SUBJECTIVE REFRACTION

AUTHOR (S)
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Considerations before subjective refraction

 Instruments for subjective refraction
 Starting point of the subjective refraction
 Best vision sphere determination
 Monocular balancing techniques
 Astigmatic error determination
 Binocular balancing techniques

INTRODUCTION

Subjective refraction determines the refractive status of the eye using the patient's input. Subjective refraction is to
determine, by subjective means, the spherical and cylindrical lenses that are necessary to provide the patient with the
best visual acuity with accommodation relaxed. This is determined by responses from the patient. This examination
relies completely on the patient’s perceived differences between letters on a VA chart being viewed through each
variation in refractive power. It should be noted that since the technique is subjective in nature, it does not always
represent the full refractive status of the patient being tested.

June 2012, Version 1 Clinical Optometric Procedures 1, 13-1

 Subjective
Refraction

CONSIDERATIONS BEFORE SUBJECTIVE REFRACTION

According to Benjamin in Borish’s Clinical Refraction (Butterworth-Heinemann, 2006) intelligence, past experience,
accustomed visual imagery and uncertainty in discriminating between small differences may prevent perfect
correlations between the subjective findings and that of the true refractive status of the eye. The discrimination
between dioptric changes differs from individual to individual. Some individuals are very sensitive to even the smallest
changes in dioptric change. Others are less sensitive and require significant changes in dioptric power for differences
in VA to be perceived. Some patients may perform poorly on subjective refractions because of the forced/paired
choice presentations of lenses being presented. Geriatric or paediatric patients may find the process difficult or
confusing. Malingers might tend to mislead the examiner, due to a preference for spectacles (whether as a fashion
item or seeking attention).

Other factors that should be considered when performing a subjective refraction which could influence the patient’s
performance include:
 Health status of the eye
 Systemic health
 Use of medications or drugs that may have ocular and visual effects
 Age of the patient
 Extended depth of focus of a small pupil
 Choice of target, its distance and composition
 Room illumination
 Physiological pupil size and retinal adaptation
 Time allowed for discrimination between lens changes

INSTRUMENTS FOR SUBJECTIVE REFRACTION

TRIAL CASE, TRIAL FRAME (TF) AND PHOROPTER

The main equipment used in subjective refraction is either a trial frame used in conjunction with a case of trial lenses
(Fig. 13.1 a, b) or a phoropter (Fig. 13.2)

Figure 13.1 (a) Trial frame Figure 13.1 (b) Trial case

The use of the trial frame and trial case versus the use of a phoropter for the subjective refraction can be based on
availability and various other factors including age of patient, refractive status of the patient, compactness of
instrumentation. It is important to acknowledge that phoropters are expensive and that with the context of the
developing world, trial frames are more readily available, however, each has an equal degree of importance especially
when conducting binocular vision testing. Trial frames are also a useful way of demonstrating the final prescription,
especially for presbyopic correction.
In many cases where a patient presents with high amounts of refractive error, the variation of the phoropter in terms of
face form, vertex distance (in some instances) and pantoscopic angle from that of spectacles makes the trial frame the
preferred instrument in the subjective refraction.
 Figure 13.2 Phoropter used in
refraction

The subjective refraction is a step-by-step procedure involving the patient’s ability to evaluate the clarity of a distance
target as a series of paired comparisons of lenses are presented by the examiner. The patient fixates throughout the
procedure on a distance target which consists of symbols or letters on a chart or projected chart. The examiner must
ensure that this chart is of optimal quality in terms of contrast (should be 100%). Room lighting must allow normal pupil
size and retinal adaptation and the chart to be visible.
Subjective refractions can be of two types, namely monocular or binocular. The binocular subjective is sometimes
preferred because it keeps the eyes in its normal state of binocularity, i.e. both eyes are open during the course of the
refraction and the accommodative state is more stable and relaxed for distance viewing. Monocular refractions involve
occlusion of the non-tested eye. In monocular refraction, the final end point of the refraction requires accommodative
balance and binocular determinations. In cases where a patient is monocular in nature (i.e. strabismus, blind in one
eye, uni-ocular) a monocular refraction is performed without binocular balance.

