Lecture: Refraction in the Real World: Tips and Tricks for Refracting Your Patients

DR. MARHEFKA: Hello, everyone. Thank you so far for coming to our webinar today. I am going to share my screen so that we can go ahead and begin with the presentation. And today’s lecture is: Refraction in the Real World: Tips and Tricks for Refracting Your Patients. I’m Dr. Caroline Marhefka, an optometrist. And I specialize in pediatric optometry. I completed my residence any pediatrics at the New England College of Optometry and went on to join as faculty, I’m now Assistant Professor at the New England College of Optometry. I’m very excited to share my tips and tricks for refracting patients. I have learned how to do it in adults and also had to learn how to do it in pediatric patients as well. Here is a copyright notion for your review. Today we will be discussing the art of refraction. And it truly is an art form. It has very unique modifications for every patient, despite having a general standardized procedure. We’re going to be discussing both subjective and objective refraction techniques. And look the at multiple tools that we can use to determine a patient’s refractive error. The key to refraction is realizing that you are in charge of the refraction. It is not what the patient says, although they’re a key part and a great tool to use with their subjective responses. But ultimately, you are the doctor in charge of the glasses prescription. Keep if mind, it is just that. A prescription. It’s something that you have the final say in determining. So, that it best fits the needs for your patient. Today’s objectives will be to review subjective and objective measures of refraction. We will be discussing how to perform retinoscopy in a clinical setting. We will determine how to calculate the net retinoscopy finding. Outline the procedure of manifest refraction, and sharing pearls for refraction in a clinical setting. For the purposes of this lecture, keep in mind, we will be working in minus cylinder for refractive purposes. If you are more comfortable with plus cylinder, you can easily transpose. We call it combine, change the sign, and rotate by the powers. Changing the sign of the cylinder and rotating 90 degrees. Our methods of refraction are subjective and objective. Our subjective methods include our manifest refraction, where the patient sits behind the photopter, and gives which are more clear to them. And also subjective in a trial frame that can be placed on a patient in any setting if they’re not to be place in the phoropter, and try it by alternating the lenses. Objective measures include our autorefractor, in addition to retinoscopy. Retinoscopy is an excellent tool for patients who may not be able to sit behind the photopter, or are not able to give us reliable, subjective responses. First we will be looking at the objective refraction, called retinoscopy. How goal of vicinity to objectively neutralize a patient’s refractive error. The key here is that it’s done objectively. Our patients do not need to give us feedback on this process. Consider a patient who comes in and you have no starting point for the refraction. Maybe they brought an incorrect pair of classes or a very outdated pair. Perhaps they gave you their near vision-only glasses and didn’t realize so you have the incorrect one, the photopter, you could do a retinoscopy to get a more accurate starting point if you start to notice that your subjective refraction in the photopter isn’t going quite as planned. Consider pediatric patients who, one, cannot sit behind the photopter just due to limitations in their small bodies sizes, and to remove the stimulus that we want to avoid in pediatric patients. Retinoscopy is a great tool for non-verbal patients or any patients who may have autistic spectrum disorder. Any patients sitting behind the photopter due to mobility limitations. Patients in wheelchairs or who have physical or motor disabilities, unable to sit in the exam chair and unable to have that photopter in front of their head for a long period of time. Great for vision screenings when we’re not able to roll in the entire photopter. And just to get an estimate of prescriptions and whether they should be referred for further eye evaluation. So, how does retinoscopy reveal the patient’s prescription? We have to consider both the image point and the far point when we’re doing retinoscopy. Consider the image point as light that is coming into the system. Where light rays are converging in the back of the eye. Our far point it like going out of the system. Or diverging rays from the retina. This is the location of the farthest object on which the fully relaxed eye is able to focus. Our retinoscope is at a set distance from infinity. We have to look at a prescription, which is what we call the refractive error, and then put in lenses that are in glasses, what is the refractive correction. These neutralize the refractive error so that light focused at the right place on the retina. We use it to place the far point at our retinoscope. You have to remove that equivalent to the working distance. Commonly 50 or 67 centimeters for most practitioners. There are three scenarios that may occur in each of our principal meridians. First is emmetropia. That’s when our image point is at the retina and the far point is located at infinity. This is when no lenses are there for neutrality. Considering the working distances as it will not appear neutral with no retina in place because your working distance is at play. We can also have myopia, where the image point is in front of the retina. Causing our far point closer than infinity. Minus lenses will be needed to neutralize that refractive area. Final is hyperopia, in which plus lenses are needed to neutralize the refractive error because that image point is behind the retina. Here is a photo of the retinoscope that can be used. You can see the front of the retinoscope, looking at the minister for, the handle with the battery installed. The back is the portion that will be placed in front of the observer’s eye. The brow rest, the observer window where the observer’s eye looks through the peephole. And the sleeve or collar, allows us to change between diverging or converging light rays. I would recommend keeping this down for diverging rays. Our retinoscopy reflex is evaluating light that’s coming out of the system. This is moving the streak of the retinoscope across the patient’s eye, which produces the movement of the patient’s retinal reflex. One option is the with motion, we move our retinoscope in a direction and that reflex moves in the same direction. In this example, you can see that the reflex is moving to the left just as the examiner is moving their streak to the left. This case is when we want to add plus to neutralize. Another option is against motion. Meaning that as we move our reflex in one direction, the examiner’s scope goes the other way. So, you can see here is the examiner moves their scope to the right, the reflex actually shifts the opposite direction to the left. Creating an against motion. This is when you would want to add minus to neutralize the reflex. Our final option is a neutral reflex, which is essentially a full pupil. There’s no with or against motion. And that is our end point. And we’ve determined the correct lens to place in front of the eyes. You can see here as the examiner moves the streak, the pupil is fully illuminated. There’s no motion neither with nor against. Our lenses are add the in front of the patient’s eye until to movement is observed. This occurs when the lenses place the patient’s far point at the retinoscope and is when we are able to plot that lens value that neutralizes the movement on our optical cross. We’ll be starting our first poll question. This question asks: Which patient would be the most appropriate to perform retinoscopy on for proper assessment of refractive error? This would be a 19-year-old patient with myope and astigmatism. A 4-year-old patient who failed a vision screens Al school. The 70-year-old patient who arrives to your office with a cane. Or a 35-year-old patient with a history of optic neuritis. And we’ll give you a few seconds to go ahead, submit your responses. Great. We have 83% agreeing that the 4-year-old patient who are failed the vision screening at school would best benefit from retinoscopy. Our