Clinical Refraction

David Meyer OD FAAO

Objectives
Review concepts related to clinical refraction

Learn practical approaches to daily patient care

Retinoscopy
Very important for:
• Objective refraction determination
• Detecting optical aberrations (keratoconus)
• Opacities (PSC)
Useful for:
• Infants
• Wiggly children
• Adults and children unable to cooperate/poor at subjective refraction
Retinoscopy
Use plano mirror setting
• Sleeve all the way down

Have pt fixate on large distance object

• Relaxed accommodation

• 20/400 letter

• May need to cycloplege kids

Retinoscopy
Three basic types of reflexes:
• “With” motion
• “Against” motion
• “Neutral” or no motion

Involves the “far point”

• The farthest away the eye can see clearly with accommodation entirely
at rest is the FAR POINT (more on this later)
Retinoscopy and the Far Point
If the far point is BETWEEN the examiner and the patient, then divergence of the
light rays occur
• “Against” motion

If the far point is is BEHIND the examiner, the light moves in the same direction of
the sweep
• “With” motion

If the light fills the pupil and does not move, then NEUTRALITY is found
• Moving back would cause the far point to be between you and the patient, so AGAINST
motion would be seen. Opposite if moving forward.
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Retinoscopy Quiz
You are using a retinoscope on Cloyd, your -2.00 D myopic patient

If you were sitting 100cm away, what motion would you see?

Cloyd’s far point: 1/D = 1/2 = 0.50m (or 50cm)

At 50cm, so the far point is between you and him:
“Against” motion

At 50cm, you would see “neutral”

At any distance closer than 50cm, you would see “with”
Retinoscopy
Characteristics of the reflex:

• Speed
 The closer you are, the faster the reflex speed
• Brilliance
 Brighter reflex as neutrality is approached
 “With” reflexes are usually brighter than “against”
• Width
 The reflex broadens as you approach neutrality
Retinoscopy
“With” motion - add plus

“Against” motion - add minus

Retinoscopy
Working Distance:
• Based on how far away you are from the patient
 Inverse relationship
• Subtracted from the power of the correcting lens
If you are sitting___away Then subtract:

50cm 2.00D

67cm 1.50D

100cm 1.00D
Retinoscopy
Finding the axis

• The eye is made up of two principal meridians

• Neutralize the less plus axis first

• Then, rotate the streak 90 degrees. You should see “with” motion

• Align the axis of the phoropter with your streak and add plus cyl until
“neutral” is found
You are doing retinoscopy on an aphakic child with Down Syndrome. With
the streak oriented horizontally you get a neutral reflex with a +22 D lens.

With the streak oriented vertically you get a neutral reflex with a +27 D lens.

Assume a working distance of 50 cm. What is the distance Rx of the child?

+22 +20
-2

+27 -2 +25

Answer: +20.00 +5.00 x 090

+20.00 +5.00 x
90
Subjective Refraction
Astigmatic Dial Technique

• Rarely used
• Steps:
 Fog the patient by adding more (+) sphere
 Identify the blackest and sharpest lines
 Add plus cylinder with the axis parallel to the blackest and sharpest line until all
lines appear equal (plus cyl)
 Reduce (+) sphere to un-fog the patient
Subjective Refraction -Cross-Cylinder Technique
By far the most common method +0.25

• Jackson cross cylinder

 -0.25 +0.50 x 180 -0.25

• Refine axis before refining power

 Position the JCC’s principal meridians 45 degrees away from the correcting cyl
 “Straddle the line”
 “Chase the white” (plus cyl)
• Refine the power
 Align the JCC with the principal meridians of the correcting lens
Axis refinement Power refinement
Subjective Refraction -Cross-Cylinder Technique
Don’t forget about spherical equivalent!
For every 0.50 change in cyl, make a 0.25 change in the sphere

Cylinder
Spherical Equivalent = Sphere +
2

Example:
Natalie’s Rx: +2.00 +3.00 x 180 What is the spherical equivalent?
2 + 3/2 = +3.50
Subjective Refraction -Refining the Sphere
Goal: The strongest (+) sphere (or weakest (-) sphere) that yields the best VA

Reduce (+) sphere until optimal VA is reached

• Watch out for “darker and smaller” = likely over-minused

Duochrome Test
• RAM-GAP (red add minus, green add plus)
• Green has shorter wavelengths, red has longer
 Green wavelengths focus anterior to red
Red is darker and blacker.

