14—Instruments

Direct Ophthalmoscope

Introduction and Mechanism

Commonly used for routine fundus examination, especially when a slit

lamp is unavailable.

Small, easily portable, and can examine anterior eye parts.

Instrument Components:
System of lenses focusing light from an electric bulb onto a mirror.

Mirror forms a real image of the bulb filament.

Reflects light in a diverging beam to illuminate the patient's eye.

Contains a hole for observer's view.

Bulb image formed just below the hole to prevent corneal reflection in
observer's visual axis.

Field of View

Definition: Area of retina visible at one time.

Governed by the projected image of the sight-hole on the retina.

Sight-hole is either the hole in the mirror or the observer's pupil, whichever
is smaller.

Refractive Error Influence:

Smaller in myopic eyes.

Larger in hypermetropic eyes.

Intermediate in emmetropic eyes.

Pupil Size Influence:

Considerably enlarged with dilated pupil.
 🔥 HIGH-YIELD: Mydriatics are advantageous prior to fundoscopy to
maximize field of view.

Observer Proximity Influence:

Field of view increases as observer moves closer to the patient's eye.

Illumination:
Field of view not evenly illuminated due to bulb filament position.

Modern instruments largely eliminate this effect.

Dark shadow in peripheral retina examination due to total internal

reflection at crystalline lens periphery.

Image Formation in Observer's Eye

Light from illuminated retina passes through mirror hole into observer's
eye.

Image formed in observer's eye is inverted but seen as erect.

Image Size Variation with Patient's Refractive State:

Smaller in hypermetropia.

Larger in myopia.

Intermediate in emmetropia.

Emmetropic Observer Viewing Emmetropic Patient:

Parallel light rays leave patient's eye.

Focused on observer's retina without accommodation or correcting

lens.

Emmetropic Observer Viewing Hypermetropic Patient:

Diverging beam leaves patient's eye.

Observer must accommodate or use a convex correcting lens.

Without correction, image is blurred (blur circle).

Emmetropic Observer Viewing Myopic Patient:

Converging beam leaves patient's eye.

Focused in front of observer's retina.

Without correction, image is blurred (blur circle).

Observer must use a concave correcting lens.

Correcting Lenses:
Necessary for clear view in myopia or hypermetropia.

Ophthalmoscope incorporates a range of correcting lenses.

Correcting lens power should equal the vergence of light emerging

from patient's eye.

Renders the beam parallel for focused image on observer's retina.

Effect of Correcting Lens on Image Size:

Reduces discrepancy in image size.

Image is still smaller for hypermetropic eye and larger for myopic eye
compared to emmetropic eye.

Ideal conditions (patient's and observer's anterior focal points

coincide, correcting lens at that point) would result in same image size
regardless of refractive error, but rarely fulfilled.

Clinical Relevance (HIGH-YIELD):

Hypermetropia/Aphakia: Smaller image size, but wider field of view.
Allows quick scanning of the whole fundus.

Myopia: Magnified but restricted view, reduced field of view. Difficult

to examine myopic fundus due to small field of view relative to fundus
size.

Refractive State Betrayal: Fundus view in high hypermetropia or

myopia is characteristic, betraying the eye's refractive state.

Useful when retinoscopy reflex is dull/indistinct in high ametropia.

Astigmatism:
Impossible to secure a perfect view due to spherical correcting lenses.

Only one meridian can be corrected at a time.

High astigmatism causes image distortion and oval optic disc

appearance due to dioptric power disparity.

Observer's Refractive Error:

Option 1: Remove spectacles, use appropriate lens in
ophthalmoscope (algebraic sum of observer's and patient's refractive
error).
 Option 2: Use instrument with glasses on, but field of view will be
restricted.

Judging Patient's Refractive Error:

Roughly judged by noting correcting lens power used.

Assumes neither patient nor observer is accommodating.

Posterior pole of highly myopic fundus best seen if patient keeps

glasses on.

Magnification and Clinical Use

Magnification Principle: Same as a loupe; observer uses patient's eye

dioptric power as a loupe.

Formula: M = F/4 (M = magnification, F = dioptric power of loupe).

Emmetropic Eye Magnification: Assuming +60 D for emmetropic eye,

magnification is × 15.

Clinical Utility:
Useful for examining retinopathy, allowing most micro-aneurysms to
be seen (some too small).

Red-free filter: Many modern ophthalmoscopes include this.

