LABORATORY MANUAL

VISION SCIENCES
BVS-6402
1 Credit hour
120minutes

DEPARTMENT OF OPTOMETRY AND VISION

SCIENCES
USHANA JAMIL
STUDENT NAME:______________________________________
REGISTRATION # :_____________________________________
INSTRUCTOR NAME:__________________________________

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 INDEX
Week PRACTICALS DATE STUDENT INSTRUCTOR PAGE #
SIG. SIG.
1 INTRODUCTION TO INSTRUMENTS USED 4-6
IN VISION SCIENCES

2 TRIAL BOX ACCESSORIES 7-8

3 CONTRAST SENSITIVITY 9-11

4 COLOR VISION 12-14

5 VISUAL FIELD PERIMETRY 15-17

6 SQUINT ASSESSMENT 18-20

7 PUPILLARY RESPONSES 21-24

8 HISTORY TAKING 25-28

9 REVISION/ PRACTICAL ASSESSMENT ------

10 SUBJECTIVE REFRACTION 29-32

11 OBJECTIVE REFRACTION 33-36

12 PSEUDOPHAKIA/APHAKIA 37-40

13 VISUAL ACUITY ASSESSMENT 41-43

14 VISUAL ACUITY CHARTS 44-52
15 VISUAL ACUITY INTERPRETATIONS 53-54

16 REVISION OF ALL PRACTICAL WORK. 55-57

17-18 VIVA VOICE/ PRACTICAL ASSESSMENT ----------

INSTRUCTOR SIGNATURE: _____________________________

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 PRACTICAL 1
INTRODUCTION TO INSTRUMENTS USED IN
VISION SCIENCES

OBJECTIVE
 To introduce students to instruments used in vision sciences
 To know the Importance of sensory processes that underlie vision and how visual
perception informs human behavior.

LEARNING OUTCOMES
By the end of practical students will be able to:
 Explain the importance of vision
 Importance of role of optometrist in vision
sciences
 understand how vision works, why visual
problems occur and develop treatment
options

EQUIPMENT
Visual acuity charts
Color vision plates
Contrast sensitivity charts
Amsler grid
Pen torch
Near vision chart

PROCEDURE
Overview of instruments used in vision sciences practicals
Explain the purpose and uses of each instrument,
Involve the students to assess their understanding.

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Briefly discuss with students HOW:
 To emphasizes the interdisciplinary nature of vision science through broad exposure to
the basic concepts and techniques
 To provide an overview of the early stage limits to human vision, from the eye’s optics to
sampling and processing in the retina
 To learn basic optical properties of the eye as well as objective and subjective techniques
on how to measure the limits of human vision
 To learn spanning the entire neural pathway from retinal neurobiology to cortical
processing of visual signals.
 To provide an overview of how we see in time (temporal signal processing, eye motion,
motion detection), space (stereo vision, depth perception), and color as well as the
anatomical and physiological factors that facilitate these capabilities

Practice and performance

Students will be divided into groups, to utilize their skills in identification, purpose and working
of several instruments used in vision science lab hours, Visual acuity charts, Color vision plates,
Contrast sensitivity charts, Amsler grid, Pen torch ,Near vision chart.

Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 2
TRIAL BOX ACCESSORIES
OBJECTIVES
 To briefly introduce to trial box accessories
 To know the specification of each trial box
accessory

LEARNING OUTCOMES
By the end of practical student will be able
to:
 Perform refraction with the help of trial box.
 Have knowledge about different
accessories.
 Know about lens types and materials.

EQUIPMENT
Trial box

PROCEDURE
1. Trial box accessories parameters
2. Accessories description
3. Clinical use of each accessories

Practice and performance

Students will be divided into groups, to make sure to use o each accessory of trial box, recall the
purpose of each accessory.

Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.
.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 3
CONTRAST SENSITIVITY
OBJECTIVES
 To explain visual functions
 To describe Development of visual functions
 To measure contrast sensitivity

LEARNING OUTCOMES
By the end of practical student will be able to:
 measure the least amount of contrast needed
to detect a visual stimulus and gives us a more
complete quantification of patients' visual
capabilities.

EQUIPMENT
 Pelli roboson contrast chart

PROCEDURE
1. Pelli-Robson test measures contrast sensitivity using a single large letter size (20/60
optotype), with contrast varying across groups of letters. Specifically, the chart uses
letters (6 per line), arranged in groups whose contrast varies from high to low.
2. Patients read the letters, starting with the highest contrast, until they are unable to read
two or three letters in a single group. Each group has three letters of the same contrast
level, so there are three trials per contrast level.
3. The subject is assigned a score based on the contrast of the last group in which two or
three letters were correctly read. The score, a single number, is a measure of the subject’s
log contrast sensitivity.
4. Thus a score of 2 means that the subject was able to read at least two of the three letters
with a contrast of 1 percent (contrast sensitivity = 100 percent or log 2).
5. A Pelli-Robson score of 2.0 indicates normal contrast sensitivity of 100 percent. Scores
less than 2.0 signify poorer contrast sensitivity. Pelli-Robson contrast sensitivity score of
less than 1.5 is consistent with visual impairment and a score of less than 1.0 represents
in visual disability.

