia: (a)
retinal correspondence and normal projection are main- normal retinal correspondence, (b) harmonious ARC, (c)
tained by the squinting eye will the fixation object unharmonious ARC, (d) unharmonious ARC and partial
suppression. Note the narrower separation in (c) compared
appear to jump through the objective angle when the
with (a).
fixating eye is covered. In harmonious ARC there will
be no apparent movement of the object on covering the
good eye. Nevertheless, if the cover test were repeated being caused. Normal vision is thus virtually undis-
several times, it is possible that the objective angle of turbed.
the strabismus would change. This gives the important The patient views a spot of light such as a naked torch
concepts of: bulb in an illuminated room. When the strabismus is
unilateral, only one Bagolini glass is needed. This is
(1) Habitual angle ofstrabismus. The objective angle nor- placed before the deviating eye to produce a vertical
mally maintained by the patient under undisturbed streak. It is useful to demonstrate the streak to the
conditions. patient by first holding the glass for a few moments
(2) Total angle ofstrabismus. The objective angle follow- before the fixating eye.
ing prolonged or repeated dissociation of the eyes. If the patient has normal retinal correspondence, the
streak and the spot of light seen by the deviating eye
(The difference between the habitual and total angles will probably be suppressed to avoid diplopia. If there is
implies that the ARC may induce some motor fusion to no suppression, the spotlight will be seen in diplopia
hold the eyes at the habitual angle.) with the streak passing through the diplopic image
In the presence of a consolidated harmonious ARC, (Figure 10.24a) .
the change from the habitual to the total angle of stra- In harmonious ARC, only one spot will be seen with
oars does not normally affect the angle of anomaly. the streak passing through or very close to the spot
For example, if a patient with 15A of habitual esotropia (Figure 10.24b). The streak often passes within 0.5A of
was found to have a total angle of 22A, the fixation the spot rather than exactly through it. This should
object in this latter state would appear to jump through be regarded as a type of fixation disparity and not an
7A, but this is not an indication of unharmonious ARC. unharmonious ARC. The Bagolini glasses show that a
As shown in Table 10.4, the angle of anomaly remains very high proportion of strabismic patients have harmo-
eye nious ARC.
Another cause of a false indication of an unharmo- When unharmonious ARC is present, the spot will in
nious ARC is the proximal convergence induced by theory be seen in diplopia (Figure 10.24c), but the
measuring strabismus with instruments such as the sy- angle of diplopia will not correspond with the objective
noptophore. The test objects are viewed at optical infi- angle. The streak will again pass through the diplopic
nity, but the proximal convergence induced by looking image of the spot.
into an instrument which is obviously close to the eyes In some patients, suppression ofthe retinal area in the
may increase the habitual angle of an esotrope in a squinting eye that receives the image of the fixation
manner similar to the above example. object is so marked that the streak will not be seen at
Perhaps the simplest and least unnatural test for ARC all, or sometimes shows a gap (Figure 10.24d). Thus,
is the Bagolini striated glass (Bagolini and Capobianco, the diplopia of a true unharmonious ARC may be
1965). These lenses produce a faint streak of light at masked.
right-angles to the striations when a small bright Some patients may change fixation to the normally
source of light is viewed through them. Unlike the deviating eye in order to see the streak, which will then
Maddox rod, they enable the surroundings tc be seen pass through the light. For this reason the Bagolini
quite clearly, only a slight reduction in visual acuity glass should be used with a cover test to verify that the
 Exercises 189

eye behind the glass is still deviating. To check for ARC drops in each eye probably being indicated if the irides
in the vertical direction, the glass is rotated to give a are exceptionally dark in colour.
horizontal streak. Those hypermetropes whose esotropia is refractive in
In alternating strabismus, two glasses must be used, origin will show a reduced angle or may become hetero-
placed obliquely so that the streaks form an ‘X’ (St. An- phoric with correction of the error. Even when the
drew’s cross). In harmonious ARC, these will intersect angle is not totally eliminated, constant wear of the cor-
at the spot of light whichever eye is fixating. rection must be ordered, since the residual angle may
Uncertainty about the size of the subjective and objec- decrease still further with time. If left uncorrected, the
tive angles in the strabismic patient makes a full study child may develop motor changes, making later treat-
of ARC somewhat time consuming. Moreover, the false ment less likely to succeed.
conditions of examination with an instrument such as If amblyopia is present, occlusion should be prescribed
a synoptophore with its reduced field of view may cause together with a refractive correction. If the error is at
the patient to change from, say, harmonious ARC back all large, occlusion alone without spectacles is a waste
to normal retinal correspondence. Hence, the various of time.
tests for ARC allow the depth of a patient's ARC to be Patients with convergence excess, that is, those who
graded. Patients with deep ARC may need to be given show (greater) esotropia in near vision, may be further
treatment for this before dealing with the angle of devia- helped by bifocals, while exotropic patients may be able
tion, whereas ARC may be ignored if only slightly devel- to control their deviation better if given a negative
oped. spherical addition to their lenses (somewhat as sug-
gested on page 175).
.
The study of heterotropia covers many facets, not all
Motor sequelae to strabismus of which have been mentioned in this chapter. For ex-
ample, false projection and classical eccentric fixation
Some strabismus is directly due to anatomical or neuro- of several prism dioptres of eccentricity’ have purposely
been ignored as being outside the scope of the present
logical abnormalities. Even if the extra-ocular muscles
text.
were anatomically and physiologically normal before
the onset of strabismus, months or years of deviation
may eventually produce secondary changes in the mus-
cles. In a high esotropia, for example, the lateral rectus
may be permanently elongated while the medial rectus Exercises
remains in contracture. Eventually, the ability of the
eye to abduct may become restricted. A motility test 10.1 A +3.00 DS bilateral hypermetrope is orthophoric with
might initially show relatively little disproportion be- spectacles and has an AC/A ratio of 3A/D. What is the predicted
tween the left and right eyes, although the fields are lat- heterophoria in distance and near vision at 40cm without
erally displaced. Later on, the fields may take an spectacles?
10.2 (a) A —4.00 DS bilateral myope is 6A exophoric in dis-
appearance similar to that produced by an extra-ocular tance and near vision. Discuss whether his spectacles need to
muscle palsy. In the presence of a well-established ARC be accurately centred to PD, and if not, what latitude in optical
that does not break down on investigation of the moti- centration would be admissible in dispensing? (b) Repeat the
lity, the subjective angle recorded will differ from the ob- above, but for an exophoric hypermetrope.
10.3 (a) A +5.00 D bilateral hypermetrope has a fixation dis-
jective angle. As a result of both motor and sensory
parity of 1A base-up right eye. What decentration of each lens
changes, deviation that might have been readily cured is required to correct the disparity? (b) Repeat the above, but
by refractive and/or orthoptic means soon after onset for a —2.00 D myope.
may become very difficult to cure after only a few years. 10.4 A patient’s prescription is R and L +4.00DS, add
42.00 DS. Separate pairs are dispensed, both with incorrect
centration distances of 70 mm instead of the correct 64 and
61 mm. What is the induced prismatic effect in each case?
Examination and treatment of the 10.5 The Freeman—Archer tangent scale shown in Figure
10.9 is viewed by a patient with 10A of esophoria. The rod
strabismic patient before the right eye is tilted through 5° anticlockwise. What is
the false hyperphoria reading?
The examination must include a thorough history of the 10.6 A patient views a fixation disparity unit at 6 m. One of
the markers appears displaced through 20mm. What is the
patient: type of birth, whether premature or if forceps angular fixation disparity and the displacement on the retina
were needed; age at the onset of the strabismus; child- of a +60 D reduced eye?
hood illnesses; any previous treatment including specta- 10.7. Draw the appearance of bilateral fixation disparity for
cles, occlusion, orthoptics, surgery; whether parents or both horizontal and vertical markers in incyclophoria.
10.8 The spectacle correction BE +4.50 DS add +1.50D is
relations have strabismus or have to wear spectacles
made up as: (a) Executive-type bifocals; (b) plastics bifocals
(or contact lenses). with each segment geometrically inset 2 mm. Given a separa-
A thorough refractive examination of the patient is tion of 64 mm between distance optical centres, what is the dis-
essential. With a young child, it is necessary to use ob- tance between the near optical centres of each pair and what
jective methods such as retinoscopy to determine the
distance refractive error and dynamic retinoscopy to
check that full reserves of accommodation are present. “Most amblyopes may be regarded as having a very small
The child should then be refracted again under cyclople- angle eccentric fixation, indicated by the reduction in visual
gia: 1% cyclopentolate should be adequate, with 2 acuity shown in Figure 3.16.
190 Anomalies of binocular vision: heterophoria and heterotropia

is the horizontal prismatic effect at the segment centre of each MALLETT, R.E.J. (1970a) The Stanworth synoptoscope in the in-
lens? vestigation and treatment of strabismus. Ophthal. Optn, 10,
10.9 Repeat Exercise 10.8 for the prescription BE +12.00 DS 556-558, 571-573
add +3.00 D in plastics bifocals only. MALLETT, R.F.J. (1970b) Anomalous retinal correspondence —
10.10 A (dyslexic) patient suffers from slight diplopia and the new outlook. Ophthal. Optn, 10, 606-608, 621-624
confusion when reading. If the print of these exercises is read MALLETT, R.F.J. (1983) A new fixation disparity test and its ap-
from a distance of 300mm, calculate the horizontal prism plications. Optician, 186(4815), 11-15
needed to displace the image in one eye by the equivalent of MALLETT, R.F.J. and RADNAN-SKIBIN, R. (1994) The new dual
the width of four letters. fixation disparity test. Optom. Today, 34(5), 32-34
NORTH, R.V. and HENSON, D.B. (1981) Adaptation to prism in-
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NORTH, R.V. and HENSON, D.B. (1982) Effects of orthoptics upon
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Ophthal. Physiol. Opt., 12, 299-301 horizontal differential prism on the binocular contrast sensi-
LANCASTER, W.D. (1928) The Ames spectacle device for the tivity function. Ophthal. Physiol. Opt., 6, 207-212
treatment of cyclophoria, with a report of a successful case. WALSH, F.B. and HOYT, W.F. (1969) Clinical Neuro-Ophthalmol-
Archs Ophthal., N.Y., 57, 332-338 ogy, 3rd edn, Vol. 1, pp. 130-349. Baltimore: Williams and
LYLE, T.K. and BRIDGEMAN, G.J.0. (1959) Worth and Chavasse’'s Wilkins Co.
Squint, 9th edn. London: Bailliere, Tindall & Cox WOLF, K.S., CIUFFREDA, K.J. and JACOBS, S.£. (1987) Time
MALLETT, R.F.J. (1964) The investigation of heterophoria at course and decay of effects of near work on tonic accommo-
near and a new fixation disparity technique. Optician, 148, dation and tonic vergence. Ophthal. Physiol. Opt., 7, 131-135
547-551, 574-581 YEKTA, A.A., JENKINS, T. and PICKWELL, D.1I. (1987) The clinical
MALLETT, R.F.J. (1969) Binocular vision in strabismus. Ophthal. assessment of binocular vision before and after a working
Optn, 9, 812-824 day. Ophthal. Physiol. Opt., 7, 349-352
ll
Stereopsis and the stereoscope

Perception of depth and stereopsis The possibility of another mechanism serving specific-
ally as an aid to depth perception of approaching or
Monocular clues to depth perception retreating objects has recently been postulated. Re-
searches by Regan and Beverley (1978) have suggested
Though retinal local sign enables«us to determine the di-
the existence of ‘looming detectors’ in the visual
rection of objects relative to the fixation axis, on its
system. These are neurons or groups of neurons, some
own it gives no indication of the distances of objects
sensitive to an increase and others to a decrease in the
from the observer. A person with only one eye is able to
retinal image size of moving objects.
judge the relative distances of objects in space by using
various monocular clues to depth perception. Good co-
ordination of the two eyes results in binocular vision in
its highest form: stereoscopic vision or stereopsis. This
enables us to judge the relative distances of objects Stereoscopic vision
with great precision,“even in the absence of monocular
Stereoscopic vision is the ability to judge the relative dis-
clues.
tances of objects from the observer by means of bin-
Monocular clues are discussed in many textbooks on
ocular vision only. This ability depends on very small
vision (for example, Davson, 1980) and will merely be
disparities between the retinal images in the two eyes.
summarized here.
In Figure 11.1, the object Q on the horopter through
B, to which point both eyes are directed, is imaged on
(1) Size. The size of the retinal image varies directly the corresponding points Q{ and Qk. Point H, at the
with the angular subtense of the object and is also limit of Panum’s fusional space, is imaged at Hp coinci-
inversely proportional to the object distance. In nor- dent with Og and at Hj at the edge of Panum’s area
mal circumstances, an image decreasing in size is centred on Q,. It is this small disparity, Q,H{, which
not interpreted as a shrinking object but as an gives rise to stereopsis.”
object of constant size moving away (a phenomenon For the purpose of analysis, Figure 1 1.2 illustrates the
known as size constancy). The distance of an object, more general case in which the two given object points
provided it is familiar, can thus be judged by accu- QO and H are not in alignment with either eye. The line
mulated experience. The geometrical perspective of joining the right and left nodal points plays an impor-
buildings provides a similar clue. tant role as the common base of the two relevant tri-
(2) Overlap. Nearer objects obstruct the view of more angles. Its length 2a clearly varies with the state of
distant objects. convergence, but can be taken without serious error as
(3) Aerial perspective. Scattering of light in the atmo- equal to the inter-pupillary distance under the same
sphere makes distant objects appear less clearly conditions. According to our sign convention, the dis-
defined and often tones them with blue. tance / from the inter-nodal base line to the object Q is
(4) Shading. The direction of illumination gives rise to negative and the distance A/ is positive.
shadows, thus giving texture to the surface. The small angle gg subtended by the base line at Q is
(5) Parallax. As the observer moves, nearer objects the binocular parallax of Q, while the angle oy is the
appear to move in the opposite direction, further binocular parallax of H. They are expressed in radians
objects in the same direction as the observer. by the approximations
Moving objects show their own passage through
the surroundings even in the absence of observer
dg = —2a/¢
motion. Parallax and apparent size are probably
the most important elements in driving.
(6) Accommodation and convergence. Although accommo-
" This is not meant to imply that stereopsis is possible only if
dation is adjusted to focus upon a near object, it is the retinal images of a given point fall within Panum’s areas.
of little help in judging distance. Convergence, Ogle (1962) has shown that stereopsis is possible, even with
although a binocular function, is also of little aid. images significantly outside these areas.
192 Stereopsis and the stereoscope

if the quantity 7A/ is ignored as small in comparison

with 77.
It can be seen from Figure 11.1 that the relative bin-
ocular parallax in this case is the angle H,N,Q; and
that this angle determines the total linear disparity 6 be-
tween the positions of the retinal images of the two
given points. In this case the disparity occurs in the left
eye only, but if both object points were situated in the
median plane the disparity 6 would be equally divided
between the two eyes.
Stereoscopic acuity is expressed in seconds of arc as
the smallest angle n of relative binocular parallax that
can be perceived. It can be determined from equation
(11.1) by finding the smallest distance A/ that can be
seen as a difference in depth at a given object distance 7.
One method of measurement is the three-needle test.
The subject views three vertical wires, the two outer
ones being fixed in a fronto-parallel plane while the
middle one is movable back and forth along the median
plane. To obviate the important clue of parallax, the
subject's head must be held still by some means. The
three wires must be seen against a uniform background
with their tops and bottoms screened so that the vertical
angular subtense of all three remains constant. Frac-
Figure 11.1. The retinal disparity 6 associated with the tional changes in the apparent width of the middle wire
depth OH in object space. as it is moved may still provide a clue. To counteract
this effect the wires may be replaced by the straight
inner edges of two surfaces whose outer edges are
screened from view. One edge is kept fixed while the
other may be moved. A forced-choice statistical ap-
proach is normally used.
The forced-choice approach was introduced for a two-
needle test by Howard (1919). In the Dolman modifica-
tion often used in the USA, the subject moves the
second rod by remote control into the same apparent
plane as the first rod. The mean error in positioning in
a series of trials is taken as a guide to stereo-acuity.
Larson (1985) shows that the Howard—Dolman
approach is much less satisfactory than the forced-
choice approach.
The stereoscopic acuity of a trained observer is about
5 seconds of arc and can even be as fine as 2 seconds
under favourable conditions. It improves with time al-
lowed for observation up to about 1 second. Stereo-
scopic acuity is of the same order as vernier acuity, and
both are much keener than line-width acuity. If 1 is
taken as 5 seconds and the nodal point 16.7 mm from
the retina, the disparity shown in Figure 11.1 is as little
as 0.0004 mm, much less than the diameter of a single
Figure 11.2. The difference in binocular parallax, 09 and 0) retinal cone.
respectively, of object O and H at different distances. In equation (11.la) the relative binocular parallax
(O;, — 9g) is in radians. If it is replaced by its minimum
perceptible value n in seconds of arc and the appropriate
and
conversion factors are applied, the equation can be re-
by = —2a/(¢ + AL) arranged to give

with a and / in the same units. The difference (04, — 99) nl?
A¢ = +———_ (ela)
is known as the relative binocular parallax and is given 206i PD
by
in which the denominator 2a has been replaced by the
—2aA/¢ PD in millimetres. For example, given n = 5 seconds,
dy °Q =F EM (iat) ¢=—1 metre and PD = 65mm, A¢/ is found to be
+3.7 x 10°*m or £0.37mm. For other values of n.
me —DaAL |e (eleetaralica))
the value of AZ would vary in proportion.
 Telestereoscopes, rangefinders and binocular telescopes 193 2

103
N X (PD)

10

8
10;
2
~

|
| |
| |
| |
{0 | |
| |
| |
aX
10re 7
pig
N / \
=0.1 —{ —10 =10* —10° ( \ ( )
€ (metres) nee s \~7

Figure 11.3. The minimum perceptible depth difference A/

as a function of object distance / for two values of the Figure 11.4. Optical arrangement of the telestereoscope.
stereoscopic acuity. Both co-ordinates are scaled
logarithmically.
Another method is to magnify the retinal images, thus
increasing the disparities on which stereoscopic vision
It can also be seen from equation (11.2) that the mini-
depends (Figure 11.1).
mum detectable depth AZ is directly proportional to the
The telestereoscope devised by Helmholtz consists es-
square of the observation distance and inversely propor-
sentially of two pairs of mirrors (Figure 11.4) so ar-
tional to the base line or PD. Figure 11.3 shows on loga-
ranged that the inter-nodal base line is increased by the
rithmic scales A/ plotted against / for two different
factor N. At the same time, the relative binocular paral-
stereoscopic acuities, 5 and 20 seconds of arc, the PD
lax and the greatest distance distinguishable from infi-
being taken as 65 mm. Since A/ is proportional to 7,
nity are also increased by the factor N. At the same
the scale factor for 7 is twice that for A/.
time, the least perceptible difference in depth is de-
It may be further deduced that beyond a certain dis-
creased by the factor N.
tance (sometimes known as the stereoscopic range), dif-
ferences in depth, however great, cannot be perceived.
These effects are enhanced if, in addition, a telescopic
This is the distance at which the base line subtends the system magnifying M times is incorporated in each side
same angle n as the subject's stereoscopic acuity. of the instrument. The factor MN should now be in-
Beyond this distance, the binocular parallax of any cluded in the numerator of equations (11.1) and
object must be less than the angle n. Consequently, the (11.la) and in the denominator of equation (11.2). In
relative binocular parallax must also be less than n. theory, the least perceptible separation A/ for a given
which by definition is the smallest perceptible value. distance / should now be 1/MN times the corresponding
For a PD of 65mm, the limiting distance is about value for the naked eyes. In practice, however, the mag-
2700m when n= 5seconds of arc but reduces to nification factor M is not as effective as predicted.
about 670 m when yn has the poorer value of 20 seconds Optical rangefinders, which combine the two expedi-
of arc. ents just described, are of two different types: the coinci-
Stereoscopic acuity declines: dence and the stereoscopic. The former type combines
half the field of view from each of the two separate view-
(1) with increasing lateral separation of the test objects, ing points and measures the adjustment needed to
(2) at increasing angular distances from fixation. bring them into coincidence. The stereoscopic type de-
In this latter respect it is similar to visual acuity, pends upon the fact that if two marks, one placed
except that the maximum may occur at about 21 min- before each eye, are seen stereoscopically, the apparent
utes of arc or slightly less from the central fovea. Meas- distance of the single percept depends on the lateral se-
urements at various angles from fixation were made by paration of the marks. These are adjusted to place the
Ogle (1962). At 6° from fixation he found stereoscopic fused percept in the apparent plane of the object
acuity to diminish by a factor in the neighbourhood of viewed. For further technical and descriptive detail, see
10-15. Jacobs (1943), Patrick (1969) or Horne (1980).
Ordinary prism binoculars also give some enhance-
“ ment of stereopsis. In those models using the conven-
tional Porro prism erecting system, the separation of
Telestereoscopes, rangefinders and the objectives is usually at least 1.5 times the PD. With
binocular telescopes an 8x magnification, the product MN would have the
value 12. It was shown earlier that the stereoscopic
Equations (11.1) and (11.1la) show that depth percep- range of a person with stereoscopic acuity of 20 seconds
tion can be improved by increasing the base line. of arc and PD 65 mm was about 670 m. With the bin-
194 Stereopsis and the stereoscope

oculars just described, the range would be increased to

8040 m or approximately 8 km.
A coefficient of stereoscopic relief R may be defined as
base-line magnification
R=N/M=— ee
image magnification
A normal three-dimensional appearance of objects will
be seen in binocular instruments if R is approximately
equal to unity, as in unaided binocular vision.

Figure 11.6. A basic method for producing a stereogram of

the tilted line object GH.

Alteration of perspective
should ideally be viewed from a distance v given by
In general, perspective is altered when objects are
viewed through magnifying devices, whether monoc- v= (f/fh)d (11.3)
ular or binocular. Figure 11.5 illustrates schematically where f, is the focal length of the camera lens, i the
two objects of equal height at J and K viewed by an un- focal length of the projector lens and d the distance of
aided observer stationed at A. The ratio of their angular the screen from the projector.
subtenses at A is equal to KA/JA (1.5 in the drawing).
If the observer now moves to the nearer point B, the
ratio becomes KB/JB, which is clearly greater (2.0)
than before. If the scene were viewed from A, through
The stereoscope
a telescope magnifying M times, the apparent angular
To simulate the slightly different images obtained by the
subtense of each object would be multiplied by M, but
two eyes, a real three-dimensional scene or object can
the ratio would remain KA/JA. Nevertheless, the per-
be photographed or drawn from two different viewing
spective is changed because the subjective effect of the
points. The resulting pair of two-dimensional pictures,
magnification is to place the observer nearer to the
called a stereogram or stereopair,’ can then be viewed
scene, say, at B where the ratio ought to have the value
in a stereoscope, a special instrument enabling the ob-
KB/JB. The telescope has apparently diminished the
server to obtain a single three-dimensional percept of
relative height of the nearer object. With binocular tele-
the original scene.
scopes, another effect of the angular magnification is to
increase the convergence normally required when
Figure 11.6 illustrates the two eyes (R and L) viewing
viewing near objects.
an obliquely placed wall GH through a window WW. Be-
Changes in perspective are often more noticeable in cause GH is tilted, its projection GH; on the window
photography. A comparison of photographs of the same from the left viewpoint is smaller than the right projec-
scene taken through a wide-angle lens and a telephoto tion GkHk. It is this difference, however small, in a pair
lens will show completely different perspective if the of stereocards which gives rise to the retinal image dis-
object distance is adjusted so that the image of the prin- parities and hence to stereopsis. The points GH need
cipal feature has the same size on each negative. Pro- not be the extremities of a single object but could also
vided that the camera lens does not introduce represent two separate objects at different distances.
distortion, pictures of a scene photographed from the If these two projections are now substituted for GH, a
same point through lenses of different focal lengths will subject with normal stereoscopic vision could obtain a
all have the same perspective (see, for example, the illus- three-dimensional impression. There would, however,
trations in Langford, 1971, or other books on photogra- be certain difficulties. The eyes may be unable to accom-
phy). For a correct impression of perspective, a modate for such a small viewing distance, especially
photograph should be viewed from a distance given by since the convergence of the visual axes must remain
the product of camera lens focal length and enlargement the same as when viewing the actual distant object.
(ratio of print size to negative). The print then subtends Furthermore, it may be disconcerting for the subject to
the same angle at the eye as the original did at the be strongly accommodating while apparently viewing a
camera lens. On the same principle, a projected image distant scene. Also, the size of the stereoscopic pair
(GrHR G_H_) is limited because the two projections
must not overlap. It was to overcome these drawbacks
that the stereoscope was invented.
Figure 11.7 illustrates the principle of the reflecting
stereoscope invented by Wheatstone in 1838. The two
mirrors VV allow the separate halves of the stereogram
to be placed at a convenient distance from the eyes
while keeping them of relatively large size. The points

K J B A
Figure 11.5. Perspective: angular subtense as a function of si The term ‘stereopair’ is better used to denote a specific pair
object distance; KA/JA<KB/JB. of R and L points presented stereoscopically.
 The stereoscope 195

Figure 11.9. The increased card size of the Brewster—Holmes

stereoscope (1861) (cf. Figure 11.8).

Figure 11.7. Principle of the Wheatstone stereoscope

(1838). The lenses allowed the pictures to be seen at optical infi-
nity and without convergence. It can be seen from
Figure 11.8 that with this arrangement the distance
G,, Gg represent a stereopair, as do H;, Hp. They are BrB, between the centres of the right and left pictures,
imaged at G;, Gp and H}.. Hk respectively. In the stereo- which limits the picture width, is the same as the dis-
gram, the distance separating G,; and Hy, is smaller tance between the optical centres of the lenses.
than that between Gp and Hr. To see G; and Gp singly, As recalled by Fincham (1948), this model was modi-
the two visual axes must lie along Z,G, and ZpGp, in- fied and improved in 1861 by Oliver Wendell Holmes,
tersecting at Gp. This is the hypothetical point which, more widely known as writer than as ophthalmologist.
viewed directly, would require the two eyes to converge The lenses were decentred outwards, becoming sphero-
exactly as in the diagram with the stereoscope in use. prisms, and the stereogram holder was mounted on a
For this reason it was termed by Bennett (1977/78) the central bar along which it could slide, thus adjusting
equivalent binocular object (point). It represents the the distance of the image to suit the user’s vision. The
position which the perceived image seen with the stereo- instrument could also be hand held comfortably.
scope might be expected to occupy. The same reasoning As shown by Figures 11.8 and 11.9, the incorporation
applies to the equivalent binocular object point Hp, of the base-out prisms increases the maximum picture
which is at a shorter distance from the eyes, thus size merely by increasing the distance between the opti-
giving a three-dimensional impression. cal centres of the lenses. Owing to these various im-
Several other designs, one using a single plano prism, provements, the Brewster—Holmes stereoscope has been
were later introduced by Brewster, whose classic work the design most widely found in clinical use. Usually
on the subject appeared in 1856. The best-known the lenses are of power +5.25 D with their optical cen-
model, which he called the lenticular stereoscope and tres 85 mm apart.
first described in 1849, achieved an enormous success Even though enjoying good stereoscopic acuity, some
as a form of home entertainment. It is illustrated patients find that it takes a little time for the three-di-
schematically in Figure 11.8. In essence, it consists of a mensional effect to emerge. Familiarity with the stereo-
box, one side housing two centred collimating lenses lat- scope pictures or the objects portrayed may help to
erally adjustable to suit the viewer’s PD. The other side speed the process.
held the stereogram, which could be a transparency. Strong evidence that retinal image disparity is a suffi-
cient as well as a necessary condition for stereopsis is
provided by ‘random dot’ stereograms. According to
Shipley (1971) the first stereogram of this type was de-
vised in 1954 by Aschenbrenner, using a simple but in-
genious method of construction.” The right and left
halves are apparently the same but, in fact, contain
corresponding portions laterally displaced with respect
to the background. As a result, these areas appear to
stand out or recede from the background despite the

By

“In fact, random dot stereograms constructed from small

black circles of different sizes, somewhat similar to Ishihara col-
Figure 11.8. Principle of the Brewster stereoscope (1849). our plates, had been marketed by Carl Zeiss (Jena) before 1930.
196 Stereopsis and the stereoscope

absence of any extraneous clues as to their size, shape or When the right visual axis is directed towards Gg and
position. the left towards G, they intersect at Gg as though the
The stereogram reproduced in Figure 11.10 was con- naked eyes were fixating a single object point in this pos-
structed from identical portions cut from two photo- ition. By a similar construction, the point Hg can be lo-
copies of a piece of Harris tweed — a material with a pro- cated.
nounced weave. When viewed stereoscopically, a face If the picture viewed is a reproduction of a real object
will be seen. The nose appears in front of the cheeks, tilt- or scene as distinct from an abstract geometrical draw-
ing towards the viewer. This effect was achieved by ing, the perspective should, if possible, approximate to
superimposing identical strips of the photocopy on the that which would be seen under natural conditions. To
right and left halves of the stereogram, both strips maintain the correct angular relationships if photogra-
being equally decentred inwards with an additional phy is used, the lateral separation of the two camera
slight inward tilt at the bottom. The eyes also stand for- positions should be the same as the viewer's PD and the
ward, while the strips for the mouth, being decentred magnification (enlargement) m of the prints should
outwards, should (but may not) be seen as a cavity satisfy the relationship
behind the plane of the face. Letratone material LT 134 Focal length of stereoscope lenses
and 136 can be used in the same way. mi - : (11.4)
Focal length of camera lens
Computer-generated stereograms on the random dot
principle have recently become familiar through the If a greatly enhanced sensation of depth is required
work ofJulesz (1960). when the stereogram is viewed, the distance between
More recently, computer programs for generating the two camera positions should be increased like the
random dot stereograms have been devised by Fowler base line of the telestereoscope. This occurs in aerial
(1985), Graham (1985) and Burek (1985). photography when the two positions may be separated
Some of the more recent theories of stereopsis, derived by several kilometres. For the accurate measurements
partly from the need to explain random dot stereopsis, required in cartography, both the camera and stereo-
are summarized by Gilchrist (1988). scope lenses should be very free from distortion (Horne,
1980).
A detailed mathematical analysis of perspective in
binocular projection can be found in Helmholtz’s classic
Optics of the Brewster—Holmes treatise (1924).
stereoscope

Basic principle Use in clinical practice

The basic principle of the instrument is illustrated in In clinical practice, the stereoscope is mainiy used as a
Figure 11.11. In the state of adjustment shown, the device for presenting different test objects or stimuli to
stereogram has been moved forwards from the anterior each eye. These may be designed to test or exercise the
focal plane of the stereoscope lenses so that the conju- muscular fusional reserves or to examine the quality of
gate image plane lies at a desired finite distance. The the perceptual fusional process, for example, with the
points (Gpr,G,) and (Hp,H,) are two stereopairs; Gp and Javal FL card. To describe any such tests as ‘stereo-
Hr are imaged by the right lens at Gp and Hp while G, scopic’ would be misleading: the term ‘stereoscope test’
and H, are imaged by the left lens at G}, and H,. Their would be preferable.
positions can be determined graphically by straight When the stereoscope is used in this way, any distur-
lines drawn from the optical centres Op and O; of the bance of the normal relationship between accommoda-
stereoscope lenses through the given object points. tion and convergence should be avoided. To meet this

Figure 11.10. A ‘Harris Tweedogram’ or a random dot stereogram constructed from identical pieces cut from photocopies of
Harris Tweed.
 Optics of the Brewster—Holmes stereoscope 197

Image Plane of
plane stereogram

Figure 11.11. Arrangement and optical principles of the Brewster-Holmes stereoscope.

incident ray, the refracted ray passes through the

Optical axis
second principal focus Fz of the lens. Wherever G is situ-
ated, its image G’ must therefore lie on the line EFg pro-
duced either way. The required position Gy of the test
object is such that GX lies on the median line at its inter-
section with FRE produced backwards. A line drawn
ae : . from Gy to Op intersects DE at the desired point Gy.
ae Median line
From the similar triangles in the diagram it can be
N e seen that

Figure 11.12. Diagrammatic construction to find the

Gd
position of the test card required to place the image of the point ae
Gy on the median line.
or

(b= q)F = =—qL’

requirement, both right and left test objects must be
imaged on the median line or at equal distances to the This gives
same side of it.
L' = {1 — (b/q)}F (11.5)
If the separation between corresponding details on the
test card is smaller than that of the optical centres of and
the stereoscope lenses, the correct adjustment of the in- L=L' —F=—(b/q)F (11.6)
strument can be found graphically, as shown in Figure
11.12. This shows that part of the instrument used by These relationships are independent of the position of
the observer's eyes.
the right eye. The lens of power F and optical centre Op
Assuming that, as is usual, F=+5.25D and 2b =
distant b from the median line is assumed to be thin.
85mm, with g = 30 mm, we should have
For ray construction it is replaced by a straight line. As
the test card is moved towards the observer, the centre 4 (42°5/30)15.05 = —=2.19 D
G of the right test object, at a distance q from the
and
median line, moves along the line DE parallel to the opti-
cal axis of the stereoscope lens. If DE is imagined as an L=—7.44D
198 Stereopsis and the stereoscope

<—— ¢” or
b-q_ b-q
Optical axis B’ =f ese
Primary line
from which

(b= q)L = (b—q')(L+F)

and
, @QL+bF
(11.8)
ree
When this expression is substituted for q’ in equation
Median line (11.7), we get

Figure 11.13. Diagram for analysis of convergence and Cz {(p — @)L + (p— b)F}Z (11.9)
accommodation through the Brewster—Holmes stereoscope. L+F-Z
This gives the uniocular convergence in prism dioptres
when p, q and b are in centimetres.
Measured from the lens plane, the accommodation re-
quired would be —L’ or approximately 2.25 D
The above construction could be reversed to find the Accommodation
necessary value of q to place the image on the median
To sufficient accuracy, the accommodation required is
line at a desired distance from the lens.
the reciprocal of the distance in metres from the image
plane to the eye’s centre of rotation. Hence

ee Sas LZ
SH ae a7
Convergence and accommodation
. (E44
The general analysis in this section is abridged from (11.10)
~L+F-Z
Bennett (1970). Figure 11.13 shows the optical ar-
rangement for the right eye, with the following dis-
tances all measured from the median line: Convergence/accommodation ratio (C/A)
b to the optical axis of the stereoscope lens, On dividing equation (11.9) by (11.10) we obtain the
p to the primary line of sight, general relationship
q toa given point GR on the stereogram,
q’ to Gp the image of Gp formed by the stereo C/A= (p — q)L+
(p— b)F (ital)
scope lens. L--F
A simpler and more enlightening expression can be de-
The first three of these distances are invariably re-
rived from equations (11.7) and (11.10), giving
garded as positive. In general, Gp does not lie on the
median line and the distance q’ is regarded as negative C/A=p-q (ee)
if it lies on the opposite sign of the median line. The normal relationship between convergence and
To receive a sharp image of Gp the eye must exert the accommodation requires Gp to lie on the median line.
necessary amount of accommodation and converge so In this event, q’ = 0 and C/A = p (compare this equation
that the visual axis is directed towards the image point
with (9.6) in which C denotes the total convergence by
Gk. The ray path through the eye’s centre of rotation is
both eyes). If expression (11.8) for q' is equated to zero,
then GrVZp.
we obtain the condition that

L = —(b/q)F
Convergence This is the same as equation (11.6) derived earlier
from a graphical construction.
Let the convergence of the eye in prism dioptres be de-
This value of L gives the position of the stereogram
noted by C. It can then be seen from the diagram that
along the axis of the instrument so that a given stereo-
Cauh =
GrD_ p-q pair defined by the distance 2q, is seen under the
DZ7 ae normal C/A ratio. Maddox called this position the ‘neu-
tral point’. If the stereogram is placed further from the
Putting L’ = 1/¢’ = (L+ F) and Z = 1/z, gives
eyes, the image point Gk then lies on the remote side of
(p—q')(L+F)Z the median line. The distance q’ thus assumes a negative
C—
L+F-Z
(11.7)
value, so that (p—q’), the measure of C/A, becomes
A more useful expression is obtained if q’ is replaced greater than p. Conversely, when the stereogram is
by other known quantities. From the similar triangles moved nearer than the neutral point, Gp shifts to the
in Figure 11.13 having a common vertex at Op the opti- near side of the median line, making q’ positive in sign
cal centre of the lens, we get and (p—q’) less than p. Negative fusional reserves of
convergence are brought into play. Alternatively, the
BGr/BOp = B’GR/B’/OR card holder is left in a position to simulate a distant or
 Additional methods of producing stereoscopic relief 199

near object, and cards having detail at steadily decreas- Cc Cc C C Cc

ing or increasing values of q are used in order to stimu-
late relative convergence or divergence respectively.
Typical cards are the Wells, Bradford (Pickwell) and
London Refraction Hospital stereograms (Mallett, 1988).
Control over the C/A ratio can be achieved by separat-
ing the two halves of the stereogram and mounting
each one on its own adjustably angled rail. Their se-
paration then varies to a predetermined degree as the
viewing distance, which can be kept the same for each
eye, is altered. By this means, the C/A ratio can be main-
tained at any desired value for all viewing distances.
This is the principle of the Asher—Law stereoscope. For
details of this and of the Barrett relative accommodation
stereoscope, see Bennett (1970).

Fixation with crossed or uncrossed axes: the

autostereoscopic effect
Single vision as opposed to double vision occurs when
the two retinal images are positioned similarly with re- LTE RE
spect to the two foveae. This is normally achieved by Figure 11.14. Principles of the autostereogram.
correct alignment of the two eyes, but when viewing
any pattern with detail repeated at regular horizontal
are of interest. If the stereogram is small, the separation
intervals, for example, wallpaper with vertical lines, it
being no bigger than the inter-pupillary distance, some
is possible for the eyes to over-converge so that the
people can fuse a stereogram unaided. This requires
right eye fixates detail to the left of similar detail fixated
them to relax their convergence while maintaining ac-
by the left eye. This is the principle underlying the
commodation.* With the visual axes approximately par-
‘three cats’ orthoptic exercise for developing positive
allel, the right eye fixates the right half and the left eye
relative convergence — see Evans (1997). The effective
the left half of the stereogram. The entire card is, in
binocular object is then situated in the plane containing
fact, viewed in crossed physiological diplopia so that
the intersection of the visual axes. Micropsia then re-
four pictures may be seen initially. If the convergence is
sults — the angular subtense of detail of size s is then
adjusted, the two centre pictures can be superimposed
s/d, where d is the distance to the wall, whereas the
to give a stereoscopic percept. This appears to be distant,
brain would expect it to subtend s//, where / is the
yet nevertheless larger than one of the single pictures
smaller distance to the effective binocular object. Since
viewed at the same distance from the eyes. The angular
s/dis less than s//, the brain interprets this as a reduc-
subtense is the same in both cases, but when the per-
tion in size. A similar effect when accommodation is
ceived image seems further away its size is accordingly
weak is noted on page 119).
judged to be greater.
The term ‘autostereogram’ has been given to dia-
Alternatively, the visual axes may be crossed so as to
grams producing this effect, for example, computerized
view the stereogram in uncrossed diplopia, the right
random dot constructions as described by Tyler (1983)
and left pictures having been interchanged. In this
and popularized in books such as Horibuchi (1994).
case, the single percept will appear to be relatively
Figure 11.14 shows the method for designing an auto-
small though closer to the eyes because of the greater
stereogram for crossed visual axes. When viewed in
convergence required. Without practice it may be diffi-
crossed convergence, the repeated letter C forms the
cult to make these relative adjustments of accommoda-
background, while the wider spacing of the letter Ds
tion and convergence.
means that they are perceived to be closer. A similar
process can be used for diagrams for uncrossed visual
axes, again with a narrower spacing for the part to be Anaglyphs
perceived closer. Orthoptic exercises for developing con-
vergence based on autostereograms are being developed An anaglyph is a stereogram produced by the method
by B.J.W. Evans (pers. comm., 1996). described by Rollman (1853). The right and left views
are printed superimposed on a white ground, but one
in red and the other in green ink. One eye looks through
a green filter, so that the green ink cannot be seen
Additional methods of producing against the apparently white ground, whereas the red
printing appears black. The other eye looks through a
stereoscopic relief

Unaided vision
“With a reading correction in use, some presbyopes find it
Since it is not always convenient to use a stereoscope, possible to diverge sufficiently to fuse a stereogram of larger
other methods of obtaining stereoscopic reproduction size.
200 Stereopsis and the stereoscope

|e
red filter and therefore sees as black the picture printed
Neo STE RisFa Z|Ne es paw aE
in green. A vivid though substantially monotone stereo-
scopic impression can be created in this way. Extensive
use of anaglyphs is made in the work by Gregory Neh Nera
(L970):
One disadvantage of this method is that the red and
green colours induce an 0.50 D difference in refraction
between the two eyes. This may have a significant
effect in studies involving monocular blur. A further
drawback is that some people have difficulty in integrat- (a)
ing the right and left retinal images if they are in com-
plementary colours. For these reasons, monocular
suppression could possibly result. It might be possible
to use narrow spectral band filters of relatively similar Smeal 4]9[NG want hantories ean
colour, but whose transmission curves hardly overlap,
for example, a bluish-green and yellow-green. Decree
NEE
lendioemer
Nee,

Use of polarized light

Somewhat like an anaglyph, a stereogram can be con-
structed from two superimposed views, each printed or
reproduced in such a way that the light entering the
eye is substantially plane polarized. The right and left (b)
planes of polarization are mutually perpendicular and
the composite picture, a vectograph, has to be viewed
through an analysing visor. This technique allows only
black and white tones to be used. However, if two trans-
parencies are made and separately projected with polar- SS
oT Sees
x xX
ized light on to a metallic diffusing screen, the original
colours can be retained. An analysing visor is still
required.

Other methods
(
Various methods whereby single coloured pictures, up (c)
to quite large sizes, can be made to give a three-dimen-
sional impression when viewed normally without a
visor have been described by Dudley (1951). In one Figure 11.15. Simulation of reversed relief or pseudoscopy
with stereocards: (a) normal view of a pyramid, apex towards
technique, for example, the picture is composed of
observer; (b) pseudoscopic view obtained by interchanging
narrow vertical strips presenting alternative right and cards; (c) pseudoscopic view obtained by laterally reversing the
left viewpoints. A prismatic Fresnel-type grid perma- individual cards.
nently superimposed on the picture ensures that each
strip is seen only by the eye intended.
Wheatstone, who used a pair of Dove reflecting prisms,
one before each eye with the two reflecting (hypotenuse)
Pseudoscopy
faces turned inwards. In effect, this is equivalent to the
Pseudoscopy is an induced impression of relief in re- arrangement in Figure 11.15(c). To generalize, pseudo-
verse, nearer objects appearing further away than more scopy is possible when there is a contradiction between
distant ones. The simplest way of producing this effect relative binocular parallax and the right and left view-
is to interchange the two halves of a stereogram. In points, either of these entities being reversed from the
Figure 11.15(a) the stereogram would be seen three-di- normal situation.
mensionally as a pyramid viewed from above with its The mirror pseudoscope invented by Stratton in 1898
apex towards the observer. When presented as in Figure is shown diagrammatically in Figure 11.16. It avoids
11.15(b), the pyramid would appear to be hollow to- the lateral inversion of the Wheatstone model. By an ar-
wards the viewer. Another possibility is illustrated,
in rangement of two plane mirrors, the right and left view-
Figure 11.15(c), in which each half of the original points are reversed; the effect of the double reflection is
stereogram has been reversed right to left. The three-di- to image the viewer's left eye in the position shown. In
mensional appearance is again that of a hollow pyr- near vision, the result of the increased path length to
amid, but laterally reversed. this eye is a smaller visual angle and hence a smaller
An optical arrangement for producing reversal of retinal image than in the fellow eye. This drawback can
relief when a real object or scene is viewed is called be obviated by various symmetrical arrangements of
a pseudoscope. The first was devised in 1838 by four mirrors, two before each eye (von Rohr, 1920),
 Clinical tests for stereopsis 201

Figure 11.16. Arrangement of the Stratton pseudoscope

(1898).

In general, pseudoscopic vision is most easily obtained Figure 11.17. One pattern from the Frisby stereotest (1978).
with geometrical constructions or objects which can The portion enclosed by the broken line is on the opposite side
of the plate. (With acknowledgements to Professor Frisby and
themselves be seen in either form; for example, a
Clement Clarke International Ltd.)
bucket which may have its open end either facing or
turned away or an embossed surface which could have
either raised or hollow relief. An everyday scene or an fact, the central part of one of the patterns, enclosed
object such as a house is unlikely to give a pseudoscopic within the dotted ring superimposed on the diagram, is
impression because it could not be accepted psycho- printed on the other side of the plate. There are three
logically, being contrary to all past experience. plates of thickness 6, 3 and 1 (or 1.5) mm. The patient
views the thickest plate first against a uniform white
background and has to say which of the four patterns
has the centre in relief, either forwards or backwards.
For young patients, this can be expressed as ‘find the
Clinical tests for stereopsis ball’ or ‘find the hole’. The plate may be turned over or
rotated so as to alter the position of the pattern with
While tests for stereopsis are relevant to certain occupa- relief. If the patient is successful with the 6 mm plate,
tional requirements, they may also be used as a test for the thinner plates are shown in turn or the observation
the quality of binocular vision. If this is poor, good distance increased. At a 40 cm observation distance,
stereopsis cannot occur. Hence the presence of reason- the three plates show a relative binocular parallax of ap-
able stereopsis may be used as a screening test to con- proximately 340, 170 and 55 (or 88) seconds of arc re-
firm that binocular vision is present and that there will spectively. These figures can be checked using equation
probably be little amblyopia. The three-needle test de- (11.2), after allowing for the ‘reduced thickness’ (t/n)
scribed on page 192 is excellent for laboratory use, but of the plates and assuming the PD to be 65 mm. Inter-
the care required to obtain accurate results makes it un- mediate values of stereoscopic acuity can be tested by
suitable for general clinical use. varying the working distance (see Exercise 11.10).
Because of its dot-like structure, the Frisby test is
sometimes mistakenly termed a random dot test. It
Stereotests for distance vision relies, however, on real three-dimensional clues, not dis-
Some test chart projectors have a vectographic slide en- parities within a stereopair.
abling the presence of stereopsis in distance vision to be To avoid the assistance given by parallax in tests
verified, though possibly at only a single angular dis- using real three-dimensional objects, the patient's head
parity. Rutstein et al. (1994) describe the Mentor bin- and the plates should be kept still, though it is surpris-
ocular vision testing system: the patient wears ingly difficult to identify the pattern with the relief by
spectacles with computer controlled liquid crystal movement. This possible source of error does not arise
lenses allowing alternating vision between the eyes at with tests using anaglyphs or vectographs. On the
60 cycles/s while the computer simultaneously alter- other hand, anaglyphs have the disadvantages men-
nates the VDU display. As this frequency is above the tioned on pages 199-200.
critical fusion frequency, a steady display is perceived.

The Titmus Wirt test

The Frisby test
The Titmus Wirt Test introduced in 1971 makes use of
The Frisby stereotest introduced in 1978 consists of a vectographs. The right and left eye pictures are polar-
square transparent plate on which four similar patterns ized at 45° and 135° respectively and viewed through a
are apparently printed on one side (Figure 11.17). In correspondingly oriented spectacle analyser. As a gross
202 Stereopsis and the stereoscope

test for stereopsis, a greatly enlarged picture of a two types of relief: Birch et al. (1982) showed that ap-
housefly has been used. Very young children may re- preciation of forwards relief developed in infants earlier
spond to this but not to less interesting though more than perception of depth, while Richards (1971) found
scientific presentations. These include a graded set of mature subjects who could see only forwards relief or
nine pictures each comprising four circles arranged in depth. Alternatively, as with fixation disparity testing,
diamond formation. One of the circles in each group is suppression areas on only one side of the fovea will
designed to stand forward in relief when seen binocu- affect relief more in one direction than the other.
larly through the visor. At a viewing distance of 40 cm, Larson (1990) sensibly suggests that stereo-acuity for
the stereo-acuity needed to identify the forward circle both advancing and receding reliefs should be measured
ranges from 800 to 40 seconds of arc.” and recorded, with the best result taken as the stereo-
Young children might manage another test in which acuity.
three rows of animal pictures are presented. In each If finer levels of acuity are required from the vecto-
row, one of the animals appears to stand forward, repre- graphic or anaglyphic tests, they may be held at a great-
senting stereo-acuities of 400, 200 and 100 seconds of er distance, or as suggested by Reading and Tanlami
arc. (1982), the anaglyphic test rotated in its own plane to
A polarized test incorporating a column of geometric reduce the horizontal component of its disparity. The
shapes is incorporated in the Mallett near fixation dis- plates must not be turned too far, as Charman and Jen-
parity unit. nings (1995) found that if the TNO test is rotated
through a right-angle so that the disparities are vertical
instead of horizontal, the presence of the test figure
The TNO test could often still be identified, though obviously without
stereoscopic relief, possibly because of binocular rivalry.
Anaglyphic separation is used in the Dutch TNOF test,
They questioned whether some of the coarse stereopsis
introduced in 1972. Demonstration plates showing but-
results reported for subjects with poor binocular vision
terflies and geometric shapes in relief serve to explain
were perceived by the same mechanism. If a patient
the test. Monocularly, they appear to be a random dis-
does not pass one test, the cause may be a lack of com-
play of dots, printed in red and green, the picture emer-
prehension rather than poor stereopsis, and another
ging only in binocular vision through the visor
test should be tried.
provided which has a red filter for the right eye, green
for the left. To measure the stereo-acuity from 480
down to 15 seconds of arc,+ test plates intended for use
at 40 cm are used. They show circles with one sector re-
maining in the plane of the background; the patient The Lang Stereotests
has to identify its position.
The Lang Stereotest,§ introduced in 1982, utilizes a
series of tiny vertical cylindrical strips to present
random dot stereograms. The first edition shows a cat
The Randot test
(1200 seconds of arc), star (600 seconds) and cat (550
The Randot stereo test utilizes vectographic dissocia- seconds), while the second shows an elephant (600 sec-
tion. Rather like the Titmus Wirt test, it includes a onds), car (400 seconds) and moon (200 seconds), to-
series of 10 groups of three circles, one in each pattern gether with a control picture of a star which may be
designed to appear standing forward. At a distance of seen with monocular vision. Both editions are available.
40 cm, the range coveredt is from 400 to 20 seconds of Because the optical arrangement is directional, the test
arc. It also has a similar set of animal pictures, while a has to be held fairly precisely in a fronto-parallel plane
third set of plates use random dot stereograms, with var- at about 40 cm. As no polarizing or anaglyphic visor is
ious hidden geometric shapes having disparities of 500 required, the test is suitable for infants down to about
or 250 seconds of arc. 6-8 months. At this age, stereoscopic vision may be re-
With both the Wirt and the TNO tests, reversing the cognized from the child’s fixational eye movements or
visor (or turning the TNO book upside down) reverses attempts to grasp the objects.
the relief, the test figure receding from the background.
Some patients, especially those with fixation disparity,
may find their ability to obtain the three-dimensional
impression affected by the direction in which the relief
Dynamic random dot stereograms
is presented. Displacement towards the eyes is usually
seen more readily than away from them. This may be Anaglyphic dissociation of computer-generated random
caused by separate neural channels for perceiving these dot stereograms displayed on computer screens has
been combined with a preferential looking test (see page
38) to investigate the development of stereo-acuity in
“ The complete range is 800, 400, 200, 140, 100, 80, 60, 50 infants.
and 40 seconds of arc.
t Institute for Perception TNO, 3769 ZG Soesterberg, The
Netherlands. The complete range is 480, 240, 120, 60, 30
and 15 seconds of arc. §In the UK, the Lang, Frisby, Titmus and Randot tests are
t The complete range is 400, 200, 140, 70, 50, 40, 30, 25 obtainable through Clement Clarke International Ltd, Edin-
and 20 seconds of arc. burgh Way, Harlow, Essex CM20 2TT.
 The synoptophore 203

Comparison of tests duced retinal illuminance because of pupillary miosis

and loss of transparency of the eye were eliminated as
Simons (1981), Hall (1982) and Heron et al. (1985)
the cause.
have made comparisons of the various clinical stereotests.
The different tests gave different values for the mean
stereo-acuity. In both studies, some subjects were found Stereopsis and refraction
to achieve finer stereo-acuities with the Frisby test than
As binocular vision is necessary for stereopsis, tests for
with the other clinical tests. Heron and colleagues
this may be used to identify patients with strabismus —
found the Frisby test to be understood by young chil-
not always easy if the angle of deviation is small.
dren, and to have the least variability in its scores.
Williams et al. (1988) found that their strabismic
Simons found the Frisby test to give lower acuities than
patients either showed no stereopsis on the TNO test, or
the other stereotests. He pointed out that the separation
managed only the demonstration plates or the 480 sec-
between the figure and background is larger in this test
onds of arc test plate. Hall (1982) similarly found very
than the other clinical tests, resulting in the lower
poor stereoscopic ability for his non-binocular subjects
score. Hall, however, reported that some patients with
on the TNO, Titmus, Frisby and two-needle tests.
poor binocular vision could achieve a coarse stereo-
Many studies have been made of the fall in stereo-
scopic acuity with this test but none at all with the vec-
scopic acuity with monocular or binocular blur. This
tographic or anaglyphic tests — this may result from
may be relevant when screening for monocular or bin-
parallax or from the reflection of the printing ink off the
ocular errors, or to the deficit produced in a presbyopic
surface of the plate if the light source is badly positioned
contact lens wearer who is corrected for near vision in
showing the Frisby pattern, while conversely, suppres-
one eye, distance in the other (Larson and Lachance,
sion with the other tests may result in their poorer per-
1983; McGill and Erickson, 1988; Collins and Bruce,
formance. Heron and colleagues found that the TNO
1994).
and Randot tests were unable to measure acuities finer
Levy and Glick (1974) found the stereoscopic acuity
than about 20 seconds of arc because the necessary in-
to drop from 40 seconds of arc to 60 seconds with mono-
crease in the testing distance meant that the dot struc-
cular blur to 20/40, and to 120 seconds with further
ture became too fine to resolve.
blurring to 20/120. Also with monocular blurring, Lo-
An obvious conclusion to be drawn from the various
vasik and Szymkiw (1985) found a drop in stereo-
studies is that the statistical, forced-choice approach of
acuity from about 25 to 40 seconds, with only 0.5 D of
the two- or three-needle test results in finer acuities
blur on the Titmus circles, and with 1.0D of blur on
than the clinical tests. Moreover, the results found for
the Randot test. With these two tests, aniseikonia of 2%
the latter vary significantly. It would appear necessary
and 6% respectively gave the same drop in stereopsis. A
for the clinician to establish his/her own norms.
moderate degree of depth judgement could be main-
tained in the presence of 2.0 D of blur, For small degrees
Development of stereopsis of blur they found the acuity measured by the Titmus
test to deteriorate about 1.8 times as fast as with the
Held et al. (1980), cited by Heron et al. (1985), used pre- Randot test.
ferential looking techniques (see page 38) to demon- Goodwin and Romano (1985), Simons (1984), Wood
strate stereo-acuities of 60 seconds of arc or better in (1983) and Schmidt (1994) all demonstrated a greater
children aged 5—6 months. Using the Frisby test, Heron drop in stereo-acuity with monocular than binocular
and blur. Goodwin and Romano found only a small drop in
colleagues found that the median stereo-acuity was acuity with blur to 20/25 (6/7.5), but at 20/30 (6/9)
27.5 seconds at 3 years of age, improving to 16.5 sec- the acuity was 78 seconds with binocular blur com-
onds at 7 years. The adults they examined showed acui- pared with 358 seconds monocularly. When blurred to
ties of 8 seconds. Because the other tests used could not 20/40 (6/12), the results were 136 and 378 seconds re-
record acuities much finer than about 20 seconds of spectively. For blurs of 20/50 or worse, the binocular
arc, both adults and older children obtained the same and monocular values were similar. Using diffusive
scores. This could be misinterpreted to mean that the rather than out-of-focus blur, Simons found the mono-
children had attained adult values for stereo-acuity. cular acuity to be about three times as bad as that with
Williams et al. (1988), using the TNO test, found that binocular blur to 20/100 (6/30). The difference be-
acuities of 60 seconds of arc or better were attained by tween subjects is demonstrated by Wood; one subject
52.7% of their 7-year-old children and 83.5% of their 9 showed only a slight drop in stereo-acuity on a two-
year olds. The numbers for 30 seconds of arc or better needle test at up 2.0 D of blur, while his other two sub-
were 4.0% and 24.7% respectively, while at age 11, jects showed increasing deterioration at more than 0.5
3.4% achieved 15 seconds of arc. or 1.0 D of blur.

Stereopsis and ‘age

Like visual acuity, stereo-acuity also appears to decline
slightly with age. Yap et al. (1994) using a two-needle The synoptophore
test found mean stereo-acuities of 8.37 seconds of arc
for a 20-29-year-old group, 9.18 seconds for a 30-49 Various trade names have been used to denote the type
age group and 11.21 seconds for a 50-67 year olds. Re- of orthoptic instrument commonly known as a synopto-
204 Stereopsis and the stereoscope

modified accordingly. In order that corresponding detail

on the right and left transparencies should appear
superimposed, the tubes must be converged to the
plane of the fixation wall or screen: 1A each if the dis-
tance is 3m.
—~ ~xis for
L Zp altering latitude

Figure 11.18. Optical arrangement of the synoptophore. The variable prism stereoscope
’.

The rotary or Risley prism (known in France as the

phore. A history of this instrument and associated ter- Créteés and in Germany as the Herschel prism) is a
minology has been given by Revell (1972). device for producing continuously variable prism
As indicated by Figure 11.18, the synoptophore is a power. It consists of two plano prisms of equal power,
much modified Wheatstone stereoscope. The test trans- mounted almost in contact in a carrier disc which can
parencies TT are illuminated by small lamp bulbs LL be placed in a standard trial frame or fitted to a refractor
and imaged at infinity by the collimating lenses CC. head.
They are seen by the subject after reflection at the silv- The principle is illustrated in Figure 11.20 in which
ered mirrors MM. Each tube is pivoted about a vertical the two prisms are shown side by side instead of super-
axis through Z, the assumed position of the eye’s centre imposed. In the zero setting (Figure 11.20a), the prisms
of rotation. This makes it possible to alter the stimulus have their bases opposed. To obtain a desired prism
to convergence and to measure the horizontal angle of power, the prisms are mechanically rotated in opposite
strabismus. The pivot separation is adjustable to suit directions through an equal angle 9. In the position
the subject's PD. Each tube may also be tilted upwards shown in Figure 11.20b, one prism has its base up and
or downwards about a horizontal axis passing through to the left, while the base of the other is down and to
Z and parallel to the axis of the tube. By this means a the left. The vertical components cancel out but the hor-
vertical oculo-motor imbalance can be measured. In ad- izontal ones are additive, giving a resultant with its
dition, both tubes can simultaneously be tilted up or base to the left. If the power of each of the single prisms
down in order to exercise the eyes or measure deviations is denoted by P, it can be seen from the diagram that
in elevated or depressed planes of gaze. The transpar- the total power of the resultant prism is simply 2P sin 0.
ency holders can also be raised or lowered to measure
Had the initial rotations been reversed in direction, the
vertical imbalances, while torsional movements are ob- resultant would have been the same but with its base
to the right.
tained by rotating the transparency holders about their
centres.
The diagram also shows that the resultant prism effect
Although the transparencies are imaged at infinity,
proximal convergence and accommodation are induced
by the known physical nearness of the test objects. A re-
duction in proximal effects was one of the advantages
claimed for the modified design due to Stanworth
(1958). The mirrors MM are replaced by transparent
glass plates PP (Figure 11.19) which allow the subject
to fixate on a wall or screen at 3-6 m from the instru-
ment. It is against this background that the transparen-
cies are seen. To prevent blurring, the collimating
lenses are moved to the position shown and their power (a)

(b)

Figure 11.20. The rotary or Risley prism. The two

component prisms are drawn side by side for clarity. (a) Zero
setting: bases opposed; (b) setting after each prism has been
Figure 11.19. Principle of the Stanworth synoptophore rotated through 9 in opposite directions from the zero position:
(1958), using partially reflecting mirrors. base of resultant prism to the left.
 References 205

is invariably perpendicular to the zero setting. The bulate from equation (11.2) the values of AZ for 7 = 0.2, 0.5,
device must therefore be appropriately orientated in the 1.0, 5, 10, 20, 30, 50 and 100 m (minus signs omitted).
11.2 A depth difference of 0.5mm is just noticeable at a
trial frame or refractor head. In the simpler models, the distance of 1 m. What is the corresponding stereoscopic acuity
carrier disc is graduated to indicate the power of the for an observer with a PD of: (a) 60 mm, (b) 70 mm?
resultant prism, the maximum value frequently being 11.3. A slit lamp’s binocular microscope has a working dis-
30A. tance of 100 mm and an objective separation (between centres)
of 25mm. At magnifications of 10x and 20x, what is the
The variable prism stereoscope (VPS) incorporates
least perceptible difference in depth corresponding to an obser-
two Risley prisms, so geared that equal amounts of ver’s stereoscopic acuity of 20 seconds of arc?
base-in or base-out prism can be placed before each 11.4 A slit lamp’s binocular microscope is formed by a nom-
eye. A total of 60A is thus available. inally achromatic objective to collimate the light from the
When the VPS is used to measure fusional reserves, object, followed by a binocular prismatic telescope to magnify
the image (see Figure 16.4 on page 304). Explain why a yellow
the prism power is initially set at zero while the patient object might appear further away than a blue object in the
observes a single vertical line of letters at 6m, or, in same plane.
near vision, a card placed in the holder provided. 11.5 An observer with PD of 65 mm views an object at —5 m.
To use the instrument as a stereoscope, a septum Find the convergence required when viewing: (a) with the un-
aided eyes and (b) through a prismatic binocular with magnifi-
should be positioned so as to prevent either eye from
cation 10x and objective separation 80 mm. What effect has
seeing the opposite half of the stereogram. Also, to the latter on ocular co-ordination?
maintain the normal relationship between accommoda- 11.6 Using the conventional Brewster—Holmes stereoscope,
tion and convergence, base-out prism should be placed what is the required separation of corresponding details on the
stereo-cards to avoid disturbing the accommodation/conver-
before each eye. Otherwise, instead of converging to a
gence relationship, the stimulus to accommodation in the lens
point in the plane of the card, éach eye might even plane being: (a) —1.00 D, (b) —4.00 D?
have to diverge in order to fixate a pair of corresponding 11.7 A stereoscope test is made with detail separation of
points. If, for example, the separation of these points is 54 mm for use with the normal Brewster—Holmes stereoscope
7 cm and the viewing distance is $m, the total base-out in the —3.00 D position. From first principles, find the binocular
(total) convergence/accommodation ratio when the card is
prism required is 21A.
placed in: (a) the —1.00D and (b) the —5.00D_ positions.
Assume a PD of 65mm, ocular centres of rotation 35mm
The stereocomparator behind the lenses and accommodation referred to the stereo-
scope lens plane.
11.8 The Brewster-Holmes stereoscope is used in the
If the right and left halves of a stereogram are identical, —3.00 D position to exercise fusional reserves. What is (a) the
no impression of relief can arise. The converse is also binocular convergence and (b) the binocular convergence/ac-
true and this is the principle of the stereocomparator. If commodation ratio for detail separations of (i) 49mm, (ii)
64 mm? (assumptions as in Exercise 11.7).
two flat objects are viewed in a stereoscope, for example,
11.9 Explain, with diagrams and typical numerical values,
a genuine bank note and a forgery, any detail which is why the stereoscopic acuity corresponding to one particular
not in exact register between the two will appear in thickness plate of the Frisby test varies with the PD of the ob-
stereoscopic relief, either forward or backwards. server, while the Titmus vectographic test gives an invariant
angular acuity. What does vary between observers with dif-
ferent PDs when viewing a particular Titmus test? Assume a
Holography constant observation distance.
11.10 A Frisby plate (a) and a Titmus vectographic plate (b)
The stereoscope enables a three-dimensional percept to both correspond to a stereoscopic acuity of n at a distance /. If
this distance is now doubled, what is the new corresponding
be obtained by binocular viewing of a two-dimensional value of stereoscopic acuity for each plate?
stereocard. Holography, a technique of recording on a 11.11 A Brewster—Holmes stereoscope has lenses (to be as-
photographic plate the fringes formed when light re- sumed thin) of power +5.50D, their optical centres being
flected off the object interferes with a reference beam, 84mm apart. Two corresponding points on a stereogram
placed 125 mm from the lens plane are 49 mm apart, equally
produces a genuinely three-dimensional image. Clinical
spaced from the median line. Determine (a) the convergence
applications may follow. (expressed in prism dioptres) which an emmetropic subject
would need to exert in order to fuse the two image points, (b)
the distance from the lens plane at which the two visual axes
Virtual reality would then intersect. Assume the subject to have an inter-
ocular distance of 58 mm, the eyes’ centres of rotation being
Computer-generated graphics coupled with miniature 30 mm behind the lens plane. Either calculation or a scale dia-
visual display units, one for each eye mounted with col- gram may be employed.
limating lenses in a helmet, enable almost realistic 11.12 An autostereogram is constructed with detail separa-
tions of C = 15mm and D = 17mm, as in Figure 11.14. If
three-dimensional scenes to be presented to the wearer. viewed with (a) crossed convergence and (b) uncrossed conver-
Feedback from sensors attached to the helmet and gence with the paper at 350 mm from the eyes’ centre of rota-
wearer enable the scene to alter in response to the indi- tion, calculate the apparent distances to the binocular percepts
vidual’s actions. This is a field in rapid development at of Cand D. Assume a PD of 65 mm.
present, with potential for education, design and simu-
lation of flight or surgery for example.

References
Exercises
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206 Stereopsis and the stereoscope

BENNETT, A.G. (1977/78) Binocular vision through lenses and LEVY, N.S. and GLICK, E.B. (1974) Stereoscopic perception and
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BIRCH, E.E., GWIAZDA, J. and HELD, R. (1982) Stereoacuity de- accommodation, retinal illuminance, and pupil size on
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12
The schematic eye

Schematic eyes in general +1.00D of hypermetropia while the No.2 version was
emmetropic.
The object of a schematic eye is to provide a basis for For general purposes, the three-surface eye put for-
theoretical studies of the eye as an optical instrument. ward by Listing is undoubtedly the best and the version
In designing such an eye, complexities not of funda- devised by Emsley (1936) on the basis of Gullstrand’s
mental importance must be ignored, but the degree to data has been widely accepted. This eye was used in
which the refracting system can be simplified varies in the two previous editions of this book, but has now
different fields of investigation. For example, replacing been replaced by a new version. Like Emsley’s eye, this
the cornea with a single refracting system would not is emmetropic in its relaxed state.
affect the size of the retinal image but would make the Three other schematic eyes of recent origin are
design unsuitable for the study of Purkinje images. worthy of mention. Le Grand (1945) has modified the
An excellent account of earlier schematic eyes, to- constants of Tscherning’s four-surface system in the
gether with a detailed table of comparative dimensions, light of subsequent researches, the equivalent power be-
has been given by Swaine (1921). The specification in- coming +59.94D. He has also modified the constants
troduced by Listing (1851) became a basis for subse- of Gullstrand’s No.2 eye to provide a simplified version
quent modifications by Helmholtz and Willner. All having the same power (+59.94 D). Ivanoff (1953) has
these versions gave the eye as a whole an equivalent produced an updated version of Listing’s three-surface
power in excess of +64.5 D, the refractive index of the model.
homogeneous crystalline lens having been assigned too For practical purposes, slight differences between dif-
high a value. ferent schematic eyes of the same basic construction
A different approach was adopted by Matthiessen, are of little consequence. Furthermore, as Ivanoff has
whose three versions of the schematic eye all retained a so justly remarked, the degree of accuracy to which
stratified structure and refractive index variation typical theoretical calculations on the subject are usually car-
of the actual crystalline lens. Even so, he arrived at a ried is not matched by our knowledge, the justification
total equivalent power greater than + 67 D. for it being the avoidance of an accumulation of errors.
In his Optique Physiologique, published in 1898, A comprehensive review of many schematic eyes is
Tscherning detailed two different models of a relaxed also given by Smith (1995).
schematic eye, one a three-surface and the other a
four-surface system. Tscherning was, in fact, not only
the first to include the back surface of the cornea but
also the first to measure its radius of curvature in vivo.
He assigned a lower refractive index to the crystalline The cornea
than his predecessors, and in consequence the equiva-
lent power of his four-surface system was +58.38 D, Gullstrand’s No.] schematic eye represents both surfaces
which is much nearer to an average value. of the cornea (Figure 2.8), their radii of curvature being
In a sense, the two schematic eyes of Gullstrand +7.7 and +6.8 mm respectively and the axial thickness
(1909) represent opposite extremes. The No.| version t being 0.5 mm. The refractive index n, of the corneal
has six refracting surfaces, whereas the No.2 consists of substance is given as 1.376 and that of the aqueous
a single-surface cornea and a ‘thin’ crystalline lens. humour n; as 1.336. This gives
Like Helmholtz and Matthiessen, Gullstrand also pro-
vided a separate version (of each of his models) repre- Front surface power
senting the eye when strongly accommodated. The
F, = 376/ + 7.7 = +48.83D
equivalent power of the No.1 eye was +58.64 D in the
relaxed and +70.57 D in the accommodated state. For Back surface power
the No.2 simplified eye the corresponding values were
+59.74D and +70.54D. Both eyes were given the ; N33
= WWE
EF, = = 5.88D
same axial length of 24mm, the No.1 version having +6.8
208 The schematic eye

profile by equation (12.1) is a useful concept. A p-value

Parabola
in the neighbourhood of 0.6-0.8 is probably the best ap-
p=0
proximation to a typical cornea. (Corneal topography is
discussed in greater detail on pages 391-397.)
Ellipses Since XX in Figure 12.1 is a unique axis of symmetry
p tve <1
Circle of the convex ellipsoid, the cornea as a whole could not
pa be a centred system unless the paraxial centre of curva-
ture of the back surface were also situated on XX. This
may not occur, in which case the cornea itself willsnot
possess a true optical axis.
Ellipses
p> 1
The crystalline lens

Hyperbolas Schematic representations

p—ve
For the purpose of a schematic eye, the crystalline lens
Figure 12.1. Conic sections all having the same radius of
with its complicated refractive index variations must be
curvature r, at the pole. A schematic aspherical cornea
showing peripheral flattening or steepening of curvature is replaced by something very much simpler. In his No.1
formed by revolution of the curve about the x-axis. schematic eye, Gullstrand represented it by the mathe-
matically based approximation shown in the upper part
of Figure 12.2. It consisted of a homogeneous nucleus
Equivalent power
of refractive index 1.406, surrounded by a cortex of re-
F = +48.83 — 5.88 fractive index 1.386. Both the aqueous and vitreous hu-
mours were considered to have a refractive index of
— {(0.0005/1.376) x 48.83 x (—5.88)]
1.336. The radii of curvature of the four refracting sur-
= +43.05D faces were, in order, +10, +7.911, —5.76 and —6 mm,
while the axial thicknesses were 0.546, 2.419 and
The distance e of the first principal point from the
0.635 mm, giving a total thickness of 3.6 mm. Calcula-
vertex of the front surface is found from
tion shows the equivalent power of the system to be
t F, 4 +19.11 D, the first and second principal points being re-
e=— X — = —0.050 mm
N> H spectively 2.080 and 2.205 mm from the anterior pole
of the lens, which is 3.6 mm from the anterior corneal
while the distance e’ of the second principal point from
vertex.
the vertex of the second surface is found from
If the crystalline lens were conceived instead as a
! Sie Fy homogeneous biconvex element with the same radii of
e= x — = —0.551 mm
N> F curvature and axial thickness as before, it may be
shown that the refractive index would need to be very
Consequently, both principal points are situated in
nearly 1.409 in order to have the same equivalent
front of the cornea, the first 0.050 and the second
0.051 mm from the front vertex. This means that they
very nearly coincide with each other as well as with
the first surface of the cornea. The single-surface
cornea used in some schematic eyes is an optically legit-
imate simplification.
Because of its peripheral flattening, an ellipsoid has
been suggested as a better schematic representation of
the front surface of the cornea than the conventional
spherical figure. Figure 12.1 shows an ellipse with its
major axis coincident with the x-axis of Cartesian co-
ordinates and its vertex A at the origin O. The point C,
is the centre of a sphere of radius r, having the same
curvature as the ellipsoid at its vertex A. Following
Baker (1943), the equation of any conic section symme-
trically placed with its vertex at O may be written as

y- ee px (Gla)

in which p is a parameter defining any one of the entire

family of conics having the same vertex radius r,. For a
circle, p= 1, while for a parabola p = 0. Intermediate
values of p define ellipses of different dimensions and
Figure 12.2. A schematic crystalline lens. The upper figure
shape and negative values of p define a family of hyper-
shows the Gullstrand No. 1 lens, the lower figure a
bolas. For the purposes of certain calculations on the homogeneous lens of the same equivalent power, outer radii
schematic eye, a single-surface cornea represented in and thickness,
 The Bennett—Rabbetts schematic eye 209

power of +19.11 D. As shown in the lower part of Figure

12.2, the principal points would shift only slightly,
now being 2.159 and 2.305 mm from the anterior pole.
The more complex structure undoubtedly shows the
main effect of the refractive index variation of the
actual crystalline lens but for most other purposes a sim-
pler representation is adequate. In fact, in his No.2 (sim-
plified) schematic eye, Gullstrand reduced the lens to a
hypothetical one of equivalent power +20.53 D and of
zero thickness, situated 5.85mm from the corneal
vertex. This is approximately the mean position of the
principal points of the lens of his No.1 eye.
In the schematic eye adopted in this text, the radii of Resultant
(D)
ametropia
| t
curvature of the homogeneous lens have been increased
to 11.0 and —6.476 mm, while the axial thickness has abe eReeene
increased to 3.7 mm. A refractive index of 1.422 gives ae” ae cee eRe
an equivalent power of +20.83 D, slightly more than in 0 5 10 1%)
the Gullstrand four-surface lens. Tilt of crystalline lens (degrees)

Figure 12.3. The effect on ametropia of a tilt of the Bennett—

Effect of a tilted crystalline, Rabbetts schematic crystalline lens.

Comparisons between measured corneal astigmatism

tions of this work. The dimensions of this eye in its re-
and the cylinder correction found by refraction suggest
laxed state are given in Appendix B.
that the crystalline lens tends to make a contribution of
Now, more than 50 years later, we believe that
‘against the rule’ astigmatism.
changes are needed. The most compelling reason is the
If the crystalline is tilted with respect to the visual
value of 4/3 chosen by Emsley for the refractive indices
axis, the resulting obliquity of incidence gives rise to ob-
of the humours, possibly to simplify mental arithmetic
lique astigmatism, even though the surfaces are per-
in the pre-calculator age. Unfortunately, it is not a rea-
fectly spherical. For a narrow pencil passing obliquely
listic value. The figure of 1.336 adopted by Gullstrand
through the centre of a thin lens of power F, the astig-
is much more defensible and is routinely used in calcula-
matic effect A can be determined from the well-known
tions on intra-ocular implants. We have therefore rein-
approximation
stated it.
A=0°F ie) Another cogent argument is that some of the present
dimensions have remained unchanged for generations
where @ is the angle (in radians) between the incident
and were originally based on a very small number ofex-
pencil and the optical axis of the lens.
perimental determinations. In particular, the values of
Applied to the tilted crystalline lens, this expression
10 and —6 mm for the radii of curvature of the outer
over-estimates the astigmatism for reasons explained
surfaces of the crystalline lens go back to Listing’s
elsewhere (Bennett, 1984). Calculation by a more accu-
model of 1851. During the past few decades, several
rate method, in which a pencil is traced from the fovea
large-scale investigations using new techniques of
through the tilted lens to the cornea, gives the results
greater reliability have provided a mass of data on
shown graphically in Figure 12.3. It will be noted that
ocular dimensions. This is the solid basis on which our
a tilt of around 14° is needed to produce lenticular astig-
schematic eye is founded. Only a brief summary of
matism of 0.50 D. To give rise to astigmatism against
these conclusions is given below. More detailed explana-
the rule, the lens must be tilted about a vertical axis.
tions have been provided in a separate publication (Ben-
The results plotted in Figure 12.3 relate to the relaxed
nett and Rabbetts, 1989).
Bennett—Rabbetts version of the crystalline lens.
According to Tscherning (1890), the crystalline lens
is usually tilted from 3° to 7° about a vertical axis, the
temporal side moving towards the cornea. There is Equivalent power of eye
often a tilt about a horizontal axis as well, the upper
part of the lens moving forward by up to 3°. Since the spread of results closely straddles +60 D,
which is the power allotted to the reduced eye, this
value in round figures should also be adopted for the
schematic eye.

The Bennett—Rabbetts schematic eye

Corneal radius
In his Visual Optics, first published in 1936, Emsley ren-
dered a valuable service by introducing his version of Although no change has been made from the
the three-surface schematic eye. As it combined dimen- Gullstrand—Emsley value of 7.8 mm, the new index of
sions from the two Gullstrand models, we termed it the 1.336 for the aqueous humour increases the surface
Gullstrand—Emsley eye when using it in the first two edi- power from 42.73 D to 43.08 D.
210 The schematic eye

Table 12.1 The Bennett—Rabbetts schematic eye, relaxed, accommodated and elderly

Quantity Accommodation

Relaxed 25D 5.0 D Tesvl)) 10.0 D Elderly

Radii of curvature
cornea r +7.80 +7.80 +7.80 +7.80 +7.80 +7.80
crystalline: first surface rr +11.00 +8.60 +7.00 +6.00 +5.20 +9.25
crystalline: second surface* 13 —6.47515 —5.909 —5.504 —5.063 —4,750 —6.130
Axial separations Se
depth of anterior chamber d, 3.60 3.475 3h ef 3.28 Il 2.95
thickness of crystalline d> 3/40) 3.825 39)3} 4.02 4.09 4.45
depth of vitreous body d3 16.79 O79) Mo 7S) 16.79 16.79 16.69
overall axial length + 24.09 24.09 24.09 24.09 24.09 24.09
Mean refractive indices
air ny ] 1 1 il 1 ]
aqueous humour nN? 1536 35:6 1.336 1S 3:6 leeyex(6) INS398K)
crystalline N3 1.422 1.422 1.422 1.422 1.422 1.406
vitreous humour n4 Ihe s¥oH(8) 1.336 1.336 1.336 1.336 WESSHS
Surface powers
cornea Fy +43.08 +43.08 +43.08 +43.08 +43.08 +43.08
crystalline: first surface Fy + 7.82 +10.00 +12.29 +14.33 +16.54 qe
crystalline: second surface F; +13.28 +14.55 +15.63 +16.98 +18.10 +11.42
Equivalent powers
crystalline Fy, +20.83 +24.16 +27.38 +30.63 +33.78 +18.71
eye 1k +60.00 +62.85 +62.62 +68.40 +71.12 +58.45
Equivalent focal lengths of eye
first (PF) Te =16:67 Sal —15.24 —14.62 —14.06 —17.10
second (P’F’) fie +22.27 +21.26 +20.36 +19.53 +18.79 +22.85
Distances from corneal vertex
first principal point A,P +1.51 +1.62 +1.71 +1.80 +1.87 +1.33
second principal point? AiR? +1.82 +1.95 42.05 +2,.15 +2.23 +1.61]
first nodal point A\N +7.11 +6.97 +6.83 +6.71 +6.60 +7.07
second nodal point A\N’ +7.42 +7.29 +7.17 +7.06 +6.95 TieO
entrance pupil A,E +3.05 +2.93 +2.83 +2.75 +2.68 +2.44
exit pupil AE’ +3.70 +3.56 +3.44 +3.33 +3.25 +3.01
first principal focus A\F —15.16 —14.29 —13.53 —12.82 —12.19 —15.78
second principal focus A,F’ +24.09 +23.21 4+22.41 +21.68 +21.01 +24.47
Refractive
state (principal point) K 0 —2.50 —5.00 —7.50 —10.00 +1.00

Distance of near point from corneal vertex —398.5 —198.3 —131.6 —98.1

All linear distances are in millimetres and powers in dioptres.

* This radius is specified to three or more places of decimals solely to ‘fine-tune’ the resulting refractive state, and does not imply that
an eye has to be constructed to this degree of precision.
+ The accurate value of 24.0859 was used in the reversed ray traces for the accommodating and elderly eyes.
t Rounding errors explain the apparent differences between PP’ and NN’ for the various eyes.

Crystalline lens while the positions of its cardinal points in the relaxed
state are illustrated in Figure 2.17.
Available data strongly suggest that the present radii of
10.0 and —6.0 mm are too short. More realistic values
for a young adult would be in the neighbourhood of The reduced eye
11.0 and —6.5mm. We have fine-tuned the latter to
To produce a power of 60.00 D with a refractive index of
—6.47515 mm and fixed the refractive index at 1.422
1.336, the radius of curvature of the reduced eye sur-
in order to arrive at the exact power of 60.00 D for the
face is 5.6 mm. Its second principal focal length, which
eye as a whole. The equivalent power of the lens itself
is also the axial length for emmetropia, is 22.27 mm
is 20.83D, which is well below Emsley’s figure of
(both rounded off to two decimal places). The pupil is as-
21.76 D but justified by available data, as is the pro-
sumed to be coincident with the refracting surface.
posed increase in centre thickness from 3.6 to 3.7 mm.

Calculation of optical constants: conventional

Axial length of eye method
The axial length for emmetropia resulting from the com- For the schematic eye in general, the conventional ap-
bination of the other dimensions is 24.09 mm. This, proach is first to determine the equivalent power Fe of
too, is consistent with published data which point to a the cornea and the position of its principal points (P,,
mean value of 24.0 mm or slightly in excess of it. P’) from standard expressions. Next, the equivalent
The complete set of dimensions is given in Table 12.1, power F of the crystalline and its principal points (P5,
 The Bennett—Rabbetts schematic eye 211

Equivalent power of eye (F,)

P' P» = Pi A> = A>P, a dj =f (Zp)

— FOU Oeil, — Seo / nam

Ay and

Py, P' Bea Pye Py

(dy se C>)Fy Fy

1000n,
e
= A077 42 20 30) = S07 = 4x0 OOO
Figure 12.4. Position of the principal points P, P’ of the
Bennett-Rabbetts schematic eye and of its components: P,, P|
coincident with A, (cornea); P>, P45 (lens).
Position of eye’s principal points (P, P’)

P’,) are similarly determined. The two systems are then Ny (d, a ® Ey
combined, making use of the familiar relationship GSN? ay |e = +1.511
mm
MDF Oo

d
Pb tt att Whe (ler) i =n (dy gli ms 4.176 mm
7 nF,
in which F is the equivalent power of a combination of AVP = Aide AD Asa As Poe eae
two systems of equivalent power*F, and F, optically
separated by a reduced distance d/n in metres. In this = 3.600+ 3.700 — 1.305 — 4.176
case, d is measured from the second principal point of = +1.819 mm
the cornea to the first principal point of the lens.
When the cornea is represented by a single surface,
the calculation becomes simplified because the equiva-
lent power of the cornea is that of the single surface Equivalent focal lengths of eye (f,. f/,)
and the two principal points coincide with its vertex.
Figure 12.4 illustrates the above procedure applied to f, = PF = —1000n,/F, = —16.667 mm
the Bennett—-Rabbetts relaxed eye, the result being as
follows:
fie? Ba 1000 ms) P= lI 22 26 72mm

Position of nodal points (N, N’)

Surface powers
As explained in Chapter 2, the nodal points of any re-
1000(n, — 336 fracting system are symmetrically positioned such that
sg rel ULE ry
ee
+7.8
eee a N’F’ = FP and NN’ = PP’. This gives
NGIN| = ape7 MIL sonia
1000(nz —n,) 86 ie
r=
7 ie)
= ie
= $7,318) and
A\N’ = +7.419mm
1000 — Nn —86
me Mle
r3
ies oD ior i sgM
—6.475

Overall length of emmetropic eye (A, F’)

AjF =A,P +P EF
Equivalent power of crystalline (F,)
= +1.819+ 22.267 = 24.086 mm
d FF

e eAOOOns
= +21.100 — 0.270 = +20.830D Alternative method of calculation
A simpler method of calculation is based on the theorem
that the equivalent power F of any refracting system
can be found from the expression
Principal points of crystalline (P>, FE)
Bey Less
/ / /

i when L, = 0 (12.4)
Lo L3 ...
G9 — AG Poe nodal = +2.217mm
- hs. n3 Fy, Thus, a parallel incident pencil is traced through the
system by ‘step-along’ methods. Applied to the
—nyd>F 5 Bennett—Rabbetts schematic eye, this procedure gives
pie phe 30s im
N3 Fy the results shown in Table 12.2.
212. The schematic eye

Table 12.2 ‘Step-along’ method of calculating equivalent power Relaxed

of eye
Bo
eee
Routine Relaxed Accommodated
eye eye (10.00 D)

1 =i +43.077 +43.077
A2
Ly = ——__——___
Li
+ 48.734
La
+48.050
> Fal

7 — (d) /nz)L}

IL =1[5,+fF) +56.552 +64.589

ES
Accommodated
Te = +66.309 +79.325
j 1 — (db /n3)L4
Ibs =13+F; +79.591 +97.431 Figure 12.5. Comparison of the positions of the principal
points P, P’ and nodal points N, N’ of the Bennett—Rabbetts
7 (mm) = 1000 74/L4 +16.786 +13.712 schematic eye in its relaxed (upper) and fully accommodated
(lower) states.
F,(from equation 12.4) +60.000 +71.120

In the above sequence of equations, d, and d are in metres. 4+20.83 to +33.78D, the equivalent power of the eye
has increased by only 11.12 D. This results from the se-
The distance A,P’ of the second principal point from paration between the two main components of the
the corneal vertex can be found at once because eye's refracting system. To a first approximation we can
take the power of the cornea as +43 D and its mean dis-
Ay?’ =A\F +F'P’ = (d, +4, +73)—f, tance from the first principal point of the lens as
To locate the first principal point, however, it is neces- 5.8 mm, ignoring the variation in this distance with ac-
sary to trace a parallel incident pencil through the commodation. The equivalent power F, of the eye
system in the reverse direction, which gives the position would then be expressed by
of the first principal focus F as an intermediate step. 0.0058 x 43 x FL
Fo 443Fy ~ 4340.81Fy
1.336
The accommodated schematic eye Consequently, a change of AF; in the power of the
crystalline would produce a change of about 0.8AF, in
As the eye accommodates, both surfaces of the crystal- the equivalent power of the eye.
line lens, but especially the anterior, become more Since the standard schematic eye is emmetropic in its
steeply curved. At the same time, the axial thickness in- relaxed state, its refractive condition K in an accommo-
creases and the lens moves slightly forward into the dated state can be taken to indicate the amount of
anterior chamber. In the Bennett—Rabbetts schematic ocular accommodation that has been brought into play
eye, as in Gullstrand’s original, the back vertex of the when measured at the eye’s first principal point.
lens is assumed to remain stationary. In the 10D ac-
commodated state the axial thickness increases by
0.39mm from 3.7 to 4.09mm and the depth of the
The schematic ‘elderly’ eye
anterior chamber accordingly decreases by 0.39 mm to
3.21 mm. Many versions of schematic eyes also adopt As will be discussed in Chapter 21, the crystalline lens
an increase in the refractive index for the crystalline grows in thickness throughout life. Experimentally, the
lens with accommodation. From the experimental data positions of both the anterior and posterior surfaces of
of Garner et al. (1997b), Garner et al. (1997a) concluded the lens relative to the cornea are measured by ultra-
that there was no significant difference between the sound (see Chapter 20). The results show some variation
lens index at different levels of accommodation. The fig- in the ageing changes of the ocular dimensions. Koretz
ures for the accommodated eye in Table 12.1, which per- et al. (1989) found no significant shift in the position of
haps should be regarded as provisional, have been the posterior lens surface, though the lens increased in
based both upon this assumption and on the propor- thickness by 0.13 mm per decade. Over a 50-year span,
tional changes to the lens found by Garner et al. Lowe (1970) found that the anterior chamber depth re-
(oo 7b) duced by 0.65 mm while the lens thickness increased
The effect of accommodation on the position of the by about 0.73 mm. If, for simplicity, this is rounded up
eye's principal points is relatively small. Both move to- to 0.75 mm, the rear surface moves back by 0.10 mm,
wards the retina by approximately 0.4 mm in the 10 D which was within the range of his experimental find-
accommodated state. The value of K’, measured dioptri- ings. The resulting lens thickness of 4.45 mm fits in
cally from the new position of the eye’s second principal with Weale’s (1982) review. Similar results were found
point, is then increased by about 1.1 D. At the same by Hemenger et al. (1995) in their groups of 48 young
time, both nodal points move approximately 0.5 mm to- eyes (mean age 22 years) and 48 older eyes (mean age
wards the cornea. Figure 12.5, drawn to scale, shows 54 years). Over this smaller time interval, the anterior
these relative movements. chamber depth reduced by 0.4mm (3.8 to 3.4 mm),
It can be seen from Table 12.1 that whereas the while the lens increased in thickness by 0.75 mm (3.6
equivalent power of the crystalline lens in the 10 D ac- to 4.35 mm). The posterior surface of their sample thus
commodated state has increased by 12.95D_ from moved 0.4 mm towards the retina.
 Schematic eyes for research 213

Since the equatorial diameter of the lens stays ap- metropia and the sheep about +1.50 D. Calculation of
proximately constant in adult life, the increased thick- all the optical constants of these eyes was carried out
ness is accompanied by a steepening of the radii of by computer, using a program devised by the same
curvature, as shown by Brown's (1974) photographic team (O'Keefe and Coile, 1988). References to schematic
evidence. Using ophthalmophakometry (see pages 398— eyes for other mammals are given in Oswaldo-Cruz et
401) and allowing for the effects of the natural lens’ re- al. (1979) and Hughes (1979), while Hodos and
fractive index gradients, Hemenger and colleagues cal- Erichsen (1990) describe an adaptation to the focusing
culated the young lens to have radii of 11.2 and of bird’s eyes to enable them to keep both the ground
—6.45mm while the older lens to be 9.3 and and the horizon in focus.
—6.15 mm, somewhat steeper than Brown's results.
Despite the change in lens shape towards an accom-
modated form with age, the typical eye's refractive
error alters either little or slightly towards hypermetro- Schematic eyes for research
pia (excluding eyes with nuclear sclerosis cataract).
This contradiction was studied by Pierscionek (1990), A number of schematic eyes have been designed for use
who showed that the nucleus of the crystalline lens in research, the general aim being to provide a model ex-
had a uniform refractive index, only the cortex having hibiting typical values of one or more of the aberrations
an index gradient. Changes in this gradient are the of real eyes. Aspherizing the refracting surfaces and de-
probable explanation for the lack of a myopic shift. parting when necessary from accepted values of refrac-
With a homogeneous lens in the schematic eye shown tive indices are the expedients mainly used.
in the extreme right column of Table 12.1, the notional In the design by Lotmar (1971), based on Le Grand’s
refractive index of the lens has therefore been reduced schematic eye, the front surface of the cornea was
compared with the young eye, and again the radius of given a contour based on a study by Bonnet and the
the posterior surface has been fine-tuned to achieve the back surface of the lens was made paraboloidal. Ray tra-
required hypermetropia of +1.00 D. cing showed the model to have spherical aberration
and peripheral astigmatism of the order required.
The eye constructed by Pomerantzeff et al. (1984) was
The eye in infancy
designed to have the same spherical aberration as the
There is insufficient information at present to develop mean value obtained from experimental measurement
schematic eyes for the infant and child. Wood et al. of 50 emmetropic subjects. The cornea was aspherized
(1996) both review previous data and used video kera- to produce a partial correction of its own spherical aber-
tophakometry to calculate the crystalline lens param- ration, but the main focus of interest was on the crystal-
eters of 27 infants. The median results were a refractive line lens. This was treated as a homogeneous nucleus
error of +1.50D, corneal power of +43.5D and lens surrounded by 200 or more extremely thin layers vary-
radii of 8.7 and —5.6mm. A notional index of 1.49 ing in refractive index and asphericity. Smith et al.
was required to give the necessary lens power of (1991) developed two schematic lenses, with both as-
46.7 D. Since these radii are only slightly steeper than pheric surfaces and a gradient refractive index. These
those of the adult eye having a power of around +21 D, were developed further to investigate the refractive
they suggest that it is predominantly a change in this index gradient in older eyes (Smith et al., 1992). A
notional index (or, in real life, the index gradient of the similar lens was used by Patel et al. (1993) to provide a
lens) that falls to maintain near emmetropia as the model eye for predicting the optical performance after
axial length grows from about 17mm at birth to its laser ablation refractive surgery (see pages 417-419).
adult size. By careful choice of lens parameters, they obtained an
eye corrected for spherical aberration. In 1995, the
same team investigated the refractive index of the cor-
neal stroma, to find a slight decrease from the anterior
Other vertebrates’ eyes (1.380) to the posterior surface (1.373), with the
epithelium having the higher index of about 1.401.
On the basis of published data supplemented by much A model having the same spherical and longitudinal
original work, Coile and O'Keefe (1988) have con- chromatic aberration as the typical real eye was de-
structed schematic eyes for six domesticated animals. signed by Navarro et al. (1985). One necessary step was
Both corneal surfaces were included and the lens as- to compile a table of notional refractive indices for the
sumed to be homogeneous. The equivalent powers of various ocular media at four different wavelengths from
the cat, dog, and pig eyes are all very close to a mean 365 to 1014 nm. The front corneal surface was made el-
value of 78.5 D. At the other end of the range are the lipsoidal (p = 0.75), the back surface remaining spher-
horse (39.5D) and the cow (47.7 D). Nearest to the ical, Following the indications of Howcroft and Parker
human eye is the sheep’s (61.3 D). The last row in the (1977), the front surface of the lens was made hyperbo-
tabulated specifications gives the equivalent focal loidal and the back surface paraboloidal. Of particular
length of the eye in air, not the retinal image size as interest is the method adopted to determine the change
stated. in the radii of curvature, thickness and notional refrac-
The cat appears to be emmetropic. The dog and the tive index of the lens when the eye accommodates.
cow are slightly myopic and the pig rather more so, Each of these quantities was defined by a formula con-
about —1.50 D. The horse has about +0.50 D of hyper- taining the amount of accommodation (A) in use. For
214 The schematic eye

Example (2)

An object 30mm high is situated at a distance of

500 mm from the corneal vertex of the Bennett—Rab-
betts unaccommodated schematic eye. Determine the
position and size of the optical image.

Measured from the first principal point P

Figure 12.6. Measurement of conjugate distances from the
eye’s principal points. f= —(500 + 1.51) = —501.51 mm ‘

so that
example, the anterior radius (r;) of the lens, taken as
L=1000/¢ = —1.99D
10.2 in the relaxed eye, assumes the new value r3(A)
given by = \| LF. = —1399 60/00 —-=-53.0 FD

r3(A) = 10.2 — 1.75 log. (A+1) ¢' = 1336/L’ = +23.03 mm

When A = 4D,1r3(A) thus becomes 7.38 mm. This distance is measured from the second principal
point P’, which is +1.82 mm from the corneal vertex
A very different aim was pursued by Kooijman A,. The image distance from A, is therefore
(1983), whose model was designed for the study of
23.03 + 1.82 = 24.85 mm
light distribution on the retina. Liou and Brennan
(1996) demonstrated that most schematic eyes showed and
significantly more spherical aberration than the average h’ = hL/L' = —1.029 mm
real eye. The reduction of spherical aberration in the
Bennett—Rabbetts schematic eye from aspherizing the
cornea is shown in Figure 15.6.
Blurred imagery

Entrance and exit pupils

As indicated in Chapter 2, the entrance and exit pupils
Paraxial relationships
of the eye play an important role in the study of blurred
imagery. The entrance pupil is the image of the real
The fundamental equations
pupil formed by the cornea. Hence, taking the centre E,
L'=L+F, of the pupil as an object for the cornea of the
Bennett—Rabbetts eye we should have
Ka=K+ EF,
co ll 1336/—3.60 = —371.11D
and
L'=L+F, =—371.11
+ 43.08 = —328.03D
ee iy La) vorerhCKay Kk)
¢’ = 1000/L’ = —3.048 mm
apply to the schematic eye provided that the distances /
ji ee
and /’, or k and k’, whichever applies, are measured
from the first and second principal points respectively, The entrance pupil is therefore some 3.05 mm behind
as in Figure 12.6. It is important to remember that in the corneal vertex, while the magnification is 1.13.
the schematic eye the distance k’ does not represent the Since the edge of the iris forming the pupil boundary
overall axial length, as it does in the reduced eye. is in approximately the same plane as the front vertex
of the crystalline, it is self-conjugate by refraction at
this surface. Accordingly, the exit pupil can be located
by considering refraction at the posterior surface only.
Example (1)
Hence
A schematic eye with the relaxed Bennett—Rabbetts op-
L = 1442/—3.70 = —384.32D
tical system has an axial length of 26 mm. What is its
refractive state? L =L-+ Fs.= —38432.1 13.28 — —3 7041
aN = tA, A\M' = —1.82 + 26 =24.18mm ¢ = 1336/3 60mm
K | 1000n,g/k’ = 1336/24.18 = +55.25D
/
i eee
K = K’ — F,( = 55.25 — 60.00 = —4.75D The exit pupil is thus situated just within the crystalline
lens, at a distance of (3.70 — 3.60) or 0.10 mm from its
k = PMpe = 1000/K = —210.63 mm
anterior pole. Its size is the fraction 1.036/1.131 or
The distance A,Mp from the corneal vertex to the far 0.916 of that of the entrance pupil.
point is found from With respect to the optical system of the eye as a
whole, the entrance and exit pupils are conjugate
A, Mp = AyP + PMp= 1.51 — 210.63 = —209.12 mm points. An incident ray directed towards the centre E of
 Blurred imagery 215

If / and /’ are the object and image distances meas-

ured (as is normal) from P and P’ respectively, then

h’ nf’ n(q' +0’) n{(n'/Q') + (n'/V')}

h We” nig o) n'{(n/Q) + (n/V)}

WOy VO
(V + Q)V’O!
R’ Equating the two expressions for h’/h gives

VV -O =V-V 07 2VV 00" =VV 00.

Figure 12.7. Measurement of conjugate distances v, v’ from
the entrance and exit pupils E, BE’. which, when divided by VV'QQ' becomes
vV'o_ VO’
+Q'—Q (e275)
the entrance pupil would be refracted by the cornea so oo ©
as to pass through the centre E, of the real pupil; then, Let the magnification of the system for the two given
after refraction by the crystalline, it would emerge as conjugates be denoted by me, so that
though from the centre E’ of the exit pupil (see Figure
Daly. mg = Q/O' = q'/n'q (12.6)

From the laws of conjugate foci we also have

-

8) Or wie
Paraxial relationships referred to pupils
When these substitutions are made in (12.5) we get
If any one pair of conjugate foci is known, they can be
used as reference points for the determination of any
mpV = V/mp + F (L257)
other pair. Thus, instead of the eye’s principal points, It is evident from the derivation of this expression that
the entrance and exit pupil centres may be used as E and E’ can refer to any pair of conjugate points. If
origins of measurement. The familiar paraxial formulas these were the principal points, for which the magnifica-
then require surprisingly little modification. tion is unity, the expression would simplify to its famil-
In Figure 12.7, P and P’ denote the principal points iar form, V and V’ becoming L and L’.
and E and E’ the centres of the entrance and exit pupils In the case of the Bennett—Rabbetts unaccommodated
of an eye. schematic eye it has already been established that
The distance of E from P is denoted by q and the dis-
ia? = Spil,
5 i liaaian
tance of E’ from P’ by q’. If n is the refractive index of
the first medium (assumed to be air) and n’ that of the and
last medium (the vitreous body), we can replace q and
Aj E = 3.048 mm
q’ by their dioptric equivalents O and Q’, obtained from
so that
C= nig and. OC =n /q
@) SVG, SS dal) Se = FE Ik 7 saa
An incident ray directed towards E, from the extre-
mity of an object BR, meets the first principal plane at Q = 1000/+1.537 = +650.62 D
H. According to a well-known principle of ray construc-
O =0+F, =+650.62'+ 60,00 = 4710.62, D
tion, the refracted ray must leave the second principal
plane at a point H’ at the same height y from the axis mp = O/Q' = 0.9156
as H. This ray must also pass through E’ since this is
For this value of mp, equation (12.7) becomes
conjugate with E. Let B/R’ be the image of BR formed
by the eye. Then the incident ray RP must give rise to 0.916V’ = 1.092V + 60.00 (12.8)
the refracted ray P’R’.
or
The next step is to find the relationship between the
object distance v, measured from the entrance pupil, V' = 1.192V+ 65.50 (12.9)
and the image distance v’ measured from the exit pupil.
The next step is to establish a relationship between
Expressing these distances dioptrically we should have
the angle u subtended by the object at the centre E of
Ve ne and Von) t the entrance pupil and the angle u’ subtended by the
image at the centre E’ of the exit pupil. In Figure 12.7
From similar triangles in Figure 12.7
i= PABA = iG)
h/y = BE/PE = —v/q = —Q/V
and
and 5
h'/y = B'E’/P’E! = —y' /q! = =) 7 =P ey PE == yg
from which
which gives
i= 9) 4 = nO nO. = min me
and
216 The schematic eye

; n centre E’ of the exit pupil. As explained in Chapter 4,

=| ——— (LZ UY)
n'my the basic height of the retinal image is the distance be-
tween the centres of the limiting blur circles. If g is the
Finally, from Figure 12.7 we can also obtain an ex-
diameter ofthe entrance pupil (not shown); g’ the diam-
pression for the transverse magnification h’/h. In this
eter of exit pupil: v’ = B’B’ the distance of the optical
diagram, the angles u and w’ are both positive in accor-
image from E’; w’ = E'M’ the distance of the retina from
dance with the sign convention set out in Chapter 2.
BE’; h'=B’Q' the optical image height; h, the basic
Hence
height of the retinal image and j the diameter of the ret-
u= —h/v = —hV/n inal blur circles; then, from Figure 12.8, the quantities
hj, and j can be found from
and
b= ht oS SV in he = (w/e (12.14)
and
which gives, using equation (12.10)

h’ “a n'ul'V pen
LRAT
hnuv’ | mp V! ( )
For the Bennett-Rabbetts unaccommodated sche-
matic eye we have n=1, n’ =1.336, and mp =
Example (3)
0.9156. With these substitutions expression (12.10) be-
comes A 60m Snellen test letter is viewed from a distance of
3m by a myope of ocular refraction —4.00 D. Find the
u’ = 0.817 u (i212)
dimensions of the blurred retinal image, taking the
and expression (12.11) becomes optics of the Bennett—Rabbetts unaccommodated eye
with a 4mm entrance pupil.
hj 11092 V/V’ (12:3)
It must be emphasized that these last two expressions, The magnification of the exit pupil, given by equation
together with (12.8) and (12.9), refer to the Bennett— (12.6), was found to be 0.916 for this eye. Conse-
Rabbetts schematic eye in its unaccommodated state. quently, its diameter g’ is 4 x 0.916 or 3.664 mm.
Calculations using the assumed values of d,, dy, r. and The image distance P’B’, measured from the eye's
r; for the states of accommodation given in Table 12.1 second principal point P’, is found from
show that the coefficients of u in equation (12.12) pro-
L'=L+F, = —0.33 + 60.00 = +59.67D
gressively decrease (2.50 D: 0.809, 5.00 D: 0.802,
7.50 D: 0.796 and 10.00 D: 0.790) as the eye accom- and thus
modates. As a result, the basic size of the retinal image
PB = 1336/5967 =22:39 mm
of an object at any distance becomes very slightly smal-
ler as accommodation is brought into play. From Table 12.1, the distance P’E’, equal to A,E’—
A;P’), is seen to be 1.88 mm. Hence
i} = 29,39 — 8S = 20 5a mim
Blurred retinal images
The value of k’ is obtained from
Blurred retinal images in the reduced eye have already
been discussed in Chapter 4. The same basic principles k= hee F, = —4.00 + 60.00 = +56.00 D
will now be applied to the schematic eye. In Figure so that
12.8, an object BQ (not shown), situated on the optical
axis of a myopic schematic eye, gives rise to the sharp k = P’M’ = 1336/56.00 = 23.86 mm
optical image B/Q’ formed in front of the retina. The dia- and
gram indicates the pencils of rays, limited by the exit
pupil H’J’, which focus at B’ and Q’ and proceed to w =k’ — P’E’ = 23.86 — 1.88 = 21.98 mm
form blur circles on the retina. The centres of these cir- The height of a 60 m Snellen letter, which subtends
cles are determined by the rays E’B’ and E’Q’ from the an angle of 50 minutes of arc (or 0.8333°) at 6m, is
6000 x tan 0.8333° = 87.27 mm
Exit
and the sharp image height h’ is therefore
pupil Retina
h’ = hL/L' = 87.27 x (—})/59.67 = —0.488 mm
Then, from equation (12.14)

hy = —(21.98/20.51) > 0:488 = —0,523 mm

and, from equation (12.15),
2OR5t |
Jj= Sie!
®) ( 50.5] = =O)»
0.263 mm

Figure 12.8. Blur-circle formation and basic height /, of the The minus sign indicates that in this case the optical
retinal image in a myopic schematic eye. image lies in front of the retina, the blur circles being
 The Purkinje images 217

formed by rays which have crossed over in the optical 2

Ny — NY
image plane. 024 (12.19)
(= ae lily )
Since the blur ratio j/hj, is approximately 0.5, the
probability is that the letter would be read. where n, and n, are the refractive indices of the first and
It is interesting to compare these results with those second media respectively. Equation (12.19) shows
obtained from the standard reduced eye of power +60 that the reflectance increases as the difference between
D. In this example, K = —4.00D and L = —0.33D, so the two refractive indices increases. In the eye, by far
that K' = +56D and L’ = +59.67D. Expression (4.19) the biggest index change is at the front surface, so that
(for the reduced eye) then gives the first reflection, from the anterior surface of the
Lia KS 707 (—4)/56 = —0.519 mm cornea, is about 100 times as bright as any of the
others.
while equation (4.16) gives Light entering the eye undergoes further partial re-
ee 56 — 59.67
59.67 _ flections at the back surface of the cornea and at the
0.262 mm outer surfaces of the crystalline lens. It is customary to
56
designate the images so produced as Purkinje I, II, Ill
and IV, the Roman numerals denoting the refracting
surfaces in the order in which they occur.
Projected blurs
For studying Purkinje I (also called the ‘corneal
If 0’ denotes the angular subtense of a blurred retinal reflex’), we can regard the anterior surface of the
image at the centre of the exit pupil, the corresponding cornea as a convex mirror. Any convex mirror gives
angle 0 in object space (with its vertex at the centre of rise to a virtual, erect and diminished image of any real
the entrance pupil), can be found by substituting 0 and object, the image moving towards the mirror and grow-
0’ for uand w’ in expression (12.10). This results in ing larger as the object approaches the mirror. Ulti-
mately, object and image coincide at the vertex of the
nee (at )9!
(1216) mirror. If the anterior radius of the cornea is taken as
n
+7.8mm, the focal plane is situated at half this dis-
= 1.2230’ ‘eye lyg tance, that is, 3.9 mm, behind the vertex, giving the sur-
face a catoptric power of some —256 D. This is so high
for the Bennett—Rabbetts unaccommodated schematic
that Purkinje I remains substantially in the focal plane
eye. 5
until the object distance is quite short. For example, if
For the reduced eye having a refractive error K, it was
an object were as close as 100 mm its Purkinje I image
shown that the angular subtense 9 of the projected
would have moved only 0.15 mm from the focal plane.
blurred image of a distant object point is gK prism diop-
To form the remaining Purkinje images, the incident
tres where g is the pupil diameter in centimetres. The
light is first refracted by all the surfaces in front of the
corresponding expression for the schematic eye is
one acting as a mirror and then, after reflection, is re-
~ gK(1+ K/Q’) GUS) fracted again by these same surfaces in reverse order
before emerging from the eye. Calculating the position
where g is the diameter of the entrance pupil.” In many
and size of these images is made simpler by using the
cases the term K/Q’ would be entirely negligible.
equivalent mirror theorem. This states that a system
comprising one or more refracting surfaces followed by
a plane or spherical mirror can be simplified for calcula-
tion to an ‘equivalent’ spherical mirror. The vertex and
centre of curvature of the equivalent mirror coincide, re-
The Purkinje images
spectively, with the images of the vertex and centre of
curvature of the actual mirror formed by the refracting
Theoretical considerations
elements.
The Purkinje images, named after the celebrated Czech In its simplest form, a system of the type under discus-
physiologist, are reflections from the various refracting sion can be represented, as in Figure 12.9, by a thin
surfaces of the eye. plus lens in front of a convex mirror with its vertex at
When light is incident on a refracting surface, a small A and its centre of curvature at C. The off-axis point Q
proportion undergoes reflection, the reflected light is an object for the system and Q} is its image formed
being plane polarized to a degree determined by the by the lens alone. If A and C are taken as object points
angle of incidence. It was Fresnel who deduced the for the lens, the rays AQ, and CQ, directed towards Q,
equations for what is now called the ‘reflectance’ (p) or must, of necessity, pass through QO after refraction,
fraction of the incident light that is reflected. For angles since Q and Q) are conjugates. Moreover, if the refracted
of incidence up to about 15°, the degree of polarization rays are produced backwards from Q, the points A’ and
is negligible and the reflectance can be found from the C’ at which they meet the axis must be respectively the
simplified expression images of A and C formed by the lens.
We now revert to Q as an object point for the system,
its first image (formed by the lens) being QO}. To find the
second image Q formed by reflection, we take Q) A and
“This expression is left as an exercise for the student to
derive by projection into object space via the centres of the exit O/C as incident rays, the first being reflected along the
and entrance pupils. symmetrical path AG and the other, which meets the
218 The schematic eye

Figure 12.9. The equivalent mirror,

shows as a broken curve, that replaces the
system formed by the thin lens at O and
mirror at A.

Since the radius of curvature r, of the cornea can be

measured directly with a keratometer, it can be used as
a basis of calculation. Thus, if hj, denotes the height of
the kth Purkinje image and r; is the radius of curvature
of the corresponding equivalent mirror,

hy, = u(r},/2)
and since, for the same object
ha = ur 2)
it follows that

rp = ryhi/hj (12.21)
This is the basis of the comparison method of phako-
metry described on page 398.
Figure 12.10. Equivalent mirror theorem applied to
reflection at the posterior surface of the crystalline lens.
Typical dimensions and properties
Le Grand’s schematic eye is a suitable one for calcula-
surface normally, being returned along its own path.
tions on the Purkinje images because it incorporates
Hence, Q4 is located at the (virtual) intersection of AG
the four surfaces responsible. Le Grand himself (1945)
and CQ}. Finally, these reflected rays are refracted by
has calculated the positions and relative sizes of the
the lens, from which they emerge in the directions A/G
images, given an object distance of 500 mm. His results
and C’Q. The final image Q% lies at the virtual intersec- are included in Table 12.3, together with similar calcula-
tion of these two ray paths. These ray paths determine
tions (by the authors) for an object at infinity. These
the final image of Q and are precisely those which latter computations covered the fully accommodated as
would result from replacing the system by a single well as the relaxed eye. For convenient reference the di-
spherical mirror with its vertex at A’ and its centre of mensions of Le Grand’s schematic eye are summarized
curvature at C’. below.
When applying this procedure to Purkinje IV (Figure
12.10), it will be found that Ay and Cy, lie on opposite
sides of the front surface of the crystalline, which is the Relaxed eye
refracting surface next in line. In this case, Cy must be Radii of curvature +7.8, +6.5, +10.2, —6.0 mm
regarded as a virtual object towards which a pencil of Axial separations 0.55, 3.05, 4.0 mm
rays is travelling in the crystalline lens before being inter- Refractive indices 1, 1.3771, 1.3374, 1.42, 1.336
cepted. As shown in the diagram, the front surface of
the crystalline then forms a real image C’. However,
this is only an intermediate image of Cy because further Eye accommodated 6.96 D
refractions at the two surfaces of the cornea are to Radii of curvature +7.8, +6.5, +6, —5.5 mm
follow.
Axial separations 0.55, 2.65, 4.5 mm
Given a relatively distant object, the size of the image Retkactivedndicess leo 7aaleleS syle ales 6
formed by reflection is proportional to the focal length
of the mirror, which is one-half of the radius of curva- Using Fresnel’s formula, Le Grand also calculated the
ture. If the object subtends an angle u (in radians), the relative brightness of the Purkinje images, taking ac-
height h’ of the image is given by count of the pre-corneal tears film (which he assumed
to be homogeneous) and of the lens capsule, which has
h' = uf’ = u(r/2) (S122,O)} a slightly lower refractive index than the adjacent
 The Purkinje images 219

Table 12.3. The Purkinje images (calculated from Le Grand’s schematic eye)

Image Relative Unaccommodated eye Eye accommodated

No. brightness 6.96 D
Distant object Object at SOO mm (distant object)

Image Relative Image Relative Image Relative

position size position size position size
(mm) (mm) (mm)

if ] +3.900 ] +3.870 ] +3.900 ]

II 0.010 +3.605 0.820 +3.585 0.821 +3.605 0.820
Il 0.008 +10.726 Al +10.610 1.945 +6.200 PO
IV 0.008 +4.625 —0.763 +4,.325 —On762 +5.237 =0.7 73

Image positions expressed as their distances from the anterior corneal vertex.

(a)

(b)

Y {NY

Figure 12.11. Relative positions and sizes of the Purkinje Source Obs.
images of a distant object-positioned 20° above the optic axis.
Figure 12.12. (a) Relative positions of the Purkinje images —
images of a distant object positioned 20° above the optic axis.
(b) The appearance within the pupil.
layers of the crystalline itself. His results are shown in
the second column of Table 12.3, taking the corneal re-
flectance of 2.1% as a basis of comparison. Several important uses have been found for the Pur-
Clark and Carney (1971) found experimentally a cor- kinje images. principally in measuring or calculating
neal reflectance of up to 8% and postulated the actual the various optical dimensions of the eye. There are
multi-layer structure of the tears film as the explana- also some useful clinical applications in establishing the
tion. The epithelial index of 1.401 mentioned above direction of the patient’s gaze or of the examiner's own
would give a reflectance of 2.8%. position relative to the patient’s visual axis.
Figure 12.11 shows the positions and relative sizes of If two small light sources are placed in the same verti-
the Purkinje images of a distant object inclined at 20° cal line, one above and one below the eye's fixation
from the optical axis. Purkinje II, being slightly smaller axis, the three pairs of visible Purkinje images (I, II,
than I and just in front of it, is normally indistinguish- and IV) will usually appear to be out of vertical align-
able from it, though Tscherning has described a simple ment. Tscherning attributed this to a tilt of the crystal-
technique of observation. With the eye in its relaxed line lens. The angle alpha can be measured by this
state, Purkinje If] is nearly twice the size of I, but as ac- means (see page 397). An extensive study of the effects
commodation is brought into play it becomes smaller of both a tilt and an off-axis displacement of the cornea
and moves forward into the crystalline. Accommodation and crystalline lens on the observed positions of the Pur-
affects Purkinje IV, which is inverted, to a much lesser kinje images has been made by Clement et al. (1987).
extent. Its size remains about three-quarters of that of Each surface was assumed to be of a specified conicoidal
Purkinje | and it moves a short distance towards the form. One of the points which emerged was that Tscher-
ning’s assumption was right. The method used in this
retina.
Purkinje III is of notoriously poor quality. This is at- study was a skew ray tracing system specially developed
for this purpose but having further possible applications
tributed to the ‘orange peel’ nature of the surface struc-
in the field of ocular dioptrics.
ture of the lens. The defects of this image are no doubt
accentuated by its greater size.
Figure 12.12 illustrates the Purkinje images I, III and
Secondary ghost images
IV, the object being an illuminated triangle lying to one
side of the eye’s optical axis. If the observation is made The reflected pencils responsible for the Purkinje images
from the other side as indicated in the diagram, the Pur- undergo further reflections at the various surfaces they
kinje images will be seen in approximately the relative meet on their outward path. However, it is only at the
positions shown on the right. front surface of the cornea that the reflectance is high
220 The schematic eye

enough for visible effects to be possible when the twice- Optical axis
reflected light reaches the retina. Account must there-
Since the eye is not a centred optical system, it does not
fore be taken of a secondary set of ghost images arising
possess a true optical axis. Using his ophthalmophak-
from reflection at the front surface of the cornea, acting
ometer, Tscherning nevertheless found it possible to es-
as a concave mirror. If formed sufficiently close to the
tablish an axis of observation, relative to the subject's
retina, the images so arising could (under suitable con-
visual axis, such that all the Purkinje images of a test
ditions) be perceived as such by the subject.
object appear in approximate alignment. This axis of ob-
For purposes of reference we shall designate the ghost
servation can be taken as the closest approximation
image formed by a first reflection at the back surface of
possible to a true optical axis. At least it has the‘merit
the cornea as Purkinje V, which is associated with Pur-
of being experimentally ascertainable.
kinje II. Similarly, Purkinje VI and VII are associated
with III and IV respectively.
Calculation shows that Purkinje V is situated well Visual axis
beyond the retina, while VI lies within the crystalline Names have been given to two different ray paths to the
lens. Neither could be perceived recognizably. On the fovea. The ray path via the nodal points N and N’ has
other hand, VII could be formed quite close to the traditionally been called the visual axis, while the ray
retina and even in sharp focus. The deciding factor is path via the centres E and E’ of the entrance and exit
the front corneal radius which determines the catoptric pupils is generally called the principal line of sight or
power Z, of this surface when acting as a concave simply the line of sight. Both paths are shown in Figures
mirror, given by Bennett (1968a) in the form 12.13 and 12.14. Applied to the ray path via the nodal
points, the term ‘visual axis’ is clearly a misnomer and
Z, = 2000 n;/r,
should be transferred to the ray path via the pupils. In
the first place, the ray from the fixation point to the
when r, is in millimetres. In the case of Le Grand’s sche-
centre of the entrance pupil is the true axis of the
matic eye, for which n, = 1.3771, this expression
pencil of rays which actually enters the eye and stimu-
would become
lates the retina. Secondly, the statement that the rays
from the fixation point to E and N are, in any case, par-
Di, = DSR, (GAZ)
allel in distance vision applies only to the emmetropic
Thus, a relatively smal! difference in r; would make an eye (Figure 12.13). The situation that arises in the
appreciable difference in the value of Z;. myopic eye is illustrated in Figure 12.14. If rays are
In the emmetropic schematic eye, Purkinje VII would traced backwards from the fovea M’ to E’ and N’, the re-
lie approximately 7mm in front of the retina, too far fracted rays will emerge from the eye as though from E
out of focus to be discernible. To place the image on the and N respectively, but in this case they cannot be par-
retina, the convergence of the pencil reflected from the allel. They are bound to intersect at the eye’s far point
cornea must be reduced, which will occur if the cornea Me since, by definition, this is the point conjugate with
were flatter. the fovea. Any fixation point such as B must clearly lie
A corneal radius in the neighbourhood of 8.4 mm is on the line passing through E and Me because this is
required to place Purkinje VII on the retina of an eye of the incident path of the ray which finally impinges on
otherwise average dimensions. Such an eye would have the fovea. Thus, in general, the so-called visual axis
several dioptres of hypermetropia. It is worth noting
that Tscherning, one ofthe pioneers in the investigation
of this topic, made the observation that myopes find it
difficult to see Purkinje VII (see Tscherning, 1924, for
further details of his experiments).
Purkinje VII is erect on the retina and would therefore
appear inverted to the subject. Its perceived size when
in focus would be about three-quarters of that of the
object seen by direct refraction. Figure 12.13. The visual axis through the entrance and exit
pupils E, E’ and the nodal axis through the nodal points N, N’ of
the emmetropic eye (not to scale). In emmetropia, the two axes
are parallel in object space.

The eye's optical centration

In Le Grand’s memorable phrase, the subject of the eye's

optical centration is ‘confus et delicat’. The plethora of
terms and conflicting definitions in this field was com-
prehensively reviewed by Martin (1942). Martin re-
duced the number of terms to an essential minimum, at
the same time defining them with the necessary (or
Figure 12.14. The myopic eye. Reverse trace from the fovea
possible) degree of precision, a course we shall adopt through the exit and entrance pupils and through the nodal
here. points, showing their intersection at Mp (not to scale),
 An ordered range of variants 221

cement of the fixation object from the axis of observation

divided by the distance of the scale from the subject's
eye gives the tangent of the angle kappa (or lambda).
Optical axis

Iris-perpendicular axis
Subjective judgement of the direction of gaze is un-
doubtedly aided by mentally constructing an axis
Figure 12.15. The optical, pupillary and visual axes of the through the pupil centre, perpendicular to the iris. This
eye (not to scale). is a particularly useful clue when the corneal reflex is
not visible because of diffuse illumination or obliquity
would not even pass through the fixation point. Thirdly, of observation. Another clue, mentioned on page 187,
the visual axis as traditionally defined, besides being a is the extent of sclera visible on each side of the cornea.
concept of limited utility, cannot be located in practice.
It is therefore suggested that the ray path to the fovea Corneal reflection PD gauge
via the nodal points should be renamed the nodal axis,
and that the term visual axis should apply to the ray For distance PD measurement, these devices use a
path to the fovea via the pupil centres. As already indi- simple telecentric system. A small observation aperture
cated on page | 3, it will be used in this sense through- is situated at the anterior focal point of a converging
out the present work. lens of about 80mm width. The subject views the
image formed at infinity of a small illuminated ring sur-
Angle alpha ° rounding the observation aperture. Since only rays sub-
stantially parallel to the optical axis can pass through
This angle, which can be measured with Tscherning’s this aperture after refraction by the lens, measuring
ophthalmophakometer, is the angle between the eye’s errors due to parallax are obviated. For each eye inde-
optical axis and its visual axis. It is taken as positive pendently, the observer moves a vertical fiducial wire
when the visual axis in object space lies on the nasal so as to bisect the corneal reflection of the annular
side of the optical axis (see page 397). source. As can be seen from Figure 12.15, the centre of
this reflected image must lie in the ray parallel to the
Pupillary axis visual axis and passing through C,, the centre of curva-
ture of the cornea. Because of the angle alpha (assumed
This can be defined as the line from the centre of the en-
to be positive), the PD thus measured will be slightly
trance pupil which meets the (single surface) cornea
smaller than the distance between the centres of the
normally. It thus passes through C,, the centre of curva-
eyes’ entrance pupils, unless the pupils are decentred
ture of this surface (Figure 12.15).
nasally. Because of this, it may be preferable to move
Typically, the pupil is thought to be decentred nasally
the fiduciary wire to bisect the pupil. For measuring the
from the optical axis by about 0.25 mm, in which case
near PD, the lens is moved closer to the aperture and
both the entrance and exit pupils would lie on the
set to a scale, so that the source image is formed at the
nasal side of the optical axis. Even a displacement as
given near distance.
small as 0.25 mm would create an angle of some 3° be-
tween the pupillary and optical axes.
There is also evidence to suggest that when the pupil An ordered range of variants
contracts, it does not do so symmetrically. Its geomet-
rical centre moves slightly nasalwards — a fact of some In general, the optical dimensions of the various sche-
significance in the study of chromatic stereopsis (see matic eyes represented mean values as suggested by
Chapter 15). available data. When studying ametropia and optical
imagery in the ametropic eye — and even in emmetropia,
Angle kappa (or lambda) for that matter — the known variations in these dimen-
As introduced by Landolt, this term denoted the angle sions must be taken into account. The values listed in
between the pupillary axis and the visual axis as then Table 12.4 were compiled mainly on the basis of
understood (i.e. the nodal axis). More recently, the Stenstr6m’s classic study (1946) of 1000 eyes in vivo.
angle kappa has been used (by Le Grand, for example)
Table 12.4 Standard values and ranges of main ocular
to denote the angle between the pupillary axis and the dimensions
principal line of sight or visual axis as redefined above.
The same angle has also been called ‘angle lambda’ by Dimension Symbol Standard value Range
some American writers.
Corneal radius (mm) r| 7.80 7.0 to 8.8
A simple means of measuring the angle kappa (in its Corneal power *(D) F, +43.08 +38 to+48
modern sense) or angle lambda has been described by Depth of anterior chamber d 3.60 2.9 to 4.5
Loper (1959). A circular fluorescent lamp is mounted (mm) (including corneal
so as to surround the object glass of a sighting telescope. thickness)
Equivalent power of lens (D) Fy. +20.83 +16 to +29
A fixation object movable laterally along a scale in Equivalent power ofeye(D) F,. +60.00 +51 to+71
nearly the same plane as the lamp is used to direct the
subject’s gaze until the first Purkinje image of the lamp “ Evaluated from the radius, assuming a single surface cornea
appears centrally within the subject’s pupil. The displa- and a refractive index of 1.336.
222 The schematic eye

Table 12.5 Variants of the Bennett—Rabbetts schematic bitrary value of d, (depth of anterior chamber) which
crystalline lens
nn LE
the eye is assumed to have in each case.
Dimension Lens A Lens B Lens C
The set of variant schematic eyes derived from this ap-
(low power) (standard) (high power) proach is detailed in Table 12.6. In addition to the di-
mensions, the table also gives the positions of the
Radii of curvature principal points and of the entrance and exit pupils, to-
' +14.25 +11.00 +7.82
r3 = 8°50 —6.475 —4.60 gether with the axial length required for emmetropia.
Axial thickness (d>) 2.90 BRA) 4.50 This is seen to vary from 20.83 to 27.67 mm. It is inter-
Surface powers esting to note that Sorsby et al. (1957) found the axial
Fy + 6.04 + 7.82 +11.00 length of 90 emmetropic eyes to vary from 21 to 26mm.
F; +10.12 +13.28 +18.70 Given a set of hypothetical eyes as tabulated, it is a
Equivalent power (FL) +16.03 +20.83 +29.04
simple matter to calculate the axial length required in
Position of principal
points from each case to produce various degrees of spherical ame-
anterior pole tropia. Table 12.7 gives the results of such a study, the
first +1.72 +2.22 +2.72 ametropia being expressed as the spectacle correction
second +1.87 +2.40 +2.90
needed at 14 mm from the eye’s first principal point.
Assumed depth of 4.10 3.60 3.00
anterior chamber (cd)
These results were used to construct the graph in
Figure 12.16. It was found possible to draw a series of
All linear dimensions are in millimetres and powers in dioptres. curved lines passing very close to all the points plotted
for a particular refractive error. To a reasonable approx-
imation, the graph shows the range of possible combina-
tions of equivalent power and axial length producing
various degrees of ametropia. It can also be used in re-
If the ‘standard’ cornea and crystalline lens are each
verse. For example, an equivalent power of +69 D and
supplemented by two others, one from each end of the
an axial length of 27 mm would result in a spectacle re-
tabulated range, the permutation of these two sets of
fraction of approximately —20 D.
variables will produce nine different feasible optical sys-
tems. Stenstrdm did not measure the radii of curvature
of the lens surfaces, but for our present purpose it will
be legitimate to assume that they maintain the same Determination of the equivalent
ratio (11:6.475) as in the ‘standard’ eye. On this basis, power of the eye
a set of hypothetical crystalline lenses has been con-
structed, the dimensions of the middle one being those A method for the determination of the equivalent power
of the Bennett—Rabbetts schematic eye. Their dimen- of the crystalline lens and of the eye, based on the
sions are given in Table 12.5. This table also gives an ar- shape of the schematic eye’s lens, is given in Chapter 20.

Table 12.6 Variants of the Bennett—Rabbetts schematic eye

Corneal power +38.01 +43.08 +48.00

Lens
A B (eC A B* 6 A B e
(low power) (standard) (high power) (low power) (standard) (highpower) (low power) (standard) (high power)

r +8.84 +8.84 +8.84 +7.80 +7.80 +7.80 +7.00 +7.00 SH A{0K0,

r +14.25 +11.00 HEM soh.2 +14.25 +11.00 +7.82 +4+14.25 +11.00 =e Oe
13 —8.50 —6.475 —4.60 —8.50 —6.475 —4.60 —8.50 —6.475 —4.60
d 4.10 3.60 3.00 4.10 3.60 3.00 4.10 3.60 3.00
do DDO 3.70 4.50 DIEXY) 33,110) 4.50 DEO 3.70 4.50
F, +38.01 +38.01 +38.01 +43.08 +43.08 +43.08 +48.00 +48.00 +48.00
Fy +6.04 +7.82 +11.00 +6.04 +7.82 +11.00 +6.04 On +11.00
F; +10.12 +13.28 +18.70 +10.12 +13.28 +18.70 +4+10.12 +13.28 +138.70
Equivalent power +51.38 +55.39 +62.32 +56.10 +60.00 +66.76 +60.68 +64.48 Seif Mealy
of eye (F.)
Focal lengths
ie —19.46 —18.05 —16.04 17.83 —16.67 —14.98 —16.48 =15.51 —14.07
fe +26.00 +24.12 +21.44 +23.82 422.27 +20.01 +22.01 +20.72 +18.80
Principal points
A\P +1.36 +1.64 +2.00 +1.24 +1.51 +1.86 +1.15 +1.4] pla S
A,P’ +1.67 +2.00 +2.41 srilsoyl +1.82 +2.21 +1.37 nO +2.0
Pupils :
A\E +3.47 +3.00 +2.46 +3.54 +3.05 +2.49 +3.60 +3.09 =A,
A, E’ +4.22 30/0 +3.01 +4.22 +3.70 +3.01 +4,22 +3.70 =+3.01
Axiallength for +27.67 +26.12 +23.85 4+25.32 +24.09 +22.22 +423.39 +22.39 +20.83
emmetropia
OO ————————LLPLL

* This column corresponds to the ‘standard’ eye.

