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21 Steps

 

Step No.  Titles
7A subjective Refraction at Near
lnduced Phoria Test at Far
9 True Adduction Test at Far
ID ...
21 Steps

 

Step No.  Titles

l3B+1.0D lnduced Phoria Test at Near +1.DDD
MA Uniused Cross-Cylinder Test at Near
1SA lndu...
Step No.  Titles

17B Negative Fusional Reserve

18A Vertical Phoria Test at Near

188 Vertical Duction Test at Near

19 A...
Purpose:  To determine the presence or absence of pathology
Intrument:  Ophthalmoscope

Methods:  1. Direct Ophthalmoscope...
ll

`Illr'~p'. 

1. Close the room light and switch on the ophthalmoscope. 

2. Use a 211.. ) z 1'~_1:a: ~ n for non-dilat...
Reflex l+l ROR (-l RDR
Media Clear Partial obstructian
CD ratio 0.8
Color pinkish-yellowis yellawish-orange
Margins distin...
Clinical Routine and observation

 

A.  Usually the eye is examined by direct aphthalmoscopy. 

B.  As the light is direc...
Clinical Routine and observation

 

C.  The Disc or Papilla

1. The size and lorm

- Located at the run. . N-. Diameter a...
Clinical Routine and observation

 

3. The margins

- The margins of the disc are usually sharply defined
and frequently ...
o.  The vessels

- The Veins
~ larger rmrl dar'- er blood vessels than arteries,  and their
surlaces do not ordinarily rei...
E.  The Fundus oculi

The color is almost a uniform red.  vorying ln shade with the general pigment irom a

light orange-r...
;. » -jiur i' -ru  a r l - rr/   Lprií 1 ~ ãJ. Ji~urr1-- 'ž/ 
purposeTn assess the rurvurure power.  and inriciiy ní the (...
Basic components

P Disanfect the chin rest und íoreheod rest wnth utcohol

 

D The patient remove his eyeglusses or cont...
Recording

 

~ Record for each eve sepnrately
~ Record the power and the meridian for the horizontal meridian lirst ll” m...
Calculation for radius

 

ExJ
OD 2 42500180 Fi!  OS :  47159180
4150990 47.259!! ! (Fill
-LOOMSO -050190

DD :  r - 3315 ...
Step#3 Habitual Phoria Test at Far

 

D Test Distance:  20 lt.  or 6 m. 
D Test Target:  Best VA in distance SneIlen's ch...
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'.  I `

Test Distance:  16" or 40 cm

Test Target:  Best VA in reduced SneIlen's chart
PD:  'pm lllumination:  ill,  hui ...
- Measures the tonic innervations oi a muscle oi a certain distance

- To determine the relative horizontal position of th...
Purpose: 

' To objectively determine the distance
reiractive status al the patients eye

- The results of this technique ...
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a---" __. __. _.. ..___   . .

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D Streak retinosc...
Set-up

 

- The patient removes his eyeglasses.  Disinfect px contact surlaces of the
phoropter. Retinoscopy is most easi...
Step by step procedure

 

l.  Instruct the px to look at the fixation target.  Examinethe px's right eye first

2. Determ...
Step by step procedure

 

a.  If the error is sphencal.  the reflex within the pupil wil be continuous with the intercept...
Step by step procedure-Neutralization

 

Refractive error Motion seen w!  Plane Motion seen wl Short Lens power needed

m...
Step by step procedure

 

4. The lens that produces neutrality is called the gross retinoscopy finding

S.  To convert th...
Recording

 

D Record the gross power of each meridian
Ex.  oo:  t” meridian =  +3.oo@9o
20 meridian =  +2.oo@1ao

P Comb...
Recording

 

- Record the net power for each eye seporately by subtroct the
gross power with the working distance (16" = ...
* NET #4 =  Gross#4 - WDE
=  Gross#4 - 2.50 (At 16")

'šivnmv um e*

P To study the accommodative and adductive response t...
Step#5 Dynamic Retinoscopy at 20"

 

P Purpose:  To objectively determine the near visual problem of the
patient's eye

P...
General Procedure

 

l.  See to it that the correct procedure is

 

followed. 
2. Instruct the px to look at the head of...
Recording

 

- Record the net power for each eye

separately by using this formula:  iarerosus - aa:  asos--toocvuieo

mi...
Recording

 

Record the px's VA for each eye through the net dynamic retinoscopy
finding (VAWJ niJtii)
Ex.0D:  +l. SDs= -...
Step#6 Dynamic Retinoscopy at 40"

- Purpose:  To objectively determine the intermediate visual problem
of the patient's e...
i.  See to it that the correct procedure is followed. 
2. Instruct the px to look at the head of the retinoscope

3. obser...
Recording

 

P Record the gross power of each meridian
Ex.  oo:  i” meridian =  +2.oo@9o
2” meridian =  +i. oo@i8o

P Cam...
Recording

 

- Record the net power for each eye separately - - - - - - - - - - - -

by subtroct the gross power with -D....
- Purpose:  To Subjectively determine the distance
refractive power of the patient's eye

- Test Distance:  20 ft.  or 6 m...
Auxiliary lens knob PD scale Strong sphere control
PD knob Spirit level

   
    
  
 
  
 
 
 

, lacksorrs unit

sphere ...
Procedure

 

I.  Stort wnth OD and occlude OS
z Present the protected Snelerfs chart und Iet me P:  reun the vrrullest am...
Place the tentative axls on the axis scole. 

Add cyhdrlcal power until all lines are equal ( blur or dark)

Unlog the Px ...
Procedure

 

Il.  Check the spherical Power (Duochrome ïest)
'Dim illuminotion

'Open the duochrome chart (Red 8. Green c...
Procedure

 

l3.Check the Equilihrlum Test
3

'occlude both eyes
'Place prism over :  J

- OD 3A Bose-Up

- OS 3A Base-Do...
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- To determ...
_ly/ r

Purpose:  To Subjectiveiy determine the near refractive power of the patients eye
lndlcations:  -For Px with presb...
Test Distance:  20 lt.  or 6 m. 

Test Target:  Best VA in distance SneIlen's chart
PD:   lllumination:  Room

Control Len...
Significance

 

- Measures the tonic 'lnnervatlons of a muscle of a certain distance

- To determine the relative horizon...
V 77777

Test Distance:  20 ft.  or 6 m. 
Test Target: Best VA in distance SneIlen's chart

interpupillary Distance i w ll...
- Blur point- represents the point when the Px can na longer
compensate for the prism lnduced retinal disparity while
main...
V

VVV? ?

Star ížlü Coriz/ ærya

Test Distance:  20 li.  or 6 m. 

Test Target: Best VA in distance Snellens
chart
interp...
Significance

 

D Break point - represents the reserve of the total convergence at for with
activation of accommodation t...
777777

 

on _OS
Test Distance:  20 ft.  or 6 m.  L,  __ g) ` : å  a A" 
Test Target:  Best VA in distance SneIlen's char...
Significance

 

- Break point - represents the negative fusional convergence in reserve
~ Recovery - represents the limit...
D Test Distance:  20 ft.  or 6 m.  g 00 W
D Test Target:  Best VA in distance Snoileifs chart ý L l A M
D interpupillary D...
Significance

 

i To determine the relative Vertical position of the visual
axes of the eyes at distance when fusion hos ...
li
`_
1:

D Test Distance:  20 tt.  or 6 m. 

D Test Target:  Best VA in distance SneIlen's chart
D interpupillary Distanc...
Recording

DS remoining prismBUr  uit n n I
R supraduction
DS remaining [NISITT '= L' . ; l' i'

R introduction

 Record o...
Significance

 

- Measures the Vertical replacement ander dissoctatian and unequal
Vertical auction in view of relatively...
Step#l3B lnduced Phoria Test at Near

 tiri-iiyïiiiïiaziií
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“g *i » .   ' '
 4- 'i' ? wil  a '
' I ' ' ` . ...
- Measures the tonic innervations of a muscle oi a certain distance

- To determine the relative horizontal position of th...
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b

b Normal: 
F _
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` 1"` ', ,:I/ 
lia”,  .c f"

Test Distance:  16" or dO cm

Test Target:  Bes...
- Measures the tonic innervations of a muscle oi a certain distance

- To determine the relative horizontal position of th...
To determine the change in
accommodative convergence that occurs
when px accommodates or relaxes
accommodation by a given ...
Measures the amount al convergence generated by
a diopter of accommodative effort

Modified the result of AC/ A ratio to t...
VVV? ?

5Iè“}i'f_i: í;i:  Uiiiusa-_J CfU~3~3“C~_'/ ll! i', l3f 'raar . as ilv

Test Distance:  15" or 40 cm. 
Test Target:...
Recording

 

Significance

- Measures the integrity and
deterioration of the visual pattem

-The remaining lens power tha...
Test Distance:  16" ar 40 rm
Test Target: 

interpupillary Distance:  Nooi
lllumination:  -~ :  in llll

Control Lens: 

v...
- Measures the tonic innervations of a muscle ot a certain distance

- To determine the relative horizontal position of th...
Add (o) temas

    

: lis

Vertica` line
(carter: 

Hi:  *irnrirai
(Dani-r)

Reduce t-l lenses

'IC Ear.  :il

 

7777777...
_ - _ Significance
The remaining lens power that gives

_ _ _ ~ Measures the amount of
equality of vertical 8. horizontal ...
Step#iSB lnduced Phoria Test Through #l4B

 

.  .r

, r . e ,  _,  7 (w;  ę : r : Ipsr ,  _   '  ' . X  n  g. 
o _ 'i - r...
- Measures the tonic innervations of a muscle of a certain distance

- To determine the relative horizontal position of th...
7777

7777

Test Distance:  16" or 40 cm
Test Target:  Best VA in reduced Snellen's chart
interpupillary Distance:  Near l...
Indicates the amount of (+) fusional innervations in
reserve available at that fixatian distance

, .
. . 7 'f N” =  .
M' ...
77777777777

Test Distance:  IS" or 40 cm. 

Test Target:  Best VA in reduced SneIlen's chart
interpupillary Distance:  Ne...
'91 Biur Significance

- Measures the fusional

i 4 innervations and the
: ñ [EJ  àgyegk accommodation

(Boume) convergenc...
VVV? 

VVV? ?

Test Distance:  15" or 40 cm
Test Target:  Best VA in reduced SneIlen's chart
interpupillary Distance:  Nea...
Significance

 

- consists of relaxation ofthe amount of (+) fusional convergence
being used to binoculariy tixation at t...
V 7777777777

Test Distance:  16" or 40 cm. 

Test Target:  Best VA IH reduced Snełlerfs chart
interpupillary Distance:  I...
g:  

: k [E]  åsreak
 L

,  Si
E : k 'P l Blur

(Double)
åRecovery

(Single)
l ui* __, ,z ` “: r--; `;i~_' -qgu
, íllzlłų...
VVV? ?

Test Distance:  16" ar 40 cm. 

Test Target:  Best VA in reduce SneIlen's chart
PD:  Near lllumination:  Headlamp
...
- To determine the relative vertical position oi the visual axes oi the
eyes at distance when fusion has been broken. 

r ...
V? V7?