Green light causes micro-aneurysms to appear as black dots
against a green background, aiding detection.

Anterior Segment Examination: Can be used as a self-illuminating loupe.

E.g., lens opacities can be inspected through a +10 D correcting lens.

Indirect Ophthalmoscope

Introduction and Comparison

Alternative for examining retina and vitreous.

Provides a very different view compared to direct ophthalmoscope.

Both instruments are complementary for clinical eye examination.

Table 14.1 Summary of Optical Properties:

 Direct
Feature Indirect Ophthalmoscope
Ophthalmoscope

Vertically and horizontally

Image Not inverted
inverted

Field of View Small (6°) Large (25°)

Magnification Large (× 15) Small (× 3 [+20D], × 5 [+13D])

Binocularity Not available Stereoscopic view

Influence of Patient's Refractive

Large Small
Error

Teaching Facility None Teaching mirror

Mechanism of Illumination and Image Formation

Condensing Lens: Powerful convex lens held in front of patient's eye.

Common powers: +20 D and +13 D.

Image Formation:
Illuminating light passes through condensing lens into eye.

Light reflected from retina is refracted by condensing lens.

Forms a real image between the condensing lens and the observer.

Observer studies this real image of the patient's retina.

Illumination Source: Usually an electric lamp mounted on observer's

head.
Light from source is rendered convergent by condensing lens.

Convergent beam enters patient's eye and focuses within vitreous.

Light then diverges to strike the retina.

Illumination is bright and even, coming from the real image of the
light source within the patient's eye.

Field of Illumination:
Largest in myopia.

Smallest in hypermetropia.
 Limited by the size of the subject's pupil in all refractive states.

Condensing Lens Position:

Held at a distance where patient's pupil and observer's pupil are
conjugate foci.

Means light from subject's pupillary plane focuses in observer's

pupillary plane via condensing lens.

A reduced image of the observer's pupil is formed in the subject's

pupillary plane (e.g., 4 mm pupil image is approx. 0.7 mm).

Only rays passing through this reduced image can enter observer's
pupil and be seen.

Image Characteristics and Magnification

Image Inversion: The real image of the retina formed by the condensing
lens is vertically and laterally inverted (upside down and back to front).

Image Position: Situated at or near the second principal focus of the

condensing lens.
Approximately 8 cm in front of a +13 D lens.

Observer Viewing: Observer views the image from a distance of 40–50 cm.
Requires observer accommodation or presbyopic correction.

Binocular indirect ophthalmoscopes incorporate +2.0 D lenses in

eyepieces to negate the need for observer accommodation.
Observers with significant refractive error or near correction >
+2.0 DS should wear their spectacles.

Linear Magnification Calculation:

Formula: Linear magnification = (focal length of condensing lens in
mm) / 15 mm (where 15 mm is the distance between the nodal point
and the retina of the subject's eye).

+13 D lens (f = 75 mm): Approximately × 5 magnification.

+20 D lens (f = 50 mm): Approximately × 3 magnification.

Angular Magnification:
+13 D lens: Approximately × 5.

+20 D lens: Approximately × 3.

 Exact values depend on observer-image distance and condensing
lens-eye distance (if ametropic).

Influence of Patient's Refractive Error on Image

Emmetropic Eye: Image of the retina is always located at the second

principal focus of the condensing lens, regardless of lens position relative to
the eye (due to parallel emergent rays).

Hypermetropic Eye: Emergent rays are divergent; real image formed

outside the second principal focus of the condensing lens.

Myopic Eye: Emergent rays are convergent; real image formed within the
second focal length of the condensing lens.

Effect of Moving Condensing Lens: Changes in image size occur when the
condensing lens is moved relative to the eye.

Field of View and Illumination

Observer's Pupil as 'Sight-hole': Size influences the field of view.

Field of View Limitations:

Limited by the image of the observer's pupil in the subject's pupillary
plane.

Limited by the aperture/size of the condensing lens.

Only rays leaving the subject's eye via the image of the observer's
pupil and passing through the condensing lens are seen.

Field of Illumination vs. Field of View:

Field of Illumination: Determined by the subject's pupil size.

Field of View: Determined by the observer's pupil size and the

aperture of the condensing lens.

Clinical Optimization:
Patient's pupil: Dilated widely prior to examination to widen the field
of illumination.

