POST REFRACTION

TESTS
Beenish Latif
Mphil Optometry, FIACLE, DLP (AUS)
COAVS
Post-refraction tests
• Spherical verification
1. Plus one (1) blur test
2. Duochrome test
3. Pinhole test
• Cylinderical correction
1. Jackson cross cylinder
2. Fan and block test
Plus +1.00 Blur Check
• The plus + 1.00 D blur check is performed towards the
end of a subjective refraction to determine if a young
patient with accomodative capacity has been over-
minused or under-plussed, ie accomodating during the
course of their refraction.
• The blur test is usually performed after the best vision
sphere subjective assessment.
Procedure
1. Occlude one eye.
2. Place a +1.00 DS trial lens over the best vision sphere of
the testing eye.
3. If the original VA is 6/6 (the average for a young patient)
it should be reduced by four lines to about 6/18 with the
blur lens.
4. If the VA is better than 6/18 with the +1.0 blur lens, it
suggests the patient has been over-minussed ie
accommodating during the refraction.
•
If a myopic reads 6/9 after +1.0 blur lens then ?
•
If a myopic reads 6/36 after +1.0 blur lens then ?

If a hyperopic reads 6/12 after +1.0 blur lens then ?

If a hyperopic reads 6/24 after +1.0 blur lens then ?

Duochrome test
• Chromatic aberration, the basis of the test, occurs
because different wavelengths of light are bent to a
different extent.
• The duochrome test involves the projection of black
letters or symbols onto a bipartite green (at approximately
535nm) and red (at approximately 620 nm) background.
The red and green wavelengths are dioptrically
equidistant, approximately 0.25 D, from the yellow
wavelength (570 nm). The longer wavelength (red) is
refracted less than the shorter (green).
Principle
• It is assumed that best vision is attained when the yellow
wavelengths are focused on the retina. During the final
sphere adjustment, it is important to find the least minus
that a patient will accept in order to ensure that
accommodation is minimized, particularly in myopic
patients.
• The eye typically focuses near the midpoint of the
spectrum, between the red and green wavelengths. With
optimal spherical correction, the letters on the red and
green halves of the chart appear equally sharp.
Procedure
• Figure demonstrating different focus points on retina
• The patient is first assessed with refraction and given the
best correction.
• With that correction in the phoropter or trial frames in
place, the duochrome chart can then be projected.
• The test starts by occluding one eye (left eye first by
convention)
• Room lights must be turned off slightly dim in order to
allow the pupil to dilate which would allow for increase
chromatic aberration of the eye
• Ask the patient to compare the letters on green and red
sides of the test
• If the letters on the red side stand out more continue to
add more minus power using -0.25 DS steps
• If the letters on the green side stand out more continue to
add more plus power using +0.25 DS steps
• Neutrality is reached when the letters on both the red and
the green background appear equally distinct.
• If more than +/- 0.5D is required to balance then the test
is unreliable
continued..
• RAM–GAP mnemonic: Red Add Minus; Green Add Plus
• The Red-Green duocohrome test is traditionally
recommended to verify the spherical endpoint.
• Duochrome test is applicable to the color blind or color
deficient people as it is based on the chromatic aberration
of the eye.

• It may be used prior to determining the cylindrical

component of the refraction using a Jackson Cross
Cylinder (JCC) and subsequent to this determination.
• A rule of thumb:
• leave younger patients one step into the green,
• Older patients one step into the red,
Poll 1

• If a patient sees the green side more clearly

than the red side, what adjustment is needed?

• a) Increase the minus power (-)

b) Increase the plus power (+)
c) No change needed
d) Use a cylindrical lens
Poll 1

• If a patient sees the green side more clearly

than the red side, what adjustment is needed?

• a) Increase the minus power (-)

b) Increase the plus power (+)
c) No change needed
d) Use a cylindrical lens
Pinhole visual acuity
• The pinhole is an eye shield with several small holes that
allow light rays to reach the retina without the interference
of optical problems of the eye. It is an excellent way to
screen for uncorrected refractive errors and disorders of
the ocular media. However, young children, elderly
people, and mentally impaired individuals often have
difficulty using it.
Continued..
• The “pinhole effect” is an optical concept suggesting that
the smaller the pupil size, the less defocus from spherical
aberrations is present. When light passes through a small
pinhole or pupil, all unfocused rays are blocked, leaving
only focused light to land on the retina to form a clear
image.
• In contrast, patients who have very large pupils, whether it
is physiological or from pharmacological dilation,
experience image “ghosting,” or a blurring halo around an
otherwise sharp image.
Jackson cross cylinder

• In 1887, Edward Jackson described a method of detecting

astigmatism using modified Stokes’ lenses. He further
modified this in 1907 to detect the axis of astigmatism by
using a cross cylinder. This cross-cylinder lens with a
handle is called Jackson's cross-cylinder (JCC).
• JCC is a spherocylindrical lens in which the
power of the cylinder is double the power of
the sphere and of opposite sign e.g.
+0.5DS/-1.0DC or +0.25DS/-0.5DC.

