OPHTHALMIC EQUIPMENT MAINTAINENCE

INTRODUCTION TO BASIC OPHTHALMIC EQUIPMENT

SLIT LAMP PHOTOGRAPHY

1. Slit lamp photography: is the photography of the structure of the eye

with a specially designed horizontally mounted microscope. The primary
illumination for the microscope is produced by a light which can be
adjusted from a very large pattern to a very slit of light. It is from this slit
of light that the slit derived its name. the slit can be used to isolate
structures in the eye.
2. Specular micrography: it is a special type of slit lamp photographer to
photography the individual cell of the backside of the cornea called
cornea endothelium. This photography is used by physician to help
determine the state of health of the cornea.
3. Giono photography: auxiliary lenses are sometimes used with a photo
slit lamp to photography the inner structure of the eye that cannot be
directly viewed with a slit lamp. Th most common lens type is the giono
contact lens that utilize the internal mirror angle at approximately 60
degrees to provide observation of the filtering angle of the anterior
chamber. Other mirrors used to virtualize the eye iris, ciliary body,
peripheral retina. To evacuate vascular and structural changes in the eye
in assessing the progression of the disease such as glaucoma diabetic
retinopathy, and macular degeneration.
4. The retina camera: it is used to photograph the back of the eye including
the retina. It is use to document eye disease. The camera produces a
bright flash when a pivcture is taken.
 5. Autorefractor: an autorefractor is a machine used to measure a person’s
refractive error and prescription for eyeglasses or contact lenses. This is
achieved by measuring how light is change as it enters a person’s eye.
The automated refraction technique is quick, simple and painless. The
patient takes a seat and places their chin on rest. One eye at a time, they
look into the machine at a picture inside. The picture moves in and out of
focus as the machine takes it readings to determine when the image is on
the retina.
Several readings are taken which the machine averages to form
prescription. No feedback is required from the patient during this process.
6. Manual keratometer: a manual keratometer is used to determine how
flat or steep the cornea is. It is used often to measure and diagnose
conditions such as astigmatism, keratonus, corneal scarring and corneal
distortion. A keratometer is commonly used to fit contact lenses as well.

K-reading
Measurement of the curvature of the cornea.
Normal value is 43 to 44 diopters

A-SCAN BIOMETRY

Measurement of Axial Eye Length by ultrasound.

A-scan Ultrasound Biometry also uses to monitor elongation of children’s eye

length for myopia control.

Average Axial Length of Normal Eye is 23.06mm (majority 22.0 to 24.5mm)

Accuracy of all Measurement using a-scan ultrasound is + or – 0.1mm

Difference in all Measurement between both eyes + or – 0.3mm

 ULTRASOUND BIOMETRY

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Ultrasound is
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produced in the The probe
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ultrasonographi emits and
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Normal iol power is 22 to 24 dioper

PACHYMETRY

Measurement of Central Corneal Thickness.

Normal is between 520 to 540 microns

Thinner point below 520 microns

Thicker point above 540 microns

ABNORMAL RESULT

Abnormal thick or thin measurements indicate.

a. Corneal thinning
b. Corneal edema
c. Lower or higher than suspected intraocular pressure.

B-SCAN ULTRASOUND

B-scan, or brightness scan, is another method used for ocular assessment via
ultrasound. It can be performed directly on the anesthetized eye. In cases of
trauma or in children, B-scan can be performed over the eyelid with coupling
jelly

Measurements derived from b-scan include visualization of the lesion,

including anatomic location, shape, borders and size. It can be used for a
detection of wide range of pathological structures, including

a. Retinal or choroidal detachment,

b. Foreign bodies
 c. Calcium
d. Tumors

MICROSCOPE

The human eye is an extremely delicate organ, and so performing ophthalmic

surgery requires the ability to monitor progress on a microlevel. Ophthalmic
operating microscope are designed to provide high contrast and detailed
imaging of all regions of the human eye. To evaluate vascular and structural
changes in the eye in assessing the progressing of diseases such as glaucoma,
Diabetic retinopathy and macular degeneration.

Fluorescein angiography

Fluorescein angiography is an eye test that uses a special dye and camera to
look at blood flow in the retinal and choroid. These are the two layers in the
back of the eye.

How the test is performed

You will be given eye drops that make your pupil dilate. You will be asked to
place your chin on a chin rest and your forehead against a support bar to keep
your head still during the test.