Observer's pupil: Not practical to dilate (impaired visual acuity,

increased aberrations, loss of accommodation).

Condensing lens: Choose largest possible aperture for widest field of

view.
 Aspheric condensing lenses: Wide aperture lenses must be aspheric
to minimize aberrations.

Field of view achieved: Approximately 25° (four times larger than

direct ophthalmoscope).

🔥 HIGH-YIELD: Great advantage when examining highly myopic eyes.

Relative Merits of Direct vs. Indirect Ophthalmoscope

Size: Direct ophthalmoscope is much smaller, lighter, and many models are
pocket-sized.

Illumination: Indirect ophthalmoscopes have more powerful light sources

due to larger size, making them more useful for examining patients with
ocular media opacities.

Clinical Relevance (HIGH-YIELD):

Retinal detachments: Indirect ophthalmoscope is the instrument of
choice due to good illumination and wide field of view. Poor
illumination with direct ophthalmoscope may miss underlying
malignancy in extensive subretinal fluid. Also allows indentation of
peripheral retina.

Retinal detachment surgery: Indirect ophthalmoscope is preferred

as it's used at a distance, preserving sterile operative field.

Laser photocoagulation: Laser energy can be delivered through the

indirect ophthalmoscope for retinal photocoagulation.

Retinoscope

Introduction

Provides accurate objective measurement of the refractive state of an eye.

Technique is called retinoscopy.

Three Stages:
1. Illumination stage: Light directed into patient's eye to illuminate the
retina.

2. Reflex stage: Image of illuminated retina formed at patient's far-point.

 3. Projection stage: Image at far-point located by moving illumination
across fundus and noting behavior of luminous reflex in patient's
pupil.

Illumination Stage

Historical System: Light source beside patient's head, reflected into eye
from plane or concave mirror held by observer. Observer viewed through
small hole in mirror.

Modern Electric Retinoscope: Largely replaced historical system but

principles and nomenclature remain unchanged.

Plane Mirror:
Light moved across patient's fundus by rotating the plane mirror.

Illuminating rays move in the same direction as the mirror.

Concave Mirror:
Focal length less than distance between patient and observer.

Real image of light source formed between patient and observer, close
to patient's eye.

Illumination moves in the opposite direction to the mirror.

Movement of reflex is reversed compared to plane mirror.

Modern Electric Retinoscope Design:

Incorporates both plane and concave mirror systems.

Uses a condensing lens that can be moved within the instrument

shaft.

Lowest position: Plane mirror effect.

Highest position: Concave mirror effect.

Intermediate position: Focused image of retinoscope bulb filament

falls on patient's eye (no value for retinoscopy).

Optimal position: Condensing lens moved slightly back from

intermediate position.
Retains plane mirror effect with much brighter illumination.

Virtual image of light source formed just behind patient's eye.

 Acts as concave mirror with focal length slightly exceeding
observer-patient distance.

Clinical advantages: Retains preferred plane mirror effect and

provides bright light for small pupils and media opacities.

Reflex Stage

Image of illuminated retina formed at patient's far-point.

Image constructed using three rays:

1. Ray from retinal point on principal axis, leaving eye along principal
axis.

2. Ray from off-axis retinal point, traveling parallel to principal axis to

principal plane, then refracted through anterior principal focus.

3. Ray from retinal point passing undeviated through nodal point.

Projection Stage

Observer views the image of illuminated retina from a convenient distance

(usually 1 meter).

Observer sees rays from the image as an illuminated area or reflex in the
patient's pupil.

Movement Patterns:
Hypermetropia: Luminous reflex moves in same direction as
illuminating light ('with' movement).

Emmetropia: 'With' movement observed.

Myopia less than working distance dioptric value: 'With' movement

still obtained.

Approaching neutral point: Reflex appears to move more rapidly as

refractive error approaches the dioptric value of observer's working
distance.

Neutral point: Patient's far-point coincides with observer's nodal

point. No movement discernible; observer sees diffuse bright red
reflex (infinitely rapid movement).

Myopia exceeding working distance: 'Against' movement observed.

Practical Retinoscopy
 Lenses are placed in front of the patient's eye until the point of reversal is
observed.

Correction for working distance:

Add –1.5 D for 2/3 meter working distance.

Add –1.0 D for 1 meter working distance.

The corrected value of the lenses equals the patient's refractive error.

