Raúl Martín Herranz Optometry I Subjective Refraction Methods

Subjective Refraction Methods

Specific Objectives of the Topic
At the end of the topic, the student will be able to:

1. Identify when the loss of AV may be a consequence of an error of

refraction using the pinhole camera.

2. Differentiate between subjective refraction and objective refraction.

3. Identify when or in which types of patients it is most indicated to use the glasses of
tests or the phoropter to perform refraction. Describing its main features
characteristics.

4. Describe, step by step, the procedure necessary to perform refraction in a

a subject with a refractive defect, whether it is myopia or hyperopia,
astigmatism, presbyopia or their possible combinations, using the following
tests

4.1. Monocular subjective distance.

4.2. Duochrome test.
4.3. Donders Method.
4.4. Test schedule.
4.5. Jackson's crossed cylinders test.
4.6. Meridional Refraction.
4.7. Distant binocular subjective.
4.8. Binocular balance.
4.9. Near monocular subjective (crossed cylinders or trial method).
4.10. Subjective binocular near (crossed cylinders or trial method).

5. Decide, based on the results of the refraction, whether it is indicated to prescribe or

modify the patient's previous refraction, whether they are emmetropic, myopic,
farsighted, astigmatic, or presbyopic. Without taking into account the sensory state and the
Binocular vision of the patient (will be the subject of the next academic course).

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Introduction
Refraction can be defined as the process by which one manages to conjugate the
retina with the optical infinity with the help of lenses placed in front of the eye.

Subjective refraction is understood as the technique that consists of comparing the visual acuity that
it provokes one lens in relation to another, using as a criterion the changes in vision that
they produce. Their goal is to achieve the combination of lenses that provide the maximum
AV. Since the final result depends on the patient's subjective response, it is possible
that does not correspond with the real refractive value of the eye.

For a certain patient, it is possible to find 200,000 combinations.

Possible spherocylindricals, it is the optometrist's obligation to define which is the most suitable.
based on the quality of vision (AV) and the visual performance they provide to
patient (binocular and accommodative balance).

To define refraction, a series of techniques is indicated among which

they stand out; objective refraction, monocular subjective, binocular subjective,
accommodative balance (binocular equilibrium) and fogging. In patients who do not
present binocular vision (strabismus, amblyopia, suppression) subjective refraction
it may be enough.

The first stage of subjective refraction depends on the level of vision obtained by the
patient when measuring the VA. It is necessary to note the VA without correction for each eye, occlude
one of them and perform monocular refraction under normal lighting conditions
to maintain the conditions most similar to the use of correction. Exceptionally
refraction can be performed in twilight or darkness when the glasses are going to
to use in such specific conditions.

Subjective refraction may begin with the result of retinoscopy (or of

autorefraction meter or the prescription of the patient's glasses) although in the event of not
mastering this technique may indicate starting the refraction, either from scratch or only
with the spherical component found in retinoscopy. In this way, the
time required to perform the refraction and avoid errors.

Decreased Vision. Pinhole Test.

In a patient with reduced AV, the pinhole opening increases depth of
focus and reduce the blurriness of the retinal image, in this way if there is no
organic alteration of the ocular structures (ocular media, retina, and visual pathways)
the AV has to increase with its use.

Its use is indicated when the visual acuity without correction, also called spontaneous, of
the patient is less than 0.6, although there are different criteria according to the authors.

In the case of a patient with low visual acuity without correction (less than 0.1), it can be assumed that if
The visual acuity improves with the use of the pinhole, the refractive defect may be less.
from 7.00DP while if it does not improve with pinhole the ametropia will be greater than

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

5.00DP will present some type of associated pathology. During refraction, it has to
achieve and even surpass the VA obtained with the pinhole.

If a patient shows an AVsc of 0.2 and reaches with the pinhole.

an AV of 0.8 (VE) with refraction will have to reach an AV equal to or
greater than 0.8 otherwise there will have been some error in the refraction.

The value of the lenses to be used in the refraction process will depend on the visual acuity and
patient sensitivity, thus in very reduced AV changes of 0.50 DP may not be
appreciated by the patient, indicating to increase the lens power to 1.00,
2.00 or even 3.00 DP to be able to start the refraction. As the lens does
close to the patient's refraction it may be necessary to reduce the power of the
lenses, to refine the final result.

General Guide for the Prescription of Glasses

A series of 'rules' can be defined to take into account when carrying out the
optical prescription, whether for the first time or when the patient's refractive defect
has been modified. These can be summarized as:

• Do not prescribe small changes, less than 0.25DP.

• Specify the distance to the vertex in powers greater than 5.00DP.
• Try to avoid changes in the axis of the cylinder greater than 10º. If the change
It is necessary to test the new prescription beforehand on the trial glasses.
for 20-30 minutes to assess the patient's response.
• In the case of doubtful refractions, ALWAYS test the new prescription.
in the test gauge to assess the patient's response. It is also
necessary when there are important changes in refraction.
• Check the recipe, errors in transcribing the data are very common.
to the paper.
• The use of cycloplegic eye drops to paralyze accommodation is
especially useful when performing refraction especially in children and patients
young people.

