CLINICAL OPTOMETRIC PROCEDURES

SUBJECTIVE REFRACTION
WHAT IS SUBJECTIVE REFRACTION?

• Subjective refraction determines “the

refractive status of the eye” by subjective
means (requires patient’s response)
• Determine best spherical and cylindrical
lenses to provide best VA with
accommodation relaxed.
• Technique is subjective  therefore does not
always represent full refractive status of the
patient
WHAT IS SUBJECTIVE REFRACTION?

• Discrimination between dioptric changes

differs from individual to individual
• Influenced by:
− Intelligence
− Past experience
− Accustomed visual imagery
− Uncertainty in discriminating small differences
(Benjamin, Borish’s Clinical Refraction, Butterworth-Heinemann, 2006)

• Malingers can mislead examiner

− Due to preference for spectacles as a fashion
item, seeking attention, etc.
FACTORS INFLUENCING PX PERFORMANCE
ON SUBJECTIVE REFRACTION

• Health status of the eye

• Systemic health
• Use of medications or drugs with ocular and visual effects
• Age of the patient
• Extended depth of focus of a small pupil
• Choice of target, its distance and composition
• Room illumination
• Physiological pupil size and retinal adaptation
• Time allowed for discrimination between lens changes
 INSTRUMENTATION

• Trial case and trial frame

− Readily available
− Useful for demonstrating
final Rx, especially for
near work or for high
amounts of refractive error
• Phoropter
− Expensive
− Designed to allow a broad
range of tests including
binocular vision tests
USE OF A TRIAL FRAME AND LENSES

• Based on:
− Age of patient
− Refractive status of patient
− Compactness of instrumentation
• Trial frame preferred:
− High refractive error (RE)
− Vertex distance
− Pantoscopic angle
TYPES OF SUBJECTIVE REFRACTIONS

• Monocular
• Involve occlusion of non-tested eye
• End point of refraction requires accommodative balance
• Ideal in cases of:
− Strabismus, Px blind in one eye, uni-ocular
• Binocular
• Sometimes preferred because:
− Eyes in normal state of binocularity
− Accommodative state more stable and relaxed
for distance viewing
STEPS IN SUBJECTIVE REFRACTION

Best vision sphere OD Best vision sphere OS

Duochrome OD Duochrome OS

Astigmatism Astigmatism
Determination OD Determination OS

Binocular balancing
 STARTING POINT OF SUBJECTIVE
REFRACTION
• Starting point of monocular Objective
subjective refraction refraction

− Objective techniques
Best vision sphere OS
• Retinoscopy
• Autorefraction.

• Findings (lenses) placed in Duochrome OS

TF or phoropter
Astigmatism
• Alternatively Determination OS

− Refraction can begin from

Binocular balancing
Pxs previous Rx
 PLACEMENT OF TRIAL FRAME

Trial frame centered before the eyes.

 OBJECTIVE OF SUBJECTIVE
REFRACTION
Maximum plus
or
Minimum minus spherical lens power
↓
provides Px with maximum VA
 BEST VISION SPHERE (BVS)

• Accommodation must be in Objective

refraction
passive position
Instrumentation Best vision sphere OD

• Visual acuity chart

Duochrome OD
• Trial frame and trial case
(or a phoropter) Astigmatism
Determination OD

Binocular balancing
 BVS PROCEDURE

• Determine best monocular unaided VA for OD

(if no objective or previous Rx )
• OS is occluded
• Select a letter on line above best VA of OD
as target for BVS
• Plus and minus lenses used as probe lenses
• Dioptric value of probe lens depends on Pxs VA
(table below)
VA Probe lens
6/60  1.00D
6/12  0.50D
> 6/12  0.25D
 PROCEDURE FOR BVS
Shown first + lenses - lenses
with or without

Plus preferred

Place in TF

Continue adding + lenses

asking which lens is

“Clearer and sharper”

Stop when letters

become blurry

Remove +0.25DS that

causes blur
 PROCEDURE FOR BVS
Shown first Shown second
+ lenses - lenses
with or without without or with

Plus rejected Minus accepted

Place in TF
No more plus presented
Continue adding - lenses
asking which lens is
Move on to present
“Clearer, sharper, darker”
minus lenses

