REFRACTION HANDBOOK

FOR CLINICIANS
Authors: Sarah Wassnig B.Optom(OcTher), MPH & Diane Russo OD, MPH, FAAO

New England College of Optometry created this handbook for the use of Orbis International trainees.

This publication is the property of New England College of Optometry and permission is required to
reproduce any of this publication.

To use content please contact:

New England College of Optometry
424 Beacon Street
Boston, MA, 02115
Email: orbis@neco.edu

REFRACTION HANDBOOK FOR CLINICIANS 2

Table of contents:

Section I: The Equipment ……………………………………….. Page 4

Section II: Set up …………………………………………………….. Page 9

Section III: Trial Frame Refraction Steps ……………………. Page 10

Section IV: Phoropter Refraction Steps ……………………… Page 15

Section V: Binocular Balance Alternatives ………………… Page 19

Section VI: Astigmatism Method Alternatives …………….. Page20

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Section I: The Equipment
The Phoropter

Leveling Knob
Pupillary Distance
(PD) Knob
Auxillary Lens Knob

Forehead Rest Knob

Jackson Cross
Cylinder Unit
Sphere Power Scale

Prism Unit
Cylinder Power Scale
Cylinder Axis Indicator

Cylinder Power and

Axis Knob

Occluder
Retinoscopy Lens

Open

Level Knob Level

PD Knob

PD Position
PD Scale Levers

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 Sphere Lens Dial

Sphere Power Scale

Cylinder Axis Indicator

Cylinder Power Scale

Cylinder Axis Knob

Cylinder Power Knob

Cylinder Axis Indicator

JCC Unit

Red dots for minus axis orientation:

usually -0.25D

White dots for plus axis orientation:

usually -0.25D

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 The Trial Frame

Nose Bridge Knob

Temple Tilt Knob

Pupillary Distance (PD) Knob

Pupillary Distance (PD) Scale

Nose Bridge Tilt Knob

Nose Bridge

Temple Front Lens Wells

Axis Scale

Axis Scale Knob

Vertex Distance Scale

Back Lens Wells

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 Jackson Cross Cylinder “JCC” Lens

JCC Power

JCC Positive Axis

JCC Negative Axis

JCC Handle

Plano Red and Green Filter

Occluder Pinhole Stenopaeic

Slit

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Positive Cylinder Lens Negative Cylinder Lens

Positive Lens Negative Lens

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Section II: Set up
Preparing the room

Position the phoropter or trial frame:

Trial frame
• Shorten temple behind the patient’s ear
• Adjust the temple so trial frame is straight
• Adjust pupillary distance
• Adjust nose bridge to sit on the bridge of the nose
• Ensure eyes align with lens center

Phoropter
• Position in front of the patient
• Ensure eyes align with lens center
• Adjust the level to straighten phoropter
• Adjust pupillary distance
• Move pupillary distance to distance position
• Adjust forehead rest to be against the patient’s forehead

Chart conditions:
• Mark where your chart distance is on the floor, if not permanent
• Have a clean chart with white background and distinct black letters for good contrast
• Place the chart at eye level
• Test in good lighting with minimal shadows around the chart

Patient set up:

• Ensure the patient is sitting back in the chair comfortably
• Test the patient’s habitual vision, both monocularly and binocularly.

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Section III: Trial Frame Refraction Steps

1. Occlude the left eye

2. Measure best visual acuity with your starting point

a. retinoscopy,
b. autorefraction, or
c. previous prescription
− Show full chart
− Encourage the patient to continue reading down to their best visual acuity

3. Refine the sphere

− Show the full chart, directing the patient's attention to the line of their best acuity
− Take a +0.25D lens and a -0.25D lens in one hand
− Show the patient the two lens options asking which makes their best visual acuity clearer
− Add the lens that makes it clearer – careful not to over minus here, the patient needs to
READ more letters if the patient wants more minus
− Keep repeating until the patient reports “same” or cannot read more with the preferred lens

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4. Duochrome

− Clearer in the red, add -0.25DS: myopia is under-corrected or hyperopia is over-corrected

− Clearer in the green, add +0.25DS: hyperopia is under-corrected or myopia is over-
corrected

“Equal”

“Red”

“Green”

− Stop when equal or 1 step on green for accommodating patients

− This test does not always work:
i. Red preference: if the patient continues to say red then, go back to your
original prescription and skip this test.
ii. Cannot be performed on patients with vision worse than 20/30 (6/9, 0.63)

− If there is not a red/green chart available, loose red and green filter lenses can be used

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5. Astigmatism/Jackson Cross Cylinder
− Isolate (or point to) the line 1 step larger than current VA
− If the tentative or starting astigmatism is more -0.50DC, refine your axis first
− If tentative or starting astigmatism is -0.50DC or -0.25DC, refine power first

