OPT 303

OPT 303
PRINCIPLES & PRACTICE OF REFRACTION
RETINOSCOPY
RETINOSCOPY
INTRODUCTION: INTRODUCTION:

Previously referred to in various terms as skiametry, skiascopy, keratoscopy, etc retinoscopy is an objective method of evaluating the optical property of the eye i.e. determining the refractive state of the eye.
OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION
RETINOSCOPY

The technique is based on the power of lens required to neutralize the movement of light reflex generated in the eye of a subject when a beam of light is incident and swept across it. it.
RETINOSCOPY

The instrument used is the retinoscope. retinoscope.

Copeland Streak retinoscope
Welch Allyn retinoscopes

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION 4
RETINOSCOPY
HISTORY: HISTORY:

Jack Copeland: is the greatest contributor to the Copeland: development and teaching of retinoscopic techniques but the following also made contributions: contributions: William Bowman: in 1861 noticed and described the light Bowman: and shadow observed in the pupil when the ophthalmoscope was tilted. He also described the tilted. shadow and movement in astigmatism. astigmatism. Parent: Parent: introduced lenses for qualitative measurement. measurement. Meager: Meager: publicized the method of retinoscopy. retinoscopy.

RETINOSCOPY
HISTORY: HISTORY:

Leroy, Monoyer, Van der Begh and Landolt: at one time Landolt: or the other, each gave theoretical explanation to the path of light rays from the observed eye to that of the observer eye. Chilret: Chilret: proposed the term skiascopy. Cuignet: Cuignet: in 1873 described and used retinoscopy as a method of determining the refractive state of the eye. Jackson and Duane: gave impetus to retinoscopic Duane: technique.

RETINOSCOPY
HISTORY: HISTORY:
Jack
Copeland designed and developed the streak retinoscope and introduced streak retinoscopy into eye-care. eye-care.
RETINOSCOPY
PRINCIPLES: PRINCIPLES:

Retinoscopy is based on the principles of Foucault s method of determining the focal power of a lens i.e. locating the conjugate foci of the eye s optical system in space with a source of light at a known point. The source of light and the fundus image are the point of conjugation, which is only observed if the emergent light can be separated from the incident light. The separation is achieved in retinoscopy by reflecting light into the eye of the subject with the observer observing through a hole in the mirror.
RETINOSCOPY
PRINCIPLES:
Apparent light source Observer s eye Mirror Subject s eye
Peephole
Light source
RETINOSCOPY

Following the separation, a reflex is generated with the reflected light incident on the eye. This reflex moves in accordance with movement of the incident light. Sometimes the reflex movement is in the direction of the movement of the incident light, but in most cases, it is in the reverse direction. Incident light first used in retinoscopy was sunrays reflected into the eye by a plane mirror having a hole through which the reflex can be observed.
RETINOSCOPY

Because of the poor reflex brightness achieved with this technique, the plane mirror was replaced by a concave mirror which concentrated the rays for greater brightness. The gaslight later replaced sunrays as the source of light and the incandescent source replaced the gaslight much later. Today, a built-in miniature bulb is used in retinoscopes. builtThis has changed the form of retinoscopes from reflecting types as they were known, to self-luminous or selfsimply luminous types.

RETINOSCOPY
PRINCIPLES:
Apparent light source Mirror Subject s eye
Light source
When a plane mirror is used in retinoscopy, the apparent source lies behind the instrument thereby producing a virtual image of the source of light.
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RETINOSCOPY
PRINCIPLES:
Concave mirror Subject s eye Apparent source
Light source
When a concave mirror is used, the apparent source lies in front of the instrument thereby producing a real image of the source of light. OPT 303 - PRINCIPLES & PRACTICE OF 13
REFRACTION
RETINOSCOPY

The effect of the system is such that the reflex movement of a concave mirror retinoscopy is opposite that of a plane mirror. However, the greater brightness achieved in concave mirror effect gives it an edge over plane mirror effect.
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RETINOSCOPY

Originally, the beam produced in self-luminous selfretinoscopes was a round spot. In an attempt to enhance the retinoscopic reflex and to make determination of astigmatism easier, the streak retinoscope was developed. The streak was first produced by a slit-shaped mirror but slittoday a bent filament bulb is used.
RETINOSCOPY
CONSTRUCTION OF RETINOSCOPES: RETINOSCOPES:

A retinoscope may be self-luminous or non-luminous; selfnonplane or concave; and spot or streak. The modern retinoscope tended to incorporate as much of these features as possible. Therefore, the modern retinoscope is self-luminous, spot selfor streak with variable vergence system which enables a switch from plano effect to concave effect or vice versa.
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RETINOSCOPY

However, every modern retinoscope consists of two major parts:

1. 2.
The projection or illumination system; and The observation system.
The projection system illuminates the retina, while the observation system allows a view of the pupil reflex generated by retinal illumination.
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RETINOSCOPY
1)

The projection system: system: The projection system contains the following components:
Light source: source: It is a bulb with linear filament which projects a line or streak of light in the case of a streak retinoscope; or a tungsten bulb which projects a spot of light in spot retinoscope.

