Clinical Procedures in Optometry

Bachelor's Degree in Optometry and Vision Sciences - University of Minho

Name____________________________________________________
Number_________

Practice 1
Revisions of phoropter, retinoscope, trial box and frame, and acuity scales
visual (AV)

P1.1 - Summary

Practice U. Credit Duration Activity Class Registration

Procedures Recall the function and Record 1 of the notebook of

#1 Clinics in 3h use of equipment laboratory record - attachment
Optometry optometric to this protocol.

MaterialProtocol P1 - this guide

["Phoropter","Test box and framework","Retinoscope","Optotype projector"]

P1.2 - Introduction

The Credit Unit (CU) of Clinical Procedures in Optometry is structurally practical and
it depends a lot on the teaching component of previous units, where functions were addressed and
functioning of the optometric equipment to be used here.

The purpose of this first practical class is to recall some of these equipment, their function, use and
functioning.

It is essential to have a good knowledge and handling of the following mentioned equipment so that the
the remaining practical classes be profitable and useful. This deep knowledge of the equipment will allow
to the student the focus on the practice of optometric routine and corresponding achievement of results and not on
manipulation of the equipment.

P1.3 - Methodology

In groups of two or at most three students, using the optometric equipment.

available and listed in the attached laboratory register, fill in the spaces with the name or function
white, thus characterizing as completely as possible the optometric equipment.

João Linhares —jlinhares@fi[Link] 1

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Name____________________________________________________
Number_________

P1.4–Record1ofthelaboratoryrecordbook

Identifyeachoftheelementsofthefolowingequipmentpresented.

P1.4.1–ThePhoropter

1 12

213

3 14

4 15

516

6 17

7 18

819

9 20

10 21

11

John Linhares —jlinhares@fi[Link] 2

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Name____________________________________________________
Number_________

P1.4.2–Theframeandthetestbox

1 6

2 7

3 8

4 9

1 4

2 5

3 6

John Linharesjlinhares@fi[Link] 3
 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Name____________________________________________________
Number_________

Indique o nome de 5 lentes e respectiva função, da secção de lentes especiais

markedbypoint2orpoint5.

1 4

2 5

P1.4.3–Retinoscope

In a normal retinoscopic exam of an emmetropic patient, conducted at a

workn
i gdsi tanceof50cm,whatsi themovementofthefrn
i geoftheretn
i oscopecomn
i gfrom

patients' eye?
__________________________________________________________
__________________________________________________________

Whattypeoflensesisaddedtoneutralizethemovementofthefringe?
Ifthemovementis"with":________________________________________
Ifthemovementis"against":_______________________________________

John Linhares -jlinhares@fi[Link] 4

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Name____________________________________________________
Number_________

P1.4.4–OptotypeScale

1 - What do the numbers on the right side of the scale mean?

in the form of fractions?

2 - What is the name of this scale? Do you know another type?

of scales and its name?

3 - What other types of optotypes exist in

What projector is available? What is its function?

João Linhares — jlinhares@fi[Link] 5

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Practice 2
Preliminary optometric exams: Medical history, Measurement of Visual Acuity,
Inter-pupillary distance, Visual contrast sensitivity, H test, Reflexes
Pupils, Cover Test

P1.1 - Summary

Practice U. Credit Activity Duration Class Register

Procedures Anamnesis, measurement of Acuity Register 2 of the notebook

Clinics in Visual, interpupillary distance, of laboratory record
#2 3h
Optometry Visual contrast sensitivity test attached to this
do H, Pupillary Reflexes and Cover Test. protocol.

Material Protocol P2 – this guide; Optotype projector; Millimeter ruler; Ginsburg exam
(SVC); Lanterna; Oclusor; Caixa de Provas

P2.2 - Introduction

Preliminary exams in optometry are extremely important. The optometrist

Through these exams, it is possible to obtain the state of the patient's ocular and overall health at the beginning.

from the consultation, as well as the main reason for your presence at the optometry consultation. With the

data obtained from the anamnesis and preliminary examinations can the optometrist outline a
consultation plan, obtain data for future comparison and be informed about the basic visual state of
patient. This way you will be able to assess whether the new prescription, for example, is beneficial or

prejudicial for the patient, using only the comparison of Visual Acuities (VA) before and
after the new degree. The comparison of visual acuity with and without the current prescription
it also allows to assess the usefulness of the current prescription.

In this practical lesson, we will focus on only seven preliminary exams: Anamnesis, the AV, the
Interpupillary Distance (IPD) to Visual Contrast Sensitivity (VCS), the pupillary reflexes (PR),
the H test and the CoverTest (CT).
The DIP allows for adjusting the optical instrumentation to the patient's pupil distance, limiting it.
the formation of induction of prismatic effects caused by decentered optical lenses. In the case
the use of the phoropter will also allow the adjustment of the PD to minimize the effect of tunnel vision
provoked by the foropter's optics. The VA examination will allow for a quick assessment of the capacity
the patient's visual, and estimate the impact of the change in current compensation on their daily life.
In addition to this factor, and as already mentioned, establish a threshold value for the patient's vision.

João Linhares — jlinhares@fi[Link] 1

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

The refractive exam to be performed must maintain or improve this value of visual acuity, never worsen. The exam

SVC is quite important and often neglected. Its importance stems from
information that may be provided when compared to classic AV exams in which the
contrast is maximal. Subtle pathological ocular changes may be detected with this
examinations are not done with traditional AV measurement. Pupil reflexes are executed quickly and
allows evaluating the patient's neurological responses to light through contraction and dilation
pupillary. The H test and the Cover Test allow for the evaluation of the oculomotor and phoric state of the patient.
diagnosing the existence of latent or manifest deviations. Lastly, but of high
we have the initial basis of the optometric exam: the Anamnesis. This questionnaire
the patient should seek to obtain as much information as possible that we can
to facilitate the outline of an optometric diagnosis and to address the patient's complaints
neglecting any aspects of the patient's eye and general health.

P2.3 - Methodology

Perform the procedures in groups of two, using the optometric equipment.

available and listed in the attached laboratory register. The anamnesis and the measurements of DIP, AV, SVC, RP, H
the CT should be carried out in blocks of 30 minutes, repeating the blocks as many times as necessary until completing the

class time. The protocols presented below must be used for conducting the measurements.
During the execution of the lesson, the attached tables to this protocol must be filled out, responding
also to the questions asked.

P2.3.1–MedicalHistory–adaptedfromBasicProceduresforOptometricExaminations
-S. Franco, J. Jorge and M. Lira, University of Minho, 1999.

The clinical case history or anamnesis is one of the most important procedures in conducting
of an optometric exam. Although each optometrist has their own method for conducting it,
there are some fundamental questions. In this protocol we will address the topic in a basic way,
leaving your exhaustive explanation for the theoretical classes and to be addressed in other subjects.

The objective of this practical class will be the clinical practice of anamnesis, trying to reach the patient of

direct format with open-ended and closed-ended questions. As an example of a question

open: "Is everything okay with the health skirt?" As an example of a closed question: "When did you do it?"

blood tests last time? How was your diabetes and cholesterol?

Some topics to address:

Dados biográficos - Nome, morada e contactos, data nascimento, profissão, passatempos.

João Linhares — jlinhares@fi[Link] 2
 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Reason for the consultation - What is the reason the patient is in our consultation, signs and symptoms

presented.

Patient's ocular history - Eye diseases, eye complaints, date of last consultation,
ocular refraction, any problem related to eye health, patient's eye needs,
previous recommendations regarding the use of prescriptions or eye treatments.

Medium patient history - General health status, current medication, surgeries undergone
It should be noted that sometimes patients do not consider allergies or general or ocular hypertension.
like changes in general health, responding that everything is fine to the question 'how is your health'.
so it is important to establish solid communication with the patient and guide our
questions about more specific topics using closed-ended questions: 'When did you analyze the'
blood?"; "What is your blood pressure?"; "What is your diabetes value?"; "Do you take pills even if
occasionally?"; "Do you have allergies and take medication?"; "Do you have sinusitis?"…

Ocular history of direct family members - Direct family members who have high refraction or who
tenham problemas de saúde ocular (glaucoma, cataratas, cirurgias refractivas, Lasers,…)

Family medical history - Health problems of relatives (use the same techniques as the
described in the patient's medical history.

General observation - physical anomalies, facial asymmetries, ocular deviations, behavior

guys...

P2.3.2 - Measurement of Interpupilary Distance (IPD) - adapted from Procedures

BasicsofOptometricExams–[Link],[Link],[Link],Universityof
Minho,1999.

