CP D P ROGRAMME

The Dying Art TEST 265

The Optical Assistant

2 CEU Points
of Retinoscopy Have you tried our fast & convenient
On-Line CPD
Submission?

By Marolize Botha
B Optom (UJ)

M
odern day technology has spoiled us as convergent light is produced, and the movement seen
optometrists. A basic refraction is led by is reversed.
autorefraction readings which is, in many cases,
adequate, but going back to the basics, picking up the Spot retinoscopy however does not have a light
retinoscope and getting an idea of the natural refractive streak, but rather a spot of light. The spot of light
error of a patient is seemingly a dying art. can be changed by moving a knob on the side of the
retinoscope. The spot of light is not rotated to examine
The retinoscope is one of the most useful methods the different axis. The same neutralisation techniques
to objectively determine the patient’s refractive error. are applied as with streak retinoscopy.
When used correctly it provides useful information
about the visual system, including ocular pathology, and Both techniques can be used in clinical practice,
therefore it certainly has its place in modern ophthalmic but the streak retinoscope does out-perform in cases
practice. Modern equipment such as automated of astigmatism, as the streak retinoscope can detect
phoropters are growing in popularity but are not always the linear fundus reflexes created by astigmatic eyes.
designed to be used with a retinoscope and some The spot retinoscope often out-preforms the streak in
modern practitioners can’t really remember what a trial dynamic retinoscopy techniques, as the astigmatism is
frame looks like. Without a manual phoropter or a trial already compensated for in the trial frame, therefore
frame, retinoscopy is not easily managed in the clinic. the reflex observed with spot retinoscopy is often bigger
and easier to interpret than that of the streak reflex.
A comprehensive paediatric ocular examination With the sleeve of the streak retinoscope all the way
should always contain retinoscopy. By doing retinoscopy down it is similar to the spot reflex, but the sides are
it is easy to see how active the child’s accommodative cut off. The streak retinoscope offers less illumination,
system is. therefore it is more difficult to observe small changes
in the brightness or colour than it would be with spot
Patients who are unable to communicate or do not retinoscopy.
speak the language of the practitioner, infants with
Down’s syndrome, cerebral palsy, hyperopia and Retinoscopy is now applied to neutralise the
accommodative abnormalities are seemingly impossible movement of the pupil reflex. The working distance
to refract until you realise how easily it can be done lens should be removed after neutralisation, and if
with a retinoscope (Wannan, 2016). There are several done correctly the distance prescription should be fairly
different retinoscopy techniques that can be used. These accurate. If the reflex movement is dim, slow or difficult
are mainly classified under two broad spectrums, Static to interpret it is often useful to add large amounts of
retinoscopy and Dynamic retinoscopy. positive or negative power, which often results in a
quicker movement being seen as you get closer to the
Static retinoscopy endpoint. By moving the retinoscope sleeve up slightly
This technique should be familiar to all practitioners. a beam is produced which is less divergent and can
It is the traditional retinoscopy used to determine the speed up the movement; if the sleeve is moved up too
refractive error for distance vision. The normal working high a reversed reflex movement will be seen.
distance lenses are set in place and the patient is
instructed to fixate on a large distance target. Some The characteristics of the reflex noted can guide the
literature suggests instructing the patient to fixate on clinician to what result can be expected.
the green section of the duochrome, as it induces the
least amount of accommodation (Patel, 2014). The Brightness of the reflex:
sleeve of the streak retinoscope should be all the way • A bright reflex will be seen in emmetropes and when
down, to produce divergent light; if the sleeve is up, neutrality is reached.

