Entoptic Phenomena

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 Entoptic phenomena
 Normally, visual experiences are caused when light
stimulates the retina.
 Entoptic phenomena are produced when something
other than light stimulates the retina, i.e., they are
visual sensations that arise from within the eye
itself.
 Most are benign but some are clues to underlying
pathology and the clinician should understand their
causes and be alert to them in patients’ reports.
 Not all entoptic images arise from characteristics of
the optics of the eye; e.g., some arise from higher
neuronal processing.
Causes of Entoptic Phenomena

1. Refractive Effects
2. Diffraction Effects
3. Shadows
4. Xanthophyll Effects
5. Pressure Phosphenes
6. Electrical Phosphenes
Refractive effects

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 Refractive effects

• Small surface changes across the cornea can redirect

light outside the retinal image.
1. Tear film
• When the eye blinks, a horizontal ridge of tears is
left momentarily where the lids came together.
• Some observers report a “shadow” effect seen as a
horizontal striation.
• Mucous strands can do the same thing, but they
last longer and move around with the blink.
2. Corneal corrugations

Squeezing the lids tightly shut gives transient

ridges on the cornea that can give
“shadow” streaks, monocular diplopia,
and even decreased visual acuity, which in
extreme cases can last longer than an
hour.
Diffraction effects
 Corneal Halos
• The stroma of the cornea is composed of collagen
fibrils between 19-34 nm in thickness.

• The interfibrillar separation is much smaller than

the wavelength of light, so light scattered by one
fibril can’t constructively interfere with that of
another fibril. No diffraction pattern is formed.

• In addition, there is destructive interference

between scattered and non-scattered light,
further reducing the effects of the scatter.
 Colored Halos
Corneal
 Corneal edema can be caused by, among other
reasons, increased intraocular pressure that
forces water into the cornea producing water
clefts, which act as diffractive particles.
 e.g., patients may report colored halos
around small bright lights during episodes of
acute glaucoma.
 Swimming in chlorinated pools and overwear of
contact lenses may give a similar effect.
• With corneal edema, the regularity of the collagen
fibrils is disrupted and the normal beneficial destructive
interference no longer occurs.
– With severe edema and water droplets or water
clefts in the epithelium, even more scattering
occurs.
• With monochromatic light, an Airy-disc like appearance
is seen.
• With white light, a white center will be surrounded by
chromatic rings or red-yellow, purple, etc. This is called
the corneal halo.
 Lenticular Halo
• The lens also has regularly-arranged fibers. With the
exception of the zonular area and the anterior
cellular area, its fibers are laid out in a radial
fashion.

• The axial part of the lens is uniform, so no halo is

seen with small pupil diameters (< 3mm).

• Under low light conditions or when dilated, the

effects of the peripheral zones become apparent
and a halo is seen.
 Emsley-Fincham test

• A lenticular halo is normal!

• Since the corneal and lenticular halos look similar and

the corneal halo is not normal, they must be
differentiated via the Emsley-Fincham test.

– Move a stenopaeic slit across the pupil.

– The corneal halo is reduced in brightness a bit no
matter where the slit.
– The lenticular halo changes in shape as the slit
moves!
Distinguishing a Lenticular Halo
 Asterisms
• Small bright objects against a dark
background usually have spikes surrounding
their geometric images.
• An example of this is bright stars where the
effect is so prominent that artists
frequently depict stars with spikes.
• This effect is assumed to be due to
diffraction off the suture lines of the
crystalline lens.
 Shadows

1. Ocular opacities
2. Purkinje tree
3. Blue field entoptoscope
 Shadows
• The passage of light through the ocular media may
be affected by localized heterogeneities in
refractive index that scatter light, or by opacities
that absorb or scatter light.
• Unless an opacity is nearly the same size as the
pupil or close to the retina, it won’t cast a significant
shadow.
• We use a small light source to make the shadows
denser and more defined.
 Shadows and Parallax

• By using parallax, the location of an opacity

can be localized.
– If the opacity is behind the exit pupil,
against motion is seen.
– If the opacity is in front of the exit pupil,
with motion is seen.
– The farther away from the exit pupil, the
more motion seen.
 Locating the Site of Opacities
• Parallax
 Ocular Opacities
• Corneal scars, lens opacities, intraocular
foreign bodies, vitreal floaters and blood cells
would all be expected to cast shadows.