Figure1Adjustmentofthezerooftherulerwiththetemporalimitoftherighteyes'pupil,

askingthepatienttolookattheopeneye.

João Linhares — jlinhares@fi[Link] 3

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

A) InLongVision(VL)
i) Standinfrontofthepatient.
ii) Closetherighteye(OD)andaskthepatienttolookatthecenterofthepupil.
oftheopeneye(inthiscasethelefteye(LE))
iii) Alignthezeroofthescaleoftherulerwiththetemporaledgeofthepupiloftherighteye.

patient,asilustratedinFigure1.
iv) Observing with the OD, closing with the OE and without moving the ruler,ask the
peaiontlotknightaetceneothrfepuophtlfigerheytT
[Link]
blegivienby

valueofthescaleoftherulercoincidingwiththenasaledgeofthepupilofthelefteye

patient,asilustratedinFigure2.
v) Recordtheresult.
vi)

Figure2Measurementofinterpupilarydistance,askingthepatienttolookat
eyeopen.
B) InCloseVision(CV).
i) Standinfrontofthepatient.
ii) Pointoutthemidpointbetweentheeyebrowsoftheoptometristandaskthepatient.
tolookoverthere.
iii) Alignthezeroofthescalewiththetemporaledgeofthepatients'rightpupil.
themeasuremenotfDIPinVPisthevalueonthescalethactoincideswiththenasaeldgeof

pupiloftheOE,asilustratedinFigure3:
iv)

Figure3Measurementofinterpupilarydistanceinnearvision.
iv) Note the result.
João Linhares — jlinhares@fi[Link] 4
 Procedimentos Clínicos em Optometria
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

C) InLongVision(LV)usingcornealreflections.
i) Positonyourselfinfrontofthepatient.

ii) Holdtheflashlightwiththerighthandnextoyourfaceatheheightoftheoptometrist'eye.
iii) AskthepatienttolookattheODoftheoptometrist.
iv) Alignthezerooftherulesr'scalewiththecornealreflectionofthepatienst'righteye,such
asilustratedinFigure4.

Figure4Zeroadjustmentoftherulerwiththecornealreflectionoftherighteye,askingthe

patienttolookintotheopeneye.

v) Without moving the ruler and continuing to hold the flashlight with the right hand,
placetheflashlighntextothefaceatheheighotftheODoftheoptometrist.

vi) AskthepatienttolookattheODoftheoptometrist.
vii) The value of the DIP will be given by the value of the scale of the ruler coinciding with the

cornealreflexofthepatients'lefteye,asilustratedinFigure5:
eightRecordtheresult.

Figure5Measurementoftheinterpupilarydistance,askingthepatientolookathe
openeyeandadjustingthescalebythecornealreflection.

D)Em Visão de Perto (VP) utilizando reflexos corneais.

i) Stand in front of the patient.
ii) Place the flashlight next to the optometrist's chin to illuminate the area
averageofthepatients' faceateyebrowheight.

João Linhares — jlinhares@[Link] 5

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
iii) Pointoutthemidpointbetweentheeyebrowsoftheoptometristandaskthepatient.
tolookoverthere.
iv) Alignthezeroofthescalewiththecornearleflexofthepatienst'[Link]
DIPinVPisthescalevaluethatcoincideswiththecornealreflexoftheOE,such

asilustratedinFigure6,andnotetheresult.

Figure6Measurementofinterpupilarydistanceinnearvision,adjustingthescale
throughcornealreflections.

E) Corneal reflex pupillometer

i) Pre-adjust the pupilometer to the distance for which it is intended to be determined
the value of the interpupillary distance.

Support the pupillometer on the patient's nose.

iii) Instruct the patient to focus on the luminous point inside the pupillometer.
iv) Using the appropriate commands to align the vertical references of
pupilometerwithcornealreflexes,oneineacheye.
If the patient reports seeing two bright spots, occlude one of the eyes.
patientandperformthemeasurementmonocularly.
vi) Read and note the indicated value on the scale.

P2.3.3–MeasurementofVisualAcuity(VA)–adaptedfromBasicProceduresof
OptometricExaminations–[Link],[Link],[Link],UniversityofMinho,1999.

A) Measurement of AV in VL, with and without compensation.

First, carry out the measurement of AV without compensation, only afterwards with compensation.

habitual compensation of the patient.

ii) Use ambient lighting, except if you intend to assess the AV under conditions
específicas(porexemploconduçãonocturnacomelevadodiâmetropupilar).
iii) Occlude the patient's eye with the occluder without closing or pressing on the eye.

João Linhares — jlinhares@fi[Link] 6

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
iv) [Link]
the patient does not see the optotype choose an optotype with a lower visual acuity (0.1 or)

0.2).
v) Askthepatienttoreadtheoptotypeuntilthesmalesttheycanread.
vi) Encouragethepatienttoreadthenextlineandstopwhentheyfailmorethanhalf.
ofaline,sincetheAVlimitmayberestrictedbylegibility
theletersandnotbytheirresolution.
vii) Changetheoccludertotherighteye,[Link].
viii) Repeattheprocessbinocularlystartingfromonelinebelowthebestvisualacuity.
patient obtained monocularly. If the patient cannot read the line
presented,startwiththeAVlineof0.6.
ix) RecordtheresultintheformAVV L/SC=1.25+ 2 .VL = distance vision; SC or CC =
withoutcompensation;1.25=scalevalue;+2or-2=numberofletersthat
readonhtefoolwnignileohrtafatslinhtecurenotne.

B) MeasurementofAVinVPw
, ithandwithoutcompensation.

i) PerformthesameprocedureasinA)replacingtheVLoptotypewitha
optotipodeVPeutilizandomuitoboailuminaçãonooptotipo.
ii) The VP optotype should be placed at about 40 cm or at reading distance.
ofthepatient.
C) Useofthepinholecamera(PC).
ItoccurswhenthepatientshowsadecreaseinAV(AV≤0.6ora
bigdifferencebetweenthetwoeyes).ThismethodallowsdeterminingiftheVA
itisduetoanuncompensatedrefractiveerrororotherocularpathologies(ifthe
probelmforonyl refracvite,thevsiualacuyti whti htebeetreyeimproves).Thsimehtodonyl se

itisusedonlywhentheAVwithcompensationislessthan06..

i) Useambientlighting.
ii) Place the visual acuity (VA) value obtained with the eye that is
intendstoevaluate.
iii) Occludetheeyeofthepatientthatwilnotbeevaluated,withoutclosingorpressing.
StartwiththeODincaseofevaluatingbotheyes.
iv) AskthepatienttolookthroughtheETandindicatethesmalestletersthat
canyouread.
v) Encouragethepatienttoreadthenextlineandstopwhentheyfailmorethanhalf.
fromaline,asthelimitoftheAVmayberestrictedbyreadability
theletersandnotbytheirresolution.
vi) RecordtheresultsintheformofAV.V L/SC/BE1.25+ 2 .VL = visão longe; SC = sem
compensação; BE = buraco estenopeico; 1.25 = valor da escala; +2 ou -2 =
numberofletersreadinthefolowinglineorthatfailsinthecurentone.

João Linhares — jlinhares@fi[Link] 7

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
D) MeasurementofAVinVLandVPusingsphericallensesof+2Dand-2Dand
pinhole
i) RepeathemeasurementoftheAVinVLandVPwiththeinclusionofsphericalensesof+2Dand

-2D,startingfromthebestVAobtainedatthepreviouspointsforeacheye.
ii) Evaluatetheinfluenceofdiferentsphericalpowersonvisualacuity.
iii) If there is a decrease in theAV in any of the cases, test theAV with the
pinholeandregisterthemaximumAVachieved.

P2.3.4 – Measurement of Visual Contrast Sensitivity (SVC) – adapted from

Basic Procedures forOptometric Examinations – S. Franco, J. Jorge and M. Lira
UniversityofMinho,1999.

A) VisualSensitivitytoContrastinVL
i) Ambient lighting of the room, without causing shadows, reflections or areas
briliantontheexamboard.
ii) The patient should use or not their usual compensation, depending on the
whatisintendedtobeevaluated.

iii) Usethefourcircleslocatedatthebaseoftheexamboardtodemonstrate
to the patient, the functioning of the exam and what type of responses are expected,

asilustratedinFigure7.

Figure7SVCexaminationchartfromVistechorGinsberg.

iv) Palcethepaeitnt3meetrsfromtheexamniaoitnchartandocculdethelefteyewhtioutcolsnigi.t

to press.

