THE DYNAMIC

RETINOSCOPIES

I
„ Kenneth C. Koslowe, O.D., M.S. INTRODUCTION limited variability. The static retinoscopy
technique is performed with the patient
Hadassah Academic College, School of Optom-
t became apparent to me and fellow
fixating a target placed at optical infinity
etry, Jerusalem educators of the need to better ex-
or with accommodation otherwise relaxed.
Bar Ilan University Department of Optometry plain the plethora of tests collectively
Ramat Gan, Israel The basic mechanics of retinoscopy and
known as near or dynamic retinoscopy.
explanation of the various motions are
Some practitioners and students may be
comprehensively and clearly explained
Abstract unaware of the development of these tests.
elsewhere.1 (pp. 659-95)
Dynamic retinoscopy techniques have Further, some may wonder why so many
Starting in the early 1900s, various inves-
long been a part of standard optometric variations have evolved of what appears
tigators began utilizing the retinoscope to
practice. Over time numerous techniques at first glance the same clinical probe. It
determine the amplitude or status of ac-
have been added and methods have been is noteworthy that while the basic premise
commodation in non-verbal patients. It
modified. The purpose of this paper is to and procedure for each of these tests have
was during this time the term dynamic ret-
provide some background into the various remained fairly constant, variations have
inoscopy emerged.1 (pp. 697-713) It has come to
techniques as to purpose, standard meth- evolved. This paper addresses these is-
mean a retinoscopy technique performed
odology and application. The student or sues to facilitate the understanding of the
where the patient fixates a near object but
new practitioner is often puzzled by the tests and enlighten the readers to the use
should not be confused with Mohindra
number of possible retinoscopy probes of these respective techniques.
Retinoscopy. The Mohindra Retinoscopy
and the one to apply for a specific patient. A Brief History of Dynamic is performed at near on infants or very
In addition many optometrists have lost Retinoscopy young children. In this procedure the sub-
sight of the value of any or all of these The retinoscope is actually an outgrowth ject monocularly fixates on the light from
techniques. It is hoped that this review will of the ophthalmoscope. In 1861, Wil- the retinoscope, but the object of the test
enable more students and optometrists to liam Bowman noted the changes in is to estimate the infants’ refractive condi-
use and understand these valuable tech- light and shadow that occurred within tion at distance.2
niques. the pupillary border when he tilted his A.J. Cross3 is credited with introducing
ophthalmoscope. Meagan publicized the the basic theory and method for dynamic
Key Words method while Parent introduced the ap- retinoscopy. Others who elaborated on the
cognitive demand, dynamic retinoscopy, plication of lenses to allow a quantita- theory and procedure were Sheard,4 Nott,5
lag of accommodation, lens prescribing tive measurement rather than simply a and Skeffington.6 Once the technique be-
qualitative judgement.1 (pp. 659-95) The basic came more popular, some optometrists
principle is Foucalt’s knife edge method developed variations based on their par-
of determining the focal power of a lens ticular model of vision.
with the refractive status of the eye being Aside from the initial goal of using dy-
considered an unknown lens.2 Thus, in namic retinoscopy to determine accom-
theory, the refractive power of the eye can modative response, the goals of various
be determined by locating its conjugate techniques came to include factoring in
focus in space. In practice, the concept the near phoria. It also helped determine
works much better with an optical bench the most appropriate near prescription
than with a human eye. The first applica- with testing conditions ranging from
tion of retinoscopy was the objective and minimal to more complex cognitive de-
quantitative determination of the distance mands. The two major variables in these
Koslowe KC. The dynamic retinoscopies. J Behav refractive status (static retinoscopy) with tests are the clinical purpose and the level
Optom 2010;21:63-67. accommodation either inactive or with of cognitive demand. Cognitive demand
Journal of Behavioral Optometry Volume 21/2010/Number 3/Page 63
is inferred by the task the patient is asked Table 1. Summary of Dynamic Retinoscopy Techniques
to perform while the retinoscopy is be- Test Aspect assessed Cognitive Target location Expecteds
ing completed. Consequently, a number demand
of procedures have evolved based on the
interplay of these variables. Some of these Monocular Positioning of Moderate 16 inches (40 +0.50
Estimate accommodation rela- cm) or Harmon
techniques will be discussed with regard Method (MEM) tive to convergence distance for
to: purpose, cognitive demand, materi- some youngsters
als, procedure, interpretation and clinical Nott Dynamic Positioning of Moderate 16 inches (40 +0.50
utilization. (Table 1) None of these tech- accommodation rela- cm)
niques are designed to determine the ac- tive to convergence
commodative amplitude.
