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Subjective refraction ,[object Object],By ,[object Object],                                              praveen ,[object Object]
Subjective refraction technique rely on the patient’s response to obtain the refractive correction that gives the best visual acuity .,[object Object],If all the refractive errors were simply spherical ,subjective refraction will be easy.,[object Object],Determining the astigmatic portion of the correction is more complex .,[object Object]
Different subjective refraction techniques are employed .09323330039 paul,[object Object]
Cross-cylinder technique[jackson cross cylinder ] ,[object Object],First step in cross cylinder refraction is adjusting the sphere to yield best visual acuity without accommodation .,[object Object],Place the prescription the patient is wearing ,if any ,into a trial frame or phoropter .,[object Object],Fog the eye to be examined with plus sphere while the patient views a visual acuity chart.,[object Object],Then decrease the fog until best visual acuity is obtained ,[object Object]
If no cylindrical correction is present initially ,the cross cylinder may still be used ,placed arbitrarily at 90 0 and 180 0 .,[object Object],To check the presence of astigmatism .,[object Object],If  a preferred flip position is found ,cylinder  is added with axis parallel to the respective plus or minus axis of the cross cylinder until the two flip choices are equal .,[object Object]
If no preference is found with the cross- cylinder axis at 90 0 and 180 0 ,45 0 and 135 0  should always be checked before assuming that no astigmatism is present .,[object Object],Once any cylinder  power is found , axis and power are refined in the usual manner .,[object Object]
Cylinder axis is always refined first .,[object Object],This sequence is necessary  because the correct axis can be found in the presence of an in correct power .,[object Object],But the full cylinder  power will not be found in the presence of an incorrect axis .,[object Object]
To refine the axis place the cross cylinder with its principal meridians 45 0 away from the principal meridians of the correcting cylinder .,[object Object],Present the patient with alternative flip choices and inquiring which is” blackest and sharpest “.,[object Object],Rotate the axis of the correcting cylinder toward the corresponding plus or minus axis of the cross cylinder .,[object Object]
Low-power cylinder are rotated in large steps ,high powered cylinder are rotated in small steps ,repeat the procedure until the flip choices appear equal .,[object Object],To refine cylinder power ,align the cross – cylinder axis with the principal meridians of the correcting lens .,[object Object],As the examiner changes cylinder  power according to the patient’s response .,[object Object],The spherical equivalent of the refractive correction should remain constant . ,[object Object]
That is for every 0.50 D of cylinder power change ,the sphere is changed 0.25 D in the opposite direction .,[object Object],If the cylinder  power is changed a large amount ,the sphere power should be readjusted for best visual acuity .,[object Object],Continue to refine cylinder power until choices appear “about the same “to the patient ,that will be the correct endpoint .,[object Object]
Remember always to use the proper cross cylinder for the patient’s visual acuity level .,[object Object],For eg :- +- 0.25 D cross cylinder is commonly used with visual acuity levels of 20/30 and better .,[object Object],A high cross cylinder [+- 0.50 D or +- 1.00 D ] should be used with poorer vision .,[object Object]
Following steps are used in cross –cylinder refraction .,[object Object],Adjust sphere to the most plus or least minus that gives best visual acuity .,[object Object],Use test figure one or two lines larger than the patient’s BCVA , because the introduction of the JCC produce blur .,[object Object],If cylinder correction is not already present ,look for astigmatism .,[object Object]
Refine axis first ,[object Object],Refine cylinder power .,[object Object],Refine sphere ,cylinder axis ,and cylinder power .,[object Object]
Tricking  ,[object Object],Avoid confusion with previous choices by giving different number to subsequent choices ,[object Object],Which is better ,one or two ,three or four?,[object Object],If the patient persists in always choosing either the first or the second number ,reverse the order .,[object Object]
Clock Dial ,[object Object],When the clock dial is presented to the patient under sufficient fog .,[object Object],The examiner’s first job is to determine the axis of the correcting cylinder .,[object Object],This is done by first asking the patient if he or she can see three lines in any or all of the spokes .,[object Object],And then ask to report in which of the spokes the three lines are the sharpest or most distinct .,[object Object]
Subjective refraction by optom praveen