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Practice and performance
Students will be divided into groups, to measure contrast sensitivity on one another, recall the
diseases causing reduction in contrast.

Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 4
COLOVISION

OBJECTIVES
 To measure colorvision.
 To understand the color vision
defects .
LEARNING OUTCOMES
By the end of practical student will be
able to:
 Measure colorvision.
 Detect different color vision
defects.

EQUIPMENT
 Ishihara test book

PROCEDURE
1.Introduce about ishihara test book.
The Ishihara plates come in the original 36-plate version or the shortened 24-plate version.
Only the first 17 plates of the 36-plate version and the first 13 plates of the 24-plate version
should be used in most assessments. Further plates are meant for individuals who cannot read
numbers or determine the extent of red-green blindness.
2.If the patient usually wears glasses for reading, ensure these are worn for the assessment.

Steps to perform ishihara test

 Ask the patient to cover one of their eyes.

 Then, ask the patient to read the numbers on the Ishihara plates. The first page is usually
the ‘test plate’, which does not test colour vision but assesses contrast sensitivity. If the
patient cannot read the test plate, you should document this.

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  If the patient can read the test plate, you should move through the Ishihara plates, asking
the patient to identify the number on each. Stop at the plate that reads “73” (the last plate
with a number).

4. Once the test is complete, document the number of plates the patient identified correctly,
including the test plate (e.g. 17/17). Also, make a note of the reading speed for each eye.

5. Repeat the assessment on the other eye.

6. Asses the results and make a probable diagnosis.

Practice and performance

Students will measure color vision on ishihara and record the result accordingly, and recall the
diseases which cause colorvision defects.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 5
MEASURING VISUAL FIELD

OBJECTIVES

 To measure visual field

 To explain types of parametery

LERNING OUTCOMES
By the end of practical student will
be able to:
 Do confrontation and amsler grid for
visual field assessment

EQUIPMENT
Amsler grid
occuloder

PROCEDURE

1. Hold the grid at a comfortable reading distance (generally, about 12-14 inches away).
Wear your reading glasses if you normally use them.

2. Cover one eye and focus on the black dot in the middle of the grid.
3. Cover the other eye and repeat the test. If the lines appear to be wavy, dim, irregular, or
fuzzy, schedule an eye exam immediately.

Confrontation visual field testing involves having the patient looking directly at your eye
or nose and testing each quadrant in the patient's visual field by having them count the
number of fingers that you are showing.
Performing the exam:

1. Have the patient remove their hat or anything that could interfere with their peripheral
vision.
2. Sit approximately three to four feet away and directly in front of the patient. If possible,
adjust your seat height until you are at eye level with the patient.

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 3. Ask the patient to gently cover their left eye with their left hand and instruct the patient to
fix their gaze directly on your left eye throughout the test.
4. While the patient is focusing on your eye, close your right eye and maintain fixation on the
patients open eye. Raise your hand to the inferior temporal edge of your peripheral vision
halfway between yourself and the patient, while holding up 1, 2, or 5 fingers. Using only
1, 2, and 5 fingers helps to make the number more easily distinguished by the patient. Ask
the patient how many fingers are seen.
5. Repeat step 4, testing all four visual quadrants of the left eye: Inferior temporal, inferior
nasal, superior temporal, and superior nasal.
6. Repeat steps 3, 4, and 5 for the patient’s right eye.

Practice and performance

Students will perform practical assessment of visual field by confrontation method and amsler
grid.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 6
SQUINT ASSESSMENT

OBJECTIVES
 To measure different type of ocular
deviations.

LEARNING OUTCOMES

By the end practical student will be able to:

 Gain knowledge about ,Perception of
space, direction, and distance. Binocular
retinal correspondence, horopters,
differential magnification effects and
anomalies of binocular vision
development. Sensory vision, local
stereopsis, static and dynamic stereopsis,
binocular depth cues

PROCEDURE
Torch Examination:
 Hirschbergs test
 Pseudostrabismus
 AHP
 Pupil (direct, consensual, RAPD)
 Epicanthus, telecanthus
 Ocular torticollis
Extraocular Movements:
 Versions
 Vergence
 Belchosky
 Diplopia
 Ductions if any obstruction in versions
 Saccades
 Duane’s retraction
 Nystagmus

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 Cover Tests:
 Cover, uncover, alternate cover and uncover test

 i. Distant with glasses

ii. Near without glasses

Practice and performance

Students will perform strabismus evaluation on one another, to rule out any ocular motility
disorder.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 7
PUPILLARY RESPONSES

OBJECTIVES
 To measure pupillary responses.

LEARNING OUTCOMES
By the end of practical student will be able to:
 Identify different pupillary light reflex.

