PHOROPTER REFRACTION

AUTHOR

Patricia Hrynchak : School of Optometry and Vision Science, University of Waterloo

PEER REVIEWER

Jean-Charles Allary : Chiswick, London

INTRODUCTION TO THE PHOROPTER

According to the Dictionary of Visual Science “a phoropter is an instrument for determining the refractive status of the
eyes, phorias, vergences, amplitude of accommodation, etc., consisting of essentially a housing containing rotating
disks with convex and concave spherical and cylindrical lenses, pinhole disks, occluders, and sometimes colour filters
and prisms. Attached to the front of the housing are crossed cylinder lenses, rotary prisms, and Maddox grooves
1
[rods].”

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-1

 Phoropter Refraction

INTRODUCTION TO THE PHOROPTER (CONTD)

Figure 21:Phoropter, front view. Reproduced with permission from Reichert Ophthalmic Instruments .

Instrument Components:

1. Rotation adjustment knob 14. Cross cylinder unit

2. Mounting bracket 15. Cylinder power case
3. Tilt clamp knob 16. Cylinder axis reference scale
4. Forehead rest knob 17. Cylinder axis indicators
5. Split level 18. Cylinder axis scale
6. PD knob 19. Sphere dial in 0.25D steps
7. Near vergence lever 20. Sphere power scale
8. Auxillary lens scale 21. Sphere dial in large scale
9. Auxillary lens knob 22. Levelling knob
10. Corneal aligning device 23. PD scale
11. Rotary prism unit 24. Near reading rod holder
12. Cylinde axis knob 25. Near reading rod clamp screw
13. Cylinder power knob

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-2

 Phoropter Refraction

Figure 20-2: Phoropter, back view. Reproduced with permission from Reichert Ophthalmic Instruments .

Instrument Components (cont.):

26. Forehead rest 27. Spring clip

Figure 20-3: Attaching the Rotochart to the near reading rod holder. Reproduced with permission from Reichert Ophthalmic
Instruments.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-3

 Phoropter Refraction

COMPONENT ACTION
1. Rotation adjustment knob: Allows rotation of the phoropter about a vertical axis.

2. Mounting bracket: Mounts the phoropter to the phoropter arm on the instrument stand.

3. Tilt clamp knob: Sets the pantoscopic angle of the phoropter relative to the patient’s face.

4. Forehead rest knob: Moves the forehead rest (#26) on the back of the phoropter so that the vertex distance
can be adjusted.

5. Spirit level: Shows whether the phoropter is level, necessary for accurate cylinder axis determination. The
phoropter can be made level by adjusting the levelling knob # 22. This must be done when the phoropter is in
place in front of the patient.

6. PD knobs: Located on the right and left sides of the phoropter. Sets the binocular interpupillary distance of the
patient shown in the PD scale window #23.

7. Near vergence levers: These levers converge the instrument apertures and simultaneously decrease the PD
for near point testing. For a distance PD of 64 mm moving both levers from an extreme outward to an extreme
inward position converges the apertures for near testing at 40 cm and decreases the aperture separation by 4
mm. For PD settings greater than 64 mm the apertures are slightly underconverged and will require an
additional reduction of the PD by 1 mm or less. For PD settings that are less than 64 mm the instrument
apertures are slightly over converged; this is compensated for by a slight outward adjustment of the levers
from the fully converged position. Do not attempt to fully converge the instrument below a distance PD of 55
mm.

