Entoptic phenomena

1. Entoptic Phenomena
• Optometry 662, Spring 2010
• Pacific University College of Optometry
• James Kundart, O.D., M.Ed., F.A.A.O.
http://www.migraine-
aura.org/content/e27891/e27265/e42285/e42442/e54887/in
dex_en.html

2. Focus Questions
1. Why do we see the Purkinje Tree under the slit lamp, but
not in the sunshine?
2. Why are “flying corpuscles” better described as “flying
spots?”
3. Which entoptic phenomena can be used by an observant
patient to monitor glaucoma? Which can be used to
monitor diabetic retinopathy?
3. What part of the retinal causes the polarization
responsible for the Hadinger Brush effect?
4. What is Maxwell’s spot? When is it seen?

3. What Are Entoptic Images?
• “Visual perceptions that are produced or
influenced by native structures in your own
eyes” are entoptic phenomena
• For example, you have all seen your retinal
vessels when sitting for slit lamp exams. This
is called the Purkinje tree.
• Why don’t you see it all the time?
• Why should you care?
• We will answer these question today

4. Why Haven’t I Heard
About This Before?
• It’s not just because you are second years! Hart and
Westheimer (in Adler) say:
– “Because of their subjective nature, entoptic phenomena
require a savvy, articulate patient to observe and describe
them.”
• They also can’t be photographed, so I can only show you
drawings
• We will cover these phenomena from anterior to posterior
eye structures
• Because entoptic phenomena improve your understanding of
the physiology of vision and visual perception, and can
sometimes be used to monitor ocular disease

5. Some Entoptic Phenomena
1. Corneal Mosaic
2. Physiologic Halos
3. Vitreous Floaters
4. Retinal Phosphenes
5. Purkinje Tree
6. Flying Spots
7. Blue Retinal Arcs
8. Haidinger’s Brushes

6. 1) Corneal Mosaic
• You have seen what sodium fluorescein
looks like on the tear film of your
classmates, and the corneal epithelium by
now
• Did you know you can see your own corneal
mosaic without a slit lamp?
• If a small (0.1 mm) pinhole is placed at the
spectacle plane (17 mm in front of the eyes)
and backlit, you can see your own tear film,
and irregularities in the cornea
• The resulting image is limited in size by the
pupil, not the pinhole

7. Imagining the
Corneal Mosaic
Adler, figure 16-4
Corneal Guttata
http://www.flickr.com/photos/12212056
@N04/2035013811/

8. What Can Be Seen with the Pinhole
Technique?
• According to Adler, folds in corneal
epithelium appear as horizontal bands
• Excessive oil or mucus in the tear film look
like bright blobs surrounded by a dark ring
which “swim” up and down on blink
• Shallow, linear channels made by ridges in
Bowman’s membrane can be seen with
sodium fluorescein, as are sometimes
caused by contact lens wear

9. Endothelial Dystrophy
and the Corneal Mosaic
http://www.opt.pacificu.edu/ce/catalog/10603-AS/Cornea.html
http://www.flickr.com/photos/jrmod/221356083/

10. Tattooing the Cornea
• What is the treatment for symptomatic partial
corneal scarring where transplants
(penetrating keratoplasty or DSEK) are not
available?
• With a translucent scar, patient symptoms
would decrease when the scar was made
opaque by surgical tattoo of the cornea
• This is because a true opacity reduces the light
that reaches the retina, but does not reduce
overall contrast like a translucent defect does
• “Special pigments can be embedded in the
cornea to hide corneal scars and to block light
from entering the eye through iris defects”
http://www.michigancornea.com/tech_Iris.htm

11. 2) Physiologic Halos
• You may have learned about pathologic
halos, such as those from a steamy,
edematous cornea, from contact lens
overwear or ocular hypertension
• Physiologic halos are different -- they are
colored rings from chromatic aberration
caused by the corneal mosaic -- but they still
come from the cornea
• They are dimmer, and their size varies with
wavelength (color) of the light
• All colors of the rainbow are present --
which are smallest, and which biggest?
_______________ (Remember: blue bends
best!)

12. Which of These Will Cause a
Pathologic Halo?
http://www.atlasophthalmology.com/atlasimg/Img0086_51_low.jpg http://www.flickr.com/photos/jrmod/339707643/
Nuclear sclerotic cataract vs. corneal opacity
The cornea causes haloes, and the lens…

13. Lenticular
Diffraction Spikes
• Instead of haloes, the surface of the crystalline
lens causes diffraction of pinpoint light, such as
starlight
• Everyone knows that you don’t need a cataract
to see starbursts around lights this way, so…
• They must originate from a healthy lens, too
• Physiologic sutre lines are the likely culprit
• The same pinhole technique used for the
corneal mosaic can be used to image lens
opacities, which otherwise simply dampen light
http://www.astronomie.de/astropraxis/starhopper/canis-major/sirius.jpg

14. Why Patients Don’t See Their Cataracts
Directly
Adler, figure 16-4Chttp://www.flickr.com/photos/whvick/132165203/

15. Early Cataract as It Appears
Through a Pinhole
Adler, 9th edition, figure 15-4http://www.flickr.com/photos/mak506/283085523/
Please resist temptation to use the
abbreviation “cats” for cataracts

16. 3) Vitreous Floaters
• We are all familiar with the muscae volitantes
(flitting flies) that patients believe are in their tear
film, but you know are actually in the vitreous
• Some of these are remnants of the hyaloid artery
that feeds the fetal lens. Others may be due to
retinal tears or hemorrhage, like so-called tobacco
dust floaters
• When they settle to the inferior vitreous due to
gravity, we don’t see them
• Remember, the vitreous never circulates or gets
replenished, so floaters are forever. Learn to love
them.