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 CPD PROGR A MME

• Large errors have a dull reflex, smaller errors have a a working distance lens any with movement will be
bright reflex. eliminated.
• A dimmer reflex may be due to smaller pupils • It is sometimes helpful to first neutralise the sphere
(elderly and hyperopes), darkly pigmented retinal movement in both eyes, followed by neutralising the
pigment epithelium or media opacities. cylindrical component.
• In the presence of large ametropia, use large dioptric
Speed of the reflex: intervals when changing the lens. This is useful to both
• With the working distance lens in place the relative reach an end point quickly, but also minimalising the
speed of the reflex will depend on the patient’s residual accommodative effect induced by continually changing
ammetropia. lenses in the trial frame.
• If the speed is less than half the speed of the • This tip is also helpful in young children and
movement, the ammetropia is more than 3.00 D from individuals with disabilities. See speed retinoscopy.
neutrality. • Neutralise the “with” movement first; this ensures
• If the speed is 3 times the speed of the movement maximum plus is placed in front of the eye.
the ammetropia is 0.50 D from neutrality, and 6 times
indicates 0.25 D from ammetropia. Cycloplegic retinoscopy (Wet retinoscopy)
• When neutrality is reached the speed of the reflex is The same procedure as explained above is applied but
at infinity and the entire pupil seems covered with the the target is not essential because the patient is unable
reflex. to accommodate. Some clinicians prefer the patient to
still fixate on the largest target on the Snellen chart and
Width of the reflex: others prefer the patient to look directly at the light.
• The streak appears narrower the further from the Due to the dilated pupil and peripheral aberrations, the
end point; as neutrality is approached the streak widens. reflex may appear distorted or difficult to interpret.

Ref l ex O b se rv a ti o n Me a ni ng
D im F a r fr o m pr escr ipt io n
B righ t ness
B rig h t C l o se t o pr escr ipt io n

N ar r o w F a r fr o m pr escr ipt io n
Stre ak siz e
Wid e C l o se t o pr escr ipt io n

Wit h A dd mo r e pl u s
Mo v emen t di r e c t i o n
Aga in st A dd mo r e min u s

Slow F a r fr o m pr escr ipt io n

Mo v emen t s pe e d
Fas t C l o se t o pr escr ipt io n

It is important that the patient’s accommodation It is helpful to concentrate on the central 3-4mm of
system is as relaxed as possible during static the pupil. Visual acuity might be slightly reduced due to
retinoscopy to ensure accurate results. The following aberrations induced by the enlarged pupils, but in most
tips may be useful during static retinoscopy to control cases a poor 6/6 should be expected in the absence of
accommodation: no other pathology.

• Instruct the patient to focus on the largest target on The spectacle prescription to provide to the patient
the green Duochrome, it has been shown that this has will not always be full cycloplegic refraction. It is very
the least accommodative effect on the patient’s eye. important to keep this in mind before simply providing
• Advise the patient to inform you if your head obstructs full cycloplegic refraction for spectacle wear:
the target, this will ensure that the patient does not
stimulate accommodation by focussing on your head. • For children under the age of 4 years presenting with
• Add a fogging lens to eliminate any with movement binocular abnormalities in the form of esotropia, the
seen in the eye not being checked first. Often using full cycloplegic correction should be considered but it is

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 CP D P ROGRAMME

important to also determine the effect of the lenses on light of the retinoscope to fixate on. The reasoning
the esotropia and visual acuity. behind this is that the accommodative system is then
• For all other cases, the prescription should be not stimulated beyond that of the child’s dark state of
adjusted by -0.50 D to -1.00 D due to ciliary tonicity. accommodation. Some literature suggests occluding the
It is important to not deviate too far from the normal eye not being examined, and others state both eyes can
manifest refraction which will allow to hopefully reduce be open during the process. The reflexes observed are
symptoms, but not induce blur at distance. now neutralised the same way as in static retinoscopy.

