Retinoscopy PART 1

PART- 1
Optom.ASKAR.PK
Basics about retinoscopy
November 29, 2019 Retinoscopy 1

"You can’t learn retinoscopy by
reading a book…”

Today’s goals
• By the end of today’s lecture, you should
be able to explain how to perform
retinoscopy
November 29, 2019 3Retinoscopy

Retinoscopy
• The determination of the refractive state of the eye
by means of retinoscope.
• Reduce the refraction time.
• It is invented by Ophthalmologist Dr. Jack Copeland.

The retinoscope
• Eyepiece
• Light source
– Spot or streak bulb
• Collar
– Moves up and down to change
the vergence of the light
– Rotates to change the angle of
the beam
• On/off/brightness control

Types of Retinoscopy
(On basis of technique)
• Static
• Dynamic

• Streak
• Spot
Types of Retinoscopy
(Based on illumination)

Principle
• Foucault's principle
• The examiner should simulate infinity at the
working distance to obtain the refractive
power

Working distance
• The distance at which the examiner observes
the reflex

Working lens
• The required lens power to be placed in front
of the patient's eye in order to compensate for
the working distance
• Depends upon what distance is comfortable
for the examiner to reach and operate on the
trail frame.

Reflex
• The reflected light from the patient's retina.
• The light of the retinoscope seen in the
patient’s pupil

Intercept
• The light of the retinoscope seen on the patient’s
face.
13

The basic streak reflexes
If the streak move across the pupil, there are 3
basic types of reflexes will be seen.
1. With motion
2. Against motion
3. Neutral reflex

The basic streak reflexes contd….
1. With motion-
if the streak moves across the pupil,
the reflex moves across the pupil in
the same direction.
2. Against motion-
if the streak moves across the pupil,
the reflex moves in the opposite
direction.
3. Neutral reflex-
if the streak touches the pupil, the
pupil fill with red reflex & remains
constant as the streak over across
the pupil.

With movement

Against movement

Neutral

Scissoring motion

Characteristic of the reflex
• 3 components of reflex movements:
– Speed
– Brilliance
– Width

Speed
• The reflex moves slowest when you are far
from the focal point and gets more rapid as
you get closer
• Large errors have a slow moving reflex.

Brilliance
• The reflex is dull when far from the focal point
• Becomes brighter as you approach neutrality.
• Against reflexes are usually dimmer than with
reflexes.

Width
• Narrow when you are far from the focal
point and
• broadest as you approach the focal point
• fills the entire pupil at the focal point itself.
23

But in high myopes or hyperopes
• The reflex seen in the patients pupil is not only
dull but is larger than the diameter of the
patient’s pupil.
• Therefore difficult to judge the speed or
movement of the reflex and
• Only on adding adequate plus or negative
power, the examiner will be able to identify
the direction of the reflex.

Ret reflex can tell us a lot
Reflex Observation Meaning
Brightness Dim Far from Rx
Bright Close to Rx
Streak size Narrow Far from Rx
Wide Close to Rx
Movement direction With Need more plus
Against Need more minus
Movement speed Slow Far from Rx
Fast Close to Rx

When should I do it?
• Everyone!
• It is an objective test - it does not need any input
from the patient
• May be the only way of determining refractive error
for non-communicative or non-cooperative patients
– Children
– Illiterates
– Learning difficulties
– Malingerers

Procedure
• Hold the retinoscope in you right hand and RE for
patient’s RE (swap for LE)
• Position yourself at your correct working distance
– Stretch out your left arm and touch the trial frame
• This is your working distance (WD) – always check this
• Get as close to your patient’s visual axis as possible
– Your head should almost be in the way!
– Confirm this by asking your patient

Procedure
• Move the retinoscope collar so it is at the bottom
• Turn the retinoscope on and rotate the collar so the
light is vertical
– More information about using other positions in
the next lecture
• Shine the light into your patient’s right eye and
observe the red reflex
– Is it bright/dim, wide/narrow?
– ie. is there a high refractive error?

WITH MOVEMENT
• WITHOUT WC
 Hyperopia
 Myopia<1.5 D
 Emmetropia
• WITH WC
 Hyperopia

AGAINIST MOVEMNT
• WITHOUT WC
 Myopia >1.50 D
• WITH WC
 Myopia

GLOW
• WITHOUT WC
 Myopia of -1.50 D
• WITH WC
 Emmetropia

Concave mirror effect
• The fundus image is displaced opposite to the
rotation of retinoscope.
• In the plane mirror position the streak will be
maximally wide and out of focus.
• With the concave mirror position, the steak
will form a thin, focused line.

• Appearance of streak in
plane mirror position
• Appearance of streak in
concave mirror position

Use of concave mirror
• Small pupils
• To confirm or check readings.
• When you change from plano to concave
mirror the with motion becomes against.

Checking the result
• When neutrality approaches, reflex movement
becomes too fast to judge
• If your have correctly neutralised your patient,
– Move towards your patient, you will see “with” movement
– Move away from your patient, you will see “against”
movement
• If not, the movement will not be opposite in different
positions so make small changes to the power
(0.50DS) until you can see what I’ve described above
• You could achieve the same result by adding ±0.50DS
and checking that the movement is opposite

Accuracy of retinoscopy:
• Incorrect Working distance
• Scoping off the patient’s visual axis
• Failure of the patient to fixate the distant target
• Failure to obtain a reversal
• Failure to recognize scissors motion
• Should be combined with subjective testing
whenever possible.

Clinical Pearls
• When pupil constricts – Redirect attention;
patient is looking at light.
• Varying reflex - cycloplegia is contemplated.
• Do refraction with a +10.00 D lens for
Aphakes.

• For dull reflex,
– try high plus or minus lenses.
– Try doing retinoscopy at closer working distances
(Radical retinoscopy)
• For opacities obscuring the reflex, try off axis
retinoscopy
• For high myopes, use concave mirror, the reflex will
be clear and show a with movement.
• If objective and subjective refraction do not
correlate, then do a cycloplegic refraction.

DOUBTS???

FURTHER READING
Primary care optometry 4th edition
Theodore Grosvenor (PG NO: 233-243)
OPTOMETRY: Science, techniques and management
2nd edition(PG NO: 187-208)
Bennett and Rabbetts: Clinical visual optics
WWW.WIKIANSWERS.COM
WWW.OPTOMETRYSTUDENTS.COM

PROFICIENCY QUESTIONS

What will be the refractive error if it neutrals
at +3.00DS without WC (WD-50 cm) ?
1. +1.50 DS
2. +2.00 DS
3. +1.00 DS
4. +1.25 DS

If the retinoscopy movement is againist
(without WD) it implies??
1. Myopia <1.50 D
2. Myopia of 1.50 D
3. Myopia > 1.50
4. Hyperopia
5. Emmetropia

If it is close to neutrality the reflex ??
1. Brighter
2. Dim
3. Narrow
4. Wide
5. Both 1 & 4
6. Both 2 & 3

If there is any opacities?
1. Increase WD
2. Decrease WD
3. Try ‘off axis’
4. None of the above

USE RETINOSCOPE
ALWAYS FOR A BETTER
START…!!

PART - 2
Will bediscuss it on next article……….

THANK YOU 

Retinoscopy PART 1

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Retinoscopy PART 1