Refractive Examination and

Spectacles for GP
Grimaldi Ihsan,SpM(K),FICS
National Eye Center Cicendo Hospital
Bandung Eye Center
 OUTLINES

• INTRODUCTION
• REFRACTIVE ERRORS
• REFRACTIVE EXAMINATIONS
• LENS PRESCRIPTION
• TAKE HOME MESSAGES
INTRODUCTION

KEPUTUSAN MENTERI KESEHATAN NOMOR 514

STANDAR KOMPETENSI DOKTER UMUM TAHUN 2012
TAHUN 2015

LEVEL KOMPETENSI 4A
INTRODUCTION

MYOPIA ASTIGMATISME HIPERMETROPIA

Less than 3 D Less than 2 D Less than 3 D

Surat PP Perdami kepada Dirjen Yankes Kemenkes, no.0275/Perd.XIV/Sek/7/2019

 What causes refractive errors ?

E y e b a l l l e n g t h C o r n e a ’ s p r o b l e m sA g i n g o f t h e l e n s
Eyeball grows either Changes shape of Cloudy lens
too long or short cornea
 Refractive Error
R e frac tive e r r or i s a p r obl em w i t h f ocu s ing l i ght a c cu rat ely o n t he r e t i na d u e t o t he s ha pe
o f t he e y e

Myopia Hypermetropia Astigmatism Presbyopia

 R e f r a c t i v e E r r o r

Myopia
Nearsightedness

Definition Etiology Mil

Eye disorder when the lights focuses in front of Genetics and environmental
d factors
retina → objects look blurry <3
D
Modera
te
Characteristic Prevalence 3D –6D

Juvenile onset (7-16 years old) 2% begins at 6 years old

Adult onset (begins at 20 3% in children under five and 25% in
years old) adolescents
 R e f r a c t i v e E r r o r

Hyperopia / Hypermetropia
Farsightedness

Parallel rays converge at focal posterior to the retina

Causes :
- Lens changes
- Insufficient refractive power
- Short globe (axial)

Prevalence
Early 40’s (20%)

70-80 years old

( 60%)
 R e f r a c t i v e E r r o r

Astigmatism

Light rays focus on more than one point

(unequal refraction of light in defferent meridians)
Its often simultaneously with another refractive error
People born with it partially, but many people develop it
as children or young people
 R e f r a c t i v e E r r o r

Astigmatism’s Symptoms

Cornea or lens has different Cloudy lens makes light

shape than normal bend differently as it enter
(congenital / acquired) the eye
 R e f r a c t i v e E r r o r

Astigmatism’s Symptoms
Trouble seeing at night Eye strain

Need to squint to Mild astigmatism might

see clearly not notice any symptom

Blurry vision Headache

 R e f r a c t i v e E r r o r

Presbyopia

Gradual loss of accommodative response resulting

from reduced elasticity of the lens
Accomodative insufficiency → loss of accommodative amp
Insufficient to read and carry out
near vision tasks
It is begin after 40 years
 R e f r a c t i v e E r r o r

Presbyopia

Source : AAO Clinical Optic 2018-2019

 Treatment of Refractive Error

Spetacle lenses Contact lenses Refractive surgery

Spherical lenses, Soft, hard, rigid gas Radial keratotomy,
cylindrical, multifocal permeable LASIK
lenses
 REFRACTIVE EXAMINATION

SUBJECTIVE OBJECTIVE
SUBJECTIVE EXAMINATION
To Determine by subjective combination of spherical and
cylindrical lenses necessary to provide best visual acuity

Rely on the patient’s responses to the refractive correction

 MEASURE
PUPILLARY
DISTANCE
Add 2 mm for pupil
Drop the flashlight light distance for far
onto both eyes Measure the distance
The patient look at
distance of the light op the flashlight light
the observer
spot between OD onto both eyes
forehead or the
and OS as near
lights
pupil distance
PUPILLARY DISTANCE
Visual Acuity Examination
Snellen Chart
Bailey-Lovie Chart
Testing
Distance Visual
Acuity
IDEAL DISTANCE : 6 METER
Testing Distance Visual Acuity

