Global Optometry Resources

Clinical Optometric Procedures 1

 CLINICAL OPTOMETRIC
PROCEDURES I
STUDENT MANUAL

AUTHOR (s)
Luigi Bilotto Brien Holden Vision Institute, Sydney, Australia. University of Montreal, Quebec, Canada

Pirindhavellie Govender University of KwaZulu Natal (UKZN) Durban, South Africa

CONTRIBUTING AUTHOR (s)

No additional contributing authors

PEER REVIEWER
Bina Patel New England College of Optometry, United States

PROJECT DIRECTOR, EDITOR-IN-CHIEF

Luigi Bilotto Brien Holden Vision Institute, Public Health Division, Durban, South Africa. University of Montreal, Quebec, Canada

Associate Editor
Pirindhavellie Govender University of KwaZulu Natal (UKZN) Durban, South Africa

Technical Editors
Vicki Evans, Elaine Quinn, Kerryn Hart

Layout Editors
Rajni Chhabra, Prashant Kumar

Graphics
Design, Brien Holden Vision Institute, Sandeep Kumar

Brien Holden Vision Institute Foundation (formerly ICEE) is a Public Health division of Brien Holden Vision Institute

DISCLAIMER:

DISCLAIMER

The material and tools provided in this publication are provided for purposes of general information only. Brien Holden Vision Institute is not providing specific advice concerning the clinical
management of any case or condition that may be mentioned in this publication, and the information must not be used as a substitute for specific advice from a qualified professional.

The mention of specific companies or certain manufacturers’ products does not imply that those companies or products are endorsed or recommended by the Institute in preference to others of a
similar nature that are not mentioned. The Institute makes no representation or warranty that the information contained in this publication is complete or free of omissions or errors. To the extent
permitted by law, The Institute excludes all implied warranties, including regarding merchantability and fitness for purpose, and disclaims any and all liability for any loss or damage incurred as a
result of the use of the material and tools provided.

COPYRIGHT:
COPYRIGHT © 2010 Brien Holden Vision Institute. All rights reserved.

This publication is protected by laws relating to copyright. Except as permitted under applicable legislation, no part of this publication may be adapted, modified, stored in a retrieval
system, transmitted or reproduced in any form or by any process, electronic or otherwise, without Brien Holden Vision Institutes prior written permission. You may, especially if you
are from a not-for-profit organisation, be eligible for a free licence to use and make limited copies of parts of this manual in certain limited circumstances. To see if you are eligible
for such a licence, please visit: education.brienholdenvision.org.
 COURSE OUTLINE

COURSE AIM
This module aims to advance the student's knowledge of the theory behind various clinical procedures used in the
practice of optometry to determine an individual's visual and ocular status.

COURSE OBJECTIVES
The knowledge gained in this module will enable the student to design an appropriate management plan based on
relevant clinical results for the patient's visual comfort and ocular well-being.

On successful completion of this course the learner should be able to:

 Describe the standard optometric examination
 Ensure appropriate infection control in their optometric consultations
 Complete formal records of the optometric eye examination
 Understand, explain and perform preliminary eye testing and various clinical methods to assess visual and ocular
health

COURSE CONTENT
The topics covered in this course include:
 Introduction to standard optometric assessment
 Infection control in the optometry clinic
 Record keeping
 Preliminary eye examination
 Visual health assessment
 Ocular health screening

COURSE DELIVERY

This course is designed to be delivered over 1 year (2 semesters). The total delivery time is 42 hours. In some
contexts COP 1 needs to be divided into 2 courses, COP1A and 1B, each with 21 hours of lecture time. In these
cases, COP 1A will comprise units 1-4 plus Objective refraction from unit 5. COP 1B will comprise units 5 and 6 and
will include topics from subjective refraction to normal fundus findings.

Learning and Teaching Methods & Resources

The suggested teaching methods for this course include: PowerPoint presentations, discussions, role plays, practical
sessions and clinical attachments.
 The practical component attached to this module will involve rotations for clinical practice, observation in the
optometry clinics, screening activities and site visits. This can be varied to suit the local context.
Course resources available at the Brien Holden Vision Institute site: education.brienholdenvision.org.
Student manual: 19 manual chapter units (listed on p4)
 PowerPoint Presentations corresponding to each of the 30 units

Suggested equipment for teaching includes:

 Computer & projector
 White board

Suggested equipment for practical sessions are highlighted in the various procedures outlined in the text.

RECOMMENDED ASSESSMENT

 Written examination
 Objective Structured Clinical Examination (OSCE)

TEXT BOOKS

Prescribed texts
 Brien Holden Vision Institute Global Optometric Resource Module. Brien Holden Vision Institute. 2010.
 Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3rd Edition. USA: MacGraw-Hill
Companies, Inc. 2004.
 Benjamin W. Borish's Clinical Refraction. 2nd Edition. St. Louis: Butterworth-Heinnemann. 2007.
 Elliott DB. Clinical procedures in primary eye care. 3rd Edition. Oxford: Elsevier. 2008.

Recommended readings
 Anderson DR. Testing the field of vision. St-Louis: C.V. Mosby Company. 1982.
 Zadnik K and Lampert R. The Ocular Examination: measurements and findings. Philadelphia: WB
Saunders. 1997.
 Henson DB. Optometric Instrumentation. 2nd Edition. California: Butterworth-Heinemann, 1996.
 Ball, GV. Symptoms in eye examination. London: Butterworths. 1982.
 Benjamin L and James CB. Ophthalmology: investigation and examination techniques. Oxford:
Butterworth-Heinemann. 2006.
 Grosvenor T. Primary Care Optometry. 4th Edition. St. Louis: Butterworth-Heinemann/Elsevier. 2007.
 Brookman KE 1996. Refractive management of ametropia. Boston: Butterworth-Heinemann. 1996.
 Fingeret M, Casser L and Woodcome HT. Atlas of primary eyecare procedures. 2nd Edition. Norwalk, CT:
Appleton & Lange. 1997.
 Milder B and Rubin ML. The fine art of prescribing glasses without making a spectacle of yourself. 3rd
Edition. Gainesville, Fl: Triad Publishing Co. 2004.
 Doshi S and Harvey W. Investigative techniques and ocular examination. Spain: Butterworth-Heinemann.
2003.
 Alexander LJ. Primary care of the posterior segment. 3rd Edition. Norwalk, CT: The MacGraw-Hill
Companies. Inc. 2002.
 Rabbetts RB. Bennett and Rabbetts’ Clinical visual optics. 4th Edition. London: Butterworth-Heinemann.
2007.

USEFUL WEBSITES

Ophthobook: Free online ophthalmology textbook: http://www.ophthobook.com/

American Optometric Association (practice guidelines): http://www.aoa.org/x4813.xml
 TABLE OF CONTENTS
STUDENT MANUAL

1. Introduction
2. Infection control
3. Patient profile and case history
4. Basic ocular inspection and associated procedures
5. Visual acuity
6. Near point of convergence
7. Cover test
8. Motilities
9. Pupillary testing
10. Visual fields
11. Colour vision
12. Objective refraction
13. Subjective refraction
14. Accommodation and presbyopia
15. Muscle balance
16. Ocular health examination
17. Slit lamp biomicroscopy
18. Tonometry and Pachymetry
19. Management plan
20. Phoropter refraction
21. Appendix 1: Comprehensive optometric assessment
22. Appendix 2: Order of refraction tests
23. Appendix 3: Etiology of visual and ocular symptoms
24. Appendix 4: Record card
25. Appendix 5: List of most used abbreviations
 Level 4 North Wing Rupert Myers Building
Gate 14 Barker Street UNSW Sydney 2052
PO Box 6328 UNSW 1466 Sydney NSW
www.brienholdenvision.org
academy.brienholdenvision.org
[email protected]
Brien Holden Vision Institute Academy is the education branch of the
Brien Holden Vision Institute.

Copyright © 2015 Brien Holden Vision Institute

 CLINICAL OPTOMETRIC PROCEDURES 1
RECOMMENDED DELIVERY TIME OF LECTURES

Lecturing time
(no. of hours)
0. Introduction 0.5

1. Infection control 1

2. Patient profile and case history 2

3. Basic ocular inspection and associated procedures 2

4. Visual acuity 2

5. Near point of convergence 0.5

6. Cover test 1.5

7. Motilities 0.5

8. Pupillary testing 2

9. Visual fields 2

10. Interpupillary distance 0.5

11. Colour vision and stereopsis 1

12. Objective refraction 3

13. Subjective refraction 5

14. Accommodation and presbyopia 3

15. Muscle balance 3

16. Ocular health examination 5

17. Slit lamp biomicroscopy 2

18. Tonometry and Pachymetry 2

19. Management plan 0.5

20. Phoropter refraction 3

21. Appendix 1: Comprehensive optometric assessment

22. Appendix 2: Order of refraction tests

23. Appendix 3: Etiology of visual and ocular symptoms

24. Appendix 4: Record card

25. Appendix 5: List of most used abbreviations

 Clinical Optometric Procedures Module

CLINICAL OPTOMETRIC
PROCEDURES MODULE

CONTRIBUTING AUTHORS

Luigi Bilotto Brien Holden Vision Institute, Sydney, Australia, University of Montreal, Canada
Pirindhavellie Govender University of KwaZulu Natal (UKZN) Durban, South Africa
Patricia Hrynchak School of Optometry and Vision Science, University of Waterloo

PEER REVIEWER

Bina Patel New England College of Optometry, United States

Benoit Tousignant University of Montreal, Canada
Jean-Charles Allary Chiswick, London

INTRODUCTION TO THE OPTOMETRIC EXAMINATION

The optometric examination or refraction is aimed at detecting ocular abnormalities and determining functional
corrections for eye defects. The examination must be carried out thoroughly in relation to the specific needs of
the patient. In addition to the detection, the practitioner must suggest or provide remedial visual training where
necessary and provide advice to the patient on aspects of visual efficiency. The comprehensive eye
examination comprises a battery of tests and investigations to elicit the information in order to determine the
patient’s needs, provide a diagnosis and offer remediation (if possible) for the problems reported. In addition to
performing the tests, equally essential is the recording of information which in most cases is a legal
requirement to safeguard both the patient and the practitioner. Ultimately the practitioner must exercise his or
her professional judgment in determining which tests are relevant to the specific patient examination given the
patient complaints. However, he or she must not lose sight of the tests which are mandatory in order to make a
diagnosis regarding the various aspects that are investigated in refraction. These include an assessment of the
motor, refractive and sensory systems and an assessment of the ocular health of the patient. List of tests that
investigate these various aspects are listed in Appendix 1 at this end of this module.

FOUR KEY AREAS OF THE OPTOMETRIC EXAMINATION

A: Preliminary examination
B: Visual function assessment
C: Ocular health examination
D: Management plan

Each of these key areas has numerous investigations or procedures which make up the comprehensive
optometric examination. The procedures follow a sequential pattern from the eliciting of patient complaints,
investigation of tentative diagnoses through a series of problem and patient appropriate tests of eye health,
refraction and binocular vision. The formulation of an appropriate management plan is the end result of the
assessment process. This approach is sometimes referred to as the “problem-oriented” optometric
examination.
June 2012, Version 1-1 Clinical Optometric Procedures 1, 0-1
 Clinical Optometric Procedures Module

PROCEDURES INCORPORATED IN THE KEY AREAS OF OPTOMETRIC EXAMINATIONS

A: PRELIMINARY EXAMINATION
 Patient profile and case history
 Visual acuity
 Near point of convergence
 Cover test
 Motilities and saccades
 Pupil reflexes
 Confrontation fields
 Interpupillary distance measurement
 Colour vision testing

B: VISUAL FUNCTION ASSESSMENT

 Objective refraction: retinoscopy, autorefraction, keratometry
 Subjective refraction
 Corrected visual acuity
 Measurement of horizontal and vertical phorias
 Fusional vergences
 Fixation disparity
 Accommodation testing
 Stereoacuity

C: OCULAR HEALTH ASSESSMENT

 Fundus examination under non-dilated and dilated conditions
 Slit-lamp biomicroscopy
 Tonometry and pachymetry
 Other tests as indicated

D: MANAGEMENT PLAN
Clinical decision making is an integral part of the management plan. It requires a practitioner’s ability for
“clinical judgment, inference and diagnostic reasoning”. The deductive clinical reasoning behind patient care
can be systematically managed by employing the “SOAP” format. This acronym stands for Subjective,
Objective, Analysis and Plans. This basically translated indicates the practitioner would carefully gather the
subjective and objective information gathered from the patient assessment, he would develop an assessment
and plan and follow-up for each problem identified during the comprehensive optometric assessment.

Appendix II has a suggested order for performing various procedures in refraction. This has been adapted from
Clinical Procedures in Primary Eye Care by DB Elliot.

BIBLIOGRAPHY
Elliot, DB. 2007. Clinical Procedures in Primary Eye Care. 3rd Edition. Butterworth Heinemann, Elsevier, Philadelphia”

June 2012, Version 1-1 Clinical Optometric Procedures 1, 0-2

 INFECTION CONTROL

AUTHOR (S)
Luigi Bilotto Brien Holden Vision Institute, Sydney, Australia

PEER REVIEWER (S)

Bina Patel New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Hygiene
 Care of solutions and pharmaceutical agents
 Disinfection
 Protection
 Biohazards
 HIV/AIDS and infection control

INTRODUCTION

Infection Control is an absolutely essential component of the practice of primary eyecare. Given the risks of being
exposed to infectious organisms, it is recommended that all patients be treated as potentially infected individuals.
The clinician must be knowledgeable & remain vigilant about proper hygienic procedures for routine and specialized
eye care. While the optometric environment has been rarely noted to involve invasive procedures, there are numerous
optometric procedures that involve contact with mucous membranes and this very frequently is the area of contact with
pathogenic organisms.
There are several guidelines that the eye care practitioner should follow in order to minimize the risk of cross infection,
that is, from ensure that the practitioner does not transfer infection to the patient or vice versa.

HYGIENE

Hygiene begins with very simple and basic steps. Hand washing, the most essential personal procedure, must
become a reflex and should be performed before, during and after patient examinations.

HAND WASHING
Figure 1.1 provides a diagrammatic representation of the process of hand washing. In cases where there are
no levers to close the water supply, the clinician should use a clean tissue to close the tap and discard the
tissue thereafter.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 1-1

 Infection Control

Figure 1.1 Hand washing procedure. (Inspired by hand washing procedures

suggested by the Royal Children’s Hospital Melbourne)

Suitable hand washing agents listed from the most effective antimicrobial activity includes alcohol preparations,
chlorhexidine, iodophors and plain soap. Newer developments in maintaining hand hygiene include alcohol-based
hand gels which can be very effective in situations where adequate hand washing facilities are unavailable.

CLEANING OF SURFACES
Surfaces such as tabletops need to be cleaned with commercial solvents or solutions to remove dust, dirt, oils or
other accumulations that may harbor organisms (Fig.1.2). Instruments should be constantly cleaned. Areas of dermal
contacts (e.g. phoropters, slit lamp, headrests, etc.) must be wiped with alcohol swabs after examination of each
patient.

Figure 1.2 Cleaning of surfaces

June 2012, Version 1-1 Clinical Optometric Procedures 1, 1-2

 Infection Control

CARE OF SOLUTIONS AND PHARMACEUTICAL AGENTS

EXPIRATION DATES OF SOLUTIONS

Dates on solution and medication bottles should be respected and bottles that are outdated or opened for more than
1 month should be discarded It is advisable to record the opening date on the bottle.

CONTAMINATION OF BOTTLES
Contamination of bottles should be avoided not to spread organisms from one patient to another. Bottle tips should
not come in contact with eyes or dermal areas (Fig. 1.3). Bottle caps must not be placed on surfaces but rather
remain in the practitioner’s hand until the bottle is recapped after instillation of drugs.

Figure 1.3 Contact from the nozzle of the

bottle should be avoided to prevent contamination

DISINFECTION

Disinfection involves the treatment of surfaces or medical devices by an agent to destroy infectious organisms.
Tonometer tips, gonioscopes and other eye contact devices should be washed with soap and water after use then
soaked for 10 minutes in a disinfecting agent. The recommended agent is 1-part house bleach to 100 parts distilled
water solution. Hydrogen peroxide (3%) can also be used instead of bleach solution but it is more costly.
IMPORTANT: Following disinfection, rinse thoroughly with sterile saline and air dry.
Unused bleach: water solution is good for two weeks. The solution used in vials for the disinfection process of
instruments must be changed daily. The vials must also be washed with soap and water. Extending soaking beyond
10 minutes can damage the instruments and is not recommended.
An alcohol swab can also be used to wipe the eye contact devices in the presence of low infection risks or if (for
some reason) the above steps cannot be performed. Treating every patient as potentially infectious, however,
the bleach/water or peroxide methods should be respected as much as possible.
Contact lenses should be washed, rinsed, disinfected & stored appropriately after each trial using an approved
method. Usually contact lenses are cleaned with contact lenses specific cleaning agent, rinsed with saline and
disinfected in 3% hydrogen peroxide. The peroxide is then neutralized appropriately and the lenses are stored in
multi-purpose solution. Alternatively, contact lenses can be cleaned with a cleaning agent, rinsed and disinfected in a
contact lens autoclave in sterile non-preserved saline.
Surgical instruments should be ideally heat-sterilized by autoclave or by ethylene oxide gas sterilization and sterile
wrapped for storage. An alternative, more “office-based” approach is to wash the instruments with soap and water
(using cleaning brushes) and store them in a stainless steel tray with appropriate commercial storage solutions (eg.
benzalkonium chloride). The solution needs to be changed weekly. To dry store, the instruments are rinsed with
saline and air-dried. Before use, they are again cleaned, disinfected with the solution and rinsed with saline.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 1-3

 Infection Control

PROTECTION

Latex gloves should be worn whenever there is a risk of contact with body fluids or tissues, especially in the
presence of a skin break on the patient or you (Fig.1.4). Always wash hands before and after glove use. Eye
protection, masks and gowns should also be remembered and used in instances when there may exist the possibility
of liquid or tissue splashes.

Figure 1.4 Wearing latex gloves decrease chances of exchange

of body fluids between the patient and clinician incase of any skin break

BIOHAZARDS

Waste products (tissues, cotton tip applicators, etc.) should never be left around to be picked up and disposed later.
Wastes should always be disposed immediately in the proper wastebaskets with a garbage bag. Blood & tissue
products must be separated and disposed in specially marked garbage bags. Needles, blades and sharps go in
specifically dedicated hard plastic containers marked for dangerous and contaminated products (Fig.1.5).

Figure 1.5 Sign indicates that the bag contains dangerous and contaminated products

HIV/AIDS AND INFEECTION CONTROL

The current global HIV/AIDS epidemic and the increased risk of cross infection, has provoked a greater emphasis on
disinfection of instrumentation in the health care environment and protection against cross contamination. HIV has
been found in tears and has also been isolated from contact lenses and ocular tissues; however, there have been no
reports of transmission through these routes. Infection of this type generally requires that there must be direct
contact between blood or body fluids and mucous membranes or damaged skin. The practitioner with any sort of
open wound on the hands should ensure that they are gloved when handing a patient to protect the patient if the
practitioner is infected or protect himself if the patient is infected.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 1-4

 PATIENT PROFILE
AND CASE HISTORY

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Patient profile
 Case history

PATIENT PROFILE

A patient’s profile is essential in every eye exam. It involves the extraction of information on the demographics of the
patient and their profile in terms of his or her family life, education, marital status, etc. It has been suggested that a
patient profile will allow the practitioner to be effective in providing patient care if he or she has knowledge of the
patient’s profile. The demographic information extracted facilitates future communication with the patient. In addition,
the significance of the information gathered in this part of the examination is linked in large part to susceptibility to
normal or abnormal conditions of vision or ocular health. For example, a patient who is approximately 50 years of age
is likely to complain of near vision problems due to age related changes in focusing ability at a near distance
(presbyopia). In the broader sense, information elicited also informs the practitioner’s differential diagnosis or
formulation of a tentative diagnosis.
Information extracted includes the following aspects:
 Name of patient
 Address
 Contact details
 Age
 Occupation
 Race/ethnicity
 Gender
 Hobbies/lifestyle
 Education level

These aspects are the first that are recorded in the patient record card (Table 2.1).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-1

 Patient Profile and Case History

Table 2.1 Patient profile aspect of the record card

(Adapted from Clinical Procedures in Primary Eyecare Care: DB Elliot)

Eye Examination Record Card

First name: Age Date:
Surname D.O.B.: Gender:
Address: Contact number:
PX ID

Occupation:

Hobbies: Race:

CASE HISTORY

The Case History comprises a numerous aspects, namely:

1. Communication
2. The chief complaint
3. Patient’s ocular history and ocular health
4. Patient’s medical history
5. Medications
6. Allergies
7. Family ocular and medical history
8. Vocational and recreational visual requirement

INTRODUCTION
Generally, case histories are taken at the beginning of a consultation. However, with experience the eyecare
practitioner will notice that history taking continues throughout the examination as more information arises from
conversations, occurring during the course of the examination. A case history should be taken in an appropriate
location so that the patient is free to provide as much information as they can without any apprehension and respectful
to the patient’s privacy. Ideally the practitioner should be facing the patient and should be positioned at about the
same level. Room lights should be on fully. These simple guidelines will allow the patient to be more comfortable with
the eyecare practitioner and establishes a good rapport with the patient.

MAIN OBJECTIVES OF A CASE HISTORY

1. To elicit reasons for visit
2. To ascertain patient’s expectations
3. To acquire relevant background information
4. To determine the specific tests or procedures that should be performed during the examination
5. To form a tentative diagnosis

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-2

 Patient Profile and Case History

1. COMMUNICATION

Figure 2.1 Communication

 Greet the patient with confidence. Introduce yourself. Be professional

 Establish a relationship of trust
 Show genuine interest
 Be courteous and respectful
 Ask open-ended questions. For example, an open ended question would be: “What difficulties are you
experiencing with your vision?” while a closed-ended question would be: “Can you see clearly at distance?”
 Open-ended questions (open probing) are more likely to elicit useful information, e.g. ‘How does your eye feel?’,
rather than ‘Does your eye feel painful? If necessary, list symptoms or conditions to elicit specific information.
Generally, asking questions which can be answered by a simple ‘yes’ or ‘no’ (closed probing) should be avoided,
unless such a response is all that is sought.
To ensure that a comprehensive case history is obtained, questions should be asked in a logical sequence. Repetitive
or redundant questions avoided. Questions should be asked in a clear and concise manner. The use of jargon and
technical terms must be avoided under all circumstances. Either a standard form or a structured approach can be
employed.
There are six elements that are essential in a case history. They include: the chief complaint, patient’s medical history,
visual and ocular history, medication and allergy history, family ocular and medical history and vocational and
avocational visual requirements.

2. THE CHIEF COMPLAINT

The chief complaint is usually the primary reason for the patient seeking consultation. The patient’s chief complaint
may be a symptom that is concerning them. One may be able to elicit the chief complaint by asking:
 “What is the reason for your visit?’’
 “What brings you to the practice today?’’
 “What seems to be the problem?’’

HOW TO EXPLORE THE CHIEF COMPLAINT?

Once the chief complaint(s) has/have been elicited, more details must be elicited from the patient. Depending on the
complaint the following questions will help gather detailed information.
For example, if the patient comes in complaining of a headache, the information gathered about headache would
cover the following aspects which can be remembered by using the mnemonic DR. FALLOPPES. The pneumonic
is elaborated as follows:

Description of the complaint/symptoms: headache

 Duration: How long does it last? Sometimes symptoms can present themselves for short periods of time due
to their association with other systemic conditions. For example, migraine sufferers would usually experience
a visual aura that lasts for approximately 20 minutes before the headache presents itself

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-3

 Patient Profile and Case History

 Relief or remitting factors: What relieves it? Both of these factors would contribute to one establishing an
appropriate aetiology or tentative diagnosis for the patient.
 Frequency: How often does it occur? It is important to determine the periods of exacerbations and remissions
of the signs or symptoms presented by the patient.
 Associated signs or symptoms: the practitioner must be aware of other associated signs and symptoms to the
patient’s chief complaint. e.g. headache follows loss of vision
 Location: Where is the sign of symptom manifested? For example, headaches can have a specific location,
e.g. temporal, frontal, and occipital, etc. Blurred vision can be at a particular distance, e.g. distance or near,
or in some cases at both distances
 Laterality: e.g. right, left, or both eyes?
 Onset: When did the symptom(s) start? This will help in deciding the aetiology of the condition. For example,
a sudden loss of vision may be associated with a vascular problem. A gradual loss of vision may be associated
with a cataract
 Pain: Is there pain associated with the main complaint. If it is reported, the practitioner should probe further
to determine if it is dull, dull, sharp, piercing, radiating, etc.
 Prescription medication: Does the patient take any prescription medication? If the patient is doing so, what
is the regimen, its regularity, is there any abuse of medication, etc.
 Exacerbating factors: Are there any factors or circumstances that tend to make the symptom experienced
worse?
 Severity: How severe is the sign or symptom being experienced? One may ask the patient to rate the severity
of the problem on a scale from 0 to 10 with 0 being minimal discomfort and 10 being unbearable and debilitating.
This can be especially significant when investigating a complaint of pain.
Regardless of the chief complaint however, the practitioner must still explore other aspects of blurred vision,
flashes and floaters, etc.

AN EXAMPLE OF A PATIENT WHO COMPLAINS OF BLURRED VISION

Routinely, patients should be asked if they have experienced any visual symptoms. Since blur may be due to a range
of causes other than uncorrected refractive error, it is necessary to follow-up a positive response to blur by seeking
further details.

Description of the complaint/symptoms: blurred vision

 Duration: Is the blurred vision constant or transient (lasting only a couple of minutes to hours or days only).
 Relief or remitting factors: Is the vision less blurred when the patient moves closer or further from the task
at hand.
 Frequency: Does the blurred vision last for long periods of time or is it unchanging? If it does change as in
the case of diabetic patients, it can be related to episodes of high blood sugar levels.
 Associated signs or symptoms: Does the patient squint to make the vision better creating a pinhole effect
that has a tendency to improve vision slightly?
 Location: Is this blurred vision at distance or near?
 Laterality: Is the blurred vision bilateral, unilateral, is one eye worse than the other, etc.?
 Onset: Did the blurred vision occur gradually like in the case of age related changes or did is occur suddenly
as in the case of a retinal blood vessel occlusion or a vascular problem?
 Pain: Is there pain associated with the blurred vision? The patient should rate its severity.
 Prescription medication: Does the patient take any prescription medication that could account for the visual
disturbance? In the case of blurred vision, it can be related to the ocular side-effects of the medication.
 Exacerbating factors: Does the blurred vision get worse at various times of the day? For example, myopes,
tend to have greater difficulties with their vision at night or under conditions of low illumination.
 Severity: How severe is the blurred vision? The patient’s function may be a good indicator of the severity
of the symptom.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-4

 Patient Profile and Case History

LIKELY AETIOLOGIES FOR BLURRED VISION INCLUDE

 Ametropia/presbyopia
 Night myopia
 Malingering
 Ocular disease conditions, e.g. cataracts, retinal disease, optic nerve diseases
 Amblyopia
 Accommodative dysfunction
 Constant distance and near blur could be refractive such as astigmatism
 Constant distance blur could be refractive such as myopia
 Intermittent near blur could be refractive such as moderate hyperopia
 Constant near blur - presbyopia or high hyperopia
 There may be other causes of blur or even multiple causes compounding one another
Other chief complaints are explored in a similar manner.

POSSIBLE CHIEF COMPLAINTS COULD INCLUDE

 Decreased vision
 Headache
 Eyestrain/asthenopia
 Itching
 Burning/stinging eyes
 Tearing
 Foreign body sensation
 Double vision (diplopia)
 Flashes
 Floaters
Appendix III contains a list of the various aetiologies of visual and ocular symptoms: adapted from Clinical Procedures
in Optometry: Eskridge et al.

3. PATIENT’S OCULAR HISTORY

 Last eye examination: When? By whom? Outcome? This aspect of enquiry will provide the practitioner
information about the patient’s knowledge of their visual status, the progression of the condition from the last
examination and regularity with which the patient is monitoring their visual status, especially in those patients
where systemic conditions can have detrimental effects on a patient’s visual status.
 It is important to have knowledge of previous ocular disease or trauma/injury. This aspect of investigation would
provide the practitioner with information regarding possible changes that could have resulted since the last visit,
the visual and functional outcomes of conditions previously diagnosed and possible complications that could
ensue.
 An ocular surgery history provides information on what condition the eyes may be found in at examination time
for example if they are aphakic or pseudo-phakic or had any refractive error surgery, etc.
 Any history of strabismus or amblyopia.
For each condition reported the optometrist must ask when the condition was diagnosed and what its current status is.

PREVIOUS PRESCRIPTIONS INCLUDING SPECTACLES OR CONTACT LENSES

One needs to explore the type or purpose of the prescription, age when the prescription was first worn, the age
of the current prescription, the patient’s subjective assessment of current prescription (is it still helping or not).
 Ascertaining when the patient’s first vision correction was prescribed. This will provide information on the onset
of their refractive error.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-5

 Patient Profile and Case History

 The date of the patient’s current prescription will give an indication of how stable their refractive status is. A
comparison can be made between their current and new prescriptions. A sudden change in refractive state
requires further investigation.
 Determining the wearing schedule or regimen of the patient’s current spectacles (e.g. reading only, or distance
only, or both distance and near) may influence the type of lenses prescribed. The prescription is also influenced
by the characteristics of their previous lenses, especially powers, prism (if any), materials, tints, etc.

4. PATIENT’S GENERAL HEALTH OR MEDICAL HISTORY

This should explore the existence of previous and current health problems. This should include the following: heart or
kidney disease, high blood pressure, diabetes, arthritis, general fitness, headaches (those not related to vision) or any
other systemic condition.
Patients who have heart disease, high blood pressure (hypertension) and/or diabetes are at a higher risk of retinal
changes that can have a signification effect on vision.

 Last medical examination: When? By whom? Outcome? This would provide the practitioner with information
regarding the regularity with which they are monitoring their health status and its possible effect on the patient’s
visual status.

5. MEDICATIONS AND ALLERGIES

Specific information should be elicited, namely: drug name, purpose, dosage, compliance, side effects and the
duration of the treatment. Taking note of these drugs would alert the practitioner to the possibility of the nature, course
and ocular side-effects/complications of the drugs and their associated conditions.
Some medications have ocular side effects that may account for symptoms of dry eye, burning eyes or, in some
cases, decreased amplitudes of accommodation resulting in problems at near, etc. It is therefore important for the
practitioner to be familiar with the various drugs, its mode of action and effects and side-effects. If the practitioner is
unfamiliar with the drugs used at the time of the eye examination, looking up at the relevant information is necessary.
Allergies may cause ocular irritation. Patients will often report itchy, watery and red eyes which can be attributed to
allergies. Address how the patient has sought relief/treatment. These could have implications on contact lens wear
and the presentation of certain symptoms. One should note the cause of allergy, if it is environmental or due
to a medication.

6. FAMILY OCULAR AND MEDICAL HISTORY

Family ocular history: glaucoma, low vision/blindness, significant refractive errors (exclude presbyopia). This aspect of
the case history is important because of the genetic implications of certain inherited conditions like retinitis pigmentosa
for instance. Patients with any family ocular history of disease should receive a comprehensive ocular health
examination to rule out the presence of the same condition in the patient.
Family health history: heart / kidney disease, high blood pressure, diabetes, etc. Who suffers from the condition (this is
a factor that is considered with respect to genetic inheritance) like mother, father, sibling(s), grandparents (maternal or
paternal side), etc. How long have they had the condition and what treatment is being used? Again, the implications of
this area of questioning are based on the genetic implications for the patient.

7. VOCATIONAL AND RECREATIONAL VISUAL REQUIREMENTS

This will guide the practitioner to take note of the patient’s special needs and prescribing accordingly, for example,
 Lighting conditions
 Computer monitor use
 Print size(s)
 Working distance(s)
 Safety/eye hazards

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-6

 Patient Profile and Case History

In certain specialty areas, like that of low vision for instance, these aspects of the case history are especially important
to ensure that the individual is able to remain as productive and functional as possible. In addition, closer review of
these factors could indicate to the practitioner if certain environmental or physical settings can be changed without the
need for or dependency of the patient on spectacles.
Careful consideration of all of the aspects listed above can lead the practitioner to formulating a tentative diagnosis
which can be confirmed or refuted by performing clinical testing. Finally when considering the history and testing the
practitioner is able to arrive at a final diagnosis. The patient profile and case history is therefore one of the most vital
aspects of the clinical assessment since it provides direction to the practitioner in terms of investigation and
management or referral.
Refer to Appendix IV for a draft Record Card (Adapted from DB Elliot: Clinical Procedures in Primary Eye Care)

Table 2.1 Common abbreviations used in recording the case history

(Source: Clinical Procedures in Primary eye care: DB Elliot)

Px (or Pt) Patient Rx Prescription

DS Sphere DC Cylinder
CC Chief Complaint DV Distance Vision
NV Near Vision h/a Headache
R Right L Left
RE (or OD) Right Eye LE (or OS) Left eye
B (or binoc) Binocular BE Both eyes
c With s Without
1/52, 3/52 1 week, 3 weeks 3/12, 6/12 3 months, 6 months
 Increase  Decrease
OK Okay Sx Symptoms
FOH Family ocular history FMH Family medical history
GH General health Meds. Medication
LEE Last eye examination LME Last medical examination
Occ. Ointment Gutt. Drops
BID Twice a day TID Three times a day

Refer to Appendix V for a comprehensive list of the “Most commonly used Optometric abbreviations” referenced from
Berman M and Stelmack T. Ophthalmic clinical abbreviations. Journal of the American Optometric Association 1984;
55:601-604.

BIBLIOGRAPHY
rd
Elliot DB. Clinical Procedures in Primary Eye Care. 3 Edition. Philadelphia: Butterworth Heinemann/ Elsevier. 2007.

Eskridge et al. Clinical Procedures in Optometry. Lippincott Williams & Wilkins. 1991.

Berman M and Stelmack T. Ophthalmic clinical abbreviations. Journal of the American Optometric Association 1984; 55:601-604.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 2-7

 BASIC OCULAR INSPECTION
AND ASSOCIATED
PROCEDURES

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Public Health Division, Sydney, Australia

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Face/head
 Nodes
 Sinuses (frontal and maxillary)
 Orbit/rim
 Adnexae (lids, lashes, conjunctiva, lachrymal apparatus)
 Globe
 Thyroid assessment
 Cornea
 Iris color, pupil and anterior chamber

INTRODUCTION

Gross ocular inspection consists of gross visual assessment, palpation and manipulation of the face, eyes, lids and
adnexae to detect any unusual condition or deviation from normal. Although in the course of an eye examination many
structures will be assessed specifically and in detail, it is often critical and useful to get a global picture of the patient
especially in the area of the head and neck. In other words, it is wise to “look at the whole forest, before looking at
each tree”.
Gross observation may be supplemented by some associated procedures to aid not only in the examination and
documentation of findings but also in the diagnosis of abnormal conditions. These will be discussed where pertinent
under each structure or area under inspection.

FACE / HEAD

OBSERVATION
Observation of the face and neck is important in detecting various anomalies that may be related to the patient’s ocular
status or total wellbeing. Areas of interest are listed below:
 Facial expressions and symmetry
 Skin color and texture
 Muscular fasciculation or fibrillation
 Hair color and texture
 Gross eye movements and position
 Head position
June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-1
 Basic Ocular Inspection and Associated Procedures

NODES

PALPATION
Palpation of the pre-auricular and sub-mandibular (Fig. 3.1) nodes for swelling and tenderness can be quite useful in
the presentation of some ocular conditions particularly in cases of red eyes. Normal nodes cannot be felt. Swollen and
tender nodes typically and most often point towards conjunctivitis or systemic infections by viral organisms. Red eyes
secondary to chlamydial infections can sometimes present with swollen but not tender nodes. Severe allergic reactions
and malignant affections can also produce nodal inflammation.

Figure 3.1 Position of the pre-auricular and sub-mandibular nodes

(Inspired by LJ Catania, Primary Care of the Anterior Segment, Appleton and Lange, 1996)

SINUSES (FRONTAL AND MAXILLARY)

TAPPING AND TRANS-ILLUMINATING

Tapping and trans-illuminating the sinuses can be helpful in detecting sinus inflammation.
Tapping is performed by gently hitting over the sinus areas using 1 or 2 fingers to detect tenderness or pain. Trans-
illumination is performed in a completely dark room to assess the sinuses for clarity. Tenderness, pain or the presence
of dark shadows may indicate the presence of fluids or masses within the sinus cavities.

ORBIT AND RIM

PALPATION
Palpation of the bony contour looking for irregularities or breaks may give important clues about the status of the orbit
and rim especially in cases of trauma. Tenderness, pain, lumps or crepitus (air in soft tissues) may prove to be valuable
diagnostic indicators. The practitioner should of course be familiar with the normal aspect of the orbit and rim.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-2

 Basic Ocular Inspection and Associated Procedures

ADNEXAE (LIDS, LASHES, CONJUNCTIVA, LACHRYMAL, APPARATUS)

OBSERVATION AND PALPATION

Observation and palpation of the lids, lashes, conjunctiva, lachrymal apparatus as well as noted abnormalities provide
important diagnostic information. The inspection of tissues under natural lighting is probably the easiest and most
reliable way to examine the mentioned areas. Natural lighting provides a soft illumination and an undisturbed view that
is often necessary to properly assess tissues. Feeling and squeezing abnormalities also yields information about the
content and nature of any observed anomaly.
In assessing structures via observation and palpation, it is worthwhile noting findings concerning color, texture, integrity,
position, symmetry, elicitation of tenderness or pain.

FUNCTIONAL ASSESSMENT
Functional assessment of the adnexae can also be performed by simple visual inspection. The blink quality,
completeness and rate or the tear drainage are best studied while the patient is sitting undisturbed.

LID EVERSION
Lid eversion may be warranted while the patient is sitting in the ophthalmic chair and not necessarily behind a
biomicroscope. The lid should be everted whenever an anomaly or a foreign body is suspected under the lid. A single or
double lid eversion can be performed. A double lid eversion, more properly called lid retraction, is usually reserved
when a foreign body is suspected in the superior cul-de-sac.

SINGLE LID EVERSION

 Position the patient’s head firmly on the chair’s headrest
 Have the patient look down keeping the eyes opened and relaxed
 Grasp the lashes of the lid between the index and thumb of one hand
 With the other, place the index or a cotton tip gently above the lid crease (tarsus)
 Gently press downward on the lid
 Avoid pulling on the lashes; proper pressure is sufficient to cause the lid to evert
 With the lid everted, examine the conjunctiva using a transilluminator or the spotlight

DOUBLE LID EVERSION

 Proceed as above but use a Desmarres Lid Retractor (Fig. 3.2)

Figure 3.2 Desmarres Lid Retractors

 Place the retractor gently over the tarsus (Fig. 3.3 a) until a single lid eversion is obtained (Fig. 3.3b)
 Slowly lift the handle of the retractor to elevate the lid a little higher
 One may have to gently hold the everted lid on the retractor while lifting the retractor (Fig. 3.3c)
 Illuminate and observe the superior cul-de-sac
Note: that a double eversion does not actually take place. The lid is simply elevated enough to expose the deep cul-de-
sac. Care must be taken not to pull the retractor too far back.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-3

 Basic Ocular Inspection and Associated Procedures

a b c

Figure 3.3 Double lid eversion procedure

LID MEASUREMENT
Lid measurement is indicated when ptosis is observed. The three measures shown below must be noted. Since ptotic
patients often attempt to raise the falling lid(s) with the frontalis muscle, it is advisable when indicated to firmly hold
down the forehead muscle with the palm while performing the measurement. The comparison between both eyes is
instrumental in ptosis assessment. As such, the test set-up must be maintained as constant as possible when
measuring each eye.

LID APERTURE (LA)

It is the widest portion of the lid aperture when the eye is in primary position. The LA is taken from the lower lid margin
to the upper lid margin (Fig. 3.4a)

LA

Figure 3.4a Lid aperture measurement for determination of ptosis

LID CREASE (LC)

It is the widest region between the upper lid margin to the lid crease (Fig. 3.4b), which is formed by the insertion of the
levator muscle into the lid tarsus.

LC

Figure 3.4b Lid crease measurement for determination of ptosis

LEVATOR FUNCTION (LF)

It is the measure of distance from the upper lid margin when patient is looking down maximally to the same upper lid
margin when patient is looking up maximally (Fig. 3.4c).

LF

Figure 3.4c Levator function measurement for determination of ptosis

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-4

 Basic Ocular Inspection and Associated Procedures

GLOBE

FINGER TENSION
Finger Tension provides a very gross assessment of intra-ocular pressure (IOP). Finger tension IOP should be reserved
as a last resort where more sophisticated methods are not available or possible (e.g. uncooperative patients, infants,
developing countries).
 Have the patient look down
 Gently press on the globe through the upper lid with the tip of both index fingers
 Compare between the eyes
 Assessment of the globe softness
 The harder the globe, the higher the IOP
 Record as: soft, medium, or hard

RETRO-DISPLACEMENT
Retro-displacement is used to assess the presence of globe congestion (resistance), due to space occupying lesion,
vascular anomaly, or edema. The method is very similar to finger tension IOP except that a more forceful pressure is
applied to the globe in order to push it backward into its socket.
 Have patient close eyes
 Simultaneously push back the globes with your thumbs into orbits.
 Note any asymmetry in globe displacement or bilateral limited displacement (resistance)
 Note patient discomfort

EXOPHTHALMOMETRY
Exophthalmometry is used to look for any forward protrusion (exophthalmos) or backward displacement
(enophthalmos) of the eye(s) in the orbit. The measurement is performed by assessing the anterior projection of the
cornea relative to the lateral orbital rim.

LUEDDE/RULER EXOPHTHALMOMETER (FIG. 3.5)

 Patient looks straight ahead
 Feel bony temporal orbital rim
 Place the notch of the exophthalmometer firmly on it, with the scale facing towards the side.
 Look from the side above the ruler or through the transparent Luedde scale.
 Close one eye to reduce parallax (with the Luedde, align the scales on each side as well)
 Assess and note where the apex of the cornea intersects the mm scale
 Test the other eye
 Example of recording: (OD/OS): 17/19mm

Figure 3.5 Luedde Exophthalmometer

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-5

 Basic Ocular Inspection and Associated Procedures

HERTEL EXOPHTHALMOMETER (FIG. 3.6)

 Loosen the screw of the crossbar and ensure that the numeral scale is on top

Figure 3.6 Hertel Exophthalmometer

 Have the patient look straight ahead
 Feel bony ridge of lateral orbital rim
 Ask patient to close eyes and slowly bring the exophthalmometer forward
 Place right internal arc on right bony temporal rim, then slowly close the exophthalmometer and place internal
arc of left arm on left temporal orbital rim
 Tighten the locking screw and note base reading closing 1 eye to eliminate parallax
 Have patient open his eyes and look straight ahead
 Look into the mirrors and measure where the apex of the cornea falls on the mm scale (Fig. 3.7).

Figure 3.7 Hertel Exophthalmometer in use

 Note result of both eyes

 Take base reading before removing instrument away from patient
 Example of recording: (OD/OS @ base): 17/18 @ 100mm or

NORMS FOR EXOPHTHALMOMETRY

Difference between both eyes < 3mm (Casse et al, 1997)

Caucasians: 12 to 20mm

Africans: 12 to 24mm

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-6

 Basic Ocular Inspection and Associated Procedures

THYROID ASSESSMENT
The thyroid gland consists of a left and right lobe connected inferiorly by the isthmus, a narrow band of tissue roughly
midway between the thyroid cartilage and the suprasternal notch, below the cricoid cartilage. The lobes of the thyroid
surround the cartilage of the trachea between the trachea and the sternomastoid muscle.

PROCEDURE
 Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical.
 Have the patient tilt the head slightly back to accentuate asymmetry or gland enlargement.
 Look for deviations of the trachea.
 Locate the isthmus by palpating just below the cricoid cartilage
 Have the patient swallow. Feel the gland move freely.
 Evaluate the left and right lobes of the gland
 Use the thumb of one hand to fix the lobe on one side
 With the other hand, locate the other lobe between the trachea and sternocleidomastoid.
 Palpate the other side using the index and middle finger
 Identify the cricoid cartilage and move downward 2-3 tracheal rings palpating for the isthmus.
 Move laterally from the midline while palpating for the lobes of the thyroid.
 Reverse hand position and examine the other lobe.

CLINICAL RELEVANCE
A thyroid gland inspection is indicated in cases of systemic and ocular signs and symptoms consistent with
Grave’s disease.
The normal gland is often not palpable. If palpable, the normal gland feels fairly flat, with the consistency of muscle
and should not be tender, spongy, hard, or nodular. A visibly enlarged thyroid gland is called a goiter.

CORNEA

DIRECT ASSESSMENT
Direct assessment of corneal clarity looking for the presence of scars, foreign bodies, infection or inflammation cornea
is often useful and easily performed by simple observation.

CORNEAL SENSITIVITY
Corneal sensitivity measurement can be useful in diagnosing pathological conditions and neurological disorders
affecting the nerves innervating the cornea. Corneal sensitivity can be assessed grossly using the cotton wisp method
or more precisely using the esthesiometer. The qualitative assessment of a difference between the two eyes is more
useful clinically.

COTTON WISP METHOD

 Educate patient about the test and ask him to signal as soon as sensation is felt
 Prepare cotton wisp by pulling and twisting a small thread of the extreme cotton part
 Have patient look up
 Place your hand on the patient cheek
 Point the cotton-tip applicator parallel to the corneal plane
 Move cotton wisp slowly from the side towards the apex of the cornea
 Gently touch the cornea somewhere between the limbus and apex (avoid visual axis)
 Continue touching the cornea with the wisp until the patient signal its sensation
 When sensation occurs ask patient to grade it comparing both eyes
 Observe if patient tears or blinks after the wisp contacts the cornea
 Test the other eye
 Example of recording: OD: 50% of OS corneal sensitivity

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-7

 Basic Ocular Inspection and Associated Procedures

AESTHESIOMETRY
Aesthesiometry is a more precise method that uses a calibrated device. The Cochet-Bonnet esthesiometer, the most
popular one, uses a nylon filament to evaluate the sensitivity of the cornea. Used more often in research modalities, it is
rarely used in practice for diagnostic testing

IRIS COLOUR, PUPIL AND ANTERIOR CHAMBER

INSPECTION
Inspection of the iris and pupil for irregularities or asymmetry in color, size, position and shape is quickly and often best
performed with natural lighting while facing the patient. Anterior chamber clarity can also grossly be assessed via direct
observation searching for findings such as blood or inflammation, which would obscure the view of the iris.

ANTERIOR CHAMBER DEPTH

Anterior chamber depth can roughly be assessed to determine if the patient is at risk of AC angle closure. Although
more precise methods exist, it may be necessary in some cases (e.g. non-cooperative patients, unavailable material) to
do so using a gross estimation method with a penlight known as the shadow test (Fig. 3.8).

PENLIGHT METHOD (SHADOW TEST)

 Have patient look straight ahead
 Dim room illumination
 Place penlight temporally parallel to the corneal plane
 Direct the light towards the nasal limbus
 Determine which percentage of the nasal iris is illuminated
 Record whether the angle is wide open, moderately narrow, or extremely narrow

Figure 3.8 Shadow test method used for anterior chamber angle depth
(Inspired by Eskridge JB, et al., Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-8

 Basic Ocular Inspection and Associated Procedures

Table 3.1 Estimation of AC angle and likeliness of angle closure

Nasal Iris Angle between Angle Probability

Figure Angle Type
Illumination iris and Cornea Grading of closure
A Wide open 100% 45 4 Impossible
Unlikely to
B Open 75% 35 3
Impossible
Moderately
C 50% 20 2 Possible
open
Extremely
D 25% 10 1 Very likely
Narrow
Closed 0% 0 0 100%

Adapted from Eskridge JB, et al., Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.

BIBLIOGRAPHY
LJ Catania. Primary Care of the Anterior Segment, Appleton and Lange 1996
Eskridge JB, et al. Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
Casser L, Fingeret M and Woodcome HT. Atlas of Primary Eyecare Procedures. Appleton and Lange, Conneticut, USA, 1997.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 3-9

 VISUAL ACUITY

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Classification of visual acuity

 Notations of visual acuity
 Clinical testing of visual acuity
 Distance visual acuity measurement
 Near visual acuity measurement

CLASSIFICATION OF VISUAL ACUITY (VA)

Visual acuity is defined as the “spatial resolving capacity of the visual system” (Benjamin, 2006) and refers to the
sharpness of vision or the patient’s ability to recognize a minimum size target. Visual acuity is customarily abbreviated
as 'VA'. The measurement of VA should be performed at every visit on completion of a case history. It is one of the
most informative tests conducted. Visual acuity provides information on;
 Refractive status of the eye
 Indication of macula function
 Indication of neural integrity
One can compare visual status of an eye and/or between one eye and another to see if the visual acuity is similar or
different. VA allows us to compare the sharpness of vision between the two eyes, the eyes of the same patient at
different times, or between the eyes of different patient’s. It provides a scale by which we can communicate our
assessment of a patient’s visual ability to other optometrists.

Figure 4.1 A Visual acuity chart

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-1
 Visual Acuity

TESTS OF VISUAL RESOLUTION

According to Benjamin (2006), there are a variety of tests of visual performance that measure some aspect of the limits
of the visual system’s ability to discern detail or to recognize detailed targets.

These include:

1. MINIMUM DETECTABLE RESOLUTION

Minimum detectable resolution refers to the threshold of an individual’s visual system to detect the presence of a spot or
a line stimulus against its background. This assessment of visual performance does not require the discrimination of
target detail but rather requires the individual to perceive the presence or absence of an aspect of the stimuli presented.
Positive contrast is depicted by a bright stimulus (point or line) against a dark background (Fig. 4.2 a) while negative
contrast is observed when a dark point or line is presented against a bright background (Fig. 4.2 b). Minimum
detectable resolution is usually of little clinical application, except in night-driving vision and is not considered to be a
routine examination technique.

Figure 4.2 (a) positive contrast; (b) negative contrast

2. MINIMUM RESOLVABLE
Minimum resolvable visual performance involves the resolution of detail. Clinical evaluation of VA is based upon this
type of visual performance. Most of our tests of VA are recognition tests that involve the measurement of the smallest
symbols, shapes, letters that can be correctly identified, or resolved, by the viewer.

This type of acuity can be separated into 2 forms:

a) Form sense: (Landolt rings, Tumbling E’s), in which a simple form is used and some task, such as orientation,
is used to determine the acuity (Fig 4.3 a and b).

Landolt C’s/Rings: These are circles with a gap (Fig. 4.3 a). The gap is orientated in four directions, viz. up,
down, right or left. In some cases, charts also include oblique positions of the gaps in addition to cardinal
positions.

Tumbling E’s: This test involves the presentation of an “E” in different orientations (cardinal and/or oblique)
at every acuity level (Fig. 4.3 b). The patient is instructed to identify the direction in which the limbs of the E
are pointing. This test, like the Landolt C test is useful in measuring the VA in people who are not familiar with
letters of the alphabet such as toddlers.

b) True minimum legible: In which complex patterns such as letters or numerals are used as the test stimulus
(Fig. 4.3 c). These are referred to as letter optotypes (targets) (Fig. 4.3 c). These were originally designed
by Snellen using sans-serif letters and later were changed to Sloan letters since the serifs did create
some confusion.

Figure 4.3 (a) Landolt C’s; (b) Tumbling E’s; (c) Letter optotypes

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-2

 Visual Acuity

3. MINIMUM SEPARABLE / VERNIER ACUITY

The assessment of vernier acuity involves the individual’s ability to detect that a group of points or lines are separate
and distinct, e.g. detecting a break in a line. This type of acuity is usually used to measure the resolution capacity of the
visual system. Targets are usually presented as either lines or gratings of equal separation from each other. The patient
has the task of determining the minimum separation between line targets that allows them to distinguish the lines from
each other. For grating targets, the patient has to determine the finest grating that can be distinguished from a uniform
field of uniform luminance.

4. STEREOACUITY
Stereoacuity involves the use of both eyes. It measures a person’s ability to resolve slight differences in distance of
target objects when looking at special stereoscopes. Stereoacuity is measured in seconds of arc (using
stereotests like the random-dot stereogram, for instance).

NOTATIONS OF VISUAL ACUITY

VA expresses the angular size of the smallest target that can just be resolved by the patient.
There are various different ways in which they can be specified, namely:
1. Snellen Fraction
2. Decimal Notation
3. Minimum angle of resolution
4. Logarithm of minimum angle of resolution
5. Visual acuity rating
6. Visual efficiency

1. SNELLEN FRACTION
SNELLEN PRINCIPLE
The Snellen test is a form of minimum legible visual task (i.e. involving the resolution of detail). Helmholtz found that for
2 objects to be distinguished as separate, they must be separated by a minimum angle of resolution of one minute of
arc at the nodal point of the eye. If the images of 2 distant bright objects fall on a single cone receptor in the retina,
the observer will only be aware of a single light stimulus.
If the stimuli are moved further apart so that their images form on 2 adjacent cone receptors, the observer will still be
aware of only a single light stimulus. If the objects are moved still further apart so that one unstimulated cone receptor
lies between the 2 stimulated cone receptors (Fig. 4.4), the observer will be aware of 2 light stimuli. This threshold of the
observer’s ability to resolve detail is represented by the diameter of one foveal cone which is 0.002mm (2 microns).

Figure 4.4 (a) Diagram depicting separation of cones to resolve 2 objects as separate

Figure 4.4a shows a diagrammatic representation of points A and B which represent 2 visual stimuli that are presented
to the eye, N the nodal point of the eye, P the principle plane of the eye, a and b the retinal images of the visual stimuli
A and B respectively.
When considering the angular subtense at the nodal point of the eye, it was found that this threshold was approximately
one minute of arc. This implies that targets must be separated by at least 1' of arc in order for detail to be discernible.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-3

 Visual Acuity

Figure 4.4 (b) Angular subtense to perceive 2 separate visual stimuli

In the construction of an ‘E’ on a letter chart, the thickness of the limbs and the spaces between them each needs to
subtend an angle of ‘1 minute of arc’ at the nodal point of the eye for the eye to detect the separation between the
various parts of the letter E. These gaps in the letter provide identity clues to the viewer. Using the principle of gap
separation and angular subtense of elements of letters presented to a viewer, a test chart consisting of about 10 lines of
letters of different sizes of letters was constructed. The overall height of all of these letters subtended 5 minutes of arc in
total, with the detail size or limb width each subtending 1 minute of arc (Fig. 4.5).

Figure 4.5 Construction of a Snellen E

The overall height of a letter subtending 5 minutes at 6m was measured at 8.73mm. Snellen thus concluded that a test
letter 8.7mm (Fig. 4.6) high presented at a distance of 6m would just be resolvable by an unaided, healthy, 'normal' eye,
giving the patient a visual acuity of 6/6.

