Subjective Refraction

Safeet Shahbaz
MCQ 1
• Which of the following is not a step of subjective refraction:

a) Over-refraction.
b) Fogging.
c) Straddling with Retinoscope’s streak.
d) Straddling with Jackson cross cylinder.
MCQ 2
• Pick the correct sequence of subjective refraction:

a) Adjust sphere, Refine cylinder axis, Refine cylinder power, Duochrome

test.
b) Duochrome test, Adjust sphere, Refine cylinder axis, Refine cylinder
power.
c) Adjust sphere, Refine cylinder power, Refine cylinder axis, Duochrome
test.
d) Refine cylinder axis, Refine cylinder power, Adjust sphere, Duochrome
test.
MCQ 3
• Pick out the false statement about prescription of refraction:

a) Should not prescribe a large cylinder for any patient who has never
worn a cylindrical correction before.
b) It is better to leave myopes under-corrected.
c) It is better to over-correct hypermetropes.
d) Vertex distance for lenses with power of greater than or equal to
5.00 D should be specified.
MCQ 4
• During subjective refraction, cylinder cannot be refined by:

a) Astigmatic Dial Technique

b) Prism Dissociation Technique
c) Cross-Cylinder Technique
d) Stenopeic Slit Technique
MCQ 2
• Pick the correct sequence of subjective
refraction:
a) Adjust sphere, Refine cylinder axis,
Refine cylinder power, Duochrome
test.
b) Duochrome test, Adjust sphere, Refine
cylinder axis, Refine cylinder power.
c) Adjust sphere, Refine cylinder power,
Refine cylinder axis, Duochrome test.
d) Refine cylinder axis, Refine cylinder
power, Adjust sphere, Duochrome test.
• Ans A: AOA 2014-15 Section 3 Optics Pg.
105
• Always refine cylinder axis before refining
cylinder power. This sequence is necessary
because the correct axis may be found in
the presence of an incorrect power, but
the full cylinder power is found only in the
presence of the correct axis.
• To verify the spherical endpoint, the
duochrome test (also known as the red-
green or bichrome test) is used
MCQ 3
• Pick out the false statement about • Ans C. Elkington Pg. 238
prescription of refraction:
• Do not overcorrect
a) Do not prescribe a large cylinder for any hypermetropes: better to leave
patient who has never worn a cylindrical them 0.25 DS under-corrected so
correction before. they can read the
b) It is better to leave myopes under- bus numbers in the far distance.
corrected.
c) It is better to over-correct hypermetropes.
d) Specify vertex distance for lenses with
power of greater than or equal to 5.00 D.
Steps
• Retinoscopy.
• Adjust sphere.
• Refine cylinder axis.
• Refine cylinder power.
• Refine sphere.
• Duochrome test.
• Binocular balancing (Fogging/ Prism dissociation).
• Reading add.
• Back vertex distance.
• Inter-pupillary distance.
• Prescription of spectacle lenses.
Adjust sphere
• Place one of the following lens prescriptions in the trial frame:
a) Retinoscopic findings
b) Previous eye glass prescription
c) Previous manifest refraction
• Occlude the eye not being tested.
• Measure visual acuity for the eye to be tested, using the standard Snellen chart and
technique.
• Use test figures one or two lines larger than the patient's best visual acuity for testing.
• Adjust the sphere to the most plus or the least minus that gives the patient the best
visual acuity.
Refine cylinder axis
• The first step in cross-cylinder refraction is adjusting the sphere to yield
the best visual acuity with accommodation relaxed. Fog the eye to be
examined with plus sphere while the patient views a visual acuity chart;
then decrease the fog until the best visual acuity is obtained.
• If astigmatism is present, decreasing the fog places the circle of least
confusion on the retina, creating a mixed astigmatism. Then use test
figures that are 1-2 lines larger than the patient's best visual acuity. At this
point, introduce the cross cylinder.
• If cylindrical correction is not already present, look for astigmatism by
testing with the cross cylinder at axes 90° and 180°. If none is found there,
test at 45° and 135°
Refine cylinder axis
• Position the Jackson cross cylinder in front of the eye to be tested,
with the axis 45° to the principal meridians of the cylinder axis (this
