2023

Pearls of Clinical Optometry

A COMPLETE GUIDE TO OPTOMETRIC PRACTICE

ISBN 978-93-6076-131-8
Cover image: Canva.com
Cover design by Dipanwita Ghosh
Preface

In the preface of this optometry book, I aim to provide readers with context, insights, and a
roadmap for navigating the content within these pages. As a practicing optometrist with a passion
for advancing clinical knowledge, my goal is to offer a comprehensive resource that caters to both
students entering the field and seasoned professionals seeking updated insights.
Introduction to Optometry. We begin by exploring the foundational principles of optometry,
delving into the intricate balance of vision science, ocular anatomy, and clinical applications. This
book is designed to serve as a guide through the multifaceted aspects of the optometric profession.
Evolution of Optometric Practices: Optometry is a dynamic field, witnessing constant
advancements in technology and clinical methodologies. Throughout the book, I highlight these
evolving practices, ensuring readers are equipped with the latest information to provide optimal
patient care.
Comprehensive Coverage: From basic vision assessment to specialized topics like contact lens
fitting, binocular vision, and ocular diseases, each chapter is crafted to provide a well-rounded
understanding. Real-world case studies and practical insights are interwoven to bridge the gap
between theory and application.
Target Audience: This book is tailored for optometry students, residents, and practicing
professionals seeking a resource that seamlessly integrates theoretical knowledge with clinical
expertise. Whether you are beginning your optometric journey or looking to enhance your skills,
you'll find valuable insights within these pages.

1|P a ge
Acknowledgements

I extend my heartfelt appreciation to colleagues, mentors, and institutions that have contributed to
my growth in the field. Their support has enriched the content of this book, and I am grateful for
their shared dedication to advancing optometry. I would like to express our sincere gratitude to all
the clinical optometrists whose dedication and expertise continue to advance the field of eye care.
Their commitment to improving patient vision and overall eye health is invaluable. We
acknowledge the vital role they play in diagnosing, managing, and treating a wide range of ocular
conditions. Special thanks to Mr. Saurabh Adhikari, Chief Operating Officer Swami Vivekananda
University, Barrackpore, West Bengal, whose insightful feedback and support have been
instrumental in the completion of this work. Additionally, we appreciate the contributions of the
Swami Vivekananda University for providing the necessary resources and support for this study.
We also extend our thanks to the patients who participated in our research, without whom this
work would not have been possible. Their willingness to contribute to the advancement of
optometric knowledge is deeply appreciated. I invite you to embark on this journey through the
fascinating world of optometry, exploring its intricacies, challenges, and the rewarding
experiences that come with providing exceptional eye care. Lastly, we recognize the collaborative
efforts of the interdisciplinary teams, including ophthalmologists, researchers, and healthcare
professionals, who work alongside optometrists to ensure comprehensive eye care and the
advancement of clinical practices in optometry.

Dipanwita Ghosh
Department of Optometry
December, 2023

2|P a ge
 Content
Preface……………………………………………………………………………………………… i

Acknowledgements…………………………………………………………………………………. ii

Chapter 1 Physiology of vision

1.1 Maintenance of Clear Media……………………………………………………………….6

1.2 Introduction………………………………………………………………………………...7
1.3 Preservation of Transparent Eye Structures………………………………………………...8
1.4 Photochemical Change Encompass…………………………………………………………9
1.5 Study of Biological Processes Involved in Vision………………………………………...10
1.6 Visual Perception………………………………………………………………………….11

Chapter 2 Visual Acuity & Clinical Refraction

2.1 Introduction…………………………………………………………………………………………17

2.2 Significance …………………………………………………………………………………………17

2.3 Visual Acuity………………………………………………………………………………………..17

2.3.1 Clinical procedure to measure visual acuity……………………………………………….18

2.4 Different types of vision chart use in refraction……………………………………………………..19

2.5 Subjective & objective refraction……………………………………………………………………21

2.6 Cycloplegic refraction……………………………………………………………………………….21

2.7 Retinoscopy………………………………………………………………………………………….22

2.7.1 Static Retinoscopy………………………………………………………………………….23

2.7.2 Dynamic Retinoscopy………………………………………………………………………24

Reference…………………………………………………………………………………………….25

Chapter 3 Introduction to Refraction & Ophthalmic Dispensing

3.1 Introduction…………………………………………………………………………………………….27

3.2 Subjective & Objective refraction……………………………………………………………………..27

3.3 Retinoscopy……………………………………………………………………………………………28

3.3.1 Dynamic retinoscopy…………………………………………………………………………28

3.4 Clinical procedures (Subjective refraction)……………………………………………………………29

3.4.1 Discussion (Subjective Refraction)………………………………………………………….29

3.5 Power verification……………………………………………………………………………………..30

3.5.1 Fogging technique……………………………………………………………………………31

3.5.2 Duo Chrome test……………………………………………………………………………..31

3.5.3 Pin hole………………………………………………………………………………………31

3.6 Cylinder power refinement……………………………………………………………………………31

3.6.1 JCC………………………………………………………………………………………….31

3.6.2 Astigmatic fan & block………………………………………………………………………32

3.7 Binocular Balancing…………………………………………………………………………………..32

3.7.1 Alternate occlusion technique…………………………………………………………………32

3.7.2 Prism dissociation test…………………………………………………………………………32

3|P a ge
 3.7.3 Prism dissociation with Duo chrome…………………………………………………………32

3.8 Components of power prescription…………………………………………………………………33

3.9 Pupillary Distance (PD)…………………………………………………………………………….34

3.10 Spectacle lens types…………………………………………………………………………………34

3.11 Tinted lens…………………………………………………………………………………………..35

3.12 Polarized sunglass…………………………………………………………………………………..35

3.13 Spectacle frame parts & types………………………………………………………………………36

3.14 Different types of faces and frame fitting…………………………………………………………..37

3.15 Spectacle care advice to patient…………………………………………………………………….38

Chapter 4 Low Vision and Visual Aids

4.2 Introduction………………………………………………………………………………………40

4.2 Effects of Low Vision on Visual Perception……………………………………………………40

4.3 Primary Factor Contributing to Visual Impairment……………………………………………..40

4.4 Optics of Low Vision……………………………………………………………………………42
4.5 Add Perception………………………………………………………………………………….44
4.6 Evaluation of Visual Impairment……………………………………………………………….44
4.7 Assessing the Potential Beneficiary…………………………………………………………….. 44
4.8 Defect in the Field……………………………………………………………………………….47
4.9 Assessment and Evaluation of Aids for those with Low Vision…………………………………47
4.10 Fundamental Principals of a Magnifier………………………………………………………….48
4.11 Surveillance System Using Closed Circuit Television………………………………………….51
4.12 Special type Aids………………………………………………………………………………..53
4.13 Headwear Option………………………………………………………………………………..53
4.14 Utilising Contact lens for Assistant……………………………………………………………..55
4.15 Advancements in the Field of Aids……………………………………………………………..56
4.16 Training in Orientation and Mobility……………………………………………………………59

Chapter 5 Paediatric Eye and Binocular Vision Examination

5.1 General Introduction…………………………………………………………………………….64

5.2 Paediatric eye and vision examination………………………………………………………….65

5.3 Examination sequence…………………………………………………………………………..67

5.3.1 Case History……………………………………………………………………...67

5.3.2 Refraction………………………………………………………………………...72
5.3.3 Binocular Vision & Ocular motility Assessment………………………………...73
5.3.4 Ocular Health Assessment……………………………………………………….74

5.4 Conclusion………………………………………………………………………………………74

Chapter 6 Enhancing Performance Through Sports Vision Training

6.1 Introduction……………………………………………………………………………………78

6.2 Understanding Sports Vision………………………………………………………………….78

6.2.1 Dynamic Visual Acuity…………………………………………………………….78

6.2.2 Depth Perception……………………………………………………………………79

6.2.3 Peripheral Vision……………………………………………………………………80

6.2.4 Eye-Hand Coordination……………………………………………………………..80

6.2.5 Visual Reaction Time……………………………………………………………….81

6.3 Sport-Specific Visual Demands…………………………………………………………………82

6.4 Sports Vision Training Methodologies………………………………………………………….82

6.5 Conclusion………………………………………………………………………………………83

4|P a ge
Chapter 7 Introduction to Contactology

7.1 Introduction…………………………………………………………………………………….86

7.2 History of contact lens…………………………………………………………………………86

7.3 Classification of Contact lenses………………………………………………………………...87

7.3.1 FDA Classification…………………………………………………………………88

7.3.2 Nature of contact lens………………………………………………………………88

7.3.3 Classification based on wearing schedule…………………………………………..88

7.3.4 Classification based on water content……………………………………………….88

7.3.5 Based on Anatomical location………………………………………………………88

7.3.6 Anomalies of Refraction …………………………………………………………….88

7.4.1 Indications………………………………………………………………………………………89

7.4.2 Contra-indications………………………………………………………………………………89

7.5.1 Manufacturing techniques for Soft Contact lens……………………………………………….90

7.5.2 Manufacturing techniques for rigid Contact lens………………………………………………91

7.6 Contact lens materials for soft and rigid contact lenses…………………………………………92

7.7 Contact lens properties…………………………………………………………………………..93

7.7.1 Refractive index…………………………………………………………………….93

7.7.2 Water content……………………………………………………………………….94

7.7.3 Oxygen permeability………………………………………………………………..94

7.7.4 Oxygen and light transmission………………………………………………………94

7.7.5 Wettability……………………………………………………………………………94

7.8 Conclusion…………………………………………………………………………………………94

Chapter 8 Clinical Guide to Contact Lens Fitting and Care

8.1. Introduction…………………………………………………………………………………….97

8.2.1 Refractive Errors ………………………………………………………………………………97

8.2.2 Symptoms of refractive errors…………………………………………………………………98

8.3.1 Soft Contact lens fitting……………………………………………………………………….98

8.3.2 Clinical eye examination………………………………………………………………………99

8.3.3 Instruments used for contact lens fittings……………………………………………………..99

8.3.4 Fitting procedure (Soft contact lens)………………………………………………………….99

8.3.5 Assessment of contact lens fit…………………………………………………………………100

8.4.1 RGP Contact lens fittings……………………………………………………………………..101

8.4.2 Assessment of fit………………………………………………………………………………102

8.5. Contact lens complications……………………………………………………………………103

8.6. Contact lens care & maintenance……………………………………………………………..104

8.7. Special contact lens…………………………………………………………………………..105

8.8. Conclusion………………………………………………………………………………….105

5|P a ge
Physiology of Vision

Dr. Prabirendra NS,

D.O.S (PG), DCLP
Assistant Professor
Department of Optometry
Swami Vivekananda University

6|P a ge
 Ensuring the clarity of the eye's optical
Physiology of Vision components.
Ensuring the correct pressure inside the eye
is maintained.
Maintenance of Clear Ocular Media.
 The process of creating an image
Phototransduction refers to the process by  The study of how vision works in the
which light is converted into electrical body
signals in the retina of the eye.  The study of how the eyes move and
 The physiological mechanisms how they work together to provide
behind the generation and depth perception
constitution of tears.  The study of how the pupil functions
 Visual signal processing and The most significant biological effect of light
transmission. is the physiological process that occurs when
 The physiological properties of the it reaches the retina. This process is crucial
cornea. since it is responsible for the entire process of
vision. There are three essential components
Visual perception is the cognitive process by for vision: light to stimulate the nerve
which the brain comprehends and gives endings (rods and cones in the retina) of the
meaning to visual stimuli that are received visual system, a visual mechanism to convert
via the eyes( 1) this light energy into nervous energy
(Phototransduction) and transmit it to the
 The physiological mechanisms of the brain, which coordinates the received
crystalline lens. impulses and triggers appropriate responses,
 The study of the movement of the and finally, a consciousness or mind to
eyes and the coordination of vision interpret the visual pattern and control the
from both eyes (2). responses(2).
 The text discusses the physiological
aspects of aqueous humour and the During the visual act, these different
mechanisms involved in regulating components occur in a continuous manner
intraocular pressure. and interact with one other.
 Oculomotion analysis • The physical mechanism involves the
 The study of the physical properties formation of the retinal picture.
and functions of vitreous humour.
 The study of the biological processes • Physiological process refers to the passage
involved in seeing a single image of retinal impulse to the brain in order to
with both eyes create visual sensation.

Introduction: • Psychological process refers to the

phenomenon that happens when visual sense
Vision is an intricate process involving the is coordinated with conscious awareness,
coordinated functioning of two eyes and their resulting in perception in the mind, and the
central coordination. Ocular physiology synthesis of sensations becomes flawless (4).
refers to the biological processes that are
essential for the proper functioning of the Preservation of transparent eye structures
eyes (3). The items are: Clear refractive medium of the eye is
essential for proper visual function. The
7|P a ge
primary determinant of the transparency of The crystalline lens is a transparent ocular
ocular media is their lack of blood vessels. structure that plays a crucial part in the
The sequential arrangement of refractive process of visual focusing, with a refractive
media in the eye, from front to back, is as power of +19 diopters (with the ability to be
follows (5): adjusted within the range of +4 to +6
diopters). The physiological aspects
 The word "tear film" denotes the thin encompass:
coating of tears that envelops the
eye's surface. Transparency refers to the quality or state of
 The cornea is the clear anterior being transparent, which means being clear,
portion of the eye that protects the open, and easily understood (7).
iris, pupil, and anterior chamber.
• Cellular metabolism
 The aqueous humour is a fluid found
in the eye. • The refractive index of the anterior part of
 The vitreous humour is a gel-like the accommodation is 1.387, whereas the
substance found in the eye. refractive index of the equator is 1.375.
Crystalline lens Accommodation refers to the eye's capacity
to enhance its ability to concentrate on nearby
Lacrimal glands, situated in the upper outer objects. This is achieved by the contraction of
corner of the eye, generate tears. They serve the ciliary muscle, which causes the
several physiological functions, including crystalline lens to adopt a more rounded
lubricating the eye, protecting it from foreign shape, essentially increasing its refractive
particles, and maintaining the health of the power. Accommodation is a factor in depth
ocular surface. perception, as the brain relies on the level of
The tear film is essential for preserving focused effort to determine the distance to an
transparency. Regarding the cornea. The item. During the process of accommodation,
answer varies based on the tear's quality and the eyes undergo convergence, causing them
amount. The refractive index is 1.375. to shift inward, and the pupil constricts,
The study of the functions and processes of resulting in a smaller size. This sequence of
the cornea. occurrences is occasionally referred to as the
accommodating reflex, despite not being a
The cornea is the primary surface of the eye genuine reaction(4 ,8).
responsible for refraction, with a refractive
power ranging from +42D to +43D. The study of the physiological mechanisms
Physiological factors pertaining to the cornea of the aqueous humour and the regulation of
encompass(6): intraocular pressure.

• Clarity The aqueous humour is a transparent liquid

that fills the anterior chamber of the eye with
The study of the nourishment and chemical a volume of around 0.25 ml, and the posterior
processes involved in the cornea. chamber with a volume of about 0.06 ml. The
The ability of the cornea to allow substances aqueous humour is crucial for regulating
to pass through it. intraocular pressure by transporting
substances and eliminating waste products
The refractive index is 1.376. from the cornea and crystalline lens (9).
The physiology of the crystalline lens The refractive index is 1.336.

8|P a ge
Study of the properties and functions of the THE PHOTOCHEMICAL CHANGES
vitreous humour ENCOMPASS:
The vitreous humour is a clear gel mostly Photons with wavelengths ranging from 400
consisting of water (about 99%), collagen, to 780 nm enter the eye and interact with the
and hyaluronic acid. It is situated in the back pigment molecules in retinal cells, leading to
part of the eye. It aids in preserving the different structural changes in these cells.
spherical form of the eyeball. During These photochemical reactions transpire
motions, the vitreous adheres to the retina, when the wavelength of light is transformed
causing motion in the gel. This motion, in into its chemical energy equivalent. These
turn, creates tensions inside the vitreous and modified molecules are accountable for the
on the retina. subsequent intracellular cascade sequence,
ultimately leading to a series of electrical
Study of the biological processes involved impulses transmitted to the brain. The brain
in vision will receive and interpret information based
The physiology of vision is an intricate on the frequency and pattern of these
process that remains incompletely impulses(8, 10).
comprehended. The primary determinants in
The photochemical changes encompass:
this process are:
 Rhodopsin bleaching is the gradual
The process of vision initiation, known as
reduction in the effectiveness of the
phototransduction, is carried out by the
visual pigment rhodopsin. Rhodopsin
photoreceptor cells, namely the rods and
is found in the retinal rods and is
cones.
accountable for scotopic vision,
The processing and transmission of visual which is the ability to perceive in low
impulses is a function performed by the light conditions. Rhodopsin consists
image processing cells of the retina and of an achromatic protein called
visual pathway. Opsin, which is associated with a
carotenoid called Retinine (also
Visual perception is a cognitive process that known as Vitamin A aldehyde or 11-
relies on the functioning of the brain, namely cis-retinal). The incoming light
the visual cortex and its associated parts. induces the transformation of the 11-
Phototransduction refers to the process by cis-retinal component of rhodopsin
which light is converted into electrical into all-trans-retinal through a
signals in the retina of the eye. sequence of stages. The all-trans-
retinal that is generated is rapidly
Phototransduction is the conversion of light dissociated from opsin.
into electrical impulses in the retina. Visual Photodecomposition is the term used
perception occurs through the activation of to describe the process of separating
photoreceptor cells, specifically rods and compounds using light. Similarly, the
cones, which generate nerve impulses that are fading of rhodopsin caused by light is
sent to the brain. This intricate biochemical commonly referred to as bleaching
process involves the absorption of photons by  Rhodopsin assimilates light energy,
visual pigments, changes in membrane resulting in the division of opsin and
potential, and the transmission of information all-trans-retinal. Subsequently, the
across the visual pathway(10). all-trans-retinal undergoes retinal
isomerization to be transformed back

9|P a ge
 into 11-cis-retinal. Ultimately, the 11- RhodopsinLight  Bathorhodopsin 
cis-retinal is amalgamated with opsin Lumirhodopsin  Metarhodopsin I
in order to restore rhodopsin. Metarhodopsin II  all trans retinal 
(NADH to NAD) All trans- retinol(vit A)
Rhodopsin light energy All trans-  isomarse- 11-cis-retinolNAD to
retinal (opsin separated)  11-cis- NADH- 11-cis- retinal Opsin add-
retinal  ( Retinal isomarse)  and opsin Rhodopsin.
added  Rhodopsin
Electrical changes:
Regeneration of rhodopsin:
Upon exposure to light, rhodopsin becomes
Rhodopsin regeneration entails the activated and triggers a complex cascade of
conversion of the dormant Metarhodopsin II metabolic events, culminating in the
back into its active state, rhodopsin. The generation of receptor potential in the
process is referred to as rhodopsin photoreceptors. This process involves the
regeneration or visual pigment renewal. conversion of light energy into electrical
Maintaining light sensitivity in the retina,
energy or nerve impulses, which are then
particularly in low light conditions, is crucial. communicated to the brain via the visual
The regeneration of rhodopsin is
pathway (9).
accomplished by a sequence of metabolic
events that involve the conversion of retinal Visual impulse processing and
(a derivative of Vitamin A) back into its transmission:
active forms, namely 11-cis-retinal. Enzymes
and other biological components in the The visual system undergoes a complex
retinal cells aid in facilitating this process. sequence of stages to analyse and transmit
Rhodopsin regeneration is essential for the visual impulses. The concise summary:
eyes to adjust to varying light circumstances • Photoreception in the Retina
and is a critical component of the visual
cycle, maintaining the uninterrupted Signal transduction in photoreceptor cells
operation of the visual system (7, 8). initiates a series of interconnected actions.

Rhodopsin undergoes a sequence of changes • Signal propagation to bipolar cells

when it is exposed to light. The sequence of The bipolar cells transfer signals to the
transformations is as follows: ganglion cells.
bathorhodopsin is initially formed, which
then converts into lumirhodopsin, and then The formation of the optic nerve occurs when
into metarhodopsin I and metarhodopsin II. the axons of ganglion cells come together to
This process results in the production of all- create the optic nerve.
trans retinal, which is then transformed into
The optic chiasma is a structure in the brain
all-trans retinol (vitamin A) by the reduction
where the optic nerves partially cross over.
of NADH to NAD. Subsequently, the all-
trans retinol undergoes isomerization to • The optic tract transmits visual information
become 11-cis-retinol, which is further to the lateral geniculate nucleus (LGN)
transformed into 11-cis-retinal by oxidising located in the thalamus.
NADH to NAD. Ultimately, the 11-cis-
retinal and opsin merge to restore rhodopsin The visual cortex receives visual signals from
(7). the thalamus and is located in the occipital
lobe. The visual cortex is accountable for the

10 | P a g e
subsequent processing and interpretation of Photoperception - It is the cognitive
visual inputs. recognition of light.
• Higher Visual Processing: Visual • Light minimum - The lowest level of
information undergoes processing in several brightness needed to elicit a perception of
higher visual regions beyond the primary light. The measurement should be taken
visual cortex, enabling the perception, when the eye has undergone dark adaptation
recognition, and interpretation of complex for a minimum of 20 - 30 minutes.
visual situations. The visual pathway is now
understood to consist of two distinct The human eye has the ability to function
pathways: the magnocellular route, correctly in a broad range of lighting
comprised of big cells, and the parvocellular conditions throughout the day due to a
pathway, comprised of tiny cells. These can complicated process known as visual
be likened to two lanes of a road. The M route adaptation (10).
and P pathway are engaged in the The process of visual adaptation primarily
simultaneous processing of the picture, involves:
namely in the examination of distinct
characteristics of the image (8 ,9). Dark adaptation refers to the process of
adjusting to low levels of light. Dark
Difference in sensitivity of M and P cells to adaptation is the eye's capacity to adjust to
stimulus features: lower levels of light, allowing it to transition
from brilliant sunshine to a poorly lit space.
Colour contrast. M cell. - No. P cell. - Yes
This process takes time and involves the
Luminance contrast. M cell. - Higher. P cell. increased sensitivity of rods, which are more
- Lower sensitive than cones. The illness of RDS,
such as Retinitis Pigmentosa and Vitamin A
Spatial frequency M cell - Lower P cell - insufficiency, leads to a delay in the process
Higher of dark adaption (11).
Temporal frequency M cell - Higher P cell • Light Adaptation refers to the process of
- Lower. acclimating to intense lighting conditions.
VISUAL PERCEPTION When an individual transitions abruptly from
a dimly lit environment to a brightly
Visual perception refers to the cognitive illuminated one, their retina adjusts to the
process by which the brain comprehends and heightened light intensity, causing an
gives meaning to visual stimuli that are increase in the visual threshold. This rapid
received via the eyes. The process adjustment process is referred to as light
encompasses many phases of processing that adaptation, which typically takes around 5
convert unprocessed visual data into minutes to complete. Light adaptation
meaningful perception. The organisation of essentially supersedes the previous state of
the receptive fields in the retina and brain is dark adaptation.
utilised to encode information pertaining to a
visual picture. The fundamental components The Form sense
of visual perception encompass the ability to Sense refers to the capacity to distinguish the
see light, discern forms, perceive contrasts, form or structure of items. The cones play a
and distinguish colours (10). significant role, and the sensation of shape is
most vivid near the fovea, where they are

11 | P a g e
densely packed and highly distinct. The separate visual items. Crucial elements of the
perception of form is not just dependent on sensation of contrast encompass (12):
retinal function, but also involves significant
• Luminance Contrast refers to the disparities
physiological processes( 10).
in brightness or intensity between
Element of visual sharpness neighbouring regions.
Visual acuity refers to the clinical • Colour Contrast - Variances in hues among
measurement of the ability to distinguish objects or areas contribute to the sense of
between two spatially distant targets, which colour.
is mostly dependent on the function of the
• Texture Contrast-Variance refers to
fovea.
variations in texture, such as disparities in
• Minimum visibility refers to the capacity to patterns or surface roughness.
discern the presence or absence of an item.
• Spatial Contrast - Describes variations in
Resolution pertains to the capacity to spatial frequencies that impact the ability to
differentiate between two objects situated at see intricate details or patterns.
distinct places. The histological diameter of a
cone in the foveal region measures 0.004 Temporal Contrast refers to variations in
mm. Therefore, this signifies the most visual stimuli across time, including
concise distance between two cones. In order alterations in brightness or motion.
to produce an image that is at least 0.004 mm Contrast sensitivity refers to the capacity to
in size, the object must generate a visual perceive differences in contrast levels.
angle of 1 minute at the nodal point of the
eye, which is referred to as the Minimum Various variables including as ageing,
Angle of Resolution (MAR)( 5 ) . refractive errors, glaucoma, diabetes, optic
nerve illness, and lenticular alterations might
Clinical tests for visual acuity assess the eye's impact contrast sensitivity.
capacity to see shape or read.
Colour Perception
Recognition refers to a cognitive task that
involves identifying or acknowledging Colour sense, or colour perception, is the
something. capacity of the human visual system to
interpret and differentiate between different
Furthermore, considering spatial resolution. wavelengths of light, leading to the
In order to achieve recognition, the individual experience of diverse hues. Colour vision is
must possess both familiarity with the set of primarily dependent on the cones, making it
test figures used and the ability to more pronounced during photopic vision
successfully answer them. The identification (daylight vision). In poor lighting conditions
of faces is the most prevalent example of the (scotopic vision), all colours appear as shades
recognition phenomenon. of grey. This phenomenon is known as the
Purkinje shift. The salient aspects of colour
Perception of Disparity
perception encompass(11):
The concept of Contrast pertains to the visual
system's capacity to discern disparities in. The colour vision mechanism refers to the
Differences in brightness, colour, or texture physiological process by which humans see
can be observed between neighbouring or and distinguish different hues. The process is
primarily facilitated by three types of cones
in the eye that are responsive to distinct

12 | P a g e
wavelengths of light: short (blue), medium • Cranial Nerves - The regulation of ocular
(green), and long (red). movement is governed by three cranial
nerves: the oculomotor nerve (CN III),
• Colour blending - The brain perceives trochlear nerve (CN IV), and abducens nerve
colours by combining impulses from three (CN VI).
types of cones.
The extraocular muscles function in pairs
The user's text is a bullet point. with opposing activities to generate eye
The colour spectrum encompasses the range movement.
of visible light, extending from the shorter-
Eye movements can be conjugated, meaning
wavelength violet to the longer-wavelength that both eyes move simultaneously in the
red. same direction. This allows for synchronised
• Primary Colours - In the RGB (Red, Green, visual tracking.
and Blue) colour paradigm, are considered • Vergence Movements: These movements
the fundamental colours. refer to the inward movement of the eyes
The Opponent Process Theory explains (convergence) or the outward movement of
colour perception by proposing that brain the eyes (divergence) in order to preserve
processes in the visual system operate in binocular single vision.
opposition to one other, namely in the case of • Saccades refer to rapid and voluntary eye
red vs green and blue versus yellow. movements that transfer the focus from one
• Color Constancy - The capacity to see the location to another.
unchanging colour of an item regardless of Smooth Pursuit refers to the deliberate and
variations in lighting circumstances. uninterrupted eye movements that enable the
• Cultural and Individual Variation- The tracking of a moving object. Operated by
perception of colour can differ among Pursuit System.
individuals as a result of variables such as The optokinetic reflex is a visual response
genetics and age. that combines both pursuit and saccadic eye
• Color Vision Deficiency - Certain movements in order to track a moving object.
individuals experience defects in one or more Aids in maintaining visual stability
types of cones, resulting in colour blindness. throughout prolonged movement.
The predominant forms of colour blindness The Vestibulo-ocular Reflex (VOR) is a
are red-green and blue-yellow colour vision mechanism that synchronises eye movements
deficiencies (11). with head movements in order to provide
The study of the movement of the eyes and steady vision when the head is in motion.
the coordination of vision from both eyes. Requires input from the Vestibular System.
Ocular motility physiology encompasses the Regulating ocular motility is crucial for
synchronised actions of the muscles ensuring clear and steady vision during a
responsible for precise visual tracking and range of tasks, such as reading and tracking
alignment. The concise summary: moving objects. The incorporation of visual,
vestibular, and proprioceptive stimuli
The motions of each eye are controlled by six guarantees the precision and effectiveness of
extraocular muscles. ocular motions.