The health care provider will take pictures of the inside of your eye, after the
first group of pictures is taken, a dye called fluorescein is injected into a vein.
Most often, it is injected at the inside of your elbow. A camera-like device takes
pictures as the dye moves through the blood vessels in the back of your eye.
How to prepare for the test

You will need someone to drive you home. your vision may be blurring for up
to twelve hours after the test.

You may be told to stop taking medicines that could affect the test results. Tell
your provider about any allergies, particularly reactions to iodine.

You must sign an informed consent form. You must remove contact lenses
before the test.

Tell the provider if you may be pregnant.

How the test will feel

When the needle is inserted, some people feel slight pain. Others feel only a
prick or sting. Afterwards, there may be some throbbing.

When the dye is injected, you may have mild nausea and a warm feeling in your
body. These symptoms go away quickly most of the time.

The dye will cause your urine to be darker. It may be orange in color for a day
or two after the test.

Why the test is performed

These tests is done to see if there is proper blood flow in the blood vessels in the
two layers in the back of your eye (the retina and choroid).

It can also be used to diagnose problems in the eye or to determine how well
certain eye treatments are working.
NORMAL RESULTS

A normal result means the vessels appear the normal size, there are no new
abnormal vessels, and there are no blockages or leakages.

What abnormal results mean

If blockage or leakage is present, the pictures will mark the location for possible
treatments.

An abnormal value on a fluorescein angiography may be due to:

 Blood flow (circulatory) problems, such as blockage of the arteries or

veins
 Cancer
 Diabetic or another retinopathy
 High blood pressure
 Inflammation or edema
 Macular degeneration
 Microaneurysms- enlargement of capillaries in the retina
 Tumors
 Swelling of the optic disc

The test may be done if you have:

 Retinal detachments
 Retinitis pigmentosa

RISKS

There is a slight chance of infection anytime the skin is broken. Rarely, a person
is overly sensitive to the dye and may experience:

 Dizziness or faintness
 Dry mouth or increased salivation
  Hives
 Increased heart rate
 Metallic taste in mouth
 Nausea and vomiting
 sneezing

OPHTHALMIC OFFICE INSTRUMENTS

1. Pen Torch

Normal pupil
an aperture presents in the center of the iris
the size pf the pupil determines the amount of light that enters the eye
the pupil size is controlled by the dilator and a sphincter muscles of the iris
Normally there’s one pupil in each eye
Rarely, there may be more than one pupil. These congenital anomalies are
called polycoria
Size: normal pupil size varies from 2.5-4mm depending upon the illumination.
miotic pupil are less than 2mm
mydriatic pupils are greater than 7mm
2. Retinoscope
A retinoscope is used to shine light into a patient’s eye for an eye doctor to
observe the reflection off the retina. The light is moved back and forth across
the pupil. A retinoscope is especially useful in prescribing corrective lenses for
patients who are unable to give oral feedback to the eye doctor. It is also useful
for determining how well the eye works together, or accommodate, to see
clearly
3. Lensometer
A lensometer is an instrument used to measure the power of an existing lens. An
optician uses a lensometer to determine the prescription of a patient’s eye
glasses.
An optical instrument used for determining the vertex power, axis direction and
optical center of an ophthalmic lens. The instrument can be either manual or
automated.
4. Tonometer
A tonometer is used to measure the pressure of the eye. The test is used to help
detect glaucoma. Numbing drops are used for the type of tonometer that
actually touches the eye. Some doctors use the air- puff tonometer in which no
numbing drops are needed. A tonometer measures the production of aqueous
humor, the liquid found inside the eye and the rate at which it drains into the
tissue surrounding the cornea.

Applanation tonometer

 It is more accurate than an indentation tonometer and it is based on

Imbert-ficks law
 Instead of measuring the amount of indentation, applanation tonometer
measures the amount of force needed to flatten or applanate the known
area of the cornea.

This concept is introduced by Goldman in 1954, it consists of double prism

mounted on a standard slit lamp

Indentation tonometer

Schiotz indentation tonometry

a. Body-foot plate-rests on the cornea

b. Plunge
c. Weights-5.5gm-permanently fixed additional weights-7.5g10g, 15g.
 5. Direct Ophthalmoscope

A direct ophthalmoscope is a handheld instrument used for examining the

interior structure of the eye, especially the retina, it consists of a mirror that
reflects lights into the and a central hole through which the eye is examined.

6. Binocular indirect ophthalmoscope

An ophthalmoscope is an instrument used for examining the interior structure of

the eye, especially the retina, consisting of a mirror that reflects light into the
eye and a central hole through which the eye is examined. A binocular indirect
ophthalmoscope (BIO) is worn an eye doctor’s head in order to have the use of
both hands to examine the eye

Eye magnification provides excellence views of the optic disc and macula

WHAT IS OPTICAL COHERECE TOMOGRAPHY?