Figure 4.6 Height of a Snellen ’E’

If we designed a chart to measure visual acuity using letters which are 8.7 mm high, we could measure the VA on
anyone. For those with normal acuity, this task would be easy. However, for those patients who are either myopic or
hyperopic, this task would be difficult at a 6m distance. The patient would need to move closer to the chart. The
assessment of his VA would entail discerning the 8.7 mm letter at 3 metres, or at 2 metres, etc. This would however be
a cumbersome manner in which to measure visual acuity.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-4

 Visual Acuity

It follows that if a patient is able to discern an 8.7 mm letter at 6 metres, then he will be able to discern a 17.4 mm letter
at 12 metres. So we could thus design a VA chart with letters in multiples of 8.7 mm size changes. For our patient who
could not see the 8.7 mm letters at 6m, we could simply present letters of larger sizes at a distance of 6 m and we can
then determine his VA relative to 'normal' VA.
e.g. If the patient was able to discern the 26.1 mm letter at 6 metres, then we could denote the VA of this patient as
being the same as a normal sighted patient at 18 metres. The VA would be recorded as 6/18.

SNELLEN FRACTION
The Snellen fraction is an expression of the angular size of optotypes by specifying the test distance and the height of
the letters. In this fraction, the number indicating the height of the letters is actually the distance at which the letter
height that is discernible subtends 5 minutes of arc. For example, a 6/6 letter is a letter of a specific height that subtends
5 minutes of arc at 6 meters.

The Snellen fraction is denoted as:

ER T R T st istan
L C T
E T R istan at i L tt subt nds o

NB: The Snellen test assumes 6 meters to be equivalent to optical infinity.

i.e. there is no clinically significant stimulus to accommodation

LETTER SIZE AND TEST DISTANCE

The range of letter sizes (Fig. 4.7) on most charts from top to bottom is as follows:-

6/60; 6/36; 6/24; 6/18; 6/12; 6/9; 6/7.5; 6/6; 6/5.

Figure 4.7 Progression of letter size on a Snellen Chart

The letter 6/60 is ten times larger than the 6/6 letter, i.e. 87mm. If the patient cannot see this letter, then the examiner
should either move the chart closer to the patient or the patient closer to the chart. The chart is moved to a distance of 3
m and the procedure repeated. Following the inability of the patient to resolve the letters at 3m, the chart is moved to a
distance of 1 m. If the patient is unable to read the letters on the chart even at the closest distance prescribed for a
particular chart, then one may follow the sequence below for recording the VA.
June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-5
 Visual Acuity

 Finger Counting (FC) – record the farthest distance fingers are seen
 Hand movement (HM) – record the farthest distance fingers are seen
 Light projection (ability to detect a penlight at different quadrants and distance)
 Light perception (LP = ability to respond to a penlight). A failure of this task is
recorded as NLP = no light perception.

It is important to note that VA charts are designed for used at a distance of 6 meters which represents optical infinity.
When the testing distance is decreased in cases when the patient displays poor VA, then there has to be an
accompanying adjustment incorporated into the trial frame for the closer than infinity testing distance. For example,
when the viewing distance is 4 meters, this distance is 1/4th the distance from infinity (0.25DS). The VA must either be
taken with this correction in place or the subjective finding must be adjusted accordingly.
Projectors and paper charts that present the Snellen letters the right way around are known as direct charts. Those
which present the letters reversed are known as indirect charts. These require the use of a mirror.
In the United States, the test distances are expressed in feet and are referred to as the Imperial notation of the Snellen
acuity, while in many other countries it is expressed in meters (metric notation). Irrespective, these are interchangeable
and one may adopt the notation that best suits him or her. e.g. 20/20 = 6/6.

2. DECIMAL NOTATION
This notation reduces the Snellen fraction to a decimal quantity.

For example, 20/20 (6/6) = 1.0 decimal notation,

20/200 (6/60) = 0.1 decimal notation.

This notation is generally used in European countries. One draw back of using this type of notation is that while it
reduces the VA to a single number, it does not specify the distance at which the test was conducted.

3. MINIMUM ANGLE OF RESOLUTION (MAR)

The MAR is typically expressed in minutes of arc and is equal to the reciprocal of the decimal acuity value or the
Snellen fraction,

For example, 20/20 (6/6) = 1.0MAR,

20/40 = 2MAR, 20/100 = 5MAR.

This notation reflects the angular size of the critical detail with a just-resolvable target.

4. LOGARITHM OF MINIMUM ANGLE OF RESOLUTION (LOGMAR)

This notation was introduced by Bailey and Lovie in 1976. It is merely a common logarithm of the MAR,

For example, 20/20 = 1.0 MAR  LogMAR = log 10 (1.0) = 0.0.

For 20/200 = MAR = 10,  LogMAR = log 10 (10) = 1.0.

It must be noted that when the VA score becomes better than 20/20, then the LogMAR becomes a negative value. These
charts are gradually becoming the favored charts for VA determination because of a consistent progression of size
difference between the lines on the chart, each line on the chart has only 5 letters, each letter on the chart can be
assigned a value of 0.02 on the LogMAR scale. Research studies tend to use this notation to record visual acuities
since it provides a more precise measurement of visual acuity.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-6

 Visual Acuity

5. VISUAL ACUITY RATING (VAR)

This notation is derived from the LogMAR values. VAR = 100 – 50 (LogMAR).

For example, 20/20 has a VAR of 100, while a VA of 20/200 has a VAR of 50.

The VAR is greater than 100 when the VA is better than 20/20. When comparing the LogMAR chart and the VAR, one
would notice that the VAR changes by 5 for each increment of LogMAR.

6. VISUAL EFFICIENCY (VE)

This VA notation/scale was introduced for use in quantifying visual loss for legal and compensation purposes.
VE is assumed to be 1.0 or 100% when the VA is 20/20 and an arbitrary benchmark of 20% (0.2) was adopted
for a VA of 20/200 or 6/60.

(MAR – 1)/9
VE is given by the formula: VE = 0.2

In some cases, it is expressed as:

Log (VE%) = 3.0777 – 0.0777 (MAR)

Table 4.1 Conversion table for distance visual acuity notations: Source: Borish’s Clinical Refraction by WJ Benjamin

Overall
Snellen equivalent Metric letter
VE
LogMAR MAR Decimal Imperial notation size VAR
(at 6M) %
(at 20ft)
(in mm)
-0.30 0.5 3.00 20/10 6/3 109.4 115
-0.2 0.63 1.60 20/13.5 6/4 106.8 110
-0.1 0.8 1.25 20/16 6/5 103.6 6.96 105
0.00 1.00 1.00 20/20 6/6 100.0 8.70 100
0.10 1.25 0.80 20/25 6/7.5 95.6 10.88 95
0.20 1.60 0.63 20/32 6/9 89.8 13.05 90
0.30 3.0 0.50 20/40 6/12 83.6 17.04 85
0.40 3.5 0.40 20/50 6/15 76.5 21.75 80
0.50 3.2 0.32 20/63 6/18 67.5 26.10 75
0.60 4.0 0.25 20/80 6/24 58.5 34.80 70
0.70 5.0 0.20 20/100 6/30 48.9 65
0.8 6.3 0.160 20/125 6/38 38.8 60
0.9 8.0 0.125 20/160 6/48 28.6 55
1.00 10.0 0.100 20/200 6/60 20.0 50
1.10 13.5 0.080 20/250 6/75 13.8 45
1.20 16 0.063 20/320 6/95 6.8 40
1.30 20 0.050 20/400 6/120 3.3 35
1.40 25 0.040 20/500 6/150 1.4 30

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-7

 Visual Acuity

CLINICAL TESTING OF VISUAL ACUITY

VISUAL ACUITY CHART DESIGN

1. SNELLEN CHART
The original Snellen design of chart comprised a single large letter at the top of the chart and smaller letters below. The
number of optotypes increased progressively as the size of the letters became smaller. There have been several
deviations from the original design which include letter design and selection, spacing between letters, size progressions
and the number of letters at each size progression, however the standard Snellen chart still remains a chart with a
single letter at the top of the chart followed by an increase in the number of letters as the letter size becomes smaller.

2. BAILEY-LOVIE DESIGN
The Bailey-Lovie recognized some of the inherent flaws in the Snellen design and developed a set of principles that
make the task of VA measurement the same at each size level. In order to achieve this form of standardization, the VA
task required the following:
 A logarithmic size progression, i.e. a constant ratio from one letter size to the next.
 The same number of letters at each size progression.
 The spacing between the letters and rows must be proportional to the letter size.
 There must be equal or similar legibility for each optotype at each size level.

This chart used a VA scoring in LogMAR units. This scoring allowed for equal additional credit for each optotype that
was read correctly. These charts are available in various forms, namely, landolt C’s, Tumbling E’s, letter charts and
number charts. They have also been constructed in various language variations as well. While the Snellen VA chart is
still more widely used, the LogMAR chart is gaining more popularity based on the aforementioned criteria and there is a
shift toward it becoming the standard chart for VA measurements.

CHART FORMATS
There may be various types of chart formats that VA charts are present in, namely:
1. PRINTED CHARTS
These may be printed on opaque card or plastic. They require direct illumination. Some charts may be printed on
translucent material that may be used with back illumination or may be mounted on a box and would require internal
illumination. Printed charts are usually used at 6 meters (or 20 feet) and acuities are recorded in Snellen notation. In
some cases if the room size does not permit or the patient has low vision, the chart may be presented at an alternative
distance as long as there is an exact measurement of the testing distance in order to record the VA. While 6 meters is
the most commonly used test distance, 4 meters has been recommended by Hofstetter (1973) while making a dioptric
allowance of 0.25D to the refractive correction since the chart is placed closer than optical infinity. It is suggested that
this distance facilitates a comparison with near vision measurements in which 40 cm is the standard testing distance.

2. PROJECTOR CHARTS
Projector chart image angular sizes are independent of observation distance when the projector lens and the patient’s
eye are equally distant from the projection screen. The placement of the projector (Fig. 4.8) is performed carefully and
the VA is recorded in whatever appropriate notation is adopted by the chart.

Figure 4.8 The projector

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-8

 Visual Acuity

3. CHARTS ON DISPLAY SCREENS

Computer generated displays are gradually being used in practice. They bear some inherent advantages such as being
able to vary optotypes, change letter sequences and vary stimulus parameters such as contrast, spacing, and
presentation time to patients.

DISTANCE VISUAL ACTUITY MEASUREMENT

PROCEDURE
1. This test should be conducted under adequate illumination conditions.
2. One should ensure that there are proper instructions given to the patient. Let the patient know that you are
going to assess “how well they can see”.
3. Use the occluder (cover) to cover the patient's LE and record the VA of the RE (Fig. 4.9a). One may just
suggest that the patient form a cup with the left hand and place it over the left eye, ensuring that the fingers are
not placed over the eye and that the patient is not peeking (Fig. 4.9b). One must also ensure that the patient
does not apply too much of pressure on the eye because this can blur the vision to a certain extent.
4. Next, proceed to occlude the RE and record the VA of the LE.
5. Remove the occluder and record the VA of both eyes.
6. Don't correct any mistakes that the patient may make. If the patient reports that he can no longer see, urge him
to try a few more letters by pointing out letters that you know are easier than others so that you get an accurate
assessment of the limit of his VA. We conventionally record the VA of the right eye, then the left eye, followed
by both eyes.
7. is important that one avoid memorization of the letters on the chart. This is best done if one knows which of the
eyes is the poorer of the 2, and then this eye should be tested first. Another way to prevent memorization would
be to allow the patient to read the letters first without the habitual Rx and then with.
8. One needs to ensure that the patient is not peering (sometimes referred to as squinting) in order to get better
visual acuity. This action creates a pinhole effect thereby allowing the patient to resolve smaller letters than
he/she ordinarily would without peering.
9. If the patient has an abnormal head posture, one needs to determine if it’s a posture that he assumes in order
to see clearly, if not, instruct him to keep his head in the upright position. If it is a corrective head posture to
obtain better vision (like in the case of patient’s who have media opacities that cause low vision), the
practitioner must make note of the abnormal head posture.
10. Another method to prevent memorization is to have the patient read the line of letters in reverse.

a b

Figure 4.9 Occlusion of the eye when taking a VA

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-9

 Visual Acuity

RECORDING OF DISTANCE VISUAL ACUITY

If the patient reads an entire line correctly and stops there, then you record that line as his VA, e.g. 6/6.
If the patient correctly reads more than half the number of letters on a line, then you score him as that line minus the
number of letters that could not be read or were miscalled. e.g. The patient reads only the letters that are underlined
below, then the VA measurement will be recorded as:

-2 -2/5
A B C D E (6/9) = 6/9 or 6/9

If the patient reads less than half the number of letters on a line, then you score him as the previous line plus the
number of letters that he correctly identified in the last line.

e.g.,
BC E 6/12 2 2/
6/12 or 6/12
I 6/

Also essential in the recording of a patient’s V is whether the V is being taken with or without a prescription.

VA is abbreviated without correction or with correction

Recordings would thus look like this:

e.g. Unaided VA (sometimes abbreviated UCVA = uncorrected VA or )

Projector chart

OD: 6/6 OS: 6/9 OU: 6/7.5

Or
RE: 6/6 LE: 6/9 BE: 6/7.5

e.g. Best corrected VA [i.e. with Rx] (sometimes abbreviated BCVA = Best corrected VA or )

Projector chart

OD: 6/6 OS: 6/9 OU: 6/7.5

Or
RE: 6/6 LE: 6/9 BE: 6/7.5

OD = Oculus Dexter RE = Right eye

OS = Oculus Sinister LE = Left eye
OU = Oculi Uterque BE = both eyes

N.B.: Recording of LogMAR visual acuity measurements will be discussed in greater detail in the low vision module.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-10

 Visual Acuity

PINHOLE VISUAL ACUITY

The pinhole consists of either a single small hole or multiple small holes. The pinhole allows narrow bundle of light rays
to enter the eye and prevents light scatter to provide an adequate image without the need for additional optical aids.
This measurement is an essential part of the measurement of VA. It is probably the one measurement that gives the
examiner some perspective regarding the goal of the refraction routine. It is the measurement that prevents the
examiner from going down the futile road of trying to achieve 6/6 visual acuity when it is not possible. When the VA
cannot be improved to 6/6, one can deduce that the visual impairment may not be entirely due to refractive error. The
recommended diameter of the pinhole is about 2 mm. Smaller pinholes may reduce the best vision or VA achievable.

Figure 4.10 The pinhole test (with a multiple pinhole)

PROCEDURE
1. The pinhole may be hand-held (Fig. 4.10) or placed in a trial frame.
2. When performing the test, the examiner must ensure complete occlusion of the fellow eye.
3. The examiner must instruct the patient about the aim of using the pinhole.
4. The patient is asked to look through the tiny hole in the lens. This is sometimes quite difficult to achieve.
The patient is therefore encouraged to move his/her head or his/her eyes till he/she is able to find the hole in
the lens. The measurement of VA is the same as without the pinhole lens in place.
5. The test may be performed either at the beginning of the refraction when taking the VA, and if 6/9 or better is
not achieved. It may be performed during the subjective refraction when the examiner becomes aware that
normal vision cannot be achieved. The point at which this test is performed is sometimes an area of contention
among eye care practitioners.
6. A single pinhole may decrease acuity in cases of media opacities. In these cases, the multiple pinhole
is preferred.

INTERPRETATION OF RESULTS
 If the pinhole VA is better than the VA presenting during subjective refraction, then the examiner should be aware
that he might need to adjust the refractive findings to achieve the “goal V ” presented with the pinhole.
 If the VA stays the same, then prompting the patient to achieve better would be futile. The visual acuity may not
improve either due to reasons such as media opacities, optic nerve/macula diseases, strabismus, varying types
of amblyopia, etc.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-11

 Visual Acuity

COMMON ERRORS WHEN TAKING VISUAL ACUITIES

1. Allowing the patient to decide their acuity and not prompting them to try further. Permitting patients to squint.
2. Permitting the patient to look around the occluder or through their fingers.
3. Using a dirty chart or one of low illumination.
4. Placing the chart at an incorrect working distance.
5. Not recording the result immediately and guessing the wrong result at the end of the examination.
6. llowing the patient to use their hand to occlude their eyes but not ensuring that the palm of the patient’s hand
is blocking the eye. This permits the patient to peek through the gap in the fingers.

FACTORS AFFECTING THE MEASUREMENT OF VISUAL ACUITY

1. REFRACTIVE ERROR
 Myopia decreases the VA by approximately one line for every 0.25DS of refractive error.
 Astigmatism decreases the VA by 2 lines for every 0.50DC of refractive error. Oblique astigmatism has a greater
effect on VA than vertical astigmatism which in turn has a greater effect on VA than horizontal astigmatism.
 yperopia generally does not affect V in young patient’s adversely because they can accommodate to neutralize
the error and they appear emmetropic. yperopia, in elderly patient’s on the other hand will decrease the V by
one line for every 0.25DS error present since no accommodation is present to neutralize the error.

2. ILLUMINATION AND PUPIL SIZE

 The brighter the room illumination, with a smaller pupil size will serve to increase the depth of focus effect of the
pupil. The blur circles are reduced and the adverse effect of refractive error is decreased and thus the VA is
improved (similar to the effect of a pinhole).
 In a dark room, the pupil enlarges and spherical aberration increases. Thus there is an increase in the myopia in
most emmetropic and myopic patients.
 Room illumination should therefore be representative of the daily environment. There are some tests requiring the
use of lower illumination levels or situations in which the lighting should be adjusted for the patient, for example,
some amblyopic patients present with better VA under mesopic conditions and low vision Patients with specific
pathological conditions leading to their VA decrease present with better VA when the lighting is not too bright, e.g.
patients with albinism. These are areas that will be covered in greater detail in the specialist areas of clinical
optometry.

3. SPACING BETWEEN LETTERS AND LINES (CROWDING PHENOMENON)

 The closer the spacing of the letters the more difficult it is to discern the letter. Single letter acuity is therefore
better than single line acuity. It is therefore advisable not to use cramped letter charts, especially if they are
Tumbling E's or Landolt C's. This crowding phenomenon is especially important in the diagnosis of and prognosis
for amblyopic patients.

4. CHOICE OF LETTERS / OPTOTYPES

 Targets used in the measurement of VA must follow several specific design requirements. These specially
designed test targets/letters are often referred to as optotypes. The variable legibility, readability, discernability,
and difficulty of the different letters of the alphabet determines the choice of letters on a VA chart. The following
letters have been recommended in the literature:

LTVUCOYFPDZNERSGHB

It was also recommended that each of the letters above appear only once on the total chart and that not more than
one of the following letters appears once on any line:
B-E-S
C-G-O
F-P
D-O
Other letters e.g. 'I' was not included in chart design because it did not fit the 5 x 5 format and it was too easy
to guess.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-12

 Visual Acuity

 Because different letters of the same subtense (angular size) vary in difficulty, it is often found that a patient will be
able to read only some letters on the smallest line that can just be distinguished. Letters that are similar in
appearance are more difficult to distinguish than letters that vary greatly in their appearance.

5. DESIGN OF THE LETTERS

 The 'old-fashioned' printed capitals with serifs/hooks were used since they conformed to the 5 x 5 format. These
decorative features are discarded in modern charts since these serifs obscure the legibility of the letter.

6. CONTRAST
 Printed charts: maximum black/white contrast must be maintained. Charts should not be soiled as this disrupts
the contrast and the thus alters the VA.
 Internally illuminated charts: should be viewed with the room lights on. In a dark room the internal illumination
from the chart generates a contrast glare which degrades the legibility of the letters.
 Modern projector charts: should also be viewed with the room lights on. Older charts which utilize an
incandescent bulb do not provide enough light to be used with the room lights on and therefore it is recommended
that these projectors be discarded.

7. TIME
 One should not rush the patient as he may get the impression that you are in a hurry and he may not try to discern
the smaller letters.

8. CHART LUMINANCE
 In most instances, VA is measured under photopic light conditions.
 Standardized chart luminance range is from 85 to 300 cd/m2. Because it is usually difficult to achieve a specific
luminance level with the various types of charts (printed, projector, display screens), 80 to 320 cd/m2 has been
adopted as a clinical tolerance.

NEAR VISUAL ACUITY MEASUREMENT

BACKGROUND
Just as a patient has to have their VA assessed at distance, so too is it required for near. Just as the patient who has
their V for distance on a 20/20 letter subtend ’ of arc, a 20/20 letter on a near chart subtends a visual angle at the eye
of 5' of arc.
It has been noted that myopic patients without a correction, tend to have a better visual acuity at near than at far, while
a hyperopic patients without correction have better acuity at far than at near. Usually, an individual who has 20/20 VA at
distance tends to also have 20/20 VA at near (if not accommodative anomalies exist), until they reach their early to mid-
forties, at which time presbyopia sets in. Their uncorrected near visual acuity decreases, creating the need for reading
spectacles or bifocals.
Near V is typically measured at distances within an arm’s length. A testing distance of 40cm is usually considered to
be the standard. However, there are special cases in which this distance may be altered.

NOTATIONS FOR NEAR VISUAL ACUITY

There are several different methods/notations that are used to specify the near VA of a patient. They include
the following:
THE M NOTATION
 This notation of “M units” was introduced by Sloan and abel
 In this notation, the size of the letters is indicated by the distance (in meters) at which lowercase letters subtend 5
minutes of arc at the retina. Thus a 1M letter would subtend 5 minutes of arc at a distance of 1meter and is of
1.45mm in height.
 Regular newsprint is usually about 1.0M in size.
 Near VA is usually recorded in this notation as 0.40/1.0M, indicating that the test distance was 40cm and the near
VA was 1.0M letter size, just as with standard recording of VA measurements.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-13

 Visual Acuity

 In cases where patients may bring in the print that they wish to view, one may be able to determine the visual acuity
of that print in M-notation by measuring the height of the letters and multiplying it by 0.7.

THE POINT SYSTEM

 This notation was established by the printing industry to categorize letter sizes with 1 point being equivalent to 1/72
of an inch. This size extends from the bottom of a descender on a letter like “j” to the top of an ascender like a letter
“f”. Usually smaller letters like “x, a, e, etc” are half the size of a total height.
 Newsprint is usually 8 points in size. Therefore the letter “x” for example, is about 4 points.
 Usually an 8 point raring in a newspaper is equivalent to an M unit rating of 1.0M.
 According to Benjamin in Clinical Refraction (2006):

1.0 units 1.4 mm ≈ 8 points (lower- as n spap styl ) ≈ typi al n sp int.

THE JAEGAR NOTATION

 Jaegar was the first to introduce a reading card with paragraphs set in type of ascending size. He numbered the
type available so that the smallest became known as the Jaegar1, or J1 and the largest J20. The notation is given
by the size of print preceded by the letter J. (J2 letter will be equivalent to a 0.6M letter @ 40cm)
 The near VA is recorded as the print size and the test distance, e.g. J6 @ 40cm.
 The lack of standardization of the letter sizes has made the Jaeger notation inappropriate for the measurement
of near VA.

THE N-NOTATION / METER SYSTEM

 Initially the London Faculty of Ophthalmology decided to follow the example of their favorite newspaper which used
Times Roman type-face and they declared this the most suitable for reading-chart use.
 The size label of N4 for example indicated that a standard near test font was being used and that its size
was 4 points.
 The near VA recorded with these charts was recorded in the N notation followed by the distance at which the test
was conducted, e.g. N4 @ 40cm.
 Print of N-notation can be converted to M-notation by using dividing the N-notation value by 8.

N 8 / 8 = 1.0 M

THE REDUCED SNELLEN / EQUIVALENT SNELLEN NOTATION

 The system utilizes the conventional Snellen distance VA chart which is photographically reduced such that a 6/6
letter subtends 5 minutes of arc at the retina at a test distance of 40cm.
 A print size of 1.0M presented at 40cm is usually labeled as 20/50 equivalent because the Snellen fraction of 20/50
is equivalent to 0.40/1.00.
 This is not usually a favored method of recording near VA.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-14

 Visual Acuity

PURPOSE OF RECORDING NEAR VA

The recording of near visual acuities is essential in selection of near fixation targets, determining the patient’s functional
losses as a result of refractive error, pathology, etc. An important purpose of determining a near visual acuity is to
determine an individual’s near vision correction, especially in the case of presbyopes.

PROCEDURE
1. Provide adequate illumination for the near card (Fig. 4.11). The use of additional lighting is sometimes
controversial as this may not be the habitual practice of the patient and by using additional lighting the task
becomes even easier for the patient.
2. Position the near visual acuity chart at 40cm from the patient. In some cases the near chart may be held at
whatever distance the patient is most comfortable at, however it is vital to note this test distance.

Figure 4.11 Near VA chart

3. Occlude the patient’s LE (or if known – the better eye) and proceed with recording the visual acuity of the RE.
4. Ask the patient to identify the smallest line/paragraph of letters that he/she is able to see clearly.
5. Occlude the RE and repeat the procedure for the LE.
6. Remove the occluder and repeat the procedure to obtain the binocular near visual acuity.

RECORDING NEAR VA
This depends on the type of near card that one may utilize to determine the near VA. Record the size of the print that
the patient was able to see and the test distance.

If one uses the Jaegar notation: OD: J3 @ 40cm OS: J6 @ 40cm OU: J3 @ 40cm

In M-notation: OD: 0.40/1.0M OS: 0.40/3.0M OU: 0.40/0.8M

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-15

 Visual Acuity

Table 4.2 Near visual acuity equivalents at a working distance of 40cm

Source: Clinical Procedures in Primary Eye Care (DB Elliot)

Point
N-notation Common usage M-notation J-notation
notation
3 Medicine bottle labels 0.4 3 --
4 Stock market print 0.5 4 1
5 Footnotes 0.6 5 2
6 Telephone directories 0.8 6 3
8 Small column newsprint 1.0 8 5
10 Typewritten 1.2 9 7
13 Books age 9-12 years 1.6 12 10
16 Computer display (80 column) 3.0 14 --
20 Books age 7-8 years 3.5 18 12
24 Large print books 3.0 -- 14
32 Subheadings 4.0 24 15
65 Newspaper headlines 8.0 -- 16

INTERPRETATION OF RESULTS
The near visual acuity measurement that we record is essential in telling us about the functional losses of the patient.
So, one has to note the deviation from the normal. Also note any asymmetry between the 2 eyes.
The visual acuity allows us to cater for the specific needs of the patient, e.g. If the patient needs to read the newspaper,
then the near visual acuity that is required is 1M. So when the examiner is providing the near addition, he needs to
make certain that the patient is able to view the 1M print. If the patient is working in the printing industry, then they
would encounter print even smaller than 1M, the prescription of a near spectacle needs to take this into account.
While the overall procedure of taking a visual acuity will remain the same for most patients, there are some variations
that may be employed in certain circumstances. For example when taking the VA of a patient with nystagmus, one
would need to use a translucent occluder/fogging lens over the eye not being tested. In addition, in nystagmus patients
finding the null point (point of least movement of the eyes), may be essential to obtain a visual acuity assessment. In
cases of Amblyopia, single letter acuity tends to be better than line acuity and therefore each letter should be isolated.
In addition, the age and literacy level of a patient will determine the type of chart being used.

BIBLIOGRAPHY
Benjamin WJ. Clinical Refraction. WB Saunders Company. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 4-16

 CONVERGENCE AND
THE NEAR POINT OF
CONVERGENCE

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Convergence
 Near Point of Convergence (NPC)

CONVERGENCE

Convergence is a fusional movement that is essentially reflex in nature; however, an individual can exert conscious
control over the movement. Most people can be trained to exercise voluntary control. Convergence can thus be
stimulated voluntarily, disparate stimulation (disparity or fusional vergence) and accommodation (accommodative-
convergence synkinesis). The voluntary centre is situated in the frontal oculogyric centre while the reflex action
originates in the occipital lobe.

Figure 5.1 Schematic showing movement of eyes when converging

If an object is brought closer to the eye from a distant position, the light rays from that object are divergent and hence
won’t form a clear, single image on the retina as the eye would be in a distance viewing position. The eye therefore
has to make adjustments to clear the image and make it single. The change in the refractive power of the crystalline
lens enables the patient to restore the clarity of the object, this is known as accommodation. Simultaneously,
compound movements of the extra-ocular muscles, predominantly the medial rectii muscles position the eyes in such
a way that the visual axes now intersect at the object of regard and it is seen singly, this is known as convergence
(Fig. 5.1). The medial rectii like all other extraocular muscles (EOMs) is striate in nature and is therefore under control
of the voluntary nervous system. Therefore, convergence is faster acting than accommodation.

TYPES OF CONVERGENCE
TONIC CONVERGENCE
All muscles exist at a certain base line level of contraction, this inherent convergence due to muscle tonus is referred
to as tonic convergence and the accompanying eye position is referred as the ’physiological position of rest’. When
there is no tonus or innervation to any of the EOMs then the position of the eye is referred to as the ’anatomical
position of rest’.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-1

 Convergence and the Near Point of Convergence

PROXIMAL CONVERGENCE
Proximal convergence is also referred to as voluntary convergence and is induced by the awareness of the nearness
of an object.

ACCOMMODATIVE CONVERGENCE
Accommodative convergence occurs due to the link between accommodation and convergence and is described as
a function of the accommodative effort.

FUSIONAL CONVERGENCE
This type of convergence is also referred to as reflex convergence and is characterized by the eye’s ability to move
into a position to fuse 2 single images into a single concept. It compensates for any excess or deficiency in tonic
convergence using retinal disparity as its stimulus.

QUANTIFYING CONVERGENCE
METRE ANGLE
While accommodation is measured in dioptres it was difficult to apply to convergence and therefore the concept of
the METRE ANGLE was introduced by Nagel in 1880.
Meter angle is defined as that rotation (amount of convergence) of the eye to view an object on the midline at 1m
distance (Fig.5.2).

Figure 5.2 The metre angle

The metre angle is also defined as “the reciprocal of the target distance in meters”, and is equal to the product of the
vergence demand in prism dioptres and the interpupillary distance in centimeters.
Therefore for both eyes to converge at a point 1m in distance, 2 MA effort is required since each eye will rotate by 1
MA. It was found that patients with wider interpupillary distances would need to make a greater rotational effort
versus those that have a narrow interpupillary distance (PD). This presented a problem and thus the concept of the
prism dioptre was introduced.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-2

 Convergence and the Near Point of Convergence

PRISM DIOPTRE
A prism dioptre takes into account the distance by which an image appears to have been displaced. It expresses this
displacement as a function of the distance of a prism from the object (Fig. 5.3).

Figure 5.3 Prism dioptre

If a patient has with an interpupillary distance (PD) of 6 cm converges to the midline to fixate a point at a distance
of 1 m, each eye will turn inward by 3 prism dioptres and there will be a total convergence for both eyes of
6 prism dioptres.

( = prism dioptre)

For distance other than 1m, we used the following formula:

1
Convergence (in ∆) = ×
Distance (m)
P.D. (cm)
2

(N.B.: The above formula applies to convergence of one eye only)

Example:
A patient having a PD = 60 mm fixates on an object along the midline 2 m away.
Calculate the total convergence in prism dioptre.

Convergence = 1/2  6/2

= 1.5 for each eye

Therefore total convergence = 3

In order for the above patient to rotate one eye to view an object on the midline 2 m away, he will have to create the
equivalent of 1.5 of deviational effort in order to make the same effort if a single binocular concept of a total of 3  is
to be obtained.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-3

 Convergence and the Near Point of Convergence

NEAR POINT OF CONVERGENCE (NPC)

The near point of convergence is the point of intersection of the lines of sight of the eyes when maximum
convergence is utilized, while still preserving single binocular vision. The measurement obtained is more correctly
called the ‘NPC distance’. However, in clinical practice it is referred to as the NPC. Patients who have reduced NPC
distances may have visual and ocular discomfort when performing near point vision tasks.

INSTRUMENTATION
1. RAF-rule (RAF= Royal Air Force)
2. Penlight (usually a preferred target)
3. Wolff ball, finger puppet (these are motility targets, but can be used for patients who have problems fixating
on the penlight target).

MEASUREMENT OF THE NPC

There are several methods that may be utilised to measure the NPC. These include:

RAF-RULE TECHNIQUE
Procedure
1. Patient is seated comfortably and is wearing the habitual Rx under full room illumination conditions.
2. The RAF-rule is held below the line of sight at an angle of 45 and the patient is concentrating on the target
consisting of a vertical line with a dot at the midpoint (Fig. 5.4). This position is selected as it is the habitual
reading position.
3. Previously the NPC target merely consisted of a single line, but to facilitate better fixation, the newer target
has a single small dot on the vertical line target. Ask the patient to fixate upon the dot with both eyes open.
Move the target slowly and steadily toward the bridge of the nose, the patient must try and keep the target
single for as long as he/she can and report when the line doubles. The speed of the target movement should
be such that it takes 10 seconds to move the target from 50cm to the bridge of the nose.
4. When the patient reports diplopia, note the distance from the bridge of the nose to the point of diplopia. This
is the subjective near point of convergence. In some cases the patient may not report diplopia even though
the point of maximum convergence has been reached since the suppression mechanism takes effect to
avoid diplopia. In this case, one should employ the objective near point of convergence that is detected
when the examiner observes the deviation of the non-dominant eye. One needs to take note of the break
and recovery points when measuring the NPC.
5. The break point is the point at which the patient reports double (subjective) or the examiner sees one eye
move out (objective).
6. The recovery point is the point at which the patient reports single vision once again as the examiner slowly
moves the target away from the patient (subjective) or the practitioner notices that both eyes are directed at
the target once again (objective).
7. The technique must be repeated several times since it has been known to recede with fatigue. It has been
noted that the NPC can recede in both normal and abnormal patients, however, in patients with binocular
and accommodative dysfunction, it has been found to recede by a greater amount.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-4

 Convergence and the Near Point of Convergence

Figure 5.4 RAF rule technique

(Photo courtesy of Pirindha Govender, University of Kwazulu Natal (UKZN)
Recording
The NPC measurement is recorded in centimeters from the bridge of the nose. It is recorded as break / recovery,
e.g. 10 cm / 15 cm. The measurements should be taken to the nearest ½ centimeter.

Common errors with this procedure include:

1. The patient confuses blurring with diplopia
2. Inappropriate targets (like a pen)
3. Testing in an upward or primary gaze instead of in a slightly inferior position which is the habitual
reading/near point task posture for the eyes
4. Moving the target too rapidly and unsteadily
5. The practitioner not encouraging the patient enough to maintain single binocular vision.

RED LENS TECHNIQUE

Procedure:
 Patient is seated comfortably with habitual Rx in place.
 Place a red lens or filter before one of the patient’s eyes (Fig. 5.5).
 A penlight torch is held at 40 cm away at the level of the bridge of the nose.
 The patient should see a single light that is a mixture of red and white.
 The penlight torch is then moved slowly towards the patient. The patient is instructed and encouraged to fixate
the light and report when a red and white light is seen. Watch for one eye to turn out. This is the break point.
Measure this distance with a PD-rule.
 Move torch away from patient until patient sees a single light again. This is the recovery point. Measure this
distance with a PD-rule.

Figure 5.5 Patient using red lens before right eye

(Photo courtesy of Pirindha Govender, University of Kwazulu Natal (UKZN)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-5

 Convergence and the Near Point of Convergence

For both techniques, the examiner’s observed positions of the point at which the convergence effort is abandoned
by the patient is the indication of the objective NPC.

Outcomes of the NPC test:

1. One eye will swing out abruptly and the other eye which retains fixation is the dominant eye.
2. Both eyes may turn out.
3. Both eyes may turn out and up.
4. The patient may be able to sustain binocular fixation by far a short distance but will try to defeat your efforts
to bring the target closer by backing away from it.
5. Some patients will fail to report diplopia because one eye “switches off” or suppresses and the brain
therefore cannot perceive diplopia. There is then no subjective NPC and the objective NPC must suffice.
If you notice suppression it needs to be investigated further.

Normal values:
According to Scheiman and Wick (2008), the normal values of the NPC differ depending on the test target used.

Accommodative target:
Break: 5 cm ± 2.5
Recovery: 7 cm ± 4.0

Penlight or red lens test:

Break: 7 cm ± 4.0
Recovery: 10 cm ± 5.0

Interpretation of findings:
If a patient has a remote NPC (usually greater than 10 cm), then he would most probably present with symptoms
such as diplopia, frontal headaches, decreased reading comprehension, asthenopia and occasional fatigue when
undertaking near tasks.
These problems are managed with vision training actively or prism prescription passively.

POINTS TO NOTE FOR THE NPC

The NPC when determined using a non-accommodative target like in the case of the red lens test tends to produce
readings that are more receded than that determined by a method that uses an accommodative target like that of the
RAF-rule method. In addition, more recent research conducted by Scheiman have revealed that the NPC when
determined by the RAF-rule method, should ideally be determined using a vertical row of letters as the fixation target
for the patient.

BIBLIOGRAPHY
Scheiman M and Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders.
3rd Edition. Lippincott, Williams and Wilkins. Philadelphia. 2008.
Benjamin WJ. Borish’s Clinical Refraction. WB Saunders Company. Philadelphia. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. Philadelphia. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 5-6

 THE COVER TEST

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Features of ocular deviation

 Cover test assessment of ocular deviation
 Von Graeffe assessment of ocular deviation
 Maddox rod assessment of ocular deviation

FEATURES OF OCULAR DEVIATION

BACKGROUND INFORMATION
The cover test is used to determine whether there is any tendency of the eyes to deviate from well co-ordinated
behavior. If a deviation is detected, the cover test will show a deviation if it is latent (heterophoria - tendency to turn
under certain conditions) or manifest (heterotropia - permanent turn). The cover test can also be used to estimate or
measure the direction and size of the deviation, and give some indication whether it is compensated or not.
Every patient’s deviation must be described in terms of its frequency, direction, magnitude, laterality and comitancy.
 Frequency: may be either constant or intermittent.
 Direction: may be horizontal, vertical or rotatory (cyclo). In addition, no deviation of the line of sight is termed
othortropia/orthophoria. Horizontal deviations are either inward (nasal) deviation from the line of sight (known
as an eso deviation) or outward (temporal) deviation of the line of sight (known as an exo deviation). A vertical
upward deviation of the line of sight of one eye is referred to as a hyper deviation while a vertical downward
deviation of the line of sight and is referred to as a hypo deviation of the eye (Fig. 6.1). When there is a deviation
of the eye around the antero-posterior axis of the eye, then the eye is said to have a cyclo or torsional deviation.
An excyclodeviation is characterized by a temporal rotation of the superior aspect of the globe while an
incyclodeviation is characterized by a nasal rotation.
 Magnitude: According to Daum in Eskridge et al (1991), “the magnitude of the deviation is the angular
measurement of the difference in direction of the lines of sight of the eyes for a specific fixation distance and
direction of gaze”. The magnitude of a deviation is specified in prism dioptre () units.
 Laterality: is usually only specified when the deviation is constant. A constant strabismus may be either unilateral
or alternating. If the deviation is unilateral, then it implies that the deviation is constantly in only one eye, for
example right constant exotropia. If the patient uses either eye to fixate, then the deviation is referred to as an
alternating deviation and the deviating eye cannot be specified due to its alternation. This type of deviation would
simply be documented as an alternating tropia.
 Comitancy: refers to the magnitude of the deviation when the eye changes to various directions of gaze.
If a deviation is comitant or concomitant then it implies that the magnitude of the deviation remains the same
irrespective of the direction of gaze of the patient. If it is incomitant or inconcomitant then it implies that the
magnitude of the deviation changes when the eye shifts its gaze from one direction to another.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-1

 The Cover Test

Figure 6.1 Diagrammatic representation of tropias

BINOCULAR IMPLICATIONS
The use of the information gathered from establishing the binocularity of the patient has several implications:
 The clinician may chose to perform further testing of the oculomotor system
 There may have to be modifications in the typical refraction routine. Additional specific tests may need to be
performed. For example, a patient who has a tropia is considered monocular and therefore cannot undergo
binocular balancing tests.
 The binocular status may suggest the presence of eyestrain, headaches, decreased performance, Amblyopia
or reduced stereopsis.

COVER TEST ASSESSMENT OF OCULAR DEVIATION

The cover test can be divided into 2 categories, viz. objective and subjective.

OBJECTIVE COVER TEST

The objective cover test is sometimes termed the ’cover-uncover’ test. It is probably one of the most important of all of
the tests to determine the oculo-motor balance of a patient. It may be carried out at distance and near. It can also be
carried out on patients wearing no correction or wearing a habitual prescription. If the patient has a habitual prescription
then the cover test should be conducted with the prescription on at all times when tested. According to Benjamin in
Borish’s Clinical Refraction (2006), the unilateral cover test confirms the presence of a tropia or phoria and defines
its directions.

There are 2 types of cover tests:

1. Unilateral cover test (cover-uncover test)
2. Alternate cover test

1. UNILATERAL COVER TEST (COVER-UNCOVER TEST)

The unilateral cover test is performed by placing an occluder in front of one eye and then observing the movement, if
any, in the fellow eye. This test is used to detect the presence of a tropia / heterotropia / strabismus. A tropia is a
deviation of the eye that is visible by simply looking at the patient. In Figure 6.2, when observing the position of the
patient’s eyes, once can see that the right eye is turned inward. This eye is the deviating eye while the other eye is the
fixating (dominant) eye. One would therefore classify this deviation as an esotropia.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-2

 The Cover Test

Figure 6.2 Schematic of unilateral cover test

2. ALTERNATE COVER TEST

The alternate cover test is performed by alternating the occluder from one eye to the other while the patient fixates a
target and observing the movement, if any, in the eye that has just been uncovered (Fig.6.3).

Figure 6.3 Schematic of unilateral cover test showing an esophoria.

PERFORMING THE COVER TEST

AIM
 The cover test is an objective method of evaluating the presence, direction and magnitude of a strabismus (tropia)
or phoria

EQUIPMENT
 VA chart
 Occluder
 Near point target
 Overhead lamp (only if required)

SET-UP
 Patient wears the habitual Rx for the distance being tested, i.e. either distance Rx or near Rx as in the case of
presbyopes.
 Choose a single letter as a target, on a line above the patient’s best VA in the worse eye, (preferably a letter at
the edge of a line to avoid distractions). Either you or the patient can hold the target (whichever makes you
comfortable) at 40 cm to stimulate accommodation. If the habitual working distance is not 40 cm, then the chart
for near cover test must be held at the patient’s habitual working distance
 If the patient’s VA is 6/18 (20/60) or less, then the target must be a spot of light, however, if the patient’s VA is
better, then a spot of light is not a preferred target since it will not stimulate an under corrected hyperope’s
accommodation
 The room must be well illuminated for eye movement observation. A lamp placed directly above patient may
be used if needs be
 The examiner must be positioned so that observation of the eyes is possible without interfering with the patient's
view of the target

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-3

 The Cover Test

PROCEDURE: UNILATERAL / COVER-UNCOVER

1. Start off with both eyes open, and initially hold the occluder at the patient’s nose (Fig. 6.4A). To test the left
eye, cover the patient's right eye and observe the left eye for movement as soon as the right eye is covered
(Fig. 6.4B). Remove the occluder and wait for two seconds before covering the right eye again, thereby
allowing both eyes to fixate the target. This step is performed to test the presence of a slight deviation in the
left eye which may not have been perceptible the first time the right eye was covered.
2. To test the right eye, start with both eyes open (Fig. 6.4C) and cover the patient's left eye (Fig. 6.4D).
Observe the right eye as soon as the left eye is covered. Remove the occluder and wait for two seconds
before repeating (Fig. 6.4).

Figure 6.4 Unilateral cover test to diagnose a left exotropia

3. If no movement is observed then there's no tropia, in which case the patient is said to have an
ORTHOTROPIA (however, do not discount the presence of a microtropia – this will be discussed further
in the Orthoptics course)
4. If there is an outward movement, then it implies that the eye was occupying an inward position and
therefore the patient is said to have an ESOTROPIA
5. If there is an inward movement, then it implies that the eye was occupying an outward position. Therefore
the patient is said to have an EXOTROPIA (Fig. 6.4 illustrates the findings in a patient with a left exotropia)
6. If there is an upward movement, then it implies that the eye was in the downward position. Therefore the
patient is said to have a HYPOTROPIA
7. If there is an downward movement, then it implies that the eye was in the upward position and therefore
the patient is said to have a HYPERTROPIA

RECORDING
 Orthotropia: (no horizontal or vertical deviations)
 Exotropia = XOT or XT
 Esotropia = SOT or ET
 Hypotropia = hypotropia
 Hypertropia = hypertropia

INTERPRETATION OF FINDINGS
Alternating strabismus
 If upon covering the left eye, the right eye makes a movement to take up fixation and a versional movement is
made by both eyes, that suggests a tropia of the right eye.
 Upon removing the cover however, the right eye remains fixating (without versional eye movement).
 When the cover is placed over the right eye, now the left eye moves to take up fixation, and similarly a versional
movement of both eyes can be observed, which suggests a tropia of the left eye. Upon removing the cover from
the right eye, the left eye remains fixating and there is
no versional movement of the eyes. Then in which eye is the tropia? The deviated eye as well as the fixating eye
can vary and this confirms the presence of an alternating strabismus.
 In this case the deviating eye cannot be specified as it would be with a unilateral strabismus.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-4

 The Cover Test

PROCEDURE: ALTERNATING COVER TEST

 Start off with both eyes open (Fig. 6.5).
 Place the occluder over one and then move the occluder over the patient’s other eye so that at no time both eyes
are allowed to fixate the target together (Fig. 6.5 B and C).
 Upon moving the occluder to the fellow eye, the examiner must observe any movement of the eye that has just
been uncovered.

Figure 6.5 Alternate cover test diagnosing exophoria (observe position of eye under occluder)

 If no movement observed then there's no phoria, in which case the patient is said to have ORTHOPHORIA
 If there is an outward movement, then it implies that the eye was occupying an inward position. Therefore the
patient is said to have an ESOPHORIA
 If there is an inward movement, then it implies that the eye was occupying an outward position. Therefore the
patient is said to have an EXOPHORIA
 If there is an upward movement, then it implies that the eye was in the downward position. Therefore the patient
is said to have a HYPOPHORIA
 If there is a downward movement, then it implies that the eye was in the upward position. Therefore the patient
is said to have a HYPERPHORIA

RECORDING
 Orthophoria: (no horizontal or vertical deviations)
 Exophoria = XOP or XP
 Esophoria = SOP or EP
 Hypophoria = hypophoria
 Hyperphoria = hyperphoria

The practitioner can through clinical experience estimate the deviation or measure the deviation using prisms. This will
be further explained in your binocular vision / orthorptics module. If you determine a measurement, then it should be
recorded. For example, you measure a constant XOT of 4 prism dioptres in the right eye, then this result is recorded
As: 4RXOT

EXPECTED VALUES
Distance phoria: 1 XOP ± 1
Near: 3 XOP ± 3

Note: Patients with binocular vision anomalies may present with diplopia, abnormal head posture, reports of eyestrain /
asthenopia and various other complaints based on the type of deviation that exists and its magnitude, frequency, etc. All
of these factors will be explored further in the binocular vision module.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-5

 The Cover Test

SUBJECTIVE COVER TEST

The subjective cover test was introduced by Duane in 1925. He called it the parallax test. This test is performed to
assess a phoria. It is sometimes referred to as the Phi phenomenon and describes the patient’s perception that the
target object is moving during the cover test.

Figure 6.6 Ray diagram showing the subjective cover test for an esotrope.

In Figure 6.6, a case of esophoria with the right eye being covered and then the cover is moved to the left eye. The
image in the right will initially fall on the nasal retina (B’R) and the image will be projected temporally (i.e. to the right of
the eye: B’R).
Due to these movements, the individual will perceive the fixation object apparently jumping to the right (B’R).
Consequently the right eye will rotate rapidly to return the image to the fovea (M’R).

OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE

VON GRAEFE ASSESSMENT OF OCULAR DEVIATION

The Von Graefe method measures the phoria subjectively. It uses dissociating prisms and measuring prisms. It has the
same prerequisites as that of the objective determination of the deviation. The target still has to be one of detail that
would stabilize accommodation and provide good target alignment. It is performed at distance and near and can be
performed with or without an Rx.

PURPOSE
The von Graefe phoria test is a subjective method of evaluating the presence, direction and magnitude of a phoria at
distance or near

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-6

 The Cover Test

EQUIPMENT
 Phoropter with Risley prisms (Fig. 6.7)
 VA chart at distance
 Near VA chart with an isolated letter or line of 20/30 size

 
12 BI 6 BU
Measuring prisms Dissociating prisms
Figure 6.7 Detailed view of Risley prism orientation when conducting Von Graefe technique.

PROCEDURE
1. Place phoropter with the patient’s distance Rx before the patient. Ensure that the pupillary distance is
appropriate for the testing distance, i.e. distance PD for distance Von Graefe and near PD for near Von
Graefe. If conducting the near Von Graefe test, a near point card must be attached to the phoropter
at 40 cm.
2. When conducting the distance test, an isolated letter one line above the best acuity at distance must be
provided as the target. This target may differ slightly based on the equipment available for testing. For
example, if it is not possible to isolate a single letter, the practitioner may have to use a vertical column
of letters.
3. The practitioner instructs the patient to close their eye’s while the Risley prisms are set at 12 BI RE and
6BU LE (some texts mention that the practitioner may use 10BI RE and 6BU LE) as in Fig. 6.7.
4. The practitioner then has the patient open both eyes. The patient is asked to report how many targets
he can observe and where they are located relative to each other. The practitioner should verify that the
patient indeed sees two images by occluding one eye and asking the patient to verify how many targets
he now sees. The two images seen by the patient are positioned such that one image is up to the right
and the other one down and to the left (Fig. 6.8).
5. If the patient reports seeing only 1 of the targets, the practitioner must occlude one eye and assist the
patient in locating the targets out in space. Alternatively, the practitioner can alter the position of the
dissociating prisms before the eyes from the BU to the BD position or the practitioner may increase the
amount of measuring prism.

Figure 6.8 Resulting images viewed when using the dissociating and measuring prism

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-7

 The Cover Test

MEASURING THE HORIZONTAL PHORIA

1. When measuring the horizontal phoria, the 12BI represents the measuring prism while the 6BU
represents the dissociating prism.
2. The patient’s fixation is directed to the lower target and he is instructed to keep it clear (Fig. 6.8).
3. While the patient is observing the lower target, the 12BI measuring Risley prism before the RE is reduced
at a rate of about 2 per second until the patient reports that the targets are aligned vertically one above
another or sometimes describe to the patient as “buttons on a shirt” (Fig. 6.9).
4. The practitioner must record the amount and direction of prism to achieve alignment of the targets.
5. To confirm the final result, the practitioner may overshoot the point of alignment and move the prism back
in the direction toward the value that was originally obtained for alignment. If there is a difference in the
amount of prism that produces alignment of the targets between the original and rechecked values, then
the practitioner may take the average of the 2 measurements, however, it is advised that if the 2 values
differ by more than 3, the practitioner should repeat the measurement.

 
1.5 BI 6 BU
Measuring prisms Dissociating prisms
Figure 6.9 Scenario of position of Risley prisms when conducting Von Graefe technique
when measuring the horizontal deviation (end point)

Measurement outcomes
 If on alignment, the 12BI has been reduced to zero  no horizontal phoria
 If remaining prism is BI  Patient has XOP
 If remaining prism is BO  Patient has SOP

e.g. in the case above (Fig. 6.9), the final result is 1.5 BI. This result indicates that the patient has an XOP
of 1.5 in magnitude.

Implications of findings: It is important to note that a patient may not always end up with a result of zero. The eyes
have a tolerance to overcome a small amount of latent deviation of the eyes, however, if the magnitude of the deviation
lies outside of the tolerance or the patient is unable to compensate for the deviation with their inherent fusional ability, it
is likely that the patient will have symptoms of asthenopia and double vision. A management plan which may include
active vision therapy or a prism prescription is crucial in these patients.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-8

 The Cover Test

MEASURING THE VERTICAL PHORIA

1. When measuring the vertical phoria, the 12 prism.
2.
patient as “headlights on a car” or “side by side”. In this case it implies that the 6BU is the measuring prism
and 12BI is the dissociating prism. (Fig. 6.10)
3. The practitioner must record the amount and direction of prism to achieve alignment of the targets.

 
12 BI 3 BU
Dissociating prisms Measuring prisms
Figure 6.10 Scenario of position of Risley prisms when conducting Von Graefe technique
when measuring the vertical deviation and the resultant position of the targets

MEASUREMENT OUTCOMES
 If on alignment, the 6BU has been reduced to zero  no vertical phoria
 If aligning prism is BU  Left hypophoria or Right hyperphoria
 If aligning prism is BD  left hyperphoria or Right hypophoria

e.g. In the case above (Fig. 6.10), the practitioner is left with a measurement of 3∆ BU which indicates that the patient
has either a Left hypophoria or Right hyperphoria.

EXPECTED VALUES
(Scheiman and Wick, 2008)

Distance Near
Horizontal/lateral phoria: Horizontal/lateral phoria:
Children and young adults: 1 XOP ± 1 Children and young adults: 3 XOP ± 3
 
For Presbyopes: 1 SOP ± 1 For Presbyopes: 8 XOP ± 3
Vertical phoria: no deviation Vertical phoria: no deviation

MADDOX ROD ASSESSMENT OF OCULAR DEVIATION

The Maddox rod test is a method of detecting and measuring a tropia or phoria subjectively. The Maddox Rod is a trial
lens composed of a series of powerful planoconvex cylinders in red or white plastic. Dissociation with this lens is
produced by the distortion of a spot of light into a line target. When the rod is orientated with the cylinders in the
horizontal direction, it produces a line target that is vertical. When orientated vertically, it produces a line target
that is horizontal.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-9

 The Cover Test

EQUIPMENT
 Phoropter or
 Loose Maddox Rod (it may be a clear lens or red lens) (Fig. 6.11) with trial frame and loose prisms
 Penlight torch or transilluminator

Figure 6.11 Maddox rod

PROCEDURE
1. The patient is seated comfortably and wearing their best distance refractive correction.
2. The test may be performed at distance or near.
3. The Px fixates a spot of light from penlight or transilluminator. Ideally, this is not the best target for
accommodative stabilization.
4. The room lights should be dimmed to allow a better view of the streak produced by the Maddox rod
(red lens in this example).

MEASURING THE HORIZONTAL PHORIA

1. Place the Maddox Rod before one eye (usually the deviating eye) with the cylinder axis orientated
horizontally. This produces a streak that is vertical in orientation.
2. The other eye remains fixated on a spot of light.
3. The eyes are now dissociated with one eye seeing the streak of light and the other seeing the spot of light.
If the patient is unable to see both the streak and the spot of light then suppression is indicated and the test
cannot be performed.
The perception of the direction of the images in the Maddox rod test is based on retinal projection as
depicted in figure 6.13. For example, an object that is perceived in the temporal visual field is traced back to
the nasal retina in the eye. Therefore, a patient who experiences crossed diplopia indicates the presence of
an exophoria (Fig 6.12a) while uncrossed diplopia is indicative of esophoria (Fig. 6.12c). Coincidence of the
streak and spot of light depicts a case of orthophoria (Figure 6.12b).