By adding minus...

...then green becomes darker

and blacker
Subjective Refraction -Binocular Balance
Fogging
• Rarely used
• Uses a +2.00 D sphere over each eye and compare
Prism Dissociation
• Much more common
• Add vertical prism to one or both eyes to create two images
• Add plus to the clearest image
Prism Dissociation OD has BD prism in front
of it and sees this

“The top line is more

sharp and clear” FZBDE
OS has BU prism in front of it and
sees this

FZBDE
If Base DOWN prism was in front of the right eye, then add +0.25 in
OD until both lines appear equal in clarity.
A Final Word on Subjective Refraction...
Every 0.25 change is APPROXIMATELY equal to one improved line in VA

Example:

• Hedwig’s habitual Rx and VA in OD: -1.50 DS 20/30

• Adding -0.25 should get him to about 20/25

• Adding another -0.25 should get him to about 20/20

• Expected refraction: -2.00 DS

Spectacle Correction of Ametropias
Far Point

• The farthest away the eye can see clearly with accommodation entirely
at rest is the FAR POINT
 For myopia: far point is between infinity and the patient
 For hyperopia: far point is behind the retina
• To correct the ametropic eye the correcting lens must place its image
(Secondary focal point – f 2) at the eye’s far point.

• The image of the far point plane becomes the object that is focused on
the retina
Vertex Distance
Changing the position of the correcting lens changes the relationship between
F2 and the eye’s far point
• Very important for prescriptions greater than +5.00/-5.00
 Standard glasses vertex is 12mm
• Critical for contact lens prescribing
Following Example:
• Lonzo wears +10.00 glasses that sit 10mm in front of his eyes. If he
prefers to wear those lenses at 5mm in front of his eyes, what power
should you prescribe?
A +10.00 lens is moved from 10mm to
5mm away from the cornea What power lens has a focal length of 95mm (9.5 cm)?
1 1
D = = = +10.5 D
f .095 m

10 mm

5 mm
+10
+10.5

Far Point - 90mm

behind the cornea

95 mm

100 mm
Prescribing for Children
Myopia
• Retinoscopy and cycloplegia are critical

• Children tolerate cylinder well

• Consider contact lenses for high minus or anisometropic eyes

Prescribing for Children
Hyperopia
• More complex than myopia - patient sometimes can’t see distance
or near
• Often accompany strabismus and accommodation issues
• Retinoscopy and cycloplegia are very critical
• Except in cases of esotropia, “cut the plus”
 Children may not be able to fully relax accommodation
• Children often tolerate cylinder and anisometropia well
Clinical Accommodative Problems
Presbyopia
• Gradual loss of accommodative amplitude

Accommodative Insufficiency
• Premature loss of accommodative amplitude
• Blurring of near objects, fatigue
• Require additional reading plus power
• Often simply due to uncorrected hyperopia
Clinical Accommodative Problems
Accommodative Excess
• AKA: ciliary muscle spasm
• Headache, brow ache, variable distance vision, very close near point
• Can occur after prolonged and intense periods of near work
• Can be difficult to refract; cycloplegia is necessary
AC/ A Ratio
Accommodative Convergence/Accommodation Ratio
• How much do your eyes converge when you accommodate 1 D?
• Normal AC/A is 3:1 - 5:1
i.e. for every diopter of accommodation, your eyes converge 3 - 5 prism diopters
How to measure: 2 ways
1. Heterophoria method
 Move the fixation target from distance to .33 meters
 Use an equation
 Rarely used
AC/ A Ratio
2. Gradient Method (more common) - two different ways to measure
A. Stimulate accommodation
• Measure heterophoria at distance, then add -1.00, measure again
• AC/A is the difference between the 2 measurements
B. Relax accommodation
• Set the target at 0.33 m and measure the heterophoria
• Add +3.00 D sphere, then measure again
• The phoria difference divided by 3 is the AC/A ratio
AC/ A Ratio Example
Larry has a measured phoria of 8 BI (8 prism diopters of exophoria) at distance

After adding -1.00 D, you measure 2 BI (2 prism diopters of exophoria)

What is Larry’s AC/A?

