1. OPTO 4101: Refraction1 Subjective verification for refraction
MSc Mohammed A.M Aljarousha
Department of Optometry
Faculty of Allied Health Sciences
Islamic University-Gaza

2. Verification for spherical power

3. Duochrome test

4. Typical wavelength of colors VIBGYOR
Wavelength/ nanometer
Color
410
Violet
450
Indigo
550
Blue
570
Green
580
Yellow
610
Orange
660
Red

5. Duochrome test
The index of refraction varies for different wavelengths of light.
The index of refraction is greater for short wavelength light rays than for longer ones.
Green light is refracted to greater degree than yellow light, which is refracted to a greater degree than red light, and so on.
Incoming rays of white light are dispersed, with blue refracted to a greater degree than red.
In an emmetropic eye, therefore, yellow light is focused on the retina, green light is focused anterior to the retina, and red light is focused posterior to the retina.
In myopic eye, red is closer to the retina, while in hypermetropic eye green is closer.
If the red green test is used and the patient is myopic and insufficiently corrected , then the letters on the red side will stand out blacker, clearer and sharper. They will require more minus power for the green to be as distinct as the red.

7. On the other hand if the same myope is overcorrected and made artificially hypermetropic, then the letter against the green background appear blacker, clearer and sharper.
The sphere is adjusted until letters on both sides are of equal quality.
Duochrome test is useful only in refining spherical power, contributing nothing to the determination of cylinder power or axis.

8. 2. Trial and error
This method is simply adding +0.25Ds and -0.25Ds in a monocular fashion and asking the patient if the vision is better or worse:
If the patient report that it is better without any lens, then he is emmetrope, and his refractions is correct.
If the patient report that it is better in adding the +0.25Ds, continue adding plus until no further improvement is achieved. Then add the new addition power for his previous prescription.
If the patient responds that vision is worse, remove +0.25Ds or prepare to add -0.25Ds; ask the patient if the letters are sharper and clearer or not?
If it is better, continue adding minus until no further improvement is achieved, and then add the new addition power for his previous prescription.
- This method of verification completely depends on patient’s answers, so the accuracy will be determined according to the patient observations.

9. 3. Pinhole
The pinhole lens is a lens that has a hole in the center of lens, this hole has the effect of reducing the width of the bundle of diverging rays (called a ‘‘pencil of light’’) coming from each point on the viewed object.
Normally, the full opening of the pupil admits light.
It is the improper bending of the outermost rays in that pencil of light which causes refractive errors such as myopia, hyperopia, presbyopia and astigmatism to be noticeable.
Pinhole can brings about clearer vision in all these conditions.
By blocking these peripheral rays, and only lettering into the eye those rays which pass through the central portion of the pupil, any refractive error in the lens or cornea is not noticed as much.
The pupil may be wide open, but only the central portion is receiving light. The improvement in visual acuity can be striking.
So if the vision is improved when looking through the pinhole lens, that’s mean the prescription is not accurate, not completely correct and then verification is necessary to be done.

10. Verification for cylindrical power ‘‘astigmatism’’

11. 1. Astigmatic fan
It is used to verify the axis of trial cylinder lens.
On looking at such fan if any of the lines are seen more clearly than the others astigmatism must be present.
If the vertical line is clear more than the horizontal meridian it is the less emmetropic one (has the defect). (Inverse relation).
more clear line = less emmetropic.
Less clear line = more emmetropic.
A cylinder lens is placed in front of the eye with its axis horizontal will correct the vertical meridian and when the correct glass power is to be worn all the lines of the astigmatic fan appear equally distinct.
The cylinder which thus renders the outline of the whole lines equally clear is the amount of astigmatism and the axis of the cylinder is at right angle to the line which was initially seen most clearly (less emmetropic) according to the sign of the cylinder lens.

12. 2. Staenopic slit
It is essentially an accessory in the trial set that consists of an elongated pin hole aperture as a slit cut in an opaque disc, used to detect the axis of astigmatism if present.
When put before the eye it allows only rays of light in a particular meridian to enter the eye.
If the slit is placed horizontal before the eye the vertical meridian is pin holed and produces a point image.
After correction of any spherical ammetropia all meridians in 360 degree can be seen equally on rotating the staenopic slit.
In presence of a high astigmatism and before correction , the staenopic slit can detect the axis of correcting cylinder if it's properly positioned.
The slit is sometime useful in determining the astigmatism when other devises are unsatisfactory.
When the image is equally clear in 360 degree in presence of the slit no astigmatism is present , all lines are equally clear.

13. N.B. The main difference between the stenopic slit and astigmatic fan is the slit of this device detect the less ametropia or the emmtropic meridian (has the defect) and the axis of the correcting cylinder lens is put on this meridian (at zero power).
Ametropia= more clear
Ametropia= less clear

14. 3. Rotation of dial screw
It is simply done by asking the patient to rotate the screw of the trial frame to rotate the cylindrical lens in the trial frame, the patient will rotate the screw until he see the best clear image.
At this point the rotation is stopped, and we can determine the accurate axis of the cylindrical lens.