2019

CLINICAL PROCEDURES MANUAL

IN FUNCTIONAL OPTOMETRY
Integrated Clinical Practices

Prof. Anyella I.P.B Malburg O.D. Esp. FIACLE

Prof. Ariel Scussel Malburg O.D. Esp. FIACLE
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

RATIO COLLEGE

Technologist in Optometry

FORTALEZA - CE

Developed by:

Prof. Anyella Pérez Malburg O.D., Esp. FIACLE–Associate Coordinator Faculty of Optometry.

Prof. Ariel Scussel Malburg O.D. Esp. FIACLE - Coordinator of clinical practices.

Reproduction and sharing of this material is prohibited.

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

1. BODY OF THE CLINICAL HISTORY.................................................................................................. 6

2. PATIENT IDENTIFICATION.................................................................................................. 9

2.1 FILLING IN PERSONAL DATA............................................................ 9

2.1.1 OOBJECTIVE........................................................................................... 9
2.1.2 PRÉ-REQUIREMENTS.................................................................................... 9
2.1.3 PPROCEDURE..................................................................................... 9
2.1.4 ANOTATION IN THE CLINICAL HISTORY....................................................................10
3.1 FILLING OUT THE ANAMNESIS........................................................................................ 10
3.1.1 MREASON FOR CONSULTATION .............................................................................11
3.1.2 ABACKGROUND....................................................................................11
3.1.3 SINTOMATOLOGY..................................................................................12

4. PRESCRIPTION IN USE: LENSOMETRY.................................................................................... 13

4.1 OBJETIVO............................................................................................................................... 13
4.2 PROCEDURE................................................................................................................... 13
4.3 NOTE IN THE CLINICAL HISTORY.................................................................................... 13

5. VISUAL ACUITY.................................................................................................................. 14

5.1 VISUAL ACUITY................................................................................................................. 14

5.2 VISUAL ACUITY WITH THE PINHOLE (PH).......................................................... 16

6. PUPIL - MOTOR EVALUATION............................................................................................. 18

6.1 DYNAMIC ASSESSMENT OF PUPILS................................................................................... 18

6.1.1 OOBJECTIVE..........................................................................................18
6.1.2 EEQUIPMENT.....................................................................................18
6.1.3 PREPAIR......................................................................................18
6.1.4 PSTEP-BY-STEP PROCEDURE.....................................................................18
6.1.5 ACLINICAL NOTATION 19
6.2 MOTOR EXAMINATIONR 19
6.2.1 DDEFINITION19
6.2.2 OOBJECTIVES.................................19
6.2.3 RREQUIREMENTS19
6.2.4 TTHIS IS FOR MOTOR DIAGNOSTIC................................................................20
6.2.5 ANOTATION IN CLINICAL RECORD 23

7. EYE HEALTH ASSESSMENT............................................................................................ 24

7.1 BIOMICROSCOPYA ......................................................................................................................... 24

7.1.1 QUADRO SUMMARY OF TYPES OF LIGHTING........................................................28
7.1.2 ANOTATION IN THE CLINICAL HISTORY 30
7.2 DISTANT OPHTHALMOSCOPY............................................................................................ 32
7.3 DIRECT OPHTHALMOSCOPYA..................................................................................................... 33
7.3.1 OOBJECTIVE..........................................................................................33
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

7.3.2 PSTEP BY STEP PROCEDURE.....................................................................33

7.3.3 ANOTATION........................................................................................34

8. VISUAL EVALUATION................................................................................................................ 37

8.1 CERATOMENTRY.................................................................................................................... 37
8.2 STATIC RETINOSCOPY40
8.3 DYNAMIC RETINOSCOPY42
8.4 SUBJECTIVE49
8.5 REFINING........................................................................................................................ 53
8.6 OUTPATIENT TEST57
8.6.1 OOBJECTIVE..........................................................................................57
8.6.2 TTECHNIQUE...........................................................................................57
8.6.3 IINTERPRETATION....................................................................................57
8.6.4 IINDICATIONS........................................................................................57
8.6.5 POSSIVABLESRRESULTS .............................................................................58
8.7 COMPLEMENTARY TESTSS58
8.7.1 OOBJECTIVE..........................................................................................59
8.7.2 IINDICATIONS59
8.7.3 TTHISVRED– VEARTH(BICROMATIC) 59
8.7.4 EPAYMENT– (MIOPIZATION) ...................................................................60
8.7.5 PRISMASDASSOCIATES.............................................................................60
8.8 TECHNIQUES FOR NEAR VISION......................................................................................... 61
8.8.1 PPROCEDURE.

9. ADDITIONAL DIAGNOSTIC SUPPORT TESTS....................................................................... 62

[Link] EVALUATION OF THE ACCOMMODATIVE MECHANISM...................................................... 62

9.1.1 AAMPLITUDE OF ACCOMMODATION......................................................................62
[Link] Donders Method........................................................................................................ 62
[Link] Sheard Method.......................................................................................................... 63
[Link] Jackson Method63
[Link] Clinical annotation.............................................................................................................. 63
9.2 FLEXIBILITY AND EASE OF ACCOMMODATION................................................................ 63
9.3 ADDITIONAL TESTS OF FUNCTIONAL OPTOMETRY CLINICAL HISTORY.......................... 65
9.3.1 RBOOKINGFUSIONALCOMPRISMASSOLTOS...........................................................65
VNORMAL VALUES FOR AN ORTHODONTIC PATIENT. .......................................................66
9.3.2 TTHIS OF STEREOPSIS OFREINDER..................................................................66
9.3.3 FRISBY............................................................................................67
9.3.4 LPSEUDOISOCHROMATIC AMINES OFISHIHARA...
9.3.5 TABELA OFAMSLER.................................................................................70

10. DIAGNOSIS76

10.1 VISUAL DIAGNOSIS........................................................................................................ 76

10.2 DMOTOR DIAGNOSIS.............................................................................................................. 76

10.3 DEYE DIAGNOSIS............................................................................................................. 76
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

11. CONDUCT.............................................................................................................................. 76

11.1 CONDUTA VISUAL.................................................................................................................... 76

11.2 CMOTORBOAT...................................................................................................................... 76
11.3 COCULAR ONDULATE................................................................................................................... 77
11.4 PFILLING OF FINAL VISUAL CORRECTION(RXFINAL) ............................................................ 77

12. TERM OF CONSENT........................................................................................... 77

BIBLIOGRAPHIC REFERENCES.................................................................................................. 78
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

OBJECTIVE

The purpose of this protocol is to unify clinical procedures and methods.

of their annotation in the integrated clinical practical activities (PIC) of the course of
Technologist in Optometry from Ratio College.

It is sought that academics and professors follow the same line of reasoning and
development of clinical records during practical activities and that the method of
evaluation should be objective, clear and efficient.

It is announced to the academic that this protocol describes the objectives of each test,
step by step procedures and the correct way to record in the medical history that
complement the material provided by the teachers in the theoretical subjects.

This material was prepared for the exclusive use of students in the Technologist Course in
Optometry of the Ratio College in its practical activities and therefore should not be used.
as bibliographic references for final course projects or research papers of the
subjects.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

1. BODY OF THE CLINICAL HISTORY

MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

2. PATIENT IDENTIFICATION

2.1 FILLING IN PERSONAL DATA

2.1.1 Objective
These data allow to identify and locate the patient.

2.1.2 Prerequisites
It is important that the patient is verbal and in the case of minors under 18 or the patient

special (geriatric, syndromes, low vision, blind, etc.) the responsible person must be present to
correctly identify the patient and answer the questions asked by the examiner. The name
The identification of the responsible party must be recorded along with that of the patient in the clinical file.

2.1.3 Procedure
In the identification of the patient, we have fields to fill out personal data.
that allow the information to enter our system identifies you in the community.
It also allows us to perform epidemiological analysis and contact in case control is needed.
of any condition that concerns us.

The data that should be collected are:

a) Date of evaluation,
b) Full name and surname,
c) Gender,
d) RG or CPF,
e) Name, surname, and document of the companion if necessary,
f) Date of birth and age (for children up to 3 years, it is recorded in years and months)
g) Endereço (rua, nº, bairro e cidade),
h) Phone (landline and mobile),
i) Occupation or profession is a very important piece of information for development.
anamnesis is for defining the tests that will be used during the
optometric evaluation. It is also important to know if the patient has any
hobby that could be the origin of the presented symptoms and that is not
associated with your occupational activity,
j) Date of the last exam: It is important to know if the patient has been examined before,
how long ago and by which professional,
k) Occupation or profession is very important data for development.
anamnese and the purpose of the examination. It is also important to know if the patient
presents a hobby that may be the origin of the patient's symptoms and
that is not associated with your occupational activity.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

2.1.4 Annotation in the medical history

The data must be recorded with a blue ballpoint pen in legible handwriting on the
corresponding spaces.

3. ANAMNESIS

3.1 FILLING OUT THE ANAMNESIS

Definition: Series of questions asked to the patient with the purpose of understanding the
reason for the consultation, which in turn allows for guiding the diagnosis
presumptive condition of the patient.

Establish through questions the identification of the patient, the reason

of consultation, personal and family background in addition to the condition
currently presented.

Properly correlate the primary information (reported by

Objectives: patient) with secondary information (obtained through questions).

Systematically and orderly record all relevant information

obtained during the examination, as well as that which allows to guide a
presumptive diagnosis.

Demonstrate security and mastery through this first contact for

build trust.

Generate a pleasant environment as an essential requirement.

with the established situation.

Use clearly understandable terminology.

Demonstrate confidence, emphasizing the importance of listening to the patient.

Requirements of demonstrating dedication in solving your problems.
examiner:
For patients with expression difficulties (due to age or
(disabilities) the presence of an additional interlocutor is necessary
(responsible) who knows the reason for the consultation and the background of the
patient.

The examiner must possess the required skills to conduct the

questions according to the manifestations reported by the patient and
extract all relevant information.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

3.1.1 Reason for consultation

The patient is asked why they decided to consult, since when they have been feeling this way.
the difficulty/discomfort that bothers you, at what time of the day and with
Objective:
how frequently it manifests, emphasizing whether the problem is present or not
associated with visual activities.

The main complaint or reason for the consultation should be thoroughly investigated by the
examiner, in preparing the reason for the consultation, the patient is asked
Procedure: the following questions:

Time, associations, detailed description.

This space on the medical record should strictly note the words
Annotation
used by the patient to describe their problem(s) always
clinic
using quotes, e.g. “itch and burn”.

3.1.2 Background

The background allows us to determine if the reason for the consultation has a
Objective: direct relationship with the patient's overall health and vision or if the symptoms are of
primary origin, that is, independent of the backgrounds.

The story of the case is one of the most important and most difficult procedures.
learn from all the repertoire of the exam. To be able to obtain a good story
one must have a broad basic knowledge and years of clinical experience. The anamnesis
it is divided into three main stages.

In the first interview with the patient, the optometrist asks the questions
openly to understand the cause or reason for the consultation (main complaint) and to
Procedure: find out the patient's usual visual needs. In case they do not have
no complaints should be made, ask relevant questions to investigate your
visual state.