Regarding the lamination, it should be noted that:

• In myopic patients, hypercorrection should be prevented when accommodating the...

The patient may state that the letters appear darker and smaller.
• In myopic patients over 40 years old, it is necessary to check that the
Distance prescription does not produce symptoms of presbyopia. Verify that
they can read comfortably.

Regarding hyperopia, it is important to keep in mind that:

• In hyperopic children over 3.00D; children with anisometropia

greater than 1.00DP especially if it causes a decrease in VA, children with
presence of convergent strabismus (esotropias) and in cases where it
improve the AV with the correction, always prescribe glasses. In some
in cases where the objective of refraction is not to achieve good quality of
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Raúl Martín Herranz Optometry I Subjective Refraction Methods

vision, but what is intended is to restore sensory balance

motor, in this case it refers to therapeutic refraction, one example could be
is the refraction in accommodative convergent strabismus, in which
compensates for the total hyperopia to correct strabismus.
• In adult hyperopes, it is advisable to assess the prescription for distance.
Uncorrected visual acuity from a distance, corrected visual acuity, and comfort in vision
next.

Regarding astigmatism, it is important to keep in mind that:

• In children under 4 years old with astigmatism greater than 1.00D the
glasses are indicated (therapeutic effect).
• Changes in astigmatism or its prescription for the first time may
cause distorted vision and problems when calculating distances. In
adult patients these variations can hinder the normal use of the
glasses.
• Inform the patient that to adjust to the new refraction they may need
certain period of time, this may also be necessary with changes
large in spherical value.

Regarding presbyopia, it is important to keep in mind that:

• In presbyopic patients, minor additions are rarely justified.

0.75DP.
• That the use of certain drugs (barbiturates, tricyclic antidepressants,
antihistamines and decongestants) can increase the symptoms of
presbyopia.
• Nearsighted patients with less than 3.00 diopters can read without taking off their glasses.
problems for which it is necessary to know their reading habits and distance
before prescribing a bi or multifocal.

Optical Considerations
Pantoscopic Angle: The glasses have a tilt between the plane of the lens
corrector and the viewing plan of between 5º and 10º. This angle ensures the adjustment of the
rotation of the eye around the optical axis of the lens in order to avoid problems in the
adaptation such as the effects of oblique astigmatisms.

Schematic representation of the test glasses

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Pupillary Distance (P.D.): In 90% of adults, the P.D. ranges from 60 to 68mm.
Normally the nose is equidistant from
both pupils but they can exist
asymmetries that need to be valued at
mount the glasses, especially in
high ametropias. Decentrations in
lenses over 4.00D can
provoke prismatic effects that affect
the binocular vision of the patient (Law of
prentice).
Measurement of the D.I.P.

Introduction to the Phoropter

The phoropter is a complex design of trial lenses that helps streamline the process of
refraction and conduct the study of binocular vision. All the processes that are carried out
a phoropter can be used with a trial frame and the appropriate accessories.

In the case of young children or individuals with disabilities, the phoropter will not be indicated.
that does not allow seeing the patient's face, preventing the detection of the "traps"
(wink or look with both eyes at the same time) that the patient can do to
falsify the exploration.

It may pose the drawback of inducing more instrumental or proximal accommodation.

that the trial frame. However, it has the advantages of allowing a refraction
faster and more convenient, both when checking the spherical or cylindrical component (axis and
power) and allow for the study of binocular vision (measurement of phorias and
capacity for convergence and divergence.

They generally consist of the following parts:

Lens control.

It consists of three groups of lenses, one for spherical lenses, another for plano-
cylindrical and a last control with auxiliary lenses.

• Control of Spherical Lenses: It is made up of two wheels of spherical lenses.

(one for each eye) that can range from the±20:00 or±30:00DP in steps of
0.25DP. It generally consists of two lens passing systems, one that
allows passing lenses of 0.25DP in 0.25DP and another that allows doing it in steps
of 3.00 DP. Negative lenses are usually represented in red and the
positive in black or white.

• Cylinder Control: The phoropter consists of two wheels of plano lenses.

cylindrical (one for each eye) in which its value can be modified
dioptric as the orientation of the axis in 360º. The range of dioptric power is
very variable from one model to another, being advisable that it reaches a minimum
from 6.00DP in steps of 0.25DP. In European phoropters, it is common

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find negative cylinders but in the US there are also cylinders

positives.