pediatric patients are incredible subjects for retinoscopy. It’s very difficult to get accurate subjective responses from them. And retinoscopy following a cycloplegic refraction is the gold standard to get the best glasses prescription for our patients. We will go over the procedure of retinoscopy and multiple ways that we can do this. One is inner did the photopter, fear and cylinder, the photopter will be placed in front of the patient’s eyes. One for vision screenings and on pediatric patients, for those who cannot have the photopter placed in front of the eyes are loose lens bars. The red bar contains minus lenses. And half-diopter steps, ultimately going to full-diopter steps in the higher powers. Our black bar is plus lenses, which we would use to neutralize the with motion. With motion to start with no lenses in place, we would go ahead and grab that black retinoscopy bar and add plus power until we get neutral and see reversal. We know that we have gone too far and added too much of the with power. The procedure for retinoscopy start by holding the retinoscope in your hand. And use your index finger to change the meridian. Ultimately you want to have the streak facing directly up vertically. But not every patient has an axis that is at the 180 or 190 degree meridian. You want to have your finger ready to go to rotate the orientation of your beam to best fit the patient’s true axis. And you should be comfortable using both your dominant and non-dominant hand and eye. As you can see here, the examiner has her right eye in line with the patient’s right eye. And the body is set to the left so that we’re not blocking the patient. If she was to switch to do the left eye, she would actually have to hold the retinoscope in the left hand and over the left eye so she is now to the right of the patient and not blocking that central visual axis. My patient education here is that I’m gonna be using my instrument to get an estimate of your glasses prescription. Please look at the letter behind me. Try to relax your eyes and let me know if I block you at any point in time. You will then proceed to turn off the exam room lighting so that you can appreciate the reflex more clearly. You will display a target. I recommend a 20/400 letter as seen here. Other options include reverse contrast or a red/green screen. The examiner will then line up their right eye visual axis with the right eye visual axis of the patient and we will use their preferred working distance. This can be either 50 or 67 centimeters. And I do recommend the reverse contrast. It’s not shown up here. We have the standard contrast with the black letter and white background. The reverse contrast really helps to limit glare as well. First you’ll look through the peep pole of the retinoscope and check the patient’s pupillary reflex. Assume 180 and 190 degrees for this example. And the examiner will place their brow on the scope and you will orient the beam vertically. You’ll move your head and hand in a slight motion that allows the light to sweep across the pupil and you would appreciate a horizontal movement of your scope. Once you’ve neutralized that meridian, we rotate our axis 90 degrees and proceed to sweep our light across the opposite meridian. Now we are moving in vertical movement. Moving our head up and down slightly. And keep in mind, the meridian you’re scoping is opposite of the direction of your light streak. When our beam is facing vertically and we are scoping side to side or horizontally, we are actually scoping the 180-degree meridian. You’re scoping your vertical directly across the vertical meridian. And vice versa, when our beam is facing horizontally, we’re now scoping up and down along that 90 degree meridian. You then add the appropriate lenses, depending on whether you see with or against motion, that neutralizes each of the principal meridians. In the previous example, we had 180 or 190 degree, we had a perfectly vertical and a perfectly horizontal streak. This is not always the case if a patient has oblique cylinder or not at 190. And you will notice the break, it’s misaligned with our streak beam. This causes skew, which is the motion of the reflex when it’s misaligned with our streak beam. It’s very difficult to appreciate. You notice the scissors effect that is not a nice, clear beam. The brightness will also be dimmer. The margins will be less distinct when you’re further away from the patient’s true axis. You always want to make sure that our retinoscope streak is aligned with the patient’s true axis and reflex. The width of the beam tends to get wider and less defined you are the further you are away from the patient’s true axis. I recommend using three-eye technique for our retinoscopy. This is a technique that helps to control for accommodation. What you would do is initially perform retinoscopy on the patient’s right eye and you would neutralize both the primary meridians and place these on a power cross. Next, you’ll perform retinoscopy on the patient’s left eye. You’ll neutralize both of those primary meridians. However, consider that when we perform retinoscopy on the right eye, no lenses were in place in front of that left eye. We have not, essentially, fogged or added plus to the patient due to the examiner’s working distance. Which, if you have a 50 centimeter working distance, that is a two diopter working distance. So, you would have two diopters in front of that left eye that are now in place. You want to go back to the right eye and make sure that you re-scope and check that there’s not any additional plus now that we’ve taken out that accommodative component in the left eye. Other yays to control for accommodation for our patient include using a large letter like the 2400 letter. Keeping the light low. Reminding the patient to look at the letter, not to look at you. Or to let you know if you blocked them at any point in time. And to ensure that both eyes are open. Try not to have your patient squinting one eye or the other. This is a chart that outlines how your retinoscopy procedure may look. In this case, we have a patient with spherical refractive error. You would start by serving that reflex in both of your primary meridians. When you find with motion, you will add plus until neutrality. If you see against motion, you’ll add minus. In the case of a spherical refractive error, when we rotate our axis 90 degrees, it will still appear neutral. Both meridians have the same power and are neutral with the same lens power. So, in this case, our retinoscopy is complete. We can write down that spherical power and there is no cylindrical component. A more complex case would be if you survey the reflex in both primary meridians and you realize the eye has astigmatism. First you will locate the principal meridians of the patient and you can do in using the break, skew, intensity, and width of the retinoscopy reflex. If you see with motion, you will add power until neutral motion is observed. When you rotate the axis 90 degrees, one option that may happen is now we see against motion. As we’re working in minus cylinder, that means that we have to rule out how much cylinder is involved. So, we will set our minus cylinder axis parallel to the against motion reflex. At this point, we have to then add minus power until that motion becomes neutral. Now that we have both of those values written on our power cross and we have the correct axis, we know that all meridians are neutral and that is our end point. The other option that may happen as you start to scope the first primary meridian is that you add power in one meridian until neutral is observed, and you rotate your axis 90 degrees and instead of against motion, we’re actually still seeing with motion. That means that you did not start by neutralizing your most plus or least minus meridian. This means that you have to continue to add plus in that meridian until it becomes neutral. When you rotate back 90 degrees, the other principal meridian should now have against motion. Make sure to change your axis to 90 degrees away. Add that minus cylinder power until the against motion becomes neutral and by then, you have met your end point. Here is an example of what this may look like on a power cross. Keeping in mind if you have a 50 centimeter working distance, meaning from your eye to the patient’s eye, we have 50 centimeters between our