ERROR OF REFRACTION

Outline
I. Introduction
A. Optics
B. Refraction
C. Emmetropia and Ametropia
II. General Symptomatology
III. Errors of Refraction
A. Hyperopia
B. Myopia
C. Astigmatism
D. EOR secondary to Aging
E. Congenital EOR
F. Iatrogenic EOR
IV. Measurement of EOR
V. Management
 OPTICS
LENS - a device
which causes
light to either
converge and
concentrate or to
diverge, usually
formed from a
piece of shaped
glass
OPTICS
 POSITIVE OR CONVERGING LENS

If the lens is biconvex or plano-convex, a collimated or parallel

beam of light travelling parallel to the lens axis and passing
through the lens will be converged (or focused) to a spot on
the axis, at a certain distance behind the lens.
 NEGATIVE OR DIVERGING LENS
If the lens is biconcave or plano-concave, a collimated beam
of light passing through the lens is diverged (spread)
The beam after passing through the lens appears to be
emanating from a particular point on the axis in front of the
lens
Diopter - is the standard unit to express
the refractive power of optical lenses.
It is the reciprocal of the distance,
expressed in meters, between a lens
and its focus (its focal length)

D = 1
f
D: diopter f: focal length (in
meters)
 OPTICS

D = 1/f

Example:
Focal length = 1 meterFocal length = 0.5 meter
Focal length = 0.25 meter
D = 1/1 D = 1/0.5 D = 1/0.25
D = 1 diopter D = 2 diopters D = 4 diopters
 OPTICS
MAIN OPTICAL
COMPONENTS
OF THE EYE:
• Cornea 43 D
• Lens 17 D

The anterior surface of the cornea is the major

refractive surface of the eye
 DEFINITION OF TERMS:
Emmetropia
• optical condition in which an eye does
not have an error of refraction
• Light from a distant object is focused on
the retina.
 AMETROPIA
optical condition in which parallel rays of
light from an object an infinite distance
from the eye does not come to focus
(form an image) exactly at the retina

Three general types: HYPEROPIA, MYOPIA AND

ASTIGMATISM
 Ammetropia

Axial ametropia - Abnormal length of

the globe
Curvature Ametropia - Abnormal
curvature of the cornea or the lens
Index Ametropia - Abnormal
refractive indices of the media
Abnormal position of the lens
GENERAL SYMPTOMATOLOGY

 Decreased visual acuity

Pin hole test

 Ocular discomfort

 increased sensitivity to
light, decreased efficiency,
various aches and fatigue

 Headache
 HYPEROPIA
• Farsightedness
The refractive power of the
cornea and lens are weak, or a
relatively short eyeball
• light from distant objects focus
behind the retina
Axial Hyperopia - the eyeball is
shorter than average
 Hyperopia

• Accomodation increases the

refractive power of the lens and
may compensate for hyperopia
Headache – due to excessive
sustained accomodation required
for clear vision
• Corrected by: Convex lenses
Hyperopia
 MYOPIA
• Nearsightedness
The refractive power of the cornea
and lens are too strong, or a
relatively long eyeball
• light from distant objects focus in
front of the retina
• Axial myopia - The eyeball is longer
than average
Curvature Myopia – due to abnormal
curvature of the cornea
(Keratoconus)
 MYOPIA

Corrected by: Concave lenses

 Astigmatism
 Abnormalities in corneal shape
A condition wherein the light rays entering
the eye focus on two or more separate
lines instead of one point
This happens when the refractive power is
not uniform in all meridians
Principal symptom: inability to have clear
image
Usually accompanied by myopia or
hyperopia
TREATMENT: Cylindrical Lens
 TYPES OF REGULAR ASTIGMATISM

1. Compound myopic
Both anterior and posterior focal lines are in front of the
retina
2. Simple Myopic
Anterior focal line is in front of the retina while posterior
focal line is on the retina
3. Mixed
Anterior focal line is in front of retina while posterior focal
line is at the back of the retina
4. Simple Hyperopic
Anterior focal line is on the retina while posterior focal line
is behind the retina
5. Compound hyperopic
Both focal lines are behind the retina
1. Compound myopic 4. Simple Hyperopic

2. Simple Myopic

5. Compound hyperopic

3. Mixed
 ERRORS OF REFRACTION 2O
Accomodation
TO AGING
- As object comes closer to the eye, lens
increases its power by altering its shape to
become more convex
- Accommodation = oculomotor nerve
stimulation (parasympathetic fibers)
Presbyopia
- manifest in 5th decade
- overcome by convex lens (Reading
glasses)
 PRESBYOPIA
• loss of accommodation due to aging
• Inability to read small print
Due to a reduction in the deformability of the lens
Corrected by: convex lenses (reading glasses),
bifocals or progressive lenses
ERRORS OF REFRACTION 2O
TO AGING
• “Second Sight” – Myopic shift
↑ density of lens nucleus (nuclear
sclerosis)
• ↑ refractive power → myopia
• distant vision → blurred and out of focus
near vision→ improves
 Anisometropia
• difference in refractive power
between the two eyes
major cause of amblyopia due to
failure of both eyes to
accommodate independently
• cause complications in refractive
correction due to:
differences in size of retinal images
(aniseikonia)
 CONGENITAL ERRORS OF
REFRACTION
 Hyperopic at birth (+1.50 D)

