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21-STEPS

IN
OPTOMETRY

Property of:
Deneb A. Daymon, O.D.
1
OPHTHALMOSCOPY

An objective method of examining the interior of the eye.


Instrument: Ophthalmoscope
Methods: a) direct ophthalmoscope
b) indirect ophthalmoscope
Illumination: Dim Illumination
Test Target: Gross Target
Test Distance: 6ft.
Working Distance: 16”
Manner of Examination: OD to OD; OS to OS
Recording of expected normal findings:
(+) ROR reflex,
clear media
distinct border (disc),
cd ratio, h. 3; v.3 or .4mm
av ratio 2:3;
(-) exudates
(-) hemorrhages
good foveal reflex (pinpoint reflex)
Procedure:
1) start at 16” w/ +8.00d in place in ophthalmoscope power
2) move closer to he pxn and go more minus until you will arrive to the amount of lens
that will give a clear fundus image at a distance of less than 1”
2
Ophthalmometry

Procedure:

-adjust eye piece, adjust body, the drums (at 44D), align the patient’s lateral canthus
with the canthus marker
-turn on the instrument and find the mires
-adjust the mires that the circle, + and – signs will be aligned.
-get the reading
-solve for the base curve: 337.5/flattest K
-get the corneal astigmatism: subtract the powers then use the axis of the meridian of
the least power

*Answer is always in minus sign.

SIGNIFICANCE:
-To measure the anterior radius of curvature of cornea.
-To determine Base Curve for CLs Fitting (hard CLs)
-Assess the quality of tears (N° 3secs.)
-To assess if cornea is steep or flat
-To assess any ocular pathology e.g. Keratoconus / Kl plana
3
Habitual Phoria Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance Snellen’s Chart
Illumination: Room Illumination
PD: Far
Control Lens: Old Rx (far) or Plano (if none)
Prism: OD = 12^BI (measuring ^)
OS = 6^BU (dissociating ^)
Procedure: Dec. 12^BI until vertically aligned
Response: Vertical Alignment
Recording: Remaining BI = __ Exophoria
Remaining BO = __ Esophoria
Zero = Orthophoria

Normal Recording : 0.5^ Exophoria

Significance:
To measure the tonic innervation of the muscles at 20 ft.
To determine the relative horizontal position of the visual axes when fusion has been
broken
13A
Habitual Phoria Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: Old Rx (TN) or Plano (if none)
Prism: OD = 12^BI (measuring ^)
OS = 6^BU (dissociating ^)
Procedure: Dec. 12^BI until vertically aligned
Response: Vertical Alignment
Recording: Remaining BI = __ Exophoria
Remaining BO = __ Esophoria
Zero = Orthophoria
Normal Recording : 6^ Exophoria
Significance:
To measure the tonic innervation of the
muscles at 16 inches/40 cm

Significance:
To determine the relative horizontal position of the visual axes when fusion has been
broke
4
Static Retinoscopy

Test Distance: 20 ft/6 m


Working Distance: 16”= f
Working Distance Equivalent: D=1/f; (D=2.50)
Test Target: Far
Illumination: Dim Illumination
PD: Far
Control Lens: Plano or WDE

Procedure:
*if Against movement = add minus lenses;
*if With movement = add plus lenses
Net#4 = Gross #4 – Working Distance (WDE)
Gross#4: change to sphero-cylinder

Significance:
To determine the refractive power of the eye objectively
5
Dynamic Retinoscopy @ 20”

Test Distance: 20”


Working Distance: 20 inches
Test Target: Head of Retinoscope or magnets
Illumination: Dim Illumination
PD: Near
Control Lens: Gross of #4
Manner of Exam: OD to OD; OS to OS
Procedure:
*if Against movement = add minus lenses;
*if With movement = add plus lenses

Significance:
Measures intensity & deterioration of visual pattern
6
Dynamic Retinoscopy @ 40”

Test Distance: 40”


