Amsler grid | |
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Purpose | Used to detect vision problems resulting from damage to the macula or the optic nerve [1] |
Test of | Central visual field |
The Amsler grid, used since 1945, is a grid of horizontal and vertical lines used to monitor a person's central visual field. The grid was developed by Marc Amsler, a Swiss ophthalmologist. It is a diagnostic tool that aids in the detection of visual disturbances caused by changes in the retina, particularly the macula (e.g. macular degeneration, Epiretinal membrane), as well as the optic nerve and the visual pathway to the brain. Amsler grid usually help detecting defects in central 20 degrees of the visual field. [2]
In the test, the person looks with each eye separately at the small dot in the center of the grid. Patients with macular disease may see wavy lines or some lines may be missing.
Amsler grids are supplied by ophthalmologists, optometrists or from web sites, and may be used to test one's vision at home.
The original Amsler grid was black and white. A color version with a blue and yellow grid is more sensitive and can be used to test for a wide variety of visual pathway abnormalities, including those associated with the retina, the optic nerve, and the pituitary gland.
In 1869, Jacob Hermann Knapp described scotoma and metamorphopsia in traumatic maculopathy with choroidal rupture using horizontal lines. Similarly in 1874, Richard Forster demonstrated metamorphopsia using a square grid. [3]
Swiss ophthalmologist Marc Amsler described the Amsler grid in the year 1945. It was the first functional test proposed to evaluate metamorphopsia. [4] He may have gotten the idea of the grid from Edmund Landolt, who used a similar small card with a grid pattern to be kept in the center of the visual field testing instrument perimeter. [3]
Amsler grid can be used in detecting central visual field defects in following conditions:
There are 7 types of Amsler grid charts. All charts measure 10 cm × 10 cm (3.9 in × 3.9 in), which when viewed at a distance of 33 cm (13 in) from the eye can be used to measure defects in the central 20 degrees of the visual field. [3]
Chart 1 is the basic version, which is the most familiar and widely used chart among all the charts. In this chart the grid consists of 0.5 cm squares (each for 1° visual field), which totally measures 10 cm X 10 cm size. Most commonly grid is in white color with black background. [3] Grid with black lines in white background is also available (see infobox picture).
Chart 2 is similar to chart 1, but it has diagonal cross lines, which assist correct fixation in case of central scotoma.
Chart 3 is also identical to chart 1, but color is red on black. Stimulating long wavelength foveal cones, this type of chart may help in detecting color scotomas and desaturation which may occur in toxic maculopathies, toxic optic neuropathies and pituitary tumors etc. [9]
Chart 4 has no lines, only a random pattern of white dots in black background. It was intended to differentiate areas of scotoma and metamorphopsia.
Chart 5 has central white dot and horizontal white lines on black background 5mm apart, which allow detecting metamorphopsia.
Chart 6 is similar to chart 5, but lines and central dot is in black on white background. The lines near to fixation points are closer than the chart 5.
Chart 7 is similar to chart 1, however central squares are further divided into 0.5 degree squares.
Micropsia is a condition affecting human visual perception in which objects are perceived to be smaller than they actually are. Micropsia can be caused by optical factors, by distortion of images in the eye, by changes in the brain, and from psychological factors. Dissociative phenomena are linked with micropsia, which may be the result of brain-lateralization disturbance.
Macropsia is a neurological condition affecting human visual perception, in which objects within an affected section of the visual field appear larger than normal, causing the person to feel smaller than they actually are. Macropsia, along with its opposite condition, micropsia, can be categorized under dysmetropsia. Macropsia is related to other conditions dealing with visual perception, such as aniseikonia and Alice in Wonderland Syndrome. Macropsia has a wide range of causes, from prescription and illicit drugs, to migraines and (rarely) complex partial epilepsy, and to different retinal conditions, such as epiretinal membrane. Physiologically, retinal macropsia results from the compression of cones in the eye. It is the compression of receptor distribution that results in greater stimulation and thus a larger perceived image of an object.
A scotoma is an area of partial alteration in the field of vision consisting of a partially diminished or entirely degenerated visual acuity that is surrounded by a field of normal – or relatively well-preserved – vision.
Macular degeneration, also known as age-related macular degeneration, is a medical condition which may result in blurred or no vision in the center of the visual field. Early on there are often no symptoms. Over time, however, some people experience a gradual worsening of vision that may affect one or both eyes. While it does not result in complete blindness, loss of central vision can make it hard to recognize faces, drive, read, or perform other activities of daily life. Visual hallucinations may also occur.
The visual field is "that portion of space in which objects are visible at the same moment during steady fixation of the gaze in one direction"; in ophthalmology and neurology the emphasis is on the structure inside the visual field and it is then considered “the field of functional capacity obtained and recorded by means of perimetry”.
