ENTOPTIC PHENOMENA AND

ALLIED PHENOMENA
 ENTOPTIC PHENOMENA
• Visualisation of reproducible visual
perceptions arising from within the eye
• These sensations arising from the normal
intraocular structures(such as retinal blood
vessels) or sensations arising from opacities in
the ocular media
• It includes halos and phosphenes
ENTOPTIC PHENOMENA
• HALOS-entoptic visualisation of coloured ring
around small white light viewed from a
distance
• PHOSPHENES-glowing sensations which result
from inadequate retinal stimuli
• Factors which influence the entoptic visualisation
of opacities in the ocular media include
• Vergence of light within the eye
• Location of opacities within the eye relative to
photoreceptor layer
• Density of the opacities
• Refractive nature of the opacities
• Any object situated anterior to the
photoreceptor layer of the retina can be seen
entoptically , provided its optical density differs
from the surrounding media
• Any opacity within the entoptic field throws a shadow-
umbra,penumbral or both depends on transluency
and location of retina
• NON-TRANSLUCENT OPACITIES –opaque foreign
bodies of the cornea,pigment clumps on the anterior
surface of lens capsule,lenticular opacity,opaque intra
ocular foreign bodies,asteroid bodies and some
vitreous floaters
• It absorbs light, cast dense shadows and reduce the
amount of light reaching the retina
• When located anteriorly cause little disturbance in
vision even if they are large in size
• When situated posteriorly may cause positive scotoma
• TRANSLUCENT OPACITIES-Tear droplets and
mucus threads on the corneal surface, breaks
in descemets membrane,corneal scars,early
lenticular changes and vitreous floaters
• Scatter light and often damaging to vision
even when they are relatively small in size
ENTOPTIC PHENOMENA RELATED WITH THE
TEAR FILM AND CORNEA
• Tear droplets and mucus on the corneal
surface acts as convex lens and when viewed
by pinhole method are seen as bright spots or
bright lines surrounded by dark margins
• It moves up and down with the movements of
the lids when palpebral tissue is widened or
narrowed
 IRREGULARITIES OF THE CORNEAL SURFACE
AND CORNEAL SCAR
• With pinhole method of viewing, superficial
horizontal bands caused by wrinkling and
folding of the corneal epithelium seen in the
entoptic field as bright horizontal striae with
dark edges
• Following rubbing these striae convert into
irregular trelliswork pattern,from the irregular
wrinkling of corneal epithelium
 RELATED TO LENS
• Most have small opacities in the lens,do not
interfere with vision
• Under normal illumination ,lenticular imperfections
which are dense are not aware,they block rather
than scatter light
• Opacities anterior to the retina do not cause
shadows
• It is observed very easily by the pinhole method and
the vacoules,clefts and star figures readily perceived
• Psc opacities usually scatter &diffract light and
produces great visual disturbance and
annoyance
• They appear dark(RI is less) ang light(greater
RI)
 RELATED TO VITREOUS
• MUSCAE VOLITANTES(FLYING FLIES)-OR the
vitreous floaters resulting from small vitreous
opacities are most common
• Causes are senile vitreous degeneration and
pvd,vitreous haemorrhage,inflammatory cells
and exudates and myopic vitreous degeneration
• Opacities in posterior vitreous are annoying
because of large and more defined umbrae
• Vitreous floaters are hazy spots or specks, hair
like objects,single or chained globules, dark
lines or cob web meshwork
• It drifts away with movements of the eyes
• It becomes conspicious while staring at a
bright uniform background
• VF situated anterior to the centre of rotation
of eye ball appear entoptically to move against
the movement of eye ball,posterior moves
with the movement
RETINAL AND CHOROIDAL VESSELS
• RETINAL BLOOD VESSELS
• It lies anterior to the photoreceptors
• Purkinje for the first time noted if light thrown into the
eye at an unusual angle, either obliquely through the
cornea or sclera,so shadow falls upon a different set of
photoreceptors, the vessels become entoptically
visible
• The magnified shadows of the vascular network seen
surrounding the foveal avascular region are called as
purkinje figures
 METHODS
• TRANSILLUMINATION-it is commonly used
clinical test of retinal function
• A small flashlight is placed over the closed
eyelids near the outer canthus or directly on
the conjunctiva and is oscillated in position to
prevent local adaptation to the shadows of
retinal vessels
• Vascular tree is visualised in the presence of
dense opacities, it is used as a retinal test
• PIN HOLE DISC
• Better method
• In this,subject is asked to look at a bright
background through a pinhole disc kept in
motion infront of the eye
• Blood vessels are seen as dark branching lines
on a bright background
• Constant motion of pinhole avoids retinal
image stabilisation and vessels seen
continously
 Clinical applications
• It can be performed as retinal function test
• Has great value in the study of stabilised retinal image
• In measuring the foveal avascular zone
• Pulsations of retinal vessels visualised after physical
exercise.it is of two phases
• The first is of rapid expansion of the arterial tree which is in
synchronous with cardiac systole
• This is followed immediately by second phase which is
slower contractile motion and corresponding to the flatter
and more slowly moving descending limbs of the pulse wave
 RETINAL CAPILLARY CIRCULATION
• Movements of rbcs and wbcs across the retinal
capillaries can be perceived as luminous darting points
• It is used clinically as another method of measuring
the central avascular zone of the fovea
• In relaxed accomodation,when we look at a brightly
illuminated surface, it can be perceived as small
luminous dancing spots
• It has short tails like comets, which represent after
images
 CHORIOCAPILLARY CIRCULATION
• While gazing intently with relaxed
accomodation at any bright light,luminous
darting points are seen
• On continuing the gaze, these may disappear
and be replaced by darkened field in which
chorio capillary circulation is observed
• Effect lasts for few secs
 HALOS
• Coloured halos refer to entoptic visualization
of coloured rings around small white light
viewed from a distance
• It results from breaking of the white light into
seven colours by the various layers of cells of
the ocular media through which the light pass
to retina
• It can be physiological or pathological
 PHYSIOLOGICAL HALOS
• 3 diameter halo-it is least distinct of the four halos and
formed by corneal epithelial cells
• 4.5 diameter halo-it is one of the more distinct halos
and formed by corneal endothelial cells /lens
epithelial cells
• 6 diameter halo-most distinct and is formed by
diffraction of the light by the radially arranged lens
fibres
• Lenticular halo composed of innumerable radial rays
of varying lengths and brightness,each ray being a
complete six coloured spectrum
LENTICULAR HALO
• All the rays combine to form a halo composed
of concentric coloured rings
• In the centre, there is a disc of white called
the ciliary corona
• 9 diameter halo-very indistinct halo and
believed to be a second order of diffraction
from the structures that produce 4.5 halo
CILIARY CORONA
 PATHOLOCIGAL HALOS
• COLOURED HALOS OF CORNEAL EDEMA
• It is caused by edema of the deeper layers of the corneal
epithelium
• Vivid halos are produced either from the droplets of fluid
between the cells or from the cells swollen with fluid
• It is associated with raised intraocular pressure and halo
formation may wax and wane with elevation and
lowering of IOP
• Other causes are bullous keratopathy and ultraviolet
keratopathy.diameter is about 7-12
• COLOURED HALOS OF CORNEAL MUCUS
• Seen in patients with conjunctivitis are
produced by mucus or pus or particulate
matter on the corneal surface
• It disappears immediately on cleaning .the
surface diameter is large-12-14
COLOURED HALOS OF IMMATURE CATARACT

