ORDER

1
2
3
4
5
6
7
8
9
10
11
12
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16
17

STEPS
Retinoscope or start with old glasses in Phoropter.
Occlude opposite eye (usually OS).
Check visual acuity.
Adjust sphere power in 0.50 D steps toward plus first, and then try minus.
If patient can see a difference, try 0.25 D steps.
Check visual acuity.
Give patient an easier line to see (1-2 lines larger).
Place Jackson Cross Cylinder in position to check AXIS. Flip.
For Plus Cylinder Phoropters, move axis toward the WHITE dot choice. Repeat until
both flips seem the same.
Place Jackson Cross Cylinder in position to check POWER. Flip.
Adjust power until both flips seem the same. Add power (WHITE) or reduce power
(RED) of Plus cylinder.
Remove Cross Cylinder and refine sphere. For every 1 diopter change in cylinder
power, you must adjust the sphere by 0.50 D.
Check visual acuity.
Repeat all above steps on opposite eye. Remember to occlude the OD to check
OS!
Perform Duochrome Test if appropriate.
Perform Balancing Test if appropriate.
Perform Amplitude Test if appropriate.

TIPS:

Order = sphere, cylinder axis, cylinder power, refine sphere.

Use cross cylinder appropriate for visual acuity. If VA is better than 20/40
use 0.25 D. If less than 20/40 use 0.50 D cross cylinder.
The red dot is minus; the white dot is plus.
The stronger the cylinder, the more critical the axis.
As age goes up, plus cylinder axis shifts toward 180.
The higher the refractive error, the more critical the vertex distance. Better
to use trial frames.
Be careful NOT to over minus a patient who already reads 20/20.
Forget about the duochrome test if the VA is worse than 20/60.
Forget balancing if VA differs more than two lines or is worse than 20/50.
Amplitudes should be the same OU. If not, recheck the Manifest Refraction.
Calculate Bifocal Add at 16 inches, or 40 cm. The MD will adjust for actual
patient needs and Rx.

Deanna Presnell, M.Ed.,COMT

Plus Cylinder Refractometry

ORDER
STEPS
1
Retinoscope or
start with old glasses in Phoropter.
2
Occlude opposite eye (usually OS).
3
Check visual acuity.
4
Adjust sphere power in 0.50 D steps toward
plus first, and then try minus.
5
If patient can see a difference,
try 0.25 D steps.
6
Check visual acuity.
7
Give patient an easier line to see
(1-2 lines larger).
8
Place Jackson Cross Cylinder in position to
check AXIS. Flip.
9
Move axis toward the WHITE dot choice.
Repeat until both flips seem the same.
10
Place Jackson Cross Cylinder in position to
check POWER. Flip.
11
Adjust power until both flips seem the same.
Add power (WHITE) or reduce power
(RED) of Plus cylinder.
12
Remove Cross Cylinder and refine sphere.
For every +1 diopter change in cylinder
power, you must adjust the sphere by -0.50
D.
13
Check visual acuity.
14
Repeat all above steps on opposite eye.
Remember to occlude the OD to check OS!
15
Perform Duochrome Test if appropriate.
16
Perform Balancing Test if appropriate.
17
Perform Amplitude Test if appropriate.
You are finished!
Cut this out and carry it as a job aid in your lab coat
pocket!

Deanna Presnell, M.Ed.,COMT

Plus Cylinder Refractometry

ORDER
STEPS
1
Retinoscope or
start with old glasses in Phoropter.
2
Occlude opposite eye (usually OS).
3
Check visual acuity.
4
Adjust sphere power in 0.50 D steps toward
plus first, and then try minus.
5
If patient can see a difference,
try 0.25 D steps.
6
Check visual acuity.
7
Give patient an easier line to see
(1-2 lines larger).
8
Place Jackson Cross Cylinder in position to
check AXIS. Flip.
9
Move axis toward the WHITE dot choice.
Repeat until both flips seem the same.
10
Place Jackson Cross Cylinder in position to
check POWER. Flip.
11
Adjust power until both flips seem the same.
Add power (WHITE) or reduce power
(RED) of Plus cylinder.
12
Remove Cross Cylinder and refine sphere.
For every +1 diopter change in cylinder
power, you must adjust the sphere by -0.50
D.
13
Check visual acuity.
14
Repeat all above steps on opposite eye.
Remember to occlude the OD to check OS!
15
Perform Duochrome Test if appropriate.
16
Perform Balancing Test if appropriate.
17
Perform Amplitude Test if appropriate.
You are finished!
Cut this out and carry it as a job aid in your lab coat
pocket!