In the second part of the anamnesis, the questions will help to determine if the patient
there is no risk of neurological, ocular or general pathological issues.

Finally, after listening to the patient, we will be able to analyze if the reason for
The consultation is related to a visual, motor, or ocular problem or also if the
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

the reason for the consultation is related to changes of another origin.

In the medical history, one should research the patient's ocular history as well as the
family that may be associated with the main complaint or that is a reason for
risk for further analysis.

If correction is used, usage time, type, and consistency are researched.

In the patient's medical history, their general health, time, and place where it was done are researched.
your last complete physical exam, prove risk factors such as diabetes,
high blood pressure or another ocular and/or systemic medical condition.

If taking medication, ask about the dose, frequency, and reason for taking it.
medications. If you are allergic to drugs or have other types of allergies.

In the family history, it is inquired if there is anyone (related up to a maximum of

third degree) who suffers from cataract, glaucoma, blindness, strabismus or some
another eye condition that uses eye medication etc.

Note on Use clear and legible lettering, placing the terms used in between commas.
clinical history: patient. The use of a blue pen is mandatory.

3.1.3 Symptomatology

Objective: Determine the subjective clinical symptoms and signs.

At this moment of the consultation, the signs and symptoms are noted.
referred by the patient. There is no universal way to
data annotation in the anamnesis, but rather bases on
Procedure: mechanism of questions asked to the patient.

a) Assess through questioning whether the symptoms are

of visual, motor, ocular origin or of alterations
different generalities.
a) Note the symptoms specifying the intensity, duration
of evolution, which associates the symptomatology and the
frequency.
b) Identify the location. Associate it with some task of the
Annotation in the history
day, have you had any treatment or consulted another
clinical specialist, appears only at certain moments of
day? At what distance does the vision problem worsen.
c) Try to ask trying to extract the most
patient information. If the patient doubts
ask several times and always demonstrate confidence.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

4. PRESCRIPTION IN USE: Lensometry

4.1 OBJETIVO
Determine the current dioptric state of the patient, type of lenses in use, and the condition.

of these.

4.2 PROCEDURE

The lensometry will be performed only when authorized by the teaching instructor and
always at the end of the complete functional examination.

4.3 NOTATION IN THE CLINICAL HISTORY

In this case, the annotation must specify the spherical, cylindrical degrees, and the axis,
but also the characteristics of the lenses such as: their condition, type of lens, type of material,

state of the frame and the lenses, and coloring characteristics.

 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

5. VISUAL ACUITY

5.1 VISUAL ACUITY

Objective or subjective method that provides us with information related to the

Definition: resolving power of the eye.

Visual acuity depends on the integrity of neurological elements and

of the interpretive capacity of the brain.

a) To know the patient's visual discrimination ability

monocularly.
b) Qualitatively and quantitatively note the value or characteristic of
visual capacity of the examined.
c) Determine the patient's ability to respond appropriately with the
Objectives:
purpose of choosing the appropriate test to employ.
d) Obtain the initial AV record to be compared with the
final data of the development of the clinical history (CH),
data correlation.
e) Measure the binocular visual acuity in order to know the capacity
what the individual has to observe things in normal conditions.
a) It is essential for the measurement of visual acuity that the optotypes are
clearly printed, legible and also well lit
uniformemente e limpos.
From the office and b) Make the necessary adjustments according to the distance that
exists between the patient and the test.
tables of
c) If a projector is used, it is necessary that the manual of it
optotype be available in order to establish the font size of
20/200 (referenced in most manuals), the distance at which
it will measure the AV and later make the letters clear
designed. This ensures that the measurement of the AV with this device
be trustworthy.
d) To be emmetropized.
e) To have a thorough understanding of the test used.
f) Must have the ability to handle different tests.
From the examiner:
g) The examiner must be alert to notice when the patient
He is maneuvering to better visualize the optotype, such as
palpebral fissure, compensatory head position or moving the
occluder for looking with both eyes.
h) One should never force the patient to read a certain level of VA.
reading should be done without any difficulty or effort.
i) Optotype tables according to the patient's age for vision of
Equipment: far sight and near vision.
j) Occluder or pirate plug in the case of pediatric patients.
Room with good lighting.
The patient takes their habitual correction for the distance they are going.
Preparation: to measure, correction (CC) is used and without correction (SC).
The patient is asked to hold the occluder.
n) Present the table according to age/education.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

o) Always observe the patient and never the optotype table (Ideal
for the optometrist to memorize the chart.
p) Ask the patient to close the left eye and not to shut the right one.
look or change the position of the head.
Ask the patient until which line they can see clearly.
clear. If the patient can read more than half of the line, pass.
for the line further down or for the more demanding visual acuity.
If the patient cannot read the chart at 6 meters, bring it closer.
based on the 20/200 line, ask if you can see it
now at half the distance (3 m).
If the patient cannot see at 3 m, bring the chart closer.
half (1.5 m).
If you can't read at any distance, the following will begin
test sequence:
u) Count fingers (CD): Present a series of fingers from one hand to a
distance of 30 cm. Ask the patient how many fingers they see. The
optometrist withdraws until he no longer responds
correctly. Approach again until you can see the fingers
correctly and without problems.
v) Hand movement (HM): Use the hand in motion as
fixation point and ask the patient if they see the hand in
movement. Start at a distance of 30 cm, and move away until
Procedure:
the patient cannot see the hand. Approach again until
he sees it.
w) Light Projection Perception (LPP): Hold a flashlight or trans-
illuminator in different areas of the visual field at a distance of
50 cm of the patient. Ask the patient to point with their finger.
where he is seeing the light at every moment.
x) Light perception (LP): Direct the light onto the patient and
ask if she can see.
y) Perception of phosphenes (PF): With eyes closed locate the light of the
flashlight or trans-illuminator applying light pressure on the
eyeball.
z) No perception of light (NPL): Blind patient or amaurotic eye.

aa) Repeat the procedure for the left eye asking the patient
what covers the right eye. Do it correctly if the patient uses it
without correction.

bb) Now measure the near visual acuity using the same.
procedure at a distance of 33 to 40 cm with a table
suitable for the age and the distance (33 cm Jaeger, 40 cm
Snellen). Measure for the right eye by covering the left one and
vice versa with and without close correction in the case that the patient
always use good lighting through a lamp.
a) According to the type of table and the distance from the office already
compensated.
Clinical annotation:
b) It is recorded in Snellen or decimal reading.
c) The acronym CC and SC is used. And the abbreviation for right eye (OD) and
for left eye (LE).
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

d) Note each eye separately, OD and then OS.

e) First note the distance vision (DV) and then the near vision (NV).
f) If the patient reads more than half of the line minus some(s)
letters, note how many letters the patient did not read.
g) If you read a few more letters being less than half of the line, note it down.
complete the previous line plus the letters you read from the following line.
h) In the case where it is necessary to approximate the table, note the
visual acuity already compensated.
If you did not read at any distance, specify the technique and the
distance:
j) CD a: _______________________ (distance).
k) MM a:_______________________ (distance).
l) PPL. Note the visible areas.
m) PL
n) NPL.
Note: Always record the table used.

5.2 VISUAL ACUITY WITH THE PINHOLE (PH)

Determine if the decrease in visual acuity can be corrected with

lenses. The pinhole aperture increases the depth of focus for the patient and
Objective: reduces retinal aberrations. This way, if there is none
retinal or visual pathway abnormality the patient improves his
acuity.

Visual acuities lower than 20/40 with the best optical correction or
Indications:
habitual.

Projector or optotype chart for distance vision.

Equipment:
Stenopoeic hole of the test box or the greens.

Occluder.

In distance vision and the patient without correction.

Preparation:
Monocular is only at a distance.

Ask the patient to cover the eye that will not be examined or cover it.
with the occluder.

Procedure: Inform the patient that a small hole (PH) will be placed and that
you should try to look at the letters through it. Try to take the patient in the
maximum visual acuity.

Annotation in The annotation will be made after measuring the distance visual acuity.
medical history: in the corresponding format for the right eye and the left eye.
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

If the visual acuity improves with the pinhole, it is indicative that it is

due to an uncorrected refractive error.

If visual acuity with the pinhole does not improve, it indicates that it does not
it is due to an uncorrected refractive error.

Analysis: It is expected that with retinoscopy the achieved visual acuity will be better.
of what the AV has with PH.

The use of this element and its method also helps in

procedures of the subjective, especially for cases of patients
that do not recover the AV with the best correction obtained; it is a way
to check the patient's visual capacity.

Note. In clinical practice, the pinhole will be used whenever the patient without
correction cannot see acuities below 20/40, for didactic purposes, even.
that he can achieve visual acuities superior to 20/40 corrected.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

6. PUPIL - MOTOR EVALUATION

6.1 DYNAMIC EVALUATION OF THE PUPILS

6.1.1 Objective
Evaluate the afferent and efferent pathways responsible for pupillary function, evaluate the

permeability of the optical pathway and whether the neurological system is normal.

6.1.2 Equipment
Lantern.
2. Distant mounting point.
3. Near accommodative table.

6.1.3 Preparation
Ambient lighting that allows for viewing both pupils.
b) Position yourself 25 cm away from the patient outside their line of sight or of their
visual axis.
c) The patient must remove their glasses, if they use them.

6.1.4 Step by step procedure

a) Ask the patient to look at the fixation point at distance vision.
b) Shine the flashlight or transilluminator into the right eye (OD) and observe the size,
speed and pupillary miosis in this eye. This procedure is known as response
direct or photomotor.
c) Repeat the procedure two more times.
d) Shine the light in the right eye and assess the response of the left eye (LE) observe the

size, speed and miosis. This is the consensual or indirect reflex.

e) Repeat the procedure two more times.
f) Move the flashlight quickly from one eye to the other, pausing on each eye.
from 3 to 5 seconds. Observe the direction of the response (dilated and constricted) and the size of

each pupil at the moment of light incidence. This procedure is called 'Swinging
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Flash Test or pupillary escape test. This test is performed to evaluate pupillary escape or
the response of Marcus Gunn, indicating a relative afferent pupillary defect.

g) The balance test will be conducted over two to three complete cycles.

h) Ask the patient to continue looking at the fixation point in the distance while holding the
accommodation table for patients approximately 10 to 40 cm.
i) Then ask the patient to look closely at the chart and observe if the pupils
they undergo miosis. This is the accommodative reflex.

j) During the test, assess whether the pupil is round, symmetrical, and equally reactive.

6.1.5 Clinical Annotation

If the three reflexes are present and active (reactive) in both eyes, note them down.
as: Present.

In the presence of any abnormality in the exam, note the eye, type of alteration, if the
reflexes are absent or in the case of asymmetry measure and note the eye and the difference in

millimeters.

6.2 MOTOR EXAM

6.2.1 Definition
Clinical methods through which an assessment of balance is sought
oculomotor

6.2.2 Objectives
Determine through objective tests the state of oculomotor equilibrium
patient.
Obtain the qualitative description and quantitative value of the latent or manifest deviation of

patient.

