1. Introduction to Retinoscopy
Vike Vicente, MD
Assistant Professor of Clinical Pediatrics and Ophthalmology
Georgetown University Hospital

2. Introduction to Retinoscopy
Retinoscopic refraction allows the examiner to objectively determine a patient’s refractive error and to prescribe proper glasses.
This is very useful in nonverbal or preverbal patients and patients with inconsistent responses to a subjective refraction.
The results may be affected by the patient’s accommodation, and therefore, the patient should be fully cyclopleged (or be cooperative enough to focus on a distant target).

3. Cycloplegia In our practice we use:
< 6 months of age: 1 drop OU of cyclopentolate 0.5%/phenylephrine 2.5%
6 months to 12 years: 1% cyclopentolate
> 13 years: 1% tropicamide and 2.5% phenylephrine for 13 years and older.
Patients with dark eyes may require two sets of drops 5 minutes apart.
It is important to avoid overdosing young patients as they will be more susceptible to anticholinergic effects such as gastroparesis, psychosis, flushing, etc.
A larger, dilated pupil will also make it easier for the examiner to see a larger red reflex.

4. Loose Lenses vs. Phoropter
For young patients who cannot sit at the phoropter, trial lenses may be used.
A phoropter can be used after the age of 5 years. It is useful if the phoropter has an “R” setting. This places a sph lens over the eye and allows the examiner sitting 66 cm to measure the refraction without having to subtract the working distance.

5. The Retinoscope: Sleeve up or down
Retinoscopes are made by different brands, with different sleeve positions. They will have a sleeve up or sleeve down position (see next slides).
It is important to use the sleeve position which produces a divergent light.
If the sleeve is in the proper position, the streak of light will be divergent and can not be focused on a wall at any distance.

6. Retinoscope Streak retinoscope bulb has linear filament
Move sleeve up or down to produce divergent light
Sleeve position varies among instruments

8. Which sleeve position should you use?
Unable to bring in focus no matter where you hold the retinoscope

9. When would you use the sleeve up, or a thin focused intercept?
To better determine the astigmatic
axis off the phoropter or trial
frame

10. When would you use the sleeve up, or a thin focused intercept?
To better determine the astigmatic axis off the phoropter or trial frame

11. Retinoscope Sleeve test Put sleeve all the way up
Aim streak toward your sleeve
Move retinoscope to and fro
If streak can focus, put sleeve all the way down

12. Examiner position:
The examiner and retinoscope should be 66 cm away from the patient. The reciprocal of this working distance, 1.5 D, should be subtracted from the final prescription to place the far point of the patient at infinity.
If retinoscopy is performed on a patient’s right eye, the examiner should use his or her right eye and hold the retinoscope in their right hand. This will allow the patient to look past the examiner’s right shoulder at a distant target.
If the examiner is too far to the right or left of the patient a false plus cylinder error will be induced at 180 degrees.

13. As the rectangular light intercept is swept across the pupil, it will create a red reflex that moves or fills the pupil (end point of refraction). The rectangle’s long axis should be parallel with the direction in which it is being swept. The light rectangle should be vertical if it is being swept left to right across the 90 degree axis.
If the patient’s far point is behind the examiner (hyperopia), the red reflex will move in the same direction as at the light intercept, this is called “with motion.” Plus lenses should be added to converge the red reflex light and bring the far point onto the examiner until the “with motion” is neutralized and the pupil fills in.
If the patient’s far point is between the patient and the examiner (myopia) the red reflex will move in the opposite direction as the light intercept and is called “against motion”. Minus lenses should be placed until the motion is neurtralized and the light is diverged away from the patient, onto the retinoscope.
If the patient has astigmatism a different red reflex motion will be observed in different axes. If you are working in plus cylinder form, neutralize the most minus or against motion first, then add sphere or cylinder power at the axis 90 degrees away.

14. With vs. Against movement
Intercept
Pupil
Peephole
Far point
At neutralization

15. With vs. against movement
Intercept
Pupil
Peephole
Far point
“With” movement

16. With vs. against movement
Intercept
Pupil
Peephole
Far point
“Against” movement

17. Remember…
An emmetropic child retinoscoped from the side will show against-the-rule astigmatism
Horizontal displacement from the visual axis
Plus axis of correction at 180 degrees
Correct, patient: plano
Incorrect patient: x 180

18. Plain, sphere

19. With motion…. Add plus

20. Against motion…. Add minus

21. Fills in… just right

22. Example # 1

23. With motion….
Add plus

24. +5.00
Add minus
Oops too much plus,
Now against motion…

25. +3.00
Final Rx?
+1.50 sph
Fills in… just right

26. Example # 2

27. Against motion….
Add minus

28. -5.00
Oops too much minus
With motion…. Add plus

29. -3.00
Final Rx?
-4.50 sph
Fills in… just right

30. With Astigmatism
Example #1

31. With motion at 90
Against motion at 180…
1st neutralize the against motion
Add some minus

32. -3.00
180 is neutralized

33. -3.00
Now neutralize 90
With motion…
Add plus

34. +1.00
Final Rx?
X 90
Fills in… just right

35. -3.00
+4.00
Or you could also
do it this way
X 90

36. With Astigmatism
Example #2

37. 1st neutralize the against motion
Add some minus
With motion at 90
Against motion at an oblique angle

38. -3.00
OK oblique
Against motion
is neutralized

39. -3.00
Now neutralize
Oblique with
motion

40. -3.00
+4.00
Final Rx?
X 70

41. More examples

42. Scissors
Keratoconus
Occurs when one part of the lens or cornea is more myopic

43. Posterior Lenticonus?

44. PSC?

45. Way off lens power
Cataract
Dull reflex DDx?

46. What is going on?
Changing direction…
The patient is still accommodating! Miosis
This is useful for dynamic retinoscopy
Can a young hyperope accommodate to a near point? …

47. Always do what the central area tells you.
What is causing the different zones?
Does this patient see better at night or during the day?

48. Spherical Aberration Produces bulls-eye retinoscopic reflex
Especially in young children
Peripheral portions of pupil myopic compared with central portion at neutralization
(“With” movement centrally, “against” peripherally)
Concentrate on central part of reflex