EQUIPMENT
Pen torch

PROCEDURE
There are several ways that a patient’s pupillary light reflex can be tested.
The light reflex test: This test is performed in a dim room. The patient is asked to focus on a
distant target while a light is shone independently on the right eye and then the left eye. During
this test, we check to see if the pupil restricts when the light is shined directly on it, and if the
other pupil constricts as well.
Swinging flashlight test: A swinging flashlight test allows our doctors to compare the pupil
reflex of one eye to that of the other. This test is usually performed right after a light reflex test.
With the room dim, a flashlight beam will be shined on one eye, and then swung to the other eye.
This allows us to measure the response of one eye against the response of the other.
Near reflex test: A near reflex test allows us to observe a pupil’s reflex when the eyes fixation is
shifted to a close object. This test is performed in a normally lit room. The patient is asked to
focus on a distant target, and then shift their target to an object that is placed near their eyes.
 When performing a pupillary exam, it sometimes helps to illuminate pupils indirectly
from the side, so you can actually see what is happening.
 Observe the pupil size and shape at rest, looking for anisocoria (one pupil larger than the
other)
 Observe the direct response (constriction of the illuminated pupil)
 Observe the consensual response (constriction of the opposite pupil)
 Repeat with the opposite pupil
 Check for accommodation (constriction of pupil when viewing a close object)

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Abnormal Pupillary Responses
Anisocoria
Refers to the asymmetric sizes of pupils
Physiologic anisocoria can is very common and a normal variant in up to 20% of the population.
The variation should be no more than 1mm and both eyes should react to light normally.
Can be dangerous if a manifestation Horner's syndrome (e.g. carotid dissection) or from damage
to the third nerve (e.g. aneurysmal expansion)
Consider further workup such as imaging if anisocoria is suspected to be from a pathologic
process
Relative Afferent Pupillary Defect (RAPD, Marcus Gunn Pupil)
An RAPD is a defect in the direct response. It is due to damage inoptic nerve or severe retinal
disease.
It is important to be able to differentiate whether a patient is complaining of decreased vision
from an ocular problem such as cataract or from a defect of the optic nerve. If an optic nerve
lesion is present the affected pupil will not constrict to light when light is shone in the that pupil
during the swinging flashlight test. However, it will constrict if light is shone in the other eye
(consensual response). The swinging flashlight test is helpful in separating these two etiologies
as only patients with optic nerve damage will have a positive RAPD.
Swinging Flashlight Test:
Swing a light back and forth in front of the two pupils and compare the reaction to stimulation in
both eyes.
When light reaches a pupil there should be a normal direct and consensual response.
An RAPD is diagnosed by observing paradoxical dilatation when light is directly shone in the
affected pupil after being shown in the healthy pupild to be from a pathologic process
This decrease in constriction or widening of the pupil is due to reduced stimulation of the visual
pathway by the pupil on the affected side. By not being able to relay the intensity of the light as
accurately as the healthy pupil and visual pathway, the diseased side causes the visual pathway to
mistakenly respond to the decrease in stimulation as if the flashlight itself were less luminous.
This explains the healthy eye is able to undergo both direct and consensual dilatation seen on the
swinging flashlight test.

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Practice and performance
Students will be divided into groups, to perform pupillary light reflex test on one another.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 8
HISTORY TAKING

Objectives
 To know the purpose of history taking.

LEARNING OUTCOMES
By the end of practical student will be able to:
 Take history from different aspects of
optometry

EQUIPMENT
History taking proforma

PROCEDURE
 General communication skills which apply to all patient consultations include:
1. Demonstrating empathy in response to patient cues: both verbal and non-verbal
2. Active listening: through body language and your verbal responses to what the patient
has said
3. An appropriate level of eye contact throughout the consultation
4. Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning
slightly forward in the chair)
5. Making sure not to interrupt the patient throughout the consultation
6. Establishing rapport (e.g. asking the patient how they are and offering them a seat)
7. Signposting: this involves explaining to the patient what you have discussed so far and
what you plan to discuss next
8. Summarising at regular intervals
Presenting complaint
Use open questioning to explore the patient’s presenting complaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:

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“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Once the patient has finished speaking, it is helpful to check if there are any other issues. If the
patient has multiple presenting complaints, work with them to establish a shared agenda for the
rest of the consultation:
History of presenting complaint
Begin by clarifying some key details including:
the primary complaint (e.g. visual disturbance, red-eye and/or pain)
whether one or both eyes are affected
how the problem starte

Associated symptoms
Ask if there are other symptoms associated with the primary symptom:
“Are there any other symptoms that seem associated with the pain?”
Time course
Clarify how the symptom has changed over time:
“How has the pain changed over time?”
“Does the pain come and go?”
“Do you feel the pain is getting worse over time?
Exacerbating or relieving factors
Ask if anything makes the pain worse or better:
“Does anything make the pain worse?” (e.g. blinking, touching the eye, moving the eye, bright
light)
“Does anything make the pain better?” (e.g. analgesia, cool water, warm compress, removing
contact lenses, dimming the lights)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever
experienced?”