Test Distance:  16" or 40 cm. 

(JT) D's
Test Target:  Best VA in reduced SneIlen's chart l “If”.  s;   is"
interp...
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lê E I u

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" jil'
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D

D Test Target:  Sement i* ihm:  wat uï r. -;w. :'

D Response:  DliiiCLlHų' ui naunimu of the lurueis

Test Distance:  ...
Recording

 

“AAz Amplitude of Accommodation
“TPN Total Plus added = (Number of Plus click x 0.25)
“ïMAz Total minus adde...
Step#20 Positive Relative Accommodation

 

D Test Distance:  16" or 40 cm. 
D Test Target:  BVA in reduced Snellen s char...
PD:  tiear

l

Response: 

Výýýýýý? 

Procedure: 
of the targets

Prism:  _ii . __.  i.  ~ '

Test Distance:  16" or 40 cm...
- Measures the tonic innervations oi a muscle ol a certain distance

- To determine the relative horizontal position of th...
Step#21 Negative Relative Accommodation

D Test Distance:  16” or 40 cm. 
D Test Target:  BVA in reduced SneIlen's chart

...
Test Dustonce:  16" Or 40 cm
Test Target:  Best VA in reduced Snelłenš churt . il z _ l 
PD:  Near illuminotion:  Headlamp...
- Measures the tonic innervations of a muscle oi a certain distance

- To determine the relative horizontal position of th...
- Uescnbed by BORISH ll945)an over iaggmg procedure done
after compietion c~t Zlstep

- Paiticularlv n í ;  ~ n ~  .  z

i...
Expected finding

The lens powers remaining in the relractometer ii intent hvvemnm or nn

l Delayed Subjective Finding )

...
Cycloplegic Refraction

 

- The refractive state al the eye when accommodation is totally or portlaly poralyzed by a
cvci...
7 ATROPINE use lor 6 voor-s below

Problems and Donners
I. 

The parent must cooperote by Instllllng the
ointment In the c...
Choice of a Cycloplegic agent

 

Subjzon +B.00--l. OOx90 VA za/ za
“""'“““'V as +7.00--l. D0x90 VAZO/ ZU
vk -' ,  ni" _ n...
Il routine refractive techniques were unable to relax the
accommodative system,  additional plus will be found in the
sphe...
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21 step-Diagnosis Procedure Refraction

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Publié le

20/12/14-Reference :
-Clinical Procedures for Ocular Examination 3rd edition by Carlson, Kurtz, Heath, Hines
-OPM 303: Diagnostic Procedures - Refraction By: Dr. Pornpatcharin Wongsaisri
Faculty of Optometry.Rangsit University Thailand