Subjective refraction comprises a host of various techniques. They include:

1. Determination of the best vision spherical Rx and visual acuity

2. Duochrome (monocular balancing of spherical power)
3. Astigmatism determination methods
a. Jackson crossed cylinder technique
b. Fan-and-block technique
c. Humphriss dots
d. Stenopaic slit technique
4. Binocular balancing techniques
a. Equalization by alternate occlusion
b. Prism dissociation method
c. Fogging method (Humphriss)
d. A method using a Septum (Turville)
e. Polarization method (Vectographic)
f. Dissociated duochrome method
5. Recording of final refractive error with best corrected visual acuity (BCVA) in each
eye and both eyes together

STARTING POINT OF THE SUBJECTIVE REFRACTION

The starting point of the monocular subjective refraction is determined by various objective techniques, including
retinoscopy or autorefraction or alternatively the patient’s previous spectacle correction. These findings (lenses) are
placed within the trial frame or phoropter. The starting lenses must be placed such that the optical centres of the
lenses are coincident with the geometric centres of the entrance pupil of the eyes (Fig. 13.3). This is ensured by
adjusting the TF or phoropter to the patient’s correct interpupillary distance measurement. (It must be noted whether
IPD setting is used in the binocular or monocular form – determined by earlier tests). In addition, the correct vertex
distance and pantoscopic angle must be used.
The greatest challenge when performing the monocular subjective refraction is ensuring that accommodation is in its
relaxed state. Fluctuations can induce inaccuracies in the determination of the correcting lenses.

Figure 13.3 Trial frame centred before the eyes.

The objective of conducting a subjective refraction is to determine the:

Maximum plus or minimum minus spherical lens power that provides

the patient with maximum visual acuity

If the plus lens is weakened or minus lens strengthened thereafter, no improvement in acuity can take place, merely
accommodation. If accommodation is being exerted during this procedure, it means that the patient is unable to attain
the clearest, comfortable vision without exerting accommodation and hence will experience asthenopic symptoms.
The monocular aspects of the refraction involve determining visually the best spherical correction, balancing of the
monocular spherical correction and astigmatic refraction (which can be determined by various procedures). Thereafter,
based on the refractive differences, visual acuity differences, motor and sensory binocularity of the patient, the
procedures for binocular balancing will follow. Variations may also occur in the sequence of tests depending of the
patient’s co-operation levels.

BEST VISION SPHERE DETERMINATION

There are several methods of determining the best spherical correction of the patient. Each of the techniques is aimed
at maintaining the accommodation in a passive position.

INSTRUMENTATION
1. Visual acuity chart
2. Trial frame and trial case (or a phoropter)

PROCEDURE
1. Determine the presenting or habitual monocular visual acuity in the right eye as outlined in the chapter on
visual acuity. (This may be the patients uncorrected VA if no objective refraction was performed or could
be the patient’s corrected VA with the objective findings or previous refractive findings in place).
2. Occlude left eye.
3. Select a letter on the line above the best visual acuity of the right eye as the target for the test procedure.
4. Plus and minus lenses are used as probe lenses. The amount of dioptric value of the probe lens will
depend on the patient’s visual acuity.

PROBE LENSES
6/60 VA  1.00D probe lenses
6/12 VA  .50D probe lenses
< 6/12 VA  0.25D probe lenses
 5. The more plus option (+0.25D lens) is always presented first. This is to ensure that accommodation is in
its passive state or that the examiner alters accommodation in a minimal capacity. The patient is instructed
to tell the practitioner if the letter on the chart appears “brighter, sharper and clearer” with the plus lens
or without.
6. If the patient chooses the plus lens, place this in the trial frame and present a further +0.25D lens before
the eye and determine the maximum plus lens that the patient will tolerate before the letter becomes
“blurry”. Remove this “blurry” lens.
7. If the patient rejected the +0.25D lens initially, then, introduce the –0.25D lens before the eye. Once again,
ask the patient whether the letter is “sharper, clearer or darker” without the lens or with. (NB: The more
plus option is always presented first)
8. If the patient prefers this minus lens, then keep adding minus lenses no improvement is gained and
remove the last lens that made the target appear darker or smaller but not clearer. Remember that even
though the added minus may not affect the clarity of the target letter, the size decrease should indicate
that you are over-minusing and accommodation is no longer at rest. Therefore the practitioner must
always emphasise 2 aspects, namely clarity and whether the lenses make the letters “smaller, darker and
better”. The lens that makes the letters clearer can be retained, however the lens that makes the letters
“smaller, darker and better” should be discarded and the previous minus change is accepted as the end
point of the test.
Another check that the practitioner can employ to ensure that he/she is not over-minusing the patient is
to take the VA with the changes in lens power. A lens that produces the same VA as the previous lens
with not other improvements with respect to clarity is probably one that is not required and the practitioner
must therefore remove this last -0.25DS lens.
9. Once best subjective spherical error of the right eye, repeat the procedure for the left eye.

HINTS
 One should ensure that there is an increase in visual acuity when adding minus lenses before the eye. This may
not be the case with plus lenses presented before a latent hyperope.
 If 6/6 visual acuity is attained with a –0.50D lens and with further increase in minus lenses the same visual acuity
attained, one would prescribe the least minus lens that provides the 6/6 visual acuity.
 If 6/6 visual acuity with a +0.50D lens and with further increase in plus lenses attain the same visual acuity, one
would prescribe the maximum plus lens that provides the 6/6 visual acuity.
 Some methods of determining the best spherical correction are initiated from the point of fogging, thus ensuring
that accommodation is not involved in the findings.