Figure 6.12 Ray diagrams showing principles of crossed and uncrossed diplopia in
(a) exophoria; (b) orthophoria and (c) esophoria.

4. If the patient is able to perceive both targets, then he is asked to report if the spot of light appears to the
right, left or on top of the streak (Fig. 6.13).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-10

 The Cover Test

Measurement outcomes (Maddox rod before RE)

Figure 6.13 Patient’s perceptions of the targets in cases of

(a) exophoria; (b) orthophoria and (c) esophoria

MEASURING THE VERTICAL PHORIA

1. The Maddox Rod is placed before one eye (usually the deviating eye) with the cylinder axis orientated
vertically. It will then produce a streak that is horizontal in orientation.
2. The other eye remains fixated on the spot of light.
3. The eyes are now dissociated with one eye seeing the streak of light and the other seeing the spot of light.
4. The patient is asked to report if the spot of light appears to the above, below or on top of the
streak (Fig. 6.14).

Measurement outcomes (Maddox rod before RE)

Figure 6.14 Patient’s perceptions of the targets when measuring the vertical deviation

POINT TO NOTE
The Maddox rod test is not able to differentiate existence of a tropia or phoria. The practitioner must deduce this from
the cover test or from the patient’s subjective complaints of diplopia.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-11

 The Cover Test

MADDOX WING ASSESSMENT OF OCULAR DEVIATION

The Maddox wing test was introduced in 1912. It is a convenient hand held quick and efficient test for near phoria using
the Maddox wing instrument (Fig. 6.15).
 The scales are mounted at a fixed viewing distance of 33cms. This is generally much closer than the standard
working distance for most patients and the findings are therefore questionable.
 A septum on the instrument divides the visual field into two sections, thereby allowing the right eye to see only
the white and red arrows, whilst the left eye sees only the horizontal and vertical rows of figures.
 The horizontal deviations are indicated by the white arrow pointing to the white figures.
 The vertical deviation is indicated by the red arrow pointing to the red figures.
 Cyclophoria is assessed by sliding the arrow which overlaps the edge of the chart until it appears parallel with the
white line above. Incyclophoria is indicated when the arrow points above the zero while excyclophoria is indicated
when the arrow points below the zero.

Figure 6.15 Maddox wing

BIBLIOGRAPHY
Scheiman M and Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders.
3rd Edition. Lippincott, Williams and Wilkins. Philadelphia. 2008.
Benjamin WJ. Borish’s Clinical Refraction. WB Saunders Company. Philadelphia. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. Philadelphia. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 6-12

 OCULAR MOTILITIES

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Types of eye movements

 Binocular eye movements

INTRODUCTION

Ocular motilities refer to eye movements. The purpose of these eye movements is to assess the patient’s ability on
conjugate eye movements. Vertical and lateral gaze movements direct the lines of sight along the Y and X axis
respectively. Rotations of the eyes along these axes result in the eyes moving toward targets within any of the four
quadrants. In this process the lines of sight of the eyes are directed up, down, right or left, away from the primary
position of gaze (straight ahead position of gaze).
Reflexive and voluntary eye movements are controlled by a cortical network involving the frontal, parietal and occipital
areas of the brain that send premotor signals to the nuclei of the 3rd, 4th and 6th cranial nerves. Voluntary movements
originate in the frontal areas of the brain, while reflexive movements originate in the posterior portion of the brain.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -1

 Ocular Motilities

TYPES OF EYE MOVEMENTS

BINOCULAR EYE MOVEMENTS

CONJUGATE EYE MOVEMENTS
Versions are movements of both eyes in the same direction, i.e. the lines of sight are parallel to each other. They may
be to the right (Fig. 7.1), left (Fig. 7.2), up or down. These movements are tested to determine if the neuromuscular
systems controlling the movements are functioning and intact.

Figure 7.1 Schematic of eye movement on dextroversion (to the right)

Figure 7.2 Schematic of eye movement on levoversion (to the left)

DISCONJUGATE EYE MOVEMENTS

Vergences are movements of both eyes in opposite directions e.g. convergence (toward the nose) or divergence
(away from the each other or the nose) where the lines of sight are not parallel to each other (Fig.7. 3).

Figure 7.3 Schematic of eye movement in convergence and divergence

TORSIONAL EYE MOVEMENTS

These eye movements allow a rotation of the eyes clockwise and counterclockwise. They can be incyclotorsion
refers to a movement when the eye rotates toward the nose and excyclotorsion is the movement of the eyes when
the top of the eye rotates away from the nose.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -2

 Ocular Motilities

CONTROL OF CONJUGATE EYE MOVEMENTS

The signal for eye movements originates in the cerebrum and is transmitted to the gaze centers in the midbrain and
motor nuclei in the Pons. Signals from here are transmitted via the 3rd, 4th and 6th nerves to the EOMs. Supranuclear
pathways conduct impulses to the gaze centers while internuclear pathways coordinate the gaze centers with the
motor nuclei. Abnormalities detected with conjugate eye movements informs the practitioner of lesions which involve
one or more of the 3 cranial nerves controlling eye movements or lesions located at the motor nuclei in the midbrain,
Pons and gaze centers in the upper midbrain or the cerebral centers where the eye movements are initiated.

MONOCULAR EYE MOVEMENTS

Ductions refer to monocular eye movements. The muscle or muscles that contract to produce the movement of the
eye are the agonist(s). When 2 muscles move the eye in the same direction to produce a movement, then the muscles
are synergists. For each agonist that contracts to move the eye, an antagonist muscle which produces a movement in
the direction opposite the agonist, relaxes.

BINOCULAR EYE MOVEMENTS

Bifoveal fixation is the goal of the coordinated action of the EOMs. Movement of the eyes to the right is referred to as
dextroversion (Fig. 7.1) while movement to the left is levoversion (Fig. 7.2). An assessment of motilities allows us to
evaluate the oculomotor system. Abnormal eye movements may be caused by fatigue, poor attention span, aging,
drugs or medications, and neurological problems.

ACHIEVEMENT OF BINOCULAR EYE MOVEMENTS

Conjugate eye movements are produced when the direction, speed and magnitude of rotation of the eyes are equal.
This is enabled since the EOMs of both eyes are yoked together. There is identical excitatory or inhibitory innervation
supplied to the corresponding yoked muscles. The equal, simultaneous innervation sent to the yoked EOMs to
produce voluntary conjugate eye movements is governed by Hering’s Law of Equal Innervation. This law applied
whether the eyes are fixating binocularly or monocularly.

Table 7.1 Yoked Pairs of Ocular Muscles

Right Eye Left Eye

Lateral rectus Medial rectus
Medial rectus Lateral rectus
Superior rectus Inferior oblique
Inferior rectus Superior oblique
Superior oblique Inferior rectus
Inferior oblique Superior rectus

TYPES OF CONJUGATE EYE MOVEMENTS

There are 3 types of conjugate eye movements, viz. pursuits, saccades and vestibular eye movements. Pursuits and
saccades are initiated in the cerebral hemispheres and are mediated by supranuclear pathways. Vestibular (reflex)
eye movements are initiated in the ear canal and mediated by the cerebellum and brain stem.

PURSUITS
Pursuits are slow, smooth tracking conjugate eye movements which are stimulated by target motion. They are elicited
by asking a patient to follow a slow moving target.

SACCADES
Saccades are rapid, voluntary or reflex fixational movements. It is elicited by having the patient fixate various targets.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -3

 Ocular Motilities

VESTIBULAR EYE MOVEMENTS

Vestibular eye movements are a mix of smooth image stabilizing movements or rapid saccadic eye movements. They
occur in response to continuously moving stimuli in the visual field or to stimulation of the semicircular canals.

PURSUIT EYE MOVEMENT TESTING / BROAD-H TEST

A pursuit or broad H test refers to a following eye movement when the eye moves to follow the visual clue of an object
moving in the field of vision.
The findings of the Broad H test consider the fields of action of the six extrinsic ocular muscles. The field of action of a
muscle refers to the field in which a particular muscle has its greatest action, e.g. RLR has its field of action in the right
hand field while RMR has its field of action in the left hand field. The consideration of the lateral and medial rectii
muscles is simpler than that of the vertically acting muscles. The fields of action of these muscles are based on their
muscle planes. For example, the SR and IR muscles lie in a plane that makes an angle of 23 degrees with the primary
position (Fig. 7.4) and when the eye is orientated in this direction, the SR and IR muscles function as pure elevators
and depressors respectively. In other words, in order to isolate a problem with the SR muscle, the practitioner would
have to instruct the patient to move their eyes 23 degrees from fixation and then attempt to elevate the globe.
The SO and IO muscles of the eye lie in a plane that is 55 degrees from the primary position. Therefore, when the eye
is turned inward by 55 degrees, the SO would function as a pure depressor while the IO would function as pure
elevator. Limitations of eye movements when the eye looks first inward by 55 degrees and then either up or down can
be isolated to a problem with the IO or SO respectively.
It is not practical to have the patient look exactly 23 degrees outward or 55 degrees inward from the primary position
when testing motilities. It has been found that limitations of movement can be detected when the eye changes gaze
approximately 30 to 40 degrees in either direction.

Figure 7.4 Muscle planes of the rectii (left) and oblique (right) EOMs .

INSTRUMENTATION
Various targets may be used to evaluate the motilities of a Px, viz. penlight or transilluminator, tip of a knitting needle,
Wolff ball, finger puppet or another interesting target in the case of children. However, if the practitioner wishes to
observe the correspondence in the corneal reflexes on both eyes, then the penlight / transilluminator is the
ideal target.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -4

 Ocular Motilities

Figure 7.5 Broad H testing on a patient with restricted lateral rectus function

PROCEDURE
 The examiner stands directly in front of the patient in a well lit room.
 The patient is seated comfortably with his/her head in the primary position and directly in front of the patient.
 The success of the test depends on proper instruction to the patient. The examiner should tell the patient “I am
now going to evaluate whether your eye muscles work well together. For me to do this, I need you to follow the
movement of the target with your eyes while keeping your head still”. The examiner must also ensure that he/she
does not move the target too fast as fixation may be lost and this would produce inaccurate fixation characteristics.
 The loss of the corneal reflex can help to indicate that the examiner has moved the target out of the binocular field.
 The target is positioned in the primary position at a distance of 40cm away from the patient’s eyes.
 The target is moved into the 9 diagnostic positions of gaze by moving the target in a broad H pattern (Fig. 7.5).
 It may be necessary to hold the lids up when observing the patient’s eye position during downgaze to observe
any misalignment of the corneal reflexes.
 In addition, a pattern X is also done, which checks for any oblique muscle problems.

OBSERVATIONS
One needs to take note of the following:
 Is the movement smooth / jerky / inaccurate?
 Is the movement full and unrestricted / restricted? (are there any over or under actions)
 Is the Px using head movements to follow the target?
 Is the Px feeling any eye pain or discomfort on eye movement (in conditions like retrobulbar neuritis)?
 Does the Px detect diplopia at any stage of the test?

RECORDING
If the patient follows the light smoothly, accurately, and with full extent of movement, the pursuits are recorded
as being SAFE. SAFE means that eye movements were S = Smooth; A = accurate; F = full and E = extensive.

Alternatively they may be recorded as being FROM = Full range of motion.

Ocular motility may also be graded on a scale where:

4 = smooth and accurate

3 = one obvious jerky movement (fixation loss)
2 = two obvious jerky movements (fixation losses)
1 = more than two obvious jerky movements

 If the patient has a limited range of motion or restriction in a particular field of gaze, the practitioner must record
either an overaction or limited range of motion on the diagram of the diagnostic action fields. A plus (+) sign
would indicate an overaction in a particular direction of gaze and a minus (-) sign would indicate an underaction
in a particular direction of gaze.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -5

 Ocular Motilities

OTHER FINDINGS
 End point nystagmus: When testing the horizontal meridian one may observe a slight end-point nystagmus.
This is a physiological nystagmus and is therefore not an abnormal finding.
 Midline jump: One may also observe a midline jump in the oblique meridians. This is usually found in children
at up to 6 years of age. If the Px uses head movements to follow the target then it could imply that the Px may
have a muscle restriction.

SACCADIC EYE MOVEMENTS

BACKGROUND
A saccadic eye movement refers to rapid eye movements to bring a point of regard onto the fovea. It is an example of
a fast binocular eye movement. Saccades are employed in tasks like reading or shifting fixation from one object to
another in daily life. Saccades are characterized by extremely high initial acceleration of up to 30000 /second. They
usually begin with a latency of about 200 milliseconds. Saccades are known to end just as abruptly as when they
begin. Saccadic movements are produced and controlled by various central structures including the occipito-parietal
cortex, the frontal lobes, the superior colliculus, the basal ganglia, the cerebellum and the brainstem. These
movements may be voluntary or reflexive. Reflexive saccades are initiated by the appearance of a new target while
voluntary saccades are initiated by the volition of the subject.

There are 3 aspects that are crucial in the assessment of saccadic eye movement. They include:
 Latency of the saccade which is the difference in time of the presentation of the stimulus and the movement
intended to acquire the target. The mean latency of normal subjects is around 200ms.
 Velocity refers to the peak velocity obtained during the eye movement.
 Accuracy refers to the exactness of the movement for the target displacement. It can be either hypermetric
(overshoot) which is larger than appropriate for the target displacement or hypometric (undershoot) which is
smaller than needed. Saccadic hypometria is usually normal and is only regarded as abnormal if it is extremely
undershooting the target. Even a small amount of hypermetria is considered abnormal and indicates the presence
of a cerebellar problem.

INSTRUMENTATION
 2 pursuit targets.

PROCEDURE
1. Targets are presented at 40cm in front of the Px in primary position of gaze.
2. Targets are held 25cm apart.
3. The Px is directed to shift fixation from one target to the other as the examiner calls them out. The examiner
must ensure that the patient is maintaining a straight and stationery head position.
4. Targets must be presented along the horizontal, vertical and oblique meridians.

OBSERVATIONS
The examiner needs to note the following:
 Is the fixation accurate?
 If fixation is not accurate, is the Px under- or overshooting. If so, by how much.
 Is fixation on the object of regard well sustained?

RECORDING
 Accurate, overshooting or undershooting.
One must always record the directions/meridians in which the movement is produced.
e.g. Patient is undershooting in all meridians.

FINDINGS
 Normal individuals show a small degree of undershooting. This undershooting may be more pronounced
with aging and fatigue.
 Overshooting is less common and abnormal, and may be a sign of neurological disease.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -6

 Ocular Motilities

BIBLIOGRAPHY
Scheiman M and Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders.
3rd Edition. Lippincott, Williams and Wilkins. Philadelphia. 2008.
Benjamin WJ. Borish’s Clinical Refraction. WB Saunders Company. Philadelphia. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. Philadelphia. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 7 -7

 PUPILLARY TESTING

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Sydney, Australia

Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Anatomy of the pupil and iris

 Pupillary pathways
 Evaluation of pupil size and symmetry
 Evaluation of pupil reflexes

BACKGROUND INFORMATION
Pupillary testing provides the practitioner information regarding the integrity and function of the iris, the optic nerve,
anterior visual pathways, parasympathetic and sympathetic nervous systems and general systemic health.
In order to fully understand pupillary testing, one must be familiar with the iris anatomy and neural pathways which
regulate pupil size.

TERMINOLOGY
Miosis = pupil constriction
Mydriasis = pupil dilation
Anisocoria = unequal pupil size

ANNATOMY OF THE PUPIL AND IRIS

The pupil is bounded by the iris, which determines its shape and size. The iris is made up of 2 groups of muscle, viz.
the circular muscle fibres at the pupil margin = sphincter pupillae. The other group consists of the radial fibres that
extend from the iris root to the border of the iris = dilator pupillae.
 Pupillary Testing

PUPILLARY PATHWAYS

There are several parts that make up the pupil reflex pathways. It involves transmission of signals from the outside
world to the brain via the afferent papillary pathway. The control of the pupil size is controlled by the Parasympathetic
Nervous System (PNS) and Sympathetic Nervous System (SNS) which makes up the efferent pathways involved
in transmission of signals from the brain to the effector organs.

A simple way to remember this is:

Afferent = At brain
Efferent = Exit or Effector
AFFERENT PUPIL PATHWAY
The afferent pupil pathway begins with the primary sensor for light, i.e. the photopic system which comprises primarily
the cones of the retina. The light reaching the retina is the primary determinant of the pupillary light reflex. Once the
fovea is stimulated by light entering the eye, it sets ups signals that are transmitted by retinal nerve fibers. This then
relays information for pupil control through the optic nerve to the optic chiasm, at which point half the fibers decussate
to the contralateral (opposite) optic tract which the remaining fibers continue on the ipsilateral (same) optic tract to the
pupil light control centers in the midbrain. This entire section of the light reflex pathway is the afferent system. The
system returning from the midbrain is the parasympathetic pathway (discussed below).

PARASYMPATHETIC PATHWAY
This is a 3 neuron pathway (Fig. 8.1). The pathway begins at the Pretectal nucleus of the midbrain and ends at the iris.
The fibres from the pretectal nucleus semidecussate to the Edinger Westphal nuclei (i.e. one fibre from each pretectal
nucleus to both Edinger Westphal nuclei) at which point they exit the midbrain as the 3rd nerve and synapse in the
ciliary ganglion, and finally reach the sphincter pupillae of the iris via the short ciliary nerves. The majority of the fibres
of the 3rd nerve, innervate the ciliary muscle which controls accommodation while only about 3% of fibers innervate
the iris sphincter muscle (Benjamin: Borish’s Clincial refraction).

Flow chart of the parasympathetic pathway Figure 8.1 The parasympathetic pathway

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-2

 Pupillary Testing

SYMPATHETIC PATHWAY
This is a 3 neuron pathway that begins in the posterior hypothalamus (Fig. 8.2). The efferent fibers travel to the brain
stem and synapse in ciliospinal center of Budge (intermediolateral gray matter of the spinal cord) at the level of T2
along the spinal cord. The fibers from this point on, are the preganglionic fibers (second order neurons). They exit the
spine at the level of the thorax (T1) and travel to the synapse in the superior cervical ganglion which is located at the
level of the angle of the jaw. From here the post ganglionic fibers (third order neurons) follow the internal carotid
artery, through the cavernous sinus and reach the orbit through the superior orbital fissures. These nerves join the
ophthalmic division of the 5th cranial nerve to reach the iris dilator pupillae via the long ciliary nerves. The nerves split
at the carotid bifurcation, to supply various organs including the sweat glands, iris dilator fibers and Muller’s muscle in
the upper lid.

Flow chart of the sympathetic pathway Figure 8.2 The sympathetic pathway

OCULAR VOLUNTARY NERVOUS SYSTEM

The ocular voluntary nervous system provides the output for the Near Synkinesis (also called Near Triad). The Near
Synkinesis is a combination of 3 functions (accommodation + convergence + pupil constriction) that normally function
in a connected way. Under normal conditions, they occur simultaneously and are inseparable from one another. When
one accommodates, both convergence and pupil constriction automatically occur. This function is technically not
controllable but is categorized as a voluntary function because it requires conscious voluntary effort. It can occur even
in the blind.
The pathway for the Near Synkinesis is not fully known but it appears to begin in the frontal visual association
areas (# 19):

Accommodation
Anterior visual CN III nuclei Follows p
Convergence
association areas (more ventral than pre-tectal input) route
Pupillary Constriction

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-3

 Pupillary Testing

EVALUATION OF PUPILS

When evaluating a pupil we have to consider several criteria, viz.

 Size and symmetry/shape of the pupil
 Pupil reaction to light and accommodation (briskness)
 Speed of the reflex

ANALYSIS OF PUPIL SIZE

RULER OR HAAB SCALE METHOD
The assessment of pupil size requires that the patient be adapted to the level of light within the
environment. This is typically done under normal room illumination. The patient fixates a distance target.
The diameter of the pupil is measured using a millimeter rule (PD rule) or a HAAB scale which
comprises series of coloured circles of known diameters. The ruler is held against the patient’s
cheekbones while covering the lower half of the patient’s pupil. When measuring the pupil diameter
using the millimeter rule, the size should be recorded. In cases when the iris color is very dark,
additional overhead lighting to be able to observe the pupil diameter will be needed. If the practitioner
notices a significant difference in pupil diameter (anisocoria), the pupil diameter can be estimated under
bright and dim illumination conditions in order to determine if the anisocoria is physiological or
pathological. Physiological anisocoria is observed when the difference in pupil size in bright light is
comparable to that under reduced lighting conditions. Physiological anisocoria of ≥ 0.4mm difference is
observed in 20% of the normal population. This ratio increases with age thereby resulting in 33%
of individuals above 60 years old having physiological anisocoria. In 25% of cases, anisocoria is Figure 8.3 HAAB scale
along the side of an
not constantly present.
occluder

An exact measurement value of the pupil diameter is not absolutely critical for clinical purposes since the pupils are
constantly changing in size due to variable light conditions and the inherent tonic pupil reflex (hippus). An estimation of
pupil size is therefore sufficient. The measurement of pupil size becomes more critical when there are specific clinical
needs, e.g. contact lens fitting or research studies where ambient conditions are controlled. However, clinically, the
most relevant aspect is to assess whether the pupil is abnormally large (mydriatic pupil) or abnormally small (miotic
pupil) or whether there is a difference between the two (anisocoria).

Procedure:
 Patient fixates at distance target to minimize accommodation
 Room illumination is dim to produce large pupils & maximize observable reaction
 The stimulus should be a cool and bright light. The transilluminator or binocular indirect ophthalmoscopes are
ideal, as they are both cool & bright but also adjustable.
 The light (in relatively dim state) is directly from below the line of sight to illuminate both eyes equally
 The pupils are observed simultaneously to compare their relative size
 Estimate the pupil sizes. You can measure the pupils if need be. However for clinical purposes, since pupils are
constantly changing, estimating the pupil size is sufficient.
 If anisocoria is present however, the difference should be evaluated with a pupil ruler or qualitatively assessed for
a varying difference in dim & bright illumination.
 If relative difference() in dim equals difference in bright illumination, it must be noted in the chart:

 Dim =  Bright

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-4

 Pupillary Testing

DIRECT OPHTHALMOSCOPE METHOD

An alternative method of assessing the pupil diameter is with the use of a direct ophthalmoscope. This is done with a
+1.00DS lens in place, a testing distance of 1 meter and illumination set to maximum. The intensity of the
ophthalmoscope is reduced for assessment of the pupil under reduced illumination conditions and the pupil size
differences are compared under dim and bright light settings. Infants and uncooperative patients can be assessed
more easily with this method.

EXPECTED FINDINGS
In bright light: pupil diameter normally ranges between 2 to 4 mm in size
In dim light: pupil diameter normally ranges between 4 to 8 mm in size (Benjamin, 2006).
Physiological anisocoria: is when the difference in pupil diameter remains the same in dim and bright light settings.

Pathological anisocoria can reflect a problem either with the PNS or SNS systems.
When considering the difference in pupil size under bright light: the pupil with the larger diameter is considered to be
the pathological pupil. Under dim light settings, the pupil with the smaller diameter is considered to be the pathological
pupil. Conditions that result in anisocoria that is greater in bright conditions include Adie’s tonic pupil or a third nerve
palsy, while conditions that result in anisocoria that is greater in dim light include Horner’s syndrome.

RECORDING
The pupil size must be recorded separately for dim and bright light settings ( = change).

 Dim =  Bright

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-5

 Pupillary Testing

EVALUATION OF PUPIL REFLEXES

The evaluation of pupil reflexes involves a series of assessments that collectively will be able to indicate the integrity of
the neural pathways involved in the maintenance of pupil size, symmetry and response to light and accommodation.

THE DIRECT LIGHT REFLEX

The direct light reflex involves the assessment of the pupil’s response when a light source is introduced before the eye
being tested to observe the expected constriction. This constriction is followed by slight dilation, followed by
constriction again, until the pupil size has stabilised. This is referred to as the tonic pupil reflex or hippus, which occurs
because the iris is constantly trying to allow an adequate amount of light onto the retina. A successful direct response
indicates that the efferent systems are working appropriately and helps us rule out mechanical restriction that may
impair the pupil’s reaction. An afferent defect may still be present if the direct reflex appears intact.

INSTRUMENTATION
 Penlight / transilluminator
 Distance target
 Near target

PROCEDURE
1. The test is conducted under conditions of normal or dim room illumination with the patient’s fixation is directed
to a distance target to avoid accommodation.
2. A handheld source of light (penlight, transilluminator) is directed toward the patient’s right eye from slightly
below the line of sight (to avoid the patient fixating the light source and inducing accommodation) for 2 to 4
seconds and is then removed.
3. The magnitude (quantity) of change of the pupil size and its rapidity (quality) is assessed in the pupil that is
illuminated. When conducting the procedure, it is important to avoid illuminating the fellow eye simultaneously.
It is normal for the constriction of the pupil to be faster than that of the dilation.
4. The procedure is repeated about 2 or 3 times to confirm the patient’s response.
5. The procedure is repeated for the left eye.
6. One should ensure that they do not “bleach” the eye by presenting the light source for too long on the eye. In
addition, the light should always be kept below eye level to avoid accommodation and illumination of the fellow
eye must be avoided.

Expected findings:
 The expected response is a brisk constrictionfollowed by a pupillary escape - a small, slow dilation to an
intermediate pupillary size. A physiological pupil unrest called Hippus should also be seen: this is a bilaterally
symmetrical variation in size variation when the light is kept on the eye. The size change is usually less than 1 mm
and has a frequency (~ 3 Hz) that decreases with age.

 Evaluate & Note:

Quantity: amplitude of constriction graded from 0 (no reaction) to 3 (big reaction)

&
Quality: briskness or speed of reaction graded fast (+) or slow (-)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-6

 Pupillary Testing

CONSENSUAL RESPONSE
The consensual response is produced by the neuro-anatomical decussations of the pupillary neuro-pathways at the
chiasm and at the posterior commissure. The efferent response triggered by a light stimulus in one eye is normally
distributed to both eyes equally and simultaneously. The resulting constriction observed in one eye that is directly
stimulated with light should be observed in the fellow eye.

 The Key clinical observation for normals is that the:

consensual pupil response

=
direct pupil response

PROCEDURE:
With the same setup as above, one can note the consensual response of one eye by directly stimulating the fellow eye
(i.e. looking at the non-illuminated eye) & comparing the response obtained. Clinically, this method is not practical and
the consensual response is not tested this way. Instead the “Swinging” or “Alternating Light Test” is used.
The Swinging Light Test allows us to directly compare the direct response with the consensual response of an eye. As
stated above, when a direct response is triggered in one eye, a similar response should be observed in the other eye
through the consensual pupil pathways. Under normal conditions, if the light stimulus is moved from one eye to the
other, therefore, no change should be observed in the fellow eye. If the light is the swung back to the first eye, again,
no change should be observed, and so on.
A brisk constriction followed by a slight dilation may be observable given the pupillary escape. The intermediary pupil
size reached should be the same in both eyes. In other words, direct stimulation in one eye should cause an equal
constriction in both eyes.
 patient, room illumination, stimulus same as above
 the light is shined directly into one eye for 2-3 sec
 observe the initial constriction and subsequent slight dilationto an intermediate size
 quickly swing the light to the other eye
 observe the pupil constrict from the intermediate size & return to intermediate sizequickly swing the light to the first
eye...
 repeat 3-4 times comparing the response and intermediate size in each eye
 switch to a 1 second per eye alternation and repeat 3-4 times
 The 1-sec. phase, is used to assess the constriction (more sensitive test!)
 the expected response is that the direct & consensual responses of both eyes are equal

 The Key clinical observation for normals is that the:

Constriction OD = Constriction OS

Intermediate position OD = Intermediate position OS

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-7

 Pupillary Testing

SWINGING FLASHLIGHT TEST

The swinging flashlight test is conducted to compare the strength of the direct light reflex of one eye with that of the
consensual light reflex from another eye (Fig. 8.4). An abnormality observed in this test is an indication of a problem in
the afferent pupil pathway.

PROCEDURE
1. The procedure is the same as that of the direct reflex test, except that the light source is alternated between
one eye to the other and back and forth.
2. A handheld source of light (penlight, transilluminator) is directed toward the patient’s right eye for 2 to 4
seconds and is then quickly moved to the fellow eye which is illuminated for 2 to 4 seconds.
3. The exposure of the eyes to the light source must be of the same duration to avoid false positive results.
4. There must be a slight delay between the stimulation of the fellow eye so that it is able to respond to the
consensual response of removing the stimulus from the other eye. Swing light source from one eye to the
other and look to see if you get any dilation. You are comparing the afferent pathways of both eyes. The
swinging motion must not be done in a horizontal direction from one eye to the next but rather from one
to the next using a “U” pattern of movement of the light source. This provides a slight delay for the introduction
of light source before the fellow eye.
5. If one observes a relative dilation (i.e. one eye dilates more than the fellow eye) it implies that a problem
with the afferent neural pathway exists and this is referred to as a Relative Afferent Pupillary Defect (RAPD)
or Marcus Gunn pupil (MG). When stimulating the good eye, one gets both the direct and consensual light
reactions to light. Upon withdrawal of the stimulus from the good eye, there is pupil dilation in response to
the decreased light level. When you introduce the stimulus before the poor eye (i.e. the eye with the afferent
defect), the afferent stimulus of that eye is weaker than the fellow good eye producing effectively a lower
efferent response, hence a dilation results. The efferent response being bilateral, both pupils will dilate.
When the light is shone back on the good eye, the direct response being good, a more vivid efferent response
will result, and a bilateral constriction ensues.
NB: A RAPD is not a diagnosis, but a sign of anterior visual system dysfunction such as retinal or optic nerve lesions that decrease
the direct light reaction of the eye. It is important to realize that an RAPD is a relative defect where a smaller light signal is
transmitted by one eye. The conduction defect must be unilateral or asymmetric for it to be observed at the Swinging flashlight test

Figure 8.4 Swinging flashlight test with an abnormality detected in the left eye

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-8

 Pupillary Testing

RAPD Grading
The RAPD is graded subjectively from Trace to 4+ according to the following observations following the light swing
from the normal eye to the affected eye:

immediate dilation of pupil ==> 3+ / 4+ RAPD

(instead of normal pupil initial constriction)

no change in pupil size initially ==> 1+ / 2+ RAPD

(followed by dilation of pupil)

initial constriction, but greater escape ==> Trace RAPD

to a larger intermediate size vs. other eye

The RAPD can also be graded more objectively using Neutral Density Filters of 0,3 log units. The filters are added
befpre the good eye until the RAPD is “canceled” or “equalized” by the reduced transmission caused by the filters in
the good eye.

RAPD - Tips for success!

1. Always look at the eye with the light on!
Many get confused as to which eye to look at during the RAPD testing. Just remember that throughout the whole
pupil assessment, the eye of interest is the one with the light on.

2. Beware of physiologically induced RAPD

I. Light induced RAPD: keeping the light too long on the same eye will blanch & desensitize the retina
causing an apparent RAPD. Make sure both retinas are equally exposed to the light.

II. Occlusion induced contralateral RAPD: eyes that are shut or covered for long periods (e.g. ptotic or
patched eyes) will be highly sensitive to light and the swinging light test may reveal an apparent RAPD in
the other eye.

III. Cataract induced RAPD: the retina behind a unilateral cataract (e.g. pseudophakes) is more sensitive to
light because of the natural occlusive effect of the cataract. When light is shone in the eye, the increased
sensitivity coupled to the light dispersion caused by the cataract may cause it to respond more briskly and
cause an apparent RAPD of the other eye.

3. Adjust the brightness or alternating speed of the stimulus when necessary

Some pupils react very briskly to bright light and mild RAPD will be masked. Reducing the light intensity often
facilitates the observation of an RAPD.

4. “Tilt” the RAPD if necessary

A 0,3-log unit neutral density filter will not change the pupil response when placed over a good eye but will
markedly affect it over an affected eye. If an RAPD is suspected but difficult to confirm objectively, perform the
swinging light test with the filter over the suspected eye. The filter will accentuate the RAPD & facilitate
its observation.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-9

 Pupillary Testing

5. Support the swinging light test with a subjective RAPD test

Brightness or color comparison from one eye to the other will support “subjectively” the presence of an RAPD. An
eye with a conduction defect will have a reduced stimulus input and therefore a reduced sense of color and light
brightness when compared to the other.

6. Make use of the direct ophthalmoscope(DO)!

For infants and non-cooperative patients, the swinging light test can be performed by observing the red reflex
through the DO in a dark room at a distance of 50 cm.

Reverse or Indirect RAPD

When 1 pupil is non-reactive or not visible because of trauma, synechia, drug effect, etc., an RAPD can still be
detected using a modified alternating light test. In this test the reactive pupil is always observed as the swinging light
test is performed. The direct and consensual responses of the working pupil are compared using the same principles
described above.
If the direct response of the working pupil is greater than the consensual response obtained by flashing the other eye,
an RAPD is present in the other eye (non-working or non-visible pupil).
If the direct response of the working pupil is less than the consensual response obtained by flashing the other eye, an
RAPD is present in the eye with the working pupil.

NEAR REFLEX (PUPIL RESPONSE TO ACCOMMODATION)

The near reflex involves the observation of the pupil reactions with the introduction of near accommodative stimulus. It
is suggested that if the direct response is brisk and intact then the practitioner need not assess the near response
since it is rare that the near reflex is abnormal, when the direct response is intact (Benjamin, 2006).

PROCEDURE
1. The patient is directed to a distance target they can view clearly in normal room illumination.
2. No light stimulus must directed toward the eyes
3. The pupils are observed and their size noted.
4. A near target is introduced at a distance of 25 to 30 cm before the patient. The illumination of this near
target must not differ from that of the distance target.
5. The patient’s fixation is alternated from the distance to the near target.
6. The pupils reactions are assessed for - Quantity & Quality as the direct response
7. The expected response is a brisk contraction similar to the direct response with equal constriction for
both pupils
8. The Key clinical observation for normals is that the:

near pupil response

=
direct light response

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-10

 Pupillary Testing

RECORDING PUPIL RESPONSES

Use the PERRLA +/- RAPD notation to describe the pupillary findings (size, shape, direct & consensual reactions,
etc.) of the above tests:

P Pupils
E Equal
R Round
R Reactive
L Light
A Accommodation (near)

RAPD +/- Marcus Gunn

Examples:

OD 4 3+
E R R (-)RAPD
OS 4 3+

5 3+
E R R (-)MG (Dim = Bright)
3 3+

4 0 3+
E R R A (-)RAPD
4 1+ 3+

4 2+
E R R (2+) MG OD
4 3+

4 3+
E R R (-) RAPD (OD pupil distorted)
4 3+

Pupil Test Summary

1. Comparison If Anisocoria, assess in Dim & Bright illumination
2. Direct Evaluate Quality/Quantity
3. Alternating Evaluate Consensual indirectly to Rule-out RAPD
4. Near Only necessary if direct reaction to light is weak

June 2012, Version 1-1 Clinical Optometric Procedures 1, 8-11

 VISUAL FIELDS AND VISUAL
FIELD SCREENING

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Sydney, Australia
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Visual field – definition

 Perimetry
 Terminology
 Visual pathway, lesions and accompanying visual field defects
 Features used in describing a visual field defect
 Testing the visual field using non-automated instruments and techniques

There are some basic definitions and terms that one should be familiar with before knowing how to conduct a visual
field screening.

VISUAL FIELD – DEFINITION

According to Benjamin (1998) in Borish’s Clinical Refraction, the visual field (VF) is “that area of space that a person
can see at one time”. Even though we function binocularly in most circumstances, the clinical testing of the visual field is
rarely conducted binocularly.
The monocular visual field is 3-dimensional and known as the “Hill of Vision”. The outer edges of which represent the
outermost limits of the area in space, termed the visual field, that can be seen at any one time. Any target, irrespective
of its size or intensity, cannot be seen beyond this area.
The outer or absolute limits of the monocular visual field are: superior: 55-60 degrees, inferior 70 degrees, temporal 100
degrees, & nasal 60 degrees (Fig. 9.1). The shape of the VF is therefore that of a horizontal oval.
 Visual Fields and Visual Field Screening

Figure 9.1 Schematic representation of the extent of the normal visual field of the RE

The nasal limit of the VF in the primary gaze position is limited by the bridge of the nose while superior it may be limited
by anatomical variations including deep-set eyes, ptosis, blepharochalasis or a prominent brow. The practitioner can
verify if the restriction is due to an anatomic restriction by asking the patient to turn their head toward the area of the
suspected anatomic restriction while still maintaining fixation in the straight ahead position. If the restriction was initially
due to an anatomic variation, then the VF will expand outward however, if it does not, then the practitioner may suspect
organic VF defects.
When considering the VF of both eyes in combination, the lateral extend of the VF is about 200 degrees extending from
the right temporal to the left temporal edge. There is an area of overlap between the VF of each eye in the central 120
degrees (nasal edge to nasal edge). This central 120 degrees is referred to as the binocular VF where each eye is able
to detect a stimulus within this region.
The ability to detect a stimulus within the boundaries of the VF depends on the sensitivity which varies with eccentricity,
testing stimulus and the state of retinal adaptation. The Hill of Vision is a three dimensional representation that
represents the sensitivity of eye, with the higher Hill of Vision indicating that there is a greater sensitivity at that location
of the hill. The central part of the eye (i.e. foveal area) contains the highest resolution and is represented by the peak of
the Hill of Vision. The peak sensitivity of the Hill of Vision exists under photopic conditions. Lowering of the lighting
conditions to scotopic conditions depresses the Hill of Vision. It is therefore important for the practitioner to take
cognisance of this since testing should be conducting under photopic conditions. These conditions must remain
constant for successive VF testing in order to make comparisons between successive VF plots.
The blindspot which represents the optic nerve head lays 15.5° temporal to fixation and 1.5° below the horizontal
meridian. The physiological blindspot is 5.5° wide by 7.5° high in diameter. The peripheral parts of the retina display
a decrease in resolution, especially as the distance gets further from the macula.

PERIMETRY

The science of measuring the visual field is referred to as perimetry. There are generally 2 testing strategies to perform
perimetry.

KINETIC PERIMETRY
Kinetic perimetry involves the placement of a selected test stimulus of known size and intensity outside the borders of
the visual field or within the blindspot and then moving it until a point at which it is detected. The boundary at which the
target is first seen have equal sensitivity and if connected, they will form a ring-shaped locus of points referred to as the
isopter. When the size and intensity of the stimulus is changed, another boundary is mapped. These isopters therefore
provide the practitioner with the overall extent of the visual field and gives a measure of the sensitivity of the visual field.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-2

 Visual Fields and Visual Field Screening

The isopter may be plotted by target stimuli of various sizes and intensities. This method of visual field measurement
was the traditional approach and remains useful in determining the borders of larger or deeper visual field defects. It is
also generally more useful in peripheral field defects (greater than 30 degree from fixation) and not so useful in central
fields. This has been attributed to the fact that the sensitivity within the central field slopes off at a slow rate resulting in
a zone of greater variability of patient responses. It has also been noted that small isolated reductions in sensitivity
referred to as scotomas are easily missed with kinetic perimetry.

STATIC PERIMETRY
Static perimetry involves the presentation of a stimulus to a specific location on the retina. The intensity of the stimulus
is presented in increasing levels until it is detected by the retina is that specific location. The intensity of the stimulus at
the point of detection is referred to as the threshold. Static perimetry is a good method to detect the sensitivity of the
visual field in a specific area of the retina and is used in Automated perimeters. This method is time consuming and in
newer automated perimeters, strategies are employed to decrease the testing time. Static perimetry is generally much
better at detecting small scotomas such as those that accompany early glaucomatous change.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-3

 Visual Fields and Visual Field Screening

TERMINOLOGY

 Units of measurement of a visual field: The visual field is recorded as degrees from fixation.
 Perimetry is the science of measuring the visual field.
 Scotomas refer to an area of reduced or absent visual sensitivity inside an isopter surrounded by an area
of normal or higher sensitivities. It can be classified as:
a) Relative scotoma: is described as an area of depression, in which the target may seem blurry. If a patient has
a relative scotoma, then it is possible that the patient will be able to perceive the target should its intensity and
size be larger.
b) Absolute scotoma: This is an area where the retinal sensitivity in an area that has an absolute scotoma
cannot be increased and therefore even if the practitioner increases the stimulus intensity, the patient will
not be able to perceive it.
c) Unilateral defect: affecting one eye or field
d) Bilateral defect: affecting both eyes or fields

Table 9.1 Comparison of various characteristics between absolute and relative scotomas

Scotoma Type Lesion Margins Scotoma Size

Different size targets will give

Absolute Inactive Steep proportionally the same size
scotomas
Different size targets will give a
Relative Active Sloping different and proportional size
scotoma

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-4

 Visual Fields and Visual Field Screening

VISUAL PATHWAY, LESIONS AND ACCOMPANYING VISUAL FIELD DEFECTS

A proper understanding of the visual pathway is essential since neurological damage can produce distinctive VF
defects. The shape of the VF defect can assist in identifying the location of the specific disease process that could be
affecting the visual pathway. For example, a bitemporal hemianopsia indicates that the problem is in the optic chiasm
region of the visual pathway.
The visual pathway begins in the retina and terminates in the occipital lobe (Fig. 9.2). Refer to notes in the ocular
anatomy module for a closer review of literature on the visual pathway.

Figure 9.2 A schematic diagram of the visual pathway, its lesions and their accompanying visual field defects

Damage at the level of the retina up to the optic chiasm will result in an ipsilateral defect. A defect that is prechiasmal
may affect both eyes. This occurs at the anterior knee of von Willebrand. Here the nasal fibres that decussate at the
chiasm project forward into the contralateral optic nerve. A lesion in this region results in a junctional scotoma which is
characterised by an ipsilateral complete loss of vision in one eye and a hemianopsia in the other eye.
Chiasmal and post-chiasmal lesions usually cause VF defects that respect the vertical midline. The most common
chiasmal lesion is a bitemporal hemianopia. Post-chiasmal lesions also respect the vertical midline, cause bilateral VF
defects and are typically homonymous hemianopsias. VF defects on the right are associated with problems on the left
hand side of the brain. Lesions along the optic tract also produce bilateral VF defects. Lesions in the temporal lobe
usually result in bilateral homonymous quadranopsias which are typically superior since they affect the inferior fibres
that traverse Meyer’s loop in this region of the brain. These visual field defects are sometimes referred to as “pie in the
sky” defects. The superior fibres pass posteriorly through the parietal lobe and therefore lesions in this area of the visual
pathway tend to produce bilateral homonymous inferior quadranopsias also sometimes referred to as “pie on the floor”.
Eventually fibres pass through to the occipital cortex.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-5

 Visual Fields and Visual Field Screening

FEATURES USED IN DESCRIBING A VISUAL FIELD DEFECT

A visual field defect may be described by position, shape, laterality and/or similarity (congruity).

POSITION OF THE VISUAL FIELD DEFECT

When commenting on the position of the visual field defect, one may begin by mentioning that it is either central which
means that the visual field defect will lie within 30° from fixation or it could be peripheral in which case it will lie greater
than 30° from fixation.

SHAPE OF THE VISUAL FIELD DEFECT

The shape can differ when considering its laterality (unilateral or bilateral)

UNILATERAL SHAPES
 The shape of unilateral visual field defects are usually oval or round scotomas. These scotomas are described
by location and shape.
o Central scotomas are defects which involve the fixation point (Fig 9.3 a)
o Centrocoecal scotomas are defects which include the fixation point and the blind spot (Fig 9.3 b)
o Paracentral scotomas are any scotoma within 20°(some say 30°) from fixation but not including fixation
(Fig 9.3 c)
o Pericentral scotomas are defects which surround the fixation point more or less symmetrically (Fig 9.3 d)
o Peripheral scotomas are defects that lie outside the central area
o Bjerrum and Arcuate scotomas are defects that arch over or under fixation into the nasal field. These are
defects that follow the retinal nerve fibre layer. It is a defect that is frequently seen in cases of glaucomatous
damage. Bjerrum’s area extends between 5-20° from fixation (Fig 9.3 e)
o Zonular scotomas are defects which may occupy any part of the visual field with the concavity of the defect
always directed to the fixation point (Fig 9.3 f)
o Altitudinal defects are defects affecting the whole upper or lower field, i.e. above or below the horizontal
midline

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-6

 Visual Fields and Visual Field Screening

a b c

d e f
Figure 9.3 Schematic diagrams of various types of unilateral field defects
a: central scotoma; b: centrocecal scotoma; c: paracentral scotoma
d: pericentral scotoma; e: Bjerrum’s/arcuate; f: zonular scotoma

BILATERAL SHAPES
 Bilateral visual field defects are often associated with neurological problems. They have a tendency to respect the
vertical meridian.
 Terms used to described bilateral shapes of visual field defects are:
o Hemianopsias are defects that correspond to half of the field (Fig. 9.4 a)
o Quadrantanopsias are defects which correspond to a quarter of the field (Fig. 9.4 b)

Figure 9.4 Schematic diagrams of various types of bilateral field defects

a:hemianopsia; b: quadrantanopsia

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-7

 Visual Fields and Visual Field Screening

LATERALITY
Laterality of VF defects refers to which side the defects occur, i.e. right or left.

HOMONYMOUS DEFECTS
Homonymous defects are defects that occur on the same side, i.e. either on the right or left hand side of the VF. When
classifying a homonymous defect, the practitioner must make mention if it is a right or left homonymous defect.

HETERONYMOUS DEFECTS
Heteronymous defects are defects affecting opposite sides, i.e. right side of the VF in one eye and the left side in the
other eye. The term heteronymous is sometimes replaced by stating whether a VF defect is either binasal or bitemporal.

Figure 9.5 Schematic diagrams visual field defects described by laterality

(a) homonymous defect; (b) heteronymous defect

CONGRUITY
Congruity of a VF defect is considered when a VF defect is bilateral.

NON-CONGRUOUS (INCONGRUOUS) DEFECTS

Non-congruous defects are those visual field defects that are not similar to each other (Fig. 9.6a).

CONGRUOUS DEFECTS
Congruous defects are those visual field defects similar to each other between the 2 eyes. Congruous VF defects are
often found in the more posterior aspects of the visual pathway (Fig. 9.6b).

Figure 9.6 Schematic diagrams visual field defects described by congruity

a: Incongruous defect; b: Congruous defect

After screening or testing the VF, one must be able to compare the findings to those that one would expect with defects
along the visual pathway.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-8

 Visual Fields and Visual Field Screening

TESTING THE VISUAL FIELD USING NON-AUTOMATED INSTRUMENTS

AND TECHNIQUES

1. CONFRONTATIONAL VISUAL FIELDS

Introduction
 Confrontational fields allows the detect of moderate size visual field defects

Indications
 A screening test that is an essential part of the routine comprehensive eye examination
 It is performed when one requires a general field screening
 It is especially useful in patients whom automated perimetry is impossible to perform, for example, bedridden
patients, children

Advantages
 It is a simple test to perform
 It is quick
 It does not require any special instrumentation

Disadvantages
 It is able to only detect gross defects
 It may not be used for monitoring purposes
 It allows too much inter-examiner variability in terms of deviation of methodologies, stimuli sizes and speed
of presentation of stimuli

METHOD 1: CONFRONTATION FIELD SCREENING METHOD

Technique
1. Facial Amsler (FA)
2. Central Finger Counting (FC)
3. Simultaneous Finger Counting (SFC)
4. Hand comparison (HC)
5. Peripheral Finger Counting (PFC)

Preparation
1. An overhead lamp is placed above the patient’s head and directed toward the practitioner.
2. The practitioner sits directly across from the patient, at eye level, so that your face is about 60cm from the
patient (Fig. 9.7).
3. The patient is instructed to occlude one eye (LE first) with the palm of the left hand.
4. Patient fixation is directed at the practitioner’s nose.
5. The practitioner must ensure that they observe the patient’s fixation throughout the test procedure.
6. The practitioner’s hands are placed halfway between himself and the patient for each of the following
procedures.
7. The targets presented are the practitioner’s fingers in 0 (no fingers shown), 1, 2, 5 finger combinations.
Others combinations are avoided as they may cause confusion for the patient.
8. No prescription is necessary. If the patient does have a high refractive error, then the prescription is used for
the central visual field assessment and removed for the peripheral visual field assessment. This is done since
the spectacle frame would prevent the patient from detecting the presence of the target in the peripheral
positions due to it physically obstructing the peripheral targets.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-9

 Visual Fields and Visual Field Screening

Figure 9.7 Position of practitioner and patient facing each other at eye level during screening
of visual fields using the confrontation test

1. Facial Amsler (FA)

 Occlude the patient’s non-tested eye
 The patient is asked: “Can you see my nose? And “While looking at my nose, is there anything missing or blurry or
dimmer on my face? Can you see my eyes, ears, chin, top of my head and eyebrows?”
 This test checks for central scotomas and scotomas in the central field
 The distance you are sit from the patient will alter the location of findings

2. Central Finger Counting (FC)

 The target (hand position as in Fig. 9.8) is presented to the patient in each of the 4 quadrants separately (Fig. 9.9)
 The patient is asked: “How many fingers do you see?” Start with a close fist
 This step detects the presence of absolute scotomas in each of the 4 quadrants. One quadrant is tested at a time
 Throughout the procedure, the practitioner must ensure that the patient is fixating the practitioner’s nose or eye

Figure 9.8 Hand position in finger counting examination of confrontation field test

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-10

 Visual Fields and Visual Field Screening

Figure 9.9 Presentation of fingers in the upper left quadrant of the visual field before patient

3. Simultaneous Finger Counting (SFC)

 Two targets (hands as in Fig. 9.10) are presented targets simultaneously, first in each of the 2 upper quadrants
(superior temporal and superior nasal fields) and then in the 2 lower quadrants (Fig. 9.11)
 The practitioner must ensure that the patient remains fixating the practitioner’s nose throughout the procedure
 The patient is asked: “How many fingers in total do you see?”
 This step detects the extinction phenomenon which may be present in parietal lobe lesions

Figure 9.10 Hand position in simultaneous finger counting examination of confrontation field test

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-11

 Visual Fields and Visual Field Screening

Figure 9.11 Presentation of fingers in upper quadrants of the visual field

4. Simultaneous Hand Comparison (SHC)

 Simultaneous hand comparison detects relative defects
 It must be noted that neurological defects respect the vertical midline

This procedure is made up of 2 parts:

a) The practitioner presents his hands with palms facing himself, side by side on either side of the vertical,
an imaginary line (Fig. 9.12).
- The patient is asked: “As you look at my nose, is one hand clearer or brighter than the other
or are they about equal?”
- The practitioner must be careful of shadows produced by light that is unequally distributed
or misdirected in the testing environment
- This step checks for a relative hemianopsia

Figure 9.12 Presentation of hands during simultaneous

hand comparison for the detection of relative hemianopsias

b) The practitioner presents his hands one above the other on either side of the horizontal, the fingers of each
hand pointing towards each other. Position them first nasally, then temporally (Fig. 9.13).
- The patient must remain fixating the practitioner’s nose throughout the procedure
- The patient is asked the same questions as for step a, i.e. “As you look at my nose, is one hand clearer
or brighter than the other or are they about equal?”
- This step detects the presence of relative quadranopsias, altitudinal hemianopias and nasal steps

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-12

 Visual Fields and Visual Field Screening

Figure 9.13 Presentation of hands during simultaneous hand comparison for the detection
of relative quadranopsias, altitudinal hemianopias and nasal steps

5. Peripheral Finger Counting (PFC)

 This procedure detects finger counting in the periphery of each of the 4 quadrants
 Fingers are shown as far out as possible in a place halfway between the examiner and the patient, just inside
the boundary of the examiner’s own field in the examiner’s corresponding eye (Fig. 9.14). (One assumes that the
examiner’s visual field is normal)
 E.g. testing the patient’s RE, the target is presented just inside the boundary of the field of the examiner’s LE
 This allows a comparison of the examiner’s field with the patient’s field since the 2 fields correspond
 An alternative technique for this step is the kinetic confrontation visual field examination which also determines
the extremities of the patient’s visual field

Figure 9.14 Presentation of fingers in peripheral finger counting

Recording the findings
The visual field results are recorded as follows:
For a normal visual field:
OD: full (with facial amsler testing method) or comparable to examiner (with kinetic field screening)

For a visual field with a restriction:

OD: restricted in superior temporal quadrant
June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-13
 Visual Fields and Visual Field Screening

METHOD 2: KINETIC CONFRONTATION VISUAL FIELD EXAMINATION

This test not only allows one to determine the boundaries or extremities of the visual field, but is also capable
to detecting defects within the boundaries.

Instrumentation
 Overhead lamp (not always necessary)
 Target (transilluminator, knitting needle, white sphere suspended on a non-glossy black wand)
 Some texts prescribe a spherical target of 4mm diameter on a thin stick.

Procedure
1. Have the patient remove his/her spectacles. The rims of the spectacles may obstruct the view of the target
and should therefore be eliminated.
2. The practitioner and the patient face each other and must be at eye level at about an arm’s length away
(approximately 60cm).
3. The test is performed monocularly.
4. Instruct the patient form a cup with his left hand and place it over his left eye, while you form a cup with your
right hand and place it over your right eye. Ensure that the patient is using the palm of his hand and not the
fingers, as he may look through them.
5. While the patient is instructed to keep looking into your open right eye, bring in the target from an unseen
position to a point at which the patient is able to “notice” the target in their field of vision gradually. This target
must be held midway between yourself and the patient (Fig. 9.15). The patient needs to be made aware
of the fact that they will not “see” the target clearly but rather that they will be aware of its presence in the
field of vision.
6. The target is moved in towards the patient in the different visual field quadrants.
7. One should not stop moving the target once the patient reports that he first notices the target in his field
of vision. Thereafter the target is moved across the central area of the field to determine if there are any
central visual field losses. The Px must be asked to report if the target disappears or fades at any point.
8. The procedure of moving the target from unseen to seen and then within the central area of the visual field
must be conducted along the 8 radial meridians. At all times, the examiner must watch that the Px does
not lose fixation. If this happens, then the procedure must be repeated along that meridian.
9. One may also be able to plot the dimensions of the blindspot.
10. Once you have mapped out the visual field of the right eye, repeat the procedure for the left eye.

This test compares the Px’s visual field with that of the examiners. It is conducted under the assumption that
the examiner has a normal visual field. (Remember to check yours!!)

Figure 9.15 Position of the target midway between the practitioner and patient
when conducting the kinetic confrontation field test

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-14

 Visual Fields and Visual Field Screening

Findings
If one detects a visual field restriction, one needs to record in which direction the field defect lies. By mapping these
defects, one may hazard a guess as to where the problem lies within the visual pathway. It should be mandatory for the
examiner to request a comprehensive visual field examination should there be any inconsistencies with the results of
the confrontation field test. Defects within the extremities of the visual field may sometimes are usually significant
enough before this gross screening test is able to detect them.
One should note that in cases of suspected glaucoma, especially in the early stages, the visual field changes are more
subtle. Even if the confrontation test yields no gross visual field defects, further visual field testing should be
recommended to the patient given the ocular disease history.
NOTE: Retinal defects are in the opposite direction to the visual field defect, i.e. a superior visual field defect implies an
inferior retinal defect.

