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The retinoscope allows the physician to objectively determine the spherocylindrical refractive
error, as well as observe optical aberrations, irregularities, and opacities.
Most retinoscopes in use today employ the streak projection system developed by Copeland. The illumination of the retinoscope is provided by a bulb with a straight fila ment that forms a streak in its projection. The light is reflected from a mirror that is either half silvered (Welch-Allyn model) or tota lly silvered around a small circular aperture (Copeland instrument) (Fig 4-1). The filament can be moved in relation to a convex lens in the system. If the light is slightly divergent, it appears to come from a point behind the retinoscope, as if the light had been reflected off a plano mirror ("plano mirror setting:' Fig 4-2). Alternatively, when the distance between the convex lens and the filament is increased by moving the sleeve on the handle, convergent light is emitted. In this situation, the image of the filament is between the examiner and the patient, as if the light had been reflected off a concave mirror (Fig 4~3) . Retinoscopy is usually performed using the plano mirror setting. Not all retinoscopes employ the same sleeve position for this mirror setti ng. For example, the original Cope~ land retinoscope is in plano position with the sleeve up; the Welch~AlIyn is in plano posi~ tion with the sleeve down. The axis of the streak is rotated by rotating the sleeve.
still be seen between the center of the pupil and the lateral edge of the lens.
Finding Neutrality
In against movement, the far point is between the examiner and the patient. Therefore, to bring the far point to the peephole of the retinoscope, minus lenses are placed in front of the patient's eye. Similarl y, in the case of with movement, plus lenses are placed in front of the patient's eye. This leads to the sin1ple cl inical rule: If you see with motion, add plus power (or subtract minus); if you see against motion, add minus power (or subtract plus) (Fig 4-9). Because it is easier to work with the brighter, sharper with motion image, overmi nus the eye and obtain a with reflex; then reduce the minus (add plus) until neutrality is reached. Be aware that the slow, dull reflexes of high refractive errors may be confused with the neutrality reflex. Med ia opacities may also produce dull reflexes.
meridians. The reflex streak in the pupil is not aligned with the streak projected on the iris and surface of the eye, and the line appears broken (Fig 4-10). The break disappears (ie, the line appears continuous) when the projected streak is rotated to
the correct axis. Width. The width of the reflex in the pupil varies as it is rotated around the correct axis. The reflex appears narrowest when the streak, or intercept, aligns with the axis (Fig 4-11 ). Intensity. The intensity of the line is brighter when the streak is on the correct axis. Skew. Skew (oblique motion of the streak reflex) may be used to refine the axis in small cylinders. [fthe retinoscope streak is off-axis, it will move in a slightly different direction from the pupillary reflex (Fig 4-12). The reflex and streak move in the same direction when the streak is aligned with one of the principal meridians. When the streak is aligned at the correct axis, the sleeve may be lowered (Copeland instrument) or raised (Welch-Allyn instrument) to narrow the streak, allowing the axis to be more easily determined (Fig 4-13). This axis can be confirmed through a technique known as straddling, which is performed with the estimated correcting cylinder in place (Fig 4- 14). The retinoscope streak is turned 45 off-axis in both directions, and if the axis is correct, the width of the reflex should be equal in both off-axis positions. If the axis is not correct, the widths will be unequal in these 2 positions. The axis of the correcting cylinder should be moved toward the narrower reflex and the straddling repeated until the widths are equal.