Working Distance: 40”
Test Target: Head of Retinoscope or magnets
Illumination: Dim Illumination
PD: Near
Control Lens: Gross of #5
Manner of Exam: OD to OD; OS to OS
Procedure:
*if Against movement = add minus lenses;
*if With movement = add plus lenses

Significance:
Measures of negative relative accommodation @ 40”
7
Subjective Refraction Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Procedure:
-monocular
-Correct the Ametropia
-fog 2 lines above best VA
-Present astigmatic chart (ask if all lines are equally blur/dark)
*if equally blur/dark proceed to duo chrome test
*if there are darker lines (ask what lines are darker and get the middle then x30 to get
the tentative axis)
* if 4 lines are darker add 0.25 then get TA
-place Cyl. Scale handle on the TA
-add Cyl. Lens until all lines are equal
-Unfog px until 20/20 on DSC is clear
-check Cyl. Axis: JCC handle on TA (compare lenses: better lens, move 10-15 degrees
to the red dot, 2nd move 5 degrees towards the red dot, next…5 degrees till equal)
*Tell the px: “Px I will flip this lens, and tell me if they are equal or the other is
distinctively better than the other.”
-compare and get final axis
Check Cyl. power:
JCC red dot along final axis
*flip and let the px compare if the two positions are equal or clear or the other is
distinctively better or clearer than the other
*if red dot is near the Final axis, add more (-) cyl.
*if white dot is near the Final axis, dec. (-) cyl.
Check for Sphere Component:
Duo Chrome Test:
-room illum.
-compare letters inside the red and green chart
*if red darker, dec. (+) sphere; if green darker inc. (+) sphere

Repeat with OS
Significance: to check the equality of spherical amount
Check OU:
Equilibrium balance:
Prism OD 3^BU & OS 3^BD
*if equal or if there is a clearer target, add + sphere lens: Upper Chart clearer, add (+)
sph on the right; Lower Chart clearer, add (+) sph on the left
Equlibrium Test (Binocular Balance)
Significance: Checking the equalization on both eyes using the 3^BU & 3^BD (upper
left and lower right)
7A
Refraction Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: #7 Finding
Procedure:
Binocularly add + lens until J1+ or until clear
Response: Clarity of best VA in RSC or J1+
Recording: Add = # of clicks x 0.25
EXPECTED ADD
37 – 40: 1.00D
41 – 43: 1.25D
44 – 47: 1.50D
48 – 50: 1.75D
51 – 54: 2.00D
55 – 57: 2.25D
58 – 60: 2.50D
61 – 64: 2.75D
65 – ABOVE: 3.00D
8
Induced Phoria Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (far)
Prism: OD = 12^BI (measuring ^)
OS = 6^BU (dissociating ^)
Procedure: Dec. 12^BI until vertically aligned
Response: Vertical Alignment
Recording: Remaining BI = __ Exophoria
Remaining BO = __ Esophoria
Zero = Orthophoria
Normal Recording : 0.5^ Exophoria

Significance:
To measure the tonic innervation of the muscles at 20 ft.
To determine the relative horizontal position of the visual axes when fusion has been
broken
9
True Adduction Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (Far)
Prism: OU Ready to produce ^BO (zero @ 90 degrees)
Procedure:
Binocularly, gradually and smoothly increase ^BO until slight blur
Response: Slight Blur
Recording: Sum of both prism readings
Normal Recording : 7^ - 9^

Significance:
Blur Point – represents the point when the pxn can no longer compensate for the
prism induced
10
Convergence Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (Far)
Prism: #9 Prism findings
Procedure: inc. ^BO until diplopia; Dec. ^BO until single
Response: doubling and single (break/recovery)
Recording: Sum of ^BO for break and Recovery
Normal Recording: 19^/10^

Significance:
Break Point – represents the reserve of the total convergence @ far with activation of
accommodative convergence; Represents the point when the Pxn using all the
vergence resources can no longer maintain single vision
Recovery Point – the limit of fusion field in a distance of 20 feet; indicates that the
induced retinal disparity has been decreased to the point that the pxn can access the
vergence system & regain single vision
11
Abduction Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (Far)
Prism: OU ready to produce ^BI until single
Procedure: inc. ^BI until diplopia; Dec. ^BI until single
Response: doubling and single (break/recovery)
Recording: Sum of ^BI for break and Recovery
Normal Recording: 9^/5^