Instruments Used to Study Corneal Curvature

Importance of Corneal Curvature

Anterior corneal surface is the main refracting surface of the eye.

Its curvature is crucial for refracting power and optical properties.

Small changes or irregularities profoundly affect visual acuity.

Accurate measurement is important in ophthalmology and essential for

contact lens fitting.

The anterior corneal surface reflects light, acting as a convex mirror; its
curvature can be examined by studying the catoptric image.

Placido’s Disc

Purpose: Studies the general shape of the cornea.

Components: Flat disc with concentric black and white rings.

Mechanism:
A convex lens is mounted in the center aperture for magnification and
to reduce accommodation need.

Examiner looks through the central aperture, observing the image of

the disc reflected from the patient's cornea.

Best results with bright illumination behind patient's head, keeping

patient's eye in shadow.

Interpretation:
Nature of the reflected image reveals regularity or distortion of corneal
curvature.
 Shorter radius of curvature leads to smaller reflected image and closer
rings.

In astigmatic cornea, rings appear closer in the steeper meridian.

Surgical Application: Used during surgery to detect corneal astigmatism

and guide suturing by observing reflection from a circular object (e.g., ring
of lights).

Keratometer or Ophthalmometer

Purpose: Measures the radius of curvature of the central area of the cornea
(approx. 3 mm diameter).

Corneal Characteristics:
Central/axial area (approx. 4 mm diameter) is usually assumed to be a
spherical refracting surface.

Radius of curvature of axial zone in emmetropic eye is about 7.8 mm.

Optical power can be expressed in dioptres.

Precise value determined by anterior/posterior surface curvature and

refractive indices.

Keratometer equation approximation: Refractive index of tears

(1.336) standardized to 1.3375, so 7.5 mm radius corresponds to 45 D.

Formula: D = (n-1)/r (where D is power in dioptres, r is radius in

meters, n is refractive index).

Peripheral cornea is flatter and non-spherical; central 4 mm spherical

zone is utilized for vision.

Visual acuity suffers with widely dilated pupil.

Optical Principle:
In practice, image (I) is very close to focal point (F), so v ≈ r/2 (where r
is radius of curvature).

In all keratometers, 'u' (focal distance of viewing telescope) is

constant.

Image Doubling: Overcomes natural eye movements; if eye moves, both

doubled images move together, allowing alignment and reading.

The Keratometer of Von Helmholtz

 Mechanism: Uses two rotating glass plates for image doubling.

Process:
Light passes through a graticule, shines on cornea, forming reflected
image (I) of graticule.

Reflected light passes through two inclined parallel-sided glass plates

(X and Y).

Plates laterally displace light, creating two virtual images (I' and I'').

Observer varies angle of inclination until edges of I' and I'' touch.

Distance between centers equals diameter of I, allowing corneal

curvature calculation.

Calibration: Calibrated in terms of corneal radius of curvature and dioptric

power.

Astigmatism Measurement: Can be rotated to measure astigmatism.

The Javal–Schiøtz Keratometer

Mechanism: Uses an object of variable size.

Components: Pair of mires (A and B) mounted on curved side arms,

projecting each side of viewing telescope.
One mire is step-shaped, the other rectangular.

Space between mires (ab) is the object size.

Arms can be rotated to take readings in any meridian.

Image Doubling: Achieved by a Wollaston prism in the viewing telescope.

Wollaston prism: Two rectangular quartz prisms cemented together.

Quartz is doubly refracting, splitting incident light into two polarized

emergent beams.

Prisms cemented with optical 'grain' at right angles, separating beams

by a fixed angle while neutralizing dispersion.

Measurement: Distance between mires adjusted until doubled images just

touch.

Calibration: Calibrated in terms of corneal radius of curvature and dioptric

refracting power.
Each step of mire A is equivalent to one dioptre of corneal power.
 Example: If inner images align in one meridian but overlap by 1.5 steps
in the 90° meridian, 1.5 D of corneal astigmatism is present.

Astigmatism Axis and Magnitude: In astigmatic corneas, two images are

vertically displaced in all but the two principal meridians, allowing
measurement of axis and magnitude.

Haag–Streit Javal–Schiøtz keratometer: Mires incorporate a horizontal

line for vertical alignment.

Additional Use: Can measure curvature of contact lenses.

Computerised Analysis of Corneal Topography

Purpose: Studies corneal topography (surface shape) by computer analysis

of reflected image.

