Transcript for:
Just Look Retinoscopy: Procedure and Uses

hello and good evening ladies and gentlemen welcome to these 135 season of Miro II tax webinar this is Kapil Gautam Singh is your host for the today session and I'm also glad to have you all here today prior to the beginning of this session I request you all to drop your queries that you have in between the session uh to our chat box we shall then discuss it on our next session that is the discussion session which is going to be conducted on the end of the webinar for now I'd like to move ahead to integrate the today's session uh joining us today is speaker and speaking delegates is Dr Dean T still to share his Insight on topic just look retinoscopic procedure and uses before he begins Let Me highlight his short introduction that he still is an OD Co VD and fellow of the American Academy of Optometry and also retired profession of bariatric optimism still I welcome you on our italics webinar on the behalf of Miro I found this and then all our participants thank you so much for your presence so now it's over to you you can please proceed thank you and good evening everyone and it's my pleasure to be here with you and uh I hope that some of the things that I have to share uh will be uh beneficial to you every day and seeing your patients we will start sharing the screen now and now good so just look retinoscopy is a procedure that that I have put together from uh several different uh colleagues over time so nothing that I'm going to say is is unique to me except just the organization I have no Financial disclosure so I have nothing to sell we always have to do that so I want to make sure but I do have other disco disclosures everything I'll discuss is from the perspective of the processes of vision becoming the leader and instigator of action if you just think about how much vision is involved in everything we do and it becomes the leader when compared to a person who is blind versus a person who has cited how much greater reach the sighted person has doesn't have anything to do with intelligence but it's that reach and you can evaluate those processors from there so vision is very powerful in everything we do in humans and we've always been taught that Eisen brain uh eyes and vision are directly related to the brain in reality they're a part of the brain we call them an extension of the brain and if they're an extension of the brain then they are a part of the brain so when there's activity in the brain there will be activity in the eye because activity in the brain when you stimulate a certain part they know through scans that a certain area lights up by the same token I contend when there's activity in the brain The retinoscopic Reflex similarly brightens so those are the kind of things we're going to discuss today when we're touched we look to see where we're touched we don't just uh go ahead and and keep going and ignore the touch when we hear a sound we look to see the origin of the sound but I want to expand one thing there think of the difference between hearing just hearing the sound and then listening and in the same way I want to think about seeing and then looking so looking is the kind of of process that we want to assess where do the eyes of wine connoisseurs go when differentiating wine in the region of the year they start searching visually for those kinds of things so a stimulus from anywhere May originate in any of the so-called senses but then how we look to determine where it is what it is and how we're going to respond is what I'm going to be talking about and all that happens in a split second you'll see in one of the videos I have in just a second so I want to repeat everything I do is based on the premise that vision is the leader an instigator of overall development and if it's a leader in overall development then it's the leader in life you think from crawling to running to walking to riding to driving the binocular function extra bism assembly open refractive development every part of development has a support and direction through the processes of vision so just look right now because it means observing the parents patterns of action when they're engaging in a task or their patterns of visual manipulation and what do I mean by visual manipulation we don't just look at something and see we look we focus we we refocus we engage ourselves in that particular test that's what visual manipulate what I mean by visual manipulation we make observations regardless of the age of the patients some of these things you say well in near retinosity that's only good for kids it's good for patients of any age or the lens power that's there observations here are related to the patient's intentional actions and intentional attempts to engage in the task or the target that's presented and it's a very simple test you turn the retinoscope on have the retinoscope you turn it on and you um you you look through the peephole and then you shine it in the patient's eye and you Marvel at what happens there so it's deceptively simple but it's a test with many complex parts it's such a simple procedure yet they're all very complex our attention to the complexity emerges out of the choices we make every day when we're doing the procedure so you can't expect to you remember back when you learned retinoscopy how long did it take you to to do learn to do retinos could be the very first time it took you a whole Lab period now you do it in just a few seconds so you can do the procedure but then the complexity becomes uh more available to you and in fact the more we look the more we see so don't think about it don't think you're going to take just look right and ask me and look the first time and uh well I see something or I don't you're going to have to look more and then you get children who don't develop the foundational abilities to look attend focus and then find gates are typical for a that our typical grade are more vulnerable and susceptible to challenges and disruptions so if they don't develop these foundations and I call the foundations Envision I want to look I've got to attend I've