7

Objective
refraction

lntroduction 76
Measuring pupillary distance 76
¡ i-
Adjusting the trial frame 77
Adding lenses to the trial frame 78
A note on phoropters 80
R.etinosc·opy 81
1
Target 81
i:l i Light conditions 82
1

!' Position 82
Working distance 82
Fogging 83
lnitial lens 84
Plus or minus cylinder? 85
Streak or spot? 86
Streak retinoscopy 86
Alternative methods 89
Tips far difficult retinoscopy 91
The stenopaic slit 91
Non-refractive uses of retinoscopy 92
Autorefractors 92
Cycloplegic refraction 95
When should cycloplegic refraction be done? 95
Should I use an anesthetic first? 95
Which cycloplegic? 96
How do I get the drops in? 96
 1 1

;,.:,:; ._,; ' Adjustlng the trial frame

'. ., Objective refraction
· es, ....,, · .

--'76 ¡-lntr odu ctio n·

Objective refraction includes retinoscopy or
autor efrac tors, which are appe aring in
tive
opto
meth
the use of
metr
ods
ic practice in
are not
The pupillary distance for near may be meas
the patient to look at the bridge of your nose.
using the left eye and the PD read using the
Quite why you would wish to do this is anot
amount of inset required will vary with both
distance of the patient, so unless you know
ured by instructlng
The zero is lined up
right eye as befare.
her matter. The actual
the PD and working
these and place your
-
77

increasing numbers. In general, objec

urem ent is of
n. They mere ly need to get · nose in precisely the right position, the meas
requi red to give us a final prescriptio n in Table 7.1 .
meth ods can take us to the dubious value. The actual inset required is show
us to a point from which subjective
With an alert and comp liant
end poin t accurately and quickly.
----, - , •-·'
- - •- - - ,- · - · - - · - - - ----· · ·
,' ~ r

rate resul t using subje ctive

subje ct it is possible to get an accu ( Acii,ü,~ting the trial 'fram_e _
In gene ral, exces sively prolo nged - -• - -• • • - •-- - •

meth ods alone, but it takes time.

_ ,. ___ _ _ ' • • • - - - -
••- - _ _ _ _ _ _ _ __
•. L_ _ • • • • ••• , _ ¡'. • -

usual ly indic ative of poor

refraction of normal patients is The optical cente rs of the trial frame should
be set to the
practice, and if
technique rathe r than "professionalism". With éiscance PD. lf there is mark ed facial asym metr y you may need
n, objec tive refra ction should frame accordingly.
a previous prescription is know to measure monocular PDs and adjust the trial
tak.e secon ds rathe r than minu tes.
L<lte1·; wh,;r; you move on to near vision
tests the optical cente rs
lpate in a subjective ped slightly by .
Ther e are patients who are unable to partic ,>~r. h~ :;:Jju.Hed to equal the near PD, and drop
of under stand ing or communlcation. However, this should
refraction, because of limitations ,:¡,d¡,.,:.dr.¡ ,:h,~H():s~pi1::ce of the trial frame.
Alzh eime r's disea se or a learning intend to presc ribe are
The very young, those with 1.;-111-:;r ;;,-.:c lx-: :;:, 1'f ó~ .s~•éCtacles that you
riptio n is arriv ed at purely from pre-presbyopic patie nt the .
disability may require that a presc r.;,-:, r.:,¡,,; ~1':t :J9, ;,,,~r vislon only. On a
ld have realis tic expe ctations of throu ghou t the
the objective frndings. We shou opdc3: 1::~!>•~e~r~ sÍl0~ld stay set far distance
is only a 50 perce nt probability be affected by
retinoscopy. lt seems that there refracdr>:,, i\ ~'. ·,:};l:! r1ear ocular moto r balance will
ents of spher e powe r would be
that two consecutive measurem the c~m ~ríon ~f the lenses (Table 7.1 ).
most repea table , follow ed by
within 0.40D. Cylinder axis is the
r.And unles s you are fully
cylinder power, then sphere powe
one eye than the
ambidextrous you are likely to be bette r with
1

' 1

other. Of course, the skill of the exam iner will influence both Table 7. t Binocular inset appropriate for specific PDs !

