NATIONAL POLYTECHNIC INSTITUTE

INTERDISCIPLINARY CENTER FOR HEALTH SCIENCES

SANTO TOMAS UNIT

Bachelor's Degree in Optometry

CLINICAL REFRACTION BASIC

Profesor: RICARDO FLORES MORENO

ALUMNO: GARCIA HERNANDEZ ANDRE D.

PRUEBAS SUBJETIVAS
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INTRODUCTION
Once the refractive values are obtained objectively (retinoscopy), we move on to
corroborate said data through subjective evidence (in which one should not spare
time is indeed what, in the eyes of
patients give a feeling of personalized attention to their
problem and not just a simple step through more or less teams
sophisticated. On the other hand, they are the tests that give us

they will talk about the certainty of our objective data and the
tolerance or adaptability of the patient to their glasses.

WHAT ARE THEY?

Subjective tests or also known as

subjective refraction consists of a series of tests
employed in obtaining the correction of the
examined patient, using your response
subjective for this purpose. This exam usually starts from
retinoscopy and its result is usually similar,
although it can vary substantially in cases of
those who have accommodative alterations, keratoconus, or media alterations.
For its completion, it is necessary to have a good dialogue between examiner and
patient, with special care from the specialist when explaining each
test of the exam, thus avoiding misinterpretations that could lead to
erroneous test results. These tests are performed monocularly
until reaching the patient's bestAV, to later be balanced
binocularly.
The tests begin to adjust or fine-tune the spherical component (bichromatic test and
MPMAV) and the cylindrical component as well as its correcting axis (CCJ are adjusted.
and Astigmatic Dial

MAXIMUM POSITIVE BEST VISUAL ACUITY (MPMAV)

El propósito de esta prueba es determinar la máxima potencia esférica positiva que
provides the maximum visual acuity. It is the most commonly used method for determining
of spherical subjective refraction is known as blurring or fogging, and
It consists of blurring the patient with a positive sphere over their objective refraction.

PROCEDURE
It is performed monocularly starting with the right eye. A lens is added
+1.00D over the obtained retinoscopy, causing a blurriness on
patient and causing the relaxation of the lens.
2. Changes are being made to the spherical component in steps of 0.25 D
reducing the positive sphere or increasing the negative depending on the case of the
patient, until achieving the best visual acuity
3. Reduce positively with caution not to exceed (add negative) 0.25 in increments of 0.25
D, gently urging the patient to try reading one line further down,
improving the obtained AV by 0.25 D at each step.
4. Do not add more negative (decrease positive), so that the patient sees something better.
if he/she does not manage to win one more line on the optotype, and there the test concludes.
5. The final AV is verified that was reached with the test and then the process is carried out.
same procedure with the left eye, excluding the right eye.
 BICROMATIC TEST

The objective of this test is to determine the corrected spherical power, it must be used
as a final point of adjustment of initial M.P.M.A.V. The result does not depend on the
color perception (can be carried out in protanopes and deuteranopes).

PROCEDURE
1.- The left eye is occluded, and the right eye is started with.

2.- Using the optotype projector (the test chart can also be used
bichromatic) place the red-green filter over the letters.
3- Show the line above their best visual acuity
4.- Myopic with +0.50 or +0.75 D sph.
5.- Ask the patient to look at the green side, then at the red and back to the green, and that
Tell us ABOUT WHICH BACKGROUND THE LETTERS APPEAR CLEARER or if they are the same.
6.- In case they stand out more against the red background, we add spherical lenses.
negatives in steps of -0.25. If they appear more clearly against the green background, add
positive lenses in steps of +0.25.
7.- The test ends when we find the smallest amount of negative sphere or the
greatest amount of positive sphere in which the patient achieves their best acuity
visual.
8.- Perform the same procedure with the OI.
 ASTIGMATIC WATCH
The astigmatic clock or hour test allows us to estimate the axis of astigmatism and its
power appealing to the patient's response. The principle of this test is based on the
astigmatic paradox. So, if the patient presents uncorrected astigmatism
with the maximum meridian in the horizontal direction and the minimum in the vertical direction and,
In addition, it is blurred in such a way that both foci are found by
in front of the retina. The patient will observe, in a radial pattern of lines, some more
blacker than others, according to the axis and amount of astigmatism

PROCEDURE
1.- OI is occluded and it starts with OD.
2.- Decrease the cylindrical power 0.75 D or 1.00 D
3.- Myopize with +0.50 and +0.75 D sphere.
4.- Show the test and ask what they see. Ask the patient which line appears more.
dark or clear as if it were a clock (example: 12 and 6, 3 and 9)
If all the lines appear equally blurry, it indicates that there is no cylinder.
finish this test.
 If the line that appears sharpest is that of 12 and 6, its correcting axis will be 0º.
If it is the one at 3 and 9, the corrective axis will be 90º.
●
5.- In case it is a different line from the mentioned ones, the number must be multiplied.
lower than said direction by 30º, obtaining the axis of astigmatism.
For example, if the patient (Px) reports seeing line 5 to 11, the number 5 is multiplied by
30°, therefore the correcting axis is: 150°.