All linear dimensions are in millimetres and powers in dioptres.
 The aphakic eye 223

Table 12.7 Axial lengths (in mm) of the variant schematic eyes detailed in Table 12.6 when exhibiting various amounts of spherical
ametropia
a BB ht a
Spectacle Power of cornea (F\)
refraction
+38.01 +43.08 +48.00

Lens A Lens B Lens C Lens A Lens B Lens C Lens A Lens B Lens C

(low power) (standard) (highpower) (lowpower) (standard) (highpower) (low power) (standard) (high power)

+10.00 2287) 21.94 20.48 PPS) 20.47 ORS 19.85 1S) QP iS} Y)
+5.00 Doma D399 22.14 23.24 DOP) 2078 BAGO, OWS OES
@) DAS 26.12 23.85 DS 3) 24.09 Dae) D338) 22239 20.83
—5.00 3027, DS35 DONS 27.48 RSV DSP) D5e28 24.00 22.16
—10.00 33.02 30.66 Q7Go16 29.74 MHD: INS ANS) DAMA 25.65 23.48
—15.00 35.94 33.08 DONT 32.08 29.88 26.78 29.04 Dip 3) 24.80
—20.00 39808 35.60 31.02 34.52 IS) 28.33 31k02 29.01 G3}
—25.00 42.32 38.24 Be Ail 37.06 34.03 BIS ISNO) 33.06 30M 27.46

The spectacle refraction is the distance correction that would be needed at 14mm from the eye’s first principal point or approximately
12.5 mm from the corneal vertex.

only one refracting surface, the power of which is given

to a fair degree of accuracy by the keratometer.
Removal of the crystalline lens entails a drastic reduc-
tion in the power of the eye’s optical system and, in
most cases, the need for a strong plus correction. In the
Bennett—Rabbetts schematic eye the axial length is
24.09 mm and the power of the single corneal surface
is +43.08 D. Thus

Ke lI 1336/24.09 = +55.46D
K = K'—F, = +55.46 — 43.08 = +12.38D
(mm)
length
Axial
To correct this eye for distance, a spectacle lens with

ALAA
its back vertex 12 mm from the cornea would need to

Sea have a back vertex power of approximately +10.75 D,

since

k = 1000/+12.38 = +80.78 mm

and
50 52 54 56 58 60 62 64 66 68 70 72
Equivalent power of eye (D) toe =k+d=-+92.78mm

Figure 12.16. Graph showing possible combinations of axial Thus

length and equivalent power required to produce various
spectacle refractions at 14 mm from the eye’s first principal
F,, = 1000/+92.78 = +10.78D
point (compiled from the data of Tables 12.6 and 12.7).
Older operation techniques for cataract extraction with
long incisions and their necessary sutures often left
some deformation of the cornea, resulting in significant
astigmatism, though this often decreased postopera-
The aphakic eye
tively.
The post-cataract correction needed in a particular
The distance correction
case is clearly related to the previous refractive state of
Etymologically, the term ‘aphakia’ denotes the absence the eye, but this is not the only determining factor. The
of the (crystalline) lens. Its surgical removal because of optical dimensions of the given eye also play an impor-
cataract is by far the most common cause of this con- tant role. As a result, the relationship between the post-
dition, but the term is also applied to cases in which the cataract spectacle correction F, and the previous specta-
lens has become displaced from the pupillary area (sub- cle refraction F,, shows a spread of some 3-5 D on each
luxation) and plays no part in the eye’s refracting side of the mean. This can be seen from Figure 12.17,
system. : which was constructed by calculating the post-cataract
The equivalent power of the aphakic eye is that of the corrections needed by a range of variant schematic eyes
cornea alone. As we have already noted, the principal having the refractive errors and axial lengths similar to
points of the typical cornea very nearly coincide with those shown in Table 12.7.
each other and with the vertex of its front surface. We In Figure 12.17, the central unbroken line refers to
may thus regard the aphakic schematic eye as having eyes having the optical system of the Bennett—Rabbetts
224 The schematic eye

Aphakic Spectacle 10% in near emmetropia and 35% in extreme cases of

Correction (D)
antecedent myopia. All these results, shown graphically
+20 in Figure 14.3, are further discussed on pages 262-263
with particular reference to unilateral aphakia.
+16 A number of other problems, described by an aphakic
ophthalmologist (Woods, 1952), arise from the unin-
tended but unavoidable effects of high-powered specta-
ie +12
cle lenses. These subsidiary effects of lenses are
discussed in detail in Chapter 13. me
+8

+4

Intra-ocular lenses

Replacing the natural crystalline with an artificial lens

of similar power in a similar position would leave the
eye in a much more normal optical state. The term pseu-
dophakia to denote this ocular condition has found gen-
-24 -20 -16 -12 -8 -4 0 4 8 eral acceptance.
After Harold Ridley’s pioneer work in fitting posterior
Previous spectacle correction (D)
chamber implants, development turned to the anterior
Figure 12.17. Approximate power of the aphakic spectacle
chamber as a more convenient site. Thanks to the work
correction needed at 12 mm vertex distance as a function of the
correction before operation. of Strampelli and many others, the surgical and optical
problems posed by this procedure have been greatly re-
duced. Nevertheless, posterior chamber implants (of
eye. A reasonable approximation to this curve is given new designs placed in the original lens capsule) have
by the linear equation. now returned to favour in order to avoid the possibility
P= 0.6. Fe + 10.75 (12.24) of damage to the corneal endothelium and anterior
chamber angle.
It can be seen from the graph that eyes in this category When in position, the front vertex of an anterior
having some 18-20 D of myopia would become nearly chamber implant is about 2.0-2.5 mm from the back
emmetropic (apart from any astigmatism) after extrac- surface of the cornea. For a posterior implant, the corre-
tion of the crystalline. This procedure was, in fact, pro- sponding distance is about 3.0—4.0 mm. No differences
posed by Fukala (1890) in cases of high myopia, but of principle are involved and the following discussion
was not well received. embraces both types.
In general, only spherical surfaces are used, but the
The near correction form of the lens varies in different designs. In addition
to the corneal power, the overall axial length of the eye
Because removal of the crystalline lens deprives the eye should be determined, the latter usually by ultrasono-
of its mechanism of accommodation, a near addition is graphy. While the intention is frequently to aim at em-
invariably required; factors relevant to the prescribing metropia or low myopia, a residual error similar to that
of such additions have already been discussed on pages in the patient’s other eye to avoid anisometropia may
119-121. be a wiser option, especially if cataract surgery is not
likely to be needed in this eye for some time. Auxiliary
spectacles may be needed to correct pre-existing corneal
Visual problems in aphakia
astigmatism, residual errors of refraction and the lack
Though surgery has restored their sight, aphakics have of accommodation. Moreover, the controlled use of an
a number of visual problems. The loss of accommoda- auxiliary lens gives a useful means of varying the size
tion is not usually a serious blow because the majority of the retinal image (see pages 262—263 on unilateral
of aphakics are elderly and already have a greatly de- aphakia).
pleted amplitude. A more serious disturbance is the con- If the thickness of the implant is ignored, the required
siderable increase in the size of the retinal image when power F (in situ, not in air) can be found to a reasonably
a spectacle correction is worn. As shown by Bennett close approximation by the step-along vergence method
(1968b) when all the relevant factors (including varia- illustrated in Figure 12.18. The intended auxiliary lens
tions in ocular dimensions) are taken into account, the (if any), placed at a vertex distance d from the single sur-
spectacle-corrected aphakic may have a retinal image face cornea, is of power BS and its effective power at
from about 17 to 53% larger than in his previous refrac- the cornea is
tive state. An average figure would be in the neighbour- jee

hood of 30-35%. In unilateral aphakia, this enormous fo eee Saas

(12225)
1 — dF sp
disparity between the two eyes would make single bin-
ocular vision impossible. With a contact lens correction, The implant is at a distance d, from the cornea and the
the increase in the retinal image sizes ranges from zero . . ) . .
refractive index n’ of the ocular medium is taken as
in the eye previously strongly hypermetropic to about 1.336. The measured power of the cornea is F, and the
 Intra-ocular lenses 225

Powers

Vergences:
Object

Image
Figure 12.18. Step-along method of
calculation to determine the power F of
a thin intra-ocular implant.

overall axial length of the eye is x. All axial distances are Practical approximate formulae
in metres.
Given a distant object, the vergence at the eye is E. A better formula than equation (12.30) can be derived
Thus for calculating the required power of an implant if its
thickness is ignored and if it is intended to make the
Li =E+F, eye emmetropic. Let F. denote the corneal power, d the
and
distance from the corneal vertex to the implant but this
time in millimetres, and x the axial length, also in milli-
aor E+F, oui metres. Then, assuming parallel incident light, the ver-
Get (in) Baer) wie gence L, at the implant is
After refraction by the implant, the pencil has the ver- F,
1 — d(F./1336)
L —
gence L5, equal to n’//5, and will focus on the retina
provided that
After refraction by the implant, the vergence L
(iid, needed to place the focus on the retina is

/ 1336
L5 —
x—d
? ee 1
(ee) Consequently, the required power F of the implant is
wa, (x/n')—<d,/n')
1336 ie
Let X = n’/x. Then, by substitution in equation (12.27), F = ibs L, == (12.33)
: x—d 1 — d(F./1336)
xX
Li, = —————> 12.28
a 1— (d, /n')X ( ) For examples tie. — 43.03 Did 5:6 mmyandaye——
24.09 mm, so that (x — d) = 18.59 mm,
The required power F of the implant can now be found
from equations (12.26) and (12.27), since Gp SNS SCR Rees. 510)

Fewet te 43.08
S TEAC yar 6) csia
Xx E+F,
~1—(d,/n)X 1—(d/n\(E+F,) = YY S)= S255) == SEN)
GS 1D)

are If a planoconvex lens is fitted with its plane surface to

(e229)
~ (1 = (Gi)/n)X}0 = (di
/nVE + Fe} the cornea, its reduced thickness should be added to d
when using simplified equations such as equation
By expanding the denominator and ignoring terms in
(M2533).
(d, /n’)?, this expression can be simplified with little loss
Errors in determining or estimating the values of x
of accuracy to
and d would have the following effects on the calculated
= X—E-F, power of the implant for the typical eye:
F
~ 1 —(d,/n’)(X
+ E+ F,) Error ind (only) Approximate error in power
Although the implant is usually inserted as part of the Each 0.1 mm too deep 0.14 D too strong
Each 0.1 mm too shallow 0.14 D too weak
cataract operation, an anterior chamber lens could be
inserted into an aphakic eye later as a second operation. Error in x only
In this case, the overall length of the eye expressed as X Each 0.1 mm too long 0.30 D too weak
dioptres can be détermined fairly accurately without re- Each 0.1 mm too short 0.30 D too strong

course to ultrasonography. In addition to the corneal

Equation (12.33) can be adjusted in various ways to
power F,, it is necessary to determine the spectacle re-
compensate for systematic inaccuracies arising in prac-
fraction and convert it into the ocular refraction K. The
tice. A comparison of several such formulae has been
value of X can then be found from
made by Sanders and Kraff (1984), Olsen et al. (1990)
Xa ke. and Douthwaite (1993).
226 The schematic eye

The SRK formula The principal points of the lens in the Bennett—Rab-
betts ‘elderly’ schematic eye shown in Table 12.1 lie ap-
This simple formula, devised by Retzlaff et al. (1981), proximately 2.58 and 2.74mm behind the anterior
was the outcome of an entirely different approach. Ex- lens pole. A posterior chamber implant designed to lie
pressed in the symbols used in this chapter, it becomes approximately 5.5mm behind the front surface of the
F=A—25—O0O:9 FF. (* in mm) (12.34) cornea will therefore have its principal plane situated
close to those of the crystalline lens it replaces, and so
in which A is a numerical term differing for each lens
will have little effect on the equivalent power of the eye
type and manufacturer. For anterior chamber implants,
as a whole. There will then be little effect on the retinal
the mean value of A approximates to 115, while for pos-
image size, provided that there is little change in the pa-
terior chamber implants it is about 116.8. A table of
tient’s refractive error. For example, if the Bennett—Rab-
values is given by Sanders and Kraff (1984).
betts schematic eye is provided with a thin implant at
It is noteworthy that a specified value for the anterior
5.6mm depth, the required power as shown above is
chamber depth is not required, being reflected in the
+19.68 D. This gives an equivalent power to the eye as
variation of the numerical term A. Thus, in the numeri-
a whole of 59.20 D, giving a relative image size 1.3%
cal example above, if a lens with an A constant of
larger than the previously emmetropic young schematic
119.0 is implanted in the schematic eye, the power F of
eye. Anterior chamber implants, however, give a signifi-
the implant for emmetropia is +20.00 D.
cantly greater image size.
The SRK formula was based on a statistical analysis of
Where a patient’s fellow eye is nearly emmetropic, or
several thousand cases from various practitioners, cov-
where both eyes will need implant operations within a
ering many different implant designs. It is a regression
short space of time, the surgeon will probably aim to
formula, with the coefficients of corneal power and
choose an implant lens that subsequently renders the
axial length calculated to give the best fit for the entire
patient emmetropic or mildly myopic. Where a patient’s
available sample. Its main advantage is that, being
fellow eye retains good vision and has a significant re-
derived from case records, it takes account of system-
fractive error, the surgeon should aim to duplicate that
atic measuring errors and uncertainties such as
error or perhaps slightly reduce it, otherwise anisome-
postoperative corneal curvature changes and anterior
tropia (Chapter 14) will result. In the neighbourhood of
chamber depth.
emmetropia, the implant power should be decreased by
While coping well with eyes of average axial length,
about 1.5 D for every dioptre of residual hypermetropia
the SRK formula was less accurate in predicting the im-
that is desired, and conversely, increased for myopia.
plant power required for longer and shorter eyes.
For larger residual errors, decreases of 1.65 D or in-
Sanders et al. (1988) suggested correction factors for
creases of 1.35 D per dioptre will be more accurate.
modifying the constant A for eyes with axial length out-
side the range 22.0—24.5 mm.
Although the SRK formulae have worked well, they
have not been based on the vergences within the eye, Exercises
as described above. They therefore (Retzlaff et al., 1990)
developed a theoretically based formula, SRK/T, though
even this had various multiplying factors derived from 12.1 A schematic eye suggested by W. Swaine consists of two
a regression analysis of pre- and postoperative results. thin lenses in air, separated by 4mm. The first, representing
It includes correction factors for axial length in long the cornea, has a power of +43.00 D and the second repre-
senting the crystalline lens, has a power of +20.50 D. Find: (a)
eyes, an estimated value for the postoperative anterior
the equivalent power ofthis eye, (b) the positions of its principal
chamber depth calculated from the (corrected) axial points, (c) the axial length needed for emmetropia.
length and keratometry findings, and retinal thickness. 12.2 Assume that the schematic eye detailed in Question
12.1 has the correct axial length for emmetropia (17.81 mm)
and that the power of the second lens is increased by 5.00 D to
represent the maximum effort of accommodation. Find: (a) the
Lens form and image size position of the near point, (b) the increase in the equivalent
power of the eye. How do you reconcile these results?
Intra-ocular lenses are less than 1 mm thick and their 12.3 If the Bennett—Rabbetts unaccommodated schematic
principal planes will be about 0.12 mm apart and will eye had an axial length of 26.00 mm, all other details being un-
lie towards the front, centre or rear surface depending changed, what would be the precise values of K and K’? At
on the implant lens form, that is, on whether it has what distance from the corneal vertex would the eye’s far
point be situated?
most of its power on the front surface, is equiconvex, or
12.4 Assuming the optical system of the Bennett—Rabbetts
has a near plano front surface power. unaccommodated schematic eye, determine the axial length
In view of the uncertainties involved in implantation corresponding to a principal point refraction of —2.50 D.
and the fact that their principal points are only about 12.5 A possible mechanism for accommodation was thought
0.12 mm apart, they may almost be regarded as ‘thin’ to be a forward axial shift of the crystalline lens. Calculate the
refractive state (measured at the corneal vertex) of the relaxed
lenses. Bennett-Rabbetts schematic eye following a 1.0 mm advance-
The draft Standard ISO 11979: Intra-ocular lenses — ment of the Jens.
Part I — Terminology classifies their strength on the 12.6 Recalculate the data of Table 12.1 for a relaxed, emme-
basis of their equivalent power. The A constant in the tropic eye with a changed refractive index of 1.333 for the aqu-
eous and vitreous humours, all other dimensions except depth
SRK formulae for any particular design will take ac-
of vitreous body remaining the same.
count of the lens form and the average anterior chamber 12.7 An uncorrected myopic eye with a 3 mm entrance pupil
depth after implantation. and the optics of the Bennett—Rabbetts schematic eye views a
 References 227

car at 100 m. If the rear lights are 1.5 m apart and the retinal CLARKE, B.A.J. and CARNEY, 1.G. (1971) Refractive index and
blur circles just touch, what is the ametropia? reflectance of the anterior surface of the cornea. Am. J.
12.8 In a given eye, the radii of curvature of the first and Optom., 48, 333-343
second surfaces of the cornea are 7.8 and 6.9 mm respectively. CLEMENT, R.A., DUNNE, N.C.M. and BARNES, D.A. (1987) A
The cornea is 0.6mm thick and has a refractive index of method for ray tracing through schematic eyes with off-axis
1.376. Find the size and position of the eye’s entrance pupil, as- components. Ophthal. Physiol. Opt., 7, 149-152
suming the real pupil to have a diameter of 4.5 mm, the depth COILE, D.C. and O'KEEFE, L.P. (1988) Schematic eyes for domes-
of the anterior chamber to be 3.2 mm and the refractive index tic animals. Ophthal. Physiol. Opt., 8, 215-220
of the aqueous humour to be 1.336. DOUTHWAITE, W.A. (1993) The intraocular lens. In Cataract, De-
12.9 A myopic eye has its crystalline lens removed and is tection, Measurement and Management in Optometric Practice
then found to be emmetropic. What was the previous spectacle (Douthwaite, W. A. and Hurst, M. A., eds), pp. 114-127.
refraction, assuming the optical system of the Bennett—Rabbetts Oxford: Butterworth-Heinemann
schematic eye with the spectacle plane 12 mm from the cornea? EMSLEY, H.H. (1936) Visual Optics. London: Hatton Press
12.10 An aphakic eye is corrected for distance by a thin lens FUKALA, V. (1890) Operative Behandlung der héchstgradigen
of power + 12.50 DS placed 134mm from the cornea. How far Myopie durch Aphakie. Albrecht v. Graefes Arch. Ophthal.,
and in what direction would this lens have to be shifted to 36(2), 230-244
allow the eye to see distinctly at 5 m from the cornea? GARNER, L.F. and SMITH, G. (1997a) Changes in equivalent and
12.11 A Bennett—Rabbetts schematic eye is rendered aphakic gradient refractive index of the crystalline lens with accom-
and is subsequently corrected by a plano-convex spectacle lens modation. Optom. Vision Sci., 74, 114-119.
8.0 mm thick (with its convex surface forward) at a vertex dis- GARNER, L.F. and YAP, M.K.H. (1997b) Changes in ocular di-
tance of 12 mm. Calculate, and draw a scale diagram showing, mensions and refraction with accommodation. Ophthal. Phy-
the positions of the cardinal points of the system. Assume a re- siol. Opt., 17, 12-17
fractive index of 1.523 for the spectacle lens. GULLSTRAND, A. (1909) Appendix 11.3. The optical system of
12.12 The image size in a corrected eye is proportional to the the eye. In Helmholtz, H. von, Physiological Optics, Vol. 1,
equivalent focal length (in air) of the system. At what distance pp. 350-358. English translation: J.P.C. Southall (ed.). New
should a patient with a corrected aphakic eye (as in the pre- York: Optical Society of America. Reprinted 1962: Dover
vious example) view a 1 m Bjerrum screen, so that the blind Publications, New York
spot will be plotted at the correct distance from the centre of HEMENGER, R.P., GARNER, L.F. and OO1, c.s. (1995) Change
the screen? with age of the refractive index gradient of the human ocular
12.13 Ultrasonography gives the length of an eye as lens. Invest. Ophthalmol. Vis. Sci., 36, 703-707
20.00 mm, while the corneal radius is measured as 7.60 mm. HODOS, W. and ERICHSEN, J.T. (1990) Lower-field myopia in
Assuming an index of 1.336 for the ocular humours and a birds: an adaptation that keeps the ground in focus. Vision
single surface cornea, find: (a) the aphakic ocular refraction, Res., 30, 653-657
(b) the power of the ‘thin’ implant needed at 3.5 mm from the HOWCROFT, M.J. and PARKER, J.A. (1977) Aspheric curvatures
cornea to give emmetropia. for the human lens. Vision Res., 17, 1217-1223
12.14 (a) An aphakic eye is represented schematically by a HUGHES, A. (1979) A useful table of reduced schematic eyes for
single surface cornea of radius of curvature 7.6 mm, the axial vertebrates which includes computed longitudinal chromatic
length being 24.50 mm and the refractive index 1.336. What aberration. Vision Res., 19, 1273-1275
distance correcting lens would be needed at 13 mm from the IVANOFF, A. (1953) Les Aberrations de | ‘Oeil. Paris: Editions de
cornea? (b) Compare the size of the retinal images in this cor- la Revue d'Optique
rected aphakic eye with those formed in the schematic emme- KOOIJMAN, A.C. (1983) Light distribution on the retina of a
tropic eye of power +60 D. wide-angle theoretical eye. J. Opt. Soc. Am., 73, 1544-1550
12.15 Draw a diagram to 5x scale showing the iris perpen- KORETZ, J.F., KAUFMAN, P.L., NEIDER, M.W. and GOECKNER, P.A.
dicular axis and the pupillary axis for the right eye, given a cor- (1989) Accommodation and presbyopia in the human eye —
neal radius of 8.0 mm, anterior chamber depth of 3.5 mm and aging of the anterior segment. Vision Res., 29, 1685-1692
pupillary decentration of 1 mm temporally. LE GRAND, Y. (1945) Optique Physiologique, Vol. I. Paris: Edi-
12.16 Draw a diagram similar to Figure 12.15 to show the tions de la Revue d'Optique. English translation: S.G. El
ray path of a corneal reflection PD gauge for an emmetropic Hage (1980) Springer, Berlin, Heidelberg and New York
eye. Assume the PD gauge to be set for distance vision, an exag- LIOU, H.L. and BRENNAN, N.A. (1996) The prediction of spher-
gerated angle alpha of +15° and the pupil to be centred on the ical aberration with schematic eyes. Ophthal. Physiol. Opt.,
optical axis of the eye. 16, 348-354
LISTING, J.B. (1851) Dioptrik des Auges. In Handwéorterbuch der
Physiologie, Vol. 4. (Wagner, R., ed.). Brunswick: Vieweg
LOPER, L.R. (1959) The relationship between angle lambda and
the residual astigmatism of the eye. Am. J. Optom., 36,
365-377
References LOTMAR, W. (1971) Theoretical eye model with aspherics.
J. Opt. Soc. Am., 61, 1522-1529
BAKER, T.Y. (1943) Ray tracing through non-spherical sur- LOWE, R.F. (1970) Anterior lens displacement with age. Br. J.
faces. Proc. Phys. Soc., 55, 361-364 Ophthalmol., 54, 117-121
BENNETT, A.G. (1968a) Emsley and Swaine’s Ophthalmic Lenses. MARTIN, F.E. (1942) The importance and measurement of
London: Hatton Press angle alpha. Br. J. Physiol. Optics, 3, 27-45
BENNETT, A.G. (1968b) The corrected aphakic eye: a study of NAVARRO, R., SANTAMARIA, J. and BESCOS, J. (1985) Accommo-
retinal image sizes. Optician, 155, 106-111, 132-135 dation-dependent model of the human eye with aspherics.
BENNETT, A.G. (1984) Astigmatic effect of a tilted crystalline J. Opt. Soc. Am. A., 2(8), 1273-1281]
lens. Ophthal. Optn, 24, 793-794 O'KEEFE, L.P. and COILE, D.c. (1988) A BASIC computer pro-
BENNETT, A.G. (1988) A method of determining the equivalent gram for schematic and reduced eye construction. Ophthal.
powers of the eye and its crystalline lens without resort to Physiol. Opt., 8, 97-100
phakometry. Ophthal. Physiol. Opt., 8, 53-59 OLSEN, T., THIM, K. and CORYDON, L. (1990) Theoretical versus
BENNETT, A.G. and RABBETTS, R.B. (1988) Schematic eyes — time SRK I and SRK II calculation of intraocular lens power.
for a change? Optician, 196(5169), 14-15 J. Cataract Refract. Surg., 16, 217-224
BENNETT, A.G. and RABBETTS, R.B. (1989) Letter to the Editor OSWALSO-CRUZ, E., HOKOG, J.N. and SOUSA, A.P.B. (1979) A
(on proposals for new reduced and schematic eyes). Ophthal. schematic eye for the opossum. Vision Res., 19, 263-278
Physiol. Opt., 9, 228-230 PATEL, S., MARSHALL, J. and FITZKE III, F.W. (1993) Model for
BROWN, N. (1974) The change in lens curvature with age. Exp. predicting the optical performance of the eye in refractive
Eye Res., 19, 175-183 surgery. Refract. Corneal Surg., 9, 366-375
228 The schematic eye

PATEL, S., MARSHALL, J. and FITZKE III, F.W. (1995) Refractive STENSTOM, S. (1946) Untersuchungen tiber die Variation und
index of the human corneal epithelium and stroma. J. Refract Kovariation der optischen Elemente des menschlichen
Surg., 11, 100-105 Auges. Acta Ophthal., suppl. 26. English translation: D.
PIERSCIONEK, B.K. (1990) Presbyopia — effect of refractive Woolf. Am. J. Optom., 25, 218-232, 1948
index. Clin. Exp. Optom., 73, 23-30 SWAINE, W. (1921) Geometrical optics — VII: paraxial sche-
POMERANTZEFF, O., PANKRATOV, M., WANG, G.J. and matic and reduced eyes. Optn Scient. Instrum. Mkr, 62, 133-
DUFAULT, P. (1984) Wideangle optical model of the eye. 1367
Am. J. Optom., 61, 166-176 TSCHERNING, M. (1890) Etude sur la position du cristallin de
RETZLAFF, J., SANDERS, D.R. and KRAFF, M.D. (1981) A Manual l'oeil humain. In (Javal, L.E., ed). Mémoires d’Ophtalmometrie.
of Implant Power Calculation: SRK Formula, Medford, Oregon: Paris: Masson
published by the authors TSCHERNING, M. (1924) Physiologic Optics, 4th edn (trans. C.
RETZLAFF, J., SANDERS, D.R. and KRAFF, M.D. (1990) Develop- Weiland). Philadelphia: Keystone Publishing Co.
ment of the SRK/T intraocular lens implant power calcula- WEALE, R.A. (1982) A Biography of the Eye. London: H. Lewis
tion formula. J. Cataract Refract. Surg., 16, 333-340 WOOD, I.J.C., MUTTIO, D.O. and ZAONTIA, K. (1996) Crystalline
SANDERS, D.R. and KRAFF, 1.C. (1984) Determination of proper lens parameters in infancy. Ophthal. Physiol. Opt., 16,
intraocular power for implant patients: intraocular lens 310-317
power calculation formulas, A-scan instruments, and tech- woops, A.c. (1952) The adjustment to aphakia. Am. J. Ophthal.,
niques for use. In Cataract and Intraocular Lens Surgery, 35, 118-122
Vol. 1 (Ginsberg, S.P., ed.), pp. 44-59. Amsterdam: Kugler
Publications
SANDERS, D.R. RETZLAFF, K.A. and KRAFF, M.D. (1988) Compar-
ison of the SRK II ‘™ formula and other second generation
formulas. J. Cataract Refract. Surg., 14, 136-141 Further reading
SMITH, G. (1995) Schematic eyes: history, description and ap-
plications. Clin. Exp. Optom., 78(5), 176-189 BARNES, D.A., DUNNE, M.C.M. and CLEMENT, R.A. (1987) A sche-
SMITH, G., ATCHISON, D.A. and PIERSCIONEK, B.K. (1992) Model- matic eye model for the effects of translation and rotation of
ing the power of the aging human eye. J. Opt. Soc. Am. A, 9, ocular components on peripheral astigmatism. Ophthal.
2111-2117 Physiol. Opt., 7, 153-158
SMITH, G., PIERSCIONEK, B.K. and ATCHISON, D.A. (1991) The DUNNE, M.C.M. (1993) Model for co-ordination of corneal and
optical modelling of the human lens. Ophthal. Physiol. Opt., crystalline lens power in emmetropic human eyes. Ophthal.
11, 359-369 Physiol. Opt., 13, 397-399
SORSBY, A., BENJAMIN, B., DAVEY, J.B., SHERIDAN, M. and TAN- DUNNE, M.C.M., BARNES, D.A. and CLEMENT, R.A. (1987) A
NER, J.M. (1957) Emmetropia and its aberrations. Spec. Rep. model for retinal shape changes in ametropia. Ophthal.
Ser. Med. Res. Coun., No. 293 Physiol. Opt., 7, 159-160
13
Subsidiary effects of correcting lenses;
magnifying devices

Principal subsidiary effects cover both possibilities, we take the size of the retinal
image in the uncorrected eye to be its basic height,
In natural vision, object space is the same for each eye, which is independent of the degree of blurring (see
apart from the slight difference in viewpoints. Wearing Chapter 4, page 69). Spectacle magnification SM may
spectacles creates an entirely different visual situation. therefore be defined as the ratio
A common object space is now replaced by two separate SM Retinal image size in corrected eye
image fields formed by the right and left lenses. As a Basic height of retinal image in uncorrected eye
result, spectacle lenses give rise to a number of sub-
(UB.1)
sidiary effects. In particular, they may alter
In this context; the word ‘corrected’ simply implies that
(1) Monocularly a lens is being worn, irrespective of the degree to which
(a) The size and possibly the shape of the retinal it ‘corrects’ the ametropia.
image. The basic height of a retinal image is determined by
(b) The amount of accommodation needed in near the limiting ray through the centre of the eye’s exit
vision. pupil. As we saw in Chapter 12, the angle u’ which this
(2) Binocularly ray makes with the optical axis bears a constant ratio
(a) The ocular rotations needed to place the retinal (for any given eye) to the angle u made with the optical
image of a given point in space on the fovea of axis by the conjugate incident ray directed towards the
each eye. centre of the entrance pupil. Thus the basic height of
(b) The relationship between accommodation and the retinal image is directly proportional to the angular
convergence (see Chapter 9). subtense of the object at this point.
In general, these side-effects are caused by the lens— This enables spectacle magnification to be defined in
eye separation and the fact that the lens does not move more general terms as the ratio of the angular subtense
with the eye. Consequently, they are either absent or at the eye’s entrance pupil of the image formed by the
are much less pronounced when contact lenses are lens to that of the object viewed directly without
change of position.
worn.
In this chapter we shall also be looking at the various
effects of plano prisms, fields of view through spectacle
lenses and the optics and clinical use of lenses, and opti-
cal systems designed to magnify the retinal image in Distance vision: single lens
normal visual tasks. The aberrations or image defects of Figure 13.1 shows a plus lens of meniscus form, A,
ophthalmic lenses will also briefly be discussed. being its back vertex, F’ its second principal focus, and
P and P’ its first and second principal points respec-
tively. Let F; and F, denote the front and back surface
powers, t the centre thickness in metres and n the refrac-
Spectacle magnification tive index of the material.
Then its equivalent power F is given by the expression
Definitions F=1/f' =F, +F, —(t/n)F\F, (le)
Spectacle magnification relates to the change in the ret- and its back vertex power, denoted by F, rather than he
inal image size in any given eye as a result of wearing since the theory is applicable to both spectacle and con-
either a spectacle or a contact lens. tact lenses, by
The retinal image in the uncorrected ametropic eye is
not necessarily blurred, because in hypermetropia it could
be brought into focus given sufficient accommodation. To
230 Subsidiary effects of correcting lenses; magnifying devices

Table 13.1 Spectacle magnification: typical values (distance

vision, a = 0.016 m)
eee
Se Te
Details of lens Shape Power — Spectacle
factor factor — magnification
Fi 7(mm) F, (S) (P) (PS)

—20.00 ORF O OOOO San ORZ5S

—15.00 Or 0 1.000 0.806 0.806
—10.00 0.8 +3.00 1.002 0.862 0.864
—5.00 0.8 +4.49 LL OO25 O92 6m O25~
O 1.8 +5.96 LOO SOOOR O07
+5.00 4.5 +10.19 1.031 OST ees
+10.00 7.0 +12.27 OCOM UALS ORNS e2.oul
+15.00 8.5 +13.84 1.084 1.316 1.426
Figure 13.1. Spectacle magnification in distance vision: the
ratio of the angular subtense wu’ of the image height h}, at the
centre E of the eye’s entrance pupil to that w, of the distant
object.
Numerical values
Table 13.1 has been compiled to give an idea of the range
of typical values of spectacle magnification and its com-
ponents.
Si 1—(/mF, (13.4)
In computing the power factor, the distance a from
the back vertex of the lens to the eye’s entrance pupil
The quantity S is known as the ‘shape factor’ because
was taken as 0.016 m. Average values were assigned to
the centre thickness and front surface power determine
the front surface power F, and centre thickness t, on
the profile of a cross-section of the lens.
which the shape factor principally depends, and the re-
In Figure 13.1, E is the centre of the eye’s entrance
fractive index of the material was taken as 1.523. Poss-
pupil and a its distance AE from the back vertex of the
ible differences in this value would have a relatively
lens. Suppose Q to be the extremity of a distant object si-
slight effect on the value S.
tuated on the optical axis. Its image Q) formed by the
Spectacle magnification can conveniently be ex-
lens is the intersection with the second focal plane
pressed in percentage terms. For example, values of
(through F’) of the ray from P’ parallel to the incident
1.12 and 0.96 could be expressed as +12 and —4% re-
ray QP. The entire image, of height h, subtends an
spectively.
angle u’ at E such that
In the case of contact lenses, the value of a can be
ites =H a aii = hE taken as 0.003 m and so the power factor P would vary
EES fee rae from about 0.94 on a —20D lens to 1.03 on a +10D
lens. Over the same range of powers, the shape factor
Using equation (13.3) we can rewrite this last expres- would vary from about 1.01 to no more than 1.02.
sion as The fact that the spectacle magnification of contact
—h' FS lenses remains much closer to unity over the whole
Y= a = =—h; FSP range of powers is one of the principal ways in which
1 —aF,
they differ optically from spectacle lenses.
where

a a
a (i355)

A generalized approach
The quantity P is called the power factor. The object
itself would subtend at E an angle u, given by A more general method of calculating spectacle magnifi-
cation is needed in those rare cases when the correction
Uy = =i P’F’ = =h; fig = = F is a combination of two or more lenses. It could, of
course, be applied to a single lens as well.
The spectacle magnification, being the ratio of u’ to u,, is
given by In a system of k surfaces, the last two in order are
(k— 1) and k, shown in Figure 13.2. The emergent ray
i =hy FSP is directed towards B; (in this case the centre of the
=H EF eye's entrance pupil) and makes a small angle uj, with
the optical axis. Prior to this last refraction, the ray
]
= PS =
(13,6) made an angle u, with the optical axis and was directed
{1 — aFy}{1
— (t/n)F} towards the axial point B,, conjugate with Bj. The
By using equation (13.3), an alternative expression for point of incidence G, is at a height y, from the axis.
the shape factor S can be obtained in the form If we denote the dioptric distances of B}, and B, from
the last vertex by L}, and L, respectively, then
be
S=1+--(5) (iste)
I
! / y,.L
JIk¥k
Up = Ye/Cx = ——
This is sometimes more convenient. Nk]
 Spectacle
I magnification
gn 231

We can find F, from the expression

FE’ = F,
F, _ euiG
1+ (t/n)(F) — F) eae

derived from equation (13.3). This gives F, =

+10.54D. Starting from a= 16mm=0.016m, we
have
Ns Niles I OOM Sasa RSTONID)
Ly = Ly — Fy = +65.50D
Figure 13.2. Refraction by a series of coaxial surfaces, A;_, le
and A, being the poles of the penultimate and last surfaces. Ly =———
= +52.06D (from equation 2.11)
1+ (t/n)L5
and
and
tal Fp = 452 D
Uy = Yx/Ce = we:
Nr
which gives
SM = 1.1964 (from equation 13.9)
Since B; is used here to represent the centre E of the
eye’s entrance pupil, the distance A,B; is not only the Using the analysis explained on pages 229-230, we
last image distance /;, but is also the distance previously should arrive at
denoted by a. Hence L; = 1/a. SRO 453 (from equation 13.4 or 13.7)
The angular magnification m, at this last refraction is
the ratio uj/u,, ie. the ratio of the apparent angles P= 1.1468 (from equation 13.5)
made by the object after and before refraction. Thus
from which
ue mig” Ty
mm =— = x
Up May Ly SIME = IPS == ILG64

Similarly, at the previous surface

/
My | Lay Pupil magnification
a LL
Nk k-1
The pupil seen on looking at a naked eye is the entrance
and so on until, at the first surface pupil, the image of the real pupil formed by the cornea.
A correcting lens, in turn, forms a second image which
ny i
my, =— x — becomes the entrance pupil of the lens—eye system. To
ny Ly
distinguish between them we will call these first and
The spectacle magnification is the product of all the second images of the real pupil the ocular entrance
separate values of m. All the refractive indices except pupil and the effective entrance pupil respectively.
the first and last cancel out, so that Their respective diameters will be denoted by g and q.
The linear magnification of the ocular entrance pupil
bef /
. n Bibra 3 alba by the correcting lens is the ratio g./g. We shall now
SM =—!_ x
Mey Ly Ly. Ly show that this ratio, the pupil magnification, is nu-
merically equal to the spectacle magnification.
If the first and last media are the same, as is usually the In Figure 13.3, HJ represents the ocular entrance
case, this expression simplifies to pupil and H’J’ the effective entrance pupil, the image of
HJ formed by a lens having k surfaces. If we reverse the
direction of the light, at the same time interchanging

where L;, = 1/a, as also in equation (13.8).

/
The required values of L and L’ at each surface can be
found from a backward paraxial trace through the
system, beginning with the known value of L;. The fol-
lowing example using a single lens illustrates the above
method.

d] '
4, | J
Example (1)
Find the spectacle magnification, given that — €
+8.00 D, F,=—3.00 D,n=1.523 and t=6.0mm. The Figure 13.3. Imagery of the pupil by a lens system. HJ is the
eye’s entrance pupil is to be taken as 16 mm from the ocular entrance pupil. Its image H’J’ formed by the lens system
back vertex of the lens. becomes the effective entrance pupil.
232 Subsidiary effects of correcting lenses; magnifying devices

object and image, H’J’ becomes a virtual object for the Since E and Ej; are conjugate points, the incident ray
lens and HJ its real image. The distance a of HJ from the RS directed towards E; gives rise to the refracted ray TE.
back vertex of the lens then becomes the last image dis- The object subtends an angle u at E, while the image
tance /;, so that L, = 1/a. The paraxial formula (2.10) subtends an angle u’. Consequently, the spectacle mag-
for linear magnification then gives nification is the ratio u’/u. If Q were a distant object
point on the same ray path RS, all the rays from Q
h’ HJ Gin lilies
m 7s VI yy? /
reaching the lens would make the same angle u, with
ets ge LL, Wp the optical axis, while the image of Q would be seen in
and thus the direction ET, making an angle wu’ with the optical
axis. Hence, for distance vision, the spectacle magnifica-
pupil _ ge _ Inka... Ly tion — shown previously to be the product of the power
Wah. == == (Sea)
magnification g Ly,L,...L, and shape factors — would be the ratio u’/u,. Thus we
where Lj, = 1/a. obtain
7 50 /
SM (near vision) = u//u
This is mathematically identical with the general ex-
pression (13.9) for spectacle magnification. The princi- i Se ee
=— X — = PS x —
ple of equation (13.9) has been used by Garcia et al. pe aU u
(1995) to develop a matrix formulation, together with
= IESIN) (Al 31D)
numerical examples, for both spectacle and relative
spectacle (see page 236) magnification. where N is the proximity factor u,/u.
The importance of pupil magnification is its effect on An accurate expression for N in terms of the known
the amount of light admitted to the eye. This is propor- object distance and the quantities defining the lens has
tional to the area of the relevant entrance pupil, and been given by Ogle (1936). It is, however, too cumber-
thus to the square of its diameter. For example, if a some for practical use. Calculation from first principles
myope wears a spectacle correction with a spectacle by finding the position and size of the image formed by
magnification of 0.9, then the lens would be both easier and quicker.
Je =0.9g and g? =0.81g7 Since the value of N is in any case very close to unity,
an approximate expression is adequate for all practical
The amount of light admitted to the eye is thus reduced purposes. To obtain this we imagine the lens, of power
by nearly 20%. A contact lens correcting the same sub- F., to be of negligible thickness and situated at the back
ject would have a spectacle magnification of the order vertex A, of the real lens, from which the object distance
of 0.97, giving ge = 0.94 9° —a reduction of only 6%. / is measured. We also consider E;, at a positive dis-
Thus, for the same real pupil diameter (to which g re- tance a’ from Aj, to be a virtual object point for light
mains proportional in any given eye), more light would passing through the lens from left to right in Figure
be admitted. The reverse applies to hypermetropia. 13.4. The point E, at a distance a from Aj, is then the
real image of Ey, formed by the lens. The paraxial law of
conjugate foci then gives

Spectacle magnification in near vision 1/a’ -1/a=F,

The spectacle magnification of a lens used in near vision which gives
is a product of three factors: the power and shape factors
; a
already defined, and a third which might be called the al a (13.13)
V
‘proximity factor’.
Figure 13.4 depicts an object BR and its virtual image when the binomial expansion is taken as far as terms in
}
B‘R’ formed by a lens. The centre of the eye’s entrance GE
pupil is at E, and Ej is its image formed by the lens. From the diagram it can be seen that

R’

Figure 13.4. Derivation of expression for

spectacle magnification in near vision.
 Spectacle magnification 233
h h and E, denote the centres of the real pupil, the entrance
is =—— = ;
BE, —¢+a pupil for the steeper meridian and the entrance pupil
and for the flatter meridian respectively. Surprisingly at first
sight, Ep is nearer than E, to the corneal vertex Aj,.
h h
————— A distant object, for example a circle with its centre
AG PL i on the optical axis of the eye, subtends an angle 2u.
so that The rays from each extremity then make an angle u
n ale oO Solas
with the axis. In the steeper meridian, a ray OR directed
towards E,, passes, after refraction, through E, and
u Seen le aL
emerges from the crystalline lens as though from E’. In
The binomial expansion of this expression up to the the flatter meridian, a ray JK directed towards Eg is also
second power of a and a’ gives refracted through E, and emerges from the lens as
Ne Lae Pa a
2 >
“Le =e) though from E’. It can be seen from the diagram that
the retinal image is larger in the meridian of steeper cor-
=1+-(@—a)L+a (a =a)i7 neal curvature.
The entrance pupil being the image of the real pupil
Finally, on substituting the value of a’ from equation
formed by the cornea, it seems logical to denote the dis-
(13.13) in this last expression and neglecting terms in
tances A,E, and A,Ep by d’, and di, respectively.
a’ and higher powers, we get
Because the rays RE, and E,V are conjugate, as are
N=1+@F,L (13.14) the rays KE, and E,W, it follows from the paraxial law
of refraction that
If L is taken as —3.00D and an average value of
16mm or 0.016 m is assigned to a, equation (13.14) VA;/WA 3 = RA,/KA,
becomes
The following relationship can also be deduced from
N= 1—0.000 8 F, Figure 13.5

N is thus a negligible factor, except for high-power VA3/WA; = u,/Uup

lenses.
and
RA,/KA, = d,,/dp
The astigmatic eye
which gives
When the effects of blurring are excluded, the retinal
U,/Up = d,/dp (S25)
image in the uncorrected astigmatic eye is slightly dis-
torted because of the different magnification in the two
principal meridians. If the astigmatism is attributed to Example (2)
the cornea alone, the exit pupil remains the same for
Find the distortion of the basic retinal image in an un-
both principal meridians. The following simple analysis
corrected eye with 1.00 D of corneal astigmatism with
can then be made.
the rule. Assume the constants of the Bennett—Rabbetts
Figure 13.5 represents part of a schematic eye with an
schematic eye for the horizontal meridian.
astigmatic cornea. As before, the subscript « has been
used to denote the principal meridian of steeper and B Horizontal meridian Vertical meridian
the meridian of flatter corneal curvature. Ray paths in F, = +43.08 D F, = +44.08 D
these meridians have been superimposed on the same d, = 3.6mm a= 3.6 mam
diagram, bold lines referring to the steeper meridian
and thinner lines to the flatter. In Figure 13.5, E,, E, from which

Figure 13.5. A schematic eye with

astigmatic cornea: subscripts % and
refer to its stronger and weaker
principal meridians respectively. Ray
paths from a distant object through
the centre of the pupil are shown for
both meridians.
234 Subsidiary effects of correcting lenses; magnifying devices

dy = +3.048 mm d@) = +3.058 mm and

and AS = (t/n)C,

ul, /uk = 3.058 /3.048 = 1.003 where C, is the cylinder power incorporated in the front
surface of the lens. Thus, the meridional difference AP
giving percentage distortion = 0.3%. is accentuated by a small difference AS in the shape
A general expression for the percentage distortion factor if the front surface of the lens is cylindrical or tor-
may be deduced as follows. The law of conjugate foci oidal. If, however, the lens is a ‘minus base’ toric with a
gives spherical front surface, the shape factor is the same for
both principal meridians. This is one of the arguments
1
used in favour of minus base torics.
1.336 da — Fy
Astigmats of moderate and high degree may complain
Differentiating of distortion. for example. circles appearing to be ellipti-
cal, when changing from spectacle to contact lenses.
Ad’ _ l _@? Paradoxically, their troubles arise because they have
AF, FS (2-356 ad, = F,)? become habituated to the distortion of spectacle lenses
and have initial difficulty in adapting to the relatively
In this context, d’ represents the lesser quantity ds, the
undistorted retinal images obtained with contact lenses.
increment Ad’ the difference (d, — ds) and AF, the cor-
Calculation of spectacle magnification becomes more
neal astigmatism. Hence
complicated when the principal meridians of the cor-
d, = ds = di x Ast recting lens and those of the cornea (and possibly of the
other refracting surfaces) are all at variance. Rigorous
and solutions have been formulated from two different ap-
j
percentage distortion = 100
; xq di, proaches, one employing matrix methods (Keating.
1982) and the other paraxial ray tracing procedures
Un
5b
(Bennett, 1986).
100ds x Ast (13.16)

If ds is taken as 0.003 m this last expression shows

the distortion to be about 0.3% per dioptre of astigma-
tism.
Astigmatic line rotation
It should be borne in mind that ray paths through the
pupil centres determine only the basic height of the ret-
In general, a straight line viewed through an astigmatic
inal image. that is the distance between the centres of
lens appears to have rotated through an angle which
the limiting blur formations. In the astigmatic eye. the
changes as the lens itself is rotated. This well-known
blurred image of a point is generally elongated. As a
effect is the result of the different spectacle magnifica-
result, the distortion of the basic retinal image could
tions in the two principal meridians of the lens. To a suf-
well be masked, accentuated or even reversed by the ef-
ficient degree of accuracy. an analysis can be made
fects of blurring.
without taking the thickness of the lens into account.
In the corrected astigmatic eve, distortion of the sharp
This enables an expression for spectacle magnification
retinal image arises from the unequal spectacle magnifi-
to be obtained in a much simpler form.
cation in the two principal meridians. Equation (13.5)
In Figure 13.6, the near object BQ subtends an angle u
for the power factor leads to the binomial approximation
at the eye’s entrance pupil E, while its image BQ’
Px~1+aF, formed by a thin lens of power F subtends an angle w’.
Thus
If we ignore the slight difference in the value of a for the
two principal meridians, the meridional difference AP
SM
= w /u = ——_—
x —_—_
can be expressed as eae h

AP = aC (13.17) and, since h’/h = L/L’ and L’ = L+F

since C, the cylinder power of the lens, is the meridional SM = ene + a) = 1 — oa
difference in F.. L'(-“#' +a) 1l—al
For a spectacle lens we can taken 0.016 m as an aver-
age value for a, in which case A=
= aS
an
L
(13.18
? 3)

AP—0-016E when the distance a from the back vertex of the lens to
This represents a distortion of 1.6% for every dioptre of the entrance pupil is replaced by its dioptric equivalent
cylinder power. For contact lenses, this figure reduces A, equal to 1/a.
to about 0.3% per dioptre. For an astigmatic lens, if F,, denotes the power along
A similar method of approximation can be applied to the ‘minus axis’ or principal meridian of higher plus or
equation (13.4) for the shape factor. giving lower minus power, F, the power along the ‘plus axis’
(having the lower plus or higher minus power), M,,
Sx=1+(t/n)F and M, the spectacle magnifications in these meridians
 Astigmatic line rotation 235

Figure 13.6. Spectacle magnification

of a thin lens in near vision.

and p the ratio M,,/M,. then diagram,

i A AE %, tango = y/x
oe ae es A= and
1,1 _ YM,
a
i= F--F:
13.19
Stat
tan o’=y
xM,
=utan od
—
13.20)

It is possible to derive a simple relationship between The values of the quantities in equation (13.19) may
the actual and apparent directions of a straight line be such that y has negative as well as positive values.
viewed through an astigmatic lens. Because M, and When the lens is held relatively close to the eye. A has
M,,, have different values, the proportions of a rectangle a positive value generally high enough to make both
with its sides parallel to the principal meridians of the the numerator and the denominator of equation
lens will apparently be altered. Thus. OSOT in Figure (13.19) positive in sign. Since F,, > F,, the value of p: is
13.7 will appear as OS'O'T’ such that greater than unity in this case. When this occurs, the
apparent movement of the limbs of a crossline chart
y¥/y=M,
/
and x'/x=M, when the lens is rotated is of the familiar ‘scissors’ type.
This is illustrated in Figure 13.8 which shows the ap-
As a result the diagonal OO making an acute angle o pearance after the plus axis of the lens has been rotated
with the plus axis OP will appear in the different direc- through a small clockwise angle from the horizontal.
tion OO’ making an angle 6’ with OP. From the The horizontal limb of the chart now makes a positive
acute angle o,, measured from the plus axis. Since
u > 1,64 > oy and so this line appears to have made
an ‘against’ movement, that is a rotation in the opposite

P
/us FX/5

Figure 13.7. Spectacle magnification of an astigmatic lens

derived from the distortion of a rectangle with its sides along Figure 13.8. Derivation of expression for scissors distortion
the principal meridians. of a crossline chart viewed through an astigmatic lens.
236 Subsidiary effects of correcting lenses; magnifying devices

direction to that of the lens. With the lens in the same F*, the relative spectacle magnification RSM is the ratio
position, the acute angle dy from the plus axis to the
RSMe==eiy iki
vertical meridian is negative in sign, equal to 90° — dy
but oy is a larger angle since > 1. Consequently, the Suppose that the given eye, of equivalent power F, is
vertical line of the chart appears to have made a ‘with’ corrected by a thin lens of back vertex power F,, placed
movement. The rotation test, as it is called, is a very with its vertex at a distance d from the eye’s first princi-
simple and reliable means of distinguishing an astig- pal point. Then, in accordance with a well-known for-
matic from a spherical lens and of locating its principal mula for equivalent power
meridians. An against movement identifies the plus axis
and a with movement the minus axis.
F* = PF 4B, — dFF, (13.23)
It can be deduced from equation (13.20) that as ¢ in- As with spectacle magnification, the form and thickness
creases a ‘turning point’ is reached beyond which 6’ in- of the lens can be allowed for by introducing the shape
creases at a slower rate than . In consequence, the factor S. On this basis, the expression for relative spec-
direction in which the given line appears to rotate is re- tacle magnification becomes
versed, the line seen through the lens returning to its
true direction when =90°.
F.S
RSMiaheS ih (13.24)
Other forms of apparent movement can be produced Fo oP, de,
when A and L are given suitable values. For example, This is a general relationship and particular cases can be
when the value of (A — L) is intermediate between F,, examined by assigning the appropriate value to F,. Un-
and F,, W assumes a negative value. As a result, @ and fortunately, a reliable determination of the eye’s equiva-
’ become opposite in sign and there are no turning lent power is outside the scope of normal clinical
points. Both limbs of the crossline continue to rotate in practice.
the same direction as the lens is turned, at the same If the back vertex of the spectacle lens coincides with
time making a scissors movement. the eye’s anterior focal point, the distance d becomes
Pure rotation without scissors effect occurs when equal to 1/F., in which case the value of F* (equation
t= —1, resulting in 6 and $’ remaining numerically 13.23) is seen to reduce to F,. Then, on the assumptions
equal though opposite in sign. The necessary condition that F. = F, as in ‘axial’ ametropia, and that the shape
is that factor is negligible, the relative spectacle magnification
becomes unity. This result is known as Knapp’s law.
Equation (13.24) can be put in a more significant
or
form by making use of the expressions
Fy + F,
A=L+ (CI10) Pa Kak (from equation 4.2)
2
and
This is the value of A when the eye is placed at the dis-
tance from the lens at which the circles of least confu-
=ST:
. (from tion
equation 4.10
4.10)
sion are formed. Both limbs of the crossline then appear
to rotate at twice the speed of the lens, always re-
When these substitutions are made in equation (13.24)
maining mutually perpendicular.
it becomes
If A=L+F,, the value of , becomes infinity, so that
’ is 90° irrespective of the value of . This means that (1 + dK)F,S
any line viewed through the lens will then appear paral-
RSM = e225)
K’
lel to the minus axis and remain parallel to it as the
The equivalent power F,, of an emmetropic eye is equal
lens is rotated.
to the quantity K),. Thus
In a similar way, if A=L+F,, the value of pt (and
hence of $') becomes zero. As a result, the apparent di- Pai haRe ake kK
rection of any line must always be parallel to the plus
axis. where k’ and ki, are the distances from the second prin-
cipal point to the retina in the ametropic and reference
eyes respectively. This relationship enables equation
(13.25) to be written in the form

RSM = AES (13226)

Relative spectacle magnification where

Relative spectacle magnification is the ratio of the ret- A = ametropia factor = 1+ dK (Ci 7))
inal image size in the corrected ametropic eye to that in
E = elongation factor = k’/k, (13.28)
a specified emmetropic schematic eye. It thus compares
the given corrected eye with a hypothetical standard. and
Given the same distant object, the images formed by
S = shape factor defined by equation (13.4)
two different lenses or optical systems are inversely
proportional in size to the respective equivalent powers. On the basis of normally available clinical data. the
Hence, if the equivalent power of the reference eye is de- value of E can only be conjectured, but could be esti-
noted by F, and that of the given lens—eye system by mated from ultrasonography (see pages 378-380).
 Plano prisms bo N
Ww

Plano prisms

Definitions and sign conventions

Prism power

The power of an ophthalmic plano prism is the deviation

in prism dioptres of a ray at normal incidence on either
surface, the wavelength being that for the d-line of the
helium spectrum (587.6 nm). The deviation for this spe-
cified ray path is slightly greater than the minimum,
Apparent
which occurs when the ray path through the prism is
symmetrical.
The main effect of an ophthalmic prism is to alter the
ocular rotation that would otherwise be required to
place the retinal image of a given point of regard on the Periphera
fovea. The amount by which the rotation is altered may
be called the effective prism power.

Sign convention for prism base settings

Uncorrected
A sign convention for prism base settings is needed in
order to arrive at universally valid expressions. The Figure 13.9. Sign convention for image displacement 6 by a
accepted convention is: plano prism of power P (in prism dioptres): (a) incident ray from
left, (b) incident ray from right.
(1) Horizontal prisms. Base-out is positive; base-in is
negative.
(2) Vertical prisms. Base-down is positive; base-up is prism P in prism dioptres. From the definition of the
negative. prism dioptre it follows that

When required for*mathematical treatment, the sign P = —1008/q (iS 22;9))

of the deviation undergone by a ray on passing through if 6 and q are in the same units, or
a prism must be taken as that of the prism base setting.
P= —6/q (S230)
Thus, the deviation produced by a base-up prism (nega-
tive) is itself of negative sign. if 6 is in centimetres and q is in metres.
The minus sign is needed to conform to the various
sign conventions. This can be seen from Figure 13.9 in
Sign convention for image displacements and which the prism can be viewed as base-down for either
ocular rotations eye or base-out for the left eye, P thus being positive in
either case. We also have
The deviation of a ray on passing through a plano prism
could be expressed in terms of a transverse displacement 5 = =GP (13.31)
din a plane at a distance q from the prism. The following where 6 is in centimetres and q is in metres.
sign convention applies not only to these displacements Despite first appearances, the sign convention for
but also to ocular rotations: ocular rotations is in harmony with that for prism base
setting. For example, a prism base-down (P positive) in-
(1) Horizontal image displacements or ocular rotations.
duces an upward ocular rotation (also positive), and so
Inwards is positive; outwards is negative.
on.
(2) Vertical image displacements or ocular rotations.
Upwards is positive; downwards is negative.

If the displacement is measured from a point on the

incident ray, the distance q is regarded as negative, Effective prism power
being measured against the direction of the incident It has long been recognized that the effective power of a
light. If the displacement is measured on the refracted plano prism in near vision is less than its nominal
ray, q is regarded as positive. In Figure 13.9, for exam- power. The same is also true of a prism incorporated in
ple, the point J on the incident ray is imaged at i’ on a correcting lens of minus power, whether by decentra-
the refracted ray produced backwards. In this case, 6 is tion or otherwise. In Figure 13.10, a prismatic spherical
positive because the deviation is upwards, whereas q is lens is represented by its optical equivalent in the form
negative. On the other hand, the point K’ on the re- of a thin centred lens of power F in contact with a sepa-
fracted ray path can be taken as the image of K on the rate plano prism of power P. Given an axial object point
original ray path produced. The displacement 6 is now B at any distance, the lens will form an axial image
negative because downwards, but q is positive. point B) according to
For small angles of incidence, the deviation produced
L'’=L+F
by a prism can be regarded as equal to the power of the
238 Subsidiary effects of correcting lenses; magnifying devices
Apex

Figure 13.10. Effective power in near vision of a prism when

incorporated in a minus spectacle lens.

The image B{, becomes an object for the prism which

forms a second image B) displaced through a distance 6
in the direction of the apex. The ocular rotation 0
needed to fixate B4 represents the effective prism power.
It can be seen from the diagram that
Base
ia Figure 13.11. Prism magnification and distortion.
—f'+2
Appearance of a square grid viewed through a base-down flat
whereas plano prism with its base tilted towards the eye.

pe
Op ae
Thus

neg ES as pe eee
a | Sn A

Pes oS (13.32)
Ze
For all negative values of F, the effective power of the
prism is less than its nominal value. The difference is of
little significance in prescribing, because the same effect
would arise with combinations of trial lenses and
prisms used in subjective testing. Figure 13.12. Ray trace through a flat plano prism of a
narrow bundle of rays initially enclosing the small angle Aj,.
When the lens is of positive power and the near object
distance such that L’ is negative, the effective prism
power is again less than its nominal value. On the image of the grid seen through a tilted base-down
other hand, if L’ is positive, the images B{ and B4 are prism would then appear somewhat as shown in Figure
formed behind the lens and the effective prism power 13.11. Three different features of the image distortion
becomes greater than its nominal value. This result
can be distinguished. The first is the elongation in the di-
agrees with equation (13.32), which is valid generally.
rection of the base—apex line. Reversing the tilt so as to
It is left to the student to construct a diagram on the
bring the apex nearer to the eye produces the opposite
lines of Figure 13.10 to illustrate the case where L’ is
effect. This elongation or compression of the image is
positive.
known as ‘prism magnification’. Since it varies with the
In the case of a plano prism, the image point B’ in
angle of incidence, the magnification is not uniform.
Figure 13.10 would be replaced by the object point B
Another element of the distortion is the varying curva-
itself at a dioptric distance L from the lens. On putting
ture of straight lines perpendicular to the base—apex

(25)
F = 0 in equation (13.32), we then have
direction. This effect is known as ‘prism metamor-
phopsia’. Perhaps the least noticeable aspect of prism
(13.32a)
distortion is the fanning out of lines parallel to the
base—apex direction, the divergence being away from
For all normal values ofZ and L, the effective power of
the base of the prism. It is interesting to note that tilting
a plano prism in near vision is in the neighbourhood of
5-10% less than its nominal power. the apex of the prism nearer to the eye does not reverse
the direction of the curvature and fanning effects.
A simple expression for prism magnification can be
obtained from Figure 13.12, showing a flat plano prism
Prism distortion and magnification
of refractive index n surrounded by air. An incident ray
If asquare grid is viewed through a flat plano prism with PR makes an angle of incidence i,, with the first surface,
its back surface approximately normal to the primary while a neighbouring ray QS makes the slightly larger
line of the eye, a typical distortion pattern may be ob- angle of incidence (i; + Ai,). After the first refraction,
served. The effect is enhanced by tilting the prism so as the angle between the rays is Ai}, equal to Ai,, since
to bring its base closer to the eye than the apex. The the refracted rays from the first surface become the inci-
 Prismatic effects of lenses 239

Table 13.2 Deviation and prism magnification (plano prisms 4A in flat and meniscus forms; z = 27 mm,n = 1.523)

Ocular rotation Type ofprism

Flat Meniscus
(fF) = —6.00 D)

Deviation Prism magnification Deviation Prism magnification

cs) towards apex 4.78 1.039 4.82 1.024

4.13
+15° 1.014 4.35 1.008
4.00 0.996 4.00 0.996
a
4.35 ORIEL Beh 3 0.986
a, towards base
sy 5.38 ON945 3)7 45) OR:

The back surface of the prism is normal to the primary of the eye.

dent rays at the second. After refraction at this surface,

the angle between the rays becomes Ai, and they meet
at E where an observer's eye is placed.
It can be seen from the diagram that an object sub-
tending an angle Ai,, would appear to subtend an
angle Ai} when viewed through the prism. Thus, for
any given ray path, the ratio Ai /Ai, is the prism mag-
nification.
Differentiating the basic expression for refraction, we Figure 13.13. Optical arrangement of Brewster's teinoscope
obtain using prism magnification.

n' cosi/Ai’ = ncosi Ai

Applied to each surface of the prism in turn, this yields magnification, but the deviation and chromatic aberra-
tion produced by the first prism are neutralized by the
Ai; _ cosiy second. At the same time the asymmetry of the magnifi-
Ai; ncos i} cation is largely eliminated. An arrangement of this
kind ‘for extending or altering the lineal proportions of
and
objects’ was devised by Brewster (1813) who called it a
teinoscope. The principle found a recent application in
the motion-picture industry in order to ‘squeeze’ a hori-
zontally wide-angle view into a frame of standard size
which gives
and proportions, the process being reversed when the
Ai, cos i, Cos iy film was projected.
Mi, _ Cosi, cost 33S) It was shown by Bennett (1951) that the meridional
magnification of a teinoscope is equal to the ratio g/g’
This reduces to unity for the symmetrical ray path
of the widths of a parallel incident pencil of rays and of
giving minimum deviation.
the conjugate emergent pencil. This property was al-
Prism magnification and distortion are not very no-
ready well known in reference to telescopes consisting
ticeable with most plano prisms as normally mounted
of lenses.
for ophthalmic use or in testing. Some idea of the magni-
tudes involved can be seen from Table 13.2 which is
based on accurate ray-trace data. It lists the deviation
and prism magnification at various ocular rotations of
Prismatic effects of lenses
a 4A prism, both in flat and meniscus form (back surface
power —6.00 D). The latter form is superior because it
General expressions for prismatic effects
makes the various ray paths more symmetrical and the
angles of incidence more uniform. A ray passing through any point of a lens other than its
A further modest improvement would result from tilt- optical centre undergoes a deviation known as the ‘pris-
ing the prism through some 5-10° so that its apex matic effect of the lens’ at that point. For clinical pur-
moves nearer to the eye. poses, the magnitude P of the prismatic effect,
A mathematical analysis of prism distortion was pub- measured in prism dioptres, can be found with sufficient
lished by Ogle (1951, 1952), the treatment being re- accuracy from Prentice’s rule
stricted to untilted prisms (i.e. with the back surface [P) =o(68 (13.34)
normal to the primary line of the eye). Using the same
approach as Ogle, Adams et al. (1971) compared the where ¢ is the distance in centimetres of the given point
various computed distortions of conventional ophthal- from the optical centre and F the power of the lens.
mic prisms with those of the Fresnel type. Neither Prentice’s rule is an approximation based on paraxial
variety showed overall superiority. theory applied to a thin lens. It also assumes that the
If a pair of flat plano prisms is arranged as in Figure prismatic effect is independent of the direction of the in-
13.13, each contributes an element of meridional cident ray.
240 Subsidiary effects of correcting lenses; magnifying devices

In the case of a spherical lens, the base—apex direction Example (3)

of the prismatic effect lies in the meridian containing and
Find the prismatic effect at a point 8mm below
the given point and the optical centre of the lens. The
2 mm inwards from the optical centre of the lens
base is towards the optical centre of a plus lens and
away from the optical centre of a minus lens. R — 3.00 DS/—2.00 DC axis 60
The above applies to a spherical lens or to the spher- From the given data, x = +0.2, y= —0.8 and >=
ical component of an astigmatic lens. Prentice’s rule is (180 — 60) = 120° which gives
applicable also to cylindrical surfaces, where the dis-
tance c is now the length of the perpendicular from the A=—3.00 = 2.00 (sin* 1207) =—4.50
given point to the cylinder axis and F is the cylinder
B = —2.00 (sin 120° cos 120°) = +0.866
power. The base—apex line of the prismatic effect is in
the meridian perpendicular to the cylinder axis, the and
base being towards the axis of a plus cylinder and away
from the axis of a minus cylinder.
D= 3.00 = 2.00teos" 120 )= =3:50
For the solution of specific problems on astigmatic giving
lenses, various useful graphical constructions have
H =(—4.50x0.2)+(0.866
x —0.8) =—1.59A(base in)
been devised. They are explained in most textbooks on
ophthalmic lenses. For the purpose of analysis or for and
routine practical use, such as computer programming, V=(0.866x0.2)+(—3.50x —0.8) =+2.97A(base down)
mathematical formulae are needed. Two different sys-
tems may be used.
Polar co-ordinates
In this system, the given point is defined by its distance c
(in centimetres) from the optical centre of the lens and
Rectangular co-ordinates the acute angle ¢ from the cylinder axis to the meridian
containing the given point. The normal mathematical
The point at which the prismatic effect is to be calcu-
sign convention applies, the anticlockwise direction
lated is defined by its co-ordinates (x.y) with respect to
being positive. Similarly, the prismatic effect is obtained
horizontal and vertical meridians through the optical
in terms of its magnitude P and the angle \ from the
centre of the lens. Regard must be paid to the following
cylinder axis to the base—apex meridian of the prismatic
sign convention, which is the same for right and left
effect. There are two separate calculations to be made
lenses:
in the following order:

x positive inwards, negative outwards S+C

tan = ( < )tane (13.40)
y positive upwards, negative downwards
and
These distances are both to be expressed in centimetres.
P = |cS(cos €/cos y)| (13.41)
The prismatic effect at the point (x,y) is obtained in
terms of its horizontal component H and vertical compo- One further item of information is needed. It is not
nent V, both in prism dioptres. The following sign con- enough to know, for example, that the base—apex merid-
vention applies: ian is 130°; the prism base setting (i.e. whether base up
or base down) along this meridian must also be known.
H positive base-out, negative base-in A way of resolving this ambiguity when the answer is
V positive base-down, negative base-up not obvious is described in this solution of Example (3).
Let the optical centre be denoted by O and the given
Let S be the spherical power of the lens, C the cylindri- point by Q. A preliminary calculation shows that the
cal power of the lens, $ for the right lens be 180° - meridian OQ is at 104° in standard notation, so that
cylinder axis in standard notation and for the left lens, e= 104-60 = 44
the cylinder axis in standard notation.
while
Then
H=Ax-+- By (Sa)5) ¢=00= 0.8" £027 =0:325.0m
and Then, from equation (13.40)

V = Bx
+ Dy (BG) wW = arc tan (—5.00/ — 3.00) tan 44° = +58°

where so that the base—apex meridian is (60+58) or 118°,

while from equation (13.41)
A=S+Csin* (Is .3)
P = |(0.825 x —3.00)(cos 44°/cos 58°)|
B=Csin dcos o (35'S)
= 3.36A
and
In the absence ofthe cylinder, the prismatic effect at Q
D=S+Ccos’ o (13.39) would be base down along 104°, that is, base away
 Prismatic effects of lenses 241

from the optical centre because the spherical power is of assume a mean position of the near visual points as
minus sign. The rule is that the same condition must being 8 or 10 mm below and 2 mm inwards from the op-
apply to the modified base setting of the prism. In this tical centre of the distance portion, the same for both
case, the base must still be away from the optical lenses.
centre, along the 118° meridian. Thus Suppose that in a given case the vertical prismatic ef-
P = 3.36A base 118 down fects at the near visual points are found to be R 4.4A
base down and L 6.9A base down. The relative prismatic
This will be found to resolve into the horizontal and ver- effect or imbalance is therefore 2.5A base down L, and
tical components already obtained in Example (3). For it is assumed that the eyes would need to make vertical
mixed lenses (principal powers opposite in sign), this rotations differing by this amount. There are, in fact,
method is unsuitable. two sources of inaccuracy in this procedure. A numeri-
cal example illustrating this will be given later, but in
the meantime, the following relationships can readily
Ocular rotation factor
be deduced from Figure 13.14. Rotations and prismatic
The prismatic effects of spectacle lenses alter the ocular effects are in prism dioptres throughout. Any units, pro-
rotations required for fixation. If 8, denotes the ocular vided they are the same for all, may be used in expres-
rotation from the primary line needed to fixate a given sions containing only distances, but distances must be
point viewed directly and 0 the rotation needed when in centimetres whenever they appear in expressions
the point is viewed through a spectacle lens, then the also containing dioptric powers or vergences.
ratio 0/0, is the ocular rotation factor, ORF. In the case
of a thin centred spherical lens, it*takes a comparatively
simple form.
Ocular rotation 0, for the unaided eye
In Figure 13.14, in which Q is the point of fixation, the
relationship between the angles 0, and 0 is of exactly 100! —hLZ
the same form as between u and wu’ in Figure 13.6, the je —f+z
esZ-L (13.43)
difference being that z and Z now take the place of a
and E. So we can simply rewrite equation (13.18) as
0 Z—L
ORF =—= Ocular rotation 0 for the corrected eye
“ara hr
Thus the ocular rotation factor is akin to, but numeric- A 100h’ — —h'L'Z
ally different from, spectacle magnification. In most
i ae
cases the two values would not differ by more than
—hLZ
10%, usually less than this. ees (13.44)
Z—L—F

Visual points
The visual point is the intersection of the visual axis Distance OV (c)
with the back surface of the lens, or the lens itself if as-
sumed thin, in a specified direction of the gaze. In cases h'z —hL
of anisometropia the right and left ocular rotation fac- pier acne
—f'+2z2 Z—-L—F
eure (13.45)
tors are different. Difficulties may then arise, especially
if large vertical rotations are needed for binocular fixa-
tion. A common method of assessing the situation is to
assume arbitrary positions for the right and left visual Prismatic effect P at visual point
points and to compare the prismatic effects at those
points. For example, in considering the optical suit-
peepee.
S=6. —— (13.46)
tO:
ability of various types of bifocals, it is customary to Z—L—F

Figure 13.14. Ocular rotation

factor. The ratio of the angle 0
subtended by the image point Q’ at the
eye's centre of rotation Z to the angle
0, subtended by the object point Q.
242 Subsidiary effects of correcting lenses; magnifying devices

Effective change in ocular rotation (8 — 0,) would be R 3.75A base down and L 6.75A base down,
the relative prismatic effect thus being 3.00A base
l 1 down L. This is appreciably greater than the actual dif-
VER ee
: ae ae ference between the necessary ocular rotations, but the
error can at least be said to be on the safe side.
—hLFZ
(Gh Shp TENE = 10)

which, with the aid of equation (13.46), can be simpli-

General expression for ocular rotations
fied to
This has already been discussed in relation to spherical
6-6, =cF - g ) (13.47) lenses. The same simple treatment can be extended to
Tat astigmatic lenses when the cylinder axis is horizontal
This last result is similar to the relationship expressed or vertical, in which case the horizontal and vertical
by equation (13.32a) for the effective power of a plano components of ocular rotations are calculated sepa-
prism. In both cases the deviation at the lens or prism rately by applying equation (13.42) to each of the two
has to be multiplied by the factor Z/(Z—L) to obtain principal meridians in turn.
the ocular rotation. When the cylinder axis is oblique, the solution be-
Students may find it instructive to make a drawing comes more complicated. In Figure 13.15, Z is the eye's
and work from first principles. The appropriate expres- centre of rotation and O the optical centre of the lens,
sion can then be used to check the result. its optical axis coinciding with the primary line of the
eye. The object of regard is the point Q(x,, y,), lying in
a vertical plane containing the axial point B at a dis-
Example (4) tance / from the lens. The chief ray path by which a ret-
A subject wearing centred lenses R—5.00 DS L —9.00 DS inal image of Q is formed on the fovea is QVZ, V being
fixates an object point 120 mm below the level of the the visual point.
primary line of sight in a plane at one-third of a metre To determine the necessary ocular rotation, resolved
from the lenses. The centre of rotation of the eye is into horizontal and vertical components, the co-ordi-
25mm from the lens. Determine the downward ocular nates (x,y) of the visual point must be found. The direc-
rotations required for fixation. tion ZV of the visual axis can be considered as the
The calculations are as described above, and the basic resultant of a horizontal rotation 0), defined by
data and results are tabulated below. Chee = OVE = Ree aL (13.48)
Right eye Left eye and a vertical rotation 0y, defined by
Zt —333.3 mm —333.3 mm
It —3.00 D —3.00 D Oy = y/OZ = y/z = yZ (13-49)
F —5.00 D —9.00 D
ih! —§.00 D —12.00D
The required relationship between the co-ordinates
¢! —125mm —§3.33 mm (Xo, Yo) and (x, y) can be found by treating ZV as an inci-
Z +25 mm +25 mm dent ray to be traced backwards through the lens re-
Zé, +40 D +40 D garding (x,y) as the known and (x,,.y,) as the
h —120 mm —120 mm
unknown quantities.
h! —45 mm —30 mm
05 —33.49A (downwards) —33.49A (downwards) But for the prismatic effect of the lens at V, the ray ZV
0 —30.00A (downwards) —27.69A (downwards) would continue undeviated to meet the object plane at
Cc —0.75 cm —0.692 cm the point V’(x’,
y’) such that
ie 3.75A (base down) 6.23A (base down)
0—0, 3.49A 5.80A Mf
BA tee
ue Mia OL | Peed
It can be verified that (8 — 0,) for each eye is equal to
P multiplied by the factor Z/(Z—L), as indicated in
equation (13.47).
The difference between the right and left ocular rota-
tions is nominally 30—27.69 or 2.31A. It should be re-
membered, however, that the prism dioptre is not a
strictly additive unit. If the two values of 9 are converted
into degrees, they become 16.70° and 15.48°, the differ-
ence being 1.22° which is equivalent to 2.13A. The
same procedure should really be adopted to evaluate
(0 — 0) when these angles are large. .
It will be noted that the two values of c differ by about
0.6 mm. The larger value is always associated with the
lower minus or higher plus power.
The conventional approach would be to assume that
both visual points were at the same distance from the
Figure 13.15. Prismatic effect of an astigmatic lens at a
optical centre. It would be argued, for example, that at given visual point V: three-dimensional representation of the
0.75 cm below the optical centres, the prismatic effects general case.
 Binocular vision through spectacle lenses or prisms 243

In fact, the prismatic effect of the lens displaces V’ to O in equations (13.48) and (13.49), these equations
by a horizontal shift 84 and a vertical shift 5y, in accor- become
dance with equation (13.31). Since the displacement is
being measured in the refracted ray path, the distance q 0 =
—LZ{(J — Ccos” )x, + (Csin bcos )y,}
in this expression must be regarded as positive and iio
must be replaced by —/. Thus CUS 52)

by =(H=H/L and 8 =/V=V/L and

in which H and V are respectively the horizontal and 9, —LLAA(Csin

V =:
cos )xo + (J = C sin” >)yo}
vertical components of the prismatic effect at the visual JJ
— C)
point. From the diagram it can be seen that (13.53)
Cot OR +e
Example (5)
and
The correction for the right eye is
eae y(Z—L) V
Ue a Oe i L +2.00 DS/ + 4.00 DC axis 150

which gives The co-ordinates of the point of fixation in a plane

250mm from the lens are x, = +6cm, yo = —15 cm,
lal == 30IL, V—yol
= Zo andi syi— a hed the distance z being 25 mm. Find the horizontal and ver-
tical components of the necessary ocular rotation.
In these expressions, H and V can be replaced, using
equations (13.35) and (13.36) to give We have S=+4+2, C=+4, 6 = 30°, Z=+40 and
oe FAN vd aCe p= 442.
Z=L
Thus
and
eae 40{(39 x 6) + (1.732 x -15)}
pe ee ID — will 42 x 38
Z—L
= +20.85A (inwards)
which gives
and
(Z—L = A)ix By) = = Nall,
ve 4 x 40{(1.732 x 6) + (41 x —15)}
and 42 « 38
[3 (7b == Sb, = IDM) Ib = —60.61A (downwards)

The solution of these as a simultaneous equation is (The sign convention for ocular rotations was given
on page 237.)
E(Z—L SD) x, A Bys}
ee een ee ae
and
TiBx
et (2b Aly) Binocular vision through spectacle
y= (ee = Be lenses or prisms
These expressions become lengthier when the coeffi- The effective binocular object
cients A, B and D are written out in full. On the other
hand, a useful piece of simplification can be introduced In Figure 13.16, a horizontal line object GH is viewed
by putting through base-out prisms of equal power. The right
prism forms an image GpHep of the same size and in the
J=Z-L=S same plane as the object but displaced towards the apex
which enables the expressions for x and y to be reduced of the prism. In a similar manner, the left prism forms
to the image G,H}. In order that the image of G should
fall on the fovea of each eye, the right visual axis must
Pele Ccos? $)xo + (Csin b cos b)yo} be directed so as to pass through Gk and the left visual
“a ir) axis through G;. These two axes intersect at the point
(13.50) Gz. A similar construction determines the point Hg.
Thus, corresponding to the real object GH there is a hy-
and 4 pothetical object GgHp which, if viewed by the unaided
eyes, would require the same ocular rotations for bin-
-L{(Csin cos )xy + J — Csin* b)yo}
ocular fixation. It has been called the ‘effective binocular
‘a JJ -C) object’, defined by Bennett (1977/8) as the hypothetical
(Gisesalb}
object corresponding to a real object of regard, that
Finally, when these expressions for x and y are inserted would require, at all points, the same ocular
244 Subsidiary effects of correcting lenses; magnifying devices

G L
|
| inte
H 1B
Te |
ee
G
Se ee

pa
SS
H

G'p
Figure 13.16. The effective |
binocular object GgHg corresponding |
to the real object GH viewed through Hy |
equal-powered base-out prisms. R

Figure 13.17. The effective

binocular object GpHg corresponding
to the real object GH viewed through
equal powered minus lenses centred for
distance vision.

rotations for binocular fixation by the unaided eyes as prisms. If the prisms are of unequal power, an additional
the real object viewed through spectacle lenses or effect occurs: the effective binocular object is displaced
prisms. laterally towards the primary line of the eye wearing
The importance of this concept is that it provides a the stronger base-in or weaker base-out prism.
valuable clue to the probable appearance of the real
object seen binocularly. For example, it has already
been used in Chapter 11 to explain the theory of the Lenses
prism stereoscope. The principal conclusions reached Figure 13.17 illustrates the principle of the construction
by Bennett can be summarized as follows. applied to the particular case in which minus lenses,
centred for distance vision, are of the same power. As
before, GH is a horizontal line object. The image distance
Horizontal prisms and size, the same for both lenses, are determined from
The effective binocular object is formed at a distance /, the basic conjugate foci relationships. In this case, the
from the spectacle plane such that effective binocular object is the same size as the real
object but at a greater distance from the eyes. These
2p-—2z
a (7g and z in m, p in cm) properties are characteristic of all corrections of equal
2pL—A
minus power, whatever that power might be, provided
where L denotes the dioptric distance of the real object, p that the lenses are centred for distance vision. With si-
the semi-interocular distance and A the total prism milar centration, plus lenses of equal power give rise to
power, positive if base out and negative ifbase in. , an effective binocular object of the same size as the real
The effective object subtends at each eye the same object but situated nearer to the eyes.
angle as the real object viewed directly, but is not at The effect of horizontal decentration with lenses of
the same distance. In the case of base-out prisms it is at equal power is an equal lateral displacement of the
a nearer position where the real object would subtend a images formed by the right and left lenses. In conse-
larger angle. Since, however, the visual angle is not in- quence, both the distance and size of the effective bin-
creased, the subjective impression is an apparent reduc- ocular object are altered, though it retains the same
tion in size. The opposite occurs in the case of base-in angular subtense. If the decentration produces base-in
 Binocular vision through spectacle lenses or prisms 245

prismatic effect, the binocular object moves away from Se Re ~~

coe
the eyes while increasing in size. The opposite effects
arise from decentration producing base-out prism. An
interesting case arises when the lenses are decentred in- \ ZR
wards to suit a given working distance. The effective \
|
binocular object corresponding to a real object in this i]
plane is then formed in the same plane, but is larger if |
M oe
the lenses are of plus power and smaller if of minus
power.
j cena

!
!
!
Limitations on the construction !
1 IL
!
If the eyes’ centres of rotation are regarded as lying in a i
horizontal plane, the visual axes are bound to intersect
He dé
when the ocular rotations needed for binocular fixation
are purely horizontal. If, however, the necessary rota- Figure 13.18. Curvature of the effective binocular object
tions include a vertical component, the visual axes Gp,Hg constructed from accurate ray tracing as opposed to
paraxial approximations.
cannot intersect unless this component is the same for
each eye.
In spherical anisometropia, for example, the effective similar effect is produced by base-out prisms. With
binocular object can be constructed for any point or minus lenses and base-in prisms, a convex appearance
line lying in the horizontal plane containing the optical is normally seen.
centres of the two lenses. A line such as GH in Figure The explanation is that the deviation undergone by a
13.17 can then be shown to give rise to an effective bin- ray on refraction is always greater than that given by
ocular object that is tilted towards the eye wearing the the simplified ‘paraxial’ law of refraction (n'i’ = ni).
higher minus or lower plus correction. A typical value Moreover, the excess deviation increases at a faster rate
of this tilt would be approximately 8° for every dioptre than the angle of incidence. This is the basic cause of
of anisometropia. For any object point lying above or image defects such as spherical aberration and distor-
below the horizontal plane just specified, the images tion.
formed by the right and left lenses would be of different When exact ray-tracing methods are employed, the
heights and require unequal vertical components of ro- equivalent binocular object for a plane surface is found
tation to obtain binocular fixation. The visual axes to be curved in accordance with observations. The pro-
would consequently fail to intersect, in which case the cedure is shown in Figure 13.18, in which M is a point
effective binocular object cannot be constructed. Un- on the median line and G and H, equidistant from M,
equal vertical rotations would also be required with a are points on the horizontal perpendicular through M.
large number of astigmatic prescriptions and in all pre- By a process of iteration (successive approximations),
scriptions incorporating vertical prism. The possibilities the position of the visual point Vp is determined such
of constructing extended effective binocular objects are that the reverse ray ZpVp passes through the point G
thus severely limited. after refraction by the right lens. The visual point V;
In some cases the effective binocular object is found to for the left lens is located in the same way. By definition,
be behind the subject's head. This would occur, for ex- the intersection Gz of the visual lines ZpVp and Z; Vy is
ample, when a distant object is viewed through base-in the equivalent binocular object point corresponding to
prisms, requiring the visual axes to diverge. the real point G. By the same procedure, the equivalent
These various limitations illustrate the fact that spec- binocular object point Mg can be located, while Hg is
tacle-corrected eyes are frequently required to make co- symmetrically placed with respect to Gg. The curved
ordinated ocular rotations that no real object could line through these three points is not necessarily circu-
demand ofthe unaided eyes. lar, but when additional points on it are plotted by the
Further details are given in the paper by Bennett al- same method it is found to be very nearly circular for
ready mentioned. It includes mathematical expressions lenses of moderate power.
enabling the effective binocular object to be located by The pioneer work in this field of Whitwell (1921/22)
calculation instead of by graphical construction. is worthy of mention. To reduce the amount of ray-tra-
cing required — then an extremely laborious procedure
— Whitwell assumed the equivalent binocular object to
Apparent field curvature be a plane surface and determined the curvature of the
The geometrical construction of the equivalent bin- corresponding real object plane. He also described a
ocular object as shown in Figures 13.16 and 13.17 simple but ingenious method of calculating the vertical
assumes the lenses and prisms to be free from aberra- curvature from the results obtained in the horizontal
tions. On this basis, the equivalent binocular object of a meridian. For a +4.00 D lens he found the vertical cur-
plane surface is another plane surface. Experiment vature to be approximately one-third of the horizontal,
shows this to be an over-simplification. If a plane surface irrespective of the lens form. This is also the case for a
is viewed through a pair of centred plus lenses of equal —4.00 D lens. Thus, a real plane surface viewed through
power, it appears concave to the normal observer. A lenses of equal power gives rise to an equivalent bin-
246 Subsidiary effects of correcting lenses; magnifying devices

Table 13.3 Typical binocular field curvatures (m ~ )

Fields of view
Horizontal Vertical
Definitions
+4.00 DS each eye
Plano-convex +3.0 +1.0 A distinction must be made between the macular field of
Meniscus: base —6.00 D +2.0 +0.7 view, within which objects can be imaged on the fovea
—4.00 DS each eye of the rotating eye, and the peripheral field (of indirect
Plano-concave —2.3 —0.8 vision) with the stationary eye in its primary position.
Meniscus: base +6.00 D —1.4 —0.5
The term field of fixation is sometimes applied to the ma-
SA base-in each eye —4.9 —2.3
cular field, though its meaning is not as precise. The ex-
SA base-out each eye +5.1 +2.4 pression field of view implies that the eye is viewing
through an optical appliance, whereas field of fixation
Field curvatures computed for a near object plane at —350 mm
from the lenses and for n = 1.523, average centre thicknesses, is also applied to the naked eye.
z = 27mm and inter-ocular distance 64 mm. In addition to the field of corrected vision through a
Plus curvatures denote a surface concave towards the observer, lens, there is also an uncorrected peripheral and poss-
minus curvatures the opposite effect. ibly an uncorrected macular field of view outside the
lens periphery, especially in the temporal region.
The following definitions of the corrected fields, illu-
ocular surface of approximately toroidal formation, with
strated in Figure 13.19, apply to any specified meridian
its shallower principal meridian vertical. Whitwell also
of a spectacle lens. In this diagram, the upper half
showed that the horizontal field curvature produced by
shows the macular and the lower half the peripheral
lenses is affected by inward or outward decentration.
fields when the eye is in its primary position.
He did not investigate the behaviour of plano prisms.
]
Binocular field curvatures in reciprocal metres (m — )
for typical plus and minus spectacle lenses and for flat Apparent macular field of view
plano base-in and base-out prisms have been calculated The angle subtended by the lens periphery at the eye's
by the authors. An indication of the trend can be centre of rotation Z. This may also be termed the ap-
gleaned from Table 13.3. parent field of fixation.
Unlike other aberrations of spectacle lenses such as
oblique astigmatism and distortion, binocular field cur-
Real macular field of view
vature is not a property of the lens or lenses alone.
Nevertheless, it is affected by the lens form and, like dis- The object space contained within the angle subtended
tortion, diminishes as the base curve becomes increas- by the lens periphery at the virtual image Z’ of the eye’s
ingly steep. centre of rotation formed by the lens.

Uncorrected

Apparent Apparent

Peripheral fields

Uncorrected

Figure 13.19. The fields of view through (a) plus and (b) minus lenses. The upper part of the diagram illustrates the macular fields
of view with the rotating eye, the lower part the peripheral field with the static eye. E is the centre of the eye's entrance
pupil, Z its
centre of rotation. The corrected fields apply to the most oblique peripheral ray path through the lens, the uncorrected
fields to the
least oblique ray passing outside the lens. The stippled area is not seen.
 Optics of magnifying devices 247

Apparent peripheral field of view peripheral field, disappears from view while crossing
the gap in this field. It then reappears on entering the
The angle subtended by the lens periphery at the centre
corrected portion of the peripheral field. If ithas now en-
E of the eye’s entrance pupil.
gaged the subject's attention and he turns his eye to
view it directly, it will again disappear and reappear on
Real peripheral field of view crossing the gap in the macular field of view.

The object space contained within the angle subtended

by the lens periphery at the virtual image E} of the Minus lenses
centre of the eye's entrance pupil formed by the lens.
The real field of view of a minus lens is larger than the
apparent field, resulting in a band of diplopia. Objects
Linear extent of field within this area can be seen doubly, both through and
outside the lens. The macular band of diplopia is shown
The height or width of the real field of view, generally in the upper part of Figure 13.19(b). In some cases, the
the macular field, measured at a specified distance from obstruction caused by the edge of the lens or rim of the
the lens.
frame may prevent the formation of a diplopic band, as
shown in the lower part of this diagram.
Semi-field of view
Applicable to any of the above, that part of the total field Vignetting
from the optical axis of the lens outwards. The area of a lens transmitting pencils filling the pupil
The field of view provided by a lens of given power de- does not extend to the extreme edge. There is a periph-
pends mainly on its diameter, but is maximized by fitting eral zone within which the width of those pencils en-
it as close to the eye as possible. A third factor is the tering the pupil gradually diminishes to zero. There is
back surface curvature; the more concave this is made. thus a progressive loss of illumination called ‘vignet-
all other things being equal, the larger the field of view. ting’. This word originally meant the artistic border of
Hence, high-powered lenses, if made in bi-convex or bi- vine leaves round the title page of a book and then, by
concave form, perform poorly even if they are thinner. extension, the variably shaded border that used to be
ra put round photographic portraits.

Boundary effects
Spectacle frame obstruction
Because of the finite size of the pupil, the sharp bound-
Depending on the pupil size in relation to other dimen-
aries between the various fields are, in fact, blurred and
sions, the rims and sides (temples) of a spectacle frame
show some overlapping. As a result, the effects about to
may cause either a partial or total occlusion (Swaine,
be described may be masked or modified to some extent.
1933). In the former case there is merely a penumbra
effect of which the wearer is conscious, though he can
Plus lenses see through it. Wide temples, which are totally oc-
cluding, create potentially dangerous scotomata in the
It will be seen from Figure 1 3.19(a) that the incident ray temporal fields of vision, especially when the frame is
OR aimed at Z’ enters the rotated eye in the changed di- not of ‘high joint’ construction.
rection RZ. Consequently, an object point situated
along OR will be seen in the direction ZRS. There is
thus, in object space, an angular gap surrounding the
lens periphery. Objects within this gap, indicated by the
stippled area in the diagram, cannot be seen in direct
Optics of magnifying devices
vision either through or outside the lens. A similar gap
surrounds the segment of an ‘invisible’ fused or solid
Definition
(one-piece) bifocal and the effective aperture of a lenti-
cular lens. As shown in the diagram, the peripheral The definition of magnification given in the draft Inter-
field is affected in precisely the same way. national Standard is ‘the ratio between any linear di-
The angular width of the gap, being equal to the pris- mension of the retinal image when the magnifying
matic effect of the lens at its periphery, can be found to device is in use and the corresponding dimension when
a first approximation from Prentice’s rule. the object is viewed without the magnifier’. Although
the phrase ‘retinal image size’ is included, it is usually
only necessary to calculate the change in angular sub-
Jack-in-the-box effect tense at the entrance pupil of the eye. The small change
This term, given currency by Welsh (1961), describes a in image size caused by changes in the principal power
phenomenon particularly noticeable to aphakics of the eye with accommodation can generally be ig-
wearing high-powered spectacle lenses. Suppose an nored.
object is moving from right to left across the field of Because the magnification given by a lens varies with
view, the subject originally looking approximately the manner in which it is used, any numerical value for
straight ahead. The object, first seen in the uncorrected magnification needs clarification.
248 Subsidiary effects of correcting lenses; magnifying devices

Angular magnification parallel after refraction. The magnification m is thus

given by
Applicable to telescopic devices for distance vision, this
term denotes the ratio of the angle subtended by the ih Yee I Te
image to that subtended by the object. The system is as- If, following the accepted convention, P is taken as
sumed to be in ‘normal adjustment’, both object and —4D, then
image then lying at infinity.
m= F/4 (Ces}e'sy's3)
The following terms relate to near-vision devices.
In the assumed condition of use, the distance of the lens
from the eye does not affect the magnification, though
it does affect the field of view. Thus, if the eye were
Conventional magnification placed at E’ instead of E, the raypath from Q would pass
The traditional formula for determining the ‘magnifica- nearer to the edge of the lens, but the image Q’ at infi-
tion’ of magnifiers and eyepieces for optical instruments nity would still subtend the same angle u’ at the eye.
is F/4, where F is the equivalent power of the lens or Although the front or back vertex powers of the mag-
system. We shall call this the ‘conventional magnifica- nifier are frequently easier to measure than the equiva-
tion’. lent power, they are numerically larger and give a false
Note should be taken of the assumptions made in de- indication of the magnification. Hence both the draft
riving the formula quoted. The first is that the eye is em- International and the current British Standard (BS
metropic or corrected for distance vision. The second is 7522: 1992: Low Vision Aids: Part 1: Specification for
that when the object is viewed by the naked eye it will hand and stand magnifiers, including magnifiers with an in-
be held at what used to be termed the ‘least distance of tegral source of illumination) stipulate that equivalent
distinct vision’. This depends on the amplitude of ac- power shall be used in determining the magnification
commodation but the traditional distance of 10 in or and in labelling on the magnifier or its packaging.
250mm, requiring 4D of accommodation, is now
better termed the ‘reference seeing distance’. The third
Magnifiers and the accommodating eye or
assumption is that when the magnifier is in use, the
object will be held in its anterior focal plane. Since the near addition
image will then be formed at infinity it can be viewed It is unrealistic to expect a magnifier to be used with its
without accommodation. image at infinity — a young observer will accommodate,
In Figure 13.20, an object BO of height his placed at a while the presbyopic patient will probably be wearing
distance p from an eye at E, thus subtending a positive near-vision spectacles or bifocals. If the accommodating
visual angle u, given by eye or an eye corrected for near vision is regarded as a
Uy = —h/p = —hP relaxed emmetropic eye with a supplementary positive
power A, then the equivalent power entered in the equa-
If placed at the anterior focus of a magnifier of equiva- tion is that of the combination of the magnifier’s power,
lent power F, the same object would subtend a larger F, and A, thus giving:
angle u at the optical centre (or first principal point) of
the lens defined by
Fe = PA dP A (13.56)
w= —h/ f= hE where d is the separation between magnifier and eye.
For example, a +20 D equivalent power magnifier held
The image, formed at infinity, would subtend the same 200 mm in front of spectacles incorporating a +2.50 D
angle uw at the eye because all the rays from QO are near addition gives a total equivalent power of:
Feg = +20 + 2:50 — 02 20% 2:5 = 412/50)

Hence, provided that the object is held in the anterior

focal plane of the combination so that it is seen in
focus, the magnification will be +12.50/4 or 3.25.
The magnification is now seen to depend upon the se-
paration of magnifier and eye. If the magnifier is
brought closer, to say 100 mm from the spectacles, the
equivalent power becomes +17.50 D, whereas it falls to
only +7.50 D if it is held further away at 300 mm. As
pointed out by Rumney (1992), the equivalent power
formula reduces to F.g =F, when the separation d
approximates to the focal length of the magnifier — see
Exercise 13.19. Also, when the magnifier is held in this
position, the field of view equals the diameter of the lens.
Figure 13.20. Conventional magnification formula. Without
the magnifier, the object is held at a specified distance p from
the eye, at which it subtends an angle u,. With the magnifier in Trade magnification
use, the object is placed at its anterior focal point, where it
subtends the increased angle u, equal to the angular subtence 1/ If the separation between the magnifier and spectacle
of the image. plane reduces to nil, F.g =F +A. If A is assumed to
 Optics of magnifying devices 249

take the relatively high value of +4.00D, then Equivalent viewing distance and power
Fog = F + 4, whence the magnification becomes
These terms were introduced by Bailey (see, for example,
m=1+B/4 (357) Bullimore and Bailey, 1989) as an aid to low-vision
This formula increases the conventional magnification work and to break away from the concept of magnifica-
of a lens by one. It has been promoted by manufacturers tion linked to the reference seeing distance. If, for ex-
in several countries, and perhaps could be termed ample, a patient can read N1O print with a spectacle
‘trade magnification’. Because it assumes the user to correction at —}m, then N5 print should then, in
have a high level of accommodation or a near addition, theory, be legible at half the distance. Rather than hold
together with minimal vertex distance, this amount of print this close with a +6.00D addition, or using a
magnification is unlikely to be realized in practice. For +6.00 D magnifier with the image at infinity, a combi-
this reason, this formula is no longer used in the draft nation of a magnifier and near addition having an
International Standard. equivalent focal length, fg, of ~167mm may allow a
Conversely, the conventional formula would suggest more comfortable posture.
that a +4 D lens does not give a magnified image. De- The equivalent focal length can be shown to be identi-
pending upon the conditions of use, equation (13.56) cal to Bailey's equivalent viewing distance, EVD. He de-
shows that it does. Thus, if held 15 cm from an eye ac- fined this as the actual viewing distance, a, to the
commodating 2D, F.g is +5.88 D, giving a magnifica- virtual image formed by the magnifier divided by the
tion of 1.47. magnification (m, = L/L’). Bailey termed this magnifica-
tion the ‘enlargement ratio’. Ignoring signs, and assum-
ing that the image is placed in the anterior focal plane
of the spectacles so that/eg = Os
Iso-accommodative magnification
EVD = a/m, (13.60)
To overcome the objection that magnifiers are rarely
held very close to the eye or with the image at the refer- Thus, in the above example, a magnifier giving a linear
ence seeing distance, Bennett (1977) introduced the magnification of 2.5 will give an EVD of 167 mm if the
image is viewed at 167x2.5 = 415 mm from the spec-
concept of iso-accommodative magnification. This de-
notes the magnification achieved if the observer has the tacle plane.
same amount of accommodation or the same near addi- If, for example, the patient holds the magnifier too far
tion, both with and without the magnifier in use. In away so that the virtual image is not in the anterior
Figure 13.21, q denotes the subject's normal reading dis- focal plane of the spectacle addition, the final image
tance, taken to equal 1/A. If no reading correction is will be out of focus on the retina. The equivalent power
formula should not be applied, but the EVD can still
worn, g is measured from E, the centre of the eye’s en-
trance pupil; otherwise it is measured from the spectacle give an idea of the magnification. In general, the present
authors prefer the equivalent power formulation since
point S. The magnification is then
it is such a fundamental optical principle.
m= F,,/A (GliSe5'S}) The equivalent viewing distance concept can also be
An early British Standard on magnifiers (BS 5043 : applied to closed circuit television systems. If such a
1973: Bookholders, magnifiers and prismatic spectacles for system gives an image on the screen which is ten times
use as reading aids in hospitals and the home) adopted a se- larger than the original, but is viewed from 0.5 m, then
paration d of 100 mm and A as 4D, whence the iso-ac- the EVD is 0.5/10 m or 50 mm.
commodative magnification is 1+0.15 F. Equivalent viewing power is defined as the reciprocal
A more general expression is given if the magnifier is of the EVD, and may be shown as follows to be the
used with accommodation A, but compared with un- equivalent power of the system. Thus, for the magnifier:
aided viewing of the object at any arbitrary dioptric dis- Ib, i ie
tance P. The magnification is now given by Lar
1
Mea er (dise59)) Then, equivalent viewing power, from equation
The reader is directed to Exercise 13.18 for an alterna- (13.60) is given by
tive derivation and formula. 1 om =F
We) =
EVD “a al!
Of

1
SECS
but, from Figure 13.21, and writing a instead of q,
IN
iG f= 0B = 0E+ER =d=a
A adiyi; " so, therefore
|e B mes E (or S)
] A
(i= =
d—a Ad—1
aft ’
* . 7 / .
and substituting for L’ gives

Figure 13.21. Iso-accommodative magnification. Without A-F(Ad—1

the magnifier, the object is placed at a distance g (= 1/A) from EVP = — Sap A
a
the eye E (or spectacle plane S). With the lens at O, the object is
moved until its image lies in the original object position. From equation (13.60), EVP may also be expressed as:
250 Subsidiary effects of correcting lenses; magnifying devices

EVP = m,A (13.61) like a spectacle magnifier, this is not the way such mag-
nifiers are commonly used. Despite the reduction in
The identity of the EVP and the equivalent power of
magnification, they are usually held at about 10cm
the system was demonstrated by Bailey (198 1a).
from the eye in order to increase the working distance.
If one of the patient's eyes is significantly poorer than
Spectacle magnifiers the 6ther, it may be advantageous to close or occlude
the weak eye. If the two eyes are equally good, one
Spectacle magnifiers’ are high-powered plus lenses would expect a better performance if they could both
mounted close to the eye, either in a spectacle frame or view through the same magnifier. This is termed bi-
as a clip-on. They are limited to monocular use, the ocular viewing, as opposed to binocular viewing when
other eye being occluded if necessary. a separate lens is used for each eye, as in the prismatic
Despite the fact that iso-accommodative magnifica- binocular loupes discussed below. Unfortunately, there
tion is a more appropriate basis of numbering in all are two possible disadvantages in bi-ocular use. First,
clinical applications, it has become customary for man- the magnifier restricts both monocular fields, generally
ufacturers to specify spectacle magnifiers by their con- allowing each eye to see only a portion of a line of
ventional magnification. print. If so, only the overlapping area in the centre can
One of the drawbacks of spectacle magnifiers is that be seen simultaneously by the two eyes. This area in-
since the object has to be held close to the anterior creases with longer working distances, but to the disad-
focal plane of the lens, the working distance is often un- vantage of magnification. Increasing the power of the
comfortably short. A further difficulty is the extremely lens to compensate is counter-productive as it usually
restricted depth of field, requiring the reading matter to entails a smaller size. A second disadvantage is that the
be positioned very accurately. When the object is held magnification across the lens is not uniform, so there
in the anterior focal plane of the lens, L=—F and may be discomfort in fusing the two images. These ob-
L'=0. Suppose that L’ may vary up to +E dioptres jections do not apply to large aspherical magnifiers of
before acuity is noticeably impaired by out-of-focus low power specially designed for bi-ocular use.
blurring. Then L in turn may vary by +E dioptres. The
corresponding variation in the object distance may be
found by differentiating the expression / = 1/L, giving

d¢/db= 1/1? = -1/F? Galilean-type magnifiers’

In this context, dL represents the permitted tolerance +E The short working distance of a spectacle magnifier can
in the value of L, while d/ is the depth of field or permis- be increased, perhaps more than doubled, by using a Ga-
sible variation in the object distance. By substitution in lilean system comprising a positive front lens of power
the previous expression, we therefore obtain F, and an eye lens of power Fy. The conventional mag-
nification of the system is F/4, where F is its equivalent
Depth of field (in mm) = +1000 E/F? (13.62)
power calculated from
It can be found from this that if E is taken as £1.00 D,
asl, + F,—dF,F,
the depth of field is about +7 mm on a 3x spectacle
magnifier, reducing to as little as +1 mm with an 8x In this expression d represents the optical separation in
and +0.6 mm with a 10x lens. metres between the components, measured from the
As the magnification increases, the field of view con- second principal point of the first to the first principal
tracts, reducing to approximately the diameter of the point of the second lens. Very high lens powers are
lens itself when the magnification reaches 10x. needed to keep d below 30mm while doubling the
working distance.
By comparison with spectacle magnifiers of the same
Hand readers power, Galilean magnifiers have a smaller field of view
and the same restricted depth of field. On the other
Hand readers are used mainly by elderly people whose
hand, the longer working distance has the further great
visual acuity has declined and whose accommodation
advantage of making possible a binocular construction.
is very limited. In most cases a reading correction is
worn. This enables the patient to look at large print, for
example, the headlines in the paper, and then use the
hand reader as an adjunct for the smaller print. Magnifi-
cation is greater with the near addition in use than
Prismatic binocular loupes
with the distance correction. A typical hand reader con- Another method of adapting spectacle magnifiers to bin-
sists of a single lens of relatively large diameter and of ocular use is to add strong base-in prisms. An empirical
power between +3.50D and + 2.00D. Although the rule which has been found generally successful is to in-
maximum monocular field of view and magnification corporate in each lens one prism dioptre base in for
are obtained when the reader is held close to the eye every dioptre of lens power.
A theoretical basis of design for a standard range is
shown in Figure 13.22. The eyes’ centres of rotation
* Occasionally called ‘microscopic lenses’, following the obso- are at Zp and Z,. First, the lens power for a given con-
lete term ‘simple microscope’ for a single magnifying lens. ventional magnification is determined from the formula
' Occasionally called ‘telemicroscopes'’. m = F/4. Next, the image plane is fixed at a suitable dis-
 Optics of magnifying devices 251

Plane of
convergence

Qe,

Figure 13.22. Scheme for designing a prismatic binocular loupe. Qp represents the axial position of the effective binocular object
to which the eyes converge.

tance /’ from the lens, which in turn determines the lar magnification is f{,/ —f5, while the optical separation d
object distance. One further arbitrary distance remains between the lenses is f; +5. Thus
to be fixed — from the lens to the plane of convergence
in which the effective binocular object (EBO) is situated. (ee dee
Let Q, lying on the median line, denote the mid-point of =) ne = d 1 = dF,

the object and Q, the corresponding EBO at the prede-

termined distance from the lens. Lines drawn from Zp where d is in metres. This is the basic design formula.
and Z, through Qpg meet the image plane at Op and QO}. Correction of any ametropia is essential. In the origi-
the images of Q formed by the right and left lenses re- nal design introduced by Carl Zeiss of Jena, a separate
spectively. It thus follows that lines then drawn from correcting lens was mounted immediately behind the
QO and Q} through the object point Q will determine eye lens. In the design produced by Stigmat Ltd in
the required positions of the respective optical centres, 1951 — the first to use an aspherical object glass —
Op and O,. Finally, to obtain coincident fields of view, every eye lens was worked individually so as to incorpo-
the geometrical centres of the lenses, Gp and G, should rate the correction needed.
be located on ZpQp and Z; Qz respectively. According to a well-known theorem in geometrical
From drawings such as Figure 1 3.22 the essential lens optics, if light of vergence L is incident on a telescopic
and frame dimensions could be obtained for a range of system of magnification m, the vergence of the emergent
conventional magnification and inter-ocular distances. light is approximately m7L. Thus if m = 2x, four diop-
The optical performance of the lenses is improved by an- tres of accommodation would be needed to focus an
gling them, as shown, so that the optical axis (repre- object at one metre. For this reason, an auxiliary lens
sented by the broken line) passes through the eye’s of power —L needs to be fitted in front of the object
centre of rotation. glass to adapt the basic unit to vision at a dioptric dis-
A more flexible design procedure enabling prescribers tance L.
to draw up specifications to suit patients’ individual re- By decreasing the working distance and fitting a
quirements has been described by Westheimer (1954). ‘reading cap’ of high plus power over the objective, the
In another type of prismatic binocular loupe, the magnification in near vision can be increased. If the
lenses are held at a distance of some 40-60 mm from power of the auxiliary lens is F.,,, the total magnifica-
the eyes, thus permitting a longer working distance tion becomes m x (F.ap/4). Thus, a basic unit of magni-
fication 1.8 used with a +12 D reading cap would have
with moderate magnification. Headband magnifiers for
industrial and general use are in this category. The a conventional magnification of 1.8 x 3 or 5.4x.
user is able to wear spectacles if necessary and to look An alternative method to focus for near vision is to in-
crease the separation between the components of the
below as well as through the prismatic magnifying
system. If the increase in the separation from that for a
lenses.
distant object is A, then the equivalent power in near
vision is —AF,F,, which can be shown to equal AmF7
or (L,/L4)Fy or m/(¢,; +f), where m is given by equa-
tion (13.61) above. For an ametropic observer, the effec-
«
tive eyepiece power to be inserted is (F, — K).
For Keplerian systems similarly adjusted, the equiva-
Telescopic spectacles lent power is negative, but because the object is situated
Magnification in distance vision requires some form of closer to the instrument than the first principal plane,
telescopic system, the choice of a Galilean design being the object vergence for the system as a whole is positive.
dictated by the need for compactness and an erect The image would, of course, be erected by a compact
image. When the system is in normal adjustment, the angu- prism system.
252 Subsidiary effects of correcting lenses; magnifying devices

For further discussion on the optics of telescopic aids, magnifiers, generally of elongated or rectangular
the reader is referred to Bailey (1978, 1979, 1981b), shape, are designed in this way. Patients with a homon-
Long and Woo (1986) and Woo et al. (1995). ymous hemianopia or bilateral loss of field to the right
of fixation may be helped by learning to read with the
print held diagonally, or even upside down, so as not to
be reading into the blind area.
Helping the partially sighted patient
It is not easy to keep on track of a line of print when
reading with a high-powered magnifier. With small
Some guiding principles stand magnifiers, a thin narrow strip of suitable material
For occasional use in distance vision, high-powered tele- may be fixed across the bottom of the stand to provide a
scopes may be of use for identifying bus numbers, train reference line. Alternatively, a ruler may be placed
indicator boards, etc. For prolonged use in distance and across the page and the magnifier slid along it. A
intermediate vision, the only help available is limited to simple device with added advantages was introduced
telescopic systems with a magnification seldom ex- by Charles F. Prentice, who called it a typoscope. It con-
ceeding 2.5x. Otherwise, the normal refractive correc- sists of a rectangular piece of matt black material with
tion must suffice. Patients with cloudy media may be a long but narrow horizontal slit exposing just one or ~
further helped by tinted lenses, especially prescription two lines of print. The patient slides the device down
sunglasses when out of doors, since these reduce pupil the page as he reads. Light from above and below the
miosis. For television viewing, sitting nearer to the line of regard is absorbed by the black material and
screen will make the picture appear larger. cannot be scattered within the eye by hazy media. A
For near vision much higher magnifications can be rigid clipboard to hold the paper flat and still may be
provided. Nevertheless, the lowest magnification that helpful.
meets the patient's needs should normally be prescribed.
Inherent drawbacks and difficulties — in particular, a
reduced field of view and shorter working distance —
Refraction; high reading additions
are then minimized. Patients with a strong desire not to
lose their ability to read have a good chance of adapting Refraction of the partially sighted patient begins in the
themselves to these limitations. Unfortunately, some normal manner with retinoscopy or some other objec-
elderly patients in particular may be unable or lack suffi- tive technique. If the patient is aphakic and the vitreous
cient motivation to do so. cloudy, keratometry will give a good indication of the
Improving the near acuity to N5 (or J2) should not ocular astigmatism. In this case the correcting cylinder
necessarily be the aim. Although the most common size in the spectacle plane should be of somewhat lower
of newsprint is equivalent to N8 (J6), the contrast is power, as indicated by the approximate expression
poorer than in test types. An improvement to N6 (J3) (20.5). When necessary, the subjective refraction can
may be necessary to enable a newspaper to be read satis- be carried out at the reduced distance of 3, 2 or even
factorily. The use of a typical newspaper for test pur- 1 m, with lens powers changed in 1 or 2 D steps as indi-
poses is both practically and psychologically beneficial. cated by the acuity.
Large-print books have already been mentioned on In near-vision testing, a trial frame is preferable to a
page 44, while a large print newpaper is available refracting unit because it allows normal head posture
weekly in the UK.” For patients with poor vision, the and movements. When the unaided acuity is very low,
ability to read newsprint is a grossly optimistic aim: it is standard reading test types are unsuitable for assessing
better to concentrate on achieving ‘survival reading’ to the magnification required. A specially designed set of
enable the patient to read cooker settings, instructions types such as the Keeler A Series, described on page 29,
or correspondence. Rumney (1995) points out that con- makes this task much simpler.
trast sensitivity is also an important factor in reading. With about a +2.50D addition in place, the near
Apart from CCTV systems, described on pages 44 and acuity should be measured both monocularly and bin-
249, magnifiers cannot enhance the contrast of an ocularly. The first line of approach is to determine
object. Increased illumination, however, often improves whether the acuity can be raised to the desired level by
the contrast sensitivity of the eye, thus effectively im- increasing the reading addition. If, for example, N12
proving the contrast. Whittaker and Lovie-Kitchen (or J10) can be read at the patient’s normal working dis-
(1993) emphasize that a reserve of magnification and tance, a magnification of 2« should give N6 (J4). This
contrast sensitivity are required to provide a reserve for may be obtained by halving the normal working dis-
comfortable tance, which will require the near addition to be in-
reading. creased by the dioptric change in the working distance.
A difficulty may arise if there is a field defect immedi- Thus, a change from 35cm (—2.86D) to 17.5cm
ately to one side of fixation, as shown by the Amsler (—5.70D) would require an extra addition of about
chart (usually a chart with a grid of white lines on a +2.75 or possibly +3.00 D.
black ground). In this case the patient may benefit by a With the stronger reading addition in place, the
magnifier which is more powerful in the vertical than patient is encouraged to read smaller and smaller print,
in the horizontal meridian. A number of simple stand shortening and adjusting the working distance to find
the clearest position. The effect of increasing or decreas-
ing the addition by 0.50 or 1.00 D should also be tried.
* Big Print, PO Box 308, Warrington WA1 JJE. Ifa reduced addition does not noticeably impair the per-
 Helping the partially sighted patient 253

formance, it should be prescribed. In addition to givinga port the wrists. Alternatively, a reading stand to be
more comfortable reading position, it will also reduce placed on a table may be formed by upturning a card-
the effort of convergence required. board box cut diagonally.
Relatively high binocular additions often require the With a short working distance, illumination of the
help of base-in prisms. The amount can be based on the reading matter may require special attention. Built-in
cover and fixation disparity tests, with a check on the illumination is provided for magnifiers of very high
‘better with or without?’ basis. For this purpose, the power in some manufacturers’ ranges.
trial frame should be correctly centred for the near PD
at the given working distance. Even when base-in
prisms appear to give little subjective improvement in Hand magnifiers (hand readers)
comfort, it is a good idea to prescribe them when pro-
While a younger patient can learn to master a very
longed reading is likely. In this case the empirical rule
short reading distance, the older patient is rarely able
normally adopted for binocular loupes (1A base-in each
to change the habits of a lifetime. Provided the acuity is
eye for each dioptre of near addition) can be taken as a
guide. not too poor, the familiar hand reader may prove
helpful. It enables the reading matter to be held at
If binocular vision is poorly sustained or one eye has a
nearly the normal distance. Moreover, the ordinary
much lower acuity, it is probably wiser to concentrate
reading spectacles may enable headlines and pictures
on the better eye. The poorer eye can be occluded or
to be discerned, with resort to the magnifier only when
possibly furnished with a distance correction or much
needed.
weaker addition for looking at headlines. Many elderly
The weakest (also, generally the largest) lens consis-
patients appear to be exotropic in near vision without
tent with adequate vision should be advised, so as to
noticing diplopia.
obtain the additional advantage of less critical pos-
itioning. A plastics lens reduces weight considerably,
Other magnifying devices though demanding more care to prevent scratching.
An aspheric lens with its larger field of good definition
Spectacle magnifiers is worth the extra cost if more than minimal use is con-
templated.
Ifa binocular addition as high as +6.00 D is still insuffi-
Though Fresnel sheet magnifiers appear attractive be-
cient, a higher monocular addition may be given, the
cause of their thinness and weight saving, it is rarely
other eye being occluded. When the total lens power
understood by the layman that, like conventional mag-
for reading reaches about +10D or more, a lens de-
nifiers, they have to be held off the page. In general, the
signed as a spectacle magnifier is indicated. If the
image contrast and quality are relatively poor while the
curves are specially calculated to minimize aberrations
magnification of the large ones is limited.
for the appropriate working distance, spectacle magni-
It is useful to demonstrate to the patient that the field
fiers with spherical surfaces will give quite acceptable
of view of a hand reader is increased if the lens and
results in magnifications up to about 5x. One such
print are held closer to the eye, though they need not
series is the Stigmagna range (3x, 4x and 5x). For
be as close as with a spectacle magnifier.
higher magnifications aspherical surfaces are required,
as in the Igard Hyperocular range (4x, 5x, 6x, 8~x,
10x and 12x). Compound magnifiers, each comprising
Stand magnifiers
two lenses (preferably both aspheric) with magnifica-
tions up to 20 are also available. A hand tremor or poor dexterity caused by arthritis, for
No correction for spherical ametropia need normally example, may rule out a hand reader. In such cases a
be considered, because a small adjustment of the work- stand magnifier may be helpful because it rests directly
ing distance will suitably modify the vergence of the on the object to be viewed. This then fixes the object
pencils reaching the eye. A troublesome degree of astig- and image conjugates, thus determining the magnifica-
matism can be overcome by incorporating a prescribed tion of the virtual image. Provided that the distance or
cylinder in a specially worked lens of the same basic vergence of this image from the surface of the magnifier
design as the standard range. nearer the eye is known (a requirement of the draft
To enable a very short working distance to be cor- International Standard on magnifiers), the separation
rectly maintained, the lens may be surrounded by an ad- between lens and eye or spectacles can be determined,
justable transparent collar against which the reading and hence the equivalent power. Expression (13.61)
matter is held. Another method is to attach an adjust- also shows that the transverse magnification m, would
able post to the spectacle frame. It is generally easier to usefully be marked on the device.
pass a book across the face than to scan it by head and One type, designed specifically for low visual acuity,
eye movements. The book should be moved in a series consists of an aspheric lens of about 44 mm diameter
of steps like the saccades of the normally sighted. By and equivalent power about +15D. The image is
this means, the advantage of a stationary field is ob- formed about 250 mm behind the object plane, enabling
tained. The same principle applies when a hand-held the magnifier to be used in conjunction with ordinary
magnifier is moved across the reading matter. With reading spectacles. If these incorporated a +3.00 addi-
weaker additions, a plank may be placed across the tion, then the distance between magnifier and spectacles
arms of a chair to support the reading matter, or a will need to be about 80mm, giving an equivalent
piece of tape passed behind the neck with loops to sup- power of about +14.5 D and hence magnification about
254 Subsidiary effects of correcting lenses; magnifying devices

3.5. This will vary with the near addition and separa- working distance of about 11cm compared with the
tion. Another convenient form of stand magnifier is the 5cm working distance of the 5x hyperocular. On the
‘bright field’ lens formed from a hyper-hemisphere of other hand, the respective fields of view are approxi-
glass or plastic, the flat face resting on the paper, or mately 5 cm and 7 cm.
with a shallow rim on the underside to lift it slightly to In theory, a much less conspicuous telescopic system
prevent scratching. can be provided by mounting the object glass in a spec-
A large number of bulkier but adjustable stand mag- tacle frame and using a high-powered minus contact
nifiers have been produced with normally sighted users lens as the eyepiece. The magnification obtainable is
in mind. In suitable cases they could be equally useful limited by the relatively small optical separation,
to partially sighted patients. 16-18 mm at the most. To avoid disconcerting pris-
matic effects, the contact lens must be fitted so that it
moves relatively little in relation to the eye. Unlike a
Fibreoptic magnifiers spectacle-mounted telescope which can be removed for
walking about, the contact-lens device would have to
A promising innovation is to employ fibreoptic bundles
be worn constantly.
(Peli and Siegmund, 1995) to act as a magnifier. Each
individual fibre is tapered, with the narrow end resting
on the paper. Provided that the mosaic of the fibre ends Television magnifiers
is fine enough to resolve the print, an enlarged view is
These devices have been described on page 44.
seen on the upper face of the magnifier, the magnifica-
tion simply being the ratio of the diameters of the two
A more detailed treatment of the whole subject of low-
ends of the fibre. As Peli and Siegmund point out, the
vision aids can be found in one of the specialized text-
optics of fibre bundles means that the patient does not
books, such as those by Mehr and Freid (1975), Faye
have to align the eye with the magnifier, while illumina-
(1976) and Dowie (1988).
tion is provided by light passing down the tapered fibres.

