CLINICAL REFRACTION

Prefinals | OPTO 302: Subjective Refraction

REFRACTION USING TRIAL LENS SET than the Best Line. It is usually +0.25D to +0.75D
Principles Used When Using the Trial Lenses sph over the Tentative sphere.
• Remove the previous minus (-) sph lenses before
placing another one. INTRODUCTION TO THE PHOROPTOR
• Place/insert a succeeding plus (+) sph lenses before Refraction
removing the previous lens. • A vision test that determines your best V/A with
corrective lenses.
EYE REFRACTION WITHOUT ASTIGMATISM • Can be done using:
1. Fog the eye by adding plus spheres until the biggest o Auto refractometer
letter (20/200) is barely readable. o Retinoscope
2. Then reduce the lens power until clear vision is o Trial lens set
obtained. o Phoroptor Unit
3. Add about +0.50D over the Tentative Sph to make
vision one or two lines worse than the best line. PHOROPTOR UNIT
4. Present the Astigmatic Chart, ask the question, “Are • A complex lens holder
the lines equally blurred or equally clear?” • Designed to allow the examiner.
5. If answer is Affirmative (Yes), present again the • To change lenses efficiently and easily.
Snellen Chart.
6. Reduce the plus or increase the minus sph until the Components of a Phoroptor Unit
best vision is obtained. • Lens Controls
7. Endpoint criterion is MPMVA (Maximum Plus for • Auxiliary Lens Knob/Aperture Control
Maximum Visual Acuity) • Ancillary Control
• Mechanical Control /Adjustments
NAKED V/A (20/40)
• Patient may be Myopic or has Absolute Hyperopia LENS CONTROLS
1. Spherical Lens Control
Myopia • Weak Sphere Dial – sph lens in 0.25D steps
1. ADD +0.25D lens in quarter D steps until 20/200 • Strong Sphere Dial – sph lens in 3.0 – 4.0D
line is blurred or has worsen his vision. steps
2. REDUCE the plus lens or unfog the eye until 2. Cylinder Lens Control
sufficient minus is added to improve the Px’s vision. • Cylinder Power Knob – cyl lens in 0.25D
3. STOP unfogging when the best line is reached. steps
4. Make certain that any greater minus lens added must • Cylinder Axis Knob
produce an improvement of vision and • Cylinder Power Scale
5. NO attempt should be made to improve beyond the • Cylinder Axis Indicator
20/20 line. • Cylinder Axis Reference Scale
Hyperopia AUXILLIARY LENS KNOB/APERTURE CONTROL
1. ADD +0.25D lens in quarter D steps until 20/200
• O – Open
line is blurred or has worsen his vision.
• BL – Blank
• This Plus may at first improve his V/A, and
• OC – Occluder
so add more plus to blur the 20/200 line.
• RL – Retinoscopy Lens
2. REDUCE the plus lens or unfog the eye until Px
• PH – Pinhole
reaches the 20/20 line or his best v/a is reached.
• R – Red Lens
3. STOP unfogging when px can NO longer read
• P – Polaroid or Polarizing Lens
20/20.
4. This represents the maximum plus lens w/c produces
an improvement of vision. ANCILLARY CONTROL
• JCC – Jackson Cross Cylinder
• Maddox Rod
IMPORTANT NOTES o RMH – Red Maddox Horizontal
• When unfogging, vision should improve by one fine.
o WMH – White Maddox Horizontal
If VA does not improve by one line, that means the
• Rotary or Risley Prisms
patient has reached his Best Line, and the sphere in
o 10 ^BI
place is the Tentative Sphere.
o 6^BU
• The Proper Fog or Sphere used to Fog is reached
when the V/A of the Px is one or two lines worse

