1/13/2015

Retinoscopy Near Dynamic Retinoscopy • Why do we do retinoscopy? It’s Not Your Mother’s Retinoscopy • If simply to arrive at a “refraction,” we are limiting the information we are getting Glen T. Steele, O.D. FCOVD FAAO • Retinoscopy for refraction is like Twitter – limited Professor of Pediatric understanding Southern College of Optometry • If you are trying to determine how someone is attempting to obtain information and the amount Memphis, TN of energy required and monitor these changes through time, longer observations are necessary

Retinoscopy Retinoscopy

• What skills do we expect a child to show when we • How frequently do you have to remind them to look evaluate? • What if their point at the target but you see marked • Look changes in the reflex – balance, brightness, motion and color • Align • This is a direct measure of self-regulation – important for • Follow later classroom activity • Focus – ability • Also a developmental test – Are they fully ready to look and • Focus – sustain sustain looking?

Retinoscopy My Retinoscopy Tenets • How do we assess whether they can do that or not? • Retinoscopy should be our mental video of what • Qualitative AND quantitative measures goes into all those things that make up what we • Subjective compared to objective responses call “refractive state” • As a part of other testing • Observing the process of effective looking requires patience on the part of the patient – and the • All of the above optometrist • We often rush to the conclusion – with considerable impatience

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My Retinoscopy Tenets My Retinoscopy Tenets

• Refractive status is not static or stable – it is ever-changing • True looking during retinoscopy requires patience • Retinoscopy is an observation of the variations present in and practice every patient • Much can be missed when one limits their brief looks • There is a presentation of the retinoscopic reflex that I only to a final “number” perceive to be ideal • This has blunted the impact of Getman, Streff, Kraskin and others in our patients lives • Patients/people may not consistently show this ideal reflex or may not show it at all • Dynamic retinoscopy can give us valuable information about the way the patient is selectively “looking” - If • In the presence of a less than ideal reflex presentation, I first WE take the time to “look” look for a lens to move them toward this ideal

My Retinoscopy Tenets

• The more the retinoscope is used to observe the visual performance of an individual, the more the observer will come to respect and appreciate the dynamics of the total visual system, and all of the influences the total organism will bring into the visual act. Just Look! Retinoscopy • My preference is a spot retinoscope in order to observe ALL meridians simultaneously

Just Look! I Don’t Start Without These

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Or These Key Issues in Just Look! Retinoscopy

• Start looking with retinoscope before the target is introduced • Determine what it takes to get them to look • Can they sustain for a sufficient time • Do you have to continually remind them to look • Continue looking with retinoscope AFTER removing the target • This is a continuum from before they are aware of the target through removal of the target – what is the process?

Just Look! Retinoscopy Just Look! Retinoscopy

• Begin looking before you even introduce the target • Observe each of the above as targets are moved • Compare right and left initially – do they look alike • Push plus at nearpoint until reversal of motion • Observe during movements • Watch and listen as the patient reads letters, finds pictures and • Observe during alignment testing reads sentences • Observe pupil size and compare right and left • Move targets in all points of gaze and note “hot spots” – indication of a starting point during

Just Look! Retinoscopy Targets for Just Look!

• Think about expecteds as you observe near retinoscopy • Watch with +/- 2.00 • Watch accommodation as you do push-up amp • Observe initial response to equal low plus • Observe as YOU move either with them as they look or in particular meridians

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Targets for Younger Kids + 2.00 and 6BI/12 BO Flippers

• 12 cycles per minute at school age for each set • Watch for decrease in quality of clearing during the minute • Watch for suppression on the Bernell #9 slide (polarized lines) • Children in kindergarten are expected to begin major copying from the chalkboard

Flippers Targets for Push-up Observation

What do You do with the Information? What do You do with the Information?