Speed retinoscopy With static retinoscopy the working distance lens is

A lecture held by Prof Bennett McAllister at the removed to obtain the final refractive result; however,
Paediatric Training Academy in 2018 explained the with Mohindra retinoscopy there is no working distance
technique of Speed retinoscopy. lens. Therefore, the value optioned must be adjusted
Two principal meridians are scanned in a quick left to by -1.25 D for infants and for children over the age of 2
right movement and up to down movement. A meridian years a value of -1.00 must be added (Benjamin, 2006).
is chosen but instead of neutralising in small steps of Some tips that might be useful when conducting
±0.25 D, larger steps are made such as +2.00 D when a Modindra/near retinoscopy:
with movement is seen until reversal is noticed. Again
the reduction in plus is made in large steps so that a • Darken the room as much as possible, which
bracket can be found in which the prescription most encourages the patient to fixate on the light and
likely falls. maintains their concentration.
• Avoid holding the light on the pupil for long periods
For example: Your patient presents with +4.00 of time, as this may stimulate accommodation.
Hyperopia with no astigmatism. • The result obtained must be adjusted according to
A large with movement is expected with retinoscopy. the age of the child to obtain the final value.
By placing a +3.00 D lens over the working distance, a
smaller but still with movement is noticed. Dynamic retinoscopy
Dynamic Retinoscopy is used to determine the
If you place a +5.00 D lens in front of the eye, the patient’s refractive error at near. The goal is to determine
movement is reversed and you see an “against” accommodative response and the most appropriate
movement. This means your patient’s refractive error prescription at near in different testing conditions. It
must be somewhere between +3.00 D and +5.00 D. By provides information about the degree to which the
choosing a lens in the middle of this range you have accommodation is fluctuating when near tasks are
easily reached neutrality. conducted, or if the eyes are equally balanced at near.
Dynamic retinoscopy is always done without cycloplegia
It is also advised to scan each principal meridian only because these techniques are used to evaluate the
once, deciding on what strength may be needed based refractive status of the eye when accommodating at
on the size, speed, direction and brightness of the reflex near.
seen. This, of course, becomes easier with practice.
The room lighting should be on and the final distance
Mohindra Retinoscopy prescription should be in place in a trial frame. The
Mohindra retinoscopy is also known as near retinoscope is held 50 cm from the patient and a target
retinoscopy and is also a form of static retinoscopy. is placed on the retinoscope (such as MEM cards). Age
It is a very useful technique to use on children. Patel appropriate reading text should be provided, but for
(2014) indicated there is a good correlation between little children and individuals unable to read, pictures
Mohindra retinoscopy and a cycloplegic retinoscopy in are adequate.
children with low or moderate hyperopia. However, a
poor correlation is shown in children with esophoria and The patient is instructed to read the words out loud
esotropia and large amounts of hyperopia. The main or explain the picture seen. One would expect a “with”
advantage of this technique is that it requires less co- movement with the distance prescription in place, and
operation and is more child-friendly than some other plus lenses should be added binocularly until there is
techniques. no movement in the reflex seen. The final value should
be adjusted to compensate for accommodative lag by
With this technique there is no working distance lens 0.50D
used and the practitioner is positioned 50cm from the
child, this technique is not done with a phoropter but Theoretically the technique is more reliable because
rather with a trial frame. The room lighting is darkened the light beam is on line with the fixation axis, the pupil
as much as possible so that the child only has the size reduces and less peripheral aberration is present.

