Clinical Refraction Guide

Clinical Refraction
Guide
Clinical Refraction
Guide
Ajay Kumar Bhootra

B Optom DOS FAO FOAI FCLI
ICLEP FIACLE (Australia)
Diploma in Sportvision (UK)
CEO and Dean
Krishnalaya School of Optometry
Kolkata, West Bengal, India
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Clinical Refraction Guide

First Edition: 2014
ISBN 978-93-5152-063-4
Printed at ? ? ?
Dedication
Achieving goals and objectives in life can truly be difficult yet

so rewarding. Enthusiasm, self-discipline, commitment, and
perseverance are all needed to get the desired results. But, once
the goal is realized, it is like a dream turned into reality, a shift
occurs, and people receive acknowledgment and acceptance.
While you are on your way to your desired goals, you come across
with several people. Some really leave mark that you can never
forget. I humbly remember Late Sri KK Binani, who taught me
the basics of clinical refraction.
I would like to dedicate this book to him.
Preface
Over the last 30 years, a lot of technological advancements

have occurred in the field of optometry and ophthalmology.
The progress has provided many equipment and instruments
to perform the clinical refraction to elicit various refractive
errors. Many textbooks have focused on the different aspects of
the whole procedure. Several multivolume books detailing the
procedure have been written. Yet, there remains a need for a
handbook which can serve as a reference guide.
The idea of Clinical Refraction Guide has been conceived
to fill this gap and to create a source, which is readily available
with the eyecare practitioners in their bag. The book is designed
to have the relevant texts so that the reader can assess the key
information quickly. The majority of the chapters also follow the
sequential steps of the whole procedure. Meticulous planning
has been done to design the contents and put them into different
chapters.
The book has two sections: Section I explains the basic
clinical procedures used for routine refraction and Section II
deals with retinoscopy procedure. Retinoscope is one of the most
wonderful and simple instruments used for ocular examination
as the clinical procedure. Retinoscopy is an art that cannot
be learned through books. It needs a long practice either on
schematic eye or on patients to really master the art. I have tried
to arrange the basic information as to the use and application of
the retinoscope in a very small package, so that an individual can
turn over its pages to look for the assistance.
The book has been compiled in a very simple language so that
it serves as a reference guide in the clinic as well as in the classes.
The readers must take the help of other textbooks available on
the subject to get into the depth. I hope, it serves the purpose
for which it has been written. I would also like to welcome your
suggestions to improve it in further edition.
Ajay Kumar Bhootra

Acknowledgments
I am extremely delighted to take this opportunity to accept and

acknowledge the support and cooperation which I got from
Mr SK Lohia of Modern Surgical, Kolkata, West Bengal, India;
Tatjana Heidorn of Heine Optotechnik GmbH & Co. KG, and
Mr Saleem Bhalla, the country manager of Heine Optotechnik
GmbH & Co. KG. I do not have any hesitation to accept that it
is their support in the form of pictures and text material that
helped me to complete this book in time.
Contents
Section I: Clinical Refraction Procedure 1–79
Chapter 1 Introduction 3
Chapter 2 Know Your Trial Lens Set 5
Trial Lenses 5
Prism Lenses 6
Pinhole Disk 6
Stenopaic Slit 7
Red and Green Lens 7
Maddox Rod 8
Occluder 9
Trial Frame 9
Chapter 3 Snellen’s Visual Acuity Test 11
Chapter 4 Near Visual Acuity Test 15
Chapter 5 Flow of Refraction Procedure 17
Chapter 6 Initiating the Process 19
Chapter 7 Routine Procedure 27

Dominant Eye Test 27
Monocular Distance Subjective
Refraction 29
Determination of Near Addition 33
Think and Go Ahead 36
Chapter 8 Refinements 37
Duochrome Test for Spherical End Point 37
Binocular Balancing 39
Stop and Think 41
Chapter 9 Prescription 42
Chapter 10 Controlling Accommodation 44
Chapter 11 Refraction in Hypermetropia 47
Chapter 12 Refraction in Myopia 49
xii Clinical Refraction Guide
Chapter 13 Refraction in Astigmatism 52
Chapter 14 Refraction in Presbyopia 54
Chapter 15 Refraction in Anisometropia 56
Chapter 16 Refraction in Aphakia 58
Chapter 17 Refraction in Children 60
Chapter 18 Refraction in Visually Impaired 62
Chapter 19 Refraction in Keratoconous Patient 64
Chapter 20 Tips for Clinical Care 66
Chapter 21 Lensometry 70
Chapter 22 Application of Stenopaic Slit for
Refraction 76
Chapter 23 Maddox Rod Test 78
Section II: Retinoscopy Guide 81–120
Chapter 24 Introduction 83
Importance of Retinoscopy 83
Chapter 25 Retinoscopy and Autorefractometer 85
Chapter 26 Parts of Retinoscope 86
Projection System 86
Observation system 87
Types of Retinoscope 88
Chapter 27 Optical Principle of Retinoscope 90
Chapter 28 Heine Beta 200 Retinoscope 92
Chapter 29 Choosing the Working Distance 94
Room Illumination 95
Chapter 30 Patient and Practitioner Posture 96
Chapter 31 Projecting the Light Beam 98
Contents xiii
Chapter 32 The Reflex 99
Speed 99
Brilliance 99
Width 100
Chapter 33 Spherical and Astigmatic Reflex 101
Chapter 34 Movement of the Reflex 102
With Motion Reflex 102
Against Motion Reflex 103
Scissor-like Movement 103
Confusing Reflex 104
Triangular Reflex 104
Chapter 35 Correcting Lens 105
Chapter 36 Neutralization 106
Interpreting Neutrality 107
Pseudoneutrality 108
Chapter 37 Estimating Cylinder Axis 109
Break Phenomena 109
Thickness Phenomena 110
Intensity Phenomena 110
Skew Phenomena 110
Chapter 38 Straddling the Axis 112
Chapter 39 Retinoscopy Results 113
Chapter 40 Step by Step Procedure 114
Chapter 41 Case Studies 116
Chapter 42 Tips for Difficult Retinoscopy 118
Chapter 43 Additional Applications of Retinoscopy 120
Bibliography 121
Index 123
Section-I
Clinical Refraction
Procedure
• Introduction
• Know Your Trial Lens Set
• Snellen’s Visual Acuity Test
• Near Visual Acuity Test
• Flow of Refraction Procedure
• Initiating the Process
• Routine Precedure
• Refinements
• Prescription
• Controlling Accommodation
• Refraction in Hypermetropia
• Refraction in Myopia
• Refraction in Astigmatism
• Refraction in Presbyopia
• Refraction in Anisometropia
• Refraction in Aphakia
• Refraction in Children
• Refraction in Visually Impaired
• Refraction in Keratoconous Patient
• Tips for Clinical Care
• Lensometry
• Application of Stenopaic Slit for Refraction
• Maddox Rod Test
1
Chapter Introduction
Refraction is the primary consideration for all patients with

vision related problems. The procedure is the part of total eye
care examination in which an eye care practitioner determines
the need for suitable prescription for lenses. Refraction refers to
the sum total of different processes that are applied to measure
the refractive error of an eye and assessing the visual needs
of an individual, and arriving at a clinical judgment as to the
prescription for the lenses to prescribe. It is an art and the science
that involves a combination of skills and intellectual process to
examine the eye and visual system of an individual to prescribe
a suitable correction so that he can perform his visual task. It is
an art as the experience adds to the skill of clinical procedure
and is science as there is an involvement of optics and science
related to ocular structure and its functioning. Refraction is done
with the help of a set of trial lenses, visual acuity test charts and
various tools and equipments in a clinical set up. The patient is
asked to look at the test chart and read the letters from a distance
of 20 feet. From 20 feet, the light rays entering the eyes are taken
as parallel and the crystalline lens of the eye is relaxed and thin.
The room illumination should be enough to allow normal pupil
size and retinal adaptation and should be sufficient enough for
observation by the examiner. Dim light should ideally be avoided
as accommodation may not relax and pupil dilates which may
increase the effect of wide beam aberration of peripheral light
4 Clinical Refraction Guide
rays. The procedure determines the amount of maximum plus
needed for hypermetropic patient and minimum minus needed
for best possible visual acuity for myopic patient. The end
point of the procedure is taken when the visual acuity reaches
6/6 or 20/20 on Snellen’s Test Chart. The theoretical goal of the
refraction is to prescribe a pair of lenses that ensure retina to
be in conjugate with optical infinity. But the true objective is
to provide the patient clear and comfortable vision to which
the patient adapts quickly and which allows him to work for a
longer period of time without any symptoms. The mechanics
of refraction should not only aim to enhance the vision but also
focus to minimize the disadvantage, if any.
2
Chapter
Know Your Trial Lens
Set
A standard trial lens set used for clinical refraction contains the
following gadgets—
TRIAL LENSES
A comprehensive trial lens set contains a set of lenses that are
designed to fit a standard trial frame and encircled by a metal
rim for protection in spherical and cylinder powers. Spherical
trial lenses have handles, whereas cylinder trial lenses do not
have any handle. The set contains following lenses (Fig. 2.1):
Figure 2.1: Trial lens set

• A pair of plus sphere lens ranging from +0.12D to +20.00D
• A pair of minus sphere lens ranging from –0.12D to –20.00D
• A pair of plus cylinder lens ranging from +0.12D to +6.00D
• A pair of minus cylinder lens ranging from +0.12D to +6.00D.
The trial lenses are put in the trial frame and the patient is
asked to read the test chart through them.
PRISM LENSES
Prism lenses are triangular or wedge-shaped piece of glass or
plastic that displaces the bundle of light towards the base. When
they are placed in front of the eyes, an object viewed through
them will appear to be displaced towards its apex. During the
clinical refraction, they are employed to measure the presence
and amount of any tropia or phoria. A standard trial lens set con-
tains the following prism lens measured in diopter –0.5∆, 1∆, 2 ∆,
3∆, 4∆, 5∆, 6∆, 8∆.10∆,12∆ (Fig. 2.2).
PINHOLE DISK
Pinhole disk is a small disk with central opening that prevents
peripheral rays of light to pass through (Fig. 2.3). The optimal
size of the central opening is 1.2mm. Larger size pinholes do not
effectively neutralize refractive error and smaller size pinholes
significantly increases diffraction and decreases the amount of
light entering the eye. Some trial lens set also contains multiple
pinhole disk which also serves the same purpose. The patient
finds easier to use multiple pinhole disk as he does not require
Figure 2.2: Prism lens Figure 2.3: Pinhole disk

Know Your Trial Lens Set 7
searching for a single tiny hole. The disk permits the examiner
to differentiate between the reduced visual acuity caused by
refractive error and the reduced visual acuity caused by some
pathological changes within the eyes. In general visual acuity
that is not improved with pinhole disk, cannot be improved by
the use of lenses.
STENOPAIC SLIT
Stenopaic slit is an elongated pinhole (Fig. 2.4) which is used to
allow the light transmission in one meridian and is a useful tool
for the correction of astigmatism. The width of the slit aperture
ranges between 0.50–1.00mm and the length is 15mm and is as-
sumed to limit the light admission to one meridian. When slit
is used for meridional refraction, only spherical trial lenses are
used to correct the refractive error in different meridians.
RED AND GREEN LENS

The standard trial lens set also contains one red and one green
filter lens (Fig. 2.5). Some trial lens also contains one yellow
filter. These filter lenses are used to check over-correction and
under-correction of refractive error. Under ordinary condition
of illumination, the eyes are emmetropic for yellow, myopic for
green and hypermetropic for red. With each eye occluded in
turn, the uncovered eye views the best line first through the red
filter, which is rapidly exchanged for green filter successively.
Figure 2.4: Stenopaic slit

Figure 2.5: Red and green lens
The patient is asked to make a comparison of definition through

the filter to notice the clarity of letters. If the patient states:
• No apparent difference between the two, it implies optimum
correction is present.
• Vision is clearer with red, the eye is slightly fogged. A small
minus can be added until equality is achieved.
• Vision is clearer with green, the eye is hypermetropic and a
plus lens can be added until equality is reached.
• If red and green appear clearer alternatively before any
adjustment is made in the correction, this indicates
accommodation is active. In such case it is better to abandon
the test
Red and green filters are also used for macular perception
test. If the patient can identify red and green color, macula can
be taken as functioning. They are great tool for Worth 4 Dot
test to ensure eye teaming or to detect diplopia. Yellow filter is
sometimes used to break the confusion of the patient to identify
correct observation.
MADDOX ROD
Maddox Rod is a group of either red or colorless parallel rods
taken together act as a cylinder (Fig. 2.6). The purpose of the
Maddox Rod is to dissociate the two eyes and prevent the images
to fuse. It accomplishes its function by changing the size, and
shape of a point source of light. It is useful tool to detect tropia
or phoria.
Know Your Trial Lens Set 9
Figure 2.6: Maddox rod
OCCLUDER
During a routine eye examination, the practitioner often needs
to check one eye’s acuity compared to other. Examiner uses a
set of special eye covers known as occluders. Occluders usually
prevent the full penetration of light (Fig. 2.7). There are also
translucent occluders which creates blurry effect over the eye.
TRIAL FRAME
A trial frame is used to use the trial lenses for refraction. It is
designed to accommodate 3–4 lenses for each eye. It can be
Figure 2.7: Occluder

adjusted from its earpiece and bridge to rest behind the ears
and to alter interpupillary distance. Some trial frame also have
an adjustment facility to alter its pantoscopic tilt. The front
surface of the front lens cell of trial frame is marked with degree
from 0 –180°. The new design of trial frames have a thumbscrew
mechanism on the side of the trial frame to rotate the front lens
carrier.
Modern Phoropters or refractors are an alternative to trial
lens set. All the lenses in the phoropters are inbuilt with the help
of motors. There are basically two types of phoropters—Manual
and Automatic. Two spherical lens assemblies and two cylinder
lens assemblies are housed in the phoropter for each eye.
Cylinder axis is altered by turning a knob for each eye that rotates
the axis through meridian from 0–180°. Two cross cylinders, two
rotary prisms, pinhole, stenopaic slit, occluders, red lens and
polarizing analyzer are also included on accessory post. The
patient is asked to be seated behind the phoropter. Horizontal
and vertical position of the lens apertures are determined by
the mechanical arm adjustment suspending the phoropter. The
adjustment knob for IPD is used to adjust the geometric centers of
apertures before the eyes. Pantoscopic tilt can be incorporated by
adjustment of the swing connection between the phoropter and
the mechanical arm. The light mounting provides illumination
of the near test card. Newer generation phoropters also provide
additional feature to tilt during the course of reading to ensure
natural reading posture. The only drawback of phoropter is the
eyes of the patient is hidden behind the phoropter which means
the practitioner cannot see patient’s reactions and operational
flexibility is less as it is fixed at one place. It is difficult to have
eccentric viewing which may be a reason why it is not suitable for
visually impaired patient. However, there are certain advantages
of the phoropter. They can also measure phoria (natural resting
position of the eyes), accommodative amplitudes, horizontal
and vertical vergences, and many more.
3
Chapter
Snellen’s Visual Acuity
Test
Figure 3.1: Snellen’s chart
Dr Herman Snellen, a Dutch ophthalmologist proposed his

optotypes in 1862 which is still widely used to measure the visual
acuity during clinical refraction. Snellen’s letters (Fig. 3.2) were
so constructed that their constituent parts, i.e. the limbs and
spaces between them, each subtends an angle of 1 minute of arc
at a specified distance. The linear size of the Snellen’s 6 meters
letters is given by the following notation:
h
tan 1 minute of arc =
6000 mm
(where “h” is the size or height of the letter)
Taking the value from log table
0.000292 = h
6000 mm
Or, 0.000292 × 6000 = h
Or, h = 1.75mm
Therefore, 5 minutes of arc 5 × 1.75 = 8.75mm
On Snellen’s test chart, 6/6 or 20/20 letter size subtends an
angle of 5 minutes of arc which has a letter size of 8.75mm.
Snellen’s fraction says that visual acuity depends on two factors:
1. Size of the letter seen
2. Distance at which it is presented.
The numerator in the fraction denotes test distance, i.e. the
distance at which the letter subtends 5 minutes of arc and the
denominator indicates the size of the letter presented.
Visual acuity = Viewing distance
Distance at which the letter size subtends
5 minutes of arc
A visual acuity score of 20/200 implies that the test is done at
20 feet and denominator presents the size of the smallest letter
that is being read would subtend an angle of 5 minutes of arc
when at a distance of 200 feet. The angular size of such letter
at 20 feet is 50 minutes of arc and the linear size is 87.50mm as
derived by above equation. Similarly visual acuity score of 20/20
implies that the test is done at 20 feet and the size of the smallest
letter that is being read would subtend an angle of 5 minutes of
arc when at a distance of 20 feet. The angular size of such letter
at 20 feet is 5 minutes of arc and the linear size is 8.75mm as
derived by above equation.
Figure 3.2: Snellen’s 5 minutes of arc visual acuity

