Refraction is an art , optometrist is noble trade for serving Mankind, make good decisions about your patient wellbeing, don't cheat

1. REFRACTION
PROCEDURE
MR. JAINULL ABEDIN
(OPTOMETRIST)
CALL & WHATSAPP
#9437902254

2. LET’S START WITH SOME OUTSOURCING
KNOWLEDGE
• MAKE SURE THAT YOU ARE ON A RESPONSIBLE CHAIR.
• YOU ARE TALKING TO SOMEONE WHO CAME TO YOU ON RESPECT
WITH SOME OCULAR PROBLEMS / SUGGESTION
• IT’S YOUR CHOICE WHETHER YOU TREAT YOUR PATIENT AS AN
OPTOMETRIST OR AS A TECHNICIAN, WHICH DEPENDS UPON THE
WAY OF YOUR CONVERSATION.
• EVERY STEP OF YOUR CONVERSATION SHOULD BE FOLLOWED WITH
ALL CONFIDENCE.
• FINALLY A STRONG AND STRICT RULE THAT YOU SHOULD NEVER
FORGET THAT YOU ARE PROFESSIONAL AND BEHAVE LIKE A

3. INTRODUCTION
• REFRACTION IS A COMMON CHOICE FOR ALL PATIENTS IN ALL AGE
RELATED TO VISION.
• AN EYE CARE PRACTITIONER DECIDE THE NEED OF AN INDIVIDUAL
FOR A IDEAL LENS PRESCRIPTION BY A CLINICAL JUDGEMENT.
• IT’S A COMBINATION OF SKILLS AND EXPERIENCE TO EXAMINE THE
EYE WITH A SUITABLE CORRECTION SO THAT ONE CAN PERFORM
HIS VISUAL TASKS.
• REFRACTION IS DONE WITH THE HELP OF A TRAIL SET (
CONTAINING VARIETIES OF LENSES ), VISUAL ACUITY TEST CHART
AND SOME OTHER EQUIPMENT IN A CLINICAL SETUP.

4. TIPS TO REMEMBER
• DISTANCE OF PATIENT TO THE VISION CHART SHOULD BE 20FT
/6MTR
• VISION CHART SHOULD BE WELL ILLUMINATED
• VISION CHART SHOULD BE PARALLEL TO THE EYES OF PATIENT
• ALLOW THE PATIENT TO SIT COMFORTABLE AND BE COMFORTABLE
WITH YOU
• CONFIRMED THE PATIENT LITERACY FOR YOUR COOPERATION
• ILLUMINATION OF ROOM TO AVOID CONFUSION ON
ACCOMMODATIVE CONDITIONS
• START WITH POLITENESS AND PROFESSIONAL KNOWLEDGE

5. STEP‘S
1. HISTORY TAKING
2. TORCH LIGHT EXAMINATION
3. OCULAR MOVEMENT
4. VISUAL ACUITY TEST
5. CONTROLLING ACCOMMODATIVE EFFORTS
6. REFRACTION MONOCULAR FOR DISTANCE
7. BINOCULAR BALANCING
8. NEAR ADDITION
9. PRESCRIPTION WRITING
10. ADVICE

6. HISTORY TAKING
• THE PROCESS OF REFRACTION STARTS WITH A CLEAR CONSIDERABLE CASE HISTORY
• THIS HELPS YOU TO UNDERSTAND THE PATIENT AND CREATE A RELATIONSHIP
BETWEEN YOU AND THE PATIENT.
• IT ALSO HELPS YOU TO RULE OUT THE DIAGNOSIS PROCESS.
• IT HELPS TO GET THE REASON OF VISIT (WHETHER CAME FOR ROUTINE CHECK UP /
HAD ANY SPECIFIC REASON )
• EACH COMPLAINT SHOULD BE ASKED WITH IT’S DURATION, SEVERITY AND
ASSOCIATED CONDITIONS. ( DM, HT, THYROID, CHOLESTEROL, FAMILY HISTORY OF
CATARACT, GLAUCOMA OR BLINDNESS ETC. )
• ASK THE PATIENT VISUAL NEEDS WITH RESPECT TO HIS/HER HOBBIES AND OTHER
ACTIVITIES
• IF THE PATIENT IS USING EYEGLASSES THEN ASK THE DURATION OF LAST

