Effects of several coloured interventions on reading performance in age-related macular degeneration (ARMD)

A literature review revealed that very little work has been conducted to investigate the possible benefits of coloured interventions on reading performance in low vision due to ARMD, under conditions that are similar to the real world reading environment. Further studies on the use of colour, as a rehabilitative intervention in low vision would therefore be useful. A series of objective, subject based, age-similar controlled experiments were used to address the primary aims. Trends in some of the ARMD data suggested better reading performance with blue or green illuminance but there were also some individuals who performed better with yellow, or with illuminance of reduced intensity. Statistically, better reading in general occurred with a specialised yellow photochromic lens and also a clear lens than with a fixed lens or a neutral density filter. No reading advantage was gained from using the coloured screen facility of a video-magnifier. Some subjects with low vision were found to have co-existent binocular vision anomalies, which may have caused reading difficulties similar to those produced by ARMD. Some individuals with ARMD benefited from the use of increased local illuminance produced by either a standard tungsten or compact fluorescent lamp. No reading improvement occurred with a daylight simulation tungsten lamp. The Intuitive Colorimeter® can be used to detect and map out colour vision discrimination deficiency in ARMD and the Humphrey 630 Visual Field Analyser can be used to analyse the biocular visual field in subjects with ARMD. Some experiments highlighted a positive effect of a blue intervention in reading with ARMD.

Application of digital image processing techniques to the photometric testing of vehicle headlamps

The aim of this Interdisciplinary Higher Degrees project was the development of a high-speed method of photometrically testing vehicle headlamps, based on the use of image processing techniques, for Lucas Electrical Limited. Photometric testing involves measuring the illuminance produced by a lamp at certain points in its beam distribution. Headlamp performance is best represented by an iso-lux diagram, showing illuminance contours, produced from a two-dimensional array of data. Conventionally, the tens of thousands of measurements required are made using a single stationary photodetector and a two-dimensional mechanical scanning system which enables a lamp's horizontal and vertical orientation relative to the photodetector to be changed. Even using motorised scanning and computerised data-logging, the data acquisition time for a typical iso-lux test is about twenty minutes. A detailed study was made of the concept of using a video camera and a digital image processing system to scan and measure a lamp's beam without the need for the time-consuming mechanical movement. Although the concept was shown to be theoretically feasible, and a prototype system designed, it could not be implemented because of the technical limitations of commercially-available equipment. An alternative high-speed approach was developed, however, and a second prototype syqtem designed. The proposed arrangement again uses an image processing system, but in conjunction with a one-dimensional array of photodetectors and a one-dimensional mechanical scanning system in place of a video camera. This system can be implemented using commercially-available equipment and, although not entirely eliminating the need for mechanical movement, greatly reduces the amount required, resulting in a predicted data acquisiton time of about twenty seconds for a typical iso-lux test. As a consequence of the work undertaken, the company initiated an 80,000 programme to implement the system proposed by the author.

How accurate are photographic surrogate markers used to detect macular oedema in the english national Screening Programme?

Introduction: Macular oedema is not directly visible on digital photographs used in screening. Photographic surrogate markers are used to detect patients who may have macular oedema. Evidence suggests that only around 10% of patients with these surrogate markers referred to an ophthalmologist have macular oedema when examined by slit-lamp biomicroscopy. Purpose: The purpose of this audit was to determine how many patients with surrogate markers were truly identified by optical coherence tomography (OCT) as having macular oedema. Method: Data were collected from patients attending digital diabetic retinopathy screening. Patients who presented with surrogate markers for macular oedema also had an OCT scan. The fast macula scan on the Stratus OCT was used and an ophthalmologist reviewed the scans to determine whether macular oedema was present. Results: Out of 66 patients with maculopathy defined as haemorrhages or microaneurysms within one optic disc diameter (DD) of the fovea and visual acuity (VA) worse than 6/9 11 (17%) showed thickening on the OCT, only 4 (6%) had macular oedema. None required laser. Out of 155 patients with maculopathy defined as any exudate within one DD of the fovea or circinate within two DD 45 (29%) showed thickening on the OCT of these 27% required laser. Conclusion: OCT is a useful tool in screening to help identify those who need a true referral to ophthalmology for maculopathy. If exudate is present the chance of having macular oedema and requiring laser treatment is greater than the presence of microaneurysms within one DD and reduced VA.

How accurate are photographic surrogate markers used to detect macular edema in the English national screening programme?

