STATIC REFRACTION by NANCY

CLINICAL REFRACTION | PREFINAL | 1st SEMESTER
STATIC RETINOSCOPY the distance between the examiner and the patient until the
reflex is enhanced. Then rotate the streak of the retinoscope
Purpose through 360°, looking for the break phenomenon, the thickness
To determine the distance refractive status of the patient's eyes phenomenon, the skew phenomenon, or changes in the
objectively. The results of this technique serve as a starting point brightness of the reflex within the pupil.
for the subjective refraction or as the patient's final prescription a. If the error is spherical, the reflex within the pupil will be
if the patient is unable to respond to subjective testing. continuous with the intercept of the streak on the patient's face
(i.e., there will be no break phenomenon). If the error is
Equipment astigmatic, the reflex within the pupil may not be continuous
 Streak retinoscope. with the intercept on the patient's face (i.e., there will be a break
 Phoropter, lens rack, or loose trial lenses. The technique phenomenon) (see Figure 3-8).
described here refers to lenses in the phoropter because that
is the usual clinical method of retinoscopy. The same b. As the streak is rotated through 360°, the thickness of the
principles can be applied to retinoscopy using loose lenses reflex within the pupil will be constant in a spherical error and
or a retinoscopy rack instead of the phoropter. vary in an astigmatic error (thickness phenomenon) (see Figure
 Fixation target: 20/400 E projected through a red/green 3-9). Moreover, as the streak is rotated, the brightness of the
filter. pupillary reflex will remain constant in a spherical error and
may vary in an astigmatic error. The principal meridians
Setup correspond to the orientations of the streak that provide the
The patient removes his corrective lenses. thickest and thinnest ref exes and/or the brightest and dimmest
reflexes and/or the orientation of the streak in which the ref ex
Adjust the height of the examination chair so that the patient's
within the pupil is exactly continuous with the intercept of the
eyes are at the same level as yours.
streak on the patient's face.
Disinfect patient contact surfaces of the phoropter by wiping it
c. In an astigmatic error, as the streak is swept across the
with alcohol and drying it with a tissue. patient's pupil, the reflex within the pupil will move parallel to
Place the phoropter in front of the patient with the interpupillary the movement of the streak on the patient's face when the streak
distance (PD) set to match the patient's distance PD. Level the is aligned with one of the two principal meridians. The reflex will
phoropter so the patient's eyes are centered in the apertures. move in a different direction than the streak when the streak is
not aligned with one of the principal meridians (skew
Instruct the patient to keep both eyes open during retinoscopy. phenomenon). There will be no skew phenomenon in a spherical
Ask the patient to inform you if your head blocks his view of the error (see Figure 3-10).
fixation target. It may be necessary to rotate the phoropter
slightly or to move the target off the screen and onto the wall to
allow the patient to see the target while you maintain alignment
along the patient's visual axis. During retinoscopy, the examiner
keeps both of his eyes open and examines the patient's right eye
with his right eye and examines the patient's left eye with his left
eye.
The examiner holds the retinoscope 20 in (50 cm) or 26 in (67

cm) from the patient's eye. The retinoscope is held in the
examiner's right hand to examine the patient's right eye and in
the examiner's left hand to examine the patient's left eye.
Retinoscopy is most easily done in dim illumination. An

illustration of the performance of static retinoscopy is provided
in Figure 3-7.
Step-by-Step Procedure
1. Instruct the patient to look at the fixation target. Examine the
patient's right eye.
2. Determine if the refractive error is spherical or astigmatic by

changing the position of the sleeve of the streak retinoscope and
CLINICAL REFRACTION | PREFINAL | 1st SEMESTER
that observed near the center of the pupil. This is called "scissors
motion." For purposes of refraction, the goal is to achieve
neutrality at the center of the pupil, ignoring peripheral reflex
movements.
5. When both principal meridians are neutralized, recheck the

meridian neutralized with sphere and adjust the spherical power
if necessary.
6. When neutrality is reached, recheck all meridians with the

