DARK ROOM

INSTRUMENTS
PIN HOLE
• Identification: Black disc with a small central hole attached to a small
handle.
• Principle: The small pencil of ray passes through the principle axis of
the eye which is undeviated. All the refraction would be eliminated
and a clear image may thus be formed.
• Method: Kept in the trial frame in front of patients eyes and the
patient is asked to read the snellens chart through it.
• Uses: To differentiate between DOV due to refractive error or media
opacity, macular or neuro-ophthalmic disease.
Lister’s Bulb

• Used as a source of light for retinoscopy

Stenopaeic Slit
• Identification: Black disc with a large slit like opening at the center with a
small handle.
• Method: Placed in front of the eye in the trial frame.
• Uses:
1. Detection of cylindrical axis.
2. Fincham test to differentiate between colored halos of cataract and
glaucoma
3. To detect the best meridian for optical iridectomy.
4. Low visual aid.
5. Used as a part of Maddox wing.
Ophthalmic Lenses
• Methods of identification of lenses:
1. Look at any object through the lens with only one eye open and see
for minification and magnification of lenses.
2. Hold the lens close to the right eye with thumb and index finger and
concentrate on the distant object through the lens and then move
the lens in:
a. Horizontal lens.
b. Vertical Lens.
c. Rotatory Fashion.
 SPHERICAL LENSES:
• No distortion of image on rotatory fashion
• Object appears to move in both direction i.e., horizontal and vertical.

 CYLINDRICAL LENSES:
• Distortion of image on rotatory fashion
• Object appears to move in one direction only

CONVES LENS:
• Magnification of image
• Object appears to move in opposite direction to that of the lens

CONCAVE LENS:
• Minification of image
• Object appears to move in same direction to that of the lens
CONVEX SPHERICAL CONCAVE SPHERICAL
Correction of refractive status: Correction of refractive status:
1. Hypermetropia 1. Myopia
2. Aphakia
3. Presbyopia
4. As LVA
Instrumental uses: Instrumental uses:
1. Direct Ophthalmoscopy 1. Direct Ophthalmoscopy
2. Indirect Ophthalmoscopy 2. Telescopic loupe
3. Microscope
4. Synaptophore
5. Telescopic loupe
Diagnostic Uses: Diagnostic Uses:
1. Volk + 90 D lens + 78 D lens 1. Hurby lens
2. Placido disc 2. Fundus contact lens
3. Malingering 3. Central lens of gonioscope
4. For laser therapy 4. Malingering
• Convex Cylinder: Regular hypermetropic astigmatism
• Concave Cylinder: Regular myopic astigmatism
Red and Green Glasses

Used to dissociate binocular single vision in various tests:

1.Worth’s four dot test.

2.Hess screen test.
3.Diplopia charting
 Placido Disc
IDENTIFICATION: Medium sized circular disc with a central hole and attached to a
handle. On one surface of disc there are alternate black and white circle like bull’s
eye.

PROCEDURE: Placido disc is held in front of the patient’s eye while examiner looks
through the hole in the centre of the disc. The examiner then observe the corneal
image of the disc as a reflected from the light behind the patient.

USES:
1. Assess corneal surface and anterior corneal curvature.
2. Loss in sharpness of image denotes a loss of smoothness of the anterior
surface.
3. Elliptical image in regular astigmatism
4. Irregular image in keratoconus.
Prisms:
• IDENTIFICATION: Wedge shaped refracting material (Glass or plastic)
with thin edge at one side and thick edge on the opposite side.
Triangular in cross section with an apex and base.
• REFRACTION THROUGH A PRISM:
Total deviation of a light towards the base of the prism. The image is
displaced towards the apex of prism.
• USES:
1. To diagnose latent squint and measure the amount of squint.
2. To detect malingering
Instrumental uses: Therapeutic uses:
1. Applanation 6. Treatment of heterophoria
2. Ophthalmoscope 7. Temporary relief in diplopia in
3. Slit lamp paralytic squint
4. Operative microscope 8. As LVA – Fresnel Prism
5. Keratometer
Maddox Rod
• IDENTIFICATION:
It consists of a series of parallel high power, plus cylinders (rods) of red glass placed side by
side in a disc. Converts a point light into a red streak light at the right angle to the axis of rods.

Methods: When held in front of one eye, the image of point source of light becomes dissimilar
between the two eyes and fusion dissociates.
Performed at 6 m and 33cm from a bright spot light in a dark room.

Use:
1. To test the latent squint for distance.
2. Orthoptic exercise for cyclophoria.
3. Test macular function in presence of opaque media.
DARK ROOM PROCEDURES
• RETINOSCOPY
• DISTANT DIRECT OPHTHALMOSCOPY
• DIRECT OPHTHALMOSCOPY
• INDIRECT FUNDUS BIOMICROSCOPY
• BINOCULAR INDIRECT OPHTHALMOSCOPY
RETINOSCOPY
Retinoscope
• IDENTIFICATION- Circular plain mirror with central aperture in a
plastic frame with handle. Sometimes, a concave mirrior of 2.0 d may
be attached with other end in a dumble shaped frame.
• Uses-
• Determination of refraction.
• Distant direct ophthalmoscopy (at 22cm)
• It entails a study of the movements of the retinal image produced by a
beam of light that sweeps across the pupil.
• The observer then watches this illuminated retinal image by looking down
the path of incident light, through a hole in the center of a mirror
(retinoscope).
• If the eye is emmetropic: Parallel rays of light come to a point focus on
retina, so they are emerging in the same pathway.
• If the eye is hypermetropic: Parallel rays converge behind the retina and
hence, the emerging rays are divergent.
• The principle of retinoscopy is to make every observing eye emmetropic, so
that the emerging rays should form a parallel beam.
Dark-room Test

