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Diagnosis of eye disorders is initially based on the symptoms that the person is experiencing, the appearance of the eyes, and the results of an examination. A variety of tests can be carried out to confirm a problem or to determine the extent or severity of the disorder. Each eye is tested separately.
Refraction
Refraction is the procedure by which focusing error is assessed. Problems with visual acuity (sharpness of vision) that result from refractive errors, such as nearsightedness, farsightedness, astigmatism, and presbyopia, are diagnosed by refraction. Acuity is usually measured on a scale that compares a person's vision at 20 feet with that of someone who has perfect vision. Thus, a person who has 20/20 vision sees objects that are 20 feet away with the same clarity as a person with normal vision, but a person who has 20/200 vision sees at 20 feet only as clearly as a person with perfect vision sees at 200 feet. One important visual acuity test uses the Snellen chart (eye chart), which is a large card or lighted box that displays rows of letters in smaller and smaller sizes. The chart is read from a standard distance. The degree of visual acuity is determined by the size of the row of letters that the person can read. For those who are unable to read, a modified chart can be used in which the letters are represented by an upper case "E," which is rotated randomly. The person is asked to describe the way the "E" is facing.
Automated refraction is performed with machines that determine the refractive error of the eye by measuring how light is changed when it enters the eye. The person sits in front of the autorefractor, a beam of light is emitted from the device, and the eye's response is measured. The machine uses this information to calculate the lens prescription needed to correct the person's refractive error. This measurement takes only a few seconds.
A phoropter is the device commonly used, in conjunction with a Snellen chart, to determine the best corrective lenses for a person being assessed for eyeglasses or contact lenses. The phoropter contains a complete range of corrective lenses, allowing the person to compare different levels of correction while viewing the chart. Typically, the eye doctor will use the phoropter to refine the information obtained from the autorefractor before prescribing lenses.
Visual
Field Testing
The visual field is the entire area of vision that one sees out of each eye, including the corners (peripheral vision). The visual field may be tested as a routine part of an eye examination. It may also be tested in detail if people notice specific changes in vision, for example, if they keep bumping into objects on one side. The simplest way to test peripheral vision is for a doctor to face the person and gradually move a finger in toward the center of vision from above, below, left, and right. The person tells the doctor when the moving finger is first detected. The person must fix his vision on the doctor's face (and not look for the finger) for the result of the test to be valid. The eye not being tested is closed.
The visual field may be measured in greater detail with a tangent screen or a Goldmann perimeter. With these tests, the person stares at the center of a black screen or a hollow, white, spherical device (which resembles a small satellite dish). An object or a light is moved slowly from the periphery toward the center of vision from many different directions. The person indicates when light is first seen out of the corner of the eye. A mark is made on the screen or perimeter indicating where the person can see, thus allowing recognition of blind spots. Visual fields can be measured using computerized automated perimetry. Here, the person stares at the center of a large shallow bowl and presses a button whenever a flash of light is seen.
The Amsler grid is used to test the central area of vision. The grid consists of a black card covered with a white grid and with a white dot in its center. The person notes any distortion in the lines of the grid while staring at the white dot. Each eye is tested at a normal reading distance and while wearing reading glasses, if the person normally uses them. If an area of the grid cannot be seen, an abnormal blind spot may exist. Beyond the area tested by the Amsler grid, there is a normal, small blind spot where the optic nerve leaves the eye; however, people are not aware of it. Wavy lines suggest a possible problem with the macula. The test is simple enough to be used at home and is useful for monitoring macular degeneration.
Color
Vision Testing
A variety of tests can be used to detect a reduced ability to perceive certain colors (color blindness). Ishihara plates, which are most commonly used, are patterns of small, colored circles crowded together on a white background to form a large circle. The small circles are usually arranged so that people with normal color vision see a particular number. Those who have color blindness see another number or no number, depending on the type of color blindness.
Ophthalmoscopy
A direct ophthalmoscope is a handheld device like a small flashlight with magnifying lenses that shines a light into the eye to enable a doctor to examine the cornea, lens, vitreous humor (the jellylike substance that fills the back of the eye), retina, optic nerve, and the retinal veins and arteries. The person looks straight ahead as the beam of light is shone into the eye. Often, eye drops are given to dilate (enlarge) the pupil, which allows the doctor to have a better view. Ophthalmoscopy is painless, but if eye drops are used to dilate the pupils, vision may be temporarily blurred, and the person will be more sensitive to light for a few hours afterward.
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What Is an Ophthalmoscope?
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An ophthalmoscope is an instrument that enables a doctor to examine the inside of a person's eye. The instrument has an angled mirror, various lenses, and a light source. With it, a doctor can see the retina, the optic nerve, the retinal veins and arteries, and certain problems that can affect the vitreous humor (the jellylike substance in the eye).
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Ophthalmoscopy is a standard part of every regular eye examination. Ophthalmoscopy is used to detect not only changes in the retina due to eye disease but also changes in the eyes due to certain diseases affecting other parts of the body. For instance, it is used to detect the changes that occur in the retinal blood vessels in people who have high blood pressure, arteriosclerosis, and diabetes mellitus. Ophthalmoscopy may also provide a clue to elevated pressure within the brain, which results in a swelling (pushing-out) of the normally cupped optic disk (papilledema). Tumors on the retina can be seen with ophthalmoscopy. Macular degeneration can be diagnosed with ophthalmoscopy as well.