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Moderate to severe pain is a red flag symptom. Patients should be referred to a high street
optometrist or the hospital eye clinic for an ophthalmology opinion promptly.
Severe pain is often associated with acute angle-closure glaucoma, in which case the patient will
also likely complain of visual disturbance, nausea and vomiting.
Summarise what the patient has told you about their presenting complaint. This allows you
to check your understanding of the patient’s history and provides an opportunity for the patient
to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.

Practice and performance

Students will practice the way of taking history from patient. Scenarios will be discussed.

Applicability
After completion of practical students can apply their knowledge in the following areas,
Teaching institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based
optometric practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 10
SUBJECTIVE REFRACTION

OBJECTIVES
 To determine a patient's need for refractive correction, in the form of glasses or contact
lenses.

LEARNING OUTCOMES
By the end of practical student will be able to:
 improve current unaided vision or vision
with current glasses. Glasses must also be
comfortable visually.

EQUIPMENT
Manual refraction unit or phoropter
Trial frame
Trial lenses and confirmation set
Snellen's chart
Pinhole
Occluder
Jackson cross cylinder
Duochrome test

PROCEDURE

Subjective Refraction Steps

 Subjective refraction monocularly
 Binocular balancing
 Near vision correlation

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Monocular Subjective Refraction
The primary goal of monocular refraction is to find the spherical power, cylindrical power, and
axis.
Steps
 Baseline starting point selection and verification
 Cylindrical lens power and axis refinement and finalization
 Spherical lens refinement and finalization
Baseline Starting Point Selection and Verification
The subject is seated at 6 m. A trial frame is placed over the eye, and the visual acuity is tested
for each eye separately. Although subjective refraction can be easily obtained directly, it is
always recommended to get objective refraction done first.
The objective refraction is done using retinoscopy, old glass prescription, and autorefractometry.
While starting to perform the subjective refraction, the uncorrected visual acuity will give an
idea about the amount of ametropia. The verification of cylinder and sphere is usually performed
by trial and error.
Trial and Error Method
Spherical Lenses
This should be verified first. In the case of myopia, the weakest concave lens, and in
hypermetropia, the strongest convex lens forms the best vision sphere. To find the best vision
sphere, a series of low power spheres such as +0.25, +0.5, -0.25, and -0.5 are quickly
interchanged over the front trial lenses. The myopic patients are asked which correction makes
the letter appear clearer and darker.
Cylindrical Lenses
The cylindrical lenses need axis and power verification. Usually, the axis is checked first.
Axis Verification- This is done by rotating the cylinder's axis in increments of 5 and 10 degrees
in either direction and confirming from the patient whether the visual acuity improved or not. It
is challenging to appreciate the change in smaller cylindrical powers at which axis the acuity is
better. Under such cases, a more substantial cylindrical power is tried to verify the axis.
Power Verification- is done after axis verification by changing the cylindrical power.
Cylindrical Axis and Power Finalization and Refinement
Usually, the spherical component is refined and corrected after cylindrical astigmatism has been
taken care of to obtain a sharper and clearer image. Hence, it is always mandatory to correct and
refine the cylindrical astigmatic error before the spherical component. There are various methods
of purifying the cylindrical correction.

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These include
 Astigmatic fan and block technique
 Jackson cross-cylinder technique
 Astigmatic clock dial and fogging technique
Methodology to Assess Subjective Refraction
 History
 Subjective Refraction
 Assessing the fixation target
 Instruction to patients
 Visual acuity assessment
 Starting point
 Localizing principal meridian
 Astigmatism procedure
 Near vision assessment + Near correction
 Measurement of interpupillary distance
 Advice and prescription

Practice and performance

Students will be perform subjective refraction .

Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

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OBSERVATIONS AND RESULTS

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 PRACTICAL 11
OBJECTIVE REFRACTION

OBJECTIVES
 To know the purpose of retinoscopy
 To detect the refractive status of eye objectively.

LEARNING OUT COMES

By the end of practical student will be able to:
 Perform retinoscopy to obtain objective
measurement of refractive status of eye.

PROCEDURE
 Early “Estimates”
Spectacles
If the patient is wearing spectacles (i.e. you are lucky enough that they aren’t hidden!),
inspection may estimate their refraction:
Hypermetropic (patient’s face is magnified whilst wearing them)
Myopic (patient’s face is minified whilst wearing them)
Visual Acuity (Uncorrected)
Although not always permitted in examinations, testing this gives a rough indication whether the
patient is a hypermetrope or myope. The patient should cover the eye that is not being refracted.
1. Place the Trial Frame on Their Head
Adjust the Inter-pupillary distance (IPD), bridge height and length of side arms. These may not
be tolerated by children, in which case the lenses can be held in place by hand
2. Fixation
Switch off the lights and ask the patient to look at a target in the distance (do not occlude their
other eye- they fixate with this). Align your head as close as you can to their fixation axis
without blocking their view. Off axis refracting can lead to astigmatic errors. If you are confident

