AAO READING

Objective Refraction
Technique: Retinoscopy
Dwinda Aulia Aslam

Pembimbing :
dr. Purnamanita Syawal, Sp.M,
MARS
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RETINOSCOPY

´Retinoscopy is an important skill and tool for

ophthalmologist
´Retinoscope à a tool to detect
spherocylindrical refractive error of the eye,
optical aberrations, irregularities, and
opacities
´Useful to examine infants, children, and adults
who are unable to communicate
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RETINOSCOPY

´ Most retinoscope employ Copeland streak

projection system
´ Illumination model of retinoscope à bulb with
straight filaments form a streak in its projection or
slit-shaped aperture
´ Light reflected from a mirror:
o Half-silvered (Welch Allyn, Heine models)
o Totally silvered (Copeland instrument) (Fig. 4)
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RETINOSCOPY
´ The filament light source (or the slit
aperture) can be moved in
relation to a convex lens in the
system à use sleeve of
retinoscope
´ If the light is slightly divergent à
appears to come from a point
behind the retinoscope à as if the
light were reflected off a flat mirror
(ie, a plane mirror setting) (Fig 4-2)
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RETINOSCOPY

´ When the distance between

the convex lens and the
filament is increased by moving
the sleeve on the handle à
convergent light is emitted
´ In this situation, the image of
the filament appears between
the examiner and the patient
à as if the light were reflected
off a concave mirror (Fig 4-3)
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RETINOSCOPY

´ Retinoscopy performed with either a

concave mirror setting or a plane mirror
setting, determined by the sleeve
´ Plane mirror setting is usually performed
so that light is parallel (or slightly
divergent) as it enters the pupil of the
patient’s eye
´ The direction of motion in concave
mirror effect is opposite that of the plane
mirror effect
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RETINOSCOPY

´Concave setting function à to sharpen

the reflex while determining the axis of
astigmatism
´Using concave setting during power
determination (of sphere of cylinder) à
may lead to false end points (neutrality)
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RETINOSCOPY

´ Not all retinoscopes employ the

same sleeve position for the plane
mirror setting
´ Example:
o Copeland retinoscope à plane
position with the sleeve up
o Welch Allyn (or Heine) à plane
position with the sleeve down
§ The axis of the streak is rotated with
the sleeve
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Positioning and alignment

´Examiner uses his or her right

eye to perform retinoscopy on
the patient’s right eye, vice
versa
´Doing so prevents the
examiner’s head from moving
into the patient’s line of sight à
inadvertently stimulating
accommodation
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Positioning and alignment

´If the examiner looks directly through the optical

centers of the trial lenses à reflections from the
lenses may interfere
´If the examiner is too far off- axis à unwanted
spherical and cylindrical errors may occur
´The optimal alignment is just off center à lens
reflections can still be seen between the center of
the pupil and the lateral edge of the lens
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FIXATION AND FOGGING

´ Retinoscopy should be performed with

patient’s accommodation relaxed
´ Patient should fixate at a distance on a
nonaccommodative target
´ For example à the target may be a dim
light at the end of the room or a large
Snellen letter (20/200 or 20/400 size)
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FIXATION AND FOGGING

´ Plus lenses may be introduced in front of

the eye not being examined to aid in
the relaxation of accommodation
´ Children typically require
pharmacologic cycloplegia (such as
cyclopentolate 1%)
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RETINAL REFLEX

´ The projected streak illuminates an area of the

patient’s retina, and this light returns to the
examiner
´ By observing characteristics of this reflex, the
examiner determines the refractive status of the
eye
´ If patient’s eye is emmetropic à light rays are
parallel to one another
´ If patient’s eye is myopic à rays are convergent
(Fig. 4-4)
´ If the eye is hyperopic à the rays are divergent
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RETINAL REFLEX

´Through the peephole in the retinoscope, the

emerging light is seen as a red reflex in the patient’s
pupil.
´If the examiner (specifically, the peephole of the
retinoscope) is at the patient’s far point à all the
light leaving the patient’s pupil enters the peephole
and illumination is uniform
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RETINAL REFLEX

´If the far point of the patient’s eye is not at the

peephole of the retinoscope à only some of the
rays emanating from the patient’s pupil enter the
peephole à illumination of the pupil appears
incomplete
´If the far point is between the examiner and the
myopic patient à the emerging rays will have
focused and then diverged
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RETINAL REFLEX

´ The border between the dark and lighted portions of the pupil will
move in a direction opposite to the motion (sweep) of the retinoscope
streak (known as against movement) as it is moved across the
patient’s pupil
´ If the far point is behind the examiner, the light moves in the same
direction as the sweep (known as with movement; Fig 4-5)
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RETINAL REFLEX

