Isra Postgraduate Institute of Ophthalmology,

Al – Ibrahim Eye Hospital, Malir Karachi.

Phone: 021-4560708, Fax: 021-4560718
E-mail: [email protected]
E-mail: [email protected]

Made by ;
Mr. Muhammad Asif
Ms. Izmal Urooj
Introduction and consent
Introduction: This is the first step and most important during conducting examination, in
this step examiner verbally introduce (concise) himself to the patient.
Consent: Consent mean to get the permission from the patient
Generally speaking, obtaining informed consent means that a patient who agrees to undergo a
treatment or procedure does so only after being made aware of the associated benefits, risks,
and alternative treatments. While there may be a degree of risk involved with any procedure,
it is up to the patient to determine if the danger associated with a treatment is acceptable.
Typically, patients are made to sign forms indicating that they understand and consent to a
procedure before it can proceed; however, “consent” and “informed consent” can be two very
different animals. Even when these forms are signed, if a patient was not given sufficient
information regarding a procedure and an injury occurs, that patient may have a medical
malpractice case on their hands.

Taking a Medical History

A history is when we ask people about their eyes health, vision, general health and other
questions to give us information to help us decide what is wrong with the person’s eyes and
what is the best thing to do.
Aim:
• To find out as much as you can about the patient’s condition in order to come to the
correct diagnosis.
• To find out the patients symptoms and improve or cure them.
• To establish whether the condition is serious and needing referral to other medical
specialists.

Good communication skills:

• To get the most information from a person, and so that they can trust and have confidence
in you, you need to use good communication skills:
• Greet the person warmly and introduce yourself.
• The person may be nervous, so you should make them feel comfortable.
• Show the person where to sit and sit facing them
Procedure:
• Illumination:
– Room light should be on before entering the patient
• Patient/Examiner position
– The patient and examiner should be seated about 1 to 1.5m apart at eye level.
– The examiner should face the patient and assume intermittent eye contact.
– The examiner should have the examination form on a clipboard and record the history
as the question is being asked.

Equipment
• Record card or notebook
• Pencil or pen
• Clipboard
Record the age of the patient and in the case of a child what relative is giving the history.
Then ask the following questions-

Demonstration:
Biodata:
• Name
• w/o, s/o, d/o
• Age
• Sex
• Occupation
• Address

Chief complain: Reasons for the patient presenting for the examination.
• Onset
• Type/occurrence
• Type/severity
• Location
• Effect on the patient
• Self-treatment and its effect.
Associated complain: Associated complain with chief complain.
Such as:
• Itching
• Watering
Medical History:
• Ocular History: previous glasses/prescription, glaucoma, cataract, squint, retinal
detachment, any ocular history etc
• General history: diabetic, hypertension, heart disease, allergy with any drug etc
• Birth History of child patient
Family history of eye and general health problems
 o Health: diabetic, hypertension, heart disease etc
o Ocular: glaucoma, cataract, squint, retinal detachment etc
Socioeconomic status.
VISUAL ACUITY
Visual Acuity is a Resolving power of the eye
Or
Ability of the eye to see the clear image when accommodation is at rest

