Abstract:
A retinoscopic device, technique and scale for estimating the reflectance of the macula pigment optical density (MPOD) in normal and abnormal eyes in order to detect early pathology of the retinal pigment epithelium and photoreceptors thus screening for macular pathology the most prevalent of which is Age-related Macular Degeneration (AMD) and retinal edema and cystoid macular edema post cataract surgery.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation-in-part of application Ser. No. 14/618,360, filed on Feb. 10, 2015, which is currently pending. The patent application identified above is incorporated herein by reference in its entirety to provide continuity of disclosure. 
    
    
     FIELD OF THE INVENTION 
     This invention relates to a method and system for using a calibrated retinoscope and parallel light technique to estimate the reflection of melanin particles in the retina to detect macular degeneration prior to physical symptoms. 
     BACKGROUND OF THE INVENTION 
     In the Western world, maculopathy or AMD is the leading cause of blindness in the elderly population and affects 10%-13% of adults over 65 in North America, Europe, Australia and Asia In 2012 the undiagnosed prevalence of AMD in the USA was estimated to be 2.3 million. Estimates of the global cost due to AMD are US$343 billion with US$255 billion in direct health care costs. 
     According to the International Classification age-related maculopathy (ARM) is a degenerative disease of the macula characterized in the early stage by large, soft yellow drusens, hyper-/hypopigmentation of the retinal pigment epithelium (RPE), and a moderate loss of central vision (age-related maculopathy). Age related maculopathy disease (AMD) is a late stage of ARM. Dry AMD refers to geographic atrophy and wet AMD is characterized by choroidal neovascularization (CNV), detachment of the RPE, subretinal hemorrhage or retinal scarring. 
     Currently, several AMD classification schemes, grading systems, and severity scales have been developed in an effort to provide standards to assist clinicians and researchers in the diagnosis and management of this important disorder. The most current clinical classification of AMD takes in consideration pigment abnormalities and is illustrated in  FIG. 16 . 
     It is believed the ultimate therapy for AMD will lie in the preclinical identification of those who are genetically “at risk” for the disease and treatment with genetically specific supplements. At the present time, AMD is initially diagnosed by an ophthalmologist or optometrist with a fundus examination and Amsler grid of patients who complain of a decrease in their vision. The hallmarks of early AMD are yellow drusens and pigment abnormalities (hypo and hyperpigmentation) of the retinal pigment epithelium (RPE) which occur after the onset of the AMD process. AMD is characterized by a degeneration of the retinal pigment epithelium and photoreceptors (rod and cones) and a thickening of the Bruch&#39;s membrane in the macula. 
     The early detection of AMR could reduce the growing societal burden by targeting and emphasizing modifiable habits earlier in life. With genetic testing antioxidants and other supplements specific to the patient&#39;s genotype can be recommended. More frequent examinations of those at high risk due to family history or signs of early or intermediate disease would be beneficial. 
     It is believed that the pigmentary changes observed in the macula of AMD eyes are attributable to degenerative changes in the highly melanized RPE cells because most of the early clinical signs and histopathological changes have been localized to this cell layer. It has been suggested that melanin in the retinal pigment epithelium (RPE) and choroid may protect the macular region by its antioxidant capability and its capability to attenuate or reflect light thereby decreasing photochemical light damage. 
     In retinoscopy, a light is shone into a patient&#39;s eye and the reflected “streak” of light is used to estimate the correction of a patient&#39;s refractive error. The results are then the beginning point for a refraction. However, with the calibrated retinoscope and this technique, the brightness of the reflected beam is dependent on the health of the pigment epithelium and thus gives an early indication of macular pathology. This calibrated diagnostic retinoscope and technique allow the general ophthalmic physician to detect early and late stages of the destruction of the retinal pigment epithelium in AMD. The common denominator between AMD and the pupillary reflex in retinoscopy lies in the melanin pigment particles of the microvilli of the retinal pigment epithelium (RPE) which surrounds the photoreceptors, the choroid and/or the outer segment of the cones. 
     In 1926, Jacob C Copeland designed a retinoscope (U.S. Pat. No. 3,597,051) and a technique of retinoscopy which has since been taught to optometrists and ophthalmologists for obtaining an objective measurement of the refractive error of patient&#39;s eyes for spectacles and/or contact lenses. All retinoscopes have been based upon on his work. 
     Originally, Copeland&#39;s and other retinoscopes used diverging light and spots of light to estimate the refractive error. Copeland introduced streak retinoscopy in the US and it was rapidly accepted because it made determination of the axis of astigmatism more precise. The technique was referred to as “streak retinoscopy” because a streak of reflected light, or the pupillary reflex, was produced during the technique. 
