All the different methods of color vision assessment and lacrimal apparatus assessment are provided in these set of slides.

1. COLOUR VISION TESTING &
EXAMINATION OF LACRIMAL
APPARATUS

2. Type of colour vision test
• Pseudoisochromatic (PIC) plate tests
• Most commonly used tests,
• Easily and rapidly administered.
• Designed to screen for the presence of red-green inherited
color vision defects.
1. Ishihara Plates
2. American Optical Hardy-Rand-Rittler Plates
3. Standard Pseudoisochromatic plates
4. City University test

3. Ishihara test
• Comes in three different forms: 16 plates, 24 plates, and
38plates.(10th edition)
• Plates should be held at 75 cm under good illumination .
• Numerals should be answered in not more than 3 sec
• Pathway tracing should be completed within 10 sec.
• Designed in four ways
1st plate-
for demonstration and malingerers

4. Transformation plate
• 2-9 plates
– A number seen by a colour normal appear different to colour deficient
subject.

5. Vanishing plate
• Plate no. 10-17th
• A number is seen by a colour normal but cannot be seen by a colour
deficient subject.

6. Hidden-digit plates
• (18-21)plate- normal person does
not see a figure while a CVD will
see the figure.
Diagnostic plates
• (22-25)plate- seen by normal
subjects, CVD one number more
easily than another.
• Protans only see the no. on the
right side and deutans only see
the no. on the left.

7. • Out of initial 21 plates, if 17 or more plates are
read correctly by an individual his colour sense
should be regarded as normal.
• If 13 or less plates are correctly read then the
person has a red-green colour defect.
• Plates 22 to25 are for differential diagnosis of
Protans and Deutans.
• Disadvantage of this test is that it neither test
for tritanope nor grade the degree of
deficiency

8. American optic hardy rand ritter
• There are plates with paired vanishing designs
• Contain geometric shapes (circle, cross and triangle)
• Shape is in neutral colours on a background matrix of grey dots.
• Six plates for screening (four red-green and two tritan),
• 10 plates for grading the severity of protan and deutan defects
• Four plates for grading tritan defects
• Ideal for paediatric testing of congenital colour blindness

9. CITY UNIVERSITY COLOUR VISION TEST
• 10 Plates ,35 cm,daylight,right angle.
• Where a centre coloured plate is to be matched to its closest hue
from four surrounding colour plates.
• Three peripheral colours are typical isochromatic confusions with
the central colour in colour deficiency.
• The fourth colour is an adjacent colour in the D15 sequence and is
the intended normal preference
• Identifies moderate and severe colour deficiency only.

10. Arrangement test
• Easily administered
• Useful for both inherited and acquired color defects.
• Results permit diagnosis of the type of defect, and may be
analyzed quantitatively for assessment of severity.
1. Farnsworth-Munsell 100 hue test
2. Farnsworth-Munsell Dichotomous D-15 or Panel D-15 test
3. Lanthony Desaturated D-15
4. Adams Desaturated D-15

11. FARNSWORTH- MUNSELL 100 HUE
TEST:
• Very sensitive reliable and effective method
of determining colour vision defect.
• The test consists of 85 movable colour
samples arranged in four boxes of 22 colours
• Subject has to arrange 85 colour chips in
ascending order.
• The colour vision is judged by the error
score.

12. • The results are recoded in a circular graph
• The Farnsworth-Munsell Hue Test Scoring Software has been
developed to speed up and simplify scoring of the FM 100 Hue
test and to provide a powerful set of analytical and administrative
tools

13. FARNSWORTH- MUNSELL D-15 HUE
TEST –
– Abridged version
– Patients are asked to
arrange 15 coloured caps in
sequential order based on
similarity from the pilot
colour cap
– Intended for screening color
vision defects only.
– Used to detect color vision
defects such as red-green
and blue-yellow deficiencies
as opposed to color acuity.

14. HOLMGREN’S WOOL TEST
 The subject is asked to make a
series of colour matches from a
selection of skeins of coloured
wools.

