2arriote Optician €35930 Elements of refraction - part 3 Closing Date: 17/04/2014 i Subjective refraction techniques, as the name suggests, rely on the patient’s response to obtain the refractive correction that gives the best visual acuity. While itis prudent to say that this technique can only be performed on patients who can communicate effectively, the development of computerised and projector test charts has enabled the practitioner to adapt subjective techniques by using alternative targets to carry out a subjective routine, Before commencing your refraction, communication is of prime importance. Obtaining all the relevant information necessary from the patient regarding their reason for visit, visual symptoms, previous ocular history and so on is essential and allows you to adapt your examination to deal with the patient's concerns and help you form your conclusions more easily. (http:/assets.markallengroup.com/article-images/image-library/147/uploads/sites/9/2014/03/1a,jpg) Figure 1: Measuring pupillary Subjective refraction Putting together a well thought out, structured routine to maximise pat practitioner to work as quickly and as efficiently as possible. The subjective refraction should ideally be performed in conditions that simulate the patient's normal viewing environment. For most, this will be in ambient lighting and binocular viewing, nt response and comfort will allow the Performing the test in dim illumination will cause the pupils to dilate and increase spherical aberrations, which could in turn have an impact on the refraction. hitps:lwwnopticanontine.netvcstarchive!1 ans.2am2018 Optician Carrying out a binocular refraction (using a fogging lens rather than an occluder) can assist to control spherical aberrations, help to relax accommodation and speed up the subjective routine as there is no need to carry out binocular balancing. Binocular refraction can also be particularly useful when examining patients with refractive conditions that can be further manifested by the use of an occluder, for example, hyperopia, pseudomyopia, latent nystagmus and rotational phorias (cyclophorias). Patients presenting with highly dominant eyes, unequal acuities and greatly fluctuating accommodation, will find it difficult to perform a binocular refraction and they will report symptoms of diplopia. It is not always apparent when a binocular or monocular refraction will be most appropriate for the patient. For the purposes of these next two articles a monocular refraction will be described first and a brief explanation of the binocular refraction technique will be illustrated later on. Subjective routines can vary between practitioners and depend on the patient. Whatever order you choose to carry out the subjective routine, it should flow effortlessly and have logical progression. ‘Always ensure you explain the test/procedure to the patient and what they may expect. Be clear and concise, know how to explain the test you are conducting and keep it simple. (http://assets.markallengroup.com/article-images/image-library/147/uploads/sites/9/2014/03/trial-frame- billjpe) Figure 2: Oculus trial frame Overview of the subjective routine ? Measure the pupillary distance (PD) 2 it the trial frame ? Measure vision/visual acuity at distance and near 2 Determine and refine the best vision sphere (BVS) Without retinoscopy ~ Fogging technique hitps:lwwnopticanontine.netvcstarchive!1 262arriote Optician Following retinoscopy ~ Fogging technique ~ Using +/-twirls ~ Duochrome ?.Check duochrome/circle of least confusion (where appropriate) 2Cross cylinder/fan and block Jackson cross cyl - Axis -Power Fan and block 2 Final sphere check 21.00 blur check ? Binocular balancing ? Binocular addition ? Binocular visual acuity 2 Recording the results. ‘The pupillary distance (PD) Measuring the PD enables the practitioner to set up the trial frame correctly so that the optical centres are correctly aligned for the patient to avoid induced prisms and aberrations. Procedure for measuring the distance PD 2Sit directly in front of the patient and at the same eye level to avoid parallax ? Instruct the patient to look at your left eye, while you close your right eye. Rest the rule on the patient's forehead and line up the outer edge of the PD ruler with the centre of the patient's right pupil (to avoid parallax) ? If your patient has dark brown eyes this may be difficult and therefore it may be easier to line the PD rule up with the temporal limbus (the junction between the cornea and sclera) ? Keep the ruler in place, now direct the patient to look at your right eye while you close your left eye; look at the scale of the ruler directly in line with the centre of the patient's left pupil (or nasal limbus) using your right eye (this avoids parallax). The measurement between these two points is called the distance PD. hitps:lwwnopticanontine.netvcstarchive!1 ai