Practical Refraction English

O PHTHALMIC O PTICS F ILES
PRACTICAL REFRACTION
OPHTHALMIC OPTICS FILES
© Essilor International
Copyright © 2008 ESSILOR ACADEMY EUROPE, 13 rue Moreau, 75012 Paris, France - All rights reserved – Do not copy or distribute.
Author
Dominique Meslin
Essilor Academy Europe
POUR
IF YOU
COMMANDER
WISH TO ORDER
UNE AVERSION
PRINTEDIMPRIMÉE
VERSION DE
OF CE
THIS
CAHIER
FILE
CClliiqc u
k ehz e Ircei
www.essiloracademy.eu
GENERAL CONDITIONS OF USE

of the
Essilor Academy Europe Publications
ESSILOR ACADEMY EUROPE ACADEMY EUROPE has developed a Publication called
“Practical Refraction”
Copyright © 2008 ESSILOR ACADEMY EUROPE, 13 rue Moreau, 75012 Paris, France
All rights reserved – Do not copy or distribute
(hereinafter the “Publication”)
1. The Publication and all its content is the property of ESSILOR may not use any trademark, service mark or other intellectual pro-
ACADEMY EUROPE, its affiliates, or other third parties holding the perty appearing in the Publication, or frame or incorporate into ano-
relevant right (“Licensors”) and is protected by copyright, trademark ther document or other medium any of the content of the Publication,
and other intellectual property laws. No right or licence can be gran- without the prior written consent of ESSILOR ACADEMY EUROPE.
ted for any of the aforementioned elements without the written agree- 6. The Licensee is not authorised to modify the Publication without
ment of ESSILOR ACADEMY EUROPE, its affiliates or Licensors. ESSILOR ACADEMY EUROPE’s prior written approval.
Although ESSILOR ACADEMY EUROPE makes the Publication infor-
mation freely accessible, ESSILOR ACADEMY EUROPE does not 7. The Licensee shall not copy nor translate in whole or in part the
intend to give up its rights, or anyone else’s rights, to the Publication content of the Publication without the express written consent of
and any materials appearing therein. ESSILOR ACADEMY EUROPE.
2. ESSILOR ACADEMY EUROPE accepts to grant a non exclusive, non 8. The Licensee shall not remove any proprietary, copyright or tra-
transferable license to use the Publication upon the General demark legend from the Publication.
Conditions set forth hereinafter to the Licensee, provided that such
Licensee has : 9. As a condition for the use of the Publication, the Licensee warrants
a. recorded its name, e-mail address and other personal details and to ESSILOR ACADEMY EUROPE that he/she will not use the
b. has hereby expressly accepted the present General Conditions Publication for any purpose that is unlawful or prohibited by these
of Use, as a condition precedent to downloading the Publication terms, conditions and notices.
on ESSILOR ACADEMY EUROPE web site.
10. The Publication is provided on an “As Is basis”:
3. The Licensee acknowledges that ownership of and title in and all a. The Licensee acknowledges that no representation or warranty,
intellectual property rights in the Publication are and shall remain in express or implied, is made by ESSILOR ACADEMY EUROPE with
ESSILOR ACADEMY EUROPE its affiliates or Licensors. The Licensee respect to the truth, accuracy, sufficiency, absence of defect or
acquires only the right to use the Publication and does not acquire infringement of third parties rights, completeness or reasonable-
any ownership rights or title in or to the Publication and any materials ness of the Information displayed in the Publication
appearing therein. b. If the Licensee is dissatisfied with any of the contents of the
Publication, or any of these terms of use, the Licensee’s sole and
4. The reproduction or downloading of the Publication is authorised exclusive remedy is to discontinue using the Publication.
solely for informational purpose in the context of personal and priva-
te use; any reproduction and use of copies made for any other pur- 11.APPLICABLE LAW
pose is expressly prohibited. THESE GENERAL CONDITIONS OF USE ARE GOVERNED BY, INTER-
PRETED AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF
5. The Licensee may not reproduce the Publication or any part the- FRANCE, BY THE FRENCH COURTS ATTACHED TO THE PARIS COURT
reof without ESSILOR ACADEMY EUROPE’s consent. The Licensee OF APPEAL.
ISBN 979-10-90678-11-8
9 791090 678118
Summary
Summary
Introduction p.5
1 Emmetropia, Ametropia, Presbyopia and their correction

A Emmetropia p.6
B Ametropia p.7
1) Myopia
2) Hypermetropia
Practical Refraction
3) Astigmatism
C Near Vision, Accommodation and Presbyopia p.9
Supplement: The Optical Principles of the Correction of Ametropia

and Presbyopia p.10
Supplement: Equipment p.12
2 Preliminary Examination
A Case History p.13
B Preliminary Investigations p.14
Supplement: Visual Acuity p.17
3 Objective Refraction
A Auto-Refractometry p.19
B Retinoscopy p.20
4 Subjective Refraction – Distance Vision

A Determining the Sphere p.22
B Determining the Cylinder
- using the objective refraction or previous prescription
as a starting point p.24
- without prior knowledge of the refraction p.26
Supplement: Estimating the Refractive Error from the Level of

Uncorrected Vision, The Jackson Cross Cylinder, The Duochrome Test,
The Pinhole p.30
C Binocular Balance p.32
D Final Check of Binocular Sphere, Subjective Appreciation and Comfort
(including Binocular Vision Screening) p.34
Copyright © 2008 ESSILOR ACADEMY EUROPE, 13 rue Moreau, 75012 Paris, France - All rights reserved – Do not copy or distribute. 3
Summary
Summary
5 Subjective Refraction - Near Vision

A Determining the Near Addition (Presbyopia) p.37
1) Accommodative Reserve method
2) Minimum Addition method
3) Binocular Fixed Cross Cylinder method
Supplement: The Consequences of Prescribing

an Excessive Near Addition p.40
B Verification of Binocular Balance at Near p.42
C In the case of the Non-Presbyopic Patient p.43
6 Binocular Vision Evaluation

A Phoria, Fusional Reserves and Tropia p 44
B Identifying the Problem p.46
C Prescribing Prism p.50
Supplement: Definition, Measurement and Summation of Prism p.51
7 The Prescription (The Final Rx)

p.52
Conclusion p.54
4 Copyright © 2008 ESSILOR ACADEMY EUROPE, 13 rue Moreau, 75012 Paris, France - All rights reserved – Do not copy or distribute. 3
Introduction
Introduction
The accurate determination of the refraction is an essential prerequisite to ensuring clear and comfortable vision for the
patient. Particular attention must always be paid to its assessment.
This document in the Essilor Ophthalmic Optics Files series examines refraction from a practical point of view. The file
provides a concise summary of a number of simple and proven techniques selected from the large number of methods
available. Its goal is not to deal exhaustively with the subject, but rather to discuss certain basic principles of refraction
that are useful to practitioners. The file has been developed in response to numerous requests from practitioners in
countries where the practice of refraction is rapidly expanding. The principal objective of this file is to help eye care pro-
fessionals manage their patients and meet their eye care needs, in the hope that this may increase the level of customer
and practitioner satisfaction.
1. Emmetropia, Ametropia,
Emmetropia,
Presbyopia and their correction

Ametropia
When the eye is out of focus, the vision is blurred. There may be several reasons why an eye is not in proper focus, and
indeed the reasons why a person develops a refractive error are many and multifactorial, but no matter what the rea-
son, the end result is that there is a mismatch between the power of the refracting elements of the eye and the position
of the retina (that is, the length of the eye). The eye has a refractive error and the vision is out of focus when the image
formed by the refracting components of the eye is located in front of and/or behind the retina, rather that exactly on it.
1
A Emmetropia
An eye is said to be emmetropic (from the Greek
emmetros = proportionate (measurement) and ops
= eye) when the image of an object located at infi-
nity is formed on the retina of the unaccommodated
eye. In the emmetropic eye, the retina is conjugate
with optical infinity and therefore lies in the image
focal plane of the ophthalmic system. The emme-
tropic eye sees distant objects clearly, without
accommodation. Figure 1: Emmetropic Eye
The eye as an optical system:
The unaccommodated emmetropic eye can be

modelled as an optical system composed of the cor-
nea, the aqueous humour, the crystalline lens and the
vitreous humour. The characteristics of one such
theoretical system (called a schematic eye) are shown
in the table below:
Thickness Refractive Anterior Posterior

radius of radius of
(mm) index curvature (mm) curvature (mm)
- (single
Cornea surface)
- 7.80 -
Aqueous 3.60 1.336 - -

humour
Crystalline 3.70 1.422 11.00 -6.48
lens
Vitreous 16.79 1.336 - -
humour
Overall length of eye: 24.09 mm

Reference: Bennett and Rabbetts’ Clinical Visual
Optics, fourth edition, 2007
+42 +22
A simplified eye can be obtained (Figure 2) by simpli- n=1,336
fying this model; that is, by (i) combining the elements
n=1,336
that make up the eye, (ii) considering the cornea and S L l=24 mm R
l
the lens as thin lenses (as opposed to thick lenses),

(iii) using the same index n = 1.336 for the aqueous

and vitreous humours and (iv) rounding off the calcu-
lations. This simplified eye totals 60 dioptres, is 24
mm in length and is comprised of a transparent sphe-
d=5,8 mm
re with an optical power of 42 dioptres (the cornea)
separating the air from the aqueous humour, and a
thin lens with an optical power of 22 dioptres (the Figure 2: Simplified Emmetropic Eye
lens) separating the aqueous humour from the
vitreous, located 5.8 mm behind the cornea.
Although greatly simplified, this model is nevertheless
an acceptable optical representation of the human
eye (in the unaccommodated state).
6 Copyright © 2008 ESSILOR ACADEMY EUROPE, 13 rue Moreau, 75012 Paris, France - All rights reserved – Do not copy or distribute.
Emmetropia,
Ametropia
B Ametropia
An eye which is not correctly focussed (that is, where the image of a distant object is not formed on the retina of the
unaccommodated eye) is said to have a refractive error or an ametropia (from the Greek meaning disproportionate eye).
1
The different types of ametropia are classified into three categories: myopia, hypermetropia and astigmatism.
1) Myopia (Shortsightedness): 2) Hypermetropia (Longsightedness):

Myopia is the state of refractive error in which the image Hypermetropia (or hyperopia) is the state of refractive
of an object located at infinity is formed by the eye (in error in which the image of an object located at infinity
its relaxed state) in front of the retina. The word myopia is formed by the eye (in its relaxed state) behind the reti-
comes from the Latin myops and Greek muôps meaning na. The word hypermetropia comes from the Greek
a person who narrows the eyes (“squints” or peers). The hyper = beyond (measurement) and ops = eye.
person with uncorrected myopia sees distant objects as
blurred but can see close objects clearly (they are “sigh- Optically, the hypermetropic eye presents a lack of
ted” at “short” range). power relative to its length. This may be classified either
as being because it is too short relative to its power
Optically, the myopic eye presents an excess of power (axial hypermetropia (the majority of cases for hyper-
relative to its length. This may be classified either as metropia in excess of 5.00D)), or because it is insuffi-
being because it is too long relative to its power (axial ciently powerful relative to its length (refractive hyper-
myopia (the majority of cases for myopia in excess of metropia).
5.00D)), or because the eye is too powerful relative to its
length (refractive myopia). Hypermetropia is corrected by the introduction of a plus
(positive) powered lens so as to move the image forward
Myopia is corrected by the introduction of a minus and reposition it onto the retina.
(negative) powered lens, so as to move the image back
and reposition it onto the retina.
Figure 3: The Myopic Eye and the Principle of its Figure 4: The Hypermetropic Eye and the Principle of
Correction its Correction
Emmetropia,
Ametropia
3) Astigmatism: - if emmetropic in one principal meridian and

1
An eye is said to be astigmatic when its optical power myopic in the other, the astigmatism is termed sim-
and therefore its focus differs according to its different ple astigmatism
meridians. The eye thus presents an asymmetric ame- - if emmetropic and hypermetropic, it is termed
tropia with different focal positions in different planes. simple astigmatism
For example, a person with astigmatism who is looking - if myopic in all meridians, it is termed com-
at a capital letter E may see the vertical line clearly but pound myopic astigmatism
the horizontal lines as blurred. - if hypermetropic in all meridians, it is termed

compound hypermetropic astigmatism
In an eye with astigmatism, there is always a meridian of - if hypermetropic in one principal meridian and
maximum refractive power and another meridian of myopic in the other, it is termed mixed astigmatism
minimum refractive power; these are termed the principal
meridians. Between these, the refractive power varies The astigmatism is said to be with the rule if the most
between the maximum and minimum limits. powerful meridian of the eye is close to the vertical
(that is, located between 70° and 110°). It is said to
When the astigmatism is regular, the principal meridians be against the rule if the most powerful meridian is
are perpendicular to each other (that is, 90º apart) and close to the horizontal (located between 160° and
the power varies in a regular fashion between these two 200°, or +20° and -20°). When the astigmatism is
limits. Astigmatism may also be irregular, where the prin- neither with the rule nor against the rule, it is said to
cipal meridians are not perpendicular to each other; be oblique.
this may result from an injury, for example, and is not
able to be corrected by spectacle lenses alone. The optical system of the astigmatic eye forms a com-
plex light beam image of an object point. This beam is
characterised by two small linear foci, each at one ext-
reme of the interval, which are perpendicular to each
other. These two foci correspond to the images formed
by the principal meridians of the eye. Inside this Interval
of Sturm, lies a particular location called the Disc of
Least Confusion. At this location the section of the astig-
matic beam is a minimum and at its smallest size. The

disc of least confusion is dioptrically equidistant from
the two foci, that is, near the midpoint of the interval; it
is this location which is positioned on the retina when
the best vision sphere is in place (see later).
The principle of correction of the astigmatic eye is to

introduce a lens of variable power so as to reposition the
image onto the retina. The power of this lens varies
according to its meridians, inversely to the astigmatism
of the eye. The lens is called sphero-cylindrical, cylindri-
cal, or toric. The difference between the refractive power
of its maximum and minimum meridians (the cylinder)
compensates for the astigmatism of the eye, thereby
merging the two linear foci into a single point focus,

while its spherical component places this image point on
the retina. With the rule astigmatism is corrected by a
minus cylindrical lens with an axis close to 180° and
against the rule astigmatism by a minus cylindrical lens
with an axis close to 90°. The axis of astigmatism varies
Figure 5: The Astigmatic Eye and The Principle of its throughout life, generally from with the rule as a child to
Correction against the rule as an older adult. Also, the axis of astig-
Different types of astigmatism are possible, depen- matism in the two eyes is such that it is generally sym-
ding on the location of the two principal foci (that is, metrical around the vertical meridian (the nose).
the refractive power of the maximum and minimum
meridia):
Emmetropia,
Ametropia
C Near Vision, Accommodation and Presbyopia
When an object being viewed is brought closer to the Presbyopia :
1
eye, the image of this object would be formed further An eye is said to be presbyopic (from the Greek meaning old
behind the retina unless the power of the eye is increa- eye) when the shape and position of its lens are no longer
sed so as to maintain the image on the retina. The eye able to be altered sufficiently to allow sufficient increase in
has the capacity to increase its overall power and this is the refractive power of the eye for a clear image of near
achieved by changing the surface curvatures, thickness objects to be formed on the retina; that is, when the ampli-
and position of the lens; this process is the phenomenon tude of accommodation is insufficient for near visual needs.
of accommodation.
Left uncorrected, presbyopia will cause near objects to be
seen as blurry.
The amplitude of accommodation is the range over
which the eye can focus. It represents the distance bet- The principle of correction of presbyopia is to supplement
ween the furthest object point seen clearly without the insufficiency of the amplitude of accommodation (in
accommodation (the Far Point, or Punctum Remotum) near vision) by means of a plus lens. This lens, which is addi-
and the closest object point seen clearly with maximum tional to any correction of ametropia, is called a near addi-
accommodation (the Near Point, or Punctum Proximum). tion, or more simply an add. Thus:
In the emmetropic eye, this accommodation range - the presbyopic emmetropic eye is corrected by a
extends from infinity to the near point (which is a finite plano lens for distance and a plus lens for near;
distance). In the myopic eye, the range is real and loca- - the presbyopic myopic eye is corrected by a minus
ted entirely at a finite distance in front of the eye. In the lens for distance and a lens which is “less minus” for near
hypermetropic eye, the accommodative range is either (this may mean that the near correction may be minus,
partly virtual (behind the eye) and partly real (in front of plano or even plus, depending on the level of myopia and
the eye) or wholly virtual. the add);
- the presbyopic hypermetropic eye is corrected by a
The value of the amplitude of accommodation determi- plus lens for distance and a stronger plus lens for near
nes the nearest point at which an object may be viewed
and for which the eye can form a clear image on its reti-
na. The amplitude of accommodation (maximum) is
approximately 20 dioptres at birth (corresponding to a
near point of ~5cm), >10 dioptres (~10cm) by age 20
years, no more than a few dioptres by age 40 years
(~35cm), with a total loss of accommodation by the age
of approximately 50 years (depending on various fac-
tors). This loss of the ability of the eye to accommoda-

te is termed presbyopia.
Figure 7: Ametropia and Presbyopia
Figure 6: Near Vision
Supplement:
1 Supplement
The Optical Principles of the Correction of