• Lenticular halos are distinct,but smaller

• EMSLEY-FINCHAM STENOPAEIC –SLIT TEST
• In this test,an open slit 1mm wide is passed
infront of the pupil from right to left
• During this test, halos due to corneal edema
remain intact while lenticular halos broken
into segments
• SIMSON PIN HOLE TEST
• It is done by replacing stenopaeic slit with a
2mm pin hole
• As the pin hole cannot illuminate more than
small section of the grating at any time,the
complete halo cannot be seen
 PHOSPHENES
• Glowing sensations produced by non photic or
inadequate stimuli
• SELF-ILLUMINATION
• Refers to the sensation of greyness or of light
experienced by an individual, when the eyes are
kept in dark and dark adaptation is complete
• It arises from both retina and cortex and is
called self light of eye
• MECHANICAL OR PRESSURE PHOSPHENES
• Sensations produced by pressure on the eye
ball
• PURKINJE BLUR RING OF GENTLE PRESSURE
• Very bright ,well circumscribed ring of blue –
white used by a direct pressure effect on the
sensory retinal elements in the dark adapted
eye
• It occurs in opposite periphery,immediately
following pressure on the eye ball
• FRIEDMANS BLUE RING OF PROLONGED
PRESSURE
• Broad ,circular band of blue colour produced
by a prolonged digital pressure over the eyes
• The centre is oval and devoid of colour
• Measured from fixation point it extends about
2 above and below and about 3 on each side
• It is due to ischemia
• FERY RINGS OF PURKINJE
• Dark grey or pale blue oval area ringed by a bright
blue-white border which appears in the region of
blind spot when eye ball is turned ,while staring at
an evenly illuminated object

It is produced by stimulation of retina adjacent to

optic disc,through traction of optic nerve
• Similar can be produced in peripheral retina by
more extensive eye movements which are caused
by retinal stimulation due to scleral traction of
muscle insertion
• ACCOMMODATE PHOSPHENES OF CZEMARK
• This is produced by peripheral retinal
stimulation by pull on the ora serrata by the
contracting ciliary muscle during a sudden
movement of accomodation
• Produced by strenous exercise and
mechanical movements of detached retina
• FLICK PHOSPHENE OF NEBEL
• It is a short-lived ,bright,sheaf like patterned
phosphene which occurs when the fully dark
adapted eyes are rapidly rotated
• Seen simultaneously and are two separate images
• It is said that it originates from an instantaneous
transient deformation of posterior surface of
vitreous close to optic disc
• Occurrence represents an early stage of posterior
vitreous degeneration
• This rapid eye movement phosphenes occurs in
individuals over 40 yrs of age
 MOORES LIGHTNING STREAKS
• Flashes of light seen on the temporal field of
vision are vertical in direction
• It is accompanied by simultaneous
development of opacities in vitreous
• Patient subjected to thorough vitreal and
retinal examination upto ora serrata
• It is probably due to vitreous detachment
 NON SPECIFIC LIGHT FLASHES
• Similar to moores but do not have specific
pattern
• It is related to VD,VRT,retinal hole,retinal
detachment
• Thorough vitreoretinal examination to be
done
PATTERENED ELECTRICAL PHOSPHENES

