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Accommodation is the eye's way of changing its focusing distance: the lens thickens, increasing its ability to focus at near. A young person's ability to accommodate allows him or her to see clearly far away and up close. At about the age of 40, the lens becomes less flexible and accommodation is gradually lost, making close-range work increasingly difficult. This is known as presbyopia.

Amsler Grid for Retinal Testing
The Amsler Grid is used to test the macula, the very central part of the retina. The test is simply a grid made of evenly spaced horizontal and vertical lines. A small dot is located in the center of the grid for fixation. Simply follow the instructions below the grid.

While focusing on the dot in the center of the grid, with one eye covered, ask yourself the following questions:

•Am I able to see the corners and sides of the square?
•Do I see any wavy lines?
•Are there any holes or missing areas?

If the lines of grid do not look straight or areas appear to be missing and or distorted, you should inform a retinal specialist.
This simple screening test is used to assess the macula (the center of the retina). The Amsler Grid consists ofevenly spaced horizontal and vertical lines printed on black or white paper. A small dot is located at the center of the grid for fixation. While staring at the dot, the patient looks for wavy lines and missing areas of the grid. This test is especially helpful for monitoring vision at home.

The Arden Screening Test is a simplified version of a more complex test developed by Dr. Arden at Moorfield's Eye Hospital in England. Glaucoma research has shown that glaucoma affects the color vision (especially blues and yellows) before itcan be identified with an eye exam or visual field test. Dr. Arden developed a special color vision test to help identify and treat glaucoma patients as early as possible.

Scott Brodie, MD, an eye surgeon from New York, designed a simplified version of this color test that can be completed in just minutes. For the Arden Screening Test, the patient is seated in front of a computer screen and a series of colored circles are displayed that have a break, or missing area on contrasting backgrounds. While looking straight ahead, the patient identifies the location of the break with her peripheral vision. As the test progresses, the contrast between the circle and the background slowly decreases until patient can no longer identify the break.

This test is very important when determining whether glaucoma treatment is appropriate. NY Eye Institute is one of the few facilities in the country to offer the Arden Screening Test. This test enables us to separate patients who have elevated pressures or other suspect glaucoma signs that are normal from those who truly have the disease and require treatment.

Contrast Sensitivity
Contrast sensitivity testing is method used to assess the quality of vision. It differs from typical visual acuity testing in that it simulates "real-world" circumstances. Routine visual acuity testing measures eyesight under best possible conditions. It does not reflect the difficulties one might experience when driving at night, or trying to read a sign on a cloudy, overcast afternoon.

The test is performed by showing the patient a series of stripes or bars that slant in different directions. The patient must identify which way each series of stripes is tilted. As the test progresses, the bars become thinner and lighter. Patients with excellent contrast sensitivity can determine the direction very light, thin bars are slanted.

This is particularly useful for measuring visual acuity in patients who report difficulty with their vision, yet see well on the conventional eye chart.

Corneal Transplant
The cornea is normally a clear layer of tissue covering the front of the eye, similar to a watch crystal. Its purpose is to refract or bend light rays as they enter the eye, allowing them to focus on the retina. In cases where the cornea has become clouded as a result of disease, swelling, scarring, infection, or chemical burns, a corneal transplant (also called keratoplasty) is sometimes necessary to restore functional vision. For this procedure, the surgeon carefully removes the central corneal tissue and replaces it with a precisely shaped replica of donor tissue.

The success rate of corneal transplant is about 85%. However, factors such as glaucoma, retinal degeneration, or optic nerve disease may affect the final visual result even if the surgery is successful.

The procedure usually takes approximately one hour and is performed with local anesthesia on an outpatient basis. After the surgery, a plastic shield or glasses should be worn at all times to avoid accidentally rubbing, bumping or hitting the eye. Drops are prescribed to prevent rejection of the donor cornea.

During the postoperative period, the surgeon monitors the cornea's healing with special computer mapping called corneal topography. This allows the doctor to evaluate the shape of the new cornea and remove sutures as needed to control astigmatism.

