Subjective refraction

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(Top) 0.50 confirmation set; (Middle) trial lens box, including pinhole and occluder; (Bottom) Snellen chart Some of the equipment used during a Subjective Refraction.jpg
(Top) 0.50 confirmation set; (Middle) trial lens box, including pinhole and occluder; (Bottom) Snellen chart

Subjective Refraction is a technique to determine the combination of lenses that will provide the best corrected visual acuity (BCVA). [1] It is a clinical examination used by orthoptists, optometrists and ophthalmologists to determine a patient's need for refractive correction, in the form of glasses or contact lenses. The aim is to improve current unaided vision or vision with current glasses. Glasses must also be comfortable visually. The sharpest final refraction is not always the final script the patient wears comfortably.

Contents

Equipment & Requirements

The following equipment is used to complete a Subjective Refraction:[ citation needed ]

Performing the test

Test Requirements

Before commencing a Subjective Refraction, ensure that:

Trial frames fitted comfortably on the patient and occluder over left eye. Trial frames.jpg
Trial frames fitted comfortably on the patient and occluder over left eye.

Setting up the patient

  1. Comfortably fit the trial frames onto the patient, by adjusting the nose piece, Inter-Pupillary Distance (IPD) and vertex distance to ensure that they are properly centered. [4]

Preliminaries

  1. The examination begins by testing the patient's BCVA in both eyes separately, without correction. [4] Conventionally, the right eye is tested first. An occluder is placed over the eye that is not being tested (e.g.: over the left eye, to test the right eye's vision).
  2. A pinhole occluder is then placed before the patient's eye, and their vision is then tested again (each eye separately) to determine if the patient's poor visual acuity is a result of optical irregularities, or pathological issues. If the patient is able to read more lines on the Snellen chart with the use of the pinhole, this indicates the presence of refractive error. This is based on the principle that the pinhole blocks out any peripheral rays of light, so that only the principal ray falls on the fovea, decreasing the size of blur circles. [5]
  3. In the presence of refractive error in most patients, visual acuity will improve with the use of the pinhole. The examiner aims to achieve this level of visual acuity, or better, by the end of the Subjective Refraction.

Steps

Step 1: Using the +/-0.50DS on the confirmation set to determine the initial best sphere correction. Step 1) Initial Best Sphere Correction.jpg
Step 1: Using the +/-0.50DS on the confirmation set to determine the initial best sphere correction.
Step 2: Presenting the 0.50JCC initially @ 90deg to determine any presence of astigmatism on that axis. Step 2) Searching for Astigmatism.jpg
Step 2: Presenting the 0.50JCC initially @ 90deg to determine any presence of astigmatism on that axis.
Step 3: The axis of the JCC must straddle the axis of the correcting cylinder in the trial frames, in both flip positions. Step 3) Refining the cylinder axis..jpg
Step 3: The axis of the JCC must straddle the axis of the correcting cylinder in the trial frames, in both flip positions.
Step 4: The axis of the JCC must superimpose the axis of the correcting cylinder lens in the trial frames. Step 4) Refining cylinder power.jpg
Step 4: The axis of the JCC must superimpose the axis of the correcting cylinder lens in the trial frames.
Step 5: Spherical lens power is altered and refined, if required. Step 5) Adjusting for best sphere correction.jpg
Step 5: Spherical lens power is altered and refined, if required.

The entire process of Subjective Refraction involves the patient fixating at the Snellen Chart, whilst the clinician presents a variety of lenses and alters the power of the lenses in the trial frames according to the patient's subjective responses regarding improvements to their vision.

1) INITIAL BEST SPHERE CORRECTION

2) SEARCH FOR Astigmatism

3) REFINE CYLINDER AXIS

4) REFINE CYLINDER POWER

5) ADJUST FOR BEST SPHERE CORRECTION

Duochrome Test

"Do the letters stand out more on the red or green background?" Duochrome Test.jpg
"Do the letters stand out more on the red or green background?"
Duochrome is based on chromatic aberration of the eye. Principles of the Duochrome Test.jpg
Duochrome is based on chromatic aberration of the eye.
The patient's subjective response to the duochrome test is a perfect indicator as to whether you have under-corrected, over-corrected, or adequately corrected their refractive error during the subjective refraction process. Interpreting Duochrome test results.jpg
The patient's subjective response to the duochrome test is a perfect indicator as to whether you have under-corrected, over-corrected, or adequately corrected their refractive error during the subjective refraction process.