• Auxiliary lens control: Each opening through which the patient will maintain their
mirada has a panel of lenses and accessories that allow for different
positions. The most common ones to find are the opening or open (Open),
closed or occluded (Occluded oBlank), the retinoscopy lens of +1.50 or
+2.00DP (R), the crossed cylinders of±0.50DP also called Jackson
(±.50), a pinhole (PHpin hole), a red filter (RLRed Lens) and
a green one (GLGreen Lens) normally the red comes in the right opening and
the green on the left, a vertical Maddox rod (RMV in the case of
red rods and they are white) in one eye and horizontal in the other (RMH
red rods and white YWMHsi, a polarized filter (P), and prisms
verticals and horizontals (6-10∇).

Schematic diagram of a phoropter

2. Auxiliary Units.

The phoropter has two or three auxiliary units that can be presented.
in front of the eye when necessary.

• Jackson Crossed Cylinder Unit (CC) (see below). The cylinder

negative is marked with a red dot while the positive is marked with a
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Raúl Martín Herranz Optometry I Subjective Refraction Methods

white point. It is advisable that they are synchronized with the control of the axis of
cylinder. It is used to check the axis and cylindrical power.

• Diasporometer Unit or Risley rotating prism. This system allows

introducing prisms with variable power and orientation according to the needs of
test or trial being conducted. They are useful in the quantitative measure of the
forias (Von Graefe method) and the capacities of convergence and divergence
of the patient.

• Maddox rod. This option is present when they do not appear in the
Maddox rods are special lenses.
formed by small cylinders with the particularity that the image that
They form a luminous point as a straight line. They are useful for study and
classification of the phorias.

3. Adjustment Controls.

The phoropter contains different controls to allow for an adequate position of the
patient during the examination. With them, the interpupillary distance can be adjusted.
(DIP), the inclination of the instrument, the control of the distance to the vertex, the
pantoscopic tilt and the convergence of the visual axes.

When using the phoropter, the patient is positioned approximately 16mm from the lenses instead
of the 12mm accepted in the use of the trial frame, this difference in distance to
it is advisable to test the final refraction in the trial lens to verify the
Refractive outcome. This maneuver is particularly interesting in ametropias.
elevated above 4.00DP, there are also distometry tables to carry out these
calculations.

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Subjective Monocular Distant

It is accepted that prior to the execution of any monocular refraction method
the patient must be positioned correctly and comfortably, whether with the glasses of
tests or with the phoropter. An interesting rule to avoid mistakes could be to start
refraction always in the same eye, it is traditionally recommended to start with the
right eye, excluding the left.

The objective of subjective refraction is to achieve the combination of spherical lenses.

more positive (or less negative) cylindrical lenses that provide the maximum AV and
patient comfort.

Procedure:

1Starting point. Place the result of the retinoscopy (autorefraction or

previous graduation) in the phoropter or test glasses. You can start from the value
spherical of retinoscopy (removing the cylindrical value) or without any lens.
Introduce positive spherical lenses for hyperopes and negative for myopes.
steps of 0.25D if using the phoropter and 0.50D if using the trial frame.
In this last case, Freeman's torsion spheres are especially useful.
that consist of two spheres of±0.25 or±0.50 DP.
2 Control of Accommodation. To avoid stimulating accommodation, it is
It is indicated to increase the spherical value by +0.75 or +1.00 DP (fogging) at the start.
refraction, especially if starting with the value of refraction
objective.
Spherical Correction. It can be done in different ways, one of the most
used when using the trial frame is the method of torsion spheres of
Freeman. It consists of showing a positive sphere, allowing some to pass through.
seconds (2”-3”), turn the lens and show the negative sphere of it.
power, asking the patient in which position they see better or more clearly.
Depending on whether it is seen better in positives or negatives, the spherical value will increase.
address. If Freeman's spheres are not available, this can be done
step comfortably and quickly holding both lenses of the test box in
a hand and placing them on the line of sight without attaching them to the glasses of
tests. When using a phoropter, it is advisable to use Donders' method or
increase spherical power in steps of 0.25 or 0.50 D by asking, in
each change, if it improves the AV.
Cylindrical Correction. The ideal is to increase the spherical power until reaching
the AV 1.0. If astigmatism is not achieved or the presence of astigmatism is suspected
perform the circle clock test. An interesting maneuver is to project the test.
from the hourly circle upon reaching the AV of 0.5 or 0.6 to detect the presence of
cylindrical component. In case it exists, identify its orientation (rule
of 30) and its power (lens with which the patient sees all the lines
approximately equally black). After this, it is indicated to check the axis and the
power with the Jackson Cross Cylinder. The meridional refraction can
to be especially indicated in low visual acuity.

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Even if an AV 1.0 is achieved, it may also be necessary to perform the Test of

Clockwise circle to verify the existence of uncorrected astigmatism and
to be focusing on the retina the circle of least diffusion of the Sturm's Conoid
this is known as Spherical Equivalent.
The Spherical Equivalent (SE) is the spherical refraction that conjugates the retina.
with the circle of least diffusion of the Sturm Conoid. It is calculated by summing
algebraically half of the cylinder to the sphere.
For example: -5.50 Sph –2.00 Cyl 90º its Spherical Equivalent is –6.50 Sph.
+3.75 Sphere –2.00 Cylinder 75º its Spherical Equivalent is +2.75 Sphere.

