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BLOCK 1: Clinical Exams

BLOCK 1: Clinical Exams. Theme 1: Case History Theme 2: Material Theme 3: Visual Acuity Theme 4: Retinoscopy Theme 5: Subjective Theme 6: Covert Test Theme 7: Accomodation. Theme 4: Retinoscopy. 4. Utility. 5. Material. Method. 9. Previous conditions. 10.

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BLOCK 1: Clinical Exams

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  1. BLOCK 1: Clinical Exams Theme 1: Case History Theme 2: Material Theme 3: Visual Acuity Theme 4: Retinoscopy Theme 5: Subjective Theme 6: Covert Test Theme 7: Accomodation

  2. Theme 4: Retinoscopy 4 • Utility 5 • Material • Method 9 Previous conditions 10 Retinoscopic observations 10 Description Analysis parameters 12

  3. Theme 4: Retinoscopy • Method Technique General mechanics 26 Examples 31 Emmetropia 34 Spherical ametropia Astigmatic ametropia 39 • Self-evaluation 48 • Bibliography 59

  4. Utility The static retinoscopy is an objective technique that provides the value of the refraction in distance vision. Utility …the analysis of the reflection of light that is obtained upon projection of a ray of light onto the patient’s pupil. It is based on…

  5. Material Lenses Support Test of visual acuity Retinoscopy / Skiascopy

  6. Material Retinoscope Optotype for dynamic retinoscopy Flat mirror () Concave mirror ()

  7. Method There are diverse retinoscopic techniques: Accomodation does not take part. The subject observes an optotype for distance vision and the fogging technique is relied upon to relax accomodation. • Static: Realized with near vision. There are many techniques: Cross, Mohindra, etc. • Dynamic: In this chapter we only address the static.

  8. Method 1. Previous conditions 2. Retinoscopic observations 2.1. Description 2.2. Analysis parameters 3. Technique 3.1. General mechanics general 3.2. Examples

  9. Method 1. Previous conditions Light It can be more comfortable to perform it in faint light. A pupil of greater size and less reflection appears. Graduation The patient will have both eyes open and wil be without his/her graduation, (to the contrary, we would be doing one with graduation). Myopization* In order to control accomodation, it is a good idea to start with a fogging around 0,3-0,4.

  10. Method 2. Retinoscopic observations 2.1. Description Mirror of the retinoscope Object of study Sclera Retinoscopic reflection Pupil Iris

  11. Method 2. Retinoscopic observation The retinoscopic reflection is analyzed with respect to the mirror and the result of this analysis will provide us with information on the type and quantity of Any existing ametropia. • The type of movement • Parallelism The parameters of analysis are: • The width of the reflection

  12. Method 2. Retinoscopic observation 2.2. The Parameters of analysis Mirror of the retinoscope • The type of movement • Parallelism • The width of the reflection Retinoscopic reflection

  13. Method 2. Retinoscopic observation 2.2. The parameters of analysis • The type of movement With Movement (WM) Mirror and reflection go in the same direction Against Movement (AM) Mirror and reflections go in opposite directions

  14. Method 2. Retinoscopic observation 2.2. The parameters of analysis • The type of movement Upon moving the retinscopic mirror, depending on the type of ametropia and the mirror used, we will observe whether the retinoscopic reflection moves in the same or the opposite direction as the mirror. Selection of the mirror

  15. Method 2. Retinoscopic observation 2.2. The parameters of analysis • The type of movement Hypermetropia* Myopia* With Movement Against Movement Flat mirror Against Movement With Movement Concave mirror Correction with positive lens Correction with negative lens *Supposing the working distance has been compensated for

  16. Method 2. Retinoscopic observation 2.2. The parameters of analysis Mirror of the retinoscope • The type of movement • Parallelism • The width of the reflection Retinoscopic reflection

  17. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism • It refers to the parallelism between the mirror of the retinoscope and that pertaining to the retinoscopic reflection. Mirror of the retinoscope Retinoscopic reflection Not parallel Parallel

  18. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism • If when turning 360º there is parallelism spherical ametropia Mirror of the retinoscope Spherical ametropia Retinoscopic reflection Parallel Parallel

  19. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism • The lack of parallelism indicates Astigmatic ametropia Faced with this situation, the principal meridians must be looked for. Said meridians are found in the direction where said parallelism appears. Mirror of the retinosccope Retinoscopic reflection Not parallel

  20. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism The retinoscopic mirror will be turned until the degrees in which parallelism appears between the mirror and the retinoscopic reflection are found. Mirror of the retinoscope The “track” of the direction provides us with the retinoscopic reflection. Retinoscopic reflection Not parallel

  21. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism 60º 150º Mirror of the retinoscope Retinoscopic reflection Parallel Parallel Not parallel Principal meridians (Perpendicular)

  22. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Parallelism It is important to determine the existence of the principal meridians since the neutral point of the retinoscopic reflection must be realized according to them. Once the meridians are determined, the mirror will be analyzed for the parameters of width and the type of movement in order to try to achieve the neutral point.