8. Auxiliary lens scale: There are 10 auxiliary lenses and two open apertures. Turning clockwise the lenses are:
0: open aperture
R: +1.50 retinoscopy lens
P: polarizing lens for binocular retraction techniques. Axis 135 in the right eye and axis 45 in the
left eye
WMV or
RMV: Vertical Maddox rod, red in the right eye and white in the left eye
WMH or
RMH: Horizontal Maddox rod, red in the right eye and white in the left eye
RL: red lens used for binocular vision tests
GL: green lens used for binocular vision tests
0: open aperture
+.12: plus 1/8 dioptre sphere lens, for refracting to eighth dioptre accuracy
PH: pin hole
6 UP or
10 IN: 6 prism dioptres base up in the right eye and 10 prismdioptres base in in the left eye. Used for
binocular vision testing
0.50: 0.50 fixed cross cylinder for near point addition determination
OC: occluder

9. Auxiliary lens knob: Changes the auxiliary lenses in the phoropter.

10. Corneal aligning device: Determines the vertex distance. When the pointers and black line are aligned with the
corneal apex (zero position) the vertex distance is 13.75 mm. Each of the hash marks represent a distance of
2 mm. If the cornea is seen nasally to the zero position the distance must be added to 13.75 to obtain the
vertex distance. The distance can be adjusted using the forehead rest knob #4.

11. Rotary prism unit: Used to introduce lateral or vertical prism in front of the main aperture. With the zero
positioned at 90° lateral prism can be introduced with the finger roll knob. With the zero positioned at 180°
(usually nasally) vertical prism can be introduced. The arrow indicates the base direction and amount of the
prism, e.g., with the zero positioned at 90° and the arrow pointing at the 6 on the nasal side the amount of
prism is 6pd base in.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-4

 Phoropter Refraction

COMPONENT ACTION (CONTD)

12. Cylinder axis knob: Changes the axis of the cylinder introduced over the aperture. Rotating the knob will rotate
the cylinder axis indicators #17 simultaneously.

13. Cylinder power knob: Allows the addition of cylinder lenses. Phoropters can be ordered with either minus or
plus cylinder powers, not both. Optometrists normally work with minus cylinder powers.

14. Cross cylinder unit: For use in the cross cylinder tests for astigmatism determination or verification. The
standard powers are 0.25 D. The red dots represent the axis of the minus cylinder and the white dots
represent the axis of the plus cylinder. There are click stops for the axis position and for the power position.
When in the power position the “P” is lined up with the cylinder axis in the phoropter. When in the axis position
the flipping knob is lined up with the cylinder axis in the phoropter.

15. Cylinder power scale: Shows the amount of the cylinder power introduced with the cylinder power knob #13.

16. Cylinder axis reference scale: Shows the cylinder axis in increments of 15°.

17. Cylinder axis indicators: Points to the cylinder axis in the aperture and the cylinder axis scale. Turning the
cylinder axis knob will rotate both indicators simultaneously.

18. Cylinder axis scale: Shows the cylinder axis in increments of 5°.

19. Sphere dial in 0.25D steps: Allows the addition of sphere powers over the aperture in increments of 0.25 D.
Rotating the dial down will introduce lenses in the plus power direction and rotating the dial up will introduce
lenses in the minus power direction.

20. Sphere power scale: Shows the sphere power introduced in the aperture. The black numbers are plus powers
and the red numbers are minus powers.

21. Sphere dial in large steps: Rotating the back knurled portion of the auxiliary lens dial will introduce sphere
powers in increments of 3 D in the aperture.

22. Levelling knob: Adjusts the level of the phoropter. Used in conjunction with the spirit level # 5.

23. PD scale window: Shows the distance and near binocular PD settings.

24. Near reading rod holder: Holds the reading rod vertically out of the way when not in use. The reading rod
should not be removed from the phoropter but put up out of the way when not in use.

25. Near reading rod clamp screw: Locks the reading rod in place.

26. Forehead rest: Adjusts the vertex distance.

27. Spring clip: Holds the white face shields in place. Attach the face shields by sliding them under the clip.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-5

 Phoropter Refraction

SUBJECTIVE REFRACTION USING THE PHOROPTER

Recommended Test: Subjective Manifest Refraction

Indications:

 Subjective refraction is done as part of all full oculo-visual assessments, unless precluded by patient inability to
provide reliable responses.
 It is done for the determination of best corrected visual acuity in partial oculo-visual assessments.
 It is done as part of partial oculo-visual assessments with complaints such as blurred vision, broken spectacles, lost
spectacles and unstable refraction.