One may also be able to predict the size of the spherical ametropia by means of the unaided visual acuity (Table 13.1).
Table 13.1 Correlation between visual acuity and refractive error

REFRACTIVE ERROR (D)

VISION SPHERICAL
Myopia and ASTIGMATISM
absolute Hyperopia
6/6 = 20/20 Small Small
6/9 = 20/30 0.50 1.00
6/12 = 20/40 0.75 1.50
6/18 = 20/60 1.00 2.00
6/24 = 20/80 1.50 3.00
6/36 = 20/120 2.00 4.00
6/60 = 20/200 2.00 to 3.00 High

N.B. The predicted vision with astigmatism is on the assumption that the circle of least confusion lies on or close
to the retina.
MONOCULAR BALANCING TECHNIQUES

DUOCHROME OR BICHROMATIC TECHNIQUES

BACKGROUND
This procedure involves determining the maximum plus and minimum minus lens that places the circle of least
confusion on the retina. To a certain extent, this test may sometimes be referred to as a check for the best sphere
correction with the best acuity that was just determined. It is a test that utilizes the different refraction angles
associated with different wavelengths or colours of light.
The human eye is not corrected to focus light of different wavelengths 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.
Green light (535nm) is refracted at a greater angle than red light (620nm). While yellow light (570nm) focuses on the
retina, green light will focus 0.20D in front of the retina and red light will focus 0.24D behind the retina (Fig. 13.4).

Figure 13.4 Focus of green, yellow and redt light in the

eye

The above illustration depicts the focus of yellow light on the retina, with the focus of red and green light wavelengths
equidistant from the retina.
Since the red and green foci are equidistant about the retina, an emmetrope or corrected ametrope should report
seeing black test objects on the two coloured backgrounds equally clear.
Since the white (yellow) focus of a low myope falls short of the retina, a myope will see the test objects on the red
background clearer and darker (Fig. 13.5) since this wavelength of light is closer to the retina.

Figure 13.5 Focus of light in a myopic eye

Similarly, since the focus of a hyperope falls behind the retina, a hyperope will see the test objects on the green
background clearer and darker (Fig. 13.6) since the green wavelength of light is closer to the retina.
 Figure 13.6 Focus of light in a hyperopic eye

With older patients, the crystalline lens becomes markedly yellow, thus causing the absorption and scattering of blue-
green light. This tends to give a red bias in these patients. Thus achieving equality or a reliable result tends
to be difficult.
It has been said that a red-green colour deficiency would not alter the results of the test as long as the practitioner
stresses the darkness of the letters as opposed to the brightness of the backgrounds. Protanopes or protanomalous
persons may experience that the red half of the target may not be as bright as the other half.
Ultimately, the aim of conducting the duochrome test is to determine the spherical end points in a monocular fashion
for each eye.

THE DUOCHROME TEST TARGET

The duochrome test target comprises a distance visual acuity chart with black letters or sometimes symbols, split into
identical halves. The letters on one side have a green background and the letters on the other side have a red
background. It is these backgrounds that straddle the preferred yellow focus of light by approximately ± 0.25D.

PERFORMING THE DUOCHROME TEST

Instrumentation
 Bichromatic/Duochrome test target (one may have a set target slide (Fig. 13.7) or one may have a red/green
filter which is placed over the chart of letters/numbers (Fig. 13.8).
 Trial frame and lenses (or phoropter)

Figure 13.7 Duochrome/Bichromatic target

Procedure
1. This test is done monocularly.
2. Since the test utilizes chromatic aberration which is greater when the pupil is dilated, the technique
requires that the room lights turned off.
3. Once the best vision sphere has been determined, the patient is directed to the bichromatic test target.
4. If show a chart like the adjacent one to the patient, the patient is instructed to report which of the numbers
appear “darker, sharper and clearer”? Either the 72 or 27, or the numbers on the right or left. Ensure that
the patient understands you are referring to the clarity of the black test objects against the R/G filter
backgrounds and not the colour of the background.

Figure 13.8 Bichromatic target with number optotypes

There are usually 2 methodologies that may be employed from this point on to reach the end point.
5. Vision is slightly fogged with +0.25DS lenses until the letters on the red background appear to stand out
better. This should not take more than 1 or 2 increments of plus power, however, if it does, it indicates
the patient has been over-minused.
6. The plus power is then reduced until the letters on the 2 sides appear equally clear or the letters on the
green background appear more distinct. When an endpoint of equality is not achieved, then leaving the
patient seeing green better is favored because it indicates that the patient is slightly over-minused
especially considering that the room is dark and the pupil is dilated.