17. Why Patients Do See Vitreous
Floaters
Adler, figure 16-4B

18. Which Floaters Are Harmless?
• We quickly become accustomed to reassuring patients
that floaters are normal, but sometimes they are not
• Familiar, countable floaters can be normal might as well
become your friends
• Recent-onset, innumerable floaters often are due to
retinal tear or detachment
• Likewise, large, new spider-shaped floaters can be a
retinal hemorrhage, so ask your patients to describe
what they see
• Will patients with active uveitis see their cells and flare?
What about asteroid hyalosis? Why not? ___________

19. Are These Floaters Symptomatic?
Some Treat Asteroid Hyalosis with Laser
http://dro.hs.columbia.edu/asthyalosis.htm

20. When Do You Expect To See Floaters?
• When the lighting is bright and there is
stationary background, floaters are most
visible
• For example, you might see your floaters
against the blue sky or snow on the SOA ski
trip
• As we have seen, they also have to be close
to the retina to cause a penumbra (shadow)
• Holding a pen tip so that it casts a shadow
on a paper gives you an idea, as the shadow
fades the further away you hold the pen
from the paper

21. 4) Retinal Phosphenes
• We are all familiar with the bright glow you see when
rubbing your closed eyes
• This is known to occur due to increase in vitreal pressure on,
and deformation of, the retina
• This causes the photoreceptors to fire, and for you to
perceive light, especially if you are in a dark room
• Why don’t you feel pain? Hint: where are pain sensors in the
eye? How high does your IOP have to be to feel painful?
• These are different than other entopic phenomena as they
require a nonlight stimulus -- rubbing or quick eye or head
movements (flick phosphenes)
• Infants with low vision are thought to rub their eyes
incessantly in order to trigger phosphenes and stimulate the
optic nerve (this helps diagnosis)

22. Phosphenes and the B&L Proview Eye Pressure
Monitor
Adler, figure 16-6
http://coopereyecare.com/glaucoma.htm

23. Moore’s Lightning Streaks
• These are entoptic phenomena that occur at
the vitreal-retinal interface
• They are most often seen in the temporal
visual field and are vertically oriented
• They were first described in 1935, but are
very common in middle-aged patients
• It is now thought that they are brought on
by posterior vitreous detachment, or PVD
• This is a universal condition that some
patients never see because it happens in the
periphery

24. Posterior Vitreous Detachment
(PVD) vs. RD
http://www.flickr.com/photos/nrgthedude/3359660841/

25. Why Do We Get PVD?
• Since the vitreous never replenishes, it
degenerates over a lifetime in all patients
• Think of it like a bowl of jello left out of the
refrigerator on a warm day. What happens?
• The jello is the vitreous, and the bowl is the
retina from which it can become detached
• The jello becomes liquified and separates
from the bowl the longer it sits out (or the
older your patient is)
• This liquefaction is called vitreous syneresis

26. 5) Purkinje Tree
• The Purkinje tree is a good example of how the
visual cortex separates self from non-self
• It’s there, but we don’t see it most of the time,
EXCEPT…
• The retinal arteries (arterioles) and veins
(venuoles) show up in stark relief when you sit in
the slit lamp for your classmates. Have you seen
it?
• Why??? The slit lamp isn’t brighter than, say, the
sun, and the sun doesn’t make it appear, right?
• When you see the Purkinje Tree, one part of the
biomicroscope is moving faster than the sun
moves in the sky -- which part? light

27. Jan Evangelista Purkyně
(1787-1869)
A monk who raised flowers, like Mendel
http://en.wikipedia.org/wiki/Jan_Evangelista_Purkyn%C4%9B

28. The Purkinje Tree
http://www.snof.org/vue/entoptique.html

29. How the Purkinje Tree
is Similar to PVD
• Both are seen only when conditions change,
like when the light moves, or when the
vitreous becomes liquified
• We see them because they are close to the
retina, unlike corneal or lens defects
• So, can O.D.’s use this phenomenon so that
their diabetic patients can check themselves
for retinal hemorrhages at home?
• If you instruct the patient to move a penlight
over their closed lids in a dark room, you can!
• You can also use a blue light, as in the next
example

30. 6) Flying Spots
(not in Adler)
• When looking at a brightly-lit blue field with
no background (moving or stationary), a
series of fast-moving whitish spots are seen
that move along curves and leave a trail, like
a comet
• Since blue light is the type absorbed by
hemoglobin, these flying spots are thought to
be white blood cells in the retinal vessels
• Thus, the flying spots are sometimes called
flying corpuscles (an old name for blood
cells), or the blue field entoptic phenomenon