• JCC are available in different powers including +/-1.00,

most commonly used are of +/- 0.25 and +/- 0.50.

• There are dots or lines to indicate axis of minus and plus

powers.
• The cross-cylinder technique derives its name from the
fact that each of those cylinders can be considered as the
combination of two equal but opposite astigmatic lenses,
placed perpendicularly to each other.

• As the spherical equivalent of the lens is zero, placing it

in front of the patient's eye doesn’t change the position of
the conoid of Sturm, it can however reduce or increase
the astigmatic error.
• you take any power Jackson cross cylinder and
write it down in the prescription.
• 0.25 JCC = +0.25DS/-0.50DC X 90
• 0.50 JCC = +0.50DS/-1.00DC X 90
• 1.00 JCC = +1.00DS/-2.00DC X 90
• 2.00 JCC = +2.00DS/-4.00DC X 90

• The spherical equivalent of all the lens is zero,

• The technique of determining astigmatism power and axis
using a JCC lens. However, the same principle applies
when refracting a patient in the phoropter. The cross-
cylinder technique starts by detecting the astigmatic axis
first, then correcting the power of the astigmatism.
procedure
• Detecting astigmatism
• Best corrected vision with only spherical lenses is first
determined.
• The patient is asked to see a line that 1-2 lines larger
than the smallest line he/she can comfortably see.
• Then, a JCC lens of adequate power is placed, first with
axis along 180 degrees and then at 90 degrees.
• If no difference is seen between the two axes, then the
axis is changed to 45 degrees and 135 degrees
• If no difference is detected, then patient likely has no
astigmatism and one should proceed with refining the
spherical lens.
• Correcting the astigmatic axis
• The examiner holds the JCC instrument, with its handle aligning
with the projection of the astigmatic axis, thus the positive and
negative cylinder axes are straddling the astigmatic axis.
• By flipping the cross cylinder, the patient is asked to choose
one position better
• Position 1 or position 2
• an axis that is closer to the positive or negative cylindrical axis
of the JCC instrument.
• If the patient prefers the positive axis (for + cylinder lenses), we
turn the axis 5-10 degrees towards it and the opposite if the
patient prefers the negative axis instead.
• This process is repeated until the patient doesn’t notice any
difference. This is the correct axis.
• Correcting the power of astigmatism
• With the axis in place, the accurate power of the cylinder
can be determined. The positive axis of the JCC lens (for
+ cylinder lens) is turned parallel to the astigmatic axis. By
repeating the same process as previously,
• the astigmatic lens power can be increased or decreased
until the patient perceives no difference.
• Once the power of astigmatism is ascertained, the sphere
is adjusted to obtain best correction.
Astigmatism charts

• Two of the most commonly used astigmatism chart are

the Clock dial chart and the astigmatism fan chart. This
test well controls accommodation as fogging is done prior
and has an advantage over the Jackson cross cylinder
where one of the focal lines is behind the retina which can
disrupt the rest of the accommodation.
• Due to test complexity for both practitioner and patient, it
is less often used in clinical practice compared to the
Jackson cross cylinder. But becomes one of the essential
test when the Jackson cross cylinder fails.
Fan and block chart
• The Fan and block chart is similar to an astigmatism fan
chart but additionally includes a block which contains an
arrow at the center and two blocks of the line adjacent to
the arrow which are perpendicular to one another. This
additional block makes this test easier for the patient.
Procedure
Step 1: Determine the patient’s Best vision sphere and record visual
acuity.

Step 2: Add plus power (equal to half of approximated cylinder power

depending upon patient visual acuity.At this point, the patient should
have one set of lines in the chart more clearly compared to others, if
not add more plus power. Or fog patient using plus power until all lines
in the astigmatic fan chart appear to blur and slowly reduce plus power
in 0.25 D step till one set of lines becomes clear compared to the other.

Step 3: Read the correcting cylindrical axis from the chart and rotate
the arrow so it points towards a clear line. Ask the patient to only focus
on two blocks containing lines. Both block line’s orientations will be
perpendicular to one another.
Step 4: Add a minus cylinder lens with it axis similar to that
mentioned in the chart and simultaneously keep
questioning about equal clarity of the two blocks. The
examiner continues adding a minus cylinder lens until the
patient reports both blocks are equally clear.

Step 5: To determine whether you found the correct

cylindrical power or not. Add +0.50 DS and ask the patient
for the appearance of the two blocks. If both are equally
blur means astigmatism is fully corrected. If one block is
clearer than another it means astigmatism is still present.
Step 6: Remove additional +0.50 DS. Note down the final
power of the patient.

Step 7: Repeat a similar procedure for the left eye.