Spherical Aberration

• Rays at different heights focus at

different points
• Makes for a mushy focus, with a halo
• Positive spherical lenses have
positive S.A., where exterior rays
focus closer to lens neg. S.A.
• Negative lenses have negative S.A., as
do plates of glass in a converging
beam lens side zero S.A.
• “Overcorrecting” a positive lens
(going too far in making asphere)
results in neg. S.A. pos. S.A.

Winter 2012 UCSD: Physics 121; 2012 1

Coma
• Off-axis rays meet at different places
depending on ray height
• Leads to asymmetric image, looking
something like a comet (with
nucleus and flared tail)
• thus the name coma
• As with all aberrations, gets worse
with “faster” lenses
• Exists in parabolic reflectors, even if
no spherical aberration

Winter 2012 UCSD: Physics 121; 2012 2

Chromatic Aberration
• Glass has slightly different
refractive index as a function of
wavelength
• so not all colors will come to
focus at the same place
• leads to colored blur
• why a prism works
• Fixed by pairing glasses with
different dispersions (dn/d)
• typically a positive lens of one
flavor paired with a negative lens
of the other
• can get cancellation of aberration
• also helps spherical aberration to
have multiple surfaces (more
design freedom)

Winter 2012 UCSD: Physics 121; 2012 3

 Simple myopic astigmatism
Circle of Least Confusion
Focal lines are equally blurred

Blur is due to combination of… Interval of Sturm

CLC in front of the retina Distance between the focal lines
Focal lines being separated
With BVS
Circle of Least Confusion
Has moved, is now on the retina

All blur, is now due to uncorrected cyl Interval of Sturm

Length unchanged
Reason the vision is still blurred
RE LE
Check sphere Check sphere

Check cyl Check cyl

(Axis and power) (Axis and power)

Recheck sphere Recheck sphere

BE Binocular balance

Final prescription (Rx)

SPHERICAL REFINEMENT
• The red-green duochrome test: if red is more clear, add minus; if
green is more clear, add plus = mnemonic RAMGAP (red add minus,
green add plus)
• Fogging: refining sphere after dialing in extra plus spherical power to
avoid over-minusing. One method, called binocular balancing, uses
the prism dials on the phoropter to split the binocular image vertically
into separate images and fogs each eye to make sure neither is over-
minused.
Duochrome test

 Uses longitudinal chromatic aberration to determine the refractive error

 Whichever colour is focussed nearest to the retina will be seen as clearest
 Emmetrope = equal
 Myope = red clearer
 Hypermetrope = green clearer
Optical principles of duochrome test
Chromatic aberration

Prismatic effect of lens

leads to dispersion
Optical principles of duochrome test

0.50DS
Performing the duochrome test
• Switch on duochrome test and establish that the patient can see the
ring targets
• Ask “Are the circles sharpest and clearest on the red or on the green
background?”
• Alter power by 0.25DS according to patient’s response
• Minus if red clearest, plus if green clearest
• Repeat until no difference seen
• Be wary of accommodation and red-preference
“They look the same”
• If patient answers “Same” or “No difference” at first presentation
• Duochrome is balanced
• Confirm by using +0.25DS (red now clearest)
• Rx too far out
• Use other tests, when vision 6/12 or better, return to duochrome
• Small pupils
• If no change in response with lens change, move to another test (though the effectively of all
is reduced)
• Vision too poor due to pathology
• Abandon duochrome – try plus/minus test with large steps instead
Limitations of duochrome
 The ring targets are usually constructed of ring thicknesses equivalent
to 6/9 (inner) and 6/12 (outer) Snellen equivalent targets
 Will not work if vision is less than 6/12
 The difference in focal position due to chromatic aberration is 0.50DS
 Will not work if prescription is significantly incorrect
 Small pupil will reduce size of blur circles
 Difference between the clarity of red and green is reduced
 Reduce room lighting for older patients
 REFINEMENT AND FINALIZATION OF THE
SPHERICAL LENS
1. Fogging technique using snellen’s visual acuity chart:
• A simple criteria is that to fog the eye and then unfog by
reducing every time +0.25DS till the best snellen’s visual
acuity is attained.
2. Duochrome test
• Based on the principle of chromatic
aberration.
• In emmetropes yellow light (570mm)
is focused on the retina, while red (620mm) and green light (535mm)
are focused behind (0.24D) and in front (0.20D) of the retina.