6.2.3 Requirements
A minimum level of cooperation is required to perform the motor evaluation.
Of the patient: Follow or fix the attachment points according to the examiner's instructions.
One should apply the usual correction to avoid the instability of the deviation.
Keep your head steady.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

One should position oneself at the same height, trying to stay on the visual axis.
of the patient.
One must achieve an accurate examination by obtaining the cooperation of the patient.
Do without causing fatigue.
The distance must be accurate for the execution of each test.
Examine carefully to avoid the patient's loss of attention and correct
its compensatory positions.
Determine the dominant eye for the exercise of the different tests.
Do
A quiet environment with good lighting.
office
The assessment of motor function involves the development of multiple tests.
that grouped describe the motor state of the patient. Since the assessment of
Procedure: position of the eyes, the function of the extraocular muscles and the measurement of
deviations through forometry.
6.2.4 Tests for motor diagnosis
Observation of the location of the eyeball in
Objetivos:
regarding the orbit.
Highlight the ocular deviations.
Using a flashlight or
transilluminator located on the visual axis of
KAPPA ANGLE: examined at a distance of 50 cm in front of
Procedure:
patient, one of the patient's eyes is covered and
It is the existing angle with the other one should fix the light determining the
between the pupillary line position of the corneal reflex, if it is not central
the center and the axis nasal or temporal displacement is observed.
visual, the interval of The form of annotating the reflex is done
angle is generally qualitatively and it describes:
from 5th. Centralizado: se fica no centro da pupila. Anota-se
Ways to
like zero (0).
note:
Positive: located nasally. Noted as
(+).
Negative: temporally located. It is noted.
as negative (-).
Evaluate the equivalent position of each cornea.
Objective:
corneal reflex (First Purkinje image).
Prior realization of the Kappa angle for
HIRSCHBERG: determine the symmetry.
Does not limit the type of fastening.
Requisitos:
Be aware of the size of the pupil interval of
approximately 4 mm.
Look at corneal integrity and transparency.
The patient is asked to fixate with both eyes.
Inspection of the reflections the luminous point at 30 or 40 cm away,
horns the examiner must be located in front of the
binocularly. A Procedure: patient and evaluate the equidistant position of the
displacement of 1 corneal reflexes. It is expected in the case of strabismus
mm will correspond to that a relative displacement of the
an angle of 7º. image.
Forms of Centered: includes the upper symmetrical location,
annotation inferior, nasal or temporal of the corneal reflexes.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

clinic Off-centered: the degrees and the must be described.

decentralization position, whether it is nasal (indicates X) or if
it is temporal (indicates E).
Determine the existence of paresis or paralysis of the
Objective:
extraocular muscles.
Immovable head.
Fixation point according to visual acuity
Requirements:
of the patient or a light source.
Monocular study.
The examiner located in front of the patient
ask him to follow the fixation point or light a
a distance of 40 cm. Starts from the position
DUCTIONS: primary gaze and invites you to follow the
Procedure:
movement in the 8 diagnostic positions with the
Monocular assessment lantern or fixation point. Thus one discovers the
of the movement normal functioning of the eye muscles or the
ocular. limitation for any diagnostic position.
If the excursion of the movements is slow and in a way
it is noted as: smooth and continuous.
If the tour shows certain limitations, but the
muscle surpasses the midline is noted as:
Forms of
paresis must be accompanied by the muscle and
note: through the eye.
If the excursion does not exceed the average line, the form
the note will be: paralysis of the muscle or eye
correspondent. It is noted as SPEC.
Determine the modifications of the corneal reflex.
about the non-fixating eye and generally the
Objective: modifications of the situation of this eye in relation to
with the focusing eye. It indicates hyper or
hyperfunctions, and constraints.
Binocular test.
The examiner located on the visual axis of
patient.
Head still and vertical.
Requirements:
The patient fixes the light source that fixes the eye.
VERSIONS: director
It is the study of The test starts from the primary looking position.
movements and it continues in the 8 diagnostic positions.
binoculars. The patient in front of the examiner fixes the light at 40
Procedure: cm of distance, from the primary position to
complete the 8 diagnostic positions.
Based on the negative mathematical scheme for
the hypo functions and positive for the hyper functions. It is
important to know the fields of action of
Annotation:
muscles, the position of the fixing eye and the positions
diagnostics.
Look at the attachment.

Diagnosis of the state of binocular balance

Objective: patient, through the capability of motor fusion
necessary vergence reflex movements
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

to maintain the correct binocular alignment of

COVER TEST: a patient.
Knowing the type of deviation present in the patient.
Objective test that Determine the latent and manifest presence of
allows to determine the a deviation.
type of change Obtain the prismatic value of the deviation: prism cover
oculomotor test.
allows the diagnosis Maximum cooperation establishing the fixing point
and the quantification. determined by the examiner.
Head in the direct position, facing forward and without
movement.
To know e acquire a skill no
development of the test. Control the fixation of
patient with attractive fixation points or light.
Explain the procedure to the patient (if possible) and
the importance of your collaboration. Conduct the test
preferably with o maximum control
Requirements:
accommodative, it implies the use of Rx
habitual and in some cases compare the result
with and without correction. Determine the presence of
compensatory head positions, and in the case of
to exist, the data is recorded remaining with
the compensatory position and with the head located
straight and turned forward. Determine the eye
patient's dominant. Determine the type of
patient fixation. The requirement for the realization
The test is to check the stable central fixation.
First, the cover uncover is done and then
to cover alternate testing without possibility of
fusion. If the patient does not cooperate, carry out the
Procedure:
procedure with the light of the transilluminator or
with a flashlight.
Know the maximum capacity of convergence
PPC: What does the patient have while maintaining the alignment of the

visual axes on the fixation point. Determines

Objective:
Point close to the ability to converge and merge, including the
convergence. capacity for voluntary convergence e
involuntary.
Stable central fixation. It should be done with and without
correction. The attachment point must be
Requirements:
proportional to VA in near vision. In cases of
And the point is more endotropia is performed (coincidence of axes).
next in which a The patient is asked to look at the flashlight or the
a person is capable of fixation point at 40 cm, should mention how many lights
maintain images is seeing. When seeing double one should
simple and clear. move away from the initial distance until you can see
Involves all the Procedure: a single fixation point.
convergences: Then the fastening object should be brought closer until
Tonic, by that it looks double or is observed to lose fixation.
proximity, by You can move the flashlight away and note where it returned.
accommodation and the to see a single image.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

fusional. The annotation is made in centimeters without a filter (with

Annotation: the lantern), with filter and real object. If the patient
Use glasses should be noted with and without correction.

6.2.5 Annotation in the medical history

Hypoactivity or hypofunction: Mild (-)

Moderate (=)
Severe (=)

Hyperation or hyperfunction: Light (+)

Moderate (++)
Severe (+++)

Name Annotation
Exoforia X
Endoforia - Esoforia E
Right hyperphoria - left hypophoria D/E
Left hyperphoria - right hypophoria E/D
Right exotropia XTD
Left exotropia XTE
Endotropia - Right Esotropia ETD
Endotropia–Left Esotropia ETE
Right hypertrophy DT/E
Left hypertrophy ET/D
Right hypotropia E/DT
Left hypotropia D/ET
Alternating exotropia XTA
Alternating esotropia ETA
Intermittent exotropia X(T)
Endotropia - Intermittent esotropia E(T)
Note first on torsional strabismus o XTD DT/E
horizontal component and then the vertical deviation
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

7. EYE HEALTH ASSESSMENT

7.1 BIOMICROSCOPY

The assessment of the conditions of the anterior segment constitutes a point

fundamental in the diagnosis of the anatomical, physiological, and pathological state of
Definition: external structures of the eye. Two types of illumination are used: direct and
indirectly, with which we can evaluate in detail all the structures
from the previous segment.

Conduct a detailed inspection of the external segment structures to

to be able to know your anatomical and pathophysiological states.
Objectives:
Describe and draw the changes found in the previous segment of
look, analyze and define the differential diagnosis.

The patient should remain comfortably seated or standing depending on the

age and height and explain the purpose of the exam. The chin and the forehead must
being well located just like the external palpebral fissure. It depends a lot
of the patient's collaboration.

Of the device: the lamp should be calibrated at the moment of starting the
Requirements:
evaluation, the sufficient energy source to elevate the device and to a
height that allows for comfortable assessment of the patient.

From the examiner: to know the parts of the lamp and their function, indication for
the patient about the purpose of the exam, skill and dexterity in the technique and in the
illuminations and avoid the fatigue of the examined.

The patient is examined without correction.

2. The lighting of the cabinet must be dim (mesopic).
3. Adjust the height of the instrument to a comfortable position for the
patient and for the examiner.
4. Place the reflective mirror in the 'click stop' position.
5. Ask the patient to place their chin on the chin support and
Procedure the head resting on the upper support.
6. Adjust the height by aligning the outer corner of the patient's eye with the
step to
mark that is on the side of the forehead support.
step: 7. Make the increase smaller (6X OR 10X) and remove all filters from
lighting system.
8. Ask the patient to close their eyes. Turn on the instrument. Focus.
each eyepiece using the patient's eyelashes as a fixation point
closing one eye and the other alternately and rotating the ocular.
Always start with the largest positive and rotate in a clockwise direction.
until the first clear image appears.
9. Open both eyes and adjust the IPD by varying the distance between the eyes.
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

oculars. If the IPD is correct, a binocular vision should be obtained

when observed through the eyepieces.
Use one hand to control the direction (to align and focus the
microscope) and the other hand to operate the slit controls, adjust
the angle between the lamp and the microscope and manipulate the eyelids
of the patient.
11. The anterior segment is examined in a specific order:
eyelids, eyelashes and eyebrows, conjunctiva, sclera, cornea, angle
from the previous chamber, iris and lens.

Eyelids, eyelashes, and eyebrows.

12. Use diffuse lighting with a 30º angle from the normal.
Low magnification.
14. Ask the patient to close their eyes. Examine the upper eyelid and
the eyelashes
15. Ask the patient to open their eyes while observing the lower eyelid.
the eyelashes, tear meniscus, position of the eyelids on the globe and the
Meibomian glands.

Conjunctiva.

16. Narrow the beam of light to a wide parallelepiped with an angle of

30° lighting.
17. Keep low magnification (6X OR 10X).
18. Ask the patient to open their eyes and look up.
19. Inform the patient that you will touch their lower eyelid.
Place the cotton swab on the lower edge of the eyelashes and evert the eyelid.
inferior. Examine the bulbar and lower palpebral conjunctiva in search of
of elevations, depressions or discolorations. Evaluate the points
tearful.
20. Ask the patient to look down.
21. Inform the patient that you will touch the upper eyelid. Place the
Cotton swab on the edge of the upper eyelashes and elevate the eyelid. Examine.
the entire bulbar conjunctiva.
22. Ask the patient to look to the left first while
examine the nasal bulbar conjunctiva and do the same procedure for
the temporal bulbar conjunctiva.
23. It is indicated to evert the upper eyelid.
24. Place a cotton swab in the superior orbital-palpebral sulcus and evert the
Upper eyelid. Examine the entire upper tarsal conjunctiva.