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 CPD PROGR A MME

Dynamic retinoscopy is an objective measurement The expected result should be to observe a normal
of the degree of blur acceptance at near, and assists MEM result; this may indicate that the patient may
the accommodative and vergence systems to ensure benefit from using correction at near. If the movement
comfort when conducting near tasks. The different does not change and remains a negative value, do not
modifications of this technique are: prescribe plus lenses for near work, but rather recheck
the refraction of the patient.
MEM retinoscopy
MEM retinoscopy is preformed monocularly and Nott Retinoscopy
should be fairly well known to optometrists. The The purpose of Nott retinoscopy is identical to that of
accommodative lag is determined without disturbing MEM retinoscopy. With the distance prescription in place
the accommodative state. MEM ret is useful to observe in a trial frame, a block of 6/6 letters are placed at 40
the spontaneous accommodative response to a detailed cm from the patient. The patient should read the letters
target at the patient’s normal working distance. while the retinoscope is moved further from the patient
in the plane of regard until the motion is neutralised. The
Room lighting should be good. The examiner should dioptric value of the difference between these distances
be positioned slightly below the vertical midline of the is equal to the lag of accommodation (Benjamin, 2006).
patient at the about 40cm from the patient. Appropriate For example: The initial distance is 40cm (2.50 D),
MEM cards are placed on the retinoscope. The light neutrality was observed at 50cm (3.00 D). The lag of
should be aimed at the bridge of the patient’s nose. The accommodation is then 0.50 D.
patient should start reading the words or describing the
pictures seen. A very quick horizontal movement should This technique is more accurate than MEM, because
be made over the one eye and then the other. A slight the accommodative response to plus lenses occurs
with movement is expected. within one fifth of a second. The practitioner has very
little time to determine the correct lag with MEM.
A positive spherical lens should be placed in front of
the eye and scanned again with the retinoscope until Bell Retinoscopy
neutralisation is achieved. It is very important that the The technique was first done by suspending a cat bell
lens is not placed in front of the eye for longer than 2 on a string, but modern techniques have modified the
seconds, as this affects the accommodation. Therefore, target to a Wolff ball or Wolff wand which provides a
this technique is slightly more difficult. The process three-dimensional viewing target. It is useful to evaluate
should be repeated for the other eye. the performance of the accommodative system under
moving and real life conditions in free space. It also
Tips for MEM Retinoscopy: requires little cognitive demand from the patient.
• This technique is used to determine whether
a patient’s accommodative response is equal to The patient should have their distance correction in
the accommodative stimulus and what the natural a trial frame. The retinoscope is placed 50cm from the
accommodative state is, without disrupting the patient while the Wolff ball is slowly moved toward
accommodation system. the patient. The patient is instructed to maintain
• The lenses should not be in front of the eye form fixation on the target. As the ball gets closer a fast
more than 2 seconds, otherwise the accommodative “with” movement is usually observed. The reflex then
system is disrupted. changes to “neutral” and then “against”. The “against”
• If the procedure is conducted off-axis an “against” movement becomes slower as it approaches the patient.
movement may be seen. Therefore, the cards are The ball should still be moved toward the patient until
designed with a hole in the centre so that the beam it reaches the patient’s nose. Now the target should be
can be as close to the visual axis as possible. The target moved backward to observe the motions in reverse.
chosen should be age appropriate.
• The normal value expected with MEM retinoscopy is First record the distance the ball is from the patient at
a lag of +0.50 D to +0.75 D. If the results are more than the point that the movement changes from a “with” to
this, one should consider correction for near work. In an “against” as the ball is moved toward the patient.
children this may also be indicative of latent hyperopia Also record the distance the target is from the patient
and a cycloplegic refraction should be considered. when the reflex changes from an “against” to a “with”
• If the MEM result is negative however, it may indicate when the target is moved away from the patient.
that the patient is over-accommodating. It is useful to
check this by adding plus lenses binocularly in a trial The two measurements are recorded as a fraction for
frame. Wait a few minutes for the patient to adapt to example, 20/30 (this means the movement went from
the lenses and then repeat MEM to assess the effect “with” to “against” when the target was moved toward
the plus lenses have on the accommodative system. the patient at 20cm and the movement changed from