13 | P a g e
 is essential for performing a wide range of
daily activities accurately and effectively.
Stereoscopic Vision
Binocular vision is the capacity to utilise both
eyes at the same time in order to experience a Reference
singular, three-dimensional representation of
one's environment. Important components of 1. Bowmaker, J. K. (1998). Evolution of
colour vision in vertebrates. Eye, 12(3), 541-
binocular vision encompass (13):
547.
Stereopsis refers to the visual sense of depth
and the capacity to accurately assess the 2. Krag, S., & Andreassen, T. T. (2003).
Mechanical properties of the human lens
distance of objects.
capsule. Progress in Retinal and Eye
Binocular disparity refers to the little Research, 22(6), 749-767.
variation in the pictures of an item that are
3. Lichtinger, A., & Rootman, D. S. (2012).
perceived by each eye on the retina.
Intraocular lenses for presbyopia correction:
Convergence refers to the inward movement past, present, and future. Current opinion in
of both eyes in order to focus on a close ophthalmology, 23(1), 40-46.
object.
4. Buisseret, P. (1995). Influence of
Binocular summation is the process by which extraocular muscle proprioception on vision.
visual perception is improved, particularly in Physiological reviews, 75(2), 323-338.
low-light situations, by the integration of
5. Bloomfield, S. A., & Völgyi, B. (2009).
information from both eyes.
The diverse functional roles and regulation of
Binocular rivalry is a phenomenon that neuronal gap junctions in the retina. Nature
happens when conflicting pictures are Reviews Neuroscience, 10(7), 495-506.
presented to each eye, resulting in a perceived
6. Do, M. T. H., & Yau, K. W. (2010).
shift between the two images.
Intrinsically photosensitive retinal ganglion
Visual Field Overlap refers to the ability to cells. Physiological reviews.
see a wide range of objects and events,
7. Imamoto, Y., & Shichida, Y. (2014). Cone
including those in the periphery, which is
superior than the limited field of view visual pigments. Biochimica et Biophysica
Acta (BBA)-Bioenergetics, 1837(5), 664-
provided by monocular vision.
673..
The brain creates a "cyclopean eye" by
merging information from both eyes to 8. Zhou, X. E., Melcher, K., & Xu, H. E.
(2012). Structure and activation of rhodopsin.
generate a cohesive visual perception( 13).
Acta Pharmacologica Sinica, 33(3), 291-299.
The benefits of binocular vision include
enhanced depth perception, precise distance 9. Senin, I. I., Koch, K. W., Akhtar, M., &
estimate, improved visual acuity, and Philippov, P. P. (2002). Ca2+-dependent
control of rhodopsin phosphorylation:
increased contrast sensitivity.
recoverin and rhodopsin kinase.
Binocular vision normally emerges Photoreceptors and Calcium, 69-99.
throughout infancy when the visual system
matures and the brain learns to combine 10. Saito, H. A. (1983). Morphology of
information from both eyes. Binocular vision physiologically identified X‐, Y‐, and W‐type

14 | P a g e
retinal ganglion cells of the cat. Journal of
Comparative Neurology, 221(3), 279-288.
11. Solomon, S. G., & Lennie, P. (2007). The
machinery of colour vision. Nature Reviews
Neuroscience, 8(4), 276-286.
12. Yau, K. W., & Hardie, R. C. (2009).
Phototransduction motifs and variations.
Cell, 139(2), 246-264.
13. Harris, K. D., & Mrsic-Flogel, T. D.
(2013). Cortical connectivity and sensory
coding. Nature, 503(7474), 51-58.

15 | P a g e
Visual Acuity & Clinical Refraction

Arup Saha,
D.Pharm, B.Optom, M.Optom
Assistant Professor
Department of Optometry
Swami Vivekananda University

16 | P a g e
 clinical refraction. It is a technical way to
Visual Acuity & measure the eye health about its refractive
Clinical Refraction status. Cornea and lens are called as major
refractive surface as it is responsible for light
refraction to project it properly on the visual
sensitive retina to form the image and
responsible for visualization. Sometimes
pathological, mechanical or developmental
2.1 Introduction
facts can affect its quality to support the
In the field of optometry “Refraction” is refraction process by affecting its anatomical
described as a clinical procedure to asses health like transparency, curvature, refractive
refractive condition of a patient eye to rule index etc. Aim to clinical refraction is to rule
out refractive errors also termed as ametropia out the errors and finding its best correction
to provide appropriate refractive correction to improve the vision quality.
and power prescription. Now a day’s
Visual acuity can be described as the
refractive error is quite common and from the
acuteness `of vision that is the ability of an
research study we can find a huge percentage
individual patient how better quality it can be
peoples significantly pediatric group of
visualized/A is a compulsory assessment and
patients suffering from refractive errors. To
step of clinical refraction conducted to see the
prevent avoidable blindness from a country it
refractive ability in distance and near both
is mandatory to provide appropriate
monocular and binocular mode. Different
correction among maximum population.
types of charts are available like Snellen’s
In this chapter we will discuss in detail about chart, log MAR Charts, tumbling E charts,
ocular health examination including vision LEA symbol charts etc. normally used in
assessment, Subjective & objective type of clinical refraction. Following the quality of
refraction, different types of charts used in visual acuity objective and subjective
refraction process, basic skill to retinoscopy refraction conducted to do measurement,
performing to estimate about the errors, correction, refinement and prescription for
trial& error process to find patient individual managing refractive errors. Trial box, trial
refractive power acceptance, power lenses including spherical and cylindrical
refinement processes, binocular balancing lenses, Maddox rod, set of prisms, pinhole,
and making power prescription with its Red & Green filters, stenopic slit etc. are the
components and proper format. All of these regular instruments for refraction processes.
are the vital points of clinical refraction Beside this W4dot test, Duo Chrome test,
procedure to find the best correction and JCC etc. are also important for binocular
enhancing vision quality. In this discussion balancing and corrective power refinement.
we have tried to discover on clinical Here all clinical steps, indications, necessary
significance, necessary equipment’s, test instruments, factors interfering, evaluation,
procedures, cautions, proper patient interpretation, estimation methodology will
management and refractive errors correction. be focused.

2.2 Significance 2.3 Visual Acuity

Clinically assessment of refractive errors and Visual acuity can be described as the
finding its proper corrections termed as sharpness of vision that means the ability of

17 | P a g e
an individual patient to see the clear image at 2.3.1 Clinical procedure to measure visual
the distance both distance and near. As per acuity:
measurement with Snellen visual acuity chart
it can be determined as 20/200 0r 6/60 that is  To asses visual acuity at first need
a ratio regarding the letter optotypes in the to verify about light source of
chart and measurement distance at 20 feet or vision chart, room illumination,
6 meters at distance. Near vision distance patients’ ability to seat properly
normally taken as 33cm to perform daily and the distance measurement. In
reading activities.20/200 means the case of symbol identification need
assessment of visual acuity targeting to provide proper direction to the
particular optotypes with a specific letter size patient so that they can help to
that can be visible by an emmetropic patient provide positive response
from 200 meters away but these are visible to according to their visual ability.
that particular subject patient from 20 meters  In case of outdoor camp vision
only. About the components of vision, it can screening, vision chart should
be described as minimum visible, resolution, keep in a proper illuminated place.
recognition and minimum discrimination.  For the 6-meter Snellen chart
Minimum angle of resolution (MAR) is an patient need to sit properly at 6
important part of visualization when light meters away from the chart and in
rays from the target objects are able to form some time for the low space mirror
at least 1 minute of arc visual angle at the is used to manage as it can double
nodal point of eye responsible to make visual the visual distance.
differences between two spatially separated  If patient already have the power
target points. As per diagnostics procedures correction, then we need to asses
to measure visual acuity following vision wearing power correction to
follow up previous diagnosis
equipment’s are needed.
termed as aided vision.
 Snellen /log MAR visual acuity  For the monocular vision test we
chart as distance and near target. need to occlude another eye with
 Occluder to block one eye for the help of blocker. Patient have to
monocular vision assessment. read or identify the largest to
 Pinhole to observe central vision maximum smallest pattern
quality. according to the patient capability
 Torchlight to asses light .Patient is directed to read from the
perception and projection. left of a particular line to the right.
 Appropriate medical records to In case of illiterate patient asked
note the acuity result. about pattern or direction of letter.
Tumbling E chart is used mostly.
In case of visual acuity check up by wearing  Patient is asked about to read the
previous power glass can be termed as aided smallest line and letters as per
vision and without wearing any corrective capability. Each line from the
glasses can be termed as unaided vision. If Snellen vision chart has particular
patient already have power prescription, then value expressed as a fraction like
Optometrist practitioner normally preferred 6/12 or 6/9.Here the upper number
to take aided visual acuity to continue patient is the distance between the patient
previous visit follow up. and chart (6 meter).Lower number
also means the distance about the

18 | P a g e
 measurement of that particular
optotypes so that normal or
emmetropic is able to read the  If patient is able to count fingers
same size optotypes from that from 1 meter, then it can be
mentioned distance in meter. So, if recorded as CF at 1 meter but if
patient is able to read 6/9 without failed the need to closer again to
correction with the help of right check hand movement. If patient
eye, then it can be said that give positive response, then it is
Unaided vision of OD =6/9.6/9 recorded as Hand movement close
means that particular line or to the face.
optotypes size can be seen by a
normal emmetropic patient from 9  When patient failed to identify
meters but that particular patient hand movement then next step is to
can see or identify that from the 6 check the light perception. If
meters. patient is able to identify light
perception and projection then it is
 Pinhole is used check the central recorded as PLPR+.
vision by blocking the peripheral
light rays and aberrations. So, if
patient have the visual acuity  If patient unable to response about
OD=6/12 and improved with light perception, then recorded as
pinhole to the smallest line can be NPL that means no light
recorded as with ph vision 6/6. perception.

 Need to repeat total procedure for

 If patient is able to read 6/18 with another eye.
unaided vision and 3 letters from
the next line that it can be write as
6/18+3 and if it is improved with
pinhole vision to 6/6 then it is
determined that refractive error  Report can be summarized as
can be correct up to 6/6. OD=6/12 unaided with pinhole 6/6
OS=6/18 unaided with pinhole 6/6
 If patient unable to see the top
most largest letter then needs to
reduce 1 meter the distance 2.4 Different types of vision chart use in
between chart and patient eye until refraction
it become visible. It can be
recorded as 3/60 as the distance
between chart and patient eye Vision charts normally use to provide target
reduced from 6 meters to 3 meters optotypes to the patients as part of vision
to make it visible. But if patient assessment. Patients are directed to read or
failed again to identify the largest identify the patterns staring from the largest
letter from 1 meter, then need to size to the smallest according to patient
ask about the hand movement and capability. Snellen chart is mostly used
finger counting. clinical purpose. Beside this Tumbling E
chart is also available as illiterate chart. Each

19 | P a g e
optotypes are constructed in such a way that emmetropic eye if placed at 24 meters away
it can form 5 minutes of arc visual angle. As from the eye but visible by that particular
example 6/9 optotypes are constructed in patient when kept at 6 meters’, D, E, F, L, N,
such a way that it can form visual angle of 5 O, P, T, and Z are the letters that specially
minutes of arc from 9 meter at the nodal point designed to construct the chart. By occluding
of an emmetropic eye. Log MAR chart one eye patient is directed to read the letters
mostly used in glaucoma and diabetic cases from top and largest to the smallest line as per
to observe mild visual improvement as patient possibility to recognize.
because more perfection of V/A assessment.
2) Log MAR Chart

Log MAR chart invented and developed by

1) Snellen Chart
Jan E Lovie Kitchin and Lan Baily that’s why
it also called as Baily Lovie chart. Optotype
principles and construction are same but
about to visual acuity measurement it is more
specific. It has equal progression and each of
letters can give specific acuity measurement.
Chart contains 14 lines and each line each of
line made up of 5 letters with standard
spacing. Logarithm of MAR (minimum angle
of resolution) help to determine the score of
visual acuity assessment according to log
MAR chart. If Snellen score is 20/20 then
MAR can be calculated as 20/20=1.So log
MAR of 1 score 0 that can form 1 min of arc
visual angle.

3) Landolt C

Landolt C chart established and developed by

Snellen’s visual acuity chart was invented by Edmund Landolt. Chart consists of broken
Herman Snellen during 1862 to check visual ring which are the target optotypes. Similar
acuity. It contains optotypes 5x5 unit grades as Snellen chart letter size gradually become
that is able to form 5 minutes of arc visual smaller from top to downwards. Ring
angle for a particular distance. That distance optotypes has small gap or broken part so
considered as 6 meters or 20 feet between the patient is directed to find that broken part.
chart and patient eye. The chart consists of 11 This broken part or small gap can be located
lines of block letters denote visual acuity as a at upper or lower position and also can be at
fraction right or left. Similar as the Snellen chart ring
6/60,6/36,6/24,6/18,6/12,6/9,6/6,6/5. If optotype also constructed as 5x5 grid unit so
patient is able to see the letter mentioned as it can form 5 minutes of arc visual angle
6/24 that means that particular letter can form when minimum 1 min of arc visual angle is
visual angle 5 minutes of arc in an needed to make difference between two

20 | P a g e
spatially separated points. Patient sit 6 meters basically depends on calculation
away from the chart so that visual acuity can interpretation and evaluation with the help of
be recorded as 6/9 ,6/6. equipment’s and machine-like auto-
refractometer, retinoscopy etc. Objective
refraction is the initial part of refractive error
4) Tumbling E assessment. Static Retinoscopy, Dynamic
retinoscopy, autorefractometry etc. are the
Tumbling E chart is also similar as Landolt C significant point under objective part.
chart but difference is that here only English Subjective refraction depends on patients’
letter E is used without other letters. Similar response and it is part of refractive error
as Snellen chart it is also constructed as 5x5 examination with help of trial lenses, trial
unit grid and able to form 5 minutes of arc frame, vision chart, pinhole, Maddox rod,
visual angle from a particular distance. stenopic slit, astigmatic fan and block,
Patient id directed to identify the direction of Jackson cross cylinder, fogging technique
E open side. It is designed as all direction like etc. After clearing objective part, we can find
up, down, right and left. If patient able to estimation about the refractive errors. Then
identify the smallest line E letter direction according to the result, we perform
denoted as 6/6 that means it can form 5 monocular subjective corrective correction to
minutes of arc visual angle from the 6 meters find best acceptance using spherical and
distance. cylinder lenses. Trial and error method used
to find the best sphere and cylinder power
5) Lea test chart correction according to the patient’s
refractive demand. Duo chrome test is helpful
to find over or under correction and JCC,
Lea test chart developed and designed based astigmatic fan & block, stenopic slit etc. used
on symbol optotypes so that paediatric find cylinder power with proper axis
patient not able to read properly can identify alignment. After completing subjective
the patterns. Lea symbol chart also developed correction all procedure both at distance and
to assess colour vision, contrast sensitivity near, it is needed to perform binocular
etc. Normally patterns used to construct the balancing also with help of Duchrome test
chart like circle, pentagon, square etc. All that with fogging, prism dissociation etc.
patterns quite different from each other and
patient directed to identify the patterns with
different size. 2.6 Cycloplegic refraction
Cycloplegic refraction normally performed
to rule out the latent problems like latent
hypermetropia, accommodation excess, etc.
In case of pediatric patient or school going
2.5 Subjective & Objective refraction
patient accommodation is highly active.
Total refraction procedure can be classified Excessive near work is also responsible for
into subjective and objective part. Subjective accommodative problems. Mydriatic drugs
means active participation of patient with are used to relax the circular muscle so that it
response when patient response plays a will not affect normal refraction. Cycloplegic
significant role to find the correction. On the drugs like cyclopentolate can create
other hand, during objective refraction temporary paralysis used to relax high

21 | P a g e
accommodation. Due to high accommodative
power artificially, myopia may occur but it
can be unmasked if accommodation relaxed.
But in case of Cycloplegic refraction it will
take times to create effect. So, refraction done
before drug application and also need to
repeat that again when drug application
become effective. So, the interval between
refraction without drug effect and after dug
instillation depends on the drug. Within 30
minutes Cyclopentolate can create total
accommodative relaxation and after 3 hours
approximately effect will be lower but dilated
pupil may take 24 hours to become normal. Retinoscopy is the objective way of
Atropine may take minimum 3-4 days to refraction to estimate the refractive errors.
become normal but in case of adverse effect Retinoscopy works on Illumination stage,
or complication it must be stopped projection stage and reflex stage. Based on
immediately. illumination technique it can be divided as
2.7 Retinoscopy self-illuminated streak retinoscope and plane
mirror or Priestley smith (both concave and
Retinoscopy is a significant part of objective plane effect) retinoscope. In case of plane
refraction to find out estimation about the mirror retinoscope additional light source is
refractive errors. As per procedure it can be needed to reflected by the mirror and
divided into static and dynamic. In case of projected into patient’s eye retina. When the
static refraction accommodation will be at light rays reflected off from the retina it is
rest because patient s directed to focus at a observed by the observer through the peep
distant point or target. For a normal patient hole to evaluate the nature of retinal reflex.
far point is located at infinity but in case of That retinal reflex observed by the
refractive errors like myopia it become finite. practitioner, its nature (with motion or
So, by neutralization of the papillary reflex against motion) depends on the refractive
observed by retinoscope we can detect status of the patient’s eye. Retinal reflex
estimate error values. occurring when light rays projected into
If accommodation become functioning patients’ eye and illuminated retinal area then
instead of relaxing as target is located nearby the light rays reflected off from the retina
to the eyes, then it is termed as dynamic specifically from that illuminated area focus
retinoscopy. on the observer eye to view the image of that
illuminated area that depends on patients’
refractive status.
Principles: In case of static retinoscopy far point located
at the infinity but when it located between
patients’ eye and infinity point, patient
become myopic and if the far point located
behind the infinity, patient become
hypermetropic.

22 | P a g e
According to the retinoscopy observation direction to the streak can be
when patient focusing at distance target point termed as against motion. When
and accommodation is at rest, if far point is there will be total illuminated
located behind the retinoscope may cause pupillary reflex without motion
with reflex. When far point is located can be termed as neutralization
between the patient’s eye and retinoscope point.
may cause against reflex. If far point located  Observer normally performs
at the retinoscope plane then neutral effect retinoscopy from 1 hand distance
may occur. that is 66 cm termed as working
distance. That will be
compensated later during
2.7.1 Static retinoscopy technique calculation of refractive power.
 Based on streak reflex nature, with
 If patient has previous medical movement can be neutralized with
data, then need to find the previous plus lens and against movement
glass prescription and aided visual will be neutralized with the minus
acuity. But if patient bearing no lens.
previous medical data, then need  Neutralization stage depends on
to start from unaided visual acuity the nature of streak reflex
and recording medical history. (intensity, width and speed of
 At the staring of retinoscopy motion).
patient is recommended to seat When the refraction steps will
properly so that patient eye level become closer to the neutralization,
and observers eye level can be the reflex will be wider, brighter and
adjusted with same height. faster.
 Retinoscopy performed under dim  In case of cross retinoscopy both
light room illumination because principle meridians need to be
dim illumination help observer to checked properly to find the
find the bright reflex. neutralization value. As example if
 Patient is directed to focus at the horizontal light reflex finds the
distance target point (like large power meridian 90 degree and
optotype) to make the vertical light reflex find the power
accommodation at relax. meridian 180 degree. Suppose
 During retinoscopy performing, horizontal reflex find
observation point of retinoscope neutralization at +2.00 and vertical
should be aligned with the reflex find data as +1.50.It can be
patient’s visual axis. written as
 Light source from the streak
retinoscope projected into +1.50
patients’ eye to find the red reflex.
 Need to observe to movement of
red reflex associated with the +2.00
streak movement. If the reflex
movement observed similar
direction with the steak termed as
with motion. If streak reflex
motion observed as the opposite

23 | P a g e
  Astigmatism means the different 2.7.2 Dynamic retinoscopy:
refractive powers existed in Unlike static retinoscopy, accommodation is
different meridians. In such cases active because patient is directed to focus t
at first need to neutralize the most nearby object located at the same line with
prominent with motion steak the peephole. Dynamic retinoscopy
reflex and the Cylinder axis will be recommended for the patient suffering from
90 degrees away from the accommodative excess, ill sustain, spasm or
previously neutralized well insufficiency cases. This is the objective way
defined streak reflex meridian. In to check the accommodative functions.
case of finding correct axis reflex During dynamic retinoscopy patient is
will be found as narrow and directed or encouraged to utilize
brighter. accommodative ability.
 After getting the both meridian
neutralized powers need to Procedure:
compensate the working distance.  To perform dynamic retinoscopy,
For the 1 hand distance 66cm need need to sit patient properly same as
to deduct power amount static technique as eye level of
calculation like that inverse of patient and observer should be
100/66 meter (working distance same.
should be in meter). That is 1.51D.  Dim light illumination preferred to
 So, after the hand distance perform retinoscopy because light
calculation it can be estimated as reflex can be observed properly.
  Patient is directed to see the near
+/- plano object to stimulate the
(vertical axis) (meridian a) accommodation. Dim light
allowed seeing the near object
properly.
+0.50 (horizontal axis) (meridian b)  Based on retinoscopy technique it
can be classified as Mahendra,
MEM, NOTT, BELL retinoscopy
etc.
So as per finding if we consider plano  During near retinoscopy distance
(meridian a) for the spherical power then the correction should be given to make
cylinder power calculation will be (meridian the far point at infinity.
b – meridian a).so here calculated value is  At the beginning patient is directed
+0.50D and axis is 180 degree. to see the distance and that time
We can write estimate power value as pupillary reflex need to be
observed though retinoscopy. In
+/_Plano/ +0.50 x 180 degree.
case of normal patient with
 In case of presbyopia correction movement can be seen.
additional power given over the  Retinoscopy should perform from
distance power according to the reading distance. Near target
patient age, acceptance and should be located at the same line
reading or working distance. with the peephole.