The red-green duochrome test is performed monocularly, and is used to refine the spherical component of the refraction. It is based on the principles of chromatic aberration; red (longer wavelength) is refracted less than green (the shorter wavelength). Therefore, a myope (generally with a longer axial length) sees red clearer as red focuses closer to retina than green. The examiner asks the patient: "Do the black letters stand out more on the red or green background? Or do they appear equal?"
Neutrality is achieved when the patient subjectively reports that the letters on both backgrounds appear equally as prominent. [7]

Recording

1) It is important to record the initial level of visual acuity, including the pinhole:

KEY:

2) The final prescription is recorded as follows:

KEY:

3) The Duochrome result is recorded as follows:

KEY:

Evaluation

Overall, the reliability of subjective refraction is high. However, it comes with advantages and disadvantages.[ citation needed ]

Advantages

Disadvantages

See also

Related Research Articles

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A corrective lens is a transmissive optical device that is worn on the eye to improve visual perception. The most common use is to treat refractive errors: myopia, hypermetropia, astigmatism, and presbyopia. Glasses or "spectacles" are worn on the face a short distance in front of the eye. Contact lenses are worn directly on the surface of the eye. Intraocular lenses are surgically implanted most commonly after cataract removal but can be used for purely refractive purposes.

<span class="mw-page-title-main">Farsightedness</span> Eye condition in which light is focused behind instead of on the retina

Far-sightedness, also known as long-sightedness, hypermetropia, and hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blur is due to incoming light being focused behind, instead of on, the retina due to insufficient accommodation by the lens. Minor hypermetropia in young patients is usually corrected by their accommodation, without any defects in vision. But, due to this accommodative effort for distant vision, people may complain of eye strain during prolonged reading. If the hypermetropia is high, there will be defective vision for both distance and near. People may also experience accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus. Newborns are almost invariably hypermetropic, but it gradually decreases as the newborn gets older.

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<span class="mw-page-title-main">Eyeglass prescription</span> Order written by an eyewear prescriber

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<span class="mw-page-title-main">Astigmatism (optical systems)</span> Optical aberration

An optical system with astigmatism is one where rays that propagate in two perpendicular planes have different foci. If an optical system with astigmatism is used to form an image of a cross, the vertical and horizontal lines will be in sharp focus at two different distances. The term comes from the Greek α- (a-) meaning "without" and στίγμα (stigma), "a mark, spot, puncture".

<span class="mw-page-title-main">Visual acuity</span> Clarity of vision

Visual acuity (VA) commonly refers to the clarity of vision, but technically rates an animal's ability to recognize small details with precision. Visual acuity depends on optical and neural factors. Optical factors of the eye influence the sharpness of an image on its retina. Neural factors include the health and functioning of the retina, of the neural pathways to the brain, and of the interpretative faculty of the brain.

<span class="mw-page-title-main">Intraocular lens</span> Lens implanted in the eye to treat cataracts or myopia

An intraocular lens (IOL) is a lens implanted in the eye usually as part of a treatment for cataracts or for correcting other vision problems such as short sightedness and long sightedness; a form of refractive surgery. If the natural lens is left in the eye, the IOL is known as phakic, otherwise it is a pseudophakic lens. Both kinds of IOLs are designed to provide the same light-focusing function as the natural crystalline lens. This can be an alternative to LASIK, but LASIK is not an alternative to an IOL for treatment of cataracts.

<span class="mw-page-title-main">Eye chart</span> Chart used to measure vision

An eye chart is a chart used to measure visual acuity comprising lines of optotypes in ranges of sizes. Optotypes are the letters or symbols shown on an eye chart. Eye charts are often used by health care professionals, such as optometrists, physicians and nurses, to screen persons for vision impairment. Ophthalmologists, physicians who specialize in the eye, also use eye charts to monitor the visual acuity of their patients in response to various therapies such as medications or surgery.

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An eye examination, commonly known as an eye test, is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ophthalmologist, or an orthoptist. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.

<span class="mw-page-title-main">Phoropter</span> Ophthalmic testing device

A phoropter or refractor is an ophthalmic testing device. It is commonly used by eye care professionals during an eye examination, and contains different lenses used for refraction of the eye during sight testing, to measure an individual's refractive error and determine their eyeglass prescription. It also is used to measure the patients' phorias and ductions, which are characteristics of binocularity.

<span class="mw-page-title-main">Defocus aberration</span> Quality of an image being out of focus

In optics, defocus is the aberration in which an image is simply out of focus. This aberration is familiar to anyone who has used a camera, videocamera, microscope, telescope, or binoculars. Optically, defocus refers to a translation of the focus along the optical axis away from the detection surface. In general, defocus reduces the sharpness and contrast of the image. What should be sharp, high-contrast edges in a scene become gradual transitions. Fine detail in the scene is blurred or even becomes invisible. Nearly all image-forming optical devices incorporate some form of focus adjustment to minimize defocus and maximize image quality.

<span class="mw-page-title-main">Astigmatism</span> Type of eye defect

Astigmatism is a type of refractive error due to rotational asymmetry in the eye's refractive power. This results in distorted or blurred vision at any distance. Other symptoms can include eyestrain, headaches, and trouble driving at night. Astigmatism often occurs at birth and can change or develop later in life. If it occurs in early life and is left untreated, it may result in amblyopia.

