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Phoropter • an instrument commonly used by optometrists and ophthalmologists during an eye examination to measure an individual's refractive error and determine his or her eyeglass prescription • also measure phorias (natural resting position of the eyes), accommodative amplitudes, accommodative leads/lags, accommodative posture, horizontal and vertical vergences Major • • • Components JCC (Jackson Cross-Cylinder) used for astigmatism correction Risley prisms to measure phorias and vergences cylinder lenses
History of Phoropter By the 17th century, lenses were being used to subjectively determine the best optical correction before trying on a pair of spectacles. Since the 1800’s, practitioners of clinical refraction have been trial lenses with objective or subjective techniques to arrive at a final refractive correction. By early 1900’s, optometry was becoming a licensed profession in the United States, refraction was no longer the only part of the optometrist’s education. The scope of optometry expanded, but the subjective refraction remained a major part of the vision examination. In 1915, Baush and Lomb started to make trial cases (known as the precision trial case) and trial frames. The limitation of constant center thickness meant that the overall diameter of the lenses had to be kept small. The precision trial case lenses had a diameter of only 15 mm. The first phoropter that in any way resembled today’s phoropters was developed by De Zeng. De Zeng’s phoropter consisted of a series of four discs, each having a maximum of eight lenses glazed in apertures situated around the edge. By rotating the discs, lens powers from +15.00 to – 20.00 D could be obtained at the sight holes of the instrument. Later on, two additional smaller discs were added that contained cylindrical lenses. To obtain the correct axis for the cylinders, the discs were rotated about the sight hole. Most modern refracting units contain the sphere and cylindrical lenses on three discs. The wheel closest to the patient’s eye usually contains the high power spheres, the second disc contains the low power sphere and the third disc contains the cylindrical lenses. Commercially available manual phoropters are manufactured by Reichert, Woodlyn, Topcon, Burton, and Marco. Most manual refractors are similar in design to the original American Optical Ultramatic. However, Reichert has purchased rights to manufacture the former Bausch and Lomb Green’s refractor as well.
Parts and Function
1. Rotation Adjusment Knob 2. Mounting Bracket 3. Mounting Adjustment Knob 4. Forehead Rest Knob 5. Spirit Level 6. P.D Knob 7. Vergence Lever 8. Auxiliary Lens Scale 9. Auxiliary Lens Knob 10.Corneal Aligning Device 11.Rotary Prism Unit 12.Cylinder Axis Knob 13.Cylinder Power Knob 14.Cross Cylinder Unit 15.Cylinder Power Scale 16.Cylinder Axis Reference Scale 17.Cylinder Axis Indicator 18.Cylinder Axis Scale 19.Weak Sphere Dial 20.Sphere Power Scale 21.Strong Sphere Control
22. 23. 24. 25.
Leveling Knob P.D Scale P.D Scale Reading Rod Clamp Screw
1. Rotation Adjusment Knob - It controls the housing rotation. Turning this knob adjusts the direction of the phoropter.
2. Mounting Bracket - It is used attaches the phoropter head to support arm. 3. Mounting Adjustment Knob - This knob is used to tighten the phoropter to stand and controls the pantoscopic tilt. 4. Forehead Rest Knob - It controls patient vertex distance. Adjusting this knob will secure that the eyelids are not touching the back of the phoropter. 5. Spirit Level - It projects horizontal tilt of the phoropter head and indicates level position. position. 6. P.D Knob - The interpupillary distance or PD is simply the distance in millimeters between the center of the pupil of the two eyes. This distance is needed to center spectacle lenses properly in an eyewire. The P.D Knob is use to line up the patient’s eyes in the center of the eye ports. It does not converge below 55 mm. Its maximum extension is 75 mm. 7. Vergence Lever - It controls the near or far Interpupillary Distance. It is adjusted in testing of near or far vision with an inward for 4mm decrease and slight inward tilt. 8. Auxiliary Lens Scale - The values to be selected upon rotating the auxillary lens knob. 9. Auxiliary Lens Knob - An Aperture Control Knob which determines what the customer actually looks through, when seated behind the phoropter. This control has different positions. The most frequently- used positions are Occluded which means the eye is completely blocked or Open which means that the customer sees through only the lenses that the refractionist has “dialed into” position before the customer eye 10.Rotary Prism Unit - Also known as the Risley Prism Control. It is on the Rotary same arm that holds the Cross-Cylinder. The R-prism is an ingenious device consisting of two rotating 10 diopter prisms mounted in a metal case. When the prisms are aligned base-to-base, the total prism strength is 20 diopters. When the prisms are aligned apex-to-base, they cancel each other and the total prism strength is zero. 11.Cylinder Axis Knob - Axis is the meridian of cylinder with the minimum Cylinder power perpendicular to maximum power meridian. This knob controls the Cylinder Axis of the phoropter. It has maximum of 360° of rotation for scale of 0°-180°. Like the cylinder power knob, it controls the minus cylinder lenses that are mounted inside the instrument in a rotating wheel. 12.Cylinder Power Knob - Cylinder is a lens that has different refractive or Cylinder optical power in each meridian. It is used to correct astigmatism. It is a