Contraindications/Considerations:

 Young children and persons with developmental delays may not be able to cooperate with this testing as it does
require an ability to make judgments and communicate choices.

Target Presentation: The projected Snellen chart is used (make sure the projector is calibrated for the appropriate test
distance) or a digital visual acuity system.

Patient/Examiner Position: The patient should be seated comfortably in the examining chair. The phoropter should be
situated so that the patient can comfortably view through the centre of the lenses. It should also be level, and adjusted
for vertex distance and the patient's interpupillary distance. The examiner should sit off to the side of the patient so that
manipulation of both the phoropter and the projector is easy.

Illumination: If using a digital visual acuity system room illumination can remain full. If using a manual or automated
projector the projector illumination should be approximately 215 to 500 lux with all lights off and the meter directed
towards the projector. With the lights on, the background level should be approximately 13% of the projector level. The
overhead lights should be off at the chart end of the room and the rheostat adjusted to the halfway point for the lights
over the patient. The stand lamp should be off. There should be adequate illumination for the examiner to view the dials
on the phoropter and avoid scotopic refracting conditions. In a mirrored room turn the fluorescent lights off and dim the
pot lights midway between the full and half positions of illumination.

I MONOCULAR REFRACTION

Indications

 Absolute presbyopes.
 Strabismic patients with suppression (occlude the non-turning eye to test the turning eye).
 Patients who do not tolerate the blur during binocular refraction.

Contraindicatons/Considerations

 Hyperopic patients young enough to have active accommodation often give poor results with this procedure due to
habitual accommodative spasm, particularly if they have been habitually uncorrected or their habitual spectacle
prescription is too low in plus (as may be suggested by retinoscopy findings). In these patients a binocular refraction
procedure will usually be more successful, as binocularity tends to encourage accommodation to relax more readily.
 The same consideration may apply to any young patients with accommodative spasm, who may initially appear to be
emmetropes or low myopes (pseudomyopia). However, this is usually not a concern in more myopic patients and
patients who are established presbyopes.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-6

 Phoropter Refraction

Procedure

1) Begin with the net retinoscopysphero-cylinder before each eye.

2) Occlude the untested eye (e.g., left).

3) Determine the Best Sphere:

a) Show the chart from 6/15 to 6/4.5. Direct the patient's attention to the best acuity line of the right eye.
Identify the initial lens combination as "one". Add +0.25 D and identify this as "two". Ask the patient if 1
or 2 is CLEARER or if they are THE SAME. If the patient has reduced visual acuity a larger change may
be required (see the section on Trial Frame refraction).

b) If the acuity improves or remains the same with the additional plus, then continue adding plus sphere
lenses until the acuity first blurs. Stop at the most plus/least minus lens that does not blur the visual
acuity.

c) If the visual acuity blurs with the plus lens, then remove it and add a -0.25 D lens. If the visual acuity is
unchanged or decreased by the addition of a minus lens, then remove the lens. If visual acuity improves
with the lens, then add further minus lenses (in 0.25 D steps) only as long as the visual acuity improves.

If the resulting visual acuity is less than 6/9, and the patient has the potential to see 6/6 from the aided
visual acuity discard the cylinder from retinoscopy and replace it with the cylinder measured in the
habitual Rx if it is known, and recheck the acuity to see if it has improved. If the visual acuity is 6/9 or
better continue with the following procedure:

4) Check Test for Cylinder Axis:

a) Isolate the letter "O" on the 6/9 row of letters (alternatively, the whole row can be used; or, if available, a
row of Landolt C’s or a random dot pattern may also be effective targets). Move the Jackson Cross
Cylinder (JCC) in front of the phoropter aperture. Advise the patient that neither of the lens
combinations that will be shown will be completely clear. If no cylinder was found with retinoscopy go to
step 6.

b) Set the JCC so that the red minus cylinder axis and the white plus cylinder axis straddle the phoropter
cylinder axis. With most phoropters the JCC will click into place at this correct orientation. Have the
patient compare this initial lens position, “1", to its flipped counterpart, "2".