Field expanders
Telescopic systems
The opposite principle of minifying the external scene to
The Galilean telescopic system can be adapted for use as increase the effective field of patients with severely re-
a spectacle magnifier at near or intermediate distances. stricted or tunnel vision has been suggested in the form
It has the big advantage of giving a longer working dis- of a field expander (Drasdo and Murray, 1978). A re-
tance. When such a system is used binocularly, the op- verse Galilean system is used, the object glass being of
tical axes of the right and left halves must be aligned negative and the eye lens of positive power. The sug-
very accurately so as to intersect on the median line at gested magnification is of the order of 0.2x. Unfortu-
the intended working distance. It is therefore impractic- nately, the reduced size of the retinal image results in a
able to adapt the same unit for use at different distances. corresponding reduction in visual acuity.
On the other hand, a monocular Galilean unit designed
for near vision can easily be converted for distance use,
or vice versa, by means of an auxiliary lens fitted over
the objective. In fact, a bifocal lens allows simultaneous Aberrations of correcting lenses
use at two different distances.
A telescopic spectacle designed for distance vision General considerations
should incorporate the patient’s distance correction. A
suggested routine is to put up this correction in a trial Spectacle lenses are subject to various ‘geometrical’
frame with an afocal telescopic unit in front of it. The re- aberrations which should be noted in prescribing or dis-
sulting improved acuity may enable the refraction to be pensing.
further refined.
For magnification in outdoor situations — for example,
Monochromatic aberrations
to distinguish bus numbers or street names across the
road — a small Galilean telescope mounted on a finger This term is given to those aberrations which would be
ring can be of great assistance. A miniature prismatic present even if light of only one wavelength were con-
monocular or binoculars will provide even greater mag- sidered, though the amount may differ with wavelength.
nification and a bigger field of view. Binoculars of the Spherical aberration and coma come into this category,
roof prism type are smaller and neater than those of the but in general are disregarded in spectacle lenses
Porro prism type. because the pupil admits only relatively narrow pencils
The use of auxiliary plus lenses to increase the magni- of rays. Oblique astigmatism and distortion are the
fication of a telescopic unit for near vision has already monochromatic aberrations that need to be taken ser-
been discussed in the previous section on page 251. iously.
Compared with a spectacle magnifier giving the same
magnification, the telescopic system gives a useful in-
Chromatic aberration
crease in the working distance but a smaller field of
view. For example, the Stigmat telescopic unit with a This takes two forms. Axial chromatic aberration (ACA)
reading cap giving a total magnification of 5.25x has a refers to the variation with wavelength in the paraxial
 Aberrations of correcting lenses 255

power or focal length of an optical surface or lens. The flected or refracted pencil then forms two separate focal
power variation over a given spectral range is propor- ‘lines’, characteristic of astigmatism, in two principal
tional to the paraxial power itself but is basically depen- meridians called tangential and sagittal. The tangential
dent on the dispersive properties of the lens material meridian contains the incident and reflected or refracted
(see also pages 275-281). rays, together with the optical axis, while the sagittal
Transverse chromatic aberration (TCA) arises from meridian is perpendicular to the tangential.
the variation with wavelength in the prismatic effect at Figure 13.23(a) shows a parallel pencil of rays obli-
given distance from the optical centre or axis. As a quely incident on a plus spectacle lens, the eye having
result, blue or orange-red colour fringes may sometimes pivoted about its assumed centre of rotation Z so that
be noticed when the gaze is directed through a periph- the refracted pencil falls on the fovea. Though the pupil
eral part of the lens, though transverse chromatic aber- moves with the eye, all the oblique pencils entering the
ration is more often noticed as a reduction in sharpness. eye in direct vision must necessarily pass through Z. In
effect, the real pupil is replaced by an imaginary dia-
Common properties phragm situated at Z.
To correct the eye for distance, the second principal
With the exception of axial chromatic aberration, all the focus F’ of the lens must coincide with the eye’s far
significant aberrations mentioned have certain proper- point Mp. As the eye rotates, the far point travels along
ties in common: a curved surface, with its centre of curvature at Z,
(1) They apply only to pencils passing obliquely known as the far point sphere. Ideally, all the refracted
through the lens and entering the rotated eye. pencils should focus on this surface but generally exhibit
(2) They are approximately proportional to the square oblique astigmatism. In Figure 13.2 3(a), rays in the tan-
of the distance » from the optical axis at which the gential meridian of the pencil illustrated form a short
incident pencil meets the lens. line focus at T5 and in the sagittal meridian at 8. For a
(3) They are affected by the form of the lens, defined by given object distance, these separate foci of pencils from
the value given to one of its surface powers. all possible directions lie on two curved surfaces known
Unfortunately, the form needed for optimum correc- as image shells. Their sections are represented in the
tion differs from one aberration to another. diagram by the solid lines. When the defect is very
Moreover, the lens form best for distance vision is marked, they resemble a teacup (tangential) and saucer
generally not the-best for vision at intermediate (sagittal) — a useful mnemonic.
and near ranges. As with astigmatic refraction in general, the focal
lines are each perpendicular to the associated principal
Oblique astigmatism meridian. Thus, if the pencil is incident immediately
above the optical centre, making the tangential merid-
Oblique astigmatism is an important defect because it ian the vertical one, the focal line at T4 is horizontal
impairs the sharpness of the images presented to the while the line at S4 is vertical. In Figure 1 3.23(b), the di-
eye. It is essentially a defect of narrow pencils obliquely rections of the focal lines are shown in various merid-
incident on a reflecting or refracting surface. The re- ional sections of the image shells taken at regular inter-
vals round the circle. The tangential line foci lie along
the tyre, and the sagittal foci form the spokes of a
wheel — another useful mnemonic.
The elimination of oblique astigmatism requires the
two image shells to coincide. Within limits, but over a
wide range of lens powers, this aim can be achieved by
a correct choice of lens form. A lens free from oblique as-
tigmatism for a stated object distance and centre of rota-
tion distance A>Z is called point-focal. A valid equation
for determining the necessary lens form was first derived
by Airy (1830). It was also shown by Airy in the same
paper — and later, independently, by Petzval — that if ob-
lique astigmatism is eliminated, the single image shell
(generally known as the Petzval surface) remains
curved. For a thin lens, its radius of curvature was cor-
rectly given by Airy as —nf’. As indicated by Figure
Petzval
13.23, this is generally longer than the radius of the
surface far point sphere, both for plus and minus lenses. A hy-
permetrope would accordingly have to accommodate a
little to place the image on the retina in oblique direc-
(b)
tions of the gaze. A myope would be slightly blurred
Figure 13.23. Oblique astigmatism of a plus spherical lens in and not helped by accommodating.
distance vision. (a) Tangential and sagittal image shells, the Although the foregoing discussion has been limited to
Petzval surface and the far-point sphere. (b) A three-
spherical lenses, the same considerations apply sepa-
dimensional view of the ‘teacup and saucer’ formation of the
image shells is outlined in the inset figure. rately to the two principal meridians of an astigmatic
256 Subsidiary effects of correcting lenses; magnifying devices

erm eal Ideally there should be two different ranges of ‘best

\ form’ or ‘corrected curve’ lenses, one designed specific-
| |] ally for distance and the other for near vision. Since
| | this is neither commercially nor otherwise feasible,
| | most designs are now based on a compromise between
| | the conflicting requirements of distance and near vision.
] | The introduction of several new glasses of high mean
\ refractive index (1.7 or over) and mid-index resins (of
index over 1.55) but also of greater dispersive power
has raised an interesting question. Because of these ma-
Figure 13.24. (a) Pincushion and (b) barrel distortion terials, high-powered lenses, both plus and minus, can
caused by plus and minus lenses. be made much thinner and often lighter in weight than
is possible in the traditional hard crown glass. However,
the higher dispersion means a substantial increase in
lens. If a point is selected on one of these meridians and both axial and transverse chromatic aberrations. The
a second point on the other, both at the same distance axial aberration of plus lenses is additive to the eye’s
from the optical centre, the main effect of oblique astig- own appreciable error, whereas that of minus lenses
matism is generally to change the prescribed cylinder helps to counteract the eye’s. There is some evidence to
power at the two given points by different amounts. suggest that the increased chromatic aberration of
Nevertheless, a lens form can often be found in which high-index lenses of high powers is less acceptable to
the effective cylinder power is the same at both points, hypermetropic and aphakic patients than to myopes.
though slightly different from the prescribed power. Even the most favourable form of plus lenses in the
cataract range of powers leaves large amounts of uncor-
Distortion and transverse chromatic rected oblique astigmatism and distortion, if spherical
aberration surfaces are used. Both defects can be greatly reduced si-
multaneously by the use of one aspheric surface of sub-
In an optical context, distortion means a lack of corre- stantially ellipsoidal form. Though lenses of this type
spondence between the shapes of object and conjugate were introduced by Carl Zeiss of Jena as long ago as
image. In general, rays incident at increasing distances 1909, their mass production in both single vision and
from the optical centre of a lens are deviated more and bifocal forms has only become possible by plastics lens
more in excess of the paraxial value expressed by Prenti- technology in the late 1970s. Aspheric surfaces are
ce’s rule. Consequently, the magnification of a plus lens now employed in low power lenses, both to improve ap-
increases from the centre outwards and the image of a pearance and optical performance in large lens sizes.
square exhibits the ‘pincushion’ distortion shown in For a more detailed treatment of spectacle lens design,
Figure 13.24(a). Conversely, a minus lens gives rise to including many tables of the various aberrations present
the ‘barrel’ distortion shown in Figure 13.24(b). As ina over a wide range of lens forms, see Bennett and Edgar
plano prism, an oblique ray passing through a lens un- (1979/80). The last one of these papers summarizes the
dergoes the minimum deviation when the total is entire series.
equally divided between the two surfaces. This require-
ment when applied to spectacle lenses leads to an unac-
ceptably bulbous appearance if spherical surfaces are Contact lenses
used. Because contact lenses move with the eye, at least to a
Similarly, since dispersion is approximately propor- great extent, they do not give rise to the oblique aberra-
tional to the mean deviation, the lens forms for mini- tions of spectacle lenses. Their principal effect is on the
mum transverse chromatic aberration are far too eye’s spherical aberration. The liquid meniscus formed
steeply curved to be practicable. by hard contact lenses largely neutralizes the front sur-
face of the cornea and replaces it with a convex spher-
Spectacle-lens design ical surface. Since the peripheral flattening of the
cornea has been rendered ineffective, the spherical aber-
There has been a long history of controversy in the field ration of the corrected eye must show a substantial in-
of spectacle-lens design, principally about what its aims crease. Contact lenses with aspheric front surfaces are
should be, particularly in relation to oblique astigma- designed to remedy this drawback — see Chapter 15.
tism. One school of thought favoured its elimination
whenever possible by means of point-focal lenses. An
opposing view first advocated in 1901 by the English
Exercises
ophthalmologist Percival and later in 1928 with some
corrections in matters of detail, was that the tangential
13.1 A meniscus lens (n = 1.523) of power +4.00 D, centre
and sagittal image shells should be made to straddle the thickness 3.8 mm and front surface power +10.50 D, is placed
far (or near) point sphere as the case may be. The circles 16mm from the entrance pupil of the subject's eye. Find the
of least confusion would then be focused on the retina, spectacle magnification: (a) ignoring lens form and thickness,
thus avoiding the marginal loss of power of point-focal (b) taking these factors into account.
13.2 (a) Define spectacle magnification and relative spectacle
lenses at the expense of a small amount of residual astig- magnification. (b) An eye is corrected for distance by a thin
matism. ~4,00D lens placed 16 mm from the entrance pupil. What is
 Exercises 257

the spectacle magnification? (c) A hypermetropic eye is cor- L=—2.50D of a 1A prism associated with lens powers of
rected for distance by a thin +5.50D lens. Find the relative +10.0, +5.0, +2.5, 0, —2.5, —5.0 and —10.0D, taking the
spectacle magnification assuming (i) axial ametropia, (ii) centre of rotation distance as 25 mm.
refractive ametropia, (iii) an axial length of 21 mm. Use the re- 13.16 Construct a diagram to half scale showing the position
duced eye as the basis of calculation, the reduced surface of the effective binocular object for: L=—4.00D, F,, =
being 14 mm behind the spectacle plane. +7.00 D, z = 25 mm and PD = 64 mm, the lenses being centred
13.3 A thin correcting lens of power —12.00 DS/—4.00 DC for distance vision.
axis 150 is placed at 15 mm from the principal point of a re- 13.17 A 38 mm diameter spherical lens of power +12.00 D is
duced eye. Find the relative spectacle magnification, given that mounted 15 mm from the entrance pupil and 25 mm from the
the axial length of this eye is 26.0 mm and the power of the centre of rotation of an aphakic eye. On an accurate drawing
reference eye +60.0 D. twice actual size, show the angular extent of: (a) the real ma-
13.4 In acertain eye, the size of the retinal image of a distant cular field of view, (b) the real peripheral field of view with the
object is 10% larger when the eye is corrected by a spherical eye in its primary position. Include the fields seen both through
lens placed in contact with the reduced surface than when a and outside the lens. Ignore the effects of pupil diameter and
correction is worn in its anterior focal plane. Find the spectacle lens thickness.
refraction and ocular refraction on the assumption that the 13.18 Derive from first principles the expression m=
power of the eye is +60.0 D. 1—F/L' for the iso-accommodative magnification of a lens
13.5 A subject's right eye is corrected for distance by the thin held close to the eye. Compare the effects of taking the dioptric
lens —10.00 DS/—4.00 DC axis 45 placed 14 mm from the re- distance of the image L’ as —3.00 and —4.00 D.
duced surface. Find the dimensions of the retinal image of a cir- 13.19 Using equations (13.56) and (13.59), tabulate the
cular object 6 m in diameter at a distance of 300 m, assuming magnifications given by a +8 D lens when d= 0, 5, 10, and
the eye to have an axial length of 26.00 mm. 20cm, with the eye in focus for each of the following dioptric
13.6 By means of a backwards ray trace from the ocular en- distances (A): 4D, 2D, 1 D and 0. The value of P is to be taken
trance pupil, and using effectivity relationships, show that as —4D, as in the expression for conventional magnification.
pupil magnification by the correcting lens may be expressed as Why is the combination of d= 30cm and A = 4D not a prac-
S x P, where S and P are the shape and power factors of the tical possibility?
lens. 13.20 Compare the magnification produced by a_ thin
13.7 A myope is corrected by a —5.00 DS thin lens at 18 mm +3.00 DS lens when used as: (a) a spectacle lens at an entrance
distance from the ocular entrance pupil which is 4 mm in diam- pupil distance of 17 mm correcting an eye for distance vision,
eter. Compare the effective entrance pupil areas when corrected (b) its conventional magnification and (c) its iso-accommoda-
by a spectacle lens and a contact lens. Take the entrance pupil tive magnification, the eye being in focus for vergence
as 3 mm behind the corneal pole. —4.00 D with (i) the lens held close to the eye and (ii) the lens
13.8 An aphakic with an originally emmetropic Bennett-— held 100 mm in front of the eye.
Rabbetts schematic eye is corrected by a plastics lenticular 13.21 An absolute presbyope with poor vision can just read
lens of thickness 6 mm, refractive index 1.500 and back surface N10 print with a +2.50D addition. What power addition
power —5.00 D at a vertex distance of 14 mm from the cornea. should be chosen initially for trial in attempting to read N5?
Compare the effective entrance pupil diameters in the pre- 13.22 A patient wears a telescopic unit adjusted for near
aphakic and corrected post-aphakic state, given a 3 mm ocular vision at 20 cm from the objective. What power of end cap is re-
entrance pupil diameter in both cases and K = +12.38D in quired to enable him to focus on a television screen at | +m?
the aphakic state. Also, compare the illuminances of the retinal 13.23 A patient wears a telescopic unit adjusted for near
image of an extended object in the two states. vision at 25 cm. What power of end cap is needed to increase
13.9 (a) Find the apparent inclination of: (i) a distant vertical the magnification by: (a) 50%, (b) 100%
line, (ii) a distant horizontal line viewed through the plano- 13.24 A presbyopic, emmetropic patient's eye has a depth of
cylinder —3.00 DC axis 45 placed 15mm from the cornea. focus of +1.00 D. What is the range of clear vision when: (a)
Assume the entrance pupil to be 3 mm behind the cornea. (h) wearing a thin lens spectacle magnifier of 4x conventional
Find the apparent inclination of the same lines viewed directly magnification and (b) wearing a Galilean telescope also giving
by an eye with —3.00D of corneal astigmatism at axis 45. a 4x conventional magnification with a working distance of
Assume the corneal power to be +40 D in the weaker principal —t m from the objective lens and a lens separation of 25 mm?
meridian and the real pupil to be 3.6 mm behind the corneal (Assume the objective lens to be composed of a collimating
vertex. lens and an objective for a distance telescope.)
13.10 At what distance should a lens +5.00 DS/—2.00 DC be 13.25 The angular field of half illumination of a Galilean tele-
held from the eye so that the lines on a cross-line chart at scope is limited by the ray passing through the extremity of
—1.0m from the eye appear to rotate without scissors distor- the objective and the centre of the eye’s entrance pupil. Deter-
tion? mine this field for: (a) a 1.5 telescopic spectacle with a compo-
13.11 A cross-line chart at —1_m from the eye is viewed nent separation of 163 mm and vertex distance 12 mm, (b) a
through a +3.00 DS/+2.00 DC lens held at 40 cm from the 1.5 system comprising a spectacle-lens objective at a distance
eye. What type of image movement will be seen on rotating of 165mm from a contact-lens eyepiece. Assume all elements
the lens? thin, the objective aperture 34 mm, and entrance pupil 3 mm
13.12 An eye views an object point at a distance of 350 mm behind the corneal vertex.
from its centre of rotation. A 10A prism base up is now inter- 13.26 A fixed-focus stand magnifier is designed for an object
posed at a distance of 320 mm from the object. Through what distance 7, of —333 mm from the front surface. The lens
angle would the eye need to rotate in order to keep the retinal (n= 1.490) has surface powers of +4.50D (front) and
image on the fovea? +13.50 D (back) and its centre thickness is 13 mm. Calculate:
13.13 A patient wearing: RE+1.00 DS, LE+1.50 DS/+1.50 (a) the conventional magnification, (b) the actual magnifica-
DC axis 90 views a point on the median line 500 mm from the tion when the eye is placed at the following distances from the
spectacle plane. Both lenses are decentred 5mm outwards object: (i) 150 mm, (ii) 250 mm, (iii) 350 mm.
with respect to the subject’s inter-ocular distance of 65 mm. 13.27 A —6.00D myope uses a +20.0 D lens close to the un-
Assuming the centres of rotation to lie 27 mm behind the spec- accommodated eye as a magnifier. Is the magnification greater
tacle plane, find the necessary convergence of the visual axes when wearing spectacles or without?
for binocular fixation of the given point. 13.28 Both by algebraical manipulation of equation (13.5),
13.14 A patient wearing R +5.00 DS and L +9.00 DS fixates and by regarding the spectacle corrected eye as a telescope of
an object point 120 mm below the level of the primary line of objective power F,, and eyepiece power K, show that the
sight in a plane at one-third of a metre from the lenses. The power factor of spectacle magnification is P = K/F,,. Discuss
centre of rotation of the eye is 25 mm from the lens. Calculate the errors or assumptions inherent in this expression. Show
the vertical rotation of each eye to view the object, and com- also that the power factor may be expressed as (1+aK).
pare with Example (4) in the text on page 242. 13.29 Calculate the power factor of the spectacle magnifica-
13.15 Tabulate the effective power in near vision at tion in each principal meridian of a £0.25 D and a £0.50D
258 Subsidiary effects of correcting lenses; magnifying devices

cross cylinder used at a vertex distance (a) 25 mm (typical for a pow1k, A.T. (1988) Management and Practice of Low Visual
trial frame) and (b) 60 mm (typical for a refracting unit). Acuity. London: Association of British Dispensing Opticians
DRASDO, N. and MURRAY, I.J. (1978) A pilot study on the use of
visual field expanders. Br. J. Physiol. Optics, 32, 22-29
PAYE, E.E. (1976) Clinical Low Vision. Boston: Little, Brown
References GARCIA, M., GONZALEZ, C. and PASCUAL, 1. (1995) New matrix
formulation of spectacle magnification using pupil magnifica-
ADAMS, A.J., KAPASH, R.J. and BARKAN, E. (1971) Visual per- tion. 1. High myopia corrected with ophthalmic lenses.
formance and optical properties of Fresnel membrane prisms. Ophthal. Physiol. Opt., 15, 195-205
Am. J. Optom., 48, 289-297 KEATING, M.P. (1982) A matrix formulation of spectacle magni-
AIRY, G.B. (1830) On the spherical aberration of the eye-pieces fication. Ophthal. Physiol. Opt., 2, 145-158 Se
of telescopes. Trans. Camb. Phil. Soc., 3, 1-63, 18 LONG, W. and woo, G. (1986) The spectacle magnification of
BAILEY, I.L. (1978) Measuring the magnifying power of Kepler- focal telescopes. Ophthal. Physiol. Opt., 6, 101-112
ian telescopes. Appl. Optics, 17, 3520-3521 MEHR, E.B. and FREID, A.N. (1975) Low Vision Care. Chicago:
BAILEY, I.L. (1979) A lensometer method for checking tele- Professional Press
scopes. Optom. Monthly, 70, 94-97 OGLE, K.N. (1936) Correction of aniseikonia with ophthalmic
BAILEY, I.L. (198la) The use of fixed-focus stand magnifiers. lenses. J. Am. Opt. Soc., 26, 323-337
Optom. Monthly, 72, 37-39 OGLE, K.N. (1951) Distortion of the image by prisms. J. Opt. Soc.
BAILEY, I.L. (1981b) New method for determining the magnify- Am., 41, 1023-1028
ing power of telescopes. Am. J. Optom. Physiol. Opt., 55, OGLE, K.N. (1952) Distortion of the image by ophthalmic
203-207 prisms. AMA Archs. Ophthal., 47, 121-131
BENNETT, A.G. (1951) Some curious optical systems. IV: prism PELI, E. and SIEGMUND, W.P. (1995) Fiber-optic reading magni-
magnification. Optician, 121, 37-39 fiers for the visually impaired. J. Opt. Soc. Am, A., 12, 2274-
BENNETT, A.G. (1977) Review of ophthalmic standards. Part 11: 2285
Hand and stand magnifiers. Manufact. Opt.- Internat., Feb, PERCIVAL, A.S. (1928) The Prescribing of Spectacles, 3rd edn.
67-73 Bristol: John Wright
BENNETT, A.G. (1977/78) Binocular vision through lenses and RUMNBPY, N.J. (1992) Low vision aids in practice. Optom. Today,
prisms. Optician, 174(4511), 7-11; (4512), 7-12; 21 Sept., 22=2'7
176(4560), 8 RUMNEY, N.J. (1995) Contrast thresholds in low-vision prac-
BENNETT, A.G. (1986) Two simple calculating schemes for use tice. Optician, 210(5531), 24-27
in ophthalmic optics — I. Tracing oblique rays through sys- SWAINE, W. (1933) Some difficulties of ophthalmic lens fitting.
tems including astigmatic surfaces. II. Tracing axial pencils In Proceedings ofthe Optical Congress. London: Hatton Press
through systems including astigmatic surfaces at random WELSH, R.C. (1961) Postoperative-Cataract Spectacle Lenses.
axes. Ophthal. Physiol. Opt., 6, 325-331, 419-429 Miami: Miami Educational Press
BENNETT, A.G. and EDGAR, D.F. (1979/80) Spectacle lens design WESTHEIMER, G. (1954) The design and ophthalmic properties
and performance. Optician, 178(4597), 9-13; (4602), 9-13; of binocular magnification devices. Am. J. Optom., 31,
(4606), 21-26; (4610), 13-15, 20; (4615), 9-11, 15-17; 578-584
179(4), 20-22, 28-30; (9), 13-16, 20-23; (13), 10-11, WHITTAKER, S.G. and LOVIE-KITCHEN, J.E. (1993) Visual re-
15-18; (17), 10-11, 15-18; (23), 30-35; 180(4653), quirements for reading. Optom. Vis. Sci., 70, 154-165
18-25; (4659), 25-28; (4666), 28-31; (4669), 14-22, 42 WHITWELL, A. (1921/22) On the best form of spectacle lenses —
BREWSTER, D. (1813) A Treatise on New Philosophical Instru- XX to XXV. Optn Scient. Instrum. Mkr, 62, 209-213,
ments. Edinburgh: W. Blackwood, and London: J. Murray 311-313, 387-389; 63, 19-21, 143-148, 331-332
BULLIMORE, M.A. and BAILEY, I.L. (1989) Stand magnifiers: an WOO, G.C., LU, C. and WESSEL, J.A. (1995) Estimation of back
evaluation of new optical aids from COIL. Am. J. Optom. Phy- vertex power and magnification of variable focus telescopes.
siol. Opt., 66, 766 Ophthal. Physiol. Opt., 15, 319-325
14
Anisometropia and aniseikonia

Anisometropia: optical difficulties spherical lenses, iso-prism lines are concentric circles
surrounding the optical centre. For example, with a
Anisometropia is a difference in the refractive state of 4.00 D lens the iso-prism lines for 1A and 2A would be
the right and left eyes. Trivial amounts excepted, the circles of radius 2.5 and 5 mm respectively. In all astig-
condition is not common because the two eyes of a pair matic lenses, the iso-prism lines are concentric ellipses,
tend to be generally similar. There is even a tendency, degenerating into straight lines parallel to the axis in
when astigmatism is present, for the right and left cy- the case of a plano-cylinder. The direction of the pris-
linder axes to be symmetrically orientated. matic effect at any point on an elliptical iso-prism line
Prescribing for anisometropia of moderate and high can be found by a simple graphical construction due to
degree presents problems of its own which are made Bennett (1968).
worse by the unwanted side-effects of correcting lenses For spherical lens or surface powers, the concept is
discussed in Chapter 13. Those with particular rele- that of iso-V-prism lines, which join all the points on a
vance to anisometropia are: lens at which the vertical component of the prismatic
effect has a given value. As shown by Bennett, they are
(1) unequal prismatic effects of the right and left lenses, parallel straight lines, obliquely orientated in the pres-
(2) unequal amounts of ocular accommodation theore- ence of an oblique cylinder, though not necessarily par-
tically required, allel to its axis. If such a map is constructed for the two
(3) unequal relative spectacle magnifications. lenses of a pair, inspection will show the extent of
The first two of these need not be considered when con-
common field within which vertical relative prismatic
tact lenses are worn.
effects remain within a specified limit.

Relative prismatic effects

Unequal demand on accommodation

The relationship between ocular and spectacle accom-

In any given direction of gaze, the intersection of the
modation when a distance correcting lens is used in
visual axis with the back surface of the lens is called
near vision was discussed in Chapter 7. It was shown
the visual point. The difference between the prismatic ef-
that the ocular accommodation demanded varies with
fects at the right and left visual points is the relative
the spectacle refraction, other factors remaining equal.
prismatic effect. To obtain single vision, this unwanted
In cases of anisometropia, it follows that the ocular ac-
prismatic difference must be overcome by adjustments
commodation theoretically required is different for the
to the ocular rotations.
two eyes.
For the purposes of discussion, relative prismatic el-
A good idea of the magnitude of this effect can be ob-
fects are usually resolved into horizontal and vertical
tained from a study of Figure 7.6. The change in ocular
components. The latter is the more troublesome one.
accommodation per dioptre of anisometropia is seen to
Few subjects can maintain single vision with a plano
vary between extremes of 0.05D in high myopia to
prism over 4 base down placed before one eye or tolerate
about 0.12 D in high hypermetropia. A typical value is
half this amount for a prolonged period.
in the neighbourhood of 0.07—0.08 D. It would thus
For spherical lens or surface powers, the approximate
take about 3 D of anisometropia to make a difference of
prismatic effects can be found from Prentice’s rule. The
0.25 Din the accommodative demand on the two eyes.
prismatic effect of a cylinder is invariably exerted in a di-
rection perpendicular to its axis. If this is oblique, the
prismatic effect has both horizontal and vertical compo-
nents. Unequal retinal image sizes
Prismatic effects over the whole area of a lens can be
depicted graphically by iso-prism lines. These are lines The sharp retinal images in a corrected pair of eyes will
joining all the points on a lens at which the prismatic be of equal size if the relative spectacle magnification is
effect has a given value, its direction being ignored. In the same for each. Unfortunately, as pointed out on
260 Anisometropia and aniseikonia

page 236, this quantity cannot be determined without a will initially be assumed to be thin, so that the shape
knowledge of the eye’s equivalent power or its axial factor of magnification becomes unity.
length. There are two approaches to evaluating the difference
Some useful generalizations can nevertheless be de- in image sizes between two eyes. The first is based on de-
duced from the analysis of 67 cases of anisometropia riving useful approximations from the formula for rela-
ranging from 2 to over 15 D, made by Sorsby et al. tive spectacle magnification. The second is based on the
(1962). The ocular dimensions of each subject were retinal image size ratio (RISR), a term introduced by
measured and separate tabulations made of the differ- Obstfeldt (1978).
ence between the right and left corneal power, depth of
anterior chamber, crystalline lens power and axial
length — the last of these both in millimetres and diop- Axial anisometropia
tres. From these data it emerged that axial length was In axial ametropia the eye is assumed to have the ‘stan-
the predominant causative factor. There was no sub- dard’ power F,. Hence, when F, is substituted for F. in
stantial difference between hypermetropic and myopic equation (13.24) for relative spectacle magnification, it
anisometropia. In 49 cases it contributed at least 70% becomes
to the total anisometropia and at least 90% in 23 cases. F
In only two cases did it make no significant contribution RSM =
whatever. No differences greater than 2.0 D in corneal F. + FE, —dF4F,
power were found and only 10 greater than 1.0 D. In = nia (14.1)
45 of the cases, the difference ranged from zero to liv vhs je al a dF)
0.5 D. Differences in the crystalline lens power covered
This expression can be simplified if the position of the
a wider range, up to approximately 4 D, but even so the
spectacle point is now defined by its distance x from the
difference did not exceed 1.0 D in 50 of the subjects. In
anterior focal plane of the eye, so that
the 53 subjects with anisometropia between 2.0 and
5.0 D, differences in lenticular or corneal power were 1 —dF,
x = —f, -d=1/F,
—d =——— 14.2
the main cause in only four cases each. Similar findings Fy oe
were reported by Garner et al. (1992) for Malay chil- (A similar use of the symbol x is used in Newton's equa-
dren, the 2D weaker lens partially compensating for tion.) Hence, by substitution in equation (14.1)
the 3mm longer axial length in their myopic sample
F 1
(mean refractive error —6 D + 1.8 D). The myopes also RS Mii . =
showed a slightly flatter corneal radius than the emme- Pea ha Wein
tropes but this was not statistically significant. 1 = xr, (ein m) (14.3)
Differences in corneal and lens powers are the main
Thus, given purely axial anisometropia, the difference in
components of refractive anisometropia, since the ante-
relative spectacle magnification between the two eyes is
rior chamber depth plays only a negligible part in this
(—xAF{,), where AF’, is the anisometropia in terms of
context. In routine ophthalmic practice, the corneal
spectacle refraction. The percentage difference in RSM
powers can readily be determined by keratometry, but
is therefore, with x now in millimetres,
the contribution of the lens can only be conjectured
within the guidelines already indicated. Thus most % size difference + 0.1xAF,, (x in mm) (14.4)
cases of natural anisometropia are axial. Surgically in-
For example, with the spectacle plane 2 mm closer to the
duced anisometropia, however, will be refractive. Uni-
eye than its anterior focal point, the retinal image size
lateral aphakia was both the most common cause and
difference would be approximately 0.2% per dioptre of
gave the greatest amount of difference, but the use of anisometropia. The size difference and AF, must both
intraocular lenses has minimized its occurrence, be taken as right minus left.
though it may still arise as a result of trauma. Smaller When the spectacle point is in the eye’s anterior focal
amounts of refractive anisometropia may be met when plane, x = O and the relative spectacle magnification be-
intra-ocular implants are of the incorrect power, or comes unity for all degrees of axial ametropia (Knapp’s
after refractive surgery (see page 417), especially in the law). A graphical demonstration of Knapp's law is
period between the operations on the first and second given by Figure 14.1, showing a hypothetical ray
eyes. Applegate and Howland (1993) discuss the impli- (dotted line) from a distant object Q passing undeviated
cations of the change in retinal image size after refrac- through the optical centre of a thin correcting lens
tive surgery on visual acuity. placed at the eye’s anterior principal focus F,. After re-
In cases where both axial and refractive elements are fraction by the eye, the ray proceeds parallel to the opti-
operative, the percentage size difference can be calcu- cal axis, so that the height of the sharp image is
lated from each of the two expressions (14.4) and independent of the position of the retina. If the eye
(14.6). The correct value can reasonably be assumed to were emmetropic and no correction in use, the ray RP
lie within these limits at a point corresponding to the falling on the eye’s principal point would be the one re-
relative weight of the axial and refractive elements. fracted to the image point Q/, on the retina. If, however,
Although the division is too schematic, it is helpful in the eye was myopic and had a greater axial length, the
this context to consider ametropia as either axial or re- ray TU incident on the minus correcting lens would be
fractive, so that the range of possibilities can be ex- deviated to the eye’s principal point P and from there to
plored. In the following discussion, the spectacle lenses the image point Q’ on the retina of the myopic eye. All
 Unequal retinal image sizes 261

Figure 14.1. Spectacle magnification and Knapp’s law in

axial myopia. If the spectacle lens is placed in the anterior focal
plane of the eye, the resulting image height is independent of
axial length. Figure 14.2. Spectacle magnification in refractive
ametropia.

three incident rays in the diagram are parallel because

they originate from the same distant object point. A si- the amounts. Laird (1991) showed that a model ellipti-
milar ray construction could be drawn for the axially cal scleral contour almost exactly predicted the experi-
hypermetropic eye. mental differences in aniseikonia in spectacle and
The shape factor of the actual lenses, given by equa- contact lens corrected anisometropic myopes. It has
tion (13.4), should now be taken into account. If they also been argued in another context (see page 272) that
are of minus power, the small centre thickness and image sizes in the uncorrected eyes should be left undis-
rather shallow front surface curvature will in many turbed.
cases make the shape factor very nearly the same for
both. With plus lenses, the difference would tend to be
Refractive anisometropia
larger. In terms of percentage magnification, the shape
factor S is reducible to As shown in Figure 14.2, the situation in refractive ani-
sometropia is the reverse. In this case the two eyes of a
S% ~0.1(t/n)F, (t in mm) (14.5) pair are of the same length, so that the retinal image
point Q’ could be taken to apply to both, irrespective of
For example, given “t=4.8mm, n=1.498 and
refractive error. If a ray from Q’ were traced backwards
F, =+9.00D, the value of S would be approximately
through the principal point P, it would emerge from the
2.9% The value would need to be calculated for each
eye in the direction PU and meet the spectacle plane at
lens separately. Small percentage magnifications can
the same height y for both lenses. Since they are of dif-
simply be added or subtracted without significant error.
ferent power, however, they exert a different prismatic
To summarize: the right and left retinal images in un-
effect and so the ray paths in object space would differ,
corrected axial anisometropia are unequal in size, being
as shown in the diagram. It follows, therefore, that the
proportional to axial length, but can be made approxi-
same point in object space cannot give rise to equal ret-
mately equal by spectacle lenses placed close to the
inal images unless the separation d is reduced to zero.
eyes’ anterior focal plane. The shape factor may need
On the assumption of thin lenses, the only component
consideration.
of relative spectacle magnification applying to refractive
It would be wrong to conclude from this that contact
ametropia is the ametropia factor A, given by equation
lenses, which make little alteration to retinal image
(13.27) as
sizes, are necessarily inferior to spectacles in this refrac-
tive condition. They have the merit of causing little of Ax1l+dk_ (din m)
the induced prismatic effects in oblique vision associated which gives
with spectacles. Moreover, it is open to question
Percentage
whether equality of retinal image sizes is the right aim =(.1ldAK (din mm) (14.6)
to pursue. Unequal density or spacing of retinal recep- size difference
tors, which may result from a difference in axial lengths, where AK is the anisometropia in terms of ocular refrac-
could partly or wholly offset the effect of unequal image tion. For example, if d= 12 mm, the retinal image size
sizes. Thus although in spectacle corrected anisometro- difference is approximately 1.2% per dioptre of ocular
pia, the image sizes in the two eyes will be physically si- anisometropia. The shape factor may again need consid-
milar, the possibly increased retinal receptor spacing in eration. As before, the size difference and AK must both
the longer, more myopic eye may mean that this eye's be taken as right minus left.
image is interpreted as being smaller than the physical
dimensions would predict. Contact lens correction
Retinal image size ratio
would leave the more myopic eye’s image physically
larger and hence physiologically more similar to that in Obstfeld (1978) defined the retinal image size ratio,
the less myopic eye. Support for this view is given in RISR, as:
the paper by Winn et al. (1988). Despite the axial ani-
Relative spectacle magnification for right eye
sometropia of the 18 subjects examined, each showed aS Ree : 5
Relative spectacle magnification for left eye
less aniseikonia with a contact lens correction than
with spectacles. A synoptophore was used to measure
(14.7)
262 Anisometropia and aniseikonia

which, from equation (13.24), simplifies to

Pont se Fol Fe _ Sr
RUSS —% (14.8)
For
spR + Pop Gai spR gpher ool panic a sapere 26

ee
V7 spectacle lenses
In axial ametropia, the eye is assumed to have the = MLA LE VAL
standard power F,,, so if the vertex distance is the same Y=} VMI OI).
for the two eyes, expression (14.8) reduces to:

eet 4s
af IF! OF.
RISR = Pett Fo = Mootle
Sp
SR (14.9) mz; MI
Fat UAE eB Sk
Alternatively, equation (13.26) for RSM may be em-
o
(%)
increase
Percentage
ployed to give the RISR: CEE
; kp Sp C a e l
ApERSa — (1
a aa
am dKp )
Ris Re KiSy
AgE;S, (1 ae dK; )
==20 == 6) wae 2 —8 —4
The ametropia factor A can, by substitution and ma- Previous spectacle correction on
nipulation of the vergence effectivity formula (equation
2.11), be shown to equal the power factor P of spectacle Figure 14.3. Percentage increase in the retinal image size in
magnification and also the ratio K/ Fey — see Exercise the aphakic eye corrected by spectacle and contact lenses. The
graph indicates the possible spread of values.
13.28. Hence

PrSgky —SMp ~ kp
RUS eee = 14.10)
PLSik, SMR ky, |
and 1.18
KR. "spl y Kr
1.16
EX (14.11) 1.14
Ki. Fook ky, St
1en2
In refractive anisometropia, the eye is of standard 1.10
length so that the elongation factor kp/k;, is unity, 1.08
whence equation (14.10) becomes simply the ratio of 1.06
the spectacle magnifications. 1.04
1.02
Cant.) ~B
(post.)
1.00
C (post.) 0.98
0.96
Unilateral aphakia implant
with
Magnificati
+ 0.94
0.92
Unilateral aphakia can be regarded as an extreme form
(ener jae ae 0.90
of refractive anisometropia in which single binocular -8 -6 -4 -2 O° +2 +4 +6 =48
vision is impossible if a spectacle correction is worn.
Pre-aphakic spectacle correction (D)
The insuperable obstacle is the great increase in the
size of the retinal image in the aphakic eye, often ex- Figure 14.4. Graphs illustrating the magnification of the
ceeding 30%. When contact lenses are worn, this in- retinal image in the pseudophakic eye relative to the pre-
crease is reduced to the order of 10% in cases where aphakic state: A, implant giving full correction; B, implant
requiring pre-aphakic spectacle correction; C, implant
the refractive error of the pre-aphakic eye was small.
requiring —2.00 D addition to pre-aphakic spectacle correction.
A general comparison is shown in Figure 14.3, which Ant. and Post. refer to anterior and posterior chamber
shows the increase in the retinal image size in the implants.
aphakic eye in comparison with its pre-aphakic state
with a spectacle correction in use. A typical form and
thickness were assumed for each lens so that the shape the two eyes may be small enough to permit single bin-
factor of magnification could be taken into account. ocular vision.
The graph is based on calculations covering a wide Intra-ocular lenses, described on pages 224-226,
range of possible combinations of the eye’s optical di- open up wider possibilities for single binocular vision in
mensions. Because of these variables there is a surpris- unilateral aphakia. The relative spectacle magnification
ing spread in the calculated figures for spectacle-lens RSM compares the image size in the pseudophakic eye
corrections. The black line near the centre of this band with that in the schematic emmetropic eye. Though
gives the results for eyes with the Gullstrand—Emsley this is a useful guide, it may be better to know the mag-
dioptric system. With contact lenses, the effect on the nification in comparison with the patient’s own pre-
previous retinal image size varies appreciably with the aphakic eye, assumed to be corrected when necessary
pre-aphakic spectacle refraction, but the possible spread by spectacles. Figure 14.4 presents a general picture
is much narrower. The lowest increase in size occurs based on theoretical calculations. It covers spherical re-
when the eye was previously strongly hypermetropic. fractive errors in the pre-aphakic eye ranging from
Within this refractive range, the size difference between —8.00 to +8.00 D.
 Prescribing for anisometropia 265

Three different aims of correction (denoted by A, B test usually works well since it is independent of a differ-
and C) have been considered and two separate graph ence in acuity between the two eyes. Slight amblyopia
lines given for each, one relating to anterior-chamber will prevent an acuity balance with black figures on a
and the other to posterior-chamber implants. The pair white ground, though it is possible to confirm that the
marked A refer to implants intended to neutralize any addition of extra positive power blurs both eyes. Where
previous spherical ametropia. When this course is fol- slight amblyopia is present, the inability to read small
lowed, it will be seen that the magnification varies con- letters on a binocularity or suppression test, such as
siderably with the previous spectacle correction. The that illustrated in Figure 10.13(b), may indicate insuffi-
lines marked B refer to implants intended to leave the cient acuity rather than true suppression. Reduction of
patient requiring the same spherical correction as pre- the anisometropia to that indicated by monocular find-
viously. This course leads to a magnification of about ings or to equal spherical powers often results in a disap-
4% for anterior implants and about 2.5% for posterior pearance of the test characters in the field of view of
implants, irrespective of the previous spectacle correc- the worse eye. This may be used to show the patient
tion. The lines marked C refer to implants designed to the benefits of the full refractive correction. The patient
leave the patient needing a —2.00 D addition to the pre- should also be told that when the better eye is shut,
vious spectacle correction. This technique, aimed at vision in the poorer eye will seem blurred because of
avoiding any appreciable change in the retinal image the over-action of the focusing muscles; the idea is to
size, is seen from the graph to be well founded. give the maximum benefit with both eyes open.
All the graphs are based on eyes of average dimen-
sions with a crystalline lens (assumed thin) of power
+20 D, placed at 6 mm from the corneal vertex, the ap- Prescribing
proximate mean position of the principal points of the
The amblyopic patient
real lens. The implant, also regarded as thin, was
placed at 3 mm from the corneal vertex if in the anterior Anisometropic amblyopia is a type of refractive am-
chamber and at 5 mm from it if in the posterior cham- blyopia, and has been discussed on page 42. If the child
ber. It would need a variation of about +5 D in the lens is young enough and the acuity not worse than 6/60
power to alter the magnification by +1%. Corneal (20/200) so that there is a chance of improving it, a
power variations have even less significance. Changes full anisometropic correction should be provided for
in the form of the implant have a slight effect. The mag- constant wear, coupled with part-time occlusion of the
nification may be reduced by up to 1% or so (e.g. from better eye. The relative prismatic effects when looking
4 to 3%) by incorporating the whole of the power in through the marginal areas of the lenses may cause sup-
the back surface of the implant lens. pression, thus preventing stimulation of the weaker
For simplicity, the calculations for Figure 14.4 as- eye's macula. This may be avoided if the patient wears
sumed the corneal radius to be unchanged by surgery. a contact-lens correction. Although the practitioner
If predictable, any such changes should be taken into usually cannot ascertain how this affects retinal image
account when determining the necessary power of the sizes, it does appear to assist the improvement in acuity
implant. The magnification indicated by Figure 14.4. (Edwards, 1980). In general, soft lenses give better re-
would be little affected. sults than rigid ones. Once the acuity has improved,
the patient will probably prefer to wear the full anisome-
tropic correction, especially for critical vision.
If the patient is over 10 years old, with the acuity less
Prescribing for anisometropia than 6/60 (20/200) or the anisometropia more than
about 5D, it is probably not worth trying to improve
Refraction of the anisometropic patient the acuity. The amblyopia will cause no symptoms and
While a cycloplegic refraction may be needed or neces- a refractive correction will be needed only if the better
sary, a normal routine refractive examination will eye requires it. Protective lenses are essential in these
work satisfactorily with many anisometropic patients, circumstances. Even if a spectacle correction is unlikely
provided that the corrected acuities are similar. The to be needed in the future, the patient or the parents
ocular dominance is likely to be strong, so that the should be advised of the possible need for eye protection
Humphriss fogging technique will probably not work in hazardous situations. They should also be advised
for the refraction of the weaker eye. Monocular refrac- that having only one good eye will not cause it to dete-
tion in a young patient with anisometropic hyper- riorate through ‘having to work harder’ or ‘extra
metropia often leads to an under-estimate of the ani- strain’.
sometropia because the more ametropic eye is often
slightly amblyopic and accommodation goes into spasm Anisometropia without significant amblyopia
in an effort to see more clearly. Prescribing these find-
ings will result im the more hypermetropic eye re- The presence of even several dioptres of anisometropia
maining under-corrected. in later years does not necessarily imply that there was
Static, Barrett or dynamic retinoscopy should give a a significant refractive difference in infancy, when the
good indication of the anisometropia, which can be con- development of vision is at its most rapid and critical
firmed subjectively under binocular conditions. Either stage.
the Turville infinity balance septum technique or disso- It is thus possible for a patient to have one clinically
ciation by polarization may be used. The bichromatic emmetropic eye, while the other is moderately hyperme-
264 Anisometropia and aniseikonia

tropic, myopic or astigmatic. If the patient has merely are the same as those due to single-vision lenses of the
been referred because of a screening test, there may be same distance prescription. To simplify the determina-
no need to prescribe the correction unless the patient tion of these effects, many tables and graphs have been
feels that it produces a significant improvement in com- produced by lens manufacturers and writers on
fort or clarity. If, however, the better eye needs a refrac- ophthalmic lenses. It should be noted that strong cylin-
tive correction, the anisometropic correction should be ders at oblique axes, on their own, can generate an un-
tried, especially if the binocularity test shows little sup- desirable amount of horizontal prism at the near visual
pression. A partial correction of the anisometropia may points.
be more readily accepted by the patient initially. If the patient has worn a correction for several Years,
he may have adapted to relative prismatic effects. Thus,
Allen (1974) found a high degree of compensation for
Anisometropia in the presbyopic patient oculo-motor imbalance in a study of 20 anisometropes.°
Transition from all-purpose single-vision lenses to bifo-
Many patients come for their first eye examination with
cals should be uneventful, provided that the vertical im-
near vision difficulties at the onset of presbyopia. Since
balance in near vision is small or compensated when
the patient has probably relied for several years on one
examined with typically depressed gaze through the ex-
eye, the more ametropic eye being out of focus, some
isting correction. Neither the refractor head nor re-
practitioners would advise giving an equal correction
duced-aperture trial case lenses permit a sufficient
to both eyes to avoid upsetting the habitual arrange-
angle of depression for this purpose.
ment. It is generally worth trying to correct the ani-
sometropia if there is only 2—3D difference of either
A patient who has rarely worn spectacles or whose
spherical or astigmatic power, provided that the cy- anisometropia is increasing, possibly because of nuclear
linder axes are close to horizontal or vertical. However,
sclerosis of the crystalline lens, may need vertical pris-
a strong oblique cylinder before one eye will almost matic relief in the near portion of bifocals. Several spe-
certainly cause greater symptoms than benefits and is cial types of bifocals have been designed to fill this
probably best omitted. Bilateral astigmatic corrections need. Some permit the near optical centres to be placed
should be tried since they may gradually give improved at any specified position. Others enable the vertical pris-
vision, but a partial prescription would be sensible initi- matic effects at the near visual points to be equalized by
ally. Again, if the binocularity test shows significant a compensating prism incorporated in the near portion
suppression, a balancing lens for the poorer eye is prob- of one or both lenses. The dividing lines of all such
ably advisable. An indication of the value of the full lenses are somewhat conspicuous.
correction may be given by holding the appropriate sup- In suitable cases, conventional bifocal types can be
plementary lens in front of the poorer eye with the re- used. One possibility is to prescribe solid (one-piece) bifo-
duced correction in position. cals with different segment diameters, for example, 45
If the anisometropic correction is prescribed, the with 38, 38 with 28 or even 38 with 22mm. The
patient should be told that he will be using his two eyes amount of vertical prism compensation in prism dioptres
fully together for the first time for years and conse- is half the difference in centimetres of the segment dia-
quently it may take a few days or weeks to become ac- meters multiplied by the reading addition. The smaller
customed to the lenses and gain the resulting benefits. segment is prescribed for the eye with the greater
Should this not occur, a ‘balance’ lens can then be pre- myopia or smaller amount of hypermetropia in the verti-
scribed. cal meridian.
The occasional patient has one emmetropic and one Another possibility is to use fused or hard resin bifo-
moderately myopic eye. One eye may therefore be used cals with straight-top segments and to work a compen-
for distance and the other for near vision. This type of sating prism over the entire lower half of one lens by
imbalance is sometimes copied for contact-lens wearers the bi-prism (slab-off) construction. ‘Executive’-type
to avoid a bifocal correction. In the pre-presbyopic solid bifocals can be treated similarly. Alternatively,
patient, dynamic retinoscopy or the polarized bichro- conventional bifocals to be worn for brief periods of
matic test should be used to check which eye is in focus near vision can be supplemented by single vision lenses
in near vision since, surprisingly, it is occasionally the for prolonged close work.
emmetropic eye. For prolonged viewing, the proper bin- The effects of vertical centration should be considered
ocular correction is likely to be preferred. when dispensing all anisometropic prescriptions. The
distance refraction is normally measured with the
lenses centred to the visual axes, but the primary line
Anisometropia and bifocals of sight often passes 2-5 mm above the optical centres
Unlike wearers of single-vision lenses, who can reduce
of the prescribed spectacle lenses. Thus, a person for
whom the refractive findings are
unwanted prismatic effects by head movements to bring
the visual points much closer to the optical centres, bi-
R plano L+3.00DS_ 1A base down
focal wearers cannot take advantage of this manoeuvre
in near vision. They are obliged to look through the seg-
ments, the near visual points having a mean position
some 8-10 mm below and 2 mm inwards from the dis- * After as little as 24 hours of wear, Henson and Dharamshi
(1982) found marked oculo-motor adaptations to 3D of
tance optical centres. With conventional types of bifo- induced anisometropia. Adaptation to induced prismatic effects
cals, relative prismatic effects at the near visual points is further discussed. See also page 181.
 Aniseikonia 265

may well need no prismatic help in the spectacles. The produce the specified magnification, as well as the sub-
prism indicated during the refraction procedure may sequent manufacture of the lenses. (For a full account
have been merely to correct a compensating hetero- of the theoretical and experimental bases, see Ogle,
phoria induced by habitually viewing above the optical 1950.)
centres of spectacle lenses.
In general, a prescribed vertical prism has its nominal
effect only at the point where it is intended to be meas-
ured. In British Standards this is called the centration Size lenses
point and in US Standards the major reference point. At
Lenses designed for the investigation or correction of
other points above or below it, the effect of the prism is
aniseikonia are usually called size lenses. Afocal size
modified by the relative prismatic effect due to the ani-
lenses are of two main types. Those giving overall mag-
sometropia.
nification, that is, the same in all meridians, are of me-
For example, given the above prescription with the
niscus form, an afocal meniscus lens acting as a solid
prism included, the actual effect would be approximately
Galilean telescope. Such a lens possesses spectacle mag-
2.5A base down L at 5mm above the centration point
nification by virtue of its shape factor, even though the
and 0.5A base up L at 5 mm below it.
power factor is zero. As expected, the use of higher re-
With conventional bifocals, another method of redu-
fractive indices than standard crown glass or resin will
cing the vertical prismatic imbalance at the near visual
result in thinner lenses or flatter front surfaces — see
points is to order the distance optical centres to be
Exercise 14.8 or Stephens and Polasky (1991) who
placed near the dividing line instead of the usual 5—
have published nomograms relating magnification,
6mm above it. Thus, with 3 D of vértical anisometropia
thickness and front surface power for various refractive
the relative prismatic effect at the near visual points
indices. If the spherical surfaces are replaced by cylind-
would be reduced by 1.5-1.8A. Unfortunately, there
rical surfaces with their axes parallel, the result is an
would now be an opposite imbalance of this same
afocal meridional size lens with its magnification in the
amount at the normal optical centre level, but this expe-
direction perpendicular to the cylinder axes.
dient is worth consideration in suitable cases.
Great care is required in manufacturing these bi-cy-
lindrical lenses to keep the two axes in register, because
the afocal property of the lens depends on their exact
Aniseikonia ; alignment. If there is an error, the magnification may
not be appreciably affected, but the lens will exhibit an
Introduction astigmatic effect arising from the obliquely crossed cy-
linders. Surprisingly enough at first sight, the axis direc-
Aniseikonia, a term denoting inequality of image sizes,
tion of the unwanted cylinder is approximately at 45°
is the name given to anomalies of binocular space per-
to the meridian of magnification.
ception which can be corrected or alleviated by altering
The numbering of afocal size lenses denotes the spec-
the relative dimensions of the right and left retinal
tacle magnification expressed as a percentage, either
images. Fortunately, no knowledge of their actual di-
overall or meridional as the case may be. Thus, if m is
mensions is required and, in any case, aniseikonia may
the percentage magnification and M the corresponding
have other causes. For example, the relative distribution
spectacle magnification,
of retinal receptors is a possible source. The larger
globe of the moderate to high myope may result in a m= 100 (M—1) (14.12)
larger spacing between receptors, and the converse and
may apply to a small hypermetropic eye. Space percep-
M=1+m/100 (14.13)
tion could thereby be affected if interpretation of retinal
image size is based on the number of receptors stimu- By convention, the orientation of a meridional magni-
lated. Stretching of the retina following treatment for a fication is specified as in the example 2% x 30°, indicat-
detachment has been found to result in very marked ing that the direction of the magnification is along the
aniseikonia. 120° meridian.
The pioneer work in this field was carried out at the Provided that they are small, percentage magnifica-
Dartmouth Eye Institute, New Hampshire, USA by a tions can be regarded as additive. For example, a 2%
large research team. Basic principles were established and a 4% overall size lens in combination could be
and an instrument known as a space eikonometer was taken as equivalent to a single 6% lens. Strictly, the
developed to facilitate clinical prescribing. On the prac- spectacle magnifications are 1.02 and 1.04, giving a
tical side, the American Optical Company produced a product of 1.0608 or a magnification of 6.08%.
table model of the space eikonometer suitable for clinical If an afocal size lens is placed with its convex surface
use and created facilities for the execution of prescrip- next to the eye, its effect is to diminish the retinal
tion orders. This service included the computation of image size. Experiment confirms that increasing the ret-
the surface powers and lens thicknesses required to inal image size in one eye has the same apparent effect
as a corresponding reduction in the other eye. The cru-
cial quantity is evidently the ratio of the right and left
image sizes.
“Including (in alphabetical order) Adelbert Ames Jr, R.E.
Bannon, P. Boeder, H. Burian, G.H. Gliddon, W.B. Lancaster Because of this it is possible, as well as convenient for
and K.N. Ogle. calculation, to regard any required magnification as
266 Anisometropia and aniseikonia

placed before the patient’s right eye. Suppose, for exam- If only for cosmetic reasons, spectacle lenses for ani-
ple, that the correction found by test is seikonia are designed so that, where possible, each lens
makes a roughly equal contribution to the required
R27 x90! Lily x 180
image-size adjustment. The magnification ellipse is the
The 1% magnification at axis 180° for the left eye is basis for these subsequent computations.
equivalent to a 1% decrease at axis 180° for the right
eye. Thus, in terms of spectacle (not percentage) magni-
fication, the aniseikonic correction could be written as
Basis of eikonometry
R1.02x 90 by 0.99 x 180
This approach leads to the useful concept of the magnifi- The test object of the space eikonometer
cation ellipse.
Eikonometry depends on the observed effect of various
afocal size lenses on a specially designed test object
The magnification ellipse (Figure 14.6a). It consists of two pairs of vertical cords
or narrow rods, each pair lying in a fronto-parallel
The correction of aniseikonia may require the relative plane. Between them, in another such plane, is an ar-
size of one retinal image to be magnified or diminished rangement of three cords forming a cross with its limbs
by two different amounts in mutually perpendicular at 45° and 135° together with a third vertical cord
meridians, the orientation of which must also be speci- through the centre of the cross. The test object is
fied. There are thus three parameters to be determined. viewed against a plain black ground through an aper-
Figure 14.5, referring to the right eye, represents a ture which masks the extremities of all the cords,
circle which has been magnified by approximately thereby eliminating as far as possible extraneous clues
100% at axis 25° and 40% at axis 115°. The resulting to their location. Figure 14.6(b)-(e) illustrates the effects
figure is the magnification ellipse. Because of the obli- produced when an afocal meridional size lens is placed
quity a scissors effect is introduced: the horizontal and before a normal subject's right eye so as to magnify the
vertical radii of the circle, OH and OV, are transformed retinal image in the meridian stated. In all these dia-
into the oblique lines OH’ and OV’ — both tilted towards grams the arrow indicates the direction in which the
the meridian of higher magnification (115°).
subject is looking.
In practice, a direct determination of oblique magnifi-
cations and their orientation is not feasible. It therefore (b) R Overall magnification
becomes necessary to determine the magnification el- The right-hand cord of each vertical pair apparently
lipse by a different set of three parameters. The most recedes but the appearance of the cross is
amenable to clinical procedures are the horizontal mag- unchanged.
nification (OH’/OH), the vertical magnification (OV’/
OV) and the vertical declination angle (VOV’). All three
can normally be measured subjectively with a single
piece of apparatus known as an eikonometer.
<- <

(a) (b)

(c) (d)

<<

(e)

Figure 14.6. The space eikonometer: various appearances of

Figure 14.5. The magnification ellipse. The central circle is test object when viewed in the direction of the arrow through
magnified by 2.0 axis 25 and 1.4 ax 115. 4, is the declination afocal size lens. (a) Normal appearance, (b) R overall, (c) R
angle or tilt of the originally vertical meridian. horizontal (x 90°), (d) R vertical (x 180°), (e) R oblique (x45°).
 Basis ofeikonometry 267

(c) R Horizontal magnification (axis 90°)

The right-hand cord of each vertical pair apparently
recedes and the cross appears to have pivoted about
a vertical axis, making its right side further away.
(d) R Vertical magnification (axis 180° )
The position of the vertical cords appears
unchanged but the cross appears to have pivoted
about a vertical axis, making its left side farther
away.
(e) R Oblique magnification (axis 45° ) Figure 14.8. Effect of a vertical magnification of the right
The cross appears to have rotated about a horizontal eye's image of the cross.
axis, its top receding from the observer.

The effects described above are those caused by mag- The percentage increase mis 100 (M — 1), so that
nifying the right eye's retinal image. It follows, there- m% = 100 e/d (14.14)
fore, that if the patient experiences any such effects
without size lenses, the relative size of the right eye’s ret- It can also be seen from the diagram that e = 2ptan o.
inal image in the appropriate meridian should be re- Thus
duced. The same argument applies to any effect seen in
200p tan
reverse, indicating that the relative size of the left retinal m%Oa =a= 7 (14.15)
image needs to be reduced. P
By considering the effect of a horizontal image-size
disparity on the longitudinal horopter, Ogle arrived at a
theoretical relationship equivalent to

Horizontal and vertical magnifications _ 200p tan

m% = (14.16)
For brevity, an apparent rotation of the cross about a cet ES ptan
vertical axis will be called lateral and rotation about a Equations (14.15) and (14.16) yield very similar nu-
horizontal axis frontal. merical results, since d is usually large in relation to p.
The effect of a horizontal magnification of the right In the following brief discussion of vertical magnifica-
eye's retinal image can be explained using Figure 14.7. tion, consideration is limited to the effect produced
Suppose two vertical rods are placed obliquely at S and when the oblique cross of the eikonometer test object is
T on the primary lines of the eyes: if the angle they sub- viewed by a normal observer through afocal size lenses.
tend at the left nodal point is 9, a larger angle M0 will Other forms of test objects may give rise to different
be subtended at the right eye. It can therefore be effects.
argued that the effect on a normal subject of increasing As already stated, a horizontal magnification of one
the horizontal size of one retinal image is to produce an retinal image makes the cross appear to have rotated
apparent lateral rotation o of a fronto-parallel plane. about a vertical axis in one direction, whereas a vertical
From the diagram, magnification in the same eye will produce an apparent
tan M6 = 2p/d rotation in the opposite direction. In other words, a ver-
tical magnification in one eye has the same effect as a
and horizontal magnification in the fellow eye.
An explanation on geometrical lines can be given as
tan 0 = 2p(d +e)
follows. In Figure 14.8, L is the upper part of the cross
where 2p is the inter-ocular distance, d the distance from seen directly by the left eye and R the cross as it would
T to the left nodal point N; and (d+e) the distance appear to the right eye monocularly when magnified by
from S to the right nodal point Np. a factor M in the vertical meridian. D; and E;, are
Since 0 and M are both small we can put points on the limbs of cross L at the same height h from
the centre line and Dg and Ep are the corresponding
tan M@/tan 0 = M = (d+e)/d
points on cross R at a height Mh from the centre line.
In the single binocular percept, the two points of inter-
section O; and Og would certainly be fused, but since
there is nothing to identify any other points on any of
the lines, fusion is most likely to occur between points
at the same level. Thus, D;, and Ej, would be fused with
Fp and Gr at the same height h. From the geometry of
the figure it can be seen that D,E, =2 and that
FpGp = 2h/M, the ratio of the two widths being 1/M
for all values of h. The cross thus appears to have rotated
laterally so as to present (in this case) a smaller angle
fh d to the right eye.
The relationship between horizontal image
It follows from the above that the respective widths at
Figure 14.7.
magnification M and apparent tilt ¢ of a fronto-parallel plane. any height h would subtend angles 0, and 0, at the
268 Anisometropia and aniseikonia

In Figure 14.9, the initial right and left retinal images

are represented schematically by rectangles having the
dimensions a,b,c and d as shown. The ratio of the two
image sizes (right divided by left) in the horizontal
meridian will be denoted by H and in the vertical merid-
ian by V. Initially
Hab and VY — cad
b
Figure 14.9. Letter symbols denoting the dimensions of the so that .
right and left retinal images. H/V = ad/be
If the right eye’s retinal image is now magnified by M
right and left nodal points such that
vertically, dimension c becomes Mc and
Op /91, = 1/M
H/V = ad/Mbc
This is the inverse relationship between the same angles If, instead, the left retinal image is magnified by M hori-
in Figure 14.7 in which the retinal image of the right zontally, dimension b becomes Mb and the ratio remains
eye is magnified by M horizontally. Consequently, equa-
H/V = ad/Mbc
tion (14.15) for the magnitude 9 of the tilt is equally
valid for a vertical magnification, though the apparent Finally, if either retinal image is given an overall magni-
tilt is in the opposite direction. fication, the initial ratio ad/bc is not affected. It will be
It should be noted that the apparent location of the recalled that an overall magnification of one image
paired vertical lines of the eikonometer test object is not does not appear to tilt the cross.
affected because the effect of vertical magnification is
merely to elongate them. Similarly, an overall magnifi-
cation of one retinal image does not give rise to an ap-
Oblique magnifications
parent lateral tilt of the cross because the magnified
image has its limbs in the same orientations as the origi- Figure 14.10 shows an initially vertical line BT of height
nal. h with its base on the median line, tilted
With certain forms of test objects or scenes, an appar- backwards from the observer through the positive (an-
ent lateral tilt may still be observed when one retinal ticlockwise) angle wy. It is now in the position BT’. The
image is magnified vertically. Because it cannot be ex- perpendicular dropped from T’ meets the median line at
plained in the same simple way as the tilt of the oblique G. From the nodal point Np of the observer’s right eye,
cross, it has been called an induced effect. The following a line is drawn through B produced to B’. the point at
consideration of relative image sizes could, perhaps, which it meets the fronto-parallel plane containing GT’.
suggest a basis for a general explanation. Thus, B’T’ is the apparent position of the tilted line

sD eae

hcos ‘

G ql =o
B'

Figure 14.10. Construction for deriving the

relationship between declination angle 6 and
backward tilt W.
 Clinical eikonometry 269

tion error of the patient's own eyes. Thus, a positive

error would be corrected by an oblique magnification
with axes converging downwards so as to produce a
compensating negative error.
From Figure 14.10, a simple theoretical relationship
can be deduced between the angles W and 6. First
GT’=hcosy and GB=hsinw
Next, from the similar triangles in the diagram,
GB'/hsin y = p/d (14.18)
where p can be taken as half the inter-pupillary distance
and d is the distance BM, both regarded as positive. Then
tan 5p = GB’/GT’ = GB’/hcos (14.19)
Finally, by eliminating GB’ from equations (14.18) and
Figure 14.11. Generation of the vertical declination errors
(14.19) we obtain
dp and 6, by means of magnifying meridional size lenses, axes
as shown. tan dp = (p/d) tan (14.20)
It can be seen from this that and dp have the same
projected on to this plane, as seen by the right eye. From sign and that dp would normally be quite small in rela-
the examiner's standpoint, looking at the patient, it tion to W.
makes a positive angle 5p with the vertical, which is To vary the vertical declination angle produced by a
also the case with its retinal image. In the left eye there given meridional size lens it merely needs to be rotated.
would be an equal tilt in the opposite (negative) direc- This is the principle of the declination unit used for
tion. measurement in the space eikonometer. A pair of afocal
If the right and left vertical declination errors, dp and lenses of the same meridional magnification, one before
d,, are in opposite directions — whatever their sizes — each eye, are geared together so as to rotate equally in
their effects are numerically additive. Thus in all cases opposite directions from the zero setting in which both
the vertical declination angle dy of the magnification el- axes are vertical. Symmetry is thus obtained, leaving
lipse is found from relative image dimensions in the horizontal and vertical
meridians undisturbed. The calibration of the unit fol-
Sy = op — Oy, (14517)
é|

lows from the general expression (14.32), giving the re-

lationship between the vertical declination angle of a
Let us now suppose that the line object BT is in its up-
single meridional size lens and the orientation of its
right position, giving rise to a vertical line image on
axis in standard axis notation.
each retina. From Figure 14.5 it is apparent that these
images could be made to tilt as before by the declination
errors inherent in oblique magnification. In the case
under discussion (Figure 14.10) the right eye's retinal Clinical eikonometry
image (from a front view) was tilted anticlockwise and
the left eye’s clockwise. This would be the effect pro-
The AO space eikonometer
duced by a pair of afocal meridional size lenses placed
before the eyes, as shown in Figure 14.11, with their A direct comparison of the right and left visual images
axes symmetrically orientated and converging upwards. can be made with the aid of a stereoscope or synopto-
With these lenses, a normal observer would be expected phore or by presenting a test object to each eye alter-
to see a vertical line or plane as though it were frontally nately in a regular sequence of exposures (Brecher,
tilted with its top away from him. This inference is 1957). A simple test could be constructed by horizontal
borne out by experiment, subject to a surprising reserva- lines placed equidistant above and below a fixation
tion. A plain expanse of wall does appear to be leaning mark. If the lines for the left eye are placed slightly to
with its top farther away, and the floor to run downhill. the left of fixation, those for the right eye to the right,
Nevertheless, the test object of the space eikonometer then any aniseikonia in the vertical meridian should be
behaves differently. The vertical lines should appear to visible as a misalignment of the images for the two
tilt while the cross should remain unaffected. In fact, eyes. Fixation disparity and the precision of vernier
the opposite occurs. The mind refuses to accept that the acuity in peripheral vision limit the success of this
separated vertical lines are tilted. Instead, cyclofusional method. McCormack et al. (1992) found that a similar
movements take place, as a result of which the lines printed test (the New Aniseikonia Test) employing red/
appear vertical and the oblique cross frontally tilted in green anaglyphic dissociation grossly underestimated
the opposite direction to the wall and the floor. In this aniseikonia induced with size lenses. A computer
case, with the axes of the size lenses converging up- screen simulation proved better. Such methods have
wards and 3, positive, the tilt would be towards the ob- their uses, but prescribing for aniseikonia requires a
server. sensitive method of measurement.
Whatever the perceived direction of the frontal tilt, This need was filled by the AO space eikonometer. It
the remedy is to counteract the relative vertical declina- presents the patient with a three-dimensional image of
270 Anisometropia and aniseikonia

the test object shown in Figure 14.6(a), apparently at a each one so that the whole array appears to be in a
distance of about 3 m (10 {t). A compact optical system fronto-parallel plane. The angle of any tilt in this array
for producing variable magnification at axis 90° is posi- is then recorded. This procedure is repeated with the
tioned in front of the patient's right eye and a similar rods set at 45° and 135° in standard axis notation.
unit set at axis 180° before the left eye. Each unit has a From the results of these three settings it is possible to
range from 5% magnification to 5% reduction, but re- construct the aniseikonic ellipse. In clinical practice,
ductions are calibrated to read as relative magnification this procedure would have the great advantage of being
for the opposite eye. In front of these units is the geared readily understood and carried out by patients without
pair of afocal meridional lenses used to determine the the need for prior training. “t
vertical declination angle.
In brief outline, the recommended routine proceeds as
follows. With all three units set at zero, the patient is
asked to say if there is an observable lateral tilt of the
two pairs of vertical rods. If so, a horizontal difference is The aniseikonic correction
indicated and the unit before the right eye is adjusted
until the tilt is corrected. With this horizontal correction
Iseikonic lenses: translation procedure
left in position, the patient’s attention is now directed
to the oblique cross. If this, too, appears laterally tilted Translation of the eikonometer findings into a spectacle
in either direction, it can only be due to a vertical discre- correction incorporating a regular prescription as well
pancy. Accordingly, the unit before the left eye is ad- is an intricate process. One essential step is to determine
justed so as to correct the tilt. Then, with both the magnification ellipse from the given values of the
corrections in place, the patient is asked to report if three parameters. In the main, the following outline is
there is a frontal tilt of the oblique cross. If so, it denotes based on Ogle’s treatment (1950).
that the magnification ellipse is obliquely orientated. Figure 14.12 represents an afocal combination of two
The declination unit is then brought into play and the meridional magnifications, A at axis 0 and B at axis
geared lenses rotated to bring the cross into an upright (90 +90). As in Figure 13.8, the angle measured from
position. The scale reading gives the vertical declination the reference axis 9 to the vertical meridian is denoted
angle of the magnification ellipse. by oy and the corresponding angle to the horizontal
There are, of course, possible complications and diffi- meridian $;;. From any point Q on the vertical meridian
culties arising from anomalous appearances of the test a perpendicular is drawn to the reference axis, meeting
object, the presence of heterophoria, poor stereoscopic it at R. The image Q’ of the point Q is found by making
acuity and other causes. These and other practical OS/OR=B and the perpendicular Q/S/OR=A. The
points are discussed in the manual issued with the in- angle from the reference axis to the meridian OQ’ is de-
strument (American Optical Company, 1951) and in noted by oy. In the vertical meridian, the magnification
the later work by Bannon (1954). My is defined by the ratio OQ'/OQ, which is seen from
the

Simple eikonometers
Another method of eikonometry uses a real test object of
the classic space eikonometer design, made on a conve-
niently reduced scale with movable parts. After the test (90
+ 6)
object has been put out of square, the patient is required
to re-locate the movable elements in what appears to be
their correct position or orientation. Any errors which
are made are shown by graduated scales. They are con-
verted into the three parameters of the magnification el-
lipse by means of the theoretical relationships given by
equations (14.16) and (14.20). Conversion tables can
easily be prepared from these expressions.
A simple portable eikonometer of this type was de-
signed by Hawkeswell (1975). The oblique cross (with-
out the vertical line through its centre) was mounted in
a frame rotatable about horizontal and vertical axes in-
dependently. Narrow rods, one fixed and the other
movable, replaced the front pair of vertical lines, the
rear pair being omitted. A test procedure aided by
tables was also described.
A space eikonometer of simpler design than the AO
model has been described by Remole (1983). A battery
of 11 parallel rods, each separately movable, is viewed
Figure 14.12. Derivation of the parameters of the
by the patient in binocular vision. In the first presenta- magnification ellipse 4, B and 0 from the horizontal and vertical
tion the rods are vertical and the patient has to position magnifications and vertical declination dy.
 The aniseikonic correction 2 = —

triangle OSQ’ to be which, using equation (14.31), reduces to

_ OS/cos by
My ‘ (A — B) tan by
OR/cos oy tan dy ee
B+ Atan* oy
= Bcos oy /cos by
Multiplying throughout by cos” dy then gives
so that
(A — B) sin oy cos dy
Mj, cos* by = B* cos*by (14.21) tan dy =
Asin? by + B cos? by
also

_ O'S/sin b%
Since the denominator differs little from unity, it can be
ignored without serious error, leading to
My OR/sin by
tan dy = (0.01a — 0.01b) sin by cos dy
= Asin oy/sin o)
= 0.005 (a— b) sin 2oy
so that
= 0.005f sin (180 — 20)
Mj sin? by = A’ sin? oy (14.22)
= 0.005f sin 28 (14.32)
Adding equations (14.21)and (14.22) we obtain
Since for small angles
My = A?’ sin? oy + B* cos? dy 23)
The percentage magnification v is now substituted for tan dy = dyrad = by/57.3°
My, as indicated by equation (14.13), while A and B
equation (14.32) may be written as
are similarly replaced by the percentage magnifications
a and b. As a result, My becomes (1 +0.01v)? which dy = 0.29f sin 20 (14.33)
can be taken as (1 + 0.02v). When the other quantities
are similarly treated, the modified equation (14.23) can Division by equation (14.29) then gives
be reduced to
p=b+ (a—b) sin’ 4, (14.24) (an20 = 2 (14.34)
Similarly, the horizontal percentage magnification is The effect of magnifying the image in the right eye by
given by x% in any given meridian is the same as reducing the
h=b+(@=b) sin” oy (14.25) left eye’s image by x% in the same meridian. Hence, a
meridional magnification is regarded as positive if
From Figure 14.12 it can be seen that oy = (90 — 9) placed before the right eye but negative if placed before
and ,, = —9. Then, if these substitutions are made and the letivevies
(a — b) is replaced, following Ogle, by the symbolf, equa- The eikonometer gives dy, together with the horizon-
tions (14.24) and (14.25) become tal magnification h and vertical magnification v ex-
v=b+f cos? 0 (14.26) pressed as

and h RorL% x 90

h=b+f sin’ 0 (427) vy Ror L% x 180

Adding these last two equations gives

These three readings can then be converted as follows
v+h=2b+f=a+b (14.28) into the required mutually perpendicular meridional
magnifications, together with the axis direction 0 appro-
while subtraction gives
priate to a. First, 0 is determined from equation (14.34).
v —h=f(cos*
§— sin? 0) = fcos 20 (14.29) If 20 is found to have a negative value, it is converted
into standard axis notation by adding 180°; for ex-
The vertical declination angle dy is defined by
ample, —124° would become 56°.
Sy = by — by (14.30) The quantity f can now be found by rewriting equa-
tion (14.29) in the form
To eliminate dy we can see from the diagram that
tan oy = (Q’S/OS) and tan >, = QR/OR f = (v—h)/cos 20 (14.35)

so that Then, from equation (14.28)

Q’S/OR
tan oy = (OR/OS )ean by b=4(v+h-f) at axis
8+ 90 (14.36)

= (A/B) tan oy (14.31) and

From a well-known identity, equation (14.30) leads to a=sS(v+h+f) at axis 9 (14.37)

tan dy — tan by As with h and v, positive values of a or b denote magnifi-

tan dy =
1 + tan ${ tan by cation for the right eye, negative values for the left eye.
272. Anisometropia and aniseikonia

Example (1) this means, the two sets of axes can be reconciled. Both
lenses could in theory then be made in bi-toroidal form,
Axis 90: R2% Nite) with the mechanical axes of front and rear surfaces in
Axis 180: L1.5% (v=-—1.5) alignment. If this expedient should lead to a cosmeti-
cally unacceptable solution, the lenses could be made
Sy) A050 in bi-toroidal form with the mechanical axes obliquely
From equation (14.34) crossed. In either case, even a small error in axis align-
ment could give rise to unacceptable errors of effective
k= = DOr = aysic?:
lens power. *
which gives A fully detailed exposition of the entire translation
procedure, with many worked examples, is given in a
C= 76.7,
publication by American Optical Company (1967). So-
From equation (14.35) f= 3.91 lution by matrix methods of magnification problems re-
From equation (14.36) b=—1.71 x 166.7— lating to aniseikonia and its correction have been
From equation (14.37) a=2.20 x 76.7° formulated by Keating (1982).
Rounded off, the required magnification would be Before prescribing iseikonic lenses, it is often consid-
ered advisable to make a preliminary trial by mounting
R222 5% X 77, = Le 5% «67 an afocal size lens in a clip-over fitted to one rim of the
If v=h, equation (14.34) gives 20=90°, thus patient’s spectacles. If this is apparently successful, the
cos 20 = 0 and equation (14.35) becomes indetermin- clip-over is transferred to the opposite rim and the cor-
ate. In this case, f can be obtained by eliminating 20 rection is not prescribed unless decisively rejected when
from equations (14.29) and (14.33), giving over the wrong eye.

jo =e + (3.55y) (14.38)
Isogonal lenses
A graphical method of solution is explained in the
comprehensive set of magnification tables issued by The idea of isogonal lenses was put forward by Halass
American Optical Company (1957). (1959). They are based on the proposition that since
Before carrying out the above procedure, it may be aniseikonia is significantly related to anisometropia, it
necessary to modify the eikonometer readings. In gener- may well be caused in such cases by the unequal spec-
al, any refractive correction worn during the test will tacle magnifications of the subject’s spectacle lenses. If
affect the magnification of the retinal images. Therefore, this is so, the remedy is to disturb the basic retinal
if there is any difference between the spectacle magnifi- image sizes in the naked eyes as little as possible. Con-
cations of the right and left trial lens combinations, it tact lenses would thus be the ideal form of correction. If
must be added to the eikonometer readings. To calculate contact lenses are ruled out, an alternative solution
this so-called ‘spurious’ magnification, the form, thick- would be to design a pair of isogonal spectacle lenses
ness and separations of the trial lenses must be known. such that the spectacle magnification is the same for
In the case of astigmatism at oblique axes, a further each one and for both principal meridians as well if the
complication arises because the axes of the spurious lens incorporates a prescribed cylinder.
magnification will also be oblique. However, by follow- A computer program for the design of isogonal lenses
ing a procedure based on equations (14.28) and has been devised by Lang and Lederer (1972). Astig-
(14.30), spurious magnification can be expressed in matic isogonal lenses are bi-cylindrical or bi-toroidal in
terms of the eikonometer parameters, thus permitting a form. Like iseikonic lenses, they are usually very thick
simple summation. The magnification ellipse is then de- and steeply curved, at least in one of the principal
termined from these new values of v,h and dy. meridians.
In designing a pair ofiseikonic lenses, the essential re- Various compromise lens designs known as non-sym-
quirement is to control the spectacle magnification of metrical isogonal, semi-isogonal and _ semi-iseikonic
each lens so that, in conjunction, they conform to the have also been proposed, based on different principles
specified magnification ellipse. As shown on_ pages of correction (Halass, 1960).
229-231, spectacle magnification has two components.
The power factor contains the distance a from the back
vertex of the lens to the eye’s entrance pupil. Altering
this distance may, in suitable cases, make a useful con- Incidence and importance
tribution. In general, the shape factor affords more of aniseikonia
scope for manipulation because it contains two vari-
ables: the front surface power and the centre thickness The predominant symptoms of aniseikonia — asthenopia,
of the lens. Since an increase in either increases the headaches, photophobia and reading difficulty — are not
spectacle magnification, cosmetic considerations can be distinctive and anomalies of space perception are re-
borne in mind to some extent. Once again, complica- ported in only a small percentage of cases. Because of
tions arise if the axes of the magnification do not coin- this, eikonometry has generally been regarded as a last
cide with the axes of astigmatism. Two possibilities resort in difficult cases when other attempts to relieve
then arise. One is based on the theorem that a meridio- ocular discomfort have failed.
nal magnification at a given axis can be replaced by Image-size disparities up to 1% are not uncommon
two meridional magnifications at any axes desired. By and generally cause no problems. Nevertheless, amounts
 References 273

as low as 0.75% can be clinically significant if accompa- (HCL) of the frame being 6 mm below the primary line of sight,
nied by severe symptoms (Bannon, 1954). Estimates of and (b) executive-type bifocals with a +1.50D addition, the
HCL of the frame being 3 mm below the primary line of sight
the nurnber of cases in which an iseikonic correction and the segment tops 3mm below HCL. Assume the near
would prove beneficial are necessarily tentative but gen- visual points to be 10 mm below the primary line of sight.
erally in the region of 3-5% of the population. Some 14.5 A test for cyclophoria due to Meissner (1858) is based
70% of prescribed corrections are believed to have been on the principle of Figure 14.10. A string in the median plane
is viewed in crossed diplopia. If the string is placed at 400 mm
successful.
from the eyes, and its top has to be tilted 8° away from the ver-
Nevertheless, after an initial burst, interest in anisei- tical (and patient) for the diplopic images to appear parallel,
konia has now waned to the point where investigation what is the cyclophoria given a PD of 66 mm? (The cyclophoria
and prescribing are now almost confined to a few specia- measured is that present for the actual fixation distance, but
list clinics and university optometry departments. The the declination equation applies to the distance of the string.)
14.6 A patient’s vision was investigated with a space eikon-
special facilities originally provided by American Optical ometer, and the settings for the correct appearance of the dis-
Company are no longer available. As possible reasons play were found to be:
for this decline, Burian suggested inertia, the need for
x90: R 3% (i.e. h = +3)
simpler instruments, the complications of lens design MUS ONL lorices v— 2)
and unsatisfactory economic return (Neumueller et al., 6: +0.4
1970).
What are the parameters of the magnification ellipse?
It is understandable that few practitioners would have 14.7 Compare (a) the basic retinal image heights for distance
the confidence to undertake themselves the translation vision in two 60D reduced eyes, one of which is emmetropic
procedure in its full rigour and the other axially myopic by —6.00 D, and (b) the number
Recognizing this fact, Berens and Bannon in an ear- of retinal receptors per unit length, assuming the posterior
hemisphere to contain the same number of retinal receptors
lier paper (1963) had summarized a number of methods
and the globe to have a radius of curvature equal to 45% of
whereby an estimate can be made of the probable the axial length. Also discuss the implications for aniseikonia
amount of aniseikonia and an approximate correction when corrected by spectacles and contact lenses.
provided by altering the base curves and centre thick- 14.8 A size lens of 5% magnification has a front surface
radius of curvature of 70mm. What thickness is required if
ness of the patient’s existing spectacle lenses. Further
made (a) in resin with n = 1.498, (b) in high-index glass with
contributions to this approach were made by Rayner ele OO2
(1966) and Brown and Enoch (1970). It is possible that 14.9 Show that the power factor of spectacle magnification of
a number of cases are successfully treated in this way. a lens of the required power at a vertex distance d of an eye
Another practical problem is the difficulty in getting showing ocular refraction K, assumed to be measured at the
cornea, can be expressed as P = 1 +aK.
iseikonic prescriptions manufactured. Paradoxically,
the revolution in lens production methods in recent dec-
ades has made it increasingly uneconomic to make spe-
cial lenses of complicated design.
There is no doubt whatever that aniseikonia is the References
cause of curable ocular discomfort suffered by a rela-
tively small but not insignificant number of people. It ALLEN, D.C. (1974) Vertical prism adaptation in anisometropes.
Am. J. Optom., 51, 252-259
would be highly regrettable if this branch of optometry
AMERICAN OPTICAL COMPANY (1951) The AO Space Eikonometer
were allowed to wither away completely. and the Measurement and Correction of Aniseikonia. South-
bridge, Mass.: AO Co Bureau of Visual Science
AMERICAN OPTICAL COMPANY (1957) Magnification Tables for
Use with the Space Eikonometer. Buffalo, NY: AO Co Instru-
Exercises ment Division
AMERICAN OPTICAL COMPANY (1967) How to Design Iseikonic
14.1 Suggest cosmetically acceptable front surface powers Lenses. Southbridge, Mass: AO Co Lens Development Dept.
and thicknesses for the lenses in the following anisometropic APPLEGATE, R.E. and HOWLAND, H.C. (1993) Magnification and
prescriptions, the object being to reduce the difference in the visual acuity in refractive surgery. Arch. Ophthalmol., 111,
1335-1342
spectacle magnifications between right and left:
BANNON, R.E. (1954) Clinical Manual on Aniseikonia. Buffalo,
(a) R +4.00 DS L+1.00 DS NY: AO Co Instrument Division
(b) R —6.00 DS L —2.00 DS BENNETT, A.G. (1968) Emsley and Swaine’s Ophthalmic Lenses,
pp. 213-223. London: Hatton Press
State the spectacle magnifications of the lenses proposed. BERENS, C. and BANNON, R.E. (1963) Aniseikonia: a present ap-
14.2 Draw a diagram similar to Figure 14.1 showing the ray praisal and some practical considerations. Archs. Ophthal.,
paths for a corrected and uncorrected hypermetropic eye. NY, 70, 181-188
14.3. A patient requires a near addition of +2.00 DS. What BRECHER, G.A. (1957) Image aberrations as a method for anisei-
compensating prismatic effect could be obtained by using invi- konia measurement. Am. J. Ophthal., 43, 464-465
sible solid (one-piece) bifocals with a 45 mm diameter segment BROWN, R.M. and ENOCH, J.M. (1970) Combined rules of thumb
for the right eye and a 30mm diameter for the left eye? in aniseikonic prescriptions. Am. J. Ophthal., 69, 118-126
Assume the near visual points to be: (a) 5 mm, (b) 8 mm below EDWARDS, K.H. (1980) The management of ametropic and ani-
the segment tops. é sometropic amblyopia with contact lenses. Ophthal. Optn,
14.4 A patient with the distance correction 19, 925-929
GARNER, L.F., YAP, M. and scortT, R. (1992) Crystalline lens
R =3.00
power in myopia. Optom. Vision Sci., 69, 863-865
L —5.00/—2.00« 180
HALASS, S. (1959) Aniseikonic lenses of improved design and
shows no hyperphoria when looking through the optical cen- their application. Aust. J. Optom., 42, 387-393
tres ofthe trial lenses. Discuss the vertical optical centration de- HALASS, S. (1960) Special lenses in anisometropia and aniseiko-
sirable for (a) single-vision lenses, the horizontal centre line nia. Aust. J. Optom., 43, 417-420, 469-471
274 Anisometropia and aniseikonia

HAWKESWELL, A. (1975) The development of a portable space NEUMUELLER, J., BANNON, R.E., BOEDER, P. and BURIAN, H.M.
eikonometer. Br. J. Physiol. Optics, 30, 25-33 (1970) Aniseikonia and space perception — after 50 years.
HENSON, D.B. and DHARAMASHI, B.G. (1982) Oculomotor adap- Am, J. Optom., 47, 423-441
tation to induced heterophoria and anisometropia. Invest. OBSTFELD, H. (1978) Optics in Vision, pp. 132-134. London:
Ophthalmol. Vis. Sci., 22, 234-240 Butterworths
KEATING, M.P. (1982) The aniseikonic matrix. Ophthal. Physiol. OGLE, K. (1950) Researches in Binocular Vision. Philadelphia:
Opt., 2, 193-204 W.B. Saunders Co.
LAIRD, 1.K. (1991) Anisometropia. In Refractive Anomalies, Re- RAYNER, A.W. (1966) Aniseikonia and magnification in
search and Clinical Applications (Grosvenor, T. and Flom, M. ophthalmic lenses. Problems and solutions. Am. J. Optom.,
C., eds), pp. 174-198. Boston, Mass.: Butterworth- 43,
Heinemann 617-632 BS
LANG, M.MCN. and LEDERER, J. (1972) Computerised optometry. REMOLE, A. (1983) A new eikonometer: the multimeridional
Aust. J. Optom., 55, 373-399 apparent frontoparallel plane. Am. J. Optom., 60, 519-529
MCCORMACK, G., PELI, E. and STONE, P. (1992) Differences in SORSBY, A., LEARY, G.A. and RICHARDS, M.J. (1962) The optical
components of anisometropia. Vision Res., 2, 43-51
tests of aniseikonia. Invest. Ophthalmol. Vis. Sci., 33,
STEPHENS, G.L. and POLASKY, M. (1991) New options for anisei-
2063-2067
konic correction: the use of high index material. Optom. Vis.
MEISSNER (1851) Beitrdge zur Physiologicedes Sehorgans. Cited by
Sci., 68, 899-906
Helmholtz, H. Von, Physiological Optics, Vol.3, p.114. English
WINN, B., ACKERLEY, R.G., BROWN, C.A., MURRAY, F.K., PRAIS, J.
translation ed. J.P.C. Southall, N. Y.: Optical Society of Amer-
and st. JOHN, M.F. (1988) Reduced aniseikonia in axial ani-
ica. (Reprinted 1962 by Dover Publications, N. Y.)
sometropia with contact lens correction. Ophthal. Physiol.
Opt., 8, 341-344
15
Ocular aberrations

General considerations

The eye, in common with many other refracting sys-

tems, is subject to a number of aberrations affecting the
resolution and fidelity of the image. A partial correction
for spherical aberration is provided by the peripheral
flattening of the cornea and probably of the crystalline
lens, especially in its accommodated state. On the other
hand, the eye’s optical system is virtually uncorrected
for chromatic aberration. Despite these imperfections, 700
the overall performance of the eye is little short of aston- Wavelength (nm)
ishing.
Figure 15.1. Graph of the spectral luminous efficiency
Traditional methods of examining the resolution of
function V(A). (a) The photopic curve for an equi-energy
the image and measuring its various aberrations spectrum. (b) The curve when weighted for the redder light of a
cannot be applied to the eye because its interior is inac- tungsten lamp, Standard [luminant A.
cessible for this purpose. Consequently, objective meas-
urement of ocular aberrations must be made in object
space on pencils of light originating from the retina. De- known in Great Britain by the initials CIE of its French
spite its limitations, this method at least has the advan- name (Commission Internationale de |’Eclairage), is the
tage of expressing spherical and chromatic aberration accepted international organization concerned with
in terms of refractive errors relative to a definable norm. photometry and colorimetry. Its various published
tables, reproduced in most textbooks on these subjects,
are of fundamental importance in quantitative work.
They relate, in part, to the properties of a number of
Chromatic aberration ‘standard illuminants’ and to certain characteristics of
the eye of a ‘standard observer’.
Basic concepts and data The normal human eye perceives as ‘light’ the range
Chromatic aberration arises from the fact that the re- of electromagnetic radiations between wavelengths of
fractive index of the optical media decreases as the approximately 380-780 nm. The relative luminosity at
wavelength increases. The shorter wavelengths at the different wavelengths is called the spectral luminous effi-
blue end of the visible spectrum are thus more strongly ciency, also known as the ‘V(i) function’. The two
refracted than the longer ones at the red end. curves in Figure 15.1 are plotted from the CIE tables
For practical purposes, it is necessary to choose a and show the V(2) function under different conditions.
wavelength to which the ‘mean refractive index’ of opti- Curve (a) shows the relative luminosity at different
cal materials is to be related. Dioptric powers and focal wavelengths when the physical energy has been ad-
lengths are then understood to refer to this wavelength justed to remain at the same level throughout, the
unless otherwise indicated. The mean wavelength wavelength of peak luminosity then being at approxi-
(2 = 589.3nm) of the two adjacent D-lines of the mately 555 nm.
sodium spectrum used to be the accepted standard, but Although the energy distribution of sunlight is ap-
this has been replaced in some countries by the d-line proximately uniform within the visible spectrum, this is
of the helium spectrum (7 = 587.6 nm). More recently not characteristic of light sources in general. In particu-
there has been a move in some countries to replace the lar, the energy emitted by the CIE Standard Iluminant
d-line by the mercury e-line (A = 546.1 nm), but no A, which typifies the familiar tungsten-filament electric
general agreement on such a change is in prospect. The lamp, increases at an almost uniform rate with wave-
wavelength 587.6 nm will accordingly be taken as the length. Curve (b) in Figure 15.1 shows the effect of this
norm for the determination of chromatic aberration. type of illumination on the V() function.
The International Commission on Illumination (ICI), It was plotted by taking the figures for the equi-energy
276 Ocular aberrations

Table 15.1 Notional refractive indices at selected wavelengths of the ocular media
ee

Spectral line F’ d Abbe number

Wavelength (nm) 380 480.0 587.6 643.8 780 (v)

Humours 1.3488 1.3407 13160 343 1.3314 DAS)

Crystalline lens
Relaxed eye 1.4389 1.4282 1.4220 1.4198 1.4159 50.1
Eye accommodated* | 1.4389 1.4282 1.4220 1.4198 1.4159
Elderly eye 1.4223 1.4120 1.4060 1.4039 1.4001

“On the provisional basis that the accommodated lens has the same refractive index as the unaccom-
modated lens (see page 212), these values are the same as in the row above.

spectrum, represented by curve (a), and weighting them Refractive indices of the ocular media
by the relative energy of Standard Illuminant A, the
The values adopted by Le Grand (1956) for the humours
amended figures then being re-scaled to make the maxi-
are undoubtedly typical of the human eye, while his fig-
mum equal to unity. This has the effect of shifting the
ures for the crystalline lens necessarily relate to a simpli-
wavelength of peak luminosity towards the red end of
fied hypothetical substitute.
the spectrum, to approximately 570 nm. This has an im-
In determining a set of values for the Bennett—
portant bearing of the theory of bichromatic tests, dis-
Rabbetts schematic eye, the authors have adopted the
cussed later in this chapter.
d-line values of 1.336 for the humours and 1.422 for
In designing achromatic lenses and optical instru-
the unaccommodated lens. Values for the F’ and C’
ments for visual use, consideration has traditionally
wavelengths were calculated in the light of Le Grand’s
been limited to that part of the visible spectrum bounded
figures for constringencies and partial dispersions, for
by the hydrogen F-line (A = 486.1 nm) and the hydro-
example (np — ng)/(Mp — Ne’). Finally, the values for
gen C-line (A= 656.3 nm). Figure 15.1 shows that
wavelengths 380 and 780 nm — the limits of the visible
beyond these limits the relative luminous efficiency be-
spectrum — were calculated from Schmidt’s dispersion
comes very low. In 1962, the International Commission
formula (n =n, + Ad | + BA *). The complete list is set
for Optics decided to adopt a revised list of wavelengths
out in Table 15.1. A detailed discussion of this topic can
for refractive index determination, the main considera-
be found in Le Grand (1956).
tion being experimental convenience. As a result, the F
and C lines were both discarded and replaced by the
neighbouring F’ and C’ lines (A = 480.0 and 643.8 nm
Chromatic difference of equivalent power
respectively) of the cadmium spectrum. Despite this, the
1984 version of ISO 7944: Reference wavelengths defines Aberration implies departure from a norm. In this case,
the Abbe number or constringence v of an optical the norm is the equivalent power of the eye for a given
material as reference wavelength. Thus if A, is the reference wave-

iia,
hay
OLS eS fe
ye) (15.1)
length, n/, the refractive index of the vitreous humour
Ne Te lips = Nei
and F’, the equivalent power of eye for this wavelength,
n,, the refractive index of the vitreous humour and F),
in which the subscripts denote the spectral line to which the equivalent power of the eye for the new wavelength
the refractive index refers. If F is the mean power (for i and AF, the chromatic difference of equivalent power,
the d-line) of a thin lens or surface in air, its axial chro- then
matic aberration, or difference in power over the spec-
tral interval F’ to C’, is the fraction F/v. ARS AlRye Be (15.2)
The ocular humours are largely composed of water, Table 15.2 gives values of F,, and AF, for the Bennett—
which has an Abbe number of approximately 55. Thus Rabbetts schematic eye, both in its relaxed state and ac-
the axial chromatic aberration of the single-surface re- commodated 2.50D. As expected, the aberration is
duced eye of power +60D would be about 60/55 or slightly greater in the accommodated state because the
just over 1.00 D. In the accommodated state when the mean power of the eye is greater. It can be seen that
power of the eye is increased, the chromatic aberration the total variation in the equivalent power ofthe relaxed
would increase proportionately. eye over the entire visible spectrum is very nearly
3.25 D. Over the central band between the F’ and C’
wavelengths it is 1.20 D.
Chromatic aberration of the schematic eye Table 15.2 also gives the positions of the principal
It is useful to study chromatic aberration in the sche- points and entrance and exit pupils. The variation with
matic eye as it provides a valuable guide to the perform- wavelength is very small and can be ignored over the
ance of the living eye. Initially, a set of values must be
F’—C’ interval.
decided upon for the refractive indices of the ocular
media over the visible spectrum. Another requirement
is to distinguish between three different aspects of chro-
Chromatic difference of refraction
matic aberration, since the term is too vague to be used It is not feasible to determine values of F,, by experiment
in a quantitative sense. on the living eye. A related but clinically more signifi-
 Chromatic aberration bo = I

Table 15.2 |Chromatic aberration of the Bennett—Rabbetts schematic eye

(a) Unaccommodated

Spectral line F’ d Gi
Wavelength (nm) 380 480.0 587.6 643.8 780

Equivalent power ofeye (D) Fy, 62255) 60535 60.00 59) 10 DOIG

Position of principal points (mm) A\P Sul Ia gsi ES Spl

A;P’ 1.83 ey? 1ROZ 1.82 1.82

Position ofentrance and INE 5.08 3.04 3.05 3705 3.05

exit pupils (mm) AE’ WA) 3.70 3.70 3) 3.70

Chromatic difference of power (D) AF. +2.33 +0.85 0.00 —0.30 —0.84

Chromatic difference of refraction (D) AK —1.73 —0.64 0.00 +0.22 +0.63

Chromatic difference of magnification Vr} Vo 0.9928 0.9974 1 1.0010 1.0027

(b) Accommodated 2.50 D*

Spectral line . Ip d (C!

Wavelength (nm) 380 480.0 587.6 643.8 780

Equivalent power ofeye (D) Fy 6on29) 63.475 62.84 62255 61.96

Position of principal points (mm) AP LA2 1.62 1.62 1.62 162

AP’ 1.96 ILO) ISOS NYS) 9

Position of entrance and A\E 2.96 DD DROS De) 3 DSS

exit pupils (mm) AE’ 3.56 3.5.6 3.56 35K) 3.56

Chromatic difference of power

(D) NES 42.45 +0.90 0.00 —0.32 —0.89

Chromatic difference of refraction (D) AK —1.73 —0.68 0.00 +0.24 +0.67

Chromatic difference of magnification Vr/Vo OSD Seon S22 1 1.0010 ROOD

nS

* That is. for an object plane —400 mm from the first principal plane. The author (R.B.R.) has data for
the other levels of accommodation.

cant quantity is the chromatic difference of refraction i.K, the ocular error of refraction for wavelength A
AK measured at the first principal point. In simple and AK the chromatic difference of refraction, then
terms, this quantity is the variation in refractive error
AK =K, —K, (5:3)
with wavelength and can easily be determined experi-
mentally. which, from equation (4.3), can be put in the form
It might be natural to suppose that a given chromatic
difference of equivalent power would result in a refrac-
IN Oe ear ea en
tive change of equal magnitude but opposite in sign. SA edd ol Guede)
For example, an increase in power of 0.30D
= =A. als (Kj, i K4) (15.4)
(AF. = +0.30D) could be expected to result in relative
myopia of the same amount (AK = —0.30D). In fact, If the second principal point is regarded as stationary,
this is not so. In the schematic eye, the distance k’ to ki = ki, and equation (15.4) can be written as
the retina is measured from the second principal point, 1) = No \
/ /

the position of which varies very little with wavelength. AR = Ares (™ °K, (55h)
n
Nevertheless, its dioptric equivalent K’, being equal to
n’/k’, is affected. Since the basic relationship Values of AK and AF, are given in Table 15.2, and
shown graphically in Figure 15.2. Following Pease and
K=k —F, (4.3) Barbeito (1989) and Koczorowski (1990), these results
have been plotted against reciprocal wavelength or
holds good for all wavelengths and since K’ and F, are wavenumber @. As the above authors point out, the
both affected, it follows that AK cannot be equal to graphs in Figure 15.2 are nearly linear when plotted
—AF,. against wavenumber @, whereas they are significantly
If ki, =k’ for a reference wavelength A, and curved when plotted against the more traditional
Ki =n,/k,,k, =k’ for wavelength A and K,= wavelength. The theoretical justifications for this
ni,/ki,, Ky is the ocular error of refraction for wavelength choice of abscissa are that the frequency of light (its
 278 Ocular aberrations

Wavelengths (nm) and Spectral lines constant, u’ varies with refractive index and hence
Pl d C'
with wavelength. As a result, even though the position
700 750
of EB’ and hence the distance E’M’ remain practically un-
changed, the image height y is affected by wavelength.
The change in y for a given angle u can be regarded as
a change in magnification. If y, and y, denote the re-
spective values of y for the reference wavelength A, and
another wavelength A, the chromatic variation of mag-
nification can be expressed as the ratio y),/yo. Values of
this ratio are included in Table 15.2.
For a small object at Q, it is not the chromatic varia-
tion in magnification at Q’ that is important but the
chromatic variation in position or transverse chromatic
aberration (TCA). Because the fovea is not situated on
the optical axis of the eye, TCA here gives rise to chro-
matic stereopsis, discussed on pages 290-293. In the
Chromatic
difference
(D) retinal periphery, values of TCA will be much larger,
but the lower resolution of the retina and reduced spec-
tral sensitivity render TCA unimportant.

Experimental determinations
Wavenumber x 10°
In experimental determinations, the quantity measured
Figure 15.2. The chromatic difference of equivalent power is AK, the chromatic difference of refraction. One tech-
AF, and the chromatic difference of refraction AK plotted as a
function of wavenumber. The reference wavenumber
nique, used by Wald and Griffin (1947), Howarth and
corresponds to a wavelength of 587.6 nm (the helium d-line). Bradley (1986) and Kruger et al. (1993) is to determine
the ocular refraction for different wavelengths with a
Badal optometer system, the optometer lens being well
velocity in vacuum divided by wavelength) is unaltered corrected for chromatic aberration. To help keep the ac-
on passage from one medium to another and that the commodation relaxed, a distant fixation object is ar-
energy of radiation is proportional to its frequency. ranged so that it is visible to both eyes while only one
Moreover, inspection of Schmidt's equation (page 276) eye sees the optometer test object. Cooper and Pease
shows that the refractive index may be expressed as (1988) similarly used a Badal optometer but combined
n=n, + Aw@-+ Bo", and as the last term is about one- it with a Scheiner disc to improve precision.
twentieth of the second, refractive index is almost a The basis of another method is shown in Figure 15.4.
linear function of wavenumber. A pencil of composite light diverging from the fovea M’
is able to leave the eye only through a small area G of
Chromatic variation of magnification the pupil at a distance y from the axis. If the emergent
ray corresponding to the reference wavelength i, inter-
The two aspects of chromatic aberration already dis- sects the axis at a distance k,, the ray corresponding to
cussed refer to axial effects, but transverse effects are some other wavelength i will intersect the axis at a dif-
caused by chromatic aberration. In Figure 15.3, E and ferent distance k,. Since ray paths are reversible, it fol-
E’ are the respective centres of the entrance and exit lows that two small or narrow test objects placed at Ty
pupils and B’ the posterior pole of a schematic eye, all and T, and illuminated by light of wavelength A, and A
three of these points lying on the optical axis. QE is the respectively, would both be imaged on the fovea. To the
chief ray of an incident pencil filling the pupil and observer, they would thus appear to be coincident.
makes an angle u with the optical axis. The conjugate This arrangement has been used by several teams.
refracted ray, EQ’, makes an angle wu’ with the axis, Thibos et al. (1990) used a pinhole in front of the eye in
meeting the retina at a height y from this axis. Even if order to isolate the required zone of the pupil. The verti-
the refracted pencil does not focus on the retina, the cal test objects T, and T, are seen in silhouette against
point Q’ nevertheless determines the centre of the the two different colour backgrounds. Ivanoff (1953)
blurred retinal image of the given object point. employed a Maxwellian view system in which a pinhole
It can be seen from equation (12.10) that if wuremains disc is imaged by the upper half of an achromatic doub-

To ee hs Ky
Q
Figure 15.4. Optical arrangement for measuring chromatic
Pigure 15.3. Chromatic variation of magnification: angle w’ difference of refraction by means of light leaving or entering the
and intercept height y vary with wavelength. pupil through a restricted zone at G.
 Chromatic aberration 279

let in the subject’s pupillary plane. After reflection by a Wavelengths (nm) and Spectral lines
mirror, a second pinhole is imaged by the lower half of
AK = d C'
the doublet at the same quasi-point focus G in the sub-
(D) 400 450 500 550 00 650 | 700 750
ject’s pupillary plane. With T, and T, in actual coinci-
dence, the position of the subject's eye is adjusted until
they appear to him coincident. This establishes the
‘achromatic axis’” of his eye. The subject's head is sup-
ported on a carriage and then moved laterally through
a predetermined distance y. As a result, the two test ob-
jects now appear to be separated. To restore apparent
coincidence, T, has to be moved through a distance a
which is measured.
The distances a and y in Figure 15.4 are considered
opposite in sign if they are on opposite sides of the axis.
It can then be seen that
= ky = ky, = Ky = Ky = AK

yk, K, iS
which gives
AK = —aK,/y (15.6a)
or, rearranging, .

a/k, = —yAK (15.6b)

Wavenumber x 10° (m~)
Equation (15.6b) shows that a graph of a/k, plotted
against y has a slope AK, the chromatic difference of re- Figure 15.5. Chromatic difference of refraction.
Experimental results adjusted for 4, = 587.6 nm or
fraction. This is the technique used by Thibos et al.
wavenumber 1.702 x 10°. Results of @ Wald and Griffin
(1990) and Simonet and Campbell (1990). (1947), A Ivanoff (1953), O Bedford and Wyszecki (1957). The
Published results of experimental determinations are curved line represents the mean. @ indicates calculated results
not always based on the same zero-point wavelength. for the schematic eye.
The best choice for this would probably be 587.6 nm,
the reference wavelength chosen for the schematic eye
and the determination of lens power. When necessary accommodation in play, the value of F, having in-
adjustments have been made to put the zero point at creased by 2.83 D. In percentage terms, this amounts
587.6 nm, a remarkable compatibility emerges despite to an increase in AK of about 2.5% per dioptre of AF,.
differences in experimental techniques. This is shown A similar result was obtained experimentally by Char-
by Figure 15.5, in which three different sets of results — man and Tucker (1978) over the spectral interval
by Wald and Griffin (1947), Ivanoff (1953) and Bedford 442-633 nm. Similarly, Sivak and Millodot (1974)
and Wyszecki (1957) — have been plotted on the same found the residual longitudinal chromatic aberration
graph. The curved line represents the mean. The results with an achromatizing lens (see below) to increase from
of Jenkins (1963) for 32 eyes fit the curve well, though a minimal amount in the unaccommodated state to
showing slightly higher values for wavelengths over about 0.75D at 7D of accommodation. Cooper and
600 nm. Pease (1988), however, found very little difference in
Figure 15.5 also shows some calculated values of AK AK over the interval 400-700 nm for both all their 14
for the Bennett—Rabbetts schematic eye. A number of subjects or for the eight aged less than 30 when chang-
writers have commented on the difference between the ing fixation from a distant object to one at 0.4 m.
calculated and experimental values in the blue region, An objective method of measurement, devised by
but the same trend appears at the other end of the spec- Charman and Jennings (1976a) and giving good results,
trum. A possible explanation is that the dispersions of makes use of the double-pass photoelectric scanning
the ocular media — probably of the crystalline lens in technique described on page 49.
particular — is higher than the values generally adopted.
Since the eye’s power increases with accommodation,
so should its chromatic aberration. The experimental re-
sults of Nutting in 1914 showed such an increase, as Achromatizing lenses
pointed out by Jenkins (1963). Over the interval EF’ to
The purpose of an achromatizing lens is to counteract,
C’, Table 15.2 shows AK of the schematic eye to increase
as far as possible, the eye’s chromatic difference of re-
from 0.86 D for the relaxed eye to 0.93 D with 2.5 D of
fraction. It requires at least two components made of
«
materials having different dispersions. One such lens
(Thomson and Wright, 1947) is a cemented doublet si-
* This term, used by Ivanoff, denotes the ray path for incident milar in construction to a telescope objective, but with
light such that, despite dispersion at the various ocular refract-
the chromatic aberration greatly over-corrected so as
ing surfaces, rays of different wavelengths reunite at the fovea.
A more detailed explanation is given on pages 290-293 about to neutralize the eye’s.
chromatic stereopsis. An improved design by Carman, described by Bedford
280 Ocwlar aberrations

Table 15.3. Details of an achromatizing lens of the Carman the USA, it has been slightly modified by Lewis et al.
design (1982), using Schott glasses F3 613370 and SK4
613586. The surface radii are unchanged at 14mm,
Spectral line h d
Wavelength (nm) 404.7 587.6 750 but the centre thickness of the equi-convex element has
been increased to 5.2 mm and that of the outer compo-
Refractive indices nents reduced to 0.9 mm. The lens diameter is 14.5 mm.
Positive component 1.63776 1.62041 1.61417
An air-spaced achromatizing lens system, comprising
Negative components 1.65120 1.62049 1.61076
a cemented triplet and a cemented doublet, has been de-
Back vertex power —186D —0.01D +0.47 D scribed by Powell (1981). It has the advantage of redu-
———
cing residual transverse as well as axial chromatic
Effective power at —-1.82D —0.01D +0.48 D
aberration to negligible proportions over a wider field of
cornea (d = 12 mm)
view than simpler designs.
Eye's AK (experimental) | —1.70D 0 +0.58 D

Residual AK +0.12D +0.01D +0.10D

Chromatic difference of 0.963 l 1.011

Two current controversies
magnification (—3.7%) (+1.1%)
The first concerns the eye’s chromatic difference of re-
Radius of curvature of curved surfaces +14.4mm. Centre fraction, usually referred to in the literature as LCA
thickness: 1.0 mm (negative components), 5.0 mm (positive com-
(longitudinal chromatic aberration). Despite the close
ponent).
agreement of earlier studies, as indicated by Figure
15.5, doubt has been cast on the validity of these find-
and Wyszecki (1957), takes the form of a symmetrical ings at the blue end of the spectrum. Measurements of
cemented triplet with plane outer surfaces, the central the dispersion of the crystalline lens and cornea by
element being equi-convex and the outer ones plano- Sivak and Mandelbaum (1982) suggest that their dis-
concave. Ideally, the materials used for the positive and persions at short wavelengths are greater than ex-
negative components should have the same refractive pected, especially that of the lens. As a result, the eye’s
index for the reference wavelength — usually the calculated LCA between wavelengths 440 and 660 nm
helium d-line or the mean sodium D-line. At this wave- would become 2.73 D (Mandelbaum and Sivak, 1983).
length the lens will then act as a flat parallel plate of This is considerably higher than the previously accepted
zero power. Two suitable main-type glasses from value in the neighbourhood of 1.50 D.
Chance-Pilkington’s catalogue would be DBC 620603 Despite this prediction, experimental results for the
(ng = 1.62041, v= 60.3) for the positive component LCA continue to show results similar to the earlier find-
and DF 620362 (ng = 1.62049, v = 36.2) for the nega- ings. Thus Howarth and Bradley (1986) measured the
tive. right eye of 20 approximately emmetropic subjects,
Details of an achromatizing lens made from these ma- under cycloplegia, to determine the LCA over the spec-
terials are given in Table 15.3. Its back vertex is assumed tral range 420-660 nm. The residual chromatic error
to be 12mm from the Bennett—Rabbetts emmetropic
was also measured with each of two commercially avail-
able achromatizing lenses placed before the eye. The
schematic eye. Over the range of wavelengths from the
mean value of the LCA was found to be 1.82 D, very
h-line (404.7 nm) to 750 nm, the eye’s experimentally
close to the earlier results, with only small inter-subject
determined chromatic difference of refraction AK is sub-
differences. Both achromatizing lenses performed satis-
stantially corrected. The residual errors all lie between
factorily, giving a mean under-correction of 0.11 D
zero and +0.12 D of hypermetropia.
(Powell) and 0.17 D (Lewis) at the extreme blue end of
Because of the lens—eye separation, an achromatizing
the spectral range investigated.
lens produces an effect similar to spectacle magnifica-
Similar results have been obtained by Cooper and
tion. Since the lens has negative power at the short-
Pease (1988) using a Badal optometer combined with a
wavelength end of the spectrum and positive power at
Scheiner disc (2.17D between 488 and 633 nm),
the other end, the retinal image size increases with
Howarth et al. (1988), also using a Badal optometer
wavelength. Table 15.3 shows that the variation is
(0.97 D between 466 and 615 nm, 2D between 420
small — less than 5% over the range of wavelengths con-
and 645 nm), Morrell et al. (1991) using a laser speckle
sidered. Without the achromatizing lens, the blurred
technique (1.05D between 488 and 633nm) and
retinal images at out-of-focus wavelengths would show
Kruger et al. (1993) with an infra-red optometer (1.7 D
a very much larger size difference. Consider, for exam- between 450 and 670 nm).
ple, a distant test object of 5 minutes of arc angular sub-
The second controversy relates to the possibility of a
tense viewed by the unaccommodated schematic eye reduction in LCA of the eye with increasing age.
and in focus for the reference wavelength (587.6 nm). Although this was suggested by Millodot (1976), both
The diameter of the sharp retinal image would be Howarth et al. (1988) and Morrell et al. (1991) found
0.024 mm, but the overall sizes of the blurred retinal no significant difference between their two age groups.
images at other wavelengths would be 0.056 mm at There is no obvious mechanism why the dispersion of
480.0 nm (F’) and 0.035 mm at 643.8 nm (C’). These the ocular media should vary with age, though the in-
figures refer to a 3 mm entrance pupil. creased absorption and scattering of short wavelengths
To make the Carman lens commercially available in may have influenced Millodot’s work.
 Spherical aberration 281

Chromatic aberration and visual acuity

Because of the eye’s consideration chromatic aberra-
tion, there should be an improvement in visual acuity
when monochromatic illumination is used. Campbell
and Gubisch (1967) showed that this improvement is
much more marked and theoretically predictable when
expressed in terms of contrast sensitivity. This quantity
is the reciprocal of the luminance contrast threshold
(see pages 46-52). Using a sinusoidal grating with a
spatial frequency of 30 cycles per degree, they measured
the contrast threshold with white light, monochro-
matic green (=546nm) and monochromatic yellow
(=578nm). Separate readings were taken with artificial Figure 15.6. Induced transverse chromatic aberration when
pupils of 1.5, 2.5 and 4 mm diameter in use. The mean an achromatizing lens is misaligned with the eye’s achromatic
results, nearly identical for the two monochromatic axis, AA. (a) When aligned, the images Bj, and By lie on the
achromatic axis. (b) When displaced, a transverse spectrum is
lights, showed the contrast sensitivity to be increased formed on the retina.
by 55-57% with the accommodation paralysed and by
31-35% with normal accommodation.
On the other hand, experiments made by various re- Zhang et al. (1991) showed that the angular separation
searchers have shown that an achrgmatizing lens does 0 between the two images is given by
not improve the visual acuity. The team of researchers
0 = y(Fr — Fp)
at Indiana University have put forward several possible
reasons for this, the most important being (a) that longi- where Fr and Fp, are the powers of the achromatizing
tudinal chromatic aberration has less effect on visual lens for the long and short wavelengths and y the misa-
acuity than might be expected, and (b) that unless very lignment (in metres). They suggested that only 0.4 mm
carefully centred, an achromatizing lens causes blur be- of misalignment was enough to cancel out any improve-
cause the various coloured images are separated on the ment from correcting the LCA.
retina. Other possible causes discussed by the team (Bradley
Thus Bradley (1992), expanding on the argument et al., 1991) are that the achromatizing lens inade-
first put forward by Helmholtz in his Physiological quately corrects the LCA of the eye, but as Table 15.3
Optics, argued that although the total LCA in the eye shows, a Carman lens provides excellent neutralization
may be around 2 D, the effect of the spectral luminosity of the eye’s LCA. Also, experimental determination by
Howarth and Bradley (1986) and Kruger et al. (1993)
function V(A), as shown in Figure 15.1, is to diminish
of the residual LCA of eyes corrected by achromatizing
the luminosity at the ends of the spectrum where the
lenses have shown negligible aberration.
dioptric error is largest. Moreover, assuming the eye is
in focus for the wavelength at the peak of the luminosity
curve, the wavelengths at half the luminous intensity
will be only about 0.3 D out of focus — well within the
Spherical aberration
depth of focus of the eye, while only the relatively dim
ends of the spectrum will be more than 0.5D out of
General characteristics and definitions
focus.
In terms of the ocular Modulation Transfer Function The study of spherical aberration can be simplified by in-
(page 46), the same team argue (Thibos et al., 1991) itially considering only monochromatic light of the
that for a white visual display unit phosphor and a chosen ‘mean’ wavelength, in this case 587.6 nm.
2.5 mm pupil, the MTF is reduced approximately equally Spherical aberration of the wavefront can be exhib-
because of diffraction and LCA, the LCA being equiva- ited by all surfaces of revolution and is a defect of axial
lent to about 0.2 D of spherical defocus. If the LCA were pencils. In its classical form, rays become excessively de-
eliminated, they predict that the foveal visual acuity viated as the point of incidence gets further from the op-
cut-off given by the intersection of the MTF and the ret- tical axis. Thus, in the case of a converging lens or
inal contrast threshold curve would improve by only surface forming a real image, rays passing through
about 5 cycles per degree, i.e. from 50 to 55 cpd. This zones of increasing diameter are converged to axial
would predict only a marginal change in acuity. points nearer and nearer to the surface. This type of
Their second argument is illustrated by Figure 15.6, spherical aberration is called ‘uncorrected’. If, by some
which is derived from Figure 15.4. The upper diagram means, the reverse condition applies — the marginal
shows the achromatizing lens aligned with the eye’s zones becoming progressively weaker than the paraxial
achromatic axis, a real object B being imaged closer to region — the aberration is called ‘over-corrected’.
the lens and eye at B, for a short wavelength, and In general, a single refracting surface can be made
further from the eye at B, for a long wavelength. If the free from spherical aberration for a given pair of conju-
lens is decentred, either by a head movement or by gate axial points if its section is a Cartesian oval. This is
faulty positioning, the two images will no longer lie on a curve of the fourth degree, not an ellipse but a true
the achromatic axis, and will be imaged adjacent to oval, named alter Descartes who deduced its properties
each other on the retina giving a blurred image. in 1637. For certain special pairs of conjugates, the
282. Ocular aberrations

curve degenerates into various conic sections including

a circle, hence the ‘aplanatic points’ of a sphere. Unfor-
tunately, a surface free from spherical aberration for a
specified pair of conjugates will exhibit some aberration
for all other pairs.
Spherical aberration of the eye affects both ingoing
pencils and pencils diverging from the retina. In numer-
ical terms, the internal spherical aberration (ISA) is the
difference between the dioptric distances of the paraxial
and marginal foci, measured from the eye’s second prin-
cipal point. Thus, if these distances (in metres) are /),
for paraxial rays and /,, for rays incident at a distance y
from the axis, the internal aberration in dioptres is
ISA? = 1125 (U5.7)
where n’ is the refractive index of the vitreous humour.
A positive value of the ISA denotes uncorrected aberra- (D)
aberration
spherical
Internal
tion and relative myopia. For the unaccommodated eye,
this amounts to the difference in equivalent power.
Similarly, the external spherical aberration (ESA) —
referring to pencils diverging from the retina — is the dif-
ference between the dioptric distances of the paraxial
and marginal foci, measured from the eye’s first princi-
pal point. This is the quantity measured in experimental
determinations. Hence, for the unaccommodated eye, Incidence height y at cornea (mm)
Figure 15.7. Internal spherical aberration of the Bennett—
ESAG KK, (15.8) Rabbetts schematic eye in: (a) its unaccommodated and (d) its
where K, and K, are the respective refractive errors for fully accommodated state. The reduction of the aberration in
the relaxed state by a cornea with peripheral flattening is
marginal and paraxial rays. A negative value of the shown by (b) an ellipsoidal cornea (p = 0.5) and (c) a
ESA denotes uncorrected aberration and_ relative paraboloidal cornea.
myopia. For example, if K, is -0.75 Dand Ky is —1.25 D,
ESA = —1.25 — (—0.75) = —0.50D The spherical aberration of the schematic eye is
Spherical aberration exerts its separate effect on light greatly reduced by making the corneal profile a conic
of every wavelength in the incident pencils. The struc- section (the simplest class of curves showing peripheral
ture of refracted pencils of composite light within the flattening). As explained on page 208, all its various
eye is thus extremely complex. forms can be defined by the single Cartesian equation

y? = 2rox
— px? (15 1)

in which they are distinguished by the value given to

Spherical aberration of the schematic eye
the parameter p.
The spherical aberration of the schematic eye is easily In Figure 15.7, the internal spherical aberration ofthe
determined by accurate ray tracing. This has the value unaccommodated Bennett—Rabbetts schematic eye is
of revealing the great superiority of the real eye. In plotted for three different corneal forms: (a) spherical,
brief, the results show that (b) ellipsoidal (p = 0.5) and (c) paraboloidal. The calcu-
lated figures on which these graphs are based are
(1) The pattern and amount of the aberration is very
nearly the same for all wavelengths. shown in Table 15.4. For any particular incident
(2) For any given wavelength and incidence height, height, the ISA varies almost linearly with corneal p-
there is very little difference between the internal value over the range p= 0 to p= 1. Small changes in
and external values. In practice, it is the external the parameters of the eye, for example anterior chamber
value which is measured, as with chromatic aberra- depth, make a noticeable difference to the aberration.
tion.
(3) For the Bennett—Rabbetts unaccommodated eye, the Table 15.4 Internal spherical aberration in dioptres of the
internal aberration is closely fitted by the approxi- unaccommodated Bennett—Rabbetts schematic eye with various
mation : corneal forms
——
e ee SS ee
[SAG 0) 38y7 (y in mm) (eliS59)) Distance from Corneal form
axis (mm)
(4) For the fully accommodated Bennett—Rabbetts eye, Spherical Ellipsoidal (p = 0.5) Paraboloidal
the internal aberration is reasonably fitted for small
values of y by the approximation ] +0.36 +0.18 +0.02
2 ae Syl +0.77 +0.08
ISAc= 0.61y7 (y in mm) (GS S10) 3 j-o209 +1.96 +0.42
—
es
 Spherical aberration 283

Since accommodation increases the power of the eye, tion in 164 eyes of subjects aged 2—60 years. He found
the fully accommodated schematic eye with a spherical over-corrected aberration in 25 of the 31 children aged
cornea shows a marked increase in spherical aberration, under 6, but above that age he found preponderance of
as shown by equations (15.9) and (15.10). The figures the uncorrected type. Of the 42 subjects aged over 8,
given by ray-tracing are represented by graph (d) in only one was found with over-corrected aberration.
Figure 15.7. As pointed out in Chapter 12, spherical Cornsweet and Crane (1970) also reported on such an
aberration in schematic eyes can be eliminated by eye.
making all the surfaces aspheric. By a method similar to that shown in Figure 15.4,
Jenkins proceeded to measure the semi-meridional
spherical aberration of 12 eyes of subjects aged 18-34.
Measurements were made not only on the relaxed eye,
Experimental determinations but also with —1.50 D and —2.50 D lenses in the specta-
cle plane to stimulate accommodation. His mean results
Experimental investigations of the eye’s spherical aber- for both halves of the vertical meridian are plotted in
ration have been made by a variety of methods over a
Figure 15.8(d). Results for the horizontal meridian
long period of time. Perhaps the earliest was made by
showed less asymmetry, both nasal and temporal sides
Thomas Young (1801), using the optometer described
generally resembling the upper semi-meridian. With
on page 75. He replaced the double-slit aperture by
the 2.50 D stimulus to accommodation, all semi-merid-
four narrowly spaced slits so that he could compare the
ians were found to have become over-corrected.
position of focus for the inner pair with that for the
For ease of comparison, three results from these inves-
outer pair. With accommodation relaxed and with him-
tigations have been redrawn on identical grids (Figure
self as subject, the two foci coincided, but when accom-
15.8), together with the curve for the unaccommodated
modating he found his eye to exhibit spherical
schematic eye. A different grid was necessary to show
aberration of the over-corrected type.
the results of Jenkins.
Since the reflex locates the exact area of the subject's
A few generalizations can be ventured on the basis of
pupil transmitting rays from his retina into the obser-
the limited data available:
ver’s eye, retinoscopy (see Chapter 17) affords a simple
means of investigating differences of refraction in differ-
(1) Unlike chromatic aberration, ocular spherical aber-
ent pupillary areas. The pioneer of this method was
ration varies considerably from person to person.
Edward Jackson (1888). Out of 100 subjects he found
i) It rarely shows axial symmetry. The findings of
the great majority to have uncorrected spherical aberra-
Ames and Proctor are, in general, supported by the
tion: 44 with 0.50D at the pupillary margin and 19
results of retinoscopic and other objective measure-
with 1.0 D. Only 6 had 2.0 D or over. Nine subjects ex-
ments of ocular refraction in different pupillary
hibited over-corrected aberration, varying from 1.0 to
areas of the same eye.
2.0 D, while another group of 13 were listed as having
(3) Within a central pupillary area of about 1 mm dia-
0.25 D ‘either way’.
meter, the aberration is of the uncorrected type in
Later determinations have attempted a more precise
the relaxed eye and slightly less than that of the
measurement showing the dioptric variation with inci-
schematic eye. As the diameter of the zone
dence height. Ames and Proctor (1921) used a series of
increases, the spherical aberration continues to
rotatable double-slit apertures with a range of separa-
tions, thus isolating a central and small off-axis area of increase but at a much slower rate.
the pupil. Measurements could then be taken along any (4) The effect of accommodation is to reduce the
desired meridian on both sides of the corneal vertex se- amount of uncorrected spherical aberration and
parately. The far-point distance determined by the occasionally to convert it into the over-corrected
intersection of the axial and off-axis pencils emerging type.
from the subject's eye was measured by a Badal-
In general, the corneal profile is closer in form to an
type optometer with a concave mirror instead of a lens.
ellipse than a circle. There is little doubt that its periph-
No measurements were taken on the accommodated
eral flattening contributes to reducing the eye’s spher-
eye.
ical aberration, though the mean p-values of 0.7 (see
Koomen et al. (1949) isolated a series of narrow annu-
lar zones of the pupil and measured the spectacle refrac- pages 391-394) would still leave a schematic eye with
tion for each zone in turn with a refracting unit. By considerable aberration (a curve almost midway be-
means of a beam-splitting cube placed close to the eye, tween (a) and (b) of Figure 15.7. The crystalline lens,
a subsidiary ray path to a distant fixation object was either by way of its flattening or its refractive index
provided. Lenses of minus power could be placed on gradient, may also contribute to the reduction in spher-
this ray path to stimulate various amounts of accommo- ical aberration. Although the experiments of Millodot
dation. - and Sivak (1974) indicate that the crystalline lens
Because of various experimental difficulties, particu- plays no role in reducing the aberration of the unaccom-
larly that of aligning the visual axis with sufficient accu- modated eye, the reduction which accompanies accom-
racy, both these teams found it possible to make modation can be explained by the reasonable
reliable measurements only on themselves. Using retino- assumption that the front surface (especially) of the
scopy in four pupillary quadrants, Jenkins (1963) lens assumes a shape of relative peripheral flattening as
recorded the type and mean amount of spherical aberra- its curvature increases.
 284 Ocular aberrations

+2.0

aty

+1.0

0 1 2 3 0 1 2 3
Distance from axis (mm) Distance from axis (mm)
+2.0

0 1 2 3 Lower Upper
Distance from axis (mm) Distance from axis (mm)
Figure 15.8. Experimental results of the external spherical aberration of the eye.
In graphs (a) to (c) the solid line shows the
aberration of the relaxed schematic eye. (a) After Ames and Proctor
(1921). L: lower quadrant, T: temporal quadrant. (b) and (c)
after Koomen et al. (1949). Numbers on curves denote stimulus
to accommodation. (d) After Jenkins (1963). O accommod
relaxed, @2.5 D stimulus to accommodation. ation

Other monochromatic aberrations metrical results of other techniques could be a result of

choosing an incorrect position for the reference axis.
The centred optical system of the schematic eye together Although Ivanoff (1953, 1956) used the achromatic
with the assumption that the image lies on the optical axis as his reference, both Jenkins (1963) and Campbell
axis means that only spherical aberration is important, et al. (1990) used the centre of the pupil. Campbell
and
coma and other asymmetric aberrations being irrele- colleagues used a modified version of Ivanoff's techniqu
e
vant. Figures 15.7 (a) and (b) show that the aberration (Figure 15.4), the decentred beam entering the
pupil
of real eyes differs in various quadrants. Possible causes through a Maxwellian view system, the reference
beam
are asymmetry in any of the refracting surfaces, with, through the whole pupil area.
for example, steeper curves on one side of the optical Figure 15.9(a) shows an eye with positive spheric
al
axis than the other, lack of centration of the ocular sur- aberration, the paraxial conjugates being at B
and B’.
faces, a decentred pupil and the fact that the fovea lies A ray leaving the fovea through the top of the
pupil in-
some 5 to the side ofthe optical axis. tercepts the object plane below B at U, while
The experimental techniques of Koomen et al. (1949) a ray
through the bottom of the pupil passes above
using annular apertures meant that only a mean value B. A plot
of the intercept height, a, against pupil locus
for spherical aberration could be investigated. They y is, as
shown in the inset, an odd-powered function
later suggested (Koomen et al., (1956) that the asym- of y. First-
order spherical aberration, in these terms,
would be
 Wave-front aberrations 285

The results indicate that when the pupil diameter ex-

ceeds about 3mm, marked differences between indi-
vidual eyes are revealed. They also show that the
wave-front is rarely symmetrical about the pupil
centre. This is further demonstrated in a subsequent
paper (1988) in which the wave-front aberrations of
two eyes are expressed in sphero-cylindrical notation
for small isolated regions, decentred 1, 2 or 3 mm along
meridians at 15° intervals. This asymmetry was also
shown to give different results for the modulation trans-
fer functions when calculated for 2 and 3 mm artificial
pupils decentred horizontally in each direction. Atchi-
son et al. (1995) measured the variation in aberrations
with accommodation in 15 subjects. They found two
subjects showing increased wave-front aberration with
increasing accommodation, three with decreasing aber-
Figure 15.9. Effects of (a) spherical and (b) comatic
ration, eight with maximum aberration at 1.5 D of ac-
aberration on rays emerging from the eye from the top and
bottom of the pupil. The inset figures show a plot of deviation a commodation, and the remaining two with minimum
in the object plane against emerging height ) in the pupil. aberration at this level. Comatic aberrations were four
times as pronounced as spherical aberration.
*
The most recent development (Walsh and Cox, 1995)
proportional to y®. Figure 15.9(b) shows an eye with a is to replace the photographic camera with a video
coma-like aberration. Although a paraxial bundle leav- device, thus recording the image in a form allowing im-
ing B would be imaged at B’, peripheral rays might in- mediate computer calculation of the wave-front. While
tercept the retina below B’, giving an asymmetric the wave-front aberration is more difficult to understand
blurred image. Conversely, rays leaving B’ through the than a refractive error, it enables the optical perform-
top and bottom of the pupil would both pass below B. A ance of the eye to be determined in the form of the
plot of a against y would now be an even-powered func-
MTF. The MTF may also be calculated from the point
tion of y, for example a x y?.
spread function. Thus Santamaria et al. (1987) used a
Campbell and colleagues’ results show some subjects
video-computer analysing system to record the image
with mostly spherical aberration, and others with
of a point light source after the double passage of light
mostly comatic aberration, while another showed vir-
in and out of the eye. This, however, again normally
tually no aberration.
gives a radially symmetrical pattern to the apparent
aberrations. Artal et al. (1995) pointed out that coma
could be demonstrated if the diameters of the beams en-
tering and leaving the eye were of unequal size.
Wave-front aberrations
A promising objective technique for the measurement
of wave aberrations is the use of a Hartmann—Shack
A subjective method of measuring the eye’s monochro-
wave-front sensor (Liang et al., 1994). In this, a point
matic aberrations has been described by Howland and
source of light is focused on the retina to form a second-
Howland (1977), while Charman (1991) provides a
ary source. The emerging wave-front passes through a
more recent review. Like the ‘aberroscope’ described by
cylindrical lens array which is formed by two rows of cy-
Tscherning (1924), it depends on projecting the
shadow of a grating on to the subject's retina, but it lindrical lenses placed at right-angles, rather like two
uses a more sensitive means of doing so. From a drawing trial case Maddox rods superimposed. This gives an
made by the subject of the distorted grid pattern as ob- array of 1mm square lenses, each of focal length
served, it is possible to construct and interpret a numer- 170 mm. A perfect wave-front emerging from an emme-
ical equation to the wave aberration surface at the tropic eye would give a regular grid of spots on the CCD
pupil. One of the conclusions reached is that spherical photodetector, just as the aberroscope would give a reg-
aberration is often of a largely meridional character. ular grid pattern on the retina of a perfect eye. The com-
Another is that coma, an aberration hitherto regarded puter linked to the CCD calculates the wave-front
as unimportant in the eye, plays a dominant role in the aberration. The published data of the two eyes that
wave equation at all pupil sizes. were measured again shows coma to be as or more im-
A notable advance in this method was announced in a portant than spherical aberration. Cox and Merino
paper by Walsh and Charman (1985). By means of an (1996) found the method to give repeatable results on
ophthalmoscopic arrangement, the distorted retinal the 10 eyes examined, while Smith et al. (1996) give a
image of the square grid can be photographed. The re- mathematical analysis.
sults obtained from the 10 subjects examined are repro- Hemenger et al. (1996) converted the corneal shape
duced, together with computer-generated contour data given by a video-keratoscope (see Chapter 20) to
maps of the wave-front departures from the ideal plane the wave-front aberrations produced by refraction at
surface. From these, in turn, drawings giving a three-di- the cornea alone. As shown by the eye chosen for illus-
mensional impression of the wave-front surface were tration, the typical asymmetry of corneal curvature pro-
produced and are displayed in the paper. duces comatic aberration.
286 Ocular aberrations

Refractive
(D)
error

0 5 640 15° 920), 725

Angle of obliquity 41 Angle of obliquity u;

Figure 15.11. Refractive errors in the sagittal (S) and

Figure 15.10. The tangential and sagittal foci of the relaxed tangential (T) meridians caused by oblique astigmatism of the
Bennett—Rabbetts schematic eye for a distant object and ray bundles emerging from the relaxed Bennett—Rabbetts
various angles of incidence. The image shells straddle the schematic eye: (a) spherical cornea, (b) paraboloidal cornea.
retina, with the tangential in front of the sagittal as in Figure
Note the reduced astigmatism in (b).
R23):

sign, their sagittal and tangential vergences express the

Oblique aberrations eye's refractive error in these two meridians at the
given obliquity or field angle (wu, in Figure 15.9). The al-
Pencils entering the eye gebraic difference between the two vergences has been
Objects in the peripheral field are seen by virtue of obli- termed the eye’s peripheral astigmatism. Figure 15.11
quely incident narrow pencils of rays which are limited shows the results of two sets of calculations on the un-
by the pupil. Because of this, the refracted pencils show accommodated Bennett—Rabbetts schematic eye, with a
oblique astigmatism. Each one has two principal sec- spherical cornea (p=1) and with a _paraboloidal
tions. The tangential (meridional) one lies in the plane cornea (p = Q) (see page 282). Ellipsoidal corneas would
containing the chief ray of the pencil and the eye's op- give results intermediate between these two.
tical axis; the sagittal (radial) one is perpendicular to The differences between graphs (a) and (b) arise from
the tangential. Thus, a pencil incident on the cornea di- one of the properties of conicoidal surfaces. As conic sec-
rectly above its centre has its tangential section vertical tions with the same vertex radius progress from the cir-
and its sagittal section horizontal. As with all astigmatic cular through the ellipses to the parabolic and
pencils, the two focal lines are each perpendicular to hyperbolic forms, the sagittal” radius of curvature at a
the meridian to which they are related. In this instance, given distance from the axis becomes longer. At the
the tangential focal line would be horizontal and the sa- same time, the tangential radius of curvature increases
gittal line vertical. at an appreciably faster rate. As a result, the oblique
For a given object distance, the centres of the focal errors, as plotted in Figure 15.11, both move in the di-
lines formed by pencils entering the eye from all direc- rection of hypermetropia, but the tangential approxi-
tions lie on two curved surfaces known as the tangential mately twice as much as the sagittal.
and sagittal image shells. Thomas Young calculated Experimental determinations of the ocular refraction
their curvatures for a typical human eye as long ago as at various angles of obliquity can be made with an ob-
1800, showing that they straddled the retina. Similar jective optometer. In one such study, Ferree and Rand
results are found by calculation on modern schematic (1932) reported on 21 eyes examined with a Zeiss paral-
eyes. For example, Figure 15.10 shows, to scale, the pos- lax optometer (see previous editions of this text). The re-
itions of the tangential and sagittal focal lines of five fraction was measured at various angles of horizontal
pencils from a distant object plane, incident at different obliquity up to 60° on each side of the fixation axis.
obliquities u,;, on the relaxed Bennett—Rabbetts eye. If The eyes had been selected to include pronounced as
the spherical cornea of this eye were replaced by an el- well as slight errors of central refraction. Three of them
lipsoidal or even a paraboloidal surface, the effect on exhibited marked asymmetry between the nasal and
the curvature of the image shells would be relatively
temporal fields. The others fell into two recognizable ca-
slight. Although becoming flatter they would continue
tegories. Twelve, designated as type A, were found to
to straddle the retina, so that the circles of least confu-
have oblique errors in general conformity with the pat-
sion would remain very close to it. There is no doubt
tern of the graph in Figure 15.11(a), while the remain-
that the curvature of the retina is admirably adapted to
ing six (type B) presented the essential features of the
the eye's optical system. -
graph in Figure 15.11(b).
Though it is reasonable to assume that type B could
Pencils emerging from the eye result from a greater than usual degree of peripheral
(peripheral astigmatism)
Emergent pencils from the peripheral retina are also af- ' The sagittal meridian is perpendicular to the tangential,
flicted with oblique astigmatism. With a reversal of which contains the incident ray and the optimal axis.
 Aberrations of contact lens wearing eyes 287

corneal flattening, there is another contributory factor. Some degree of asymmetry has been reported by all
According to Gliddon (1929), it is generally accepted investigators, varying from the slight to the pro-
that the retinal radius of curvature is one-half of the nounced. In the horizontal meridian, differences be-
overall length of the eye and the calculations for Figure tween the temporal and nasal sides are associated with
15.11 were made on this basis. Any shortening of this the tilt of the crystalline lens described by Tscherning.
radius, with all other dimensions remaining unchanged, A detailed study of the effects of a tilted lens and
would make both principal meridians of the emergent cornea, and also of an off-axis translation of the cornea
pencil less convergent or more divergent. As a result, has been made by Barnes et al. (1987). The effects of cor-
the corresponding refractive errors would move in the neal tilt and translation on the eye’s entrance pupil
direction of hypermetropia, towards type B. were also considered. A corneal tilt was suggested as a
Conversely, a lengthening of the retinal radius would reason for large amounts of asymmetry in peripheral as-
make the emergent pencil less divergent or more conver- tigmatism.
gent. The result could be to produce a third type (C) in Retinoscopy has also been used as a means ofestimat-
which the refraction is myopic in both principal merid- ing the ocular refraction at various degrees of obliquity,
ians, the tangential one having the greater error. for example, by Hodd (1951) and Rempt et al. (1971).
Plotted as in Figure 15.11, both curves would lie below In this later study, both eyes of 442 subjects were exam-
the horizontal zero line. Obviously an uncorrected ined. Further analysis of these results by Lotmar and
myopic eye would be expected to show myopia in the Lotmar (1974) demonstrated a spread of astigmatism,
periphery: it is the relative change between the central most eyes showing between 1 and 5D at 40° eccentri-
and peripheral refraction that is of interest. city, with no suggestion of a breakdown into types A
and B. If angle alpha was taken as 4°, the nasal and
temporal results were found to be symmetrical.
Figure 15.11 shows the importance of performing reti-
Variation with ametropia
noscopy as close as possible to the patient’s visual axis.
Figure 15.11 applies to the emmetropic eye. The effect of If the axis of observation is to one side of it, the tangen-
axial ametropia was briefly considered by Bennett tial meridian is horizontal and a minus cylinder axis ver-
(1951), whose calculated values of peripheral astigma- tical would be needed to correct the induced oblique
tism were mainly for emmetropic eyes. He assumed the astigmatism.
retina to remain spherical and of radius half the axial
length. Although the amount of peripheral astigmatism
was found to increase in myopia and decrease in hyper-
Aberrations of pseudophakic eyes
metropia, its pattern remained in the type A category
over the ametropic range from —10 D to +5 D.
The spherical aberration of pseudophakic eyes will be re-
Measurements by Millodot (1981) on 62 eyes (32 sub-
duced if the intra-ocular lens is designed to be almost
jects) showed a more fundamental difference between
convex-plano in form, with a shallow convex curve for
the results in the three main refractive groups. The per-
the back surface. To minimize coma, a_ posterior
ipheral astigmatism of the emmetropes was found to be
chamber implant conversely requires a meniscus lens
generally of type A, with the hypermetropes in type B
with an anterior concave surface. The retinal image
and the myopes in type C. These results clearly point to
size will be nearest that of the previously phakic eye
a discernible pattern of change in retinal curvature in
with a posterior chamber implant of plano-convex
relation to ametropia.
form, so that its principal points lie close to those of the
A possible basis for such a variation has been ad-
original crystalline lens. At present, intra-ocular lenses
vanced by Dunne et al. (1987). It assumes the ametropia
are manufactured with spherical surfaces, but asphe-
to be axial, and all such eyes to have a retina of the
rical surfaces could be employed to reduce aberrations.
same equatorial radius. The retina is then envisaged as
For further discussion, the reader is directed to papers
a semi-ellipsoid in which the semi-minor axis b is invari-
by Smith and Lu (1988), Atchison (1989a,b) and
able, while the semi-major axis a varies according to
Gonzalez et al. (1996).
the given eye's refractive error. Calculations on this
basis showed values of tangential and sagittal errors in
conformity with the classifications found by Millodot.
This would also agree with the present author's (RBR) Aberrations of contact lens wearing
observations that the periphery of many medium to eyes
high myopes’ fundi are less myopic in ophthalmoscopy
than the posterior pole. Rigid lenses
General agreement with Ferree and Rand's results
was shown by Jenkins (1963) for the horizontal and When a rigid contact lens is worn on an eye, the tear
vertical semi-meridians of 10 eyes. Except for one eye, lens neutralizes most of the refraction at the anterior
the tangential foci were always in front of the retina, corneal surface, and hence also its contribution to the
but the position of the sagittal foci varied. Five of the reduction in ocular spherical aberration from its periph-
eyes conformed substantially to type A and one to type eral flattening. Thus a contact lens with a spherical
B. while the others fluctuated between the two at front surface would be expected to increase the overall
different angles of obliquity or in different semi-merid- spherical aberration. Cox (1990) points out, however,
ians. that negatively powered lenses with their flatter front
288 Ocular aberrations

surfaces will induce less positive spherical aberration Depth offield

than plus powered lenses. Collins et al. (1992) fitted a
Applied to the eye in a given state of accommodation,
group of low to moderate myopes with rigid lenses
the depth of field is the range of object distances (which
having spherical or flattening front surfaces. Nine sub-
may be expressed in dioptres) within which the visual
jects preferred the spherical lenses, three preferred
acuity does not detectably deteriorate.
lenses with a front surface of p-value 0.74, while all re-
The depth of field in object space can be regarded as
jected lenses having a p-value of 0.49. A complication
conjugate with the depth of focus in image space.
of rigid lens wear is that the lenses move relative to the
An eye seeing clearly an object at a dioptric distance
visual axis. As Atchison (1995) points out, movement
L, would obtain the same standard of vision for other
of lenses with aspherical front surfaces will induce
objects lying between the distal end of the depth of field
coma, and thus may give a poorer image when poorly
(dioptric distance Ly) and the proximal end (dioptric dis-
centred than a lens with spherical surfaces.
tance L,). Expressed in dioptres, the depth of field is
Rigid lenses with an aspherically flattening back sur-
(Lg —L,). If Lg and L, are equally spaced dioptrically
face are frequently fitted to provide a theoretically
about L,, then
better mechanical fit on the cornea. The back surface
has a reduced negative power towards the periphery, La — Ibi +e E

and although the effect on the eye is only about one-

Lp =L,—E
third of the effect in air, the overall action of the lens
will be towards a relatively more positive power in the
and depth of field = +F (dioptres) (ALS},112);
periphery compared to the centre.
A low value of E denotes high sensitivity, inasmuch as
the object position then becomes more critical and the
Soft lenses depth of focus smaller.
The back surface of soft lenses drapes closely to the
cornea, and thus the front surface of low-powered Example (1)
lenses may adopt a similar asphericity to that of the
cornea. Cox (1990) calculated that high-powered nega- a — 255 0D) SE =- Oh 5D)
tive lenses became even more aspheric (lower p-value)
while positively powered lenses transferred less of the Lg = —2.25D so that 7g = —444 mm
corneal asphericity through to the front surface. L, = —2.75D so that 7, = —364mm
Because soft lenses centre much better to the cornea,
aspherical surfaces may give more consistent changes (Linear) depth of field = 80 mm
to the overall ocular aberrations. Thus the peripheral However, if E has the larger value of 40.50 D, these
back surface flattening of spun-cast lenses translates quantities become
into peripheral steepening of the anterior lens surface. Lg = —2.00D so that 7; = —500 mm
Similarly, there are lenses manufactured with periph-
eral steepening of the front surface (Patel, 1991) to L, = —3.00 D so that 7, = —333 mm
counteract an assumed average spherical aberration of (Linear) depth of field = 167 mm
the eye. As has already been pointed out, there is consid- The concept of ‘hyperfocal distance’, originating in
erable variation in ocular aberration, so that it seems photography, has also been applied to the eye. It denotes
unlikely that any single lens design could benefit all the value of L, for which the distal end of the depth of
eyes. field lies at infinity. In this case,
Ly = 0 and L, = —E so that

Tipee Nonealtima
Depth of field Vision would thus remain at the same standard for all
distances from infinity to the linear equivalent of —2E
dioptres.
Definitions

Largely because of the aberrations already described,

there is a certain latitude in the eye’s focusing. The
terms ‘depth of focus’ and ‘depth of field’ tend to be Experimental determinations
used indiscriminately but their meanings are quite dis- The variables affecting the eye's depth of field have been
tinct. studied by Campbell (1957). He found that the depth of
field became smaller as illumination and luminance con-
Depth of focus trast were increased.
With increasing pupil diameters, the retinal blur cir-
For a given object distance, the depth of focus is the dis- cles become larger and so the retinal image goes more
tance through which the image-receiving surface can quickly out of focus, again reducing the depth of field.
be moved without detriment to the quality of the In exploring this relationship, Campbell kept the retinal
image; or, given a fixed image-receiving surface, the illumination constant for all pupil diameters, taking
greatest focusing error consistent with this requirement. into account the Stiles—Crawford effect. To a close
 Bichromatic test filters 289

Retina Retina

| A’ B’ A’ B’
'g00 800! tH 760 400 500 id t399
: Conjugate
(a) Conjugate (b) with near
with oe object plane Transmittance

Figure 15.12. Depth of focus of the human eye. The bold

arcs indicate the waist of the image focus over which acuity
remains constant. The rear of the waist falls on the retina in
distance vision (a), the front in near vision (b). Although
400 500 600 700
spherical aberration contributes to the waist, the superimposed
Wavelength (nm)
wavelength scale indicates the tendency for red or green focus
in distance or near vision. Figure 15.13. Transmittance curves of Courtoid Red 15 and
Green 16 filter material, both 0.25 mm thick.

approximation his results are fitted by the empirical

equation. made measurements over the extended range of accom-
modative stimuli from 0.65 to 8.3 D.
E = £{(0.75/g) + 0.08} (15.13)
in which the pupil diameter g is in’millimetres.
Given optimum conditions of illumination and con- Bichromatic test filters
trast, Campbell found the depth of field to be about
+0.3D for a pupil size of 3mm. This is somewhat
The clinical use of red—green bichromatic tests has been
larger than most previous determinations and estimates.
discussed on pages 96-97. For any such tests to operate
However, as Ogle and Schwartz (1959) pointed out in
efficiently, the coloured filters used must be chosen
their own study, experimental results are affected not
carefully.
only by the test method, but also by the criterion The transmittance curves of two cellulose acetate ma-
adopted for out-of-focus blurring. To the extent that terials meeting the requirements of the relevant British
comparison is possible, their own results are of the Standard* are reproduced in Figure 15.13. They are
same order as Campbell's. now called Courtoid Green 16 and Red 15 and both are
The manner in which the eye exploits its depth of 0.25 mm thick. Bichromatic tests are normally illumi-
focus merits attention. In distance vision (Figure nated with tungsten-filament lamps. To assess the effect
15.12a), it would clearly be advantageous to have the of the filters, the spectral luminous efficiency curve for
posterior end B’ of the depth of focus placed near the the standard CIE observer weighted for Standard
retina, with the anterior end A’ conjugate with infinity. Iluminant A should be referred to (see Figure 15.1b).
Optimum vision would thus be obtained at all distances The numerical value at each wavelength must be multi-
from infinity to the plane of B, conjugate with B’ in the plied by the transmittance of the filter, expressed as a
depth of focus. In near vision at close range (Figure fraction. Figure 15.14 shows the result of this operation.
15.12b) the situation is reversed because it would be ad- For the green filter, the peak wavelength is at approxi-
vantageous for the depth of field to extend beyond the mately 535 nm, while the peak for the red is at approxi-
plane of regard. This change of retinal intercept with mately 620 nm.
object distance minimizes the accommodative adjust- The scale above the graph shows the value of AK
ment needed between distance and near vision and vice (chromatic difference of refraction) with its zero at
versa. It supports the resting-state theory of accommo- 570 nm. It was constructed from the mean experimental
dation outlined in Chapter 7. values plotted in Figure 15.5, adjusted by the addition
These theoretical assumptions have been confirmed of +0.09D to shift the zero point from wavelength
experimentally by Ivanoff (1953). His method was to 587.6 to 570 nm. For the green filter, the wavelength
use the eye’s chromatic aberration as a measuring scale of peak luminous efficiency is at approximately
and to determine which wavelength was focused on the 539 nm, corresponding to myopia of —O.21 D, while for
retina in different states of accommodation. Ivanoff the red filter the peak wavelength is at approximately
found that the relaxed eye focused a wavelength of ap- 620 nm, corresponding to hypermetropia of +0.24D.
proximately 680 nm on the retina. As accommodation Thus, if the green half of the test is in focus, the addition
was brought into play, the wavelength focused gradu- of +0.50 DS would bring the red on to the retina.
ally moved towards the blue end of the spectrum, reach- It is important that the two filters should have ap-
ing about 500nm with 2.50D of accommodation in proximately equal luminous transmittance (formerly
use. In terms of dioptres, this shift represents approxi- known as integrated visible transmission). This quantity
mately 0.70 D or £0.35 D from a zero mean. can be calculated from the data plotted in Figure 15.14
Results very similar to Ivanoff’s were later obtained by and is proportional to the area enclosed by the curve
Kellershohn et al. (1957), who also found that the eye's
depth of focus is used in essentially the same way what-
ever the source of illumination used. Similar results “BS 3668: Red and green filters used in ophthalmic dichromatic
were later reported by Millodot and Sivak (1973) who and dissociation tests.
290 Ocular aberrations

Figure 15.15. The transverse spectrum formed in the

macular region when a positive angle alpha is associated with a
centred pupil. View of right eye from above.
transmittance
Weighted

oO Chromatic stereopsis appears most strongly when two

400 500 600 700 colours from opposite ends of the spectrum are placed
Wavelength (nm) close together and viewed against a black ground.
Figure 15.14. Transmittance curves of Courtoid Red 15 and When viewed against a white ground a reversal of the
Green 16 material of 0.25 mm thickness weighted for both the effect is usually observed, though to a lesser extent.
spectral luminous efficiency and Standard [luminant A. Brucke (1868), one of the earliest investigators of the
Ordinate scale in arbitrary units from zero. The superimposed
phenomenon, rightly concluded that it was caused by
scale shows the chromatic difference of refraction.
the eye’s chromatic aberration, coupled with its optical
asymmetry. He mentioned, in particular, the angle
and the x-axis. It can be seen that the two materials in alpha. It was left to Einthoven (1885) to fill in the pic-
question are reasonably well matched in this respect. ture py drawing attention to the role of pupillary decen-
Their luminance transmittance is, in fact, about 18.6% tration. The illusion can be enhanced, neutralized or
for the green filter and 15.9% for the red. reversed by observing the scene through variably de-
For the protanope these figures are no longer valid centred pinhole apertures or horizontal prisms.
and although the principle of the test is otherwise little The effect of the angle alpha is explained by Figure
affected, the marked reduction in the luminosity of the 15.15. This represents an unaccommodated schematic
red panel must introduce a bias. emmetropic eye with the pupil centred on the optical
It was pointed out on page 289 that as accommoda- axis but with a positive angle alpha of 5°. To be focused
tion is brought into play, the wavelength focused on on the fovea, an incident pencil of parallel rays must be
the retina moves towards the blue end of the spectrum. inclined at a horizontal angle of 5° to the optical axis,
If red—green equality is taken as the end-point in bichro- as shown. The distance y from this axis at which the
matic near vision tests, the reading addition prescribed ray passing through the centre of the pupil impinges on
on that basis may be theoretically 0.25D or even the retina can be calculated as outlined on pages 278—
0.50 D too strong. For this reason, Wilmut (1958) advo- 279. The results for three different wavelengths are as
cated the use of blue and yellow filters so as to shift the follows:
mid-point of the test by about 0.25 D in comparison
Wavelength (nm) Distance y (mm)
with the normal green and red filters. In practice, the
conventional red—green bichromatic test provides an ex- F’ = 480.0 (blue) 1.442
cellent procedure for the presbyopic patient (see page
d= 587.6 (yellow) 1.446
121). Nine out of 20 of Rosenfield et al.’s (1996) young
subjects could not manage a blue—yellow test — the pre- C’ = 643.8 (red) 1.448
sent writer suspects inadequate luminance to be the
cause. In binocular vision, red would thus appear nearer
than blue in the absence of other factors, if the angle
alpha is positive. Though the dispersion of 0.006 mm
shown by this table may seem extremely small, even
modest levels of stereoscopic acuity depend on much
Chromatic stereopsis smaller disparities than this (see pages 191-192). It
should, however, be pointed out that the incident pen-
Major factors cils of all out-of-focus wavelengths will form a series of
overlapping blur circles (or ellipses) of varying size. The
Surface areas in the same vertical plane but of different selected chief rays shown in Figure 15.15 determine the
colours appear to some observers to be at different dis- geometrical centres of the respective retinal blurs. The
tances from the eyes. This phenomenon is called chro- effect of pupillary decentration is shown in Figure
matic stereopsis. It is a true stereoscopic effect, 15.16, which represents a horizontal section through
disappearing when one eye is closed. According to a the right eye viewed from above. In the schematic eye,
well-known saying among artists, red is an ‘advancing’ the position of the exit pupil H’J’ varies very little with
colour, whereas green and blue are ‘retreating’ colours. wavelength and in this context can be taken as fixed.
Though this may be a majority viewpoint, many people The points B’ (blue) and R’ (red) refer to the foci for par-
see the opposite effect. allel incident pencils making an angle of 5° with the
 Chromatic stereopsis 291

Figure 15.18. The chief rays of all wavelengths closely

follow a common path to the fovea when the pupil is centred on
the nodal axis.