Recording
 Record all defects and their approximate locations (Fig. 9.16). e.g. for left homonymous superior quadranopsia

Figure 9.16 Recording of visual field defects

2. TANGENT SCREEN
 This is a kinetic investigation of the visual field and is a common perimetric method available. It is more sensitive
than confrontation or finger counting fields
 It is able to provide an accurate charting of central and paracentral visual field defects
 Useful in testing patients with hysterical fields
 However, tanget screen is not considered standard of care in managing glaucoma

Instrumentation
 The tangent screen is a screen made of a black felt background with semi-visible black circular stitching every
5° (Fig. 9.17). It usually also has radial stitching that starts at the 180 meridian running through the fixation point
every 22.5 degrees (however, this can vary from chart to chart)
 It tests the central field, 30º of visual field
 It uses a test distance of 1 meter
 It is useful in detecting the size and location of larger scotomas. It allows the examiner to vary the target size

Figure 9.17 The tangent screen

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-15
 Visual Fields and Visual Field Screening

Procedure
1. Testing distance is typically 1m.
2. Monocular test. Patch the non-tested eye.
3. Patient is directed to view a central fixation dot.
4. The patient should be wearing their prescription if over -1.75DS or +1.00DS. If they are presbyopic they should
have a +1.00 D lens placed in a trial frame over their distant correction, assuming the tangent screen is at one
meter. Patients should never wear glasses with multifocal lenses when being tested as it causes too many
distortions and the chart will not be clearly visible in the straight ahead position.
5. The practitioner begins exploring the visual field by presenting targets beginning with a 3mm white target unless
visual acuity reduction necessitates the use of larger target.
6. If the patient cannot see the central dot due to the presence of a central scotoma, 2 lines of white tape that
cross at the fixation dot (form an “X”)may be used. The patient should be directed to fixate “straight ahead”
where he thinks the 2 lines cross, even if that region is obscured or distorted.
7. All plotting is done from non-seeing to seeing. It is a good idea to plot the patient’s blind spot first so the patient
understands everyone has an area of non-seeing which is normal, plus, they will have a better understanding
of what it is like when the target disappears.
a) Testing the visual field: Determine the threshold at 25° temporally. Take a 1mm white target and ask
patient if they see it. Hold it statically at 25°. Increase the size of the target incrementally till the patient
sees the target.
b) This will be the threshold target. Plot 4 points on the temporal field (just above and below the horizontal
meridian).
c) Proceed to plot the blind spot. Plot 8 points to outline the blind spot from non-seeing to seeing. Once
plotted take target around the blind spot circumference to verify border.
d) Plot temporal field at 15° intervals. Scan along the inside of the temporal field to ensure no scotomas are
in this area.
e) Repeat 7d. but on the nasal aspect.
8. One must be careful when interpreting findings. There are some conditions that may cause field defects that
resemble glaucoma defects.(i.e., cataracts and drusen of the optic nerve heads) may result in an arcuate fibre
scotomas. Enlargement of the blind spot is not diagnostic of glaucoma.
9. The practitioner should always plot from non-seeing to seeing from the periphery starting on only one side
of the tangent screen.
10. The practitioner should never lean across to plot the opposite side, but rather walk around the back of the
patient to the other side and repeat the same procedure. He should make sure as he plots the hemi-field
that he runs the target through the blind spot to insure the patient is paying attention.
11. As a check for patient attention, the practitioner can also turn the target over so the patient can no longer see
it, checking to see if the patient is paying attention. About 90% of the time the practitioner must be watching
the patient ensuring they are indeed looking at the fixation point and not at the target.
12. The tangent screen targets are pigments. Therefore, the test is more sensitive the dimmer the lighting is on
the screen (more difficult to see). The light falling on the tangent screen should be 7 foot candles. This is not
that important when using white targets as it is with colored targets. Therefore, if the practitioner does not have
good control over the lighting in an examination room the test can be run with subdued lighting and not the
recommended 7 foot candles.
13. With coloured targets the lighting is very important and one must try and have the illumination as to near to
7 foot candles as possible. The nasal field represents the temporal retina and the temporal field represents
the nasal retina.
14. If the practitioner wishes to extend the range of the visual field being tested using the Tangent Screen, he can
increase the testing distance of the patient from the chart, but must take note that the position of the blind spot
indicated on the chart will not be in the same position. If the practitioner doubles the testing distance then he will
also double the size of the blind spot and any other scotomas detected.
15. The doubling of the testing distance is sometimes used as a method of detecting malingering in a patient. Plot
field using a 3mm white target at 1m. Then re-plot using at 2 m with a white target. If the linear size for both field
plots is the same, it indicates a hysterical field. Alternatively, the test distance can be kept the same and modify
only the test target: e.g. a 6mm white target at one meter should give a bigger field then a 3 mm target.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-16

 Visual Fields and Visual Field Screening

Recording
 The recording of findings of the actual points detected with the stimulus are plotted on the Tangent screen recording
sheet (Fig. 9.18).

Figure 9.18 Tangent screen recording form

 In addition to a diagrammatic representation must include :

a) Test Target Size (mm) written over Testing Distance (mm), e.g. "1 mm W" /"1000 mm"
b) Target Color. e.g. White (W)
c) Patient cooperation
d) Visual Rx and acuity

Example of a tangent screen plot (Fig. 9.19).

Patient X:
OD: + 1.00DS (6/6) OS: + 1.00DS (6/5) OU: 6/5

The test was conducted with a 1mm size white target at a distance of 1meter.

Figure 9.19 Example of tangent screen plot

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-17

 Visual Fields and Visual Field Screening

3. AMSLER GRID
The Amsler grids kit is a set of 7 charts (10 X 10 cm) used to detect small abnormalities (~1°) in the central VF that
could remain undetected by the usual methods of VF testing. At the appropriate testing distance, the charts are
specifically designed to assess a central 20° field. Anatomically, this correlates with the area just inside the temporal
vascular arcades but excluding the optic nerve (Fig. 9.20).
Each chart has a different pattern and is recommended for different purposes. In general, however, the charts serve to
detect small central scotoma or metamorphopsia. Metamorphopsia is an anomaly of visual perception in which objects
appear distorted, larger (macropsia) or smaller (micropsia). This is generally due to pathological changes in the fundus
that result in a displacement of photoreceptors. Metamorphopsia may, however, also have a central origin
(e.g. migraine).

Figure 9.20 Amsler grid representation on the retina

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-18

 Visual Fields and Visual Field Screening

Instrumentation

Chart #1
The first Amsler chart is the standard grid which is the most familiar and widely used.
It is a 20X20 white square grid on a black background with a white central fixation dot.
Each square (5mm) corresponds to 1° of VF at the standard testing distance of 30cm.
The chart is used to reveal distortion, relative and absolute scotomas.

Chart #2
The second chart is similar to the first except that 2 diagonal lines intersect at the
center of the grid. These are used for patient with a central scotoma that cannot
fixate the central dot. The lines will orient the patient’s fixation by allowing fixation
approximately where the lines would cross.

Chart #3
The third chart is similar to the first but the squares are red instead of white. The chart
is particularly useful for patients with suspected central or cecocentral scotomas that
are commonly due to toxic (e.g. alcohol, chloroquine, etc.) or nutritional amblyopia.
It may also used as a deceptive test to detect malingering (faking, false vision loss)
when used with red-green lenses. In normal condition, the red grid will disappear
when viewed through a green lens but will remain when viewed through a red lens.
Malingerers will claim that the lines are invisible in both the red and green filters.

Chart #4
The fourth chart is composed of small white dots (no lines) on a black background.
The chart is indicated for patients with one or more paracentral scotoma making
it easier to delineate the affected areas.

Chart #5
The fifth chart consists of 20 white horizontal lines evenly spaced by 5mm on a black
background. The chart may be rotated for evaluation in any meridian to facilitate the
identification of “oriented” metamorphopsia which primarily affects lines going in
one direction.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-19

 Visual Fields and Visual Field Screening

Chart #6
The sixth chart is similar to the 5th except that it is made of black lines on a white
background. It also contains 2 additional lines in the 1° region above and below the
fixation dot. This chart is meant to facilitate the observation of metamorphopsia
along the reading level.

Chart #7
The last chart is similar to chart # 1 but the inner 6° X 8° which corresponds
anatomically to the macular area includes smaller 0.5° white squares instead of 1°.
The smaller grid is intended to facilitate the detection of subtle visual disturbances
in the macular area.

Procedure
The Amsler grids are performed under uniform bright illumination (F+) at a testing distance of 30 cm. The patient must
be undilated with the best near Rx in place. The test is performed preferably before any contact or fundus observation
procedure to insure that the result is unaffected by previous tests. Amsler grids are always tested monocularly with the
better eye tested first to facilitate the patient’s understanding and observations. Fixation must constantly be
monitored. The test is performed asking the following 5 questions to the patient:

1. Can you see the central white dot?

This question rules out relative or absolute central scotomas. If no central dot is visible then an absolute scotoma
is present and chart #2 should be used. If the central dot appears faint or blurry, a relative scotoma may be present.

2. Continue looking at the central white dot. Can you see all 4 sides & corners of the large square?

This rules out arcuate, altitudinal, quadrantic, hemianopic or field constriction defects. If the answer is “no”, the patient is
asked to document the defect. Chart #3 may be used to facilitate the observation of a suspected cecocentral scotoma.

3. Continue looking at the central white dot. Are any of the small squares blurry or missing on any part of the
grid?

This step rules out relative or absolute paracentral, cecocentral, or altitudinal scotomas. If the answer is “yes” first rule
out bad refractive correction or media opacities. If squares are definitely missing or blurry then an absolute or relative
scotoma may exist and the patient is asked to document the defect. To make defect clearer chart #4 may be presented.

4. Continue looking at the central white dot. Do any of the horizontal or vertical lines that make up the square
appear wavy or bent?

Metamorphopsia is addressed here. If the answer is “yes”, first rule out artifacts resulting from multifocal lenses. Then
ask the patient to document the defect. Waviness can range from minimum to severe with some of the lines being
discontinuous or broken.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-20

 Visual Fields and Visual Field Screening

Macropsia, which results from increased photoreceptors density, will make a square appear
rounded like a barrel.

Micropsia, the opposite, will make the square appear like a pinecushion.

5. Continue looking at the central white dot. Is any part of the grid shimmering, flickering, or colored?

This helps rule out scintillating scotomas which are commonly associated to migraines but which can also result from
retinal causes (e.g. serous detachment) or visual pathway lesions (e.g. AV malformation).

Modified Procedures
Threshold Amsler grids: A modified testing procedure can help increase the sensitivity of Amsler grids to detect very
shallow (subtle) VF defects. Two cross-polarized filters are placed in front of the eyes and rotated with respect to each
other to reduce the contrast of the grid against the black background until it is barely discernible. This sets up a
threshold situation that facilitates the recognition of VF alterations. Relative scotomas are easier to detect and absolute
scotomas easier to observe. The procedure is the same as described above.
Modified Amsler grids: Several modified Amsler charts are available on the market. Despite some additional features
that may present some advantages, their principle remains similar to the conventional Amsler grids.

The Yanuzzi card is a minified version of Amsler chart # 7 the

size of a credit card (16° X 10°). The advantage of the Yanuzzi
card lies in its ease of portability.

The Transilluminated grid is similar to the standard Amsler grid except that it is constructed by punching 1mm holes
(5mm apart) in a steel card to form the grid pattern. The transilluminated chart is advantageous in patients with media
opacities that cannot view the standard chart.

The Diamond chart is similar to Amsler chart #5 except that it

has black lines on a white background. The advantage of the
Diamond chart lies in that it contains a 5mm central red fixation
dot and a red diamond 10cm to one side of the dot that allows for
proper distance control. When held at the proper working
distance (40cm for Diamond grid), the diamond falls into the
blind spot and disappears. The diamond also ensures monocular
viewing: should the test accidentally be performed binocularly,
the diamond will not disappear.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-21

 Visual Fields and Visual Field Screening

ADDITIONAL INFORMATION
Amsler grids are frequently dispensed for patients to perform self-monitoring at home. These are useful to monitor
progressive, recurrent, active or inactive diseases that affect the central area and threaten vision. Amsler grids are
particularly useful for age-related macular degeneration which affects a significant segment of the older population.
The self-assessment Amsler grids are prescribed for the interval between eye examination. Depending on the severity
of the condition, the frequency of self-testing can range from once a day to once a week. The self-monitoring Amsler
grid should be placed in an area where patients will be reminded to perform the procedure (e.g. on the refrigerator, toilet
mirror etc.) The instructions described above are given both verbally and in writing and the patient is advised to call the
office and return for consultation immediately should any visual change be noticed.

Recording
If scotomas are noted, the patient is asked to describe, show and draw the location & delimitation on the chart. Patient’s
remarks about the appearance and depth of the scotoma are added. Comments about the result’s reliability based on
the patient’s characteristics and expressions are noted as well. The grid is identified, dated and appended to the
patient’s record.

Lines distorted scotoma

BIBLIOGRAPHY
Benjamin WJ. Clinical Refraction. WB Saunders Company. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 9-22

 INTERPUPILLARY DISTANCE
MEASUREMENT (IPD)

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Distance PD measurements
 Near PD measurements
 Monocular PD measurements

INTRODUCTION

The Interpupillary distance (IPD) measure is also referred to as the pupillary distance (PD). The determination of this
measurement is an important part of the ophthalmic prescription and the refraction routine. The use of the PD
measurement begins when refracting the patient with the trial frame or phoropter. Thereafter, it is indicated on a
prescription form for the ordering of spectacle lenses. The specification of this measurement is essential in order to
place the optical centers of lenses in their required position, which in most cases lies in front of the patient’s line of sight
or pupil centers.
The entrance pupil of the eye determines the size and location of the bundle of light that enters the eye to stimulate the
retina. By definition, the PD is the horizontal distance in millimeters between the entrance pupils of the 2 eyes for a
given viewing distance (Fig. 10.1). Practically, it is the distance between the centre of the pupil of one eye and the
centre of the pupil of the other eye. The PD will not be the same for all people and is measured for distance and
near fixation.

Figure 10.1 Interpupillary distance of a patient’s eyes

The distance PD is placed at the optical centers of the spectacle lenses before the entrance pupils of the eyes when
patients are looking in primary gaze. The distance PD is related to the amount of binocular convergence required by a
patient for bi-foveal fixation. Patients with larger distance PDs have greater demands for convergence to a near target
than patients with smaller PDs.
There are several factors one must take into consideration when measuring the PD of a patient. They include:
 Binocularity of the patient (is strabismus/tropia present?)
 Is there any facial asymmetry
 Are the irises too dark to determine the pupil center

June 2012, Version 1-1 Clinical Optometric Procedures 1, 10-1

 Interpupillary Distance Measurement (IPD)

These factors would contribute to the method that is used to determine the PD measurement. For example, if the pupils
are too dark, and there is no facial asymmetry and the patient is binocular, one may use other reference points as
opposed to using the center of the pupil. One may in this case, use the limbal edges as the reference points to take the
measurements. If there is facial asymmetry or a strabismus present, the lenses will be placed such that the optical
center of the lens is coincident with the entrance pupil of the eye. In this case, the practitioner would need to take a
monocular PD measurement.

DISTANCE PD MEASUREMENTS

INSTRUMENTATION
 Millimeter ruler (accurate)

PROCEDURE
1. The practitioner and the patient must be positioned directly in front of each other (at eye level) at an arm’s
length away (± 40cm).
2. The patient is directed to fixate the practitioner’s left open eye, while the examiners right eye is closed.
3. Align the zero mark on the millimeter rule with the temporal limbus of the patient’s right eye (Fig. 10.2a) (The
limbal reference point is used when it is difficult to precisely locate the center of the entrance pupil in a clinical
situation). Some refraction manuals suggest that the practitioner use the pupillary margins as the reference
points, however, this is provided that the pupils are symmetric (Fig. 10.2b). The practitioner can also align the
PD rule with the pupil center of the patient’s right eye to pupil center of the patient’s left eye (Fig. 10.2c).

Figure 10.2 (a) IPD temporal limbal alignment;

(b) IPD temporal pupil margin alignment; IPD pupil center alignment

4. The practitioner then closes his left eye and opens his right eye and directs the patient to bi-foveally fixate the
practitioner’s open right eye.
5. The examiner then notes the position on the ruler that corresponds to the nasal limbus of the patient’s left eye
(or pupil center of the patient’s left eye).
6. This measurement is noted as the distance PD (Fig. 10.3).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 10-2

 Interpupillary Distance Measurement (IPD)

Figure 10.3 IPD measurement using pupil center alignment.

7. The procedure may be repeated to ensure alignment of the ruler and accuracy of the measurement.
8. While the patient is not actually directed to a distance target, it should be noted that the patient’s fixation of the
practitioner’s eye is not enough to deviate the patient’s eyes from the straight ahead position by an amount
that would significantly alter the measurement.
9. In cases where a patient has an alternating strabismus, the measurement is taken in a similar manner, except
that the patient’s non-fixating eye is occluded during the alignment process. In this way, the practitioner is
confident that the patient will be viewing through the optical center of the lens if that particular eye is fixating a
distance target (Fig. 10.4).

Figure 10.4 PD measurement in a case of an alternating strabismus, each eye fixating

at a time with the non-fixating eye being occluded.

NEAR PD MEASUREMENTS

PROCEDURE
1. The position of the patient and the examiner is as per the distance measurement.
2. The patient is directed to view the tip of the examiner’s nose (or some other near target), thereby causing the
patient to converge slightly.
3. Align the zero mark on the millimeter rule with the temporal limbus of the patient’s right eye (or pupil center of
the patient’s right eye) while the examiner’s right eye is closed.
4. The examiner closes his left eye and opens his right eye and notes the position on the ruler that corresponds
to the nasal limbus of the patient’s left eye (or pupil center of the patient’s left eye).
5. This measurement is noted as the near PD.

RECORDING

The values are normally recorded as distance PD/near PD (in millimeters). e.g. PD: 63/60.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 10-3

 Interpupillary Distance Measurement (IPD)

INTERPRETATION
 According to Benjamin (2006) in Borish’s Clinical Refraction, the mean PD for adults is 64mm and for children in
the range between 50 and 60mm. It is important to note these norms vary in different ethnic groups.
 The distance PD for women is most commonly in the range of 55-65mm, men 59-70 and in children may be as low
as 45mm.
 The distance PD is usually 3-4mm greater than the near PD.

COMMON ERRORS IN THE PROCEDURE

Moving the rule during the measurement and losing the alignment. The hand holding the ruler must therefore be very
steady. To achieve this, it is recommended that the examiner grasp the millimeter rule between the thumb and
forefinger and rest the remaining fingers of his hand on the patient’s cheek.

MONOCULAR PD MEASUREMENTS

Since very few eyes are actually symmetrically located relative to the nose, take a binocular PD measurement may be
somewhat inaccurate in determining the placement of the optical centers of the lenses before each eye. It is more
useful for the practitioner to determine a monocular PD (Fig. 10.5).

Figure 10.5 Monocular PD in relation to a binocular PD measurement

INDICATIONS
 Unilateral strabismus
 Facial asymmetry
 High refractive error
 Multifocal dispensing measurements

PROCEDURE
1. Monocular PDs are measured just as the distance and near PDs but with slight variations in procedure.
2. The patient fixates the practitioner’s open left eye while his right eye remains closed.
3. The PD rule is aligned at the zero mark with the center of the patient’s right pupil.
4. The practitioner notes the measurement from the center of the patient’s right pupil center to the center of the
bridge of the patient’s nose. This measurement is the patient’s right monocular PD.
5. The patient is then directed to fixate the practitioner’s open right eye while his left eye remains closed.
6. The practitioner notes the measurement from the center of the bridge of the patient’s nose to the center of the
patient’s left pupil. This measurement is noted as the left monocular PD. Sometimes, the practitioner may
move the zero mark from the patients right pupil to the center of the bridge of the patient’s nose and then note
the measurement from the center of the bridge to the patients left pupil.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 10-4

 Interpupillary Distance Measurement (IPD)

RECORDING
Monocular PD measurements are recorded in millimeters with the right monocular PD preceding the left monocular PD,
i.e. OD/OS. e.g. 31/30.

DIFFICULTIES WITH TAKING A MONOCULAR PD

 It is sometimes difficult to detect the center of the patient’s pupil in patients with darkly pigmented irides. In these
cases, many practitioners prefer to use the corneal reflexes as a landmark to take the measurements. In this case,
instead of the patient using their finger to direct the patient to fixate their open eye, they hold a penlight directly
below their open eye for the patient to fixate.
 It must be noted that this measurement may tend to underestimate the monocular PD since the corneal
reflexes tend to be located 0.4mm nasal to the center of the entrance pupil.

BIBLIOGRAPHY
Benjamin WJ. Borish’s Clinical Refraction. Butterworth Heinnemann/Elsevier. 2006.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 10-5

 COLOUR VISION

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Public Health Division, Sydney, Australia

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Normal color vision

 Defective color vision
 Color vision testing
 Pseudoisochromatic Plates
 Color Arrangement Tests

INTRODUCTION

Color vision is the visual function that allows one to perceive variation among the physical wavelengths of light that
compile the visible spectrum.

NORMAL COLOUR VISION

Persons with normal color vision are termed trichromats. Trichromats have 3 different divisions of cone photoreceptors
within the retina which contain photopigments to absorb the wavelengths of light within the visible spectrum.
 Erythrolabe refers to the photopigment that absorbs red wavelengths.
 Chlorolabe refers to the photopigment that absorbs green wavelengths.
 Cyanolabe refers to the photopigment that absorbs blue wavelengths.

All the spectral hues can be matched by an additive mixture of the three primary colors taken from the long-wave
(red), medium-wave (green), and short-wave (blue) parts of the spectrum (Fig.11.1).

Figure 11.1 Colors of the rainbow viewed by an individual with normal color vision
June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-1
 Colour Vision

DEFECTIVE COLOUR VISION

Defective color vision is either congenital or acquired.

CONGENITAL COLOUR DEFICIENCIES

Approximately 4% of the total population has congenital color deficiencies out of which about 95% are males.
Deficiencies may present as a partial abnormality which is more common, or as a complete absence of specific cone
photopigments which comprise the retinal pigment system.

Certain abbreviations are designated to each portion of the retinal pigment system:
 Prot refers to the red or erythrolabe cone photopigment system
 Deut refers to the green or chlorolabe cone photopigment system
 Trit refers to the blue or cyanolabe cone photopigment system

There are three different types of color deficiency that are based on how many colors of the cone pigment system it
takes to make a color match on an anomaloscope, a device specifically used to distinguish the various color
deficiencies. The patient must adjust the ratio of red and green lights to match a yellow light in terms of hue,
brightness and saturation.

TYPES OF COLOUR DEFICIENCES

MONOCHROMACY
Monochromats have an absence of two or all three cone photopigments. There are two types, the rod or typical
monochromat and the cone or atypical monochromat. The rod monochromat has no functioning photopic system.
Persons with rod monochromatism generally have macular dysfunction, nystagmus and low vision. The cone
monochromat has one functioning cone photopigment of the photopic system. Persons with cone monochromatism
may be further characterized as red, green or blue monochromats. The red or green monochromat has reduced but
adequate visual acuity while the blue monochromat has very poor visual acuity. All types of monochromatism which
are extremely rare lead to no available color discrimination (Fig.11.2b).

A B

Figure 11.2 (a) Colors of the rainbow viewed by an individual with normal color vision;
(b) Colors of the rainbow viewed by an individual with monochromatism

Dichromats have an absolute defect or complete absence of one portion of the cone pigment system. Dichromatism
is further separated into Protanopia, Deuteranopia and Tritanopia. In all dichromats there is a neutral point within the
spectrum. Under photopic conditions, it is the point that appears achromatic. There is no hue present at the neutral
point because it is the position where the remaining 2 photopigments are balanced.
Protanopia is an abnormality of erythrolabe. There exists a major luminosity loss on the red end of the spectrum.
These individuals experience color confusions or difficulty discriminating between green, yellow and red. For example,
the color red is perceived as a darker color perhaps similar to brown (Fig. 11.3b). Finally, their spectral sensitivity shifts
towards shorter wavelengths.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-2

 Colour Vision

A B

Figure 11.3 (a) Colors of the rainbow viewed by an individual with normal color vision;
(b) Colors of the rainbow viewed by an individual with protanopia

Deuteranopia is an abnormality of chlorolabe. There is a luminosity loss in the green portion of the spectrum. These
individuals experience color confusions or difficulty discriminating between green, yellow and red (Fig.11.4b). Their
spectral sensitivity does not shift.

A B

Figure 11.4 (a) Colors of the rainbow viewed by an individual with normal color vision;
(b) Colors of the rainbow viewed by an individual with deuteranopia

Tritanopia is an abnormality of the cyanolabe. There exists a major luminosity loss on the blue end of the spectrum
(Fig.11.5b). Their spectral sensitivity shifts towards longer wavelengths.

A B

Figure 11.5 (a) Colors of the rainbow viewed by an individual with normal color vision;
(b) Colors of the rainbow viewed by an individual with tritanopia

ANOMALOUS TRICHROMACY
Anomalous Trichromats have a partial defect or alteration of one portion of the cone photopigment system.
Anomalous Trichromats are further separated into:
 Protanomalous Trichromacy
 Deuteranomalous Trichromacy
 Tritanomalous Trichromacy

June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-3

 Colour Vision

The colors matches of anomalous trichromats appear a little different due to the weakness but there are no confusions
in color. Persons with these types of defects generally disagree on exact shades of color.

Table 11.1 Classification of Congenital Color Deficiency

Designation Prevalence Hue

(based on number of cone photopigments) Male (female) Discrimination

Monochro Typical or Rod 0.003 Absent

1
mat Atypical, Incomplete or Cone 0.000001 Absent
Protanope 1 (0.01)
2 Dichromat Deuteranope 1 (0.01) Severely impaired
Tritanope 0.002
Protanope 1 (0.01)
Anomalous Variable
(2 normal; Deuteranope 5 (0.25) impairment
3 Trichromat 1 defective)
Tritanope trace
Normal 92 (910.6) Optimum

AQUIRED COLOUR VISION DEFICIENCIES

Acquired color deficiencies are usually associated with trauma, drug toxicity or disease. These all have the potential
of affecting the retina or optic nerve. Persons with acquired color deficiencies most frequently present with a
blue-yellow defect. The color deficiency may be present before the patient experiences light sensitivity or a reduction
in visual acuity.

COLOUR VISION TESTING

Routine color vision testing serves several clinical purposes necessary to proper patient care. Firstly it aides in the
diagnosis of color deficiency and secondly it allows for distinction between acquired and inherited color deficiencies.
Finally, it contributes to the evaluation and quantification of retinal and optic nerve function.
The present tests work by exploiting the difficulty of color discrimination experienced by persons with color
deficiencies. There are two types of tests for practical in-office use:

PSEUDOISOCHROMATIC PLATES
Pseudoisochromatic plate (PIP) tests requires that the patient identifies a symbol made of colored dots of varying size
in a colored background. The figure and ground are chosen so that the symbol is confused by color-deficient patients.
There are many types available. The most common are the Ishihara, Hardy Rand Rittler (HRR) and Dvorine tests.

ISHIHARA PSEUDOISOCHROMATIC PLATES

Instrumentation:
 Pseudoisochromatic plate test

Procedure:
1. The patient’s VA must be better than 6/60 (0.1) in order to conduct the test.
2. Good illumination is absolutely necessary; The Macbeth Easel Lamp is the standard.
3. Testing is performed monocularly.
4. The test is held 75 cm in front of patient.
5. The plates must be perpendicular to visual axis.
6. Viewing time should be at least 3 seconds and not longer than 5 seconds.
June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-4
 Colour Vision

7. The patient is asked to identify the digits on the presented plate.

8. Patients can alternatively be asked to trace the digits (or tracing patterns) using a cotton tip applicator if they
are unable to identify numbers.
9. The 1st plate is a demonstration which everyone should see. Patients who fail to see the number may be
misunderstanding the instructions, malingering or have a significantly decreased VA.
10. Plates 2 to 7 are transformation plates with normals seeing the correct number while color deficient patients
read another.
11. Plates 8 to 13 are vanishing plates with normals seeing them but color deficient not being able to see them.
12. Plates 14 to 15 are hidden design plates with normals not being able to see a number but color deficient
may.
13. Plates 16 to 17 are diagnostic plates which help determine the severity of the deficiency.
14. Plates 18 to 24 are tracing plates which may be used for individuals who are illiterate or children.

Table 11.2 Ishihara Pseudoisochromatic Score Chart

Total Color
Plate Normals Red-Green Defect
Blindness
1 12 12 12
2 8 3 X
3 29 70 X
4 5 2 X
5 3 5 X
6 15 17 X
7 74 21 X
8 6 X X
9 45 X X
10 5 X X
11 7 X X
12 16 X X
13 73 X X
14 X 5 X
15 X 45 X
Protan Deutan
Strong Mild Strong Mild
16 26 6 (2) 6 2 2 (6)
17 42 2 (4) 2 4 4 (2)

The mark X shows that the plate cannot be read. Blank space denotes that the reading is indefinite.
The numerals in parenthesis show that they can be read but they are comparatively unclear.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-5

 Colour Vision

Shortened method:
(Commonly used clinically to save time)
 The 7 left-side plates are used to test the patient’s right eye and vice versa.
 By this method 8 plates are tested on each eye (the first plate is presented to both eyes)
e.g. OD: 1,3,5,7,9,11,13,15
OS: 1,2,4,6,8,10,12,14
 If the patient identifies any plate incorrectly, then the examiner must present all 17 plates.

Recording the findings:

 The grading criteria is defined as:
Normal: < or = to 4 errors out of 17 plates
Failure: > or = to 5 errors out of 17 plates
 The examiner records the results by noting the # correct/total # plates followed by type of plates used. The missed
plates & numbers called may also be noted to help determine the color vision defect.
e.g . 7/7 OD, 7/7 OS Ishihara
e.g. 12/17 OD, 11/17 OS Ishihara
 If possible, the type of color vision defect is determined and noted using the Score Chart provided (Table 11. 2).

HARDY RAND RITTLER (HRR) TEST

The HRR test was developed by Hardy, Rand and Rittler and published by American Optical in 1955. Since then it has
been revised several times with the currently distributed version being the Richmond HRR test.

The HRR has been designed to:

 Screen individuals for defective or normal color vision.
 Provide a qualitative assessment color defect by detecting the type of defect as being either protan, deutan or
tritan.
 Provide a quantitative assessment of the color defect by grading the degree of the color defect as being mild,
medium or strong.
While the Ishihara test has probably been the most widely used tests to screen for protan and deutan deficiencies, it is
unable to provide an assessment of the blue (tritan) color defects. The HRR test on the other hand while using the
same principles of testing as the Ishihara test is slightly superior in its ability to detect protan, deutan and tritan
defects. Only moderate or severe tritan defects may be identified. While the grading plates are effective, the test is
unable to distinguish dichromats and severe anomalous trichromats.

Instrumentation:
 HRR pseudoisochromatic plates
 Laminated scoring sheet
 Camel’s hair brush (to avoid patient’s touching the color plates)

Procedure:
1. The test set up and requirements are similar to that of the Ishihara test.
2. The HRR test comprises of 24 plates, with each plate containing 1 or 2 symbols which can be either cross,
circle or a triangle. The symbols comprise colored dots which appear on a background of grey dots.
3. The 1st plate is a demonstration which everyone should see. Patients who fail to see the number may be
misunderstanding the instructions, malingering or have a significantly decreased VA.
4. There are 4 demonstration plates with the symbols being seen by all individuals, including those with color
deficiencies. One of the plates does not have a symbol so that the patient understands that there may be
a plate on which they may not see a symbol.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-6

 Colour Vision

5. There are 6 screening plates, 4 for protan-deutan deficiencies and 2 for tritan deficiencies. The colors of the
symbols lie on the protan, deutan and tritan achromatic confusion loci. Patients with severe specific
deficiencies will not see the symbols with colors lying on the specific confusion loci, however, will see other
symbols which do not lie on the other confusion loci.
6. There are 14 diagnostic plates which help to grade the severity of the deficiency. Ten plates are for protan,
deutan defects, and 4 plates for tritan defects.

COLOUR ARRANGEMENT TESTS

The most common are the Farnsworth D-15 and Farnsworth-Munsell 100 Hue. They are generally used once the
pseudoisochromatic plates are failed or if the examiner would like to further qualify a color deficiency. Arrangement
tests classify color vision deficits as protan, deutan or tritan, but they are unable to distinguish dichromats from
anomalous trichromats. A score sheet is used to record the order of the patient’s arrangement of hues in relation to
their correct sequence. Once the sequence is recorded it is then placed on an analysis graph. The color deficiency will
parallel the axis of color confusion.

FARNSWORTH D-15
The Farnsworth D-15 consists of 16 colored caps. The 16 different colors are selected from the Munsell system color
circle. The chosen color samples are equally spaced around the Munsell system color circle. Therefore, distinction
between bordering caps is quite clear to the person with normal color vision. Persons with severe color vision defects
have major color confusions and will make significant arrangement errors when performing the test. Persons with mild
color vision defects have minor color confusions and will generally not make significant arrangement errors when
performing the test. Consequently, the Farnsworth D-15 is used to differentiate between severe color deficiencies
in which the patient fails and mild to moderate color deficiencies in which the patient passes.

Figure 11.6 Recording sheet for the Farnsworth D-15 color vision test

Lantony’s Desaturated D-15 test according to Farnsworh is also available. It uses much paler colors so it is more
sensitive to subtle or acquired defects. It is performed and interpreted similar to the standard Farnsworth D-15. In
addition to the Protan, Deutan and Tritan axis of the standard Farnsworth D-15 analysis graph, the Desaturated D-15
June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-7
 Colour Vision

graph contains a Tetartran axis which may be affected in acquired pathology and a Scotopic Axis. The Lantony’s
Desaturated D-15 test is intended for use in conjunction with the standard Farnsworth D-15 for comparison.
The Farnsworth D-15 colour vision test is one that is used more frequently in clinical practice and is actually a
condensed version of the Farnsworth-Munsell 100 Hue test. It is more commonly used since it is less time consuming
than the Farnsworth-Munsell 100 Hue test, however, if defects are noted on this test and more sensitive testing is
required, then the Farnsworth-Munsell 100 Hue test is the test of choice.

Procedure:
1. The test is performed monocularly.
2. The patient is seated with caps placed 50 cm away & views the caps at a 60 angle. The proper light source
(preferably a Mac Beth Easel Lamp) illuminates from above the test.
3. The patient is to select the cap that looks the most like the fixed cap (reference cap) and place it next to it in
the box. The patient then selects from the remaining caps the one that looks the closest to the one just placed
in the box and continue until all caps are in the box. There is no time limit imposed for this test.
4. The examiner scores the test by recording the cap sequence on a standard recording sheet (Fig. 11.6). A
failure is recorded as 2 crossings on the diagram. Crossings require the caps to be placed at least 4 numbers
apart. Once the graph is plotted, the examiner must determine which index line is closely parallel to the
patient’s error crossing(s).

FARNSWORTH-MUNSELL 100 HUE

The Farnsworth-Munsell 100 Hue test consists of 85 colored caps, in addition to the 15 from the D-15, which are
placed in 4 separate boxes. Both the first and last cap of each box sequence is fixed. The 85 different colors are
selected from the Munsell system color circle. The chosen color samples are spaced uniformly around the Munsell
system color circle. The distance between bordering colors is quite small. Since there is only a slight variance in
colors, the test allows for fine color discrimination. The Farnsworth-Munsell 100 Hue test is a more sensitive test for
mild and moderate congenital color deficiencies and early detection & classification of acquired color deficiencies due
to ocular disease. Since it is a lengthy exam, it is used as a specialty test in specific clinical situations.

BIBLIOGRAPHY
Scheiman M and Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders.
3rd Edition. Lippincott, Williams and Wilkins. Philadelphia. 2008.
Benjamin WJ. Borish’s Clinical Refraction. WB Saunders Company. Philadelphia. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. Philadelphia. 1991.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 11-8

 OBJECTIVE REFRACTION

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Retinoscopes
 Retinoscopy

INTRODUCTION

Objective refraction comprises a host of various techniques that may be employed to determine the patient’s refractive
correction. It is usually performed for the determination of the starting point of a subjective refraction. More importantly,
it is a technique which the practitioner has to rely on entirely when a subjective refraction cannot be ascertained. This
would be in cases of the patient malingering (i.e. feigning poor/better acuity than they actually have), uncooperative
patients like children, patients who are unable to communicate subjective responses to you and in patients who are
unreliable in terms of subjective responses. It is a procedure that becomes more accurate with a greater amount of
practice. Both retinoscopy and autorefraction are methods of objective refraction. In many cases, autorefraction is
used to replace retinoscopy, however, issues of instrument reliability, problems inherent due to the nearness of the
target in the instrument, and poor cooperation on the part of patients makes retinoscopy a far more superior and more
adaptable technique to perform than autorefraction.
Retinoscopy is a technique that is used to objectively determine the refractive error of a patient. It does not require the
patient’s responses and therefore can be performed on children and non-verbal individuals.

There are two kinds of retinoscopes:

1. Spot retinoscopes – contain an ordinary light source which projects a “patch” or “spot” of light
2. Streak retinoscopes – contains a special source with a linear filament which produces a “line” or “streak”
of light

RETINOSCOPES

The first retinoscopes used a light source placed just behind the patient’s shoulder while modern retinoscopes have
the light source built into them (i.e. they are self-luminous retinoscopes). Retinoscopes allow us to shine a light into a
person’s eye and look at the light reflected back from their retina. This reflected light as seen in the person’s pupil is
called the retinoscopic reflex or “ret reflex”.
 Objective Refraction

ADVANTAGES OF RETINOSCOPES
SPOT RETINOSCOPES
1. Astigmatism can be detected with spot retinoscopy by noting the shape of the ’ret reflex’. In an uncooperative
patient, it may not be possible to achieve prolonged viewing if the patient’s fixation is not steady, and the
examiner has to depend on occasional glimpses for assessment of the reflex. In streak retinoscopy the reflex
is always a slit, regardless of the presence of astigmatism, whereas in spot retinoscopy significant astigmatism
will make the reflex appear elliptical. The correct axis of the astigmatic correction is more rapidly determined
than with spot retinoscopy.
2. The time it takes for the examiner to rotate the streak from one position to another, an uncooperative patient
may change their fixation position to one requiring more or less accommodation. This might be interpreted as
astigmatism. With the spot retinoscope, the eye with no astigmatism (or corrected astigmatism) will always
return a circular reflex, even though the speed and/or direction may change.

STREAK RETINOSCOPES
1. The end point of retinoscopy is sometimes easier to observe with streaks than with spot retinoscopes.
2. All modern streak retinoscopes have an adjustment for changing the retinoscope beam vergence from being
divergent to convergent. This is not always available on spot retinoscopes.
Apart from the problems with uncooperative patients noted above, the choice of “spot” or “streak” is a matter
of individual preference.

OPTICS OF THE RETINOSCOPE

The retinoscope consists of two major systems that have various parts. The systems of the retinoscope are the
projection system and the observation system (Fig. 12.1).

PROJECTION SYSTEM
This part of the sytem illuminates the retina and comprises the following parts:
 Light source, i.e. a small bulb that projects light onto the retina (RPE and choroid)
 Condensing lens which lies in the path of the light projected from the bulb to focus the light onto the mirror
 Mirror which is placed within the head of the instrument. It bends the light at right angles to the axis of the handle
so that the light is projected from the head of the instrument
 Focusing sleeve which varies the distance between the bulb and the lens so that the light projected from the
retinoscope either diverges (plane mirror effect) or converges (concave mirror effect)
 Current source or rechargeable/replaceable battery in the retinoscope handle

OBSERVATION SYSTEM
This part of the retinoscopic optical system allows the practitioner to view the retinal reflex. The light reflected off the
retina passes through an aperture in the mirror and out through the sight hole at the rear of the head. The light that is
reflected from the retina are acted upon by the optical components of the eye and therefore the observation of this
reflected light provides the practitioner information about the optics of the patient’s eye

June 2012, Version 1 Clinical Optometric Procedures 1, 12-2

 Objective Refraction

Figure 12.1 The retinoscope

BEAM SETTINGS OF THE RETINOSCOPE

The sleeve not only rotates the streak orientation but also changes the beam from divergent to convergent (Fig. 12.2).
 When the beam is divergent (sleeve down) add plus for a “with” motion and minus for an “against” motion. This
is also referred to as plane mirror retinoscopy ( “with” motion = same direction of reflex movement as the motion
from the restinoscope’s streak/ “against” motion = opposite direction of reflex movement as the motion from the
retinoscope’s streak)
 When the beam is convergent (sleeve up) add plus for an “against” movement and minus for a “with” movement.
This is also referred to as concave mirror retinoscopy (see the below diagrams)

CONVERGENT AND DIVERGENT BEAM SETTINGS

a: The divergent beam b: The convergent beam

Figure 1.2 (a) Retinoscope in divergent beam position; (b) Retinoscope in convergent beam position

In most cases, the practitioner will have the sleeve in the down position (divergent beam/plane mirror); however,
convergent beam or concave mirror retinoscopy may be preferred when:
 The practitioner is unsure if the movement being observed is either “with” or “against”. By changing from divergent
to the convergent beam, the movement should change direction of the movement. This would make it easier to
decide if there really is movement present (“with” will become “against” and “against” will become “with”).
June 2012, Version 1 Clinical Optometric Procedures 1, 12-3
 Objective Refraction

 Convergent beam allows more light to enter the eye, making it easier to perform retinoscopy on patients with small
pupils or opacities in the media.
 Many practitioners favor the “with” movement as opposed to the “against” movement since it is easier to perceive.
This is especially the case in high ametropia where the reflex is very dull and the “against” movement is difficult to
discern. Practitioners therefore slide the sleeve up to the concave or convergent position so that the dull against
movement becomes a distinct slow with movement which is now easier to neutralize.
 While the practitioner should take cognizance of these changes in the direction of the movement of the “ret reflex”,
he must keep in mind that the refractive correction is the same, the refractive state of the patient is the same, it is
only the direction of the ret reflex that is different.

RETINOSCOPY

TYPES OF RETINOSCOPY
STATIC RETINOSCOPY
A technique which allows the determination of the refractive error for distance while maintaining accommodation in a
fixed state. Patient fixation is maintained at a distance of 6m.

DYNAMIC RETINOSCOPY
A technique that determinesthe accommodative response at near, while not having control over accommodation. This
method of retinoscopy investigates the patient’s accommodative response. Patient fixation is less than 6m.

MOHINDRA RETINOSCOPY
A technique that determines the distance refractive error when patient fixation is more difficult to maintain. This
method encourages the patient to fixate the light source.

RADICAL RETINOSCOPY
A variation of static retinoscopy that is employed especially in cases where media opacities are present and in cases
of very high refractive error.
For the purposes of this module, only static retinoscopy will be discussed, however, this and other methods of
retinoscopy will be discussed in other specialised modules such as low vision.

RETINOSCOPE REFLEX MOVEMENTS

The retinoscopic reflex when viewed through the retinoscope appears to be located in the plane of the patient's
pupil. It is recommended that the observer must be within one meter or less from the patient’s eye in order to
clearly see the fundus reflex. When the light is passed over the eye, the reflex will appear to move. The direction
of the movement helps us to assess the patient’s refractive error.
If there are different movements in different meridians this indicates the condition of astigmatism where there are
differences in the refractive corrections for the principle meridians.

June 2012, Version 1 Clinical Optometric Procedures 1, 12-4

 Objective Refraction

Rays of light from a normal (emmetropic) eye are reflected off the retina (from the retinoscope) and exit the pupil
as parallel rays. If the retinoscope is held at a distance of one meter from the patient's eye, then a +1.00 D
spherical ('working lens") is required to focus the parallel light rays at a one-meter distance. This is known as
making the patient’s eye conjugate with the optometrist's eye. Similarly, working at any distance
can be compensated for with an appropriate working distance lens. For example, if refracting at a distance of
50cm, a +2.00D spherical working lens is needed.The aim of retinoscopy is to find the lens that would produce a
neutral reflex. This neutral reflex is one that appears stationery and fills the pupil. However, it must be noted that
this reflex is at an infinite speed making it appear to be stationery. Neutrality is achieved by adding lenses to
make the reflex brighter, move faster, and ultimately neutralize the movement.
While autorefractors have become quite accurate, an experienced retinoscopist can achieve the same degree of
accuracy. Performing retinoscopy also allows the examiner to view the quality of the optical medium of the eye,
picking up cases of keratoconus and providing information that the autorefractor cannot.
The practitioner will observe the streak reflected from the rim of a trial lens held in front of a patient’s eye. Through the
trial lens and pupil a narrower band of light being reflected from the person’s retina will be observed. This is the ’ret
reflex’ (Fig. 12.3).

Figure 12.3 Retinoscopic reflex

Figure 12.4 View through a trial lens using a streak retinoscope

When you move the retinoscope (spot or streak), the ‘ret reflex’ moves. The movements of the ret reflex may be
‘‘with’’, ‘’against’’ and neutral. This reflex is not always positioned in the principal meridians but can appear in oblique
orientations as well (Fig. 12.4).

WITH MOTION
‘’With’’ motion, the ‘ret reflex’ moves in the same direction as the sweeping of the retinoscope streak. Figure 12.5
shows the streak moving across the rim of the trial lens from your left to right. If the ret reflex moves in the same
direction as the streak projected from the trial lens rim, this is termed “with” motion.

June 2012, Version 1 Clinical Optometric Procedures 1, 12-5

 Objective Refraction

Figure 12.5 View of with motion through streak retinoscope sight hole

AGAINST MOTION
In an ‘’against’’ motion, if the streak moves from left to right, the ret reflex will move from right to left (opposite
direction). The ret reflex is moving in the opposite direction as the streak projects from the trial lens rim (Fig. 12.6).
This is an “against” movement.

Figure 12.6 View of against motion through streak retinoscope sight hole

NEUTRALITY (NO MOVEMENT)

With the streak moving from left to right when the whole pupil is filled with light and there is no observable movement
of the “ret reflex” as the streak sweeps across the pupil (Fig. 12.7). This is considered neutrality or end point.

Figure 12.7 View of neutrality through streak retinoscope sight hole

June 2012, Version 1 Clinical Optometric Procedures 1, 12-6

 Objective Refraction

ASTIGMATIC REFLEX
As previously said, astigmatic reflex is characterised by different movements in different meridians. These meridians
can be in any direction (horizontal, vertical, oblique) but are usually perpendicular to one another. An astigmatic reflex
present with several types of movements: (if neutralizing with minus cylinders and using the divergent beam)
 Both meridians presenting with ‘’against’’ motion. The practitioner will neutralize the meridian with faster motion
first.
 Both meridians presenting with ‘’with’’ motion. The practitioner will neutralize the meridian with slower motion first.
 If you find it difficult identifying the difference in the speed of the movements, check both meridians with each
addition of lens, until one gets neutralised. The remaining meridian should have an ‘’against’’ movement which
you will now neutralize with minus cylinders with the axis parallel to the streak. If instead you observe a “with”
movement, neutralize this meridian with plus spherical lenses. Revert to the first meridian which will now show an
“against” movement and neutralize it with minus cylinders.
 Example 1; You observe the reflexes along each of the meridians when conducting retinoscopy and notice that in
the vertical meridian the reflex moves with the movement of the retinoscope and in the horizontal meridian, the
reflex moves against the movement of the retinoscope. The following scenario presents itself during
neutralisation:

This means the Rx for this patient is: +1.50/-2.00x90

 Example 2: You observe the reflexes along each of the meridians when conducting retinoscopy and notice that in
the vertical meridian the reflex moves with the movement of the retinoscope and in the horizontal meridian, the
reflex moves with the movement of the retinoscope. You start to neutralise the slower with movement. The
scenario presents itself during neutralisation;

This means the Rx for this patient is: +2.00/-0.50x180

June 2012, Version 1 Clinical Optometric Procedures 1, 12-7

 Objective Refraction

PERFORMING STATIC RETINOSCOPY

SET UP
 Retinoscopy must be performed with the examiner and patient being at eye level. The examiner is directly in front
of the patient, with his right eye aligned with the patient’s right eye (Fig. 12.8). The examiner must ensure that
while he is in front of the patient, he must not obstruct the patient’s view of the presented or projected target.

Figure 12.8 The pathway of the retinoscopes light and the examiner’s visual axis coincide

 Set the trial frame to the correct PD and make sure it fits the patient comfortably. This ensures that the lenses
fitted in the trial frame have their optical center coincident with the patient’s visual axis. The vertex distance may
also be set on the trial frame to the standard employed in your country. In many cases it can range from 12 to
14mm. This measurement is especially important when taking into consideration high prescriptions where even
slight adjustments of the vertex distance can produce a resultant difference in the prescription being offered
to the patient. This can result in problems when patients are finally prescribed their spectacles and they are
unable to view through them unlike through the trial frame.

PROCEDURE
1. Static retinoscopy is a binocular technique in which both eyes may be fogged with the working distance lenses
or the technique can be performed without the working distance lenses. However, adjustments (subtraction of
plus power appropriate to working distance used) must be made to the final Rx. Each method has its inherent
advantages.

 Performing the technique with working distance lenses

The advantage of using this method is that “with” movements indicates hyperopia and “against” movements
indicates myopia (while using divergent beam). In addition, the fogging lenses are able to fully relax the
patient’s accommodation, especially in cases of low hyperopia.

 Performing the technique without working distance lenses

The advantage of this technique is that it frees up trial lens spaces in the trial frame. It also prevents additional
reflection surfaces from the working distance lenses and the correcting lenses.

How to calculate the working distance lens:

The working distance lens is determined by the dioptric equivalent of the working distance (FW). For example, if the practitioner used a
working distance of 50cm (fW), then the appropriate working distance lens is given by:

FW=1/fw  FW=1/0.5m  FW= +2.00DS.

One must make note that there are set lenses when working with phoropters. For example, most phoropters have a working distance lens
of +1.50DS, indicating that the practitioner needs to perform their retinoscopy at a working distance of 67cm.

June 2012, Version 1 Clinical Optometric Procedures 1, 12-8

 Objective Refraction

2. The room illumination should be dim, otherwise it will be difficult to observe the “ret reflex”. If the room is
too dim, it will be difficult for the practitioner to see what he/she is doing. The patient’s pupil will be larger
and therefore the examiner would be faced with more aberrations as a result of the larger pupil diameter.

3. Check that the retinoscopic beam is divergent by moving the sleeve to its lowest position. That is, closest
to the battery handle.

 Start with the streak of the retinoscope orientated vertically. Observe the position of the reflex within
the eye. In cases where the principle meridians lie at 90 and 180 degree, this vertical streak will coincide
with one of the principal meridians. The streak is then orientated horizontally to observe the reflex in this
meridian (Fig. 12.9a). However, in cases where they don’t coincide (Fig. 12.9b), then the practitioner
must rotate the streak on the retinoscope so it is in line with the “ret reflex” (Fig. 12.9c).

Figure 12.9 Aligning the beam of the retinoscopic light source with that of the ret reflex

 If you are doing retinoscopy on the person’s right eye, you need to place the retinoscope over your right
eye. Your right eye should be in line with the person’s right eye. Hold the retinoscope in your right hand.
 Ask the patient to look at a fixation target like a spot of light or a 6/60 target at least 3 metres away. This
helps to relax accommodation and keep the eyes steady.
 To get an accurate measurement of refractive error you need to keep the retinoscope very close to the
patient’s line of sight (visual axis).
 Ask the patient to inform you if your head gets in the way of the target. Encourage him to look at the
distance target and keep reminding him to keep looking at the distance target and not at the ret light. Also
ensure that the patient keeps both eyes open.
 For retinoscopy on the person’s left eye, move to the left side of the person and use the retinoscope in
your left hand with your left eye (examiner’s right eye for patient’s right eye, examiner’s left eye for
patient’s left eye). Remember to keep close to the patient’s visual axis.

4. Scoping/sweeping to observe the ret reflex

 Sweeping the Horizontal Axis:
o Use the sleeve to turn the streak to a vertical direction (90).
o Move the streak/retinoscope from right to left to sweep the horizontal axis.
o The sweeping motion is a smooth movement that may be repeated several times while
you watch the “ret reflex”

 Sweeping the Vertical Axis:

o Use the sleeve to turn the streak to a horizontal orientation (180°)
o Move the streak up and down to sweep the vertical axis
o The sweeping motion is a smooth movement that may be repeated several times while
you watch the “ret reflex”

5. Neutralizing the ret reflex

 The reflex seen is neutralized by using lenses
o Add plus to neutralise a “with” movement
o Add minus to neutralise an “against” movement
 If you add too much plus, the movement will change to “against”. This means you have passed neutrality
and you need to remove some of the plus to return to the neutral point

June 2012, Version 1 Clinical Optometric Procedures 1, 12-9

 Objective Refraction

 If you add too much minus the movement will change to “with”. This means you have passed neutrality
and you need to remove some of the minus to return to the neutral point

FACTORS AFFECTING RETINOSCOPY REFLEX

1. Ametropia: the type and magnitude of the ametropia can be determined by the speed and brightness of the
observed reflex.
2. Patient’s pupil size: affects the amount of light entering and leaving the pupil. With more light entering the
pupil, the reflex will appear brighter; however, in cases of very large pupil sizes, aberrations are encountered.
3. Working distance: shorter working distances leave less of a margin of error, however, appropriate
adjustments can be made to the findings in the trial frame to compensate for the reduced working distances.
4. Illumination source: one that is too bright may make the pupil smaller and hence prevent enough light
entering or leaving the pupil, however, a dull light source can also be problematic.
5. Nearness to neutrality: the rapid speed of the reflex as it approaches neutrality makes it difficult for the
practitioner to perceive the direction of movement of the reflex.
6. Aberrations of the eye: will affect the quality of the ret reflex.
7. Obliquity of observation: viewing off-axis will induce an error of parallax that will affect the end result and
produce inaccuracies.
8. Regularity of optical components: media opacities and pathological conditions affecting the media will have
a tendency to degrade the light entering or leaving the eye.
9. Poor optics of the retinoscope: will produce poor reflexes.

COMMON ERRORS
1. Performing retinoscopy off-axis.
2. Performing retinoscopy at an incorrect working distance affects the working distance lens used.
3. Blocking the patient’s view of the distance chart which results in accommodation being stimulated.
4. Confusing the retinoscope sleeve positions. Using concave mirror retinoscopy instead of plane mirror
retinoscopy and not making the necessary adjustment.
5. Holding lenses away from the spectacle plane.
6. Not concentrating on the movement in the centre of the pupil in patients with large pupils.

Clinical Pearl: USING MOVEMENT TO CHECK NEUTRALITY

When you think you have neutrality, you can check by:

 When you move forward, the ret reflex will become “with”
 When you move backward, the ret reflex will become “against”.