Most clock dial charts equipped with numbers similar to those on the face of a clock .,[object Object],Expected  response of the patient is that the spoke from 12 to 6 ,from 1 to 7 ,from 2 to 8 o’clock is most distinct .,[object Object],To determine the axis of the correcting cylinder ,the smaller of the two number reported by the is multiplied by 30.,[object Object]
For example ,if the patient reports that the 12 t 6 o’clock spoke  is most distinct the examiner would place the axis of the correcting cylinder at 180 degrees.,[object Object],The examiner then begins adding minus cylinder power ,0.25 D at a time .,[object Object],Questioning the patient each time as to the relative sharpness of the lines in the spokes representing the two principal meridians of the eye . ,[object Object]
If sufficient minus cylinder power is added ,the horizontal and vertical focal lines will be located in the same plane .,[object Object],Then the patient will report that the 12 to 6 and the 3-to -9 spokes are equally distinct .,[object Object],This procedure is referred to as “collapsing the conoid of sturm “ the horizontal and vertical focal line are replaced by a point image .,[object Object]
Monocular  subjective refraction ,[object Object],Monocular subjective refraction consists of the following procedure ,[object Object],Determining the cylindrical correction under fog. ,[object Object],Refining the cylindrical correction without fog .,[object Object],Determining the spherical end point .,[object Object],Following these procedure ,one or more binocular balancing tests are performed .,[object Object]
Determining the cylinder under fog ,[object Object],Suitable fogging lenses will have to be put into place before beginning the monocular  subjective refraction .,[object Object],The left eye is occluded ,a block of letter is introduced at the 6-m distance .,[object Object],Plus power in front of the right eye is reduced ,0.25 at a time until the patient can read all of the 20 /40 letters .,[object Object],Ensures that the eye is fogged by approximately 1.00 D ,so the entire conoid of sturm is in front of the retina . ,[object Object]
The astigmatic chart is presented ,and the axis of the correcting cylinder is determined .,[object Object],If clock dial is used ,the patient is asked first whether three lines can be seen in any or all of the spokes .,[object Object],If he can see then ask the patient to report in which of the spokes the three lines are the most distinct .,[object Object]
Minus cylinder is added to the indicated axis 0.25 D at a time until equality is obtained .,[object Object],Additional minus cylinder power is then added 0.25 D at a time to obtain a reversal .,[object Object],Then the examiner returning to the lowest-power cylinder that brings about equality .,[object Object]
The right is then occluded and the procedure are repeated for the left eye .,[object Object]
Refining the cylinder without fog ,[object Object],On completion of the astigmatic chart test .,[object Object],The right eye is defogged ,reducing plus lens power 0.25 D at a time ,until the best visual acuity line [20/20 or 20/15 ] is reads.,[object Object],When the removal of additional plus power [or addition of minus power ]fails to improve visual acuity ,the spherical lens power is returned to the maximum plus or minimum minus power that resulted in the best visual acuity for that eye .,[object Object]
Beginning with the cylinder power and axis found with the astigmatic chart under fog .,[object Object],The practitioner first refines cylinder axis and then cylinder power .,[object Object]
Crossed –cylinder test for Axis ,[object Object]
Crossed –cylinder Test for power,[object Object]
Additional cylinder check tests ,[object Object],Additional check test for cylinder power .,[object Object],Many patient tended to reject cylinder power in the crossed- cylinder test even though it has been evident both in retinoscopy and in the astigmatic chart test .,[object Object],This occurs ,the patient is asked to watch the smallest readable row of letters .,[object Object]
An additional -0.25 D cylinder is placed in the refractor ,and the patient is asked to report which of the two views appears to be more distinct .,[object Object],If the additional -0.25 D cylinder does not improve the clarity of the letters ,the original cylinder power is left in the refractor .,[object Object]
If the additional cylinder power causes the letters to be more distinct ,the examiner can choose to leave the additional cylindrical power in the refractor.,[object Object]
Additional check test of axis ,[object Object],The additional cylinder check test for axis is sometime referred to as bracketing .,[object Object],It is useful mainly when the power of the correcting cylinder is 1.00 D or more .,[object Object],The patient is asked to view a row of 20/20 or 20/15 letter ,[object Object],And ask to report when the cylinder lens in the refractor is slowly rotated.,[object Object]