3. Pinhole testing
• Pinhole test is helps in confirming whether the optical correction is
correct or not.
Overminus problem
• Will be required to accommodate to see clearly, even in the distance
• Headaches, tired eyes, discomfort
• Potential to induce myopia (?)

Overplus problem
• The cyl findings are probably incorrect
• Circle of least confusion needs to be on, or slightly behind, the retina
• So if more minus needed in the final stages, your patient was over-plussed on
cross-cyl
• May be a latent hypermetrope
• Consider a cycloplegic refraction
Avoiding over-plussing
• Small pupils
• ±0.25DS sphere will make minimal difference to blur circle: consider ±0.50DS
pendulum
• +1.00DS test will not blur back as far as 6/18, so add more plus
• Media opacification or other pathology causing poor VA
• Creates problems detecting 0.25DS change
Binocular balancing
Binocular balancing
• Binocular balancing is a technique used to equalise
• Vision
• Accommodative demand
• Occlusion can stimulate accommodation
• Refracting under monocular conditions may not get out all the plus
• So binocular balance also serves to check sphere under binocular conditions
Procedure
• Always done after the monocular refraction for each eye has been
completed
• i.e. initial sphere, x-cyl., then final sphere
• Many different techniques are available, but fogging techniques are
easiest in practice
1. FOGGING AND ALTERNATE OCULLUSION METHOD
• In this method , both eye (with best accepted lens) are fogged with
>/< 1.0DS , reducing vision and then alternate cover test is performed
and ask patient to whether the eye showing comparatively clear
image.
• If balanced  then equal blur in both eye and  if not then add
+0.25DS until both eyes are equally blurred.
2. DUOCHROME TEST WITH FOGGING
• In this , each eye ( best correcting lenses) observes the vision chart
while the fellow eye is fogged with +1.0DS. Sphere before observing
eye is adjusted to give red or green preference.
3.PRISM DISSOCIATION METHOD
• This method is done by , fogging both eye with >/< 1.0DS and a
vertical prism of 3or 4 placed base down in front of right eye and base
up in front of left eye and then single line usually 6/12 is projected on
the chart.
• If binocular balance present then patient se the same line with both
eyes simultaneously, if not ( difference in clarity) then +0.25DS is
placed before the eye with better vision, done until two lines are
equally distinct for both eye.
• Considered as the most sensitive method and so practised more
commonly.
4. TURVILLE INFINITY BALANCE TECHNIQUE
5. POLAROID FILTERS
Not To Do Balancing
• When not to use binocular balancing
• A patient with strabismus
• Amblyopia or other cause for significant visual reduction
• Uneven acuities of more than one Snellen line
• When to be wary of binocular balancing
• Patients with compromised binocularity e.g. evidence of a poorly compensated phoria – this
will make sense next semester
• Anisometropia (uneven prescriptions), especially on fogging technique
• Perform on patients with no accommodation
• still do it as it is a double check of your monocular findings
• Doesn’t work well in patients with small pupils due to the increased depth of focus
Visual Acuity (VA)
Definition
• The ability of the individual to discriminate detail
• Ability to resolve a pattern into spatially separated elements
• Denotes the size of detail that can just be resolved by an individual
• Visual resolution
Alternative tests for young children
• Lea symbols
• Landolt C
• E charts
• Single Sheridan Gardener
Lea Symbols
Design
• Based on same principle as
logMAR acuity tests
• Linear test
• 4 symbols
• Square, house, circle apple
• Key card

A. Distance VA test for testing 2-4 year olds

B. Distance VA test for testing children 4 years +
Lea Symbols
• Method
• Test performed at 3m
• Occlude 1 eye Crowded
• Key card
• Point to symbols from top of
chart
• Count number of symbols
seen on lowest line of
symbols Single
• VA range 0.10 to 2.00
logMAR
Landolt C/ E charts
• VA test targets termed optotypes
• Design
• Based on grid pattern
• 5 units high & 5 units wide
• Method
• Gap of E & C in 4 ways
• Up, down, right or left side
• Indicate direction of E or C
• Performed at 6m
• Key card
Single Sheridan Gardener
Design
• Flip-over book with single letters of ↓size
• 7 letters
• O, A, T, X, U, H, V
• Matching key card
• Performed at 6m
• Patient with poor VA ~ test can be performed
at closer distances
• Linear S.G. chart is also available
• Performed at 6m
• VA range 6/60 - 6/4
Snellen Chart