Figure 15.16. The effect of pupil decentration on the relative decentration for three different colours, the d-line wave-
positions of the red and green blur circles: (a) centred pupil, (b)
length being assumed to be in focus on the retina. The
pupil decentred nasally. Right eye viewed from above, with a
positive angle alpha. calculations were based on the Gullstrand—Emsley unac-
commodated schematic eye, with the angle alpha taken
as 5°. It will be noted that the effect of such an angle
would be neutralized by an inward pupillary decentra-
tion of about 0.3 mm.
It is most probably the relationship between these two
major factors which determines individual awareness of
chromatic stereopsis and especially whether red or
green is seen in front in comparable conditions.
The conditions whereby rays of different wavelengths
in the same incident pencil can re-unite at the fovea
after following slightly different paths within the eye is
illustrated in Figure 15.18. Like the eye’s principal
points, its nodal points are barely affected by changes of
1.430 (mm)
Incidence
height
retina
at wavelength. Given a positive angle alpha, with the
(ss (0s; 4 fo 0) OL OHS) f0)f3} fovea on the temporal side of the optical axis, the princi-
Nasal Temporal
pal ray path to the fovea via the nodal points is as
shown in the figure. Consequently, if the pupil centre E
Pupillary decentration (mm)
is located on this ray path, the necessary condition is
Figure 15.17. Incident height y on the retina of the chief ray satistied. Simple calculation shows that with a positive
through the pupil (from Figure 15.15) as a function of pupillary angle alpha of 5°, the required inward decentration of
decentration. Plots of red (C’), yellow (d) and blue (F’) light. the pupil is approximately 0.3 mm. This agrees with
the result given in Figure 15.17.
optical axis, corresponding to a typical angle alpha. In Chromatic stereopsis results from the binocular effects
Figure 15.16(a), the pupil is centred with respect to the of transverse chromatic aberration. Rynders et al.
(1995), using crosses of red or green light, or black on
optical axis. If the retina is assumed to lie between the
a red or green background, investigated the subjective
blue and red foci, overlapping blur circles will be
TCA of 170 eyes. The mean value found was close to
formed on it, as indicated by the limiting ray paths. It is
zero, suggesting that as a whole, the pupil is well
the red circle which, of the two, lies further from the op-
centred to the nodal axis to the fovea both horizontally
tical axis. For clarity, their relative positions have been
and vertically. If, however, the direction of the chro-
indicated by semi-circles drawn on opposite sides of the
matic aberration is ignored, the mean TCA at the fovea
retina. If the pupil is sufficiently decentred inwards, the
was ().83 minutes of arc, equivalent to a decentration
altered ray paths reverse the relative positions of the
of less than 0.4 mm of the pupil from the nodal axis.
overlapping blur circles, as shown in Figure 15.16(b).
A simple approximate equation relating the chro-
Figure 15.15 shows the distance y from the optical
matic variation of magnification, CVM, and AK was de-
axis at which the rays through the centre of the pupil rived for a simple reduced eye by Zhang et al. (1991):
impinge on the retina when the pupil is itself centred.
If the pupil is decentred, a different ray of the incident CVM = EN AK (15.14)
pencil will pass through its centre and meet the re-
tina at a different distance from the optical axis. where EN is the distance between the entrance pupil and
Figure 15.17 shows the variation in y with pupillary first nodal point, as in Figure 15.18. A more detailed
292 Ocular aberrations

Blue Red
formulation is given in Thibos et al. (1990), while
fringe fringe
Bradley et al. (1991) point out that an artificial pupil
placed in front of the eye gives an exaggerated value for
the chromatic variation of magnification because it in- Red
creases the effective distance EN.
|

Blue Blue

Reversal and other effects pee

(b) {c) (d)
Those who see red in front of blue on a black ground in
good illumination may experience a reversal of the
effect as the illumination is reduced. Although the pre-
cise reason for this is still uncertain, there is little doubt
(e)
that it is the change of pupil diameter which is respon-
sible. One theory is that pupillary dilation in such cases
is eccentric. An alternative explanation by Vos (1960,
1963) is based on the directional sensitivity of the
Red Blue
retina (Stiles—Crawford effect). Contrary to the eccentric
fringe fringe
dilation hypothesis, Sundet (1976) found that when
the natural pupil is dilated and replaced by a series of Figure 15.19. Modification of images by chromatic
dispersion when the object is on a white or coloured
carefully centred artificial pupils of different size, the re- background. (a) A black rectangular outline viewed through a
versal effect still occurred. prism with its base to the left, (b) an object, (c) its image seen
A partial explanation may be the eye's increasing through the prism and (d) its image with a spectrum fringe. (e)
spherical aberration as the pupil dilates. In Figure The similiar effect produced when a black and white object on a
red ground is viewed through a prism with its base to the left.
15.16, the ray paths determining the outer extremities
of the two blur circles are H’R’ (red) and J’B’ (blue).
The effect of spherical aberration with a larger pupil
would be to deviate both limiting ray paths further to- strip of equal width with their edges aligned,
wards the axis, as a result of which they could well surrounded by a red area. Viewed by the right eye
cross over before reaching the retina, even when the through a prism base in, the entire pattern would appar-
pupil is centred. ently be displaced to the right. Moreover, the left edge
The reversal which normally occurs when the two co- of the white strip would appear additionally displaced
loured areas are viewed against a white ground was ex- by the merging of the red fringe with the red surround.
plained in principle by Einthoven (1885). It is due to
Similarly, the right-hand edge would seem additionally
the dispersion of light from the white areas at their lat-
displaced to the right by the whitish overlap of the blue
eral boundary with the coloured areas. The horizontal
fringe and the red surround. Relatively to the black
spectrum formed at the fovea by the effect of a positive
strip, the white strip is now seen temporalwards, sug-
angle alpha is similar to that produced by a base-in
gesting that it is more distant than the black.
prism. If the object shown in Figure 15.19(a) is viewed
If black is seen nearer than white on a red ground, the
through a horizontal prism with its base to the left, a
reverse will appear on a blue ground. These are the ef-
blue fringe will appear along the right-hand side of the
fects normally observed by those who see red nearer
enclosed white area and a reddish fringe on the left-
than blue on a black ground. The corresponding oppo-
hand side. Figure 15.19(b) represents a red and a blue
site relationships also apply.
area, initially on a black ground. When viewed through
a horizontal prism with its base to the left, the red area An interesting perceptual effect can be observed when
is displaced less than the blue, resulting in the appear- two adjacent vertical strips, one black and one white,
ance illustrated in Figure 15.19(c). If, however, the are mounted on a background divided horizontally into
background is white instead of black, the coloured red and blue (or green) halves. Theory predicts that the
areas are displaced as previously but modified by the two strips would appear broken, the top half of one
fringes from the surrounding white area (Figure seeming to be nearer than the bottom half, and vice
15.19d). At their right-hand side (the left-hand side of versa for the other strip. Refusing to accept that the
the white surround) the red fringe extends the upper strips are not continuous, the mind adopts a compro-
red area to the right while encroaching on the blue to mise solution. To many observers the strips appear to
give a whitish overlap. At the left-hand side, the blue remain continuous but tilted in opposite directions
fringe from the white surround extends the blue area to about a horizontal axis.
the left while encroaching on the red. The resulting A similar effect is produced when two separated con-
effect can be neatly demonstrated by projecting a slide centric rings, one red and the other blue, are mounted
made from transparent coloured materials and holding on a background divided vertically into black and
a horizontal prism in front of the projector lens. white halves. In this case, the rings may appear to be
As commercial artists are aware, striking effects can tilted in opposite directions about a vertical axis. Steady
be produced by black and white areas on a blue or red fixation for several seconds or more may be needed to
ground. Figure 15.19(e) represents a black and white give both effects enough time to develop.
 Monocular diplopia and polyopia 293

Example (1)
Let the given wavelengths be 480nm (blue) and
620nm (red) and let 4=—lm, y=+2mm, and
a= 32mm.
S
For the given wavelengths, AK is approximately
—0.88 D. Equation (15.15a) then gives, with all dis-
Median line
tances in metres,
b= ae —0.002 x (—0.88) -
€ 4 A¢ — —-— = +().052 m (52 mm)
0.032 + 0.00176
Figure 15.20. Narrow-beam stereoscopy: construction to For simplicity, the angle alpha has been ignored in
determine the relationship between the various parameters.
this approach. When the viewing distance is 1 m, the
necessary correction is of the order of 2AK mm per
Narrow-beam stereoscopy degree of angle alpha, to be added algebraically to the
value of A/ for positive values of alpha and subtracted
Narrow-beam stereoscopy provides a means of in- algebraically for negative values. In the above example,
creasing and measuring the effects of chromatic if angle alpha is +5°, the correction is (2 x —0.88) x 5
stereopsis. Results obtained in this way can then be or —8.8 mm.
compared with calculated figures. To isolate small areas Confirmation of this principle is given by Ye et al.
of the pupil with variable horizontal decentration, ad- (1991). They measured the induced transverse chro-
justable pinhole or vertical stenopaeic apertures are matic aberration of five subjects as a function of the dis-
placed before both eyes. Two adjacent vertical slits placement y of small artificial pupils in front of the eye
placed symmetrically about the median line (or one under monocular conditions. The position of the achro-
above the other) are illuminated by lights of different matic axis for each eye, i.e. where there was no trans-
narrow wavebands of known peak values. One slit is verse chromatic aberration, was also determined.
fixed and the other movable along the median line. Under binocular conditions, the artificial pupils were in-
Both are seen against a black ground, with extraneous itially placed on each eye's achromatic axis. They were
clues as to their location excluded as far as possible. then moved symmetrically outwards or inwards, and
With the pinhole or slit separations set for a range ofdif- the chromatic stereopsis measured. Excellent agreement
ferent values in turn, the subject adjusts the position of was obtained between these experimental results and
the movable slit until it appears to be at the same dis- the predictions from the monocular transverse chro-
tance as the other one. matic aberration. As expected, outwards decentration
The predicted result can be obtained from the geom- of the artificial pupils resulted in the red stimulus ap-
etry of Figure 15.20, in which R represents a fixed red pearing in front of the blue, requiring it to be positioned
object at a distance / from the eyes and B a movable further away from the observer to appear coincident.
blue object. The visual axis is directed towards R and B An additional experiment showed that it was the dis-
has been moved a distance A/ from R so that it appears tance between the two artificial pupils relative to the
in the same position as R. For simplicity, the pinhole distance between the two achromatic axes which gov-
aperture is assumed to be in contact with the eye. Its erned the chromatic stereopsis. Thus a decentration of
centre C is at a distance a from the median line and y only one pupil through 2 mm was equivalent to a decen-
from the visual axis, y being taken as positive when out- tration of both pupils through 1 mm in opposite direc-
wards (as in the diagram) and negative when inwards. tions.
The left eye, not shown in the diagram, is assumed to
be in symmetrical relationship. Let S be the point on
the visual axis where it is intersected by the ray BC.
The eye’s chromatic difference of refraction with respect
Monocular diplopia and polyopia
to R is then given by
Monocular diplopia may have pathological or neurolo-
AK = 1/PS—1/PR gical causes but the most common variety is optical in
origin. Typically, a faint secondary image of a suitable
and the angle 6 measured from the ray RC to BC by
test object is observed, nearly always displaced in an ap-
6 = y/PS — y/PR = yAK (15.15) proximately vertical direction and usually upwards.
This angular displacement is of the order of 3—6 minutes
The angle 6 can also be expressed as of arc, the mean being equivalent to about 0.12A.
6 = {a/(¢ + AL)} —a/¢ Either or both eyes may be affected, but usually only
one. In a study of 70 eyes of subjects between the ages
Equating these last £wo expressions we get of 18 and 45, Fincham (1963) found no fewer than
40% with monocular diplopia.
=e eS (15.15a) Investigating possible optical causes, Fincham was led
ae yfAK
to exclude the cornea and the surfaces of the crystalline
in which all distances are in metres. Since the two peak lens. Experiments with a rotatable luminous slit as test
wavelengths of the colour filters are known, the corre- object and with stenopaeic and pinhole apertures
sponding value of AK can be found from Figure 15.5. moved across the pupil suggested that the origin was
294 Ocular aberrations

Rabbetts emmetropic eye. Also, to subtend 5 minutes at

the nodal point, y’ must be about —0.024 mm. With
these values substituted in equation (15.16), we have
y = 0,024-(17-5/0'4 i= 1:05 mm
which is a reasonable figure.
It is hard to visualize a local variation of refractive
index capable of producing a relatively undistorted sec-
ondary image, unless it extends to the surfaces of the
crystalline lens. We are therefore led to suppose an
Figure 15.21. Monocular diplopia: region JK of the index variation such that a lens power of about +21 D
crystalline lens is more powerful, resulting in a ghost image is increased to + 22 D in a typical case. If the refractive
indicated by the shaded ray bundle.
indices of the humours and the lens are taken as 1.336
and 1.422 respectively, the necessary change An in the
within the lens: specifically, in the upper part of the pu- latter must be such that
pillary aperture. Within this area, a refractive index var- 22/21 = (1.422 An—1.33,6)/(1.422 1336)
iation had the effect of a weak base-down prism. In
many cases the faint secondary image was seldom no- which gives
ticed, even in visual tasks such as reading. An & 0.004
With the aid of his coincidence optometer (see pre-
This, too, is a not unreasonable figure. Partial occlusion
vious editions of this text). Fincham was able to measure
of the pupil suggests that the affected area of the lens is
the ametropia in the upper and lower parts of the pupil
narrow in width.
separately. He found that although the horizontal re-
One of the authors (A.G.B.) had monocular polyopia
fraction tended to remain unchanged, nearly every eye
in both eyes. Experiments in 1982 showed that the two
showed a difference in the vertical meridian. In all but
perceived secondary images in the right eye were dis-
3 of the 70 eyes examined, the power of the eye was
played obliquely downwards by about 6 minutes of arc
stronger in the upper part of the pupil, leading to rela-
from the main image at axes of approximately 60° and
tive myopia with respect to the lower half. The differ-
120°. In the left eye, the similar patterns showed smaller
ence ranged from 0.50 to 1.75 D in 30 of the eyes. No
displacements. At that time, each eye had about
monocular diplopia was detected in the remaining 37
+2.50D of absolute hypermetropia, with a VA better
eyes, having a difference less than 0.50 D. In nearly
than 6/5 (20/15). Polyopia is sometimes attributed to
every case, the refraction in the lower half of the pupil
incipient cataract, but no sign of this was then present.
agreed with the best correction found by subjective
Polyopic images are most noticeable when the eye is
tests.
out of focus for the object of regard. They may relate to
On the basis of Fincham’s work it is possible to con-
the marked asymmetries of ocular wave-front aberra-
struct a hypothesis numerically consistent with his ex-
tions of the type found by Walsh and Charman (1985)
perimental findings. Monocular diplopia with the
(see page 285).
secondary image seen above the main image is evidently
In a comprehensive review and analysis by Amos
associated with relative myopia in an upper part of the
pupillary area. This greater refractive power is accom-
(1982) of the previous literature, other possible optical
panied by a base-down prismatic effect. It follows that causes (including corneal irregularities) are described.
the part of the crystalline lens associated with the sec- One is the presence of small extra-pupillary apertures
ondary image must lie wholly above its optical centre in the iris, operating like the Scheiner disc to produce
and must also be relatively small, in keeping with the re- doubling of the retinal image when out of focus.
duced brightness of this image.
In Figure 15.21, the actual crystalline lens is repre-
sented by a hypothetical thin lens placed at its optical
centre O, about 2.4 mm behind its anterior vertex. The Irregular refraction
main image of an axial object point is formed on the
fovea at M’, while S’ is the optical image formed in front Irregular refraction may arise from a distortion or asym-
of the retina by refraction through a relatively myopic metry of any ocular refracting surface or by index inho-
upper area of the lens extending vertically from J to K. mogeneity of the crystalline lens. Corneal scars and
The secondary image on the retina is the blur bounded early cataract are common causes. Keratoconus can
by rays through S’ from J and K. If y is the height of K produce very marked irregularity, though it is relatively
from the optical axis and y’ the separation between the uncommon, affecting only one in 10 000 or so.
main and secondary images on the retina, then Objective techniques will reveal irregularity but are
y= —y (OS'/S'M’) (15.16) seldom an adequate guide to the optimum correction.
Standard refractive procedures may be used in many
Fincham’s numerical results suggest that if the appar- cases and the best astigmatic correction found by the
ent angular separation of the diplopic images is 5 min- cross-cylinder technique. If the visual acuity is poor,
utes of arc, this would correspond to relative myopia of the trial and error method described on page 105 may
about 1 D. If so, S‘'M’ would be approximately 0.4 mm be adopted. The pinhole disc should be used to verify ret-
while OS’ would be about 17.5 mm in the Bennett- inal integrity. :
 Scattered light 295

In cuneiform cataract, the crystalline lens is divided rell and McCally, 1976) showed that the wavelength de-
into areas which may differ in their refractive effect, pendency of scattering was proportional to A but
with possibly more than one giving good acuity with that in oedema, the scattered intensity became propor-
the appropriate correction. In such cases, the lens tional to 4 7. They considered that this was due to
power most similar to the previous prescription, or to fibril-free ‘lakes’ about 230 nm in diameter. As the par-
that of the fellow eye, should be chosen. If monocular di- ticle size decreases to significantly less than the wave-
plopia is experienced, its source may be located by gra- length of light, the scattered intensity becomes
dually occluding the pupil from top to bottom or from proportional to 4 *, Rayleigh’s law. Accordingly, blue
side to side. A slight alteration to the correction may sulf- light is scattered more than red. This is undoubtedly
ficiently reduce the intensity of the ghost image for the one reason for the yellowing of the crystalline lens with
patient to ignore it. age, though the principal cause is pigmentation. He-
The patient with irregular corneal curvature is best menger (1984) pointed out that Rayleigh scattering is
helped by a rigid contact lens because the tears layer be- in all directions, giving ‘back-scattered’ light. Hence
tween lens and cornea virtually neutralizes the latter’s the yellowing of the lens may be seen by the practitioner
irregularities. Light scattered by anterior corneal scar- with a slit lamp. The entoptic phenomena of corneal
ring may be reduced for the same reason. and lenticular haloes are described in Chapter 22.
Because of the Stiles-Crawford effect, scattered light
falling obliquely on the retina stimulates the retinal
Scattered light cones less than simple photometry would predict. The
same undoubtedly applies to light diffusing within the
retina. Nevertheless, the result is a veiling haze through
Sources of scatter
which the true image has to be seen. A bright source of
By reducing contrast, light scattered within the eye has light near the object of regard is called a glare source. It
an effect similar to aberrations, in that it degrades the can cause discomfort, or, indeed, disability glare. The
retinal image. The crystalline lens and cornea are re- sensitivity of the eye is then significantly depressed, as
sponsible for most of the scattered light but there are occurs when looking to one side of a low sun.
several other sources:

(1) diffuse reflection of obliquely incident light from per- Experimental investigations
ipheral parts of the retina and choroid, as at D in
Figure 15.22; While ‘back-scattered’ light may be recorded objectively
(2) diffusion within the retina in the immediate vicinity by, for example, slit lamp photography, investigations
of the image; of ‘forward-scattered’ light which affects the subject’s
(3) multiple internal reflections, for example, light vision may be made by measuring:
reflected back from the retina and returned by the
(1) the effects of veiling glare on visual observation,
crystalline lens or cornea;
(2) scattered intensities in excised animal eyes,
(4) light penetrating the iris or sclera and choroid in the
(3) linespread function,
lightly pigmented eye, especially in albinos. (4) contrast sensitivity function (discussed in the later
The angular distribution and wavelength dependence section on Glare and contrast sensitivity).
of the proportion of light scattered by an inhomoge-
neous substance depend upon the size of the scattering
Veiling glare techniques
particle. Generalized equations for scattering by spher-
ical particles were derived by Mie in 1908, and are de- A typical study is that by Fry and Alpern (1953). Two
scribed by Born and Wolf (1980). Particles a little small rectangular fields of illumination, symmetrically
larger than the wavelength of light mostly scatter in a placed above and below a fixation mark, are presented
forward direction. Work on corneal transparency (Far- such that the upper field is seen only by the left eye and
the lower one only by the right eye. A beam splitter
D before this eye introduces an overlying patch of veiling
haze (H in Figure 15.23a) not seen by the left eye. With
the luminance of the left field kept constant, the subject
adjusts the luminance of the right field to match the left
for various values of the veiling haze luminance. In a si-
milar arrangement (Figure 15.23b), the right eye only
is presented with two glare sources GG, the separation
and intensity of which can be varied.
Both the veiling haze and the glare sources were
found to reduce the apparent luminance of the affected
(right eye's) test field. The luminance required for a
match had to be increased with increasing haze or
glare-source luminance and also with decreasing glare-
source separations. Fry and Alpern concluded that the
effect of a glare source was to produce, by scattering, a
Figure 15.22. Light diffusely reflected at the fundus at D
veils the foveal image at M’. veiling haze which partially bleaches the retinal recep-
296 Ocular aberrations

ae
.

)
(a) (b)
Figure 15.23. Veiling glare and scattered light. Upper
rectangle is the left eye’s field, lower is the right eye’s.
Arrangement (a) introduces a surrounding background haze H.
Arrangement (b) uses two glare sources GG. Both H and GG are
seen by the right eye only. (Redrawn from Fry and Alpern,
1953.) illuminance
relative
Log

tors. An increased luminance of the true image is then

required to restore the same sensation. An alternative
view which Fry and Alpern rejected is that the neigh-
bouring glare sources produce lateral inhibition in the
neural networks.
Le Grand (1956) also made a direct comparison of the
luminance of the veiling haze with the illuminance of a
glare source measured in the plane of the pupil. The 10 20 30 40
graph of his results is shown in Figure 15.24. More Glare angle (degrees)
recent experiments, for example those of Ijspeert et al.
(1990), use a flickering annular glare source surround- Figure 15.24. Comparison of the stray light distributions
obtained by two methods. Direct measurement of illuminance:
ing a central test area flickering alternately so that one
x Boynton -—- De Mott and Boynton for the bovine eye.
is luminous when the other is off. The luminance of the Veiling effect of glare sources on vision: + Le Grand,
test area is adjusted to give a minimum apparent flicker, >) Holladay. All curves arbitrarily equated at 10° glare angle.
thus matching that of the scattered light. These re- (Reproduced from De Mott and Boynton, 1958a, by kind
permission of the publishers of J. Opt. Soc. Am.)
searchers found that the veiling glare depended on a
function of the fourth power of the subject’s age, dou-
bling between ages 20 and 70. As expected, they also narrow beam of light was passed obliquely into the eye
found that there was more veiling glare in Caucasian through the centre of the pupil and the scattered light
subjects with blue eyes compared with brown eyes, recorded by photography through the glass plate. They
while dark-skinned non-Caucasian subjects showed concluded that about 70% of the scattered light comes
even less.
from the cornea and the remainder from the lens,
mainly from the subcapsular and nuclear portions. In
order to study changes with oedema, Lovasik and
Direct measurement Remole (1983) developed an instrument for investigat-
ing the light scattered by excised corneas. A horizontal
Using freshly excised bovine eyes from an abattoir, De
arc up to 70° on either side could be measured.
Mott and Boynton (1958a) measured the illuminance
Both Beckman et al. (1992) and Whitaker et al.
of the scattered light from a glare source that emerged
(1994) give useful background theory and methods for
from a small hole cut at the posterior pole. The relative
measuring veiling glare, while Thaung et al. (1995) dis-
position of the source could be changed so as to vary
cuss modifications to the equation for the light-
the ‘glare angle’ — the angular separation between the
scattering function for the Pelli-Robson chart described
retinal image of the source and the recording aperture.
in Chapter 3.
As the glare angle increased, a rapid fall was found in
the illuminance of the scattered light relative to that of
the glare source. At 1° glare angle the relative illumi-
Linespread function
nance was about 0.5 but at 4° had fallen to 0.01. The
results are shown in Figure 15.24, together with thase If a very narrow line is imaged by an optical system, a
for an elderly enucleated human eye and from psycho- plot of the image luminance in a direction perpendicular
physical experiments of the type already described. As to the line is called the linespread function (see page
expected, all the curves are of similar form. 49). Its shape, generally resembling a normal distribu-
To try to identify the sources of scattered light in the tion curve, is conventionally indicated by its ‘half-
eye, De Mott and Boynton (1958b) again used excised width’, being the width of the curve at half the peak
cattle eyes, but this time with the posterior third of the luminance. When the image is in best focus, the line-
globe removed and replaced by a flat glass plate. A spread function represents the combined effects of dif-
 Scattered light 297

fraction, light scatter and the eye’s spherical and chro- This formula might explain the relief obtained by
matic aberrations. Direct measurements were made by some patients when wearing tinted lenses, despite the
De Mott (1959) on excised cattle eyes, both for dark fact that B, and B, are reduced in the same proportion.
lines on a luminous ground and for a luminous slit. The If the luminous transmittance of the lenses is denoted
latter gave a linespread with a half-width of 3 minutes by t, B, and B, become tB, and TB,,.
of arc. The value of Be Bee which can be regarded as a
For human subjects, the linespread function is meas- glare index, is then reduced to the fraction t””” of its pre-
ured in a double-pass system similar to indirect ophthal- vious value. Thus, lightly tinted lenses with a luminous
moscopy. Light reflected by the retina and returned transmittance of 0.85 would reduce the glare index to
through the eye’s optical system forms an aerial image 0.91 of its previous value. With t = 0.2 (a typical value
which can be monitored. Though the aerial image of for sunglass lenses) the reduction would be 0.38 of the
the line has a much broader spread than that on the original glare index.
retina, the retinal linespread function can be calculated
from the double-pass image. Thus, Westheimer and
Campbell (1962) showed that the retinal linespread
Glare and ageing changes
with the image in best focus could be indicated as fol-
lows: While scattered light may not have too detrimental an
effect on vision in an eye with clear media, its effects
Distance from centre Relative
can be marked in one with cloudy media or cataract.
of line image illuminance
(minutes of arc) . Such patients often complain of poor vision, especially
when out of doors facing the sun or at night from
O WAG vehicle headlamps. Hess, cited by Arden (1978) and
Ox5 Paulsson and Sjéstrand (1980), found that early
Bee :
6.5 0.01 changes in the crystalline lens can have a marked effect
on contrast sensitivity, even when the visual acuity re-
These results show an angular half-width of 1 minute of mains good. In a subsequent paper, Abrahamson and
arc compared with the 3 minutes found by Boynton for Sjostrand (1986) showed that their ‘glare score’, a func-
the bovine eye — doubtless due to a difference between tion involving the ratio of the contrast sensitivity with
species. the glare to that without, was better related to patient
Charman and Jennings (1976b) suggested that the symptoms and degree of lens opacification than it was
broad skirt at each side of the double-pass linespread to visual acuity. Measurement of contrast sensitivity
function is caused by light scatter in the ocular media with and without a glare source had been used by
at short wavelengths and by penetration into the Griffiths et al. (1984, 1986) and Elliott et al. (1989) to
deeper layers of the retina and choroid at long wave- investigate the increase in light scatter of the oedema-
lengths. tous cornea and ageing crystalline lens. In these more
Westheimer and Liang (1994) investigated the closely recent studies, circular fluorescent lights concentric
related pointspread function to find an increase in light with the fixation axis to the contrast sensitivity televi-
scatter with age. They suggested comparing the sion monitor have been used, both to provide more uni-
amount of light falling within a 14 minute of arc radius form glare and to reduce any tendency for fixation to
of the centre of the image with that in a surrounding an- wander to a localized glare source.
nulus from 14’ to 28’. Their results suggest that more Hemenger (1984) points out that light scattered
light falls into the peripheral annulus as age increases. through angles of less than 1° is the most important in
affecting contrast sensitivity. It is suggested by Sloane
et al. (1988) that the light scatter function at first drops
quite rapidly as a function of spatial frequency and
then levels off at about 10 cycles/degree. Conversely,
Practical importance of scattered light the contrast sensitivity function drops faster after this
Fry and Alpern (1953) showed that a glare source pro- frequency.
ducing an illuminance E at the eye gave a veiling haze Elliott et al. (1990), Beckman et al. (1992) and Regan
luminance proportional to E/@?”, where 0 is the angle et al. (1993) have studied the effects of glare and catar-
between the glare source and the visual axis (Figure act on the visual acuity measured with low-contrast
15.23b). This relationship was similar to previous re- letter charts. Like contrast sensitivity measurements,
sults by Holladay, Stiles, and others. all found that the drop in acuity with glare was more
The Building Research Station (cited by Durrant, predictive of patient symptoms than a drop in normal
1977) found that discomfort glare due to artificial light- high-contrast VA without glare. Moreover, Elliott and
ing was proportional to colleagues found that the binocular VA in the presence
of cataract could be less than the best monocular VA.
1.6
[Bar
0.8 From a study of subjects with clear media, Birchao et al.
es10)
1.6 (1995) suggested that at mesopic luminances, sudden
By OP
transient glare in the peripheral field may be more dis-
where B, is the luminance of the source, B, the lumi- turbing than continuous glare. They felt this might par-
nance of the background, @ the solid angle subtended ticularly affect people with slight cataracts when
by the source and p a position index. driving at night.
298 Ocular aberrations

BEDFORD, R.E. and WYSZECKI, G. (1957) Axial chromatic aber-

Elliott (1993) gives a review of cataract and vision;
ration of the human eye (correspondence). J. Opt. Soc. Am.,
see also pages 44-45 47, 564-565
BENNETT, A.G. (1951) Oblique refraction of the schematic eye as
in retinoscopy. Optician, 121, 583-588
BIRCHAO, I.C. YAGER, D. and MANG, J. (1995) Disability glare:
effects of temporal characteristics of the glare source and of
Exercises
the visual-field location of the test stimulus. J. Opt. Soc, Am.
A., 12, 2253=2258
15.1 (a) Taking the depth of field as +0.3 D for a 3 mm pupil BORN, M. and woLe, &£. (1980) Principles of Optics, 6th edn.
and a + 60D emmetropic eye, calculate the size of the retinal Oxford: Pergamon Press ‘
blur circles corresponding to an object positioned at the extre- BRADLEY, A. (1992) Glenn A. Fry Award Lecture 1991: percep-
mity of the depth of field. (b) On the basis of blur circle geom- tual manifestation of imperfect optics in the human eye: at-
etry, what is the predicted linear depth of field of the same eye tempts to correct for ocular chromatic aberration. Optom.
when accommodated by 2.50 D, the pupil size being 1 mm? Vist SGenO9 sola —oonl
15.2 (a) A hypothetical avian eye of reduced form has an BRADLEY, A., ZHANG, X. and THIBOS, L.N. (1991) Achromatizing
axial length of 6 mm, a pupil diameter of 0.75 mm and a cone- the human eye. Optom. Vis. Sci., 68, 608-616
to-cone spacing of 0.015 mm. Taking this last value as the per- BRUCKE, E. (1868) Uber asymetrische Strahlenbrechung im
missible blur-circle diameter, what is the dioptric depth of menschlichen Augen. Sber. Akad. Wiss. Wien, Abt. Il, 58,
field? (b) If the eye has 6 D of accommodation, and when re- 321-328
laxed has its far point at the hyperfocal distance, what is the CAMPBELL, F.W. (1957) The depth of field of the human eye. Op-
nearest point of clear vision? tica Acta, 4, 157-164
15.3 In their experiments on the eye's depth of focus Tucker CAMPBELL, F.W. and GUBISCH, R.W. (1967) The effect of chro-
and Charman (1975) used a pinhole disc in front of the eye. In matic aberration on visual acuity. J. Physiol., 192, 345-358
order to centre it (on the achromatic axis) the subject viewed a CAMPBELL, M.C., HARRISON, E.M. and SIMONET, P. (1990) Psy-
square, the top left and bottom right quarters of which were chophysical measurement of the blur on the retina due to op-
green, the opposite pair red. Show how and explain why the ap- tical aberration of the eye. Vision Res., 30, 1587-1602
pearance of the square is altered by the transverse chromatic CHARMAN, W.N. (1991) Wavefront aberration of the eye: a re-
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(b) to the right of the axis. CHARMAN, W.N. and JENNINGS, J.A.M. (1976a) Objective meas-
15.4 By differentiating the expression K = K’ — F, with re- urements of the longitudinal chromatic aberration of the
spect to n, and then substituting K’ = F, for approximate em- human eye. Vision Res., 16, 999-1005
metropia, derive Zhang et al.’s (1991) equation for the CHARMAN, W.N. and JENNINGS, J.A.M. (1976b) The optical
chromatic difference in refraction of a reduced eye: quality of the monochromatic image as a function of focus.
An’ Br. J. Physiol. Optics, 31, 119-134
AK =— CHARMAN, W.N. and TUCKER, J. (1978) Accommodation and
nr
color. J. Opt. Soc. Am., 68, 459-471
where r is the corneal! radius of curvature. COLLINS, M.J., BROWN, B., ATCHISON, D.A. and NEWMAN, S.D.
(1992) Tolerance to spherical aberration induced by rigid
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COOPER, D.P. and PEASE, P.L. (1988) Longitudinal chromatic
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KOOMEN, M., TOUSEY, R. and SCOLNIK, R. (1949) Spherical aber- tion of the eye with achromatizing lens. J. Opt. Soc. Am., 64,
ration of the eye. J. Opt. Soc. Am., 39, 370-376 1724-1725
KRUGER, P.B., MATHEWS, S., AGGARWALA, K.R. and SANCHEZ, N. SLOANE, M.E., OWSLEY, C. and ALVAREZ, S.L. (1988) Ageing,
(1993) Chromatic aberration and ocular focus: Fincham re- senile miosis and spatial contrast sensitivity at low lumi-
visited. Vision Res., 33, 1397-1411 nance. Vision Res., 28, 1235-1246
300 Ocular aberrations

SMITH, G. and LU, Cc. (1988) The spherical aberration of intra- WALSH, G. and CHARMAN, W.N. (1985) Measurement of the
ocular lenses. Ophthal. Physiol. Opt., 8, 287-294 wavelront aberration of the human eye. Ophthal. Physiol.
SMITH, G., APPLEGATE, R.A. and HOWLAND, H.C. (1996) The Opin Oar
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culation of the aberrations. Ophthal. Physiol. Opt., 16, tration and diameter on ocular performance. Vision Res., 28,
659-665
SUNDET, J.M. (1976) Two theories of colour stereoscopy. Vision WALSH, G. and cox, M.J. (1995) A new computerised video-
Res., 16, 469-472 aberroscope for the determination of the aberration of the
THUANG, J., BECKMAN, C., ABRAHAMSSON, M. and SJOSTRAND, J. human eye. Ophthal. Physiol. Opt., 15, 403-408
(1995) Importance of stimulus geometry. contrast definition WESTHEIMER, G. and CAMPBELL, F.W. (1962) Light distribution
and adaptation. Invest. Ophthalmol. Vis. Sci., 36, 2313-2317 in the image formed by the living human eye. J. Opts,Soc.
THIBOS, L.N., BRADLEY, A., STILL, D.L., ZHANG, X. and HO- Am., 52, 1040-1045
WESTHEIMER, G. and LIANG, J. (1994) Evaluating diffusion of
WARTH, P.A. (1990) Theory and measurement of ocular
light in the eye by objective means. Investig. Ophthalmol. Vis.
chromatic aberration. Vision Res., 30, 33-49
Sci., 35, 2652-2657
THIBOS, L.N., BRADLEY, A. and ZHANG, X. (1991) Effect of ocular
WHITAKER, D., ELLIOTT, D.B. and STEEN, R. (1994) Confirmation
chromatic aberration on monocular visual performance
of the validity of the psychophysical light scattering factor.
Optom. Vision. Sci., 68, 599-607
Invest. Ophthalmol. Vis. Sci., 35, 317-321
THOMSON, L.c. and WRIGHT, W.D. (1947) The colour sensitivity
WILMUT, E.B. (1958) Chromatic selectivity of the eye in near vi-
of the retina within the central fovea of man. J. Physiol.,
sion. Optician, 135, 185-187
105, 316-331
YE, M., BRADLEY, A., THIBOS, L.N. and ZHANG, xX. (1991) Inter-
TSCHERNING, M. (1924) Physiologic Optics, 4th edn (trans. Wei-
ocular differences in transverse chromatic aberration deter-
land, C.). Philadelphia: Keystone Publishing Co.
mine chromostereopsis for small pupils. Vision Res., 31,
TUCKER, J. and CHARMAN, W.N. (1975) The depth of focus of the
1787-1796
human eye for Snellen letters. Am. J. Optom., 52, 3-21 YOUNG, T. (1801) On the mechanism of the eye. Phil. Trans. R.
vos, J.J. (1960) Some new aspects of colour stereoscopy. J. Opt. Soc. 1800, 92, 23-88 + plates
Soc. Am., 50, 785-790 ZHANG, X., BRADLEY, A. and THIBOS, L.N. (1991) Achromatizing
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Vision Sci., 6, 456-458
16
Visual examination of the eye and
ophthalmoscopy

Introduction: focal illumination

Like the ophthalmologist, the optometrist must examine

the eye to make sure that there is no abnormality or
pathology present, and if there is, to try to identify the
condition. Examination is conveniently divided into
two areas:

(1) the anterior segment comprising the bulbar con-

junctiva, anterior sclera, cornea, aqueous humour,
iris and anterior part of the crystalline lens;
(2) the posterior segment, which for this purpose can be
taken as the remainder of the eye including the crys-
talline lens, vitreous humour and the fundus (the
view through the pupil of the retina, choroid, sclera
Figure 16.1. Focal illumination using a hand slit lamp and
and optic nerve head). loupe.

The anterior segment, together with the eyelids,

should first be examined in good general diffuse illumi- the cross-section. An 8x or 5x magnifier held in the
nation. The cornea, aqueous, and anterior crystalline other hand or a binocular headband magnifier aids the
lens may then be examined under localized illumina- examination. Corneal opacities may also be detected by
tion. While the instrument of choice is the slit lamp, to the method of scleral scatter, in which the beam is
be described below, historically the method of focal illu- aimed at the sclera just to the side of the limbus: light
mination was employed. An electric lamp bulb was enters the cornea through its edge, and is totally intern-
imaged on the eye by means of a condensing lens of ally reflected at both surfaces. As a result, the cornea ap-
power approximately +13.0 DS and aperture 50 mm. pears dark but any opacity will scatter light and show
The anterior segment was then examined either with up as a lighter area.
the unaided eye or with a hand or binocular headband These methods are useful for general routine exami-
magnifier. nation, but for more precise inspection the major slit
The hand slit lamp provides a more convenient lamp is essential because of its luminance, binocular
method of focal illumination (Figure 16.1). In the major- viewing and magnification.
ity of such instruments a low-voltage bulb has a fila-
ment of uncoiled wire shaped like a goal post, an image
of which is projected on to the cornea by a high-pow-
ered condenser. The better instruments have a com- The siit lamp
pound condensing system so as to reduce aberrations
and give sharper definition to the filament image. To in- The term ‘slit lamp’ is now usually reserved for the
crease the depth of focus, the condenser aperture may major stand instrument or biomicroscope. There are
be stopped down with a rectangular diaphragm parallel two main parts, the illuminating system and the obser-
to the bulb filament. A useful technique is to position vation system, mounted on a movable trolley. Both
the instrument so that the beam is initially out of focus. parts are rotatable about the same vertical axis, which
Corneal opacities are best revealed by a beam about also coincides with their respective foci. By this means,
1mm wide. The distance of the instrument from the the slit image illuminating the eye and the observing mi-
eye can then be adjusted to focus the filament image on croscope remain simultaneously in focus on the same
the cornea, thereby obtaining a more detailed picture of part of the eye.
302 Visual examination of the eye and ophthalmoscopy

some slit lamps incorporate an aperture stop of variable

width placed near the lens.
In some instruments, the slit can be rotated from its
customary vertical orientation. Coloured filters can
often be inserted: for example, a green ‘red-free’ filter
for viewing blood vessels, and a blue filter to accentuate
fluorescein-stained areas of damaged epithelium. The
contrast of fluorescein-stained areas may be further en-
hanced by placing a yellow barrier filter in front ofthe
microscope, thus absorbing the blue light but transmit-
ting the yellow-green fluorescence. Suitable filters are
Lee 101 yellow* and Kodak Wratten 15. Neutral-den-
sity filters can be used as an alternative to voltage con-
Figure 16.2. Illuminating system of the major slit lamp. (a) B
lamp bulb, C condenser, A aperture controlling slit length, S trol of illumination, while a diffuser may be fitted over
slit, F colour filter, D diffuser, P projection lens. (b) Basic the projection lens to give a larger field of illumination.
principles of illumination system. LM extremities of lamp Figure 16.3 illustrates a modern instrument. In these,
filament, HJ extremities of slit, M’L’ inverted image of lamp the illuminating system is essentially vertical, a mirror
filament, JH’ inverted image of slit.
or prism reflecting light on to the patient's eye. This ver-
tical layout (either above or below the microscope) was
A well-designed illuminating system will have the fol- originated by H. C. Binstead, and allows the lamp on its
lowing features: shorter arm to be moved easily from one side of the mi-
croscope to the other, or even directly in front of it.
(1) The slit image projected on to the eye will be ade- The eye is observed through a binocular stereoscopic
quately and uniformly illuminated over its entire microscope, often called a Greenhough microscope,
area. For example, graduations of corneal opacity although it was Czapski who first used it on the slit
which could be masked by uneven illumination are lamp. Like the illuminating system, the microscope can
then more easily discerned. be freely swung around their common axis of rotation.
(2) The width of the slit image will be reducible to The principle of keeping the microscope and slit lamp si-
0.02 mm or less to illuminate a very narrow ‘optical multaneously focused on their centre of rotation had
section’ of the cornea or lens. been introduced in 1923 by E. F. Fincham, who
(3) The slit image should present a good luminance achieved the effect by mounting the two systems on a
contrast, with its edges well defined. circular arc.
(4) There should be adequate depth of focus so that a The microscope provides magnification from about
reasonably thin section can be obtained through- 5x to 40x or occasionally higher, but the constant
out, say, the thickness of the crystalline lens. tiny movements of the eye and the very small depth of
field at high magnifications set an upper limit to the
The optical system now used and shown diagramma- useful range. Various means are used to alter the magni-
tically in Figure 16.2, is that of the slide projector and fication:
was first used in the instrument by Vogt. To illustrate
the principle more clearly, the system has been reduced (1) Changing the objectives, which usually give initial
to its simplest form in Figure 16.2(b). The lamp filament magnifications between |x and 2x,
LM is imaged by the condenser lens at L’M’ in the plane (2) Changing the eyepieces (often 10x, 12.5x, 15x
of the projection lens. This, in turn, forms an image of 20x),
the slit aperture HJ at H’J’. As shown in the diagram, a (3) The use of a zoom system,
part of the full pencil of rays from L passes through the (4) The incorporation of a revolving turret of small
slit and is focused at L’ on the projector lens. After re- Galilean telescopes, a device due to Mueller. As
fraction, the rays cross over and become divergent, at shown in Figure 16.4, this is placed between a
the same time being deviated towards the optical axis large objective which collimates the light from the
by the prismatic effect of the lens and thereby passing object, and two small objectives which form the aer-
through the image H’J’. Since the whole of the slit was ial images magnified by the eyepieces. If the convex
evenly illuminated by the pencil from L, it follows that component of the telescope is placed nearer
the slit image is evenly illuminated. In a similar the microscope objective, the magnification is
manner, pencils from every point on the filament are increased, but if the telescope is reversed the magni-
capable of passing through both the slit and the projec- fication is decreased.
tion lens, thus contributing to the illumination of the
A low magnification (about 7x or 8x) with its corre-
image. :
spondingly wide field of view is ideal for such things as
Most instruments allow a continuous variation of slit
observing the relative movements of a soft contact lens
width, while the length may be altered by means of
on the eye, and removing ingrowing eyelashes. These
aperture stops or an iris diaphragm near the condenser.
The depth of focus of the slit image is mainly dependent
on the width of the lamp filament image in the plane of
* Lee Filters, Central Way, Walworth Industrial Estate, And-
the projection lens. As a means of controlling this, over, Hants SP10 5AN.
 Gonioscopy 303

The axes of the twin eyepieces may be parallel or

convergent. While parallel axes are theoretically more
restful as the accommodation and convergence are re-
laxed, the proximal convergence and accommodation
frequently exerted by younger observers may lead them
to prefer instruments with a convergent system. Eye-
piece adjustment for ametropia is usually incorporated.
Alternatively, and especially if the observer is markedly
astigmatic, eyepieces with extra-long eye relief allowing
spectacles to be worn may be of service.
The performance of the instrument as a whole de-
pends on several factors:

(1) the intensity of illumination of the slit beam, espe-

cially when the slit is at its narrowest;
(2) the width and definition of the beam;
(3) the quality of the microscope;
(4) the accuracy with which the focus of the slit projec-
tion system is positioned above the common axis of
rotation — otherwise, the beam may be in focus
when incident from the left but not from the right;
(5) the accuracy with which the foci of the slit projec-
tion system and of the microscope coincide.

One method of judging the performance of the instru-

ment is to look for the relatively dark line formed by the
epithelium in a cross-section of the cornea, using a
very narrow beam coming first from one side of the in-
strument, then from the other. The angular separation
between slit lamp and microscope should be about 50°
and the magnification about 20x. Another test is
whether the instrument provides a good view of the cor-
neal endothelium, using the method of specular reflec-
tion. (Particular aspects of the basic optical design of
the instrument are brought out in the Exercises at the
end of the chapter.)
The use of the slit lamp in clinical practice is described
by Sheridan (1989) and Morris and Stone (1992), the
latter giving a useful bibliography of texts on pathology.
In addition to providing a view of the anterior seg-
ment, the slit lamp may also be used for viewing the
angle of the anterior chamber (gonioscopy), examining
the fundus, measuring corneal and anterior chamber
depths, tonometry and photography.

Gonioscopy

Gonioscopy is the technique for viewing the angle of the

Figure 16.3. The Haag—Streit 9OOBOQ slit lamp. An anterior chamber where the cornea meets the root of
attachment fitting for tonometer, pachometer, etc, F fixation the iris. It enables the skilled observer to assess the
lamp, H headrest, I illuminating system, J joystick control, L
width or narrowness of the angle. A narrow angle pre-
lamp house, M microscope, P projection lens, R mirror, S slit
assembly, T turret magnification changer. Photograph disposes to a disease known as angle-closure glaucoma
reproduced by kind permission of Clement Clarke where the pressure of the fluid in the eye rises rapidly,
International Ltd. causing pain and damage. Even when the angle is rela-
tively wide, the pressure may rise if the drainage
through the trabecular meshwork is deficient. A distinc-
tasks are helped if a diffuser can be attached between the tion is necessary in determining the medical treatment.
prism or mirror of the illumination system and the pa- Because of refraction at the strongly curved anterior
tient’s eye to provide a large field ofillumination. Magni- corneal surface, it is not possible to view the angle of
fications of 30x or more are needed for observing the the anterior chamber without special aid (Figure
corneal endothelium. 16.5a). The principle of the gonioscopy contact lens is
that the corneal surface is approximately neutralized by
304 Visual examination of the eye and ophthalmoscopy

(a)

Figure 16.4. (a) Plan view of the binocular microscope of the Carl Zeiss slit lamp. (b) Side view of rotating Galilean magnification
changer. (Redrawn from illustrations kindly supplied by Carl Zeiss Ltd.)

Iris

Aqueous Corneal
section section

(c)

Scieral
overlap

Tears
lens

Figure 16.5. Gonioscopy: (a) ray paths showing that the angle of the anterior chamber is not visible without aid, (b) a prism type
of gonioscopy contact lens, (c) the Van Herick technique for estimating anterior chamber depth.

the rear surface of the contact lens and the tears lens as near as possible to the limbus (Figure 16.5c). The
formed between this surface and the cornea. Light from patient looks at the microscope which should be set at
the slit lamp can thus pass into the angle and return to 60° to the slit lamp, so that the illumination strikes the
the microscope. Figure 16.5(b) shows a simple gonio- cornea approximately at right angles. With low magnifi-
scopy lens, the slit lamp and microscope being directed cation to obtain sufficient depth of field, the observer re-
approximately normal to the inclined surface of the lens. lates the apparent thickness of the dark space between
There are many different types of gonioscopy lens: il- the posterior surface of the cornea and the illuminated
lustrations are given by Sabell (1970) and Stone patch on the iris — the aqueous section — to the apparent
(1989). Prokopich and Flanagan (1996; 1997) give an thickness of the corneal section.
introduction to the technique, while an extensive treat- Polse (1975) suggested that the depth at the nasal
ment is given by Fisch (1993). limbus should also be evaluated: the microscope will
The gonioscopy lens is an awkward diagnostic tool for need to be set somewhat temporally so that the illumi-
a quick analysis of the angle of the anterior chamber. nation will pass the patient's nose. Van Herick showed
An indirect but simple technique for assessing the that the slit lamp appearance may be related to gonio-
width of the angle with the major slit lamp was intro- scopy grades as follows:
duced by Van Herick et al. (1969). A very narrow illumi- Grade 4 Aqueous section equal to or greater than
nating beam is aimed at the temporal side of the cornea corneal section.
 Slit-lamp examination of the fundus 305

Grade 3 Aqueous section between | and j of corneal

section.
Grade 2 Aqueous section approximately | of corneal
HSI
section.
Grade 1 Aqueous section less than |!4 of corneal
section.

An eye with a grade 2 chamber has a relatively

narrow angle which could give rise to angle-closure
glaucoma.
A grade 1 chamber is dangerously narrow. Sym-
pathomimetic or parasympatholytic drugs should be
Figure 16.6. The Koeppe fundus contact lens.
avoided both topically and orally. Thus, mydriasis to
allow better inspection of the fundus would be unwise,
while referral for gonioscopy or provocative tests for L.H. objective
potential angle-closure glaucoma may be worthwhile.
Be Effective
M entrance Fundus
pupil imageg T
Slit-lamp examination of the fundus

Contact-lens devices

The slit lamp and microscope are designed to illuminate Iluminant

and observe objects at a finite distance, about 100 mm

from the microscope lenses. It is therefore unable to pro-
vide a view of the ocular fundus, the image of which (in Figure 16.7. Simplified diagram of fields of view of the slit
lamp and Koeppe lens: TU, GK are the monocular fields, GU the
the eye’s far point plane) may be at any distance up to binocular field.
infinity.
Koeppe (1918) introduced a glass flat-fronted contact
lens which approximately neutralizes the whole refrac- Though a rigorous study of the field of view obtained
tive power of the eye. The fundus is then brought di- with this arrangement involves many complications, a
rectly into the focusing range of the instrument. sufficiently accurate picture can still be obtained if the
A modified plastics form of the Koeppe lens* due to problem is reduced to its barest essentials. In Figure
Goldmann (1938) has a slightly convex anterior surface 16.7 the left-hand microscope objective is directed to-
of radius 70 mm and a concave rear surface giving ade- wards the centre of the fundus image, which has to be
quate corneal clearance (Figure 16.6). A surrounding viewed through a centrally placed diaphragm H’J’, an
black hood allows the observer to manipulate the lens image of the pupil. Straight lines through AH’ and BJ’
while preventing the patient’s eyelids from sweeping meet the fundus image at R and S. Every point within
across it. The space between the rear surface and these limits — bounding the field of full illumination — is
cornea is filled with viscous artificial tears, forming a clearly capable of sending a pencil filling the microscope
liquid lens that is generally of low positive power. objective. Outside this area is a zone bounded by the
When this is taken into account, the total power added points G and K lying respectively on MH’ and MJ’ pro-
by the Koeppe lens is in the neighbourhood of —55 to duced. Pencils from these limiting points can still cover
—60D. Consequently, if the eye is emmetropic, the half the width of the objective and the circle through G
fundus M’ is imaged at M” in the focal plane of the and K is taken to be the useful field of view. The symme-
Koeppe lens, about 18mm behind its front surface. trically placed circle TU marks the field provided by the
Since the Koeppe lens and the eye are usually of similar right-hand objective, the shaded area of overlap GU re-
but opposite power, the fundus image is not inverted presenting the binocular field of view.
and its magnification is negligible. To illuminate the fundus, the lamp is placed approxi-
With all fundus-viewing lenses, whether of the con- mately mid-way between the two objectives. Since the
tact-lens type or not, the slit lamp and microscope are source is relatively small, the illuminated area is of simi-
initially placed as close together as possible. Most lar diameter to the monocular fields GK and TU. This
modern instruments allow the slit lamp to be placed im- area of illumination is indicated in the diagram by the
mediately in front of the microscope, between the objec- dotted outline and can be seen to cover a good part of
tives, though often at a slightly lower level. The both monocular fields. The remainder will be relatively
patient’s pupil needs to be dilated. When the fundus dark, being illuminated only by light reflected or scat-
image is in focus,ethe slit lamp may be displaced side- tered within the eye.
ways through about 10° to give slightly oblique illumi- The area of fundus observed may be altered by asking
nation of the fundus, enhancing the stereoscopic view the patient to turn his eye sideways or up or down. De-
through the microscope. spite this, it is not possible to view the whole fundus
with such a simple lens. Other designs incorporating a
prism or mirrors, somewhat similar to gonioscopy
“ Produced by Haag-Streit, Berne. lenses, are described in the references previously
306 Visual examination of the eye and ophthalmoscopy

(b) (a)
camer|Ea

H’| lH’

J’] ar
Figure 16.9. The El Bayadi lens. *

but also moves forward as the lens is moved away from

Figure 16.8. The Hruby lens: image H’J’ of the actual the eye (Figure 16.8). As a result, the field of view is re-
entrance pupil HJ formed by the lens in two positions (a) and
duced by more than one-quarter when the distance of
(b), the longer vertex distance reducing the field of view.
the lens from the eye is increased from 10 to 20 mm.
For the same reason, the Koeppe lens fitted in contact
quoted. These allow a view of the peripheral fundus with the eye gives a larger field of view than the Hruby
even up to the ora serrata. lens.

The Hruby lens

The El Bayadi and Volk lenses
Contact lenses for fundus viewing have the disadvan-
tage that the patient's cornea needs anaesthetizing. Unlike the Hruby lens which approximately neutralizes
This can be overcome by a lens of similar negative the dioptric power of the eye, these positive lenses form
power placed before but not in contact with the eye. In- a real and inverted image of the fundus as shown in
troduced by Lemoine and Valois (1923), a lens of this Figure 16.9. In effect, the slit lamp is converted into a
kind was popularized by Hruby (1941, 1942). stereoscopic indirect ophthalmoscope (see pages 318—
The lens power is usually about —55 D, the concave 3233).
surface being placed as close to the cornea as possible. The original El Bayadi lens (1953) was of power +55-—
Reflections from the surfaces are reduced though not 60D and, if of plano-convex form, was placed with its
eliminated both by coating the lens and tilting it convex face towards the patient's eye. Kajiura (1978,
slightly. In addition, the front surface of the lens is cited by Rumney, 1988) suggested using aspherical sur-
sometimes made slightly convex to reduce the size of faces to improve the field of view of the El Bayadi lens.
the reflections from it. A recent development is the introduction by Volk of a
The slit-lamp beam and microscope axis should initi- range of anti-reflection coated lenses in bi-convex form
ally be placed as close together as possible. If the lens is with both surfaces aspherical, with powers between 60
spring-mounted on the microscope to bear against a and 150 D (Table 16.1), and smaller ranges from Nikon
bar on the headrest, the whole instrument should be and Ocular Instruments.
slowly moved forward until the fundus image comes To optimize viewing conditions, the distance of the
into focus. If the lens is mounted on the instrument's lens from the patient’s eye must be such that an en-
headrest, the slit lamp should first be focused on the larged image HJ’ of the eye’s entrance pupil HJ is
lens and then moved towards the patient. formed in the plane of the microscope objectives, com-
Though the field of view through the Hruby lens is pletely surrounding them. The 90 D and SuperField NC
proportional to the size of the patient’s pupil, the dis- (non-contact) lenses should be held about 6.5—7 mm
tance of the lens from the eye is also of importance. The from the cornea. Assuming that the microscope’s objec-
entrance pupil of the lens-eye system is the virtual tives are 27 mm from outer edge to outer edge, the pa-
image H’J’ of the eye’s own entrance pupil HJ formed tient’s pupil must be at least 3mm in diameter. This,
by the Hruby lens. This image not only becomes smaller however, allows no latitude in positioning the lens nor

Table 16.1 Details of the Volk fundus biomicroscopy lenses

Lens type Lens Field of Working distance Fundus Pupil

aperture (mm) view (°) from cornea (mm) magnification magnification

60 D 3] 67 ll —] —1/6
78D 31 13 7 —0.77 —1/7.8
90D Dates 69 615. —0.67 —1/9
SuperField 26 120 6.5 —0.67 —1/9
NC (90 D)
SuperPupil 16 120 2to4 —0.4 —1/15
NC (150 D)

The fundus magnification is based on a power of +60 D for the patient’s eye, while the pupil magnifica-
. . . T me Ti . “p . . . . rs . . . MG
tion is the ratio g/q in Figure 16.23, i.e. the magnification with which the slit lamp objectives are imaged into
the patient's pupil. The microscope is assumed to have a working distance of 1OO mm to the fundus image.
 Slit-lamp examination of the fundus 307

Table 16.2 Slit-lamp examination of the fundus: comparison of useful fields of view with different supplementary lenses

Ocular refraction Koeppe lens Hruby lens El Bayadi lens Aspherical +90 D
(K) —66D —55D +55D (at 9 mm aperture)

Monocular Binocular Monocular Binocular Monocular Binocular Monocular — Binocular

(mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm)

—10.00 ed: DA) al Fon 2no)) 7.4 4.3 (6.4) 14.6 11.0 (13.4)
Emmetropia Ios 32 01((6.0)) 4.1 had (3s) Gee SOO) We 8.6 (10.9)
+5.00 HD DEON) 4.3 dts 5) olf 2.5 (4.6) iol 7.8 (10.0)

for the movement of the objective’s image within the SuperField lens seems the most practical, especially as
pupil as the instrument is scanned across the fundus there are a range of auxiliary lenses both to increase
image, so a larger pupil is preferable. If the eye is emme- the lens power and hence field of view or to decrease it
tropic, the fundus image M” lies in the focal plane of to give a similar magnification to the 78 D lens. Two
the lens. The magnification is then —F,/F, where F, is contact lens adaptors are also available to convert it to
the equivalent power of the eye and F that of the lens. a Koeppe-type lens.
This is, however, augmented by the magnification of Apart from the manufacturer's handbooks, Austen
the slit lamp’s microscope, though the use of higher (1993), Cavallerano et al. (1994) and Flanagan and
magnifications is often limited by*the quality of the pa- Prokopich (1995) give advice. Field and Barnard
tient’s media. (1993) point out that for habitual users of the direct
In use, the slit lamp is usually positioned symmetri- ophthalmoscope (described later in this chapter), obser-
cally between the two microscope objectives, and, if vation of the inverted image requires thought: drawing
possible, the beam tilted up to reduce reflections from is simplified by turning the record sheet upside down,
the aspheric lens. A neutral filter to reduce brightness while viewing adjacent areas is best achieved by imagin-
will aid patient comfort, while a yellow filter or a ing that the fundus is on the outside of aconvex surface,
yellow-coated lens will minimize any hazard from so that one moves in the opposite direction to that nor-
excess blue light. The slit lamp is first focused on the pa- mally used.
tient’s cornea. While viewing from the side, the lens is
positioned in front of the eye, and then viewing through
the eyepieces the instrument is next withdrawn some The Panfunduscope
25 mm from the eye until the inverted fundus image is This instrument, originally suggested by Goldmann in
seen in focus. 1965 and developed by Schlegel, is a high-powered op-
As the maximum beam width of many slit lamps is tical system forming an inverted image of the fundus in
9mm, this value has been adopted for the diameter of close proximity to the eye. Like the El] Bayadi lens, the
the lens when calculating the fields of view given in Panfunduscope acts as the condensing system of an in-
Table 16.2. In practice, the width of the illuminating direct ophthalmoscope, the inverted image being
beam is reduced to 2-3 mm for patient comfort and to viewed through and magnified by the slit-lamp micro-
reduce reflections, and hence a narrower field of view is scope. The name given to the instrument reflects the
given at any one instant. The aperture of the lens is uti- claim by the manufacturers* that the whole posterior
lized by traversing either the illuminating beam (by dis- hemisphere can be viewed without movement of either
sociating the illuminating and observation systems) or lens or eye. The field of view is, in fact, limited by that
the whole instrument across the lens. If the image in of the microscope itself.
one eyepiece becomes relatively dimmer than the other, The optical system of the instrument is shown in
equality is often restored by slightly moving the lens Figure 16.10(a), drawn approximately to scale. A pencil
sideways towards the dimmer image. While dilated from the macula M’ is converged by a high-powered
pupils are greatly advantageous, the Volk Instruction contact lens and then refracted by a complete sphere
Manuals for the 90 D and SuperField NC lenses suggest which forms an inverted but virtual image of the
that, with practice, a view of about 3 mm of the fundus fundus at M”. The system also forms an enlarged image
(2-3 disc diameters) can be obtained through an undi- H’J’ of the eye’s entrance pupil HJ, approximately in the
lated pupil of 2.5—3 mm diameter. Pupil miosis as a plane of the microscope objectives. In round figures, the
reflex to the light may restrict the pupil diameter to less magnification of the fundus image at M” is —0.7, while
than this and lens position becomes critical. The Super- the magnification of the entrance pupil is —7.5.
Pupil lens has a much greater power so that the micro- To show the path of the rays through the sphere in
scope objectives are imaged closer together into the more detail, a separate drawing has been inserted
patient’s pupil, thus allowing a better view without dila- (Figure 16.10b) with the angles exaggerated. The axial
tion. pencil from M’ is converged by the contact lens towards
The lower power lenses in Table 16.1 give larger the point B,;, which becomes a virtual object for the
fundus images, allowing detail to be more readily ob- first surface of the sphere. After refraction, this pencil is
served, and can be held further from the patient's eye
so that they are less likely to be soiled by the lashes.
The lateral position will possibly be more critical. The * Produced by Rodenstock, Munich.
308 Visual examination of the eye and ophthalmoscopy

J!

Be Bi (Bp)
Figure 16.10. Optics of the Panfunduscope. (Redrawn from material kindly supplied by G. Rodenstock Instrumente GmbH.)

converged to the image point Bi, which becomes the tive separation of the objectives to 4.5°, or about 8 mm.
object point B, for the second surface of the sphere. The This greatly increases the field of view, as indicated by
emergent pencil diverges from the virtual image point the figures in brackets in Table 16.2, though with some
B5, which fixes the position of the fundus image M” pre- reduction in stereoscopic effect. Although the introduc-
sented to the microscope. tion of the Volk aspheric lenses has reduced the need
for this device, it still remains useful with fundus
contact lenses. The Stereo-Variator also provides a
binocular view of the corneal endothelium and the pos-
Comparison of fields
terior pole of the crystalline lens when using the
Table 16.2 gives an indication of the fields of view of the method of specular reflection, thus giving better resolu-
fundus given by the four types of supplementary lens. tion.
The figures refer to the useful fields of view represented
by GK (monocular) and GU (binocular) in Figure 16.7.
In all cases, the diameter of the eye’s entrance pupil Ocular measurements with the
was taken to be 7 mm and the objective aperture 5 mm
at a working distance of 100 mm to the fundus image.
slit lamp
The centres of the objectives were taken to be separated
by 23 mm, corresponding to the 13° angular separation The slit lamp provides a convenient means of measuring
subtended at the object that has been adopted by Haag- the corneal thickness and the depth of the anterior
Streit. The effective aperture of the El Bayadi lens chamber. In Figure 16.11, a ray from the back vertex
(placed at its optimum distance of approximately A, of the cornea emerges as though from the image of
18.5 mm from the corneal vertex) was taken as 8 mm. the back surface formed at A‘ by refraction at the front
surface.
The Hruby lens was assumed to be 10mm from the
cornea. These dimensions should be understood to be By focusing the microscope first on the front vertex A,
no more than broadly representative. and then measuring’ the travel required to focus on
Of all the lenses, the aspherical is seen to perform best the image point Aj, the apparent thickness d’ can be de-
of all, thus vindicating its popularity. Of the three older termined. The true thickness d can then be calculated
types of lens, the El Bayadi lens is seen to perform the from the conjugate foci relationship. Let r,; denote the
best in myopia, while the Koeppe lens is the best in em- radius of curvature, F; the power ofthe anterior corneal
metropia and hypermetropia. The Hruby lens has the surface and n the refractive index of the corneal sub-
smallest field throughout the range investigated. A stance, normally taken as 1.376. Then, in outline,
further comparison may be made with the fields ob-
tained in direct and indirect ophthalmoscopy (tech-
“Some early instruments allowed the microscope to be
niques which are discussed on pages 312-324). The
moved forwards against a linear scale, independently of the
direct method gives about 2mm with a 4mm pupil, instrument as a whole. A different arrangement on modern
while the indirect method gives about 7 mm or more. instruments is to measure the travel of the whole instrument.
The calculations show that the binocular field is very Perkins (1988) determined the anterior chamber depth and
much less than the monocular. To improve on this, the lens thickness by adding a pointer arm to the slit lamp’s trolley
axle. If the diameter of the trolley wheels is known, the angle
Haag-Streit 900 BQ slit lamp introduced in 1986 can of rotation can be measured against a protractor scale and con-
be fitted with a Stereo-Variator, which reduces the effec- verted into a linear distance.
 Ocular measurements with the slit lamp 309

A4R refracted by the upper plate emerges along the

same path as the ray A,S through the fixed plate. In
Axis of illumination
this setting, the appearance is as suggested by Figure
16.11(b). The arrangement described would, in fact,
produce a complete doubling of the image, but a special
eyepiece incorporating a bi-prism and slit aperture in
Displaced the exit pupil plane is used to remove the unwanted
image half of each image. This makes coincidence setting
easier.
The lateral displacement a produced by a plate of
thickness t can be found from
eae Oey)
; (16.2)
cos d
where @ is the angle of incidence of the given ray and
Figure 16.11. (a) Measurement of the apparent thickness of
the cornea by the pachometer method ofJaeger. (b) Appearance the corresponding angle of refraction. In this case, ¢ is
of doubled image in correct setting. (Diagram not to scale.) also the angle through which the plate has been tilted
from its zero setting. A tilt of about 25° is needed for a
¢ = —d (d is taken as +ve) cornea of typical thickness.
mye : From the triangle A, A4T it will be seen that

joy ne Se d' = A,T cosec 0 = acosec 0 (TGz3;)

(= 1, = —d'(d also-eve) These two expressions enable the angle of tilt to be
plotted against the apparent corneal thickness d’.
which gives
Hence, by assuming particular values for r; and n in
© n
d (16.1) equation (16.1), the pachometer can be calibrated to
id a give a direct reading of the corneal thickness or depth
< n of anterior chamber. To measure the latter, a separate
(16.1a)
Sd ye model with thicker plates (about 5.5mm instead of
Measurement of the anterior chamber depth involves 1.25 mm) is made in order to give the larger displace-
the complication that refraction takes place at both sur- ment required.
faces of the cornea. For many purposes, however, it is An idea of the apparent thickness a is obtained by re-
sufficient to assume a single-surface cornea and to garding the cornea as a flat parallel plate of thickness
regard the depth of the anterior chamber as including 0.5 mm and index 1.375. For an observation angle 0 of
the corneal thickness. If so, equation (16.1) can still be 40°, the thickness d’ is about 0.26 mm, giving an appar-
used, provided that n now denotes the refractive index ent thickness a of about 0.20 mm. Exact ray tracing is
of the aqueous humour. necessary to take into account both the obliquity of the
ray from A, and the curvature of the cornea. Equations
are given by Patel (1981) and in the Appendix of Bren-
nan et al. (1989). Alternatively, experimental calibra-
The pachometer
tion on contact lenses could be used.
One drawback of the successive focusing method is that Correction tables are provided for use when the actual
an involuntary movement of the subject’s head may corneal radius differs from the standard value assumed.
take place between the two settings. This difficulty is If this difference is denoted by Ar,, it can be deduced
overcome by a device designed by Jaeger (1952) and from equation (16.la) that the resulting error E is
generally known as a pachometer, which fits over one given by the reasonable approximation
of the slit-lamp microscope objectives. The mode of
=(a i) Ar,
action of the Haag—Streit model is shown schematically ia ae
(16.4)
nry
in Figure 16.11. A vertical section of the anterior seg-
ment is illuminated by directing a very narrow beam Taking, as average values, 7.8 mm for r;, 0.5 mm for
through an aperture stop projecting from one side of the corneal thickness and 3.6 mm for the depth of ante-
the pachometer. The intended angle (40°, for example) rior chamber, we should have
is thus obtained between the axes of observation and il-
E = —0.0011 Ar, for the cornea
lumination, the patient looking at the light. Variable
doubling of the observed optical section is produced by and
two glass plates positioned in front of the microscope ob-
E = —0.053 Ar, for the anterior chamber
jective so as to bisect its aperture horizontally. The
fixed lower plate is normal to the optical axis, but the The effect of refractive index changes in the media
upper plate can be tilted about a vertical axis. As a should also be considered. If the true value is (n + An)
result, rays passing into the objective through this plate instead of the assumed value n, the value of d obtained
undergo a lateral displacement a which varies with the from equation (16.1) will be n/(n+ An) times the cor-
angle of tilt @. A duplicate image is thus formed. rect figure. For average ocular values, the resulting
The diagram shows the tilt adjusted such that the ray error in corneal thickness will be approximately
310 Visual examination of the eye and ophthalmoscopy

0.0004 mm for every 0.001 variation in the corneal re- is equivalent to a 1° change in angle between slit lamp
fractive index and the error in the depth of anterior and microscope.
chamber will be approximately 0.003 mm for every Another method of measuring the depth of anterior
0.001 variation in the refractive index of the aqueous. chamber is to photograph a slit-lamp section of the ante-
In monitoring thickness changes, accuracy depends rior chamber, the method used by Sorsby et al. (1961).
on measuring exactly the same part of the cornea or Clark and Lowe (1973, 1974) have discussed the
anterior chamber on each occasion. One method is to mathematical treatment of the measurements from the
direct the patient to look into the beam. The lateral pos- resulting photographs. =
ition of the instrument is then adjusted so that the Other methods of measuring corneal thickness and
beam reflected from the cornea forms a narrow patch of depth of anterior chamber, less suitable for routine clin-
light symmetrically distributed about the pachometer’s ical use, are described in Chapter 20.
aperture stop (Clark and Lowe, 1973; Stone, 1974). An-
other method (Mandell and Polse, 1969) is to fit small The applanation tonometer
lamps above and below the microscope objective and to
adjust the instrument so that the reflections of these The Goldmann applanation tonometer is a reliable
lights are immediately above and below the corneal sec- device for measuring the intra-ocular pressure. A plane
tion when viewed through the microscope. It is now surface is pressed against the anaesthetized cornea with
the observation, not the illuminating beam, that is a variable force until a circular area of 7.35 mm? (diam-
normal to the cornea. In the Holden—Payor technique, eter 3.06 mm) is flattened. The force then applied can
the illuminating beam is 40° to the side of fixation, ob- be shown to equal the pressure within the globe. One of
servation 25° from the other, while the angle of tilt of the factors determining the above choice of diameter
the pachometer plates is monitored by a computer so was that | g weight of force is then equal to the pressure
that many instrument settings may be recorded very
of 10 mmHg.
quickly.
In the original Goldmann design, the truncated cone
used to apply the force incorporates a prismatic dou-
A micropachometer bling device to ensure that the applanated area is of the
correct diameter. In Figure 16.12(a), illustrating a
The thickness of the corneal epithelium is less than
100 tum (microns). To measure it in vivo and without
touching the eye, apparatus called a micropachometer
has been devised by Wilson et al. (1980). A projection
system incorporating variable doubling plates was used
to form two bright slit images, each of about 0.007 mm
in width, very close to the corneal apex. Observation
was made through a Zeiss (Jena) slit lamp with a magni-
fication up to 100~x. For the three subjects examined,
the mean results from 40 measurements on each were
55.3, 65.4 and 65.5 um.

Depth of anterior chamber

A clinically orientated technique for measuring the
depth of anterior chamber with a slit lamp alone has
been described by Smith (1979). The instrument used
was a Haag-Streit 900 which has a scale recording the
length of the slit. With the slit horizontal and of mod-
erate thickness, the beam is focused on the subject's
cornea from the temporal side at an angle of 60° from
the visual axis. Observation is made along the visual
axis. The length of the slit is adjusted so that the inter-
section of its leading edge with the crystalline lens ap-
pears in alignment with the intersection of the opposite ¢ | Applanated | p
area
edge with the posterior surface of the cornea. The depth
of anterior chamber is found by multiplying the required
slit length by 1.117 and adding 0.5079 mm; or, more (b)
simply, multiplying by 1.1 and adding 0.5mm. The
derivation of this formula is described in detail.
Douthwaite and Spence (1986) modified Smith's tech-
nique by using a horizontal slit of fixed 2mm length
(governed by what is normally the height control), and ae aS
varying the obliquity of observation, the patient fixating Figure 16.12. (a) Cross-section of the Goldmann
applanation cone for measuring intra-ocular pressure: Gr Dj is
the slit. A conversion table was provided to give the the image of CD formed by prism P,; C5D4 the image formed by
anterior chamber depth. A change of 0.1 mm in depth prism P>. (b) Appearance ofthe split ring at the correct setting.
 Photography of the anterior segment 311

cross-section of the Goldmann cone, prism P, should be Slit-lamp photography

visualized as lying above the plane of the diagram and
prism P, below it, the two adjacent plane edges being Photography through the slit lamp with a relatively
in contact. The points C and D mark the horizontal broad beam of illumination may be undertaken by at-
diameter of the area to be flattened. The upper half of taching a camera to the eyepiece (Holden and Zantos,
1979; Thaller, 1983). Khaw and Elkington (1988) re-
this circle is deviated to the left by prism P,, which
commended the use of a single-lens reflex camera with
images CD at C,D,. The lower half is imaged by prism
an exposure meter recording from a small area in the
P, at C,D). The dimensions and angles of the prisms
centre of the viewfinder.
are so arranged that D, and C, are just in contact
Photography of a narrow section of the cornea re-
when CD has its predetermined value of 3.06 mm.
quires special apparatus. First, the illumination must be
Fluorescein stain is used so that the prismatic ring of
increased. One method is to boost the voltage supply to
tears liquid surrounding the applanated area becomes
the ordinary tungsten-filament bulb at the moment of
luminous under blue light. Since it is the internal per-
photographic exposure. Even so, relatively long expo-
iphery of this ring which defines the applanated area,
sures of perhaps 1/30 second may be needed, increasing
the correct setting is that shown on the left in Figure
the risk of an eye movement during this time. A much
16.12(b). The setting shown on the right is incorrect
superior method using electronic flash requires a modifi-
and would give too low a reading.
cation or addition to the slit-lamp system. One arrange-
This tonometer is conveniently used in conjunction
ment is to mount the flash tube in the position
with a slit lamp, on which it is mounted in front of the previously occupied by the tungsten-filament lamp. The
patient’s headrest. As well as giving the necessary sup- latter is moved further away from the projection lens
port, adequate magnification and illumination with and imaged on the flash tube by an extra condensing
blue light are also provided. system. Since the flash tube is transparent, it does not
It is important to adjust the level of the cone so that interfere with the illumination provided by the ordinary
the circle appears symmetrically split into two equal lamp for routine use of the slit lamp and focusing for
halves. Just before the cone touches the eye, the reflec- photography. When fired, the flash tube has a light
tion of its tip in the cornea may be seen through the mi- output many times greater than that of the lamp, but
croscope and this, together with the pupil, will aid for a duration of only about 1/1000 second.
initial alignment. Only a small final adjustment will The camera of the conventional photo slit lamp may
then be necessary after contact with the cornea has either have its own objective giving a magnification in
been made. The prism dividing line is usually set at hor- the range —0.5 to —2.0, or may view through one of
izontal, but when the cornea is markedly astigmatic the microscope objectives. In this case the magnification
should be set at 43° to the minus cylinder axis to allow is usually that of the microscope objective, possibly mul-
for the elliptical area of contact. tiplied by the zoom or Galilean magnification changer
The Goldmann cone is also used in the Perkins hand- incorporated in the instrument. Depending on the par-
held applanation tonometer, which gives a comparable ticular model, it is in the range —0.65 to —6.5. Both
standard of accuracy. still and continuous video displays using the normal
tungsten lamp and a CCD camera are also coming into
use.

Tilted image plane

Photography of the anterior segment
At magnifications in the neighbourhood of unity, the
External eye photography depth of field is very limited, even if the apertures of
both the camera lens and slit projector are reduced. As
A satisfactory view of the face can be obtained with an a result, only a portion of the slit-lamp section can be ac-
ordinary camera, using natural lighting, flood lighting curately in focus. This problem was overcome by
or electronic flash. For close-up photography (macro- Brown (1972) and Brown et al. (1987) in a research in-
photography) with object image reductions of 2:1 or strument designed to record anterior chamber geometry
even 1:1, a single-lens reflex camera can be used, prefer- and the relative amounts of light scattered by the
ably with a special macro-lens. The appropriate close- media. By using Scheimpflug’s principle of tilting the
up lens and extension tube or bellows must be fitted. A plane of the film with respect to the optical axis of the
headrest is required to keep the patient’s head steady, camera lens, a focused image of the complete slit-lamp
while the camera is best mounted on a sliding base si- section of the anterior segment can be obtained.
milar to that of the slit lamp. Informative papers written
for ophthalmic practitioners have been published by
Wagstaff (1970), Bfshop (1976) and Zantos and Pye Photography of corneal endothelium
(1980). Larger works on this topic by Hansell (1957), To obtain the higher magnification needed to record de-
Justice (1982) and Long (1984) may also be consulted. tails of the corneal endothelium, a conventional single-
lens reflex camera can be mounted behind one of the
microscope eyepieces. The latter then contributes to the
“Supplied by Clement Clarke International Ltd, Edinburgh final magnification (Holden and Zantos, 1979;
Way, Harlow, Essex CM20 2TT. Bellisario-Reyes et al., 1980). Alternatively, Long and
312 Visual examination of the eye and ophthalmoscopy

Murphy (1987) suggested doubling the magnification of in order to photo-coagulate it. Alternatively, if sufficient
a conventional slit-lamp camera by adding a telecon- energy is concentrated in an exposure of only a few na-
verter immediately in front of the camera body. They noseconds, the atoms of the tissue are ionized to form a
also recommended the use of fine-grain black and white gaseous plasma, thus obliterating it. For this purpose,
film such as Kodak Technical Pan 2415. thé laser radiation must be of a wavelength which the
The endothelium is best observed by the method of tissue absorbs strongly.
specular reflection, in which an obliquely incident The cornea transmits radiation of wavelengths be-
narrow illuminating beam is reflected by the cornea tween 300 and 1500nm and can therefore.be re-
into the observation system. The Eisner lens (1985), a shaped by the ultra-violet energy of shorter wavelength
hand-held contact lens giving a 2.2 magnification, from an excimer laser. The word ‘excimer’ is derived
has been developed for visual observation. A number of from ‘excited dimers’, a term denoting a highly unstable
specular photo-microscopes have been designed for this combination of an inert gas with a halogen, for example,
method. For example, the Nikon instrument uses a con- argon fluoride. As these molecules decay, ultra-violet
ventional photo slit-lamp illuminating system and ax light is emitted in extremely short pulses. For argon
or 10x camera objective to form an image directly on fluoride, the wavelength is 193 nm. A more detailed ac- -
the film.” The Leitz design follows earlier research in- count of this technique has been given by Marshall
struments in using a plano-convex lens to applanate an (1988). The infra-red energy emitted continuously
area of the cornea, thus increasing the area that can be from a carbon dioxide laser at 10 600 nm or from the
photographed in one exposure. holmium laser may also have application here.
Automated non-contact specular microscopes are The neodymium—-YAG (neodymium ions within a yt-
now available. Viewing a video monitor, the observer trium-aluminium-garnet crystal) pulsed laser emits in
places the instrument in approximately the correct pos- the near infra-red at 1063 nm. Radiation of this wave-
ition in relation to the patient’s eye. When the image of length passes through the cornea and can be used for
the endothelium is in focus, the computerized system cutting the posterior capsule if it should become cloudy
triggers the flash. The image is stored digitally, displayed after an extra-capsular cataract implant operation.
on the monitor and can be printed out on a video printer Punching a small hole in the iris of patients with poten-
at about 120x magnification. The cell density may also tial angle-closure glaucoma is another of its uses.
be calculated and displayed. The diode laser’s near infra-red radiation (810 nm)
and the krypton laser’s red light (647 nm) are absorbed
by melanin, and may be used for treatment of retinal
conditions. As the krypton laser’s wavelength is trans-
Photographic recording of a cataract
mitted by the yellow pigment of the macula, it may
have applications where coagulation is required close
The conventional photo-slit lamp may be used to photo-
to the fovea. The diode laser may be employed in con-
graph lens changes, either in slit section or by retro-illu-
junction with indocyanine green dye, since this absorbs
mination, the slit beam passing through the dilated
at this wavelength, re-emitting also in the near infra-
pupil and preferably being reflected from the optic disc.
red. The dye may be used to photograph choroidal ves-
For research purposes, a more precise recording of
sels, or for photocoagulation since it will accumulate in
areas and densities of the opacities is needed. In addition
zones of leakage.
to the tilted image plane camera described above,
The argon laser emits both blue (488 nm) and green
Brown et al. (1987) and Brown (1987) describe a retro-
light (514 nm), which are absorbed by both melanin
illumination system specifically designed for this. The il-
and haemoglobin. This laser is used to seal leaking
luminator and camera are positioned at right-angles,
blood vessels, and, with the addition of a green filter to
the illuminating beam being directed into the eye by a
absorb the blue light, may also be used near the
semi-reflecting mirror. The Purkinje images are almost
macula. Both this and the krypton lasers give continu-
eliminated by using a polarized hollow conical illumi-
ous emission of light as distinct from pulses. A low-
nating beam, with a crossed analyser in the viewing
intensity beam is produced for aiming, a high-power
pathway. Devices of the types described on page 44 for
flash being triggered when required. Instruments
assessing what is termed the retinal visual acuity are
mounted on slit lamps. having ultra-violet, infra-red or pulsed lasers need to in-
corporate low-powered lasers as well to give a continu-
ous emission of visible light for aiming purposes.

Lasers in eye treatment

The direct ophthalmoscope
Lasers can be incorporated in specialized slit lamps for
various therapeutic or surgical procedures. An account
Basic principle
has been given by Brown (1986). As these intense
sources of light can be aimed and focused very precisely, The ophthalmoscope is the standard instrument for ex-
the energy can be used to heat localized areas of tissue amining the posterior segment of the eye and fundus,
as well as allowing a view of the anterior segment in
general diffuse illumination. In normal conditions, the
“A 10x objective lens had previously been used in a similar pupil of the eye appears dark to an observer. Figure
way by Brown (1970). 16.13 represents a myopic eye, with H and J the edges
 lq’

i
Limiting cone
of rays

Figure 16.13. Observation of the fundus point Q. Both the Figure 16.15. Illumination of the fundus by the
light source and the observer's eye must lie within the cone ophthalmoscope.
Q'HJ.

Table 16.3. Diameter in millimetres of illuminated retinal patch

in direct ophthalmoscopy

g w= —25mm w= —35mm
(mm)
K K
—10D O +10D —10D O +10D

Examiner’s Patient’s 2 N53} Wes 0.6 OS) es

eye
eye - 4 2 ei 335.5) Ne? Ne) 2a
6 3.0 4.0 5.0 19 DS 3-9)
Figure 16.14. The simplest form of direct ophthalmoscope.

of the pupil, Q a point on the retina and Q’ its image in refraction, the rays of light converge to a focus behind
the eye’s far-point plane. The point Q would be illumi- the retina, illuminating an area of diameter j smaller
nated by a source of light placed anywhere within the than that of the pupil (Figure 16.15).
cone Q’HJ. For Q to be visible to an observer, the obser- If the size of the source is ignored, the illuminated
ver's eye must also be placed within this same cone. area of the fundus can be regarded as a blur circle. Its
Normally, the observer's head prevents illumination en- diameter j can thus be obtained from equation (4.16a)
tering the eye from within the cone. The ophthalmo- by substituting W(= 1/w) for L. Thus
scope is a device incorporating some form of beam
splitter to allow a beam of light to enter the eye, undergo (ai)
Jeet) K! (16.5)
diffuse reflection at the fundus and return to the exami-
ner’s eye by the same or a neighbouring path. At its sim- Table 16.3 gives specimen values for j over a range of
plest, the beam splitter is an inclined glass plate (Figure values of g,K and w, the dioptric length of the eye, K’.
16.14) reflecting light into the eye and allowing direct being taken as +60 D.
observation of the patient’s fundus. This method of Two points should be noted. The field of illumination
ophthalmoscopy is accordingly called direct to distin- in an emmetrope with a 4mm pupil is about the same
guish it from the ‘indirect’ method described on pages size as the optic disc, which is approximately 2 mm ver-
318-324. tically by 1.5 mm horizontally. Secondly, irrespective of
The detailed design of the direct instrument is consid- refractive error, the field of illumination reduces rapidly
ered later in this section. In outline, a modern system with increasing distance between instrument and eye.
usually consists of a small low-voltage bulb whose fila- In reality, the source has a finite size, say about 1 mm.
ment is imaged on an inclined mirror or reflecting This would increase the diameter of the illuminated
prism. This image acts as the immediate source of light. area by about 0.5 mm.
Just above the reflector is a sight hole through which The angular divergence of the cone of illumination,
the patient’s eye is viewed. One of a series of lenses can angle HS'J in Figure 16.15, need be no greater than
be placed behind the sight hole to allow any part of the would fill a fully dilated pupil of about 7 mm at a work-
media of fundus of an emmetropic or ametropic eye to ing distance of 35mm, an angle of about 11.5°. A
be brought into focus. These lenses could simulta- wider angle than this would not increase the area of
neously correct the spherical component of the exami- fundus illuminated.
ner’s own ametropia. With a normal, smaller sized pupil, the cone of illumi-
nation overlaps its margins, allowing some inexactness
in the position of the instrument relative to the patient's
eye. Controlling the area of fundus illuminated is impor-
Illumination of the fundus
tant and is discussed below.
The cone of rays jeaving the filament image or im-
mediate source will, in general, more than fill the pa-
tient’s pupil. The instrument is held close to the
Observation system
patient’s eye, but at its closest the immediate source
will be at a negative distance w, some 25 mm from the The optical system of the unaccommodated emmetropic
patient’s cornea and usually nearer 35 mm. This is well eye of power about +60 D forms an erect image of the
beyond the anterior focal point of the eye so that, after fundus at infinity. For an unaccommodated emmetropic
314 Visual examination of the eye and ophthalmoscopy

realistic value is that given by the ‘field of half illumina-

tion’. The meaning of this term is that the illumination
at the edge does not fall below 50% of its value at the
centre. This reduction is relatively unimportant because
physiologically and psychologically the observer adapts
to the difference, and can also turn the instrument to
bring the object of regard into the centre of the field of
view. The limiting ray is HC, originating from the point
S on the retina. It can be visualized from Figure 16.16
Figure 16.16. Fields of view of the direct ophthalmoscope.
Limiting ray paths: THB (maximum field); SHC (field of half that the full pencil of refracted rays from S covers the
illumination); RHA (field of full illumination). lower half of the sighthole. For the same values ofg and
w as previously, the field of half illumination would be
Gnome
or corrected observer, it thus acts like a magnifier of
power 15x. The same observer would also obtain a
clear view of the fundus of an ametropic eye by placing Field of full illumination
the appropriate lens before the sighthole, thereby cor-
This is the field within which every incident pencil fills
recting the spherical element of the subject's ametropia.
the sighthole. The limiting ray is HA, originating from
Although the ophthalmoscope can provide an approxi-
the retinal point R and meeting the axis at L. The field
mate estimate of the mean refractive error, a number of
is twice the angle HLP. On the same basis as before, its
factors lead to inaccuracies (Emsley, 1952).
value would be only 3.3°, but this figure is of little im-
Small amounts of astigmatism do not impair the view
portance in practice.
but higher amounts have marked effects. Because of the
different magnifications in the two principal meridians,
some scissors distortion may be evident and the optic Linear extent of fields
disc may appear to be unusually oval. Retinal blood ves-
The diameter of the observation field of half illumination
sels running in directions approximately parallel to one
(also known as the ‘useful field of view’) may be ob-
of the principal meridians may appear blurred in com-
tained by regarding C, the centre of the sighthole, as an
parison with others perpendicular to it, needing a differ-
object for the patient’s eye and calculating the blur-
ent sighthole lens to bring them into focus.
circle diameter on the patient's retina. Equation (16.5)
A much clearer view of the fundus of a highly astig-
and Table 16.3 can thus be regarded as giving the
matic eye is usually obtained by observation through
useful linear field of view as well as the field of illumina-
the patient’s spectacles. (For reasons discussed later,
tion. In practice, the sighthole is often 2-5 mm behind
this is also true of the highly myopic eye.) The highly
the filament image, thus making the useful field of obser-
astigmatic examiner should wear his correction or
vation slightly smaller than the field of illumination.
mount a lens or lenses of the appropriate power in a sup-
There is also a slight displacement, approximately 12°,
plementary cell or disc behind the sighthole.
between these two fields because the bulb filament is
imaged just below the sighthole.
Fields of view The other linear fields can be obtained in the same
way, taking L and M as object points. For the reduced
The fields of view are governed by the subject's pupil
emmetropic eye and other values as before, the results
diameter g, the sighthole aperture a, and their separa-
would be 2.86 mm (maximum) and 0.95 mm (full illu-
tion w. Given an eye with only moderate ametropia, the
mination).
pencil of rays emerging from any point on the retina
will be approximately parallel. In Figure 16.16, the var-
ious semi-fields of view are determined by rays emerging
from the upper extremity H of the pupil and passing re-
spectively through the upper extremity A, the centre C Magnification
and lower extremity B of the sighthole. Although it is easy to determine the ratio of image size
on the observer's retina to an object size on the patient's
Maximum field of view fundus, a more informative approach is to compare the
apparent subtense of a fundus element with the angle
The limiting ray is HB which originates from the point T that the same element would subtend if placed at the as-
on the retina and just enters the sighthole after inter- sumed reference seeing distance, i.e. —250mm or
secting the axis at M. The field of view is twice the —4 D. This is analogous to the method used to determine
angle HMP. For the typical values of g= 4mm, the conventional magnification of the ordinary magni-
a= 2mm and w= 35mm (neglecting its minus sign), fying glass (see page 248) and similarly neglects any dif-
the maximum field of view is 9.8°. ference between observers due to their own refractive
errors.
Field of half illumination Figure 16.17(a) illustrates the relationship for an em-
metropic eye. The fundus element M’Q of height h sub-
Because of vignetting, the illumination falls to zero at tends an angle u at the eye's principal point P. The
the extreme edge of the maximum field of view. A more image, being formed at infinity, subtends the same
 The direct ophthalmoscope 315
: rad 1

M = $/u, == x (16.9)
1—wk
Since w is a negative quantity, the term (1 — wK) is
greater than unity in hypermetropia and less than
unity in myopia. Consequently, for a given value of Kk’
the magnification is greater for the myopic than for the
hypermetropic eye. For example, if K’ is taken as +60 D
and w as —35mm, the magnification is 18.2 when
K = —5.00 D but only 12.8 when K = +5.00 D. On the
other hand, as shown by Table 16.3, the field of view is
greater in hypermetropia than in myopia. It has already
been pointed out that this table and equation (16.5)
apply also to the useful linear field of view. If equations
(16.5) and (16.9) are multiplied together, the result
can be reduced to
M = —gWw/4j (16.10)
showing that for given values of g and w the magnifica-
tion is inversely proportional to the useful linear field of
view j.
In medium and high myopia, it is often advantageous
to examine the central fundus through the patient's
own spectacles. The field of view is enlarged, while the
Figure 16.17. Magnification in direct ophthalmoscopy.
Patient's eye; (a) emmetropic, (b) hypermetropic, (c) myopic. fundus does not go out of focus so rapidly should the ex-
aminer move away from the patient.
In with-the-rule astigmatism, the disc will appear
angle u’ at the centre of the sighthole C as at P. In ra- more oval than usual because of the higher magnifica-
dians, these angles are given by tion in the eye’s stronger (vertical) principal meridian.
However, if the patient is made emmetropic by means
u=h/k’
of a contact lens, the working distance w no longer af-
and fects the magnification, which now becomes K’/4. Con-
sequently, the disc may not appear quite so oval,
Ho) =
though in high astigmatism its actual shape is possibly
Viewed directly from a distance of 250 mm or 0.25 m, abnormal. In myopia, the disc may indeed be larger
this same fundus element would subtend an angle u, than normal, as well as the increased magnification
equal to h/0.25. The magnification M under which it is making it appear so.
seen through the ophthalmoscope is therefore

Mau ju, =O25K =k /4 (16.6) Design requirements

Thus, for the standard reduced eye, M = 15. Several criteria must be satisfied for the instrument to
A hypermetropic eye is illustrated in Figure 16.17(b). provide a clear view of the fundus. These are:
The fundus is imaged behind the eye at MpQ’ where it
subtends a smaller angle at C than at P. The reverse ap- (1) Adequate illumination of the fundus. Halogen lamps
plies to the myopic eye, as shown in Figure 16.17(c). In of higher intensity are tending to replace the con-
both cases, the image height h’ is given by ventional tungsten-filament types but should not be
used any brighter than is necessary.
We = WK JK (16.7) (2) Control over the intensity of illumination. This is
often provided by a variable resistance, either in
and the angle which it subtends at the sighthole by
the instrument handle or in the transformer circuit.
be MpQ’ a h’ (3) Control over the area of fundus illuminated (the rea-
CMe CP PMa son for this is described on pages 317-318 on clini-
cal use of the direct ophthalmoscope).
h’ h'K
(4) Freedom from harmful radiation: the low-voltage,
~ —w+k Silom: low-wattage lamps normally used emit negligible
Using equation (16.7) we can replace h'K in this last ex- ultra-violet radiation and the amount of infra-red is
pression by hK’, giving too small to cause trouble. Strong illumination by
blue light, which can easily penetrate the ocular
OS (16.8) media, especially that of an aphakic, may also be a
possible cause of trouble (see 1980 Symposium on
As previously, for the unaided eye we have Intense Light Hazards and Ophthalmic Diagnosis
and Treatment, particularly the paper by Calkins et
it, = OQ Se
al., 1980). In general, examination of any one area
The magnification M can therefore be put in the form of the retina with the direct ophthalmoscope is
316 Visual examination of the eye and ophthalmoscopy

Ly
Figure 16.19. Imagery of the field stop DE in the direct
ophthalmoscope (mirror omitted for clarity). The source S is
imaged at S’ on the mirror by the condensing lenses L, and L),
and the stop at infinity by lens Ly. A second image (D5E5) of the
stop is thus formed on the retina of the emmetropic eye.

16.18). Sighthole flare is eliminated at the same time.

The lamp filament must be compact and_ special
pre-centred bulbs allow accurate positioning of the fila-
ment image on the mirror without requiring centring
adjustments on the instrument itself.
The corneal reflex and specular reflexes from the ret-
inal blood vessels and internal limiting membrane may
be eliminated by placing a piece of Polaroid material in
the illumination system below the mirror, and a crossed
analyser behind the sighthole. Since the diffusely re-
Figure 16.18. Optical system of the Keeler Vista Specialist flected light from the fundus does not remain polarized,
ophthalmoscope. (Redrawn from material kindly supplied by it is not extinguished by the analyser. The bulb output
Keeler Instruments Ltd.) has to be increased by about four times because the po-
larizer absorbs approximately 50% of the light, while a
further 50% of the scattered light from the fundus is ab-
unlikely to be prolonged enough to cause trouble,
sorbed by the analyser.
but the indirect instrument and fundus cameras to
be described below need careful design and use. To
reduce both the blue light hazard and glare to the
patient, the use of yellow-coated indirect ophthal- Typical designs
moscopy lenses is recommended.
(5) Freedom from stray light reflected from the edges of Figure 16.18 illustrates a modern ophthalmoscope.
the sighthole and lens mounts, known as sighthole Light from the bulb is collected by the multi-element
flare. condensing system and is imaged to form the immediate
(6) Minimization of the corneal reflex. source on the inclined stainless steel mirror just below
the sighthole. A series of diaphragms of different sizes
are mounted in the first focal plane of the last element
of the condensing system. They are therefore imaged in
The corneal reflex
sharp focus on the fundus of an emmetropic eye. Round
The cornea acts as a convex mirror and forms an image stops give illuminated field diameters subtending ap-
of the immediate source about 3.6mm behind its proximately 6, 12 and 30A at the eye’s nodal point.
vertex. When the sighthole lenses are adjusted to view Figure 16.19 shows these diaphragms to be aperture
this region of the eye, the corneal reflex forms a tiny stops with regard to the filament image, but field stops
bright spot in the field of view. When the lenses are for the instrument and eye together. Other shaped
changed to bring the fundus into focus, a much larger stops, graticules and filters may also be provided. The
though dimmer blur patch is formed on the observer's sighthole lenses are mounted in individual metal cells
retina, veiling the view of the central fundus. The size which are driven round a channel in the instrument by
of this blur patch may be reduced by decreasing the means of a cog wheel. This type of lens arrangement,
diameter of the sighthole to between 2 and 3 mm, but dating from 1883, was introduced by Morton as an im-
this also reduces the apparent brightness of the fundus. provement on Couper’s original system.
Early ophthalmoscopes often consisted of a silvered Figure 16.20 illustrates a somewhat different type of
mirror which reflected light from an external lamp into instrument. The condensing system consists of two
the eye, while the fundus was observed through a lenses and the convex lower face of a prism, which also
pierced hole in the mirror. This gave rise both to sight- reflects the light into the patient’s eye. This is a modifi-
hole flare and to a corneal reflex positioned in the cation of the instrument introduced in 1914 by May.
centre of the field of view. The corneal reflex may be de- The sighthole lenses are mounted around the circumfer-
centred by reflecting the light from just below the sight- ence of a disc — a development of the Rekoss disc of
hole. In many instruments, the immediate source is an about 1852. This type of arrangement is also often
image of the lamp filament which is formed on and re- called a May head. The May disc has fewer lenses than
flected by an inclined stainless steel mirror which ex- the Morton race, but both instruments are often pro-
tends only as far as the bottom of the sighthole (Figure vided with an auxiliary lens disc with further strong
 Clinical use of the direct ophthalmoscope 317

Still looking through the sighthole, the eye may be ap-

proached to a distance of about 35 mm or less, while
the lens power is reduced to focus progressively back-
wards in the eye to the fundus. The instrument should
be kept continuously in motion, angling it up and
down and from side to side to view neighbouring regions
of media and fundus. The patient is also requested to
look up, down, left, right or in oblique positions of gaze
so that the entire periphery of the fundus may be seen.
If the patient has small pupils, the largest field stop on
the ophthalmoscope will illuminate the iris. Light re-
flected by a light-coloured iris can make observation of
the fundus very much more difficult. Selection of a
medium-sized aperture will reduce the angle of the
cone of light and area of iris illuminated, making con-
ditions easier.
If the fovea is illuminated with the large field stop in
position, reflex miosis of the pupil is often very great:
pupil reaction is more pronounced when the central
rather than the peripheral retina is stimulated. This
effect could be reduced by dimming the illumination,
but it is then more difficult to see fine detail. The colour
Figure 16.20. (a) Optical system of the AO Fulvue
of the illumination will also become more red, upsetting
ophthalmoscope, using a modified May prism, also shown in
(b). (Reproduced by kind permission of American Optical the observer’s judgement of colour. A small field stop —
Corporation.) the macular stop of about 6A size — reduces the pupil
constriction because a smaller area of the retina is illu-
minated, even though the full intensity of light is main-
positive and negative lenses in order to extend the tained. This macular stop is, however, too small to
range. ’ allow easy observation of peripheral regions of the
Although the aperture stops and graticule are imaged retina.
sharply only on the fundi of emmetropes, a sharp image
Because of the small field of view with the macular
will still be formed in marked ametropia if the patient
stop, the macula may be difficult to find, though the
wears his refractive correction. In the Keeler Acuity
optic disc can usually be found easily. From the disc,
Scope, a graticule incorporating gratings of decreasing
the ophthalmoscope beam is moved temporally through
size is projected onto the fundus to evaluate the clarity
about three disc diameters, when the relatively vessel-
of the ocular media. In some other instruments the
free, darker red macula should be seen. The fovea is
graticule is mounted on an axial slide between the ele-
easily found if the patient is asked to look directly at the
ments of the condensing system, so that compensation
light, but it is then dangerously easy to miss a parama-
for the patient's refractive error can be made within the
cular lesion, and pupil miosis seems to be even greater
instrument. The slide is calibrated in dioptres to give a
with active than with passive fixation. This ‘lazy’
rough indication of the ametropia.
method is, however, useful at times and can help in de-
tecting eccentric fixation. Care should be taken to look
at the region one to two disc diameters on the temporal
side of the fovea. This seems to be particularly prone to
Clinical use of the direct diabetic retinopathy.
ophthalmoscope The observer's right eye should be used to view the
patient’s right eye, and left eye for left. For the right
It is essential to follow a routine in ophthalmoscopy so eye, the ophthalmoscope should be held in the right
that the eyes are examined thoroughly. With the hand, while the left hand rests either on the back of the
widest field stop in place, the instrument provides a uni- patient's chair, or on the patient’s forehead to make ob-
form illumination for inspecting the lids and tarsal and servation steady. This second position is preferable
bulbar conjunctiva with the naked eye. With the instru- when the pupil is small since it enables the practitioner
ment now held against the observer’s brow and a pos- to come as close as is safely possible to the patient’s
itive lens of power +10.00 DS to +15.00 DS in the eye, thereby increasing the field of view (see Table
sighthole, a magnified view of these structures can be 16.3). When the patient is looking down, the thumb of
obtained. The homogeneity of the cornea and crystalline the left hand can gently raise the upper lid, holding it
lens may also be checked, irregularities in structure about 10 mm above the margin. This allows the patient
often showing up as shadows against the fundus glow — to make a partial blink and is more comfortable than
light reflected back from the fundus. This glow usually when the lid is held immediately above the lashes.
becomes whiter and brighter if the ophthalmoscope is Irregularities in the contour of the fundus, such as
aimed at the optic disc, but peripheral lens opacities cupping or elevation of the disc, may be detected in
will not then be visible. three ways. First, a change in the power of the sighthole
318 Visual examination of the eye and ophthalmoscopy

Vv eral vision at all. This can be seen from Figure 15.10. Be-
cause of convergence, the area of an axial pencil at the
rear of the crystalline lens is about 75% of its area at
the pupil (see Figure 22.7 on page 425). An opacity on
the-axis of the lens will therefore obstruct a greater pro-
< portion of light directed towards the fovea if positioned
de ee near the rear rather than the front of the lens. A poster-
ior cataract is perhaps more difficult to see than an ante-
rior one, especially by focal illumination or the slit
lamp and thus may need to become more severe before
being discovered. The impairment of vision on eventual
Figure 16.21. Location of opacities in the media by diagnosis will thus be greater.
parallactic motion. Occasionally, disturbances in the deeper layers of the
fundus are better observed by illuminating a region
neighbouring the suspected area, which is then illumi- .
lens may be needed to focus on the structure at different nated by light scattered within the retina.
levels. This difference can be expressed in dioptres or The fundus appears red because of blood and pigment
converted approximately to millimetres by the rule in the retina and choroid. If the fundus is illuminated
ID 2mm (see page 64). (Clinically, the area of cupping by red-free light (usually obtained by placing a green
of the disc is often more important than the depth. Prob- filter in the illumination system and increasing the vol-
ably because there is less scattered light within the pa- tage supplied to the bulb), the retinal blood vessels
tient’s eye, the colour, contrast and demarcation of the appear black against a greenish ground. The contrast
cup are frequently enhanced if viewed with the macular of small haemorrhages or aneurysms is therefore in-
stop.) Secondly, if a streak of light is projected on to the creased. An even more dramatic enhancement of con-
fundus, irregularities of contour may be observable as trast of the vascular system is obtained by the
deviations in the edge of the streak. Some ophthalmo- technique of fluorescein angiography, in which fluores-
scopes have a slit aperture stop which can be used for cent dye is injected into a vein and the fundus photo-
this purpose. Alternatively, the edge of the largest field graphed in blue light. Fundus cameras are described on
stop might serve as a substitute for a light streak. In pages 324-327.
this use of the instrument, however, the very small Because the sighthole is usually placed above the im-
angle between the axes of illumination and observation mediate source, the conventional ophthalmoscope gives
becomes a disadvantage. For this reason, observation poorer illumination of the fundus at the handle end of
with a slit lamp in conjunction with a Volk or similar the field of view. The effect is worst when the instrument
lens as described earlier is much more satisfactory. Par- is held vertically and angled to view the inferior
allactic motion is the third clue to a difference in level. fundus, mainly because of the foreshortening of the
It may be observed, for example, with respect to blood pupil due to the obliquity of observation. A contributory
vessels at the margin of a cupped disc or shallow retinal factor is that more light is lost by surface reflections
separation as the axis of observation is moved across when the angle of incidence is very large, as in this
the pupil. case at the anterior surface of the crystalline lens. If the
Parallax may also be used to locate opacities in the instrument is held horizontally and rotated about the
media relative to the pupil margin (Figure 16.21). Opaci- axis of its handle, the inferior fundus may often be seen
ties anterior to the pupillary plane appear to move more brightly.
‘against’ the movement of the instrument, those in the
crystalline lens ‘with’ the ophthalmoscope. The corneal
reflex, although positioned near the middle of the crys-
talline lens, cannot be used to judge parallax since it
The indirect ophthalmoscope
also moves ‘with’ the motion of the ophthalmoscope.
The presence of extensive lenticular opacities always Basic principle
hinders fundus observation. A medium or small stop in The method of indirect ophthalmoscopy differs from the
the instrument is helpful and the ophthalmoscope direct in that a positive lens is used to form a real in-
should be held as close as is safely possible to the pa- verted image of the patient's fundus. This intermediate
tient’s eye so that any clear region of the media will sub- aerial image is viewed by the observer, who may need a
tend the maximum angle at the observer's eye. Dilation sighthole lens to bring it into focus.
of the pupil with a mydriatic often helps, but care must The principle of the method is shown in Figure 16.22.
be taken not to dilate the pupil of an eye with a very The immediate source (usually an image of the actual
narrow anterior chamber angle. : source) is placed in close proximity to the observer's
It is sometimes said that since a lens opacity or irregu- pupil (or sighthole) and both are imaged by a conden-
larity at the posterior pole of the crystalline lens is near sing lens into the plane of the subject's entrance pupil.
the nodal point of the eye, it will cause a greater dete- Since the condenser also forms the aerial image of the
rioration in vision than a similar opacity placed ante- fundus, its diameter controls the size of the field of obser-
riorly. In fact, an anterior cataract will spoil the vation as well as of illumination. The retinal fields of il-
definition of both central and peripheral images on the lumination and observation are of the same size and
retina, while the posterior defect may not affect periph- very nearly coincident, a small discrepancy arising
 The indirect ophthalmoscope 319

patch and substantially decreases the overall distance.