Cornea.
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

25. Reduce the width to a narrow parallelepiped approximately of 1-

3 mm wide. The angle of illumination should be
approximately 30º to 45º.
26. Set average magnification (16X or 20X).
27. Ask the patient to look at a point ahead. Examine the
central portion of the cornea in search of opacities or irregularities.
When reaching the peak of the cornea, pass the illumination arm to
the other side and continue with the exam.
28. Ask the patient to look down. Raise the upper eyelid with
The cotton swab and examine the upper third of the cornea. Remember to
pass to the other side when you reach the peak of the cornea.
29. Ask the patient to look up. Lower with the cotton swab the
lower eyelid and examine the lower third of the cornea.
30. It is recommended to perform the mirror reflection at this moment.

Estimation of the anterior chamber depth using the Van Herick technique.

31. Illumination angle 60º on the temporal side of the fixation line
patient. One alternative is to place the light arm at 30º from
temporal side and the microscope at 30º from the nasal side in such a way that
there is a 60º angle between the lamp and the microscope.
32. Average magnification (16X or 20X).
33. Narrow the slit to an optical section.
34. Ask the patient to look straight ahead.
35. Focus on the temporal limbus of the cornea.
36. Compare the width of the shadow formed by the iris (representation of
depth of the anterior chamber) with the width of the optical section
(representation of corneal thickness). Note: the shadow is a
dark interval between the light and the cornea and the light in the iris, which
represents the optically empty aqueous humor of the anterior chamber.
37. If the angle size is equal to or less than ¼:1, it must be carried out
gonioscopy to evaluate the angle more precisely.
(Refer to the ophthalmologist).
38. If the arm of the microscope is moved to perform this
procedure to put it back in the starting position (facing front) before
continue with the exam.
CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

Annotation:

The angle will be qualified according to the system described by Van Herick:

SCAP = Shadow created by the previous peripheral chamber

GCA= Espessura corneal aparente

✓ GRADE 1: SCAP < ¼ GCA

✓ GRADE 2: SCAP= ¼ GCA
✓ GRADE 3: SCAP > ¼ E < ½ GCA
✓ GRADE 4: SCAP > 1
Interpretation:

The evaluation and quantification of the angle is handled by degrees from 1 to 4. Being
grade 1 is the narrowest and grade 4 is the widest. To know the grade, a
estimation by comparison with the amplitude of the luminous beam of the section
optics on the cornea.

✓ Narrow angle: the black width is less than ¼ of the beam over the
cornea Grade 1
✓ Average angle: the black amplitude is ¼ of the beam over the cornea:
Grade 2
✓ Wide average angle: the black width is from ¼ to ½ of the beam over the
cornea Grade 3
✓ Wide angle: the black width is equal to or greater than the beam
luminous over the cornea:
Grade 4

The technique does not replace gonioscopy and in cases of the presence of pterygium or
of the senile arch, where light does not fall on the limbus, without an adequate
reflection cannot carry out the evaluation.

Iris.

39. Increase the size of the parallelepiped and the angle of illumination of
30º to 45º.
40. Maintain the average magnification.
41. Examine the surface of the iris for irregularities.

Crystal clear.

Lighting angle 20 º to 30 º
43. Maintain the average magnification.
44. Reduce the gap to a narrow parallelepiped.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

45. Mover a lâmpada até o paciente bem devagar até que a luz entre
through the pupil and observe the anterior face of the lens focused.
Continue bringing the lamp closer to the patient to examine the
deeper layers of the lens. Pass the light arm to
the other side and perform the same procedure from the previous chamber
until later.

7.1.1 Summary table of types of lighting

Type of Click Angle of Width of Height Structures

Lighting Magnification
lighting stop strip band from the strip observed

Lower General observation

Variable 45º a of all the
Adjusted 4 mm Maximum Average
60º structures of the
Diffuse
6X -10X anterior segment

Low
Focal direct Adjusted 45º to 60º 1–2 mm Maximum Media Cornea and lens.
6X–10X

30º to 60º:

30º

Conjunctiva
Lower 6X to
30º to 45º: Cornea
medium
Direct focal
Adjusted Cornea and iris 2-3 mm Maximum Average Crystal clear.
parallelepiped

60º: injury
10X - 20X
three-dimensional
of the cornea

20º a 30 º:
crystalline

Corneal layers,
tear film,
60 degrees
Average a camera angle
Adjusted depth Minimum Maximum 10 X -16X
Focal direct maximum.
from the injury almost anterior.
optical section
extinguished

40º Minimum High High Aqueous humor

Minimum
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Focal direct Adjusted circular

with bundle
conical

45 º to the Corneal epithelium,

Adjusted epithelium, 50º 1 mm Maximum Media 16X-40X layers of the film

Reflection
lacrimal, endothelium
speculate
a 60º for the corneal, mosaic of
endothelium. endothelial cells.

Tangential Adjusted 90º 2 mm Average Download the

Conjunctiva, iris.

moderate

Irregularities,
corneal injuries
No refractories not
60 º 1 mm Maximum Media 10X–16X
adjusted opaque like micro
Indirect
cysts and signs
digitals.

Adjusted 45 º to 60 º 1-2 mm Maximum Average Download 7x Cornea

Dispersion
scleral

Vacuoles, scars,
Retro edemas,
lighting pigmentations,
direct Adjusted 50 º - 60 º 1 mm 3 mm Average 6X-10X blood vessels
in cornea.

Cornea, Bruckner,
0 coaxial with the diffuse defects or
Retro Adjusted 2 mm 2 mm Maximum (light 6X-10X
microscope located in
lighting environmental
directly from the iris
epithelium.
off

Cornea, deposits

No on the membrane of
Retro 50 º - 80 º 1 mm 3 mm Media 6X-10X
adjusted Descemet is
lighting
irregularities of
indirect
corneal surface
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

posterior.

Cornea, formations
Retro epithelial cysts,
lighting Adjusted 50º to 80º 1 mm 3 mm Average 6X - 10X compressed air bubbles
marginal in LC and circulation
lacrimal in LCG.

7.1.2 Annotation in the medical history

Each eye should be noted separately.

2. Write the examined structures with the corresponding observations for each one
of them.
3. Describe any abnormality.
It is recommended to illustrate those cases that help in the description.
5. See example:

FINDINGS
STRUCTURE

EYEBROWS Complete and uniform AO

PÁLPEBRAS AO Uniforms

Eyelashes Aligned WITH

CONJUNCTIVA Calm transparent AO

CORNEA Transparent AO

ANTERIOR CHAMBER VH: 4, absence of cellularity AO

IRIS Blue AO

CRYSTAL CLEAR Present and transparent TO

PUPIL

Note: take into account the biosafety regulations: the cotton swabs should not be left in

top of the table of the slit lamp and should be thrown in the trash; the strips of fluorescein do not

they must be cut and saline solution should not be used.

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

7.1.3 Summary table for the evaluation of structures with slit lamp

STRUCTURE TYPE OF LIGHTING ADDITIONAL OPERATION

Eyelids - eyelashes -
Diffuse
eyebrows

Dyeing with rose of

Conjunctiva Diffuse, wide parallelepiped.
Bengal.

Narrow parallelepiped,
Lighting with blue filter
specular reflection,
cobalt, dyeing with
Cornea indirect lighting, retro-
disodium fluorescein, pink
illumination, dispersion
from Bengal.
scleral,

Previous chamber Cone beam. Red-free filter.

Iris Tangential.

Parallelepiped, optical section

Crystal clear
with backlighting.

90 Diopter lens, lenses

60 D, 78D, Super pupil XL
Diffuse, parallelepiped
Retina Super field NC, Super Zoom
narrow.
78/90, three-mirror lens
of Goldmann
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

7.2 DISTANCE OPHTHALMOSCOPY

Explore the transparency of the means.

Objective:
Explore the reflection of Bruckner.

To the patient: invite the patient to focus on an object in the distance to

avoid myosis.

The examiner: assessment of the patient's anxiety level, always

explain the type of exam that will be conducted and about the approach that the
exam requires to observe the patient's eye fundus. To know the
available techniques for fundus assessment and its due
Requirements:
application according to each case. Skill in technique and knowledge of
universal notation forms. Use of supplements according to the
patient's needs.

For the procedures to be carried out, the environment must be in

penumbra, the elements must be manipulated according to the rules of
Biosafety and their maintenance must be periodic.

Working distance: 40 or 50 cm.

2. Ophthalmoscope with the lens at 0 (zero).
3. Evaluation of the examined person's right eye with the right eye of
examiner. And vice versa.
4. Evaluate the reflections of Bruckner and compare the reflection of each eye.
5. Ask the patient to look at a fixed point (E of the optotype). With
the dark cabinet so that it produces a wide mydriasis.
6. Stand 50 cm in front of the patient (aligned with the axis and
with the ophthalmoscope at zero diopters.
A light red and continuous background is observed. Any
opacity will be seen as a black point that contrasts with the
Procedure fundus of the eye.
step by step: 8. PUPIL: should appear in a more or less intense red color and
with no opacity
9. INTRAOCULAR LENSES: if there is any opacity it will be seen
black on red background
10. LOCATION OF OPACITIES: if there is an opacity
We should locate it and determine whether it is fixed or mobile. In the first
the case will move with the eye while the other remains still
moving when the eye is still. Thus, the
mobile opacities are only located in the vitreous or chamber
previous.
The determination of the depth at which the opacities are located is done by
the means of its movement with respect to the edge of the pupil.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

During distant ophthalmoscopy, it is noted whether the media are transparent and if
Bruckner's reflection is symmetrical.
Ways of
annotation: In the case that the reflexes are pathognomonic (due to some pathology)
note the eye that shows the difference and the type of reflex. If it is clear or
dark, whether it is mobile or fixed.

7.3 DIRECT OPHTHALMOSCOPY

Employee for detailed observation of the structures. In this case, the fundus is
observed through a magnifying glass, as a direct image since optical aids are not needed
additional.

7.3.1 Objective

Through the magnifying lenses, it is possible to determine the anatomical conditions of

components of the anterior and posterior segments.

7.3.2 Step-by-step procedure

Preparation:

a) Adjust the office chair so that the patient is a bit lower than
eye level of the examiner.
b) Ask the patient to remove their glasses if they are a user, and look into the distance at a
a determined distance fixing a non-accommodative point.
c) It should be done in a room with dimmed lighting.
d) With the ophthalmoscope in your right hand and your right eye, examine the eye
patient's rights.
e) Using the lens wheel, with powers ranging approximately from +40 D to -35 D,
Structures such as eyelids and cornea (+40D), anterior chamber (+20D), iris will be observed
the anterior face of the lens (+12D), vitreous body (+8, +6, +4D), up to the retina (+2.0 to–
The observation is made at about 2.5 cm.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

f) Position yourself at a distance of 2.5 cm with a lens + 20.00 D and an inclination of

about 30 degrees and observe the cornea.
g) As you gradually reduce the positive power of the lens, the focus of
the observation extends backward and inward into the eye. More or less like this
(in the case of emmetropic eyes).
h) The power of the lens depends on the refractive error of the patient.

i) Logically, it will depend on the patient's ametropia whether the lenses are used for
observation, for example, a myopic person with -3.00 diopters will need to be observed
through the lens of -3.00 and an aphasic with a sufficiently + lens to
compensate for your flaw.
j) In each of the structures, it should be verified that they are free of any
anomaly.
k) The inclination of + or -30 degrees temporally, is done to reach directly
at the head of the optic nerve.
Note: remember that the protocol must be complete.

