AAO READING
OBJECTIVE REFRACTION TECHNIQUE:
RETINOSCOPY
Khairun Nisa
Pembimbing :
dr Adelina T. Poli, Sp.M, M. Kes
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RETINOSCOPY
Retinoscopy is an important skill and tool for ophthalmologist
Retinoscope a tool to detect spherocylindrical refractive
error of the eye, optical aberrations, irregularities, and opacities
Useful to examine infants, children, and adults who are unable
to communicate
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RETINOSCOPY
Most retinoscope employ Copeland streak projection system
Illumination model of retinoscope bulb with straight
filaments form a streak in its projection or slit-shaped aperture
Light reflected from a mirror:
o Half-silvered (Welch Allyn, Heine models)
o Totally silvered (Copeland instrument) (Fig. 4)
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RETINOSCOPY
The filament light source (or the slit
aperture) can be moved in relation to a
convex lens in the system use sleeve of
retinoscope
If the light is slightly divergent appears
to come from a point behind the
retinoscope as if the light were reflected
off a flat mirror (ie, a plane mirror setting)
(Fig 4-2)
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RETINOSCOPY
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 appears between the examiner
and the patient as if the light were
reflected off a concave mirror (Fig 4-3)
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RETINOSCOPY
Retinoscopy performed with either a concave
mirror setting or a plane mirror setting,
determined by the sleeve
Plane mirror setting is usually performed so
that light is parallel (or slightly divergent) as it
enters the pupil of the patient’s eye
The direction of motion in concave mirror
effect is opposite that of the plane mirror
effect
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RETINOSCOPY
Concave setting function to sharpen the reflex while
determining the axis of astigmatism
Using concave setting during power determination (of sphere of
cylinder) may lead to false end points (neutrality)
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RETINOSCOPY
Not all retinoscopes employ the same
sleeve position for the plane mirror setting
Example:
o Copeland retinoscope plane
position with the sleeve up
o Welch Allyn (or Heine) plane
position with the sleeve down
The axis of the streak is rotated with the
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sleeve
POSITIONING AND ALIGNMENT
Examiner uses his or her right eye
to perform retinoscopy on the
patient’s right eye, vice versa
Doing so prevents the examiner’s
head from moving into the patient’s
line of sight inadvertently
stimulating accommodation
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POSITIONING AND ALIGNMENT
If the examiner looks directly through the optical centers of the
trial lenses reflections from the lenses may interfere
If the examiner is too far off- axis unwanted spherical and
cylindrical errors may occur
The optimal alignment is just off center lens reflections can
still be seen between the center of the pupil and the lateral edge
of the lens 11
FIXATION AND FOGGING
Retinoscopy patient’s accommodation
needs to be relaxed
Patient should fixate at a distance on a
nonaccommodative target
For example the target may be a dim light
at the end of the room or a large Snellen
letter (20/200 or 20/400 size)
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FIXATION AND FOGGING
Plus lenses may be introduced in front of
the eye not being examined to aid in the
relaxation of accommodation
Accommodating after fogging is
performed will only further blur the image
Children typically require pharmacologic
cycloplegia (such as cyclopentolate 1%) 13
RETINAL REFLEX
The projected streak illuminates an area of
the patient’s retina, and this light returns to
the examiner
By observing characteristics of this reflex,
the examiner determines the refractive status
of the eye
If patient’s eye is emmetropic light rays
are parallel to one another
If patient’s eye is myopic rays are
convergent (Fig. 4-4) 14
If the eye is hyperopic the rays are
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RETINAL REFLEX
Through the peephole in the retinoscope, the emerging light is
seen as a red reflex in the patient’s pupil
If the examiner (specifically, the peephole of the retinoscope) is
at the patient’s far point all the light leaving the patient’s
pupil enters the peephole and illumination is uniform
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RETINAL REFLEX
If the far point of the patient’s eye is not at the peephole of the
retinoscope only some of the rays emanating from the
patient’s pupil enter the peephole illumination of the pupil
appears incomplete
If the far point is between the examiner and the myopic patient
the emerging rays will have focused and then diverged
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RETINAL REFLEX
The border between the dark and lighted portions of the pupil
will move in a direction opposite to the motion (sweep) of the
retinoscope streak (known as against movement) as it is
moved across the patient’s pupil
