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01/08/2014 1 Biological Optics & Retinoscopy Introduction & Principles Introduction Retinoscopy - an objective measure to determine refractive error Retinoscope illuminates the eye and we observe the light reflected from retina Refractive components of the eye influences the way the light is reflected i.e. reflex Introduction Refraction and final Rx are usually from the combination of objective measurement (retinoscopy) and refinement with subjective refraction Principles of Retinoscopy When light enters the patient’s eye, cornea and crystalline lens focus (converge) the light and an image is formed on the retina (fovea) Important term: Conjugates* The position of the image can be determined if the position of the object is known, and vice versa and both of them are conjugates Ametropia The far point is not at infinity Further divided into: Spherical ametropia (myopia & hyperopia) Aspherical ametropia (astigmatism)

Retsimp 2013

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Lecture slides on retinoscopy and very basic physics of light. Retinoscopy for clinicians and students. Recognising astigmatism and normal reflexes via retinoscopy.

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Page 1: Retsimp 2013

01/08/2014

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Biological Optics & Retinoscopy

Introduction & Principles

Introduction

• Retinoscopy - an objective measure to determine refractive error

• Retinoscope illuminates the eye and we observe the light reflected from retina

• Refractive components of the eye influences the way the light is reflected i.e. reflex

Introduction

• Refraction and final Rx are usually from the combination of objective measurement (retinoscopy) and refinement with subjective refraction Principles of Retinoscopy

• When light enters the patient’s eye, cornea and crystalline lens focus (converge) the light and an image is formed on the retina (fovea)

• Important term: Conjugates*

– The position of the image can be determined if the position of the object is known, and vice versa and both of them are conjugates

Ametropia

• The far point is not at infinity

• Further divided into:

– Spherical ametropia (myopia & hyperopia)

– Aspherical ametropia (astigmatism)

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Reflex Analysis: Spherical Refractive Error

Principles

• Illuminate patient’s retina with light from retinoscope, and observe the reflected light

• With regards to the location of the far point, if the patient is

– Emmetropic: reflected light is parallel

– Hyperopic: reflected light is divergent

– Myopic: reflected light is convergent

What does it all mean?

• If the patient’s far point is behind the retinoscope (the peephole)

– WITH movement is observed

• If the far point is in front of the retinoscope

– AGAINST movement is observed

In real life,

• We can only observe the movements of the reflex (with/against)

– We cannot really observe if the far point is behind or in front of the peephole

• Based on the reflex’s movement, we can deduce that if

– AGAINST – far point is in front of the retinoscope

– WITH – far point is behind the retinoscope

• If a positive lens is placed in front of an emmetropic patient’s eye,

– The retina will conjugate with the dioptric distance of the positive lens, and no movement is observed (neutral)

– The lens is known as working distance lens

– E.g. If a +1.50DS is used, the retinoscopist should perform the examination at 67cm away (why?)

Working distance lens

• Movement of reflex (with working distance lens)

– Emmetrope • No movement, NEUTRAL

• Retinoscope is at the far point, ie, infinity

– Hyperope

• WITH movement

• Far point is behind the retinoscope

– Myope

• AGAINST movement

• Far point is in front of the retinoscope

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Video

Working distance & Working distance lens

• Any working distance can be used when performing retinoscopy

• Need to consider:

– Brightness of the reflected light from the retina

– Access to patient

– Distance error when choosing a working distance

The Power of the WD Lens?

• If the working distance is too small, eg. 25cm

– Brighter retinal reflex, but larger distance error

• If the working distance is too large eg. 100cm

– Dimmer retinal reflex but smaller distance error

• Usually working distance of 67cm or 50cm is used

Neutral zone

Reflex characteristics

• Speed – Fast when approaching neutral

– Slow when far from neutral

• Brightness – Bright when approaching neutral

– Dim when far from neutral

• Width – Wide when approaching neutral

– Narrow when far from neutral

Neutral zone

• There is a zone (not a point) where neutral reflex can be observed

• Inside the neutral zone: there is a confusion whether the movement is WITH or AGAINST

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Handling the Retinoscope

• Right hand/Right eye – examines patient’s right eye

• Left hand/Left eye – examines patient’s left eye

• Look through peephole with one eye

Handling the Retinoscope

• Hold with one hand

– Change the streak orientation only

• Ambidexterity (skill) & the ability to suppress the unused eye is very important

• Align the retinal reflex with pupil

– Retinoscope’s head rests on brow or spectacles

Model eye

• Simulation is achieved by changing the length of the model eye

– Increase length: simulate myopia

– Decrease length: simulate hyperopia

• To simulate high spherical Rx (using trial lenses), use:

– positive lens: __________

– Negative lens: _________

Retinoscopy:

Neutralising Astigmatism

Astigmatism

• Meridian: 1 to 180 deg • Two meridians are usually 90 deg from each

other – Regular astigmatism (meridians 90 and 180 deg) – Oblique astigmatism e.g. 45 and 135 deg – Irregular astigmatism – principal meridians are not 90

deg from each other

• With the Rule (WTR) – Axis of the –ve cyl lens is at 180 deg

• Against the Rule (ATR) – Axis of the –ve cyl lens is at 90 deg

Type of Astigmatism

• Simple hyperopic

• Compound hyperopic

• Simple myopic

• Compound myopic

• Mixed

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Reflex of an Astigmatic Eye Neutralising Astigmatism

