1. If the patient wears glasses for close work, these should be used.

2. Hold Gulden fixation stick 40 cm from the patient’s face at eye level and place the +2.00 lens in front of the patient’s eyes.

3. The test is initially performed binocularly.

1. Ask the patient to try to get the letters clear and single as quickly as possible.

2. Instruct the subject to report (say “clear”) as soon as the letters are clear.

3. When the letters are reported to be clear, quickly flip the flipper so the minus side is before the same eye, again instructing the subject to read the letters and report when the letters appear clear or if they disappear.

4. Continue alternating sides of the flipper lenses for 1 minute, calculating the cycles per minute achieved (1 cycle = plus and minus).

5. Repeat the procedure monocularly if the patient is unable to pass binocularly. The only difference in monocular testing is that the patient only has to report when the target is clear (diplopia is no longer an issue).

6. Record the cycles per minute. Record if one side (plus or minus) of the flippers was more difficult, or if neither side was more difficult.

1. The differences in this age group are the working distance and the lens power to be used.

2. We suggest using the amplitude scaled facility approach discussed earlier in this chapter (Table 1.7).

3. When using this method, select the lens power and working distance based on the amplitude of accommodation.

4. For example, if you are working with a 32-year-old patient with an amplitude of accommodation of 7.0 D, you would use ±1. 0 0 D lenses and the target would be placed 32 cm from the patient.

1. The patient can complete 18 flips in 1 minute. This equals 9 cpm.

2. If the patient cannot clear −2.00 at all, record as 0 cpm, fails minus.

1. Patient is out of the phoropter, wearing his or her prescription.

2. The examiner sits opposite the patient, at eye level with the target, at either the patient’s habitual reading distance (ask the patient) or Harmon distance.

3. Illumination must be sufficient so that the patient can easily see the words or pictures on the MEM card.

4. Select the appropriate MEM card corresponding to a grade or reading level closest to that of the patient. Card selected can be low demand (large print) or high demand (small print).

1. Instructions: “With both eyes open, please read the words (or name the pictures) on the card out loud.”

2. Make a sweep with the retinoscope and try to estimate the amount of “with” or “against” motion for each meridian. Repeat the sweeping motion as many times as needed. Repeat the measurements for the other eye.

3. To verify the estimation, a neutralizing trial lens is interposed very briefly, in front of one eye at a time, as the retinoscope light passes across the eye. If the motion is “with,” interpose a plus lens. If the motion is “against,” interpose a minus lens. When the true amount of lead or lag is measured in that meridian, a neutral response will be seen with the lens in place.

1. Try to estimate the lens needed to neutralize the motion.

2. When using lenses, try to minimize the amount of time the lens is placed in front of the eye.

1. Have the patient stand directly in front of the examiner.

2. No instructions are given to the patient to move or not to move his or her head.

3. Two modified Gulden fixation targets are used and held at the Harmon distance (the distance from the patient’s elbow to the middle knuckle) or no farther than 40 cm from the patient.

4. The examiner holds the targets so that each target is about 10 cm from the midline of the patient.