Snellen’s Visual Acuity Test 13
20/20 is being chosen as normal or standard on the basis for
being “easy to recognize”. In fact healthy eye always exceeds the
standard. In population samples the average acuity does not
drop to 20/20 level until the age of 50 or 60 years. In fact a normal
young adults with healthy eyes can easily read over a range which
may extend beyond 20/20 to 20/15 or so. 20/20 is not the level
where the average visual acuity is truncated. Snellen’s fraction
may also be read as:
Visual acuity = Test distance
Distance from which a normal eye can
see the letter on the chart
20/200 in the above fraction means that test was conducted at 20
feet and the patient is able to read the size of the letter which a nor-
mal person with healthy eyes can read from a distance of 200 feet.
In USA the distance is expressed in feet and clinician invariably
uses the Snellen’s fraction with 20 feet as the numerator. In most
other countries metric unit is more popular with 6 meter being
the common test distance. Snellen’s fraction is internationally
recognized both in meters and feet. The notations recorded to
show various levels of visual acuity are as under:
Visual Acuity Notations
In meters in feet Linear size of letter
6/6 20/20 8.75 mm

6/7.5 20/25 10.95 mm
6/9 20/30 13.14 mm
6/12 20/40 17.52 mm
6/15 20/50 21.90 mm
6/21 20/70 30.66 mm
6/24 20/80 35.04 mm
6/30 20/100 43.80 mm
6/45 20/150 65.70 mm
6/60 20/200 87.50 mm
6/120 20/400 175.20 mm
Snellens Chart is standardized for size and contrast. Care must

be taken while measuring the acuity to encourage the patient to
keep reading. You may ask the patient to relax and blink regularly.
Avoid making comments while the patient is reading the chart
such as “You got that letter wrong” or “Are you sure?”. They affect
the patient’s behavior and can influence the outcome. Be aware
that frequent presenter may memorize the chart. In such case
you may use different charts, if available or you may ask them to
read backward. In addition to Snellen’s numeric notations, there
are several abbreviations used to record visual acuity in patient’s
prescription and attention should be given to the appropriate
use of these abbreviations:
VA — Visual acuity
VAcc — Visual acuity with correction
BCVA — Best corrected visual acuity
UCVA — Uncorrected visual acuity
VAsc — Visual acuity without correction
Visual acuity charts may be prepared as:
1. Printed panels
2. Projection charts
3. Video display generated.
The charts are often viewed directly. However, when the room
dimensions do not permit the desired test distance, mirrors
may be used to lengthen the optical path from the chart to the
patient’s eyes. High contrast between the black letters and white
background is the basis behind the Snellen’s test chart which is
possible mostly on printed panels. Projector charts and the video
generated charts lack the contrast. However, Projector charts
allows adjustment of optical path length from the patient to the
screen. Computer generated display provides the means to select
different optotypes to change the letter sequence and to vary the
stimulus parameters such as contrast, spacing arrangements
and presentation times. However, pixilated letters, brightness
and contrast of the screen display may alter the acuity results in
critical cases. While placing the test charts one should take care
to avoid glare sources within the patient’s field of view.
4
Chapter Near Visual Acuity Test
Near visual acuity test is usually done at a distance within arm’s

length. A distance of 40cm is usually taken to be standard and
is assumed to be a distance where usually most people keep
their objects while reading. However, distance also varies as
per individual needs, varying between a range of 33–50cm.
Reading tests are primarily used to verify the prescribed reading
correction as a part of routine eye examination. The emphasis
while reading test is on reading performance and not on optics.
This implies that any reading sample, whether it is letter text
or word text or continuous text may be used for the purpose.
Convention is to use the continuous text in the form of small
paragraphs set in different sizes because in normal day to day
life most people read continuous text arranged in different
paragraphs, not just an isolated letter or word. Another important
aspect to understand is that the near acuity score should be
equal to the score of distance visual acuity provided that the test
chart luminance level are comparable and letter test charts used
are on same principle and the eye is accommodated for near or
optically corrected to provide good focus for retinal image.
However, there is exception, as patients with posterior
subcapsular cataract whose pupil constriction at near vision
tasks causes the pupil area to become more completely filled
with the cataract so that the visual acuity becomes degraded.
The size of the typeset used is specified in “Point” units
which is widely used in printing industry. One point is equal to
1/72nd of an inch. In order to standardize the near vision test,
ophthalmologists in UK adopted the Times New Roman font
as standard font for testing near vision and they recommended
that the print size should be indicated in points. The size level
“N8” is the smallest letter print size that can be read at a distance
of 40cm. Jaeger notations are also used to record the size of the
text read at near distance. In Jaeger number there is no intrinsic
meaning to the number that indicates the print size. The J
number goes up as the print size of the text you read goes up.
The higher the J number, the worse is the acuity recorded for
near vision. The number can range from J1 to J16. For example:
J1 means that you could read the smallest text on the chart and it
can be taken as to relate with 20/15 vision at distance, J2 means
the line of text you were able to read had larger print than J1 and
it can be taken as to relate with 20/20 vision at distance, J3 means
the line of text you were able to read had larger print than J1 and
J2, and it can be taken as to relate with 20/40 vision at distance
and so on. However, this is not based on any logical relation.
Reduced Snellen notation expresses the near visual acuity that
is mathematically equivalent to distance visual acuity. The
principle is based on a standard test distance of 40cm and letter
size measurement in M units.
5
Chapter
Flow of Refraction
Procedure
The ocular refraction procedure starts with an extensive

history taking of the individual and ends with an individualized
prescription and appropriate management provided to him. A
quick and efficient refraction involves a number of procedures
and if done in a logical order, really provides the most predictable
results. The entire flow of the refraction procedure can be
grouped under three broad categories:
1. Initiating the process
2. Routine procedure
3. Refinement.
The different categories include different techniques but the
aim of all the techniques is to provide a suitable pair of lenses that
will provide the patient clear and comfortable vision to which the
patient will adapt rapidly. It must be kept in mind that refraction
is done for an individual person and not for a pair of eyeballs
which means importance should be given to the results based
on all the techniques including intellectual process involved. In
general the common flow of the refraction procedure is as under:
A. Initiating the Process
1. History taking
2. Lensometry
3. Visual acuity test : UCVA , VAcc, Pinhole Acuity
4. Objective measurement of refractive error: Retinoscopy, Ker-
atometry, Autorefractometry
5. Think and go ahead.
B. Routine Procedure
1. Dominant eye test
2. Monocular subjective refraction
3. Determination of near addition
C. Refinements
1. Duochrome test
2. Binocular balancing
3. Stop, think and prescribe.
6
Chapter Initiating the Process
Initiating the process during clinical refraction refers to esta-

blishing the goal and direction that allows the practitioner to
achieve the desired end results. The examiner applies certain
procedures that allow him to get into the refractive status of
the patient, and then he makes the objective evaluation of the
refractive error. Based on the information gathered, the examiner
makes the predictions about the refractive status and decides a
course that will lead him to write the final prescription. The flow
of the process should follow the sequence:
1. History taking
2. Lensometry
3. Visual acuity test
4. Objective evaluation of refractive error
History Taking
The process of refraction starts with extensive case history. His-
tory taking establishes a relation between the patient and the
practitioner and helps the practitioner in differential diagnosis
and patient education. It should start with an aim to establish
the reason for the patient’s visit. The questions may be asked in
the following order:
1. What is the reason for your visit today?
2. Is it a routine check up or you have specific reason?
3. Ask the chief complains. Each complains should be enquired
with its frequency, onset, duration, associated factors and
severity.
4. The practitioner needs to understand the patient’s visual
demands. Ask questions like What do you do? What are your
hobbies? Do you drive?
5. When was your last eye examination done? By whom and
what was its outcome?
6. How long have you been using the glasses? Is it for distance
vision or near vision or both? Can you see clearly and com-
fortably with them now?
7. General health including pressure and diabetes.
8. Family history of cataract, glaucoma or blindness.
A brief record of all information should be made. Care must
be taken to record the information derived in the manner it is
being presented by the patient.
Lensometry
If the patient is already an user of spectacles, the lens power
of the old spectacle should be found out using electronic
equipment known as Lensometer. The procedure as how to use
the equipment has been dealt with separately. The lens power of
the old spectacle lens provides an important platform on which
the refraction procedure can be initiated. Sometimes it is also
used as initial trial lenses. It also helps during the intellectual
process to decide the final lens prescription and helps to compare
the refractive status of the patient’s eyes during the process of
counseling. Hand neutralization is an alternate method which
utilizes loose trial lenses of known power to find the power of
unknown spectacle lenses.
Visual Acuity Test

Visual acuity is the spatial resolving capacity of the visual system.
It is the ability to see and discriminate a certain size target at a
specified distance. Monocular visual acuity must be measured
on all patients following the history taking at a distance of 20 feet
or 6 meters. This is most commonly measured using Snellen’s
Acuity Charts. Normal acuity on Snellen’s Test Chart for a healthy
eye is recorded as 6/6 or 20/20. A line is said to be read when more
Initiating the Process 21
than its half of the letters are identified correctly. The optical
system should project sharp image of the object onto the retina.
The retina must be able to translate the image into the neural
impulse and finally the neural impulse must travel to the brain,
where they are interpreted. Thus the visual acuity is the good
indicator that all the levels of the visual system is functioning
properly. The measurement of visual acuity is done when the
room is sufficiently illuminated so that the extra illumination
will not improve the visual acuity readings. If the patient cannot
read the largest letter in the test chart at the standard distance,
reduce the test distance between the patient and the chart. In
case the patient cannot see letters at any distance, you may
follow the following sequential procedure to record the acuity:
1. Counting fingers
2. Hand motion
3. Light projection
4. Light perception.
Visual acuity needs to be recorded in three states of condi-
tion:
1. Uncorrected visual acuity (UCVA)
2. Visual acuity with corrected correction (VAcc)
3. Pinhole acuity.
Uncorrected visual acuity (UCVA)

UCVA refers to the measurement of acuity when no glasses or
contact lenses are used and is most commonly measured imme-
diately after history taking. This is an important measurement
to know the current refractive status of the eye and it becomes a
benchmark against which the benefits of using refractive correc-
tion may be referred. Care must be taken to ensure that the pa-
tient does not squint or reduce the palpebral aperture to reduce
the blur created by defocus or optical irregularities.
Visual acuity with corrected correction(VAcc)

A well taken visual acuity measurement is critical to ensure an
accurate spectacle correction—just right …..not too strong…..
and not too weak. This implies that examiner is looking for the
finest detail that the visual system can resolve. Measuring the
visual acuity with existing correction reveals information as to the
possibilities of improvements. Many a times the patient carries
a perception that his acuity is better with his old correction than
the new one. Recording the acuity with old correction provides
opportunity to compare with the new correction and is also a
strong indicator on which the subjective refraction may be
initiated.
Pinhole acuity
Pinhole acuity can be measured if the visual acuity is worse than
20/30. It is a critical measurement to determine whether the
decreased visual acuity is correctable by lenses. When pinhole
acuity is used, the size of the blur circle on the retina created by
uncorrected refractive error is reduced which establishes that
better visual acuity may be improved with refraction (Fig. 6.1).
Care must be taken in patients with keratoconus and cortical or
posterior subcapsular cataracts because it can channel the light
through a better region of the eye’s optics. But it will not have
significant impact on visual acuity that is reduced because of
amblyopia or retinal disorder.
Objective Evaluation of Refractive Error

Objective refraction is the method to determine the refractive er-
ror of an eye without taking any responses from the patient,i.e.
the patient is not asked to read anything and provide any input
to the practitioner. This gives a good starting point for the subjec-
tive refraction for the regular patients and is the only technique
for the patient whose subjective responses are absent, limited or
unreliable. There are several ways to obtain an estimate of refrac-
tive error of a patient objectively. The most common of them are:
Figure. 6.1: Pinhole acuity

1. Retinoscopy
2. Keratometry
3. Autorefractometry.
Retinoscopy
Retinoscopy has gained the recognition of gold standard and is
an excellent method for not only estimating the refractive error,
but also to serve as first opportunity to view the internal struc-
ture of the eye. However, accurate measurement requires a lot
of training and practice. It is best done on undilated eyes with
an exceptions of patients with pupil less than 2mm and young
patients with active accommodation. In case the retinoscopy is
performed on a dilated eye, ignore the confusing reflexes seen
at the pupil edge and pay attention to central reflex only. Refer
to ‘Section 2’ of this book for clinical procedure of Retinoscopy.
Keratometry
Keratometry is an instrument used to measure the front surface
curvature of the cornea. The readings provide information as to
the corneal astigmatism which may be used as baseline cylinder
correction needed for the patient. They are also of great impor-
tance for fitting contact lenses and for calculating the power of
intraocular lens to be implanted.
Axis of the corneal astigmatism (Fig. 6.2) can be measured by
rotating the keratometer tube until the left mire and the focus-
Figure. 6.2: Cylinder axis measurement

ing mire plus signs are not staggered and perfectly in line. For
moderate to high corneal astigmatism, this is simple. To verify
alignment for low astigmatism, the focusing mire can be thrown
slightly out of focus, and the left mire plus sign should line up
exactly between the doubled plusses.
With two position instruments, rotate the body of the kerato-
meter through 90° to locate and align the second meridian.
An estimation of corneal astigmatism can be done by meas-
uring the curvatures of the cornea at two principal meridians
and recording the values as under:
Flat K Values: 44.00D @ 180° or 7.80mm @ 180°
Steep K Values: 45.00D @ 90° or 7.70mm @ 90°
Estimated Corneal Astigmatism : -1.00D @ 180°
However, the amount of astigmatism derived by keratometer
may differ from that of spectacle refraction. It may be more than
the spectacle refraction, or less than the spectacle refraction or
may be same.
Autorefractometry
Autorefractometer is an automated, fastest and very reliable
method of objective refraction. The results obtained from
autorefractometer are highly repeatable. It not only provides
several estimates of the refractive error but also suggests an
average reading. Some autorefractometers also provide the
reliability coefficient values of the readings taken which helps
the examiner judge the accuracy of the readings.
Autorefractometer basically comprises of an infrared source
(800–900nm), a fixation target and a Badal Optometer. The light
is reflected back from the deeper layer of the eyes and the ocular
refraction is determined by measuring how the light is changed
as it enters a person’s eye. The fixation targets are used to relax
the accommodation from less interesting stars to pictures with
peripheral blur to further relax the accommodation.
The procedure takes hardly a few seconds. The patient is
seated on a chair behind the autorefractometer and is asked to
rest his chin on the chinrest with brow against the forehead rod.
He is asked to fixate at the picture inside the autorefractometer.
The operator must align the instrument on the center of the
entrance pupil and focus the instrument on the plane of the
pupil (iris). This is usually performed with the use of joystick
and the reading is displayed on the display panel. Before each
reading target is blurred which comes back to focus when the
reading is displayed. Several readings are taken that the machine
averages to form a prescription. No feedback is required from
the patient during this process. Within seconds an approximate
measurement of a person’s prescription can be made by the
machine and printed out.
Although many studies have evaluated the accuracy
and repeatability of autorefractometer relative to subjective
refraction, the ability of patients to adapt and tolerate these
prescriptions has not been addressed. Experience has shown that
autorefractometer usually provides minus spherical correction
at a higher side. This could be probably because of the chromatic
aberration coupled with ocular spherical aberration.
Autorefractometer readings are unobtainable in the follow-
ing cases:
1. Small pupils— In such cases the patient may be asked to sit
in the dark room for some time before putting him onto the
autorefractometer.
2. Inadequate fixation.
3. Opacities or cloudiness of ocular medias.
4. Certain geriatric and pediatric patients are difficult to
measure because of their inability to keep the head in
position and eyes fixated, and patients with Parkinson’s
disease or nystagmus may prove impossible to clinically
perform autorefractometry.
5. Some posterior segment abnormalities reduce the intensity
and definition of fundus reflex.
6. Corneal irregularities arising naturally or resulting from
refractive surgical procedures can cause autorefractometer
results to differ from subjective results.
7. Ametropia beyond the range of the instruments.
8. Accommodative abnormalities as a result of such latent
hypermetropia or pseudomyopia. Young patients with active
accommodative spasm may produce more in minus than
revealed in retinoscopy or subjective refraction and the
amount of over minus reduces with age.
Think and Go Ahead