´ The state in which the light fills the pupil and apparently does not
move à neutrality (Fig 4-6)
´ If the examiner moves forward (in front of the far point), with
movement is seen
´ If the examiner moves back and away from the far point, against
movement is seen
´ The far point may be moved with placement of a correcting lens in
front of the patient’s eye
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CHARACTERISTICS OF THE REFLEX

´The moving retinoscopic reflex has 4 main characteristics

(Fig 4-7):
1. Speed. The reflex seen in the pupil moves slowest
when the far point is distant from the examiner
(peephole of the retinoscope). Large refractive errors
have a slow- moving reflex, whereas small errors have
a fast reflex
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CHARACTERISTICS OF THE REFLEX

2. Brilliance. The reflex is dull when the far point is

distant from the examiner; it becomes brighter as
neutrality is approached
3. Width. When the far point is distant from the
examiner, the streak is narrow. As the far point is
moved closer to the examiner, the streak
broadens and, at neutrality, fills the entire pupil
à only to with movement reflexes
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CHARACTERISTICS OF THE REFLEX

4. Regularity. An irregular reflex indicates a media

problem that should be further explored in
examination
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THE CORRECTING LENS

´When the examiner uses the appropriate correcting

lenses (with either loose lenses or a phoropter), the
retinoscopic reflex is neutralized
´In other words, when the examiner brings the
patient’s far point to the peephole, the reflex fills the
patient’s entire pupil (Fig 4-8)
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THE CORRECTING LENS

´ The power of the correcting lens (or lenses) neutralizing the

reflex is determined by the refractive error of the eye and the
distance of the examiner from the eye (the working distance)
´ Theoretically, the working distance should be at optical infinity
but this does not practically allow for changing lenses in front of
the eye or seeing the retinal reflex
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THE CORRECTING LENS

´ Dioptric equivalent of working distance à subtracted from the

power of the correcting lens to determine the actual refractive
error of the patient’s eye
´ Common working distances are 67 cm (1.50 D) and 50 cm
(2.00 D), and many phoropters have a 1.50 D or 2.00 D
“working- distance lens” for use during retinoscopy à then
removed at the end of the retinoscopy (however, this lens can
produce bothersome reflexes)
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THE CORRECTING LENS
´ If the examiner is not using the “built-in” working lens in the
phoropter, he or she must algebraically subtract the
appropriate amount of spherical power to move the
neutralization point from the examiner to infinity
´ Example: examiner obtains neutralization with a total of +4.00 D
over the eye (gross retinoscopy) at a working distance of 67 cm
à Subtracting 1.50 D for the working distance yields a refractive
correction of +2.50 D
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THE CORRECTING LENS

´ Any working distance may be used

´ If the examiner prefers to move closer to the patient for a
brighter reflex, the working-distance correction is adjusted
accordingly
´ Working without an explicit lens to correct for the working
distance may allow the use of fewer lenses held in front of the
eye, reducing distracting reflections from the lens surfaces
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FINDING NEUTRALITY

´ In against movement, the far point is between the examiner

and the patient
´ Therefore, to bring the far point to the peephole of the
retinoscope, a minus lens is placed in front of the patient’s eye
´ Similarly, in the case of with movement, a plus lens is placed in
front of the patient’s eye
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FINDING NEUTRALITY

´ This procedure gives rise to the simple clinical rule: If with

movement is observed, add plus power (or subtract minus
power)
´ If against movement is observed, add minus power (or subtract
plus power) (Fig 4-9)
´ One should “overminus” the eye and obtain a with reflex; then
reduce the minus power (or add plus power) until neutrality is
reached
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FINDING NEUTRALITY

´ Be aware that the slow, dull reflexes of high-refractive errors may be

confused with the neutrality reflex
´ Media opacities may also produce dull reflexes
´ Once neutrality is found, the lens to correct for the working distance
must be removed, whether it is the built-in retinoscopy lens in the
phoropter or by subtracting the appropriate correcting lens based on
the working distance used
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ASTIGMATISM
´ Most eyes have some regular astigmatism, in such cases,
light is refracted differently by the 2 principal astigmatic
meridians
´ Moving the retinoscope from side to side (with the streak
oriented at 90°) measures the optical power in the 180°
meridian
´ Power in this meridian is provided by a cylinder at the 90°
axis
´ The convenient result is that the streak of the retinoscope is
aligned with the axis of the correcting cylinder being
tested
´ In a patient with regular astigmatism, one seeks to
neutralize 2 reflexes, 1 from each of the principal meridians
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FINDING THE CYLINDER AXIS