Most authors agree in highlighting that the objective of the subjective

Monocular is correcting astigmatism with the smallest cylindrical lens.
power.
Spherical Equalization. This maneuver is performed to avoid accommodation.
It is done using the techniques of binocular balance. The bichromatic test is also useful.
Oh Red-Green.
6Binocular Subjective. The refraction concludes with the binocular subjective that will
provide the most positive lens (least negative) that provides the
maximum AV in binocular conditions.
Duochrome Test or Red-Green

The purpose of this test is to determine the spherical power that corrects the ametropia of
patient. The red-green filter consists of a filter projected onto the screen of the
optotypes, dividing it vertically into two halves, one red and the other green.
This filter allows projecting different AV lines simultaneously.

It can be used for different purposes, such as an initial test to differentiate between a
myopic patient and a hyperopic patient, to fine-tune or adjust the spherical power after the
monocular subjective and to equalize the accommodation stimulus between both eyes.

Duocromo Test As Initial Test.

Procedure:

1 Place the red green filter over the optotype of best visual acuity.
Ask the patient to look at the green side and then at the red and indicate which letters.
they appear clearer or if both sides are seen with the same clarity.
In the case of seeing the letters better on the red side, the patient will be myopic.
Introduce negative lenses in steps of 0.25D until the patient notices.
both sides with the same clarity. With each new lens, it is necessary to ask
if both sides have been equalized.
In the case of seeing the green side better, the patient will be farsighted.
it is indicated to introduce positive lenses, until achieving unit visual acuity.

Refraction will be achieved when the patient sees equally sharp.

letters on both sides of the test.
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6 Close the right eye, open the left one and repeat steps 1-5.

This test is useful in patients with color vision abnormalities as it is based on the
principle of chromatic aberration of the eye. It is not a test that allows correction of the
astigmatism.

Some patients do not respond to this test because they always see one side clearer.
Regardless of the lenses that are used, if this happens, other ones will be resorted to.
subjective tests.

2. Duochrome Test to Adjust Refraction.

Once the subjective refraction is obtained, the red-green test is projected onto the
maximum AV line.
2 Follow the methodology from point 1 to 5 in the procedure as Test
Initial.
3. Duochrome Test to Match the Accommodation Stimulus.

1 Perform this test if at the end of the refraction both eyes have different visual acuity or
Is there any reason to believe that the accommodation is different between the two?
eyes.
Uncover both eyes.
Project the red-green test onto the maximum AV line seen by the worst eye.
4 Place a vertical prism of 3-4 ∆ upper base in one eye (right) and another
of equal power but lower base in the other eye. The goal is to produce
diplopia.
5 Ask the patient to look at the line below and indicate if both sides, the red
and the green, look just as sharp.
If the letters on the red side appear sharper, add negative lenses and if it is
the green side add positives in steps of 0.25 DP to the value of the sphere in the
explored eye (lower right, upper left).
7 Ask to focus on the letters above and repeat the steps from 5 to 6.
8 Repeat steps 5-7 until the visual sharpness of both is maximized.
eyes.

Donders' Method

The purpose of this test is to determine the spherical power that corrects the ametropia of
patient. It basically consists of introducing spherical lenses until reaching the
maximum AV of the patient.

Procedure:

1 In the case of a myope, introduce negative lenses in increments of 0.25D or

0.50DP until reaching unit AV. If the patient were hyperopic, introduce
positive lenses.
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2 Uncover the left eye, occlude the right one, and repeat the process.

A variant of this method, more useful for preventing patient accommodation, consists of
in the execution of the test called FOGGING or mist. There are different
modifications of this technique depending on the authors, but the classic technique consists
basically in the following steps:

1 Pupil dilate the patient by placing a positive lens of +3.00 or +4.00 DP.
in a way that causes an AV of 0.1 or lower.
2 Project a low visual acuity optotype (0.05 or 0.1).
Gradually decrease the power of the positive lens, based on the
increase in the patient's visual acuity, until the patient reaches the necessary visual acuity
to perform astigmatic discrimination (Clock Test), in the range of 0.5 to
0.6 on the Snellen scale.
4 Neutralize the cylindrical component of the refraction.
5 Continue modifying the spherical power until reaching a unit AV.
6 Repeat with the other eye.

When placing a +3.00DP, the patient has to present a visual acuity of 0.1.
Reduce the power to +2.50DP then the patient sees 0.2, upon reaching
+2.00DP the AV is 0.4, and so on until a +0.50 is reached.
AV 1.0. Therefore, the Fogging result is +0.50 Esf.

If, on the contrary, it were a myopic patient of -5.50 DP, when placing the lens of
+3.00 the total power would be -2.50 DP. The power would increase by
steps of -0.25 DP until the patient reached VA 1.0.