Now with the completion of first step of the clinical refraction
the examiner gathers the information about patient’s history, his
chief complains, current status of the visual system of the eye
and also the results of the objective assessment of the refractive
errors. Its time to relate all collected information, make a judg-
ment as to the further course of action and decide a goal for
the treatment. The routine visit implies that the patient has no
complains with his old correction, whereas visit with specific
reason asks the examiner to address the same. An asthenopic
symptoms may be relieved by looking at cylinder and its axis
correction. Reduced vision with habitual correction implies that
a change in refraction may yield an improvement in acuity. A
quick and in depth brain storming exercise is needed to relate
the symptoms with the objective assessment results. The general
guideline for probable refractive error which is given as under
has to be kept in the mind during the process:

V/A in feet V/A in meters Probable refractive error
in diopter
20/20 6/6 0.00
20/30 6/9 –0.50D
20/40 6/12 –0.75D
20/50 6/15 –1.00D
20/70 6/20 –1.25D
20/100 6/30 –1.50D
20/150 6/45 –2.00D
20/200 6/60 –2.50D
The idea behind this exercise is to think ahead the nearest

final prescription and set a goal for the rest of the process. The
process also helps to decide the selection of the initial lenses for
subjective refraction to be followed.
7
Chapter Routine Procedure
The second phase of the clinical refraction starts when the

complete process of first phase is carried out and the goal has
been set with all predictions done in the mind. By now the
examiner knows how the visual system of the patient is behaving,
patient’s chief symptoms and his visual demands. The tools and
equipments used in this phase are:
• Trial lens set and trial frame/phoropter
• Snellen’s test chart
• Cross grid test
• Near duochrome test
• Near test chart
• Hole in the card.
The total routine procedure is done in the following sequence:
1. Dominant eye test
2. Monocular distance subjective refraction
3. Determination of near addition.
DOMINANT EYE TEST

The dictionary of visual science defines ocular dominance as,
“The superiority of one eye over the other in some perceptual
or motor task. The term is usually applied to those superiorities
in function which are not based on a difference in visual acuity
between the two eyes, or a dysfunction of the neuromuscular
apparatus of one of the eyes.” This implies that dominant eye
is not necessarily an eye with superior visual acuity, still it
contributes most to the visual perception. The extension of the
concept of dominant eye is:
• It is the fixating eye in the binocular vision
• It aims at the object
• It leads in receiving the visual inputs.
The concept ocular dominance may be studied in three
different categories:
• Sensory dominance
• Oculomotor dominance
• Directional dominance.
Sensory dominance may be because of difference in
retinal images of the two eyes in terms of image clarity, color
or brightness that may lead to some binocular interaction.
Oculomotor dominance occurs when an eye does a better job
of fixating on an object of regard. Directional dominance is the
sighting dominance, i.e. the eye that is sighted at the target.
Sighting dominant eye aims at the target and the non dominant
eye follows and looks at the same target slightly at a different
angle. The small difference provides us the required depth
perception. A stable dominant eye is, therefore very important
to hold the visual system steady at the fixating target. It leads in
visual inputs in binocular vision. Eye dominancy is someone’s
innate characteristics. If there is dominance conflict, then often
attention jumps several words or even lines and hence affects
comprehension. It leads to binocular instability. Human species
are predominantly right eye dominant. Nearly 70% of the total
population is believed to be right eye dominant. However,
prevalence of left eye dominancy is also present simultaneously.
Therefore, establishing which eye is dominant plays a vital part
in binocular vision function. The dominance may be weak,
strong or highly profound which may also have fairly good
impact on the visual performance when the visual demand
exceeds the ability of the visual system. Some patients may feel
uncomfortable if their dominant eye is fractionally blurred,
whereas a small residual refractive error in the nondominant eye
may not give any discomfort.
The concept of dominant eye is very important in case of
monovision correction in presbyopia. Usually dominant eye
is being corrected for distant vision and nondominant eye is
corrected for near vision. It has also been seen that when light
level changes from low to high as it happens when coming
Routine Procedure 29
out from dark room to bright sunlight, the dominant eye
closes leaving the nondominant eye responsible for vision. It
is, therefore, useful not only clinically to know the dominant
eye, but to remember throughout the procedure. The test for
dominant eye can be done by a simple test called “Hole in the
card test” (Fig. 7.1). The test procedure is as under:
• The subject is given a card with a small hole of 25mm and is
instructed to hold it with both hands stretched out.
• He is then instructed to view a distant object through the hole
with both eyes open.
• If binocular vision is present they tend to center the hole
between their eyes.
• When the observer looks at the patient’s eyes through the
hole in the card from a distance, he will see his dominant eye.
MONOCULAR DISTANCE SUBJECTIVE REFRACTION

Subjective refraction is a method of estimating the refractive
error that is largely dependent upon the patient himself. Under
this technique one lens is compared against another and the
patient is asked to provide input on changes in visual acuity as
demonstrated on the Distance Vision Test Chart. Therefore, the
accuracy of the results largely depends upon the intelligence,
cooperation and observational ability of the patient. The process
is completed for each eye separately. Traditionally right eye is
completed first and is followed by the left eye. The ultimate goal
Figure. 7.1: Dominant eye

is to arrive at a combination of lenses that result in maximum
visual acuity. Subjective refraction is initiated by selecting an
initial trial lens which may be based on the following factors:
1. Current lens prescription of the patient
2. A set of lenses you decide based on your initial data collection
3. It may be the results of autorefractometer or retinoscope.
Once the initial trial lens is put in the trial frame, you ask the
patient to look at the Distance Vision Test Chart through a lens
power one step stronger or one step weaker and inform which
one appears clearer to him. Depending upon the lens the patient
chooses, you compare another combination of one step stronger
or one step weaker. “Clearer” being the key word as in many
cases neither lens choice is very clear. Do not worry even if there
is a mistake in picking up the correct response as the next pair of
lenses will take you back to where you were.
Broadly speaking there are three methods which are most
commonly followed in the clinical practice for subjective refrac-
tion:
1. Manifest subjective refraction
2. Fogging method of subjective refraction
3. Trial and error method.
Manifest Subjective Refraction

Usually the following sequential procedure is followed while do-
ing manifest subjective refraction:
1. The first step is to find out the initial or working sphere. Put
the sphere power in the trial frame and change at a step of
0.50D. Always put plus lens first and then minus lens. Obtain
the best possible acuity by giving most plus or least minus. You
may take the help of “Initial Duchrome Test” to find out initial
or working sphere. Ask the patient to look from the green side
to the red side and then back to green side and indicate which
side has the clearer letters or both the sides are equally clear.
Do not use the word “better”, “darker” or “brighter”. Red side
clearer indicates the need of minus spherical and green side
clearer implies the need of plus spherical. Keep changing
the spherical lens until both side’s letters are equally clearer.
Introduce an additional 0.25D minus spherical power. Then
the patient is into the green. Now check the visual acuity on
the Snellen’s Chart. Remember that visual acuity of 20/20 or
6/6 may not be possible at this point as cylinder correction has
not yet been refined. Now it’s time for astigmatic correction.
2. The second step is to ascertain the need for astigmatic
correction. This is done in two steps— first the axis of cylinder
is determined and then the amount of cylinder is measured.
Use Jackson Cross Cylinder for the purpose.
3. With initial spherical lens in front of the eye the patient may
inform visual acuity of, say 20/30. Now ask the patient to look
at a target which is slightly larger than the achieved acuity.
In our example it may be a 20/50 line. Hold the JCC in front
of the patient eye and ask him to concentrate on how things
look. It is not necessary to read the line but to concentrate on
how it looks. Then flip the JCC and ask the patient to compare
the two and report which is better. Give enough time to the
patient before flipping the JCC. If both the position looks
equally clear at the very first time, it implies either you have
found out the correct axis or there is no astigmatism. In case
he likes either of two, you must rotate the JCC to realign the
axis. To do this, you must figure out what was the orientation
of JCC that he likes better. Then rotate the JCC so that the axis
you flipped around gets rotated by 15°–20° in the direction
of the axis of the plus cylinder. Now repeat the process and
ask the patient “which is better”. If he says, both look alike, it
implies you are straddling the axis. This is the endpoint of the
test.
4. The next step is to determine the amount of cylinder lens
needed. In order to determine the amount of cylinder, the
axis of the JCC has to be line up with the axis determined as
above. Wait for a moment and then flip the JCC. If the patient
truly needs the cylinder, he will appreciate one more than
other. In order to be sure, flip the lens back to the one that is
preferred. Now put +0.25 cylinder at the axis. Then repeat the
procedure. Then again ask the patient to see 20/50 line and
ask which flip is better? Continue the process till both looks
alike. Remember to reduce 0.25 sph for every 0.50 cylinder
addition.
5. Now refine the spherical lens by changing at a step of 0.25D.
Stop at most plus or least minus when images are about the
same. Note down the visual acuity.
Fogging Method of Subjective Refraction

Fogging method of subjective refraction allows controlling
the accommodation. In case you follow the fogging method of
refraction, start with higher plus than the results of objective
method of refraction in case of hypermetropia and with low
plus in case of low myopia and no plus lens is needed in case of
high myopia. Most commonly Fan and Block Test is used for the
fogging method of refraction. The step by step procedure is as
under:
1. Occlude the left eye and put the fogging spherical trial lens in
the trial frame in front of right eye as selected above and start
reducing the fogging. While reducing fogging care must be
taken to put the new plus lens first and then remove the one
from the trial frame and for minus lens, remove the minus
lens first and then put the new one.
2. Obtain the best visual acuity using spherical lenses only, i.e.
best vision sphere. It is assumed the best vision sphere will
put the circle of least confusion on the retina and the patient
will report the acuity of 6/9 or more.
3. Now ask the patient to look at the Fan Chart for astigmatic
correction and ask which line or group of lines appears
clearest and darkest. This gives an approximate direction of
the astigmatic error.
4. If no lines appears to be black than the other, there are two
possibilities— either the patient may not need any astigmatic
correction or the eye is excessively fogged. In case the patient
identifies any one line or group of lines as darker than all
others, align the Maddox Arrow with the same.
5. Now direct the patient’s attention to Maddox Arrow. Ask him
if both the limbs of the arrow are equally blurred. Rotate it
away from the black limb towards the blur limb until both
limbs appear equally blurred. This gives the axis of the
astigmatic correction. Care must be taken to ensure that the
patient head is upright.
6. Then direct the patient’s attention to two blocks. The patient
will report that one of the two blocks is clearer and darker
than the other. Add minus cylinder at the appropriate axis
until the second block becomes as clearer as the first one. If
this is not quite possible, over add cylinder lens by –0.25D
to get the reversal. Once the reversal is achieved, you may
reduce the additional cylinder lens added and go one step
down. Remember it is always better to under correct than to
overcorrect, leaving the initial block clearer than the other.
7. Finally, with corrected sphere and cylinder ask the patient
to look back to Snellen’s chart to refine the spherical. Do not
continue reducing plus unless you are very sure that they re-
ally need it to see clearly. Similarly do not go on adding minus
as well, it will not make the letters clearer, rather letters will
become sharp black and small. The goal is to find “maximum
plus to best acuity” or “minimum minus to best acuity”.
8. A simple fogging with +0.50Dsph and then reducing fogging
at the step of 0.25 step may be applied. At this stage it is quite
likely that unfogging another 0.25D may also yield 6/6 acuity.
A clinical judgment based on patient’s past correction and his
visual demands may help.
Trial and Error Method

Trial and error method of clinical refraction includes the
application of different trial lenses to determine the spherical
and the cylinder correction needed. Results of autorefractometer
may be used as a starting guideline. The steps may follow the
following order:
1. Determine the maximum plus or minimum minus spherical
lens that gives the maximum acuity. Care must be taken to
explain the patient to understand the difference between
“changes that makes the letters clearer and changes that
makes the letters darker and smaller”.
2. Then check for astigmatic correction. Find out the axis first
by rotating a cylinder lens in the step of 5°–10° in either
direction and asking the patient whether the acuity improves.
The important factor is to decide the amount of cylinder to
be used for the purpose. Usually when the patient needs low
cylinder correction, it is difficult for him to pick the correct
position of clarity while rotation. Under this situation a
stronger cylinder lens may be used.
3. Once axis is determined, the amount of cylinder correction
can be determined by changing the cylinder lens at the re-
spective axis.
DETERMINATION OF NEAR ADDITION

Around the age of 40 years when a patient starts squinting at the
near reading object, he has achieved middle age and is assumed
to have presbyopia. A presbyopic patient needs “near addition”
or “add” as a correction to read comfortably in addition to
distance correction. The “add” is the positive spherical lens
power that is added to the distance correction of an individual.
Near addition is determined with both eyes open with target
kept at a distance of either 40cm or habitual near working
distance. A careful distance refraction provides the foundation
for determining the management of presbyopia. The optical
correction for presbyopia is the sum of the refractive correction
for distance correction plus the power of the near addition.
Different methods may be applied to perform the test for near
addition. Most common of them are:
1. Cross grid test
2. Near duochrome test
3. Trial and error method.
Cross Grid Test

• Use phoropter
• Place the cross grid at a near point distance
• Reduce room illumination
• Put ±0.50D cross cylinder with minus axis vertically in front
of both eyes with distance correction in place
• Now ask the patient which set of lines are clear and sharper—
Horizontal or Vertical
• Expected answer : Horizontal lines
• Add plus lens binocularly until vertical lines are clear and
sharper
• Then reduce plus to achieve equal clarity and sharpness (Fig.
7.2)
• That’s the end point.
Figure. 7.2: Cross grid test

Near Duochrome Test

• Ask the patient to hold the Near Duochrome Test in his hand
with distance correction in place in the trial frame at a dis-
tance as decided.
• Duochrome with black rings or letters may be used. Keep
both eyes open and ask the patient which black rings are
clearer or darker. Three possible responses can be expected:
1. Either black rings on green background is clearer and darker
which indicates the need for plus lens.
2. Or, black rings on the red background is clearer and darker
which indicates the need for reduction of plus power.
3. Rings on both sides – red and green background appear simi-
lar.
In a young patient with active accommodation the preference
for red and green will be alternate indicating that there is no need
for any near “add”. Uncorrected or undercorrected presbyopes
will have marked green preference. The most important thing to
note is that this test applies only for a particular fixation distance
used during the test. If the test distance is moved towards the
eyes about 5 cm, the green preference will again be dominant
and if the test distance is taken away by 3cm from the fixation
point, the red preference will become dominant.
Once the near addition is determined by any of the above
methods, put the proposed near addition lens in the trial frame
in front of the distance correction, ask the patient to hold the
reading text chart and make sure that he has fairly good visual
performance at a range of distance of his normal near working
distance.
Trial and Error Method