33
that your patient is fully cyclopleged or pseudophakic (that is, they cannot accommodate) you
can get them to fix on your retinoscope light instead
3. First Sweep
Set the “plane mirror” (condensing lens) right down on the retinoscope. This “slows down” the
reflex (by putting a wider beam onto the retina), making it easier to interpret.
Use your right eye to look at the patient’s right eye and vice-versa.
Remember to maintain a known working distance (traditionally 66cm but use a measuring tape
to measure the working distance you are most comfortable with). Extending your left arm to
gently rest the tips of your fingers beside their eye may assist in maintaining a constant distance.
It is a common error under examination conditions to lean forward, shortening the working
distance.
Determine whether the reflex in the pupil gives a “with” movement (the patient is
hypermetropic) or an “against” movement (the patient is myopic). It is simplest to begin two
“sweeps” with the beam first at 900, then at 1800. If the refraction is spherical, these two sweeps
will give the same reflex. If there is astigmatism, the following may be seen:
“Break”- the reflex in the pupil will not be continuous with the streak on the patient’s face
“Skew”- the reflex will only move in the same direction as the streak when the streak is aligned
with one of the principalmeridia. Rotate the streak by small amounts (±10°) and move small
amounts side to side until the “streak” and the reflex are aligned
“Thickness”- the reflex will be thinnest when the streak is aligned with one of the principal
meridia
If astigmatism is suspected, perform sweeps whilst rotating the retinoscope streak through 3600
until the principal meridia are determined (as above). Irregular astigmatism may cause scissoring
of the light reflex (one part of the reflex is myopic, the other part is hypermetropic)
4. Further Sweeps
How you proceed is determined by whether you prefer using the “sphere-sphere” or “sphere-
cylinder” method. The “sphere-cylinder” method is often more accurate, but the “sphere-sphere”
method is simpler and makes it easier to write a power cross that some examiners may request.
Hand holding spheres may also be the only method tolerated by some young children.
Sphere-Sphere Method
Begin by neutralising one of the principal power meridia. It is usually easiest to begin with the
one closest to 180° (align streak at 90° to the meridian). Always try to neutralise the central
portion of the light reflex, that is, the reflex in the pupil centre. Check that you are aligned to the
axis of a principal meridian by checking “break”, “skew” and thickness as above
With movement → Add plus (e.g. +2D)

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Against movement → Add minus (e.g. +2D
Finding the Power
Change the trial lens powers until the retinal reflex no longer has “movement” (if there is “with”
movement add plus, if there is “against” movement add minus).
Continue adding plus or minus lenses until the horizontal sweep shows no movement in the
reflex. At this point the reflex will be diffuse, bright and fast.
→ This is the (first) sphere
Look carefully where the streak falls on the trial frames. This is the axis of this power meridian.
Consider pushing the sleeve of the retinoscope up so that you get a narrower streak to measure
the axis (but remember to push it back down when “sweeping”). Remove the first (spherical)
lens and place it on the table (with its “handle” pointing in the direction of the sweep) until you
are ready to document it. Repeat the process for the power meridian closest to 90° (axis 180°)
→ This is the (second) sphere
→ Draw a “power cross” by recording the power of the neutralizing sphere in the direction of
your sweep in each meridian. Remember that the axes lie at 90° to the power meridian drawn in
the power cross. Subtract the working distance and convert to a sphere-cylindrical form.

Practice and performance

Students will practice/ perform retinoscopy and power crosses.

Applicability
After completion of practical students can apply their knowledge in the following areas,
Teaching institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based
optometric practice.

35
OBSERVATIONS AND RESULTS

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 PRACTICAL 12
PSEUDOPHAKIA/APHAKIA
OBJECTIVES
 To know the steps for the management of pseudophakia/aphakia
 To know how optical changes occur due to these condition.

LEARNING OUTCOMES
By the end of practical student will be able to:
 Able to manage patient with pseudophakic/ aphakic correction

EQUIPMENT
Trial box
Autoref
Near vision chart
Ophthalmoscope

PROCEDURE
Subjective Refraction Steps
 Subjective refraction monocularly
 Binocular balancing
 Near vision correlation

Monocular Subjective Refraction

The primary goal of monocular refraction is to find the spherical power, cylindrical power, and
axis.
Steps
 Baseline starting point selection and verification
 Cylindrical lens power and axis refinement and finalization
 Spherical lens refinement and finalization

