7/7/17
REFRACTION
BRACKETING Required before testing vision capabilities
SUBJECTIVE REFRACTION TECHNIQUES Visual acuity
FOR VISUALLY IMPAIRED PATIENTS Contrast Sensitivity
Visual Fields
Reading Performance
and performance at may ADL tasks
Low vision patients can be less sensitive to refractive changes
Many clinicians use larger steps of power
Ian L Bailey, OD, MS, DSc(hc), FCOptom, FAAO based on the patient’s visual acuity.
School of Optometry
University of California, Berkeley,
CA 94720-2020
They assume a “JND” = Just Noticeable Difference
Commonly JND = MAR/10 (20/200, 6/60, 0.10 JND =1.00D)
[email protected]
Consider bracke?ng with +/- 8D
THE FUNDAMENTALS OF BRACKETING begin with best es+mate of spherical refrac+on in place
0
BEGIN PaYent looks at chart
Embrace “ look at some of the smallest leWers that you can see”
Things are beWer between the two limits INTRODUCE +8D MUST BECOME BLURRED
Does this lens make it .... blurred? “Better” or “No difference”
BOTH limiYng lenses should be rejected
+8 .... beWer?
.... not much difference?
means no bracketing
How blurred? Terribly blurred
Definitely blurred
DifferenYal responses
A little blurred
“Shades of Certainty” judged by response speed, tone, or words DIFFERENCE
Better Much better
SWITCH to -8D
Depend on paYent’s discriminaYon abiliYes Definitely better
and size of differences between comparisons -8 Does this make it .... more blurred?
.... less blurred?
A little better
Worse Much worse
Encourage - descripEons and comments .... not much difference? Definitely worse
A little worse
Discourage - simple binary choices (do not ask ‘beLer 1 or 2?’) No difference
MUST BECOME BETTER
U C B Progressively reduce size of bracket 0 U C B
REMOVE -8D
Does this make it .... more blurred?
“Worse” or “No difference”
means no bracketing
From each brackeYng, esYmate the final answer. .... less blurred? Better Much better
Optometry The next bracket should embrace your current best esYmate of the answer Optometry
.... not much difference? Definitely better
A little better
Bracke?ng with +/- 8D 2D myopia
Bracke?ng with +/- 8D
Bracketing with +/-8D
Bracketing with +/-8D
16 16
Blurred Blurred
-2D Myope 14 14
+3D hyperope
DEFOCUS (absolute)
DEFOCUS (absolute)
12 12 -8
1. INTRODUCE +8D 1. INTRODUCE+8D
Blurred by 10D Blurred by 5D
10 +8 10
2. SWITCH to -8D 2. SWITCH to -8D
Blurred by 6D 8 8 Blurred by 11D
6 -8 6 +8
3. REMOVE -8 3. REMOVE -8D
becomes Plano becomes Plano
2D defocus 4 4 3D defocus
2 no lens 2
Clear 0
-8 -6 -4 -2 0 2 4 6 8
Clear 0
-8 -6 -4 -2 0 2 4 6 8
REFRACTIVE ERROR REFRACTIVE ERROR
U C B U C B
Optometry Optometry
1
7/7/17
TIGHTER BRACKETS ASTIGMATISM
Jackson Crossed Cylinder
Add best esYmate/guess of sphere afer ±8.00D bracket
Typically JCC of ±0.50D
Use leWers close to VA threshold on leWer chart
NEXT: smaller bracket EsYmate Axis Flip at 90°/180° then flip at 135°/45°
Typically ±3.50D bracket
Adjust spherical correcEon to best esEmate EsYmate Power
Introduce -1.50D cyl at esYmated axis
More cyl or Less cyl along esYmated axis
NEXT: smaller bracket Refine cyl axis
Typically ±1.25D bracket Refine sphere power
Refine cyl power
Adjust spherical correcEon to best esEmate
Refine sphere power
Refine cyl power
EsYmate axis 90 or 180?
- #1 #2
EsYmate power
of cyl
-1.50D #1
+
-#2
+
+
+
-
-
+ +
-
-
-
+
+
Typically 2 flips Perhaps....... #2 is a bit better Perhaps.... #1 is a bit better
Typically begin
only I think " slightly with the rule???" I think " a little more than -1.50D"
with -1.50D
90°/180°
45°/135°
45 or 135?
#1 #2
of cyl along
esYmated axis
-3.00D #1
+
-#2
-
+
-
+
+ -
-
+
-
+
-
+
Ah Ha #2 is better
#2 is much better
I think " Oblique astigmatism !! about 135"
I think " much closer to -1.50D than -3.00D "
Best estimate axis = 145 My estimate -2.00 x 145
SUBJECTIVE REFRACTION
Thank you!
ESTIMATE SPHERE (brackets ±8.00D, ±3.50D, ±1.25D)
Then ESTIMATE CYL AXIS (Two flips 90°/180 at 135°/45°)
and ESTIMATE CYL POWER (begin with -1.50D
at esYmated axis)
Refine Sphere
Then Refine Cyl Axis
and Refine Cyl Power
Ian Bailey
Fine-tune Sphere [email protected]
Fine-tune Cyl Power
