Visual Test

INTRODUCTION
HOW DO WE SEE?

There are many different parts of the eye that help to create vision. Light passes through the cornea, the clear, dome-
shaped surface that covers the front of the eye. The cornea bends - or refracts - this incoming light. The iris, the
colored part of the eye, regulates the size of the pupil, the opening that controls the amount of light that enters the
eye. Behind the pupil is the lens, a clear part of the eye that further focuses light, or an image, onto the retina. The
retina is a thin, delicate, photosensitive tissue that contains the special “photoreceptor” cells that convert light into
electrical signals. These electrical signals are processed further, and then travel from the retina of the eye to the brain
through the optic nerve, a bundle of about one million nerve fibers. We “see” with our brains; our eyes collect visual
information and begin this complex process.
VISUAL ACUITY

Visual acuity-When you read letters on a distance chart, you are measuring your visual acuity. Visual acuity is given
as a fraction (for example, 20/40). The top number is the standardized testing distance (20 feet) and the bottom
number is the smallest letter size read. A person with 20/40 visual acuity would have to get within 20 feet to read a
letter that should be seen clearly at 40 feet. Normal distance visual acuity is 20/20.

ASTIGMATISM

Astigmatism is a common vision condition that causes blurred vision. It occurs when the cornea (the clear front cover
of the eye) is irregularly shaped or sometimes because of the curvature of the lens inside the eye. 

An irregularly shaped cornea or lens prevents light from focusing properly on the retina, the light-sensitive surface at
the back of the eye. As a result, vision becomes blurred at any distance. This can lead to eye discomfort and
headaches.



Astigmatism frequently occurs with other vision conditions like myopia (nearsightedness) and hyperopia
(farsightedness). Together these vision conditions are referred to as refractive errors because they affect how the
eyes bend or "refract" light.
The curvature of the cornea and lens bends the light entering the eye in order to focus it precisely on the retina at the
back of the eye. In astigmatism, the surface of the cornea or lens has a somewhat different curvature. 



The surface of the cornea is shaped more like a football instead of round like a basketball, the eye is unable to focus
light rays to a single point. Vision becomes out of focus at any distance. 



In addition, the curvature of the lens inside the eye can change, resulting in an increase or decrease in astigmatism.
This change frequently occurs in adulthood and can precede the development of naturally occurring cataracts.
Types of Astigmatism
There are two types of astigmatism.
1. Regular astigmatism is when the cornea is curved more in one direction than the other. It is the most common
form of astigmatism and can be corrected easily with glasses or toric contact lenses.
2. Irregular astigmatism is far less common and happens when the curvature of the cornea isn't even. It may be
the result of an eye injury and related damage to the cornea, or a condition such as keratoconus, a progressive
eye condition where the central cornea thins and becomes irregular in shape. It can't always be corrected with
glasses, but it may be possible to correct with specialist contact lenses.

Astigmatism Eye Test

1.If you wear glasses or contact lenses, put them on.
2.Sit about 35 cm (14 inches) away from your computer screen.
3.Look at the chart with your hand covering one eye. How do the lines appear? Are they all equally clear and sharp?
4.Follow these steps again to test the other eye.
What do your results mean?
If you do not have astigmatism, the lines should appear sharply focused and equally dark. You may have
astigmatism if some sets of lines appear sharp and dark, while others are blurred and lighter. Whatever your
result, an astigmatism diagnosis can only be confirmed by an optician.
ACCOMMODATION
Accommodation is part of a complex triad that maintains clear near vision and is called the near response or the near
reflex. Even though the components of the near response—accommodation, convergence, and pupillary miosis—
normally work together during near viewing, each component can be tested separately. For example, one can
weaken the stimulus to accommodation with plus lenses or strengthen the stimulus to accommodation with weak
minus lenses without stimulating convergence or miosis. One can use weak base-out prisms to stimulate
convergence without changing accommodation. Under certain conditions, one can test accommodation without
inducing pupillary constriction. In addition, even in presbyopia in which accommodation fails, convergence and miosis
continue. Furthermore, if one paralyzes accommodation with drugs, convergence remains intact. Relative
accommodation is the term used to describe the amount of accommodation that is unrelated to convergence; relative
convergence describes the amount of convergence unrelated to accommodation.

There are actually three aspects of accommodation: the near point of accommodation, the accommodative
amplitude, and the range of accommodation. The near point of accommodation (NPA) is the point closest to the eye
at which a target is sharply focused on the retina. The accommodative amplitude is the power of the lens that permits
such clear vision. This power is measured in units called diopters (D) and is calculated by dividing the NPA in
centimeters into 100. The accommodative amplitude is thus simply the reciprocal of the NPA (e.g., a patient with an
NPA of 25 cm has an accommodative amplitude of 100/25 4 D). The range of accommodation is the distance
between the furthest point an object of a certain size is in clear sight and the nearest point at which the eye can
maintain that clear vision.
Accommodation (response to looking at something moving toward the eye). Accommodation is
impaired in lesions of the ipsilateral optic nerve, the ipsilateral parasympathetics traveling in CN III, or the pupillary
constrictor muscle, or in bilateral lesions of the pathways from the optic tracts to the visual cortex. Accommodation is
spared in lesions of the pretectal area.
Accomodation reflex involve a triad of changes when a person looks at a nearby object.
1. Convergence of eye due to contraction of medial and lateral rectus muscle
2. Miosis -constriction of pupils due to constrictor pupillae muscle contraction.
3. Accomodation is associated with increased refractive power of the lens.This is due to the contraction of ciliaris
muscle.