Near addition may be prescribed by trial and error method. In this
process near addition is decided based on the age of the patient
and the lenses are put in the trial frame to verify that vision is
fairly good and the patient is comfortable at his usual working
distance. One problem with this approach is that it assumes
that all individuals of same age have the same amplitude of
accommodation, which is not the case in practice. The typical
age table with correspondingly required near addition may be
designed as under:
Age Near addition

40 years 0.75 D
42 years 1.00 D
44 years 1.50 D
46 years 1.75 D
48 years 2.00 D
50 years 2.25 D
THINK AND GO AHEAD

All clinical steps of the refraction procedure are completed and
the examiner has landed to a result. During the process the
results may be affected by any of the following factors:
1. The patient may provide wrong information by accident,
especially if he is tired, bored or have trouble understanding
the examiner.
2. Accommodation may fluctuate and mislead the results,
especially with patients who have active accommodation.
3. Patient may squint to see or he may read by memory to
misguide the results.
This implies that there is scope for the intellectual process
where the examiner has to think and decide the next suitable
step for verifying results so obtained to get into the final step of
clinical procedure of refraction.
8
Chapter Refinements
The last part of the whole process is endpoint techniques which

aim to refine the results of the complete test. Two clinical tests
are usually performed for the purpose— one aim to refine the
results monocularly and the other aim to ensure that the results
of monocular subjective refraction works binocularly without
any problem. The two tests are:
• Duochrome test for spherical end point
• Binocular balancing.
DUOCHROME TEST FOR SPHERICAL END POINT

Aim
The test is performed to refine the spherical correction or to de-
termine the spherical end point of the refractive error after the
subjective refraction is completed.
Illumination
The test has to be done under complete darkness as it reduces
veiling luminance and dilates the pupil, thereby increases the
chromatic aberration, making the test more effective.
Position
The patient should be asked to sit with face upright and results
of subjective refraction should be in the trial frame in front of his
eyes. The patient is sighting at distance chart.
Test Distance
The test has to be done at usual distance of 20 feet.
Principle
The test makes use of chromatic aberration present in the
human eyes. Near the end point, an eye that is residually myopic
by a small degree of spherical, sees black letters having a red
background to be sharper and darker, with more defined borders.
Letters on the green background appear slightly fuzzy and less
dark with less defined border. An eye that is residually hyperopic
by a small degree of the spherical power sees the letters on the
green background sharp, darkened and more defined. Residually
emmetropic eye sees the letters on both sides of the chart to be
equally sharp, dark and defined.
Color blindness does not invalidate the test because chro-
matic aberration is present even in color blind subject.
Critical Factor
It is important to control the accommodation by slight fogging.
Add +0.25Dsph lens monocularly before asking the patient to
notice the difference between letters of two backgrounds. The
idea is to take the patient in a position where he reports that the
letters on the red background appear to stand out better. This
should occur in only one or two increments of plus sphere unless
the eye is over minus.
Normative Data
The test is very sensitive to even a small change of 0.25DS. The
plus sphere is reduced until letters on the both backgrounds
appear equally distinct. Or the next reduction of only 0.25D
makes letters on the green background more distinct. Ideally,
spherical end point should be decided when the letters on the
red background are comparatively sharper.
Limitations
Although the test is very effective but its applications are also
limited as may be seen in following cases:
• Test may be ineffective when the pupil is exceedingly small.
Refinements 39
• Red and green wavelengths of different charts may bring in
disparity in results.
• Aging of bulb, faded or dirty charts may adversely affect.
• Yellowing of crystalline lens in cataract tends to reduce
transmission of shorter wavelength, it may alter the patient’s
preference for one color or visual acuity is not adequate to
discern a difference.
• The instruction to the subject is to emphasize the sharpness,
darkness and definition of the black letters and not their
background.
BINOCULAR BALANCING
Aim
The test is performed to equalize the stimulus to accommoda-
tion for the two eyes.
Test
The two most common procedures that are normally used are:
• Alternate Occlusion Test
• Prism Dissociated Test.
Illumination
The test has to be done under standard room lights.
Patient Position
The patient is asked to sit upright with monocular correction in
the trial frame and both eyes open.
Test Distance
The test is performed at a distance of 20 feet.
Critical Factor
If balancing is not possible, leave the patient at a point which
produces least difference. The dominant eye is left with little
clearer vision.
Indications
The test is performed in the following cases:
• W
 hen visual acuity in both eyes is nearer to 20/20
• W hen both eyes visual acuity is equal
• The test is not effective for amblyopes.
Procedure of Alternate Occlusion Test

1. Ask the patient to keep both eyes open.
2. Begin with the results of monocular subjective refraction.
3. Ask the patient to look at a line three lines above BCVA, i.e.
20/50.
4. Fog both eyes with +0.75Dsph.
5. Alternately occlude each eye and ask the patient with which
eye he sees better.
6. Add +0.25Dsph to the better eye and continue until each eye
sees equally blur or clearer vision switches to other eye.
7. This is the end point.
8. In order to confirm, add +0.25Dsph before both eyes and re-
peat the test. If balance is correct, both eyes will lose equal
amount of acuity.
9. Now both eyes are in perfect balance.
10. Subtract 0.75 Dsph from each eye.
11. Do this while the patient is viewing full chart with 20/20 at
bottom.
Procedure of Prism Dissociated Test

1. Ask the patient to keep both eyes open.
2. Begin with the results of monocular subjective refraction.
3. Fog both eyes with 0.75Dsph or 1.00Dsph.
4. Isolate a line of letters (pref 20/40 or 20/50).
5. Put 3 prism dioptre base up over right eye and 3 prism diopter
base down over left eye.
6. Make sure that the patient sees same line as two-one on top
of other.
7. Instruct the patient to compare two lines.
8. Images of both the lines should be equally blurred.
9. Add +0.25Dsph to better eye and continue until each eye sees
equal blur or clear vision switches to the other eye.
10. This is the end point.
11. Now both eyes are in perfect balance.
12. Subtract the original fogging lens power from each eye.
Refinements 41
STOP AND THINK

The final results are arrived at, refinements are done and a
suitable correction is being decided. Now it’s the time for the
clinical judgment to prescribe the lenses and also suggest the
suitable mode of correction. The examiner needs to keep in mind
that over-minus will stimulate accommodation and over plus will
blur the vision. Another important fact he has to keep in mind
that both health and the visual function problems will manifest
themselves because of the change in lens prescription. Explain
the status of the refractive system of the eye and prescribe the
lens power. The examiner also needs to do cover test, near point
of convergence test, ocular motility test, slit lamp examination
and ophthalmoscopy so that he can make necessary referrals.
9
Chapter Prescription
At last the examiner records his final decision as to refractive

correction of the patient, his diagnosis together with advices
and referrals, if any on a prescription and handover the same to
the patient. A prescription is a medicolegal document. It should
be written in either black or blue ink. Prescriptions are three
way contract with an obligation for the examiner, the optician
and the patient. It must be written in clear and legible manner
so that the optician is able to read and interpret. It starts with
date, name, age and the gender of the patient. On the left hand
side of the prescription, patient’s complains along with the gist
of history is noted and the examination results of various tests
are also mentioned under the head “On Examination”. On the
right hand side of the prescription, mention previous correction,
if there is any.
In case the prescription format provides specific columns and
rows for writing new lens power, use them to prescribe. However,
in the absence of any specific column or rows, the new corrections
are mentioned around the middle of the prescription. In case the
prism correction is being needed, it must be mentioned with its
base direction. Interpupillary distance measurement has to be
mentioned separately for distance and near. Finally advises as
to lens recommendations and next check up date have to be
mentioned. Prescription is then handed over to the patient duly
signed by the examiner.
Prescription 43
While writing the prescription a real professional practitioner
takes the opportunity to educate the patient for different modes
of correction, put an emphasis upon a specific product which
suits his lifestyle, establishes the additional need for separate
correction for specific purpose and insists upon following with
him for further professional advises.
10
Chapter
Controlling
Accommodation
Accommodation is the ability of the eye to change the refractive

power of the crystalline lens which enables the eyes to focus
at various distances. The accommodative process involves
contraction of the ciliary muscle, which releases the tension on
the zonular fibers, allowing the elastic lens capsule to increase its
curvature, especially that of the front surface. Accommodation is
measured in diopters (D), which is the reciprocal of the fixation
distance. If the fixation distance is 1.00 m, the accommodation
is said to be 1.00 D; if it is 0.50 m or 0.33 m, the accommodation
is 2.00 D or 3.00 D respectively.
The furthest distance at which an object can be seen clearly is
called the Far Point (punctum remotum). In order to see such an
object the eye is in a state of rest, the ciliary muscle is relaxed, and
the refractivity is at minimum. When maximum accommodation
is in force, the nearest point which the eye can see clearly is called
the Near Point (punctum proximum). The difference between
the refractivity of the eye in the two conditions – when at rest
with minimal refraction, and when fully accommodated with
maximal refraction – is called the Amplitude of Accommodation.
In order to accurately perform visually guided daily tasks, it is
necessary for the accommodative system to be dynamic, fast,
and precise to ensure a well-focused image on the retina. The
amplitude of accommodation is age dependent, it is least around
the age of 65 years and is very strong below the age of 20 years.
Controlling Accommodation 45
Aphakes and pseudophakes have no accommodation. During
refraction active accommodation can result in over correction
in myopia or undercorrection hypermetropia. Accommodation
is the enemy of the good refraction. Accommodation clears
vision in hyperopia and blurs vision in myopia. Controlling
accommodation is very critical to the success of the results
of the clinical refraction. There are two ways of controlling
accommodation:
1. Fogging
2. Cycloplegic Refraction
Fogging
Fogging implies controlling accommodation by using plus lens.
In case you follow the fogging method of refraction, start with
higher plus than the results of objective method of refraction in
case of hypermetropia and with low plus in case of low myopia
and no plus lens is needed in case of high myopia. There are
rules to follow to reduce the fogging-put new plus lens first then
remove old plus lens from the trial frame and while removing
minus lenses, remove old minus lens from the trial frame first,
then put new. In case of astigmatic eye under fog, both the
principal meridian will not focus at the same distance. The
difference between the two principal meridian power is the
cylinder, which is designed in minus form.
Cycloplegic Refraction
Cycloplegic refraction is the procedure used to determine
patient’s true refractive error by temporarily paralyzing the
muscles that aid in focusing, using dilating drops. Cyclopentolate
1% is used to paralyze the muscles. Doses 1 drop each eye 6
times at 15 minutes interval on the day of refraction. Refraction
is done after 45 minutes of last drop. The younger patient needs
stronger drops and /or more application is needed. Patients
with light colored iris need less strength or fewer applications.
Patients who have never been dilated, or who are new to the
clinic, should be examined for narrow angles prior to dilation.
Another thing to take care is that the patient can be allergic to
any of the cycloplegics, which needs to be enquired. Cycloplegic
refraction is indicated in the following cases:
1. When esophoria is present or latent hypermetropia is sus-
pected
2. A young patient with hypermetropic eyes
3. Children below the age of 8 years.
Only distance correction can be done after cycloplegia. Near
vision is not examined as accommodation is being suspended.
Near vision must be checked during manifest refraction prior
to cycloplegia. Same visual acuity may not be achieved with
cycloplegic refraction as dilated eyes lacks the pinhole effect
of small pupil. Therefore, cycloplegic refraction should be
conducted after completing all other eye tests. Cycloplegic
refraction indicates the magnitude of refractive error and
noncycloplegic refraction indicates the acceptability. Usually
it gives a little high plus correction. Prescription of lens power
has to be backed with clinical decision. About 0.75D should
be subtracted from the net finding, if we know that complete
cycloplegia has been achieved before the refraction.
11
Chapter
Refraction in
Hypermetropia
Hyperopia is a refractive error in which parallel rays of light

entering the eye reach a focal point behind the plane of the
retina, while accommodation is maintained in a state of
relaxation. In a hypermetropic eye the focal point is located
behind the retina which may be brought to the retina by
accommodation and therefore the patient can see the distant
objects clearly by exerting accommodation. In the process they
exert all of the accommodative ability to see distance object, and
nothing is left for near vision. Hence they cannot see near object.
Hypermetropia is of three types:
• Latent Hypermetropia
• Manifest Hypermetropia
• Absolute Hypermetropia.
• Latent Hypermetropia is totally by eye’s own accommodative
ability, can be detected only by cycloplegia.
• Manifest hypermetropia can be corrected either by
patient’s own accommodation or by plus lens. When it is
compensated by patient’s own accommodation, it is called
Facultative Hypermetropia, and when it is not corrected by
accommodation, it is called Absolute Hypermetropia.
• Total hypermetropia is the sum of manifest and latent hyper-
metropia.
Treatment of hypermetropia depends upon patient’s ability
to compensate for close work and symptoms. In case of young
patients, if it is not associated with accommodative strabismus,
it may be avoided and in case of old patient, hypermetropia is
corrected to improve near vision.
Fluctuating accommodation can confuse the retinal focus
presented by each change of lens combination before the
eyes; accommodation must be maintained at the relaxed state.
Therefore, fogging method of subjective refraction is preferred
for determining the refractive correction to prescribe, especially
for the older child or adult patient. Remember to put the reducing
plus before and then take out old plus from the trial frame.
12
Chapter Refraction in Myopia
Myopia presents with blurry distance vision but generally gives