Alternative approach
1. If the patient reports the targets on the red background appear darker, clearer or sharper, then place a
–0.25DS lens before the eye being tested. If the same target is still clearer, then a further –0.25DS lens
is added, until the targets on both backgrounds are equal. (NB: the red bias in older patients)
2. If the patient reports the numbers on the green background appear darker, clearer or sharper, one would
introduce a +0.25DS lens before the eye and repeat the question. If the same target is still clearer, then
add +0.25DS lenses until both targets are equally clear or there is a “slight green” end-point.
3. It is stressed that no reference should be made to the colour of the targets such that one would not
introduce a colour preference to the patient.
4. When the spherical refractive error correction is inaccurate by more than ±1.00D of the optimum
correction, the patterns of both sides will be grossly out of focus and a reliable result will not be achieved.
5. Once monocular balance is achieved in one eye, the test is conducted in the fellow eye, ensuring
occlusion of the eye that has just been tested.
ASTIGMATIC ERROR DETERMINATION

INTRODUCTION
Astigmatism is defined as a refractive condition in which a variation of power exists in the different meridians of the
eye. It is caused by differences in curvature of the refractive surfaces of the ocular media, namely the cornea and lens.
Corneal astigmatism may be described as being either regular or irregular. Regular astigmatism is a condition in which
the principal meridians lie at right angles to each other while in irregular astigmatism this does not.

CLASSIFICATION OF REGULAR ASTIGMATISM

ON THE BASIS OF THE MUTUAL ALIGNMENT OF PRINCIPLE MERIDIANS
 With-the-rule (WRT) astigmatism – the curvature of greatest power lies nearest the vertical meridian
 Against-the-rule (ATR) astigmatism – the curvature of greatest power lies nearest the horizontal meridian
 Oblique astigmatism – the meridian of greatest curvature lies in the oblique positions

ON THE BASIS OF THE FOCUS OF THE PRINCIPLE MERIDIANS

 Compound myopic astigmatism – indicating that with accommodation fully relaxed, both line foci from
the principal meridians lie in front of the retina (Fig. 13.9a).
 Simple myopic astigmatism – indicating that with accommodation fully relaxed, one meridian focuses on
the retina while the other focuses in front of the retina (Fig. 13.9b).
 Mixed astigmatism – indicating that with accommodation fully relaxed, one line focus lies in front of the
retina while the other lies behind the retina (Fig. 13.9c).
 Simple hyperopic astigmatism – indicating that with accommodation fully relaxed, one meridian focuses
on the retina while the other focuses behind the retina (Fig. 13.9d).
 Compound hyperopic astigmatism – indicating that with accommodation fully relaxed, both line foci
from the principal meridians lie behind the retina (Fig. 13.9e).

Figure 13.9 Classification of astigmatism based on focus of principle meridians

METHODS OF EXAMINATION TO DETERMINE ASTIGMATIC REFRACTION COMPONENT

The astigmatic or cylindrical component of the refractive correction is determined by several methods of
examination, namely:
 Cross cylinder technique
 Fan-and-block method
 Clock dial method
 Stenopaic slit method

The choice of technique employed depends on the practitioner and the instrumentation and charts available. The most
commonly performed technique is the cross cylinder method.
The determination of the cylindrical component follows after the determination of the spherical component of the
refractive correction. It begins at the point that the “circle of least confusion” is placed on the retina (achieved by
duochrome test).
What is the circle of least confusion?
An astigmatic focus is produced in an individual whose refractive error comprises of both spherical and cylindrical
components. This astigmatic focus consists of a vertical focal line which corresponds to the focus of the horizontal
principal meridian and a horizontal focal line which corresponds to the focus of the vertical principal meridian. The
region between these two lines is known as the conoid of Sturm or Sturm's interval (Fig. 13.10). The dioptric mid-point
between these two focal lines, the astigmatic focus forms a circular patch known as the circle of least confusion. The
location of this circle of least confusion is equal to the spherical equivalent of the prescription.

Figure 13.10 Ray diagram of the Circle of least confusion and Conoid of
Sturm

1. CROSS CYLINDER TECHNIQUE

The cross cylinder test is conducted using the Jackson Cross cylinder. This is referred to as the JCC test. The test
begins at the point when the circle of least confusion is placed on the retina.

Instrumentation
 Visual acuity chart
and
 Jackson Cross cylinder (Fig. 13.11)
 Trial frame
 Trial lens set with minus cylindrical lenses
or
 Phoropter