c) If the two lenses appear equally blurred to the patient, then move on to step 4d. If not, adjust the JCC
(and phoropter cylinder axis will follow) toward the minus cylinder axis (red) of the preferred lens position
(1 or 2). The amount of the axis change will depend upon the amount of the cylinder power. The higher
the power the smaller the change required. Enough of an axis change should be made so that the next
response will likely be in the opposite direction. For example a change of 20° may be appropriate for a
0.25 D cylinder power and a change of 5° may be appropriate for a 3.00 D cylinder power.

Repeat the comparison and if the response is in the opposite direction move the axis back by half the
amount changed the first time, i.e., split the difference. If the response was not in the opposite direction
make another sizable change of axis (always towards the red) until the response is in the opposite
direction. Continue with this bracketing method until the patient notices no difference between the two
lens positions.

d) If the two initial lens positions appear the same, confirm that the current axis is the correct one by
moving the JCC and phoropter axes off by an appropriate amount and having the patient compare “1”
and “2”. The patient should return you to the initial axis orientation if it was correct. Make sure that you
bracket the correct axis from both directions in this way.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-7

 Phoropter Refraction

5) Check Test for Cylinder Power. (Figure 20.4)

a) Orient the JCC so that either the minus axis or plus axis parallels the phoropter cylinder axis (the JCC
should click into place with most phoropters). Often there will be a “P” on the crossed cylinder indicating
the correct orientation. Have the patient compare the relative clarity of “1” to “2” as before.

b) If there is no difference between “1” and “2” then the correct power of cylinder is in place. To confirm this
remove -0.25 D cylinder and repeat the comparison. If the initial lens was correct the patient will call for
more cylinder by choosing the lens that has the red minus cylinder axis parallel to the phoropter axis. In
this case, increase the cylinder power to its original amount.

c) If there is a difference between “1” and “2” then adjust the cylinder power. Add minus cylinder (-0.25 D) if
the patient prefers the red minus cylinder axis parallel to the phoropter axis or remove 0.25 D cylinder if
the patient prefers the white plus cylinder axis parallel to the phoropter axis. Continue this process until a
difference between Lens 1 and 2 cannot be detected. If the power has been bracketed to less than a
0.25 D (at one position the patient chooses red then when increased 0.25 the patient chooses white)
leave it on the least minus cylinder position. If there is a significant change in the power a recheck of the
axis may be prudent.

Note: If the value goes down to zero and the patient still chooses the white, the cylinder axis was 90° off.
Change the axis by 90° and continue the power check.

a)

b)

Figure 20.4: Cylinder axis and power determination: a) Orientation of the cross cylinder for axis determination, b) Orientation of the
cross cylinder for power determination.

d) For each 0.50 D change in cylinder power, change the sphere power by 0.25 D in the opposite direction
(e.g., if you add -0.50 D of cylinder, then add +0.25 D of sphere before comparing the lens positions).

6) Power check test when no cylinder is found with retinoscopy.

a) This test checks for cylinder power at four different axes to rule out the presence of cylinder.

Add –0.25 D cylinder at axis 180 and do a power test to see if the cylinder is accepted. If the response is
the same or if the red is chosen the cylinder has been accepted. If the cylinder is accepted go on to do
the axis and the final power tests.

If the cylinder is not accepted repeat this procedure for axes 135, 90 and 45 looking for power in all of
these positions. If the cylinder is rejected at all four positions, the person has not subjectively accepted
any cylinder. If the cylinder is accepted at any of the positions go on to do cylinder axis tests and the
final power tests.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-8

 Phoropter Refraction

7) Repeat steps 1-6 for the other eye (OS).

8) Record the monocular acuities. If these acuities are unequal, then omit the remaining steps. You may want to
confirm that the most plus/least minus prescription is in place by performing a red/green test monocularly.