is referred to as straddling the axis).
• Then rotate the axis of the correcting cylinder toward the
corresponding plus or minus axis of the cross cylinder (plus cylinder
axis is rotated toward the plus cylinder axis of the cross cylinder, and
minus cylinder axis is rotated toward the minus cylinder axis of the
cross cylinder).
Refine cylinder power
• Align the cylinder axis with the Jackson cross cylinder axis. This is
sometimes referred to as on axis. Flip the cross cylinder and ask the patient,
"Which is better, choice one or choice two, or are they the same?“
• If the patient prefers the plus cylinder, add cylinder power (+0.25 D), If the patient
prefers the minus cylinder, subtract cylinder power(-0.25 D)
• The examiner should change cylinder power according to the patient's responses;
the spherical equivalent of the refractive correction should remain constant to
keep the circle of least confusion on the retina.
• Ensure that the correction remains constant by changing the sphere half as much
and in the opposite direction as the cylinder power is changed. In other words, for
every 0.50 D of cylinder power change, change the sphere by 0.25 D in the
opposite direction.
Refine sphere
• Add +0.25 to +0.50 D and ask the patient, "Which lens makes the
letters clearer, number one or number two, or are they the same?”
• The patient is presented with two choices and will select either the
original lens (choice one) or an additional spherical power (choice
two).
• Continue adding or subtracting in increments of -0.25 to -0.50 D
sphere until the patient notes that the two choices are equivalent.
Duochrome test
• Each eye is tested separately for the duochrome test, which is begun
with the eye slightly fogged (by 0.50 D) to relax accommodation.
• The letters on the red side should appear sharper; the clinician should
add minus sphere until the 2 sides appear the same.
• If the patient responds that the letters on the green side are sharper,
the patient is over minused, and more plus power should be added.
• Some clinicians use the RAM-GAP mnemonic-"red add minus; green
add plus"-to recall how to use the duochrome test.
Fogging
• When the endpoint refraction is fogged using a +2.00 D sphere before each eye, the
visual acuity should be reduced to 20/200-20/100 (6/60-6/30).
• Place a -0.25 D sphere before first 1 eye and then the other, and rapidly alternate cover;
the patient should then be able to identify the eye with the -0.25 D sphere before it as
having the sharper image at the20/100 (6/30) or 20/70 (6/20) level.
• If the eyes are not in balance, sphere should be added or subtracted in 0.25 increments
until balance is achieved.
• In addition to testing for binocular balance, the fogging method also provides
information about appropriate sphere power. If either eye is over minused or under
plussed, the patient should read farther down the chart-as far as 20/70 (6/20), 20/50
(6/15), or even20/40 (6/12)-with the +2.00 D fogging spheres in place. In this case, the
refraction endpoints should be reconsidered.
Prism dissociation
• The most sensitive method of binocular balance is achieved by fogging
the refractive end point using +1.00 D spheres and then placing vertical
prism of 4~ or 5~ before one eye.
• A single line, usually20/40, is projected on the chart. The patient is then able to view a single line
with both eyes simultaneously but with the two images vertically displaced, one above the
other. The two images should be comparable in size and clarity.
• Differences between the fogged images in the two eyes of 0.25 D sphere
or even less can be identified readily by the patient. A +0.25 sphere is
placed before one eye and then before the other. In each instance, if the
eyes are balanced, the patient will report that the image corresponding to
the eye having the additional +0.25 sphere will be more blurred.
• Once a balance between the two eyes has been established, the prism is removed.
The fogging lenses are then gradually reduced simultaneously from the
two eyes, in 0.25 D increments.
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