Dynamic Retinoscopy

Front 1

What is the purpose of dynamic retinoscopy?

Back 1

to determine the near point of the eye

Front 2

Dynamic retinoscopy aka ____

Back 2

near retinoscopy

Front 3

In STATIC retinoscopy, accomodation must be ____

Back 3

relaxed (fogging left eye, looking for against OS, blocking right eye with your head).

Front 4

In STATIC retinoscopy, you are determining the patient's ___ ___.

Back 4

far point

Front 5

In DYNAMIC retinoscopy, accomodation must be ____

Back 5

functioning/engaged

Front 6

In DYNAMIC retinoscopy, you are determining the patient's ___ ___.

Back 6

near point

Front 7

Do you have to worry about taking out your working distance with dynamic ret?

Back 7

NO!

Front 8

What do you ask the patient to do when performing dynamic ret?

Back 8

Keep the target clear! Ask the patient to engage their accomodation.

Front 9

True or False: Dynamic retinoscopy is done without a working lens.

Back 9

True: the lens is supplied by the eye.

Front 10

True or False: Dynamic retinoscopy uses the same movement determination as static retinoscopy.

Back 10

True

Front 11

define "with motion"

Back 11

eye conjugate to a point eye's near point is behind the retinoscope.

eye is underaccomodating

lag of accomodation

Front 12

define "against motion"

Back 12

eye conjugate to a point between the eye and the retinoscope (in front of the retinoscope)

indicates that the eye's near point is in front of the retinoscope (between clinician and patient)

eye is overaccomodating

lead of accomodation

Front 13

define "neutrality"

Back 13

eye conjugate with the retinoscope

indicates that the eye's near point is located at the retinoscope aperture

no lag, no lead

eye is accomodating exactly +2.50 D at 40 cm

Front 14

When you perform you determine the eye's near point, you are determining the eye's accomodative ___, or ___

Back 14

response, POSTURE (where in space the accomodative system likes to hang out)

Front 15

What other test will also help you gauge accomodative posture?

Back 15

Fused Crossed Cylinder (FCC)

Front 16

Is the eye's accomodative response equal to the accomodative demand?

Back 16

generally not

Front 17

Is the eye accomodating exactly +2.50 D for an object at 40 cm?

Back 17

USUALLY NOT... usually the eye UNDERaccomodates by about +0.50-0.75 D (lag)

Front 18

Is the response always equal to the stimulus?

Back 18

No

Front 19

Name two things that define the demand?

Back 19

1) stimulus - where in space the target is

2) have a refractive error that is not their own (overplussed/overminused)

Front 20

True or False: dynamic ret also reveals the stability or the degree of fluctuation of the accomodative system

Back 20

True:

Results stable - means accomodation is not fluctuating much (GOOD!)

Results fluctuate - means you may be dealing with an accomodative spasm OR the patient may not be fixating correctly

Front 21

The ____ is provided by the distance from the eye to the target.

Back 21

accomodative STIMULUS (i.e. target at 40 cm = 2.50 D stimulus)

Front 22

The ____ is provided by the target distance as well as refractive error/uncorrected refractive error.

Back 22

accomodative DEMAND (i.e. target at 40 cm and patient overminused by 1.00 D = 3.50 D demand

Front 23

The difference between the accomodative stimulus and accomodative response equals the ___ or ___ of accomodation.

Back 23

lag, lead

Front 24

Stimulus of 2.50, but only accomodating 2.00 = __ of __

Back 24

lag, +0.50

Front 25

Stimulus of 2.50, but accomodating 2.75 = __ of __

Back 25

lead, -0.25

Front 26

When the accomodative system is ___, there is a lag of accomodation.

The system is lagging ___ the target.

Patient's eye is focused where?

Back 26

underactive

behind

at a point beyond the target

Front 27

When the accomodative system is ___, there is a lead of accomodation.

The system is ___ the target.

Patient's eye is focused where?

Back 27

overactive

leading

at a point in front of the target.

Front 28

How does a lag or lead work, and still have a clear image?

Back 28

Because of depth of focus and depth of field, the accomodative response is generally less than the stimulus (usually by +0.50 to +0.75)

Front 29

If at 40 cm Brian has a normal lag of +0.50, his accomodative system is focused where?

Back 29

10 cm behind the target

(he's only accomodating 2.00 D for 40 cm, so he has a +0.50 lag - he's focused at 50 cm instead of 40 cm, so that's 10 cm behind the target)

Front 30

When do we perform dynamic ret?