OEP #5 Positioning of Moderate 16 inches (40 Evaluated in
I. Monocular Estimate Method accommodation in cm) comparison to
(MEM) Retinoscopy space test #7
Purpose and Cognitive Demand Bell Positioning of Low 20 inches (50 With motion at
This technique was attributed to Dr. Har- Retinoscopy accommodation rela- cm) at start of 14-17 inches
old Haynes at the Pacific University Col- tive to convergence testing changing to
lege of Optometry.7 It is a method that against
motion at 15-
gives an estimated measure of the spa-
18 inches
tial positioning of accommodation with
Stress Point Response to stress Moderate 20 inches (50 Stress point
regard to where the eyes are postured in
(Kraskin) to high cm) at start of at least 10 cm
space (convergence). Thus, there can be a testing closer than Har-
lag, a lead, or the two visual components mon Distance
can be coincident. The cognitive demand Book (Getman) Level of Visual High Habitual Near Task related
is moderate. Processing Working
Materials and Procedure Distance
A spot retinoscope or streak retinoscope
with the sleeve in the down position is nique requires leaving the lens in place for tient. The procedure was first performed
the basic instrument. The targets used less than one full second. This technique in and more recently, both in and out of
here are a series of cards with a central is then repeated on the fellow eye.8-10 the phoropter. The patient wears his com-
aperture, mounted on a retinoscope. The Interpretation and Clinical Utilization pensating distance lenses and is directed
cards can have printed letters, or words, In most cases, there will be a “with” reflex to read the letters. The examiner performs
or pictures that range in size from 20/160 (assuming the use of a spot retinoscope or retinoscopy by moving farther from the
(6/120) to 20/30 (6/9). The targets are ar- a streak retinoscope with the sleeve in the plane of regard until the motion is neu-
ranged around the aperture in a manner down position) corresponding to accom- tralized. The dioptric difference between
that facilitates the examiner’s position so modation postured farther from the pa- these two distances equals the lag of ac-
that retinoscopy is performed as close as tient than the stimulus.10 The amount of commodation. It is performed on each eye
possible to the visual axis. the “lag of accommodation” is the amount separately.21
The patient is seated. The target on the of plus lens that neutralizes the reflex. A Interpretation and Clinical Uutilization
retinoscope at 40 cm (16 inches) from the key here is that the amount of lens is esti- As with the MEM procedure, in most
patient or, in some cases with a child, is at mated based on the amount of movement cases, there will be a “with” reflex corre-
the patient’s Harmon distance. The patient observed. sponding to accommodation postured far-
wears their compensating lenses. This Although color and brightness changes ther from the patient than the stimulus. In
procedure is termed “monocular” because will be apparent in the majority of observ- addition to the measured accommodative
only one eye is scrutinized during the test- ers, this is not part of the evaluation.11 A lag, this method can be valuable in evalu-
ing; however, both eyes are open. The pa- number of studies have been performed ating the stability of the accommoda-
tient is instructed to keep the targets clear. to validate this technique. MEM has been tive response. This method is frequently
Often the examiner may request that the found to accurately measure the lag of ac- studied with and compared to the MEM
targets be read aloud to induce a greater commodation in an objective manner.12-19 method.12,14-26
cognitive demand. II. Nott Dynamic Retinoscopy III. Analytical Sequence Dynamic
The examiner sweeps the retinoscope Purpose and Cognitive Demand Retinoscopy (#5 and #6)
beam across one of the patient’s eyes This was developed by I. S. Nott in the Purpose and Cognitive Demand
and observes the motion of the retino- 1920s.29 The main purpose is identical to These two techniques (#5 and #6) are
scopic reflex. An estimate of this dioptric the MEM method, to give an objectively identical except for the distance where
movement is made and then the examiner measured estimate of the spatial position- they are performed. Very few optometrists
