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Automated refraction
Design and applications
relax accommodation. All autorefractors
now use the fogging technique to relax
hen the first autorefractor was developed over 30 years
Figure 1 Figure 2
The Shin Nippon NVISION-K 5001 Basic principle of the autorefractor
Infrared light
To PC Slit
more minus 0 more plus
image
28 | June 4 | 2004 OT
Clinical
optimal focus of the slit on the retina. Three types of autorefractors profile tells the autorefractor that the
Optimal focus is achieved when a peak Fundamentally, there are three types of Badal lens is not in the correct position to
signal is received from the light sensor. autorefractors which derive objective correct the meridional power. When the
The polarising beam splitter effectively refraction by: intensity profile reaches a peak, the Badal
removes reflected light from the cornea optometer reading is taken to signify the
whereas the slit image on the retina passes Image quality analysis power of the meridian being measured.
through the polarised beam splitter. The Scheiner double pin-hole refraction Once this is performed for three
system measures at least three meridians Retinoscopy meridians, the sine-squared function is
of the eye in order to derive the refractive used to derive the sphero-cylindrical
power of the eye using the sine-squared Each of these will now be discussed in prescription.
function6. more detail. Perrigin et al7 compared the refractive
The sine-squared function of ocular data from the Dioptron Nova with
astigmatism describes the variation of Image quality analysis subjective refraction in a clinical setting for
meridional astigmatic power. Thus, for any This method is not used very much in 236 patients. Dioptron and subjective data
given prescription sph/-cylx, the power modern-day autorefractors. It was had an agreement of 0.50 for 74% of eyes
along any given meridian is given by the originally used in the Dioptron with respect to mean spherical equivalent
formula sph+(cyl x sine2). Figure 3 autorefractor. However, for completeness, power. Mailer8 compared the accuracy of
illustrates the sine-squared function for it will be discussed here. the Dioptron II pre and post cycloplegia
the prescription +2.00/-5.00x90. In Figure 2, the basic design of the with subjective refraction in 84 patients.
Autorefractors only need to calculate autorefractor is described. Here, the There was 46% agreement to 0.25DS for
the power at three chosen meridians in optimal position of the Badal optometer spheres, 51% for 0.25D cylinders and
order to calculate the sphero-cylindrical lens was determined by the output signal 44% for mean spherical equivalent. After
prescription using the sine-squared of the light sensor. The rotating drum cycloplegia, there was 47%, 51% and 51%
function. Basically, the three power effectively produces a light/dark agreement respectively. Furthermore,
measurements at the three respective alternating target. The light sensor matches cylinder axis agreement was 46% without,
meridians provide three points on the the intensity profile of the incoming light and 29% with cycloplegia for 5 degrees
sine-squared function graph. From this, from the eye, to the light intensity pattern axis error. The author concluded that the
the rest of the curve can be extrapolated in from the rotating slit drum. Dioptron provided a useful starting
order to calculate the maximum and Figure 4 shows how the image analyser point to subjective refraction8. Similar
minimum power values, i.e. the principal determines the optimal position of the conclusions have been drawn in other
focal planes. Badal optometer lens. A low intensity studies9,10.
Signal Signal
to eye to eye
Signal to Signal to
light sensor light sensor
Sub-optimal position of Badal optometer lens Optimal position of Badal optometer lens
Result in: low detector output Result in: high detector output
Figure 3 Figure 4
The sine-squared function describes the meridional power variation Autorefraction using the image analysis principle
of sphero-cylindrical refractive error
Distance light Scheiner double Semi-silvered mirror
source pin-hole Narrow pin-hole
EYE
CROSSED Dual LEDs
DIPLOPIA
Condensing lens Objectives
Dual photodetector
UNCROSSED
DIPLOPIA
Figure 5 Figure 6
Optical principles of the Scheiner double pin-hole Principle of the Scheiner double pin-hole based autorefractors
29 | June 4 | 2004 OT
Clinical Trusit Dave PhD, BSc, MCOptom, FAAO
Kinge et al, 1996 Subjective refraction vs. 448 eyes subjective refraction Both autorefractors over minus Valuable complement to
BJO Nidek AR-1000 & 448 eyes Humphrey 500 Humphrey 500 by R -0.23D subjective refraction
Humphrey 500 160 eyes Nidek AR-1000 L -0.20 not a replacement.