accuracy and repeatabllity. PO Binocular inset for near vlslon at:

e~~f~:;1~~-~.ü~i~~r~
33 cm 40 .cm
1~~f~~~-- ~:;~:~:~-· ·~-~ - _
1
74mm 5.5 mm 4:s mm

70mm •. 5.0m m · A.5 mm

accurately, because
lt is important that we set up the trial frame
cts into the final 66 mm 5.0 mm 4.0 mm
failure to do so may Introduce signifrcant artifa .,
nt to look frrst at
result. Use a frame rule and instruct the patle 62mm 4.5 mm .1.0 mm
temporal limbus.
your left eye. Line up the zero curso r with the ,4;5 ,mm
the position of the , 58 mm 3.5 mm
The patient now looks at your right eye, and ' .
not moved the
nasal limbus is measured, ensuring that you have , 56mm · 4.0 min - 3.5 ~in
.rule meanwhile.
 Objective refraction
Adding lenses to the trial frame

A
Figure 7.1 Look at the erial frame and check that it is level

• Look ·a t the trial frame and check that it is leve!, allowing for ariy
facial asymmetries that may be present (Figure 7.1 ). lf the frame
~
is not level, the cylinder axis that you find may be wrong, and !

---
' ~·
vertical prismatic effects may cause artifacts on binocular tests.
• _check that the pantoscopic angle of the frame is sensible 1 :(

(Figure 7.2). lf the frame is wrongly tilted, high-powered

prescriptions may throw up ·significant errors in both sphere
and cylinder. ·
~
• Make sure that the back vertex distance is sensible. lf the
~ power of the sphere you find is over ±4.00 DS you should
_, measure the BVD and note it on the final Rx.

~
·AddirJg lenses to the trial frame
~

•., • Place s·pheres in the back cells of the trial frame. Where you
are using more than one sphere in the trial frame the most
powerful shou/d be at the back to minimize the effect of Figure 7.2 Check that the pantoscopic angle of the frame is sensible :~? :~
~ i--
~f:'.-._~:~
.... ·.•.· ~-.: .
 Object ive refract ion Retinoscopy

--
80

1
r
'
~

' ,_
~
1
E]

! ·-
a -;--
,.' .•
' -;,·, ..

Figure 7.3 The most powerful sphere should be placed in the first of
Figure 7.4 lncreasingly, pho,:opter heads are used instead of trial frames
the rear cells

vertex distance. However, if you are using an Oculus TM insertion, greate r accuracy in axis location, more rapid comparison
or similar trial frame, which incorp orates a built-in vertex prasentation of lenses, use of variable prism, and a variety of
distance scale, the most powerful sphere should be placed in furthar options depending on the model, such as immediate
the first of the rear cells (the back cell one neares t the front) co;npa rlson of new refractive findings with previous results.
(Figure 7.3). This is the cell to which the scale is referenced. Thr:;•' ari: not advisable far a few situations, notably low-vision ·
~ •.;.;;.;:f ;,--,:';-rit ;;nd over-refraction of multifocal contac t
lenses,
• When you change spheres, try to ensure that the patient is never
grossly under-plussed when you change lenses. lt is best to add the ·,,,,;;¡",;:, fr,~ reduced light levels may affect visual perfor mance or
~· ;,_;,;..:!!! ~íZ!, 1~1;spectively and may hinder binocular
assessment.
next plus lens before you remove the current one. lt can be tricky
with modem triaJ frames but it becomes easier with practice.
• lt is essential to make sure that all lenses are thoroughly clean
'
throug hout refraction. Experience suggests this is often not
• • 1

the case.
Targe t
ldeally, we want a target that will prome te accura te and steady
AJ:1ote o·n,1?h9ropte_rs_ fixation but no stimulus to accommodation. Various targets are
- ._~_;--_ - - -- - . - --=--- - - =- - -~ - -
used and they probably make little difference to the end result,
lncreasingly.-phoropter heads are used instead of tria! frames
but there is sorne evidence that the rings on the green block
(Figure 7.4). Modern autom ated lens carriages allow fast lens
Objective refraction

Retinoscopy · W, .