7.3.3 Annotation

It is advisable to follow a systematic order in observation to not forget any.

structure:

Record each eye separately.

It is recommended to draw the negative observations to assist in the description.
3. Note the characteristics of each of the following structures:

Structure Clinical feature

We will observe their edges that must be defined and flat. The coloring of
Papilla
disc (soft yellow), the size and shape: round, slanted, oval.

Shape, cup-disc relationship, relative measurement of the size of the excavation in

fraction or relation, depth (increase negative lens from the papillary edge
Excavation
until observing the sieve-like blade, taking into account the difference between the initial lens and the
final (every 3.00 D equals 1 mm of depth).

Space understood between the edge of the papilla and the edge of the excavation that marks
Ring
the entry of the optic nerve fibers and their presence indicates normality. It should be
neuro-
note as present or the quadrant where its thickness is reduced. Norma
retinal
ISN'T.

The symmetry of both eyes must be compared. The changes indicate the beginning of
Symmetry
alteration or possibility of present pathologies.

Glasses We will observe its course from the papilla to the periphery, its tortuosity and the
arteriovenous crossings. The veins are darker in color than the arteries and
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

twice as thick (Ratio 2:1). Relation artery vein, crossings (signs

de Gunn), ciliary-retinal artery, types of vessels, changes in vessels in color,
diameter, thickness, new vessels.

Rosado, normal.

Core - Its coloration is evaluated and generally its content, as it is not normal to see stains.
fund red or white in the background of the eye, must be free of any alteration.
Color of the fundus: uniform pale red, with normal variations according to
race, refractive state, and age.

Blade Fibrous and elastic connective tissue. It is the posterior edge of the sclera that forms the
sully canal. It is visualized at the base of the crown.

Crescent-shaped scleral, choroidal, pigmented, peri-papillary atrophy.

Located on the temporal side of the papilla and about two papillary diameters from

Macula distance.

We will observe the foveal brightness, its uniformity, and absence of vessels.

Switch to the fixation reticle and ask the patient to look at the light,
while occluding the other eye. One must understand how the position of the point or area
in which a patient uses to observe shapes, sizes, colors, and details
two objects. If the brightness stays in the center without movement we talk about: FIXATION
CENTRAL ESTAVÉL. If the shine stays in the center but has movements: FIXATION
CENTRAL INSTAVÉL. If the shine is off-center: ECCENTRIC FIXATION.
Excentric fixation can be: Erratic: it does not have a stable fixation point.
Nostalgic: the movement is pendular in the same area. With foveolar steps:
moments in which the macula can remain within the circle of the lattice.

Fixation
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

Lent: With which the fundus of the eye was visualized.

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

8. VISUAL ASSESSMENT

8.1 CERATOMETER

Objective: Determine the central corneal curvature.

Exact adjustment of the keratometer according to the patient. The examination is conducted
Prerequisites:
monocular, first right eye and then the left eye.

Javal type ophthalmometer:

a) Adjust the keratometer's eyepiece to the examiner's refractive state.

This step is very important for the obtained measurement to be
exactly, if the ocular is not well focused, an error will be induced
at the time of measurement.

b) Ask the patient to rest their chin and forehead on their respective
supports.
c) Occlude the OE with the fixed occluder of the appliance.

d) Move the chin support up or down until the height

Procedure the patient's eyes align with the mark on the side
step by step: left of the chin support.
e) Indicate to the patient to observe the luminous fixation point that
there is inside the instrument.
f) Align the instrument with the patient's eye. This first adjustment
it is done by looking through the eyepiece, aligning with the lever of
control, the brand and the fit of the instrument with the center of the

patient's right eye pupil.

Focus and center the image of the sights reflected by the surface
anterior of the cornea. This second adjustment is more precise. It is done

observing through the eyepiece and the displacement of the instrument

forward or backward.
h) Take the measure of the first main horizontal meridian,
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

aligning the line of faith of the central images, making them coincide
tangentially, without overlapping.
i) Memorize the value of the radius, the power, and the meridian in which it
it reached the end of the measure.

j) Rotate the instrument approximately 90º until locating the other

main vertical meridian.
k) Take the measure of the second main vertical meridian, aligning
again the line of faith of the central sights and, consequently,
make them coincide tangentially.
l) Note the values. First the stored values of the meridian
horizontal, followed by the values corresponding to the meridian
vertical.
m) Repeat all the steps for the OE excluding the OD.

Helmholtz type ceratometer:

Adjust the eyepiece of the keratometer to the refractive state of the examiner.

This step is very important to obtain accurate values.

o) Ask the patient to support their chin and forehead on their respective
supports.
p) Occlude the left eye with the keratometer occluder.

Adjust the height of the patient's eyes until it aligns with the mark
what is on the left side of the chin rest.
Align the leveler of the keratometer with the eyelid opening.
temporal of OD.
s) Instruct the patient that both eyes should remain open and to focus
the image of the eye that is seen reflected in the center of the instrument.

t) Gently move the ceratometer horizontally until the

examiner observes, without looking through the eyepiece, the image of the

reflected ceratometric measurement on the cornea.

u) Look through the eyepiece.

v) Move the instrument vertically until the central cross is
observed through the eyepiece and stay in the center of the lower circle
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

that is located further to the right.

w) Focus the reflected image by moving the instrument forward and

back, until the lower circle is further to the right, and is seen
initially unfolded (unfocused). An image should be seen
simple, in such a way that only three circles are observed in the
image that is reflected on the cornea.
x) Constantly maintain focus and take the measurements of the meridian
horizontal, superimposing the positive signals, with command of the

left. Then take the measure of the vertical meridian

overlapping the negative signs with the command on the right. Both
the commands are alternated until the cross of signals
negatives should be aligned.
y) Repeat all the steps to obtain the OE measurements.
Note: In the case of very curved or flat corneas, the use of the lens is necessary.

ortogon

The intervals of the keratometers are mostly between 36.00 and 52.00 D.
When the value of keratometry exceeds these values, we must increase the
interval of the keratometer with the orthogonal lens.

The orthogonal lens is made up of a +1.25 lens (for very corneas

curves) or -1.00 (for very flat corneas), which are located in front of
optical system, decreasing or increasing the image reflected on the
cornea.

When the curvature is greater than 63.00 D or less than 36.87 D, add 9.00 D
when the cornea is too curved or decreases 6.00 D in very curved corneas

plans.

The conventional notation according to IACLE is used:

Annotation:
Flattest meridian/curviest meridian by the axis of the flattest.
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

The type of keratometer used is noted.

Describe the state of the keratometric markers.

8.2 STATIC RETINOSCOPY

Objectively determine the refractive status of the patient with the

Objective:
rest accommodation.

Prerequisites: Central fixation.

Use binocular compensation lens (according to the distance of

examiner's work), the patient looks into the void and begins the neutralization
by the negative cylinder-plane technique. Use the proof box or the
phoropter (greens).

Team:

a) Band Retinoscope.
b) Phoropter (greens) or test box or if applicable ruler
esquiascopic.
c) Fixation point: Snellen or figure of 20/200.
Preparation:

Procedure: a) The patient without glasses or contact lenses, if he is a user.

b) Adjust the height of the chair so that the patient's eyes
be at the height of the optometrist.
c) Place the greens or the test frame in front of the patient with the
corresponding interpupillary distance and adjust the level of
instrument focusing the eyes on the openings.
d) Ask the patient to keep both eyes open during the
retinoscopy. Ask the patient if the head is blocking
your line of sight. In order to maintain this alignment with the axis
visually, on some occasions it is necessary to tilt the greens or
move the fixation point off the screen.
e) Use the right eye to examine the patient's right eye and the
the examiner's left eye assesses the left eye of the
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

examined.
f) Hold the retinoscope 40 or 50 cm away from the patient with your hand.

right to evaluate the right eye and with the left hand to evaluate
left eye.
It is better and easier to perform retinoscopy in dim light.
Step by step procedure:

Patient fixed to infinity (6 meters).

2. RL (Compensating lens according to the working distance)
binocularly.
3. First, determine the type of shadows whether they are in favor or against the

retinoscope movement, meridian by meridian:

If the horizontal meridian is favorable and the vertical is against: according to the

the speed of movement is different at each meridian = defect

spherical - cylindrical.

If the two meridians have the same direction of movement and the same
speed = spherical defect.

If the speed of the retinoscopic shadow is slow: high refractive defect.

If the speed of the retinoscopic shadow is fast: low ametropia or

neutral point or emmetropia.

4. Neutralization process: neutralization in retinoscopy

means finding the point or the area through which by adding
spherical and cylindrical lenses eliminate the movement of the reflection or

retinoscopic shadow.
The static retinoscopy will be recorded as a total value, that is, already without the

compensating lens (RL). Each eye, separately and always noting

first the most positive spherical meridian and second the meridian
cylindrical or more negative along the axis of the more positive. Check the acuity
Annotation:
visual for each eye and note it down.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

OD AV

OE AV

Example:

OD: +2.00–1.00 X 180° AV 20/15

+1.00–1.50 X 180° AV 20/15

8.3 DYNAMIC RETINOSCOPY

Objectively determine the refractive state of the patient with accommodation.

Objective:
active.

According to the chosen dynamic technique.

The technique will be selected according to the clinical characteristics of the

patient and the needs of the examiner to determine the diagnosis

more accurate.

Procedure: Monocular dynamic technique at 40 cm

Working distance: near vision 40 cm.

a) Monocular evaluation.
Neutralize using the negative cylinder lens technique.
c) For the Rx in distance vision: algebraically compensate (-1.25)
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

This compensation value is the one theoretically used as value

approximate Lens + or addition in a patient with presbyopia.

DYNAMIC RETINIOSCOPY IS ALWAYS MORE POSITIVE THAN THE

STATIC BY THE ACCOMMODATING LAG.
LAG ACC: depth of field, the amount that an image can be
move in the field of the retina.

Dynamic MEM technique: monocular estimation method

Objective:

Objectively measure the accommodative response at the working distance of

close. This technique is very useful for diagnosing binocular anomalies and
predict the efficiency of some therapeutic methods.

Equipment:

Retinoscope, MEM retinoscopy chart, trial lens box.

Preparation:

a) The MEM table must be adhered to the retinoscope in such a way

that the beam of light passes through the central hole of the table. In general

these tables have a magnet that adheres to the retinoscope.

b) Ambient lighting.
c) The patient takes their usual near correction.
d) The test is performed under binocular conditions.

Step by step procedure:

a) Position oneself in such a way that:

b) The MEM table should be at the usual working distance. With

children are usually used at Harmon distance (distance
elbow to wrist) as an alternative measure.
c) Position yourself at the patient's midline so that the eyes of the
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

the patient is slightly looking down as if he is

reading.
d) The light beam of the retinoscope should be oriented vertically and
placed on the patient's nasal bridge.
e) Ask the patient to read the letters from the chart. In children it is

it is advisable to have them read aloud.

f) While the patient reads, quickly bring the strip to the right eye and
assess whether the reflex is direct, inverse, or neutral. The reflex must be
observed in the center of the pupil, not at the edge.

g) Estimate the dioptric value to neutralize the forward movement

positive, against–negative.
h) Place a lens of approximate power in front of the patient and
observe the reflection in the line of sight, if the power is correct it will be

observed neutrality. NOTE: it is important to put oneself in and take oneself out

the lens in a quick manner just like the evaluation of the reflection. A

prolonged exposure of the lens can induce a response

accommodative and therefore obtain an invalid result.
i) Repeat the steps for the left eye.