IMPORTANT
Prior to starting your refraction, baseline visual acuities (OD, OS and OU) must be
determined. For individuals with near vision complaints, and all presbyopia, near acuity
should also be documented using M notation, with the testing distance documented if
different than 16 inches (40 centimeters).
Accurately assessing visual acuity is important for many reasons. It allows clinicians to:
➢ Determine best corrected acuity with refraction
➢ Monitor the effect of treatment and/or progression of disease
➢ Verify eligibility for tasks such as driving
➢ Verify eligibility as “legally blind”
When measuring distance acuity, there is no longer a need to measure visual acuity in a
darkened room. In the past, when projected charts were used, the room lights had to be
lowered for better contrast on the chart. Now, with high definition LCD monitor acuity
charts and ETDRS charts, contrast is no longer an issue. Additionally, for some patients,
particularly those with difficulties adjusting to lower lighting conditions, taking them from a
normally lit waiting room into a darkened clinic or work up room will artificially lower their
acuity, because they do not have enough time for their eyes to adjust to the lower light
conditions. Because clinical decisions are based on these acuity measurements, accurate
assessment of each person’s acuity is critically important
Visual acuity (VA) Visual acuity is dependent on optical and neural factors, i.e.
 A reference value above which visual acuity is considered normal is called 6/6 vision,
the US equivalent of which is 20/20 vision:
 In the expression 6/x vision, the numerator (6) is the distance in meters between the
subject and the chart and the denominator (x) the distance at which a person with 6/6
acuity would discern the same optotype.
 Distance from the chart
 D (distant) for the evaluation done at 20 feet (6 meters).
 N (near) for the evaluation done at 15.7 inches (40 cm).
 Eye evaluated
 OD (Latin Oculus Dexter) for the right eye.
 OS (Latin Oculus Sinister) for the left eye.
 OU (Latin Oculi Uterque) for both eyes.
 Usage of spectacles during the test
 CC (Latin Cum Correctore) with correctors.
 SC: (Latin Sine Correctore) without correctors
Pinhole Visual Acuity: For individuals who do not have any type of ocular disease, a
pinhole aperture can be a useful tool in determining if a refractive error is present or if a
refractive change is needed. The most useful pinhole diameter for clinical purposes is 1.2
millimetres. This size pinhole will be effective for refractive errors of +/- 5.00D. A pinhole
improves visual acuity by decreasing the size of the blur circle on the retina resulting in an
improvement of the individual's visual acuity. However, if the pinhole aperture is smaller
than 1.2 millimetres, the blurring effects of diffraction around the edges of the aperture will
actually increase the blur circle, causing the vision to be worse.
Procedure
• First Monocular (right eye/left eye) without glasses and with glasses.
• Second monocular (right eye/left eye) with pinhole.
• Near vision right eye/left eye and binocularly.
The visual acuity is measured uniocularly for distance and near, unaided and
with existing spectacles.
Fog the fellow eye of patients with nystagmus with a high plus lens as complete
occlusion makes the nystagmus worse and lowers the uniocular acuity.
If the acuity is very poor, examine briefly with the ophthalmoscope at this stage
to exclude a pathological cause.
More detailed scrutiny of the fundi should be left until after the refraction to
avoid photostress-induced reduction of acuity.

Principle
To make the angle of 5 mint of arc on the nodal point of the eye

Record:
Distance VA: (6/6, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60 or > 6/60)

(SC) OD_______ OS ________ OU________

(CC) OD_______ OS ________ OU________

(PH) OD_______ OS ________

Near Vision OD_______ OS ________ OU________

Refraction
There are two types of refraction in eye clinics
• Objective refraction
• Subjective refraction

Objective refraction:
Fit the trial frame, taking care that the lens apertures are centred on the pupils
with the patient gazing straight ahead. The frame must be level across the face,
and as close to the eyes as the lashes will allow.
Remember always to place high power trial lenses in the back cell of the trial
frame. Perform the retinoscopy with the patient gazing at a distant object, such
as the top letter of the test type.
It is important to perform the retinoscopy as close to the patient's visual axis as
possible in order to measure the true optical length of the eye. Care should be
taken to ensure that the patient's view of the distant fixation object is not
obstructed. To this end the examiner should ideally use his right eye to
examine the patient's right eye and his left eye for the patient's left eye. If the
examiner does get in the way, the patient loses distant fixation and may start to
accommodate. (If the patient does accommodate and fix on the examiner, this
will be betrayed because the pupil will constrict and the retinoscopy reflex
become more difficult to see.) During retinoscopy it is considered better to fog
the patient's fellow eye rather than to occlude it in order to discourage
involuntary accommodation.
In the presence of manifest squint the dominant eye may have to be occluded to
achieve steady fixation with the non-dominant eye.
In the case of young children, or children who have a latent or manifest squint,
the ciliary muscle should be paralysed with a topical cycloplegic drug before
retinoscopy is performed. This allows the true magnitude of any refractive error
to be determined.
Some refractionists place a plus lens of the dioptric value of their working
distance (e.g. +1.50 DS for 2/3 metre) in the trial frame before commencing the
retinoscopy. Once the point of reversal or neutral point has been reached for
both eyes, this lens is removed and the subjective examination started.
After viewing the retinoscopy reflex through the working distance lens, further
spherical lenses are added, convex if the movement is 'with' and concave if
'against' until the neutral point is reached.
Principle of Retinoscope
To bring the far point of patient at the nodal point of the observer at the working distance