• It is observed with passage of weak electrical

currents through the eye
• It is beautiful,coloured pattern seen when
most of retina was uniformly illuminated and
subjected to alternating electric current
• It arises proximal to the receptors and used to
study the integrity of conduction pathway
 RADIATION PHOSHENES
• Appear with the passage of x -rays or other
ionizing radiations through the retina
• X irradiation phosphene described as
homogenous ,luminous blue green or yellow
green glow filling the visual field
• It is only perceived if eye is capable of
perceiving light and intact central visual
pathway
 LIGHT ENERGY INDUCED
• BLUE ARCS OF THE RETINA
• It is perceived as two blue-colored arcswhich
radiate from a fixation point and converge to
blind spot
• Areas correspond to parafoveal arcuate pathway
• It is perceived by observer when in a dark room,
he fixates a point slightly to temporal of small
source of light
• It may be reinforced following moderate light
adaptation, where arcs degenerates in
prolonged dark adaptation
• If upper edge of light is fixated,only lower arc
appears and converse
• Fixation on nasal side of source produce a blue
haze b/w area where upper and lower arcs
appeared-BLUE SPIKE
• Mostly it occurs from secondary excitation of
adjacent retinal nerve fibers or neurons of
active nerve fibers
 HAIDINGERS BRUSHES
• It is an entoptic phenomenon perceived by a normal
eye while observing a surface illuminated by plane-
polarised light
• It appears as faint yellow and blue brush like pattern
radiating from fixation point with their long axis
oriented at rt angles to transmission plane
• Method is to look at background of diffuse blue light
through a sheet of polariod
• It is due to variations in absorption by oriented
macular pigment in foveal region
• It detects early changes in macula such as
edema before occurrence of visual
disturbances
• Used in diagnosis and treatment of binocular
supression scotoma in some forms of
esotropia
• Used in study of stabilized retinal images and
birefringency of eye and cornea
 MAXWELL SPOT
• It is an entoptic phenomena in which an
observer sees a circle surrounded by a blue
halo in intermittent diffuse blue light
• It occurs at point of fixation
• Represent visualization of pigment
xanthophyll within central fovea
• It is also related to fact that central fovea is
devoid of blue color receptors
 STILES-CRAWFORD EFFECT
• Pencils of light entering the eye obliquely are less
effective as stimuli than those entering pupil centrally
• It is due to orientation of receptors in the retina
• Directional sensitivity of retina is referred as stiles-
crawford effect
• It provides evidence of retinal contuors in myopia
• In some myopia,macula stops in posteronasal
direction,in this cones within temporal fovea are
stimulated head on where as nasal fovea stimulated
obliquely
 AFTER IMAGES
• It refers to the visual sensations experienced
following cessation of stimulation of the eye
by light or patterns of light and dark
• It is not an entoptic phenomoenon
• it arises from outside, in contrast to the
entoptic phenomenon which arises from
within the eye
• It was studied comprehensively by purkinge
 TYPES OF AFTER IMAGES
• POSITIVE VERSUS NEGATIVE AFTER IMAGES
• POSITIVE AFTER IMAGE-visualised similar to
the original stimulus –dark areas of the
stimulus appear dark and light areas appear
light
• NEGATIVE AFTER IMAGE-It is reversed-light
areas of the stimulus appear dark and dark
areas appear light
• HOMOCHROMATICVS COMPLEMENTARY
• Homochromatic after image- same colour as the
stimulus
• Complementary-it is of the colour complementary to the
colour of the stimulus
• VISUALISATION OF AFTER IMAGES
• NEGATIVE-these can be observed after staring for a few
moments at a bright source of light snd then transferring
the gaze to a dimly illuminated even background
• A dark image of the light will be seen surrounded by a
light illuminated field.
• A coloured stimulus will be seen in its complementary
colour
• It fades in about 15 secs but can can usually be brought
back ultimately prolonged for a minute, if the yes are
repeatedly closed for a few seconds and reopened
• POSITIVE-it can be visualised staring at a dark pattern
in very bright light for only 2-3 sec and then occluding
the yes
• A faint positive pattern similar to the original can be
seen with closed eyes for about 5-10 secs since they
are more transient
• Classical method for study of after images is with the
help of disc of bidwell. It produces afetrimageru known
as bidwells ghost
 FACTORS AFFECTING NATURE OF AFTER
IMAGES
• Nature and intensity of stimulus
• Occurrence of succeeding stimuli
• Region of the retina stimulated
• State of retinal adaptation
• It arises due from photochemical reactions in the
retina
• Bielschowskys after image test and the after image
transfer test are used clinically in the diagnosis of
retinal correspondence