     In 1968, Copeland and Walter M. Lewis designed the Copeland Optec 360 Streak Retinoscope, U.S. Pat. No. 3,597,051 (as illustrated in  FIG. 17 ). This retinoscope contains a +20.00 D condensing lens and a bi-pin filament bulb. When the thumb-slide is in its upper position, the filament of the lamp is less than five centimeters from the condensing lens and the rays emanating from the filament and passing out of the condensing lens are diverging. Moving the thumb-slide to a lower position causes the light rays to converge. When the filament is at the focal point of the +20.00 D lens or approximately 5 cm from the +20.00 D lens, the light rays are parallel. 
     Sims&#39; calibrated refractive retinoscopic techniques uses converging rather than diverging light. The Sims&#39; retinoscope can also be used for calibrated diverging or conventional diverging retinoscopic techniques. It has been modified so that auxiliary lenses can be attached to the back of the head of the retinoscope to place the examiner&#39;s eye in focus with the patient&#39;s pupillary plane in order to have an identical (conjugate) image of the pupillary reflex. Parallel light is used after the refractive error has been determined to judge the streak on a reflectance scale 0 (very poor and difuse) to 4 (brilliant). 
     In conventional retinoscopy, the pupillary reflex cannot be used to evaluate the melanin reflectance. The endpoint of conventional retinoscopy is an infinity neutrality reflex which fills the pupil and there is no streak. The width of the reflected retinoscopic light from the reflecting membrane spans an area much larger than the size of the pupil and is enormous, making it impossible to evaluate the reflectance of the macular pigment (MP). With conventional retinoscopy, the refractive error is initially determined by under correcting the refractive error to create a visible with-motion pupillary streak reflex that expands and moves at an exponentially increasing speed as neutrality is reached. These exponential changes of the with-motion streak makes it impossible to evaluate the reflectance of the MP. 
     Production of the Pupillary Reflex: 
     The cones act as an optical waveguide for visible light due to their tubular structure and the index gradient between the cell wall and internal medium. Since the cone&#39;s receptors are tightly packed, they act as a “fiber optic plate” extending from the external limiting membrane to the pigment epithelium (as illustrated in  FIG. 18 ). Therefore light, that strikes the outer limiting membrane located at the openings of the photoreceptors, is transmitted to the photosensitive pigment in the outer segments by a waveguide mechanism and then reflected to the outer limiting membrane. 
     The reflected light from the retina pigment epithelium (RPE) interface appears to be due to Fresnel reflection from the melanin granules within the melanosomes in the RPE. A Fresnel reflection is a reflection of light on a planar interface between two homogeneous media having different refractive indices. The melanin granules in the pigment epithelium have a high index of refraction compared to the surrounding tissue. The reflected light then reenters the photoreceptors and transmitted to the external limiting membrane (ELM) and pupil. The ELM is considered the effective ocular reflecting surface for visible light in the performance of retinoscopy or photorefraction. Conventionally, the pupillary reflex is used to measure or estimate a refractive error, not to evaluate the reflectance from the melanin pigment. 
     Macular Degeneration and Reflectance: 
     Most of the early clinical signs and histopathological changes have been localized to the pigment epithelium. It is believed that it is the melanin in the retinal pigment epithelium (RPE) and choroid which protects the macular region through its antioxidant capability and its capability to attenuate blur light thereby decreasing photochemical light damage. Healthy pigment epithelium is more reflective than that which is damaged and when evaluated produces a brilliant to clear streak. 
     The calibrated retinoscope and diagnostic technique described in this patent application allows the average ophthalmic physician to detect early and late stages of the destruction of the retinal pigment epithelium in AMD. 
     The relevant prior art includes the following references: 
                                                 U.S. Pat. No.   Inventor   Issue/Publication Date                           3,597,051   Copeland   Aug. 3, 1971           5,430,508    Sims   Jul. 4, 1995           5,500,698    Sims   Mar. 19, 1996           5,632,282    Hay et al.   May 27, 1997           5,650,839    Sims   Jul. 22, 1997           6,578,965   Grant   Jun. 17, 2003           6,640,124   Elsner et al.   Oct. 28, 2003           2008/0221416   Baker   Sep. 11, 2008           7,467,870   van de Kraats et al.   Dec. 23, 2008           8,272,739   Sims   Sep. 25, 2012           8,272,740   Sims   Sep. 25, 2012           8,485,664   Rowe   Jul. 16, 2013           2014/0140112   Lashkari   May 1, 2014           CN202458313   Zhang   Oct. 3, 2012                        
(Non-Patent Literature)
 