Pre-requirement of retinoscopy
• Dark room: 6 m long
• A trial box
• A trial frame
• Phoropter
• Distance vision chart
 • Near vision chart
• Retinoscope

Types of retinoscopy
• Dry retinoscopy
• Wet retinoscopy
Procedure of retinoscopy
• Patient is made to sit at a distance of 2/3rd (67cm) of a meter
• Accommodation should be relaxed
• Use right eye for patients right eye and left for left
• Trial frame is fitted
• Direct the light from Retinoscope into patient’s pupil
• Move the Retinoscope in horizontally and observe the red reflex
• Suitable lens is placed before the eyes to neutralize the band when the pupil will be
filled with uniform light
• Now move vertically ,if still pupil is filled with uniform light ,no astigmatism

Confirmation of neutrality
• Reversal with overcorrection by 0.25D
• On alternating the working distance, slight forward, ‘with’ movement and an ‘against’
movement by slight backward movement
• Streak up technique
e.g.
R/E +2.50DS

180 +2.50DS

90 (Dry at 67 cm working
distance)

Prescription
RE = + 1.00DS

Other objective refraction techniques

• Auto refractometer
• Keratometer
• A.Scan
Helpful Hints to Avoid Intolerance
• Do not change the axis of the cylinder, especially in a myope, unless there are
compelling reasons for doing so.
• Do not change the lens form worn by a myope.
• Do not prescribe a large cylinder for any patient who has never worn a
cylindrical correction before. Break them in gradually. The exception to this is
pseudophakic patients who tolerate a full astigmatic correction well.
• Do not overcorrect hypermetropes: better to leave them 0.25DS
undercorrected so they can read the bus numbers in the far distance.
• Do not fully correct myopes: better to leave them 0.25 DS undercorrected so
they do not have to use their accommodation for distance.
• Do not give too great a reading addition, so the patient cannot read the
newspaper held at arm's length.
• Do not recommend bifocal or progressive lenses without carefully considering
the needs, occupation and frailties of the patient.
• Discuss with the patient the subjective and practical points relevant to the new
prescription, e.g. warn a new bifocal wearer to be careful at steps.
• Do not alter a satisfactory prescription unless there is a very definite reason to
do so.
• Do not advise patients to buy new glasses because of a minor change in
prescription that they will not be able to appreciate subjectively.

Most common errors:

1. Performing retinoscopy at an incorrect working distance, e.g. working at
about 50 cm, while using a 1.50 D working distance lens.
2. Performing retinoscopy off-axis.
3. Blocking the patient’s view of the distance chart, thereby probably
stimulating accommodation.
4. Confusing the retinoscope collar positions (plano-mirror and concave-mirror
positions).
5. Not concentrating on the movement in the centre of the pupil in a patient with
large pupils.
Subjective Refraction:
During subjective refraction, the examiner communicates with the patient
and, using the patient’s responses to the vision provided with various
lenses, determines the optical correction that best suits the patient. It is
therefore only possible to perform subjective refraction with patients who
can communicate effectively with you. When a subjective refraction is not
possible, limited or unreliable, it is preferable to have more than one
assessment of objective refractive correction (e.g. retinoscopy and
autorefraction).
Techniques
• BEST VISSION SPHERE
• DUOCHROME
• CROSS CYLINDER TECHNIQUES
• BINOCULAR BALANCING

SPHERICAL CORRECTION
“Strongest plus lens and weakest minus lens which gives the best visual acuity to the
patient”
• Accommodation must be in passive position

BEST VISION SPHERE (BSV)