Figure 13.11 Jackson cross cylinder

June 2012, Version 1 Clinical Optometric Procedures 1, 13-10

Procedure
1. Select an appropriate target. One should choose a circular letter one line above the best visual acuity
of the eye being tested. This visual acuity is based on the best VA that was achieved with monocular
subjective correction in place.
2. Occlude the patient’s left eye.
3. Position the cross cylinder in front of the patient’s RE. The first step is to bracketing the quadrant within
which the axis lies. To do this one must introduce the cross cyl such that the power lines (usually marked
red/green, red/white or grey/white) lie at 90 and 180. The patient is asked to tell you in which position the
circular letter appears ‘rounder, clearer and sharper’. Remember to note the position of the minus power
line. Next place the cross cyl with the power lines along 45 and 135 and repeat the question, again
taking note of the position of the minus power line. Once one has done this, you would have determined a
45 bracket in which the axis lies.
4. After determining the bracket, introduce a trial cylinder lens of –0.25DC (or -0.50DC if patients have
trouble understanding the concept) midway in the 45 bracket.
There are instances in which a patient does not prefer a particular orientation of the minus cylinder axis.
In this case you would just skip that bracket and move onto the next. For example, the minus cylinder axis
is presented at 90 and 180 and the patient prefers neither orientation. The practitioner then will ignore
these brackets assuming that the cylinder axis bracket lies somewhere around the 45 and 135 brackets
and must proceed to verify this alternative.
5. When refining the cylinder axis, ensure the handle of the cross cylinder is parallel to the axis line
corresponding to the trial cylinder. Each time ask the patient in which position does the circular letter
appear ‘rounder, sharper and clearer’. The trial cylinder should always be moved in the direction of the
minus power line (minus cylinder axis). The end-point of the axis determination is when both axis
positions about the trial cylinder are the same or when the patient starts to move back and forth about
a specific position.
6. Once the axis is determined, the power of the cylinder required can be determined. The cross cylinder
now has to be held with the power lines on the cross cylinder parallel to the axis marking on the trial
cylinder. The patient is now instructed to tell which lens (+0.25DC or –0.25DC) makes the letters "sharper,
clearer and darker”. If the patient chooses the +0.25DC lens then it implies that the patient has rejected
the cylinder and that he/she merely has a spherical refractive error. If the patient prefers –0.25DC then it
implies that the patient is accepting the cylinder and one would increase the cylinder power from –0.25DC
to –0.50DC.

N.B. FOR EVERY -0.50DC CHANGE IN CYL POWER,

ONE NEEDS TO ADD A +0.25DS LENS.

This is done to shift the circle of least confusion back onto the retina. The end-point of this step is when
the patient chooses the +0.25DC lens position or if both views appear the same. If the patient preferred
the
+0.25DC lens position, then the practitioner removes the last cross cyl added, ensuring adequate
spherical correction as well.
It has been noted that the determination of an accurate cylindrical power can be challenging for the patient
as the changes are within a narrow range. Borish therefore suggested that one may present the entire VA
chart to the patient when determining the cylindrical power and determine the power that allows the patient
to read the furthest down the chart.
7. Once the cylindrical error of the right eye is determined, the right eye is occluded and the practitioner
continues with determining the refractive error of the left eye

June 2012, Version 1 Clinical Optometric Procedures 1, 13-11

2. FAN-AND-BLOCK
METHOD Equipment
 Fan and block chart (Fig.
13.12)

Figure 13.12 Fan and block test chart

Procedure
1. The test is monocular.
2. Occlude the un-tested eye.
3. The best monocular spherical correction must be determined.
4. Determine the patient’s best VA with the spherical correction in place. Any cylindrical component
determined from retinoscopy must be removed.
5. Plus lenses are added in 0.25DS steps until the VA in the eye being tested drops by 1 line. Verification
can be performed on the duochrome test to ensure that the targets on the red side are darker, sharper
and clearer.
6. The patient’s attention is drawn to the fan chart and using the analogy of hours of a clock, the patient is
asked if any of the lines on the fan appear clearer and darker than other lines.
7. The arrow that joins the blocks is then orientated toward the clearest line. The arrow is adjusted until its
2 arms are equally clear. The one block (with its lines parallel with those on the block which are clearest)
should be clearer than the other.
8. If the patient reports that all lines are equally clear or blurred, then fog the target with a further +0.50DS
and ask the patient again if any lines appear clearer and darker. If they remain equally clear or blurred,
this suggests that there is no astigmatism present.
9. If an astigmatic component is found, the cylinder axis in the trial frame is set to the axis indicated by the
arrow. Negative cylinder is added at this axis until the blurred block just becomes as clear as the other.
One can then add the cylinder power found during retinoscopy. If one cannot obtain equal clarity of the
two blocks, then the lowest power cylinder must be added.
3. CLOCK DIAL CHART METHOD
Equipment
 Clock dial chart (Fig. 13.13)