Corneal curvature is much steeper (6.59 mm

radius) at birth and flattens to adult curvature
(7.71 mm) by about 1 y/o

Cornea and lens grow and eyes elongate with

child growth thus,

HYPEROPIA --> EMMETROPIA OR MYOPIA

 IATROGENIC ERRORS
OF REFRACTION

 Cataract Surgery:
a. Tension in suture astigmatism
• Reduced by suture removal
• Induced astigmatism may persist

b. Removal of lens
• Artificial lens replacement
 MEASUREMENT OF EOR
1. Subjective method

- utilizes the ability of the individual to choose the lens that

gives him the best image

- a set of trial lenses is usually used

2. Objective method
Retinoscopy
• makes use of an instrument (retinoscope) that catches
the rays of light reflected at the patient’s retina whose
source comes from a mirror near the examiner’s eye
• useful in children, the low intelligent, semiconscious or
unconscious
 MEASUREMENT OF EOR
3. Cyclopegic Refraction
 drugs that paralyze accommodation are used to
measure accurately the refractive error the individual has
by the objective method

 usually performed in children

4. Keratometry
 measurement of the corneal astigmatism

 the curvature of the cornea is measured in various

meridians by reflected light on the cornea coming from
plates with various transparent configurations
 CORRECTION OF EOR
• Spectacle lenses
- safest method of refractive correction
- correct low degrees of ametropia
- bifocals: lens for both near and distant
vision in single frame
- progressive: graduated lens for objects
at any distance
- may be cosmetically unacceptable for
high degrees of ametropia
 Limitation of
•
Spectacles:
Most spectacles are worn
successfully. Problems occur with
increasing refractive power.
Cosmesis : convex magnify,concave
minify
• Distortion of objects in peripheral
vision
• Magnification of objects by highly
convex lenses
Weight
 Contact Lenses
DISADVANTAGES:
 worn beneath the eyelids
anterior to the cornea not appropriate for
children
 May be hard or soft
Maintenance
 Used to neutralize ametropia
Size
 To protect the healing cornea
Irritation
 To conceal unsightly
damaged eyes infection
 TYPES OF CONTACT LENSES:

1. Hard contact lenses 2. Soft contact lenses

 Offer clear, crisp

vision and are durable  More comfortable

 Correct major errors of  Require little

refraction adjustment to their use
 Easier to insert and
 Indicated for remove than hard lenses
correction of irregular
astigmatism little correction of
astigmatism
 Correct by changing Provide poorer corrected
the curvature of the vision than do hard lenses
anterior surface of the
eye
 Contact Lens Care
• Do not exceed the
recommended wearing time
Observe meticulous hygiene
• Do not clean with tap water or
saliva
• Remove if the eye becomes
sore or inflammed
• Remove soft lenses while
administering preservative
containing drops
 Complications of
Contact Lens use
 Giant papillary conjunctivitis – a condition in
which wearers of (usually) soft contact lenses
develop increasing ocular discomfort and itching

 Corneal vascularization - more common in

soft lens due to larger surface area covering the
part of the sclera and limbus

 Corneal ulceration

 Corneal infection
CORRECTION FOR EOR

• Keratorefractive Surgery

Radial Keratotomy
• Photorefractive Keratectomy (PRK)

Laser Assisted Intrastromal

Keratomileusis (LASIK)
 Keratorefractive
surgery
Radial keratotomy
• incisional technique
to alter corneal
curvature
• Cornea becomes
flatter as incision
heals
Excimer laser: shaves off ultra-thin
discs of corneal tissue to reduce
refractive power in myopia

PRK (photorefractive keratectomy)

LASIK (laser assisted in-situ
keratomileusis)
 Photorefractive Keratectomy
(Excimer laser)
• Uses an excimer laser to reshape the
outer surface of the cornea
Benefits:
-myopia
reliable(-2
correction of low to moderate
to -6 diopters)
- improvement in unaided visual acuity
• Complications:
- corneal haze
- post op pain
- loss of best-corrected visual acuity
- regression of effect
 LASIK
• corneal flap is created --- Excimer laser
reshapes the cornea
reliable correction of low to high myopia (-2 to
-12 diopters)
• Benefits
• Clear vision in 24 hours
Minimal post-op pain
• Limitation
Additional surgical step
 QuickTimeª and a
decompressor
are needed to see this picture.
CORRECTION OF EOR
• Intraocular lenses- phakic IOLs