❖ Determine monocular best un aided VA of both eyes
❖ Then One eye occlude
❖ Select a letter on a line above best VA of OD as target for BVS.
❖ Plus and minus lenses used probe lenses
❖ Dioptric value of probe lens depends on patient VA

VA probe lens
 6/60 + or – 1.50D

6/12 + or – 0.50D
<6/12 + or -0.25D

Duechrome
▪ This procedure involves determining the maximum plus and minimum minus lens that
place the circle of least confusion on the retina.
▪ The human eye is not corrected to focus light of different wavelength at the same
image point the eye suffers both axial and transverse chromatic aberration the axial
aberration is used to determine the spherical ametropia of the eye.
▪ Yellow light (570nm) is focused on retina, while red (620nm).
▪ And green light (535nm) is focused0.24 behind the retina and 0.20 infront of retina.

Principle: It is based on the chromatic aberrations

Binocular Balancing
After determine the BVS “To check balance the state accommodation of both eyes, not
correct or balance visual acuity”.

PURPOSE : Allow for subjective refraction under binocular condition, which maintain
peripheral fusion while testing foveal vision unilaterally this is accomplished by placing a
fogging lens over the non-tested eye to induce suppression of the central retina on non-tested
eye. Non foveal zone remain binocularly active and suppress accommodative fluctuations

METHOD: At the end of refraction Place the +1.00D lenses on corrected refraction
❖ E.g. After perform refraction a person corrected VA 6/6, +1.00D lenses put in trial
frame in front of right eye, left eye occlude, his vision decrease should be four lines,
Repeat same process in left eye
▪ If patient myopia with +1.00D decrease 3 lines, not a 4 mean patient 0.25 over
correct
▪ If patient Hyperopic With +1.00D decease 3 line mean 0.25 under correct,
▪ In last both eyes should be same balance.

Jackson cross cylinder (JCC)

The Jackson Cross Cylinder is a sphero-cylindrical lens in which the power of the cylinder is
twice the power of the sphere and of the opposite sign.

Spherical Equivalent (SE): The spherical equivalent of JCC is always 0.

PRINCIPLE
To keep the circle of least confusion on the retina

Procedure
• JCC is done monocular (right eye first) with adjacent eye occluded.
• Before starting JCC, patient’s circle of least confusion must be placed on retina. This
can be achieved by placing monocular spherical correction (Best Vision Sphere) in
the trial frame.
• The patient is then given a target on VA chart that they can see easily. The target
optotype is usually 1 or 2 lines above the vision achieved with BVS.
• Performing JCC can be cut down into three steps.
• To find if patient needs a CYL or not.
• To refine the axis of CYL.
• To refine the power of CYL.
Need of CYL
A. Place the handle of JCC at 45° so that the two principal meridians are at 90° and
180°. Place the handle of JCC at 90° so that the two principal meridians are at
45° and 135°.
• In both settings, give three choices to the patient by flipping and then removing the
JCC.
• In first two choices, the positions of + CYL & - CYL axis are interchanged.
• In third choice, the patient is made to see the target optotype without JCC placed over.
• The patient is then asked to judge which choice is best amongst all. This way, we
bracket the 45°arc on which one of the principal meridian of patient lies. The second
step of JCC follows from here.
• If the patient chooses without JCC choice in both settings, we will drop this technique
right here because the patient is not accepting a CYL.
Refinement of axis
• We have got two techniques to refine the axis, either by using – or by using + CYL.
• In + CYL technique, we’ll chase black power line. And in – CYL technique, we’ll
chase red power line.
• Infront of BVS (best vision sphere), we’ll place a + CYL if doing + CYL technique or
we’ll place a – CYL if doing – CYL technique.
• The power of CYL will be half of the JCC power (equal to the powers of individual
CYLs of JCC).
E.g. ±0.50 DC if JCC is of ±1.00 DC (+0.50 DC & -0.50 DC)
1. Align the JCC handle parallel to the axis of CYL that is placed in trial frame.
2. Give three choices, first two by flipping the JCC & third by removing it. If patient
chooses one of the first two choices, rotate CYL by 10° toward the line we are chasing.
3. We will repeat the above step again & again until the choice shows the power line we
are chasing, now on the opposite side as of the side we were preceding until now, we’ll
rotate back the CYL only 5° this time.
4. The end point is when the patient prefers choice 3. The CYL axis is refined now.
Refinement of power