6:1

Pt tends to converge a lot for every diopter of accommodation

Pt may complain of eye strain at near

Accommodation
Accommodative Amplitude

• How much a patient can accommodate

• The dioptric difference between the near point and the far point
 MYOPE

Far
Point

Near Point
 Hyperopia

N
F
•
Accommodation
Quiz:

Jerry’s far point is 33cm. What is his refractive error? -3.00

Say Jerry can accommodate 4 diopters. Without glasses, what is his near point?

3.00D of myopia + 4.00D of accommodation = 7 D

f = 1/D

1/7 = .1428m = 14.28cm

Another Example
How much would Jerry have to accommodate (without glasses) to see something
20cm in front of his face?

Far point is 33cm (-3.00D myope)

Must accommodate to see something at 20cm (13mm closer than his far point)

1/.20 = 5 D. But since he is already has 3D of myopia:

5D - 3D = 2 D
Selecting an Add Power
Many different methods

From the patient’s measured accommodative amplitude, allow ½ to be held in

reserve

Example:

If a patient has 2.00D of max accommodation, they can accommodate 1.00D

comfortably
Selecting an Add Power
Example:

You determine that Shannon has 1.50D of max accommodation

0.75D may be comfortably contributed by the patient

At near, pt needs 2.50D of accommodation (40cm away)

Total amount of accommodation needed - pt’s available accommodation =

add power needed

2.50D - 0.75D = +1.75 add
Types of Multifocal Lenses
Bifocals

• See the following picture

Trifocals

• Distance, intermediate, and near

PALs (Progressive addition lenses)

• Can provide clear vision at all ranges

Anatomy of a PAL (Progressive Addition Lens)
4 types of optical zones

• Distance, intermediate (corridor), near, and peripheral distortion.

Drawback: some degree of peripheral distortion is present in ALL types of

PALs

• “Hard Design” vs “Soft Design”

• Sand analogy
Ideal for: Ideal for:
● Advanced presbyopes ● Early presbyopes
● Small, detailed near-work ● General use
● Large area for distance viewing ● Computer use
● Watchmakers
Prentice Rule
All lenses act like prisms when not looking through the optical center

hD

Prismatic effect (in prism diopters)

h Distance from the optical center (in centimeters)

D Lens power (in diopters)

Important
An easy way to look at glasses:

Plus Lens Minus Lens

Image Displacement
An unequal displacement of images

• Caused by different lens powers

• Occurs when you are not looking through the optical center

Let’s do an example...
Image Displacement
OD: +4.00 D OS: +1.00 D

8mm 8mm

2mm 2mm

Vertical: 0.8 x +4.00 = 3.2 BU Vertical: 0.8 x +1.00 = 0.8 BU

Horizontal: 0.2 x +4.00 = 0.8 BO Horizontal: 0.2 x +4.00 = 0.2 BO
Induced phoria:
OD: 3.2 - 0.8 = 2.4 BU
OD: 0.8 BO + 0.2 BO = 1 BO
Image Displacement Good for
Bad for
myopes;
hyperopes;
makes image
minimizes image
displacement
displacement
worse

Round Top

Bad for Good for

hyperopes; myopes;
makes image minimizes
displacement displacement
worse

Flat Top
Image Displacement
Bottom line:

• Round-top bifocals work better on hyperopes

• Flat-top bifocals work better on myopes

Image Jump
Results from the difference between prismatic effects of the distance and near
portion at the junction line
• i.e. image moves when looking from distance portion to the bifocal

Jump depends only on the power of the seg and the location of its optical center

Important: “The closer the optical center of the segment approaches the top edge
of the segment, the less the image jump is.”
• Flat top segments produce less image jump than round-tops
Less image jump
More image jump
How to you combat image displacement and jump?
Press-on prisms
• Fresnel prisms are easy to try
Slab-off
• Basically creating base-up prism over the more minus lens
Reverse slab-off
• Much more common method
• Add base-down prism over the more plus lens
How to you combat image displacement and jump?
Dissimilar segments

• i.e. round top in one eye, flat top in the other

Reading glasses

Contact lenses

Refractive surgery
Prescribing Special Lenses
Aphakic Lenses

• Use retinoscope

• “Pincushion” distortion

• Recommend smaller lenses

• Best idea: contact lenses

Therapeutic Use of Prisms
Vertical fusional amplitudes are usually small

• Prisms may be very helpful

• Usually prescribe the minimum amount to eliminate diplopia

• Trial with Fresnel prisms is useful

Horizontal heterophorias

• Usually require higher amounts of prism correction

• Watch for adaptation

Questions?