João Linhares — jlinhares@fi[Link] 8

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
v) Starttheexamfromtheleftcircleofthe1strow(rowA)andaskthepatient
thatforeachcircleindicatetheorientationofthestripes.

vi) OccludetheODwithoutclosingorpressingandrepeatheprocedurefortheOEandAO.
vii) Record the results on the graph and compare with the considered values
normal,asilustratedinFigure8.

Figure8Exampleofarecordsheetforcontrastsensitivityvisualexam
[Link]
pathologicalchanges.

B) VisualSensitivitytoContrastinVLwithpolarizedfilters
i) Perform the previous procedure using a polarizing filter and take note of the
results.

João Linhares — jlinhares@fi[Link] 9

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
P2.3.5 – Evaluation of Pupilary Reflexes – adapted from Basic Procedures
OptometricExams–[Link],[Link],UniversityofMinho,1999.

A) PupilDiameter
i) Observetheshapeandcenteringofthepupil.
ii) Measurethepupilarydiameterwithambientlightingandwithlowlighting.
iii) Measurethepupilarydiameterwhenthepatientlooksatavisualacuityoptotypeandwhen
observeavisualacuitychart.

B) Evaluationofthepupilaryreflextolight
i) The lighting in the room should be dimmed but still allow for observation of.
bothpupilssimultaneously.
ii) The optometrist should be situated about 25 cm from the patient, without obstructing the
VLoptotype.
iii) Askthepatienttolookatthevisualacuitychart.
iv) Shinethelightontherighteyeandobservethevariationinpupildiameterandthespeedof
contractionofthepupilofthesameeye(directresponse).

v) Repeat3ormoretimestoevaluatetheconsistencyoftheanswers.
vi) Shinealightintherighteyeandobservethevariationinpupildiameterandthespeedof
conrtacoitnofhtepupolifhteelfetye(consensuarlesponse).

vii) Repeat3ormoretimestoevaluatetheconsistencyoftheresponses.
viii) Shinelightontheeyeandobservethevariationinpupildiameterandthespeedof
contractionofthepupilofthesameeye(directresponse).

ix) Repeat3ormoretimestoevaluatetheconsistencyoftheresponses.
x) ShinelightontheOEandobservethevariationofpupildiameterandthespeedof
conrtacoitnohtfepupolihtfergihetye(consensuarelsponse).

xi) Repeat3ormoretimestoassesstheconsistencyoftheresponses.
xii) Recordtheresults.
a) Iftheanswersarecorrect,itisnoted:
PERRLA - Pupils Equal, Round, and Reactive to Light and Accommodation.

C) Marcus Gunn test or afferent pupilary defect (assesses defects in the nerve)
opticpre-chiasmaticipsilateral
i) The room's lighting should be reduced but still allow for observation of
bothpupilsatthesametime.
ii) The optometrist should position themselves about 25 cm away from the patient, without obstructing the

VLoptotype.

iii) Askthepatienttolookatthevisualacuitychart.

João Linhares — jlinhares@[Link] 10

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
iv) Quicklymovetheflashlightfromoneeyetotheother,iluminatingeacheye.
forabout3seconds.
v) Observewhetherthepupiloftheiluminatedeyedilatesorconstrictsandthediameterofthe

pupilatthemomentwhenlightstrikestheeye.
vi) Repeat3ormoretimestoevaluatetheconsistencyoftheanswers.
vii) Notetheresults:
a) MG-Positive(present-doesnotcontractipsilateraleye).
b) MG-Negative(absent-contractsipsilateraleye).

P2.3.6–CoverTest–adaptedfromBasicProceduresofOptometricExaminations
– S. Franco, J. Jorge e M. Lira, Universidade do Minho, 1999.

The performance of this test requires the ful colaboration of the patient, who is present.

centralfixationandthatthereisnodeepamblyopia.
Clinicaly,itisdonefordistancevision,nearvision(NV),andintermediatevisionwith

[Link] for the purposes of this protocol will be carried out only
inVP,withoutcompensation.

Use a leter or figure optotype as a fixation point for beter.

controltheaccommodation.

A) Unilateralcovertest:
i) PlacetheoptotypeinVP,about40cmfromthepatient.
ii) Askthepatienttofocusonavisualacuityleterequaltoorslightlylowerthanthevisualacuity.
fromhteworsetye.

Nom
reyapleoT
[Link]
eiradnefgohstivenarhyitO
(eD
eaynhO
e(t)fldeiE.)

iii) [Link]

a) IftheOEdoesnotmove

(1) Ohtrortpehoaytilef

(2) AlternatingtropiaoftheOEwiththisfixedathemomentoftheexam.

João Linhares — jlinhares@fi[Link] 11

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
b) IftheOEmoves
(1) NasalparaTemporal=>Endotropia
(2) Temporal for Nasal => Exotropia.
(3) Aetlrnanitgrtopaiofhtergihetyewhtifxiaoitnahtemomenotfhteexamniaoitn.

iv) U n c l o g t h e O D a n d o b s e r v e i t .
a) IftheODdoesnotmove

(1) OrthophoriaofOD
b) IftheODmovestofixatetheoptotype=>Righteyephoria

(1) NasalparaTemporal=>Endoforia
2 Temporal for Nasal => Exophoria.
c) IftheODremainsdeviatedfromthefixationoftheoptotype

(1) Tropaoihtfgeriheyte(nasoaetlm
r podralependnigonhteoerinaotinohtfgeriheyte)

(2) Alternatetropia
v) Repeattheclosureoftherighteyeseveraltimestoverifytheresult,insistingwith
the patient to maintain fixation.
vi) RepeattheprocedurefortheOEandnotetheresults.
B) Alternatecovertest:
i) Keepthefixationoptotypeatabout40cmfromthepatient.
ii) Askthepatienttofixateonavisualacuity(VA)equaltoorslightlylowerthantheVA.
oftheworsteye.

iii) Occludetherighteyeandthelefteyealternately,withoutalowingfusiontooccur,thatis,
alwayskeeponeeyecovered.
iv) Observetheuncoveredeye.
v) RecordtheresultsaccordingtowhatisdescribedinpointA).

P2.3.7–HTest-motorskils.

This test aims to explore the patients' ocular motility, requiring them to
eyemovementtoextremepositionsofgaze.
Changestoasmoothandprecisesegment,orfixationchangesinoneeye
orinbotheyesmustberegistered.

i) The lighting should be ambient and should not create shadows in the eyes of
patient.
ii) Instructthepatienttolookattheflashlightlightwhilekeepingtheirheadstil.
heshouldonlymovehiseyes;thepatientshouldindicatewhenheseesthedoublelight
youfeeldiscomfort.

João Linhares — jlinhares@fi[Link] 12

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
iii) The lantern should be about 40cm from the patient and should be moved under the
shape of an H in an arc, with the patients' head in the [Link] loss of
Cornealreflexhelpstodeterminethelimitofthebinocularvisionzone.
iv) Movetheflashlighttotheninediagnosticpositionsasindicatedin
[Link]
holdthepatients' uppereyelidsinthelowerpositionsoftheflashlight
[Link]
byhand.
v) Pay attention to any misalignment of the eyes (the corneal reflection may
help)andassesstheaccuracyandsmoothnessofthetrackingmovements.
vi) Registertheobservations.

Figure9Extremegazepositionsforassessingocularmotilityand
[Link]
extremepositionsofthegaze.

João Linhares — jlinhares@fi[Link] 13

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
P2.4-Record1ofthelaboratoryregistrationnotebook

RegistrationofDIPintwopatients:

DIPVL DIPVP

Patient1

Patient2

Inthecaseofpatientswithlargebinoculardeviations,wherebotheyes
theyarefunctional,howcanDIPbemeasured?
___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

AVregistration

Patient1

OD OE AO

AV V L / S C

AV V L / C C

AV V P / S C

AV V P / C C

AV V L/CC+ 2 D

AV V P/CC+ 2 D

AV V L/CC- 2 D

AV V P/CC- 2 D

AV V L/CC/BE+ 2 D

AV V P/CC/BE+ 2 D

AV V L/CC/BE- 2 D

AV V P/CC/BE- 2 D

W
hteosfh+
icfat2DsphelcneoiarslnevoasirnV
(PD
?)doetceirsasveuiacyuA
l(tiVW
?) hy?

_______________________________________________________________________
_______________________________________________________________________

Um VL? Why?