retinoscope and the patient’s eye. You must subtract your 2 diopter working distance. If you have a little longer arms, you’re a little taller and sit back, you may need up to 67 centimeters. I recommend this as your working distance because you can easily subtract 1.5 diopters from your retinoscopy findings. In this case, we can look at a lens that was neutralized at 450. And excuse me, these axes are flipped. The 450 is at the 180 axis. Once we have neutralized at 450, you can see we flipped 90 degrees, and neutralized the 90 degree axis at plus 2.5. Subtracting our working distance of 2, we end up with a retinoscopy finding of plus 250 and minus.75. However, keep in mind that the cylinder is actually the difference between these two meridians. So, you have to find the difference between our plus 2.50 minus 75 which gets us to our final retinoscopy finding of plus 250 minus 325 at 180. And you can see here that we have the cross retinoscopy finding to start. And once we have subtracted our working distance, we have the net retinoscopy finding which is our final working distance. And we have another poll question here. And this question: You neutralize the 90 degree meridian with a plus 3.50 lens. You rotate your beam 90 degrees and see against motion. You then neutralize the 180 degree meridian with a plus 2.25 lens with. Your working distance is 50 centimeters. What are your net retinoscopy findings? All right. So, a little bit spread out across the board here. However, most did get this one correct. So, our answer here is C. Looking at this example, you can see that as we scope and neutralize the 90 degree meridian, we neutralize with plus 3.50. When we rotate our beam, we neutralize the 180 degree meridian with plus 2.25. Our most plus meridian is the spherical component. So, after taking out a 2 diopter working distance because we were at 50 centimeters, we end up with plus 1.50 at our 90 degree meridian on the power cross, and plus 1.25 at the 180 degree meridian. Our axis is at 90 because that’s our most plus meridian. And then we proceed to find the difference between our two meridians which is actually a 1.25 diopter difference between those two powers. That gets us our net finding of plus 1.50, minus 1.25 at axis 90. Some clinical pearls for retinoscopy include moving your retinoscope faster to make the reflex easier to see. You don’t to want slow down and let the patient accommodate through the lenses that you’re neutralizing with. Doing very quick, brisk motions actually gets you a much clearer reflex and makes it a lot easier to see if you’re seeing with or against motion. Make sure that we’re moving the lenses frequently and avoid scoping that same lens for extended periods of time. Accommodation can actually induce against motion. So, we don’t want to keep scoping the same lens in front of the eye for too long for fear that the patient might accommodate through it and give us false results. As the far point moves closer to the retinoscopy or closer to that neutrality point, the reflex becomes brighter, thicker, and faster. So, if your reflex is very dim, very slow and difficult to appreciate, you can assume that you’re likely very far off from neutrality and you might want to make bigger jump when is you’re adding either plus or minus lenses. And if you’re although neutral with the sleeve of the retinoscope down one you should push up to see motion as well to double check yourself. Pushing the sleeve upwards allows for a thinner, brighter streak. Sometimes this can help determine the cylinder axis. You should be bracketing with plus or minus 50 diopters and the reflex will be with if you move far past neutral with the minus direction, which is in the less plus re, for example, and against if you move past knew trillion that the plus or less minus direction. This is a good way to check yourself, even if you’ve hit neutrality, you can convince yourself that you’re not missing any added power because you truly see that reversal. We’ll now be moving into manifest or subjective refraction techniques. This is an overview of our phoropter. You can see a variety of knobs. We see our lock knob right up top so it’s nice and stable in front of our patient. One important knob is the PD knob so that we can add in the correct distance between our pupils for our patients and get the most accurate results. We also want to make sure to level the phoropter, and between the level knob and the bubble in the top right corner, it’s below the small white dot to indicate it’s level. We have a variety of lenses we can add in. We have a Risley Prism unit for adding prime minister in front of our patients, as well as the J creatinine (C unit. You can see the sphere dial on the right there and also on the left that we can use our hand to shuffle up and down. In addition to our cylinder axis knob and our cylinder power knob. Your exam room setup should include the patient seated comfortably in the exam chair about 10 to 20 feet away from the VA chart. Make sure that visual acuity chart is calibrated for your exam room distance. You should also project full room illumination and the phoropter should be placed in front of the patient and leveled. There are a few places that you can start from to put into your phoropter. If they are a previous patient, their previous glasses prescription is a great place to start. For a new patient, you can always use an autorefractor and try to put those findings in. This is less accurate for pediatric patients who are able to accommodate a great amount. So, I would recommend starting with your retinoscopy for pediatric patients. You can also put in previous glasses prescription if the patient brought in their lenses and conduct lensometry to find out what they’re wearing currently. This is a overview of the steps of manifest refraction. And we’ll go through them one-by-one, keeping in mind for this lecture, we will be talking about minus cylinder. The first step is sphere refinement. Where we occlude the patient’s other eye. We determine the working visual acuity based on what we’ve entered have the phoropter and keep in mind the patient should be at least 20/50 to proceed. We will project a line — three lines — above their working VA, which is the lowest line of letters that the patient can find between the retinoscopy findings or their habitual RX in the phoropter. And adding sphere power plus lenses in plus .25 diopter steps. This helps relax accommodation for the patient. Minister patient education is I will be showing a series of lenses to refine your glasses prescription. You will let them know, we’re going to make these letters blurry on purpose. Let me know when they’re blurry, but just readable. And one clinical tip is don’t forget to occlude the patient’s other eye. We want to make sure this is gone monocularly. Always alternate the O for open with the bold line underneath to the right to the OC which occludes the eye. So, if the right eye is open, make sure that left eye you alternate the knob to OC. It will then project the working visual acuity line and check that it’s blurry for the patient. You’ll then un-fog the patient or add more minus. And .25 diopter steps until they can read the smallest line possible. This is done until no improvement in the quantity of letters is achieved. You can attempt a quality quarter, meaning they may have gotten five out of five lines on the 20/20 line, or five out of five letters, but whether we add in the extra click of minus, they’re able to read a lot quicker and subjectively really appreciate that additional minus. We then move on to cylinder refinement. This is when we introduce the JCC lens in front of the patient and show a single line that’s, again, three lines above their working VA. The patient was 20/20, I recommend putting up 20/40 line — flip of the dial. One produces an image in front of the retina, the other an image behind the retina. The closer the image gets to the retina is the patient’s preferred astigmatic reflection. It will be closer and closer to the retina. The goal is to get the images to look the same as you flip through both of the JCC lenses. If you start with a minus .75 diopter of cylinder or greater from your ret findings, I recommend jumping straight to axis refinement and then doing a cylinder power refinement. If you have minus .50 of cylinder or less, recommend power refinement, proceeding