Back 30

1) Any adult exam where they have a near complaint or where you suspect an accomodative spasm

2) suspect overminused or overplussed

3) suspect latent hyperopia or accomodative spasm

4) possible emerging presbyopes

5) presbyopes, in order to determine tentatve add power

6) All pediatric eye exams

7) BV exams, follow-ups if warrranted

Front 31

Near complaints include:

Back 31

1) near blur
2) asthenopia
3) diplopia
4) headache
5) trouble reading
6) focusing problems at near
7) unable to read for prolonged periods of time

Front 32

What are the results of this test used for?

Back 32

-Primarily used to confirm suspected cases of vergence of accomodative dysfunction

-to determine whether a patient is over or undercorrected

- results give you the same info as FCC - dont do both

Front 33

How do you perform dynamic retinoscopy?

Back 33

neutralize the reflex of the eye while the patient accomodates to fixate a target at near (40 cm)

Front 34

With motion means?

Back 34

lag of accomodation

Front 35

Against motion means?

Back 35

lead of accomodation

Front 36

Name the two accepted methods of dynamic ret?

Back 36

1) MEM (monocular estimate method)
2) Nott Method

Front 37

What kind of trial lenses do you add when you see against motion with MEM?

Back 37

MINUS

Front 38

What kind of trial lenses do you add when you see with motion with MEM?

Back 38

PLUS

Front 39

Where is the target placed when doing both MEMs and the Nott Method?

Back 39

at patient's working distance (usually 40 cm)

Front 40

How do you perform the Nott Method?

Back 40

clinician with retinoscope moves toward and away from the patient until views neutrality

through phoropter: manifest dialed into phoropter and patient fixating 40 cm target. clinician moves in or out with retinoscope until reflex is neutralized.

Front 41

in the Nott method, if you see against motion, which direction should you move?

Back 41

move closer to patient

Front 42

in the Nott method, if you see with motion, which direction should you move?

Back 42

move further away from patient

Front 43

Can you perform MEMs with the phoropter instead of trial lenses?

Back 43

yes

(BVA dialed into phoropter; the clinician with retinoscope must stay at the plane of the target)

Front 44

Should MEMs and the Nott method be performed with the patient's correction for distance or near on?

Back 44

Yes (glasses/CLs, phoropter with BVA, trial frame)

Front 45

If the patient is a presbyope, should MEMs be done through the distance or near portion?

Back 45

near add

Front 46

True or False: Cylinder should not be corrected when doing MEMs

Back 46

FALSE! cylinder SHOULD be corrected, unless very small amount

(if 1.00 D cyl - put in trial frame)

Front 47

True or False: Patient is viewing target binocularly, but eyes are examined one at a time.

Back 47

True

Front 48

True or False: For kids, the target for dynamic ret is placed at 40 cm.

Back 48

FALSE!! Kids hold things closer, so use Hartmann's distance.

Front 49

What is Hartmann's Distance?

Back 49

used for determining target distance for kids in dynamic ret.

put hand behind ear, that distance to elbow is where you do retinoscopy on a kid.

Front 50

The target should be an excellent stimulus for accomodation. What is this size?

Back 50

.37 to 1M

Front 51

What is the lighting like when doing dynamic ret?

Back 51

Low light intensity (of retinoscope)

&

dim room lighting, but target illuminated with stand lamp

Front 52

Rapid estimation means?

Back 52

be quick with dazzle of light from retinoscope; beam into pupil for short periods of time (1 sweep across pupil, 2 at most)

Front 53

Do you need the stand lamp on during dynamic ret?

Back 53

Yes, the target is illuminated with the stand lamp

Front 54

If you do dynamic ret from an oblique angle, will that skew your results?

Back 54

Yes, remain as close to the patient's line of sight as possible when neutralizing reflex.

Front 55

What are your instructions to the patient?

Back 55

1) Ignore the light!
2) Steadily view the target, keep it clear!!
3) Read the letters to yourself/or out loud!

Front 56

How do you perform the MEM method?

Back 56

1) briefly place lenses to neutralize the reflex (examine the reflex in the horizontal meridian- light beam vertical)
2) retinoscopist and target at patient's preferred working distance (usually 40 cm)
3) patient wears correction for distance or near (if they have both, choose near)

Front 57

When doing MEMs, do you keep the beam vertical or horizontal?

Back 57

vertical, only sweeping the horizontal meridian (b/c they have their correction on and you already corrected their cylinder)

Front 58

True or false: the lens should not be there longer than 1/2 sec.

Back 58

True

Front 59

True or false: the lens that creates neutrality is the value of the accomodative lag/lead

Back 59

True: plus (lag), minus (lead)

Front 60

Should you bracket?