VISUAL ACUITY = 6/6 OR 1.0

Testing Distance Visual Acuity
Ask
• Ask the patient to stand or sit at
a designated testing distance
Ask
• Ask the patient to say aloud
each letter or number, or name
the picture object on the lines of
successively smaller optotypes,
from left to right.
Occlude
• Occlude the left eye. Be sure
01 that the occluder is not touching
or pressing against the eye.
02
Note
• Record the acuity value for each
03 eye separately, with correction
and without correction
 Testing Distance Visual Acuity
If the patient misses half or fewer than half the letters on the smallest readable line, record how
many letters were missed. If acuity is worse than 20/20, recheck with a 2.4 mm pinhole

Repeat steps for the left eye, with the right eye covered.
If desired, retest acuity with the patient using both eyes simultaneously and record acuity OU

Record the power of the corrective lenses worn for the distance acuity determination
UCVA : 6/9 F2

PINHOLE : 6/8

TARGET !!!
 PINHOLE VISUAL ACUITY

If Acuity worse than 6/6 or 20/20

Position patient and occlude eye that not being tested

Ask patient to use pinhole occluder in front of eye

Instruct patient to look at distance chart

Read the smallest letter that are legible on previous vision test
with pinhole

Record the snellen chart

PINHOLE
ANATOMY OF PUPILLARY DISTANCE ADJUSTER

TRIAL
SPECTACLES

AXIS ADJUSTER

AXIS INDICATOR
CORRECTION LENS
Occlude the eye not being tested

Add a +0.50 D sphere. NO: add more plus spherical power

with +0.50 D until the vision clearer.
Is the vision worse?
YES: add minus spherical power
Duochrome test. with -0.50 D until the best line can
be resolved. .

Record the Corrective Lens

Repeat the procedure for another eye

 SPHERICAL
DIOPTER
INDICATOR LENS
 Position book a
Wear reading comfortable Occlude
glasses if distance from untested eye
necessary the eye

NEAR VISUAL
ACUITY

Repeat
Ask patient to
procedure for
read each Record it
another eye
letter or word
and both eye
Astigmatic Eye
ANATOMY OF PUPILLARY DISTANCE ADJUSTER

TRIAL
SPECTACLES

AXIS ADJUSTER

AXIS INDICATOR
 DIOPTER INDICATOR

CYLINDRICAL
LENS

AXIS INDICATOR
Snellen Chart
ASTIGMAT DIAL
 FOGGING +/- 0.50 D

NOTE THE THICKEST LINE

ADD CYLINDER WITH AXIS

PERPENDICULAR TO
THICKEST LINE

REDUCE FOGGING

CONTINUE TO SNELLEN
CHART
 ADD CYLINDER WITH AXIS
90 DEGREE

CYLINDRICAL
LENS
LENS PRESCRIPTION
AXIS FOR ASTIGMATISM

TYPE OF LENS

DISTANT SPECTACLES

NEAR SPECTACLES
CASE ILUSTRATIONS
CASE, Male, 41 yo

• VA OD: 0.5 PH 0.8 → S-0.50 : 1.0

• VA OS : 0.5 PH 0.8 → S-0.50 : 1.0

• Near Vision : add +1.00

( can read the smallest letter in 30 cm )

• Pupillary Distance : 62/60

LENS PRESCRIPTION

-0.50 -0.50 62

Add Add
+1.00 +1.00
60
CASE, Male, 21 yo

• VA OD: 0.32 PH 0.5 → S-0.50 C -0.75X180 : 1.0

• VA OS : 0.32 PH 0.5 → S-0.50 C-0.75X180 : 1.0

• Near Vision : can read the smallest letter in 30 cm

• Pupillary Distance : 62/60

LENS PRESCRIPTION
180
180

-0.50 -0.75 180 -0.50 -0.75 180 62

TAKE HOME MESSAGE
• Encourage yourself
• Practice
• Refer in Complicated Cases
• Help the patients
THANK YOU