Publié dans : Formation

21 step-Diagnosis Procedure Refraction

  1. 1. i y-`x` . `ý% x -. . y -šçäxi yu , v - `. t a , j ` o al' . C.lrs| nun~vvcvl ! x`)~*": "*-I III . 'V. ^I'ł: .ai a ulalfø vir: uw" n J['llø'/ lIl_I`. 'I. /Illl l . ..I . al . n Innzk, Ill. I); -l/ lIlx'. olv xmixlxqnx x pun l. làro : se (th onųqlï xl`1) 15.1: ruuun hruuwirųx: in Inn *xłnų x. Sin -run/ r I) *uursitæg II rnuggla ha' o '-~ : f: l`ł()()k. Jrtichę, ckx? lthcu 1: h: into m. ru. - ins! IL' . . M'n". . »`_ . .łų 'l «i`l| 'rvn' ` " 'å 21,. , EL, i: . x ` . ""[r"`! 'ł, ~.1.-. k : Ãlłtfpųúł n Êxï xXx | : uw d.
  2. 2. N; $23- n l i 'kan v'. ly, " uu. n" . :s-. ø HJB u-: J = :: . ; _ r. 'en ; .: ` r 32.3." . :q : íif-ïëïgjåžlý 1:1 m ? ii 1 *. _,_'. V "' 'Iii . ._ iii e ~~~tłl. ę.. x' . . ammo: “Êigiiaiggííïgš i- 51945; g
  3. 3. 21 Steps Step No. Titles 7A subjective Refraction at Near lnduced Phoria Test at Far 9 True Adduction Test at Far ID Convergence Test at Far II Abduction Test at Far IZA Vertical Phoria Test at Far IZB Vertical Duction Test at Far 138 lnduced Phoria Test at Near n "'n. `n. lo" i p. ;;"sg: f'i. łtliä: llï *", r"vè t. d' p. ” ïxexx , . - 7 . 1- 9 . nvłwęí rrI”"_'. .-. ~. O* a. ..! t'“'" * l w Anh* 1:17" 'W' -II P
  4. 4. 21 Steps Step No. Titles l3B+1.0D lnduced Phoria Test at Near +1.DDD MA Uniused Cross-Cylinder Test at Near 1SA lnduced Phoria Test Through 14A 148 Fused Cross-Cylinder Test at Near lSB lnduced Phoria Test Through 148 16A Positive Relative Convergence 16B Positive Fusional Reserve l7A Negative Relative Convergence . ...
  5. 5. Step No. Titles 17B Negative Fusional Reserve 18A Vertical Phoria Test at Near 188 Vertical Duction Test at Near 19 Amplitude of Accommodation 20 Positive Relative Accommodation 20 Phoria Positive Relative Accommodation Phoria 21 Negative Relative Accommodation 21 Phoria Negative Relative Accommodation Phoria När: Vi'i"'juzlrií. l', 'çiíiilsk: n: ýCł-'ł, "Virtual t. .. y xyXxVü
  6. 6. Purpose: To determine the presence or absence of pathology Intrument: Ophthalmoscope Methods: 1. Direct Ophthalmoscope 2. Indirect Ophthalmoscope ? ii-HL 3. Telescopic Ophthalmoscope x . Test Target: Gross Target "WW"- _ _` , /"-'-'-'å'-`-`ï? ~"ï37-`3`~ Test Distance: 20 ft. or 6 m. ` Width Distance: From 16" to less than 1" -`-'~'3'~'T«ï"~'- . y lllumination: Dim Manner of Examination: OD to DD : OS to OS n-Lųn lla9røłil DIRÊCT OPHTHÂLÊCOPÊ . .ý_ . . _ _ . . _". t”. n r«-"" : I- p' u'~*""`-: Nł4 ' -Il` If' . d" . .". »|"" głïúłl 1,7!) l)l`l"l'. ` )(“'k. . ' d`pp i'. à' `N"` " lłU/ "l . v ł("', 'c t n "' ' n t --. e n' *`, ..i tl“ų'. .rc. ' " . l`, "e` . a n! " "m"
  7. 7. ll `Illr'~p'. 1. Close the room light and switch on the ophthalmoscope. 2. Use a 211.. ) z 1'~_1:a: ~ n for non-dilate pupils 3. Start at 16" with +8.0D D is place in ophthalmoscopic power 4. Shine the light into the right pupil-> observe Red Orange Reilex S. Move closer to the Px 8. go more minus until you arrive to amount of lens that will give a clear iundus image at a distance of less than 1" -> Oluserve CD margin a CD raiio -> Av ratio a Av crossing -= - i-iacular a Foveal rellex -r- Peripheral iundus i . 1)! ” , 1 a is ' - u v "- l" 'brul "'11 "My k "`d`II`J "àxrxl "l l " r`~ I [: I"' | l, ( u . v H X ` ' u' I 11 . H k N , I If: ,l/ .. lll'l' 1)' . " t 'x l 13" I'. l
  8. 8. Reflex l+l ROR (-l RDR Media Clear Partial obstructian CD ratio 0.8 Color pinkish-yellowis yellawish-orange Margins distinct indistinct AV ratio 2:3 1:2 Macula üownish Reddish Peripheral Clear Hemorrhages , ns -' , v! " _ nm ' g t" ruv' “tv ' t l" - 'J Paar: hrfięçjøøt/ sgëcøiñvúę; JH? : jus' d p wyųe" I? ł'r, '_lf1(fï)l, 'iid (, ra I. t. el-l'l "v l l) slï"á . I lt. .." “t”.
  9. 9. Clinical Routine and observation A. Usually the eye is examined by direct aphthalmoscopy. B. As the light is directed into the eye - The pupil will glow with light. This glow of the pupil should be uniform. Variations in color may suggest tumors, detached retinas, or heterogenous medial indices. Dpacities or markings of the media, cornea, or lens surface will be observed in the front of either diftused areas or black abstructions.
  10. 10. Clinical Routine and observation C. The Disc or Papilla 1. The size and lorm - Located at the run. . N-. Diameter al the disc is usually 1.* u. shape is usually iúųifl C-r 2 511113: 111-21 with the langer axis in the Vertical meridian 2. The color - The color of the disc is due to a combination of the hi; limmvi Li . ililgi - -m : hi: 'VW-g cri): and the almost transparent reddish-grey fibers where the iibers are densest. the disc will appear redder usually on the nasal side of the disc. s ~ : v ~ sucæv n n -uu- u nv- " "r nvłü: lyf' ljütųøtlñtųãrko "f UP . ęuàl d" txcï* v _ . . . p 'ų/ "" u ' . *pl 's' h* ` - l "' `v~`N gf" I/ l . v I ) 091 ( ni' ` : I . at . l
  11. 11. Clinical Routine and observation 3. The margins - The margins of the disc are usually sharply defined and frequently bounded by marginal rings which may extend entirely around the disc itsell Choroidol ring The ruil: rvr' läTllLłçfj 11.1: llwž: u-: Lųmųluliiïni: ui 19.111.112'. Sdenlring ' at the aperture through which the optic nerve passes and is known as the choroidal ring The white ring, usually found inside of the other. is known as the scleral ring and w. :ųrrini 11 r, tin ųirr 1' I'll Mu lltn' ln n lurgirl ilwririwful uliųflilli; "", .lpk". .'1: bs)"l, hllllrslrlg ik. .`l-glk`p `r` git- ('. ')| . . " . v"" 3,111' l, r,, l7't, l- . g `7“, (, . 1 3 d 'la' i. .- `N"` -gl . HH/ AN . v ff" , _ac-z 'i C . .I1"t n 'o l .1$"` . l Il" w".
  12. 12. o. The vessels - The Veins ~ larger rmrl dar'- er blood vessels than arteries, and their surlaces do not ordinarily reilect the light Copper wire a Silver wire - They also pursue mure [UHLMLS paths than arteries. - The arteries f - usually slentlere' (4/5 the diameter oi the veins) l time: _i ' brltlililj! red in color, und struityttur than are the veins f. " - The ciliog-retinal arteries -small vessels curving roughly towards the macula. i pt" 1 _ r- . n _ 1./ y [a tlhllrliylųųl, al, " 'QI/ lt-, F `l`di`j `lüïtäí 'f' l ` `. " A *v I" D* : . l ' I"', I.I III/ l I, I" l t In IT 4 I". l X" x il " łfr ' I' i- 17 I* 0,1. . w I I'
  13. 13. E. The Fundus oculi The color is almost a uniform red. vorying ln shade with the general pigment irom a light orange-red to a dark broyønish-red. Both the pigment distribution in the retina and that of the choroid affect the total color. The tzàsselaied iundas is commonly' ? aand in UTURPIIES. F . The macula lt is the area where in lawaai reileæ; located - usually lound almost directly lišnïprjirtilwtlrtls al the disc in an area devoid of major blood vessels li appears as a somewhat darker spot on the background. Normal Fundus i ui" . r _ w' . is ' - 1./ - . v l ł . ill r 1 `ll x'/ ,,^1: k 2"` -)"A" t l. , i . " N , I/'l l, ldl 13,1" l `, (, . |1`: Cłl-'u "Må N"" I , lll 'lll, ,, ø~ 1)' ""t , Ilæy- I' | |."
  14. 14. ;. » -jiur i' -ru a r l - rr/ Lprií 1 ~ ãJ. Ji~urr1-- 'ž/ purposeTn assess the rurvurure power. and inriciiy ní the (omen “"" W" “"'“"'*"'"" ų. il. .-ųcu~«-. ø Lqaipment* V Keratometer / ophthaimameier *sir www an Iii-rua l ir. " 'l"*'t'~!1“ Mnr. HHH! r Iruiamvlt- 'wmtr ~ - - ' - . law '114 - , É_Irfl ø 'nui *r "Jam, r; . iųm M: 1_-l. .rv ii 'ir r*'.1 umu . ... ... ,~. n.; _ Iii <. - . r 5 "_*'_, 'm Im “pm Hart's 291 a tf-Purnclr' . ,,. ., p: . . ,, ._. m., ,,`. . IL Iïrnatirmøvrv tyd-ir, - tip-gn l. l`_' ir" . ,. n um , -. - 'm ~ lrųvrłtllųïlf'a-Jywltw, .r uur tuur t'a-ght u' : lw cnlrrr r-| l-_ uur". .- . .. . ..n t . ... ... .. ` ` ` . ` X x* y I l l l' ' ' '
  15. 15. Basic components P Disanfect the chin rest und íoreheod rest wnth utcohol D The patient remove his eyeglusses or contact lense: D Focus the eyeptece ot the kerutometer u. Turn on the power b. Set the adjustoble eve-piece is hrst seen m sharp focus nnd tum Horizontal &Vertical Drum on 44 D - Adjust the height of the potient's Chili! and the instrument to o comtonobrle position for both the patient and the exmnmer - Adiust the honzontut und the verticul power wheels until the mites ure in close opposition - Adjust the honzontui power wheel until the horizontal mites uie coincident - Ad| ust the verticul power wheel until the vertncot mites ure cotncident ? Jwi- it the cumeul ustigmutism IS irregular. the two mendiuns will not be 90” upurt. ud| ust the tocus und recenter the reticle us neeaea ' observe the integntv of the Cornea bv observing the condition ot the mites *. p. oø '. a . "to u o , l'- (I Iųtuíłul", l, r( gl4,'*l llI5{; :,, ",k. .Ir . p Êęl. - t `~"`. " 1' l- I g - . .fl ' ' a . 1 III", (. v l7'l', ,.. c~ , ' '11' "`* . al 'o l l nlï"ä . I I`. r' _uu-
  16. 16. Recording ~ Record for each eve sepnrately ~ Record the power and the meridian for the horizontal meridian lirst ll” mendion) - write a slash mark alter the l” meridian and record the power and meridian lor the Vertical meridian (2" meridian) - Record the amount ol corneal astigmatism in diopters - Record the axis al corneal ostigmotism by using the Hottest power meridian Example: Expand "ham, lvpe ot astigmtism 't OO 42 ? Olillłlï 50090 - u: ot u iwinaruzsooo - A """“""""'“` '" ""” in. l "A ir. U l . 1'. n ių g. .. . _ 9 In. a' , V , r . w i' d W: _ as u “n” 0 a u nou Stuur 0 i* i Jíýf l _ i Hø- VIII [IWYDU iwvmhm in r-nr-ocii-iiin rw 90 uma 53431999 ' ` 4 ` (t i' verlam - ran 2' vieruur - 90 V , r a an. , w", ,l m. .. ". ..n s. Vł i' menn: - - US. Z' maar - u n - ųuurnu rele-ł mu: wam v nmrmiwrørúøi "h" """"“""' I' mun: - - izo 2' vriendin - so no. - iiuøiu-łnųr mann nrm w' a! n . m IH ' ' . . V 'f g. . _ k . - . . as I4", TNII| ę: U-"łçrøïc '. g:| `. u| l"`p `r. ":{ (l. '," . " VI"` (gl/ l 1,, " I, 1 l- i, l (, ` to" - "| l(, i. .- "`IU"` . ..j . ł/l' ł . v ł. ()l) . oCG-i () m! ! "` . II J' nI"`_ . | ". .Kn-