Advantages over Keratometry:

Detects even minor variations in curvature.

Obtains information from a large area of the corneal surface

(keratometry only central zone).

Clinical Utility:
Measurement of corneal astigmatism.

Contact lens fitting.

Refractive surgery.

Early diagnosis and monitoring of keratoconus.

Reveals patterns of corneal astigmatism not apparent from refraction

or keratometry.

Methods:
Computerised Videokeratography (CVK): Most common clinical
method.
Placido's disc projected onto a 5- or 6 mm-diameter area of the
cornea.

Reflection converted into a digital image.

Steeper cornea: reflected rings lie closer together.

Computer analysis produces a color-coded contour map of

corneal surface (same dioptric power = same color).
 Raster Photogrammetry:
Two-dimensional grid pattern projected onto precorneal tear
film after fluorescein dye.

Reflection of grid indicates height of corneal surface above a

reference plane.

Constructs a topographic curve, represented as a color-coded

map (curvature or height) or a 3D net-like image.

Image can cover entire cornea and extend onto sclera, even with
irregular or poorly reflecting surfaces.

Compound Microscope

Definition and Application

Provides a magnified view of a near object (vs. telescope for distant

objects).

Used in many ophthalmic instruments for magnified eye views:

Slit-lamp microscope.

Operating microscope.

Keratometer.

Instruments used with slit-lamp (pachometer, applanation tonometer,

gonioscopy lens).

Specular microscope: Specially modified microscope for examining and

photographing corneal endothelium.

Components and Image Formation

Consists of two convex lenses: objective and eyepiece lenses.

Objective Lens (OL):

Object (O) placed just outside its anterior focal point (F_o).

Forms a real, inverted, magnified image (i) some distance behind it.

Eyepiece Lens (EL):

Placed so that the image (i) formed by the objective falls at or close to
its principal focal plane (F_e).
 Acts as a loupe, further magnifying the image.

Final Image: Vertically and horizontally inverted.

Porro prisms: Incorporated in clinical microscopes to erect the image.

Zoom Lens System

Operating Microscope Requirements: Smooth change in magnification

without changing object or image position.

Single Convex Lens: Magnification varies by moving the object, which also
changes the object-image distance.

Compound Microscope Zoom: Achieved by incorporating extra movable

lenses within the system to change overall power.

Uncompensated Zoom System: Simplest form with a single movable

concave lens between microscope lenses; results in significant image
position change.

Compensated Zoom System: Requires several mobile lens elements to

achieve a constant object-image distance; more elements lead to less image
shift during magnification change.

Slit Lamp

Introduction

Routine method for examining the outer segment of the eye.

Consists of a relatively low-powered binocular compound microscope

linked to an adjustable bright light source.

Named for the narrow vertical slit of light typically projected onto the eye.

Basic Features

Common Focal Plane: Microscope and illumination system are aligned so

the point of focus for both corresponds.

Common Axis of Rotation: Lies in the common focal plane.

Long Working Distance: Considerable distance between the microscope

and the patient's eye.
 Allows for maneuvers like foreign body removal.

Provides space for optical devices (e.g., +90 D lens, three-mirror

contact lens) to inspect vitreous and retina.

Image Erection: Prisms incorporated to shorten microscope tubes and

invert the image vertically and horizontally, so it appears erect to the
observer.

Variable Magnification: A bank of Galilean telescopes of different powers is

included to vary the observation system's magnification.

Methods of Examination

Direct Focal Illumination: Most generally useful method; slit beam is

accurately focused on the part of the eye under inspection.

Diffuse Illumination: Beam is thrown slightly out of focus across the

structure, illuminating a large area diffusely. Helpful for looking at the
anterior lens capsule.

Lateral Illumination: Illuminating a structure with light reflected from

tissue just to one side of it (e.g., directing a beam on the pupil margin to see
the sphincter muscle rim).

Retro-Illumination: Examining a part of the eye by light reflected from a

structure behind it. The structure behind acts as a mirror.
Example: Identifying iris atrophy by light reflected from the choroid.

Technique: Illuminating column of the slit lamp should be co-axial

with the microscope's objective lenses.

Specular Reflection: Examining mirror-like surfaces (corneal surfaces,

anterior lens capsule) by studying the reflected light rays.
Technique: Patient's gaze bisects the angle between the illumination
axis and the microscope axis.