A sleeve or knob is provided in streak retinoscope to rotate the projected streak.

RETINOSCOPY
CONSTRUCTION OF RETINOSCOPES: RETINOSCOPES: 1) The projection system: system:
Condensing lens: lens: This rests in the path of light.

The lens focuses rays from the bulb onto the mirror.
Mirror: Mirror: This is placed in the head of the instrument at about 45 angle.

It bends the light path at right angle to the axis of the handle. In effect, the beam projects from the head of the instrument.
RETINOSCOPY
Focusing sleeve or knob: knob: This varies the distance between the bulb and the lens to allow the retinoscope project rays which are either diverged (plane mirror effect) or converged (concave mirror effect).

Hence the sleeve or knob is also called the vergence control. In controlling vergence, either the bulb or the condensing lens is moved up or down.
RETINOSCOPY
Current source: source: Current is provided from its handle by a 3V battery, which is either replaceable as dry cell or rechargeable battery.

When connected to the mains, it is done through a transformer stepped down to 2.5V or 3.5V.
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RETINOSCOPY
CONSTRUCTION OF RETINOSCOPES: 1) The projection system: system:
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RETINOSCOPY
CONSTRUCTION OF RETINOSCOPES: RETINOSCOPES: 2)

The observation system: system: The observation system allows a view of the pupil reflex generated by retinal illumination. illumination. The light reflected from the illuminated retina enters the retinoscope, passes through an aperture in the mirror and out of the peephole at the rear of the head. head. Thus a reflex is seen through the peephole. peephole. This appears as a glow in the pupil and referred to as pupil reflex or just retinoscopic reflex. reflex.

RETINOSCOPY
CONSTRUCTION OF RETINOSCOPES: RETINOSCOPES: 2)

The observation system: system: With movement of light of the retinoscope, the retinal illumination or retinal image moves and the pupil reflex also moves in response to the movement of the retinal image. image.
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RETINOSCOPY
FEATURES OF THE RETINOSCOPE: RETINOSCOPE:

The modern retinoscope is a single unit containing a plano mirror, a condensing lens and a light bulb. bulb. The retinoscope in most cases also has as operating sleeve for varying the vergence of the emergent beam. beam. (The sleeve is contained on the handle in the case of the Copeland Streak Retinoscope). Retinoscope). The modern retinoscope is self-luminous. self-luminous.
RETINOSCOPY

This is made possible by a separate attachable unit, the handle. handle. This handle contains the power for the light bulb of the retinoscope. retinoscope. The power can be from batteries contained in the handle. handle. The batteries may be the dry cell or rechargeable type. type.
RETINOSCOPY

Direct connection to the mains can be made possible if provided with an electrical cord handle and 2.5 3.5V transformer. transformer. In most cases, the standard diagnostic kits use the same handle for the ophthalmoscope and transilluminator. transilluminator.
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RETINOSCOPY
INSTRUMENT CARE: CARE:

The retinoscope is a handy but simple instrument. Most clinicians take its simplicity and efficiency for granted, but unless proper operational guidelines are maintained, its longevity and illumination brightness may be compromised. Under no circumstance should the mirror be touched or stained with the fingers. If dust accumulates on the surface, it should be wiped out gently with a very soft tissue.
RETINOSCOPY

The instrument, particularly the mirror and the transparent shield at the peephole can be protected by covering up the aperture with its protective shield and returned to its case after use. Unnecessary manipulation of the sleeve (i.e. vergence control) can cause misalignment of the bulb or condensing lens. This should be avoided.
RETINOSCOPY

As much as possible, coated bulbs and old batteries should not be used. These reduce illumination brightness. When the bulb or battery is changed, effort should be made to guide and screw their bases back properly, otherwise worn out grooves and improper electrical contact may result. The mains cord handle with its transformer provides constant optimum brightness as against the dry cell or rechargeable batteries.