good near vision. Myopia may be low ranging between –0.25D to
–3.00D, it may be medium which is usually between –3.00D to
–6.00D and high myopia which is anywhere above –6.00D.
• Myopia is rare at birth
• Manifests after 4th year of life
• Progression is relatively constant until the time of puberty. At
around this age power changes rapidly
• Usually myopia is arrested when full maturity is reached.
Myopia is a one symptom refraction problem, i.e. blurring
of distance vision. Correction of the myopia should eliminate
this symptom, but a prescription for glasses may, produce other
symptoms which may be equally or more disturbing. Some of
the common difficulties in prescribing for the myopic patient
are:
1. Failure to recognize accommodative stress masquerading as
low myopia.
2. Confusion as to when, or whether, to prescribe for the unilat-
eral myopic patient.
3. Overcorrecting the myopic refractive error and failure to ap-
preciate the symptoms that result from overcorrection.
4. Difficulties in gaining acceptance of bifocals by the myopic
presbyopic patient.
Although myopia would appear to be the least troublesome
of all refractive problems, maximizing of visual potential with
comfort and safety needs refracting skills, experience, and clini-
cal judgment.
Issues to be considered:
To create a truly clear retinal image of a distant object, the full
extent of myopia must be corrected. However, several issues
need to be considered.
• Room length
• Room lights
• Pseudomyopia: Over stimulation of accommodative respo-
nse
• Progressive myopia : Requires frequent changes
• Prescribing full correction is based on clinical decision.
If the length of the examination room is significantly shorter
than standard distance which may result in slight under
correction but this is typically no more than 0.25D. to 0.50D.
This discrepancy may be irrelevant. However, it depends on the
individual’s tolerance for blur and his or her visual requirements.
Another factor is night myopia, which results in reduction of
contrast induced by low illumination. This causes the patient’s
focus to drift towards a resting level of accommodation which
is not at infinity, thus inducing some degree of residual myopia.
Night myopia may be symptomatic, and patients may report
blurred vision or halos around lights at night. Symptomatic
night myopia requires correction, such as wearing night time
driving glasses. Night myopia is primarily produced by ocular
accommodative response under very low illumination level.
If a significantly myopic patient has never worn a correction
before, prescribing the full correction may result in significant
asthenopia. The patient may feel dizzy and uncomfortable and
end up rejecting the glasses. In such cases, especially in older
patients, partial correction of the myopia will dramatically
improve vision, and permit easier adaptation. It is a matter of
clinical judgment whether or not to prescribe the full prescription
to start with or, alternatively, to prescribe only a partial correction
of the myopia.
Younger patients who are engaged more in near tasks
sometimes report pseudomyopia which results in blurring of
distance vision brought about by spasm of the ciliary muscles.
Patient appears to have myopia due to an inappropriate
accommodative response. The diagnosis is done by cycloplegic
Refraction in Myopia 51
refraction using a strong cycloplegics like Atropine or
Homatropine eyedrops.
Progressive myopia requires relatively frequent alterations
in the prescription. Refractive development can be ascertained
through a history, previous patient record and referral
information. They need more frequent consultations to monitor
refractive changes.
Fogging the lens with eyes with plus lens is not very critical
in case of high myopia as the insufficient spherical minus lens
in front of uncorrected eye, is enough to blur the distant vision
and does not allow the patient to bring the focus onto the retina
by accommodation. However, in very low myopia, fogging with
plus lens essentially makes the patient’s eye myopic in both the
prinicipal meridians. A test chart is then presented and plus is
reduced or the minus is increased. Unfogging is done until least
minus brings the desired acuity.
13
Chapter
Refraction in
Astigmatism
The astigmatic eye is unique in the sense that it has two far
point planes, one for each of the two principal meridians of
the refractive error. In simple myopic astigmatism, one plane is
located at infinity and the other is at a finite distance in front
of the eye. In compound myopic astigmatism, the two far point
planes are located at different distances in front of the eye.
Similarly, in simple hyperopic astigmatism, one plane is located
at infinity, and the other is located behind the eye, whereas in
compound hyperopic astigmatism, both planes are located at
different distances behind the eye. In mixed astigmatism, one far
point plane is located in front of the eye, and the other is located
behind the eye. To correct astigmatic refractive error, cylindrical
lenses are used. Such lenses create two line images, each with
a specific orientation. Patients with astigmatism cannot achieve
perfect retinal clarity by holding an object at any single position,
as the myope is able to do. Neither will accommodative effort
help the astigmatic patient achieve proper focus as it will for the
prepresbyopic hyperope. For patients with astigmatism, optical
correction is the only option for creating sharp retinal image.
Non-uniform image magnification and minification by a
spherocylinder lens sometimes causes meridional aniseikonia
which produces disturbances in spatial orientation. A common
complaint is that flat surfaces appear tilted. However, almost
always, the patient will rapidly adapt to these initial symptoms,
Refraction in Astigmatism 53
that ceases to be annoying. If not, simply reducing the amount
of astigmatic correction, while maintaining the spherical
equivalent, is often all that is necessary to alleviate such
symptoms. The following factors must be kept in mind for
astigmatic patients:
• Astigmatism may be of two types: Regular and Irregular.
Irregular astigmatism is difficult to correct with lenses
• Astigmatism is usually because of unequal radius of curvature
of cornea
• Cornea at birth is usually perfect sphere
• By age of 4 years it loses its spherical properties
• Horizontal axis, i.e. vertical radius of the cornea becomes
more steeper than horizontal radius of the cornea (WTR)
• With the advancing of age, anatomical structure and lid
tension have been postulated as a cause of corneal flattening
above and below the horizontal meridian (ATR).
In with-the-rule astigmatism, the focusing elements of the
eye require more convergent power in the 180° meridian, which
is corrected by plus cylinder axis 90° (or minus cylinder axis
180°). In against-the-rule astigmatism, the focusing elements
of the eye require more convergent power in the 90° meridian,
which is corrected by plus cylinder axis 180° (or minus cylinder
axis 90°).
JCC, Stenopaic Slit and Fan and Block Tests can be applied to
perform the refraction for astigmatic patient. However, no single
technique serves adequately in all situations. The optometrist
must be able to conduct a suitable alternative procedure.
14
Chapter
Refraction in
Presbyopia
Presbyopia is normal age-related loss of ability to focus on

things up close. It affects all of us once we reach our 40s. If
you are presbyopic, your eyes will need at least two different
prescriptions: one for far away, and one for up close. An
alternative way to deal with presbyopia is called monovision. In
monovision, your dominant eye is given a distance prescription,
while your other eye is given a near prescription. Contact lens
practitioners and refractive surgeons practice monovision very
often to treat their presbyopic patients. While monovision can
decrease the need for reading glasses, it can take some time to get
used to. Monovision can affect depth perception, and you may
not feel comfortable driving or reading for extended periods.
The presbyopia is corrected with near addition or “add”, the
strength of which depends upon the age, preferred working
distance and the best corrected distance visual acuity. The
strength of near “add” increases as the age increases. The
preferred working distance is the distance that an individual
like to keep between their eyes and the near task. Usually a short
height person with short arm has closer working distance than
a tall person with longer arms. A person who wants a closer
working distance would need a higher add than a person who
wants a longer working distance. While prescribing near add
you must ask his required near working distance. Usually this
distance is 40cm, but it may be more or less. Be careful while
asking the near working distance. An emerging presbyope may
Refraction in Presbyopia 55
want longer working distance. He might not be able to tell you
exactly his required near working distance as he becomes used
to working at little longer distance. A good way of asking about
near working distance is to ask them where their arms feel
comfortable while holding the near task. The goal is to find lowest
plus that gives clearest vision at required near distance. Usually
near add should be verified with both eyes together and the near
acuity should be equivalent to that of the distance. If not, you
may consider increasing the near add. Ideally the near add for
both eyes should be same. However, near add should always be
responsive to the patient’s visual needs. The final consideration
is patient’s comfort and his satisfaction.
15
Chapter
Refraction in
Anisometropia
Anisometropia represents the condition in which a patient’s

refractive error significantly differs between the two eyes. To
what degree the term significant implies is unclear, as the
threshold of inequality resulting in adverse symptoms is unique
to any given individual. Most commonly, a refractive difference
of 2.00D is considered significant in defining the presence of
anisometropia. The amount of difference between the refractive
error of two eyes is at least 2.00D which may cause aniseikonia
and also anisophoria. Result is significant adaptation problem,
symptoms are headache, eyeache, tearing, decreased reading
stamina, vertigo, spatial distortion, meridional aniseikonia
in case of astigmatism. However, some patients may be
asymptomatic.
Unfortunately, the asymmetric spectacle lenses that are
prescribed in an attempt to equalize visual acuity create their
own asymmetrical effects on magnification, and a discrepancy
between the retinal image sizes between the two eyes is the
final consequence. Aniseikonia (the perception of an image
size difference between the two eyes) can create significant
adaptation problems and prove to be a management challenge.
These patients may complain of headache, eyeache, tearing, and
decreased reading stamina. Patients may also experience vertigo
and spatial distortions, sometimes so severe that steps and
Refraction in Anisometropia 57
curbs may appear tilted. Asymmetric astigmatism may result in
meridional aniseikonia creating similar symptoms.
With commonly available instruments it is difficult to measure
aniseikonia. The difficulty in solving the aniseikonia problem
starts with the inability to exactly quantify its degree. The Space
Eikonometer, an instrument that was designed to measure
small amounts of aniseikonia, is no longer manufactured,
though there is some newly available computer software, an
approximate estimate of 1% image size difference per diopter
of anisometropia is taken as reasonable measurement. 5% may
probably be taken as extreme tolerance limit. The worst side is
patient tends to suppress the image in one eye if the refractive
error is great which may lead to amblyopia in suppressed eye.
Contact lenses are successful modality of treatment. Prism may
be used to treat secondary muscular imbalance. Base curve,
thickness of the lens and vertex distance changes may also help.
16
Chapter Refraction in Aphakia
When the crystalline lens is removed and intraocular lens is

not implanted, the patient needs a very strong plus correction.
In such situation absence of accommodation and clear vision
hinders fixation and therefore, retinoscopy is of little help.
Multiple pinhole may be used to assess the potential of the eye.
Keratometer and autorefractometer both may provide good
starting point. An aphakic eye and a normal eye do not work
together as a team. First refraction after surgery is advisable after
6 weeks of surgery and final prescription is given after a recheck
again at a week’s interval.
Fogging method is of no use. Refraction with the stenopaic
slit is very quick method of refraction in such case. Most aphakes
are against-the-rule astigmatism with the axis of plus cylinder
lens around 180°. Place 1mm wide slit in the trial frame and a
high plus spherical lens. Rotate the slit until the position of best
acuity is found. Compare the acuity with the slit position at
opposite meridian. Once the two principal meridians are found
out, correct the meridian with better acuity first with spherical
lens and then the other with additional plus spherical lens. The
first corrected meridian will give spherical correction and the
second corrected meridian will give the summation of spherical
and cylinder. The cylinder will be found by subtracting the first
meridian correction from the second one. The first meridian will
Refraction in Aphakia 59
be taken as axis of the cylinder lens. Once the maximum acuity
is achieved, remove the slit and replace the additional lens with
plus cylinder, and verify.
17
Chapter Refraction in Children
The refraction in children with refractive error is possibly the

most interesting aspect of refractionist’s job. The children up
to the age group of 8 years are at the risk of developing squint
or amblyopia. Uncorrected or undercorrected refractive error
are one of the reasons. With adult patients, the examiner can
normally place reasonable confidence in the answers given
to questions asked in the subjective part of refraction. These
answers can help substantiate the objective findings. With the
child, the objective findings are critical in determining the true
refractive error. With very young children, subjective questioning
is absolutely impossible. Although autorefraction can be used
reasonably successfully on older children, unsatisfactory
accommodation control and daunting size of the instrument
rules out its use on younger children.
Another important aspect is to know the development of
visual system of a child. At birth a baby’s eye is about 75% of
the size of an adult eye, i.e. the baby is born with hyperopia
with an average error of +2.00D. Premature baby have been
shown to be less hyperopic. During the first two years of life, the
ocular structures continue to develop. The most rapid decline
in hypermetropia occurs between 6 months to 2 years of age
in normally developing eyes. However, children who develop
strabismus do not show emmetropization and demonstrate
either increasing hypermetropia or no change in refractive error.
Refraction in Children 61
The newborn’s visual acuity is approximately 20/200. Vision
slowly improves to 20/20 by age of 2 years. Color vision is present
at birth.
Another important fact to be kept in mind is that there is
high prevalence of against the rule astigmatism in the newborn
infants than in adults. The age of 3.5 years is an important
milestone in the development of astigmatism. The prevalence of
astigmatism drops significantly by this age and there is a shift
in the prevalence of astigmatism as with the rule astigmatism
appears. After 5 years of age, with the rule gains prevalence.
The uncorrected hypermetropic child overcomes some or all
of his hypermetropia by exercising extra accommodation. When
glasses are worn for the first time, the accommodation may not
relax and the vision will be blurred. Usually accommodation
relaxes after a few days if the glasses are continued. At times
accommodation fails to relax and under such condition pres-
cription needs to be reduced. Cycloplegic refraction is necessary
to obtain an accurate retinoscopy results in infants and children.
If this is done some degree of ametropia will be found in most
cases and a clinical judgment must be exercised to decide
whether spectacle will be of use or not. While refracting the eyes
of the children, care must be taken to:
• Be very quick as the concentration span of child is very short
• Be very casual and friendly to them
• Engage them to the fullest and ensure that they are given the
full attention
• Offer things which interest them like toys, candies and
colorful objects
• Do not force any test. Go with the mood of the child
• If the child is comfortable with his parents close to him, let
them be so
• Counseling is very critical for the first time wearers.
The important thing to remember in the mind is that one of
the reasons for checking young children’s eyes is not to detect
myopia but to find amblyopia.
18
Chapter
Refraction in Visually
Impaired
Visually impaired patient tend to have high prevalence of

uncorrected refractive error. A good refraction is likely to yield
a substantial improvement in visual acuity. Objective refraction
either by retinoscopy or by autorefractometer may not be
possible in many cases of media opacity, optical irregularities,
pupil size and location. Therefore subjective refraction is more
important in such cases. Use hand held trial frame and trial
lenses rather than phoropter as it will allow eccentric head and
eye position, most patient would like to acquire. Also try larger
changes of lenses, allow time to read the chart.
Don’t even hesitate to change the distance between the
patient and the chart. Keratometer may help to get the baseline
astigmatic correction. Repeated presentation to certain patient
may be necessary to yield satisfactory results. Significant
refractive error may be associated with certain ocular condition
like albinism, retinitis pigmentosa, corneal scarring. The high
astigmatic error that occurs nearly in all cases of albinism is
usually accompanied by myopia or hyperopia. Patient with
retinitis pigmentosa may have normal or near to normal central
vision until cataract or macular changes occur. Pathological
myopia is generally assumed to be caused by the developmental
failure of one of the ocular components. High astigmatism
greater than 5.00 D is most often a form of irregular astigmatism.
Refraction in Visually Impaired 63
High hyperopia is generally associated with refractive amblyopia
with no subjective complains. The practitioner must be alert for
these deviations from the routine norms in order to diagnose
and manage the high ametropic patient.
19
Chapter
Refraction in Kerato-
conous Patient
Keratoconus is an asymmetric and progressive thinning,

steepening and centrally scarring of the cornea. Keratoconus
patient often complain of photophobia, squinting to see
better, halos or flare around lights particularly during night
driving, asthenopia.Some patients also report ghost images and
monocular diplopia. They are seldom satisfied with their vision.
Objective and subjective both the refraction procedures are
significantly different from those performed on normal patients,
and are really difficult and time taking procedure. Retinoscopic
image is distorted, still it gives an approximate estimate of the
refractive error. The retinoscopy end point is difficult to define
accurately, while performing retinoscopy, attention has to be paid
to the reflex appearing in the central pupillary area. Keratometry
may give the practitioner a starting point with regard to cylinder
power and axis.
Keratoconic patient mostly need myopic correction with
significant amount of astigmatic correction. The degree of
myopia and astigmatism increases with the progression of the
condition. Subjective refraction is mostly performed by trial and
error method, starting with minus spherical lens to be followed
by minus cylinder lens. In case where objective refraction is not
feasible, the refraction should begin with monocular subjective
refraction by the addition of minus sph lenses at an increment of
2.00 Dsph or 3.00 Dsph to determine if there is any improvement
Refraction in Keratoconous Patient 65
in acuity. If the visual acuity is not improved to the expectation,
the examiner may take –2.00 Dcyl or –3.00 Dcyl and rotate it to
determine if there is any meridional position with improved
acuity. High cylinder lens may be used to find the meridian
which provides improved acuity. A great deal of patience is
required because patient’s ability to distinguish between the
incremental changes will be lessened according to the severity
of disease. Stenopaic slit may be used to isolate the meridians
which provide the clearer vision. The refraction may be carried
on different meridians and the results of which may be used as
the basis of the full refractive error. Binocular equalization has
little meaning.
A more dynamic approach may be tried by putting the RGP
lens on the patient’s eyes and performing the objective and
subjective refraction over RGP lens. The examiner should select
the suitable base curve on the basis of K reading or corneal
topography for RGP lens and do the approximate correction
over it. Nearly all corneal irregularity and distortion is masked,
monocular diplopia is reduced and the patient is able to respond
better to different lens changes.
20
Chapter Tips for Clinical Care
The foundation of clinical refraction lies in the mastery of