• Examiner sits at 1 meter away from the patient. It is even more

convenient to sit at arm’s length.
• The patient is normally seated and looking toward the far end of the
room (relaxed eye).
• Source of light is from behind the patient.
• The surgeon looks through a plane mirror with central perforation,
and light is reflected into the patient’s eye.
• The mirror is slowly moved from side to side in different meridians,
and movement of the shadow is noted.
• In hypermetropia, emmetropia and myopia <1.0D = the reflex moves in the same
direction, in myopia of 1.0D = there is no shadow, in myopia of >1D = the shadow
moves in the opposite direction.
• Increasing convex (if the movement is on the same side) or concave (if on the
opposite side) lenses are placed before the eye until the point of reversal is reached.
• At this point there will be no movement of the shadow, and pupil will be brightly
illuminated.
• The procedure is done for each meridians separately.
• In simple spherical refractive error—the movement and the point of reversal will be
same in both meridians.
• In astigmatism, they are different. If the axes are oblique, the shadow themselves will
seem to move obliquely and the mirror is then tilted accordingly.
Streak Retinoscope
Reflexes taken by streak retinoscope at different points.
a. Reflex parallel to retinoscopic streak
b. Reflex and streak in a “with” movement in hypermetropia
c. Reflex and streak in an against movement in myopia
d. Reflex at the point of neutralization
• Instead of circular light as obtained by a plain mirror, a self-
illuminated streak of light is used. Here, the appearances of the
shadow are more dramatic.
• Axis of the astigmatism is easily determined. It has certain other
advantages:
• It can be done in any position of the patient.
• It can be done in difficult patients, e.g. in children or non cooperative
patient or for the patient under general anesthesia.
• It can be used peroperatively.
Direct ophthalmoscope
• It is a hand-held optical instrument used to inspect the fundus or back of the eye.
• The ophthalmoscope contains a handle with a rechargeable battery and a head,
frequently detachable, that contains a bulb, a set of apertures for the light source,
and a set of lenses.
• The view provided by the ophthalmoscope is monocular, non-stereoscopic (2D),
narrow field (5°), and is magnified about 15 times.
• Light from a bulb is reflected at right angles and projected as a spot through the
iris of the patient to illuminate the retina. This reflection is achieved using a mirror
or prism.
• The illuminated retina is seen directly by the health professional (the user)
through the iris of the patient
• The ophthalmoscope can be adjusted to suit the task at hand.
• A disc or wheel contains lenses of different powers and the required lens can be brought
into the line of sight to correct any refractive error on the part of the patient.
• The user looks just above the mirror or reflecting prism.
• Many ophthalmoscopes include a set of filters to cut out reflection from the cornea or to
reduce the red glare from the retina.
• A disk or wheel allows the user to change the aperture of the light source.
• A small aperture is used for an undilated or small pupil.
• A regular aperture is used otherwise.
• A slit aperture is used as in a slit lamp.
• Finally, the brightness of the light can be adjusted by rotating the collar surrounding the
on/off button.
DISTANT DIRECT OPHTHALMOSCOPY

• It should be performed routinely before the direct ophthalmoscopy.

• It can be performed with ophthalmoscope or a simple plain mirror
with a hole in the centre.
• Procedure- the light is thrown into the patient’s eye with the patient
sitting in semi dark room form a distance of 20-25 cm, and the
features of the red glow in the pupillary area are noted.
Uses-
• To know any opacity in the media.
• To discover the edge of the subluxated or dislocated lens.
• To recognize a retinal detachment or tumour.
• To confirm the results found by external examination.
Direct ophthalmoscopy
• The ophthalmoscope is held close to the observer’s eye and approximately 15 cm from the
patient’s eye.
• It is held in the right hand and observer uses his/her right eye to examine patient’s right eye.
Similarly to examine the patient’s left eye, it is held in the left hand and the observer uses his/her
left eye.
• The patient should fix on a distant target with the eye as steady as possible.
• The observer has to adjust ophthalmoscope power setting to accommodate for the patient’s
refractive error and/or his/her own.
• If both patient and observer are emmetropic, the lens is set at 0. A red reflex will be seen and is
considered normal.
• Moving the ophthalmoscope as close to the patient’s eye as possible and using the ‘plus’ or
‘minus’ lens, the observer will able to see central retina in details upto the equator.
• Lens setting at more ‘plus’ power will focus the ophthalmoscope in the vitreous or more anterior.
INDIRECT FUNDUS BIOMICROSCOPY
• +78D and +90D are most commonly used fundus non-contact lenses
for indirect slit-lamp biomicroscpy.
• Real, inverted image is formed between the condensing lens and
objective lens of slit lamp.
• Field of view – high powered lens provided larger field of view but
lesser magnification. E.g - +90D lens provides bigger field of view but
gives lesser magnification than +78D lens.
• Technique –
• Set the slit lamp magnification.
• Adjust the slit lamp beam to about 4mm wide with the brightest light
intensity.
• Set illumination angle coaxial with the slit-lamp viewing system.
• Hold +78D or +90D lens stationary b/w thumb and forefingure ,
approx. 5-10 mm from patient’s cornea.
• Examine the fundus by moving the joystick.
BINOCULAR INDIRECT
OPHTHALMOSCOPY
The indirect ophthalmoscope advantages over the direct ophthalmoscope:

• It permits binocular vision with depth perception (stereoscopic vision).

• It has a wider field of view.
• It can be combined with scleral indentation to examine the anterior retina.
• It is not affected by the refractive state of the patient’ eye.
• It may be used in the operating room without contamination.
• It accommodates a larger and brighter light source, which permits the
examiner to penetrate moderate cataracts and to see more retinal detail