 Retinoscopy
o Dynamic retinoscopy: clinician moves retinoscope further away or closer to
patient to find neutrality
o Static streak retinoscopy: determines the refractive error of the eye relative to
the point of fixation
 Patient fixated at optical infinity (viewing a distance target) with
accommodation relaxed
 Accommodation relaxed by either:
1. Patient with no accommodation (presbyope)
2. Cycloplegia
3. “Fogging”
o Retinoscope has 2 modes
 Plano mirror---light beam is divergent
 Apparent source is behind the retinoscope aperture
 Concave mirror---light beam is convergent
 Forms a virtual image in front of the retinoscope
 Motion opposite that found with plano mirror
o Purpose is to find the far point of the eye
 Moderate to high myopia
 Far point between clinician and patient
 Low myopia (lower than clinician’s working distance)
 Far point is behind clinician
 Emmetropia
 Far point is at infinity
 Hyperopia
 Far point is behind patient
 Astigmatism has 2 far points (one for each principal meridian)
o With motion: reflex moves in same direction as you are moving the light bean
 Far point either behind retinoscope (myopia less than your working
distance) or behind the patient’s retina (hyperopia) or at infinity
(emmetropia)
 Add PLUS lenses (“down with”)
o Against motion: reflex moves in opposite direction from the direction you are
moving the light beam
 Far point is between your retinoscope and the patient’s eye (moderatehigh myopia)
 Add MINUS lenses (“up against”)
o Neutrality: when the far point is at the retinoscope aperture (not “with” or
“against”)
 Range of neutrality ~0.50 D
 Upper end of neutrality is called “high neutral” (most PLUS
endpoint)
 Lower end is called “low neutral” (most MINUS endpoint)
 ALWAYS COME FROM AGAINST MOTION
Occurs initially (no lenses added) only with myopia exactly equal to your
working distance
The clinician uses the retinoscope and lenses of a known amount to create a
myopic eye in which the far point coincides with the retinoscope aperture
Retinoscope light should be moderate intensity
 Too bright will constrict pupil, cause glare, and too much infrared may
damage the eye
 Too dim and you cannot see reflex well
The reflex is an image of illuminated section of fundus focused in the far point
plane, and the retinoscopist’s visual system projects the image onto the pupil of
the patient
Reflex characteristics
 Direction
 With: myopia less than your working distance, hyperopia,
emmetropia
 Against: moderate to high myopia
 Brightness
 At neutrality, most of the light that exits the patient’s pupil will be
focused at the retinoscope aperture= bright reflex
 If the far point is some distance away from the retinoscope
aperture, only a small amount of light enters the retinoscope= dim
reflex
 Note: for highly ametropic eyes, little light enters the aperture
making the reflex very dim
 Dim reflex may also be the result of small pupils (hyperopes,
elderly), highly pigmented RPE and media opacification
(cataracts)
o To increase brightness: increases the intensity of
retinoscope, decrease working distance, dilate pupil, or
move to concave to concentrate light on a smaller area of
the fundus
 Reflex is brightest at neutrality
 Speed
 Speed is related to working distance, vertex distance, and residual
ametropia
o If working and vertex distances are constant, speed is
determined by the eye’s residual ametropia
 More than 3.00 D away, it is only half as fast as the speed of light
on the iris
 Reflex speed is about the same as the light on the iris at 1.50 D
from neutrality (at 0.50 D 3X speed, 0.25 D 6X speed, 0.12
D 12X speed of the incident beam)
 At neutrality, the speed is infinite
 Note: close to neutrality small changes in working distance can
make a big difference in motion seen (worse for shorter WD)
 Closer to neutrality, faster reflex

o
o
o
o
Width
 Reflex is about the width of the pupil at + 3.00 D from neutrality
 Coming from with:
o Plus lenses are added to move neutrality reflex gets
thinner
o Reflex is skinniest at hyperopic point where the far point
coincides with the apparent light source of the retinoscope
and the blur circle is smallest
o After skinniest point, more plus is added and reflex gets
wider
o At neutrality, reflex gets so wide it fills the pupil
 Coming from against:
o Minus lenses are added to reach neutrality  streak stays
wider than pupil
o Fills the pupil at neutrality
 Further from neutrality, wider reflex
 Definition
 Coming from with:
o Reflex will be most sharp when the far point of the patient’s
eye coincides with the apparent source
 Same place reflex is thinnest
o Sharpness decreases as more plus is added and neutrality
is reached
 Coming from against:
o Definition of the reflex becomes sharper until neutrality is
reached
o A very sharp reflex is not seen because the far point never
coincides with the apparent source before neutrality is
reached
 Closer to neutrality, sharper reflex
 Alignment
 Retinoscope beam aligned with axis of cylinder straight line
 Retinoscope beam rotated away from axis skewed line
o If you are not lined up, the motion will not be directly with or
against
o Minus cylinder phoropter
 Find neutrality for the principal meridian with the least minus or most plus
first (least myopia or most hyperopia)
 Both against motion- scope against closest to neutrality
 Both with motion- scope with farthest from neutrality
 One with and one against- scope the with
*** YOU ARE SCOPING THE MERIDIAN YOU ARE PERPENDICULAR TO ***
(Axis of cylinder is perpendicular to the principal power meridian)
o Scissors motion
 Refractive status of the eye is different in one part of the pupil than
another