Figure 13.13 Clock dial chart for determination of astigmatism

Procedure
1. The chart is presented to the patient with sufficient fog in place and the axis of the correcting cylinder
is determined. To achieve this, the practitioner asks the patient if he or she can see in any or all of the
spokes. If there is an area that is clearer, then the patient is asked to report, which of the spokes (the
3 lines) are sharpest or most distinct.
2. The chart is equipped with numbers similar to those of a face of a clock (Fig. 13.13). When patient’s are
questioned about the clarify of the spokes, they would typically report that the spokes are clear along
12 to 6 o’clock, 1 to 7 o’clock, etc. When determining the axis, the smaller of the 2 numbers reported are
multiplied by 30. For example, if the spokes between 2 to 8 o’clock are clearest, then the 2 is multiplied by
30 to produce an axis value of 60 If the patient reports that the spokes between 3 to 9 o’clock are clearest
then the axis is given as 3, multiplied by 30 and is therefore 90.
3. To determine the power, the practitioner begins adding minus cylinder lenses in 0.25DC steps with the
axis determined in step 2 of the procedure. Each time, the practitioner must question the patient with
respect to the distinctness of the lines in the spokes along the 2 principal meridians. For example,
comparing the spokes along 12 to 6 o’clock to 3 to 9 o’clock and so forth.
4. Considering a patient with with-the-rule astigmatism, adding minus cylinder power with the axis along the
horizontal meridian, one would only be moving the horizontal line focus closer to the retina together with
moving the circle of least confusion toward the retina, however, the vertical line focus will not be altered. At
some point when sufficient minus cylinder power is added the horizontal and vertical line foci lie in the
same place and this collapses the Conoid of Sturm. When this happens, the patient would report that the
spokes of both principal meridians are equally clear. However, it should be noted that this image is not on
the retina and the image on the retina will be a blur circle.
5. At this point the practitioner adds additional cylindrical power with 0.25DC at a time until a reversal occurs.
For example, if the patient initially reported that the 12 to 6 o’clock spokes were clearer, he will now report
that the 3 to 9 o’clock spokes are clearer. In most cases, it has been found that once equality of the
principal meridians has been achieved, a further addition of 0.25DC will produce reversal of the clarity
of the spokes.
4. STENOPAIC SLIT METHOD
The stenopaic slit method of astigmatism determination is one that is especially useful when a patient has high or
irregular astigmatism in conditions like keratoconus. The slit can vary in width and like a pinhole, allowing light only in
through the meridian while the other remains blocked.

Instrumentation
 Trial case with stenopaic slit of 1 mm width (Fig. 13.14)
 Trial frame

Figure 13.14 Stenopaic slit

Procedure

1. The patient is directed to a distance visual acuity chart to letter just above the best VA of the eye being
tested while the other eye is occluded.
2. Spherical error is determined with best acuity in the eye.
3. The eye being tested is fogged by a +1.00 to +1.50DS lens.
4. The stenopaic slit is introduced in front of the fogged eye. If the patient’s acuity is significantly reduced,
then a wider slit beam may be used.
5. The slit is rotated until the patient’s best vision is found. This meridian is the primary meridian of most plus
and least minus power (i.e. minus cylinder axis). The position of this meridian can be verified by moving
the stenopaic slit off the position determined by the patient by 10 on either side.
6. The lenses before this fogged eye are reduced until the best VA can be achieved.
7. The power remaining in the trial frame is recorded on an optical cross making note that the axis of the
power lies parallel to the slit orientation.
8. The power now needs to be determined for the other principal meridian. This is determined by rotating the
stenopaic slit through 90 or until the patient reports that the position of worst acuity is found. If there is
irregular astigmatism, this meridian will not lie at precisely 90 to the primary meridian.
9. Reduce the fogging lenses before this position until the best VA is achieved. Record the resultant power
as in step 7.
10. Once the power of the both principal meridians has been determined and they are represented on the
optical cross, the findings must be transposed into sphero-cylindrical format.
11. With the final prescription in place, the patient’s best VA through this prescription must be recorded.
12. The right eye is now occluded and the procedure is repeated for the left eye.
BINOCULAR BALANCING TECHNIQUES

BACKGROUND
The monocular subjective findings at distance are followed by an attempt to equalize the accommodative effort exerted
during habitual gaze by the two refractively corrected eyes on patients who are binocular. In many cases, the spherical
equalization is taken erroneously to mean the equalization of the visual acuities between the two eyes. It should be
noted that even if the corrected acuity between the 2 eyes is the same, the quality of vision obtained between the two
eyes may be different.
The process of ‘balancing’ equalizes the accommodative responses with respect to potentially different
accommodative demands required by the eyes for distance viewing. A patient must be binocular for this test to be
conducted. In cases where the patient is monocular (i.e. suppressing one eye or a strabismus exists), the practitioner
does not conduct the balancing technique and should move on to other tests in the battery forming the refraction.

METHODS FOR BINOCULAR BALANCE TECHNIQUES

There are various methods that may be employed to perform binocular balancing of a prescription. These include:
 Equalization by alternate occlusion
 Prism dissociation method
 Fogging method (Humphriss)
 A method using a Septum (Turville)
 Polarization method (Vectographic)
 Dissociated duochrome method

1. EQUALIZATION BY ALTERNATE
OCCLUSION Procedure
The equalization by alternate occlusion technique is probably one of the simplest methods of binocular balancing that
is employed. Add plus lenses binocularly till the patient barely sees the 20/30 line or two lines above his/her best
binocular acuity. The patient is asked to compare the legibility of the letters between two eyes, while performing a slow
alternate occlusion. The end point is equal acuity between two eyes. If the patient reports one eye is clearer than the
other eye, then plus lenses are added in +0.25DS steps before the clearer eye to equalize the blur.