In most cases, vision returns very gradually. The healing process may vary greatly from one individual to the next. Some may enjoy improved vision within a few months after surgery, for others, it may take up to a year.

Do you think of getting your eyes dilated as a nuisance? We'll be the first to admit that even though it's painless, dilating your eyes is probably annoying at best. Maybe you've never really understood just what we're accomplishing by putting those pesky drops in your eyes. Here's your chance to find out.

Your eye exam begins with a thorough investigation of the lids, lashes, conjunctiva, sclera and cornea – the external surfaces. Using a microscope and a bright light, the doctor will move in for a closer look at the anterior chamber, iris and crystalline lens. The iris is very similar to the shutter of a camera. When you take a picture on a bright sunny day, the shutter becomes smaller, allowing less light to enter. Likewise, your pupil becomes smaller when we shine a bright light at your eye, making it very difficult to peer inside. That's where the dilating drops come in.

Dilating drops work on one of two principles: they either stimulate the iris muscle that opens the pupil (the dilator), or prevent action of the iris muscle that closes the pupil (the sphincter). After the drops take effect, your doctor can get a much better view of your retina, optic nerve and vessels in the back of the eye. This is a very important part of your preventative eye care as well as some eye surgeries. From this simple step, we are able to gather a lot of important information about your eyes. In fact, some systemic diseases such as hypertension and diabetes are first discovered during the dilated eye exam.

Some dilating drops also prevent accommodation. The natural lens is able to accommodate or adjust the eye's focus until about the age of 40. Children and young adults are especially good at this, and their ability to accommodate sometimes prevents the doctor from getting an accurate refraction for glasses. That's why young eyes are often dilated for a "wet" refraction so the doctor can get a true picture of what the child's prescription really is.

There are a few things you can do to make your visit a bit more comfortable:

•Don't plan any activities after your appointment that require crisp vision.
•Bring dark sunglasses for the ride home. Don't worry if you forget yours, just ask for a disposable pair as you check out.
•If you know you'll have trouble seeing to drive home (even with the sunglasses), please bring a friend.
•Bring a newspaper, book or magazine with larger print to read after the drops begin to work.

Eye care professional's Title explained
Ophthalmologist (MD or DO): An ophthalmologist is a medical doctor whose training includes: bachelor degree, 4 years of medical school, a 1-year internship, and a 3-4 year residency program. Many doctors continue their education with a 1-2 year fellowship that concentrates on a particular subspecialty such as glaucoma or retinal disease. Ophthalmologists are trained to diagnose and treat eye diseases and conditions with medications and surgery.

Optometrist (OD): An optometrist has acquired a bachelor's degree, and completed 4 years of additional education at an accredited school of optometry. Optometrists specialize in prescribing and fitting glasses and contact lenses as well as the detection and diagnosis of eye diseases. Optometrists often work with ophthalmologists to manage diseases and to care for patients following eye surgery.

Ocularist: An ocularist is specially trained to fit prosthetic (artificial) eyes after surgery or to cover disfigurements. Ocularists must complete a 5 year apprentice program and pass a board examination for certification.

Orthoptist (CO): Orthoptists specialize in evaluating the visual system and muscle function, especially with infants, children, and young people. They work along with optometrists and ophthalmologists to provide non-surgical treatments to correct muscle imbalances and associated eye problems. An orthoptist must complete 2 years of specialized training as well as a board examination.

Optician (ABOC - American Board of Opticianry Certified and NCLC - Certified National Contact Lens Examiner): An optician is specially trained to make and fit eyeglasses. Opticians require 2 years of training prior to sitting for a board examination. Some opticians also become certified in contact lens fitting.

Allied health personnel (COA, COT, COMT): Ophthalmic medical personnel assist the physician in the diagnosis of conditions, treatment of disease and injury, and care of patients. The Joint Commission on Allied Health Personnel grants certification at three difference levels after passing a board examination and skill test: certified ophthalmic assistant (COA), certified ophthalmic technician (COT), and certified ophthalmic medical technologist (COMT). Each level of certification requires additional education, skill and experience over the previous level.