got to focus I've got to identify and engage now identify could be oh I've seen that before and I don't like it and I go away but that that's where the identification it doesn't just come from first look you have to do that so it's important then to identify those at the earliest time and intervene at the earliest time because they will set the foundations for these babies as they're developing through life one of the programs that I've been involved in is called infancy and we see babies between 6 and 12 months of age during that first year of life to help them set those foundations those visual foundations and so my statement is it's a continuous observation over several seconds that creates the mental video of the changes in the reflexes and this allows one to determine if there are possible times when the reflex moves towards better engagement or away from engagement so think about that as you go through initial assessments would just look at us we should just be done with no lenses in place how is the patient operating because what I want to see is not a refraction it's not that kind of number it's a number of when I put lenses in front of the patient what changes do I see in the retroscopy reflex and we'll have a video of some of those changes and I use lenses as probes in in her book coming to our senses Susan Berry states that as the philosopher Avenue has written perception is not something that happens to us or in us it's something we do and so I want to you could consider that in in your observations you're assessing how the patient is doing and so if perception is something we do then that intentional action can be observed with uh just look right now when observing the intentional action she also quotes we move our body head and eyes to look and listen to take in information about the world we don't see until we look so since we direct what we see developing Vision as an adult is an intensely active process so what we're assessing with just look retinoscopy is that active process a new pair of eyes won't lead to Vision unless the owner of those new eyes pays attention to what he has senses and figures out its meaning Now new eyes we're talking about babies who are born but being a new eye but they have to develop these foundations just like retinoscopy we can determine how they're going about that the active processes through just look retinoscopy Arnold gazelle where I did my fellowship before there was such a thing as Optometric residencies I said the retina scope is revealed an intimate relationship between the functional complex of the visual system and the maturity of the total Action System and that's a paper he presented in 1949. I contend that that statement is just as true today as it was in 1949. one year later he said in the Yale research it was found the returning light in the young retina varied significantly in relation to identifiable moments of the visual Act the variation were manifested in motion the direction the speed the brightness and sometimes the color of the retinal reflex characteristically he says an increase of brightness in the reflex occurs at the moment when the infant identifies an object of Interest so again I've got a video clip that's a very short 30 second video clip that shows so much of what he is saying here and then you might see a darling as they search to identify and then brightening when once they do identify so as they're looking and more intently and intently you'll see that reflects dull down and then you'll see it brighten whenever they get there and here's a short video to before we get to retinoscopy that that um I want us to use to set the stage and this was done by Arnold gazelle in 1950 again I take I'm taking some of these things from many years ago but again because they're so applicable today pay attention to eyes and pay attention to how the baby is looking and then his comments the eyes are Pathfinders the infant takes hold of the world with his eyes long before he takes hold with his hands a one-inch tube Reveals His Eye hand coordination at the age of four months he moves his eyes selectively he looks from Cube to hand and then back again from hand to cube his eyes fastened upon the test Donzi and they maintain a firm grasp the hands are activated even though they cannot as yet obey precisely it is again evident that the eyes have a top priority in the scheme of development he can reach with his eyes but not with his hands now what what I want you to understand there gazelle was a pediatrician gazelle and was not an optometrist gazelle was not an ophthalmologist gazelle was a pediatrician making these observations some 70 um 80 years ago now compare that to an article by Andy melsoff on gays following and gays following is if I'm the baby and you're the parent and I see you looking at a particular object that I will hold in my hand if I see you looking there and I look there I follow your gaze to that point then if I do that at two and he he may assess that at 10 and a half months two and a half years and four and a half years and he showed higher gaze following scores at ten and a half months produced significantly more mental state words at two and a half years in other words they knew more words at two and a half years and with more mental state words at two and a half years were more successful on theory of Mind battery at four and a half years those are some tests that I don't understand but the important thing is here he's using how the baby looks at a parent a caregiver a person doing testing follows their gaze to where they are looking and and if they do that by the by four and a half years they are ahead of other people these predictive longitudinal relationship remain significant after controlling for General language maternal education and non-social attention so they they took all of those other factors and and ignored those just look at gays following and found it was significant this was from 2015 connecting the Dutch from Embassy to Childhood now if performance at four and a half years uh performance at four and a half years does have a foundation