• Unaided VA
  • Cover test (ask them to look at letter on worst line, or line above if both same) – record either exo/eso phoria, tropia or NMD & recovery
  • Prelims (fields, Hirschberg/kappa, motility, pupils)
  • PD
  • Fit trial frames
  • Do pinhole if necessary
  • Retinoscopy – dim lights, put in working distance at back, check that there is against movement in LE before starting RE, if necessary add more plus but REMEMBER to REMOVE this once done with RE
  • Take out working distance, check VA on Snellen one eye at a time
  • ONLY DO BEST SPHERE WITH F&B – do F&B with harder cyl
  • F&B – occlude other eye, take out cyl from ret. & put in fogging (half estimated cyl + 0.50DS – half estimated cyl is part of Rx!)

Ask them to look at fan & point to clearest line (= axis) “Are two limbs of V equally blurred?” “Which block of lines is clearer?”

Start off by putting estimated cyl in at that axis, if block that is clear is same as before, need more negative cyl & if other block is clearer, need more positive cyl. Remember to compensate for every -0.50DC give +0.25DS

When both blocks & all lines appear equal, hold +0.50DS over as a check – everything should still be equal

Now check VA on Snellen chart – remove +0.50DS from fogging slowly (want to push the plus)

  • Now do +1.00 & duochrome, & write final result
  • Cross Cyl – make sure eye is on green on duochrome! Take out after

Leave cyl in & turn on bright circles/drum – ask them to focus on inner circle

Find axis first – hold handle at axis of cyl & twirl “Is the circle clearer, blacker & rounder with lens 1 or lens 2?” – & move the axis towards the -0.25 (negative) – repeat until “about equal”

Now find power – align markings of power on cross cyl with axis & ask “is the circle clearer blacker & rounder with lens 3 or lens 4?” – repeat until about equal

Check VA & optimise sphere (with cyl in)

Do +1.00 & duochrome, & write the final result

  • Binocular Balancing – HIC: fog one eye with +0.75DS & do best sphere on the other eye – exactly the same as BS “do you prefer it with this lens or without/is it easier to read with this lens or without?”

Switch eyes & do the same

Then check with twirl binocularly & if they say they prefer with extra plus add extra +0.25DS in both eyes

  • Maddox Rod – turn OFF lights, put in RE horizontal first so they see a vertical line – if line is to the left of the spot it is EXOphoria (opposite side), if on right side then ESOphoria (same side)

Correct with Base facing direction that line is in from the spot – so if on left side of spot it’s base IN, if right side base OUT etc.

Correct with appropriate prism & record

Now put in Maddox Rod in RE vertically so that they see a horizontal line – should go straight through spot but if not correct & record. Only record HYPER

  • Near Add – adjust PD to near PD, ask them to hold near reading chart at normal reading distance & measure their working distance (WD)

Put +2.00DS in each eye & hold RAF rule to their face, put target at the end of the rule & tell them to read N5, first push UP until it gets blurry then pull DOWN until it gets clear – take average – this is their Amplitude of Accommodation. Do this monocularly (by occluding one eye at a time) & then binocularly – take binocular reading (REMEMBER TO MINUS THE +2.00DS)

Measure the Near add by using formula: (1/WD) – (2/3 x AA)
Put in calculated Near Add & check with near chart (doesn’t usually work)

Then put in estimated Near Add & refine by using flipper

Find range – if more range at front than back then decrease the plus to push the focus back, if more range at back then go for a higher plus to push forwards

  • (Check Near VA with booklet?)
  • Maddox Wing – Ask them to hold it & ask “which white number does the white arrow point to?” & same for red arrows

White arrows = horizontal phoria – even numbers = exo & odd numbers = eso

& red arrows = vertical phoria

  • Take vertex distance if needed (only with 5.00DS or higher) with a (PD) ruler or scale on trial frame (have strongest power which is usually the sphere in the back)


  • Write Px’s name & DOB
  • Take unaided vision of both eyes then record
  • Write results of cover test
  • Write PD (distance & near)
  • Write Ret. Rx & VA with it
  • (with F&B eye doe best sphere & record, leave best sphere of cross cyl eye blank)
  • Do F&B but write the +1.00 & duochrome results first & then write final Rx in F&B box
  • Do CC, optimise sphere write the +1.00 & duochrome results first & then write final Rx in CC box
  • Now doing BB, write separate add for each eye (monocular add)
  • Then use both lenses on flipper for binocular add & record
  • For Maddox rod record prism found & base direction, & put either ф or ө where needed
  • Near add: record working distance, monocular amplitudes of accommodation for each eye separately & then binocular
  • Now use formula to find Near add, but don’t usually use that one so put in estimated instead, refine & then record final Near add
  • Find range & record
  • Write N5 (what they can read) in Near VA
  • With Maddox wing, write prism dioptres (number they see) in correct type of horizontal or vertical phoria – leave other boxes blank
  • Say if they have exophoria – write prism dioptres in exophoria box, (they should see zero for vertical phoria) & write 0∆ where it says vertical
  • Put vertex distance beneath final Rx