--
of the duochrome · h b
accommodation I m1g t e_the ones that produce least
Ta_ble 7.2 Appropriate lens allowance for working distance
the rings on th . n the absence of any contradictory evidence
target far retin:;;~;;. would be the recommended fixation Working dlstance (cm) Worki~g-lens allowance (D) 83
so 2.00
57 1.75
Light conditions
66 1.50
A ~arkened room will cause pupil dilation and make the
80 1.25
retino_scope reflex more visible, though complete darkness
can st~mulate accommodation. lt might also be difficult to find 100 1.00
the tnal lenses.

to allow for it. Make sure that you can return to it by measuring
Position with your arm. Usually the base of the fingers or the wrist is
used as a reference point, as this allows you to change lenses
You-must try to work within 5 degrees of the visual axis both
horizontally and vertically. Adjust the chair height for ve~ical
¡ without moving your body position. Check your working distance
1 when you have moved from it (e.g. to change a lens). lf your ·
alignment, allowing far the fact that the test chart may be above .1 working distance allowance is wrong, errors in the power of the
the patient, so the patient may be looking slightly upward. Errors sphere (and usually the cylinder too) will result For example,
of the arder of -0.SODC x 90 occur if 1Odegrees off horizontally. if you are 100 mm out at 2/3 m the sphere will be approximately
Unless you have reduced vision in one eye use your right eye to 0.25D in error. Note, however, that the shorter the working
test thé-patient's right eye, and your left eye for the patient's left distance, the greater the error that will be introduced by 100 mm
eye. lf this is impossible, the Barratt method should be employed variation (Table 7.2).
(see page 89). For horizontal alignment, get the patient to look at
the green of the duochrome, get your head in the way and ask
the patient to tell you when they can just see the green panel.
Ask the patient to tell you if your head gets in the way. C-~!til"l!'. ~Hjnoscopy, it is the fixating eye that controls
i1C•::or.in-1odation, so it must be fogged to ensure that
a:cornmodation is relaxed. However, if you overdo it, you
Working distance ~cíl induce accommodation, so the fogging should be less
You should work at a distance that allows you to change the thai1 2.00D.
lenses in the trial frame without changing body positlon, and for · ln:tial!y both eyes should be corrected with what you think is
most people this means that the working distance will be less likely to be che full plus correction, based on the patient's existing
than the 2/3 m which seems to be the expected norm. Only the correction (if available), VA, and symptoms and history, plus the
tall can reach if they work at 2/3 m and for many 1/2 m is more working distance allowance. Check with the retinoscope that you
realistic. lt doesn't matter what the distance is provided you have an "against" movement in either eye. From time to time
know how much to allow for your working lens and the dlstance during retinoscopy, pass the retinoscope beam across the fixating
is maintained throughout the test. Measure your cus~omary eye to make sure that it is still fogged. This is particularly 1

working distance so that you know how much sphencal power important with young hyperopic patients. 1
J

e,.,..
~-: ,.1

Objectlve réfraction

--
~~' ·Retlnoscopy

lnitial iens
84 Table 7.4 Expected vlslon for any unco rrecte d cylln der
lf you have the patient's last spectacle prescription,
this is a good
85
Equlvalent cyHnder
starting point. lf the patient has lost thelr spectacles Vlslon
and no (w!th best visión sphere In place)
1

previous prescription is available, conslder the unaid

ed vlsion and 6/9
far point.A little thought at this stage can save a lot 1.00-1.25 DC
of time and
effort.There Is nothlng to stop you checking the VA 6/12 1.25-1.75 DC
when you .
have n_eutralized_the more positive merldian, to get
an idea of the ¡ 6/-18 1.75-2.25DC
cyllnder power required.
Dista nce unaided vlsion is related to refractive 6/24 . 2.50-3.00 oc
error in
myopes and manifest hyperopes (Table 7.3). 6/36 3.oO.:....oo oc
In purely astlgmatic refractive error s (or with the
best vision
sphere in place (Table 7.4)):
• lt is important to remember that these are only far distance to discourage accommodation, but rathe t
average val- r less
ues. Patients with small pupils (usually presbyopes than 2.00D. The easiest type of reflex to interp ret
) wlll experi-
ence less blur per diopter, and those wlth large pupils
more. "wlth" movement which should occur if the patien
is a quick
t is slightly •
Far myopes, the far point at which small print can
clearly varles inversely wlth refractive error (Table
be seen
7.5).
underplussed far your working distance. They will
somewhat fagged far the distance that the patien
still be· ·
•
• The working lens should be incorporated lnto
the correctlng as your retinoscope and the patient are separated
t is fixating
by 1.50D; •
sphere. The use of a sepárate worklng lens introd
uces an extra
set of reflections and uses up one of the ·trial frame
may need far the patient's prescriptlon. Far the ideal
spaces you Ph1i ;i:r )1:i-:ri~,.;2J ~'f}.h1de r? •
'
..,,.,,~i:2'11,~ - :..,~a,,,.-~
starting a"'-';,_ . _ _
p_oint, we would want the patient siightiy fogged Plwi: t-r l;i.·,:,(S)'•:· , :\~j i:,~:·,.-~ ·,o gli,•e a clearer, more easily
(overplussed) neutralized