cylinder power control with 0.25 DC steps. It rotates clockwise for -0.25 DC (relative) change and rotates counter-clockwise for +0.25 (relative) change. 13.Cross Cylinder Unit - It usually contains a +0.25 cyl. Combined with -0.25 Cross cyl. The refractionist can rotate this lens to determine the axis of cylinder. 14.Jackson Cross-Cylinder (JCC Flip Cylinder) - The Jackson Cross Cylinder Jackson determines the power and axis of the cylinder. It is a lens with equal + or – 90 degrees apart. It is mounted in a ring with a handle halfway between the + and – axis or mounted in the phoropter with a knurled knob that rotates. 15.Cylinder Power Scale - The axis of the cylinder lenses is shown on the Cylinder cylinder power scale. It provides the current cylinder value with a maximum scale value of -6.00 DC and uses auxiliary cylinders for higher values 16.Cylinder Axis Reference Scale - The axis position of the cylinder lenses are Cylinder shown on the cylinder axis reference scale, easily found and read on the phoropter. Gross axis cylinder with an accuracy of +/-15° 17.Cylinder Axis Indicators - It provides the value of the cylinder axis. Cylinder 18.Weak Sphere Dial - This is a sphere power control which can be rotated up Weak and down. The dial or wheel controls spherical lenses from plano to + or – 20.00 diopters in 0.25 diopters steps. 19.Sphere Power Scale - Sphere is a lens with optical power being the same in Sphere all meridian. It is expressed in diopters. It provides the measured sphere power. Black color is for plus (+) while red color is for minus ( - ) 20.Strong Sphere Control - It provides a large change in sphere power with Strong 3.00 DS steps. Its maximum value is combined with weak sphere dial ranges from +16.75 DS to -19.00 DS. A clockwise rotation can bring +3.00DS change in the reading and a counter-clockwise rotation will produce -3.00 DS change. 21.Leveling Knob - Use to make the bubble on the level aligns with the dot. Leveling With this, you can able to tell if the patient is level. If not, try to get her to cock her head to a level position. 22.P.D Scale - An indicator of the measurement made by turning the P.D Knob. P.D 23.Reading Rod Clamp Screw - A near-point holder lock. Reading Auto Phoropter This machine is divided into main body and keyboard. Keyboard:
It includes all the operating elements to control the motor-drives for patient chair, telescopic table, phoropter arm and various lighting, such as reading light, room lighting, and fixation lights. A control rheostat to regulate the lighting of the table instruments and the main switch for the unit is also integrated into the keyboard. 1. Color LCD 10x2 touch-controlled screen 2. buttons Operation: Visual acuity is defined as the resolving power of the eye, or the ability to see two separate objects as separate. “Refraction” refers to the sum total of refractometry (measuring the refractive error of an eye), assessing the visual needs of an individual, and arriving at a clinical judgment as to which prescription to provide.” The overall process of refraction can be divided into three parts. parts. Part one is called the "starting point." The refractionist collects basic "starting point." information about the visual conditions of the customer. Second part is often referred to as the "refinement" phase of the process. In "refinement" this section, the refractionist would normally use a phoropter. Third part of the refraction is usually referred to as the "end point." This part "end point." of the refraction is perhaps the most critical portion. The refractionist must evaluate all the available information to solve the customer's refractive problems. The initial set-up: 1. The customer should be seated and comfortable. 2. The phoropter should be set to match the customer’s distance P.D. Adjust the level, adjust the forehead rest, and square to the eye chart. You can measure the patient’s PD and set the PD scale of the phoropter, or you can visually line up the patient’s eyes in the center of the eye ports using the PD adjustment. 3. The phoropter should be positioned comfortably in front of the customer like a pair of glasses. 4. The phoropter must be leveled. 5. A full- screen visual acuity chart with a 20/15 line at the bottom must be well illuminated for the customer. 6. As a starting point for the customer’s refraction, the final retinoscopy finding is usually set in place in the phoropter. An alternative starting point would be to place the customer’s current distance prescription in the phoropter.
