High Power Refractometry

Introduction Distometer Phoropter vertex device Over-refraction method Trial frame method High astigmatism Review

Introduction When glasses prescriptions exceed six diopters you have to take into consideration the distance from the cornea to the glasses lens. This is referred to as the vertex distance. The greater the lens power is, whether plus or minus, the more important the vertex distance becomes. In the higher powers small changes in the lens to eye distance make big changes in the clarity of the image projected onto the retina. When you are refracting aphakic patients, their prescriptions may be in the +11 to +17 range. On the minus side some patients are in the -20 range. For these patients it is absolutely necessary to adjust the lens power for the proper vertex distance. For those patients closer to the 6 diopter end, it is not as critical, but usually it does make a difference. The final refraction is written on the Rx form along with the vertex reading. The optician does a vertex reading from the glasses/frames that the patient will wear and adjusts the prescription, using a table, according to the difference between the frame vertex and the prescription vertex reading. The Distometer The distometer is a device used to measure the vertex distance. It is usually used to measure the distance between the closed the eyelid and the back surface of the spectacle lens. It can also be used with a trial frame and with the phoropter. Part B touches the closed eyelid. Part A moves when the plunger (D) is pushed. Part A is moved using Part D until Part A is touching the back of the lens. At this point the vertex distance is read from the scale at C. The distometer scale

accounts for the thickness of the eyelid. Your office or clinic should have one of these. The operation will become obvious once you have used one. The phoropter vertex device The least desirable method for taking a vertex reading is the use of the vertex device on the phoropter. This involves using the sight on the side of the phoropter to align the corneal apex with a scale mark. I do not recommend that you use this method. In my experience it is not accurate. It is reasonably accurate to use the distometer with the phoropter. The patient is refracted in the usual manner with the phoropter. The distometer is then used to measure the vertex distance with the patient still positioned at the phoropter. The part of the distometer that touches the lens must go through the port hole at the back of the phoropter until it touches the lens. This technique will not work on phoropters that have a protective lens covering the hole. The over-refraction method Refract the patient, using the phoropter, as you normally would any patient. The over-refraction method is useful if the cylinder axis has remained about the same and if the cylinder power has not decreased. This method can be used if the patient will be using the same frames, or similar frames. In this case simply have the patient put her glasses on and do a spherical over-refraction. This method is accurate with very high lens powers. Overrefraction was the method of choice when dealing with aphakic corrections before the intra-ocular lens came along. Have the patient place the occluder over the lens of the opposite eye, just as she does when you are checking her vision. Have the patient view a line on the chart that she can see, but is challenging. If the cylinder power determined by using the phoropter has increased, include a trial cylinder lens (representing the difference) in the overrefraction. Hold up a +0.50 trial lens (do not use a +0.25 lens) in front of her glasses lens and ask her if the vision improves. If it does, hold up another +0.50 trial lens over the one already in place and ask if the vision improves. If the vision improves again replace the two +0.50s with a +1.00 and hold up one of the +0.50s over the +1.00 and again ask if the vision improves.

Continue in this fashion until no improvement is seen, just as you would with the phoropter. Of course if the patient sees no improvement in the plus direction you will want to check (with over-refraction) in the minus direction. Lets say the patient sees improvement with the +1.00 lens held up, but the vision gets worse with the addition of another +0.50. You would then add the +1.00 power to the sphere power of the patients glasses. This is the sphere power that is written on the prescription. The cylinder power and axis would be taken from the readings on the phoropter. The vertex distance can be measured using the distometer with the patient wearing her glasses, or a note can be made on the prescription that the vertex distance is the same as the present glasses. The trial frame method A refraction can be performed with a phoropter, or a refraction can be performed with the trial frame. If you use the phoropter, and an overrefraction is not practical because the cylinder power and/or axis are significantly different, then the trial frame is used. Why not use the trial frame for the refraction from the beginning? You can, of course, do this if you like. You may find it easier, faster, and more accurate to check the cylinder axis and power with the phoropter rather than a trial frame. If you used the phoropter, put the refraction from the phoropter into the trial frame. Be sure to put the high power spherical lens in the slot on the back side of the trial frame the slot that is closest to the patients eye. Trial frame viewed from the side. The high powered spherical trial lens goes in the slot on the back side. The cylinder trial lens goes in one of the front slots. Once you have the refraction from the phoropter in the trial frame, do a spherical over-refraction as described earlier. What you end up with in the trial frame as the best correction is then written on the Rx form. You must now measure the vertex distance of the lenses in the trial frame with a distometer and write this number on the Rx form.

High astigmatism The above discussion assumes a low to moderate amount of astigmatism. If there is a combination of high sphere power and high cylinder power, then the cylinder power may also need to be adjusted for the vertex distance. Let's assume that a high myope from out of town has lost his glasses and comes to your office for an "emergency" refraction. You perform refractometry with the phoropter and arrive at -14.50-5.50 x 90. You don't trust taking a vertex reading with the phoropter, so you put the correction in a trial frame. Now perform a spherical over-refraction and a cylinder power over-refraction starting with a lower power, because the power in one meridian is -14.50 and the power in the other meridian is -20..00; a significant difference. Review The patient is wearing the following glasses Rx: -10.00-1.50X60 Refract the patient using the phoropter. One of two endpoints will be reached: 1) The cylinder correction stays about the same. For example, the patient refracts to -11.00-1.75X65 in the phoropter. Go to Plan A. 2) The cylinder correction changes. For example, the patient refracts to 10.75-1.00X90. Go to Plan B. Plan A: Do a spherical over-refraction over the patient's present glasses. Let's assume that the patient's vision improved with -0.50 over the -10.001.50X60. The final refraction would read -10.50-1.75X65. The refractometry notes would indicate that the vertex distance is the same as the VD of the present glasses, or the VD distance of the present glasses could be measured for the exact mm value. Plan B: Since the cylinder correction changed, you will need to use a trial frame, with the high powered lens in the back slot (closest to the eye) of the trial frame. The phoroptor refraction of -10.75-1.00X90 is placed into a trial frame. Do a spherical over-refraction over the trial frame correction to arrive at the vertex corrected power. Suppose the patient sees best with +1.00 over the correction. The final refraction would be -9.75-1.00X90. You will have to measure the vertex distance of the lenses in the trial frame and note it with the refractometric reading. For example: VD=

13mm.