optics, information about the epidemiology and physical
considerations with models of myopia, hypermetropia and
astigmatism, knowledge about the use of tools of refraction such
as keratometer, retinoscope, autorefractometer and subjective
refraction procedure. The complete process, if done sequentially,
looks like an art and as for any other art, refraction also needs
to be practiced to master. Another important aspect about
the procedure is that measuring refraction is one thing and
prescribing the correction is another thing. The examiner needs
to judge the effectivity of those results together with following
factors in his mind:
1. Patient’s expectations
2. Patient’s past experience
3. State of adaptation
4. Previous correction
5. Patient’s visual system.
The aim is not to treat the eyes, but to treat the patient as a
whole. This implies that a proactive approach is essential.
1. Analyze previous correction and current visual status with
previous correction.
2. Analyze the patient and his lifestyle, profession, working
distance, clarity of vision necessary.
3. Avoid large change in prescription, do not change spherical
by more than 0.75D, cylinder by 0.50D and axis by 10°.
Tips for Clinical Care 67
Excess changes call for counseling for probable problems.
Whenever, you get a major changes in cylinder or the axis, do
not forget to check for aniseikonic effect.
4. One of the simplest ways to check over correction – lift away
the trial frame and increase the vertex distance.
5. Verify high astigmatic correction with the help of slit.
6. If the distance visual acuity in two eyes is significantly
different, determine the near addition for each eye separately
and reverify it binocularly.
7. Do not forget to ask patient’s habitual near working distance
while checking the near addition. Be careful while prescribing
near addition to a patient below the age of 38–40 years just
because it makes the text clearer. Rule out the possibility of
latent hypermetropia or esophoria.
8. Remember the importance of room lights. For example full
room lights while correcting on visual acuity test chart and
for pinhole acuity, dim light condition for Duochrome Test
and for Fan and Block Test.
9. Do not prescribe large cylinders to a patient who has never
worn before. Break them gradually. The effect of uncorrected
cylinder varies from one patient to another. Oblique axis,
changes in axis and cylinder powers may likely to cause
spatial distortion.
10. Always advise the patient for next check up due date.
11. Explore the need for specific purpose correction.
12. Measure the vertex distance in high refractive error above
–5.00D for myopes and above +4.00 D in hyperopes as
the effect of prescribed minus power will reduce if vertex
distance increases and it will increase with plus lens. When
you measure, write in the prescription.
13. Follow the philosophy of professional practice as under:
• Develop a strict routine series of tests
• Listen, look and feel
• Apply suitable tests and develop strong observation
ability
• Educate the patient
• Refer to appropriate professional
• Monitor the condition.
Patient who does not respond to the normal refraction
procedures can be puzzling. Some patient may need large
changes of powers before they notice any difference. There are
others who insist on commenting upon colors being introduced
as you change the lens, usually in connection with Fan and Block
techniques – one way to remedy this difficulty is to add a yellow
filter. Permitting the patient to rotate a cylinder trial lens himself
suggests failure on the part of the examiner, but often works
wonders. Sometimes the lens in the trial frame moves helplessly
– possibly because the patient shakes his head excessively.
The most common mistake that an examiner makes while
doing refraction is giving the person more minus power. This
is because adding a small amount of extra minus power may
not make the vision worse. They may say that their vision looks
the same or sometimes better. In such cases the patient may
complain asthenopia after wearing them for longer hours of
time. Sometimes symptoms may be so bad that the person will
not be able to wear the spectacles.
Some avid computer users most often complain that their
distance vision does not clear immediately. It takes a little more
time. This may be because of accommodative spasm, i.e. their
accommodation locks at near and takes little more time to relax.
The following additional steps in the procedure may help such
patients:
1. Complete the routine procedure with near addition determi-
nation, if the patient is presbyopic.
2. Keep the best distance correction in trial frame, if the patient
is nonpresbyopic. If the patient is presbyopic, also put the
tentative near addition in front of distance correction.
3. Ask the patient to hold the near test chart at a distance of
40 cm under bright light and ask him to keep both eyes open.
4. Direct the patient’s attention to letters one or two line larger
than his near visual acuity on the near test chart.
5. Make sure that the letters are clearer at the beginning of the
test. If not, add plus spherical power at the step of +0.25D at a
time in front of both eyes until patient reports that the letters
are clear. This becomes the tentative near prescription.
6. Now add plus lenses binocularly at the step of +0.25Dsph until
the patient reports the first sustained blur and the patient
notices that letters are not as clear as they were initially, even
if the patient can read.
7. Note the total plus added so. Keeping the plus lenses in the
trial frame, divert patient’s attention to the distance chart.
Tips for Clinical Care 69
8. Isolate the line of letters to the patient’s best distance acuity,
but not smaller than 20/20. The patient should report that it
is blurry.
9. Reduce the plus binocularly at the step of 0.25D until letters
are clear.
10. You may confirm the endpoint using duochrome test.
11. The additional plus so derived may help such patient.
21
Chapter Lensometry
Figure. 21.1: External part of lensometer
Aim
Lensometry is used to ascertain the spherical, cylinder and axis
of an ophthalmic lens. It is also used to locate the optical center
and to determine the base direction and the amount of prism
present.
Targets
Reticle inside the lensometer is used for focusing the instrument
with the help of eyepiece and to determine the prism power.
Lensometry 71
Figure. 21.2: Different target and reticles types
The reticle is a permanently etched series of concentric rings.

It also contains orientation lines for each lens meridian and a
protractor scale. Each ring denotes one prism diopter.
Target consists of two sets of illuminated lines perpendicular
to one another for reading the power of the lens. These lines are
focused by the power wheel. They are closely spaced. Target types
vary with different brands and different models of lensometer.
Three common types of targets are most commonly seen (Fig.
21.2):
• Star burst type
• Cross line type
• AO type cross line.
Critical Factor
Lensometer does not read lens prescription, it measures the
powers of the lens in each meridian. In order to distinguish the
sphere and cylinder lines for your particular lensometer, with no
lenses in place set the axis wheel to 180° and focus the lines. The
vertically oriented lines are the sphere lines and the horizontally
oriented lines are the cylinder lines. Keep the lensometer in
switch off condition and focus the reticle with the eyepiece.
Then switch on the instrument. At this time the power wheel
should actually read zero diopter because there is only air in
place. But often a small offset may be detected. Findings should
be adjusted for any offset observed at this time.
Step by Step Procedure

1. Sit right in front of the lensometer and focus the black
reticle with eyepiece. If it is not in focus, the reading will be
Figure. 21.3: Adjusting the eye piece of the lensometer
Figure. 21.4: Switching on the lensometer
erroneous. This is to be adjusted to accommodate the user’s

own refractive error (Fig. 21.3).
2. Now switch on the lensometer (Fig. 21.4), set the axis wheel
on 180° and bring the reading scale to zero and see whether
the illuminated targets and the black reticle both are sharply
in focus.
3. Place the back vertex (ocular side) of the (Fig. 21.5) lens
against the stop of the lensometer on the platform or if the
lens is fitted in a spectacle frame place the spectacle lens so
that, the temples of the frame is away from you. Make sure
both eye rims-right and left are in contact with the platform.
Lensometry 73
Figure. 21.5: Placing spectacle lens onto the platform
4. Center the lens by moving it on the platform so that the

illuminated target is aligned in the center of the reticle by
moving the lens side to side or up and down. In case of prism,
it will be difficult to do so.
5. Rotate the power wheel to focus the targets sharply and
observe the two illuminated lines which are perpendicular to
each other. If both the lines are in focus together, the lens is
said to have only spherical power. The star burst ring is seen
as a well-defined circular ring made of identifiable dots. The
amount of spherical can be read on the power reading scale
(Fig.21.6). Red letter shows minus power and the other shows
plus power.
6. If only one set of lines is in focus and the other is blurred,
the lens is said to have cylindrical power. Since cylinder lens
forms the line image, the circular star burst ring made of dots
Figure 21.6: Power reading scale inside the lensometer

is seen as oblong shape image made of a well-defined lines
which are focused twice on two principal meridians.
7. Cylinder power may either be planocylinder or spherocylinder.
In case of planocylinder the spherical line will be focused
when the power scale reads zero and cylinder line at some
number which will show the amount of cylinder present in
the lens. In case of spherocylinder lens, the spherical line
will be focused first at some number which will show the
spherical component and then the cylinder line at some
other number which will show the summation of spherical
and cylinder. The difference between the two will give the
cylinder element.
8. Axis will be seen when the cylinder line is focused sharply.
Orient the axis wheel of the lensometer such that the cylinder
lines are perfectly continuous together with the oblong
illuminated image. Read the axis from the axis wheel. When
the axis is not correctly positioned, the lines will appear
“broken” or as if a “gates were left open.”
9. Axis can directly be seen by rotating the protractor ring. The
black line when parallel to focused cylinder line will point at
the axis on the protractor.
10. Before removing the lens, put the dot on the optical center of
the lens using the ink marking device. While doing so, make
sure target should be right at the center of the reticle.
11. To ascertain the power of the multifocal lenses, following
additional steps are needed:
a) Read and record the power of the distance portion as
above.
b) Turn the lens around so that the ocular surface faces you.
The bifocal segment power is measured with temples
pointing towards you (FVP) when the lenses are fitted in
the spectacle frame.
c) Raise the platform up and check the power through the
near segment area.
d) Compare the spherical power through the near segment
to the spherical power through the distance portion. The
difference between the two is taken as near “add”.
12. If the lens is ground with prism, it may be impossible to
center the target in the reticle. Mark a dot at the point where
the patient’s interpupillary distance coincides. Align this dot
Lensometry 75
Figure. 21.7: Prism shifts the star burst circular ring position
at the center of the reticle. Read the position of the star burst
circular ring with respect to the number of circle in the reticle.
Each circle denotes one diopter of prism (Fig. 21.7).
13. Record the readings so derived.
22
Chapter
Application of
Stenopaic Slit for
Refraction
Aim
Stenopaic slit is used to determine the refractive error in each
of the meridians individually. It is a great help when the patient
needs high astigmatic correction.
Test
The stenopaic slit consists of rectangular aperture ranging from
0.50–1.00mm in width and upto 15mm in length. It is assumed to
limit the admission of light to one meridian. A target with a large
letter may be used if the standard chart seems insufficient, or the
patient may be asked to move closer to the test chart.
Illumination
Room illumination has to be sufficient.
Test Distance
Once the primary meridians are located, the test is done at a
standard distance of 20 feet.
Patient Position
The patient may assume an unusual posture to look through the
slit aperture.
Application of Stenopaic Slit for Refraction 77
1. To begin the patient is fogged and unfogged monocularly
until the best possible initial acuity is recorded.
2. Now place the slit before the eye being tested and slowly
rotate while the patient’s attention is towards the chart.
3. The patient is instructed to point out if at any position the
visual acuity improves or better than other position.
4. If such a position is found, it is refined and bracketed by slight
rotation of the slit on either side.
5. To be sure rotate the slit by 90° to opposite meridian to
compare the acuity. If astigmatism is significant, the second
position should reveal poor acuity than the first one. The
disparity of acuity relates to the magnitude of the cylinder
correction.
6. Correct the better acuity meridian first with spherical lens
and then correct the opposite meridian again with spherical
lens.
7. Achieve the best possible acuity in both the meridians
separately and then remove the slit from the trial frame.
8. Transform the meridian values so derived into spherocylinder
form and refine the same.
9. Record the results.
23
Chapter Maddox Rod Test
Aim
Maddox Rod Test is used to measure the lateral and vertical pho-
ria at distance and at near.
Test
The test uses Maddox Rod and the spot light for distance and
penlight for near together with the prism lenses from the trial
lens set or prism bar. Maddox Rod is used to break the fusion.
Illumination
The test is done in dimly lit room.
Test Distance
Distance test is done with spot light fixed at a distance of 20 feet
and the near test is performed at a distance of 40cm.
Patient Position
Patient sits upright in front of the target with corrected correction
in front of his eyes.
Critical Factor
Horizontal phoria measurement is reliable only when the
accommodation is held constant at the measuring distance.
Maddox Rod Test 79
Therefore, keep reminding the patient to look at the light
carefully. Vertical phoria is measured with patient’s eyes in the
primary position of gaze. It may vary with the direction of gaze.

1. Place the Maddox Rod horizontally before the patient’s right
eye in front of his correction and ask the patient to keep his
both eyes open.
2. Now with the right eye the patient sees vertical red line, if the
red Maddox Rod is put and with left eye, he sees spot light.
3. If there is no phoria, the vertical line will appear to pass
through the spot light.
4. In case the red streak appears to be on the right side of the
spot light, a homonymous diplopia is produced indicating
esophoria. If the streak appears to be on the left side of the
spot light, there is crossed diplopia, indicating exophoria.
5. The amount of horizontal phoria is measured by placing a
prism lens of suitable strength in front of the other eye (left in
this case), that ensures the red streak passes through the spot
light and the result is expressed in terms of prism diopter.
6. Now measure the vertical phoria keeping the horizontal
prism lens in place. Rotate the Maddox Rod vertically before
the right eye.
7. If the patient sees red streak below the spot light, it implies
right eye hyperphoria and left eye hypophoria.
8. The prism diopter is measured similarly with prism base
down or base up.
9. The amount of prism diopter measured for lateral phoria
may be divided half-half between both the eyes with base of
the eyes in the same direction. However, care must be taken
to split the vertical phoria between right and left eyes. Base
orientation is not the same in both eyes for vertical phoria.
For example, 3∆ BU in right eye can be splitted as 1.5∆ BU in
RE and 1.5∆ BD in LE or unequally.
Section-II
Retinoscopy Guide
• Introduction
• Retinoscopy and Autorefractometer
• Parts of Retinoscope
• Optical Principle of Retinoscope
• Heine Beta 200 Retinoscope
• Choosing the Working Distance
• Patient and Practitioner Posture
• Projecting the Light Beam
• The Reflex
• Spherical and Astigmatic Reflex
• Movement of the Reflex
• Correcting Lens
• Neutralization
• Estimating Cylinder Axis
• Straddling the Axis
• Retinoscopy Results
• Step by Step Procedure
• Case Studies
• Tips for Difficult Retinoscopy
• Additional Application of Retinoscopy
24
Chapter Introduction
Retinoscopy is an objective method to determine the refractive

status of the eye with respect to the point of fixation. If the point
of fixation is at a close distance, it is called “Near Retinoscopy” or
“Dynamic Retinoscopy” and if it is at a long distance, it is called
“Static Retinoscopy”. In order to determine the refractive status
of the eye, it projects the light beam onto the retina through the
pupil. When the light beam focuses onto the retina, the direction
of light travel is reversed. The observer sees the light reflex coming
from the pupil through peephole in the scope and determines
the refractive error by observing the behavior of the reflex under
certain condition. Thus the results of the retinoscopy are not
dependent upon the patient’s response. The basic principles of
retinoscopy for both static retinoscopy and dynamic retinoscopy
are common.
IMPORTANCE OF RETINOSCOPY
Since the introduction of retinoscopy as a clinical procedure
for eye examination, it has been performed as one of the very
first procedures during the eye examination. It is a great tool
to establish a strong basis for the refractive status of the eye
on which subjective refraction can be followed. In addition
retinoscopy helps to detect the aberrations of the cornea and the
crystalline lens. It also provides some clues in respect of opacities
of ocular media. Retinoscopy is particularly very helpful tool
with uncooperative or malingering patients, infants, deafs and
in all such cases where language or communication creates
difficulties during the process of refraction.
25
Chapter
Retinoscopy and
Autorefractometer
The advent of autorefractometer has changed the scenario of

eye examination procedure. Today many practitioners have
started relying more on autorefractometer for the simple reason
of its speed and accuracy. Autorefractometer uses infrared light
to determine the refractive status of the eye. In a way we may
say that autorefractometer performs retinoscopy, compute the
amount of refractive error on the basis of different readings and
finally gives a print out of the results. The human observation
and judgment involved during retinoscopy are being replaced by
the logic function of the computer from the beginning till the
endpoint, making the practitioner more machine dependent
rather than relying on his own judgment. Retinoscopy and
autorefractometer both are ineffective in case of media opacities
or corneal irregularities (Figs 25.1 and 25.2).
Figure 25.1: Autorefractometer Figure 25.2: Retinoscope

26
Chapter Parts of Retinoscope
The modern retinoscope is designed as a very compact hand

held instrument which has two main systems, these are:
1. Projection system
2. Observation system.
PROJECTION SYSTEM (FIG. 26.1)

Projection system projects the light beam through the pupil and
illuminates the retina. It contains the following components:
Figure 26.1: Projection system

Parts of Retinoscope 87
1. Light source
2. Condensing lens
3. Mirror
4. Focusing sleeve
5. Power supply.
Light Source
The light source contains powerful halogen bulb and is at the
bottom of the instrument. The streak retinoscope contains bulb
with a linear filament to project a streak of light.
Condensing Lens
Condensing lens is a plus lens that lies in the path of light. It
gathers the light emitting from bulb and focuses them onto the
mirror. The position of this lens in relation to the bulb can be
changed by raising or lowering the focusing sleeve.
Mirror
The mirror bends the path of light at right angle such that the
light beam is projected onto the retina. It also facilitates reflected
light from the retina to enter the examiner’s eye.
Focusing Sleeve
Focusing sleeve varies the distance between the bulb and the
lens. Changing the distance between the bulb and the lens is re-
sponsible for plane mirror effect or concave mirror effect. Sleeve
up produces plane mirror effect and sleeve down produces con-
cave mirror effect. Sleeve also controls streak rotation. Turning
the sleeve rotates the bulb, which in turn rotates the projected
streak.
Power Supply
Power supply needed to project the light beam may be generated
either through battery or it may be electric operated.
OBSERVATION SYSTEM (FIG. 26.2)

