Textbook of

Visual Science
and
Clinical Optometry
 Textbook of
Visual Science
and
Clinical Optometry

Bikas Bhattacharyya MBBS (Honours), MS, DO

Consultant Eye and Laser Surgeon
Apollo Gleneagles Hospitals, Kolkata
Sambhu Nath Pandit Hospital, Kolkata
Wockhardt Medical Centre
Kolkata, West Bengal, India

Foreword
Debashish Bhattacharya

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Textbook of Visual Science and Clinical Optometry

© 2009, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author will
not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters
are to be settled under Delhi jurisdiction only.
First Edition: 2009
ISBN 978-81-8448-599-8
Typeset at JPBMP typesetting unit
Printed at
 To
My parents Prativa Bhattacharya and
Late Biresh Chandra Bhattacharya
along with
My parents-in-law
Geeta Roychowdhury and
Late Satyabrata Roychowdhury
 Foreword

Textbook of Visual Science and Clinical Optometry is a wonderful

knowledge book for the ophthalmic practitioners, optometrists and
students of ophthalmology.
This book explains the anatomy and physiology of the eye in
a very well-formatted concise manner. It enlightens the optical
defects and its correction in a most lucid and methodical way. In
the glamour of ophthalmic innovations, the fundamental optics and
refraction of the eye have become a forgotten territory.
I thank Dr Bikas Bhattacharyya for bringing out this book in
such a “transparent and structured format”. Bikas, 2 years junior
to me in Medical Education in the same University, is always
remembered for his unusual inclination to minute details and
documentation. This book is reflection of his qualities.
I am sure we will learn a lot of skills from this book and use
it for more efficient eye care. This will be the most fitting tribute
to the hard work that he has put into writing this book.

Dr Debashish Bhattacharya
Chairman
Disha Eye Hospital and Research Centre (P) Ltd
Barrackpore, West Bengal, India
 Preface

Textbook of Visual Science and Clinical Optometry is designed to cater

to the needs of eye care team which includes ophthalmologists,
ophthalmology residents, optometry students and ophthalmic
technicians.
The book includes 18 chapters which are divided into 6 sections
and each chapter is supplemented by numerous illustrations. Every
attempt is made to make this book as clinically relevant as possible.
Section 1 to 3 deal with the normal human eye and its optical
principle. Section 4 deals with the different types of refractive errors
and its correction. Section 5 stresses on the various optical lenses,
frames, measurements and contact lenses. Knowledge on these
topics (Section 5) is usually not covered in books on ophthalmology.
The last section is unique in a way as it covers three special
chapters on ophthalmic instrumentation techniques, low visual
aids and paediatric eye examination, which is invaluable to all
those involved in eye care.
I hope that my humble efforts would prove successful in helping
the beginners in ophthalmology. I have tried to make the topics as
comprehensive and simplified as possible. However, certain
inaccuracies may arise for which I apologise sincerely.
Any suggestions and comments on the book would be greatly
appreciated.

Bikas Bhattacharyya
e-mail: [email protected]
 Acknowledgements

During my residency training and subsequent practising years, I

felt the need of a comprehensive book covering all aspects of
practical ophthalmic examinations and clinical optics.
I would like to thank M/s Appasamy Associates, Chennai,
India for giving me the relevant photographs for publication.
I would also like to express my gratitude to Mr Sirajul Mullick,
Department of Optometry Science (DOS) for the invaluable
assistance he has extended to me during preparation of the chapters
related to clinical optometry.
I would like to convey my gratitude to M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi and all the technical staff.
I would also like to thank all my colleagues in different
institutions for their continued encouragement.
Finally, I would like to thank my wife and children for their
continued support and their patience for tolerating my
preoccupation with the book.
 Contents

SECTION 1: ANATOMY
1. ANATOMY OF THE EYEBALL ........................................... 3
i. Cornea ............................................................................................ 4
ii. Sclera ............................................................................................... 8
iii. Limbus ............................................................................................ 9
iv. Anterior Chamber ...................................................................... 10
v. Posterior Chamber ..................................................................... 12
vi. Uveal Tract ................................................................................... 12
vii. Retina ............................................................................................ 18
viii. Optic Nerve ................................................................................. 24
ix. Lens ............................................................................................... 25
x. Vitreous Humour ....................................................................... 27
xi. Blood Supply of Eyeball ........................................................... 28
2. ANATOMY OF APPENDAGES OF THE EYEBALL ..... 31
i. Conjunctiva .................................................................................. 31
ii. Eyelids ........................................................................................... 32
iii. Lacrimal Apparatus .................................................................... 36
iv. Muscles of the Eye ..................................................................... 38
v. Levator Palpebrae Superioris ................................................... 41
3. ANATOMY OF THE ORBIT ............................................... 43
i. Roof ............................................................................................... 43
ii. Medial Wall .................................................................................. 44
iii. Floor .............................................................................................. 45
iv. Lateral Wall .................................................................................. 45
v. Orbital Contents ......................................................................... 45
vi. Superior Orbital Fissure (Sphenoidal) .................................... 45
vii. Interior Orbital Fissure (Sphenomaxillary) ........................... 46
viii. Optic Foramen (Optic Canal) ................................................... 46
ix. Surgical Anatomical Spaces within the Orbit ....................... 47