Ametropia and Presbyopia
The Principle of the Correction of Myopia The Principle of the Correction of
and Hypermetropia Astigmatism
The basic optical principle in the correction of ametropia The principle of correction of the astigmatic eye is to intro-
is the use of a lens to form optical images of objects duce an astigmatic lens of a power which varies according
(seen as blurred by the uncorrected ametropic eye) to the different meridians so as to counteract the astig-
which the ametropic eye can see clearly. More specifi- matism of the eye. This lens, called sphero-cylindrical, has
cally, correction consists of projecting optical images of a difference of optical power between its maximum and
objects that are seen as blurred without correction into minimum power meridians (the cylinder) that compensa-
the space which is seen clearly by the ametropic eye. tes for the astigmatism of the eye by merging the two
linear foci into an image focal point, and a spherical power
In particular, to restore the ametropic eye to the situa- that repositions this image point onto the retina.
tion of the emmetropic eye, the correction consists in
the lens’ forming an image of a distant object at the The power of the cylinder acts on the linear focus parallel
point which the ametropic eye sees clearly without to its axis. In the case of a prescription for a sphero-cylin-
accommodation, that is, at its far point. As the image of drical lens expressed in minus cylinder form, it can be said
a distant object formed by a lens is, by definition, loca- that the 180° axis cylinder causes the horizontal focus to
ted in its image focal plane, the principle of correction of coincide with the vertical focus, merging them into a single
the ametropic eye is to determine the power of correc- image point, and that the spherical power ‘repositions’
tion so that the second principal focus of the lens coincides this image point onto the retina. The power axis of a cylin-
with the far point of the ametropic eye to be corrected. drical lens is perpendicular to its cylinder axis.
Figure 9: The Principle of Correction of the Astigmatic Eye
In the case of the myopic eye (Figure 8a), the image of
an object at infinity is formed at the (virtual) image focus a) the effect of the cylindrical component of the correction
of the minus lens. That image in turn becomes an object
for the eye which, because it lies at the far point, is pro-
jected clearly onto the retina since it is conjugate
+
through the optical system of the eye. In the case of the
hypermetropic eye (Figure 8b), the image of an object at
infinity is formed at the (real) image focus of the plus -
lens. That image becomes an object for the eye which,
because it is located at the far point, is projected clear-
CYL-
ly onto the retina. -
Figure 8: The Principle of Correction of Ametropia CYL -
a) the myopic eye +
b) the effect of the spherical component of the correction

R
F'l
b) the hypermetropic eye

SPH+
F'l
R
1 Supplement
The Optical Principle of the Correction of
Presbyopia
The effect of prescribing a near addition is to restore to point Rl; the image of the near vision far point Pp seen
the presbyopic eye the ability to see near objects clear- through the addition is the distance vision near point Pl.
ly. Its purpose is to produce an image of a near object Since Rl is located at infinity (that is, at the corrected far
at a further distance from the eye which lies within the point of the ametropic eye or the real far point
remaining range of accommodation. The apparent range of the emmetropic eye), it follows that Rp always lies in
of near vision which results has the optical property of the focal plane of the addition (Figure 10).
being the object conjugate of the distance vision accom-
modation range. The image of the near vision far point
Rp seen through the addition is the distance vision far
Acc=0 Acc=max
Rl Pl
8
Rp Pp
Add
Fadd Rl
8
Acc=0 Acc=max
Figure 10: The Principle of Correction of the Presbyopic Eye
Real and Virtual Optical Spaces

Two optical spaces can be distinguished in the ametro- Any optical space extends really or virtually to infinity;
pic eye corrected by a spectacle lens: that is, the apparent optical space extends in front of
- the apparent or corrected optical space, which is and behind the lens and the real optical space extends
restored to the ametropic eye by its refractive correction in front of and behind the eye. The corrective lens acts
and in which exist the physical objects that it sees. This as a creator of apparent optical space. The image of this
is the object space of the lens. space is formed, through the lens, in the optical space
- the real optical space, which is the optical image perceived clearly by the ametropic eye. This is why it is
space for the lens and the object space for the eye, in a little improper to speak of optical correction by spec-
which exist the optical images of the objects formed by tacle lenses as the lens does not really correct the ame-
the corrective lens. These are the images which are seen tropia. It would be more appropriate to speak of the
by the ametropic eye and which are formed on its retina. optical compensation of ametropia by spectacle lenses.
Supplement:
1 Supplement
Equipment
To perform refraction, appropriate equipment and facili- Beyond this fundamental equipment, further enhance-
ties are required. ments may be added, including: tape measure (for mea-
suring reading distance, test distance, near point of
Preferably the location used will be a room specifically accommodation, etc), flippers (for example +/- 0.25D,
dedicated to visual examinations, located in a quiet area 0.50D, 1.00D, 2.00D and base in/out prism), pen torch,
away from the other activities of the practice or shop, in red filter, polarizing lenses, prism bars, stereoscopy test,
order to ensure the patient's privacy and to facilitate cycloplegic topical preparations for use with retinosco-
concentration. The lighting of the room should be of py, where available and appropriate and a contrast sen-
medium brightness in order to correspond to standard sitivity test.

vision conditions. It is important to avoid carrying out
visual examinations in dim conditions (unless a particu-
lar investigation is required). A distance of 4 to 6 m
(depending on the country) will be required, at which a
vision chart may be placed to test distance vision. This
distance can be obtained directly or by reflection in a
mirror. Tests should be presented at the height of the
patient's eyes (that is, so the patient looks at distance in
primary gaze).
Certain minimum equipment is required:
- Visual Acuity (VA) chart (distance) (including VA

charts for children (with confusion bars, and matching
prompt cards, etc) and for non-communicating patients
(e.g. Illiterate E, Landolt C, matching cards))
- Reading Card or VA chart (near)
- Lens Set (trial frame and trial lens set, manual pho-
ropter or automated phoropter)
- Jackson Cross Cylinder(s) (hand-held or in phoropter)
- an occluder
- appropriate lighting level (for distance vision tes-
ting as well as focal lighting for near vision evaluation)
- equipment relating to an objective method of
refractive measurement (retinoscope or auto-refractor)
- a vertometer/lensometer/focimeter (its name varies
depending on the country), for measuring the current
spectacles
Figure 11: Refraction Equipment – Manual Phoropter
It goes without saying that the use of these different

instruments is restricted to eye care professionals with
the required level of qualification and skill, in accordan-
ce with the regulations in force in each country.
2. Preliminary Examination
Examination
Preliminary
A Case History
To commence any visual examination, it is necessary to It is also vital to know how and when the patient will use
review the case history of the patient. This should be their new glasses; in particular for which professional or
2
done in order to understand the symptoms that have leisure activities. Again, this should be determined by
motivated the patient to seek a consultation as well as asking a few questions, such as:
their visual needs. The record of this information is pre- - concerning professional activities: description of
cious and will enable the eye care professional to per- the activity or activities, working distance(s) required,
form the visual examination in an orderly fashion, as well position of work (for example: at, above or below eye
as know, before commencing the visual examination, the level, directly in front or off to the side), lighting, sur-
likely reasons for the symptoms (for example, the type of roundings, degree of attention required, duration of
refractive error). tasks, etc.
- concerning leisure activities: type(s) of sport, rea-
Firstly, it is important to understand the reasons for the ding, do-it-yourself odd jobs around the home, driving,
consultation, by asking the patient a few open questions television, music, painting, sewing etc.
such as ‘What is the reason for your visit?’, ‘What seems The ideal, in particular cases, is to be able to simulate
to be the problem?’, or ‘What visual problems do you the visual conditions of the situation(s) most frequently
have?’ encountered by the patient, so as to ensure the visual
correction prescribed is the most appropriate.
Next, ask further questions to help specify the visual
problem. For example: Finally, it is important also to find out about any special
- the exact nature of the problem: visual fatigue, characteristics that could affect the patient’s vision. Ask
blurred vision, double vision? questions about their eye health: for example, family
- the location at which the problem occurs: in the far
distance, mid-distance, close up, centrally, peripherally,
one eye or both?
- the circumstances in which the problem occurs:
reading, working at a computer screen, driving?
- the time and the frequency of occurrence: mor-
ning, evening, intermittently, constantly, immediately or
only after a long period of reading?
- the lighting conditions: in strong light, low lighting,
night vision, sensitivity to glare?

- the date and mode of occurrence: when did it hap-
pen, was this the first time, sudden or gradual onset?
- the time of onset and nature of the problem: has
the problem become better or worse, what solutions has
the patient found to relieve or exacerbate the condition?
- etc. Figure 12: The Preliminary Interview: An Essential
First Contact
During this discussion, the patient's answers may be res-
tated in order to ensure that they have been properly history of eye problems, eye infections, eye surgery,
understood. If need be, ask a few closed questions or vision training undertaken, etc. Also ask about the
suggest examples to clarify their responses. patient’s general health: diabetes, high blood pressure,
allergies, injuries, medications taken, etc.
In addition to the patient’s personal details (name, date
of birth, etc), you should note the visual history and Recording the case history of the patient is of the grea-
more particularly all the details of the patient’s previous test importance. The rigour and seriousness with which
glasses; this may be done either from the previous this first interview is carried out will give the patient
patient file, through information provided by the patient, confidence for the rest of the examination and provide
or by measuring the prescription currently worn by the key information for the eye care professional. By the
patient. This can be done either before or after perfor- end of the case history, the practitioner should have a
ming the refraction; preferably after, so as to avoid good idea of the cause of the patient’s symptoms and
potentially influencing the subjective refraction by likely (refractive) findings and the most appropriate
having prior knowledge of the previous correction. visual correction(s) for the patient.
Examination
Preliminary
B Preliminary Investigations
The first step in any visual examination is to perform a Accommodative and Convergence Function
2
certain number of simple preliminary measurements. It is essential to check the patient’s accommodative and
The practitioner should already have an idea of the convergence function at near. To do this, identify:
refractive status of the patient’s eye thanks to the case - the Near Point of Accommodation: move a very
history; furthermore these measurements will help to small target (e.g. optotypes or small print) towards the
identify and confirm the patient’s visual problem(s). patient (wearing their distance correction) until they can
They also provide an opportunity to observe more clo- no longer see it clearly; note the distance; then, move
the target away from the patient until they can see it
sely the patient’s behaviour.

clearly again; note the distance. These two positions
Start by evaluating the patient’s level of distance vision should not differ by more than 1 or 2 cm. This measu-
(without, then with, the current correction, monocularly rement should be performed monocularly and binocu-
then binocularly); next, evaluate their behaviour and larly. It is particularly useful in patients with pre-pres-
reading capacity at near; then check ocular dominance byopia to screen for accommodative dysfunction and in
and, finally, screen for binocular vision anomalies. patients with anisometropia to demonstrate accommo-
dative disparities between the two eyes. (The remaining
Distance Vision accommodation (in dioptres) may be estimated by this
A patient’s distance vision is usually measured on a Push Up method, as it is the inverse of the closest distan-
ce (in metres) at which the patient can still see clearly (that
visual acuity chart placed at a distance of 4 - 6 m,
is, the near point of accommodation). The measurement of
without then with correction, monocularly then binocu- the amplitude of accommodation by this method is simple
larly. The patient reads aloud the letters on the chart. but not the most accurate method of true amplitude of
Patients often tend to stop reading the first time they accommodation. However, for practical purposes and for
have trouble deciphering a letter. It is important to this file, it suffices and gives a good working indication of
encourage them to continue by asking, for example, the patient’s accommodative function).
‘And what can you make out on the next line?’ The level - the Near Point of Convergence: have the
of vision achieved can be considered as the smallest line patient focus on a fine target such as a pen tip or small
in which three out of five letters (or optotypes) are cor- print (both eyes open). Slowly move the target closer to
rectly recognised. Alternatively, on a logMAR chart, with their nose until the patient sees two targets instead of
the equivalent task of five letters per line and the regu- one (double vision) and/or you notice that one of the
lar progression of size between lines, each letter read patient’s eyes loses fixation (that is, deviates); note this
correctly may be noted; each letter read correctly sco- distance (break) and which eye deviated. Now slowly
res 0.02 of a logMAR unit, starting from the logMAR 1.0 move the target away from the patient until they can
(0.1 decimal) line. once again see the target singly and you notice that they
regain fixation with both eyes (recovery); note this dis-
There are many and varied visual acuity charts in exis- tance. Repeat the test one or two times and note consis-
tence and a variety of methods of the notation of visual tency or any large variation. Normally the break position
acuity. For international simplicity, in this document, is no more than 5-10 cm from the nose, the difference
decimal notation will be used. (Please see the supple- between break and recovery is only a few centimetres at
ment “Visual Acuity” for a comparative list of different VA most, and the measurements are very repeatable. If a
notations and a more detailed comparison of the diffe- patient’s break point is at a distance >20cm or if it rece-
rent notations). des very quickly as they fatigue with repetitions of the
test, this is indicative of convergence insufficiency.
While the patient reads the VA chart, observe his/her
behaviour: for example, be sure to avoid that the Near Vision
Have the patient hold a reading test card at whatever
patient squints during vision measurement.
reading distance they naturally choose. Provide appro-
priate focal lighting. Ask the patient to read, aloud,
During monocular vision testing, it is important to make smaller and smaller print until they have reached the
sure the occluded eye is not affected. It is preferable smallest characters able to be read. As with the distance
that the practitioner hold an occluder over the patient’s vision test, the patient should be encouraged to continue
eye in such a way that the eye is not touched and so as to read beyond where difficulty is first encountered. This
to avoid the patient’s covering their eye with their hand measurement should be carried out using high contrast
and coincidently pushing on the eye or even closing their (100%) print, in good lighting conditions.
eye, all of which may affect the vision. Some consider
that a translucent occluder is preferable to an opaque The test can also be performed with low contrast (10%)
occluder, as observation may be made of the covered print: the difference between the two measurements
eye at the same time; however in general, this may be should not exceed 1-2 paragraphs (size increment). A
performed using the separate Cover Test (both unilateral larger difference may be indicative of a refractive defect
and alternating) for a fuller evaluation (see later). or a pathological problem.
Examination
Preliminary
Reading Distance Dominant Eye
It is important to know the patient's usual or required wor- Before proceeding to refraction, it is useful to know which
king distance. This may vary considerably from one person of the patient’s eyes is dominant. Just as people are right-
to another; for example close precision work at 25 cm, or left-handed, all generally have a preference for one eye.
work with different computer screen positions, or specific Use the CheckTest™ (Figure 14) to determine which eye is
tasks such as reading sheet music. The visual environment
dominant. Have the patient hold the CheckTest™ at arm’s
may also vary widely. It is therefore important to unders-
tand fully the patient’s main near tasks, by asking for detai- length and look through the hole within it, with both eyes
led descriptions or even simulations. This way, you may tai- open, at a distant target. Occlude one of the patient’s eyes
lor their visual correction to suit. at a time and have them compare the position of the tar-
get within the hole of the CheckTest™. The dominant eye
The reading distance varies in accordance with the patien- is the one for which the target remains most centred when
t’s tasks and habits and often also in relation to their phy- the other eye is occluded. The ocular dominance may or
sical size. To check a patient’s habitual reading distance, may not correspond with the patient’s hand dominance.
ask them to hold a reading test card where it feels comfor- Knowing which eye is dominant has a threefold interest:
table to them; measure the distance from the eye to the - some consider it preferable to start refraction with
card. This distance is usually comparable with Harmon’s the non-dominant eye so the subject can ‘practise’ before
Distance, the distance from the elbow to the tip of the the refraction of the dominant eye is determined;
index finger when it is touched to the thumb (see Figure - during binocular balance, if the perfect balance can-
13); this is a benchmark measurement which generally not be obtained, the dominant eye should be favoured;
represents the reading or writing distance at which a per- - during dispensing, the centring of the lenses may be
son should be able to read comfortably. Observe whether adapted to suit any strong lateralisation, as this may have
the patient reads naturally at, closer than or further than an impact on the patient’s head and eye posture when loo-
this distance. This may provide further information regar- king, particularly at near.
ding the patient’s level of vision (weak or good), accommo-
dative capacity (sufficient or not) and binocular behaviour
(esophoric or exophoric). Finally, during this test check
whether the patient reads centrally or tends to offset the
text to the right or left.
Figure 13: Reading Distance and Harmon’s Distance Figure 14: Determining the Dominant Eye (using the
CheckTest™)
Examination
Preliminary
Screening for Binocular Vision Anomalies 15a