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 CP D P ROGRAMME

“against” to “with” when the target second is an inner canthal twitch and +0.75D lenses relieve the near
moved away from the patient at the last is a change in the colour of point stress, and the +1.25D lens
30cm). The norm for Bell retinoscopy the retinal reflex (Bhalla & Mohan, induces a new pattern of near-point
is a “with” movement at 35-43cm, 2014). stress. This technique is helpful
changing to “against” movement at to determine the most adequate
38–45 cm (Bhalla & Mohan, 2014) The latter is labelled as popping amount of plus the patient may
of the reflex and is described as need for comfortable near work.
If the results obtained are not an initial brightening of the reflex
within these ranges, the procedure followed by it becoming dull, and Book Retinoscopy
is repeated with plus lenses and again brightening. The Wolff ball is This technique observes the
the amount of plus added to moved closer to the patient as is retinoscopy reflex at different levels
obtain normal results should be a done with bell retinoscopy while the of cognitive involvement. The child
suitable near-point prescription. examiner observes the reflex. At the is instructed to view a reading chart
This technique also provides insight point where the reflex “pops” the with their distance prescription in
on other systems such as the distance is noted by the practitioner place. The practitioner is positioned
accommodative flexibility which (Griffin & Borsting, 2010). near the reading chart so that the
can be assessed by observing how retinoscopy reflex can be seen.
quickly or sluggishly the reflex The normal distance for the reflex
changes. The eye movement control to change in children is noted 10cm The child is instructed to read
can be assessed by observing the closer to the patient than their different charts with different levels
extent to which the ball can be Harmon distance. In adults the of difficulty. The first chart should be
fixated on, in addition to the normal normal value is between 20cm and an easy reading chart, something
NPC convergence test. Eye-hand 22.5cm from their face. that is on the level of the child’s
coordination can be evaluated by reading ability or even below. The
asking the patient to touch the Wolff But how does this help us? movement one would expect here
ball during the procedure. If an 11-year old child has a should be a neutral to with, the
Harmon distance of 22.5cm, one reflex should be bright, sharp edged
Stress point retinoscopy would expect the stress-point result and pink in colour, indicating free
During Bell retinoscopy the change to be 12.5cm. If the child’s actual reading level.
in reflex direction is observed, while result is 20cm, the test is repeated
in stress point retinoscopy the with plus lenses. The chart is now changed to
change in reflex quality is observed. something more difficult, which
Three things can occur when near- For example if the result is 15cm requires more concentration, and
point stress is observed, the first is with +0.75 D, and 22.5cm with cognitive involvement but must be
a change in the patient’s pulse, the +1.25D, it is easy to see that the comprehensible by the child.

Summary of Dy n a m i c Re t i n osc o py te c hni que s

Cognitive
Test Aspect assessed Target location Norms
demand
Position of accom- 40cm or Harmon
MEM modation relative to Moderate distance in chil- +0.50
convergence dren
Positioning of accom-
No tt Re t ino s-
modation relative to Moderate 40 cm +0.50
c op y
convergence
“With” movement at
Positioning of accom- 50 cm at the
B e l l Re t ino s- 35-43cm, changing to
modation relative to Low beginning of the
c op y “against” at 38 – 45
convergence test
cm
50cm at the Stress point at least
St r es s -po int Moderate to
Response to stress beginning of the 10cm closer than Har-
R e t ino s c o py high
test mon Distance
B oo k ret ino s- Level of visual pro- Habitual near
High Task related
c op y cessing working distance

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 CPD PROGR A MME

The reflex movement is now expected to be a fast the patients face so that the practitioner is able to see
against movement, which should be bright, sharp and both the child’s pupils in the light beam through the
very pink, indicating instructional level. ophthalmscope (similar to the Bruchner test), and the
reflex is observed as the target is moved closer to the
Lastly, the chart must be changed to a reading patient’s nose.
level that induces frustration, such as text in another
language, or university level text. The reflex should In a person who is not cyclopleged, the reflex is
now become a slow against movement, with a dull expected to become more myopic (inferior crescent)
intensity and be dark red, indicating frustration level. up to a point where the accommodative system can no
If the appropriate movement is not seen, the addition longer compensate for demand, at which point the reflex
of plus lenses might help to observe the appropriate will rapidly change to a reflex which the practitioner is
movements and therefore may be prescribed to help unable classify.
with near tasks. The child’s cognitive ability and any
other possible abnormalities, such as dyslexia and poor To determine if full cycloplegia is reached the same
eye movements must of course be taken into account. process is conducted, but one would not expect any
change in the reflex, as the patient does not have the
Other uses for Retinoscopy accommodative ability to focus on the target.