15. Spectral anamaloscope
• Accepted as the most accurate for diagnosis
• unlike most other tests,they require a fair amount of skill on the
part of the examiner.
1. Nagel anomaloscope
2. Oculus HMC (Heidelberg Multi Colour) anomaloscope
3. Neitz anomaloscope
4. Pickford-Nicolson anomaloscope

16. NAGEL’S ANAMALOSCOPE
• GOLD STANDARD
• Extraordinarily sensitive.
• In this test the observer is asked to mixed red and green colours in such
a proportion that the mixture should match the yellow colour disc.
• Indication of defect is relative amount of red and green required.

17. • The mixture field
• Upper half of the bipartite field
• Composed of a mixture of two wavelengths - 670 nm (red) and 546 nm
(green)
• Patient adjusts the relative mix of these two colors using a control knob
that ranges from a value of 0 for pure green to 73 for pure red.
• Total luminance remains constant for all mixture settings.
• For a normal trichromat (with normal a V(λ) function), the brightness will
appear constant for all settings.

18. • The test field
• Lower half
• One fixed wavelength - 590 nm (yellow) light
• Luminance is adjustable from a scale of 0 (dim) to 35
(bright)
• Protanope match either a 546-nm or 670-nm light to
a 590-nm light by adjusting their relative
brightnesses
• Deuteranope can also be fooled into incorrectly
matching those hues with 590-nm without much
change in brightness

19. • Consider deuteranomalous trichromats as being
“green-weak.” to compensate, they will tend to add
more green to the mixture than normal.
• Consider protanomalous trichromats as being “red-
weak.” To compensate, they will tend to add more
red to the mixture than normal.
• As described above, protans will make abnormal
brightness settings.so it helps to differentiate
between protanomalous versus deuteranomalous
trichromats.

20. Graphic
representation of
diagnostic results
obtained with the
nagel
anomaloscope
showing different
matching ranges
and yellow
luminance values
in protan and
deutan colour
deficiency

21. • Occupational tests
• same as those used clinically (PIC and
arrangement tests),
• special tests designed for particular vocational
requirements.
• Lantern test
1. Edridge-Green Lantern
2. Farnsworth Lantern
3. Holmes-Wright Lantern
4. Martin Lantern

22. LANTERN TEST
• Vocational tests to select applicants for occupations in the transport
industries that required signal-light identification
• The test is performed in a dark room at 6 meters distance
• It has five rotating discs
• Disc 1 – aperture sizes varies 1.3 to 13 mm.
• Disc 2-4 – Eight colour filters (2 red, 2 green, white, yellow, blue,
Purple)
Fransworth lantern
Edridge green lantern

23. • Disc 5 – a clear aperture, 5 neutral density filters, a
ribbed glass
(simulate rain), frosted glass (simulate mist)
• Recommendations of the test state that a candidate
should be
rejected if he calls:
• Red as Green
• Green as Red
• White light as Green or Red or vice versa
• Red-Green or White light as black

24. DIAGNOSTIC EVALUATION OF
LACRIMAL SYSTEM
Diagnostic evaluation should include:
1. Quantification of tear production
2. Assessment of nasolacrimal system patency
3. Differentiating epiphora from lacrimation
4. Defining the pathological process of epiphora
5. Differentiating anatomical from functional
obstruction
6. Attempting to locate the obstruction in order to
define the optimal surgical approach

25. Classification of Tests for lacrimal
drainage pathway
• Anatomical tests
• Functional tests
• Secretory tests
Anatomical tests:
These tests are performed to locate the probable area of lacrimal
tract obstruction. These tests include:
• Palpation of lacrimal sac
• Syringing / irrigation
• Diagnostic probing
• Dacryocystography
• Nasal examination
• CT / MRI

26. Functional tests
• These are performed to access the function of
lacrimal apparatus under physiologic conditions.
• This test is performed if there is no obstruction as
evidenced by negative anatomical tests.
• These tests include:
1) Flourescein dye disappearance test
2) Scintigraphy
3) Jones dye test I
4) Sacharin test

27. Tests of secretion
• These tests are performed to assess secretory
function of the lacrimal apparatus.
• These tests are performed in examining dry eyes.
• These tests include:
1) Schrimers test
2) Bengal Rose test
3) Tear-film break up
4) Tear lysozyme

28. Inspection and palpitation
• 1. Eyelids
• 2. Medial canthus
• 3. Palpation of lacrimal sac
Eye lid examination:
• Look out for lower eyelid laxity
• Ectropion
• Punctal eversion
• Trichiasis
• Blepharitis

29. Snap-back test
• This test is performed by pulling the lower eye lid down
and away from the globe and held for several seconds.
• On release the lower lid resumes its normal position.
• The time taken for resumption of normal position is
noted.
• The patient should not blink during the test.

