BLOCK 1: Clinical Exams
•Theme 1: Case History
•Theme 2: Material
•Theme 3: Visual Acuity
•Theme 4: Retinoscopy
•Theme 5: Subjective
•Theme 6: Covert Test
•Theme 7: Accomodation
Theme 4: Retinoscopy
• Utility
4
• Material
5
• Method
Previous conditions
Retinoscopic observations
9
10
Description
10
Analysis parameters
12
Theme 4: Retinoscopy
• Method
Technique
General mechanics
26
Examples
Emmetropia
31
Spherical ametropia
34
Astigmatic ametropia
39
• Self-evaluation
48
• Bibliography
59
It is based on…
Utility
Utility
The static retinoscopy is an objective technique that provides the
value of the refraction in distance vision.
…the analysis of the reflection of light that is obtained upon
projection of a ray of light onto the patient’s pupil.
Material
Lenses
Support
Test of visual acuity
Retinoscopy / Skiascopy
Material
Retinoscope
Optotype for
dynamic
retinoscopy
Flat mirror ()
Concave mirror ()
Method
There are diverse retinoscopic techniques:
• Static:
Accomodation does not take part.
The subject observes an optotype for distance vision
and the fogging technique is relied upon to relax accomodation.
• Dynamic:
Realized with near vision.
There are many techniques: Cross, Mohindra, etc.
In this chapter we only address the static.
Method
1. Previous conditions
2. Retinoscopic observations
2.1. Description
2.2. Analysis parameters
3. Technique
3.1. General mechanics general
3.2. Examples
Method
1. Previous conditions
Light
It can be more comfortable to perform it in faint light.
A pupil of greater size and less reflection appears.
Graduation
The patient will have both eyes open and wil be without his/her
graduation, (to the contrary, we would be doing one with
graduation).
Myopization*
In order to control accomodation, it is a good idea to start
with a fogging around 0,3-0,4.
Method
2. Retinoscopic observations
2.1. Description
Mirror of the
retinoscope
Sclera
Retinoscopic
reflection
Pupil
Iris
Object of
study
Method
2. Retinoscopic observation
The retinoscopic reflection is analyzed with respect to the mirror and the result of
this analysis will provide us with information on the type and quantity of
Any existing ametropia.
The parameters
•The type of movement
of analysis are:
•The width of the reflection
• Parallelism
Method
2. Retinoscopic observation
Mirror of the
retinoscope
2.2. The Parameters of analysis
•The type of movement
•Parallelism
•The width of the reflection
Retinoscopic
reflection
Method
2. Retinoscopic observation
2.2. The parameters of analysis
•The type of movement
With Movement (WM)
Mirror and reflection go in the same direction
Against Movement (AM)
Mirror and reflections go in opposite directions
Method
2. Retinoscopic observation
2.2. The parameters of analysis
•The type of movement
Upon moving the retinscopic mirror, depending on the type
of ametropia and the mirror used, we will observe whether the
retinoscopic reflection moves in the same or the opposite
direction as the mirror.
Selection of the
mirror
Method
2. Retinoscopic observation
2.2. The parameters of analysis
•The type of movement
Hypermetropia*
Flat mirror
Concave mirror
*Supposing the working distance has been compensated for
Myopia*
With Movement
Against Movement
Against Movement
With Movement
Correction with
Correction with
positive lens
negative lens
Method
2. Retinoscopic observation
Mirror of the
retinoscope
2.2. The parameters of analysis
•The type of movement
• Parallelism
•The width of the reflection
Retinoscopic reflection
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Parallelism
• It refers to the parallelism between the mirror of the retinoscope and that
pertaining to the retinoscopic reflection.
Mirror of the
retinoscope
Retinoscopic
reflection
Parallel
Not parallel
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Parallelism
• If when turning 360º there is parallelism
spherical ametropia
Mirror of the
retinoscope
Spherical
ametropia
Retinoscopic
reflection
Parallel
Parallel
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Parallelism
• The lack of parallelism indicates
Astigmatic ametropia
Faced with this situation, the principal
Mirror of the
retinosccope
meridians must be looked for. Said meridians
are found in the direction where said
Retinoscopic
reflection
parallelism appears.
Not parallel
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Parallelism
The retinoscopic mirror will be turned until the degrees in which parallelism appears
between the mirror and the retinoscopic reflection are found.