Causes of scissors:
 Large pupils with spherical aberration and coma (myopes, light
irides, young dilated all have big pupils)
o SA and coma make the eye’s refractive power greater in
the periphery of the pupil (more myopic at the edge)
 Keratoconus
 Irregular astigmatism
 Neutralize the central reflex (ignore the peripheral)
 May need to make room brighter to constrict pupils
o False neutrality
 Due to the sleeve pushed into concave somewhat and light is focused on
the entrance pupil
 Retroillumination—the light source at the pupil illuminates the
whole fundus
 No reflex motion
o Control of accommodation
 Use a lighted, distance, target bi-ocularly (20/400 E with red/green)
 Red/green filter reduces the brightness of the target so there are
fewer reflections from the lenses in front of the patient’s eyes
 Sudden changes in reflex and pupil constriction, patient accommodating
 If accommodation fluctuates a lot, suspect latent hyperopia,
psuedomyopia, or other accommodative problem
 Fogging
 Add plus lenses to fixating eye until it shows against motion
o Will be overplused by at least your working distance
 Patient will not accommodate because it will not make the target
any clearer
 After you neutralize the right eye, move directly over to examine
left **Right will be fogged with your working distance**
 If fogging does not work, do a wet retinoscopy (cycloplegic)
o Cycloplegia may eliminate the normal tonic accommodation
and the wet ret may be +0.50D or +0.75D more
 Fogging may not work for latent hyperopia, psuedomyopia, or
other accommodative problems
o Latent hyperopes initially fogged have accommodative
spasm, but will continue to relax during retinoscopy
o Clinical technique
 Prepare distance target
 Seat patient and adjust the patient’s chair
 Adjust PD and level the phoropter
 Reduce room illumination
 Explain to the patient where to look
 If patient cannot view the target with the fixating eye b/c the eye
being examined is strongly dominant, move farther temporally or
rotate phoropter slightly or shift target off onto the wall


If patient has a large-angle strabismus or large phoria and the
non-fixating eye drifts in/out from primary position, 1) change
position of gaze of the fixating eye to bring the examined eye
closer to the midline, 2) move to a position that will line you up
with the pupil of the deviated eye being examined or 3) some
combination
 Sit temporal to the patient’s eye you are neutralizing
 Holding retinoscope with right hand, look through the aperture with your
right eye and change lens power with left hand (vice versa)
 Fog patient
 If significant against motion is present in the two principal
meridians of the left eye, the eye is already fogged greater than
you working distance
 If one (or both meridians) is at neutrality or has with motion, add
plus lenses until significant against motion is seen for both
meridians
 Note: if specular reflections from the cornea or on the lenses are
interfering with your ability to see the reflex, either 1) tilt lenses in front of
patient or 2) move a little less or a little more temporal
 Find the endpoints and correct for your working distance
 Remove from both meridians is using a lens cross with spherical
trial lenses or lens bars
 If you use phoropter or trial frame with cylindrical lenses, only take
working distance out of sphere *DO NOT CHANGE THE
CYLINDER*
 Check monocular VAs
o Potential errors
 Variable working distance
 Irregular astigmatism
 Scissors
 False neutrality
 Obliquity of observation
 More temporal the aperture is to the patient’s line of sigh, the more
against the rule minus cylinder is induced
o With 5° of obliquity 0.12 DC x 090 is induced
o With 10° of obliquity 0.37 DC x 090 is induced
o With 15° of obliquity 0.75 DC x 090 is induced
 If your head blocks the view of the examined eye but the fixating
eye can see the target, the obliquity is less than 3°
o Retinoscopy has the tendency to be more hyperopic than refraction by +0.25D
to +0.50D in young eyes but the tendency becomes more minus with age