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Refractive Exam and Spectacles Guide for GPs
- 1. Refractive Examination and Spectacles for GP Grimaldi Ihsan,SpM(K),FICS National Eye Center Cicendo Hospital Bandung Eye Center
- 2. OUTLINES • INTRODUCTION • REFRACTIVE ERRORS • REFRACTIVE EXAMINATIONS • LENS PRESCRIPTION • TAKE HOME MESSAGES
- 3. INTRODUCTION KEPUTUSAN MENTERI KESEHATAN NOMOR 514 TAHUN 2015 STANDAR KOMPETENSI DOKTER UMUM TAHUN 2012 LEVEL KOMPETENSI 4A
- 4. INTRODUCTION Less than 3 D MYOPIA Less than 2 D ASTIGMATISME Less than 3 D HIPERMETROPIA Surat PP Perdami kepada Dirjen Yankes Kemenkes, no.0275/Perd.XIV/Sek/7/2019
- 5. Eyeball grows either too long or short Eyeball length Changes shape of cornea Cornea’s problems Cloudy lens Aging of the lens What causes refractive errors ?
- 6. Refractive Error Refractive error is a problem with focusing light accurately on the retina due to the shape of the eye M y o p i a H y p e r m e t r o p i a A s t i g m a t i s m P r e s b y o p i a
- 7. Myopia R e f r a c t i v e E r r o r N e a r s i g h t e d n e s s Genetics and environmental factors Etiology Eye disorder when the lights focuses in front of retina → objects look blurry Definition Juvenile onset (7-16 years old) Adult onset (begins at 20 years old) Characteristic 2% begins at 6 years old 3% in children under five and 25% in adolescents Prevalence M i l d < 3 D M o d e r a t e 3 D – 6 D
- 8. Hyperopia / Hypermetropia R e f r a c t i v e E r r o r F a r s i g h t e d n e s s Early 40’s (20%) 70-80 years old (60%) - Lens changes - Insufficient refractive power - Short globe (axial) Causes : Parallel rays converge at focal posterior to the retina Prevalence
- 9. Astigmatism R e f r a c t i v e E r r o r Its often simultaneously with another refractive error Light rays focus on more than one point (unequal refraction of light in defferent meridians) People born with it partially, but many people develop it as children or young people
- 10. Cornea or lens has different shape than normal (congenital / acquired) Cloudy lens makes light bend differently as it enter the eye Astigmatism’s Symptoms R e f r a c t i v e E r r o r
- 11. Astigmatism’s Symptoms R e f r a c t i v e E r r o r Trouble seeing at night Mild astigmatism might not notice any symptom Blurry vision Need to squint to see clearly Eye strain Headache
- 12. Presbyopia R e f r a c t i v e E r r o r Insufficient to read and carry out near vision tasks Gradual loss of accommodative response resulting from reduced elasticity of the lens It is begin after 40 years Accomodative insufficiency → loss of accommodative amp
- 13. Presbyopia R e f r a c t i v e E r r o r Source : AAO Clinical Optic 2018-2019
- 14. Spherical lenses, cylindrical, multifocal lenses Spetacle lenses Soft, hard, rigid gas permeable Contact lenses Radial keratotomy, LASIK Refractive surgery Treatment of Refractive Error
- 17. To Determine by subjective combination of spherical and cylindrical lenses necessary to provide best visual acuity Rely on the patient’s responses to the refractive correction
- 18. MEASURE PUPILLARY DISTANCE Measure the distance of the light spot between OD and OS as near pupil distance Add 2 mm for pupil distance for far distance op the flashlight light onto both eyes Drop the flashlight light onto both eyes The patient look at the observer forehead or the lights
- 21. Snellen Chart
- 24. IDEAL DISTANCE : 6 METER
- 25. Testing Distance Visual Acuity VISUAL ACUITY = 6/6 OR 1.0
- 26. Testing Distance Visual Acuity 01 Ask • Ask the patient to stand or sit at a designated testing distance 02 Occlude • Occlude the left eye. Be sure that the occluder is not touching or pressing against the eye. 03 Ask • Ask the patient to say aloud each letter or number, or name the picture object on the lines of successively smaller optotypes, from left to right. Note • Record the acuity value for each eye separately, with correction and without correction
- 27. If the patient misses half or fewer than half the letters on the smallest readable line, record how many letters were missed. If acuity is worse than 20/20, recheck with a 2.4 mm pinhole Repeat steps for the left eye, with the right eye covered. If desired, retest acuity with the patient using both eyes simultaneously and record acuity OU Record the power of the corrective lenses worn for the distance acuity determination Testing Distance Visual Acuity
- 28. TARGET !!! UCVA : 6/9 F2 PINHOLE : 6/8
- 29. PINHOLE VISUAL ACUITY If Acuity worse than 6/6 or 20/20 Instruct patient to look at distance chart Ask patient to use pinhole occluder in front of eye Position patient and occlude eye that not being tested Record the snellen chart Read the smallest letter that are legible on previous vision test with pinhole
- 30. PINHOLE
- 31. ANATOMY OF TRIAL SPECTACLES AXIS ADJUSTER AXIS INDICATOR PUPILLARY DISTANCE ADJUSTER
- 32. CORRECTION LENS Occlude the eye not being tested Duochrome test. Is the vision worse? Add a +0.50 D sphere. Repeat the procedure for another eye Record the Corrective Lens NO: add more plus spherical power with +0.50 D until the vision clearer. YES: add minus spherical power with -0.50 D until the best line can be resolved. .
- 34. NEAR VISUAL ACUITY Record it Occlude untested eye Wear reading glasses if necessary Position book a comfortable distance from the eye Ask patient to read each letter or word Repeat procedure for another eye and both eye
- 36. Astigmatic Eye
- 37. ANATOMY OF TRIAL SPECTACLES AXIS ADJUSTER AXIS INDICATOR PUPILLARY DISTANCE ADJUSTER
- 39. Snellen Chart
- 40. ASTIGMAT DIAL
- 41. FOGGING +/- 0.50 D NOTE THE THICKEST LINE ADD CYLINDER WITH AXIS PERPENDICULAR TO THICKEST LINE REDUCE FOGGING CONTINUE TO SNELLEN CHART
- 42. CYLINDRICAL LENS ADD CYLINDER WITH AXIS 90 DEGREE
- 43. LENS PRESCRIPTION AXIS FOR ASTIGMATISM TYPE OF LENS DISTANT SPECTACLES NEAR SPECTACLES
- 45. CASE, Male, 41 yo • VA OD: 0.5 PH 0.8 → S-0.50 : 1.0 • VA OS : 0.5 PH 0.8 → S-0.50 : 1.0 • Near Vision : add +1.00 ( can read the smallest letter in 30 cm ) • Pupillary Distance : 62/60
- 47. CASE, Male, 21 yo • VA OD: 0.32 PH 0.5 → S-0.50 C -0.75X180 : 1.0 • VA OS : 0.32 PH 0.5 → S-0.50 C-0.75X180 : 1.0 • Near Vision : can read the smallest letter in 30 cm • Pupillary Distance : 62/60
- 48. LENS PRESCRIPTION -0.50 -0.50 62 -0.75 -0.75 180 180 180 180
- 49. TAKE HOME MESSAGE • Encourage yourself • Practice • Refer in Complicated Cases • Help the patients
- 52. THANK YOU