Retinoscopy

- clinical techniques -
Dr Byki Huntjens

Clinical Skills module co-
ordinator
Learning outcome
To give the definition of retinoscopy and know when
it is used in practice (see lecture Induction week)
Describe the refractive states of the eye
Clarify the features of the retinoscope
Describe the technique of correcting ametropia and
astigmatism using a retinoscope
Refractive states of the eye
Emmetropia: vision is perfect

Ametropia
Myopia - the myopic eye has excessive refractive
power (too positive)
Hyperopia - the hyperopic eye has too little
refractive power (lacks positive power)
Astigmatism
Emmetropia
State of vision where an object at infinity
is in sharp focus with the ocular lens in a
neutral or relaxed state, without any
correction required


Myopia
A refractive defect of the eye in which parallel
rays from infinity focus in front of the retina,
and produces image in the vitreous inside the
eye rather than on the retina

The eye is too long,
or the cornea is too steep
Hypermetropia
Occurs when light entering the eye focuses
behind the retina, instead of directly on it.
Patients usually have trouble seeing up close,
but may also have difficulty seeing far away.

The eye is too short,
or the cornea is too flat
Astigmatism
A visual defect in which the unequal curvature of one
or more refractive surfaces of the eye (usually the
cornea), prevents light rays from focusing clearly at
one point on the retina, resulting in blurred vision.

Retinoscope
Central sight hole
Angled mirror
Collar
Vergence slide/ Streak rotator
Internal light source
Rheostat (light control)
For more details see the retinoscopy videos on Moodle!
Retinoscopy
Cone of light is shone into eye through pupil and
optometrist observes movement of light reflected
from the retina
Remainder falls on face
Image forms within plane of
the PUPIL

Optometrist oscillates/tilts the retinoscope about
any axis and observes movement of the reflex (from
the retina) compared to the light (from the face)

Spot versus Streak
Spot retinoscope
Adequate results with both
Spot allows you to see both
principle meridians at same
time
Easier for children and
uncooperative pxs
Streak retinoscope
Better at detecting and
correcting small
astigmatisms
Axis to determine more
accurately, especially in
high cylinders
Changing the retinoscope
bulb allows you to swap
between streak and spot
Set up
Vergence slide
Keep collar down

The vergence
control should
normally be in the
down position.

By moving it up, a
with movement can
be changed into an
against and this can
be confusing!
beam
DOWN
handle


Set up
Streak has to be horizontal
if it is moved vertically

Streak has to be vertical if it is
moved horizontally

Beam is always at same angle to the
meridian being assessed
Ret beam
R
e
t

b
e
a
m

Set up
Working distance and height
The distance from the retinoscope to
the patients eye is known as the
working distance
Ideal working distance > 6 m but
reflex difficult to interpret and
impractical. Therefore the
retinoscope is held ~ 2/3 m (= 66cm)
from eye (arms length)
Set up at same visual axis (eye level)

Working distance (w.d)
The w.d allowance lens simulates infinity
Performing ret at a closer w.d means light is
focussing at this distance
Emergent light from the eye is seen
reversal in the pupil
Retinoscope & retina are conjugate
For the emmetrope light appears from
infinity and is focused clearly on the
retina but difficult to carry out
retinoscopy at >6m
w.d allowance lens
Working distance (w.d)
The w.d allowance lens simulates infinity
Performing ret at a closer w.d means light is
focussing at this distance
Emergent light from the eye is seen
reversal in the pupil
Retinoscope & retina are conjugate
(oppositely related)
For the emmetrope light appears from
infinity and is focused clearly on the
retina but difficult to carry out
retinoscopy at >6m
w.d allowance lens
Working distance allowance lens
After we neutralized the dummy lens, the px can
see clearly at 66cm (corresponds to w.d.l)
Obviously, we need to remove this lens after we
neutralized the dummy lens so patient can see
clearly at 6m (infinity or distance)
Rule:
We NEVER leave this lens in but we deduct its power
afterwards
If you add this lens at the start it increases reflections
W.D allowance lens calculations
Result after retinoscopy - 4.25DS
working distance = 66cm
working distance lens 100/66 = +1.50D

Answer
Final power -4.25 1.50DS = -5.75DS
Spherical Dummy
Lenses
Video retinoscopy
http://www.youtube.com/watch?v=kAreDffu
VCQ&feature=related