RETINOSCOPY

Alkaline batteries and the like are the best dry cell types for retinoscopes because they maintain fairly constant brightness before they die off. Also, chemical leakage is rare with this group of batteries. In the rechargeable type, fairly constant brightness can be maintained if the handle is placed back into the charging port after each procedure.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE:

Before describing a clinical procedure, the student should realize that there are many types of retinoscopic technique i.e. spot or streak retinoscopy, plus or retinoscopy, minus cylinder retinoscopy, dynamic retinoscopy, retinoscopy, book retinoscopy, Mohindra retinoscopy, etc. retinoscopy, Skills in these techniques can be learnt in retinoscopy laboratory and the student can after proficiency in them select those ones he can be comfortable with during objective refraction. The technique to be described here involves minus cylinder streak retinoscopy hoping that it can serve as a guide in describing other retinoscopic techniques.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: It is customary to work and present retinoscopic results in minus cylinder form because of the effect of accommodation when scoping human eyes.

Most phoropters are therefore built with minus cylinders only. This makes minus cylinder retinoscopy the preferred technique in routine refraction.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: With the patient comfortably seated, the phoropter is properly positioned before the patient s face, adjusting the headrest and setting the PD for distance (or fit the trial frame on the patient s face snuggly with correct PD, vertex distance and nosepiece setting).

The room illumination is dimmed and the patient asked to fixate the largest optotype on the Snellen chart 6 meters away (i.e. the target). To further enhance relaxation of accommodation, a fogging lens equivalent to the working distance may be placed in front of the eye not being examined (i.e. the 34 OPT 303 - PRINCIPLES & PRACTICE OF fixating eye). REFRACTION
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: Both eyes should remain uncovered during the exercise.

The examiner should then position himself at his working distance in front of the patient but slightly lateral on the same side as the eye to be refracted (or assessed). It is customary to hold the retinoscope in the right hand and look through the peephole with the right eye, if the right eye of the patient is to be scoped; and held on the left hand looking through the peephole with the left eye, if the left eye of the patient is to be scoped.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: In each case, the free hand is used to introduce lenses to neutralize the motion of the reflex.

Switching on the power of the retinoscope and looking through the peephole, the beam is directed at the eye to be scoped. While constantly reminding the patient to fixate at the target, the beam in its vertical orientation is swept across the patient s eye in the horizontal plane through the aperture of the phoropter (or trial frame).
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: The motion of the reflex at the pupil is observed and the procedure repeated along the various meridians particularly the vertical meridian, by rotating the beam as it is swept across the eye. eye.

By this means the principal meridians can be located and astigmatism recognized if present. present. If no astigmatism, neutralization of one principal meridian will automatically neutralize the other. other. This should however be confirmed by scoping. scoping. End point should be refined with bracketing technique. technique.

RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: Neutralization of astigmatism requires starting at the principal meridian with the slowest with-motion and withincreasing plus sphere power until that meridian is neutralized and then turning to the other principal meridian which should have become against-motion. against-motion.

This motion would then be confirmed and neutralized with minus cylinders placed in the appropriate axis. axis. The axis can be refined with the straddling technique. technique. The results can be recorded directly from the sphere power, cylinder power and cylinder axis used in the total neutralization. neutralization.

RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: If spheres were used to neutralize both principal meridians in astigmatism, the results are therefore placed on optical cross and transposed.

Having scoped the right eye, the procedure is similarly carried out on the left eye. Refinement of the findings should be carried out for both eyes when necessary.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: The quality of the end-points depends on the control of endthe following factors: Comfort of the patient; 2. Optical effect in pathological conditions such as lenticular sclerosis, irregular astigmatism, etc; 3. Pupillary constriction; and 4. Patient s fixation.
1.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE:

Minus cylinder streak retinoscopy: retinoscopy: Control of patient s fixation is particularly important in the clinic during retinoscopy, as this will determine:
i. ii.
The level of patient s accommodation, and The type of retinoscopy performed.
When the patient is fixating at infinity (distance), the accommodation is relaxed and presumably zero. Retinoscopy under such condition yields static retinoscopy. retinoscopy.
RETINOSCOPY
CLINICAL PROCEDURE: PROCEDURE: Minus cylinder streak retinoscopy: retinoscopy: When the patient is fixating at a near target, accommodation is in play and we have dynamic retinoscopy. retinoscopy.

Drugs can be used to paralyse accommodation during retinoscopy. When this is done, we have cycloplegic refraction taking place. Retinoscopy in cycloplegic refraction is not disturbed by inaccurate fixation
RETINOSCOPY
RECORDING OF RESULTS: RESULTS:

This is similar to that of spectacle prescription but the working lens has to be subtracted from the total lens power used to achieve neutral point. The total lens power used to achieve neutralisation is known as the gross finding. finding. The gross finding contains the working lens and the refractive finding. The gross finding minus the working lens equals the net finding.