     Ferris, F L III, Wilkinson, C P, Bird A, et al. CLINIAL CALSSIFICATION OF AGE-RELATED MACULAR DEBENERAITON. Ophthalmology, 2012, 844-851 Beatty S, Boulton M, Henson D, Koh H H, Murray I J (1999) Macular pigment and age related macular degeneration. Br J Ophthalmol 83:867-77 
     SUMMARY OF THE INVENTION 
     The primary object of the present invention is to improve the detection of age-related maculopathies (ARM &amp; AMD) other maculopathies and cystoid macular edema post cataract surgery using a modified retinoscope. 
     An additional object of the present invention is to provide a retinoscope capable of performing several calibrated refractive and diagnostic retinoscopic techniques and conventional retinoscopy. 
     The present invention fulfills the above and other objects by providing a retinoscopic device, technique and scale for estimating the reflectance of the macula pigment optical density (MPOD) in normal and abnormal eyes in order to detect early pathology of the retinal pigment epithelium and photoreceptors thus screening for macular pathology, the most prevalent of which is Age-related Macular Degeneration (AMD). 
     The retinoscopic device of the present invention is a calibrated, converging light retinoscope which improves the accuracy of retinoscopy by calibrating a pupillary streak to the vergence of the retinoscopic light and the retinoscopic working distance. This technique predicts the final correction so closely, it is referred to as “Refractive Retinoscopy”. 
     An improvement of the present invention adds a technique using parallel light which enables an examiner to use a subjective scale or the “Primary Scale” to evaluate the pupillary streak to scan for Age-related Macular Degeneration (AMD). The pupillary streak produced by retinoscopy of a healthy eye differs from that produced in an eye with Age Related Macular Degeneration (AMD). The Primary Scale, requires the examiner to make an initial judgment as to the brightness of the pupillary streak produced by parallel light from one&#39;s retinoscopic working distance (RWD). This technique is referred to as “Diagnostic Retinoscopy” since it detects early AMD and the various progressive stages of AMD. 
     A more objective scale or the “Optical Scale” involves reducing the intensity of the chosen pupillary streak by increasing the focal length of the converging retinoscopic light. A healthy eye will be able to reflect a pupillary streak even when the light intensity of the pupillary reflex is maximally decreased. An eye with AMD pathology will cease reflecting a pupillary streak commensurate to the degree of macular damage. The advantage of the Optical Scale is it is easier to judge when the pupillary streak disappears than to make a subjective judgement of the brightness of the pupillary streak using the Primary Scale. 
     Although the device for carrying out the method and system described herein is optical and manual, the method and system of the present invention may also be used with an electronic instrument with a continuous scale much like a rheostat which could measure the optical scale even more precisely. 
     With continued use of the method and system of the present invention, it would be possible to establish a continuous scale probabilities of having macular problems which would correlate to the Optical Scale. 
     The above and other objects, features and advantages of the present invention should become even more readily apparent to those skilled in the art upon a reading of the following detailed description in conjunction with the drawings shown and the described illustrative embodiments of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       In the following detailed description, reference will be made to the attached drawings in which: 
         FIG. 1  is a side partial cutaway view of a condensing lens, a mirror, a lamp, a power capsule with a knurl for rotating the power capsule and a thumb-slide which moves the power capsule housing the lamp; 
         FIG. 2  is a schematic of the knurl area on the power capsule with a circumferential calibration line; 
         FIG. 3  is a schematic view of light rays emanating from a retinoscope in a diverging pattern; 
         FIG. 4  is a schematic view of light rays emanating from a retinoscope in a converging pattern; 
         FIG. 5  is a flow chart for optically measuring one&#39;s retinoscopic working distance; 
         FIG. 6  is a chart for calibrating the retinoscope using diverging rays for an infinity retinoscopic and +0.50 D endpoints and for calibrating a retinoscope using converging rays for +0.50 D and +0.75 D retinoscopic endpoints; 
         FIG. 7 -A is an attachable plate for retrofitting a retinoscope for a +0.50 D retinoscopic endpoint using converging rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 7 -B is an attachable plate for retrofitting a retinoscope for a +0.75 D retinoscopic endpoint using converging rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 7 -C is an attachable plate for retrofitting a retinoscope for an infinity retinoscopic endpoint using diverging rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 7 -D is an attachable plate for retrofitting a retinoscope for a +0.50 D retinoscopic endpoint using diverging rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 8  is a flow chart showing the steps for calibrating a retinoscope for a +0.50 D retinoscopic endpoint using converging retinoscopic light rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 8 -A is a retinoscope showing proper attachment of the +0.50 D converging plate after calibration of retinoscope light rays to the examiner&#39;s retinoscopic working distance; 
         FIG. 9  is a flow chart showing the steps for calibrating a retinoscope for a +0.75 D pupillary reflex endpoint using converging retinoscopic light rays; 
         FIG. 9 -A is a retinoscope showing proper attachment of the +0.75 D converging plate after calibration of retinoscopic light rays to the examiner&#39;s retinoscopic working distance; 
         FIG. 10  is a flow chart showing the steps for calibrating a retinoscope for an infinity retinoscopic endpoint using diverging retinoscopic light rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 10 -A is a retinoscope showing proper attachment of the infinity diverging plate after calibration of the retinoscopic light rays to the examiner&#39;s retinoscopic working distance; 
         FIG. 11  is a flow chart showing the steps for calibrating a retinoscope for a +0.50 D retinoscopic endpoint using diverging retinoscopic light rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 11 -A is a retinoscope showing the proper attachment of the +0.50 D diverging plate after calibration of retinoscopic light rays to the examiner&#39;s retinoscopic working distance; 
         FIG. 12  is a flow chart showing the steps for performing a calibration check of a retinoscope emanating converging rays calibrated to the examiner&#39;s retinoscopic working distance; 
         FIG. 13  is a rear view of a retinoscope showing a slide bar which can be adjusted to maintain the thumb-slide in a fixed position to maintain the calibration of the retinoscope for future retinoscopies; 
         FIG. 14  is a side view of a retinoscope showing a slide bars which can be adjusted to maintain the thumb-slide in a fixed position to maintain the calibration of the retinoscope for future retinoscopies; 
         FIG. 15  is a front perspective view of a bulb extender of the present invention; and 
         FIG. 16  is a chart showing the clinical classification of age-related macular degeneration; 
         FIG. 17  is a side view of a retinoscope of the prior art; 
         FIG. 18  is an illustration of histology of the macula with pigment epithelium; 
         FIG. 19A  is a side view of a retinoscope calibrated to emit parallel light rays to make the streak pupillary reflex image and the image seen by the examiner conjugate; 
         FIG. 19B  is a side view of a retinoscope calibrated for converging retinoscopy with a +0.50 D pupillary streak endpoint and parallel retinoscopy for the detection of age-related maculopathies; 
         FIG. 19C  is a side view of a retinoscope calibrated for converging retinoscopy with a +0.75 D pupillary streak endpoint and parallel retinoscopy for the detection of age-related maculopathies; 
         FIG. 19D  is a side view of a retinoscope calibrated for diverging retinoscopy with a +0.50 D pupillary streak endpoint and parallel retinoscopy for the detection of age-related maculopathies; 
         FIG. 19E  is a side view of a retinoscope calibrated for diverging retinoscopy with an infinity neutrality pupillary endpoint and parallel retinoscopy for the detection of age-related maculopathies and having slide locks above and below the thumb slide to allow the examiner to change the divergence or convergence of the retinoscopic light to parallel light rays without moving the retinoscope; 
         FIG. 20A  is an illustration of an extrapolated focal point (Image I 3 ) behind a retina when the retinoscopic light is parallel (Image I 1 =0.00 D); 
         FIG. 20B  is an illustration of a reflected pupillary image (Image I 3 ) focused to a hole in a mirror with the examiner seeing a reflected streak pupillary image (Image I 3 ) as a conjugate image; 
         FIG. 21  is a side view of a retinoscope calibrated to emit parallel light and an attachable emblem having a parallel light line attached to the slide plate after calibration of the retinoscope; 
         FIG. 22  is a primary scale for detection of RPE maculopathy and age-related maculopathy or degeneration (AMD); 
         FIG. 23  is a pupillary streak brightness scale; 
         FIG. 24  is an illustration of power settings for calibrated converging retinoscopic settings (+1.50 D, +1.00 D, +0.75 D, +0.62 D and +0.50 D) expressed in diopters for a 67 cm RWD; and 
         FIG. 25  is a chart illustrating the focal lengths of the pupillary reflex and the decrease in the light intensity of the pupillary reflex for a retinoscopic working distance (RWD) of 67 cm which is the most common RWD. 
     
