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vertex distance
matters when +/- 3.00D

should be btw 14 -17
2nd ret w/VA worse than 20/30
& no Improvement w/Pinhole

What next
Monocular Red Green Sphere Check
Cyl VA rule
1 line / -1.00DC off
Sphere VA rule
1 line / 0.25D off
distance btw Red & Green light
0.50D
During the Monocular Red-Green Sphere check, they are looking at red & glance to green -->
Over minus

--> leads to under minus/missing Cyl
Dark Focus
-0.75 to 1.50

leads to over minus
What are the sphere check methods
Step Down

Monocular Red-Green Sphere Check
Sphere Check to use on amblyope
Red Green Sphere Check
Don't do Red Green Sphere Check
not totally dark

Protan

Clean projector
Problem with Step Down Sphere Check
tends to over minus
JCC most sensitive
0.25D
JCC easy to resond
0.50D
MPMA types
A: First Fuzzy

B: 2nd Step Down Method

C: 3 Clicks Method
MPMA Procedure A: First Fuzzy Steps
add + until fuzzy, if lost 2+ letters back up.

more than 3 clicks --> check cyl power
MPMA Procedure A: Pros/Cons
less prone to over minus

can over plus (make sure they can read the line)
MPMA Procedure B: 2nd Step Down Method's Steps
After JCC, Refog to 20/40

Keep adding Minus till they can read 20/20
MPMA Procedure B: 2nd Step Down When to use
Use if you over minused Rx,
Acc Spasm, Hyperope --> Humphriss better

High Myope,
MPMA Procedure C: Three Click Method
smallest line blur out

then add Plus till they can read smallest line (Monocular Subjective should be 3 -0.75)
MPMA Procedure C: when to use
poor responder

Technique not as stable
When would you Rx the MPMA
Latent Hyperopia

Convergence/Accommodation Excess

1st time Rx
MPMA & Balance
MPMA is a type of Monocular Balance (estimate of Balance)

sets limit for BVA lens

Final Rx should be w/in -0.75D
Balancing Types
Monocular

Bi-Ocular

Binocular
Monocular Balancing Techniques
MPMA

Alt Occlusion
Bi-Ocular Balancing Techniques
Eyes see separate images

1. Traditional Prism Dissociated Blur

2. Goodwin Technique

3. Red Green Prism Dissociated Balance
Binocular Balancing Techniques
images fused; unstable Pt

1. Vectographic Refraction

2. Humphriss Immediate Refraction
Purpose of balance
match Acc Stimulus for both eyes
only Balance Technique that doesn't require equal VAs
Red Green Prism Dissociated Balance
Steps for Traditional Prism Dissociated Blur Balance
Chart 20/15 - 50
20/30 Blur, Isolate 20/40
3 down Right/ 3 Up Left

+ 0.25 to clearer eye
isolate 30 & repeat
Traditional Prism Balance Exophoria
5 BD Right

10 BI Left
Traditional Prism Balance Esophoria
5 BD Right

6 BO Left
Bino 20/20
duing Final Stepdown (After Balance)
1st lens to read 20/20

Binocular equivalent of MPMA

BVA ~ -0.25 to -0.75
MPMA Balance: Indications
Presbyopes

CLS over refractions
Alternate Occlusion Balance
trail frame refraction (wheelchair)

check other balance

Monocular Refraction must be close & VAs equal

done at 40 fog, MPMA, BVA