2
The following tests may be undertaken:
- checking fusion by means of a red filter: the aim

is to assess the patient’s level of binocular fusion by par-
tially dissociating the images of the two eyes. Have the
patient look at a distant point of light (for example, a pen
torch at 5-6m). Place the red filter over one eye. If fusion
is good, the patient will see only a single, pink light. If
fusion is weak and thus disturbed, the patient will see
either two lights (one white, one red in the case of com-
plete dissociation of the eyes) or a single light (either white
or red, depending on which eye is suppressed). If sup-
pression is incomplete, the patient may see one light,
alternating red and white (depending on which eye is sup-
pressed). Perform this test by placing the red filter over 15b
each eye, one at a time. The point of light is seen as a dar-
ker pink (‘more red’) when the red filter is placed over the
dominant eye.
- screening for heterophoria or tropia with the

Cover Test: the aim is to check whether the subject has
a latent deviation of the visual axes, for which they may
have difficulty compensating. Have the patient focus on
a target (this test should be performed both at distance
and near). Place an occluder in front of one eye then
remove it (Unilateral Cover Test). Observe if and how the
eyes move under cover, immediately after having been
under cover, and while the other eye is covered. Note
the direction in which the eye(s) move(s) to recover fixa-
tion once the cover has been removed. If an eye realigns 15c
itself (to fixate on the target) via a temporo-nasal move-
ment, the eye was turned out under cover and so the
patient has an exophoria. If the movement is naso-tem-
poral, the patient has an esophoria. If the eye does not
move, the patient has orthophoria. The unilateral cover
test should be performed by covering first one eye, then
the other. The alternating cover test involves the trans-
fer of the occluder directly from the first eye to the
other, and back again, before uncovering and returning

the patient to the binocular state. The movements of
the eyes under cover and after removal of the cover, pro-
vide information as to the presence of phoria and tropia.
The amplitude and speed of the movements (phorias or
tropias) should also be noted. These findings constitute
Figure 15: Screening for Binocular Vision
only a preliminary indication, as heterophoria poses a
Anomalies (using the Cover Test)
problem only if its compensation proves difficult.
These preliminary measurements generally provide a

wealth of information and usually allow some of the
patient’s problems to be identified before going on to per-
form refraction itself.
Supplement:
Supplement
Visual Acuity
Visual acuity is, by definition, the capacity of the eye to distinguish There are many types of visual acuity scale:
the smallest details of a high contrast object; that is, its finest - depending on the type of optotype used: letters, numbers,
detail resolution achievable. It was defined by Dutch ophthalmo- the Landolt ring or C (1888), Snellen's E (1862), pictures, etc.
logist Herman Snellen (1834-1908) as the inverse of the angle, - depending on the progression of acuity values: scales may
expressed in minutes of arc, subtended at the eye by the smallest be decimal (Monoyer, 1875), angular (in minutes of arc (Mercier,
detail that can be distinguished by the eye. The human eye can,
1944)), inverse (1/10, 1/9, 1/8 etc.), rational, (that is, inverse for
on average, discriminate between two points separated by an
angle of 1 minute of arc (that is, 1/60th of one degree). That value the low acuities then decimal for higher acuities (Lissac, 1956)), or
(established by German ophthalmologist Hermann Von Helmholtz, logarithmic (Bailey and Lovie, 1976).
1821-1894) has been accepted as a universal benchmark.
(However, it is important to remember that even amongst a popu- This logarithmic scale presents an arithmetic progression by 0.1
lation of people with normal eyesight, there is a range of normal unit step of the logarithm of the Minimum Angle of Resolution
10
visual acuity and some will see finer detail than the 1 minute of arc (MAR); in other words a geometric progression of √10 = 1.259 of
average). the MAR. This regular progression of size between each line of the
chart means that the value of the angle is halved (doubled) every
It is important to note also that visual acuity is the measure of the 3 lines and multiplied (divided) by 10 every 10 lines. (For exam-
eye’s maximum ability to resolve detail of high contrast; it is a
ple, descending from the large letters to the smaller, the size of the
measure of the eye’s maximum ability (the best achievable) and is
therefore measured under ideal conditions, that is, maximum letters on every 3rd line is halved and so the acuity is doubled.
contrast, good lighting level and with best refractive correction. Ascending from the smaller letters to the larger, the size of the let-
Therefore, visual acuity is noted at the end of the refraction; any ters doubles every 3 lines). This type of scaled chart offers a regu-
measurements of vision with prior glasses, or without any refracti- lar progression, flexible test distances, an identical number of
ve correction, are not measurements under best conditions and so optotypes (and therefore an identical visual task) on each line of
are measurements of “uncorrected vision” or “vision with current the chart, a coherent choice of letters and simple conversion of the
correction/corrected vision” rather than a true measure of “best visual acuity measurement at all distances, and has therefore
corrected visual acuity”. become an international standard (Figure 16).
Many acuity scales have been created by many authors; this is not
Distance Vision an exhaustive list.
In the ordinary refractive practice, the eye care professional deter-
mines morphoscopic or image recognition acuity (by having the
patient read a variety of letters which they must recognise by dis-
criminating the letter detail and recognising its shape), rather than
actually determining the minimum discrimination of the eye, as is
tested when using the E or C charts, for example (where the same
symbol is used throughout the chart and so it is discrimination
which is tested rather than letter recognition).
Visual acuity notation differs from one region of the world to ano-
ther. Generally speaking:
- in Latin countries, the notation is decimal (0.1, 0.2, 0.3, …,
1.0, etc.) or expressed in tenths (1/10, 2/10, 3/10,…, 10/10, etc.).
It corresponds with the inverse of the angle subtended at the eye
by the critical detail of the optotype: 10’ of arc for 1/10, 5’ for
2/10, 2’ for 5/10, 1’ for 10/10, etc.
- in English-speaking countries, the notation is expressed as a
fraction of six (6/60, 6/36, 6/30,…, 6/6 etc.) or twenty (20/200,
20/120, 20/100, …, 20/20 etc.) depending on whether the stan-
dard test distance is referred to in metres or feet (6 metres ~ 20
feet; 1 foot = 0.3048 m). This notation uses the Snellen fraction
principle where the numerator represents the test distance and
the denominator the distance at which the smallest detail of the
optotype subtends an angle of 1 minute of arc at the eye (that is,
the distance at which it can be deciphered by a subject with visual
acuity of 1.0 (the reference benchmark for average, normal
vision)). Thus acuity of 6/12 (20/40) indicates that the subject can
read at 6 metres (20 feet) what a person with normal, average
acuity of 1.0 can read at 12 metres (40 feet). For the same nume-
rator (test distance), the larger the denominator, the worse the
visual acuity. Calculating the Snellen fraction gives the decimal
notation (for example, 6/6 = 20/20 = 1.0).
Figure 16: Logarithmic Acuity Progression Scale
Conventionally, the height of an optotype corresponds to five
times that of the detail to be distinguished: the thickness of the (Bailey-Lovie distance chart)
strokes of the characters and the gap of the letter C represent, for Published with the kind permission of Ian Bailey and Jan Lovie-Kitchin.
example, one fifth of the total height of the character (optotype). Original reference: New Design Principles for Visual Acuity Letter Charts, Ian L.
That is, the height of an optotype subtends an angle of 5 minutes Bailey and Jan E. Lovie, American Journal of Optometry and Physiological Optics,
of arc at the eye. Letter width may be 4 or 5 times the detail to 1976.
be distinguished. There exist international standards which stipu-
late letter formats (for example, 5 x 4 and non-serif in form) and
specify the optotypes or the limited selection of letters to be used,
those being letters of similar legibility.
Supplement
Near Vision - If P4 is read at 50 cm acuity is 0.50 m / (4 x 0.25 m)

Two different approaches can be used to assess the visual per- = 0.5 (5/10), and if P1.5 is read at 45 cm acuity is 0.45 m / (1.5
formance of a patient in near vision: the patient’s visual acuity x 0.25 m) = 1.2 (12/10).
can be measured by means of a near acuity scale, or the patien- Many versions of this scale have been published. It is used today
t’s reading capacity can be measured by texts using characters more out of tradition than for its qualities of precision and sim-
of different font sizes. (Note that the measurement of near plicity.
visual acuity is a different task from the assessment of a patien- - Scale and notation in typographic points (N notation):
t’s reading capacity; the latter may be more representative of used predominantly in English-speaking countries, this scale uses
day to day near visual function and activity). standard typographic units (font sizes). It uses the ‘Times Roman’
typeface and the paragraphs are graduated according to the size
Near Visual Acuity Scales of the characters, expressed in typographic points (N5, N6, N8
As with distance vision, there are many different near visual etc.). Near reading performance is noted by N (for ‘Near’), follo-
acuity scales. The most commonly used is the logarithmic pro- wed by the size of the character, along with the reading test dis-
gression scale, a near version of the scale used for distance tance (for example, N5 at 40cm). The advantage of this test is
vision. that reading performance is assessed on exactly the same types
of printed material as those the patient is likely to encounter in
The benefits of the logMAR system for near are those as outli- daily life.
ned above, for distance assessment. On the Bailey-Lovie word - Jaeger scale and notation (J notation): often used in the
reading chart, a variety of words of different lengths have been United States of America, this scale also uses typographic cha-
specifically chosen to ensure a consistent task at each line, and racters with a notation depending on the size of the typeface font.
the text is composed of unrelated words rather than an extract The notation is, for example, J1, J2, J3, etc, the J being from the
of text, such that the patient is obliged to read each word rather name of its inventor (Viennese ophthalmologist Eduard von
than guess from the context of the sentence; this provides a Jaeger, who developed this system in 1854) and the number indi-
more accurate assessment of their near acuity. Again, the regu- cating the size of the font. Unfortunately, the sizes of the charac-
lar progression of size between each line of the chart allows for ters are not standardised. There have been numerous variants of
easy conversion and flexibility of test distance and confidence this scale with arbitrary graduations and variable character sizes.
of predictability of performance for changes in different factors. Despite its imprecision, it is still in extensive use.
For these reasons the near logMAR chart is universally recogni- - Metric scale and notation (M notation): this system was
sed and has particular application in research and low vision developed by two American research scientists, Louise Sloan and
assessment. There exists also the Bailey-Lovie reading chart Adelaide Habel, in 1956. The size of the characters is described
where the text forms a coherent sentence or phrase, to reflect by the letter M preceded by a number which is the distance in
a reading task. metres at which the characters subtend at the eye an angle of 5
minutes of arc. The detail to be distinguished is conventionally
Reading Capacity Measurement Scales equal to one fifth of the height of the character. Therefore, for
Scales and types of notation differ from country to country; example, the notations 1.0M and 0.50M mean that visual acuity
only the most common methods are listed here: is 1.0 at the distances of 1.0 m and 0.50 m, respectively. The
- Parinaud’s scale and notation (P notation): very widely size of the letters is specified in M units corresponding to a height
used in French-speaking countries, this scale was developed in 1.45 mm: thus, 1.0M corresponds to a character of height 1.45
1888 by French ophthalmologist Henri Parinaud. The scale is mm, 0.50M to 0.725 mm, etc. To know the M value of a text,
calculated for a distance of 25 cm, with an arbitrary 20% simply divide the height of the letters by 1.45. This M unit also
reduction in the size of the characters relative to distance vision corresponds to the acuity denominator expressed as a Snellen
scales (4’ of arc of visual angle instead of 5’). This reduction is fraction. This type of notation is internationally recognised, is
designed to take into account the effects of reduced pupil size simple and practical and has proven to be particularly useful in
for near vision and thus render the scale comparable to the dis- low vision assessments.
tance visual acuity test. Each paragraph corresponds to acuity
of 1.0 for the reference distance and so permits near visual The common thread amongst these different near scales is, simi-
acuity to be estimated in accordance with the distance, by the larly as for distance visual acuity, the patient’s visual performan-
ratio of reading distance/reference distance (the reference dis- ce is assessed by noting the size of the smallest characters deci-
tance being equal to 0.25 m x Parinaud Number). Thus: phered, necessarily accompanied by the test distance used. For
- if P1, P2, P4 are read at the reference distances 0.25 example, P1.5 at 37 cm, N5 at 40 cm, J2 at 40 cm or 0.4M at
m, 0.50 m, 1.00 m, respectively, this corresponds to an acuity of 40 cm are considered as good levels of near vision.
1.0 (10/10).
3. Objective Refraction
Refraction
Start the refractive examination by determining the objective refraction, so called because it does not rely on any input from the
Objective
patient. To determine the objective refraction, the eye care professional can use either the technique offered by auto-refractors, or
the classic technique of retinoscopy. Whatever the method used, objective refraction should always be performed, but can consti-
tute only an initial approach to refraction which must be confirmed subsequently by a subjective refraction examination. Only in
exceptional circumstances, where subjective refraction is impossible, such as in the examination of a baby, young child, or another
patient who is unable to communicate, should the objective refraction be used for the final prescription.
A Auto-Refractometry
Automatic refractometry is a quick and easy way of Auto-refractors also often integrate a keratometry mea-
obtaining an objective measurement of the patient’s surement. As well as the obvious application that this
refraction. measurement has to the fitting of contact lenses, it can
also be used to assess whether the patient’s ametropia
The patient places their head in the appropriate chin is more axial or refractive.
and forehead rests of the instrument, so as to be still,
and then fixates on the target inside the instrument, While it is not desired to discredit the contribution of
whilst blinking normally as required. The practitioner these instruments in any way, it is important to state
then moves the instrument until it is centred on the clearly that the auto-refractometry measurement alone
patient’s eye and the image of the eye is focussed. cannot suffice to determine a patient’s refraction and
When this is the case, the measurement may be taken that, where possible, it should always be complemen-
automatically or manually, depending on the mode ted by a subjective examination.
selected. A series of measurements is taken and the
average value is calculated. The process is repeated for
the other eye and results may then be printed.
Most auto-refractors operate on the principle of the

emission of an infrared light beam. An opto-electronic
sensor captures the image of this beam after it has been
reflected by the retina and has passed through the eye
twice (that is, upon entry and exit). This image is pro-
cessed and analysed by computer software and the
refraction value is extracted. Different optical principles
are used depending on the instrument. For further
details please refer to the technical data supplied by the
instrument manufacturer.
Despite the progress achieved, auto-refractors do not

yet provide a perfectly reliable measurement of refrac-

tion. The sphere is often over-minussed (that is, myopia
is over-estimated and hypermetropia under-estimated)
because of the stimulation of accommodation when loo-
king inside the instrument (instrument myopia). Indeed,
the higher the degree of ametropia, the greater the deg- Figure 17: Auto-Refractor
ree of imprecision. This is why it is important to ensure
that the patient is properly relaxed during the measure-
ment and to use the result only as a first step in deter-
mining the patient’s refraction. The cylinder too is often
over-estimated and the precision of its axis (often to the
degree) is sometimes falsely excessive. The fixation and
attentiveness of the patient may also affect the precision
of the measurement. The art of the practitioner lies in
being able to manage these factors in order to obtain a
useful measurement, which is indeed more difficult to
achieve than it might appear.
Refraction
Objective
B Retinoscopy
Retinoscopy (or skiascopy, from the Greek skia = The direction, speed and brightness of the reflex are
shadow and skopein = examine) is a technique which related to the refractive error (the brighter the reflex
permits an estimation of the refractive status of an and the faster its speed, the lower the refractive
eye, based on the movement of the light reflex from error). The observer assesses the form, movement
the eye, as observed through an optical instrument and brightness of the reflex and places appropriate
known as a retinoscope. It was introduced at the end lenses in front of the eye until the speed of move-
of the 19th century by Ferdinand Cuignet, a French ment of the reflex is infinitely quick (“reversal”). The
military ophthalmologist (1823-1889). Being an power of the lens at which reversal is achieved is the
objective technique, it does not require any patient amount which neutralizes the refractive error of the
input and is therefore useful as a pre-subjective eye. In the case of astigmatism, neutralization is
refraction tool for all patients, but particularly determined independently in each principal meri-
infants and those unable to communicate. It also dian.
provides incidental information about the clarity and
regularity of the ocular media and hence the antici- A working distance lens (generally either +1.50D
pated level of vision. (67cm) or +2.00D (50cm)) must be placed in front
of the eye during retinoscopy to account for the fact
Retinoscopy was derived from ophthalmoscopy and that the observation is made through the retino-
is similar to the technique of manual lens neutraliza- scope which is not at optical infinity. This working
tion (and the fundamentals of vertometry/lensome- distance lens must be considered separately from
try/focimetry). The light from the retinoscope is the power of the lens at which neutralization occurs.
shone into the patient’s eye and the retina acts as a
reflective screen over which the light is moved; the The most common kind of retinoscopy is static reti-
light reflected from the retina (now acting as a secon- noscopy as outlined above. Within this there are two
dary light source) and different kinds: spot and streak (depending on the
hence out of the eye is form of the light shone from the retinoscope). There
called the “reflex” (as are also other, less common techniques by which
with the red reflex retinoscopy may be used, including Mohindra Near
through the pupils in a Retinoscopy and Dynamic Retinoscopy, which may
flash photograph). The provide an assessment of the refractive and accom-
retinoscope is tilted such modative status at near.
that its light sweeps
across the eye; in com- Accommodation must be stabilized during retinosco-
parison to the movement py and for this reason it is performed in the dark and
of the light from the reti- the patient is given a distance target to observe. The
noscope, the reflex will size of the target is large, so it may be seen through
move in the same direc- the blur caused by the working distance lens.
tion (“with” movement) Cycloplegia may also be induced prior to performing
or in the opposite direc- retinoscopy and this is particularly useful when
tion (“against” move- assessing young children and patients with large
ment). amounts of latent hypermetropia.
Figure 18: Retinoscope
Refraction
Objective
Figure 19: Different Reflex Effects in Retinoscopy
With movement
Against movement
Oblique effect
Neutralization point or “reversal”