7. HISTORY TAKING OF PAEDIATRICS
BIRTH HISTORY OF CHILDREN IS VERY MUCH ESSENTIAL FOR
DIAGNOSIS
• BIRTH WEEK OR AGE OF GESTATION
• COMPLICATIONS AT THE TIME OF BIRTH
• TYPE OF DELIVERY ( NORMAL OR C- SECTION )
• BIRTH WEIGHT
• ANY HOSPITALIZATION OF BABY POST BIRTH
• FAMILY HISTORY OF PARENTS
• ANY DELAYED DEVELOPMENT OF CHILD OR DISABILITY
• ANY PREVENTIVE TAKEN TO AVOID CONCEIVE OF GESTATION

8. TORCH LIGHTS EXAMINATION
ONLY TO SEE THE ANTERIOR SEGMENT OF EYE
• FIND OUT IF THERE WAS ANY REDNESS, SWELLING OR CONTAMINATION ETC. AND
THE REASON
• ANY VISIBLE FOREIGN BODIES
• PUPIL REACTION , SIZE AND LOCATION
• ANTERIOR CHAMBER DEPTH ( TO FIND ANY ANGLE CLOSED GLAUCOMA ) BY
PLACING THE LIGHT TEMPORARILY AND GRADING THE SHADOW
• CORNEAL REFLEX, SIZE, OPACITY OR ANY SIGNS OF KERATOCONUS
• TROPIA OR PHORIA BY COVER UNCOVERE OR ALTERNATIVE COVER TECHNIQUES
• LENS OPACITY OR ANY SIGNS OF CATARACT
• TO CHECK RAPD BY SWINGING THE LIGHT AND OBSERVING THE OPPOSITE PUPIL
REACTION

9. EOM ( EXTRAOCULAR MOVEMENT )
OBSERVES THE MOVEMENT OF THE EYES IN ALL GAZES AND
DIRECTIONS
• SIT IN FRONT OF PATIENT EYES HORIZONTALLY BY HOLDING A PEN TORCH OR ANY
FIXATION TARGET.
• MAKE SURE THAT YOUR PATIENT HEAD POSITION IS NORMAL
• ASK THE PATIENT TO FOLLOW THE LIGHT / TARGET BY ROTATING THE EYE TO THE
RESPECTIVE SIDE WITHOUT MOVING THE HEAD
• ASK YOUR PATIENT TO INFORM YOU ABOUT ANY DOUBLE VISION, WHICH SHOULD BE RULE
OUT BY DIFFERENT METHODS.
• MOVE THE TARGET SLOWLY SLOWLY TO ALL THE DIRECTIONS TO FIND OUT THE
RESTRICTIONS OR OVER ACTIONS OF OCULAR MUSCLES
• YOU CAN ALSO DIAGNOSE YOUR PATIENT LESIONS IN CENTRAL NERVOUS SYSTEM /
BRAIN IF YOU FIND THE EXACT NERVE PALSY OF THE RESPECTIVE MUSCLES MOVEMENT /

10. VISUAL ACUITY TEST
CLARITY OF VISION WHICH DEPENDS ON OPTICAL AND NEURAL FACTORS
• VISUAL ACUITY IS TO BE TESTED AT A DISTANCE OF 20FT / 6MTR IN A WELL
ILLUMINATED ROOM AND VISION CHART, BY COVERING ONE EYE / MONOCULAR .
• ASK THE PATIENT TO READ THE LETTERS FROM TOP TO BOTTOM IN THE RESPECTIVE
VISION CHART.
• IF THE PATIENT ABLE TO READ THE TOP LETTER AND FOLLOWED THE INSTRUCTIONS BY
READING NEXT ROW LETTERS LIKEWISE THEN RECORD THE VISUAL ACUITY OF THE
PATIENT LAST READABLE LINE WHETHER IT WAS COMPLETE OR PARTIAL ( MAYBE
6/60,36,24,18,12,9,6P )
• IF THE PATIENT COULD NOT ABLE TO READ THE TOP LETTER THEN, ASK THE PATIENT
TO COUNT THE FINGER OF YOUR HAND WHICH SHOULD BE SHOWN 6 MTR / 20 FT
DISTANCE BY GETTING CLOSER TO THE PATIENT AND RECORD THE PATIENT VISUAL
ACUITY WHERE HE/SHE ABLE TO COUNT THE FINGER COMFORTABLY ( MAYBE
5,4,3,2,1/60 OR CFCF OR PL+ )
• IF CFCF THEN RECORD THIS AS VA IF PL+ THEN GO FOR PR BY PROJECTING RAY FROM