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     With reference to  FIG. 1 , a side partial cutaway view of a retinoscope  1  having a thumb-slide  2  and a condensing lens  3  and a lamp  4  is shown. The lamp  4  includes a linear filament  5  designed to create a “streak” image which is reflected from a patient&#39;s retina and seen by a practitioner, such as an optometrist or ophthalmologist. The thumb-slide  2  moves the power capsule housing the lamp  4  moves up and down along a handle of the retinoscope  6  so that when the thumb-slide  2  is in a maximal upward position, the filament  5  is less than 5 cm from lens  3  which has an approximate power of +20.00 D. When the thumb-slide  2  is in a maximal down position, the filament  5  is approximately 6.6 cm from the lamp  4 . The practitioner can view the light rays reflected from the patient&#39;s retina through a small openings  7  in mirror  8  and head of retinoscope. The examiner can only see the retinoscopic light on the patient&#39;s iris and the reflected pupillary reflex. The examiner nevertheless is able to move the pupillary reflex toward neutralization by the movement and orientation of the pupillary reflex. The examiner draws all of the retinoscopic signals from the pupillary reflex, that is, when to change or rotate the retinoscopic streak to achieve neutralization of the spherical and cylindrical error. 
     With reference to  FIG. 2 , calibration of the retinoscope requires a calibration line  11  in the knurl area  9  on the power capsule  10  to align the Plates  7 A and  7 B for converging infinity retinoscopy and Plates  7 C and  7 D for diverging retinoscopy after the retinoscope is calibrated to the specifications in the Calibration Chart  18 , as illustrated in  FIG. 6 . 
     With reference to  FIG. 3 , a schematic view of light rays  12  emanating from a retinoscope  1  in a diverging pattern  13  is shown. In diverging retinoscopy the lamp  4  is within the focal length of lens  3 . The proximity of the lamp  4  to the lens  3  causes the light rays  12  emitted from the retinoscope  1  to spread out into a diverging pattern  13 . 
     The retinoscopic technique of identifying and neutralizing a refractive error is the same with calibrated diverging retinoscopy as with conventional retinoscopy. Calibrated diverging retinoscopy differs from conventional retinoscopy in that the divergence of the emitted retinoscopic light rays  12  is calibrated to a fogging lens whose focal length is equal to one&#39;s retinoscopic working distance. The endpoint of calibrated diverging retinoscopy can be an infinity retinoscopic endpoint which is identical to the endpoint of conventional retinoscopy or a +0.50 D with-motion pupillary reflex. 
     With reference to  FIG. 4 , a schematic view of light rays  12  emanating from a retinoscope  1  in a converging pattern  14  is shown. In converging retinoscopy, the lamp  4  is displaced beyond the focal length of lens  3 . The increased distance of the lamp  4  from the lens  3  causes the light rays  12  emitted from the retinoscope  1  to focus into a converging pattern  14 . 
     With reference to  FIG. 5 , a flow chart showing the steps for measuring a retinoscopic working distance for use in calibrating a retinoscope for converging and diverging retinoscopy is shown. The examiner&#39;s retinoscopic working distance is optically measured by focusing the retinoscopic light into an emmetropic eye using the thumb slide until a neutrality reflex occurs 15. Then, the retinoscopist holds the thumb-slide on the retinoscope in place and the emitted retinoscopic light is focused onto a wall by moving the retinoscope towards the wall until the streak is in focus  16 . Finally, the distance between the wall and retinoscope is measured to obtain the examiner&#39;s retinoscopic working distance  17 . 
     With reference to  FIG. 6 , a calibration chart  18  is shown. The calibration chart  18  lists the retinoscopic working distance in centimeters  19  and the required power of the calibration lens to be held in front of the retinoscope, which is displaced from a wall a distance equal to the examiner&#39;s retinoscopic working distance  19 , in order to calibrated the diverging retinoscopic light for an infinity endpoint  20  and a +0.50 D endpoint  21 . Chart  18  also lists the distance a retinoscope must be held from a wall to calibrated the retinoscope using converging light for a +0.50 D endpoint  22  and a +0.75 D endpoint  23 , when performing retinoscopy from one&#39;s retinoscopic working distance. 
     With reference to  FIG. 7 -A, an attachable plate  24  for retrofitting a retinoscope  1  when calibrated for a +0.50 D with-motion endpoint pupillary reflex using converging rays  14  emitted from the retinoscope  1  is shown. The plate  24  shown here is a +0.50 D converging plate  25  and is used when the converging light emanating from the retinoscopies is calibrated for a +0.50 D with-motion retinoscopic endpoint, as shown further in  FIG. 8 -A. The +0.50 D converging plate  25  has a front surface  26 , a rear surface  27  and an alignment line  28 . The plate  24  is attachable to the retinoscope via an attachment means  29 , such as screws nuts, etc. The plate  24  is moveable via an adjustment means  30 , such as a slot that moves along a screw, so that a user may adjust the alignment line  28  up or down to be in alignment with the calibration line  11  on the power capsule  10 . After the retinoscope is calibrated and plate  24  secured into position, the alignment line  28  on plate  24  allows the retinoscopist to know where to place the calibration line  11  on the power capsule  10  to obtain a +0.50 D retinoscopic endpoint using converging light, as shown further in  FIG. 8 -A. 
     With reference to  FIG. 7 -B, an attachable plate  24  for retrofitting a retinoscope  1  when calibrated for a +0.75 D with-motion retinoscopic reflex using converging light rays  14  emitted from the retinoscope  1  is shown. The plate  24  shown here is a +0.75 D converging plate  31  and is used when the converging light  14  emanating from the retinoscope is calibrated for a +0.75 D with-motion retinoscopic endpoint, as shown further in  FIG. 9 -A. The +0.75 D converging plate  31  has a front surface  26 , a rear surface  27  and an alignment line  28 . The plate  24  is attachable to the retinoscope via an attachment means  29 , such as screws nuts, etc. The plate  24  is moveable via an adjustment means  30 , such as a slot that moves along a screw, so that a user may adjust the alignment line  28  up or down to be in level with the calibration line  11  on the power capsule  10 . After the retinoscope is calibrated, as illustrated in  FIG. 9 , and plate  24  secured into position, the alignment line  28  on plate  31  allows the retinoscopist to know where to place the calibration line  11  on the power capsule  10  to obtain a +0.75 D retinoscopic endpoint using converging light, as shown further in  FIG. 9 -A. 