24 | P a g e
  Then gradually patient will focus 3. Kaur K, Gurnani B. (Updated
from distant point to the near 2023,June11).Statpearls.Treasure Island,
object that stimulates Subjective refraction techniques.
accommodation. http://www.ncbi.nlm.nih.gov/books/NBK58
 Due to changing focus from 0482/
distance to near it will create
accommodative demand so in case 4. Marsden, J. (2014). How to measure
of normal eye slightly against distance visual acuity. PubMed Central
movement we can see. Then we (PMC).
can note that as accommodation https://www.ncbi.nlm.nih.gov/pmc/articles/P
can act rapidly with complete and MC4069781/
steady. 5. Disha_Eye_Hospital. (2018, March 14).
17Interesting Facts on Eye Chart -Disha Eye
care.Disha Eye Care.
https://www.google.com/amp/s/www.dishae
ye.org/blog/17-interesting-facts-eye-chart/
6. Isdin Oke (2023, July 10). Retinoscopy-
Eye Wiki
https://eyewiki.org/Retinoscopy#:~:text=Ret
inoscopy%20is%20an%20exam%20techniq
ue,light%20in%20a%20patient's%20pupil.R
 In case of dull glow, greater
etinoscopy
against movement may occur due
to excess action and greater with 7. Mark E Wilkinson, (ODJanuary 2016)
motion can be a sign of sluggish Plus Cylinder Subjective Refraction
action or lag of accommodation. Techniques for Technicians| General
Refraction Techniques page 1-
7https://webeye.ophth.uiowa.edu/eyeforum/
video/Refraction/pdfs/Std-subj-Refract-Plus-
Cyl-Tech-s.pdf
Reference:
8. Duochrome test-Eye wiki (n.d)
1. 2020-2021. BCSC Basic and Clinical https://eyewiki.org/Duochrome_Test
science Course. American Academy of
Ophthalmology. 9. Eyemantra. (2023, January 23).Eyeglass
https://www.aao.org/education/bcscsnippetd prescription|OD&OS| RX Information.
etail.aspx?id=2db1ca5e-45e0-45e8-9991- EyeMantra.
8955754ffd8c https;//eyemantra.in/eyeglasses/eyeglasses-
prescription/
2. Themes,U. (2020,November 28).Clinical
Refraction.Ento Key.
https://entokey.com/clinical-refraction-/

25 | P a g e
Introduction to Refraction
&
Ophthalmic Dispensing

Arup Saha,
D.Pharm, B.Optom, M.Optom
Assistant Professor
Department of Optometry
Swami Vivekananda University

26 | P a g e
 prisms,pinhole,Red & Green filters,stenopic
Introduction to Refraction slit etc. are the regular instruments for
refraction processes.Beside this W4dot
& test,DuoChrome test,JCC etc. are also
important for binocular balancing and
Ophthalmic corrective power refinement. Here all clinical
steps,indications, necessary
Dispensing instruments,factors interfering,evaluation,
interpretation,estimation methodology will
be focused.
3.1 Introduction
Clinically assessment of refractive errors and
finding its proper corrections termed as
clinical refraction.It is a technical way to
measure the eye health about its refractive 3.2 Subjective & Objective refraction
status.Cornea and lens are called as major
refractive surface as it is responsible for light Total refraction procedure can be classified
refraction to project it properly on the into subjective and objective part. Subjective
visualsensitive retina to form the image and means active participation of patient with
responsible for visualization. response when patient response plays a
Sometimespathological, mechanical or significant role to find the correction. On the
developmental facts can affect its quality to other hand, during objective refraction
support the refraction process by affecting its basically depends on calculation
anatomical health like transparency, interpretation and evaluation with the help of
curvature, refractive index etc.Aim to clinical equipment’s and machine-like auto-
refraction is to rule out the errors and finding refractometer, retinoscopy etc. Objective
its best correction to improve the vision refraction is the initial part of refractive error
quality. assessment. Static Retinoscopy, Dynamic
retinoscopy, autorefractometry etc. are the
Visual acuity can be described as the significant point under objective part.
acuteness `of vision that is the ability of an
individual patient how better quality it can be Subjective refraction depends on patients’
visualized/A is a compulsory assessment and response and it is part of refractive error
step of clinical refraction conducted to see the examination with help of trial lenses, trial
refractive ability in distance and near both frame, vision chart, pinhole, Maddox rod,
monocular and binocular mode.Different stenopic slit, astigmatic fan and block,
types of charts are available like Jackson cross cylinder, fogging technique
Snellen’schart,log MARCharts, tumbling E etc. After clearing objective part, we can find
charts,LEA symbol charts etc. normally used estimation about the refractive errors. Then
in clinical refraction. Following the quality of according to the result, we perform
visual acuity objective and subjective monocular subjective corrective correction to
refraction conducted to do find best acceptance using spherical and
measurement,correction, refinement and cylinder lenses. Trial and error method used
prescription for managing refractive errors. to find the best sphere and cylinder power
Trial box,trial lenses including spherical and correction according to the patient’s
cylindrical lenses,Maddox rod,setof refractive demand. Duo chrome test is helpful

27 | P a g e
to find over or under correction and JCC, with reflex. When far point is located
astigmatic fan & block, stenopic slit etc. used between the patient’s eye and retinoscope
find cylinder power with proper axis may cause against reflex. If far point located
alignment. After completing subjective at the retinoscope plane then neutral effect
correction all procedure both at distance and may occur.
near, it is needed to perform binocular
balancing also with help of Duchrome test
with fogging, prism dissociation etc. 3.3.1 Dynamic retinoscopy:
Unlike static retinoscopy, accommodation is
active because patient is directed to focus t
3.3 Retinoscopy
nearby object located at the same line with
Retinoscopy is the objective way of the peephole. Dynamic retinoscopy
refraction to estimate the refractive errors. recommended for the patient suffering from
Retinoscopy works on Illumination stage, accommodative excess, ill sustain, spasm or
projection stage and reflex stage. Based on insufficiency cases. This is the objective way
illumination technique it can be divided as to check the accommodative functions.
self-illuminated streak retinoscope and plane During dynamic retinoscopy patient is
mirror or Priestley smith (both concave and directed or encouraged to utilize
plane effect) retinoscope. In case of plane accommodative ability.
mirror retinoscope additional light source is
needed to reflect by the mirror and projected
into patient’s eye retina. When the light rays Procedure:
reflected off from the retina it is observed by
the observer through the peep hole to  To perform dynamic retinoscopy,
evaluate the nature of retinal reflex. That need to sit patient properly same as
retinal reflex observed by the practitioner, its static technique as eye level of patient
nature (with motion or against motion) and observer should be same.
depends on the refractive status of the  Dim light illumination preferred to
patient’s eye. Retinal reflex occurring when perform retinoscopy because light
light rays projected into patients’ eye and reflex can be observed properly.
illuminated retinal area then the light rays  Patient is directed to see the near
reflected off from the retina specifically from object to stimulate the
that illuminated area focus on the observer accommodation. Dim light allowed to
eye to view the image of that illuminated area see the near object properly.
that depends on patients’ refractive status.  Based on retinoscopy technique it can
be classified as Mahendra, MEM,
In case of static retinoscopy far point located NOTT, BELL retinoscopy etc.
at the infinity but when it located between  During near retinoscopy distance
patients’ eye and infinity point, patient correction should be given to make the
become myopic and if the far point located far point at infinity.
behind the infinity, patient become  At the beginning patient is directed to
hypermetropic. see the distance and that time pupillary
According to the retinoscopy observation reflex need to be observed though
when patient focusing at distance target point retinoscopy. In case of normalpatient
and accommodation is at rest, if far point is with movement can be seen.
located behind the retinoscope may cause
28 | P a g e
  Retinoscopy should perform from the refinement then cylinder power
reading distance. Near target should be with axis and power meridian
located at the same line with the verification with JCC, stenopic
peephole. slit, Astigmatic fan and block chart
 Then gradually patient will focus from etc.
distant point to the near object that  Binocular balancing to enhance
stimulate accommodation. quality of single vision.
 Due to changing focus from distance Astigmatism mayoccur when
to near it will create accommodative curvature irregularity found.
demand so in case of normal eye  After distance correction, near add
slightly against movement we can see. power isprovided according to
Then we can note that as patient’s age, visual status and
accommodation can act rapidly with reading or near work distance.
complete and steady.  Pupillary distance measurement
 In case of dull glow, greater against (IPD) to align the eye properly
movement may occur due to excess without aberration.
action and greater with motion can be  Beside this optical center marking,
a sign of sluggish action or lag of segment height, segment top,
accommodation. segment drop, distance reference
point etc. are also necessary for
proper spectacle alignment.
3.4 Clinical procedures (Subjective  Prescription formatting and
refraction) advice.
During subjective refraction patients’
response is very significant as it helps to find 3.4.1 Discussion (Subjective Refraction)
the patient acceptance so that practitioner can
Next to the medical history
provide the best correction.
recording,Visual acuity measurement
As per methodology and objective correction estimation
need to start the subjective correction
 Visual acuity needs to record to find the best acceptance of power
under monocular condition both monocularly.
for distance &nearby. Aided if  Trial frame provided to patient and
patient bearing power spectacle or need to ensure about that patient is
medical record and unaided for the comfortable with that to see without
new patient not carrying medical any obstruction.
reports and previous follow up  With help of blocker need to block the
data. other eye.
 Need to perform objective method  According to the objective value
to find the estimation of refractive found earlier need to start correction
errors. with sphere lenses. In case of old
 Trial and error method monocular follow up then power glass
condition to find the acceptance. prescription also will be helpful.
 Power refinement and cross  Correction should be initiated with
checking to confirm about the weakest concave lens to correct
refractive power. Spherical power myopia or convex lens maximum

29 | P a g e
 value for the hypermetropia provide according to age binocularly
correction. from a particular reading or near work
 During lens trial, loose lenses from the distance and need to check that patient
trial box used to set into trial frame and can read or identify the smallest print
need to ask patient about the to have normal near vision.
improvement of vision.
 After providing the sphere correction
nearby to the final correction we can
trial +0.25,-0.25,+0.75,-0.75,+0.50,-
050 lenses over that.So that patient 3.5 Power verification:
may give response to the correction.
3.5.1 Fogging technique:
 After getting the best sphere if still
recognition problem reported about  Fogging performed to relax the
the smallest lines, then cylinder power accommodative reflex so that accurate
needs to trial. power can be finalized.
 Patient is asked that cylinder power  During the beginning of the procedure
vision improving or not. If improving need to provide pus lens over the
with the cylinder lens then we can correction according to the NRA value
align the axis according to the (Negative relative accommodation). In
objective correction. But if rejected case of sphero-cylinder correction we
then there is no cylinder power. Need can provide spherical equivalent
to verify with the pin hole. With pin power and over that we can do the
hole vision if improved visual acuity fogging procedure.
then need to verify with loose trial  After fogging up to 6/24 line we need
lenses again until best correction. to reduce fogging. To reduce fogging,
Same procedure repeated to another we need to place next lower plus lens
eye by occluding the recent corrected over the main convex lens that used to
eye. Fogg previously then we can remove
 After distance correction provided to that previous one.In such a way we can
both eye then occlusion eliminated to gradually decrease fogging amount to
see that binocularly patient is enhance vision clarity.
comfortable or not to see the normal  While finding the best acceptance
vision. We can check the powers by maximum plus lens is preferred. So, if
Fogging, Duo-Chrome etc. to verify the subjective correction value is
about the over correction o under +1.00 and during fogging reducing it
correction. JCC can be performed to is reported that clear vision observed
check the cylinder power both power at +1.25 then +1.25 is the final
meridian and axis meridian. Binocular power.In same way if the correction is
balancing method helps to align the -1.25 and during fogging it is found
corrective powers binocularly so that that patient feeling comfortable while
patient will have best vision using +0.50 over the previous
correction. correction -1.25.So,the final power is -
0.75 because maximus plus
acceptance preferred when minimum
 Next to the distance correction for the minus is acceptable.
presbyopia correction near add power

30 | P a g e
 3.5.2 Duo Chrome test:  If pin hole is provided over the
correction and if patient can see the
 Duo means two and Chrome means previously unreadable smaller line that
color.So, during the Duo Chrome test means more correction needed to
two colored optotype target chart achieve the best refractive power.
provided to find the acceptance
between two colors. 3.6 Cylinder power refinement:
 During the test green and red these two
colors preferred.Normally green  As part of cylinder power refinement
colorhas the tendency to focus 0.24D both the power meridian and the axis
in front of the retina and red color has meridian recheck is mandatory.
the greater wavelength sofocus 0.20D  Appropriate cylinder lens correction is
beyond the retina. needed to provide the sharper image
 So, incase of myopic patient have the quality.Here we will discuss briefly
tendency to see red colour better about JCC and astigmatic fan & block
because of focusing in front of retina technique.
soit can project red colour to the fovea
(visual sensitive part of retina). On the 3.6.1 JCC:
other hand, hyperopic eye can see the
green color better because due to  Jackson Cross Cylinder consists of
focusing beyond the retina it can drag two types of cylinder lens which are
the green colors upon fovea. equal strength but opposite power.
 The aim of the test to make the balance  Main principle of JCC technique is
between the powers sothat patient will collapsing Strums Conoid.
report both the colors are equally same  Commonly +/-0.25D and +/-0.50D is
or equally clear. used.
 In case of green color is better as  (Axis verification) To find the axis
reported by patient then we have to alignment need to adjust the JCC
add +0.25 and need to ask that both handle with the axis meridian of
colors are becoming equal clear or not. correcting cylinder lens and it is
Similarly,if patient reported red color performed under monocular condition.
has better clarity, then we need to  Next to alignment observer do the
provide -0.25 over the eye until patient flipping of JCC and patient is asked
will report both colored optotype are that which position is clear. If patient
equally clear. report the vision improvement while
flipping then need to rotate the
3.5.3 Pin hole: cylinder lens axis towards the red
marks for 10 degrees.
 Sometimes pin-hole plays greater role  Now again need to align the JCC
in sphere power refinement.Pin hole handle with the new axis and need to
has the central aperture and all the verify that patient can see clear in any
peripheral areas are blocked so, that it position or both position is blur. If
can reduce the aberrations occurring patient reports clear image while
from the peripheral rays blocking to flipping when red mark of JCC is
enhance the central vision. locating opposite position during the
previous lens alignment. So, it is

31 | P a g e
 reversal point and again need to rotate direction as 1 o clock or 3 o clock in
lens towards red line for 5 degrees. such types of direction.
This procedure continued until patient  If patient denote the fine line as 2 o
reports both flipping and placing clock, then it is 130 degrees.
position of JCC is appearing blur.  Need to apply cylinder power axis
 (Power verification) Need to align perpendicular to the 130 degree that is
JCC axis with the cylinder lens axis. 40 degrees and this will be continued
Then need to ask patient that is the until patient reports all meridian
vision becoming clear while flipping. equally clearer.
Due to flipping, + axis and then – axis  If overcorrection applied then only
both will align with the cylinder opposite axis may be clearer compare
correction lens axis so power will be o others. In such cases need to
decrease or increase by 0.25D(because decrease the power to make all
+/-0.25 JCC lens is using here).If meridian clearer.
patient reports clear vision while
aligned with minus lens then cylinder
power will be increased by 0.25.
 Need to continue that until patient 3.7 Binocular Balancing:
reports blur during both flipping sides. Binocular balancing performed at the last
phase of entire refraction procedure. It helps
to maintain balance between two eyes about
accommodative effects and equalization of
vision.
3.6.2 Astigmatic fan & block:
Here we will discuss shortly about alternate
Astigmatic fan used to find the cylinder occlusion technique, Prism dissociation test,
power refinement axis and power. Test is prism dissociation with duo chrome balance
performed monocularly. test as part of binocular balancing.
 Chart consists of radiating lines like
sun shine. Patient need to seat properly
and power correction provided. 3.7.1 Alternate occlusion technique:
 Fogging procedure performed to relax  Test initiated by blocking one eye and
accommodation so the axis ca be correction provided to both eyes.
verified easily.
 Rapidly need to alternate the occlusion
 Due to fogging both principle with a half of second interval so that it
meridian will become myopic but one will prevent stimulating
particular meridian will be closer to accommodative actions.
the retina. So, it is reported by patient  Fogging applied by +1.00 to both yes
as a clear line. so, V/A will become blurred up to 6/12
 If patient reports that all the lines are
 Patient is asked during alternate
equally clear then there is no occlusion about which eye can see
astigmatism. clearer.
 If patient reports clearer single line,  If patient reports that right eye feels
then need to find the direction. Patient clearer, need to increase fogging value
is asked to think the fan chart as clock
of right eye by adding +0.25 D until
dial. So that patient can make reply the

32 | P a g e
 patient reports that both eyes become
fogged equally.
 After that need to reduce the fogging y 3.7.3 Prism dissociation with Duo
+0.25 until best vision quality chrome:
achieved.  To perform the test 3Prism diopter
 As per patient response if right eye prism, loose convex lenses, Duo
accepted +0.25 extra fogging to chrome test chart trial frame all are
maintain balance between two eyes needed.
and the previous acceptance power is -  Test is conducted in dim light
1.75D then finally after balancing it illumination so that patient can see the
will be -1.50D and other eye will have target optotype letters clearly.
power same as previous acceptance  Similarly, as Prism dissociation test
because during balancing no extra need to provide base up prism to the
power required there. right eye and base down prism to the
left eye.
3.7.2 Prism dissociation test:  After that patient is directed to look at
 During prism dissociation test 3D the duo chrome test chart and
prism needed to perform the test and simultaneously +0.25 lenses provided
fogging also need to be applied. to both eye until patient report both the
 Fogging technique applied over the colour Red & Green can be seen
correction so that V/A will be reduced equally clear.
to 6/12.  Now patient is directed to see the
 Both eyes need to occluded with the lower image at the right eye and
blocker. Then 3 Prism Diopter applied gradually fogging lens power reduced
over right eye as base up and same until patient report the both colours on
applied over another eye as base duo chrome test chart is equally clear.
down.  Then patient is directed to see the
 Then occlusion is removed from to higher image at the left eye and same
eyes and asked to see the target about process applied to reduce fogging until
6/12 or best vision as per quality. black letters on both red & green
Patient directed to report that both colour background can be reported
eyes are equal blurring or not. If not equally clear.
blurring equally then +0.25 will be  Next to this step, prisms are removed
applied over the better eye having from both eyes and again fogged with
comparatively clear vision to make +1.00 lens then gradually reduced 0.25
equal blurring between two eyes. steps until achieving best maximum
 If patient replied about equal blurring, plus acceptance and having best visual
then gradually fogging and Prism will acuity.
be removed.
 If patients left eye needed +.25D extra
to maintain balance the vision and if 3.8 Components of power prescription:
the previous corrective subjective
power is -.00/1.00x180 degree then After achieving best power correction by
the final power will be -1.75/-1.00 x subjective and objective method, sphere
180 degree. & cylindrical refinement, completing
binocular balancing steps, distance &

33 | P a g e
near vision to confirm the final  PD means the Pupillary distance can
acceptance, it is needed to prescribe the be measured by straight line distance
power components properly. from the nasal bridge to the pupillary
center points on each eye.It is also
 Power prescription consists of sphere termed as monocular PD.
power, cylinder power and axis.  Distance between the pupillary centers
Spherical power means the specific between two eye termed as IPD that is
spectacle lens power that located at all inter pupillary distance measured as
the meridians. On the other hand, mm.Normal IPD range 60-65mm.
cylinder power is located in a
particular axis termed as power
meridian and perpendicular to the
power meridian is termed as axis 3.10 Spectacle lens types:
meridian that is mentioned in the
prescription. Normally cylinder power  Spectacle lens is provided to correct
is used to correct the astigmatism refractive errors to achieve best vision
means the irregular refractive surface by fitting into ophthalmic frame that is
curvature. Spherical power is used to suitable to patients face.
correct the refractive errors like  Based on the vision zone spectacle
myopia, hypermetropia, and lens can be divided into single vision,
presbyopia types of refractive errors. bi focal, tri focal, multifocal and
progressive lenses.
 Example:
 Normally pediatric patient specially
OD: +1.25/-0.50 x 180 6/6.Near
school going age,young adults, adult
add: +1.25 Ds N6.
In this prescription format we can age below 40 years old prefer that
find +1.25 Ds power as a spherical single vision lenses.It is also cheaper
power. compare to other types.
-0.50D cylinder power and the axis  Single focusing lens has only one
meridian are written as 180 degrees vision Zone so that patient can focus at
when the power meridian is at 90 distance, intermediate and near
degree. simultaneously.
To correct the presbyopia near  Bifocal lens consists of two vision
addition power provided +1.25 Ds to zone specialized to treat presbyopia
correct near refractive error due to and distance correction both at a time.
physiological loss of  Upper vision zone designed for
accommodation. distance vision and lower part is
So, the Near power will be specialized for the near power. During
+2.50/-0.50 x 150 (N6). Near power study o near work eye deviated nasally
slightly due to accommodative
– Distance power = near addition
power. convergence with down gaze.
 As per design of Near vision zone
design corridor it can be classified as
3.9 Pupillary Distance (PD):
straight bifocal, round bifocal,
 Optical Centre of lens need to be
coincided with the Pupillary Centre of Kryptok bifocal, Moon shaped bifocal,
D bifocal etc.
that eye to minimize the aberration.It
is measured by PD ruler or
Pupilometer.

34 | P a g e
 In such type of lenses 3 types of vision 3.11 Tinted lens:
zone designed. Upper most area
specialized for distance vision, lower  Tinted lens used to reduce glare
most part is specialized for lower problem, enhance focus depth,
vision. Middle zone is specialized for reduce fatigue ,photophobia block
intermediate vision zone. It reduced UV rays and protect our eyes. In
the image jumping tendency and some cases also enhance clarity of
enhanced the vision quality. vision during dim light helpful for
night driving.
 Multifocal lenses designed as  Grey tints ->(used as anti
multifocal vision zone is able to see fatigue,reduce glare)
the target object form variable Yellow tints ->(Used in low light
distance. Progressive lens is the condition and increase visibility)
updated modified version of Green tints ->(minimize light
multifocal design. About the sensitivity and reduce eye stress)
progressive lens there is no vision Brown tints ->(Enhance
zone marking so that cosmetic sharpness and depth of vision during
appearance is good but both side have day time, restrict harmful light rays
the aberration zone. Patient has to look and reduce stress)
through the vision corridor located Blue tints->(cosmetic purpose
between the aberration. Based on use,improve colour depth, enhance
vision corridor design it is also further perception)
classified into hard design and soft
design. It is popular for the computer
users because at a time patient is able
3.12 Polarized sunglass:
to see computer monitor, keyboard,
mouse located at variable distance.
Polarization makes a huge difference when it
comes to sunglasses. When sunlight or light
coming from any external source comes
down and hits an object specially an object
with a flat horizontal surface such as the road,

35 | P a g e
car windshield, lake water surfaces then
reflect off from it doesn’t scatter in all
direction but it going to bounce off in a flat
horizontal way then we can call it as
polarized light. Polarized filter selectively
neutralizes horizontal lights and eliminate it
so that we need not to see the whole reflection
from that type of surfaces. For this reason, it
can enhance focus depth, decrease eye stress
and irritation, enhance clarity and very useful
for the light sensitive patients reducing glare
problem.

3.13 Spectacle frame parts & types:

 Based on rim design and structure we

can divide spectacle frame structure as
Full rim
Semi rimless or half frame
Rimless.

 Frame materials
Acetate,
Plastic

36 | P a g e
 Metal
Titanium e

Based on temple design it can be

classified as
-> Skull
-> Library
-> Convertible
-> Riding Bow
 Based on nose bridge style it can be -> Comfort cable
classified as
Narrow bridge
Comfort fit 3.14 Different types of faces and frame
Wide bridge fit fitting
High bridge
Low nose
Saddle

37 | P a g e
 ->Patient is advised to keep the spectacle
frame always inside the box after its use
-> If possible, need to wash the lenses at least
once a day.
->Microfiber is the best option to clean the
lens.
-> Use of any other rough cloths like tower,
shirt, saree can be harmful for the lens as nit
may cause for unexpected scratches and also
affect the coatings.
-> Need to avoid unnecessary touch to the
lens.
-> Need to keep spectacle before sleeping.
-> Need to avoid very warm places to keep
the spectacle.
-> For the older patient better use of a eye
glass string.
-> Need to avoid ammonia-based household
cleaner.
->Always need to wear spectacle holding
both temples.

Reference:
1) American Association for pediatric
Ophthalmology and strabismus. August
1,2023. Retinoscopy.
https://aapos.org/glossary/retinoscopy
2) 2020-2021. BCSC Basic and Clinical
science Course. American Academy of
Ophthalmology.
https://www.aao.org/education/bcscsnippetd
etail.aspx?id=2db1ca5e-45e0-45e8-9991-
8955754ffd8c
3) Hollis J, Allen PM, Heywood J.
Learning retinoscopy: A journey through
3.15 Spectacle care advice to patient: problem space. Ophthalmic and
Spectacle care and maintenance is needful for Physiological Optics 2022: 940-947
proper use of that.