to axis refinement and doing a final power refinement to check. During power refinement, your axis dots on your ACC are refined. During our axis refinement, you have to twist the knob so that the axis knobs are straddled. And my clinical tip here is to always end with a power screening. By aligned, you can see here, that where the P for power stands, it’s aligned with the red dot. The small arrow is pointing directly to the red dot and we are doing the power refinement. Whether you switch to axis, you can see here that we alternated the knob so that the arrow is now pointing directly in between both the red and the white dots. We’ve straddled the axis. And now we know that we can proceed to do our axis refinement. With cylinder refinement, you want to use very clear patient education from the start. You will ask the patient: Which of these choices makes the letters more clear? They may both be blurry, but let me know which step is more clear. You want to make sure that if they choose the red dots that this is adding more minus lens. If they choose the white dot, this is essentially adding plus lenses or less cylinder correction. Acceptance for the patient is when they report that both options look the same or that the red dot option is more clear. Rejection of power is when the patient refers the white dot option in which you would remove more power. You’ll show them both options until the patient report they look the same or until they continue with reversal between two options. One clinical tip is that for every .50 diopters of cyl that you add, you must remember to add plus .25 to your sphere power to compensate. For axis refinement, you’ll orient the JCC in the straddle the position. 45 degrees on either side of the axis you found during the retinoscopy and ask which choice is more clear. You want to chase the red dots here. We call it chasing the red. So, when you show them axis 1 versus 2, if they choose axis 1 or choice 1, make sure that you orient your beam in the direction that the red dot is facing. You’ll bracket around the preferred axis until the patient reports the same or has a slight reversal and toggles back and forth between two options. With less cyl power, you can alternate these axis in different increments. With .5 to 1 diopter in your cyl power, you can make 15 degree changes. As the cylinder power increases, the patient tolerates less and less change in axis. I recommend using only 10 degree changes. And anything over .25 diopters — or 2.25 diopters of cyl, only 5 degrees. Keep in mind, some patients may be pickier than others. Remind them it’s okay that both options are the same. Volume type A and want to get this very precise and want a right answer. But remind you, you are the doctor if had control, and we know we have been toggling around multiple attempts, it’s close to the end point and we can end the axis refinement and do any necessary refinement and trial frame out of the phoropter. You can see here that you’ll use your thumb to rotate a time the dial to show them option 1 or 2. You can see that the cyl power is added in that small box. We have .75 diopters of cyl in there now. And turning the cyl power dial on the outside. And to change your axis you know rotate the innermost dial. Right now we’re at about axis 30. If the patient preferred a option that was in the direction of a red dot, we would orient towards the red. Our final sphere refinement, once we’ve completed JCC, is to remove our JCC lens, and you’ll now project the 20/20 line. I will again fog the patient or adds plus in .25 diopter steps and then slowly reduce those minus diopters until the patient can read the 20/20 line. If the patient can read 20/15 with improved clarity, you can offer a one click of minus quality quarter as long as it does not make the letters smaller and darker. You want to verify, does it truly make it clearer, or just smaller and bolder. If they are smaller and bolder, you have likely over-minused your patient and give them back the click of plus. We will go to binocular balance. We have completed refraction for the right and the left eye and we will open both eyes. We are balancing accommodation for the patient here. So, this has to be done with visual acuity is equal if both eyes. Two options are prism disassociation in addition to alternate occlusion. Prism disassociation compares our clarity while simultaneously viewing two targets. This can induce vertical diplopia. Base down over one eye and base up over the other eye and they’re able to see both options simultaneously. Alternate occlusion, they compare when the examiner covers one eye at a time and asked them which one is more clear? And I would recommend alternate occlusion. If the patient tends to suppress, they’re not able to appreciate both of the two images at the same time, or if they’re very uncomfortable with the double vision. It is a little disassociating for some patients and it makes some a little bit dizzy. So, alternate occlusion is a great one. For prism binocular balance, we added in our Risley prisms over both eyes, and 4 base up over the right eye and 4 base down over the left eye. The procedure will be to project three lines above the working VA. Again, if they’re 20/20, projecting 20/40, and fog both eyes. About three clicks of plus. Then you’ll ask the patient if one line looks more clear than the other. Make sure you tell them it may not look as bright as the other, but focus on which one is specifically more clear. If there’s no difference, they can go ahead and remove that prism. If a difference is observed, you’ll go ahead and add plus to the clearer eye until they report they’re equally blurry or if reversal occurs. Our alternate occlusion is the same procedure, however, we’re not adding in the Risley prism lenses. So, we’ll project a line 3 above their working VA. Add about three clicks of plus to fog them. And then we alternately cover each eye, asking which is clearer. Here we’re covering the right eye, then switch to left. And add plus to the eye that the patient reports is more clear. This effectively make it is equally blurry to the eye they’re still perceiving that’s still a little bit blurry. Be very clear on the language you use. Make sure you are aware, whether you’re asking them which one looks more clear or which one looks more blurry. Because that’s going to determine whether you add plus to the right or the left eye. Once we have completed binocular balance, we assume that the patient is still fogged. They still have those plus lenses in place. And we project the 20/20 line. We’ll then remove plus or add minus binocularly until they’re able to read the 20/20 line with both eyes. Here you can attempt the quality quarter which I would recommend only doing if they truly subjectively appreciate that extra click of minus. If it just makes it darker and bolder or they don’t notice much of a difference, avoid over-minusing them and make sure to go with the most plus end point. We have another poll option here. During — regarding binocular balance. During binocular balance, you place 4 prism diopters base down over the patient’s right eye. And 4 prism diopters base up over the patient’s left eye. After fogging the patient, they tell you the bottom image is more clear than the top image. What is your next step?
