The document provides an in-depth overview of retinoscopy, a technique for determining refractive errors in the eye, including its history, types, and methods. It discusses the evolution of retinoscopes, the principles of operation, and various forms of retinoscopy, such as static and dynamic retinoscopy. Additionally, it highlights the importance of retinoscopy for patients who cannot communicate traditionally and outlines relevant procedures and potential challenges in performing the technique.

1. RETINOSCOPY
Presenter : Dr. Aakanksha Bele
M.S. Ophthalmology

2. Introduction
• Also known as sciascopy or shadow test or
pupilloscopy or korescopy.
• Started by Sir William Bownman in 1859.
• Term retinoscopy was coined by Parent in 1881.
• Definition – Objective method of finding out the
error of refraction by utilizing the technique of
neutralization.

3. Evolution of
Retinoscope
• 1859 – Sir William Bowman – introduced retinoscopy, he saw
peculiar linear reflex while viewing astigmatic eyes with
Helmholtz’s new ophthalmoscope.
• 1873- Ferdinand Cuignet ( father of retinoscopy) – first
described retinoscope and the objective diagnosis of
refractive errors.
• 1901 – Wolff introduced first electric retinoscope.
• 1902 – A.J. Cross introduced dynamic retinoscopy.
• 1903 – Duane – advocated use of cylindrical lenses in
astigmatism.
• 1927 – Copeland (father of streak retinoscopy) – introduced
streak retinoscope.

4. Why to do
Retinoscopy?
• To estimate a person’s refractive error before
starting subjective refraction.
• To estimate refractive errors of people who have
problems communicating:
- Babies or young children.
- People with physical or mental disability.
- People who speak language that is difficult to.
Understand.
- Deaf or mute people.

5. How does
the
retinoscopy
work?
• The retinoscope illuminates the inside of the
patient’s eye.
• The clinician examines the light as it is reflected
from the external limiting membrane of the
patients retina.

6. Optics
• Focault’s Principle :- When light is reflected
from a mirror into the eye, the direction in
which the light will travel across the pupil will
depend upon the refractive state of the eye.
• 3 stages :
1. Illumination stage – illumination of subjects
retina
2. Reflex stage – the reflex imagery of this
illuminated area formed by the subject’s
dioptric apparatus
3. Projection stage – projection of image by the
observer

7. Optics of Retinoscope
• Projection System :
- Light source
- Condensing lens
- Mirror
- Focusing sleeve
- Current source
• Observation System : for
examiner to see the retinal
reflex from the far point.

8. Optics of
emmetropia,
hypermetropia
and myopia

9. With
movement

10. Against
movement

11. The Goal

12. Types of
Retinoscopy
• Static vs Dynamic Retinoscopy
• Wet vs Dry Retinoscopy

13. Static
Retinoscopy
• Definition - patient fixates on a distance target
with accommodation relaxed.
• Shine the streak of light into patient’s eye and
move it within the pupil.
• Observe how the streak appears to move in the
patient’s pupil which tells us where the far point
of his eye is located.

14. Dynamic
Retinoscopy
• Definition - Patient fixates on a near target and
the status of his/ her accommodation is
evaluated
• Refraction with active accommodation

15. Near
Retinoscopy
• The patient is looking at a near object, with
accommodation at rest.

16. Types of
Dynamic
Retinoscopy
• Monocular estimation method – helps to calculate patients
lag or lead of accommodation.
• Bell retinoscopy – retinoscope remains in a fixed position
& target is moved.
• Nott’s retinoscopy – determines lag/ lead of
accommodation by moving retinoscopic aperture towards
or away from the eye
• Book retinoscopy – aka getman retinoscopy. Developed to
obtain information about the visual processing of
nonverbal infants
• Cross retinoscopy
• Sheard’s retinoscopy
• Tait’s retinoscopy
• Mohindra retinoscopy – also known as near monocular
retinoscopy. For determining the refractive state of infants
& children.

