Balance and Binocular Subjective

 Balance
o Purpose: to equalize the stimulus to accommodate (match the
accommodative demand of the two eyes)
 You are not trying to equalize the response, equalize the visual
acuities or balance the refractive errors
o Balance all patients with remaining accommodation
 Absolute presbyopes, strabismics, and monovision patients may be
better out of balance
o If patients are not balanced, one or both eyes may have blurred vision, stereo
acuity may be reduced and fusional vergence may be decreased
o Balance is performed after the monocular subjective and before binocular
subjective, binocular testing and near testing
 Equal visual acuities after 2nd Best Sphere
o Dissociated blur
 Monocular MPBVA MUST be equal
 Use 3 Δ BD in front of OD and 3 Δ BU in front of OS to dissociate
(Risley prisms on phoropter)
 The right eye sees the chart on top and the left sees the chart
on bottom
 +0.75 D is added to the monocular subjective
 Use the 20/40 LOL (~3 LOL above MPBVA)
 Procedure
 Confirm the patient sees two LOL
 Ask patient “Ignoring brightness, which LOL seems to be
clearer, the upper or the lower one, or are they about the
same?”
 If one line is clearer, add +0.25 D to that eye
 Endpoint is when both charts appear equally blurred or closest
to being equal
o Goodwin
 Monocular MPBVA MUST be equal
 Use 3 Δ BD in front of OD and 3 Δ BU in front of OS to dissociate
(Risley prisms on phoropter)
 The right eye sees the chart on top and the left sees the chart
on bottom
 +0.25 D is added to the monocular subjective
 Use the 20/20 or 20/25LOL (~1LOL above MPBVA)
 Procedure
 Confirm the patient sees two LOL
 Ask patient “Ignoring brightness, which LOL seems to be
clearer, the upper or the lower one, or are they about the
same?”
o About the same: balance is finished
o If the images are unequally clear: follow flow chart
 o Alternate Occlusion
 Use 1 LOL above VA with 2nd best sphere
 Alternately occlude the right and left eyes and ask which one looks
clearer
 If equal: proceed to binocular subjective
 If unequal: add +0.25D to the better seeing eye
o If the better seeing eye reverses, ask in which case are
they most alike
 Unequal visual acuities after 2nd Best Sphere
o Bichrome or Duochrome
 Monocular MPBVA do not have to be equal
 Room lighting must be dark (darker than refraction)
 Use 3 Δ BD in front of OD and 3 Δ BU in front of OS to dissociate
(Risley prisms on phoropter)
 The right eye sees the chart on top and the left sees the chart
on bottom
 +0.75 D is added to the monocular subjective
 Use the 20/40 LOL (~3 LOL above MPBVA) with the red/green filter
 Procedure
 Confirm that the patient sees two LOL
 Ask patient “Looking at the upper chart, where do the letters
appear darker/blacker/sharper, on the red or green side?”
 Responses
o Red: add -0.25 to OD until “about the same” or reversal
 Red is focused closer to the retina (unless they
are overminused)
o Green: add a few clicks of plus to OD until they say red
o About the same (as initial response): add a click or two
of plus to OD until they say red
 o Too blurry to tell a difference: patient is too fogged; add
minus to OD until they say red
o About the same (after coming from red): stop and repeat
with the OS
 Ideally you want to leave each with the same end point
o Vectographic
FYI from the lab manual: Vectographic refraction offers a binocular (or fused)
type of refraction in which a binocular balance automatically occurs (the
balance, so to speak, is built in to the refraction and so there is no need for a
separate balance procedure following the 2 nd best sphere)
 Uses polarized chart and polarized lenses (analyzers) in the phoropter
 Use monocular subjective in phoropter with +0.50D or +0.75D added
to both OD and OS
 Confirm that the patient sees both sides of the chart
 Direct patient to look at one side while keeping both eyes open
 Decrease plus while the patient’s attention is focused on that side to
obtain the MPBVA
 Until a click of plus makes it worse or does not make it better
 Repeat directing attention to the other side of chart
 Remove analyzers and polarized chart
o Turville Infinity Balance (TIB)
 Offers a binocular (or fused) balance
 Balance is “automatic”
 Uses a septum splitting chart (OD sees right side; OS sees left side)
 Perform 1st best sphere, JCC and 2nd best sphere on OD and
repeat for OS
 Remove septum
o Cross Grid
 No available chart
 Patient is not fused (not binocular)
 Binocular Subjective
o Fog both eyes 3-4 lines above VA with 2nd best sphere (may already be
fogged from balance)
o Reduce plus (add minus)