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Refraction

Refraction Dr. Edia Asmara Soelendro, SpM Dr. Pandji A. Akbar, SpM

Dr. Edia Asmara Soelendro, SpM Dr. Pandji A. Akbar, SpM

Refraction
Refraction

Consists of :

General Optics The optical system of the eye Clinical anomalies : refractive errors

Optic
Optic

Dioptri (D) : Lens power unit, is an inverse of focal distance in meters

D = 1/f

1 D lens, parallel light will be directed into focal spot in 1 meter distance

2 D = 1/f

---->

f =

?

If f = 25 cm , ----> D =

?

• Parallel rays will be converged to the focus ---> Plus lens (+)
• Parallel rays will be converged to the focus
---> Plus lens (+)
• Parallel rays will be converged to the focus ---> Plus lens (+) • or will
• Parallel rays will be converged to the focus ---> Plus lens (+) • or will

or will be diverged as if it comes from the focus ----> Minus Lens (-)

• Parallel rays will be converged to the focus ---> Plus lens (+) • or will

Principles

Principles • Rays coming from distance > 5 m parallel rays • Rays coming from distance

Rays coming from distance > 5 m parallel rays

Rays coming from distance < 5m divergent rays

• Spherical lens – Is a lens with the same curvature diameter in all meridians
• Spherical lens
– Is a lens with the same curvature diameter in
all meridians

Spherical Convex (+)

• Spherical lens – Is a lens with the same curvature diameter in all meridians Spherical

Spherical Concave (-)

A convex lens may be regarded as a series of prisms bases toward the middle of the lens

• A convex lens may be regarded as a series of prisms bases toward the middle

A concave lens may be regarded as a series of prisms apex toward the middle of the lens

• A convex lens may be regarded as a series of prisms bases toward the middle
• A convex lens may be regarded as a series of prisms bases toward the middle
• Prismatic Effect that occur on eye glasses explain :
• Prismatic Effect that occur on eye glasses
explain :

Against motion with (+) Lens With motion, with (-) Lens

Spherical Lens :

Plus sphere : Convex

characteristic : makes larger and nearer images

+2 +2 Biconvex
+2
+2
Biconvex

0

+4 Plano K
+4
Plano K
+5 -1
+5
-1

Concave K

Minus sphere : Concave

– Characteristic : makes smaller and farther images
– Characteristic : makes smaller and farther
images

-2

• Minus sphere : Concave – Characteristic : makes smaller and farther images 0 -4 +1

-2

0

• Minus sphere : Concave – Characteristic : makes smaller and farther images 0 -4 +1

-4

+1

• Minus sphere : Concave – Characteristic : makes smaller and farther images 0 -4 +1

-5

Bi Concave

Plano K

Convex K

Parallel rays will be centered or diverged from the focus

Cylindrical Lens • Is a kind of lens that have two meridians that are perpendicular to

Cylindrical Lens

Cylindrical Lens • Is a kind of lens that have two meridians that are perpendicular to

Is a kind of lens that have two meridians that are perpendicular to each other

The meridian that has no power is called the axis

The other meridian, has the power

Spherocylindrical Lens

– Is a combination between spherical lens and cylindrical lens
– Is a combination between spherical lens and
cylindrical lens

Example :

S + 2.00 D

C + 1.00 D X 90 0

+ 2.00 + 2.00
+ 2.00
+ 2.00

+

0.00 + 1.00
0.00
+ 1.00
• Spherocylindrical Lens – Is a combination between spherical lens and cylindrical lens – Example :

+ 2.00

 

0.00

   

+ 2.00

+ 1.00

+ 2.00 + 3.00
+ 2.00
+ 3.00
• Transposition – Methods :
• Transposition
– Methods :

Sphere : Sum with algebra ways SPH + CYL

Cylinder : replace power marks (Neg axis change 90 degrees

Pos),

Example : S + 2.00

S + 3.00

C + 1.00 X 90

0

0

C - 1.00 X 180

Eye as an Optical Instrument

Eye as an Optical Instrument • Refraction media : – Cornea n = 1.33 – Humour
Eye as an Optical Instrument • Refraction media : – Cornea n = 1.33 – Humour

Refraction media :

 

Cornea

n = 1.33

Humour Aqueous

n = 1.33

Lens

n = 1,41

Vitreous body

n = 1.33

Haziness on refraction media --> disturbances of vision

• Power of refraction of the eye ball
• Power of refraction of the eye ball

Totally

: 60 dioptri

Cornea

: 40 dioptri

Lens

: 20 dioptri

• Accommodation Process
• Accommodation Process

Capability of adding the refraction power of the eye, by increasing the convexity of the lens

normal : rays that come from > 5 m - distance object regarded as parallel light; the eyes are in relax position, the images are focused right on the retina (fovea centralis)

For object at less than 5 • meters distance, the rays do not come parallel but

For object at less than 5

For object at less than 5 • meters distance, the rays do not come parallel but

meters distance, the rays do not come parallel but divergent. If the eyes are still in relax position, the images will be focused behind the retina. So the

object will be seen blurred.

These images must be moved forward so it will be

focused on the retina by increasing the convexity of the lens. This process is called accommodation

process.