38 | P a g e
4) Kaur K, Gurnani B. (Updated 2023, 13)Idnay S. (2023, March 21). What are the
June11). Statpearls.Treasure Island, different types of eyeglass frames. Marvel
Subjective refraction techniques. Optics. https://marveloptics.com/blog/eye-
http://www.ncbi.nlm.nih.gov/books/NBK58 health/what-are-the-different-types-of-
0482/ eyeglass-frames/
5) Isdin Oke (2023, July 10). 14) Yashasvi. (2023, June 1) Different types
Retinoscopy-Eye Wiki of face shapes and its significance. Styles at
https://eyewiki.org/Retinoscopy#:~:text=Ret Life. https://stylesatlife.com/articles/types-
inoscopy%20is%20an%20exam%20techniq of-face-shapes-how-to-determine-it/
ue,light%20in%20a%20patient's%20pupil.R
15) Spectacles and how to choose them: an
etinoscopy
elementary monograph-Digital collections-
6) Elliott DB. Clinical procedures in National Library of medicine.
primary eye care E-Book. Elsevier Health (n.d.)http://esource.nlm.nih.gov/68050750R
Sciences;2020.
7) Corboy JM. The Retinoscopy Book:
an introductory manual for eye care
professionals. Slack incorporated;2003
8) Themes,U. (2020,November
28).Clinical Refraction.Ento Key.
https://entokey.com/clinical-refraction-/
9) Disha Eye Hospital (2018,
March14).17 interesting Facts on Eye Chart-
Disha Eye Care.
https://www.google.com/amp/s/www.dishae
ye.org/blog/17-interesting-facts-eye-chart/
10) Retinoscopy-Eye Wiki (2023, July
10)
https://eyewiki.org/Retinoscopy#:~:text=Ret
inoscopy%20is%20an%20exam%20techniq
ue,light%20in%20a%20patient's%20pupil.R
etinoscopy
11) Mark E Wilkinson, (ODJanuary
2016) Plus Cylinder Subjective Refraction
Techniques for Technicians| General
Refraction Techniques page 1-
7https://webeye.ophth.uiowa.edu/eyeforum/
video/Refraction/pdfs/Std-subj-Refract-Plus-
Cyl-Tech-s.pdf
12) Varghese, A. (2021, September7).
Tinted lens guide-Spectacular by lenskart.
https://spectacular-blog.lenskart.com/

39 | P a g e
Low Vision and Visual Aids

Dr. Prabirendra NS,

D.O.S (PG), DCLP
Assistant Professor
Department of Optometry
Swami Vivekananda University

40 | P a g e
 • Peripheral vision loss - Individuals with
Low Vision and Visual peripheral vision loss have challenges in
Aids navigating independently, which vary
depending on the extent of their visual loss.
The initial stage difficulty is very
insignificant, but in the advanced stage
(known as tunnel vision), individuals may be
unable to see steps. This condition can be
INTRODUCTION attributed to several factors such as Retinitis
Low vision refers to a condition when an pigmentosa, Hemianopia, Glaucoma, and
individual has inadequate vision that hampers Juvenile diabetes.
their ability to accomplish everyday tasks, • Generalized Visual Impairment -
even when using the most effective Generalised visual impairment refers to a
corrective glasses, contact lenses, or condition where an individual has a decrease
undergoing medical interventions such as in the capacity to see clear and crisp details,
surgery. Possible causes of vision loss often caused by changes in the refractive
include: media of the eyes. Experience symptoms
• Reduced visual clarity. such as complete loss of vision, diplopia,
impaired nocturnal vision, reduced contrast
• Impairment of the visual field sensitivity, and difficulties with glare caused
• Reduced ability to distinguish between by congenital injury, age-related cataracts,
different levels of contrast corneal opacity, myopia, and amblyopia,
among other conditions.
• Deprivation of ability to perceive colour
Night Blindness, also known as nyctalopia, is
Low vision, as defined by the World Health a condition characterised by the inability to
Organisation (WHO), refers to individuals see in low light conditions such as at night, in
who have visual impairments that persist moonlight, or in dimly lit areas. This
even after receiving treatment such as condition can be caused by several factors
surgery or refractive correction. These including Retinitis pigmentosa, diabetes,
individuals have a visual acuity of less than retinopathy, and glaucoma.
6/18 to light perception (PL) or a visual field
of less than 10° from the point of fixation Patients with conditions such as retinitis
(i.e., 20° across). However, they are still able pigmentosa or cataracts experience reduced
to use their vision, or have the potential to use brightness difference and impaired contrast
it, for planning and/or executing tasks. sensitivity, leading to difficulties with light
and glare.
EFFECT OF LOW VISION ON VISUAL
PERCEPTION PRIMARY FACTOR CONTRIBUTING
TO VISUAL IMPAIRMENT
• Central vision loss refers to the impaired
capacity to view objects or people's faces Macular Degeneration, Glaucoma, Diabetic
directly in the line of sight. This can occur Retinopathy, Retinitis Pigmentosa, Cataract,
due to conditions such as macular and other retinal dystrophies are the primary
degeneration, albinism, stargardt disease, factors leading to impaired vision in western
toxoplasmosis, histoplasmosis, and others. nations. These ocular conditions impact
visual perception in various manners. The
severity of each condition is correlated with
41 | P a g e
the degree of impairment in visual acuity, Diabetic retinopathy
visual field, and contrast sensitivity, and this
Diabetic retinopathy, a disorder characterised
will differ among individuals.
by alterations in the minuscule blood vessels
Age-related macular degeneration that provide nourishment to the retina, is the
primary cause of visual impairment in
Macular Degeneration (MD) is the primary individuals with diabetes. During the initial
cause of blindness in Australia. The condition phases of diabetic retinopathy, there is a
leads to gradual deterioration of the macula, weakening of small blood vessels, causing
the core region of the retina, which ultimately them to leak fluid or small quantities of
leads to loss of central vision. Age-related blood. This leakage leads to distortion of the
Macular Degeneration (AMD) is the most retina. During the later stage, the blood
prevalent type of Macular Degeneration. arteries in the retina become obstructed or
Macular degeneration (MD) impacts around entirely closed, leading to the death of
14% of Australians aged 50 and beyond, and specific parts of the retina.
its prevalence rises with advancing age.
Macular degeneration (MD) may be Cataracts
classified into two types: Dry MD and Wet
A cataract is the condition in which the
MD. Dry MD, which is the predominant form
of the illness, leads to a progressive decline normally clear lens of the eye becomes
cloudy. As a cataract develops, the lens
in central vision. Moist
becomes cloudy, similar to frosted glass,
Macular degeneration is marked by an abrupt which results in the inappropriate focusing of
decline in visual acuity and is caused by the light onto the retina, leading to a blurry
proliferation of anomalous blood vessels image. Cataract removal can be
inside the retina. accomplished by cataract surgery, which
depends on the advice of an ophthalmologist
Glaucoma and the individual's unique requirements.
Glaucoma refers to a collection of ocular
Retinitis Pigmentosa
conditions characterised by gradual
deterioration of the optic nerve located in the Retinitis pigmentosa is a hereditary disease
posterior of the eye. The injury typically that leads to the gradual deterioration of the
arises from an obstruction in the flow of retina. Typically, it is characterised by first
aqueous fluid in the eye or its drainage, symptoms of nyctalopia, often known as
resulting in elevated intraocular pressure. night blindness, which is subsequently
Alternatively, it may arise from inadequate accompanied by a progressive decline in
blood circulation to the nerve fibres, a peripheral vision. It has the capacity to finally
deficiency in the optic nerve's strength, or a lead to total blindness. Retinitis pigmentosa
deterioration in the overall health of the nerve is a kind of retinal degeneration that is the
fibres. Glaucoma progressively impairs an leading cause of blindness among young
individual's eyesight, first with the peripheral persons in Australia. Among individuals in
vision. Individuals may possess glaucoma their twenties and thirties, this condition is
without any awareness of its presence, as the the second most prevalent cause of blindness,
predominant kind of glaucoma typically surpassed only by diabetes. The majority of
lacks discomfort or first indicators. Timely cases of retinitis pigmentosa are hereditary.
diagnosis is crucial as any loss of vision is However, in some instances, a genetic
permanent. mutation may occur, leading to the

42 | P a g e
manifestation of the disease even without any dioptric power. This estimate relies on the
hereditary predisposition. presumption that the patient's unaided eye
has the ability to adjust its focus sufficiently
Achromatopsia to keep the object at a distance of 25 cm.
Absence of colour perception in its entirety. Furthermore, it assumes that while using
Abnormal cone shape. Visual acuity reduced magnification, the reading material is placed
to 6/36. Colour blindness. Nystagmus is a accurately at the primary focal plane of the
possibility. Severe sensitivity to light. The lens. However, in actuality, none of these
impact on visual field and near eyesight is assumptions are valid in practical scenarios.
minimal. Hence, the degree of magnification may be
modified by changing the distance between
Albinism the object and the lens. This category consists
Hypopigmentation refers to the whole or of spectacles and portable magnification
partial absence of pigments in the eye, skin, equipment.
or hair, which is characterised by a light- The formula may be represented as M = D +
colored iris and eyebrow. Retinal A/2.5, where A is the amplitude of
abnormality, undeveloped macula, and accommodation. The formula for
improper eye-brain connection. Visual acuity magnification, M, is given by M = D + A - h
has decreased to a range of 6/36 to 6/18. AD/2.5, where D is the distance between the
Visual acuity at close range is hardly eye and the lens.
impacted. Experiencing severe sensitivity to
light. Nystagmus is a condition characterised Where h is the distance of the eye lens,
by involuntary eye movements. Visual acuity measured in metres.
will be poor in those with high refractive This indicates that:
errors and significant astigmatism.
• To enhance magnification, it is advisable to
Aniridia position the eye in close proximity to the lens,
Iridal hypoplasia refers to the incomplete hence minimising h.
development of the iris, resulting in partial or • The reading material should be positioned
near-total absence of the iris. This is a as near to the patient's eye as possible.
congenital anomaly that often affects both
eyes. The overall look resembles that of an according to the limitations of his lodging.
exceptionally huge pupil. Severe sensitivity
to light. Reduced visual clarity. Nystagmus is • When the optical lens distance is
a condition characterised by involuntary and predetermined, the object is positioned at a
repetitive eye movements. Tunnel vision, defined distance. The highest magnification
characterised by the narrowing of the visual occurs when the eye is positioned as close as
possible to the lens. This is utilised in stand
field, may be observed.
magnifiers. Therefore, it is accurate to
OPTICS OF LOW VISION indicate the magnifying power of the gadget
in Diopters rather than using the X notation.
The underlying concept of all low vision Due to variations in manufacturer
optical devices is to magnify the size or calculations, the X notation may not align
proportion of visual things. The precisely. Nevertheless, this statement
magnification of most modern aids is remains mostly accurate for all practical
calculated using the formula M = D/4, where
intents and calculations.
M indicates magnification and D represents

43 | P a g e
To get the "Dioptric Power" of the lens, just Angular magnification refers to the ratio of
multiply the magnification by a factor of 4. the apparent size of an object as seen via an
To determine the distance in inches from the optical instrument, such as a microscope or
eye, divide the Dioptric power by 40. As an telescope, to its actual size.
illustration, a lens with a magnification factor
of 4X corresponds to a power of 16 Diopters. Magnification refers to the perceived change
When divided by 40, we have a working in size of an item when viewed via a device,
distance of 2.5 inches. A lens with a relative to its actual size when viewed
magnification of 5X is equivalent to 20 without the instrument. This form of
Diopters and has a reading distance of 2 magnification is typically achieved using
inches. telescopic devices (Fig. 3.3).

Factors to Consider Regarding Magnification Electro-optical magnification refers to the

process of increasing the size or scale of an
in Devices for Individuals with Low Vision
image using electronic and optical
Low vision devices utilise one or a technologies.
combination of the following four types of
This is accomplished via the use of electronic
magnifications:
devices that either magnify items directly by
1. Proportional magnitude scanning or generate them using computers.
There are four methods for achieving the
2. Proximity appearance of bigger objects.
3. Angular is a framework for building web 1. Approach the object: Bringing the object
applications. closer by a factor of 2 will result in a 2X
4. Pertaining to the interaction of electricity increase in size. When an object is positioned
and light. near the eye, it necessitates a significant
amount of accommodation. While children
Proportional Magnitude are capable of accomplishing this, adults find
Magnification refers to the process of it more challenging. Children can enlarge text
increasing the size of an item without the use and small objects by holding them in close
of an optical system. It involves making the proximity to their eyes, thereby eliminating
thing larger to match the visual acuity levels the need for magnifiers to view nearby
of the patient, such as using a large print objects in some cases.
textbook. 2. Increase the size of the item
Relative distance magnification refers to the 3. Utilise an optical instrument
amplification of the apparent distance
between two objects. 4. Utilisation of electronic and projection
methods to increase the size of an image.
Magnification is accomplished by bringing
the item closer to the observer, causing a Increased magnification results in (Fig. 3.4):
bigger picture to be formed on the retina. The 1. Reduced in size
degree of magnification is inversely related
to the distance difference from the initial 2. Reduced proximity between objects
position. Optical systems, such as
conventional magnifiers, are typically used to 3. Requires additional lighting
create this effect. 4. Increased challenge in utilisation

44 | P a g e
5. Decreased focal plane. 10 Diopters. The projected number of
Diopters of spectacle glasses needed by an
• Higher magnification results in a reduced individual with reduced visual acuity to read
field of view. Although a 6X magnifying a specific print size is calculated based on
offers more magnification compared to a 3X their corrected visual acuity. In order to
magnifier, it also has several disadvantages. estimate the addition, it is necessary to first
The magnifier lens undergoes a reduction in know the corrected visual acuity and the
size, resulting in a decrease in both the desired print size. The magnification power
working distance and depth of focus. may be determined by calculating the
Similarly, a telescope with a magnification of Logarithm of the Minimum Angle of
3X has a field of view measuring 12.5 Resolution (Log MAR) visual acuity.
degrees, but a telescope with a magnification Assume that the highest level of visual acuity
of 4X narrows the field of vision to around 10 after correction is 6/60 or 0.10. The desired
degrees. Consequently, the selection of the level of visual acuity is 6/12, which is
device is contingent upon these equivalent to 0.The needed magnification is
considerations, rather than only on the equal to the denominator of the required
desired outcome. vision, which is calculated as 60/12 or
ADD PREDICTION 0.10/0.5, resulting in a magnification of 5X.
Therefore, it is recommended to attempt the
There are two methods for determining the use of 5X magnifiers for this patient.
Dioptric add for individuals with impaired
vision: EVALUATION OF VISUAL
IMPAIRMENT
1. The inverse of Snellen's visual acuity may
be determined by calculating the reciprocal In order to assist individuals with limited
of the Snellen fraction. For example, if a vision, it is imperative to conduct a
patient has a visual acuity of 2M print, the comprehensive evaluation of their visual
Snellen equivalent is 6/30 or 20/100. The capabilities.
inverse of the fraction 20/100 is 100/20, The evaluation of a patient with low vision
which is equivalent to 5 Diopters. aims to determine the extent of their available
Reciprocals may be calculated for any vision and how they utilise it in their daily
examination using either metric or Snellen's activities. A comprehensive understanding of
notation. their visual abilities and needs enables
2. The inverse of the distance: For instance, professionals to provide appropriate
while testing near acuity at a distance of 40 recommendations and make informed
cm, if a 1M print is viewable at 2M, the decisions regarding the prescription of
patient would need to hold it at a distance of optical and non-optical aids.
20 cm. This is because the retinal size of the ASSESSING THE POTENTIAL
picture is magnified. The needed addition is
BENEFICIARIES
calculated by dividing 100 by 20 (the
distance), resulting in 5 Diopters. During the assessment, the low vision
Furthermore, if the visual acuity was 4 metres specialist should collect a thorough medical
at a distance of 40 centimetres in order to read history and inquire about the individual's
1 metre. The patient is now required to bring functioning challenges. Furthermore, it is
the object within a distance of 10 centimetres crucial to examine any physical constraints
in order to read it. The needed sum is that can impede the use of particular
obtained by dividing 100 by 10, resulting in equipment. Afterwards, a sequence of
45 | P a g e
examinations should be conducted to • Navigating through unexpected territories
evaluate the patient's visual capabilities, and environments.
which encompass visual acuity, visual fields
(both central and peripheral), contrast The wishes of poor vision patients may
sensitivity, and colour vision. The data generally be effectively addressed. However,
acquired from these tests will yield useful these wants may or may not be explicitly
insights into the potential benefits of gadgets expressed by certain patients, thus it is
and, if applicable, the specific sorts of necessary to ask a series of questions in order
technology that should be recommended. The to comprehend their demands.
examination for individuals with low vision Requirements and anticipated outcomes for
is carried out in a collaborative manner by an long-range visual acuity
ophthalmologist and an optometrist. Each
specialist concentrates on comprehending the A low vision assessment, often the initial
patient's specific visual impairments and stage in vision rehabilitation, aims to
evaluating their visual needs. precisely evaluate the functionality of one's
eyesight in real-life situations and daily
Evaluation of Requirements for Patient with activities. Visual acuity extends beyond the
Visual Impairment ability to read an eye chart and include the
Low vision patients may not be able to capacity to perceive people, street signs,
television screens, blackboards in school, and
perform all tasks as a typical person would.
However, by identifying the appropriate mix other visual cues that assist individuals in
navigating their daily lives. Distance vision is
of visual and non-visual equipment, it is
possible to improve their quality of life and a fundamental requirement and a common
expectation for all patients. It is necessary to
provide them with a certain level of
comprehend one's potential daily tasks and
independence.
how remote equipment should be
The predominant requirements of these recommended in order to be employed.
patients include: Visual acuity criteria for close-up vision The
patient will need to be queried with targeted
• Engaging in the act of reading or writing inquiries on their vision. The objective is to
• Financial management for housekeeping ascertain individuals' ability to manage tasks
that are in close proximity (8,9). In order to
• Authentication evaluate this, it will be necessary to ask
• Visual impairments or difficulties in certain questions. These factors will also vary
viewing television based on the patient's level of literacy. It is
crucial to assess his reading skills before
• Recreational pursuits commencing the study of history. Frequently,
the patients recommended for low vision
• Variations in luminosity
prescription are individuals who are unable to
• Travelling throughout the night read or write and have no interest in doing so.
Their requirements differ significantly from
• Perceiving the distance or depth of objects those of the literate individuals. Additional
• Absence of glare variables that might influence this decision
include the rate at which one reads, the level
• Identifying and distinguishing between of exhaustion (fatigue) experienced from
different faces and items reading, the accessibility of eyeglasses and
assistive devices for individuals with

46 | P a g e
impaired vision, as well as the availability of Activities of daily living encompass personal
printed or Braille materials. Distance visual care, such as reading mail, writing checks,
acuity should not be employed as the only telling time, recognising money, making
criterion for determining the optimal reading meals, and identifying and measuring drugs.
equipment. The near vision exam requires
only a brief period of focused attention. Journeying
Certain jobs may need prolonged focus on Recognising addresses and street signs,
items in close proximity. Tiredness and securely navigating street crossings, and
exhaustion can have an impact on eyesight. utilising public transit.
Dyslexia Recreation
Reading is highly coveted by both students The activities include reading books,
and working individuals. Many of them rely watching TV, playing cards, solving
on others or family members to read books to crossword puzzles, crocheting, and utilising a
them. The majority of the elderly population computer.
in rural areas of our country have either not
had access to education or have limited Lighting Requirements
reading skills. Conversely, many literate To determine appropriate recommendations
elderly individuals struggle with reading as for illumination, it is necessary to inquire
their main challenge. It is common to find patients about their individual requirements.
age-related macular degeneration (ARMD)
in this age group, which leads to a state of Do you experience visual challenges in
being "disilliterate." These individuals have a various lighting environments?
strong desire to spend their time reading and
Lighting encompasses both natural and
improving their reading skills, and this is
artificial sources of illumination. The
achievable for many through the use of
quantity and orientation of light play a crucial
optical aids or speech output devices.
role in optimising visual performance. While
Disability in Writing individual lighting preferences may vary,
generally speaking, enough lighting is most
The majority of individuals are able to beneficial. Some individuals may choose
maintain their writing skills, but they are incandescent bulbs, while others may prefer
unable to read their own handwritten fluorescent tube lighting.
documents, resulting in a loss of motivation
to write. Patients, particularly students, may Does the individual perform more effectively
indicate that they can write, but their speed in well-lit conditions than in areas with
may be slow or they may struggle to write in reduced sunlight?
straight lines. Some individuals may also
Does the presence of light from a door or
report experiencing fatigue due to leaning too
window enhance a person's productivity
closely while writing.
indoors?
Everyday Tasks
Is there any disparity in the manner in which
To optimise the utilisation of low vision an individual can navigate in darkness as
equipment, it is advisable to inquire about the opposed to in illuminated conditions?
individual's routine activities. Here are many
Issues with excessive brightness and
illustrative instances:
reflection

47 | P a g e
Does the individual experience sensitivity to Work-related requirements
glare, whether it be in outdoor or indoor
settings? Do they have challenges in visual The use of vision for specific purposes is
perception in varying lighting conditions? Do essential in performing daily tasks at the
they exhibit improved vision on sunny or workplace. Allocating sufficient time to each
overcast days? Does the person attempt to patient and inquiring about their individual
shield their eyes from the sun using a hat, needs is crucial. The more time spent on
evaluating their requirements and
hand, or by turning away?
comprehending their issues in low vision
Highlight the differences work, the higher the likelihood of achieving
success. Dealing with the remaining tasks
How does he articulate his visual impairment will then become much easier.
in perceiving contrast (6,7), such as
differentiating a light grey clothing against a ASSESSMENT AND EVALUATION OF
white bedspread, drinking milk from a white AIDS FOR THOSE WITH LOW
cup, or reading print that is not sufficiently VISION:
black, as seen in bank pass books?
Document in the Sequential Sequence
DEFECT IN THE FIELD
1. Collecting personal information will
Does he experience any areas of visual involve obtaining details such as the
blurring or distortion? If yes, where are these individual's name, age, residence, family
areas located? Does his vision improve when members, family income, current occupation,
he looks slightly away from the object? Can and current academic achievements.
he perceive items on both sides? These
inquiries can help assess the presence of any 2. Details on the ocular illness, including its
aetiology, age of onset, and familial
visual field abnormalities.
background.
Locomotion and Direction
3. The complaints include issues with distant
Do you travel without assistance? Do you vision, close vision impairments, specific
encounter any difficulties when moving lighting requirements, problems with glare,
independently indoors or outdoors? The and difficulties with movement. These are all
purpose is to assess your visual ability to part of the functional vision checklist.
navigate and avoid collisions. Please provide
information about your mobility status both 4. Assessing visual acuity using Snellen's,
indoors and outdoors. Additionally, please Log MAR charts, or any other designated
describe how well you can perceive objects chart for near visual acuity.
when looking directly at them, to the side, 5. Prior refractive error or prescription
above, and below. Are you limited to a small strength of glasses.
area or can you freely move throughout the
entire village or town? 6. Evaluate the refraction and acceptance of
the binocular vision and compare it with the
Colour performance of the prior glasses.
Accurate utilisation and comprehension of 7. Indicate the functioning eye.
colour is crucial in certain circumstances.
The selection and coordination of colours 8. Assessment of contrast sensitivity.
hold significance in many household 9. Utilisation of Goldman or Amsler charts
activities. for visual field assessment.
48 | P a g e
10. Has any prior assessment been conducted unenlarged image. For some patients, a
about low vision devices? If so, please magnifier may be the primary solution to
provide details on the tests conducted, the address all of their reported difficulties.
outcomes, the specific low vision device that Alternatively, it can serve as an excellent
was recommended, and an analysis of the secondary aid. For instance, a patient may use
reasons behind the device's success or failure a spectacle microscope for reading but rely
in the past. on a handheld magnifier for checking prices
while shopping.
11. Visual acuity in the presence of glare.
FUNDAMENTAL PRINCIPLES OF A
12. Commence the experimentation with
MAGNIFIER
optical instruments. Document the
enhancements seen for both close-range and 1. As the power of the lens increases, the
long-range applications, and provide diameter decreases.
comments about their success or failure.
2. The lens must be positioned closer to the
13. Provide recommendations for non-optical paper as its strength increases.
assistance based on individual requirements.
3. As the magnification increases, the seen
14. Concluding prescription. area decreases.
15. Determine if the vision has been A stronger lens limits the transmission of
achieved. If not, recommend rehabilitation light, necessitating a greater amount of light.
assistance.
5. The orientation of a magnifier can have a
16. Subsequent appointment. Continuously significant impact.
monitor and record his additional
requirements, as well as his levels of 6. The proximity of the eye to the magnifier
directly correlates with the breadth of the
contentment and discontentment.
field of view.
Categories of visual aids for those with low
High-powered lenses exhibit significant
vision
distortion.
• Optical devices designed to assist those with
Classification of magnifiers
visual impairments
There are several categories of magnifiers,
• Non-optical aids (devices)
including hand-held, stand, lighted, and
Optical aids, such as a magnifier, can be used pocket magnifiers. Within each category,
to enhance visual clarity. these magnifiers can have a magnification
power ranging from 2× to 10×. Lower
Magnifiers are specifically designed to assist powered magnifiers are bigger in size, while
individuals with low vision in performing more powered ones have narrower lenses.
tasks up close while wearing their current
reading glasses. They have been utilised as a PORTABLE MAGNIFYING GLASS
means of enhancing vision for many years.
The fundamental principle behind the use of Hand-held magnifiers are the most
magnifiers is to enlarge the image, covering commonly used visual aids. To view an
a larger portion of the retina. This increased object, it should be held at the focal distance
coverage allows the brain to interpret the of the magnifying lens. For instance, if a 5x
image more easily compared to an magnification lens with a power of +20.00 D
is used, the object should be held at a distance
49 | P a g e
of 5 centimetres (100/20 centimetres = 5 The benefits of a fixed focus stand magnifier
centimetres) from the magnifier. At this are as follows:
distance, the light rays exit the magnifier with
zero vergence. This means that the magnifier 1. Consistent emphasis achieved by
can be held at any distance from the eye inflexible lens attachment.
without affecting the le 2. Reading distance is within the standard
Characteristics range.

1. Hand-held magnifiers are more suited for 3. Beneficial for particular, temporary, and
brief tasks, but for extended periods of unique jobs that need attention to detail.
reading, the patient may struggle to maintain 4. Beneficial for youngsters.
the proper focal length.
5. Can be utilised with a conventional reading
2. The need to enlarge the field of view while supplement.
using a magnifier closer to the eye renders
them monocular, unless a very big lens is The drawbacks of a fixed focus stand
used. magnifier are as follows:

Handheld magnifiers come in several forms 1. Limited visual field.

and sizes, which vary based on their power 2. The posture might be uncomfortable and
and intended use. fatiguing.
Magnifying glass on a stand 3. The occurrence of aberrations is reduced
The stand magnifier is a popular choice when the image is seen at an angle.
among patients due to its user-friendly Focusable units are effective in correcting
nature. It automatically positions the minor refractive faults and serve as a viable
magnifier at the correct distance from the option for patients who are unable to
reading material. The stand magnifier can comfortably utilise powerful glasses or hand
come with or without illumination, and it can magnifiers due to the need for a certain
also be focusable or non-focusable. A non- reading distance. The focusable unit allows
focusable stand magnifier consists of a the eye to be positioned in close proximity to
convex lens mounted rigidly, which is the lens.
intentionally placed closer to the page than its
focal distance. This reduces peripheral The benefits of the focusable stand magnifier
aberrations. As a result, the rays that come include:
out of the stand magnifier are no longer
• Accommodation is not necessary and is
parallel but divergent. This requires some
beneficial for patients who have declined
effort to adjust the focus or the use of a
magnifiers or glasses due to challenges in
moderate reading addition to bring the image
maintaining focus distance.
into focus.
The drawback of the focusable stand
This virtual picture is designed to be
magnifier is its limited field of view.
observed from a typical distance with an
addition of +2.50 D. However, in reality, Magnifying glass for bars
patients typically prefer a higher addition in
order to bring the image closer and expand A bar magnifier is a cylindrical reading tool
their field of view. that rests horizontally on a page. It stretches
the letters without causing them to separate,

50 | P a g e
resulting in magnification only in the vertical vision can be either focusable or non-
direction. Individuals with a limited central focusable.
field of vision who require minimal
magnification can benefit from this optical A Keplerian telescope employs convex
characteristic. Bar magnifiers are typically lenses for both the objective lens and ocular
lens. The inverted image is corrected by an
only offered in low magnification options.
internal prism system. Keplerian telescopes
Magnifier of the Fresnel type generally offer superior image quality and
brightness throughout the field of view
A Fresnel lens magnifier is a thin plastic lens compared to Galilean telescopes. Keplerian
used as a handheld magnifier for people with telescopes typically have a larger field of
subnormal vision. The lens surface is created view and are available in higher
with a series of rings or zones that are pressed magnifications than the Galilean design.
into the material. This manufacturing method
allows for the production of spherical, Optical device used for magnifying distant
elliptical, and parabolic surfaces in various objects, typically used by those with visual
sizes at a low cost. The resolution and impairments.
magnification power, which can reach up to
A bioptic telescope may be recommended for
10 times for ophthalmic purposes, are
determined by the number of rings per inch. individuals who require a telescope for
regular use but have a mobile lifestyle. This
The main advanta
type of telescope utilises standard plastic
Optical instruments used for observing ophthalmic lenses within a frame, with a
distant objects by collecting and magnifying small aperture drilled into the upper section
light. of each lens. A miniature telescope is then
mounted within each aperture. The
Telescopes enhance the resolution of faraway conventional lens is used for general viewing
objects by enlarging the image through purposes, while the bioptic telescope is
angular magnification. A basic telescope employed for observing distant objects with
consists of two optical components: the greater detail. To utilise the bioptic
objective lens and the eyepiece. In telescopes telescopes, the individual lowers their head
that provide angular magnification, the and raises their eye to peer through the
objective lens has a positive power and is telescope portion. When the telescope is not
positioned towards the object being needed, the individual raises their head and
observed, such as in Galilean and Keplerian resumes viewing through the conventional
or prismatic telescopes used for individuals lenses.
with impaired vision.
Telescope with a wide field of view
A Galilean telescope consists of a convex
objective lens and a concave ocular lens. The full field telescopes provide complete
When these lenses are separated by the coverage of the lens within the frame. While
difference in their focal lengths, they create a they offer a wider field of view compared to
real and upright image. The concave ocular bioptic telescopes, they are exclusively used
lens always has a higher power. The rays for visual tasks that can be performed while
leaving the system are parallel when the standing or sitting. Walking with this type of
secondary focal point of the objective lens lens is challenging and should only be
aligns with the primary focal point of the attempted under the guidance of a
ocular lens. Galilean telescopes used for low knowledgeable low vision instructor.