• Align the power lines of JCC parallel to the axis of CYL whose axis was refined in
previous step.
• Give three choices, first two by flipping the JCC & third by removing it. If patient
prefers one of the first two choices, see which power line is parallel to the CYL axis.
➢ If the power line that we are chasing is parallel to the CYL axis, increase
respective CYL power in steps of 0.50 DC. (Because the individual CYLs of
the JCC we are using are of ±0.50 DC)
➢ If the opposite power line is parallel to the CYL axis, decrease respective CYL
power in steps of 0.50 DC.
➢ Half of CYL power adds into the sphere for keep the circle of least confusion
on the retina.
➢ The end point is when patient sees better with choice 3. The CYL power is
refined.

Fan and block test:

The fan and block test was developed to increase the sensitivity of the earlier fixed
astigmatic dials, such as the ‘clock’ and ‘sunburst’ dials, and the rotary dials, such as the
‘Rotary T’. All lack sensitivity, particularly in determining the cylinder axis. The relatively
large 30° gaps between adjacent sets of lines on the clock dial test, for example, significantly
limit its sensitivity, and any present-day use appears to be based on tradition (Borish &
Benjamin 2006). The fan and block test is only available with wall charts and includes a fixed
dial with a rotating arrowhead and blocks and combines the techniques used in the earlier
tests.
Procedure:
The technique described assumes that you perform the test using the information gained from
an objective refraction.
1. This ensures the circle of least confusion is on the retina.
2. Occlude the untested eye (i.e. LE, OS).
3. Remove the cylinder determined from retinoscopy from the right eye, and add 0.50 DS to
the sphere. The circle of least confusion is now in front of the retina. If the retinoscopy
cylinder was correct or overestimated, then both focal lines will be in front of the retina.
4. Draw an analogy between the lines on the fan and the hours of a clock, and ask the patient
if any of the lines on the fan appear clearer and darker than the other lines.
5. If the patient reports that all the lines are equally clear (or blurred) then fog by a further
0.50 D and ask the patient again if any lines are clearer and darker. If they remain equally
clear or blurred, then this suggests there is no astigmatism present.
6. If some lines are reported as clearer, point the arrow that joins the blocks towards the
clearest line. Adjust the arrow until its two barbs appear equally clear. One block (with its
lines running parallel with those on the fan which are clearest) should be clearer than the
other.
7. Ask the patient to look at the clearer block and add 0.50 DS and ask if the block blurs. If it
does blur, continue to step 8. If the block does not blur, it is possible that the retinoscopy
result provided a significantly under-corrected cylinder, leaving the back focal line behind the
retina after step 3. In this case, additional 0.50 DS lenses should be added until the clearer
block just blurs.
8. Set the cylinder axis in the trial frame/ Phoropter at the axis indicated by the arrow. Add
negative cylinder at this axis until the blurred block just becomes as clear as the other. If there
is a reversal, in that the more blurred block becomes clearer, take the lower cylinder power.
9. Reduce the plus fogging sphere to determine the best sphere as previously explained.
10. Repeat steps 1 to 9 for the left eye.

Clock dial test:

This technique is similar to the fan and block technique, but only consists of the ‘fan’ (i.e.
clock dial) part of the technique.

Procedure:
The technique begins in the same manner as the fan and block steps 1 to 5. The suggested
axis is determined by multiplying the smaller of the two clock dial values of the clearest lines
by 30. For example, if the patient thinks that the 2 and 8 o’clock lines are the clearest, then
put the cylinder axis at 60° (2 × 30). If the patient thinks that the 4 and 10 o’clock lines are
clearest, place the cylinder axis at 120°. If the patient believes that two clock dials are
clearest, then the axis should be placed midway between the two values indicated.
For example, if the patient believes that the 1 o’clock and 2 o’clock lines are clearest, then
place the cylinder axis at 45° (1.5 × 30). The cylinder power is then increased until the most
blurred lines are brought to the same level of clarity as the clearest lines. 30°.