Pathway of accommodation
1. Afferent impulses from retina pass along the normal visual pathway to reach the visual areas in the occipital lobe
2. From the visual areas fibers descend to the oculomotor (3rd cranial nerve) nucleus of both side in the midbrain.
3. Efferent fibers pass along the 3 rd cranial nerve to the eye to supply the following muscle
Medial rectus muscle
Constrictor pupillae muscle
Ciliaris musle
In accommodation reflex the fibers reach the lateral geniculate body and the occipital cortex but they donot pass
through the pretectal nucleus situated in midbrain.

Other method of testing accommodation reflex

The patient is asked to look at a distant object and then at the examiners finger which is gradually brought within 5cm
of the eyes.When the gaze is directed from a distant object to near one contraction of medial rectus brings about a
convergence of of the ocular axis and along with this accommodation occurs by the contraction of ciliaris muscle and
pupil constrict as a part of associated movement .

COLOR BLIND (ISHIHARA TEST)

The most common types of color blindness are inherited. They are the result of defects in the genes that contain the
instructions for making the photopigments found in cones. Some defects alter the photopigment’s sensitivity to color,
for example, it might be slightly more sensitive to deeper red and less sensitive to green. Other defects can result in
the total loss of a photopigment. Depending on the type of defect and the cone that is affected problems can arise
with red, green, or blue color vision.
Color blindness occurs when cone cells, located in the retinal tissue at the back of the eye, don’t function or are
damaged. There are two main kinds of color blindness:
Red/green color blindness, the most common type, is congenital or inherited. It’s far more common in males than
females, but still very rare. It affects 5 to 8 percent of males, and 0.5 percent of females. For people with red/green
color blindness, reds and greens look similar to each other as a kind of brownish, muted tone. There is also a blue/
yellow type of color blindness, but it's even more rare.
A second, and less common, kind of color blindness is acquired, or related to an eye disease or condition. Retinal or
optic nerve disorders are most likely to cause this kind of color blindness. In these cases, symptoms such as overall
failing vision or persistent dark or white spots may be noticed first. An ophthalmologist may test for color blindness to
help diagnose the problem. The doctor may start with an Ishihara screening test and, if that’s positive, move to more
sophisticated testing.
MORE DETAILS ON COLOR BLINDNESS
Red-Green Color Blindness
The most common types of hereditary color blindness are due to the loss or limited function of red cone (known as
protan) or green cone (deutran) photopigments. This kind of color blindness is commonly referred to as red-green
color blindness.
Protanomaly: In males with protanomaly, the red cone photopigment is abnormal. Red, orange, and yellow appear
greener and colors are not as bright. This condition is mild and doesn’t usually interfere with daily living. Protanomaly
is an X-linked disorder estimated to affect 1 percent of males.
Protanopia: In males with protanopia, there are no working red cone cells. Red appears as black. Certain shades of
orange, yellow, and green all appear as yellow. Protanopia is an X-linked disorder that is estimated to affect 1 percent
of males.
Deuteranomaly: In males with deuteranomaly, the green cone photopigment is abnormal. Yellow and green appear
redder and it is difficult to tell violet from blue. This condition is mild and doesn’t interfere with daily living.
Deuteranomaly is the most common form of color blindness and is an X-linked disorder affecting 5 percent of males.
Deuteranopia: In males with deuteranopia, there are no working green cone cells. They tend to see reds as
brownish-yellow and greens as beige. Deuteranopia is an X-linked disorder that affects about 1 percent of males.
Blue-Yellow Color Blindness
Blue-yellow color blindness is rarer than red-green color blindness. Blue-cone (tritan) photopigments are either
missing or have limited function.
Tritanomaly: People with tritanomaly have functionally limited blue cone cells. Blue appears greener and it can be
difficult to tell yellow and red from pink. Tritanomaly is extremely rare. It is an autosomal dominant disorder affecting
males and females equally.
Tritanopia:  People with tritanopia, also known as blue-yellow color blindness, lack blue cone cells. Blue appears
green and yellow appears violet or light grey. Tritanopia is an extremely rare autosomal recessive disorder affecting
males and females equally.
Complete color blindness
People with complete color blindness (monochromacy) don’t experience color at all and the clearness of their vision
(visual acuity) may also be affected.
There are two types of monochromacy:
Cone monochromacy:  This rare form of color blindness results from a failure of two of the three cone cell
photopigments to work. There is red cone monochromacy, green cone monochromacy, and blue cone
monochromacy. People with cone monochromacy have trouble distinguishing colors because the brain needs to
compare the signals from different types of cones in order to see color. When only one type of cone works, this
comparison isn’t possible. People with blue cone monochromacy, may also have reduced visual acuity, near-
sightedness, and uncontrollable eye movements, a condition known as nystagmus. Cone monochromacy is an
autosomal recessive disorder.
Rod monochromacy or achromatopsia: This type of monochromacy is rare and is the most severe form of color
blindness. It is present at birth. None of the cone cells have functional photopigments. Lacking all cone vision, people
with rod monochromacy see the world in black, white, and gray. And since rods respond to dim light, people with rod
monochromacy tend to be photophobic – very uncomfortable in bright environments. They also experience
nystagmus. Rod monochromacy is an autosomal recessive disorder.