Sometimes the doctor uses an instrument called an indirect ophthalmoscope, in which a binocular device is placed on the doctor's head and a handheld lens is used in front of the person's eye to focus the image inside the eye. This method gives a three-dimensional view, allowing a better view of objects that have depth, including a detached retina. It also allows a brighter light source to be used, which is important if the interior of the eye is cloudy, for instance, because of a cataract. The indirect ophthalmoscope also allows a much wider field of view than a direct ophthalmoscope, so that the doctor can examine more of the retina.
Slit
Lamp Examination
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What Is a Slit Lamp?
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A slit lamp is an instrument that enables a doctor to examine the entire eye under high magnification and that allows measurement of depth. The slit lamp focuses a bright light into the eye.
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The slit lamp is a table-mounted binocular microscope that shines a light into the eye to allow the doctor to examine the entire eye under high magnification. The slit lamp has better optics than the direct ophthalmoscope, providing magnification and a three-dimensional view, which allows measurement of depth. Often, eye drops are used to dilate the pupils so that the doctor can view even more of the eye, including the lens, vitreous humor, retina, and optic nerve. Sometimes, in people who have or might have glaucoma, an additional lens is placed on or held in front of the eye to allow examination of the "angle" between the iris and the front part of the eye (inside surface of the cornea). This examination is called gonioscopy.
Tonometry
With tonometry, the pressure of the aqueous humor within the eye can be measured. The aqueous humor is the fluid in the front part of the eye between the cornea and the iris. Normal pressure within the eye is 8 to 21 millimeters of mercury (mm Hg). Pressure in the eye is measured to detect certain types of glaucoma and monitor its treatment.
The noncontact ("air-puff") tonometer can be used to screen for elevated pressure in the eye. This device is not highly accurate, but it is useful in identifying people who may need further testing. A small puff of air is blown against the cornea, which causes the person to blink but is not uncomfortable. The puff of air flattens the cornea, and the device measures the time (in thousandths of a second) it takes to do so. It takes less time for the puff of air to flatten the cornea in an eye with normal pressure than it does an eye in which pressure is elevated.
Portable, handheld instruments are also used for tonometry. Eye drops that numb the eye are given, then the instrument is gently placed on the cornea, and a pressure reading is obtained. Portable tonometers can be used in the emergency department or a doctor's office to quickly detect increased pressure in the eye.
Applanation tonometry is a more accurate method. The applanation tonometer is usually attached to a slit lamp. After numbing the eye with drops, the doctor observes the eye through a slit lamp while the instrument is gently moved until it rests on the cornea. The amount of pressure it takes to flatten the cornea is related to the pressure within the eye.
Fluorescein
Angiography
Fluorescein angiography allows a doctor to clearly see the blood vessels at the back of the eye. A fluorescent dye, which is visible in blue light, is injected into a vein in the person's arm. The dye circulates through the person's bloodstream, including the blood vessels in the retina. Shortly after the dye is injected, a rapid sequence of photographs is taken of the retina. The dye inside the blood vessels fluoresces, making the vessels stand out. Fluorescein angiography is particularly useful in the diagnosis of macular degeneration, blocked retinal blood vessels, and diabetic retinopathy.
Electroretinography
Electroretinography allows a doctor to examine the function of the light-sensing cells (photoreceptors) in the retina by measuring the response of the retina to flashes of light. Eye drops numb the eye and dilate the pupil. A recording electrode in the form of a contact lens is then placed on the cornea, and another electrode is placed on the skin of the face nearby. The eyes are then propped open. The room is darkened, and the person stares at a flashing light. The electrical activity generated by the retina in response to the flashes of light is recorded by the electrodes. Electroretinography is particularly useful for evaluating diseases, such as retinitis pigmentosa, in which the photoreceptors are affected.
Ultrasound
The eye can be examined by ultrasound. A probe is placed gently against the closed eyelid and painlessly bounces sound waves off the eyeball. The reflected sound waves produce a two-dimensional image of the inside of the eye. Ultrasound is useful when an ophthalmoscope or slit lamp cannot view the retina because the inside of the eye is cloudy or something is blocking the line of sight. Ultrasound can be used to determine the nature of abnormal structures, such as a tumor, inside the eye. Ultrasound also can be used to examine blood vessels supplying the eye (Doppler ultrasound) and to determine the thickness of the cornea (pachymetry).
Pachymetry
Pachymetry (measuring the thickness of the cornea) is very important in refractive eye surgery, such as laser in situ keratomileusis (LASIK).
Pachymetry is usually performed by using ultrasound. For ultrasound pachymetry, the eye is numbed with drops, and an ultrasound probe is placed gently onto the surface of the cornea. Optical pachymetry methods do not require numbing eye drops because the instruments do not touch the eye.
Computed
Tomography and Magnetic Resonance Imaging
These imaging techniques can be used to provide detailed information about the structures inside the eye and the bony structure that surrounds the eye (the orbit). Computed tomography (CT) is particularly useful for locating foreign bodies inside the eye.
Last full review/revision December 2006 by Kathryn Colby, MD, PhD
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