It can be accepted that graduation with the fogging technique determines the state.
refractive in physiological conditions providing a refraction within the
tolerable limits for the majority of patients.

It is necessary to clarify that fogging cannot replace cycloplegic refraction in the

cases of children or young hyperopes. There are studies that relate refraction to
cycloplegic and the fogging allowing us to conclude that cycloplegic refraction provides
a more positive result in young people, which can be frequent in nearsighted individuals
to find more negative refractions as a consequence of spherical aberration of the
be careful when presenting the dilated pupil and that the clinical difference is minimal (Borish 1970).

Test Schedule

The purpose of this test is to subjectively determine the presence of component

astigmatic and calculate the cylindrical lens that corrects it, both in power and in axis u
orientation. This test is performed when AV unity has not been achieved with spheres or
when the existence of a cylindrical component is suspected (appearance of cylinder in
keratometry, retinoscopy or autorefractor.

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Astigmatic paradox. In a patient with direct astigmatism, the necessary cylinder

to correct it when it is negative its axis must be positioned at 180º and the foci
the principals will be situated as follows:

a) The horizontal meridian (less powerful) will be located on the retina, and its image
it will be a vertical line.
b) For its part, the vertical meridian (more powerful) will be positioned in front of the
retina and its image corresponds to a horizontal line.

This paradox, the image of the vertical meridian is a horizontal line and vice versa, is
known as astigmatic paradox. For example, when the patient sees more clearly the
line of 3 and 9 the axis is at 90º and when it sees the meridian of 12 and 6 the axis is
will be positioned at 180º.

Procedure:

1 Carry out this test upon reaching visual acuity 0.5 with spheres (either with the method
Duocromo, Donders or Fogging.
2 Project the time test on the optotype screen.
3 Ask the patient if they see all the lines the same or if, on the contrary,
some appear darker, blacker, or sharper. If not (see all
the lines are the same) the patient does not have astigmatism or the cylinder that he has in
the trial frame or phoropter compensates it completely and correctly. In this
if the test has finished. Repeat on the other eye.
In case of a positive result (if there are some lines darker than others) ask for
indicate the numbers they correspond to. If you cannot distinguish them
it is useful to compare the test with a clock and ask the patient to indicate
the lines as if they were the hands of the clock.
5 If a group of lines appears more
darkness to calculate the axis of the cylinder
negative it is indicated to apply the rule of
30 which consists of taking the smallest of the
numbers on the line that the patient sees the most
sharp and multiply it by 30. For example,
if the patient sees the line of 2 more clearly
at 8 the axis of the cylinder would be located at 60°
because 2x 30=60º. If the patient sees better
a value is taken between two lines
intermediate, for example between the lines of
1 and 7; and 2 and 8 the axis would be positioned at 45º (1.5 x
30=45º).
Schedule test diagram

Once the axis is defined, negative cylinders are added in steps of 0.25DP.
until the patient indicates that all lines look equally sharp.
7 After this test, it is necessary to verify the sphere, estimating that by
For every -0.50DP of cylinder, +0.25DP must be added to the sphere.
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Once equality among all the lines has been achieved, it is usually necessary
continue with the Donders method or another, until reaching AV unit.

9 Repeat in the other eye.

Jackson's Crossed Cylinders Test

The purpose of this test is to determine the

presence of small astigmatisms and verify
both the axis and the power of the cylinder that the
correct.

The crossed Jackson cylinder (CCJ) consists of

a lens that has one of the meridians
mainly a negative power (0.25; 0.50;
1.00DP) and identical power but positive in the
another meridian. They usually have some marks
that will be red for the negative axis of the cylinder and
white for the positive cylinder axis, also
they can carry another linear mark to indicate the
intermediate meridian between both.

For its realization, it is not necessary that the

the patient is myopic (positive lenses).

Its use is mainly indicated for specifying

the magnitude and the axis of the cylinder and not for
detect the presence of astigmatism, when it exists
other faster procedures for this purpose.

Jackson Cross Cylinder (CCJ)

But, if the presence of cylindrical correction has not been detected and one wants to verify if
exists (for example, when the time test does not provide a conclusive result) it
They can use the CCJ for this purpose. It would start by placing the CCJ at 90º and 180º turning.
(positive cylinder at 90 and 0) and ask in which position he sees better, and then at 45º and 135º,
turn and ask again. Between the two positions of best view, the axis would be located at
cylinder. The next step would be to place a cylinder, of 0.50 or 1.00 DP
equidistant from the two previously detected positions and fine-tune the axis and power
with the standard procedure.

It is advisable to perform this test with a letter chart larger than the last line of visual acuity.
viewed by the patient, approximately 3 lines of lower AV (if the patient saw 0.8)
use 0.5) since the contacts will blur the vision a bit. There are also tests
specifics in the projectors for their implementation.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Position 1: Position 2: Position 3: Position 4: Axis quadrant.