This technique while simple to conduct does have several inherent problems, namely:
1. The patient compares a target to one that is no longer visible to that eye and the comparison is
drawn from memory.
2. The end point is equal acuity and therefore no allowance is made for patients with unequal
maximum VA between the two eyes.
3. The alternate occlusion must be performed in a slow enough speed so that the patient can make
a comparison between the images of the two eyes.
4. Each eye may assume its monocular accommodative status when alternatively occluded.

2. PRISM DISSOCIATION METHOD

This method is also referred to as “dissociated blur balance”. This test is based on a comparison of the VA of both
eyes and therefore requires that the VA after distance monocular subjective be the same. If there is a difference in VA
between the two eyes, then it recommended that the practitioner conduct the prism dissociated duochrome test.

Procedure
1. The test in binocular, however it is performed monocular until dissociation is achieved.
2. Each eye is fogged with a +0.75DS lens after the best monocular refraction findings.
3. The patient’s binocular VA is measured thereafter to ensure that the VA is 20/25 or worse.
4. Projected line above the VA is isolated.
5. The chosen acuity line or chart is dissociated with a phoropter’s Risley prism with equal amounts of
vertical prism (usually 3-4∆ BU in front of right eye and 3-4∆ BD in front of left eye). This is done since it is
easier to dissociated with vertical prism. The equal amounts of prism also ensure that each eye is
exposed to the same amount of prismatic distortion.
 6. When the occluder is removed, the patient should be able to report that there are two identical targets
(as in diplopia), with each eye observing only one target. If the patient cannot see the two images
binocularly, the practitioner should recheck the view of each eye and then binocular views. An increase in
the amount of prism may also aid in the perception of diplopia of the target. If this can still not be achieved,
then it indicates that the patient is suppressing the target.
7. The subject is asked to compare the legibility of the targets. They should be equally blurry.
8. If the patient reports that one target is more legible than the other, then plus lenses are added in +0.25DS
steps before the clearer eye to equalize the blur. An alternative approach is to leave the dominant eye
slightly clearer than the other eye.
9. When the blur end point is reached, the prism is removed.
10. Binocularly, the patient’s acuity is brought down to 20/20 or better by un-fogging (reducing the prescription
in -0.25DS steps).

3. HUMPHRISS IMMEDIATE CONTRAST METHOD

Purpose
This test allows for subjective refraction under binocular conditions, 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 in the non-tested eye. Non-foveal zones remain binocularly active and suppress
accommodative fluctuations.
Like other binocular balancing tests, this test is a method of refinement and is conducted after retinoscopy and
monocular subjective testing.

Instrumentation
 Trial frame and trial set (or phoropter)
 Distance visual acuity chart

Procedure
1. Direct the patient to a letter/s on the line above the best corrected acuity, e.g. if the patient was corrected
to 6/6, then a target on the 6/7.5 line is used.
2. Place a +0.75 / +1.00DS fogging lens before the LE. The fogging should be verified by occluding the RE
and asking the patient if the 6/6 line is still readable. If the correct amount of fog is being utilized then this
line will be blurred together with 3-4 lines on the chart. If the line is still readable then it implies that a
greater amount of fog is required. This is usually the case in older individuals since dioptric blur has less
of an effect due to their tendency to have smaller pupil sizes.
3. Following step 2, the rest of the procedure is done binocularly.
4. Place a +0.25DS lens (lens 1) over the RE. Quickly replace this lens with a –0.25DS lens (lens 2) and
once again revert to the +0.25DS lens (lens 1). Ask the patient to compare the 2 lenses (lenses 1, 2, and
1) and to tell you which of the two lenses makes the target letter/s clearer, sharper and more comfortable
to look at.
5. If the patient reports that lens 2 is better, then add a further –0.25DS lens to the subjective finding and
repeat step 4. Stop when the patient reports that the view through both lenses is the same or until the
patient chooses lens 1. If he reports that the view is the same, leave the last lens in the subjective finding.
If the patient selects the plus lens now, it implies that he rejects the minus lens. As discussed earlier, one
needs to stop at the least minus lens. Therefore one removes the last –0.25DS lens and begins testing the
other eye.
6. Once having determined the error of the RE, remove the fogging lens from the LE and place it over the
RE. Ensure that the RE is fogged and repeat the procedure for the LE.
NOTE:
 Binocularity has to be intact, i.e. there should be no tropia.
 There should be no greater than a 2 line visual acuity difference between the 2 eyes.