17. Dry
Retinoscopy
• Without Cycloplegics

18. Wet
Retinoscopy
• With the use of cycloplegics.
• Indications :
- Accommodative fluctuations indicated by a
fluctuating pupil size and/or reflex during
retinoscopy
- Patients with esotropia or convergence excess
esophoria
• Disadvantages :
- Temporary symptoms of blurred vision &
photophobia
- Adverse effects & allergic reactions

19. Salient features of common cycloplegic & mydriatic drugs
Sr.no Drug Age of
patient
when
indicated
Dosage Peak effect Time for
retinoscopy
Duration of
action
Period of
post
cycloplegic
test
Tonus
allowance
1 Atropine sulphate
(1% oint)
< 5 years TDS X 3 days 2-3 days 4th
day 10-20 days After 3 wks
of
retinoscopy
1 D
2 Homatropine
hydrobromide (2%
drops)
5 - 8 years One drop
every 10 min
for 6 times
60-90 mins After 90 min
of instillation
of first drop
48 – 72 hrs After 3 days
of
retinoscopy
0.5 D
3 Cyclopentolate
hydrochloride (1%
drops)
8 – 20 years 1 drop every
15 min for 3
times
80– 90 mins After 90 min
of instillation
of first drop
6 – 18 hrs After 3 days
of
retinoscopy
0.75 D
4 Tropicamide (0.5%,
1%)
Used only as
mydriatic
1 drop every
15 min for 3-
4 times
20 – 40 mins 4 – 6 hrs
5 Phenylephrine (5%,
10%)
Used only as
mydriatic
1 drop every
15 min for 3-
4 times
30 – 40 mins 4 – 6 hrs

20. Far point
• Definition – Point in space that is conjugate to
the fovea, when accommodation is at rest
• Myopes – Far point is between clinician & patient
• Hyperopes – Far point is behind the patient
• Astigmatism – Have 2 far points
• Emmetropes – Far point is at infinity.

21. Working
Distance
• How far are we from our patient….
• The working distance typically used when
performing retinoscopy is 67cm (26”).
• This created working distance lens of 1.50D
• Short arms ???
- 50 cms (20”)
- 2.00D working distance lens

22. Assessing
the reflex
Reflex Observation Refractive Error
Width Narrow Large
Wide Small
Brilliance Dull Large
Bright Small
Speed Slow moving Large
Fast moving Small
Direction With Hyperopia
Against Myopia

27. Types of Retinoscope
Self illuminated retinoscope:-
1. Spot retinoscope – have an ordinary
light globe that gives a “patch” or
“spot” of light
2. Streak retinoscope – have a special
globe that gives a line, or “streak”, of
light

28. Parts of
streak
retinoscope

29. Types of Retinoscope
Reflecting mirror retinoscope
1. Plane mirror
2. Priestley – smith’s mirror (plane and
concave mirrors)

30. Loose lenses or
Phoropter??
• For young patients who cannot sit
at phoropter, trial lenses may be
used
• Phoropter can be used after age
of 5 yrs

31. The retinoscope:
Sleeve up or Sleeve down
• It is important to use the
sleeve position which
produces a divergent light.
• Streak retinoscope bulb has
linear filament. Move sleeve
up or down to produce
divergent light.

32. Procedure
• Patient is made to sit at a working distance of
2/3rd
m from the examiner.
• The room should have dim light
• Hold the retinoscope in your right hand & right
eye for patient’s right eye (swap for left eye).
• Ask the patient to focus on a far point.
• Turn the retinoscope on & rotate the collar so the
light is vertical
• Shine the light into patient’s right eye & observe
the red reflex.
• Now move the light from side to side 3 or 4
times.
• Observe, Neutralize & Interpret.