Check VA
with lens changes

Stop when letters become smaller or

no change in VA

Remove last -0.25DS

CORRELATION BETWEEN RE AND VA
REFRACTIVE ERROR (D)
VISION SPHERICAL
ASTIGMATISM
Myopia and absolute Hyperopia
6
/6 = 20
/20 Small Small
6
/9 = 20
/30 0.50 1.00
6
/12 = 20
/40 0.75 1.50
6
/18 = 20
/60 1.00 2.00
6
/24 = 20
/80 1.50 3.00
6
/36 = 20
/120 2.00 4.00
6
/60 = 20
/200 2.00 to 3.00 High
 MONOCULAR BALANCING
TECHNIQUES
Objective
Duochrome / Bichromatic refraction
techniques
• Involves determination of Best vision sphere OD
maximum plus and minimum
minus lens that places the circle of
Duochrome OD
least confusion on the retina.
• Check-test for BVS Astigmatism
Determination OD
• Uses different refraction angles
associated with different
Binocular balancing
wavelengths or colours of light
 PRINCIPLE OF DUOCHROME

• Human eye not corrected to focus different

wavelengths of light at same image point
• Eye suffers axial and transverse chromatic
aberration
• Axial aberration used to determine
spherical ametropia of the eye.
 PRINCIPLE OF DUOCHROME

• Green light (535nm) refracted at greater

angle than red light (620nm)
− Green light focus 0.20D before retina
− Red light focus 0.24D behind retina
• Yellow light (570nm) focused on retina
 EMMETROPIA

• Red and green

foci equidistant
about retina
• Emmetrope reports
seeing black test
objects on two
coloured backgrounds
equally clearly
 MYOPIA

• White (yellow) focus of low myope falls

before retina
 myope sees test objects on red background
clearer and darker
 HYPEROPIA

• White light focus of hyperope falls

behind retina
 hyperope sees test objects on green
background clearer and darker
 POINTS TO NOTE

• Older patients
− Crystalline lens becomes yellow  causing
absorption and scattering of blue-green light
 red bias
• Red-green colour deficiency will not alter results
of test
 Protonopes may see red half of target not
as bright as other half
 Practitioner must stress darkness of letters
 DUOCHROME TEST TARGET

• Distance VA chart with

− black letters or symbols
− split into identical halves
• Letters/shapes on one
side have green
background
• Letters/shapes on other
side have red
background
 DUOCHROME PROCEDURE
• Monocular test.
• Room lights off
− Test utilizes chromatic aberration which is
greater with pupil dilation
• Px directed to duochrome test target.
• Px instructed to report which numbers
appear “darker, sharper and clearer”?
− either 72 or 27 or
− numbers on the right or left
• Ensure Px understands you referring
to clarity of black test objects and not
colour of backgrounds
 DUOCHROME PROCEDURE

• If targets on red background appear darker, clearer or sharper

− add –0.25DS before the eye being tested
• If same target is still clearer
− add further –0.25DS lens until targets on both backgrounds are equally
“dark and sharp”
• If targets on green background appear darker, clearer or sharper
− add +0.25DS before the eye being tested
• If same target is still clearer
− add further +0.25DS lens until targets on both backgrounds are equally
“dark and sharp”
• If spherical Rx is inaccurate by > 1.00D patterns will be grossly out of focus
− reliable result will not be achieved
• Once monocular balance is achieved in one eye, the test is repeated for the
other eye
ASTIGMATIC ERROR DETERMINATION

• Astigmatism Objective
refraction
refractive condition with variation
of power in different meridians of
the eye Best vision sphere OD
• Caused by differences in curvature of
the refractive surfaces of the ocular
Duochrome OD
media
 cornea and lens
Astigmatism
• Corneal astigmatism Determination OD

− Regular: principal meridians lie at 90

Binocular balancing
− Irregular: principal meridians lie at
oblique angles
 ASTIGMATISM

• With-the-rule (WRT) astigmatism: curvature of

greatest power lies nearest the vertical meridian (A)
• Against-the-rule (ATR) astigmatism: curvature of
greatest power lies nearest the horizontal meridian (B)
• Oblique astigmatism: the meridian of greatest
curvature lies in the oblique positions
INTERPRETATION OF FINAL RESULTS

Compound Simple Simple Compound

Mixed
myopic myopic hyperopic hyperopic
astigmatism
astigmatism astigmatism astigmatism astigmatism