Observation system lies towards the practitioner while using the
retinoscope to observe the reflex. The system contains a peep-
Figure 26.2: Observation system
hole that allows the observer to see the retinal reflex from the
pupil.
When the observer wiggles the scope while looking through
the peephole, he sees the movement of streak projecting on the
retina through the peephole. The rays of light emerging from
retina are affected by the optical components of the eye. The
manner in which they are affected tells us about the optics of the
patient’s eye.
TYPES OF RETINOSCOPE
Basically there are two types of retinoscope:
• Spot Retinoscope
• Streak Retinoscope.
Spot Retinoscope has an ordinary light globe that gives
a patch or spot of light. Streak Retinoscope has a special light
bulb with linear filament that gives a streak or line of light. The
reflex appears as a red to red-orange glow with a slight shadow
around it. The streak has both plano mode and concave mirror
mode. The spot has a plano mode only. When streak is used in
the plano mode, it is basically a spot with sides cut off. The streak
retinoscope has less illumination and the optical phenomena
that takes place away from the center of the streak are obscured.
It will be more difficult to observe subtle changes in color or
Parts of Retinoscope 89
brightness. Generally this information is available with spot
retinoscope. However, in practice streak retinoscope is more
popular as it facilitates refinement of axis of cylinder correction.
In all our further discussion we will consider the use of streak
retinoscope.
27
Chapter
Optical Principle of
Retinoscope
Retinoscopy works on the concept of Far Point (Fig. 27.1) which

is an important aspect of visual optics. The concept states that
the “Far point” is the point in the space at which the object must
be placed along the optical axis so that its image is focused on
the retina when the eye is not accommodating. It is the farthest
point from the eye at which the object is kept so that one can
see it clearly when the accommodation is at rest. The meaning,
therefore, is that the object has to be brought to a point conjugate
to the retina in order to be seen clearly by the unaccommodating
eye. Accommodation is needed only when the object is brought
Figure 27.1: Far point principle

Optical Principle of Retinoscope 91
closer to the eye than the conjugate point. A myope has the far
point at a finite distance from the eye. High myopes have closer
far point than the low myopes. In hypermetropic eye the far point
always lies behind the retina. The far point of an emmetropic eye
is at infinity.
The aim of static retinoscopy is to find the position of the
paraxial far point of the eye.
The refractive components of the eye apply vergence to the
emerging rays of light. Using the plane mirror, the outgoing rays
of light leaves the eye according to the nature of refractive error.
In emmetropia rays of light leaves parallel, in hypermetropia the
outgoing rays of light are diverging and in myopia the emerging
rays are converging. When the practitioner looks through the
peephole, he sees those emerging rays as retinal reflex in the
patient’s pupil. Sweeping the streak across the pupil moves the
reflex. If the movement of reflex is in the same direction of the
streak, it is called “with motion reflex” and is because of the fact
that the rays of light have not yet converged to far point. If the
reflex moves in the direction opposite to the streak, it is called
“against motion reflex” and is because the rays have come to a
focus and then have diverged. So we see “against motion reflex”.
Simplifying the concept, if the observer sees against motion
reflex, he is beyond the far point. If you see with motion reflex,
the far point is beyond him.
28
Chapter
Heine Beta 200
Retinoscope
Heine Beta 200 is one of the most popular retinoscope available

which is made by HEINE OPTOTECHNIK GmbH & Co.KG. It has a
single control sleeve which is a control ring to adjust the vergence
of light beam. The control ring also provides streak rotation. The
streak retinoscope can be changed to spot retinoscope simply by
changing the bulb. The salient features of this retinoscope are as
under:
1. The retinoscope has two different types of brow rests (Fig.
28.1) which can be changed according to the user’s prefe-
rence. The detachable brow rest is more convenient for
spectacle wearer practitioners.
Figure 28.1: Brow rests

Heine Beta 200 Retinoscope 93
Figure 28.2: MEM card
2. The single control ring is used to rotate the streak image 360°.
When the control ring is positioned down, it gives divergent
beam or concave mirror effect and when the control ring is
positioned up it provides parallel beam or plane mirror effect.
3. Parastop limits the upward travel of the control ring and is
designed to simplify precise selection of the parallel beam.
4. Two optional attachments are available with the retinoscope
— One near fixation card for dynamic retinoscopy (Fig.
28.2) and another detachable orange filter for light sensitive
patients.
5. The internal polarization filter eliminates strong light and
internal reflections without reducing brightness (Fig. 28.3).
Figure 28.3: Heine beta 200 retinoscope

29
Chapter
Choosing the Working
Distance
The working distance while doing retinoscopy is the distance

between patient’s eye and the practitioner’s position as shown
in the Figure 29.1. It is an important factor which may range
anywhere between 40–100cm. Usually we choose to hold the
retinoscope either at 66cm away from the patient or 50cm if
your arms are short. The closer distance provides bright reflex
but distance error is high, whereas larger distance provides dim
illumination but distance error is low.
When the neutrality is reached, it implies that the patient’s
retina is in sharp focus. If you were 6 m away from the patient,
the lenses needed to neutralize the reflex would be the same as
Figure 29.1: Working distance

Choosing the Working Distance 95
the person’s refractive error. But this is impractical. That is why
a shorter working distance is chosen. When we choose a shorter
working distance, we need to compensate the results of the
retinoscope for the working distance.
For a working distance of 66 cm we subtract the retinoscopy
results by 1.50D and for 50 cm, we subtract the retinoscopy result
by 2.00D.
ROOM ILLUMINATION
Retinoscopy should ideally be done in a dimly lit room. In
total dark, accommodation is not completely at rest. Complete
darkness also creates problem in movement and handling the
correcting lenses and is absolutely not advised when there is
gender difference. Dim light facilitates ease of movements and
also allows the patient to fixate at suitable target.
30
Chapter
Patient and
Practitioner Posture
The patient should sit on the patient’s chair upright in front of

the practitioner at the same level. He should keep looking at
the fixation target at the distance to keep his accommodation
at rest. A light usually provides most suitable fixation target. If
nothing is available 6/60 letter of the illuminated vision drum is
suitable. He should also wear the trial frame to facilitate the use
of correcting lens.
The practitioner should sit before the patient on his chair. He
should move slightly to the patient’s right as shown in the Figure
30.1. while scoping his right eye and slightly to the patient’s left
while scoping his left eye. Use right hand to hold the retinoscope
for patient’s right eye and left hand to hold retinoscope for
Figure 30.1: Practitioner and patient posture

Patient and Practitioner Posture 97
Figure 30.2: Using brow rest with spectacle
Figure 30.3: Practitioner posture
patient’s left eye. Both eyes should be open and the instrument
should rest firmly against the brow (Fig. 30.3) or spectacle frame
(Fig. 30.2). Using both hands has following clinical implications:
1. It allows the patient to fixate at the target with the eye not
under observation
2. It allows the practitioner to use his other hand for handling
the correcting lenses
3. Helps maintaining horizontal and vertical alignment with
the patient.
31
Chapter
Projecting the Light
Beam
In order to move the projected streak, he needs to wiggle the

scope. The streak is always moved perpendicular to its axis, i.e.
place the streak axis vertical and move it sideways and place the
streak axis horizontal to move up and down. The streak is moved
only a few mm across the patient’s pupil.
Streak vertical Streak horizontal
Figure 31.1: Projecting streak

32
Chapter The Reflex
When we project light on the retina with the retinoscope, the

retina is illuminated as if it were a luminous body. The emerging
rays of light from the retina are being observed as a retinal reflex
in the patient’s pupil while looking through the peephole in
the retinoscope which moves if we sweep the streak across the
pupil. The moving reflex should be analyzed under the following
categories:
1. Speed
2. Brilliance
3. Width.
SPEED
The speed of reflex movement is an indicator of the amount of
refractive error. Reflex moves slower when the neutrality is far
away or you are far from the far point. As you get closer to the
neutrality, the speed of reflex movement becomes rapid, and on
reaching the neutrality, no movement is seen, i.e. the pupil fills
completely. It implies that fast moving reflex is seen in case of
smaller refractive error and slow moving reflex is seen in case of
large refractive error.
BRILLIANCE
The brilliance of the reflex also indicates the amount of the
refractive error. A bright reflex is being seen when you approach
Figure 32.1: Appearance of streak: Narrow
Figure 32.2: 14 Appearance of streak: Wide
the neutrality and a dull reflex is being seen when you are far
away from the neutrality, i.e. away from far point. This implies
larger errors have a dull reflex and smaller errors have a bright
reflex. The brilliance of reflex is also different in case of “with
motion reflex” and “against motion reflex”. It is comparatively
dull in case of against motion reflex at any comparable distance
from the far point.
WIDTH
The change in width of the reflex band is noticed as you approach
neutrality. It is narrow when you are far away from the neutrality
and is widest, i.e. entire pupil fills up, when the neutrality is
achieved. The width of the band increases gradually from narrow
to wide as you approach the far point.
33
Chapter
Spherical and
Astigmatic Reflex
The spherical refractive error shows different characteristics

than the astigmatic reflex. Reflex in spherical error has following
features:
• The reflex will appear similar in all the meridians
• The reflex will be not show “break phenomenon”
• Similar brilliance and width are seen in all meridians
• Speed of movement of reflex is same in all meridians
• As the streak is rotated, the reflex stays aligned with the streak
in all meridians
• Reflex will be neutralized in all the meridians by the same
lens power.
The astigmatic reflex has the following features:
• The retinal reflex will appear different in different meridians
• The reflex will show “break phenomena” and will be aligned
to the streak only in two principal meridians
• In each principal meridian, the reflex will show different
brightness and width
• The reflex may have different movement in each of the
principal meridians. Their speed may also differ
• The reflex will be neutralized in each of the two principal
meridians by different correcting lens
• Occasionally unusual reflex may be seen.
34
Chapter
Movement of the
Reflex
Figure 34.1: With motion reflex
The concept of retinoscopy is based on the movement of the

reflex observed within the pupil. While attempting to estimate
the refractive error, the retinoscopist tries to understand the
movement of the reflex and to stop its movement to reach
at neutrality. During the process he may observe one of the
following different types of movement of the reflex:
WITH MOTION REFLEX (FIG. 34.1)

When the retinoscopist wiggles the retinoscope, the reflex moves
in the same direction as the streak. This is called “with motion
reflex”. This is neutralized with plus lenses when the sleeve is
moved up. The reflex appears at the same side of the pupil where
Movement of the Reflex 103
Figure 34.2: Against motion reflex
the streak is projected and moves along with the streak to disap-
pear at the opposite side of the pupil.
AGAINST MOTION REFLEX (FIG. 34.2)

When the retinal reflex moves in the opposite direction of the
streak, it is called “against motion reflex”. This is neutralized with
minus lenses when the sleeve is positioned up. The reflex first
appears at the side of the pupil opposite to the streak and moves
in opposite direction across the pupil to disappear at the side of
the pupil opposite the streak.
SCISSOR-LIKE MOVEMENT (FIG. 34.3)

Scissor-like movement seems to split and move in opposite
direction like the blades of the scissor. This is often seen in
distorted corneas and large pupil. Scissor movement is difficult
to work with while doing retinoscopy. The retinoscopist should
attempt to align with the intercept by rotating the streak. If he
fails, he should concentrate on the central reflex.
Figure 34.3: Scissor-like movement

Figure 34.4: Triangular reflex
CONFUSING REFLEX
In irregular astigmatism, all sorts of distorted shadows may be
observed which may move about in a confusing manner. In such
cases retinoscopy results are not reliable and are used to guess
the approximate values.
TRIANGULAR REFLEX (FIG. 34.4)

Conical corneas shows triangular shadows with their apex at the
center of the cone which appears to swirl round as the streak is
moved.
Neutralizing using “against motion reflex” poses quite a lot of
problems. It is, therefore, prudent to avoid it. In case of “against
motion reflex” the retinoscopy reflex first appears at the side of
the pupil opposite to the streak and moves in opposite direction
across the pupil to disappear at the side of the pupil opposite
the streak. This makes it difficult to quantify the characteristics
of the reflex. Speed is difficult to estimate when it is moving in
the opposite direction. Against motion reflex is more aberrated,
dull, and difficult to evaluate. With motion reflex is bright, crisp
and seldom confusing. Brilliance also reduces which makes
judgment process difficult. This in turn makes it hard to see the
width clearly.
35
Chapter Correcting Lens
While doing the retinoscopy our job is to find a correcting lens

that brings the far point to the peephole of the retinoscope. The
lens that does so is known as correcting lens and is the measure
of the refractive error. Since the plus lens converges the emerging
rays, they will pull in the far point towards the eye and minus
lens diverges the emerging rays; they will push the far point away
from the eye. Hyperope, will therefore, take plus lens and myope
will take minus lens. This can be done either with the help of trial
lenses or with lens rack.
36
Chapter Neutralization
Retinoscopy is done with the aim to ascertain the refractive error

of the eye and this is achieved by neutralizing the movement of
the reflex seen within the pupil. Neutralization in this context
is the process to neutral the movement of reflex with suitable
correcting lens. Neutrality is the state arrived while neutralizing
the moving reflex that shows no movement of the reflex within
the pupil during sweeping the streak and the pupil is completely
filled up with the red glow. Neutrality implies that the far point
of the eye is at the peephole of the retinoscope. The correcting
lens that neutralizes the reflex is the measure of the refractive
error, ignoring the working distance and this is the endpoint of
the retinoscopy.
Figure 36.1: Pupil is filled with glow

Neutralization 107
It is important to note that neutrality is not a specific point
that is easily identified. Rather it is a range of uncertainty
between perceptible “with” and “against” motion reflex. It is,
therefore, prudent to bracket midway between just noticeable
with and against motion. Neutralization is difficult to achieve
with ‘against motion reflex’. It is therefore good to overneutralize
when you see against motion reflex to ensure that you see “with
motion reflex”, and then simply reduce ‘with’ until you reach
neutral. Always use plane mirror while neutralizing. The rule is
look for the “with” and then follow it to neutrality.
INTERPRETING NEUTRALITY
The neutrality achieved during retinoscopy is not a specific
point. It is a zone of uncertainties between with and against
movement, created by spherical aberration and other factors.
The size of zone varies with pupil size and the working distance. It
increases in direct proportion with the size of pupil and is narrow
with small pupil whereas wider with large pupil. The width of
the zone also varies because of working distance: narrow when
working at a closer distance than that of a longer distance.
Usually neutrality is achieved first at the center of the pupil
and then at the periphery. Neutralization of peripheral reflex
needs more minus. Therefore, it is prudent to concentrate on
central pupillary reflex while scoping the patient with dilated
pupil. At times there are following doubts within the zone of
neutrality:
1. Nature of movement— WITH or AGAINST
2. WITH in the center and AGAINST in the periphery
3. Presence of movement.
It is wise not to get into these uncertainties and make
judgment just ahead of where the zone of doubt begins, i.e. stay
in a little plus.
How to be sure about neutrality?

