SUBJECTIVE REFRACTION

TECHNIQUES
 SUBJECTIVE REFRACTION
TECHNIQUES.

• In subjective examination the refractive

status of eye is determine by obtaining the
response from the patient to change in
power of lenses .This method of
examination determine the combination of
the lenses which gives patient max. visual
acuity.
 SUBJECTIVE TECHNIQES

• 1)Fogging technique
• 2)Duochrome test
• 4)Stenopaic slit
• 5)Astigmatic fan
• 6)Jacksons cross cylinder
Fogging Technique

• Principle – To make the patient artificially

myopic by plus lenses.
• Aim- To relax the accommodation.
To determine maximum plus
spherical power which provides the subject
max. visual
acuity.
Procedure –
- Done monocularly.
- Start with gross retinoscopic values
• Defog the patient by 0.25D or 0.50D steps
till the max. v/a is obtained.
• While doing defogging in hypermetropes
first put next defogging lens in trial frame
& then remove previous lens which not
stimulate accommodation.
End point is we get max. plus or min. minus
which gives best v/a.
 Duochrome Test
• Principle- This test is based on the principle of
Longitudinal Chromatic Aberration.
• Aim- To determine end point of subjective

refraction.
- Avoid over\under correction.
• The duo chrome test is a distance V/A chart
with black letters, split equally into two
identical halves, one against red & other
green background.6/18,6\9 &6\6 letters.
• Green light of 535nm tends to focus 0.20D
in front of the retina &red light of 620nm
tends to focus 0.24D behind the retina.
• The Myopic patient can see letters on red
background more clearly

• The Hyperopic patient can see letters on

green background more clearly

• & Emmetropic patient can see letters on

both backgrounds equally clear.
Technique:-

• The maximum plus or least minus that allows the

subject to read the best line of acuity possible is
determined.
• Then distance chart is presented in darkened
room.
• The darkened room dilates the pupil & it will
leads to increase the chromatic aberration
• Vision is fogged slightly by adding plus sphere in
+0.25Ds steps until letters on the red
background appear better. This occur in 1-2
increments of plus.
• The plus power sphere is reduced till a end point
of equality that is-
• a} Letters on both charts appear distinct.
• b} Until the next reduction of 0.25Ds makes
letters on the green background more distinct
• The spherical power at first green is taken to
be slight overminused.
• If change in lens power produces exact reversal
of from red to green ,then sph. At first green is
more accurate in young.
 Stenopaic Slit

• Principle- It gives pinhole effect.

It is 16-18 mm in length &1-1.5 mm in
width
Uses-
-High astigmatic with low visual acuity.
-To detect principle meridian.
-Cataractus &glaucomatus haloes.
-To detect vertex distance.
 Method -1
• Occlude patients one eye.
• Correct v/a up to 6/18
-fogging in hypermetrope.
-mini. Minus lens in myope.
• Place stenopaic slit in front of fogging lens.
• Rotate slit till good v/a meridian found.
• Defog patient until that meridian gets
clear, it gives spherical power on one
meridian
• Rotate the slit perpendicular
• Then add minus cylinder lens at axis
perpendicular to stenopaic slit low to high
power.It will give power of cylinder.
Astigmatic fan

Principle – Based on principle of strums

conoid
Uses

• To distinguish between Spherical and

cylindrical errors.
• To Find the more Emmetropic meridian .
• Distinguish between Regular and Irregular
astigmatism.
• To find the astigmatic error
Procedure

1.Occlude one eye

2. Correct the patient visual acuity till
6/18 by fogging method, that means
both meridians becomes myopic
3. Show him the astigmatic chart & ask
him to report which line is clear
If vertical line is more clear then we place the
axis of cylinder perpendicular to the axis of
the clearest line
6. Now slowly increase cylinder in 0.50 DC
steps
7. Till all lines of the astigmatic fan will be
equally clear

8. Go back to Snellen’s chart & change the

sphere till max. possible line can be read in
V/A
Jackson crossed cylinder

• JCC is combination of
two cylinders of equal
strength but with opposite
sign placed with axis at
right angles to each other
• Commonly used powers
0.25,0.50
 Uses
• To discover the astigmatism
• To refine the axis of cylinder
• To refine the power of cylinder
• To measure the presbyopic add
• To measure the amplitude of
accommodation
• Checking the accuracy of axis-
• Principle - oblique cylinder.
• Correcting cyl. place in trial frame at an
axis as per our examination.
• Cross cyl held in front of trial case with the
handle parallel to axis of cyl. Show 2 diff.
position to patient &ask about any visual
improvement.
• Visual improvement at one or other axis then
correcting cyl turn in direction of cyl at same sign
(+\-) of J.J.C.
• Process is repeated till patient say no any visual
improvement at both position.
• If vision is neither improve nor distorted at two
position of cross cylinder then our given axis is
correct.
• Checking accuracy of cylindrical power
• Handle of J.J.C. is place at 45 degree
• Flip cross cylinder show 2 position to
patient
• If visual improvement occur at position
when – of cross cyl coincides with axis of
-cyl. then increase the power of cyl. (same
for +) opposite of it power decreases
• If no improvement at any other position
then our given power of cyl is correct
Binocular
Balancing
 Purpose:
• To equalize the stimulus to
accommodation between the two eyes
• It is Not utilized to equalize the best
corrected visual acuity between the two
eyes
 Why?
• Pre-presbyopic patients can accommodate
during the distance monocular refraction
• Patients may actually accommodate
different amounts between the left and
right eyes
• One solution: pharmacologic agents to
supress accommodation….(aka
Cycloplegic Refraction)
 however
• When a manifest refraction is desired you
need to balance the stimulus to
accommodation in each eye
• Once you have equalized the stimulus to
accommodation between the two eyes,
you have successively binocularly
balanced the patient. This is the
prescription recorded on the examination
form.
 5 Methods
• Successive Alternate Occlusion
• Vertical Prism Dissociation
• Blurring (Humphriss Immediate
Contrast)
• Polaroid Vectograph (will discuss only)
• Turville Infinity Balance (Septum
technique- we will discuss this only)
 Most Popular Techniques
• 1. Successive alternative occlusion
• 2. Vertical prism dissociation
• Most patients will understand the tests,
and they work quite well
 Vertical Prism Dissociation
• Technique:
• The two eyes will be dissociated using the Risley prisms
in the phoropter
• Depending on Text read, 3 or 4 Δ BD OD and 3 or 4 Δ
BU OS
• Equal and opposite
• Same amount of fog as last technique +1.00DS OU
• Same isolated line used 20/50
 Cont’d
• BD prism will cause image to be higher (top)
• The image will be displaced towards the
apex (point) of the prism Δ
• BU prism will cause image to be lower
(bottom)
• BD for OD and BU for OS, therefore;
• EGNU5 seen by OD
• EGNU5 seen by OS
 Cont’d
• Patient instructions: “I know these images
are blurred, I want you to take a few
seconds and look at the image on the top,
and then take a few seconds and look at
the image on the bottom, tell me is one
image clearer or are they equally blurred?”
 Cont’d
• If the patient reports the top image clearer,
add +0.25DS to the OD and repeat the
question
• If the patient reports the lower image
clearer add +0.25DS to the OS and repeat
the question
• Double check
• Remove prisms and take down binocularly
to BCVA (adding quarter steps of minus
OU)
 Cont’d
• Do not add minus to the more blurry
image, instead add plus to the clearer
image
• Then bring patient down out of the fog OU
by –0.25 steps until the BCVA is reached