51 | P a g e
Telemicroscopes Microscopes with a wide field of view
Telescopes are specifically built to see items Full field microscopes are installed in
that are far away. They are not suitable for traditional frames at a standard vertex
viewing objects that are close by since they distance. They can be constructed using
do not have the ability to adjust focus. various lens designs such as spherical lenses,
However, certain telescopes are equipped aspheric lenses, and doublets.
with an ocular lens that can be adjusted
outward, which creates a magnifying effect Microscopes with half-eye design
and allows for focusing on nearby objects. Half eye microscopes consist of convex
A telemicroscope is essentially a telescope lenses that are mounted in a half eye frame
and worn at a normal to slightly longer vertex
that has a reading cap integrated into its front,
specifically the objective lens. The working distance. The main benefit of using a half eye
microscope is the ability to view distant
distance of the telemicroscope is determined
by the power of the reading cap. To ensure objects without obstruction. Traditional half
eye microscopes are made up of convex
that no converging rays enter the telescope,
the material must be positioned at the focal spherical lenses with a prism base designed
for binocular vision. Each lens typically
point of the reading cap. The magnification
of the telemicroscope varies depending on includes prism that is equal to the power of
the strength of the reading cap. For instance, the microscope plus diopter.
using a 4.00 D cap, the magnification of the For instance, a half eye with a power of +8.00
telemicroscope is equal to the power of the D would possess a base-in prism of 8.00 D in
telescope. A reading cap stronger than +4.00 front of each eye.
D will increase the magnification, while a
reading cap weaker than +4.00 D will Bifocal microscopes
decrease the magnification. The Bifocal microscopes are installed within
magnification can be calculated using the standard frames at a typical distance from the
following formula— eye's vertex. The height of the segment is
The power of a telemicroscope is equal to the determined by the individual's requirements
product of the power of the telescope and the and the strength of the bifocal lens. The
diopter of the cap divided by four. microscope lens enables the user to have both
hands available and is particularly
Telemicroscopic lenses offer a larger advantageous for extended periods of
working distance compared to microscopic reading. Additionally, it offers the widest
lenses, but they do so at the expense of a field of view. However, it does reduce the
reduced field of view. distance at which one can work.
Optical instruments used for magnifying SURVEILLANCE SYSTEM USING
small objects and structures are called CLOSED-CIRCUIT TELEVISION
microscopes. (CCTV)
A low vision microscope is essentially a Closed circuit television (CCTV) is an
convex lens that is installed on spectacles. It electronic magnification system used by
operates based on the idea of magnifying visually impaired individuals to read. It
objects by adjusting their relative distance. utilises the principle of projection
When choosing a microscopic lens, there are magnification to allow low vision patients to
many fundamental alternatives to consider— visually examine printed or handwritten

52 | P a g e
material, as well as various objects, through a 3. Insufficient accessibility to maintenance
magnified image projected onto a monitor services for components.
screen.
4. The initial expense is exorbitant.
The conventional Closed-Circuit Television
(CCTV) system comprises three primary Devices that do not rely on optics or light-
elements: a camera, a monitor, and a mobile based technology.
reading platform. The camera is focused on Non-optical devices are crucial in enhancing
an object, and its image is displayed on a the effectiveness of optical low vision
television monitor. The monitor functions as devices. In cases where optical devices have
the screen where the magnified print image is limitations, non-optical devices can assist in
projected. The movable platform is their usage. Non-optical devices are also
positioned on a flat surface, such as a table or frequently used independently. The
desk, and the reading material is placed on it. following non-optical aids are commonly
The platform is specifically designed to be utilized—
positioned beneath the camera.
Large print
The CCTV system allows the patient to
choose between ordinary polarity, which is Large print involves the use of relative size
black lettering on a white backdrop, or magnification, where making an object larger
reverse polarity, which is white letters on a makes it easier to see. The amount of
black background, for reading. Furthermore, magnification depends on comparing the new
many black and white CCTV systems offer a larger object to the standard size object. The
"photo mode" in addition to the polarity shift. advantages of using large print include its
easy acceptance by individuals with low
When chosen, the camera returns to the vision. Large print is sometimes used in
default contrast and brightness settings, combination with low power optical devices
which are optimal for viewing photographs. to achieve the appropriate level of
The CCTV systems offer a range of magnification. However, a major drawback
magnification levels, from 4 x to 65 ×, with of large print is its limited magnification
minor changes in the screen size system. The capabilities. Large print books typically do
not exceed 18 points, providing only a 1.8 ×
benefits of CCTV systems include
magnification. As a result, only a small
1. Controls for adjusting brightness and portion of the low vision population can rely
contrast are provided. solely on large print.
2. Photographs may be readily observed. Lighting
3. Binocularity remains achievable even Proper lighting is crucial for patients with
while using higher levels of magnification. low vision. The intensity of light should be
adjusted on the printed material and should
Nevertheless, there are also drawbacks linked not shine directly into the eyes. Illumination
with the use of CCTV— refers to the light that hits the material being
1. The physical dimensions may impede the viewed and reflects directly into the eye. This
ability to carry and move it around easily. light enhances contrast by increasing the
difference between the light coming from the
2. Adequate training and dedicated practise object being viewed and the background light
are necessary to attain proficiency as a user. level. Glare, on the other hand, is unhelpful

53 | P a g e
light that comes from indirect sources and HEADGEAR OPTIONS: VISORS AND
enters the outer edges of the eye, thereby CAPS
increasing the background light and reducing
contrast. Since glare reduces contrast and Visors and hats can serve as a means of
causes fatigue and strain, it is important to shielding oneself from the sun's rays.
consider using illumination control devices Conversational Goods
with all optical aid systems. A gooseneck
lamp or a flexible arm lamp can be extremely Devices such as talking books, talking
beneficial. However, not all patients require watches, talking calculators, and talking
a high level of light. Therefore, the low vision telephones are commonly available with
specialist must determine the most speech output. Many of these voice-output
comfortable level of light for each patient. products also feature a large display that
includes magnification and voice output.
SPECIAL TYPE AIDS This combination creates a highly practical
INK PEN WITH A BLACK FELT TIP product.

Using a black felt tip pen instead of a blue Haptic goods

ballpoint pen helps increase contrast, which The sense of touch serves as the second most
is important for reading printed information. significant sensory input when the visual
Additionally, the felt tip pen allows for sensory input is impaired. Braille is the
greater writing, creating a magnified picture. predominant means of providing this tactile
Typoscopes input.
Tool for easily guiding a thread through the
A typoscope is a device made of black
cardboard that has a narrow opening. It eye of a needle.
effectively obscures all text except for the A needle threader is a non-optical tool
line being read through the opening. By designed specifically for the job of threading
framing a single line of text with black, it a needle.
enhances the visibility and sharpness of the
line, hence enhancing the contrast. NOTEX

BOOKSTAND Notex can be designed to help identifying the

different notes.
A reading stand serves the purpose of
providing a convenient position for holding Nocturnal visual assistance device
reading material, allowing the patient to A Nightscope or torch can be used to provide
maintain a close working distance without extra lighting during nighttime movement.
exerting strain on the neck and back muscles
or fatiguing the arms. Some individuals may A pinhole spectacle is a type of eyewear that
choose to incorporate an adjustable lamp into uses a series of small holes to improve vision.
the reading stand to assist with reading,
Pinhole spectacles, whether single or
particularly during prolonged periods.
multiple, can be beneficial for individuals
Additionally, reading stands can be utilised to
with lens opacities, pronounced vitreous
decrease the distance between the individual
opacities, and corneal scars. Unlike
and the reading material, thereby enhancing
traditional glasses, pinhole spectacles are
the magnification effect.
made from an opaque material such as metal
or plastic. The user looks through one of the

54 | P a g e
small holes in the material, which has the using yellow, orange, or red filters. In
effect of narrowing the bundle of diverging general, these filters enhance contrast, which
rays from each point on the object being is particularly beneficial for patients with
viewed. This helps to eliminate peripheral mobility issues in low-contrast environments.
beams, glare, and any refractive errors in the
lens or cornea. The size of the aperture should Absorptive lenses offer several advantages
be determined through a trial and error for individuals with low vision, including the
method. When using reduced apertures, it is elimination of discomfort glare, reduction of
important to compensate for the loss of veiling glare, improved ability to adapt to
illumination. Additionally, it should be noted changes in lighting conditions, and enhanced
that increased illumination leads to greater contrast and/or visual acuity. These lenses are
available in both glasses and plastic
pupil contraction.
materials, offering a range of options for low
Optical lenses have the ability to absorb vision patients.
light.
1. Noir Filter: Noir Medical Technologies
Low vision encompasses more than just poor produces a wide range of plastic filters with
visual acuity. It also involves dealing with different levels of light transmission in both
issues such as glare and contrast goggles and frames. The Noir UV shield
enhancement, which pose unique challenges styles provide various levels of light
for clinicians working with individuals with transmission while completely blocking UV
low vision. To address these challenges, low rays, while the Noir filter styles not only
vision absorptive lenses should possess the block UV rays completely but also
ability to absorb ultraviolet light. Certain significantly reduce infrared rays.
absorptive lenses, which function as filters,
can alter the perception of brightness or 2. Corning Photochromatic Filters (CPFm)
have been developed with the aim of creating
darkness in a scene, block out specific
colours, or enhance contrast without a filter that can safeguard the eyes from
increasing retinal degenerations.
affecting the overall colour spectrum.
Coloured lenses have the most significant 3. The Younger Protective Lens Series has
impact on colours that are opposite to them. created filter lenses that safeguard the eyes by
For instance, a red lens allows red light to blocking out UV and short-wavelength blue
pass through but blocks or absorbs blue and light.
green light. When a low vision patient uses a Polarisation refers to the process of dividing
red filter, it eliminates blues and greens. A or causing a division between two opposing
green lens blocks red or orange light, while a groups or individuals, often resulting in a
yellow filter blocks blue light. Using an clear distinction or separation between
orange or yellow filter on a cloudy day can them.</text
create the illusion of sunshine. Neutral
density lenses decrease the amount of light The addition of a filter to the lens can
that reaches the eye without changing its enhance glare reduction by introducing
colour. These lenses are beneficial for polarisation. Polarisation effectively
patients who experience photophobia or have diminishes glare caused by reflected
a sensitivity to light. surfaces. Various lens designs are available
that include polarised filters, including as
Patients experiencing discomfort from red- single vision, bifocal, trifocal, and
deficient fluorescent light may find relief by

55 | P a g e
progressive lenses, which are offered in both them. In contrast people who prefer yellow
glass and plastic materials. tint are suspicious about everything. They are
found to be seen suffering from inferiority
Reflective coating complex, zealous and always indulged in
Applying a mirror coating to a lens finding faults in others. They lack love and
diminishes the amount of light that passes affection and may be selfish, mischievous
through and functions as a filter. The mirror and cunning. Red tinted liking people may be
coating can be either complete or partial. seen as stubborn with fixed ideas. Desire to
be alone and, escaped may be the traits of
Coating designed to reduce reflection their nature. They keep their difficulties and
An antireflection coating is used to minimise anxieties within them and sulk over them.
lens reflection. It can be applied as a single Love, affection and mercy towards others are
layer or multiple layers. In the case of usually not seen among them.
prescriptions for low vision patients, lenses UTILISING CONTACT LENSES FOR
with extreme curvatures or doublet lens ASSISTANCE WITH LOW VISION
designs are often needed. However, these
lenses tend to produce reflections that The utilisation of contact lenses for low
negatively impact visual performance. vision patients has significant applications
Antireflection coating is effective in reducing for individuals of all ages. When properly
these reflections. utilised, this specialised technique can
provide clear benefits compared to other
PSYCHOLOGICAL INDICATORS OF methods of correcting low visual acuity,
COLOUR PREFERENCE often yielding more effective results. Both
Dr. Sumitra DOS holds a Bachelor of corneal and haptic contact lenses are used in
Optometry (B Optom), a Diploma in Medical the practise of improving subnormal vision.
Billing and Coding (DMBS), and a Doctor of Highly myopic individuals can benefit from
Medicine in Biology (MD BIO). using contact lenses.
The choice and preference of a particular tint Patients with progressive or pathological
may reflect the mood, behaviour, nature, myopia can achieve favourable clinical
personality and also the attitude of a person outcomes by using contact lenses. Spectacle
towards the perception of life. Different lenses may not offer satisfactory visual
people like different tints. Certain tints are quality due to aberrations, distortions, image
preferred more on particular occasion than size issues, or other optical phenomena.
others. At times its influence may also be Hence, contact lenses should be taken into
seen on the tint selection for visual purposes consideration.
irrespective of their effects and benefits. The
choice between three primary colors-blue, Albinism and Contact Lenses
yellow and red may reflect different nature Albino patients often experience glare and
and mood of a person. A person who lacks sensitivity to light. They commonly exhibit a
self confidence, concentration, courage, specific type of eye movement, known as
energy and also has poor memory with absent pendular nystagmoid movements, when
mindedness may be found to prefer blue tint. trying to use their maculas. This movement
Usually these kinds of people change their can negatively impact their vision. To
mood frequently and are restless. Lack of alleviate the sensitivity to light, contact
practical application is mostly seen among lenses can be tinted or designed with an

56 | P a g e
opaque outer edge. This can also help slow by comparing the dioptric power of the
down the nystagmoid movement and contact lens to that of the spectacle lens.
potentially improve visual acuity.
ADVANCEMENT IN THE FIELD OF
Aniridia contact lenses AIDS RESEARCH AND TREATMENT
Patients with aniridia can benefit from Field-expansion assistive devices provide a
specialised prosthetic lenses that help range of choices for those with limited visual
alleviate the issue of photosensitivity. fields. There are three alternatives for
individuals seeking to compensate for a
Keratoconus Contact Lenses
wider region of missing field:
Keratoconus is a condition where the cornea, 1. Optimise the picture compression to
the transparent outer layer of the eye, maximise the utilisation of the available
becomes thin and distorted, resulting in a viewing space.
protrusion or bulging. It typically affects both
eyes, with one eye showing more progression 2. Offer prisms that transfer pictures from the
than the other. The irregular shape of the blind region to the visible area.
cornea makes it difficult to improve vision
using glasses. However, using contact lenses 3. Utilise a mirror to project an image from
can provide immediate benefits as they serve an area that is not within one's line of sight.
as a substitute for the cornea and help to A reverse telescope has been employed to
expand the effective visual range for patients
refract light properly.
experiencing loss of peripheral vision. In this
Colour vision deficiency contact lenses technique, the person gazes through the
objective lens of the telescope instead of the
At times, a contact lens can be utilised to ocular lens. By reversing the telescope, the
improve colour perception. Individuals user is able to observe an entire scene because
experiencing challenges with distinguishing the image is not enlarged, but rather reduced
red and green may be prescribed a specialised
in size. However, in order to derive benefits
lens known as the X-Chrome lens.
Fresnel prism lenses are flexible plastic
X-Chrome is a crimson contact lens that is lenses that can be temporarily attached to
often worn on the non-dominant eye, but regular spectacle lenses. They are commonly
there are exceptions. Its main purpose is to used as trial lenses for testing spherical
induce retinal rivalry, a phenomenon that power, bifocal segments, or prisms. One of
allows the brain to see and differentiate their main applications is in the treatment of
between different hues. field loss. Fresnel prisms can cover the entire
Utilising contact lenses as a telescopic lens or only extend into the area of field loss.
system. When the individual looks through the prism
area, they will see a lower contrast image
A Galilean telescopic system can be from the missing field. Due to the decrease in
constructed using a contact lens. In this visual
system, a high-powered concave contact lens
serves as the eyepiece or ocular lens, while a Monocular hemianopic mirrors are employed
lower-powered convex spectacle lens is worn to redirect an image from a blind area into the
over it as the objective lens. The total visible field of view.
magnification of the system can be calculated Computer-assisted devices

57 | P a g e
In the past patients with severe visual OCUTECH is a company that specialises in
impairment were severely restricted in what the development and production of advanced
they could read and write. They needed to visual aids.
wait for a scheduled radio broadcast or the
arrival of an audiotape or brailled materials. Ocutech, Inc., founded in 1984, is a
The introduction of hi-tech aids like Closed prominent worldwide pioneer in creating
Circuit Television and advances in optical sophisticated bioptic telescopes for people
systems have enabled the patients with with vision impairments. The firm has
residual vision to access normal print, but obtained significant financial backing,
with higher magnification, some patients surpassing $1.5 million, from the National
experience difficulty searching, scanning and Eye Institute (NIH) and the Ontario Ministry
writing with these devices. The development of Health in Canada. The Ocutech bioptic
of computer assistive devices have the systems have undergone rigorous research
potential to remove many of these and thorough independent clinical studies,
restrictions. With specialized assistive where they have been chosen above
equipments, some patients with low vision alternative solutions at a ratio of 3 to 1.
can use the home computer to convert Ocutech VES®-Bioptic telescopes are relied
digitized text into a format that compensates upon by a large number of visually impaired
for any degree of visual impairment, persons across the world.
enlarging text on a screen or converting it The initial iteration of the Ocutech bioptic
tospeech. With the computers, the patient can telescope, known as the VES®, was created
locate specific information using search or by Russ Pekar, Ph.D., the visually challenged
find functions and type his message and president of Ocutech. Dr. Pekar has firsthand
correspondence. Once the information is knowledge of the demands and difficulties
found, the patient can read by listening them. experienced by those with visual
Financial and banking transactions can be impairments. He is dedicated to developing
conducted with computers. Newspaper and low vision devices that are efficient, user-
magazines are available on the World Wide friendly, aesthetically pleasing, and pleasant
Web or on commercial on-line information to use. In 1996, Ocutech gained global
services. Thus the personal computers have recognition for developing the pioneering
become an important assistive devices that VESAutoFocus (VES®-AF), the sole
allows for accessing and processing autofocusing bioptic telescope in existence.
information, and therefore, a world of limited The VES®-AF development project spanned
vision may no longer be a restrictive a duration of more than 6 years and incurred
environment. For a low vision patients four a total expenditure of almost $1 million in
basic types of adaptation may enable them to order to achieve its completion. Currently,
use a computer as low vision device: the VES-AF is worn by several individuals
worldwide, allowing them to get the most
1. Low vision aids that rely on hardware
realistic magnified vision attainable using a
components
low vision device. The VES-AF provided
2. Low vision aids that rely on software newfound independence to those who
previously experienced little success with
3. System for vocalisation or recognition of bioptic telescopes. Numerous individuals
speech have expressed that it had a transformative
4. System for displaying Braille impact on their lives. Ocutech was awarded
the Winston Gordon Award by the Canadian
Ocutech Vision Enhancing Systems
58 | P a g e
National Institute for the Blind in 1999 for its • A consistently sharp image at a minimum
creative development of the VES- distance of 12 inches
AF.Ocutech is dedicated to meeting the
requirements of those with vision • This 4 × bioptic telescope has the largest
impairments and provides extensive field-of-view currently available.
warranties for its products. Ocutech Low • Lightweight (weighs only 2.3 ounces)
Vision Aids may be obtained from
specialised doctors and clinics that focus on • Simple to showcase, suitable for use, and
low vision treatment worldwide. Your distribute
queries are warmly welcomed. The focusing eyepiece can effectively correct
Note: All Ocutech products have received CE refractive errors ranging from +12 to -12.
approval. The VES®-AF Bioptic Telescope • Eyepiece and filter adjustments are offered
System (4x) is a self-focusing bioptic
telescope that has won awards. It is the only • Equally simple to order, just like any
one of its kind in the world. The VES®-AF traditional bioptic telescope system
offers the most natural magnified vision
Ocutech's innovative bridge mounting
possible, as the image becomes clear
mechanism allows for customizable
immediately wherever you look, just like
adjustment of the eyepieces.
natural vision. It eliminates the
inconvenience of having to focus and the The OCUTECH VES® II is available with
fatigue of having to hold still to keep the three magnification options: 3X, 4X, and 6X.
image in focus. The VES®-AF consists of a
4x Keplerian telescope connected to a safe The Ocutech VES-II, the original Ocutech
computerised infrared autofocusing system. system, is the preferred choice of patients in
This system measures the distance of focus NEI funded research, with a ratio of 3 to 1.
more than 30 times per second, ensuring a The Ocutech Vision Enhancing System®
clear image immediately, even at a distance (VES®-II) is an improved version of
as close as 12 inches. This clear vision allows Ocutech's original bioptic telescope system.
visually impaired individuals to work more It was developed and tested with funding
efficiently and in a more relaxed and from the National Eye Institute. The VES®-
comfortable position. The VES-AF operates II addresses the main issues of conventional
all day long with a rechargeable battery pack. bioptic telescope systems(1,2), such as
The VES®-AF offers the broadest visual limited field of view, unattractive
range among 4 power bioptics and has a appearance, heavy weight, and lack of
weight equivalent to conventional manual- control over positioning. These issues have
focus expanded field devices from other hindered their acceptance by patients and
manufacturers. The development of VES®- caused difficulties for prescribers. The
AF was supported by the National Eye VES®-II bioptics p
Institute and its effectiveness has been The OCUTECH VES®-MINI is a visual
demonstrated in clinical trials funded by the enhancement system with a magnification
NIH. power of 3X and a field of view of 15
Characteristics degrees.

• Optimal, enhanced visual perception Introducing the most compact, lightweight,

and broadest field bioptic telescope to
date!The Ocutech VES®- Mini is a compact
59 | P a g e
and advanced bioptic telescope system that • Demonstrating, fitting, and ordering are
provides a 3x enhanced field of view using effortless.
Keplerian optics. The device offers a unique
mix of a remarkably broad 15-degree field- • Prescribe for single-eye, both-eye, and both
of-view inside a small and space-efficient near and far vision needs
physical structure. The VES®—Mini has the • Equally effortless to distribute, just like any
same dimensions as tiny focusing Galilean typical bioptic telescope system
telescopes and is only half the size of typical
extended field telescopes offered by rivals. • Suitable for all bioptic applications.
The Mini's optics offer precise internal
focusing capabilities for correcting refractive
flaws ranging from +12 to -12, as well as for TRAINING IN ORIENTATION AND
near seeing at a minimum distance of 7 MOBILITY
inches. The user-friendly diagnostic kit
Orientation refers to the understanding of
simplifies the process of showcasing and
one's position in space, whereas mobility
recommending this top-notch telescope
refers to the capacity to move about the
system, while minimising the time, effort,
environment in a safe, efficient, and
and any risks involved. The VES®-Mini may
autonomous manner. All low vision patients
be prescribed and ordered like any other
may not need orientation and mobility
traditional bioptic telescope system. It is
training, but those who are unable to move
available for both monocular and binocular
about with ease and independently may be
use, and can be used for both distance and
gradually exposed to the situations like
close applications. The device may be
traveling in residential, school or business
purchased either with Ocutech's stylish
areas and using public transportation.
ophthalmic frames as a whole package or it
Successful mobility depends on the effective
can be put into frames given by the
use of visual informations rather than visual
prescriber.
acuity. The other variable which affect
Characteristics mobility training are peripheral field defects,
light levels and contrast sensitivity. Some
• This bioptic telescope is unique because it patients can be made self-sufficient with the
offers both a large field of vision and a small use of low vision travel devices (3,4). For
size in a single device. others whose problems are not completely
• Optics are specifically engineered to reduce solved with these devices, the referral for an
interference from the telescope structure and orientation and mobility evaluation is
maximise the useable area of the carrier lens. indicated. The mobility instructor performs a
functional vision assessment to evaluate
• Adjustable focus range from infinity to a mobility potential and plan a training
minimum distance of 7 inches programme emphasing effective use of vision
• Automatically adjusts for refractive error and other services. Recommended travel aids
adjustments ranging from +12 to -12. are incorporated into the programme.

• Eyepiece, reading cap, and filter Assessment of functional orientation and

adjustments are provided. mobility

• Can be easily mounted in various stylish Prior to commencing a training programme,

it is imperative to conduct a comprehensive
frames
assessment of the visually impaired patients'

60 | P a g e
low vision. This assessment should take into While there exists a wide range of mobility
account the patient's case history and aids, specifically five categories of visual
functional evaluation for orientation and aids are employed for the purpose of
mobility. It is essential to conduct this enhancing mobility -
evaluation both during the day and at night.
If the patient requires evaluation in different 1. Traditional eyeglasses or contact lenses.
environments such as residential areas, 2. Glare and light regulating devices such as
college campuses, businesses, indoors, absorptive lenses.
outdoors, or other specific surroundings,
multiple sessions may be scheduled to 3. Optical devices such as handheld
prevent excessive fatigue. Various monocular telescopes and head-mounted
behaviours are observed in all settings and bioptic telescopes that provide magnification
under different lighting conditions. assistance.

1. Object recognition and avoidance 4. Compressing devices.

distances: The patient's ability to identify and 5. Prisms and mirrors are utilised to shift the
subsequently avoid objects is assessed based position of an image. Certain individuals with
on their size, colour, texture, and distance. It impaired vision may require nonvisual
is noted whether the patient can identify both techniques to enhance their vision in
stationary and moving objects. Additionally, unfavourable circumstances, such as during
the assessment includes determining whether the night, in unfamiliar areas, or in bad
the patient relies on tactile or auditory cues weather. There are six categories of
before utilising their vision. nonvisual aids that can be employed either
2. Movement assessment: The system detects independently or in conjunction with visual
the direction and distance of vehicles, people, aids—
and other objects. 3. Scanning behaviour: 1. Sighted guide refers to the act of holding
The system also observes if the patient tends onto the arm of a person who can see.
to focus more on one side than the other.
2. Extended cane or assistive cane.
4. Gaze: The patient's direction of focus,
whether it is straight at the item, to the side, 3. Utilise a defensive arm manoeuvre to
or slightly up or down. Also, if fixating on an prevent physical contact or harm to the upper
object triggers nystagmus or not. and lower regions of the body.
5. Orientation Landmarks: What hints and 4. Trailing refers to the act of moving along a
landmarks does the patient rely on for wall with the rear of the hand.
orientation? If visual landmarks are
5. Canine guide.
employed, do they share common qualities
such as size, colour, and relative location? 6. Electronic devices.
6. hue perception: Does the patient exhibit a Reference
preference for a specific hue over others?
How does the lighting conditions impact their 1. Sivakumar, P., Vedachalam, R.,
capacity to perceive and utilise colours? Kannusamy, V., Odayappan, A., Venkatesh,
R., Dhoble, P., ... & Narayana, S. (2020).
Assistive devices and methods for movement Barriers in utilisation of low vision assistive
products. Eye, 34(2), 344-351.