30. • This test provides an assessment of laxity of lower lid.
• The longer it takes for the lower lid to spring back to
position the more lax it is.
• This test is graded on a scale of 4 starting from 0. 0=
normal and 4= lax lower lid.
• Medial canthal laxity
• Lateral canthal laxity
• Orbicularis oculi muscle tone check

31. Dye excretion tests
• These tests help in ascertaining drainage functions and
patency of the entire nasolacrimal system.
• Fluorescein dye is used for this purpose.
• This test is considered to be more physiological since
the lacrimal system is not instrumented and the dye
flows along with tears through the normal passages.
• The principle of this test is evaluation of residual
fluroescein dye in the eye following instillation of one
drop of it into the unanaesthetized conjunctiva.
• Caution: This test does not distinguish anatomical from
functioning defects.

32. • In performing this test one drop of 1%
fluorescein is instilled into the lower fornix of
each conjunctival sac.
• After 5 mins, the thickness of fluorescein of
the tear meniscus is measured using cobalt
blue filter.
• Studies reveal that it takes 5 mins for tears to
normally drain through the system.
• This test can safely be performed in infants
and children.

33. • Presence of fluorescein gives no information
on the localisation of obstruction.
• Presence of residual fluorescein is an
indication for probing and syringing.
• When performing this test in infants the child
should be held in a vertical position.

34. Dye test grading
• 0=No fluorescein in the conjunctival sac
• 1=Thin flurescing marginal tear drop persists
• 2=More fluorescein persists somewhere between 1
and 3 grades
• 3=Wide brightly fluorescein tear strip.
Among these grades 0 and 1 are considered normal
False negatives can occur in:
1. Large lacrimal sac.
2. Mucocele.
3. Distal nasolacrimal duct block.

35. Jones dye tests
• This group of tests are used to distinguish between
functional and anatomic outflow problems.
• The primary test is performed by placing topical anesthetic
and flurescein dye into the conjunctival sac.
• Topical 4% xylocaine and oxymetazoline nasal sprays may
be used to anesthetize and vasoconstrict the inferior
meatus of the nose.
• A cotton tipped applicator is placed beneath the inferior
turbinate near the opening of the nasolacrimal duct.
• Recovery of fluorescein dye in the nose indicates a
functionally and antomically patent system.
• Non recovery of the dye (negative result) suggests a
functional or anatomic blockage.

36. • In the event of negative dye test, secondary dye
test should be performed.
• This test is performed after removal of residual
fluorescein from the conjunctival sac.
• Clear saline solution is placed into the inferior
canaliculus using a syringe / cannula.
• The irrigant is retreived from the nasal cavity by
tilting the patient's head forward over a basin.
• If fluoresein dye is present in the irrigant (positive
result) then it is assumed that the upper lacrimal
system is functional while the lower system is
partially open and is not functional.
• Recovery of a clear irrigant (negative result)
indicates a functional problem with the upper
system.

37. Diagram showing primary Jones test

38. Saccharin test
• This test is more or less similar to fluorescein dye
test.
• This test is also hence physiological.
• A drop of saccharin is placed into anesthetized
conjunctival sac and the time taken for the
patient to taste saccharin is measured.
• Approximate time is about 3.5 mins.
• The flip side in this test is that the patient should
have normal taste sensation.

39. Diagnostic probing and lacrimal
syringing
• These are invasive tests.
• They provide valuable information on location of
obstruction.
• They establish diagnosis of anatomical obstruction in
the lacrimal system.
• This test is virtually useless in functional obstruction.
• Syringing / irrigation of lacrimal system is not a
physiological test since the pressures used is more
than the normal pressure of lacrimal system.
• Hence this test should be interpreted with
fluorescein dye test and clinical examination.

40. Procedure
1. Topical 4% xylocaine drops applied to the
conjunctiva.
2. Punctum dilator is used to dilate the punctum
and ampulla.
3. A blunt cannula is placed in the inferior
canaliculus.
4. The lower eyelid is pulled down to straighten the
inferior canaliculus.
5. Superior canaliculus is gently stretched laterally
prior to irrigation.