On the other hand, compared with the traditional
+13D lens, the magnification is reduced — the price
usually paid for an enlarged field of view, and vice versa.
As pointed out by Calkins et al. (1980), lenses of
power +20D and higher give a lower retinal illumi-
nance than a +14D lens because the illuminating
Figure 16.22. Basic principle of indirect ophthalmoscopy: beam is spread over a larger area. They also have the ad-
the observer's and patient’s pupillary planes are made
conjugate by the condensing lens UV. The immediate source S’
vantage of needing a smaller pupil and so a less power-
is thus imaged at S”. The dashed rays show the limits of the ful mydriatic can be used.
possible field of view and the dotted arrow the visible extent of
the illuminated aerial image.

from the separation of immediate source and sighthole. Magnification

In practice, it is the effective aperture of the lens which
limits the fields — the diameter within which its image Figure 16.23 shows the limiting ray paths from an illu-
aberrations remain unobtrusive. minated point R on the retina of a hypermetropic eye
The traditional power of the condenser is +13 D, and the formation of the aerial image. The distances k
though a power of +20 or 25D may be easier to use. and k’ are still regarded as positive, but for the return
To steady the condenser, the outstretched little finger of beam the direction of the light is reversed, so that q is
the hand holding it should be able to rest on the pa- negative and q’ positive. For calculation, Q(= 1/q) is
tient’s forehead. This limits the distance between patient conveniently regarded as —11.25D and Q'(= 1/q') as
and examiner. On the other hand, for comfortable view- +2.75D, the power F of the condenser being +14 D.
ing, the examiner should not be too close to the aerial The linear distances q and q’ are then —88.9 and
image. If a +13 D lens is held at about 91 mm from the +363.6mm respectively. By virtue of the returning
patient's entrance pupil, the correct distance for the ex- light, an image H’J’ of the subject’s pupil HJ is formed
aminer is about 500 mm from the condenser. The illu- in the plane of the sighthole by the condenser. Given
minated patch on the retina would then have a Q = —-11.25D and Q' = 42.75 D, the image H’J’ is 4.1
diameter of about 7mm, assuming the condenser to times the size of HJ. Every full pencil emerging from the
have an effective aperture of 40mm. This is in the subject's pupil and able to pass through the condenser
neighbourhood of three times its diameter in the direct must fill the exit pupil H’J’. Consequently, the full field
method at normal working distances. of view will be obtained provided that the sighthole is
By using aspherical surfaces to minimize aberrations, positioned anywhere within H’J’. Without such latitude,
it has been possible to increase both the actual and effec- indirect ophthalmoscopy in this simple form would be
tive diameters of the traditional condenser, and also to impracticable.
produce a range of considerably higher powers. For The subject's eye forms an image of R at R} in its far-
example, the current Nikon range’ comprises the fol- point plane. The emergent pencil of rays from R there-
lowing nominal powers with the effective apertures fore appears to diverge from R{ and is bounded by the
shown in parentheses: +14D (52mm), +20D rays HA and JB. After refraction by the condenser, the
(48.6 mm) and +28D (38.8 mm). Their centre thick- ray HA is bound to pass through H’ because H’ and H
nesses range from 12 to 14.5 mm; these lenses cannot are conjugate points. Similarly, the ray JB is bound to
be treated as thin. In the following discussion the pass through J’. The point at which these two refracted
power F of the condensing lens is therefore to be taken rays intersect, R5, is therefore the aerial image of
as its equivalent power. Also, the distances qg and q’ in R{, their virtual origin. In addition, the central ray
Figure 16.23 are measured from the respective principal path R4{ PGC also passes through R}. Figure 16.24
points of the lens, which are internal, uncrossed, and se- shows the corresponding construction for a myopic eye.
parated by about one-third of the centre thickness. As a When the sighthole is at the correct distance q’ from
result, the vertex distance from the lens to the eye will the condenser, it is unnecessary to determine h) in
be somewhat shorter than q, while the overall distance order to calculate the magnification. The angle u sub-
from the patient’s eye to the observer's is increased by a tended by h, at P and its conjugate angle u’ (OPG) are
trifling amount. expressed by
The purpose of the higher powered lenses is to in-
crease the field of view by holding the lens closer to the = hy RK
eye without increasing the overall working distance.
For example, the +14 D aspherical lens held at 84 mm and, because of the reverse ray trace
from the eye would give an illuminated retinal patch of
about 10mm diameter while slightly decreasing the i Sr nn hy
/
(16.11)
overall distance. The +20 D lens, designed to be held at
58 mm from the eye, gives an even larger illuminated The aerial image subtends the angle ¢ at the sighthole.
From the triangles OCG, OPG it can be seen that

* The Volk range extends from +15 to +40 D. d/u' =OP/0C=a/q' =0'/0
320 Visual examination of the eye and ophthalmoscopy
Return beam

Figure 16.23. Formation of the fundus images R} and R34 in indirect ophthalmoscopy with a hypermetropic patient. Positive
distances are measured towards the right in the incident beam (labelled below the optical axis) but towards the left in the return
beam (labelled above the axis).

so that, from equation (16.11) Table 16.4 Calculation of aerial image size and
magnification
b =u'(Q'/Q) = hy K'(Q’/Q) (16.12)
Given data K=+6D,K’=+64D
Viewed directly from the reference seeing distance of h=3mm,g = —90 mm
250mm, on which the determination of conventional F =+13D,d= +480 mm
magnification is based, the fundus element of height h,
would subtend an angle u, equal to h,/0.25 or 4h,. Calculating scheme Worked example
Consequently, the magnification M can be found from
Refraction by eye
the expression iy = AONE +32 mm
k = 1000/K +166.67 mm
M = o/u, = (K’'/4)(Q’/Q) (16.13)
Refraction by condenser
Thus, given the conjugates Q and Q’, the magnification f=q-—k —256.67 mm
is directly proportional to the dioptric length of the eye L = 1000/¢ = 57 S010)
L'=L+F Spo LOND
and inversely proportional to its axial length. If
6 = l000/7" +109.89 mm
k= 60 DO 11.25 Diand O' = 42°75 DP) 0 701s lies = Mik IL Tey =I 3357 saavan)
—().244 and the magnification is —3.66, the minus sign
Angular subtense at eye
denoting inversion of the image. This is much lower
a +370.11 mm
than in the direct method. p= h/(d—¢") —0.0370
If the +14D lens is used with the conjugates
Magnification
O==1050D (¢qe—95mm) and ©O'=4+43.50D
a) 0.012
(q’ = +285.7 mm), Q'/Q becomes —0.333. The magnifi- M = 0/uo —3.08
cation when K’ = +60 D is then increased to —5.0.
The ratio Q'/Q depends on the power of the conden-
sing lens and the distance chosen to separate the pa-
tient’s and observer's eyes. When these quantities are
QO, O' and F shows that if the magnification decreases, it
fixed, the necessary value of q can be found from conju-
indicates hypermetropia in excess of about +3 D. Other
gate foci relationships, leading to Q and Q’. When as-
refractive states give rise to an increase in magnifica-
pheric condensers of increasing power are used, the
tion.
working distance is progressively reduced and with it
A general ‘step along’ method of determining the pos-
the ratio Q’/Q. It varies from about —0.25 for a +14 D
ition and size of the aerial images, together with the
lens to about —0.12 for a +28 D lens. For the +90D
magnification obtained, is set out in Table 16.4, which
BIO lens (page 306) it is about —O.1.
should be used in conjunction with Figure 16.25. It is
The position of the aerial image varies considerably
applicable to cases in which the sighthole is not neces-
with the subject’s ametropia. In emmetropia it is
sarily at the correct distance q’ from the condenser but
formed in the anterior focal plane of the condenser. In
at some specified distance d from it.
hypermetropia, the pencils leaving the eye are diver-
gent, causing the image to be formed at a greater dis-
tance from the condenser. The reverse applies in
myopia.
Reflex-free observation
A rough idea of the subject’s ametropia can be ob- In direct ophthalmoscopy, the corneal reflex of the
tained by moving the condenser closer to the examiner's source can be displaced from the centre of the field of
eye. Calculation based on the conventional values of view and reduced in size by appropriate design of the
 The indirect ophthalmoscope 3 bo a

Figure 16.24. Formation of the fundus image for a myopic eye.

+ve

Figure 16.25. Magnification in indirect ophthalmoscopy. For dimensions indicated below the axis, the positive direction is to the
right. For dimensions above the axis, it is to the left.

geometrical optics of the instrument. Similarly, in the If the separation is insufficient, the corneal reflex may
indirect method, the corneal reflex and light reflected possibly be eliminated but the beams will overlap
back or scattered by the crystalline lens can be rendered within the crystalline lens as in Figure 16.26(c). Light
harmless, provided that certain conditions are met. scattered by lenticular opacities may then cause flare
Both the immediate source and the entrance pupil of visible in the return beam.
the observer’s eye are imaged in the plane of the pa- In most systems of indirect ophthalmoscopy, further
tient’s pupil at a magnification of Q'/Q, say about 0.2. reflections could arise from the surfaces of the condenser
These images are thus quite small. The image of the ob- lens. They can be reduced by anti-reflection coating the
server's pupil acts as the exit pupil for the return beam. lens and displaced by tilting it slightly.
Only those rays emerging from within this area can In general, a fairly large or even a pupil dilated by my-
enter the observer's pupil. Being small, the two images driasis is required for the indirect method.
in the patient’s pupil can be completely separated.
Given enough separation, any overlap between the en-
Types of indirect ophthalmoscopes
tering beam and the return beam through the exit
pupil can be avoided in the region of the cornea and Instruments for indirect ophthalmoscopy can be divided
crystalline lens. Specular reflections from the entering into two main categories: those which use the same con-
beam at the various surfaces are then unable to affect denser for both illumination and observation and those
the return beam. This condition, due to Gullstrand, is il- which do not. The principle of the first category is illu-
lustrated in Figure 16.26(a). strated in Figure 16.22.
 The lens is held close to the patient’s eye, and moved to
centralize the fundus glow within the condenser. The
lens is then withdrawn from the patient’s eye until the
expanding fundus glow fills the condenser. At this se-
paration, the patient's pupil is imaged in the plane of
the observer's. The observer will have to accommodate
for a distance closer than the condenser, possibly by
wearing a near correction. :
An ordinary direct ophthalmoscope could be used, but
this is not very satisfactory as the internal condensing
(a)
system produces a beam with too wide an angle. A mod-
ified condensing system is needed to provide a narrower
spread of light, so that the aperture of the hand-held
condenser is only just covered. If the examiner views
the fundus image through the normal sighthole, the
image will appear even duller. Since the sighthole usual-
ly has a diameter between 2 and 3 mm and is imaged
into the patient’s eye with a magnification of —O.2 or
less, the exit pupil for the return beam is very small.
Moreover, the separation of the illuminating and obser-
(b)
vation systems is too small to allow reflex-free observa-
tion. Some direct ophthalmoscopes can be converted for
indirect use by increasing the separation between the
immediate source and sighthole and by using larger
than normal sighthole lenses. Alternatively, the top of
the instrument is removed, allowing the observer to
look above the ophthalmoscope. His own pupil then
forms the aperture stop for the system.
An early stand instrument of this type was the large
simplified Gullstrand ophthalmoscope. The photometry
of the indirect method is discussed further by Martin
Figure 16.26. Paths of the entrance and exit bundles (L95a9)
through the anterior segment of the eye in indirect
ophthalmoscopy: (a) complete separation of the beams giving
reflex-free conditions, (b) inadequate separation giving both Binocular indirect ophthalmoscopy (BIO)
corneal reflex and lens flare, (c) focus readjusted to eliminate
corneal reflex at the expense of increased lens flare, the beams This method of indirect ophthalmoscopy has been elabo-
having the same separation as in (b).
rated into a binocular system. An example is shown in
Figure 16.27. A lamphouse, mounted above and be-
Single-condenser instruments tween the examiner’s eyes on a headband or spectacle
frame, illuminates the condenser which images the
To observe the patient's right fundus, the light source is source at the bottom of the patient’s pupil. Paired mir-
held in the right hand and the condenser between the rors before the observer's eyes reduce the inter-pupillary
thumb and forefinger of the left hand, the little finger distance so that the effective entrance pupils are
resting on the patient’s forehead or zygomatic bone. imaged side by side near the top of the patient's pupil.

Figure 16.27. Layout of the headband or spectacle binocular indirect ophthalmoscope.

 Comparison of methods ho
WwW

Figure 16.28. Stereopsis in binocular indirect

ophthalmoscopy. The view of the image of B by the left eye is to
the right of the image of A, exactly as when viewing B and A
directly.

On some modern instruments, the distance between

these paired mirrors and also between them and the
lamphouse are adjustable. The narrowest separation is
employed if the patient has small pupils, while the
wider separation gives better stereopsis and less media
flare. This type of device was originally introduced by
the French ophthalmologist Giraud-Teulon and inde-
pendently by Schepens (1947, 1951). The right eye is
imaged at the left of the patient's pupil and vice versa
for the left eye. This inversion of the exit pupils does
not give pseudoscopic vision because the aerial image is
also inverted. Figure 16.28 shows two objects, A on the
fundus and B in front of the fundus. The image B’ of B
is nearer the observer than the image A’. To his left eye
it appears on the right on A’, and to his right eye on
the left of A’. This crossed projection is exactly the
Figure 16.29. The AO monocular indirect ophthalmoscope.
same as if A’ and B’ were real objects instead of inverted (Photograph reproduced by kind permission of the American
images. The stereoscopic view produced by this instru- Optical Corporation Inc.)
ment is extremely useful clinically, while the head-
mounted illuminator allows one hand to remain free to
manipulate the patient's eyelids, draw the fundus and focus on the erect aerial image, the position of which
varies with the subject’s refractive error. With a typical
so on. Potter et al. (1988) and the Volk Optical Instruc-
eye, the magnification is about 5x, while the angular
tion Manuals (see References) are useful sources de-
field of view can be extended to 20°. This instrument
scribing the clinical techniques needed for this type of
ophthalmoscopy. could be particularly useful for practitioners who have
A binocular stand instrument was introduced by only one eye with good acuity.
Bausch and Lomb in the 1930s. In the Zeiss Jena Bin-
ocular Ophthalmoscope 110, the aerial image of the
fundus is further magnified by an additional system in
front of the eyepiece, giving final magnifications of Comparison of methods
15x, 20 and 40x; the corresponding fields of view
are 40°, 29° and 14.5”. The advantages of indirect ophthalmoscopy over the
The El Bayadi and aspherical lenses discussed on direct method are that:
pages 306-307 convert the slit-lamp biomicroscope to (1) a much larger field is obtained, giving a general
a binocular indirect ophthalmoscope. view of the fundus and of changes over a large area
(especially useful in myopia);
(2) flare caused by poor media can be reduced, a rea-
Instruments with separate condensers
sonable view of the fundus often being obtained
In this second category of indirect ophthalmoscopes, se- where no useful view can be achieved with the
parate condensers are used for illumination and obser- direct instrument;
vation. One of the earliest stand instruments — the (3) the fundus periphery is seen more clearly, perhaps
Gullstrand reflex-free ophthalmoscope — uses _ this because the small exit pupil and lower magnifica-
system, which is now incorporated in the modern hand tion reduce the effects of oblique image aberrations;
instrument illustrated in Figure 16.29. The lamp fila- (4) a stereoscopic view can be obtained.
ment is imaged by a multi-lens condenser system and
The disadvantages are:
semi-reflecting mirror into the bottom of the subject's
pupil. Instead of a series of stops, an iris diaphragm is (1) The much lower magnification, 2-4 as opposed to
used to vary the field of view. Observation is made by about 15x, though specially designed instruments
means of a second multi-lens condenser, the aerial incorporating a telescope can narrow or restore
image being re-inverted by an erecting system before this discrepancy. Important but tiny foveal lesions
being viewed through the eyepiece. The instrument can easily be missed.
thus shows the fundus in the same orientation as the (2) The technique is rather more difficult to use, espe-
direct ophthalmoscope. The eyepiece is adjustable to cially with a patient who cannot keep his eye still.
324 Visual examination of the eye and ophthalmoscopy

It is very easy to lose the image completely when the which it was used. At that time, however, the very
patient's eye is turned so that the fundus periphery short life of the electric bulb and the bulk of the battery
may be viewed. were serious drawbacks. It was the development of min-
(3) The indirect system normally gives an inverted iature low-voltage bulbs and torch batteries which
image, which is confusing to practitioners who could be housed in the instrument handle that led to
rarely use the method since the instrument has to the variety of instruments available today. In recent
be moved in the opposite direction to that in the years, halogen bulbs have been introduced because of
direct method. their higher luminance, colour temperature and longer
(4) Unfortunately, the larger field of illumination tends life.
to produce greater pupillary contraction than the Although Helmholtz had realized that indirect
direct method so that a mydriatic is usually needed ophthalmoscopy was possible, he thought it would
to dilate the pupil. have little advantage over the direct method. Ruete, in
1852, was the first to use the indirect method.
On balance, the direct method is more useful gener- Descriptions of the development of the ophthalmo-
ally to optometrists, the indirect method being used scope are available in the excellent text by Rucker
when appropriate. (1971) and details of some of the early instruments are
also to be found in Helmholtz’s treatise (English edition
1924) and of a number of later designs in the work by
Development of the ophthalmoscope Emsley (1952).
As Rucker points out, the term ophthalmoscope — de-
Three stages can be discerned in the development of the rived from the Greek ophthalmos (eye) and_ skopos
ophthalmoscope, the first being the illumination of the (target) — was not used by Helmholtz but soon came
fundus in such a way that the pupil appears luminous into use in America. Helmholtz called the instrument
to an observer. Everyone is familiar with the bright an Augenspiegel (eye mirror), the term still in use in
reflex in the pupils of cats and dogs caught in the German-speaking countries.
beams of vehicle headlights. This reflex is easily seen be-
cause of the large proportion of incident light reflected
at the retinal tapetum and the wide pupillary aperture.
In 1823, Purkinje described how the pupils of dogs, The fundus camera
and then humans, were made luminous by light re-
flected into their eyes from a concave front surface of The fundus camera is based upon the reflex-free indirect
the spectacle lenses worn to correct his myopia. William ophthalmoscope. Reflections from lenses within the in-
Cumming, while at the Royal London Ophthalmic Hos- strument must also be eliminated by careful design of
pital, took the investigation of the reflex a stage further lens-surface curvatures and the positioning of internal
in his attempt to relate its colour and luminosity to var- aperture stops.
ious pathological conditions. In 1846, he described The illuminating system consists of a tungsten bulb to
optimum conditions for clinical observation of the pupil- set up and focus the instrument, with an electronic
lary reflex and noted that the axes of illumination and flash or strobe (a xenon arc discharge tube) for the
observation should be as close together as possible. photographic exposure. As in some photo slit lamps,
To obtain a useful view of the illuminated fundus was the tungsten bulb can be focused on to the flash tube
the next stage. The first true ophthalmoscope, in the by means of a relay condenser. When the flash is fired,
sense of an instrument providing such a view, was its intensity is many times greater than that of the tung-
made in about 1847 by the English mathematician sten lamp, the effective exposure being about
Charles Babbage, best known for his pioneer work on 1/500 second or less. Alternatively, the light from the
computing engines. His simple device consisted of a tungsten bulb can be reflected towards the eye by
plane mirror with perforations in the silvering. Because means of an inclined glass plate, light from the flash pas-
Babbage’s idea was never developed into a clinical in- sing straight through it.
strument, Hermann von Helmholtz is usually regarded In the system shown in Figure 16.30, the illuminating
as the inventor of the ophthalmoscope. His first model, beam enters the eye through the lower part of the
announced in 1850, used three microscope cover- pupil, observation and photography being through the
glasses, bound together and mounted at an angle to the upper part. In the different arrangement shown in
sighthole, to reflect light into the subject's eye from an Figure 16.31, illumination from the flash enters the eye
oil lamp placed beside his head. Provision was made for through an annular area, observation being made
incorporating lenses for the correction of ametropia, through the centre of the pupil. During photography,
but a later model in 1852 used the more convenient,
ro- the mirror (3) reflecting light from the flash into the
tating disc of lenses suggested by Rekoss. A large system swings up and another mirror (15) folds down
number of different instruments using light reflected to allow exposure of the film. The head (18) may be in-
from an external source were produced during the terchanged to allow stereoscopic fundus photography,
years up to the early part of the twentieth century. while the alternative lenses (13) provide a 50° field at
The final major development into the now familiar 1.5 or a 30° field at 2.5 on the film.
type of hand ophthalmoscope arose from the invention A blue filter can be inserted in the illumination beam
of the electric lamp. In 1885, the American ophthalmol- and a yellow filter in the observation path in order to
ogist Dennett produced the first ophthalmoscope in photograph the passage of fluorescein dye through the
 The fundus camera 325

Eyepiece beam is in focus on the patient’s iris. A slight movement

of the camera will then allow the light to pass into the
eye with the camera’s illumination and observation
pupils correctly positioned for reflex-free observation
2X converter and maximum field of view. Rotation of the eye to
photograph another part of the fundus will almost
always require repositioning of the camera.
Modern fundus cameras can provide fields up to 45°
and over. Aspheric condensing lenses are often used
| \ and some cameras now have an additional lens placed
Tungsten Flash
in contact with the cornea. By this means, fields up to
observation
lamp 100° can be obtained.

Figure 16.30. Simplified diagram of the optical system of the

Kowa RC2 fundus camera. (Redrawn from information kindly
given by Keeler Instruments Ltd.) Non-mydriatic fundus cameras
Non-mydriatic fundus cameras incorporate an infra-red
video camera to allow alignment with the patient’s eye
retinal vessels, a process called fluorescein angiography.
and focusing on the fundus. Working in a darkened
The power supply for the flash has,to be capable of al-
room enables the pupil to remain naturally dilated,
lowing exposures every few seconds. Black and white
whereas the focusing beam of the usual fundus camera
monochrome film is normally used in this technique. would constrict the pupil. Provided that it dilates to
For normal work, a high-contrast colour film with good about 4-4.5 mm, satisfactory photographs can be ob-
colour discrimination at the red end of the spectrum is tained because the electronic flash is quicker than the
needed. pupillary reflex. Some patients find the resulting bright-
Details in the photographs may be enhanced for speci- ness and after-image more disturbing but are spared
fic purposes by dark-room methods (see, for example, the time needed for a mydriatic both to work and wear
Shakespeare, 1987), or computer processing (Gilchrist, off. Polaroid film is often employed for convenience,
1987a,b; Cox and Wood, 1991a,b). though 35 mm film records finer detail. Still video or
The patient’s pupil must first be dilated with a cyclo- computer recording with the image captured by a CCD
plegic or strong mydriatic. With the patient seated com- camera needs less light than conventional photography.
fortably with the head on the rest, the camera is moved Pupil dilation is probably still required in the presence
so that the image of the aperture stop of the illuminating of media opacities.

2 7 "} i 16
=e. ~- ise aeas cal
(NRE eee | |
Formed Ve (aer=
—— -—.
ra <A =(——>
7
7
“4
whe tS Q y)
Se % >

>
Figure 16.31. Optical system of the Zeiss Oberkochen stereo fundus camera FK 50. Key: | flash tube, 2 tungsten lamp, 3 swing-in
mirror, 4 filter, 5 illumination aperture stop, 6 illumination field stop, 7 annular mirror, 8 aspheric objective, 9 patient’s eye, 10
internal viewing system (for camera alignment, ray path incomplete for clarity), 11 astigmatism compensator, 12 internal focusing,
13 50°/30° field-selection system, 14 filter, 15 swing-in mirror, 16 stereo-binocular tube with eyepieces, 17 film plane, 18
interchangeable ocular head (the secondary photographic or observation system within head 18 has been omitted for clarity).
326 Visual examination of the eye and ophthalmoscopy

HeNe

Detector

Retina Confocal
ee aperture, A

B" B' Be Figure 16.33. The confocal principle. The confocal aperture
A is imaged at A’, so light returning from A’ strikes the
Figure 16.32. Optical system of the Scanning Laser detector. Most ofthe light returning from deeper in the retina at
Ophthalmoscope. Key: HeNe helium—neon laser, B beam B is occluded by the aperture surround.
diverter. H, V horizontal and vertical scanning mirrors, N, O
concave mirrors, L lens, P pupil, A confocal aperture, D
detector. For simplicity, the deviation produced by all the
mirrors except B has been ignored. The input beam is shown so that the scanning instrument may be used in a non-
shaded. mydriatic mode.
Webb et al. (1987) give a detailed description of both
the optical and electronic arrangement of the instru-
Measurement of fundus details ment. They point out that because the observation
beam is only about 10~° the intensity of the illuminat-
The image height on a fundus photograph of a structure ing beam, if lenses were incorporated in the instrument,
such as the optic disc may depend upon several vari- reflections would grossly reduce the clarity of the
ables, for example the axial length of the patient’s eye, image. Hence imaging in the part traversed jointly by
the amount of ametropia, the design of the camera and the illuminating and observation beams is performed by
the photographic format such as 35 mm or Polaroid. mirrors.
Littman (1982, 1992), cited by Rudnicka et al. In Figure 16.32, which gives a simplified schematic of
(1992), developed a Zeiss fundus camera with its objec- the laser ophthalmoscope, the illuminating beam is
tive based on telecentric principles. Like the Badal opt- directed by a small mirror B towards the patient's eye.
ometer illustrated in Figure 4.25, the angle u is given This is scanned horizontally across the fundus by
by the relation: means of a rotating polygonal mirror H. Since this is
u=nh/k placed in the image plane P” of the pupil formed by mir-
rors O and N, the beam passes through a stationary
where his the height of the fundus detail. These workers
zone | or 2 mm in diameter in the middle ofthe patient's
showed that h can be expressed as a function of the
pupil, even though the beam is moving across the
image size h’ by an expression of form:
fundus. Similarly, the vertical scanner V is placed in
h = pk’h'/57.296n' = pk’h'/76.539 (16.14) the first image plane P’ produced by mirror O, which is
where p is a value depending on the camera and n’ is as- equivalent to the normal ophthalmoscopy lens.
sumed to be 1.336. The value for k’ for any particular The observation beam is formed by light leaving the
patient can only be surmised. The combination of cor- eye through the annular zone between the pupil
neal power and refractive error K would give a clue, margin and the image B” of the beam diverter. The
while the addition of ultrasonography would refine the third aerial image of the fundus is positioned at A.
estimate further. For the original Zeiss camera, p took These instruments have been further developed to pro-
the value 1.37, but this could be ascertained experimen- vide confocal imaging. In this, not only is a small
tally for any camera by photographing an object of region illuminated, but the image is recorded from light
known size on the ‘retina’ of a model eye for various de- scattered back from only a small volume surrounding
grees of ametropia. A camera of telecentric design the illuminated point. The instrument is made confocal
should give a constant value for p irrespective of the by placing a small aperture here, as shown in Figure
ametropia while Rudnicka and colleagues showed that 16.33. A narrow illuminating beam is shown passing
p was linearly proportional to the ametropia for a perpendicularly into the retina. Light returning from
camera that was not telecentric. around point A’ will pass through the confocal aperture
A, whereas light from deeper in the retina, say at B, is
mostly occluded. The ophthalmoscope records informa-
tion from a depth of about 300 tm around the illumi-
Scanning laser ophthalmoscopes
nated point. This greatly reduces loss of definition by
Scanning laser ophthalmoscopes are video fundus cam- light scattered from the media, or from deeper or more
eras, in which a laser is used to illuminate a very small superficial layers of the fundus. Thus contrast of structures
area of the fundus at any one instant. A red helium— such as the lamina cribosa of the optic disc are much
neon laser at 633 nm is generally employed, giving a clearer than in a conventional fundus photograph,
spot about 25-30 um in diameter. The full picture is ob- though conversely, thick scattering layers such as exu-
tained by sweeping the illuminating beam across the date show up less well. Alternatively, a small occluder
fundus while the electron beam of the video-display at A will eliminate light returned from the volume
moves in harmony. Even though the spot is relatively around this point, but records light scattered from
bright, very much less radiation is entering the patient's deeper or shallower layers, in a manner reminiscent of
eye than with a conventional indirect ophthalmoscope dark-field microscopy. The instrument may also be used
 References 327

with no aperture here, in which case it performs more the pupil diameter to be 4mm and the ophthalmoscope sight-
like a normal fundus camera. hole and immediate source to be at 37 mm from the cornea, cal-
culate the field of illumination on the fundus and
The ability to image defined depths in the eye enables magnification for both cases.
the instrument to provide sections of the eye in a plane 16.9 In direct ophthalmoscopy, what are the apparent mag-
perpendicular to the axis of illumination. Thus the Hei- nifications of the fundus in the principal meridians of an astig-
delberg retina tomograph can, for example, record 32 matic eye of ocular refraction +4.00/—6.00 x 180, the
ophthalmoscope being 40 mm from the eye’s principal point.
confocal sections of the nerve head, from which it can
Assume K’ to be +62 D.
plot out a cross-section showing the depth and width of 16.10 In direct ophthalmoscopy, what proportion of the
the cup. fundus may be seen without moving the instrument? Assume
An argon laser providing blue light allows fluorescein an emmetropic reduced eye with pupil diameter 5mm,
angiography to be undertaken, while a diode laser oper- F, +60 D, working distance 40 mm and a maximum possible
field with instrument movement of only the posterior hemi-
ating in the near infra-red at 805 nm allows indocya- sphere, the radius of which may be taken as 12 mm.
nine green angiography. If the output from the laser is 16.11 The image of the bulb filament formed on the mirror of
modulated, test stimuli can be projected on to the a direct ophthalmoscope is 2 mm in height. Calculate the pos-
retina and simultaneously viewed by the examiner. The ition and size of the Purkinje I image when the mirror is: (a)
40 mm, (b) 25mm from the patient's cornea, the radius of
retinal region employed for reading by patients suffering
which is 8 mm.
from macular damage can then be observed (e.g. 16.12 Indirect ophthalmoscopy is carried out on a hyperme-
Culham, 1991). Reviews of the instrument are given by trope of +4.00 D (axial error) with the aid of a +16.00 D con-
Woon et al. (1992), Culham (1991) and Bhandari and denser held 75 mm from the subject's eye. Determine: (a) the
Fitzke (1994). . correct position of the observer's eye for optimum viewing con-
ditions, (b) the position and size of the aerial image of the optic
disc (1.5 mm diameter) and (c) the magnification under which
the fundus would be seen by an accurately placed observer.
16.13 The fundus of an emmetropic eye of normal length is
viewed in indirect ophthalmoscopy by means of a +16.00 D
Exercises condenser held 500mm from the observer's eye. How far
should the condenser be placed from the subject’s eye and
16.1 A slit-lamp microscope has an objective diameter of what would be the linear extent of fundus visible if the con-
8 mm and a working distance of 80 mm. Calculate the limit of denser had a useful aperture of 36 mm?
resolution. What is the necessary magnification for this limit 16.14 (a) In indirect ophthalmoscopy, an eye of power +60 D
to subtend 2 minutes of arc at the observer's eye? is observed with a +20D condenser lens placed with its
16.2 A slit lamp has a projector aperture (horizontal) of second principal focus coincident with the eye’s first. The obser-
8mm and working distance of 80mm. Calculate the depth of ver's eye is placed in the plane of the aerial image of the pa-
focus for the beam such that its width does not exceed: (a) tient’s eye. Calculate the diameter of that area of the patient’s
0.02 mm, (b) 0.05 mm, the slit width itself being assumed to pupil utilized by the return beam filling the observer's entrance
be infinitesimal. (Compare these results with the thickness of pupil of 4mm diameter. (b) Calculate the magnification of the
the cornea.) fundus for: (i) an emmetrope, (ii) an axial myope of —5.00 D.
16.3 In pachometry, a narrow beam of nearly parallel light is 16.15 In indirect ophthalmoscopy, an eye is observed with a
incident on the cornea, its width at the cornea being 0.05 mm. +20 D lens held 55mm from the apparent pupillary plane of
Calculate the width of the reflected beam at the pachometer the patient’s eye, while the observer's eye is 250 mm from the
stop 100 mm away, assuming the radius of curvature of the condenser. What diameter of the condenser is filled with light,
cornea to be 8 mm. assuming the observer's pupil diameter to be 4 mm?
16.4 In measuring anterior chamber depth, the patient looks 16.16 What are the requirements, in both direct and indirect
at the slit lamp while observation is made from 45° to the side. ophthalmoscopy, for maximizing the field of view? Are there
On the basis of paraxial theory, what is the transverse linear any disadvantages if these conditions are obtained?
doubling required to obtain coincidence of the anterior corneal 16.17 A range of aspheric indirect ophthalmoscopy lenses
and lens surfaces? Assume a single-surface cornea of radius has the following particulars:
8.0 mm and values of 3.6mm and 1.336 respectively for the
Equivalent power (D) q (mm) Diameter (mm)
anterior chamber depth and refractive index of the aqueous.
16.5 Calculate the sighthole lens power needed by an unac-
(a) +14 Oh Sy
commodated emmetrope to view the fundus of: (a) a hyperme-
(b) +20 —60.0 48
trope of +10.00D, (b) a myope of —10.00D_ spectacle
(c) +28 —40.8 39
refraction, both at 15 mm vertex distance. Assume a 35 mm se-
paration between the subject's cornea and the ophthalmoscope Calculate for each: (i) the magnification that will be given for a
lens. (Note the difference in these results.) patient's eye of standard dioptric length +60 D, the observer's
16.6 In direct ophthalmoscopy the subject is an unaccommo- eye being placed in the optimum position; (ii) the angular field
dated uncorrected myope of —10.00 D spectacle refraction and of view as given by the subtense of the lens aperture at the pa-
the observer an uncorrected myope of —5.00 D spectacle refrac- tient’s eye. (The distance q as given is measured from the prin-
tion. The spectacle plane is 15 mm from the eye in each case. cipal point of the lens nearer to the patient's eye, but for the
If the observer obtains a clear view of the fundus with a purpose of this question all the lenses may be regarded as thin.)
—20.00 D lens in the sighthole, how much (spectacle) accom-
modation is he exerting? Assume the eyes to be separated by
50 mm with the sighthole 20 mm from the observer's eye.
16.7. Calculate the magnification in direct ophthalmoscopy,
assuming the subject’s*eye to be 25mm from the sighthole,
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JAEGER, W. (1952) Tiefenmessung der menschlichen Vorder- the anterior chamber. Br. J. Ophthal., 63, 215-220
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age of three. Spec. Rep. Ser. med. Res. Coun., No. 301, Appen- WAGSTAFE, D.F. (1970) External eye photography in ophthal-
dices C and D. London: HMSO mic practice. Ophthal. Optn, 10, 17-20, 25-28
STONE, J. (1974) The measurement of corneal thickness. WEBB, R.H., HUGHES, G.W. and DELORI, F.C. (1987) Confocal
Contact Lens, 5(2), 15-19 scanning laser ophthalmoscope. Appl. Optics, 26,
STONE, J. (1989) Special types of contact lenses and their uses. 1492-1499
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THALLER, V.T. (1983) An inexpensive method of slit-lamp WOON, W.H., FITZKE, F.W., BIRD, A.c. and MARSHALL, J. (1992)
photography. Br. J. Ophthal., 67, 63-66 Confocal imaging of the fundus using a scanning laser
VAN HERICK, W., SHAFFER, R.N. and SCHWARTZ, A. (1969) Esti- ophthalmoscope. Br. J. Ophthalmol., 76, 470-474
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VOLK OPTICAL (no date) Instruction Manuals. For example, for
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Optical

¥B Braille Institute Library Services

17
Retinoscopy (skiascopy)

Objective refraction Table 17.1. Comparison between neutralization and retinoscopy

Neutralization Retinoscopy
Subjective refraction as described in Chapter 6, though
an accurate method for determining any optical correc- Stationary test object Test object moves across retina
tion required, does depend upon the patient's ability to Lens under test is moved Eye examined is stationary
discern changes in the clarity of the test object as the
trial lenses are changed. In objective refraction, it is the Lens power indicated by Refractive error indicated by
direction and speed of image by direction and speed of
practitioner who decides with the aid of auxiliary appa- reflex movement (fundus glow
movements
ratus which lens combination gives the best optical cor- in pupil)
rection for the ametropia. The examiner's opinion
Trial lenses of known power Trial lenses added to obtain
replaces the patient’s preference. Some apparatus re-
added to neutralize movement ‘reversal’
places even the human examiner with an electronic
system. The findings of objective refraction should, if End-point: no movement End-point: extremely rapid
movement and disappearance
possible, be checked subjectively, and even these results
of reflex
may need modification to increase the comfort of the
lenses prescribed.
Objective refraction is not only useful but often essen-
the same clinic (1880-81), Parent introduced the term
tial, for example, when examining young children and
‘retinoscopie’, since he believed that the source of the
patients with poor communication due to mental or lan-
reflex was the retinal pigment layer. This method of re-
guage difficulties. Moreover, a refraction will be much
fraction was popularized in the USA by Jackson. The ter-
easier and quicker if it is based on an objective estimate
minology is rather confused. Especially with poor
instead of only a knowledge of the unaided vision.
illumination, the movement of shadows in the pupil is
There are many different techniques of objective re-
easier to follow than that of the light reflex. Hence,
fraction, but they fall into three basic classes:
names such as umbrascopy, skiascopy and skiametry
(1) retinoscopy, were introduced, the last two being widely used in the
(2) objective optometers (refractionometers), USA. The term retinoscopy — although a misnomer — is
(3) automated optometers. generally accepted in Great Britain and some other
countries.
This chapter deals only with retinoscopy. Other objec-
Retinoscopy is a process having similarities with neu-
tive methods and apparatus are described in Chapter 18.
tralization (the method of determining the power of a
lens by adding another lens or lenses of approximately
equal and opposite power to produce an afocal combina-
tion). Table 17.1 sets outs a comparison.
Retinoscopy
The sighthole of the instrument acts in a similar way
to the knife edge in the Foucault test for aberrations.
Retinoscopy is an offshoot of ophthalmoscopy. In
The retina is made conjugate to the sighthole, so that if
ophthalmoscopy, the principal aim is to inspect the
the eye were aberration free, there would be an instan-
fundus. In retinoscopy, the fundus acts as a fixed
taneous cut-off of the return beam entering the exami-
screen over which a spot of light is moved. The practi-
ner’s eye as the light patch moves over the patient's
tioner watches the shape and movement of the patch of
retina.
reflected light within the pupil (the ‘reflex’) and, by pla-
cing trial lenses in front of the patient's eye, modifies
the speed of movement of the reflex to arrive at a par-
ticular condition called ‘reversal’. The self-luminous retinoscope
The technique of retinoscopy was introduced in 1873
by the French ophthalmologist Cuignet (d.1889) and It was seen (pages 312-313) that the direct ophthalmo-
was brought to Paris by his pupil Mengin in 1878. At scope needed the source of light and observer's eye to
 Principles of retinoscopy 331

be placed very close together in order that light entered

the patient’s eye and returned to the observer. The sim-
plest way to do this is to reflect the light from a bulb off
an inclined semi-silvered mirror and view by trans-
mission through the mirror, i.e. to use a beam splitter.
An alternative method is to use a fully silvered mirror
Light
and to view the pupil through a perforation in the
trap
silvering.
Self-luminous retinoscopes often have a bulb with a S‘5 msi = pee ae My
tiny coiled filament about 1-2 mm in size. This is
imaged by a lens of about 20 mm focal length to give a
divergent beam of light. In some instruments, the lens (b)
may be moved along its axis to give a vergence of light
after refraction from —0.50D to —7.00 D. The virtual
image of the source, called the immediate source, is
then positioned between 2m and 140 mm behind the
instrument. Figure 17.1 shows two instruments (not to
scale) with perforated and semi-reflecting mirrors. Note
that a sighthole is still required in the latter instrument
to give definition to the appearance of the reflex. A Figure 17.1. The self-luminous retinoscope: (a) an
instrument with perforated mirror, (b) one with a semi-silvered
diameter of about 1.5mm is satisfactory, although a
reflector. The immediate source is the bulb image S}.
larger diameter giving a brighter reflex may be useful
in the early stages of learning retinoscopy.
A slightly different type of instrument — the streak re-
tinoscope — uses a bulb with an uncoiled linear filament
and also provides a greater range of vergences. It can
even give a real image of the filament in front of the in-
strument (see pages 347-349).
In the past, instruments were designed which could
be modified from an ophthalmoscope to a retinoscope.
In principle, the only modification needed is an extra
condensing lens so that the immediate source may be
positioned on the mirror for ophthalmoscopy; removal
gives a divergent beam for retinoscopy. In practice, se- Figure 17.2. Rotation of the retinoscope through angle 0
gives a source movement through angle wu with respect to P.
parate instruments left in permanent adjustment per-
form better, though economies can still be made in the
form of an interchangeable handle.
mirror, the blur-circle diameter and the basic image
height are both small, about 0.02 and 0.05 mm respec-
tively. For simplicity, the illuminated fundus area is con-
Principles of retinoscopy sidered to be a point.
Figure 17.3 illustrates a myopic eye (or an eye ren-
In retinoscopy, the instrument is moved so that the dered myopic by trial lenses). Light reflected back from
beam travels across the patient's pupil. Simultaneously, the fundus at M’ must pass through the far-point Me.
the immediate source (the image of the real source At the mirror, the emergent beam diameter is larger
formed by the retinoscope lens and mirror) moves trans- than the sighthole AB. Only light in the dotted part of
versely to the axis of the patient’s eye so that a patch of the beam will enter the observer's eye, so that the pupil
light moves across the fundus. In Figure 17.2, which will appear dark with a bright glow in the centre. This
refers to a self-luminous retinoscope, the instrument glow, irrespective of size or position, is the reflex.
has been rotated through an angle 9. Since the bulb is When the trial lenses are changed so that the (artifi-
fixed in relation to the mirror, the immediate source cial) far-point closely approaches the sighthole, all the
also rotates through angle 0, moving from S’ to 8”. The light leaving the patient’s eye reaches the observer's
incident ray path S’P makes an angle u with the eye’s
optical axis, and the conjugate refracted ray PQ the
angle wu’.
When the immediate source is behind the retinoscope, Far-point
9, wand w’ all have the same sign. Thus the illuminated (a) Mirror
plane
fundus patch moves across the retina in the same direc-
tion as the mirror rotation.
In general, the immediate source does not lie in the
eye’s far-point plane. So the image formed by the eye is
blurred and the illumination falls away at the edges. Figure 17.3. (a) Formation of the reflex in a myopic eye. (b)
Near reversal, when the retina is conjugate with the Appearance in the pupil.
 by a diagrammatic demonstration of the stages in its for-
mation. In all these diagrams, the patient's eye will face
(a)
left and there is therefore no change in the sign of k
and K. The incident light (illuminating beam) travels as
usual to the right.
Six elements are involved in the analysis of the reflex:

Figure 17.4. (a) Formation of the reflex in a myopic eye, the (1) illumination of an area of the fundus,
far-point approaching the sighthole. (b) Appearance in the (2) formation of an image of this fundus patch (the fun-
pupil.
dus image),
) the potential reflex,
(b)
) formation of the actual reflex,
) direction of motion of the reflex,
) the end-point or reversal.
As shown in Figure 17.2, all relevant distances will be
measured from the patient’s eye, the point P being con-
sidered both as principal point and pupil centre. The re-
tinoscope is at a distance w (which is always negative),
Figure 17.5. (a) Effect of retinoscope tilt on the formation of
the reflex: against movement. (b) Appearance in the pupil.
called the working distance. It is normally two-thirds of
a metre, so that the practitioner can easily reach the
trial frame or refractor head with his free hand to
(Figure 17.4). The whole pupil then appears to be lumi- change lenses.
nous. The immediate source S’ is at a linear distance x (diop-
tric distance X), depending on the instrument and tech-
nique used.
Effect of rotation

Suppose the retinoscope is angled slightly so that the

patch of light passes upwards over the patient's eye.
The illuminated patch on the fundus will move upwards Formation of the fundus image
from M’ to Q, while its image in the far-point plane
moves downwards to Q’. Figure 17.5 shows that only The fundus image is important for the following reasons:
light leaving through the lower part of the pupil passes
(1) A reflex will be visible if light can pass from the
through the sighthole. The remainder of the light is oc-
patient's pupil into the observer's pupil via the fun-
cluded by the mirror to give a crescent-shaped shadow
dus image.
at the top of the pupil. The reflex has moved downwards
(2) The fundus image indicates the behaviour of the
in the opposite direction to the instrument rotation.
reflex. When viewed from the sighthole, the reflex
This is therefore called an against movement.
invariably moves in the same direction as the fun-
dus image.
Condition for reversal

When the retina is made conjugate with the plane of the Myopia: K|
> |X|
sighthole (Figure 17.6), the emergent pencil of light is
In myopia in which the far-point plane is between the
either wholly admitted or totally occluded. The reflex
eye and immediate source (Figure 17.7), the image of
would then appear and disappear instantaneously
S” formed by the eye must lie in front of the retina, say
when the retinoscope is moved. In reality, this does not
at S””, on the refracted ray PQ. Drawing the pencil of
happen quite instantaneously because of the finite size
rays from the centre of the immediate source S” to the
of the illuminated retinal patch and sighthole, and the
pupil margins H and J, we can construct the refracted
effect of ocular aberrations. It is this part of the process
rays HU and JV through S” to define the illuminated
that resembles the Foucault knife-edge test.
circle on the retina.
Since the far-point plane is conjugate with the retina
and ray paths are reversible, Q’, the image of Q, is the in-
Analysis of the reflex: introduction tersection of S”P with the far-point plane. Similarly, U’
and V’ are the images of U and V.
It is useful to precede the algebraic analysis of the reflex Therefore the circle in the far-point plane bounded by

Figure 17.6. Complete transmission or occlusion of the reflex at reversal.

 Direction of the reflex movement 333

Far-point Fundus Potential Retina

Immediate plane Mirror image reflex af
source } |
Si

Coa V
i
U

Figure 17.10. Projection from the sighthole AB through the

fundus image UV’ to give the potential reflex in a myopic eye.
Figure 17.7. Formation of the blurred retinal image UV of
the immediate source and the resulting fundus image U’V’ in
the far-point plane in a myopic eye. of low degree such that the far point lies beyond the
plane of the immediate source.
Far-point
plane
i

Mai
Formation of the reflex

The fundus image, governed by the position of the im-

mediate source and pupil margins. is bounded by U’
| Complete .
fundus image and V’, as shown in Figure 17.10 which follows on
from Figure 17.7.
Figure 17.8. The fundus image of an extended source RT. Projection from the sighthole margins A and B
through U’ locates circle u in the pupillary plane. If the
U’ and V’ is the image of the illuminated fundus patch pupil were of unlimited size, a pencil from U on the
due to the pencil from S$”. This general theorem makes retina could emerge through circle u to enter the sight-
it unnecessary to consider the detailed course of the hole via U’. The area u of the pupil would therefore
rays within the eye in the other cases. appear luminous. Similarly the circle v is defined by pro-
In reality, the immediate source has a finite size, say jection from A and B through V’.
RT. A fundus image circle may be drawn in the far- The envelope of all such circles constitutes what may
be called the potential reflex.
point plane to correspond to each point of the source.
The complete fundus image is the envelope of all such The visible reflex is bounded by the overlap of the
circles (Figure 17.8). potential reflex upon the actual pupil. If the retinoscope
is tilted to move the potential reflex upwards, the actual
reflex will be seen to move upwards across the pupil. In
Figure 17.10 it nearly fills the pupil, leaving a crescent-
Hypermetropia
shaped ‘shadow’ at the top. It will then proceed to fill
In all degrees of hypermetropia (Figure 17.9), the fundus the pupil, making the whole of it glow and then its
image will be formed in a far-point plane behind the pa- lower edge will travel upwards, leaving a shadow in its
tient’s eye and is constructed by producing the rays wake.
8”H and S”J. The source image, S$”, will also lie behind Figure 17.11, following on from Figure 17.9, illus-
the eye. trates the formation of the reflex in hypermetropia. In
this diagram, the potential reflex overlaps the upper
part of the pupil. This is therefore the illuminated area,
Myopia: |K| < |X| the lower part remaining dark.
A third similar construction could be drawn for myopia

Far-point Direction of the reflex movement

plane

Only a single point of the immediate source and fundus

Fundus
image
er (ue
Potential Dee
reflex Ses ae

Figure 17.11. The potential reflex in hypermetropia.

Figure 17.9. The fundus image in hypermetropia. Direction of the reflex movement.
334 Retinoscopy (skiascopy)

Low myopia Myopia Hypermetropia

K\< |W IK\>IWl (all degrees)
with movement against movement with movement
add plus Reversal add minus add plus
Figure 17.12. The direction of reflex movement in the three main categories of ametropia.

image need be considered. In Figure 17.12, as the mirror

with its sighthole at C is rotated through angle 0 from
its central position, the immediate source moves from Reversal
S’ to 8”. The ray S”P to the centre of the pupil is re-
fracted to QO. The end-point for retinoscopy, called reversal, occurs
The fundus image QO’ must lie on the ray SP, pro- when the far-point plane coincides with the plane of
duced if necessary in either direction, according to the the sighthole (Figure 17.13). If the working distance w
position of the far-point plane. The reflex is seen in the is two-thirds of a metre, giving W = —1.50D, reversal
direction CQ’, making an angle ¢ with the axis. would be obtained with an uncorrected myope of
The relative speed of reflex movement is the ratio $/9. ocular refraction K = —1.50D. In general, lenses are
A plus sign denotes a with movement, in that the reflex placed in the subject’s spectacle plane to give an artifi-
moves upwards when the path of light from the retino- cial far-point positioned in the plane of the sighthole. If
scope beam on the patient’s face also moves upwards. the patient were actually a —2.00D myope, there
A minus sign denotes an against movement. would be an initial against movement with no trial
The direction of the reflex movement depends upon lenses in place. If a —1.00 DS lens were inserted, the ar-
the position of the far-point. There are three distinct tificial far point would now be behind the mirror, re-
ranges, as shown in the diagram. In range B, where the sulting in a with movement. The end-point is the lens
myopia is such that the far-point plane lies between the power from which a change of 0.25 DS or less converts
patient and sighthole, a negative lens is indicated by an against movement to a with movement, or with to
the against movement, exactly as in neutralization. against.
Negative lenses of increasing power are added until re- The lens giving reversal can be considered as the sum
versal is obtained, a condition described more precisely of two components:
below.
In the two regions A and C, the with movement indi- (1) a lens of power F,, representing the distance specta-
cates the need for a plus lens in the spectacle plane to cle correction,
obtain reversal. In hypermetropia (region C), a gradual (2) a positive lens of power —W to make the patient
addition of plus power will move the resulting artificial artificially myopic for the plane of the sighthole.
far point to infinity on the right of the diagram. It will
Thus, Figure 17.14 shows a pencil from M’ conver-
then approach the sighthole from infinity in region A.
ging towards the true far-point Mp on emerging from
the eye. A lens of power F,,, renders it parallel and a pos-

—W Feo

wa
vA
k (= w) eee!
K=W F

Figure 17.13. Condition for reversal: the fundus image is Figure 17.14. The trial lens power F at reversal considered
formed in the plane of the sighthole, the residual error K then as a combination of the spectacle correction F,, and a plus lens
being equal to the dioptric working distance W. of power —W to compensate for the working distance.
 Factors affecting the speed of the reflex movement WN Ww WI

itive lens of power —W converges the pencil to the plane i(=ve) PMg(—ve) PMR
of the sighthole. In clinical work, F,, is more important u(+ve) CMp(+ve) CP+PMp
than the ocular refraction K, though for simplicity in
ae ae
the next section, K will be used.
Wie ak aw,
Let F be the power of the single reversing lens. Then
Multiplying throughout by K (= 1/k) and W (= 1/w)
F= Fs, Ar ew, gives
which gives eeWok
i (eli)
;
F,,=F+W
The main variable in this factor is the ametropia. Also,

For example, if F = —6.00 D and W = —1.50D u(+ve) CS’ (—ve) CP +PS’

8 (+ve) PS’(-ve) PS!
te = 6.00 = 1:50
Vi Se Ae x — WwW
II —7.50D
i x
For F = +4.00 D, with W as before, then Multiplying throughout by X and W gives
We Wee
Pee 200 = 0 Glas
6 WwW
5 (ID) .
This factor is dependent on the optical arrangement of
It is easier to remember that one always algebraically the retinoscope. Finally, multiplying equations (17.2)
subtracts +1.50 DS (or +1.00 DS if working at 1m, and (17.3) we obtain
+2.00 DS if at 0.5 m) than to add negative power. > angular movement of reflex WW—X
This alteration to be made to the lens power at rever- V7 4
0 mirror rotation W-K ( )
sal is called the ‘allowance for working distance’. One
possible routine is to keep a pair of lenses of power
+1.50 DS in the trial frame while retinoscopy is per-
formed. Their subsequent removal then leaves the dis-
tance correction of power F,, in the trial frame. Factors affecting the speed of the
Drawbacks are the additional weight and reflections. reflex movement
Some manufacturers of refractor heads apply anti-reflec-
tion coatings to all the lenses in their instruments. Amount of ametropia
The relative speed ratio given by equation (17.4) can be
considered as the product of two factors, one varying
with the ametropia and the other with the retinoscopy
arrangement. If W and X are held constant, the effect
Relative speed of the reflex movement of K on the speed of reflex depends solely on equation
(17.2), the ametropia factor. By way of illustration, sup-
The simple equation derived below is the key to the cri- pose that the dioptric working distance W is —1.50 D.
tical use of the instrument. The ametropia factor then becomes
In Figure 17.15, the mirror is assumed to have rotated
—1.50
anticlockwise through an angle 9 so that the immediate
source has moved through an identical angle from the —1.50—K
optical axis of the patient’s eye. The resulting position This plots as a hyperbola (Figure 17.16) which is asymp-
of the fundus image must be found and hence the angle totic to the vertical at K=Wz=-—11.50D but ap-
, subtended at the sighthole by its displacement. proaches zero as the ametropia increases in either
From the triangles PMpQ’, CMpQ’ in the diagram we direction.
have If it is also supposed that the immediate source is at a

Figure 17.15. Derivation of relative speed of reflex.

<
336 Retinoscopy (skiascopy)

10 (a) +3
3
8 +2
Divergence |Decreasing convergence->
6 2 -—800 Distance of beam focus from sighthole (mm)
Selo ee
1000 C 2000
4 5
= 1s
@ =
nee :
o ane
mie
y
2
o
(u/@)
factor
Retinoscope
e 25 =
is Fs(a
_4
+3 +2 +1 +0.75
= \ | + Paralet + L l
—6 —2
1500 —1000 —500 0 +500 +1000 +1500
Upper scale: X(D)
—8 Lower scale: x(mm)
—3
—10:
—16 —12 -8 —4 0 +4 +8 +12 +16
Residual ametropia (D)

Figure 17.16. The ametropia factor W/(W — K) plotted asa

function of residual ametropia. Dioptric working distance
—1.50 D. The right-hand ordinate is scaled for relative speed of
reflex when Y = —1.00 D.

dioptric distance of —3.00D from the retinoscope

< ——
mirror, then it is also at a linear distance x of —l1m u t+ve u +ve
from the eye, so that X = —1.00D. The retinoscope increasing u —ve decreasing
factor, equation (17.3), then assumes the value (—1.50
Figure 17.17. (a) The retinoscope factor (W — X)/W plotted
+1.00)/—1.50 or 1/3. The right-hand ordinate scale in
as a function of the distance x for W = —1.50 D. (b) The sign
Figure 17.16 represents the total relative speed ratio, and relative size of angle w when the immediate source is in
which in this case is one-third of the ametropia factor. each of the regions A, B and C.
If K is considered, not as the subject's ametropia but
as the residual ametropia at any stage when trial lenses When x is zero, X is infinite and thus so is the speed of
are placed before the eye, Figure 17.16 shows the rela- the reflex movement. An apparent reversal has been
tive speed of the reflex to increase more and more ra- reached, but it is independent of the residual ametropia.
pidly as reversal is approached. Theoretically, the speed This condition is called false reversal and occurs if the
then becomes infinitely great. immediate source lies in the pupillary plane. As shown
by Figure 17.18, a slight angling of the mirror from the
Distance of the immediate source central position will displace 8’ to S”, where the light is
totally occluded by the iris. The reflex therefore sud-
The distance x of the immediate source from the eye is
denly disappears. Although the self-luminous spot reti-
not a completely independent variable since it is affected
noscope cannot usually be adjusted to image the
by the adjustment of the retinoscope and the working
filament on the patient’s eye, this can occur with the
distance w. It may, however, be regarded as a variable
streak retinoscope. Care must therefore be taken not to
if wis kept constant.
generate this condition during use.
The relationship expressed by equation (17.3) could
Figure 17.17(a) shows that altering the adjustment of
be called the retinoscope factor because u/0, equal to
(W — X)/W, is the ratio of the angular movement of the the instrument varies the speed of the reflex movement
immediate source (with respect to the patient's eye) to
for a particular ametropia. When the ametropia is high,
the rotation of the mirror. In Figure 17.17(a) the retino- the ametropia factor is low, giving a slow reflex move-
scope factor is plotted as a function of the distance x ment. It is therefore an advantage to make the retino-
when W is fixed at —1.50D. It takes a positive value scope factor as large as possible so that there is a
when the immediate source S’ is on the far side of,the perceptible movement in the reflex. This can be done by
patient’s eye (region C). Should the source be imaged be-
tween the patient's eye and the mirror (region B), the re-
tinoscope factor takes a negative value; the direction of
the reflex for a particular residual ametropia is reversed.
A moderately myopic eye will then show a with move-
ment instead of the customary against movement. Re-
gions A, B and C correspond exactly to those of Figure
Figure 17.18. False reversal: the immediate source lies in
NG NAR the patient's pupil plane.
 Brightness of the reflex and ametropia 337

making the beam diverge as little as possible. If the im- 1.5m, concentrating light towards the patient’s eye.
mediate source is moved from 200mm to 500mm The disadvantage was that the resulting reflex move-
behind the mirror, X falls from —1.15 to —0.86D and ment was very much quicker for the same angular
the retinoscope factor almost doubles from 0.23 to 0.43. movement of the mirror. It must be noted that whenever
Near reversal, the higher value for the retinoscope the source is external to the instrument, as in all non-
factor means that the reflex movement is faster than it luminous instruments, the immediate source moves
need be. The trial lens consequently appears closer through double the angle that the mirror is turned. The
than it really is to the power needed for true reversal. If right-hand side of equation (17.3) and (17.4) must
preferred, the reflex movement can now be slowed therefore be doubled.
down by making the beam as divergent as possible. A ‘short-focus’ concave mirror having a radius of cur-
This is illustrated in the following example. vature about ; m was also used. This, too, gives a bright-
er reflex than the plane mirror, but reverses the
direction of the reflex movement because the immediate
Example (1) source falls within range B of Figure 17.17.
Residual Beam Retinoscope Relative speed For streak retinoscopy, toroidal mirrors were used.
error divergence factor of reflex
Working distance
0.50 D 0.69
Reversal is obtained when the far-point plane coincides
Maximum ORs
with the mirror. In moderate and high ametropia, the
0.25 D - 1.38
far-point is much closer to the eye than the normal
0.50 D 1129) working distance. The reflex moves very slowly and its
Minimum 0.43 direction may be difficult to determine. If so, the reflex
O23. Des speed may be increased by approaching much closer to
the eye. This can readily be deduced from equation
(17.4) giving the relative speed of the reflex.
Approximately the same final reflex speed is obtained Table 17.2 shows the relative speed for a range of dif-
with the less divergent retinoscope beam at 0.50 D ferent values of the ametropia K and dioptric working
from reversal, as occurs with the more divergent beam distance W. The immediate source was assumed to
at only 0.25 D from reversal. remain at 250mm behind the mirror, whatever the
Figure 17.17(b), drawn in register with Figure working distance. It can be seen that in all refractive
17.17(a), shows the sign and relative size of the angle conditions the speed increases with a shorter working
u when the immediate source, after a mirror rotation 0, distance, but more so in high myopia than in high hy-
is in each of the three regions A, B and C. permetropia.
If no adjustment of the vergence is possible, an instru-
ment with a fixed divergence between —3 and —5 D is
preferable to one with a nearly parallel beam. Brightness of the reflex
and ametropia
Non-luminous retinoscopes: a retrospect
In Figure 17.19, the fundus image with the far-point
Retinoscopy was originally performed with an external
light source such as an oil lamp. Later, an opal or pearl
glass electric lamp bulb masked to give a range of aper- Plane of
sighthole seas
tures (known as a Lister lamp) was placed to the side of
Immediate \Z, Iu e co.(Supaelves
the patient's head. The retinoscope often consisted of a
source
small plane mirror with a perforated sighthole. Since
R
relatively little light reached the patient’s eye, the reflex ,

was dim.
To overcome this drawback, a ‘long-focus’ concave
mirror could be used, giving an immediate source posi-
tioned behind the patient’s head. Figure 17.19. The influence of the relative positions of far-
Such a mirror might have a radius of curvature of 1 to point and sighthole on reflex brightness.

Table 17.2 Effect of working distance on relative speed of reflex

W W —X Ametropia
(D)

(D) (D) —10.00 —5.00 —2.50 —1.50 0 +5.00 +10.00

—1.00 —0.20 —0.022 —(0,050 —().133 —0,.400 0.200 0.033 0.018

—1.50 —0.41 —0.048 —0.117 —0.409 ee O72 0.063 0.036
—2.00 —0.67 —0.083 —0,.222 —1.333 BOO 0.333 0.095 0.056
—2.50 —0.96 —0.128 —0.385 oo 0.962 0.385 0.128 0.077
—3.00 —1.29 —0.184 —0.643 DIST 0.857 0.428 0.161 0.099
338 Retinoscopy (skiascopy)

plane in position 1 is formed by the intersection of the

limiting rays RH and TJ with this plane. The image is
thus bounded by U/V}.
The cross-section of the return beam from the eye is
found by projecting from H and J through U) and V}.
Thus, in the plane of the mirror, the cross-section is
bounded by Z, on JU{ produced, and forms circle 1 of
radius CZ).
In the less-myopic eye with the far-point plane in pos-
ition 2, the fundus image is bounded by U5 and V5, and
the cross-section of the beam in the plane of the mirror
by Z5 determining circle 2 of radius CZ).
Although light distribution in the beam is not uniform
because of vignetting, intensity per unit area is ob-
viously higher in position 2 because the same quantity
of light is spread over a smaller area.
Hence the brightness of the reflex increases as neutra-
lization is approached and the fundus image moves
nearer to the mirror.

Figure 17.21. Retinoscopy in astigmatism with the rule. P

represents the patient’s pupil centre, C the sighthole centre. (a)
The vertical section of the return beam, the retinoscope beam
Sighthole shadow having been tilted upwards, (b) the horizontal section of the
return beam, the retinoscope beam having been tilted to the
If the mirror is pierced, or the silvering removed, no right. In both diagrams, the hatched area shows that portion of
light is reflected from the sighthole. With respect to the the beam cut off by the edge of the sighthole.
immediate source, the mirror acts like a clear window
with an opaque central spot. There is thus a narrow oc-
cluded cone within the pencil from each point on the im- Retinoscopy in astigmatism
mediate source (Figure 17.20).
The area bounded by DAEB is common to all the oc- Retinoscopy is of very great value in estimating the
cluded cones and is therefore a blind area in the illumi- astigmatic error, particularly if large. In order to sim-
nating beam. plify the initial discussion, the behaviour of the reflex
The fundus image is the intersection of the illuminat- will be considered in a myopic eye for which the far-
ing beam with the far-point plane. Hence, if the far- points in the two principal meridians are on opposite
point plane lies between D and E, the fundus image will sides of the sighthole (Figure 17.21). The astigmatism is
have a dark central spot, giving rise to a ‘sighthole with the rule. Consequently, in the axial position the
shadow’ in the centre of the reflex. This occurs only return beam will form a horizontal focal line at Mpyy
when close to reversal. the far-point for the vertical meridian, and a vertical
If the fundus image lies exactly in the plane of the line at Mpry the far-point for the horizontal meridian.
mirror, its dark area coincides with the sighthole. Con- If the mirror is now tilted so as to move the illumi-
sequently, no reflex should be visible. This prediction nated retinal patch upwards to U (Figure 17.21a), the
has been demonstrated with a well-corrected artificial return beam with its focal lines will move downwards.
eye by Bentall and Diprose (1932). Rays emerging from the top of the pupil are the first to
In reality, the aberrations of the eye and light scatter be occluded as the beam crosses the sighthole boundary.
within it give rise to some residual illumination. The The reflex is therefore seen to move downwards, show-
shadow tends to be more obvious the smaller the im- ing an against movement. Figure 17.21(b) shows the
mediate source. Since, however, it is the edge of the situation in the horizontal meridian after the mirror
reflex rather than the centre which is important, sight- has been tilted anticlockwise about a vertical axis so
hole shadow is not necessarily a disadvantage. The that the illuminated fundus patch moves rightwards to
shadow may be eliminated by using a semi-reflecting R from the examiner’s point of view. The first occluded
mirror in conjunction with a separate small aperture rays are those emerging from the left-hand side of the
(Figure 17.21b). pupil, thus showing a with movement of the reflex.
Thus each principal meridian behaves like an eye with
spherical ametropia ofthe identical amount. If the direc-
Ries H tion of either one of them were known in advance, reti-

: ee Sih M
noscopy of the astigmatic eye would present no special
problem.
alee There are two different clues to the axis direction of
J the correcting cylinder. First, in Figure 17.21, suppose
that the horizontal focal line is just in front of the sight-
Figure 17.20. Formation of sighthole shadow. RT the hole, a position close to reversal for the vertical merid-
immediate source, AB the sighthole. ian. (This apparent paradox arises from the fact that
 Retinoscopy in astigmatism 339

every point on the horizontal focal line is the focus of a K = —2.75

pencil of rays in a particular vertical section of the 30°
pupil.) As a result, the cross-section of the beam in the
plane of the sighthole is elongated horizontally, causing
the reflex to be drawn out vertically and to have ap-
proximately straight edges. Similarly, if the vertical line
were brought close to the sighthole, the reflex would
show a horizontal elongation. In general, the shape
and edges of the reflex near reversal in either meridian
give an approximate indication of the astigmatic axis.
The higher the astigmatism, the more obvious and accu-
rate this indication will be.
The usual procedure is to obtain reversal with spher-
ical lenses in the meridian of greater hypermetropia or
lower myopia first, leaving the far-point in the other
meridian in front of the sighthole. Suppose retinoscopy K =-2.50
to be performed on an eye with a refractive error of
+4.75/—2.25 x 140
the working distance being (minus) two-thirds of a
metre (W = —1.50D). When the beam is driven along
the 140° meridian, reversal will be nearly attained
with +6.00 DS before the eye. The reflex would appear
elongated in this meridian, showing a border at the top
and bottom roughly aligned with it. After completion of
reversal, the speed of reflex movement when the beam
is driven along the 50° meridian will give some indica-
tion of the cylinder power needed. Minus cylinders are
now placed before the eye at axis 140° until reversal is
obtained in the 50° meridian also. To allow for the
working distance, 1.50 D would have to be subtracted
(from the spherical power only) of the final retinoscopic
findings. Figure 17.22. The relative speed and direction of reflex
movement in astigmatism. The beam is driven from O to B. OM
With low astigmatic errors, the elongation of the
and ON represent the eye's principal meridians, OM’ and ON’
reflex may be insufficient to give an accurate indication the components of reflex movements along these meridians,
of cylinder axis. The second clue is particularly useful and OR the resultant movement. (a) K = —2.25/—0.50 x 120,
in such cases. If the retinoscope beam is driven across (b) K = —0.75/—1.75 x 120.
an astigmatic eye in a direction oblique to the principal
meridians, the reflex will move in a different direction.
Since both movements are against, we construct the
This may be inferred from the different speeds of the
point M’ on the 30° meridian on the side of O opposite
reflex movements in the principal meridians.
from M such that OM’= —0.4 OM. Similarly, N’ is lo-
In the following examples, W is assumed to be
cated on the 120° meridian on the side of O remote
—1.50D and X to be —1.00 D.
from N such that ON’= —0.67 ON. The diagonal OR of
the completed rectangle OM’N’R indicates both the rela-
tive speed (compared to OB) and direction of the reflex
Example (1) movement. It is seen to be an against movement along
the 166° meridian, thus making an angle d of 14° with
K = —2.25/—0.50 x 120 the direction along which the beam was driven.
In Figure 17.22(a), O represents the centre of the
pupil! and the retinoscope beam is driven rightwards
from O to B along the horizontal meridian. Perpendicu-
Example (2)
lars BM, BN are dropped from B to the principal merid-
Ke 0.75/ 1075 R120
ians. The arbitrary length OB can be considered as the
resultant of a travel OM along the 30° meridian and We now obtain
ON along 120°. From equation (17.4), the relative
speed of the reflex u“when resolved along these merid- Along 30° Along 120°
ians is found to be:
K —2.50D
Ll —0.5 TORO,
Along 30° Along 120°

K —2.75D —2.25D The construction (Figure 17.22b) proceeds as before

LU —(0.4 —0.67 except that, since there is now a with movement along
340 Retinoscopy (skiascopy)

Qa (a)
126°

Figure 17.23. Angular separation of beam and reflex

movements in retinoscopy along an oblique meridian of the
astigmatic eye. The eye’s principal meridians are designated
alpha and beta, the latter corresponding to the axis of the
minus correcting cylinder.

the 120° meridian, N’ lies on the same side of O as N.

The construction shows an against reflex movement
along 68°, a considerable angle from the direction of
the beam. Such angles do not occur when there is a
with or an against movement in both principal merid-
ians, as in Example (1).
In principle, this graphical method is identical with
Figure 13.7 on page 235 illustrating the analysis of
astigmatic line rotation and the resulting ‘scissors
effect’. It leads to the general relationship shown in
Figure 17.23, in which «& refers to the eye’s principal
meridian of greater power and f# to the meridian of
Figure 17.24. (a) The trial cylinder is placed at the incorrect
lower power. The beta meridian is therefore the axis of
axis 10° instead of the correct position of 20°. The resulting
the minus correcting cylinder. The refractive errors in reflex direction (40°) is close to the axis (36°) of the residual
these two meridians are denoted by K, and Kg respec- error. (b) The principle of Lindner’s method for verifying the
tively. If the retinoscope beam is driven at an angle a astigmatic axis.
from the beta meridian, the reflex movement makes an
angle a’ from the beta meridian such that
ment of the reflex will be along the 40° meridian. This
fang = (G5) is anticlockwise from the trial cylinder axis, indicating
that the latter should be moved in this direction. If
Angles a and a’ are subject to the usual sign convention. necessary, the procedure is then repeated.

Scissors reflex movements in retinoscopy are also very If the trial cylinder is of the correct power C but is set
apparent when trial cylinders are placed before the eye at > degrees from the true direction, the residual refrac-
at an incorrect axis. Suppose the refractive error to be tive error can be found from equation (6.1). The resul-
tant principal meridians are at 45° on each side of the
+6.00/—1.50 x 20
mean direction of the true and incorrect cylinder axes,
and retinoscopy performed at W = —1.50D and with while the refractive errors in these meridians are nu-
X = —1.00 D. With +7.50 DS before the eye, reversal is merically equal to Csind but are opposite in sign.
obtained in the 20° meridian. Now suppose a —1.0,.0 DC Though affected numerically, these relationships are
trial cylinder is added at axis 10°. Calculation (see not changed fundamentally if the trial cylinder power is
pages 87-89) shows the residual refractive error to be inaccurate but close to that required and ¢ is small.
The above is the basis of Lindner’s method of refining
+0.08/—0.66 x 36
the cylinder axis, cited by Pascal (1930) and Freeman
The residual astigmatic axis is 26° oblique to the trial and Hodd (1955). Reversal is first obtained in the more
cylinder axis (Figure 17.24a). From the construction of hypermetropic meridian. Then, with the minus trial cy-
Figure 17.22 it can also be determined that if the retino- linder in position at the estimated axis, the retinoscope
scope beam is passed along the 10° meridian, the move- beam is driven along the two meridians at about 45° to
 Spot retinoscopy in practice 341

the cylinder axis, which are close to the principal merid-

ians of the residual refractive error (Figure 17.24b).
This diagram refers to the same example as Figure
17.24(a). A with movement will be seen when the reti-
noscope is driven along the 55° meridian and an against
movement when driven along 145°. Since a with move-
ment is required, the cylinder axes should be rotated to-
wards the 55° meridian. When the cylinder is at the
correct axis, the movement in the two meridians at 45°
to it should be the same, both with or both against, de-
pending on whether the astigmatism is under- or over-
corrected.
When the true cylinder axis has been determined, by
whatever method, the cylinder power should be ad-
justed to obtain reversal in the second meridian. The
practitioner should then lean forward about 50 mm
and check that a with movement is obtained in both
meridians. Leaning backwards by the same amount
should produce an against movement in all meridians,
confirming that sphere and cylinder are both correct. If Figure 17.25. A possible illusion affecting the apparent
movement of an elongated reflex when the retinoscope beam is
the patient's accommodative state has changed between
driven along an off-axis meridian. The direction of the reflex
the two reversals, both sphere and cylinder will be wrong. movement appears to be perpendicular to the edge of the reflex
Positive cylinders may be used in retinoscopy, in (shown stippled).
which case the more myopic or less hypermetropic
meridian should be corrected first, leaving a with move-
horizontally across it and finally disappears at the
ment in the second meridian. When the trial plus cylin-
bottom. Exactly the same appearance would be caused
der is inserted, the retinoscope beam should be passed
if the band reflex were moved vertically downwards.
along its axis, the practitioner leaning forward slightly
This is the interpretation placed on it by the observer.
to obtain a with movement. If the reflex movement devi-
ates anticlockwise from the trial axis, the latter should
be rotated slightly in the opposite direction. If Lindner’s
method of driving the beam at 45° on each side of the Spot retinoscopy in practice
trial axis is used, the cylinder axis should be rotated to-
wards the meridian showing the against movement. Static retinoscopy
A disadvantage of plus cylinders may occur when the
The trial frame or refractor head is correctly adjusted
patient is young and has active accommodation. When
and centred before the patient’s eyes. Working distance
reversal is obtained in the less hypermetropic meridian,
lenses may be inserted or not according to preference
the astigmatic image plane for the second meridian lies
or practical convenience. The consulting room should
behind the retina if the astigmatism is more than be darkened; the patient’s pupil will dilate a little and
1.50 D (or greater than |W|). This may act as a stimulus the low ambient illumination will make the reflex much
to accommodation because the eye is fogged in both easier to see.
meridians only when the plus cylinder has been put in Accommodation should be relaxed by asking the
place. The same problem arises in a subjective examina- patient to look at a distant fixation object. The spot
tion if plus cylinders are changed without temporary oc- light of the test cabinet is often used, but the green of
clusion. Another possible disadvantage of plus cylinders the bichromatic panel, being a larger stimulus, is less
is that difficulties may arise during the subjective exam- likely to provoke spasm of accommodation in the young
ination if the fan and block technique is used. patient. To examine the right eye, the practitioner
Plus cylinders of power less than +1.50 D (or |W]) do should sit so that the patient can just see the fixation
have the advantage of giving a less diffuse reflex. When object to the right of the practitioner’s head. The latter’s
reversal has been obtained in the less hypermetropic right eye will then be very close to the patient’s right
meridian, the eye’s artificial far point for the other visual axis. A quick look with the retinoscope is made
meridian is closer to the immediate source. For the at the patient's left eye to check that there is an against
same reason, the reflex is improved when minus cylin- movement. If not, as is usually the case, sufficient pos-
ders are used by setting the retinoscope beam at maxi- itive spherical power must be placed before the left eye
mum divergence. to produce an against movement. The left eye is then
One interesting paradox concerning retinoscopy of fogged, so helping to ensure that accommodation is re-
the astigmatic eye has already been mentioned. A laxed.
second one arises with marked astigmatism and con- Retinoscopy is now performed accurately on the right
cerns the apparent path of the reflex. In Figure 17.25, a eye. The movement of the reflex is observed as the reti-
horizontal band reflex is shown in three positions as noscope is tilted slightly to drive the patch of light
the beam is directed downwards along the 110° merid- slowly in the horizontal, vertical and mid-way oblique
ian. It first appears at the top of the pupil, then extends meridians. If the reflex movements in these meridians
342 Retinoscopy (skiascopy)
Table 17.3. Procedure for static retinoscopy in hypermetropia
are a mixture of with and against, indicating at least a oe So mn a ee ee
moderate amount of astigmatism, an approximate cylin- Right eye Left eye
der axis may be discernible. The same applies if the
reflex tends to follow a fixed direction irrespective of the Error +4.00 +4,.00
beam direction. Usually, however, the reflex shows the Start of retinoscopy
same variety of movement in all meridians. There may Trial lens 0 +2.50 | against
then be no useful clue to an axis direction until reversal Accommodation +3.00 +3.00 J
Total +3.00 +5.50— fogged
is approached with plus or minus spheres. With experi- *

ence, the lens power needed for reversal in the more hy- During retinoscopy
permetropic or less myopic principal meridian can be Trial lens +4.50 ) rr +-2.50 \ with
Accommodation +1.00 J +1.00
found with only a few trials. An against movement re-
Total +5.50— fogged +3.50— clear
mains in the meridian at right-angles. If the retinoscope
is now moved in this meridian, the orientation of the Add more plus to L eye
Trial lens +5.50) reer +6.00 ) against
edge of the reflex will often give a good indication of
Accommodation O 0
the astigmatic axis. One of the procedures described on Total 5.50 (Fyp» -W) +6.00— fogged
pages 338-341 should then be used to refine the axis
and check the cylinder power. It is often an advantage
to lean forward slightly when driving the retinoscope
the working distance made. It might, however, be inad-
beam along the cylinder axis to check its orientation.
Reversal then changes to a moderate with movement
visable to remove the correction if the patient is a
and any discrepancy between the directions of reflex young hypermetrope.
and beam is then easier to see. If more convenient, a working distance other than the
If a spot retinoscope with focusing adjustment is used, usual two-thirds of a metre can be adopted, in which
a less divergent beam will give a brighter reflex than a case the allowance must be altered correspondingly.
more divergent one: this is helpful when examining When the patient has a strabismus of more than a few
patients with high ametropia or small pupils. On ap- prism dioptres, the safest procedure to ensure refraction
proaching reversal, a more divergent beam should be near the visual axis of the normally deviating eye is to
used, both to slow down the relative speed of reflex occlude the eye not under examination. Distance fixa-
movement and to provide a crisper reflex for identifying tion can be made as before. The patient will usually say
the astigmatic axis and for neutralizing the relatively if the refractionist’s head obscures the fixation object.
myopic second meridian. Observation of the corneal reflection of the retinoscope
While examining the right eye of a markedly hyper- light relative to the pupil centre will show if the retino-
metropic patient, an occasional quick look should be scope axis is too oblique to the patient's axis.
made at the left eye to ensure that an against movement A suggested routine for static retinoscopy on the
remains. Accommodation may have relaxed as positive astigmatic eye is as follows:
power is increased before the right eye, leaving the left
(1) Add spherical lenses to approach reversal.
eye unfogged. This can be best demonstrated by an ex-
ample. Suppose the patient is a +4.00 DS bilateral hy- (2) (a) If reflex elongated and approximate axis direc-
permetrope accommodating about 3.00 D. Initially, tion apparent, proceed to obtain reversal in the
there is no lens before the right eye and +2.50 DS is more hypermetropic or less myopic principal meri-
found to be needed before the left to produce an against dian. Note orientation of reflex margins at reversal.
movement. Retinoscopy now shows that a +4.50 DS (b) If axis direction uncertain, drive the retinoscope
lens gives reversal for the right eye, apparently indicat- along the 180°, 90°, 45° and 135° meridians, not-
ing that this eye is only +3.0 DS hypermetropic. The pa- ing direction and speed of reflex movements. From
tient’s accommodation may now have relaxed from these observations it should become apparent if
3.00 to about 1.00 D enabling him to see clearly with there is any astigmatism present. If so, its approxi-
the supposedly fogged left eye. If maintained, this mate axis direction should also be suggested.
1.00 D of accommodation will upset the measurement (3) Adda minus trial cylinder of the estimated power at
for the right eye. A further look at the left reflex at this the axis found in procedure (2).
stage would indicate the need for additional plus power Drive retinoscope beam along trial cylinder axis.
to keep the eye fogged. Reversal for the right eye will If reflex moves anticlockwise to trial cylinder axis,
now be given by +5.50 DS, indicating the true manifest rotate trial cylinder anticlockwise (or if it moves
error of +4.00 DS. This procedure is set out in Table 17.3. clockwise, rotate trial cylinder clockwise).
The practitioner should now move his stool so that he (6) When reflex moves along trial cylinder axis, the axis
sits to the left of the patient, who can just seen the fixa- is correct.
tion object past the practitioner’s left ear. The retino- (7) Check that reversal is still maintained in cylinder
scope is held in the left hand in front of the left eye, so axis meridian.
that retinoscopy is again as near as possible to the (8) Determine cylinder power required for reversal in
visual axis. second meridian.
At the end of the procedure, the trial frame or refrac-
tor head should be removed to give the patient a brief Stafford and Morris (1993) give a useful guide to reti-
rest while the results are noted, and the allowance for nosopy in practice.
 Errors and accuracy of retinoscopy 343

The Barrett method racks used for dynamic retinoscopy (see pages 345—
347), are for one eye only. The suggested lenses are
This technique of retinoscopy was advocated for routine
+0.50 to +3.50DS in 0.50D steps in one rack, and
use by Barrett (1945) with the object of bringing the pa-
+4.00 to +8.00D in 1.00D_ steps together with
tient’s fixation line close to the retinoscope. For various
+10.00 and +13.00D lenses in another. A similar
reasons, some practitioners are unable to do accurate
range of minus lenses is provided by another two racks.
retinoscopy with both eyes, in which case the Barrett
The racks enable different meridians of the eye to be ex-
method may provide a good alternative. The retinoscope
amined in quick succession, thus avoiding the use of cy-
should have a bright luminous fixation object on the
lindrical lenses.
body of the instrument, near the mirror. The patient
The recommended working distance is 0.5 m, but an
looks with both eyes at this fixation object, which is
allowance of only 1.25 D should be deducted from the
devoid of fine detail that might stimulate the accommo-
retinoscope findings. This suggests that, on average,
dation. Retinoscopy at the normal working distance is
infant patients accommodate by approximately 0.75 D
then undertaken on both eyes in turn, the observer's
during the examination. Owens et al. (1980) have con-
better eye being used. As with normal retinoscopy, the
cluded, however, that this amount of accommodation is
patient’s left eye must be fogged before the right eye is
not induced by an active effort to focus the source
examined. In general, since the convergence to the fixa-
image but is a form of inadequate stimulus myopia (see
tion object will stimulate some accommodation, an al-
pages 132-138), caused by the absence of any visual
lowance for this is made as follows. When reversal has
detail in the darkened room and the lack of any struc-
been obtained for both eyes, the patient's attention is re-
ture in the source itself.
directed towards a distant fixation”object such as the
Older patients could be expected to react similarly.
green bichromatic panel. If the practitioner’s left eye is
The present writer (RER) has compared conventional
the better, he re-examines the patient’s left eye with the
static and Mohindra near retinoscopy, though not with
patient looking past his left ear. A small increase in the
infants. Some young children appear to go into accom-
positive (or decrease in the negative) sphere power will
modative spasm, while others do not: this could perhaps
often be required, though the astigmatic element
be a reflection of the varying amounts of inadequate sti-
should not change appreciably. The resulting spherical
mulus myopia found in the general population. The
adjustment is made for both eyes, since accommodation
technique was useful with those patients whose fundi
is presumed to be stimulated equally in each of them.
appear to be tilted in relation to the visual axis and
This adjustment is fairly reliable in all except young
with those unable to maintain the fixation required in
school children, who may have exerted an excessive
the static method. It has also been advocated for the
amount of proximal accommodation. When fixation re-
measurement of the eye’s resting state of accommoda-
turns to the distant object, the accommodation may not
tion, provided that the eye not being refracted is oc-
relax sufficiently to give an accurate result.
cluded to eliminate any control of accommodation by
The convergence required may induce a_ small
the convergence pathway.
amount of miosis, which makes retinoscopy more diffi-
cult. Another disadvantage of the Barrett method is
that the patient’s heterophoria may sometimes be
broken down into a heterotropia. The retinal illumina- Errors and accuracy of retinoscopy
tion from the immediate source is often many times
greater than from the fixation object and therefore daz- Although the principles of retinoscopy can be described
zles the patient. This tends to dissociate the eyes, result- in simple optical terms, there are several possible
ing in a manifest deviation. sources of error. Despite these difficulties, experience
The Barrett method may also be useful in the domicili- makes the retinoscopy findings an extremely useful esti-
ary situation where a convenient distance fixation mate of the refraction. An accuracy better than 0.50 D
object may not be available. For elderly patients, the al- on the ametropia in either principal meridian and
lowance for accommodation will be unnecessary, within 15° on the astigmatic axis of 1.00 DC should
though to ensure that the eye being examined is the easily be obtained, given a medium-sized pupil and no ir-
one fixating, it may be advantageous to occlude the regular refraction.
other. The typical eye with relaxed accommodation has pos-
itive spherical aberration in which the refractive power
increases from the paraxial region outwards (see pages
Mohindra near retinoscopy 281-284). Spherical aberration becomes apparent in re-
This technique was developed by Mohindra (1975) to tinoscopy when the pupil is large, especially when di-
allow the refraction of infants without the use of cyclo- lated with mydriatics or cycloplegics. As a result, the
plegics. Retinoscopy is undertaken in a completely dark reflex may simultaneously show a with movement in
room, the patient fixating the immediate source, i.e. the the centre of the pupil and an against movement in the
retinoscope filament image. The child’s attention periphery. It is important in retinoscopy to watch the
should be held by interesting audible effects. While trial reflex in the centre of the pupil, ignoring the remainder.
case lenses or the refractor head may be used for older
patients, the use of retinoscopy racks is advocated for
The split (or scissors) reflex
infant patients. The racks should be painted matt black
to avoid distracting the patient, and, unlike the paired Particularly in the vertical meridian, the reflex may oc-
344 Retinoscopy (skiascopy)

casionally appear to be split, moving simultaneously in the eye a slightly lower power for red than for white
opposite directions from the centre of the pupil. There is light, this factor would result in a slightly hyperme-
no easy rule to decide what should constitute reversal tropic estimate. Charman (1975), taking into account
in such an eye. Usually the refraction may be the spectral variations of the source emittance, the ret-
‘bracketed’, an overall with movement being obtained inal reflectivity and the eye’s refractive power, con-
when, for example, a —0.50 DS is added, and an overall cluded that retinoscopy findings would be about 0.1 D
against movement when +0.50 DS is added. Roorda more hypermetropic than the subjective refraction.
and Bobier (1996) have demonstrated that coma is the Further experiments by Charman involving, retinal
probable cause of the split reflex. Large-scale irregulari- photography and electronic objective optometry with
ties in the media due to corneal scarring or lens changes light of various colours suggested that the longer wave-
will considerably reduce the accuracy of all objective lengths are reflected from deep within the retina.
methods of refraction. Glickstein and Millodot (1970) and Millodot (1974)
have reintroduced the contrary idea that the reflection
takes place in front of the retinal receptors. Their argu-
Off-axis errors
ment is as follows. In animals with eyes very much
As mentioned on pages 286-287, oblique astigmatism smaller than those in man but of equal retinal thickness,
of the beam leaving the eye can cause significant errors reflection at an anterior layer such as the internal limit-
if retinoscopy is performed more than 5° from the ing membrane would give a result several dioptres
visual axis. Figure 15.11 for the schematic eye shows more hypermetropic than reflection at the retinal recep-
that an induced astigmatic error of about —0.50 tor level. Their experiments with the electroretinogram
DC x 90 would arise at 10° horizontal obliquity of obser- (ERG), in man with visually evoked cortical response
vation. (VECR) and several other animal studies, confirmed
that the refraction thus measured was significantly less
hypermetropic than the retinoscopy findings, especially
Ocular abnormalities and asymmetries
in small animal eyes. Indeed, there would be no advan-
As the result of a localized bulge (perhaps due to a tage to an animal in being excessively hypermetropic.
tumour) or a depression (for example, posterior staphy- This discrepancy between retinoscopy and physiological
loma as in high myopia), that part of the fundus forming findings is sometimes termed the ‘artefact of retino-
the source for the returning light may be situated scopy’. Since chromatic aberration alone is insufficient
nearer or further from the principal planes of the eye to account for the discrepancy, its cause must be that re-
than the fovea. The accuracy of the estimated spherical flection takes place at or near the vitreous—retinal
component of refraction would be affected by this boundary — see Exercise 17.15.
(Hodd, 1951). It is also possible that the errors arising Millodot and O'Leary (1978a) rationalized this as fol-
from obliquity of observation could be increased by var- lows: using 1078 records from three practitioners, they
ious ocular asymmetries. Spherical aberration, in par- investigated the mean difference between retinoscopy
ticular, is seldom symmetrical. Because of the Stiles— and subjective findings in various age groups, to find a
Crawford effect, a tilted fovea might also have optical ra- nearly linear drop from +0.35D on the 5-15 age
mifications as yet unexplored in this context. group to almost —O.1 D in the over-65 group. In the
young patient, they postulated that the reflex originates
Accommodative tonus predominantly from the internal limiting membrane,
but with sufficient reflection from the deeper layers to
The spherical element of the refraction may not be con- give the red coloration. To confirm this, they (1978b)
firmed subjectively if the fogging of the working distance undertook retinoscopy on 305 eyes of various ages
lenses forces a young hypermetrope to relax his accom- with a retinoscope providing a polarized beam. The
modative tonus. A higher positive error is often found sighthole was fitted with an analyser, which when
by retinoscopy than is manifested subjectively, es- aligned with the polarizer, tended to select light reflected
pecially if the patient has been previously uncorrected at the internal limiting membrane, while with a crossed
or does not need to wear the full refractive findings con-
analyser, the reflex is produced predominantly by light
stantly. The typical subject is a young +3.00 D hyper-
diffusely reflected from the retina. The latter results
metrope, wearing the correction only for critical vision
gave a similarly myopic bias to retinoscopy at all ages,
indoors and with no problems of oculo-motor imbal-
while the results with the aligned analyser gave results
ance.
similar to those of the first study. This can be explained,
since, with increasing age, the refractive index differ-
Position of the reflecting surface . ence at, and hence reflectance from, the internal limit-
ing membrane decreases. Also, changes in the plane of
The reflex in the human eye is distinctly red, suggesting polarization of light passing through the eye (e.g. van
that the reflection occurs at the pigment epithelium
Blokland, 1985; and Gorrand, 1986), mean that even
layer since the retina itself is transparent. If so, the
with aligned polarizers, some ofthe light will be reflected
axial length of the eye for retinoscopy would be longer
at surfaces other than the internal limiting membrane.
than the true length to the retinal receptor layer, re-
sulting in a slightly myopic estimate of the refraction.
On the other hand, because chromatic aberration gives
 Dynamic retinoscopy 345

Error in the working distance luminated aperture on the retinoscope. The retinoscope
beam, however, should be as dim as possible to reduce
The spherical component will obviously be in error if the
any tendency to dissociate the eyes. The beam is moved
working distance is incorrect. This can easily occur if re-
in a continuous path to investigate the horizontal
fracting a young child or a patient with small pupils,
meridians of the two eyes in rapid succession.
when one tends to get closer than usual without rea-
lizing it. The sphere balance will obviously be upset if
the refraction for the two eyes is done at different dis-
Separate fixation method
tances. An error of about 100 mm is required at two-
thirds of a metre to give an error of 0.25 D in the refrac- The fixation object, which should be well illuminated, is
tion. held in the median plane at the patient’s customary
reading or working distance. The practitioner holds the
retinoscope just behind and above the fixation object
Subjective checks and passes the beam across the pupils. A with move-
Despite these possible errors, retinoscopy gives a good ment indicates that the retinoscope should be moved
estimate of the refraction of most patients, and has to further away from the eyes, the fixation object re-
be relied on in certain circumstances. Since the patient's maining stationary.
vision in everyday life is, however, a subjective re- In general, the with movement will change to an
sponse, a subjective check of the retinoscopy findings against movement for both eyes at the same distance of
should always be made or attempted, except in the the retinoscope from the fixation object. Provided that
youngest of patients. If the response to the subjective the patient's astigmatism is properly corrected, this indi-
test is poor, but the vision with the retinoscopy findings cates that the spherical component of the refraction is
is good, then, and only then, may the subjective tests balanced in near vision.
be abandoned. The final sections of Chapter 6 describe Should reversal in the two eyes be obtained at differ-
a routine to follow retinoscopy. ent distances, low positive or negative lenses are added
before one eye until simultaneous reversal in both is ob-
tained in a single sweep of the retinoscope. This is
easily checked by leaning forward slightly with the reti-
Dynamic retinoscopy noscope, when a with movement should occur in both
eyes, or leaning back when an against movement
Basic principle should be seen.
Any change required in the spherical balance may in-
In the techniques described so far, a common factor is
dicate that the distance findings are incorrect. Dynamic
the aim of inhibiting or minimizing the patient’s accom-
retinoscopy can thus be a useful method of checking
modation. Although the Barrett method requires fixa-
the subjective balance when confirmation is desired. A
tion at the normal working distance, there is little
genuine change in the spherical balance when vision
stimulus to accommodation because the fixation object
switches from distance to near could, of course, arise
is relatively large and luminous. Some proximal and
from unequal accommodation or from eye to spectacle
convergence-induced accommodation may occur. Both
plane effectivity in marked anisometropia.
of these techniques, together with Mohindra’s, are
A change in the astigmatic component of the refrac-
forms of static retinoscopy inasmuch as active accom-
tion is indicated if the reflex moves obliquely instead of
modation is not required.
exactly along the horizontal meridian of the eye. This
In dynamic retinoscopy, introduced by Cross in 1902
may be due to astigmatic changes in the crystalline
(see Cross, 1911), the aim is to investigate the accommo-
lens in its accommodated state.
dative state of the eye in near vision. There are two dis-
tinctly different techniques:

(1) The patient observes a separate fixation object while Dynamic lag of accommodation
the retinoscope is held behind it. The distance
In dynamic retinoscopy, the patient must try to main-
between the object and retinoscope at reversal indi-
tain accurate fixation and accommodation for the fixa-
cates the accuracy of accommodation.
tion object. This should have small letters, for example,
(2) The fixation object is on the retinoscope, the level of
a reduced Snellen chart or a series of small dots to be
accommodation being measured by trial lenses
counted. Despite this stimulus, the reversal position of
placed before the eyes.
the retinoscope usually lies about 120 mm behind the
In both techniques the patient wears the distance cor- fixation object. The difference in the dioptric distances
rection, usually as found by the subjective tests. The of fixation object and retinoscope sighthole from the pa-
fixation object must be well illuminated and finely de- tient’s eyes is known as the dynamic lag of accommoda-
tailed so as to provide a good stimulus for accommoda- tion. As explained later, a more specific term for it is
tion. An Anglepoise type of light, positioned about 30— the ‘low neutral’ dynamic lag.
40 cm above the patient’s head and aimed downwards, Woodhouse et al. (1993) mounted an internally illu-
will give adequate illumination of the stimulus while minated fixation stimulus on an accommodation rule,
keeping both the patient’s and retinoscopist’s faces in thus enabling the accommodative demand and the pos-
the shade. Alternatively, an internally illuminated fixa- ition of the retinoscope to be measured accurately.
tion stimulus could be used, either separately or as an il- The researches summarized on pages 288-289 show
346 Retinoscopy (skiascopy)

that in white light the wavelength focused on the retina (3) Exophoria in near vision, accommodation being sti-
is in the green region in near vision but approaches the mulated through the mechanism of convergence-
red region in distance vision. Subjectively, this can induced accommodation.
easily be shown with the bichromatic apparatus. If the
test patterns on the two colours are made equally clear The amplitude of accommodation in a juvenile patient
in distance, the subject will nearly always report that may be checked objectively by bringing the fixation
the green is clearer in near vision. A lag of accommoda- object closer and closer to the patient, the retinoscope
tion in dynamic retinoscopy could therefore be expected. following behind. An against movement will initially be
Rosenfield et al. (1996), comparing this technique of re- seen, changing to a with movement near the face. At
tinoscopy with the near bichromatic test and the near this point, the dioptric distance of the sighthole from
cross cylinder test, found that retinoscopy gave the best the spectacle plane is a measure of the amplitude.
agreement for the accommodative response as measured The quick and useful techniques described above
with an infra-red aurorefractor (see Chapter 18). follow approximately those of Nott (1925) and Freeman
The possible errors of static retinoscopy apply equally and Hodd (1955).
to the dynamic method, except those arising from obli-
quity of observation. There is, however, the added risk
that normal binocular vision might be disturbed by the
glare source of the retinoscope lamp. The accommoda-
Method using trial lenses
tion could also be affected even if binocular vision is
properly maintained. Good illumination of the fixation An alternative technique is for the patient to observe a
stimulus is therefore essential. detailed fixation stimulus attached to the retinoscope,
which is held at the near working distance. The patient
again wears the distance subjective or static retinoscopy
findings. A with movement will usually be seen in both
Variation in dynamic lag eyes as the retinoscope is passed quickly across their
If the lag is very high, the accommodation must be in- horizontal meridians. Equal positive power is added
sufficient. This could suggest that: before each eye until reversal is obtained. This process
can be simplified by using dynamic retinoscopy racks,
(1) The amplitude of accommodation is low and extra
holding a paired series of lenses of increasing plus
positive power is needed for near vision. Sometimes
power, and with a cut-out slot for the patient’s nose.
the dynamic lag is initially normal, but rapidly
The lowest lens power giving reversal is the dynamic
increases, showing the accommodative effort to be
low neutral, which corresponds to the finding ofthe pre-
ill-sustained. Extra help is again indicated. Near
vious technique. In the normal pre-presbyopic patient,
additions in presbyopia may be estimated by adding
this will be about 0.50 or 0.75 DS.
positive spheres until a normal lag is obtained.
If the plus lens power is increased, the neutral reflex
(2) The distance refractive error has been wrongly
appearance will remain over a significant change, up to
determined, for example, hypermetropia either
about + 1.50 DS. Beyond this point an against move-
under-corrected or with a large latent component,
or myopia over-corrected. A refraction under cyclo- ment will occur. The strongest reversing lens is known
plegia is probably indicated. as the ‘high neutral’: the difference between the high
(3) The patient is a low myope, infrequently wearing and low neutrals is assumed to correspond to negative
the distance correction for near vision. The accom- relative accommodation — the amount by which accom-
modative mechanism is therefore sluggish. modation can be relaxed while accurate and constant
(4) An esophoria in near vision. Inhibition of conver- convergence is maintained (see pages 164-165).
gence to prevent a breakdown into a manifest devia- This method of retinoscopy using additional trial
tion may also inhibit accommodation. lenses and its various techniques have been described
by many authors including Swann (1944) and Borish
Reversal may be obtained near or in the plane of the (USTAO)):
fixation object or there may even be an against move-
Whitefoot and Charman’s (1992) study into this tech-
ment with the retinoscope in that position. The small
nique of dynamic retinoscopy found that the mean re-
dynamic lag thus shown may indicate:
sults of the low and high neutrals for pre-presbyopic
(1) Spasm of accommodation in near vision. This could patients were 1.10+0.58 D and 1.52 +0.36D respec-
occur normally when a previously under-corrected tively. The size of the standard deviations, however, in-
young hypermetrope is given a marked increase in dicated a wide spread of values in the normal
correction. The patient is habitually used to accom- population, indicating that a deviation from the mean
modating both for the refractive error and for the did not mean an abnormal result. As expected from the
distance of regard and now has to accommodate effects of convergence-induced accommodation (see
only for the latter element. This effect does not pages 163-164) with binocular fixation, there was a
always occur but may sometimes be seen when the tendency for both neutrals to be higher in esophoria
refractive correction for a young patient is increased and lower in exophores. They concluded that dynamic
by about +2.00 DS. retinoscopy might have a role in binocular balancing in
(2) Spasm of accommodation in near vision unrelated near vision, and in the investigation of patients with
to distance refraction. specific near-vision symptoms.
 Streak retinoscopy 347

MEM retinoscopy

In the method of dynamic retinoscopy described above,

the stimulus to accommodation is altered by the pres-
ence of the trial lenses. In the monocular estimate
method, described by Greenspan (1974), Rouse et al.
(1982) and Eskridge (1989), the patient again binocu-
larly fixates a stimulus mounted on the retinoscope. In- (a) (b)
stead of the binocular rack, a single lens is briefly held
in front of one eye and the beam passed across. With
practice, it may be possible to refract the eye faster
than it can react to the change in stimulus (about 0.3
sec — see page 130). The method is applied to one eye at
a time, though both should be checked if it is wished to
use the technique to verify the near binocular balance
or accommodative response. The lens giving reversal
gives the value of the low neutral.

Streak retinoscopy ; (c) igi heed

Figure 17.26. Streak retinoscopy in astigmatism: minus
cylinder axis 110°, indicated by the line. (a) Streak horizontal,
The idea underlying streak retinoscopy is to elongate
scanning vertical, the reflex is oblique; (b) streak rotated until
the illuminated fundus patch and hence the potential reflex appears parallel and both are now parallel to the required
reflex while simultaneously narrowing its width. The axis; (c) reversal in 110° meridian, reflex filling the pupil; (d)
presence of low astigmatism then becomes more ap- beam rotated to 110° meridian to examine the 20° meridian,
initial against movement.
parent and its axis direction more easily determined. To
this end, the coiled-filament lamp of the spot retinoscope
is replaced by a goalpost filament lamp mounted to give the beam that spill over on to the lens surrounds, as in
a very narrow linear source perpendicular to the axis of Figure 17.26(b). The beam is then at right-angles to the
the condensing lens. The lamp can be rotated so that its cylinder axis, which can be read by temporarily focusing
rectangular beam can be set at any orientation. At all
the beam on to the cylinder axis scale.
times, the beam is passed across the pupil at right-
With the beam made divergent again, it is swept
angles to its length.
along the 110° meridian and the sphere power adjusted
In streak retinoscopy, the orientation of the streak
to obtain reversal. As shown in Figure 17.26(c), the
reflex or its borders is of great importance. It cannot be
reflex then fills the pupil (unless there is pronounced
exactly parallel to the illuminating streak unless this is
spherical aberration). An against movement will now
itself parallel to one of the eye’s principal meridians or
be seen when the beam is swept along the 20° meridian.
unless no astigmatism is present. Another important
The reflex still covers the width of the pupil (Figure
fact is that because of the illusion illustrated in Figure
17.26d) and reversal is obtained with a minus cylinder
17.25, the direction of travel of the streak reflex always
at axis 110°.
appears to be perpendicular to its length, provided that
An alternative procedure can be followed by the ex-
it extends over the entire width of the pupil.
perienced practitioner after reversal has been obtained
Streak retinoscopy is performed somewhat similarly
in the more hypermetropic meridian. The beam ver-
to spot retinoscopy. With a divergent beam the patient's
right eye is examined first, the left eye having been gence is then adjusted to position the immediate source
fogged. Then, with the beam always kept perpendicular between the retinoscope and the patient's eye. The
to the meridian explored, the direction of the reflex reflex now shrinks to a well-defined band in the pupil.
movement is noted in the horizontal, vertical, 45° and A relatively rapid with movement is produced, neutra-
135° meridians. Unless the astigmatism is high, the lized as before with a minus cylinder.
reflex will be nearly parallel to the beam and will show Francis (1973) has devised the following alternative
the same kind of movement, with or against, in each method of determining the presence of astigmatism and
meridian. Spherical lenses as appropriate are then its axis direction:
added to approach reversal.
Figure 17.26 illustrates the stages in the subsequent (1) Reversal with spherical lenses is obtained in the
more hypermetropic or less myopic meridian, in the
procedure, the refractive error being taken as +5.00/
normal manner.
—1.00 x 110. With +6.00 DS before the eye, there will
be a with movement in the vertical meridian and an (2) The retinoscope beam is set for maximum diver-
against movement in the horizontal, the same as in gence, so that the immediate source then lies about
spot retinoscopy. When the beam is horizontal, that is 1 m from the patient's eye, with a working distance
to say, at 20° from the orientation required, the reflex of two-thirds of a metre.
will appear tilted as shown in Figure 17.26(a). As the (3) The lens power for reversal is reduced by +0.50 DS
beam is rotated anticlockwise about the pupil centre, so that the immediate source becomes focused on
the reflex will gradually come into line with the ends of the retina in the meridian neutralized. As a result,
348 Retinoscopy (skiascopy)

the reflex shrinks to a narrow line instead of filling

Ratio (q/g)
the pupil.
2.5
(4) The beam is now rotated through 90°. If the reflex
remains narrow, no astigmatism is present, but
even the smallest amount will cause the reflex to
fill the pupil as the beam completes its rotation. Its
orientation when the reflex is at its narrowest is per-
pendicular to the axis of the required minus cylin-
der.
(5) The +0.50DS deducted is restored and reversal
obtained in the second meridian in the usual man-
ner.
+2) +3 et4 tO
Ametropia (D)

Width of the potential reflex

The length of the potential reflex, corresponding to the
length of the immediate source, is of no particular in-
terest because it is nearly always greater than the pupil
diameter. Its width, however, is important in streak reti-
noscopy. For simplicity, the cross-sectional diameter of
Figure 17.28. Graph showing the ratio of the width of the
the filament can be neglected and the immediate source potential reflex to the pupil diameter, plotted against
regarded as an axial point at a dioptric distance X from ametropia. Dioptric working distance —1.50 D. (After Francis,
the patient's eye. The refractive error, or residual refrac- OVS)
tive error when a lens is placed before it during retino-
scopy. is denoted by K, the dioptric length of the eye by ratio to the pupil diameter. The width of the observed
K’ and the pupil diameter by g. In Figure 17.27, his the reflex cannot, of course, exceed the pupil diameter.
half-width of the blurred retinal image of the point In Figure 17.28, the ratio q/g is plotted as a function
source and h’ half the size of its image in the eye’s far- of the ametropia K when W=-—1.50D and X=
point plane. From equation (4.16a), replacing L by X —1.00D. The graph is a hyperbola, asymptomatic to
and j by 2h, we then have the vertical at K = W (reversal). It will be seen that as
7 7 a hypermetropic (but not a myopic) meridian is gradu-
Al= <= (C776) ally brought to reversal, the width of the reflex de-
NS
creases, becoming theoretically zero (an Euclidean line)
while the conjugate foci relationship gives when K = X.
h' = hK'/K (Gbers) The hypothetical point source is then in focus on the
retina and the actual reflex observed is at its narrowest.
Viewed from the centre C of the sighthole, its diameter It then expands rapidly to fill the pupil when reversal is
being ignored, the total width gq of the potential reflex is
obtained. A more detailed discussion is given by Francis
equal to 2y. From the similar triangles in the diagram (1973), on whose graphs Figure 17.28 is based.
we get
w
ie Orientation of the reflex
w—k
K In Figure 17,29, the refractive error of the eye repre-
= 2h’ x (17.8)
kK—W sented is
Finally, multiplying together equations (17.6)-(17.8) —1.75/—0.25 x 50
produces
so that K,=—2.00D and Kg=-1.75D. If W=
ieee 17.9 —1.50D and X = —1.00D, the relative speed of reflex
ea es, Me) movement tt in the two meridians is found to be,
which can also be put in the form |, = —1 and pg = —2. The illuminating streak IS is
horizontal and has been moved vertically downwards
q/g= (K — X)/(K — W) (17.10)
from the pupil centre O. To find the corresponding pos-
This gives the width of the potential reflex in terms of its ition of the streak reflex SR, it is merely necessary to
consider the points C and D at which the illuminating
streak intersects the principal meridians. In the 140°
(alpha) meridian where p, = —1, C’ is located on the
side of O remote from C such that OC’= —OC. Similarly,
in the 50° (beta) meridian where Its = —2, D’ is located
on the side of O remote from D such that OD’/= —2 OD.
The streak reflex therefore lies along the line C’D’.
Let 6 denote the angle from the beta meridian to the
Figure 17.27. The potential reflex in streak retinoscopy. Q is illuminating streak and ’ the angle to the streak
the edge of the potential reflex, not the edge of the pupil. reflex. Then, from the geometry of the diagram,
 Exercises 349

Apparent True KA 175 Figure 17.22 can be used. Perpendiculars BM and BN

direction direction B
of reflex of reflex a are dropped from B to the principal meridians. Then, M’
movement movement 4 and N’ are located from OM’=p»,OM=—OM and
ON’= !tgON = —2(ON). The point B’ is the fourth
corner of the completed rectangle OM’N’B’. The con-
struction is confirmed by finding B’ to lie on C’D’. Thus,
the centre of the streak reflex has moved in a direction
OB’ which is not only oblique to that of the illuminating
streak but also to its own apparent movement, which,
as shown in Figure 17.25, is perpendicular to its
length. From the geometry of Figure 17.29 we have
Horizontal
tana’ N’B'/ON’ OM’/ON’ ut el

tana NB/ON ~ OM/ON jy

Since this expression is identical in form to equation
(17.11), it can similarly be written as in equation
(17.12), with a’ and a substituted for ’ and 9.
50° Beam 140°
Figure 17.29. Derivation of orientation and true and A new method
apparent directions of movement of the reflex in streak
retinoscopy.
An interesting variation of streak retinoscopy was intro-
duced by Parker (1966). The retinoscope is fixed in
alignment with the patient’s pupil and the vergence
tang’ OC’/OD' yp, control adjusted to give minimum reflex width. Lenses
Giza)
tand OC/OD — Lg are added to increase this width by reducing the ame-
tropia. Neutralization occurs when the reflex fills the
Using equation (17.4), this relationship can also be
pupil.
written as

Ehihan o _ sey
Wor an.d ( 17.12
des ) Exercises

In the example shown in Figure 17.29 we should have 17.1 Retinoscopy is performed at a working distance of two-
thirds of a metre with a self-luminous retinoscope. The bulb
221502175 5 filament is 1 mm across and is imaged to the immediate source
tango = : tan (—50°)
=1.50 + 2.00 by a lens of power +20.00 D. Neglecting the distance between
this lens and the mirror, find the overall size of the illuminated
= 0.5 tan (—50°) patch on the retina when the vergence of the retinoscope
beam, measured at the mirror, is (a) —1.00D, (b) —5.00D,
giving 6’ = —30.8°. If d and $’ are measured from the
(c) +3.00 D. Assume the patient's pupil to be 5 mm in diameter,
alpha meridian, the coefficient of tan@ in equation the ocular refraction —3.75 D and the axial length of the eye
(17.12) need merely be inverted. In the same example, 24mm.
would become 40° and we should have 17.2 Retinoscopy is carried out at a working distance of half
a metre, the immediate source being 25 mm in diameter and
tan o’ = 2 tan 40° 750 mm behind the mirror. Find the size of the image of the il-
luminated fundus patch, given that the subject has a 4mm
giving pupil and is (a) myopic —0.50 D, (b) myopic—5.00 D, (c) hyper-
metropic +1.00 D.
@, = 9.27 17.3 A myopic eye of 26% mm axial length has an ocular re-
Some interesting deductions can be made from equa- fraction of -12.50D and a 6mm pupil. Light is reflected from
an illuminated point on the retina 0.3 mm directly below the
tion (17.12). For example, when reversal occurs in the
optical axis. On a diagram with the actual size along the axis
beta meridian, the term (W — Kg) becomes zero. Conse- and five times the actual size vertically, show the emergent
quently, ’ remains zero irrespective of the value of 6. pencil of rays and shade that part of it which would enter the
That is to say, the reflex remains aligned with the beta 4mm pupil of an observer's eye placed 120 mm from the re-
meridian whatever the orientation of the streak. Simi- duced surface of the subject’s eye. On a separate drawing five
times actual size, show what part of the subject's pupil would
larly, when reversal occurs in the alpha meridian, ¢’ be- appear to be illuminated.
comes 90° for all values of ¢, the reflex thus remaining 17.4 (a) An astigmatic eye has ocular refraction of
aligned with the alpha meridian. — 1.00 DS/—3.00 DC axis 180
Assuming light to be reflected from a single point on the retina,
Direction of the reflex movement draw a scale diagram showing a section through the emergent
pencil in each principal meridian. Hence construct a separate
In Figure 17.29, thé angle a’ gives the direction of the diagram showing the appearance of the reflex as seen by an ob-
reflex movement when the illuminating streak moves at server at 1 m. Assume both pupils to have a diameter of 4 mm.
an angle a, both angles measured from the beta merid- (b) How would the reflex appear to move if the luminous point
were to move across the retina (i) horizontally, (ii) vertically,
ian. The relationship between them, stated without
(iii) in the 45° meridian?
proof as equation (17.5), can be derived very simply. 17.5 (a) Retinoscopy is performed at two-thirds of a metre.
To locate B’, the point on the reflex corresponding to B The immediate source, assumed to be a point, is placed
on the illuminating streak, the procedure illustrated in —800 mm from the subject's eye. Calculate the diameter of the
350 Retinoscopy (skiascopy)

potential reflex when the ametropia is: —0.50, —1.00, —2.00, form, emmetropic for the d-line with index n= 1.336 and
—2.50DS. Assume K’=+60D and pupil diameter 4mm. index n = 1.334 for red light.
(b) Suppose the bulb filament image or immediate source is
now made 2mm in diameter. Calculate the new potential
reflex dimensions. Since the actual reflex diameter cannot
exceed the pupil diameter, discuss the practical difference be-
tween these results. (c) The point-source retinoscope is adjusted References
so that the immediate source is —400 mm from the subject's
eye. Calculate the new potential reflex dimensions. Comment BARRETT, C.D. (1945) Sources of error and working methods in
in relation to streak and spot retinoscopy. retinoscopy. Br. J. Physiol. Optics, 5, 35-40 x
17.6 A streak retinoscope is used at a working distance of BENTALL, W.K. and DIPROSE, D.R. (1932) A practical examina-
two-thirds of a metre. From first principles find the angular tion of certain theoretical aspects and anomalies connected
movement of the reflex when the mirror rotates 0.1 rad, in with static retinoscopy. Trans. Inst. Ophthal. Optns, Nov. 1932
each of the following cases: (a) patient's eye myopic —1.00 D, VAN BLOKLAND, G.J. (1985) Ellipsometry of the human retina in
beam vergence at the mirror +4.00 D; (b) patient’s eye hyper- vivo: preservation of polarization. J. Opt. Soc. Am. A., 2,
metropic +5.00 D, beam vergence at the mirror +1.00 D. 72-75
17.7. Retinoscopy is performed at —O0.5m on a patient with BORISH, I.M. (1970) Clinical Refraction, 3rd edn. Chicago: Pro-
refractive error —1.75 D. Find the angular speed of the reflex fessional Press
relative to the retinoscope movement when the immediate CHARMAN, W. (1975) Some sources of discrepancy between sta-
source is positioned —0.5m, —0.17m and +0.17 m from the tic retinoscopy and subjective refraction. Br. J. Physiol. Op-
retinoscope.
tics, 30, 108-118
17.8 (a) Retinoscopy is performed with a luminous instru- cross, A.J. (1911) Dynamic Skiametry in Theory and Practice.
ment on a myopic eye of —12.50D ocular refraction, the im-
New York: A. Jay Cross Optical Co.
mediate source being 500mm behind the mirror. By what ESKRIDGE, J.B. (1989) Clinical objective assessment of the ac-
factor is the speed of the reflex movement increased when the
commodative response. J. Am. Optom. Assoc., 60, 272-275
working distance is reduced from two-thirds to one-tenth of a
FRANCIS, J.L. (1973) The axis of astigmatism with special refer-
metre? (b) Repeat (a) for an aphakic eye of +12.50 D ocular re-
ence to streak retinoscopy. Br. J. Physiol. Optics, 28, 11-22
fraction.
FREEMAN, H. and HODD, F.A.B. (1955) Comparative analysis of
17.9 (a) Retinoscopy is performed at a working distance of
retinoscopic and subjective refraction. Br. J. Physiol. Optics,
- 2 m on a patient with a 5 mm diameter pupil. The instrument
12, 8-36
uses a point source and a +30 D lens which can be positioned
GLICKSTEIN, M. and MrLLopotT, M. (1970) Retinoscopy and eye
to give a beam divergent (i) —2 D, (ii) —5 D on leaving the reti-
size. Science, 168, 605-606
noscope lens. For both adjustments, calculate the diameter of
GORRAND, J.M. (1986) Separation of the reflection by the inner
that area of the retinoscope lens through which light can pass
limiting membrane. Ophthal. Physiol. Opt., 6, 187-196
into the patient’s pupil, and also the solid angle subtended by
GREENSPAN, S.B. (1974) M.E.M. retinoscopy. Bausch & Lomb
this area at the actual source. For which adjustment is the
reflex brighter? (b) Repeat for a different instrument with a
Today, 18, cited in Eskridge (1987)
HODD, F.A.£. (1951) The measurement of spherical refraction
lens of power +10 D but giving the same beam vergences.
17.10 In static retinoscopy, the patient's right eye looks just by retinoscopy. In International Optical Congress 1951,
past the refractionist’s right ear, so that the retinoscope is pp. 191-231. London: British Optical Association
25mm to the side of the right visual axis. Calculate the obli- MILLODOT, M. (1974) Some aspects of experimental optometry.
quity of the axis of retinoscopy to the visual axis for the right Ophthal. Optn, 14, 99-104
eye, and also for the patient’s left eye, the examiner not MILLODOT, M. and O'LEARY, D. (1978a) The discepancy be-
moving. Assume the patient’s PD to be 68 mm, the working dis- tween retinoscopic and subjective measurements: effect of
tance 3 m, and no vertical discrepancy. age. Am. J. Optom., 55, 309-316
17.11 In static retinoscopy, working 4° temporally to the MILLODOT, M. and O'LEARY, D. (1978b) The discepancy be-
visual axis, the refractive error is found to be 1 D more myopic tween retinoscopic and subjective measurements: effect of
than the subjective finding. Assuming this to be caused by a light polarization. Am. J. Optom., 55, 553-556
slope in the retina (of a reduced eye of power +60 D), calculate MOHINDRA, I. (1975) A technique for infant vision examina-
the angle between the visual axis and the plane of the retina. tion. Am. J. Optom., 52, 867-870
17.12 (a) Reversal having been obtained at a working dis- NoTT, 1.8. (1925) Dynamic skiametry, accommodation and
tance w, the retinoscope is tilted so that the ray from the convergence. Am. J. Physiol. Opt., 6, 490-503
centre of the patient’s pupil just grazes the upper edge of the OWENS, D.A., MOHINDRA, I. and HELD, R. (1980) The effective-
sighthole, which has an effective vertical diameter a. At the ness of a retinoscope beam as an accommodative stimulus.
same time, a ray from the upper extremity of the pupil just Invest. Ophthalmol. Vis. Sci., 19, 942-949
grazes the lower edge of the sighthole. Derive an expression for PARKER, J.A. (1966) Stationary streak retinoscopy. Can. J.
K, the relative refractive error at the pupil margin, equal in Ophthal., 1, 228-239
amount but opposite in sign to the zonal spherical aberration. PASCAL, J.I. (1930) Modern Retinoscopy. London: Hatton Press
(b) Tabulate the values of K for sighthole diameters 1, 2 and ROORDA, A. and BOBIER, W.R. (1996) Geometrical technique to
3 mm and pupil diameters 2, 4 and 6 mm, the working distance determine the influence of monochromatic aberration on re-
being =m. tinoscopy. J. Opt. Soc. Am. A., 13, 3-11
17.13 In dynamic retinoscopy, the fixation object is 350 mm ROSENFIELD, M., PORTELLO, J.M., BLUSTEIN, G.H. and JONES, C.
from the mid-point between the patient's eyes. If the retino- (1996) Comparison of clinical techniques to assess the near
scope is held (a) 80, (b) 100, (c) 120 mm behind the test object accommodative response. Optom. Vis. Sci., 73, 382-388
at reversal, what is the dioptric value of the dynamic lag (with ROUSE, M.W., LONDON, R. and ALLEN, D.C. (1982) An evaluation
respect to the mid-point between the eyes)? Calculate also the of the monocular estimate method of dynamic retinoscopy.
horizontal angle between the visual and retinoscopic axis, as- Am. J. Optom., 59, 234-239
suming both the fixation object and retinoscope to be held in STAFFORD, M. and MORRIS, J. (1993) Retinoscopy in the eye ex-
the median plane, and a PD of 64 mm. amination. Optom. Today, 8 Feb, 17-25, and reprint from
17.14 Oncomparing retinoscopy with the method ofparallax Optom. Today
used on an optical bench to locate the position of an image, SWANN, L.A. (1944) Dynamic Retinoscopy. London: Raphaels
what similarities and differences could be listed? Ltd
17.15 Calculate the artefact of retinoscopy produced for eyes WHITEFOOT, H. and CHARMAN, W.N. (1992) Dynamic retino-
of axial length (a) 5, (b) 7.5, (c) 10, (d) 15, (e) 20 and (f) scopy and accommodation. Ophthal. Physiol. Opt., 12, 8-17
25 mm if, (i) the reflection takes place 0.1 mm in front of the WOODHOUSE, J.M., MEADES, J. S., LEAT, S.J. and SAUNDERS, K.]J.
plane of the receptors and if (ii) the discrepancy is caused by (1993) Reduced accommodation in children with Down's
chromatic aberration. Assume the eyes to be of simple reduced syndrome. Invest. Ophthalmol. Vis. Sci., 34, 2382-2387
18
Objective optometers

Introduction Most objective optometers, whether designed for clini-

cal or research purposes, are based on the method of in-
While retinoscopy is an excellent method of objective re- direct ophthalmoscopy. A simple system could be
fraction, it is a procedure that net every practitioner designed as in Figure 18.1, using two objectives or con-
manages to accomplish accurately. Moreover, in some densing lenses and a beam splitter. As in normal indirect
countries it is illegal for opticians to perform retino- ophthalmoscopy, the immediate source is imaged near
scopy, and they must therefore rely on some other objec- the edge of the pupil, shown inferiorly for convenience
tive method. in the diagram. A test object T can be moved along the
Instruments called optometers or refractionometers axis of the projection system; when in the anterior focal
offer an alternative means for evaluating the optical cor- plane of the projection lens L,, its image T’ will be at in-
rection of the eye. finity and will therefore be sharply focused on the
Automated electronic optometers, often termed auto- retina of an emmetropic eye. If the patient is myopic,
refractors, offer the advantage of greater speed. Also, the test object will have to be moved towards L, in
they can be operated by trained auxiliaries, thereby order to be imaged on the fundus. The reverse applies
saving the practitioner’s time. in hypermetropia. If the second focal plane of L, coin-
Developments in autorefractors have rendered the cides with the average position of the spectacle plane,
visual optometers and some of the early electronic in- the illumination system also becomes a Badal optometer
struments obsolete. In the first edition of this work we (see page 75) and the scale indicating the position of T
gave detailed accounts of the different optical principles relative to the anterior focal plane of L, can be cali-
on which the three pioneering autorefractors were brated linearly in terms of spectacle refraction.
based. Their manufacturers were more ready to publish When attempting to measure the refraction of the eye
details of the optical design than is now generally the with such an instrument, the first adjustment would be
case. Since many of the currently available models to focus the source image on the patient’s iris by
appear to embody no new optical principles, as opposed moving the whole instrument towards or away from
to electronic refinements, we have continued to describe the eye. This will simultaneously position L, at the cor-
the older instruments as well as some of the newer de- rect distance from the eye required by the optometer
signs. The older visual instruments were described in graduation. With the instrument then moved sideways
previous editions of this book. Other treatments of the slightly so that the fundus is illuminated, the observa-
subject are to be found in the work by Henson (1996) tion telescope would be focused to give a reasonable
and the contribution by Wood (1988) to another work. view of it. Finally, the test object’s position would be ad-
justed to give a clear image. In astigmatism, there are
two positions where the two mutually perpendicular
meridians of the test object become clear in turn.
Visual instruments
Hence, for the detection and measurement of astigma-
tism, a test object with a ring of dots, a pattern of radial
We have seen (see pages 314 and 317) that the direct
lines or a rotating cross is required.
ophthalmoscope can give an approximate idea of the
The accuracy and speed of operation will be increased
spherical ametropia but lacks accuracy. Accommoda-
if movement of the test object is simultaneously coupled
tion by either patient or observer affects the result and
with focusing of the observation system. To the obser-
the sighthole lens is about 20 mm from the spectacle
ver, the test object will then appear to go in and out of
plane. Some improvement can be made by incorporating
focus at twice the rate that occurs when only the test
an axially sliding graticule in the illumination system
object is moved.
that can be focused on the retina, the position of the gra-
A combination of Scheiner disc and coincident align-
ticule indicating the amount of ametropia. Even so, the
ment at the correct focus can also be used in subjective
accuracy is not greatly improved, and estimation of as-
tigmatism and axis detection are particularly difficult
optometers, for example, as described by Fry (1937)
and Allen (1949).
by this means.
352 Objective optometers

<——

Figure 18.1. Indirect ophthalmoscope modified to act as an optometer.

Moses (1971) and Jaschinski-Kruza (1988) developed the glare. Since the light reflected by the fundus was
an elegantly simple hand optometer. The eye is centred orange-red in colour, very little light was lost to the ob-
behind a 4 mm artificial pupil covered by two abutting server.
pieces of Polaroid filter with their polarizing axes at
right-angles. On the opposite side of the +5.0 D Badal
optometer lens is a narrow bar of light-emitting diodes
(LEDs) orientated parallel to the dividing line between Electronic optometers
the Polaroid filters. These LEDs are also covered by two
pieces of Polaroid, so that each half of the bar is viewed The objective optometers formerly used relied on the ex-
through only half the pupil, thus providing a simple sub- aminer’s decision on when the image is clearest or in co-
jective Scheiner-disc vernier-alignment optometer. The incidence setting; they were objective only in the sense
LEDs are flashed on for only 200 ms so as not to stimu- that the patient's subjective choice has been replaced
late the accommodation. by the choice of an experienced examiner.
Electronic optometers fall into two classes:

(1) Instruments designed to measure automatically the

Some general considerations refraction of the eye and capable of being operated
by auxiliary staff; these may be called objective opt-
With all objective optometers, the patient can see the ometers in the fullest sense.
test graticule and may be required to fixate it. As a N Instruments designed for research on accommo-
result, accommodation may be stimulated and lead to dation, when a fast and continuous response is
an incorrect low hypermetropic or high myopic reading. required.
Because the patient is looking into an instrument posi-
tioned very close to his face, proximal accommodation In most cases, all these instruments use infra-red
may well be induced. For these reasons the graticule radiation instead of visible light to ascertain the focus
should be moved to a position of hypermetropia before of the eye. Research instruments can thus measure
measurements are taken. The graticule will then accommodation without distracting the subject or sti-
appear fogged to the patient, helping to relax accommo- mulating accommodation. Similarly, the clinical instru-
dation. ments should be able to refract the relaxed eye: a visible
Some instruments provide a second graticule for the fixation stimulus has to be provided, however, and this
patient to observe through an auxiliary optical system, may stimulate the accommodation unless the eye is
so that it appears adjacent to the measuring graticule. fogged.
The fixation stimulus is moved with the measuring gra-
ticule, but is arranged to be fogged in relation to the
measuring beam. This will also aid in relaxation of ac- Autorefractors
commodation, especially when measuring the less hy-
permetropic or more myopic meridian, when the As explained in detail by Bennett and Rabbetts (1978),
patient could accommodate to keep the first meridian’s some electronic optometers operate in various forms on
image in focus if the normal measuring graticule served the principle of meridional refraction. There is a persis-
as fixation. Alternatively, a fixation stimulus could be tent fallacy that a sphero-cylindrical lens has a focal
mounted on the carrier of the measuring graticule, but ‘power’ equal to (S+Csin* 6) in the meridian at 0°
positioned a little further away from the objective or in- from the cylinder axis. In fact, those rays passing
termediate lens than this test graticule. through any oblique meridian of an astigmatic lens un-
Several instruments incorporated an orange filter in dergo skew convergence or divergence and fail to re-
the illuminating system. This reduced the amount of unite at any focus. The expression quoted does, how-
light entering the patient's eye and hence moderated ever, correctly express the prismatic power of the lens
 Autorefractors 353

along a specified meridian, ignoring the prismatic com- To simplify the descriptions, the aligning and patient’s
ponent at right-angles to it. fixation optical systems have been ignored in most of
It had previously been shown by Bennett (1960) that the following explanations. Most instruments employ
if Scheiner disc refraction is performed with spherical an infra-red camera and video display to enable the
lenses, it is the prismatic power of the eye in the merid- operator to place the instrument approximately in the
ian parallel to the Scheiner disc apertures that is meas- correct position in front of the eye; the instrument will
ured. From three determinations of (S+Csin* 6) in then automatically centre itself to the pupil at the cor-
different meridians, it is possible to calculate the sepa- rect working distance. A visible fixation stimulus is in-
rate values of the three quantities S$, C and 0 which corporated on the optical axis — this is generally
define the optical correction needed. The prediction was positioned to appear fogged to the patient, the vergence
made that this was a possible basis for automated refrac- being adjusted according to the measured refractive
tion. error.
Electronic optometers fall into six main classes de- The author is indebted to Dr C. Campbell of Humphrey
pending on the operational method used: Instruments (Carl Zeiss Inc.) for details of some of the
newer instruments.
Analysis of image quality
(Dioptron, early Canon Autorefractors, Hoya Autore-
fractor) The Dioptron
Retinoscopic scanning The Dioptron (manufactured by Coherent Radiation but
(Ophthalmetron, Nikon 5000 and+*7000) now obsolete) consists of a measuring head, digital com-
Scheiner disc refraction puter and printer. The measuring head is illustrated
(6600 Autorefractor, Nidek autorefractors) schematically in Figure 18.2. Infra-red radiation illumi-
Knife edge refraction nates the test graticule T, formed by a series of slits in
(Humphrey Auto Refractor) the cylindrical surface of a drum rotating about the op-
Analysis of image dimensions tical axis. The beam splitter P, and lens L, collimate
(Topcon Autorefractors) the beam from T, while the movable lens L, forms an
Vergence measurement aerial image T), of the graticule. This image forms an
(Canon autorefractors) object for the Badal optometer lens L3; and is moved by
’
L, along the axis of the instrument until it is conjugate
The first electronic optometer to appear was the Col- with the patient's fundus. It then lies in the artificial
lins Electronic Refractionometer, designed and patented far-point plane of the eye as formed by lens L3.
by the English optometrist Collins (1937). It has been The returning beam, after refraction by lens L3, forms
appraised in the light of subsequent developments by an image T of the fundus in the same plane as T. It is
Charman (1976) and Bennett (1978). Its basic features then collimated by lens L, and imaged by lens L, as T)
were incorporated in the Dioptron instrument to be de- in the plane of a mask M in front of the photoelectric de-
scribed, but it was less sophisticated in that the optical tector system D. If the mask is made as a positive replica
system was adjusted manually to determine the end- of an aperture in the revolving drum, the radiation
point. forming the aerial image T, when this is in focus on

Figure 18.2. Simplified optical layout of the Coherent Radiation Dioptron. IRF infra-red transmitting filter, F auxiliary fixation
system. (Redrawn from an illustration kindly supplied by Coherent Radiation Inc.)
354 Objective optometers

the mask, will pass through it to the detector with little the eye. Like all clinical instruments, it was designed to
loss except from aberrations. When it is well out of provide a single measurement of refractive error in
focus, a much greater proportion of the energy will be each operating cycle. Modifications described by Pugh
intercepted by the mask, thus giving a low input to the and Winn (1988), Davis et al. (1993) and Wetzel et al.
detector. As the drum revolves, successive images T, of (1996) make possible the continuous measurement of
its slits pass laterally across the mask. When these accommodation, including its micro-fluctuations. De-
images are in focus, they are alternately passed and oc- scriptions of the AutoRef R-] are given in the papers by
cluded by the mask to give a high-amplitude output Pugh and Winn (1988) and McBrien and Millodot
from the detector. When the images are slightly out of (1985). Clinical evaluations are given both in this
focus, the alternating amplitude is lower, while when latter paper and by Berman et al. (1984).
greatly out of focus a steady output results. An AC elec-
tronic amplifier tuned to maximum response at the
‘chopping’ frequency feeds the computer, which pos- The Ophthalmetron and
itions the lens L, to maximize output. Nikon autorefractors
An aperture stop placed between L, and L, is imaged
near the patient’s pupil. This stop has a round aperture
The Bausch and Lomb Safir Ophthalmetron, no longer
extended by four slits in the form of a cross. Their pur-
in production, described by Knoll and Mohrman
pose is to add a contribution of radiation passing
(1972), was the first instrument to be based on the prin-
through the pupil periphery to the more important cen-
tral zone. To reduce the effects of stray light, the first re- ciple of streak retinoscopy. A somewhat similar system,
to be described, is used by Nikon. An infra-red LED and
flecting prism P, polarizes the light. The beam splitter
P, reflects light of this orientation towards the patient’s condensing lens L; are surrounded by a chopper drum
eye, while the double passage through the quarter- (Figure 18.3) which sweeps the beam across the pupil,
wave plate Q rotates the plane of polarization through and hence fundus, in a manner analogous to retino-
90° so that the returning beam is now transmitted scopy. The returning beam passes through a beam
through P, to the detector. splitter to be received by a positive lens L, which forms
The operator aligns the instrument with the patient's an image of the patient’s pupil on a four-element de-
eye by means of an auxiliary observation system. The il- tector. The upper and lower infra-red detectors, being
luminating system, the beam splitter P,, mask and quar- basically parallel to the chopper’s slit apertures, record
ter-wave plate all rotate simultaneously to investigate whether the resulting reflex has a with or an against
various meridians of the eye. A peak response due to movement, depending on which cell of the pair is stimu-
either of the eye’s two principal astigmatic meridians is lated first. If the scanning direction is not aligned with
first sought, after which the instrument measures the the eye’s principal astigmatic meridians, the returning
refraction in six different meridians. If only the mini- reflex will be twisted, and hence will strike the two lat-
mum of three readings are taken, a small error in any eral receptors at different times.
one or more of them can lead to a disproportionately The amount of meridional ametropia is calculated
large error in the calculated refraction. The six readings from the time interval between the returning beam
are analysed by a computer to obtain the best-fitting re- striking the upper and lower detectors. The sighthole of
fraction, while the degree of consistency between them conventional retinoscopy is replaced by a slit aperture S
is used to express a ‘confidence factor’. The mathe- parallel to the scanning apertures. S is positioned in the
matical procedures involved in this analysis have been second focal plane of the lens L3, so that the retinoscopy
detailed by Long (1974, 1981). working distance is infinite. Alternatively, S may be re-
Further descriptions of the instrument have been garded as being imaged at S’ in the focal plane within
given by its inventor (Munnerlyn, 1978) and by Wood the patient’s eye. The returning beam from the illumi-
and French (1981). A review of its accuracy was given nated fundus patch has to pass through 8’, and then
by French and Wood (1982). through H’ or J’, the images of the photodetectors in
the pupil. For the myopic eye illustrated in the inset,
the upwards moving fundus patch will leave the eye

The early Canon autorefractors

These were based on a similar operating system to the H _— C
Dioptron. The now obsolete AutoRef R-1 had the cy if oy J |_|SSy
unique feature of utilizing an imaged refraction system,
an example of which is illustrated in Figure 19.3 (page (— ) \\ Dates
eee
371). The patient was thus allowed a binocular view of
a real object through the inclined semi-reflecting mirror
which reflected the measuring infra-red radiation from
and to the autorefractor positioned below the line of
sight. Thus, myopic patients could view a real object
2 P
across the room, helping to relax accommodation. This
instrument is now proving useful in research into ac- Figure 18.3. Simplified optical layout of the Nikon
Autorefractometer. C chopper drum, E LED, H and J detector
commodation, allowing an objective measurement of system, L; and Ly positive lenses, P Pechan prism for astigmatic
the ocular response to stimuli at known distances from scanning, S slit aperture.
 Autorefractors 355

first though J’ and then H’. The nearer the eye is to em- nil-difference signal from the corresponding pair of
metropia, the closer the two secondary sources SS, and photodetectors. This position gives the refractive error
SS} on the fundus, and hence the shorter the time inter- in spherical ametropia.
val between the responses of the detectors. A second pair of LEDs and photodetectors are pro-
A Pechan prism is used in some of the instruments to vided, both arranged orthogonally to the first. These
rotate the direction of scan of the beam around the in- LEDs are powered at a different frequency from the first
strument’s axis, thus allowing the measurement of the and effectively allow the detection of astigmatic scissors
refractive error. The annular shape of the detector rotation of the oscillating light patch on the fundus.
allows the instrument to centre itselfto the pupil, but in- The sources and detectors are automatically rotated to
evitably means that the peripheral rays are being meas- align with the astigmatic meridians of the patient’s eye,
ured. A more sophisticated design discards the Pechan while the axially moving system moves to measure the
prism by employing oblique slits in the chopper drum, a two refractive powers.
circular sighthole and more complex computer proces- Auxiliary systems are incorporated to allow accurate
sing of the time data from the four-element detector. alignment of the instrument including the vertex dis-
A description of these instruments has also been given tance setting and to provide a diffuse green fixation
by Wood (1988). source (McDevitt, 1977).