Annotation:

1. Note the technique used MEM

2. Note the required lens power to achieve neutrality in the
OD and no OE.

Examples:

MEM OD: +0.50

+0.75

Standards:

The required lens power to achieve neutrality represents the LAG of

MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

patient accommodation. The classical interpretation in clinical experience

established some normal values of retinoscopy MEM from +0.50 to +0.75.
Recent studies suggest that it is more appropriate to consider higher values
wide, from neutral to +0.75 D.

Hyndra - Mohindra dynamic technique

Objective:

Objectively determine the distance vision status of patients who do not

they collaborate in subjective exams or cannot maintain attention on
optotype. It can also be used in all those cases where there is suspicion of
an inadequate accommodative activity (convergent strabismus,
latent hyperopia, pseudomyopia,...

Material:

• Retinoscope.
• Box of proofs.
• Baby bottle in children under one year old.

Method:

Completely reduce the lighting in the room to prevent the retinoscope from functioning

as an accommodative stimulus.

Ask the patient to observe or try to maintain attention (in the case of
very small children) in the light of the retinoscope (whose intensity must be the
minimum possible)

Neutralize the retinal reflex using the techniques developed in the title
retinoscopy and skiascopy at 50 cm.

Calculate the net value of refraction (as a function of working distance) and
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

to add a correction factor due to the accommodative activity of the obscure focus
from accommodation, of +0.75 D. In the end, algebraically sum the value of -
1.25D to the gross value of retinoscopy.

Notes:

This technique is used as an option for those cases where it is not possible.
use cycloplegia (successive returns, glaucomatous background,
allergic or secondary reactions to any component of the drug.

Techniques with cycloplegia (for knowledge only)

Objective:

Objectively determine the distance vision status of patients who do not

they collaborate in subjective examinations or cannot maintain attention on the

optotype. In this objective refraction with cycloplegia, it is maintained controlled.

(paralyzed) the accommodation through the use of drugs. It can also be

to be used in all cases where there is suspicion of inappropriate activity of
accommodation (convergent strabismus, latent hyperopia, pseudomyopia,
variable shadows.

Material:

▪ Retinoscope.
▪ Caixa e armação de provas ou refrator.
▪ Optotypes for distance vision.
▪ Cycloplegic. The most commonly used are the following:
Drug T.M. Republic ofD.O.
Turkey D.M. A.M.

Atropine 1% 30’ – 60’ 12–24

24 h
10–18
+
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

h d

Scopolamine 0.25% 30' - 60' 1h 2h 4–6 days +

36–48
Homotropine 5% 30' 1h 1–2 h ++
h

Cyclopentolate 1% 20' 20’ – 45’ 30' 6–8 h ++

Tropicamide 1% 20 minutes
20' - 45' 15' 2–6 h +++

- T.M.: Tempo que leva para atingir a máxima midríase (minutos)

T.C.: Time taken to reach maximum effect of cycloplegia (hours/

minutes).

D.O.: Optimal duration of cycloplegic effect (hours/minutes).

D.M.: Maximum duration of cycloplegic effect (days/hours).

A.M.: Residual accommodation effect of cycloplegia.

Method:

▪ Choose the most appropriate cycloplegic for the patient (based on the
age, visual problem and patient's visual demand), instill and
wait for its effect before taking the exam. Follow the dosage instructions.

suitable for each drug.

▪ Neutralize the retinal reflex using the techniques developed in
index. It is not necessary to myopize since in this case the accommodation

is paralyzed.
▪ Calculate the net value of refraction (as a function of distance from)

work).

Observations :

▪ It is not necessary for the patient to look at the vision optotype.

long, as it can look at the light inside the retinoscope.
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

▪ The fact of presenting pronounced mydriasis can lead to errors in

refraction (due to peripheral aberrations), therefore limiting the
observation of the pupil zone (diameter of approx. 4mm).
▪ At the time of prescribing, some authors consider a factor
corrective (spherical power) that is added to the net value. This
the factor is determined taking into account:
The relationship of the tone of the ciliary muscle, induced by the drug.

When we find more positive refractive values, to

prescribe this excess of positive power from
spherical found in the net value. This value is
approximately 1 A.D.
The function of refractive error: in myopes it will not be necessary.

discount all the positive value, however we

hyperopes is necessary.
The function of aligning the visual axes and its relationship with

accommodative activity, that is, in endophorias and entropias

with accommodative component, the maximum is prescribed

positive of refraction.
▪ Possible contraindications of these must be taken into account.
drugs before performing this exam. Among these, the risk stands out.
to provoke an acute glaucoma crisis in patients with a chamber
narrow anterior.
▪ Inform the patient about the inconveniences of this exam: photophobia and

inability to focus on close objects during the hours

following the exam. In the case of small children, they may
introduce changes of behavior (drowsiness,
irritability, etc...) as side effects of the drug, which
they disappear in a few hours.

Annotation of the results:

✓ Only the net value of the examination should be indicated.

Note: This retinoscopy can only be performed with medical supervision.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Only the net value of the examination must be indicated.

The dynamic retinoscopy will be noted the same way but specifying the technique.
used and noting the net amount already settled according to the technique.

Annotation: OD AV

OE AV

Technique:
_______________________________________________________________.

8.4 SUBJECTIVE

Objective: Subjectively determine the refractive state of the patient.

TEAM

Projector (optotype tables: letters, cross, clock or astigmatic dial).

Greens or proof boxes with proof framing.

TECHNIQUE

Procedure: Preparation:

The patient should be seated comfortably.

b) Measure the pupillary distance on the greens or on the test frame.
Level the greens.
d) Design the complete optotype.
e) It usually starts from the result of retinoscopy
static on greens or framework of tests before starting the
subjective.
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Step by step procedure:

a) Monocularly. Open the right eye and cover (occlude) the eye.
left.
b) Regarding static retinoscopy or the most positive, add sufficient
positive power (+2.00 D) to achieve blurring the vision of
patient and bring him to the 20/200 visual acuity line.
c) If the cylindrical value is less than 1.00 D, start only with the sphere, if it is

greater than 1.00 D and less than 3.00 D leave half, if it is greater
from 3.00 D leave 75% of the astigmatism found in the retinoscopy
static.
d) Take the measure of visual acuity to be sure that the
the patient is seeing at line 20/200.
e) Start the accommodating massage by increasing the positive sphere of

+0.25 D and decreasing +0.50 D, do not allow the patient to be

without lens or you will lose the entire massage. Keep massaging
until taking the patient to line 20/40.
f) On line 20/40, switch the patient to the astigmatic dial or fan.
astigmatic to obtain cylindrical correction in the case that the patient
be astigmatic. Ask the patient:

g) Are all the lines the same? Are they equally blurred or
equally black.
Is one of the lines clearer or less clear than the other?
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Which line stands out the most?

Possible patient responses:

j) If all the lines on the dial are equal, it means that the patient
there is no cylinder or the cylinder initially placed is
correct.
k) If a line stands out more, then at 90° of its position is the axis.
initial.
Note: take into account the refractive defect for the realization of the subjective and

remember that this technique should be applied to all verbal patients.

If two lines stand out more, then at 90° from a position

the axis of astigmatism is found in the intermediate.

If three lines stand out more than the others, then the 90° line
the center is the axis of astigmatism.
n) If more than three lines turn dark, it means that the patient does not
understood the test or simply does not have astigmatism.

Note: The axis of astigmatism can be calculated using the 30 rule.

consists of following these steps:

o) Determine the most highlighted line.

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Each line has a number from one to six. Excluding the axis 0 –
180.
q) Take the marked number and multiply it by 30. Example: 4 x 30 =
120°. TABO position.
If the patient reports seeing the intermediate line more clearly than the others.

they are numbered, take the number of the next line in order
counterclockwise and multiply it by 30, to
result some 15, obtaining the axis of astigmatism. Example:
report more clearly the line between 2 and 1, so: 1x30= 30 +
15 = 45° TABO.
s) Place the axis of the cylinder obtained with the dial, add cylinder
negative until the patient reports that all lines are
either clear or blurred. If the patient reports inversion of
contrast, that is, to start seeing at 90° from the initially
seen decreased by 0.25 D in the cylinder.
t) Change the dial using the long-distance view and ask the patient
how far you can read. The visual acuity should improve if the

astigmatism is well corrected.

u) Continue the massage until achieving the best visual acuity with
the maximum positive lens.
v) Repeat the procedure for the left eye.

RECOMMENDATIONS:

Keep in mind that the negative lens increases contrast, which can be
interpreted by the patient as better vision record, but an increase
In A.V., it can only mean greater discrimination and not better.
image quality.

Note the data found in the subjective technique and the visual acuity data.
reported by the patient.
Annotation:
OD AVL AVP

OE AVL AVP
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Always correct with the utmost positive lens you can and improve.
Rule: visual acuity in distance vision and minimum positive lens for calculation of the
addition.

8.5 REFINEMENT

Objective: Refine the subjective correction.

Technique: Jackson Cross Cylinder

Axis refinement:

1. Place the correction obtained in monocular subjective refraction by

myopization.
Close the left eye.
3. Ask the patient to read one line above their best.
A.V.
4. Explain to the patient that they should choose a letter from the line above.
with the best visual acuity and that responds in which position they see
better the letter, whether it is in the first or second.

5. Explain to the patient that the chosen letter will change its shape and

Procedure: two different images of this same letter will appear, but it
you should choose the image that looks the clearest, responding
which is better.
6. Ask the examinee if they see the two images the same way or if
one of them is better (clearer and more comfortable).
The examiner rotates the crossed cylinder in both positions with the handle in the

direction of the axis and repeats the same questions.

8. Is it better in position 1? Wait for 3 to 6 seconds before

pass to the second position.
9. Or is it better in this position 2? Repeat the procedure again with
the same questions and add a third question (or are)
equal?) to better clarify the test.
10. Or are they the same? If they are equal, the axis of the cylindrical power is correct.

11. Once a position is chosen, rotate the axis in the test frame 5° in
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

directions to the red points and keep adjusting the axis, placing the
cable on axis changed.
12. If the astigmatism is greater than 2.00 diopters, rotate by 5° increments.

13. If the astigmatism is between 1.00 D and 2.00 D, rotate by 10° increments.

14. If the astigmatism is less than 1.00 D, rotate by 15°.

15. The axis of astigmatism will be correct when the patient sees
equally clear or blurred in both positions.

Refinement of cylindrical power:

16. Place the red dots parallel to the axis of the found cylinder.
not subjective.
Present the two images to the patient by rotating the handle of the cylinder.
crossed and asked: In which of the two positions do you see better?