61 | P a g e
2. Agarwal, R., & Tripathi, A. (2021). 11. Sapkota, K., & Kim, D. H. (2017). Causes
Current modalities for low vision of low vision and major low-vision devices
rehabilitation. Cureus, 13(7). prescribed in the low-vision clinic of Nepal
Eye Hospital, Nepal. Animal cells and
3. Demmin, D. L., & Silverstein, S. M. Systems, 21(3), 147-151.
(2020). Visual impairment and mental health:
unmet needs and treatment options. Clinical 12. Deemer, A. D., Bradley, C. K., Ross, N.
Ophthalmology, 4229-4251. C., Natale, D. M., Itthipanichpong, R.,
Werblin, F. S., & Massof, R. W. (2018). Low
4. Honavar, S. G. (2019). The burden of vision enhancement with head-mounted
uncorrected refractive error. Indian Journal video display systems: are we there yet?.
of Ophthalmology, 67(5), 577-578. Optometry and Vision Science, 95(9), 694-
5. Javadi, M. A., & Zarei-Ghanavati, S. 703..
(2008). Cataracts in diabetic patients: a 13. Lee, S. M., & Cho, J. C. (2007). Low
review article. Journal of ophthalmic & vision devices for children. Community Eye
vision research, 3(1), 52.
Health, 20(62), 28.
6. Vashist, P., Senjam, S. S., Gupta, V., 14. Şahlı, E., & İdil, A. (2019). A common
Gupta, N., & Kumar, A. (2017). Definition of approach to low vision: examination and
blindness under National Programme for rehabilitation of the patient with low vision.
Control of Blindness: Do we need to revise Turkish journal of ophthalmology, 49(2), 89.
it?. Indian journal of ophthalmology, 65(2),
92-96. 15. Hayhoe, M., Gillam, B., Chajka, K., &
Vecellio, E. (2009). The role of binocular
7. Ganesh, S. C., Narendran, K., Nirmal, J., vision in walking. Visual neuroscience,
Valaguru, V., Shanmugam, S., Patel, N., ... & 26(1), 73-80.
Ehrlich, J. R. (2018). The key informant
strategy to determine the prevalence and 16. Neve, J. J. (1989). Reading with hand-
causes of functional low vision among held magnifiers. Journal of medical
children in South India. Ophthalmic engineering & technology, 13(1-2), 68-75.
epidemiology, 25(5-6), 358-364..
17. Spitzberg, L. A., & Goodrich, G. L.
8. Minto, H., & Butt, I. A. (2004). Low vision (1994). New ergonomic stand magnifiers. In
devices and training. Community eye health, Low Vision (pp. 159-162). IOS Press.
17(49), 6.
18. Rohrschneider, K., Bayer, Y., & Brill, B.
9. Ager, L. (1998). Optical services for (2018). Closed-circuit television systems:
visually impaired children. Community Eye Current importance and tips on adaptation
Health, 11(27), 38. and prescription. Der Ophthalmologe, 115,
548-552.
10. Jackson, M. L., Schoessow, K. A.,
Selivanova, A., & Wallis, J. (2017). Adding 19Bendall, M. L., De Mulder, M., Iñiguez, L.
access to a video magnifier to standard vision P., Lecanda-Sánchez, A., Pérez-Losada, M.,
rehabilitation: initial results on reading Ostrowski, M. A., ... & Nixon, D. F. (2019).
performance and well-being from a Telescope: Characterization of the
prospective, randomized study. Digital retrotranscriptome by accurate estimation of
Journal of Ophthalmology: DJO, 23(1), 1. transposable element expression. PLoS
computational biology, 15(9), e1006453.

62 | P a g e
20. Katz, M., Citek, K., & Price, I. (1987).
Optical properties of low vision telescopes.
Journal of the American Optometric
Association, 58(4), 320-331.
21. Gilbert, C., & Van Dijk, K. (2012). When
someone has low vision. Community Eye
Health, 25(77), 4.

63 | P a g e
Paediatric Eye and Binocular
Vision Examination

Dipanwita Ghosh,
PhD Scholar, M.Optom, B.Optom, C.C.E.H
Assistant Professor & Head
Department of Optometry
Swami Vivekananda University

64 | P a g e
 leading causes are cataract and refractive
Paediatric Eye and error. [2,3] Unfortunately lack of knowledge
Binocular Vision and awareness among parents leading to late
detection of vision disorders. Optometrists as
Examination a primary eye care practitioner need to do
vision screening of every single children in
the community until receives professional
eye examination. (Table 1)
5.1 GENERAL INTRODUCTION
This chapter of Pearls of Clinical Optometry
describes the protocol of proper eye health
and visual examination procedure for infants
Optometrists as a primary health care and and children for timely detection, diagnosis
comprehensive eye care practitioner are and treatment to promote normal visual
clinically trained to provide effective eye and development. The aim of this chapter is to
vision care to children in India. Primary evaluate the clinical methods of pediatric
health care practitioners are the first level of visual system assessment.
contact with patient who provides all basic
necessary health care and create the bridge to This clinical practice guideline provide a
enter the specialty care of those conditions outline for pediatric eye health examination
needs referral.[1] Through eye care patient which also includes proper recommendation,
enters the health care system because our eye timely detection and diagnosis with
and visual system are directly connecting necessary referral for treatment. The goal is
with systemic health conditions. Every to develop proper protocol and timetable to
individual need eye care at a certain point of examine eye health and visual system of
time in life. pediatric patient, to reduce the complications
of visual system by early detection,
According to the last report in 2020, 35 treatment, and prevention. Also to increase
million people are visually impaired and 0.24 awareness among parents, patients other
million children are blind in India and the health care providers about the importance of
regular eye check up.

65 | P a g e
Table 1: Comparison of components of vision screening and regular visual examination of
pediatric age group [4]

5.2 Pediatric eye and vision examination:  School aged children ( 6- 18 years)
The pediatric population signifies a wide
range of age from birth till 18 years.
Although this age group varies in their Clinically it has been found that the most of
capabilities significantly. Thus the pediatric visual milestones developed by the age of
age group has been subdivided into 3 6month to 6 years, thus it’s called the critical
subcategories as follows: period of visual development.(Table 2) Thus
the first eye examination should be done at a
 Infant & toddler ( Birth to 2 years 11 age of 6 month. About the age of 3 years a
months) child develops a
 Preschool children ( 3-5 years
11month)

66 | P a g e
good receptive and cognitive abilities and  Create awareness and educate patient
also express in language. By the age of 6 and parents for preventive measures
years a child developed all the visual abilities
like a adult thus any tests can be done. While
selecting testing procedure for children it is Early detection and treatment of various
very important to rely on chronological age ocular conditions is very necessary to avoid
of the child and their specific capabilities. the potential causes of permanent visual
The goal of pediatric eye examination impairment. Although screening of the
includes: pediatric population specially infant and
toddlers are very challenging, thus can lead
 Examination of the function of visual
system to misdiagnosis or underdetection of various
ocular conditions like amblyopia,
 Examination of ocular health and
anisometropia, refractive error, strabismus
systemic health conditions
etc.
 Diagnosis and management plan

Table 2: Visual Development Inventory

67 | P a g e
5.3 Examination sequence: - Is there any hereditary health /eye
problem exists among the family
Examination of pediatric patients may of both parents?
include the following procedures:
 Birth history during Pregnancy –
5.3.5 Case History - Mother age at the time of birth
A comprehensive history taking - Any use of medication during
staring from demographic details of pregnancy?
the patient may include the following - Any exposure to radiation during
questionnaire: pregnancy?
- Any history of infection during
 Firstly ask the parents if they pregnancy?
have noticed any visual - Any history of smoking, alcohol
problems that’s define as or drug consumption during
chief complain pregnancy?
 Visual and ocular history  Birth history during Delivery
 Family history - Term of pregnancy
 Birth history - History of lack of oxygen at the
 Developmental history time of birth or any history of
 Medication history oxygenation?
 Allergy history - Type of delivery includes forcep
delivery, C section
 Family History – - Duration of the labor
Following questions can be asked: - APGAR score
- History of jaundice or  Visual Problems
phototherapy - Does the child rubs her eyes?
 Developmental history - Any history of eye turning
- Birth weight noticed?
- Any history of multiple ear - If yes then at what time of
infections or other illnesses? day? Which eye deviates
- Any delayed development? most frequently?
- Vaccination status - Direction of deviation?
- Any history of allergy from
any drug? Many cases squinting is the common
- History of any head or eye presenting complaint. However rule out true
injury? squint from a pseudo deviation is a critical
thing in infants because of there epicanthal vision problems verbally. Therefore, various
fold or tele canthus. Most of the infants techniques are employed to measure visual
achieved proper alignment between two eyes acuity in this population. It is difficult to get
within 6 months of age. a precise visual acuity in infants. As the
regular subjective visual acuity testing charts
i. Visual Acuity can not be used infants thus some special tests
Pediatric visual acuity measurement is are done to make assumption of visual acuity.
crucial for assessing the vision of infants, In infant and toddler the test procedure
toddlers, and young children. Unlike adults, includes:
who can usually communicate about their
vision, children may not be able to express - Fixation preference test

68 | P a g e
 - Forced choice preferential looking fixation pattern from a small whole at the
test with Teller acuity card center. 1 teller card with stripes imprinted
- Catford Vision Drum Test will be place on one side of the testing plate
- Optokinetic Nystagmus (OKN) drum and a same luminance empty grey
test background. The different resolution of lines
- Bock candy bead test of each Teller cards correspond different
acuity. The test is performed at a distance of
Fixation preference test is done with a 16 inch. If the child fixates at the tellers
vertical 10D base up or base down prism grating card that signifies the child can
which causes vertical separation of image. resolve the stripes. The examiner observes
The child being sited on mothers lap the where the child prefers to fixate. The
examiner looks at the fixation preference of resolution of the card started wit hthe largest
both eyes. It has found very effective in stripes and then with each completing steps
detection of 3 line difference between the two increase the stripes acuity. The infants visual
eyes in moderate amblyopia. acuity noted from the last card responded
Forced choice preferential looking test uses correctly. Clinical use of forced choice
the black and grey stripped 12 Teller acuity preferential looking test is very successful
cards and presented as a game in front of a although in case of strabismic amblyopia is
baby. The baby will be sited on mothers lap can underestimate the acuity. Thus to confirm
white the examiner will be standing behind the acuity electrodiagnostic tests like VEP
the testing cards and will look at the infants should be done for direct assessment.

Fig 1. Teller Acuity Card Test

69 | P a g e
Goldman was the first to propose presenting
oscillating stimuli in front of the patient and
observe the eye movement. The optokinetic
nystagmus (OKN) drum test is a diagnostic
tool used to evaluate the visual system's
response to moving stimuli, particularly in
assessing the integrity of the ocular motor
system and visual pathways. The OKN drum
consists of a drum-shaped device with
vertical stripes or patterns on its surface. The
drum can rotate horizontally around the
subject's line of sight. The patient sits or Fig 2. OKN Drum test
stands facing the drum at a comfortable
distance. They may wear an eye patch over Bock Candy bead test is done in children
one eye to allow for monocular testing if below 1 years of age. Different size colorful
necessary. Examiner rotates the drum, candy bead are placed on examiner’s hand. If
causing the stripes or patterns to move the child grab the bead and eat it signifies the
horizontally across the patient's visual field. child resolve the acuity of the size of the
The speed of rotation can be adjusted candy as small as 1mm. Although many
depending on the patient's age, condition, and researches have shown that this test only
the specific purpose of the test. The examiner equivalent about 20/200 Snellen’s acuity.
observes the patient's eye movements, The test should be done monocularly.
specifically looking for the presence of In case of any abnormality detected in
optokinetic nystagmus. Nystagmus is a examination of toddlers or infant
rhythmic, involuntary movement of the eyes, electrodiagnostic tests or Teller acuity card
and optokinetic nystagmus is triggered by the test should be done to get precise
movement of visual stimuli across the retina. measurement of visual acuity.
Optokinetic nystagmus typically consists of
slow eye movements in the direction of the
moving stimuli (smooth pursuit) followed by
Assessment of Visual Acuity in preschool
quick, corrective movements in the opposite
children includes:
direction (saccades). The presence,
symmetry, and quality of optokinetic  Lea Symbol chart
nystagmus can provide valuable information  Broken Wheel test
about the integrity of the patient's visual  HOTV test
system. The visual angle is calculated from  Landolt C test
the size of the stripe from the specific  Tumbling E test
distance. Then it’s converted into Snellen
 Allen picture card test
acuity.
 Lighthouse flashcard test
 Sjogren Hand test
A child of 3 years age developed almost all
the visual abilities and also psychological and
behavioral development. Thus subjective
tests can be done but some special
modifications that involve minimum verbal

70 | P a g e
interactions and allows simple tasks like
matching or pointing objects.
The Lea Symbols Chart Test is particularly
useful for testing young children or
individuals who may have difficulty with
letter recognition, as it relies on simple
geometric shapes instead. Additionally, it
helps minimize the potential for
memorization compared to letter-based
charts, ensuring more accurate results,
especially during repeated testing. It consists
of 4 shapes (apple, house, square and circle).
The child has to point out the similar object
from a testing distance of 3meter. The chart
consists of LOGMAR acuity and also
provide Snellen acuity for each line.
Similarly HOTV test consists of only 4
optotypes which is easier to recognized by a
preschool child. In studies it has been found
that Lea symbol chart is having high
testability than HOTV test in 3 years old
child. [4]
Fig 4. HOTV test chart

Broken wheel test also very interesting test to

perform in child 3-5 years of age. This test
card consists of 7 pairs of 5×7 inch cards that
is shown from a distance of 6meter. The
optotype ranges in a size from 20/100 to
20/20. If the child shows the broken wheels
card correctly four pictures of a row then
smaller size cards are then shown.

Fig 3. Lea Symbol chart

71 | P a g e
Fig 5. Broken wheel test

Landolt C test, tumbling E test and Sjogren Fig 7. Tumbling E Test

Hand test are direction identification tests . Test like Allen picture card consists of 7 test
The child has to identify the direction of the plates of familiar shapes or objects. The test
open side of the figures i.e left, right, up, card designed for a standard distance of
down. The test should be done both 30feet and can be converted into Snellen
monocularly and binocularly. The acuity acuity easily. The child asked to point out the
represented in Snellen acuity. similar object from sample card or respond
verbally.

Fig 6. Landolt C Test

Though this test required accurate
understanding of spatial orientation. It has
been found that tumbling E test is found to be
more accurate to understand the optotypes. Fig 8. Allen picture card test

72 | P a g e
 Cycloplegic Retinoscopy
It is very important to choose the cycloplegic
agent carefully based on the iris
pigmentation, patient with Down syndrome,
trisomy of chromosome 13/18, cerebral palsy
children with Down syndrome, cerebral
palsy, trisomy 13 and 18 and any CNS
disorder. It can cause hypersensitivity
reactions even in low weight child.
Cyclopentolate hydrochloride 0.5% (below 1
year) , 1% (above 1 year) is a choice of drug.
It is used twice in 5min interval and
retinoscopy is performed 20-30 mins after
Fig 9. Sjogren Hand Test last drop. A mixture of 0.5% cyclopentolate,
Visual acuity of school aged children may be 2.5% phenylephrine and 0.5% tropicamide
assessed with Snellen chart. can produce both cycloplegic and mydriatic
effect. In studies it has been found that
5.3.6 Refraction tropicamide 1% is a useful alternative of
The procedure of refraction in child is very cyclopentolate in nonstrabismic infants.[5]
different from adult. The procedure depends Near retinoscopy is an alternative technique
on the age of the child. The prescription in infants may be done in patients with
mostly completely based on objective hypersensitivity to cycloplegic drugs.
retinoscopy. After birth all the child with Though it has been not found as reliable
good health are usually found hypermetropic. comparative to cycloplegic refraction. [6-8]
Some less amount if astigmatism found to be
present in children below one year but In Child below 1 year of age 2D of
reduces with age. In preschooler age it is hypermetropia has been found , also it has
possible to take subjective visual acuity been seen 2D of astigmatism in patients till 3
measurement but subjective refraction again years of age.[9] Although this amount mostly
remains challenging thus glass prescription reduces with age by 2.5 years to 5 years of
rely on objective refraction. After 5 years of age.[10-11] Thus it is advised to monitor this
age it is possible to take visual acuity low amount of refractive error in children
measurement and also follow subjective before prescribing. (Table 3)
refraction like adults.
Measurement of refractive error in infant and
toddlers involve only
 Cycloplegic retinoscopy
 Near retinoscopy
In preschoolers static retinoscopy and
cycloplegic retinoscopy may be performed.
In school going child we can perform static
retinoscopy, cycloplegic retinoscopy and
subjective refraction.

73 | P a g e
 fixation while doing retinoscopy in child. The
distance target should placed at 6meter.
Monocular Estimate Method (MEM)
The MEM retinoscopy is performed to
evaluate the accommodative status of the eye.
The test is performed at a near working
distance of the child. The goal is to check
whether the accommodative response is
equal to the accommodative stimulus or not.
The MEM card consists of letters , symbols
or picture printed on the side that can be
attached at the retinoscopy head with a center
Table 3: Guidelines for refractive correction
hole to observe the reflex of the patient’s
in infants and toddlers
pupil. The child should wear their spectacle
For older children usually traditional and asked to read the target letters loudly.
procedures are followed that include The examiner should place the retinoscopy
cycloplegic refraction and subjective plane at slightly downgaze. The test should
refraction . Retinoscopy may be performed be performed very quickly. If with motion
with loose lens rock so that the examiner can seen then plus lens used to neutralize
observe the proper fixation of the child at indicates lag of accommodation. If against
distance. motion observed then it should be neutralized
with minus lens indicates lead of
Keratometry accommodation. The lens should be placed
Keratometry may be performed to evaluate quickly and estimation is done so to avoid
the corneal astigmatism. Corneal reflection alteration of accommodation system. Normal
of the rings are observed to determine the lag of accommodation is between +0.50D to
corneal astigmatism. Intact circular ring +0.75D.
indicate spherical cornea and distorted ring
indicate toric cornea. For children hand held
keratoscope is useful and acurate to detect 5.3.7 Binocular Vision & Ocular
astigmatism or any irregularities in the motility Assessment
cornea.
Evaluation of binocular vision,
Retinoscopy accommodation system and ocular motility
includes the following tests:
Retinoscopy is a vital tool to assess refractive
state in child. It is necessary to perform  Cover test
retinoscopy rapidly in infants and toddlers  Ocular motility test
rapidly due to limited attention. To perform  Near point of convergence
retinoscopy in infant may be necessary to  Amplitude of accommodation
attract attention at far distance by the parents  Monocular estimated method
with colorful toys or object. Retinoscopy can  Stereopsis
be easily performed on preschooler and older  Version and vergence
children as they easily fixate on then distance  Accommodative convergence versus
target. It is better to ask the child to read the accommodation ratio (AC/A ratio)
target letters loudly to ensure the proper  Negative relative accommodation

74 | P a g e
  Positive relative accommodation Color vision testing generally done with
pseudoisochromatic test plates having high
In infant and toddlers corneal reflex tests like testability in preschool aged and in older
Bruckner test, Krimsky test are the choice of
child.
evaluation of ocular deviation. Extraocular
motility may be performed using interesting
targets or pen light in all cardinal positions of
Intraocular pressure generally measures with
gaze.
help of Perkins hand held tonometer and
In preschool aged child also, the same tests tonopen. Another easier method is Keeler air
may be performed to assess the binocular puff tonometer. Tonopen gives a precise data
status. Cover test mat be performed at in older child. To perform the test in infant
primary gaze. While measurement of NPC may be done in sleeping condition also. If
recording of both break point and recovery unable to perform the IOP with these method
point is also necessary. Fusional vergence then conventional digital IOP measurement is
can be assessed objectively using prism bar also acceptable in infants.
step vergence test. Stereopsis can also be
assessed with normal commercially available Examination of the pupil size and
observation of the reflex both direct and
tests. Extraocular motility should be
performed to check all the 6 cardinal consensual in children is also necessary. In
neonates pupils are small and equally round.
direction of gaze.
In school aged child it has been found that the Evaluation of visual field may be done using
most prevalent ocular condition are confrontation test in pre school age children.
accommodative and anomalies of binocular Pediatric visual field testing devices may be
vision. [12] This conditions effects their used for school aged children and HVF also
school performance and the child experience in older children.
symptoms like headache, eye strain, blurred Direct ophthalmoscopy is an objective
vision, diplopia, skipped lines which method to evaluate the posterior segment of
decrease the comprehensive reading attention the eye in children. To perform the test in
in child. [13,14-20] Evaluation of infant, mother may hold the baby
accommodation and vergence system also horizontally in her arms or may be placed the
include fusional vergence amplitude, facility. baby on her shoulder. It is advised to avoid
Qualitative testing of eye movements like touching the face of the baby and the
saccades, pursuits and fixation pattern should attention of the baby should be keep at
be assessed. different distance all over the room with help
of assistant. Set the ophthalmoscope at zero
power with white filter. The red reflex of both
5.3.8 Ocular Health Assessment eyes should be compare. Then move towards
the baby in slightly 15 degrees and shine the
Ocular health assessment in children include: light through the pupil. It is necessary to note
 Evaluation of anterior segment and down that the reflex is clear and red.
ocular adnexa 5.4 Conclusion
 Intra ocular pressure measurement
 Evaluation of posterior segment After completion of the assessment
 Pupillary response Optometrist should analyze the report to
 Visual field screening diagnose and plan the management. In

75 | P a g e
necessary cases proper referral to retinoscopy" and retinoscopy under
Ophthalmologist, pediatrician and other cycloplegia. Am J Optom Physiol Opt
primary care practitioner are indicated. 1985; 62:169-72.
8. Wesson MD, Mann KR, Bray NW. A
comparison of cycloplegic refraction
References: to near retinoscopy technique for
refractive error determination. J Am
1. Behera, B. K., Prasad, R., & Optom Assoc 1990; 61:680-4.
Shyambhavee (2022). Primary 9. Banks M. Infant refraction and
health-care goal and accommodation. Int Ophthalmol Clin
principles. Healthcare Strategies and 1980; 20(1):205-32.
Planning for Social Inclusion and 10. Gwiazda J, Mohindra I, Brill S, Held
Development, 221–239. R. Infant astigmatism and meridional
2. Mannava, Sunny; Borah, Rishi Raj1; amblyopia. Vision Res 1985;
Shamanna, B R. Current estimates of 25:1269-76.
the economic burden of blindness and 11. Mohindra I, Held R, Gwiazda J, Brill
visual impairment in India: A cost of S. Astigmatism in infants. Science
illness study. Indian Journal of 1978; 202:329-30.
Ophthalmology 70(6):p 2141-2145, 12. Scheiman M, Gallaway M, Coulter R,
June 2022. et al. Prevalence of vision and ocular
3. Vashist, P., Senjam, S. S., Gupta, V., disease conditions in a clinical
Gupta, N., Shamanna, B. R., pediatric population. J Am Optom
Wadhwani, M., Shukla, P., Manna, Assoc 1996; 67:193-202.
S., Yadav, S., & Bharadwaj, A. 13. Scheiman M, Rouse MW. Optometric
(2022). Blindness and visual management of learning related
impairment and their causes in India: vision disorders. St. Louis, MO: CV
Results of a nationally representative Mosby, 1994:321- 2.
survey. PloS one, 17(7), e0271736. 14. Duke-Elder S. System of
4. Hered R, Murphy S, Clancy M. ophthalmology, vol V. Ophthalmic
Comparison of the HOTV and Lea optics and refraction. St. Louis, MO:
Symbols charts for preschool vision CV Mosby, 1970:451- 86.
screening. J Pediatr Ophthalmol 15. Daum KM. Accommodative
Strabismus 1997; 34:24-8. dysfunction. Doc Ophthalmol 1983;
5. Twelker JD, Mutti DO. Retinoscopy 55:177-98.
in infants using a near noncycloplegic 16. Hennessey D, Iosue R, Rouse MW.
technique, cycloplegia with Relation of symptoms to
tropicamide 1%, and cycloplegia with accommodative infacility of school
cyclopentolate 1%. Optom Vis Sci aged children. Am J Optom Physiol
2001; 78(4):215-22. Opt 1984; 61:177-83.
6. Saunders KJ, Westhall CA. 17. Haddad HM, Isaacs NS, Onghena K,
Comparison between near Mazor A. The use of orthoptics in
retinoscopy and cycloplegic dyslexia. J Learn Disabil 1984;
retinoscopy in the refraction of 17:142-4.
infants and children. Optom Vis Sci 18. Sheedy JE, Saladin JJ. Association of
1992; 69:615-22. symptoms with measures of
7. Borghi RA, Rouse MW. Comparison
of refraction obtained by "near

76 | P a g e
 oculomotor deficiencies. Am J on psycholinguistic processing in
Optom Physiol Opt 1987; 55:670-6. reading. J Am Optom Assoc 1989;
19. Ludlam WM, Ludlam DE. Effects of 60:38-44.
prism-induced accommodative
convergence stress on reading
comprehension. J Am Optom Assoc
1988; 59:440-5.
20. Garzia RP, Nicholson SB, Gaines CS,
et al. Effects of nearpoint visual stress

77 | P a g e
Enhancing Performance Through
Sports Vision Training

Dipanwita Ghosh,
PhD Scholar, M.Optom, B.Optom, C.C.E.H
Assistant Professor & Head
Department of Optometry
Swami Vivekananda University