  17. 17. Calculation for radius ExJ OD 2 42500180 Fi! OS : 47159180 4150990 47.259!! ! (Fill -LOOMSO -050190 DD : r - 3315 r flnt K reading - 3375 0 42.50 ('JM OS: r - 3375 9 fiat K reading ' 3315 r 47.25 ' O' llat K reading r - 7.14 3151 "LDS 1754? wsííooïgę: 19.92. 1:45' wha" na'ł'"ę. (rrI” 'in o" a. ..! t' *tn r. 1 " nah* . I nIV" *'-
  18. 18. Step#3 Habitual Phoria Test at Far D Test Distance: 20 lt. or 6 m. D Test Target: Best VA in distance SneIlen's chart D Interpupillary Distance: Far lllumination: Room D Control Lens: Dld Rx at far l Plano D Prism: OD IZA Bi - Meusuring Prism D OS GA BU - Dissociating Prism D Response: Vertical olignment of the targets D Procedure: Herran-e pram Bi until Vertical olignment al the targets D Record: Remaining prism 8l - EXDPHORIA. Remaining prism BO- ESDPHDRlAJndicator at O - DRTHDPHORIA D Normal: asti EXDPHORIA 719777; r0”"Ê. }~a 0' 'ÊA ""'. '.iké ' " 7 _dT 3.1 H"'" 'm'
  19. 19. . a: . .. .al irïųiøtirxirïsliisllłųųlíłir; . . iitíiiiimflælsił . .. .Fire. icøsųęhrnųuftwbåaenæu . e w: . JJ. " 5 a e g". f: 9 J c i' kan t-_a 'taxi 19.3 'ca-ægåaå-_t r' l z 'J' I ų ' ï t 3' 4:57' *i : ,gesteur-aa mits-a?
  20. 20. '. I ` Test Distance: 16" or 40 cm Test Target: Best VA in reduced SneIlen's chart PD: 'pm lllumination: ill, hui . r Control Lens: Total near of old Rx l Plano Prism: OD 1213 Bi ~ Measurinq Prism DS GA BU - Dissociating Prism Response: ii i ii ~ . i . i ofthe targets lZ' I! ! - Hoosunng Prism b ' BD - Dissociating Prism 77777777 Procedure: iii* ~ ' zr' vi: li of the targets until vertical olignment D Record: Remaining prism Bl-EXOPHDRIA BD-ESDPHORIA, Indicator at C. - DF-: T Iïiiïlillivïifi D Normal: a; : iv-iiirłnw. "g . - r . æ- ' l', _|_ _ : 'a- . l"`. _ ` . ~ . p *'. ', r3", , : II I” | '.l `, ( "t""' l'l"" ~. . an" . c/"H n. ” . ilï . ik '
  21. 21. - Measures the tonic innervations oi a muscle oi a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken b , |)0* ,1 _ w' . n - yu ' J 'i ' 'mw' `7. ^""": .i~~= "`c1ii9 "T : ~' m ' m* N, ,, ,I 'l, l 1,113' l l()("t. `1|'. '. '"v 'l ' . w `-" 't' 'I' av I) lt . ulxłv I"` I | '
  22. 22. Purpose: ' To objectively determine the distance reiractive status al the patients eye - The results of this technique serve as o starting point lor the subjective refraction or os the patient's final prescription ii the patient is unable to respond to subjective testing - Necessary r `| s' _ kg; u. l _ . (1 jil k `_ ll`j ~ s' "` t"`_Cl_'ų. 'l( ų "xx l" | Ixo . w" ill'
  23. 23. n- -'-11l l l "I-i 4 , ná . tw V l -_, t, si`l . 1IJAK`| E a---" __. __. _.. ..___ . . Flutlou cua D Streak retinoscope "m" _ Duotłnø i Phoropter. lens rock, or loose trial lenses sum: oom ł Fixation target: 20/400 E projected Test Distance: 20 ft. or 6 m. witdtnoiýstançe: 16" or 20" Test Target: Gross Target of SneIlen's chart UÊQMWQUQDI Dim "Retinoscope" CIOCI LÂMOII Control Lens: l. Plano in without WDL method 33151323 2. WDE in with WDL method cum. .." Roullon llløłnøl Interpupiilary Distance: Far '“"""' W' Maggie: gųqrningtjgnzitp, DD : v gå to _gåu . lt" _n _ u- - 'l| I . al " , i l, I, /l) l, ,_t"ltäl, t,. , . l`. . x _, l,, (l 1,, " f. .. "to|1 ~. l-'rl III" . f' -v-æ “' . c| ` , ryk-
  24. 24. Set-up - The patient removes his eyeglasses. Disinfect px contact surlaces of the phoropter. Retinoscopy is most easily done in dim illuminotion - Adjust the height of the examination chair so that the px's eye are ot the some level as yours . Place the phoropter in lront of the patient with the interpupillory distance (PD) set to match the px's distance PD - Instruct the px to keep both eyes open during retinoscopyDuring retinoscopv. the examiner keeps both eyes open and examines the px's right eye with his right eye and examines the px's left eye with his Ielt eye - The examiner holds the retinoscope 20" (S0cm) lrom the px's eye. The retinoscope is held in the examinefs right hand to examine the px's right eye and do the same with lelt eye o I! hui. ” ' p. l'5l"à 17,1;". å~lr"t. t"`zí (lí', " . Alf" : l ns . "“"? l:; l)" 13,7' lø-øoêcł. b t. ./ >Il'" . v "()l' . -I*6 t, ma' t" _. :lk0
  25. 25. Step by step procedure l. Instruct the px to look at the fixation target. Examinethe px's right eye first 2. Determine if the refractive error is spherical or ostigmatic by changing the 7 Position of the sleeve of the streak A a retinoscope and distance b/ w the j - j' -o examiner and the px until the reflex Imo: phanonúnon m". ". ..mm is enhanced. Then rotate the steak of the retinoscope through 350". 1 looking lor the iwęv. D"'. rj: `;= ;iíi: {i~"* r M n ų . ( J í : iirti Pics; _iurigiiLïïïilí i : ig B "' 'P' - I* CI ' 9 ' i' n nln. n.l 13' lłlfai"l, slllx , ". i| l If' " (II, U . " _vrrýløn/ I n, [)ro_ I, ` cu c 11'. rv. , fl4~ h `~`Xt w. nul' . . pm' 4-4 n' * . .l t" . . a . nh . a n" "" "'
  26. 26. Step by step procedure a. If the error is sphencal. the reflex within the pupil wil be continuous with the intercept al the streak on the px's foce(No break phenomenon) b. ll the error is astigmatic. the reflex within the pupil may not be continuous with the intercept on the px's face (Break phenomenon) c. As the streak is rotated through 360". the thickness al the reflex within the pupil will be constant in spherical error and vary “in on astigmatic error (thickness phenomenon) d. In an ostlgmotlc error. as the streak is swept across the px's pupil, the rellex within the pupil will move parallel to the movement of the streak on the px's face when the streak is aligned with one of the two principal meridians. The reflex will move in a different direction than the streak when the streak is not aligned with one of the principal meridians (Skew phenomenon) 3. lf the error IS spherical, observe the reflex for with or against motion and add plus or minus lenses until there is no motion of the rellex ( the power of 2 meridians are equaly) p' _ on _ al `; .o lt ""` r'- p. u'-*ł""_~íl'ł~' ' ui" I . ' "' P" ' "T lI/ "|"lã: x`l)n"k' 2 dïp. n il” T : , . < 11 . IA/ l", .v I'()l, , alby' ( ma. t" . na 'v l . |IT"? ` . I . tlr "un-
  27. 27. Step by step procedure-Neutralization Refractive error Motion seen w! Plane Motion seen wl Short Lens power needed mirror retinoscope concove mirror for Neutrallzation (sleeve down) retinoscope (sleeve up) Emmetrope With Against + Hyperope Low myope Myope>wD Against With - 4. To neutrolize on astígmatic error, P' identify the 2 principal meridians. then neutrolize each meridian seporately. l" meridian (Vertical meridian) will neutrolize I” with plus ar minus lens until its neutrolize, then rotate the streak of the retinoscope to 2” meridian (Horizontal meridian) neutroize with plus or minus lens until its neutrolize t, I()a? ",; |.r`: ø' 73,53,” kllg "ï tir"`n `r". ' ; (/li', "-
  28. 28. Step by step procedure 4. The lens that produces neutrality is called the gross retinoscopy finding S. To convert the gross retinoscapy finding to a net finding. algebraically add a sphericol minus equal to your working distance in diopter (D-l) Ex. working distance - 16" F-_LQorF-QD: or F-Qjçm) D D D F v _ag - 2-50 D 16 Ex. Working distance - ZD" F - 4_Q - 2.00 D 20 6. Measure the px's VA in each eye through the net static retinoscopy finding v" " i: ”"' sf/ 'ä' u! "' . úåçy ëyl-: Jlärøułšàçauäv 1: V
  29. 29. Recording D Record the gross power of each meridian Ex. oo: t” meridian = +3.oo@9o 20 meridian = +2.oo@1ao P Combine the power of 2 meridions in Rx form by use the more power be the sphericol power, then subtroct the power of the 2 meridians. so the subtroct power will be the cylindrical power, then oxis use from the unused power Morępower Lsubtroct power Ex. OD: +3.00s= -1.00cylxl80 (Gross#4) Axtlsïtnused : n . g'n 97:11.! If: dll": ,': r_ę fïęå; alfzåäè Ãęęrší lłíl, l "`. " . v , . z 1 -_ 1. . n : Â-I" 'f' ł"" m 9' “'31 t' " 'lun ' "i . nh"`# MIV" "" "
  30. 30. Recording - Record the net power for each eye seporately by subtroct the gross power with the working distance (16" = 2.50 D) Ex. OD: +3.00s= -1.00cyIx180 -2.S0 Working distance +o. _SOs--1.00cyIx18O (Net#4) - Record the px's VA for each eye through the net static retinoscopy finding (VA @ for) EX. ODI +U. SDS= 'LUUCY| XIÊU VA 20/50 052 +1.50s= -0.S0cylxl7S VA 20/20 n lt "'33". ": `:"'"'}`7~ 'lgwn' ql"". 1" 'f, u, " . 77.3' ff" 25:31.: (v: “'-lltl. “`l`" x : ęæ i"- . l nn” in? " '~' "-
  31. 31. * NET #4 = Gross#4 - WDE = Gross#4 - 2.50 (At 16") 'šivnmv um e* P To study the accommodative and adductive response to monoculor stimulation as compared to binocular stimulation of subjective refraction. P A measure of P one of the diagnostic symptoms of un P' objective meosurement of the i* objective measurement of t , l)"' l u* . xt - LJ v l u'. _, xI“V. 'lł al, " `l lt. F `Q`CH` `ffïł`l [I] l ` v` x 1 , t , l r x* ' A z! " 1 l ' 17' | `I ' H , x* I ł/ t ' l J 'l'{', ,_. a~ ')| I" t : Ix- I' ni" I | |"'