Stenopaic Slit:
Stenopaic slits are found in most trial lens sets and consist simply of a piece of cardboard
from which a slit shaped aperture has been cut out.
Cover/ uncover
Cover test is an objective test to dissociative the images of both eye and find out the tropia/
manifest or latent/phoria deviation for distance and near.

Uncover test
1. It is also objective test
2. To dissociative the images of both eye
3. In uncover test we check the cover eye
4. And find phoria / latent deviation
5. This test can be done for near and distance
6. At 33cm and 6 m
Types of cover test
• The Unilateral Cover Test.
• The Alternating Cover Test.

Cover / Alternate cover test

➢ One or other eye is covered alternately throughout the test to ensure the complete
dissociation that is necessary to detect latent deviations
➢ Movement of the uncovered eye is noted as the cover is changed from one eye to with
latent deviations
➢ The eye deviates under cover of the occlude
Target
• Near At 33 cm
• Distance 3m
• Far Distance >3m
From conformation gained from cover testing manifest deviation
➢ Type of deviation Eso, Exo, Hyper, Hypo or Cyclo.
➢ Size of deviation slight small moderate marked
➢ Speed to fixation
➢ Dissociated vertical deviation DVD

Information gained from uncover testing

• Type of deviation
• Size of deviation
• Rate of recovery
• Rapid moderate slow
• Partial recovery
Extraocular muscles
• Any of the six Muscle that control the movement of the eye ball within the socket
• The Extraocular Muscle is actions that they are responsible for eye movement depend
on the position of eye at the time of muscle contraction.
• Failure or Defect to maintain this function results into strabismus or squint.

Extraocular Muscles

Four Rectus Muscles 2 oblique Muscle

1) Lateral Rectus
2) Medial Rectus 1) Superior oblique
3) Superior Rectus 2) Inferior oblique
4) Inferior Rectus
IPD (Interpapillary Distance) and BVD (back vertex distance)
IPD is the distance from the center of one pupil to the center of the second pupil, Measured in
millimeters.
• Goal in taking a PD is to place the optical centers of the lenses directly in front of the
subject’s eyes. (to avoid any prismatic effect)
• Over time, this error causes visual discomfort and asthenopia Symptoms

BINOCULAR PD
 Between center of two pupil
 Right temporal pupillary margin to left nasal pupillary margin
 Right temporal limbus to left nasal limbus
 Right temporal Canthus to left nasal canthus

Steps in Measuring binocular distance PD using a ruler

1. Dispenser position at 40 cm (16 inches)
2. Dispenser closes right eye, patient fixes at dispensers open left eye
3. Dispenser lines up the ruler zero point on the subject’s right pupil, left pupillary border
or left limbus.
4. Dispenser closes left eye, patient fixes at dispensers open right eye
5. Dispenser reads scale directly in line with subject’s left pupil center, left pupillary
border or left limbus
6. Dispenser closes right eye, opens left; subject fixates on dispenser’s left eye
7. Dispenser checks to make sure that zero point is still correct

Near Intera Pupillary Distance

• Begin as you would for distance PD
• Before asking your patient to shift their viewing to your open right eye, note the
corneal reflex or pupil of the left eye. This is the near PD
• Also subtract the 3mm in distance PD
BVD (Back Vertex Distance)
The distance between back surface of lens and infront surface of cornea
• The standard vertex distance is about 12mm.
• The vertex distance affects the effective power of the lens, especially in higher power
(>4.0D) prescriptions.
• We must need to check BVD in refraction (for most important to high power
spectacles and contact lens.

Lens Effectivity
• Lens optical effect may vary with vertex distance.
• Vertex distance responsible for decrease of vision.
• If moves away from eye,
+ Lens becomes stronger.
— Lens becomes weaker.