Distance Dynamic Direct Ophthalmoscopy Keratoconus

Distance Dynamic Direct Ophthalmoscopy (DDDO) is Contrary to popular belief, retinoscopy can be a very
not a retinoscopy technique, but is a useful technique useful tool in keratoconus patients. If a scissor reflex is
to determine whether your patient is completely seen, it may suggest irregular astigmatism. In addition
cyclopleged, as mydriasis does not always mean the relative position and size of the cone can be
cycloplegia. estimated, as well as best corrected VA with spectacles.
Therefore, retinoscopy is a useful tool in identifying
The patient is instructed to view a target held at the irregular corneas; however, it is not as useful to classify
practitioner’s nose, the ophthalmoscope is pointed to the stage of keratoconus (Booysen, 2018).

Figure 1 shows the typical red-reflex and retinoscopy reflexes seen in Keratoconus. If an
“against” movement is seen it indicates myopia and “with” indicating hyperopia. If the move-
ment of the light reflex is not the same as the beam astigmatism is indicated, as illustrated by
the first two examples. The bottom four examples show fish mouth reflexes and illustrate how
difficult it may be to classify the stage of Keratoconus with retinoscopy. Permission obtained
from the author to use the illustration (Booysen, 2018).

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A study was conducted on 45 young patients Maybe it’s time to dust off your retinoscope and
with Down’s syndrome, 11 of the participants had practise some forgotten ophthalmic skills?
keratoconus and the rest had healthy corneas. Slitlamp
showed signs of astigmatism in the 11 keratoconus References:
patients, but the presence of early stage keratoconus BENJAMIN, W. 2006. Borish’s Clinical Refraction,
was picked up with retinoscopy and confirmed by Butterworth-Heinemann.
Penctacam. This is particularly helpful, as children with BHALLA, S. and MOHAN, S. 2014. The Lost Art of Dynamic Retinoscopy
Down’s syndrome often have decreased central corneal Delhi Journal of Ophthalmology, 25, 141-143.
thickness of below 500 microns (Evereklioglu C, 2002). BOOYSEN, D. J. 2018. In Contact: Clinical Contact Lens Practice, Notion
Corneal cross-linking should be conducted on corneas Press.
with a minimum thickness of 400 microns. This leaves EVEREKLIOGLU C, Y. K., BEKIR NA. 2002. Decreased central corneal
the window for treatment by cross linking very small; thickness in children with Down syndrome. Journal of Pediatric
therefore, early diagnosis is essential (Wannan, 2016). Ophthalmology and Strabismus, 39, 274-277.
GRIFFIN, J. R. and BORSTING, E. J. 2010. Binocular Anomalies:
Conclusion Treatments & Techniques, OEP Foundation.
In the modern era with all its fancy autorefractors and PATEL, T. 2014. Elements of refraction - part 2 Elements of refraction
digital phoroptors, the humble retinoscope seems to Optician.
be obsolete. However, the astute clinician values his/ WANNAN, O. 2016. The importance of ‘Ret’. 13/10/2016 ed.
her retinoscope and uses it frequently, especially when Optometry Today.
dealing with children and challenging patients.

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 CP D P ROGRAMME
TEST 265 - The Dying Art of Retinoscopy — Questions