in Gays following it 10 and a half months and a part of that looking can be observed with just look right and Oscar so it's where they start looking and how they start looking the processes of vision play a critical role in the very early start of all development and can be observed through just look greatness now he did one other thing he said again looking at gays following when babies had active gaze following by 12 months of age at 18 months of age they understood 335 words now babies will only say a few words at 18 months I think but they understood and responded to 335 words they had active gay spawner if they did not have active gays following they only understood 195 words so vision is so critical and so foundational in all of development throughout and this was from 2005 the development of gays following was a predecessor to the the previous article that we said so vision is critical in knowledge of development now here's an article I found from 2018. when your eyes move so do your eardrums if the eyes move to the right am I right remember that whichever the eardrums bulge left and that happens 10 milliseconds before the eyes move almost as if the brain is saying ears get ready the eyes are about to move so it these this process of vision doesn't just happen in isolation the process of hearing of listening the process of feeling in touch doesn't happen in isolation particularly in the younger Ages which you can follow that and you can assess that through that it's not whether a child can complete a task or not that leads to success or lack of success it's how they do develop their curiosity and their curiosity to engage becomes so critical it's more the effort that must go into the action required to complete the task so if they have a little curiosity more effort's going to be required if they have a lot of curiosity they can move on from thing to things and get that more depth where more effort is required less action will be completed due to many of the following in other words if the child has to put more effort into the activity it's going to be less action and engagement complete completing leads to fatigue it decreases the Curiosity it could relate to stress to complete any of the tasks my games and video games are much easier what kids will often say they make mistakes related to Africa because they're they're focused so intently they don't see the whole problem or the whole sentence or the whole wording they get frustrated it's just too much and it overwhelms and then they give up not because they're not smart it's just it's just cause this requires so much effort but the assumption is and they've probably told many times I'm not smart you're not smart you're not working hard enough when in fact these kids are working finally they just say I'm not even going to to play the game I'm not even going to get initiate in the in the the activity I'm not going to work on math I'm not going to work on spelling and reading it's too hard I'm just not going to do it so they can start and progress through without incident if is the way development starts they can encounter obstacles and alter the processes any point but then they have to get back to the traditional way of doing things the expected way of doing things however if they run into problems they can develop patterns and habits that redirect overall development it's all a matter of how they develop patterns to engage in the tasks of life and I think think of development is revealed in the following you see this this puzzle with many pieces if you consider this as a baby the baby has to put themselves together from inside they have to through their own curiosity and developing foundations and exploration they have to put themselves together now we expect it to go very much like this they're a little older now they're a little older now and then when they get to be a child you expect them to be all put together but what if they miss a piece or two along the way and what if they they develop these substitute pieces and substitute patterns that that that don't allow full and complete development for the culture and all cultures are different um and all households are different so they approach it in different ways but think of this pattern of putting the puzzle together we think of a puzzle many times it's externally we put the pieces together but these babies put these pieces together internally and the final puzzle is the way they have gone about it so we can observe those and see those through retinoscopy and if the reason we do retinoscopy is a rabbit or refraction we then are limiting our own puzzle our own ability to put pieces together of this patient we limit the information available to us it's sort of like a tweet uh you can you can tweet very limited information because you only have a certain number of characters and and it's like so many uh insurance plans in in the U.S and particularly in governmental plans everywhere you've got to do so much information but but to be able to be profitable for you you've got to do it in a hurry and and so you do less uh testing to be able to see more patients um but that's like the tweet I want to give you a a little more involvement through uh just look retinoscopy you can access so many things in a short amount of time once you just get a little bit of experience because then your own curiosity takes over and you go go into there this video will provide an idea of what what's available as a patient approaches a tax so I want you as we go through this video I want you to pay careful attention to all the things you see now um this is my grandson and and what I'm having him do is just look at a Target you'll see and we'll play this video all right Levi touch that good now again touch it from straight up underneath good now I want you to just look at that no touching and again look at me and now look at that again no touching good now what information could be added when you if You observe with a retinoscope especially in that no touching part but you can also add the touching part where are they looking and how are they looking when