🔥 HIGH-YIELD: Best way to inspect the corneal endothelium with the

slit lamp.

Sclerotic Scatter:
Slit beam directed onto the limbus (e.g., at 9 o'clock), causing the
whole limbal area to glow (maximum glow at 3 o'clock).
 Light is reflected back and forth between the cornea's internal limiting
surfaces and scattered centrifugally around the cornea.

Filters

Blue Cobalt Filter: Used during applanation tonometry.

Blue and Green (Red-free) Filters:

Useful in vitreous examination.

Visibility of vitreous gel structure depends on scattered incident light.

Scattering is greatest for short wavelength light (blue and green are
scattered more than red).

Provides a relatively dark fundus background, making it easier to

detect structures like the vitreous cortex in posterior vitreous
detachment.

Fundus Examination

Limitation of Basic Slit Lamp: Cannot see further back than the anterior
third of the vitreous because the eye's refractive power renders emerging
light parallel, so no image is formed in the microscope's focal range.

Solution: An additional lens is used to overcome the eye's refractive power.

Optimizing View: Corneal reflections should not enter the viewing system.
This is achieved by tilting the illumination column so its axis is below the
viewing system's axis.

Hruby Lens

Purpose: Examines the fundus and posterior vitreous with the slit lamp
microscope.

Lens Type: Powerful plano-concave lens (–58.6 D).

Mechanism:
Held immediately in front of the eye (concave surface towards the
eye).

Forms a virtual, erect, and diminished image of the illuminated

retina.

Image is anterior to the retina and within the focal range of the slit
lamp microscope.
 Technique: Best view is obtained with the lens held near the eye, with the
retinal image found in the pupillary plane.

Fundus Viewing Contact Lens

Purpose: Allows examination of the posterior vitreous and posterior pole of

the fundus with the slit lamp microscope.

Common Lens: Goldmann lens.

Mechanism: Plano-concave contact lens made of high refractive index

material. When applied to the cornea, it allows fundus examination by the
same mechanism as the Hruby lens.

Other Lenses: The central zone of a gonioscopy lens or three-mirror

contact lens can also be used.

Surgical Use: A plano-concave contact lens is used during vitrectomy for

fundus visualization through the operating microscope.

90 D and 78 D Lenses

Principle: Adapts the indirect ophthalmoscope principle for slit lamp use.

Mechanism: A high power condensing lens (90 D or 78 D) forms a real

image of the retina that can be viewed through the slit lamp microscope.

Image Characteristics:
High power shortens the light path, bringing the retinal image within
the slit lamp's focal range.

Loss of image size from high power is compensated by the slit lamp's
magnification.

Comparison:
90 D lens: Wider field of view, less magnification.

78 D lens: Narrower field of view, more magnification.

Clinical Use: Excellent for viewing the posterior pole of the fundus; less
suitable for the peripheral retina.

Panfunduscope Contact Lens

Advantage: Provides a wider field of view.

Components:
 High convex power contact lens (acts as a condensing lens).

Spherical glass element incorporated within the panfunduscope.

Mechanism:
Forms a real, inverted image of the fundus located within the
spherical glass element.

The glass element flattens the image and redirects the diverging light
towards the observer.

Field of View: Very wide due to the condensing lens being close to the eye.
The whole fundus to the equator may be seen in one view.

Image Size: Correspondingly smaller, requiring high slit lamp magnification

for detailed examination.

Other Panfunduscope Contact Lenses: Other manufacturers produce similar

lenses based on the same principle (condensing lens applied as a contact lens,
transmitted light collected and redirected).

Applanation Tonometer

Purpose: Measures intraocular pressure (IOP).

Principle: Tonometer head applied to the cornea with sufficient force to produce
a standard area of contact.

Force required is directly proportional to IOP when the area of contact is

approximately 3 mm in diameter.

At this diameter, the effect of surface tension (S) and corneal rigidity (R)
cancel each other out.

Larger contact areas: corneal rigidity causes inaccuracy.

Smaller contact areas: surface tension causes errors.

Specifically, at 3.06 mm diameter, R = S, and the applied force (W) is

proportional to IOP (P).

Ocular volume change is very small at this contact area, ensuring a true IOP
reading.

Goldmann and Schmidt Applanation Tonometer

 Fulfills the conditions with a 3.06 mm diameter contact area.

Components: Applanation head mounted on a spring-loaded lever.