The use of retinoscopy requires experience which may

be acquired only by regular practice. Although the tech-
nique takes longer to master than that of auto-refracto-
metry, it can prove just as efficient and at times more
practical.
4. Subjective Refraction
Distance Vision
Subjective
Refraction
Subjective Refraction is a technique used for determining the refractive error of the eye and involves the patient’s ability to discern
changes in the clarity of the test object when different lenses are placed in front of their eyes. By definition, it requires patient input.
Subjective Refraction will usually be performed as a check and “fine tuning” following an initial, objective assessment of the refrac-
tion. The starting point may be the objective refraction result or a previous prescription. Subjective refraction is performed mono-
cularly at first, then verified in the binocular state thereafter. The recommended order for the process of performing subjective
4
refraction is: monocular determination of the sphere, cylinder axis and power of each eye, followed by performance of binocular
balance. Minus cylinders should be used.
The method described below is a proven method, but just one of many possible methods of subjective refraction.
A Determining the Sphere

The so called ‘fogging’ method may be used to find the will experience even greater blur if they accommodate,
sphere. The idea behind this method is that a blur or ‘fog’ and so they gradually relax their accommodation to
is created initially, with the aim of relaxing the patient’s minimise the blur. The method involves placing a (plus)
accommodation. This may be achieved because the patient lens in front of the patient’s eye so as to bring the reti-
nal image forward and in front of the retina, causing blur,
Figure 20: Principle of the ‘Fogging’ Method then gradually reducing the power of this lens until the
a) fogging with +1.50D image is brought back into focus on the retina. The most
suitable level of fog has been determined to be that
which reduces the patient’s vision to the level of ~0.16
(generally ~+1.50DS); any greater blur than this may
induce accommodation to the tonic level, rather like the
accommodative tone exhibited in dark focus, and less
blur may not control accommodation sufficiently.).
The sphere is firstly determined monocularly. Many

practitioners perform refraction in the standard order of
right eye then left eye (then binocularly), and this has
the advantage of minimising transcription errors when
noting results. Others believe it is helpful to perform
b) fogging with +0.75D
refraction on the non-dominant eye firstly, so the patient
may learn the technique and be sure to give good
responses for the dominant eye tested thereafter.
This method is detailed below:
1) Place the starting correction (objective refraction

or previous prescription) in front of the patient's eye

(occlude the other eye) and measure and record the cor-
rected vision.
2) Fog (blur the patient) by adding +1.50 D (For this

power of sphere, vision would be expected to drop
c) with the best vision sphere in place to ~0.16)
a. If vision is now better than 0.16, the patient is
insufficiently fogged, implying that the initial correction
was insufficiently plus; fog by further increments of
+0.25D until vision is reduced to the ~0.16 level.
b. If vision is now worse than 0.16, this implies that
the initial correction was excessively plus or insufficient-
ly minus; start to remove fog, in increments as detailed

below.
Subjective
Refraction
3) Remove fog progressively in steps of 0.25 D 4) Continue to remove fog until the level of vision
(that is, add -0.25D per step) and check at each step does not improve further; that is, until the level of
that vision improves (by approximately one line per vision reaches a plateau.
4
0.25D)*
* Theoretically, each 0.25D reduction of fog should
improve vision by one graduation on the inverse acuity 5) Return to the sphere prior to the last removal of
scale (known in France as “Swaine’s Rule”) in accordance fog that did not give an improvement in vision; that
with the theoretical sequence below for spherical ame- is, select the most plus (least minus) sphere giving
tropia (or the spherical equivalent of the ametropia in maximum vision at this stage (in order to prevent the
the case of astigmatism). The rule: ametropia = sphe- retinal image from shifting back behind the retina, so
re value – 0.25 D / level of vision (see table). The exam- allowing the patient to accommodate). Bear in mind
ple given is that of an emmetropic eye with initial cor- also the sphere expected from the level of uncorrected
rection of plano and average normal visual acuity of 1.0: vision and consider if it is consistent with this finding. (At
this point, if starting from plano rather than the objecti-
ve refraction result, the sphere is the Best Vision Sphere,
and the vision is the best achievable with a spherical cor-
1.0 1.0 • •
rection alone).
1/2 0,5 • •
1/3 0,33 • •
1/4 0,25 •
1/5 0,20 •
1/6 0,16 •
1/7 0,14 •
1/8 0,12 •
1/9 0,11 •
1/10 0,10 •
+2,50
+2,25
+2,00
+1,75
+1,50
+1,25
+1,00
+0,75
+0,50
+0,25
0
-1,00
-2,00
-3,00
-4,00
Fog / Brouillard Accommodation (=3,00D)
Figure 21: Level of Vision and Removal of the Fog
Fog (on top of Effective ametropia

starting refraction) Acuity as fraction Acuity as decimal
with fog in place
+1.50 D 1/6 0.16 = 1.6/10 Sph -1.50 D
+1.25 D 1/5 0.2 = 2/10 Sph -1.25 D
+1.00 D 1/4 0.25 = 2.5/10 Sph -1.00 D
+0.75 D 1/3 0.33 = 3.3/10 Sph -0.75 D
+0.50 D 1/2 0.5 = 5/10 Sph -0.50 D
+0.25 D 1/1 1.0 = 10/10 Sph -0.25 D
During removal of the fog:

- if vision does not improve (or worsens) when the
power of the fogging lens is reduced by a further 0.25 D,
the patient may have accommodated by 0.25 D (or
more). In this case, wait a few seconds to allow the
patient to relax accommodation and check their vision
again.
- check that the improvement in vision is consistent
with that expected; the level of vision can be used at any
time to estimate the effective ametropia with the fog in
place, in accordance with Swaine’s rule
B Determining the Cylinder
Subjective
Refraction
After determining the sphere, the next step is to determine the power and axis of the cylinder. The cylinder axis is determined
firstly, followed by the cylinder power
The method detailed below uses the Jackson Cross Cylinder. During this procedure it is best to have the patient look at a round
target; for example, either a letter O (of appropriate size for their level of vision) or the cluster of round dots available on many
projector charts.
4
Jackson Cross Cylinders are available in powers including ±0.25D and ±0.50D. The ±0.25D cross cylinder will permit a more
accurate result but it will be more difficult for the patient to discern the difference between the images during refraction. Some
consider it most appropriate to use the ±0.25D at all stages, changing to the ±0.50D only when the patient has impaired vision
and is unable to distinguish between the images presented. Others consider the ±0.50D should be used when determining the
cylinder axis and the ±0.25D when determining the cylinder power.
USING THE OBJECTIVE REFRACTION 22a

OR PREVIOUS PRESCRIPTION AS A
STARTING POINT
1) Determining the cylinder axis:
Have the patient look at a letter (of a size appropriate for
their level of vision), preferably a round letter such as an
O, or the cluster of dots, throughout the duration of
using the cross cylinder.
a. Position the handle of the cross cylinder 22b

along the axis of the corrective cylinder (in the trial
frame or phoropter). Advise the patient that it is normal
for this to cause a worsening of the vision. This is the
position 1 of the cross cylinder.
b. Twist the cross cylinder quickly (around the axis
of its handle) so as to present the alternative view, posi-
tion 2. Ask the patient to indicate which of the two posi-
tions offers clearer vision (that is, a sharper, blacker,
rounder target) by asking a question such as “Which view
gives rounder, clearer, sharper dots?” or “Which view is 22c
less blurred, 1 or 2? …or are both views equally blur-
red?”; note the location of the negative axis of the cross
cylinder for this preferred position
Remember that the patient’s vision is blurred slightly by
the cross cylinder and so both positions may be blurry;

reassure the patient that you seek to know which view is
clearer, or more correctly “less blurred”.
You may need to repeat the presentations of positions 1
and 2 by continuing to twist the cross cylinder and pre-
senting the two positions, to allow the patient several
views to help them decide between them, particularly if
22d
the difference is minimal. Sometimes both views may
appear equally blurred to the patient.
c. Change the axis of the (minus) corrective

cylinder by 5°, turning it towards the location of the
preferred minus cross cylinder position.
d. Repeat steps a to c until the patient can see

no difference or almost no difference between the
two positions (views). The corrective cylinder is now
lined up along the correct cylinder axis (that is, the axis Figure 22 a, b, c, d: Determining the Cylinder Axis
of astigmatism), as is the handle of the cross cylinder.
Subjective
Refraction
2) Determining the cylinder power: 23a
a. Position the negative axis of the cross cylin-

der along the axis of the (minus) corrective cylinder.
This is position 1.
b. Twist the cross cylinder to present position 2
and ask the patient to indicate which position gives clea-
rer (less blurred) vision.
c. If the patient prefers position 1 (minus axis of

the cross cylinder along the axis of the minus corrective
23b
cylinder), it indicates they prefer more minus cylinder, so
increase the minus corrective cylinder by -0.25D. If
position 2 is preferred, it indicates they prefer less
minus, so remove -0.25D.
d. Repeat steps a to c until the patient has no
or virtually no preference or the preference is rever-
sed. This is the cylinder power of the refraction.
So as to maintain the spherical equivalent, remember to

adjust the sphere power by +0.25DS for every extra
-0.50DC cylinder added, and by -0.25DS for every extra 23c
-0.50DC removed.
If hesitating between two cylinder powers (that is, if the

patient does not reach a point at which the two choices
are exactly equal), err on the side of prescribing the les-

ser (minus) cylinder power.
23d
Figure 23 a, b, c, d: Determining the Power of the Cylinder
Subjective
Refraction
WITHOUT PRIOR KNOWLEDGE OF THE 24a

REFRACTION
4
1) Determining the cylinder axis
The following bracketing method may be used:
a. Position the handle of the cross cylinder along

the horizontal axis (such that its principal meridians are

along 45° and 135°). This is position 1. Twist the cross
cylinder to present position 2 and ask the patient to indi-
cate which position gives clearer (less blurred) vision; note 24b
the orientation of the negative axis of the cross cylinder
for this preferred position (either along 45º or 135º).
b. Now position the handle of the cross cylinder
along 45° (handle along 45°, meridians along 180°
and 90°). This is position 1. Twist the cross cylinder so
as to present position 2 and ask the patient to indicate
which position gives clearer (less blurred) vision; note
the orientation of the negative axis of the cross cylinder
for this preferred position (either along 180º or 90º).
24c
By combination with the previous measurement (results
of steps a and b together), the cylinder axis of the
patient’s refraction is now known to be located within a
45° sector.
c. Position the handle of the cross cylinder
along the bisector of the 45 sector identified (or,
with experience, nearer the axis for which the subject
has expressed the clearer preference). Twist the cross
cylinder and ask the patient which view they prefer.
24d
d. Rotate the axis of the minus corrective cylin-
der 5° in the direction of the minus axis of the prefer-
red cross cylinder (or place it at the bisector of the resi-
dual angle between the handle of the cross cylinder and
the limit of the 45° sector).
e. Repeat steps c and d until the patient has no

preference or almost no preference of the two views
presented. The position of the handle of the cross cylin-
der now indicates the corrective cylinder axis. a, b, c, d: Localization of the cylinder axis within a
45° sector
Figure 24 a to l: Determining the Cylinder Axis
(without prior knowledge of the refraction)
Subjective
Refraction
24e which position gives clearer (less blurred) vision and note the
location of the negative axis of the cross cylinder, for the
patient’s preferred position. Rotate the axis of the correcti-
ve cylinder by a small increment towards the axis of the
negative cylinder of the cross cylinder.
© Essilor International e. Repeat step d until the patient has no preference
or almost no preference between positions 1 and 2. The
corrective cylinder is now aligned along the cylinder axis of
the patient’s refraction.
24i
24f
24j
24g
24k
24h
24l
e, f, g, h: Determining the cylinder axis using the cross cylinder

alone
Alternative technique:
c. Place a -0.50D corrective cylinder in the trial
frame or phoropter, at an axis located in the middle of the
45° sector identified.
d. Position the handle of the cross cylinder along
the axis of this cylinder (this is position 1); twist the cross
cylinder to present position 2; ask the patient to indicate i, j, k, l : Determining the cylinder axis using a trial cylinder and the
cross cylinder
Subjective
Refraction
2) Determining the cylinder power: 25a

4
Proceed as detailed above, considering the starting

point as the best vision sphere (in place) and the -0.50D
corrective cylinder (in place) used to refine the cylinder
axis.
Have the patient continue to fixate on the cluster of dots
or a round optotype on the distance chart. The power

of the corrective cylinder will be adjusted progressively
in steps of -0.25 D as the patient is presented the diffe-
rent views using the cross cylinder.
25b
a. Position the cross cylinder such that its minus
axis is along the axis of the (minus) corrective cylin-
der.
b. Twist the cross cylinder to present the two
views and ask the patient which position they prefer.
c. If the patient prefers the position with the

minus axis of the cross cylinder in line with the minus
axis of the corrective cylinder, add more minus (-0.25) D
to the corrective cylinder; otherwise remove -0.25 D.
Remember also to maintain the spherical equivalent - adjust 25c
the sphere power by +0.25DS for every extra -0.50DC
cylinder added, and by -0.25DS for every extra -0.50DC
removed.
d. Repeat steps a to c until the patient has no
preference between the two views of the cross cylinder,
almost no preference or their preference is reversed.
e. Select the value of the weakest minus correc-

tive cylinder giving maximum vision.
25d
Figure 25 a, b, c, d: Determining the Cylinder Power
Subjective
Refraction
AFTER DETERMINING THE CYLINDER An Astigmatic Prescription Should Always Be
Determined in Negative Cylinder Form
3) Final check of the sphere An astigmatic correction can be expressed in either
positive or negative cylinder form. However, the pres-
Once the axis and the power of the corrective cylinder cription is normally determined as a negative cylinder.
have been determined, proceed to a monocular verifica- The ‘fogging’ method described above involves blurring
tion of the sphere by means of + and -0.25 D spherical the patient’s vision by positioning both foci (of the prin-
lenses in order to confirm that the sphere obtained is cipal meridians of the astigmatism) in front of the retina,
actually the ‘maximum plus offering maximum visual then moving them back by gradually adding negative
acuity’. Thus: spheres in order to place the more posterior focus on
- with an extra +0.25 D, vision should be slightly the retina and subsequently merging the two foci into a
reduced; if it is not, add the +0.25 D and repeat the single point by using a negative cylinder to move the
checking of the sphere; more anterior focus posteriorly.
Depending on the country, however, practitioners and
- with an extra -0.25 D, vision should remain the
manufacturers may express the prescription in positive
same (or be slightly reduced). or negative cylinder form. The process of transposition
allows the conversion from plus cylinder form to minus
cylinder form and vice versa.
Figure 26: Final Monocular Verification of the Sphere

Transposition of a Sphero-Cylindrical Prescription
a) with +0.25 D: vision is reduced
To transpose a prescription from plus to minus cylinder
form and vice versa:
Step 1) the algebraic sum of the sphere + the cylinder
gives the new sphere
Step 2) change the sign of the cylinder=>this gives the
new cylinder
Step 3) change the axis of the cylinder by 90° (by

either adding or subtracting 90° as required so the
result is between 0° and 180°)=> this gives the new
cylinder axis
Example
b) with -0.25 D: vision remains the same To transpose -2.00 / +3.00 x 105 to minus cylinder
form:
Step 1) (-2.00) + (+3.00) = +1.00 (the new sphere)
Step 2) +3.00 becomes -3.00 (the new cylinder)
Step 3) 105 – 90 = 15 (the new axis)
so this prescription written in minus cylinder form is
+1.00 / -3.00 x 15
(Note that by convention, the degree symbol is not writ-

ten in a prescription; this is to avoid possible confusion.
For example, 18° may be confused with 180 and vice
versa).
Supplement:
4 Supplement
Estimating the Refractive The Jackson Cross Cylinder