  32. 32. Step#5 Dynamic Retinoscopy at 20" P Purpose: To objectively determine the near visual problem of the patient's eye P Test Distance: zo" P width Distance: 20" P Test Target: Head of the retinoscope P lllumination: Dim P Control Lens: Gross step#4 P interpupillary Distance: Near P Manner of Examination: oo to ao; OS to os 0 , unknïru ęå-àkdęãękøg aräïwp ". .tu - dan. - , g/('ry 3,111' , g bro a l)0(, c'11'- 0,112' sh' 'j . nc'f"_. . røl" . ..a Of . ..I t". * l ' . nl`, "$ . a n! " "“"
  33. 33. General Procedure l. See to it that the correct procedure is followed. 2. Instruct the px to look at the head of the retinoscope b Recordiug 3. observe for the P' movement of refiex Record the om: now o! 00th motion which is "against" Ex. aa: i' mmm - *zsoeea 'åųuinsl teller; llit_>'u`t'_'llil2l1i ~Pt`s 2' meridian - *tsootso iittiimn' irloiitz-ri IS vJLïWL' Horn going l Swaan pou/ u 4. Reduce the control lens (grossłłd) until 5* 09? '3-509'"-099*"30 “'59 neutral. u, å" S. Do the same procedure with the other eye. 6. Do with both eyes open. *so '. :”. oø .4l', h- . g.; n . - "Iïvtnum" * k' "o d",
  34. 34. Recording - Record the net power for each eye separately by using this formula: iarerosus - aa: asos--toocvuieo mii - o* Ewopborin m - 5.00!) P lun-human: News - 4-250 - (g) a - »z. so - I.00 om; .-. 21.29. o P Prost/ ou: muis - +2.S0 - (a x 5:90.) B S U +2.S0 - 1.00 MES: *J-_SQD _, 100%" I? ”"; u5g'" . Intl "' af""' M'n" feinn"
  35. 35. Recording Record the px's VA for each eye through the net dynamic retinoscopy finding (VAWJ niJtii) Ex.0D: +l. SDs= -l. DDcylxl80 VA Srl/ EU ar 12 OS: +l. oos= -o. Socylxl8o VA 20/20 ar ll+ Significance - Measurement of the negative relative accommodation at 20 inches. - Meosures the integrity and deterioration of the visual pattern. - one of the diagnostic symptoms at B and C type. - objective meosurement of anisometropio at near '* '. . p 8 <I"Ê' 7 ' "t G' , "' t' ljrltlłyll" l, r() l[, "l llhęłrïãjk. .IT t "`. " '. II' ". u! " fi' h ht' ` Â "' yx-b `N gf" imm- łll l . v 'f' ælä , .ali t lik' al, .l
  36. 36. Step#6 Dynamic Retinoscopy at 40" - Purpose: To objectively determine the intermediate visual problem of the patient's eye - Test Distance: 40" - Width Distance: 40" - Test Target: Head of the retinoscope - lllumination: Dim ~ Control Lens: Gross steplłs ~ interpupillary Distance: Near - manner af Examination: OD to DD: as to DS , .,“ DO . : "IVO-P 'I' V o ` u" m" . as k. , up 'V"'y: :-'”" en' "for a ba? : d ' » * e. V” r" uu- . l71'r, _.1 I? " -cd (j nt' t . -n "v _. ųI1" . I (t.
  37. 37. i. See to it that the correct procedure is followed. 2. Instruct the px to look at the head of the retinoscope 3. observe for the initial movement of reflex which is against. "i . Ê~. i"1l11~'. i iiw irii~~ i': ;:_iii -; -:~ iii`i, -_. -." i: iïiïi ii*“i`i in iii"iii 4. Reduce the control lens (GrossłłS) until neutral. S. Do the same procedure with the other eye. 6. Do with both eyes open. l p . 'l 0.; "'" xl/ It 'k : ">`H-o'n`ul u". -x , i l v, ,ruil l , nu l “a 'nn dit l , jrñ "N l ' x _ H l I , ;t"' g)| 'gl * __, `_ I' `3`1` '| | "
  38. 38. Recording P Record the gross power of each meridian Ex. oo: i” meridian = +2.oo@9o 2” meridian = +i. oo@i8o P Cambine the power of 2 meridians in Rx form by use the more power be the spherical power, then subtroct the power of the 2 meridians, so the subtroct power will be the cylindrical power, then axis use from the unused power More powex áubtroct power Ex. DD: +2.oos= -l. oocylxl8o (Gross#6) 1 Axis unused lý "lł, r~í, 'lfr_ęlïtłí, k 1.1! i| ïèų, ęttší (lílïl `FJ"` " t ïz. -r"""rrrl"' . ..« v' d. - id" ' k' ' ' n"` . a ni" """'
  39. 39. Recording - Record the net power for each eye separately - - - - - - - - - - - - by subtroct the gross power with -D.2S : Sigmñccmce a oo, +z_oos__l_oow| xlau j-Heasures the negative relative I accommodation ot 40 inches. -a.2s . l n k' o , n m 'n, z-Detection of the visual e . problem ot intermediate - Record the px's VA for each eye through the net . distance dynamic retinoscopy finding (VAebnear) Ell. OD: HJSSP-IIIOCVIXIGO VA 20140 ot l3 OS: *LZSP-OÂOCVDKIBO VA 20130 or 12 I Formula ' | 'nn-n - Grosslñ - ags | -ïïł-tï--ïï v' "rýútlł 331.273* 7:51' : gcåš: 3V"ïP `rjtïęr`dípw “en , ' I - 3 _ I . n ` : P:'r"(. .) 7l"'. '.ad O* a . l 0199. 'p l "i nnïv" . a [G'n "“"
  40. 40. - Purpose: To Subjectively determine the distance refractive power of the patient's eye - Test Distance: 20 ft. or 6 m. ~ Test Target: Distance SneIlen's chart - interpupillary Distance: Far - lllumination: Room - Control Lens: old Rx at for l Plano - Equipments: Phoroptenoistance SneIlen's chart l ii lrøljo: __, ,1 , Npr- "`| s' ï' kg! 'liv' | r  . x l IN" . zl ni* CUP jr*' , l , ,/I [l lt? '1 . ,l I ærr 'l , tl/ Ill* t I'
  41. 41. Auxiliary lens knob PD scale Strong sphere control PD knob Spirit level , lacksorrs unit sphere i Power Scale jacksons 4 flipper knob weak sphere scale Risley prism ~ _ unit Cylinder l Power Scale i Risley f ranting knou Cylinder axis knob Aperture Cylinder power knob Cylinder axis reference scale PHOROPTER
  42. 42. Procedure I. Stort wnth OD and occlude OS z Present the protected Snelerfs chart und Iet me P: reun the vrrullest ame oł the letters mut ne or she can 3. Add (d or (-) (enses umil vou get the lwst VA o! (hv u. . (Full R1; 4 Foø the P: 2 lines above the EVA hv uddrnq (+) lenses until 2 lines above oł the BVA becomes blur S Present the usngnntrc chart (Clock ma! (hut) 'Ask the Px (I the lrnes ure equalv bluz? - n vos. P: hus w". nsrumvrtxsrn -> Go to Duochrome test - t! no, vmat rs the Garies! line? - (I Ines l a 7 n 1 x 30 = 30 -r temarwe uxrs - H lines l (7) a 2 (B) get the huddle n - 1.5 x 30 - 45 -> Teotcmvc aan - (1 ines l (7) å 2 (B) å 3 (9) - 2 x 30 r 60 -> Yenranve mus - n 4 or more Imes ore seen durkest, Px hus na astrant-Juan: n hut* " 1: p' 7usí""`-Ain1r3 'N u""`. p WW". O (Ul"" , Al' 1 is _ . 1 _v. ørlýlf; ,,j 1:21' "følg" t, ncrlâ. '1`, ' dtųų. _just ų `N`sk Ir" m-r' . . ro" . .. n -n d' ' : ake . ..æh- . a n' "'""'
  43. 43. Place the tentative axls on the axis scole. Add cyhdrlcal power until all lines are equal ( blur or dark) Unlog the Px by reducing the (+) lenses until BVA ol Px Check lor the cyllndrlcal Axis 'Place the locltsorfs cross-cylnder (ICC) with the handle over the tentntive oxis 'lnstruct the P: il every ílip is equal or not? - Il yes. that is right axis (Find om) -Il not. move the axis towards the red dot s-ro” and lllp again until 2 poslttons are equal IO. Check lor the (vllndrlcal Power “ Place the lacksarfs crass-cylinder (ICC) with the red dat over the final axis 'Present the BVA, then flip - Il the red dat is on the oxis -> Increase the cylindrical power - ll the gaan l white dot ls on the (nds -> Decrease the cylmútcal power urmllz postttons are equal 99:49' IS " g I! " _ : mr I" 09' t. " ' t l" *càí 125%' vwíïa= "“iíå'o“æíïïd'âå'šus' d '” . ..nee Q; an! ! t. `.e-ll 'v l . .1I1“s g. “t”.
  44. 44. Procedure Il. Check the spherical Power (Duochrome ïest) 'Dim illuminotion 'Open the duochrome chart (Red 8. Green chart)&Ask the Px ui what color she/ he sees? Let the Px read the letters inside the red and green. 'Ask the Px il the letters have equal boldness in green and red? _ , 4 I I lø l - If equal -> the spherical power is correct 1 m" w' 'n m. " - li green darker -> increase (+) spherical lenses -ł ! a: * h _ I f - li red darker _o increase (-) spherical lenses . r 'NW m' w" 'I 'm ' Until the letters are equally dark in both red and green. _ -å lr-uenelęi spherical lenses 12. Do the same procedure with DS and occlude OD. ouocnlountst u' : v *' 11th v! ut' u n" ~- w ; ;:. « ^"'. š1*: ..r~. -'f m : mm '” www I' g) g - . . 1 - u 1 tra'/ '". . r'"". .c~a i" (`-a` l"" : a 'v l l . qv""` . l IH". ""”"
  45. 45. Procedure l3.Check the Equilihrlum Test 3 'occlude both eyes 'Place prism over : J - OD 3A Bose-Up - OS 3A Base-Down ao OS 'Open both eyes; ~ Ask the Px: How many charts does she/ he sees? t Ask the Px: Which chart appears better? 'IC (O) hul! OU l$llúo - ll upper a. lower charts ore equal -> no modilication m. . H "$9.53" "VOC - tl Upper chart is blur -> radius: OS - ll Lower chart is blur -> adjust 00 u lnł”` " l? p. )`: u5l"” hu! ." ar"`u Søg” r. díl7"' 'r u5 ko lP s' n* on' '" n 17" prü' o" z . j 14- XX* . vt 2 . . - D , (11 - , c . l7d'r, '.l. ,: flx"l. l-cd 1,. anti (". e-lt 'v l l' . ųlï"g . I Itlrn "n'-
  46. 46. ., ø« f” ` - f -. u' i' r _i ` 'x , _.` ' 1 'II l " " 'l 2 - . il '41, 1' . .- l f. , 1 I. " r e ~ - To determine the refractive status of the eye by the use of subjective criteria usually in a form of response from the Px to the changes in the lens power before the eye relative to the appearance of the letters in the test chart : a 71.* g `_' 'n t I, ,r N”, In: "h“( I~~ ` CHP _ 'Hel "vwx . uI" i' in" Il" tw n" 14' _ I' I* , Je . w l Il
  47. 47. _ly/ r Purpose: To Subjectiveiy determine the near refractive power of the patients eye lndlcations: -For Px with presby~ope or Rx at near -For Pit with medium to high Myopia -Far P: with plus ut near 1 Test Distance: 16” or 40 cm Test Target: Best VA in reduced SneIlen's chart 1 interpupillary Distance: Near lllumination: Headlamp 1 (ontroi Lens: Stepfl? D Procedures: Do bïnoculariy (OU) l. Place the lens power in stepłl? in uie phoropter 2. Add (i) lenses until the Pi: achieves acuity in 20/20 or lI~ at near Expected Add ' 37-40' 1.00 0 48-50' 1.75 D 58-60* 2.50 D ' 41-43' 1.25 D ' 51-54' 2.00 D ' 51-64' 2.75 D - 44-47- 1.50 D ' S5-S7- 2.25 D ' SS-abovr- 3.00 0 ' "T, z r*""` . l'o r7'*, .i N" . Jý- " . nv- ' l n"