78 | P a g e
 Dynamic visual acuity refers to the ability
Enhancing to see objects clearly while they are in
Performance motion. In sports like baseball or cricket,
where the ball travels at high speeds,
Through Sports athletes with superior dynamic visual acuity
Vision Training can track the ball more effectively, giving
them an advantage in timing their actions.
Athletes must maintain clear vision even
when objects are in motion. This skill is
crucial in sports such as baseball, tennis,
6.1 Introduction and soccer, where athletes need to track
Sports vision encompasses the visual skills fast-moving balls accurately.
necessary for optimal performance in Measuring dynamic visual acuity (DVA)
athletic activities. From tracking a fast- involves assessing an individual's ability to
moving ball to judging distances see objects clearly while they are in motion.
accurately, athletes rely heavily on their
Several methods can be used to quantify
visual system to succeed in their respective DVA, each with its own advantages and
sports. We will discuss about the limitations. Here are some common
significance of sports vision training in
approaches:
enhancing athletic performance, the key
visual skills involved, and the 1. Computerized Tests
methodologies used to develop and
improve these skills. Athletes rely heavily Computerized tests present moving stimuli
on their visual abilities to excel in their on a screen, and participants are required to
respective sports. From tracking fast- identify characteristics of these stimuli,
moving objects to making split-second such as letters, shapes, or symbols. The
decisions, the visual demands placed on stimuli may move horizontally, vertically,
athletes are diverse and rigorous. This or in other directions at varying speeds. The
chapter delves into the specific visual participant's responses are recorded, and
requirements of athletes across various their accuracy or reaction time is measured.
sports and the implications for training and Examples of computerized DVA tests
performance enhancement. include:
Tachistoscope Tests: Present stimuli for
brief durations, requiring participants to
6.2 Understanding Sports Vision identify them accurately despite their rapid
movement.
Vision is not solely about seeing clearly; it
involves a complex interplay of various Flicker Tests: Display rapidly alternating
visual skills. In sports, these skills include images to assess participants' ability to
eye-hand coordination, dynamic visual perceive moving objects accurately.
acuity, peripheral vision, depth perception
and visual reaction time. Each of these
skills plays a crucial role in different sports,
from baseball and basketball to soccer and
tennis. 2. Vision Tracking Systems
Vision tracking systems utilize specialized
equipment to track participants' eye
6.2.1 Dynamic Visual Acuity movements as they attempt to follow
moving objects. By analyzing eye
movement patterns and gaze fixation

79 | P a g e
points, these systems can provide insights Participants view images containing
into an individual's dynamic visual tracking randomly distributed dots, with some dots
abilities. forming a pattern that creates a sense of
depth perception when viewed with both
3. Clinical Assessments eyes. The Stereo Fly Test and the Randot
In a clinical setting, optometrists or Stereotest are examples of random dot
ophthalmologists may perform DVA stereograms used for assessing stereopsis.
assessments using standardized visual Titmus Fly Test:
acuity charts or equipment. These
assessments typically involve presenting This test uses polarized glasses and a book
moving targets or optotypes at specific of stereoscopic images to assess stereopsis.
distances and speeds, with the participant Participants identify specific figures or
indicating their ability to discern the details patterns that appear three-dimensional
of the stimuli. when viewed with both eyes.
4. Sports-Specific Tests 2. Depth Perception Tests
Some sports-specific assessments Frisby Stereotest:
incorporate dynamic visual tasks relevant to
particular athletic activities. For example, Participants identify the orientation or
in baseball or cricket, athletes may be tested position of three-dimensional shapes
on their ability to track a moving ball presented at varying depths. The Frisby
accurately using specialized equipment or Stereotest assesses both stereopsis and
depth perception by requiring participants
simulated game scenarios.
to manipulate shapes to match a reference
model.
6.2.2 Depth Perception Random-Dot Kinematograms:
Depth perception allows athletes to These tests involve moving random dot
accurately judge distances between objects patterns presented on a screen to create the
in their environment. Accurate depth illusion of depth. Participants may be asked
perception is essential for judging distances to identify the direction of motion or judge
and spatial relationships between objects. the relative depth of objects within the
In sports such as golf or archery, precise stimuli.
depth perception is essential for accurately
aiming at targets situated at varying 3. Clinical Assessments
distances. Randot Stereoacuity Test:
Measuring stereopsis and depth perception This clinical test uses polarized glasses and
involves assessing an individual's ability to a series of graded circles to assess
perceive depth and spatial relationships stereoacuity, which is the smallest
accurately. These visual skills are essential binocular disparity (difference in retinal
for various activities, including sports, images between the two eyes) that can be
navigation, and tasks requiring hand-eye perceived. Results are typically reported in
coordination. Here are several common seconds of arc.
methods used to quantify stereopsis and
depth perception: Howard-Dolman Test:

1. Stereopsis Tests This test measures depth perception by

presenting participants with a series of
Random Dot Stereograms: three-dimensional shapes or objects at
different distances. Participants identify the

80 | P a g e
order of the objects based on their perceived results are plotted on a visual field map to
depth. assess sensitivity across different regions.
4. Virtual Reality (VR) Simulations 2. Kinetic Perimetry
VR-Based Depth Perception Tasks: Goldmann Perimetry:
Participants interact with virtual Goldmann perimetry involves
environments containing objects at various systematically moving a target, typically a
distances. Tasks may include reaching for colored or illuminated stimulus, from the
virtual objects, judging distances periphery towards the central visual field.
accurately, or navigating obstacles within Participants indicate when they first detect
the virtual space. the target's movement or appearance. This
method assesses the visual field's extent and
6.2.3 Peripheral Vision sensitivity to moving stimuli.
Peripheral vision enables athletes to be 3. Automated Perimetry
aware of their surroundings without directly
focusing on them. It is crucial in team sports Humphrey Field Analyzer (HFA):
like basketball or soccer, where players
need to be constantly aware of the positions The HFA is a computerized device that
presents stimuli of varying brightness levels
of teammates, opponents, and the ball, even
when it is not within their central field of at different locations within the visual field.
Participants respond when they detect the
vision.
stimuli, and the results are analyzed to
Measuring peripheral vision involves assess sensitivity across the visual field.
assessing an individual's ability to detect
and recognize visual stimuli located outside 4. Clinical Assessments
the central field of view. Peripheral vision Amsler Grid Test:
is crucial for situational awareness,
navigation, and detecting objects or The Amsler grid consists of a grid of
movements in the environment. Here are horizontal and vertical lines with a central
several common methods used to quantify fixation point. Participants view the grid
peripheral vision: with each eye separately and identify any
distortions, missing areas, or other
1. Confrontation Visual Field Testing abnormalities in the grid's pattern,
indicating potential peripheral vision
Finger Counting:
deficits
During a confrontation visual field test, the
examiner or participant raises fingers in the 6.2.4 Eye-Hand Coordination
periphery of their visual field while the Eye-hand coordination involves the
participant maintains fixation on a central synchronization of visual input with motor
target. The participant then counts the responses. It is fundamental in sports like
number of fingers presented in each visual tennis or table tennis, where athletes must
quadrant. precisely time their movements to meet a
moving object with their racket or paddle.
Static Perimetry:
Static perimetry assesses the visual field's Measuring eye-hand coordination involves
sensitivity by presenting stimuli at various assessing the ability of an individual to
locations within the peripheral visual field. synchronize visual input with motor
Participants indicate when they detect the responses accurately. Several methods can
stimuli using a button or keypad. The be used to quantify eye-hand coordination,

81 | P a g e
each focusing on different aspects of this High-speed cameras and motion capture
skill. Here are some common approaches: technology track participants' hand
movements with precision. This allows for
1. Targeted Tasks detailed analysis of movement trajectories,
Pegboard Test: velocities, and coordination patterns during
specific tasks.
Participants are asked to insert pegs into
corresponding holes on a pegboard as 6.2.5 Visual Reaction Time
quickly and accurately as possible. This test Visual reaction time is the speed at which
assesses fine motor control and
an athlete can respond to a visual stimulus.
coordination. In sports such as boxing or basketball,
Coin-Stacking Task: quick reactions can mean the difference
between success and failure. Quick reaction
Participants are tasked with stacking coins times are vital in sports like sprinting,
or small objects into a tower using tweezers basketball, and martial arts, where athletes
or their fingers. This test evaluates must respond rapidly to visual stimuli to
precision, dexterity, and spatial awareness. gain a competitive edge.
2. Object Manipulation Tasks Measuring visual reaction time involves
Dexterity Tests: assessing how quickly an individual can
respond to a visual stimulus. Visual
These tests involve manipulating objects of reaction time is crucial in various situations,
varying sizes, shapes, and textures using including sports, driving, and occupational
hands or handheld tools. Tasks may include tasks that require rapid responses to visual
assembling puzzles, threading needles, or cues. Here are several common methods
sorting objects based on specific criteria. used to quantify visual reaction time:
Finger Dexterity Tests: 1. Simple Reaction Time Tasks
Participants perform specific finger Choice Reaction Time Test:
movements or sequences, such as tapping
fingers in a coordinated pattern or rapidly Participants are presented with multiple
moving fingers between designated points. stimuli, each associated with a specific
These tests assess finger agility and response. They must quickly identify the
coordination. correct stimulus and execute the
corresponding response. This task assesses
the time taken to discriminate between
stimuli and initiate a motor response.
3. Virtual Reality (VR) Simulations
2. Clinical Assessments
VR-Based Coordination Games:
Light or Sound Trigger Tests:
Participants interact with virtual
environments using hand-held controllers Participants are instructed to press a button
or gestures. Tasks may include catching or perform a specific action in response to
virtual objects, navigating obstacles, or the sudden appearance of a light or sound
completing hand-eye coordination stimulus. The time between stimulus onset
challenges within the virtual space. and response execution is recorded using
specialized equipment.
4. Biomechanical Analysis
3. Computerized Tasks
Motion Capture Systems:
Go/No-Go Tasks:

82 | P a g e
Participants are presented with a series of Combat sports such as boxing, mixed
visual stimuli and instructed to respond martial arts (MMA), and fencing require
(e.g., press a button) when a specific target athletes to react swiftly to opponents'
stimulus appears (Go trials) while movements, anticipate strikes, and maintain
refraining from responding to other stimuli focus and concentration under pressure.
(No-Go trials). Reaction times are
measured for correct responses to Go trials.
Computerized Reaction Time Tests: 6.4 Sports Vision Training
Methodologies
Computerized programs present visual
stimuli on a screen, and participants are Sports vision training aims to improve these
visual skills through targeted exercises and
instructed to respond as quickly as possible
when a target stimulus appears. Reaction drills. These may include:
times are recorded automatically by the 1. Ocular Motor Exercises: Activities that
software. enhance eye movement control, such as
tracking moving objects or following
4. Sports-Specific Assessments
patterns.
Reactive Agility Tests:
2. Visual Awareness Drills: Exercises
Athletes perform agility drills or sports- designed to expand peripheral vision and
specific movements in response to visual increase awareness of the entire visual field.
cues, such as changes in direction or the
appearance of a target stimulus. Reaction 3. Depth Perception Training: Techniques
to improve depth perception, such as virtual
times are measured based on the time taken
reality simulations or specialized
to initiate the required movement.
equipment that alters visual depth cues.

6.3 Sport-Specific Visual Demands

Team Sports
In team sports such as basketball, soccer,
and volleyball, athletes must quickly scan
the field or court, anticipate opponents'
movements, and make split-second
decisions based on visual cues from
teammates and opponents.
Individual Sports
In individual sports like tennis, golf, and
archery, athletes rely heavily on their visual
skills to aim accurately, track the trajectory
of the ball or target, and adjust their
movements accordingly.
Combat Sports
Fig 2. Bernell’s Rotator

83 | P a g e
4. Hand-Eye Coordination Drills: Practice dynamic visual acuity, peripheral vision,
routines that challenge athletes to depth perception and visual reaction time,
synchronize visual input with motor athletes and coaches can implement
responses, such as juggling or ball-catching targeted training methodologies to
exercises. maximize their visual capabilities and gain
a competitive edge on the field or court.
This chapter provides an overview of the
importance of sports vision and strategies
for training visual skills to enhance athletic
performance.

References:
1. Hitzeman SA, Beckerman SA.
What the literature says about sports
vision. Optom Clin. 1993;3(1):145-
69. PMID: 8324322.
2. Abernethy B.(1996) Training the
Fig 3. Marsden Ball with stick exercise
Visual-Perceptual Skills of
5. Reaction Time Training: Activities Athletes. Insights from the study of
focused on improving the speed and motor expertise. The American
accuracy of visual responses, such as Journal of Sports Medicine 224(6),
reacting to visual cues with specific 89-92.
movements.
3. Abernethy B., Wood J.M.(2001) Do
6. Cognitive Training generalized visual training
programs for sport really work? An
Cognitive training techniques, including
experimental investigation. Journal
visual attention and decision-making
of Sports Sciences 119, 203-222.
exercises, can sharpen athletes' mental
processing speed and improve their ability 4. Abernethy B., Wood J.M., Parks
to interpret and respond to visual S.(1999)Can the anticipatory skills
information effectively. of experts be learned by
7. Technology Integration novices? Research Quarterly for
Exercise and Sport 770, 313-318.
Incorporating advanced technologies such
as virtual reality (VR) simulations, eye- 5. Adam J., Paas F., Buekers M.,
tracking systems, and neurofeedback Wuyts I., Spijkers W., Wallmeyer
devices into training regimens can provide P.(1999) Gender differences in
athletes with valuable feedback and choice reaction time: evidence for
enhance their visual performance in differential
simulated game-like environments. strategies. Ergonomics 442(2), 327-
335.
6.5 Conclusion
6. Allen R., McGeorge P., Pearson
Sports vision training plays a vital role in D.G., Milne A.(2006) Multiple-
enhancing athletic performance by target tracking: a role for working
improving the visual skills necessary for memory. The Quarterly Journal of
success in sports. By understanding the
importance of eye-hand coordination,

84 | P a g e
 Experimental Psychology 59, 1101-
1116.

7. Allen R., McGeorge P., Pearson D.,

Milne A.B.(2004) Attention and
expertise in multiple target
tracking. Applied Cognitive
Psychology 118, 337-347.
8. Alvarez G.A., Franconeri
S.L.(2007) How many objects can
you track? Evidence for a resource-
limited attentive tracking
mechanism. Journal of
Vision 77(13:14), 1-10.
9. Bressan E.S.(2003) Effects of
visual skills training, vision
coaching and sports vision
dynamics on the performance of a
sport skill. African Journal of
Physical, Health Education,
Recreation and Dance 99(1), 20-31.
10. Bressan E.S.(2003) Effects of
visual skills training, vision
coaching and sports vision
dynamics on the performance of a
sport skill. African Journal of
Physical, Health Education,
Recreation and Dance 99(1), 20-31.
11. Maman P., Sandeep K.B., Jaspal
S.S.(2011) Role of sports vision and
eye hand coordination training in
performance of table tennis
players. Brazilian Journal of
Biomotricity 55(2), 106-1.

85 | P a g e
 INTRODUCTION TO
CONTACTOLOGY

Dr. Manas Chakraborty,

D.H.M.S , D.O.S, D.C.L.P, B.OPTOM, M.OPTOM
Assistant Professor
Department of Optometry
Swami Vivekananda University

86 | P a g e
 affixed water filled lenses on the eyes to
Introduction to neutralize the refractive errors.
Contactology In 1823 the British astronomer demonstrated
the practical contact lens design and in 1887
Muller, German physicist created the first
glass contact lens design. At the same time
7.1 Introduction
Swiss physician Adolf E Fick and Paris
Contact lenses are thin, curved surface optician Edouard Kalt made and fitted the
placed directly over the surface of the eye to first glass contact lenses to correct vision
correct vision and are used for cosmetic & problem in the year 1888. In 1939 contact
therapeutic purposes. Contact lens made up lens design and material modified from glass
of flexible plastic material that allows to plastic. In 1948 such plastic contact lenses
oxygen to pass through to the eye. The worn on to the cornea as corrective corneal
function of contact lenses depends on lenses. Californian optician Kevin Tuohy
wettability, water content, oxygen resembled the modern gas permeable
permeability, oxygen transmissibility, light contact lenses which are the most popular
transmissibility, refractive index, and contact lenses now days.
resistance to temperature, dimensions and
The revolution happened in the history of
flexible stability. It’s a popular alternative to
contact lenses when the first hydrophilic
eye glasses as they are less noticeable and
hydrogel soft contact lens material invented
can providewider field of vision.
by Czech chemist Otto Wichterle and
Drahoslav Lim in 1959 in which led to
launch of the first FDA approved soft
contact lensin United States in the year 1971
7.2 History of contact lens by Bausch & Lomb’s SOFLENS brand as
contact lens.
In 16th century the renowned Italian scientist
inventor & artist Leonardo Da Vinci first In 1887-88 the gas permeable contact lenses
sketched the concept of the contact lens. The introduced but gradually modification made
concept of sketch was how the refractive and in 1978 finally modern gas permeable
error can be corrected by looking through contact lens established.
the bottom of a glass bowl filled with In 1981 extended wear soft contact lenses
water.Thus, the concept of contact lens came produced which could be worn overnight. In
up and the ideas have been modified and 1986 again modified gas permeable contact
developed in times. Such concept happened lens made of fluroperm material introduced
on 1508. In 1638 French philosopher Rene where oxygen transmissibility is highest
Descartes also given the concept of a glass (RGP). In 1987 disposable soft contact lens
tube filled with liquid which placed directly established and the concept of planned
over the cornea for the correction of replacement therapy introduced.
refractive error. As it placed over the corneal
surface, there were problems for blinking Specifically in 1996 one day disposable
properly and that’s why the concept (daily disposable) contact lens introduced.
rejected. In 1801 Thomas Young made a
In 2002 another remarkable materials
pair of contact lenses by using wax and it
Silicon amalgamate with Hydrogel material
(soft) formed silicon hydrogel material of

87 | P a g e
soft contact lens which has great value in
transmitting the oxygen near about 95% for
maintaining the absolute nutrition of the
cornea.
In 2010 total custom made contact lenses
manufactured for the benefit of corneal
health and the clarity of vision with
optimum comfort.
Soft contact lens made of hydrogel and
silicon hydrogel materials have been huge
success and become the most popular. 7.3.2Nature of contact lens
->Rigid non gas permeable contact lens
7.3Classification of contact lenses (PMMA)
Based on purpose of use contact -> Rigid gas permeable contact lens (CAB)-
lens can be classified into, > Soft contact lens made up of Hydrogel and
a) Optical
b) Therapeutic
c) Cosmetic
d) Soft contact lens

Silicon Hydrogel

Tinted contact lens

Scleral lens fitting
7.3.1 Based on Anatomical location
->Corneal contact lens -> Hydrogel having low oxygen
transmissibility (less than 50%), Silicon
->Scleral contact lens Hydrogel have high oxygen transmissibility
->Semi scleral contact lens (near about 95%)
 Filcon-- these are hydrophilic, non-rigid
lens material.

88 | P a g e
Focons—these are hydrophobic rigid lens Group 3
materials.
Low water content, ionic polymers
(Balafilcon A, Deltafilcon A, Bufilcon A)
Group 4
7.3.3 Classification based on wearing High water content, ionic polymers
schedule (Etafilcon, Etafilcon A, Ocufilcon D)
 Daily wear contact lenses
->Hard (non-gas permeable)
7.3.6 Anomalies of Refraction
->Rigid gas permeable
-> Refractive anomalies that mean errors in
-> Soft Hydrogel. refraction while the light rays either focus in
front or behind the sensitive retina
 Extended wear contact lens responsible for blurry image formation also
->Highwater content soft contact lens (more termed as Ametropia.
than 50%) -> Refractive anomalies can be classified
Disposable contact lenses made of silicon into 4 types
hydrogel. Myopia: When light rays are focusing in
front of retina also called near sightedness.
Myopia can be corrected with the help of
7.3.4Classification based on water content concave spherical lenses.
High water content lens (more than 50%) Hypermetropia: When light rays are
Low water content lens (less than focusing behind the retina also called as far
50%) sightedness. Hypermetric conditions can be
corrected with convex spherical lenses.

7.3.5 FDA Classification

Group 1
 Low water content, Nonionic polymers
(Tefilcon, Tetrafilcon A, Lotrafilcon,
galyfilcon)
Group 2
High water content, Nonionic polymers
(Alphafilcon A, Omafilcon A, Omafilcon,
Afilcon A)

89 | P a g e
Astigmatism: When particular meridian of Here we will briefly discuss about
a refractive surface is responsible for excess dispensing contact lenses to correct the
or less amount of focus due to surface refractive errors and its fitting procedures
irregularity and ultimately cause to distorted with assessment.
blurry vision can b corrected with
cylindrical lens.
Presbyopia: Physiological loss of 7.4Indicationand contraindication of
accommodation may cause less amount of Contact lens
focusing capacity responsible for 5.4.1Indications
hypermetropic condition during near vision.
The amount of refractive error based on the ->Contact lenses are simply used in
amount of accommodation losing connected 1) Optically for high refractive error
with aging. Additional plus lens provided correction specially Myopia, Unilateral
with the regular correction to correct such Aphakia, Irregular Astigmatism,
types of near refractive errors. Anisometropia, Keratoconus.
2) In case of iris deformities such as
Symptoms of refractive errors: Aniridia, Coloboma, Albinism.

->Double vision 3) In Glaucoma drug delivery system.

->Hazy vision 4) Operative - Pars plana vitrectomy, Photo

coagulation, Goniotomy, post vitreo retinal
-> Glare and halo appearance surgery in some cases epithelial defect.
->Strabismus conditions 5) Diagnostics- Gonioscopy, Electro
Retinography, Fundus examination in
->Headache
->Eye stress
->Trouble while changing focus from
distance to near or intermediate vision
zones.
Refractive errors can be managed by
providing
->Eyeglasses
->Contact lens correction
-> Refractive Surgery
Diagnosis and management procedures
can be described as medical &ocular
history taking, Visual acuity testing,
Refraction, finding acceptance and patients with astigmatism, fundus
correction, comprehensive eye photography.
examinations.

90 | P a g e
6) Therapeutic: Corneal pathologies, Pseudo involves in choice of materials and the
Aphakic Bullous Keratopathy, Corneal production technology.
ulcer, Recurrent corneal erosion syndrome,
Fillamental Keratitis, Post superficial
keratectomy, Dry eyes, Post keratoplasty, The semi molded manufacturing ->
Post cornel tear repair – microleak.
The prime thing of semi molded
7) Pediatric: Amblyopia Opaque contact manufacturing is lathe cutting. Lathe cutting
lens for occlusion. is the technique where small hard disk of
contact lens (blank) material on a rotating
8) Preventive: Trichiasis, Exposure
Keratitis, Prevention of shaft which rotates at 6000 revolutions per
minute and shaped with a computerized
symblepharon.
cutting tool. After making the lens it goes
9) Occupational: Sportsmen, Police, and through different stages of shaping,
Pilot. polishing, hydration and then quality
assurance with sterilization process. In this
10) Cosmetic: Pthysis bulbi, corneal scur manufacturing process the focus is to control
human factors.

7.4.2 Contraindications
1) Absolute contraindication:
Chronic dacryocystitis, dry eyes, hordeolum
Internum and externum, Uveitis, Blepharitis,
conjunctivitis, Scleritis, 5th& 7th nerve palsy,
Allergic conjunctivitis, Superficial punctate
keratitis, Sub epithelial keratitis, Corneal
ulcer.

2) Relative contraindication:
Pregnancy,
Giant papillary conjunctivitis, Strabismus
conditions.
3) Corneal hypoaesthasia
7.5.1 Manufacturing techniques for Soft
Contact lens
-> Contact lens manufacturing process is a
complex technique involving cutting, quality
testing, sterilization and tools setting for
incorporating dioptric power in it also

91 | P a g e
 7.5.2 Manufacturing techniques for rigid
The full molded manufacturing -> Contact lens
The full molding process mainly uses The majority of rigid contact lenses are
precision molds to form contact lens at one made by lathe cut technique rather than
time through a numerical control mode molded. The following manners to be
mainly injection molding process. Injection followed;
molding is the process of heating the soft
contact material to a liquid state and then ->Contact lens blank buttons are cut from a
injecting it into a precise pressurized mold. rod of plastic that looks like a curtain rods.
After molding polishing moisturizing and ->The inside curve is then cut and polished.
quality assurance test are performed. In this stage the lens is referred to as a semi-
Cast molding: finished blank.
Cast molding is the process of designing a ->The front surface is than cut and polished.
mold, injecting liquid material into the mold ->Intermediate and peripheral curves are
then hardening it with high temperature and
applied.
pressure then demolding grinding, polishing
and finally hydrating it into a finished -> The edge is then finished and this is now
product. a completed RGP lens.
Most disposable contact lenses are #Modification of finished lens
manufactured by this method.
->Diameter reduction:
Spincasting:
The lens is mounted concave side up on a
Liquid material of contact lens injected into rotating spindle and the blade of the razor or
the rotating mold and the centrifugal force, knife is rocked back and forth on the edge.
gravity and surface tension forming smooth The file and emery board are used mainly
film which is then hydrated into a finished for small reduction of lens diameter. When
product. the lens has been reduced the intermediate
peripheral curves must be applied and
blended.