Set the CC to 0º and 90º and rotate to position 2. Ask the patient in which position they see better, in 1st or 2nd.
In the 2nd. (Let's assume the patient prefers the 1st position). Rotate the CC 45º. Ask in which position.
and better if in the 3rd or in the 4th. (The patient chooses position 3rd). The quadrant where the axis would be located
cylinder (with a negative axis) to correct astigmatism would be placed between position 2 and position 4. Marked
in gray.

First of all, the axis must be checked in order to subsequently verify the power of the
correction cylinder, once the test is done it is necessary to readjust the value of the sphere if
it is necessary.

Axis verification

Procedure:

1 Locate the axis of the cylinder with which the patient achieves the best visual acuity.
(Retinoscopy, schedule test).
2 Place the CC at 45º to the proposed axis, or in other words, with the handle of the
cylinder parallel to the cylinder of the trial frame or phoropter.
3 Rotate the CC 180º and ask the patient in which position they see better.
In the best vision position, turn the axis of the corrective cylinder (glasses of
tests or phoropter) towards the axis of the CC with the same sign, for example, if the
the cylinder is negative it will move its axis towards the red mark and
vice versa.
The more powerful the cylinder, the less need there will be to turn the axis.
Move 5º if it is about cylinders over 1.00DP and 10º in cylinders.
minors.
6 Repeat steps 2 and 3 until the patient expresses the same vision in the
two positions. This means that the meridians of the CCJ are situated
equidistant from the corrective cylinder of astigmatism and therefore produce the
same blurriness.
Power verification

Procedure:

1 Once the position of the axis has been verified, turn the CC so that it matches one.
from the main meridians with the axis of the correcting cylinder.
Turn 180º and ask in which position they see better.
If it looks better in the position of the negative CC (red point) it is necessary to add
more negative power (or decrease positives). If on the contrary the patient
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Raúl Martín Herranz Optometry I Subjective Refraction Methods

It prefers the position of the positive cylinder to reduce negatives or

add positives.
The purpose of the test is for the patient to see equally clearly (or blurry) in both.
positions.

5 Repeat in the other eye, first the axis verification and then
power.

A: Verification of the cylinder axis B: Verification of cylinder power

Just like in the case of the hourly test, for every 0.50DP of cylinder it would be indicated.
to modify, at least theoretically, the sphere by 0.25D in the opposite direction, is
To say, if the cylinder increases by -0.50 DP, the sphere would be added +0.25 DP.

Example:
Assume a patient who presents the same corneal astigmatism as refractive.
Keratometry shows a value of 8.00 * 7.50 at 50º. Therefore, its astigmatism is 2.50.
DP. It has been compensated with spheres until achieving a visual acuity of 0.5. The patient does not
respond appropriately to the time test (although perhaps he prefers it in the meridian between 1-
7, but it is not a reliable result, but they seem to equalize somewhat with a cylinder of -1.75 to
30º) and the retinoscopy does not yield a conclusive result. Spheres are introduced until
achieve the maximum AV, which is improved by the use of the pinhole.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

therefore one can suspect the presence of a certain astigmatic component in the
refraction.

1. Situation of the main focal points.

2. The cylinder is placed at -1.75 at 30º. This

cylinder is called decylinder of
work.

3. The cylinder axis is verified,

according to the proposed methodology.

4. The CC is placed so that the

cylinders remain at 45º to the axis of the cylinder
of work.

5. In the first position the cylinder

positive drops to -15º and the negative to 75º.

6. Flip, leaving the cylinder at 75ºº

positive and at -15º the negative.

The patient will prefer the first position.

8. Rotate the axis 15º in the direction of the axis

negative (counter-clockwise) of the
position of better AV placing the
Working Cylinder at 45º.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

9. The positive cylinder is placed at 90º and the

negative to 0º. The patient turns and
prefers the second position.

10. Rotate the working cylinder axis until

60º. The CC will remain with the cylinder
positive at 15º and the negative at 105º flip
and ask the patient. He/She will prefer the
second position. This indicates that we
we had passed by turning the cylinder of
work.

11. Turn the work cylinder towards the

negative cylinder (clockwise) of 5º
in 5th. We assume that we have arrived at the
position of 50º.

12. With the Cylinder at 50º, the CC will remain with

the positive cylinder at 95º and the negative at
5º turn and ask the patient. In this
in case both positions should provoke
the same blurriness..

The patient will see the same in both.

positions which indicates that the axis is the
correct.

14. The power is verified. For

Hello, the handle of the CC is placed at a 45º angle.
proposed axis, or in other words it is
place a cylinder (the positive or the
negative) parallel to the axis (50º) and the other
It will remain perpendicular to it.

15. The positive cylinder is placed at 160º and the

negative at 50º. Flip it, leaving the
positive cylinder at 50º and the negative at
160º. The patient prefers the first one.
position for adding power in
steps of –0.50DP and turning the CC in
each change º.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

16. When the work Cylinder has -

2.50 DP when performing the maneuver, the
the patient should see the same in both
positions (same distance in the
Sturm's Conoid) which indicates that the
the cylinder is fully compensated.