41. 6. Tip of the irrigator is placed in the inferior
canaliculus, first vertically and then
horizontally with the eyelid on stretch.
7. The tip is advanced 3-7 mm into the
canaliculus and sterile saline is injected.
8. It is important to avoid forced irrigation to
avoid damage to the canaliculi.

42. Interpretation
• Regurgitation of irrigated saline through the
opposite punctum indicates an obstruction in the
common canaliculus or more distal structures.
• Regurgitation of fluid via the same canaliculus
indicates punctal obstruction and syringing
should be repeated via the opposite canaliculus.
• Irrigation into the nose indicates normal
drainage function.
• It does not rule out functional obstruction.

43. Probing (Diagnostic)
• This test should be performed if syringing test indicate
obstruction and the location of the obstruction is to be
ascertained.
• Obstruction can be located in the canaliculi and their
assessment is vital in deciding the mangement modality in
these patients.
• If irrigated fluid regurgitates through opposite punctum
obstruction of common canaliculus or more distally is
possible.
• The exact site in this scenario could be ascertained by
careful probing of the entire system.
• Probing can be performed using blunt Bowman's probe
which come in various sizes.

44. Procedure
• After instilling topical anesthetic drops into the conjunctiva
the punctum is dilated using lacrimal probe.
• The probe is then passed vertically and then horizontally
with the eyelid in stretch till the lacrimal bone is
encountered or soft obstruction is reached.
• If the probe encounters lacrimal bone then it is known as
hard stop.
• This is actually normal.
• If the probe encounters obstruction then it is
• known as soft stop.
• If irrigation showed reflux through the opposite punctum
and the probe encounters hard stop then obstruction could
be at the level of lacrimal sac or nasolacrimal duct.

45. Interpretation of irrigation and
probing results
Liquid in
nose/pharynx
Reflux into
lower
canaliculus
Reflex into
upper
canaliculus
Result
Hard stop Yes No No Normal
No No Yes Nasolacrimal
duct stenosis
No No No Subsaccal
obstruction
Soft stop No Yes No Medial
canalicular/
Common
canalicular
block
No No Yes Distal common
canalicular
block

46. HARD STOP

47. SOFT STOP

48. Secretory tests
• These patients are useful in evaluating those with complaints of dry eye.
Schirmer's test: (basic lacrimation)
• This test is basically prepared to quantitate tear production.
• This test is performed by placing strips of white filter paper 35x5 mm at
the junction of the middle and lateral thirds of the lower eyelids after
administration of a topical anesthetic agent.
• The tear production is measured with the eyes closed.
• Produced tears will wet the filter paper.
• The length of the filter paper which becomes wet is assessed at the end
of 5 minutes.
• Normal test result is between 10mm and 30 mm of wet filter paper.
• Normally it should not exceed 30 mm.
• A value of more than 30 mm is considered to be epiphora.
• A value of less than 10 mm is considered to be dry eye (hyposecretion).

49. schirmer's test

50. Cotton thread test
• Otherwise called as phenol red thread test also.
• Anesthetic not required for this test.
• Instruct the patient to look up and gently place the bent portion of
the thread at the 1/3rd distance from the lateral to the nasal
canthus.
• Ask the patient to keep the eyes open and blink normally.
• Remove after 15 sec. and measure the wetted area with a scale in
mm readings.
• Wetting of 10 to 20mm is considered normal.

51. Breakup time test
• This test indicates function of mucin layer / reflex hypersecretion of aquous
component of the tears.
• One drop of fluorescein is instilled into the external canthus of a lower lid and the
patient is instructed to blink once and then to keep his eyes open.
• The holes developed in the tear film are observed at the cornea through a slit-
lamp with illumination through the cobalt filter.
• The normal breakup time should be approximately 15–30 sec.
• A break-up time of less than 10 s indicates a deficiency and the dryness should be
treated with libricating eye drops .
• If the tear film consistently breaks up in the same location, its indicative of corneal
epithelial defect rather than a tear deficiency.

52. Bengal Rose test
• This test is also similar to that of Break up
time test.
• One drop of Bengal Rose dye is placed in the
conjunctiva and the patient is instructed to
blink several times within a minute.
• Interpalpebral staining is seen in patients with
dry eye.