quickly interposes a trial lens at the spec- ing of accommodation with regard to perform the #6. Only the #5 procedure
tacle plane that is deemed sufficient to where the patient is converged at the same will be described here. This technique was
neutralize the reflex motion. time. The cognitive demand is moderate. developed in concert by a number of op-
The examiner should take care that the Materials and Procedures tometrists but was heavily influenced by
inserted lens changes the accommodative A reduced block of 20/20 (6/6) letters is the input of Dr. A. M. Skeffington.6
response as little as possible. This tech- placed at 16 inches (40 cm) from the pa-

Volume 21/2010/Number3/Page 64 Journal of Behavioral Optometry

The purpose of the procedure is not to scription. It is not meant to be interpreted closer to the patient there will be a point
prescribe the measured value but as a key by itself or to determine the amount of the where the motion changes from “with” to
finding in the analysis of “syndromes.” accommodative lag. This method has not “against.” The examiner should continue
Depending upon the syndrome found, the been the subject of extensive independent to move the target closer to the patient an-
comparison of the #5 to other findings al- study. other three to five cm. (1 - 2 inches) then
lowed the modification of the lens recom- IV. Bell Retinoscopy move the target away from the patient.
mended for both distance and near wear. Purpose and Cognitive Demand The “with” motion should again be seen
The cognitive demand is moderate. This method was developed over time, at some point.
Materials and Procedure mainly by Drs. W.R. Henry and R.J. Ap- Conceptually, the lag of accommodation
The target is a block of 20/40 (6/12) let- pel.23,24 It gives an estimated measure of as a linear measurement is being evalu-
ters or slightly larger if acuity demands. the spatial positioning of accommodation ated rather than with lenses. The distance
The letters are ideally arranged around with regard to convergence. Thus, there between the retinoscope and the target
an aperture to facilitate retinoscopy on or can be a lag, lead, or the two visual com- when the motion change occurs is a physi-
close to the visual axis. ponents can be coincident. It also allows cal measure of the lag of accommodation.
The instructional set follows. the examiner to view the results of chang- Typically we expect to see a change from
The lens power in the instrument es in this relationship when wearing a lens “with” to “against” at or about 35 - 42
would be found by the distance reti- at near. The cognitive demand is low as cm. (14 - 17 inches) and a change from
noscopy finding (the #4). The opera- the patient passively observes the target as “against” to “with” at 37 - 45 cm. (15 -18
tor positions himself 20 inches (50 it moves. inches). If the lag of accommodation does
cm) away. The fixation target con- Materials and Procedure not fall within these ranges, the procedure
sists of a group of small letters in Perhaps the most marked difference be- is repeated with various probe lenses of
close proximity to and in the plane tween this technique and previously dis- relative plus power until a lens combina-
of the retinoscope. The patient’s at- cussed techniques is the use of a three tion provides the desired change in spatial
tention is directed to the letters and dimensional viewing target. The retino- location.
he is again asked to read the various scope remains in a fixed position and the Lenses that normalize these ranges are
letters that the examiner indicates. target is moved. considered an acceptable near point pre-
Enough plus is added bilaterally to This procedure was named for a small, scription. Do not merely assume that a
the distance retinoscopy finding to highly reflective bell dangling from a lens calculated from the Bell Retinoscopy
cause a definite against motion in string that was used as a fixation target. measurements will have the desired ef-
all meridians.22 In practice, the bell has generally been re- fect. One should actually repeat the test
While the patient actively observes the placed with a Wolff Wanda (a reflective, with the suggested add, new anisometrop-
target the examiner sweeps the 180th me- gold or silver, ½ inch diameter, metal ball ic correction or cylinder in place.