Very useful!!
Retinoscopy - Movements

An WITH movement is seen
Hyperopia add PLUS
Some degrees of low myopia
Retinoscopy - Movements

AGAINST movement is seen
Myopia add MINUS
Retinoscopy - Movements

No movement is seen
Whole pupil glows with light
NEUTRAL AGAINST WITH
5 3 1 0 -
+
1 3 5
SLOW FAST SLOW FAST
Retina
Reflex characteristics
Dull & slow = large refractive error present; add high
powered lens

Bright and fast = small refractive error present; add
low powered lens

Bright & no movement = reversal; no lens required
but beware a dull and slow movement can often be
interpreted as no movement

Retinoscopy - Accuracy
Optometrist will need to wear their own
spectacles or contact lenses
Uncorrected ametropia will affect the accuracy of
your results

Making decisions
Ensure working distance remains constant
Make large sweeping movements of the
beam from one side of the centre of the
pupil to the other, go out of the pupil area
at 1-2 sweeps /sec
Limit number of sweeps make quick
decisions
3-4 maximum at a time
Changes to trial lenses
Make large changes in lens power if reflex is
dull and difficult to see (+ or sphere)
Smaller changes as reflex becomes brighter
Create a bracket of interest between with
and against movements
Bracketing technique
Ret. Lens added Pupil reflex
slow against
-5.00 faster against
-7.00 with
-6.00 fast with
-5.50 reversal
Reversal-Neutralisation
Check tests
Add +0.25DS: reversal will change to against
Add -0.25DS: reversal will change to with
Move closer: reversal changes to with
Move further away: reversal changes to against
Move collar up: reversal will change to with
movement
Recording results
Eye Power of
reversing lens
Dioptre Sphere
(DS)
Working distance
allowance
DS

Final Power
DS
Right
+3.75 -1.50 +2.25
Left
-1.75 -1.50 -3.25
Right
+1.50 -1.50 Plano
Left
-3.00 -2.00 -5.00
Terminology
Reflex = The appearance of the reflection of the
retinoscope light seen in the pupil
Sphere = power of correcting spherical lens, this may
be positive (+) or negative (-)
Reversal = end point at which ametropia is corrected
Working distance =The distance from the
retinoscope to the patients eye is known as the
working distance
Working distance allowance lens = the power of the
lens equivalent to the working distance at which
retinoscopy is carried out at
Astigmatic Dummy
Lenses
Learning outcome
What is astigmatism
Lenses used to correct astigmatism
Principles of astigmatism
Interpreting reflex seen in astigmatism
Retinoscopy and astigmatism technique
Recording results
Ret on the human eye
Astigmatism
A visual defect in which
the unequal curvature of
one or more refractive
surfaces of the eye, usually
the cornea, prevents light
rays from focusing clearly
at one point on the retina,
resulting in blurry,
distorted vision at all
distances.
The Trial Case
Positive
Spheres
Negative
Spheres
Negative
Cyls
Positive
Cyls
For more details see the trial case lecture on Moodle!
Correcting astigmatism
Spherical Ametropia
One power in all principal meridians
Use only spherical lenses to correct Rx

Astigmatic Ametropia
Different powers in the 2 principle
directions
Use 2 spherical lenses for each meridian
OR spherical & -ve cylinder lenses to
correct Rx
+62
+62
+60
+62
Principal meridians always 90 to each other
Ret reflex principal meridians
Ret beam is horizontal and
reflex in pupil seen at 180
The ret beam is rotated to
90 and the second
principle meridian is seen
Ret reflex - Degree of Astigmatism
As each principle meridian
has a different power, the
reflex seen in each meridian
will be of a different speed
and shape

If the astigmatism is high
the reflex will be more
prominent band shaped

Low degree of astigmatism
Medium degree
High degree
Ret reflex - Movement
Cylinder axis 90 Cylinder axis 180 Cylinder axis 135