4. TURVILLE INFINITY BALANCE

Turville infinity balancing technique was first described by A.E. Turville in 1946 but subsequently modified by Morgan.
It is a method of binocular refraction which employs a septum to block part of the chart so that the right eye sees the
right side of the chart and the left eye sees the left side of the chart. The border of the chart and the field surrounding
the chart are seen binocularly.
The septum can be placed either: on the mirror in a mirror room (placed in the middle of the mirror), in a room without
a mirror the septum is placed approximately midway between the patient and the chart.
Equipment
 Phoropter/Trial Frame
 Septum of proper width with a rod or stand to hold it

Procedure
1. The test is performed with the patient’s best monocular distance correction in place.
2. The septum is mounted on a rod such that one half of the distance VA chart is visible to one eye while
the other half of the chart is visible to the other eye. The distance of the stand from the patient and the
width of the septum are calculated using the formulae stated below.
3. The projector slide is adjusted such that the top of the 20/20 set of lines of letters are at the bottom of
the chart.
4. For eyes which have equal acuity, alternatively add +0.25DS lens of fog to each eye until the patient
reports that both eyes are blurred.
5. To determine binocular balancing;
a. If the 2 halves of the chart are equally blurred, then alternately unfogged to obtain best VA
in each eye, ensuring balance as the procedure is continued.
b. If the 2 halves of the chart are not equally blurred, the sphere is adjusted until they are balanced
and slightly blurry. Then alternately un-fog until best VA in each eye is achieved, whilst checking
balance as the procedure is continued.

Recording of findings
Indicate which test was being used for binocular balancing, i.e. Turville Infinity Balance or TIB Record the final Rx for
each eye, taking into account the eye, the spherical and cylindrical powers, axis of the cylinder and the monocular
VAs.

5. VECTOGRAPHIC REFRACTION (POLARIZATION)

Vectographic binocular balancing using polarization was first described by Grolman in 1966. It is a technique that uses
the American Optical (Reichert) vectographic projector slide. Polaroid filters are placed in front of the patient's eyes. A
high quality aluminized screen must be used and it must be placed so that a line normal to the screen bisects the
angle between the projector and the patient's eyes. If the projector and screen are not aligned properly, reflections
may be affected to the point where the test is ineffective. The analyzer and the polarized targets have the same axis of
polarization. Each eye sees part of the chart. Some letters are seen only by the right eye and some are seen only by
the left eye. There are also letters on the chart that are seen by both eyes.

6. DISSOCIATED DUOCHROME METHOD

The duochrome of bichromatic chart is used in this method of balancing to ensure that the stimulus to accommodation
is equalized between the two eyes.
This test is preformed when the VA between the two eyes differs after the monocular subjective refraction, or if the
practitioner suspects that the accommodation differs between the two eyes.

Procedure
1. The technique is performed in a semi-darkened environment.
2. The test is performed binocularly.
3. The patient is directed to a duochrome target.
4. A line of letters above the best VA of the poorer eye is introduced to the patient with the duochrome
mask above it.
5. Risley prisms are placed over each eye, with 3-4∆ BU before the right eye and 3-4∆ BD before the left eye.
6. The introduction of prism before both eyes should induce diplopia forcing the patient to see 2 lines of red-
green letters. The practitioner must ensure this dissociation.
7. The patient is directed to the lower line of letters.
8. The patient is asked to report whether the red or green side of the line of letters is sharper and clearer or
if they are equally clear.
9. If letters on the red side are sharper or if both sides are equally clear, then the practitioner must introduce
-0.25DS. If he/she reports that the letters on the green side of the chart are clearer, then the practitioner
must add +0.25DS before the eyes.
10. Thereafter the patient is directed to the upper line of letters, and the procedure is repeated.
 11. The final lens prescription for this type of binocular balancing test is to leave the patient preferring the “just
green” better option indicating that the minimum minus lens power is provided, so patient first reports the
green is slightly better than the red side or if both the red and green sides of the target are equally clear.

BINOCULAR VISION TESTING

Once the subjective monocular refraction and binocular balance has been completed, then those techniques that
investigate the post-refraction binocular vision are performed.

These include:
 Amplitude of accommodation
 Binocular status in the primary position
 Fixation disparity
 Accommodative convergence/accommodation ratio
 Stereoacuity
 Fusional reserves
 Degree of incomitancy.
Not all of these aspects will be discussed in this module. They will be discussed in the more specialized binocular
vision module.

BIBLIOGRAPHY
Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3/e. The MacGraw-Hill Companies, Inc. United States. 2004
Benjamin W, Borish's Clinical Refraction, Butterworth-Heinnemann, 2007
Elliott DB. Clinical procedures in primary eye care 3/e. Oxford, Elsevier, 2008.
Ettinger ER and Rouse MW., Clinical Decision Making in Optometry, 1/e, Butterworth, Heinemann 1997.
Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.