Certified Ophthalmic Retinal Photographer (CRA): Certified ophthalmic photographers specialize in photography of the eye used for diagnosis and documentation. Individuals may become certified by sitting for a board examination and passing a skill evaluation.

Ophthalmic Registered Nurse (ORN): An ophthalmic registered nurse has received special training and certification ophthalmology in addition to his or her nursing education of 2-4 years.

Fluorescein angiogram (FA)
Fluorescein angiography (fluorescein - the type of dye that is used; angiogram - a study of the blood vessels) is an extremely valuable test that provides information about the circulatory system and the condition of the back of the eye. FAs are useful for evaluating many eye diseases that affect the retina.

 The test is performed by injecting a special dye, called fluorescein, into a vein in the arm. In just seconds, the dye travels to the blood vessels inside the eye. A camera equipped with special filters that highlight the dye is used to photograph the fluorescein as it circulates though the blood vessels in the back of the eye.
Retinal photograph of a patient complaining of decreased vision. Fluorescein angiogram indicating fluid leakage within the retina.
If there are any circulation problems, swelling, leaking or abnormal blood vessels, the dye and its patterns will reveal these in the photographs. The doctor can then make a determination as to the diagnosis, and possible treatment options for the patient. In many cases, these photos are taken with a digital camera system, allowing the physician to interpret the results immediately.

Fundus Photography
Don't be surprised if someday, your eye doctor orders photographs of the back of your eye. These pictures are necessary to document the health of the optic nerve, vitreous, macula, retina and its blood vessels. The photographs are used for comparison, documentation, and sometimes to diagnose certain eye conditions.

Because fundus photography is a highly specialized form of medical imaging, it can't be done with an ordinary camera. It requires a customized camera that is mounted to a microscope with intricate lenses and mirrors. These high-powered lenses are designed so the photographer can visualize the back of the eye by focusing light through the cornea, pupil and lens.

Before beginning, the pupil is dilated with drops. Otherwise, it would automatically constrict from the bright light of the camera flash. The patient is asked to stare at a fixation device so the eyes are still. While the photographer is taking the pictures, the patient will see a series of bright flashes. The entire process usually takes approximately five to ten minutes.

Glare Test
One of the earliest symptoms of cataracts is glare at night. Glare occurs when light enters the eye and bounces off an opacity such as a cataract. Most cataract patients first notice glare when looking at headlights.

The glare test is used to assess visual function when looking at bright lights. While looking at an eye chart, lights are introduced that simulate the effect of bright sunlight or nighttime glare. The results of the test are important when considering cataract surgery. This is because some patients without a significant decrease in vision under normal lighting conditions notice that their vision drops considerably in sunlight or when looking at lights.

This test is performed on patients who have glaucoma or when the disease is suspected. A special mirrored contact lens is used to allow the doctor to examine the structures in the front of the eye. With this lens, the doctor can assess the eye's drainage system.

Indocyanine Green Dye Study
The "hot spot" is indicated by the white (hyperfluorescent) area. (arrow)

An Indocyanine Green study (ICG) is a special dye test used to evaluate the circulatory system of the choroid, the layer just behind the retina. ICG reacts to light with a longer wavelength than fluorescein dye, allowing the doctor to pinpoint the location of leaking vessels deeper within the eye that may not be apparent with fluorescein angiography.

After the ICG is injected into the patient's arm, it travels through the bloodstream to the eye in about 15 to 20 seconds. Once there, it illuminates the leaking vessels or "hot spots" in the choroid.
Using a digital camera equipped with a special filter, the retinal photographer takes photos as the dye travels through the vessels in the eye. The doctor interprets the digital photos and determines whether treatment is needed. If there is an active leak, the photos serve as a guide to seal the vessel with laser. The ICG study helps the doctor target the leak with greater accuracy

Intraocular Pressure (IOP)
The intraocular pressure, an important part of any eye exam, is measured with a special instrument called a tonometer. The IOP is determined by a balance of the eye's production and drainage of aqueous (the clear fluid inside the eye) from the anterior chamber into the trabecular meshwork. If the IOP is elevated, it can cause pressure within the eye to increase and damage the optic nerve. Since abnormal pressures usually don't cause symptoms, it's very important to have the pressure checked regularly.