Error from the Level of Determining astigmatism by the cross cylinder method
was made popular at the beginning of the 20th century
Uncorrected Distance Vision by American ophthalmologist Edward Jackson (1856-
The spherical equivalent of a patient’s refractive error 1942). The cross cylinder is a sphero-cylindrical lens,
may be estimated from their level of uncorrected dis- the spherical equivalent of which is plano. The principle
tance vision. Although attributed in France to the of the technique is to place the cross cylinder in front of
English physicist and optometry teacher William Swaine the patient’s eye and study the variations in vision that
(1894-1986) and called Swaine’s Rule, the rule is not result from the combination of the astigmatism of the
known by this name in the English-speaking world. The eye and that of the cross cylinder placed in different
rule stipulates that the level of vision is reduced by one positions.
step on an inverse scale (1/1, 1/2, 1/3, ¼, etc.) for each
A cross cylinder is a lens that combines two plano-cylin-

drical lenses of identical powers but with opposite signs.
Level of Vision Level of Vision Expected Ametropia The cylinders’ axes are perpendicular to each other
(decimal) (inverse scale) (spherical equivalent)
(hence the name ‘cross cylinder’). A ±0.25 cross cylin-
1.00 1/1 0.25 D der (that is, a cross cylinder created by combining
0.50 1/2 0.50 D
+0.25D and -0.25D cylinders) is a +0.25/-0.50 lens; a
±0.50 cross cylinder is a +0.50/-1.00 lens. This lens is
0.33 1/3 0.75 D
mounted in a special frame, the handle of which bisects
0.25 1/4 1.00 D the cylinder axes, such that the positive and negative
0.20 1/5 1.25 D axes of the cross cylinder may be easily swapped, by
twisting the handle (Figure 27).
0.16 1/6 1.50 D
0.14 1/7 1.75 D When placed in front of the patient’s eye and so combi-
0.12 1/8 2.00 D ned with the astigmatic eye, the cross cylinder accen-
tuates or reduces the astigmatism and consequently
0.11 1/9 2.25 D
causes variation in the level of the patient’s vision. The
0.10 1/10 2.50 D cross cylinder is twisted and so its two positions presen-
ted to the patient, who is then asked to indicate which
0.25DS of spherical refractive error. Thus a myopic position gives the better vision. The cross cylinder is
patient with refractive error of -0.50 D is expected to used in two different aspects of subjective refraction:
have uncor rected vision of approximately 1/2 (0.5), a determining the cylinder axis and the cylinder power of
myopic patient with refractive error -0.75 D uncorrected the patient’s refraction.
vision of 1/3 (0.3) and so forth (see table).
Detailed procedures for using the cross cylinder are des-
This rule allows the practitioner to estimate the patient’s cribed above.
refractive error from their level of uncorrected distance
vision and hence have an idea of the expected prescrip-
tion before starting objective and subjective refraction.
Also, during refraction using the fogging method, (which
involves rendering the patient effectively myopic by the
addition of a plus lens), the rule can be used to assess
the spherical blur created and thus anticipate the value
of the final ametropia of the subject. For example, if
during the initial fogging, the patient's vision is 1/6
(0.16), it can be estimated that the patient’s ametropia
is equal to the value of the fogging sphere – (6 x 0.25D)
= +1.50 – (1.50D) = plano; if vision is 1/5 (0.20), the
patient’s ametropia is ~ +1.50 – (5 x 0.25D) = +1.50
- 1.25 = +0.25D. The rule allows changes in vision to
be monitored during fogging and removal of the fog.
This rule is most effective for myopic refractive errors
and less consistent for hypermetropia or astigmatism. It
is not always a precise rule but may be used as a good
guide, allowing the practitioner to assess the consisten-
cy of the expected level of the patient’s ametropia with
the final refraction found. Figure 27: Jackson Cross Cylinders
Supplement
Note that the Duochrome Test is equally applicable to
The Duochrome Test those who have a colour vision deficiency; their altered
perception of colours (light of different wavelengths) is
The Duochrome Test may be used to check the spherical independent from the chromatic aberration of the eye. In
correction. It makes use of the natural axial chromatic this case, simply ask the patient to indicate the side of the
aberration of the eye which causes light of different chart on which they see the letters more clearly, rather than
wavelengths to be refracted differently by the eye. specifying “the red side” or “the green side”.
Longer wavelengths (perceived as red) are refracted less
than shorter wavelengths (perceived as green) and so Note also that the chromatic aberration of the eye changes
“red” light will be focussed more posteriorly than “green” with the changes that occur within the refractive media of the
light. (This gives rise to a range of focus rather than a eye with age; in particular, with the development of cataract.
true point of focus on the retina. The eye is in correct In this case, the Duochrome Test may be unreliable.
focus when the central point within this small range (cor-
responding to “yellow” light) is positioned on the retina). This test can be used for distance and near vision, in a mono-
The test is used to assess the eye’s focus by the obser- cular situation to check the sphere and in a binocular situa-
vation of characters on a red and green background. tion to balance the correction and for the final verification of
The patient is asked to look at the chart and compare the prescription.
the letters on the red and green backgrounds. The prac-
titioner may ask “On which side do the letters appear At near it may be used to assess the accommodative beha-
blacker and clearer? …or do they appear equally black viour of a young patient or to check the addition of a patient
on both sides?” Thus, as shown in Figure 28 with presbyopia.
a) if the patients sees the characters more clearly on the
red background, the central point of focus is anterior to
the retina and so a minus lens is required to correct
28a The Pinhole

The pinhole is a small hole (usually 1 – 2 mm in diameter) in

the centre of a solid black disc. Its principal use during sub-
jective refraction is that, in the case of reduced vision, it may
enable differentiation of its cause, between refractive and
pathological causes. For example, it may enable imprecise
refraction to be distinguished from amblyopia (‘lazy eye’).
28b
In practice, the pinhole is placed centrally in front of the
patient’s eye, over any correction already in place, and the

vision is measured. If vision is improved with the pinhole, the
cause of the reduced vision is a refractive one; for example
an uncorrected, or ill-corrected, refractive error. If vision is
not improved or becomes worse, the cause is not refractive
in origin and amblyopia or other pathology should be
suspected. In the absence of any pathology or opacity of
28c the refractive media of the eye, the level of vision obtained
with the pinhole should be able to be obtained by accurate

refraction.
Figure 28: The Duochrome Test

the focus onto the retina (e.g. undercorrected myopia or

overcorrected hypermetropia);
b) if the patient sees the characters more clearly on
the green background, the central point of focus is pos-
terior to the retina and so a plus lens is required (or the
patient may accommodate) to correct the focus onto the
retina (eg overcorrected myopia or undercorrected
hypermetropia);
c) if the patient sees the characters as equally clear
on the red and green backgrounds, the central point of
focus is positioned on the retina and the patient is pro-
perly focussed for this test distance.
In order to prevent any unwanted effects of accommodation

(which could lead to a preference for the characters on the
red side), the practitioner may have the patient look at the
green background before comparing it with the red, or the
practitioner may fog by +0.50 D to obtain a preference for Figure 29: The Principle of the Pinhole
the red and then remove fog gradually until a balance bet-
ween the red and the green sides is obtained.
Subjective
Refraction
C Binocular Balance
Having determined the refractions of the right and left 1) Dissociate the two eyes by:
eyes separately under monocular conditions, it is impor- - alternate occlusion: this involves occluding first
tant to ensure that these refractions correspond well one eye then the other and rapidly continuing to alter-
under binocular conditions. This is the aim of binocular nate this occlusion such that the patient sees with both
balance. The spherical component is adjusted as neces- eyes but never simultaneously. During this test, the
sary to equalize the accommodative effort of the two eyes, patient should never be placed in binocular vision condi-
tions where both eyes see the target at the same time.
so that the retinal images of both eyes may simulta-
In particular at the beginning of the test (that is at the

neously be in focus. If this is not the case, asthenopia may end of monocular subjective refraction), occlude the eye
result, as accommodation is destabilized. that is open before uncovering the eye that is still closed.
Initially, the patient should be placed in (incomplete) bino- - vertical prism: this involves placing a total of 6
cular vision conditions in such a way that both eyes see base down right to dissociate the eyes, split between the
separate views of the same test (simultaneous monocular eyes (3 BDR and 3 BUL) so the effect of the prism len-
vision). With each eye seeing the same image separately, ses on the quality of vision is equal for each eye. The
the right and left eyes’ vision can be compared and the introduction of this prism results in two images: the
best refractive balance found. higher image is seen by the right eye, the lower by the
left eye and thus the patient may compare the two ima-
ges/eyes.
Various methods can be used to achieve such “simulta-
neous monocular” vision conditions. The two eyes are dis- - polarizing filters/lenses: this method achieves
sociated such that either (i) both eyes see the same target dissociation by the use of polarized targets and polari-
but never simultaneously, or (ii) each eye sees a different zing lenses of mutually perpendicular orientations.
image of the same target and both are viewed simulta- Targets may include letters or polarized duochrome
neously. The patient is then asked to compare the clarity charts.
of the two images. If one is seen more clearly than the
other, plus lenses are added to the eye seeing the clearer 2) Fog binocularly by +0.50 D: Vision is reduced
image, until the two eyes see equally clearly. If there is slightly and such blurred conditions enable the patient
never a point at which the patient sees equally clearly with to make a comparison more easily.
both eyes, the dominant eye should be favoured and left
slightly clearer. 3) Ask the patient to compare the images (which
will be slightly blurred) seen by the right and left
Note that most binocular balance techniques can be per- eyes and indicate which eye sees more clearly (image
formed only when the patient has equal visual acuity in less blurred)
both eyes; only certain techniques allow some binocular
balance to be achieved when the visual acuities are 4) Equalise the vision (equalise the blur) of both
unequal (for example, the doubled duochrome method). eyes by further fogging the eye which sees more clearly
(less blurred). Do this by adding plus lenses in +0.25 D
Procedure: steps until both eyes see equally. If both eyes never see
1. dissociate the two eyes equally, favour the dominant eye (leave it slightly clea-
2. add +0.50 D fog rer) so that the refractive correction respects the natural
3. have the patient indicate which eye sees more clearly ocular dominance.
4. add plus lenses in front of this eye until the both eyes
see equally (If both eyes never see equally, favour the 5) Remove +0.50D from both eyes, place the patient
dominant eye (leave it slightly clearer)). in full binocular vision conditions (both eyes open, vie-
5. Remove +0.50 D from both eyes. wing the same target) and check the level of vision, bino-
cularly.
Note that binocular balance may be performed at both

distance and near (see below).
Subjective
Refraction
Figure 30: Binocular Balance
a) + 0.50 D fog
b) balance in the blur/fog © Essilor International

c) removal of fog binocularly

D Final Check of Binocular Sphere, Subjective
Subjective
Refraction
Appreciation and Comfort (including Binocular

Vision Screening)
Finally, having determined the refraction of each eye 3) Now, in the same manner, place -0.25 D in
separately and balanced one with the other, the front of both eyes.
4
sphere must be confirmed binocularly. The patient’s a. If vision is worse, the refraction result in the
binocular visual acuity may then be measured and trial frame is now correct. This is the final refraction.
furthermore their subjective appreciation of the final b. If there is no change, the refraction result in
prescription judged. the trial frame is correct or slightly over-minussed.
Make a judgment whether or not to add the extra -
Preferably, this final binocular verification of the
0.25D.
sphere should be performed using a trial frame to

allow more natural visual and spatial conditions than c. If vision is better, the refraction is over-plus-
those achieved when the patient is positioned sed or under-minussed: add -0.25 D and repeat step
behind a phoropter. 3). If >-0.50 needs to be added, redo the refrac-
tion.
Have the patient look at distance at some small
detail. Present ±0.50D and ±0.25D binocularly In summary, the response sought during binocular
over the existing correction and ask the patient to verification of the sphere correction is a reduction of
choose which lenses give the best vision. Record the clarity and comfort with an extra +0.25 D and an
binocular visual acuity. absence of real change observed with an extra -0.25 D.
The value of the sphere in the patient’s refraction
Remember to take into account in the final prescription should be adjusted binocularly in order to obtain
the fact that the subjective refraction has been perfor-
this result.
med at a finite distance and not at optical infinity. For
this reason, when judging the final binocular sphere and
comfort of the prescription, it is preferable to have the
patient look outside, at the horizon. Indeed, the conven-
tional test distance does not correspond to optical infi- Figure 31: Binocular Check of the Sphere, Subjective
nity. Subjective refraction performed using a chart at a Appreciation and Comfort
distance of 6m gives rise to an error of 1/6m = 0.16D;
5m to an error of 1/5m = 0.20D. Although these errors a) with +0.25D – vision is blurred
are less than a prescribing increment of 0.25D, they are
nonetheless potentially significant and may necessitate
the adjustment of the final prescription by -0.25DS
binocularly.
The binocular sphere may be checked as follows:

1) Place the subjective refraction result in the trial
frame and have the patient focus as far away as possi-
ble (for example, on the horizon), looking with both eyes
open.
2) Place an extra +0.25 D in front of both eyes b) with -0.25D – vision is unchanged
(using a binocular lens holder) and ask the patient if this
makes their vision ‘better, worse or no different’.
a. If vision is worse, the refraction result in the trial

frame is correct or over-plussed. Do not add the extra
+0.25D to the refraction result. Go on to step 3).
b. If there is no change, the refraction result in the
trial frame is over-minussed or under-plussed; add the

+0.25 D binocularly to the refraction result and repeat
step 2).
c. If vision is better, the refraction result in the trial
frame is (even further) over-minussed or under-plussed;
add +0.25 D and repeat step 2). If >+0.50 needs to
be added, redo the refraction.
Subjective
Refraction
Binocular Vision Screening
At this stage of the examination, it is important to check the
patient’s binocular vision; more precisely, it is important to
confirm that the patient has good simultaneous vision and
that the images perceived by both eyes are fused without
difficulty. To evaluate this, the patient’s binocular vision
must be dissociated in order to check that:
1) there is not total or partial suppression of the vision
in one eye, by ensuring the permanent presence of two
images
2) there is not potential deviation or significant pho-
ria, by checking the alignment of the two images. Figure 32: Dissociation by Prisms
Note that simultaneous vision may already have been - Conversely, if the image seen by the right eye is to
observed during the binocular balance test. the left and the image seen by the left eye is to the right,
there is exophoria.
Depending on whether binocular vision is dissociated by - Most people have some degree of heterophoria.
means of prisms, red-green filters or polarized filters, for This poses a problem only if compensation for it proves
example, one of the following tests could be carried out: difficult, for example.
Dissociation by coloured filters (Schober test):

Dissociation by prisms (Von Graefe method)
This test is comprised of a red cross and 2 green circles
Its principle is to dissociate binocular vision by means of seen through red and green filters by the right and left
vertical prism. The patient looks at a line of letters, first eyes. The eye fitted with the red filter sees the red cross;
vertical then horizontal. Proceed as follows: the eye fitted with the green filter sees the green circles.
a) Place a 6 base down prism in front of the right Proceed as follows:
eye (or 3 BDR and 3 BUL). a) Place a red filter over one eye and a green filter
over the other.
b) Check that the patient sees two images simulta- b) Ask the patient what they see:
neously, one high (the right), the other low (the left) (the a. If both the cross and the circles are seen,
image is moved towards the prism’s apex). If only one there is simultaneous vision.
image is seen, one eye is suppressed. b. If only the cross or only the circles are seen,
there is suppression in one eye.
c) Have the patient assess the horizontal separation c) Ask the subject to identify the location of the
of the two vertical lines (or measure by means of prisms) cross relative to the circles:
a. If the two lines are aligned, there is ortho- a. If the cross is seen in the centre of the circles,
phoria. there is orthophoria.
b. If the cross is seen as off-centre, there is
b. If the two lines are offset, there is (horizontal)
heterophoria.
heterophoria. (Combined horizontal and vertical phoria,
or cyclophoria, may also be revealed with this test). Normally the patient should see both the red cross and the
green circles. The cross should lie within the green circles.
d) Now perform the test by dissociating the eyes by
using a horizontal prism of 10 to 15 base in over one
eye and by having the patient look at a horizontal line of
letters; two images should be seen separated horizon-
tally; any vertical heterophoria may be demonstrated
and measured.
Remember that for all dissociation tests:

- If the image seen by the right eye is to the right and
the image seen by the left eye is to the left, there is eso-
phoria.
Figure 33: The Schober Test
Subjective
Refraction
Dissociation by polarized tests (Polarized Cross Test): Stereopsis