they come right up underneath the target you see the first time he sort of started out here uh and and went on the the z-axis away from him the second time I asked him to come directly up underneath where is he looking and what's the accuracy of his look when you observe with the retina scope now this this next video pay attention also to several aspects of that and think what you expect to set it up we're we're I have my retinoscope and I am going I'm starting with a wand here with a ball to Target I'm moving that Target towards them and watching the eye as we um as we move the target towards them [Music] Target is moving forward now did you see the the pupil constrict is the target was moving forward that's something I'm not seeing as much anymore with these kids who are Gamers let's go a little further um so we'll get it we'll get a couple of circles here this is really hard yeah we gotta set it up on a table now look at the Target sweetheart there wow and it's back into playing the red and stuff now look at the Target sweetheart there and it's back now pay attention to the increase in brightness and that comes from a simple change in instructions but but just imagine that that brightness is a reflection of what's going of attention that's happening in the brain now I'm not a person who is a neuro person but I know that those can things can't happen in isolation but well let's watch one more time the increase in brightness the increase in attention that we can see the plane of the red and stuff now look at the Target sweetheart there we go [Music] now if you saw the pupil size change you you saw it move into against motion which means they're following with accommodation you saw darkness of the reflex because that's a distance from The increased distance from the scope but it's also an increase in the effort required to focus as they come in an increase to sustain attention and you saw that Mark brightening the chains that we saw remember there were no instructions given at the very beginning it's just we I said the target is we're removing the target towards the patient it's when I said now look at the Target sweetheart that we got that instantaneous change now what I want to see with with uh just look retinoscopy is if I put a lens such as this in front of a patient this is a plus 50. this could be a plus one if I put that in and I get that kind of instantaneous increase in brightness that's a huge difference in what they say so what do they all tell us what would have been noticed if you're only trying to determine refraction you would have had them continue to look and you paid attention to the motion to the brightness not even the brightness you just paid attention to the most because your goal is trying to get to a number even with the auto refractor what is an art refractor give you it doesn't give you those kinds of observations that you can make during that it it takes several different measurements and then they they average them into one single refractive measurement I'm not saying an Autumn refractor is a bad instrument it just does what it does it won't do more and so with the retinoscope in your own observations your intelligence your educational background you can make those observations as they are happening now I want to show you uh one other one you might want to dim the lights in your own room just a bit because the back the the the the video I'm going to show you is is rather dark but this is CJ he had a right exotropia distance and near we got 2080 in the right eye 2020 in the left eye um I'm not going to convert that to metric but but you can just see that the right eye doesn't see as well as the left eye does and so here there was no response to near testing and here's the retinoscopy observations now we're with my spot retinoscope I'm able to see more than just a single eye and begin to see both eyes at the same time and you'll see that as we go through oh no credit Dr Paul Harris who was helping me uh on the original video and now helping me again on this video not quite you see as it comes over you can see the clearly much brighter very bright I can see the left eye much brighter whenever we're doing that I can't tell if I'm a little high or not he's more over to the left eye now but now you can see it's actually relatively dope right now and remember the right eye is the exotropic eye and you can see it very unstable in there in the way it's holding alignment no not quite there you go just keep looking right there and it's really bright still really bright okay okay incredibly bright we had one of those white moments oh open Real wine okay now watch the watch the pupil keep looking when I take my hand away ready watch the people we're gonna do it one more time watch the pupil size change you can see all the modulations that are going on in there and now you see the pupil size chain so you see a difference in brightness between the eyes but you see those modulations especially in the right eye and and so you want those to you you want to have a fully illuminated pupil you see a difference in configuration what I mean by configuration you you just see that the right left eye is more round than the right eye and and the the the right eye is just trying to to work at focusing and and it's reached a point where it says I'm not going to play anymore and that's where the amblyopia comes in but what concerns me is you got to Mark pupil constriction when the covers or moves so if you say well I'm going to patch the left eye what what level of curiosity is that child going to have to developing the ability to focus almost happens by chance and if they don't have a good internal curiosity to work at developing focus in that right eye patching is not going to be effective in this case so you can learn those kinds of things from just observing with your retinoscope and where it was a focused when the left eye was covered certainly not on the target certainly not on the target he was focused somewhere else and when the left eye was uncovered then he regained focus on the target so again considerations for management especially