SECTION 2: PHYSIOLOGY AND

NEUROLOGY OF VISION
4. PHYSIOLOGY OF THE OCULAR STRUCTURES ......... 51
i. Aqueous Humour ...................................................................... 51
ii. Vitreous Humour ....................................................................... 54
xiv Textbook of Visual Science and Clinical Optometry

iii. Cornea .......................................................................................... 55

iv. Lens ............................................................................................... 59
v. Tears .............................................................................................. 60
5. PHYSIOLOGY OF VISION ................................................. 64
i. Photochemical Changes ............................................................ 64
ii. Electrical Changes ....................................................................... 65
iii. Visual Perceptions (or Sensations) .......................................... 69
iv. Colour Sense ..................................................................... 76
6. THE NEUROLOGY OF VISION ........................................ 84
i. Visual Pathway ........................................................................... 84
ii. Pupillary Pathway ...................................................................... 86
iii. Pupillary Reflexes ....................................................................... 88
iv. Pupillary Reaction Disorders .................................................... 90

SECTION 3: LIGHT AND OPTICAL PRINCIPLES

7. LIGHT AND HUMAN EYE: BASIC OPTICAL
PRINCIPLES ............................................................................ 95
i. Light and Electromagnetic Spectrum ..................................... 95
ii. Basic Optical Principles of Human Eye ................................. 97
iii. Axes and Angles of the Eye .................................................. 101
iv. Optical Aberrations of the Eye ............................................. 102
v. Purkinje Images ........................................................................ 108
vi. Retinal Image ............................................................................ 109
8. ACCOMMODATION AND ITS ANOMALIES ............ 110
i. Accommodation ........................................................................ 110
ii. Insufficiency of Accommodation ........................................... 113
iii. Paralysis of Accommodation ................................................. 113
iv. Spasm of Accommodation ..................................................... 114

SECTION 4: REFRACTIVE ERRORS

AND CORRECTION
9. ERRORS OF REFRACTION ............................................... 119
i. Hypermetropia .......................................................................... 120
ii. Myopia ........................................................................................ 123
iii. Astigmatism ............................................................................... 127
iv. Anisometropia ........................................................................... 132
v. Aphakia ....................................................................................... 134
vi. Pseudophakia ............................................................................. 137
vii. Presbyopia .................................................................................. 139
 Contents xv

10. ESTIMATION AND CORRECTION OF

REFRACTIVE ERRORS ....................................................... 142
i. Retinoscopy ................................................................................ 142
ii. Autorefractometry .................................................................... 150
iii. Photorefraction .......................................................................... 150
iv. Subjective Refraction ................................................................ 150
v. Prescription for Spectacles ...................................................... 152

SECTION 5: PRACTICAL OPHTHALMICS AND

CLINICAL OPTOMETRY
11. MATERIALS—OPHTHALMIC LENS
AND SPECTACLE FRAME ................................................ 159
i. Ophthalmic Lens Materials ..................................................... 159
ii. Spectacle Frame Materials ...................................................... 163
12. OPHTHALMIC LENSES .................................................... 170
i. Spherical Lenses ........................................................................ 170
ii. Cylindrical Lenses ..................................................................... 173
iii. Unit of Lens Power ................................................................. 174
iv. Special Types of Lenses .......................................................... 175
v. Transposition ............................................................................. 178
vi. Neutralisation (Determination of Power of a Lens) ........ 179
13. COATINGS AND TINTS OF LENSES........................... 183
i. Antireflection Coating (AR Coating) ................................... 183
ii. Tints ............................................................................................. 187
iii. Photochromism ......................................................................... 188
iv. Hard Coating/Scratch Resistant Coating ............................ 190
v. Ultraviolet Inhibitors ................................................................ 191
vi. Water Resistant/Hydrophobic Coating ............................... 191
vii. Polaroid Lenses ......................................................................... 192
viii. Lens Care and Cleaning ......................................................... 193
14. FRAMES AND LENSES: DIMENSIONS,
MEASUREMENTS AND STYLES .................................... 194
i. Spectacle Frame Dimensions .................................................. 194
ii. Parts of a Frame ...................................................................... 195
iii. Common Terminologies Associated with Frame ............. 196
iv. Shapes of Frames ..................................................................... 196
v. Common Types of Frames .................................................... 197
vi. Special Types of Spectacle Frames ....................................... 198
vii. Informations Available from the Frame ............................. 198
viii. Lens Styles ................................................................................. 200
xvi Textbook of Visual Science and Clinical Optometry

ix. Optical Centre of Lens ............................................................ 207

x. Pupillary (or Interpupillary) Distance .................................. 207
xi. Vertex Distance ......................................................................... 210
15. CONTACT LENS ................................................................. 211
i. Indications .................................................................................. 211
ii. Advantages Over Spectacles .................................................. 212
iii. Optics of Contact Lenses ........................................................ 213
iv. Scleral Contact Lens ................................................................. 214
v. Semiscleral (or Soft or Hydrogel) Contact Lens ............... 215
vi. Corneal (or Rigid) Contact Lens .......................................... 216
vii. Fitting Procedures .................................................................... 217
viii. Contact Lens Related Informations and Terminologies .. 220
ix. Assessment of Soft Contact Lens Fitting ............................ 222
x. Assessment of Rigid Contact Lens Fitting ......................... 223
xi. Determination of Contact Lens Power ............................... 225
xii. Complications of Contact Lens Wear .................................. 226