RETINOSCOPY

The working lens is the dioptric equivalent of the working distance. If the working distance is 1m, the working lens is +1.00D. If the working distance is 66cm, the working lens is +1.50D. If the working distance is 50cm, the working lens is If the working distance is 40cm, the working lens is If the working distance is 33cm, the working lens is

. .
RETINOSCOPY

The working lens is the dioptric equivalent of the working distance. If the working distance is 1m, the working lens is +1.00D. If the working distance is 66cm, the working lens is +1.50D. If the working distance is 50cm, the working lens is +2.00D. If the working distance is 40cm, the working lens is If the working distance is 33cm, the working lens is

RETINOSCOPY
RECORDING OF RESULTS: RESULTS: Retinoscopic Gross = Retinoscopic Net + Working lens or Retinoscopic Net = Retinoscopic Gross Working lens

The working lens is a sphere and when subtracted from the gross, only the sphere component would be affected. The cylinder component would not change. E.g. If after neutralisation scoping at a distance of 66cm and the total lens power obtained is +2.50D, the refractive error of the patient is +1.00DS.

RETINOSCOPY

If after neutralisation scoping at a distance of 66cm and the total lens power obtained is +3.50D -0.75 x 180, the refractive error of the patient would be +2.00 -0.75 x 180. If after neutralisation scoping at a distance of 66cm and the total lens power obtained is +1.00D -0.75 x 180, the refractive error of the patient would be -0.50 -0.75 x 180. If after neutralisation scoping at a distance of 66cm and the total lens power obtained is -3.50D -1.25 x 090, the refractive error of the patient would be -5.00 -1.25 x 090.
RETINOSCOPY
RECORDING OF RESULTS: RESULTS: Given: Gross retinoscopic finding of +0.25DS, and working distance of 66cm, what is the refractive error of the patient? Given: Gross retinoscopic finding of -0.50 -1.00 x 030, and working distance of 50cm, what is the refractive error of the patient?
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RETINOSCOPY
RECORDING OF RESULTS: RESULTS: Given: Gross retinoscopic finding of +1.25 -2.25 x 095, and working distance of 100cm, what is the refractive error of the patient? Given: Gross retinoscopic finding of -0.50 -1.50 x 115, and working distance of 66cm, what is the refractive error of the patient?
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RETINOSCOPY

Recording net finding is similar to that of spectacle prescription. Therefore, if the findings were placed on the optical cross, they must be transposed into a sphero-cylinder spheroform and recorded. The minus sphero-cylinder form is preferred but it is not spheroforbidding to record in plus sphero-cylinder form e.g. spheroMinus sphero-cylinder form: spheroOD +1.00 -0.50 x 120 or OSOS -1.50 -1.00 x 090 OS -2.50 +1.00 x 180
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Plus sphero-cylinder form: spheroOD +0.50 +0.50 x 030
RETINOSCOPY
INTERPRETATION OF RESULTS: RESULTS:
1.
Retinoscopic results are objective findings which require confirmation through subjective refraction. refraction.

It is therefore a good starting point for the subjective. subjective. In the end, a good retinoscopic finding would not differ very much, if any, from subjective end-point. end-point.
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RETINOSCOPY
2.
Usually, the retinoscopic finding would reveal less minus in myopia than in subjective and more plus in hyperopia. hyperopia.

Retinoscopic results are more reliable in latent hyperopia and in macular degeneration. degeneration. They come handy in prescribing for malingerers, amblyopic patients, children, mentally handicapped subjects and hysterical patients. patients. They are also very valuable in detecting spasm of accommodation. accommodation.
RETINOSCOPY
3.
Retinoscopic results are very unreliable in very dense media opacities, conical corneas and in many congenital deformational anomalies. anomalies.

Iatrogenic conditions like: like: updrawn pupil, ectopia pupillae, and IOL dislocation pose a lot of difficulties during retinoscopy. retinoscopy.
THE END
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OPT 303 - Guide to Retinoscopy Techniques & Principles

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PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

The instrument used is the retinoscope. retinoscope.

Welch Allyn retinoscopes

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

However, every modern retinoscope consists of two major parts:

The projection or illumination system; and The observation system.

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

A sleeve or knob is provided in streak retinoscope to rotate the projected streak.

Condensing lens: lens:  This rests in the path of light.

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

The level of patient s accommodation, and The type of retinoscopy performed.

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

Plus sphero-cylinder form: spheroOD +0.50 +0.50 x 030

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

OPT 303 - PRINCIPLES & PRACTICE OF REFRACTION

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Condensing lens: lens: This rests in the path of light.