The arrow indicates the direction that the retinoscope should be
moved along
Set up
Working distance
Visual axis
Vergence slide
Retinoscope light level
Direction of beam
Technique astigmatic correction
Determine principal meridians
Begin with beam at 90(streak), rotate collar/vergence
slide to 180, then to 45 and last to 135
Interpret the reflex
Direction of reflex
Speed of the reflex
Shape of the reflex
Add correcting lenses
Begin with Sphere then Cylinder
High/medium/low power
Record results
EXAMPLE
1. Principle meridians
90
Ret beam is placed at
90 and 180
Reflex reveals
principle meridian is
at 140 and 50
Ret beam re-
positioned to new
axis of 140 and 50
180
140
50
2. Interpret reflex
Direction of reflex in each
meridian
With?
Against?
Speed
Fast?
Slow?
Shape (amount of
astigmatism)
Oval/circular
Distinct band/ Indistinct
140
50
3. Adding correcting lenses
Start by
neutralising the
most hyperopic
(+ve)/ least
myopic (-ve)
meridian first with
Spherical (sphere)
lenses
140
50
3. contd
Spherical lens of X power
added until neutralisation
(reversal/no movement) seen
in one meridian

!! Keep spherical lens in !!

Now observe the movement in
the opposite meridian- MUST
ALWAYS SHOW AGAINST
140
50
3. contd
Observe speed of
movement

Add ve (minus)
cylindrical (cyl)
lens of X power
until
neutralisation
seen
140
3. contd
End point:
Reversal-
(neutralisation)
seen in both
meridians
50
140
Scenarios
Scenario 1
with movement seen in both meridians
Neutralise the slowest with movement first with sph lens
Scenario 2
with movement seen in one meridian and against in the other
Neutralise the with movement first with sph lens
Scenario 3
against movement seen in both meridians
Neutralise the fastest against movement first with sph lens
Scenario 4
No movement seen in one direction and with in the other
Neutralise the with movement first with sph lens
Scenario 5
No movement* (neutralisation) seen in one direction and against in
the other
No sphere lens needed, add ve cylinder in against meridian
South Wimbledon Football
Association
SWFA
Slowest WITH fastest AGAINST
Any other suggestions?
Example Dummy eye
Dummy lens X - fast against seen around vertical
slow against seen around horizontal
Fast against slow against
Neutralise fast
against first
Fast against = add low
powered ve sphere
e.g -1.00DS
Fast against
neutralised with
-1.50DS
KEEP SPH IN!
Example Dummy eye
Dummy lens X - fast against seen around vertical
slow against seen around horizontal
Fast against slow against
Neutralise fast
against first
Fast against = add low
powered ve sphere
e.g -1.00DS
Fast against
neutralised with
-1.50DS
KEEP SPH IN!
Example Dummy eye
Dummy lens X - fast against seen around vertical
slow against seen around horizontal
Fast against slow against
Neutralise fast
against first
Fast against = add low
powered ve sphere
e.g -1.00DS
Fast against
neutralised with
-1.50DS
KEEP SPH IN!
Example contd
Move ret beam to
horizontal axis
Slow against = high
powered ve cyl
e.g. -3.00DC x180
Against movement
remains but now faster
against = continue
adding ve cyl
e.g. replace with
-4.00DC x180
Against movement
neutralised with a
-4.50DC x180
Example contd
Move ret beam to
horizontal axis
Slow against = high
powered ve cyl
e.g. -3.00DC x180
Against movement
remains but now faster
against = continue
adding ve cyl
e.g. replace with
-4.00DC x180
Against movement
neutralised with a
-4.50DC x180
Example contd
Move ret beam to
horizontal axis
Slow against = high
powered ve cyl
e.g. -3.00DC x180
Against movement
remains but now faster
against = continue
adding ve cyl
e.g. replace with
-4.00DC x180
Against movement
neutralised with a
-4.50DC x180
Example contd
Recheck vertical and horizontal
for neutralisation
Normal check tests!

Lenses for reversal
-1.50/-4.50 x180
Final Rx (remove w.d. lens)
-3.00/-4.50 x180
Common errors
High powers (dull/no movement) confused for
reversal
Neutralised incorrect meridian first resulting in +ve
cyl!!!
Low cyl powers confused for reversal therefore not
corrected
Cylinder axis off recheck constantly especially in
high powers/changes
Tip:
Make sure you have read AND
understood this lecture BEFORE
your future practical sessions


Good luck!!!!
Reading for next week
Page 80 83
Identifying the principal
meridians
Neutralizing the meridians

Small Quiz will be available on
Moodle (under 2. Assessments)
between 17/10 (9am) and 18/10
(6pm): 5 minutes, 6 MCQs
Mandatory!?