92 | P a g e
->Blending: edge of the lens must touch the tool at the
same time. Equal pressure should be exerted
Blending is done to make the junction on all meridians of the lens.
between intermediate and peripheral zone
smooth finishing. In this process the lens is -> Removing Scratches:
held by a suction cup and rotated on the tool
During the Scratch removing time care
in the opposite direction to the tool rotation.
should be taken so as not to deformed the
->Edge shaping optics of the lens. In some cases, new lenses
affected optically by scratches that should be
If a lens has a secondary curve but no bevel.
removed carefully. During the scratch’s
Then it is necessary for shaping the edge of removal process from the rigid lenses, the
the lens. The edge will be smooth and lens is fitted with a suction cup or a spindle
rounded by the help of a file or razor blade. against the velveteen covered drum when it
After shaping the edge, it is polished by a
is rotated.
rag wheel, or a felt disc or a sponge.
X-PAL polishing agent is used to remove
->Power Change scratches from the inside (Base curve) of a
Velveteen and drum tool are used. lens. Convex shaped tool is used to remove
Velveteen is soaked with water and then the scratches and polish the lens with X-
pulled over the sides of a drum tool and PAL. The best procedure to use sponge tool
fastened tightly with rubber bands. A to remove scratches from inside of a lens.
depression is formed in the tool the lens is
held by a brass lens holder and suction cup.
To add plus power the lens is held so that
the convex surface is against the velveteen
and is exactly centered on the tool. To add 7.6 Contact lens materials for soft and
minus power the lens is held so that the rigid contact lens
convex surface is against the velveteen at (Rigid)
the outer edge of the tool. The lens is rotated
once or twice a full 360 degree against the Hard (Rigid non gas permeable) contact
rotation of the tool. lens made up of PMMA (Poly Methyl
Methacrylate) having negligible oxygen
transmissibility with less wearing time and
comfortability. That is why it is becoming
->Peripheral curve
most unpopular.
Peripheral curve can be applied by the use of
a tool having a radius of curvature of 12.25, Rigid Gas permeable contact lenses made
up of CAB (Cellulose Acetyl
11.5, 10.5, 9.5. Lens is carefully mounted
over the lens block so that it is not act angle. Butyrate),silicone (high O2 transmissibility
with less wettability), Styrene(less O2
It may be fixed by a double-sided tape. The
block is kept perpendicular to the tool that transmissibility with good wettability),
means concave side down and Sharp pointed Silicon Acrylate, Fluoropolymers having
pencil acts as a spindle. The polishing agent more oxygen transmissibility than PMMA.
(X-PAL) is applied to the surface of a radius  Cellulose Acetyl Butyrate (CAB) is type
tool and lens is held so that the concave of thermoplastic material and derivative of
surface rests lightly against the tool, wood cellulose. It has good wettability but
revolving at about 1500RPM. The entire disadvantage is the tendency to wrap.

93 | P a g e
Silicon Acrylate materials are the co- Disadvantage of this type of lens that it can
polymers of PMMA and silicon Vinyl draw out tears from eye surface to maintain
monomers, such two mixed materials its moisture and responsible to drying out of
unitedly known as Siloxanyl Methacrylate. eye in sometimes.
MMA have the standard wettability and
silicon material have the quality of high
oxygen transmissibility. Silicon content can 7.7 Contact lens properties
be altered and manufactured with different
Dk values with high oxygen permeability. 7.7.1 Refractive index

Fluoropolymers: Refractive index of a contact lens material is

an important physical parameter that effects
RGP lenses with co-polymer of Fluorine, the lens design as the refracting power of a
which have high oxygen permeability and lens for any given thickness and curvature is
high-quality surface properties lead to directly related to its refractive index. It is
extended wear contact lenses. also an indirect measure of the water content
of a soft contact lens, the RIs are closely
corelated with the water content. Contact
(Soft) lenses are worn on the eyes have index of
1.42-1.52 and thickness is 0.2 mm. The
Hydrogel lenses (Hydroxyethyl equation that relates the focal length of a
Methacrylate): spherical lenses to the index of refraction of
These soft lenses are widely used, made the lens and radii of curvature for the front
of Hydroxyethyl Methacrylate which are and back surfaces is called Lens Maker’s
resistant to any chemical or enzymatic Equation.
reaction biodegradation and can bear with
Lens Maker’s Equation:
the chemical & thermal sterilization.
1/F = (n-n0)(1/r1-1/r2)where n0=1.00 for air.
Silicon Hydrogel lenses
7.7.2 Water content
These lenses have high Dk value and low
water content. The silicon material satisfies Water content is an important feature of soft
the high oxygen transmission capacity so contact lenses.Water enriches contact lenses
such lenses are used for prolonged wearing with oxygen so the high-water content lens
schedule. becomes more oxygen permeable. This is
why the patient gets more comfortable
wearing and breathable cornea. According to
High Water content lenses water content the contact lenses can be
divided into 3 different categories such as,
 These are more than 60% water content
lenses used for increased exposure of the  High water content lens.
cornea to atmospheric gases as it has high (percentage of water content is 61%-
water content characteristics so reduced lens 75%). Not only wearing comfort but
thickness also can deliver much amount of also easier to handle when inserting,
oxygen delivery within the lenses so more removing and disinfecting.
oxygen reaches to cornea. This type of lens  Mid water content lens. (41%-60%
is considered to be easier to handle when water content)
inserting, removing and disinfecting.

94 | P a g e
 Suitable for flowing oxygen to the
cornea without absorbing the water
of the natural tear film. Also, 7.7.5 Wettability
comfortable to wear, inserting, Wettability means how easily a liquid spread
removing, cleaning & disinfecting. over the surface of a contact lens.
 Low water content lens (25%-40% Wettability can be quantified by the contact
water content) angle. Contact angle is specific angle which
Helpful for comfortable wearing and is formed between drop of liquid and the
the breathable eye without drying out surface of the lens, where contact angle is
the cornea. low then the wettability of that surface is
high.

7.7.3 Oxygen permeability

7.8 Conclusion
It is the parameter of a contact lens that
denotes the ability of lens to let oxygen The introduction to contactology provides
reach the eye by diffusion that means how an overview of the field that focuses on
easily oxygen passes through the particular contact lenses. It highlights the study of
material. In soft contact lenses the oxygen various aspects such as design, materials,
permeability depends on the thickness and fitting, and usage of contact lenses.
material of the lens especially concerning Contactology is an important discipline that
the water content because permeability contributes to improving vision correction
depends on lens thickness. Oxygen options for individuals who prefer contact
permeability denotes by Dk where “D” lenses.
denotes the Diffusion coefficient and “K”
denotes Solubility co-efficient.

References:
7.7.4 Oxygen and light Transmission
Oxygen transmissibility depends on the
thickness of lens and lower thickened have 1) Kumar P,Mohamed A, Bhombal F,
the tendency to pass through oxygen Dumpati S, Vaddavalli PK. Prosthetic
quickly. It is denoted by Dk/t where “t” is replacement of the ocular surface ecosystem
the thickness of the contact lens. for corneal irregularity: Visual improvement
and optical deice characteistics.Cont Lens
Light transmission properties depend on the Anterior Eye. 2019 Oct;42(5):526-532.
optical properties of the material of the
contact lenses. Light converging capability, 2) Rathi VM,Mandathara PS, Dumpati
refractive index, surface smoothness, S. Contact lens in Keratoconus. Indian J
transparency, thickness, abbe value Opthalmol.2013 aug;61(8):410-5
(chromatic dispersion), specific gravity, UV
3) Lee SE, Kim SR, Park m. Oxygen
rays absorbing property etc. may interfere
permeability of soft contact lenses in
light transmission through a particular
different pH,Osmolarity and buffering
material. All these are the inherent
solution.Int j Opthalmol. 2015;8(5):1037-42
properties of contact lenses.

95 | P a g e
4) Musgrave CSA, Fang F. Contact lens 13) Contact Lenses 101, Part 1: Contact
Material: A Materials Science lens materials. (n.d.). CooperVision.
perspective.Materials(Basel).2019 https://coopervision.com/practitioner/ecp-
Jan14;12(2) viewpoints/technicians-and-staff/contact-
lenses-101-part-1-contact-lens-materials
5) Alipour F, Khaheshi S,
Soleimanzadeh M, Heidarzadeh S, 14) Gurnani, B. (2023b, June 11). Contact
Heydarzadeh S. Contact Lens-related lenses. StatPearls - NCBI Bookshelf.
complications: A Revew. J Opthalmic Vis https://www.ncbi.nlm.nih.gov/books/NBK5
Res.2017 Apr-June;12(2):193-204. 80554/
6) Gurnani, B. (2023, June 11). Contact 15) Musgrave, C. S. A., & Fang, F.
Lenses. StatPearls - NCBI Bookshelf. (2019). Contact Lens Materials: A Materials
https://www.ncbi.nlm.nih.gov/books/NBK5 Science perspective. Materials, 12(2), 261.
80554/ https://doi.org/10.3390/ma12020261
7)A brief history of contact lenses. (n.d.-b). 16) Lentiamo.co.uk. (2021, January 17).
Visiondirect.co.uk. Are contact lenses with high water content
https://www.visiondirect.co.uk/blog/history- better?
of-contacts https://www.lentiamo.co.uk/blog/contact-
lenses-high-water-content.html
8) Center for Devices and Radiological
Health. (2018b, January 16). Types of contact 17) SRO, A. (n.d.). Oxygen permeability
lenses. U.S. Food And Drug Administration. | Alensa UK.
https://www.fda.gov/medical- https://www.alensa.co.uk/dictionary/oxygen
devices/contact-lenses/types-contact-lenses -permeability.html
9) Center for Devices and Radiological 18) Lee, S. E., Kim, S. R., & Park, M.
Health. (2018c, January 16). Types of contact (2015). Oxygen permeability of soft contact
lenses. U.S. Food And Drug Administration. lenses in different pH, osmolality and
https://www.fda.gov/medical- buffering solution. DOAJ (DOAJ: Directory
devices/contact-lenses/types-contact-lenses of Open Access Journals), 8(5), 1037–1042.
https://doi.org/10.3980/j.issn.2222-
10) Gurnani, B. (2023, June 11). Contact
3959.2015.05.33
lenses. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK5 19) A review of contact angle techniques.
80554/ (2017, January 31). Contact Lens Update.
http://contactlensupdate.com/2017/01/31/a-
11) Lenses, F. C. (2023, August 30). review-of-contact-angle-techniques/
Contact lens manufacturing methods.
Wholesale Contact Lens From Manufacturer| 20) Themes, U. (2016, July 10). Basics of
Cosmetic Contact Lens Wholesaler. soft contact lens fitting. Ento Key.
https://www.freshladylenses.com/contact- https://entokey.com/basics-of-soft-contact-
lens-manufacturing-methods/ lens-fitting/
12) Erickson, G. B. (2022). Prescribing 21) Mondal, S. (2022, January 30).
for the athlete. In Elsevier eBooks (pp. 83– FITTING PROCEDURE FOR RIGID
116). https://doi.org/10.1016/b978-0-323- CONTACT LENS. Optography.
75543-6.00012-7 https://optography.org/fitting-procedure-for-
rigid-contact-lens/

96 | P a g e
 CLINICAL GUIDE TO
CONTACT LENS FITTING &
CARE

Dr. Manas Chakraborty,

D.H.M.S , D.O.S, D.C.L.P, B.OPTOM, M.OPTOM
Assistant Professor
Department of Optometry
Swami Vivekananda University

97 | P a g e
 Clinical Guide to
Contact Lens Fitting
& Care

8.1. Introduction
Contact lenses are thin, transparent
refractive surface placed over the cornea
to correct refractive errors. Normally
contact lens mostly used to fix refractive
anomalies but now a day’s also it
becoming significant in vision therapy,
drug delivery, cosmetic purposes etc. In
case of astigmatism hard or semi gas
permeable contact lens provided to correct
surface irregularities also with help of
forming tears lenses. Beside this Ortho K or
overnight contact lenses also designed to
reshape corneal curvature as part of myopia
control managements. For perfectly contact
lens use, care and practice it is necessary to
know about the steps of contact lens fitting,
calculation of the different parameters of
cornea & contact, trial and fitting
assessments and also steps of contact lens 8.2.1 Refractive Errors
care with multipurpose solutions. Due to
->Refractive anomalies that mean errors in
improper use of contact lens may be
refraction while the light rays either focus
harmful for our vision as it can induce
in front or behind the sensitive retina
allergic changes, infections,
responsible for blurry image formation also
neovascularization, irritation to patient eye
termed as Ametropia.
with stress, falling of visual acuity, excess
dryness etc. Beside this in case of lack of -> Refractive anomalies can be classified
awareness about contact lens use also into 4 types
responsible for contact lens quality loss,
protein deposition, less amount of oxygen Myopia: When light rays are focusing in
supply capacity to corneal surface, tear front of retina also called near sightedness.
exchange etc. In this chapter we will Myopia can be corrected with the help of
discuss about contact lens fittings, clinical concave spherical lenses.
steps of management and evaluation, Hypermetropia: When light rays are
parameters and calculations, fitting focusing behind the retina also called as far
assessments, complications, special and sightedness. Hypermetric conditions can be
recent advancements, care and maintenance corrected with convex spherical lenses.
etc.
Astigmatism: When particular meridian of
a refractive surface is responsible for excess
or less amount of focus due to surface
irregularity and ultimately cause to

98 | P a g e
distorted blurry vision can be corrected Patient selection is very important to fit the
with cylindrical lens. contact lens to the patients.
Presbyopia: Physiological loss of Patient selection procedure:
accommodation may cause less amount of
focusing capacity responsible for a) General & Ocular history
hypermetropic condition during near b) Patients’ motivation.
vision. The amount of refractive error based c) Actual requirement of contact lens.
on the amount of accommodation losing d) Assessment of general hygiene of
connected with aging. Additional plus lens the patient.
provided with the regular correction to All these are considered for the
patients and practitioner’s
correct such types of near refractive errors.
beneficial purpose.

8.2.2 Symptoms of refractive errors:

->Double vision
->Hazy vision
-> Glare and halo appearance
->Strabismus conditions
->Headache
->Eye stress
8.3.2 Clinical eye examination:
->Trouble while changing focus from
distance to near or intermediate vision
zones.
Refractive errors can be managed by
providing
->Eyeglasses
->Contact lens correction
-> Refractive Surgery
Diagnosis and management procedures can
be described as medical &ocular history
taking, Visual acuity testing, Refraction,
finding acceptance and correction,
comprehensive eye examinations.
Here we will briefly discuss about
dispensing contact lenses to correct the
refractive errors and its fitting procedures
with assessments.

a) Visual Acuity test.

8.3.1 Soft Contact lens fitting b) Clinical Refraction for
distance & near both.

99 | P a g e
 c) Corneal Topography.
(Anterior Optic Zone Radius
and Base Curve)
d) Palpebral Aperture Size.
e) Horizontal Visible Iris
Diameter. HVID
f) Ocular Motility test.
g) Corneal Sensitivity test.
h) Tear Film Break Up time.
i) Intra Ocular Pressure
Before trial fitting of soft contact
checkup.
j) Fundus Examination. lens, a complete eye examination to
k) Slit Lamp Bio Microscopy
Lids and lid margins
Conjunctiva (Palpebral and
Bulbar)
Tear film assessment
Cornea
 Pupil
Anterior Chamber
 Angle
 Lens be done
Measurements:
Refraction
8.3.3 Instruments used for the
Detailed slit lamp examination
assessments
Visual acuity chart (Snellen Keratometric Reading is needed to find
chart, Bailey Lovie LOGMAR the radius of curvature of anterior cornea in
Chart etc.) millimeters and HVID.
Retinoscope (Static & Dynamic)
Trial lens set or Phoropter.
Simple ruler.
Slit Lamp Biomicroscope with
filters use with fluorescein (Wratten
filter no12).
Schiotz or Goldman applanation
tonometer.
Cover-uncover test.
Prism Vertex compensation should be
Direct or Indirect measured if the patient’s spectacle
Ophthalmoscope. refraction more than +/- 4.0 D.
Cochet-Bonnet aesthesiometer.
(Corneal sensitivity measurement) It can be measured by a conversion table or
vertex distance compensation formula that
is
F (spectacle sphere power)÷
8.3.4Fitting procedure: 1-d (vertex distance) x F (spectacle sphere
power)

100 | P a g e
Vertex distance is measured by the 2) Lens movement should be observed on
distance from back surface of the spectacle
lens to anterior surface of the eye.
After compensating the vertex distance, the
new refractive power will be the power of
the contact lens.
Base Curve of the optic zone of the cornea
will be the base curve of the trial contact
lens. Base curve is measured by vertical K1
and horizontal K2 reading in millimeter
then add both and divided by 2 to find the
base curve of the trial lens.
Overall diameter of cornea is measured by
taking the vertical measurement (VVID)
and HVID in mm. Then need to add both
and then divided by 2 to find the average
diameter of cornea.
For the soft contact lens trial need to select
the overall diameter by adding 1.5 to 2.0
mm with the average diameter of the
cornea.
Now need to select the trial
Soft Contact Lens based on
the above-mentioned
parameters and to put the lens
on the corneal surface.
Then need to observe the
comfortability of the patient
by wearing the SCL and visual
status. Then if all these are
reported ok then need to check
movement of the trial contact lens over the Primary gaze, up gaze, lateral gaze with
cornea. If all the parameters of the trial push up test.
contact lens found ok then the final soft 3) Surface evaluation.
contact lens will be ordered as per the
parameters of trial contact lens. 4) Vision
8.3.5 Assessment of fit: 5) Comfort
To assess the optimum fit the followings 8.4. RGP Contact lens fitting:
need to be checked
Three main areas should be considered:
1) Centration: Well centered lens should
1) Basic Parameters measurements
provide
2) Lens fitting evaluation
a) Good corneal coverage 3) Prescription
b) Overlapping on limbus in all quadrants 1) Basic Parameters measurement:
by 1 mm.

101 | P a g e
->Full eye examination (Including Slit ->If the average Keratometric reading is
lamp examination, routine refraction test, 7.65mm then the base curve of trial contact
Visual acuity and vertex distance lens should be selected as 7.65mm.
measurement)
->Visual field test
-> Tonometry
-> Binocular vision assessment
->Keratometry, Keratoscopy.
->Measurement of HVID
-> Vertical palpebral aperture.
-> Pupil diameter examination in various
illuminated conditions
-> The position of lids

-> Tear break up time

8.4.1 Assessment of fit:

Now after inserting the lens (TCL) on the
2) Lens fitting Evaluation: cornea need to give approximately 10
minutes to the patient to subside the excess
After examination of all these parameters
RGP trial lens should be selected according
to overall diameter, base curve and power
which is closest to the optimum correction
of the patient.
->Corneal anterior optic zone base curve
should be selected and align with the
posterior base curve of the RGP contact
lens.
-> Overall diameter of the RGP lens will be
1.5-2 mm less than average corneal
diameter (both from HVID and VVID).
->If a patient having +/- 4 Diopter refractive
errors then the vertex distance
compensation is not necessary but if greater
than that then vertex compensation is
necessary to select the trial contact lens
power.
tears and initial discomforts.
->If the diameter of the cornea becomes 11
or 11.5mm then the diameter of the Trial Then we can perform the fitting evaluation.
contact lens (TCL) will be 9-9.5mm.

102 | P a g e
The lens movement should be checked. The Ideal fluorescein pattern:
lens should move around 1-1.5 mm with
each blink and will be smooth, unobstructed Centration: Central
and uniformed. Normal movement Movement: 1-1.5 mm and smooth
indicates the normal tear exchange that
removes the debris under the lens and Central: Alignment
significant exchange of oxygen underneath The Mid: Peripheral bearing minimal
the RGP during blink.
Centration: Well centered lens
will remain over the cornea during
all gaze positions otherwise the
lens may be low riding or high
riding.
Corneal coverage: The overall
diameter of the RGP lens is always
smaller than the overall diameter of
cornea.
Alignment: Static and dynamic;
alignment is perfectly evaluated by
the fluorescein pattern called as
fluorescein pattern test.
->Static:
When the lens is in stationary
position the fluorescein pattern
with central alignment meet
peripheral minimal clearance and
adequate pooling in the peripheral
curves should be evaluated.

Edge Band: 0.26- 0.35mm

->Dynamic:
Evaluation of the movement of the lens Steep fittings:
with the blink and tear exchange under the
lens along with centration and the coverage Centration: Central
should be evaluated. Movement: Restricted.
Central: pooling.
The following three areas should be
The Mid: Mid Peripheral bearing heavy.
observed to evaluate the ideal fit of the RGP
lens over the cornea. Edge Band: Narrow (less than 0.25mm.)
 Central
 Mid peripheral
 Edge width with clearance Flat fittings:
Centration: Poor, unstable

103 | P a g e
Movement: Excessive, Rotation
Central: Touch with corneal apex.
The Mid: Mid peripheral bearing pooling.
Edge Band: Wide. (Greater than 0.4mm.)

8.5. Contact lens complications

So many complications may arise if the
care, maintenance and fittings of the contact
lenses not handled properly. All those
complications like corneal abrasions,
epithelial edema, microcysts, superficial Some basic points regarding contact lens
punctate keratitis, peripheral corneal maintenance are as follows
staining (3-9 o clock position), sterile
corneal infiltrates, corneal 1) Before wearing (over the eyes) the
neovascularization, microbial infection, lenses, patients should wash and dry
infective keratitis, Warpage, endothelial hands thoroughly.
changes etc. being included during the 2) Contact lens should be cleaned with
wearing of contact lenses.
Conjunctival complications included
allergic conjunctivitis (mainly thiomersal
containing contact lens solutions). Giant
Papillary Conjunctivitis (GPC,
Immunological complications in which the
contact lens deposits and proteins acts as
allergic stimulus). Superior Limbic
Keratoconjunctivitis (Hyper sensitivity
reaction to Thiomersal or Preservatives
used in contact lens solution.
Other complications like associated with
physical damage to the contact lens (lens
breakage, chipping, cracking etc.)
recommended contact lens
Lens discoloration (complications for
systemic use of drugs like Rifampicin,
Fluorescein, Phenylephrine etc.).
Loss of lens, deposits over the lens

8.6. Contact lens care and maintenance

Proper care of different types of contact
lenses is very important for successful
wearing of contact lenses and also reducing
the risk for adverse effects. solutions.

104 | P a g e
 3) After removing (from the eyes) the
contact lenses rinse the lenses
thoroughly with the recommended

solutions and gently rub the lenses to clean

the lenses properly and then keep the lenses
in the lens box filled with solutions. During Thimerosal, Chlorhexidine
contact lens wear, remaining solution gluconate, Benzalkonium Chloride,
should be thrown away and air dried
properly to maintain healthy lens storage.
4) After contact lens removal need to
rub that properly with help of clean
fingers and use of saliva or ordinary
homely made saline water strongly
prohibited.

5) Need to avoid activities like

swimming, taking bath, using
swimming pool during using
contact lenses.
6) Except specialized contact lens
normally recommended daily use
contact lenses contraindicated for
the overnight use while sleeping.
7) To maintain lens care properly
correct and detailed instruction is
necessarily should be provided to
the patient with proper periodic
follow up and application of right
contact lens care solution with a
correct manner.
8) Lens solution is needed to properly Alcohol based disinfectants (like
cleaning all protein debris and isopropyl alcohol 20%, Ethanol 5%
precipitations and disinfections. etc.). Sorbic acid, DYMED,
Chlorine systems etc. are the newest
less sensitive chemical agent used
as preservatives.

105 | P a g e
 9) Now days multipurpose solution
introduced (like ReNu multi-
purpose solution, Opti free express
etc.) indicated for lens cleaning,
disinfecting and protein debris
cleaning so that different types of
solutions for different purposes are
no longer needed. Multipurpose
solution composed of surfactant
(ionic or non-ionic chemical
agents), antimicrobial, Buffer ->In case of albinism patients (lack of
system to maintain pH, Chelating pigmentation) patient suffer from the glare
agents, abrasive particles, problem and colour contact lens widely use
osmolarity to maintain isotonicity in the field of ophthalmic practice to
etc. minimize such type of problems.
-> Prosthetic contact lens is type of
opaque or occlusive contact lens use
8.7. Special contact lenses broadly in case of ocular prosthesis practice
Now a day’s contact lens is also using in field to cover the congenital or acquired eye
different purposes rather than correcting deformities.
refractive power by conventional lenses. -> Contact lens also used in vision
Contact lens also using in Orthokeratology, therapy to patch the right eye and make
Therapeutic colored contact lenses, tinted force to the affected amblyopic eye to
lenses for cosmetic purpose use, prosthetic improve fixation stimulations behavior.
contact lenses, Occlusive contact lens u
8.8. Conclusion
se in vision therapy, contact lens use in drug The clinical guide for contact lens fitting
delivery etc. and care serves as a valuable resource for
eye care professionals, providing essential
->Orthokeratology lens specially designed information and guidelines for ensuring the
RGP lens that can reshape corneal safe and effective use of contact lenses. By
curvature during overnight using while following the recommendations outlined in
sleeping. Ortho-K lens are playing vital role the guide, practitioners can optimize patient
in myopia control. outcomes and minimize the risk of
complications associated with contact lens
wear. With regular updates and adherence
to best practices, this guide continues to
play a vital role in improving patient safety
and promoting long-term ocular health in
contact lens wearers.

106 | P a g e
References: 1037–1042.
https://doi.org/10.3980/j.issn.2222-
1) Gurnani, B. (2023, June 11). 3959.2015.05.33
Contact Lenses. StatPearls - NCBI
Bookshelf. 9) A review of contact angle
https://www.ncbi.nlm.nih.gov/books/NBK techniques. (2017, January 31). Contact
580554/ Lens Update.
http://contactlensupdate.com/2017/01/31/a
2) Center for Devices and -review-of-contact-angle-techniques/
Radiological Health. (2018b, January 16).
Types of contact lenses. U.S. Food And 10) Themes, U. (2016, July 10). Basics
Drug Administration. of soft contact lens fitting. Ento Key.
https://www.fda.gov/medical- https://entokey.com/basics-of-soft-contact-
devices/contact-lenses/types-contact-lenses lens-fitting/
3) Center for Devices and 11) Mondal, S. (2022, January 30).
Radiological Health. (2018c, January 16). FITTING PROCEDURE FOR RIGID
Types of contact lenses. U.S. Food And CONTACT LENS. Optography.
Drug Administration. https://optography.org/fitting-procedure-
https://www.fda.gov/medical- for-rigid-contact-lens/
devices/contact-lenses/types-contact-lenses
4) Lenses, F. C. (2023, August 30).
Contact lens manufacturing methods.
Wholesale Contact Lens From
Manufacturer| Cosmetic Contact Lens
Wholesaler.
https://www.freshladylenses.com/contact-
lens-manufacturing-methods/
5) Erickson, G. B. (2022). Prescribing
for the athlete. In Elsevier eBooks (pp. 83–
116). https://doi.org/10.1016/b978-0-323-
75543-6.00012-7
6) Contact Lenses 101, Part 1: Contact
lens materials. (n.d.). CooperVision.
https://coopervision.com/practitioner/ecp-
viewpoints/technicians-and-staff/contact-
lenses-101-part-1-contact-lens-materials

7) Musgrave, C. S. A., & Fang, F.

(2019). Contact Lens Materials: A
Materials Science perspective. Materials,
12(2), 261.
https://doi.org/10.3390/ma12020261
8) Lee, S. E., Kim, S. R., & Park, M.
(2015). Oxygen permeability of soft contact
lenses in different pH, osmolality and
buffering solution. DOAJ (DOAJ:
Directory of Open Access Journals), 8(5),

107 | P a g e