patching this is one that you want to be very careful in doing any patching with and here is his his um the EP and you'll see the green there is with the both eyes together the orange or yellow is with the left eye and here's the right eye well interestingly both eyes together come down to the point of the right eye the point of least resistance rather than being able to come on up here so it shows in the vep but you can do that much more quickly and much more efficiently just watching with your your retinoscope just look at everything as it happens consider this Continuum from exploration to fixation and the quality of fixation consider the stability of the reflex how stable is it whenever they're trying to focus consider the modulations you're going to get these little variations as they try to focus in and and really engage in the task um but but it's it's just um you're you're folk going from focusing from exploring seeing everything out here until you find something you want to zero in on and then everything changes so eye movement simulations more shows a single model of ocular motor behavior that can explain the psychatic Continuum from exploration to fixation we too often think of exploration and fixation just as as two different things but it's two it's the end of an of a of a spectrum and that you can go through a linear explanation here it's it's exploration and here is fixation uh so as you watch that whether it's self-regulation you can see how that child is really zeroing in on the target and if they're exploring they're not regulated or they're not not uh really really focused or at the other end of that whole Continuum you have controlled and it's regulated what happens if the child doesn't learn through the early development to come to this control State how does that put them in things like reading so development it's consistently moving from one stream to the one extreme to the other and and that's why babies will be walking along the floor and they'll see something on the floor that nobody else sees because we've already learned that so if you have a persistence in any direction such as we as adults I'm going to go on a little bit mother further but exploration is okay at two but not at five why not at five you need control because you've got to sit down in the classroom and sit still and control yourself and it'll learn that self-regulated position so where you want to see a child the longest Continuum depends on what the expectations are for the age and so if if they're uh terrible twos aren't called that for a reason they're exploring everywhere and they don't want to sit down and focus um four-year-olds wander off because they see something they see something else and they see something else and then with parent in the store and all of a sudden parent has lost them because the child is just one let their curiosity take them off but when they start to school they must now sit still and pay attention and do all of the things they need to do the way they practice these patterns in early development comes the foundation and and we can see those foundations in early development for instance gazelle says these are four quotes from our gazelle the child is born with visual hunger in other words they are always looking the red is my my comment on that but the child is born with visual hunger seeing is not a separate isolatable function it's profoundly integrated with the total Action System what they look for my comments again what they look for is determined by their internal curiosity so curiosity determines what they look for what they look for how they look for it determines what we see in just look retinoscopy because they'll also says to understand vision we must know the child and to understand the child we must know the nature of his vision and the last part is very to understand this child we must know how they're looking you can get that through just look retinoscopy and then as he said in the video the infant takes hold of the world with his eyes long before he takes over this hand you can just remember that the child was almost anticipating oh my goodness I want that but I haven't yet developed the ability to reach out and grab that young child go they go through the process of development these patterns are just fragmented and variable but later they become more stable than defined and that doesn't happen just with gross and growth and development that happens from the internal curiosity of what they do and how they go about doing it if you limit how they do it for instance this wouldn't I would suspect if this is the focused and control then this patient might become this child might become more have a greater tendency to become myopic because they have limited what they do if in fact though it was Lim it was on the other end of the scale they might become the athlete and have difficulty focusing in those are just two extremes but we we begin to call those patterns habits they we call them diagnoses and if we treat just the diagnosis rather than looking at the Habit rather than looking at the pattern and trying to change the pattern then we're shortchanging the the patient so with threatenoscopy just look retinosity you can observe these definable form patterns and you can be fragmented invariable or stable and defined in the manipulation so what do I expect a child to show I want to see them look I want to see them attend I want to see them Focus I want to see them identify and then engage in the Target now think about all of those that you could do with just look retinoscopy look are they pointing their eyes where's the purkinje image we see a lot of kids with dark eyes and dark pupils of course and it's really hard to tell precise alignment but you can take your retinoscope and and you can look and now you've got an illuminated background and if you've got that illuminated background of the light coming back reflective you can tell where the bikini image is you can tell where they're pointing are they attending do they begin to focus on the target do they stay there how many times during ocular motility