Optical coherence tomography (OCT) is a non-invasive imaging test. OCT uses

light waves to take cross-section pictures of your retina.

With OCT, your ophthalmologists can see each of the retina distinctive layers.
This allows your ophthalmologists to mark and measures their thickness. These
measurements help in diagnosis. They also provide treatment guidance for
glaucoma and diseases of the retina. These retinal diseases include:

 Age-related macular degeneration (AMD)

 Diabetic eye disease
WHAT HAPPENS DURING OCT?

To prepare you for an OCT exam, your ophthalmologists may put dilating eye
drops in your eyes. These drops widen your pupil and make it easier to examine
your retina.

You will sit in front of the OCT machine and rest your head on a support to
keep it motionless. The equipment will then scan your eye without touching it.
Scanning takes about 5-10 minutes. If your eyes where dilated, they may be
sensitive to light for several hours after the exam.

What conditions can an OCT help to diagnose?

OCT is useful in diagnosing many eye conditions including:

 Macular hole
 Macular pucker
 Macular edema
 Age-related macular degeneration
 Glaucoma
 Central serous retinopathy
 Diabetic retinopathy
 Vitreous traction

OCT is often used to evaluate disorders of the optic nerve as well. The OCT
exams helps your ophthalmologist see changes to the fibers of the optic nerve.
For example, it can detect changes caused by glaucoma.
OCT relies on light waves. It cannot be used with condition that interfere with
light [passing through the eye. This condition includes:

 Dense cataract or significant bleeding in the vitreous.

VISUAL FIELD TESTING

Many eye and brain disorders can cause peripheral vision loss and other
visual field abnormalities. Visual field tests are performed by eye care
professionals to detect blind spots (scotomas) and other visual field defects,
which can be an early sign of these problems.

The size and shape of a scotoma offers important clues about the presence
and severity of the diseases of the eye, optic nerve and visual structures in the
brain. For example, optic nerve damaged caused by glaucoma creates a very
specific visual field defect.

Other conditions associated with blind spot and other visual field defects
include: diseases of the retina, neuropathy, brain tumors and stroke.

During a routine eye exam, your optometrists or ophthalmologists may

recommend visual field testing to assess full the horizontal and vertical range
and sensitivity of your vision. This baseline visual field test results can then be
used to assess potential changes in your visual field in the future.

TYPES OF VISUAL FIELD TEST

1) Confrontation visual field testing

Typically, it is used as a screening visual field test.one eye is covered, while

the other eye fixates on a target object, such as the doctor’s open eye, while the
doctor stands or sits directly in front of you. You then are asked to describe
what you see on the far edges or periphery of your field of view.
As an example, your eye doctor may hold up different number of fingers within
your peripheral field of view. And ask how many can be seen while you
continue to fixate on the doctor’s eye.

If an eye disease is suspected you may need to undergo more comprehensive

formal types of visual field testing to evaluate the quality of your central vision
and peripheral vision. A variety of sensitive tests for measuring visual field loss
exists, including:

 Automated perimetry.
Various forms of automated perimetry test measures your responses to
the presence of object in different areas of your field of view.
While your head is held still, usually with a forehead and chinrest inside a
large bowl-like instrument, you stare at a source of light straight ahead
and tiny lights of different intensities are flashed from random points in
your visual field. Each time you see one of these lights, you immediately
press a button or use some other means to indicate your response.
If you can’t see the light in certain parts of your field of view, then you
may have a blind spot indicating vision loss.
 Frequency doubling perimetry
This is based on an optical illusion produced with vertical bars of
contrasting colors (usually black and white), appearing on a screen. These
bars appear to double a number when they alternately flicker at higher
frequencies, a phenomenon thought to be due to the unique response of
specific light sensitive cells (photo receptors) in the retina.
Inability to see vertical bars at certain frequencies could indicate optic
nerve or other types of eye damage with accompanying loss of vision in
certain areas of the visual field.
 Electro retinography
This test measures electrical activities generated by the photoreceptor
cells in the retina when the eye is stimulated by a special stroke light or a
reversing checker board pattern of light. The measurement is captured by
an electrode placed on the front surface of the eye (cornea), and graphic
record called an electro retinogram is produced.
Electro retinography is useful in diagnosing several hereditary and
acquired disorders of the retina, including: retinitis pigmentosa, a
detached retina or functional changes in the retina caused by
arteriosclerosis (hardening of the arteries) or diabetics.