Retinoscopy is an objective method for determining the refractive error of an eye.

It's a
fundamental skill for optometrists, ophthalmologists, and opticians. Here's a breakdown of key
retinoscopy notes, covering principles, procedure, interpretation, and common considerations:

Retinoscopy Notes
I. Principles
●​ Neutralization: The goal of retinoscopy is to find the point where the light reflex from the
patient's retina neutralizes, meaning it fills the pupil completely and moves neither with
nor against the retinoscope's movement. This indicates that the light rays exiting the
patient's eye are parallel at the plane of the retinoscope.
●​ Working Distance: A known working distance (e.g., 50 cm, 67 cm) is used to create an
artificial far point. The lens power needed to neutralize the reflex at this distance is then
adjusted to determine the patient's true refractive error.
●​ Types of Reflexes:
○​ "With" Movement: The light reflex moves in the same direction as the
retinoscope's sweep. This indicates hyperopia or under-corrected myopia.
○​ "Against" Movement: The light reflex moves in the opposite direction to the
retinoscope's sweep. This indicates myopia (over-corrected or significant).
○​ Neutralization: The reflex fills the pupil and appears bright and quick, showing no
discernible movement.
○​ Scissors Movement: Two bands of light moving in opposite directions, often seen
in irregular astigmatism or keratoconus.
○​ Dull/Faint Reflex: Indicates high refractive error (either hyperopia or myopia) or
media opacities.

II. Equipment
●​ Retinoscope:
○​ Streak Retinoscope: Most commonly used, produces a streak of light. Allows for
easier identification of astigmatism and axis.
○​ Spot Retinoscope: Produces a spot of light. Less common for routine refractions.
●​ Trial Frame or Phoropter: To hold trial lenses.
●​ Trial Lens Set: Spherical and cylindrical lenses.
●​ Fixation Target: Accommodative target (e.g., distant letter chart, picture) to ensure the
patient is fixating for distance. For children, a non-accommodative target can be used.

III. Procedure (Streak Retinoscopy)

1.​ Preparation:
○​ Darken the Room: Essential for clear visualization of the reflex.
○​ Patient Position: Comfortable, looking straight ahead at a distant,
non-accommodative target.
○​ Retinoscopist Position: Maintain a consistent working distance (e.g., 50 cm for
+2.00 D compensation, 67 cm for +1.50 D compensation).
2.​ Starting Point:
 ○​ Start with a low plus sphere (e.g., +1.00 D or +1.50 D) in the trial frame to relax
accommodation, especially in younger patients.
○​ For highly myopic patients, a minus lens might be needed initially to obtain a clear
reflex.
3.​ Determining Sphere (Rough Estimate):
○​ Shine the retinoscope light into the patient's pupil.
○​ Observe the "with" or "against" movement of the reflex.
○​ If "with" movement: Add plus sphere lenses until the reflex becomes neutral.
○​ If "against" movement: Add minus sphere lenses until the reflex becomes neutral.
○​ This initial step helps approximate the spherical component.
4.​ Detecting Astigmatism:
○​ Rotate the retinoscope streak 360 degrees.
○​ If the reflex appears as a single, consistent band regardless of streak orientation,
there is likely no significant astigmatism.
○​ If the reflex appears wider or narrower, or if the movement varies significantly in
different meridians, astigmatism is present.
○​ Identifying Principal Meridians: The brightest, narrowest, and most distinct reflex
will be seen when the retinoscope streak is aligned with one of the principal
meridians. The other principal meridian will be 90 degrees away.
5.​ Neutralizing Astigmatism:
○​ Step 1: Neutralize the First Meridian: Align the retinoscope streak with the first
principal meridian (e.g., the one showing the "with" movement with the most speed,
or the slowest "against" movement). Add spherical lenses until neutralization is
achieved in this meridian. Note the power.
○​ Step 2: Neutralize the Second Meridian: Rotate the retinoscope streak 90
degrees to align with the second principal meridian. Add plus cylinder lenses
(starting with the axis aligned with the second meridian) until neutralization is
achieved in this meridian.
■​ Alternatively (More Common): Once the first meridian is neutralized with
sphere, continue to add sphere until the other meridian also shows a "with"
movement. Then, add minus cylinder with the axis aligned with the first
neutralized meridian until the "with" movement in the second meridian is
neutralized.
■​ Important: Always keep adding lenses until both principal meridians are
neutralized.
6.​ Confirmation (Slight "With" Movement):
○​ Once neutralization is achieved, slightly remove the last lens added. You should
see a very slight "with" movement. This confirms you've accurately reached
neutralization.
7.​ Subtracting Working Distance:
○​ Once the eye is neutralized at the working distance, subtract the working distance
power from the total spherical power in the trial frame.
○​ Example:
■​ Working distance = 67 cm (+1.50 D)
■​ Neutralization achieved with +3.00 D sphere in trial frame.
■​ Patient's sphere = +3.00 D - 1.50 D = +1.50 D.
○​ For cylinder: The cylinder power and axis determined during retinoscopy are
typically the patient's full cylinder.
IV. Interpretation and Calculation
●​ Spherical Equivalent: (Sphere + Cylinder/2) - Working Distance
●​ Final Prescription:
○​ Sphere: Calculated by subtracting the working distance from the spherical power at
neutralization.
○​ Cylinder: The cylindrical power used to neutralize astigmatism.
○​ Axis: The axis of the cylinder, as determined during retinoscopy.

V. Common Considerations and Tips

●​ Accommodation Control: This is the most critical aspect, especially in children and
young adults.
○​ Use a distant, non-accommodative target.
○​ Fog the non-refracted eye.
○​ Use cycloplegic drops (e.g., cyclopentolate) for highly accommodative or
uncooperative patients, especially children.
●​ Working Distance: Maintain a consistent working distance throughout the procedure.
●​ Miosis/Mydriasis: Small pupils can make retinoscopy difficult. Dilated pupils can reveal
aberrations.
●​ Media Opacities: Cataracts, corneal scars, or vitreous opacities can distort or obscure
the reflex.
●​ Off-Axis Retinoscopy: Avoid looking through the periphery of the pupil, as this can
induce spherical aberration.
●​ Scissors Movement: Often indicates irregular astigmatism. Focus on neutralizing the
most prominent band.
●​ Patient Cooperation: Explain the process to the patient to ensure they remain still and
fixate properly.
●​ Validation with Subjective Refraction: Retinoscopy provides an objective starting point.
Always follow up with subjective refinement (Phoropter or Trial Frame refraction) to
fine-tune the prescription based on the patient's visual perception.
●​ Head Tilt: Ensure the patient's head is straight to avoid inducing apparent astigmatism.
●​ Understanding the "Rule of Thumb":
○​ If the reflex is bright, fast, and wide: Closer to neutralization.
○​ If the reflex is dull, slow, and narrow: Further from neutralization (high refractive
error).
●​ Practice, Practice, Practice: Retinoscopy is a skill that improves significantly with
practice.
By understanding these principles, procedures, and considerations, you can perform accurate
retinoscopy and confidently determine a patient's objective refractive error.