did you have to tell the patient keep looking to Target keep looking at the Target well now in retinos we're going to know are they just pointing their eyes to the Target or are they really looking at the Target and engaging in the Target so you can observe all of those kinds of things um what if your eyes point to the Target but you see Mark modulations and balance and brightness and motion and color if you see those kinds of things if they happen just for an instant and now they've got it and hold it that's one thing but if they continue that that means you can pretty much be assured this is a child that's going to have difficulty in anything they have to do where they have to maintain Focus so it's also a developmental test how prepared are they visually to do the activities that are going to be required of them every day are they fully ready to sustain and to look and sustain the process of looking um on the the object or the task and we can do that through um and just look a retinoscopy so we want to make those observations as they approach the task while sitting in the chair in other words I pick up my retinoscope and I start looking before I say and this will be a Target that I use before I say now find an A on here which would be one of the things that I would ask them to do find an a find a b and and I do have uh letters missing so I can tell whether or not they're really fine but I can already tell because I can tell by the way they focus and change Focus refractive status is not static or stable it's ever changing depending on the task and changes according to the task that's why I'm not such a proponent of psychoplegic retinoscopy in in doing these kinds of things because it knocks out accommodation psychoplegia is used to eliminate those those ever-changing motions and movements I think that's very important as we watch that we can observe when there are inappropriate modulations and if the presence of a less than ideal I first look for a lens to move them towards this ideal so how I do that you'll see in the short video I have but I'm holding these up and then I hold lenses in front of the patient as I watch and see what happens so I want to make sure that I I see those too often we just rushed to the conclusion with our impatience and and look at refraction but by taking the time we can get a mental video of what goes on in this in this to make up this process of looking and I say it's the continuous observation over several seconds that creates a mental video of the changes in the reflex this allows one to determine if there are possible times where the reflex moves towards better engagement or away from the engagement with the task at hand so are they further engaging and working to are they avoiding the task so as you do it and use it more frequently you you you come to respect and appreciate the Dynamics of the system and and you become to appreciate more the value of the retinoscopic reflex so you use it to gain the ability to to observe and do that I don't start without the hyperopic presbyo so so these are my lenses I use a double D seg and if you look now if you can see me in here if if I'm using my my progressives here if I want to see I've got to put myself out of an upright posture just to be able to look through there whereas with these uh Double D said lenses on I can now hold myself in I can't put them on too well now I can hold myself in an upright posture and I can see um more clearly so think about that as you do particularly if you're a presbyo these are all the things that I use and I carry most of the the the the the testing materials around in a little fanny pack I don't wear the fanny pack but my retina scope my lenses I use plus and minus two flippers a lot now I've got targets for different age groups here and and then another set of flippers in there but just again start looking before the target is introduced what does it take and the child who immediately begins to look at the Target is better set to to be in get to engage than the child you have to tell them to look at the Target if I say find the A and I have to tell them now find a b Now find the C and they don't pick up the the speed of doing that then they're not going to be as well so what does it take to get them to look can they sustain it you can watch are they do they sustain their focus for a sufficient amount of time to go through the Target and I'm only going to be there 30 to 45 seconds in looking at that and I'm asking them to find letters and what happens when I get to the F which is a missing letter on my target do uh do they continue looking do they just say yeah there it is which means they weren't looking at all so how did they do that then I continue looking with my retinoscope after I removed from the remove the target where do they look and how do they keep looking so there's this Continuum from before they're aware of the target to the removal of the Target and what's their pattern and as they now look at the Target test compare left and right initially you might see differences from right eye and left eye but when you start putting lenses in front and these are plus 50s uh plus ones I can combine the front and the second one for a plus 150. when I start comparing those many times I will see this imbalance come to balance with equal lenses so don't immediately jump to conclusions that there's going to be um an anisomotropia there observe during eye movements I observe many times when I'm doing eye movements here just look how do they do they hold the balance and observe during alignment testing observe pupil size how do we best determine where they alone know the expectations you know if I have your child is going to have to sit in a classroom so what's the optimum where you want to be can we fully move them or partially move them if we can fully move if I get a change in brightness like we saw with Nova on that really big change I know I'm going to get a good response with lenses but if I get just a little response I know I'm not going to get as good a response with lenses and I may have to resort to things like vision