When the blur is reported ,the change in the axis is noted mentally .,[object Object],And the test is repeated with the same instructions .,[object Object],For example : if the original correcting cylinder axis is located at 180 degrees .,[object Object],The patient reports a blur at 15 degrees and blur at 165 degrees ,then the examiner can assume that the orginal axis was correct .,[object Object]
Determining the spherical end point ,[object Object],Each eye is fogged to 0.75 or 1.00 D and defogged to best acuity.,[object Object],Maximum plus power of best visual acuity .,[object Object],Examiner should present a block of letters extending from 20/40 to 20/15.,[object Object],We should make a mental note of the patient’s acuity for each eye through the +0.75 or +1.00 D fogging lens prior to defogging .,[object Object]
It is important that accommodation be relaxed in arriving at the monocular end point .,[object Object],For example : +1.00 D fog may blur the right eye to 20/30 ,but it may blur the left eye only to 20/20 .,[object Object],This evidence that the left eye is underplussed [or over minused ] ,and the subjective end point for both eye should be determined again .,[object Object]
Patient instruction ,[object Object],To determine the monocular endpoint correct patient instruction are important .,[object Object],The examiner should understand that the patient’s subjective evaluation of the clarity or distinctness of the letters is not the important consideration .,[object Object],The important ,overriding consideration is the ability of the patient to resolve the letters .,[object Object]
As plus power is decreased 0.25 D at a time .,[object Object],When the point has been reached where an additional decrease in plus power of 0.25 D does not make any more letter readable.,[object Object],On the other hand ,if the examiner allows the patient to respond in terms of clarity of the letter or in terms of which lens is preferred .,[object Object]
Many young patient will continue to accommodate with each 0.25 D of reduction in plus ,with the result that the end point will be completely invalid.,[object Object],When minus lens power is added to the point that accommodation is necessary to keep the letters in sharp focus on the retina ,[object Object],Many patient will notice that the letter appear to be smaller . ,[object Object]
This is purely optical effect ,known as accommodative micropsia .,[object Object],it is right to ask the patient if the letter looks smaller to avoid overminusing the patient .,[object Object],If patient report that the letter are not smaller should not  be taken as evidence .,[object Object]
Binocular balance ,[object Object],The purpose of binocular balancing tests is not to balance the visual acuity but to balance the state of accommodation of the two eyes .,[object Object],If the corrected visual acuity is same in both eye ,the balancing procedure may consist of comparison of the visual acuity for the two eyes .,[object Object],If the correcting visual acuity is not same in both eyes ,then a method not based on visual acuity must be used .,[object Object]
Procedure used for balancing the state of accommodation for the two eyes are often referred to as equalization tests or as binocular balancing tests .,[object Object]
Balancing with little or no fog ,[object Object],On completion of the monocular subjective refraction ,the lenses are left in the refractor .,[object Object],The occluders has to remove from both eyes .,[object Object],The patient’s attention is called to a block of letters at 6 m.,[object Object],Plus lens power is added in front of both eyes until the 20/20 letter are blurred but the 20/25 letter are easily resolved .,[object Object]
This normally requires an increase in plus or a decrease in minus of 0.25 to 0.50 D.,[object Object],Then ask to compare the clarity of the 20/25 letters for the two eyes .,[object Object],Using either prism dissociation or alternative occlusion . ,[object Object]
Prism dissociation ,[object Object],The examiner  place 3      of base –down prism in front of the right eye and 3     of base-up prism in front of the left eye .,[object Object],The patient will see two charts separated –vertically .,[object Object],The upper chart seen by right eye .,[object Object],Patient attention is called to the 20 /25 letters . ,[object Object]
Then asked to report whether the letter are more distinct or easier to read in the upper chart or the lower chart .,[object Object],If the equally distinct for the two eyes, the accommodative state of the two eyes is considered to be balanced ,and the test is over .,[object Object]
If the patient reports a difference in clarity of the letters for the two eyes.,[object Object],0.25 D is added in front of the eye with the better vision and the test is repeated .,[object Object],Often the patient fails to report equal clarity for any lens combination .,[object Object],This problem can be solved by instructing the patient to report “which of the lens combination causes the upper and lower charts to be more nearly equal .,[object Object]