17. Check the sphere. For every 0.50DP of

cylinder may need to be added
0.25DP of opposite sign to the sphere, in
The example will be positive spheres.

Meridional Refraction

To perform meridional refraction, the Pinhole Slit is necessary, which

it consists of a groove approximately 0.75mm wide and 15mm high.
The effect on the meridian perpendicular to the groove is similar to that of a
pinhole. The slit is placed, it is turned until the position is detected in which
the patient sees better, this coincides with the axis of the negative cylinder.

The procedure for performing meridional refraction is as follows:

Place the pinhole slit.

2. Turn until locating the position of maximum vision.
3. Myopia correction with positive lenses.
4. Reduce the power of the lens to its maximum VA.
5. Rotate the pinhole slit 90º.
6. Repeat steps 3 and 4 in this position.
7. With the two obtained spheres, calculate the sphero-cylindrical formula.
8. Repeat on the other eye.

Refraction with the pinhole slit can be useful when methods fail.
conventional refraction. The main causes of failure are severe ametropias,
confusing answers and irregular astigmatisms.

In the case of irregular astigmatisms, the sphero-cylindrical formula can be calculated at

Starting from the two obtained cylinders, taking into account their value and axis. Long in 1974
he warned that there is an infinite number of sphero-cylindricals that produce any
combination of cylinders, and suggested that the one presenting should be taken
minimum cylindrical component.

A simple way to calculate the spherical-cylindrical formula is to place the two cylinders.
with its corresponding orientation on the frontofocometer.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Binocular Subjective
The purpose of this test is to obtain the most positive formula with the least amount of
cylinder and less anisometropia that provides a sufficient visual acuity. For its realization
The use of the phoropter is practically essential.

Procedure:

Normal lighting.

2. Be part of the refraction obtained in the monocular subjective.

3. The test is divided into four maneuvers:

Equalization of Spheres.
It will always try to equalize towards the most convex or positive.
reducing the dioptric value in the more myopic eye or increasing
the least hyperopic.

Equalization of cylinders:
It attempts to equalize towards the value of the smallest cylinder, until
equalize the value of both cylinders.

Binocular cylinder reduction:

Attempts to simultaneously reduce the cylindrical value of both.
eyes.

Myopization or Binocular Fogging:

Based on the result of the previous three maneuvers, a
fogging binocular.

4. Of the four previous maneuvers, the first two, matching spheres and cylinders.
they can only be performed when the difference in VA obtained after the subjective
does not exceed a tenth. The three maneuvers, equalizing spheres, cylinders and
cylinder reduction is stopped when the patient notices a decrease
of vision or lack of comfort.

Binoocular Balance
The purpose of this test is to equalize the accommodation stimulus of both eyes.
relaxing it to the maximum. In many patients, this test helps to equalize the VA of
both eyes.

This test is indicated if the same has been reached during monocular refraction.
AV with both eyes. In the case that the AV is different but there are reasons to believe
that the accommodation is different between both eyes, it is indicated to perform the duochrome test
with dissociated prisms.

There are different methods to achieve binocular balance, all based on

present two images, one to each eye and have the patient compare the sharpness between them
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Raúl Martín Herranz Optometry I Subjective Refraction Methods

both. The simplest consists of alternately occluding the patient's eyes.

asking which eye is better, introducing plus lenses in the eye with better Visual Acuity. The rest of
The methods use prisms, red-green or polarized filters for their realization.

Procedure:

Make sure both eyes are uncovered.

2. Some authors recommend lightly smudging both eyes with a

+0.75DP or higher until the vision is 0.8.

3. Place a prism of 3-4 ∆ upper base in the right eye. In this way in
patient sees two lines of optotypes, the upper one with the left eye while
that the lower one will be seen by the right eye. It is also indicated to place a
prism in each eye, in this way the blurriness caused by the prism is
same in both eyes and does not affect the test result.

4. Inform the patient that they will see two lines of letters that are more or less blurry.

5. Ask the patient to look at both lines of letters and indicate which one they can see with
more clarity.

Add +0.25 spherical DP in the eye that sees more clearly.

7. Repeat steps 5-6 until the visual acuity of both eyes is equal. In all steps
the letters must be legible at all times, if the eye with the worst vision cannot
reading the letters is necessary to introduce negative spheres of 0.25 in 0.25DP up to
who can read it.

8. When equal vision is achieved with both eyes, remove the prism. It is
It is common to find that the dominant eye has better vision even afterwards.
to achieve binocular balance. If it was decided to correct to a visual acuity of 0.8
It is necessary to verify the spherical power until reaching the unit VA.

It can be especially interesting to perform the biocular balance after the third one.
binocular subjective distance test maneuver (after matching spheres, cylinders and
reduce cylinders binocularly) prior to binocular fogging.