The practitioner can apply three methods:
1. Move closer with your scope and see “WITH” motion
movement and then move away from the working distance
and see “AGAINST” motion movement.
2. Go above and below the neutral lens to set the limits.
3. Verify the neutrality with sleeve down position. If it is neutral-
ized with sleeve up position, it will be neutralized with sleeve
down position also.
PSEUDONEUTRALITY
Many a times pseudoneutrality appears as a full motionless
reflex which suggests that the endpoint is being reached. In
order to be sure about it, simply lean in 10–15cm, if the reflex
does not change, we are not near neutrality. Try stronger lens to
see if there is any change in the reflex.
37
Chapter
Estimating Cylinder
Axis
There are four important phenomenon that helps finding the

axis. All of them are the results we observe from the off-axis
reflexes and oblique motion you observe when the streak is not
on the cylinder meridian. These are:
• Break Phenomena
• Width Phenomena
• Intensity Phenomena
• Skew Phenomena.
BREAK PHENOMENA (FIG. 37.1)

When the intercept and the reflex are not aligned, it forms
a broken line which can be seen simply by rotating the streak
Figure 37.1: Break phenomena

Figure 37.2: Thickness phenomena
to either side of the astigmatic reflex. It disappears when the

intercept and the reflex are aligned, i.e. when the streak is on the
axis. For example if the axis is 90°, rotate the streak to about 15° on
either side, i.e. from 75°–115° to observe the break phenomena.
Break is most marked at the extremes of the arc and it decreases
as you approach the axis. Observing break proves effective in
locating large cylinders, but it provides no help in dealing with
small cylinders.
THICKNESS PHENOMENA (FIG. 37.2)

When you rotate the streak to either side of the correct axis,
the thickness (width) of the reflex varies. The reflex appears
narrowest when the streak aligns with the axis and wider when
it is off aligned. Observe the variation in the width of the reflex
using your other eye.
INTENSITY PHENOMENA
The brightness of the reflex changes slightly as we rotate the
streak about the cylinder meridian. The reflex is brighter when
the streak is on the correct axis. This phenomena is not very
useful in small cylinder.
SKEW PHENOMENA (FIG. 37.3)

Skew phenomena is very useful in case of low cylinders. In order
to observe the skew phenomena, we do not rotate the streak,
instead we wiggle the streak to either sides of the apparent axis
perpendicularly and compare the motion of the reflex with that
of intercept. The retinal reflex moves parallel to the intercept
Estimating Cylinder Axis 111
Figure 37.3: Skew phenomena
when the streak is on the proper axis. When the streak is off the
axis, the reflex and intercept move in different direction, i.e. their
motion is skewed. The concept can be put in other words as:
If we streak a meridian that is away from the meridian of the
correct axis, the streak reflex will tend to travel along the correct
meridian rather than follow the streak. This guides us back to the
correct meridian.
38
Chapter Straddling the Axis
When both the principal meridians are neutralized in case of

astigmatism, the axis of the cylinder can be verified by streak-
ing the meridians 45° on either side of the meridian believed to
be the axis of the cylinder. Streaking the 45° on either side, the
streak reflex will widen and degrade in sharpness on both the
sides equally. This confirms the correct axis. The thinner image
on one side gives a guide to correct the axis towards which the
axis of the cylinder lens should be rotated.
39
Chapter Retinoscopy Results
The retinoscopy results provide gross refractive error. These re-

sults are to be recorded on a cross chart as meridian values. In
order to arrive at the net retinoscopy results compensation has
to be done for the chosen working distance.
Take for example 90° meridian is neutralized with +2.00Dsph
and 180° meridian is neutralized with +3.00Dsph at a working
distance of 66cm. Record this as meridian values on a cross chart
as under:
+2.00D
+3.00D
Subtracting the values by 1.50D, the resultant result would be:

+0.50D
+1.50D
Therefore, the lens power derived from the net retinoscopy re-
sult would be +0.50Dsph/ +1.00Dcyl × 90°.
40
Chapter
Step by Step
Procedure
Retinoscopy, if done following the sequential steps can be com-

pleted very fast with good results. The following steps in the giv-
en order may be followed:
1. Ask the patient to sit on patient’s chair and instruct him to
look at the fixation target.
2. Reduce the room illumination and assume your sitting pos-
ture.
3. Set the focusing streak to plane mirror mode and fix up the
distance between you and the patient in such a position that
enhances the reflex.
4. Project the light beam onto the patient’s right eye.
5. Now we need to make four fast decisions:
• Whether the eye is spherical or astigmatic
• Then we decide whether the eye is myopic or hyperme-
tropic
• Next we locate the principal meridians
• Finally we estimate the lens power needed to neutralize
these meridians.
6. Now in order to determine whether the refractive error is
spherical or astigmatic, rotate the streak through 360° to look
for the break, thickness and skew phenomenon or changes in
brightness of the reflex within the pupil as explained earlier.
7. If the error is spherical, observe the reflex for WITH or
AGAINST motion and add plus or minus to reach neutrality.
Step by Step Procedure 115
8. Neutralize WITH motion reflex with plus lenses while keeping
the sleeve up position and AGAINST motion reflex with
minus lenses.
9. While neutralizing the AGAINST motion reflex, over neutralize
a little and then come to an endpoint from the WITH motion
reflex.
10. In order to determine astigmatic error, first identify two
principal meridians and then neutralize each meridians
separately.
11. The simplest method is to neutralize both the meridians with
spherical lens to find out the meridian values. Note down the
results on a cross chart.
12. In case of hypermetropia, neutralize the least plus meridian
first with plus spherical lens and then rotate the streak to
opposite meridian and add more plus lens to neutralize.
13. In case of myopia, neutralize the most minus meridian first
and note down its value on the cross chart.
14. This will result in WITH motion reflex in the other meridian.
Add plus spherical lens to neutralize the same and note the
value on the cross chart.
15. Now subtract 1.50D from both the meridian values, if
retinoscopy was conducted at a working distance of 66cm.
16. Elicit the lens power from the meridian values and put the
same into the trial frame.
17. Hold +1.50D spherical in front of the trial lenses and verify
the neutralization in all four major meridians.
18. Recheck the neutrality with sleeve down. It should also show
neutrality.
19. Repeat all the above steps for the other eye.
This is one of the methods for neutralizing the refractive
error with retinoscope. However, some practitioners may be
more comfortable using cylinder lenses in case of astigmatic eye.
There are different methods. The idea behind this book is to give
you the basic guideline about the technique and not to discuss
all the procedure.
41
Chapter Case Studies
Case 1: Low Hyperope +2.00D Spherical

• Focusing sleeve position: Up
• Rotation of streak: Uniform observation of reflex width and
brightness. No break and skew phenomenon observed
• Movement: WITH motion reflex
• Reflex Band: Medium wide
• Put +1.00 Dsph
• Observe WITH motion reflex
• Reflex band slightly wider and faster
• Replace +2.00 Dsph
• Reflex band widens again
• Replace +3.50 Dsph
• Pupil completely illuminated
• Move back and forth to confirm
• Hold +0.50 Dsph in front and see NEUT going to AGAINST
• Now hold –0.50 Dsph in front and see NEUT going to WITH
• This confirms NEUTRALITY
• Compensate for working distance.
Case 2: Low Minus –2.00D Spherical
• Rotation of streak: Uniform observation of reflex width and
brightness. No break and skew phenomenon is seen
• Movement: AGAINST motion reflex, difficult to observe
• Reflex band: Quite wide, almost filled
Case Studies 117
• Put –0.50 Dsph
• The degree of AGAINST motion reflex becomes more difficult
to judge as you approach NEUT
• Replace –1.00 Dsph
• Observe: WITH movement
• Reduce WITH movement
• Replace –0.50 Dsph
• Pupil completely illuminated
• Move back and forth to confirm
• Hold +0.50 Dsph and –0.50 Dsph alternately and verify again
• Note down the results
• Compensate for working distance.
Case 3: +1.00 Dcyl × 90° Low Astigmatism
• Rotation of streak: Observe variation in reflex width and bri-
ghtness
• Enhance the reflex by moving closer and verify to observe
skew phenomenon
• This establishes presence of astigmatism
• 90° meridian shows thinner retinal reflex and 180° meridian
shows wider reflex
• Now ease back to normal working distance and neutralize
the two principal meridians 90° and 180°
• Movement: 90° meridian, we see WITH motion reflex
180° meridian, we see WITH motion reflex
• Put +1.50 Dsph
• 90° meridian shows no movement and 180° meridian retinal
reflex widens
• Put +1.00 Dsph in front of +1.50 Dsph
• Observe AGAINST motion reflex in 90° and no movement in
180°
• Put the retinoscopic results on the cross chart
• Compensate for working distance and elicit the lens power.
• Put the lens power into the trial frame, i.e. +1.00 Dcyl at 90°
and hold +1.50D lens in front and neutralize in both the prin-
cipal meridians
• Also verify in all four major meridians.
42
Chapter
Tips for Difficult
Retinoscopy
1. Split reflex which may be observed in cases of keratoconus

or corneal scarring. They are difficult to neutralize. In such
cases retinoscopy gives an approximate results. So do not try
to obtain reversal, use bracketing technique. Also make sure
that the trial lenses used are clean and centered properly.
2. In cases of media opacities, try to work around the opacities
by moving off-axis. It might be needed to work closer to
obtain a brighter reflex.
3. In a young hyperope, retinoscopy results often show
more plus than eventual subjective refraction due to high
accommodative tonus. Patience is the key in such situations.
Keep asking the patient to fixate at target and keep sweeping
the beam across the pupil. Also try fogging retinoscopy in such
cases. Fogging retinoscopy can be done by putting higher plus
lenses in front of the eye than expected retinoscopic results.
Ask the patient to look straight ahead at the distance target
without making effort to see clearly and perform retinoscopy.
Care should be taken to insert the lens first and then remove
the replacing lens while reducing plus.
4. Dull retinoscopic reflex is usually observed in case of am-
blyopia.
5. High myopes-moving closer to the patient helps.
6. If pupil is dilated, be sure to watch the center of the reflex.
Tips for Difficult Retinoscopy 119
7. At times the retinal reflex is not visible. This happens with
small pupil, hazy media and high degree of refractive error.
Try eliciting the retinal reflex with concave mirror or use
mydriasis.
43
Chapter
Additional
Applications of
Retinoscopy
Retinoscopy may be performed before ophthalmoscopy, and

thus it may serve as first chance to view the internal structure
of the eye. The appearance of retinal reflex may be altered under
certain conditions which may provide a clue to diagnose certain
ocular abnormalities. For example:
1. The reflected light from retina retroilluminates the lens, iris
and the cornea. The opacities in the lens and the cornea
around the pupil can be seen as dark areas against red
background.
2. Keratoconus distorts the reflex and produces a swirling
motion.
3. Retinal detachment involving the central area will distort the
reflecting surface and a hence the reflex observed may have
grayish appearance.
4. A tight soft contact lens will have apical clearance in the
central area which will distort retinal reflex.
Bibliography
1. A protocol for the measurement of eye dominance in young

children, by Siofra Harrington.
2. Borish’s Clinical Refraction

Editor: William J Benjamin
3. Clinical Procedures for Ocular Examination

Nancy B Carlson, Daniel Kurtz
4. The Ophthalmic Assistant

Harold A Stein
Raymond M Stein
Melvin I Freeman
5. Theory and Practice of Optics and Refraction

AK Khurana
6. The Retinoscopy Book: An Introductory Manual for Eye care

Professionals
John M Corboy
David J Norath, Richard Reffner
Index
A Hypermetropia
absolute 47
Additional applications of reti-
latent 47
noscopy 120
manifest 47
Alternate occlusion test
procedure of 40 L
Application of stenopaic slit for
refraction 76 Lensometry 20, 70
B M
BCVA 14 Maddox rod 8
Binocular balancing 39 Maddox rod test 78
Monocular distance subjective
C
refraction 29
Correcting lens 105 fogging method of subjective
Crystalline lens 3 refraction 31
Cycloplegic refraction 45 manifest subjective refraction
30
D trial and error method 33
Determination of near addition Movement of the reflex 102
33 against motion 103
cross grid test 34 confusing 104
near duochrome test 35 scissor-like movement 103
trial and error method 35 triangular 104
Dominant eye test 27 with motion 102
Duochrome test for spherical end Moving reflex
point 37 brilliance 99
speed 99
E width 100
Estimating cylinder axis N
break phenomena 109
intensity phenomena 110 Near visual acuity test 15
skew phenomena 110 Neutralization 106
thickness phenomena 110 interpreting neutrality 107
pseudoneutrality 108
F
O
Flow of refraction procedure 17
Fogging 45 Objective evaluation of refractive
Fogging method 58 error 22
H autorefractometry 24
keratometry 23
Heine beta 200 retinoscope 92 retinoscopy 23
Occluder 9 Snellen’s visual acuity test 11
Optical principle of retinoscope Spherical and astigmatic reflex
90 101
Stenopaic slit 7
P Straddling the axis 112
Parts of retinoscope 86
T
observation system 87
projection system 86 Targets
Pinhole disk 6 AO type cross line 71
Prism dissociated test cross line type 71
procedure of 40 star burst type 71
Prism lenses 6 Tips for clinical care 66
Projecting the light beam 98 Tips for difficult retinoscopy 118
Trial frame 9
R
Trial lenses 5
Red and green lens 7 Types of retinoscope
Refinements 37 spot 88
Refraction 47, 49, 52, 54, 56, 58, streak 88
60, 62, 64
in anisometropia 56 U
in aphakia 58 UCVA 14
in astigmatism 52
in children 60 V
in hypermetropia 47
in keratoconous patient 64 VA 14
in myopia 49 VAcc 14
in presbyopia 54 VAsc 14
in visually impaired 62 Visual acuity test 20
Retinoscopy pinhole acuity 22
importance of 83 uncorrected visual acuity
and autorefractometer 85 (UCVA) 21
results 113 visual acuity with corrected
correction(VAcc) 21
S
W
Snellen’s chart 11
Snellen’s test chart 4 Wide beam aberration 3

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Clinical Refraction

Ajay Kumar Bhootra

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

© 2014, Jaypee Brothers Medical Publishers

Clinical Refraction Guide

Achieving goals and objectives in life can truly be difficult yet

Over the last 30 years, a lot of technological advancements

Ajay Kumar Bhootra

I am extremely delighted to take this opportunity to accept and

Section II: Retinoscopy Guide 81–120

Refraction is the primary consideration for all patients with

Figure 2.1: Trial lens set

Figure 2.2: Prism lens Figure 2.3: Pinhole disk

RED AND GREEN LENS

Figure 2.4: Stenopaic slit

Figure 2.5: Red and green lens

The patient is asked to make a comparison of definition through

Figure 2.6: Maddox rod

Figure 2.7: Occluder

Figure 3.1: Snellen’s chart

Dr Herman Snellen, a Dutch ophthalmologist proposed his

Figure 3.2: Snellen’s 5 minutes of arc visual acuity

Visual Acuity Notations

In meters in feet Linear size of letter

6/6 20/20 8.75 mm

Snellens Chart is standardized for size and contrast. Care must

Near visual acuity test is usually done at a distance within arm’s

The ocular refraction procedure starts with an extensive

Initiating the process during clinical refraction refers to esta-

Visual Acuity Test

Uncorrected visual acuity (UCVA)

Visual acuity with corrected correction(VAcc)

Objective Evaluation of Refractive Error

Figure. 6.1: Pinhole acuity

Figure. 6.2: Cylinder axis measurement

Think and Go Ahead

The idea behind this exercise is to think ahead the nearest

The second phase of the clinical refraction starts when the

DOMINANT EYE TEST

MONOCULAR DISTANCE SUBJECTIVE REFRACTION

Figure. 7.1: Dominant eye

Manifest Subjective Refraction

Fogging Method of Subjective Refraction

Trial and Error Method

DETERMINATION OF NEAR ADDITION

Cross Grid Test

Figure. 7.2: Cross grid test

Near Duochrome Test

Trial and Error Method

Age Near addition

THINK AND GO AHEAD

The last part of the whole process is endpoint techniques which

DUOCHROME TEST FOR SPHERICAL END POINT

Procedure of Alternate Occlusion Test

Procedure of Prism Dissociated Test

STOP AND THINK

At last the examiner records his final decision as to refractive

Accommodation is the ability of the eye to change the refractive

Hyperopia is a refractive error in which parallel rays of light

Myopia presents with blurry distance vision but generally gives

Presbyopia is normal age-related loss of ability to focus on

Anisometropia represents the condition in which a patient’s

When the crystalline lens is removed and intraocular lens is

The refraction in children with refractive error is possibly the