11. CONTROLLING ACCOMMODATIVE EFFORTS
• AS CONCERNED ABOUT MYSELF I THINK THAT IN WHOLE REFRACTION PROCEDURE THE
ROLE OF ACCOMMODATION IS MUCH MORE IMPORTANT TO UNDERSTAND, IF FAILED
THEN I AM SURE YOU ARE GOING WITH WRONG PRESCRIPTION.
• SO BEFORE UNDERSTANDING THE SAME WE NEED TO DISCUSS SLIGHTLY ABOUT
ACCOMMODATION.
1. ACCOMMODATION IS AN ABILITY OF EYE TO ADJUST ITS OPTICAL POWER IN ORDER TO
ACHIEVE CLARITY OF VISION ALONG THE VARIABLE DISTANCE
2. WE ALL KNOW THAT IN EVERY REFRACTIVE ERROR WE MENTION ( WHILE THE
ACCOMMODATION IS AT REST) IF WE CAN UNDERSTAND WHY THE ACCOMMODATION
WILL BE ON REST TO DEFINE THE REFRACTIVE ERROR THEN WE HAVE DONE
3. SO IF WE FIND THE EXACT REASON FOR WHAT WE NEED THE ACCOMMODATION SHOULD
BE ON REST WE WILL NEED TO GO AHEAD WITH REFRACTION IF NOT THEN IT’S
NECESSARY TO MAKE SURE ABOUT
4. ONCE WE ARE ABLE TO CONTROLLED THE ACCOMMODATION THEN WE ARE THE BEST🙂
OTHERWISE WE COULD BE BEST 🙂

12. MONOCULAR REFRACTION
IT WILL BE FUNNY IF I WILL
EXPLAIN WHY WE NEED TO GET
MONOCULAR REFRACTION
😛😛😛

13. BINOCULAR BALANCING
BASICALLY THERE ARE 2 COMMON METHOD FOR BINOCULAR BALANCING AS I
KNOW 🙂
BLUR TEST AND PRISM DISSOCIATION
THE FINAL STEP OF SUBJECTIVE REFRACTION IN WHICH WE NEED TO BALANCE THE
SPHERICAL POWER ALONG WITH ACCOMMODATIVE EFFORTS IN ORDER TO AVOID
ASTHENOPIC SYMPTOM WHICH OCCURRED DUE TO IMBALANCES RETINAL IMAGE
KEEP IN MIND THAT IN THIS PROCESS WE WILL NOT FOCUS ON VA BUT WE NEED TO BALANCE
THE STATE OF ACCOMMODATIVE EFFORT OF 2🙂
LIMITATION OF BINOCULAR BALANCING IS AMBLYOPIA, THAT MEANS BOTH EYE BCVA
SHOULD BE EQUAL
SO PROCEEDING WITH BLUR TEST

14. BLUR TEST
• START WITH BEST CORRECTED MONOCULAR VISUAL ACUITY WITH BOTH EYES OPEN
• INSTRUCT THE PATIENT ABOUT THE TARGET LINE ACCORDING TO HIS VA BY PLACING
+1D SPHERE
• DO ALTERNATE OCCLUSION WHILE THE PATIENT OBSERVING THE SNELLEN CHART
• ASK THE PATIENT IF THE LETTERS ARE CLEARER THAN OTHER EYE
• IF THE IMAGES ARE EQUALLY CLEAR, THE BALANCE IS CORRECT AND NO FURTHER
ADJUSTMENT OF LENS POWER IS NECESSARY
• IF THE PATIENT NOTICES A DIFFERENCE IN CLARITY , LET THE PATIENT IDENTIFY WHICH
EYE POSSESSES THE CLEARER IMAGE
• ONCE THE EYE WITH THE CLEARER IMAGE HAS BEEN IDENTIFIED, THEN WE HAVE 2
OPTIONS
ADD PLUS SPHERE IN +0.25DS STEPS BEFORE THE BETTER EYE TO ACHIEVE EQUALLY POOR VISION IN BOTH
EYE.ADD MINUS SPHERE IN -0.25DS BEFORE WITH THE POORER VA IN ORDER TO ACHIEVE EQUALLY SHARP IMAGE
IN BOTH EYE.
# COVER PADDLE SHOULD BE REMOVED QUICKLY.