Calibration: Adjustment knob calibrated in terms of IOP (mmHg).

Standard Area Achievement: Applanation head contains two prisms with

bases in opposite directions.
Operator views through the head, seeing the circle of corneal contact
split into two half-circles, laterally displaced.

Operator adjusts pressure until half-circles just overlap, indicating a

3.06 mm contact area (inner edges of fluid meniscus align).

Astigmatism Error: High corneal astigmatism results in an elliptical contact

area, causing an error of approximately 1 mmHg per 4 dioptres of
astigmatism.
To correct: Measurement made at 43° to the meridian of lower
corneal power (43° to the axis of the minus cylinder).

Tonometer prism mount has a white line (horizontal for general use)
and a red line (at 43° to horizontal) for alignment.

Non-Contact Tonometer

Mechanism: Flattens the cornea with a puff of air, avoiding direct eye
contact.

Measurement: Corneal applanation measured by collecting light reflected

from the central cornea.
Parallel light beam directed at 30° onto central cornea.

Reflected light measured by a photodetector at 30° reflection angle.

Reflected beam is strongest when cornea is flat (acting as a plane

mirror).

Output: Records air force required to flatten cornea and displays

corresponding IOP.

Operation: Must be used at a set distance from the cornea; incorporates an

optical alignment system.
Pachymeter (Pachometer)

Purpose: Measures corneal thickness.

Types: Employ either optical or ultrasound principles.

Optical Pachymeters

Principle: Uses Purkinje–Sanson images.

Corneal thickness: Measured using images formed by anterior and
posterior corneal surfaces (images I and II).

Anterior chamber depth: Measured using images formed by posterior

corneal surface and anterior lens surface (images II and III).

Attachment: Attached to the slit lamp.

Image Doubling: Doubles the observer's image of the field of view.

Achieved by splitting incident light beam (Maurice and Giardine) or
splitting observer's view (Jaeger).

Jaeger Pachymeter

Widely used.

Setup: Illumination axis perpendicular to cornea; observation axis 40° to

one side.

Mechanism: Observer's corneal image is split horizontally by two glass

plates (lower fixed, upper tiltable).
Observer aligns anterior surface of cornea in one image with its
posterior surface in the second image.

Degree of tilt proportional to corneal thickness, read off a scale.

Anterior Chamber Depth Measurement: Posterior corneal surface of one

image aligned with anterior lens surface of second image.

Models: No. 1 measures depths up to 1.2 mm; No. 2 measures depths up to

6 mm.

Maurice and Giardine Pachymeter

Employs a perspex plate with a cut-out area, covered by colored celluloid,

placed in slit lamp beam.
 Splits beam: some light undeviated, some laterally deviated by perspex.

Images formed by two beams at corneal surfaces are viewed; plate rotated
until images superimpose.

No longer in widespread use.

Ultrasound Pachymetry

Provides much more precise measurement of corneal thickness.

Mechanism: Ultrasound probe applanates the cornea; gives a reading only

when perpendicular to the posterior surface.

🔥 HIGH-YIELD: Invaluable for planning corneal incision depth in graft and

refractive surgery.

Specular Microscopy

Principle: Specular reflection – reflection of light at different angles by structures

with different refractive indices (more pronounced for larger differences).
Angle between illumination and observation axes is critical.

Viewed with one eye only.

Demonstrates irregularity of a smooth reflecting surface at the boundary of

structures with different refractive indices.

Example: Corneal endothelium (cell body and intercellular material)

appears dark/light.

Technique: Reflection from corneal surface reduced by direct instrument-cornea

contact.
Focus on area of interest, then carefully change illumination angle.

Clinical Use: Assesses health of donor cornea.

Can also visualize lens epithelium and zones of discontinuity within the
lens.

Optical Coherence Tomography (OCT)

Description: Experimental imaging technique analogous to B-scan ultrasound.

 Mechanism: Uses time delay of infrared light reflected by the retina.
Provides cross-sectional images of the retina with resolution as small as 10
µm.

Infrared source (843 nm) light is split into a reference beam (reflected off a
mirror) and a sample beam (reflected off the retina).

Temporal differences between reflections result in an interference signal,

processed to produce a digital image.

Automated Clinical Refraction

Historical Context: Attempts to automate refraction for 200+ years with little
success; no reliable substitute for skilled human refractionist.

New generation of autorefractors now available.