CALI‘S TRANSES 1
 MECHANICAL CONTROL/ADJUSTMENTS
• PD Knob
• Leveling Knob with Spirit Level
• Vertex Distance Control
• Pantoscopic Tilt Control
SUBJECTIVE REFRACTION
• Target presentation: the projected Snellen’s Chart
in appropriate test distance.
• Patient/Examiners position: the patient should be
seated comfortably w/ the phoropter in front. PD
must be adjusted, the level, the center of eyes and
vertex distance. The examiner may sit or stand off to
the side of px so manipulation of the phoropter is
easy.
• Illumination: With room illumination. Overhead
lights should be off at the chart end. The stand lamp
should be off.
• Distance: 20Ft
Steps to Follow:
1. Fogging technique
2. Determination of tentative cyl axis
3. Determination of the tentative cyl amt
4. Checking of cyl axis
5. Checking of the cyl amt
6. Elimination of the fog
7. Duochrome test
8. Equilibrium test
9. Trial frame
Reminder: Always start with right eye/the bad eye.
A. FOGGING TECHNIQUE
a. Present the Snellen’s chart and get px’sO BVA.
b. If BVA is 20/20, add plus lenses until the 20/30
or 20/40 becomes slightly blur.
c. If BVA is worse, add minus lenses first to attain
the best corrected VA and gradually decrease
minus lenses to make one or two lines above the
corrected VA slightly blur.
d. If a patient has an old Rx at far let him wear it.
Get BVA with old RX and reduce minus lenses
until slightly blurring of one or two lines above
BVA.
B. DETERMINATION OF ASTIGMATIC CXN
With the fogging lenses in place, present the astig.
Dial. Ask if there is equality of lines or not. If more
than four lines are darkest, then there is no
astigmatism. If there is equality of lines, try adding
+0.25D to check if the px is underfogged. If results
-
are the same, no astig exists. If one or more lines are
darker than the other, then there is astigmatism.
Determination of Cyl Axis with Clock Dials
• One line darkest = smaller # X 30
• Two lines darkest = add smaller #s X 30
• Three lines darkest = middle smaller # X 30
Determination Of Cyl Amt.
• After you have found the axis, rotate the
phoropter’s axis on the tentative axis of the
darkest line.
• Introduce minus cylinder to equalize the
shade of the lines equally blur or equally
dark is your tentative cyl. amount.
C. CHECKING THE CYL. AXIS BY CROSS CYL
METHOD
a. If the cyl amt. is less than -0.75
• The cc is placed w/ the handle along
the tentative axis. Thus, the axis of the
correcting cyl is midway bet. the (+) &
(-) cc.
b. The px is asked to fixate the letter chart (fogging
line), note its appearance while we flip the
handle.
c. If the px prefers one position than the other,
rotate the handle & axis on the phoropter about
10 deg towards the red dot. Repeat the
procedure until equality of vision (blurred) is
attained.
d. If the cyl. Amt. is more than -0.75
• Px views the acuity line, rotate the axis
away from its initial place until the px
first notices a blurring of the line (note
the axis). Return back the axis until
clear (note the axis.
• Rotate the axis in opposite direction
until blurred (note). Return back the
axis until clear (note). The common
axis of which the chart appears clear is
Best the correct axis.
D. CHECKING THE CYL. AMT. BY CROSS CYL.
METHOD
• Coincide red dot w/ the tentative cyl. Axis. This
time the handle of the CC straddles the axis.
This is pos. 1.
• Quickly flip to position 2 w/ white dot along the
tentative cyl. Axis.
• Ask the px to compare his vision in position 1
& 2 (target; Fogging line) red -0.50Dwhite
+0.50D
Responses & Mgt:
a. When the positions are either equally
blurred or equally clear, the tentative cyl.
Amt. is correct.
b. On flip position 1 or 2 is better, tentative
cyl amt. should be altered.
• inc. (-) cyl if pos.1 is better (rim)
• dec (-) cyl if pos.2 is better (gap)
c. Repeat until equality of both positions is
attained.
E. DOUCHROME TEST (FOR SPHERICAL
AMT.)
a. If red is clearer, then the px is overplussed &
minus be added. (rim)
CALI‘S TRANSES 2
 b. If green is clearer, then the px is overminused & 5. Trial frame presents a more natural viewing
plus be added. (Gap) situation, similar to the final spec. cxn, than the
c. Repeat the procedure for fellow eye. phoropter

This procedure does not ensure that the px is
binocularly balanced. Do the equilibrium test.
F. EQUILIBRIUM TEST OR DISSOCIATED
BICHROME TEST
OD 3PBU
OS 3PBD upper left/lower right
Disadvantages of Trial Frame Refraction
1. Takes more time.
2. Lens changes are awkward.
3. Procedures involving accessory tests (maddox rod,
prims etc.) are more awkward & time consuming.
4. Binocular testing procedures are more cumbersome
& time consuming.