  23. Method 2. Retinoscopic observation 2.2. The parameters of analysis Mirror of the retinoscope • The type of movement • Parallelism • The width of the reflection Retinoscopic reflection

  24. Method 2. Retinoscopic observation 2.2. The parameters of analysis • Width of the reflection (EP) The width of the retinoscopic reflection is the streak of light reflected that occupies the pupil, totally or partially. This “occupied space” provides information on the quantity of ametropia. The sensation of “occupation” (width), will be determined by the pupillary diameter and by the level of ametropia.

  25. Method 2. Retinocopic observation 2.2. The parameters analysis • The width of reflection (EP) With respect to the level of ametropia, if we evaluate the width, the reflection occupies more space in: - Elevated ametropias Accompanied by a dull reflection Accompanied by a more luminous reflection - Near the neutral point

  26. Method 3. Technique 3.1. General mechanics (static RT) • Cover RE and fog the patient LE to VA 0,3-0,4 • Uncover RE and place the lens corresponding to the work distance (WD) in front (for example 50 cm. corresponds to +2,00D). • Indicate to the patient that he/she will see the test in DV (VA 0,3-0,4) • Observe the reflection of the patient’s RE with the examiners RE. • Analyze and neutralize the retinoscopic reflection • Leave the gross value (settting aside the lens that corresponds to the WD situation of fogging) and move on to observe the LE Retinoscopy RE

  27. Method 3. Technique 3.1. General mechanics (static RT) • With the RE the optotype for DV was observed (it is fogged when setting aside the retinoscopic lens). • Place a lens corresponding to the work distance in front of the LE • Observe the patient’s LE with the examiner’s LE. • Analyze and neutralize the retinoscopic reflection. Retinoscopy LE (During the realization of the test, we must insist that the patient continues looking at the optotype for DV).

  28. Method 3. Technique 3.1. General mechanics (static RT) Upon finishing this process we find that the subject has, placed in front of him/her, the lenses: - corresponding to the work distance (WD) Gross value Net value - corresponding to the refractive defect

  29. Method 3. Technique 3.2. Examples Next, the observation and neutralization of diverse ametropic situations are going to be described. Retinoscopic reflection (pupil) Sclera 2.00 Lens compensating for work distance streak of light of the retinoscope

  30. Method 3. Technique 3.2. Examples The type of movement Flat Mirror (FM): Paraneters Parallelism Description of the observations The width of the reflection Summary of the Observation Neutralization Action to realize Lens Value of the refractive correction (Net value of the retinoscopy)

  31. Method 3. Technique 3.2. Examples 1. Emmetrope eye 2. Spherical ametropia 3. Astigmatic ametropia

  32. 2.00 2.00 Method 3. Technique 3.2. Examples 1. Emmetrope eye The type of movement Flat mirror (FM): Without movement Concave mirror (CM): Without movement Parameters Parallelism The streak of light is not observed in the retinoscopic reflection It fills the pupil in what is known as NEUTRAL POINT (NP), point of neutralization The width of the reflection

  33. 2.00 Method 3. Technique 3.2. Examples 1. Emmetrope eye 2.00 Summary of the observation Neutral point. All of the pupil illuminated, there is no streak of light with either of the mirrors Neutralization Lens There is no precise lens to neutralize Value of the refractive correction Neutral

  34. Method 3. Technique 3.2. Examples 1. Emmetrope eye Hypermetropia of +3,00 D 2. Spherical ametropia Myopia of - 3,00 D 3. Astigmatic ametropia

  35. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 2. Spherical ametropia HP +3,00D (Observation with FM*) The type of movement Flat Mirror* (FM): With Concave Mirror (CM): Against Parameters Parallelism Parallelism in 360º The width of the refraction Intermediate

  36. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 2. Spherical ametropia Hp +3,00D (Observation with FM*) Summary of the Observation With movement with FM*. A streak of light of intermediate width is observed, parallel to the streak of light of the retinoscope in 360º Neutralization Lens Positive lenses are put in front of the subject until neutral point is achieved. + 3,00 D Value of the refractive correction