     With reference to  FIG. 7 -C, an attachable plate  24  for retrofitting a retinoscope  1  when calibrated for an infinity endpoint using diverging light rays  13  emitted from the retinoscope  1  is shown. The plate  24  shown here is an infinity endpoint diverging plate  32  and is used when the diverging light  13  emitted from the retinoscope is calibrated for an infinity retinoscopic endpoint, as shown further in  FIG. 10  and  FIG. 10 -A. The infinity diverging plate  32  has a front surface  26 , a rear surface  27  and an alignment line  28 . The plate  24  is attachable to the retinoscope via an attachment means  29  such as screws, adhesive, nuts, etc. The plate  24  is moveable via an adjustment means  30 , such as a slot that moves along a screw, so that a user may adjust the alignment line  28  up or down to be level with the calibration line  11  on the power capsule  10  after the retinoscope is calibrated. After the retinoscope is calibrated and plate  32  secured into position, the alignment line  28  on plate  32  allows the retinoscopist to know where to place the calibration line  11  on the power capsule  10  to perform retinoscopy with diverging light rays to obtain an infinity retinoscopic endpoint adjusted to one retinoscopic working distance as shown further in  FIG. 10 -A. 
     With reference to  FIG. 7 -D, an attachable plate  24  for retrofitting a retinoscope  1  when calibrated to a +0.50 D with-motion pupillary reflex endpoint using diverging retinoscopic light rays  13  is shown. The plate  24  shown here is a diverging plate  33  and is used when the diverging light emanating from the retinoscope is calibrated for a +0.50 D with motion retinoscopic endpoint as shown further in  FIG. 11  and  FIG. 11 -A. The +0.50 D diverging plate  33  has a front surface  26 , a rear surface  27  and an alignment line  28 . The plate  24  is attachable to the retinoscope via an attachment means  29 , such as screws, adhesive, nuts, etc. The plate  24  is moveable via an adjustment means  30 , such as a slot that moves along a screw, so that a user may adjust the alignment line  28  up or down to be in alignment with the calibration line  11  on the power capsule  10  after the retinoscope is calibrated. The alignment line  28  on plate  33  allows the retinoscopist to know where to place the calibration line  11  on the power capsule  10  to perform retinoscopy with diverging light rays to obtain a +0.50 D retinoscopic endpoint adjusted to one retinoscopic working distance as shown further in  FIG. 11 -A. 
     With reference to  FIG. 8 , a flow chart showing the steps for calibrating a retinoscope for a +0.50 D with-motions retinoscopic endpoint using converging retinoscope light rays  14  is show. First, the retinoscopic working distance is optically measured  34  as shown in  FIG. 5 . Then, the required focal length of the emitted retinoscope light for a +0.50 D retinoscopic endpoint is determined  35  using the calibration chart  18  illustrated in  FIG. 6 . For example, if the retinoscopic working distance is 67 cm, the required focal length of the emitted retinoscopic light is 100 cm. Next, the retinoscope is placed at the proper focal length from a wall  36  and focused  37 . Finally  38 , the alignment line  28  on the +0.50 D converging plate  25  is aligned with the calibration line  11  on the power capsule  10  as shown further in  FIG. 8 -A and secured  39 . 
     With reference to  FIG. 8 -A, a retinoscope  1  having a +0.50 D converging plate  25  attached thereto is shown. The retinoscope  1  has been calibrated for a +0.50 D pupillary reflex endpoint using converging retinoscope light rays  14 . The technique for performing retinoscope using a retinoscope calibrated for a +0.50 D retinoscopic endpoint is the same as in conventional retinoscopy, except that the calibration line  11  on the power capsule  10  is aligned with the alignment line  28  on the +050 D converging plate  25  and the retinoscopic endpoint is a +0.50 D with-motion retinoscopic reflex with the +0.50 D pupillary reflex and intercept moving in unison. 
     With reference to  FIG. 9 , a flow chart showing the steps for calibrating a retinoscope for a +0.75 D with-motions retinoscopic endpoint using converging retinoscope light rays  14  is show. First, the retinoscopic working distance is measured  34  as shown in  FIG. 5 . Then, the required focal length of the emitted retinoscope light is determined  35  using the calibration chart  18  illustrated in  FIG. 6 . For example, if the retinoscopic working distance is 67 cm, the required focal length of the emitted retinoscopic light is 133 cm. Next, the retinoscope is placed at the proper focal length from a wall  36  and focused  37  and the thumb-slide held in position. Finally  38 , the alignment line  28  on the +0.75 D converging plate  31  is aligned with the calibration line  11  on the power capsule  10  of retinoscope  1  as shown further in  FIG. 8 -A and secured  40 . 
     With reference to  FIG. 9 -A, a retinoscope  1  having a +0.75 D converging plate  31  attached thereto is shown. The retinoscope  1  has been calibrated for a +0.75 D endpoint using converging retinoscopic light rays  14 . The technique for performing retinoscopy using a retinoscope calibrated for a +0.75 D retinoscopic endpoint is the same as in conventional retinoscopy, except the calibration line  11  on power capsule  10  is aligned with the alignment line  28  on the +075 D converging plate  31  and the retinoscopic endpoint is a +0.75 D retinoscopic and moves in unison with the intercept. 
     With reference to  FIG. 10 , a flow chart showing the steps for calibrating a retinoscope  1  for an infinity retinoscopic endpoint using diverging retinoscopic rays  13  is shown. First, the retinoscopic working distance  34  is measured in centimeters, as shown in  FIG. 5 . Next  41 , the retinoscopic working distance in centimeters  19  is matched to the power of the calibration lens required  20  using the calibration chart  18 . For example, if the retinoscopic working distance is 67 cm, the power of calibration sphere would be +3.00 D. Next, the retinoscope  1  is placed at a distance from the wall equal to the retinoscopic working distance  42 . Next, the +3.00 D calibration sphere as determined from  41  is placed in front of the retinoscope  43 . With the thumb-slide  2  in the maximal upward position and the diverging retinoscopic light shining through the +3.00 D calibration spherical lens, the thumb-slide  2  is lowered until the retinoscopic streak is focused onto the wall  37 . If the retinoscopic streak fails to focus onto the wall, the bulb  4  is advanced towards the condensing lens  3  within the retinoscope  1  and the procedure repeated until the retinoscopic streak is focused onto the wall,  44 . Next  45 , the alignment line  28  on the infinity diverging plate  32  is aligned with the calibration line  11  on the power capsule  10  and secured in position  46  as shown further in  FIG. 10 -A. 
