Mamdouh EL Kafrawy

Clinical

Mamdouh EL Kafrawy
Subjective
Refraction
 Subjective
Reraction

Spherical Cylinderical
lens lens
 Subjective Refraction
Spherical lens
• Fogging technique.
• Duochrome test.
Cylinderical lens
• Cross cylinder.
• Astigmatic dial and fan.
• Stenopic slit.
 Subjective Refraction
• Accurate determination of
distance refractive errors
requires suspension of
accommodation by :
Cycloplegic drugs ( children < 15
years)
Non cycloplegic methods ( for
adults > 20 years )---►fogging.
 Fogging
Technique
Fogging Technique

• The commonest non

cycloplegic method to

suspend accommodation.
Fogging Technique
• High +ve lens is added in
front of the eye bringing
F2 of the eye into the
vitreous cavity.
cavity ( till the
visual acuity is less than
6/36)
 F2

High +ve lens is added in front of the eye

 F2

bringing F2 of the eye into the vitreous cavity

 F2

till the visual acuity is less than 6/36

•So accommodation is
completely relaxed
because any further
accommodation will
increase blurring.
Fogging Technique
• The power of the +ve
lens is reduced
gradually ( + 0.25 D
interval ) until clear
vision is reached.
 F2

The power of the +ve lens is reduced gradually

 F2

until clear vision is reached ) D interval 0.25 + (

F2
•One can add + 1 D to
patient’s retinoscopic
findings or to the
patient’s old glasses
-------► then reduce power
gradually.
Duochrome
Test
 Ocular Chromatic
Aberration
• Refraction by the human eye
is also subject to chromatic
aberration, the total
dispersion from the red to
the blue image being
approximately 2.00D.
 D 2.00

Myopia Hypermetrope
D 1.5 - D 0.5 +
 Ocular Chromatic
Aberration
• The emmetropic eye focuses
for the yellow–green (555
nm) as this is the peak
wavelength of the photopic
relative luminosity curve.
 Ocular Chromatic
Aberration
• This wavelength focus lies

between the blue and red

foci, being slightly nearer to

the red.
 D 2.00

This wavelength focus lies between the blue

and red foci, being slightly nearer to the red
Cobalt glass allows red and
blue to be seen through it
Cobalt Blue Glass Test
• This test is used to detect the
refractive error.
error
• Cobalt glass allows red and
blue to be seen through it.
• If we view a frosted lamp
through this cobalt blue at a
distance of 6 meter :
Cobalt Blue Glass Test
• If red is seen in focus and
blue is shown as a circle of
diffusion --------► so this eye
is myopic.
• If blue is seen in focus and
red is shown as a circle of
diffusion --------► so this eye
is hypermetropic.
 Blue

Cobalt Red
Red and blue
glass Red
Blue

Blue

Because of chromatic aberration, red light focuses

behind the retina and blue light focuses in front of it.
Duochrome Test
• In clinical practice the

chromatic aberration of

the eye is made use of in

the duochrome test.

Duochrome Test
• The test consists of two
ranks of black Snellen letters,
silhouetted against
illuminated coloured glass.
• The upper rank is mounted
on red glass, and the lower
rank is on green glass.
Verhoeff's Circles
Duochrome Test
• Red and green are used
because their wavelength
foci straddle the yellow–
green by equal amounts
(approximately 0.40D on
either side).
Duochrome Test
Duochrome Test
• The patient views the letters
by means of red and green
light respectively, and can
easily tell which appear
clearer.
• The test is sensitive to an
alteration in refraction of
0.25 D or less.
Duochrome Test
• A myopic eye sees the red
letters more clearly than
the green while a
hypermetropic eye sees
the green letters more
distinctly.
Duochrome Test
• The test is of particular use in
the refraction of myopic
patients, who experience eye
strain if they are overcorrected
(and thus rendered
hypermetropic), forcing them
to use their accommodation for
distance vision.
Duochrome Test
•The patient must see
the red letters more
clearly than the green
at the end of the
subjective refraction.
 The
Cross-
Cylinder
 The Cross-Cylinder
• The cross-cylinder is a type
of toric lens used during
refraction.
• Its use was popularised by
Edward Jackson (1893–
1929) and it is often referred
to as 'Jackson's cross-
cylinder'.
 -
0.25
Jackson Cross Cylinder

• Cross cylinder is a
spherocylinderical lens with
cylinder twice the power of the
sphere and of opposite sign.

