PHOROPTERS

Phoropter
• an instrument commonly used by optometrists and ophthalmologists
during an eye examination to measure an individual's refractive error
and determine his or her eyeglass prescription
• also measure phorias (natural resting position of the eyes),
accommodative amplitudes, accommodative leads/lags, accommodative
posture, horizontal and vertical vergences

Major Components
• JCC (Jackson Cross-Cylinder) used for astigmatism correction
• Risley prisms to measure phorias and vergences
• cylinder lenses

History of Phoropter
 By the 17th century, lenses were being used to subjectively determine the
best optical correction before trying on a pair of spectacles.
 Since the 1800’s, practitioners of clinical refraction have been trial lenses
with objective or subjective techniques to arrive at a final refractive
correction.
 By early 1900’s, optometry was becoming a licensed profession in the
United States, refraction was no longer the only part of the optometrist’s
education. The scope of optometry expanded, but the subjective
refraction remained a major part of the vision examination.
 In 1915, Baush and Lomb started to make trial cases (known as the
precision trial case) and trial frames. The limitation of constant center
thickness meant that the overall diameter of the lenses had to be kept
small. The precision trial case lenses had a diameter of only 15 mm.
 The first phoropter that in any way resembled today’s phoropters was
developed by De Zeng. De Zeng’s phoropter consisted of a series of four
discs, each having a maximum of eight lenses glazed in apertures
situated around the edge. By rotating the discs, lens powers from +15.00
to – 20.00 D could be obtained at the sight holes of the instrument. Later
on, two additional smaller discs were added that contained cylindrical
lenses. To obtain the correct axis for the cylinders, the discs were rotated
about the sight hole.
 Most modern refracting units contain the sphere and cylindrical lenses
on three discs. The wheel closest to the patient’s eye usually contains the
high power spheres, the second disc contains the low power sphere and
the third disc contains the cylindrical lenses.
 Commercially available manual phoropters are manufactured by
Reichert, Woodlyn, Topcon, Burton, and Marco. Most manual refractors
are similar in design to the original American Optical Ultramatic.
However, Reichert has purchased rights to manufacture the former
Bausch and Lomb Green’s refractor as well.
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Parts and Function

1. Rotation Adjusment Knob 22. Leveling Knob

2. Mounting Bracket 23. P.D Scale
3. Mounting Adjustment Knob 24. P.D Scale
4. Forehead Rest Knob 25. Reading Rod
5. Spirit Level Clamp Screw
6. P.D Knob
7. Vergence Lever
8. Auxiliary Lens Scale
9. Auxiliary Lens Knob
10.Corneal Aligning Device
11.Rotary Prism Unit
12.Cylinder Axis Knob
13.Cylinder Power Knob
14.Cross Cylinder Unit
15.Cylinder Power Scale
16.Cylinder Axis Reference Scale
17.Cylinder Axis Indicator
18.Cylinder Axis Scale
19.Weak Sphere Dial
20.Sphere Power Scale
21.Strong Sphere Control
1. Rotation Adjusment Knob - It controls the housing rotation. Turning this
knob adjusts the direction of the phoropter.
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2. Mounting Bracket - It is used attaches the phoropter head to support arm.

3. Mounting Adjustment Knob - This knob is used to tighten the phoropter to

stand and controls the pantoscopic tilt.

4. Forehead Rest Knob - It controls patient vertex distance. Adjusting this

knob will secure that the eyelids are not touching the back of the phoropter.

5. Spirit Level - It projects horizontal tilt of the phoropter head and indicates
position.
level position.

6. P.D Knob - The interpupillary distance or PD is simply the distance in

millimeters between the center of the pupil of the two eyes. This distance is
needed to center spectacle lenses properly in an eyewire. The P.D Knob is
use to line up the patient’s eyes in the center of the eye ports. It does not
converge below 55 mm. Its maximum extension is 75 mm.

7. Vergence Lever - It controls the near or far Interpupillary Distance. It is

adjusted in testing of near or far vision with an inward for 4mm decrease
and slight inward tilt.

8. Auxiliary Lens Scale - The values to be selected upon rotating the auxillary
lens knob.

9. Auxiliary Lens Knob - An Aperture Control Knob which determines what

the customer actually looks through, when seated behind the phoropter.
This control has different positions. The most frequently- used positions are
Occluded which means the eye is completely blocked or Open which means
that the customer sees through only the lenses that the refractionist has
“dialed into” position before the customer eye

Rotary Prism Unit - Also known as the Risley Prism Control. It is on the
10.Rotary
same arm that holds the Cross-Cylinder. The R-prism is an ingenious
device consisting of two rotating 10 diopter prisms mounted in a metal
case. When the prisms are aligned base-to-base, the total prism strength is
20 diopters. When the prisms are aligned apex-to-base, they cancel each
other and the total prism strength is zero.