With the customer seated comfortably, the refractionist is ready to begin the distance “subjective refraction” one eye at R time. The purpose of this is to determine the most plus or (least minus) spherical power that will provide the customer with his or her best visual acquity. Testing Procedure: Order of Refraction: a. Sphere – Lens with optical power being the same in all meridians and is expressed in diopters (reciprocal of focal length) b. Axis – Meridian of the cylinder with the minimum power perpendicular to the maximum power meridian. Refers to orientation where the corneal problem occurs and expressed in degrees. c. Cylinder - Lens that has different refractive power in each meridian. d. Refinement of Sphere - You will now want to got back and re-check the sphere power using the same procedure you used with the initial check of the sphere power.
Procedure: 1. Occlude the left eye and open the right eye with the auxiliary lens knob on the phoropter. 2. Blur or “fog” the vision in the right eye by placing the “Retinoscopy Lens” in place over the right eye by turning the auxiliary knob on the phoropter. This should fog the customer’s vision so that he or she cannot see the 20/20 vision line on the eye chart. 3. The refractionist’s use the “rule thumb” that basically the customer should be able to read the one additional line of visual acquity for each 0.25 diopters of minus sphere added (or each 0.25 diopters of plus sphere power that is removed) 4. The refractionist reduces the plus power or adds minus power, 0.25 diopters at a time. With each click of the wheel, the customer is encouraged to read the next smaller lines. 5. The refractionist must be careful not to give the customer too much minus power. This will cause the letter to look smaller and darker, but not allow them to read the next smaller line in the case of myope. Likewise, too much minus power on a hyperope will cause the customer to begin to accommodate to see in the distance. The degree of myopia or nearsightedness is determined by the phoropter to be the weakest minus sphere power for each individual eye (monocularly) which will provide 20/20 visual acquity. Too much minus will stimulate the customer’s accommodation and will result in an over-minused Rx. Auto Phoropter:
This type of phoropter has same principle of operation like in the manual phoropter. But, this one is easier to operate. Just press one button to start the test. The machine also contains the memory system, it stores all the testing process you setup before, and then just press one key all will start and finish automatically. If you have any problems or questions on how to operate the machine, just press the HELP key, and then the machine will tell you how to go forward on the screen. It is simple and convenient, and everyone can use it. Advantages
More comfortable for patients Lenses do not become so dirty Axis of any cylindrical correction can be read off from the refractor Additivity errors can be reduced.
Disadvantages The examiner depends on the subjective response of the patient. Refracting units hide the patient’s face. It only detects or corrects lower aberrations. Any cylindrical correction may be prescribed off axis Consists of several manual steps.
Advancements Micro-ElectroMechanical System (MEMS)-based Adaptive Optics Phoropter (MAOP) - award-winning system which uses wavefront sensors and deformable mirrors instead of glass lenses, to do everything a traditional Phoropter can
the first system to measure higher-order aberrations in the human eye, apply corrections, and immediately allow the patient to see the results. an innovative technology for early detection and treatment of retinal diseases that cause vision loss and blindness
Adaptive-Optics technology - used in advanced telescopes for high-resolution imaging of astronomical objects Micro-Electro-Mechanical Systems (MEMS) deformable mirror technology has significantly reduced the mirror size and that of the adaptive optic instrument.
Superluminescent Diode - A light source focused onto the patient’s eye, creates an image on the retina and is reflected. Wavefront Sensor and Corrector - are the key components for of higher-order aberrations. the correction
Fundus camera - The current retinal imaging device used by clinicians. Cornea and Lens - optical structures in the eye that can distort wavefronts and thus produce the aberrations we encounter in our natural vision. Adaptive Optics System - measures aberrations with a wavefront sensor and uses a wavefront corrector to compensate for the distortion. Wavefront Sensor - determines how much the wavefront is distorted as it passes through the eye’s cornea and lens.
It sends information to the computer interface, telling the computer how to adjust the corrector.
Computer - uses information from the wave sensor to create an internal, threedimensional (3D) representation of the distorted wave. Flip-in Mirror - allows a computer to calculate the needed correction. That 3D shape is then used to instruct the 144 MEMS actuators to move to positions that will minimize the distortion and “flatten” the wavefront. Processor - determines the correction needed to the detected wavefront and sends signals of different voltages to the appropriate structures on the deformable mirror. Deformable Mirror - uses a standard Shack–Hartmann wavefront corrector and changes shape and corrects the image seen by the eye.
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