Local appropriate refraction training

The Pacific Eye Institute (PEI) is a regional training centre for Pacific doctors, nurses and technicians. PEI offers locally relevant training in programs ranging from 6 months (Postgraduate Certificate in Eye Care) to 1 year (Postgraduate Diploma in Eye Care, Postgraduate Diploma in Ophthalmology). Master level training is also available for select graduates of Diploma programs. Students are responsible for a variety of competencies including refraction. This paper compares and contrasts three methods of conducting refraction, which are appropriate for different cadres and clinical contexts in low income countries. Clinical, educational, practice and community advantages and disadvantages of each are discussed. The three methods are: 1) The gold standard method of refraction i.e. objective measurement (retinoscopy) followed by subjective measurement (sphero-cylindrical refraction). 2) Monocular subjective measurement of each eye (“Best Vision Sphere” (BVS)), followed by binocular balance of the eyes. These methods are taught in a 5 week classroom and clinical laboratory setting, and also included in 20 weeks of supervised clinical rotations. 3) A simpler method of subjective refraction (Binocular Subjective Refraction (BSR)) is presented in a 2 week classroom and clinical laboratory setting, and also included in 12 weeks of supervised clinical rotations. The BSR is conducted binocularly and lens choices are based on the power of ready-made spectacles available. The relative reliability and validity of the outcomes of these three methods will be discussed. As well, implementation issues: training requirements, different levels of competencies, refraction equipment and suitability for differing levels of community access will be considered.