Let the px compare the clarity of the upper & lower Steps to Follow
targets. 1. Fogging technique
• Spherical lenses are placed in the rear cells
Responses & Management of the trial frame & cyl are placed in the
a. Equally clear – no modification forward cells.
b. Upper target better – increase (-) for OD to clear 2. Present astig. Dial-get the axis same w/ common
the lower target refraction
c. Lower target better-increase (-) for OS to clear 3. Obtain the cylindrical cxn that equalizes the lines.
the upper 4. If you have a handheld JCC, the cylinder axis & amt.
is checked in the usual way.
5. If none, do rotation to blur w/ appropriate astig.
ALTERNATE OCCLUSION COMPARISON BALANCE Error.
• Substituting the use of prisms for suppressing pxs. 6. Unfog the px.
• The occluder is alternately moved back & forth 7. Douchrome test
before the eyes. This comparison balance is ideal for 8. Alternate occlusion Balance tests
suppressors, but the disadvantage is it doesn’t allow 9. Let the px walk with it.
simultaneous comparison.

Normal result of #7: results should be compatible w/ kera

PUPILLARY REFLEXES
readings, retinoscopy results, visual acuity, accommodation, 1. Direct reflex
px’s occupation & ocular health. 2. Indirect reflex/consensual/ bilateral
Interpretation: inconsistent results may be due to technique 3. Accommodative/ near reflex
error or the px may be an unreliable observer or has 4. Cilio-spinal reflex/platysmal
something wrong w/ his visual systems (lack of sleep, hang- 5. Orbicularis reflex
over, etc) 6. Psychic reflex

MOST COMMON ERRORS IN REFRACTION PUPIL ABNORMALITIES

1. Unclear px’s instruction or questions 1. Adie’s Tonic Pupil – due to lesion of the ciliary
2. Poor control of accommodation ganglion
3. Flipping the JCC too fast • Characteristics:
4. Allowing the px to direct the exam. a. Anisocoria – one pupil reacts more.
5. Not monitoring the VA b. Sluggish accom. Reflex
6. Improper technique for checking the cylinder. c. (-) direct, (-) indirect
7. Adding (-) rather than (+) when checking the 2. Argyll-Robertson’s Pupil – due to CNS defect,
fogging spheres neurosyphilis, lesion in oculomotor nucleus &
pretectal fibers.
• Characteristics:
TRIAL FRAME REFRACTION a. (-) direct, (-) consensual
Indications for TFR: low vision refraction, high ref error, b. Miosis
aphakia, px posture doesn’t allow normal positioning, c. Anisocoria
pediatric refraction, community outreach medical missions & d. No dilation in the dark
starting practitioners. e. Irregular pupillary border
f. No effect to atropine
Advantages Of Trial Frame Refraction g. No effect with medriatic drugs
1. Allows the px to maintain unusual head & eye h. (+) accommodative reflex
postures that are not possible w/ the phoropter. 3. Amaurotic Pupil
2. Trial lenses typically have a larger aperture than the • Amaurotic eye stimulated – (-) direct, (=)
phoropter. consensual when good eye is stimulated.
3. The examiner is able to see the px’s eye throughout • Normal eye stimulated – (+) direct, (-)
the test. consensual when amaurotic eye is
4. Large dioptric changes in lens power can be made stimulated.
very easily.

CALI‘S TRANSES 3
 4. Marcus Gunn Pupil – due to multiple sclerosis,
optic neuritis, retrobulbar neuritis.
• Characteristics: less constriction if normal
eye is stimulated, there is dilation if abn eye
is stimulated (pupillary escape).
5. Bechterew’s Pupil – pupil dilate with light.
6. Hutchinson’s Pupil – due to CNS lesion ~

Pupil Affects Retinal Image

1. Controls the entering light reflex.
2. Modifies depth of focus
3. Varies the extent of optical aberration present.

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