Cylinder Axis Knob - Axis is the meridian of cylinder with the minimum
11.Cylinder
power perpendicular to maximum power meridian. This knob controls the
Cylinder Axis of the phoropter. It has maximum of 360° of rotation for scale
of 0°-180°. Like the cylinder power knob, it controls the minus cylinder
lenses that are mounted inside the instrument in a rotating wheel.

Cylinder Power Knob - Cylinder is a lens that has different refractive or

12.Cylinder
optical power in each meridian. It is used to correct astigmatism. It is a
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cylinder power control with 0.25 DC steps. It rotates clockwise for -0.25 DC
(relative) change and rotates counter-clockwise for +0.25 (relative) change.

Cross Cylinder Unit - It usually contains a +0.25 cyl. Combined with -0.25
13.Cross
cyl. The refractionist can rotate this lens to determine the axis of cylinder.

Jackson Cross-Cylinder (JCC Flip Cylinder) - The Jackson Cross Cylinder

14.Jackson
determines the power and axis of the cylinder. It is a lens with equal + or –
90 degrees apart. It is mounted in a ring with a handle halfway between the
+ and – axis or mounted in the phoropter with a knurled knob that rotates.

Cylinder Power Scale - The axis of the cylinder lenses is shown on the
15.Cylinder
cylinder power scale.
scale It provides the current cylinder value with a maximum
value of -6.00 DC and uses auxiliary cylinders for higher values

Cylinder Axis Reference Scale - The axis position of the cylinder lenses are
16.Cylinder
shown on the cylinder axis reference scale, easily found and read on the
phoropter. Gross axis cylinder with an accuracy of +/-15°

Cylinder Axis Indicators - It provides the value of the cylinder axis.

17.Cylinder

Weak Sphere Dial - This is a sphere power control which can be rotated up
18.Weak
and down. The dial or wheel controls spherical lenses from plano to + or –
20.00 diopters in 0.25 diopters steps.

Sphere Power Scale - Sphere is a lens with optical power being the same in
19.Sphere
all meridian. It is expressed in diopters. It provides the measured sphere
power. Black color is for plus (+) while red color is for minus ( - )

Strong Sphere Control - It provides a large change in sphere power with

20.Strong
3.00 DS steps. Its maximum value is combined with weak sphere dial
ranges from +16.75 DS to -19.00 DS. A clockwise rotation can bring
+3.00DS change in the reading and a counter-clockwise rotation will
produce -3.00 DS change.

Leveling Knob - Use to make the bubble on the level aligns with the dot.
21.Leveling
With this, you can able to tell if the patient is level. If not, try to get her to
cock her head to a level position.

P.D Scale - An indicator of the measurement made by turning the P.D Knob.
22.P.D

Reading Rod Clamp Screw - A near-point holder lock.

23.Reading

Auto Phoropter
This machine is divided into main body and keyboard.
Keyboard:
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It includes all the operating elements to control the motor-drives for

patient chair, telescopic table, phoropter arm and various lighting, such as
reading light, room lighting, and fixation lights. A control rheostat to regulate
the lighting of the table instruments and the main switch for the unit is also
integrated into the keyboard.
1. Color LCD 10x2 touch-controlled screen
2. buttons

Operation:

Visual acuity is defined as the resolving power of the eye, or the ability to see
two separate objects as separate.
“Refraction” refers to the sum total of refractometry (measuring the
refractive error of an eye), assessing the visual needs of an individual, and
arriving at a clinical judgment as to which prescription to provide.”

The overall process of refraction can be divided into three parts.

parts.

Part one is called the "starting

"starting point."
point." The refractionist collects basic
information about the visual conditions of the customer.

Second part is often referred to as the "refinement

"refinement"" phase of the process. In
this section, the refractionist would normally use a phoropter.

Third part of the refraction is usually referred to as the "end

"end point."
point." This part
of the refraction is perhaps the most critical portion. The refractionist must
evaluate all the available information to solve the customer's refractive
problems.

The initial set-up:

1. The customer should be seated and comfortable.

2. The phoropter should be set to match the customer’s distance P.D.
Adjust the level, adjust the forehead rest, and square to the eye chart.
You can measure the patient’s PD and set the PD scale of the phoropter,
or you can visually line up the patient’s eyes in the center of the eye
ports using the PD adjustment.

3. The phoropter should be positioned comfortably in front of the customer

like a pair of glasses.
4. The phoropter must be leveled.
5. A full- screen visual acuity chart with a 20/15 line at the bottom must be
well illuminated for the customer.
6. As a starting point for the customer’s refraction, the final retinoscopy
finding is usually set in place in the phoropter. An alternative starting
point would be to place the customer’s current distance prescription in
the phoropter.
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With the customer seated comfortably, the refractionist is ready to begin the
distance “subjective refraction” one eye at R time. The purpose of this is to
determine the most plus or (least minus) spherical power that will provide the
customer with his or her best visual acquity.