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Baseline Starting Point Selection and Verification
The subject is seated at 6 m. A trial frame is placed over the eye, and the visual acuity is tested
for each eye separately. Although subjective refraction can be easily obtained directly, it is
always recommended to get objective refraction done first.
The objective refraction is done using retinoscopy, old glass prescription, and autorefractometry.
While starting to perform the subjective refraction, the uncorrected visual acuity will give an
idea about the amount of ametropia. The verification of cylinder and sphere is usually performed
by trial and error.
Trial and Error Method
Spherical Lenses
This should be verified first. In the case of myopia, the weakest concave lens, and in
hypermetropia, the strongest convex lens forms the best vision sphere. To find the best vision
sphere, a series of low power spheres such as +0.25, +0.5, -0.25, and -0.5 are quickly
interchanged over the front trial lenses. The myopic patients are asked which correction makes
the letter appear clearer and darker.
Cylindrical Lenses
The cylindrical lenses need axis and power verification. Usually, the axis is checked first.
Axis Verification- This is done by rotating the cylinder's axis in increments of 5 and 10 degrees
in either direction and confirming from the patient whether the visual acuity improved or not. It
is challenging to appreciate the change in smaller cylindrical powers at which axis the acuity is
better. Under such cases, a more substantial cylindrical power is tried to verify the axis.
Power Verification- is done after axis verification by changing the cylindrical power.
Cylindrical Axis and Power Finalization and Refinement
Usually, the spherical component is refined and corrected after cylindrical astigmatism has been
taken care of to obtain a sharper and clearer image. Hence, it is always mandatory to correct and
refine the cylindrical astigmatic error before the spherical component. There are various methods
of purifying the cylindrical correction.

These include
 Astigmatic fan and block technique
 Jackson cross-cylinder technique
 Astigmatic clock dial and fogging technique
Methodology to Assess Subjective Refraction
 History
 Subjective Refraction

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  Assessing the fixation target
 Instruction to patients
 Visual acuity assessment
 Starting point
 Localizing principal meridian
 Astigmatism procedure
 Near vision assessment + Near correction
 Measurement of interpupillary distance
 Advice and prescription

Practice and performance

Students will be divided into groups recall causes of pseuophakia/aphaki, practically perform
subjective refraction, special focus on near add.

Applicability
After completion of practical students can apply their knowledge in the following areas,
Teaching institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based
optometric practice.

39
OBSERVATIONS AND RESULTS

40
 PRACTICAL 13
VISUAL ACUITY ASSESSMENT

OBJECTIVES
 To know the process of recording correct
visual acuity
 To know Steps by step visual acuity
assessment

LEARNING OUTCOME
By the end of practical student will be able to:
 Know the process by which actual visual
acuity can be obtained in minimum time.

EQUIPMENT
Visual acuity charts
Occluder
Trial frame
pinhole

PROCEDURE
 Purpose of the test
You may need an eye exam if you feel you’re experiencing a vision problem or your vision has
changed. A visual acuity test is one part of a comprehensive eye exam.
Children frequently take visual acuity tests. Early testing and detection of vision problems can
prevent issues from getting worse.
Optometrists, driver’s license bureaus, and many other organizations use this test to check your
ability to see.
Two commonly used tests are Snellen and random E.
 Snellen

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The Snellen test uses a chart of letters or symbols. You’ve probably seen the chart in a school
nurse’s office or eye doctor’s office. The letters are different sizes and arranged in rows and
columns. Viewed from 14 to 20 feet away, this chart helps determine how well you can see
letters and shapes.
During the test, you’ll sit or stand a specific distance away from the chart and cover one eye.
You’ll read out loud the letters you see with your uncovered eye. You’ll repeat this process with
your other eye. Typically, your doctor will ask you to read smaller and smaller letters until you
can no longer accurately distinguish letters.
 Random E
In the random E test, you’ll identify the direction the letter “E” is facing. Looking at the letter on
a chart or projection, you’ll point in the direction the letter is facing: up, down, left, or right.
These tests tend to be more sophisticated when performed at an eye clinic than in a nurse’s
office. At an eye doctor’s office, the chart might be projected or shown as a mirror reflection.
You’ll look at the chart through a variety of different lenses. Your doctor will switch out the
lenses until you can see the chart clearly. This helps determine your ideal eyeglass or contact
lens prescription, if you need vision correction
 Understanding your test results
Visual acuity is expressed as a fraction, such as 20/20. Having 20/20 vision means that your
visual acuity at 20 feet away from an object is normal. If you have 20/40 vision, for example,
that means you need to be 20 feet away to see an object that people can normally see from 40
feet away.
If your visual acuity is not 20/20, you may need corrective eyeglasses, contact lenses, or surgery.
You might also have an eye condition, such as an eye infection or injury, that needs to be treated.
You and your doctor will discuss your test results as well as any treatment or correction that
might be necessary.

Practice and performance

Students will be divided into groups , student can perform the procedure of visual acuity taking
and practice accordingly.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice,Low vision clinics,Orthoptic clinic,Refraction clinic.

42
OBSERVATIONS AND RESULTS

43
 PRACTICAL 14
VISUAL ACUITY CHARTS
OBJECTIVES
 To understand the role of vision related activities at certain age
 To know how to take visual acuity
 To know how to take visual acuity by certain
charts.

LEARNING OUTCOMES
By the end of practical student will be able to:
 Know the names and purpose of different visual
acuity charts to be used for certain age group.

