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Prescription
A PRACTICAL GUIDE
Dr Harbansh Lal
Spectacle
Prescription
A Practical Guide
Dr Harbansh Lal
Dr Ikeda Lal Dr Tinku Bali
Dr Divya Saxena Dr Madhura Ukalkar
DOS Office Bearers
Dr. Subhash C Dadeya Dr. Pawan Goyal Dr. Namrata Sharma Dr. Hardeep Singh
President Vice President Secretary Joint Secretary
Dr. Jatinder S Bhalla Dr. Vinod Kumar Dr. Manav Deep Singh
Treasurer Editor Library Officer
Executive Members
Dr. Dewang Angmo Dr. Jatinder Bali Dr. Shantanu Gupta Dr. C. P. Khandelwal
Dr. Rahul Mayor Dr. Vipul Nayar Dr. Rajendra Prasad Dr. Kirti Singh
Dr. Jeewan S. Titiyal Dr. M. Vanathi Dr. Rakesh Mahajan Dr. Arun Baweja
DOS Times Editorial Board
The process of clinical refraction is the most Prof. (Dr.) Namrata Sharma
Hony. General Secretary
common and one of the first skill that we
teach our students and it is the procedure that they are required to
repeat more than any other procedure during their training. Best
corrected visual acuity obtained via skilfully performed retinoscopy
and subjective refraction, is the primary measure that guides much
of our treatment and surgery. The practical guidelines and tricks for
prescribing spectacles are taught neither frequently enough nor well
enough. Most of the students are often left to learn these practical
points by trial and error, with not enough time, or not enough
interest, to engage senior colleagues to learn from their wisdom and
experience.
III. RETINOSCOPY 7
1. Retinal Reflex 7
2 Correcting Lens 8
3. Finding Cylindrical Axis And Power 8
4. Practical Aspects 9
5. How To Plot Retinoscopy 9
• Oblique Axis
• Range Of Neutralization.
6. Autorefractometry 11
2. Pinhole Occluder
The use of the ideal pinhole leads to the formation of a clear retinal
image irrespective of the refractive state of the eye. However, in
high degrees of ametropia, although the pinhole helps, the retinal
image is still too diffuse to achieve the improvement that is found
in a case of low refractive error. Thus, errors outside the range +5 D
to –5 D sphere are not correctable to 6/6 with a pinhole. The most
useful pinhole diameter for general clinical purposes is 1.2mm. The
best use of the pinhole is to find out whether or not the patient’s
vision is going to improve with spectacles.
3. Refractive Error
Emmetropia:
Light rays coming from infinity will focus on the retina, without
accommodative effort.
In This figure, V stands for vertical rays and H, for horizontal rays.
POINT A: The vertical rays are converging and have not reached
the point of focus. The horizontal rays are crossing the point of focus
and have started diverging. So, the gap between the blue line is less
as compared to the red line, that means the diffusion of blue rays
is less than that of the red rays. Hence, the shape of cross-section
is vertically oval. POINT B: The convergence of vertical rays is
exactly equal to the divergence of the horizontal rays from the axis.
So, here the section is a circle which is known as the Circle of Least
Diffusion or Circle of Least Confusion. POINT C: The divergence
of horizontal rays is more than the degree of convergence of vertical
rays. Hence the shape of cross-section is horizontally oval.
4. Accommodation
Accommodation is a complex mechanism involving the sensory and
neuromuscular phenomena. The human eye, through contraction of
the ciliary muscle, changes the optical power of the lens to assist
the convergence of the image to the retina, adjusting the focus
to different distances between the object of regard and the eye.
If the lens becomes stiffer and unable to alter its shape, physical
accommodation is impaired even with the strength of the preserved
ciliary muscle. A similar process may occur with physiological
accommodation if the weakness of the ciliary muscle exists.
5. Presbyopia
Presbyopia is the gradual loss of accommodative response resulting
from reduced elasticity of the crystalline lens. Accommodative
amplitude diminishes with age. It becomes a clinical problem
when the remaining accommodative amplitude is insufficient for
the patient to read and carry out near-vision tasks comfortably.
Fortunately, appropriate convex lenses can compensate for the
waning of accommodative power. The symptoms of presbyopia
usually begin to appear in patients after 40 years of age. The age
of onset depends on the pre-existing refractive error, the depth of
focus (pupil size), the patient’s visual tasks, and other variables.
The complete accommodative reserve is exhausted by the age of
about 60 years. Over-accommodation in moderate hyperopes may
result in accommodative fatigue and premature presbyopia. It is also
interesting to note that in moderate myopes (–3 D to –4 D), where
the far point equals to about 25 cm to 33 cm, simple removal of the
distance refractive correction results in the patient being able to see
well for near. Such patients may not require near vision glasses. In
6. Anisometropia
When the refraction of the two eyes is different, the condition is
known as anisometropia. A small degree of anisometropia is common
place. Larger degrees are a significant cause of amblyopia. A disparity
of more than 1 D in a hypermetropic patient is enough to cause
amblyopia of the more hypermetropic eye because accommodation
is a binocular function, i.e., the individual eyes cannot accommodate
by different amounts. The more hypermetropic eye, therefore,
remains out of focus. The myopic patient with anisometropia is less
likely to develop amblyopia because both the eyes have clear near
vision. However, when one eye is highly myopic, it usually becomes
amblyopic.