If the far point is behind the examiner, the light moves in the
same direction as the sweep (known as with movement; Fig 4-
5) 18
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RETINAL REFLEX
The state in which the light fills the pupil and apparently does
not move neutrality (Fig 4-6)
If the examiner moves forward (in front of the far point), with
movement is seen
If the examiner moves back and away from the far point,
against movement is seen
The far point may be moved with placement of a correcting
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lens in front of the patient’s eye
CHARACTERISTICS OF THE REFLEX
The moving retinoscopic reflex has 4 main characteristics
(Fig 4-7):
1. Speed. The reflex seen in the pupil moves slowest when
the far point is distant from the examiner (peephole of the
retinoscope). Large refractive errors have a slow- moving
reflex, whereas small errors have a fast reflex
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CHARACTERISTICS OF THE REFLEX
2. Brilliance. The reflex is dull when the far point is distant
from the examiner; it becomes brighter as neutrality is
approached
3. Width. When the far point is distant from the examiner,
the streak is narrow. As the far point is moved closer to the
examiner, the streak broadens and, at neutrality, fills the
entire pupil only to with movement reflexes 22
CHARACTERISTICS OF THE REFLEX
4. Regularity. An irregular reflex indicates a media problem
that should be further explored in examination
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THE CORRECTING LENS
When the examiner uses the appropriate correcting lenses (with
either loose lenses or a phoropter), the retinoscopic reflex is
neutralized
In other words, when the examiner brings the patient’s far point
to the peephole, the reflex fills the patient’s entire pupil (Fig 4-
8)
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THE CORRECTING LENS
The power of the correcting lens (or lenses) neutralizing the
reflex is determined by the refractive error of the eye and the
distance of the examiner from the eye (the working distance)
Theoretically, the working distance should be at optical infinity
but this does not practically allow for changing lenses in front
of the eye or seeing the retinal reflex
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THE CORRECTING LENS
Dioptric equivalent of working distance subtracted from the
power of the correcting lens to determine the actual refractive
error of the patient’s eye
Common working distances are 67 cm (1.50 D) and 50 cm
(2.00 D), and many phoropters have a 1.50 D or 2.00 D
“working- distance lens” for use during retinoscopy then
removed at the end of the retinoscopy (however, this lens can
produce bothersome reflexes) 28
THE CORRECTING LENS
If the examiner is not using the “built-in” working lens in the
phoropter, he or she must algebraically subtract the appropriate
amount of spherical power to move the neutralization point
from the examiner to infinity (Clinical Example 4-2)
Example: examiner obtains neutralization with a total of +4.00
D over the eye (gross retinoscopy) at a working distance of
67 cm Subtracting 1.50 D for the working distance yields a
refractive correction of +2.50 D 29
THE CORRECTING LENS
Any working distance may be used
If the examiner prefers to move closer to the patient for a
brighter reflex, the working-distance correction is adjusted
accordingly
Working without an explicit lens to correct for the working
distance may allow the use of fewer lenses held in front of the
eye, reducing distracting reflections from the lens surfaces 30
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, a minus lens is placed in front of the patient’s eye
Similarly, in the case of with movement, a plus lens is placed in
front of the patient’s eye
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FINDING NEUTRALITY
This procedure gives rise to the simple clinical rule: If with
movement is observed, add plus power (or subtract minus
power)
If against movement is observed, add minus power (or subtract
plus power) (Fig 4-9)
One should “overminus” the eye and obtain a with reflex; then
reduce the minus power (or add plus power) until neutrality is
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reached
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FINDING NEUTRALITY
Be aware that the slow, dull reflexes of high-refractive errors
may be confused with the neutrality reflex
Media opacities may also produce dull reflexes
Once neutrality is found, the lens to correct for the working
distance must be removed, whether it is the built-in retinoscopy
lens in the phoropter or by subtracting the appropriate
correcting lens based on the working distance used 34
RETINOSCOPY OF REGULAR ASTIGMATISM
Most eyes have some regular astigmatism, in such cases, light is refracted
differently by the 2 principal astigmatic meridians
Moving the retinoscope from side to side (with the streak oriented at 90°)
measures the optical power in the 180° meridian
Power in this meridian is provided by a cylinder at the 90° axis
The convenient result is that the streak of the retinoscope is aligned with