     With reference to  FIG. 10 -A, a retinoscope  1  having a diverging plate  32  attached thereto is shown. The retinoscope  1  has been calibrated for an infinity retinoscopic endpoint using diverging retinoscope light rays  13 . The technique for performing retinoscopy using an infinity retinoscopic endpoint with the emitted retinoscopic light rays calibrated to the examiner&#39;s retinoscopic working distance is the same as in conventional retinoscopy, except that the calibration line  11  on the power capsule  10  is aligned with the measuring line  28  on the infinity plate  32 . 
     With reference to  FIG. 11 , a flow chart showing the steps for calibrating a retinoscope  1  for a +0.50 D retinoscopic endpoint using diverging retinoscope light rays  13  is show. First the working distance is measure centimeters  34 , as shown in  FIG. 5 . Next  41 , the retinoscopic working distance in centimeters  19  is matched to the power of the calibration lens required  21  using the calibration chart  18 . For example, if the retinoscopic working distance is 67 cm the power of the calibration sphere would be +3.50 D. Next, the retinoscope  1  is placed at a distance from the wall equal to the retinoscopic working distance  42 . Next, the +3.50 D sphere is placed in front of the retinoscope  43 . With the thumb-slide  2  in the maximal upward position and the diverging retinoscopic light shining through the +3.50 D calibration lens, the thumb-slide  2  is lowered until the retinoscopic streak is focused onto the wall  37 . If the retinoscopic streak fails to focus onto the wall, the bulb  4  is displaced toward the +20 D condensing lens  3  within the retinoscope and the procedure repeated until the retinoscopic streak is focused onto the wall,  44 . Next  47 , the alignment line  28  on +0.50 D diverging plate  33  is aligned with the calibration line  11  on the power capsule  10  and secured in position  48  as shown further in  FIG. 11 -A. 
     With reference to  FIG. 11 -A, a retinoscope  1  having a +0.50 D diverging plate  33  attached thereto is shown. The retinoscope  1  has been calibrated for a +0.50 D retinoscopic endpoint using diverging light rays  13  exiting the retinoscope. The technique for performing retinoscopy using a retinoscope calibrated to one&#39;s retinoscopic working distance for a +0.50 D retinoscopic endpoint is the same as conventional retinoscopy except the retinoscopic endpoint is a +0.50 D with-motion retinoscopic endpoint and the calibration line  11  is aligned with the alignment line  28 . In contrast to the +0.50 D retinoscopic endpoint produced with converging rays emitted from the retinoscope in  FIG. 8 -A, with diverging rays the +0.50 D retinoscopic endpoint moves faster than the intercept. 
     With reference to  FIG. 12 , a flow chart showing the steps for performing a calibration check on retinoscopes calibrated to emit converging rays  14  as shown in  FIGS. 8 -A and  9 -A is shown. First, the practitioner assumes his or her routine retinoscope distance  49 . Then the practitioner lowers the thumb-slide  2  of the retinoscope from its maximal upward position until a neutrality reflex is seen in an emmetropic eye  12  and holds the thumb-slide in this position  15 . If the calibration line  11  on the power capsule  10  is level with the alignment line  28  on the converging plates  25  or  31 , the retinoscope is calibrated  50 . In the Copeland Optec 360 Streak Retinoscope, the thumb-side is kept in the most superior position by a spring. 
     With reference to  FIGS. 13 and 14 , a rear view and a side view, respectively, of a retinoscope  1  having an upper slide bar  51  attached to the body of the retinoscope and located superiorly to the thumb-slide  2  thereto and having a lower slide bar  56  attached to the body of the retinoscope and located inferiorly to the thumb-slide  2  is shown. The slide bars  51 ,  56  are attachable to the retinoscope via an attachment means  29 , such as screws, nut, etc. The slide bars  51 ,  56  are moveable via an adjustment means  30 , such as a slot that moves along a post  54 . After the retinoscope is calibrated, the slide bars  51 ,  56  are adjusted to touch the top and bottom, respectively, of the thumb-slide  2  and locked in place via a locking means  55 , such as a screw, etc., to prevent the thumb-slide  2  from moving upward or downward. 
     Although a practitioner may use a +0.50 D retinoscopic endpoint or a +0.75 D retinoscopic endpoint, the +0.50 D retinoscopic endpoint is easier, faster and more convenient to confirm than the +0.75 D retinoscopic endpoint, since during retinoscopy, the neutrality reflex is displaced 2 lenses from the +0.50 D retinoscopic endpoint and 3 lenses from the +0.75 D retinoscopic endpoint. 
     Finally with reference to  FIG. 15 , a front perspective view of a bulb extender  52  of the present invention is shown. The bulb extender  52  acts as a spacer to increase the height of a lamp  4  and filament  5  within the retinoscope  1 . The bulb extender  52  elevates lamps  4  having shorter filaments  5  towards the lens  3  to increase the divergence of emitted retinscopic light. The bulb extender  52  has at least one aperture  53  to allow electronic communication between a power source of the retinoscope  1  and the filament  5 . 
     With reference to  FIGS. 19A-22 , the measurement of the reflectance of the MPOD is preferably performed with a modified Copeland Optec 360 Streak Retinoscope, with a halogen or incandescence bulb with a linear filament and an elongated permanent or attachable head rest, as illustrated in  FIG. 19A  projecting parallel light rays. The thumb-slide moves the bulb in relation to a +20.0 D spherical lens within the retinoscope to emit parallel light. The slide locks maintains the retinoscope in calibration when performing retinoscopy with diverging, converging or parallel retinoscopic light (as illustrated in  FIGS. 1-15 ). The retinoscopic technique for detecting AMD requires the retinoscope to emit parallel light rays from the same retinoscopic working distance for each eye. 
     Formula for Calibration of Retinoscope to Emit Parallel Light: 
     The formula for determining the focal length and power of the pupillary image of the retinoscope emitting parallel light is:
 