A couple more seconds here. All right. So, very evenly split. So, the correct answer here is A. Add plus .25 spear over the left eye. Keep in mind when we add prism, the direction of the base is not where the image is. The image is sent up towards the apex of the prism. So, when we place 4 base down over the right eye, that right eye is seeing the top image. And our left eye is seeing the bottom image. Since the patient is telling us that the bottom is more clear, that means that we want to fog it further, make it more blurry. And the left eye is seeing that bottom image so we would go ahead and add plus over that left eye. Our final step of refraction that a lot of examiners forget about is trial frame. In the phoropter, they may be 20/20, but we want our patients to be what we call 20/happy. Not only clear, but — and they may wavy or distorted in trial frame walking around in a real life scenario. You want to put your phoropter findings in trial frame and have the patient walk around. You can ask about wavy lines, whether walls look distorted. Are they experiencing eyestrain or headache and have them go into a hallway, look out a window and really cause a real life situation for them. Because that’s how they’re gonna be walking around with their glasses. You can always add plus or minus .25 or .50 over each eye just to make sure that it’s still clear and comfortable. Or whether they appreciate a small change in that sphere power while in trial frame. You can assess their comfort at multiple working distances as well. I call this the money step. This is the step that we should be taking with every patient to make sure that their glasses not only give them good, clear vision, but also very functional vision for their lifestyle. Have the patient view distance objects that are far away. I like either the end of the hallway or even out a window. That will simulate what it might be like when they’re driving or using their glasses looking at very far distances. Intermediate might be a good option for someone who works on a computer often or a laptop. You can have a patient actually sit in front of a computer and demonstrate their true working distance between them and their home computer for you. And then you can trial those lenses to what is optimal and most comfortable for them. I often have patients check their near add by using their own cell phone. Because that’s something that’s very applicable to every day-to-day life. Or a book that they would read with a very comfortable print size so they can show me their own working distance in case it’s not at that standard 40 centimeter working distance. Again, 20/happy is what we call a patient who has clear and comfortable vision. This is our end goal for every refraction. And it’s up to you to help your patient determine what is most comfortable for them. Even if they’re 20/15 in the phoropter with their full cylinder correction, they may feel more comfortable with reduced cyl correction in trial frame even though they’re only seeing 20/20 in both eyes. You want to go with what provides the patient the most comfortable vision. And finally, to wrap up, a few thoughts and clinical pearls that I’ll leave you with are making sure to use an objective measure of refractive error as a starting point. This can be your autorefractor, a retinoscopy finding. Something that lets you know you’re very close to their end point. And then letting them give their input on that subjective component as another tool. You want to be very clear and use simple language. You want to tell them: I’m going to show you two choices. Neither may be clear. Let me know which one looks more clear. That helps you avoid the patient who just says: Both blurry. And you start to lose their responses because they are frustrated. Let them know some choices might be blurry, they both might be blurry, we want to get the one that’s the most clear. It’s okay to look the same. A lot of patients think that the same is an incorrect answer. Or that they’re not going to get the most accurate prescription if they don’t tell you one or two. The same is always a good answer, and always remind them it is a choice before starting your refraction. I would recommend maintaining efficiency by bracketing. If you’re toggling between two choices, such as if your patient brings you between 5 degrees, between two axis points and they say the red’s more clear and then you flip it and now they like the red in the other direction, and we’re just toggling back and forth. It’s okay to stop the refraction as the examiner knowing you’re near end point and putting it in trial frame and refining it in real space. Slower responses also mean that you’re likely getting close. If they can’t tell which one looks significantly more clear, it means that we’re very close to our endpoint. And that’s a good sign. So, say a patient with your patience. You’re the doctor and it’s up to you to decide when to move on. And when your patient may be really anxious or not sure what the procedure is, be patient with them. Give them some time to respond. But don’t be afraid to say: This is our endpoint. We’re going to move on. This is the most clear that my patient has seen. And always remember you’re in charge of the refraction. You ultimately get to decide that final prescription for your patient. You do not always have to describe what you end with in the phoropter. It’s up to you to determine what provides the most clear and comfortable vision for your patients. That is the end of my presentation. Thank you all for coming out and learning a little bit more about tips and tricks for refracting our patients in the real world. Both are great tools that you can use in a variety of clinical settings and it really benefits our patients when we know how to get them that best corrected visual acuity. It also helps us know that we have reached their true visual potential gives us an accurate assessment of how much vision they reduced from other factors like ocular disease. And I will now open up the floor to questions. If you have additional questions following the question session, please feel free to reach out to me. My email is listed here and I will be happy to discuss more with you. All right. I will be going through our Q&A. So, our first question: Can you advise on how an examiner who can only one eye during retinoscopy? I believe that may be referring to if you’re not comfortable using your left eye. I would advise becoming very ambidextrous and becoming comfortable with it. It does take practice. So, even if you are right-eye or left-eye dominant, I would advise practice. Unfortunately, retinoscopy is a skill that takes a lot — a lot of practice to really nail down. All right. And we have in retinoscopy, I usually get a half diopter more than the subjective refraction. What might be the reason? So, we had a comment that on subjective, they may not accept your full objective amount. That’s a great consideration. Again, retinoscopy is a starting point that you can put in the phoropter. And I had a question: What is place on the power cross. And that’s what we had gone over in the lecture, you find your meridian, neutralize it, and put that lens power down so you don’t forget it. And then you proceed and rotate your axis 90 degrees and you can put down that value on the power cross. And that’s a very efficient way so you have both the powers that you use to neutralize written down on the correct corresponding meridian. And then we take our working distance out, either 2 diopters or 1.5 diopters subtracted from that. And you can find your net retinoscopy. And I have a great question: up to what age do we do cycloplegic reaction? Cycloplegic reaction is the gold standard to get the most accurate refractive error, particularly in pediatric patients. It is something we use for a lot of kiddos and there’s no true answer for when we don’t use it. When I tell my students is that if you want to cycle a patient, you have to explain to me why. So, what I will do is assess: How old is the patient? Usually before 7 years old I will cyclo to get an initial assessment of their refractive error. I will make sure they’re not hiding any plus transcription that they’re accommodating through. Another is in patients with amblyopia or strabismus, it’s critical that we get the most accurate prescription. Other indications may be a patient symptomatic for eyestrain, headaches, a lot of visual symptoms, trouble keeping things clear at near intermittent blur. That suggests that there may be a latent hyperopia component. Or an accommodative dysfunction in which it benefits us to their full cyclopledged refraction. You can do it on adults as well provided they are symptotic and you want to know their true refractive status. I had a question to reiterate three eye technique. And that technique is that when you start on the right eye, and you proceed to go to the left eye, you want to consider that when you’re scoping the left eye, you’ve already added lenses to our right eye. It’s fogged, essentially, with your working distance. When we move on to the left eye, I’m very confident that that’s the accurate prescription because the right eye is very blurry. It’s likely not accommodating. What I started though, the left eye could have still influenced by accommodating. So, I moved back to my right eye and just double check. So, three eye technique is essentially a double check to make sure that no