• Examples • Pupils larger when looking at nearpoint than at farpoint • With at nearpoint and -2.00 at farpoint • Pupils smaller when searching for smaller letters • 10 mm pupils • Initial alignment of ET with +2.00 and +4.00 regardless of motion • Equal against and pupil constriction at you move up on an A pattern ET • Follow-up • Takes several seconds or instruction to get them to look at • How often do you see them for follow-up the target

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Pupil Size Bubba’s Method for Prescribing

• Recent increase in • Prescribe from a developmental perspective awareness of very large • Observe reflex – how active and regulated pupil sizes – 8-10 mm • Estimate the amount of movement • Does not change with accommodative target • Add lens power until first brightening although does show • Begin there in order to let the process of accommodative response development take over on retinoscopy • Monitor frequently • Modify power depending on the response

Summary

• Think of Just Look! as a continuum • Observe where the patient might be in their developmental process • When do perceived minor issues become toxic? Cases • Are they able to self-regulate at an age- appropriate level • When the patient is in a specific stage of development, it will show in retinoscopy if one will Just Look!

Seminar Observation Jasmine – age 2 years

• Parents note normal development • A-pattern esotropia – left eye up and in on upward gaze • On Lea Gratings, she shows easier response when looking with left eye than right • Retinoscopy - +0.75 in primary position – equally bright • Retinoscopy appears slightly darker on right eye • Retinoscopy was observed with ocular motility in When asked about feeding modality, parent indicated she • the vertical position was bottle feeding - and always held the baby in her left arm • Left eye up and in just past horizontal midline

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Jasmine – age 2 years Jeremiah – age 10 months

• Marked and equal increase in against motion OU • Moderate head turn to left • Marked equal decrease in pupil size OU and in • Equal retinoscopy reflexes when looking at near target with brightness OU head turn • Is this expected? • Dolls Head maneuver moving to straight ahead position – moderate against in left eye although right eye remains similar • Parent comments about extreme difference when breast feeding from Mom’s left side versus the other

Patient TM - age 12 mos Patient TM - age 12 mos

• Taken from birth parents at age six months • Just Look! reflexes showed slightly brighter OS compared to • “Shaken Baby Syndrome” dx OD • Intermittent RXT with increasing frequency reported by foster • What does this tell us? parent • Do we attempt treatment? • Previous dx of subretinal hemorrhage in the macular area of • For? the right eye • Visual acuity – OD FDL at 12” OS FDL at 50”

MG – 9 yrs – Don’t Depend on Current Rx MG – 9 yrs – Don’t Depend on Current Rx

• First seen 8/12/13 • Student could not get improvement using +/-5.00 over Rx • OS cataract sx – 2008 • Near ret with Rx – very dark OD bright OS • OD cataract sx – 2011 • Near ret with no lenses – Right relatively equal to Left and • Has been seen by several OMD shows moderate with • Wearing OD -17.00 OS +3.00 with a +3.00 add OU • +5.00 to relatively equal neutral at nearpoint • VA cc – • With +3.00 OU – VA OD 20/70 OS 20/25 • OD - <20/400 • Final OU +3.00/+2.00 add • OS – 20/70

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JBR – age 10 – ET rec for sx JBR – age 10

• Seen 9/28/09 • “Follow-up” on 2/10/14 • 35 pd Alt ET – prefers RE fixation • Did not go for surgery four years ago due to insurance issues • Dry and cyclo distance rets are equal - +0.50 – presumed non- • Unaided Distance VA – 20/25 OD OS OU with OS slightly more accommodative difficult • Near not performed • 16 pd Alt ET at far and 30 AET at nearpoint– prefers RE fixation • Distance VA – 20/20 OD OS OU • Distance refraction not performed • Referred for strabismus surgery because not accommodative

JBR – age 10 Addressing These Issues

• Near ret initially show equal with slight with - +0.50 • Movement activities – initially random movement to • Runs up in plus – to +2.00 movement with a purpose • When +1.50 introduced, JBR goes essentially straight at • Eye stretches to accurately reaching for target nearpoint • Lenses at any time there is a better balance between eyes or • OU distance VA with +1.50 = 20/20 better rapport with the chosen targets • Rx +1.50 with return in 6 weeks • Office VT if neither of the above shows almost immediate promise • Obviously, any combination of the above at any time

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