Table 7.3 Expected vislon for any uncorrected mean spher

e
:.tr.·,iJ;;.k ;~;,e::; .,,,I, í:;.\'"•,>J.¡r~ by sorne práctitioners who
r•at /'10 ~T~,( i· ,-,:, r"?•r,:N!.:J~ a final prescriptlon (e.g.
sp"1d:;;i W•J M S :.::~-.:i~;.r,tr.). However, uslng minus
1
rely on
working with
· cylinders dóes
'•
ti!
Vislon .
Equivalen~ sphere
(~yopla/man'ifest hyperopla) Table '!.5 Vi,,rla tlon of far polnt wlth uncorrected myop
,,
6/$ Plano , Spherlcal refractlve error (dlopters)
ia
,.
6/6 0.25.,-0.5Q DS 2.00
Far pqlnt (cm)
50
,,
6/9 0.50--0.75 DS 4.00 f
6/12 25
0.75-1 :Q0 DS 6.00
6/18
6/24
1.00-1.25 DS
1.25-1:75,D~
8.00
10.00
~
16.7
12.5 '
l
6/36 U5-2:25 DS.
12.00
"' 10 ..
8.3 4
.,...
~
•
..
Ob¡ectlve refractlon Retlnoscopy •

- 86
ensure that accommodatlon Is better controlled nnd
most automated refractor heads do not have a plus-cyllnder

-
87

--
optlon. Mlnus-cylinders are more commonly used In routlne
111 refraction.

-- St~ orspot?
Either type of retinoscope will do the job, In the hands of

--
someone familiar with lt. Streak retlnoscopes are currently
fashionable and they do make axis determlnatlon easier where
there are high cylinders, but spot retinoscopes probably make lt

-
easier to deal with lower levels of astigmatism. Sorne retinoscopes
now come wlth a choice of bulb, so practitioners can experiment
for themselves.

Streak retlnoscopy
lnltially the retinoscope should be set to glve maximum Figure 7.5 Wlth medium to hlgh degrees of astigmatism, this deviadon
divergence (the collar should be down). The beam is swept along Is apparent even when the beam is static
the 90° and 180° merldians and the reflex observed. lf the patient's
principal meridians lie along 90° and 180° the reflex within the \
pupil wlll be seen to move parallel to the directlon that you are -- _.... -,~r -.,•-·=,-o-
sweeping. lf not, the reflex moves obliquely to the direction of
sweep. With medium to high degrees of astigmatlsm, thls deviation ,,
-·--
is apparent even when the beam is static (Figure 7.5). Rotating
the streak will align the reflex and the directlon of sweep
(Figure 7.6). When the two coincide, you are sweeping along
one of the principal meridians, the other being at 90º if the
astigmatism is regular.
Neutralize the more positive or least negative meridian first.
To decide which this is:
• lf you have a "with" movement in both meridians, the meridian
showing the slowest movement is the more positive.
• lf you have "with" in one meridian and "against" in the other; the
meridian showing the "with" movement is the more positlve.
• lf you have an "against" movement in both meridians, that
showing the faster movement is the more positive or least Figure 7.6 Rotacing che screak will align che reflex and the direction
negative. of sweep
r
t-----,--

':Í-) Objectlve rofractlon

Retlnoscopy

--
88
When you thlnk you have reversa!, use a bracketlng technlque
to check.

