OPT 2083

CLINICAL STUDIES I
L8 SUBJECTIVE REFRACTION

VINCENT WONG, MHSc.(Optom)

Learning Objective
To begin students with the basic practical aspects of assessment of
refractive status using monocular subjective refraction technique.
Learning
Outcomes
i. Demonstrate understanding
of the basic principles in
subjective refraction.
ii. Perform monocular
subjective refraction
procedure.
iii. Demonstrate understanding
of the relevant theory behind
the monocular subjective
refraction procedures.
SUBJECTIVE REFRACTION
Distance or near • Patient fixate at distance or specific near distance
refraction
Monocular or • Refraction done with one eye occluded or both
binocular refraction unoccluded

With or without • Objective refraction done prior to subjective

objective measure refraction

With or without • In some patient, refraction need to be done under

cycloplegic agents the effect of cycloplegic
Distance or Near Refraction
• Distance refraction is more important.
• Near refraction is rarely done except in patient who had problem at
near with the distance correction.
Monocular or Binocular Refraction
• In monocular refraction, one eye is occluded or the two
eyes do not share any same stimulus (one eye is
dissociated).
• Monocular subjective refraction should not be used in
patient with latent nystagmus & any cyclodeviation.
• The occluder used in monocular refraction
manifests latent nystagmus and makes subjective
refraction difficult.
• The occluder can also manifests any cyclophoria
that could lead to an incorrect assessment of
astigmatism.
nystagmus
Monocular or Binocular Refraction
• In binocular refraction, both eyes are not occluded but only one eye is
looking at the specific target at a time. One eye is fogged.

• Objective refraction is usually done binocularly whereas subjective

refraction is usually done monocularly.
Monocular or Binocular Refraction
• Monocular subjective refraction is limited as the occlude can lead to
less relaxation of accommodation compared to binocular refraction.

• This can lead to possible over-minusing or under-plussing the

refractive correction in patients with hyperopia, pseudomyopia and
antimetropia.
Binocular refraction
Advantages of binocular refraction
Accommodation and convergence system may be
maintained/ more natural viewing
No binocular balancing needed
Can be done with cyclophoria/ latent nystagmus
Disadvantages
Binocular refraction should not be used where acuities
are markedly unequal, or one eye is strongly
‘dominant’. If you do start to apply it to an unsuitable
patient, they will usually tell you fairly quickly (‘Should
I be seeing double?’).
Strongly affect by objective refraction
After objective refraction,
RE VA 6/18 LE VA 6/7.5

LE require very high plus lens to fog, may result in double vision and
dizziness
With or without cycloplegic agent
• Refraction in some patient needs to be done under cycloplegia.
• Paralyse ciliary muscle so that the refraction is not influenced by the
accommodation.
• Need to know the indication.
• Most of the patient do not need cycloplegic refraction.
Cycloplegic and accommodation
REFRACTIVE ERROR
• Emmetrope/emmetropia
• Ametropia
• Myope/myopia
• Hyperope/hypermetropia/hyperopia
• Astigmatism
• Simple myopic astigmatism
• Simple hyperopic astigmatism
• Compound myopic astigmatism
• Compound hyperopic astigmatism
• Mixed astigmatism
MONOCULAR SUBJECTIVE
REFRACTION
Monocular Subjective Refraction - Procedure
• Determination of the refractive correction of the patient based on
their responses to the additional of various lenses.

• Monocular subjective refraction → one eye is occluded while the

refractive correction of the other eye is determined.
Monocular Subjective
Refraction…cont’

• Performed right after retinoscopy.

• VA from retinoscopy →can estimate residual

spherical component.

• Involved in the usage of trial lens/phoropter as

well as the auxiliary lenses.
Monocular Subjective Refraction…cont’
• Monocular subjective refraction involved the following processes:
• Initial MPMVA/BVS
• Duochrome test
• Astigmatism determination
• Jackson Cross-cylinder
• Fan & Block
• Monocular endpoint

• After monocular subjective refraction has been performed on RE and

LE → binocular balancing will be performed →binocular endpoint
→refraction process finish.
Monocular Subjective Refraction…cont’
• Indications
• Routine procedure for all patients.
• Those with symptoms/ signs of refractive error
• Patient with symptoms/signs of current Rx changes
• Contact lens pre & post fitting procedure
• Patient with symptoms/signs of current CL Rx change
• Severity of the ocular diseases/ Referral need of OD
Basic Requirement
1. Examination Room with Good
Illumination
▪ e.g. chart illuminance 480 lux,→
surrounding illuminance 160 lux.
(to avoide discomfort glare)
▪ Room too bright – pupil constrict
(u/correct Rx)
▪ Room too dim – pupil dilate (tend to
o/correct minus)
Basic Requirement…cont’.
2. Test Chart
▪ 6m viewing distance
▪ Direct 6m
▪ Indirect (3m with reflecting mirror)
▪ Consists of:
✓ Snellen chart
✓ Fan & Block chart
✓ Duochrome
✓ Cluster dots
✓ Spot of light
Basic Requirement…cont’.
3. Trial Lens Set
▪ Trial frame
▪ Flip lenses (confirmation tester)
➢ ±0.25DS, ±0.50DS, ±1.00DS
▪ Cross-cyl
➢ ±0.25DC, ±0.50DC, (±0.75DC) &
±1.00DC
➢ Contains 2 cylindrical lenses having
same power with opposite sign
blended together.
➢ Axis of 2 cyl lens ┴ each other,
resultant power is plano.
4. Hand held occluder
TRIAL LENS SET OR TRIAL BOX
 TRIAL LENS SET OR TRIAL BOX

• Contents of the Trial Lens Set :

1. Spectacle trial frame
2. Spherical lenses
3. Cylindrical lenses
4. Prisms
5. Occluder
6. Pin hole
 TRIAL LENS SET OR TRIAL BOX

• Contents of the Trial Lens Set :

7. Plano lenses
8. Red and Green filter
9. Maddox rod
10. Stenopic slit
11. Jackson Cross cylinder
Phoropter

The phoropter is a complex lens holder

designed to allow the examiner to
change lenses efficiently and easily
Phoropter vs Trial lens set
Principles of Refraction
1. Accommodation – relaxed state
2. Maximum PLUS, minimum minus
3. Always trial frame before prescribing
4. Take into account vertex distance especially high RX
Next….Initial MPMVA/BVS