therapy to do that how long do they hold the optimum it's better so think of just look right now it's being more of a than a number think of this as a video you're taking and watch and listen as the patient responds look for information how the patient is looking and the ease and effort and these are my targets and I always refers to binocular procedure uh this is for older kids this is for younger kids all who know their letters again elf is missing here f is missing here but I by looking at the uppercase letters or the capital letters of the lowercase letters and small letters you have a difference in an accommodative uh response and expectation there so look at that and this is the way I would do that and if I were seeing with motion here the first thing I would do add lenses a small amount and then increase the lenses a little bit and push up until I get a consistent reversal of the motion so think about the expected watch accommodation with plus and minus two I find this very important especially in kids today who are doing an extreme amount of of work on uh and and play on digital devices it's very important what accommodation is you do a push-up amp is it equal and observes you moved either with them or look in particular meridians so observe as As you move with them as they look or even watch what happens when you put that lens in front and Watch What Happens uh as as you uh include include that now this is a flippers I use these are letter size I use I expect maybe 12 Cycles a minute for each school age set um watch for a decrease in quality as you clear and I want to get on to a couple of things here this is the way I will do that I'll show you a brief video like this yeah plus two minus two end and I'm watching them clear now what I did with with you do with a a small group of kids that did not clear the plus and minus two and when you compare that to the covd quality of life checklist it's 19 questions and I found that 58 or 15 of them had over 25 which is a concern on this a a caution is that had eight of them or 31 uh that would be between 20 and 25. only three out of those that did not pass the plus and minus two facility um had under 20 which is the expected so 23 out of 26 or 89 of them did not pass uh did not score well on the covd checklist so I use a plus and minus two where parents complain of intermittent and I turn and you don't see it because when I'm you put the Plus in front I expect on an exit rope I might see the eye turn out or with esotropia I might see the eye turn in whenever I put the plus and minus twos in front so there's so many different ways you can do that so any deviation from alignment will indicate a fragile binocular system so feel comfortable supporting the parent if you see this even though you don't see it it does take several instructions does it take several instructions to get them to look and what happens if I keep adding plus and they push up to 2 plus 250. I tell my students who are rushing to get to dilation inside complete that's it if you get the dilation and you don't know where that patient is that that they're going to to blow up on you in other words they're going to increase significantly amount of plus you haven't been paying attention as they go along so are the pupils larger you get 10 millimeter pupils do they constrict when looking for smaller letters you get Alignment Plus two and plus four regardless of motion so I'm becoming very aware of these kids and I'm gonna pretty much close it down here even though I've got some more but I'm becoming very aware of kids with the large pupils who come in and these are kids who are on game doing Gamers and I'm talking about a pupil like that you say that's a dilated people no and and I used to see maybe one or two of these a semester now I'm seeing five or six a day and I've linked it to the kids use on digital devices now before you say well they've got to learn those in school I'm not talking about the time they use the digital devices in classroom or study or learning I'm talking about the time they use it on social media and gaming so what do you do on social media and gaming you've got to be very aware of the periphery if you focus on the periphery you defocus Central if you defocus Central focus on the periphery what happens to pupil size pupil size will get bigger as you focus on Central people's size get smaller so if you vote keep focused you're going to see a larger pupil side if you defocus a lot during the day these kids are up to 12 1 2 o'clock in the morning on their social media it's like doing a VT procedure to defocus all day long and so I'm seeing these persistently they don't respond to accommodation they do respond to to pin line but they don't respond to accommodation so we're setting these kits up as parents but giving them devices to use to play games with because how many times have you been in a store in in line and a baby is screaming and you say oh is the baby would shut up the parent pulls out a phone a tablet gives it the baby and they immediately calm down just think of that so my method for prescribing is from a developmental procedure perspective how stable is it estimate the amount of movement add lens power till you get a good brightening and they begin there that's with high plus High minus High astigmatism only add lens power to you get to the first brightening and that then lets the child take over in their own stages of development if delayed they don't respond to the lenses initiate daily looking monitor frequently follow up how often do you see them for follow-up you don't prescribe the lens and say we'll see you in a year I want to see you in three months and maybe more often that I may need to modify the power depending on how they've responded to those lenses so think of just look as a view of the Continuum from exploration to fixation where they might be in their developmental process are they able to self-regulate to self-control focus at an age-appropriate level and when they're at a specific stage of development and shown retinoscopy if you'll just look we all have been trained in a limited