RECORDING FINDINGS
 If using a working distance lens:

The refractive correction is recorded in spherocylindrical format after removing the working distance lenses.
e.g. OD: -1.00 / - 2.00 x 90 OS: -1.00 / -1.75 x 95

Do not use the DS for dioptres of spherical power, DC for dioptres of cylindrical power or the degree sign
when recording the prescription in this form. Also use the symbol “x” for the word axis. If the axis is 0º, then it
is recorded preferably as an axis of 180. These are one and the same.

June 2012, Version 1 Clinical Optometric Procedures 1, 12-10

 Objective Refraction

 If not using a working distance lens:

The refractive correction is recorded in spherocylindrical format after adjusting the retinoscopy result in the
trial frame by the appropriate working distance correction.
e.g. If a working distance of 50cm was used and the retinoscopy result in the trial frame was as follows:

OD: -1.00 / - 2.00 x 90 OS: -1.00 / -1.75 x 95

One would need to subtract a correction of 2.00DS from this spherical aspect of the final result. The final
prescription would thus be recorded as:

OD: -3.00 / - 2.00 x 90 OS: -3.00 / -1.75 x 95

Similarly, if a retinoscopy result of OD: +5.00 / - 2.00 x 90 OS: +3.00 / -1.75 x 95 was found, the final Rx,
with assuming 50cm working distance, would be recorded as: OD: +3.00 / - 2.00 x 90 OS: +1.00 / -1.75 x 95.

INTERPRETATION OF THE FINAL RESULTS

The following classification of refractive error is commonly used:
 Simple myopia: minus sphere lens only.
 Simple hyperopia: plus sphere lens only.
 Simple myopic astigmatism: plano sphere with minus cylinder.
 Simple hyperopic astigmatism: plus sphere of same power as minus cylinder.
 Compound myopic astigmatism: minus sphere with minus cylinder.
 Compound hyperopic astigmatism: plus sphere with minus cylinder of less magnitude than the sphere.
 Mixed astigmatism: plus sphere with minus cylinder of greater magnitude than the sphere.

OTHER SCENARIOS
 Latent hyperopes have a tendency to display more sphere on retinoscopy than on dry subjective
refraction.
 Patients with media opacities may display dim/dull reflexes which can make retinoscopy difficult
to perform. In these cases one may need to perform radical retinoscopy, with a reduced working
distance or off-axis position.

BIBLIOGRAPHY
Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
Benjamin W, Borish's Clinical Refraction, Butterworth-Heinemann, 2007

June 2012, Version 1 Clinical Optometric Procedures 1, 12-11

 SUBJECTIVE REFRACTION

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Considerations before subjective refraction

 Instruments for subjective refraction
 Starting point of the subjective refraction
 Best vision sphere determination
 Monocular balancing techniques
 Astigmatic error determination
 Binocular balancing techniques

INTRODUCTION

Subjective refraction determines the refractive status of the eye using the patient's input. Subjective refraction is to
determine, by subjective means, the spherical and cylindrical lenses that are necessary to provide the patient with the
best visual acuity with accommodation relaxed. This is determined by responses from the patient. This examination
relies completely on the patient’s perceived differences between letters on a VA chart being viewed through each
variation in refractive power. It should be noted that since the technique is subjective in nature, it does not always
represent the full refractive status of the patient being tested.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-1

 Subjective Refraction

CONSIDERATIONS BEFORE SUBJECTIVE REFRACTION

According to Benjamin in Borish’s Clinical Refraction (Butterworth-Heinemann, 2006) intelligence, past experience,
accustomed visual imagery and uncertainty in discriminating between small differences may prevent perfect correlations
between the subjective findings and that of the true refractive status of the eye. The discrimination between dioptric
changes differs from individual to individual. Some individuals are very sensitive to even the smallest changes in dioptric
change. Others are less sensitive and require significant changes in dioptric power for differences in VA to be
perceived. Some patients may perform poorly on subjective refractions because of the forced/paired choice
presentations of lenses being presented. Geriatric or paediatric patients may find the process difficult or confusing.
Malingers might tend to mislead the examiner, due to a preference for spectacles (whether as a fashion item or
seeking attention).

Other factors that should be considered when performing a subjective refraction which could influence the patient’s
performance include:
 Health status of the eye
 Systemic health
 Use of medications or drugs that may have ocular and visual effects
 Age of the patient
 Extended depth of focus of a small pupil
 Choice of target, its distance and composition
 Room illumination
 Physiological pupil size and retinal adaptation
 Time allowed for discrimination between lens changes

INSTRUMENTS FOR SUBJECTIVE REFRACTION

TRIAL CASE, TRIAL FRAME (TF) AND PHOROPTER

The main equipment used in subjective refraction is either a trial frame used in conjunction with a case of trial lenses
(Fig. 13.1 a, b) or a phoropter (Fig. 13.2)

Figure 13.1 (a) Trial frame Figure 13.1 (b) Trial case

The use of the trial frame and trial case versus the use of a phoropter for the subjective refraction can be based on
availability and various other factors including age of patient, refractive status of the patient, compactness of
instrumentation. It is important to acknowledge that phoropters are expensive and that with the context of the
developing world, trial frames are more readily available, however, each has an equal degree of importance especially
when conducting binocular vision testing. Trial frames are also a useful way of demonstrating the final prescription,
especially for presbyopic correction.
In many cases where a patient presents with high amounts of refractive error, the variation of the phoropter in terms of
face form, vertex distance (in some instances) and pantoscopic angle from that of spectacles makes the trial frame the
preferred instrument in the subjective refraction.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-2

 Subjective Refraction

Figure 13.2 Phoropter used in refraction

The subjective refraction is a step-by-step procedure involving the patient’s ability to evaluate the clarity of a distance
target as a series of paired comparisons of lenses are presented by the examiner. The patient fixates throughout the
procedure on a distance target which consists of symbols or letters on a chart or projected chart. The examiner must
ensure that this chart is of optimal quality in terms of contrast (should be 100%). Room lighting must allow normal pupil
size and retinal adaptation and the chart to be visible.
Subjective refractions can be of two types, namely monocular or binocular. The binocular subjective is sometimes
preferred because it keeps the eyes in its normal state of binocularity, i.e. both eyes are open during the course of the
refraction and the accommodative state is more stable and relaxed for distance viewing. Monocular refractions involve
occlusion of the non-tested eye. In monocular refraction, the final end point of the refraction requires accommodative
balance and binocular determinations. In cases where a patient is monocular in nature (i.e. strabismus, blind in one eye,
uni-ocular) a monocular refraction is performed without binocular balance.

Subjective refraction comprises a host of various techniques. They include:

1. Determination of the best vision spherical Rx and visual acuity

2. Duochrome (monocular balancing of spherical power)
3. Astigmatism determination methods
a. Jackson crossed cylinder technique
b. Fan-and-block technique
c. Humphriss dots
d. Stenopaic slit technique
4. Binocular balancing techniques
a. Equalization by alternate occlusion
b. Prism dissociation method
c. Fogging method (Humphriss)
d. A method using a Septum (Turville)
e. Polarization method (Vectographic)
f. Dissociated duochrome method
5. Recording of final refractive error with best corrected visual acuity (BCVA) in each eye
and both eyes together

STARTING POINT OF THE SUBJECTIVE REFRACTION

The starting point of the monocular subjective refraction is determined by various objective techniques, including
retinoscopy or autorefraction or alternatively the patient’s previous spectacle correction. These findings (lenses) are
placed within the trial frame or phoropter. The starting lenses must be placed such that the optical centres of the lenses
are coincident with the geometric centres of the entrance pupil of the eyes (Fig. 13.3). This is ensured by adjusting the
TF or phoropter to the patient’s correct interpupillary distance measurement. (It must be noted whether IPD setting is
used in the binocular or monocular form – determined by earlier tests). In addition, the correct vertex distance and
pantoscopic angle must be used.
June 2012, Version 1 Clinical Optometric Procedures 1, 13-3
 Subjective Refraction

The greatest challenge when performing the monocular subjective refraction is ensuring that accommodation is in its
relaxed state. Fluctuations can induce inaccuracies in the determination of the correcting lenses.

Figure 13.3 Trial frame centred before the eyes.

The objective of conducting a subjective refraction is to determine the:

Maximum plus or minimum minus spherical lens power that provides

the patient with maximum visual acuity

If the plus lens is weakened or minus lens strengthened thereafter, no improvement in acuity can take place, merely
accommodation. If accommodation is being exerted during this procedure, it means that the patient is unable to attain
the clearest, comfortable vision without exerting accommodation and hence will experience asthenopic symptoms.
The monocular aspects of the refraction involve determining visually the best spherical correction, balancing of the
monocular spherical correction and astigmatic refraction (which can be determined by various procedures). Thereafter,
based on the refractive differences, visual acuity differences, motor and sensory binocularity of the patient, the
procedures for binocular balancing will follow. Variations may also occur in the sequence of tests depending of the
patient’s co-operation levels.

BEST VISION SPHERE DETERMINATION

There are several methods of determining the best spherical correction of the patient. Each of the techniques is aimed
at maintaining the accommodation in a passive position.

INSTRUMENTATION
1. Visual acuity chart
2. Trial frame and trial case (or a phoropter)

PROCEDURE
1. Determine the presenting or habitual monocular visual acuity in the right eye as outlined in the chapter on
visual acuity. (This may be the patients uncorrected VA if no objective refraction was performed or could
be the patient’s corrected VA with the objective findings or previous refractive findings in place).
2. Occlude left eye.
3. Select a letter on the line above the best visual acuity of the right eye as the target for the test procedure.
4. Plus and minus lenses are used as probe lenses. The amount of dioptric value of the probe lens will
depend on the patient’s visual acuity.

PROBE LENSES
6/60 VA  1.00D probe lenses
6/12 VA  .50D probe lenses
> 6/12 VA  0.25D probe lenses

June 2012, Version 1 Clinical Optometric Procedures 1, 13-4

 Subjective Refraction

5. The more plus option (+0.25D lens) is always presented first. This is to ensure that accommodation is in
its passive state or that the examiner alters accommodation in a minimal capacity. The patient is instructed
to tell the practitioner if the letter on the chart appears “brighter, sharper and clearer” with the plus lens
or without.
6. If the patient chooses the plus lens, place this in the trial frame and present a further +0.25D lens before
the eye and determine the maximum plus lens that the patient will tolerate before the letter becomes
“blurry”. Remove this “blurry” lens.
7. If the patient rejected the +0.25D lens initially, then, introduce the –0.25D lens before the eye. Once again,
ask the patient whether the letter is “sharper, clearer or darker” without the lens or with. (NB: The more plus
option is always presented first)
8. If the patient prefers this minus lens, then keep adding minus lenses no improvement is gained and remove
the last lens that made the target appear darker or smaller but not clearer. Remember that even though
the added minus may not affect the clarity of the target letter, the size decrease should indicate that you are
over-minusing and accommodation is no longer at rest. Therefore the practitioner must always emphasise
2 aspects, namely clarity and whether the lenses make the letters “smaller, darker and better”. The lens
that makes the letters clearer can be retained, however the lens that makes the letters “smaller, darker
and better” should be discarded and the previous minus change is accepted as the end point of the test.
Another check that the practitioner can employ to ensure that he/she is not over-minusing the patient is
to take the VA with the changes in lens power. A lens that produces the same VA as the previous lens with
not other improvements with respect to clarity is probably one that is not required and the practitioner must
therefore remove this last -0.25DS lens.
9. Once best subjective spherical error of the right eye, repeat the procedure for the left eye.

HINTS
 One should ensure that there is an increase in visual acuity when adding minus lenses before the eye. This may
not be the case with plus lenses presented before a latent hyperope.
 If 6/6 visual acuity is attained with a –0.50D lens and with further increase in minus lenses the same visual acuity
attained, one would prescribe the least minus lens that provides the 6/6 visual acuity.
 If 6/6 visual acuity with a +0.50D lens and with further increase in plus lenses attain the same visual acuity, one
would prescribe the maximum plus lens that provides the 6/6 visual acuity.
 Some methods of determining the best spherical correction are initiated from the point of fogging, thus ensuring
that accommodation is not involved in the findings.

One may also be able to predict the size of the spherical ametropia by means of the unaided visual acuity (Table 13.1).
Table 13.1 Correlation between visual acuity and refractive error

REFRACTIVE ERROR (D)

VISION SPHERICAL
Myopia and absolute ASTIGMATISM
Hyperopia
6/6 = 20/20 Small Small
6/9 = 20/30 0.50 1.00
6/12 = 20/40 0.75 1.50
6/18 = 20/60 1.00 2.00
6/24 = 20/80 1.50 3.00
6/36 = 20/120 2.00 4.00
6/60 = 20/200 2.00 to 3.00 High

N.B. The predicted vision with astigmatism is on the assumption that the circle of least confusion lies on or close
to the retina.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-5

 Subjective Refraction

MONOCULAR BALANCING TECHNIQUES

DUOCHROME OR BICHROMATIC TECHNIQUES

BACKGROUND
This procedure involves determining the maximum plus and minimum minus lens that places the circle of least
confusion on the retina. To a certain extent, this test may sometimes be referred to as a check for the best sphere
correction with the best acuity that was just determined. It is a test that utilizes the different refraction angles associated
with different wavelengths or colours of light.
The human eye is not corrected to focus light of different wavelengths at the same image point. The eye suffers both
axial and transverse chromatic aberration. The axial aberration is used to determine the spherical ametropia of the eye.
Green light (535nm) is refracted at a greater angle than red light (620nm). While yellow light (570nm) focuses on the
retina, green light will focus 0.20D in front of the retina and red light will focus 0.24D behind the retina (Fig. 13.4).

Figure 13.4 Focus of green, yellow and redt light in the eye

The above illustration depicts the focus of yellow light on the retina, with the focus of red and green light wavelengths
equidistant from the retina.
Since the red and green foci are equidistant about the retina, an emmetrope or corrected ametrope should report seeing
black test objects on the two coloured backgrounds equally clear.
Since the white (yellow) focus of a low myope falls short of the retina, a myope will see the test objects on the red
background clearer and darker (Fig. 13.5) since this wavelength of light is closer to the retina.

Figure 13.5 Focus of light in a myopic eye

Similarly, since the focus of a hyperope falls behind the retina, a hyperope will see the test objects on the green
background clearer and darker (Fig. 13.6) since the green wavelength of light is closer to the retina.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-6

 Subjective Refraction

Figure 13.6 Focus of light in a hyperopic eye

With older patients, the crystalline lens becomes markedly yellow, thus causing the absorption and scattering of blue-
green light. This tends to give a red bias in these patients. Thus achieving equality or a reliable result tends
to be difficult.
It has been said that a red-green colour deficiency would not alter the results of the test as long as the practitioner
stresses the darkness of the letters as opposed to the brightness of the backgrounds. Protanopes or protanomalous
persons may experience that the red half of the target may not be as bright as the other half.
Ultimately, the aim of conducting the duochrome test is to determine the spherical end points in a monocular fashion for
each eye.

THE DUOCHROME TEST TARGET

The duochrome test target comprises a distance visual acuity chart with black letters or sometimes symbols, split into
identical halves. The letters on one side have a green background and the letters on the other side have a red
background. It is these backgrounds that straddle the preferred yellow focus of light by approximately ± 0.25D.

PERFORMING THE DUOCHROME TEST

Instrumentation
 Bichromatic/Duochrome test target (one may have a set target slide (Fig. 13.7) or one may have a red/green filter
which is placed over the chart of letters/numbers (Fig. 13.8).
 Trial frame and lenses (or phoropter)

Figure 13.7 Duochrome/Bichromatic target

June 2012, Version 1 Clinical Optometric Procedures 1, 13-7

 Subjective Refraction

Procedure
1. This test is done monocularly.
2. Since the test utilizes chromatic aberration which is greater when the pupil is dilated, the technique requires
that the room lights turned off.
3. Once the best vision sphere has been determined, the patient is directed to the bichromatic test target.
4. If show a chart like the adjacent one to the patient, the patient is instructed to report which of the numbers
appear “darker, sharper and clearer”? Either the 72 or 27, or the numbers on the right or left. Ensure that
the patient understands you are referring to the clarity of the black test objects against the R/G filter
backgrounds and not the colour of the background.

Figure 13.8 Bichromatic target with number optotypes

There are usually 2 methodologies that may be employed from this point on to reach the end point.
5. Vision is slightly fogged with +0.25DS lenses until the letters on the red background appear to stand out
better. This should not take more than 1 or 2 increments of plus power, however, if it does, it indicates
the patient has been over-minused.
6. The plus power is then reduced until the letters on the 2 sides appear equally clear or the letters on the
green background appear more distinct. When an endpoint of equality is not achieved, then leaving the
patient seeing green better is favored because it indicates that the patient is slightly over-minused
especially considering that the room is dark and the pupil is dilated.

Alternative approach
1. If the patient reports the targets on the red background appear darker, clearer or sharper, then place a
–0.25DS lens before the eye being tested. If the same target is still clearer, then a further –0.25DS lens
is added, until the targets on both backgrounds are equal. (NB: the red bias in older patients)
2. If the patient reports the numbers on the green background appear darker, clearer or sharper, one would
introduce a +0.25DS lens before the eye and repeat the question. If the same target is still clearer, then
add +0.25DS lenses until both targets are equally clear or there is a “slight green” end-point.
3. It is stressed that no reference should be made to the colour of the targets such that one would not
introduce a colour preference to the patient.
4. When the spherical refractive error correction is inaccurate by more than ±1.00D of the optimum correction,
the patterns of both sides will be grossly out of focus and a reliable result will not be achieved.
5. Once monocular balance is achieved in one eye, the test is conducted in the fellow eye, ensuring occlusion
of the eye that has just been tested.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-8

 Subjective Refraction

ASTIGMATIC ERROR DETERMINATION

INTRODUCTION
Astigmatism is defined as a refractive condition in which a variation of power exists in the different meridians of the eye.
It is caused by differences in curvature of the refractive surfaces of the ocular media, namely the cornea and lens.
Corneal astigmatism may be described as being either regular or irregular. Regular astigmatism is a condition in which
the principal meridians lie at right angles to each other while in irregular astigmatism this does not.

CLASSIFICATION OF REGULAR ASTIGMATISM

ON THE BASIS OF THE MUTUAL ALIGNMENT OF PRINCIPLE MERIDIANS
 With-the-rule (WRT) astigmatism – the curvature of greatest power lies nearest the vertical meridian
 Against-the-rule (ATR) astigmatism – the curvature of greatest power lies nearest the horizontal meridian
 Oblique astigmatism – the meridian of greatest curvature lies in the oblique positions

ON THE BASIS OF THE FOCUS OF THE PRINCIPLE MERIDIANS

 Compound myopic astigmatism – indicating that with accommodation fully relaxed, both line foci from the
principal meridians lie in front of the retina (Fig. 13.9a).
 Simple myopic astigmatism – indicating that with accommodation fully relaxed, one meridian focuses on the
retina while the other focuses in front of the retina (Fig. 13.9b).
 Mixed astigmatism – indicating that with accommodation fully relaxed, one line focus lies in front of the retina
while the other lies behind the retina (Fig. 13.9c).
 Simple hyperopic astigmatism – indicating that with accommodation fully relaxed, one meridian focuses on
the retina while the other focuses behind the retina (Fig. 13.9d).
 Compound hyperopic astigmatism – indicating that with accommodation fully relaxed, both line foci from
the principal meridians lie behind the retina (Fig. 13.9e).

Figure 13.9 Classification of astigmatism based on focus of principle meridians

METHODS OF EXAMINATION TO DETERMINE ASTIGMATIC REFRACTION COMPONENT

The astigmatic or cylindrical component of the refractive correction is determined by several methods of
examination, namely:
 Cross cylinder technique
 Fan-and-block method
 Clock dial method
 Stenopaic slit method

The choice of technique employed depends on the practitioner and the instrumentation and charts available. The most
commonly performed technique is the cross cylinder method.
The determination of the cylindrical component follows after the determination of the spherical component of the
refractive correction. It begins at the point that the “circle of least confusion” is placed on the retina (achieved by
duochrome test).

June 2012, Version 1 Clinical Optometric Procedures 1, 13-9

 Subjective Refraction

What is the circle of least confusion?

An astigmatic focus is produced in an individual whose refractive error comprises of both spherical and cylindrical
components. This astigmatic focus consists of a vertical focal line which corresponds to the focus of the horizontal
principal meridian and a horizontal focal line which corresponds to the focus of the vertical principal meridian. The
region between these two lines is known as the conoid of Sturm or Sturm's interval (Fig. 13.10). The dioptric mid-point
between these two focal lines, the astigmatic focus forms a circular patch known as the circle of least confusion. The
location of this circle of least confusion is equal to the spherical equivalent of the prescription.

Figure 13.10 Ray diagram of the Circle of least confusion and Conoid of Sturm

1. CROSS CYLINDER TECHNIQUE

The cross cylinder test is conducted using the Jackson Cross cylinder. This is referred to as the JCC test. The test
begins at the point when the circle of least confusion is placed on the retina.

Instrumentation
 Visual acuity chart
and
 Jackson Cross cylinder (Fig. 13.11)
 Trial frame
 Trial lens set with minus cylindrical lenses
or
 Phoropter

Figure 13.11 Jackson cross cylinder

June 2012, Version 1 Clinical Optometric Procedures 1, 13-10

 Subjective Refraction

Procedure
1. Select an appropriate target. One should choose a circular letter one line above the best visual acuity
of the eye being tested. This visual acuity is based on the best VA that was achieved with monocular
subjective correction in place.
2. Occlude the patient’s left eye.
3. Position the cross cylinder in front of the patient’s RE. The first step is to bracketing the quadrant within
which the axis lies. To do this one must introduce the cross cyl such that the power lines (usually marked
red/green, red/white or grey/white) lie at 90 and 180. The patient is asked to tell you in which position the
circular letter appears ‘rounder, clearer and sharper’. Remember to note the position of the minus power
line. Next place the cross cyl with the power lines along 45 and 135 and repeat the question, again taking
note of the position of the minus power line. Once one has done this, you would have determined a 45
bracket in which the axis lies.
4. After determining the bracket, introduce a trial cylinder lens of –0.25DC (or -0.50DC if patients have trouble
understanding the concept) midway in the 45 bracket.
There are instances in which a patient does not prefer a particular orientation of the minus cylinder axis.
In this case you would just skip that bracket and move onto the next. For example, the minus cylinder axis
is presented at 90 and 180 and the patient prefers neither orientation. The practitioner then will ignore
these brackets assuming that the cylinder axis bracket lies somewhere around the 45 and 135 brackets
and must proceed to verify this alternative.
5. When refining the cylinder axis, ensure the handle of the cross cylinder is parallel to the axis line
corresponding to the trial cylinder. Each time ask the patient in which position does the circular letter
appear ‘rounder, sharper and clearer’. The trial cylinder should always be moved in the direction of the
minus power line (minus cylinder axis). The end-point of the axis determination is when both axis
positions about the trial cylinder are the same or when the patient starts to move back and forth about
a specific position.
6. Once the axis is determined, the power of the cylinder required can be determined. The cross cylinder now
has to be held with the power lines on the cross cylinder parallel to the axis marking on the trial cylinder.
The patient is now instructed to tell which lens (+0.25DC or –0.25DC) makes the letters "sharper, clearer
and darker”. If the patient chooses the +0.25DC lens then it implies that the patient has rejected the
cylinder and that he/she merely has a spherical refractive error. If the patient prefers –0.25DC then it
implies that the patient is accepting the cylinder and one would increase the cylinder power from –0.25DC
to –0.50DC.

N.B. FOR EVERY -0.50DC CHANGE IN CYL POWER,

ONE NEEDS TO ADD A +0.25DS LENS.

This is done to shift the circle of least confusion back onto the retina. The end-point of this step is when
the patient chooses the +0.25DC lens position or if both views appear the same. If the patient preferred the
+0.25DC lens position, then the practitioner removes the last cross cyl added, ensuring adequate spherical
correction as well.
It has been noted that the determination of an accurate cylindrical power can be challenging for the patient
as the changes are within a narrow range. Borish therefore suggested that one may present the entire VA
chart to the patient when determining the cylindrical power and determine the power that allows the patient
to read the furthest down the chart.
7. Once the cylindrical error of the right eye is determined, the right eye is occluded and the practitioner
continues with determining the refractive error of the left eye

June 2012, Version 1 Clinical Optometric Procedures 1, 13-11

 Subjective Refraction

2. FAN-AND-BLOCK METHOD
Equipment
 Fan and block chart (Fig. 13.12)

Figure 13.12 Fan and block test chart

Procedure
1. The test is monocular.
2. Occlude the un-tested eye.
3. The best monocular spherical correction must be determined.
4. Determine the patient’s best VA with the spherical correction in place. Any cylindrical component
determined from retinoscopy must be removed.
5. Plus lenses are added in 0.25DS steps until the VA in the eye being tested drops by 1 line. Verification
can be performed on the duochrome test to ensure that the targets on the red side are darker, sharper
and clearer.
6. The patient’s attention is drawn to the fan chart and using the analogy of hours of a clock, the patient is
asked if any of the lines on the fan appear clearer and darker than other lines.
7. The arrow that joins the blocks is then orientated toward the clearest line. The arrow is adjusted until its
2 arms are equally clear. The one block (with its lines parallel with those on the block which are clearest)
should be clearer than the other.
8. If the patient reports that all lines are equally clear or blurred, then fog the target with a further +0.50DS
and ask the patient again if any lines appear clearer and darker. If they remain equally clear or blurred,
this suggests that there is no astigmatism present.
9. If an astigmatic component is found, the cylinder axis in the trial frame is set to the axis indicated by the
arrow. Negative cylinder is added at this axis until the blurred block just becomes as clear as the other.
One can then add the cylinder power found during retinoscopy. If one cannot obtain equal clarity of the
two blocks, then the lowest power cylinder must be added.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-12

 Subjective Refraction

3. CLOCK DIAL CHART METHOD

Equipment
 Clock dial chart (Fig. 13.13)

Figure 13.13 Clock dial chart for determination of astigmatism

Procedure
1. The chart is presented to the patient with sufficient fog in place and the axis of the correcting cylinder
is determined. To achieve this, the practitioner asks the patient if he or she can see in any or all of the
spokes. If there is an area that is clearer, then the patient is asked to report, which of the spokes (the
3 lines) are sharpest or most distinct.
2. The chart is equipped with numbers similar to those of a face of a clock (Fig. 13.13). When patient’s are
questioned about the clarify of the spokes, they would typically report that the spokes are clear along
12 to 6 o’clock, 1 to 7 o’clock, etc. When determining the axis, the smaller of the 2 numbers reported are
multiplied by 30. For example, if the spokes between 2 to 8 o’clock are clearest, then the 2 is multiplied by
30 to produce an axis value of 60 If the patient reports that the spokes between 3 to 9 o’clock are clearest
then the axis is given as 3, multiplied by 30 and is therefore 90.
3. To determine the power, the practitioner begins adding minus cylinder lenses in 0.25DC steps with the axis
determined in step 2 of the procedure. Each time, the practitioner must question the patient with respect to
the distinctness of the lines in the spokes along the 2 principal meridians. For example, comparing the
spokes along 12 to 6 o’clock to 3 to 9 o’clock and so forth.
4. Considering a patient with with-the-rule astigmatism, adding minus cylinder power with the axis along the
horizontal meridian, one would only be moving the horizontal line focus closer to the retina together with
moving the circle of least confusion toward the retina, however, the vertical line focus will not be altered. At
some point when sufficient minus cylinder power is added the horizontal and vertical line foci lie in the same
place and this collapses the Conoid of Sturm. When this happens, the patient would report that the spokes
of both principal meridians are equally clear. However, it should be noted that this image is not on the retina
and the image on the retina will be a blur circle.
5. At this point the practitioner adds additional cylindrical power with 0.25DC at a time until a reversal occurs.
For example, if the patient initially reported that the 12 to 6 o’clock spokes were clearer, he will now report
that the 3 to 9 o’clock spokes are clearer. In most cases, it has been found that once equality of the
principal meridians has been achieved, a further addition of 0.25DC will produce reversal of the clarity
of the spokes.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-13

 Subjective Refraction

4. STENOPAIC SLIT METHOD

The stenopaic slit method of astigmatism determination is one that is especially useful when a patient has high or
irregular astigmatism in conditions like keratoconus. The slit can vary in width and like a pinhole, allowing light only in
through the meridian while the other remains blocked.

Instrumentation
 Trial case with stenopaic slit of 1 mm width (Fig. 13.14)
 Trial frame

Figure 13.14 Stenopaic slit

Procedure

1. The patient is directed to a distance visual acuity chart to letter just above the best VA of the eye being
tested while the other eye is occluded.
2. Spherical error is determined with best acuity in the eye.
3. The eye being tested is fogged by a +1.00 to +1.50DS lens.
4. The stenopaic slit is introduced in front of the fogged eye. If the patient’s acuity is significantly reduced,
then a wider slit beam may be used.
5. The slit is rotated until the patient’s best vision is found. This meridian is the primary meridian of most plus
and least minus power (i.e. minus cylinder axis). The position of this meridian can be verified by moving the
stenopaic slit off the position determined by the patient by 10 on either side.
6. The lenses before this fogged eye are reduced until the best VA can be achieved.
7. The power remaining in the trial frame is recorded on an optical cross making note that the axis of the
power lies parallel to the slit orientation.
8. The power now needs to be determined for the other principal meridian. This is determined by rotating the
stenopaic slit through 90 or until the patient reports that the position of worst acuity is found. If there is
irregular astigmatism, this meridian will not lie at precisely 90 to the primary meridian.
9. Reduce the fogging lenses before this position until the best VA is achieved. Record the resultant power
as in step 7.
10. Once the power of the both principal meridians has been determined and they are represented on the
optical cross, the findings must be transposed into sphero-cylindrical format.
11. With the final prescription in place, the patient’s best VA through this prescription must be recorded.
12. The right eye is now occluded and the procedure is repeated for the left eye.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-14

 Subjective Refraction

BINOCULAR BALANCING TECHNIQUES

BACKGROUND
The monocular subjective findings at distance are followed by an attempt to equalize the accommodative effort exerted
during habitual gaze by the two refractively corrected eyes on patients who are binocular. In many cases, the spherical
equalization is taken erroneously to mean the equalization of the visual acuities between the two eyes. It should be
noted that even if the corrected acuity between the 2 eyes is the same, the quality of vision obtained between the two
eyes may be different.
The process of ‘balancing’ equalizes the accommodative responses with respect to potentially different accommodative
demands required by the eyes for distance viewing. A patient must be binocular for this test to be conducted. In cases
where the patient is monocular (i.e. suppressing one eye or a strabismus exists), the practitioner does not conduct the
balancing technique and should move on to other tests in the battery forming the refraction.

METHODS FOR BINOCULAR BALANCE TECHNIQUES

There are various methods that may be employed to perform binocular balancing of a prescription. These include:
 Equalization by alternate occlusion
 Prism dissociation method
 Fogging method (Humphriss)
 A method using a Septum (Turville)
 Polarization method (Vectographic)
 Dissociated duochrome method

1. EQUALIZATION BY ALTERNATE OCCLUSION

Procedure
The equalization by alternate occlusion technique is probably one of the simplest methods of binocular balancing that is
employed. Add plus lenses binocularly till the patient barely sees the 20/30 line or two lines above his/her best binocular
acuity. The patient is asked to compare the legibility of the letters between two eyes, while performing a slow alternate
occlusion. The end point is equal acuity between two eyes. If the patient reports one eye is clearer than the other eye,
then plus lenses are added in +0.25DS steps before the clearer eye to equalize the blur.

This technique while simple to conduct does have several inherent problems, namely:
1. The patient compares a target to one that is no longer visible to that eye and the comparison is drawn
from memory.
2. The end point is equal acuity and therefore no allowance is made for patients with unequal maximum
VA between the two eyes.
3. The alternate occlusion must be performed in a slow enough speed so that the patient can make a
comparison between the images of the two eyes.
4. Each eye may assume its monocular accommodative status when alternatively occluded.

2. PRISM DISSOCIATION METHOD

This method is also referred to as “dissociated blur balance”. This test is based on a comparison of the VA of both eyes
and therefore requires that the VA after distance monocular subjective be the same. If there is a difference in VA
between the two eyes, then it recommended that the practitioner conduct the prism dissociated duochrome test.

Procedure
1. The test in binocular, however it is performed monocular until dissociation is achieved.
2. Each eye is fogged with a +0.75DS lens after the best monocular refraction findings.
3. The patient’s binocular VA is measured thereafter to ensure that the VA is 20/25 or worse.
4. Projected line above the VA is isolated.
5. The chosen acuity line or chart is dissociated with a phoropter’s Risley prism with equal amounts of vertical
prism (usually 3-4∆ BU in front of right eye and 3-4∆ BD in front of left eye). This is done since it is easier to
dissociated with vertical prism. The equal amounts of prism also ensure that each eye is exposed to the
same amount of prismatic distortion.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-15

 Subjective Refraction

6. When the occluder is removed, the patient should be able to report that there are two identical targets
(as in diplopia), with each eye observing only one target. If the patient cannot see the two images
binocularly, the practitioner should recheck the view of each eye and then binocular views. An increase in
the amount of prism may also aid in the perception of diplopia of the target. If this can still not be achieved,
then it indicates that the patient is suppressing the target.
7. The subject is asked to compare the legibility of the targets. They should be equally blurry.
8. If the patient reports that one target is more legible than the other, then plus lenses are added in +0.25DS
steps before the clearer eye to equalize the blur. An alternative approach is to leave the dominant eye
slightly clearer than the other eye.
9. When the blur end point is reached, the prism is removed.
10. Binocularly, the patient’s acuity is brought down to 20/20 or better by un-fogging (reducing the prescription
in -0.25DS steps).

3. HUMPHRISS IMMEDIATE CONTRAST METHOD

Purpose
This test allows for subjective refraction under binocular conditions, which maintain peripheral fusion while testing
foveal vision unilaterally. This is accomplished by placing a fogging lens over the non-tested eye to induce suppression
of the central retina in the non-tested eye. Non-foveal zones remain binocularly active and suppress
accommodative fluctuations.
Like other binocular balancing tests, this test is a method of refinement and is conducted after retinoscopy and
monocular subjective testing.

Instrumentation
 Trial frame and trial set (or phoropter)
 Distance visual acuity chart

Procedure
1. Direct the patient to a letter/s on the line above the best corrected acuity, e.g. if the patient was corrected
to 6/6, then a target on the 6/7.5 line is used.
2. Place a +0.75 / +1.00DS fogging lens before the LE. The fogging should be verified by occluding the RE
and asking the patient if the 6/6 line is still readable. If the correct amount of fog is being utilized then this
line will be blurred together with 3-4 lines on the chart. If the line is still readable then it implies that a
greater amount of fog is required. This is usually the case in older individuals since dioptric blur has less
of an effect due to their tendency to have smaller pupil sizes.
3. Following step 2, the rest of the procedure is done binocularly.
4. Place a +0.25DS lens (lens 1) over the RE. Quickly replace this lens with a –0.25DS lens (lens 2) and once
again revert to the +0.25DS lens (lens 1). Ask the patient to compare the 2 lenses (lenses 1, 2, and 1) and
to tell you which of the two lenses makes the target letter/s clearer, sharper and more comfortable to look
at.
5. If the patient reports that lens 2 is better, then add a further –0.25DS lens to the subjective finding and
repeat step 4. Stop when the patient reports that the view through both lenses is the same or until the
patient chooses lens 1. If he reports that the view is the same, leave the last lens in the subjective finding.
If the patient selects the plus lens now, it implies that he rejects the minus lens. As discussed earlier, one
needs to stop at the least minus lens. Therefore one removes the last –0.25DS lens and begins testing the
other eye.
6. Once having determined the error of the RE, remove the fogging lens from the LE and place it over the RE.
Ensure that the RE is fogged and repeat the procedure for the LE.
NOTE:
 Binocularity has to be intact, i.e. there should be no tropia.
 There should be no greater than a 2 line visual acuity difference between the 2 eyes.

4. TURVILLE INFINITY BALANCE

Turville infinity balancing technique was first described by A.E. Turville in 1946 but subsequently modified by Morgan.
It is a method of binocular refraction which employs a septum to block part of the chart so that the right eye sees the
right side of the chart and the left eye sees the left side of the chart. The border of the chart and the field surrounding
the chart are seen binocularly.
The septum can be placed either: on the mirror in a mirror room (placed in the middle of the mirror), in a room without
a mirror the septum is placed approximately midway between the patient and the chart.
June 2012, Version 1 Clinical Optometric Procedures 1, 13-16
 Subjective Refraction

Equipment
 Phoropter/Trial Frame
 Septum of proper width with a rod or stand to hold it

Procedure
1. The test is performed with the patient’s best monocular distance correction in place.
2. The septum is mounted on a rod such that one half of the distance VA chart is visible to one eye while
the other half of the chart is visible to the other eye. The distance of the stand from the patient and the
width of the septum are calculated using the formulae stated below.
3. The projector slide is adjusted such that the top of the 20/20 set of lines of letters are at the bottom of
the chart.
4. For eyes which have equal acuity, alternatively add +0.25DS lens of fog to each eye until the patient
reports that both eyes are blurred.
5. To determine binocular balancing;
a. If the 2 halves of the chart are equally blurred, then alternately unfogged to obtain best VA
in each eye, ensuring balance as the procedure is continued.
b. If the 2 halves of the chart are not equally blurred, the sphere is adjusted until they are balanced
and slightly blurry. Then alternately un-fog until best VA in each eye is achieved, whilst checking
balance as the procedure is continued.

Recording of findings
Indicate which test was being used for binocular balancing, i.e. Turville Infinity Balance or TIB Record the final Rx for
each eye, taking into account the eye, the spherical and cylindrical powers, axis of the cylinder and the monocular VAs.

5. VECTOGRAPHIC REFRACTION (POLARIZATION)

Vectographic binocular balancing using polarization was first described by Grolman in 1966. It is a technique that uses
the American Optical (Reichert) vectographic projector slide. Polaroid filters are placed in front of the patient's eyes. A
high quality aluminized screen must be used and it must be placed so that a line normal to the screen bisects the angle
between the projector and the patient's eyes. If the projector and screen are not aligned properly, reflections may be
affected to the point where the test is ineffective. The analyzer and the polarized targets have the same axis of
polarization. Each eye sees part of the chart. Some letters are seen only by the right eye and some are seen only by the
left eye. There are also letters on the chart that are seen by both eyes.

6. DISSOCIATED DUOCHROME METHOD

The duochrome of bichromatic chart is used in this method of balancing to ensure that the stimulus to accommodation
is equalized between the two eyes.
This test is preformed when the VA between the two eyes differs after the monocular subjective refraction, or if the
practitioner suspects that the accommodation differs between the two eyes.

Procedure
1. The technique is performed in a semi-darkened environment.
2. The test is performed binocularly.
3. The patient is directed to a duochrome target.
4. A line of letters above the best VA of the poorer eye is introduced to the patient with the duochrome
mask above it.
5. Risley prisms are placed over each eye, with 3-4∆ BU before the right eye and 3-4∆ BD before the left eye.
6. The introduction of prism before both eyes should induce diplopia forcing the patient to see 2 lines of red-
green letters. The practitioner must ensure this dissociation.
7. The patient is directed to the lower line of letters.
8. The patient is asked to report whether the red or green side of the line of letters is sharper and clearer or
if they are equally clear.
9. If letters on the red side are sharper or if both sides are equally clear, then the practitioner must introduce
-0.25DS. If he/she reports that the letters on the green side of the chart are clearer, then the practitioner
must add +0.25DS before the eyes.
10. Thereafter the patient is directed to the upper line of letters, and the procedure is repeated.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-17

 Subjective Refraction

11. The final lens prescription for this type of binocular balancing test is to leave the patient preferring the “just
green” better option indicating that the minimum minus lens power is provided, so patient first reports the
green is slightly better than the red side or if both the red and green sides of the target are equally clear.

BINOCULAR VISION TESTING

Once the subjective monocular refraction and binocular balance has been completed, then those techniques that
investigate the post-refraction binocular vision are performed.

These include:
 Amplitude of accommodation
 Binocular status in the primary position
 Fixation disparity
 Accommodative convergence/accommodation ratio
 Stereoacuity
 Fusional reserves
 Degree of incomitancy.
Not all of these aspects will be discussed in this module. They will be discussed in the more specialized binocular
vision module.

BIBLIOGRAPHY
Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3/e. The MacGraw-Hill Companies, Inc. United States. 2004
Benjamin W, Borish's Clinical Refraction, Butterworth-Heinnemann, 2007
Elliott DB. Clinical procedures in primary eye care 3/e. Oxford, Elsevier, 2008.
Ettinger ER and Rouse MW., Clinical Decision Making in Optometry, 1/e, Butterworth, Heinemann 1997.
Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-18

 ACCOMMODATION
AND PRESBYOPIA

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Accommodation – definition and mechanism
 Types of accommodation
 Amplitude of accommodation
 Presbyopia
 Relative accommodation
 Determination of AC/A ratio

ACCOMMODATION – DEFINITION & MECHANISM

DEFINITION
“Accommodation refers to the process whereby changes in the dioptric power of the crystalline lens maintains a clear
focus of an object as it draws closer to the eye”.

MECHANISM
If an eye is emmetropic, an object viewed at a distance, will form a clear image on the retina (Fig. 14.1a). When the
eye shifts its fixation to a near object, the retina senses a blurred image (Fig. 14.1b). The sphincter muscles of the
ciliary body constrict thereby decreasing the diameter of the circular support for the (zonule of Zinn) zonular fibres.
These fibers relax allowing the fibrous contents of the lens to increase pressure on the capsule. The capsule then
bulges at the centre and flattens at the periphery thereby taking a more convex form (Fig. 14.2a & 14.2b).
In the fully accommodated state the retina will be conjugated with the near point of accommodation (punctum
proximum) (Fig. 14.1c).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-1

 Accommodation and Presbyopia

Figure 14.1 Focus changes with distance viewing and accommodation

Figure 14.2 Cross-section of lens showing an increase in convexity with accommodation

ACCOMMODATION REACTION TIME

Because accommodation (ACC) is under the control of the autonomic nervous system and the ciliary body comprises
smooth muscles, the system is relatively slow in reacting as compared to the extra-ocular muscles which are striated.
Accommodative-reaction time is approximately 0.36 + 0.09 seconds, and is further reduced by low levels of
illumination (Campell and Westheimer, 1960)

AMPLITUDE OF ACCOMMODATION
The closest distance a target can be seen clearly is referred to as the near point, while the farthest point that a static
eye can see clearly is referred to as the far point. The dioptric equivalent of this near point is the amplitude of
accommodation e.g. if the near point is 8cm, then the amplitude of accommodation is 100cm/8cm = 12.50D.

TYPES OF ACCOMMODATION:

There are various types of accommodation, namely:

REFLEX ACCOMMODATION
This is an autonomic reaction or adjustment of refractive state to obtain and maintain a sharply defined retinal image in
response to a blur input. This occurs for relatively small amounts of blur, around 2.00D, however, beyond this
magnitude, voluntary accommodation is required. Reflex accommodation is the largest and most important component
of accommodation under both monocular and binocular viewing conditions.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-2

 Accommodation and Presbyopia

CONVERGENCE ACCOMMODATION / VERGENCE ACCOMMODATION

This accommodation is induced by the innate neurological linking and action of disparity (fusional) vergences. It gives
rise to the convergence accommodation/convergence ratio (i.e. CA/C ratio). This is the second major component of
accommodation.

PROXIMAL ACCOMMODATION
This is accommodation due to the influence of knowledge of the apparent nearness of an object. It is initiated by
objects within 3 meters of the individual.

TONIC ACCOMMODATION
This type of accommodation is found in the absence of blur, disparity, proximal and voluntary inputs. There is no
stimulus for tonic accommodation. It is the baseline neural innervation from the midbrain. It represents the normal
tonus of the ciliary body at rest. The mean tonic accommodation in young adults is 1.00D. Tonic accommodation
decreases with age because of the biomechanical limits of the crystalline lens.

ACCOMMODATION ASSOCIATED WITH THE DARK (DARK FOCUS OF ACC)

The dark focus of accommodation is the accommodative posture that the eye assumes in the absence of visual
stimuli. It lies approximately 1.00D inside the far point. This phenomenon helps to explain “night myopia” or “empty
field myopia”.

AMPLITUDE OF ACCOMMODATION:

MEASUREMENT OF THE AMPLITUDE OF ACCOMMODATION

There are several methods of measuring of the amplitude of accommodation. Any of these measurements can
only be made after distance correction.

PUSH-IN-TO-BLUR METHOD (PUSH-UP TEST)

This method utilizes the RAF (Royal Air Force) – rule.

Procedure
1. The patient’s distance Rx should be in place.
2. The LE is occluded.
3. The RAF-rule is held firmly against the patient's cheeks and tilted inferiorly from the patient’s eye level at
about 30°. The patient is directed to small reading print on the sliding target, which should be placed at the
far end of the rule.
4. The target is moved slowly towards the patient. The movement toward the patient is stopped when the
patient reports just blur. The patient is asked to blink a few times and try and clear the print. If the print
clears the target is moved closer still till the patient reports that it is blurred again.
5. The end-point of this test is when the patient experiences sustained blur, i.e. the target blurs and remains
blurred even after blinking and trying to clear it. The position of the target in centimeter is converted to
dioptric value.
6. The procedure is repeated 3 times to obtain an average measurement of the amplitude.
7. The procedure is then repeated for the LE with the occluder over the RE.
8. The occluder is then removed and the measurement is taken for both eyes. This measurement should
usually be greater than the individual 2 measurements provided that there are no binocular vision
anomalies present.
9. The practitioner takes note of the distance at which sustained blur is obtained and converts this distance
to a dioptric equivalent to reflect the amplitude of accommodation.
NB: One of the disadvantages of this method of measurement is that it tends to over-estimate the amplitude. Due to linear
magnification - as the target gets closer to the eye, it appears larger and hence blur is noticed later than it would be with
a smaller target.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-3

 Accommodation and Presbyopia

Expected findings
18 – 1/3 age (± 2.00DS) (Scheiman and Wick, Clinical Management of Binocular Vision, Lippincott Wiliams & Wilkins 2008)

PUSH-OUT-TO-CLEAR METHOD
Procedure
This method is similar to the push-in-to-blur method except that the target is placed inside of the near point and is
gradually moved away from the patient until the print is no longer blurred and the patient can read the letters. The
measurement is simply read off the RAF-rule scale.

MINUS LENS TO BLUR METHOD

Procedure
1. Distance prescription should be in place
2. The test is performed first monocularly and then binocularly
3. The near card is held at 40cm and the patient is asked to look at a target one line above the best near VA
4. The target is illuminated by overhead lamp or lighting
5. Minus lenses are added in 0.50 to 1.00D steps until the patient reports first sustained blur (patient blinks
and can no longer clear the target).
6. The amplitude is determined by adding the absolute value of the minus lenses cleared to the dioptric value
of the working distance, i.e. 2.50DS for a 40 cm working distance. For example, a patient presents with a
minus-lens-to-blur measurement of -4.00DS at a working distance of 40cm (-2.50DS). The total amplitude
of accommodation for this patient would be -6.50DS.

Expected findings
2.00DS < push-up test (Scheiman and Wick, 2008)

DYNAMIC / MONOCULAR ESTIMATED METHOD (MEM) RETINOSCOPY

Dynamic retinoscopy provides an objective evaluation of the accommodative response. Dynamic retinoscopy is used
when the patient’s accommodation is kept in an active state by encouraging the patient to fixate on an accommodative
target at approximately 50-66 cm on the retinoscope.

Procedure
1. The test is conducted under conditions of normal room illumination. This is especially important since
accommodation is affected by illumination
2. Distance prescription on.
3. The patient is asked to fixate on an appropriate target on the MEM card attached to the retinoscope.
4. The examiner then moves the retinoscope and target closer to the patient while observing the
retinoscopic reflex.
5. The initial reflex at the patient’s Harmon’s distance will be a bright, broad and fast “with” movement
(indicating a normal accommodative lag).
6. A change of this reflex to a narrower, dimmer and slower reflex indicates the focusing is lost and that
the amplitude of accommodation has been exceeded.
7. The distance at which the movement changes is noted and converted to a dioptric equivalent from the
spectacle plane to provide the amplitude of accommodation.
8. If the initial reflex was against, the amplitude is reached when there is a change in the reflex to a
“with” movement.

(Bennet and Rabbets, Clinical Visual Optics, Butterworths 1984; Eskridge, Clinical Procedures in Optometry, Lippincott 1991)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-4

 Accommodation and Presbyopia

Expected findings for accommodative response

+0.25DS to +0.50DS ± 0.25DS
It is suggested that a value below +0.25DS or over +0.75DS should raise suspicion and therefore be investigated
further. (Scheiman and Wick, 2008)

Clinical pearls

 The above methods can produce different values for the amplitude because of the varied
techniques.
 Subjective measures of amplitude give larger values than objective measures because pupil
constriction during subjective measures keeps the image from blurring. Thus objective and
subjective measures can differ by up to 2D.
 Target size, target illumination, and speed of target approach will affect the measurement of the
amplitude of accommodation.

ESTIMATION OF AMPLITUDE OF ACCOMMODATION

There are several methods than one may utilize to estimate the amplitude of accommodation in order to ascertain the
strength of the patient’s ability to stimulate accommodation. These include:

1. HOFSTETTER’S RULE
Hoffstetter’s rule provides an estimation of the average amplitude of accommodation, in diopters, for a patient of a
given age. A measurement lower than the expected is regarded as a deficiency in accommodation.

rd
Average amplitude = 18.5 – 1/3 Age

2. DUANE-HOFSTETTER FORMULA
The Duane-Hoffstetter formula for probable amplitude of accommodation should assist one in determining whether the
amplitude for the patient is adequate or not. It considers not only the average amplitude but the range of minimum and
maximum values when considering the age of the patient (Table 14.1).
Table 14.1 Methods of calculation of the maxiumum, average and minimum amplitudes of accommodation using
variations in the Duane-Hofstetter formula

Maximum amplitude = 25.0 – 0.40 x age

Average amplitude = 18.5 – 0.30 x age
Minimum amplitude = 15.0 – 0.25 x age

Points to remember:
 For a presbyopic patient you may have to add +1.00DS before each eye and carry out the procedure as
the Px may not be able to see the target. Sometimes, if the reading addition has already been determined,
measure the amplitude of acc with the 'add on'. However, the lens used must be subtracted from your
findings e.g. if the reading on the RAF-rule is +3.00D and you used +1.00DS lens, the amplitude of acc will
be: +3.00-(+1.00) = +2.00D
 Similarly if you had a young patient or a highly myopic patient, you may have to put up minus lenses before taking
the readings. Remember to add that power on. e.g. reading on RAF-rule is +10.00D, and you place a -2.00 DS
lens the amplitude of acc will be: +10.00 - (-2.00D) = +12.00D
 The above four methods will produce different values for the amplitude of accommodation in the same patient.
In the push-in method, the patient will tend to report blur when experiencing difficulty to read. In the push-out
method, the patient will wait until the print becomes clear. Therefore instruct your patient clearly or ask the patient
to read letters/words out loud. One will also experience variability of the results if the slide on the RAF-rule is
moved too fast towards or away from the patient
 The minus-lens-to-blur method generally produces a lower amplitude of acc because of the unnatural manner
of the procedure. Due to the minification of the target through a minus lenses, the brain perceives the target
to be further away and more difficult to see

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-5

 Accommodation and Presbyopia

IMPLICATIONS OF THE AMPLITUDE OF ACCOMMODATION

ACCOMMODATIVE INSUFFICIENCY
 This is a situation in which accommodation is persistently lower than expected for the patient’s age
 A reduction of the amplitude of acc by 2.00D or more is a hallmark
 Accommodative insufficiency would present as general asthenopia
 There may be subcategories of accommodative insufficiency, viz
o Ill-sustained accommodation: which is accommodation which is initially sustained, however, over time,
it cannot be maintained. It is sometimes referred to as accommodative fatigue
o Paralysis of `accommodation: is a condition in which the amplitude of acc is markedly reduced or totally
absent. It is usually the result of an organic condition or head trauma
o Unequal accommodation: is an amplitude that is a difference of at least 0.50D or more between the 2 eyes.
It can be due to an organic condition, head trauma or functional amblyopia

ACCOMMODATIVE EXCESS
 This refers to a condition in which accommodation is persistently higher than that expected for the patient’s age
 More recent definitions regard this condition as the inability to relax accommodation readily, leading to a spasm
of accommodation

ACCOMMODATIVE INFACILITY
 This condition is characterized by a slowing of the dynamics of accommodation, viz. latency, time constant and
peak velocity.
 Change in accommodation only occurs with effort and difficulty.
 The most common symptom experienced by patients is the difficulty to change focus from distance to near and
vice versa.

FACTORS AFFECTING THE AMPLITUDE OF ACCOMMODATION

1. The original refractive state: A myope may show a greater amp of acc than a hyperope.
2. General health of the patient: The amplitude may be reduced and poorly sustained if the patient is ill.
Systemic conditions that can affect the amplitude of accommodation include anaemia, influenza, mumps,
measles, whooping cough, tonsillitis, multiple sclerosis, mysasthenia gravis, myotonic dystrophy, diabetes,
whiplash injuries, secondary glaucoma, Parinaud’s syndrome. Sinusitus can also affect accommodation
without affecting pupil reflexes.
3. Vascular and Glandular defects: Compromise of the vascular supply to the ciliary body may affect the
accommodative effort.
4. Presbyopia: Loss of elasticity of the crystalline lens
5. Drugs: Certain drugs that affect the autonomic nervous system will have an effect on the accommodation
e.g. Antihistamines, tranquilizers, drugs used for Parkinson’s disease.
6. Convergence problems: Any problems with convergence can affect the binocular accommodative effort.
7. Method of measurement: Different techniques may produce different amps of acc.

PRESBYOPIA

“Presbyopia refers to the gradual, naturally occurring, age-related, irreversible reduction in maximal accommodative
amplitude resulting in symptoms of blur and ocular discomfort or asthenopia at the customary near working distance”.
In healthy individuals, the amplitude of accommodation diminishes gradually from the first few years of life until 55
years at which time it is considered to be zero. When this amplitude of acc is insufficient for comfortable, clear vision at
his or her customary working distance, the individual suffers from presbyopia.
It has been documented that most people become presbyopic around the age of 40-45 years. Presbyopia occurs
earlier in some ethnic groups, people with short arms or working distances, and hyperopes. The reason this occurs is
due to a loss of accommodative effort. These patients therefore require additional plus power than expected.
Research has found that the time of appearance and progression of presbyopia depends on various factors including:
 Patient’s habitual working distance
 Distance refractive error
June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-6
 Accommodation and Presbyopia

 Visual needs of the individual

 Other factors such as race, gender, illumination conditions, ambient temperature and geographic factors

There are various methods that one may utilize to determine the presbyopic addition for a patient, namely:

 Tentative add determination

 Determining the patient’s exact requirements
 Fused cross cyl method

The determination of the final prescription that goes into the patient’s spectacles is given by the refinement of the add
determined by whichever method

METHODS TO DETERMINE THE PRESBYOPIC CORRECTION

TENTATIVE ADD DETERMINATION
The tentative add determination involves the use of a formula to determine the presbyopic addition that the patient
would require. It is given by the formula:

Tentative Add = Age/10 – 3.50 D

This formula has been suggested for patients less than 55 years of age and who have an average working distance of
40cm. For patients greater than 55 years of age, accommodation is virtually zero and therefore the formula above
does not hold.