Mirror of the
retinoscope
The “track” of the direction provides us with the
retinoscopic reflection.
Retinoscopic
reflection
Not parallel
Method
2. Retinoscopic observation
2.2. The parameters of analysis
•Parallelism
60º
150º
Mirror of the
retinoscope
Retinoscopic
reflection
Not parallel
Parallel
Parallel
Principal
meridians
(Perpendicular)
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Parallelism
It is important to determine the existence of the principal meridians since the neutral
point of the retinoscopic reflection must be realized according to them.
Once the meridians are determined, the mirror will be analyzed for the parameters
of width and the type of movement in order to try to achieve the neutral point.
Method
2. Retinoscopic observation
Mirror of the
retinoscope
2.2. The parameters of analysis
•The type of movement
• Parallelism
•The width of the reflection
Retinoscopic
reflection
Method
2. Retinoscopic observation
2.2. The parameters of analysis
• Width of the reflection (EP)
The width of the retinoscopic reflection is the streak of light reflected that
occupies the pupil, totally or partially.
This “occupied space” provides information on the quantity of ametropia.
The sensation of “occupation” (width), will be determined by the pupillary diameter
and by the level of ametropia.
Method
2. Retinocopic observation
2.2. The parameters analysis
• The width of reflection (EP)
With respect to the level of ametropia, if we evaluate the width, the reflection
occupies more space in:
- Elevated ametropias
- Near the neutral point
Accompanied by a dull reflection
Accompanied by a more luminous
reflection
Method
Retinoscopy RE
3. Technique
3.1. General mechanics (static RT)
1.
Cover RE and fog the patient LE to VA 0,3-0,4
2.
Uncover RE and place the lens corresponding to the work distance
(WD) in front (for example 50 cm. corresponds to +2,00D).
3.
Indicate to the patient that he/she will see the test in DV (VA 0,3-0,4)
4.
Observe the reflection of the patient’s RE with the examiners RE.
5.
Analyze and neutralize the retinoscopic reflection
6.
Leave the gross value (settting aside the lens that corresponds to
the WD situation of fogging) and move on to observe the LE
Method
3. Technique
Retinoscopy LE
1.
3.1. General mechanics (static RT)
With the RE the optotype for DV was observed (it is fogged when
setting aside the retinoscopic lens).
2.
Place a lens corresponding to the work distance in front of the LE
3.
Observe the patient’s LE with the examiner’s LE.
4.
Analyze and neutralize the retinoscopic reflection.
(During the realization of the test, we must insist that the patient continues looking at the
optotype for DV).
Method
3. Technique
3.1. General mechanics (static RT)
Upon finishing this process we find that the subject has, placed in front of him/her, the
lenses:
Net
value
- corresponding to the refractive defect
Gross value
- corresponding to the work distance (WD)
Method
3. Technique
3.2. Examples
Next, the observation and neutralization of diverse ametropic situations are going
to be described.
Sclera
Lens compensating for
work distance
2.00
Retinoscopic reflection
(pupil)
streak of light of the
retinoscope
Method
3.2. Examples
The type of movement
Flat Mirror (FM):
Parallelism
Summary of the
Observation
Lens
Value of the refractive correction
(Net value of the retinoscopy)
Action to realize
Neutralization
The width of the reflection
Description of the observations
Paraneters
3. Technique
Method
3. Technique
3.2. Examples
1. Emmetrope eye
2. Spherical ametropia
3. Astigmatic ametropia
Method
3. Technique
3.2. Examples
1. Emmetrope eye
Parameters
2.00
The type of movement
Parallelism
The width of the reflection
2.00
Flat mirror (FM): Without movement
Concave mirror (CM): Without movement
The streak of light is not observed in the retinoscopic reflection
It fills the pupil in what is known as NEUTRAL POINT (NP), point of neutralization
Method
3. Technique
3.2. Examples
1. Emmetrope eye
Neutralization
2.00
Summary of the
observation
Lens
Value of the refractive correction
2.00
Neutral point. All of the pupil illuminated, there is no streak of light with either
of the mirrors
There is no precise lens to neutralize
Neutral
Method
3. Technique
3.2. Examples
1. Emmetrope eye
2. Spherical ametropia
Hypermetropia of +3,00 D
Myopia of - 3,00 D
3. Astigmatic ametropia
Method
3. Technique
3.2. Examples
2. Spherical ametropia HP +3,00D
(Observation with FM*)
Parameters
2.00
2.00
The type of movement
Parallelism
The width of the refraction
Flat Mirror* (FM): With
Parallelism in 360º
Intermediate
2.00
Concave Mirror (CM): Against
Method
3. Technique
3.2. Examples
2. Spherical ametropia Hp +3,00D
(Observation with FM*)
Neutralization
2.00
2.00
2.00
Summary of the
With movement with FM*. A streak of light of intermediate width is observed,
Observation
parallel to the streak of light of the retinoscope in 360º
Lens
Value of the refractive correction
Positive lenses are put in front of the subject until neutral point is achieved.