João Linhares — jlinhares@fi[Link] 14

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
_______________________________________________________________________
_______________________________________________________________________

Whydoesnt'asphericallensof-2Dhavethateffect?
_______________________________________________________________________
_______________________________________________________________________

hncteIaspon+
elhcfsa2eilrD
ahndstB
oew
ihcvsenftihs,E
m
atiehnrsIa?tporvem
nvasuycieuatn?lit

Howmanylines?
_______________________________________________________________________
_______________________________________________________________________

VisualContrastSensitivityTestRecord

Is the patient's ASVC observed normal? _________________________________

Whatistheeffectandjustificationforusingapolarizingfilter?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Evaluationofpupilaryreflexes

Is the pupil size of the right eye the same as the left eye? Their reactions to light are the same.

the same?
_______________________________________________________________________
_______________________________________________________________________
Aretheaferentandeferentreactionsnormal?
_______________________________________________________________________
_______________________________________________________________________

CoverTestandMotorSkils
WasanymovementdetectedduringtheCoverTestoranomalyintheHtest?
Howdoyouclassifyanomalies?
_______________________________________________________________________
_______________________________________________________________________

João Linhares — jlinhares@fi[Link] 15

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Practice 3
Preliminary optometric exams: Keratometry.

P3.1 - Summary

Practice U. Credit Activity Duration Class Register

Procedures Assessment of the sphericity of the cornea Record 3 of the notebook

Clinicians in through keratometry. of laboratory record
#3 3h
Optometry attached to this
protocol.

MaterialProtocol P3 - this guide; Javal and Bausch and Lomb keratometer and auto-
refractometer.

P3.2 - Introduction

In optometry, the use of techniques that allow for obtaining information about sphericity (or lack of
The layers of the cornea are of vital importance, for example, in contactology and in such a complete description.
as much as possible from the optical surface with the greatest dioptric power of the eye - the cornea. The acquisition of rays of

the curvature of the cornea will allow the selection of the contact lens that will best fit the cornea of the

patient, estimate the amount of corneal astigmatism, as well as the regularity or irregularity of the
cornea, among others.
The curvature radii of the anterior cornea can be measured by means of keratometry. This is a
quick and simple technique, having as its main limitation the fact that it only takes measurements in one
small central area of the cornea, ignoring the remaining area. There are two types of keratometers.
main: Javal's and Bausch and Lomb's.
One way to overcome the main limitations imposed by conventional keratometers is to
use of videokeratometers or corneal topographers.
These last ones evaluate the topography of the cornea in almost its entire area allowing for more analyses.
detailed and more information about the anterior surface of the cornea.
In this practical class, corneal measurements will be taken using Javal keratometers.
Bausch and Lomb.
Register all your measurements on the attached registration form.

João Linhares — jlinhares@fi[Link] 1

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
P3.3 - Metodologia

In pairs, using the available keratometers, perform the measurements of the radius of
corneal curvature in 4 eyes in the central, nasal, and temporal positions following the instructions below
presented.
During the execution of the class, the tables attached to this protocol must be filled out.
also responding to the indicated questions.
At the end of the class, the teacher responsible for the subject will receive the sheets related to Record 3 of

laboratory record notebook for later evaluation according to the criteria defined in the framework of
page 1 of this protocol.

P3.3.1 – Corneal curvature with Javal keratometers – adapted from (Borràs

Garcíaetal.,1999).

Figure1–JavalKeratometer.

A) Centralcurvaturerays.
i) Adjustthekeratometereyepiecetotheoptometrists' [Link]
step may induce erors in the measurement of the radi of curvature. The adjustment is

madeinsuchawaythatthediagonalblackline(s)arethebestfocused
possible.
ii) Askthepatienttoplacetheirchinonthechinrestandtheirforeheadonthesupport.
correspondent, adjusting the eye height to the reference height mark
ocular
iii) Occludethelefteye(LE).
iv) Guidethepatienttolookattheluminousfixationpointinsidethe
instrument.

João Linhares — jlinhares@fi[Link] 2

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
v) Align the instrument with the patients' [Link] first adjustment should be
performedusingtheexterioroftheinstrumentasareference,aligningthemark
(pinandlineandreference)foradjustmentwiththecenteroftherighteyepupil(OD)
of the patient. The crosshairs of the keratometer should be placed in position

horizontal.
vi) Centerandfocusthekeratometer'ssightsreflectedbytheanteriorsurfaceofthe
[Link]' eyepiece.
tocarryitout,movingtheinstrumentbackandforthinmovements
shortandgentle(tonotstraytoofarfromtheinitialadjustmentpoint).
vii) Themirasshouldremainincontactwithoutoverlappingandtheircentrallines
aligned,asshowninFigure2,makingthelineoffaith(blacklinein
Ocular)passintheintersectionofthecentralines.

Figure2AlignmentoftheJavalkeratometer'[Link]
withoutoverlap.Eachsteponthegreentargetcorrespondsto1Dofastigmatism.

viii) If it is not possible to align the central line as shown in Figure 2

It may be necessary to adjust the position of the sights to one other than the
horizontal,meaningthatthisadjustmentdoesnotalowthemainhorizontalmeridianto
itwilbefoundmoreat180º.Inthiscase,theadjustmentofthesightsmaybethesameas

showninFigure3.

Figure3-Adjustmentofthecentrallinebyrotatingthekeratometers'[Link]
inhorizontalpositionthecentrallinesdonotalign(c),rotatingthesightswilalowa
bestadjustment((d)and(e)).

nine Afteraligningthesights,readthevalueonthescaleinmilimetersandtheanglein
analysisandmemorizethem.

João Linhares — jlinhares@fi[Link] 3

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Science - University of Minho
Nome____________________________________________________ Número_________
x) Rotate the sights 90º, approximately, and find the position of the second.
meridian(wherethesightsalignperfectly).Performthesametypeof
adjustmentstoalignthecentrallineswithoutthesightsoverlapping.A
Thelineoffaithwilhavetobeusedagainasareference.
xi) Note the values. First the stored values, coresponding to
horizontalmeridian,[Link]
thelastcorrespondtotheverticalmeridian.
xii) Ifthemeasureonthehorizontalmeridianisthesameasthatoftheverticalmeridian
the anterior surface of the cornea did not have astigmatism.
xiii) RepeatthesameprocedurefortheOEexcludingtheOD.

Therecordingofkeratometryshouldbedoneintheformof:

OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

B) Peripheralcurvaturerays
i) Follow the same procedure as in A), but instruct the patient to look.
forthelimitofthecentralopeningofthekeratometer(rightorleftdepending
area of the cornea to be evaluated) and perform the measurements.

ii) In this way, the curvature of the anterior surface of the nasal cornea is evaluated,
temporal,inferiorandsuperior.
iii) ThedataregistrationmustbethesameasindicatedinA).

P3.3.2–CornealcurvaturewithBauschandLombkeratometers–adaptedfrom
(BorràsGarcíaetal.,1999).

Figure4-BauschandLombKeratometer.

João Linhares — jlinhares@fi[Link] 4

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
A) Centralcurvaturerays.
i) [Link]
step may induce measurement errors of the curvature radi. The adjustment is
madeinawaythatthediagonalblackline(s)arebestfocused
possible.
ii) Occlude the OS and orient the keratometer to the OD. Gently move the
keratometer until your targets are visibly reflected in the cornea of
patient,withoutlookingthroughtheeyepiece.

iii) Lookthroughtheocularandfocustheaimsofthekeratometerbymovingitforwardand
paratrá[Link]ãofocadasquandonãohouverimagensduplasdassuas
lines,asinFigure5.

Figure5-Blurredsights(left)andfocusedsights(right).

iv) Keeping the focus constant align the sights use the buttons that allow
adjustthesightsonthehorizontalandverticalmeridianssimultaneously.
The alignment of the sights consists of placing the guiding cross in the center of the

lower right circle, overlapping the + and – signs that surround it, just like
represented in Figure 6. Simultaneously remove the values from the meridians.
horizontalandverticalaswelasyours

Figure6-AlignmentofthetargetsoftheBauschandLombkeratometerwiththe
signals+and-usinghorizontaldisplacement(+)andvertical(-).

João Linhares — jlinhares@fi[Link] 5

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
vi) At times, it is impossible to align the + and - sights using only the buttons.
horizontal and vertical displacement. To align them, it wil be necessary to rotate the

keratometeradjustingsimultaneouslythehorizontalanddisplacementbuttons
Verticaluntilthe+and-sightsalign,asshowninFigure7.