the axis of the correcting cylinder being tested
In a patient with regular astigmatism, one seeks to neutralize 2 reflexes, 1
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from each of the principal meridians
FINGDING THE CYLINDER AXIS
Before the powers in each of the principal meridians can be
determined, the axes of the meridians must be determined
Four characteristics of the streak reflex aid in this determination:
1. Break. A break is observed when the streak is not oriented
parallel to 1 of the principal 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) 36
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FINGDING THE CYLINDER AXIS
2. 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)
3. Intensity. The intensity of the line is brighter when the
streak is on the correct axis
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FINGDING THE CYLINDER AXIS
4. Skew. Skew (oblique motion of the streak reflex) may be
used to refine the axis in small cylinders. If the
retinoscope streak is off- axis, it moves in a slightly dif fer
ent direction from that of the pupillary reflex (Fig 4-12)
When the streak is aligned at the correct axis sleeve may be
lowered (Copeland instrument) or raised (Welch Allyn
instrument) to narrow the streak, allowing the axis to be
determined more easily (Fig 4-13) 40
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FINDING THE CYLINDER AXIS
This axis can be confirmed through 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 width of the reflex should be equal in both
off- axis positions
If the axis is not correct widths are unequal in these 2 positions
The axis of the correcting plus cylinder should be moved toward the
narrower reflex and the straddling repeated until the widths are equal
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FINDING THE CYLINDER POWER
After the 2 principal meridians are identified, the previously explained
spherical techniques are applied to each axis:
o With 2 spheres. Neutralize 1 axis with a spherical lens; then
neutralize the axis 90° away. The difference between these readings
is the cylinder power. For example, if the 90° axis is neutralized
with a +1.50 sphere and the 180° axis is neutralized with a +2.25
sphere, the gross retinoscopy is +1.50 +0.75 × 180. The examiner’s
working distance (ie, +1.50) is subtracted from the sphere to obtain
the final refractive correction: plano +0.75 × 180.
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FINDING THE CYLINDER POWER
o With a sphere and cylinder. Neutralize 1 axis with a
spherical lens. To enable the use of with reflexes, neutralize
the less plus axis first. Then, with this spherical lens in
place, neutralize the axis 90° away by adding a plus
cylindrical lens. The spherocylindrical gross retinoscopy is
read directly from the trial lens apparatus.
It is also possible to use 2 cylinders at right angles to each other
for this gross retinoscopy 46
ABERRATIONS OF RETINOSCOPIC REFLEX
With irregular astigmatism, almost any type of aberration may
appear in the reflex
Spherical aberrations tend to increase the brightness at the
center or periphery of the pupil, depending on whether they are
positive or negative
As neutrality is approached, 1 part of the reflex may be myopic,
whereas the other may be hyperopic relative to the position of
the retinoscope such situation produces a scissors reflex 47
ABERRATIONS OF RETINOSCOPIC REFLEX
Causes of the scissors reflex keratoconus, irregular corneal
astigmatism, corneal or lenticular opacities, and spherical
aberration
All of these aberrant reflexes, in particular spherical aberration,
are more noticeable in patients with large scotopic pupils the
examiner should focus on neutralizing the central portion of the
light reflex
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Table 4-1 provides a summary of the technique of retinoscopy using a plus cylinder
phoropter
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PSEUDONEUTRALIZATION
As discussed before, in general, with reflexes are brighter,
sharper, and easier to perceive and interpret than against
reflexes
In particular, the reflex in severely myopic eyes is seldom
recognizable as an against reflex— rather, one sees only a dull,
motionless illumination of the entire pupil
pseudoneutralization
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PSEUDONEUTRALIZATION
This is best handled by reversing the sleeve of the retinoscope:
o Welch-Allyn to the maximal sleeve-up position
o Copeland maximal sleeve-down position
This will convert the dull pseudoneutral reflex to a readily
recognizable with reflex, but in this case, the with reflex must
be neutralized by adding minus sphere power
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PSEUDONEUTRALIZATION
As true neutrality is approached, return the retinoscope sleeve
to the usual position
The reflex will revert to an against reflex as in typical myopic
eyes
Continue to add minus sphere power until a with reflex is
obtained, and then reduce the minus sphere so as to reach true
neutrality from the with direction 53
THANK YOU
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