DESIGN. Retrospective analysis PURPOSE. Macular oedema is not directly visible on two dimensional digital photographs such that surrogate markers need to be used. In the English National Screening Programme these are exudate within one optic disc diameter (DD) of the fovea, group of exudates within two DD of the fovea and haemorrhages or microaneurysms (HMA) within one DD of the fovea with best corrected visual acuity (VA) worse than 6/9. All patients who present with any of these surrogate markers at screening are referred to an ophthalmology clinic for slit lamp examination. The purpose of this audit was to determine how many patients with positive maculopathy diagnosis on photography were truly identified by optical coherence tomography (OCT) with macular oedema. METHODS. Data was collected from patients attending digital diabetic retinopathy screening. Patients who presented with surrogate markers for macular oedema also had an OCT scan. The fast macula scan on the Stratus OCT was used and an ophthalmologist reviewed the scans to determine whether macular oedema was present. RESULTS. Maculopathy by exudates: Of 155 patients 45 (29%) showed thickening on the OCT of these 12 required laser. Those who also had pre-proliferative retinopathy (n=20) were more likely to have macular oedema (75%) than those with background diabetic retinopathy. Maculopathy by HMA and VA worse than 6/9: Of 66 patients 11 (16.7%) showed thickening on the OCT. 5 (7.6%) of these had macular oedema, 5 (7.6%) epi-retinal membrane, and 1 (1.5%) age related macular degeneration. None of these patients required laser. CONCLUSIONS. The likelihood of the presence of macular oedema and requiring laser treatment is greater with macular exudation than HMA within one DD and reduced VA. Overall the surrogate markers used show low specificity for macular oedema, however combining OCT with photography does identify those with macular oedema who require a true referral for an ophthalmological slit lamp examination.

Design and validity of a miniaturized open-field aberrometer

PURPOSE: To validate a new miniaturised, open-field wavefront device which has been developed with the capacity to be attached to an ophthalmic surgical microscope or slit-lamp. SETTING: Solihull Hospital and Aston University, Birmingham, UK DESIGN: Comparative non-interventional study. METHODS: The dynamic range of the Aston Aberrometer was assessed using a calibrated model eye. The validity of the Aston Aberrometer was compared to a conventional desk mounted Shack-Hartmann aberrometer (Topcon KR1W) by measuring the refractive error and higher order aberrations of 75 dilated eyes with both instruments in random order. The Aston Aberrometer measurements were repeated five times to assess intra-session repeatability. Data was converted to vector form for analysis. RESULTS: The Aston Aberrometer had a large dynamic range of at least +21.0 D to -25.0 D. It gave similar measurements to a conventional aberrometer for mean spherical equivalent (mean difference ± 95% confidence interval: 0.02 ± 0.49D; correlation: r=0.995, p<0.001), astigmatic components (J0: 0.02 ± 0.15D; r=0.977, p<0.001; J45: 0.03 ± 0.28; r=0.666, p<0.001) and higher order aberrations RMS (0.02 ± 0.20D; r=0.620, p<0.001). Intraclass correlation coefficient assessments of intra-sessional repeatability for the Aston Aberrometer were excellent (spherical equivalent =1.000, p<0.001; astigmatic components J0 =0.998, p<0.001, J45=0.980, p<0.01; higher order aberrations RMS =0.961, p<0.001). CONCLUSIONS: The Aston Aberrometer gives valid and repeatable measures of refractive error and higher order aberrations over a large range. As it is able to measure continuously, it can provide direct feedback to surgeons during intraocular lens implantations and corneal surgery as to the optical status of the visual system.

Cataract, macular characteristics and assessing lens opacities

Age-related macular degeneration and cataract are very common causes of visual impairment in the elderly. Macular pigment optical density is known to be a factor affecting the risk of developing age-related macular degeneration but its behaviour due to light exposure to the retina and the effect of macular physiology on this measurement are not fully understood. Cataract is difficult to grade in a way which reflects accurately the visual status of the patient. A new technology, optical coherence tomography, which allows a cross sectional slice of the crystalline lens to be imaged has the potential to be able to provide objective measurements of cataract which could be used for grading purposes. This thesis set out to investigate the effect of cataract removal on macular pigment optical density, the relationship between macular pigment optical density and macular thickness and the relationship between cortical cataract density as measured by optical coherence tomography and other measures of cataract severity. These investigations found: 1) Macular pigment optical density in a pseudophakic eye is reduced when compared to a fellow eye with age related cataract, probably due to differences in light exposure between the eyes. 2) Lower macular pigment optical density is correlated with thinning of the entire macular area, but not with thinning of the fovea or central macula. 3) Central macular thickness decreases with age. 4) Spectral domain optical coherence tomography can be used to successfully acquire images of the anterior lens cortex which relate well to slit lamp lens sections. 5) Grading of cortical cataract with spectral domain optical coherence tomography instruments using a wavelength of 840nm is not well correlated with other established metrics of cataract severity and is therefore not useful as presented as a grading method for this type of cataract.