Acceptable Alternate Procedure: CHECK TEST FOR CYLINDER WHEN NONE IS FOUND WITH
RETINOSCOPY

1) If there has been no cylinder found with retinoscopy, then set the JCC so that it’s minus cylinder axis (red dots)
and the perpendicular plus cylinder axis (white dots) assume the 90 and 180 positions. There is no cylinder in
the phoropter. It does not matter which dot is at 90 and 180 . Refer to the current JCC orientation as "1". Flip
the JCC with the attached knurled knob to reverse the positions of the minus and plus axes. Refer to this latter
orientation as "2". Have the patient compare the relative clarity of "1" and "2". The patient is to choose the lens
that makes the letters the clearest or indicate if they look the same. Note the orientation of the red dot (minus
cylinder axis) of the chosen number. Rotate the JCC so that the red and white dots assume the 45 and 135
positions. Repeat the above comparison and note the orientation of the minus cylinder axis of the chosen lens.

If all the lenses seem equally clear, then there is no cylinder. If only one lens position was preferred then set the
axis at that position. If more than one was preferred then set the axis between the preferred settings (e.g., if
minus cylinder was called for at 180 and 45 , then set the phoropter cylinder axis to the approximate midpoint,
i.e., 25 ). Place -0.25 or -0.50 D cylinder power in the phoropter and proceed with the check test for cylinder axis
then the test for power once the axis has been refined.

Note: If a tentative cylinder axis preference is indicated by either of the techniques described above, many examiners
prefer to quickly verify whether the tentative cylinder will actually be accepted at or near the proposed axis before
spending time on axis refinement. To do this, dial in a -0.25 cylinder at the indicated axis and place the cross-
cylinder in power position. If the patient prefers the white plus cylinder axis parallel to the proposed phoropter
cylinder axis, the -0.25 tentative cylinder may be removed and it may be concluded that no cylinder will be
required in the refractive correction, thus avoiding wasting time attempting to refine the axis of a cylinder that will
ultimately be rejected. On the other hand, if the patient prefers the red minus cylinder axis parallel to the
proposed phoropter cylinder axis or has no preference between the red and white cross cylinder axes, then it
may be concluded that the tentative cylinder will not be rejected and the examiner should go on to refine its axis
and power (respectively) using the check tests as described above.

II BINOCULAR REFRACTION
Indications:

 Patients who can tolerate the blur.

 Patients who understand the test.
 Nonstrabismic patients.
 Prepresbyopes, especially those that are hyperopic.
 Suspected latent hyperopia.

1) The non-tested eye can be fogged by occluding the tested eye and adding plus to the fellow eye until the acuity
reaches 6/12 (if the starting visual acuity was 6/4.5 or 6/6). This would usually require adding +1.00 D to the
fellow eye. The occluder is then removed from the tested eye.

If the starting visual acuity is less than 6/6 sufficient plus is added to ensure central suppression of the untested
eye. This is normally around +1.00 or +1.25 D.

Note: As a clinical “short cut”, some examiners find it effective to merely introduce the +1.50 retinoscopy lens in
the phoropter and confirm that this blurs the acuity of the untested eye to at least 6/12 or 6/15. However, do not
arbitrarily add a set amount of plus to the eye without checking the visual acuity. If the patient has been
significantly overminused on retinoscopy the plus will not blur the acuity and the subjective refraction will not be
successful.
2) Proceed with steps 3 to 8 above.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-9

 Phoropter Refraction

III BALANCING THE ACCOMODATIVE DEMAND

1) Prism Balance:

Indications:

 Patients with accommodation who have equal monocular acuities. This test is used to balance the accommodative
demand between the eyes, and is normally done after a monocular refraction. It may be a less essential procedure if
a binocular refraction has been performed.

Contraindication/Considerations:

 A prism balance is of little value on absolute presbyopes (patients over 60), and in fact is usually of questionable
validity due to unequal quality of vision in the two eyes. In these patients it is often more useful to use plus and minus
monocularly to assess the depth of focus and prescribe an Rx that puts the patient in the midpoint of this range (i.e.,
when the same amount of plus and minus creates equal blur), or possibly biasing slightly to the plus side of the
midpoint if the patient has significant visual demands in the intermediate range. This is often best assessed using
trial frame refraction and demonstration.