ridian with a single, continuous motion of mounted on the end of a rod) or a trans- For example, it is possible at the begin-
the retinoscope, noting successively the lucent sphere. The wand is held by the ning of the procedure to find against mo-
right and then the left reflex. With added examiner so that the ball is at the patient’s tion even at 50 cm indicating over-accom-
plus power in place, “against” motion eye level and midway between the two modation. It is then appropriate to add
of both reflexes is anticipated. If this is eyes. The ball will be moved closer to plus lenses and re-perform the procedure.
not the case, increase the plus bilaterally and farther from the patient along this If the lenses lead to relaxation of accom-
until the 180th meridian of both reflexes midline. The retinoscope is positioned modation, a more normal reflex is seen.
shows “against” motion. Reduce plus in slightly above this line at a fixed distance The data gathered here is somewhat simi-
0.25 D steps, bilaterally, until “neutral” or of 50 cm. (20 inches) from the patient. lar in purpose to the Analytical Sequence
“with” motion is produced. If one reflex (Figure 1) Dynamic Retinoscopy but it does not re-
neutralizes sooner than the other, continue The patient fixates the target and the ex- quire comparison to other findings.
to reduce the plus unilaterally on the un- aminer notes the direction of the reflex V. Stress Point Retinoscopy
neutralized side. Record the lenses which with slight movements of the retinoscope. Purpose and Cognitive Demand
first give “neutral.” If there is no “neutral” The ball is moved toward the patient slow- This technique was suggested by Darell
(the reflexes go from “against” directly to ly and smoothly. Note any changes in the Boyd Harmon, Ph.D. and brought to
“with”), then record the last lenses which reflex. The examiner primarily observes fruition by Dr. Robert A. Kraskin.25,29 Al-
gave “against,” as the #5 finding. the motion of the reflex, but color and though it appears to be a similar technique
Interpretation and Clinical Utilization brightness changes can also be observed. to other methods, it is actually a radically
The #5 retinoscopy finding has no specif- The distance of the target from the patient different concept. The other techniques
ic meaning by itself until it is compared to when neutrality is seen is recorded when measure the patient’s accommodative
other findings as part of the total analyti- a change in motion, color or brightness is mechanism to learn how to alter accom-
cal examination. In many cases, the #5 observed. modation. Stress Point Retinoscopy pur-
will approximate the most plus lens that Interpretation and Clinical Utilization ports to evaluate the response of the en-
is acceptable at near. The patient, if given With a hyperopic patient or a person tire organism to stress. This is especially
time to acclimate to the lenses, may “free wearing compensatory lenses matching true at that level of stress that exceeds the
up” more accommodation resulting in more the distance refractive status we expect to capabilities of the organism. At the stress
plus acceptance. The resultant power gives see a “with” motion at the beginning of point, as the reaction of the organism
an indication of the amount of plus accept- Bell Retinoscopy. As the target is moved changes from fight (trying to manage the
able at near in addition to the distance pre-
Journal of Behavioral Optometry Volume 21/2010/Number 3/Page 65
 Figure 1. A Device for Facilitating Bell and With Stress Point Ret- the optometrist to gain insight into where
Stress Point Retinoscopy inoscopy, the clinician stress begins for the individual.
is measuring a vol- VI. Book (Getman) Retinoscopy
ume of space inside Purpose and Cognitive Demand
the patient’s Harmon Book Retinoscopy was developed at the
distance where the vi- Gesell Institute of Child Development at
sual process is active. Yale University. While numerous optom-
During this “on” or etrists and other professionals aided in its
“engaged” phase, the development, it is most identified with Dr.
reflex remains bright, Gerald Getman.32 Originally, this type of
although there may testing was developed to obtain informa-
be a slight sense of tion about the visual processing of non-
increased brightness verbal infants. Later optometry began to
the closer the target apply the technique with many types of
approaches the stress patients. Kruger’s29,30 work is quite sup-
point. The stress point portive of this method of retinoscopy. Its
then defines the inner major purpose is to evaluate the subject’s
limit of space where cognitive processes when reading. The
The Bell can slide either closer to or further from the patient. Reproduced vision is function- cognitive demand is high.