• Clear lens extraction for myopia

- extraction of non-cataractous lenses

- eyes must be highly myopic in order for

the operation to be a success.
Lens
 Lens
• transparent,
avascular, biconvex
• Held in position by
zonules
• Surrounded by the
lens capsule
• 1 of the main
refracting surfaces of
the eye
• Has inherent
elasticity
 Lens
Cross section
 Causes of Cataract
• Age related
• 50 % in 65 – 74 yo
• 70 % in > 75 yo
• 3 main types
• Subcapsular
Cataract
• Nuclear Cataract
• Cortical Cataract
 Cataract
• Subcapsular cataract
• May be anterior or posterior
• Anterior type is associated with
fibrous metaplasia of the
anterior epithelium of the lens
• Posterior type is associated
with posterior migration of the
epithelial cells of the lens
 Cataract
• Nuclear Cataract
• Sclerosis and yellowing of the lens
nucleus
• Myopic shift “second sight”
• Advanced cases, nucleus becomes
opaque and brown (brunescent
nuclear cataract)
•
Cataract
Cortical cataract
• Hydropic swelling of the lens fibers
• Due to ionic changes in the lens fibers
• Formation of radial cortical spokes.
• Mature Cataract – Entire cortex becomes
opaque
• Hypermature Cataract – Leakage of
degenerated cortical material through the
lens capsule leaving the capsule wrinkled and
shrunken.
• Morgagnian Cataract – further liquefaction of
the cortex allows free movement of the
nucleus
 Cataract
Mature Cortical Cataract
 Cataract
Hypermature Cataract
 Cataract
Morgagnian Cataract
 Traumatic Cataract
• Direct Penetrating Injury - lens capsule ruptured
with hydration of lens fibers
• Blunt injury
• stellate or rosette shaped opacification
• Vossius ring – imprinting of iris pigment onto
the anterior lens capsule
• Electric shock – causes protein coagulation and
cataract formation
• Ionizing radiation - damage to actively growing
lens cells, younger patients more susceptible
Traumatic Cataract
Severe penetrating trauma
Traumatic cataract
Vossius ring
 Metabolic Cataract
Diabetes Mellitus
“Snow flake” Cataract
Inc. glucose in aqueous humor

Glucose enters lens by diffusion

Influx of water in the lens

Glucose converted to sorbitol

 Metabolic Cataract
• Galactosemia
• Autosomal recessive
• Inability to convert galactose to glucose
• Symptoms of Malnutririon,hepatomegaly,
jaundice and mental deficiency
• 75 % develops cataract few weeks after birth
• Inc. galactose and glactiol in the lens cells
• Nucleus and deep cortex opacified
• “Oil droplet” cataract
 Metabolic Cataract
• Wilson’s disease
• Autosomal recessive
• Disorder in copper metabolism
• Cuprous oxide (reddish brown pigment)
is deposited in the anterior lens capsule
• “sunflower cataract”
 Toxic Cataract
• Steroid induced cataract
• Posterior subcapsular cataract
• Phenothiazines
• Yellow brown granules on the anterior capsule
• Visually insignificant
• Miotics - cholinesterase inhibitors
• Anterior subcapsular vacuoles
• Amiodarone
• anterior subcapsular lens opacities
• Visually Insignificant
 Secondary Cataract

• Chronic Anterior Uveitis

Most common cause of secondary cataract

• Formation of posterior synechiae
• Thickening of anterior lens capsule
• Formation of fibrovascular membrane
Chronic Anterior
Uveitis
 Secondary Cataract
• Acute angle closure glaucoma
• glaukomflecken
 Congenital Cataract
• lens opacity present at birth

Rubella
• Maternal infection with rubella virus
• Cardiac defects, deafness, mental
retardation
• Cataracts are characterized by pearly
white nuclear opacification
Abnormalities of Lens Shape
and Position
• Coloboma-congenital absence of an eye
structure

Lenticonus-cone formation in the anterior

or posterior pole of the lens
• Microphakia-lens with a smaller than
normal diameter

Microsherophakia-not only small but

spherical
 Ectopia Lentis
• Marfan Syndrome’s
Widespread abnormality of connective tissue

• Autosomal Dominant

• Cardiac anomalies - aneurysm of the ascending

aorta.

Skeletal anomalies – limbs are inappropriately

long.

• Arachnodactyly - excessively long fingers

• Muscular underdevelopment

• Zonular attachment of the lens usually are intact but

become stretched and elongated
Marfan’s Syndrome
 Marfan’s Syndrome
• Ocular feature
• Bilateral lens subluxation – 80 % of
cases
 Ectopia Lentis
• Homocystinuria
Autosomal recessive
• Error of methionine metabolism
• Lenses are usually subluxated inferiorly
• Zoules have high levels of cysteine and
tend to be brittle
 Management of
Cataract
• Cataract Surgery

Intracapsular Cataract Surgery

• Extracapsular Cataract Surgery

Phacoemulsification
Extracapsular Cataract
Extraction
Phacoemulsification
 QuickTimeª and a
decompressor
are needed to see this picture.
After Cataract

YAG laser capsulotomy

 Complications of Cataract
Surgery
• Early

Inc intraocular pressure

• Iris prolapse
• Wound leak
• Acute Bacterial Endophthalmitis
Pupil Block
Iris Prolapse
Wound Leak
 Bacterial
Endophthalmitis
Complications of Cataract
Surgery

• Late

Toxic suture syndrome

• Corneal Decompensation

Irvine-Gass Syndrome
Toxic Suture
Syndrome
 Corneal
Decompensation
Irvine-Gass Syndrome

Cystoid
macular edema
Thank You!