  37. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 3. Spherical ametropia Mp - 3,00D (Observation with FM*) The type of movement Flat Mirror* (FM): Against Concave Mirror (CM): With Parameters Parallelism Parallelism in 360º The width of the reflection Intermediate

  38. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 3. Spherical ametropia Mp - 3,00D (Observation with FM*) Summary of the observation Against movement with FM. A streak of light of intermediate width is observed, parallel to the streak of light of the retinoscope in 360º Neutralization Lente Negative lenses are placed in front of the subject until neutral point is achieved - 3,00 D Value of the refractive correction

  39. Method 3. Technique 3.2. Examples 1. Emmetrope eye 2. Spherical ametropia -3 ,00D 180º 3. Astigmatic ametropia -3 ,00D 90º

  40. 2.00 2.00 Method 3. Technique 3.2. Examples 2. Astigmatism - 3,00D 180º (Observation with FM*) Vertical retinoscopic streak of light: Does not exist The type of movement Flat Mirror* (FM): Parameters Horizontal retinoscopic streak of light: Against

  41. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 2. Astigmatism - 3,00D 180º (Observation with FM*) Parallelism Retinoscopic streak of light at: Parameters 90º: When there is not a streak of light of the reflection parallelism is not determined 45º: There is no parallelism, we are not along any of the main meridians 180º: There is parallelism between the streak of lightS. We are along the ametrope meridian

  42. 2.00 2.00 2.00 Method 3. Technique 3.2. Examples 2. Astigmatism - 3,00D 180º (Observation with FM*) Summary of the observation Against movement with the FM with retinocscopic streak of light at 180º. Neutral point with FM with retinoscopic streak of light at 90º. Neutralization Place negative lenses in front of the subject until neutralization of movement is achieved. If an astigmatic lens is used the axis will be in the same direction as the Movement. Lens - 3,00 180º Value of the refractive correction

  43. 2.00 2.00 2.00 « « - 3 Method 3. Technique 3.2. Examples Summary - 3,00D 180º (Observation with FM*) Neutral point Against movement (streak of light parallel) Increase negative cylinder with the horizontal axis until movement is neutralized RE 0,00 - 3,00 180º Value of the refractive correction

  44. 2.00 2.00 Method 3. Technique 3.2. Examples 2. Astigmatism - 3,00D 90º (Observation with FM*) Vertical retinoscopic streak of light: Against The type of movement Flat Mirror* (FM): Parameters Horizontal retinoscopic streak of light: Does not exist (neutral point)

  45. 2.00 2.00 2.00 Method 3.Technique 3.2. Examples 2. Astigmatism - 3,00D 90º (Observation with FM*) Parallelism Retinoscopic streak of light at: Parameters 90º: There is parallelism between streak of light. We are along the ametropic meridian. 45º: Thre is no parallelism, we are not along any of the meridians. 180º: When there is no existing streak of light of the relfection parallelism is not determined.

  46. 2.00 2.00 2.00 Method 3. Technique 3.2. Example 2. Astigmatism - 3,00D 90º (Observationswith FM*) Summary of the observation Against movement with FM with retinoscopic streak of light at 90º. Neutral point with FM with retinoscopic streak of light at 180º. Neutralization Place negative lenses in front of the subject until neturalization of movement is achieved. If an astigmatic lens is used the axis will be in the same direction as the movement. Lens RE - 3,00 90º Value of the refractive correction

  47. 2.00 2.00 2.00 « « - 3 Method 3. Technique 3.2. Examples Summary - 3,00D 90º (Observations with FM*) Neutral point Against movement (Parallel streak of light) Increase the negative cylinder with the vertical axis until neutralization of movement has achieved. RE 0,00 - 3,00 90º Value of the refractive correction

  48. Exercises Self-evaluation

  49. Exercises Exercise 1 Methodology Exercise 2 Spherical ametropia Exercise 3 Astigmatic ametropia Exercise 4 Astigmatic ametropia

  50. Exercises Exercise 1 Indicate the best option with regards to the methodology of the static retinoscopy a. At a distance of 1m., the corresponding working lens is of +2,00 D b. If we realize the retinoscopy to the left eye, the right has to be covered c. If after placing the lens corresponding to the work distance in front of the subject we observe against movement along all meridians with the flat mirror, the streak of light is wide, not very bright and slow, we are faced with a low myopia. d. When realizing the retinoscopy on the right eye, the left eye must be foggedd and using distance vision.

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