Image  I   1 +Image  I   3   =t ( D ) at emmetropia
 
Image  I   1 =vergence of retinoscopic light( D  
 
Image  I   3 =pupillary reflex( D )
 
 t ( D )=RWD expressed in diopters
 
Since the vergence of parallel light (Image I 1 ) is 0.00 D, the pupillary reflex is equal to the retinoscopic working distance (cm) expressed in diopters.
 
Image  I   3   =t ( D ) at emmetropia
 
Upon neutralization of the patient&#39;s refractive error and the fulfillment of the examiner&#39;s retinoscopic requirements, conjugate or identical images are formed in the patient&#39;s and an examiner&#39;s eyes.
 
Requirements for Examiner to See Conjugate Images of the Reflected Pupillary Streak (Image I 3 )
         1. The examiner&#39;s refractive error must be corrected.   2. If the retinoscopist is presbyopic, a spherical lens with a focal length equal to the retinoscopic working distance attached to the back of the retinoscope will produce a clear image of the pupillary streak.   3. The retinoscopic working distance must be the same for the right and left eyes.   4. The patient&#39;s right eye must be examined by the retinoscopist&#39;s right eye and vice versa.   5. The evaluation of the diagnostic pupillary streak requires an 8-10° off-axis retinoscopic position, laterally displaced. This allows the patient to fixate on the Snellen letters, reduces accommodation and maintains central fixation. An 8-10° off-axis position requires the retinoscope to be displaced 4 cm laterally to the patient&#39;s pupil for a 60-65 cm retinoscopic working distance.   6. The highest concentration of pigment  15  located in the fovea. The foveal pigment decreases precipitously by a factor of 1/300, 7-8° from the foveal axis to the periphery of the retina (Beatty). A decrease in the 8-10° off axis reflectance of the pupillary reflex as compared to on-axis retinoscopy is more indicative of RPE damage and loss of melanin pigment of the retinal pigment epithelium.   7. A 3-4 mm undilated pupil produces the optimal conjugate pupillary reflex. A dilated pupil induces higher order aberrations blurring the optical qualities of the pupillary streak. A dilated pupil will induce aberrant astigmatic error in the pupillary reflex, especially in the vertical meridian.
 
Calibration of Retinoscope to Emit Parallel Light Rays:
   1. Move the thumb-slide to focus the retinoscopic light through a spherical lens onto a wall displaced the focal length of the sphere from the wall. Adjust slide bars  51  and  56  to keep retinoscope calibrated emitting light.   2. Align the arrow head of the “parallel calibration line”           symbol on the calibration plate or the attachable           emblem in  FIG. 21  with the circumferential calibration line above the knurl to mark the position of the power capsule housing the bulb for future parallel infinity retinoscopies.   4. Attach calibration plate to the side of the retinoscope, as illustrated in  FIG. 21 .   5. Adjust the slide-bar to maintain the thumb-slide in a fixed position to maintain the calibration of the retinoscope for future diagnostic parallel and converging or diverging retinoscopies, as illustrated in  FIG. 19B-E . The thumb-slide and slide bars allows one to change the vergence of the retinoscopic light from converging or diverging retinoscopy to parallel without moving the retinoscope or changing the retinoscopic working distance.       

     The luminance of the calibrated pupillary streak is graded on a scale of 0-4, as illustrated in  FIG. 22 , to evaluate the severity of the age-related maculopathy or degeneration (AMD) and other maculopathies. 
     With reference to  FIG. 19 , a calibrated streak retinoscope for use with the Primary Scale is illustrated. The retinoscope has the following features:
         1. Elongated head rest allows examiner to wear glasses in order to see the pupillary reflex clearly.   2. A trifocal lens is attached to the back of retinoscope for Presbyopic examiners.   3. Slide locks maintain calibration of the retinoscope as the thumb slide moves from calibrated converging or conventional retinoscopy to parallel for diagnostic retinoscopy,   4. Position for +0.50 D converging retinoscopy used in refractive retinoscopy.   5. Position for parallel retinoscopy (         ) used in diagnostic retinoscopy.
 