Factors affecting corneoscleral topography

PURPOSE: To evaluate factors affecting corneoscleral profile (CSP) using Anterior Segment Optical Coherence Tomography (AS-OCT) in combination with conventional videokeratoscopy. METHODS: OCT data were collected from 204 subjects of mean age 34.9 years (SD: ±15.2 yrs, range 18 to 65) using the Zeiss Visante AS-OCT and Medmont M300 corneal topographer. Measurements of corneal diameter (CD), corneal sagittal height (CS), iris diameter (ID), corneoscleral junction angle (CSJ) and scleral radius (SR) were extracted from multiple OCT images. Horizontal visible iris diameter (HVID) and vertical palpebral aperture (PA) were measured using a slit lamp graticule. Subject body height was also measured. Associations were then sought between CSP variables and age, height, ethnicity, sex and refractive error data collected. Results: Significant correlations were found between age and ocular topography variables of HVID, PA, CSJ, SR and ID (P<0.0001), while height correlated with HVID, CD and ID, and power vector terms only with vertical plane keratometry, CD and CS. Significant differences were noted between ethnicities with respect to CD (P=0.0046), horizontal and vertical CS (P=0.0068 and P=0.0095), and also horizontal ID (P=0.0010), while the same variables, with the exception of vertical CS, also varied with sex; horizontal CD (P=0.0018), horizontal CS (P=0.0018) and ID (P=0.0012). Age accounted for up to 36% of the variance in CSP variables. Conclusion: Age is the main factor influencing corneoscleral topography; consequently, this should be taken into consideration in contact lens design, in the optimization of surgical procedures involving the cornea and sclera and in IOL selection.

Talbot-like bands for a laser diode below threshold

We report on the problems encountered when replacing a tungsten filament lamp with a laser diode in a set-up for displaying Talbot bands using a diffraction grating. It is shown that the band pattern is rather complex and strong interference signals may exist in situations where Talbot bands are not normally expected to appear. In these situations, the period of the bands increases with the optical path difference (OPD). The visibility of bands as dependence on path imbalance is obtained by suitably obstructing halfway into the arms of a Michelson interferometer using opaque screens.

The relation between physical properties of the anterior eye and ocular surface temperature

PURPOSE. To examine the relation between ocular surface temperature (OST) assessed by dynamic thermal imaging and physical parameters of the anterior eye in normal subjects. METHODS. Dynamic ocular thermography (ThermoTracer 7102MX) was used to record body temperature and continuous ocular surface temperature for 8 s after a blink in the right eyes of 25 subjects. Corneal thickness, corneal curvature, and anterior chamber depth (ACD) were assessed using Orbscan II; noninvasive tear break-up time (NIBUT) was assessed using the tearscope; slit lamp photography was used to record tear meniscus height (TMH) and objective bulbar redness. RESULTS. Initial OST after a blink was significantly correlated only with body temperature (r = 0.80, p < 0.0005), NIBUT (r = -0.68, p < 0.005) and corneal curvature (r = -0.40, p = 0.05). A regression model containing all the variables accounted for 70% (p = 0.002) of the variance in OST, of which NIBUT (29%, p = 0.004), and body temperature (18%, p = 0.005) contributed significantly. CONCLUSIONS. The results support previous theoretical models that OST radiation is principally related to the tear film; and demonstrate that it is less related to other characteristics such as corneal thickness, corneal curvature, and anterior chamber depth. © 2007 American Academy of Optometry.

Comparison between graticule and image capture assessment of lower tear film meniscus height