Testing Procedure:

Order of Refraction:

a. Sphere – Lens with optical power being the same in all meridians and is
expressed in diopters (reciprocal of focal length)
b. Axis – Meridian of the cylinder with the minimum power perpendicular
to the maximum power meridian. Refers to orientation where the corneal
problem occurs and expressed in degrees.
c. Cylinder - Lens that has different refractive power in each meridian.
d. Refinement of Sphere - You will now want to got back and re-check the
sphere power using the same procedure you used with the initial check
of the sphere power.

Procedure:
1. Occlude the left eye and open the right eye with the auxiliary lens knob
on the phoropter.
2. Blur or “fog” the vision in the right eye by placing the “Retinoscopy Lens”
in place over the right eye by turning the auxiliary knob on the
phoropter. This should fog the customer’s vision so that he or she cannot
see the 20/20 vision line on the eye chart.
3. The refractionist’s use the “rule thumb” that basically the customer
should be able to read the one additional line of visual acquity for each
0.25 diopters of minus sphere added (or each 0.25 diopters of plus
sphere power that is removed)
4. The refractionist reduces the plus power or adds minus power, 0.25
diopters at a time. With each click of the wheel, the customer is
encouraged to read the next smaller lines.
5. The refractionist must be careful not to give the customer too much
minus power. This will cause the letter to look smaller and darker, but
not allow them to read the next smaller line in the case of myope.
Likewise, too much minus power on a hyperope will cause the customer
to begin to accommodate to see in the distance.

The degree of myopia or nearsightedness is determined by the phoropter

to be the weakest minus sphere power for each individual eye (monocularly)
which will provide 20/20 visual acquity. Too much minus will stimulate the
customer’s accommodation and will result in an over-minused Rx.

Auto Phoropter:
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This type of phoropter has same principle of operation like in the manual
phoropter. But, this one is easier to operate. Just press one button to start the
test. The machine also contains the memory system, it stores all the testing
process you setup before, and then just press one key all will start and finish
automatically. If you have any problems or questions on how to operate the
machine, just press the HELP key, and then the machine will tell you how to go
forward on the screen. It is simple and convenient, and everyone can use it.

Advantages

 More comfortable for patients

 Lenses do not become so dirty

 Axis of any cylindrical correction can be read off from the refractor

 Additivity errors can be reduced.

Disadvantages

 The examiner depends on the subjective response of the patient.

 Refracting units hide the patient’s face.

 It only detects or corrects lower aberrations.

 Any cylindrical correction may be prescribed off axis

 Consists of several manual steps.

Advancements

Micro-ElectroMechanical System (MEMS)-based Adaptive Optics Phoropter

(MAOP) - award-winning system which uses wavefront sensors and
deformable mirrors instead of glass lenses, to do everything a traditional
Phoropter can

 the first system to measure higher-order aberrations in the human eye,

apply corrections, and immediately allow the patient to see the results.

 an innovative technology for early detection and treatment of retinal

diseases that cause vision loss and blindness

Adaptive-Optics technology - used in advanced telescopes for high-resolution

imaging of astronomical objects

Micro-Electro-Mechanical Systems (MEMS) deformable mirror technology -

has significantly reduced the mirror size and that of the adaptive optic
instrument.
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Superluminescent Diode - A light source focused onto the patient’s eye,

creates an image on the retina and is reflected.

Wavefront Sensor and Corrector - are the key components for the correction
of higher-order aberrations.

Fundus camera - The current retinal imaging device used by clinicians.

Cornea and Lens - optical structures in the eye that can distort wavefronts and
thus produce the aberrations we encounter in our natural vision.
Adaptive Optics System - measures aberrations with a wavefront sensor and
uses a wavefront corrector to compensate for the distortion.

Wavefront Sensor - determines how much the wavefront is distorted as it

passes through the eye’s cornea and lens.

 It sends information to the computer interface, telling the computer how

to adjust the corrector.

Computer - uses information from the wave sensor to create an internal, three-
dimensional (3D) representation of the distorted wave.

Flip-in Mirror - allows a computer to calculate the needed correction. That 3D

shape is then used to instruct the 144 MEMS actuators to move to positions
that will minimize the distortion and “flatten” the wavefront.

Processor - determines the correction needed to the detected wavefront and

sends signals of different voltages to the appropriate structures on the
deformable mirror.

Deformable Mirror - uses a standard Shack–Hartmann wavefront corrector

and changes shape and corrects the image seen by the eye.