AMPLITUDE OF ACCOMMODATION
This method assumes that the prescription of addition should not use more than ½ to 2/3 of the total amplitude of
accommodation. The amplitude is determined as instructed in the section on accommodation. This value is used in a
formula to determine the add that should be prescribed for a working distance of 40cm.

Add = 2.50D – 2/3 Amp of Acc

AGE EXPECTED ADDITION

Several authors have suggested a table of expected adds based on the age of the patient. Table 14.2 provided below
is from a recent article by Antona et al in Clinical and Experimental Optometry 2008; 91(3).

Table 14.2 Tentative near additions based on the patient’s age in years

Age in years Tentative add

40 – 42 +0.75 D
43 – 45 +1.00 D
46 – 47 +1.25 D
48 – 50 +1.50 D
51 – 52 +1.75 D
53 – 55 +2.00 D
56 – 57 +2.25 D
58 – 60 +2.50 D

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-7

 Accommodation and Presbyopia

FUSED CROSS-CYLINDER METHOD

The fused cross-cylinder test is a subjective evaluation of the accuracy of the accommodative response under
binocular viewing conditions. It is a functional analysis that is performed when over- or under-accommodation is
suspected, and it can be used to determine a tentative near addition for a presbyopic patient.

Equipment
 Phoropter with ±0.50 D cylinder lenses
 Near point rod
 Cross cylinder grid target (which is a grid of vertical and horizontal sets of lines, Fig. 14.3).
 Adjustable illumination

Figure 14.3 Cross-cylinder grid target

Procedure
1. The patient is seated behind the phoropter with the best corrected distance Rx in place and near PD set.
2. The fused crossed cylinder is placed before each eye with the minus cylinder axis orientated vertically
(red dots on 90 orientation).
3. The patient is directed to the grid target, which is placed at a distance of 40cm in a dimly lit room.
4. The test is performed binocularly.
5. With cylinders in place, the patient is asked to report which of the lines on the grid appear sharper and
more distinct, the vertical (lines going up and down) or horizontal (lines going across).
6. If the minus cylinders are oriented to a vertical axis, then the horizontal lines are expected to appear
sharper than the vertical lines.
7. If the patient reports that the vertical lines are sharper than the horizontal lines, then reduce the
illumination in the room before proceeding to binocularly adding lenses before the eyes. If the patient
continues to report that the vertical lines are still sharper than the horizontal lines, flip the cylinders before
the eyes to an axis orientation of 180. If the patient still reports that the vertical lines are sharper, then
terminate the test and record that the patient has a “vertical preference”. If with the new axis orientation,
the patient reports that the horizontal lines are sharper than the vertical lines, then the practitioner should
record the findings as “lead of accommodation”, “minus add indicated” or “minus projection”.
8. If upon starting with the minus cylinder axis oriented vertically, the patient reports that the horizontal lines
are sharper than the vertical lines or that both sets of lines appear equally clear, then the practitioner may
add +0.25DS lenses binocularly before the eyes until the patient reports that the vertical lines appear
sharper than the horizontal lines.
9. At this point, the practitioner then decreases the amount of added plus lenses again in +0.25DS steps
until both sets of lines appear equally clear.
10. If equality cannot be reached, then the practitioner must stop at the highest plus lens that result in the
patient perceiving the horizontal lines sharper.

Recording findings
The final amount of added plus lenses are recorded, relative to the patient’s distance prescription. In some cases,
the practitioner may have to record “minus add indicated” as explained above.

Example
FCC = +1.00DS

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-8

 Accommodation and Presbyopia

Expected findings
Non-presbyopic patients: +0.50DS ± 0.25DS (Scheiman and Wick, 2008)
Presbyopic patients: the lag of accommodation is expected to increase with age.

RELATIVE ACCOMODATION
Relative accommodation is a measure of the patient’s ability to relax or stimulate accommodation to a fixed
vergence target. These tests inform the practitioner of the interaction between the patient’s accommodative-
convergence system.
Negative Relative Accommodation (NRA) is an indication of the patient’s ability to relax accommodation for a fixed
vergences demand.
Positive Relative Accommodation (PRA) is an indication of the patient’s ability to stimulate accommodation with a
fixed vergence demand.

Equipment
 Phoropter
 Near reading card
 Near point rod
 Illumination source

Procedure
1. The patient is seated usually behind a phoropter with the distance Rx in place and near PD set. In the
case of presbyopic patients, their tentative near add is placed in the phoropter as well.
2. A near target is presented to the patient at 40cm.
3. The patient’s attention is directed to a row of letters that is 1 or 2 lines better than the near VA on the near
card. One must ensure that these letters are clear before beginning the test since the end point of the test
is to determine the lenses that make the letters blurry. If for some reason, the letters are not clear, then
the practitioner must add lenses in +0.25DS steps until the letters become clear. This additional lens
power now becomes the tentative near addition. In some cases, if clarity cannot be obtained even with the
addition of the additional plus lenses, then the practitioner must terminate the test and record that the
NRA/PRA cannot be performed.
4. The NRA is performed first. Lenses are added before the patient in increments of +0.25DS until the
patient reports the first sustained blur.
5. Once the NRA is determined, proceed to determine the PRA. Lenses are added before the patient in
increments of -0.25DS until the patient reports the first sustained blur.

Recording findings
The practitioner must take note of the added plus and minus lenses for the NRA and PRA respectively. This is
determined relative to the starting point of either the distance refraction or the tentative near add that was placed in the
phoropter.

Examples of recording
NRA/PRA: +2.00/-2.25
NRA/PRA: +2.00/-2.25 through a tentative add of +1.50DS

Expected findings: Pre-presbyopic patients

NRA: +2.00 ± 0.50D PRA: -2.37 ± 1.00D (Scheiman and Wick, 2008)

Expected findings: Presbyopic patients

According to Carlson and Kurtz (1996), the NRA and PRA may vary widely in presbyopic patients. However, the sum
of the add and NRA should not exceed +2.50DS.
Values of less than 1.50D for either the NRA or PRA, or a difference of 1.00D are indications of possible inadequate
accommodation function.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-9

 Accommodation and Presbyopia

DETERMINATION OF AC/A RATIO

Purpose
The determination of the AC/A ratio involves the determination of the change in accommodative convergence that
occurs when a patient accommodates or relaxes accommodation by a given amount.
The AC/A ratio is a key element that is used in the determination of an appropriate management plan for a given
patient condition. For example, a patient who presents with esophoria at near and a high AC/A ratio would benefit from
the practitioner simply prescribing spectacle lenses as opposed to prisms. However, if the same patient had a low
AC/A ratio, it would be advisable for the practitioner to prescribe prisms or vision therapy as opposed to lenses.
The AC/A ratio may be calculated or performed practically:

1. CALCULATED AC/A RATIO

The calculated AC/A ratio is determined using the following formula:

AC/A = IPD (cm) + NFD(m) (Hn – Hf)

Where:

IPD = interpupillary distance (in centimeters)

NFD = near fixation distance (in meters)
Hn = near phoria (eso is plus and exo is minus)
Hf = distance phoria (eso is plus and exo is minus)

For example: IPD = 60mm, patient’s phoria is 4XOP at distance and 12XOP at near (40cm).
Calculated AC/A = 6.0 + (0.4) (–12 + 4)  AC/A = 6.0 + (-3.2)  AC/A = 2.8 : 1

2. GRADIENT AC/A RATIO

The gradient method of AC/A ratio determination involves measuring the phoria and then measuring
it a second time using a lens of known power, either -1.00DS or -2.00Ds. The change in the phoria that is
observed with the added minus lenses gives the AC/A ratio.

For example: If the near phoria was 2SOP with the patients distance Rx and with an added -1.00DS lens
is 7SOP, then it implies that the change in the phoria is 5 and the AC/A ratio is 5:1.

The calculated AC/A ratio is usually larger than the gradient method because of the effect of proximal vergence
whichhas an effect on the near phoria measurement.

Expected findings: The normal AC/A ratio is expected to be 4:1 (±2)

BIBLIOGRAPHY
Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3/e. The MacGraw-Hill Companies, Inc. United States. 2004
Benjamin W, Borish's Clinical Refraction, Butterworth-Heinnemann, 2007
Elliott DB. Clinical procedures in primary eye care 3/e. Oxford, Elsevier, 2008.
Ettinger ER and Rouse MW., Clinical Decision Making in Optometry, 1/e, Butterworth, Heinemann 1997.
Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
Scheiman M and Wick B. Clinical management of binocular vision. Philadelphia: Lippincott Williams & Wilkins. 2008.
Antona et al. Comparing methods of determining addition in presbyopes. Clinical and Experimental Optometry 2008; 91(3).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 14-10

 MUSCLE BALANCE
ASSESSMENT

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Fusional vergences
 Vergence facilities
 Fixation disparity
 Stereoacuity

INTRODUCTION

The end point of refraction is to enable the patient to have clear, comfortable binocular vision for all of his visual tasks.
To ensure this, the practitioner needs to investigate various visual skills. The patient must be able to align his two eyes
and maintain alignment for sustained periods of time. In addition, the patient must have sufficient accommodation to
enable him to focus on a task and sustain his accommodation comfortably. Muscle balance techniques are therefore
performed to ensure that the patient’s accommodation and convergence interact appropriately. The practitioner by
conducting the techniques will be able to determine if the patient’s can be corrected with lenses. If there needs to be
modifications to the final lens prescription to ensure that the patient reaches the goal of clear, comfortable binocular
vision, a more comprehensive binocular work-up or vision therapy is required.
It is important for the practitioner to note that a patient’s prescription will have influenced the status of the patient’s
accommodative and vergence systems. The muscle balance techniques are conducted through the patient’s habitual
prescription. If the practitioner determines changes, then a new prescription would be considered.

DISTANCE NEAR LATERAL AND VERTICAL PHORIAS

The assessment of the distance and near lateral and vertical phorias are determined as outlined in chapter 6, except
that this time, these tests are carried out through the patient’s prescription. This gives the practitioner an idea of how
he has changed the patient’s muscle balance with the introduction of a prescription. It also assesses the vergence and
accommodative system.

FUSIONAL VERGENCES

Fusional vergences are generally performed to determine through the application of prisms, the patient’s ability to use
their vergence system to maintain binocularity. In this way, prisms are used to induce retinal disparity. The prism
is gradually increased in magnitude, forcing the patient’s vergence system to compensate for the disparity that has
been created.
Fusional vergences may be horizontal and vertical. It is more common to find someone conducting a horizontal
fusional vergence as opposed to both horizontal and vertical. This is due to the fact that a normal vertical phoria can
be up to ½ ∆ and the amplitude of vertical vergences to compensate is about 1 ∆ . It has been recommended that free
space methods (using a prism bar) are preferred since they mimic natural viewing conditions as opposed to using the
phoropter method. You will learn more about this in the binocular vision module of the course.
June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-1
 Muscle Balance Assessment

HORIZONTAL SMOOTH FUSIONAL VERGENCES

When testing horizontal fusional vergences the following aspects are recorded:

1. Blur point: this is the point when the patient can no longer compensate the prism induced retinal disparity
while maintaining stable accommodation. In other words, it’s the point at which the accommodative system
can no longer assist in holding the eyes together. Only the vergence system is involved in keeping the image
single. This point is not usually found in patients at distance divergence since the accommodative effort of the
patient is completely relaxed with the refractive correction. If a blur value is obtained, then the practitioner
should consider re-refraction.
2. Break point: this is the point at which the patient’s vergence system can no longer compensate the further
increase in prism and cannot maintain the target single anymore. Fusion breaks and produces a double
image.
3. Recovery point: this is point at which the patient’s vergence system can recover its fusional ability and regain
single vision as the induced retinal disparity decreases.

EQUIPMENT
 Phoropter
 A distance VA chart in which one can isolate single letters

Figure 15.1 Setup of Risley prism for negative fusional reserves Base In (BI) prism

Figure 15.2 Setup of Risley prism for positive fusional reserves Base Out (BO) prism

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-2

 Muscle Balance Assessment

HORIZONTAL SMOOTH FUSIONAL VERGENCES AT DISTANCE AND NEAR

PROCEDURE
1. The patient must be wearing their best corrected distance or near prescription. The distance or near PD must
be set depending on the distance at which the vergences (reserves) are being measured.
2. The target is an isolated letter one line larger than the patient’s best corrected VA in the poorer eye.
3. The Risley prism is set at zero before both eyes.
4. Direct the patient to the target and instruct him to keep both eyes open. The patient should be able to see one
clear image. If the patient sees two targets (i.e. reports diplopia), either Base In (BI) or Base Out (BO) prism
must be added before the patient to achieve fusion and this point becomes the starting point of the test
(Scheiman and Wick, 2008). Carlson and Kurtz (2004) on the other hand suggest that diplopia must be
recorded if the patient reports seeing two targets and the test should be abandoned . (Scheiman and Wick,
Clinical Management of Binocular Vision, Lippincott Williams and Wilkins, 2008. Carson and Kurtz, Clinical Procedures
for Ocular Examination, McGraw-Hill, 2004).
5. The patient is instructed to look at the target and to keep it clear and single. The patient is then asked to report
if the target blurs (blur point), becomes double (break point) and when the target is single once again
(recovery point).
6. BI or negative fusional reserves (Fig. 15.1) are always measured before BO or positive fusional reserves (Fig.
15.2) since BO testing affects accommodation and convergence which may affect the results obtained during
the determination of BI reserves.
7. Prism is gradually increased from a zero point either on the phoropter or a prism bar until the patient reports
the first perceptible blur. Prism is added at a rate of 2 ∆ per second. The patient should be encouraged to
determine the point of sustained blur (i.e. when the patient can no longer clear the target at the point of blur).
This point is recorded as the blur point. Make a mental note of the amount of prism at this point. If no blur point
is reported, then an “x” is recorded.
8. The prism is then further increased until the patient reports that the target first becomes double. This point
is taken as the break point. Increase the prism (overshoot) until a point of sustained double is determined.
9. After the double point has been determined, the practitioner must slowly reduce the amount of prism until the
patient reports that the two images have become single again. This is the recovery point. Make a mental note
of the prism at this point.
10. The values that are noted are taken from both eyes. For example if you have 2 ∆ in front of one eye and
3 ∆ before the other, then the total value is added together making a total of 5 ∆ for either the blur, break
or recovery.

RECORDING THE FUSIONAL RESERVES

 The test distance must be recorded, i.e. Distance or Near.
 Each result should have three values, namely a blur / break / recovery
 If no blur value is obtained, then an “x” is recorded
 Positive fusional reserves or BO reserves: X / 14 / 10
 Negative fusional reserves or BI reserves: 12 / 18 / 10

e.g. Distance: BI x / 10 / 4 Near: BI 13 / 18 / 8

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-3

 Muscle Balance Assessment

Table 15.1 Expected findings for smooth vergence testing

Adapted from Morgan’s table of expected findings in an adult, clinical population (Scheiman and Wick, 2008)

∆ ∆
Distance Value Std deviation
BO Blur 9 ±4
Break 19 ±8
Recovery 10 ±4

BI Break 7 ±3
Recovery 4 ±2
Near
BO Blur 17 ±5
Break 21 ±6
Recovery 11 ±7

BI Blur 13 ±4
Break 21 ±4
Recovery 13 ±5

INTERPRETATION OF FINDINGS
The values obtained for fusional reserves must always be compared to the normal range of fusional reserves. The
determination of fusional reserves is conducted to determine if a patient has the ability to overcome or compensate for
his/her phoria.
A patient with an exophoria obviously displays a tendency for the eyes to turn outward and therefore one would have
to consider the BO reserves or positive fusional reserves to determine if the eyes have the capability to exert enough
effort to overcome the tendency for the eyes to deviate outward. The determination of the required amount of reserves
for a patient to have comfortable single clear binocular vision (compensated) is given by Sheard’s and Percival’s rules.
Sheard’s criterion states that: the compensating vergence should be at least twice the heterophoria amplitude. This
means a patient with a 5 ∆ BI (exophoria) at near, will be compensated and comfortable at near if his positive (BO)
fusional reserve is at least 10 ∆ or greater.

VERTICAL FUSIONAL VERGENCES

The patient must be wearing their best corrected distance or near prescription. The distance or near PD must be
in place according to the distance tested.
Blur points are not reached when measuring vertical fusional reserves. One will be able to measure vertical fusional
reserves by placing Base Up (BU) prism before one eye and Base Down (BD) prism before the other. It is also
possible to determine the reserve by placing either a BU or BD prism before one eye since both eyes work relative to
each other, i.e. a supravergence in front of one eye is equal to an infravergence in the other eye.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-4

 Muscle Balance Assessment

Figure 15.3 Setup of Risley prisms for BD or supravergences

PROCEDURE
1. The patient is directed to an appropriate letter and asked to report the break and recovery points are recorded
with changes in prism.
2. Prism is changed before the eye at a rate of 1 ∆ per second before the eye.
3. If BU is placed before the RE, then it indicates the practitioner is determining right infravergence.
The practitioner must note the amount of prism before the right eye when the patient detects break.
4. Once the break is determined, the practitioner may overshoot the value by about 2-3 ∆ and then reduce
the prism until the patient observes the recovery point at which the target is single again.
5. These steps are repeated with BD prism over the RE, indicating right supravergence (Fig. 15.3).

RECORDING THE FUSIONAL RESERVES

Recording of vertical fusional reserves are similar to that of horizontal. Only two values will be recorded, namely, break
and recovery

e.g. Distance vertical vergences: OD infra 4 / 2, supra 2 / 1

INTERPRETATION OF FINDINGS
While the reserves may be compared to population norms, it should be compared to the specific vertical phoria that
the patient may present with.

Note:
Vertical fusional vergences are not commonly performed by practitioners since the vertical amplitudes (reserves) are
usually between 1-2 ∆ . The eye can only tolerate a vertical deviation of ½ ∆ . However, if the phoria shows up as being
greater than 2 ∆ vertically, then it is worth investigating the vertical fusional vergences to determine compensation of
the phoria.

EXPECTED FINDINGS FOR SMOOTH VERGENCE TESTING

(Carlson and Kurtz, 2004)

Break: 3 ± 4 ∆ Recovery: 1.5 ± 2 ∆

VERGENCE FACILITY
The purpose of vergence facility testing is to evaluate the performance of the disparity of the vergence system within a
specified time period to determine the vergence system’s speed and resistance to fatigue. It is a test that can be
performed at distance and/or near.

PROCEDURE:
1. Direct the patient to a distance target that is large enough. This may comprise a vertical column of 20/30
letters or better. In some cases however, the entire chart may be used as a fixation target. If performing the
test at near, a vertical column of letters or block of letters may be an ideal target.
2. The patient views the target through the habitual Rx under normal room illumination.
June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-5
 Muscle Balance Assessment

3. BO prisms are used in powers of 4 ∆ and 6 ∆ to 8 ∆ and 12 ∆ .

4. The prisms may be introduced in flippers or loosely held by each hand.
5. Prism is introduced with BI first followed by BO prism, while continuing this cycle of introduction for about
4 cycles. Each cycle is a direct change from BI prism to BO prism without a delay between the presentation
of either type of prism.
6. The test may be performed objectively by the practitioner observing the patient’s fusional response with the
introduction of the prism or subjectively when the patient reports double vision upon introduction of the prism
and then single vision when there is adaptation to the prism before the eye.
7. The practitioner must record the amount of time for each cycle or the total time take for 4 cycles.

EXPECTED VALUES FOR JUMP VERGENCES

According to Griffin and Grisham in Binocular Anomalies: Diagnosis and Vision Therapy (Butterworth-Heinemann, 2002):
Average for 16 ∆ jump vergences is 3-5 seconds per jump or 6-10 seconds per cycle. These expected values may
differ with the age of the patient. It should be noted that the larger the prism range chosen, the slower the expected
cycle time.
Research by Gall et al (Optom Vis Sci, 1998), 15 cycles per minute is the preferred rate using 3 ∆ BI /12 ∆ BO for near
testing. Less than or equal to 12 cycles per minute are indicative of binocular problems.

ASSOCIATED PHORIA AND FIXATION DISPARITY

If an object is fixated without both visual axes precisely intersecting on the object and single binocular vision is still
maintained the patient is considered to have a “fixation disparity”.
If the visual axes are slightly divergent this is an exophoric fixation disparity (EXO FD). If the visual axes are slightly
convergent this is an esophoric fixation disparity (ESO FD). In the case that the visual axes are vertically misaligned
this is a hyperphoric or hypophoric fixation disparity (HYPER or HYPO FD)

THE MALLET UNIT

The Mallet unit contains a distinctive central fixation target of letters “OXO” with coloured vertical strips above and
below the target that are polarized for the left and right eye respectively. In the near Mallet unit, the target is buried
within a block of surrounding text that is used to help maintain binocular vision and keep the eyes associated through
peripheral cues for sensory fusion.

Figure 15.4 Mallet unit, central distance (red strips) and near targets (green strips)

PURPOSE
The Mallet unit is a commonly used FD test which evaluates binocular vision under associated conditions (unlike the
cover test and von Graefe tests).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-6

 Muscle Balance Assessment

INSTRUMENTATION
Distance or near Mallet unit
Polarising filters
Trial frame and lenses with best distance or near Rx

PROCEDURE
 Px must be binocular  no tropia
 Normal room illumination
 Mallet unit turned on and OXO is orientated in horizontal position (red strips vertical)
 Polarising filters placed within or over trial frame
 RE sees slip below X
 LE sees slip above X
 When both eyes are open first direct the patient to look at the surrounding text to reinforce binocular vision
 Then direct patient the fixation target
 Px reports if two slips are seen
 No  central suppression
 No further measurement possible
 If both slips seen, Px reports alignment of strips with respect to the central ‘X’

EXO FD L EXO FD ESO FD

c
a b
Figure 15.5 Fixation disparity on distance target of Mallet unit showing Exo (both strips divergent form the centre, L Exo (top strip
divergent form the centre) and Eso appearance (both strips have ‘crossed’ or converged from the centre).

MEASURING FD
Once a FD is established then a small prism / spherical lens added to reduce disparity to zero.
Once a horizontal FD has been measured then the OXO target is rotated so strips lie in horizontal orientation.
This allows determination of a vertical FD.

PRESCRIBING FOR FD
It is important to only correct FD if the Px is symptomatic. Prescribe prism before the eye with FD or if the
FD is bilateral then split the prism between the two eyes.

POINTS TO NOTE
The size of the FD is not always proportional to the size of any existing phoria. Sometimes a small phoria gives rise
to FD or conversely a large phoria can be fully compensated by the binocular system.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-7

 Muscle Balance Assessment

TREATING FD
EXO FD
 Prescribe weakest BI
 Especially in older Px’s
 In younger Px’s it is possible to use additional minus lenses to simulate accommodation and accommodative
convergence.
 Train positive fusional reserves to allow Px better control over deviation

ESO-DISPARITY
 Prescribe weakest BO
 Especially in older Px’s
 In younger Px’s
 Additional plus lenses to relax accommodation and accommodative convergence
 Train negative fusional reserves to allow Px better control over deviation
 Vertical-disparity:
 Only vertical prism

THE FD CURVE
Increasing prism before an eye can change fusional vergence demand while FD is monitored. The FD may change
with changes in vergence demand
  in BO produces  EXO-FD
  in BI produces  ESO-FD
The findings can be represented graphically on fixation disparity curve (Figure 15.6) which is charactersied by:

X-intercept: (associated phoria)

o Amount of prism required to reduce a FD to zero
o Noted as a prescribing benchmark
o Usually measured clinically using Mallet unit
o Magnitude:
- Less than dissociated phoria in XOP Px’s
- More than dissociated phoria in SOP Px’s

Y-intercept: (fixation disparity)

o FD graphically represented is y-intercept on FD curve

Slope of the curve

o Determined practically by calculating change in FD between a prismatic demand of 3 BO and 3 BI

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-8

 Muscle Balance Assessment

Figure 15.6 Typical fixation disparity curves

Clinical Appearance of FD curves (Table 15.2).

Table 15.2 Types of fixation disparity curves

Type of Patient Adaptation to lateral

Description
FD curve characteristics prism

Asymptomatic Px’s adapt equally to BI or

Type I Symmetric
Px’s BO stress

Flat on the More adaptation to BO and

Type II ESO
BO side less adaptation to BI prism

More adaptation to BI and

Flat on the BI
Type III EXO less adaptation to BO
side
prism

Little change
Binocular
Type IV with added
instability
prism

FD curves with flatter slopes are associated with symptom-free patients. FD curves with steeper curves are associated
with symptomatic patients. The visual system does not readily adapt to prism and success of vision therapy observed
in changes of FD curves from steeper to flatter.

STEREOACUITY
Stereoscopic vision is the individual’s ability to appreciate relative depth (nearness/farness). Stereoscopic vision
results from the retinal disparity that exists between integration of monocular images. The stereoacuity test measures
the smallest amount of horizontal retinal image disparity between each eye that gives rise to the sensation of relative
depth and is measured in seconds of arc.
Normal stereopsis is required for certain vocations such as airline pilots, police, and stereophotogrammers. Stereopsis
measurements may thus be helpful in determining future vocation options.
Stereopsis measurement is important in the diagnosis of variable binocular anomalies. Patients with certain forms of
strabismus (e.g. constant) or refractive anomalies (e.g. anisometropia) may not be able to appreciate stereopsis.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-9

 Muscle Balance Assessment

Stereoacuity measurements may also be important for predicting the prognosis for successful treatment of a specific
binocular anomaly. The prognosis for the improvement of binocular anomalies is better when the stereopsis is
appreciated (i.e. the better the stereoacuity, the better the prognosis).
Finally, stereopsis measurements may be useful in the detection of certain neurological conditions, particularly right
posterior cerebral lesions.

PROCEDURE
Many stereoscopic tests are available for clinical purposes. The most common clinical method uses linear polarized
tests such as the Titmus or Randot tests. The tests may differ in their properties and some may test contour stereopsis
while others test global stereopsis.
Contour or local stereopsis is produced by two similar targets that are laterally displaced (Fly, Wirt circles, animals).
These have the disadvantage of offering monocular cues. A patient with a constant strabismus may appreciate up to
70 seconds of arc (sec. arc).
Global stereopsis is produced by random dot targets that have no monocular cues (RDE, randot targets). A constant
strabismic could not pass a 660 sec. arc target. Global stereopsis is generally preferred for clinical use.

METHOD
1. The test distance is 40 cm.
2. Best Rx must be worn. For presbyopic patients, a near Rx must be worn.
3. No rotation is allowed or monocular cues will be given.
4. The monocular cues are tested first (letters R & L)
5. The circles are then tested and if impossible the larger forms (lower disparity) are tried
6. Guessing must be encouraged

RECORDING
 Stereo scores are noted from the scores provided on the test charts employed and noted in seconds of arc
(e.g. 30”)

EXPECTED VALUE
 20 sec. arc

SCORING CHARTS FOR THE TITMUS & RANDOT STEREO CLINICAL TESTS

Figure 15.7 (a) and (b) Randot stereo test and diagram of shapes

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-10

 Muscle Balance Assessment

Table 15.3 Stereo test results (Titmus and Randot)

Correct Stereo Angle Shepard Verhoff

Test
Answer at 40cm. Percentage Distance
A Cat 400 sec. 15% .1
B Rabbit 200 sec. 30% .2
C Monkey 100 sec. 50% .3
Stereo Angle Stereo Angle
Test TITMUS RANDOT
at 40cm. at 40cm.
1 Bottom 800 sec L 400 sec
2 Left 400 sec R 200 sec
3 Bottom 200 sec L 140 sec
4 Top 140 sec M 100 sec
5 Top 100 sec R 70 sec
6 Left 80 sec M 50 sec
7 Right 60 sec L 40 sec
8 Left 50 sec R 30 sec
9 Right 40 sec M 25 sec
10 R 20 sec

BIBLIOGRAPHY
Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3/e. The MacGraw-Hill Companies, Inc. United States. 2004
Benjamin W, Borish's Clinical Refraction, Butterworth-Heinnemann, 2007
Elliott DB. Clinical procedures in primary eye care 3/e. Oxford, Elsevier, 2008.
Ettinger ER and Rouse MW., Clinical Decision Making in Optometry, 1/e, Butterworth, Heinemann 1997.
Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
Scheiman M and Wick B. Clinical management of binocular vision. Philadelphia: Lippincott Williams & Wilkins. 2008.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 15-11

 OCULAR HEALTH EXAMINATION

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Tests included in assessment of ocular health

 Direct ophthalmoscopy
 Normal fundus
 Diagrammatic representation of the various structures of the fundus

INTRODUCTION

Anecdotal reports reveal that most practitioners assume that an assessment of ocular health is a posterior segment
evaluation of the fundus. The ocular health examination reveals information on the current status of ocular health,
conditions that have the potential to result in ocular damage and to monitor the effect of systemic disease
on the ocular system. The effect of systemic disease is not only limited to an assessment of the posterior segment
of the eye, but involves assessment of pupils, visual fields, binocularity, etc.

TESTS USED FOR ASSESMENT OF OCULAR HEALTH

Assessment of ocular health should include tests such as:

1. Pupillary responses (which can also be performed as part of the preliminary examination)
2. Evaluation of the anterior segment and adnexae (may be achieved by direct observation and slit lamp
biomicroscopy)
3. Evaluation of ocular media (achieved by slit lamp biomicroscopy, direct ophthalmoscopy, visual acuity)
4. Evaluation of the posterior segment. An assessment of the posterior segment may be achieved by several
methods of examination, namely:
a. Direct fundus examination (direct ophthalmoscopy)
b. Dilated fundus examination
- Stereoscopic fundus biomicroscopy
- Binocular indirect ophthalmoscopy
5. Visual field screening (confrontation)
6. Measurement of intraocular pressure (this may be achieved by using non-contact and contact methods
of measurement)
7. Systemic health screening tests
We shall describe now the techniques used for the assessment of ocular health in more detail:

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-1

 Ocular Health Examination

1. PUPILLARY RESPONSES
This has been discussed in Chapter 8 of the module (Preliminary Eye Examination).

2. EVALUATION OF THE ANTERIOR SEGMENT AND ADNEXAE

1. This may be achieved by gross direct observation or with the slit lamp biomicroscopy
2. Gross observation of the patient’s body, face and head must take into consideration. These observations
provide clues regarding the visual, ocular and general health issues involved
o Body positioning: this could provide information about the presence or evidence of a stroke
o Head turn, tilt or elevation could indicate extraocular muscle difficulties, visual field problems and possible
ocular pathology (like ptosis or macular degeneration) leading to compensatory head position changes
o An assessment of the external and anterior segment ocular structures, i.e. the eyelids, eyelashes, puncta,
conjunctiva, cornea and iris. Some of these structures can be observed with the naked eye, with extra light
and slight magnification (+10.00DS lens or Burton lamp) or with a slit lamp biomicroscope.
3. In addition to the gross observation of the external ocular structures, the practitioner can also make an
assessment of the anterior chamber angle width in the absence of other instrumentation such as a slit-lamp
or gonioscope or when these techniques cannot be performed like in the paediatric population. This method
of examination is also referred to as the Shadow method.

SHADOW METHOD PROCEDURE

o Direct the patient to a distance target in primary gaze
o The practitioner holds a penlight temporal to the eye at about 15cm from the eye so that the penlight lies
in line with the pupil (Fig. 16.1a). To achieve an accurate positioning of the penlight, the practitioner can
begin by placing the penlight behind the eye/head position and then move it anteriorly until the practitioner
is able to observe the illumination of the iris surface (Fig 16.1b).

Figure 16.1 Positioning of the penlight for the shadow method of anterior chamber angle width estimation

o The tangential illumination source (Fig. 16.2) will allow the practitioner to observe a crescent shaped shadow
on the iris area opposite to the position of the penlight (Fig. 16.3) when the patient’s eye is in primary gaze

Figure 16.2 Illumination of the iris surface with the temporal tangentially placed penlight

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-2

 Ocular Health Examination

o The crescent-like shadow observed is produced by the elevation of the iris on the side of the penlight
illumination, thus preventing the light from passing across the entire iris surface unobstructed (Fig.16.3a).
The width of the crescent-like shadow will vary depending on the width of the anterior chamber angle.
If the practitioner notices no shadow created (Fig. 16.3b), then it would indicate that there is a deep
anterior chamber depth and therefore a lesser chance of the presence of angle closure glaucoma
or a lesser chance of precipitating angle closure glaucoma with dilated fundus examinations.

Figure 16.3 (a) Grade 2 anterior chamber depth (risk of angle closure);
(b) Grade 4 anterior chamber depth (open angle)

o The grading of the anterior chamber angle depth and its likelihood to precipitate an angle closure is
illustrated in figure 16.4. These guidelines are used to complement practitioner sketches in an effort
to allow the practitioner to grade angle depth.

Grade 4 Grade 3
Angle closure is unlikely – Dilation possible

Grade 2 Grade 1
Dilation maybe risky Dilation is contraindicated

Figure 16.4 Grading scale used for the classification of the anterior
chamber angle depth based on LOCS III photographs

3. EVALUATION OF OCULAR MEDIA

 The ocular media comprises the cornea, anterior chamber, crystalline lens and vitreous body.
 The main feature of the ocular media is that they should be transparent. The purpose of the ocular health
examination to assess the transparency of these structures. The practitioner shines the direct ophthalmoscope
light into the eye and observes the light reflected from the retina. This is observed as a red glow within the pupil
area, referred to as the red reflex. A lack of transparency is inferred when there is an obstruction in the light
returning back through the pupil, which is observed as a shadow. In addition, the red glow returning from both
eyes should similar. A lack of similarity could indicate the presence of subtle media opacities.
 In addition, an asymmetrical brightness of the reflex between the two eyes may indicate the presence of
strabismus, or anisometropia where the eye with the abnormality is brighter eye. This is referred to as the
Brückner test. It is a valuable objective assessment of ocular alignment or refractive status in
 patients where the practitioner may receive limited subjective feedback. This will be discussed in much more
detail in the binocular vision module.
 When assessing the ocular media using the ophthalmoscope, it may be necessary for the practitioner to vary
the focus by rotating the lens wheel to a more plus power to focus on the more anterior structures of the eye.
 When observing corneal abnormalities with direct examination, it usually will appear white instead of as a black
shadow obstructing the red reflex.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-3

 Ocular Health Examination

4. EVALUATION OF THE POSTERIOR SEGMENT

 An assessment of the posterior segment may be achieved by several methods of examination, namely:
a. Direct fundus examination (ophthalmoscopy)
b. Dilated fundus examination
- Stereoscopic fundus biomicroscopy
- Binocular indirect ophthalmoscopy
 For the purposes of the scope of this course, direct ophthalmoscopy will only be discussed. The other methods
of examination will be discussed in Clinical Optometric Procedures II module.

5. VISUAL FIELD SCREENING (CONFRONTATION)

 Discussed in preliminary examination chapter 9.

6. MEASUREMENT OF INTRAOCULAR PRESSURE

 The measurement of intraocular pressure may be achieved by non-contact and contact methods., discussed
in chapter 18.

7. SYSTEMIC HEALTH SCREENING TESTS

 Besides direct ophthalmoscopy providing the practitioner with information regarding the systemic health of the
patient, other tests like blood pressure measurements, carotid auscultation, etc. will be discussed in the Clinical
Optometric Procedures II module.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-4

 Ocular Health Examination

DIRECT OPHTHALMOSCOPY

PURPOSE OF THE DIRECT OPHTHALMOSCOPY

Direct ophthalmoscopy provides a view of the posterior pole region of the fundus, which includes the optic nerve and
its vascular arcades and the macula.
The method of direct ophthalmoscopy has various advantages and disadvantages in its use in the ocular health
examination.

ADVANTAGES
 Easier to conduct than other methods of posterior segment evaluation
 Performed upright on patients allowing for more comfort
 Can be performed on large or small pupils
 Provides a relatively higher level of magnification ~15X
 Allows the assessment of media
 Portable/Handheld
 Upright image

DISADVANTAGES
 Lack of stereoscopic view of the posterior segment
 Close working distance
 Provides a small field of view
 Produces distortion with off-axis views of the eye
 Limited views of media opacities are present

PARTS AND OPTICS OF THE DIRECT OPHTHALMOSCOPE

PARTS OF THE DIRECT OPHTHALMOSCOPE
 Rheostat to control illumination
 Variable aperture sizes small to large - varying diameters (pupil size adjustment)
 Lens power indicator (plus and minus)
 Auxiliary controls:
o Red-free filter is used to differentiate retinal and choroidal lesions, hemorrhages, pigment, subtle optic
nerve head drusen and nerve fibre layer defects
o Fixation cross is used to assess fixation and in some cases grade position and size of defects.
o Slit beam is used to detect elevated lesions on the fundus and macula holes (Watzke-Allen test)
o Cobalt blue filter is used together with fluorescein on the cornea to assess corneal scar and abrasion
as well as pupil size in the dark.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-5

 Ocular Health Examination

OPTICS OF THE DIRECT OPHTHALMOSCOPE

Figure 16.5 Optics of the ophthalmoscope

The direct ophthalmoscope comprises an observation system and illumination system. More recent changes in the
illumination system have included a halogen light source, which was introduced by Welch Allyn in 1973. Other
improvements include optically coated lenses and prisms to reduce the amount of glare reflected into the practitioner’s
eye. Auxiliary features of the ophthalmoscope include: apertures of varying diameters, fixation and slit apertures,
fixation target cross and various filters including the red-free filter, and cobalt filter.

1. Illuminating system

Figure 16.6 Optics of the illuminating system of the direct ophthalmoscope

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-6

 Ocular Health Examination

The illumination system comprises:

 A tungsten bulb, condenser system, projection lens and reflector
 Bulb is centered and produces a filament image on the reflector
 Can be filled with halogen gas . increase light output
 Reflectors can be either mirrors, metallic plates, prisms
 A range of aperture stops and filters are present between the condensing and projection lens
 The illumination system also Includes a series of different size apertures
 A series of filters are also part of the illumination system, namely the red free filter which increases the contrast
between vessels and retinal background, differentiates retinal and choroidal lesions, differentiates hemorrhages
and pigment (Fig. 16.6)

2. Observation System:

Figure 16.7 Optics of the observation system of the direct ophthalmoscope

The observation system comprises:

 A sight-hole/peephole and focusing system
 A focusing system made of a rack of lenses
 Sight-hole positions the viewing axis to one side of illumination axis and so displaces the corneal reflex
 A bright corneal reflex can be eliminated by using a polarizing filter, however, it causes a loss of light (Fig. 16.7)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-7

 Ocular Health Examination

PROCEDURE FOR CONDUCTING DIRECT OPHTHALMOSCOPY

1. The practitioner must grasp the ophthalmoscope such that his/her fingers are placed on the lens wheel,
which allows the practitioner to adjust lens power in either the plus or minus direction.
The right hand is used to hold the instrument when performing the technique on the right eye and by the
left hand when performing on the left eye. Practitioners who have physical or visual limitations may not be
able to adapt to this method of instrument handling.
2. The observation aperture of the ophthalmoscope must be directly before the practitioner’s eye, thereby
requiring the practitioner to move his/her head, arm and ophthalmoscope as one unit.
3. Fixation and its maintenance is essential to performing a problem-free ophthalmoscopic examination on
a patient. The patient must be directed to view in the primary or straight ahead position since the optic nerve
head of the posterior pole is the structure that is observed first. One may provide a large fixation target on
a VA chart to assist in this process or in the case of paediatric evaluation, an interesting visually stimulating
distance target.
4. The technique is best performed in dimly lit room to ensure that the pupil size is maximal in size to encourage
a larger field of view upon examination.
5. It is essential to provide the patient with adequate instructions. This would include the purpose of the test
the bright light and that you are likely to come very closer to their eye or face. In this way, the patient is ready
for you to invade their internal space.
6. When beginning the examination, the practitioner begins with approximately +10.00DS lens and positions
himself/herself at about 10cm from the patient (equivalent to the focus of the +10.00DS lens). This lens
power facilitates a view of the anterior media structures. One would be able to observe the red-reflex which
is the reflection off the fundus. Any media disturbance would usually obstruct the view of this red-reflex.
As you focus towards posterior structures, i.e. from aqueous to lens to retina, decrease the power of the
focusing lens.
7. The patient is usually not required to use their prescription unless he/she has a very high refractive error.
8. Media opacities are assessed using the principle of motion of parallax plus nodal point as reference.
a. If the opacity lies in the anterior capsule, then the opacity appears to move in the same direction
as the movement of the eye
b. If the opacity lies in the posterior capsule, then the opacity appears to move in the opposite direction
as the movement of the eye
c. If the opacity lies posterior to the lens, in the vitreous gel, usually floaters, they will appear to move
as the patient moves his/her eye and then float back to the original position.
9. As the practitioner completes the examination of the media, he/she will be moving closer to the patient.
However, the practitioner should not get closer than the extent of the eyelashes.
10. Adjustments in the prescription used to view the eye may need to be calculated as per formula in order
for the practitioner to be able to see the patient’s retina clearly. The power of the correcting lens must be
the algebraic sum of the ametropias of the practitioner and the patient minus the dioptric amount of their
accommodation.

F correcting lens = (Examiner’s Ametropia + Patient’s Ametropia) – accommodation

For example: (-2.00 + 5.00) – 1.00 = +2.00DS

11. When the practitioner is ready to view the fundus and more specifically the optic nerve head (ONH), he/she
may move to a position that is slightly temporal to a central view. At this point, the patient is observing along
the visual axis. In some cases, it may be difficult for the practitioner to be able to obtain an immediate view
of the ONH even in this position. If so, the practitioner must find a bifurcation of the vessel forms a “V”
shape, which will give the practitioner a guideline as to which direction to move in order to find the ONH.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-8

 Ocular Health Examination

12. Once the practitioner reaches the ONH, there are several features that the practitioner would have to take
cognizance of in order to determine the health status of the retina. These features include:

 Disc margin contour and distinctness

 Neuroretinal rim tissue. This lies between disc and cup margins and its pattern of width. This needs to
be observed carefully as it may be an indicator of risk of glaucomatous change occurring in patients.
 Cup-to-disc ratio (C/D ratio)- horizontal and vertical
 Depth of the cup
 Visibility of the lamina cribrosa
 Contour of the cup margins
 Crescents around disc margin
 Central retina artery (CRA) and Central retinal vein (CRV)
 Spontaneous venous pulsation
 Artery-to-vein thickness ratio (A/V ratio)
 Artery and vein crossings, which should be assessed away from ONH
 Arteriolar light reflex
 Other variations in vasculature that include circumlinear vessels, cilioretinal vessels,
undermined vessels, neovascularisation, etc.

13. The practitioner is required to examine all four quadrants. Either the practitioner will move towards the
different quadrants or the patient looks in different directions of gaze.
14. Any abnormalities/lesions should be noted in terms of size, position from the disc in clock position.
15. The macula is examined by asking the patient to look into the light source of the ophthalmoscope, or the
practitioner should move their view in a temporal direction to reach the macula. The practitioner must note
the colour, any abnormalities, presence of a foveal reflex, steadiness of the position of foveal reflex with
fixation and uniformity of the colouration of macula.
The assessment of ocular health using ophthalmoscopy cannot be achieved without the practitioner being aware
of the normal fundus appearance and its variations.

NORMAL FUNDUS

COLOUR OF THE FUNDUS

 There is variation in the background colour of the overall fundus between individuals.
 The background colour of the fundus is reddish-orange due to the pigment in the retinal pigment epithelial
layer (RPE), choroid and vasculature.
 In individuals with sparse pigment, like in Caucasians, the choroid vasculature is more visible and the
fundus therefore has a more red appearance.
 In individuals with dense pigment, like in Asians and African patients, the increased pigment content in the fundus
gives a tessellated or tigroid appearance which are observed as dark streaks of pigment

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-9

 Ocular Health Examination

OPTIC NERVE HEAD (ONH)

 The ONH lies nasal to the macula or can be observed most easily when the practitioner observes the retinal when
he is about 15 degrees temporally positioned relative to the eye being examined.
 The ONH dimensions on average: 5.5° wide and 7.5° wide. Its projection in the visual field is referred to as the
blindspot, since the ONH is devoid of photoreceptors.
 The outer margins of the ONH are indicated as the disc margin and should be clear and defined. A lack of clarity
of these margins may indicate the presence of pathological conditions.
 The central portion of the ONH is marked by an excavation which is referred to as the physiological optic cup.
It is the point of exit of the ganglion cell fibres from the retina into the optic nerve. The intraocular pressure tends
to have an impact on the morphology of the cup and the neuro-retinal rim.
 An assessment of the C/D ratio is the size of cup relative to disc.

RETINAL VESSELS
 The fundus is the only site in the body where the blood vessels can be visualized directly.
 The veins are thicker, darker because they carry de-oxygenated blood. They have transparent walls.
 The arteries are narrower and brighter red in colour.
 The CRA and CRV emerge at optic disc and enter the nerve fibre layer.
 Both arteries and veins have a relatively smooth path. Tortuosity may be a congenital variation or indicate the
presence of vascular pathology.
 An assessment of the AV ratio (thickness of A compared to V) usually is conducted after the second bifurcation
of the vessels. The normal A/V ratio is 1:2, 2:3.

MACULA
 The macula lies approximately 2 disc diameters (DD) temporal to the optic disc.
 Its area spans 5mm in diameter.
 Macula is darker in pigmentation than the rest of the fundus. This is attributed by;
 Increased pigmentation in the RPE layer
 Xanthophyll pigment giving the macula an orange/brown hue
 Macula pigment is uniformly distributed.
 Abnormalities of the macular pigmentation is usually observed as an uneven colouration and referred to
as being mottled.
 It is area of the fundus that is rich in retinal cone photoreceptors.
 The central region of the macula is known as the fovea centralis (foveal avascular zone). It is an area that is
very slightly excavated relative to the surrounding area of the macula. It gives rise to a foveal reflex when
illuminated, as it is a thinner aspect of the macula.
 Foveal avascular zone (center portion of macula) is entirely dependent on the choriocapillaries for its nutrition
and O2 supply.
The diagrammatic representation of the above mentioned structures are discussed in greater detail in the next section.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-10

 Ocular Health Examination

REPRESENTATION OF THE VARIOUS STRUCTURES OF THE FUNDUS

1. Disc margins of the ONH

2. Neuroretinal rim tissue between disc and cup margins
3. Cup-to-disc ratio (C/D ratio)
4. Depth of the cup
5. Visibility of the lamina cribrosa
6. Contour of the cup margins
7. Crescents around the disc margin
8. Central retina artery (CRA) and Central retinal vein (CRV)
9. Spontaneous venous pulsation
10. Artery-to-vein thickness ratio (A/V ratio)
11. Artery and vein crossings
12. Arteriolar light reflex
13. Other variations in vasculature that include circumlinear vessels, cilioretinal vessels, undermined
vessels, neovascularisation, etc.

1. MARGINS OF THE CUP OR DISC

OPTIC DISC

Optic disc size:

 The size of the optic disc (OD) is not constant among individuals
 According to Jonas et al (1999)
o OD in men > women
o high myopia > high hyperopia
o OD varies with race, with White/Caucasians < Asians/Hispanics < African-American

Optic disc diameter:

 . ~ 5° wide horizontally and ~7° wide vertically (Fig. 16.8).

Figure 16.8 Dimensions of the optic nerve head

Optic disc shape:

 The OD is slightly vertically oval. On average, vertical diameter being about 7-10% larger than the horizontal
 Not uncommon to find spherical ODs
 Abnormal disc shapes may be correlated with increased corneal astigmatism

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-11

 Ocular Health Examination

Disc margins:
 The scleral rim (Fig. 16.9) is the limit of the disc and may appear as a partial or total white circle peripheral
to the normally pink neuroretinal rim (NRR)
 Margins of the disc may be either distinct or indistinct
 Margins may be elevated or blurred. Examples of cases presenting with blurred disc margins are: ONH drusen,
benign intracranial hypertension, advanced systemic hypertension, etc. When this occurs, it is necessary to
distinguish them from a normal variation or pathology
 The symbols used to denote the margins of the disc are:
Distinct contour Indistinct contour

a b

Figure 16.9 Normal optic nerve head

– (a) scleral rim is indicated between arrows; (b) distinct optic disc margin

a b

Figure 16.10 (a) ONH with indistinct disc margin; (b) Diagramming of indistinct margins

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-12

 Ocular Health Examination

Shape of the optic disc

 The shape of the disc may be circular (Fig. 16.11a), oval (Fig. 16.11b), or tilted (Fig. 16.11c).

Figure 16.11 (a) circular shaped disc; (b) oval shaped disc; (c) tilted

Position of the cup within the disc

 The position of the cup within the disc may be central or decentered
 One must always draw the cup in its correct position within the disc.
 The position of the cup drawn as either: (a) central (Fig. 16.12a) or (b) decentered (Fig. 16.12b)

Figure 16.12 (a) Centrally placed cup within the optic disc;
(b) decentrally placed cup within the optic disc

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-13

 Ocular Health Examination

OPTIC CUP (OC)

Optic cup size in relation to the Optic disc size
 The optic cup is the excavation of the ONH
 The border between the OC and the NRR is determined by contour and not pallor (this is best achieved
by stereoscopic examination of the ONH)
 The border of the cup may be determined by locating the contour of vessels (Fig. 16.13)
 Cup is larger in a larger optic nerve head but C/D ratio is relative to ONH size

Figure 16.13 Contour changes to the vessels (indicated by arrows) indicates the margin of the optic cup

2. NEURORETINAL RIM (NRR)

NEURORETINAL RIM SIZE
 This is the pink ring of capillary-rich tissue present on healthy optic nerve heads.
 It is the intrapapillary equivalent of the retinal nerve fibres and ON fibres.
 NRR assessment is necessary in ophthalmoscopic evaluation of the ONH.
 The NRR size is correlated with disc area. A larger disc has a tendency to have a larger NRR.
 Axons of the ganglion cells closer to the optic disc lie more centrally in the disc compared with axons from the
retinal periphery, which lie at the ONH margins.

NRR SHAPE
 NRR shape is based on the vertically oval shape of the OD and the horizontally oval shape of the optic cup
 NRR is usually broadest Inferiorly, followed by Superior disc margin, Nasal disc area and finally the Temporal
disc region (the “ISNT rule” as termed by Werner) (Fig. 16.14)
 NRR pallor may be a sign of ON damage
 Notching of the cup or vertical elongation of the cup indicates compromise to the nerve fiber. Assessment of the
NRR will show narrowing or thinning in this aspect of ONH. Assessment of this on visual fields is critical and may
present with a visual field defect.
 The change in size and thickness of the NRR (review rule of ISNT) is of utmost importance in the diagnosis
of early glaucomatous ONH damage, which may show up before visual field defects

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-14

 Ocular Health Examination

a
r

Figure 16.14 Comparisons of the neuroretinal rim indicating that the ISNT rule is satisfied

3. CUP-TO-DISC-RATIO (C/D)
 C/D ratios are dependent on the size of the OD and OC
 The estimation of the C/D ratio is independent of the magnification of the optic media and the method
of examination of the ONH
 Physiological cupping usually indicates a large C/D ratio (> 0.5) but no functional damage (i.e. visual field loss)
 Asymmetric C/D ratios that differ by 0.2 or more between the 2 eyes is usually suggestive of glaucoma or
other pathology
 The red free filter is helpful when judging the C/D ratio and macula
 To determine the C/D ratio, the disc diameter is designated a value of 1.0 or 10
 One must determine what the ratio is between the horizontal and vertical diameter of the cup to the horizontal
and vertical diameter of the disc
 Both horizontal and vertical axes are specified (e.g. 0.4HX0.5V)
 The C/D ratio may be given as a decimal form (e.g. 0.5) or a percentage ratio (e.g. 50%)

METHODS OF DETERMINING THE CD RATIO

a. Fitting the cup within the disc diameter
One can estimate the CD ratio by estimating how many times the cup can fill the diameter of the disc. In figure 16.15,
the cup can fit into the diameter of the disc 3 times and there still some NRR that cannot be accommodated. This
means that the CD ratio is approximately 0.3 along the horizontal and 0.3 vertical dimensions. C/D = 0.3HX0.3V

Figure 16.15 Diagram of how to determine the CD ratio

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-15

 Ocular Health Examination

b. Ruler method
Another method is to divide a disc into 10 parts across the diameter of and determine how many of those 10 divisions
are occupied by the cup (Fig. 16.16). e.g. 4 parts of the 10 along the horizontal axis is filled by the cup making the CD
ratio along the horizontal 0.4 or 40%. A similar procedure is followed to determine the vertical ratio.

Figure 16.16 Diagram of how to use the rule method to determine the CD ratio

4. DEPTH OF THE CUP

 Cup depth can be flat, moderate (sloping margins) or deep (steep margins).
 The depth of the cup may be inferred from the change in power to view the cup from the neuroretinal rim.
A change in power of 3.00 DS = 1 mm depth
 A deep cup usually is one that may be associated with the presence of lamina cribrosa
 Abnormalities in the depth of the cup may be indicated by bean-pot cupping or baring vessels where
circumlinear vessels were noted previously

5. LAMINA CRIBROSA
 The lamina cribrosa is a collagenous connective and glial tissue that is continuous with and bridges the
scleral canal.
 It is sieve-like tissue that provides support to the exiting ganglion cell nerve fibres.
 Visualized in about 35% of normal eyes as laminar dots at the base of the cup, i.e. they appear as greyish,
washed-out spots (Fig. 16.17).

Figure 16.17 (a) Direct schematic view of the lamina cribrosa observed within the cup;
(b) Profile of the ONH and the lamina cribrosa in relation

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-16

 Ocular Health Examination

 The lamina cribrosa is indicated by hash (#) signs or small circles (Fig. 16.18).
 It is generally more useful to diagram lamina with small circles. In conditions such as glaucoma, the lamina
may become distorted (change shape from round to elongated) following the direction of cup damage. This
can be drawn as elongated.
 Normal lamina is drawn as while distorted lamina is drawn as .

Figure 16.18 Diagrammatic representation of the lamina cribrosa and its distortion

6. CONTOUR OF THE WALLS OF THE CUP

 While the cup depth can be even in the entire cup, there are instances in which it can vary from one end
of the cup to the other.
 If the cup is deeper in one end and slopes at the other end, then it is indicated by oblique radiating lines
(Fig. 16.19).

Figure 16.19 Radiating lines indicating sloping in a cup

 The contour of the cup in addition can also be judged by the turning of the blood vessels at the margin of the
cup. If the blood vessels make a sharp turn, then it indicates the cup contour is steep and if the blood vessels
make a slight turn, then it indicates that the cup contour is sloping.

