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Subject Name CLINICAL STUDIES I

Lab 10

MONOCULAR SUBJECTIVE REFRACTION III

Topic
− The Fan & Block Test and Second Monocular MPMVA

Introduction

Fan & Block technique is an alternative procedure for the assessment of astigmatism. Not
all patients will be able to respond accurately to the demands of the Jackson cross-cyl
(JCC) and the fan and block or similar technique should be used in these cases.

Objective

• To consider multiple subjective measures of astigmatism in order to refine any residual

astigmatism during objective refraction.
• To be indicated if starting techniques of the refraction indicated none cylinder
correction but patient does not achieve sharp vision with sphere correction.

Equipment

• Trial frame/phoropter
• Trial lens set (if with trial frame)
• Snellen chart
• Fan & block chart

Step-by-Step

1. Measure your patient’s IPD.

2. Position a trial frame/phoropter with the appropriate distance PD. Occlude the
untested eye.
3. Measure vision/unaided VA. Estimate patient’s refractive error. Repeat for the other
eye.
4. Perform gross retinoscopy. Insert WDL OU, look at the movement of the ret reflex,
dump in the refractive error estimated from VA on OD and neutralise it using the
sphero-cylindrical technique. Then repeat for OS.
5. With the net static retinoscopy findings, measure the VA and estimate residual
refractive error.

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6. Proceed with the first part of monocular subjective refraction that is the determination
of initial MPMVA/ BVS. Occlude OS and start with OD. You can either use fog/unfog
or plus/minus technique (most plus that gives the best VA).
7. Remove the cylinder determined from retinoscopy from the right eye and add
+0.50 DS to the sphere. The circle of least confusion is now in front of the retina. If the
retinoscopy cylinder was correct or overestimated, then both focal lines will be in front
of the retina.
8. Draw an analogy between the lines on the fan and the hours of a clock, and ask the
patient if any of the lines on the fan appear clearer and darker than the other lines.
9. If the patient reports that all the lines are equally clear (or blurred) then fog by a further
+0.50 DS and ask the patient again if any lines are clearer and darker. If they remain
equally clear or blurred, then this suggests that there is no astigmatism present.
10. If some lines are reported as clearer, point the arrow that joins the blocks towards the
clearest line. Adjust the arrow until its two barbs appear equally clear. One block (with
its lines running parallel with those on the fan which are clearest) should be clearer
than the other.
11. Ask the patient to look at the clearer block and add +0.50 DS and ask if the block
blurs. If it does blur, continue to step 12. If the block does not blur, it is possible that
the retinoscopy result provided a significantly under-corrected cylinder, leaving the
back focal line behind the retina after step 7. In this case, additional +0.50 DS lenses
should be added until the clearer block just blurs.
12. Set the cylinder axis in the trial frame/phoropter at the axis indicated by the arrow. Add
negative cylinder at this axis until the blurred block just becomes as clear as the other.
If there is a reversal, in that the more blurred block becomes clearest, take the lower
cylinder power.
13. Record patient’s VA. Estimate residual spherical error.
14. Reduce the plus fogging sphere using fog/unfog technique to determine the second
monocular MPMVA.
15. Reach an appropriate stopping point. To decide when to stop the second monocular
MPMVA, choose one of the following monocular spherical endpoints:
a. The DUOCHROME endpoint
i. Turn on the duochrome chart.
ii. Direct the patient’s attention to the line of letters one line above his best VA so far.
For some patients it may necessary to isolate this.
iii. Tell the patient to look from the green side to the red side and back to the green
side. Have him state which side has the sharper, clearer (not ‘better’, ‘darker’, or
‘brighter’) letters or to state if the two sides are equally clear.
iv. If the letters on the red side are clearer or if the letters on both appear equal,
introduce an additional -0.25 DS over the eye being tested. If the letters on the
green side are clearer, remove -0.25 DS (or add another +0.25 DS).
v. Repeat step (iii) and (iv) above until the patient reports the both red-green sides are
equally clear or the green side has clearest letters (the minimum amount of minus
power).
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vi. Recheck the VA.

Note:
Some patients always seem to choose one side or the other,
regardless of the lens powers in place. Be alert to the possibility that
your patient is unresponsive to this test and prepare to abandon the
duochrome test in favour of other endpoints.

b. The ‘SMALLER/DARKER’ end point

i. Introduce one more of -0.25 DS (less plus).
ii. Ask the patient whether the change makes the letters clearer or smaller, darker, or
‘better’.
iii. If the change makes the letters subjectively clearer to the patient, accept the change
and repeat steps (i) and (ii) above. If the change merely makes the letters smaller,
darker, or ‘better’, do not accept the change and take away the 0.25D added in step
(i) above.
16. Record patient’s Rx and VA. Repeat the procedure for OS by occluding OD.

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