EQUIPMENT
Visual acuity charts

PROCEDURE
Visual Acuity Assessment for Various Age Groups
Infants
 Fixation
The fixation normally should be central, steady and maintained (CSM)
Fixation behavior and fixation preference testing can be described using the CSM (Central,
Steady and Maintained) notation. Fixation during monocular viewing is described as central
(foveal) or noncentral (eccentric), and steady (stable eye position) or non-steady (roving eye
movements or nystagmus). Maintained refers to fixation that is held during binocular viewing
after the opposite eye is uncovered during fixation preference testing.
 Menace Reflex
Menace reflex is a reflex blinking that occurs in response to a rapid moving object and visual
threat. The reflex develops by 5 months of age
 Brukner's reflex
Brukner's reflex can help in rapid screening of the refractive errors. The test is performed in a
dark room and both the eyes are simultaneously illuminated with the direct ophthalmoscope and

44
the reflex is noted at a distance of 1 meter as well as at 3 meter . An inferior crescent
suggests myopia, a superior crescent is seen in hyperopia. Resistance to occlusion of the eye with
good vision also gives an estimation about the visual acuity discrepancies.
 Opto-kinetic nystagmus
Opto-kinetic nystagmus is used to objectively determine the visual acuity of the child. A
succession of black and white stripes are passed through the patient's visual field. The visual
angle subtended by the narrowest width of the strip eliciting an eye movement measures the
visual acuity. The visual acuity in the newborn child is at least 6/120 (20/400) by opto-kinetic
nystagmus that improves in the first few months of life. However, the opto-kinetic nystagmus
can be false positive in the patients with cortical blindness as sub-cortical mechanisms have been
suggested to be involved in the generation of opto-kinetic nystagmus. The test can be false
negative in infants with delayed development of the motor pathways and due to lack of attention
 catford drum test
Catford drum test was introduced by Olive and Catford. It is an objective method to evaluate the
objective visual acuity by inducing optokinetic nystagmus. The motor driven drum consist of
separated black dots of various sizes on a white background projected through a screen
measuring 4*6 cm. These dots can be rotated from left to right and then back from right to left in
a rotating manner. The test is carried at a distance of 60 cm, and the child is instructed to watch
the dot. The visual acuity is assessed by reducing the size of the dot until the smallest dot is
found that can no longer induce optokinetic nystagmus. The end point is recorded and converted
to given Snellen's equivalent. The drum has been calibrated between the visual acuity of 20/20 to
20/600 of Snellen's acuity based on the dot size at 60 cm.
 Preferential Looking test
These tests are based on the principle that infant's attention is more attracted by a patterned
stimulus as compared to a homogenous surface. Hence, if the infant is given a choice between a
pattern and a plain surface the infant prefers towards the patterned surface.
 Teller's acuity cards
The Teller's acuity test was first described by Fantz and was further developed by Dobson and
Teller. During the test the observer is hidden behind the screen. The screen consist of a
homogenous surface on one side and is alternated randomly with black white stripes on the other
side. The baby is faced towards the screen and the observer records the direction of head
movement and eye movements in response to the patterned stimulus. The test is suitable for
testing visual acuity in infants upto 4 months of age as older infants are easily distracted. Visual
acuities tested by this method range from 6/240 (20/800) in the newborn to 6/60 (20/200) at 3
months and 6/6 (20/20) at 36 months of age. Later Teller's acuity cards were introduced by Mc-
Donald et al. [Teller's acuity cards contain grating patterns of spatial frequencies. The cards are
shown at a distance of 38 cm, an observer watches an infant's eye and head movements in
response to repeated presentation of these cards. In children with amblyopia grating acuity is

45
affected, because of which visual acuity can be under-estimated. As a visual screening test Teller
cards has a high false positive results.
 Lea's gratings
Lea gratings are preferential looking test used for visual acuity assessment of infants and
children with disability. Grating levels printed on each handle are: 0.25, 0.5, 1.0, 2.0, 4.0 and 8.0
CPCM (cycles per centimeter of surface).
 Visual evoked potential (VEP)
VEP is the measure of the cortical activity generated in response to the patterned stimulus,
checker board or square wave grating. In young children flash or patterned VEP can also be used
to record the visual acuity. Visual acuity of 6/6 (20/20) is achieved in VEP by 6-12 months of
age.
1-2 Years
Worth's Ivory ball test
 Claud Worth in 1896 introduced the ivory ball test for the visual acuity assessment of
children between 1-3 years of age. There is a set of 5 balls ranging from 0.5 inch to 2.5
inch. The child with both eyes opened is initially made familiar with the balls. One eye is
then covered and each ball is then thrown at a distance of 18 feet beginning from the
largest and the child is asked to retrieve each of the balls. Visual acuity is assessed by the
size of the smallest ball that can be seen by the child.
Boeck Candy test
In this test the child is shown candy beads of different sizes at a distance of 40 cm. The child is
then expected to pick up the candy beads. The smallest bead that the child can pick up gives the
approximate estimation of the visual acuity.
Screening
2-3 years
 Cardiff Acuity test
The test is based on the principle of vanishing optotypes and is a set of six cards with six easily
recognizable shapes (house, fish, dog, duck, train) positioned either at the top or bottom half of a
card. The cards are calibrated to give visual acuity of equivalent of 20/20 to 20/200 at 1 meter
viewing distance. The child is comfortably seated and the cards are presented at eye level at a
distance of 1 meter. The examiner watches the eye movements towards the shape. If the child is
looking at the shape, then the next card is presented. This procedure is continued until no definite
fixation is observed. The test is performed at 1 meter distance but altered to ½ meter if the child
is unable to see the first card. The identification score and Snellen's equivalent of each card is
mentioned at the back of card.