with permission from Vision Therapy Equipment (VTE) ally comfortable. Dr. Materials and Procedure
Kraskin felt that one This technique is performed at the pa-
demand) to flight (abandoning the attempt observes ONLY brightness changes and tient’s habitual near working distance
to meet the demand level). The cognitive color changes are merely a side effect of while their habitual compensatory lenses
28
demand is moderate to high as the target brightness changes. are worn. The patient is given reading ma-
is invading the patient’s space. The validity of evaluating changes in the terial at varying levels of difficulty. Reti-
Materials and Procedure brightness of the retinoscopic reflex was noscopy is performed over the top edge
The technique is performed with the ha- demonstrated elegantly in 1977 in two of the material, as the subject reads aloud.
29.30
bitual prescription in place in free space 31 studies by Kruger. In those studies a One should start two grade levels below
as the patient observes a Wolff Wand held photo-electronic retinoscope was used, the child’s reading level. Alternatively,
directly above the retinoscope, just out- attached to a photometer rather than a hu- a series of cards (usually from the Gray
side the patient’s Harmon Distance. With man observer. Kruger concluded that the Oral Reading Test) can be used. The test
Stress Point Retinoscopy the retinoscope changes were due to changes in accom- is meant to be performed at the child’s
is not moved but rather is held station- modation. However, an alternative expla- habitual near working distance.33 The ad-
ary, centered on the pupil of the patient’s nation has been proposed that the cause of vantage of this technique is that informa-
eye. The target is moved toward the pa- the shift in luminance may be a change in tion is gathered in real time with a task
tient. (Figure 1.) Changes in luminance the reflectance of the retinal tissue in re- that is close to their normal work situa-
are observed. There should a very brief sponse to the neurological response from tion. The examiner should strive to stay as
31
large increase in the brightness of the fight to flight. Individual nerves cells do close as possible to “on visual axis” while
reflex that is often very difficult to see, change reflectance roughly proportionally the child reads.
followed by a “dulling” of the reflex as to the frequency firing of action poten- Once the reading level baseline is ob-
31
this point is passed. This second reflex is tials. tained, plus lenses over and above the dis-
much easier to see as it becomes the new The point between the examiner and the tance findings are used to see if changes
baseline luminance. The procedure is re- patient where this change occurs is the occur. The amount of plus can be based on
peated a number of times through various point where the individuals’ visual behav- other test results such as the fused cross
probe lenses (bilaterally similar low plus ior apparently shifts from fight to flight. cylinder or a practitioners own “standard”
lenses) and the different distances are re- The distance where the change occurred is probe lenses.
corded where the stress point change oc- noted. Probe lenses are then introduced to Interpretation and Clinical Utilization
curs through each lens. change shift this stress point. The goal of Getman and Kephart described the follow-
Interpretation and Clinical Utilization this procedure is to find the lens that brings ing response levels with this technique:34
As the wand is brought towards the pa- the stress point closest to the patient. Very A. Free reading level: Desirable, The re-
tient, inside the patient’s Harmon distance, low powered plus lenses tend to shift the flex varies from neutral to with and is
the patient must change how they are see- stress point closer to the patient. At some bright and sharp and pinkish. At this
ing, to remain engaged with the target. In point, the stress point stops shifting closer stage the subject is reading and com-
different patients this is accomplished in to the patient and will actually begin shift- prehending the material easily.
different ways. Some may show outward ing outwards from the patient. Kraskin B. Instructional level: This is more de-
signs of increased effort, some may only considered the lens that brought the stress manding than the free reading level.
show a shift in the vergence position of point closest to the patient, the optimum The reflex is a varying, fast against
the eyes with little or no other observable lens and often prescribed this as the near motion while the color is bright, sharp,
shifts, some may show pupil changes. lens. Thus, instead of looking for an op- very pink and fluid.
tical phenomena, this technique allows

Volume 21/2010/Number3/Page 66 Journal of Behavioral Optometry

C. Frustration level: Even though the sub- est among ophthalmologists of dynamic 15. McClelland JF, Saunders KJ. Accommodative
ject is “focused” on the page he is not retinoscopy.35,36 lag using dynamic retinoscopy: Age norms for
school-age children. Optom Vis Sci 2004;81:929-
interpreting the information properly. In the final analysis, this review can serve 33.