Significance of Vertex Distance

• In prescription must have the same effective power as the refraction test.
• The vertex distance of the Phoropter / trial frame must match the VD of the spectacle
lenses
• A vertex distance becomes significant if the diopter power of the prescription exceeds
4.0D.
Pupillary reflex test
 To check pupillary responses and its conditions in normal room light.
 It helps in diagnosis as it can be a symptom of serious medical problem
Methods
1. Direct & Consensual light reflex
2. Swinging flashlight test
3. Near Reflex (Accommodation reflex)
1: Direct & Consensual light Reflex:

To observe the pupillary reaction in the illuminated eye is called direct reflex, and reaction in
non-illuminated eye is called consensual reflex.
• To detect (RAPD) defect also called “Marcus Gunn pupil”.

Grading of RAPD:
• Grade I: Initial constriction then dilation.
• Grade II: No initial constriction, slowly dilation.
• Grade III: Immediate dilation but <50% larger than normal.
• Grade IV: Immediate dilation and >50% larger than normal.
2: Swinging flash light test:
It is the test which compares the direct light reactions of both eyes.

OBJECT:
• It is used to detect afferent pupillary defects (APD).
• It results from unilateral damage to the visual Pathway causing transmission defect.

METHOD:
• Perform in semi darkened room
• Use bright torch with narrow beam light
• Stand from side of patient
• Ask patient to maintain fixation at distance target to relax accommodation
• Shine light in one eye and note pupil constriction in both eyes.
• Then move light quickly to other eye again note pupil constriction in both eyes.
• In normal eyes pupils of both eyes constrict equally.
• When conduction defect is present, then pupil of affected eye will dilate when
flashlight is moved from normal to affected eye.
3: Near reflex (accommodation reflex)
• It is synkinetic reflex, which focus the object clear at a near / distance.
• It Includes: Convergence of eyes, accommodation and pupillary Constriction.

OBJECT:
To detect the integrity of central connection between accommodation and pupillary
constriction

METHODS:
• Perform in normally illuminated room
• Ask patient fixate at distance target
• Instruct patient to shift fixation from distance to near target
• Observe pupillary reflex, when patient is shifting fixation from distance to near
• Normal test shows both pupil will constrict at near target (due to accommodation),
and dilate due to (relaxation of accommodation).
• When light reflex is present, there is no disease in which the light reflex is present and
near response is absent.
MADDOX ROD (MD)
Maddox Rod is consists of series of Plano-convex cylindrical lenses and available in Red and
White Color used for the diagnosis of Extra Ocular Muscle Imbalance/ detect the distance
phoria.

PRINCIPLE
“Dissociate two dissimilar objects by breaking the fusion to find out the phoria for distance”
PROCEDURE
• Room illumination dim.
• Can be done at 3m and 6m.
• Maddox rod is placed in RE (right eye).
• Provide spot of light target at distance.
• RE views a line image, while LE views a spot of light.
HORIZONTAL DISTANCE VERTICAL DISTANCE PHORIA
PHORIA
Uncrossed (Esophoria) (Hyperphoria)
Crossed (Exophoria) (Hypophoria)

A= Esophoria B= Exophoria C= Hypophoria D= Hyperphoria E= Orthophoria

MADDOX WING

It is an instrument used to detect near phoria at (33cm)

Principle
“To dissociate two dissimilar images of near phoria”
Procedure
I. It is quantitative and subjective method
II. The right eye sees red and white arrow each of which point to scale with number seen
by the left eye
III. The room should be brightly illuminated and patient should be optically corrected
IV. The examiner instructs the patient to hold the maddox wing and identify the number
that the white vertical arrow and red horizontal arrow.
NPC (Near Point of Convergence)
It is a fusional movement that may be stimulated by disparate stimulation, accommodation
and the point of intersection of the lines of sight of the eyes when maximum convergence is
utilized.

Clinical use
 The near point of convergence distance is a measurement of the maximum
convergence ability of a patient.
 Patients who have reduced near point of convergence distances may have visual and
ocular discomfort when performing near point vision tasks.

