Cylinder Power Optimization

Introduction The power ratio and spherical equivalency What is the spherical equivalent? How is the spherical equivalent used in refractometry? Examples Technique Using minus cylinder Using plus cylinder Slide sequence

Introduction Some teachers of refractometry advise you to make an automatic .25D change in the sphere power for each .50D change in the cylinder power. What they are advising you to do is to keep the same spherical equivalency. The problem with this approach is that you are assuming that you have already found the correct ratio between the sphere power and the cylinder power. You are assuming that you have the "circle of least confusion" on the retina, and this is not always a good assumption. (For more on the circle of least confusion, see Module 19). The power ratio and spherical equivalency I would advocate that the first check of the cylinder power be made without regard to adjusting the sphere power. For example, if cross cylinder results are telling you to increase the cylinder power, then make your first cylinder power increment .5 D without changing the sphere power. Test with the cross cylinder again. If the patient is asking for another cylinder power increase, then increase the power another .5 D. This time, do recheck the sphere power. Continue with this two step process until you reach an endpoint. The last step should always be rechecking the sphere power. This two step process allows the patient to guide you to the correct sphere/cylinder power ratio. If retinoscopy has guided you well, this will not be more than a one or two step process. However, having the correct ratio (spherical equivalency) does not guarantee that you have found the cylinder power and the sphere power that provide the best vision without distortion. This is where a check of spherical equivalents comes in. This technique tells you if you have used too much cylinder power, or conversely, if you have not used enough. The objective is to find the optimum cylinder power, which is the lowest cylinder power that gives the best vision.

What is the spherical equivalent? Mathematically the spherical equivalent is computed by algebraically adding half the cylinder power to the sphere power of a sphero-cylinder. Plus cylinder example: -1.00+3.00x180 -1.00+(1.50)= +0.50 Optically, the spherical equivalent represents the diopter value that produces the clearest image using only spherical lenses to correct an astigmatic eye. How is the spherical equivalent used in refractometry? The refractometric technique involves presenting the patient with spherically equivalent choices (this does not involve the use of the cross cylinder). This technique is used after you have completed an initial refraction on the eye, including sphere power, cylinder axis, and cylinder power checks. Remember, you are trying to determine the lowest cylinder power that provides the best visual acuity. Lets look at some examples. The prescriptions are spherically equivalent. Example A: Consult the table below. You finish your refraction routine having found that the patient prefers #3. The patient is looking at the 20/30 line and you present a choice between #3 and #4. The patient prefers #3. You now present a choice between #3 and #2. The patient says the choices look about the same. You check the vision, and the best vision with #3 is 20/25. You check the vision with #2 and it is 20/20, so you prescribe #2 because it improves the vision. Minus cylinder 1.+1.50-3.50x90 2.+1.25-3.00x90 3.+1.00-2.50x90 4.+0.75-2.00x90 5.+0.50-1.50x90 6.+0.25-1.00x90 Plus cylinder 1.-2.00+3.50x180 2.-1.75+3.00x180 3.-1.50+2.50x180 4.-1.25+2.00x180 5.-1.00+1.50x180 6.-0.75+1.00x180

Example B: You finish your refraction routine having found that the patient prefers #3. You present a choice between #3 and #2. The patient prefers #3. Your present a choice between #3 and #4. The patient says they look about the same. You present a choice between #4 and #5. The patient says they look about the same. You present a choice between #5 and #6.

The patient prefers #5. Now you have a situation where #5, #4, and #3 look about the same. You check the vision with #5 and it is 20/25. The vision is not improved by #4 or #3. You prescribe #5 because it is the lowest cylinder power for the best vision. Technique The technique for presenting the spherically equivalent choices involves simultaneously changing the sphere wheel and the cylinder power wheel. One hand is on the sphere wheel and the other hand is on the cylinder power wheel. It takes some practice; you want to make a smooth change so as not to distract the patient. Using minus cylinder: Look at 1 through 6 below. When you increase the cylinder power by .50, you change the sphere power .25 in the plus direction. When you decrease the cylinder power by .50, you make a simultaneous .25 sphere change in the minus direction. Minus cylinder 1.+1.50-3.50x90 2.+1.25-3.00x90 3.+1.00-2.50x90 4.+0.75-2.00x90 5.+0.50-1.50x90 6.+0.25-1.00x90 Plus cylinder 1.-2.00+3.50x180 2.-1.75+3.00x180 3.-1.50+2.50x180 4.-1.25+2.00x180 5.-1.00+1.50x180 6.-0.75+1.00x180

Using plus cylinder: When you make a .50 increase in cylinder power, you make a simultaneous .25 sphere change in the minus direction. When you make a .50 decrease in cylinder power, you make a .25 change in the sphere power in the plus direction. The sequence below illustrates the technique with a plus cylinder phoropter.