It is better seen when the red points coincide with the axis of
astigmatism: INCREASE negative cylinder in steps of 0.25 D. And
continue spinning the cross cylinder, images are still preferred
when the red dots are positioned, increase by -0.25 in
correct axis and continue performing until the images are similar.
It becomes clearer when the green points coincide with the axis of
astigmatism: REDUCE negative cylinder in steps of 0.25 D until
the two images are similar.
20. The verification of the power will end when any of the following
conditions must be met:
21. Both images remain the same.
22. The changes in the patient's responses are very close. In this
if you select the power that is closest to the minimum correction
cylindrical.

Tuning of spherical power:

23. Change the optotype to the cross.

MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

24. Place the crossed cylinder in position A.

25. Ask the patient which component of the cross they see most clearly:
Horizontal or vertical?
26. Possible answers:
27. To better see the HORIZONTAL component, INCREASE power
increase or DECREASE negative power in steps of 0.25 D. Until the
two components are equally seen.
28. To better see the VERTICAL component, decrease positive power
or increase negative in steps of 0.25 D. Until the two
components should be viewed equally.
29. Take A.V.
30. Repeat the entire tuning procedure for the left eye.
closing the right eye.

Refinement for near vision:

31. OBJECTIVE: Fine-tune the correction for near vision, to a

working distance determined according to the requirements of
patient (addition).
32. TECHNIQUE:
33. Switch to the optotype table for near vision fixation:
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

34. Place the trial correction for near vision according to the table
for compensation for the distance of work, about the correction for
vision from afar already tuned.

Close the patient's left eye.

36. Place the crossed cylinder in POSITION A.
37. Ask the patient to focus on the near vision chart placed in front of them.
usual working distance.
38. Ask: Which of the components of the pamphlet (horizontal or vertical) is
see more black or sharper?
39. If the patient reports seeing better:
40. The horizontal components: INCREASE the positive power of the spherical

in steps of 0.25 D, until the components of the booklet are

similar or reverse the pattern (better see the vertical components).
41. The vertical components: DECREASE the positive power of the spherical by

steps of 0.25 dpts. Until the components of the booklet are

similar or reverse the pattern (see the components better)
horizontal).
42. Repeat the procedure for the left eye

Note the final prescription (final RX) with your visual acuity.

OD AVL AVP

Annotation: OE AVL AVP

Technique: CCJ
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

8.6 OUTPATIENT TEST

It is a test that consists of assembling the final refraction in the frame of trials and doing

let the patient walk around the examination room for about 5 minutes so that they can feel how
it will be your new correction.

8.6.1 Objective

Subjective binocular test, conducted to determine the degree of acceptance of the correction.

attempt, based on visual comfort.

Test the patient's tolerance to the trial formula.

8.6.2 Technique
1- Adjust the test framework taking into account:

a. Pupillary distance.
b. Distance to the vertex.
c. Pantoscopic angle.
d. Height of the bridge.

e. Length of the rods.

2- Place the attempted correction in the proof framework.

3- Ask the patient to look around; looking in all directions; ask them to
observe the angle of the objects (floor, frames, doors, etc.).

8.6.3 Interpretation
a. If the patient reports comfort and tolerance, total correction can be prescribed.
attempt, according to the case and the examiner's criteria.

b. If the patient reports discomfort: spatial distortion (floors and walls) or have
difficulty in moving with total correction, calculate a partial correction (see
criteria for partialization) and retake the outpatient exam.

8.6.4 Indications
a. High refractive defects corrected by 1atime.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

b. Against-the-rule astigmatism corrected by 1 atime.

c. Astigmatism with opposite axes (heteronymous).

d. Mixed astigmatism corrected by 1avez.
e. High astigmatism.
f. Astigmatismo oblíquo.
g. Anisometropias.
h. Antimetropias.

Note: After the exam is verified by the instructor, the intern may administer this test in
together with your instructor.

8.6.5 Possible Results

a. Children: They should be made to walk around the room and in an outdoor environment observing the

children's behavior and their way of walking. It is also valid to ask for
child drawing circles and squares observing if it picks the objects correctly
or you look for them before the paper. Many times, in these cases it is necessary to lower values

spherical lenses so that the child has better well-being and comfort with their glasses.

b. Adult: when walking in the exam room and in the external environment, they should be questioned.

and thus report if you feel dizziness or nausea, in this case it is necessary to lower

spherical component and take the test again until the patient reports feeling-
be well with the glasses. Next, measure near visual acuity and if it is
It is necessary to follow the correction technique for near in the following item of the booklet.

8.7 COMPLEMENTARY TESTS

The subjective test based on the elementary comparative principle of both eyes:

Fogginess: Adding positive lenses.

Dissociation: Through prisms, filters (red-green - polarizers); with the

purpose of breaking part of the fusion.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

8.7.1 Objective
Equalize the accommodation stimulus in both eyes, with the aim of achieving
a similar A.V.

8.7.2 Indications
It is carried out in cases where the monocular visual acuities are similar after
the tuning of the subjective has been carried out.

8.7.3 Red-Green Test (Bichromatic)

a. Place the correction found in the tuning.
b. Change the standard optotype to the red and green optotype at 6 m.
c. Ask the patient to focus on a line above their maximum monocular visual acuity and
after binocular.
d. Ask: On which side are the letters clearer, if it is on the background
red or against the green background? Be careful because the question must be clear.

directed for the patient to observe and choose the letters against the red background
green, not the color that you see better.

e. Possible Answers:
f. On the red background: increase negative spherical lenses or decrease positive.
g. On the green background: decrease negative spherical lenses or increase positive ones.
h. If the responses are the same regarding both funds, this will be the final value of the refraction that will be

prescribed for the use of glasses.

i. Register the data.
j. Conduct an outpatient test for this patient and check the near visual acuity with
the final refraction.
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

If the patient requires correction for near vision, perform the techniques for vision.
next.

8.7.4 Fogging – (Myopization)

a. Add positive lens binocularly until achieving a visual acuity of three lines
below that obtained with the refinement (worse than AV 3 lines of the observed line with the

tuning)
b. Explain to the patient that both images are blurred.
c. Alternately close your eyes and ask: are the two images equal?
erased?
d. If you can see one of the two clearer, increase the lens by +0.25 D in the eye with it.
who sees more clearly.

e. Repeat the procedure until both images are equally blurred.

f. Alternately reduce the positive lens (increase the negative) in steps of 0.25 D,
ensuring that the most negative eye is the one that sees clearest at this moment
until achieving maximum visual acuity.

8.7.5 Dissociated Prisms

a. Place the correction found in the sharpening of distance vision.

b. Embrace by adding positive lenses until achieving a visual acuity of 20/50.
c. Place 3 to 4 prisms with the base up in the right eye and 3 to 4 prisms with the base down.

inferior in the left eye.

d. Explain to the patient that they will see two lines 20/50, one above the other and
both erased.
e. Ask the patient to move from one line to the other, observing which one they can see.
clearer or sharper.
f. Add +0.25 D to the eye that reports a clearer vision.
g. Repeat the process until the patient reports seeing two equally blurred lines or
cannot define quickly.
Remove the dissociating prisms to achieve the fusion of the images.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

i. Decrease positive lens binocularly in steps of 0.25 D until achieving the best
visual acuity.
j. Record the data.

8.8 TECHNIQUES FOR CLOSE VISION

Basically, the technique for close vision is very simple. There are several ways
to be carried out, however, they require greater care and necessary materials to make it effective.

8.8.1 Procedure
1. The patient sitting with correction for distance holds the near chart at a distance of
40 cm and responds to which line it sees clearly.

2. Care for the patient's age is essential; however, greater attention should be
with this patient's professional activity.

3. Defined the near visual acuity and the correction for this distance begin.
monocularly adding on top of the distance correction, positive spherical lenses
from +0.75 D and increase by 0.25 D until the patient sees the line of best vision
visual acuity.

4. Repeat the procedure for the other eye and record the results.

5. Binocularly, ask the patient to read the chart up close and position themselves at
same distance from your work.

6. Always respect the accommodation lag according to your patient's age (see
table), so that it is neither hyper corrected nor hypo corrected nearby.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

9. ADDITIONAL DIAGNOSTIC SUPPORT TESTS

9.1. CLINICAL EVALUATION OF THE ACCOMMODATIVE MECHANISM

The objective of these tests is to determine the ability to maintain a sharp image of
objects at different distances and the ability to make sudden changes in focus on
visual system. For a correct assessment of the accommodative function, the following tests are required

amplitude of accommodation, of accommodative flexibility and of accommodation lag

accommodative, from positive and negative relative accommodation, from dynamic retinoscopy and from AC/A.

9.1.1 Amplitude of accommodation

Determine the maximum accommodation capacity to maintain a clear image of the
object on the retina. It is evaluated monocularly, since it manifests binocularly
convergence. The most commonly used tests in the clinic are the Sheard, Donders, and Jackson tests and
the modified technique of dynamic retinoscopy.

Materials for conducting tests:

Tables for close-up view

2. Occluder
3. Proof box
4. Setup of evidence
5. Illuminated office.

Procedure:

[Link] Donders Method

Also known as the approximation method, it consists of approximating a table of

optotype to the patient's eyes. Monocularly and emmetropized or corrected, ask the
patient looks one line above their best near visual acuity. Approaches the chart
from the optotype until the patient indicates seeing the letters on the chart blurred. The distance that

separate the table of the glasses plan or the corneal plan (in meters), it must be converted into
diopters and will give the value of the amplitude of accommodation in diopters. (AA:1/distance(m)).
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

[Link] Sheard Method

Also known as the method of negative lenses. Monocularly, they are added
negative lenses in steps of 0.25 D, the patient must be corrected or emmetropized in
vision at a distance and in the case of presbyopes it must also be corrected for near vision, however
It is deducted at the end. The patient is instructed to focus their vision one line above their best.

visual acuity at a distance of 33 to 40 cm. The patient is asked to indicate when

see the blurred letters and when you can no longer read. The value of the amplitude of
accommodation will be the value of the negative lens plus the value of the distance compensation

adjusted and in the case of the presbyters with correction to near, the addition should be deducted.

[Link] Jackson Method

It is similar to the Sheard method, but it is performed for distance vision.

[Link] Clinical notation

Technique:

Visual level:

Working distance:

Fogging Borriness Focus

The clinical note must specify the technique that was used with the visual level.
corresponding to one line above the best visual acuity that the patient has, the distance
The work will correspond to the lenses that will be used in the case of the Sheard technique.

It is important to record the compensated absolute value and the moment when the patient

blurs, smudges (AA) and focuses again.

9.2 FLEXIBILITY AND EASE OF ACCOMMODATION

They aim to measure the patient's ability to activate or relax accommodation.

quickly and effectively in monocular and binocular conditions. This test is part of the analysis
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

functional optometry and its results help in the detection of accommodative anomalies
primary.

Necessary equipment:

Lenses of +/- 2.00 in the shape of flippers

2. Close table
3. Pirate-type occluder
4. Polarized glasses
5. Light source
6. Transparency with polarized bars
7. Watch or stopwatch

Preparation:

The patient must be wearing their distance correction;

2. The patient or the examiner keeps the chart close at a distance of 40 cm.
illuminated;

Procedure:

1. Place the lenses according to the distance of +2.00 (50 cm) from the patient's eyes and ask
when you can see the table clearly;

As soon as he sees clearly, replace the lenses with -2.00 diopter negatives.