Figure7–Misalignedsights(left)andalignedsightsafterrotationandadjustmentH
the Vido keratometer.

vii) Repeat the previous procedure for the OS, excluding in this case the OD.
It is also possible to use this keratometer to perform keratometry.
peripheral, similar procedures should be followed as those used for the
Javalkeratometer.

Therecordingofthekeratometryshouldbedoneintheformof:
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

P3.3.3–Cornealcurvatureandrefractiveerrorwiththeautorefractometer.

Usingtheauto-refractometer,measuretheradiusofcurvatureoftheODandthe
Seeyourrefractiveerrorsandnotethemdown.

Toassesstheeffectofaccommodationonrefractiveerrormeasurements,placea
[Link].

R e f e re n c e s :

Borràs García, M. R., Castañé Farran, M., Parra, J. C. O., Cutillas, M.P., March, E.P.
Herrero, E. S., & Puentes, C.V. (1999). Optometry: Manual of Clinical Examinations.
Barcelona:PolytechnicUniversityofCatalonia.

João Linhares — jlinhares@fi[Link] 6

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Science - University of Minho
Nome____________________________________________________ Número_________
P3.4-Record1ofthelaboratorynotebook

Keratometryrecordin3patients,centralcornea:

Patient1
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______
Patient2
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

Keratometryrecordinapatient,peripheralcornea:

Patient1–Nasal
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______
Patient1-Temporal
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

Whatistheaverageofthekeratometriesperformedonthecentralcorneaofthe2patients?

Av e r a g e
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

Comparingthecentralcornealmeasurementwiththeperipheralone,whatcanyousayabout
Whaatrethediferencesincurvaturebetweenthenasatel,mporaal,ndcentraclornea?

_____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Usingtheauto-refractor,whatresultdidyouobtainforthecentralkeratometry?
OD:H-______D______mm@______/V-______D______mm@______
OE:H-______D______mm@______/V-______D______mm@______

What is the result for the refractive error?

OD:ESF______CIL______@______
OE:ESF______CIL______@______

João Linhares — jlinhares@fi[Link] 7

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Practice 4
Objective exams: Retinoscopy.

P4.1 - Summary

Practice U. Credit Activity Duration Class Register

Procedimentos Assessment of the refractive state of Record 4 of the notebook

Clinicians in patient with objective methods. of laboratory registration
#4 9h
Optometry - attached to this
protocol.

Material Protocol P4 - this guide; Retinoscope, optotype projector, trial frame and
phoropter.

P4.2 - Introduction

Retinoscopy is one of the most important visual tests in the practice of Optometry. It is an exam
objective, thus dispensing with the patient's participation in its execution. Thus it will be possible to carry out

ocular examinations for non-cooperative patients (disabled, elderly, or children) with a high degree of
confidence in the results obtained. Retinoscopy is a refractive examination when performed in its format
traditional, it can also be used to assess the accommodative state of the patient - retinoscopy
dynamic.
Besides the objective information that can be obtained through retinoscopy, the amount of
the qualitative information that can be obtained is also very large. When observing the retinal reflex,
provoked by the illumination of the retinoscope, it is possible to evaluate the speed of the fringe, color, intensity,

movement, variations in its intensity and variations in pupil diameter. For example, high
corneal irregularities, such as in the case of keratoconus, may cause scissor-like fringes. In the case of
waterfalls, the characteristic orange reflection will be invaded by dark and lightless areas (opacities of
(crystalline). Regarding the speed of the reflex, the faster it is, the greater the patient's refractive error.
Retinoscopy is thus a technique of high refractive importance and a complementary analysis tool.
of eye health should be performed on all patients.

João Linhares — jlinhares@fi[Link] 1

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

P4.3 - Methodology

In pairs, using the available retinoscopes on the bench, perform the examination of
refraction objective for the right eye (OD) of the patient and subsequently for the left eye (OE). This
the procedure aims to reveal the refractive state of the patient for distance vision (DV) for the right eye (RE) and

the OE.

Throughout the procedure, and as a clinical practice, the patient should be informed of the steps.
that we are doing to make him feel comfortable with our procedure and understand the reason for the
examination routine to be carried out during the exam, such as low ambient lighting or obstruction/
miopização. Como exemplo, a miopização poderá provocar ansiedade no paciente se não se explicar que
it is part of the exam, since the patient will not understand why they are seeing poorly, when because
norma sees better than what she is currently seeing.

During the execution of the class, the tables attached to this protocol must be filled in.
also answering the indicated questions.

P4.3.1–Retinoscopy–adaptedfrom(BorràsGarcíaetal.,1999;DavidEliott,2007).

A) Seatthepatientcomfortablyandadjustthephoropterortrialframe(AP)
tothepatient,takingcaretoadjusttheinterpupilarydistance(IPD)ofthephoropter/
APtoDIPofthepatient.Alsoadjustthevertexdistancetoabout12mm.
B) Occludethepatients' righteyeandaddpositivesphericallensestothelefteyeuntil
[Link]ívasaté
The patient reaches a VA of 0.3 or 0.4 but unfocused. If it is a patient
MyopicISYOURAVFORLESSTHAN0.3putinthenecessarynegativelenses
unlitreachesthereferedvsiualacuyti(VA)oraetlrnaviteylpalceavsiualacuyti(VA)chartofhgiheracuyti

(preferable), explaining that everything is part of the exam and that you are seeing poorly.

[Link].
toseetheletersinVL(theletersmustbeblurred).
C) Informthepatientthattheambientlightingwil [Link]
patient objects, refer that with ambient lighting the exam does not produce
resultsaspreciseasinlowlight.
D) UnblocktheOD.
E) Standatadistancewithyourarmandhandoutstretched(thefingersoftheoutstretchedhand
shouldtouchtheAP/foropter,whichwilcorrespondtoadistanceofabout50or
66cm)in,frontoftheODandperformtheexamination.

João Linhares — jlinhares@fi[Link] 2

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
F) EnsurethatthepatientisataltimesusingtheOEtoseethe
[Link]

patienttoinformtheoptometristwhenevertheirvisionbecomesobstructedand
cannotseetheletersinVL.
G) The optometrist should use the OD to evaluate the patient's OD and the OE to evaluate
Patient's OE (consensual observation).
H) Observethestrip-shapedreflectionoftheretinoscopecomingfromthepupil(strip).
i) Take mental note of the width of the bangs, color, and shine.
ii) Thisproceduremustbeperformedonallmeridiansandnotjustonthe
main(rotatethefringe360degreesforaninitialevaluation).
iii) Performbothwiththeflatmirrorandwiththeconcavemirror.
I) Withthefringehorizontaly(H)movetheretinoscopeverticaly(V)toassessthe
meridianV,asindicatedinFigure1.

Figure1-HorizontalreflectionofthestreakoftheretinoscopeT
. hestreakinthispositonwil

evaluatetheverticalmeridian.

I) [Link]
[Link]
diference,inthetransitionfromonemeridiantoanothertheprojectedfringedoesnot

alignswiththereflectedfringe(seeFigure2(c)),asrepresentedinFigure2.
Inthecaseofnotfindingadifferenceinthewidthofthefringeasyouassessthe
different meridians, assume by default the main meridians at 90° and 180°.
Thiswilbethefirstindicatoroftheexistenceornotofastigmatismintherefractionof

patient.(seenotepointT)

Figure2-Identificationofthemainmeridiansthroughtheassessmentofwidth
[Link],theprojectedfringedoesnotalignwiththe

[Link]
inthecaseofsphericalrefractions,thefringeisequalinwidthandbrightnessinal

meridians.

João Linhares — jlinhares@fi[Link] 3

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
J) Usingtheplanemirror,startbyneutralizingthemeridianthathasthefringe.
withlessmovementandbrighter(dotheoppositewithaconcavemirror).
Destaformaoajustedapotênciacilíndricaserárealizadocomcilindrosnegativos.
Ifitsnotpossibletodefinewhichonetostartwithb,eginwiththehorizontal.

i) Ifthemovementis"with"(Figure3-projectedandreflectedfringemove-
in the same direction) add positive lenses (more positive or less
negative).
ii) If the movement is a'gainst' (Figure 4 - projected and reflected fringe
they move in opposite directions) add negative lenses. (less
positiveormorenegative.
iii) Stopaddinglenseswhenyoufindtheneutralpoint–thereflectedfringe
filstheentirepupilwithoutidentifyingfringeorshadow
nomeridianunderanalysis(Figure5-a).

Figure3-Movementw
' ith,'inwhichtheprojectedandreflectedfringeis
moveinthesamedirection.