<span class="mw-page-title-main">Emmetropia</span> State of vision

Emmetropia is the state of vision in which a faraway object at infinity is in sharp focus with the ciliary muscle in a relaxed state. That condition of the normal eye is achieved when the refractive power of the cornea and eye lens and the axial length of the eye balance out, which focuses rays exactly on the retina, resulting in perfectly sharp distance vision. A human eye in a state of emmetropia requires no corrective lenses for distance; the vision scores well on a visual acuity test.

<span class="mw-page-title-main">Cylindrical lens</span> Optical device

A cylindrical lens is a lens which focuses light into a line instead of a point as a spherical lens would. The curved face or faces of a cylindrical lens are sections of a cylinder, and focus the image passing through it into a line parallel to intersection of the surface of the lens and a plane tangent to it along the cylinder's axis. The lens converges or diverges the image in the direction perpendicular to this line, and leaves it unaltered in the direction parallel to its cylinder's axis.

<span class="mw-page-title-main">Pinhole occluder</span> Ophthalmological testing tool

A pinhole occluder is an opaque disk with one or more small holes through it, used by ophthalmologists, orthoptists and optometrists to test visual acuity. The occluder is a simple way to focus light, as in a pinhole camera, temporarily removing the effects of refractive errors such as myopia. Because light passes only through the center of the eye's lens, defects in the shape of the lens have no effect while the occluder is used. In this way, the ophthalmologist, orthoptist or optometrist can estimate the maximum improvement in a patient's vision that can be attained by lenses to correct errors of refraction. This can be used to distinguish visual defects caused by refractive error, which improve when the occluder is used, from other problems, which do not. The pinhole occluder can also be used in testing visual acuity in mydriatic patients. In this case, the pinhole occluder compensates for the inability to contract the iris assisting the eye in obtaining a retinal projection similar to that of a non-cycloplegic eye.

The eye, like any other optical system, suffers from a number of specific optical aberrations. The optical quality of the eye is limited by optical aberrations, diffraction and scatter. Correction of spherocylindrical refractive errors has been possible for nearly two centuries following Airy's development of methods to measure and correct ocular astigmatism. It has only recently become possible to measure the aberrations of the eye and with the advent of refractive surgery it might be possible to correct certain types of irregular astigmatism.

<span class="mw-page-title-main">Duochrome test</span>

A duochrome test is a test commonly used to refine the final sphere in refraction, which makes use of the longitudinal chromatic aberration of the eye. Because of the chromatic aberration of the eye, the shorter wavelengths (green) are focused in front of the longer red wavelengths. It is assumed that best vision is attained when the yellow wavelengths are focused on the retina.

Contoura Vision is a topography guided laser technology used to correct refractive error and thereby decreasing or eliminating dependency on glasses or contact lenses. The technology reduces side effects linked with laser procedures like LASIK and SMILE. It was FDA approved in the US in 2016. The method provides measurement of 22,000 points as compared to 200 points provided by wave front-guided LASIK method. The imperfections in the cornea are recorded and then corrected using a laser.

<span class="mw-page-title-main">Ophthalmic trial frame</span> Tool used in eye examination

A trial frame is a tool used by ophthalmic professionals like ophthalmologists and optometrists. It is basically an adjustable spectacle frame with multiple cells, used to hold corrective lenses, and other accessories in subjective refraction and retinoscopy.

<span class="mw-page-title-main">Jackson cross cylinder</span> Ophthalmic instrument

The Jackson cross cylinder (JCC) is an instrument used by ophthalmologists, orthoptists and optometrists in their routine eye examination, particularly in determination of corrective lens power in patients with astigmatism. It is also used for testing near point of the eye.

References

  1. Khurana. (2008). Theory and Practice of Optics and Refraction (2nd ed.). Elsevier: Okhla, New Delhi. pp147
  2. Rabbetts, R.B. (1998). Bennett and Rabbett‟s Clinical Visual Optics. (3rd ed.). Oxford: Butterworth-Heinemann. pp99
  3. 1 2 Rabbetts, R.B. (1998). Bennett and Rabbett‟s Clinical Visual Optics. (3rd ed.). Oxford: Butterworth-Heinemann. pp94
  4. 1 2 3 4 5 Khurana. (2008). Theory and Practice of Optics and Refraction (2nd ed.). Elsevier: Okhla, New Delhi. pp148
  5. Benjamin, W.J. (2006). Borish's Clinical Refraction (2nd ed.) Elsevier: Butterworth-Heinemann.
  6. 1 2 3 4 5 6 7 8 Michaels, D. D. (1980). Visual Optics and Refraction: A Clinical Approach. (2nd ed.). Missouri: C.V. Mosby Company. pp379-383
  7. Colligon-Bradley, P (1992). "Red-green Duochrome Test". Journal of Ophthalmic Nursing and Technology. 11 (5): 220–2. PMID   1469739.