15. PRISM DISSOCIATION
FOLLOW UP THE TOTAL PROCESS OF BLURRING TEST, THE ONLY THING IS THAT YOU NEED
TO PUT 5D IN BASE UP AND DOWN DIRECTION IN EITHER EYE INSTEAD OF +1D SPH
NEAR ADDITION
• AS WE ALL KNOW THAT THE ADDITION POWER IS ONLY FOR THE PURPOSE OF NEAR WORK
• SO BEFORE GIVING THE ADDITION KINDLY GET UPDATE WITH THE NEAR WORKING
DISTANCE OF YOUR PATIENT
• NEVER GO WITH THE AGING ADDITION
• AFTER PUTTING THE ADDITION POWER ASK YOUR PATIENT TO CHECK THE READING
ABILITY WITH VARIABLE DISTANCE

16. DUOCHROME
• START WITH BEST CORRECTED MONOCULAR VA TRAIL LENS IN TRIAL FRAME
• LET THE PATIENT ASSUME WHETHER RED OR GREEN BAR SEEM TO BE MORE CLEAR
• IF RED OR GREEN PREFERENCE IS EQUAL THEN NO ADJUSTMENT WILL BE NEEDED
• IF NOT THEN THE SPHERE BEFORE THE OBSERVING EYE IS THEN ADJUSTED TO GIVE EQUAL
RED PREFERENCE OR EQUAL GREEN PREFERENCE AS FELT APPROPRIATE
END POINT
• THE TARGET LETTER SHOULD BE 20/20 OR BCVA
• ADD +0.25DS IN FRONT OF BOTH EYES AND ASK FOR ANY DIFFERENCE IN CLARITY
• THE SAME QUESTION SHOULD BE ASKED FOR THE 2ND AND 3RD TIME AFTER ADDING
+0.25DS EACH TIME
• EXPECTED RESPONSESLIGHTLY BLURRED, BADLY BLURRED OR BLURRED OUT
• SOME UNEXPECTED RESPONSE - STILL READABLE"
• RESULT - PATIENT ACCOMODATION WAS NOT COMPLETELY RELAXED DURING
SUBJECTIVE RESPONSE UNTIL COMPLETE CYCLOPLEGIC

17. CONGRATULATION WE HAD COMPLETED OUR REFRACTION WITH
ALL GOOD
NOW IT’S OUR TURN
• BEFORE WRITING THE PRESCRIPTION YOU NEED TO DOUBLE CHECK YOUR POWER
• DON’T BE IN HURRY OTHERWISE YOU CAN MAKE A MISTAKE ON WRITING A
PRESCRIPTION
• WRITE THE PRESCRIPTION IN GOOD HANDWRITING SO THAT EVERYONE CAN
UNDERSTAND
• THERE ARE COMMONLY 2 TYPES OF PRESCRIPTIONS FOR BIFOCAL, ONE IS DIRECTLY
FOR NEAR ANOTHER IS FOR ONLY NEAR ADDITION , THIS IS THE MOST COMMON
MISTAKE OF ALL WHICH I HAD NOTICED IN MY PAST.
PRESCRIPTION WRITING

18. ADVICE
• PATIENT SATISFACTION WILL BE OUR THUMB RULE IF WE NEED TO MAKE NAME AND FAME
• ONCE YOU GET IT DONE THEN YOU DON’T NEED TO RUN YOU ONLY NEED TO WALK LIKE
ELEPHANT
• NEVER TRY TO CHEAT YOUR PROFESSION BY CHEATING ANYONE UNPROFESSIONALLY
• IF YOU ARE REFERRING YOUR PATIENT TO SOMEWHERE, KINDLY FOLLOW UP THE PATIENT
BY ASKING ABOUT THE EXPERIENCE OF THAT REFERRAL CENTER, IT WILL HELP YOU TO
UNDERSTAND YOUR COOPERATION WITH THE REFERRAL CENTER
• LAST BUT NOT THE LEAST = BE PROFESSIONAL, LOOK PROFESSIONAL, WELL DRESSED, WELL
GROOMED, SWEET TALKING ATTITUDE ……….. 🙂🙂🙂

19. DON’T FORGET THAT YOU ARE AN
OPTOMETRIST
DON’T TRY TO BE A DOCTOR NOR A
TECHNICIAN
THANKS WITH
REGARDS JAINULL
ABEDIN
OPTOMETRIST