João Linhares — jlinhares@fi[Link] 4

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Figure4-Movement"against",inwhichtheprojectedandreflectedfringe
theymoveinoppositedirections.

K) Afterfindingtheneutralpointonameridian,rotatethefringe90ºtoobservethe
anotherprimemeridian.
i) Iftheneutralpointpersists,[Link].
hereistheneutralization.

ii) If there is movement, then the patients' refraction is astigmatic, just like
representedinFigure5-b:
a) Align the axis of the neutralizing cylinders with the axis of the fringe of
retinoscope.
(1) If with the mirror plane you observe movement against adding lenses
negative cylindrical. Expected situation if the prime meridian to
neutralizewasthebrightest/slower(withtheflatmirror).
(2) If with the mirrorplane you observe movement when adding lenses
positivecylinders.
(3) If with the concave mirror you observe movement with added lenses
negative cylindrical. Expected situation if the prime meridian to
neutralizewasthemostbriliant/slowest(withtheflatmirror).
(4) Ifwiththeconcavemiror,movementagainstheadditonoflensesisobserved.
positivecylindricals.
(5) Addcylindricallensesuntiltheneutralpointisfound.

L) When finding the neutral point in the second meridian, verify in all
meridians,withthetwomirrors,ifindeedtheneutralizationoccurredinall
meridians.
M) Leavethegrossretinoscopyvalueintherighteye.

João Linhares — jlinhares@fi[Link] 5

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
N) PerformthesameprocedurefortheOE,giventhattheODwilalreadybemyopized.
onceyouhavethetotalvalueoftheretinoscopy,adjustingthepowerofthelensesuntil
thatthepatienthasablurredvisionof0.3or0.4.

a b

Figure5-Evidenceoftheexistenceofastigmatisminthepatientunderobservation.
Neutralpointwiththefringehorizontalandfringeontheverticalmeridian.

O) Afterperformingretinoscopyonthelefteye,checkagainiftherighteyeisinfocus.
neutral.Ifthevariationisgreaterthan0.5D,repeattheexam.

P) The net value of the retinoscopy will be obtained in the phoropter/AP (gross value of the
retinoscopy)minusthedioptricequivalentattheworkingdistance(2Dat50cmand
1.5Dat66cm.
Q) Registerthenetvalueofretinoscopy:
i) OD-±ESF±CIL@[Link]:-2.00-1.00@1801.0+ 2
ii) OE-±ESF±CIL@[Link]:-2.25-0.75@1801.25- 2
R) Registerthepatients'AVwiththenetvalueoftheretinoscopy.
S) Throughout the exam, give permanent indications to the patient to fix the
[Link],itisavoided

thatthepatientistobeaccommodatedduringtheretinoscopy.
T) To better find the axes of astigmatism in the preliminary analysis, place the
retinoscope in concave mirror. Observe the reflected fringe. Add lenses
positiveuntilseeingathinfringe(stil inconcavemirror).Inthisconditionof
visualadjustmentofthereflectedfringetothebestorientationoftheprojectedfringeby
[Link],beginthewithdrawalofthe
positivelenses,[Link]
stop being so noticeable, turn into a flat mirror and neutralize the movement
(alwayswiththeflatmirror).

R e f e re n c e s :

João Linhares — jlinhares@fi[Link] 6

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
Borràs García, M. R., Castañé Farran, M., Parra, J. C. O., Cutillas, M.P., March, E.P.
Herrero, E. S., & Puentes, C.V.(1999). Optometría : manual de exámenes clínicos.
Barcelona:PolytechnicUniversityofCatalonia.

[Link](2007).[Link]-
Heinemann.

P4.4-Record4ofthelaboratoryrecordnotebook

Retinoscopyrecordin4patients:

Retinoscopy(netvalue) AV
OD-ESF______CIL______@_______º
Patient1
OE-ESF______CIL______@_______º

OD-ESF______CIL______@_______º
Patient2
OE-ESF______CIL______@_______º

OD-ESF______CIL______@_______º
Patient3
OE-ESF______CIL______@_______º

OD-ESF______CIL______@_______º
Patient4
OE-ESF______CIL______@_______º

João Linhares — jlinhares@[Link] 7

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
Whenatneutralpointandplanemirror,slightlybringtheretinoscopecloser.
Whatmovementdoesthepatientobserve?
___________________________________________________________________________
Is he distancing himself from the patient?

___________________________________________________________________________
Whatadditionalinformationdothesedatagiveyou?

___________________________________________________________________________

Wheninneutralpositionandflatmirror,telthepatienttolookatthelight.
[Link]?Andtothepupil?

___________________________________________________________________________
What is the patient doing with this eye movement?
___________________________________________________________________________

João Linhares — jlinhares@fi[Link] 8

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

Practice 5
Subjective exams: Distance vision based on Visual Acuity and Retinoscopy

P5.1 - Summary

Practice U. Credit Activity Duration Class Register

Procedures Assessment of the reflective state Entry 5 of the notebook
#5 Clinicians in 6h of the patient using laboratory - attached to this
Optometry subjective methods. protocol

Material Protocol P5 - this guide.

Retinoscope, optotype projector, phoropter, trial frame, and trial box.

P5.2 - Introduction

The subjective vision test aims to determine the best

possible optical compensation that adjusts to the patient's refractive error. In contrast
In objective methods, in this exam the patient intervenes by indicating which is the best lens.
ophthalmic for each situation. This way, the final prescription is adjusted to sensitivity
individual and the needs of each patient. The subjective examination therefore has in
consideration of the real needs of the patient and as such it should be carried out
trying to mimic the usual conditions under which the prescription will be used. As
an example of this rule, the subjective exam should not be conducted under conditions of
low lighting and only in long vision when the patient's needs are
primarily in near vision and in a well-lit office environment.

There are also many factors that can influence the completion of the exam.
subjective, just like the light intensity or the distance at which the examination is conducted,
for a comprehensive understanding of the patient's visual needs, the conditions
how the prescription will be used and the type of prescription to be used (progressive lenses)
and/or contact lenses) must always be present during the examination
subjective.

Subjective vision tests always require the participation of the patient.

since in the case of such participation being impossible or made difficult, they must be used
objective methods to obtain the final prescription.

João Linhares — jlinhares@fi[Link] 1

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

P5.3 - Methodology

In groups of two students, a visual examination practice should be carried out.

subjective in an alternating manner, using the two methods described below:

1. From the retinoscopy.

2. Starting from Visual Acuity (VA).

The two methods are coincident in most of their procedures, except

that from the AV there is no reference prescription, so the obtaining of the
spherical power, from the axis and the cylindrical power approximations will be made from the AV
without patient compensation. From the retinoscopy point 1.a and point 1.b
previous ones are obtained directly from the net values of retinoscopy.

Regardless of the method used, there are three distinct phases:

1. Monocular examination right eye (RE) first and left eye (LE) later;

a. Approximate determination of spherical power;

b. Approximate determination of the axis and the power of the cylindrical lens;

c. Refine the axis and the power of the cylindrical lens;

Refine the spherical power.

The objective of this procedure is to find the power of the ophthalmic lens.
compensatory of the patient's reflective error.

2. Binocular balance;

This procedure aims to equalize the accommodative state of both eyes, in

conditions of ocular dissociation. This step assumes that the refractive state of each
The eye is already known and has been obtained for each eye individually.

3. Binocular balance.

This procedure aims to adjust the accommodative state under conditions

binoculars.

João Linhares — jlinhares@fi[Link] 2

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

P5.3.1 - Subjective visual examination in VL based on AV

1. Monocular examination (right eye first and then left eye)

a. Comfortably seat the patient, adjust the phoropter to their height. Adjust the PD of the
foropter to DIP in VL of the patient;

b. Adjust the lighting to ambient light levels (living room lights on)
refractive column lights off;

c. Occlude the right eye (to evaluate the left eye) and the left eye afterwards (to evaluate the right eye);

d. Myopize or OD (or OE) until the patient sees the line of AV = 0.2 blurred;

e. Decrease spherical power in steps of 0.25D until the patient is able to read the
AV line = 0.4.

2. Approximate determination of the axis and power of the cylindrical lens;

f. Project the clock face and ask the patient which line (or lines) they see.
sharper;

g. Determine the approximate direction of the cylinder's axis (ask the patient to
making an analogy between the clock circle and a watch, indicate what time it is
marked and multiply the smallest hour by 30). This way, one obtains the direction.
approximately the axis of the cylinder. For example, if the patient refers to the line of 2-8 o'clock.
the axis will be 2*30 = 60º;

h. Place the axis of the cylinder and increase negative cylindrical power until the
patient indicates that they see all lines the same (or approximately the same).
Thus, the approximate power of the cylinder is obtained;

Bisector

i. Project the AV = 0.4 line and reduce spherical power until that the patient
see the AV line = 1.0 or maximum AV (does not need to be clear).