Significance:
Break Point – represents the reserve of the total convergence @ far with activation of
accommodative convergence; Represents the point when the Pxn using all the
vergence resources can no longer maintain single vision
Recovery Point – the limit of fusion field in a distance of 20 feet; indicates that the
induced retinal disparity has been decreased to the point that the pxn can access the
vergence system & regain single vision
*If NO BLUR: no accom. At distance, accommodation could not inhibit beyond zero.
*BREAK: negative fusional reserve.
12A
Vertical Phoria Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (Far)
Prism: OD = 12^BI (dissociating ^)
OS = 6^BU (measuring ^)
Procedure: Dec. 6^BU until horizontally aligned
Response: Horizontal Alignment
Recording:
Remaining BU = __ Hypophoria
Remaining BD = __ Hyperphoria
Zero = Orthophoria
Normal Recording : Orthophoria

Significance:
To measure the tonic innervation of the muscles at 20 ft.
To determine the relative horizontal position of the visual axes when fusion has been
broken
12B
Vertical Duction Test @ Far

Test Distance: 20 ft/6 m


Test Target: Best VA (far) Distance SC
Illumination: Room Illumination
PD: Far
Control Lens: New Rx (Far)
Prism: Ready to produce ^BU or ^BD in either OD or OS (zero@180)
Procedure:
-Done in one eye only bec. its duction
Inc. ^BU or ^BD until double
Dec. ^BU or ^BD until single
Response: Doubling and Singling (break/recovery)
Recording:
Remaining BU = (b/r) L infraduction or R supraduction
Remaining BD = (b/r) L supraduction or R infraduction
Normal Recordin: Orthophoria

Significance:
To measure the vertical displacement under dissociation & equal vertical duction in
view of relatively large # of pxs
13B
Induced Phoria Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: New Rx (TN)
Prism: OD = 12^BI (measuring ^)
OS = 6^BU (dissociating ^)
Procedure: Dec. 12^BI until vertically aligned
Response: Vertical Alignment
Recording: Remaining BI = __ Exophoria
Remaining BO = __ Esophoria
Zero = Orthophoria
Normal Recording : 6^ Exophoria

Significance:
To measure the tonic innervation of the
muscles at 16 inches/40 cm
To determine the relative horizontal position of the visual axes when fusion has been
broken
13B+1D
Induced Phoria Test @ Near +1.00D

Test Distance: 16”/40 cm


Test Target: Best VA (near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: New Rx (TN) +1.00D
Prism: OD = 12^BI (measuring ^)
OS = 6^BU (dissociating ^)
Procedure: Dec. 12^BI until vertically aligned
Response: Vertical Alignment
Recording: Remaining BI = __ Exophoria
Remaining BO = __ Esophoria
Zero = Orthophoria
Normal Recording: 0.5^ Exophoria

Significance:
To measure the tonic innervation of the muscles at 16 inches/40 cm
To determine the relative horizontal position of the visual axes when fusion has been
broken
14A
Unfused Cross Cylinder Test @ Near

Test Distance: 16”/40 cm


Test Target: Cross Grid
Illumination: Room Illumination
PD: Near
Control Lens: New Rx (TN)
Prism: OD = 3^BU w/ Cross Cyl. (red dot @ 90)
OS = 3^BD w/ Cross Cyl. (red dot @ 90)
Procedure:
Let Pxn choose which one to concentrate
*if all lines are equal: Add (+) lens until vertical lines are darkest
Dec (+) lens until vertical and horizontal lines are equal
Response: Vertical lines darkest, vertical and horizontal lines are equal
Recording: Record the lens that gives equality of vertical and horizontal lines
Significance: measures the integrity and deterioration of the visual pattern; measures
the degree of embedding of the visual pattern; measures the recency of the visual
problem and anisometropia @ near
For non-presbyope
Net 14a = gross #14a- (15a/6)
For presbyope
Net 14a = gross #14a- (#15a/6) * (#19/5)
15A
Induced Phoria Test Thru 14A