Procedure

a) Isolate the 6/12 row. Introduce the Risley prisms before both eyes so that there is 3BD before one eye
and 3 BU before the other eye. Introduce the prisms one at a time with one of your hands shielding the
patient's view of the chart to avoid visual distress during prism adjustment.

b) Advise the patient that two rows should be visible, one higher than the other and that you will blur one of
them (e.g., if there is 3 BD/OD the top one will blur). Blur that eye (OD) with plus lenses a quarter
dioptre at a time until the 6/12 row is significantly blurred but not completely unreadable. This should
take approximately +1 D. Confirm with the patient that the row is indeed significantly blurred.

c) As plus lenses are added in +0.25 D steps to the other eye (e.g., OS); ask the patient to advise you
when the rows become equally blurred. When equal, bracket the value by adding an additional +0.25 D
(OS); this should make the other row blurrier. Return to the equal state. If an exact balance is not
possible, ask the patient to advise you which position creates a condition where the rows are closest to
being equally blurred. Use this result as your endpoint.

d) Remove +0.25 D from both eyes and ask the patient if the rows are still equally blurred. If so, move on
to the next step. If not, then add +0.25 D to the clearer eye until a balanced result is obtained, and then
consider removing another +0.25 D from both eyes to confirm that they are both still equally blurred at
the lower level of fog.

e) Remove the Risley prisms from both eyes (without causing visual discomfort) and display the chart from
6/15 to 6/4.5.

f) Have the patient read the smallest row of letters with the current partial fog in place. If the patient sees
the best acuity line at this point, this should alert the examiner to the fact that the patient may have been
overminused or underplused (In this case the examiner should add +0.50 or more to both eyes equally
until there is no doubt that the acuity is definitely blurred before proceeding further). If the acuity is
blurred to 6/9 or 6/7.5 then proceed to remove the fog in 0.25 D steps until the acuity no longer
improves. N.B.: Be careful to monitor the acuity and not rely on the patient's subjective impression of
improvement! Adding -0.25 D OU over the point where they can first read their smallest acuity line will
often result in a subjective improvement. If this occurs, allow the additional minus but do not allow any
further increase in minus without a corresponding improvement in acuity. High myopes will often call for
much more minus than will subjectively improve their visual acuity.

g) If either eye has been changed more than 0.25D over the monocular subjective endpoint, retest the
monocular acuity in that eye before recording the final binocular visual acuity.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-10

 Phoropter Refraction

Sample Patient Instructions: The questions are incorporated into the Procedures. Suggested wording follows:

1) When determining the best sphere (monocularly or binocularly): "Which lens is clearer, one or two, or are they
the same?"

2) When comparing JCC Lens choices: "Neither of the choices will be completely clear but which lens makes the
letters the clearest, lens one or two, or are they the same?" (Show the two lenses again, especially if the patient
hesitates to respond).

Recording: Record the final monocular refraction with the corresponding visual acuities and record the final balanced
refraction with the corresponding binocular visual acuity. Record the method used to balance, e.g., Prism Balance.

e.g., -2.50 –0.50 X 180 6/4.5

-3.00 –0.25 X 170 6/4.5

Prism Balance

-2.50 –0.50 X 180 6/4.5

-2.75 –0.25 X 170

Normal Result: The subjective results should be compatible with the retinoscopy results, visual acuities,
accommodation, the patient's age and ocular health.

Interpretation: The result represents the manifest refractive state of the eye. It is often not the same as the prescription.
When prescribing to correct the refractive error consideration is given to the patients past history of spectacle adaptation,
the needs and wants of the patient and the binocular and ocular health status of the patient. For example, a 20-year-old
person with a hyperopic refractive error of +0.75 DS, good binocular status and no ocular health abnormalities most likely
would not require a prescription.

