Pemeriksaan Refraksi Objektif

OBJECTIVE
REFRACTI
ON
Marco Angelo Liwan

INTRODUCTION
Retinoscopy is important. A retinoscope can
help the examiner detect optical
aberrations, irregularities, and opacities,
even through small pupils.
Retinoscopy is especially useful for

examinations of infants, children, and
adults unable to communicate.
● The illumination of the retinoscope is provided by a bulb with a
straight filament that forms a streak in its projection, or by means
of a slit-shaped aperture
● The light is reflected from a mirror that is either half silvered or
totally silvered around a small circular aperture
3
4
PROCEDURE
● The examiner uses his or her right eye to perform retinoscopy on
the patient’s right eye, and the left eye for the patient’s left eye
● If the examiner looks directly through the optical centers of the
trial lenses while performing retinoscopy, reflections from the
lenses may interfere.
● If the examiner is too far of-axis, unwanted spherical and
cylindrical errors may occur.
5
PROCEDURE
● Observing characteristics of this reflex, the examiner determines
the refractive status of the eye.
○ Emmetropic, the light rays emerging from the patient’s pupil
are parallel to one another
○ Myopic, the rays are convergent (Fig 4-4); and if the eye is
hyperopic, the rays are divergent.
● However, if the far point of the patient’s eye is not at the
peephole of the retinoscope, only some of the rays emanating
from the patient’s pupil enter the peephole, and illumination of
the pupil appears incomplete. 6
PROCEDURE
● Observing characteristics of this reflex, the examiner determines
the refractive status of the eye.
○ Emmetropic, the light rays emerging from the patient’s pupil
are parallel to one another
○ Myopic, the rays are convergent (Fig 4-4); and if the eye is
hyperopic, the rays are divergent.
● However, if the far point of the patient’s eye is not at the
peephole of the retinoscope, only some of the rays emanating
from the patient’s pupil enter the peephole, and illumination of
the pupil appears incomplete. 7
PROCEDURE
8
PROCEDURE
9
PROCEDURE
The moving retinoscopic reflex has 4 main characteristics (Fig 4-7):
1. Speed. The reflex seen in the pupil moves slowest when the far point is distant from
the examiner (peephole of the retinoscope). As the far point is moved toward the
peephole, the speed of the reflex increases. In other words, large refractive errors have a
slow-moving reflex, whereas small errors have a fast reflex.
2. Brilliance. The reflex is dull when the far point is distant from the examiner; it
becomes brighter as neutrality is approached.
3. Width. When the far point is distant from the examiner, the streak is narrow. As the far
point is moved closer to the examiner, the streak broadens and, at neutrality, fills the
entire pupil. This situation applies only to with movement reflexes.
4. Regularity. An irregular reflex indicates a media problem that should be further
explored in examination.
10
11
PROCEDURE
Finding the cylinder axis before the powers in each of the principal
meridians can be determined, the axes of the meridians must be
determined. Four characteristics of the streak reɻex aid in this
determination:
Break. A break is observed when the streak is
not oriented parallel to 1 of the principal
meridians. The reflex streak in the pupil is not
aligned with the streak projected on the iris and
surface of the eye, and the line appears broken
(Fig 4-10). The break disappears (ie, the line
appears continuous) when the projected streak is
rotated to the correct axis.
Intensity. The intensity of the line is brighter when

the streak is on the correct axis
12
PROCEDURE
Width. The width of the reflex in the pupil
varies as it is rotated around the correct
axis. The reflex appears narrowest when
the streak, or intercept, aligns with the axis
(Fig 4-11).
Skew. Skew (oblique motion of the streak

reflex) may be used to refine the axis in small
cylinders. If the retinoscope streak is off-axis, it
moves in a slightly different direction from that
of the pupillary reflex (Fig 4-12). The reflex
and streak move in the same direction when the
streak is aligned with 1 of the principal
meridians
13
PROCEDURE
When the streak is aligned at the correct axis, the sleeve may be lowered
(Copeland instrument)or raised (Welch Allyn instrument) to narrow the streak,
allowing the axis to be determined more easily (Fig 4-13).
14
This axis can be confirmed through a technique known as straddling, which is
performed with the estimated correcting cylinder in place (Fig 4-14). The retinoscope
streak is turned 45°off-axis in both directions, and if the axis is correct, the width of
the reflex should be equal in both off-axis positions. If the axis is not correct, the
widths are unequal in these 2 positions. The
axis of the correcting plus cylinder should be moved toward the narrower reflex and
the straddling repeated until the widths are equal.
15
Finding Cylinder Power
After the 2 principal meridians are identified, the previously explained spherical
techniques are applied to each axis:
• With 2 spheres. Neutralize 1 axis with a spherical lens; then neutralize the axis 90°
away. The difference between these readings is the cylinder power.
• With a sphere and cylinder. Neutralize 1 axis with a spherical lens. To enable the
use of with reflexes, neutralize the less plus axis first. Then, with this spherical lens in
place, neutralize the
16
Pseudonetralization
As noted above, in general, with reflexes are brighter, sharper, and easier to perceive and
interpret than against reflexes. In particular, the reflex in severely myopic eyes is seldom
recognizable as an against reflex—rather, one sees only a dull, motionless illumination of the
entire pupil. This is referred to as pseudoneutralization. This is best handled by reversing the
sleeve of the retinoscope (to the maximal sleeve-up position for Welch-Allyn type retinoscopes;
maximal sleeve-down position for Copeland retinoscopes). This will convert the dull pseudoneutral
reflex to a readily recognizable with reflex, but in this case, the with reflex must be neutralized by
adding minus sphere power. As true neutrality is approached, return the retinoscope sleeve to the usual
position. The reflex will revert to an against reflex as in typical myopic eyes. Continue to add minus
sphere power until a with reflex is obtained, and then reduce the minus sphere so as to reach true
neutrality from the with direction. Video 4-4 demonstrates pseudoneutralization.
17
TERIMAKASIH

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OBJECTIVE

Marco Angelo Liwan

Retinoscopy is especially useful for

Intensity. The intensity of the line is brighter when

Skew. Skew (oblique motion of the streak

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