SECTION 6: SPECIAL CHAPTERS

16. OPHTHALMIC INSTRUMENTATION .......................... 231
i. Slit-lamp Biomicroscope .......................................................... 231
ii. Tonometry ................................................................................. 244
iii. Gonioscopy ................................................................................ 250
iv. Indirect Biomicroscopy ............................................................ 258
v. Lens Measure (or Geneva Lens Measure) .......................... 263
vi. Keratometer (or Ophthalmometer) ...................................... 264
vii. Lensometer (or Focimeter) .................................................... 266
viii. Direct Ophthalmoscope ........................................................... 269
17. LOW VISION AND LOW VISUAL AID ....................... 273
i. Clinical Assessment of a Patient with Low Vision ........... 273
ii. Management of Patients with Low Vision ......................... 276
iii. Working Principle of Low Visual Aids ............................... 277
iv. Low Visual Devices .................................................................. 278
18. PAEDIATRIC EYE EXAMINATION ............................... 281
i. History Taking .......................................................................... 281
ii. Ophthalmic Examination Proper ........................................... 281
iii. Clinical Examination of the Eye Proper .............................. 287
iv. Milestones—Normal Visual Maturation and Reflexes ...... 288
v. Normal Visual Acuity Maturation (Age-related) ............... 289

Index ......................................................................................... 291

 Abbreviations

AC Anterior chamber
AC/A Accommodative convergence / Accommodation ratio
add Addition for near vision
ARC Abnormal retinal correspondence
ARMD Age-related macular degeneration
BE Both eyes
BIO Binocular indirect ophthalmoscopy
BOZD Back optic zone diameter
BOZR Back optic zone radius
BRAO Branch retinal artery occlusion
BRVO Branch retinal vein occlusion
BVP Back vertex power
CB Ciliary body
cd Candela
C/D Cup disc ratio
CF Counting fingers
CL Contact lens
CLARE Contact lens acute red eye
CME Cystoid macular oedema
CNV Choroidal neovascularisation
cpd Cycle per degree
CRAO Central retinal arterial occlusion
CRVO Central retinal vein occlusion
CR-39 Columbia Resin 39
Ct Carat
CVS Computer vision syndrome
D Diopter
DBL Distance between lenses
DBR Distance between rims
Dk Oxygen permeability
xviii Textbook of Visual Science and Clinical Optometry

Dk/t Oxygen transmissibility

ECCE Extracapsular cataract extraction
EOG Electrooculogram
ERG Electroretinogram
ERP Early receptor potential
EUA Examination under anaesthesia
EW Extended wear contact lens
FAZ Foveolar avascular zone
FM100 Farnsworth-Munsell 100 Hue test
ftcs Footcandles
FVP Front vertex power
GAG Glycosaminoglycans
GPC Giant papillary conjunctivitis
HEMA Hydroxyethyl methacrylate
HM Hand movements
ICCE Intracapsular cataract extraction
IO Inferior oblique
IOL Intraocular lens
IOP Intraocular pressure
IPD Interpupillary distance
IR Infrared, inferior rectus
J Jaeger type notation
KCS Keratoconjunctivitis sicca
KP Keratic precipitates
LE Left eye
LPS Levator palpebrae superioris
LR Lateral rectus
LVA Low vision aid
M Magnification
MAR Minimum angle of resolution
MR Medial rectus
N N system of notation
n Index of refraction
nm Nanometer
OD Oculus dexter, i.e. right eye
OKN Optokinetic nystagmus
OS Oculus sinister, i.e. left eye
 Abbreviations xix

OU Oculus uterque, i.e., both eyes

PAL Progressive addition lens
PAM Potential acuity meter
PAS Peripheral anterior synechiae
PD Pupillary distance
PL Perception of light
PMMA Polymethyl methacrylate
POAG Primary open-angle glaucoma
PVD Posterior vitreous detachment
PXF Pseudoexfoliation
RAPD Relative afferent pupillary defect
RE Right eye
RGP Rigid gas permeable contact lens
RPE Retinal pigment epithelium
SO Superior oblique
SR Superior rectus
TD Total diameter
TM Trabecular meshwork
UV Ultraviolet
V Abbé’s number/constringence/V-value, vision
VA Visual acuity
VEP Visual evoked potential
VER Visual evoked response
VKC Vernal keratoconjunctivitis
α Angle alpha
Δ Prism diopter
κ Angle kappa
λ Angle lambda; wavelength
∞ Infinity