Using the Primary Scale in Diagnostic Retinoscopy
       

     Diagnostic Retinoscopy is performed after a preliminary ophthalmic exam and a subjective refraction but prior to pupillary dilatation. The Diagnostic Retinoscopic Steps require:
     1. The retinoscope, as illustrated in  FIG. 1  to be calibrated to emit parallel light. Once calibrated, recalibration should be unnecessary. The brightness of the light should be evaluated often as the retinoscope is battery operated. The retinoscope may need to be re-calibrated if the bulb or the retinoscopic working distance (RWD) is changed.   2. The retinoscope is also calibrated for a +0.50 D pupillary streak endpoint ( FIG. 1 ).   3. Slide locks allow the examiner to change the retinoscopic procedure from parallel retinoscopy to +0.50 D to converging retinoscopy by moving the thumb-slide without moving the retinoscope ( FIG. 1 ).   4. An 8-10° off-axis retinoscopic position allows patients to read the Snellen chart thus maintaining foveal fixation. The 8-10° off-axis retinoscopic position allows the retinoscopic light to be focused onto the retina containing a high concentration of rods which surrounds the fovea.   5. The reflectance of the pupillary reflex is evaluated in the 180° meridian for consistency of comparison. The brightness of the 180° pupillary streak varies if the pupillary streak is rotated from the 0° meridian.
 
Primary Scale for Evaluating the Brightness of the Parallel (         ) Retinoscopic Pupillary Streak
   

     The brightness of the pupillary streak is graded on a scale of #0-#4, as illustrated in  FIG. 23 , with #4 being typical of young, healthy eyes to #0 which is typical in eyes with severe AMD. 
     After the parallel pupillary streak is evaluated and a notation made, the examiner will begin the evaluation of the pupillary streak using the Optical Scale, as illustrated in  FIG. 22 . 
     The retinoscope of the present invention allows a confirmation of the Primary Scale using a more Objective Scale comprised of four additional settings for converging light that are illustrated in  FIG. 24 . This is an important addition to the patent as it is more sensitive to the detection of early and advanced macular degeneration. By objectively confirming the initial Objective Scale, novice examiners will become more confident as they become more experienced. 
     The retinoscope and scale has been calibrated for a 65 cm retinoscopic working distance (RWD) and parallel light (+1.50 D) which produced the brightest pupillary streak and four converging retinoscopic settings (+1.00 D, +0.75 D+0.62 D and +0.50 D) which reduce the light intensity of reflected pupillary reflex by extending the focal lengths of the retinoscopic light. These positions are marked, as illustrated in  FIG. 24 , can be changed using the thumb slide. Decreasing the settings in this order renders a gradual reduction of the light intensity of the pupillary reflex seen by the examiner. 
     The scale illustrated in  FIG. 24  represents the position of the linear bulb filament for a +20.00 D lens in the power chamber of the Copeland Streak Retinoscope for a 67 cm retinoscopic working distance (RWD) to produce the pupillary reflexes (+1.50 D to +0.50 D) of decreasing light intensity. If the RWD is not 67 cm. a different scale plate calibrated to the patient&#39;s RWD is attached to the handle of the retinoscope and adjusted, as illustrated in  FIG. 19 . The calibration scales in  FIGS. 19 &amp; 24  are based upon Formula 1 below.
 
Image  I   1 +Image  I   3   =t ( D ) at emmetropia  (1)
 
Image  I   1 =vergence of retinoscopic light( D  
 
Image  I   3 =pupillary reflex( D )
 
 t ( D )=RWD expressed in diopters
 
     The decrease in the illumination of the pupillary reflex in eye with AMD and similar maculopathies can be calculated using the chart in  FIG. 25  since:
         1. The linear height size of the retinoscopic light focused onto the retina and reflected as the pupillary streak is related to the total focal length of the retinoscopic light emitted from the retinoscope (I 1 ).   2. The intensity of radiant light energy from a point surface decreases in proportion to the distance from the object squared when there is no energy absorbed or scattered by the medium.   3. The decrease in the reflectance of the pupillary streak is indicative of the degree of RPE and photoreceptor degeneration in AMD and other various maculopathiesin eyes with clear media.       

     The decrease in the illumination of the pupillary reflex can be calculate since the intensity of radiant light energy from a point surface decreases in proportion to the distance from the object squared when there is no energy absorbed or scattered by the medium. The decrease in the reflectance of the pupillary streak is indicative of the degree of RPE and photoreceptor degeneration in AMD eyes with clear media. 
     Elongating the 67 cm focal length of the papillary reflex decreases the light intensity of the parallel pupillary streak, as illustrated in  FIG. 25 . The pupillary reflex produced with the Copeland Optec 360 Streak Retinoscope cannot be measured below a +0.50 D pupillary streak with the scale, as illustrated in  FIG. 24 , as the spacing between the dioptric powers becomes infinitely small. 
     Using the Optical Scale: 
     The scale on the retinoscope as illustrated in  FIG. 24 , allows one to evaluate the RPE and photoreceptor damage by comparing the brightness of the papillary reflex produced with parallel light emitted from the retinoscope to the brightness of the pupillary reflex produced by elongating the length of the papillary reflex from 67 cm to 200 cm (+0.50 D) to reduce the light intensity of the papillary reflex as illustrated in  FIG. 25 . 
     When the pupillary streak disappears, the position of the calibration line on the scale illustrated in  FIG. 24  will be proportionate to the AMD damage. The papillary streak in a healthy eye remains visible as the light intensity of the papillary reflex is extended from 67 cm to 200 cm. 
     With Diagnostic Retinoscopy and estimating the degree of retinal degeneration, an ophthalmologist or optometrist can refer patients to a specialist prior to significant decreases in visual acuity, Amsler Grid distortions or severe retinal damage. These techniques could improve the diagnostic skills of physicians in early detection of AMD and screenings could be part of every eye examination. Early detection will greatly benefit patients, research and society. 
     It is to be understood that while a preferred embodiment of the invention is illustrated, it is not to be limited to the specific form or arrangement of parts herein described and shown. It will be apparent to those skilled in the art that various changes may be made without departing from the scope of the invention and the invention is not to be considered limited to what is shown and described in the specification and drawings.