  48. 48. Test Distance: 20 lt. or 6 m. Test Target: Best VA in distance SneIlen's chart PD: lllumination: Room Control Lens: New distance Rx (Stepln) Prism: 00 1213 Bi ~ Medsurinq Prism OS GA BU - Dissociating Prism Response: Vertical olignment ot the targets 77777777 Procedure: Reduce prism BI until vertical alignrnent of the targets D Record: Remaining prism al - EXOPHDRIA. BO - ESOPHORIA . Indicator ut U - Ll-ITHUèülíliłiiï. iz' sf- Hcosuring mm 6 ' IU - Dissociating Primi D Normal: ii 'nl L"l. iLJl`il. lF-r' : l al " . ..łnl 'r , Jłïł `l"ll: "I, '}: "Li a`l""è . " xl"` lł, zrlł I, " l' i" x 1i*,4't. |1 _' l-lu' 'i' xV"` "| ł/ C-, l v' '-{, ł' 1%. , ųli"` llk 11"` 'ui'
  49. 49. Significance - Measures the tonic 'lnnervatlons of a muscle of a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken ~«i*. szgssaïgzaęwg-æa: :ø: .ïs"r; ::ñrr'" was ïafføføarøø"ïaq Of 'ini shefíę. l ve -. .nïïå . l iuf" "“"
  50. 50. V 77777 Test Distance: 20 ft. or 6 m. Test Target: Best VA in distance SneIlen's chart interpupillary Distance i w lllumination: Room Control Lens: ~. fl: r-i r- ~ ~ - w Prism: Indicator at OIL a 90 -- OU ready ta produce prism BO Response: :I . n ur mm of the letters Procedure: n t ir in 2 gradually, smoothly and binocularly until blurring ol target. D Record: aan. :ii llllaïli en] . n lid D Normal. 7 - QA D . _.. } . ,[1I- iljl'_lł: łl""| t' , ñtg "" "I'll [', l'l/ ł! I" ": :*, .,k.1.: ï . Prag “lå v' '. '. m“'" -. w" ". .i I""', .Lu " 914! . ir
  51. 51. - Blur point- represents the point when the Px can na longer compensate for the prism lnduced retinal disparity while maintaining stable accommodation - Blur point- indicate the limit of available positive lusional convergence in reserve 1' '} t l 921:/ `l, ll px/ 'f, 'L "`clł`i`ij "'J' `X . l" N' 2 r ' i* . s' x rN/ 'H/ "nl ni" | .i<`tn. I. ." i! k NN* "l łrt , .. 'I' _. i~ i) l" alx sï" I 1'
  52. 52. V VVV? ? Star ížlü Coriz/ ærya Test Distance: 20 li. or 6 m. Test Target: Best VA in distance Snellens chart interpupillary Distance: ~ : lllumination: Room Control Lens: ii. ~., ._ . -. i. i, r in. iHli | .:. "_i'i Prism: Continue StepłlQ Procedure: increase prism BO in stepłł9 until doubiing or break, then rigi- , NE ; :i . w . .=. i im i '_ iiųií) inr ri_i, igi», i_r_ '. ;.i_~_, l4!i, “ i_ Record: Break I Recovery Normal: 19A l IDA D . FJ wdr- . ata ru 'Tu s
  53. 53. Significance D Break point - represents the reserve of the total convergence at for with activation of accommodation to add accommodative convergence D Break point - represents the point when the Px using all vergence sources can no longer maintain single vision D Recovery -the limit of fusion field in a certain distance D Recovery - indicutes that the induces retinal disparity has been decreased to the point that the patient con access the vergence system and reguin single vision . , ltłunïüųgłl ïlłø~lí, :ęs"łlï: k. . Il "ïè lęlï' l", ". "`. " . va' : l 7 -. * . 1 ' - c' æN 1 Én-rWÊL-z" '_'. ... « n' *`-. t d" . . n ' " nvh" . a ni" """"
  54. 54. 777777 on _OS Test Distance: 20 ft. or 6 m. L, __ g) ` : å a A" Test Target: Best VA in distance SneIlen's chart A, _ f' I. " . _á j_. interpupillary Distance: r : 'i _; s . j fr 7.; : i: -'- v, 5:: lllumination: Room . ~ '“ "”" e y Wag. - s ' V' N Control Lens: .i t i r ~ i ~ . n . « , aL-aa fi *, e;; ;zæs. ::. ..ø: l PfiSmI . . ")Cv_-ut Procedure: Increase prism Bl gradually until . ;. h, ” doubling. then reduce prism Bl until single : ~ [É] E : (Ucųxilr) Record: Hiwul Hi ~ . uw », - A r _ åñecovery' Normal. 9.; / , vu 0 l E | (S ng! ” _ti 1)" __, ;I _. }: ł" ; l`| .' -`. `g_ç) . l-'ų . ' rli/ 'gzru/ lllr . `ll: .,( I~~`: : CI'P_`_ “isi "vwx , j/. u _l/ H/z-ł. ” ', |.i”| "`. -|"L'{ti `w"s 'I. ||l|
  55. 55. Significance - Break point - represents the negative fusional convergence in reserve ~ Recovery - represents the limit of the fusion field n . (,ïir*r'}; `l'l! t'; ;,f_-TñB"', å: ? ætov-'aïvt-*Jrpłtr _ _s p? p" ar" we" k- . , as? ' us. “ee ÊmrfFÊarIå0"Ê. ę of 9.91 theftk. l va] -. .n““": 11.17" "“"
  56. 56. D Test Distance: 20 ft. or 6 m. g 00 W D Test Target: Best VA in distance Snoileifs chart ý L l A M D interpupillary Distance: lllumination: Room yžïeuxý. X D Control Lens: n . i : . ; * : 3;_`v-, L-". ;., , o D Prism: DD IZA Bi - Dissociating Prism i. ų }-; ;'! r . virtn-i : ~,», ..», la' E - Disscciat ni) Prasa' L ' EJ -N-Jasurria Vrtsm D Response: ~ w ~ al the targets D Procedure: Reduce prism BU until honzontal 0" 05 uhgnment of ilie targets. E f ms ų i l D Record: Remaining prism H i~ : me'. = L 5 l i aa ~ J~i`KFEF~TPHUF~FIA . Indicator ui a ~ UFwÊIHUFïnHLIFÉLT- "wat anni* Hadron" “ivm” D Normal: n . i* L7'_ H/ I r lšf" | l _' < XL" '| l'| ' , .."II, .I I), `ll , L L. `_ C| |`3 ". .lųl "`. " l H, I,/ I I] [yl ljl t`1`. 1.. .. x t' 7,1 , ł,, Il . h ', |. "ji 'L' . "`~ ll`| l
  57. 57. Significance i To determine the relative Vertical position of the visual axes of the eyes at distance when fusion hos been broken *'r'úo" _ ' Cø'_'* não-à" t 'ø'ï"^ ` v-'-- ' ur--= -' - ' . o 10" 170.”. dtp? `N"e1" . ..cd aan”. 'v l u -Ai1"9 . I 77
  58. 58. li `_ 1: D Test Distance: 20 tt. or 6 m. D Test Target: Best VA in distance SneIlen's chart D interpupillary Distance: Far lllumination: Room D Control Lens: New distance Rx (Stepfñ) D Prism: D Procedure: ]_I i i i li li ` líii l >| ii. i ni ii i LJ! " , , l r" `| s ' . " . l '“/ u«"'“; i "Jlł-xk' 2" CHP " i* , n / I' _ pm* . t . 1' I] _ . |1 "I , n , vnpl i. .. ', | ""t A'L'[ OD r. c, I" r *a _, _, ,~ z . “iæçëųtææàt i. Rivocy to praduc- prism Ell! or BD lnoicotar at DA i? lBO'
  59. 59. Recording DS remoining prismBUr uit n n I R supraduction DS remaining [NISITT '= L' . ; l' i' R introduction Record only DS l ~r 'r - L L. Normal: 3/DA L introduction JIDA L supraduction
  60. 60. Significance - Measures the Vertical replacement ander dissoctatian and unequal Vertical auction in view of relatively large number of patients ; o “ãràïf “gå w U ÊmrfFÊarø0"ï. ų of a. ..! thefgłlę. "ve -. .n““": 11.17" "“"
  61. 61. Step#l3B lnduced Phoria Test at Near tiri-iiyïiiiïiaziií ` _l I: .gr K “g *i » . ' ' 4- 'i' ? wil a ' ' I ' ' ` . :v n'. - . L g. , I . . . , . :a : ł r' , . ' : Nvt: - . _i _ _ Q l: _p r 19 . ' ' , . . "i .
  62. 62. - Measures the tonic innervations of a muscle oi a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken b , |)0* ,1 _ w' . n - yu ' J 'i ' 'mw' `7. ^""": .i~~= "`c1ii9 "T : ~' m ' m* N, ,, ,I 'l, l 1,113' l l()("t. `1|'. '. '"v 'l ' . w `-" 't' 'I' av I) lt . ulxłv I"` I | '
  63. 63. VVVVVVVVV b b Normal: F _ I! |". ,,v. ll' ` 1"` ', ,:I/ lia”, .c f" Test Distance: 16" or dO cm Test Target: Best VA in reduced SneIlen's chart interpupillary Distance: í lllumination: ii i Control Lens: ï 'i1i'| i: i` i' i : liv i +7 Prism: oa I2A Bl - Measunng Prism OS SA BU - Dissociatinq Prism Response: ~ Procedure: Reduce prism BI until Vertical 'in, ,1!i i olignment ol the targets Record: Remaining prism EI - EXOPHORIA BO - ESOPHDRIA. Indicator ut r ~ LEHZ 'i . ii'i~. L`i~ïii`. , gi, l . tl t `3`, .," I: 'Pr l "4'| _ [R4 . c` * . .I~~ i * of the targets IZ' Bi - Heosuring Prism oo E . C, - Ntsaliunmenl ïlï T E i Vertiml Altgnmant 6 ` au ~ Dissociating Prism R4! uz'
  64. 64. - Measures the tonic innervations of a muscle oi a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken r , |)0* ,1 _ w' . n - yu ' J 'i ' 'gnu' `7. ^""": .t~~= "`c1ii9 "1l“' m ' m* N, ,, ,I 'l, l 1,113' l l()t"t. `1|'. '. '"v 'l ' . w `-" 't' 'I' av I) lt . ulxłv I"` I | '
  65. 65. To determine the change in accommodative convergence that occurs when px accommodates or relaxes accommodation by a given amount Ratio al the accommodative convergence AC (in prism diapters) to the stimulus to accommodation A (in diopters) importance in analysis oi optometric data The AC/ A finding is u key characteristic in the final determination of the diagnosis The most importance findings used to determine the appropriate management sequence ior any given condition FULLTUVHJ' The result al lnduced phariu test , i near ~I_OOD (MEE 4.00) minus with the result ul ndaced phona test I near (0138) y AC/ A ratio = łfl3B +LDD - #88 h Ex. fål38 - 10 exapharin : HEH Sc-l AC/ A ratio ' 12 - IO ' 2 12 irxaphoria mlii
  66. 66. Measures the amount al convergence generated by a diopter of accommodative effort Modified the result of AC/ A ratio to the prism power pattern Ex, #13B = 10 exophoria #13B +l. D0 = 12 exophoria SQL ACIA ratio = 12 - 10 = 2 fiC/ A ratio * 2 : l ACIA ratio ~ 2 : 1 Gradient = 2" / +l. D0 D / "~"l mi: . wt nw m" _ Dit): l ç, l`: ll"qlï`ï_dl`i`? 'l 5715' e "'"` `l` a~. ') l* , ałx- 13" U".
  67. 67. VVV? ? 5Iè“}i'f_i: í;i: Uiiiusa-_J CfU~3~3“C~_'/ ll! i', l3f 'raar . as ilv Test Distance: 15" or 40 cm. Test Target: (cross rjiriri interpupillary Distance: Near lllumination: Room Control Lens: Total near of new Rx (Stepfł7A) Prism: oa 3A BU wiin icc (red dot go“i os 3A ao with icc (red dot 9a“) Responsezbir i". "ai--w u 313 BU with ICC 3A eo with icc iron oor 0 9o'i m oor ii 90') Add to) lenses Reduce (O) lenses Procedure: , t, :iiiri (+) lenses DU until vertical line dancer 2.Reduce (+) lenses DU until equality of Vertical 8. horizontal Vertical line rqųa n'* A'| t, y' Qi". t 145: 'l -| I"` `(1") x I". aullül Dï l ` Nik' . 'P (II, t' " , `1` ' I. ,l 'f' I"'(', , 1% ('l . . ""t IL I.