Forpower
• Move sllghtly backwards and forwards.The reflex should
causes the reflex to flll the pupll as the beam completes
lts rotatlon. The orlentatlon of the beam that produces the
narrowest reflex Is 90° off the mlnus cyllnder axis.
• Add +0.S0DS and neutralize the second merldlan.

change from "agalnst" to "wlth".

• Use ±0.25D twlrls.Agaln the reflex should change from Alternatlve methods
"agalnst" to "wlth". There are a number of methods that may be worth trylng lf
conventlonal methods are not posslble or are not working on
For axis (Llndners method) a particular patlent.
• Neutrallze the more posltlve merldlan.
• Sweep the beam across merl~lans at +45° and -45º to the axis Parker method
of the trlal cyllnder. The reflexes should be ldentlcal. lf one Is • ídentlfy the rneridlans In the usual way.
"with" and one "agalnst", move the axis toward the merldlan ~ '.~et dw~ •;tre<1.k a.long the axis, and adjust the streak to glve a
showlng "wlth" movement. :n¡n1m,w¡1 ',i'lílth rn"ílex.
,;i, ,\,; J~ ·,xr••~·:,'. ': '-:,¡,ilí. I:; corrected, the width of the streak
11

{nc.:,:i~·. ,,:••; ':/\"/1.,c,í•J t h~ reftex fllls the pupil the ametropia is .

Small cyllnders
:,·, ~.: ~} :'; ~•?.¡.'j ,-: rt1J1}1 ,
lf small cyllnders are present, elther:
1. Move the collar up.
• Neutrallze the more posltive meridlan.
B,:srreJ't.t: t\1..,'., ,;f;:,r•·~
The p,1tle!tt fo,:;:•t,~;~. ,, brigh t lumlnous flxation object binocularly.
• Move the collar up so that the lmmedlate source is
The ta1·g4,r. s.h::•i,!d ídeally be non-accommodatlve though the
between the retlnoscope and the eye. You should see a
retlno~cope t-:tq?;rf!t ofren used is not, completely.Alternatively
narrow reflex whlch moves rapldly In a reversed dlrectlon.
the practitloner's fore h·ead may act as the target.
Therefore a "wlth" movement Is seen, whlch Is neutrallzed
Advantages claimed lnclude:
wlth negatlve lenses. Thls technlque Is also useful as a
check test, and In hlgh ametropla where no lnltlal reflex • Worklng closer to the visual axis.
can be seen. • Smaller pupll due to near reflex. Fewer aberrations as a ·result
(but also a less brlght reflex).
2. Use the Francls method. • Only one of the practitioner's eyes Is used. This makes tlie
• Neutrallze the more posltlve merldian. method partlcularly useful for those optometrists with
• Set the collar for maxlmum dlvergence (Le. down). reduced aculty In one eye.
The immedlate source wlll lle behlnd the retlnoscope at
about 1 m wlth a worklng distance of 2/3 m. The dlsadvantage Is that the patient will accommodate , especially
• Add --0.50D5. The reflex will become a narrow llne. younger ones. The sphere must be checked with distance fixation
• Rotate the beam through 90º. lf the reflex stays narrow, In one eye elther befare or after uslng the Barratt method and
no slgnificant astlgmatlsm Is present. Even a tlny amount the final result adjusted accordlngly.

l
Objectlve refractlÓn :.n

Retinoscopy 1,
Near retlnoscopy
Mohindra's technique (1975) is a development of near-fixatlon
re_tlnoscopy which allows refractlon of infants and young children
w1t~ou~ the use of cycloplegics. The room lights are slowly
extmgu1shed and the child encouraged to look at the retinoscope
lig~t.. lt is usual to ask the parent to occlude one eye, though
~_e_!!or dlfflc~ l~etin osco~
Spllt reflex
This can occur in keratoconus, corneal scarring or lens changes.
Check that the trial lenses are clean, correctly centered and that you
are working on axis. Don't try to obtain reversa!, use bracketing.
--
91

opm1~ns vary as to whether this makes a signiflcant difference.