One line One line One line

focuses on the focuses in front focuses on the
Both line foci Both line foci
retina while the of the retina retina while the
focus in front of focus behind
other focuses in while the other other focuses
the retina the retina
front of the focuses behind behind the
retina the retina retina
 METHODS OF ASTIGMATISM
DETERMINATION
• Cross cylinder technique
• Fan-and-block method
• Clock dial method
• Stenopaic slit method
• Choice of technique employed depends on
practitioner and instrumentation and charts available
• Most commonly performed technique is the cross
cylinder method
 STARTING POINT OF TESTS

• Test begins after determination of spherical component of Rx

• Begins when “circle of least confusion” is placed on the retina
(achieved by duochrome test).
What is the circle of least confusion?
• Astigmatic focus consists of:
− Vertical focal line = focus of horizontal principal meridian
− Horizontal focal line = focus of vertical principal meridian
• Region between two lines = conoid of Sturm or Sturm's interval
• Dioptric mid-point between two focal lines = circular patch  circle of least
confusion
• Location of circle of least confusion = spherical equivalent of Rx
 CROSS CYLINDER TECHNIQUE

Instrumentation
• Jackson Cross cylinder
• Trial frame
• Trial lens set with minus
cylindrical lenses
• Visual acuity chart
 PROCEDURE

• Monocular test
• Select an appropriate target
− Circular letter one line above the best visual
acuity of eye being tested
• Position Jackson Cross Cylinder (JCC)
before patient’s RE
• First step = bracketing
− quadrant within which axis lies
 BRACKETING

• Introduce JCC such that power lines (red/green)

lie at 90 and 180
• Ask Px in which position circular letter appears ‘rounder,
clearer and sharper’.
− Note position of red line
• Next place JCC with power lines along 45 and 135 and
repeat question
− Note position of red line
 You now have a 45 bracket in which the axis lies
• Introduce a trial cylinder lens –0.25DC midway in 45
bracket
 DETERMINATION OF
CYLINDER AXIS
• If Px does not prefer any presentation of bracket,
e.g. 90 or 180
− Ignore these brackets
− Assume bracket lies around 45 or 135 and verify
• When refining cylinder axis
− Handle of cross cylinder is parallel to axis line corresponding
to trial cylinder
− Ask Px which presentation appears ‘rounder, sharper and clearer’
− Trial cylinder moved in direction of red line (minus cylinder axis)
• End-point of axis determination  both axis positions are
equal / same or Px moves back and forth about a
specific position
 DETERMINATION OF
CYLINDER POWER
• Follows end-point of axis determination
• JCC held with power lines parallel to axis marking on trial
cylinder
• Px asked which lens (+0.25DC or –0.25DC) makes the letters
"sharper, clearer and darker”
• If Px chooses +0.25DC  Px rejects cylinder  only needs
spherical Rx
• If Px chooses –0.25DC  increase cylinder power
from –0.25DC to –0.50DC
• Continue adding –0.25DC until patient rejects last
–0.25DC added
•  remove last -0.25DC
 RULE OF THUMB

FOR EVERY 0.50DC CHANGE IN CYLINDER POWER,

ONE NEEDS TO ADD A +0.25DS LENS

• Rule applies to shift circle of least

confusion back onto retina
• Once cylindrical error of RE is determined,
RE is occluded procedure is repeated
for LE
 FAN-AND-BLOCK METHOD

Equipment
• Fan and block chart
• Trial lenses
• Trial frame
 PROCEDURE

• Monocular test
• BVS must be in place
• Plus lenses added in 0.25DS steps until VA decreases by 1
line
• Direct Px to fan chart
• Px asked which lines on the fan appear “clearer
and darker”
• Arrow that joins the blocks is orientated toward
clearest line
• Arrow adjusted until its 2 arms are equally clear
• One block should be clearer than the other
 PROCEDURE

• If Px reports all lines equally clear or blurred

 Fog target with further +0.50DS
 Ask Px again if any lines appear “clearer & darker ”
 If they remain equally clear or blurred  no
astigmatism present
• If astigmatic component found
 Cylinder axis in trial frame is set to axis indicated by arrow
 Negative cylinder added at this axis until blurred block
becomes as clear as the other