  68. 68. Recording Significance - Measures the integrity and deterioration of the visual pattem -The remaining lens power that gives equality ot Vertical & horizontal - Measures the degree al 'NET #14!! embedding of the visual pattern NOWPRESÊYOPÊ ” 57055 “M ' WSÃ ' Measures the regencv of the visual 5 problem nnd anisometropio at neor PRESBYOPE -> GrossłiMA - (GISA x me) ' Mefrsures the amount O' 5 S convergence at near th", :D " [rlh v! ' 'gik' U' n" g! , III'I'| [, rl g`f I' _' , (1 g -. 7 .11 ' - nr' j Ile", i. . ł'()l', '_v-ų Q. Clic! ! "`táųn 'v l ' . .1$"" . I I`. r' "n"
  69. 69. Test Distance: 16" ar 40 rm Test Target: interpupillary Distance: Nooi lllumination: -~ : in llll Control Lens: vvvvvv Prism: OD IZÉ; Bl A MëUSUfIH-I] Prism with JCC OS 6:2'. BU - Dissociating Prism with JCC , Response: v of the “Hør-lis I? El - Pži-osuxinq Primi ñ ? id - Onxociozing Płnm ) Procedure: Reduce piism El unli' vertical ulgninciit ol the targets a” "S _a P Record: Rlłniïlllng prism i t Va E l i ų ~ E ` E EO w ZSCIFliCÃEliï. lndmutot u! Ci r ljilãTlfiFtlüïlí 1 E ł Normur M -ilgnru-"l VN! ! 1l'l: xr1rt"i i- ". .st Ly: “" ~/ i/': " " øå" kul I'll' x l jyl' ; l "~ çliï * c* ų ` l "l/ ,yl 11/11 _ | ,g| t tl1` I_', '. l . ,_` " yu , łuzl V. - ', |. . `|1 J "`, ~ | l`| i
  70. 70. - Measures the tonic innervations of a muscle ot a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken i , |)0* ,1 _ r" . n - yu ' J 'i ' 11:17" `7. ^""": .i~~= "`c1ii9 "1l“' m ' m* N, ,, ,I 'l, l 1,113' l l()("t. `1|'. '. '"v 'l ' . w `-" 't' 'I' I* I) lt . ulxłv I"` I | '
  71. 71. Add (o) temas : lis Vertica` line (carter: Hi: *irnrirai (Dani-r) Reduce t-l lenses 'IC Ear. :il 77777777 Test Distance: 16" or : to cm. Test Target: l interpupillary Distance: Near lllumination: Riàicsii: Control Lens: Gross StepiłMA Prl$m2íJUnin| rri'i'1. : rw ml ll*'l1 tlill = 'Jtfl Response: ~ Procedure: l. Am (-) lenses OU until horizontal line darker 2. Flcduci: (-) lenses OU until equality at Vertical a horizontal '*". ' '1*” iii" d'_`, _l`. `jH-`l `. `x""| ełxm'. ų3"~ I| 'l"
  72. 72. _ - _ Significance The remaining lens power that gives _ _ _ ~ Measures the amount of equality of vertical 8. horizontal oooommoootioo , m o, o : g convergence at near under tused i; Vł-! _E_T V condition l NDN-PRESBYDPE = > Gross : NAB - : nsa ' "Wittes the degtee 0' n o embedding of the visual pattern t o l 'y ł , PRESBYOPE _o Gross ons _ (gloo x mo) . Control ens for near point testing l 9 S in the presence of low amplitude ka I' , .. i , llàiųí/ "'Il. ..<I'/ "' 'Li "`l`i` ïr`t`lg ltl. " `X `~ " 1 'l' In” u" ' ' v i"` X ` 31' j '_ i) ~|1 "H ___ ` 'I ł/ l l 1,. '(, l,_. i> 1)' l a' "" als l 13" I l. "
  73. 73. Step#iSB lnduced Phoria Test Through #l4B . .r , r . e , _, 7 (w; ę : r : Ipsr , _ ' ' . X n g. o _ 'i - råtrtł, ?tlčådl om, x P i _ . ._, V . . A'. _ r. i ' . ..if-Eton n 'g' V vWà- *ÊNÊLT l . Jêm t" - ut, 5:- ? i WJJ* ý ' a ' , - u g ' y . _ 'x S _n ll. l.. .tl š '-t'l""tultíïiä` l _ '= .-; :š` V? D 4- < : o _' . . i V 1' ` io V in. _ , A; uit 1 3." “ : ėfíųiųieãlïàsgi:
  74. 74. - Measures the tonic innervations of a muscle of a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken i , |)0* ,1 _ r" . n - yu ' J 'i ' 'put' `7. ^""": .i~~= "`c1ii9 "1l“' m ' m* N, ,, ,I 'l, l 1,113' l l()("t. `1|'. '. ',ov 'l ' o* `-" 't' 'I' I* I) lt . ulxłv I"` I | '
  75. 75. 7777 7777 Test Distance: 16" or 40 cm Test Target: Best VA in reduced Snellen's chart interpupillary Distance: Near lllumination: Headlamp Control Lens: Net łłlzlB = Presbyope Total near al old Rx = Myope Total near ot new Rx = Hyperope Plano = Emmetrope Prism: OU room to prit-daca psisni BG (Chir ul 90 "l Response: Síiqlir tilamnq of the target il" blur) Procedure; increase prism BO until P* blurring. Record: 'niirii nl iiiiair: Il`I hu'. l rw"- Normal: ISÊ. U "Nik olovl? "; l,`jII| .`-l_, l}: łn. .`o`| k. aata) _m i" N p: “Nn “nul-u r IP _ i, l, :N ł, /l | _.l "4`I `_ łW" ' . .:I' n. ” . Al uk.
  76. 76. Indicates the amount of (+) fusional innervations in reserve available at that fixatian distance , . . . 7 'f N” = . M' l III/ I / "'“' `| `””, l`-. |1' : H “łñl x`4"` ` il . . u“' n' i il" , Iłxvil ni" l ii '
  77. 77. 77777777777 Test Distance: IS" or 40 cm. Test Target: Best VA in reduced SneIlen's chart interpupillary Distance: Near lllumination: Headlamp Control Lens: Net 11148 Presbyope go OS Total near of old Rx = Myope (i, 1' T _ T” 'P _L u' ? X l r J `. ų ' . i Total near of new Rx = l-lvperope , y of” r _, .i 7,, ” . . * ': ir'”___~`“; .'; i L . v Plano r Emmetrope o; (i go: 'l f; .~ _JX o'. _ r o v_ . o Prism: Continue stepłłlöA . r- / ~ j tff; ' o-: ïf-Êíäž Response: Break / Recovery -- '#3 ' ' - ' Procedure: li t. .l'_“L÷íV_' iiisii' arwi'i~"šï~fi Lil 'il utlrųili' líl l li. ii l silent- iaiiniii Lil LlllIli ii: 1.; :grin ilmi Record: ÊllE-fliï / Recc-iøeri Normal: 21:3/ 15:1 U __, i Lol* __ 1 . ui" _ `| ' _ ge. ) '. v| . `l"'! j1l"“ , I/, l "H ', .sl~~ "t çfP `ñjlibt u' ". "` , ill , Il . li! _`1l~ - . . l x | ,, /., -(I('II_-D* 'p' . x.v` t"t . u["' I' I3"k | |.l"
  78. 78. '91 Biur Significance - Measures the fusional i 4 innervations and the : ñ [EJ àgyegk accommodation (Boume) convergence in reserve that can be supplied at that point "å Recovery (Single) , ų-tåłflł) 3; ill-l "V" _nJk In. . ł n"ų xN' “Nn
  79. 79. VVV? VVV? ? Test Distance: 15" or 40 cm Test Target: Best VA in reduced SneIlen's chart interpupillary Distance: Nearlllumination: Headlamp Control Lens: Net mae = Presbvope Total near of aid Rx Myope Total near of new Rx = Hyperope Plano = Emmetrope Prism: OU readv to produce prism Bi (013 nt 90") Response: » *z n mm' ~. tw! f i Procedure: Increase prism BI until I" blurnng Record: Sum ot DflSm in both eves Normal: MA D . _ 1 _ , . . , 'iaw' Pawn/ x "ks t : JM-zy I 'I' '. . rr""“ ~. I"". .I1"' 'Him ' '.
  80. 80. Significance - consists of relaxation ofthe amount of (+) fusional convergence being used to binoculariy tixation at the near point test ; o “ãràïf “gå w U ÊmrfFÊarø0"ï. ų of a. ..! thefgłlę. "ve -. .n““": 11.17" "“"
  81. 81. V 7777777777 Test Distance: 16" or 40 cm. Test Target: Best VA IH reduced Snełlerfs chart interpupillary Distance: I-lerrs lllumination: Hctrtiicrmi) Control Lens: Net HMS - Presuyope , Total neur o! old Rx * rlyope t' ` A' : q Total near of new Rx = Hvperape Et: Qi; l Piano - Emmetrope i; X _. .~. -_ (~ jí Prism: iš C`, _` Response: In r . ' . ~. . íųílg Procedure: Increase pvrsm stepimA until aeublmg. then reduce prrsnr Bi UIIIII szngle and (ieu: RQCOIdZFI- l ïvltcl. Normal: IHL [r ' . N 0.71: ~I' q/ øll l 'I' = "`llns ï' kul “pl ' a “n 's , ,,: Il "U/ II / :l')'_ |1l", _`]`: C . lų 'I , .ł, ,l/ 1- 'p' ' "`| ` "lłyłt . .""
  82. 82. g: : k [E] åsreak L , Si E : k 'P l Blur (Double) åRecovery (Single) l ui* __, ,z ` “: r--; `;i~_' -qgu , íllzlłų/ ll i, " ; (,()"": : Cłlłlã' Iiilthl ' -«~'". '.. - n' r H“". .rc. ' " Significance - Measures the maximum inhibition of convergence at near
  83. 83. VVV? ? Test Distance: 16" ar 40 cm. Test Target: Best VA in reduce SneIlen's chart PD: Near lllumination: Headlamp Control Lens: i' ' i Prism: oo I2A Bl - Dissociating Prism IJS 6:7. Hl] ~ Iifsuñtrrrrrri I'M-im D Response: ~ i al the targets rz' rrr- mama. .., Drum e ' w -nmsmmg Drum i Procedure: Reduce prism BU until horizontal olignment of the targets. i Record: Remaining prism EU - HYPOPIIORIA BD - l-lYPERPHDRlAJndicator at L - ZIRTI *Crídlüïžïå b ' Nicol-garnaat Houromol Allgrvnuit Norma: . i . . , . , m . (7 " 71/10 . ni" glt' . tl. ) , l-' , _ l * øs' “a” . tl u* 'x1"` , )(: I'I łlll'llł"_l" :1*, .,| -.| i: 'Pro' iłlã / /C. ,,'.0'-"(', ,~U“v(, ...1ł"". .uišv l.
  84. 84. - To determine the relative vertical position oi the visual axes oi the eyes at distance when fusion has been broken. r , p-- 'ų/ r _ a ra- . n ' - tu s J n, l xl, lï'l, _sI)'l'<, /I_i. ,l`. .`I`d_", `|1 l`l III I ` "" `s 'l' , Q - j - . ` , ;II l [II __ p” 411. . ln f k x N I , l,, l.a~. ')l l al "`t : Iłxm l . Iï" I l' I
  85. 85. V? V7? Test Distance: 16" or 40 cm. (JT) D's Test Target: Best VA in reduced SneIlen's chart l “If”. s; is" interpupillary Distance: Near lllumination: Headlamp Control Lens: Total near of new Rx (StepWA) y i: Wj' . Prism: DD - No prism K å N. " 'CT DS - Ready to produce prism BU or BD, r: na, .n ni. . u. :io Indicator al ad rsa” M r W Procedure: . . . Significance I. Increase prism BU until double. then reduce prism V A Measures the vertical displacement BU until single under dissutiution und unequul duction 2. Increase prism BD until double, then reduce prism in view al relatively large number ur BD until single patients 'i' t”. iii" t l, l., l [Iii] 11,1;/ |1`, r)- "` CII" 'l . (5 "`. ~` ' 'NH rł"'ll 1- "i | "`t . J I' ii"- l Il".
  86. 86. Pnsnu V v DWecuonPñsm aw: -my H Dkecñon E 'Il -ãsmgne E n àooum lê E I u n~ 1. '. .-'* "y L7'l, ø-. I' " jil' `u N, ', /// 'III ry: ', fl" _, .-, DE | ~*z| '~1ra|14| pruanwEãłJ-l : ntrutøzlrlun: R supruducnon [_`: 'g ynnų] n m] [JHE-. m . =I_ 51.p'<1rl| .~ut| _.-n Rtnhuducuon U . '. Record onły OS -> L . nfrndurhrun -Zvoounu- L d A. supru uctton E U B : Jonnr-. L 6/031 L : nfrmåtlclndjn 6/GA Lsunroducuon n I' »"S _ xłJ , `,/ I_`- ; |l _ j | IW t” k '. dlñ V | - 'I' u I V l | HL.