Snellen = visual angle subtended at the nodal

point of the eye by altering the size of the
component parts of a letter
Snellen Letter Construction
• Each component of a letter subtends
1 minute of arc at the nodal point

• 1 cone stimulated & 1 cone gap for

appreciation

• Whole letter subtends 5 minute of

arc at the nodal point

• Many can actually discriminate 0.5 Testing distance 6m

min of arc
Problems with Snellen
• Some letters easier to
read / guess than others
• Spacing varies - no
crowding of top letters
• Big difference between
top row and next row
What is logMAR?
• logMAR =
• logarithm of the Minimum Angle of Resolution

• Minimum Angle of Resolution(MAR) is that subtended by each part of

the letter
• MAR = the angular size of detail within the optotype at threshold
 LogMAR Tests
• Introduced by Bailey and Lovie (1976)
• Aim
• Design a VA chart where the task is the same at each level
• i.e size is the only variable
• Early Treatment Diabetic Retinopathy Study (ETDRS) chart
• “gold standard” test
• LogMAR charts
• Five letters per row
• Between letter & between row spacing proportional to letter size
• Constant ratio of size progression (0.1 logMAR steps)
• Approximately equal legibility of letters at each size level
LogMAR Charts
• Each letter is given a score of
0.02 logMAR
• One line of letters a score of
0.1 logMAR
• Scoring: letter-by-letter
 Bailey-Lovie and ETDRS chart
‘Gold standard’
Bailey-Lovie ETDRS
Design Design
• Based on British standard letters • Sloan letters
• Testing distance 6m • Testing distance 4m (3m)
Example

A patient reads:
H, V, Z, D, S,
N, C, V, K, D,
C, Z, S, H, N,
O, N, V, S, R,
K, D, N, P, C,

2 letters incorrect on this line.

Whole line worth 0.60
But add 0.02 for each letter wrongly named.
=0.60 + (0.02 x 2)
=0.64
Crowded logMAR acuity test
• Glasgow acuity test
• Design on principle of Bailey Lovie
• Crowded book
• 4 letters inside a crowding bar
• Uncrowded book
• 2 letters at each acuity level
• Each letter has a score of 0.025
logMAR
• One line of letters is a score of 0.100
logMAR.
Near VA Tests
1. Typeset material
• Similar to print in newspapers or books
• arranged in sentences, paragraphs or words
• Not comparable to distance VA tests
Common tests
• “N” Test Types (Times Roman Print)
• Moorfields book
• Maclure book

2. Based on principle of being equivalent to distance

chart
Common tests
• Reduced Snellen
• LogMAR chart
• Near single Kay picture and crowded Kay picture
logMAR cards
• Lea symbols
• Single S.G.
• Landolt C & E charts
Logistic Regression
• Logistic regression is helpful in managing confounding
variables, useful with large datasets and in studies
designed to establish risk factors for chronic
conditions, cancer cluster investigations or other
situations with numerous confounding factors
Confounders
• A confounder is a variable that distorts the risk ratio or odds ratio of an exposure
leading to an outcome
• Confounding is a form of bias that can result in a distortion in the measure of association
between an exposure and disease
• Confounding must be eliminated for accurate results (1)
• Confounding can occur in an observational epidemiologic study whenever two
groups are compared to each other
• Confounding is a “mixing of effects” when the groups are compared (exposure-disease
relationship can be affected by factors other than the relationship)
Characteristics of Confounders

• Confounders must have two key characteristics:

• A confounder must be associated with the disease being studied
• A confounder must be associated with the exposure being studied
Controlling for Confounding
• To control for confounding you must take the confounding variable
out of the picture
• There are 3 ways to do this:
• Restrict the analysis—analyze the exposure-disease relationship only among
those at one level of the confounding variable
• Example: look at the relationship between HRT and cardiovascular disease ONLY among
women of high SES
• Stratify—analyze the exposure-disease relationship separately for all levels of
the confounding variable
• Example: look at the relationship between HRT and cardiovascular disease separately
among women of high SES and low SES
• Conduct logistic regression—regression puts all the variables into a
mathematical model
• Makes it easy to account for multiple confounders that need to be controlled
Why did the author use standard of 20/30 in
this journal?