• The spherical equivalent = Zero.

 DC 0.50 -

DC 0.50 +

A cross – cylinder . -0.50 DS / +1.0 DC

Jackson Cross Cylinder

• Cross cylinders are combinations

of two cylinders whose powers

are numerically equal and of

opposite sign and whose axes

are perpendicular to each other.

 DC 0.50 -

DC 0.50 +

A cross – cylinder . -0.50 DS / +1.0 DC

Jackson Cross Cylinder

• When a +/-0.50 JCC is placed on

a lensometer , with the red axis

at 0 and 180 degrees, the

lensometer will read the power

as -0.50 +1.00 x 090.

 DC 0.50 -

DC 0.50 +

A cross – cylinder . -0.50 DS / +1.0 DC

Jackson Cross Cylinder
• But, remembering that the JCC
has no spherical power, only
cylindrical power. For this
reason, we can more accurately
write the power of the JCC as –
0.50 x 180 combined with +0.50
x 90.
 The handle is placed halfway
between the plus and minus axis
45º
Jackson Cross Cylinder
• The Jackson Cross Cylinder is
usually mounted in a ring with a
handle at 45 degrees from the
axis so that a twirl of the handle
changes the cross cylinder to a
second position.
Jackson Cross Cylinder
• The axes marked on the lens are
the axes of no power of the
individual cylinders.
• The power of each cylinder lies at
90° to the marked axis and
coincides with the marked axis
(of no power) of the other
cylinder (of opposite sign)
 Axis Refractive Power
DC 0.50- 0.50+

DC 0.50+ 0.50-

The cross-cylinder showing axes as marked on the

.lens and refractive power in the principal meridians
Jackson Cross Cylinder
• Cross-cylinders are named by
the power of the cylinder,
and this is marked on the
handle.
• The cross cylinder illustrated
would be designated a 1.00
dioptre cross-cylinder.
 DC 0.50 -

1.0D

DC 0.50 +

A cross – cylinder . -0.50 DS / +1.0 DC

The cross cylinder illustrated would be
designated a 1.00 dioptre cross-cylinder
Jackson Cross Cylinder

• Cross cylinders are available

in two powers, 0.50 and 1.00

dioptre.
Jackson Cross Cylinder

• The 1.00 D cross-cylinder

is used to check the axis
of the trial cylinder and
the power in patients with
poor visual acuity.
acuity
Jackson Cross Cylinder

• The power in The 0.50 D

cross-cylinder is used to
check the power of the
trial cylinder where the
patient has good vision.
vision
 -
0.25
Jackson Cross Cylinder

• The cross cylinder is

supposed to produce mixed
astigmatism of equal power
but of opposite sign in the
two principal meridia.
Jackson Cross Cylinder
• When the JCC is placed in
contact with a spherocylinder,
it displaces both focal lines
simultaneously in opposite
directions, expanding the
initial Interval of Sturm in the
first position and contracting
it in the second.
Jackson Cross Cylinder
• However, there will be no
displacement of the Circle of
Least Confusion, only the
diameter of the circle will
increase in the first and
decrease in the second
position of the JCC.
Jackson Cross Cylinder

•Clinically the cross-

cylinder is used to
check the axis of the
cylinder prescribed and
then its power.
power
Jackson Cross Cylinder
• It can also be used to
verify that no cylindrical
correction is necessary for
the patient if no cylinder
was detected on
retinoscopy.
Jackson Cross Cylinder