1. To determine the accommo - canthal twitch, colour change of a. The target made a noise
dative lag, the most accurate retinal reflex. which maintained the attention
method is: c. Change of pulse, inner can - of the patient on the target.
a. Book Retinoscopy thal twitch, colour change of b. The Wolff ball was not yet
b. MEM Retinoscopy retinal reflex. invented.
c. Nott Retinoscopy d. One would not expect any c. It’s a three dimensional tar-
d. Bell Retinoscopy change. get, allowing the clinician to
evaluate the accommodative
2. After Mohindra ret the value 7.During static retinoscopy it is system.
obtained should be adjusted by the most helpful if the patient d. None of the above.
the following: looks at the following target:
a. The adjustment is -1.00 D a. The largest target on a 12. Retinoscopy can assist the
for infants and for children over screen at 6m. clinician with all of the follow-
the age of 2 years -1.25 D. b. The green section of the Du- ing except:
b. The adjustment is -1.25 D ochrome. a. Determining the distance re -
for infants and for children over c. Any distance target. fractive error of the eye.
the age of 2 years -1.00 D. d. a & b. b. Determining the needed add
c. The adjustment is -1.25 D for e. None of the above. of the eye to alleviate stress
infants and for children over the during near point tasks.
age of 2 years -1.00 D. 8.The accommodative system re - c. Classify the stage of irregu -
d. The standard working dis - sponds to plus lenses within: lar corneal astigmatism.
tance lens is removed. a. 2 seconds. d. To estimate the relative po -
b. One fifth of a second. sition and size of the cone in pa-
3. Dynamic Retinoscopy is: c. One eight of a second. tients with Keratoconus.
a. Used to determine the pa- d. Immediately
tient’s refractive error at near. 13. Regarding the brig htness of
e. Plus lenses relax the accom -
b. Used to determine the pa - the reflex observed during reti -
modative system and are unable
tient’s refractive error at dis - noscopy:
to create an accommodative re-
tance. a. If the reflex is bright the cli -
sponse.
c. A sub-category of Spot reti- nician is far from the endpoint,
noscopy. and if the reflex is dim the clini-
9. The dynamic retinoscopy tech-
d. A sub-category of static reti- cian is close to the endpoint.
nique where the lag is deter-
noscopy. b. If the reflex is dim the cli-
mined by taking the difference nician is close to the endpoint,
between the dioptric value of
4. The normal expected value for and if the reflex is dim the clini-
the distance between the start-
Bell retinoscopy is: cian is far from the endpoint.
ing point and the neutral point
a. 20cm/30cm c. If the reflex is dim the cli -
is:
b. 30cm/20cm nician is far from the endpoint,
a. Nott retinoscopy
c. 35-43cm /38-45cm and if the reflex is bright the cli -
b. Bell retinoscopy
d. 37cm/44cm nician is far from the endpoint.
c. MEM retinoscopy d. If the reflex is dim the cli-
d. Stress point retinoscopy
5. Which of the following are nician is far from the endpoint,
stages of book retinoscopy: and if the reflex is bright the cli -
10. The best dynamic retinos-
a. Free reading level nician is close to the endpoint.
copy technique to use on young
b. Instructional level
patients and individuals with
c. Frustration level 14. Regarding the direction of
mental handicap is:
d. a, b & c movement, which of the follow -
a. MEM
e. a & b ing is not true:
b. Nott Retinoscopy a. A “with” movement indi -
c. Bell Retinoscopy
6. Which of the following occur cates there is too little plus.
d. Stress point retinoscopy
when near-point stress is ob- b. An “against” movement in-
e. Book retinoscopy
served: dicates there is too litt le minus.
a. Change of pulse, outer can- c. A scissor reflex indicates
11. Bell retinoscopy was initially
thal twitch, change of retinal re- retinoscopy is not possible.
done with a cat bell, the reason
flex direction. d. None of the above.
for this is:
b. Change of heart rate, inner

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 CPD PROGR A MME

15. During Nott re tinoscopy your 17. Stre ak retinoscopy out per - tween the starting point and the
starting point was at 50cm and forms Spot retinoscopy in astig- neutrality point.
neutrality was reached at 66cm, matic eyes. a. True
what is the lag of accommoda- a. True b. False
tion? b. Fals e
a. 1.00 D 20. The central corneal thickness
b. 0.50 D 18. Stre ak retinoscopy out per - of individuals with Down’s syn -
c. 0.75 D forms Spot retinoscopy during drome is believed to be thicker
d. 1.25 D dynamic retinoscopy. than that of individuals without
a. True Down’s syndrome.
16. DDDO is a dynamic modifica- b. Fals e a. True
tion of which optometric test: b. False
a. Hirchberg test 19. Nott retinoscopy can be
b. Bruchner test started at any point as long as
c. Angle Kappa the distance is noted and the
d. Ophthalmoscopy dioptric value is calculated be-

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