Test Distance: 16”/40 cm


Test Target: Cross Grid
Illumination: Room Illumination
PD: Near
Control Lens: Gross #14A
Prism: OD = 12^BI (measuring^) red dot @ 90
OS = 6^BU (dissociating^) red dot @ 90
Procedure: Dec. 12^BI till vertically aligned
Response: Vertical Alignment
Recording:
Remaining BI = __Exophoria
Remaining BO = __Esophoria
Zero = Orthophoria
Normal Recording: 6^ Exo
Exophoria = record as is
Esophoria = zero
Orthophoria = zero
14B
Fused Cross Cylinder Test @ Near

Test Distance: 16”/40 cm


Test Target: Cross Grid
Illumination: Room Illumination
PD: Near
Control Lens: Gross of #14A
Prism: No Prism; OU Cross cyl, w/ Red Dot @ 90 degrees
Procedure:
*if all lines are equal: Add (-) lens until horizontal lines are darkest
Dec (-) lens until vertical and horizontal lines are equal
Response: horizontal lines darkest, vertical and horizontal lines are equal
Recording: Record the lens that gives equality of vertical and horizontal lines

Significance:
Control lens for near point testing in the presence of low amplitude of accommodation;
Measures the amount of accommodation free of convergence at near under fused
condition

Presbyopic
Net 14b = gross#14b – (#15b/9) * (#19/5)
Non-presbyope
Net 14b = gross#14b – (#15b/9)
15B
Induced Phoria Test Thru 14B

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced Snellen’s Chart
Illumination: Head Lamp
PD: Near
Control Lens: Gross #14B
Prism: OD = 12^BI (measuring^)
OS = 6^BU (dissociating^)
Procedure: Dec. 12^BI till vertically aligned
Response: Vertical Alignment
Recording:
Remaining BI = __Exophoria
Remaining BO = __Esophoria
Zero = Orthophoria
Normal Recording: 6^ Exo
Exophoria = record as is
Esophoria = zero
Orthophoria = zero
16A
Positive Relative Convergence @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX;
(emmetrope) Plano
Prism: OU Ready to produce ^BO
Procedure:
Binocularly, gradually increase ^BO until 1st blur
Response: 1st blur
Recording: sum of both prisms
Normal Findings: 15^

Significance: To indicate the amount the positive fusional reserve available at the
fixation distance. (blur point w/ prism BO)
16B
Positive Fusional Reserve Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX; (emetrope)
Plano
Prism: #16A findings
Procedure:
Continue to increase ^BO until double; Dec. ^BO until single
Response: break/recovery
Recording: sum of both prisms for break & recovery
Normal Findings: 21^/15^

Significance: To measure the fusional innervation and accommodation convergence in


reserve that can be supplied at the point
17A
Negative Relative Convergence @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX;
(emmetrope) Plano
Prism: OU Ready to produce ^BI
Procedure:
Binocularly, gradually increase ^BI until 1st blur
Response: 1st blur
Recording: sum of both prisms
Normal Findings: 15^

Significance: Consists of the relaxation of the amount of positive fusional convergence


being used to secure binocular fixation at the near point test
17B
Negative Fusional Reserve Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX;
(emmetrope) Plano
Prism: #17A findings
Procedure:
Continue to increase 17A^ until double; Dec. until single
Response: break/recovery
Recording: sum of both prisms for break & recovery
Normal Findings: 22^/18^

Significance: Measures the maximum inhibition of convergence at near


18A
Vertical Phoria Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: New Rx (TN)
Prism: OD = 12^BI (dissociating ^)
OS = 6^BU (measuring ^)
Procedure: Dec. 6^BU until horizontally aligned
Response: Horizontal Alignment
Recording:
Remaining BU = __ Left Hypophoria
Remaining BD = __ Left Hyperphoria
Zero = Orthophoria
Normal Recording : Orthophoria