Cycloplegia Nidek AR -1000 by R -0.13, Nidek better on spherical
Mean age 20.1 (SD 1.1) L -0.11. equivalent; Humphrey
Both p<0.0005 better for astigmatism
Gwiaza & Weber, Canon R1 vs. Grand Seiko REs of 50 subjects 92% measures with 0.25 for cyl Consider the agreement
2004 WR-5100K & Nidek ARK Mean age 30.5 (range 17-59) power (Nidek vs. Seiko). 42% for between autorefractor
Optom. Vis. Sci. 700A No cycloplegia Seiko vs. Canon. 40% for Nidek results as different
& Canon. manufacturers readings
Mean sphere: -2.44 Canon, -2.04 are not interchangeable
for Seiko, -2.66 for Nidek
Elliott et al, 1997 Subjective refraction vs. REs of 30 subjects Nikon NRK-8000 vector dioptric Nidek shows greater
Optom. Vis. Sci. Nikon NRK-8000 & Age range 22 to 85 distance 0.576D (0.375) agreement with
Nidek AR1000 No cycloplegia Nidek AR1000 Vector dioptric subjective refraction cf.
distance 0.427D (0.255) Nikon.
Mallen et al, 2001 Subjective refraction vs. 100 adults (200 eyes) Spherical equivalent:
Optom. Vis. Sci. Shin-Nippon SRW-5000 Mean age 24.4 (8) no cycloplegia +0.16D (0.44)
Chat & Subjective refraction vs. 44 children under cycloplegia Spherical equivalent:
Edwards, 2001 Shin-Nippon SRW-5000 Age range 6.45 (1.36) +0.24D (0.34)
Ophthal. Physiol.
Opt.
McCraghrey & Subjective refraction vs. 100 consecutive eyes in practice Mean spherical difference:
Matthews, 1993 Hoya AR550 No cycloplegia -0.015
Ophthal. Physiol. No details of sample Confidence limits:
Opt. -0.69, 0.66
Table 1
Scheiner double pin-hole double pin-hole identifies the level of Studies evaluating Sciener-based
refraction ametropia in a subject by placing it autorefractors over past 11 years
Most of the latest autorefractors used in directly in front of the patients pupil
practice today use the Scheiner principle. (Figure 5). In a myopic eye, the patient patient which image has disappeared,
The original Scheiner double pin-hole was sees crossed diplopic images, whereas in when either top or bottom pin-hole is
invented in the 16th century, however, the hyperopia, the patient sees uncrossed occluded.
basic theory of this important discovery is images. Crossed and uncrossed doubling Implementation of this technology in
still used today. In a clinical setting, the can easily be differentiated by asking the autorefractors is somewhat different. In
30 | June 4 | 2004 OT
Clinical
Detector Detector
Objective (O) Objective (O)
Figure 7a Figure 7b
Knife edge test for myopic eye. The motion of the reflex across the Knife edge test for an emmetropic eye. The reflex on the detector
detector provides information on the nature of the refractive error. moves over most of the surface
The speed of the reflex describes the magnitude of refraction
general, two LEDs (light emitting diodes) Retinoscopy based and not requiring bifocal or PALs, were
are imaged to the pupillary plane. These Some autorefractors (Welch Allen enrolled into their study. Six
effectively act as a modified Scheiner pin- Suresight and Power Refractor II) use autorefractors (Canon RL-10, Hoya AR-
hole by virtue of the narrow pencils of infra-red videorefraction. A grating, or slit, 559, Humphrey AR-595, Nidek AR-800,
light produced by the small aperture is produced by a rotating drum. Similar Nikon NR-5500 and Topcon RM-A7000)
pinhole located at the focal point of the principles to retinoscopy are used where were used to refract the patients in
objective lens. A detailed analysis of the speed of the reflex is used as an addition to carrying out subjective
Scheiner principle autorefractors can be indicator of the patients refraction. The refraction. Spectacles were made from the
discussed by observation of an older optical configuration was originally prescription of one of the six
Scheiner autorefractor, whose optical described by Foucault and was used to test autorefractors (assigned randomly) and
design is available in the public domain the surface quality of mirrors. It is now the practitioner. Subjects wore each
(Figure 6)11. better known as the knife test where the prescription for two weeks without a
Once the LEDs are imaged in the slit (or knife as it was originally called) wash-out period. Both the investigators
pupillary plane, ocular refraction leads to was produced using a pair of blades side and the subjects were masked as to the
doubling of the LEDs if refractive error is by side. The basic optical construction is prescription being worn. After each
present. After refraction, the retinal image shown in Figures 7a and 7b. period, subjects filled out a questionnaire.