João Linhares — jlinhares@[Link] 3

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

3. Refine the axis and the power of the cylindrical lens;

j. Place the cross cylinder and ask the patient to look at one or two letters.
preferably rounded, in line with AVinferiora 1.0 or at its maximum
AV; Alternatively use the point optotype.

k. Align the bisector of the crossed cylinder (an imaginary line that connects the supports of
rotation of the crossed cylinder) with the approximate axis of the cylinder;

l. Roll the crossed cylinder and ask the patient if they notice any difference and if
Note, in which of the two positions you see better. It may be helpful to instruct the patient to
respond in which positions the letters are rounder/defined;

m. Adjust the cylinder axis by rotating it in the negative axis direction of the cylinder
crossed (marked with red dots) until the patient does not notice.
difference between the two positions. One should make an adjustment between each.
procedure described in l;

Align the power axis of the crossed cylinder (marked with a red dot/
white, as indicated in the figure) with the axis of astigmatism;

o. Rotate the crossed cylinder and ask the patient if they notice any difference in the
previously marked letters and, if you notice, in which of the two positions you see
better. It may be useful to instruct the patient to respond in which of the positions the
letters show greater contrast: 'they are darker';

p. It's easier to see when the negative axis of the crossed cylinder (red dots)
coincides with the axis of astigmatism, increase -0.25DC to the value of the cylinder;

q. It is better seen when the positive axis of the crossed cylinder (white points)
coincides with the axis of astigmatism reducing -0.25DC to the value of the cylinder;

Repeat the procedure until the patient does not notice a difference between the two.
positions.

4. Refine the sphere

s. Miopizar incrementando 1.00D de potência esférica;

Ask the patient to look at the line of AV = 1.0 (or maximum in the case of the
amblyopes);

u. Reduce spherical power in steps of 0.25D until the patient could read.
the letters of line AV 1.0 (use this value only as a reference).

5. Repeat the same procedure for the OE.

João Linhares — jlinhares@fi[Link] 4

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

6. Binaural phase

Similar visual acuities

v. Occlude both eyes for greater patient comfort;

Place the dissociation prisms 3 Lower Base (responsible for the image
superior) in the right eye and 3 Superior Base in the left eye (responsible for the lower image);

x. Isolate a line of letters slightly below the worst eye's visual acuity (VA);

y. Warn the patient that they will see two images vertically displaced. Unblock.
both eyes. Ask the patient on which line they see the letters most clearly:
a. If the patient says they see the images the same, end the binocular examination.

b. If the patient sees one image clearer than the other, they should add power.
spherical in steps of 0.25D in the eye corresponding to what sees the best image
(For example, image above => OD).

c. After adding spherical power:

If the patient says they see the images the same, terminate the biocular examination.

ii. If the patient says that they still see the same image more clearly (still the image
superior => OD), increase again spherical power and return to point
b. Do not add more than 0.5 D. If it is necessary to vary the sphere further
The 0.50D should repeat the monocular exam ODE.

iii. If the patient reports that the clearest image is now the one corresponding to
outro olho (há inversão da percepção => imagem de baixo => OE), perguntar
what is the brightest image;

1) If the brightest image is that of the eye for which the inversion was made
(image below => OE), logo it also corresponds to the clearer image
finish the biocular exam.

2) If the brightest image is that of the eye that was initially penalized with
spherical power (top image => OD), remove the added power and
finish the exam. This way the brightest image (director's eye) is
also the clearest image. Thus ends the binocular examination.

Remove the prisms.

Dissimilar visual acuities (one or more lines of difference in visual acuity and the visual acuity of
worst eye is below VA = 1.0)

João Linhares — jlinhares@[Link] 5

 Clinical Procedures in Optometry
Bachelor's degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
aa. Place the dissociation prisms 3 BI in the OD and 3 BS in the OE.

bb. Place the red-green optotype;

cc. Unclog both eyes;

Advise the patient that they will see two images vertically displaced and ask them
to fix attention on the upper image => OD;

ee. Ask the patient about the background against which the letters appear the clearest, make the adjustments.
necessary (add spherical power if the best background is green and remove
spherical power if the best background is red);

Ask the patient to focus on the image below => OE and to describe what background it has.
see the clearest letters, make the necessary adjustments (add spherical power
if the best background is green and remove spherical power if the best background is the
red) ;

Toggle between the two images until achieving equality between the images in both.
fundus, monocularly:

a. If the patient cannot equalize the funds, they should be allowed to see better in the
green - the patient is slightly hyperopic;

b. If it is necessary to vary the sphere by more than 0.50D, the exam should be repeated.
monocular ODE.

hh. Remove the prisms and record the results

7. Binocular phase (In cases of dissimilar visual acuities, it is not performed)

binocular phase

ii. Ensure that both eyes are unobstructed;

jj. Myopize binocularly with +1.00D over the value of the biocular phase;

kk. Ask the patient to look at the AV line 1.0 (or maximum in the case of the)
amblyopes)

ll. Reduce spherical power binocularly in steps of 0.25D until the patient
was able to read the letters of the line at AV = 1.0. As soon as the patient can read the line
of AV = 1 ask if the letters are clear. This is the most positive value of the sphere
with which the patient achieves a good AV. Under these conditions, it is natural that the
patient reads more than the line of VA = 1.0 and that the reduction of 0.25D or 0.5D of
spherical power can substantially improve visual acuity. However, it is important to have

João Linhares — jlinhares@fi[Link] 6

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
careful not to overcorrect nearsighted patients - remove too much power
spherical; Finish the binocular exam when a reduction of 0.25D does not improve VA.

8. Record the results - Example:

Sx. VL OD: +0.75 / –1.00 x 20º (AV = 1.2)

OE: -1.75 / –0.50 x 180º (AV = 1.0) - AO: (AV = 1.2)

P5.3.2 - Subjective visual examination in VL from Retinoscopy

In this case, it is not necessary to proceed with obtaining the approximate values of the
spherical power, cylindrical power, and the axis of the cylinder, since one has the
net values of retinoscopy and these will be used as a starting point.

1. Monocular examination (OD first and then OS):

a. Comfortably seat the patient, adjust the phoropter to their height, and adjust the PD.
do foropter to DIP in VL of the patient;

b. Adjust the lighting to ambient light levels (room lights on and

refraction column lights turned off;

c. Occlude the OS (to evaluate the OD) and the OD afterwards (to evaluate the OS);

d. Slightly blur the OD (or the OS) until the patient can no longer see the line.
Maximum AV (typically with a spherical power increment of 1.00D);

e. Decrease spherical power in steps of 0.25D until the patient is able to read the
maximum AV line (It is not mandatory for AV to be = 1.0, but advisable for
guarantee a basis for comparison ODE).
2. Refine the axis and power of the cylindrical lens:
f. Proceed as indicated in point 3 of the subjective visual examination in VL from
fromtheAV.

3. Refine the sphere:

g. Proceed as indicated in point 4 of the subjective visual examination in VL from
fromAV.
4. Repeat the same procedure for the OE. (Points 8 to 10).
5. Bocular phase:
h. Proceed as indicated in point 6 of the subjective visual examination in VL from
fromAV.
6. Binocular phase:
i. Proceed as indicated in point 7 of the subjective visual examination in VL from
fromAV.
[Link] the results:
João Linhares — jlinhares@fi[Link] 7
 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
j. Proceed as stated in point 8 of the subjective visual exam in VL from
fromAV.

P5.3.3 - Subjective visual examination in VL using the bichromatic method.

There are some variations to the methods already presented for the execution of
subjective visual examination for distance vision. These variations do not affect, however, the
general structure of the exam defended in P5.3 - Methodology. What commonly happens
they are small variations of specific techniques used during the examination routine.
Uma dessas técnicas específicas é a determinação da esfera aproximada e o
refine the sphere. This technique can be adjusted to be performed by resorting
to the bichromatic method. This method explores the different refraction for different
wavelengths caused by the eye and can be used to determine and
refine only the spherical power.
In this way, the entire routine of subjective visual examination is the same as presented.
previously, except regarding how the power is determined and refined
spherical.
Although presented here, this method will not be the method of choice for
to determine and refine the sphere, since it has as a major limitation the impossibility
to be administered to patients with color vision deficiency.