6.- Add negative cylinders, with the corrective axis, until the patient indicates that they see.
equal intensity in all lines of the optotype

7.- Repeat the procedure with the left eye, excluding the right eye.

JACKSON CROSS-CYLINDER (CCJ)

For the assertion of power

the cylindrical axis is used the CCJ,
which consists of a lens
mixed cylindrical with both
equal meridians but of
opposite sign. This lens is
find subject to a handle of
handle whose axis is located at 45°
regarding the meridians
mainly, which are properly marked in red for the negative cylinder axis and
in black or another color for the positive cylinder axis.

The CCJs can be used both for the alignment of the cylindrical axis and its power.
For the first case, the CCJs generate the effect of 'rotation' of the axis of the cylinder in
sense of the negative axis of the CCJ, this is due to the sum of power of both lenses (the
CCJ and the correction cylinder.
In the adjustment of the cylindrical power, the CCJs act by increasing or decreasing the
difference between focal lines (the powers of both lenses are added or subtracted)
allowing for an appropriate comparison.

AXIS ALIGNMENT PROCEDURE

Keeping the OI closed
1.- Isolate a letter above its best score obtained
2.- Instruct the patient that they will see 2 images
3.- Myopize with +0.50 or +0.75 D
4.- Place the handle of the CCJ aligning it with the axis of the correction cylinder of the
refraction.
5.- Numbering the images asking which one is blurrier
6.- After 3 to 6 seconds, rotate the CCJ.
If the images are equally blurry, the axis is positioned correctly.
7.- If the two images are not the same, move the CCJ axis towards the negative cylinder
(red dots) 15º which gave the clearest image.
8.- The previous step is repeated but if the images are not the same, the changes are
they will carry out from 5th

9.- The alignment of the correcting axis ends when:

Both images appear the same
B) The patient's responses fluctuate within a range.
small.
10.- Repeat with OI, excluding OD
POWER ALIGNMENT PROCEDURE

1.- Place the CCJ in such a way that the points (whether they are
red or white) align with the axis of the cylinder
corrector.
2.- Two images are presented and the patient is asked if
Are both images similar or does one look better than the other?
another. (In the change, wait 3 to 6 seconds.)
3.- If the patient prefers the image when the axis of
the cylinder is aligned with the red point (the cylinder
negative) increase -0.25 D of negative cylinder and if the
the patient prefers the image when the axis of the cylinder is
aligned with the white points (positive cylinder)
decrease the power of the cylinder by 0.25D.
4.- The power verification ends when
Both images are the same.
b) The changes in the patient's response are very
next or select the smallest cylindrical power.

SUBJECTIVE BINOCULAR TEST

At the end of the subjective refraction, we perform the binocular balance, which aims to
Purpose: to equalize the accommodation stimulus of both eyes by relaxing it to the maximum.
This test is indicated if the same has been reached during monocular refraction.
AV with both eyes. In the case that the AV is different but there are reasons to believe
that the accommodation is different between both eyes it is indicated to perform the duochrome test
with dissociated prisms.

BALANCE BINOCULAR PROCEDURE

1.- At the end of the subjective refraction, we ensure that both eyes are
uncovered
2.- Myopic prescription with a +0.50 D sphere to obtain a visual acuity two lines above their best.
visual acuity, if the patient does not see blurry add +0.25D spherical.
3.- Isolate the line of letters and place a 3 dp prism base up on the right eye and 3 dp base.
down in OI either with loose prisms or with phoropter
4.- Inform the patient that they will see two lines vertically, one above the other and
they will appear blurry

5.- Ask the patient to compare the two lines and which of them appears clearer.
6.- Add a +0.25 spherical lens to the eye that sees more clearly, there can be no changes.
greater than 0.50 D, if so, it indicates an error in the skiascopy or in the procedure of
the subjective tests.
7.- The test ends when the patient sees the two lines equally blurry or otherwise.
it is possible to leave the dominant eye with the clearest subjective vision.
BIBLIOGRAPHIES
●TOLEDO F. (SIN FECHA) “MANUAL PRÁCTICO: OPTOMETRÍA CLÍNICA”
EDITORIAL OF THE UNDLP. FACULTY OF EXACT SCIENCES. BUENOS AIRES,
ARGENTINA.
●GENE A. (2020) "SCRIPTS FOR THE COURSE OPTOMETRY PRACTICES II:
PRACTICE 1: REFRACTION. DEPARTMENT OF OPTICS AND OPTOMETRY
VISION SCIENCES. UNIVERSITY OF VALENCIA, SPAIN.
●LEMOS F. (2007) “LA REFRACCIÓN CLÍNICA”RECUPERADO EL: 14-12-22.
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