sleeve of the retinoscope in both the plane mirror position and
the short concave mirror position. If true neutrality is achieved,
3. If the error is spherical, observe the reflex for with or against
all meridians will look neutral regardless of the position of the
motion and add plus or minus lenses until there is no motion of
sleeve of the retinoscope. If neutrality is not reached in all
the reflex. The type of lens needed for neutralization depends on
meridians, make necessary adjustments.
the patient's refractive error, the position of the sleeve of the
retinoscope (plane mirror position or short concave mirror 7. The lens (or combination of lenses) that produces neutrality
position), and the type of motion seen (with motion or against is called the "gross retinoscopy finding" or simply the "gross."
motion) (see Table 3-2). The gross retinoscopy finding makes the patient's fundus
conjugate with the examiner's entrance pupil, not optical
Note: With motion is easier to observe and to neutralize than
infinity. Leave the gross static finding in front of the patient's
against motion. However, if with motion is present, the patient
right eye and neutralize the patient's left eye by following steps
may accommodate, particularly if minus lenses were added.
2 through 6. When the patient's left eye is neutralized, recheck
When against motion is initially seen, it can be changed to with
the right eye and adjust the sphere or cylinder if necessary.
motion, without affecting the patient's accommodation, by
changing the sleeve of the retinoscope from the plane mirror 8. To convert the gross retinoscopy finding to a net finding,
position to the short concave mirror position. algebraically add a spherical minus lens equal to your working
distance in diopters to the spherical lens that produced
TABLE 3-2: TYPE OF LENSES USED FOR NEUTRALIZATION
neutrality. For example, add -2.00 D for a working distance of
DURING STATIC RETINOSCOPY BASED ON THE MOTION
20 in or 50 cm and -1.50 D for a working distance of 26 in or 67
OBSERVED, THE POSITION OF THE SLEEVE OF THE
cm. This is the "net static retinoscopy finding," or the "net
RETINOSCOPE, AND THE PATIENT'S REFRACTIVE ERROR
static," through which the patient's retina is conjugate with
infinity if the retinoscopy is accurate.
9. Measure the patient's visual acuity in each eye through the net
static retinoscopy finding.
Recording
 Record the net static for each eye separately.
 Record the patient's visual acuity for each eye through the
net static retinoscopy finding.
4. To neutralize an astigmatic error, first identify the two

Examples
principal meridians (see step 2). Then neutralize each meridian
separately. When using a phoropter with minus cylinders, one
meridian is neutralized with sphere only. The other meridian is
neutralized with a combination of sphere and minus cylinder.
The least myopic or most hyperopic meridian is neutralized with
sphere. The most myopic or least hyperopic meridian is
neutralized with cylinder in addition to the sphere.
Since it may be difficult for a novice retinoscopist to determine

which meridian is the least myopic, either meridian can be
neutralized first. The other meridian can then be checked and
adjustments can be made in the sphere power if necessary. If
using a plane mirror retinoscope, when one meridian is
neutralized the other meridian must show against motion in
order to be neutralized with minus cylinder power. If the
retinoscopist neutralizes the most myopic meridian first, one
meridian will show neutrality while the other shows with
motion. To correct this, the retinoscopist can add more plus to
the sphere power to neutralize the second meridian. This will
leave the first meridian showing against motion. The newly
created against motion can now be neutralized by adding minus-
cylinder power with the cylinder axis aligned with the
orientation of the streak.
It is often observed, particularly when the pupils are large, that

the motion of the reflex in the periphery of the pupil differs from

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CLINICAL REFRACTION | PREFINAL | 1st SEMESTER

The examiner holds the retinoscope 20 in (50 cm) or 26 in (67

Retinoscopy is most easily done in dim illumination. An

2. Determine if the refractive error is spherical or astigmatic by

5. When both principal meridians are neutralized, recheck the

6. When neutrality is reached, recheck all meridians with the

4. To neutralize an astigmatic error, first identify the two

Since it may be difficult for a novice retinoscopist to determine

It is often observed, particularly when the pupils are large, that

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