accommodation affected your retinoscopy results in that first eye. And we have: What is the procedure of neutralizing one meridian that’s neutral while the other has against. So, what that would mean is as you’re neutralizing your neutral meridian, or I’m assuming you’re seeing no lenses, you would write down that it’s neutral at 0.0 on that power cross. When you flip to the next axis and you’re seeing against motion, you’ll add minus lenses until you find neutral again. From that point, consider that you had a working distance involved. So, although it appears neutral with no lenses in front of it, it will likely actually be a minus 2 or minus 150 diopter finding at that axis when we take out our working distance. So, essentially, it’s the same procedure. It’s just that you have scoped — you’ve added a little bit of width and a little bit of against. And it’s still neutral. So, you know that you can write 0.0 on that power cross and then you want to go ahead and take out that working distance. And we have: Does it matter what cycloplegic agent you use? I prefer cyclopenalate in addition to tripicamide so that I get an optimal dilation. For cycloplegia, we recommend one drop of cyclopenalate, wait 5 minutes and add another drop of cyclopenalate for the full cycloplegic effect. In clinic, in might not be something that’s attainable if you have a very fast-moving clinic. We will do one drop of cyclopenalate, wait 5 minutes and add one drop of tripicamide which gets a very close effect. But ideally you want to do the two drops of cyclopenalate 5 minutes apart from each other and wait 45 minutes for that optimal cycloplegic effect. And I have a question about the principle offing toking. Fogging is another way to say that we add plus lenses and what this does is it blurs the patient. If makes things a little bit less sharp so that we take away their accommodation. The purpose of this is to make sure that we don’t over-minus a patient just because they’re accommodating and inducing that minus. And I have a question on in retinoscopy, which meridian will be chosen as a spherical meridian? The spherical meridian, when we are using minus cylinder, is going to be the most plus or least minus meridian that you neutralize. If you scope one meridian and you neutralize with plus 2, and you scope the opposite meridian and neutralize with plus 1, that plus 2 meridian is your spherical. And vice versa, if you keep in mind when we’re in minus power, if you neutralize the 180 degree meridian with minus 1 and neutralize the 90 with minus 2, that minus 1 is the least minus and the most plus meridian. So, the minus 1 at 180 would be your spherical. I have a question on the dual cone test for monocular balance, that is the red/green screen. I recommend the duo screen test only when the monocular visual acuities are not equal. If they are equal,ly do prism disassociation or alternate occlusion. If one eye is 20/20 and one eye is 20/25, then I will use that duochrome test. All right. And I have a question: Do you have any tips for a scissor-type reflex when doing retinoscopy? Scissoring is very difficult to neutralize. I would recommend really using the upper sleeve. So, pushing your sleeve up so it’s converging rays to try to get the most accurate axis. But keep in mind, it’s very difficult for all examiners even someone who is very proficient in retinoscopy to get that reflex neutralized. So, I would go in big brackets until you 100% see reversal and you can bracket from there. And ideally, you would put this in trial frame and then do a very close subjective refraction for your patient to make sure that you have the optimal axis that gives them the best visual acuity. I have a question: Do we always need to give full correction of cycloplegic refraction always? I would argue no. Very rarely do we give the full cycloplegic refraction. The cycloplegic refraction is a tool so that we may find their optimal, their full refractive error. And then we can cut equally. Keeping the — between both eyes. This will help us in a case where we scope a patient who is plus 1 in both eyes on their dry ret. When we cyclo, they may have a full plus 4 that we reveal once accommodation is knocked out. I would likely not prescribe that full plus 4 unless there was another medical indication such as an esotropia where this would benefit the patient’s eye alignment. I would cut and likely give them plus 2. Or plus 3 so that we can really relieve that demand on the eyes, but they’ll still be clear and still wear the glasses. So, a subjective refraction with the cyclopenalate in both eyes is very beneficial. And I have a comment, I have a challenge doing cyclo on children with cerebral palsy, what would be your comment on doing dry ret? I would recommend doing a dry ret in a very dark, wide spaced area and finding a very engaging target such as a video or something that the patient will enjoy watching far away. You want to make sure that we have a very far distance target so we’re not inducing accommodation. And loose lenses help here as well so that we don’t distract our patient. You can definitely do retinoscopy with the ret bars. But you can also take loose lenses and just throw them right in front of the patient’s eyes and work your way up that way. So, we have during retinoscopy: A true neutral glow is sometimes not able to to be obtained a slight degree of movement is seen. This is a great question because this goes into what I call bracketing. When we are scoping and you see very slight width, I would recommend throwing in even more plus. So, you want to throw in even more plus way past that neutrality point until you 100% clearly get that reversal into against. From that point, you know at this amount of power I’m at against. I’ve gone too far. And then you slowly work your way back down until you get that high neutral glow. You may see that very slight movement. So, I would recommend putting in the most amount of plus power released minus until reversal. I think that’s a very good technique to really convince yourself that you are seeing the most accurate refractive error. Throw in a little bit extra at the end on — to make sure that we’re actually getting that true reversal.
And we have before starting cross cyl on subjective, to you subtract the sphere by. 25 for the circle of least confusion and then return it once complete? For our cross cyl, if we add in our — whatever we scope on ret is what we put into our cylinder power. While on subjective, we add more — say that the patient accepts the red, we add more minus. And then we show them two options and they choose the red again, we add more minus in the cylinder power. Then we proceed to add plus .25. If the patient then reverses, and chooses the white, and we take out a quarter diopter, remember to take away that .25. So, you will only do that during the subjective refraction. Keeping in mind that for every .5 of cyl you add, you add plus.25, and for every you take away, during the subjective you have to add minus .25. What do you make — how do you make retinoscopy easy in a jerky eye such as nystagmus? Great question. We have a lot of patients who have nystagmus and their eyes are constantly roving. I would recommend using a high plus lens in front of the eyes. This is the same for when we take visual acuity. You want to use a frosted lens. Not a full occlusive lens. I would recommend taking a plus 5 over their habitual correction over one eye to try to slow that eye down. And then go and do your ret from that point. So, I have a comment: Many problems occur during refraction. What are major things to consider during refraction of a low vision patient? This is a good question because it brings in our retinoscopy and our trial frame refraction and how essential those are. Low vision patients benefit from a trial frame refraction, doing it in free space. And I would recommend using very big jumps. So, you want to make sure that you are using lenses that have the patients just noticeable difference. So, if they’re a low vision patient, we’re probably not showing them, which is clear, plus. 25, minus .25. They’re not gonna appreciate that difference. You want to find what they’re able to notice during the refraction. Whether you’re doing it, you may actually show them plus 1 and then minus 1 over what they have in the trial frame. So, you’re going to be making a lot