Keratometry measures the corneal curvature. It is performed for similar reasons as topography, but rather than mapping the entire corneal surface, two curves are measured – the steepest and the flattest. These measurements give the doctor information about the cornea's curvature, focusing power, and whether astigmatism is present.

Monovision addresses the problem of presbyopia that most people start to encounter at the age of 40-45 when they begin to need reading glasses or bifocals for close vision. With monovision, the dominant eye (the eye you would use to focus a camera) is focused for distance vision, and the non-dominant eye is focused for near to intermediate vision. This can be done with contact lenses, refractive surgery or intraocular lenses.

Monovision certainly isn't appropriate for everyone. However, when paired with the right person, it can be a great fit. Monovision is a blend of near and distance vision, and is ideal for people with an active lifestyle. However, there is a caveat to consider: since it is a compromise, most people's vision isn't perfectly crisp up close or far away. Instead, it offers the best of both worlds.

Most people who opt for monovision go through a brief period of adaptation as the brain "learns" to see with the eye best suited for the task. If you're considering refractive surgery as a permanent form of monovision, it might be best to consider a "test drive" with contact lenses before making a decision.

An ophthalmoscope is an instrument used to examine the retina and vitreous. Ophthalmoscopy requires dilating the pupils with drops to give the doctor the best view inside the eye.

There are two types of ophthalmoscopes: direct and indirect. The direct is a hand-held instrument with a battery powered light source. It also has a series of lenses that can be dialed in to focus the doctor's view of the retina. The direct ophthalmoscope is useful for examining the central retina.

The indirect ophthalmoscope can be used to examine the entire retina. This instrument is worn on the doctor's head. While looking through the instrument's magnifying glasses, a special lens is placed in front of the patient's eye, allowing the doctor to see the retina clearly.

The pachymeter is an instrument that measures the thickness of the cornea. It is useful in monitoring the progression of certain disorders that cause the cornea to become thickened (or filled with water), resulting in a loss of vision.

Potential Acuity
Potential acuity tests such as the Potential Acuity Meter (PAM) and the Super Pinhole function using differnet principles, however both help in assessing retinal function

The PAM projects an eye chart directly on the retina and bypasses the cataract. This allows the examiner to test the visual acuity without interference from the cloudy lens. For the Super Pinhole, the patient looks at a special chart through a disc with tiny holes. This allows the patient to isolate tiny clear spots in the cataract.

When considering cataract surgery, these tests help the doctor determine the potential visual acuity if the cataract was removed. Testing potential acuity is especially helpful when considering cataract surgery for patients with retinal disease such as macular degeneration. By performing this simple test, the amount of vision loss that can be attributed to the degeneration vs. the cataract can be determined.

Prism Testing
Prisms bend light, changing the object's position. Because of this property, they are commonly used to detect and measure strabismus (turned or crossed eye). While the patient is staring at an object, prisms of increasing strength are placed over the turned eye until it is aligned with the fellow eye. The stronger the prism that is required to align the eyes, the greater the eye turn.

Pupil Light Reflexes
The Hirschberg and Krimsky tests measure pupil light reflex and are performed by simply shining a bright light into the patient's eyes and looking at the light in the pupils. When there are no alignment problems, the light reflection will be in approximately the same position in both pupils. However, if the patient has strabismus, the light will appear off-center in the crossed eye. This test is especially useful when examining young children.

Parents can quickly screen their children at home with this test. Shine a bright light at the child's eyes while standing about 6 feet away. Is the light reflex positioned equally in the child's pupils? If the light falls in a different spot in one pupil compared to the other, consult with an ophthalmologist. Beware however, that some eye turns are very subtle and may only be detected by an eye care professional.

The refraction is a vision test that determines your best visual acuity with corrective lenses. It can be done with computerized equipment, but typically an instrument called a phoropter is used. The phoropter holds corrective lenses that are positioned in front of your eye. While looking at the eye chart through the phoropter, the technician or doctor will adjust the lenses until the chart appears the clearest possible.