This should be the method used whenever one aims to obtain the information
about the adjustment of spherical power according to the patient's real needs, that is,
to know if the patient is myopized (with spherical power in excess) or
hypermetropized (with negative spherical power). It is noteworthy that the objective
the intended use of this method is to achieve the balance of spherical power, that is,
the emmetropization, achieved when the patient sees the letters equally
about the green background and about the red background.

Place the bichromatic optotype and ask the patient which background they see more.
sharp: On the green background or on the red background?

The spherical correction is carried out as follows:

1. You can see better about the green fund by adjusting the spherical power by adding
spherical power until the two ends equal each other;
2. It is better seen on the red background to adjust the spherical power by removing power.
spherical until the two ends become equal;
3. If it is not possible to equalize the funds:
1. Let it be clearer in green if the intention is to stimulate accommodation.
insufficiency of spherical power;

João Linhares — jlinhares@fi[Link] 8

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________
2. Make it clearer in red if you intend to avoid complacency (there is
excess of spherical power.

João Linhares — jlinhares@fi[Link] 9

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

4. Check AV without the bichromatic optotype. This step is extremely

importance and serves to ensure that visual function is assessed under conditions of
normal vision.

P5.3.4 - General notes.

- The constant myopizations (addition of spherical power) serve to ensure that

is monitoring the accommodative state of the patient. All the subjective examination in distance vision
must be performed without the patient resorting to accommodation to compensate for errors
hypermetropic refractives.

- Whenever the lens power is changed on the phoropter or in the trial frame
One should always leave a lens in the trial frame or in the phoropter to avoid
to stimulate accommodation and not to give the indication to the patient that in any
the moment is without dioptric compensation.

- A spherical power variation of 0.25D is expected to improve/worsen an AV line.

If this does not happen, we may be far from the point of emmetropization and stimulating the
accommodation. In this case, the letters do not get better but become clearer. If so
to happen to go back to the anterior spherical lens.

- Whenever the patient has difficulty deciding between two positions of two
different lenses, for example in crossed cylinders, a third must be introduced
option "or are they the same". Sometimes the differences are so small that they may be
in fact very similar. A variation of 0.5D may help in making the decision
and take note of the patient's response.

References:

Borràs García, M. R., Castañé Farran, M., Parra, J. C. O., Cutillas, M.P., March, E.P.
Herrero, E. S., & Puentes, C.V.(1999). Optometría : manual de exámenes clínicos.
Barcelona: Polytechnic University of Catalonia.

David B. Elliot (2007). Clinical procedures in Primary Eye Care. 3rd [Link]-
Heinemann.

João Linhares — jlinhares@fi[Link] 10

 Clinical Procedures in Optometry
Bachelor's Degree in Optometry and Vision Sciences - University of Minho
Nome____________________________________________________ Número_________

P5.4 - Record 4 of the laboratory logbook.

Record of the result of the subjective visual exam in VL based on the patient's VA
in 4 patients.

Initial AV SX VL AV final

OD | OE | AO OD OE OD | OE | AO

Patient 1 OD|OE|AO Esf____Cil____x_____ Esf____Cil____x_____ {"OD":"OD","OE":"OE","AO":"AO"}

Patient 2 OD|OE|AO Esf____Cil____x_____ Esf____Cil____x_____ OD|OE|AO

Patient 3 OD|OE|AO Esf____Cil____x_____ Esf____Cil____x_____ OD|OE|AO

Patient 4 OD|OE|AO Esf____Cil____x_____ Esf____Cil____x_____ OD|OE|AO

Record of the result of the subjective visual examination in VL from the retinoscopy of
patient in 4 patients.

AV final
RX VL SX VL
OD | OE | AO

OD Esf______Cil______x______ Esf______Cil______x______
Patient 1 ["OD","OE","AO"]
OE Esf______Cil______x______ Esf______Cil______x______

OD Esf______Cil______x______ Esf______Cil______x______
Patient 2 OD|OE|AO
OE Esf______Cil______x______ Esf______Cil______x______

OD Esf______Cil______x______ Esf______Cil______x______
Patient 3 OD|OE|AO
OE Esf______Cil______x______ Esf______Cil______x______

OD Esf______Cil______x______ Esf______Cil______x______
Patient 4 OD|OE|AO
OE Esf______Cil______x______ Esf______Cil______x______

João Linhares — jlinhares@fi[Link] 11

 1490 [Link] Way
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[Link]

RadiusConversionTable
DIOPTER M.M. DIOPTER M.M. DIOPTER M.M. DIOPTER M.M. DIOPTER M.M.

20.00 16.875 38.75 8.708 44.12 7.649 49.37 6.836 54.62 6.179
22.00 15.340 38.87 8.682 44.25 7.627 49.50 6.818 54.75 6.164
24.00 14.062 39.00 8.653 44.37 7.606 49.62 6.801 54.87 6.150
26.00 12.980 39.12 8.627 44.50 7.584 49.75 6.783 55.00 6.136
27.00 12.580 39.25 8.598 44.62 7.563 49.87 6.767 55.12 6.123
28.00 12.580 39.37 8.572 44.75 7.541 50.00 6.750 55.25 6.101
29.00 11.638 39.50 8.544 44.87 7.521 50.12 6.733 55.37 6.095
29.50 11.441 39.62 8.518 45.00 7.500 50.25 6.716 55.50 6.081
30.00 11.250 39.75 8.490 45.12 7.480 50.37 6.700 55.62 6.068
30.50 11.065 39.87 8.465 45.25 7.458 50.50 6.683 55.75 6.054
31.00 10.887 40.00 8.437 45.37 7.438 50.62 6.667 55.87 6.041
31.50 10.714 40.12 8.412 45.50 7.417 50.75 6.650 56.00 6.027
32.00 10.547 40.25 8.385 45.62 7.398 50.87 6.634 56.50 5.973
32.50 10.383 40.37 8.360 45.75 7.377 51.00 6.617 57.00 5.921
33.00 10.227 40.50 8.333 45.87 7.357 51.12 6.602 57.50 5.869
33.50 10.075 40.62 8.308 46.00 7.336 51.25 6.585 58.00 5.819
34.00 9.926 40.75 8.282 46.12 7.317 51.37 6.569 58.50 5.769
34.50 9.783 40.87 8.257 46.25 7.300 51.50 6.553 59.00 5.720
35.00 9.643 41.00 8.231 46.37 7.280 51.62 6.538 59.50 5.672
35.50 9.507 41.12 8.207 46.50 7.258 51.75 5.621 60.00 5.625
36.00 9.375 41.25 8.181 46.62 7.239 51.87 6.506 60.50 5.578
36.12 9.343 41.37 8.158 46.75 7.219 52.00 6.490 61.00 5.533
36.25 9.310 41.50 8.132 46.87 7.200 52.12 6.475 61.50 5.488
36.37 9.279 41.62 8.109 47.00 7.180 52.25 6.459 62.00 5.443
36.50 9.246 41.75 8.083 47.12 7.162 52.37 6.444 62.50 5.400
36.62 9.216 42.00 8.035 47.25 7.142 52.50 6.428 63.00 5.357
36.75 9.183 42.12 8.012 47.37 7.124 52.62 6.413 63.50 5.315
36.87 9.153 42.25 7.988 47.50 7.105 52.75 6.398 64.00 5.273
37.00 9.121 42.37 7.965 47.62 7.087 52.87 6.383 65.00 5.192
37.12 9.092 42.50 7.941 47.75 7.068 53.00 6.367 66.00 5.114
37.25 9.060 42.62 7.918 47.87 7.050 53.12 6.353 67.00 5.037
37.37 9.031 42.75 7.894 48.00 7.031 53.25 6.338 68.00 4.963
37.50 9.000 42.87 7.872 48.12 7.013 53.37 6.323
37.62 8.971 43.00 7.848 48.25 6.994 53.50 6.303
37.75 8.940 43.12 7.826 48.37 6.977 53.62 6.294
37.87 8.912 43.25 7.803 48.50 6.958 53.75 6.279
38.00 8.881 43.37 7.784 48.62 6.941 53.87 6.265
38.12 8.853 43.50 7.758 48.75 6.923 54.00 6.250
38.25 8.823 43.62 7.737 48.87 6.906 54.12 6.236
38.37 8.795 43.75 7.714 49.00 6.887 54.25 6.221
38.50 8.766 43.87 7.693 49.12 6.870 54.37 6.207
38.62 8.738 44.00 7.670 49.25 6.852 54.50 6.192