manner with a retinoscope in other words refraction that's what it's for many people don't use it anymore because they have Auto refractor it gives you so much information take it to another level it's the continuous observation over several seconds that creates a mental video of the changes in the reflexes this allows you to determine if there are possible times where the reflex moves towards better engagement or away from better engagement of the task at hand and so I have several cases but I know we're pretty close and we want to get on to some hour um um to some questions and answers um and I will go on and I will wish everyone a happy and and meaningful to Shane it begins Monday and goes on through September the uh until October the 8th I also want to give you my email address uh uh and feel free if you have questions to email me um many times after a presentation like this it's hard to get back to you um but but feel free to to email me um get back to you simply because there's a number of people that have questions and I try to answer all of them if I can so I want to thank you very much and now we will go back into any questions and answers that folks have yes yes thank you so much still so that's a indeed Wonder appreciation with The Unborn Insight by the doctor is still and that personally I feel the quality of life might reflect from the retinoscopia that's retreating from the past and eyes always mysterious and there's still many thing to us so I hope our audience today have got enough knowledge regarding dust look Fitness copy procedure well uh now it's uh time for a discussion session to begin if you have any queries then you can come up with your question on our chat box so let me see if we have any questions maybe I guess the presentation is Thoroughly nailed I guess there is no question even though if you have any question from the redness copy bakra is still more than happy to answer it yeah and the whole key is just start you know if it's not Magic so we are waiting for one minute more so let's see I guess they don't have any questions actually well they they can feel free to they can feel free to email me um uh in in in doing uh and I will do my best to answer in this timely a manner as possible thank you anyways let me go back to one case here okay um foreign [Music] I want to go back to the these guys Jalen and Jonathan and and I wanna what I want to do is they're four-year-old twins and um they um Jonathan was all over the room I mean a typical four-year-old but Jalen just said sat in the chair he wasn't watching wasn't engaged and and of course parent both parents were with him and parents think well that's a um we just let them have their own personalities and Jalen is just much more quiet um he's not as much engaged as Jonathan Jonathan's active and we try to slow him down or whatever so what that you know what behaviors do you expect you almost expect them where one is the other one will be also so just think about any twins that you know and so Jonathan his retinoscopic reflexes look just like that but Jalen the one that's sitting in the chair looked like this and what we found with Jonathan was a plus 250 and with Jalen he was a plus nine so we've what we found was we we began to get that first brightening adding with plus fours with Jalen we didn't prescribe anything with Jonathan because plus 250 is not that far out of bounds for a four-year-old but we went with after six months of wearing the plus fours he comes in and through the plus fours you can barely tell the difference between Jonathan and Jalen after that so be very aware that that this refractive difference you might see you don't have to start with a full amount of refraction we didn't even start with half of it we started we're that first began to brighten and then guess what now Jalen is all over the room just like Jonathan and fortunately the parents recognize that that is a positive change rather than a negative change so there there are so many different um um patterns that you can see and there's one other one um anyway uh I'll um we'll go from there you know stop the share there we go all right um one other one um Paul Harris had seen a patient who was who was an accommodating isotrope and with he had prescribed the year before plus fours with a two ad and with a plus four he was traded distant with a plus six to add he was traded near that's good the student was Finding adapter more plus and said well it's an esotrope we probably need to do this well I take my retinoscope and I'm watching when we have the plus six he's perfectly aligned we've put the plus seven in front which many would have done from cycloplegia and he goes into an exitropia and so you just look gives you an opportunity to see how is that patient going to respond and react to the lenses if you just look yeah yes anyway all right so doctor I guess uh our audience do not have any question if they have they definitely mailed to you uh Mill to you and they also can directly text to us or they can also comment in our uh YouTube channel so maybe we can revert with you uh River with the answer in a few set days so once again it's our immense pleasure to have you with us today and uh I would like I I love to see you again in the future so before before opening uh today session if you have any good notes or if you want to share anything uh it's a good notes to us so uh you can see it out here well just again for for your uh celebration of the Shane coming up uh then I wish you all well and uh thank you for your time uh it it it's my always my pleasure to share because that's what I love to do um I think we've already talked about uh a brief uh one on autism so we can just look for that to come forward yes yes yes so I'm about to announce that we are also going to have a one more reason on the artistic passing so we definitely uh said this session very soon with the doctor still so once again happy to say to all of you here with I announce uh the close-up to the webinar hoping to see you all again on the next session we did Dr steel so stay safe stay connected thank you so much