The Nidek Autorefractors

The 6600 Auto-Refractor ~*
These are similar to the 6600 Auto-Refractor, being
Another objective optometer, the 6600 Auto-Refractor, based on the Scheiner disc principle. These use a pair of
was based on the Scheiner principle, being a develop- LEDs, initially, say, along the 180° meridian. A four-
ment of a research instrument (Cornsweet and Crane, element detector again records whether the fundus
1970). It was introduced in that year but is no longer patch is oscillating obliquely or if the system is aligned
available. Four LEDs of wavelength 935 nm are posi- with the eye’s principal meridians. The LEDs and de-
tioned in the anterior focal plane of the collimating lens tector assembly are rotated simultaneously, and allow
L, (Figure 18.4). The lens L, images these sources in the test aperture T to be positioned conjugate to the
the plane of the pupil and acts as a Badal optometer fundus and the refractive error determined.
lens with a circular aperture (target) as the test object. Descriptions have also been given by Wood et al.
Opposite pairs of LEDs are powered alternately and (1984), and Wood (1988). The Nidek ARK-2000 also
cause the aperture to be imaged on or near the retina combines the function of an automatic keratometer.
through two separate but neighbouring regions of the
patient’s pupil. When the aperture T is out of focus, the
illuminated fundus patch oscillates, with or against the
The Humphrey Auto Refractors
source alternation depending on whether the focus is in
front of or behind the retina. When in focus, there is no The Humphrey Auto Refractor was the first instrument
movement of the illuminated patch. which, as well as providing an automatic refraction,
Lens L3 is of the same power and positioned at the also allowed the practitioner to measure the resulting
same optical distance from the eye as the illuminating visual acuity and to obtain a subjective confirmation of
optometer lens L,. A fundus image T) is formed by L; the spherical component of the refraction. The simplest
in the plane of lens Ly which acts as a field lens. Lenses of their three present instruments no longer provides
Ls and L, form an image 1 of the fundus on the four the spherical confirmation facility, but its optical
photodetectors. The positions of the aperture T and system is the same as in the more comprehensive
lenses Ly and Ls are adjusted automatically to give a models.

Figure 18.4. The Acuity Systems 6600 Auto-Refractor: simplified optical layout. The imagery of the quadrant LEDs in the pupil is
indicated by the dashed line, a theoretical raypath that would not pass through the aperture T. The path to the fixation and
alignment systems is indicated by A. (Redrawn from McDevitt, 1977.)
356 Objective optometers

Sphere adjustment

>
Patient’s eye

|R source/detector

ixation
Fixation light
lig Cylinder adjus
: tment

(a) (b)
Acuity chart Figure 18.6. The infra-red source arrangement of the
Humphrey Auto Refractor: (a) one of the four prism
Figure 18.5. Simplified optical layout of the Humphrey Auto components together with its associated LEDs (shaded ellipses),
Refractor. (Reproduced by kind permission of Humphrey condenser lenses and L-shaped aperture, (b) the complete
Instruments Inc.) source assembly, forming an illuminated hollow cross. L and R
denote left and right pairs, T and B top and bottom pairs of
parallel source elements.
Tracing the ray path shown in Figure 18.5 backwards
from the patient’s eye, O is a Badal optometer lens
whose posterior focal plane is positioned in the eye’s
pupil. The mirrors M, fold the optical path within the in-
strument to reduce space and also provide the variable
spherical element by altering the distance between the
optometer lens O and the intermediate aerial image
formed by the relay lens R. A second pair of mirrors M)
again fold the light path. The cylindrical assembly is po-
sitioned in the anterior focal plane of the relay lens and
so is imaged in the pupil plane irrespective of the spher-
ical adjustment. The assembly is formed by two sets of
Stokes lenses, which are arranged to correct astigma-
tism in the 90°/180° and 45°/135° meridians, the two
corrections being compounded to give a single correct-
ing cylinder. Figure 18.7. A schematic construction for the formation of
The beam splitter B is designed to reflect visual light the pupil reflex in the Humphrey Auto Refractor in (a) relative
from the acuity chart, while transmitting infra-red light hypermetropia, (c) relative myopia. The arrowed areas in (b)
and (d) show that part of the pupil which appears luminous to
to and from the source and detector. The whole pupil the detector for radiation originating below the optical axis of
area is used for both incident and emergent beams. To the instrument.
investigate the returning light, the instrument performs
a Foucault knife-edge test in horizontal and vertical
meridians simultaneously. As in retinoscopy, the reflex the source plane because there is relative hypermetro-
is interpreted to arrive at the optical power adjustments pia. The Foucault slit further restricts the beam falling
needed for reversal. The system then provides a com- on the detectors, so that only the lower part is illumi-
plete ocular correction through which the test charts nated as indicated by the solid lines from H and Q.
can be viewed, whereas many automated refractors use The stippled upper part of the pupil in Figure 18.7(b)
only spherical optometer systems from which sphero- appears luminous to the photodetector. Conversely, in
cylindrical refractions are calculated. relative myopia (Figure 18.7c) the lower region of the
The infra-red source comprises eight LEDs arranged pupil appears luminous (Figure 18.74).
around the edge of an assembly of four prisms to provide The area of illumination falling on the detector de-
an illuminated hollow cross (Figure 18.6). The aligning pends on the relative ametropia. The detector is divided
pairs, for example, the lower horizontal right and left vertically and horizontally into four separately register-
sources, may be regarded as a single source, while the ing quadrants. Each pair of LEDs has a power supply of
horizontal aperture between the upper and lower pairs different frequency, while each quadrant of the detector
constitutes the knife-edge or sighthole for these pairs. A is linked to four amplifiers, one tuned to each LED fre-
positive lens behind the aperture forms an image of the quency. In this way, the illumination on each quadrant
pupil on a photosensitive detector. Figure 18.7(a) shows of the detector from each source pair can be determined.
schematically the construction of the pupil reflex for Figure 18.S8(a) represents the four quadrants num-
that part of the source below the optical axis of the eye. bered for reference. The nature of the reflex, whether
If the instrument’s sphere adjustment provides too crossed or uncrossed, arising from sources B and T is de-
little positive power, the source S is imaged behind the termined electronically by comparing their contribution
retina at S’, giving a blur patch UV on the retina, as in- to quadrants (1 + 4) with that to (2 + 3). The informa-
dicated by the broken lines. This blur forms the source tion thus obtained is used to adjust the position of mir-
for the returning beam, limited by the image UV’ rors M, and hence alter the spherical correction.
formed in the artificial far-point plane, which is behind The presence of an astigmatic error with exactly hori-
 Autorefractors 357

operator to fog the eye by pressing the ‘+Sph’ button,

say to the 20/60 (6/18) level, and then to reduce the
power in 0.12 or 0.25D steps until the smallest line
can just be read. In addition, they allow binocular fixa-
tion and provide many extra subjective tests: for exam-
ple, a bichromatic target, and cylinder and axis
refinement with both a cross-cylinder target and the
Humphrey fan target described in the footnote on page
373. Near-vision testing and low-contrast charts are in-
corporated, while the most sopisticated model also
(a) (b)
allows glare testing.
Figure 18.8. The quadrant photodetector of the Humphrey Both the objective and subjective corrections and re-
Auto Refractor. The circle denotes the pupil margin, which is sulting acuities can be printed out, together with a note
imaged on the detector and centred automatically. The stippled
areas denote radiation reaching the detector from sources T of the vertex distance and a reflex number. This effec-
and B in: (a) spherical ametropia, (b) uncorrected astigmatism tively denotes the amount of useful light returning to
at an oblique axis. the detector, small pupils or hazy media giving a low
signal. Eyes with a pupil diameter down to just under
3mm can be examined. Although it is the ocular refrac-
zontal and vertical meridians is ascertained from the dif- tion that is measured, it can be converted if required to
ference in response to the horizontal and vertical the corresponding spectacle refraction at any vertex dis-
sources. An astigmatic correction can therefore be intro- tance within the range 10.5—16.5 mm.
duced by the 90°/180° cross cylinder in order to give a
spherical response. In oblique astigmatism, the return-
ing pupil reflex is rotated, exactly as in streak retino-
scopy (see pages 347-349). Thus, in Figure 18.8(b), the The Topcon Autorefractor
illumination due to sources B on quadrant 4 is increased
relative to that on quadrant 1. Similarly sources T give This uses a modified Badal optometer system to generate
rise to a larger area ofillumination on quadrant 2 than an annulus of infra-red radiation on the fundus, the di-
mensions of which are determined by the patient’s re-
on 3. The same effect, but in the opposite direction be-
fractive error. Radiation from a small LED, E (Figure
cause of scissors movement, will occur for the vertical
18.9), is collimated by lens L,, and forms an image E’
bars. This information is used to alter the 45°/135°
after passing through the illuminating system’s opt-
Stokes lens.
ometer lens L,. The beam between these two lenses is
The instrument is initially positioned by the operator,
intercepted by an annular aperture T, which is even-
who aligns the corneal reflection of a red LED between
tually imaged on the fundus. Because the beam has to
two yellow ones, the first LED turning green on align-
pass through the small zone at E’, this forms an opt-
ment. The instrument subsequently maintains align-
ometer arrangement, and therefore the angle between
ment automatically by summation signals from the
the beam and optical axis at E’ is a constant, irrespective
quad-detector. Acuity charts are presented initially to
of the position of T. The hollow beam is then passed
obtain unaided vision if this is wanted. On pressing the
through a second annular aperture A, which is imaged
‘measure’ button, the chart is switched off and the infra-
in the plane of the pupil by relay lens L3;, which also
red source/detector system operates. The sphere adjust-
images the LED at E” in front of the pupil. The eye is
ment is first driven through its range to find an therefore illuminated by a hollow beam of infra-red ra-
approximate reversal, after which the two astigmatic diation.
systems come into operation. Since the summation sig- The test aperture T (and E and L,) can all be moved
nals for each system are independent, all three correc- along the optical axis, in order to focus T on the
tion systems drive simultaneously towards reversal. fundus. For an emmetropic patient, T is positioned
The instrument then makes an infra-red to visual further from L, than its focal length, so that it is
wavelength compensation of 0.75 DS towards myopia, imaged at T’ in the anterior focal plane of L;. Hence the
thus generating a ‘spherical error signal’, and switches zero position of T is not in the usual position for a
on the acuity chart which the patient attempts to read. Badal optometer.
Line sizes of 20/15 (6/4.5) to 20/400 (6/120) are avail- The detector beam is restricted to the central zone of
able. Positive spherical power is then slowly added the pupil since the relay lens L, and beam splitter BS
(automatically) to fog the eye, while the error signal is image the stop C into the pupil. An element of the
simultaneously monitored. If it remains constant as fundus, B, is imaged at B’, which, in turn, is imaged by
power is increased, accommodation is relaxing. When the detector optometer lens Ly at B”. The camera lens
accommodation will relax no further, the error signal Ls in turn images B” on the CCD detector D. The
begins to increase. The computer notes this value, then camera lens and detector assembly are linked to the
adds an extra 0.50 D to check that no further relaxation test object T, so that when T is imaged on the fundus,
occurs. If no more hypermetropia is revealed, the instru- the fundus is also in focus on the detector, thus enabling
ment returns to the noted position. The acuity is then more accurate measurement to be made of the image di-
checked. mensions.
The two more sophisticated models then allow the The ray paths entering the eye are similar to those
358 Objective optometers

Ls
Ly
Figure 18.9. The Topcon Autorefractor. For clarity, the illuminating and detecting pathways have been shown under each other
rather than joined by the beam splitter. E, LED, L; collimating lens, L> illuminating optometer lens, L; relay lens, Ly detector
optometer lens, L; camera lens, A annular aperture, C central aperture, BS beam splitter, D detector, T target annulus.

forming the extreme rays of a blur patch on the retina,

and are the same whether or not T is in focus on the
fundus. Hence, if the diameter of the annulus image A’
is taken as g, the basic size of the corresponding fundus
dimension j is given by:

eee) (4.16a)
K
It is thus larger in hypermetropia, smaller in emme-
tropia and elliptical in astigmatism.
The size j’ of the first aerial image of the fundus di-
mension j is given by:
Figure 18.10. The Canon Autorefractor. A annular
, Object vergence K’ . (ko) aperture, B beam splitter, C collimating lens, D linear detector,
j= Image vergenceSeK K E, LED, L), Ly and L; relay lenses, S slit aperture.

so the unknown, the dioptric length of the eye K’, is

eliminated from the expression. This would suggest
image E5 at the centre of the patient’s pupil. A hori-
that the refractive error could than be calculated.
zontal slit, S, between the collimator and first relay lens
When T is in focus on the fundus, however, the image
is imaged at infinity, and so is in focus on the fundus if
on the detector bears a constant ratio to the size of the
test annulus, irrespective of the amount of ametropia. the eye is emmetropic. By using a small LED and a
The instrument presumably calculates the refractive small aperture, the pinhole effect ensures that the illu-
error from the basic image height when the test annulus minated patch on the fundus is not grossly out of focus
and optometer lenses are set for various known amounts even in high ametropia. The returning beam from the
of ametropia. eye is reflected by the beam splitter and passes through
The Topcon RM-700 needs a 2.5 mm pupil diameter. an annular aperture A so that only radiation leaving
the eye in a zone between 2.0 and 2.9 mm diameter is
recorded. This radiation is then focused on a linear pos-
The Canon Autorefractors ition detector D by lens L3. The two ray bundles would
combine in emmetropia to form a single image on D,
These measure the vergence of light leaving the eye by while they would give crossed or uncrossed ‘images’ in
combining a Scheiner disc to select two beams, one on myopia or hypermetropia. This ambiguity is resolved by
each side of the pupil, and prisms to give a double covering the two halves of lens L; with unequal prisms,
image of the secondary source on the fundus. Thus, in so that even in emmetropia, a double image is formed
Figure 18.10, an infra-red-emitting LED, E, is placed at
on D. The spacing between the two ‘images’ now varies
the anterior principal focus of a collimator lens C, while continuously with ametropia.
a relay lens L; forms an image E} in the central aperture
of the beam splitter. A second relay lens forms an
 Research instruments 359

In order to calculate refractive error, measurement is signed by Roth (1962) used a system in which Scheiner
provided in three meridians simultaneously. The illumi- disc doubling was combined with a prism to displace
nating slit aperture is three bladed, with apertures at one image below the other on the fundus. The horizon-
120° to each other, L3 is covered with an array of three tal separation of the two images, which varied with the
pairs of prism sectors, with three radiating detectors po- accommodation, was monitored photomechanically.
sitioned to receive their respective aperture ‘images’. In a continuously recording optometer by Lovasik
(1983), infra-red radiation filtered from a tungsten
lamp is focused near the anterior focal plane of the eye
after passing through a Scheiner disc. It thus enters the
Research instruments eye through two peripheral zones of the pupil to form
two streaks on the retina. These are imaged, via the
The accommodative response of the eye to changes in whole pupil area by a beam splitter and a lens on to
object vergence may be determined indirectly by photo- two photovoltaic cells, one on each side of the axis. One
graphy of the Purkinje III image, described in more beam thus falls on each cell. As the accommodation of
detail on page 398. During accommodation, the ante-
the subject's eye alters, it changes the separation of the
rior surface of the crystalline lens becomes steeper,
streaks on the retina and also of their images on the
thereby reducing the size of an image formed by reflec-
photocells. This effect is monitored by masking the cells
tion at its anterior surface. From calibration photo-
to a wedge shape, one with the base towards the optical
graphs, the difference between the image sizes can be
axis, the other away from it. If the streaks move closer
interpreted in terms of accommodative response (see,
together towards the axis, a longer strip of one photocell
for example, Allen, 1949).
and a shorter strip of the other are illuminated. As a
The anterior surface of the crystalline lens has a cellu-
result, the respective signals are increased and de-
lar structure and gives rise to a diffuse reflection, often
creased proportionately. The two outputs are fed to a
termed ‘shagreen’ or ‘orange peel’. Measurements of
differential amplifier.
such images are therefore imprecise. Furthermore, rela-
The Scheiner principle was again employed by Fitzke
tively little light is reflected by the surface since the
et al. (1985) to investigate the refraction of pigeon eyes.
change in refractive index is low: cine photography is
The illuminating system is the same as that of the Corn-
therefore more difficult than static photography with
electronic flash. More -precise and direct results have sweet and Crane instrument, but the focus is determined
been obtained by studying the retinal image. In general, electrophysiologically by measuring the electroretino-
infra-red illumination is used to prevent interference by gram (ERG, see page 39), the peak response occurring
the measuring system with the subject’s vision. when the test grating is conjugate to the retina.
Several research instruments have been based on the A different approach was made by Allen and Carter
Scheiner disc principle. The earliest of them and prob- (1960). Their optometer (Figure 18.11) is effectively
ably the next electronic instrument after Collins (1937) based upon the reflex-free indirect ophthalmoscope
was produced by Campbell and Robson (1959). It needs using two separate objectives. The lamp S is imaged by
no description because the instrument of Cornsweet lens L; on to the upper part of the patient's pupil. The
and Crane described above is in many ways similar to measuring graticule T, a narrow rectangular aperture,
it. Heron et al. (1989) developed a binocular system, is placed in the anterior focal plane of the same lens. If
also based on the Scheiner disc principle, to investigate the subject is emmetropic, a clearly focused image T'; is
the symmetry of accommodation responses in the two formed on the axis of the subject's eye.
eyes. An aperture stop A, immediately in front of the
The recording infra-red coincidence optometer de- photomultiplier tube is imaged by lens L, in the lower

Figure 18.11. Simplified optical

layout of the recording infra-red
optometer of Allen and Carter (1960).
BS gold-coated beam splitter permitting
a view of the test stimulus, K knife-edge,
PM photomultiplier, R rotating sector
disc.
360 Objective optometers

part of the patient's pupil at A,. Thus, radiation from T} the receptors. Within the visible spectrum, however,
will leave the patient's eye through A, to form an Charman and Jennings (1976) found that while
blue
aerial image T5. Part of this image is occluded by the light was reflected from a plane anterior to the
knife edge K. receptors, yellow and red light appeared to be reflected
When the subject accommodates, the image T on the frorh a plane very close to the receptors. Moreover, ob-
retina will move downwards. The aerial fundus image servation of the fundus with infra-red radiation, as
T will move upwards (and axially towards the lens occurs with some fundus cameras, shows that the chor-
L,), so that a greater proportion of the energy will be oidal features can be seen through the partially trans-
occluded by the knife edge. A lower response by the parent retina. Hence, reflection must be regarded as
photomultiplier tube will therefore result. Infra-red- arising throughout a depth rather than from a surface
transmitting filters IRF are placed near the measuring within the fundus, though Dr C. Campbell (pers.
aperture T and also in front of the photomultiplier tube comm., 1995) suggests that the mean position is near
to absorb ambient illumination. The rotating chopper the retina—pigment epithelium interface.
disc gives a pulsating radiation level and hence a pulsat- Charman (1980) points out that the reflectance of the
ing output from the photomultiplier, which in turn fundus increases towards the red end of the spectrum,
may be fed into a tuned electronic amplifier. Ambient from about 0.003 at 400 nm to almost O.1 at 700 nm,
infra-red radiation gives a constant photomultiplier while Campbell gives a figure of 0.35 for 880 nm. As
output. This DC component will be rejected by the am- this reflectance is diffuse, there are multiple reflections
plifier, so that the final AC signal may be fed to a pen re- of scattered radiation within the eye, which, acting as
corder which is calibrated in terms of the subject’s an integrating sphere, degrade the image. Thus, Corn-
accommodation. sweet and Crane found a linespread function (see page
Kruger (1979) developed an infra-red recording reti- 49) of at least 1° as compared with a few minutes of
noscope for monitoring accommodative response. Its op- arc in the visible part of the spectrum. It is therefore
tical system is very similar to the Nikon instrument
not possible to measure the eye’s refractive error accu-
shown in Figure 18.3, but does not incorporate the
rately by means of a simple best-focus optometer.
Pechan prism since it monitors only the vertical merid-
Another result of the diffuse retinal reflectance is the
ian of the eye. The time interval between the reflex pas-
need for bright sources. Only a small proportion of the
sing over each of the two photoreceptors, and _ its
incident radiation is reflected back out through the
direction of movement, were evaluated by the electronic
pupil. A 2mm diameter pupil, for example, subtends
recording system to give a linear response over the
only about 1/100 of a steradian at the retiza, so depend-
range +6 to —6D of refractive error or change in ac-
ing on the instrument design, only about 1/100 to
commodation.
1/500 ofthe incident radiation is returned to the instru-
ment for measurement purposes. Fortunately at the re-
quired levels, the infra-red radiation is not harmful to
the eye, but care has to be taken in the instrument
Design and calibration of infra-red design to avoid reflections from relay lenses or mirrors
optometers in the common illuminating and observation paths.
The simplest method of calibrating a clinical instru-
Since the eye is not achromatic, an allowance has to be ment would be to determine a zero error by examining
made for the difference in ocular refraction between a few eyes under cycloplegia and comparing with the
visible light and whatever wavelength of infra-red ra- subjective results. With all instruments, the patient or
diation is used. This is usually about 880 nm, for which subject must be positioned at the correct distance from
the eye is 0.75-1.00 DS hypermetropic relative to the instrument or else the calibration will be upset by ef-
550nm (Cornsweet and Crane, 1970). Provided that fectivity factors.
the lenses of the optometer itself are achromatic, their Charman and Heron (1975) discuss the linearity of
refractive power should not differ too greatly between several of the research optometers from a mathematical
visible and near-infra-red radiation, while any mirrors viewpoint. Several of these instruments are seriously af-
used are naturally free from chromatic aberration. fected by changes in pupil size while accommodation is
As with retinoscopy, uncertainty over the position of being investigated. For example, the instrument de-
the plane of reflection within the eye of visible and infra- signed by Allen and Carter depends upon the amount of
red radiation may invalidate theoretical calibration of radiation that is not occluded by a knife edge positioned
an instrument. Although Kruger (1979) found his opt- near the fundus image. If the pupil size decreases, the
ometer read 0.8 D hypermetropic, Cornsweet and Crane’s energy reaching the photocell will be reduced in the ab-
optometer gave a reading about 1.50 DS more hyperme- sence of a change in accommodation. Campbell and
tropic than the subjective visual focus obtained simulta- Robson's (1959) instrument is also affected. Artefacts
neously. Thus there may be about 0.50-0.75D due to changes in pupil size may be greatly reduced by
allowance to be made in addition to the effects of chro- dilating the pupil with a mydriatic that has either little
matic aberration. This suggests that the infra-red radia- affect on accommodation or whose cycloplegic effect
tion is either being reflected from the capillary bed of occurs considerably later than the mydriatic effect.
the retina, about 0.3 mm in front of receptors, or that it Campbell and Robson also suggested that a small artifi-
is reflected from several layers, the mean effect being cial pupil placed before the eye gives a fixed pupil area
equivalent to reflection from a single plane in front of as far as the instrument is concerned and does not re-
 Clinical results with electronic autorefractors 361

quire medication. The small pupil area does reduce the Table 18.1. comparability of infra-red optometers and final
precision of the instrument. subjective refraction (percentage of results given where differences
in power or axis are less than or equal to the stated amount). Mean
Several of the research instruments use beam splitters results for 790 patients
to allow the subject to view a test stimulus while accom-
modation is being monitored. These beam splitters may Lens power ac0)25) 1) +0.50 D se EO OND)
be formed by interference techniques or by coating the Cylinder axis +5° +10 +20
Sphere 78.5 91.0 96.5
surface with a thin layer of a metal such as gold, which
Cylinder 81.2 Syl 98.5
has a high reflectance for infra-red radiation. Both Axis 40.9 62.4 SL
these techniques result in non-uniform transmission in
the visible spectrum, the gold film appearing green. A Figures abstracted from McCaghrey and Matthews (1993).
filter of a similar colour may be required before the
other eye if satisfactory investigation under binocular
conditions is required (Allen and Carter, 1960). 44% and 96%, while for +1.00D they were 68% and
100%. This would effectively confirm the accuracy of
the manufacturers’ calibration.
In a survey conducted in optometric practice, Griffiths
Clinical results with electronic
(1988) found a similar bias. In 75% of the cases where
autorefractors the difference in the mean refractive error exceeded
+0.26 D, it was the autorefractor which gave the more
Objective optometers are subject toamany of the uncer- minus or less plus result. Agreement within this
tainties of retinoscopy with regard to accuracy of meas- amount was found for about 45% of the patients, with
urement. The plane of reflection of the radiation may or rather more consistent results for the myopes than for
may not be at the percipient layer of the retina. Prox- the hypermetropes.
imal accommodation may be much more troublesome Conversely, a study of eight different autorefractors by
with the optometer, though most designs incorporate a McCaghrey and Matthews (1993) showed little evidence
fogging system for the fixation object, which is often a of consistent bias towards myopia (or hypermetropia).
pictorial representation of a distant scene in- order to In this investigation, each of the instruments in turn
minimize this effect. The fixation point is aligned with was used to examine 90-100 consecutive patients, and
the measuring system,’so that measurement is made then the instrument reading compared with the final
very close to the fovea. subjective results. The mean comparability for the 790
Especially when the ametropia is high, the distance patients over all the instruments is given in Table 18.1.
between the instrument and eye must be capable of They also evaluated the residual refractive error be-
being set very accurately or else effectivity errors arise. tween the autorefractor and subjective findings. Be-
Corrections to the results for different vertex distances tween 21 and 45% (mean 35%) of results were within
can usually be calculated automatically. a residual error of +0.50 to —0.25 DS combined with a
A minimum pupil diameter of around 2.5—3.0 mm is residual astigmatic error not greater than 0.25 DC. If
needed, depending upon the instrument design. the residual error allowed was increased to +0.75 to
Several reports have been published comparing the —0.50 DS with a cylinder not more than 0.50 DC, the
results obtained by clinical objective optometers with percentage of acceptable results increased to 64%
subjective examination: Knoll et al. (1970), Safir et al.
(52-75% depending upon the instrument).
(1970), Sloan and Polse (1974), Polse and Kerr They also evaluated the test-retest repeatability’ of
(1975), Wood (1982), French and Wood (1982). All
the instrument that appeared best in their comparability
have suggested that these objective instruments give study. For example, one of their subjects had a subjec-
fairly accurate results similar to those achieved by reti-
tive refraction of +2.25 DS/—0.50 DC x 140. The mean
noscopy. Large differences between objective and sub- and standard deviation of 50 autorefractor results was:
jective findings occurred occasionally. In general,
42.07 + 0.31/—0.35 + 0.20 x 148 + 26. A second
proximal myopia did not appear to cause difficulties in
individual with a slightly more astigmatic eye (—9.00/
the age groups surveyed. —1.25x175) gave results of —9.27 + 0.20/—1.80
Proximal myopia would be expected, however, to
+ 0.21 x 3 + 2.4°. As expected, the standard deviation
affect the refractions of younger patients. In a study of
of the axis findings decreases with increased astigma-
patients under 40 years of age, Ghose et al. (1986) ana-
tism, even though in this case the result is not particu-
lysed the distribution of the differences between autore-
larly valid.
fractor and subjective results. For emmetropes, low
The techniques of astigmatic analysis on pages 88-89
hypermetropes and low myopes, the results were
may be used to analyse differences between autorefrac-
skewed towards more minus or less plus with the auto-
tor and subjective findings.
refractor. The mean difference in the equivalent spher-
An extensive evaluation of autorefractors was under-
ical refraction (or mean refractive error) was —0.58 D
taken at Glagow Caledonian University for the British
+ 0.79 D. In a similar study but using cycloplegia, the
same team (Nayak et al., 1987) found much better
agreement between the instrument and clinical results.
The percentage showing the difference to be within “ The terms ‘accuracy’, ‘ precision’ and others having specia-
+0.25D increased from 32% without cycloplegia to lized meanings in this context, are explained at the end of Chap-
86% with it. The respective figures for +0.50D were ter 1.
362 Objective optometers

Department of Health’s Medical Devices Agency (1996 — Conclusion

evaluation report number MDA/96/36). In the first
Although the subjective refraction is frequently taken as
part of the study, test model eyes were constructed
being correct, there will be small variations in this,
from polymethyl methacrylate, with axial lengths vary-
particularly if performed by different refractionists who
ing to provide refractive errors over a range of nomin-
may take different end-points or use slightly different
ally +20D. A myopic adjustment was made to the
techniques. Thus small differences between autore-
paraxial error to allow for the effects of spherical aberra-
fractor and subjective results are to be expected, and
tion. Many, but not all, of the six different manufac- should not be taken to imply that the instruments are
turer’s instruments tested gave good agreement poor. These studies suggest, however, that it would be
between their results and the adjusted refractive error. inadvisable to rely on any instrument findings alone for
One design, however, underestimated hypermetropia of prescribing. Thus the ability of a patient to read 6/6 or
more than +8 D by about 2 D, while another showed a even 6/5 through an objective refraction (retinoscopic
negative shift of 1.5 D or more for eyes with errors arith- or autorefractor) does not necessarily mean that the cor-
metically greater than 10 D. Even when a reading was rection gives the sharpest vision or that it will be the —
obtained, pupil diameters of less than 3 mm tended to most comfortable. At present, all the instruments refract
give erroneously hypermetropic results. monocularly. If lenses are to be prescribed, autorefrac-
Two hundred and sixty-one patients in the University tors, like retinoscopy, have the important role of pro-
Eye Clinic were examined on all six instruments, by reti- viding an initial result for refinement by subjective
noscopy and by subject refraction (student refractions refraction and binocular balancing.
verified by experienced staff). To gauge the validity of If operated by a technician, automatic optometers
the results, the research team adopted a 95% confidence save the practitioner's time by replacing retinoscopy.
level of +0.82 D for the mean sphere, being twice the This does not necessarily save the patient’s time because
standard deviation of Adams et al.'s (1995) investiga- setting up takes longer than for retinoscopy even
tions. Almost 14% of retinoscopy results were outside though measuring time is less. Moreover, the uniformity
this limit, as were the measurements by three of the or irregularity of a retinoscopic reflex may provide the
autorefractors. Two autorefractors were only slightly examiner with more information about the ocular
poorer, while the sixth showed just over 21% of its find- media than an instrument’s ‘confidence factor’, if one is
ings to be outside the limit. The 95% confidence limits provided. Some autorefractors show the regularity of
for the mean sphere as found by the autorefractors was the media on the monitor screen when aligning the in-
about +1.5 D, while by retinoscopy it was +1.3 D. De- strument with the eye, although this may not be as sen-
spite measuring closer to the visual axis than retino- sitive as distortions in the retinoscopy reflex which, for
scopy, the results for the astigmatic component appear example, demonstrate keratoconic corneae, pronounced
only a little more precise (by 0.02 D in their standard de- spherical aberration of the crystalline lens and very
viation). The researchers found slight evidence for more early spoke cataracts clearly. The small pupil zones ef-
consistent results in myopic patients than in hyperme- fectively sampled by some autorefractors may cause
tropes, but no obvious variation with age. errors if they are partly occluded by opacities, whereas
They also compared the intolerance rate for spectacles visual retinoscopy may allow the practitioner to evalu-
prescribed directly from the autorefractor with those ate the whole pupil area. In general, autorefractors
made up to the subjective findings (without modification cannot be used in the domiciliary situation, for very
on the basis of the previous spectacle prescription). Out young children or for assessing near-vision perform-
of their 47 patients, ‘19.1% of the subjects were unable ance.
to adapt to wearing the autorefractor result. This com-
pares with 12.8% of the subjects wearing the subjective
prescription. A higher percentage (42.6% compared to Photorefraction
29.8%) of subjects also reported experiencing some
kind of headaches or eye strain over the two week This technique, introduced by Howland and Howland
period when wearing the autorefractor prescription in (1974), uses a photographic method to deduce the re-
comparison to the subjective result’. fractive or accommodative state of the patient’s eyes. Be-
The team found that the instruments coped well in cause the photographs can be taken immediately the
measuring eyes wearing both rigid and soft contact patient appears to be looking at the camera, this
lenses, but in the hospital environment they performed method can be used with young infants whose span of
badly on patients with cataract (as did retinoscopy), attention is too short for retinoscopy. In such cases, an
and performed worse than retinoscopy for patients with automated objective optometer is equally unsuitable be-
intra-ocular lenses or keratoconus, and were virtually cause the eye has to be positioned accurately in relation
incapable of measuring patients with nystagmus (see to the instrument. Atkinson and Braddick (1982) re-
page 184). Four of the instruments were poorer than re- commend photorefraction as a screening test for signifi-
tinoscopy for patients with amblyopia (see pages 41- cant refractive errors in young infants.
43), while age-related macular degeneration proved a The photorefractor consists essentially of a small
problem only for the instrument based on analysis of source of light (S in Figure 18.12) mounted in front of a
image quality, being upset by fundus changes causing suitable camera. The source is formed by an electronic
poor reflection. Short reviews of this study are given by flash illuminating one end of a fibreoptic lightguide, the
Ehrlich (1996) and Strang et al. (1997). other end being mounted centrally in front of the
 Photorefraction 363

Figure 18.12. The optical principles of photorefraction, the patient's eye being on the right.

camera lens. It illumimates the patient’s face and is the camera. If the eye is accommodating by A dioptres,
imaged on the fundus of both eyes. The retinal image K should be replaced by (K — A).
may be regarded as a secondary source giving rise to a As shown in Figure 18.12, if the camera is in focus for
fundus image in the plane conjugate with the retina. the pupil, its sharp image HJ’ on the film is unaffected
If the eye is in focus for the source, the light leaving by the blur in the camera lens plane. To determine the
the eye returns to the source and is thus occluded from ametropia, the camera must be defocused from the pu-
the camera lens. As a result, the pupil appears dark in pillary plane by a known amount.
the photograph. When the eye is out of focus, a blur
circle or ellipse is formed on the fundus, producing in
turn an illuminated zone around the source. The size of
this zone varies with the ocular focusing error relative
to the source.
Orthogonal photorefraction
Figure 18.12 shows the principle of the technique ap- This system of photorefraction was the original tech-
plied to a myopic eye at a distance w from the camera nique introduced and is now known as orthogonal
lens (assumed to be thin and in contact with the photorefraction. To record the ametropia in two mu-
source). As in Figure 17.7, the rays from S filling the tually perpendicular meridians simultaneously, an aux-
pupil form the retinal blur UV, imaged as UV{ in the iliary lens composed of four quadrants is placed in front
plane conjugate with the retina. If the eye is unaccom- of the camera lens. Two opposite quadrants form part
modated, this will be the far-point plane at a distance k of a convex plano cylinder of power about +1.50 DC,
from the eye’s principal point P. The reflected ray SHU with the cylinder axis across the centre of the camera
retraces its original path, while the ray UJU) through lens. The other pair of opposite quadrants also form
the opposite extremity of the pupil reaches the camera part of a +1.50 DC plano cylinder with its axis perpen-
lens plane at E. In the case of the myopic eye illustrated, dicular to that of the first pair. In this way the photo-
it is this latter ray which defines the size of the blur in graphic image is drawn out into a cruciform shape, the
the lens plane. overall length in each of the two meridians being pro-
If SE and HJ (g) are taken as positive, the triangles
portional to the corresponding blur dimension 2 SE in
U‘JH. UES give the camera lens plane. Photographs are taken with the
SE_w—k ts composite lens axes horizontal and vertical and also at
Gea 45° and 135°, the camera lens itself being focused on
the patient's pupil. The pupil size is determined by an
The blur diameter b, equal to 2 SE, is then given by additional photograph without the composite lens. (For
a detailed explanation and analysis of this technique,
b = 2g(K — W)/W (18.1)
see Howland and Howland, 1974; Howland et al.,
The term (K — W) is the residual ametropia relative to 933)
364 Objective optometers

Isotropic photorefraction
Because orthogonal photorefraction does not deter-
mine the astigmatic meridians of the eye directly,
Howland et al. (1979) developed the isotropic method.
In this technique the cylindrical lens assembly is not
used. Photographs are taken with the camera focused
first for an object distance nearer than the pupil, then
on the pupil to record its diameter and finally for an
object distance beyond the pupil. The blur dimensions
on the film in the out-of-focus settings depend both on
Figure 18.13. The myopic ‘dead space’ in isotropic
the ametropia and on the degree to which the camera photorefraction. FPP the eye’s far-point plane, CFP camera
is defocused. The reason for two out-of-focus exposures focusing plane, S source and camera lens.
is to resolve an ambiguity. Because a blur circle can be
either erect or inverted, the quantity b in equation
(18.1) could have either a plus or a minus sign. Thus, A number of simplifications were made in the above
for given values of g and W, the same numerical value analysis. As Howland and colleagues point out, the size
of b could result from two different values of K. For ex- of the camera blur is affected by the finite size of the
ample, with g=4mm and W=~—1.50D, the same source, its vignetting or occluding effects on the return-
blur diameter of 24mm would be given both by ing light and the distance of the source from the princi-
K = +3.00 D and by K = —6.00 D. Similarly, the cross- pal planes of the camera lens. For these reasons they
sectional diameter of the refracted beam in any given recommend an experimental calibration.
position of the film plane is consistent with two different Bobier et al. (1992a,b), in extensive discussions of
values of K, but only one of these is consistent with the photorefraction, point out that there is a ‘dead space’ in
dimension recorded in another position of the film. In which the blur is independent of the refractive error.
general, the blur is smaller in the setting where the Thus Figure 18.13 shows a myopic eye where the far
camera is focused nearer to the plane conjugate with
point plane FPP lies between the camera's focusing
the subject’s retina.
plane CFP and the source. The rays defining the size of
Atkinson and Braddick (1982) suggest a working dis-
the blur patch, DE, in the focusing plane are those from
tance w of —0.75m(W = —1 5 D) with the camera defo- the source to the extremities HJ of the pupil, and are
cused by an equal dioptric amount E on either side of
therefore independent of the precise amount of myopia.
the pupil setting. The value suggested for E is +45D. WIN Thus, when the camera is defocused to its closer setting,
The shorter focusing distance would thus be —0.5m
myopia between —1 3 D and —4 D gives a constant blur,
(—2.00 D) and the longer distance —1.5 m (— 2 D).
while in the further setting, refractive errors between
Figure 18.12 illustrates a simple method of construct-
low myopia of -12D to low hypermetropia of +12D
ing the beam in camera image space. In principle, it
are indistinguishable. With the pair of photographs
can be applied to similar diagrams representing other re-
from each camera setting, these errors may be evalu-
fractive states. First, the pupil image formed by the
ated.
camera lens (of power F) is at a known dioptric distance
In the isotropic method, astigmatism produces an el-
(W + F) from the lens. Its extremities H’ and J’ must lie
liptical blur, its axes identifying the principal ocular
in this image plane on the undeviated rays from H and
meridians. The use of colour film provides a separate
J through S, which also represents the optical centre of
clue to the sign of the refractive error, since the chro-
the camera lens. Then, since the ray JU{E must pass
matic aberration of the eye gives rise to a blue fringe in
through J’ after refraction, the intersection of the re-
a myopic meridian and an orange-red fringe in a hyper-
fracted ray with HU{H’ gives the second fundus image
metropic meridian.
point U5. The image point V5 is located in a similar
manner.
It can be seen that the refracted beam has three dis-
tinct sections, in any of which the film plane may lie. A
single expression for the blur diameter would thus be Eccentric photorefraction
cumbersome. By deriving equations to the rays EJ’U},
For typical values of the working distance and camera
GH'V5 and SJ'V5, it can be shown that the diameter j of
aperture, the lens plane blur fills the lens at about 4 D
the blur in the film plane is given by the larger arith-
of ametropia, equations for these values being given by
metic value of the two expressions
Bobier and colleagues. Higher refractive errors are
aw a therefore beyond the scope of both the orthogonal and
. Wee waz) isometric methods. A further technique described by
Kaakinen (1979) and discussed by Howland (1980)
and
may then be used. It is called eccentric photorefraction
—W/2—- E+ KE/W or static photographic skiascopy. In this method, the
Jj— 2a
2
Fa WuE ) (18.3)2 light-guide is decentred to the edge of the camera lens
or beyond so that, as in retinoscopy, a crescent of light
In these last expressions, as in equation (18.1), W is re- appears in the pupil.
garded as negative in sign. In Figure 18.14, the source S produces an out-of-focus
 Photorefraction 365

reflex of normal retinoscopy. This was subsequently

adapted for continuous recording of accommodation re-
sponse (Schaeffel et al., 1993).

The Cambridge and other

paediatric videorefractors
Video recording and a constant light source instead of
flash photography may be used with any of the methods
described.
In the UK, the main centre of experimental research
in photorefraction and its practical application in rou-
tine screening of infants has been the Visual Develop-
ment Unit’ of Cambridge University, headed by Dr
Janette Atkinson and Dr Oliver Braddick. A broad pic-
Figure 18.14. The optical principles of eccentric ture of both these aspects of the unit’s work is given in
photorefraction; the inset shows the appearance of the pupil, the paper by Braddick and Atkinson (1984). An impor-
the stippled zone being luminous. tant development was the appearance of the Cambridge
Paediatric Videorefractor VPR-1 which was based on
the isotropic method. The three photographs, having
blur on the retina which in turn is imaged at U’V’ in the been recorded by the computer, are displayed in turn
far-point plane of the unaccommodated eye. If C is the on the monitor screen, simultaneously with a cursor
upper edge of the camera's aperture, only the pencil of for measurement of the pupil or blur dimensions. The
rays bounded by U’YC and U’JQ will enter the camera computer then calculates the refractive error. Rapid
lens. For the hypermetropic eye illustrated, the width screening of large numbers of infants is made possible
JY of the illuminated pupillary crescent is given by the by this system.
equation Hodi and Wood (1994) compared the performance of
- the Cambridge videorefractor with the findings of cyclo-
: (h—c)W plegic spot retinoscopy. For the highest hypermetropic
Crescent
rescent wl width = g+ {eae
K_Ww (18.4)
or least myopic meridian, non-cycloplegic videorefrac-
tion gave mean results 2 D less hypermetropic, but with
where hi is the distance of the light source from the a wide scatter. As would be expected, comparing both
camera axis and c the linear semi-aperture of the findings when made under cycloplegia gave much
camera lens. In hypermetropia relative to the plane of better agreement, though still with a wide scatter. The
the flash, the luminous crescent is on the side of the results for astigmatism were poorer, and they cite
pupil opposite to the flash. Ehrlich et al. (1994) who found marked changes in
In myopia relative to this plane, the luminous cres- some infants’ refraction with change of fixation. In
cent is on the same side as the flash. Equation (18.4) their experiments, the infant looked at a toy held above
for the crescent width remains valid if the plus sign be- the camera lens, while retinoscopy was performed with
tween the two terms is changed to minus. the child looking at the light (immediate source).
An alternative method is to vary the distance h until a Hence, oblique astigmatism may be the likely explana-
crescent is just seen within the pupil. An analysis of re- tion. The occluding affect of the fibreoptic flash lead to
fractive error and theoretical and experimental crescent the videorefractor may also affect results.
width is given by Bobier and Braddick (1985). They Searle et al. (1990) and Hodi (1994) evaluated the re-
point out that the sensitivity of the film also affects the fractor for screening purposes. Provided the refraction
apparent size of the blur since it governs the threshold was done under cycloplegia, the instrument was found
of light intensity that can be recorded. The crescent is to give acceptable results for identifying those infants
therefore slightly larger than the photographs would needing further investigation. (Hodi’s results for hyper-
suggest. The eye’s aberrations also cause errors, so for metropia of > 4.00 D gave a sensitivity 83.3%, specifi-
these reasons the technique requires experimental cali- city 90.6%, while for any degree of myopia the
bration. Analyses of the technique are also given by sensitivity was 92.3% with specificity of 98.7% — these
Howland (1985), Crewther et al. (1987) and Bobier et terms are defined at the end of Chapter 1.)
al. (1992b). An interesting variation on the method, in- Ehrlich et al. (1995) compared infants showing a hy-
troduced by Abramov et al. (1990) is to leave the flash permetropic error of > 1.50 D when they should have
at a fixed small eccentricity, and photograph the eyes been accommodating for a fixation toy at —O0.75 m, ie.
at various working distances. The type of refractive they were showing an accommodative lag of > 2.8 D,
error can be deduced from the changes in crescent size. with those who showed more accurate accommodation.
An alternative technique, originally introduced for Inspection of their result confirms that non-cycloplegic
animal research (Schaeffel et al., 1987) employs a series
of LEDs arranged along a radius of the camera aperture
— these are triggered in succession, with a separate * The Visual Development Unit is situated at 22 Trumpington
photograph for each, thus reproducing the moving Street, Cambridge.
366 Objective optometers

videorefraction fails to identify a small proportion of CHARMAN, N. and HERON, G. (1975) A simple infra-red opt-
ometer for accommodation studies. Br. J. Physiol. Optics, 30,
those infants who are more than 4.0 D hypermetropic, 1-12
while a larger proportion of poor accommodators were CHARMAN, W.N. and JENNINGS, J.A.M. (1976) Objective meas-
false positives, i.e. were less than 4.0 D hypermetropic. urement of the longitudinal chromatic aberration of the
The Topcon PR-2000 is a more recent infra-red pae- human eye. Vision Res., 16, 999-1005
COLLINS, G. (1937) The electronic refractionometer. Br. J. Phy-
diatric refractor.
siol. Optics, 11, 30-42
CORNSWEET, T.N. and CRANE, H.D. (1970) Servo-controlled in-
frared optometer. J. Opt. Soc. Am., 60, 548-554 S
CREWTHER, D.P., MCCARTHY, A., ROPER, J. and COSTELLO, K.
(1987) An analysis of eccentric photorefraction. Clin. Exp.
Exercises
Optom., 70, 2-7
DAVIS, B., COLLINS, M. and ATCHISON, D. (1993) Calibration of
18.1 Compare and contrast the effects of residual ametropia the Canon Autoref R-1 for continuous measurement of ac-
in photorefraction, retinoscopy and the Foucault test as used commodation. Ophthal. Physiol. Opt., 13, 191-198
in both the Humphrey Automatic Refractor and in the Diop- EHRLICH, D.L., ANKER, S. and BRADDICK, 0.J. (1994) On- and
tron. off-axis refraction of infants. Invest. Ophthalmol. Vis. Sci., 35
18.2 (a) What is the blur dimension at the camera lens in (suppl, abs 2571),1806
photorefraction, given a working distance of —I1m, EHRLICH, D. (1996) MDA reports on autorefractors. Optom.
K = —4.00D and pupil diameter 6 mm? (b) In orthogonal re- Today, 36(16), 38
fraction with a camera lens of focal length 50mm and a EHRLICH, D.L., ANKER, S., ATKINSON, J., BRADDICK, O.J., WEEKS,
+4.00D composite cylinder, with all other details as in (a), Fr. and WADE, J. (1995) Infant photorefraction and cyclople-
what is the overall length of the image on the film? gic retinoscopy of ‘poor accommodators’. Poster at The
British College of Optometrists Centenary Conference, Cam-
bridge, UK.
FITZKE, F.W., HOLDEN, A.L. and SHEEN, F.H. (1985) A Maxwel-
lian-view optometer suitable for electrophysiological and
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FLETCHER, R.J. (1954) Near vision astigmatism. Optician, 127,
ABRAMOV, I., HAINLINE, L. and DUCKMAN, R.H. (1990) Screen- 341-345, 350
ing infant vision with paraxial photorefraction. Optom. Vis. FRENCH, C. and Woop, 1.C.J. (1982) The Dioptron II's validity
Sci., 67, 538-545 and reliability as a function of its three accuracy indices.
ADAMS, C.W., BULLIMORE, M.A., FUSARO, R.E., COTTERAL, R.M., Ophthal. Physiol. Opt., 2, 57-74
SARVER, J. and GRAHAM, A.D. (1995) The reliability of auto- FRY, G.A. (1937) An experimental analysis of the accommoda-
mated and clinical refraction. Invest. Ophthal. Visual Sci., tion—convergence relation. Am. ]. Optom., 14, 402-414
36(4), S947 GHOSE, S., NAYAK, B.K. and SINGH, J.P. (1986) Critical evalua-
ALLEN, M.J. (1949) An objective high speed photographic tech- tion of the NR-1OOOF Auto Refractometer. Br. J. Ophthal.,
nique for simultaneously recording changes in accommoda- 70, 221-226
tion and convergence. Am. J. Optom., 26, 279-289 GRIFFITHS, G. (1988) Autorefractors — their use and usefulness.
ALLEN, M.J. and CARTER, D.B. (1960) An infrared optometer to Optician, 196(5178), 22-29
study the accommodative mechanism. Am. J. Optom., 37, HENSON, D.B. (1996) Optometric Instrumentation, 2nd edn.
403-408 Oxford: Butterworth-Heinemann
ATKINSON, J. and BRADDICK, 0. (1982) The use of isotropic HoDI, Ss. (1994) Screening of infants for significant refractive
photorefraction for vision screening in infants. Acta Ophthal., error using videorefraction. Ophthal. Physiol. Opt., 14,
suppl. 157, 36-45 310-313
BENNETT, A.G. (1960) Refraction by automation? New applica- HODI, Ss. and woop, 1I.c.J. (1994) Comparison of the techniques
tions of the Scheiner disc. Optician, 139, 5—9 of videorefraction and static retinoscopy in the measurement
BENNETT, A.G. (1978) Methods of automated objective refrac- of refractive error in infants. Ophthal. Physiol. Opt., 14,
tion. Ophthal. Optn, 18, 8-13, 19 20-24
BENNETT, A.G. and RABBETTS, R.B. (1978) Refraction in oblique HOWLAND, H.C. (1980) The optics of photographic skiascopy.
meridians of the astigmatic eye. Br. J. Physiol. Optics, 32, Acta Ophthal., 58, 221-227
59-77 HOWLAND, H.C. (1985) Optics of photoretinoscopy: results from
BERMAN, M., NELSON, P. and CADEN, B. (1984) Objective refrac- ray tracing. Am. J. Optom., 62, 621-625
tion: comparison of retinoscopy and automated techniques. HOWLAND, H.C., ATKINSON, J. and BRADDICK, 0. (1979) A new
Am. J. Optom., 61, 204-209 method of photographic refraction of the eye. J. Opt. Soc.
BOBIER, W.R. and BRADDICK, 0.J. (1985) Eccentric photorefrac- Am., 69, 1486
tion: optical analysis and empirical measures. Am. J. Optom., HOWLAND, H.C., BRADDICK, 0., ATKINSON, J. and HOWLAND, B.
62, 614-620 (1983) Optics of photorefraction: orthogonal and isotropic
BOBIER, W.R., CAMPBELL, M.C.W., McCREARY, C.R., POWER, A.M. methods. J. Opt. Soc. Am., 73, 1701-1708
and YANG, k.c. (1992a) Co-axial photorefractive methods: HOWLAND, H.C. and HOWLAND, B. (1974) Photorefraction: a
an optical analysis. Appl. Opt., 31, 3601-3615 technique for the study of refractive state at a distance.
BOBIER, W.R., CAMPBELL, M.C.W., McCREARY, C.R., POWER, A.M. J. Opt. Soc. Am., 64, 240-249
and YANG, K.c. (1992b) Geometrical optical analysis of JASCHINSKI-KRUZA, W. (1988) Technical note: a hand opt-
photorefractive methods. Ophthal. Physiol. Opt., 12, 147-152 ometer for measuring dark focus. Vision Res., 28, 1271-
BRADDICK, 0. and ATKINSON, J. (1984) Photorefractive tech- 12S
niques: applications in testing infants and young children. KAAKINEN, K. (1979) A simple method for screening of children
The Frontiers of Optometry: First International Congress 1984. with strabismus, anisometropia or ametropia by simulta-
London: British College of Ophthalmic Opticians (Optome- neous photography of the corneal and the fundus reflexes.
trists). Vol. 2, pp. 26-34 Acta Ophthal., 57, 161-171
CAMPBELL, F.W. and ROBSON, J.G. (1959) High-speed infrared KNOLL, H.A. and MOHRMAN, R. (1972) The Ophthalmetron,
optometer. J. Opt. Soc. Am., 49, 268-272 principles and operation. Am. J. Optom., 49, 122-128
CHARMAN, W.N. (1976) A pioneering instrument. The Collins KNOLL, H.A., MOHRMAN, R. and MAIER, W.L. (1970) Automatic
electronic refractionometer. Ophthal. Optn, 16, 345-348, objective refraction in an office practice. Am. J. Optom., 47,
484 644-649
CHARMAN, W.N. (1980) Reflection of plane-polarized light by KRUGER, P.B. (1979) Infrared recording retinoscope for moni-
the retina. Br. J. Physiol. Optics, 34, 34-39 toring accommodation. Am. J. Optom., 56, 116-123
 References 367

LONG, W.F. (1974) A mathematical analysis of multi-meridio- SCHAEFFEL, F., FARKAS, L. and HOWLAND, H.C. (1987) Infrared
nal refractometry. Am. J. Optom., 51, 260-263 photoretinoscope. Appl. Opt., 26, 1505-1509
LONG, W.F. (1981) The accuracy of multimeridional refraction. SCHAEFFEL, F., HOWLAND, H., WEISS, S. and ZRENNER, E. (1993)
Am. J. Optom., 58, 1161-1173 Measurement of the dynamics of accommodation by auto-
LOVASIK, J.V. (1983) A simple continuously recording infrared mated real time photorefraction. Invest. Ophthalmol. Vis. Sci.,
optometer. Am. J. Optom., 60, 80-87 34(2968), 1306
McBRIEN, N.A. and MILLODOT, M. (1985) Clinical evaluation of SEARLE, C.M., MILLER, R.C., BOURNE, K.M. and CRAMPTON, A.M.
the Canon Autoref R-1. Am. J. Optom., 62, 786-792 (1990) Evaluation report — the Cambridge Video Refractor.
McCAGHREY, G.E. and MATTHEWS, F.E. (1993) Clinical evalua- Aust. Orthopt. J., 26, 13-18
tion of a range of autorefractors. Opthal. Physiol. Opt., 13, SLOAN, P.G. and POLSE, K.A. (1974) Preliminary clinical evalua-
129-137 tion of the Dioptron. Am. J. Optom., 51, 189-197
McDEVITT, H.I. JR. (1977) Automatic retinoscopy: the 6600 STRANG, N.C., GRAY, L.S., WINN, B. and PUGH, J.R. (1997) An
Auto-Refractor. Optician, 173(4485), 33, 37, 40, 42 evaluation of automated infra-red optometers. Optom. Today,
MOSES, R.A. (1971) Vernier optometer. J. Opt. Soc. Am., 61,
SIVA) rset ee
1539
WETZEL, P.A., GERI, G.A. and PIERCE, B.J. (1996) An integrated
MUNNERLYN, C.R. (1978) An optical system for an automatic
system for measuring static and dynamic accommodation
eye refractor. Opt. Eng., 17, 627-630
with a Canon Autoref R-1 refractometer. Ophthal. Physiol.
NAYAK, B.K., GHOSE, S. and SINGH, J.P. (1987) A comparison of
Opt., 16, 520-527
cycloplegic and manifest refraction on the NR-1000F (an ob-
woop, 1. (1982) A comparative study of autorefractors.
jective Auto Refractometer). Br. J. Ophthal., 71, 73-75
Ophthal. Optn, 22, 221-225
POLSE, K.A. and KERR, K.E£. (1975) An automatic objective opt-
woop, I. (1988) Computerized refractive examination. In Opto-
ometer. Archs. Ophthal., N.Y., 93, 225-231
metry (Edwards, K. and Llewellyn, R., eds), pp. 92-110. Lon-
PUGH, J.R. and WINN, B. (1988) Modification of the Canon
don: Butterworths
AutoRef R-1 for use as a continuously recording infra-red
optometer. Ophthal. Physiol. Opt., 8.°460-465 WOOD, I.C.J. and FRENCH, C.N. (1981) The Dioptron II — in
ROTH, N. (1962) Recording infrared coincidence optometer. theory. Optician, 181(4702), 7-11
Am. J. Optom., 39, 356-361 WOOD, I.C.J., PAPAS, E., BURGHARDT, D. and HARDWICK, G.
SAFIR, A., KOLL, H. and MOHRMAN, R. (1970) Automatic objec- (1984) A clinical evaluation of the Nidek autorefractor.
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Ophthal. Oto-lar., 74, 1266-1275
19
Vision screening, new subjective
refractors and techniques

poor. A supplementary check for hypermetropia with a

Vision screening
lens of appropriate plus power to verify that vision
blurs is to be strongly recommended. Suggested
There are many occasions when it is desirable to check
strengths are +2.00 DS for ages up to 20, +1.50 DS for
the visual ability of large numbers of people. For ex-
20-35 years and +1.00 DS for higher ages up to 50. Si-
ample, the presence of significant refractive errors or
milarly. the near vision, with spectacles if possessed,
anomalies of binocular vision will handicap the visual
should be measured for people over 40 years of age.
and mental performance of young children; visual com-
Binocular vision problems such as pronounced het-
fort and efficiency at work may be poorer than normal;
erophoria and poor convergence will be missed unless
routine checks on the vision of employees, new appli-
the appropriate extra tests are added.
cants for jobs, recruits to the Armed Forces and drivers
are all sensible if not compulsory.
There are not enough suitably qualified practitioners Mechanical vision screeners
to give a full eye examination to all those requiring
such a check. Moreover, the large proportion of normal These are stereoscope-type instruments presenting a se-
people renders such a procedure both expensive and quence of tests and are designed for operation by non-
time-wasting. Hence, some type of vision screening is re- professional staff. The stereoscope design allows the se-
quired to identify those people who should be referred parate measurement of both binocular and monocular
for a full eye examination and/or be rejected for certain functions. Binocular visual acuity (or vision) is tested
occupations. by presenting identical slides to each eye. Words of de-
Visual screening may be classified under various creasing size, illiterate Es and checkerboard patterns
headings of complexity: are used in different manufacturers’ instruments. Mono-
cular vision may be checked by presenting the acuity
(1) simple vision tests, test to each eye in turn. In some instruments, these
(2) mechanical vision screeners, vision tests are mounted on a background giving stereo-
(3) simplified or partial routine examination. scopic relief, in which case the vision test will be super-
In general, such screening is for visual requirements, imposed on the respective side only. If checkerboard
and no check is made on the ocular health. patterns are used, the eye not being tested will be
shown uniformly grey or finely stippled diamonds.
These two types of background give a binocular lock,
stabilizing convergence and hence accommodation.
Simple vision tests
Heterophoria may be checked by showing a line to
Screening is often undertaken by means of visual acuity one eye and a tangent scale to the other, separate tests
tests alone, often with a conventional Snellen chart. being needed for horizontal and vertical phorias. A sim-
The appropriate type of chart should be used for young pler screening test is to present a dot to one eye and a
children, for example Stycar or Ffooks. Virtually all rectangle to the other eye. The subject passes if the het-
myopes and people with medium or high astigmatism erophoria is within normal limits but fails if the dot ap-
and amblyopia will be detected. Unfortunately, some pears to lie outside the rectangle, which demonstrates
with significant astigmatism may be missed because the the presence of, say, more than 1A of vertical phoria,
unaided vision for the clear well-spaced lettering of the 3A of esophoria or 6A of exophoria.
Snellen chart may be quite reasonable. Absolute hyper- Tests may also be provided for colour vision, stereop-
metropia will also be detected, but the young person sis and suppression. The presence of low amounts of hy-
with significant hypermetropia may well be able to read permetropia can be tested on some instruments which
the 6/6 (20/20) line or better with ease since the dura- automatically insert weak plus spherical lenses or pos-
tion of the test is so short. Visual comfort for prolonged ition the slide farther from the collimating lenses. If the
viewing, especially in near vision, will nevertheless be test detail can still be seen, hypermetropia exists.
 Vision screening 369

[ |
=H AODRESS OR REF
|
ie No
MR ee

MRS.
MISS

UNDER 15 ‘a 45. OVER

AGE GROUP | |
= ae
TYPE OF WORK EYE HAZARO |
DRIVER COLOUR NEED
= a | CONSTANT | DISTANCE =| NEAR ] BIFOCAL
GLASSES WORN |

oaat YRS ot ioe waa 4S OVER”

LAST EYE EXAMINATION | | |
+ 3 :
TROUBLE WITH EYES NOW? rater
w T

MASTER SCREENER RECORD

USING NEAR GLASSES OR LOWER

PART OF BIFOCALS, IF WORN

8 ]
R EAR POT |

caf 9
L AND LOT

CAAT NE Se ee ee lteCe [74 8 10

NO DOTS NO LINE NO DOTS NO LINE
Figure 19.1. The Master Vision Scréener (Mavis): 1—7
distance targets; 8-14 near vision targets; D the distance S\N SG OMLehe [Ss | [x t[M[n[o|[P]Q
collimating lens andf its focal length; F fogging charts, viewed NO LETTERS NO ARROW NO LETTERS NO ARROW
through aperture in |; R near vision lens with object distance / sity 9 leew Sate
6 |NOlyes] O] T]F |! x |12 RED [ DOOR
for targets to be imaged at 330 mm and x for target N to be
If LOT HILL
imaged at 200 mm. Note shutter for lenses D and R.
7 [Now LOOK DOWN THROUGH 13] BUT | joB | BAT |BUS | MOB
(Reproduced by kind permission of Professor R.J. Fletcher, from NOW THROUGH THE LOWER | —
Ophthalmics in Industry, 1961.) NOW LOOK DOWN Lower || DOSOUP | SO UP | DO UP
DATE NONE = was THE
OPERATOR 14,—_—+--—-— -— —
he Kibet LM NONE 15 LAST THE
alee —_—- =|
Some of the tests may be repeated in near vision (with NOTIFIED INTERPRETATION STANDARD
different slides to avoid memorizing), either by position- BY REFERRED
Ir EXAMINED Practitioner
ing the test nearer or by viewing through weaker stereo- FSEV1S

scope lenses. In some instruments these are positioned

to allow comfortable viewing through the near portion Figure 19.2. The Mavis record card. (Reproduced by kind
of bifocals (Figure 19.1). permission of British American Optical Co. Ltd.)

The results are recorded on a special card, for example

that shown in Figure 19.2, by ticking the relevant compatible with the ambient lighting in the workplace.
boxes. These cards are then passed to professional staff, A very high test-chart illuminance may not identify
who can interpret the standard of vision in relation to those people whose vision will be inadequate if the
the requirements for the particular occupation or medi- work illuminance is poor. Conversely, a low test-panel
cal check. Anyone not meeting the standard is then re- illuminance may result in failure for a subject whose
ferred for a full eye examination. An alternative vision out of doors in daylight is (legally) adequate for
procedure is for the professional adviser to draw up lists driving. Rossi (1992) gives a recent review of vision
of standards for particular tasks. These requirements screeners.
can be marked on a transparent plastic sheet to form a
template which can be laid on top of the individual's
record, thus allowing non-professional staff to decide
whether or not to refer.
Automated vision screeners
Note should be taken of the proximal or instrument
accommodation (Chapter 7) induced in young patients, The French firm Essilor have introduced automation
particularly children under 10 years. It may lead to into screening by incorporating a voice synthesizer to
false referrals from mechanized screening because em- give instructions to the subject, together with computer-
metropes and low hypermetropes could apparently ized recording. Their simpler model named Optivision
show reduced vision through pseudo-myopia. measures the right and left monocular acuities, and in-
Patients with strabismus may well need to have their cludes a fogging test to detect hypermetropia over 1 D
better eye occluded before their strabismic eye's vision and a bichromatic test to identify lower degrees. A fan
can be measured. chart to detect astigmatism, a heterophoria screening
The test plates fn some instruments are not enclosed test and a test for binocular visual acuity are also incor-
in an instrument case and so are illuminated by the gen- porated.
eral room lighting. This means that the visual acuity re- In addition to the above automatic tests, the Ergovi-
sults especially could vary from one testing location to sion model has many extra features for testing occupa-
another. Other instruments have totally enclosed test tional vision, the appropriate functions being used as
panels and rely on internal illumination. The operator indicated. To reproduce the lighting conditions at
should ensure that the illuminance is both uniform and work, the tests can be undertaken with a surround
370 Vision screening, new subjective refractors and techniques

luminance of 15, 150 and 300 cd/m’, while vision offer advice on any workstation problems elicited by the
under mesopic conditions can be assessed with an questions. Advice on both the DSE regulations and
acuity chart at 4 cd/m7. Night vision can be further as- layout is given in Display screen equipment work — guid-
sessed by measuring the recovery time from glare, and ance on regulations (1992), published by the UK Health
driving vision checked by tests of kinetic visual acuity and Safety Executive.
and the field of vision. Provision is also made for estimat- For conventional optometric examination, the UK As-
ing binocular visual acuity at intermediate distances sociation of Optometrists recommends the following
and also with a low-contrast chart in distance vision. standards for comfortable DSE work, which are repro-
Ishihara colour vision plates, a more accurate hetero- duced here with their kind permission:
phoria test and tests for stereoscopic vision and fixation
(1) The ability to read N6 throughout the range 70—
disparity have also been added.
33cm with adequate visual acuity for any task
The Canon Auto Acuitometer also uses a voice
undertaken at a greater distance, if this is an inte-
synthesizer and computer recording to allow the subject
gral part of the work.
to test his own acuity automatically. Landolt ring
(2) Well-established monocular vision or good binocu-
charts are provided for this purpose.
lar vision. Phorias at working distances should be
The autorefractors in general, but particularly those
corrected unless well compensated or deep suppres-
incorporating test charts, could also be used as vision
sion is present.
screeners for refractive errors. They are not able to ex-
(3) No central (20°) field defects in the dominant eye.
amine other functions such as binocular co-ordination,
4) Near point of convergence normal.
for which they were not intended.
(5) Clear ocular media checked by ophthalmoscopy.

They point out that these criteria are intended to in-

Computerized screening for DSE users crease the level of operator comfort and efficiency, but
are not inflexible and should not be used to exclude per-
In Europe, workers who spend a significant amount of
sons from working with DSE.
time viewing display screen equipment (DSE — visual
display units/terminals) are entitled to regular eye ex-
aminations, partly to ensure their comfort and perform- Simplified examination routines
ance while working. For employers with large numbers
of such employees, it is economically beneficial to In view of the disadvantages of both lay-person and me-
screen to identify those who would benefit from a full chanical-instrument screening, a much reduced version
eye examination, those whose discomfort may be equip- of a normal eye examination by professional staff has
ment or environmentally related and those who are much to recommend it. A suggested scheme for older
both symptom-free and visually normal. school children and adults would cover:
While optical screening instruments of the types de- (1) Distance vision, with spectacles if possessed, mono-
scribed above may be employed, they do not necessarily cularly and possibly binocularly.
provide a suitable combination of tests for DSE users. (2) Cover test in distance vision.
Programs for use at the worker’s display unit have the (3) Near vision, with the patient’s own spectacles,
advantage of testing at the actual viewing distance and again monocularly and binocularly, at the required
angle habitually used. They can include questions on working distance.
screen size and viewing distance (for calibration for ) Near cover test and near point of convergence.
acuity and oculo-motor balance), on problems such as ) Retinoscopy sufficient to identify the presence of sig-
lighting levels, reflections off the screen and the ergo- nificant uncorrected hypermetropia, astigmatism or
nomic comfort of the layout, as well as an appropriate anisometropia. Myopia will show both here and by
selection of vision screening tasks. reduced distance vision.
Two such programs available in the UK are the City (6) Ophthalmoscopy.
University Vision Screener for VDU Users” (Thomson, 7) Colour-vision testing, where appropriate. In _pri-
1994) and the Keeler Vutest? (Scheinman, 1993). mary schools where colour coding is used in teach-
Like the optical screeners, these include visual acuity, ing arithmetic, colour-deficient children need to be
oculo-motor balance and fixation disparity tests. The identified, despite the greater difficulty of assessment
City University test also includes a subjective comfort at that age. For older children, when careers advice
rating for the legibility of print, search tasks to check is given.
whether ocular performance drops with a longer dura- (8) Stereopsis — for some industrial tasks. It can also be
tion task, and a simple central visual field check. The used as a test for the quality of binocular vision.
Vutest uses a combination search and visual field test
and an Amsler chart (see page 252) to investigate the
central fields. Both will print out a report of the visual Screening of young children
screening, while the City University program will also
The purpose of screening very young children, about 1
year old, is to try to identify those at risk of developing
strabismus and/or amblyopia. About 3.7% of the infants
* Available from City Visual Systems Ltd, Citybridge House,
235-245 Goswell Road, London, EC1V 7JD. of this age reported upon in a study by Ingram et al.
+ Available from Keeler Ltd, Clewer Hill Road, Windsor, Berks (1986b) showed a significant refractive error. Ingram
SL4 4AA. (1977) had earlier found that while over 50% of chil-
 Imaged refraction systems 371

dren presenting either of these conditions had a family While Ingram et al. (1986a) suggested refraction and
history of strabismus or amblyopia, over 70% had an possibly the cover test for screening at age 35, Dholakia
abnormal refraction defined as an error exceeding (1987) proposed that lay staff could use the 20A prism
2.00 D in the least hypermetropic meridian of either test, 7-letter Stycar chart (see page 33) and near point
eye or 1.00D or more of spherical or cylindrical ani- of convergence for 3 year olds, leaving out the last for
sometropia. Although Atkinson et al. (1987) concluded 4 and 5 year olds. To increase sensitivity to possible de-
that refractive correction at this age had a beneficial fects, the high acuity standard of 6/6 was chosen as a
effect in reducing the incidence of strabismus and am- criterion. This might be thought a very high level of
blyopia, Ingram et al. (1985) found no evidence that acuity for the younger age groups.
spectacles significantly altered the child's prospect of A simplified routine such as the above is of great
avoiding either of these conditions. Ingram et al. value, both in organized screening sessions and also as
(1986a) further suggested that screening at age 34 is an occasional procedure for young children when the
too late to be effective in combating amblyopia. While practitioner is examining parents or older siblings.
this may well be true for deep amblyopia, optometric
opinion would certainly not agree with this view when
initial acuities of 6/24 or better are obtained. Imaged refraction systems
For large-scale refractive screening of infants, the
computerized isotropic photorefractor has undoubted Introduction
possibilities, as shown, for example, by Atkinson et al.
(1987). Should acuities be required, forced-choice pre- Both the trial frame and refractor head (phoropter) re-
ferential looking or some other objective technique will quire the correcting lenses to be placed in front of the
be needed (see pages 38-39). patient's eye, hindering the refractionist’s view of the
With slightly older children the appropriate acuity face. The trial frame system is relatively heavy but does
tests should be used. Dynamic retinoscopy with a small allow the patient to move his head. The refractor head
picture or miniature toy animal or car as fixation object is supported mechanically, but the patient must keep
may give more reliable results, at least for astigmatism his head pressed firmly against it to maintain the correct
and anisometropia, than static retinoscopy, though this vertex distance. A better view for the practitioner and
possibly a greater sense of freedom for the patient
should be attempted to verify the absence of marked hy-
would be achieved if the lenses were moved away from
permetropia. The child’s mother may need to flash a
the eyes.
pen torch on and off in order to obtain a reasonable dis-
As demonstrated in a paper by Reiner (1966), it is
tance fixation. Mohindra near retinoscopy is another
possible to reproduce the refractive effect of a contact
possible option.
lens on the eye by removing the real lens to some con-
The presence of fusion may be confirmed by observing
venient distance and forming an optical image of it on
compensatory eye movements when a prism of 20A
the cornea itself. The optical system used for this pur-
base out is held before one eye. With the prism held in
pose consists of two lenses of equal positive power, sepa-
turn before both eyes, adduction of the eye behind the
rated by twice their focal length to form an inverting
prism with no movement of the other eye should occur.
afocal system of unit magnification (m = —1). In this ar-
The presence of suppression — and hence, probably, of
rangement, an object (the contact lens) placed in the
strabismus — is demonstrated by no movement of either
anterior focal plane of the first lens is imaged in the pos-
eye when the prism is held before the weak eye, and bin-
terior focal plane of the second lens, positioned to coin-
ocular version movements when the prism is placed
cide with the observer's eye.
before the dominant eye. No response from either eye
could indicate lack of attention or possibly too strong a
prism. Only 15A base out should be used with a child
under 18 months and 10A base out with a child under
1 year down to 3 months old (Bishop, A., pers. comm.,
1983).
The presence or absence of stereopsis (see Chapter 11)
may also be used for evaluating the quality of binocular
vision. The present author feels that, while a positive re-
sponse to a stereopsis test is an indicator of binocular
vision, a negative response may merely be a lack of in-
terest or understanding by a young child. Thus Broad-
bent and Westall (1990) found that 50% of their
sample of 6—-12-month-old infants responded to the
Lang test (e.g. by patting or pointing to one of the
hidden objects), rising to 75% of the children aged over
1 year, while the 3 or 6mm plates of the Frisby test
were identified by about 20% of the 6—12-month Figure 19.3. A Reiner imaged refraction system. B black
screen against which test images are viewed, C collimating
group, rising to 85% by the age of 24 months. The TNO mirror, presumably toroidal to counteract oblique astigmatism;
test, needing the child to wear red-green goggles, was M glass plate mirror; P projection lens; R refractor head; T test
unsuccessful until about 2 years of age. slide.
UoN bo Vision screening, new subjective refractors and techniques

Remote Principal
refractor planes of Spectacle
plane projection lens plane

Figure 19.4. Optical principle of remote refraction: the

\N'
remote refractor plane is made conjugate with the spectacle
plane.

Figure 19.5. The remote-refraction system of the Humphrey

Vision Analyser: C and F’ centre of curvature and principal
Figure 19.3 shows another imaged (or remote) refrac- focus of mirror M: L effective position of trial correction
tion system subsequently designed by Reiner. The (aperture WX) images at W’X’ in the spectacle plane. The ray
patient has a wide view of the room through a plate path shown is for emmetropia (trial lens power zero). In
myopia, the minus trial correction moves image T| further from
glass beam splitter, while the test charts seen through
the projector.
the refraction system appear superimposed on the black
screen. The optical principles can be derived from
Figure 19.4 which shows a projection lens of power F,,
forming an image Q’ of an object QO with a magnification mirror of the correction lens aperture WX is therefore
m, equal to q'/q. The test slide is at RB. of the same size as WX and situated in the patient's spec-
From the two pairs of similar triangles QBR, QPH and tacle plane.
O’B’R’, O'P’H’, an expression identical to equation For an emmetrope, the image of T, of the test object T
(12.7) can be derived. Using the symbols appropriate to must be projected by the system P into the mirror’s
the present system it becomes focal plane through F’ so as to give rise to parallel pen-
cils after reflection. The image T’, is then formed at infi-
mV = V/mg + Ep (19.1) nity. In order to compensate for image aberrations
For the special case in which m, = —1, this expression caused by the slightly oblique incidence, the surface of
reduces to the mirror is made fractionally toroidal.
If a low-powered negative lens is introduced at L, the
V=V + le (1922) test object will be imaged nearer the mirror, resulting
If Q’ is regarded as being in the spectacle plane and Q in in a divergent beam reaching the eye. A negative lens
the remote plane in which the refractor head lenses are of slightly higher power will put the aerial image on to
placed, V is the lens power needed in this plane to give the mirror, so that the vergence at the eye is —1/2.5 or
a vergence V’ or F,, in the spectacle plane. Thus, with —0.40 D. A steady increase in negative power will push
mg = —1 and F, = + 10D, a lens of power (+10 + F,,) the aerial image towards the eye, providing an effective
would be needed in the refractor head to ‘correct’ an test object for any degree of myopia.
ametrope. Any positive correcting lens at L will cause the first
Guyton et al. (1987) suggests various optometric uses aerial image T) to lie between the projector and the mir-
for imaged refraction systems, while Freeman (1992) ror’s principal focus, so that the second image T, by re-
described the use of a pair of nominally identical flection is formed behind the patient’s head. This is
camera lenses, mounted front elements towards each illustrated in Figure 19.6, in which the dotted lines
other, to provide a simulation system providing excel- show the ray paths when the system is at zero for an em-
lent visual performance over a 6mm diameter pupil metrope. The unbroken lines are the ray paths from W
and a visual field of £8”. and X through T). After reflection, they necessarily

The Humphrey Vision Analyser

The first commercially available system using remote re-

fraction was the Humphrey Vision Analyser, introduced
in the mid-1970s. Though it is no longer in production,
it introduced so many new concepts that it is still de-
scribed here. The positive powered imaging system is a
concave mirror of 30cm diameter, placed at about
2.5m from the patient, in which he sees the test object
by reflection (Figure 19.5). The mirror’s centre of curva-
ture C is in a mid-way position, approximately in the pa-
Figure 19.6. Humphrey Vision Analyser: ray path with
tient’s spectacle plane and in the effective plane of the positive trial-lens power in operation for correction of
correction lens unit L. The image W’X’ formed by the hypermetropia.
 aan
The Humphrey Vision Analyser 373

(a) ———> (b) ———> _(c) ———~> (d) —— => (e)

Ist sph 1st cyl 2nd sph 2nd cyl

Figure 19.8. Refraction steps with the Humphrey Vision

Analyser: patient's astigmatic meridians at 70° and 160°. (a)
Initial blur ellipse, (b) blur ellipse with best sphere, (c) blur
ellipse aligned with test line object by first cylindrical
adjustment, (d) blur circle with second spherical adjustment,
(e) point focus with second cylindrical adjustment.

axes at any specified orientation. In this case, however,

Figure 19.7. Central cross-section of the Alvarez two- no added spherical power is generated by the combina-
element variable-power lens. tion because the mean spherical power of any cross cy-
linder is zero.
- Although in the Humphrey Vision Analyser a combi-
pass through W’ and X’ to form the image T, behind the nation of variable power cross cylinders is used at fixed
patient's eye, thus simulating the effect of a plus correct- orientations 0°/90° and 45°/135°, the theory of the
ing lens placed in the spectacle plane. method is explained most simply by reducing them to
A second breakthrough of the Humphrey Vision Ana- simple cylinders, plus or minus as required, at axes 0”
lyser was to replace conventional trial lenses with con- and 45° respectively. In effect, the correcting cylinder is
tinuously variable optical systems. Spherical power is replaced by a combination of these two components, ad-
provided by a two-element Alvarez lens formed by two justed in turn to the appropriate power.
identical components _in reverse orientation (Figure The patient initially looks at a line in the 135° merid-
19.7). Placed in contact in the zero setting, they would ian of about 1 minute of arc subtense in width and ad-
form a flat parallel plate without focal power. If the left- justs the variable spherical lens system to give the best
hand component in the diagram were moved upwards view obtainable of the line. If astigmatism is present,
and its fellow downwards, the result would be to gener- the line can be seen quite clearly only if the axis of the
ate minus power — surprisingly uniform over the whole correcting cylinder is at 45°. By adjusting the power of
area of overlap. The magnitude of the power is directly the axis horizontal cylinder component, the ocular as-
proportional to the travel of the components. Relative tigmatism is then modified so that it becomes correctable
movement in the opposite direction would produce plus by a cylinder at axis 45°. Only then can the line at
power. The complex geometry of the refracting surfaces 135° be seen in its sharpest focus. The patient accord-
is lucidly explained in the patent specification (Alvarez, ingly adjusts the power of the 90°/180° cross cylinder
1967) and by Charman (1994). The astigmatic compo- until this result is achieved.”
nents are provided by systems invented by Humphrey This process is shown diagrammatically in Figure
(1973). In effect, they are cylinders of variable power 19.8 which represents the patient’s view of the test
by sliding adjustment, not by rotation as in the optically lines with the projected retinal blur ellipses (due to a
equivalent Stokes lens. The mean spherical power re- point object) superimposed on them. In Figure 19.8(a),
mains at zero, so that adjustment does not alter the pos- the test line is at 135° and the major axis of the blur el-
ition of the circle of least confusion relative to the retina. lipse is at 70°, corresponding to one of the astigmatic
A third innovation was a new technique for measur- meridians of the eye under test. The sharpest focus of
ing astigmatism, called ‘astigmatic decomposition’ — a this line is obtained by spherical adjustment to place
concept originated by Humphrey from the theory ofobli- the most favourable cross-section of the astigmatic
quely crossed cylinders as described in Chapter 5. It is pencil on the retina. This occurs when the retinal blur
based on the fact that a plano-cylinder of any given presents the least width perpendicular to this line, as
power and orientation can be replaced by two plano- in Figure 19.8(b). The major axis of the ellipse is
cylindrical components in contact, with their respective now at 160°, at right-angles to its original orientation.
axes in any specified meridians. Both plus and minus cy- Adjustment of the axis horizontal cross cylinder is
linder components are needed to cover all possibilities. then made so as to align the major axis of the resultant
The equivalent combination does, however, generate a blur ellipse with the 135° line, as shown in Figure
spherical component in accordance with equation 19.8(c).
(5.10). A general demonstration of the basic theorem The oblique line test object is now replaced by a verti-
with numerical examples has been given by Bennett
(W977).
In a similar way, a cross cylinder (as used in refrac- " Accuracy is enhanced by showing a fan of three lines. The
tion) of given power and orientation is replaceable by a middle one should appear sharpest with the two outer ones
combination of two such lenses with their respective equally blurred, somewhat similar to the Maddox v test.
374 Vision screening, new subjective refractors and techniques

cal line, and the spherical power system readjusted to hypermetrope could then accommodate and not relax
provide the best view obtainable Since the resulting sufficiently on returning his attention to the chart.
astigmatic error at this stage is at axis 45°, the clearest
view of the vertical line occurs when the circle of least
confusion is on the retina (Figure 19.8d). Adjustment of Other methods of
the 45°/135° cross cylinder should then bring it into
measuring astigmatism
sharp focus, as indicated in Figure 19.8(e).
A built-in computer calculates and displays in sphero-
Axis determination
cylindrical form the result of the spherical and two
cross-cylinder components. A print-out can also be ob- The Crisp—Stine test
tained.
This test is essentially the same as the conventional
A notable feature of this system is that it obviates the
cross-cylinder method of axis determination, except
prior need to locate the astigmatic axis of the subject's
that a cross is used, rotated to be at 45°/135° to the
eye. Thus, instructions to the patient and the decisions
trial cylinder axis. If the trial cylinder is at the correct .
required are simplified. Moreover, there are no confus-
axis, the two limbs of the cross will be equally clear. In-
ing side-effects sometimes attendant on other routines.
troduction of a cross cylinder with its axes parallel to
It is immaterial in which order the line test objects are
the cross will cause equal blurring of the two arms in
presented, provided that the correct cross-cylinder
both positions. If the trial cylinder is at an incorrect
system is adjusted on both occasions. axis, then, as shown in Table 6.3 on page 103, there is
To enable binocular examination to be made, two pro- a resultant error of refraction at an axis outside the
jection and correcting lens systems are provided side by angle enclosed between the trial cylinder and true axis.
side. Crossline targets are projected on to the patient’s One limb of the cross will thus appear clearer than the
face to allow accurate horizontal centration for each other. Introduction of the cross cylinder will either ag-
eye by means of a sliding-mirror assembly. Vertical ad- gravate or reduce the difference in clarity of the limbs.
justment is by the height of the patient's chair. The The trial cylinder and cross are then rotated towards
vertex distance is set by a supplementary projector from the negative (or positive) cylinder axis of the cross cy-
the side. It can be adjusted to zero to obviate the need linder in its preferred position, depending on whether
for effectivity allowances when contact-lens patients negative (or positive) trial cylinders are used.
are being refracted. Over-refraction through the pa- To the present writers, the technique seems to make
tient’s own spectacles, a useful expedient when they the subjective examination even more complicated for
are of high power, presents no difficulties. the patient than the standard cross-cylinder technique.
As with a refractor head or phoropter, the patient He is required to assess which of two positions shows
must keep his head still and firmly pressed up against less difference between two unclear limbs.
the rest. Especially in cases of anisometropia, lateral or
vertical head movements will generate relative prism,
while a head tilt may also cause axis errors significant
The Raubitschek arrow or paraboline chart
in high astigmatism. In this sense, the trial frame retains The writer's modification of the Maddox V and blocks
its superiority, but the clear view of the patient’s face used with the standard fan chart was described on page
with the remote refraction of the Humphrey Vision 104. The new V is a simplification of the Raubitschek
Analyser means that head movement can easily be arrow introduced by him in 1929 and later described
seen. in 1952. The arms of the arrow are curved, being
Monocular refraction may be performed either by almost parallel near the apex and curving away from
switching off one of the projector bulbs, or, more usual- each other as the base is approached (Figure 19.9). This
ly, by introducing excess positive spherical power to fog parabolic form explains the alternative name of parabo-
the eye. Conventional bichromatic and Snellen charts line chart.
may be presented. Prismatic elements can be introduced When the Raubitschek arrow is well off-axis, a length
to correct fixation disparity revealed by the special of one of the curves will appear sharp. As the arrow is
slides. Since separate channels are used for each eye, turned away from the clearer limb, the sharp portion
no analysing visor is necessary. will pass up towards the apex of the arrow. The axis set-
The eyes’ performance in near vision can be examined ting is correct when an equal portion of each limb ap-
by lowering a mounted periscope, thus permitting de- pears clear.
pressed gaze as well as convergence.
Since the test slides are viewed by reflection in a
mirror instead of by projection on to a metallized screen
Power determination
as with conventional test chart projectors, only low-
powered bulbs need to be used. High contrast is obtained In the version of the Raubitschek arrow or paraboline
in full room illumination. chart produced by the American Optical Corporation, a
With both the Reiner and the Humphrey systems, the dashed cross is superimposed to enable the power of the
patient can change fixation and view the room sur- cylindrical lens to be determined, in a manner similar
roundings unaided. While this does not stimulate ac- to (but less decisive than) the conventional blocks.
commodation in a myope, there is a possibility that the An alternative technique in which the Raubitschek
arrow is used was described by Dunscombe (1933) and
 Laser-speckle refraction 375

A retinal element QO of the observer's eye having its

image Q’ in the plane conjugate with the retina will re-
ceive light reflected from a large number of points in
the area of the surface bounded by XY.” The individual
wavefronts from each of these reflecting points retain
constant-phase relationships with each other and are
therefore capable of constructive or destructive interfer-
ence. The fringe spacing due to any two points will
depend upon their individual separation, but the eye
sees the summation of countless fringe patterns giving
the appearance of an irregular speckle in the retinal
conjugate plane through Q’.
Consequently, for the myopic eye illustrated in Figure
19.10, a head movement will result in an against move-
ment of the speckle pattern. To a hypermetropic ob-
server, the fringe pattern becomes a virtual object ap-
parently moving with the head movement. When the
retina is conjugate with the surface, the speckle appears
stationary.
Instead of moving the head, it is simpler to move the
surface by using a drum rotating slowly at between 1
Figure 19.9. The Raubitschek arrow or paraboline chart.
and 10 revolutions per hour. In this case, the plane of
‘stationarity’ (zero movement) is not the surface of the
O'Leary (1988). It relies on the fact that the axis of the drum but lies between the surface and the axis of rota-
resultant of two obliquely crossed cylinders of equal tion. Its distance x, from the latter is given by Charman
power and like sign lies mid-way between their axes. and Chapman (1980) as
Thus, if the indicated minus cylinder axis were 20°, a _ cos > (p+rcos >)
trial cylinder would be placed at, say, axis 40°. The Be (GES 23)
~ p(1+cos)+rcos2 >
true cylinder correctiorr at axis 20° may be regarded as
correcting an ocular plus cylinder at axis 20°, which is where r is the radius of curvature of the drum (regarded
astigmatically the same as a minus cylinder at axis as positive), p the radius of curvature of the incident
110°. Since the resultant axis of equally powered cylin- wavetlront (regarded as positive) and o, the angle ofinci-
ders at axes 110° and 40° is 75°, the arrow tip should dence of the wavefront relative to the direction of obser-
be pointed at 75°. Trial cylinders are then added at axis vation.
40° until the two limbs of the Raubitschek arrow are For a plane incident wavefront, equation (19.3) re-
equal. The cylinder is then turned back to 20°, and the duces to
usual fogging lens removed. rcos o
MAES eS)
For a patient who is hypermetropic with respect to the
Laser-speckle refraction plane of zero movement, the speckle moves ‘against’
the direction of the drum movement, while for a
When a broad divergent beam of coherent light from a myopic patient the speckle moves ‘with’.
laser falls on a roughly diffusing surface, an irregular Expressed in terms of the observer's viewpoint, the
speckled pattern will be seen. On moving the head, the speckle moves with an apparent angular velocity Q
speckle will appear to move ‘with’ or ‘against’ the head given by Charman and Chapman (1980) as
movement, depending upon the state of refraction of
the observer's eye. This may be explained with the aid —or(kK — V)
OF (G9 5))
of Figure 19.10. V(r — xs)
where @ is the angular velocity of drum and V is the
dioptric distance of the plane of zero movement from
the plane of the observer.
The speckle velocity is thus proportional to the ame-
tropia relative to the plane of zero movement.
The negative sign was prefixed to Charman and Chap-
man’s expression to maintain the sign convention for
angles. If the drum rotates anticlockwise, a with move-
ment of the speckle results in a clockwise movement
Figure 19.10. Laser-speckle refraction: relevant fringe
formation is in the plane through Q’ conjugate with the retina.
relative to the observer's position.
For conventional refraction purposes, the drum could
be mounted at 6m and the speckle movement elimi-
“The diameter XY will depend both upon the pupillary aper- nated (or reduced to random motion) by placing trial
ture and the position of Q’. lenses before the eye. The rotation of the drum allows
376 Vision screening, new subjective refractors and techniques

only the meridian perpendicular to its axis to be investi- From a research standpoint, speckle refraction has
gated at any one time. In the presence of an astigmatic several advantages over other subjective optometer sys-
error whose principal meridians are oblique to the tems for monitoring the accommodative state of the
drum, the perceived speckle motion will not be parallel eye. For example, unlike Scheiner disc systems, it
to the motion of the drum surface but oblique. There is allows the whole pupil area to be utilized and gets
no simple way, however, of using the laser and drum to around the difficulty of deciding upon the position of
determine the axis of the astigmatic error. If this is first sharpest focus. Aberrations may, however, affect the
determined by conventional subjective techniques, the laser refraction, since the central zones of the pupil
laser speckle can be used to measure the two meridional could be giving an against movement and relatively
corrections, the drum being placed consecutively in more myopic peripheral zones a with motion; this could
these two positions. When the first meridian has been explain the random speckle motion seen at reversal.
corrected, the speckle may appear to move along the It was frequently suggested that as the laser-speckle
drum axis. pattern did not act as a stimulus to accommodation,
Alternatively, multi-meridional refraction can be the duration of any exposure in monitoring accommo-

used. The apparent ametropia is measured in three or dation response was of little importance. Hogan and Gil-
martin (1984) showed, however, that an exposure
more regularly spaced meridians and an average
shorter than the accommodative reaction time was
sphero-cylindrical ametropia calculated to fit the results,
needed to ensure consistent results. They recommended
a process similar to that used in some of the automatic
a duration of 300 ms.
objective optometers.
Possible research uses include the investigation of in-
It was established experimentally by Haine et al.
strument or proximal myopia, inadequate stimulus
(1976) that meridional refraction by laser speckle meas-
myopias and the accuracy of the accommodative re-
ured the quantity (S + Csin* @) in the given meridian
sponse. References to some of these researches are
(see page 352). The six-meridian method was found to
made in Chapter 7 and in Charman and Chapman
yield an accuracy comparable with that of subjective re-
(1980).
fraction. A similar conclusion was reached by Phillips
Instruments based on laser speckle have been mar-
et al. (1976).
keted to allow prospective patients to screen themselves
Whitefoot and Charman (1980) compared the results
on the need for (new) spectacles or a correction for
of conventional subjective and laser-speckle refraction
night myopia when driving. Rubinstein (1987) found
using both the multi-meridional method in six orienta-
that laser-speckle refraction was not a reliable screening
tions and a twin-drum arrangement set parallel and per-
test for ametropia in children. It has been generally re-
pendicular to the subjective astigmatic axis. The latter
ported that patients with media opacities find the
technique allowed the subject to observe both meridians
speckle difficult to perceive.
almost simultaneously because sphero-cylindrical cor-
Some practical aspects of this test are brought out in
rections were used. A detailed analysis of the experimen-
Exercise 9242
tal results from the two speckle refraction methods
Modifying Palmer’s (1976) suggestion of using a
showed very little difference between them and close finely ground glass screen, Bahuguna et al. (1984)
agreement with the conventional refraction.
have put forward an alternative system for speckle re-
Morrell et al. (1991) point out that the term plane of fraction. A slowly rotating drum carrying a series of
stationarity may be a misnomer when laser speckle is torch bulbs illuminates a reflecting screen through an
generated by a rotating drum if viewed from a close dis- aperture which allows only one bulb at any instant to
tance or in a Badal optometer system. If a large area of shine on to the screen. This is made from aluminium
the drum is exposed, then the ‘plane’ of stationarity is foil that has been pressed on to emery cloth, thus form-
probably curved so that the observation distance will ing a rough reflector. Unlike the laser-speckle instru-
depend upon which part of the area is viewed. ment, the pattern that is seen is not formed by
A disadvantage of the laser system is that a small pro- interference fringes but by the distorted wavefronts
portion of patients are unable to perceive the speckle, from the individual reflection points.
possibly because their media are too irregular to allow
the constructive/destructive interference to take place
in their eyes. Another is that the light is necessarily
Exercises
monochromatic, requiring an allowance to be made for
the longitudinal chromatic aberration of the eye’ (Gil-
19.1 In laser-speckle refraction, a plane wavefront is inci-
martin and Hogan, 1985). The luminance of the speckle dent, along the subject's visual axis, on a drum of radius r.
may also be much lower than that recommended for a What is the position of the plane of stationarity?
conventional chart. 19.2 In laser-speckle refraction, the drum rotates at 0.01 re-
volutions per minute. If ris 100 mm, x;50 mm, the uncorrected
refractive error —3.00 DS and the working distance —4 m,
what is the apparent angular speed of movement of the speckle
“Miller (1987) drew attention to the uncertainties about the pattern? What does this speed become if a —2.00 DS trial lens
eye's longitudinal chromatic aberration and the wavelength is held before the eye?
for which the eye was assumed to be in focus when viewing 19.3 A remote refractor system incorporates a projector lens
objects in white light. He concluded that research reports of power +10 D effectively situated 300 mm in front of the pa-
should provide basic technical information but leave it to indi- tient’s spectacle plane. From the simple paraxial relationship,
vidual readers to make whatever adjustment they deem appro- calculate the power of the lens needed in the remote refractor
priate. A useful list of references is given. plane to correct: (a) an emmetropic eye, (b) an eye —5.00D
 References 377

myopic, (c) an eye +5.00D hypermetropic. Assume the test HOGAN, R.E. and GILMARTIN, B. (1984) The choice of laser
object to be at infinity. Verify your answers using equation speckle exposure duration in the measurement of tonic ac-
(ISL), commodation. Ophthal. Physiol. Opt., 4, 365-368
19.4 A laser-speckle device is observed by a presbyope from a HUMPHREY, W.E. (1973) Variable astigmatic lens and method
distance of 2m while wearing his distance correction. Com- for constructing lens. US Pat. 3,751,138
ment on (a) whether the speckle would appear to be stationary INGRAM, R.M. (1977) Refraction as a basis for screening chil-
and (b) whether the 3-metre observation distance recom- dren for squint and amblyopia. Br. J. Ophthal., 61, 8-15
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NOLD, P.E. and DALLY, S. (1986a) Screening for visual defects
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BAHUGUNA, R.D., HALACARA, D. and SINGH, kK. (1984) White- MORRELL, A., WHITEFOOT, H.D. and CHARMAN, W.N. (1991)
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(1987) Remote optical systems for ophthalmic examination Optn, 20, 169-173
and vision research. Appl. Opt., 26, 1517-1526 Woo, G.c. and WOODRUFF, M.E£. (1978) The AO SR III subjective
HAINE, C., LONG, W. and READING, R. (1976) Laser meridional refraction system: comparison with phoropter measures.
refractometry. Am. J. Optom., 53, 194-204 Am. J. Optom., 55, 591-596
20
Measurement of ocular dimensions

Principal methods of measurement retina gives rise to the sensation of a luminous ring. As
the beam is moved closer to the posterior pole, the diam-
eter of the ring decreases. When it finally disappears, or
General considerations
only a very small disc is seen, the distance of the beam
The ocular dimensions considered in this chapter are from the plane of the corneal vertex gives the eye's
those affecting the eye’s optical system. Various tech- axial length.
niques of measurement have been applied to them. An ingenious use of X-ray methods to determine the
Although research is one motive, there are also clinical equivalent power of the eye was later devised by Gold-
reasons for making certain measurements. For example, mann and Hagen (1942). It is particularly simple when
the change in corneal thickness may need to be moni- applied to emmetropic eyes. Two very narrow X-ray
tored in contact lens practice. The depth of the anterior beams separated by 5.2 mm were directed into the eye
chamber is significant in potential closed-angle glau- from below at an angle of about 15° from the horizontal.
coma and the axial length of the eye is an invaluable To the subject they gave the impression of two luminous
guide in the fitting of intra-ocular lenses. Certain simpli- vertical lines which could be brought into apparent co-
fications may need to be made, as in the construction of incidence with two movable line markers when pro-
schematic eyes. Most dimensions can nevertheless be de- jected on to a screen or wall at a known distance. The
termined to a satisfactory standard of accuracy. separation between the markers was then measured. In
emmetropia, the distance from the second nodal point
to the retina (the reciprocal of the eye’s equivalent
Optical methods
power) could then be determined without significant
Optical methods utilize the image-forming properties of error from the known dimensions. Goldmann and
the eye and its Purkinje images. One complication Hagen extended the same technique to ametropic eyes,
arises from the fact that a direct view of the eye’s in- the subject wearing a spectacle correction. [t was then
ternal refracting surfaces cannot be obtained. What is necessary to determine the axial length of the eye, for
seen or photographed is the image of the particular feat- which purpose Rushton’s method was used. From the
ure formed by all the eye’s refracting surfaces lying in data then available it was possible to calculate not only
front of it. An error in the determination of one dimen- the equivalent power of the eye but also that of the crys-
sion, especially of the anterior corneal radius of curva- talline lens.
ture, may thus have repercussions when this quantity
is used in the calculation of other dimensions. For sim-
plicity, the eye is generally treated as a chosen three-
surface schematic eye, such as the Bennett—Rabbetts Ultrasonography
model. Ultrasonography is a technique of spatial location or
probing, particularly suited to the determination of
X-ray methods axial dimensions of the eye. It is based on measuring
the ‘elapsed’ or total time taken by an ultrasonic wave
X-ray methods are now in disfavour for safety reasons. reflected from a boundary surface or obstruction to
Before this hazard was realized, they were successfully return to its point of origin. In ophthalmic applications,
used in a number of investigations. They depend on the the wave frequencies commonly used are 10—20 MHz,
fact that X-rays can penetrate the eye and surrounding well above the range of human audibility.
structures without being deflected and can stimulate The choice of frequency is governed by conflicting
the retina in its dark-adapted state. In 1938, Rushton considerations. A higher frequency has better resolution
described an apparatus he had devised for measuring and will reveal thinner tissues than a lower one. For ex-
the axial length of the eye. A narrow X-ray beam, in a ample, 20 MHz detects the posterior surface of the
plane perpendicular to the optical axis, is passed cornea, which 10 MHz fails to do. On the other hand,
through the eye from the temporal side, a short distance lower frequencies have more penetration and depict the
in front of its posterior pole. Its intersection with the vitreous/retina boundary more strongly.
 Principal methods of measurement 379

Figure 20.1. An ultrasonic A-scan of an eye with advanced cataract. The transducer was dipped into a saline column held above
the eye with a contact lens. Echoes beyond those of the transducer (far left) and bubbles in the saline are: 1 cornea, 2 anterior lens, 3a]
posterior lens and 4 retina. Some extra echoes caused by the cataract are seen between the principal lens echoes 2 and 3.
(Reproduced by kind permission of the late Dr J.K. Storey, 1981.)

The ultrasonic waves are generated by a small trans- (5.0/2) x 107° x 1532 x 10? = 3.8 mm
ducer, which is activated by voltage pulses. The reflected
Accuracy in determining time intervals can be improved
waves are then amplified and rectified, the negative
in various ways described in the literature. The most sa-
phases of the waveform being either suppressed or inte-
tisfactory is probably the use of an electronic interval
grated with the positive by reversing their polarity. The
counter.
resulting signal drives an oscilloscope display.
Comparison of optical and ultrasonography measure-
Ultrasonography can be performed in various ways.
ments of the thickness of the crystalline lens led Koretz
In the A-mode (time-amplitude), the direction of the ul-
et al. (1989a,b) to suggest that the velocity of ultra-
trasonic beam is fixed. For measuring axial distances it
sound in the lens was approximately linearly dependent
would be aligned with the subject's visual axis. The os-
on age and was given by the expression:
cilloscope display (with a 10 MHz frequency) then takes
the form shown in the photograph in Figure 20.1. It is velocity (m/s) = 1733 — 2.830. age (years)
virtually a graph in which the amplitude of the reflected
wave is plotted against elapsed time. The graduated Current clinical instruments are stated to be accurate
scale shows time intervals in microseconds (1s). From within +0.1 mm to +0.2 mm in the measurement of
left to right, the four numbered wave disturbances indi- axial length, leading to possible errors up to 0.25 D and
cate the anterior cornea, the outer surfaces of the crys- 0.50D respectively in the calculation of refractive
talline lens and the retina. Measurement should be errors.
taken from the beginning of each wave-form. In the If the transducer is placed close to the eye, various dis-
photograph, the time interval between the cornea and turbing effects are produced. They can largely be ob-
anterior lens surface is approximately 5.0 pts, but this viated if the beam is first made to traverse a column or
has to be divided by 2 because elapsed time includes tube of water held in contact with the cornea. Origin-
the outward as well as the return travel. To convert ally, this meant that the patient had to be supine,
time differences into distances requires a knowledge of which is undesirable because the crystalline lens may
the velocity of the ultrasonic waves in the medium in then be axially displaced by gravity. A number of differ-
which they are travelling. These velocities are sensitive ent ‘stand-off’ devices have since been designed. They
to temperature changes. The following values at 37 C not only allow the patient to be seated but also incorpo-
are accepted generally: rate a means of controlling the fixation so that the
beam can be accurately aligned.
The B-mode (intensity modulation) of ultrasonogra-
Medium Velocity (m/s) phy is extensively used in the wide field of medicine for
diagnostic and other purposes. It is capable of making a
Cornea 11 sy510)
two-dimensional survey of soft tissue by scanning. The
Humours 532
echo signals are processed in the same way as for the
Crystalline lens 1641
A-mode but the regulation of the oscilloscope display is
different. In each direction of scan, any echo modulates
Thus, from the photograph, the depth of the anterior the oscilloscope’s electron beam so as to produce a spot
chamber is approximately proportional in intensity to the amplitude of the echo. If
380 Measurement of ocular dimensions

Figure 20.3. The principle of keratometry: formation by the

cornea of a virtual image U'V’ at a predetermined distance d
from the object UV.
Figure 20.2. An ultrasonic B-scan of an eye. (Reproduced
from part of a photograph by Dr G. Baum, 1965.)
an aid to refraction, especially of the astigmatic eye.
For this purpose, an additional calibration in terms of
no echo is received, the electron beam is suppressed. In corneal power was of greater utility. The instrument's
effect, the display shown in Figure 20.1 would be re- main use now is in contact lens practice.
duced to four spots, on a dark ground, denoting the pos- Keratometers utilize the reflected image (Purkinje I)
itions of the corneal vertex, the poles of the crystalline formed by the anterior corneal surface.+ As long ago as
lens and the retina. 1619, Scheiner had suggested a method of estimating
As the direction of scan is varied by moving or rotat- the corneal radius from a set of glass spheres of known
ing the transducer, the new intersections of the ultraso- size. The examiner merely found which of them gave a
nic beam with the boundary surfaces are similarly reflected image of the same size as Purkinje I when held
plotted, rather as in a radar display. A complete cross- beside the subject’s eye. A facing window was the test
sectional view of the eye in the meridian scanned is object. Whether Scheiner, a notable experimenter, him-
thus built up (Figure 20.2). It bears a striking resem- self used this technique is not stated. Subsequent pro-
blance to the familiar diagram of the schematic eye. Un- gress, briefly reviewed by Stone (1975), has substituted
fortunately, it cannot be taken in its entirety as a true accurate measurement for visual comparison.
geometrical plan; in any direction of scan, the separa- In Figure 20.3, U and V represent the ends of an ex-
tion between surfaces represents time intervals, not dis- tended object, of height h, whose images U’ and V’ lie
tances. Because of the higher velocity of ultrasonic just short of the focus for reflection F of the cornea. In
waves in the crystalline lens, the origins of echo waves the standard paraxial expression for refraction,
passing through it are displaced forwards from their
i ee ‘
true positions.
There is now an extensive literature on ocular ultra- eis, aoe a
sonography and its biometric applications. For further n’ may be replaced by —n to obtain the following expres-
information, reference should be made to one of the spe- sion for reflection:
cialized texts, such as the work by Coleman et al. (1977).
: + ae AO), 11
aa ale ka0e)
The magnification m for reflection is given by
Corneal radii and power
m=h'/h=-—¢'/¢ (20.2)
Basic principle of the keratometer
On multiplying equation (20.1) throughout by / and
Instruments designed to measure corneal radii or curva- using equation (20.2), we get
ture are becoming generally known as keratometers.’ f= (m-—1)r/2m
An older term, ‘ophthalmometer’, is less suitable be-
cause it has a wider connotation, though it has been Similarly, on multiplying equation (20.1) throughout
adopted in the International Standard, [ISO 10343. by 7’, we get
The keratometer was first used, in the 1840s, as,a la- / )
f= (l—m)r/ 2 = (min rin
boratory instrument for acquiring data on corneal cur-
vature. Suitably adapted, it was then extensively used The positive distance d from object to image is therefore
in the late nineteenth and early twentieth century as
d= =24 7 =(1— m?)r/2m

This name has also been given to a much simpler device

(the Wessely keratometer), designed mainly for measuring ver- + Strictly, the pre-corneal tears film, assumed to be of negligi-
tex distances and visible iris diameters. ble thickness.
 Corneal radii and power 381

(a)

Figure 20.4. (a) Formation of the aerial image within the keratometer. (b) Effects of focusing error.

which gives - To prevent misunderstanding, the meridian along

2dm which the radius is measured should not be recorded as
r=—_> (2053) an ‘axis’, since the axis of an astigmatic lens is at right-
1 —m-
angles to the meridian.
= 2dm ~ 2dh'/h (20.3a) The same notation should also be used to record cor-
since m is small (0.03 to 0.04) and m? very small. neal powers. For example, assuming the calibration
The position of the image U’V’ within the cornea pre- index to be 1.332, the above would become (after
vents its direct measurement by superimposing a scale. rounding off)
Consequently, the keratometer incorporates a long-
focus microscope (or short-focus telescope) whose objec- +42.50 along 15/+43.37 along 105
tive O forms a second image in a plane accessible for
measurement. The principle of the arrangement is illu- The corneal power could thus be considered to incorpo-
strated in Figure 20.4(a). To ensure that the magnifica- rate a +0.87 D cylinder at axis 15, but in terms of the
tion q'/q of the objective remains constant, a fixed correction needed the corneal astigmatism is —O.87 DC
graticule (reticle) G is placed in the predetermined axis 15.
image plane at a distance gq’ from the second principal The effect of a focusing error is shown in Figure
point P’. The conjugate object distance q from the first 20.4(b). The eyepiece has not been adjusted and is in
principal point P is thereby also fixed. In use, the kerat- focus (for the user) for a plane behind the graticule. To
ometer is moved bodily along the subject's visual axis see the mire images clearly, the user is obliged to move
until the second image U5V4 is seen in sharp focus on the instrument closer to the patient's eye. This has two
the graticule. Since the test object UV is fixed to the in- consequences. First, the mires (a special pattern repre-
strument and moves with it, the distance d attains its senting the test object) subtend a larger angle at C, the
predetermined value simultaneously with q and q’. To corneal centre of curvature, so that the image height
bring the graticule crossline or other markings into h, is increased. Secondly, the magnification by the ob-
sharp focus for the observer, the eyepiece E (of high jective is increased because the object distance q is
power and small depth of field) can be adjusted indepen- shorter and the image distance q’ longer. Thus, both
dently. This adjustment must always be checked before errors increase the image height hy and the radius of
the instrument is used. curvature recorded is too large.
The radii of curvature of an astigmatic cornea should A somewhat similar expedient may rarely be em-
be recorded as in the example ployed to extend the range of an instrument. If a lens of
about +1.25 D is placed in front of the objective, then
7.80 along 15/7.65 along 105 the instrument will have to be brought closer to the
cornea, thus enlarging the image, and hence extending
or
the range to smaller radii. Conversely, a negative pow-
7.80 mer (or m) 15/7.65 mer (or m) 105 ered lens will extend the range towards flatter radii.
382 Measurement ofocular dimensions

Calibration graphs would need to be drawn from meas-

urements of test spheres with the lens in place.

The doubling principle

Because of the patient's involuntary eye movements, the
image height cannot be read off against a scale on the
eyepiece graticule. Instead, the image size is measured
by the lateral displacement of a doubled image. The
principle of doubling and one practical method of pro- Figure 20.6. The position of the images U’ and V’ when the
mires U and V are reflected by an astigmatic cornea. U” is the
ducing it are both illustrated in Figure 20.5. A plano
doubled image formed by the keratometer.
prism placed over one half of the objective can be
moved along the optical axis. Rays passing through the
prism are deviated by an amount proportional to the dis- The extended test object is often represented only by -
tance of the prism from the image. For simplicity, the its extremities U and V in the form of special patterns
diagrams show only the pencil initially directed towards called ‘mires’ (from the French, in which mire denotes a
the extremity V3 of the image. The deviated portion of sighting mark). In one design, U is a fine cross and V a
it forms the doubled image point. In Figure 20.5(a) the hollow cross into which the fine cross would be seen to
image displacement 6 of that part of the pencil inter- fit symmetrically when the instrument was correctly ad-
cepted by the prism is greater than the image size. justed. The doubling is effected in a direction parallel to
There is hence a separation between the doubled the meridians containing U and V. For brevity, this
images. In Figure 20.5(c), the prism is much closer to meridian will be referred to as the measuring line.
the image. The displacement is smaller than the image Figure 20.6 shows the relative positions of U and V
size and so the doubled images overlap. At a certain in- and of their reflected images U’ and V’ when the
termediate position shown in Figure 20.5(b), the dis- measuring line is horizontal but the cornea is astigmatic
placement is exactly equal to the image size, so that the with its principal meridians at 30° and 120°. For the
doubled images are just in contact. In various forms, purpose of this scale drawing, the magnifications of the
this is the criterion used in keratometry for determining cornea for reflection were taken as 0.5 along 30° and
image size. It is not affected by eye movements because 0.4 along 120°, both values considerably larger and
both images move together. with a greater proportional difference than in reality.
Mandell (1960) brought to light the fact that Jesse Referred to the astigmatic axes, the co-ordinates of the
Ramsden, the English optician and instrument maker, centre of the single cross are SU and TU, while those of
constructed the first keratometer with a doubling its image are S'U’ and T’U’ such that
device. It was described in 1796.
Keratometry of the astigmatic cornea not only re- SU’ =05 StandUW =047U
quires measurement of the differing radii of curvature The position of U’ is thereby determined, and the same
in its two principal meridians, but also a prior means of process was used to locate the extremities of the cross-
locating them. The instrument must therefore be rotata- line image. The image of the hollow cross is formed in
ble about its optical axis. To locate the eye’s astigmatic the symmetrically equivalent position as shown.
meridians, advantage is taken of the ‘scissors’ distortion Two points of note arise. First, the images U’ and V’
arising on reflection from an astigmatic surface as well are on opposite sides of the measuring line. Conse-
as on refraction by it. This has already been discussed quently, the doubled image of U’ will appear in the pos-
on pages 234-236. ition indicated by the dashed cross U", out of register
with the image of the hollow cross. Secondly, both
V'2 images exhibit some degree of scissors distortion. The
first effect is the more marked of the two and immedi-
6 ately indicates that the astigmatic meridians of the eye
are oblique to the measuring line. The latter is then ro-
(a) tated, in this example to the 30° meridian. Both mire
V'9 images then fall on the measuring line and are also free
6
from scissors distortion. Adjustment of the doubling
will bring them into correct register.
(b) In some instruments, the mire consists of a complete
circle surrounding the telescope housing, with external
V'3 coincidence marks in the form of plus and minus signs
i as shown later in Figure 20.11. With an astigmatic
cornea, the circle is imaged as an ellipse with its major
(c) axis parallel to the principal corneal meridian of longer
radius. This is not always readily detectable, but the
Figure 20.5. The doubling principle using a prism travelling
along the axis. V5 is the upper extremity of the image V5U5 in scissors distortion and displacement of the plus signs in
Figure 20.4. Note: in this and subsequent figures up to 20.11 off-axis settings operate essentially as shown in Figure
the ray path through the instrument is from left to right. 20.6.
 Corneal radii and power 383

Table 20.1 Classification of typical keratometers

Characteristics Variable mire separation Fixed mire separation

Doubling Fixed Variable

| a |
Position Two Two One

Objective aperture Pull

i Divided
|
Divided
|
Typical instrument Javal-Schiétz Zeiss Rodenstock Zeiss Bausch & Lomb
Ophthalmometer CHANG

G, H Gambs Zeiss
keratometer

Doubling arrangement Wollaston prism beam splitter and Helmholtz Risley Axially travelling
(bi-prism) transversely moving inclined prism? prisms
lenses plates

The height h of the image forfned on the eyepiece bling in one meridian only, requiring two separate set-
graticule is that of the Purkinje image h) multiplied by tings for astigmatic eyes, are known as ‘two-position’
the fixed magnification q'/q of the objective (Figure keratometers.
20.4). Doubling systems can be divided into two main Some doubling systems require the telescope objective
types: fixed and variable. In the fixed type, the height h to be divided into separate areas, each transmitting
of the test object or the distance between the mires is ad- only a portion of the incident reflected beam. In others,
justed to make h’, equal to the fixed amount of doubling. the doubling is effected with the aid of a full-aperture
In variable doubling systems, h is fixed and the corre- beam-splitting device. Table 20.1 classifies many of the
sponding image height h5 is determined by the amount current makes of keratometers according to the charac-
of doubling required. teristics of the doubling system used. We shall now look
It is possible to produce systems in which variable at six representative models in the following sections.
doubling can be effected simultaneously in two mutually
perpendicular meridians. When these have been rotated
into coincidence with the eye's astigmatic meridians, Some representative models
measurement of the two radii can be made in this one
The Javal-Schiotz keratometer
setting. Instruments using such systems are known as
‘one-position’ keratometers. The first (see Emsley, This instrument (Figure 20.7) has changed little in es-
1946) was designed by J.H. Sutcliffe, a former Secretary sentials since its introduction in 1880 and the design is
of the British Optical Association. Instruments with dou- still popular. The doubling is fixed and the separation of

(b) (c)

Figure 20.7. (a) Optical system of the Javal-Schiotz keratometer with fixed doubling. The variable separation of the mires alters
their angular subtense 0 at the corneal centre of curvature. (b) Pattern of the traditional mires, usually one green, one red. (c) The
simpler bi-prism doubling system.
384 Measurement of ocular dimensions

OK

Figure 20.8. The Zeiss (Oberkochen) Ophthalmometer

(Models G and H). (Illustration kindly supplied by Zeiss Ltd.)

the mires is varied by moving them symmetrically round The Zeiss (Oberkochen) ophthalmometers G
a circular path approximately concentric with the and H
cornea under test. A single control effects this move-
These instruments (Figure 20.8), like the similarly de-
ment. The fixed doubling is provided by a Wollaston
signed Gambs instrument, are no longer in production.
double-image prism.” It is mounted between the two
Their sophisticated optical design is free from the focus-
achromatic doublets comprising the telescope objective,
so that the light passing through it is collimated. If a ing errors discussed on page 381, and so is worth de-
parallel pencil of rays is incident on such a prism, it
scribing. The mires, which are of the pattern shown in
emerges as two separated parallel pencils at a small Figure 20.6, are separately imaged at infinity by colli-
fixed angle to each other. mating lenses mounted with a fixed angle between
The diagram shows the path of the chief ray of the their optical axes. By this means the size and separation
pencil from the inner side U of one mire. After refraction of the Purkinje images are unaffected by errors in the in-
by the second doublet of the objective, the two pencils tended working distance.
emerging from the prism are focused on the eyepiece The objective of the observation system comprises two
graticule to form the doubled images U’ and U”. Simi- achromatic lenses O, and O;. The first, acting as a colli-
larly, the inner extremity V of the other mire gives rise mating lens, is followed by a full-aperture beam-splitting
to the images V’ and V”. The separation of the mires prism which produces parallel intermediate optical
has to be adjusted so as to make U’ and V’ coincide. As axes. A weak lens of minus power (L,, L,) is placed on
shown in the diagram, it is too great. each of these axes in the plane containing the posterior
The traditional pattern of the mires is shown in Figure principal focus of the lens O; after passage of the light
20.7(b). One is usually red and the other green, any through the prism. Variable doubling is produced by a
overlap producing yellow. The steps on one of the mires lateral displacement of both lenses, in opposite direc-
give an approximate indication of corneal astigmatism. tions, from the zero position in which their optical cen-
If the mires are set in apposition for the flatter meridian, tres lie on the intermediate optical axes. The prismatic
an overlap of each step when the instrument has been effects thereby created give rise to a variable angle be-
rotated to measure the steeper meridian corresponds to tween the two emergent beams. These are then recom-
1 dioptre of astigmatism. bined by another beam-splitting prism so as to pass
When the measuring line is in an off-axis position through the second component O, of the objective to
with respect to the cornea, the black central line of one the fixed eyepiece OK.
mire image becomes out of alignment with its fellow on The magnification of the objective system is constant
the other mire. Scissors distortion of the mires may also by virtue of the fact that its two components O, and O,
be apparent. are separated by the sum of their focal lengths. It thus
Cheaper copies of this instrument utilize a bi-prism in- forms an afocal system. In all such systems, a parallel in-
stead of the Wollaston prism. As shown in Figure cident pencil emerges as a parallel pencil. The trans-
20.7(c), this would have its dividing line positioned on verse magnification h'/h for an object at any finite
the optical axis, orientated perpendicular to the plane distance is hence unchanged. Moreover, the afocal prop-
of the diagram. As this divides the objective aperture erty of the objective system is unaffected by the doubling
into two, errors caused by poor focusing are liable to be lenses L; and L, because they are situated at the
worse with this design than the original. common focal plane of O; and QO.
Thanks to these main features ofthe design, the kerat-
ometer can be used both by emmetropes and ametropes
“A detailed description of this device, which depends on the
without eyepiece adjustment. If the instrument itself is
bi-refringence of quartz, can be found in most textbooks on not correctly focused, some blurring may result but the
optics. readings will not be affected.
 Corneal radii and power 385
2

Figure 20.9. Optical system of the Rodenstock

keratometer C-MES. The astigmatism compensator is not
illustrated. (Redrawn from an illustration kindly supplied by
G. Rodenstock Instrumente GmbH.)

The Rodenstock keratometers CES and C-MES mated mires to help avoid errors caused by poor focus-
ing. The doubling system is placed in the second focal
These are two-position variable-doubling instruments
plane of the first objective, O;, and hence is imaged at
(Figure 20.9) in which the doubling is effected by tilted
infinity behind the patient's eye, also contributing to
plates, a method first used by Helmholtz in 1854. They
the error-free design. The doubling is probably produced
operate in a similar manner to those in the pachometer
by Risley prisms D (see Figure 11.20 and Figure
(see pages 309-310), the image displacement being de-
20.11b), with an outer annulus providing prismatic
pendent on their obliquity. The central plate P, tilts in
effect in one direction, and the central zone in the oppo-
one direction and the outer one P, in the opposite direc-
site. Filters R provide a red beam, possibly to reduce
tion. Unless it is in accurate focus, the image formed by
chromatic aberration from the prisms. The iris dia-
rays passing through the top and bottom sections of
phragm A can be used to occlude the outer annulus,
this plate will be doubled because the twin apertures
thus giving a single image for use with an accessory for
act like a Scheiner disc. This out-of-focus doubling
measuring contact lens diameters. By employing the
must not be confused with the measuring doubling.
ends instead of the centre of the specially designed
In the current C-MES instrument, focusing errors are
mires, measurement of soft lenses in a saline bath may
eliminated by a secondary objective system SO mounted
be made without needing to convert the scale readings.
in front of the Helmholtz plates to form a real image P’,
Because the surface reflectance is low, this measure-
behind the patient’s head, of the telescope entrance
ment requires a lot of light. The lamps of the mire
pupil P. If the instrument is moved too close to the eye
system are therefore focused by condenser lenses C and
under test, the mires subtend too large an angle. This is
projector lenses P on to the cornea. The instrument can
compensated by the greater distance of the Purkinje
measure over the radius range from 4.0 to 13.0 mm.
image from the effective entrance pupil P’. Because the
Helmholtz plates effect a lateral and not an angular dis-
placement, the doubling produced is not affected by The Bausch and Lomb keratometer
changes in the object distance. An astigmatism compen-
The Bausch and Lomb keratometer, introduced in 1932,
sator, adjusted to the corneal radius, neutralizes the
is the typical one-position instrument in current use
astigmatism generated by the oblique path of the diver-
(Figure 20.12a). It has been extensively copied in
ging beams through the plates.
recent years.
A lamp bulb illuminates the circular mire M by means
The Zeiss keratometer attachment of the concave reflector A, inclined mirror BB and annu-
lar condenser C. This latter does not impinge on the re-
This instrument (Figure 20.10) was designed as an at- flected beam used for observation. A mask S behind the
tachment for certain of the same firm’s slit lamps, but is objective system O reduces it into four separated circular
no longer in production. It replaced the first or colli- areas as shown in Figure 20.12(b). Behind apertures 1
mating objective of the microscope (see Figure 16.4). and 2 respectively are a horizontal and a vertical achro-
Collimated mires are used, as in the Zeiss ophthalm- matic prism, producing independent variable doubling
ometer already described, but the doubling is effected by movement parallel to the optical axis as in Figure
by Helmholtz tilting plates. The combination eliminates 20.5. To equalize the optical path lengths, parallel
focusing errors from this instrument also, since the plates of glass are mounted immediately behind aper-
tilting plates give the same sideways displacement irre- tures 3 and 4, which are used to form an undeviated
spective of small changes in object distance. The images image. Three images of the mire are thus seen in the
are viewed by the left eye, and the scale (not shown) by eyepiece, a central one and two others doubled in mu-
the right eye, the remaining part of the microscope tually perpendicular directions, as shown in Figure
system being used for this purpose. 20.12(c). Unless in correct focus, the central image will
itself appear slightly doubled because of the Scheiner
disc effect of apertures 3 and 4, which should not be
The Zeiss CL110 ophthalmometer
confused with measuring doubling.
This currently available instrument (Figure 20.11), like The plus and minus signs forming part of the mire
the Zeiss ophthalmometer already described, uses colli- pattern are used as fiducial marks. In any off-axis setting
 386 Measurement of ocular dimensions

cP
©: s
ee L
wy M
ZA
ye

</

SS
H

co
SS
Ss D

SS
ja O

E S
Figure 20.10. The Zeiss keratometer attachment. S lamp, L condenser lens, M mire, CP collimating projector lens, H Helmholtz
tilting plate, CO collimating objective, D dividing line between the keratometer attachment and the Gallilean turret and remainder of
the slit lamp microscope. (Redrawn from an illustration kindly supplied by Zeiss Ltd.)

Cornea

Lamp (a)
Figure 20.11. The Zeiss CL110 ophthalmometer. Key: mire projection system: R red filter, C condenser,
M mire, P projection lens.
Observation system: O,, O> objective, F fixation stimulus, D doubling device, A aperture
stop, G graticule for centration, E eyepiece.
Inset (a) plan view and vertical cross-section of one element of the assumed variable
prism doubling device. (Redrawn from an
illustration kindly supplied by Zeiss Ltd.)