+ 3,00 D
Method
3. Technique
3.2. Examples
3. Spherical ametropia Mp - 3,00D
(Observation with FM*)
Parameters
2.00
2.00
The type of movement
Parallelism
The width of the reflection
Flat Mirror* (FM): Against
Parallelism in 360º
Intermediate
2.00
Concave Mirror (CM): With
Method
3. Technique
3.2. Examples
3. Spherical ametropia Mp - 3,00D
(Observation with FM*)
Neutralization
2.00
2.00
2.00
Summary of the
Against movement with FM. A streak of light of intermediate width is observed,
observation
parallel to the streak of light of the retinoscope in 360º
Lente
Value of the refractive correction
Negative lenses are placed in front of the subject until neutral point is achieved
- 3,00 D
Method
3. Technique
3.2. Examples
1. Emmetrope eye
2. Spherical ametropia
-3 ,00D 180º
3. Astigmatic ametropia
-3 ,00D 90º
Method
3. Technique
3.2. Examples
2. Astigmatism - 3,00D 180º
(Observation with FM*)
Parameters
2.00
The type of movement
2.00
Flat Mirror* (FM):
Vertical retinoscopic streak of light:
Does not exist
Horizontal retinoscopic streak of light:
Against
Method
3. Technique
3.2. Examples
2. Astigmatism - 3,00D 180º
(Observation with FM*)
Parameters
2.00
2.00
Parallelism
2.00
Retinoscopic streak of light at:
90º:
When there is not a streak of light of the reflection parallelism is not determined
45º:
There is no parallelism, we are not along any of the main meridians
180º:
There is parallelism between the streak of lightS. We are along the ametrope
meridian
Method
3. Technique
3.2. Examples
2. Astigmatism - 3,00D 180º
(Observation with FM*)
Neutralization
2.00
2.00
2.00
Summary of the
Against movement with the FM with retinocscopic streak of light at
observation
180º. Neutral point with FM with retinoscopic streak of light at 90º.
Place negative lenses in front of the subject until neutralization of movement is
Lens
achieved. If an astigmatic lens is used the axis will be in the same direction as the
Movement.
Value of the refractive correction
- 3,00 180º
Method
3. Technique
3.2. Examples
Summary - 3,00D 180º
(Observation with FM*)
2.00
«
2.00
2.00
«
-3
Neutral point
Against movement
Increase negative cylinder
(streak of light parallel)
with the horizontal axis until
movement is neutralized
RE 0,00 - 3,00 180º
Value of the refractive correction
Method
3. Technique
3.2. Examples
2. Astigmatism - 3,00D 90º
(Observation with FM*)
Parameters
2.00
The type of movement
2.00
Flat Mirror* (FM):
Vertical retinoscopic streak of light:
Against
Horizontal retinoscopic streak of light:
Does not exist
(neutral point)
Method
3.Technique
3.2. Examples
2. Astigmatism - 3,00D 90º
(Observation with FM*)
Parameters
2.00
2.00
Parallelism
2.00
Retinoscopic streak of light at:
90º:
There is parallelism between streak of light. We are along the ametropic meridian.
45º:
Thre is no parallelism, we are not along any of the meridians.
180º:
When there is no existing streak of light of the relfection parallelism is not
determined.
Method
3. Technique
3.2. Example
2. Astigmatism - 3,00D 90º
(Observationswith FM*)
Neutralization
2.00
2.00
2.00
Summary of the
Against movement with FM with retinoscopic streak of light at 90º.
observation
Neutral point with FM with retinoscopic streak of light at 180º.