Feedm~ tends to relax accommodation. The pupil will initially Opacitles
constr1ct b~t after a few seconds dilation will occur. At this point You may have to work around them by moving off axis.Allow for
- 1

the refract1ve error may be neutralized. Lens racks may be used !

this when estimating the cylinder. lt might also be necessary to
for s_peed, each meridian being neutralized separately. Accurate work closer to obtain a brighter re~ex.
fixat1on may be encouraged in older children by asking the child
:'hen th~y can see "the black spot in the light" (i.e. the sight hole Ocular abnormallties
m the m1rror, on a spot retinoscope). Localized bulges or asymmetries may mean that the fovea is on a
The working distance is usually 0.5 m, so the expected different plane to the slightly off-axis point that ferms the reijex.
allowance for the working distance would be 2.00D. However, Therefere the sphere power may be sorne way out.
near retinoscopy does tend to· underestimate hyperopia, so a
correction factor of 1.25D is used for adults, though it has been Accommodatlve tonus
suggested that a correction factor of 1.00D is appropriate fer In young hyperopes the retinoscope result will often be conside,:ably
children older than 2 years and 0.75D for those younger. more positive than the eventual subjective refraction due to high
Opinions vary on the accuracy of this technique, particularly accommodative tonus. Patience is a virtue here if you susp~ct
in infants and those with higher refractive errors. that there might be more plus to add. Keep sweeping the beam
across, keep reminding the patient to look at the circles on the
Spot retinos copy green, and eventually you will see a "with" movement, albeit a
Spot retinoscopy is performed in the same way as streak trar.sient one. Neutralize it, and r~peat until you are sure that all of
retinos·copy but the reflex is circular in a patient without th-Ei hyperopia is corrected. lf you are consistently underplussing ~n ·
significant astigmatism.An astigmatic patient will give a reflex that :-etinoscopy, check your working distance, and slow down.
is elliptical, and this shape and the movement of the reflex relative
to the direction of sweep (which is the same as with a streak) Ti;_~te nopai c slit
enables rapid identification of the degree and axis of astigmatism.
lt is usually recommended that the more positive meridian is .This is an elongated pinhole which is used to find an approximate
neutralized befare correcting the cylinder, but you may find that correction of astigmatism in cases where retinoscopy will not give
it is easier to do when you have a rapid "with" movement in this 1.
an accurate result and high astigmatism is suspected. lt is placed
meridian. This means that you are 0.25D to 0.50D under-plussed befo re the eye being tested ~ith the BVS in place. The slit is rotated
for the distance you are working at, but the patient should still be slowly and the position that gives the patient the best acuity is
i
noted. This approximates one of the principal meridians of the eye.
fogged for their fixation distance. The c~linder power_ is !ncreased
until the reflex is circular and its speed m the two principal • With the slit still in place, + and - spheres are added to give a
meridians is the same, then you add the final bit of sphere. "best vision sphere" fer this meridian.
 .,, .,, ... q ~ ~!""
'. h' ., ...•. ,.
t
¡lr)

f 1•' f
"
'1~ 1¡
r, Objective refraction 1 i'~;J
.. ,,..,í ' Autor'efractors .. . .""1
:l
• ,; ~l -i/ i -~, -~ -~:

--
'-- ·-· 'it•• ¡t

t :v/,,::.
• The slit is then rotated t_hrough 90º and the best sphere for ¡'i ,· methods (the forerunners of modern phoropters) or obj_ective
92 the second meridian is found. :)¡ 1 methods and lt Is the automated obJective refraction instruments
l:~ J I that are now descrlbed as autorefractors.Auto refractors use an
The powers found are then converted to sphero-cylindrical form t~"·
,:~:1;1' infrared llght source (around 800 to 900 nm) which allows good
and the result placed in the trial frame, where it can be refined by
'\'l1 ocular transmission, but requires a -0.50D adjustment to the final
normal subjective techniques if appropriate. lt must be remembered :<., refraction due to error introduced by reflection from the choroid
that the axis ·is at right angles to the power meridian.
and sclera. The source projects light via a beam splitter and a
Badal lens system to form a slit image within the eye, the reflection
Non-refractive uses of retinoscopy of which passes out vía the beam splitter to reach a light sensor.
Throughout, the patient is encouraged to relax accommodation
Retinoscopy may be performed before ophthalmoscopy, so it
(a major source of error for autorefractor measurement) by
may be the first chance to view the interna! structure of the eye.
use of a fixation target or, in sorne cases, an open view to allow
A number of conditions may alter the appearance of the reflex:
fixati<;>n on a distant target. The calculation of refractive error
• The light reflected from the retina retroilluminates the lens, iris is based upen analysis of how the patient's eye influences the
and cornea. Opacities in the lens and iris can be seen as dark infrared radiation.
areas against the red background.The same effect may be The way this analysis is performed varies. Most of the original
observed with an ophthalmoscope held about 30-40 cm from ír1stn.H11e11ts used sorne form of image quality analysis, relying on
the patient's eye. Early opacities may be easier to see by retroillu- : .:-ositk:n,ing ·of the Badal lens system to achieve a maximum signal
mination than by direct observation with the ophthalmoscope. . 1
r.0 ihf li}:;ht !>ensor. The majority of modern autorefractors, of
• Where extensive transillumination defects are present in 1 'Ntid ·., i¡_he!rr., are many, rely on an adapted Scheiner disk principie.
uveitis or pigment dispersion syndrome it may be possible to -fl~i:t .:;,.rii,,mJl Scheiner disk consisted of two holes in a card placed
see them as bright radial streaks on the iris. However, the slit i":.1¡:;;-;:,,r-2 'i'Í'ie ey~. A myopic eye will see the two images from the
lamp is a better instrument to observe this. \\ ,;)Íf;~ :;•-t,r;;pped over or crossed, while the hypermetrope sees
• Keratoconus distorts the reflex and produces a swirling motion. therr: uncrossed. This may be done in various meridians to give
• Retinal detachment involving the central area will distort info rmation about the nature of astigmatism.Autorefractors 1 1
the reflecting surface and a gray reflex may be seen. simulate this using LEO light sources, the images of which are
• A tight soft contact lens will have apical clearance in the detected by a light sensor or photodetector, and the position of
central area which will cause distortion of the reflex. the LEO needed to achieve a single image over the photodetector
• lt is possible to perform indirect ophthalmoscopy with a is related to the patient refractive error.A further method
retinoscope and a high plus lens, provided the instrument employed by a few machines is an adaptation of retinoscopy,
is bright enough. where the instrument analyzes the speed of movement of-a
reflex of infrared light to measure the refractive error.
Most studies suggest that autorefractors are quick, simple,
repeatable and accurate (with sorne qualification). With
Autorefractors cycloplegia or good accommodative control the results are
very accurate. lndeed the spherical aberration introduced by
The use of a machine to me¡tsure refractive error has a long the dilation of a cycloplegic makes the method preferable to
history.The original optometers could use either subjective
retinoscopy in many cases. lts ease of use makes it suitable to
 Cycloplegic refraction

--
Objective refraction

precise error measurement but detection of large amounts of

be carried out by ancillary staff, so reducing the burden on the
ametropia or anisometropia. Other new models incorporate 95
optometrist. The machines may dlrectly link to an automated
sorne subjective assessment also, with the patient responding
phoropter head, again making the routine refractlon more fluid.
lt is useful to remember that even the most accurate objectlve to prompts to clarify a presented image.
measurement may not be that preferred by the patlent so a
subsequent subjective examination is always preferable to ensure
1. Cycloplegic refracti~~ ·
a tolerable refractive error, even though thls is sometimes
modified away from the actual refractive error present. When should cycloplegic refraction be done?
The main source of error is dueto poor fixation (dependent
very much on the target of the instrument), accommodative This is included in this chapter rather than that devoted to
fluctuation (proximal accommodation in the young invariably leads subjective refraction on the grounds that most "cyclos" are
to overminussed measurements) and media difficulties (which are performed on children whose subjective responses are not
likely to reduce the effectiveness of retinoscopy also).The lack of entirely reliable. Sorne practitioners advotate cycloplegic
1
portability of the instruments is less of an issue nowadays as examination of all new child patients. This has the advantage
1 ;
several portable models exist, and sorne have found use in child of providing more reliable baseline data· on the refractive error
screening pr.ograms (Figure 7.7) where the main outcome is not at the expense of time and sorne trauma for the patient.
· In general optometric practice, most practitioners tend to use
cycloplegics when:
11 There is undiagnosed manifest esotropia.
,. An esotropia has been noticed by the parent or guardian.
e There is unstable or uncompensated esophoria.
~ There are significant risk factors far esotropia and amblyopia
{fon,i!y history, significant refractive error, birth history, etc.).
~ t~ satisfactory level of acuity is not obtained in one or both eyes.
0 Stereoscopic acuity is unsatisfactory/absent.
@ Lat~nt hyperopia or pseudomyopia is suspected.

