Nott Dynamic Retinoscopy

Purpose: To measure the accommodative lag at near under binocular conditions.

(A difference in lag between the two eyes is an indication of refractive or accommodative imbalance. If the lag is
other than the expected +0.50 to +0.75 DS, improper accommodative function is probable.
1. Set the phoropter for the near IPD, and use the patient's distance spectacle refraction. Alternatively, a trial frame
or spectacles with the refraction may be used. The room illumination should be moderate, but the overhead lamp
should be set on high and directed for near-point viewing.
2. Place a near-point chart or block of similar (20/20 to 20/30) small letters on the near-point rod at the reading
distance, usually 40 cm. The number of letters must be sufficient to keep the patient's attention for the duration of
the measurement. The letters should be on a surface that permits the retinoscope's line of sight to be very near the
letters. A near-point card with a hole in the middle can be used. A push-up or fixation stick with the letters mounted
on it is preferred, because the retinoscope can be brought in closer to the patient, past the stick (Figure 21-12).
3. Direct the patient to begin reading the letters. Place the retinoscope just to the side of the letters, and
adjust it to project a vertical streak. Note the direction of the reflex in one eye, and move the retinoscope either
toward or away from the patient (if observing "with" motion, move away; if observing "against" motion, move
toward) until neutrality is found. Note the position of the retinoscope on the near-point rod. Repeat the
sequence for the other eye.
4. The dioptric difference between the position of the target and the position of the retinoscope when neutrality is
found is the lag of accommodation for that eye, and the lag has a sign. If the neutrality point is on the side of the
target away from the patient, the lag is plus or positive (meaning the patient is relatively hyperopic for the target
distance); if the neutrality point is on the side toward the patient, the lag is minus or negative (the patient is
relatively myopic for the target distance).

Monocular Estimation Method of

Dynamic Retinoscopy
Purpose: The monocular estimation method (MEM) of performing dynamic retinoscopy is an objective method
of measuring accommodative lag and checking for accommodative or refractive imbalance at near. MEM
retinoscopy is thought to be a better all-round choice than Nott retinoscopy for children, because it permits
them to look at accommodative targets attached to a stationary retinoscope, which is held at the near point.
Children tend to follow whatever is moving in the field rather than the target that they are told to fixate (much
less read). MEM retinoscopy also lends itself easily to use in free space away from the phoropter. Application of the
streak retinoscope to the performance of MEM dynamic retinoscopy is discussed in Chapter 18.
1. Use moderate room illumination, and direct moderate illumination from the overhead lamp onto the near-point
plane.
2. If you use a phoropter, adjust it for near-point IPD. The patient's distance spectacle refraction should be in place
in the phoropter, in spectacle form, or in a trial frame.
3. Have the patient view small letters mounted on or near the retinoscope head, which is held at the near viewing
distance (Figure 21-13). If possible, have the patient read the letters. Young children may simply be encouraged to
look at the light.
4. Set the retinoscopic mirror at plano, and observe the direction of the reflex in one eye. If you do not
observe neutrality, quickly insert an appropriate spherical lens (usually from a trial lens set) in front of that eye, and
try to obtain neutrality. "With" motion, which indicates a positive accommodative lag, requires that a plus spherical
lens be placed before the eye. "Against" motion, which indicates a negative accommodative lag, requires that a
minus spherical lens be placed before the eye. Repeat the procedure with stronger lens powers until you
observe neutrality, bracketing if necessary. Do not hold the retinoscope light or the lens in front of
the patient for more than 2 seconds; the less time, the better. You want the patient to maintain binocularity (the
bright retinoscope light effectively occludes), and you do not want the accommodative system to respond to the
change in accommodative stimulus brought on by the insertion of the lens in front of one eye.
5. Record the dioptric power of the lens that causes neutrality at the near point in each eye. Plus lenses mean that the
patient has a positive accommodative lag and that the conjugate to the retina is behind the plane of regard; in other
words, the eye is underaccommodated. Minus lenses mean that the patient has a negative lag and that the conjugate
to the retina is in front of the plane of regard; the eye is overaccommodated.
Expected: +0.25 to +0.75 DS
Bell Retinoscopy
Purpose: To evaluate the performance of the accommodative system under moving and (presumably) reallife
conditions in free space rather than behind the phoropter.
(The performance is judged by observing the way accommodation responds as a target is moved toward and away
from the patient, starting with a 20-inch target distance. Accommodative performance is monitored by
observing the retinoscopic reflex from that 20-inch observation posItion. The target is moved, but the retinoscope
remains at the 20-inch position.)
1. Place the patient at a comfortable working distance from you. Have the room moderately illuminated, but have
high overhead illumination suitable for a near target.
2. Instruct the patient to look at a near-point target at 20 inches. The target should be interesting enough to hold the
patient's attention. For adults, a small block of letters on a push-up stick is suitable. For children, a toy or bright
object can be used. Currently a clear plastic ball mounted on a rod is often used, with the child asked to look at his
or her own reflection in the ball. Originally, a small silver bell-hence the name-was used to attract and hold the
attention of a young child.
3. Place the retinoscope directly to the side or above the near-point target held at 20 inches, and note the retinoscopic
reflex in one of the patient's eyes from this 20-inch observation point.
a. If the initial reflex shows neutrality or "with" motion, move the target (not the retinoscope) toward the patient (no
faster than 2 inches per second) until "against" motion is seen at that 20-inch retinoscopic observation distance.
(When "against" motion is seen, the conjugate to the retina has just moved from beyond 20 inches to closer than 20
inches.) Note the distance from the target to the patient at which "against" motion is observed, and continue moving
the target toward the patient for several more inches. Reverse direction, and pull the target away at the same speed
from the patient until "with" motion is once again observed at the 20-inch observation distance of the
retinoscope. Note that distance. Repeat the process with the other eye.
b. If the initial reflex shows "against" motion, the patient may be judged to be overaccommodated for that distance,
and the test can be terminated. The accommodative system is not operating properly, because the patient has a
negative lag at 20 inches.
4. Record the distance between the target and the patient when "against" motion is seen as the target is pushed
toward the patient. Also record the distance when "with" motion is seen as the target is pulled back from the patient.
The results are normal if "against" motion is seen between 17 and 14 inches as the target is moved toward the patient
and if "with" motion is seen between 15 and 18 inches as the target is moved away from the patient. Alternatively,
some practitioners prefer to move the target back quickly as a direct check of the patient's ability to relax
accommodation.

REFERENCE

BORISH'SCLINICAL REFRACfION, SECOND EDITION