Purpose: To compare graticule and image capture assessment of the lower tear film meniscus height (TMH). Methods: Lower tear film meniscus height measures were taken in the right eyes of 55 healthy subjects at two study visits separated by 6 months. Two images of the TMH were captured in each subject with a digital camera attached to a slit-lamp biomicroscope and stored in a computer for future analysis. Using the best of two images, the TMH was quantified by manually drawing a line across the tear meniscus profile, following which the TMH was measured in pixels and converted into millimetres, where one pixel corresponded to 0.0018 mm. Additionally, graticule measures were carried out by direct observation using a calibrated graticule inserted into the same slit-lamp eyepiece. The graticule was calibrated so that actual readings, in 0.03 mm increments, could be made with a 40× ocular. Results: Smaller values of TMH were found in this study compared to previous studies. TMH, as measured with the image capture technique (0.13 ± 0.04 mm), was significantly greater (by approximately 0.01 ± 0.05 mm, p = 0.03) than that measured with the graticule technique (0.12 ± 0.05 mm). No bias was found across the range sampled. Repeatability of the TMH measurements taken at two study visits showed that graticule measures were significantly different (0.02 ± 0.05 mm, p = 0.01) and highly correlated (r = 0.52, p < 0.0001), whereas image capture measures were similar (0.01 ± 0.03 mm, p = 0.16), and also highly correlated (r = 0.56, p < 0.0001). Conclusions: Although graticule and image analysis techniques showed similar mean values for TMH, the image capture technique was more repeatable than the graticule technique and this can be attributed to the higher measurement resolution of the image capture (i.e. 0.0018 mm) compared to the graticule technique (i.e. 0.03 mm). © 2006 British Contact Lens Association.

Optimization of anterior eye fluorescein viewing

Purpose: To optimize anterior eye fluorescein viewing and image capture. Design: Prospective experimental investigation. Methods: The spectral radiance of ten different models of slit-lamp blue luminance and the spectral transmission of three barrier filters were measured. Optimal clinical instillation of fluorescein was evaluated by a comparison of four different instillation methods of fluorescein into 10 subjects. Two methods used a floret, and two used minims of different concentration. The resulting fluorescence was evaluated for quenching effects and efficiency over time. Results: Spectral radiance of the blue illumination typically had an average peak at 460 nm. Comparison between three slit-lamps of the same model showed a similar spectral radiance distribution. Of the slit-lamps examined, 8.3% to 50.6% of the illumination output was optimized for >80% fluorescein excitation, and 1.2% to 23.5% of the illumination overlapped with that emitted by the fluorophore. The barrier filters had an average cut-off at 510 to 520 nm. Quenching was observed for all methods of fluorescein instillation. The moistened floret and the 1% minim reached a useful level of fluorescence in on average ∼20s (∼2.5× faster than the saturated floret and 2% minim) and this lasted for ∼160 seconds. Conclusions: Most slit-lamps' blue light and yellow barrier filters are not optimal for fluorescein viewing and capture. Instillation of fluorescein using a moistened floret or 1% minim seems most clinically appropriate as lower quantities and concentrations of fluorescein improve the efficiency of clinical examination. © 2006 Elsevier Inc. All rights reserved.

Grading of corneal transparency

Aim: To examine the academic literature on the grading of corneal transparency and to assess the potential use of objective image analysis. Method: Reference databases of academic literature were searched and relevant manuscripts reviewed. Annunziato, Efron (Millennium Edition) and Vistakon-Synoptik corneal oedema grading scale images were analysed objectively for relative intensity, edges detected, variation in intensity and maximum intensity. In addition, corneal oedema was induced in one subject using a low oxygen transmissibility (Dk/t) hydrogel contact lens worn for 3 hours under a light eye patch. Recovery from oedema was monitored over time using ultrasound pachymetry, high and low contrast visual acuity measures, bulbar hyperaemia grading and transparency image analysis of the test and control eyes. Results: Several methods for assessing corneal transparency are described in the academic literature, but none have gained widespread in clinical practice. The change in objective image analysis with printed scale grade was best described by quadratic parametric or sigmoid 3-parameter functions. ‘Pupil image scales’ (Annunziato and Vistakon-Synoptik) were best correlated to average intensity; however, the corneal section scale (Efron) was strongly correlated to variations in intensity. As expected, patching an eye wearing a low Dk/t hydrogel contact lens caused a significant (F=119.2, P<0.001) 14.3% increase in corneal thickness, which gradually recovered under open eye conditions. Corneal section image analysis was the most affected parameter and intensity variation across the slit width, in isolation, was the strongest correlate, accounting for 85.8% of the variance with time following patching, and 88.7% of the variance with corneal thickness. Conclusion: Corneal oedema is best determined objectively by the intensity variation across the width of a corneal section. This can be easily measured using a slit-lamp camera connected to a computer. Oedema due to soft contact lens wear is not easily determined over the pupil area by sclerotic scatter illumination techniques.