33. Procedure
cont..
• For non cycloplegic refraction of patient who are
not presbyopia it is necessary to fog the fellow
eye.
• Occlusion is required in :
- When eye being tested is densely amblyopic
- Patient objects to fogging due to diplopia or
asthenopia
- Unable to estimate acuity & provide adequate
fog lens.
- For cycloplegic refraction there is no need to fog,
since accommodative component is removed by
cycloplegia

34. “You can’t learn retinoscopy
by reading a book”
- Jack C.
Copeland

35. Lets do some Retinoscopy

36. 3 steps to retinoscopy
Start with WITH motion
ADD power to neutralize reflex
SUBSTRACT working distance &
tonus allowance at the end

37. 1. Basics
(working with
only spherical
lens)

38. Prescription
+3.00 D sphere
-1.50 D (subtract working distance)
+1.50D (final prescription)

39. 2. Again
Sphere

40. Prescription
+2.00 D sphere
-1.50 D (subtract working distance)
+0.50D (final prescription)

41. 3. One more

42. Prescription
+1.00 D sphere
-1.50 D (subtract working distance)
-0.50D (final prescription)

43. 4. Lets start
with against
the motion

44. Prescription
-1.00 D sphere
-1.50 D (subtract working distance)
-2.50D (final prescription)

45. That easy???
No !!!
Lets solve some with
Astigmatism…

46. 5. Simple
Astigmatism

47. Prescription
+2.00 D sphere +1.00D cylindrical at 900
-1.50 D (subtract working distance)
+0.50 +1.00 at 900
(final prescription)

48. 6. Another
simple one

49. Prescription
+3.00 +2.00 at 1800
-1.50 D (subtract working distance)
+1.50 +2.00 at 1800
(final prescription)

50. 7. What if we
get against
the motion at
the beginning
??

51. Prescription
-3.00 +2.00 at 900
-1.50 D (subtract working distance)
-4.50 +2.00 at 900

52. 8. Lets do
one more

53. Prescription
-3.00 +5.00 at 1800
-1.50 D (subtract working distance)
-4.50 +5.00 at 1800

54. What about un-
rule astigmatism
angles??

55. 9. Oblique
reflex…

56. Prescription
-3.00 +2.00 at 1200
-1.50 D (subtract working distance)
-4.50 +2.00 at 1200

57. Problems in Retinoscopy
Possible causes Solutions
1. Reflex may not be visible
- Opaque/ hazy media Use mydriatics
- Small pupil Use mydriatics
- High degree of refractive error Keep on follow up
2. Varying/ Changing retinoscopic findings
- Wandering fixation Give a specific target
- Abnormally active accommodation Fogging technique
Cycloplegic refraction in young
3. Scissor reflex
- High astigmatism Rotate retinoscopic illumination to find angle where
scissor reflex is minimum
- Nebular corneal opacities Increase illumination to decrease pupil diameter
Spot retinoscopy

58. Problems in Retinoscopy
Possible causes Solutions
4. Conflicting or triangular Shadows
- Irregular astigmatism Do keratometry & subjective refraction & prescribe
minimum power that gives maximum visual acuity
- Keratoconus - Relate refraction to visual acuity
- Perform corneal topography
- Do keratometry & subjective refraction
2. Spherical aberration
- Positive aberration (in normal accommodating
lens)
- Increase retinoscope illumination to decrease pupil
diameter
- Concentrate on central bright glow
- Negative aberration (more in lenticular nuclear
sclerosis)
- Increase retinoscope illumination
- Perform dilated retinoscopy

60. Reasons for false
reading
• Inexperience
• Not aligning with visual axis of the
patient
• Definite working distance is not
maintained
• Lack of patient’s accommodation
• Defect in trial lenses
• Lack of patient’s co-ordination

61. Non
refractive
uses of
retinoscopy
• Opacities in the lens & iris – dark areas against
the red background
• Extensive transillumination defects in uveitis or
pigment dispersion syndrome – bright radial
streaks on the iris
• Keratoconus distorts the reflex & produces a
swirling motion
• Retinal detachment involving the central area will
distort the reflecting surface & a grey reflex is
seen

62. Summary
Movement
(with WD at
1m)
Against
Myopia >1D
With
Emmetropia Hypermetropia Myopia <1D
No movement
Myopia +1 D

63. Summary
Size, Speed &
Brilliance
Narrow, Fast
& Bright
Low
refractive
error
Wide, Slow &
Dim
High
refractive
error

64. Thank you