7. MARGINS OF THE CUP

 Margins of the cup are denoted in the same manner as that for the disc (Fig. 16.20)
 The symbols used to denote the margins of the cup are:
Distinct margin Indistinct margin

Figure 16.20 Diagrammatic representation of the sloping margins of a cup with indistinct margins as well

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-17

 Ocular Health Examination

Sloping cup
margins

Figure 16.21 ONH with a sloping cup and indistinct margins temporally

8. CRESCENTS
 Crescents can be either:
o Scleral: white (from the sclera)
o Choroidal: grey-green (from choroid)
o Pigmentary: black (from the RPE)

Figure 16.21 Drawing choroidal crescents

 Crescent are drawn circumferentially around the disc diagram and shaded in (Fig. 21)
 Crescents can appear as isolated anatomic alternations or can be associated with other congenital
and acquired ONH anomalies. Crescents themselves are benign
 Crescent occurs if various fundus tissues do not reach the ON or have an incomplete extension to it
o For example, a choroidal crescent is green/grey and represents choroidal tissue exposure
(Fig. 16.22a and 16.23)
o A scleral crescent is a variation of white coloration, because neither RPE nor the choroid abuts the
ONH, revealing the underlying white sclera (Fig. 16.22b and 16.23)
o Pigment crescent is secondary to RPE layer exposure and appears black in color (Fig. 16.24)
 The scleral crescent is very often associated with high myopia because of the elongation of the eyeball and
as the eye stretches, the RPE and choroids are pulled away from the disc tissue. The crescents usually occur
in the temporal aspect of the disc

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-18

 Ocular Health Examination

Figure 16.22 (a) Schematic view of choroidal crescent (b) Schematic view of scleral crescent

Figure 16.23 ONH with scleral and choroidal crescents

[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

Figure 16.24 ONH with pigmentary crescent

[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

Peripapillary atrophy is also a crescent-like feature seen around the ONH (Fig. 16.25). It can be found in a 360
degree pattern around the ONH or more commonly observed temporally. The area of PPA can be divided into a
peripheral alpha zone and central beta zone. The beta zone represents an area of total loss of the RPE and a
reduction in the number of photoreceptors thereby increasing the visibility of the larger vessels of the choroid and the
sclera. The alpha zone changes correspond to areas of RPE irregularities. The Beta zone is found more frequently
and extensively in eyes with glaucoma. The areas of PPA correlated with visual field defects that can be found in both
of these types of glaucoma. Absolute scotomas are usually

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-19

 Ocular Health Examination

found with beta zone changes while relative scotomas are found with alpha zone changes. While the etiology of PPA
has been uncertain, it has been regarded as an indication of an area of the retina that has poor blood supply resulting
in chorioretinal atrophy around the optic nerve head. Clinically it appears as an area of hyper- and hypo-pigmentation
of the RPE and choroid around the optic nerve head.

Figure 16.25 Peripapillary atrophy (indicated by arrow)

[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

9. CENTRAL RETINA ARTERY (CRA) AND CENTRAL RETINAL VEIN (CRV)

 While the central retinal artery and vein are essential in the assessment of the ONH, it is not essential to
diagram them unless abnormalities are noted
 The central retinal artery (CRA) is a branch of the ophthalmic artery (from the internal carotid system). There
is therefore a direct relationship between internal carotid disease and retinal and nerve head emboli and infarcts
 The CRA enters the nerve posterior to the globe, runs forward, constricts at the lamina and enters the globe
through the optic nerve head. It commonly has an entrance that is nasal to that of the CRV
 The CRA bifurcates into the superior and inferior papillary arteries to run into the retina to supply the inner
retinal layers
 Arteries lie in the NFL or ganglion cell layer with strong connections to the ILM
 The CRV usually forms on the disc. On occasion, it does not form until after passing through the lamina
 The CRV is thin-walled and susceptible to external pressures and compression. The lack of definitive wall
structure allows for the variable appearance in disease conditions, like venous beading in diabetic retinopathy
or distention
 The short posterior ciliary arteries, the posterior ciliary artery and the pial artery are responsible for most of the
blood supply to the nerve head. Small branches from the CRA supply the most superficial layers of the ONH

ARTERY AND VEIN COURSE

 In general, the caliber of the vessels should be uniform with no area of compression at the crossing of vessels

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-20

 Ocular Health Examination

10. SPONTANEOUS VENOUS PULSATION (SVP)

 Venous pulsation is found in about 80% of normal individuals
 It is an indication of the homeostasis between blood pressure and intraocular pressure
 The incidence of a venous pulsation increases with age because of increase in IOP and increase in
blood pressure
 Observing an SVP is recorded as positive or lack of it is recorded as negative.
 Conditions that can contribute to a venous pulsation from being seen or elicited include papilloedema,
raised intraocular pressure - IOPs or very low blood pressure

11. ARTERU-TO-VEIN THICKNESS RATION (A/V RATIO)

 The normal A/V ratio is approximately 2:3
 The A/V ratio is usually estimated beyond the second bifurcation
 Abnormalities that can alter the AV ratio include conditions such as diabetes and hypertension

12. ARTERY AND VEIN CROSSINGS

 Compression of the veins with the arteries can occur at A/V crossings
 Merging of the arterial adventitia and venous glial coverings at A/V crossings. The sharing of tissue in this area,
result in compression of the vein wall when the arteries develop arteriosclerotic changes
 One may be able to observe the following A/V crossing changes:
o Salus sign: a deflection of the underlying artery
o Gunn’s sign: tapering of the artery invades or extends into the vein
o Banking: distention of a vein peripheral to the crossing of the artery and vein

13. ARTERIOLAR LIGHT REFLEX

 The arteriolar light reflex is the ratio width of the light that is reflected off the surface of an artery to the overall
width of the artery
 Thickening of the walls of the artery allows less light to pass through the artery. Therefore light reflected is greater,
as in cases of arteriosclerosis or atherosclerosis
 The arteriolar light reflex is usually expected to be 1/3 or 1/4
 Arteriosclerotic changes involve a widening of the arterial reflex and narrowing of the vessels. This clinically
appears white or coppery in color

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-21

 Ocular Health Examination

14. OTHER VARIATIONS IN VASCULATURE

 Other variations in vasculature include circumlinear vessels, cilioretinal vessels, baring of vessels, undermined
vessels, neovascularisation, etc.

CILIORETINAL ARTERIES
 In rare cases the cilioretinal artery may be found nasally and does not branch off the CRA (Fig. 16.26a)
 The cilioretinal artery is a branch of the short posterior ciliary artery from the choroidal circulation (Fig. 16.26b)
and typically this vessel exits temporally towards the macula from the neuroretinal rim (Fig. 16.27)
 This artery is found in approximately 25% of population
 This artery may be one or on occasion 2 in number
 In a central retinal artery occlusion (CRAO) the cilioretinal artery can provide oxygen/nutrients of small surface
area of retina. If adjacent to the macula, in a CRAO can preserve a small amount of central vision

Figure 16.26 (a) Shows direct view of the exit of the cilioretinal artery from the NRR
(b) Shows the origin and path of the cilioretinal artery to supply the retina with blood in profile view

Cilioretinal

Figure 16.27 ONH with cilioretinal artery

[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-22

 Ocular Health Examination

CIRCUMLINEAR VESSELS
 Circumlinear vessel is a vessel that follows the contour of the cup partially (Fig. 16.28).
 Circumlinear vessels may become barred (barring of vessel) when the cup enlarges. The neuroretinal rim narrows
in cases of progressive glaucoma damage.

Circumlinear vessels

Figure 16.28 ONH with distinct disc margins, deep cup and a circumlinear vessel
[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

Circumlinear and cilioretinal vessels are diagrammed by a solid line that indicates the vessels origin, contour and
position on the ONH.

BARING OF BLOOD VESSELS

 Baring is a blood vessel change that is observed when the NRR erodes at the edge of a blood vessel, creating
a separation between the vessel and the neural tissue (Fig. 16.29).
 According to Vingrys (2000), blood vessels can appear bared by about 2 arterial widths and thereafter is it
considered abnormal.
 The significance of bared vessels may indicate progressive glaucomatous optic neuropathy, enlarged
cupping (Fig. 16.29, 16.30).

Bared vessel

Figure 16.29 ONH with bared vessel

[Photo courtesy of Bina Patel: New England College of Optometry (NECO)]

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-23

 Ocular Health Examination

UNDERMINED VESSELS (KINKING VESSELS)

 Undermined or kinked blood vessels occur when neural erosion in glaucoma produces different planes along
the vessel path. It is sometimes also referred to as “bayoneting”.
 Undermined vessels are found in very deep cups, which assume a “bean-pot” profile.
 The vessels are pushed significantly and their position is altered, usually by deepening and changes of cup depth.
 The vessels start at one point, disappear and then reappear within the cup at another point.
 These vessels are diagrammed with 2 solid lines in the position at which they are undermined as in the
diagram alongside (fig. 16.31).

Figure 16.31 Undermining of blood vessels

DOCUMENTING FUNDUS ABNORMALITIES

 The size and and location of lesions are based relative to the size of the ONH

e.g. The retinal scar lies at 1 o’clock, 2DD away from the ONH and ½ DD in size

Figure 16.32 Documentation of fundus abnormalities

BIBLIOGRAPHY
Jonas et al. Ophthalmoscopic evaluation of the Optic Nerve Head. Survey of Ophthalmology. 1999 43(4)
Vingrys AJ. The many faces of glaucomatous optic neuropathy. Clinical and experimental optometry. 2000 83(3): 145-160.
Alexander LJ. Primary care of the posterior segment. Appleton and Lange: Connecticut, 1994.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 16-24

 SLIT LAMP EXAMINATION
(BIOMICROSCOPY)

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Public Health Division, Sydney, Australia

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

• Purpose
• Instrumentation
• Methods of illumination
• Methods of observation
• Slit lamp assessment of anterior chamber depth
• Slit lamp biomicroscopy overview

PURPOSE

The slit lamp examination (SLE) is used for the binocular examination of the eye from the anterior to posterior
segment. More specifically, it is used for:
1. Anterior segment exam - tear film to anterior vitreous
2. Posterior segment exam with auxiliary lenses (78D or Hruby)
3. Intraocular pressure by Goldmann tonometry
4. Anterior chamber depth assessment (irido-cornea angle)
5. Contact lens fittings and assessments
6. Gonioscopy
7. Minor surgical procedures
8. Laser delivery system

INSTRUMENTATION

There are many different types of biomicroscopes with variable features. All biomicroscopes, however, are composed
of 2 basic parts that sit on a common pivoting base:

OBSERVATION SYSTEM (MICROSCOPE)

• Binocular eyepieces
• Magnification control

ILLUMINATION SYSTEM
• Adjustable light beam (variable height, width, angle)
• Filters (red-free, cobalt blue, diffuser)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-1

 Slit Lamp Examination (Biomicroscopy)

METHODS OF ILLUMINATION

DIFFUSE
A wide unfocused beam of light directed obliquely toward the eye (Fig. 17.1)

Figure 17.1 Diffuse Illumination

PROCEDURE
• 30-45° angle between observation & illumination systems
• Wide open slit beam
• Low to medium magnification
• With or without diffusing filter

PURPOSE
• Generally used to obtain an overall view of the eye and adnexa (lids, lashes, conjunctiva, sclera, cornea, iris)

OPTIC SECTION
A thin slit beam (minimum possible < 0.25 mm) that optically slices the tissues examined allowing the visualization of
tissue layers and depth. (Fig. 17.2)

Figure 17.2 Optic Section

PROCEDURE
• 30-45° angle between observation and illumination systems
• Thin slit beam (as thin as possible)
• Medium to high magnification

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-2

 Slit Lamp Examination (Biomicroscopy)

PURPOSE
• Assess the different layers and zones of the tissue examined
• Permits the assessment of the depth of anomalies or bodies within a tissue
• Generally used to evaluate the cornea & lens
• Used in the van Herick method to assess the depth of the anterior chamber (see below)

PARALLELEPIPED
A slit beam of 1-2 mm that illuminates a rectangular area of tissues
This optically sections a parallelepiped of the tissue observed providing a layered 3-dimensional view.(Fig. 17.3)

Figure 17.3 Parallelepiped

PROCEDURE
• 30-45° angle between observation and illumination systems
• 2-3 slit beam (slightly wider than an optic section)
• Medium to high magnification

PURPOSE
• Assess the different layers and zones of the tissue examined in 3-D
• Assess the depth & extent of abnormalities within a tissue (abrasions, scarring, FB)
• Allows the simultaneous visualization of the anterior, middle & posterior areas of tissues generally used for
the tear film, cornea & lens

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-3

 Slit Lamp Examination (Biomicroscopy)

CONICAL BEAM
Small spot or square of light produced by narrowing the vertical height of a parallelepiped

Figure 17.4 Conical Beam

PROCEDURE
• 40-50° angle between observation and illumination systems (Fig 17.4)
• 2-3 mm spot or 2-3 slit beam both in height & width
• Initial low magnification gradually increased to high magnification
• Room must be completely dark & examiner must be dark-adapted
• Beam is focused in the anterior chamber (localize cornea & lens and focus in between)
• Normal anterior chamber is optically empty (dark)
• Compare darkness of AC zones above and below light path to zone in the light path
• Direct the illumination source from both the nasal and temporal sides

PURPOSE
• Used to evaluate the clarity of the anterior chamber (Fig. 17.5)
• Assess debris in anterior chamber (usually cells & flare or blood)

METHODS OF OBSERVATION

DIRECT

Figure 17.6 Direct Illumination

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-4

 Slit Lamp Examination (Biomicroscopy)

PROCEDURE
• Observation and illumination systems are focused coincidentally
• The area under observation is thus directly illuminated by the incident light (Fig. 17.6)

PURPOSE
• Method most commonly used
• General examination purposes

INDIRECT OR PROXIMAL

Figure 17.7 Indirect Illumination Step 1 Figure 17.8 Indirect Illumination Step 2
PROCEDURE
• Observation and illumination systems are not focused coincidentally
• The incident light is on an area immediately adjacent to the object or area of interest (2 methods):
o Focus slit lamp on area to be examined and look adjacent to it (Fig. 17.7)
(area examined slightly adjacent to focuses area)
o Focus on area to be examined and then off-set slit beam (Fig. 17.8)
(better view is obtained because the area to be examined will be in clear focus)

PURPOSE
• Provides ‘softer’ illumination of structures and fine details
• Useful when a bright direct light source ‘bleaches out’ the area to be seen
• Used to view the iris, fine vascularization, pigment spots, corneal edema, etc.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-5

 Slit Lamp Examination (Biomicroscopy)

RETRO-ILLUMINATION

Figure 17.9 Diagram of difference between observation Figure 17.10 Diagram of difference between observation
and illumination sytems in direct retro-illumination and illumination sytems in indirect retro-illumination

PROCEDURE
• Object under observation is illuminated by light reflected from a deeper structure
• The desired area/object is viewed directly or indirectly using light shining from behind (Fig. 17.9 and 17.10)
• Any structure can be used to reflect the light including the retina
• The angle of illumination is generally between 30-45°
• For retinal retro-illumination, however, the angle of the illumination system is between 0°-5°

PURPOSE
• Provides ‘softer’ illumination of structures and fine details
• Useful when a bright direct light source ‘bleaches out’ the area to be seen
• Used to view the iris, fine vascularization, pigment spots, corneal edema, etc.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-6

 Slit Lamp Examination (Biomicroscopy)

SCLEROTIC SCATTER

Figure 17.11 Sclerotic Scatter Set Up Figure 17.12 Sclerotic scatter effect

PROCEDURE
• A bright parallelepiped focused on the limbus causes light transmission within the cornea
• In a normal cornea, light is internally reflected within the cornea
• A bright halo around the limbus is produced
• A normal cornea where the internally reflected light travels freely appears clear
• Corneal abnormalities will cause light scatter and appear gray or white

PURPOSE
• Especially useful to view subtle corneal changes (edema, scars, striae, foreign bodies, etc.) (Fig. 17.11 and 17.12)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-7

 Slit Lamp Examination (Biomicroscopy)

SPECULAR REFLECTION

Figure 17.13 Specular Reflection

PROCEDURE
• Parallelepiped beam (Figure 17.13)
• Initial low magnification
• Biomicroscope is moved to place observation system on the reflected light from the cornea
• A bright specular reflection will be seen
• Gradually increase magnification
• At this point the angle of incidence = the angle of reflection
• The tear film will appear on the anterior parallelepiped surface
• The endothelium will appear on the posterior parallelepiped surface

PURPOSE
• Used to observe irregularities, deposits, or excavations in a smooth surface
• Especially useful for corneal endothelium and tear film evaluation

FILTERED ILLUMINATION
PROCEDURE
• Use of various filters to enhance the assessment of certain structures and abnormalities e.g. cobalt blue, yellow
wratten, red-free, neutral density filters
• Often incorporated to biomicroscope, otherwise can be added

PURPOSE
• Cobalt blue: used with fluorescein dye to visualize corneal staining
• Yellow wratten: a barrier filter used with fluorescein to visualize corneal staining
• Red-free: makes blood vessels & rose bengal stain appear black to enhance contrast
• Neutral density: uniformly decrease illumination intensity

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-8

 Slit Lamp Examination (Biomicroscopy)

SLIT LAMP BIOMICROSCOPY OVERVIEW

ILLUMINATION METHOD
Table 17.1 lists the set up techniques for the most commonly used kinds of illumination.

Type→
Diffuse Illumination Optic Section Parallelepiped Conical section
Characteristic ↓
Angle between SL arms 30-45° 30-45° 30-45° 40-50°
Width of slit beam Maximal Minimal 1-2 mm 2-3mm
Height of slit beam Maximal Maximal Maximal 2-3mm
Filter None, diffuser, colored None None, Colored None
Light intensity Variable Maximal Variable Maximal
Magnification Low - Medium Medium-High Medium-High Medium-High

Table 17.1 Illumination Techniques

METHODS OF OBSERVATION
Table 17.2 details observation techniques for the slit lamp biomicrosope.

Type →
Direct Indirect Retro- Specular Dispersion
Characteristic Van Herick
Illumination Illumination Illumination Reflection Scleral
↓
Focus / Slit- Coincident or Coincident or
Coincident Coincident Coincident Coincident
lamp arm-lock not not
30-45° for
Angle between
30-45° 30-45° cornea; 0-5° 45-60° 30-45° 60°
SL arms
for lens-iris
Optic section Optic section Optic section Optic section
Type of beam or or or Parallelepiped or Optic Section
Parallelepiped Parallelepiped Parallelepiped Parallelepiped
Height of Slit Medium-
Variable Variable Variable Variable Variable
beam Maximal
None, All
Filter None None None None None
others
Intensity of light Variable Variable Variable Medium-High Maximal Medium- High
Magnification Variable Variable Medium-High Medium-High Low-High Low-High

Table 17.2 Observation Techniques

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-9

 Slit Lamp Examination (Biomicroscopy)

SLIT LAMP ASSESSMENT OF ANTERIOR CHAMBER DEPTH

VAN HERICK TECHNIQUE

Figure 17.14 Van Herick technique

Use low to medium magnification. 60° angle between arms of the slit lamp with the observation system perpendicular
to the eye. Focus an optic section of medium to maximum height exactly at the limbus (Temporal & Nasal). To be
sure, focus slit slightly on the cornea initially, and then move it outwards towards the limbus until it begins to widen
(indicates that it is bridging the corneo-scleral transition area). Move back inward to the thinnest last observable optic
section. Compare the depth of the anterior chamber indicated by the dark shadow (between the iris and cornea) to the
thickness of the cornea (indicated by the optic section). (Fig. 17.14)

Establish the ratio between the dark shadow (DAC) and the corneal thickness (CT):

Dac = Depth anterior chamber

CT = Depth of the cornea

Van Herick Grading System

Van Herick Grading System:

Grade DAC / CT
~0
0:
AC extremely narrow/closed
I: < 1/4
II: 1/4
III: 1/4 to 1/2
IV: > 1/2

Source: Van Herick W, Shaffer RN, Schwartz A. Estimation of width of angle of anterior chamber. Am J Ophthalmol 1969;68:626-9.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-10

 Slit Lamp Examination (Biomicroscopy)

SUPERIOR & INFERIOR ANGLE EVALUATION (SUPPLEMENT TO VAN HERICK TECHNIQUE)

Use low to medium magnification. 60° angle between arms of the slit lamp with the observation system perpendicular
to the eye. Focus a vertical optic section of maximum height at superior or inferior cornea and estimate the angle
between the beam on the iris and the beam on the cornea. Grade the angle in degrees: e.g. 10°, 20°…

CHANGES IN ILLUMINATION CHARACTERISTIC

The light beam on the iris surface is observed as an optic section is moved across the cornea. The relative
separation between the 2 light beams (cornea & iris) provides a gross estimation of the AC depth. The changes
occurring in the separation of the 2 beams provides a gross estimation of the iris configuration

SLIT LAMP ROUTINE ASSESSMENT

During a routine eye exam, the examiner generally adopts a systematic approach to perform a biomicroscopic
evaluation using various observation and illumination methods. The routine described here guides such an
examination ensuring that all aspects of the external eye are appropriately assessed. While the methodology points to
specific illumination and observation methods, the process is a dynamic one in which the examiner should freely
change illumination and/or observation methods to adapt and evaluate areas which vary from patient to patient and
inspect any finding. The overall routine should become a fluid continuous process over time.

1. Explain the purpose of the test and give proper instructions

2. Appropriately set up
o Wash hands
o Disinfect chin and forehead rests
o Position patient properly with chin & forehead firmly against rests
o Align markings on head rest with patient canthi
o Dim room illumination
o Prepare instrument, set up illumination
o Start with the right eye

3. Continuous measures throughout the assessment:

o Appropriately direct patient fixation
o Maintain focus throughout the examination to adequately examine tissue
o Evaluate the entire area
o Consider factors specific to the individual patient
o Maintain good lid control
o Use and alter magnification, illumination and observation methods as indicated
o Control the instrument smoothly and efficiently
o Ensure patient safety throughout the evaluation
o Recognize abnormality

4. Use efficient & logical sequence to appropriately examine all tissues of the anterior segment:

Lids / lashes (superior /inferior) → Tear film → Conjunctiva / sclera (temporal/nasal) →

Cornea → AC angle → iris → Lens → Anterior vitreous → AC clarity →
Superior tarsal conjunctiva (lid eversion)

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-11

 Slit Lamp Examination (Biomicroscopy)

Lids, Lashes, Tear film, Conjunctiva , Episclera, Sclera

- Low to medium magnification
- Diffuse (or wide parallelepiped) illumination
- Proceed:
o Scan inferior lid temporal to nasal
o Scan superior lid nasal to temporal
o Assess tear film
o Scan temporal aspects of the visible eye
o Scan nasal aspects of the visible eye
o Evert (gently pull forward) the inferior lid to assess palpebral conjunctiva
o Evert (within 2 attempts) and maintain (3sec.) the superior lid smoothly with good patient comfort
(note: in order to avoid disrupting the ocular structure and affect the rest of the assessment, this
procedure is usually kept for the end of the sequence)

- Identify and assess the:

o Lid structures
o Caruncle,
o Plica semilunaris
o Puncta
o Tarsal gland openings (superior & inferior)
o Bulbar conjunctiva, episclera and sclera

Cornea
- Start medium magnification; increase as needed to adequately examine the tissue
- Begin with gross evaluation using a wide parallelepiped beam
- Finish with an optic section scan
- Use specular reflection &/or scleral dispersion if indicated
- Identify and assess the:
o Epithelium/Bowman complex
o Stroma
o Endothelium/Bruch Complex
o Width and uniformity of cornea

Anterior Chamber Depth (ACD)

- Grade the angle using the Van Herick method (temporal, nasal)
- Assess the angle superiorly and inferiorly
- Scan the anterior chamber assessing depth and iris configuration

Iris
- Use medium magnification
- Scan the iris surface with diffuse illumination (wide parallelepiped)
- Identify and assess the:
o Iris collarette
o Pupillary ruff
o Pupillary zone
o Ciliary zone
o Pupil shape & symmetry

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-12

 Slit Lamp Examination (Biomicroscopy)

Lens / anterior vitreous

- Use medium magnification
- Examine the lens and anterior vitreous using both an optic section & parallelepiped
- Examine the lens with retro-illumination (if pupil dilation permits)
- Direct the illumination source from both the nasal and temporal sides
- Identify and assess the:
o Anterior & posterior capsule
o Epithelium
o Anterior & posterior cortex
o Nucleus
o Anterior & posterior 'y' sutures (if visible)
o Anterior vitreous

Anterior Chamber Clarity

- Use conical beam
- Scan the AC

5. Record assessment and findings appropriately (Fig. 17.15)

Biomicroscopy
NP X□ Lids/Lashes □ NP 3 x 3 mm papilloma
NP X□ Conjunctiva □ NP
X
NP X□ Tear film □ NP
X
clear X
□ Cornea □ Clear
X
NP, flat X□ Iris □ NP, flat
X
clear / quiet X
□ Anterior Chamber □ clear/quiet
X
clear□
X Lens □ cclear
□ NS
X □ SN
□ CC □ CC
□ PSC □ PSC

4 3 IC Angle (VH) 3 4

Figure 17.15 Example of biomicroscopy examination record

BIBLIOGRAPHY
Ledford JK and Sanders V. The slit lamp primer. NJ, USA: SLACK Incorporated, 2006.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 17-13

 TONOMETRY AND
PACHYMETRY

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Public Health Division, Sydney, Australia

PEER REVIEWER (S)

Benoit Tousignant: University of Montreal, Canada

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Tonometry:
o Theoretical principles of tonometry
o Commonly used techniques
o Interpretation of results
 Pachymetry:
o Purpose
o Theory and Instrumentation
o Procedure
o Recording

Tonometry is a clinical technique that provides a measurement of the internal pressure of the eye (also known as
intraocular pressure, IOP, ocular tension). Technically speaking, the value for a given IOP represents the combined
resistance of the different layers of the eye and the intraocular pressure itself.

THEORETICAL PRINCIPLES OF TONOMETRY

Tonometry can be measured following 3 different principles: applanation, indentation and manometry. Most current
clinical settings use applanation tonometry.

APPLANATION
Applanation tonometry is the most commonly used technique to measure IOP. Examples of applanation tonometers
include Goldmann, Perkins and non-contact (NCT) tonometers.

The theory of applanation tonometry is based on a physics formula called the Imbert-Fick formula. The formula states:

IOP = force / area

In other words, the IOP is related to both the force applied as well as the size of the area of the eye on which this force
is applied. IOP can be therefore be measured by keeping one variable constant and by changing the other.

Goldmann tonometry is a method by which a constant area of the cornea is applanated and the force required to
flatten the cornea to a plano (flat) surface is measured (Fig. 18.1). The IOP is directly related to the force measured.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-1

 Tonometry and Pachymetry

Figure 18.1 Applanation (flattening) of the cornea used in Goldmann tonometry

Maklokov tonometry is a method of applanation that applies a constant force to the cornea and the area applanated is
measured. This technique is not commonly used in clinical settings.

INDENTATION
In indentation tonometry, a constant force is placed on the cornea until the cornea is pushed posteriorly (Fig. 18.2). An
example of this technique is Schiotz tonometry, where a calibrated weight is dropped on the corneal apex. The depth
of resultant corneal indentation is measured and converted to an IOP value.
This technique has many limitations, which is why clinical standards now favour Goldmann or Perkins tonometry
over Schiotz tonometry; it is more invasive than applanation tonometry, it is affected by corneal rigidity (which varies
person to person) and repeated measurements may be misleading (due to aqueous humour being evacuated
at each reading).

Figure 18.2 Indentation of the cornea used in Shiotz tonometry

MANOMETRY
Manometry is the most direct and accurate method to measure intraocular pressure (IOP). However, it is not routinely
used in practice due to the invasive nature of the procedure – it is mainly used for the calibration of indirect
measurement devices. In order to measure manometry, a needle must be inserted into the eye and connected to a
column of mercury, where a direct reading of IOP is taken.

COMMON TECHNIQUES

GOLDMANN APPLANATION TONOMETRY

Goldmann applanation tonometry (GM or GAT) uses a tip or probe that contains an internal prism doubling system.
When the tip touches the cornea, an image of a circle is divided in two by the internal prism doubling system,
producing an image of two half circles called mires. The mires are visible by looking through the other end of the probe
(using a slit lamp). The clinician will bring the probe to touch the cornea and using a graduated rotating drum, force will
be gently and gradually applied until a small area (standardized to a constant 3.06mm) is flattened. This endpoint is
detected by observing the position of the mires – they must be centered and aligned horizontally so that their inner
edges touch. At this point, the IOP value can be read on the drum. Goldmann applanation tonometry is considered the
“Gold Standard” based on its accuracy and repeatability of results. A hand-held version called the Perkins tonometer is
available and will be discussed below.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-2

 Tonometry and Pachymetry

PROCEDURE
1. Instruct the patient about the procedure
2. Ensure the patient is seated comfortably at the slit lamp
3. Disinfect the tonometer tip * (Fig. 18.3)

Figure 18.3 Tonometer probe

4. Place the tip in its holder

5. Align the 180 mark on the tip of the probe with the horizontal line on the holder (for patients with less
than 3 dioptres of astigmatism)
6. if the patient has greater than 3 dioptres of astigmatism align the red line of the Goldmann with the
patient’s axis
7. Apply topical anesthetic to the cornea
8. Instill fluorescein**
9. Switch to the cobalt blue filter
10. Adjust the illumination to maximum brightness
11. Check for pre-tonometrystaining
12. Pull the slit lamp all the way back before taking the measurement
13. Set the Illumination arm approximately 60 temporal
14. Use maximum beam width
15. Set tonometer drum at 10 mmHg (marked “1” on the drum)
16. Use a magnification  10x
17. Place the tip of the probe in ‘straight ahead’ applanation position (it usually clicks into position)
18. Direct patient’s fixation straight ahead (this is absolutely important to minimize the chances of
corneal abrasions)
19. Start with the right eye
20. Bring the probe toward eye while observing from outside the slit lamp, until tip is 2-3 mm from corneal apex
(alternatively, gently place the probe on the cornea – the limbus will glow (limbal glow) when touch occurs)
21. Move to view through oculars
22. Slowly move the slit lamp forward with the joystick until tip comes in contact with the cornea - green mires
will be visible (the mires will already be visible if the probe was on the cornea already)
23. Place mires centrally by making slight slit-lamp adjustments (move towards the bigger mire) Fig 18.4a below.

Figure 18.4 (a) Move Slit lamp up (b) Move slit lamp right (c) Move slit lamp up and left

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-3

 Tonometry and Pachymetry

24. Adjust pressure reading on tonometer drum

25. Insides of the mires (semicircles) should touch (Fig. 18.5)

Figure 18.5 Correct internal alignment

26. Remove probe from cornea
27. Read IOP value on the drum (each line is worth 2mmHg)
28. Reset the drum to 10mmHg and repeat steps 19 – 26 for the left eye
29. Check for post-applanation corneal staining

* Use 1:100 bleach: water solution or 3% peroxide solution for 10 minutes – longer exposure can cause damage to the probe. Be
sure to rinse with saline prior to performing tonometry. Alcohol swabbing does not provide sufficient disinfection and is not
recommended for tonometer tips. Disposable tonometer tips are available (Fig. 18.6).
**Combination drop which contains both anesthetic and fluorescein (e.g. Fluress or Fluoracaine) are also available for tonometry.
However, Fluorescein in solution tends to harbor Pseudomonas aeruginosa a very pathogenic organism that can rapidly ulcerate
and perforate the cornea. Where hygiene is a concern, its use is not recommended.

TIPS
Sources of error
Too much fluorescein causes wide mires which results in a falsely high measurement. If this occurs, wipe tonometer
tip with a tissue, instruct the patient to wipe or blot their eyes with a tissue and repeat the procedure (Figure 18.6a).
Too little fluorescein causes thin mires which results in a falsely low measurement. If this occurs, instill more
fluorescein and repeat the procedure (Figure 18.6b)
Excessive pressure on the eye distorts the mires. Turning the reading drum will not cause any change in the
appearance of the mires. (Figure 18.6c)

Figure 18.6a Figure 18.6b Figure 18.6c

Insufficient pressure on the eye causes the mires to “jump” in and out of view – ‘pulsating mires’. If this occurs, simply
move the SL forward to increase pressure. (Figure 18.7)

Figure 18.7 Insufficient pressure on the eye on indenting the probe

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-4

 Tonometry and Pachymetry

An ocular pulse that is transmitted from systemic pressure changes may be observed when performing tonometry.
Should a patient have a strong ocular pulse it may be difficult to record an endpoint measurement because the mires
will pulsate. In this circumstance, align the image so that the gap between the mires that is created during the systole
and diastole is equal on both sides of the mires inner edge.
If the patient has a droopy lid or a tendency to blink, it may be necessary to hold the eye open (Fig. 18.9). In such a
case, tonometry is performed using one hand to alternatively adjust the slit-lamp and turn the measuring dial. This
requires a certain amount of skill and dexterity to perform.
If the cornea is scarred or edematous, Goldmann tonometry is difficult because the mires become distorted and
therefore the measurement is less accurate.

PERKINS TONOMETER
The Perkins tonometer uses the same type of probe as the Goldmann applanation method (Fig. 18.10). The
advantage of this method is that it can performed in any position (seated, reclined, or supine).

PROCEDURE
 The patient is prepared as described with the Goldmann procedure above
 By convention, the right eye is examined first
 The instrument is held in the examiner’s right hand when measuring OD; left hand for OS
 The instrument is turned on by turning silver wheel with the thumb
 The tonometer drum is set at 10 mmHg
 The patient is instructed to rest his head comfortably against headrest
 The Perkins is placed with forehead rest or the examiner’s free hand on the patient’s forehead
 The patient’s superior lid is gently held open with the examiner’s free hand
 The back of instrument hand is rested on the patient’s cheek for stability
 The tip of the probe is brought towards cornea and the limbal glow is observed
 The mires are viewed through the magnifying lens
 The procedure continues as with the Goldmann method to make proper adjustment and reading.

TIPS
A correct adjustment of the forehead rest helps to place the probe perpendicular to the cornea. The probe face must
be perpendicular to the cornea to obtain a proper tonometry reading. It is adjusted to a longer position for deeply-set
eyes and shorter for normally set or protruding eyes. To obtain a reading, it is not necessary for the tonometer to be in
a vertical position. Placing the instrument obliquely to the patient’s face makes it more comfortable for both the patient
and the examiner. The position necessary for viewing the mires is assumed before placing the probe on the cornea
because it is difficult to maintain a central placement of the tip when the examiner is moving.
If the examiner places his hand on the patient’s forehead instead of the forehead rest, he can use his thumb or index
finger as a lever for the instrument to increase stability.
If the cornea is scarred or edematous, tonometry with the Perkins is difficult because the mires become distorted and
therefore the measurement is less accurate.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-5

 Tonometry and Pachymetry

TONOPEN
The tonopen uses both applanation and indentation principles. The instrument is a portable, pen-shaped hand-held
device that uses technology based on the Mackay-Marg tonometer, an instrument no longer used. A foot-plate at the
end of the Tonopen contains a protruding plunger device with microchip technology. Inside the plunger is an electrical
transducer that senses position. The instrument is tapped against an anaesthetized corneal surface and the plunger is
forced back into the foot-plate. When the plunger is in the same plane as the foot-plate, the cornea is flattened and the
IOP measurement is recorded. Several readings are taken and averaged. A digital display indicates the IOP
measurement and the reliability of the results as a percentage. The instrument requires calibration each day prior
to its use.

PROCEDURE
 Calibration of the instrument is achieved by following the simple instructions provided on the digital display
 The sterile latex disposable cover is placed over end of instrument
 The eyes are anesthetized
 The right eye is tested first
 The patient’s fixation is directed straight ahead
 The reading button is pressed and the examiner listens for the beep
 The beep signals that the instrument is ready to take the reading
 The instrument is held perpendicular to the corneal surface
 The corneal surface is gently tapped 3 - 5 times
 The instrument will beep each time it takes a reading
 The digital display is viewed for the IOP measurement
 A line will appear over one of the reliability percentages
 A reading indicating 5% or error margin is preferred
 If a reliable result is not obtained, the procedure is repeated

TIPS
 The Tonopen has a tendency to overestimate low IOP measurements and to underestimate high IOP
measurements. However, it is a reliable instrument and the results are repeatable.
 In cases where the cornea is scarred or edematous, the Tonopen can obtain an accurate reading because
the corneal surface needed to take a reading is very small.
 The Tonopen has the added advantage of being easy to use on children, uncooperative patients or patients
who are unable to be positioned behind a slit lamp or to remain stable long enough to perform Perkins or NCT.
 The Tonopen is contraindicated in patients with known allergies to latex

NON-CONTACT TONOMETRY
Non-contact tonometry (NCT) is a type of applanation tonometry which uses a puff of air to flatten a fixed area of the
cornea instead of a tip. The measurement is taken over a period of 2 - 8 milliseconds. A mirror system monitors a light
beam that is reflected off the cornea. When the fixed area of the cornea is flattened by the force created by the air puff,
the instrument records the measurement (Fig. 18.13). The NCT records a random sample of the IOP. Since the IOP
can vary from 3-4mmHg with the ocular pulse, an average of 3 consecutive readings is recommended.

Figure 18.8 Non-contact tonometer

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-6

 Tonometry and Pachymetry

Many different types of NCT are available and each has specific instructions to take a measurement, according to the
manufacturer’s recommendations.

Generally, most NCT instruments use the following elements and steps:
 A video monitoring system to view the image of the eye
 Some sort of visible mires in the viewer (reflections off the cornea)
 Mires must be focused and aligned
 A button on the joystick is pressed (or an automatic mechanism is triggered) and the instrument shoots
its puff of air
 The reading is visible in the viewer (can also be printed on some models)

TIPS TO USE NCT

 When applicable, the chin and headrest of the instrument must be disinfected
 Demonstration the small air puff onto the patient’s fingers
 By convention, the right eye is usually tested first
 If applicable, a safety lock usually allows the instrument to stop at a safe distance from the eye
 3 readings or more are taken and averaged (to account for ocular pulse)
 NCT readings are often imprecise and are best used as screening tools or if corneal contact is not possible.
Goldmann or Perkins tonometry should be performed whenever possible, and each time an NCT
measurement is abnormal or suspicious

SCHIOTZ TONOMETER (Fig.18.9)

The Schiotz tonometer is a portable hand-held device that uses the indentation principle. The patient is placed in a
supine position for the procedure. A constant known weight is applied to the cornea and the depth of the area
depressed is measured and converted to IOP by using a graph. The foot-plate of the instrument contains a plunger
that is connected to a lever. The lever is attached to a pointer that indicates the indentation depth on a millimeter
logarithmic scale. Readings are placed on a calibration scale from which the IOP is determined (Table 18.1). The
measurement is then corrected for error induced by corneal rigidity on a graph. The Schiotz developed in 1905, is the
traditional tonometry instrument. Though it may still be used in certain resource-limited settings, the procedure is
highly unreliable and its use has virtually been discontinued with the advent of modern techniques such as the
Tonopen and Perkins.

PROCEDURE
 The instrument is disinfected and then assembled
 A 5.5g weight is placed on first
 Calibration of the instrument is achieved by placing it on the metal block provided
 The pointer should indicate 0mm on the scale
 The patient is placed in a supine position
 The patient’s eyes are anesthetized
 Begin with the OD
 The patient’s fixation is directed at the patient’s thumb which is placed above the opposite eye
 The instrument is held perpendicular to the cornea
 The instrument is placed gently on the eye

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-7

 Tonometry and Pachymetry

Figure 18.9 Schiotz tonometer

 The sleeve is allowed to lower to the measurement position

 The examiner reads the scale read by shutting one eye to eliminate parallax
 The reading is converted to an IOP using the calibration scale (Table 18.1)
 The measurement is adjusted using the analysis graph for corneal rigidity.

Table 18.1 Schiotz calibration scale

Scale Plunger Load / IOP mmHg

Reading
5.5 gm 7.5 10.0 16.0 gm
gm gm
0.0 41.5 59.1 81.7 127.5
0.5 37.8 54.2 75.1 117.9
1.0 34.5 49.8 69.3 109.3
1.5 31.6 45.8 64.0 101.4
2.0 29.0 42.1 59.1 94.3
2.5 26.6 38.8 54.7 88.0
3.0 24.4 35.8 50.6 81.8
3.5 22.4 33.0 46.9 76.2
4.0 20.6 30.4 43.4 66.2
4.5 18.9 28.0 40.2 61.8
5.0 17.3 25.8 37.2 57.6
5.5 15.9 23.8 34.4 53.6
6.0 14.6 21.9 31.8 49.9
6.5 13. 4 20.1 29.4 46.5
7.0 12.2 18.5 27.2 43.2
7.5 11.2 17.0 25.1 40.2
8.0 9.2 15.6 23.1 38.1
8.5 10.4 14.3 21.3 34.6
9.0 8.5 13.1 19.6 32.0
9.5 7.8 12.0 18.0 29.6
June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-8
 Tonometry and Pachymetry

10.0 7.1 10.9 16.5 27.4

10.5 6.5 10.0 15.1 25.3
11.0 5.9 9.0 13.8 23.3
11.5 5.3 8.3 12.6 21.4
12.0 4.9 7.5 11.5 19.7
12.5 4.4 6.8 10.5 18.1
13.0 4.0 6.2 9.5 16.5
13.5 5.6 8.6 15.1
14.0 5.0 7.8 13.7
14.5 4.5 7.1 12.6
15.0 4.0 6.4 11.4
15.5 5.8 10.4
16.0 5.2 9.4
16.5 4.7 8.5
17.0 4.2 7.7
17.5 6.9
18.0 6.2
18.5 5.6
19.0 4.9
19.5 4.5
20.0

TIPS
For high IOP measurements, it is necessary to use more weight to perform Schiotz because there is more resistance
to indentation. The additional weight is needed to indent the cornea and obtain an accurate reading. The
disadvantages of the Schiotz include: high risk of corneal abrasion, supine position of patient, influence of technique
on results, assembly and disassembly of instrument, aqueous displacement affecting repeat readings, and patient
apprehension to procedure. Since there are more reliable hand-held, portable instruments, this method is
recommended last.

FINGER TENSIONS (DIGITAL IOP)

Finger tension IOP is a crude method to grossly assess IOP used in situations where no other more precise method is
available or possible (e.g. Non-cooperative patients). One can only approximate whether the eye is soft, normal or
hard and compare both eyes for a notable difference.

RECORDING
Adequate tonometry recordings must include the following:
 The IOP value for each eye
 Type of anesthetic and instrument used
 The time that tonometry was performed.
 Repeated measurements and their time (if performed)
 Patient position (if pertinent)

These examples represent the accepted methods of recording results (Fig. 18.10).

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-9

 Tonometry and Pachymetry

15mmHg
T OD / / = 15 mmH
TGM @ 16:30
g 16mmHg
GM OS / / = 15 mmH
g Pt. told not to rub eyes for 30 minutes

PK 1 Proparacaine @ 16:30
gtts Figure 18.10 example record forms for tonometry
NCT Patient informed not to rub eyes for 30 minutes

A mention may be made to indicate that the patient has been told explicitly not to rub the eyes for the period the
cornea is anaesthetized (30 minutes).
If IOP recording is done using the two values on top of one another, the first measurement (above) is understood to be
the right eye.

INTERPRETATION OF RESULTS

“NORMAL” IOP
The mean IOP in the normal population is 16mmHg +/- 2.5mmHg (Fig. 18.11). An IOP is considered elevated when it
is 2 standard deviations greater than the mean. Therefore, an IOP greater than 21mmHg, which is statistically out of
the usual range, should be considered clinically suspicious. Glaucoma is a group of conditions characterized by optic
nerve damage. An elevated IOP (greater than 21mmHg) is a risk factor to develop a type of glaucoma called primary
open-angle glaucoma (POAG). Elevated IOP is not sufficient to diagnose POAG and an in-depth examination of the
optic nerve’s structure and function are necessary. An IOP greater than 21mmHg can be associated to a normal optic
nerve function and structure; this is termed Ocular Hypertension (OHT). Most patients with OHT (90%) do not
develop POAG.
A very high IOP (over 30mmHg) may be indicative of other types of glaucoma (secondary glaucoma, acute glaucoma,
phacolytic glaucoma, etc.), of complications due to eye surgery, of trauma or of anterior segment abnormalities. These
conditions usually have other associated clinical findings (redness and inflammation, corneal or anterior chamber
abnormalities, etc.) and specific case history elements (recent trauma, surgery, congenital defects, etc.)

Figure 18.11 Graph of the mean IOP

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-10

 Tonometry and Pachymetry

FACTORS INFLUENCING IOP

PHYSICAL FACTORS
Pressure on the Globe
 Applying pressure on the globe tends to elevate the IOP. This is important because during the procedure it
may become necessary to control the patient’s lids. Proper care should be taken to hold the lids against the
orbital rim to avoid pressing on the globe. If the clinician presses on the globe while taking a measurement,
the IOP will be artificially elevated.
 Patient blinking also results in an increase in IOP. Forceful blinking or blepharospasm can significantly elevate
the IOP due to lid muscle compression on the globe. It is therefore necessary to instruct patients to blink
gently to avoid an artificially elevated measurement.

Trauma/Inflammation
 Trauma or inflammation of the eye can either decrease or increase the IOP.
 If trauma affects the ciliary body, aqueous production may be reduced which would decrease the IOP while
if the trauma affects the anterior chamber angle structures, aqueous outflow may be reduced which would
increase the IOP.
 If a patient has an intraocular inflammation such as uveitis, the ciliary body may become inflamed and
decrease aqueous production therefore decreasing IOP. This is usually observed in the initial stages of the
inflammatory response. In the later stages, inflammatory debris tends to clog up the anterior chamber angle
and the aqueous outflow may be reduced – this causes an increase in IOP.

Medications
 Certain medications may elevate or reduce IOP
o Long-term use of corticosteroids (especially topical and oral) has proven to induce increased IOP.
o Certain blood pressure medications such as Beta-blockers when taken orally can reduce IOP.
o The use of substances such as marijuana and alcohol temporarily reduce the IOP.

PHYSIOLOGICAL FACTORS
Diurnal Variation
 The IOP tends to vary throughout the day being generally highest during the morning and lowest in the
evening. The average diurnal variation is 4mmHg. Persons with glaucoma tend to have a greater diurnal
variation. Diurnal variation exceeding 8mmHg is a risk factor for POAG. To measure diurnal variation in IOP
several measurements may be taken at various times of the day in order to make a definitive assessment.

Vascular Integrity
 If there is poor circulation to the ciliary body, then aqueous production is reduced and IOP is decreased.
This may occur in persons with cardiovascular conditions, including carotid occlusive disease. When there
is carotid artery stenosis there is poor perfusion to the eye including the ciliary body and optic nerve. This
is one of the reasons a patient with a low or “normal” IOP may still develop optic nerve damage in certain
types of glaucoma.
 Impaired venous drainage in the head-neck region can result in a decrease of aqueous outflow and
subsequently an increase in IOP up to 4-5mmHg. This can be brought on by a tight collar or when the
patient holds their breath during tonometry.

Patient Position for Measurement

 When the patient is in a supine position or if the head is below the heart, IOP is increased. The IOP is
measured to be 2-3mmHg higher lying down than when the patient is sitting upright. The increase in IOP
can be attributed to decreased aqueous outflow due to raised episcleral venous pressure.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-11

 Tonometry and Pachymetry

PACHYMETRY

PURPOSE
Pachymetry (also spelt pachometry) is the measurement of the central corneal thickness, a parameter which has
relevance in many clinical situations such as the pre-operative assessment of refractive surgery patients, the diagnosis
of corneal conditions, the fitting of contact lenses, and the accurate assessment of intra-ocular pressure. The specific
clinical use of pachymetry is elaborated under each topic. This chapter presents the theory behind the procedure and
its relevance to tonometry.
Central corneal thickness is a known risk factor for glaucoma: thinner corneas (less than mean of 555 microns) tend to
be associated with primary open-angle glaucoma. In addition, the thickness of the cornea affects the tonometric
reading since the latter is often based on the applanation of the cornea which uses the Imbert-Fick’s Law (IOP = force
/ applanated area). As a result, applanation tonometry on thicker corneas (higher force needed to applanate the fixed
area) tends to be over-estimated, while applanation tonometry on thinner corneas tends to underestimate the intra-
ocular pressure. An adjustment of the tonometric reading is therefore necessary in order to obtain an accurate
pressure (Table 18.2).

Table 18.2 Correction values according to corneal thickness of 545m

Source: (Bell, 2011)

Corneal thickness
Correction value
(m)
405 7
425 6
445 5
465 4
485 3
505 2
525 1
545 0
565 -1
585 -2
605 -3
525 -4
645 -5
665 -6
685 -7
705 -8

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-12

 Tonometry and Pachymetry

THEORY AND INSTRUMENTATION

A pachymeter is a device that can be used to measure the apparent thickness of the cornea. Several techniques,
based on optical or ultrasonic principles, are available to reliably and reproducibly measure corneal thickness.
Earlier models were based on optical principles essentially and used calibrated doubling devices mounted on slit
lamps to align the anterior surface and posterior surfaces of the cornea (Fig. 18.20a, 18.20b). In the Haig-Strait
pachymeter, for example, doubling is produced by two plano glass plates. The glass plates are placed one above the
other in front of one of the objective lenses of the biomicroscope. Both plates are perpendicular to the optical axis of
the microscope. The lower plate is fixed, but the upper plate can be rotated around a vertical axis. As the upper plate
is rotated the half image seen through this plate is displaced laterally with respect to the half image viewed through the
bottom plate. A scale connected to the moveable plate permits the amount of relative image displacement to be
determined. The slit lamp microscope is positioned at about a 40° angle with respect to the illumination system. The
illumination system is adjusted so that a very thin beam of light is directed perpendicular to the cornea. Ordinarily the
illuminated portion of the cornea observed in this manner appears like a cross-section of the cornea (called an optic
section) (Fig. 18.12a). However, when viewed through the pachymeter, the optic section will appear doubled as
illustrated below (Fig 18.12b). To measure the apparent corneal thickness, the amount of doubling is first altered to
obtain perfect alignment of the two half views (Fig. 18.13). Then in a manner very similar to the doubling procedure
used in keratometry, the amount of doubling is varied until the epithelial side of one image is aligned with the
endothelial side of the other image. The amount of doubling required provides an indication of the apparent corneal
thickness and the true corneal thickness can then be calculated. The average corneal thickness measured with this
technique is 0.52 mm (true thickness), (Bourne and Alsbirk, 2006).

Figure 18.12. (a) Optical Pachymeter (b) Pachymeter attached to the slit-lamp

Figure 18.13 Doubling is altered to create perfect alignment of the two half views

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-13

 Tonometry and Pachymetry

Modern design incorporates ultrasound technology for measurement of the thickness. In short, ultrasound technology
uses differential time taken for sound waves (echos) which are off the anterior and posterior corneal surfaces to
calculate the corneal thickness. An ultrasound unit typically consists of a transmitter, a transducer, a receiver and a
display unit. The transmitter produces a short electrical pulse that is sent to the transducer (a piezo-electric element)
which produces the ultrasound pulse. The returning echo then deforms the element which produces and electrical
signal which is sent to the receiver, a radio-like device which amplifies the sound frequencies. The display unit allows
the visualization, storage, and printing of the recorded signal.
Several instruments are available for this purpose, but all essentially consist of placing a probe (somewhat similar to a
Goldman or Tonopen) on an anesthetized cornea.

PROCEDURE
 Ensure calibration of the instrument as per respective manual of instrument used
 Disinfect the tip
 The eyes are anesthetized
 The right eye is tested first
 The patient’s fixation is directed to fixate straight ahead – a target helps
 The instrument is held perpendicular to the corneal surface
 The probe is placed gently on the central cornea until a measurement is indicated (usually by a beep)
and displayed
 Most instruments will take several readings, otherwise take several readings and average them
 The digital display is viewed for the measurements
 If a reliable result is not obtained, the procedure is repeated
 Record the central corneal thickness

Recording
CCT: OD: 620µm OS: 625 µm

IOP correction values: - 4 mmHG

REFERENCES:
BELL, J. 2011. Primary Open-Angle Glaucoma [Online]. Available: http://emedicine.medscape.com/article/1206147-workup
[Accessed 27 July 2011].
BOURNE, R. & ALSBIRK, R. 2006. Anterior chamber depth measurement by optical pachymetry: systematic difference using the
Haag-Streit attachments. British Journal of Ophthalmology, 90, 142-145.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 18-14

 MANAGEMENT PLAN

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Public Health Division, Sydney, Australia

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 SOAP format of record keeping

INTRODUCTION

Clinical decision making requires a practitioner’s ability for “clinical judgment, inference and diagnostic
reasoning”. All of these attributes stem most importantly, from close attention to patient reports and/or the case
history. This is an aspect of the optometric assessment that is said to continue throughout the assessment and is
not limited exclusively to the time dedicated to eliciting information for the case history. The second most
important aspect of the assessment is the practitioner’s overall knowledge of all the facets of an optometric
examination. These include knowledge of ophthalmic dispensing, occupational optometry, binocular vision, low
vision, pharmacology and investigative techniques. By drawing on the information gathered, the practitioner is
able to identify findings that account for patient symptoms. The practitioner is able to analyze these findings
holistically and make decisions regarding a plan of action for the clinical and therapeutic management of the
problems identified.

SOAP FORMAT OF RECORD KEEPING

The SOAP format is a formal system of record keeping that is used in the health care community and is not
limited to the practice of optometry. It is adaptable to the wide scope of the optometric profession being easily
usable also in sub-specialty areas of optometry such as contact lenses, low vision, sport vision.
The SOAP also facilitates the storage, retrieval & transfer of clinical information both inter- and intra-
professionally. This method allows for simple, complete and clear documentation of information in the patient’s
records. Patient charts can be read easily and descriptive information can be obtained easily. Furthermore, it
facilitates the computerization of clinical information, if available.
The SOAP format aids and displays the deductive clinical reasoning behind patient management and decision
making process. The logic behind the diagnosis, treatment and management of clinical conditions is outlined
explicitly for others to easily understand. When mastered, the SOAP form of record keeping adds a new
dimension to the clinician’s knowledge about primary care and increases the quality of services.

SOAP IS THE ACRONYM WHICH STANDS FOR

Comprehensive case history (information is obtained from

S = Subjective
the patient by the examiner)
Database of test results, clinical observations & findings
O = Objective
(information gathered by the examiner)
June 2012, Version 1-1 Clinical Optometric Procedures 1, 19-1
 Management Plan

Diagnosis
A = Assessment Differential diagnosis
Rule-outs (could be in plan too)
Treatment
Follow-up
P = Plan (Management) Monitoring
Consultation/Referral
Patient Education, or Advice, or Counselling

The subjective & objective information are collected throughout the examination. The assessment is completed
at the end of the subjective and objective findings. The assessment or diagnoses of all the pertinent and
significant findings are listed. Each entity listed requires a plan (management).

