THE JACKSON CROSS CYLINDER (JCC) TEST

PURPOSE
To refine the axis and power of the cylindrical component of the correction after the initial monocular MPMVA has determined the tentative spherical correction. Ordinarily one should refine cylinder axis prior to refining cylinder power. However, if the tentative cylinder power is only -0.50 or -0.25, it is permissible to perform a power check, following steps 22 through 26, prior to refining the axis. If the patient accepts the cylinder power at this time, return to step 13, the axis check, followed by refinement of the cylinder power. If the patient rejects the cylinder power at this time, proceed to step 27, the second MPMVA. PERFORM THE JCC AXIS CHECK 13. Isolate a line of letters one line above the best VA obtained so far in the monocular subjective refraction. 14. As shown in Figure 3-11, place the JCC lens before the eye such that its axes straddle at 45 angles the axis of the correcting cylinder in the phoropter. This is achieved by lining up the handle of the JCC with the axis of the cylinder in the phoropter. 15. Instruct the patient that you will show him two views of the line of letters and will identify each view with a number. Tell him that both views may be blurry, but to tell you which view is sharper or less blurry. Further instruct him to try to ignore differences in the shapes of the letters when comparing the views. 16. Have the patient look at the letters and tell him, This is view number one. 17. After 2 to 5 seconds, flip the JCC and say, This is view number two. Which view has the clearer letters? If the views are equally blurry, the axis is set in the appropriate position. Go to step 21 to refine the cylinder power by the JCC. 18. If the views are not equally blurry or equally clear, move the axis of the phoropter cylinder by 15 toward the minus cylinder axis (indicated by the red marks) that gave the clearer view. In Figure 3-11, if view number 1 provided the patient with clearer vision, the axis in the phoropter should be moved in a clockwise direction. If view number 2 provided the patient with clearer vision, the axis in the phoropter should be moved in a counterclockwise direction.

19. Shift the orientation of the JCC lens so that the handle remains aligned with the axis of the phoropter cylinder. In many phoropters, the JCC will rotate automatically along with the phoropter cylinder, so this step is unnecessary. 20. Repeat steps 14 through 19 as long as you have to keep adjusting the cylinder axis in the same direction (i.e., clockwise or counterclockwise). When the axis has to be moved in the opposite direction, repeat steps 14 through 19, but move the axis in 5 or 10 steps. Hone in on the correct axis by successively decreasing the step size. Note: The greater the cylinder power, the greater the need for precision in the axis. For cylinder powers greater than 5.0 diopters, the axis should be specified to the single degree. For cylinder powers less than 2.0 diopters, the axis should be specified to the nearest 5. For cylinder powers between 2.0 and 5.0D, exercise professional judgement. 21. End the JCC axis check when either of the following two conditions are met: a. Both views look the same to the patient. b. The patients responses move the axis back and forth within a narrow range. In this event, select an axis in the middle of the range.

Figure 3-11. Schematic diagram of the JCC for axis refinement, showing the JCC in its two positions. PERFORM THE JCC POWER CHECK 22. Place the JCC lens so that one axis is aligned with and the other axis is perpendicular to the axis of the correcting cylinder in the phoropter, as shown in Figure 3-12. 23. The instructions are the same as in steps 15, 16, and 17. It is often necessary to repeat them, however.

24. Present the two views to the patient by flipping the JCC lens. If the patient prefers the view with the RED dots (minus cylinder axis) aligned with the cylinder axis in the phoropter, view number one in Figure 3-12, increase the power of the minus cylinder in the phoropter by -0.25D. If the patient prefers the view with the WHITE dots (plus cylinder axis) aligned with the cylinder axis in the phoropter, view number 2 in Figure 3-12, reduce the power of the minus cylinder in the phoropter by -0.25D. 25. Throughout the JCC power check, maintain the spherical equivalent of the MPMVA starting point. For each increase in minus cylinder of -0.50D that the patient accepts, add +0.25D to the sphere or take away -0.25D. For each decrease in minus cylinder of -0.50D, add -0.25D to the sphere. 26. End the JCC power check when either of the following two conditions are met: a. Both views look the same to the patient. b. The patients responses call for changes within a narrow range of powers. In this event, select the power that is closer to that found in his habitual prescription. If a habitual prescription is not available, select the less minus cylinder power. Note: If the results of the JCC power check call for a change in power of greater than 0.75 diopters, compared to the starting cylinder power, recheck the cylinder axis at this point. Note: For some patients, making the choice of which view is clearer is very difficult. Borish describes a variation on the JCC technique in which the whole VA chart, from the 20/50 to the 20/15 letters, rather than an isolated line of letters, is displayed. The patient is asked to report which view allows him to read farther down the chart. By having the patient try to read the chart, the examiner can exercise his professional judgement as to the view that provides the sharper retinal image. Upon reaching the conclusion of the JCC test for both axis and power, perform the second monocular MPMVA.

Figure.3-12. Schematic diagram of the JCC for power refinement, showing JCC in its two positions.