Instrument RAF (Royal Air Force)

Procedure
The measurement of the near point of convergence distance should be performed in free
space; the clinical procedure is as follows:
1. The patient is seated comfortably with the habitual spectacles prescription in place.
2. A ruler is held below the line of sight with the zero point coincident with a line that
would pass through the center of rotation of the eye.
3. Full room illumination should be used. A small dot and line target about 40 cm in
front of the patient’s midline.
4. The patient is encouraged to maintain fixation on the target and report when it
doubles.
5. Slowly move the target (about 5cm/sec) along the midline toward the patient.
6. Note the fixation distance when one eye loses fixation on the target, or the patient
report diplopia. This is the near point of convergence. The eye that maintain fixation
is the dominant eye.
 7. Measure the distance from the near point of convergence the target (about 5cm/sec)
along the midline toward the patient.
8. Note the fixation distance when one eye loses fixation on the target, or the patient
report diplopia. This is the near point of convergence. The eye that maintain fixation
is the dominant eye.
9. Measure the distance from the near point of convergence to the center of rotation of
the eye for both the subjective.
Clinical interpretation
➢ The near point of convergence is expected to be 6 to 10cm.
➢ Closer than 5cm is considered to be convergence excess.
➢ A remote near point of convergence is suspected to have convergence insufficiency.

NEAR POINT OF ACCOMMODATION

The closest distance a target can be seen clearly is referred to as the near point (Punctum
Proximum)
Procedure
The measurement of the near point of accommodation should be performed in free space; the
clinical procedure is as follows:
1. The patient is seated comfortably with the habitual spectacles prescription in place.
2. A ruler (RAF) is held below the line of sight with the zero point coincident with a line
that would pass through the center of rotation of the eye.
3. Full room illumination should be used. A small alphabetic line target about 40 cm in
front of the patient’s midline.
4. The patient is encouraged to maintain fixation on the target and report when it blur.
5. Slowly move the target (about 5cm/sec) along the midline toward the patient.
6. Note the fixation distance when the patient report blur. After few seconds patient can
see clear due to accommodation exert.
7. Now you can again move the target toward the patient till patient again report.
8. Measure the distance from the near target (about 5cm/sec) along the midline toward
the patient.
9. Patient report continues blur, note the fixation distance, and reciprocal it if necessary.
NEAR ADD
All normal eyes show progressive decrease in amplitude of accommodation beginning from
birth and becoming symptomatic around the fourth decade.

Near add also given by the age-expected

Expected age Near add

Upto 40 years + 1.00 DS

40 – 45 years + 1.50 DS

45 – 50 years + 2.00 DS

50 – 55 years + 2.50 DS

Above 55 years + 2.50 DS continue

Final prescription of glasses

Sphere Cylinder Axis VA

Distance

Near Add

Good counselling (about eye condition, refractive error, prescription, uses and follow
up)

REMARKS: (it very necessary to give remarks because this remarks helps about condition
and management in the future).
History:
Name_______________ Age_____ Sex_____ Occupation___________________________________________
Chief Complain ________________________________ Associated complain ___________________________
Previous ocular history __________________________ General health history__________________________
Medical history________________________________ Family ocular history ___________________________
General ocular examination_____________________________________
Distance VA:
(OG) OD_______ OS ________ OU________
(SC) OD_______ OS ________ OU________
(PH) OD_______ OS ________
Near VA:
(OG) OD_______ OS ________ OU________
(SC) OD_______ OS ________ OU________
Pupillary examination _________________________________________
Cover & Uncover test _________________________________________
EOM ______________________________________________________
VF (confrontation) OD___________________ OS __________________
Objective refraction:
RE LE

WD ______________________
OD ___________________________ OS ___________________________
Subjective Refraction:
Best sphere (VA) OD________________ OS ______________
Cyl correction (VA) OD________________ OS _____________
Jackson’s Cross cylinder (axis &power conformation)
Binocular balancing ___________________________________
NPA OD_____________OS _____________ OU____________
NPC _______________________________________________
Near addition OD_________________ OS ________________
Maddox rod test _____________________________________
Maddox wing test _____________________________________
Final prescription:
OD _________________________________ OS _________________________________
Add:
OD _________________________________ OS _________________________________
BVD ________________________________
IPD (Distance) ________________________ (Near) _________________

Remarks: ___________________________________________