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Miniature toy test
 Miniature toy test
Miniature toy test was previously used with handicapped children and low intelligence patients.
It used 2 sets of miniature objects. One set with examiner standing at 10 feet away and the
patient is asked to pickup similar objects from his own set. The object chosen are easily
identifiable small toys like automobile, planes, charts, knives, spoons etc. The same objects can
be in 2-3 sizes so as to check the grade of vision.

Coin test
 Coin test
Coins of different sizes are shown to the child and is expected to pick up the coins easily visible.
 Lea symbols
Lea symbol test were developed by Finnish ophthalmologist Dr Lea Hyvärinen. The oldest and
most basic form of the LEA test is simply referred to as the "LEA Symbols Test". The Lea
symbol test consists of four optotypes an apple, a pentagon, a square, and a circle. These easily
identifiable shapes help preschool children to be tested for visual acuity long before they become
familiar with the letter and numbers used in other standard vision charts. Becker et al found Lea
symbols to be useful for the visual acuity evaluation in early childhood.

47
3-5 years

Allen picture cards. Picture courtesy Google)

 Allen's picture test
The pre-school vision test or the Allen picture card test consists of seven black and white line
drawing of birth day cake, telephone, horseman, teddy bear, automobile, house and tree. These
line drawings are drawn on a plastic (10cmx10cm) white cards. The child patient will be shown
at a closer distance so that he recognizes and identifies them.

Sheridan letter test (Picture Courtesy Google)

 Sheridan letter test

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Lea symbols (Picture Courtesy Google)
This test uses letters which children can recognize and copy at an early age. The letters V T O H
X A U are used and are shown to the child one at a time on flip card. The child is given a key
card showing all the letters and he has to point the letter he sees. After explaining the procedure
to the child the test can be done at 6 meters or 3 meters. Sheriden Gardiner test is the most
accurate of the illiterate vision test in children.
 Lippman's HOTV test
Lippman's HOTV test is similar to Sheridan letter test. It is a simpler version and consist of only
four letters HOTV.

Tumbling E Chart
 Tumbling E chart

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The E chart is commonly used. The chart consist of E with limbs of E pointing in various
directions. The test can be used in two forms either in the form of a chart (like Snellen's) or
printed on an individual card.

Sjogren's Hand test

 Sjogren's hand test
This test consist of pictures of hands with fingers pointing towards various directions.

50
  Landlot Broken Ring Chart
Landolt broken ring chart
The test is usually used for the visual acuity assessment in illiterates. In this test the broken ring
is printed in various directions. The test is performed at a distance of 6 meter and the child is
asked to indicate the direction in which the ring is open.
 Snellen's chart
In older children who can recognize alphabets Snellen's chart can be used.

51
OBSERVATIONS AND RESULTS

52
 PRACTICAL 15
Visual acuity interpretations

OBJECTIVES
 To understand how visual acuity can be interpreted at various distances.
 To know the different notion of visual acuity recording.

LEARNING OUTCOME
By the end of practical student will be able to:
 Interpret visual acuity into different notation.

EQUIPMENT
Visual acuity charts
Retinoscope
Autoref
Trial box

PROCEDURE
Numericals and Visual acuity scenarios will be discussed with the help of different charts at
varied distances.

Practice and performance

Students will practice senarios and interpertations.
Applicability
After completion of practical students can apply their knowledge in the following areas,Teaching
institutions,Optometric Clinical setup, Ophthalmology clinical setup, Hospital based optometric
practice.

53
OBSERVATIONS AND RESULTS

54
 PRACTICAL 16
Revision of all subject related practical work

OBJECTIVES
 To understand how vision sciences can contribute to the field of optometry practically.

LEARNING OUTCOME
By the end of practical student will be able to:
 perform field related tasks.

EQUIPMENT
Visual acuity charts
Retinoscope
Autoref
Trial box
Occlude
Amsler grid
Colovision plates
Contrast sensitivity chart

PROCEDURE
All practical procedures will be revised as per students demand.

Practice and performance

Students will perform all the practical already done.
Applicability
After completion of practical students can apply their knowledge in the following areas,
Teaching institutions, Optometric Clinical setup, Ophthalmology clinical setup, Hospital based
optometric practice.

55
OBSERVATIONS AND RESULTS

56
57