4
The polarized cross is available in the majority of projec- To assess the subject's stereoscopic vision, use a test
tors charts. Proceed as follows: that enables two separate images to be presented to the
On procède comme suit : subject. These images are almost identical but slightly
a) Place the polarized filters in front of both eyes. offset relative to one other so that they create a percep-
b) Ask the patient if both branches of the cross are tion of relief (that is, three dimensional vision) when they
clearly visible: merge. These tests achieve dissociation by means of red
a. If the full cross is clearly visible, there is and green filters (Brock technique) or polarized filters
simultaneous vision. (for example, polarized rack test). They involve checking
b. If only one branch is visible (or one branch that a part of the image is perceived by the patient as
tends to disappear and re-appear), there is (full or inter- being closer or further than the rest of the image. The
mittent) suppression of one eye. principle is that when the two eyes fuse, if the image
c) Ask the patient if both branches of the cross are seen by the right eye is slightly offset to the right and
perfectly centred or if one of them seems offset relative that seen by the left eye is slightly offset to the left, the
to the other: patient has the impression that the plane of the test
a. If the branches are centred, there is ortho- recedes; conversely, if the image seen by the right eye is
phoria. slightly offset to the left and that seen by the left eye is
b. If they are offset, horizontally and/or vertically, slightly offset to the right, the patient has the impression
there is heterophoria. that the plane of the test advances. The presence of
even a slight degree of stereoscopy implies a very good
level of binocular vision.
Figure 34: Polarized Cross Test
Figure 35: Brock Rings Test

Figure 36: Polarized Bar Test
If a binocular vision anomaly is detected, proceed to a more

detailed evaluation such as that described below in the
Chapter ‘Binocular Vision Evaluation’.
5. Subjective Refraction
Near Vision
Subjective
Refraction
A Determining the Near Addition (Presbyopia)
Precise determination of their appropriate near addition b) Determine the addition:

is vital for the comfort of the presbyopic patient. As with A patient may use comfortably for a sustained per-
distance vision ametropia, the patient’s presbyopia iod only 2/3 of their amplitude of accommodation
should be measured and the near addition determined (thus keeping an accommodative reserve of at least
from the measurement of the maximum remaining 1/3 of the amplitude of accommodation).
accommodation amplitude; this is because, at any given Thus the near addition is given by the formula:
age, the remaining amplitude of accommodation will dif-
Near addition = 1 / reading distance – 2/3
fer between patients.
maximum amplitude of accommodation
1) ACCOMMODATIVE RESERVE METHOD
The method involves determining the subject’s maxi- Near addition values for respective reading distances
mum remaining amplitude of accommodation and sub- of 40 cm, 33 cm and 25 cm, are given in the table
sequently calculating the value of the addition to be below:
prescribed. The procedure is performed in binocular
vision conditions, with the distance vision correction in
place, using a reading test which may be at a fixed or
variable position. Remaining
Comfortable
Accommodation
Addition Addition Addition Addition
Amplitude of for 50 cm for 40 cm for 33 cm for 25 cm
(Percival criterion)
Accommodation (=2.00D-2/3acc) (=2.50D-2/3acc) (=3.00D-2/3acc) (=4.00D-2/3acc)
(= ou <2/3 acc max)
a) Measure the remaining amplitude of 3.00 2.00 No add 0.50 1.00 2.00
accommodation: 2.75 1.83 / 1.75 No add 0.75 1.25 2.25
Using a reading test which can be moved, find the position 2.50 1.66 / 1.50 0.50 1.00 1.50 2.50
of the near point of accommodation by moving the text 2.25 1.50 0.50 1.00 1.50 2.50
towards the patient until it (just) becomes blurry (that is, 2.00 1.33 / 1.25 0.75 1.25 1.75 2.75
find the closest point to which the patient can focus at 1.75 1.16 / 1.00 1.00 1.50 2.00 3.00
near). The amplitude of accommodation is the inverse of 1.50 1.00 1.00 1.50 2.00 3.00
this distance: for example, if the distance is 0.50 m, the 1.25 0.83 / 0.75 1.25 1.75 2.25 3.25
amplitude of accommodation is 1/0.50m = 2.00 D. 1.00 0.66 /0.50 1.50 2.00 2.50 3.50
0.75 0.50 1.50 2.00 2.50 3.50
0.50 0.33 / 0.25 1.75 2.25 2.75 3.75

Using a reading test at a fixed position:
- Place the test at 40 cm (1/0.40m = 2.50D) and
ask the patient to focus on the smallest characters pos-
sible. c) Check the patient’s visual comfort
- If the smallest text is clear, introduce lenses of - Have the patient try the distance vision correc-
-0.25 D, -0.50 D, etc, until the patient is no longer
tion and the near addition (trial frame)
able to see the text clearly.
- If the smallest text is blurry, introduce lenses - Ask the patient to assess near vision comfort by
of +0.25 D, +0.50 D, etc, until the patient can (just) a reading test
see the text clearly. - Ensure the value of the addition is in accordan-
Amplitude of Accommodation = ce with the patient’s required reading/working dis-
2.50 D – power added. tance and any other visual needs; adjust if necessary.
Figure 37: Measuring the Amplitude of Accommodation

in the Presbyopic Patient
Subjective
Refraction
2) MINIMUM ADDITION METHOD d) Check the patient's visual comfort

5
This method involves restoring to the presbyopic Using trial frames and a reading test:
patient an apparent “accommodation” of 3.50 D - ask the patient to assess their visual comfort
(that is, the “accommodation” necessary for the with the addition in place
usual near activities of daily living) by bringing - bring the test closer to the patient until the
their corrected near point to a distance of 28 cm smallest characters are no longer able to be seen
(= 1 / 3.50 D). To do this, determine the mini- clearly. This should occur at approximately 25 cm
mum addition necessary for the patient to read at from the eyes (if <20 cm, the addition is too strong,
40 cm (proximity 2.50 D) and then add +0.75 D if >30 cm the addition too weak).
to +1.00 D to attain 28 cm (proximity 3.50 D). - adjust the value of the addition (from 0.25 to
0.50 D) in accordance with the required working or
a) Correct distance vision precisely reading distance, if different from the 40 cm at which
the test was conducted. Reduce the addition for a
Remember to correct the ametropia at the level of longer working distance, increase it for a shorter wor-
maximum plus for maximum visual acuity. This is king distance
important because any under-correction of hyper-
metropia or over-correction of myopia may translate
into an excessive addition for near vision and this is
best avoided.
b) Determine the minimum addition at 40 cm
Place a reading test at 40 cm and ask the patient to

00 to
D
1, 5
focus on the smallest characters. If the patient is

+ 0,7
+
presbyopic, the smallest characters will be blurry.
in
6
Add +0.25 D, +0.50 D, etc, binocularly to the dis-
/1
cm
tance vision correction until the subject can just 40
in
make out the smallest characters on the test. The

m
d
Ad
value of the lenses added is the minimum addition.
c) Add +0.75 D or +1.00 D to the minimum addi- © Essilor International

tion to find the comfortable addition.
Figure 38: Principle of the Minimum Addition

Method
Subjective
Refraction
3) BINOCULAR FIXED CROSS CYLINDER a
METHOD
This procedure involves determining the presbyopic

near addition by introducing a ± 0.50 cross cylinder
(prescription +0.50/-1.00x90) in front of both eyes
and having the patient look at a cross, made up of
horizontal and vertical lines, at a distance of 40 cm.
As the presbyopic patient has insufficient accommo-
dation, and given the orientation of the cross cylin-
ders, the horizontal lines of the cross are seen more
clearly than the vertical lines, initially. Plus lenses
b
are then introduced binocularly, progressively in
0.25D steps, until the horizontal and vertical lines of
the cross are seen equally clearly; the plus in place
at this point is the near addition for 40cm. In prac-
tice, perform the following steps (most simply using
a phoropter, as the binocular fixed cross cylinders
are integrated therein):
a) Correct distance vision precisely

Remember to prescribe maximum plus for maximum
visual acuity.
Figure 39: Binocular Fixed Cross Cylinder Test
b) Determine the addition:
- Have the patient fixate on a cross composed of
horizontal and vertical lines, placed at 40 cm.
- Introduce the ± 0.50 cross cylinder (negative
axis along 90°) in front of both eyes. The patient
now sees the horizontal lines of the cross more clearly.
- Introduce binocularly lenses of +0.25, +0.50,
+0.75 D, etc, progressively until the patient sees
the horizontal and vertical lines as equally black and
focussed.
- Continue until the patient sees the vertical lines
more clearly.
- Select as the addition the value that gives the
best equality between horizontal and vertical lines.
c) Check the patient’s reading comfort:

- Place into a trial frame the distance vision cor-
rection and the addition obtained
- Ask the patient to assess their visual comfort
via a reading test
- Adjust the value of the addition in accordance
with the patient’s required working or reading dis-
tance.
Supplement:
Supplement
The Consequences of Prescribing an

Excessive Near Addition
The amount of addition prescribed directly influences Figure 40 : Depth of Field of Clear Vision in an Early
the corrected presbyopic patient’s range of vision. Presbyope:
Indeed, the limits of the range of near vision are deter-
mined by the power of the addition and the remaining a) Single vision lens of power +1.50 D
amplitude of accommodation. The near vision accom-
modation range becomes closer and more restricted as
the addition becomes stronger, and also becomes more 0D e
+2.0 r a n g
restricted as the remaining amplitude of accommoda- Withm o d a t i v e
om
Acc
tion becomes smaller. Thus: D I S TA N C E
0,33 0,50 1 2 5 m
13 20 40 80 200 in
- a stronger addition reduces the apparent depth of
maxi
,00 D
the usable range of accommodation.
.=2
Acc
- as presbyopia progresses, the increase in addition IA
TE
25
ED
RM
cm
TE
and the reduction in the remaining amplitude of accom- IN
28
cm
modation combine to reduce the depth of the usable NEAR
range of near vision.
0D
0,0
50
As an example, consider a young presbyopic patient cor-
c.=
cm
Ac
rected by a single vision near lens of power +1.50 D
66
cm
(Figure 40a) or a progressive lens of addition +1.50 D
(Figure 40b). In accordance with the minimum addition
method detailed previously, the patient’s remaining
(maximum) amplitude of accommodation is 2.00 D. A
very simplified theoretical calculation shows that this b) Progressive lens of addition +1.50 D
range of accommodation extends in distance vision from
infinity to 50 cm and in near vision from 67 cm to 28
cm. If an addition of +2.00 D were prescribed instead
of +1.50 D, the range of near vision is modified and
then extends between 50 cm and 25 cm. Thus, over-cor-
recting the addition by +0.50 D has the consequence of
reducing the range of clear vision by 17 cm in the dis-
tance zone (from 67cm to 50cm) and procures a gain of
only 3 cm at near (from 28 to 25cm). The consequence
is that the patient has a more restricted range of clear
vision.
Supplement
A few years later this patient will have a remaining ampli- Figure 41 : Depth of Field of Clear Vision in a Late
tude of accommodation of only 1.00 D and thus requi- Presbyope
re, still in accordance with the minimum addition
method, an addition of +2.50 D (Figure 41). Their near a) Single vision lens of power +2.50 D
vision accommodation range has naturally diminished
and now extends from 40 cm to 28 cm. If the addition
is over-corrected by +0.50 D (by prescribing an addi-
tion of +3.00 D instead of +2.50 D), the range of clear
vision extends from 33 cm to 25 cm, so there is a loss .00nge
D
Wit h+d3 n ra
and restriction of 7 cm in the depth of field for interme- ccom
A
o atio
D I S TA N C E
diate vision for a gain of only 3 cm in very near vision. 0,33 0,50 1 2 5 m
13 20 40 80 200 in
maxi
,00 D
In progressive lenses, increasing the addition reduces

.=1
Acc
TE
the field of vision not only in depth, but also in width. ED
IA
,00D
25
RM
TE
.=0
cm
Prescribing an excessive near addition increases the Acc

IN
28
cm
lateral aberrations of the lens, thus reducing the usable

33
NEAR
cm
width of the central zone and increasing the effect of
40
peripheral deformations. Excessive near additions are a

cm
major cause of difficulty in adaptation to progressive

lenses.
During the determination of the addition, most presbyo-

pic patients naturally demand greater plus power becau-
se of its associated magnifying effect. However, an b) Progressive lens of addition +2.50 D
increase of +0.50 D in a near prescription, apparently
comfortable and safe during refraction, can prove
uncomfortable on a day-to-day basis. This is a reason +3.0
0D
ADDtion range
why any near prescription should be trialled by the WithAccomoda
patient in natural conditions, and the clear range of
vision checked, prior to prescribing. The art of prescri-
bing for near lies in knowing how to use the addition with D I S TA N C E
0,33 0,50 1 2 5 m
moderation and to gauge precisely the correction of ∞
13 20 40 80 200 in
presbyopia.
Acc.=
1,00D maxi
TE
IA
ED
25
RM
TE
cm
IN
28
cm
Acc =0,00D
NEAR
33
cm
40
cm
Subjective
Refraction
B Verification of Binocular Balance at Near
Once the distance refraction and near addition have 3) Assess acceptance of the near vision
been determined, the patient’s binocular balance should balance at distance:
be checked at near, also. Indeed, binocular balance has
been established in distance vision in a situation that is
If the near vision balance differs from the distance vision
seldom encountered: looking at far distance in primary
balance, in general it is preferable to favour the near
gaze (straight ahead, at eye level). In near vision, a lowe-
balance and check that it is acceptable at distance. To
red line of gaze and the stimulation of accommodation
do this, introduce the balance lens (usually +0.25 to

and convergence may modify that balance. This should
+0.50 D) over one of the eyes in front of the patient’s
be checked by dissociating binocular vision at near with
distance correction. If the patient indicates no discom-
the eyes lowered. This may be performed with instru-
fort, keep that balance. Otherwise, two sets of lenses
ments such as the Optoprox® or the Proximeter®. The
may need to be prescribed: one for distance vision, the
principle is as follows:
other for near vision.
1) Dissociate the patient’s binocular vision

at near:
Place the patient’s near correction in the trial frame.

Position the test at a set distance (for example, 40 cm)
and check that the patient’s line of gaze is lowered.
Dissociate their binocular vision:
a. by means of polarizing or red-green filters
(Optoprox®)
b. by means of the septum (Proximeter®)
The patient is now in a situation of incomplete binocular
vision which enables the vision of the two eyes to be
compared.
2) Have the subject compare the vision of Figure 42: Optoprox®

the right and left eyes and determine
balance:
a. If there is equality of vision between the right eye

and left eye, balance is achieved.
b. If there is a difference in vision between the two
eyes, balance by introducing +0.25DS on the worse eye
or -0.25DS on the better eye. Usually no more than
0.50 D adjustment is necessary.
Remember that this balance pre-supposes visual acuity