Place negative lenses in front of the subject until neturalization of movement is
Lens
achieved. If an astigmatic lens is used the axis will be in the same direction as
the movement.
Value of the refractive correction RE - 3,00 90º
Method
3. Technique
3.2. Examples
Summary - 3,00D 90º
(Observations with FM*)
-3
2.00
«
2.00
2.00
«
Neutral point
Against movement
Increase the negative cylinder
(Parallel streak of light)
with the vertical axis until neutralization
of movement has achieved.
RE 0,00 - 3,00 90º
Value of the refractive correction
Exercises
Self-evaluation
Exercises
Exercise 1
Methodology
Exercise 2
Spherical ametropia
Exercise 3
Astigmatic ametropia
Exercise 4
Astigmatic ametropia
Exercises
Exercise 1
Indicate the best option with regards to the methodology of the static retinoscopy
a. At a distance of 1m., the corresponding working lens is of +2,00 D
b. If we realize the retinoscopy to the left eye, the right has to be covered
c. If after placing the lens corresponding to the work distance in front of the subject we observe
against movement along all meridians with the flat mirror, the streak of light is wide, not very bright and
slow, we are faced with a low myopia.
d. When realizing the retinoscopy on the right eye, the left eye must be foggedd and using distance
vision.
Exercises
Exercise 1
Indicate the best option with regards to the methodology of the static retinoscopy
a. At a distance of 1m., the corresponding working lens is of +2,00 D
b. If we realize the retinoscopy to the left eye, the right has to be covered
c. If after placing the lens corresponding to the work distance in front of the subject we observe
against movement along all meridians with the flat mirror, the streak of light is wide, not very bright and
slow, we are faced with a low myopia.
d. When realizing the retinoscopy on the right eye, the left eye must be fogged and using distance
vision.
Exercises
Exercise 2
If when doing the retinoscopy and after putting the lens that neutralizes the work distance in front of
the subject, we find ourselves with the following observation (FM), indicate which lens will most
2.00
Options for neutralization
Observation
probably lead us to neutralization:
a.
+3.
-3
«
b.
2.00
c.
-3
«
Exercises
Exercise 2
If when doing the retinoscopy and after putting the lens that neutralizes the work distance in front of
the subject, we find ourselves with the following observation (FM), indicate which lens will most
2.00
2.00
Options for neutralization
Observation
probably lead us to neutralization:
c.
-3
Exercises
Exercise 3
If when doing the retinoscopy and putting the lens that neutralizes the working distance in front of the
subject, we find ourselves with the following observation (FM), indicate the combination of lenses
+3.
+
«
-3
b.
+
«
Options for neutralization
-5
«
2.00
a.
«
Observation
that will most probably lead us to neutralization:
-5
2.00
-5
«
c.
+3.
+
«
Exercises
Exercise 3
If when doing the retinoscopy and putting the lens that neutralizes the working distance in front of the
subject, we find ourselves with the following observation (FM), indicate the combination of lenses
a.
-5
+3.
+
«
2.00
Options for neutralization
2.00
«
Observation
that will most probably lead us to neutralization:
Exercises
Exercise 4
If when doing the retinoscopy and putting the lens that neutralizes the working distance in front of the
subject, we find ourselves with the following observation (FM), indicate the combination of lenses
«
2.00
-3
+
«
c.
«
Options for neutralization
+3.
«
2.00
b.
a.
-3
Observation
that will most probably lead us to neutralization:
+ 3
Ejercicios
Ejercicio 4
If when doing the retinoscopy and putting the lens that neutralizes the working distance in front of the
subject, we find ourselves with the following observation (FM), indicate the combination of lenses
Options for neutralization
-3
+
+ 3
2.00
c.
«
2.00
«
Observation
that will most probably lead us to neutralization:
Bibliography
Bibliography
• Borràs MR et al. Optometría. Manual de exámenes clínicos.
Barcelona: Edicions UPC, 1993
• Borish IM, Benjamin WJ(ed.). Borish's clinical refraction.
Philadelphia: W. B. Saunders, 1998
• Grosvenor TP. Optometría de atención primaria.
Barcelona: Masson, 2004
• Carlson NB et al. Procedimientos Clínicos en el examen visual.
Madrid: Ciagami, 1994
• Herreman R. Manual de refractometría clínica.
México: Ediciones Salvat, 1981
• www:
http://www.foto-web.com/Simuladores/