Techniques

• Minus-cyl technique

– Neutralise least minus or most plus meridian first

• Plus-cyl technique

– Neutralise most minus or least plus meridian first

• Minus-cyl technique is most commonly used

– However you can opt to do any one of them – but must be aware of the advantages and disadvantages

Two ways of neutralising

• Using spherical lenses only

– Neutralise both meridians using spherical lenses of different power

– Transpose the findings into sph-cyl

• Using spherical and cylindrical lenses

– MOST PLUS or LEAST MINUS meridian is neutralised first using spherical lens

– The other meridian is neutralised using MINUS cylindrical lens

Neutralising with sph-cyl lens for Hyperopic eye

Neutralising with sph-cyl lens for Myopic eye

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Summary: Minus-cyl Technique

Minus cyl Technique

• To obtain the spherical power of the first meridian:

– Neutral meridian with most plus or least minus first

• Reflex at second meridian

– Must be against movement

– Neutralise second meridian with –ve cyl lens, with axis parallel to streak orientation

Determining Position of Cylinder Axis

• Four ways to determine position of a cyl’s axis:

– Break phenomena

– Streak width

– Reflex intensity

– Reflex skewness

• Use enhanced light to observe (sleeve is in midway position)

• All four phenomena are observed simultaneously

• Break and width

– Easiest to observe when the cylindrical refractive error is high

• Skew and intensity

– Easiest to observe when the cylindrical refractive error is low

Retinoscopy on Human Eye

Dr. Mohd Izzuddin Hairol

UKM 2013

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Refraction

• Fixation target – Must not cause the eye to accommodate, i.e. non-

accommodative target

– E.g. spot light at 6 metres away

• Fogging lens – the eye must relax – so must use positive lenses

– Usually the power of the working distance lens (+1.50DS or +2.00DS) is enough to fog the eye – place WDLs before both eyes

– DO NOT occlude the non-tested eye

Refraction

• The position and alignment of the eyes are important to get accurate results – WDL power must match the examiner’s working

distance • If not will cause errors in the final spherical power

– Alignment with patient’s visual axis • If not will cause errors in the final cylindrical power

• Patient’s fixation of the target must not be blocked

Refraction

• Use your right eye (and right hand) to examine patient’s right eye, vice versa

• Start examination with the RE followed by the LE (do NOT take out lenses from the RE when examining LE)

Minus Cyl Technique

• Neutralise MOST PLUS or LEAST MINUS first

– This is the spherical power for the first meridian

• Reflex observed at the second meridian

– Must be against

– Neutralise the second meridian with minus cyl lens

– Axis of lens is aligned with the orientation of the retinoscope’s streak

Retinoscopy (without WDL)

• Retinoscopy can be done without WDL

– E.g. when using lens rack

– Or to reduce the light reflex from trial lenses

• Final power = spherical lens power to achieve neutrality – WDL power

Retinoscopy: Sources of Errors

• If there is a marked difference in the final Rx between objective and subjective refractions, it could be due to

– Neutral point misinterpretation

– Retinoscopist’s technique

– Confusing and irregular reflex

• Spherical aberrations

• Scissor movement

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Retinoscopist’s Techniques

• Errors could be due to incorrect working distance or misalignment of visual axis

• Incorrect working distance causes an error in final spherical correction

– Make sure that your working distance and WDL match

• Misalignment of visual axis (off-axis) causes an error in final cylindrical correction

– Make sure retinoscope is in line with patient’s corresponding visual axis

Irregular reflexes

• Sometimes reflexes can be irregular and confusing

• Different movements seen at the pupil’s centre and periphery – E.g. WITH movement at the centre and AGAINST

movement at the periphery when approaching neutrality

• Spherical aberrations especially with larger pupils – Occurs when pupils are naturally large or when using

cycloplegic agents

• To overcome: neutralise reflex movement seen at the centre of the pupil only

Common problems

• Reflex is hard to see when patient has smaller pupils – E.g. elderly patients

• To overcome: change to a shorter working distance – Make sure that the new working distance matches

the WDL used

– When reflex is observed with correcting lenses, change working distance back to 50 cm or 67 cm to minimise distance error

Common problems

• Dull reflex

– could be due to

• Cloudy media e.g. cataract

• High refractive error

– To overcome

• Cloudy media: change to a shorter working distance

• High refractive error: try using high +ve or –ve lenses until a clear reflex is observed, or use the convergent beam

Convergent beam (verifying AGAINST)

• If a patient is a high myope, an AGAINST movement is sometimes hard to observe

• Use convergent beam to verify – With a convergent beam (sleeve in UP position), a

reversal of movement is observed i.e. WITH if a patient is a myope

– If WITH movement is observed with a convergent beam • Patient is definitely a myope

• Change sleeve back to divergent and neutralise as usual

High refractive errors

• Difficult to judge reflex when refractive error is high

• Dull reflex is observed – Place high plus or high minus trial lens before

patient’s eye e.g. +5.00DS or -5.00DS, and observe the reflex

– If with +5.00DS, WITH movement is observed – continue adding plus lenses until neutral

– If with -5.00DS, AGAINST movement is observed – continue adding minus lenses until neutral

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High refractive errors

• If dull reflex is still observed with +5.00 DS or -5.00DS – Try using lenses with higher power, e.g. +8.00DS or -

8.00DS

• Reflex in uncorrected eyes with high refractive errors sometimes looks neutral (as if there is a full reflex and no movement is observed) – To differentiate:

• Reflex must be bright with fast movement

• Move forward, and reflex must be WITH. If not/does not change – the reflex observed earlier was not neutral.