that is essentially equal in both eyes. Note also that it
is necessary to know which is the patient’s dominant eye
and that a slight imbalance in favour of that eye may be
conserved. More precisely, be careful never to reverse Figure 43: Checking Binocular Balance at Near using
the natural dominance of one eye relative to the other. the Proximeter®
Checking the binocular balance at near is particularly
important in presbyopic patients who, due to loss of
accommodation, are very sensitive to the simultaneous
action of both eyes in close vision.
Subjective
Refraction
C In the case of the Non-Presbyopic Patient
For non-presbyopic patients, the near vision examination is is positioned at near, in natural down gaze, at 40 cm for
often carried out only if the patient has symptoms or expres- example. Minus lenses are introduced progressively (in
ses a visual complaint, or if an anomaly has been discovered steps of -0.25 to -0.50 D) until the patient can no longer see
during the preliminary measurements; however, it should be the small characters clearly. The value at which the charac-
performed in all cases, as many anomalies may not cause ters are still just able to be cleared by the patient is used to
significant symptoms. Usually, symptoms involve visual fati- calculate the amplitude of accommodation: amplitude of
gue (asthenopia) after periods of close work. This tiredness accommodation = 1/0.40 m – added power. This measure-
can have various origins which may be normal (that is, some ment is then compared to statistical norms. The amplitude
fatigue is expected even when the eyes and visual system are of accommodation often proves to be lower than the avera-
entirely normal) or abnormal and, in particular, may be cau- ge in such cases.
sed by a uncorrected ametropia, a binocular vision disorder - accommodative facility (may be measured using the
or accommodative fatigue. accommodative rock method): wearing the distance correc-
tion, have the patient fixate on a small word placed at 40
1) Uncorrected Ametropia cm. Using a flipper (binocular lens holder) fitted with +2.00
Usually patients will suffer symptoms of visual fatigue at near D and -2.00 D lenses, assess the number of accommoda-
in the case of uncorrected hypermetropia or at distance in tion/disaccommodation cycles that the patient can perform
the case of uncorrected astigmatism. Uncorrected hyper- in one minute. To do this, firstly place the +2.00 D lenses
metropia demands permanent accommodative effort, which (to relax accommodation) and ask the patient to indicate as
is tiring in the long term. Uncorrected astigmatism destabi- soon as the word is clear. At this point, immediately swap
lizes accommodation and requires an effort of compensa- the lenses so that now the -2.00 D lenses are in place (to sti-
tion, which can be a source of headaches. The solution mulate accommodation) and ask the patient to indicate
consists essentially in ensuring effective correction of distan- when the word is again clear. Repeat this cycle for 1 minute
ce vision and checking that this provides relief to the patient and count the number of cycles executed: generally it is
in near vision, also.
considered that ~13 or more cycles is normal, ~8 or fewer
cycles abnormal. If the patient is unable to clear ±2.00D,
A particular case is that of the pre-presbyopic patient who,
by this stage, has often been starting to be unable to com-
±1.00D flippers may be used instead, although this already
gives an indication of reduced accommodative amplitude
pensate for latent hypermetropia for some time. Latent
hypermetropia may develop more rapidly than early pres- and facility. (Accommodative infacility may often be associa-
byopia. Be sure not to confuse hypermetropia and pres- ted with accommodative insufficiency and convergence
byopia and to correct distance vision fully. Often, the patient excess and so it should not be measured in isolation).
wears this correction only at near, initially, then progressive-
ly adopts it for distance vision. If accommodative insufficiency and/or reduced accommoda-
tive facility is observed, this may sometimes be treated by
2) Binocular Vision Disorder vision therapy and eye exercises or by the prescription of a
Two of the most common disorders which may be encoun- weak plus correction in near vision, on condition that there
tered are convergence insufficiency and difficulty in compen- are no binocular counter-indications. For this reason these
sating for severe heterophoria. results should not be taken in isolation and a full binocular
- convergence insufficiency will be detected during the vision assessment should be performed by an appropriately
preliminary measurements. It may be treated primarily by qualified eye care professional.
visual training and exercises and, if this fails to prove effecti-
ve, possibly by prismatic correction.
- severe heterophoria may be accentuated by down
gaze (that is, a lowered line of gaze such as during near
vision). It may be identified at near by the unilateral cover
test, sometimes more easily than at distance. For further dis-
cussion, see the Chapter ‘Binocular Vision Evaluation’.
3) Accommodative Fatigue
This is manifested as a difficulty in maintaining focus during
near vision. The patient may suffer tiredness and blurred
vision after periods of near work. For example, this condition

is often encountered in students who have a large near
demand and so accommodate strongly over sustained per-
iods of time. To help identify the exact nature of the pro-
blem, the two following measurements may be made:
- amplitude of accommodation (by the fixed test
method described previously for presbyopes): a reading test Figure 44: Accommodative Rock Test
6. Binocular Vision Evaluation
Binocular Vision
If a binocular vision anomaly is detected through screening, it is necessary to proceed to a more in-depth examination in
order to identify and treat the problem. This should be performed only by an appropriately qualified eye care profes-
sional, with referral if necessary.
Evaluation
The object of this chapter is not to provide a full description of the investigation and treatment of binocular vision disor-
ders; this is a vast subject and beyond the scope of this file. Rather, it is simply to recall a few basic principles, to des-
cribe how to identify some binocular vision disorders and to offer some tips for prescribing a prismatic correction.
A Phoria, Fusional Reserves and Tropia

Definitions 2) Fusional (Vergence) Reserves:
The eyes naturally possess vergence reserves or

1) Phoria: fusion latitudes, indicative of the ability of the visual
system to maintain fusion and compensate for any
Heterophoria, often simply called phoria, can be defined
heterophoria. Fusional reserves are the tolerance of
as a ‘latent deviation of the visual axes compensated by
the eyes to converge or diverge relative to a given
the stimulus to maintain fusion and avoid diplopia’, or
fixation point or indeed their capacity to resist any
stated another way, the ‘tendency for the two visual axes prismatic disturbance of their fusion. When asses-
of the eyes not to be directed towards the point of fixa- sing the reserves, three particular points or stages
tion, in the absence of an adequate stimulus to fusion’. should be noted:
The eyes make a permanent effort of compensation for
any phoria so as to maintain the visual axes of both eyes - the point at which further relative vergence
on the point of fixation. induces accommodation; this point is marked by first
blurring of the fixation target (this point is the blur
Phoria can be demonstrated by dissociating binocular point);
vision in order to inhibit fusion. This dissociation can be - the point at which fusion is disrupted and
either sensorial by disrupting the similarity of the ima- where the images of the two eyes separate; this is
ges (dissociation by filters, for example) or motor by dis- usually marked by doubling of the image, or diplopia
rupting their superimposition (dissociation by prisms, for (break point);
example). Depending on the test chosen, the dissocia- - the point at which fusion of the two eyes is
tion can also be shallow or deep, central and/or per- recovered; this is usually marked by a return to a sin-
ipheral, partial or total. gle image (recovery point).
Depending on the measurement conditions, that is, Typical values of fusional reserves (the
depending on the type of dissociation selected, the pho- blur/break/recovery points) are shown in Figure 45.
ria will be said to be ‘associated’ or ‘dissociated’. In distance vision, they are approximately twice as
When the test used involves an element of fusion, per- large in convergence as in divergence. In near vision,
ceived in common by both eyes, the phoria is said to be they are noticeably more balanced between conver-
‘associated’ (the red filter test, Mallett test, etc.). When gence and divergence. In the vertical plane, fusional
no element of fusion is present, the phoria is said to be reserves are low.
‘dissociated’ (dissociation by prisms, Maddox test, etc.).
Typical values for dissociated horizontal phoria are gene-

rally considered to be ~0.5 exophoria at distance and 10 5 0 10 20 Base up
a
4 - 6 exophoria at near; for dissociated vertical phoria, 3
~orthophoria (0 ) at both distance and near. Divergence - Base in Convergence – Base out 1
0
1
b 3
15 10 0 10 15 25 Base down
HORIZONTAL VERTICAL
Blur Break Recovery

Figure 45: Typical Values of Phoria and Fusional Reserves
a) at distance
b) at near
Binocular Vision
Evaluation
To assess a patient’s fusional reserves, the practitioner Figure 46 : Screening Fusional Reserves
can either screen for fusional capacity or measure the
convergence (also called positive relative convergence) a) convergence
and divergence reserves (negative relative convergence).
The principle is to introduce prisms of different
amounts and check at each stage that the patient can
compensate for their effect at a given fixation and
accommodation point. To induce convergence, intro-
duce a base out prism; to induce divergence, use a
base in prism. Always induce and measure divergen-
ce ability before testing convergence.
a) Screening for fusional reserves: this invol-

ves checking the capacity of the eyes to compensate
for the introduction of prisms of known values; in dis-
tance vision, 5 base in and 10 base out; in near b) divergence
vision, 10 base in and 10 base out. In practice, ask
the patient to look at, for example, a vertical line of
letters, and place the prism in front of one of the
patient’s eyes. The image should initially be seen as
double, then single as the patient fuses. If this is not
so and two images are still perceived even after seve-
ral seconds then fusional reserves are low.
b) Measuring fusional reserves: this involves

using a prism bar or prisms in the phoropter, to
introduce prisms of increasing power in order to find
the blur, break and recovery points. To measure
horizontal reserves (divergence first, then convergen-
ce), have the patient look at a vertical line of small with the fixation target or object viewed by the
letters appropriate for their level of vision. Introduce patient and so its image does not fall on the fovea of
the prism, progressively increasing its power, until the tropic eye. Tropia may result from many causes
blurring occurs. (At this stage, convergence will have (refractive, anatomical, neurological or pathological)
caused the stimulation of accommodation. Also, do and may be constant or intermittent, comitant or
incomitant, unilateral or alternating, accommodative
not be concerned if the patient does not notice the
or non-accommodative, for example.
blur; some do not). Note the power of prism at this
blur point. Continue until one eye loses fixation
One cause may be the decompensation of a phoria.
and/or the patient sees double (that is, fusion breaks When the eyes can no longer compensate for phoria,
and the eyes can no longer compensate for the the turned eye’s deviation becomes marked in ordi-
prism). Note the power of prism at this break point. nary conditions of vision and may even become
Then reduce the value of the prism until fusion is continuous. The visual axis of one eye no longer
recovered (recovery). Proceed in a similar way for passes through the fixation point and it is at this
the vertical reserves, but rather with the patient loo- point that the phoria breaks down to a tropia: exo-
king at a horizontal line of letters, and using much tropia if the eye diverges, esotropia if it converges,
lower prism values. hypertropia if it turns up or hypotropia if it turns
down. It may be accompanied by diplopia (recogni-
(Vergence facility may be measured, also; this is not tion of double vision, that is the two different images
treated here.) from the two eyes) but instead is often accompanied
by cortical suppression of the vision of the turned
3) Tropia (or strabismus): eye. Diagnosis and treatment of tropia is complex
The fundamental difference between (hetero)phoria and requires the competence of a specialist in bino-
and (hetero)tropia is that bifoveal fixation is maintai- cular vision. The object of this chapter is not to dis-
ned in phoria but is not in tropia; in tropia, one eye cuss these questions in detail but only to describe
is turned such that its visual axis does not coincide and identify some examples of the condition.
Binocular Vision
Evaluation
B Identifying the Problem
When a binocular vision anomaly is detected during b) Demonstrating phoria (using the unilateral
initial screening or during the binocular verification cover test) (continued on from demonstrating
of the refraction, the nature of the problem must be tropia, above, if no tropia were demonstrated):
identified. More precisely, it is vital to establish whe- - Have the patient focus on a small target
ther the anomaly is related to a poorly compensated - Occlude the right eye for 1 to 2 seconds
phoria or a tropia. In either case, the condition must - Quickly uncover while observing the right eye
be measured and analyzed. as it is uncovered:
- If no movement is observed, there is orthopho-

1) Differentiating phoria from tropia: ria or low-level heterophoria.
- If a refixation movement is observed, there is
Phoria and tropia may be differentiated by the uni- heterophoria:
lateral and alternating cover tests. Already mentio- - exophoria, if the movement is towards the
ned among the preliminary tests, this involves obser- nose; esophoria, if the movement is towards the tem-
ving the movement of the eyes during the occlusion ple.
and uncovering of one eye then the other, while the - hyperphoria if the movement is down-
patient focuses on a target at distance or near. wards, hypophoria if upwards.
- Repeat the procedure, occluding the left eye
(Please note: and confirm the behaviour observed in the right eye.
- the examples given below include only some types - If a movement is observed in one eye or the
of phoria and tropia. other, phoria of at least a moderate amplitude is
- some very small phorias and tropias may be missed identified.
via observation with the naked eye. - If no movement is observed, there is orthopho-
- the size of the deviation may vary depending on the ria or low-level heterophoria (less then 2 to 3 ).
speed at which the cover test is performed (that is,
the duration of occlusion and the speed of
cover/uncover)).
a) Demonstrating tropia (using the unilateral

cover test):
- Have the patient focus on a target.
- Occlude the right eye while observing the left
eye:
- If no movement is observed, the left eye was
fixating and was not deviated.
- If a movement of refixation is observed, that
eye was deviated:
- if the refixation movement is towards the
nose (that is the eye was turned out) – exotropia; if
the movement is towards the temple – esotropia
- if the movement is downwards – hypertro-
pia; if upwards – hypotropia
- Remove the occluder from the right eye.
- Repeat the procedure, occluding the left eye
and observing the right eye.
- If a movement is observed in one eye or the
other, tropia is identified, the test is complete.
- If no movement is observed, proceed to search
for phoria (step b), below).
Binocular Vision
Evaluation
Phoria Tropia
a) Esophoria c) Esotropia
ou / or
b) Exophoria d) Exotropia
ou / or
Figure 47: Demonstrating Tropia and Phoria using the Unilateral Cover Test
Binocular Vision
Evaluation
2) Measuring and analyzing phoria: - Reduce the value of the prism until the patient
again sees a single line (recovery).
Once the existence of phoria is identified, its impact must * some patients do not notice the blur point and it may
be measured and the patient’s capacity for its compensa- not occur in negative relative convergence
tion must be assessed. This should be done at both dis- ** if the patient does not see double, note the position
tance and near. at which one eye loses fixation
a) Measuring phoria and fusion amplitudes - Vertical reserves:

From the many possible methods of measuring phoria, - Have the patient focus on a horizontal line of let-
the method using the alternating cover test, a trial frame ters.
and a prism bar is outlined below. This has the advantage - Introduce a base down prism. Increase the value
of measuring phoria in spatial vision conditions, in which of the prism progressively until the patient sees the line
some fusion is maintained. It may also be used where as double, then reduce the prism until the patient again
subjective input is impossible, although it relies on obser- sees a single line.
vation with the naked eye and so small phorias may be - Repeat the same sequence using base up prism.
missed. Measurement is carried out as follows, with the - Note the break and recovery points. (There is no
refractive correction in place: blur point here as vertical vergence movements do not
- Have the patient focus on a target. stimulate accommodation).
- Occlude one eye for 2 to 3 seconds.
- Quickly uncover this eye and change to occlude the b) Analyzing phoria:
other eye, without allowing binocular vision whilst moving It is important to emphasize that the size of the phoria is
the occluder between the eyes. a less important factor than the patient’s capacity to
- Occlude this eye for 2 to 3 seconds then quickly compensate for it. In other words, even a significant
occlude the other eye and so forth. phoria may pose no difficulty if the patient possesses
- Observe the refixation movement of the uncovered sufficient fusional reserves to compensate for it comfor-
eye during each passage from one eye to the other. tably. In practice, phoria would be treated only if the
- While continuing to alternate the occlusion, place patient suffers symptoms such as asthenopia, double or
the prism bar before one eye and increase the amount of blurred vision, or fatigue, or shows signs of functional
prism in small steps until the refixation movement is neu- disorders such as abnormally close or far reading dis-
tralised. tances. Other symptoms including headaches, sore or
- The value of the prism that neutralizes the red eyes, ocular discomfort, watering of the eyes, may
movement gives the measurement of the phoria.. be experienced, particularly after prolonged periods of
work. (These symptoms are of course not specific to
The prism bar may be used in a similar way to measure poorly compensated phoria).
fusional reserves:
- Horizontal reserves: This analysis can be performed according to different
- Have the patient focus on a vertical line of letters of criteria:
a size appropriate for their level of vision. - Percival’s criterion, which suggests that vergence
- For divergence (negative relative convergence): demand should lie in the middle third of the zone of sin-
- Place a low power base in prism in front of one eye. gle clear binocular vision, as demarcated by the blur or
- Increase the value of the prism (every 2 to 3 break points.
seconds) until the patient reports that the letters - Sheard’s criterion, which suggests that ‘the fusio-
become blur red *(blur), then that the line is seen nal reserves opposing the phoria should be equal to at
double **(break). least twice the phoria for the phoria to be correctly com-
- Reduce the value of the prism until the patient pensated’.
again sees a single line of letters (recovery).
- Remove the prism bar and note the These criteria may enable the value of any prismatic
blur/break/recovery points. prescription, ensuring the binocular comfort of the
- For convergence (positive relative convergence): patient, to be determined.
- Place a low power base out prism in front of one eye
Increase the value of the prism until the patient
reports that the letters become blurred *(blur),
then that the line is seen as double **(break).
Binocular Vision
Evaluation
3) Assessing and analyzing tropia:
The nature of any tropia must be determined by an

in-depth analysis. In particular it is important to dis-
cover the following characteristics of a tropia:
- constant or intermittent: is the deviation
always present?
- fixed or alternating: is it always the same eye
that deviates?
- comitant or non-comitant: is the deviation the
same in all directions of gaze?
- accommodative or non-accommodative: does
the deviation vary with accommodation? (for exam-
ple, estropia caused by a large degree of uncorrec-
ted hypermetropia)
- recent or longstanding: has it existed for a long
time or has it appeared recently?
- progressive or stable? (if progressive, suspect a
pathological origin)
- What is the angle of the deviation? Does it vary
with the fixation distance?
- Is the tropia accompanied by eccentric fixation
or by amblyopia?
- What is the degree of fusion? What is the depth
of any suppression?
- etc.
The angle of deviation may be measured by the

alternate occlusion method (see above for the mea-
surement of phoria) to determine the value of the
prism that neutralizes the refixation movement
during the alternating cover test.
Tropia can have multiple causes and treatment is