3. Repeat steps 1 and 2, noting the complete cycles that the patient can do in a
minute. Throughout the exam, one should ask the patient if they can see the letters of the
table closely through the polarized bars.

4. If the patient performs 8 or more cycles per minute, the number of cycles must be recorded.
complete, in case the patient does not reach 8 cycles in a minute, it must be done
step 5;
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

5. Occlude the left eye (LE) with the pirate type occluder and repeat steps 1 and 2 on the eye.
right (OD). Note the number of complete cycles performed in one minute,

7. Logo, occlude the right eye and repeat steps 1 to 3 on the left eye. Note the number of cycles.
completed in a minute.

Annotation:

Record the number of complete cycles in one minute binocularly (AO) and if so
possible, in a monocular way as well.

Example:

Accommodation Ease: AO 4 c/m

OD 12/ c/m

OE 11 c/m

Standard:

Binocularly, eight or more cycles per minute are expected.

Monocularly, 11 or more cycles are expected in a minute.

There are different criteria regarding the dioptric value used in the exam and the
number considered normal. Nevertheless, it is widely accepted that in near vision
with lenses of +2.00/-2.00, 12 CPM are performed monocularly and 8 CPM binocularly.
Other studies show similar results, table.

9.3 ADDITIONAL TESTS OF THE FUNCTIONAL OPTOMETRY MEDICAL HISTORY

9.3.1 Fusion Reserve With Loose Prisms

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Analyze muscle reserves through loose prisms in both distant and near vision.
It begins by placing the prisms until the patient sees double, and then the prisms are reduced until

report image fusion.

Internal base prisms are used to measure divergence and external base prisms for
measure convergence. Some values should be considered normal in a patient
orthophonic, as in the following table:

Normal values for an orthophoric patient.

Convergence V.L. +20∆ a 25∆

Positive Fusion Reserve (PFR)
Convergence V.P. +35∆ a 45∆

V.L. Divergence -8∆ a -10∆

Negative Fusion Reserve (NFR)
Divergence V.P. -10∆ a -12∆

In patients with heterophoria or heterotropia, the minimum reserve value should be the
good to the found value of deviation.

9.3.2 Reinder Stereopsis Test

Objective: Evaluate stereopsis.

Prerequisites: Central fixation.

This test consists of a polar graphic vector system made up of two

book-shaped plates seen through polarized glasses. On the right there is a
Description:
large reindeer and to the left, a series of circles and animals. The test is done at

a distance of 40 cm.

a)The arena tests gross stereopsis (simple and not very complex) (3,000

Procedure: arc seconds) and is especially useful for preschool children.

a fly can have a solid appearance and the child is encouraged to pick one up
its wings. In the absence of gross stereopsis, the fly will appear as
 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

a common flat photograph. If the book is turned upside down, the figures will appear

to be behind. If the patient reports that the wings are still forward,
he is not perceiving in stereopsis.
b) The circles comprise a graded series that tests the
fine stereopsis. Each of the nine squares contains four circles.
One of the circles in each square has a degree of disparity and will
appear in front of the reference plane in the presence of stereopsis
normal. The stereopsis angle is calculated from a leaflet that
the test follows. The degree of disparity ranges from 800 to 40 seconds of
arc. If the patient perceives the circle displaced laterally, they are not
perceiving in stereopsis, more using resources of monocular vision.
c)The two animals are similar to the circle test and consist of
rows of animals, one of which will appear displaced forward in the plane
of reference. The degree of disparity ranges from 400 to 100 arc seconds.

9.3.3 Frisby

Objective: Evaluate stereopsis

Description: This test consists of three transparent plastic plates of varying thicknesses.
variables. On the surface of each plate are printed four quadrilaterals.
of small random shapes. One of the squares contains a circle.
hidden where the random shapes are printed on the back of the board.

Procedure: The patient is asked to identify the hidden circle. The test does not require
special glasses because the disparity through the thickness of the plate can
varying by increasing or decreasing the fixation distance. The degree of

disparity ranges from 600 to 15 arc seconds.

 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Image:

9.3.4 Ishihara pseudo-isochromatic plates

Detect congenital defects of color vision and individuals with defects.

Objective:
leaves (red-green changes).

Ocluder.

Material: Ambient light.

Ishihara plates (38 or 24 plate test).

a) The patient is using the current prescription.

b) Perform the examination monocularly.

c) The test must be evenly lit.
d) Place the test 75 cm perpendicular to the line of sight.
Procedure: patient.
e) Pass the slides so that the subject identifies each of them
hidden numbers or to be able to follow the confusing paths.
f) The observation time for each slide will not exceed 3 seconds.
g) Note results.
Ishihara test of 24 plates:
Values
normals: Chromatic vision Chromatic deficiency Blindness to
Blade Block
normal red-green cor
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

1 1 12 12 12

2 8 3 -

2 3 29 70 -

57 35 -

4 5 2 -

5 3 5 -
3
6 15 17 -

7 74 21 -

8 2 - -
4
9 45 - -

10 5 - -

11 7 - -
5
12 16 - -

13 73 - -

14 - 5 -
6
15 - 45 -

It is a simplified test of the Ishihara plates. Plate 1 is demonstrative.

responses obtained from slides 2 to 15 determine the
normality or abnormality of color vision.

a) When nine or more blades are identified as normal,

the chromatic vision can be considered normal.
b) When only 5 or fewer slides are deciphered with
In normality, color vision is considered deficient.
c) If there are number identifications on sheets 14 and 15, they are considered.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

abnormal responses and therefore alterations in color vision.

d) When detecting a red-green deficiency, one can differentiate a
protanopia or deuteranopia, for this reason they should present-
the sheets 16,17 that distinguish the type of color blindness
that exists, differentiating between acute or mild abnormality.

Blade Block Chromatic vision Protanomalia Deuteranomalia

normal
A L A L

7 16 26 6 (2) 6 2 2 (6)

17 42 2 (4) 2 4 4 (2)

The blades from 18 to 24 allow the examination of people who do not

Do you know the numbers or children.

9.3.5 Amsler Chart

Determine the integrity of the visual field corresponding to the region

Objective: macular. Study the central 10°.

They highlight multiple functional changes in the central region.

It should be carried out when there is suspicion of a disease diagnosis

macular, in cases of reduced visual acuity with the best correction.

Clinical indication: optical or when the macula has an abnormal appearance on evaluation
direct ophthalmoscopic.

In every patient over 40 years old.

a) Amsler grid book.

b) Occluder.
Team: c) Framing of proof.
d) Light source.
e) Annotation form.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

a) Patient comfortably seated.

b) The patient must use their optical prescription for near vision and
Preparation: secure the occluder.
c) The optometrist holds test number 1 at 30 cm from the patient with good

lighting.
a) The patient covers the left eye or may start with the eye of
better vision, as this way the patient understands better the
test and your answers will be more reliable.
b) Ask the patient to look intently at the central point while
some questions will be asked.
c) Questions:
Table 1:

Procedure: Do you see the central point of the network?

Without taking your gaze off the central point, can you perceive the four.
songs of the net?

Without taking the focus off the central point, see the whole network intact or have

interruptions, stains or holes?

Without taking your eyes off the central point, see the horizontal and vertical lines.

lines and parallels?

Without taking the view away from the central point, see the frames of equal size and

regular?

Without taking your eyes off the central point, can you see the lines moving?

d) The patient should be observed at all times and ensure

keep your gaze fixed on the central point. It is important to let
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

clear to the patient that in all tests they must keep fixed the
vision at the central point regardless of the questions that may be

conducted by the examiner.

e) Repeat the procedure for the other eye.

Table 2:

Do you see the four corners of the square?

Do you see the complete square?

Table 3:
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Do you see the net intact?

Do you see holes or stains?

Where?

Table 4:

Table 5:

Regardless of the blurred stain or distortion, can you see something

but?
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

Do the lines move, vibrate, or become wavy?

Are there sparkles, where?

Table 6:

Same questions as in table 5.

Table 7:

At what distance from the point do you observe the distortion?

How many small squares do you find between the central point and the
blur?

Clinical annotation and If there is no problem, note AMSLER ELN: within normal limits.

possible For each eye.

b) If you have a problem, note the eye and the nature of the problem and its
diagnósticos:
network location.
MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

c) Graphically represent what the patient is reporting.

d) Each test has specific questions and is typically displayed.
test No. 1.
e) Expected answers:
Table 1:

Yes, absence of central scotoma.

- Yes, but blurred: presence of relative central scotoma.

No, invisible central scotoma: absolute central scotoma.

Table 2:

- Yes, it is complete; move on to the third question.

No, one corner or side is missing: exterior scotoma.

Table 3 and 4:

They allow the establishment of scotomas that are either juxta or para-central.

absolutes or relatives.

It allows to presume the presence of metamorphopsias.

Tables 5 and 6:

High sensitivity and location of metamorphopsias.

Incipient maculopathies with entoptic phenomena.

Table 7:

Central visual disturbances. Useful in high myopias.

 CLINICAL PROCEDURES MANUAL IN FUNCTIONAL OPTOMETRY

10. DIAGNOSIS

10.1 Visual Diagnosis

The patient's refractive defect should be filled in for each eye separately.
noting the most complete possible diagnosis.

10.2 Motor diagnosis

It is noted only if the patient has oculomotor abnormalities. It must be filled out
as complete as possible, and for that, additional tests can be performed when the intern
has available time.

10.3 Ocular diagnosis

The pathological findings found in the eye exams are described, and it is informed that
pathological suspicion that will be confirmed by the competent doctor.

11. CONDUCT

11.1 Visual conduct

In cases of presenting ametropia, note whether glasses were indicated or in cases where
that high ametropias refer to the unit of contact lenses.

Always describe the type of optical aid indicated for the patient and for how long,
the information in the medical history must be filled out.

11.2 Motor conduct

In this case, the patient should be referred to the orthoptic unit where they
They carried out the necessary tests and recommended therapies, when needed.
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

11.3 Ocular conduct

In case of presenting pathology, it is suggested that the patient seek a consultation.

ophthalmological.

11.4 Filling out the final visual correction (final X-ray)

It is important to fill in the fields completely and clearly so that the prescription
optics should be elaborated precisely.

12. TERM OF CONSENT

Statement of awareness:

I declare for the appropriate purposes that I am aware I will be attended to by an Optometrist professional.
of university training, not a doctor, qualified to provide primary care of
visual and ocular health. I also declare that the provision of this service was not conditioned to
marketing of no product offered by the establishment.

Data: /
/ Ass.:
Forwarding:

I declare that I have been advised to seek medical professional due to suspected alteration
pathological condition detected in the Optometrist's examination and that the responsibility for clinical conduct
it will be the responsibility of the doctor chosen by me.

Data: /
/ Ass.:
Notes:

SIGNATURE
PATIENT___________________________________________________________
 MANUAL OF CLINICAL PROCEDURES IN FUNCTIONAL OPTOMETRY

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