• The effect is strongest for opacities nearest to

the retina because objects near the retina
project an umbra rather than just a penumbra
onto the retina.

• Opacities may not be noticed at all by the

patient if completely opaque.
 •An example is asteroid hyalosis, which are
calcium deposits in the vitreous.
•To the doctor looking in, they look very
bright and may make a good view of the
fundus difficult due to glare; but because they
are opaque, from the retinal side they are
dark and the patient may be unaware of
them.
 Muscae Volitantes

• Cellular debris, probably from the embryonic

hyaloid vascular system.
• Cast shadows and refracts light into bright
circular spots and other shapes such as wavy
filaments or cobwebs.
• Most commonly seen when viewing a bright
background like a bright sky or white wall.
• They move on eye movement.
• Become more noticeable with age as the
vitreous liquifies.
 Vitreous Opacities
• Most vitreous opacities are harmless.
• A sudden onset of floaters may be serious,
especially if accompanied by photopsia
(flashes of light).
• The sudden appearance of a “film, haze or
cloud” of opacities may be caused by
bleeding into the vitreous or vitreous
detachment.
• Vitreous opacities may be removed by
vitrectomy.
 Purkinje Tree

• Because the branching retinal blood vessels

are in front of the photoreceptors, they can
cast a shadow that resembles a tree.

• They are normally not seen, but a small

bright light can reveal them as a branched
pattern stopping short of the avascular zone
around the fovea.
 Purkinje Tree

• Since stable images on the retina quickly fade

(the Troxler effect), the Purkinje tree is best
seen if the light source is constantly moved
over a large angle.
• Patients sometimes comment on the Purkinje
tree when they are examined with bright
lights, such as the slit lamp or BIO.
 Blood Cells and the Blue-Field
Entoptoscope
• When looking at a bright blue background such as the
sky, a person may see bright spots moving along
curved lines and their flow may even seem to pulse
with the heartbeat.
• These are thought to be white blood cells, which
interrupt the columns of red blood cells in the smaller
retinal blood vessels.
– The white blood cells allow blue light to pass,
whereas red blood cells absorb blue light.
 Blood Cells and the Blue-Field
Entoptoscope
 This entoptic image has
been incorporated into a
machine known as a
blue field entoptoscope
to serve as a gross
subjective assessment of
the vascular function of
the retina.
Xanthophyll effects

• 1. Maxwell's spot
• 2. Haidinger's brush
 Maxwell’s Spot
 If a blue filter is quickly placed in front of your eye as
you view a bright, uniform white background, a dark
disk appears in the macular area.
 This is due to a Xanthophyll pigment (zeaxanthin) in
the macula.
 This acts like a yellow filter, which excludes more of
the blue light than the surrounding retina does so
that a relatively dark spot appears in the part of the
visual field that corresponds to the macula.
 Maxwell’s Spot

• Maxwell’s spot is used in vision therapy to “tag”

where the patient is fixating.
• Maxwell’s spot can also be used to measure the
density of macular pigment. The darker
Maxwell’s spot, the denser the pigment.
 Haidinger’s Brushes
 If you look at a uniform white background through a
Polaroid filter, a small yellow, hourglass-shaped figure
appears, centered on the point of fixation.
 Haidinger’s brush is due to birefringence induced by
Xanthophyll, which is radially polarizing.
 A competing theory is that radially oriented
receptor cell axons form a birefringent layer in the
macula.
 Haidinger’s Brushes
 The figure fades rapidly due to visual adaptation, so
it must be kept in view by rotating the Polaroid filter
so that the hourglass also appears to rotate and
exposes new retina.
 A blue background helps to enhance the effect.
 Haidinger’s Brushes