Back 60

Yes, it assures an accurate endpoint

Front 61

What lens should you try first when you see with motion? against motion?

Back 61

With motion: add plus; start with +1.00 or +0.75

Against motion: add minus; start with -0.50

Front 62

True or False: measurement should be made within 2 sweeps, or 1 second (per lens used)

Back 62

True (minimizes dazzle of light and effect of lens on accomodative system)

Front 63

What are the norms of the accomodative system?

Back 63

-lag of +0.50 to +0.75 at 40 cm
-equal results between the 2 eyes
-stable results when fixation is maintained
-results should be similar to that of FCC/BCC (net)

Front 64

Will presbyopes have a normal lag of accomodation of +0.50 to +0.75?

Back 64

No, their accomodative ability declines, increasing the expected lag of accomodation (with absolute presbyopia: expected lag is +2.00 to +2.50 D, without an add in place)

Front 65

True or False: lag of accomodation changes as a funtion of the stimulus distance

Back 65

True

Front 66

Expected lag ___ dramatically as the accomodative demand increases.

Back 66

increases

This can happen when the target distance decreases or the patient is overminused or overplussed.

Front 67

What is the clinical implication of the AC/A ratio? Or what does it have to do with MEMs?

Back 67

the relationship between vergence and accomodation can be demonstrated by the accomodative posture.

Front 68

What does a high lag of accomodation (>+0.75D) mean? What are circumstances in which you would have a high lag?

Back 68

1) normal: 5.5%
2) Esophoria at near (with insufficient compensating vergences)
3) Accomodative dysfunction (insufficiency, fatigue, paresis, infacility)
4) Presbyopia, prepresbyopia
5) uncorrected hyperopia (latent hyperopia)
6)overminused
7) Patient not keeping the target clear... not acccomodating

Front 69

Why would someone have a lag greater than +2.50 (with target at 40 cm)?

Back 69

1) uncorrected hyperopia/latent hyperopia
2) overminused
**These are the only factors that could account for such a high lag.

Front 70

Why would someone have a low lag, or lead of accomodation (+0.25 or less)?

Back 70

1) Normal: 8%
2) Exophoria at near (with insufficient compensating vergences)
3) Spasm of accomodation (pseudomyopia)
4) uncorrected myope
5) malingerer
6) overplussed

Front 71

Unequal results between the two eyes usually results from a ___ ___.

Back 71

near imbalance
such as:
1) anisometropia (unequal accomodative demand)
2) improper balance of distance Rx
3) unilateral or asymmetric Adie's tonic pupil

Front 72

____ __ ____ also often indicates a near imbalance or accomodative spasm.

Back 72

Fluctuation of reflex

Front 73

What is the proper way to record dynamic ret results?

Back 73

Dynamic Ret (MEM): +0.50 lag OD, OS

Front 74

What are some sources of error that affect both dynamic and static retinoscopy?

Back 74

1) scissors
2) small pupils
3) dim media (cataracts)
4) angle

Front 75

What are some sources of error that affect dynamic retinoscopy?

Back 75

1) changes in fixation or accomodative level
2) failure of patient to understand or cooperate, poor motivation
3) patient looking at a target at a different distance than requested
4) inadequate visibility of target (by patient) or the reflex (by clinician)
5) adaptation of lenses with MEM technique - relax when plus lenses are in front of eye, stimulated when minus lenses are in front of eye

Front 76

What is the latency of the accomodative system?

Back 76

250-500 ms (0.45 -0.50 sec) - that's why lenses should be moved in and out quickly

Front 77

measurement should be made within __ sweeps or __ second

Back 77

2, 1

Front 78

What are practical problems of the Nott Method?

Back 78

1) lag too large - difficult to see the reflex (you get too far away)
2) lead - your head gets in the way

Front 79

What other tests should you look at to determine the clinical significance of your findings?

Back 79

1) patient's correction (retinoscopy, refraction)
2) accomodation
3) phoria
4) vergences
5) AC/A

Front 80

Patients with a ___ AC/A ratio will be more likely to have their accomodative posture affected

Back 80

High

Front 81

Can dynamic retinoscopy be used to determine a near add?

Back 81

yes

Front 82

How do you determine a near add using dynamic retinoscopy?

Back 82

same technique, lens that neutralizes reflex is tentative near add

Front 83

What did the Comet II study show abut SV vs. PAL's in relation to myopia progression?

Back 83

showed some evidence that a HIGH lag of accomodation may be predictor of good results with this mechanism of preventing progression of myopia in kids.