(a) (b) (c)

Figure 20.12. (a) The Bausch and Lomb keratometer. The dotted rectangle and
prism in the main figure are the doubling prisms,
positioned in front of and behind the plane of the diagram. The plane
parall el compensating plates behind apertures 3 and
shown behind plate S. (b) Subdivided areas of the objective. (c) Appear 4 are
ance in the eyepiece when correctly focused, but with
much doubling in both meridians. too
 Corneal radii and power 387

of the measuring directions relative to the astigmatic cornea is approximately 4mm, an effective aperture of
meridians of the cornea, the radial limbs of the two adja- 2mm is large enough for spherical aberration to
cent plus signs will be out of register for the reason illu- become significant. As a result, equation (20.3) derived
strated in Figure 20.6. When correct meridional from paraxial relationships cannot be used. In the
alignment has been established, the two radius settings design stage, calibration is presumably by exact ray tra-
can be made in sequence by adjusting the doubling so cing, subsequently checked with precision steel or glass
as to bring adjacent plus and minus signs into exact co- balls. Instruments in clinical use should periodically be
incidence. checked with a precision spherical surface, both for ac-
A small mirror D mounted centrally between the ob- curacy of radius and absence of skew or astigmatic mis-
jective lenses provides a fixation point for the patient, alignment.
who sees a reflection of his own eye. Though theoreti-
cally superior to a fixation light since it ensures that
the patient's eye is positioned on or very close to the in-
Corneal power calibration
strument axis, this system is unsatisfactory if the patient If the refractive index of the cornea is taken as 1.376,
has more than a small refractive error. division of the anterior radius of curvature into 376
A ring-type mire as in the Amoils Astigmometer may will give the dioptric power of its front surface. To find
also be used during cataract surgery to minimize in- the equivalent power of the cornea as a whole would re-
duced corneal astigmatism. quire a knowledge of its posterior radius of curvature
and axial thickness.
Many keratometers, however, have a useful second
A Drysdale-type keratometer ;
calibration giving an approximate value of the corneal
An accurate method of measuring short radii of curva- power. In Gullstrand’s No.l schematic eye, the equiva-
ture of optical surfaces is known after its originator as lent power is +43.05 D and the anterior radius of curva-
Drysdale’s principle. It is used in the radiuscope or op- ture 7.7mm. A single-surface cornea of this radius
tical microspherometer, an instrument described in would have an equivalent power of +43.05 D if the re-
many textbooks on contact lenses. In brief, light from fractive index of the aqueous humour were 1.3315.
an illuminated object is reflected by a semi-silvered Moreover, the same figure would be obtained for other
mirror behind the objective of a microscope to form an corneal dimensions, provided that the anterior and pos-
aerial image at the focus of the objective. When the terior radii were in the same proportion as in the Gull-
focus is placed at the centre of curvature of the surface, strand eye, namely 7.7—-6.8. The rear surface would
the rays forming the image are normal to the surface then neutralize the same proportion of front-surface
and will thus be reflected back along their own paths. If power in each case. This is the basis on which Olsen
the microscope is then moved away from the surface (as- (1987) advocated 1.3315 as the notional index for
suming it to be convex), the convergent beam as a power calibration. There is, however, a scarcity of data
whole will be reflected back along its path when the on posterior corneal radii which leaves the question in
focus is positioned at the surface with normal incidence. some uncertainty.
The object's reflection will therefore be seen in sharp The calibration index adopted by current manufac-
focus through the microscope in these two settings, the turers varies from 1.332 (Zeiss) to 1.3375 (Haag-—Streit
distance travelled between them being the radius of cur- and many others). This latter value, first chosen by
vature. Javal and Schi6dtz, was probably influenced by the fact
Applied to a keratometer, this arrangement would that 7.5 mm corresponds exactly to 45 D. Interestingly,
have the disadvantage that the subject's head could this same index is also obtained if the back vertex
move between settings. It has been overcome in a kerat- power of the Gullstrand cornea in situ is to be given by
ometer designed by Douthwaite (1987). Simultaneous a surface of radius 7.7 mm. Intermediate values for the
observation of both settings is achieved by placing a cy- calibration index include 1.336 (American Optical).
lindrical lens, or a Stokes lens, behind the microscope The writers consider this to be the best choice because
objective which converges the incident beam. Two sepa- it is the accepted value for the refractive index of the
rated astigmatic line images are thus created. When aqueous humour, and of tears, thus simplifying many
the instrument has been moved so as to place the more contact lens calculations.
remote image at the centre of curvature of the cornea, For average radii and small amounts of astigmatism, a
the other is then placed at the surface by axially useful rule of thumb is that a radius difference of
moving the cylindrical lens or adjusting the Stokes 0.2 mm indicates approximately | D of corneal astigma-
lens. Experimental trials have given promising results. tism. This rule may also be used to estimate the power
Since only a small circular area of the cornea is cov- of the tear lens trapped between a rigid contact lens
ered in any one measurement, this instrument could and the cornea, and for the power change required on
readily be adapted for use in topographical keratometry. such a lens if the Back Optic Zone Radius (base curve)
is altered.
The approximate calibration formula

Calibration of keratometers r= 2dh'/h

In the keratometer, the image-forming rays are reflected suggests that for a variable doubling instrument, where
from the cornea at a height of at least 1 mm from its h is fixed and h’ measured, the radius scale is linear. In
vertex. Since the catoptric focal length of the typical fact, although precise calibration results in a different
388 Measurement of ocwar dimensions

relationship, it is still a linear one (Bennett, 1966). Con- given for convex surfaces apply equally to concave sur-
versely, in an instrument with fixed doubling and h vari- faces. In other designs, an adjustment has to be made.
able, the power scale is uniform because curvature Tables published for the Bausch and Lomb keratometer
R(1/r) is proportional to h. show that the radius recorded for a concave surface
has to be increased by an allowance ranging from
0.02 mm on the shortest radii to 0.05 mm on the long-
Separation of measurement areas est. For other instruments, a calibration graph could be
plotted by measuring a number of contact lenseswhose
In Figure 20.4, the chief ray leaving the upper mire U is
radii have previously been determined with a radiu-
shown being reflected off the cornea at a height slightly
smaller than the height of the image U’. The approxi-
scope. Quesnel and Simonet (1994) similarly recom-
mate calibration formula shows that the image height mend that for soft lens verification a calibration graph
h' is proportional to the corneal radius. For variable be drawn from PMMA lenses measured in saline. This
doubling instruments, the two small zones utilized for overcomes the re-calibration for both the index of the
measurement are therefore separated by a variable dis- saline and the measurement of the concave surface.
tance, approximately proportional to the radius. For a
The Zeiss CL110 ophthalmometer incorporates special
typical instrument, these areas may be separated by mires enabling the normal scale reading to be employed
about 2.4mm for a radius of 6.0mm, increasing to for soft lens verification.
2.9mm at 7.5 mm and 3.4 mm at 9.0 mm. Some instru- As pointed out by Stone (1962), the practice of speci-
ments, however, measure across a smaller chord, for ex- fying contact lens radii in terms of surface power based
ample the Gambs instrument utilizes around 2.2 mm at on a notional keratometer index is inadvisable because
7.5mm, while the Bausch and Lomb keratometer spans it wrongly assumes all keratometers to be calibrated for
almost 3.2 mm (Lehmann, 1967; Stone, 1994). Thus, the same refractive index. For example, a +42 D power
apart from calibration errors, use of different instru- corresponds to a radius of 7.90 mm if the index used is
ments may result in slightly different readings for an as- 1.332, but 8.04 if the index is 1.3375.
pheric surface. It must be emphasized that the
keratometer does not measure the very centre of the Errors in keratometry
cornea, but samples from zones just peripheral to the
apex. The accuracy of keratometry depends largely on the
For a fixed doubling system, the mire separation h is care with which the instrument to cornea distance is ad-
adjusted to give a constant image height. There is thus justed. This, in turn, requires accurate focusing of the
only a very small variation in the separation of the re- eyepiece upon its graticule. To provide a diffusely illumi-
flection areas for the Haag—Streit instrument with in- nated background for this operation, the patient could
creasing radius. Lehmann found a separation of around be asked to close his eyes. The eyepiece is then screwed
3.5mm at 7.0 mm, decreasing to 3.3 mm at 9.0 mm. outwards to its most hypermetropic setting and then
moved slowly inwards until the graticule markings just
become clear. When the patient opens his eyes, the
Measurement of contact lens radii
mire images should be brought into the centre of the
The keratometer can be used to measure the radii of cur- field of view and the whole instrument moved back and
vature of contact lens surfaces. Normally, it is only the forth to obtain the best focus.
concave surface which requires to be checked because Despite the provision of external sights to align the in-
it affects the fit and also the power of the liquid lens strument with the patient’s eye, this is not always easy
formed between the contact lens and the eye. To dull because of the small field of view. Stone (1975) sug-
the unwanted reflection from the convex surface, the gested shining a torch down the instrument from
lens is placed on a drop of water, with the light from behind the eyepiece, so that a patch of light falls on the
the mires reflected downwards by a front-surface silv- patient’s face. The instrument is then moved to bring
ered or similar mirror. The lens mount and mirror are the light patch on to the eye.
attached to the instrument's headrest. While it is often stated that the conventional kerat-
To measure a soft lens, one method is to place it con- ometer measures the central corneal radius, the instru-
cave-side down in a cell filled with a saline solution and ment utilizes pencils reflected from small areas each
mounted on top of a 45° prism which reflects the light situated not less than 1 mm and up to about 1.7 mm
upwards. Because of the small difference in refractive from the centre. Because of the peripheral flattening it
index between the lens material and the solution, little is probable that the keratometer readings are slightly
light is reflected from the lens surfaces, so that a kerat- longer than the vertex radius. It is difficult to generalize,
ometer with a bright source is needed. Moreover, since but the error would probably not exceed 0.05 mm on a
light is reflected from both surfaces ofthe lens, relatively normal eye.
fine mires are necessary to allow the two sets of reflec- Those instruments with doubling systems based on
tions to be distinguished. On a minus lens, the back sur- isolated areas of the objective aperture have an exit
face is the steeper one and will produce the smaller pupil of corresponding formation of possibly 3 mm over-
image. The indicated radius of curvature has to be mul- all diameter. Marked spherical aberration or irregular
tiplied by the refractive index n of the saline, which re- refraction of the examiner’s eye will upset the apparent
duces the true radius r to its ‘equivalent mirror’ value instrument focus, especially if the head is moved. In
r/n (see Exercise 20.12). one-position instruments, uncorrected astigmatism of
If the mires are collimated, the keratometer readings the observer's eye may similarly affect the focus.
 Corneal radii and power 389

While a local distortion of the cornea in the region of able doubling keratometer in which the mires subtend
the reflection area or areas will cause a corresponding a constant angle at the cornea.
distortion of the mire, it can also render uncertain the Figure 20.13 shows a simplified scheme of ray paths
focusing of those instruments with Scheiner disc dou- in one of the three beams. The source S is a light-emit-
bling. The mire can then appear clear but double, or ting diode (LED) focused by condenser L to form an
single but blurred; or, if of circular form, part may be image S’ on the instrument's axis. This image, in turn,
single and part doubled. Since the keratometry image is acts as an object for projector lens P which forms a
formed by reflection from the tear layer, variations in second image S” behind the patient’s eye. One ray RH
this may affect both the quality of the image and its of the reflected beam — not necessarily the central one
size. Relative movement between the two mire images through L — passes into the detector D at the predeter-
immediately after a blink is a frequent occurrence while mined angle.
the tear layer stabilizes. If the patient is requested to The precise location of the reflection point R on the
blink, then to stare and refrain from blinking, the dura- cornea is determined by the position of the rotating
tion after the blink until the mire image distorts is an in- chopper C which sweeps across all three beams and is
dicator of tear quality — one of several techniques to imaged in the plane of the cornea by projector lens P.
evaluate the non-invasive tear break-up time (NIBUT). Since the image S” lies on the axis at a known position,
Cronje-Dunn and Harris (1996) found that artificial the angle at which the incident ray GR meets the
tears on a plastics artificial cornea increased the var- cornea can also be determined. From the information
iance of keratometry readings considerably. Being vis- provided by all three beams, the principal radii and
cous, they are, however, unlikely’ to wet the plastic meridians of the cornea on the visual axis can then be
corneas as uniformly as natural tears do the real eye. calculated by the internal computer.
Charman (1972) investigated the limits set by diffrac- At the start, the patient fixates a central red LED while
tion on the precision of radiuscopes and keratometers, the instrument is aligned approximately by the operator
other sources of error being excluded. He found that for and accurately by its own monitoring and servo-sys-
typical keratometers the limit on reproducibility could tems. The two beams in the same horizontal plane are
not be lower than about 0.2 D, corresponding to a then positioned on each side of the visual axis, with the
spread of about +0.04 mm on average radii, though third beam below it. In general, skew reflections occur
scale graduations finer than this are frequently pro- unless the corneal astigmatic meridians are exactly
vided. ‘ horizontal and vertical.
From a review of experimental findings, Clark Peripheral readings are then taken with the subject's
(1973a) suggested an average figure of 0.015 mm for fixation directed in turn at 13.5° to either side of the
the standard deviation of a series of radius readings. central fixation mark. Their purpose is to provide the ad-
Since 95% of a normal distribution probably lies within ditional data needed to determine the quasi-ellipsoidal
two standard deviations from the mean value, Clark’s surface giving the best fit to the cornea. The parameter
estimate is in reasonable agreement with Charman’s e” defining the ‘shape’ of this hypothetical surface in its
findings. horizontal meridian is included in the print-out, to-
gether with the estimated position of its apex relative to
the visual axis. The calculated principal radii and merid-
The Humphrey Auto-keratometer
ians at the apex of this surface are also recorded in addi-
This is an automated instrument of an entirely new and tion to those measured on the visual axis of the true
sophisticated design, providing information beyond the cornea.
scope of the conventional keratometer. It measures cor- A more detailed account of this instrument is given by
neal curvature by projecting three beams of near infra- Rabbetts (1985).
red light on to the cornea in a triangular pattern
within an area about 3 mm in diameter. After reflection,
The Canon and Topcon Auto-keratometers
they are received by directional photo-sensors which ef-
fectively isolate rays making a predetermined angle Canon produce both a separate auto-keratometer, the K-
with the instrument's optical axis. In principle, l, and another, the RK-l| which is combined with an
although the ray paths are reversed, this recalls a vari- auto-refractor. Descriptions have been given by Port
(1985) and Stockwell (1986). An annular lens projects
collimated light from a ring mire on to the cornea. The
eye is viewed by means of an internal television system
which enables the reflected mire image to be focused
and centred within a ring displayed on the TV monitor.
The operator then triggers an electronic flash positioned
behind the ring mire. Another image of the mire reflec-
tion is projected on to a photo-detector system con-
sisting of five 72° sectors. From the light distribution on
each of these sectors the computer is able to calculate
Cc D the corneal radii. A central fixation light is normally
used, but for peripheral keratometry further lights are
Figure 20.13. Principle of the Humphrey Auto-keratometer.
provided to enable fixation to be displaced by 10° in
(Drawn from information kindly supplied by Humphrey
Instruments Inc.) any of the four cardinal directions. The diameter of the
390 Measurement of ocular dimensions

measuring zone was shown by Ehrlich and Tromans astigmatism. If the latter is represented by the power C
(1988) to be slightly larger than that of the Bausch and of the correcting cylinder in the spectacle plane, and
Lomb (manual) instrument. Other auto-keratometers the corneal astigmatism A by the keratometer reading,
are manufactured by Nidek and Topcon. The Topcon in- Javal’s rule (with all quantities in dioptres) can be ex-
strument employs an optical system similar to that in- pressed as
troduced by Mandell and St. Helen (1971). In this, the Cr A Ora 0) (20.4)
observation system is telecentric, a pinhole aperture in
the posterior focal plane of the objective restricting the The corneal astigmatism A is regarded as positive
rays reflected from the cornea to paths parallel to the in- when with the rule and negative when against. Expres-
strument’s axis. sions similar to Javal’s were arrived at by other re-
searchers. Javal emphasized that the coefficients in his
expression were approximations and that further terms
Multi-meridional keratometry
may need to be added in the light of advancing knowl-
If the misalignment of the mire images in the direction edge and improved methods of refraction, among which
perpendicular to the doubling system is ignored, kerato- he included retinoscopy. Though no longer of clinical
metry readings may be taken in meridians positioned be- use, Javal’s rule throws an interesting light on the
tween the principal astigmatic ones. If these readings sources of ocular astigmatism.
are plotted against keratometer orientation, they will
lie on or very close to a sin? @ curve, where 0 is the Cylinder effectivity
angle between the keratometer orientation and the
steeper principal meridian. Conversely, measurements Javal's rule raises the question of effectivity, the change
in three or more meridians enables the corneal curva- in vergence from the spectacle plane to the cornea or
ture to be calculated without initially determining the vice versa. Unless the mean spectacle refraction M
orientation of the principal meridians. This is similar to (sphere + half-cylinder) and the cylinder power C are
the determination of ocular refractive error from an both quite small, vergence changes become significantly
analysis of the refractive error measured in three ob- different in the two principal meridians. This is best
lique meridians — see pages 352-353. Royston et al. demonstrated by a numerical example. Suppose the
(1989b) and Rosenfield and Portillo (1996) have sug- spectacle correction is
gested this technique of keratometry may provide
+5.00/—2.00 x 90
acceptable results. It is possible that some of the auto-
mated keratometers employ this principle. at a vertex distance of 14 mm. The ocular refraction K
in the two principal meridians can be found as follows:

The keratometer and Vertical meridian

D mm
ocular astigmatism Fs +5.00 = He +200
—d —14
Keratometer readings of power and astigmatism assume
I +5.38 — +186
the anterior and posterior corneal radii to be in a fixed
ratio. If astigmatism is present, the principal meridians
Horizontal meridian
of the two surfaces are assumed to be in alignment,
D mm
with the fixed ratio in operation in both of them. With
Hes +3.00 ~ co +333.33
effectivity taken into account, the back surface will
—d —14
then neutralize just over one-ninth of the front-surface
K +3.13 — +319.33
astigmatism. Should these assumptions not hold good
for any given eye, the keratometer reading of astigma-
Ocular refraction: +5.38/—2.25 x 90
tism will become inaccurate as a measure of the total
corneal astigmatism. Such errors are seldom likely to be In this example, M is +4.00 D. For all positive values
significant. of M, the spectacle cylinder is smaller than the ocular
Non-corneal factors contributing to ocular astigma- astigmatism. The reverse applies when M has a negative
tism are the two surfaces of the crystalline lens and value.
astigmatism due to oblique incidence. This may be If the vertex distance is denoted by d and the ocular
caused by a tilt of the crystalline lens or of the cornea, astigmatism by Ast, use of equation (2.12) leads quickly
so that its apex is decentred with respect to the visual to the close approximation
axis. Nevertheless, since the cornea is the dominant ele-
Cx (1 — 2dM)Ast (20.5)
ment of the eye’s refracting system, a highly astigmatic
cornea is likely to result in a similarly astigmatic ocular
refraction. Crystalline lens
Javal’s rule implies that the eye’s total astigmatism in-
Javal’s rule
cludes a contribution of 0.50 D against the rule. unac-
During the period when the keratometer was used as an counted for by the keratometer reading. It could arise
aid to refraction, Javal (1890) formulated a tentative from a tilt of the crystalline lens about a vertical axis,
statistical relationship between corneal and ocular but Figure 12.3 shows that the tilt would need to be
 Corneal topography 391

about 14°, twice the amount of actual tilt regarded as of the order of 0.35 D between readings taken along the
normal (see page 209). visual axis and at the corneal apex. No directional pat-
From a limited number of measurements made by tern of displacement emerged. On this evidence, apical
Tscherning (1924), showing the posterior corneal decentration can be regarded as contributing a random
radius in the vertical meridian to be disproportionately element to the total ocular astigmatism. Mandell et al.
short, he tentatively suggested that this might be a con- (1995) examined 20 eyes with videokeratography (see
tributory element to the 0.5 D of astigmatism against page 394), to find that the corneal apex fell below the
the rule in Javal’s expression. visual axis in 18 eyes, with slightly more lying nasally
It is possible that marked corneal astigmatism is ac- than temporally, with a mean displacement of 0.82 mm
companied by astigmatism of the same type, though and a mean difference in radius of 0.06 mm.
smaller in degree, of one or both surfaces of the crystal- Rigid contact lenses with spherical surfaces substan-
line lens. This was Javal’s own explanation of the coeffi- tially neutralize the corneal astigmatism as indicated by
cient 1.25 in his rule. the keratometer reading. Hence, any residual astigma-
Javal intended his expression to apply only when the tism with the contact lens in use should be predictable
eye’s principal meridians are approximately horizontal by comparing the keratometer reading with the specta-
and vertical. If the corneal and lenticular components cle correction found by refraction, after allowing for ef-
are at different axes, the resultant ocular astigmatism fectivity. Decentration of the corneal apex may account
will have its axis in yet another direction in accordance for those cases in which the residual astigmatism is
with the theory of obliquely crossed cylinders. Extensive found to differ significantly from the amount predicted.
tables and graphs by Neumueller (1-953) give the sum-
mation effects of corneal and non-corneal astigmatism
at differing axes.
Corneal topography

Decentration of corneal apex Introduction

As shown in Figure 20.14 (and explained more fully on The study of corneal topography presents many compli-
page 208), if the cornea resembles a conicoid with its cations, not only experimental. To simplify it at the
apex at A, the surface becomes astigmatic at all other outset while providing a basis for elaboration, it is con-
points. Suppose the visual axis passes through P, a venient to assume the corneal profile in any meridian
point in the vertical meridian above A. At this point, to be a conic section. The curvature would thus vary
the (tangential) radius of curvature PCy in the vertical continuously from the centre outwards. Except near
meridian is longer than the (sagittal) horizontal radius the limbus, this must be so because any discontinuity,
PCs. A keratometer reading from this area would there- even if physically smooth, would seriously affect the cor-
fore show against the rule astigmatism. On the other nea’s optical imagery. For this reason, the notion of a
hand, unless the angle of incidence were quite small, a ‘corneal cap’, a central area of some 4mm diameter
pencil of parallel rays refracted at this point would having uniform spherical or toroidal curvature, can be
become more convergent in the tangential than in the misleading. It would be more correct to say that within
sagittal meridian, producing an element of with the such an area the effects of curvature variation are too
rule astigmatism. A similar but opposite reversal would small to be detected with certainty by the conventional
result from a horizontal displacement of the corneal keratometer.
apex. The revolution of a conic about an axis of symmetry
An excess of tangential over sagittal power for oblique generates a conicoid. In Figure 20.14, the conic is an el-
pencils is a common feature of converging surfaces and lipse with its apex or vertex at A and its axis of symme-
lenses. As shown by Figure 15.10, it is exhibited by the try AA‘. The point Co is the centre of curvature of the
eye as a whole, making the final tangential image shell surface at A, the distance AC, being the vertex radius
more steeply curved than the sagittal. rg. For practical purposes, the apex can be defined as
It is now recognized that decentration of the corneal the point of maximum curvature or shortest radius.
apex is common. In an early study of eight subjects, The curved line CoE is one branch of the evolute of the
Mandell and St. Helen (1969) found a mean difference conic, formed by the intersection of neighbouring nor-
mals to the surface from points on the opposite side of
the axis. Every normal meets the evolute tangentially.
At any point P(x, y) other than the vertex, the surface
is astigmatic, having two principal radii of curvature in
mutually perpendicular meridians. In the tangential
meridian, coinciding with the plane of the diagram, the
centre of curvature is at Cy where the normal touches
the evolute. In the sagittal section, perpendicular to the
tangential and containing the normal, the centre of cur-

Figure 20.14. (a) Observer's view of an astigmatic cornea.

(b) Principal radii of curvature at a peripheral point P on a
conicoid: centres of curvature Cs (sagittal) and Cy (tangential). “For a fuller treatment of the mathematics of conic sections
Arcs SS and TT are in the mutually perpendicular sagittal and in relation to the cornea and contact lenses, the reader is
tangential sections. referred to the papers by Burek (1987) and Bennett (1988a).
 The aim of corneal topography is to obtain a close ap-
proximation to the corneal surface in a mathematical
formulation. This may be an equation to the surface or
of its profile in different meridians. Another approach is
to define the surface in terms of its departure from a
reference sphere in contact with its apex. For example,
one method would be to specify the difference Az in the
7.5mm
sags of the two surfaces at a given distance y from the
axis. This is a quantity of great interest in contact-lens
fitting. Alternatively, the distance between the two sur-
Figure 20.15. (a) Observer's view of a toric cornea showing
with the rule astigmatism; central radii 8.00 along 180° by faces could be measured along a normal to the corneal
7.50 along 90°. Radii along AA 8.04 mm, along BB 7.64 mm. surface making a specified angle with the axis. This
(b) Cross-section through a spherical and an ellipsoidal surface was the method used by Bonnet (1964) in his work on
having common normals at P and Q and hence giving the same corneal topography. In a critical review of these various
keratometer readings. The radius of curvature of the spherical
systems, Clark (1973b) advocated a modification of Bon- °
surface is the sagittal radius of the ellipsoid at P and Q.
net’s. In his view, the distance between the corneal sur-
face and a touching reference sphere, not necessarily of
vature is at Cs where the normal intersects the axis. As radius r,, is more conveniently measured along the
stated on page 208, the equation to a conic’ can be put normal to the reference sphere, not to the corneal sur-
in the form face.
y? = 2rpx — px? (eles)
Topographical keratometry
Instead of the parameter p, some writers use Q for
(p—1), some the ‘eccentricity’ e for (1 =e > and An instrument designed for peripheral as well as central
others the confusingly named shape factor for keratometry was described in 1964 by its inventor, R.
e= (1 — p). Bonnet. It was manufactured by Guilbert—Routit & Co.
The sagittal radius of curvature rs (PCs) is given by of Paris but is now out of production. An essential feat-
ure was that only one of the two small mires was used
rs = {ro + (1 —p)y7}*/ (20.6) for peripheral measurements, so as to restrict the reflec-
and the tangential radius ry (PCy) by tion area to a minimum. A different doubling system
was then operated to make one end of the single mire
r= ror (20.7) image coincide with the opposite end of its duplicated
For example, taking a typical value of 0.7 for p and image.
y=1.5mm, equations (20.6) and (20.7) give Following the work of Mandell (1962) a number of
rg = 8.04 and rh =8.13mm when ~r,=8mm and conventional keratometers can now be supplied or
foie Aandi — 704 mM TOL) UOTE EAS fitted with attachments for topographic use. Some pro-
shown by Bennett and Rabbetts (1991), and confirmed vide a range of fixation points to control ocular rotation,
experimentally by Douthwaite and Burek (1995), the di- while others allow central fixation by means of supple-
mension measured by the conventional keratometer is mentary mires subtending a larger angle at the cornea.
effectively the sagittal radius of curvature at the reflec- The reflection points are thus at a greater distance from
tion point (Figure 20.15). Even though it is the tangen- the visual axis.
tial image that is aligned by the doubling system, the The results need to be processed to obtain the most
tangential radius cannot be measured because its useful information. Wilms and Rabbetts (1977) have de-
centre of curvature does not lie on the axis of observa- tailed two different systems of measurement and calcu-
tion (Figure 20.14). lation. One, which is of general application, enables the
For similar curves of a higher order, Figure 20.14 ap- p (or e) parameter of the matching conic to be deter-
plies in principle but the values of rg and ry need to be mined for each of the two principal meridians of an
determined by the methods of differential calculus. For astigmatic cornea. Thus, by providing a fixation point
a cornea that is not a surface of revolution, the terms sa- 30° below the instrument’s axis, the radius along an
gittal and tangential are perhaps ill chosen, and the arc such as AA in Figure 20.15(a) may be determined.
terms axial (denoting the distance along the normal to Correcting this value by the difference in the central
the axis) and instantaneous are preferable. Figure astigmatic corneal radii gives an approximate value for
20.15(a) shows the observer's view of an astigmatic the sagittal radius for the vertical meridian, and hence
cornea with apical radii of 8.0 along the horizontal the p-value. The other system is for specific use with the
meridian and 7.5 mm along the vertical. At a peripheral Rodenstock keratometer and its topographical acces-
point P, the radius of arc BB will be the instantaneous sories.
(tangential) radius, say 7.64mm, as in Figure 20.14. A radically different approach was made by
Along AA, however, the radius will be the axial (sagit- Douthwaite and Sheridan (1989). The idea was to
tal) radius appropriate to the horizontal meridian, i.e. measure the corneal radius at two known different aper-
8.04 mm. When the keratometer is aligned to measure tures, without eccentric fixation. From the results it is
the vertical meridian, the radius determined is that of possible to calculate the corneal asphericity in terms of
the circle centred at C, radius 7.54 mm, as shown in the parameter p in equation (12.1). For this purpose, a
Figure 20.15(b). Bausch and Lomb keratometer was modified by increas-
 Keratoscopy and photokeratoscopy 393

ing the distance between the minus signs on the mire

(see Figure 20.12c) and maintaining correct calibration
by altering the power of the travelling prism for that
meridian. By this means the diameter of the zone meas-
ured was increased to about 6mm, approximately
double the normal value. In use, the corneal curvature
is first measured conventionally in the meridian using
the plus signs on the mire. The instrument is then ro-
tated through 90° and the same meridian measured
with the larger mire. The results* were found to be in
good agreement with those given by the Guilbert-
Routit topographical keratometer and the PEK (de-
scribed in the section immediately following).
General reviews of the subject have been given by
Mandell (1981), Sheridan (1971, 1989) and Stone
(1994).

Keratoscopy and photokeratoscopy

Introduction

The keratoscope is a device for studying the corneal con-

tour over a relatively large area, whether for clinical
purposes or for investigating corneal topography. Its
origins and evolution have been researched by Levene
(1965). Its simplest practical form is the hand-held Pla-
cido disc introduced in ] 880. This consists of a flat disc
with a series of concentric black and white rings. It is il-
luminated by a light placed above or beside the patient's
head, the corneal reflections of the bright rings being ex-
amined through a central aperture furnished with a
magnifying lens. Since the outer ring subtends a larger
angle at the patient’s eye than the mires of a kerat- (b)
ometer, visual inspection can be made of a central cor- Figure 20.16. Photographs produced with the Photo-
neal area 4—6 mm in diameter. The Klein keratoscope is electronic Keratoscope: (a) a normal cornea, (b) a cornea with
a similar device but is internally illuminated. keratoconus. (Reproduced by kind permission of Mr A.G.
Marked astigmatism causes the reflected rings to Sabell, 1983, and the British Contact Lens Association.)
appear elliptical, while surface irregularities due to
scars or keratoconus produce distorted or asymmetrical this design has two disadvantages: it restricts the cor-
reflections, as in Figure 20.16. Controlled displacement neal area that can be examined and gives a curved
of the patient’s fixation allows the regularity of periph- image surface, making it impossible to obtain a photo-
eral areas to be assessed, or, in keratoconus, the approx- graph with all the rings in sharp focus. A hemispherical
imate position of the corneal apex, at which point the object surface concentric with the cornea provides
reflected rings show the least asymmetry. As Levene
much larger coverage and was found to give a flatter
(1962) has pointed out, a keratoscope must be held
image. A further step forward was the demonstration
normal to the line of sight, otherwise a false impression
by Ludlam and Wittenberg (1966) that the system
of corneal toricity is given.
giving the flattest images was a series of rings arranged
The keratoscope may be converted into a quantitative
to lie on an ellipsoidal surface. For certain applications,
instrument by attaching a camera to photograph the
there are also advantages in the use of Polaroid ‘instant’
images. It is then called a photokeratoscope. The earlier
photography.
models had a flat ring surface like the Placido disc, but
The data provided by the measured dimensions of the
ring images needs to be processed to yield the informa-
tion desired. One requirement is to determine, for a
* Although their calculations were based on the assumption given point on any ring image, the location of the asso-
that the keratometer nfeasured the tangential radius of curva-
ciated reflection point on the cornea, which is related
ture, Douthwaite and Burek’s (1995) data shows that there is
very little difference in the apical radius derived from this or to the sagittal radius of curvature at that point. This
from the basis of sagittal measurement. There is a marked dif- may be seen from Figure 20.15, in which the normals
ference, however, in the p-values depending on the basis of cal- to an ellipsoidal surface from the opposite points P and
culation. Lam and Douthwaite (1994) present a computer
O are the same as those for the inscribed sphere with its
program to solve for rg and p, given the normal and widely
separated mire K-readings and the ray incidence heights on centre at C and of radius PC, which is also the sagittal
the cornea. radius of curvature of the ellipsoid at the point P (com-
 394 Measurement of ocular dimensions

pare with Figure 20.14). The same principle applies to sley’s. Further topics investigated by this team were the
keratometry with central fixation. variation in asphericity in different meridians of the
Calibration with a set of steel balls, though useful as a same eye and the effect of peripheral flattening on the
check, is inadequate if the asphericity of the cornea is eye's spherical aberration.
to be deduced. For this purpose, a number of different More recently, Guillon et al. (1986) examined 200
mathematical procedures have been evolved by various healthy eyes of 65 females and 45 males covering a
researchers including Wittenberg and Ludlam (1966), wide range of ages and refractive errors. The instrument
Townsley (1967), and El Hage (1971). These and used was the PEK keratoscope. As in previous studies, a
others are appraised in a review by Clark (1973c) large spread of p-values was found. In the flattest cor-
which evoked a rejoinder (Townsley and Clark, 1974). neal meridian, 30.9% of the total fell within the range
A review of more recent techniques is given by Fowler 0.7-0.8 and 30.5% within the range 0.8—0.9. In the
and Dave (1994). steepest corneal meridian, the corresponding percen-
An instrument designed specifically for contact-lens tages were 21.4% and 33.6%. Chinese eyes have been
practice was the Wesley-Jessen Photoelectronic Kerato- studied by Lam and Loran (1991) and Lam and
scope (PEK) described by Bibby (1976). It had seven Douthwaite (1996). Both sets of workers found the ©
rings on an ellipsoidal surface, the smallest reflected mean keratometry readings to be similar to those of
from a corneal zone approximately 3mm in diameter Caucasians, but with higher p-values, 0.82 in the hori-
and the largest from a 9mm diameter zone. From an zontal, 0.86 in the vertical meridian, indicating less per-
enlargement of the original Polaroid transparency, the ipheral flattening.
relevant dimensions of the reflected rings were deter- Some other methods of investigating corneal topogra-
mined by photoelectronic scanning. The results ob- phy are described by Kawara (1979) who used moiré
tained were then computer processed to locate the two fringe techniques and de Cunha and Woodward (1993)
principal meridians and a series of points on the profile who illuminated the cornea obliquely from the nasal
of each of them. The position of the corneal apex relative and temporal sides with vertical planes of light. Fluores-
to the visual axis was also determined, together with cein dye in the tear film enabled the intersection of the
the vertex radius and ‘shape factor’ e? (or [1 — p]), defin- planes with the cornea to be photographed electroni-
ing the conic with the best matching profile for each of cally, and the resulting data processed by computer.
the two principal meridians. This technique is claimed to be superior to other meth-
An auto-collimating photokeratoscope, claimed to ods for investigating irregular corneas. A somewhat si-
give greater accuracy than then obtainable by other milar technique is provided in a commercially available
means, was designed and described by Clark (1972). instrument, the PAR corneal topography system: in
The mathematical theory and operational procedure this, a grid of light is projected on to the cornea from
were also explained in detail. one side, and the resulting intersection pattern photo-
Much light on corneal topography has been thrown graphed obliquely from the side. Two of the advantages
by some extensive studies carried out with these in- listed by Belin et al. (1995) are that the instrument
struments.” Using the Wesley-Jessen PEK, Townsley does not have to be positioned along the visual axis,
(1970) examined the eyes of 350 contact lens patients. and can provide results even if the corneal surface is
The conic sections giving the best corneal fit in the hori- non-reflective.
zontal and vertical meridians were then determined.
For normal eyes, the curve was found to be elliptical
Computerized videokeratography
with p-values ranging from 0.84 to 0.19, the mean
being 0.70. The development of relatively inexpensive personal
Over the entire sample, the range ofp-values was from computers has enabled the introduction of many instru-
1.49 to —0.96, the mean being 0.80 in the horizontal ments in which the image of the keratoscope rings are
and 0.84 in the vertical meridian. Values of p less than recorded electronically, and fed directly to the computer
0.2, including negative values (which denote hyperbo- for measurement and subsequent processing — a tech-
las) generally indicated keratoconus. A small number nique called videokeratography. These videokerato-
of eyes were found to have p-values in excess of unity, scopes, or videokeratometers, enable the corneal shape
denoting a prolate ellipsoid (formed by revolution about to be analysed very quickly and to be presented graphi-
the minor axis) with peripherally steepening curvature. cally upon the computer screen. They usually have
Using Clark’s auto-collimating instrument, Kiely et al. more rings situated closer together than the Wesley-
(1982) examined 176 healthy eyes of 49 male and 39 Jessen PEK and therefore should give better detail.
female subjects aged 16-80. For the best-fitting conic The mathematical treatment presented here mostly
they found a range of p-values from 1.47 to 0.24. The follows that of Doss et al. (1981) and Klyce (1984). To
highest value is nearly the same as Townsley’s, While simplify the discussion, the rings of the keratoscope face-
the absence of values below 0.24 is explained by the plate are assumed to lie in a flat plane perpendicular to
fact that no cases of keratoconus were included in the the instrument's axis — the actual position of the rings
sample. The mean p-value was 0.70, very close to Town- in the typical curved array can be allowed for by
merely changing the co-ordinates in some of the equa-
tions, while Fowler and Dave (1994) assume a hemi-
‘Results were given in different parameters, but to facilitate spherical faceplate whose centre of curvature is
comparison have been converted into p-values as used in equa- coincident with the centre of curvature of the cornea.
tion (12.1) and illustrated in Figure 12.1. The first step in the analysis is to find the centre ofthe
 Keratoscopy and photokeratoscopy 395

Re

X - axis
X - axis
Cex

Figure 20.17. Scheme for calculation of the co-ordinates of Figure 20.18. Scheme for calculation of the co-ordinates of
the point A where the chief ray from ring Rag is reflected into the point B where the chief ray from the next ring Rg is reflected
the photographic system at P. - into the photographic system at P.

image of the smallest ring, since this gives the origin ON Sua
from which all image measurements are made. The
radius of this image is initially used to calculate the cen- The next step is to obtain an estimated value for the y-
tral corneal radius. In Figure 20.17, the origin of the x ordinate for the reflection point B of the next ring Rpg, si-
and y co-ordinates is taken to be the centre of curvature tuated at radius b from P. In Figure 20.18, the distance
C of the central cornea in the meridian investigated. b subtends an angle f at the centre of curvature of the
The first principal point P of the objective is assumed to cornea. The angles of incidence and reflection will be ap-
lie in the same plane as the faceplate, with the first ring proximately B/2, and as an initial trial, this value is
Ra of radius a lying a working distance wd from the also taken for the angle 0g. Figure 20.19 shows the
cornea. Unlike keratometry where the mire’s image small section of the cornea in the zone AB. The point
height is investigated, we are now interested in the pos- D has co-ordinates x,, yp so the distance DB or Ax
ition of the point A on the cornea where the ray from equals (xg —xX,), while distance DA equals —Ay or
the mire R, is reflected to enter the objective at P. If the —(yp — ya). If tangents are drawn to the cornea at A
co-ordinates of this point are x4 and ya, then the dis- and B, they will make the same angles 0, and 0, with
tance CP is given by: the x-axis as the normals to the cornea do with the y-
CP = ya + wd or instrument axis.
A geometrical construction enables the value for Ay
if the tiny difference between ys and the corneal radius to be predicted from the difference Ax. A line is drawn
for this ring is ignored. The radius of the first ring through B parallel to the tangent at A, and then perpen-
image, divided by the instrument's magnification, gives diculars to it are dropped from A and D to meet it at E
the x, co-ordinate of the reflection point. and G respectively, with DG continuing to intersect the
If the reflected ray entering the objective subtends the tangent through A at H.
angle » at P, then: Then, from triangle DBG,
tan a = x,/wd
while the angle Ry, AN equalling (2 — x) is given by:
tan (20 — a) = (a—x,)/wd

If CAS is the normal to the cornea at the reflection point,

angle SAN is given by:
o=0+4
which can be rearranged to give

§=5(26—a-2)
From the small ‘angle at the origin,
Xa = Ya tan ®

whence
Ya = Xa/tan 4 {arctan [(a — x,)/wd] — arctan (x4/wd)} Figure 20.19. Geometrical construction to calculate the
difference Ay in the y-ordinate from Ax, the change in the x-
and the central radius can be calculated from co-ordinate of the reflection point from one ring to the next.
396 Measurement of ocular dimensions

GB = Ax cos 9,

and, from triangle ADH,

AH = —Ay sin 8,

and as AE and HGD are parallel,

AH = EG
so
EB = Ax cos 0, — Ay sin 04
By drawing a tangent to the corneal profile at B and
dropping the perpendicular to it from A to meet it at F,
it may similarly be shown that
FB = Ax cos 0g — Ay sin 8
For the small length of arc AB, the lengths EB and FB are
similar. Thus equating the two equations and solving:
(x, — Xp)(cos 84 — cos Op)
i ; (20.8)
a sin 0, — sin 9g
Returning to Figure 20.18, this initial value for yp Figure 20.20. One method for calculating an approximate
value for the instantaneous radius of curvature r; of the cornea
may now be substituted to determine a more accurate
at reflection point F.
value for the angles f’ and 0g. Thus if
dy = wd+ Ya
radius for the central point F from
and if u and v are the lengths of the raypaths RgB and
BP, r= (ee — 8)? + (yp — &)?
7) ? ?

u“ = (b— xp)” + (da — yp)” Because both these methods give a discontinuous pro-
file to the cornea with an abrupt change corresponding
v? = (da — yp)? + x8 to each ring, Klein (1992) developed equations and a
and by the cosine rule from the triangle RgBP simple computer program generating a smooth curve.
The instantaneous radius can also be obtained by fitting
6’ = arccos [(b* — u* — v*) /(—2uv)|
a curve to the x- and y-co-ordinates of the cornea, and
From triangle RgBM, where M is the normal to the face- then differentiating this twice. Chan et al. (1995)
plate from B, found that the elliptical model chosen for the normal
corneal curve was unable to provide accurate values
180° = nm radians = n/2 + B'/2+ Op +
for the instantaneous radius for keratoconic eyes.
and By repeating the whole process for meridians at 1—2°
intervals, these instruments can determine the corneal
Vv arctan |[(d, — yg)/(b — xg)]
toricity, and display central ‘keratometry readings’ gen-
so that erated by the mean radii along the principal meridians
over the central 3 mm diameter reflection zone, and the
03 = n/2 — B'/2 — arctan [(d, — yg)/(b — xp)]
orientation of the principal meridians in peripheral
By substituting this value for 0, into equation (20.8), a zones of the cornea. The equations derived above re-
refined value for yg can be obtained. This iteration is quire that the incident and reflected rays both lie in the
continued until a negligible change in yg occurs. same plane as each other and with the instrument’s
The whole process is then repeated for each ring in axis, an impossibility for all except the principal merid-
turn to the edge of the keratoscope image. Since the per- ians of an astigmatic cornea. Halstead et al. (1995) ap-
ipheral radii are calculated as a function of the central proached the problem from the opposite direction.
radius, any errors in this will result in errors of scale Rather than trying to calculate the corneal shape from
for the periphery. the image dimensions, they used trial and error in the
The corneal radius at B may be calculated in at least form of computer iteration to model the corneal shape
three ways. First, it may be regarded as that of the in- that gave the image. Skew refraction could then be in-
scribed circle tangential to the cornea at B — see Figure corporated.
20.15 — giving the axial radius (see page 392) as These computerized videokeratoscopes also display
the corneal profile in terms of power maps. In general,
rp = Xp/sin Op
they are often programmed to convert radius to power
Secondly, Figure 20.20 assumes a small section of the by the simple paraxial equation F = 337.5/r. This as-
cornea to have the same radius r, at three neighbouring sumes that the ray bundle is incident normally on the
reflection points, E, F and G. The co-ordinates (h,k) of corneal surface, something definitely untrue for the per-
the instantaneous centre of curvature C; can be calcu- ipheral cornea where oblique incidence will give rise to
lated from the equations given in Klyce (1984) and the spherical aberration. To some extent, spherical aberra-
 Depth of the anterior chamber 397

tion can be incorporated by calculating the point of in- Tscherning (1924) found it to be generally of the
tersection with the instrument axis of a ray incident in- order of 2—3°, with the visual axis in object space up-
itially parallel with the axis. This, however, ignores the wards from the optical axis. Like Tscherning, Dunne et
effects of aberrations from the crystalline lens, and can al. (1993) found the visual axis to lie 5° temporal to the
hardly be reconciled with a conversion for the instanta- optical axis, intersecting the nasal retina. They also
neous radius. This use of power rather than radius may measured the objective refraction for the nasal and tem-
result from the preference in the USA to give keratome- poral retina. The plot of astigmatism, surprisingly, fell
try readings in terms of corneal power rather than to a minimum around 9° nasal to the fovea. They con-
radius. Thus Salmon and Horner (1995) recommend cluded that this difference was produced by asymmetries
that these power maps should be interpreted as dioptric in the ocular refracting surfaces.
curvature maps, while Applegate et al. (1995), like As indicated by its name, the ophthalmophakometer
Bonnet and Clark (see page 392), recommend that the can also be used, as described by Tscherning, to measure
elevation of the cornea relative to a spherical surface the radii of curvature of the crystalline lens surfaces,
may be the best method for portraying corneal shape. the thickness of the lens and the depth of the anterior
Typical plots and the use of the instrument in contact chamber.
lens practice are given by, for example, Burnett Hodd
and Ruston (1993) and Stevenson (1992, 1995). The
interested reader is referred to the November 1995 and
1997 issues of Optom. Vis. Sci., 72 and 74, which are Corneal thickness
devoted to computer-assisted corneal topography.
A comprehensive review of methods of measuring cor-
neal thickness has been given by Ehrlers and Hansen
(1971). Some in which the slit lamp is used were de-
Angle alpha scribed on pages 309-310. Ehrlers and Hansen consid-
ered the Jaeger pachometer method to be not only
The angle alpha between the optical and visual axes is simple but also the most accurate. All optical methods
conveniently measured with apparatus similar to require the anterior corneal radius r; to be determined
Tscherning’s ophthalmophakometer. This consisted of a and a value for the corneal refractive index n to be as-
graduated circular arc, supported on a stand, with an sumed. From a mathematical analysis of the possible
observing telescope T mounted in a central aperture of errors arising from an error in measuring r, and a varia-
the arc (Figure 20.21). For various purposes, lamps and tion in the value of n, Patel (1981) considered the
fixation objects could be attached to the arc and moved Jaeger method with illumination normal and viewing
along it, the subject’s eye being placed at its centre of oblique to be marginally superior to the others. The rela-
curvature. tive error of each method was expressed as the ratio
To measure the angle alpha, two lamps are placed one ét/t. When the value of 40° is assigned to the obliquity
above and one below the telescope, so as to give rise to of observation 9 in Jaeger’s method, Patel’s expression
separated pairs of Purkinje images I, III and IV. With reduces to
the subject initially fixating the telescope, the effect of dt/t = 4.8 da+ (3.6 x 10~*) br, + 0.87 Sn (20.9)
angle alpha is to displace the images horizontally by
where ais the oblique width of the slit lamp section as in
various amounts so that they appear out of alignment
Figure 16.11.
to the observer. A small fixation object F is then moved
along the arc until the six Purkinje images are brought
into the best vertical alignment obtainable. The axis of
the telescope is now assumed to coincide with the eye's
optical axis, so that the angular scale reading at F gives
Depth of the anterior chamber
the angle alpha. If the whole apparatus is rotated
Slit-lamp methods were described on pages 309-310.
through 90°, the vertical component of angle alpha
The pachometer has the merit of convenience, though
can be determined by the same procedure.
ultrasonography will simultaneously provide other
axial separations that might be needed. An ingenious
method devised by Lindstedt was improved by Stenstr6m
(1953). A well-corrected objective is masked by a plate
with four radial slits, one in each half of the 45° and
135° meridians. Rays from a small light source pass
through the 135° slits to form one image of the source.
Rays passing through the 45° slits are first intercepted
by a narrow minus lens of low power, thus forming a
second image at a greater distance from the objective
than the first. Measurement of the apparent depth of
the anterior chamber is obtained by adjusting the appa-
ratus and the axial position of the auxiliary minus lens
Figure 20.20. Basic features of Tscherning’s so that the two images fall simultaneously on the poles
ophthalmophakometer and its use in measuring angle alpha. of the cornea and anterior lens surface respectively.
398 Measurement of ocular dimensions

Tscherning’s method
Tscherning’s method, suited to his ophthalmophak-
ometer, is the inverse of the comparison method. Two
bright lamps BB (Figure 20.21) are fixed in position so
that their Purkinje images III are visible to the observer.
The positions of two dimmer lamps DD are then adjusted
so that their twin Purkinje I images have the same se-
paration between centres as the Purkinje III pair. To
(a) (b) give images h, and h} of the same size, the conjugate
object sizes h,; and h; must be inversely proportional to
Figure 20.22. Purkinje images of a double light source: (a) the equivalent mirror radii r, and ry. Accordingly,
shows the first and fourth images, (b) the third image.
ie = 1, (h,/h3) (On)

Applied to Purkinje image IV, the same method gives

Phakometry
rs =11(hy/hy) (20s)
Radii of curvature
Experimental difficulties in phakometry with particu-
The theory of equivalent mirrors applied to a three-sur- lar reference to Purkinje III images have been discussed
face schematic eye provides the simplest basis for the in detail by Fletcher (1951).
calculations involved in phakometry (see pages 217—
220). In the three-surface eye, it is the second surface
which gives rise to Purkinje III and the third surface to
Purkinje IV. These images are used to determine the Determination of actual radii
radii of curvature of the relevant equivalent mirrors. To determine the actual radius r, corresponding to the
There are two different techniques for measuring their equivalent mirror radius r it is necessary to know the
relative sizes. apparent depth d, of the anterior chamber in addition
to its real depth d, as given by the pachometer reading
or otherwise. The apparent depth can be found from
the conjugate foci relationship, which gives
Comparison phakometry
a dy
a 20.14
Two circular sources in the same vertical plane are ar- a Ny — dF, ( )
ranged so as to give rise to twin Purkinje images I and
IV as shown in Figure 20.22(a). The distances between where d, is the true depth of the anterior chamber, ny is
their centres, hi; and h4, can each be regarded as the the refractive index of the aqueous humour and F, the
height of a single Purkinje image of the same extended power of the single-surface cornea.
object of height h. Applied to the three-surface sche- In Figure 20.23, A4 is the vertex of the equivalent
matic eye, equation (12.21) gives mirror, C5 its centre of curvature, and ry its radius of
curvature A5C}. From the diagram,
rs =1(h4/h}) (20.10)
A,Co = dy a= i)
in which r’ is the radius of the equivalent mirror corre-
sponding to the posterior lens surface.” and
The ratio (h4/h{,) is determined by photographing the AiC) = d’ se T>
images, which are almost in the same plane. Since r, is
known from keratometry, the value of r can be found Since C, and C4 are conjugate by refraction at the
from equation (20.10).
Similarly, the radius r5 of the equivalent mirror corre-
sponding to the anterior lens surface is given by
j =71; (h3/h) \ (20.11)
Because the Purkinje III image is about 7 mm behind
the plane of I and IV, a second photograph is taken
with Purkinje HI brought into sharp focus to measure
h’; (Figure 20.22b). The value of h‘, is taken from the
first photograph. .

“Smith and Garner (1996) point out that equations (20.9) Equivalent
and (20.10) assume a distant test object. It may be more conve- mirror
nient to have the light sources closer to the eye, either at a
fixed distance from the eye or attached to the camera. Corrected Figure 20.23. True and apparent depths of the anterior
equations are given for these conditions, while Garner (1997) chamber, and the equivalent mirror corresponding to the front
gives an iterative computer scheme. surface of the lens.
 Phakometry 399

the equivalent mirror radius ry is found, and hence the

ratio r5/r,. If this ratio does not agree within a stipu-
lated tolerance with the figure determined experimen-
tally from the photograph of Purkinje IV and I, a new
trial value for F, is needed. Computer iteration or a gra-
phical solution can be used to find an optimum value
for Fy, which then gives the correct value for F3. For
the Bennett-Rabbetts schematic eye, the ratio r3/r, is
Figure 20.24. Step-along method for calculation of 0). 7issS)
crystalline lens surface powers.

cornea,

Np 1 Equivalent power of the crystalline lens

dy =- >) dt + rs
=F, (20.15)
When its radii of curvature and axial thickness are
From which rj, the only unknown, can be determined. known, the surface powers of the crystalline lens and
The more complicated operation of determining the its equivalent power F; can be calculated from the ex-
posterior radius r3 from the equivalent mirror radius 1’ pressions given on page 211.
has been detailed by Bennett (1961). It is, however, un- If neither radius is known, a close approximation to
necessary even to measure r} if the ocular refraction K the equivalent powers of the lens and also of the eye
is known and the eye’s axial dimensions have been itself can be calculated from a method devised by Ben-
found from ultrasonography. In this event, phakometry nett (1988b). This is based on the assumption that the
can be confined to the anterior surface, thus arriving at shape of the crystalline lens of the relaxed schematic
its surface power F). To find the power F; of the poster- eye is a reasonable approximation to that of the sub-
ior surface, an axial pencil from the eye’s far point is ject’s own lens, and hence that the principal points of
traced through the eye by the step-along method the real crystalline may be located to a sufficient accu-
(Figure 20.24). The vergence 1; at the posterior lens racy by those of a schematic lens of the same thickness.
surface is thereby determined, while the value of L’, re- The data required are the spectacle refraction (F,,) at a
quired to focus the pencil on the retina can be found specified vertex distance (v), the corneal power (F,) ob-
from tained from keratometry, and the axial separations of
is — n4/d3
the refracting surfaces and retina, found from ultraso-
nography.
where ny is the refractive index of the vitreous and d, The thickness of the crystalline lens is known. If the
the distance from the posterior pole of the lens to the positions of its principal points P, and P4 can reliably
retina. Finally, be conjectured, the two separate surfaces can then be ig-
Bs. = 14 = Ls (20.16) nored and the lens replaced by its theoretical Gaussian
equivalent of power F, (Figure 20.25).
Let us assume that values have been allotted to e, and
e>. Since the eye’s far point Mp is conjugate with the
Dunne’s method, avoiding measuring
retina, a paraxial pencil from Mp must, after emerging
Purkinje II from the lens, be focused at the axial point M’. All the re-
An alternative scheme for calculating the optical com- quired axial distances are known, and so the vergences
ponents of the eye was suggested by Dunne (1992) to L, and L can be calculated by the normal procedure.
avoid using Purkinje III. This was for three reasons: The rest then follows.
Purkinje III is poor since it is formed by reflection at the
shagreen-like anterior lens surface; a separate photo-
graph is required since the image lies deeper in the eye
than the others, and Dunne was interested in recording
Purkinje II, and equipment for generating the two cor-
neal images is inappropriate for forming an image from
the anterior lens surface.
If the posterior corneal radius is ignored, then kerato-
metry, ultrasonography and photography of Purkinje I
and IV are needed. A hypothetical trial value for the
anterior lens power-F’, is initially assumed. As shown
in Figure 20.24, a ray trace through the eye enables
the vergence of light L; incident on the back surface of
the lens to be calculated, while the vitreous depth gives
Figure 20.25. The crystalline lens of the schematic eye
the image vergence L, and hence an initial trial value replaced by its Gaussian equivalent of power F,, the positions
for the posterior lens back surface power. By calculating of the principal points P, and P5 having been conjectured. The
the image positions of the posterior pole A; and centre value of F,, is given by the vergences Ly and L}, found from the
of curvature C; formed by the anterior lens and cornea, axial ray trace as explained in the text.
400 Measurement of ocular dimensions

The required values of e) and ¢ can be determined as Thus, if an eye has the following measurements:
follows. From the equations given on page 254 we can F,, = +6.00 DS
write
at a vertex distance of 16 mm
eo = A-dy
Fy ted 75D
where
(keratometry reading of 8.05mm and assuming an
A = (n)/n3)(F3/F,) (20.17) index of 1.336) ‘%

and Anterior chamber depth, d, = 3.4mm

é&) = —B-d, Lens thickness, d, = 4.0mm
where Vitreous depth, d; = 14.9mm
B = (ng/n3)(F2/F,) (20.18)
the power of the eye is calculated as follows.
If the lens of the schematic Bennett—Rabbetts eye is The ocular refraction is given by:
taken as the norm, the numerical values will become kK =1,=+6,00/0— 0,016 < 6.00) = 46.6377)
é2 = 0.599 dy
Therefore the vergence L, leaving the cornea is:
and
Li = +6.637 + 41.75 = +48.387D
Va 5G PS 0,599 640 = 2, 396 mannan
It will be seen from the above equations that the ratio
and
B/A is equal to F,/F;, which means that the positions
of the principal points vary with the form or profile of é> =—0.353 x4.0==—1.412mm
the lens. This can also be expressed as the quantity Q
and the distance w to the first principal point of the lens
defined by
is given by:
Cyt. w = 3.44 2.396 = 5.796 mm
indicating the proportion of the total lens power contrib-
Hence
uted by its front surface. For the Bennett—Rabbetts eye,
OOS 75: b = 1336/
+ 48.387
If the actual but unknown Q-value of a real eye is not
= +27.611 mm
0.375, the values of A and B produced by the computing
scheme will be incorrect for that eye. The resulting SW) = 5)f/Soy inavan
errors in the calculated values of F, and F, are directly
¢, = +21.815 mm
proportional to the difference between the real and as-
sumed Q-values and will be quite small in most cases. giving
At both ends of the range of actual Q-values from 0.28
L, = +61.242D
to 0.48, which is thought to cover all but exceptional
lens configurations, the error in F; would not exceed The final image distance is given by
+1.0D, and the consequential error in the value of F, (5 = 6 ds = = Sm
would not exceed +0.5 D. From this point of view, the
new method compares favourably with phakometry. sO
This was confirmed by Royston et al. (1989a), but may 5 = 1336/16.312 = +81.903 D
no longer be true with more precise techniques of
ophthalmophakometry (Mutti et al., 1992). Their use of Therefore, the equivalent power of the crystalline lens,
video-recording meant that several photographs of the F,, is given by
image could easily be taken and averaged. They also Fy = L5 —L, = +20.66D
used collimated mires and a narrower angle between
these and the camera to improve accuracy. while the equivalent power of the eye, F. is given by
A possible computing scheme is set out below. F, = +41.75 + 20.66 — (5.796/1.336) x 41.75 x 20.66
fly = en ve = +58.67D
ig RE wl Free a fe
oe, = 0.5960,
ies = =0.3580; . The posterior corneal radius
5. w =d, +e)
Phakometry can also be employed to measure the radius
6. Ly = L}/[1 — (w/nz)L4] of curvature of the posterior corneal surface. The thin-
n= Ca ness and similarity in curvature of the two surfaces
Soe tae > means that Purkinje I and II are very similar in size.
Oeil, is Small, widely separated sources of light enable the two
images to be resolved. Royston et al.’s (1990) mean find-
10. Fe = Fy + Fy — (w/n2)
FyFL
ings (for the vertical meridian) were 7.77 mm for the
 Phakometry 401

anterior radius, 6.40 mm for the posterior. The latter is

significantly steeper than the figure of 6.8 mm adopted
in the Gullstrand schematic eye.

Slit-lamp determination of radii

and thickness Illuminating
slit beam
The photographic slit lamp can be employed to measure
camera
the corneal thickness and radius of curvature of its sur- objective
faces. Thus, much as in Figure 16.11(a), the slit lamp
can record the apparent cross-section of the cornea. Ifa
scale, held in focus and perpendicular to the camera, is
subsequently photographed, then the magnification of
the system, including any subsequent enlarging, can be
determined. From these scaled measurements, equations Tilted film
(16.3) and (16.1) allow the true thickness to be calcu- plane
lated, though more accurate results should be given by
the equations in the appendix of Brennan et al. (1989). Observation
The radius of curvature of the anterior surface may be axis
found in one of three ways. First, for a given chord, the
apparent sag can be measured. This is then corrected
Figure 20.26. The tilted image plane technique of
for the obliquity of view, also by equation (16.3), and Scheimpflug photography.
hence the radius of curvature found from the sag for-
mula:
ciently to allow the whole of the cornea and lens to be
photographed, the slit lamp may be displaced sideways
in the direction away from the camera. Sparrow et al.
where y is half the length of the chord and s is the sag, (1993) have published equations to correct for the re-
assuming a circular profile. sulting change in apparent lens thickness.
Alternatively, curves of known radii can be photo- A similar photographic system has been used to moni-
graphed obliquely, and templates drawn from the resul- tor the lens changes in cataract — see, for example, Spar-
tant negatives used to match to corneal photographs, row et al. (1990) and Magno et al. (1994).
while Brown (1972b) cites a method of Fisher’s for di-
rectly determining the apparent radius from the photo-
graphs. The astigmatic eye
A similar process was also used by Royston et al.
(1990) to measure the posterior radius, obtaining re- The foregoing discussion has tacitly assumed the var-
ious refracting surfaces to be spherical. In large-scale
sults agreeing with their phakometric measurements.
surveys, such as those by Sorsby et al. (1961), phako-
metry is usually carried out either in the vertical or the
Scheimpflug photography horizontal meridian, and the ocular dioptrics are then
determined as though for a section of a spherical eye in
The normal photoslit lamp cannot be used to measure
the chosen meridian. If the ocular refraction has a cy-
the crystalline lens because its thickness is too great to
lindrical component, the ‘notional’ cylinder power in
have both the anterior and posterior surfaces in focus,
the selected meridian is calculated from the expression
let alone the cornea. Brown (1969, 1972a,b) adopted
the principle of Scheimpflug photography. In one ver- Cy = Csin? 0 (20.19)
sion of this method (Figure 20.26) the subject, with
where 9 is the angle between the cylinder axis and the
pupils widely dilated, fixates the slit beam which is
selected meridian. The same procedure is applied to cor-
directed through the centre of the pupil while the eye is
neal astigmatism at an oblique axis. Thus, a corneal
photographed from 45° to the side. The cornea is closer
power equivalent to
to the camera than the posterior lens, and is therefore
imaged much closer to the camera lens. The film plane +42.00 DS/—3.00 DC axis 60
is therefore tilted approximately 60° towards the slit would be considered to have a notional power of
lamp. Because of the varying conjugates across the field (+42 — 0.75) or +41.25 D in the vertical meridian (see
of view, the magnification on the negative is not linear. pages 352-353).
The intersection of the slit beam with the anterior sur-
face of the lens is therefore always positioned in the
centre of the field, and measurements taken in relation Axial length and equivalent power of
to calibration photographs. For more details, the reader
the eye
is referred to the original articles, and to the more
recent papers by Koretz et al. (1987, 1989a,b) and At present, direct measurement of the eye’s axial
Cook and Koretz (1991). If the pupils do not dilate suffi- length is possible only by X-ray methods or by
402 Measurement of ocular dimensions

ultrasonography. If the three surface powers, depth of In the mid-1950s, electronic scanning of the pupil in
anterior chamber d,, axial thickness of lens d, and conjunction with closed-circuit television was pioneered
ocular refraction are all known, a ray trace from the by Lowenstein and Loewenfeld (1958). Various im-
eye's far point will determine the vergence L’; at which provements and refinements have since been intro-
the pencil emerges from the lens. The corresponding duced. Both analogue and digital display systems have
value of / is the axial distance d; needed to determine been used, and the pupillary area may also be recorded
the eye's overall length (d; + dy + d3). instead of or in addition to its diameter. Developments
The simplest method of calculating the eye’s equiva- in this field are briefly reviewed in the papers by Saladin
lent power from its known dimensions is given on page (1978) and Watanabe and Oono (1982) in which their
Pale own designs are described.
A pupillograph using infra-red radiation to examine
both eyes simultaneously was constructed by Clarke et
al. (1966).
Pupillometry

A difficulty inherent in pupillometry is to prevent pupil- Doubling methods

lary reaction caused by or occurring during the process The recent use of doubling devices to measure pupillary
of measurement. A change in luminance, involuntary diameter to a higher standard of accuracy (about
accommodation and pupillary reaction by the fellow 0.1 mm) than the simpler methods already noted has
eye could all affect the result. Since the pupil can be been reviewed by Charman (1980). A much earlier and
viewed or scanned only through the cornea, any meas- simpler doubling method devised by Landolt was de-
urement by such means refers to the eye’s entrance scribed by Sous (1881) as the most accurate of existing
pupil, not to the natural pupil. pupillometers. A bi-prism producing equal horizontal
deviations in opposite directions is movable along a
graduated bar having a viewing aperture for the exam-
Simple methods
iner at one end and an adjustable support to rest on the
For most clinical purposes only a modest standard of ac- subject's cheek at the other. The examiner slides the bi-
curacy is required, attainable by various simple prism along the bar until the doubled images of the
methods. Direct comparison with a graduated series of pupil are just in contact. The pupil diameter is a simple
circles or circular apertures is one such method. A function of the power of the bi-prism and its distance
scale with a lens and telecentric stop, such as the Wes- from the eye under test.
sely keratometer, is possibly more accurate. A very old
method, reintroduced from time to time in various em-
bodiments, is based on the Scheiner (twin pinhole) disc.
If held close to the eye, two entoptic images of the pupil- Exercises
lary aperture will be seen. They may be separated or
partially overlapping but will just touch if the pupil 20.1 When a tower at a distance of 500 m is viewed through
diameter is equal to the distance between the pinhole a bi-prism with its line of junction horizontal, the two images
of the tower just appear to touch end to end. The power of
centres. Small amounts of ametropia have only a negli-
each prism is 4 A. Find the height of the tower and draw a dia-
gible effect but the pupil may dilate with the occlusion. gram showing the path of the rays by which the two images
A simple device which obviates this drawback consists are seen.
of a thin transparent plate on which two strips of co- 20.2 Ina certain keratometer, the test object consists essen-
loured transparent material are mounted. Their inner tially of a circle and its diameter, the latter coinciding with the
direction of doubling. Show, by means of a diagram drawn to
edges touch at the top and are separated by 8-10 mm scale, the appearance seen by an examiner when using the in-
at the bottom. Looking between the two coloured strips strument on an astigmatic cornea, the principal radii of which
near their junction, the subject views a distant spotlight are 7.50 mm along 150° and 8.25 mm along 60’, the direction
while fogged by about +3.00 DC axis vertical. The lat- of doubling being (a) horizontal, (b) along 60°, (c) along 150°.
What would be the astigmatism recorded by the instrument if
eral edges of the blurred image of the pinhole initially
the index of calibration were 1.3375?
appear coloured. The plate is then slowly raised until 20.3 The arc of a certain Javal-Schiétz type keratometer has
these coloured borders just disappear. The distance be- a radius of curvature of 480mm. A point Q on one of the
tween the strips at this level gives the pupil diameter. mires is 200 mm from the vertex of the arc, measured along it.
Find: (a) the height from the axis at which a ray from Q would
be incident on the cornea and, after reflection, pass through
Experimental methods the vertex of the arc; (b) the angle which this reflected ray
would make with the axis. Assume that the arc containing the
By way of contrast, an extremely high standard of accu- mires is concentric with the cornea, the latter having a radius
of 8 mm.
racy is demanded of pupillometers used in visual and
20.4 A certain astigmatic cornea has its principal meridians
psychological researches. The requirements may in-
horizontal and vertical. In the horizontal, the radius of curva-
clude a continuous recording ofpupillary size at time in- ture of the front surface is 7.50 mm and that of the back surface
tervals of the order of 0.01 second. Motion-picture 6.50 mm, the radii in the vertical meridian each being 10%
photography with infra-red radiation was originally the longer than the corresponding horizontal radius. Assuming re-
fractive indices of 1.376 and 1.336 for the corneal substance
only basis for pupillometry of this kind and was consid-
and aqueous humour respectively, find: (a) the total corneal
ered by Taylor (1977) in his review of techniques to be astigmatism, (b) the astigmatism that should be recorded by a
the only one applicable to normal viewing situations. keratometer calibrated for a refractive index of 1.3375.
 References 403

20.5 (a) The astigmatism of a certain eye as recorded by a given in Tscherning’s schematic eye.) (b) Calculate the equiva-
keratometer is —4.00 DC axis 30°. Estimate the distance correc- lent power of each cornea in both meridians, assuming a thick-
tion, given that the ‘best sphere’ placed 15mm from the ness of 0.5mm and a refractive index of 1.376, the aqueous
cornea is: (a) —10.00D, (ii) +10.00D. State clearly any as- index being 1.333. Compare the resulting astigmatism with
sumptions made. (b) In general, if § is the power of the best that given by a keratometer calibrated for an index of 1.336.
sphere at a distance d from the cornea and if A is the astigma- 20.15 A Javal-Schidtz keratometer has its mires mounted on
tism recorded by the keratometer, find an approximate expres- a circular arc assumed to be concentric with the corneal
sion for C, the power of the correcting cylinder needed at the centre of curvature. The included angle 90 subtended at this
same distance d. point by the mires is adjusted so that the image height is equal
20.6 An aphakic eye has a spectacle refraction of +10.00 D to the fixed amount of doubling. (a) Show that this angle is ap-
in the horizontal meridian at a vertex distance of 12 mm. proximately proportional to the power of the cornea. (b) Calcu-
What is the spectacle refraction in the other meridian if the ker- late the amount of doubling required such that @ in degrees
atometry readings are 7.60 along 180° by 8.10 along 90°? corresponds to half the corneal power. (c) Which of the scales,
Assume a refractive index for calibration of 1.3375. power or radius, is approximately uniform?
20.7 Assuming a keratometer calibration index of 1.3375, 20.16 In the presence of oedema, the refractive index of the
what is the power difference corresponding to the following cornea probably decreases. Assuming a new value of 1.371,
radii differences: calculate the equivalent power of the cornea with: (a) radii of
curvature and thickness of the Gullstrand No. 1 schematic eye
T0-71.2; 7.91.7; 8.0-8.2; 8.5—8./ ¢ (+7.7, +6.8 and 0.5mm), (b) radii +7.5, +6.7, thickness
(Note: it is interesting to draw a Heine double scale — two col- 0.55 mm. Compare these with the equivalent power ofthe Gull-
umns to scale — in which the left is the radius in 0.05 mm strand cornea of normal index (1.376), taking the aqueous
steps, the right power in dioptres. Most keratometers have this index as 1.3333 in all cases.
on the dual-radius power calibration.) 20.17 Adopting the axial dimensions of the Bennett—
20.8 A patient’s spectacle prescriptions Rabbetts schematic eye but modified to include a cornea of
thickness of 0.5 mm, calculate the time intervals in ultrasono-
—5.00/—5.50 x 170 at 15 mm graphy between the echoes from the cornea and (a) anterior
lens, (b) posterior lens, (c) retina. Assume the velocities given
and the keratometer reading 7.50 m 170 by 6.95 m 80. Com- in the text. (d) Also calculate the extra time taken if the axial
pare the ocular with the corneal astigmatism, assuming the length were | mm greater.
keratometer to be calibrated for index 1.3375. What residual 20.18 Light from one mire of a keratometer is reflected from a
astigmatic error would you expect to find when a rigid contact point on the cornea 1.5 mm from the optical axis, the angle of
lens with spherical surfaces is placed on the eye? incidence i being 10°. The vertex radius of the cornea is
20.9 A contact lens surface of radius 7.8 mm is ordered on 7.8mm and its form is assumed to be (a) spherical, (b) parabo-
the assumption of a keratometry index of 1.3375. If the lens is loidal. Find the sagittal and tangential image distances (s’ and
erroneously produced on the basis of a notional index of: (a) t’) from the standard expressions
1.336, (b) 1.332, what radius would the manufacturer use?
20.10 A model keratometer has an objective of power V/s = (2icos i\/r— 1/s
+20.00 D and a single eyepiece lens of conventional magnifica-
1/t' = 2/(rcosi) —1/t
tion 16x. The objective magnification when the instrument is
correctly positioned is —1.0x. If the mires are in the plane of in which s and t are the sagittal and tangential object distances
the objective, what percentage error in radius is made if the (measured along the incident ray path), in this case both equal
eyepiece is positioned 1mm behind its correct plane, and to to —8O mm.
what dioptric error does the eyepiece maladjustment corre- 20.19 Using Dunne’s method (see page 399) for the determi-
spond? nation of crystalline lens dimensions, calculate the ratio r,/r
20.11 A keratometer based on the Zeiss ophthalmometers G for an eye with the anterior lens surface power of +8.25 D, as-
and H has objectives of focal length f; and f separated by the suming all axial dimensions and the corneal curvature to be
distancef, + f5. Using Newton's relation for paraxial imagery, the same as in the Bennett—Rabbetts schematic eye. Assuming
show that the linear magnification of the aerial image formed a linear relation between this ratio and the anterior lens surface
by this system is —f5/f{ and is independent of object distance power, estimate the anterior surface power of an eye showing
x,. Show also that if a prismatic deviation A is introduced in a ratio of —0.80.
the coincident focal plane of the objectives, the image displace- 20.20 A myopic eye with ocular refraction —6.00 DS has a
ment is fA and is also independent of object distance x}. corneal radius of 7.9mm, anterior chamber depth of 3.8 mm,
20.12 (a) Show that for a contact lens in saline, the apparent lens thickness of 3.9mm and axial length of 26.0 mm. Using
radius is r/n where r is the true radius of curvature and n the Bennett's scheme (page 400), calculate the eye’s equivalent
refractive index of the saline. Assuming n to be 4/3, for what power.
range of corneal radii should the keratometer be calibrated to
measure surfaces of true radii from 7.5 to 9.5 mm? (b) What is
the reflection factor for perpendicularly incident light on:
(i) tears of refractive index 1.333; (ii) PMMA of index 1.490
and (iii) the surface of a soft lens in saline, refractive indices
1.43 and 1.333 respectively? The reflection factor is References
Gi =n /(a + n)?.
20.13 An ellipsoidal cornea of vertex radius 7.8mm has a APPLEGATE, R.A., NUNEZ, R., BUETTNER, J. and HOWLAND, H.C.
parameter p of 0.7. Tabulate the sagittal and tangential radii (1995) How accurately can videokeratographic systems
at distances y from the axis of 1.0, 1.5, 2.0 and 2.5mm. measure surface elevation? Optom. Vis. Sci., 72, 785-792
Which radius, r,, or r,, does the keratometer measure? BAUM, G. (1965) A synopsis of ophthalmic ultrasonography.
20.14 (a) In his Physiologic Optics, Tscherning gives the fol- Wissenschaftliche Zeitschrift der Humboldt-Universitaet zu Ber-
lowing corneal radii in mm for three patients: lin: Mathematisch-Naturwissenschaftliche Reihe, 14(1), 51-62
BELIN, M.W., CAMBIER, J.L., NABORS, J.R. and RATLIFF, C.D.
Radius ae B C (1995) PAR corneal topography system (PAR CTS): the clin-
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Hor Vert Hor Vert Hor Vert
Sci., 72, 828-837
Tiifte) 7.90 8.29 8.33 BENNETT, A.G. (1961) Appendix D. The computation of optical
Anterior eos 7.60
dimensions. In Sorsby et al. (1961), pp. 55-64 (see separate
Posterior 6.22, 3,595) 5.66 beat Golly Sites
reference)
For each meridian, calculate the ratio of the anterior to the pos- BENNETT, A.G. (1966) The calibration of keratometers. Optician,
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21
Distribution and ocular dioptrics
of ametropia

Table 21.1 Distribution of ametropia: summary of three studies

Distribution of ametropia (the figures denote percentages of the total sample)

Three large-scale surveys Ocular Stromberg Stenstrom Sorsby et al.

refraction males males
(D) ($121 eyes) Males Females (2066 eyes)
Practice and hospital records provide useful information (685 eyes) (315 eyes)
about the demand for ophthalmic services but throw
over —8 0.1 OF 6 0.4
less light on the incidence of ametropia in the general
population. For this purpose, unselected samples are re- —8 to —7 OZ 0.3 1.0 0.2
—7 to —6 0.2 0 1.6 0.4
quired. ‘Captive’ samples, such as Army recruits and
—6 to —-5 OS 33 DS 0.4
school children, are the most amenable to large-scale —5to —4 0.3 1.6 BS) 0.4
surveys.
—4 to —3 On Dep! 32) 0.9
In classifying ametropia into spherical power groups,
—3 to —2 iat Doll Dal 115)
astigmatism presents a difficulty. Different investigators —2to-1 WQ Shs) 4.8 2.4
have adopted various means of dealing with it, which —1to0 4.] les) 11.4 Del
slightly affects comparison of their results. Though it Oto +1 64.9 DOW 46.3 40.0
does not affect low-power groupings, another point of +1 to+2 23.8 12°6 14.6 33.4
+2 to +3 1.6 2.0 a3} 6.4
difference is whether the results are recorded in terms +3 to +4 0.3 1.0 0.3 4.0
of spectacle or ocular refraction.
Table 21.1 summarizes the distribution of ametropia +4to+5 0.2 0.6 Ne) No
+5 to +6 0.2 On? O)9) 2
(in terms of spherical power) found in three notable stu- +6 to +7 0.1 0.7 0 ORD
dies by Strémberg (1936), Stenstr6m (1946) and over +7 Ox 0.9 eS 0.7
Sorsby et al. (1960). Stromberg’s subjects were 2616
Swedish Army conscripts (20-year-old males). Both
eyes were refracted, giving a total of 5121 after 111
eyes had been excluded. The figures in the table refer to
the results as amended by Stenstr6m to convert them included 16 case records selected at random from men
into ocular refraction. who had been rejected because of refractive errors, 13
In Stenstr6m’s own study, the sample consisted of of them myopes and the remainder hypermetropes. All
patients of the Eye Clinic of the University of Uppsala the subjects were aged 20-27 years and 91% of them
(Sweden), colleagues and nurses and cadet officers of were under 23. Subjective refraction following retino-
the army and air force. The first and third of these scopy was performed under mild cycloplegia. The
groups were considered to form a balance, having, re- vertex distance was measured so that the results could
spectively, a larger and smaller proportion of appreci- be expressed in terms of ocular refraction.
able refractive errors than the general population. If the astigmatism did not exceed 0.50 D, the ametro-
Potential subjects with astigmatism at axes more than pia was taken to be the mean refractive error, equal to
30° from the horizontal or vertical were excluded. All the sphere plus half the cylinder. In higher degrees of as-
the subjects were aged 20-35 years. The right eye only tigmatism, the figure tabulated was the refractive error
was examined, giving a total sample of 1000 eyes. Ame- in the less ametropic principal meridian. Results were
tropia was recorded in terms of the ocular refraction in presented both for the total sample of 2066 eyes and
the principal meridian nearer to the horizontal. also for the 1033 subjects as persons on the basis of the
In the study by Sorsby and colleagues, the subjects better eye. Very little difference was shown between the
were 1017 young men in the United Kingdom called up two sets of tabulations.
for National Service in an army unit accepting refractive Despite differences, the three studies considered agree
errors from +8D to —6D. In addition, the survey in showing that hypermetropia is much more common
 Distribution of ametropia 407

than myopia. For the male samples, 70% or more of all Table 21.2 Distribution of ametropia (analysis of 9163 distance
eyes fall into the range of hypermetropia up to prescriptions from a Ministry of Health survey in 1962)
+2.00D, while the most common refractive state for Mean refractive error Percentage geo,of total
4
both sexes is hypermetropia less than +1.00 D. The dis- (D)
tribution of myopia is also skewed because it extends to R eye Leye Overall
far higher degrees of error than hypermetropia.
over —6.00 2.65 2.54 2.6
Table 21.1 is restricted to young adults. Changes in —3.12to —6.00 5.36 Say 5.4
ametropia with age are considered on pages 411-417. —1.12 to —3.00 8.43 8.37 8.4
—0.62 to —1.00 4.04 3.94 4.0
—0.37to —0.50 D557) 2.80 Mel
—0.12to —0.25 2.76 3.08 D9
Unaided and corrected vision
Oto +0.25 8.43 8.73 8.6
Before the outbreak of war in 1939, some 90 000 young +0.37to +0.50 HAO 6.98 7.0
men between the ages of 20 and 21 had been medically +0.62 to +1.00 1570 14.30 14.6
examined under the Military Training Act of that year. +1.12 to +2.00 20.10 19.74 ENS)
The medical records, which included the unaided +2.12to +4.00 17.40 Wn WS
+4.12 to +8.00 S30) 6.08 6.0
vision, were later analysed by the Statistical Research
over +8.00 0.38 OMe, 0.4
Unit of the Medical Research Council and a report was
prepared by Martin (1949). The sample, though not
strictly random, was considered to be representative of
the young men throughout the UK.* had been issued by ophthalmic medical practitioners,
The results showed that 65.9% of the total sample ob- the remainder by ophthalmic opticians (optometrists).
tained unaided vision of 6/6 or better in both eyes, By permission of the Ministry of Health, an analysis of
while a further 13.3% achieved this standard in their the technical data was published by Bennett (1965). It
better eye. About 80% could thus be considered to pos- included a tabulation of the 21 042 single-vision lenses
sess high-grade vision. Only 9.4% fell below the stan- in the sample. Up to 6.00 DS and 4.00D every lens
dard of 6/12 in at least one eye. power was shown separately, all the astigmatic pre-
A regional analysis confirmed the popular view that scriptions having been recorded in the plus cylinder
countrymen enjoy better vision than city dwellers. transposition. This information provided an accurate in-
Some 73% of the subjects from rural areas achieved dication of the relative demand at that time for different
6/6 or better in both eyes as against 65% from else- single-vision lens powers.
where. In this analysis the London area was excluded Table 21.2 shows the distribution of ametropia, in
because of its complex character. A separate tabulation terms of mean refractive error, according to the 9163
of the overall figures for England, Scotland and Wales distance prescriptions in the same Ministry of Health
showed only trifling differences in the percentages survey. The separate tabulations for right and left eyes
reaching the highest category. confirm the well-known tendency for fellow eyes to
In the 1960 study by Sorsby and colleagues referred have similar refractions. Near vision prescriptions were
to previously, the unaided and corrected visual acuities omitted from this analysis to avoid introducing a plus
were also recorded. In general, the results for the un- bias in the spherical element.
aided vision were very similar to those found in 1939. Because many young hypermetropes do not wear a
Of the 1033 subjects, 67.7% reached 6/6 or better in at correction until the approach of presbyopia, data ob-
least one eye and a further 12.9% reached 6/7.5 tained from records of prescribing will tend to show a
(20/25). Those falling below 6/12 in at least one eye to- larger proportion of myopes than is found in the general
talled only 10.0%. population. For example, Table 21.2 indicates a total of
Figures for the corrected visual acuity in at least one 26%. This is over twice the proportion revealed by the
eye gave 88.9% with 6/6 or better and a further 8.1% study of Sorsby et al. (1960).
with 6/7.5 or better — a total of 97%. Only 0.4% re- In Table 21.3, the sample of distance prescriptions
mained worse than 6/12 and no one below 6/24. analysed in Table 21.2 has been classified into arbitrary
ametropic groups in which the two eyes of each pair
have been taken into account.
Data on ophthalmic prescribing
The most comprehensive survey of ophthalmic pre-
Sex differences in ametropia
scribing on record is undoubtedly that undertaken by
the Ministry of Health (now the Department of Health In 1950, a comprehensive survey of visual defects was
and Social Security) in 1962.° A random sample of pre- made by Giles, who summarized the data then available
scriptions totalling about 0.25% of the annual local from American and British sources. General agreement
demand was taken“*from every administrative area of was found that women tend to be somewhat more
England and Wales. About one-sixth of the prescriptions prone to myopia than men, from childhood onwards. A
corresponding difference was found in various studies
of unaided vision.
The same sex difference is revealed in Stenstrém’s
“In the UK, all but an insignificant fraction of ophthalmic
dispensing in 1962 was carried out under the National Health findings (Table 21.1) which show myopia among 24.6%
Service. of the 685 men in the sample and 34.1% of the 315
408 Distribution and ocular dioptrics of ametropia

Table 21.3 Classification of ametropia into arbitrary groups Table 21.4 Incidence ofastigmatism (analysis of 12 916
prescriptions for distance or for near vision only from a Ministry of
(same sample as Table 21.2)
Health survey in 1962)
Ametropic group” Percentage of
total sample Power of Percentage of Percentage of
correcting cylinder total sample astigmatic lenses
High myopia: over —6.00 Din (D)
worse eye Sy
0 32.0
Moderate myopia: —0.62 D to —6.00 Din
worse eye WH OP — Wao) 3 50.9 s
0.75-1.00 Wadi 26.0
Near emmetropia: —0.50 Dto + 1.00 Din
both eyes Deshi} 2552-00 9.8 14.4
Pee 3.8 5.6
Hypermetropia: over + 1.00 D to +8.00 Din 3.25-4.00 IS Dip
worse eye 47.4
over 4.00 0.6 O79
Marked hypermetropia or aphakia: over
+8.00 D in worse eye Or

Antimetropia (other than in near emmetropia) BY)

studies on small or isolated ethnic groups, has been

“ Determined by the mean refractive error. ably summarized in a dissertation by Eisenstadt (1983).

women. Both these figures are substantially higher than

those in the other two studies summarized. This may be
due, in part, to the nature of the sample. A noteworthy
feature of Stenstrém’s results is that the preponderance Incidence of astigmatism
of female myopes in his sample occurs only in errors ex-
ceeding —2.00 D, for which the percentages are 7.8 for General pattern of distribution
men and 17.9 for women.
Analysis of the data obtained by the Ministry of Health
From various studies cited by Giles it emerged that
women made, in general, a greater demand than men survey in 1962 gives an accurate idea of the incidence
for ophthalmic services. This is certainly true in the of astigmatism in the spectacle-wearing population of
UK, as shown by official statistics analysing the ‘sight England and Wales. Table 21.4 shows the picture given
tests’ (i.e. eye examinations) carried out under the by 12 916 prescriptions for distance vision or for near
National Health Service in 1959. In proportion to their vision only.
relative numbers, the demand by women exceeded the Nearly one-third of all the individual lenses were
men’s at all ages. Except in the age group 0-14 years, spherical. Of the astigmatic lenses, about one-half had
the difference was never less than 25 per thousand and cylinder powers of either 0.25 or 0.50 D, while a further
usually over 30 per thousand of the relevant popula- quarter had cylinder powers of 0.75 or 1.00 D. Less
tion. The greatest difference occurred in the age group than 1% had cylinders over 4.00 D.
15-19, in which over 140 per thousand women but A more detailed analysis of the raw data again con-
less than 80 per thousand men sought an eye examina- firms a general similarity between the two eyes of a
tion (Bennett, 1973). : pair. Over 22% of all the prescriptions in this sample
From his own practice records, Slataper (1950) found were for spherical lenses in both eyes, while another
that during the 5-year period from age 45-50, the de- 22% were for sphero-cylinders with cylinders up to
cline in the amplitude of accommodation was about 0.50 D in both eyes.
0.6 D greater for women than for men. He attributed it In the 1960 study by Sorsby and colleagues, the re-
to menopausal effects. fraction of the 1033 subjects is classified to show the in-
cidence of astigmatism. A total of 38.6% were found to
have astigmatism less than 0.2 D, while as many as
90.2% had astigmatism, if any, not exceeding 1.00 D.
Ethnic differences in ametropia No support was found for the suggestion that high de-
From the inadequate data available it would appear that grees of astigmatism tend to be associated with high
the distribution of ametropia in different ethnic popula- spherical components.
tions conforms to a broadly similar pattern. Differences In his analysis of the Ministry of Health sample, Ben-
are mainly in the incidence of myopia. The conclusion nett (1965) also found astigmatism of all degrees to be
that it is slightly more common among Jewish people is fairly evenly distributed over the range of spherical
well founded, but there is a dearth of information about powers up to plus and minus 8.00D. Beyond these
adult populations in China and Japan. The few available limits, which substantially define the boundaries of the
studies do suggest, however, that the incidence of study by Sorsby and co-workers, a marked association
myopia in these countries, especially China, is appreci- of high astigmatism with high spherical errors was
ably though not dramatically greater than in the West- found.
ern world. Variations in astigmatism with age are discussed on
The literature on this general topic, including many pages 412 and 415.
 Components of refraction 409
Table 21.5 Distribution of cylinder axis orientations (analysis of Table 21.6 Worked example of the use of Humphrey notation to
7594 astigmatic single-vision distance lenses from a Ministry of determine the mean ofthree astigmatic corrections
Health survey in 1962)
Sphero-cylinder notation Humphrey notation
Cylinder power Percentage distribution ofaxis orientation
(D) in each cylinder power S C 0° MRE G C45
sphere cylinder —_ axis
With therule Against therule Axis oblique
+2.00 —3.00 60 +0.50 +1.50 —2.60
0.50 36 34 30 —1.00 +5.00 70 +1.50 =Seissy 43} al
1.00 34 34 32 +3.00 —2.00 140 +2.00 —0.35 +1.97
LE Sx0) 35 31 34
2.00 38 24 38 Sum +4.00 —2.68 +2.58
2.50 50 18 32,
3.00 54 Wi DY) Mean +1.33 —0.89 +0.86
Je) 49 187, 34
4.00 50 Is 5D Sphero-cylinder equivalent +1.95 DS/—1.24 DC axis 158°

over 4.00 58 1S YY)

sphero-cylindrical form. A more detailed treatment of

this subject has been given by Bennett (1984).
Axis direction
Methods similar to those of Harris cited in Chapter 5
The Ministry of Health survey provided interesting data were employed by McKendrick and Brennan (1996) to
on the distribution of cylinder axis directions. In his find the mean astigmatic error of 198 young adult
1965 analysis of this material, Bennett regarded any patients’ eyes to be Right —0.17 DC x14 and Left
axis within 15° of the horizontal or vertical as with or —0.24 DC x 180. Because astigmatic errors against the
against the rule (as appropriate) and all others as ob- rule tend to cancel out those that are with the rule, a
lique. On this basis, only 38% of the astigmatic single- value for the mean error determined this way does not
vision distance lenses in the sample indicated with the imply that the mean cylindrical power is only around
rule astigmatism. The remainder was made up of 30% 0.25 DC when the axes are ignored.
against the rule and 32% oblique. In Table 21.5,
abridged from Table 7 in Bennett’s analysis, the division
into the three categories of axis direction is shown as
percentages of the total within each separate cylinder
Components of refraction
power listed. Although the percentage of oblique direc-
tions remains fairly constant, there is a marked increase The four main variables which collectively determine
of with the rule in cylinder powers over 2.00 D. the refractive state of an eye are the corneal power, the
depth of the anterior chamber, the equivalent power of
the crystalline lens and the eye’s axial length. Subject
to a proviso concerning the axial length, the spread of
Method of analysis
all four dimensions follows a normal distribution curve.
As explained in Chapter 5, the principle of ‘astigmatic They will now be considered in turn.
decomposition’ can usefully be applied to the statistical
analysis of any number of ophthalmic prescriptions.
Cornea
Those with an astigmatic component would first be
transposed into what might be termed Humphrey nota- For statistical purposes the corneal radii and power are
tion, in which the three elements C,, Cy; and M are taken as the keratometer readings, generally in a speci-
defined by equations (5.13), (5.14) and (5.16) respec- fied meridian. Different instruments may use slightly dif-
tively. In the present context, the mean power M is re- ferent notional refractive indices for converting
named the mean refractive error (MRE). Purely spher- anterior corneal radii of curvature into powers (see
ical prescriptions would also be entered under this page 387).
heading. In his 1946 study, Stenstro6m found the range to be
When tabulated in this notation, all cylinders are put from 7.0 to 8.65 mm, with a mean for all subjects of
on a common basis in which a component either with 7.86 mm (7.90 mm for males and 7.77 for females). In
or against the rule is combined with an oblique compo- about 84% of all eyes, the radius was between 7.5 and
nent, plus or minus, at the neutral oblique axis 45°. A 8.2 mm. The upper age limit of the subjects in this
numerical example is set out in Table 21.6 which is mod- sample was 35 years. Significant changes in corneal
elled on Table 5.1 On dividing the sum of the three com- curvature which begin to occur at about this age are
ponents by the number of prescriptions, the mean of discussed on pages 415-416.
the entire sample is obtained in Humphrey notation. In considering Stenstr6m’s results it should be borne
Re-conversion into its orthodox equivalent then re- in mind that they refer to readings in the principal
quires the three steps defined by equations (5.17), meridian nearer to the horizontal. With the rule corneal
(5.18a) and (5.19). astigmatism would result in somewhat shorter radii of
Corneal astigmatism could also be analysed by this curvature in the meridian nearer the vertical. Converted
new method. For this purpose it would be necessary to into corneal powers, Stenstrém’s findings show a
transpose the keratometer power readings into a spread from about +39 to +48 D, with an overall mean
410 Distribution and ocular dioptrics of ametropia

other dimensions remaining unchanged, would result

in myopia of somewhat less than —0.12 D.
Among other aspects investigated by Calmettes and
colleagues was the relationship between anterior cham-
ber-depth and ametropia. A scattergram of their results
showed that whereas the values were evenly spread
about a mean figure in all degrees of myopia, there was
a progressive reduction in depth with increasing hyper-
metropia, averaging roughly 0.17 mm per dioptre. A si-
milar trend is discernible in Table Al of the report by
Replacement of the crystalline lens by a
Sorsby et al. (1957).
Figure 21.1.
hypothetical thin lens of the same equivalent power, placed
near the principal points of the original schematic lens. A
simplified relationship between ametropia and the individual
components of refraction can then be deduced from the ray
path illustrated. Crystalline lens
In Stenstrém’s procedure the equivalent power F, of the
crystalline lens (and also of the eye) was calculated
of +42.75 D (+42.50D for males and +43.25 for fe-
from the experimental data on the assumption that the
males). Some 85% of all eyes fell within the range +41
lens was of zero thickness and situated at the front
to +45 D.
vertex of the true lens. To compensate for the errors
The ocular refraction K is the reciprocal of the dis-
thereby introduced, an addition of +3.00D to all the
tance k to the eye’s far point Mr which is conjugate
calculated values of F, was suggested. Though the
with the retina (Figure 21.1). Since the cornea is the
amended values can be regarded only as approximate,
last refracting element traversed by a pencil of rays di-
a reliable picture of the spread of values is obtained.
verging from the retina, it follows that a change AF, in
With the +3.00 D added, the range was found to be
the corneal power would result in an equal but opposite
change AK in the ocular refraction. Expressed mathe- from about +15.5 to +25D, with a mean value of
+20.35 D(+20.25 D for males and +20.56 for females).
matically,
Some 91% of the total fell within the range +18 to
GSI (21.1) +23 D. It is noteworthy that the total spread of powers,
Thus, an increase of 1 dioptre in the corneal power about 9.5 D, is slightly greater than that of the cornea.
would alter the ocular refraction by 1 dioptre in the di- If the equivalent power of the crystalline lens is varied
rection of myopia. Strictly, the distance k should be by AF,, its centre thickness and all other ocular dimen-
measured from the first principal point of the eye, about sions being unchanged, the approximate effect on the
1.5 mm behind the corneal vertex. eye's refractive state can be found from the expression
AK = —0.65AF, (21.3)
Depth of anterior chamber This was derived from the Bennett—Rabbetts emmetropic
schematic eye.
In this context, the depth of the anterior chamber is
taken to include the corneal thickness. Stenstr6m found
a range from 2.8 to 4.6mm, with an overall mean
value of 3.68 mm (3.70 mm for males and 3.61 for fe-
Axial length of the eye
males). About 84% of all eyes fell within the range 3.2—
4.0 mm. Stenstr6m determined the axial length by the X-ray
From a study of 144 subjects whose ages were fairly method of Rushton. He found a range from 20 to
evenly spread over 4—70 years, except two aged 75 and 29.5mm, with a mean value of 24.00 mm (24.04 mm
85, Calmettes et al. (1958) found the anterior chamber for males and 23.89 for females). Although no extreme
depth to increase slightly from age 4, reaching a maxi- myopes were included in the sample, the distribution of
mum at about age 20. The peak values averaged axial lengths is clearly not symmetrical but shows a pro-
3.80 mm for men and 3.73 mm for women. Because of nounced ‘tail’ on the long side. In fact, axial lengths
the subsequent gradual decrease in this dimension, to over 40mm _ have been’ reported. Nevertheless,
be discussed on page 415, the mean figure for the Stenstrom found that if eyes showing the conus or
entire sample fell to 3.58 mm. myopic crescent usually associated with pathological
In the emmetropic Bennett—Rabbetts schematic eye, a myopia were excluded from his sample, the remaining
reduction of 1mm in the anterior chamber depth results did conform to a normal distribution.
would result in myopia of —1.32 D if the axial length re- For the Bennett—Rabbetts emmetropic schematic eye,
mained constant. An increase of 1 mm would produce calculation shows that the approximate effect AK of a
hypermetropia of +1.29D. For smaller displacements variation Aa (in mm) in the axial length is expressed by
the resulting ametropia would be pro rata. Accordingly,
AK S27 Na (21.4)
if the variation in depth is denoted by Ad, (in mm),
for values of Aa up to about +1 mm. For Aa = +3 mm,
AK = 1.4Ad, (Pleo)
the coefficient in equation (21.4) would become —2.4,
Thus, the smaller depth in the average female eye, all while for Aa = —3 mm it would be —3.1.
 The growing eye 411

Equivalent power of the eye

For the reason already mentioned, Stenstrém suggested
an addition of +1.50D to his calculated values for the
equivalent power of the eye. When thus amended, the
values he found ranged from +54 to +65D, with a
mean of +59.63 D (459.32 D for males and +60.23 D
for females). Just over 90% of all the eyes fell within the
range +57 to +63 D. Once again, a normal distribution
pattern is revealed.
A very similar sex difference was found in the study by
Sorsby et al. (1961) of 628 boys and 717 girls aged of
Number
persons
from 4 to 14 years (girls to 15 years). In most of the
yearly age groups the difference fell between 1.0 and
1.4D, the mean for the whole sample being about
1.2 D. In the 14-year-old age group, the difference was eres
1.0 D. The mean equivalent powers for this group, —10 —8) —6 =4 =2 0 +2 +4
+59.1D for the boys and +60.1D for the girls, are
about 0.50 D higher than Stenstr6m’s amended figures Ocular refraction (D)
for his adult sample. They refer, however, to the vertical Figure 21.2. Histogram showing the distribution of
meridian, whereas Stenstrém’s refer to the horizontal. ametropia in 2066 young adult males. A normal distribution
curve (dashed line) is superimposed. (Redrawn from Sorsby et
al., 1960.)
Ocular refraction

For an accurate determination of a given eye’s refractive a large sample of eyes in which each component is se-
state or ametropia, the surface powers and axial thick- lected at random from the available range could also be
ness of the crystalline lens are needed in addition to the expected to show a normal distribution of refractive
four main components of refraction. For purposes of errors. A conclusive statistical exercise on these lines
statistical analysis, however, a simplified scheme can be was carried out by Sorsby et al. (1981). The fact that
adopted without introducing serious errors. It requires the actual distribution of ametropia takes a very dif-
the equivalent power of the crystalline lens to have ferent pattern is shown by Figure 21.2. The histogram
been determined accurately. A hypothetical ‘thin’ lens depicts the findings of Sorsby et al. (1960) summarized
of this power is then considered to be situated at a dis- in Table 21.1, while the dashed line is the normal distri-
tance c from the anterior pole of the true lens (Figure bution curve. (Because of the nature of the sample, the
21.1), such that it lies at or near the mean position of histogram does not show the myopic tail found in the
the principal points of the true lens. For the Bennett- general population.)
Rabbetts schematic eye the appropriate value of c is The concentration of refractions in the neighbour-
2.3mm. hood of emmetropia proves the typical eye to have a co-
Let F, denote the corneal power, d, the depth of the ordinated optical system. Moreover, since the axial
anterior chamber, w=(d,+c),F, the equivalent length of the full-term neonate eye is approximately
power of the true crystalline lens, a the overall axial 18mm, the equivalent power must be of the order of
length of the eye and n’ the refractive index of humours. +75 D. There is thus considerable scope for large refrac-
Then an axial pencil of rays diverging from the fovea tive errors to occur during the period of growth. A
can be traced through the eye by the step-along study of this process discloses the optical adjustments
method. After refraction by the cornea, this pencil must by which the necessary co-ordination is effected.
converge to (or apparently diverge from) the eye’s far
point. Its vergence L’ is therefore equal to —-K, where K
now denotes the ametropia measured at the corneal
vertex. This approach leads almost directly to the ap-
The growing eye
proximation
The infantile phase
n —(a—w)F,
K= Fy (A,Sy) In their study of 1000 neonate eyes refracted under
a— (w/n')(a— w)F,
atropine, Cook and Glasscock (1951) found about 57%
where the linear dimensions are al] in metres. to be hypermetropic up to +4 D, with a further 18% hy-
If the value assigned to a is varied or in error by permetropic beyond this degree up to +12 D. The re-
+0.1 mm, the resulting change in the value of K is ap- maining 25% were myopic, the limiting value being
proximately +0.12-D. —l2D. The mean for the entire sample was hyperme-
tropia of about +1.50 D. These findings are not far re-
moved from a normal distribution with slight skewness.
Co-ordination of components Changes in refraction during the first 3 years are
largely uncharted. Gwiazda et al. (1993) measured the
Since all the components of refraction (subject to the re- refraction in a longitudinal study in a sample of 72 chil-
servation about axial length) are normally distributed, dren, perhaps biased as over 60% of the parents were
412 Distribution and ocular dioptrics of ametropia

Table 21.7 Changes in ocular refraction and its components between the ages of
3 and 14 (or 15) (data from Sorsby et al., 1961)

Dimension Boys Girls

53 40 36 TD 34
aged 3 aged 14 aged 3 agedl14 = aged15

Corneal power (D) +42.6 +42.9 +43.8 +43.8 +43.5

Anterior chamber (mm) 3.4 35 358) 535) 365) me
Power of lens (D) +21.8 +19.9 +21.4 +20.7 +20.5
Axial length (mm) 232 24.0 DS 22.5) Disey,

Power of eye (D) +60.4 +59.1 +62.0 +60.6 +60.1

Ocular refraction (D) a a) +1.0 eT +0.8 + 0.7

myopic. In infancy, their results showed a similar distri- (Sorsby et al., 1957, 1961, 1970). Because their experi-
bution to, but were more negative than, those of Cook mental procedure included phakometry, they were able
and Glasscock, probably because Mohindra near retino- to determine the axial length of the eye as accurately
scopy without cycloplegia was used. The mean spherical by calculation as by the radiological method. A full ac-
equivalent error was slightly negative at 3 months, count of the apparatus and methods of calculation used
rising to about +0.50 D at age 1 year, which was main- is given in their 1961 report.
tained till age 8 when it moved towards myopia again. The following summary of these investigations is lim-
Plotting the results separately for the initially myopic ited to the main findings and conclusions. In the first of
eyes and for those with > +0.50 D, the graphs converge the studies, the sample population comprised 341
by the age of 1 year, demonstrating the emmetropiza- adults aged 20-60 years, with mainly spherical ocular
tion process; while the initially hypermetropic group re- refractions ranging from —21 to +12 D. The 90 subjects
mained hypermetropic, the myopic group's mean with ametropia not greater than +0.50 D were regarded
returned to myopia at the age of 8. The emmetropization as emmetropes. This group was found to have a wide
process is also shown by the spread of refractions: if the range of optical dimensions: corneal powers from +38
standard deviation is taken as the indicator, it fell from to +48 D, lens powers from +17 to +26D, and axial
+2.0D in infancy to around 1.0 D at 1 year and to a lengths from 21 to 26mm, mainly 22-26 mm. From
minimum of about 0.75 D at age 6 years.
these results it was concluded that co-ordination, not
New methods have enabled astigmatism to be meas-
conformity, is the essential feature of emmetropia.
ured in the very young. For example, Mohindra et al.
With few exceptions, the same ranges of component
(1978) made a study of 276 full-term infants aged from
values were also found in ametropia up to +4.00 D.
birth up to 50 weeks. Astigmatism over 1 D was found
Within these limits, the myopes tended to have longer
in 45% of the infants, including 12% with 3 D or more.
axial lengths and higher corneal powers than the emme-
A follow-up study was made of 28 of the infants who
tropes, while the opposite was shown by hypermetropes.
had shown over 2D of astigmatism when 3—6 months
Nevertheless, ametropia of both kinds up to 4.00D
old. Re-examined when 50 weeks old, 14 had lost their
should be regarded as resulting from an imperfect co-or-
astigmatism and 7 showed a reduction of 1—2 D. The re-
maining 7 showed no change. Further reductions con- dination of a normal spread of component values. A
tinued in the second year, and astigmatism once lost study of correlations revealed that while corneal and
was not found to return. No sign of meridional amblyo- lens powers were both well correlated with axial
pia (see page 42) was detected before the end of the length, the correlation of corneal power was particu-
third year. larly high among the emmetropes. The cornea thus ap-
Similar findings of high astigmatism were reported in peared to play a greater role than the lens in co-
a study by Howland et al. (1978) of 93 children aged ordinating the eye’s optical system. In ametropia greater
from 1 day to 12 months, using the technique of photo- than +4.00 D, the factor of axial length was undoubt-
refraction. No fewer than 60% were found to have astig- edly the major determinant. For example, no myopic
matism over 1.00 D, including 23% with over 2.00 D. eye in this range had an axial length less than 25 mm,
The work by Gwiazda and colleagues also showed a si- and no hypermetropic eye a length greater than 22 mm.
milar reduction with age. Thirty-five percent of their Growth of the eye is most rapid during the first 3
infants had 2D or more of astigmatism, 15% at 1 year years, at the end of which the adult size has almost
and none at age 4; the proportion showing errors up to been reached. Unfortunately, examination during this
2 DC remained at about 30% until 30 months, then“fall- period presents such difficulties that little information
ing to less than 10% by the age of 5 onwards. on the components of refraction is available. The
second major undertaking by Sorsby and his team was
a cross-sectional study of children aged 3 years and up-
The juvenile phase
wards, mainly drawn from day nurseries and London
Considerable light on the growing eye and the ocular schools. Approximately equal numbers, usually from
dioptrics of ametropia has been thrown by the re- 50 to 60 of each sex, were examined in every yearly
searches of the late Arnold Sorsby and his associates age group up to 14 years for boys and 15 years for
 The adult and ageing eye 413

girls. The total sample comprised 671 boys and 761

Ametropia at age 5 or 6 Predicted ametropia at 13
girls.
or 14
In the published report, the mean dimensions given
for each age group were determined after exclusion of Myopia of any degree Increased myopia
43 boys and 44 girls whose ocular refractions differed Oto +0.50 D Probably myopia
by more than two standard deviations from the mean +0.50 to +1.50 D Best chance of emmetropia
Over +1.50 D Little change in
of their own age group. Table 21.7 gives the figures for
(especially over +2.00) hypermetropia
the first and final age group. The report also gives the
mean values of ocular refraction (only) when the entire A separate report (Hirsch, 1963) had shown that as-
sample is taken into consideration. For boys, the mean tigmatism over 0.12 D was found in 55% of the children
refraction change over the whole period was from at the initial examination but in 66% at the final exami-
+2.33 to =-0.93 DD; and for girls from +2.96 to nation. The percentage having astigmatism with the
+0.64 D. The average change is thus in the direction of rule remained at a little under 40%, while against the
myopia, amounting to about 1.4D for boys and 2.3 D rule increased from 17 to 27%. This variety occurred
for girls. most frequently among myopes. Citing Gullstrand in
To supplement the cross-sectional study, a limited support, Hirsch expressed the view that against the rule
follow-up was made on 440 of the children to assess astigmatism in the young is more likely to result in
rates of change in the variable quantities. The interval symptoms than the more common form.
between the two examinations was from 2 to 6 years. Exhaustive studies have been made on myopia in the
Because of inconsistencies in the fifidings, the number hope that it might be prevented, cured or moderated.
of results analysed was reduced to 386. In brief, it was These researches, which are beyond the scope ofthe pre-
found that the rate of growth gradually decreases with sent work, are summarized in the text by Borish (1970).
age and that development is usually complete by the
age of 14. No evidence for a spurt of growth at puberty
was found. The crucial factor determining the refractive
state is the extent to which power changes, particularly
of the crystalline lens, compensate for increases in the
The adult and ageing eye
axial length. Annual rates of increase varied from less
than 0.1 to over 0.5mm, with an average of about Age norms of refraction
O.2 mm per annum. From cross-sectional analyses of large numbers of case
Because of inadequate compensation, some 13% (17 records in a single practice, it is possible to construct a
boys and 33 girls) of the total sample became myopic or picture of what Slataper (1950) termed ‘age norms of re-
showed an increase in myopia during the 2—6-year fraction’. The upper curve in Figure 21.3, in which
period between examinations. Nevertheless, even mean refractive error is plotted against age, is a
among those children whose axial length increased at smoothed version of the graph in his well-known study.
double the average rate, power-change compensations The relationship between cross-sectional studies of re-
still played an important role. Of a group of 21 children fraction and studies based on longitudinal case histories
whose ametropia changed by over 2.00 D between ex- was analysed by Saunders (1986a). He concluded that
aminations, invariably in the direction of myopia, the large-scale studies of both types should lead to statis-
average amount of compensation was approximately tically identical conclusions, and that a large-scale
1.4 D. Without this, the ametropia would have changed cross-section study is preferable to a small-scale longi-
on average by 3.9 instead of by 2.5 D. Two ofthese chil- tudinal one.
dren were already myopic, and 11 became myopic, but Age-norm graphs do not purport to represent the gen-
the remaining 8 had their hypermetropia reduced. A eral population but only those members of it who seek
more detailed study of this group reveals that the optical assistance in the given locality, a distinction
amount of compensation, though inadequate in some which almost disappears in the presbyopic age groups.
cases, was generally proportionate to the full amount
needed. For example, the girl whose axial length in-
creased the most (by 2.1 mm) had the corresponding
myopic change decreased by as much as 3.3 D.
Further observations were subsequently made on 129
of the children in the follow-up study and on 12 others
first seen at the age of 14-16 years. These investigations
formed the basis of the 1970 report by Sorsby and
Leary. Though adding much detail to the picture, they
did not change its general outlines. (D)
refractive
Mean
error
A longitudinal study of school children in California
0 10 20 30 40 50 60 70 80 90
revealed changes in refraction similar in pattern to
those found by the Sorsby team. From comparison of re- Age (years)
fractions at the age of 5 or 6 and at 13 or 14, Hirsch Figure 21.3. Age norms for refraction. (Curve FJS from the
(1964) concluded that the following generalized predic- data of Slataper, 1950. Curve HS reproduced by kind
tions would be warranted: permission of Mr H. Saunders, 1981.)
414 Distribution and ocular dioptrics of ametropia

There are, of course, many individual exceptions to the change must first be sought in the effects of ageing on
broad pattern of ametropic change presented. the components of refraction.
Whereas Sorsby and his colleagues found that hyper- Individual variations from the typical course of devel-
metropia was already declining by the age of 3, when opment are revealed in longitudinal studies, such as
the mean values were +2.33 D for boys and +2.96D those by Freeman (1956) and Elliott (1971). Elliott
for girls, Slataper’s graph shows it to increase to a peak plotted annual rates of change in the mean refractive
value of about +4D at the age of 6. It could be that error, Separate graphs showed these rates for 260 right
many of his very young patients had been brought to eyes and 257 fellow left eyes, each subdivided into
him because they were showing a tendency to esotropia those initially myopic, emmetropic and hypermetropic.
as a result of excessive hypermetropia. Little difference was found between the last two groups.
A more recent study by Saunders (1981)* of his own In the myopic group, however, the swing towards hy-
case records led him to the conclusion that the graphs permetropia after the age of about 30 appeared to be
of his findings for all patients could be fitted very closely less marked and to reach its peak several years earlier
by the cubic equation than the average. It was also found, particularly in the
hypermetropic group, that rates of change for the left ,
MRE = 2.036 — 0.227% + 5.847(10°*)x? eye of a pair were significantly smaller than for the
right eye and that the peak of the hypermetropic drift
{Serieyar (21.6)
was reached 10 or more years later.
in which MRE is the mean refractive error (or ‘equiva-
lent sphere’) and x the age in years.
For the separate sexes the following equations were Prognosis of future refraction
also given: The separate forms of equation (21.9) were later tested
by Saunders (1985) against 47 case histories from an-
Females
other practitioner. Over a short interval the error in pre-
MRE = 2.205 — 0.238x + 6.053(10*)x? diction did not exceed 0.25D in nearly 60% of the
cases and 0.50D in 92% of them. These margins of
— 3.963(10°°)x? (ZIRT) error were approximately doubled in long-term predic-
tions. The greatest uncertainty was in cases of medium
Males
and high myopia.
MRE = 1.831 — 0.214x+ 5.666(107°)x? Freeman (1956) found that moderate myopia tends to
stabilize at about the age of 20, when it rarely exceeds
= 3833(
Or ae (21.8) —6D. Higher degrees of myopia, fortunately rare, are
the result of abnormal lengthening of the globe. Such
From the above analysis the following equation was
cases become noticeable at a very early age and progress
later derived (Saunders, 1984b) to give the predicted
rapidly through school life and beyond.
MRE (S,.) at age x, knowing the MRE (S,) at age a:
Discussing this question, Goss (1987) divided child-
Se Sy 0227 =a) eS. 84700)@ =a") hood and young adult myopia into three categories. In
the first, adult stabilization, the myopia tends to settle
= 3 STO a \(xo a.) (21.9) at about —6 D by the age of 15 or so, though it may con-
tinue at a very slow rate of progress until the middle
For the separate sexes, the coefficients in this expression
twenties. About 68% of males and 87% of females in
should be replaced by those in equations (21.7) or
the sample examined were in this category. In the adult
(21.8), whichever applies.
continuation category, which included 25% of the
A series of age-norm graphs had previously been pub-
males and 13% of the females, the progress of myopia
lished by Gasson (1932). Separate graphs were given
slows down appreciably by the age of about 18 and
for hypermetropes and myopes as well as for the entire
then continues at a slower rate. In adult acceleration,
sample of 3436 patients. This latter graph, plotted in
which applied to 6% of the males and none of the fe-
terms of the mean refractive error, is similar in outline
males, myopia progresses at a faster rate after adoles-
to Slataper’s and Saunders’ in Figure 21.3 and would
cence. Various factors having a possible bearing on the
occupy an intermediate position between them. The
different rates at which myopia progresses in childhood
same applies to the graph constructed by Freeman
and young adulthood were identified.
(1956) from his own practice records. In a later paper
Practitioners are frequently asked by parents of very
(1935), Gasson analysed the relative demand for eye ex-
young myopes to give a long-term prognosis. Caution is
amination in different age groups and also published
advised by both Goss (1987) and Saunders (1986b,
age norm graphs for males and females separately. All
1986c, 1987b), who recommended that it should not
these investigations agree in showing a steady drift to-
be attempted without knowing at least two refractive
wards hypermetropia from about age 25 or 30, reaching
findings over a period of several years.
a peak between 65 and 75 years. There is then a rever-
sal which often takes the form of a fairly steep descent
towards myopia. A reason for this overall pattern of
Recent work on myopia

“Table 7 in this paper was later corrected (Saunders, Recent investigations have used keratometry and ultra-
1984a). sonography to measure the components of refraction of
 The adult and ageing eye 415

groups of emmetropes and myopes. Typical findings are This has been the accepted view for many years. Re-
those of Bullimore et al. (1992) who found the vitreous cently, however, evidence has been put forward by
depths in groups of late-onset (after the age of 15) and Brown (1987) to suggest that the radii of the external
early-onset myopes were both longer than in emme- lens surfaces become shorter with age, not longer. If so,
tropes. In general, findings show that early-onset the effect would be to make the eye relatively more
myopes have longer axial lengths than late-onset myopic. This would deprive the hypermetropic drift of
myopes, but Grosvenor and Scott (1991) pointed out the only explanation based on changes observed hither-
that the early-onset group usually are more myopic to. The only plausible explanation would be that the
than the late-onset group. Choosing sets matched for myopia induced by the suggested shortening of the lens
equal refractive error, no significant differences in the radii is more than neutralized by refractive index
components of refraction were found. Of the original changes within the lens (see page 416).
79 subjects, 53 were re-measured 3 years later The transmittance of the crystalline lens decreases
(Grosvenor and Scott, 1993). Statistically significant with age but not uniformly over the visible spectrum
slight increases in vitreous depths and axial lengths (Said and Weale, 1959). Their graphs show, for exam-
were found in the myopic groups, while the emme- ple, that for blue light the transmittance is approxi-
tropes’ lenses became slightly thicker. There was no mately 70% at age 21 but only 40% at age 63. For
change in the mean corneal power for any of the yellow light the figures are about 80% and 60%, which
groups who were in their early twenties, while the incidentally explains the yellowish tinge of the ageing
mean equivalent spherical power became mildly more lens. Over the same period of time there is also a
myopic (by < 0.25 D, though with a larger scatter to- marked reduction in pupil diameter (see page 26). Both
wards both hypermetropia and myopia for the initially changes demonstrate the importance of good illumina-
emmetropic group). tion to the elderly patient.
A group of 87 children of mean age 11 years was fol-
lowed by Goss and Jackson (1995), who compared the
mean spherical refractive error and ocular dimensions Changes in corneal curvature
of those who remained emmetropic (defined as plano to Although the corneal radius changes very little after the
+0.25 DS) with those who became myopic. They found age of 3 years until much later in life, it appears to in-
three suggestive pointers to identify those who were to crease slowly to a peak value in the second or third
become myopic, the simplest being a refractive error of decade. There is then a decrease which begins to flatten
less than +0.25D. Secondly, 87% of the boys who out after the age of 70. The dashed line M in Figure
became myopic showed keratometry readings in the 21.4(a) plots the probable variation with age of the typi-
nearer horizontal meridian of 7.85 mm or less, 64% of cal mean corneal radius. It was constructed as a compo-
the girls 7.60 mm or less. Thirdly, the ratio of axial site of the experimental findings of Heim (1941) and
length measured with ultrasonography under cyclople- Saunders (1982), together with unpublished kerato-
gia to horizontal corneal radius of greater than 3.00. metric records provided by Rabbetts. Data from this
Gwiazda et al. (1993) found that children who were latter source were also used to construct the dashed
myopic in the first few months of life, as demonstrated
by Mohindra near retinoscopy, were most likely to
become myopic later, especially if initially showing (a)
against the rule astigmatism. Those who had no astig-
matism in infancy tended, as a group, to become
myopic later, at around age 11, while the with the rule
group remained emmetropic. There was an increased
risk of myopia in children with two, compared with
none or one, myopic parents.
(mm)
Radius

Crystalline lens changes

One reason for the hypermetropic drift shown by age-
norm graphs is the continued growth of the crystalline
lens throughout life. Between the ages of 20 and 65 the
axial thickness of the crystalline lens increases by
about 1 mm, and it may be assumed for calculation
that both its radii of curvature are lengthened by
0.5 mm. During the same period the lens moves forward (D)
Power
into the anterior chamber, reducing its depth by about
0.6 mm. If the Bennett-Rabbetts emmetropic schematic 0 10 20 30 40 50 60 70 80 90
eye is modified accordingly, a reverse axial ray trace Age (years)
from the retina shows it to have become hypermetropic
Figure 21.4. The corneal radius as a function of age. (a) M
by just under +1.00 D. An increase in lens thickness of
denotes the mean radius compiled from the data of Heim
1.2mm with corresponding radius changes and the (1941), Saunders (1982) and Rabbetts. H and V denote the
same forward displacement of 0.6 mm would produce substantially horizontal and vertical radii of Rabbetts’ sample.
hypermetropia just over +1.25 D. (b) Corneal power corresponding to the mean radius M.
416 Distribution and ocwar dioptrics of ametropia

lines H and V in Figure 21.4(a), representing mean hori- percentage of prescriptions for against the rule astigma-
zontal and vertical radii. They were based on an analysis tism is not much lower than for with the rule. There is,
of 383 eyes whose meridians of corneal astigmatism however, a considerable variation with age, reflecting
were within 20° of the horizontal and vertical. the change in corneal astigmatism. This is shown by
Figure 21.4(a) clearly shows the well-known trend Figure 21.5, reproduced from the study by Saunders
away from astigmatism with the rule from early years (1981). In this analysis of 1817 prescriptions for the
onwards. Several researchers have shown that whereas right eye, astigmatism was regarded as with or against
over 90% of astigmatic corneae are with the rule in in- the rule if the minus cylinder axis was not more than
fancy, the percentage falls to below 8O by the age of 50 22.5° from the horizontal or vertical as appropriate. As-
and declines rapidly after 60. It is also apparent from tigmatism at oblique axes was subdivided into with the
the graph that although the vertical radius decreases rule (minus axis at 221 to 45° or 135 to 1575) and
from its peak value in the young adult, the horizontal against the rule (minus axis at 45 to 675° or 1123 to
radius decreases at a faster rate. This fact may throw 135°). Except in the first two decades, the total percen-
some light on the cause of differential curvature tage of oblique axes remained in the vicinity of 20-
changes. Keratometry on Hong Kong Chinese by Goh 25%. It will be noted that the two main varieties .
and Lam (1994) and Lam et al. (1994) similarly become equal at about age 45. Apart from a somewhat
showed the preponderance of with the rule astigmatism higher percentage of oblique axes, a very similar pattern
in the young (over 85% of under 40-year olds) declining of distribution was found by Jackson in 1933. A wide-
to almost equal proportions of with, against and oblique ranging investigation into the manner in which the cy-
at age 47 to less than 15% with and more than 55% linder axis changes from a with the rule into an against
the rule orientation was made in further studies by
against at ages over 60.
Saunders (1986d, 1987a, 1988).
Little detail is known about the variation with age of
the intra-ocular element of total ocular astigmatism. In
a study reported in 1954, Tait compared the corneal Refractive-index changes
and ocular astigmatism of 1600 eyes, making the appro-
Despite the lack of hard evidence, it is tempting to
priate allowance for effectivity. The difference between
invoke refractive-index changes to explain a puzzling
them was taken to be the intra-ocular astigmatism. His
feature of the age-norm graph. Figure 21.4(b) shows
total sample was equally divided among four age
the corneal power corresponding to the mean radius in
groups, the oldest of which was 50-65 years. In each
the upper part. It increases by about +0.75 D between
group, the majority of eyes showed 0.50 or 0.75 D of
the ages of 30 and 65, during which the growth of the
intra-ocular astigmatism against the rule, the mode in
lens possibly produces a change towards hypermetropia
all four being 0.50D. Nevertheless, the older age
of the order of +1.00D. The net result would be a
groups showed a wider spread of values, with more
change of only +0.25D in the direction of hyperme-
eyes having 1.00 or 1.25 D. With the rule intra-ocular
tropia. On the other hand, Slataper’s graph shows a
astigmatism, mainly of 0.25 D, was found in only a few
change of about +1.00 D. The balance of +0.75 D re-
eyes.
mains to be explained.
Because of the intra-ocular component, the overall
An increase in the refractive index of the vitreous
humour would produce relative hypermetropia for two
reasons: it would not only shorten the ‘reduced’ dis-
tance of the retina from the back surface of the lens but
also reduce the power of that surface. Calculation
shows that an increase of 0.006 in the vitreous index
would make the Bennett—Rabbetts schematic eye hyper-
metropic by the amount required. An increase of 0.006
is not inconceivable. The swing towards myopia after
the age of 65 or so, sometimes referred to as senile
myopia, can be accounted for by the increase in corneal
power. Another factor is probably a slight increase in
the refractive index of the lens nucleus. As pointed out
of
Percentage
group by Weale (1982), this quantity shows a considerable in-
crease with age in the bovine eye, though only a slight
upward tendency in the human eye during adult life.
More determinations after the age of 60 would be en-
lightening. On the basis of Gullstrand’s No. 1 schematic
eye, an index change in the lens nucleus of only
+0.005 need be postulated to account for a myopic
change of —1.00D. This suggests that only a small
Age group
change in the complex refractive index structure of the
Figure 21.5. Type of astigmatism as a percentage of the total
real lens would be needed to produce a similar result.
in each age group: @ with the rule, © against the rule, A
oblique (with the rule), A oblique (against the rule). The rapid and considerable myopic changes shown by
(Reproduced by kind permission of Mr H. Saunders, 1981. some elderly patients are undoubtedly the result of
Copyright © Pergamon Press.) index changes caused by nuclear sclerosis of the lens.
 Surgery for refractive error 417

The normal growth of the lens with age, particularly showed that 88% of the subjects could read N8 or
if the surfaces steepen, would suggest that its power better. Many of them would not have reached this stan-
would increase even in the absence of nuclear sclerosis. dard at home because of inadequate lighting. Much of
Although further work needs to be done to establish the other information given should be of value to those
agreement on the precise mechanism, Pierscionek concerned with social welfare in other localities.
(1990), Smith et al. (1992) and Hemenger et al. (1995) Stokes (1991), in a sample of 400 patients requiring
postulate a change in the gradient of the refractive domiciliary visits of whom over 40% had cataract or
index within the lens rather than a change in the index macular degeneration, found 81% could manage 4/12
itself as the stabilising factor (see also page 213). and N8 or better, though the percentage fell to 78% for
Another subject for investigation is the extent, if any, the 80 and over age group and to 57% for the over 90s.
to which the eye’s axial length diminishes in the elderly. While data including patients with identifiable ageing
The advent of ultrasonography opens up wide possi- changes is a valid indication of the capabilities of
bilities for research of this kind. Thus Lam et al. (1994), patients seeking optometric advice, better VAs occur if
among others, has shown an apparent shortening of all such patients are excluded. Thus Elliott et al. (1995),
axial length with age, their regression line suggesting using logMAR charts illuminated to 160 cd/m’, showed
by 0.02 mm per year. Grosvenor (1991) cites personal their scatter plots could be fitted by the regression line:
communications from Borish and Hofstetter as pointing logMAR = +0.0021 x age — 0.20
out that cross-sectional studies may be misleading:
younger people tend to have greater stature than their with an acuity of —0.10 or better (6/4.8) up to the
elders, so their eyes may also be longer in proportion, 55-59 age group, deteriorating to —0.02 (6/6+) at age
hence erroneously suggesting shrinkage with age. An 75 or more. Further analysis showed that although
increase in the velocity of ultrasound in the hardening their data could, like Slataper’s, also be fitted with two
elderly lens may also suggest a decrease in axial length. lines, suggesting a constant acuity up to age 50 followed
by a decline, a better fit was obtained by two lines inter-
secting at age 29. That for ages up to 29 shows a small
Changes in visual acuity and functions improvement in acuity with age:
Slataper’s age norms of corrected visual acuity included logMAR = —0.049 x age — 0.025
in his 1950 paper provide a basis for the following gen-
followed by a slow decline:
eralizations. Visual acuity begins to decline after the
age of 50, at first very slowly. It does not fall below logMAR = +0.0029 x age — 0.250
20/20 until about 65. After this age the decline is more
They concluded that the concept that the average, opti-
rapid: 20/25 (6/7.5) at 70 and 20/40 (6/12) at 80.
mally corrected visual acuity is 6/6 was incorrect.
These norms do not apply to patients with incipient cat-
Causes of such a measurement may be poor luminance
aract or other pathology. With the same exclusions,
and contrast, especially if projector charts are employed,
about 50% of those aged 70 and 15% of those aged 80
and for mean data, charts terminating at the 6/6 or 6/
can expect to retain the 20/20 standard of acuity. 5 line, a point also made by Lovie-Kitchen (1988).
A survey by Elliott (1971) of 2000 case records has Other visual functions also deteriorate with age. De-
shown that there is a wide spread of corrected as well tailed treatments are given in specialized texts by
as uncorrected acuities at all age levels. In general, her Hirsch and Wick (1960), Weale (1982) and Rosen-
figures are consistent with Slataper’s data, as were
bloom and Morgan (1986).
those of Taylor’s (1990) sample of 950 patients.
A 2-year study of the unaided vision and visual acuity
of the elderly in a small market town was made by
Lavery et al. (1988). Controlled tests were made on Surgery for refractive error
over 500 subjects, a representative sample of the popu-
lation over the age of 75. Of the four variables governing an eye's refractive error,
In respect of unaided vision, the males were more for- neither the depth of the anterior chamber nor the axial
tunate than the females, only 0.9% of whom had 6/6, length of the eye can be altered surgically. In order,
as against 2.4% of the males. Those with 6/12 or better however, to prevent further lengthening of the globe in
were 25.8% of the males and 17.3% of the females. progressive myopia, reinforcement of the posterior
Nevertheless, the mode for each sex was 6/36 (M sclera with tissue from other parts of the body has been
26.5%, F 28.5%). Vision poorer than 6/60 was shown proposed (Nesterov and Libenson, 1970).
by 13.9% of the males and 19.9% of the females. The crystalline lens can be removed, but as it provides
The corrected acuity was ascertained for 156 of the about one-third of the total refractive power of the eye,
males and 318 of the female subjects. In the age groups the patient would need to be about —16 D myopic to
76-79, 80-84, and 85+, the percentage of males at- benefit (see Figure 12.17). This operation was proposed
taining 6/12 or bettér in the better eye was 86.8, 78.8 by Fukala but is no longer advocated because both
and 77.3 respectively; for the females it was 81.8, 69.9 myopia and aphakia increase the probability of retinal
and 53.9 respectively. For all age groups combined, detachment. Should cataract extraction become neces-
only 2.6% of the males and 4.4% of the females had ac- sary in a highly myopic eye, an intra-ocular implant
uities lower than 6/36. An overall total of 73.8% of the might be inserted, even of very low power, because this
subjects attained a binocular acuity of 6/12 or better. lessens the subsequent risk of a retinal detachment. It is
Examination of near visual acuity in test conditions possible, however, to insert a negatively powered
418 Distribution and ocular dioptrics of ametropia

anterior chamber implant, similar in construction to the peripheral cornea. This then bulges forward slightly,
those used in pseudo-phakia, into the phakic myopic while the central cornea flattens. This operation is
eye. therefore suitable only for myopes, though it has also
The cornea is the most accessible part of the eye for been claimed to be applicable to astigmatism. Steele
surgery, and as equation (21.7) shows, a change in cor- (1988) points out that the principles were discussed by
neal power has an equal and opposite effect on the re- Lans as long ago as 1898. Before the importance of
fractive error. There are various possible techniques for damage to the corneal endothelium was realized, both
the surgical modification of corneal curvature (or refrac- anterior and posterior corneal incisions were used by
tive keratoplasty): Sato in Japan in the 1950s. The person most credited
with promoting the technique is Fyodorov in the USSR.
(1) keratomileusis (5) radial keratotomy
The correction obtained depends on the number of in-
(2) epikeratophakia (6) laser keratoplasty
cisions and the area of the central cornea left undis-
(3) keratophakia (7) intra-stromal ring
(4) corneal grafting turbed. Steel considers the diameter of this area to be
between 2.5 and 5 mm, the incisions not quite reaching
the limbus. It appears possible to treat an initial error of .
Keratomileusis up to about —6D. Even after healing, flare from light
This method, described by Barraquer (1964), was ori- scattered by the incisions can be disturbing at night,
ginally proposed by him in 1949. A circular trephine is while any residual refractive error can fluctuate during
used to cut part of the way through the central cornea. the day for about 6 months after the operation. Because
A disc of anterior stroma together with its epithelium is of the unusual corneal profile — flat centrally with stee-
then removed, frozen, and the rear surface turned on a pening periphery — subsequent fitting of contact lenses
lathe. To correct myopia, the surface is steepened so to correct any residual error is difficult.
that when the disc is thawed and sutured back on the The interested reader is referred to the many papers
eye, a shallower front surface results. The disc is about published in the USA on the Study on the Prospective
7mm in diameter and initially about ;mm thick. As Evaluation of Radial Keratotomy (PERK), for example in
Bowman's layer is undisturbed, the corneal epithelium Archives of Ophthalmology, 105(1), 1987.
should recover quickly.