EXAMPLE OF AN ASSESSMENT AND PLAN

Prescription given to patients: (slight change from previous Rx)

OD-11.00 DS 6/6
1. Simple myopia OD + OS OS -12.00 DS 6/6
Patient education on change in Rx and to consider high index
and polycarbonate.
Patient education and information on risks of retinal
2. Retinal hole superior retina OD
detachment. Refer to ophthalmologist for further assessment.
Patient education on importance of an annual dilated eye
3. No diabetic retinopathy OD + OS examination (April 2009). Letter to be sent to primary care
physician on findings.

Typically the first assessment is always the refractive diagnosis. Diagnosis is entered using qualifying &
descriptive terms, not as data, for example, a diagnosis (Dx) is recorded as hyperopia, and the prescription of
+1.00DS. Assessments also include the Differential Diagnosis and Rule-outs in cases of questionable
diagnosis. At the end of the record, signature of the examiner and date the examination was completed
are required.

THE ASSESSMENTS OR DIAGNOSES ARE NOTED AND NUMBERED SEPARATELY

Assessments made on each exam are also enumerated on a major problem list placed at the beginning of the
patient’s medical record. This will also include the Patient’s systemic assessment made by other physicians.
Each assessment is noted with the same assigned number to allow for a rapid overview of the patient’s clinical
history. The Plan is not indicated here. The major problem list only applies to problems pertaining to the
primary eye care exam. As such problems related to another specific area of practice, e.g. contact lenses or
low vision, would be reflected on other similar pertinent lists, e.g. contact lens overview or history list.
The Plan represents the response given to each assessment. Plans include management issues regarding
treatment, follow-up, consultation, referral, education & advice. Plans are numbered to correspond to each
assessment. The Plan includes 3 specific points: Diagnostic Measures (Dm), Treatment (Tx) and Patient
Education (Pt.edu).
 Dm: Diagnostic measures (Dm) are future actions needed to acquire additional diagnostic information or to
secure the diagnosis. Dm are not always necessary.
 Tx: Treatment (Tx) includes therapeutic measures taken to address the diagnosis. Tx may include actions such
as follow-ups, consultation and refer
 Pt. Edu: Patient education (Pt. Edu) includes the information, advice & recommendations given to patients.

June 2012, Version 1-1 Clinical Optometric Procedures 1, 19-2

 Management Plan

EXAMPLE OF SOAP FORMAT APPLICATION

The following is an example of the SOAP format applied to a clinical case:

A 50 year old male working in a car manufacturing plant presents with a complaint
of poor vision when trying to assemble motor parts and when reading car part
specifications. He also presents with a history of an occupational injury to his
Subjective: left eye.
This aspect of the SOAP may include more information elicited from the patient during
the case history.
Visual acuities:
Reduced uncorrected VA of the right eye at distance and near, with the near visual
Objective: impairment being more debilitating than distance.
Refraction reveals:
Simple hyperopic astigmatism in the right eye and uncorrectable visual impairment
in the left eye
A1: Hyperopia/presbyopia OD

P1: Tx: New Rx given – indicate the prescription in each eye with visual acuity
Ed: 1st Bifocal, options discussed, FT bifocal advised.
Polycarbonate lenses recommended for safety.
Assessment / Plan:

A2: Traumatic Cataract OS, VA = LP

P2: Dm: Return to clinic (RTC) for Laser Interferometry and pre-surgical A-scan
Tx: Refer to ophthalmologist PRN as needed for surgical consult
Ed: Nature of cataracts, surgery options & prognosis

June 2012, Version 1-1 Clinical Optometric Procedures 1, 19-3

 PHOROPTER REFRACTION

AUTHOR

Patricia Hrynchak : School of Optometry and Vision Science, University of Waterloo

PEER REVIEWER

Jean-Charles Allary : Chiswick, London

INTRODUCTION TO THE PHOROPTER

According to the Dictionary of Visual Science “a phoropter is an instrument for determining the refractive status of the
eyes, phorias, vergences, amplitude of accommodation, etc., consisting of essentially a housing containing rotating
disks with convex and concave spherical and cylindrical lenses, pinhole disks, occluders, and sometimes colour filters
and prisms. Attached to the front of the housing are crossed cylinder lenses, rotary prisms, and Maddox grooves
1
[rods].”

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-1

 Phoropter Refraction

INTRODUCTION TO THE PHOROPTER (CONTD)

Figure 21:Phoropter, front view. Reproduced with permission from Reichert Ophthalmic Instruments .

Instrument Components:

1. Rotation adjustment knob 14. Cross cylinder unit

2. Mounting bracket 15. Cylinder power case
3. Tilt clamp knob 16. Cylinder axis reference scale
4. Forehead rest knob 17. Cylinder axis indicators
5. Split level 18. Cylinder axis scale
6. PD knob 19. Sphere dial in 0.25D steps
7. Near vergence lever 20. Sphere power scale
8. Auxillary lens scale 21. Sphere dial in large scale
9. Auxillary lens knob 22. Levelling knob
10. Corneal aligning device 23. PD scale
11. Rotary prism unit 24. Near reading rod holder
12. Cylinde axis knob 25. Near reading rod clamp screw
13. Cylinder power knob

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-2

 Phoropter Refraction

Figure 20-2: Phoropter, back view. Reproduced with permission from Reichert Ophthalmic Instruments .

Instrument Components (cont.):

26. Forehead rest 27. Spring clip

Figure 20-3: Attaching the Rotochart to the near reading rod holder. Reproduced with permission from Reichert Ophthalmic
Instruments.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-3

 Phoropter Refraction

COMPONENT ACTION
1. Rotation adjustment knob: Allows rotation of the phoropter about a vertical axis.

2. Mounting bracket: Mounts the phoropter to the phoropter arm on the instrument stand.

3. Tilt clamp knob: Sets the pantoscopic angle of the phoropter relative to the patient’s face.

4. Forehead rest knob: Moves the forehead rest (#26) on the back of the phoropter so that the vertex distance
can be adjusted.

5. Spirit level: Shows whether the phoropter is level, necessary for accurate cylinder axis determination. The
phoropter can be made level by adjusting the levelling knob # 22. This must be done when the phoropter is in
place in front of the patient.

6. PD knobs: Located on the right and left sides of the phoropter. Sets the binocular interpupillary distance of the
patient shown in the PD scale window #23.

7. Near vergence levers: These levers converge the instrument apertures and simultaneously decrease the PD
for near point testing. For a distance PD of 64 mm moving both levers from an extreme outward to an extreme
inward position converges the apertures for near testing at 40 cm and decreases the aperture separation by 4
mm. For PD settings greater than 64 mm the apertures are slightly underconverged and will require an
additional reduction of the PD by 1 mm or less. For PD settings that are less than 64 mm the instrument
apertures are slightly over converged; this is compensated for by a slight outward adjustment of the levers
from the fully converged position. Do not attempt to fully converge the instrument below a distance PD of 55
mm.

8. Auxiliary lens scale: There are 10 auxiliary lenses and two open apertures. Turning clockwise the lenses are:
0: open aperture
R: +1.50 retinoscopy lens
P: polarizing lens for binocular retraction techniques. Axis 135 in the right eye and axis 45 in the
left eye
WMV or
RMV: Vertical Maddox rod, red in the right eye and white in the left eye
WMH or
RMH: Horizontal Maddox rod, red in the right eye and white in the left eye
RL: red lens used for binocular vision tests
GL: green lens used for binocular vision tests
0: open aperture
+.12: plus 1/8 dioptre sphere lens, for refracting to eighth dioptre accuracy
PH: pin hole
6 UP or
10 IN: 6 prism dioptres base up in the right eye and 10 prismdioptres base in in the left eye. Used for
binocular vision testing
0.50: 0.50 fixed cross cylinder for near point addition determination
OC: occluder

9. Auxiliary lens knob: Changes the auxiliary lenses in the phoropter.

10. Corneal aligning device: Determines the vertex distance. When the pointers and black line are aligned with the
corneal apex (zero position) the vertex distance is 13.75 mm. Each of the hash marks represent a distance of
2 mm. If the cornea is seen nasally to the zero position the distance must be added to 13.75 to obtain the
vertex distance. The distance can be adjusted using the forehead rest knob #4.

11. Rotary prism unit: Used to introduce lateral or vertical prism in front of the main aperture. With the zero
positioned at 90° lateral prism can be introduced with the finger roll knob. With the zero positioned at 180°
(usually nasally) vertical prism can be introduced. The arrow indicates the base direction and amount of the
prism, e.g., with the zero positioned at 90° and the arrow pointing at the 6 on the nasal side the amount of
prism is 6pd base in.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-4

 Phoropter Refraction

COMPONENT ACTION (CONTD)

12. Cylinder axis knob: Changes the axis of the cylinder introduced over the aperture. Rotating the knob will rotate
the cylinder axis indicators #17 simultaneously.

13. Cylinder power knob: Allows the addition of cylinder lenses. Phoropters can be ordered with either minus or
plus cylinder powers, not both. Optometrists normally work with minus cylinder powers.

14. Cross cylinder unit: For use in the cross cylinder tests for astigmatism determination or verification. The
standard powers are 0.25 D. The red dots represent the axis of the minus cylinder and the white dots
represent the axis of the plus cylinder. There are click stops for the axis position and for the power position.
When in the power position the “P” is lined up with the cylinder axis in the phoropter. When in the axis position
the flipping knob is lined up with the cylinder axis in the phoropter.

15. Cylinder power scale: Shows the amount of the cylinder power introduced with the cylinder power knob #13.

16. Cylinder axis reference scale: Shows the cylinder axis in increments of 15°.

17. Cylinder axis indicators: Points to the cylinder axis in the aperture and the cylinder axis scale. Turning the
cylinder axis knob will rotate both indicators simultaneously.

18. Cylinder axis scale: Shows the cylinder axis in increments of 5°.

19. Sphere dial in 0.25D steps: Allows the addition of sphere powers over the aperture in increments of 0.25 D.
Rotating the dial down will introduce lenses in the plus power direction and rotating the dial up will introduce
lenses in the minus power direction.

20. Sphere power scale: Shows the sphere power introduced in the aperture. The black numbers are plus powers
and the red numbers are minus powers.

21. Sphere dial in large steps: Rotating the back knurled portion of the auxiliary lens dial will introduce sphere
powers in increments of 3 D in the aperture.

22. Levelling knob: Adjusts the level of the phoropter. Used in conjunction with the spirit level # 5.

23. PD scale window: Shows the distance and near binocular PD settings.

24. Near reading rod holder: Holds the reading rod vertically out of the way when not in use. The reading rod
should not be removed from the phoropter but put up out of the way when not in use.

25. Near reading rod clamp screw: Locks the reading rod in place.

26. Forehead rest: Adjusts the vertex distance.

27. Spring clip: Holds the white face shields in place. Attach the face shields by sliding them under the clip.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-5

 Phoropter Refraction

SUBJECTIVE REFRACTION USING THE PHOROPTER

Recommended Test: Subjective Manifest Refraction

Indications:

 Subjective refraction is done as part of all full oculo-visual assessments, unless precluded by patient inability to
provide reliable responses.
 It is done for the determination of best corrected visual acuity in partial oculo-visual assessments.
 It is done as part of partial oculo-visual assessments with complaints such as blurred vision, broken spectacles, lost
spectacles and unstable refraction.

Contraindications/Considerations:

 Young children and persons with developmental delays may not be able to cooperate with this testing as it does
require an ability to make judgments and communicate choices.

Target Presentation: The projected Snellen chart is used (make sure the projector is calibrated for the appropriate test
distance) or a digital visual acuity system.

Patient/Examiner Position: The patient should be seated comfortably in the examining chair. The phoropter should be
situated so that the patient can comfortably view through the centre of the lenses. It should also be level, and adjusted
for vertex distance and the patient's interpupillary distance. The examiner should sit off to the side of the patient so that
manipulation of both the phoropter and the projector is easy.

Illumination: If using a digital visual acuity system room illumination can remain full. If using a manual or automated
projector the projector illumination should be approximately 215 to 500 lux with all lights off and the meter directed
towards the projector. With the lights on, the background level should be approximately 13% of the projector level. The
overhead lights should be off at the chart end of the room and the rheostat adjusted to the halfway point for the lights
over the patient. The stand lamp should be off. There should be adequate illumination for the examiner to view the dials
on the phoropter and avoid scotopic refracting conditions. In a mirrored room turn the fluorescent lights off and dim the
pot lights midway between the full and half positions of illumination.

I MONOCULAR REFRACTION

Indications

 Absolute presbyopes.
 Strabismic patients with suppression (occlude the non-turning eye to test the turning eye).
 Patients who do not tolerate the blur during binocular refraction.

Contraindicatons/Considerations

 Hyperopic patients young enough to have active accommodation often give poor results with this procedure due to
habitual accommodative spasm, particularly if they have been habitually uncorrected or their habitual spectacle
prescription is too low in plus (as may be suggested by retinoscopy findings). In these patients a binocular refraction
procedure will usually be more successful, as binocularity tends to encourage accommodation to relax more readily.
 The same consideration may apply to any young patients with accommodative spasm, who may initially appear to be
emmetropes or low myopes (pseudomyopia). However, this is usually not a concern in more myopic patients and
patients who are established presbyopes.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-6

 Phoropter Refraction

Procedure

1) Begin with the net retinoscopysphero-cylinder before each eye.

2) Occlude the untested eye (e.g., left).

3) Determine the Best Sphere:

a) Show the chart from 6/15 to 6/4.5. Direct the patient's attention to the best acuity line of the right eye.
Identify the initial lens combination as "one". Add +0.25 D and identify this as "two". Ask the patient if 1
or 2 is CLEARER or if they are THE SAME. If the patient has reduced visual acuity a larger change may
be required (see the section on Trial Frame refraction).

b) If the acuity improves or remains the same with the additional plus, then continue adding plus sphere
lenses until the acuity first blurs. Stop at the most plus/least minus lens that does not blur the visual
acuity.

c) If the visual acuity blurs with the plus lens, then remove it and add a -0.25 D lens. If the visual acuity is
unchanged or decreased by the addition of a minus lens, then remove the lens. If visual acuity improves
with the lens, then add further minus lenses (in 0.25 D steps) only as long as the visual acuity improves.

If the resulting visual acuity is less than 6/9, and the patient has the potential to see 6/6 from the aided
visual acuity discard the cylinder from retinoscopy and replace it with the cylinder measured in the
habitual Rx if it is known, and recheck the acuity to see if it has improved. If the visual acuity is 6/9 or
better continue with the following procedure:

4) Check Test for Cylinder Axis:

a) Isolate the letter "O" on the 6/9 row of letters (alternatively, the whole row can be used; or, if available, a
row of Landolt C’s or a random dot pattern may also be effective targets). Move the Jackson Cross
Cylinder (JCC) in front of the phoropter aperture. Advise the patient that neither of the lens
combinations that will be shown will be completely clear. If no cylinder was found with retinoscopy go to
step 6.

b) Set the JCC so that the red minus cylinder axis and the white plus cylinder axis straddle the phoropter
cylinder axis. With most phoropters the JCC will click into place at this correct orientation. Have the
patient compare this initial lens position, “1", to its flipped counterpart, "2".

c) If the two lenses appear equally blurred to the patient, then move on to step 4d. If not, adjust the JCC
(and phoropter cylinder axis will follow) toward the minus cylinder axis (red) of the preferred lens position
(1 or 2). The amount of the axis change will depend upon the amount of the cylinder power. The higher
the power the smaller the change required. Enough of an axis change should be made so that the next
response will likely be in the opposite direction. For example a change of 20° may be appropriate for a
0.25 D cylinder power and a change of 5° may be appropriate for a 3.00 D cylinder power.

Repeat the comparison and if the response is in the opposite direction move the axis back by half the
amount changed the first time, i.e., split the difference. If the response was not in the opposite direction
make another sizable change of axis (always towards the red) until the response is in the opposite
direction. Continue with this bracketing method until the patient notices no difference between the two
lens positions.

d) If the two initial lens positions appear the same, confirm that the current axis is the correct one by
moving the JCC and phoropter axes off by an appropriate amount and having the patient compare “1”
and “2”. The patient should return you to the initial axis orientation if it was correct. Make sure that you
bracket the correct axis from both directions in this way.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-7

 Phoropter Refraction

5) Check Test for Cylinder Power. (Figure 20.4)

a) Orient the JCC so that either the minus axis or plus axis parallels the phoropter cylinder axis (the JCC
should click into place with most phoropters). Often there will be a “P” on the crossed cylinder indicating
the correct orientation. Have the patient compare the relative clarity of “1” to “2” as before.

b) If there is no difference between “1” and “2” then the correct power of cylinder is in place. To confirm this
remove -0.25 D cylinder and repeat the comparison. If the initial lens was correct the patient will call for
more cylinder by choosing the lens that has the red minus cylinder axis parallel to the phoropter axis. In
this case, increase the cylinder power to its original amount.

c) If there is a difference between “1” and “2” then adjust the cylinder power. Add minus cylinder (-0.25 D) if
the patient prefers the red minus cylinder axis parallel to the phoropter axis or remove 0.25 D cylinder if
the patient prefers the white plus cylinder axis parallel to the phoropter axis. Continue this process until a
difference between Lens 1 and 2 cannot be detected. If the power has been bracketed to less than a
0.25 D (at one position the patient chooses red then when increased 0.25 the patient chooses white)
leave it on the least minus cylinder position. If there is a significant change in the power a recheck of the
axis may be prudent.

Note: If the value goes down to zero and the patient still chooses the white, the cylinder axis was 90° off.
Change the axis by 90° and continue the power check.

a)

b)

Figure 20.4: Cylinder axis and power determination: a) Orientation of the cross cylinder for axis determination, b) Orientation of the
cross cylinder for power determination.

d) For each 0.50 D change in cylinder power, change the sphere power by 0.25 D in the opposite direction
(e.g., if you add -0.50 D of cylinder, then add +0.25 D of sphere before comparing the lens positions).

6) Power check test when no cylinder is found with retinoscopy.

a) This test checks for cylinder power at four different axes to rule out the presence of cylinder.

Add –0.25 D cylinder at axis 180 and do a power test to see if the cylinder is accepted. If the response is
the same or if the red is chosen the cylinder has been accepted. If the cylinder is accepted go on to do
the axis and the final power tests.

If the cylinder is not accepted repeat this procedure for axes 135, 90 and 45 looking for power in all of
these positions. If the cylinder is rejected at all four positions, the person has not subjectively accepted
any cylinder. If the cylinder is accepted at any of the positions go on to do cylinder axis tests and the
final power tests.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-8

 Phoropter Refraction

7) Repeat steps 1-6 for the other eye (OS).

8) Record the monocular acuities. If these acuities are unequal, then omit the remaining steps. You may want to
confirm that the most plus/least minus prescription is in place by performing a red/green test monocularly.

Acceptable Alternate Procedure: CHECK TEST FOR CYLINDER WHEN NONE IS FOUND WITH
RETINOSCOPY

1) If there has been no cylinder found with retinoscopy, then set the JCC so that it’s minus cylinder axis (red dots)
and the perpendicular plus cylinder axis (white dots) assume the 90 and 180 positions. There is no cylinder in
the phoropter. It does not matter which dot is at 90 and 180 . Refer to the current JCC orientation as "1". Flip
the JCC with the attached knurled knob to reverse the positions of the minus and plus axes. Refer to this latter
orientation as "2". Have the patient compare the relative clarity of "1" and "2". The patient is to choose the lens
that makes the letters the clearest or indicate if they look the same. Note the orientation of the red dot (minus
cylinder axis) of the chosen number. Rotate the JCC so that the red and white dots assume the 45 and 135
positions. Repeat the above comparison and note the orientation of the minus cylinder axis of the chosen lens.

If all the lenses seem equally clear, then there is no cylinder. If only one lens position was preferred then set the
axis at that position. If more than one was preferred then set the axis between the preferred settings (e.g., if
minus cylinder was called for at 180 and 45 , then set the phoropter cylinder axis to the approximate midpoint,
i.e., 25 ). Place -0.25 or -0.50 D cylinder power in the phoropter and proceed with the check test for cylinder axis
then the test for power once the axis has been refined.

Note: If a tentative cylinder axis preference is indicated by either of the techniques described above, many examiners
prefer to quickly verify whether the tentative cylinder will actually be accepted at or near the proposed axis before
spending time on axis refinement. To do this, dial in a -0.25 cylinder at the indicated axis and place the cross-
cylinder in power position. If the patient prefers the white plus cylinder axis parallel to the proposed phoropter
cylinder axis, the -0.25 tentative cylinder may be removed and it may be concluded that no cylinder will be
required in the refractive correction, thus avoiding wasting time attempting to refine the axis of a cylinder that will
ultimately be rejected. On the other hand, if the patient prefers the red minus cylinder axis parallel to the
proposed phoropter cylinder axis or has no preference between the red and white cross cylinder axes, then it
may be concluded that the tentative cylinder will not be rejected and the examiner should go on to refine its axis
and power (respectively) using the check tests as described above.

II BINOCULAR REFRACTION
Indications:

 Patients who can tolerate the blur.

 Patients who understand the test.
 Nonstrabismic patients.
 Prepresbyopes, especially those that are hyperopic.
 Suspected latent hyperopia.

1) The non-tested eye can be fogged by occluding the tested eye and adding plus to the fellow eye until the acuity
reaches 6/12 (if the starting visual acuity was 6/4.5 or 6/6). This would usually require adding +1.00 D to the
fellow eye. The occluder is then removed from the tested eye.

If the starting visual acuity is less than 6/6 sufficient plus is added to ensure central suppression of the untested
eye. This is normally around +1.00 or +1.25 D.

Note: As a clinical “short cut”, some examiners find it effective to merely introduce the +1.50 retinoscopy lens in
the phoropter and confirm that this blurs the acuity of the untested eye to at least 6/12 or 6/15. However, do not
arbitrarily add a set amount of plus to the eye without checking the visual acuity. If the patient has been
significantly overminused on retinoscopy the plus will not blur the acuity and the subjective refraction will not be
successful.
2) Proceed with steps 3 to 8 above.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-9

 Phoropter Refraction

III BALANCING THE ACCOMODATIVE DEMAND

1) Prism Balance:

Indications:

 Patients with accommodation who have equal monocular acuities. This test is used to balance the accommodative
demand between the eyes, and is normally done after a monocular refraction. It may be a less essential procedure if
a binocular refraction has been performed.

Contraindication/Considerations:

 A prism balance is of little value on absolute presbyopes (patients over 60), and in fact is usually of questionable
validity due to unequal quality of vision in the two eyes. In these patients it is often more useful to use plus and minus
monocularly to assess the depth of focus and prescribe an Rx that puts the patient in the midpoint of this range (i.e.,
when the same amount of plus and minus creates equal blur), or possibly biasing slightly to the plus side of the
midpoint if the patient has significant visual demands in the intermediate range. This is often best assessed using
trial frame refraction and demonstration.

Procedure

a) Isolate the 6/12 row. Introduce the Risley prisms before both eyes so that there is 3BD before one eye
and 3 BU before the other eye. Introduce the prisms one at a time with one of your hands shielding the
patient's view of the chart to avoid visual distress during prism adjustment.

b) Advise the patient that two rows should be visible, one higher than the other and that you will blur one of
them (e.g., if there is 3 BD/OD the top one will blur). Blur that eye (OD) with plus lenses a quarter
dioptre at a time until the 6/12 row is significantly blurred but not completely unreadable. This should
take approximately +1 D. Confirm with the patient that the row is indeed significantly blurred.

c) As plus lenses are added in +0.25 D steps to the other eye (e.g., OS); ask the patient to advise you
when the rows become equally blurred. When equal, bracket the value by adding an additional +0.25 D
(OS); this should make the other row blurrier. Return to the equal state. If an exact balance is not
possible, ask the patient to advise you which position creates a condition where the rows are closest to
being equally blurred. Use this result as your endpoint.

d) Remove +0.25 D from both eyes and ask the patient if the rows are still equally blurred. If so, move on
to the next step. If not, then add +0.25 D to the clearer eye until a balanced result is obtained, and then
consider removing another +0.25 D from both eyes to confirm that they are both still equally blurred at
the lower level of fog.

e) Remove the Risley prisms from both eyes (without causing visual discomfort) and display the chart from
6/15 to 6/4.5.

f) Have the patient read the smallest row of letters with the current partial fog in place. If the patient sees
the best acuity line at this point, this should alert the examiner to the fact that the patient may have been
overminused or underplused (In this case the examiner should add +0.50 or more to both eyes equally
until there is no doubt that the acuity is definitely blurred before proceeding further). If the acuity is
blurred to 6/9 or 6/7.5 then proceed to remove the fog in 0.25 D steps until the acuity no longer
improves. N.B.: Be careful to monitor the acuity and not rely on the patient's subjective impression of
improvement! Adding -0.25 D OU over the point where they can first read their smallest acuity line will
often result in a subjective improvement. If this occurs, allow the additional minus but do not allow any
further increase in minus without a corresponding improvement in acuity. High myopes will often call for
much more minus than will subjectively improve their visual acuity.

g) If either eye has been changed more than 0.25D over the monocular subjective endpoint, retest the
monocular acuity in that eye before recording the final binocular visual acuity.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-10

 Phoropter Refraction

Sample Patient Instructions: The questions are incorporated into the Procedures. Suggested wording follows:

1) When determining the best sphere (monocularly or binocularly): "Which lens is clearer, one or two, or are they
the same?"

2) When comparing JCC Lens choices: "Neither of the choices will be completely clear but which lens makes the
letters the clearest, lens one or two, or are they the same?" (Show the two lenses again, especially if the patient
hesitates to respond).

Recording: Record the final monocular refraction with the corresponding visual acuities and record the final balanced
refraction with the corresponding binocular visual acuity. Record the method used to balance, e.g., Prism Balance.

e.g., -2.50 –0.50 X 180 6/4.5

-3.00 –0.25 X 170 6/4.5

Prism Balance

-2.50 –0.50 X 180 6/4.5

-2.75 –0.25 X 170

Normal Result: The subjective results should be compatible with the retinoscopy results, visual acuities,
accommodation, the patient's age and ocular health.

Interpretation: The result represents the manifest refractive state of the eye. It is often not the same as the prescription.
When prescribing to correct the refractive error consideration is given to the patients past history of spectacle adaptation,
the needs and wants of the patient and the binocular and ocular health status of the patient. For example, a 20-year-old
person with a hyperopic refractive error of +0.75 DS, good binocular status and no ocular health abnormalities most likely
would not require a prescription.

Inconsistent results may be due to technique error or the patient may be an unreliable observer for behavioral or visual
reasons. If results are questionable due to observer reliability, trial frame refraction may be more successful and should
be attempted.

MOST COMMON ERRORS

1) Poorly worded patient instructions or leading questions e.g., using the word “better” instead of “clearer”.

2) Poor control of accommodation, e.g., not performing a binocular refraction on a young person with hyperopia.

3) Flipping the JCC lenses too fast for the patient to compare them.

4) Allowing the patient to direct the examination.

5) Not monitoring the visual acuity to ensure that a change in lens power results in the expected change in visual
acuity.

6) Improper or inefficient technique for checking for cylinder when no cylinder is found with retinoscopy.

7) Using the prism balancing technique on a patient with unequal monocular acuities.

8) Adding minus first rather than plus first when checking the best sphere.

9) When doing the cylinder power check test not confirming that zero cylinder is the correct endpoint.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-11

 Phoropter Refraction

ACCEPTABLE ALTERNATE PROCEDURES: BALANCING THE

ACCOMODATIVE DEMAND

I HUMPHRISS IMMEDIATE CONTRAST TECHNIQUE

Indications:

 This can be done on patients who are old enough to participate in a reliable subjective refraction.
 It is done with patients who have equal visual acuity.
 It should be done when a binocular technique with peripheral fusion is preferred.

Contraindication/Considerations:

 The technique cannot be done on someone with strabismus and can be difficult in someone who has an unstable or
decompensating heterophoria.
 The technique is best suited for use in trial frame refraction as patient observation is important and lens presentation
change cannot be fast enough with a phoropter.
-
1) Add +1.00 D to the eye that is not being tested. Check to make sure the visual acuity is decreased to 6/12 . If the
-
visual acuity has not been reduced to this level then add plus +0.25D at a time until 6/12 has been reached. Do
not blur the letters until they cannot be recognized.

2) Instruct the patient that you will be showing him/her the next lenses very quickly. Compare +0.25 with –0.25 and
leave the +0.25 in place while waiting for the answer. The patient should tell you which lens is clearer (some
practitioners also ask which lens is more comfortable).

3) If one lens is clearer adjust the sphere in that direction. Repeat the comparison.

4) Only minor adjustments are made this way. If more than 0.50 D change has been made then the fog on the eye
not being tested needs to be checked.

5) Repeat with the other eye.

6) As a final check: Add +1.00 D over each eye. Check to make sure that the visual acuity has been decreased to
6/12. Add more plus if necessary to reduce the visual acuity to 6/12. Slowly decrease the plus to best visual
acuity and record the binocular visual acuity.

II BICHROME TEST

Indications:

 This test can be used when the patient has unequal visual acuities
 It is not the best test for patients who are absolute presbyopes
 This test can be used on patients who have colour vision deficiencies but should not be used on patients with
significant nuclear sclerosis
 This procedure does not ensure that the patient’s accommodation is binocularly balanced

1) All room lights should be off. The lighting is critical in this test as it maximizes the pupil dilation and therefore
increases the chromatic aberration and high contrast that facilitates the test.
2) Adjust the projection chart so that one half the chart background is red and the other half is green. The letters
will remain black. The standard acuity chart has a section where the letters are the same on the left and the
right. This is designed for the Bichrome Test.

3) The patient views the chart monocularly and comments on whether the letters on the red or green side are
clearer or blacker. The spherical portion of the correction is adjusted so that the red and green halves appear
equally clear and black. If green is clearer, then the patient is overminused and plus should be added. If red is
April 2013, Version 1-1 ClinicalOptometricProcedures, 20-12
 Phoropter Refraction

clearer, then the patient is overplused and minus should be added. Often it is recommended to use the point
where the green is just clearer as the endpoint. Also, some examiners prefer to start with the patient deliberately
overplused by 0.50 D or so, confirm that the letters are in fact clearer and blacker on the red side, and then
reduce the plus until the red and green halves appear equal.

4) The same procedure is repeated for the fellow eye.

III DISSOCIATED BICHROME TEST

Indications:

 A simultaneous comparison alternative to the bichrome test, which has the advantage of allowing binocularity without
requiring equal acuities in the two eyes.

1) To ensure that the patient’s accommodation is binocularly balanced, Technique II can be performed with 3 BD
before one eye and 3 BU before the other eye, equalizing the red and green sides of the upper and lower
bichrome charts in turn. (Optionally, as a final binocular sphere check, the prisms can then be removed and the
result confirmed with both eyes open and viewing the target under binocular, fused conditions).

IV BINOCULAR REFRACTION TECHNIQUE USING POLAROIDS

Indications:

 Used when binocular refraction is advantageous

Contraindications/Considerations:

 Not ideal in patients with poor visual acuity, low contrast sensitivity or poor binocularity

1) Position polaroid lenses in the phoropter before each eye. Use the Vectographic projector slide or a vectographic
chart on a digital visual acuity system.

2) The refraction is conducted in the same way as described above. The top two charts on the slide can be used to
conduct the "monocular" refraction of each eye (performed under binocular conditions).

2) As one side of the chart is visible only to one eye and the other side is visible only to the fellow eye the test is done under
binocular conditions with the same stimulus to accommodation in each eye. A vertical fusion bar separates the two sides.
If a gross check of the cylinder axis and power is necessary, then use the split clock dial (one half seen by one eye and the
other half seen by the fellow eye).

V ALTERNATE OCCLUSION COMPARISON BALANCE

Indications:

 Used with patients who suppress and cannot perceive the two dissociated images simultaneously during the
traditional prism balancing procedure.

1) Balancing of the visual acuity can be achieved by substituting the dissociating prisms before the eyes with
alternate occlusion of the eyes. As the occluder is alternately moved back and forth before the eyes, the patient
comments on the relative clarity of the two images using the same fogging procedure described in prism
balancing.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-13

 Phoropter Refraction

ADVANTAGES OF THE ALTERNATE PROCEDURES

1) The vectographic slide or chart allows one to assess the refractive error under more "realistic" binocular and
accommodative conditions.

2) The advantage of the dissociated Bichrome Test is that the stimulus to accommodation is balanced independent
of the resolution thresholds of the two eyes.

3) The alternate occlusion comparison balance is ideal for people who suppress and therefore cannot perceive two
rows of letters during prism dissociation balancing.

DISADVANTAGES OF THE ALTERNATE PROCEDURES

1) Patients with poor acuity, contrast sensitivity or fusion may not be able to perform well on the vectographic slide
or chart.

2) The Bichrome test is not as effective with a projection chart (it is better with a back lit, high contrast chart as
found on a digital visual acuity system). The projector and screen need to be precisely adjusted with lamp
centration, projector focus and screen position. It is less valid for patients with significant nuclear sclerosis due to
blue-green wavelength absorption.

3) The alternate occlusion comparison balance does not allow simultaneous comparison.

ACCEPTABLE ALTERNATE PROCEDURE: CYLINDER AXIS DETERMINATION

I ROTATION TO BLUR CYLINDER AXIS DETERMINATION

1) This may be done for cylinders greater than or equal to -0.75 D.

2) With the patient viewing the best sphere acuity line, rotate the cylinder axis away from its initial orientation until
the patient first notices a blurring of the line. Note this axis. Return to the original axis orientation and then repeat
the test, rotating the axis in the opposite direction. Again, note the axis of the resulting blur point. Set the new
axis midway between the determined range.

REFERENCES:

1. Cline D, Hofstetter H, Griffin J. Dictionary of Visual Science 3rd Ed. Radnor: Chilton Book Company 1980;472.
2. Grosvenor T.P. Primary Care Optometry: A Clinical Manual. Chicago: Professional Press, 1982:163-72.
3. Pace R. Low Vision: A Clinical Manual 2nd. Ed. University of Waterloo; 1990:43-7.

April 2013, Version 1-1 ClinicalOptometricProcedures, 20-14

 APPENDICES

APPENDIX I:

Classification of clinical tests into one of the four oculo-visual systems: (Adapted from Clinical Procedures
in Primary Eye Care: DB Elliot)

Refractive Sensory Motor Ocular Health

Case history Case history Case history Case history
Keratometry Visual acuity Accommodation Ophthalmoscopy
Retinoscopy Stereoacuity Phorias Biomicroscopy
Autorefraction Contrast sensitivity Fusion limits Tonometry
Subjective refraction Visual fields Pursuits Gonioscopy
Colour vision Saccades Pupil responses
Suppression Pupil responses Dilated fundus exam

Source: Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann. Oxford. 2001.

June 2012, Version 1-1 Clinical Optometric Procedures 1, I-1

 APPENDICES

APPENDIX II:

Suggested order for performing various procedures in refraction.

 Patient profile
 Case history
 Preliminary examination
o Vertometry/Focimetry
o Unaided Visual acuity
- Distance
- Near
o Aided visual acuity
- Distance
- Near
o Near point of convergence
o Cover test (unaided / aided)
- Distance
- Near
o Motility
o Pupil responses (can be performed during ocular health exam)
o Interpupillary distance
 Refraction
o Retinoscopy
o Monocular subjective refraction
o Balanced subjective refraction or binocular refraction
o Best corrected distance visual acuity
 Accommodative tests and further binocular vision tests
o Amplitude of accommodation
o Reading addition (ADD) determination and best corrected near VA – if required
o Assessment of heterophorias/hetereotropia and fusional reserves
o Fixation disparity
o Stereoacuity
 Ocular health assessment
o Direct ophthalmoscopy (if not performing a dilated fundus exam)
o Biomicroscopy
o Intraocular pressure measurement
o Gonioscopy
o Dilated fundus examination (including fundus biomicroscopy and binocular indirect ophthalmoscopy)
 Counselling

June 2012, Version 1-1 Clinical Optometric Procedures 1, II-1

 APPENDICES

APPENDIX III:

Etiology of visual and ocular symptoms (adapted from Clinical Procedures in Optometry: Eskridge et al.)

 Eyestrain/Asthenopia  Flashes (light flashes)

o Ametropia / presbyopia o Vitreous detachment
o Heterophoria / vergence o Retinal detachment
o Aniseikonia o Migraine
o Accommodative dysfunction
o Optical (induced, organic)  Loss of vision (sudden and temporary)
o Environmental o Migraine
o Perceptual o Optic neuritis / retrobulbar neuritis
o Carotid occlusive disease
 Diplopia o Temporal arteritis
o Ametropia o Hollenhorst plaques
o Strabismus o Retinal detachment/haemorrhage
o Monocular diplopia (optical, organic) o Central retinal artery or vein occlusion

 Distortion  Halos around lights (usually coloured)

o Optical o Increased IOP
o Macular o Corneal abrasions or dystrophy
o Contact lens wear
 Vertigo (dizziness) o Media opacities
o Emotional
o Inner ear disease  Loss of visual field
o Vertical deviation o Vitreous or retinal haemorrhage
o Aniseikonia (anisometropia) o Retinal damage or detachment
o Visual pathway anomalies
 Glare/light sensitivity - Vascular
o Conjunctivitis/keratitis - Neoplastic
o Anterior uveitis - Trauma
o Cataract
o Congenital glaucoma  Ocular itching/burning or mattering of lids
o Retinal diseases o Dry eye
o Blepharitis
 Floaters (spots before eyes) o Allergic/ bacterial conjunctivitis/keratitis
o Vitreous liquefaction, detachment, or o Irritants in eye (smoke, dust, makeup,
haemorrhage chemicals)
o Retinal detachment o Contact lens problems
o Physiological o Exposure to wind

June 2012, Version 1 Clinical Optometric Procedures 1, III-1

 Appendix III

 Ocular pain/foreign body sensation  Headache

o Foreign body o Vascular
o Viral conjunctivitis/keratitis - Migraine and its variants
o Corneal (ulcer, abrasion, dystrophy) - Cluster
o Trichiasis - Toxic
o Acute glaucoma - Ischemic
o Anterior uveitis o Traction and inflammatory
o Contact lens wear - Traction (mass)
- Inflammatory
 Excesssive lacrimation (tearing) o Meningitis
o Dry eye o Otorhinolaryngologic
o Conjunctival or corneal abrasion/foreign body o Ophthalmic
o External lid disease o Arteritis
o Conjunctivitis / keratitis o Cranial neuralgia
o Emotional o Muscle contraction
o Environmental factors - Acute and chronic
o Improper tear drainage: - Hysteria related
- Malposition of punctum - Asthenopia
- Stenosis / occlusion of punctum
or canaliculi
- Obstruction of lacrimal sac
or nasolacrimal duct

 Ocular tenderness/soreness
o Lid inflammation
o Conjunctivitis / keratitis
o Scleritis / episcleritis
o Anterior uveitis
o Foreign body
o Sinusitis
o Preseptal or orbital cellulitis

Source: Eskridge JB, Amos JF and Bartlett JD. Clinical

Procedures in Optometry. JB Lippincott Company.
Philadelphia. 1991.
June 2012, Version 1 Clinical Optometric Procedures 1, III-2
 APPENDICES

APPENDIX IV:

Patient Record Card

June 2012, Version 1-1 Clinical Optometric Procedures 1, IV-1

PATIENT RECORD CARD

Notes/Observations: Name:

Address:

Postal code: City:

Tel. Home: Work:

Place of birth: Date of birth:

General practitioner: Place:

Occupation: Date:

Age, Race, Gender: Reason for visit

Personal Ocular History (Refractive): Ocular Symptoms :

None:

Personal Ocular History (Health): Personal General Health History (Past and present):

Date of last eye exam: Date of last medical exam:

Who/Where: Who/Where:

Family Ocular History: General Family History (Past and present):

Medication, dosage, frequency, condition: Allergies (Medicine, General):

PATIENT RECORD CARD
VA (-) Rx (+) Rx PH (+)Rx CL CL Status (SLE)
Distance Near Distance Near Distance Distance Near
OD OD OD

OS OS OS

OU OU OU

AA (Donders) Colour Vision Stereopsis NPC (cm) Versions PD (mm) (D/N)

OD OS OD OS "
OU Test: Test: Obj Subj / OD OS

CT CF Pupils

(D) cc / sc OD E R R ( ) MG

(N) cc / sc OS
Pupil Dim/Bright Time:
Dia
m

Keratometry OD - x @ D Mires OD mm @ OS mm @

OS - x @ D Mires mm @ mm @

Objective OD VA

OS VA Complimentary tests:

Subjective OD VA

OS VA

Phoropter Trial frame ODS

Near

Tentative Add OD NRA Balanced Add:

Age #Cyl AA OS PRA

Distance
Phorias (H) Maddox VG

Vergences (H) BI / / BO / /

Phorias (V) Maddox VG

Vergences (V) BUOD / BDOD /

Near
Phorias (H) Maddox VG

Vergences (H) BI / / BO / /

Phorias (V) Maddox VG

Vergences (V) BUOD / BDOD /

Trial As per subjective Rx

Final OD VA ADD D VA WD cm
Rx OS VA ADD D VA Range tot cm
Remarks:
PATIENT RECORD CARD
OD Slit Lamp Examination OS
Eyelids
Conjunctiva
Cornea
Tear Film
Iris
Lens
Anterior chamber
T: N: AC Angle (VH) T: N:

Photo

T OD / / = mmHg
GM OS / / = mmHg
PK gtts @ :
NCT Told Px not to rub eyes for next 30 min.
PACHY

DO Photo OD OS Funduscopy Undilated Dilated with

MIO gtts % @ :
BIO gtts % @ :
VOLK Px informed of potential side-effects of medication

Cup/Disk
(H/V)

Neuro Retinal Rim

ISNT rule

AV Crossings

Venous Pulse
Lamina Cribrosa
HR HR
AS Blood vessels AS

Macula

Foveal Reflex
Vitreous

Periphery

Final Rx Add Type PD (D/N) Prism Material Seg. Ht B.C Tint/AR

OD / mm  mm D
OS / mm  mm D
Rx for: Fulltime Distance Near PRN

Final Rx Add Type PD Prism Material Seg Ht. B.C Tint/AR

OD / mm  mm D
OS / mm  mm D
Rx for: Fulltime Distance Near PRN Special instructions:
PATIENT RECORD CARD

Assessments and plans Resolution

date
A1

P1

Follow Up Reason Referral letter

Next FEE (Routine Exam) Other

 APPENDICES

APPENDIX V:

Most Commonly Used Optometric Abbreviations

A Assessment (SOAP format); Angle of anomaly C/D Cup-to-disc ratio
A/V Artery to vein ratio C/O Complains of or complaining of
ABD Abduction
CAC Convergence-accommodation ratio
AC Anterior chamber: graded by Van Herick method on a 0 - 4 scale
CACG Chronic angle closure glaucoma
AC/A Accommodation-convergence ratio
ACC Accommodation CAD Coronary artery disease
ACG Acute angle closure glaucoma CAT(s) Cataract(s)
ADD Adduction CB Ciliary body
Addition bifocal power
CC/cc Chief complaint; With correction (cum correctore)
Adv Advanced
CCC Central corneal clouding
Ag Antigen
AIDS Acquired immune deficiency syndrome CF Count fingers (note: CF 10' 20/400), also FC;
AION Anterior ischemic optic neuropathy Central fixation; Confrontation Fields
AK Astigmatic keratotomy; autokeratometer CFF Critical flicker frequency
ALT Argon laser trabeculoplasty; CHF Congestive heart failure
Alternating (strabismus) Cj Conjunctiva: also Conj
AMBL Amblyopia (may be preceded by NUTR- nutritional, TOX- toxic, Ck Check
CONG- congenital, STRAB- strabismus, HYST- hysterical, MERD- CL Contact lens (HCL-hard, SCL-soft, EWCL- extended wear, GPCL-
meridional, STIM DEPR- stimulus deprivation, REFR- refractive) gas permeable, RGP more commonly used)
ANT Anterior Cl Clear (also means closed when listed on gonioscopy exam)
APD Afferent pupillary defect (Marcus Gunn), also RAPD CME Cystoid macular edema
APPROX Approximately CN Cranial nerve (followed by roman numeral for CN # e.g., CN I)
AR Autorefractor CNS Central nervous system
ARC Anomalous retinal (cortical) correspondence CNVM Choroidal neovascular membrane; also CNM (see SRNVM)
ARMD Age-related macular degeneration COAG Chronic open angle glaucoma
AS Anterior synechiae (see PAS) Conj Conjunctiva; also Cj
Arteriosclerosis COPD Chronic obstructive pulmonary disease
ASAP As soon as possible CP Cerebral palsy
ASSN Association CPR Cardiopulmonary resuscitation
ASTIG Astigmatism CRAO Central retinal artery occlusion
ATR Against the rule CRVO Central retinal vein occlusion
BAK Benzalkonium chloride CSME Clinically significant macular edema (reference to diabetic
BC Base curve retinopathy)
BCC Basal cell carcinoma CSR Central serous retinopathy; or CSC, central serous choroidopathy
BCP Birth control pills CT Cover test (ACT-alternating, UCT- Unilateral);
BD Base down prism; BD Computerized Tomography scan
BI Base-in prism; BI CV Color vision
BID Two times a day CVA Cerebral vascular accident
BIO Binocular indirect ophthalmoscopy CWS Cotton wool spots
BLEPH Blepharitis CYL Cylinder
BM Basement membrane D Diopter; deep; day
BO Base-out prism; BO D&I Dilation & irrigation of lacrimal canaliculi
BP Blood pressure D/C Discontinue; Discharge
BRAO Branch retinal artery occlusion D/Q Deep & quiet (anterior chamber)
BRVO Branch retinal vein occlusion DDx Differential diagnosis (also DD)
BU Base-up prism, BU DFE Dilated fundus exam
BUT Break-up time; also TBUT Dk/L Oxygen transmissibility of a contact lens
c With (cum), often with dash on top DM Diabetes mellitus

June 2012, Version 1-1 Clinical Optometric Procedures 1, V-1

 Appendix V

DO Direct ophthalmoscopy HZV Herpes zoster virus (see VZV)

DR Diabetic retinopathy ICCE Intracapsular cataract extraction
DRS Diabetic retinopathy study ICE Irido-corneal-endothelial syndrome
DV Distance vision ID Identification
DW Daily wear IDDM Insulin dependent diabetes mellitus
Dx Diagnosis IM Intramuscular (e.g., IM injection)
Dz Disease INT Intermittent
E Esophoria IO Inferior oblique muscle; intraocular; indirect ophthalmoscopy
E(T) Intermittent esotropia at far IOL Intraocular lens (Preceded by PC for posterior chamber, and AC
for anterior chamber)
E(T') Intermittent esotropia at near
ION Ischemic optic neuropathy
ECCE Extracapsular cataract extraction
IOP Intraocular pressure (tension)
EF Eccentric fixation
IPD Interpupillary distance (see PD)
EKC Epidemic keratoconjunctivitis
IR Inferior rectus muscle
EMBD Epithelial basement membrane dystrophy or disease
IRMA Intraretinal microvascular abnormalities
EMM Emmetropia
IV Intravenous (injection of infusion)
ENT Ear, nose, throat
J Jaeger near acuity (e.g., J-l, J-5)
EOG Electro-oculogram
JCC Jackson cross cylinder
EOM Extraocular muscles; extraocular movement
K Keratometry
EP Esophoria at far
K’s Keratometry reading (e.g., K 45.25x44.75 @ 180)
EP' Esophoria at near
KCS Keratoconjunctivitis sicca
ERG Electroretinogram
KP Keratic precipitates
ET Esotropia at far (6M, infinity)
L Lid, e.g., preceded by R (right) or L (left); Followed by UL for upper
ET' Esotropia at near
lid or LL for lower lid, e.g., RUL right upper lid
ETDRS Early treatment diabetic retinopathy study
LOGMAR Logmar chart (acuity)
ETOH Ethanol (e.g., ETOH on breath or abuse)
LP Light perception (acuity) mark (+) or (-)in quadrant tested
EV Eccentric viewing
LP & P Light perception and projection (acuity)
EW Extended wear
LPI Laser peripheral iridotomy
EXT External
LR Lateral rectus muscle
F/U Follow-up
LTP Laser trabeculoplasty
FA Fluorescein angiography; also FANG
LV Low vision
FAZ Foveal avascular zone
M Manifest refraction (also MR)
FB Foreign body
MAC Macula; macular
FBS Fasting blood sugar
MAX Maximum
FC Finger counting at 'x' distance (note: FC 1O' 20/400) (see CF)
MEDS Medications
FHx Family history
MEM Monocular estimate method (near retinoscopy)
FMH Family medical history
MGD Meibomian gland dysfunction
FOH Family ocular history
MGMT Management
FROM Full range of motion (motility)
MIN Minimum; minute(s)
FTFC Full to finger count (used with confrontation field testing)
MR Medial rectus muscle
GCA Giant cell arteritis
MRI Magnetic resonance imaging
GI Gastrointestinal
MS Multiple sclerosis
GLC Glaucoma
N/A Not applicable, also NA
GONIO Gonioscopy (List structures anterior to posterior)
N/C No charge
gtts Drops, "guttae"; also GTTS
N/S No show (patient did not show for appointment)
GVF Goldmann visual field
NAG Narrow angle glaucoma
h.s. Bedtime ('hora somni")
NCT Non-contact tonometer
HA Headache
NEG Negative
HAB Habitual
NEO Neovascularization
HEME Hemorrhage (blood)
NFC Negative fusional convergence
HIV Human immunodeficiency virus
NFL Nerve fiber layer
HM Hand motion (acuity)
NI No improvement
hr(s) Hour(s)
NIDDM Non-insulin dependent diabetes mellitus
HSK Herpes simplex keratitis
NKDA No known drug allergies
HSV Herpes simplex virus
nl Normal
HTN Hypertension
NLP No light perception
HVF Humphrey visual field
NPC Near point of convergence
Hx History; also Hx
NPDR Non-proliferative diabetic retinopathy (ETDRS)
HYPP Hyperphoria at far (e.g., LYHPP, left hypephoria at far)
NRC Normal retinal (cortical) correspondence
HYPP' Hyperphoria at near
NS Nuclear sclerosis (LOCS III classification)
HZO Herpes zoster ophthalmicus

June 2012, Version 1-1 Clinical Optometric Procedures 1, V-2

 Appendix V

NTG Normotensive glaucoma (old term low-tension glaucoma, LTG); Rx (Take) prescription
NV Near vision; neovascular or neovascularization S Subjective (SOAP format)
NVD Neovascularization at the disc (optic disc) s Without, often with a dash on top
NVE Neovascularization elsewhere (not at optic disc) sc Without correction (sine correctore)
NVG Neovascular glaucoma S/P Status post
NVI Neovascularization of iris SCC Squamous cell carcinoma
O Objective (SOAP format) SCL Soft contact lens
OAD Overall diameter (contact lens) SEI Subepithelial infiltrates
OAG Open angle glaucoma (preceded by P for primary & C for chronic) SL Schwalbe’s line
OD Doctor of Optometry; right eye (oculus dexter) SLE Slit lamp examination
OFHx Ocular Family History (see FOHx) SLK Superior limbic keratoconjunctivitis
OHTN Ocular hypertension Sn(s) Signs
Ohx Ocular history (also POH, previous ocular history) SO Superior oblique muscle (RSO, LSO); sympathetic ophthalmia
OKN Optokinetic nystagmus SOAP Subjective, objective, assessment and plan (SOAP format)
ONH Optic nerve head SPH Sphere or spherical lens
ORTHO-K Ortho-keratology SPK Superficial punctate keratitis
P Plan (SOAP format); SR Subjective refraction; superior rectus muscle (e.g., RSR, LSR)
PAM Potential acuity meter SRNVM Subretinal neovascular membrane; also SRNV, subretinal
PAS Peripheral anterior synechiae neovascularization, CNM or CNVM, choroidal neovascular
PC Peripheral curve; posterior capsulotomy; posterior chamber membrane
PCF Pharyngoconjunctival fever SS Scleral spur
PD Interpupillary distance (see IPD) STAT Immediately (statim)
PDR Proliferative diabetic retinopathy (see ETDRS) STD Standard; sexually transmitted disease
PE Physical examination STRAB Strabismus
PEH Past eye history; also PEHx SUBJ Subjective (see SR)
PERRLA Pupils equal round reactive to light and accommodation SX Surgery
PHNI Pin hole no improvement Sx(s) Symptoms
PHx Past history T Tonometry (TA – applanation, NCT – non-contact)
PI Peripheral iridectomy; peripheral iridotomy T.S. Telescope, e.g., 2.5 X T.S.
PK Penetrating keratoplasty (also PKP) Ta Tension (IOP) by applanation
PLT Preferential looking technique TB Tuberculosis
PMH Past medical history; also PMHX TIA Transient ischemic attack
POST-OP Post-operative TID Three (3) times per day
PP Punctal plug; pressure patch TM Trabecular meshwork
PPM Persistent pupillary membrane TR Trauma or traurnatic
PRE-OP Pre-operative TRAB Trabeculectomy
PRK Photorefractive keratectomy TTN To-the-nose (NPC)
PRN As necessary (pro re nata) Tx Treatment or therapy
PRP Pan-retinal photocoagulation UCT Unilateral cover test
PS Posterior synechiae UNG Ointment (see OINT)
URl Upper respiratory tract infection
PSC Posterior subcapsular cataract (grade on 0-4+ scale)
VA Visual acuity
PT Patient
VA cc Visual acuity with correction
Px Patient
VA sc Visual acuity without corrrection
PVD Posterior vitreous detachment
VD Venereal disease
Q or (q) Every (e.g., Q2H=every 2 hours)
VEP Visual evoked potential (also VER-Visual evoked response)
QD Daily (quaque die); also qd
VF Visual field
QH Every hour
VIT Vitreous
QHS At bedtime; every night; also qhs
W.D. Working distance
QID Four times daily (or X4) (quarter in die); also qid
w/o Without
QOD Every other day; also qod
W-4-D Worth-four-dot (fusion)
RA Rheumatoid arthritis
WBC White blood cells (leukocytes)
RBC Red blood cells
WK(S) Week(s)
RD Retinal detachment
WNL Within normal limits
RE Regarding; right eye
WTR With the rule astigmatism (see WRA)
REE Recurrent epithelial erosions
X Exotropia
RGP Rigid gas permeable
y/o Year old
RK Radial keratotomy; refractive keratoplasty
YAG Yttrium aluminum garnet (laser)
RP Retinitis pigrnentosa
YR(S) Year(s)
RPE Retinal pigment epithelium
RTC Return to clinic

June 2012, Version 1-1 Clinical Optometric Procedures 1, V-3

 Appendix V

Also:

 Approximately
 Prism
 Therefore
() Intermittent (e.g. X(T) = Intermittent exotropia)
‘ Near (e.g. XP’ = exophoria at near
@ at
= Equal

Source: Berman M and Stelmack T. Ophthalmic clinical

abbreviations. Journal of the American Optometric
Association 1984; 55: 601-4.

June 2012, Version 1-1 Clinical Optometric Procedures 1, V-4