Significance:
Measures the vertical displacement under dissociation and unequal vertical ductions in
view of relatively large number of pxs
18B
Vertical Duction Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: New Rx (TN)
Prism: Ready to produce ^BU or ^BD in either OD or OS (zero@180)
Procedure:
Inc. ^BU or ^BD until double
Dec. ^BU or ^BD until single
Response: Doubling and Singling (break/recovery)
Recording:
Remaining BU = (b/r) L infraduction or R supraduction
Remaining BD = (b/r) L supraduction or R infraduction
Normal Recording : Orthophoria

Significance:
To measure the vertical displacement under dissociation & equal vertical duction in
view of relatively large # of pxs
19
Amplitude of Accomodation Test

*if px is Presbyope do this before Step 16"


Test Distance: 13”
Test Target: 0.62 EM type (Jaeger’s #28) Reduced Snellen’s Chart (not best VA)
Illumination: Head Lamp
PD: Near
Control Lens: New Rx (TN)
Prism: None
Procedure: (NPB) Add (-) lenses; (PB) Add (+) lenses, # of clicks x 0.25
Response: Chinese Characters are seen
#19AA: (NPB) Total (-) lens +2.50 = no sign
(PB) Total (+) lens -2.50 = no sign

Significance:
Measures the protection against senility
Measures the amplitude of accommodation by using minus lenses to inc. the stimulus
to accommodation.
20
Positive Relative Accommodation Test @ Near

Test Distance: 16 inches/40 cm


Test Target: Best VA (Near) Reduced Snellen’s Chart
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX;
(emmetrope) Plano
Prism: none
Procedure: add (-) lens till 1st blur
Response: 1st blur
Recording: Total (-) lens added for LTB (# of clicks x 0.25)
Procedure: reduce (-) lens till 1st clear
Response: 1st clear
Recording: remaining lens on place LTC (everything on the phoropter)
Normal Findings: -2.25D
#20 Recording: LTB/LTC
Significance: Stimulating the accommodation by increasing (-) lenses w/o affecting
convergence.
#20 Phoria Test
Prism: OD = 12^BI (measuring^)
OS = 6^BU (dissociating^)
Control Lens: #20 LTC result
"Same procedure and recording with Phoria Tests"
21
Negative Relative Accommodation Test @ Near

Test Distance: 16”/40 cm


Test Target: Best VA (Near) Reduced SC
Illumination: Head Lamp
PD: Near
Control Lens: (PB) Net #14B; (myope) TN old Rx; (hyperope) TN new RX; (emetrope)
Plano
Prism: none
Procedure: add (+) lens till 1st blur
Response: 1st blur
Recording: Total (+) lens added for LTB (# of clicks x 0.25)
Procedure: reduce (+) lens till 1st clear
Response: 1st clear
Recording: remaining lens on place LTC (everything on the phoropter)
Normal Findings: +2.00D
#21 Recording: LTB/LTC
Significance: Measure the maximum amount of accommodation relaxation.
#21 Phoria Test
Prism: OD = 12^BI (measuring^)
OS = 6^BU (dissociating^)
Control Lens: #21 LTC result
"Same procedure and recording with Phoria Tests"
DONDER’S TABLE OF AA DUANES TABLE

AGE AMPLITUDE AGE AA

10yrs. old 14.00D 10 yrs. old 11.00D


15 yrs. old 12.00D 15 yrs. old 10.25D
20 yrs. old 10.00D 20 yrs. old 9.50D
25 yrs. old 8.50D 25 yrs. old 8.50D
30 yrs. old 7.00D 30 yrs. old 7.50D
35 yrs. old 5.50D 35 yrs. old 6.50D
40 yrs. old 4.50D 40 yrs. old 5.50D
45 yrs. old 3.50D 45 yrs. old 3.50D
50 yrs. old 2.50D 60 yrs. old 1.25D
55 yrs. old 1.75D 70 yrs. old 1.00D
60 yrs. old 1.00D
65 yrs. old 0.50D
70 yrs. old 0.25D
75 yrs. old 0.00D