Laser keratoplasty (keratotomy,

Epikeratophakia
keratectomy)
In this operation, the central corneal epithelium is re-
At the time of writing, this technique is gradually be-
moved, and a shallow annular groove made in the
coming accepted, but is still under development. An ex-
cornea. A pre-shaped graft from a donor cornea is then
cimer laser, mentioned on page 312, ablates (removes)
placed on the cornea and sutured into the groove. It is
a uniform layer of the anterior corneal surface with
not possible to make either small or precise changes to
each flash. By progressively reducing the circular area
the corneal power, so that a minimum change of about
ablated, more tissue can be removed centrally than per-
8 D is indicated. The technique is useful where contact
ipherally in order to flatten the corneal curve. Marshall
lenses are rejected both in keratoconus and by aphakics
(1988) suggests that the maximum depth of stroma
who have not or cannot be given an implant. Myopes
that can be removed without causing subsequent cor-
may also benefit. A review is given by Halliday (1988).
neal haze is 50 tm (0.05 mm).
The degree of myopia that can be corrected is found as
Keratophakia follows. If the maximum area to be treated is 5 mm in
As in keratomileusis, a lamella of anterior stroma is re-
diameter and the initial corneal radius is 7.8 mm, the
sag over this chord is given by
moved. A thinner lenticule of positive meniscus form,
pre-shaped from a donor cornea, is then inserted to Sag = = a
become embedded within the stroma when the original
= 0.411 mm
lamella is sutured back in place. It may become possible
to use an oxygen-permeable synthetic plastics material The minimum sag after ablation of 0.050 mm will there-
for the lenticule. A solution to the complicated optics in- fore be 0.361 mm, which, over the 5mm chord, corre-
volved in this technique has been provided by Churms sponds to a new radius of 8.83 mm. Taking the value of
(OVD): 1.376 for the refractive index of the cornea, the change
in power is from 48.21 to 42.58 D or 5.63 D. A similar
Corneal grafting calculation would be appropriate for keratomileusis
and epikeratophakia. Although chord diameters of up
While epikeratophakia is a form of corneal grafting, a
to 7mm are now treated, a non-uniform power change
whole-thickness or penetrating graft may be needed
is made in the peripheral zones to taper the newly flat-
when the patient is suffering from severe keratoconus,
tened central zone into the untreated periphery.
or the cornea has been damaged by trauma or disease.
Astigmatic corneas may be treated by preferential ab-
lation. Surprisingly at first sight, a larger chord has to
be ablated in the flat meridian than the steeper. Thus, if
Radial keratotomy
a patient has a refractive error of —2.00/—3.00 x 180
In this technique, a series of radial incisions are made in and a cornea of radii 7.8mm along 180° by 7.3mm
 References 419

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Exercises GWIAZDA, J., THORN, F., BAUER, J. and HELD, R. (1993) Emme-
tropization and the progression of manifest refraction in chil-
21.1 In Stenstrém’s simplification of the eye, the crystalline dren followed from infancy to puberty. Clin. Vis. Sci., 8.
lens was replaced by a thin lens placed at the anterior pole of 337-344
the real lens. If the Befinett-Rabbetts schematic eye were thus HALLIDAY, B.L. (1988) Alternatives to contact lens wear: epi-
modified: (a) what thin lens power would be required to pro- keratophakia. Trans. Br. Contact Lens Ass. Int, Contact Lens
duce emmetropia, (b) what would be the equivalent power of Centenary Congr., 43-46
the eye? By what amounts do these results differ from the corre- HEIM, M. (1941) Photographische Bestimmung der Tiefe und
sponding values in the Bennett-Rabbetts schematic eye? des Volumens der menschlichen Vorderkammer. Ophthalmo-
21.2 Repeat the calculations in Exercise 21.1, but with the logica, Basel, 102, 193-220
hypothetical thin lens now placed near the mean position of HEMENGER, R.P. GARNER, L.F. and ool, ¢.s. (1995) Change with
the principal points of the schematic lens, i.e. 2.3 mm behind age of the refractive index gradient of the human ocular
its anterior pole. lens. Invest. Ophthal. Vis. Sci. 36, 703-707
420 Distribution and ocular dioptrics of ametropia

HIRSCH, M.J. (1963) Changes in astigmatism during the first trends in medium and high myopia by means of cluster anal-
eight years of school — an interim report from the Ojai longi- ysis. Ophthal. Physiol. Opt., 6, 177-186
tudinal study. Am. J. Optom., 40, 127-132 SAUNDERS, H. (1986c) Correspondence. Age of cessation of the
HIRSCH, M.J. (1964) Predictability of refraction at age 14 on the progression of myopia. Ophthal. Physiol. Opt., 6, 243-244
basis of testing at age 6 — interim report from the Ojai longi- SAUNDERS, H. (1986d) Correspondence. Changes in the orienta-
tudinal study of refraction. Am. J. Optom., 41, 567-573 tion of the axis of astigmatism associated with age. Ophthal.
HIRSCH, M.J. and WICK, R.E. (eds) (1960) Vision of the Ageing Physiol. Opt., 6, 343-344
Patient. An optometric symposium. Philadelphia: Chilton SAUNDERS, H. (1987a) A longitudinal study of the age depen-
HOWLAND, H.C., ATKINSON, J., BRADDICK, 0. and FRENCH, J. dence of human ocular refraction — IJ. The mediation of
(1978) Astigmatism measured by photorefraction. Science, changes from direct to inverse astigmatism examined by
202, 331-333 means of matrices of transition probabilities. Ophthal. Physiol.
JACKSON, E. (1933) Changes in astigmatism. Am. J. Ophthal. 16, Otay Fh, WHS AUHS)
967-974 SAUNDERS, H. (1987b) Author's reply. Cessation age of child-
LAM, C.S.Y., GOH, W.S.H., TANG, Y.K., TSUI, K.K., WONG, W.C. hood myopia progression. Ophthal. Physiol. Opt., 7, 195-197
and MAN, T.c. (1994) Changes in refractive trends and opti- SAUNDERS, H. (1988) Changes in the axis of astigmatism: a
cal components of Hong Kong Chinese aged over 40 years. longitudinal study. Ophthal. Physiol. Opt., 8, 37-42
Ophthal. Physiol. Opt., 14, 383-388 SLATAPER, F.J. (1950) Age norms of refraction and vision.
LAVERY, J.R., GIBSON, J.M., SHAW, D.E. and ROSENTHAL, A.R. Archs Ophthal., N.Y., 43, 468-481 :
(1988) Vision and visual acuity in an elderly population. SMITH, G., ATCHISON, D.A. and PIERSCIONEK, B.K. (1992) Model-
Ophthal. Physiol. Opt., 8, 390-393 ing the power of the aging human eye. J. Opt. Soc. Am. A, 9,
LOVIE-KITCHEN, J.E. (1988) Validity and reliability of visual 227
acuity measurements. Ophthal. Physiol. Opt., 8, 363-370 soRSBY, A. and LEARY, G.A. (1970) A longitudinal study of re-
MCKENDRICK, A.M. and BRENNAN, N.A. (1996) Distribution of fraction and its components during growth. Spec. Rep. Ser.
astigmatism in the adult population. J, Opt. Soc. Am. A, 13, med. Res. Coun., No. 309. London: HMSO
206-214 SORSBY, A., BENJAMIN, B. and BENNETT, A.G. (1981) Steiger on
MARSHALL, J. (1988) Potential of lasers in refractive surgery. refraction: a reappraisal. Br. J. Ophthal., 65, 805-811
Trans. Br. Contact Lens Ass. Int. Contact Lens Centenary SORSBY, A., BENJAMIN, B., DAVEY, J.B., SHERIDAN, M. and TAN-
Congr., 43-46 NER, J.M. (1957) Emmetropia and its aberrations. Spec. Rep.
MARTIN, W.J. (1949) The physique of young adult males. Medi- Ser. med. Res. Coun., No. 293. London: HMSO
cal Research Council Memorandum No 20. London: HMSO SORSBY, A., BENJAMIN, B. and SHERIDAN, M. (1961) Refraction
MOHINDRA, I., HELD, R., GWIAZDA, J. and BRILL, S. (1978) As- and its components during the growth of the eye from the
tigmatism in infants. Science, 202, 329-331 age of three. Spec. Rep. Ser. med. Res. Coun., No. 301. London:
NESTEROV, A.P. and LIBENSON, N.B. (1970) Strengthening the HMSO
sclera with a strip of fascia lata in progressive myopia. Br. J. SORSBY, A., SHERIDAN, M. and LEARY, G.A. (1960) Vision, visual
Ophthal., 54, 46-50 acuity, and ocular refraction of young men. Br. Med. J., 1,
PIERSCIONEK, B.K. (1990) Presbyopia — effect of refractive index. 1394-1398
Clin. Exp. Optom., 73, 23-30 STEELE, A.D. MCG. (1988) Radial keratotomy today. Trans. Br.
ROSENBLOOM, A.A. and MORGAN, M.W. (1986) Vision and Aging: Contact Lens. Ass. Int. Contact Lens Centenary Congr., 79-82
General and Clinical Perspectives. New York: Professional Press STENSTROM, S. (1946) Untersuchungen Uber die Variation und
SAID, F.S. and WEALE, R.A. (1959) The variation with age of the Kovariation der optischen Elemente des menschlichen
spectral transmissivity of the living human crystalline lens. Auges. Acta Ophthal., suppl. 26. (Also English translation by
Gerontologia, 3, 213-231 Woolf, D., Am. J. Optom., 25, 218-232, 1948)
SAUNDERS, H. (1981) Age-dependence of human refractive er- STOKES, T.J. (1991) How good is vision in old age? Optician,
rors. Ophthal. Physiol. Opt., 1, 159-174 201(5297), 46
SAUNDERS, H. (1982) Corneal power and visual error. Ophthal. STROMBERG, E. (1936) Ueber Refraktion und Achsenlange des
Physiol. Opt., 2, 37-45 menschlichen Auges. Acta Ophthal., 14, 281-293
SAUNDERS, H. (1984a) Matters arising. Age-dependence of TAIT, E.F. (1954) Relationship between corneal and total astig-
human refractive errors. Ophthal. Physiol. Opt., 4, 107 matism. A.M.A. Archs Ophthal., 52, 167-169
SAUNDERS, H. ( 1984b) Age-dependence of human refractive er- TAYLOR, S. (1990) An analysis of vision and VA in patients at-
rors. Ophthal Physiol. Opt., 4, 281 tending for eye examination. Optician, 199(5256), 15-17
SAUNDERS, H. (1985) Prognosis of refractive corrections. WEALE, R.A.(1982) A Biography ofthe Eye. London: H. K. Lewis
Ophthal. Physiol. Opt., 5, 391-395
SAUNDERS, H. (1986a) A longitudinal study of the age depen-
dence of human ocular refraction — I. Age-dependent
changes in the equivalent sphere. Ophthal. Physiol. Opt., 6,
39-46 Further reading
SAUNDERS, H. (1986b) A longitudinal study of the age depen-
dence of human ocular refraction — II. Prediction of future CURTIN, B.J. (1985) The Myopias. Philadelphia: Harper & Row
22,
Entoptic phenomena

Introduction

The eye's function is to form an inverted image of the

external scene and to convert this to a pattern of
neural signals for the brain to interpret. Visual sensa-
tions can also arise from shadows of opacities within
the eye, mechanical pressure on the globe and a variety
of other causes. These sensations not directly due to the
Figure 22.1. An illuminated pinhole disc placed in the
formation of an optical image by the refracting system anterior focal plane of the eye. The cylindrical column of light
of the eye are called entoptic phenomena (from the reaching the retina is ideal for demonstrating opacities.
Greek, meaning things perceived within vision).
These phenomena may be subdivided as follows:
source of light is required. In ophthalmic work, a pin-
Optical ‘ hole disc is the simplest means of producing well-defined
(1) (a) shadows due to objects or opacities in the media, shadows of opacities or refractive irregularities in the media.
(b) the blood vessel silhouette, If the strongly illuminated pinhole is placed in the
(2) haloes and diffraction patterns, anterior focal plane of the eye, the parallel beam of
(3) Haidinger’s brushes, light within the vitreous will have the same cross-sec-
(4) Maxwell's spot. tional shape and size as the exit pupil (Figure 22.1). Cre-
nellations due to irregularities in the pupil margin, and
Physiological, in the restricted sense of non-optical
fluctuations in size with alterations of pupil diameter
stimulation of the retina:
will be readily visible. The consensual pupil reaction
(5) phosphenes,
due to changes in the illumination of the fellow eye will
(6) blue arcs,
also be evident. Entoptic appearances (if any) will be
(7) after-images,
seen within the illuminated fundus patch. A small pin-
(8) Troxler effect.
hole (0.25 mm or less) gives well-defined retinal sha-
Sensations or perceptions arising in the visual cortex, dows.
for example the scintillations or fortification spectra If the ocular media were perfectly clear and the sur-
seen in migraine, or complete scenes as in dreaming, faces without blemish, the patch of light on the retina
are excluded. would be featureless. Any defect affecting the uniform
Entoptic phenomena are occasionally used to verify transmission of light will, however, cast a shadow on
the macula function in patients with cataract before op- the retina, giving rise to an entoptic phenomenon. The
eration. The shadows ofthe retinal vessels or circulation obstruction need not necessarily be opaque, but could
of white blood corpuscles within the smaller capillaries be translucent or merely a clear but refractive distur-
are mentioned by Hurst et al. (1993). bance, for example, a tear globule on the front surface
of the cornea or a vacuole in the crystalline lens.
Using a slit lamp at maximum brightness positioned at
45-50° from the fixation axis, Johnson et al. (1987)
Entoptic phenomena due to opacities
took photographs of corneal striae following soft contact
or objects in the media lens wear. They proved to be very similar to the entoptic
-
view as drawn by the subjects. Light scattered in the
Basic principles normal cornea appears as a uniform white haze.

Unless an opacity is either nearly the same size as the

pupil or close to the retina, it will not cause a noticeable
Orientation and location of obstruction
shadow. This is analogous with the shadow of objects
in a room lit by a single window. In order to make a If a pinhead is placed between the pinhole and the eye,
shadow both denser and more sharply defined, a small
 4 oO
422 Entoptic phenomena

Figure 22.2. The erect retinal shadow of a pin, placed

between the pinhole and the eye, appears inverted.

(a)

Figure 22.4. Use of the entoptic shadow of a retinal blood

vessel V to determine its distance ¢ from the percipient layer
(not to scale). The retinal elements A and B illuminated from
the right cast shadows of the vessel at C and D, seen
entoptically by projection in the directions C’ and D’.

vitreous opacities, show an against movement because

(c)
they lie behind the exit pupil.
As the obstruction approaches the retina, or ap-
ye

proaches the source if in front of the entrance pupil, the

Y amount of parallactic movement increases. Listing
(cited by Helmholtz, 1924, Vol. I) showed in 1845 that
it was therefore possible to estimate the approximate
position of an obstruction.
Figure 22.3. The use of parallax to locate the site of an
opacity. The circles on the right represent the entoptic field and This technique may be used to measure the position of
the apparent relative position of a central opacity as seen by the the blood vessels in the eye relative to the retinal recep-
subject. (a) Opacity behind pupil, pinhole central. (b) Effect on tors. The shadows of the retinal vessels are often seen
(a) of downward movement of pinhole. (c) Opposite effect of by the patient when ophthalmoscopy’ or slit-lamp ex-
pinhole shift when opacity is in front of pupil.
amination is performed in a dark room. Because the ap-
pearance is similar to the twigs and branches of a tree
erect and an apparently inverted pin will thus be seen. If silhouetted against the sky, the phenomenon is often
the pinhead is placed on the opposite side of the pinhole termed the ‘retinal tree’. It was first described by Pur-
from the eye, it will appear the correct way up because kinje in 1819 (cited by Helmholtz, 1924, Vol. I). In
the usual imagery then applies. normal conditions, light passes through the patient's
The position of the obstruction relative to the pupil pupil to form a shadow of the blood vessels on the retinal
may be indicated by parallax. Thus, Figure 22.3(a) receptors immediately behind them. These receptors
shows an axial opacity behind the exit pupil casting a and related neural cells adapt to the lower illumination,
shadow Xj, on the retina in the centre of the illuminated so that the external scene is perceived without vascular
retinal area. shadows. The ophthalmoscope beam, however, strikes
In Figure 22.3(b), the pinhole source S is lowered and one region A of the retina (Figure 22.4). This illumi-
the shadow Xj, moves downwards relative to the patch nated area acts as a fresh source of light, causing a
of light on the retina. The shadow therefore appears to shadow of vessel V to fall on retinal receptors C. Since
move upwards within the entoptic field, showing an this is not the normal position for the vascular shadow,
against movement relative to that of the source. it may be perceived (in the direction CC’), although the
In Figure 22.3(c), an axial opacity Y lies in front of the receptors soon adapt to the reduced stimulus, so causing
entrance pupil. When the pinhole is again displaced the perception to fade. If the ophthalmoscope beam is
downwards, the shadow Y’ now appears to move down- now moved to illuminate region B, the vessel shadow
wards in the entoptic field, thus showing a with move- will now fall on yet another group of retinal receptors D.
ment.
This may easily be confirmed by experiment. The en-
“Before commencing ophthalmoscopy at a patient’s first
toptic view of eyelashes shows a with movement, but
examination, it is worth mentioning that any such pattern, if
most other entoptic features, for example lenticular or seen, is normal.
 Entoptic phenomena due to opacities or objects in the media 423
———————————— nS
From a knowledge of the geometry of the eye, it is
possible to estimate the distance of the blood vessels
from the percipient layer of the retina. For this purpose,
transillumination of the anterior sclera will allow direct
measurement of the distance AB. The projected angular
separation between source and vessel shadow, and
the angular displacement 9 from C’ to D’ will need to be
measured (Muller, 1849, cited by Helmholtz, 1924,
Vol. I).
Thus, in Figure 22.4 in which t =VC and x = AV,
t/CD =.x«/AB

Assuming that the radius of curvature p of the posterior

part of the globe equals the distance between the nodal
point and the retina,

x & 2p sin (6/2)

where @ is the projected angular separation between the

source of light and vascular shadow. Also
CD = 2p sin (0/2)

Hence, the distance t between the vessel and the per-

cipient layer is

3 4p? sin (/2) sin (0/2)

ji AB
(22.1)
If the source of light does not transilluminate the
‘Image’ on retina
sclera but is imaged through the eye’s optical system,
Figure 22.5. The Brewster—Donders method of determining
then AB in equation (22.1) can be replaced by
the depth of an ocular opacity.
2p sin (W/2)

leading to Because of the two sources, an opacity O at a distance

y from the retina R casts two shadows T, and T). By si-
a 2p sin (b/2) sin (6/2)
milar triangles,
if sin (y/2)
y/v! = T2T) /JoJi (22.4)
In a more precise form derived by Jago (1864), the
source of light was considered to alternate symmetri- The points T,, T,, JS and J as projected can be
cally from one side of the optical axis to the other marked on the screen S and the ratio y/v’ found from
through an angle \ while the vessel’s shadow jumped equation (22.4). An estimated value must be given to
through an angle 0, giving the expression the distance v’ from the exit pupil to the retina, about
20.3 mm in the standard emmetropic eye. It is essential
t= pj1 2
get that fixation does not move, otherwise the projected
(2:2;3)
cos 4 =(w — 8) images will also move.

Zeffren et al. (1990) and Bradley et al. (1992) describe

a technique for visualizing the retinal vessels near the Causes of entoptic shadows
fovea.
These shadow entoptic phenomena may be caused by
opacities or refractive irregularities anywhere in the
media. Commonly observed effects are due to:
The Brewster—Donders method for the depth
(1) Lashes, lid margins, and their associated tears
of opacity
prisms.
Although Listing’s method using the movement of the (2) Mucous or oil globules, etc., in the tears layer. These
light source will demonstrate the relative depth of an appear as spots of light generally appearing to
opacity within the eye, a more exact method is due to move downwards (in reality, upwards). The glo-
Brewster (1843) in the form modified by Donders bules are pushed down on blinking but return
(1847), both cited by Helmholtz (1924) Vol. lL. A slowly upwards during the interval between blinks.
Scheiner disc SD with two small pinholes about 2 mm (3 Rubbing or pressing on the eye, which disturbs the
apart is held as near as possible to the anterior focal corneal integrity and causes an entoptic effect of
plane of the eye (Figure 22.5). The field of view is then mottling.
bounded by two overlapping circles H{J and H4J3, the Lens sutures.
points H and J being the borders of the eye’s exit pupil Cas Lens opacities. Tscherning (1924) suggests that ‘an
Ex. intelligent patient can thus follow step by step the
424 Entoptic phenomena

development of his cataract’, perhaps questionable absorbing the light. The same effect can be observed
advice to give to many patients. while reclining and looking upwards into a cloudless
(6) Vitreous floaters, as distinct from bright blue sky. There is no doubt that the methods of
(7) Muscae volitantes. These are delicate, somewhat verifying retinal integrity described on pages 44—45 are
lacy or chain-like shadows which can often be seen far’superior.
without the aid of a pinhole because they are due
to fine opacities positioned close to the retina. They
move with the gaze, but tend to overshoot and Haloes and coronas ‘
come back when ocular movement stops, as though The cornea and crystalline lens are not homogeneous
tethered to the retina. It is the jelly-like nature of but fibrous, as may be seen in life with the slit-lamp mi-
the vitreous, however, which limits the motion of croscope. As a result, a small portion ofthe light passing
the floaters. The Latin name given to these shadows through the eye is scattered. It may be scattered irregu-
means flying gnats, which aptly described their flit- larly or form a pattern on the retina, in which case it
ting nature. could be perceived as an entoptic phenomenon, given
Muscae volitantes were often assumed to be shadows suitable observation conditions. The usual effect of all °
of strings of red blood corpuscles. White and Levatin such stray light is to reduce the contrast of the retinal
(1962) measured the apparent size of ‘corpuscular’ floa- image (see pages 295-298).
ters and found it to be about 25-40 ttm, much larger
than the 8.5 um diameter of a blood corpuscle. Analysis
The corneal corona
suggested that the ‘shadows’ were actually diffraction
patterns formed by blood corpuscles suspended about The cornea is composed of layers of very fine collagen fi-
250-350 um (microns) in front of the foveal cones. brils between 19 and 34 nm in thickness, laid down in
Their apparent tendency to drop when the eye is lamellae which are 1.5—2.5 wm thick and 90-260 tm
stationary means that the corpuscles are in fact rising. wide. It is possibly the boundaries of these lamellae that
White and Levatin suggest that as the main body of the are visible in the slit-lamp beam, although Maurice
vitreous descends, the more fluid vitreous close to the (1962) postulated that some of the light was scattered
retina consequently rises. by the nuclei of the stromal cells.
It must be pointed out that the blurred image of a The healthy cornea scatters about 10% of the incident
small source of light viewed by an uncorrected ametrope light. Maurice compared the fibrils of each corneal la-
or artificially defocused emmetrope also allows many of mellae with a three-dimensional diffraction grating.’
these irregularities in the media to be perceived. Because the inter-fibril separation is much less than the
An. artificial obstruction in the form of a wire across wavelength of light, light scattered by one fibril cannot
the pupil may be used as a subjective test. Velonoskia- interfere constructively with light scattered by the
scopy, as this technique is called, was introduced by neighbouring fibril, so that no diffraction spectra can be
Holth in 1904 and further developed by Trantas formed. Moreover, any scattered light will interfere de-
(1921) and Lindner (1926). If the wire is mounted structively with non-scattered light owing to the phase
across a trial frame, the head can be rocked to traverse change on reflection. As a result, the incident beam
the wire across the pupil. As noted on pages 73-74, the must pass unattenuated through each lamella.
direction of movement of the entoptic shadow across If the corneal stroma becomes oedematous, through
the retinal blur may be used to distinguish between hy- contact-lens wear or raised intra-ocular pressure, for ex-
permetropia and myopia. To correct the eye, lenses are ample, the regularity of the stromal fibrils becomes dis-
added until the shadow disappears. The recommended turbed and the normal destructive interference of
object is a white line, orientated parallel to the wire scattered light no longer takes place. Similarly, if the
and subtending about 3 minutes of arc, mounted on a epithelium becomes oedematous, the intra-cellular spa-
red ground. Although methods for examination of astig- cing may increase to more than 0.5 um with globules
matism were introduced, the present writers have been (mostly of water) also giving rise to scattering of light.
unable to confirm their efficacy. Any particular globule in the cornea will scatter light
in all directions. Destructive interference, however, will
occur if the path difference from opposite sides of the glo-
Entoptic phenomena and cataract bule is an odd number of half wavelengths (Figure
Entoptic phenomena generated in the retina could, in 22.6). In monochromatic light, the appearance will be
theory, be used to verify reginal integrity behind a cat- that of an Airy disc and ring. In white light, the first
aract. First, as already mentioned, shadows of the ret- minimum will occur at an increasing angle from the
inal vessels may be seen if an intense light centre as wavelength increases. The white centre will
transilluminates the sclera. In another suggested tech- then be surrounded by a subtraction spectrum, with
nique, the retina is strongly illuminated with blue light. the first minimum for blue giving a reddish-yellow ring,
The slit lamp can be used as the light source, aimed di-
rectly at the pupil. To provide a larger field of illumina-
tion, a ground-glass diffuser held immediately in front ’ A diffraction grating is any two- or three-dimensional array
of lines or dots showing periodic variations of either transpar-
of the eye may be needed. The patient should be able to
ency or of refractive index. Physics textbooks often illustrate
see moving bright spots which are thought to be white clear and occluded transmission gratings (such as Foucault
blood cells in the retinal vessels, the red corpuscles gratings), but many natural structures are phase gratings.
 Entoptic phenomena due to opacities or objects in the media 425

Xx
Figure 22.6. Diffraction by a globule: the relative path H J ai
difference is 6. Ne
\ |

then the green minimum giving purple, and so on. Irre-

gular shaping of a particular globule will cause an irre- \
1x’
gular halo, but summation over the whole pupillary
H"5
area generates a symmetrical (but perhaps less well-de-
fined) corona around a light. Similar coronas will be
sf
seen if a light is viewed through spectacle lenses or a Figure 22.7. The upper figure shows the formation of the
window steamed up with fine condensation, through a normal or zero-order diffraction image, while the lower figure
blood smear on a slide or lycopodium powder. in isometric form shows the positions of the first-order
diffraction images arising from the fibres at H, J and X.
The corneal corona was first observed by Descartes in
1637 (cited by Simpson, 1953).
A similar halo is seen by the very occasional patient
with a nuclear sclerosis type of cataract, light being Although the lens fibres may not be truly radial since
scattered by the brown discoloured lens nucleus (Elliot, they are directed at the lens sutures rather than the
1921). The authors have met very few such patients. axis, any tilt in the orientation of the fibres — at H, say,
ra of Figure 22.7 — will rotate the first-order spectra H{
and H4, around the principal image, but at the same dis-
tance from it. Thus the approximate circularity of the
corona remains undisturbed, although variations in
The lenticular halo intensity are generated.
The crystalline lens gives a somewhat similar halo, but The lens halo and the corona arising from corneal
the origin is quite different. With the exception of the oedema have the similar appearance of circular rings,
zonule and anterior cellular layer, the lens is composed although the order of colours is different. Since corneal
of fibres which pass in an approximately radial manner oedema can arise from pathological causes such as an
from the anterior to the posterior sutures. These fibres increase in intra-ocular tension in angle-closure glau-
are about 8-12 um wide by 2 um thick in the outer coma, whereas the lens halo is a physiological effect, it
layers of the lens. is important to be able to differentiate between the two
The axial part of the crystalline lens appears to be sites of origin.
relatively uniform, no lens halo being observed with a Corneal oedema causes small-body diffraction, each
pupil less than about 3mm in diameter. When the element scattering light equally in all meridians. If a ste-
pupil is dilated, however, either under conditions of low nopaeic slit is held before the eye to restrict the light en-
illumination or especially with a mydriatic, the effects tering to a small zone of the entrance pupil, the corneal
of the peripheral zones become very marked. The lens halo is merely dimmed. Passage of light through a par-
may be regarded as a strong positive lens on whose per- ticular strip of the crystalline lens generates a specific
iphery is superimposed a radial diffraction grating. In double section of the lenticular halo. Moving a vertical
Figure 22.7, an element H of the radial grating will stenopaeic slit across the pupil therefore gives moving
form the zero order image B’ at the primary focus of the sectors of light, as indicated in Figure 22.8. This is the
lens (ignoring aberrations) while first-order diffraction Emsley—Fincham test (1922) for differentiating corneal
images will form above and below the focus at H), H}. from lenticular haloes, a development of Druault’s test
Similarly, the diametrically opposite element J will form of 1899 which used the edge of an occluder.
images J and J in the same place as H and H4. Var- If glaucoma is suspected as the cause of a halo, then
ious other zones of the lens will form diffraction images the intra-ocular tension can be measured with a ton-
on the radius perpendicular to the zone orientation ometer. The pressure at the time of measurement might
(such as X) so that the complete effect is one of a circular be normal, in which case the patient could perform the
corona. Fincham test if the halo should ever reappear. A fuller
The diameter or spacing of the lens fibres is not com- ocular investigation initially would be advisable. Muel-
pletely uniform so that the resultant halo is not abso- ler’s (Sattler’s or Fick's) veil occurring in contact-lens
lutely circular but somewhat erratic. Thinner fibres in wear may need to be distinguished from the crystalline
a particular direction produce longer spectra than thick- lens halo or to flare from contact-lens edges or transi-
er fibres elsewhere. tions.
426 Entoptic phenomena

(a)
¢ air/n

Figure 22.9. Derivation of the Druault coefficient for light

(b) : eee
var o %
scattered near the posterior pole A; of the crystalline lens.
far % yw ix =

Figure 22.8. (a) The Emsley—Fincham test for distinguishing Table 22.1 Conversion factors giving the true angle ofdiffraction
a lenticular halo. The stenopaeic slit is passed across the pupil, ai, corresponding to the subjective angular subtense 0
isolating differently orientated groups of lens fibres responsible
for the sections of the halo shown in (b). Source Conversion factor

Accurate Approximate
The ciliary corona
Cornea 0.909 0.925
Most people observe the ciliary corona, a spread of light Anterior lens surface 1.092 1.087
around an isolated bright source such as a street lamp. Centre of lens 1.200 LADS
Posterior lens surface i326 1.326
This is due to diffraction by particles within the eye, the
angle of scatter being lower than that for the first Airy
minimum so that only the central disc or aureole is per-
Druault (1899) introduced the principle of position
ceived. Thus, no coloured fringes are seen, the scattered
coefficients relating the apparent diameter of the entop-
light remaining white for a white source. The intensity
tic haloes to the position of their source within the eye.
of the central aureole falls as the angle of scatter in-
For example, consider light scattered at the posterior
creases (see Figure 3.4). If the source luminance is
lens surface. In Figure 22.9, the deviation 6 at the
increased, the intensity at some particular angle from
retina is given by
the image will also increase, possibly from below to
above threshold. The diameter of the aureole thus de- 5 = ASF (dair)/n (22.8)
pends upon the source brightness (and background
Projected into object space through the principal
darkness). If the light is bright enough, the corona fills
points, the apparent angular subtense of the halo is
the lenticular halo, the radius of which subtends about
given by
3-4".
Simpson (1953) showed that the diameter of the dif- = (n/P'F’){A3F’ (dair)/n}
fracting particles must be less than 10 um. This follows
from the Airy disc equation (3.2) when the value of 0 ex-
= A3F'(air)/P'F’
ceeds 4°. which gives
Unlike the corneal corona caused by oedema, the cili-
ary corona is a normal phenomenon. It may appear to
air = P'E'(0/A3F’) (22.9)
be composed of fine moving dots and lines. This form in If refraction by the crystalline lens is ignored, a simi-
which it is perceived may arise from the processing of lar equation can be derived for light scattered in the
the neural signal by elements higher in the visual cornea:
system.
bair = PF’ (0/A,F’) (22.10)
A more accurate result can be derived by finding the
position of the virtual image A‘{ of the corneal vertex
Theoretical analysis
A, formed by the crystalline lens, giving
For a grating-like source of diffraction such as the crys-
air = P'F'(0/A(F’) (22.11)
talline lens, the angle of diffraction in air, ,,,, to the
first maximum is Table 22.1 gives these conversion factors, both approxi-
mate and accurate, based on the Bennet—Rabbetts sche-
Pair = r/d (i) N unwa
matic eye.
where d is the grating element.
For diffraction by approximately spherical bodies,
such as the glaucomatous halo, the first maximum out- Haidinger’s brushes
side the central disc occurs for
Haidinger’s brushes, first described in 1844, is the name
air = 1.638A/d (22.6) given to an hour-glass or propeller-like figure seen in po-
where d is now the body diameter. larized light near the fixation point. In white light, both
For the second maximum, blue and yellow brushes are seen, at right angles to
each other. The blue brushes lie in the plane of
bain = 2.666A/d (22.7)
vibration” of the polarized light. They are best seen,
In a medium of refractive index n, the angle of diffrac- however, when a uniformly illuminated white screen is
tion becomes ,;,/n. viewed through a rotating polarizer and blue filter (an
 Entoptic phenomena due to opacities or objects in the media 427

(Henle's fibres). There is no evidence, however, that

either of these fibres is dichroic. Because of its absorp-
tion of blue light and the similar location and subtense
of Haidinger’s brushes and Maxwell's spot (see below),
a more probable explanation is the yellow macular pig-
ment. Naylor and Stanworth (1954) and Stanworth
and Naylor (1955) found excellent agreement in a com-
parison of the visibility of Haidinger’s brushes in light
of various wavelengths and the spectral absorption of
xanthophyll, a yellow carotenoid pigment which is simi-
lar to, if not identical with, the macular pigment. They
confirmed previous findings that Haidinger’s brushes
V were not visible in light of wavelength longer than
about 560 nm. They suggested therefore that a propor-
(a) (b) tion of the yellow macular pigment was orientated
Figure 22.10. A radial analyser’s selective absorption of along the supportive tissues to act as a radial analyser.
plane polarized light: (a) plane of vibration of incident light, (b)
If the pigment was dichroic, then Haidinger’s brushes
radial analyser.
would be explained. Their data conflicted with the sug-
gestion that the blue receptors had a selective response
instrument known as a Clipper’s co-ordinator), when depending upon the plane of polarization of the incident
the yellow brushes appear as dark shadows. In the light.
purple light transmitted by a cobalt blue filter, the Although the macula pigment theory appears the
phenomenon appears as dark shadows and light red- most probable, Hallden (1957) postulated that the
dish-orange brushes. brushes were caused by an interference effect. If the
There are many theories as to the cause of the retina contained a layer of birefringent substance ar-
brushes. One possibility is that some structure of the ranged with its optic axis at a constant angle to the ra-
eye acts as a radial analyser for blue light. Figure 22.10 dially analysing receptors, then coloured brushes
shows incident light with vertical vibrations falling on rotating with the plane of vibration of the incident light
a radial analyser. The horizontal section along HH has would be seen. He suggested that the birefringent Hen-
its plane of transmission at right-angles, or ‘crossed’ le’s fibres might constitute the retarding plate, while
with respect to the incident light so that blue light is ab- the analysing structure was not necessarily the blue re-
sorbed. In white light a yellow brush would then be ceptors.
seen in this direction by colour subtraction. Conversely, If a viewing screen is observed through a rotating po-
the vertical elements VV will transmit more blue light larizer, and a half-wave plate (e.g. Cellophane about
than average for the macular area so that a blue brush 40 um thick or polyethylene sheet) placed between the
would be seen. As the plane of polarization of light polarizer and the eye, the direction of rotation of the
reaching the eye is rotated, the ‘bright’ brushes would Haidinger’s brushes is reversed. If the polarizer is kept
successively fall in different planes to give the subjective still and the half-wave plate rotated, the brushes
appearance of rotation. This effect of absorption of light appear to rotate in the same direction as the half-wave
polarized in one direction and transmission in the plane plate but at twice the angular speed. Both these effects
at right-angles, as in Polaroid sheet, is known as dichro- can be explained in terms of alterations in the plane of
vibration of the light external to the eye.
ism.
Haidinger’s brushes are of clinical importance since
Many suggestions have been made as to the position
they are formed only at the fovea. If a patient with
of the analysing structure in the eye. Since aphakics
normal fixation looks through a Cuipper’s co-ordinator
can see the brushes, the crystalline lens is not the site.
and fixates a mark on the viewing screen, Haidinger’s
Stanworth and Naylor (1950a,b) have shown that
brushes will be seen to rotate around the fixation point.
although the cornea is birefringent,’ which slightly
If the patient's eye normally fixates with an eccentric
alters the quality of polarization of transmitted light, it
part of the retina, the brushes appear to rotate about a
is not responsible for the brushes. Helmholtz (1924,
point displaced from fixation. This readily measurable
Vol. IL) postulated that the cause lay in the radial struc-
discrepancy is the angle of eccentricity. Stanworth and
ture of the supporting neuroglial fibres of Miller, while
Naylor (1955) suggested that the visibility of Haidin-
another possibility is the neural outer plexiform layer
ger’s brushes was useful in assessing retinal function in
patients with macular changes such as degeneration or
oedema.
* Helmholtz stated that the yellow brush was in the plane of
polarization, but the convention for the plane of ‘polarization’
was subsequently changed to that of the electrical vibration
direction of the electromagnetic radiation. This is at right- Maxwell’s spot
angles to the original notation.
+ Birefringent: a simplified explanation is that refraction of The yellow pigment of the macula lutea has already
light inside the substance will produce an ordinary and an
been mentioned in relation to Haidinger’s brushes. This
extraordinary ray with vibration planes at right-angles, the
yellow pigment may also be seen entoptically as Max-
two rays having different velocities (cf. the Wallaston prism in
the Javal—Schiétz keratometer on page 383). well’s spot (1856) but not under normal conditions.
428 Entoptic phenomena

The absorption of blue light by the pigment would be ex- cal since they are best seen against a blue sky and
pected to cause a slight blue shadow around the fixation appear as tiny bright specks in the field of view moving
point, but the blue receptors in the macula adapt by in- along a short path and then disappearing. Barrett
creasing their sensitivity. As a result, Maxwell's spot is (1906) suggested that these were due to white blood
not normally noticeable, exactly like the Purkinje ret- corpuscles moving along the retinal capillaries.
inal tree. Some other phosphenes have recently been described
Maxwell's spot may be seen by viewing a brightly illu- by Tyler (1978).
minated white surface or the blue sky alternately
through a purple (e.g. cobalt blue) and grey filter. An ir-
regularly shaped dark-red spot will be seen through the The blue-arcs phenomenon
purple filter subtending about 6A.
If a moderately dark-adapted eye views a small source of
The yellow macular pigment cannot be seen with the
red light positioned one or two degrees from the fixation
normal ophthalmoscope. It can, however, be seen in
point, a dim bluish arc may be seen extending from the
the red-free light of mercury illumination with the indir-
coloured source. These arcs, which follow the route of
ect ophthalmoscope (Ballantyne and Michaelson,
the post-ganglionic nerve fibres towards the optic disc,
1965) or by photography with a blue filter.
were noted by Purkinje.
For an account of recent work on this phenomenon,
Physiological entoptic phenomena see Moreland (1968, 1969),

The physiological entoptic phenomena will be discussed

only briefly since they are not of optical origin. After-images
A comprehensive discussion of the physiology of after-
Phosphenes images is given by Lott Brown (1965) in the work by
Phosphenes are vague visual sensations arising when Graham and in other texts on physiology.
the retina is stimulated by energy other than light. Because the after-image is fixed in relation to the
Since the optic nerves and pathways end in the occipital retina, and will therefore be projected in a fixed position
cortex, any response by the retina will give the specific with respect to the eye, after-images may be used in
sensation of vision. The retina is very sensitive to lumi- orthoptics to verify binocular retinal correspondence
nous energy but much larger amounts of non-luminous and in the treatment of amblyopia (Caloroso, 1972;
energy are required for stimulation to occur. Hence, the Mallett, 1975).
eye must usually be dark adapted to see phosphenes.
The somewhat inappropriate term ‘inadequate stimulus’
is often used to describe non-luminous stimulation. The Troxler effect
X-rays can stimulate the retina and have been used in
Even when a specific object is steadily fixated, the eye is
measurements of the axial lengths and focal power of
constantly moving slightly. There is a high-frequency
the eye (see page 378), but their excessive use can
tremor of up to 1 minute of arc superimposed on larger
cause serious side-effects. Their wavelength, 100 nm to
drifting and saccadic movements. The image is therefore
0.01 nm, is very much shorter than the wavelength of
moving constantly over the retina so that the stimula-
light. Medical X-rays are nearer the short end of the
range. tion of the receptors is also varying. Thus on-off effects
Mechanically induced phosphenes may be of internal occur in the neural pathways and retinal adaptation is
reduced.
or external origin. The separating or ‘detaching’ retina
is a cause with serious consequences that must immedi-
If fixation is maintained as steadily as possible for 30 s
ately be investigated should a patient complain of flash- or more, objects in the periphery of the field of vision
ing lights. Similar phosphenes may occur with a fluid appear to dim, a phenomenon noted by Troxler. Because
vitreous and with some other pathological states of the size of the integrated receptor fields increases from
retina and choroid. Direct pressure on the globe with a the central retina outwards, small eye movements pro-
finger will stimulate the underlying receptors, giving a duce less fluctuation in illumination and retinal stimula-
projected phosphene on the opposite side to the finger. tion in peripheral areas. Hence, adaptation occurs first
Version movements of the eyes from side to side may in the periphery and results in the dimming of percep-
well give dull phosphenes due to the traction of the lat- tion. The shadow of the retinal vascular system is nulli-
eral and medial rectus muscles on the globe. A ring fied by sensory adaptation in an even more striking
phosphene has been reported on accommodating (Czer-
manner.
mak, cited by Tscherning, 1924). ‘ Much quicker fading of the visual field can be pro-
The blood circulation may also give rise to phos- duced if the image is stabilized on the retina. One
phenes. These are perhaps more optical than physiologi- method uses a rigid contact lens fitting tightly on the
sclera. It can carry either a test object and collimating
lens or a 45° mirror and telescope assembly of angular
magnification 0.5. Alternatively, electronic systems can
* This phenomenon, like many others, was first noted by Pur-
kinje in the 1820s. Some recent American authors, such as be used to monitor the eye movements and hence
Priestley and Foree (1955), have named it after Scheerer who adjust the object position on a video display. Techniques
investigated it in 1924. using after-images have also been devised.
 References 429

Exercises HALLDEN, U. (1957) An explanation of Haidinger’s brushes.

A.M.A. Archs Ophthal., 57, 393-399
HELMHOLTZ, H. VON (1924) Physiological Optics, Vol. I,
22.1 Show that if a pinhole is held at the anterior focal plane pp. 204-225 (optically based phenomena); Vol. II, pp. 301-
of the eye, the projected shadow of a vitreous opacity is magni- 311 (other phenomena). English translation ed. Southall,
fied by d/f., where f, is the anterior focal length of the eye and J.P.C. New York: Optical Society of America. (Reprinted
d the distance at which the projected shadow is measured. 1962 by Dover Publications, New York.)
22.2 In Helmholtz’s technique of velonoskiascopy, an oc- HOLTH, M.S. (1904) Nouveau procédé pour déterminer la re-
cluder is passed downwards across the pupil. In uncorrected fraction. Ann. Oculist., 131, 418-438
hypermetropia, does the perceived blur appear to shrink from HURST, M.A., DOUTHWAITE, W.A. and ELLIOTT, D.B. (1993) As-
bottom or top? sessment of retinal and neural function behind a cataract.
22.3 In Lindner’s technique with a white line on a red In Cataract, Detection, Measurement and Management in Opto-
ground, why does the shadow of the wire appear red? metric Practice (Douthwaite, W.A. and Hurst, M.A., eds), pp.
22.4 In Lindner’s technique, a myope observes an upright 49-51. Oxford: Butterworth-Heinemann
line with a vertical occluding wire mounted in the trial frame. JAGO, J. (1864) Entoptics, With Its Uses in Physiology and Medi-
(a) Does the shadow appear to move with or against when the cine, pp. 135-137. London: Churchill
head (together with the trial frame) is turned to the right? (b) JOHNSON, M.H., RUBEN, C.M. and PERRIGEN, D.M. (1987) Entop-
What is the horizontal retinal blur width, given an eye of diop- tic phenomena and reproducibility of corneal striae following
tric length +60D with a residual refractive error of 0.50 D? contact lens wear. Br.J. Ophthal., 71, 737-741
Assume the diameters of wire and pupil to be 1 and 4mm re- LINDNER, K. (1926) Beitrage zur subjektiven Bestimmung des
spectively. (c) Compare this with the basic image width of a Astigmatismus. Z. Augenheilk., 60, 346-360 ;
test line object subtending 0.1A. MALLETT, R.F.J. (1975) Using after-images in the investigation
22.5 (a) Calculate the Druault coefficient for diffraction in the and treatment of strabismus. Ophthal. Optn., 15, 727-729
plane of the geometrical centre of the crystalline lens. (Hint: de- MAURICE, D.M. (1962) The cornea and sclera. In The Eye,
termine the position of the image of this point formed by the Vol. 1 (Davson, H., ed.), pp. 312-322. New York and Lon-
posterior lens surface, assuming the constants of the don: Academic Press
Gullstrand—Emsley eye.) (See Appendix B.) (b) Given that the MORELAND, J.D. (1968) On demonstrating the blue arc phe-
diameter of the lens halo is 6° in sodium light (A = 589 nm) nomenon. Vision Res., 8, 99-107
and assuming grating-type diffraction, calculate the grating MORELAND, J.D. (1969) Retinal topography and the blue arcs
element (fibre size). phenomenon. Vision Res., 9, 965-976
NAYLOR, E.J. and STANWORTH, A. (1954) Retinal pigment and
the Haidinger effect. J. Physiol., 124, 543-552
PRIESTLEY, B.S. and FOREE, K. (1955) Clinical significance of
some entoptic phenomena. A.M.A. Archs Ophthal., 53,
References 390-397
SIMPSON, G.c. (1953) Ocular haloes and coronas. Br. J.
BALLANTYNE, A.J. and MICHAELSON, I.C. (1965) Textbook of the Ophthal., 37, 449-486
Fundus ofthe Eye, pp. 1-30. Edinburgh: E. & S. Livingstone STANWORTH, A. and NAYLOR, E.J. (1950a) The polarization op-
BARRETT, W.F. (1906) On entoptic vision, or the self-examina- tics of the isolated cornea. Br. J. Ophthal., 34, 201-211
tion of objects within the eye. Scient. Proc. R. Dubl. Soc., 11, STANWORTH, A. and NAYLOR, E.J. (1950b) Haidinger’s brushes
43-88, 111-136 + plates IN-VII, 1905-1908 and the retinal receptors. Br. J. Ophthal., 34, 282-291
BRADLEY, A., APPLEGATE, R.A., ZEFFREN, B.S. and VAN HEUVEN, STANWORTH, A. and NAYLOR, E.J. (1955) The measurement
w.A.J. (1992) Psychophysical measurement of the size and and clinical significance of the Haidinger effect. Trans.
shape of the human foveal avascular zone. Ophthal. Physiol. Ophthal. Soc. UK, 76, 67-79
Opt., 12, 18-23 TRANTAS, M. (1921) La velonoskiascopie et son utilité surtout
BROWN, J.L. (1965) Afterimages. In Vision and Visual Perception pour la détermination des principaux meéridiens de l’astigmie.
(Graham, C.H., ed.), pp. 479-503. New York: Wiley Bull. Mem. Soc. Fr. Ophthal., 34, 273-293
CALOROSO, E. (1972) After-image transfer: a therapeutic proce- TSCHERNING, M. (1924) Physiologic Optics, 4th edn, pp.
dure for amblyopia. Am. J. Optom., 49, 65-69 178-179. (trans. Weiland, C.). Philadelphia: Keystone Pub-
DRUAULT, A. (1899) Sur les anneaux colorés que I’on peut voir lishing Co.
autour des flammes a |’état normal ou pathologique. IX Int. TYLER, C.W. (1978) Some new entoptic phenomena. Vision Res.,
Ophthal. Gngr. (Utrecht), pp. 196-219 18, 1633-1639
ELLIOT, R.H. (1921) The haloes of glaucoma. Br. J. Ophthal., 5, WHITE, H.E. and LEVATIN, P. (1962) Floaters in the eye. Scienti-
500-502 fic American, 206(6), 119-123, 125, 127
EMSLEY, H.H. and FINCHAM, E.F. (1922) Diffraction haloes in ZEFFREN, B.S., APPLEGATE, R.A., BRADLEY, A. and VAN HEUVEN,
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Appendix A: a suggested routine
examination procedure
.

Symptoms and history (including health and medica- Oculo-motor balance, for example, cover test
tion) and fixation disparity.
Distance vision “Suppression tests.
If the patient is an habitual spectacle wearer, mea- *“Stereopsis.
sure the vision of R and L eyes through spectacles (c) Supplementary procedures
and possibly the unaided vision. If not an habitual “Cycloplegic refraction.
wearer, measure the R and L vision and also the “Orthoptic investigation.
binocular vision as this may be significantly better. (8) Colour vision
“Near vision On first examination or if an acquired defect sus-
With test types. pected.
Cover test (9) Ocular health
In distance vision, with spectacles if habitually (a) Basic procedures (These may conveniently be
worn. Also in near vision, but perhaps omit if performed here, or before the refraction, accord-
patient would need to don reading spectacles. ing to the practitioner's preference.)
) Near point of convergence Pupil reactions: direct, consensual and near.
“Motility test +Hand slit-lamp examination.
Refraction Ophthalmoscopy.
(a) Distance procedures +Confrontation test.
Objective. (b) Further procedures
Subjective, including binocular refraction or Tonometry on patients over 40 years, or
balancing when appropriate. younger where indicated.
Distance visual acuity. Major slit-lamp (biomicroscope) examination.
Distance oculo-motor balance, for example, Visual-fields examination.
cover test (and/or Maddox rod) and fixation dis- Amsler chart investigation.
parity. Mydriasis, possibly with indirect ophthalmo-
“Suppression tests. scopy (head mounted or with slit-lamp).
(b) Near procedures
Amplitude of accommodation or reading addi-
tion.
Accommodative lag: near bichromatic test or “Tests undertaken only when indicated or advisable.
dynamic retinoscopy. + The procedures in section 9b are preferable.
Appendix B: the Bennett—Rabbetts
schematic eye, relaxed and
accommodated 10 D and, for historical
reference, the Gullstrand—Emsley relaxed
schematic eye (in italics)
Quantity Gullstrand—Emsley Relaxed Accommodated (10.0 D)

Radii of curvature
cornea ry +7.80 +7.80 +7.80
crystalline: first surface ro +10.00 +11.00 +5.20
crystalline: second surface* 13 —6.00 —6.47515 —4.750
Axial separations
depth of anterior chamber d 3.6 3.60 3.2Il
thickness ofcrystalline dy 3.6 3.70 4.09
depth of vitreous body ds 16.69 16.79 16.79

Overall axial length+ 23.89 24.09 24.09

Mean refractive indices
air ny 1 1 1
aqueous humour - ny Ip oOIS) WLSSIN6) SSG
crystalline 13 1.4160 1.422 1.422
vitreous humour nN4 Hh, 33333 1E33i6 1,.33:6
Surface powers
cornea F; +42,73 +43.08 +43.08
crystalline: first surface fy +8.27 +7.82 +16.54
crystalline: second surface F; 13.18 +13.28 +18.10
Equivalent powers
crystalline Jay +21.76 +20.83 +33.78
eye hie +60.49 +60.00 +71.12
Equivalent focal lengths ofeye
first (PF) to —16.53 —16.67 —14.06
second (P’F’) ifs +22.04 +22.27 +18.79
Distances from corneal vertex
first principal point AP +1.55 +1.51 +1.87
second principal point AGP’ +1.85 +1.82 +2.23
first nodal point A\N +7.06 +7.11 +6.60
second nodal point A\N’ +7.36 +7.42 +6.95
entrance pupil DAMES +3.05 42 340)5 +2.68
exit pupil A\E’ +3.69 +3.70 +3.25
first principal focus A\F —14.98 =15.16 —12.19
second principal focus A\F’ Se (oe) +24.09 +21.01
Refractive state (principal point) K @) 0 —10.00

Distance of near point from corneal vertex —98.1

a S SS
S
ee
All linear dimensions are in millimetres and powers in dioptres. See Table 12.1 for intermediate values of accommodation — values for accommodated
eyes should be regarded as provisional until further data become available.
* This radius is specified to three or more places of decimals solely to ‘fine-tune’ the resulting refractive state, and does not imply that an eye has to be
constructed to this degree of precision.
+ The accurate value of 24.0859 was used in the reversed ray traces for the accommodating and elderly Bennett—Rabbetts eyes.
+ Rounding errors explain the apparent differences between PP’ and NN’ for the various eyes.
General bibliography
This bibliography is divided by subject matter into five PITTS, D.G. and KLEINSTEIN, R.N. (1993) Environmental
sections. Except for a number of classic and older texts, Vision. Interactions of the Eye, Vision, and the Environ-
all the works listed are in print at the time of writing. ment. Boston: Butterworth-Heinemann
In each section the works are given in alphabetical TUNNACLIFFE, A.H. (1997) Introduction to Visual Optics,
order of author’s or editor’s name. 4th edn. London: Association of British Dispensing
Opticians

Classic texts and general works Geometrical and physical optics

CRONLY-DILLON, J. (ed.) (1991) Vision and Visual Dys- BENNETT, A.G. (1985) Optics of Contact Lenses, 5th edn.
function (17 vols). Basingstoke: Macmillan. The fol- London: Association of Dispensing Opticians
lowing volumes are particularly relevant: 1: Visual DOUTHWAITE, W.A. (1995) Contact Lens Optics and De-
Optics and Instrumentation (Charman, W.N., ed.); 9: sign, 2nd edn. Oxford: Butterworth-Heinemann
Binocular Vision (Regan, D., ed.) FREEMAN, M.H. (1995) Optics, 10th edn. Oxford: Butter-
DONDERS, F.C. (1864) Anomalies of Refraction and Accom-
worth-Heinemann
modation of the Eye. London: New Sydenham Society. FRY, G.A. (1969) Ophthalmic Optics. Philadelphia: Chil-
Reprinted in facsimile: London: Hatton Press, 1952 ton
DUKE-ELDER, W.D. (ed.) (1958 onwards) System of
SOUTHALL, J.P.c. (1933) Mirrors, Prisms and Lenses, 3rd
Ophthalmology (15 vols). Edinburgh: Churchill Living-
edn. New York: Macmillan. Reprinted 1964: New
stone. The following volumes are particularly rele- York: Dover Publications
vant: IV: The Physiology of the Eye and Vision; V:
TUNNACLIFFE, A.H. and HIRST, J.G. (1996) Optics, 2nd
Ophthalmic Optics and Refraction; VI: Ocular Motility
edn. London: Association of British Dispensing
and Strabismus; VIL: The Foundations of Ophthalmology Opticians
HELMHOLTZ, H. VON (1856-66) Physiological Optics. Eng-
lish translation: J.P.C. Southall. New York: Optical So-
ciety of America, 1924. Reprinted: New York: Dover
Publications, 1962 Physiological optics and
MILLODOT, M. (1997) Dictionary of Optometry, 4th edn. visual perception
Oxford: Butterworth-Heinemann
TSCHERNING, M. (1898) Physiologic Optics. English trans- COREN, S. and GIRGUS, J.S. (1978) Seeing is Deceiving: The
lation: C. Weiland, 4th edn, 1924. Philadelphia: Key- Psychology of Visual Illusions. Hillsdale, N.J.: Lawrence
stone Publishing Co. Erlbaum Associates
DAVSON, H. (1990) Physiology of the Eye, 5th edn. Lon-
don: Macmillan
GREGORY, R.L. (1974) Eye and Brain, 3rd edn. London:
Ophthalmic practice Weidenfeld
and instrumentation HART, JR, W.M. (1992) Alder’s Physiology of the Eye, 9th
edn. St Louis: Mosby Year Book
BALL, G.V. (1982) Symptoms in Eye Examination. Lon-
don: Butterworths
BORISH, I.M. (1970) Clinical Refraction, 3rd edn (2 vols). Binocular vision and orthoptics
Chicago: Professional Press
CURTIN, B.J. (1985) The Myopias. Philadelphia: Harper EVANS, B.J.W. (1997) Pickwell’s Binocular Vision Anoma-
and Row lies, 3rd edn. Oxford: Butterworth-Heinemann
EDWARDS, K.H. and LLEWELLYN, R.D. (1989) Optometry. OGLE, K.N. (1950) Resources in Binocular Vision. Phila-
London: Butterworths delphia: W.B. Saunders Co. Reprinted: New York: Haf-
GROSVENOR, T. and FLOM, M.c. (1991) Refractive Anoma- ner, 1964
lies. Research and Clinical Applications. Boston: Butter- OGLE, K.N., MARTENS, T.G. and DYER, J.A. (1968) Oculo-
worth-Heinemann motor Imbalance in Binocular Vision and Fixation Dispar-
HENSON, D.B. (1996) Optometric Instrumentation, 2nd ity. Philadelphia: Lea and Febiger
edn. Oxford: Butterworth-Heinemann VON NOORDEN, G.K. (1995) Binocular Vision and Ocular
MICHAELS, D.D. (1985) Visual Optics and Refraction, 3rd Motility, 5th edn. St Louis: C.V. Mosby Co.
edn. St Louis: C.V. Mosby Co. WALSH, F.B. and HOYT, W.F. (1982) Clinical Neuro-
PHILLIPS, A.J. and SPEEDWELL, L. (eds) (1997) Contact Ophthalmology. Vol. 1, 4th edn. Baltimore: Williams
Lenses, 4th edn. Oxford: Butterworth-Heinemann and Wilkins
Answers

Chapter 2 Chapter 5
2.1 (a) +6.38D (b) —7.14D 5.1 Horizontal focal line: 20.87 mm from P and 0.1875 mm
Pyxi4 Sy AMES Ouran) long
2.3 Entrance pupil 2.49 mm behind cornea, m= +1.11 Vertical focal line: 21.55 mm from P and 0.1935 mm long
Exit pupil 3.07 mm behind cornea, m = +1.03 Circle of least confusion: 21.21 mm from P and 0.0952 mm
Dh NGI = = B75), AGI! == 4-50), EY = D5, IB = EF DS), diameter
PB = —625 (all in mm) Blur ellipse: 0.2 mm horiz. and 0.4 mm vert.
25 RUA, = —@ i, AGB = <2 42, DP = =esci-te, BP= 5.2 Blur ellipse on retina: 0.5 mm horiz. and 0.1 mm vert.
=f =@ =f+6 BR ==f-eieea” Projected size of blur: 180 mm horiz. and 36 mm vert.
2.0) 440 nT = 723333 5.3 Basic height of retinal image: —1}mm
Size of blur ellipse: 0.2 mm along 45° and 0.5 mm along 135°
5.4 Since the circle of least confusion lies on the retina, the
Scheiner disc will give rise to two circular patches on the
Chapter 3 retina. Also, since the rays cross over vertically but not hori-
zontally, the alignment of them is: (a) horizontal, A lying out-
3.1 6/14 (20/47), 6/7 (20/23), 6/4°7 (20/16) wards (b) vertical, A lying below (c) along 135°, A lying
S21 (a)
Oy 6 below
3.3 6-metre letter 4-metre letter 5.5 Rays in a vertical plane reach the pinhole parallel but
(a) 8.48 and 8.98 mm 5.57 and 6.07 mm rays in a horizontal plane are converged towards the pinhole.
(b) 6.73 and 7.23 mm 4.42 and 4.88 mm The retinal image of every point is therefore a long horizontal
(c) 1.66 and 1.84 mm 1.04 and 1.28 mm focal line, which when projected extends across the lens (Max-
3.4 15.0imm), 1-07 wellian view)
Sia) MES 5.6 Spectacle refraction: —1.20 DS/—2.70 DC axis 180
SA Hehe7 Suton Ocular refraction: —1.18 DS/—2.52 DC axis 180
Syke 5.7. —9.07 DS/—3.24 DC axis 120
3.8 N526/9 (20/30), N48 = 6/84 (20/280) 5.8 (a) +11.76/-5.17x90 (b) +10.25/—4.25 x 90
S39 loll ‘ 5.9 (a) —5.50/—3.19x180 (b) —6.00/—3.75 x 180
3.10 83.6% 5.12 +0.50/+2.00 x 40
3.11 (a)0.012mm (b)0.019mm (c) 0.048 mm
Srl weOF67 less AON7
3.13 6/12 (20/40), 6/24 (20/80), 6/18 (20/60), 6/30
Chapter 6
(20/90)
6.1 Axis shift varies from 28° for trial cylinder power 0.50 D
to 3.5° for cylinder power 6.00 D
6.2 +11.76D, +13.17D, +26.57 D, +28.57 D; +1.41 D and
Chapter 4 +2.00 D
—8.70 D,—9.44 D, —14.79 D, —15.38 D; —0.74 D and —0.59 D
4.1 (a) 400mm (b) 22200 mm (c)) 13 35 mm_ (d) 6.4 (a)—1.25DS (b)+0.75DCx180 (c)—0.75/
+100 mm —0.50x 80 (d) +1.25/—1.00 x 95
4.2 (a) +2.16D (b)emmetropia (c) —10.39D (d) 2.79D 6.5 (a) (i) 0.0625 mm _ (ii) 0.0833 mm _ (iii) 0.0417 mm
4.3 One dioptre corresponds to © —3/8 mm variation in axial 6.6 +1.07/-1.15 x 1623
length
4.4 K=-8.94D
4.5 Ocular refraction ranges from —15.63 D to +18.98 D
Chapter 7
4.6 +3.25D
Vink (ey (i) eID) (Gn) Nera KOND) 7d (aieintinitys toy NS 35 mm (b) Real part: infinity to
(b) (i) +15.46D (ii) +14.56D —500 mm; virtual: +364mm to infinity (c) +308 mm to
4.8 (a) +55.44D (b) —0.075 mm +1000 mm (virtual) (d) —8 34 to —62.5mm
4.9 Object is virtual, 200mm behind principal point and 7.2 (a) Spectacle accommodation 3.00 D; ocular accommoda-
1.3 mm high tion 2.40D_ (b) 3.00 D and 3.52 D respectively
4.10 —0.242 mm in the given eye, —0.237 in the emme- Wess (0) 21D) (ng) Ba 7D)
tropic eye, ratio (relative spectacle magnification) 1.021 7.4 (a)14.19D (b)11.44D (c)12.10D
—w 7.5. (a) 667 down to 250mm _ (b) 1000 down to 222 mm
ALU Wy =
Py + Fo — dhPe 7.6 Additions
4.12 (a) 44mm (b) 4.5mm
4.13 Blur circle diameter 0.172 mm, basic heights —0.025 +2.00 +2.25 62.5.0) +2.75
and —0.251 mm (a) 422 mm 382 mm 348 mm 321 mm
4.14 Projected circular blur patches are each of 60 mm diam- (b) 500 444 400 364
eter, their centres separated by 180 mm. The upper patch ap- (GO: 335) 472 422
pears red -
4.16 (a) —0.0993mm _ (b) —0.437 mm (d) 195 mm, 124 mm (e) 29 mm more on the distal side
4.17 (a) 15.625 mm per dioptre 7.7 44mm
(b) (i) —0.246 mm _ (ii) —0.291 mm Hogs IR 25S) 1D), Ih =2.86) 1D
4.19 Hypermetrope: blur ratio —4, myope: blur ratio +8 HY) 05331)
4.20 Blur ratio decreases for all except low myopes 7.10 +6.05D
4.21 3.91 mm per dioptre 7.11 9.3 and 39 minutes of arc, 3.99 mm (between N18 and
4.22 —5.00D N24)
4.23 (a) 3.29 (b) 8.06D 7.12 For 56mm PD: 2.7, 2.3, 2.0, 1.8 and 1.6 mm
434 Answers

13.9 (a) (i) 1.51° anticlockwise, (ii) 1.51° clockwise (b) (i)
Chapter 9
().26° clockwise, (ii) 0.26° anticlockwise
ce ome WAVE) 13.10 —500 mm
9.2 (a)—1.50D_ (b) yes, if accommodation sufficient 13.11 Continuous rotation with scissors movement
9.3 (a) +1.00D_ (b) only if under-corrected hypermetrope 13.12 9.14 A downwards
9.4 slight over-convergence (esophoria) 13.13 Total convergence 15.04 A (R 6.82 A, L 8.22 A)
13.14 R 37.9 A downwards, L 42.4 A downwards
13.15 1.23, 1.07, 1.00, 0.94, 0.89, 0.84 and 0.76 A
13.19 eg.d=0,A=4D,M=3.0
Chapter 10 d= Olcm aA» Dai *
10.1 Distance 9 A esophoria, near 16.5 A esophoria d= 2 Orem ODN Vip—— 2 0
10.2 (a) Optical centre distance may be up to 15 mm wider 13520) (a) MRO5S42 (bh yOn75 (6) a7 See AeS
than PD but image defects may then be apparent, (b) optical 13.21 +5.00D
centre distance should not exceed PD but may be somewhat 13.22 —4.25 DS
smaller 13.23 (a) + 2.00D, (b) +4.00 D
10.3. (a) R 1 mm up, L 1 mm down (b) R 2.5mm down, L 13.24 (a) Range —58.82 to —66.67 or 7.85 mm. (b) Range
2.5mm up —162.83 to —170.64 or 7.81 mm
10.4 Distance 2.4 A base out, near 5.4 A base out 13.25 Spectacle telescope 31.3°, contact-lens telescope 51.7°
10.5 0.96 AR hyperphoria 13.26 (a) 4.37x, (b) (i) 2.08x, (ii) 2.45 x, (iii) 2.65
10.6 1/3A,0.056mm 13.27 Without
10.8 (a) 64mm, 1.2 A base out 13°29) (@))=£016%)
215 7a) (0) a3 7o 232k 7a
(b) 63 mm, 0.9 A base out
10.9 63.2 mm, 2.4 A base out
Chapter 14
14.3) R1.5A base down
Chapter 11
14.4 (a) Decentre both lenses 3 or 4mm upwards from hori-
gil ae0O3 OS), OS) WI, HART, PO OHM sil Lucey eyaval zontal centre line. (b) Work optical centres 1 mm above seg-
7468 mm ment tops to divide vertical prismatic imbalance equally
11.2 (a) 6.2 seconds of arc (b) 7.2 seconds of arc between distance and near visual points
iiss AN INO), AAS) eee ie AO<, il.'5),juhaa) 14.5. 1.33° excyclophoria
11.4 The collimating objective may be under-powered for TAG Reo 82 elo al
blue in relation to yellow — typical of the secondary spectrum 14.7 (a) Ratio 1/1.111
of an achromatic doublet 14.8 (a)5.78 (b) 4.67
AES (a) es ib) GA
11.6 (a) 71.4mm_ (b) 48.2 mm
Chapter 15
11.7 (a) 16.8 (b) 3.8
11.8 (a) (i) 21.744, (ii) 10.39 A (b) (i) 7.24, (ii) 3.46 15.1 (a)0.015mm_ (b) —294 to -625 mm
11.10 (a)n/4 (b)n/2 15.2 (a)+4.44D (b) -—67 mm
11.11 (a) 10Aeacheye (b) 260mm
11.12 Crossed, C 284.4mm, D 277.4mm; uncrossed, C
455.0 mm, D 474.0 mm Chapter 16
U6. 637 tims 7x
Chapter 12 W629 =E0)) mmr OFS mm
16.3) 1.25mm
12.1 (a) +59.97 D. (b) First principal point P +1.37 mm from 16.4 2.15mm
first lens; second principal point P’ +1.13 mm from first lens 16.5 (a) +8.33D (b)=12°50)D
(note that principal planes are crossed). (c) 17.81 mm 16.6 2.91D
12.2 (a) Near point 286.5 mm in front of corneal vertex, (b) 16.7 (a) +15.56x ,2.57mm _ (b)4+16.67x, 2.40 mm
equivalent power increased by +4.14 D 16.8 With: 1.85 mm, 13.33, without: 1.45 mm, 18.65
123° K=—4.75D, K =+55.25 D, —209.12 mm from cor- 16.9 Horizontal: 13.36x, vertical: 16.85
neal vertex 16.10 0.37%
12.4 25.05mm 16.11 (a) +3.64 mm from cornea, height 0.182 mm
12.5 —1.34D, denoting 1.34 D of accommodation (b) +3.45 mm from cornea, height 0.276 mm
12.6 Principal values Fy = +60.23D, FL, = +21.55D, axial 16.12 (a) 375mm behind condenser (b) 77.4mm from
length +24.01 mm condenser, —5.72mm_ (c) —3.20x
12.7 —5.04D 16.13 71.4mm, 8.4mm
12.8 3.23 mm behind corneal vertex, 5.13 mm diameter 16.14 (a) 1;mm_ (b) (i) —5x, (ii) —4.58x
Wes) Says yD) 16.15 7.33 mm
12.10 Moved forward 30.56 (or 209.44) mm 16.17 (a) (i) —3.84x, (ii) 32.3°
12.11 First principal point (P) —3.74mm from cornea; (b) (i) —3x, (ii) 43.6°
second principal point (P’) —5.14 mm from cornea (note that (c) (i) —2.14x, (ii) 51.1°
principal planes are crossed)
12a eles ern
12.13 K =+22.59D, +31.0D Chapter 17
12.14 (a) +9.10D, (b) 24.8% increase
17.1 (a)0.51mm (b)0.35mm _ (c) 0.37 mm
17.2 (a)42.4mm (b)7.36mm _ (c) 27.2 mm
Chapter 13 17.4 (a) Instantaneous disappearance, (b) against move-
ment, (c) against movement in an apparently vertical direction
13.1 (a) 1.068 (b) 1.097 17.5 (a) 3:0) 2.0, 610) and! 5:Ommm) 4(b)"55559720 le Oband
13.2 (b) 0.940 (c) (i) 0.986, (ii) 1.083, (iii) 1.024 7.5mm _ (c) 8.0, 12.0, 4.0 and 0 mm
13.3 0.992 along 150° and 0.944 along 60° 17.6 (a) —0.36 rad (against) (b) +0.138 rad (with)
13.4 Spectacle refraction —6.00 D, ocular refraction —5.45 D 17.7 +4x (with), +2 (with), —4x (against)
13.5 0.342 mm along 45° by 0.326 mm along 135° 17.8 (a) Speed increased by 57.0 times (b) by 8.07 times
13.7 Spectacle lens 10.58 mm’, contact lens 12.23 mm? 17.9 (a) (i) 2.14 mm, 0.00369 sr; (ii) 1.15 mm, 0.00107 sr:
13.8 Areas ratio of pre-aphakic to corrected aphakic 0.60. [I- (b) (i) 2.14 mm, 0.000052 sr; (ii) 1.15 mm, 0.000015 sr
lumination ratio 1.08 U7 OPS Re oe liye Oya
 Answers 435

Wry NHS 20.10 Image 3% too large, interpreted as radius 3% too

17.12 (a) K = 2W (a/g) small; +3.85 D
(b) g(mm) a=1mm a= 2mm a= 3mm 20.12 (a) From 5.625 to 7.125 mm (b) (i) 2.0%, (ii) 3.8%,
2 =1.50D —3.00 D —4.50D (iii) 0.12%
4 —0.75 —1.50 —2.25 2003) 7) = inom yo min yf — 2 mm yi — 22> mom,
6 —0.50 —1.00 —1.50 r,=7.82mm 7.84 mm 7.88mm 7.92 mm
73 ea(a) OFS 3)DOO wb) OF64. Dll 35 an(G)OM si Dle33 i = Hx) 7 {N33 8.03 8.16
17.15 e.g. (i): (a) +5.45 D, (f) +0.21 D; (ii): (a) +9.14 D, (f) 20.14 (a) Ratios in order: 1.283, 1.369, 1.375, 1.546,
+0.24D 1.344, 1.419
(b) Calculated ast: (A) —1.54 «180 (B) —1.54 x 90
(C) —0.57 x 90
Chapter 18 (c) Keratometry: (A) —2.10x 180 (B) —0.66
x 90
(C) —0.19 x 90
18.2 (a)36mm _ (b) 7.58 mm 20.15 2.94 mm
20.16 (a) +42.735 D (increase of +0.072 D)
(b) +43.951 D (increase of +1.288 D)
Chapter 19 20.17 (a) 4.69 us (b) 9.08 us (c) 30.87 us (d) 1.31 ps
20.18 (a)s' = 3.773; t' =3.665 (b)s’ = +3.839; t' = +3.860
19.) 72
19.2 —79.2° per minute, —21.6° per minute
19.3 (a)+20.00D (b)O (c) +40.00D
Chapter 21
Chapter 20 21.1 (a) +16.47D (b) +57.63D (c) respectively 4.36D
and 2.37 D weaker than in the Bennett—Rabbetts eye
20.1 40m 21.2 (a) +20.25D (b) +59.47D (c) respectively 0.58D
20.2 —4.10 DC axis 60 and 0.53 D weaker than in the Bennett—Rabbetts eye
20:3 (a) 1:654mm (b) 0.20
20.4 —4.02 DC axis 90 (b) —4.09 DC axis 90
20.5 (a) (i) —7.45/—5.30 x 30, (ii) +11.41/—2.90 x 30
20.6 +12.06DS Chapter 22
DOS eS4 ele el OSsand OLoual)
20.8 Ocular ast —4.42 DC axis 170; corneal ast —3.56 DC 22.2 From bottom
axis 170; residual ast —O.86 DC axis 170 22.4 (a) With (b)1/120mm (c)1/60mm
20.9 (a) 7.765mm (b) 7.673 mm 2275 (a) al Ob) Roem
Index

Abathic distance, 156 Accommodative convergence/accommodation (AC/A)

Abduction movements, 142, 143, 158 ratio, 162-3
Aberrations, Accommodative (Donders’) squint, 185
contact lens wearing eye, 287-8 Accuracy, 4
ocular, 275-85 Achromatizing lenses, 279-80
pseudophakic eyes, 287 Acuity cards, 38
schematic eye, 213, 276-9 Adduction movements, 142, 143, 158
spectacle lens, 254-6 Aerial perspective, 191
Accidental astigmatism of accommodation, 127 After-images, 428
Accommodation, 113-39 Age-associated changes
abnormalities, 118-19 accommodation (presbyopia), 66, 117-19, 129
age effects, 117-19 near addition, 120, 122
amplitude measurement, 1 16-17 blindness, 45
anatomy, 129 contrast sensitivity, 51
anisometropia, 259 corneal curvature, 415-16
astigmatism in near vision, 127 crystalline lens continued growth, 212, 415
in asymmetrical convergence, 124—5 glare, 297-8
Brewster-Holmes stereoscope, 198 lens opacities, 66
as clue to depth perception, 191 longitudinal chromatic aberration (LCA), 280
convergence relationship see Convergence night myopia, 138
detail size dependence, | 30-1 physiological exophoria, 178
far point, 113 pupil diameter, 26
hypermetropia, 66 refraction, 413-14
intermediate addition, 1 28—9 refractive index changes, 416-17
involuntary, 133, 135 schematic eye, 212-13
magnifying devices, 248 stereo-acuity, 203
near correction, 118, 119-21, 122, 126-8 visual acuity, 417
near point, 113 yellowing of lens, 97, 415
ocular, 114-16 AMA visual efficiency scale, 40
physiology, 129-30 Amblyopia, 41-3
proximal, 134, 135 amplitude of accommodation, 132
range, 113 anisometropic, 42, 263
reaction time, 130 autorefractor results, 362
relative, 164-5 classification, 41-3
response assessment, ]21—2 congenital, 42
resting state, 113 contrast sensitivity testing, 55
schematic eye, 212 occlusion, 42
spectacle, 114-16 refractive, 42
spherical aberration, 283 screening young children, 370, 371
stimulus, 130-2 strabismic, 42—3, 186
Lone Ie 32 treatment, 189
adaptation, 138 vision screening, 368
night myopia, 133 Ametropia, 62-76
refractive error relationship, 136 ‘axial’ /‘refractive’, 63-4
retinoscopy, 344 blurred retinal imagery, 68—71
see also Inadequate—stimulus myopias classification, 62
voluntary control, 132, 134 convergence-accommodation relationship, 160-1
Accommodation response contrast threshold (ARCT), 131 contact-lens corrected ametropia, 161-2
Accommodative convergence, 159, 178 spectacle-corrected ametropia, 161
 Index N
NS)

correcting lens, 64-6 AO space eikonometer, 269-70

distribution, 406-8 Aphakia, 66-7, 223-6, 418
components of refraction, 409-1 1 distance correction, 223-4
large-scale surveys, 406-7 intraocular lenses, 224-6
ophthalmic precribing data, 407 near correction, 224
unaided/corrected vision studies, 407 size of retinal image, 224
ethnic differences, 408 unilateral, 67
growing eye, 412, 413 visual problems, 224
measurement, 95—7 Apparent field curvature, 245-6
bichromatic (duochrome) methods, 96—7 Apparent macular field of view, 246
standard routine, 95-6 Apparent peripheral field of view, 247
oblique aberrations, 287 Applanation tonometer, 310-11
retinal image following correction, 67—8 Arden test gratings, 52-3
Scheiner disc test, 73 Argon laser, 312, 327
sex differences, 407-8 Artificial pupils, 136
vision, 71-2 Asher—Law stereoscope, 199
expected, 93, 94 Astigmatic blurring, 83-4
Amplitude of accommodation, 66, 116-17 Astigmatic decomposition, 88, 89, 409
abnormalities, 118-19 Humphrey vision analyser, 373
age associations, 117-19, 122 Astigmatic error determination, 97—104
amblyopia, 132 binocular refraction, 108
near addition selection, 119-20 cross cylinder, 99-103, 105
normal spread, 118, 119 fan and block method, 97—9, 105
Anaglyphs, 199-200 following obiective refraction, 105
Anaphoria, 18 3-4 Astigmatic lenses, 78—9
Anatomical position of rest, 158, 159 cylindrical power, 79
Angle-closure glaucoma, 303, 305, 425 resultant of combinations, 87—9
Angles, 10 4 Astigmatic line rotation, 234-6
Angle alpha, 221, 397 Astigmatism, 78-91, 93
Angle kappa (lambda), 221 age-associated changes, 415-16
Angular magnification, 248 axis notation, 50
Aniseikonia, 265-73 classification, 82
causes, 265 cyclophoria, 182
correction, 270-2 cylinder axis distribution, 408-9
approximate, 273 distance correcting lens, 82—3
iseikonic lenses, 270-2 effectivity of correction in near vision, 123-4
isogonal lenses, 272 growing eye, 413
eikonometry, 266-70 historical aspects, 90-1
InGIdencey 2.3 incidence, 408-9
magnification ellipse, 266 infants, 411
size lenses, 265-6 irregular, 90
symptoms, 272-3 keratometry, 390-1
Anisometropia, 122-3, 259-65 decentration of corneal apex, 391
accommodation, 259 Javal’s rule, 390, 391
axial, 260-1 radii of curvature recording, 381
contact lens correction, 259, 261 measurement by Humphrey vision analyser,
effective binocular object, 245 373-5
prescribing, 263-5 oblique of spectacle lens, 255-6
refraction, 263 ocular, 79-80
refractive, 260, 261 image formation, 80-2
relative prismatic effects, 259 phakometry, 401
retinal image size, 259-60 residual error calculation, 86-8
retinal image size ratio (RISR), 260, 261-2 retinal image distortion, 233-4
see also Unilateral aphakia retinoscopy, 338-41
Anisometropic amblyopia, 42, 263 Lindner’s method, 340
Anomalous retinal correspondence, 186-7 static, 341
Anterior chamber, 11 streak retinoscopy, 347
examination, 301, 303 scalar representation, 89
photography, 311-12 Stenopaeic slit actions, 85—6, 87
Anterior chamber depth Stokes lens, 90
distribution, 410 tilted crystalline lens, 209, 390-1
measurement, 308, 309, 310, 397 vision, 84—5
438 Index

amount of astigmatism, 84 Bifocals, 264—5

axis direction, 85, 86 Binocular addition, 109
mean ocular refraction, 85 Binocular balancing methods, 105, 106-8
predicted, 93-4 Binocular field curvature, 245—6
vision screening, 368 Binocular indirect ophthalmoscopy (BIO), 322-3
Asymmetric aberrations, 284, 285 Binocular refraction, 105-6, 108-9
Asymmetric convergence, 124—5 Binocular telescopes, 193-4
Automated testing, 5 Binocular vision, 2, 152—7 =
Automated vision screening, 369-70 anomalies, 167-89
6600 Auto-Refractor, 355 fixation disparity, 174-7
Autorefractors, 351, 352-9 see also Oculo-motor imbalance
accommodation response assessment, 121-2 cerebral processing, 152
clinical results, 361—2 corresponding points, 154—6
research instruments, 359-60 cyclopean eye (binoculus), 156-7
use in clinical practice, 362 dominant eye, 157, 180-1
Autostereogram, 199 effective binocular object, 243-6
Autostereoscopic effect, 199 fields of fixation, 153
Axial chromatic aberration, 254 neural transmission, 153-4
spectacle lens design, 256 perceptual co-ordination, 154
Axial length of eye physiological diplopia, 156-7
age-associated changes, 417 requirements, 152
Bennett-Rabbetts schematic eye, 210 stereopsis, 157
calculation, 211 tests, 201
distribution, 410 strabsimus testing, 203
growing eye, 412, 413 vision screening, 368
measurement, 40 1—2 infants, 371
myopia, 414, 415 visual fields, 152
Axis notation, 80 Binoculus (cyclopean eye), 156-7
projection axis, 157
Back vertex power, 64 Biomicroscope see Slit lamp
Badal optometer, 75, 134, 357 Blind registration, 45
amplitude of accommodation measurement, 117 Blind spot, 14-15
Bagolini striated glass, 188 Blindness, 45—6
Bailey-Lovie charts, 30, 31, 36 definitions, 45
test-retest repeatability, 32 Blue-arcs phenomenon, 428
Balancing methods, 105-9 Blurred retinal imagery, 68-71
near correction, 128 astigmatic blurring, 83-4
Barrel distortion, 256 blur ratio, 70-1
Barrett relative accommodation stereoscope, 199 blur-circle diameter, 68-9
Barrett retinoscopy, 199, 343 entrance/exit pupils, 214
Base meridian, 78 image of extended object, 69-70
Bausch and Lomb keratometer, 385, 386 pinhole disc, 72
Bennett-Rabbetts schematic eye, 15, 209-12, 223, 421 projected blurs, 71
accommodation, 212 Scheiner disc test, 73
axial length of eye, 210 schematic eye, 214-17
corneal radius, 209-10 Bradford Near Vision Charts, 36
crystalline lens, 210, 222 Brewster stereoscope, 195
equivalent power, 209 Brewster teinoscope, 239
oblique aberrations, 286 Brewster-Donders method for depth of opacity, 423
optical constants calculation, 211-12 Brewster-Holmes stereoscope, 195
reduced eye, 210 accommodation, 198
refractive indices, 209, 276 basic principle, 196
spherical aberration, 282-3 clinical use, 196-8
variants, 222 convergence, 198
Bichromatic test filters, 289-90 convergence/accommodation (C/A) ratio, 198-9
transmittance curves, 289, 290 Brightness Acuity Meter, 43
Bichromatic tests, 96-7, 290 BS 4274, 34, 35
anisometropia, 263 BS EN ISO 8596, 35
balancing techniques, 106 BS EN ISO 8597, 35
polarized technique for near vision, 128
following objective refraction, 105 C—MES Rodenstock keratometer, 385
near addition checking, 121 Cambridge Crowding Cards, 32
 Index 459

Cambridge Low-—contrast gratings, 53 Computed videokeratography, 392-7

Cambridge videorefractor, 365—6 Conmesye eee
Campbell effect, 23-4 accommodative response, 133
Canon Auto Acuitometer, 370 retinal resolution, 21
Canon Auto—keratometer, 389 structure, 20
Canon autorefractors, 358-9 Congenital amblyopia, 42
early models, 354 Conjugate focus relationship
Cardiff Acuity Test, 33-4 reflection, 9
Carman achromatizing lens, 280 spherical refracting surface, 8
Cat schematic eye, 213 thin lens, 9
Cataract, 66 Contact lenses
autorefractor results, 362 aberrations, 287-8
direct ophthalmoscopy, 318 anisometropia, 259, 261
glare, 297-8 autorefractor results, 362
haloes, 425 design, 256
hyperacuity tests, 26, 45 fundus examination, 305, 308
myopic eye, 417 gonioscopy, 304
poor visual acuity, 43 irregular corneal curvature, 295
retinal function, 44—5 radii measurement, 388
entoptic phenomena, 424 residual astigmatism, 391
CEN (Comité Européen de Normalisation), 3 Contrast sensitivity, 51—5
Centration distance, 180 clinical considerations, 51—2
Centre of rotation, 143-4 clinical tests, 52-5
CES Rodenstock keratometer, 385 line discrimination, 19-20
Checkerboard test, 32 modulation transfer function, 47—8
Children in peripheral field, 37
accommodation, 118 poor acuity, 43
eye growth, 411-13 reading, 252
stereopsis, 203 sinusoidal gratings, 46—7
vision screening, 368, 370-1 Conventional magnification, 248
visual acuity development, 41 Convergence, 143, 158-66
visual acuity tests, 32-4 accommodation relationship, 136, 160-6
Chromatic aberration, 275-81 bio-engineering model, 165, 166
axial, 254 contact—lens corrected ametropia, 161-2
concept, 275-6 control, 165-6
experimental determinations, 278—9 emmetropia, 160
night myopia, 133-4 relative accommodation, 164—5
schematic eye, 276-8 spectacle-corrected ametropia, 161
spectacle-lens, 254—5, 256 uncorrected ametropia, 160-1
transverse, 254-5 see also Accommodative convergence;
chromatic stereopsis, 291 Convergence-induced accommodation
visual acuity, 281 Brewster—Holmes stereoscope, 198
Chromatic difference of equivalent power, 276 fusional, 159
Chromatic difference of refraction (longitudinal monocular clues to depth perception, 191
chromatic aberration; LCA), 277-8, 279, 280 near point, 159
Chromatic stereopsis, 290-3 over/under—active, 169
Chromatic variation of magnification, 278 proximal, 159
CIE (Commission Internationale de |’Eclairage), 3-4, tonic, 158-9
i> total angle, 160
Ciliary body innervation, 129 units, 159-60
Ciliary corona, 426 vision screening, 368
CIPM (Comité International des Poids et Measures), 3 voluntary control, 159
City University contrast sensitivity test, 53 Convergence-induced accommodation, 163-4
City University Vision Screener for VDU Users, 370 Cornea, 10-11
Clark auto—collimating photokeratoscope, 394 growing eye, 412
Cobalt disc, 76 E schematic eye, 207—8, 209-10
Cognitive accommodation, 132, 134 ultrasonography, 379
Colour contrast sensitivity, 55 Corneal astigmatism, 79
Comatic aberration, 284, 285 Corneal corona, 424—5
Comparability, 4 Corneal curvature
Compound hypermetropic astigmatism (CHA), 82 age-associated changes, 415-16
Compound myopic astigmatism (CMA), 82 measurement see Keratometry
440 Index

surgical modification, 417-19 age-associated changes

Corneal endothelium photography, 311-12 growth in thickness, 212, 415
Corneal epithelium thickness measurement, 310 transmittance, 415
Corneal grafting, 418 yellowish tinge, 97, 415
Corneal oedema, 425 equivalent power distribution, 410
Corneal opacities, 301 growing eye, 412, 413
Corneal power haloes, 425, 426
distribution, 409-10 opacities see Lens opacities
refractive anisometropia, 260 power, 12
Corneal radii refractive anisometropia, 260
Bennett-Rabbetts schematic eye, 209-10 relaxed/accommodated state, 11-12
distribution, 409-10 schematic eye, 208-9, 210
posterior radius phakometry, 400-1 Bennett—Rabbetts, 210, 222
slit-lamp photography, 401 tilted crystalline, 209
Corneal reflection PD gauge, 221 variants, 222
Corneal reflex see Purkinje I image ultrasonography, 379
Corneal scars, 294 Cuneiform cataract, 294
Corneal striae, 421 Cyclopean eye (binoculus), 156-7
Corneal thickness measurement, 308, 309-10, 397 dominant eye, 157, 180
slit-lamp photography, 401 projection axis, 157
Corneal topography, 391-3 Cyclophoria, 181-3
keratometry, 392-3 measurement, 183
Coronas, 424-6 proximal, 182
ciliary, 426 refractive, 182
corneal, 424—5 Cycloplegia, 111
theoretical analysis, 426 Cylinder axis, 78
Correcting lens, 64-6 Cylinder effectivity, 390
aberrations, 254-6 Cylindrical surface, 78
binocular vision, 243-6
binocular field curvature, 245-6 Dark-field myopia, 133, 135
effective binocular object, 243-4 Dark-field refraction, 135
contact lens design, 256 Dawes limit, 22
distance correction, 64 Decima V acuity, 28
fields of view, 246-7 Desnees ling
prismatic effects, 239-43 Depression movements, 142, 143
spectacle refraction, 64—5 Depth of field, 288-9
spectacle—lens design, 256 Depth of focus, 288, 289
subsidiary effects, 229 Depth perception, 191
astigmatic line rotation, 234-6 see also Stereopsis
relative spectacle magnification, 236 Development
spectacle magnification, 229-34 stereopsis, 203
Corresponding points, 154-6 visual acuity, 41
Count fingers (CF), 31 Dextroversion, 143
Cover test, 169-72, 371 Diagnostic positions of gaze, 146, 147
objective, 169-71, 187 Differential fixation, 38
subjective, 171-2, 188 Diode laser, 312, 327
Cow schematic eye, 213 Dioptre, 3, 8
Crisp-Stine test, 374 Dioptron, 353-4
Cross cylinder, 99-103 Diplopia, 2, 169
axis determination, 99-100 disparate points, 155
binocular refraction, 108 extra-ocular muscle dysfunction, 145-6
clinical aspects, 101-2 fixation disparity, 176
cylinder power determination, 100-1 heteronymous (crossed), 156
fan and block method comparison, 103-4 heterophoria, 178
near addition checking, 121 homonymous (uncrossed), 156, 157
theoretical aspects, 102-3 monocular, 293-4
effective axis shift, 102 physiological, 156-7
residual error of refraction, 102-3 Direct ophthalmoscope, 312-18, 351
spherical power adjustment, 102 clinical use, 317-18
uses following objective refraction, 104-5 design, 313, 315-17
Crowding phenomenon, 43 corneal reflex elimination, 316
Crystalline lens, 11-12 fields of view, 314
 Index 441

illumination of fundus, 313 apparent field curvature, 245-6

indirect ophthalmoscope comparison, 323-4 correcting lenses, 244-5
magnification, 314-15 horizontal prisms, 244
observation system, 313-14 limitations, 245
principle, 312-13 Effectivity, 10
Dissociated vertical deviation, 183 near vision, 125
Dissociation techniques in heterophoria, 172 astigmatic correction, 123-4
Distance test charts, 27-35, 94 trial case lenses, 95
Bailie-Lovie letter chart, 30, 31 Eikonometry, 266-70
computer presentation, 34 clinical aspects, 269-70
Ferris chart, 30, 31 horizontal magnification, 267-8
illumination/luminance contrast, 25, 34 oblique magnifications, 268—9
ISO standards, 35 test object, 266-7
letter relative legibility, 29 vertical magnification, 268
letter style variation, 28-9 Eisner lens, 312
logMAR scale, 30-1 El Bayadi lens, 306-7, 308, 323
notation, 28 Electronic optometers, 352
progression of sizes, 29 classification, 353
Distance vision, 2 clinical results, 361-2
aphakic eye, 223-4 research instruments, 359-60
spectacle magnification, 229-30 Elevation movements, 142, 143
stereopsis testing, 201 Empty-field (Ganzfeld) myopia, 132, 135, 136, 138
tests in heterophoria, 172-3 Emsley-Fincham test, 425, 426
Distortion, End-position nystagmus, 184
prisms, 238 Entoptic phenomena, 421-9
spectacle lens, 256 coronas, 424—6
Divergence, 143, 158 Haidinger’s brushes, 426-7
Dizziness, 179 5 haloes, 424-6
Dog schematic eye, 213 Maxwell's spot, 427-8
Dolman card, 180 opacities in media, 42 1—4
Dominant eye, 157, 180-1 optical, 421-8
anisometropia, 263 physiological, 421, 428
Donders’ law, 150 retinal integrity behind cataract, 424
Donders’ squint, 185 shadows, 423-4
Dot alignment perception, 26 Entrance pupil, 13
Double-pass technique, 49-50 blurred imagery, 214
Doubling devices Epikeratophakia, 418
keratometry, 382-3 Equivalent focal length calculation, 211
pupillometry, 402 Equivalent mirror theorem, 218
Druault test, 425 Equivalent power of crystalline calculation, 399-400
Drysdale-type keratometer, 387 schematic eye, 211
DSE (display screen equipment) Equivalent power of eye, 222
contrast sensitivity testing, 55 Bennett-Rabbetts schematic eye, 209
UK Association of Optometrists vision standards, 370 calculation, 211, 212
user vision screening, 370 distribution, 410-11
Duochrome methods see Bichromatic tests measurement, 402
Dynamic (kinetic) visual acuity, 37 Ergovision, 369
Dynamic random dot stereograms, 202 Esdaile—Turville equilibrium test, 128
Dynamic retinoscopy, 345-7, 371 Esophoria, 110, 168, 169
anisometropia, 263 convergence excess, 175
balancing near vision, 128 cover tests, 171
convergence-induced accommodation, 164 fixation disparity, 175, 176
errors, 346 incidence, 177, 178
heterotropia (strabismus), 189 symptoms, 178, 179
lag of accommodation, 345-6 tonic convergence, 181
monocular estimate method (MEM), 347 Examination see Visual examination of the eye
principle, 345 Excimer laser, 312
separate fixation method, 345 Excyclophoria, 182
trial lenses method, 346 Exit pupil, 13
blurred imagery, 214
Eccentric photorefraction, 364-5 Exophoria, 110, 168, 169
Effective binocular object, 243-4 divergence excess, 175
442 Index

fixation disparity, 175, 176 directional sensitivity, 22, 23, 24

incidence, 177, 178 resolution, 21
symptoms, 178, 179 Freeman—Archer oblique tangent scale, 173
tonic convergence, 181 Frisby test, 201, 203
Experimental assessment definitions, 4—5 Frontal (Listing’s) plane, 142
External eye photography, 311 Functional rest position, 158
External spherical aberration, 282 Fundus camera, 324-6
Extorsion movement, 143 fundus detail measurement, 326 <
Extra-fine reading charts, 36 non-mydriatic, 325
Extra-ocular muscles, 2, 144 optical system, 325
anatomical position anomalies, 169 scanning laser ophthalmoscope, 326-7
diplopia, 145-6 Fundus examination
fields of action, 146, 147 direct ophthalmoscope, 312, 313, 314-15, 317-18
muscle actions, 145 historical aspects, 324
pathology, 169 indirect ophthalmoscope, 318
Eyelid movements, 144 photgraphy see Fundus camera
slit lamp, 305-8
False alarm rate, 5 Fundus-viewing lenses, 305
False negative error rate, 5 Fusion reflex, 158
False positive error rate, 5 Fusion-free (passive; dissociated) position, 158, 159
False torsion, 150-2 Fusional reserves, 177, 205
Fan and block method, 87, 97-9
cross cylinder comparison, 103-4 Galilean telescopic magnifiers, 250
redesign of V and blocks, 104, 105 partially sighted patient, 254
technique, 98-9 Galvanic skin response, 39
use following objective refraction, 105 Ganzfeld (empty-field) myopia, 132, 135
Far point, 113 Gaze palsy, 183-4
Ferris chart, 30, 31 Glare angle, 296
Ffooks test, 33, 368 Glare index, 297
Fibre optic magnifiers, 254 Glasgow Acuity Cards, 32-3
Fick’s system, 149, 150 Goldmann applanation tonometer, 310-11
Field expanders, 254 Gonioscopy, 303-5
Fields of fixation grading system, 304-5
binocular vision, 153 Gonioscopy lens, 304
see also Macular field of view Grating acuity, 23
Fields of view Greenhough microscope, 302
direct ophthalmoscope, 314 Growing eye, 411-13
indirect ophthalmoscope, 318 infantile phase, 411-12
slit lamp fundus juvenile phase, 412-13
examination, 307 Gullstrand No.1 schematic eye, 207, 208
=
spectacle lenses, 246-7 Gullstrand-Emsley schematic eye, 209, 223, 431
boundary effect, 247
Fixation disparity, 174-7 Haag-Streit keratometer, 283
cyclophoria detection, 183 Haidinger’s brushes, 426—7
recording notation, 177 Haloes, 424—6
Fixation disparity units, 183 crystalline lens, 425, 426
Fixation on moving objects, 37 theoretical analysis, 426
Fixation position, 158 Hand magnifiers (hand readers), 250, 253
Fluorescein angiography, 318 Hand movement (HM), 31-2
Focal illumination, 301 Hand optometer, 352
Focusing tremor, 130 Hand readers, 250, 253
Fogging, 96 Hand slit lamp, 301
Forced choice approach Hartmann-Shack wave-front sensor, 285
preferential looking (PL), 38, 41 Head tilt, 179, 183
stereoscopic acuity, 192 ; Headache, 178
Form vision/recognition, 19 Headband magnifiers, 251
Forward spectacle shift, 126 Helmholtz’s system, 149, 150
Foucault (square-wave) grating, 22-3 Hering’s law of equal innervation, 147
Fovea, 2, 12 Hess screen, 148
area, 14 Heterophoria, 110, 167-84
cones, 20, 21 classification, 168
direct ophthalmoscopy, 317 compensated/uncompensated, 175
 Index 44.

cover test, 169-72 heterotropia (strabismus), 184—5, 189

objective, 169-71 indirect ophthalmoscopy, 320
subjective, 171-2 laser thermokeratoplasty, 419
fixation disparity, 174-7 manifest/latent error, 66
fusional reserves measurement, 177 near addition, 118
incidence, 177-8 near point, 113
instrumental measurement, 172-3 neonatal eye, 411
symptoms, 178-9 retinal image following correction, 67
tonic convergence, 181 retinoscopy, 342
treatment, 179-80 Scheiner disc test, 73, 74
version heterophorias, 183-4 spectacle refraction, 65
vision screening, 368 vision screening, 368
Heterotropia (strabismus), 2, 167-8, 184-9
accommodative, 184—5 ICI see CIE
alternating, 184 ICO (International Commission on Optics), 4
anatomical defects, 185 Illiterate E test, 32
causes, 185 Illumination effects
classification, 168 contrast sensitivity, 51-2
examination of patient, 189 distance test charts, 34
habitual angle of strabismus, 188 pupil size, 25-6
imMcidemeeneluiy, resolution, 24—5
motor sequelae, 189 Image formation, 7-10
neurological, 185 Imaged refraction systems, 37 1—2
nomenclature, 184 Inadequate-stimulus myopias, 113, 132-9
pathological, 185 correlations, 136-7
screening young children, 370, 371 Incyclophoria, 181, 182
sensory sequelae, 185-7 Indirect ophthalmoscope, 318-23
amblyopia, 186 binocular instruments, 322-3
anomalous retinal correspondence, 186—7 corneal reflex elimination, 320-1
suppression, 185—6 direct ophthalmoscope comparison, 323-4
tests, 187-9 instruments with separate condensers, 323
stereopsis, 203 magnification, 319-20
total angle of strabismus, 188 objective optometry, 351, 352
treatment, 189 principle, 318-19
unilateral, 184 single-condenser instruments, 322
vision screening, 369 Infants
Hirschberg test, 187 accommodation, 118
Holography, 205 astigmatism, 412
Horopter, 155-6 eye growth, 411-12
Horse schematic eye, 213 vision screening, 370-1
Hruby lens, 306, 308 Infra-red optometers, 134, 359-61
Humours Infraversion, 143
refractive indices Instrument myopia, 132, 135-6
age-associated changes, 416 Intermediate addition, 128
Bennett-Rabbetts schematic eye, 209 Internal spherical aberration, 282
ultrasonography, 379 International Federation of Ophthalmological Societies,
Humphrey Auto Refractors, 355-7 4
Humphrey Auto-keratometer, 389 International standards organizations, 3
Humphrey vision analyser, 88, 372-4 Inter-pupillary distance (PD), 95
Humphriss fogging method, 107, 108, 109 Intorsion movement, 143
Humphriss immediate contrast test (HIC), 107-8, 109 Intraocular lenses, 224-6, 417
Hyperacuity, 26 aberrations, 287
Hyperacuity tests, 26, 45 image size, 226
Hypermetropia, 62-3, 93 practical approximate formulae, 226
accommodation, 66, 115-16, 136 SRK formula, 226
age norms, 414 : unilateral aphakia, 262, 263
correcting lens, 64 Intraocular pressure measurement, 310-11
direct ophthalmoscopy, 315 Intra—stromal ring, 419
distribution, 406-7 ines, I, Wal
entrance pupil diameter, 232 Irregular astigmatism, 90
esophoria, 169 Irregular refraction, 294-5
facultative/absolute, 66 Iseikonic lenses, 270-2
444 Index

ISO (International Organization for Standardization), 3 Lenticular halo, 425, 426

distance test charts, 35 Letter charts see Distance test charts
[ISOM es Light perception, 19
Iso—accommodative magnification, 249 Line discrimination, 19-20
Isogonal lenses, 272 Line-width acuity, 23
Isotropic photorefraction, 364, 371 Linear extent of field, 49-50, 247
Linespread function, 296—7
Jack-in-the box effect, 247 Listing’s law, 150, 151
Jaeger pachometer, 397 Listing’s plane, 142
Javal-Schidtz keratometer, 38 3-4 Listing’s system, 149, 150, 423
Javal’s rule, 390 Localization, 19
Kataphoria, 183 LogMAR crowded test, 32—3
Keeler Vutest, 370 Longitudinal chromatic aberration see Chromatic differ-
Keratoconus, 294, 418 ence of refraction
Keratometer, 79, 380 Low visual acuity test charts, 29, 43
calibration Low-contrast test charts, 43, 54
corneal power, 387 Luminance
measurement areas separation, 388 accommodative response effect, 132
classification, 383 distance tests charts, 34
current models, 383-7 Luminance difference threshold, 19, 22
Keratometry, 380-91
astigmatism, 390-1 Macropsia, 119
decentration of corneal apex, 391 Macula, 14
Javal’s rule, 390 direct ophthalmoscopy, 317
contact lens radii measurement, 388 Macular degeneration, 43
corneal power recording, 381 Macular field of view, 246
corneal radii recording, 381 see also Field of fixation
corneal topography, 392-3 Maddox rod, 172, 173, 183
doubling principle, 38 2—3 Freeman-Archer oblique tangent scale, 173
errors, 388=9 Maddox wing test, 172, 173, 174, 183
focusing, 381 Magnification, 17
multi-meridional, 390 Magnification ellipse, 266
principle, 380-2 Magnifying devices, 247-51
tear quality evaluation, 389 accommodating eye/near addition, 248
Keratomileusis, 418 angular magnification, 248
Keratophakia, 418 conventional magnification, 248
Keratoscopy, 393-7 definitions, 247
Kinetic (dynamic) visual acuity, 37 equivalent power, 249-50
Klein keratoscope, 393 equivalent viewing distance, 249-50
Knapp’s law, 260 Galilean-type magnifiers, 250
Koeppe fundus contact—lens, 305, 308 hand readers, 250
Krypton laser, 312 iso-accommodative magnification, 249
partially sighted patient, 253-4
Laevoversion, 143 prismatic binocular loupes, 250-1
Lancaster screen, 148 spectacle magnifiers, 250
Landolt ring, 32, 36 telescopic spectacles, 251
Lang stereotests, 202 trade magnification, 248-9
Large print books, 44 Mallett fixation disparity unit, 174, 175, 176, 202
Laser keratoplasty, 418-19 Mandelbaum effect, 137
Laser ophthalmoscope, 326-7 Mavis/Master Vision Screener, 369
Laser thermokeratoplasty, 419 Maxwell's spot, 427-8
Laser treatments, 312 Mean refractive index, 10, 275
Laser-speckle refraction, 134, 135, 375-6 Mechanical vision screeners, 368—9
LASIK (Laser Assisted Stromal Interstitial Keratectomy), Melbourne Edge Test, 54
419 MEM retinoscopy, 346-7
Le Grand’s schematic eye, 218 Meridional amblyopia, 42
Lees screen, 148 Metre angle (MA), 159-60
Lens opacities, 43, 66 Micropachometer, 310
direct ophthalmoscopy, 318 Micropsia, 119
irregular refraction, 294 Microscopes, 56-7
subjective refraction, 105 instrument myopia, 135
Lenticular astigmatism, 79-80 Minus lens boundary effects, 247
 Index 445

Mirror imagery, 17 anisometropia, 122-3

Mixed astigmatism, 82 astigmatism, 123-4, 127
Modulation transfer function, 46, 47-8 balancing spherical component, 128
chromatic aberration, 281 effectivity, 123-4, 125
defocus effects, 50-1 normal routine, 1 26—7
double-pass technique, 49-50 partially sighted patient, 252
normalized spatial frequency, 48—9 spectacle magnification, 232-3
sinusoidal gratings, 46—7 Near point, 113
spurious resolution effects, 50-1 Near point of convergence, 159
square-wave (Foucault) gratings, 50 Near-point rule, 117
wave-front aberrations, 285 Neodymium-YAG laser, 312
Mohindra near retinoscopy, 343, 371, 415 Neonatal eye, 411, 412
Monochromatic aberration Nidek autorefractors, 355
ocular, 281-5 Night driving, 138
spectacle, 254 Night myopia, 133, 136
Monocular balancing methods, 106 age effects, 138
Monocular centre of projection, 154 causes, 133
Monocular clues to depth perception, 191 chromatic aberration, 134
Monocular diplopia, 293-4 correction, 138
Monocular polyopia, 294 involuntary accommodation, 133
Monocular visual field, 14-15 spherical aberration, 134
Motility testing, 147-9 Nikon autorefractors, 354—5
Mueller’s veil, 425 Nodal points position calculation, 211
Multi—meridional keratometry, 390 Non-invasive tear break-up time (NIBUT), 389
Muscae volitantes, 424 Normalized spatial frequency, 48—9
Myopia, 62, 93 Nystagmus, 184
age effects, 118
age norms, 414 r Oberkochen (Zeiss) ophthalmometers, 384
amplitude of accommodation, 136 Objective optometers, 351-66
components of refraction, 414-15 accommodation relaxation, 352
correcting lens, 64 convergence-induced accommodation, 164
direct ophthalmoscopy, 315 electronic, 352
distribution, 407 orange filters, 352
entrance pupil diameter, 232 visual instruments, 351—2
exophoria, 169 Objective refraction, 350
far point, 113 Oblique aberrations, 286—7
growing eye, 413 Bennett-Rabbetts schematic eye, 286
indirect ophthalmoscopy, 321 variations with ametropia, 287
intra-stromal ring treatment, 419 Oblique astigmatism, 255-6
laser keratoplasty, 418 spectacle-lens design, 256
near point, 113 Oblique eye movements, 149-50
neonatal eye, 411 Occlusion amblyopia, 42
ocular accommodation, 114-15 Ocular aberrations
prognosis of refraction, 414, 415 chromatic, 275-8]
retinal image following correction, 68 comatic, 284—5
retinoscopy, 332-3 spherical, 281—5
Scheiner disc test, 73 Ocular accommodation, 114-16
sex differences, 407-8 approximate expression, 116
spectacle refraction, 64, 65 Ocular dimensions measurement, 378-403
tonic accommodation, 136 Ocular movements, 142—52
VSLOMma/slee/ 2 binocular movements, 143
vision screening, 368 centre of rotation, 143-4
see also Inadequate stimulus myopia extraocular muscles, 144
monocular rotations, 142—3
Narrow-beam stereoscopy, 293 motility testing, 147-9
Near addition, 118, 119-21 muscle actions, 144—7
anisometropia, 122, 123 muscle fatigue, 145—6
aphakic eye, 224 oblique, 149-50
checking for near vision, 121 reflex movements, 144
magnifying devices, 248 torsion movements, 143
selection methods, 119-20 false torsion, 150
Near correction, 126-8 true torsion, 149
446 Index

Ocular (principal point) refraction, 63 field expanders, 254

Ocular rotation magnifying devices, 253-4
expressions, 241, 242-3 near vision, 252
units of measurement, 159 reading aids, 252
Ocular rotation factor, 241, 242 refraction, 252-3
Oculo-motor balance, 110 treatment principles, 252
Oculo-motor defects Pelli-Robson chart, 54—5
dissociated vertical deviation, 183 Perception of light (PL), 32
nystagmus, 184 Perceptual co-ordination, 154
version heterophorias (gaze palsy), 183-4 Peripheral astigmatism
Oculo-motor imbalance, 169 ametropic eye, 287
cover test, 169-72 oblique aberrations, 286
instrumental measurement, 172-3 Peripheral field of indirect vision, 246
Official standards organizations, 3 Perkins applanation tonometer, 311
Opacities in media Perspective alterations, 194
entoptic phenomena, 421-4 Phakometry, 398-401
Ophthalmetron, 354-5 astigmatic eye, 401
Ophthalmic precribing data, 407 comparison method, 398
Ophthalmoscope Dunn’s method, 399
comparative aspects, 323-4 posterior corneal radius, 400-1
development, 324 Purkinje images, 398
direct, 312-18 radii of curvature, 398
indirect, 318-23 Tschering’s method, 398-9
scanning laser, 326—7 Phosphenes, 428
shadows of retinal vessels, 422 Photoelectronic Keratoscope (PEK), 393, 394
Optic disc (papilla), 14 Photography
Optical axis, 220 anterior segment, 311-12
Optical centration of eye, 220-1 cataract changes, 312
angle alpha, 221 corneal endothelium, 311-12
angle kappa (lambda), 221 external eye, 311
iris—perpendicular axis, 221 fundus camera, 324-6
optical axis, 220 slit-lamp, 311
pupillary axis, 221 tilted image plane, 311
visual axis, 220-1 Photokeratoscopy, 393-7
Optical constants calculation, 210-12 Photometric units, 4
Optical instruments, 55—7 Photorefraction, 362-6
Optical ocular dimensions measurement, 378 dead space, 364
Optical system, 7-18 eccentric, 364-5
image formation, 7-10 isotropic, 364, 371
Optivision, 369 orthogonal, 363
Opto-kinetic nystagmus (OKN), 184 paediatric videorefractors, 365-6
arrest, 39 principle, 363
evokation, 38, 41 Photorefractor, 362-3
Optometers, 74-6 Physiological position of rest, 158—9
Orthophoria, 167 Pictorial test charts, 33
recording notation, 173 Pig schematic eye, 213
Oscillatory motion evocation, 38 Pincushion distortion, 256
Pinhole disc, 44, 72, 90, 105
Pachometer, 309-10, 397 Placido disc, 393
Paediatric videorefractors, 365-6 Plano prisms, 237-9
Panfundoscope, 307, 308 definitions, 237
Panum’s fusional area, 155, 174 distortion, 238-9
Papilla (optic disc), 14 effective prism power, 237-8
Paraboline chart (Raubitschek arrow), 374, 375 magnification, 238-9
Parallax i sign conventions, 237
as clue to depth perception, 191 Plus lens boundary effects, 247
relative binocular, 192, 193 Pointspread function, 297
Paraxial relationships, schematic eye, 214 Polarized light stereograms, 200
referred to pupils, 215-16 Polyopia, monocular, 294
Parson's cone (manoptoscope), 180 Poor acuity, 43-4
Partially sighted patient, 45-6, 252-4 visual acuity notation, 31—2
definitions, 45-6 Positions of gaze, 142
 Index

Posterior segment examination, 301, 312, 317-18 Push-up test, 117

Potential Acuity Meter, 44
Power, 8-9 Radial keratotomy, 418
Power meridian, 78 Randot test, 202, 203
Precision, 4, 5 Range of accommodation, 113
Preferential looking (PL), 38, 41 Rangefinders, 193-4
Prentice’s rule, 239, 247 Raubitschek arrow (paraboline chart), 374, 375
Presbyopia, 117-19, 129 simplification, 104
anisometropia, 264 Ray-construction methods, 16
VDU users, 128-9 Rayleigh limit, 22
Priegel test, 36 Rayleigh’s law, 295
Principal points position calculation, 211, 212 Reaction time of accommodation, 130
Prism binoculars, 55—6 Reading with poor vision, 252
stereopsis, 193 Reading-test types, 35-6
Prism dioptres, 10, 159 Bailey-Lovie word reading chart, 36
Prism distortion, 238-9 extra-fine reading charts, 36
Prism magnification, 238—9 near addition checking, 121
Prism metamorphopsia, 238 poor visual acuity, 43-4
Prism power, 10, 237 Sloan and Hubel’s M notation, 35-6
Prism recovery test, 187 : ‘Real’ image, 7, 8
Prismatic binocular loupes, 250-1 Real macular field of view, 246
Prismatic effects of lenses, 239-43 ‘Real’ object, 7
ocular rotation expressions, 241, 242-3 Real peripheral field of view, 247
visual points, 241 Receiver operating characteristic (ROC) curve, 5
Prisms Recording infra-red coincidence optometer, 359
binocular vision, 243-6 Reduced eye, 15
effective binocular object, 244 Bennett-Rabbetts schematic eye, 210
see also Plano prisms pupil, 15
Progressive power lenses, 129 Referrence wavelengths, 276
Projection axis, 154 Reflection, 9
Proximal accommodation, 134, 135 Reflex eye movements, 144
Proximal convergence, 159 Refracting unit, 95
Proximal cyclophoria, 182 Refraction, 63
Pseudophakic eyes, 287 age norms, 413-14
Pseudoscopy, 200-1 anisometropia, 263
Pupil, 11 at spherical surface, 8
diameter, 1 children, 412-13
reduced eye, 15 distribution of components, 409-11
schematic eye, 13 infants, 412
Pupil magnification, 23 1—2 irregular, 294—5
Pupil size neonatal eye, 411
age effects, 26 objective, 350
illumination effects, 25-6 partially sighted patient, 252-3
visual acuity, 24-5 stereopsis, 203
resolution effects, 23-4 see also Subjective refraction
Stiles-Crawford effect, 23-4 Refractive amblyopia, 42
Pupillary axis, 221 Refractive cyclophoria, 182
Pupillograph, 402 Refractive error, 93-4
Pupillometry, 402 astigmatic, 82
Purkinje I image (corneal reflex), 217, 219 measured in darkness, 134
direct ophthalmoscope design, 316 oculo-motor imbalance, 169
keratometry, 380 surgery, 417-19
phakometry, 400 Refractive index, 10
Purkinje images, 217-20 age-associated changes, 416-17
phakometry, 398, 400 Bennett-Rabbetts schematic eye, 276
positions, 219 4 ocular media, 276
reflectance, 218 Reiner imaged refraction system, 371
relative brightness, 218 Relative accommodation, 164—5
relative positions/sizes, 218-19 Relative binocular parallax, 192, 193
secondary ghost images, 219-20 Relative prismatic effects, 259
theoretical aspects, 217-18 Relative spectacle magnification, 232, 236
Purkinje shift, 134 Remote refraction, 372
448 Index

Repeatability, 4, 5 principles, 331—7

autorefractor results, 361 reversal, 332, 334-5
subjective refraction, 110-11 sighthole shadow, 338
visual acuity tests, 32 split (scissors) reflex, 343-4
Reproducibility, 5 static, 341-2
keratometry, 389 streak, 347-9
Resolution, 19 subjective check on findings, 345
Foucault (square-wave) grating, 22-3 Reversed relief (pseudocopy), 200-1 .
illumination effects, 24—5 Risley (rotary) prism, 204
pupil size effects, 23—4 Rodenstock keratometers, 385
receptor theory, 20-1 Rods, |
spurious, 23, 50-1 accommodative response, 133
wave theory, 21-2 structure, 20
Rest positions, 158-9 Rotary (Risley) prism, 204
Resting state of accommodation, 113 Rotation movements of eye, 142-3
Retimnagella 12 centre of rotation, 143—4
curvature, 12 Routine examination procedure, 430
function assessment with cataract, 44-5, 424
optical image formation, 20 Scanning laser ophthalmoscope, 326-7
peripheral visual acuity, 36-7 Scattered light, 295-8
receptors, | cloudy media/cataract, 297-8
structure, 20-1 experimental investigations, 295—7
Retina blood vessels, 12 practical importance, 297
shadows, 422-3 sources, 295
Retinal correspondence Scheimpflug photography, 401
anomalous, 186—7 Scheiner disc, 72—4
tests, 187-9 Brewster-Donders method for depth of opacity, 423
Retinal image, 15-16 optometery, 351, 353
algebraic treatment, 15, 16 autorefractors, 355, 358, 359
blurred see Blurred retinal imagery pupillometry, 402
object at infinity, 16 Schematic eye, 12-14, 207-27
ray-construction methods, 16 accommodated, 212
Retinal image size aphakic eye, 223-4
aniseikonia see Aniseikonia Bennett-Rabbetts see Bennett-Rabbetts schematic eye
anisometropia, 259-60 blurred imagery, 214-17
retinal image size ratio (RISR), 260, 261-2 projected blurs, 217
spectacle magnification see Spectacle magnification retinal images, 216-17
unilateral aphakia, 262-3 cardinal points, 13
Retinal image size ratio (RISR), 260, 261-2 chromatic aberration, 276-8
Retinal tree, 422 chromatic difference of equivalent power, 276
Retinoscope, 330-1 chromatic difference of refraction, 277-8
non-luminous, 337 chromatic variation of magnification, 278
Retinoscopy, 134, 330-50 cornea, 207-8
accommodative tonus, 344 crystalline lens, 208-9
accuracy, 343-5 ‘elderly’ eye, 212-13
anisometropia, 263 entrance/exit pupils, 13, 214
astigmatic error estimation, 338-4] historical aspects, 207
Barrett method, 343 infant/child, 213
binocular refraction following, 108-9 non-human vertebrates, 213
dynamic, 345-6 optical centration, 13
errors, 343-5 optical constants calculation. 210-12
off-axis, 344 optical dimensions, 221-2
position of reflecting surface, 344 paraxial relationships, 214
working distance, 345 referred to pupils, 215-16
false reversal, 336 range of variants, 221
fundus image, 332-3 refractive indices, 276
heterotropia (strabismus), 189 research applications, 213-14
Mohindra near retinoscopy, 343 spherical aberration, 282-3
oblique aberrations, 287 visual axis, 13-14
ocular abnormalities, 344 Script letter test charts, 33
partially sighted patient, 252 Self-luminous retinoscope, 330-1
practical aspects, 341-3 Semi-field of view, 247
 Index 449

Sensitivity, 5 night myopia, 134

Shadow entoptic phenomena, 423-4 pseudophakic eyes, 287
Sheep schematic eye, 213 retinoscopy, 343
Sheridan—Gardiner test, 32 rigid contact lenses, 287-8
Sherington’s law, 147 schematic eye, 282-3
SI units, 3 Spherical ametropia, 62—76
Sign convention, 2-3, 7 measurement, 95—7
plano prisms, 237 Square-wave (Foucault) gratings
reflection, 9 accommodative response, 132
Simple hypermetropic astigmatism (SHA), 82 contrast sensitivity, 53
Simple myopic astigmatism (SMA), 82 modulation transfer function, 50
Simple optometer, 74—5 Squint see Heterotropia (strabismus)
Sine-wave gratings, 46-7, 132 Stand magnifiers, 252, 253-4
Size of image, 191 Stanworth synoptophore, 204
Size lenses, 265-6 Static retinoscopy, 341-2, 371
Skiascopy see Retinoscopy Stenopaeic slit, 85-6, 87, 105
Slit lamp, 301-3 Stereocomparator, 205
corneal thickness measurement, 309-10, 397 Stereogram, 194, 195, 196
examination of fundus, 305-8, 323 anaglyphs, 199-200
comparison offields, 308 3 computer-generated, 196
gonioscopy, 303, 304-5 fusion with unaided vision, 199
illuminating system, 302 polarized light, 200
lasers incorporation, 312 reversed relief (pseudocopy), 200-1
microscope, 302, 304 Stereopair see Stereogram
ocular measurements, 308-9 Stereopsis, 157, 191-205
pachometer, 309-10 age-associated deterioration, 203
photography, 311, 312 clinical tests, 201-3
corneal radii, 401 development, 203
corneal thickness, 401 heterotropia (strabismus) testing, 187
shadows of retinal vessels, 422 refraction, 203
Stereo-Variator, 308 screening infants, 371
Sloan and Hubel’s M notation, 35-6 Stereoscope, 194-6
Smellenichanrtae2 2S 310)5 autostereoscopic effect, 199
Snellen’s fraction, 27-8 optics, 196-9
Soft contact lenses variable prism, 204—5
aberrations, 288 Stereoscopic acuity, 192, 193
corneal striae, 421 Stereoscopic range, 193
Sonksen Picture Guide to Visual Function (SPGVF), 33 Stereoscopic vision, 191—3
Space eikonometer, 265 SteTreotesuss 40 les
AO design, 269-70 comparison, 202-3
simple design, 270 Stiles-Crawford effect, 23-4, 292, 295
test object, 266-7 Stokes lens, 90
Specificity, 5 Strabismic amblyopia, 42-3
Spectacle accommodation, 114-16 Strabismus see Heterotropia
Spectacle frame obstruction, 247 Streak retinoscopy, 331, 337, 347-9
Spectacle magnification, 229-34 Shy Calntesie OMS OS royal
astigmatic image distortion, 233-4 Subjective optometers, 74—6
astigmatic line rotation, 234-6 Subjective refraction, 93-111
definitions, 229 astigamtic error determination, 97-104
distance vision, 229-30 autorefractor results comparison, 361—2
general method of calculation, 230-1 balancing methods, 105-9
near vision, 232-3 basic measuring equipment, 94—5
pupil magnification, 231-2 binocular addition, 109
Spectacle magnifiers, 250, 253 cycloplegia, 111
Spectacle refraction, 64-5 objective findings comparisons, 104—5
vertex distance, 64, 65, 66 oculo-motor balance, 110
Spectacle-lens design, 256 repeatability, 110-11
Spectral luminous efficiency, 275, 276 spherical ametropia measurement, 95-7
Spherical aberration, 281-5 Sunglasses, 252
accommodation, 283 Suppression, 185-6
definitions, 28 1—2 Supraversion, 143
experimental determination, 283, 284 Surgery, refractive error, 417-19
450 Index

Symbols, xiii, 2, 7 binocular movements, 147

Synoptophore, 203-4 units of measurement, 159
cyclophoria measurement, 183 Vertex distance, 64, 65, 66
subjective refraction, 95
Tear quality evaluation, 389 Vertigo, 179
Teinoscope, 239 Videokeratography, 392-7
Telescope, 55-6 Video-keratoscope, 285
Telescopic optometer, 75-6 Videorefractors, 365-6
Telescopic spectacle, 251, 254 Vieth-Miuller circle, 155, 156
Telestereoscope, 193-4 Vignetting, 247
Thin lens power, 9 ‘Virtual’ image, Me 8
Threshold of vision, 19 ‘Virtual’ object, 7
Tinted lenses, 252, 297 Virtual reality, 205
Tired eyes, 178 Visible light, 1
Titmus Wirt test, 201-2, 203 Vision screening, 368-77
UNOitesty 202203 automated, 369-70
Tonic accommodation see Accommodation computerized for DSE users, 370
Tonic convergence, 181 mechanical screeners, 368-9
Topcon autorefractors, 357-8 simple vision tests, 368
Topcon PR-2000, 366 simplified examination routines, 370
Toroidal astigmatic surface, 78, 79 young children, 370-1
Torsion movements, 143 Vision through optical instruments, 55-7
false torsion, 150-2 Vision, unaided, 27, 93-4
true torsion, 149 distribution, 407
Trade magnification, 248-9 objective determination, 37—9
Transverse chromatic aberration, 254-5, 278 Vistech system, 53
chromatic stereopsis, 291 Visual acuity, 19-51
distortion, 256 age-associated changes, 417
spectacle-lens design, 256 chromatic aberration, 281
Transverse magnification, 9-10 in clinical practice, 26-36
Trial case lenses, 94—5 checkerboard test, 32
near addition checking, 121 children’s tests, 32—4
Trial frames, 94, 95 comparison of notations, 31
Troland, 24 definition, 27
Troxler (extinction) effect, 21, 428 distance test charts, 27-35
Tscherning’s ophthalomophakometer, 220, 2 i) Ik, BOY Landolt ring, 32
phakometry, 398-9 notation, 28, 31-2
Turville near balance unit, 128 poor vision, 31-2
Turville’s infinity balance test (TIB), 106-7, 108, reading-test types, 35-6
HOO AS altsle 2163 repeatability of measurement, 32
Twilight myopia see Night myopia crowding phenomenon, 43
Typoscope, 252 development, 41
glare, 297-8
Ultrasonography illumination effects
anterior chamber depth measurement, 397 fixed pupil size, 24
axial length measurement, 402 variable (normal) pupil size, 24—5
ocular dimensions measurement, 378-80 kinetic (dynamic), 37
UMIST Eye System, 34 line discrimination, 19-20
Unequifocal optical systems, 9 objective determination, 37-9
Unilateral aphakia, 67 in infants, 41
intra-ocular lenses, 262, 263 methods, 38-9
retinal image size, 262-3 in peripheral field, 36—7
spherical ametropia, 71-2
Validity, 4 square-wave grating resolution, 23
autorefractor results, 362 Vernier acuity, 26
Variable prism stereoscope, 204-5 visual efficiency relationship, 39-41
Veiling glare, 295-6, 297 Visual axis, 154, 220-1
Velonoskiascopy, 424 schematic eye, 13-14
Vergence, 8-9 Visual display units (VDUs), 128-9, 370
Vernier acuity, 26 Visual efficiency, 39-41
Version heterophorias, 183-4 AMA scale, 40
Version movements, 143 Visual examination of the eye, 301—27
 Index 451

anterior segment, 301 Welfare services, 45

focal illumination, 301 Wesley-Jessen Photoelectronic Keratoscope (PEK), 393,
gonioscopy, 303-5 394, 402
posterior segment, 301 Wheatstone pseudoscope, 200
routine, 430 Wheatstone stereoscope, 194—5
slit lamp, 301-3 Wollaston double image prism, 383
examination of fundus, 305-8
Visual field efficiency, 41
Visual fields X-ray methods
binocular vision, 152 axial length measurement, 401
monocular, 14-15 ocular dimensions measurement, 378
nerve-fibre paths to brain, 153 X-ray retinal stmulation, 428
Visual perception, 2
Visual points, 241
Visually evoked cortical response (VECR), 39, 41
Yoke muscles, 146
accommodation in infants, 118
Young’s interference fringes, 44
Vitreous floaters, 424
Volk lens, 306-7, 308, 318

Wave-front aberrations, 285 * Zeiss CL110 ophthalmometer, 385, 386

Weber-Fechner fraction, 19 Zeiss Oberkocken ophthalmometers, 384
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THIRD EDITION
Bennett & Rabbetts’

| Clinical
Visual Optics
Ronald B Rabbetts |
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Practising optometrist, Portsmouth

Completely updated and revised into a third edition, this classic text provides a comprehensive review
of optics of the human eye. It covers:

@ Refractive correction and the instruments used in: eye examination, measurement
of visual acuity, contrast sensitivity, refractive errors, accommodation
and
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The oculo-motor system and stereopsis providing a firm foundation for further study

The dioptics of the eye, including its aberrations and schematic eyes

Thorough theoretical chapters and clinical chapters that contribute a fundamental

understanding of the procedures, together with sound practical advice

Recent research indicating possible future advances in techniques or explaining

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This book will be invaluable to all those studying optometry, dispensing optics and physiological optics.
The depth of coverage will make it a prime source of information for the qualified practitioner or a
prospective researcher in these fields. 3 |

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ISBN 0-7506-1817-5 §

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