bigger jumps so that they’re able to notice and appreciate those differences. For manifest refraction, you mentioned that we should start with axis refinement for about .75 cylinder or higher that they have an astigmatism. Is that a different process than the normal? So, to clarify on this, this is referring to starting with either the power or the axis refinement with the JCC in place. When we have less than .75 diopters of cyl, I like to double check the power first. So, I will show them which is clear, 1 or 2, and I’ll have my red and white dots aligned with the power. Once they have hit their end point, either they look the same or they’ve reversed between the two options, I’ll switch to do axis. And then once I refine my axis, since I don’t anticipate any big changes since it’s a lot harder for someone with very small amount of cyl to notice axis changes, I’ll go back and do a power refinement. The contrary is when they have more cyl, or they’re going to notice an axis change a lot easier. Someone with minus 3 diopters of cyl is going to notice even a 1 or 2 diopters — or 1 or 2 three axis change. I go straight to axis to make sure that we can get the best axis lined up first. And then I’ll move into power from there. And that’s just because if the axis is very far off from your ret and never a high amount of cylinder power, it’s a lot easier to get your axis all squared away first so that you’re able to appreciate the difference between the power refinement and give you the most accurate responses. How reliable is the autorefractor in determining the power of the lens in cycloplegic refraction? The autorefractor is a good starting tool. Particularly in adults. I tell my students: Do not use your autorefractor in any kiddo or anyone 16 and under who is not cyclopledged, it’s in play and you will get over-minused results. I will use the autorefractor as a tool once the child has been cyclopledged and I always trust my ret. I will say, they got a decent amount of cylinder and this axis on the auto. I’m finding something very similar. Let’s see how both of those come into play when I do my cycloplegic refraction in trial frame. But I will definitely trust my ret over a trial refractor, particularly on a pediatric patient. We have a comment: What do you do if the new prescription glasses make the patient have a headache or get nauseous, what is wrong? This is something that can happen when we forget the trial frame step. This is why I call the trial frame that money step. You want to make sure that the patient is comfortable. It sounds like we did the refraction the for opter here, finalize the full prescription and sent them on their way. With the trial frame, we’re able to make sure that in free space the patient really appreciates that cylinder correction and in axis. They may get distortion if the axis is not at their favorite subjective placement in the phoropter. We can change that in the trial frame. Any astigmatism is the axis that’s off or too much cylinder power can induce symptoms of headache or eyestrain. That’s why we double check with plus or minus 50 in our trial frame, the sphere power to make sure that’s what they prefer in free space as well. If they’re doing trial frame, I would recommend looking at the glasses modality and checking things like the pupillary diameter, making sure they’re aligned with the optical center and consulting with an optician. If you have questions on the way that the glasses were made and how they’re fitting the patient. And we have: If the person does not have distance correction, but has a need for near, up to 1 to 2 meters to watch TV, what changes will be in refraction? Or will in be other modifications? So, that’s something that you would have the patient demonstrate in office. So, keep in mind as we get closer to a target, we’re gonna need more plus in that prescription. So, you would likely want to have the patient — if they’re being symptomatic with the distance glasses you’re giving them, I would recommend having them go home and measure the distance from their couch to the TV so that you can simulate that in office and trial the most appropriate lens for them. And we have what are pearls for refraction more difficult or more uncooperative than a neurotypical pediatric patient? For this case, we call it get in and get out. Keep in mind that you are the examiner. The patient came to see you. And it is our job to engage the patient’s for testing. What I would recommend is putting on a video that they like. We have — we’ll bring in our own phones and put on Mickey Mouse or a video that’s very soothing or calming. Ask the patient’s parent what they enjoy, what they watch at home. You can have the child sit in their parent’s lap to be a little bit more comfortable and just give them some time. So, don’t jump right into throwing all these lenses in front of them. Let them watch the video a little bit. And I’ll just scope my lens in front of their eye so they get used to it. And just scope it again. And eventually I’ll go in with a loose lens and get one sweep and I slowly work my way up. So, it does take a little bit of time, but you want to modify your exam room to fit the patient and help them feel most comfortable. And we have when is the Jackson cross cylinder necessary to do? This is for any patient who has cylinder or needs additional correction. So, if you do scope sphere on your retinoscopy, I would challenge you to what we call fish for cyl in the phoropter. So, I would do the Jackson cross cylinder essentially on every patient. And what you do is even if you have zero cylinder power that you were scoping with your retinoscopy, put in plus — or minus .5 diopters of cyl in the JCC and show them all for primary meridians. So, ask them which is more clear, one or two at axis 180. If they choose the white or rejection, take it out and move to axis 45. Ask them which is better, one or two. If they choose white, it’s a rejection, move to axis 90. And so, you go to axis 135. And then you’ve shown you have shown item correction at all the primarily principle meridians and rejected it every time. Sometimes they accept it, in which case you proceed with your full Jackson cross cyl procedure. And I have why are we getting an error over corrected with high myopia in phoropter? Especially in pediatric patients, consider that the phoropter is coming closer and closer to our eyes. That’s going to induce that proximal accommodation. And that drives the patients into that accommodative status which can give us a false overestimation of minus. We know that myopes love minus. They will accept and accept and accept. Which is why I like showing my most plus retinoscopy to the patient and then slowly working them down. Even if they accept minus 2 and I’m scoping minus 1, that tells me that the patient truly does not require that full minus 2 refractive error. I will fog them and slowly work them down by adding minus until they first see that 20/20 line. So, try not to continue to over-minus that patient. And fur getting over-minus results in the phoropter, try putting your retinoscopy findings in a trial frame, and that will induce less of that proximal accommodation for the patient. And we say what about in the case of over/under correction? How do we know if they’re over or under corrected? And that would be following our cycloplegic refraction. You always want to make sure that if you are unsure or things don’t make sense, you to that cycloplegic reaction. That will let you with the scope find the true refractive status. What you’re seeing is the true reflex and the true most refractive error. And you don’t need any input from the patient to do that. That’s how you can determine whether they were over-corrected in the past and show them that this trial frame and slowly work with them to find the optimal prescription that they’re able to tolerate. Is it better to have the patient fogged or occluded when refining cyl and access? I recommend occluding the other eye so that we can do one at a time, however when we do the binocular balance, you do want both eyes open and at that point you would fog them so that we take out any accommodation that may be residual in that patient and that will get you a more accurate result during that binocular accommodative balance. How much should we subtract after cycloplegia? Again, that depends on our patient