验光三

StandardSubjectiveRefractionⅡ规范化的临床主觉验光ⅡShihaoChenM.D.,O.D.,M.S.SchoolofOphthalmology&OptometryProcedureofSubjectiveRefraction主觉验光的程序•1.Setup•2.InitialMonocularMPMVA（foggingtech)•3.DeterminationofAstigmatism•4.SecondMonocularMPMVA•5.BinocularBalance•6.BinocularMPMVADemoSetup准备阶段•Poweronandcheckdevices•SitandlevelwithChart•Clean&Sterilize•Pantoscopictiltcontrol•Levelphoropter•PD•Vertexdistance•PutresultofObjectiveR.•DimtheilluminationAlcoholpreppad/cottonballBACKPantoscopictiltcontrol多镜倾斜BACKLevelphoropter水平调整BACKPD瞳距调整BACKVertexdistance后顶点度与预设状态是否一致?•Distancerefraction与预设状态是否一致?•Distancerefraction与预设状态是否一致?Less+与预设状态是否一致?BACKLess-Illumination照明要求•AOA:testchartluminance34-51cd/m2;forreflectanceof0.8---illuminanceof130—215lux••Testchartabove84%contrast•Ambientilluminationatthetestchartnotbegreaterthan13%oftheporjectorilluminanceBACKInitialMonocularMPMVA单眼初步MPMVA•Most(Maximum)PlustoMaximumVisualAcuity最大正镜片最好矫正视力•Occludeoneeye(OS)•Fog•Defog•EndpointFog雾视•Pluslens－－Artificialmyopia－－RelaxandcontrolaccommodationFog•ObjectiveRAdd+0.75~+1.00D--20/40to20/60--0.5to0.3表格EggersChart视力-屈光不正对应表格•VisionRefractiveerror•1.020/200•0.820/25+0.25Sph/0.50DAstig•0.620/30+0.50Sph/1.00DAstig•0.520/40+0.75Sph/1.50DAstig•0.320/60+1.00Sph/2.00DAstig•0.2520/80+1.50Sph/3.00DAstig•0.1520/120+2.00Sph/4.00DAstig•0.120/200+2.00to+3.00SphSphericalEquivalent等效球镜计算SE=Sphere+½Cylinder-0.75–1.00×135SE=-0.75+½(-1.00)=-1.25JCC:-0.25×90,+0.25×180;=+0.25–0.50×90=-0.25+0.50×180SE=+0.25+½(-0.50)=0BACKDefog去雾视•Addminusin-0.25Dsteps•Instruction:“Openyoureyes,withoutsquinting”–checkVAwitheachlens–eachclickshouldaddapproxonelineofacuityDefog•Encouragepatienttoreadthenextsmallerlineeachtime•Instruction:“Trytoreadthenextlineofletters,evengiveaguess”•ContinueDefogtotheBestacuity•VA?=Thresholdofdiscriminationvision•CriterionBACKInitialMPMVAEndpoint单眼初步MPMVA终点确定–20/20or20/15–Nextlensresultsinlettersonchartsmaller/darkerbutnoimprovementinacuity(havingthechartlook“better”tothepatientisnotsufficientjustificationtogivemoreminus)–Duochrometest:oneintogreen/equallyclearDuochrometest双色试验•Letters:onelineabovebestVAobtainedsofar•Red-greenfilteroverchartDuochrometest对患者的指示•“Looksfromgreensidetoredsideandbacktothegreenside”•“Whichsidehasthesharperandclearer(not‘better’,darker,orbrighter)lettersorifthetwosidesareequallyclear”Duochrometest光学原理RGDuochrometest•Redlightfocusesfurtherbackthangreenlight–Underminusingmakesredclearer–OverminusingmakesgreenclearerRG‘oneintogreen’•Equallyclear•Redsideclearer-----addanother-0.25D-----greensideclearer•TheleastminuslensmakesgreensideletterclearerRGDuochrometest•Oneintothegreeninsuresthatpatientisslightlyover-minused•Patientcanaccommodateslightlytomakelettersclear•LettersmustbecleartoaccuratelyrespondtocomingastigmatismtestingAfterDuochrometestRemovered/greenfilterandrecheckVA1.20/20orbetter,andnoCylinderinobjectiveresult-----endpointofOD----goandcheckOS2.Lessthan20/20(Cylinderfoundornot)----checkforAstigmatismwithJCCorAstigmatismdialBACKDeterminationofAstigmatism散光的确定•JCC(JacksonCrossCylinder)lens•JCCtest1.Checkforaxisorientation2.Checkforpower3.DetectpresenceofastigmatismJCClens交叉柱镜–0.50Dcylinder–Sphericalequivalentisplano–Whitedotmarksaxisofpluscylinder–Reddotmarksaxisofminuscylinder–Ex:onemeridianis+0.25,theotheris-0.25+0.25DAxis-0.25AxisASTIGMATISM散光成像AxisMeridianHorizontalFocalLineVerticalFocalLineCircleofLeastConfusionPowerMeridianObjectSourceABDCIntervalofSturm1-D57BACKJccforastigmatismaxis确定散光轴向•Letters:onelineabovebestVAobtainedsofar•LineupJcchandlewithaxisofcorrectingcylinder(fromobjectiverefraction)inthephoropter•Instruction:“twoviewswillbeshownandnamed,bothviewsmaybeblurry,tellmethesharperorlessblurryview”•Showview1,Wait2-5”thenfliptoview2andwaitJCClensforAxisdetermination•Equallyclear/blurry---endofaxisrefinement•OtherwisechangetheaxisPatient’sjudgmentEquallyclear/blurrychangetheaxisOneviewclearerGoandcheckcylinderpowerTellmewhichsideisclearer?!#%&*@?JCClensforcylinderpowerdetermination散光度数确定•Chasetheredintheclearerview•0.25Dsteps•Maintainsphericalequivalentpower•Endpoint:–Equallyclear–Responsewithinanarrowrangeofpowers•Selectpowerclosertohabitualprescription,ifnotavailable,selectthelessminuscylinderpowerMaintainsphericalequivalentpower•MaintaintheSEoftheMPMVAstartingpoint•Keeptheminimumdiffusedfocusontheretina•2DCchange=1DSchangeforcompensationAstigmatismcheckwithJCCJCC交叉柱镜核查散光•IfnocylinderfoundonRet.andVA20/20•Place0.25DCx180,90,45,135•AlignhandleofJCCwithphoropteraxis•Ifacceptscylatanyoneaxis,continuewithaxisrefinementHandholdJCCtest•Checkforaxisorientation•Checkforpower•DetectpresenceofastigmatismSlitlens裂隙镜片•findaxisofastigmatismClockchart(sunburstdial)散光表测量散光•20/20can’tachievedwithsphericallensesandnoCylinderinobjectiveresult•IfwebelievethecylfromtheRet.isinaccurateClockchart(sunburstdial)DetectpresenceofAstig.CheckforaxisorientationCheckforpowerClockchart(sunburstdial)•RemoveanyCyl.andfogto20/40•Showtheclockchart•Toidentifythedarkest,sharpestsetoflinesaccordingtotheposition(2and8o’clock)•SetAXISaccordingto“Ruleof