  87. 87. D D Test Target: Sement i* ihm: wat uï r. -;w. :' D Response: DliiiCLlHų' ui naunimu of the lurueis Test Distance: i , L _ , ÷Cleor : iS/ JO or 0.62 EM Type (Jaeger s chart #28) lllumination: Headlamp q “CV” Hon-Presbyope - aria i-Z temas Control Lens: iuiul Iieur už raw Rx: (Steph. Â" A] (Liiii1i_"-. L* LiïLVLiLïiJi) Presbyope - odd P) lemes Procedure: I. i* wvïW: « 'i a -> uriri i-i lenses sphere until difficulty of reading -) Oiilicuity or reading 1 2. -> uriri iii lenses sphere until “W “m” (C"'"9“' difficulty of reading mamee" ~* D" ui' _- _t5"' "". ' <ñï“ iii" s, ,'; ,,l'fJ/ "'I'/ I'_ , `:, í,()k~`: t dl"ji"`l'll-`l "` ' 1.! ! _NH/ zí” I”. "". -|Jk. 'in ""` x' Ilwr
  88. 88. Recording “AAz Amplitude of Accommodation “TPN Total Plus added = (Number of Plus click x 0.25) “ïMAz Total minus added = (Number of minus click x 0.25) 'Significance ~ Measures the projection against senilrty )~ To measure the AA by using t-i lenses to increase the stimulus to accommodation lqíRJ1Iłí1R-}3í-íí-)í-3íí- k . n . 'on 4 , '_ "I _ L. . v v o -, p. a' nïfgłür. )3l1l; ,:f: ln*'”åírko i" `à`p "Êtgäí (tl, ' "`. `X . In! ('fl l I . ' l)( _ 1 . o u , (21 ` _ w . ` . >^ra'l"". '. . -r2""_-. ..- n' *'. ..i t"*g. . n ' ' . ..AW . a ru' ' 'W'-
  89. 89. Step#20 Positive Relative Accommodation D Test Distance: 16" or 40 cm. D Test Target: BVA in reduced Snellen s chart Incæaæknenses H 'enses D interpupillary Distance: Near _ _ D lllumination: Headlamp í í D Control Lens: Net #l4B = Presbyope clear P. mm, ,n men'. Total near ol old Rx = Mvope Total near ot new Rx = Hyperope Significance Plano = Emmetrope The ability al the udduct-vc function to inhibit p Procedme: i: A: -Tïï 'ncæose H 'emes "m" P! Nu' or neutralize stimulation wnoch is directed to its . zo LTC: Reduce (_) lenses until 'st deur fi:4101! us u result D' stimulation tu th? V accommodation mechanism D Record: ~ ï a * 4 JZ: ~
  90. 90. PD: tiear l Response: Výýýýýý? Procedure: of the targets Prism: _ii . __. i. ~ ' Test Distance: 16" or 40 cm Test Target: Best VA in reduced SneIlen's cnart lllumination: Headlamp Control Lens: (ommie . #20 LTC . ni, , , , ». DS GA BU - Dissociating Prism i Record: Remaining prism : ti ' of the targets la' 51- Mi asuring Prism until vertical aliqnntant ? Wim BO - EÉUPHDUIAU - OTJTHOPFÉUÊJIAN D Norm al: OD Fi DS j H `Uiv. ."t"l 'il OS "t - e"'~'ï"“*`** I ~- `Ê`ï ti vi' i. , -'_. i we; ' t-"g x : w ` " wa: A' ci ' 'du - Dissociating Prism _a n E . . V. fliu: ^Ji_)"TYl I
  91. 91. - Measures the tonic innervations oi a muscle ol a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken i , |)0* , r _ r" . n - yu ' J 'i ' 'nur' `7 . ^'""`: .i~~ = "`cm9 "1l“' m ' m* N, ,, ,I 'l, l 1,113' l l()t"t. `1|'. '. '"v 'l ' . w `-" 't' 'I' av I) lt . ulxłv I"` I | '
  92. 92. Step#21 Negative Relative Accommodation D Test Distance: 16” or 40 cm. D Test Target: BVA in reduced SneIlen's chart D interpupillary Distance: Near 'naæsųönensės p) lenses D lllumination: Headlamp D Control Lens: Net #14!! - Presbyope maar In an" I" maar Total near of old Rx - Myope Total near of new Rx - Hyperopa Plano = Emmetrope Significance D Procedurezacti L. T'? : Increase (+) lenses until t" blur Mamma, me exten, ma, m, m. , #2! LTC: Reduce (+) lenses until P' clear mhlb" "CCPWWOPUPO" DRecord: í ' -; *LTÉ i t ' = > LTC ~: '_í: t~'. ' : Lïiiwei : i Normal: +2.D: O (Li 1.; :': ;-. ::: 5šší<: .:: :íi; ':"íï'*? “. ';: :'; '.~»= ,v. '-'í»« asti* ~. ^.^: t'. `r`v= w
  93. 93. Test Dustonce: 16" Or 40 cm Test Target: Best VA in reduced Snelłenš churt . il z _ l PD: Near illuminotion: Headlamp __ g) Control Lens: funtanut* -ï-'Pl LTK J _ V Prism: ųï- a; _ jł ; :_~ ~ , : t "E" OS SA BU - UISSOCiOIIHQ Prism vvvvvvvv k . fíłų. 4* l -/ . , .. Response; of (he targets lz' a: - rtwosurtnq Pnsm b ' EU - Druoootnng Frum Procedure: until vertical aliqnntcnt of the targets jí "S z_ . . , . t [ E [ 5 7 D Record: Remurnmg prusm ' : n . _ _g . a E s | FU - E5OF'rtUł"~`. h3., (I - URTHDFHFJFJIIA. J . Hxas. _anv 'tl V~f! .u_' łthgnm I DNormnl: r- , n ' 111-'1 pt! " , `:~" , yl' xx” N 1 _ I | I , tl , n , NN/ I N ', | 'tym JL. ) "`, "NI
  94. 94. - Measures the tonic innervations of a muscle oi a certain distance - To determine the relative horizontal position of the visual axes of the eyes when fusion has been broken p , |)0* ,1 _ w' . n - yu ' J 'r ' 11:17" `7. ^""": .i~~= "`c1ii9 "T r~' m ' m* N, ,, ,I 'l, l 1,113' l l()t"t. `1|'. '. '"v 'l ' . w `-" 't' 'I' av I) lt . ulxłv I"` I | '
  95. 95. - Uescnbed by BORISH ll945)an over iaggmg procedure done after compietion c~t Zlstep - Paiticularlv n í ; ~ n ~ . z i i "Unatriiïutwuiã v lún n tun THLHÊO lükiEmlrigtrupciiÉiüDhlOPUJti l. #21 LTB - plus lenses that caused the blur remaining in (Tïrltrànslhsig u7n; )a'~íitriu rïrünçu the remaining phoropter : u ñäcųicrñïųirłu Il'l'lCf'| u'ų'>t"(L4 Subjective Refructi: inHÊE-ñL-Iünïá 2' Remove” the new Dom' Cum 'un Dlsmnce Snelle" 5 É-u'; i-. .IIÊ13|'l. i{i'Llfrilltwïųïti`| Ut“'"r(ų chart ( BVA ) The patients attention is directed to the __: ;.ïp; :,-, ,,~, 'u. p,Uï, ;uwi-tgmv. ,i B. V.A. al the distance chart (Badlv blurred) SUöJEG-vv I'r7'DP<`*i"*`*TIUF~`31111009 3. Fu w'. url IS power Plus lens h mr u* HH 14.250 wšcu". ríu : uunfn uv, min 4. The patient is ask to inform the examiner when the letters clear up _ l LJ" 'r 13- . n v' | _ ga. ) t p. łíh. lriilłill ~. I:'l. `_I, I.l. ,". ;`l | I14 t`t "il ` v" , i" , il jy! " _ 1117" 1'. . v f' ` x " 1,1/ j . x . |1 "l k X 'I _u. "' . rr"'“_-. -.I" . .|l"' . ll'»'l rw"` ill"
  96. 96. Expected finding The lens powers remaining in the relractometer ii intent hvvemnm or nn l Delayed Subjective Finding ) Record the correction and the patients VA Ex. Delayed Subjective: OD: +i. S0=-0.7Sxl7S OS: +l.2S--0.25xi0 i' I, L7'_I . i : l : l l, æl/ I, I 'J -4/('11/ VA 20/15 VA 20115 accommodative sp-: ism exists. this technique may produce a greater plus acceptance than was indicated hy routine refractive pracedures Significance -Vniurihle for a patient who comes in with usthenopic symptoms that she-it's little difference between subjective findings 'with the old prescription
  97. 97. Cycloplegic Refraction - The refractive state al the eye when accommodation is totally or portlaly poralyzed by a cvciopieøic - The process or act ol determining the refractive state of the eye when accommodation is totaly or portially paralyzed by a Cycloplegic hdicatiois D This test is useful when ít is suspected that the px has latent hyperapia. a strabismus of accommodative etlology, or nn accommodative sposm. D Cycloplegic refractions are most frequently used for examining children. and all children ander the oge of 3 D The examiner who elects to perform Cycloplegic refractions must be aware of the contralndications and side ellects ol the drug selected for this purpose vir -- , w" , :mr g I" ruv' . ..to ' t l" my wer. ” brei, ” wsíãLae ñ. . din). rus' d " he" I7d'r, '_(. ,1( fl')l7,'. '-c< (, fa I' (. `el-r| "v l "v 7 . nlï"g . I ítlr'. “n'-
  98. 98. 7 ATROPINE use lor 6 voor-s below Problems and Donners I. The parent must cooperote by Instllllng the ointment In the chltfs eye twtce per day Older Adults 9 the need for cydoplegtc refraction decrease: mrteúv with age 9 beyond 40 ot oge. the tiïnphłude ur 'm, 3 dws accommodation decreuses mpttilv Z. Cycloplegic muv lus! us long us 2 weeks 9 099 55 "'0""'9*3'9“' 0' “CWWWWW” 3. The ointment is poisonous and can cause death if : men by mouth 3 rnotordnssøm Monona: phormocemcot agents outonome: into : 4. For a : nou with on interinittent "m w' "n" n u" convergence strohismus or high esophorin i) "'”""'_'f~". m. _ _m 9 complete Cycloplegic could cause a 3 men. constant convergent strobismus '* N' """"* '*' "m" "m haar : and młhønøøriønàn Human; 1 ïàü! anew-ona -ł mammas, In. :mu-mn- immuun; aan-up; 'ï " z IW" In! ! ' I" UV' tl' ' l" ~. '.>'š"; ::: .' Mãžawstztžïúenñïwsåï-w* 'm' dnem I7C'r, '(.1 fï)l7,'. -ed 1,. . aan' t. `_el-t1 "v l t 7 _. slï"á . I 'tlr “t”.
  99. 99. Choice of a Cycloplegic agent Subjzon +B.00--l. OOx90 VA za/ za “""'“““'V as +7.00--l. D0x90 VAZO/ ZU vk -' , ni" _ nvh' g t" ruv' nto ' g n" "ųïłrç ". .s h"'"; ;:01"5l: :)('k' 8:: 'P `. jlłå" d l `N"c" ':7l'r"l. )I`()l, ,,. '-CQ ()f aan! *. `e. r:`| 'v l "C . al"`g . I I Ê. r'1 "n'- Tropicamidem use for Recørding Y_oung Adults D when using pharmocological agents aways record the agent. concentradon. number o! drops, and time adminastered D Record the refraction technique, the correction found. and the resutting VA Ex. Cycloplegic refraction: l drop Ophthoine 115%. 2 droos cyclagel 1% a 10.00 om Static: DD +8.SO= -I.5Dx9S VA ZDI3O DS *7.0D= -LDOx9O VA 20120 9 between ages 16 and 40 9 Iateat hyperapia is sometimes o problem 9 suspected whenever the patient comptnms of heodache and other symptoms associated with near wort: 9 with the use of over logging procedures make the use of cydoplegic refraction
  100. 100. Il routine refractive techniques were unable to relax the accommodative system, additional plus will be found in the spherical component oí the px's refraction under cycloplegia 'coz of the high level ot accommodative activity found in many children, the cylinder power measured during retinoscopy w/ o accommodation , |)l" 'p' . i r" . `|s “yu ' J| r ~ -/ I. -tI . I ltl , ,r wil x/ k - j _ l . " [I/ ' , ,v)l , çr ' - cłl| ,th _"l , NI , jy lt _`-| l. . ln I k x N . . 'l", ,_. a~ ')l | "`t . ulxłv I Q"` I | ' I

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