Inconsistent results may be due to technique error or the patient may be an unreliable observer for behavioral or visual
reasons. If results are questionable due to observer reliability, trial frame refraction may be more successful and should
be attempted.

MOST COMMON ERRORS

1) Poorly worded patient instructions or leading questions e.g., using the word “better” instead of “clearer”.

2) Poor control of accommodation, e.g., not performing a binocular refraction on a young person with hyperopia.

3) Flipping the JCC lenses too fast for the patient to compare them.

4) Allowing the patient to direct the examination.

5) Not monitoring the visual acuity to ensure that a change in lens power results in the expected change in visual
acuity.

6) Improper or inefficient technique for checking for cylinder when no cylinder is found with retinoscopy.

7) Using the prism balancing technique on a patient with unequal monocular acuities.

8) Adding minus first rather than plus first when checking the best sphere.

9) When doing the cylinder power check test not confirming that zero cylinder is the correct endpoint.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-11

 Phoropter Refraction

ACCEPTABLE ALTERNATE PROCEDURES: BALANCING THE

ACCOMODATIVE DEMAND

I HUMPHRISS IMMEDIATE CONTRAST TECHNIQUE

Indications:

 This can be done on patients who are old enough to participate in a reliable subjective refraction.
 It is done with patients who have equal visual acuity.
 It should be done when a binocular technique with peripheral fusion is preferred.

Contraindication/Considerations:

 The technique cannot be done on someone with strabismus and can be difficult in someone who has an unstable or
decompensating heterophoria.
 The technique is best suited for use in trial frame refraction as patient observation is important and lens presentation
change cannot be fast enough with a phoropter.
-
1) Add +1.00 D to the eye that is not being tested. Check to make sure the visual acuity is decreased to 6/12 . If the
-
visual acuity has not been reduced to this level then add plus +0.25D at a time until 6/12 has been reached. Do
not blur the letters until they cannot be recognized.

2) Instruct the patient that you will be showing him/her the next lenses very quickly. Compare +0.25 with –0.25 and
leave the +0.25 in place while waiting for the answer. The patient should tell you which lens is clearer (some
practitioners also ask which lens is more comfortable).

3) If one lens is clearer adjust the sphere in that direction. Repeat the comparison.

4) Only minor adjustments are made this way. If more than 0.50 D change has been made then the fog on the eye
not being tested needs to be checked.

5) Repeat with the other eye.

6) As a final check: Add +1.00 D over each eye. Check to make sure that the visual acuity has been decreased to
6/12. Add more plus if necessary to reduce the visual acuity to 6/12. Slowly decrease the plus to best visual
acuity and record the binocular visual acuity.

II BICHROME TEST

Indications:

 This test can be used when the patient has unequal visual acuities
 It is not the best test for patients who are absolute presbyopes
 This test can be used on patients who have colour vision deficiencies but should not be used on patients with
significant nuclear sclerosis
 This procedure does not ensure that the patient’s accommodation is binocularly balanced

1) All room lights should be off. The lighting is critical in this test as it maximizes the pupil dilation and therefore
increases the chromatic aberration and high contrast that facilitates the test.
2) Adjust the projection chart so that one half the chart background is red and the other half is green. The letters
will remain black. The standard acuity chart has a section where the letters are the same on the left and the
right. This is designed for the Bichrome Test.

3) The patient views the chart monocularly and comments on whether the letters on the red or green side are
clearer or blacker. The spherical portion of the correction is adjusted so that the red and green halves appear
equally clear and black. If green is clearer, then the patient is overminused and plus should be added. If red is
April 2013, Version 1-1 ClinicalOptometricProcedures, 20-12
 Phoropter Refraction

clearer, then the patient is overplused and minus should be added. Often it is recommended to use the point
where the green is just clearer as the endpoint. Also, some examiners prefer to start with the patient deliberately
overplused by 0.50 D or so, confirm that the letters are in fact clearer and blacker on the red side, and then
reduce the plus until the red and green halves appear equal.