AXIS REFINEMENT

− Align the HANDLE of the Jackson Cross Cylinder (JCC) with the lens axis (so the dots are
straddling the axis)
− Flip the JCC one side being “lens or option 1” and the other side being “lens or option 2”
− Advise the patient that neither lens will be completely clear, but ask which option is best
a. If the two lenses are equal, move straight on to power determination
b. If not, rotate the CYLINDER LENS axis toward the minus axis (red dot) of the JCC
§ Repeat this question
§ If the response is in the opposite direction move the axis back by half the amount
changed the first time
§ If the response was in same direction as last, make another change of axis towards
the red, until the response is in the opposite direction
§ Continue with this bracketing until the patient notices no difference between the two
lens positions

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 POWER REFINEMENT

− Align the POWER dots of the Jackson Cross Cylinder (JCC) with the lens axis
− Advise the patient that neither of the lens will be completely clear, but ask which option is
best
− Flip the JCC lens to give the two power options
a. If the two lenses are equal, you are finished!
b. If the patient prefers the red (minus) axis dots, add -0.25DC
§ Repeat until both views are clearer
§ Maintain Spherical Equivalent: For every -0.50DC added, add +0.25DS
c. If the patient prefers the white (plus) axis dots, remove -0.25DC
§ Repeat until both views are clearer
§ Maintain Spherical Equivalent: For every -0.50DC removed, remove +0.25DS

− If you change cylinder power by more than -0.75DC, check axis again

ASTIGMATISM INVESTIGATION WITHOUT TENATIVE CYLINDER

− Align the JCC so the axes are at 135/45, flip lens and take note of which axis is red preferred
− Align the JCC so the axes are at 180/90, flip lens and take note of which axis is red
preferred
− Add – 0.50 DC between the two preferred red axes
§ Add +0.25DS for spherical equivalent
− Refine the power first to see if astigmatism is accepted, and then the axis.
§ Remember to remove the +0.25DS to maintain spherical equivalent if cylinder power in
decreased

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6. Refine Best Sphere
− Show the full chart, directing the patient's attention to the line of best acuity as their vision
clears up
− Fog the vision by adding +1.00DS to bring 2-4 lines worse than current VA
§ Warn the patient it will be blurry
− Slowly reduce the plus by 0.25D steps, each time checking visual acuity
− Stop when VA does not improve, ensure the patient can, in fact, read more letters rather
than preferring minus

7. Occlude the right eye and open the left eye

− Repeat steps 1 – 6 on the left eye

8. Binocular Balance - Humphriss

− Indications: patients who are old enough to participate, equal visual acuity
− Contraindications: strabismus, unstable or decompensating heterophoria, visual acuity
between the eyes more than 1 line apart, presbyopes, only minor adjustments can be made
with this technique
− Have both eyes open
− Add +1.00 D over the eye not being tested (left)
§ Check visual acuity is decreased to 20/40 (6/12)
§ If the visual acuity has not been reduced in the left eye, add plus +0.25D until 20/40
− Compare +0.25 to -0.25 over the eye being tested (right); ask the patient which lens is
clearer. If one lens is clearer adjust the sphere in that direction.
− Repeat the comparison until equal
− Fog the right eye adding +1.00 D over the eye
− Remove the fog from the left eye
− Compare +0.25 to -0.25 over the eye being tested (left); ask the patient which lens is clearer.
If one lens is clearer adjust the sphere in that direction.
− Remove the left fog

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Section IV: Phoropter Refraction
1. Occlude the left eye

2. Measure best visual acuity with your starting point

a. retinoscopy,
b. autorefraction, or
c. previous prescription
− Show full chart
− Encourage the patient to continue reading down to their best visual acuity

3. Initial Sphere Check

− Show the full chart, directing the patient's attention to the line of their best acuity
− Show the full chart, directing the patient's attention to the line of best acuity as their vision
clears up
− Fog the vision by adding +1.00DS to bring 2-4 lines worse than current VA
§ Warn the patient it will be blurry
− Slowly reduce the plus by 0.25D steps, each time checking visual acuity
− Stop when VA does not improve, ensure the patient can, in fact, read more letters rather
than preferring minus

4. Duochrome
− Clearer in the red, add -0.25DS
− Clearer in the green, add +0.25DS
− End point is equal or one step into the green for accommodating patient

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5. Astigmatism/Jackson Cross Cylinder
− Isolate (or point to) the line 1 step larger than current VA
− Insert the JCC over the eye
− If the tentative or starting astigmatism is more -0.50DC, refine your axis first
− If tentative or starting astigmatism is -0.50DC or -0.25DC, refine power first

AXIS REFINEMENT

− Move the JCC into the axis position

− Flip the wheel one side being “lens or option 1” and the other side being “lens or option 2”
− Advise the patient that neither lens will be completely clear, but ask which option is best
a. If the two lenses are equal, move to power determination
b. If not, rotate the cylinder axis toward the minus axis (red dot) of the JCC
§ Repeat this question
§ If the response is in the opposite direction move the axis back by half the amount
changed the first time
§ If the response was in same direction as last, make another change of axis towards
the red, until the response is in the opposite direction
§ Continue with this bracketing until the patient notices no difference between the
two lens positions