 Haidinger’s brushes can be used to detect

macular edema.
 The effect is less pronounced or absent in
macular edema. This can occur even before
ophthalmoscopic signs of macular edema.
 Haidinger’s Brushes
 Because Haidinger's brush corresponds to the
macula, it is sometimes used as a gross subjective
test of macular function and sometimes as a training
technique in amblyopia to improve fixation.
 Haidinger’s brush can determine whether amblyopic
patients fixate with their foveas or not (eccentric
fixation) since the fovea always corresponds to the
center of the hourglass and the center of rotation.
 Pressure Phosphenes

• 1. Digital Pressure
• 2. Eye Movement Phosphenes
• 3. Moore’s Lightning Streaks
 Digital Pressure Phosphenes
 Phosphenes of all kinds are weak stimuli and
therefore have to be viewed in the dark.
 If pressure is applied in the dark to the side of
the eyeball through the closed lid, a circular
bright spot will be seen
 The pressure directly activates retinal cells.
 Pressure Phosphenes
• Pressure phosphenes are now being used to
monitor patient’s intraocular pressure at
home with a device called the Proview.
• The patient applies pressure through the
eyelid until a pressure phosphene is seen.
The pressure needed to produce the
phosphene is read off the instrument.
 Pressure Phosphenes
• Mechanical traction on the retina also can
cause phosphenes.
• Patients will complain of photopsia -- flashes of
light.
– This is why a complaint of flashes of light must
be treated with utmost concern. Retinal
detachments are ocular emergencies.
– Vitreous liquifaction and detachment can also
cause photopsia.
 Eye Movement Phosphenes
• If you close your eyes and move them all the way
to the left or right, then try to move them even
further, you’ll see a bright half-ring shaped light
with a dark center on the opposite side of the
field.

• This is due to the extreme contraction of the

rectus muscle deforming the globe a bit and
mechanically stimulating the photoreceptors
under the muscle’s insertion site.
 Moore’s Lightning Streaks

• When the vitreous liquefies with age (syneresis),

the points of remaining adherence between
vitreous and retina may tug on (pull) the retina,
especially during eye movements.
• This produces pressure phosphenes, which
appear as lightning streaks at points in the visual
field that correspond to the locations of
adherence.
 Moore’s Lightning Streaks
• These may be benign, but the clinician should
check carefully for the possibility of retinal
tears and detachments because they are more
likely to occur in patients who experience
these events.
Electrical phosphenes

• 1. Battery stimulation
• 2. Blue arcs of the retina
 Electrical and X-ray
phosphenes
 Battery stimulation
 If a low-voltage battery (<10 V) is placed in the
mouth between tongue and upper lip in the dark,
a faint glow will be seen over the visual field.
 Do not try this with high voltage battery
 X-rays stimulation of the retina (typically higher
doses) can also produce phosphenes.
Blue Arcs of the Retina

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 Blue Arcs of the Retina
 If a red patch of light (such as a very small red LED light)
is viewed in a dark room monocularly, blue arcs will be
seen emerging from the light source and heading
towards the blind spot.
 This is sometimes seen when looking at the red LEDs
on a digital clock in a darkened room.
 The effect is subtle, but is a little easier to see if one
fixates slightly to the side of the red light.
 The arcs follow the course of the ganglion cell axons in
the nerve fiber layer
 Blue Arcs of the Retina
• Some people explain the effect as due to an
electrical “short circuit” between the axons from
ganglion cells under the red stimulus and ganglion
cells encountered along the path of those axons.

• Others claim it is due to the electrical signals in the

ganglion cells in the fiber bundles stimulated by
the red light abnormally causing the
photoreceptors below them to respond.