•In practice the patient

is asked to look at the
line of test type two
lines above the smallest
he can see.
Jackson Cross Cylinder
• This is because the cross-
cylinder blurs the vision
and larger letters are used
to make discrimination
between the positions of
the cross-cylinder easier
for the patient.
Jackson Cross Cylinder
• To check the axis, the cross-
cylinder is held before the eye
with its handle in line with the
axis of the trial cylinder.
cylinder
• The cross-cylinder is turned over
and the patient asked which
position gives a better visual
result.
result
 Axis
3-
 Axis
3-
Jackson Cross Cylinder
• The cross-cylinder is held
in the preferred position
and the axis of the trial
cylinder rotated slightly
towards the axis of the
same sign on the cross-
cylinder.
cylinder
Jackson Cross Cylinder
• The process is repeated until
the trial cylinder is in the
correct axis for the eye, at
which time rotation of the
cross-cylinder will offer
equally unacceptable visual
alterations to the patient.
Jackson Cross Cylinder
• To check the power of the
trial cylinder the cross-
cylinder is held with first
one axis and then the
other overlying the trial
cylinder.
cylinder
Jackson Cross Cylinder

•This has the effect of

increasing and then
decreasing the power of
the trial cylinder.
 Power
3-
 Power
3-
Jackson Cross Cylinder
• To confirm the absence of a
cylinder : the cross-cylinder is
offered as an addition to the
trial sphere in four different
orientations, with its + axis
at 90°, 180°, 45°, and 135°.
Jackson Cross Cylinder
• If the patient prefers one of
these options to the sphere
alone, a cylindrical correction
is necessary.
• The exact axis and power can
then be determined by the
methods described above.
Jackson Cross Cylinder
•To achieve the best
results from the test it is
important that the
patient has the clearest
vision possible before
the cross-cylinder is
used.
Astigmatic
Fan
Astigmatic Fan
Astigmatic Fan
Astigmatic Fan
Astigmatic
Dial
Astigmatic Dial
•Series of heavy lines
arranged radially at 30°
intervals.
•Determine axis and
power.
Astigmatic Dial
Astigmatic Dial
 Astigmatic Dial
1. Fogging to suspend
accommodation ( + 0.5 D
than the most hypermetropic
meridian)
Example :
• Patient +1.25 +0.75 80°
• +2.50 sphere is ideal for
fogging.
 Astigmatic Dial
2. Test for the presence of
astigmatism and determine its
axis.
axis
• If a set of lines appears darker
or clearer  there is
astigmatism.
• The axis of astigmatism is
perpendicular to the darker
lines axis.
 Astigmatic Dial
3. Measuring the power of the
required cylinder.
• Minus cylinderical lenses are
placed in front of the eye with
their axis perpendicular to the
darker lines .
• Increase the power till all lines
are seen clearly.
 Astigmatic Dial
4. Minus sphere is then
added till best vision is
obtained.
obtained
• The idea is to collapse the
conoid of sturm till both
focal lines coincide .
Stenopaeic
Slit
Stenopaeic Slit
 Stenopaeic Slit
• The stenopaeic slit can be used
to determine the refraction and
principal axes in astigmatism.
• The slit aperture acts as an
elongated 'pin-hole', only
allowing light in the axis of the
slit to enter the eye.
 Stenopaeic Slit
• Hence , when the slit lies
in one principal axis of the
astigmatic eye, the second
line focus is eliminated
and the blur of Sturm's
conoid reduced thus
allowing a clearer image
to be formed.
 Stenopaeic Slit
• During the refraction of a patient with
astigmatism, the slit is first rotated to
a position in which the clearest vision
is obtained.
• Spherical lenses are added to give
further improvement in acuity.
 Stenopaeic Slit
• The slit is then rotated

through 90° and the spherical

lens power adjusted to give

best subjective acuity.

 Stenopaeic Slit
• The cylindrical correction
required by the eye equals the
algebraic difference between the
two spherical corrections used,
and its axis is that of the original
direction of the slit.
 Stenopaeic Slit
• In cases of corneal scarring, the
stenopaeic slit may be used to
determine the meridian along which
the cornea is least deformed.
• In those cases where an optical
iridectomy is indicated, this should be
performed in this meridian.
Thank You