Should I use an anesthetic first?

· Cycloplegics sting and very few children seem entirely grateful
for the experience. This can be ameliorated somewhat hy the use
of proxymetacaine 0.5 percent, a local anesthetic. This stings
rather less than the other local anesthetics used on the. eye, and
will remove the sting of the subsequent cycloplegic entirely.
A further advantage is that the absorption of the cycloplegic will
Figure 7. 7 Severa! portable models of autorefractors have found use in be enhanced. Proxymetacaine is available in minims, but it m~eds
child screening programs to be stored in the fridge, which is not possible at all practices.
 ·t,
:-~
!',j
,!

•·· Objective refractlon Cycloplegic refraction

~'- •.· ;·.•¡,~;
.....
.·.rJ
il?·
'./

--
~..: . 1
..~ :~- --
The only other drawback would be lf the patlent dld not llke the Table 7.6 Comparlson of atroplne, cyclopentolate
96 first drop, and declded to resist the instillation of the second. and troplcamlde · 97
Onset of Tonus
Which cycloplegic? adequ~te Duration of Du,ration of. allowance -
~gent cycloplegla cycloplegla mydrlasls needed?
At one time it was common practice to hand out atropine sulfate rlJ:.;
, ~troplne 36 hours 7-10 days 10-14 days Yes (?)
to the patient's parents to administer at home for three days prior ,i~s
to the examination. In these less innocent times, this potentially fatal >f,}~~. · <;:yclopentolate 30-60 Up to 24-48 hours Nq
hallucinogen has become rather less popular in th'e high street and minutes -. · 12 hours
patients requiring it would normally be referred to a specialist clinic. ;Jt! .!roplcamide 30 minutes 2-6 hours 8-9 hours No
Cyclopentolate is the most popular cycloplegic agent.
The 1 percent solution is suitable for most patients. One drop
1·
is usually enough, but for patients with dark iridies a second drop
may be needed if nothing seems to be happening after 15 minutes.
lt does not produce absolute cycloplegia, but the residual
accommodative tonus is less than 1.50 diopters. No "tonus
l1
• Sitting on mother's lap is a safe place to be for most small
children.
,.,; The chil d might move fairly suddenly, and you don't want to
allowance" needs to be made, so you can prescribe the "full cyclo" sú;k a minim in their eye. lf they are cooperating, get the
if you need to (and only if). The 0.5 percent solution is needed for r:;:.::kmr. w look-down, raise the upper lid gently with yo.ur
children under 3 months, though few would be encountered in ::;,\::;íi'Ú: :1:,·1d keep the neck of the minim against the thumb
the general ophthalmic services. 0
,kf\ z r.::,tí k1stlll the drop. lf the patient moves, so does your
Tropicamide 1 percent has been found to be a useful, if short- ·,:i:-:,•~r; ·1i•, :and so w ill the minim.
acting, cycloplegic for patients in their late teens and older. In adult 1: i:i ';\; ,, d 1ild w ill not open their eyes a variation of an old
patients, the short duration is a virtue and this is the ideal agent -:(:' 1t;1ct !ens trick can be useful. While trying to raise the
to investigate the adult patient who you think might be a latent upper lid with your thumb, out of the blue say "Now, open
hyperope or a pseudomyope. Two drops, approximately 5 minutes :(Our mouth as wide as you can!" lt's almost impossible
apart followlng proxymetacaine, is generally recommended. to open your mouth wide and clase your eyes tight at the
See Table 7.6 for a comparison of atropine, cyclopentolate and same time.
tropicamide. • lf the child doses their eyelids and steadfastly refuses to open
them, three drops on the upper lashes at the lid margin will
How do I get the drops in? generally ensure sorne drops enter the eye.
Children are rarely tremendously keen on having drops put in.
• Explain what you are going to do in a calm way.Avoid words
like "sting" and "pain".Tell the patient that the drops "might
feel a bit funny''.Try to avoid lying to the child.
• Watch your body language, as children are rather good at
reading it. You need to be sending out the signals that
reinforce your spoken advice.