complex. It is vital to check the patient’s motor and

sensorial binocular vision thoroughly and to identify
the cause(s) of the tropia. Once the diagnosis is
established, patient care may involve refractive cor-
rection, vision training, a prismatic prescription, sur-
gery or other treatment if the cause is of pathologi-
Figure 48: Measuring Phoria and Fusional Reserves cal origin. It is clear that the treatment of tropia
requires the competence of professional binocular
vision specialists. It falls beyond the scope of this
As a general rule, vision training (exercises aimed at file.
developing the patient's fusional reserves) is the treat-
ment of first choice, with the prescribing of prism reser-
ved as a secondary treatment.
Binocular Vision
Evaluation
C Prescribing Prism
When prism is to be prescribed, the value of the The prism prescription:

prism must be precisely determined. As a general - It may be preferable to prescribe an equivalent
rule, always seek to prescribe the minimum value of oblique prism for one eye rather than splitting a
the prism that restores comfortable fusion. horizontal prism before one eye and a vertical prism
Remember that, in effect, prism acts as a surrogate before the other.
for the eyes, leaves the eye in the deviation (‘fixes’ - Distribute most or all of the prism on the non-
the defect) and is even sometimes ‘absorbed’ by the dominant eye in order to avoid or minimize the risk of
patient. disturbing the vision of the dominant eye by the aberra-

tions introduced by the prism.
With this in mind, it may be advisable to: - Check that a single prism value is acceptable in
a) work with trial frames rather than with the both distance and near vision; if not, separate distance
phoropter, in order to allow the patient to maintain and near prescriptions will be necessary.
peripheral fusion - It may be preferable that the amount of corrective
b) prescribe the minimum prism value that resto- prism be measured on different days or occasions, when
res fusion in the presence of, for example, a weak the patient is less or more tired, as its measurement may
fusion dissociator (such as the red filter, described vary; adhesive (Fresnel) prisms (applied to the patient’s
below). spectacles) may be used to trial a prism prescription
before prescribing.
Several methods, based on different principles, may
be used to determine the value of the prism to be Many other methods can be used to determine the
prescribed. Although these methods are often sub- value of the prism to be prescribed. These include
ject to debate, this file is not the place to discuss methods based on the measurement of the phoria itself,
their relative merits. Here only one method is detai- on the evaluation of the opposing fusional reserve or on
led, that of the red filter. It may be used at distance the measurement of fixation disparity. Each of these
and near. The procedure is as follows: methods has their devotees and their detractors and no
one method is unanimously approved. However, not-
- Have the patient fixate on a point of light. withstanding the continuing debate, the important thing
- Place the red filter over one eye: the patient remains to find a solution to resolve any binocular vision
should see two points of light, one white and the other problem the patient may have, either by direct treat-
red. ment or by referral to an eye care professional speciali-
- Note the position of the white light relative to the zed in this field.
red light.
- Place a prism of appropriate power and orientation
over the eye without the red filter; the white light moves
towards the prism apex.
- Increase the value of the prism very gradually until
the patient sees only a single point of light. This per
ception must be able to be sustained by the patient
(give the patient time to assess and adjust his
vision). Note this amount of prism.
- Repeat the procedure, placing the red filter over
the other eye and note the amount of prism requi red in
this case.
- Choose, as the value of the corrective prism, the
lesser of these two amounts of prism which allow
restoration of the patient’s fusion.
Supplement:
Supplement
Definition, Measurement and Summation of Prism
DEFINITION OF PRISM GRAPHICAL METHOD OF

CALCULATING RESULTANT PRISM
The official unit of measurement of deviation is the prism
dioptre or cm/m symbolized by the Greek letter Delta, ∅. When a prismatic prescription is composed of a hori-
A prism of 1∅will deviate light rays by 1cm at a distance zontal prism and a vertical prism, these can be com-
of 1m. bined into a resultant oblique prism. The resultant
prism is calculated by taking into account both the
Another unit sometimes used is the prism degree. This
power and direction of the prisms, rather as vectors
is usually the apical angle of the prism but sometimes
are summed. Figure 49 shows a simple graphical
the deviation produced by the prism, expressed in deg-
solution. Consider the following example of a prism
rees. For a material of refractive index 1.50 the devia-
prescription of 4 ∅base in and 7 ∅base down right:
tion in degrees is equivalent to half the value of the api-
from a perspective of facing the patient, looking at
cal angle of the prism. The prisms in trial sets or prism
the right eye, start at the origin (centre) of the graph;
bars are still often labelled in this unit.
trace a line on the scale 4 squares to the right (nasal-
ly or base in) (representing the horizontal prism);
To convert apical angle in degrees to prism dioptres, P,
then, from there, trace a line 7 squares downwards
use the trigonometric ratio, P=100 x tan [(n-1) x a]
(representing the vertical prism, base down). The
where P is the prism effect (in ∅n), the refractive index of
point reached lies at the intersection of concentric
the material and a the angle of the prism (°) or, more
circle 8 and a straight line indicating an angle of
simply, use the table below (calculated for n=1.5). It
300°. The resultant (oblique) prism is thus a prism
shows, for example, that a prism with an apical angle of
of 8 ∅base 300.
10° corresponds to a prism effect of 8.75∅ and,
conversely, that a prism effect of 7∅ corresponds to a
prism with an apical angle of 8°. The main error com-
mitted when converting prism degrees to prism dioptres
is an over-estimation of approximately 10 to 15%. This
error is negligible when using small angle prisms (less
than 10°) and becomes significant only above this
range.
Conversion table: prism degrees to prism dioptres
Apicle Angle Prism Effect Apical Angle Prism Effect

(in °) )
(in ∅ (in °) (in ∅
)
1 0.9 11 9.6
2 1.7 12 10.5
3 2.6 13 11.4 Figure 49: Summation of Prism – Graphical
4 3.5 14 12.3 Determination of the Resultant Prism
5 4.3 15 13.2
6 5.2 16 14.1
7 6.1 17 14.9
8 7.0 18 15.8
9 7.8 19 16.7
10 8.7 20 17.6
7. The Prescription
(The Final Rx)
Prescription
The
The refraction as determined by the above - Remember to take into account the test dis-
methods is not always what is finally prescribed: tance at which the subjective refraction was perfor-
this is where the “art” of prescribing comes into med and adjust thereafter for optical infinity. (For
play, following the “science” of refraction. There example, a subjective refraction conducted at a test
are many factors that may influence the practitio- distance of 5 metres will be 0.20D (that is, 1/5m
ner’s decision regarding the final prescription and (power F (dioptres) = 1/focal distance (metres) )
closer than optical infinity and so the sphere may
some of these are discussed below:
have to be adjusted accordingly (remove +0.25D

or add -0.25D)). This is particularly important for
- One of the first elements to be considered is refractions conducted at significantly closer distan-
the change of correction between the new and pre- ces such as 3m, where the equivalent refractive
vious prescriptions. If a significant change has step is in excess of the 0.25D lens steps able to be
been determined and is to be prescribed (for exam- prescribed.
ple, >0.75 DS sphere, >0.50 DC cylinder, >10° in
the axis or >+0.75 D in the addition), patients - For the cylinder correction, it is preferable to
should be forewarned of the ‘learning process’ that err on the side of the lesser cylinder if a choice has
they will likely have to go through with their new to be made between 0.25D lens steps. Most consi-
correction. (A patient may find it easier to “work der that the least cylinder giving the best vision
up” to the full change via smaller steps). should be the amount prescribed. There are many
schools of thought about prescribing cylinder; in
general, the preference is to prescribe the full cylin-
- Spectacle lenses are manufactured in 0.25D
der correction at precisely the axis found.
steps (with standard tolerances) but the eye is a
biological organ that does not conform so; often, - If the cylinder correction is large or signifi-
therefore, during refraction, a choice must be made cantly different from the previous correction and
between two limits of lens steps 0.25D apart. For therefore aniseikonic effects are likely, anticipate
the spherical component of the correction, it is this by forewarning the patient; in the vast majority
advisable to err on the side of lesser minus and the of cases, even with significant cylinder corrections,
maximum plus – Maximum Plus (Minimum Minus) the patient will appreciate the best corrected visual
for Maximum Visual Acuity. acuity that the full prescription offers and adapt to
* In the case of myopia in a younger patient who any aniseikonic effects within a short period of
still has considerable amplitude of accommodation, time. On the rare occasions this is not the case, the
over-correction (over-minussing) will often be cylinder correction or the anisometropia of the
cylinder correction may be reduced, bearing in
appreciated by the patient because of the greater
mind that as the cylinder correction is reduced, the
contrast that it gives. It may be argued that -0.25D sphere should also be adjusted so as to respect the
over-correction may be acceptable in such a case. spherical equivalent of the full correction (for exam-
However, too much over-correction should be avoi- ple, if reducing the cylinder correction in a pres-
ded for reasons of visual (accommodative) comfort cription +6.00/-4.00 x 90 to a cylinder correction
and that in some cases, progression of myopia may of -3.00, adjust the sphere also and prescribe
be accelerated by over-correction, particularly +5.50/-3.00 x 90 so the spherical equivalent of
when the spectacles are worn for near work. +4.00DS is maintained in both the full and redu-
* In the case of hypermetropia in a younger patient ced prescriptions).
who still has considerable amplitude of accommo-
dation, their correction can be tricky as they have - Generally R/L eyes will be similar (minimal ani-
often become used to accommodating and so will sometropia) and cylinder axes will be roughly sym-
not accept their full correction. On the other hand, metrical around the vertical axis (nose) (for exam-
ple, R 170, L 10). If there is any significant aniso-
they are also very sensitive to over-correction and
metropia or change in Rx, forewarn the patient of
may suffer asthenopia if left too much under-cor- possible aniseikonic effects which may be induced
rected. Patients with hypermetropia should thus by the new Rx, the adaptation time required and
be offered the maximum plus power that does not precautions to take in the interim; this will minimi-
cause any worsening of their distance vision. se any patient concern and any problems during
* Remember that in the final choice of sphere, the the learning period.
binocular balance and ocular dominance should be
respected
Prescription
The
- For patients with presbyopia, distance vision - Aside from the optical considerations listed above,
correction must be accurate for two particular rea- there are many and varied ergonomic and practical
sons: (i) accommodation is longer present and so issues to consider when choosing the final prescription
any over-correction of myopia or under-correction for the patient. This is when the case history becomes
of the hypermetropia is undesirable and will worsen important again, as it is by knowing the patient’s visual
vision and (ii) any error in the distance correction needs, work environment, leisure activities and such like
may be (wrongly) compensated for by increasing that the eye care professional may best advise the
the near addition, which will have undesirable patient as to the most appropriate kinds of refractive
consequences. Also, the binocular balance should correction to suit those different tasks. No one correcti-
be respected at both distance and near. ve lens is perfect; different types of lenses suit different
tasks. Determining the best form of the prescription for
- For patients with presbyopia, for near vision your patient is part of the art of prescribing. Discuss
correction, prescribe the minimal near addition with them the situations and tasks for which the specta-
required and never over-prescribe the addition. cles (or contact lenses, etc) are to be used and explain
Patients will sometimes indicate preference for that different types of lenses may be required for diffe-
stronger additions than are necessary because of rent tasks. Spectacle lenses exist in single vision, bifocal,
the proximal magnification they give, but they also trifocal, progressive and various occupational forms, and
restrict the working distance and reduce depth of there are many different kinds of each. There are the
field. Prescribing a near addition which is stronger choices of lens material, tint, coatings, etc to be consi-
than necessary will have undesirable consequences dered also.
for the patient’s near visual comfort in all types of
spectacles (single vision near, bi/trifocals and parti- All of these considerations go into the process of deci-
cularly progressive lenses where this will increase ding on the final prescription or prescriptions.
peripheral deformation). Except in very particular
cases, the near additions should always be identi- The few indications presented in this section are shared
cal for both eyes. reflections based on the experience of a group of practi-
tioners. They are in no way intended to represent abso-
- For refractive corrections of 4.00D and grea- lute rules of prescription and are of course always open
ter (plus and minus), vertex distance changes beco-
to discussion.
me significant. If a subjective refraction has been
determined at a vertex distance which is different
from that at which the lenses will be positioned in
front of the patient’s eyes when wearing the spec-
tacle frame, the final Rx prescribed must be adjus-
ted accordingly. (The effective power of a correcti-
ve lens varies with the vertex distance at which it is
placed). This adjustment may be avoided by ensu-
ring the subjective refraction is performed at the
standard vertex distance of 12-14mm and the
patient’s spectacle frames are adjusted to this
same vertex distance.
- As a general rule, if a choice must be made,

give priority to visual comfort over visual acuity.
Remember that acuity is only one element of vision
and the only one considered during refraction.
Other factors, such as peripheral perception of
forms or movement, also contribute to the visual
comfort of the patient. This is why the prescription
should always be submitted to the ‘perceptual
appreciation’ of the patient. At the end of the exa-
mination, always test the correction in a ‘real life’
situation in a trial frame. Ask patients to assess
their visual comfort, not only in distance and near
vision but also in terms of looking around at their
immediate surroundings. The patient’s opinion,
often enlightened and relevant, may prove invalua-
ble in the final choice of the correction.
Conclusion
Conclusion
Refraction is a science but also an art. It is, primarily, the technique of determining and correcting refractive
errors of the eye. However, it is also the art of knowing which prescription to choose in order to offer patients
both the best possible vision and the best possible comfort. If the technique of refraction can be taught, the art
of prescription can only be acquired with practice and clinical experience.
This Ophthalmic Optics File ‘Practical Refraction’ is designed to share the fundamentals of one technique of
refraction. The approach is deliberately practical, with theoretical considerations limited to a minimum. It goes
without saying that a subject as vast as this cannot be dealt with fully in such a short file. Readers are thus advi-
sed to refer to the many existing publications on refraction and visual examination in order to further their kno-
wledge. Although a few general guidelines regarding prescription have been provided, nothing less than regular
practice will enable the eye care professional to acquire not only the technical skills required to practise refrac-
tion but also the experience and clinical judgment required to make the best choice of prescription for each
patient.
Hopefully, this file will help eye care professionals in their daily refraction practice. Above all it is hoped that it
will enable them to prescribe the best possible optical corrections, so as to assist their patients always to ‘see
better to live better’!
Author
Dominique Meslin
Essilor Academy Europe
www.essiloracademy.eu

Practical Refraction English

Uploaded by

Copyright:

Available Formats

Practical Refraction English

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Practical Refraction English

Uploaded by

Copyright:

Available Formats

O PHTHALMIC O PTICS F ILES

GENERAL CONDITIONS OF USE

1 Emmetropia, Ametropia, Presbyopia and their correction

C Near Vision, Accommodation and Presbyopia p.9

Supplement: The Optical Principles of the Correction of Ametropia

4 Subjective Refraction – Distance Vision

Supplement: Estimating the Refractive Error from the Level of

5 Subjective Refraction - Near Vision

Supplement: The Consequences of Prescribing

B Verification of Binocular Balance at Near p.42

C In the case of the Non-Presbyopic Patient p.43

6 Binocular Vision Evaluation

B Identifying the Problem p.46

C Prescribing Prism p.50

Supplement: Definition, Measurement and Summation of Prism p.51

7 The Prescription (The Final Rx)

Presbyopia and their correction

= eye) when the image of an object located at infi-

The unaccommodated emmetropic eye can be

Thickness Refractive Anterior Posterior

Aqueous 3.60 1.336 - -

Overall length of eye: 24.09 mm

the lens as thin lenses (as opposed to thick lenses),

(iii) using the same index n = 1.336 for the aqueous

1) Myopia (Shortsightedness): 2) Hypermetropia (Longsightedness):

3) Astigmatism: - if emmetropic in one principal meridian and

the horizontal lines as blurred. - if hypermetropic in all meridians, it is termed

matic beam is a minimum and at its smallest size. The

The principle of correction of the astigmatic eye is to

merging the two linear foci into a single point focus,

When an object being viewed is brought closer to the Presbyopia :

tors). This loss of the ability of the eye to accommoda-

Figure 7: Ametropia and Presbyopia

Figure 6: Near Vision

The Optical Principles of the Correction of

a) the myopic eye +

b) the effect of the spherical component of the correction

b) the hypermetropic eye

Figure 10: The Principle of Correction of the Presbyopic Eye

Real and Virtual Optical Spaces

medium brightness in order to correspond to standard sitivity test.

Certain minimum equipment is required:

- Visual Acuity (VA) chart (distance) (including VA

It goes without saying that the use of these different

night vision, sensitivity to glare?

sely the patient’s behaviour.

Screening for Binocular Vision Anomalies 15a

The following tests may be undertaken:

- checking fusion by means of a red filter: the aim

- screening for heterophoria or tropia with the

other, and back again, before uncovering and returning

These preliminary measurements generally provide a

Near Vision - If P4 is read at 50 cm acuity is 0.50 m / (4 x 0.25 m)

Most auto-refractors operate on the principle of the

Despite the progress achieved, auto-refractors do not

yet provide a perfectly reliable measurement of refrac-

Figure 18: Retinoscope

Neutralization point or “reversal”

The use of retinoscopy requires experience which may