31. Which Cells Cause the Flying Spots
Entoptic Phenomenon?
http://www.citylightsnews.com/randy/glossary/glossary_tuvwxyz.htm
Hint: it looks green here, but it isn’t really green

32. Other Facts About
Entoptic Flying Spots
• The spots move in pulsatile fashion that
accelerates with increased heart rate, as
after exercise
• Their aren’t enough of them to be caused by
red blood cells and they are the wrong color
(whitish)
• Applying pressure to the eye may make
them as easy to see as the Purkinje tree
• They can potentially be used to monitor for
clinically significant macular edema (CSME),
because there should be no blood vessels in
the foveal avascular zone

33. No Spots Seen in the Foveal Avascular
Zone (FAZ)
Source: Adler, page 493, 9th edition

34. From Which Vascular Beds
Do the Spots Arise?
• There are two possibilities
– One is the precapillary arterioles of the nerve
fiber layer
– The other is the capillary loops of the inner
nuclear/outer plexiform layers
• Marshall determined long ago that it can’t be
the nerve fiber layer, by using different blue
lights to illuminate the Purkinje tree in one
eye, and spots in the other
• So it’s the capillary loops that make the spots
appear

35. 7) Blue Retinal Arcs
• The nerve fiber layer itself can cause
entoptic images, also found by Purkinje
• Purkinje used “a glowing tinder taken from a
fire,” (don’t try this at home)
• Red, rectangular lights apparently the most
effective stimuli, held parallel to NFL
bundles
• For example, when a red target was seen by
nasal field, two arcs were seen, and would
change apparent distance from each other
with target movement
• The arcs are dim gray in the dark, and bright
blue in the light, like an afterimage

36. What Blue Retinal Arcs
Look Like OS
Adler, figure 16-8

37. How Does Retinal Anatomy Explain Blue
Arcs?
• The nerve fiber layer (NFL) radiate from
the optic nerve in bundles toward and
around the fovea
• They respect the horizontal midline and
do not cross it, making a seam of sorts
• Recall that this midline is called the
horizontal raphe
• The perceptual phenomenon lateral
inhibition likely plays a significant role
• Much more on lateral inhibition later!

38. Nerve Fibers Bundles and the Horizontal
Raphe OD
See also Adler, figure 16-7
http://www.glaucomaworld.net/english/010/e010i12.html

39. 8) Haidinger’s Brush
• Our last type of entoptic phenomenon,
these come from the fovea when a
spinning polarized target is used
• They are best seen with magnification
and a glass cobalt blue filter (same color
as the slit lamp filter for fluorescein)
• You can see a “brush” that spins like an
airplane propeller and moves with your
eye, looking like a Maltese cross

40. The Maltese Cross -- Can You See It On Your
Laptop Screen?
You need to use polaroid glasses to see it on a laptop
http://world.std.com/~mmcirvin/haidinger.htm
l
http://www.bernell.com/product/4092/184

41. Why Do We See the Haidinger Brush?
• Plane-oriented molecules of pigment in the
fovea causes some plane-polarized light to
be absorbed, especially if it’s blue
• So when a spinning polarizer is put in front
of a blue light, you see a propeller
• Subtle macular edema and other retinal
disease may cause the brush to disappear,
even if the retina looks normal to your
ophthalmoscope
• It is used in vision therapy to track the
location of the fovea in patients with
amblyopia and eccentric fixation

42. Which Part of the Retina Sees the
Brush?
http://cheme.che.caltech.edu/groups/jak/research/eyes/

43. Maxwell’s Spot
• Maxwell’s Spot is a close relative to
Haidinger’s Brushes
• Seen as a dark reddish circle surrounded by
a clear ring and brighter blue halo when
looking at a diffuse flickering blue light
• The size is 2-3 degrees, oval horizontally,
and may look grainy
• Xanthophyll foveal pigment is responsible
for Maxwell’s Spot
• Which color is xanthophyll? Hint: which
color is the macula lutea? ______________
http://www.nature.com/nature/journal/v175/n4450/abs/175306a0.html

44. Review Capsule
1. Why do we see the Purkinje Tree under the slit lamp,
but not in the sunshine?
2. Why are “flying corpuscles” better described as
“flying spots?”
3. Which entoptic phenomena can be used by an
observant patient to monitor glaucoma? Which can
be used to monitor diabetic retinopathy?
3. What part of the retinal causes the polarization
responsible for the Hadinger Brush effect?
4. What is Maxwell’s spot? When is it seen?

45. References & Readings
• Today’s material can be found in chapter 16
(in the 10th edition) of Adler’s Physiology of
the Eye, the chapter with the same title as this
lecture, by Hart and Westheimer. Thanks to
them!
• Next time, we will start Schwartz, chapters 1
and 2. Better buy now and keep up!
• I recommend a used copy since a new edition
is coming out by next year, and you may want
to keep your copy until after your Boards