Basic Principles Used in Automated Refraction

The Scheiner Principle

Discovery: Scheiner (1619) found that eye focus could be precisely
determined by placing double pinhole apertures before the pupil.

Mechanism:
Parallel light rays from distant object reduced to two small
bundles by Scheiner disc.

Emmetropic eye: Forms a single focus on the retina.

Refractive error: Two spots of light fall on the retina.

Refractive error determined by adjusting object position until

patient sees a single focus (judgement of singleness is more
precise than least blur).

Limitation: Examines eye only along paths of two light bundles; a

class of 'zonal focus' methods. * Widely used in autorefractor design.

* **The Optometer Principle**

* **Origin:** Term first used by Porterfield (1759) for an instrument
measuring
limits of distinct vision and determining strength/weakness of sight. * Mechanism: *
Convex lens placed in front of eye, with its focus in the spectacle plane. * Movable
target viewed through the lens. * Target at first principal focus: Light parallel at
spectacle plane, focused on emmetropic retina. * Target within focal length: Light
divergent in spectacle plane (simulates concave trial lens). * Target outside focal
length: Light convergent in spectacle plane (simulates convex trial lens). * Vergence of
light in the plane of the second principal focus is linearly related to target distance
from first principal focus. * Instrument calibrated to show vergence in dioptres based
on target position.
* **Meridional Refractometry**
* **Challenge:** Identifying principal meridians and measuring refraction
in astigmatism.
* **Discovery (1960s):** If spherical refraction is measured in at least
three arbitrary meridians, principal axes and refractive power can be found
mathematically.
* Greater accuracy with more than three meridians, but mathematics
becomes more complex.

* **Early Optometers**
* **Subjective Optometers:** Patient adjusted instrument for best
subjective focus/alignment.
* **Problems:** Alignment issues, irregular astigmatism, instrument
accommodation.
* **Alignment:** Critical for Scheiner principle-based systems
(pinholes must fall within pupil); requires skill from examiner and cooperation
from patient.
* **Irregular Astigmatism:** Scheiner principle measures only two
small portions of pupillary aperture; significant irregular astigmatism can
lead to inaccurate overall refraction.
* **Instrument Accommodation:** Inappropriate accommodation when
viewing a target known to be within an instrument. Major problem in optometer
design, still present in some modern instruments.
* Fluctuates during measurement, introducing error in astigmatic
and spherical correction if meridians not measured simultaneously.
* **Objective Optometers (Inter-war period):** Required examiner to
focus/align target image on patient's retina; not truly objective.
* Failed to gain general use due to alignment difficulties and
instrument accommodation.
* Some still accepted in Europe as alternative to retinoscopy.

* **Infrared Optometers**
* **Advancement:** Truly objective instruments; instrument senses end-
point of refraction.
* **Development:** Driven by advances in electronics and microcomputers,
facilitated by meridional refractometry.
* **Mechanism:** Filter out all but infrared light; detect end-point via
electronic focus detector.
* Some based on Scheiner principle, some simulate retinoscopy, others
use optometer principle.
* **Instrument Accommodation Mitigation:** Refract eye using invisible
infrared light.
* Requires separate fixation target to encourage accommodation
relaxation.
* **Limitations:**
* **Chromatic Aberration:** Refraction to infrared differs
significantly from visible light (0.75 D to 1.50 D more hypermetropic to
infrared).
* Manufacturers empirically calibrate instruments to correlate
with subjective clinical results.
* **Performance Issues:** Poor performance with small or distorted
pupils (e.g., broad iridectomy) or unclear ocular media (inaccurate if media
haze reduces vision to 6/18).

* **Photoscreening**
* **Purpose:** Technique for ancillary staff (nurses, health visitors) to
screen preverbal children for amblyopia-causing factors.
* **Method:** Polaroid camera with offset flash and lens photographs
child from set distance in horizontal and vertical meridians.
* **Detection:** Captures alteration of red reflex in presence of:
* Refractive error (hypermetropia, myopia, astigmatism,
anisometropia).
* Strabismus.
* Media opacity.
* **Interpretation:** Images examined by trained personnel (e.g.,
orthoptists) to identify children for referral to ophthalmologist for further
examination and cycloplegic refraction.

Conclusion: No machine can yet equal an experienced refractionist in accuracy,

ability to test abnormal eyes, patience with young/elderly, and wisdom in
prescribing suitable correction.