of the LEDs reflects from the retina back The slit is used to determine the Three subjects were removed due the fact
out of the eye. However, light emanating refractive power of the eye. The speed and that the visual acuity result from
from the eye is again reflected by a semi- direction of the movement of the reflex is autorefraction was below 6/9.
silvered mirror to a dual photodetector. In detected by photodetectors and computed Interestingly, two of these three were from
order to differentiate between crossed and to derive the meridional power. Figure 8 the autorefractor and one from the
uncrossed doubling, the LEDs flicker shows the configuration of the detectors. clinician (a latent hypermmetrope).
alternately at a high frequency. The dual The vertical slit calculates the refraction of Table 2 shows the main results from
photodetector image is designed to image the vertical meridian. The system detects the questionnaire from Strang et al12.
only one of the two LEDs in each half. As that the vertical meridian is measured by The authors concluded that
a result, crossed and uncrossed diplopia the way each detector senses the slit as it prescribing purely from the autorefractor
can be detected. As the LED system is passes over the pupil. The time difference prescription was unfeasible in practice.
moved back and forth (according to the from the slit reaching each of the Similar studies need to be conducted with
type of diplopia), the separation of the detectors allows the autorefractor to detect modern-day autorefractors and
diplopic images varies on the the meridian under investigation. The instruments capable of automated
photodetector. When the retinal image is oblique slit will likewise initiate a subjective refraction such as the Topcon
single, a single LED image is centred over different time dependent response from BV-1000 and post refraction system.
both photodetectors. The LED position the detectors, and thus derive the power
corresponds to the refractive error in that within the oblique meridian. Autorefraction in
meridian. In the case of astigmatism, four Once the optimum movement is irregular eyes
LEDs are used and the power derived corresponding to neutralisation in Increasing numbers of patients are having
perpendicular to the meridian under test is that meridian, the dioptric value is plotted surgery to correct ocular refraction. Does
measured. on the sine-squared function (Figure 3) to automated refraction have a close
It is apparent from Figure 6 that derive the sphero-cylindrical refraction. correlation to subjective refraction in
alignment of the photodetectors is these cases? Corneal shape post refractive
important. Basically, it is important that Prescribing directly surgery is clearly modified in the majority
both the patient fixation and instrument from autorefractors of procedures. Furthermore, specific
axes are coaxial. If this condition is not Although many studies have evaluated the algorithms are used in lasers which ablate
met then effectively the objective accuracy and repeatability of the cornea to reduce aberrations and
refraction is conducted from an off-axis autorefractors relative to subjective permit increased ablation zone diameters.
point and this leads to error. refraction, the ability of patients to adapt Most autorefractors (all Scheiner based)
Manufacturers have attempted to reduce and tolerate these prescriptions has not perform refraction through a fixed pupil
these errors with auto-alignment systems. been addressed. Clearly, there is a margin diameter. Therefore, the influence of
Practitioners who over-ride this function, of error that patients are willing to overall refraction throughout the
by continually holding down the joystick tolerate; the question is whether this pupillary plane will not be addressed. In
button, may effectively increase the error margin of error is within the variability eyes with a normal corneal shape, the
of measurement due to the possibility of encountered with autorefractors. Strang et results will not be affected but in
misalignment. al12 conducted an interesting study to pathological eyes such as post graft,
There have been considerable studies investigate patient tolerance to keratoconus and post refractive surgery,
evaluating the accuracy of Scheiner-based autorefractor prescriptions. the departure of corneal shape from
autorefractors. This article reviews studies Forty-seven subjects with a mean age normality may induce significant errors
published in the last 11 years (Table 1). 36.7 (16.7) and no ocular pathology, compared to subjective refraction. Many
31 | June 4 | 2004 OT
Clinical Trusit Dave PhD, BSc, MCOptom, FAAO
32 | June 4 | 2004 OT