Refractive errors associated with tilted optic discs:a prospective study

Purpose: Tilted disc syndrome has been described to be associated with obliquely directed long axis of the disc, oblique direction of vessels, retinal pigment epithelial conus, hypoplasia of retina, visual field defects and myopic astigmatism. This prospective study looks at corneal astigmatism in eyes with a tilted optic disc. Refractive errors in these eyes were also analyzed. Methods: Patients with tilted optic discs were identified prospectively by clinical evaluation (BI, VK). All the patients with obliquely directed long axis of the disc, oblique direction of vessels and retinal pigment epithelial conus were included in the study. Best corrected visual acuity, slit-lamp examination, optic disc measurements, keratometry and refraction were recorded. Results: Twenty four patients (41 eyes) were recruited for the study. Eighteen (75%) patients had bilateral tilted optic discs. Eighteen patients (75%) were females and six (25%) were males. The mean age was 62 years(range 9 – 86 years). 76% of the patients were myopic and 24% hypermetropic. The mean spherical equivalent was –7.49 dioptres (SD 1.7D, range +6D to -17D). The mean corneal astigmatism was 1.09D (SD 0.9D, range 0.25D to 3.80D). The 6 patients who had unilateral, untilted discs were used as a control group to compare their mean corneal astigmatism (1.32 D) with the rest. Student "t" test was performed. ("p" = 0.49). Conclusions: In our study, tilted disc syndrome was found to be largely bilateral and more commonly seen in females. Myopia was the commonest refractive error associated with this clinical condition. However, 24% of patients in this series were hypermetropic. No correlation between the tilting of the optic disc and significant corneal astigmatism was noted as previously reported.

Optimal time following fluorescein instillation to evaluate rigid gas permeable contact lens fit

PURPOSE: To examine the optimum time at which fluorescein patterns of gas permeable lenses (GPs) should be evaluated. METHODS: Aligned, 0.2mm steep and 0.2mm flat GPs were fitted to 17 patients (aged 20.6±1.1 years, 10 male). Fluorescein was applied to their upper temporal bulbar conjunctiva with a moistened fluorescein strip. Digital slit lamp images (CSO, Italy) at 10× magnification of the fluorescein pattern viewed with blue light through a yellow filter were captured every 15s. Fluorescein intensity in central, mid peripheral and edge regions of the superior, inferior, temporal and nasal quadrants of the lens were graded subjectively using a +2 to -2 scale and using ImageJ software on the simultaneously captured images. RESULTS: Subjectively graded and objectively image analysed fluorescein intensity changed with time (p<0.001), lens region (centre, mid-periphery and edge: p<0.05) and there was interaction between lens region with lens fit (p<0.001). For edge band width, there was a significant effect of time (F=118.503, p<0.001) and lens fit (F=5.1249, p=0.012). The expected alignment, flat and steep fitting patterns could be seen from approximately after 30 to 180s subjectively and 15 to 105s in captured images. CONCLUSION: Although the stability of fluorescein intensity can start to decline in as little as 45s post fluorescein instillation, the diagnostic pattern of alignment, steep or flat fit is seen in each meridian by subjective observation from about 30s to 3min indicating this is the most appropriate time window to evaluate GP lenses in clinical practice.

An investigation to determine the influence of illumination sources on colour discrimination in normal subjects and smokers

Accurate colour vision testing requires using the correct illumination. With the plethora of 'daylight' lamps available, is there a cost-effective alternative to the discontinued MacBeth Easel lamp? Smoking is a known risk factor for macula degeneration. As the macula is responsible for colour discrimination, any toxin that affects it has the potential to influence colour discrimination. Aims: To find a costeffective light source for colour vision testing. To investigate the effect of smoking on colour discrimination. To explore how deuteranomalous trichromats compare with normal trichromats. Methods: Using the Ishihara colour vision test subjects were classified into the groups: 'Normal/Control', 'Smoker/Test', and 'Case Study' (subjects who failed the screening test and did not smoke). They completed the Farnsworth Munsell 100 Hue test under each of the three light sources: Phillips EcoHalo Twist (tungsten halogen - THL), Kosnic KCF07ALU/GU10-865 (compact fluorescent- CFL), and Deal Guardian Ltd. GU103X2WA4B-60 (light-emitting diode - LED) Results: 42 subjects took part in the study: 18 in the Normal/Control group, 18 in the Smoker/Test group, and 6 in the Case Study group. For the Normal/Control group the total error scores (TESs) were significantly lower with the CFL than with the THL (p = 0.017) as it was for the Case Study group (p = 0.009). No significant differences were found between the Normal/Control group and the Smoker/Test group for each light source. Decision tree analysis found pack years to be a significant variable for TES. Discussion: All three light sources were comparable with previous studies. The CFL provided better colour discrimination than the LED despite them both being 6500 K. Deuteranomalous trichromats showed a greatest deviation than normal trichromats using the LED. Conclusions: The Kosnic KCF07ALU/GU10-865 is a cost-effective alternative for colour vision testing. Smoking appears to have an effect on colour vision, but requires further investigation.