Another way of resolving this difficulty is to give better acuity to the dominant eye .,[object Object],Once the patient’s acuity is balanced at 20/25 the patient is defogged binocularly.,[object Object]
Alternate occlusion ,[object Object],Patient is instructed to compare alternate views of the chart while the each eye is alternately occluded.,[object Object],Occluder in the refractor can be used for occlusion .,[object Object],Fogging to 20/25 .,[object Object],Adding 0.25 D to the better eye ,are done in the same manner of prism dissociation test .,[object Object]
Check Test for the Binocular End point ,[object Object],Once the examiner is satisfied with the binocular balance ,binocular end point can be verified .,[object Object],Patient’s attention is called to the 20 /20 letter .,[object Object],Add +0.25 D sphere to both eye and ask for any difference in the clarity of the letters.,[object Object]
The same question is again  asked after adding 0.25 D sphere .,[object Object],Again third +0.25 D sphere is added ,ask of the difference in the clarity .,[object Object],Expected response are that the 20/20 letters will be “slightly blurred “. With the first 0.25 D of plus .,[object Object],“badly blurred “ with the second 0.25D.,[object Object],“blurred  out “ with the third 0.25 D .,[object Object]
Bichrome test ,[object Object],As a monocular End –point test ,[object Object],The bichrome  test must be done in an almost completely darkened room .,[object Object],Starting with the result of monocular subjective finding .,[object Object],+0.50D or + 0.75 D of spherical power is placed in front of each eye.,[object Object],The red and green filter is placed on the projector.,[object Object]
Subjective refraction by optom praveen
The patient is asked to report which of the letters ,those on the red background or those in the green background –are “sharper blacker ,or more distinct “.,[object Object],The patient is expected to report that the letters on the red background are more distinct than those on the green background .,[object Object]
As the plus power is reduced 0.25 D at a time .,[object Object],At some point the patient should report that the letter on  red and green background are equally distinct .,[object Object],As plus  power is further reduced ,the patient should say those on the green side are more distinct than the red side .,[object Object]
If the original monocular subjective endpoint was correct ,the patient will typically report that the red letters are more distinct with +0.75,+0.50,+0.25 D fog .,[object Object],When all the fog is removed the letter will appear to be equally distinct on both the red green sides .,[object Object]
Prescribing for children ,[object Object],Prescribing visual correction for children often has two goals :,[object Object],Providing a focused retinal image .,[object Object],Achieving the optimal balance between accommodation and convergence .,[object Object],In some cases subjective refraction is impossible because child’s  inability to cooperate.,[object Object],The optimal refraction in an infant  requires the paralysis of accommodation with complete cycloplegia .,[object Object]
The presence of strabismus may modify normal prescribing guidelines .,[object Object]
Myopia,[object Object],[general guidelines for correction of significant childhood myopia],[object Object],Cycloplegic refraction are mandatory .,[object Object],Full refractive error ,including cylinder ,should be corrected .young children tolerate cylinder well.,[object Object],Some will under correct myopia ,other may even use bifocals with or without atropine ,on the theory that prolonged accommodation hastens .,[object Object]
Intentional undercorrection of a myopicaesotrope to decrease the angle of deviation is rarely tolerated .,[object Object],Indentional overcorrection of a myopic error can be of some value in controlling an intermittent  exodeviation .,[object Object],Parents should be educated about the natural progression of myopia and the need for frequent refraction and possible prescription changes .,[object Object]
Contact lenses may be desirable in older children to avoid  the problem of image minification found with high- minus lenses.,[object Object]
Hyperopia,[object Object],When hyperopia and esotropia coexist ,initial management includes full correction of the cycloplegic refractive error .,[object Object],In school age child ,the full refractive correction may cause blurring of distance vision because of the inability to relax accommodation fully .,[object Object],The amount of correction may have to be reduced for the child to accept the glasses.,[object Object]

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Subjective refraction by optom praveen

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