• Add cylinder power found from retinoscopy

 CLOCK DIAL CHART METHOD

Equipment
• Clock dial chart
• Trial lenses
• Trial frame
 PROCEDURE

• Chart presented to Px with sufficient fog

• Axis of correcting cylinder is determined
− Ask Px if he or she can see in any or all spokes
− Ask if there is an area that is clearer
− Px reports which spokes (3 lines) are sharpest
or most distinct
• If Px reports spokes between 3 to 9 o’clock
are clearest
 axis = 3 x 30 = 90
 PROCEDURE

• Power determined by adding minus

cylinder in 0.25DC steps along axis
determined above
− Px reminded about distinctness of lines
in spokes along 2 principal meridians
e.g. compare spokes along 12 to 6 o’clock
to 3 to 9 o’clock
 PROCEDURE

• Px with WTR astigmatism

− Minus cylinder power with axis along horizontal meridian  moves
horizontal line focus closer to retina together “circle
of least confusion”
− Vertical line focus not altered
• When sufficient minus cylinder power added horizontal and
vertical line foci lie in same place  collapses the Conoid of
Sturm
 Px reports spokes of both principal meridians equally clear
• Cylindrical power added in -0.25DC until reversal occurs
e.g. Px initially reported 12 to 6 o’ clock spokes
 Now reports 3 to 9 o’ clock spokes are clearer
 STENOPAIC SLIT METHOD

Instrumentation
• Trial case with stenopaic slit of 1 mm width
• Trial frame
• Trial lenses
 PROCEDURE

• Monocular test
• Px directed to distance VA chart - letter above the
best VA
• Spherical Rx in place
• Eye being tested fogged by +1.00 to +1.50DS lens
• Stenopaic slit introduced before fogged eye
• Slit rotated until Pxs best vision found = minus
cylinder axis
• Lenses before fogged eye reduced until best
VA achieved
 PROCEDURE

• Power remaining in trial frame recorded on optical cross

• Axis lies parallel to the slit orientation
• Slit rotated 90 or until Px reports position of worst acuity
• Reduce fogging lenses in this position until best
VA achieved
• Record resultant power on optical cross
• Transpose power into spherocylindrical format
• Best VA measured through this Rx
• Procedure repeated for LE
BINOCULAR BALANCING TECHNIQUES

• Aim:
− To equalize accommodative effort exerted
during habitual gaze by 2 refractively
corrected eyes on binocular Px’s
• Cannot be performed when:
− Px suppresses one eye
− Strabismus exists
− Px has only one eye
 METHODS FOR BINOCULAR
BALANCE TECHNIQUES
1. Equalization by alternate occlusion
2. Prism dissociation method
3. Fogging method (Humphriss)
4. A method using a Septum (Turville)
5. Polarization method (Vectographic)
6. Dissociated duochrome method
 EQUALIZATION BY
ALTERNATE OCCLUSION
• Simplest methods of binocular balancing
• Add plus lenses binocularly till Px barely sees
20/30 line or 2 lines above best binocular VA
• Examiner performs slow alternate occlusion
• Px compares legibility of letters between 2 eyes
• End point is equal acuity between 2 eyes
• If one eye clearer than
 plus lenses added in +0.25DS steps before clearer
eye to equalize the blur
 PROBLEMS WITH TECHNIQUE

• Comparison drawn from memory

• No allowance for Pxs with unequal
maximum VA between 2 eyes
• Alternate occlusion must be
performed slowly
• Each eye may assume monocular
accomm. status when alternately occluded
 FOGGING METHOD

• Also known as Humphriss Immediate

Contrast Test
Instrumentation
• Trial frame and trial set (or phoropter)
• Distance visual acuity chart
 PROCEDURE

• Binocular technique
• Direct Px letter/s on line above best corrected acuity
• Place +0.75 / +1.00DS fogging lens before the LE
(can be higher)
• Fogging verified: lens should blur 3-4 lines on chart
• Present +0.25DS lens (lens 1) over RE, replace
with –0.25DS lens (lens 2) and once again revert to +0.25DS
lens (lens 1)
• Px asked to compare lenses 1, 2, and 1
• Px must report which lens makes target “clearer, sharper and
more comfortable to look at”.
 PROCEDURE

• If Px reports lens 2 better  add

–0.25DS lens
• Present lenses 1, 2 and 1 again
• End point:
− Px reports view through both lenses is the same
− Reversal
• Once RE Rx balanced, fog RE and perform
procedure on LE.
 POINTS TO NOTE FOR HIC

• Binocularity has to be intact - no tropia

• No greater than 2 line VA difference
between 2 eyes