Schirmer Testing
This test is used to assess tear production and is helpful in treating dry eye syndrome. Tiny paper tabs are inserted in the lower lids and removed after a few minutes. When the tab is removed, the dampened area is measured in millimeters. This helps the doctor determine the presence or extent of a dry eye condition.

Slit Lamp
The slit lamp is a microscope with a light attached that allows the doctor to examine your eye under high magnification. This instrument is primarily used to view the anterior structures of the eye such as the cornea, iris, and lens. However, with special lenses, it is possible to examine the vitreous and the back of the eye as well.

The instrument's name is derived from its adjustable light beam. By changing the width of the beam, the doctor can gather important detail about each eye structure. The next time you accompany a family member to an eye exam, ask to look in the slit lamp. You'll be amazed at what you see!

Specular Microscopy / Photography
This test is used to monitor the number, density, and quality of endothelial cells that line the back of the cornea. A microscope magnifies the cells thousands of times and the image is captured with a camera or video camera. The number of cells within one square millimeter are counted and recorded. The endothelium of a young, ten-year-old, healthy cornea has approximately 3,500 cells in each square millimeter. Normal aging causes the cells to gradually decrease over time. By age 60, most people have approximately 2,500 cells per square millimeter
This test helps the examiner evaluate the quality of the patient's depth perception. While wearing special polarized glasses, the patient looks at a series of 3-D objects that range from being very raised to nearly flat. In each series, the patient is asked to select the object with the greatest 3-D effect.

Ultrasound utilizes sound waves to form an image of the eye. It works in a very similar manner that sonar is used to "view" the ocean floor. High frequency sound waves (out of the range of the human ear) are emitted from a probe. The sound waves travel through eye, reflect from ocular structures back to the transducer inside the probe. The transducer receives the sound waves and converts them into the image that appears on the examiner's screen.

Ophthalmic ultrasound is used to measure the parts of the eye, document pathology such as tumors, and examine inside the eye. The sound frequency emitted from the probe determines the type of image formed on the screen.

The two most common types of ultrasound used in ophthalmology are A-Scans and B-Scans. An A-Scan is a one-dimensional display of sound waves. Each time a sound wave hits a structure in the eye, a spike is formed on the examiner's screen. The height and spacing between each of the echoes provides the examiner with valuable information. A-Scans are most commonly used to measure the eye length to determine the appropriate intraocular lens for cataract surgery.

B-Scans are used to create two-dimensional, cross-section views of the eye. Multiple sound waves are emitted from the probe allowing the examiner to visualize structures within the eye. This instrument is extremely valuable when the doctor's view inside the eye is obstructed by blood, an extremely dense cataract, or other cloudy media.

Visual Field
The visual field is used to test and monitor peripheral vision. It gives the doctor very important information about the neurological function of the retina, optic nerve, and brain. This test is usually ordered to monitor certain eye diseases such as glaucoma, and also as a screening test prior to surgery.

Visual field tests come in different forms, but most have a white bowl with a small fixation light in the center. The most sophisticated ones are computerized. After your pupils have been dilated, you will be comfortably seated in front of the instrument. The trick to the test is to stare straight ahead as lights flash in the periphery. A button is available to press each time a light appears. A technician is available throughout the test should you have a question or need to pause for a break.

Afterward, the computer analyzes the data and prints a chart of the results. Your visual field results are organized in your record so that your doctor can monitor your progress.

A vitrectomy may be performed to clear blood and debris from the eye, to remove scar tissue, or to alleviate traction on the sclera. Blood, inflammatory cells, debris, and scar tissue obscure light as it passes through the eye to the retina, resulting in blurred vision. The vitreous is also removed if it is pulling or tugging the retina from its normal position.
Worth 4 Dot
For this test the patient wears glasses with one green lens and one red. The patient looks at a target with 2 green dots ad 1 white dot. Depending on the number and color of lights the patient sees, the examiner can determine whether there is normal fusion or if one eye is being suppressed (ignored).
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