Some patients accept a binocular reduction of sphere and cylinder and when performing the
In the biocular test, a huge difference in visual acuity between both eyes is observed. This result
refractive cannot be prescribed, since one eye is well corrected while the
another will present a low AV. Therefore, it is always indicated to achieve balance
biocular before the fogging binocular.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Near Monocular Subjective

Two main methods are distinguished.

Jackson Crossed Cylinders for fence

The purpose of this test is to calculate the lens that provides focusing in vision.
next. Procedure:

1. Normal lighting. Use the lighting from the refraction column to

near vision.

2. Start from the result of the subjective

binocular in both eyes. Occlude a
eye.
3. Place a crossed cylinder of
Jackson of±0.50DP so that the
negative axis is positioned at 90º. (The
A phoropter usually has this CC Grid test for vision
on the auxiliary lens control.
4. The grid test is placed 40 cm from the patient, or alternatively at a distance of
patient's usual reading.
5. Introduce a spherical lens of +3.00D. In presbyopic patients, it may be
it is necessary to increase it by +1.00DP especially in those over 50 years old,
while in young patients it may be advisable to reduce it quickly
in 0.75 or 1.00DP because this lens causes very blurry vision.
In this situation, the patient will have to see the vertical lines more clearly.
Ask the patient if they see all the lines equally black. It is not advisable.
inform the patient about what they are going to see.

7. When the patient perceives the vertical lines as darker than the horizontal ones.
start reducing convexes in steps of 0.25DP until the patient
manifest see both lines equally black or sharp (vertical and
(horizontal). In some patients, this point of equality does not exist.
as a result of the test, the last lens that allowed seeing the lines darker
verticals.
8. Repeat in the other eye.

This test may not yield a conclusive result, as some patients

You can see a difference in colors between the lines or see the horizontal ones darker.
than the verticals. In these cases, resorting to another subjective method to calculate the
prescription for near vision.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

Trial and Error Method

The purpose of this test is to calculate the necessary addition for near vision.

Procedure:

1. Normal lighting. Use the illumination from the refractive column to

near vision. Occlude one eye.
2. Introduce positive lenses until Age (Years) AA (DP)
that the patient sees the line of 8 14.0± 2
12 13.0± 2
AV unit in near vision.
16 12.0± 2
20 11.0± 2
3. Repeat in the other eye. 24 10.0± 2
28 9.0± 2
A starting point for the method of 32 8.0± 2
attempting to use the table of 36 7.0± 2
Donders' accommodation amplitude or 40 6.0± 2
the Hofstetter formula (Ad = 15 - 0.25 44 4.5± 1.5
Age). It is statistically accepted that 48 3.0± 1.5
the accommodation amplitude below 52 2.5± 1.5
from 40 years it increases 1.00DP 56 2.0± 1.0
60 1.5± 1.0
for every 4 years, decreasing further
64 1.0± 0.5
quickly over that age. 68 0.5± 0.5
Accommodation Amplitude as a Function of Age
(Donders)

Close Binocular Subjective

It is done following the same 45 years +1.00 to +1.25 DP
procedure that in subjective tests
close binoculars with the exception of 50 years +1.50 to +1.75 DP
make sure both eyes remain
open. Therefore there is a test of 55 years +2.00 to +2.25 DP
crossed cylindrical binoculars and a test 60 years +2.50 to +3.00 DP
of binocular sampling.
Table of average additions based on age

Tanteo Binocular

Positive lenses are placed in both for the distant binocular subjective result.
eyes until the patient states that they can see the near visual acuity chart properly.

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Raúl Martín Herranz Optometry I Subjective Refraction Methods

The direct choice of the patient testing the exact power corresponding to their
usual working distance, tends to be the most satisfactory method and can
to adopt this custom as a norm before defining the definitive prescription
(addition).

Prior to the final prescription, it is advisable to ensure that the chosen lens allows
maintain half of the patient's accommodation at rest. One of the most tests
appropriate in calculating the negative and positive relative accommodation and that both values
be similar in absolute value or use the limit method described in the chapter on
presbyopia.

BIBLIOGRAPHY
1)Clinical Procedures in the Visual Exam, National College of Opticians-Optometrists. 1990.
2) Castiella JC, Pastor JC. Refraction in children. McGraw-Hill-Interamericana. Madrid, 1997.
3) Wilson FM. Practical Ophthalmology. A Manual for Beginning Residents. American Academy of
Ophthalmology. San Francisco 1996.
4) Edwards K, Llewellin R. Optometry. Scientific and Technical Editions, SA Masson-Salvat Medicine. 1993
Barcelona Spain.
5) Leo Manas. The visual analysis. S.O.E. Madrid, Spain, 1965.
6) Gonzalez Diaz-Obregon E.Optometry II. Complutense University of Madrid.
7) Edwars K, Llewellyn R, Optometry, Masson-Salvat, Barcelona, 1993.

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