´ Before the powers in each of the principal meridians can be

determined, the axes of the meridians must be determined
´ Four characteristics of the streak reflex aid in this determination:
1. Break. A break is observed when the streak is not oriented
parallel to 1 of the principal meridians. The reflex streak in
the pupil is not aligned with the streak projected on the iris
and surface of the eye, and the line appears broken
(Fig 4-10)
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FINGDING THE CYLINDER AXIS

2. Width. The width of the reflex in the pupil varies

as it is rotated around the correct axis. The reflex
appears narrowest when the streak, or intercept,
aligns with the axis (Fig 4-11)
3. Intensity. The intensity of the line is brighter when
the streak is on the correct axis
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FINGDING THE CYLINDER AXIS
4. Skew. Skew (oblique motion of the streak reflex) may be
used to refine the axis in small cylinders. If the
retinoscope streak is off- axis, it moves in a slightly dif fer
ent direction from that of the pupillary reflex (Fig 4-12)
§ When the streak is aligned at the correct axis à sleeve may
be lowered (Copeland instrument) or raised (Welch Allyn
instrument) to narrow the streak, allowing the axis to be
determined more easily (Fig 4-13)
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FINDING THE CYLINDER AXIS

´ This axis can be confirmed through à straddling, which is performed

with the estimated correcting cylinder in place (Fig 4-14)
´ The retinoscope streak is turned 45° off- axis in both directions, and if
the axis is correct à width of the reflex should be equal in both off- axis
positions
´ If the axis is not correct à widths are unequal in these 2 positions
´ The axis of the correcting plus cylinder should be moved toward the
narrower reflex and the straddling repeated until the widths are equal
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 46 FINDING THE CYLINDER POWER

´ After the 2 principal meridians are identified, the previously explained spherical techniques are
applied to each axis:
o With 2 spheres. Neutralize 1 axis with a spherical lens; then neutralize the axis 90° away. The
difference between these readings is the cylinder power. For example, if the 90° axis is
neutralized with a +1.50 sphere and the 180° axis is neutralized with a +2.25 sphere.
o The examiner’s working distance (ie, +1.50) is subtracted from the sphere to obtain the final
refractive correction:

o Plano +0.75 × 180.

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FINDING THE CYLINDER power

o With a sphere and cylinder. Neutralize 1 axis with a spherical lens.

To enable the use of with reflexes, neutralize the less plus axis first.
Then, with this spherical lens in place, neutralize the axis 90° away
by adding a plus cylindrical lens. The spherocylindrical gross
retinoscopy is read directly from the trial lens apparatus.
§ It is also possible to use 2 cylinders at right angles to each other for this
gross retinoscopy
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Aberrations of retinoscopic reflex

´ With irregular astigmatism, almost any type of aberration may appear

in the reflex
´ Spherical aberrations tend to increase the brightness at the center or
periphery of the pupil, depending on whether they are positive or
negative
´ As neutrality is approached, 1 part of the reflex may be myopic,
whereas the other may be hyperopic relative to the position of the
retinoscope à such situation produces a scissors reflex
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Aberrations of retinoscopic reflex

´ Causes of the scissors reflex à keratoconus, irregular corneal

astigmatism, corneal or lenticular opacities, and spherical
aberration
´ All of these aberrant reflexes, in particular spherical aberration,
are more noticeable in patients with large scotopic pupils à
the examiner should focus on neutralizing the central portion of
the light reflex
Table
50 4-1 provides a summary of the technique of retinoscopy using a
plus cylinder phoropter
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PSEUDONEUTRALIZATION

´ As discussed before, in general, with reflexes are brighter,

sharper, and easier to perceive and interpret than against
reflexes
´ In particular, the reflex in severely myopic eyes is seldom
recognizable as an against reflex— rather, one sees only a dull,
motionless illumination of the entire pupil à
pseudoneutralization
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PSEUDONEUTRALIZATION

´ This is best handled by reversing the sleeve of the retinoscope:

o Welch-Allyn à to the maximal sleeve-up position
o Copeland à maximal sleeve-down position
´ This will convert the dull pseudoneutral reflex to a readily
recognizable with reflex, but in this case, the with reflex must be
neutralized by adding minus sphere power
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PSEUDONEUTRALIZATION

´ As true neutrality is approached, return the retinoscope sleeve

to the usual position
´ The reflex will revert to an against reflex as in typical myopic
eyes
´ Continue to add minus sphere power until a with reflex is
obtained, and then reduce the minus sphere so as to reach
true neutrality from the with direction
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THANK YOU
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