and the findings that we get. With pediatric patients, if they have an esotropia or esoposture, I do recommend pushing for full plus if they can tolerate it. From there, you will slowly reduce the plus prescription until the patient subjectively is able to see their best corrected visual acuity. So, there is a subjective component for our older kiddos. But with our younger ones, who may not have any other comorbidities, just a 5-year-old patient who has 4 diopters of cycloplegia, I will often take away about 1 to 2 diopters, depending on how much they’re able to tolerate following subjective. In a patient with any accommodative dysfunction, I will prescribe the amount of plus that takes their MEM or monocular estimate findings from a lag of accommodation into the normal range. And that’s another technique you can use to figure out how much plus you should actually be prescribing. Should the examiner wear his spec correction for doing the retinoscopy? Yes. Examiner should be fully corrected. And then you’ll just place the retinoscope at the plane of your lens as well. Is binocular balance done for all patients including amblyopic and geriatric patients? Binocular balancing is only done when both visual acuities are between both eyes. In an amblyopic patient, especially in an — one would be reduced and we would no be able to complete that binocular balance. That is a good thought there. Why do we have to make the patient see three lines above the working VA? Why not the same or just one? The thing about JCC is that it’s very hard for the patient to appreciate a difference if we’re at threshold. We recommend three above their working VA to make those letters a little bit larger so that as we show them the two options, they’re able to appreciate the difference and it makes it a little easier for the patient to give you more accurate feedback versus if they are sitting at their threshold it may be just blurry enough that they’re not able to appreciate the difference and we don’t get as accurate of results. What is the best tip in the case where the RX is trialed but still brings discomfort to the patient? Again, I would recommend talking with your optician or considering how the glasses are fitting them. You want to also make sure that you closely assess the patient’s habitual working distance. If you prescribe glasses for near and the patient is attempting an intermediate distance like the laptop, they may not have brought that up at the exam. Sit down and ask what do you use these glasses for so you can modify them to bring the most comfort for the patient. How do we adjust the post-cycloplegic correction? And how much do we increase or decrease the sphere compared to the refraction before cycloplegia? So, the post-cycloplegic correction is the same procedure as a trial frame refraction. Just post our cyclo drop. So, it can only be done at distance since we’ll be blurry at near. But I will likely put in the retinoscopy findings that I find post-cycloplegia. And then repeat that refraction. The dry refraction is a starting point, but the most accurate is the cycloplegic retinoscopy and you put that in trial frame and find where the patient is subjectively most comfortable. In the case of very, very young kids, you would ideally prescribe the full cylinder and the axis that you scope yourself on the cycloplegic retinoscopy. And then I would cut plus equally between both eyes. So, make sure that you keep the iso when you’re cutting for any pediatric patient. If the cylinder changes from negative to positive after cycloplegia, how do you prescribe? So, cylinder is either negative and minus cyl or when we talk about plus cyl, that is actually what the ophthalmologist typically use. With optometrists we use minus cyl in or phoropter because that’s more applicable to glasses and creating them and based on refractive data. However, plus cyl is more common in ophthalmology due to its surgical implications. Both create the same type of prescription, you have to transpose between the two. I wouldn’t expect that the minus cylinder would change to plus. It would likely need to be transposed into plus cylinder. But they would still have that same amount of cylinder. If you do notice a change even if it’s not necessarily from minus cyl to no cyl, you are able to prescribe that for your patient. They may reject the cylinder post-cyclo, and that’s dependent on what you’re scoping on your patient. Do we have any other methods for refining cylinder power and axis other than the straddling method? In the phoropter, that is the only method. We do have loose lens, Jackson cross cyls for low vision trial frame refraction available if you want to try it in trial frame. However, it’s a very similar concept that you’ll be showing the patient. Another option is using your scope and seeing how they feel about it in the trial frame. And someone asked what is the primary difference between subjective refraction and retinoscopy? Primary difference is that one is a subjective measure the patient give use input. They can answer and tell you which ones look more clear. Whereas retinoscopy is completely objective. You do not need your patient to give you any feedback to complete that test which is why it’s very good with young kiddos. Especially doing it in a one or 2-year-old who will not give feedback. May not know letters, not ready to match yet. But you as the examiner can use your refractive scope and get the reflex measurement. Whereas in — they’re able to give a little bit more input and you will be able to really nail down their exact subjective prescription by doing that. And would you give tips on retinoscopy over previous glasses? What would be expected? And what would be taken off from the prescription? So, this is what we call our over-refraction. Ideally, if they had an accurate refraction before, I would expect to see with motion immediately and my working distance is 50 centimeters. So, I would expect to neutralize with about a plus 2. If we are scoping more or less, you would ideally have to write down your over-refraction findings and then you will combine the two and put that into a trial frame so that you can do a more accurate subjective refraction. And what you would expect to see really depends on whether the patient requires more spherical correction, more cylindrical correction. Sometimes the axis is not correct. In which case I will typically take off the patient’s glasses and do a retinoscopy just with the patient and their true refractive error alone. And another question on binocular balancing. If a patient has minus 2.50 in both eyes and minus 8 in the other eye… with no history of glasses, how should we do binocular balancing? This would depend on the final visual acuity of the patient. So, again, binocular balance can only be done when the final visual acuity is equal between both eyes. There may be some degree of unequal corrected visual acuity with this patient. And some have commented that we could do contact lenses for the in iso. I agree with. Don’t forget about that option for your patients as well. That we want to reduce that anti-cyclo with the different image sizes. I definitely think that would be a great contact lens candidate. And we have: If a patient has a headache and they accept plano, but after cycloplegic shows plus, what do we prescribe? That’s a common scenario. Symptomatic, headaches, eyestrain. And we cyclo them, we’re not sure, and it reveals the extra power that they are accommodating and focusing through. What I would recommend is demonstrating that plus power for near vision only glasses since the accommodative demand is so much greater at near. They will likely find relief from near vision glasses with the low plus prescription to help with the symptoms. Just being very clear with them, they will take them off for distance or they will likely will blurry. If they don’t do glasses on and off, you can do a plano distance lens and create a bifocal. So, they look through the no correction at distance and then the plus portion at near. All right. I think that is it. That’s our hand for time. So, that is all the time we have for questions today. And it has been a pleasure to give this talk to all of you and discuss different strategies for refracting our patients. I hope that you took some of these clinical pearls away and will be able to apply them in clinic.