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POWER REFINEMENT

− Rotate the Jackson Cross Cylinder (JCC) into the power position
− Advise the patient that neither of the lens will be completely clear, but ask which option is
best
− Flip the JCC lens to give the two power options
a. If the two lenses are equal, move to step 6
b. If the patient prefers the red (minus) axis dots, add -0.25DC
§ Repeat until both views are clearer
§ Maintain Spherical Equivalent: For every -0.50DC added, add +0.25DS
c. If the patient prefers the white (plus) axis dots, remove -0.25DC
§ Repeat until both views are clearer
§ Maintain Spherical Equivalent: For every -0.50DC removed, remove +0.25DS

− If you change cylinder power by more than -0.75DC, check axis again

ASTIGMATISM INVESTIGATION WITHOUT TENATIVE CYLINDER

− Align the JCC so the axes are at 135/45, flip lens and take note of which axis is red
preferred
− Align the JCC so the axes are at 180/90, flip lens and take note of which axis is red
preferred
− Add – 0.50 DC between the two preferred red axes
§ Add +0.25DS for spherical equivalent
− Refine the power first to see if astigmatism is accepted, and then the axis
§ Remember to remove the +0.25DS to maintain spherical equivalent if cylinder power
in decreased

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6. Second Sphere Check
− Show the full chart, directing the patient's attention to the line of their best acuity
− Show the full chart, directing the patient's attention to the line of best acuity as their vision
clears up
− Fog the vision by adding +1.00DS to bring 2-4 lines worse than current VA
§ Warn the patient it will be blurry
− Slowly reduce the plus by 0.25D steps, each time checking visual acuity
− Stop when VA does not improve, ensure the patient can, in fact, read more letters rather
than preferring minus

7. Occlude the right eye and open the left eye

− Repeat steps 1 – 6 on the left eye

8. Binocular Balance - Prism Dissociation Binocular Balance

− Indications: patients who are old enough to participate, equal monocular visual acuity
− Contraindications: strabismus, unstable or decompensating heterophoria, visual acuity
between the eyes more than 1 line apart, presbyopes or non-accommodating patients
− Fog the vision by adding +1.00DS to bring 2-4 lines worse than current VA
§ Warn the patient it will be blurry
− Isolate one line larger than fogged VA
§ Confirm the patient can read the line with both eye
∆ ∆
− Dissociate the vision with 3 Base Up over the right eye & 3 Base Down over the left eye
− Ask the patient which line is clearer the top line or the bottom line of letters, adding
+0.25DS to clearer eye
− End point is equal blur OR the dominant eye clearer if the patient continues to switch
between eyes
− Remove the prisms and show the entire chart
− Slowly reduce fog binocularly checking there is an improvement in vision with each 0.25DS
decrease in power

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Section V: Binocular Balance Alternatives
Successive alternate occlusion
− Only works with equal best corrected VA
− Add +1.00D Sphere over each eye
− Direct the patient’s gaze to the 20/40 (6/12, 0.5) line, but show the whole chart.
§ “Can you see the line with your right eye? And now your left eye?”
§ “I’m going to cover one eye at a time. Both views will be blurry, but I want you to tell me
which view is clearer or if they look the same.”

− Continue to switch between the two eyes to give the patient a chance to compare views
§ If the patient says “Right” add +0.25D sphere to the right eye
§ If the patient says “Left” add +0.25D sphere to the left eye
§ If the patient says “the same” leave
− If the patient keeps switching between right and left, leave the dominant eye slightly clearer.
− Reduce the plus power binocularly, checking the visual acuity is improving, after each +0.25
step. Stop when visual acuity no longer improves.

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Section VI: Astigmatism Method Alternatives
− If you cannot isolate a line or if the patient is having difficulty, point to a “D”
§ Ask the patient “which lens looks more like the letter “D” and which lens makes the letter
look more like a letter “O”?”

− Round dots are a great alternative target for Jackson Cross Cylinder
§ Ask the patient “which side of the lens make the dots rounder and darker?”

Fan and block

1. Ask the patient which lines on the fan are the clearest and
darkest
2. Move the arrow so it is 90 degrees to where the patient
reports clearest (the two limbs of the arrow will be equally
clear)
3. Add positive sphere equal to half of the estimated astigmatism
4. Ask the patient to look at the blocks and ask which block is clearest – add negative
cylinder lenses -0.25DC at a time with the axis aligned with the clearer block lines
5. Continue until both blocks are equally clear
6. Refine spherical lens power by decreasing the power by 0.25DS at a time

Clock face chart

1. Add a +1.00DS lens in front of best vision sphere

2. Ask the patient “which clock position has the darkest, sharpest
lines?”
3. Multiply the smaller “o’clock” position by 30
a. E.g.: 30x2 = 60degrees
4. Place a -0.25DC lens at that axis
5. Ask again “which line is darkest/sharpest?”
6. Continue adding -0.25DC until all lines are the same, adjusting spherical equivalent

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