7. Anisekonia
When a difference of more than 3 dioptres is present between both
the eyes, and the eyes are corrected with spectacles, the difference in
the image size (aniseikonia) that is produced, can lead to difficulties
with fusion and even suppression of one of the images. The children
withstand aniseikonia to a greater extent than adults.
8. Aphakia
Aphakia is the absence of a lens in the eye, due to multiple causes.
It causes a high degree of hyperopia, loss of accommodation, and a
deep anterior chamber.
9. Pseudophakia
Pseudophakia is the condition obtained by implanting an artificial
lens in the eye. Intraocular lens implants are used in both refractive
lens exchange and cataract surgery to replace the natural lens of the
eyes and correct the refractive error.
1. Retinal Reflex
The projected streak illuminates an area of the patient’s retina, and
this light returns to the examiner. By observing the characteristics of
this reflex, the examiner determines the refractive status of the eye.
When you are not getting astigmatism right, you can ask the patient
to look into the retinoscope light itself. When a patient is looking
at this light, the astigmatism assessment is very accurate. After
assessment of the astigmatism, you can ask the patient to look at a
distance for assessment of the spherical power.
180° 180°
+4.0 DS
This patient (in the above example) has a cylindrical power of + 2.0
DC (+6-4) at 180° and spherical power {+4DS -1.5DS (retinoscopy
distance)} of + 2.50 DS.
Oblique Axis
If this reflex is oblique after making a cross, plot a dotted line and
write the axis.
For example: If the patient’s one axis lies at 70°, another axis will
be at 160°.When the streak is parallel to 70°, reading is + 4 DS and
when the streak is perpendicular to 70°, then the reading is + 6 DS.
This should be plotted as below:
+6DS
160°
+4 DS
70°
For Example:
+6.0 DS +6.0DS to +6.5DS
60° to 70°
6. Auto-refractometry
Refractometry is the estimation of refractive error with a machine,
called a refractometer. Automated Refractometers (AR) are designed
to objectively determine the refractive error and are of various types
depending upon the underlying principle they are based on. AR
comprises an infrared source (around 800-900 nm) which is invisible
and helps to overcome instrument accommodation to a certain
extent} and a fixation target. All refractometers use the anti-fogging
technique to relax accommodation before objective refraction.
1. Autorefractometry [AR]
2. Subjective Testing: Basics
3. Subjective Testing: Case Scenarios
1. Autorefractometry (AR)
Our aim is to get correct AR Readings and then do a proper subjective
testing.
a. Correct AR reading:
We need to look at the crowding of readings rather than average.
Take a printout of ‘5’ readings and then analyze them.
For Example: -1.25/-2.50 at 32°
-1.00/-2.00 at 10°
- 0.75/-2.25 at 25°
-1.50/ -2.50 at 29°
-0.75/ -3.50 at 34°
For example:
For example:
Uses:
i. To find out whether the patient needs a cylindrical correction.
ii. To find out the power of astigmatism
iii. To find out the axis of astigmatism.
First, since we don’t know the axis, we will have to try at different
cylindrical axis to assess where the patient’s vision improves.
Most of the times, the patient accommodates more when seeing with
one eye, so reduce by - 0.25DS in both eyes in myopes and check
again. Most of the patients will read clearly with no strain. In most
of the hyperopes, we can keep adding plus lenses as long as he is
comfortable and can see clearly to relax his accommodation.
So, prescribe the cylinder as per acceptance but change the spherical
power:
Options:
i. RE: +0.00 DS
LE: +2.00 DS
ii. RE: +0.50 DS
LE: +2.50 DS
iii. RE: +1.00 DS
LE: +3.00 DS
The same principle shall be followed for myopia but probably not
so strictly.
In other words, if
No symptoms
No amblyopia No spectacles
No squint
What to prescribe?
We can prescribe (b) as young children have strong accommodation.
We should review these children every 3 months and sequentially
increase the hypermetropic correction. In children, hyperopic
correction can be under prescribed but myopic correction should
be fully prescribed. Even slightly overprescribing by -0.25 DS to
-0.5DS in myopes, will do no harm as they can accommodate well.
No amblyopia
No symptoms No spectacles
No squint
Prescription:
Normally, we would have given addition +1.75 DS at his age, but this
patient needs PAL with addition of +2.25 DS for two reasons. First,
he is accepting -0.25 DS more for distance than CAR. Progressive
glasses should compensate for this -0.25 DS of over-correction.
Second, myopes tend to have poor accommodation.
Over refraction
yy Ask the patient to wear his own spectacles.
yy Now with both eyes open add -0.25 DS in front of spectacles
(figure 3).
CORRECTIVE
LENS
VERTEX DISTANCE
Figure4: Vertex Distance
You can prescribe full cylindrical correction at this age, but with
certain instructions:
yy Spectacles should be well centered.
yy For 15 days, use them for watching TV, then slowly move around
the house. Once you become comfortable, only then use them for
going out.
yy Most importantly, if you are not able to adapt, then we might have
to reduce the cylindrical power. This will increase the comfort
level at the cost of visual acuity.
Option 2:
Option 3:
Past Positions
All India Ophthalmological Society (AIOS)
• Member Scientific Committee : 2002 – 2005
• Joint Secretary : 2005 – 2008
Dr. Harbansh Lal • Treasurer : 2008 – 2014
• Dean FAICO (Fellow All India Collegium of
Ophthalmologists): 2018 – 2019
• Co-Chairman, Headquarters Committee : 2019 – 2020
• Dean FAICO Committee : 2019 – 2020
• Chairman, Headquarters Committee : 2019 – 2020
website: http://drharbanshlal.com