An eye examination is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ophthalmologist, or an orthoptist. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.
Bruch's membrane or lamina vitrea is the innermost layer of the choroid of the eye. It is also called the vitreous lamina or Membrane vitriae, because of its glassy microscopic appearance. It is 2–4 μm thick.
Metamorphopsia is a type of distorted vision in which a grid of straight lines appears wavy and parts of the grid may appear blank. People can first notice they suffer with the condition when looking at mini-blinds in their home. For example, straight lines might be wavy or bendy. Things may appear closer or further than they are.
A visual field test is an eye examination that can detect dysfunction in central and peripheral vision which may be caused by various medical conditions such as glaucoma, stroke, pituitary disease, brain tumours or other neurological deficits. Visual field testing can be performed clinically by keeping the subject's gaze fixed while presenting objects at various places within their visual field. Simple manual equipment can be used such as in the tangent screen test or the Amsler grid. When dedicated machinery is used it is called a perimeter.
A retinal implant is a visual prosthesis for restoration of sight to patients blinded by retinal degeneration. The system is meant to partially restore useful vision to those who have lost their photoreceptors due to retinal diseases such as retinitis pigmentosa (RP) or age-related macular degeneration (AMD). Retinal implants are being developed by a number of private companies and research institutions, and three types are in clinical trials: epiretinal, subretinal, and suprachoroidal. The implants introduce visual information into the retina by electrically stimulating the surviving retinal neurons. So far, elicited percepts had rather low resolution, and may be suitable for light perception and recognition of simple objects.
Ranibizumab, sold under the brand name Lucentis among others, is a monoclonal antibody fragment (Fab) created from the same parent mouse antibody as bevacizumab. It is an anti-angiogenic that is approved to treat the "wet" type of age-related macular degeneration, diabetic retinopathy, and macular edema due to branch retinal vein occlusion or central retinal vein occlusion.
Optic disc drusen (ODD) are globules of mucoproteins and mucopolysaccharides that progressively calcify in the optic disc. They are thought to be the remnants of the axonal transport system of degenerated retinal ganglion cells. ODD have also been referred to as congenitally elevated or anomalous discs, pseudopapilledema, pseudoneuritis, buried disc drusen, and disc hyaline bodies.
Epiretinal membrane or macular pucker is a disease of the eye in response to changes in the vitreous humor or more rarely, diabetes. Sometimes, as a result of immune system response to protect the retina, cells converge in the macular area as the vitreous ages and pulls away in posterior vitreous detachment (PVD).
Angioid streaks, also called Knapp streaks or Knapp striae, are small breaks in Bruch's membrane, an elastic tissue containing membrane of the retina that may become calcified and crack. Up to 50% of angioid streak cases are idiopathic. It may occur secondary to blunt trauma, or it may be associated with many systemic diseases. The condition is usually asymptomatic, but decrease in vision may occur due to choroidal neovascularization.
Choroidal neovascularization (CNV) is the creation of new blood vessels in the choroid layer of the eye. Choroidal neovascularization is a common cause of neovascular degenerative maculopathy commonly exacerbated by extreme myopia, malignant myopic degeneration, or age-related developments.
A maculopathy is any pathological condition of the macula, an area at the centre of the retina that is associated with highly sensitive, accurate vision.
Preferential hyperacuity perimetry (PHP) is a psychophysical test used to identify and quantify visual abnormalities such as metamorphopsia and scotoma. It is a type of perimetry.
Geographic atrophy (GA), also known as atrophic age-related macular degeneration (AMD) or advanced dry AMD, is an advanced form of age-related macular degeneration that can result in the progressive and irreversible loss of retinal tissue (photoreceptors, retinal pigment epithelium, choriocapillaris) which can lead to a loss of visual function over time. It is estimated that GA affects over 5 million people worldwide and approximately 1 million patients in the US, which is similar to the prevalence of neovascular (wet) AMD, the other advanced form of the disease.
The visual pathway consists of structures that carry visual information from the retina to the brain. Lesions in that pathway cause a variety of visual field defects. In the visual system of human eye, the visual information processed by retinal photoreceptor cells travel in the following way:
Retina→Optic nerve→Optic chiasma →Optic tract→Lateral geniculate body→Optic radiation→Primary visual cortex
Polypoidal choroidal vasculopathy (PCV) is an eye disease primarily affecting the choroid. It may cause sudden blurring of vision or a scotoma in the central field of vision. Since Indocyanine green angiography gives better imaging of choroidal structures, it is more preferred in diagnosing PCV. Treatment options of PCV include careful observation, photodynamic therapy, thermal laser, intravitreal injection of anti-VEGF therapy, or combination therapy.