4) The same procedure is repeated for the fellow eye.

III DISSOCIATED BICHROME TEST

Indications:

 A simultaneous comparison alternative to the bichrome test, which has the advantage of allowing binocularity without
requiring equal acuities in the two eyes.

1) To ensure that the patient’s accommodation is binocularly balanced, Technique II can be performed with 3 BD
before one eye and 3 BU before the other eye, equalizing the red and green sides of the upper and lower
bichrome charts in turn. (Optionally, as a final binocular sphere check, the prisms can then be removed and the
result confirmed with both eyes open and viewing the target under binocular, fused conditions).

IV BINOCULAR REFRACTION TECHNIQUE USING POLAROIDS

Indications:

 Used when binocular refraction is advantageous

Contraindications/Considerations:

 Not ideal in patients with poor visual acuity, low contrast sensitivity or poor binocularity

1) Position polaroid lenses in the phoropter before each eye. Use the Vectographic projector slide or a vectographic
chart on a digital visual acuity system.

2) The refraction is conducted in the same way as described above. The top two charts on the slide can be used to
conduct the "monocular" refraction of each eye (performed under binocular conditions).

2) As one side of the chart is visible only to one eye and the other side is visible only to the fellow eye the test is done under
binocular conditions with the same stimulus to accommodation in each eye. A vertical fusion bar separates the two sides.
If a gross check of the cylinder axis and power is necessary, then use the split clock dial (one half seen by one eye and the
other half seen by the fellow eye).

V ALTERNATE OCCLUSION COMPARISON BALANCE

Indications:

 Used with patients who suppress and cannot perceive the two dissociated images simultaneously during the
traditional prism balancing procedure.

1) Balancing of the visual acuity can be achieved by substituting the dissociating prisms before the eyes with
alternate occlusion of the eyes. As the occluder is alternately moved back and forth before the eyes, the patient
comments on the relative clarity of the two images using the same fogging procedure described in prism
balancing.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-13

 Phoropter Refraction

ADVANTAGES OF THE ALTERNATE PROCEDURES

1) The vectographic slide or chart allows one to assess the refractive error under more "realistic" binocular and
accommodative conditions.

2) The advantage of the dissociated Bichrome Test is that the stimulus to accommodation is balanced independent
of the resolution thresholds of the two eyes.

3) The alternate occlusion comparison balance is ideal for people who suppress and therefore cannot perceive two
rows of letters during prism dissociation balancing.

DISADVANTAGES OF THE ALTERNATE PROCEDURES

1) Patients with poor acuity, contrast sensitivity or fusion may not be able to perform well on the vectographic slide
or chart.

2) The Bichrome test is not as effective with a projection chart (it is better with a back lit, high contrast chart as
found on a digital visual acuity system). The projector and screen need to be precisely adjusted with lamp
centration, projector focus and screen position. It is less valid for patients with significant nuclear sclerosis due to
blue-green wavelength absorption.

3) The alternate occlusion comparison balance does not allow simultaneous comparison.

ACCEPTABLE ALTERNATE PROCEDURE: CYLINDER AXIS DETERMINATION

I ROTATION TO BLUR CYLINDER AXIS DETERMINATION

1) This may be done for cylinders greater than or equal to -0.75 D.

2) With the patient viewing the best sphere acuity line, rotate the cylinder axis away from its initial orientation until
the patient first notices a blurring of the line. Note this axis. Return to the original axis orientation and then repeat
the test, rotating the axis in the opposite direction. Again, note the axis of the resulting blur point. Set the new
axis midway between the determined range.

REFERENCES:

1. Cline D, Hofstetter H, Griffin J. Dictionary of Visual Science 3rd Ed. Radnor: Chilton Book Company 1980;472.
2. Grosvenor T.P. Primary Care Optometry: A Clinical Manual. Chicago: Professional Press, 1982:163-72.
3. Pace R. Low Vision: A Clinical Manual 2nd. Ed. University of Waterloo; 1990:43-7.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-14