A very slow with motion and a dull, as a guide to both new and experienced 16. McClelland JF, Saunders KJ The repeatability
brick red color is seen. practitioners in deciding the best retinos- and validity of dynamic retinoscopy in assess-
ing the accommodative response. Ophthalmic
Once the patient’s response has been de- copy technique for a clinical situation and Physiol Opt 2003;23:243-50.
termined at various demand levels, the how to use each depending on the patient 17. del Pilar Cacho M, Garcia-Munoz A, Garcia-Ber-
responses can be judged appropriate or or situation. Asking the right questions, nabeu JR, Lopez A. Comparison between MEM
deficient. The procedure can be repeated will help find and understand the answers and Nott dynamic retinoscopy. Optom Vis Sci
1999;76:650-55.
with appropriate plus lenses in order to as- you receive. 18. Leat SJ, Gargon JL. Accommodative response in
certain the effect of these probe lenses. Acknowledgement children and young adults using dynamic retinos-
copy. Ophthal Physiol Opt 1996;16:375-84.
Summary This review was based on lectures that 19. Locke LC, Somers W. A comparison study of
A number of techniques for using a retino- I give at Bar Ilan University and Hadas- dynamic retinoscopy techniques. Optom Vis Sci
scope have been described. Each method sah Academic College. They were then 1989;66:540-44.
is associated with a different optometric adapted by Drs. Paul Harris and Greg 20. Nott IS. Dynamic Skiametry, accommodation
and convergence. Am J Physiol Opt 1925;6:490-
pioneer whose insight helped to bring the Kitchener for an OEP Clinical Curriculum 503.
use of the retinoscope to the fore. It is course. After sending drafts of the course 21. Rouse MW, London R, Allen DC. An evalua-
important to note that there is no one right back and forth I can no longer ascertain tion of the monocular estimate method of dy-
namic retinoscopy. Am J Optom Physiol Opt
way to use a retinoscope and that none the parts that are solely mine and which 1982;59):234-39.
of these techniques should be thought to were adapted and edited by others. Special 22. Lesser SK. Introduction to Modern Analyti-
be necessarily better or worse than an- thanks to my mentor, Irwin Suchoff, O.D., cal Optometry. Optometric Extension Program
other. Each technique seems to lend itself and Paul Harris, O.D., for their constant Foundation Revised edition, 1974
23. Henry WR. Dangled Bell with Retinoscope. St.
to answer different questions about the assistance and guidance on this paper. Louis: Conference on Theoretical Optometry and
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Thus, it is advised that optometrists famil- a. OEP Foundation, 1921 E. Carnegie Ave., 3-L, OD, Cayucos, CA, 1959
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25. Kraskin RA. Stress point retinoscopy. J Am Op-
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to determine the size or range of the lag 12. Garcia A, Cacho P. MEM and Nott dynamic reti- Corresponding author:
of accommodation. Others may be more noscopy in patients with disorders of vergence
and accommodation. Ophthal Physiol Opt 2002;
Kenneth C. Koslowe, O.D., M.S., FCOVD-A
interested in when the system goes into
22:214-20. 10 Achimeir Stret
stress or if the patient is attending/under- 13. Jackson TW, Goss DA. Variation and correlation Petach Tikva, Israel
standing the visual material. Interestingly, of clinical tests of accommodative function in a 972-3-933-2991
while some optometrists feel that exper- sample of school-age children. J Am Optom As-
soc. 1991;62:857-66. [email protected]
tise and interest in these techniques has
14. Locke LC, Somers W. A comparison study of Date accepted for publication:
waned, there seems to be increasing inter- dynamic retinoscopy techniques. Optom Vis Sci
1989;66:540-44.

Journal of Behavioral Optometry Volume 21/2010/Number 3/Page 67