Summary of Retinoscopy
The performance of streak retinoscopy using a plus-cylinder phoropter is summarized in the following steps: 1. Set the phoropter to 0 D sphere and 0 D cylinder. Use cycloplegia if necessary. Otherwise, fog the eyes or use a nonaccommodative target. 2. Hold the sleeve of the retinoscope in the position that produces a divergent beam of light. (If the examiner can focus the linear filament of the retinoscope on a wall. the sleeve is in the wrong position.) 3. Sweep the streak of light (the intercept) across the pupil perpendicular to the long axis of the streak. Observe the pupillary light reflex. Sweep in several different meridians. 4. Add minus sphere until the ret inoscopic reflex shows with motion in all meridians. Add a li ttle extra minus sphere if uncertain. If the reflexes are dim or in distinct. consider high refractive errors and make large changes in sphere (-3 D. -6 D. -9 D. and so on). 5. Continue examining multiple meridians while adding plus sphere until the re tinoscopic reflex neutralizes in 1 meridian. (If all meridians neutralize simultaneously, the patient's refractive error is spherical; subtract the working distance to obtain the net retinoscopy). 6. Rotate the streak 90 and position the axis of the correcting plus cylinder parallel to the streak. A sweep across th is meridian reveals additional with motion. Add plus cylinder power until neutrality is achieved. 7. Refine the correcting cylinder axis by sweeping 45 to either side of it. Rotate the axis of the correcting plus cylinder a few degrees toward the "guide" line. the brighter and narrower reflex. Repeat until both reflexes are equal. 8. Refine the cylinder power by moving in closer to the patient to pick up with motion in all directions. Back away slowly, observing how the reflexes neutralize.
Change sphere or cylinder power as appropriate to make all meridians neutralize
simultaneously.
9. Subtract the working distance (measured in diopters). For example, if the working distance is 67 cm, subtract 1.5 D (1.00/0.67). 10. Record the streak retinoscopy findings and, when possible, check the patient's
visual acuity with the new prescription.
However, determining the astigmatic portion of the correction is more complex, and a variety of subjective refraction techniques may be used. The Jackson cross cylinder is the most common instrument used in determining the astigmatic correction. However, we will begin with the astigmatic dial technique because it is easier to understand.
3. Note the blackest and sharpest line of the ast igmatic dial. 4. Add minus cylinder with axis perpendicular to the blackest and sharpest line until all lines appear equal. 5. Reduce plus sphere (or add minus) until best acuity is obtained with the visual
acuity chart.
Astigmatic dial refraction can also be performed with plus cylinder equipment, but it must be used in a way that simulates minus cylinder effect. All of the above steps remain the same except for step 4, which becomes: Add plus cylinder with axis parallel to the blackest and sharpest line. As each 0.25 D of plus cylinder power is added, change the
sphere simultaneously 0.25 D in the minus direction. This simulates minus cylinder effect
exactly, moving the anterior focal line posteriorly without changing the position of the posterior focal line. .
Michaels DD. Visual Optics and Refraction: A Clinical Approach. 3rd ed. St Louis: Mosby; 1985: 319- 322.
Cross-Cylinder Technique
The Jackson cross cylinder, in Edward Jackson's words, is probably "far more useful, and far more used" than any other lens in clinical refraction. Every ophthalmologist should be familiar with the principles involved in its use. Although the cross cylinder is usually used to refine the cylinder axis and power of a refraction already obtained, it can also be used
for the entire astigmatic refraction.
The fi rst step in cross-cylinder refra ctio n is adjusting the sphere to yield best visual
acuity with accommodation relaxed. Begin by placing the prescription the patient is wearing
into a trial frame or phoropter. Fog the eye to be examined with plus sphere while
the patient views a visual acuity chart; then decrease the fog until best visual acuity is
obtained. If astigmatism is present, decreasing the fog places the circle of least confusion
on the retina, creating a mixed astigmatism. Now, use test figures 1-2 li nes larger than the pat ient's best visual acuity. At this point, introduce the cross cylinder, first for refinement of cylinder axis and then for refinement of cylinder power.
If no cylindrical correction is present initially, the cross cylinder may still be used, placed at 90" and 180", to check for the presence of astigmatism. If a preferred flip position is found, cylinder is added with axis parallel to the respective plus or minus axis of the cross cylinder until the 2 flip choices are equal. If no preference is found with the cross-cylinder axes at 90" and 180", then 45 and 13 5" should always be checked before
the assumption is made that no astigmatism is present. Once any cylinder power is found, axis and power are refined in the Llsual manner. Always refine cylinder axis before refining cylinder power. This sequence is necessary because the correct axis can be found in the presence of an incorrect pmver, but the full cylinder power is found only in the presence of the correct axis.