• This accommodation process happens as a result from the contraction of M. ciliaris in the
• This accommodation process happens as a result from the contraction of M. ciliaris in the

This accommodation process happens as a result from the contraction of M. ciliaris in the ciliary body

• These reflexes also happen during the accommodation process :
• These reflexes also happen during the
accommodation process :

Accommodation Miosis Convergents

• These reflexes also happen during the accommodation process : – Accommodation – Miosis – Convergents

Near Reflex

Refraction Anomalies

Refraction Anomalies • Normal : Emetropia • Anomalies : (ametropia) • Myopia • Hypermetropia • Astigmatism

Normal : Emetropia Anomalies : (ametropia)

Myopia Hypermetropia Astigmatism Presbiopia

Emmetropia

– Is the condition when the parallel rays focused exactly on the retina of the eye
– Is the condition when the parallel rays focused
exactly on the retina of the eye in relax condition
---> the visual acuity is maximum
• Emmetropia – Is the condition when the parallel rays focused exactly on the retina of
• Ametropia – Is the condition when the parallel rays are not focused exactly on the
• Ametropia
– Is the condition when the parallel rays are not
focused exactly on the retina of the eye in relax

condition.

The focal point may be behind or in front of the retina

Hal 47, 4.2 Duke Elder
Hal 47, 4.2 Duke Elder

Myopia

– Refractive condition in which, with accommodation completely relaxed, parallel rays are brought to a focus
– Refractive condition in which, with
accommodation completely relaxed, parallel
rays are brought to a focus in front of the retina.

Myopic eye : refractive state over plus power

• Myopia – Refractive condition in which, with accommodation completely relaxed, parallel rays are brought to

Factors that causing myopia :

– Axial : The antero-posterior axis of the eye ball > normal • in this case,
– Axial : The antero-posterior axis of the eye ball > normal
• in this case, the refraction power of the cornea, lens and the lens
position are normal.
The eye usually looks like proptosis

Curvature :

The size of the eye ball ---> normal, but there is a increasing of the cornea/lens curvature

The change of the lens e.g. : intumescens cataract

Increasing of the refraction index

could occur on Diabetic patient

Changes of the lens location

changes of the lens position to the anterior after glaucoma surgery

lens subluxation

• Clinical findings : – Farsightedness are blurred, nearsightedness are normal – Asthenopia
• Clinical findings :
– Farsightedness are blurred, nearsightedness are normal
– Asthenopia

On high myopia : hemeralopia occurred caused by periphery retinal degeneration

Floating spots visualization caused by vitreous degeneration

screw up the eye lids together, in order to get a better vision

On high myopia ----> proptosis simulation, deep Anterior Chamber

• Funduscopy : Tigroid fundus ---> thin retina and the choroid, myopic crescent arround the papilla
• Funduscopy : Tigroid fundus ---> thin retina and
the choroid, myopic crescent arround the papilla
area, sthaphyloma posterior
• Funduscopy : Tigroid fundus ---> thin retina and the choroid, myopic crescent arround the papilla
• Funduscopy : Tigroid fundus ---> thin retina and the choroid, myopic crescent arround the papilla
• Complication : – Commonly occurred on high myopia 1. Degenarated and liquefied vitreous
• Complication :
– Commonly occurred on high myopia
1. Degenarated and liquefied vitreous
  • 2. Retinal detachment

  • 3. Pigmentation changes + Macular bleeding

  • 4. Strabismus

Myopia classification :

< 3.00 D

= low myopia

3.00 - 6.00 D = moderate myopia

> 6.00

D

= high myopia/gravis

Treatment :

– Low and moderate myopia : full correction with weakest spherical lens that give the best
– Low and moderate myopia : full correction with
weakest spherical lens that give the best visual
acuity

Example :

VOD = 5/60

S -2.50 D = 6/7

S -2.75 D = 6/6

S -3.00 D = 6/6 S -3.25 D = 6/7

The glasses are S - 2.75 D

On high myopia, usually full correction are not given due to headache that may occurred. If necessary, reading glasses can be given --->

bifocal glasses

• Prognosis : – Simplex/stationer, after puberty will be constant – Progressive myopia, the myopia will

Prognosis :

Simplex/stationer, after puberty will be constant

Progressive myopia, the myopia will be continuously higher and complication may

occurred

Hypermetropia • Is a refraction anomaly that without accommodation parallel rays will be focused behind the
Hypermetropia
Is a refraction anomaly that without accommodation
parallel rays will be focused behind the retina
Divergent rays from near object, will be focused farther
behind the retina
Hypermetropia • Is a refraction anomaly that without accommodation parallel rays will be focused behind the
• Etiology :
• Etiology :

Axial ---> eye ball diameter < N Deminished convexity of cornea/lens curvature Decreasing Refractive index Changed lens position

• Clinical manifestation : – H. Manifest ---> is detected without paralazing accommodation and is represented
• Clinical manifestation :
H. Manifest ---> is detected without
paralazing accommodation and is represented

by the strongest convex glass needed , the patient sees most distinctly. It correspons to the amount of accommodation which he relaxes when a convex lens is placed before the eye. Devided into two types :

Facultative : Can be overcome by an effort of accommodation

Absolute : Can not be overcome

– Total Hipermetrop : detected after the accommodation has been paralyzed with cylcopegic agents – Latent

Total Hipermetrop : detected after the accommodation has been paralyzed with cylcopegic agents

Latent Hypermetrop : is the diference of the total hypermetrop with the manifest

hypermetrop

Hypermetrop Latent Hypermetrop Hypermetrop manifest
Hypermetrop
Hypermetrop

Latent Hypermetrop

Hypermetrop manifest

• Clinical finding : – Nearsightness are blurred
• Clinical finding :
– Nearsightness are blurred

High hypermetropia at old age : farsightedness also blurred

Astenophia accommodative (eye strain)

Children : high hypermetropia usually occurring convergent strabismus (convergent

squint)

• Treatment :
• Treatment :

If foria/tropia not present, apply strongest positive spherical lens that give the best visual

acuity

If foria/tropia present, total hypermetrop correction. If necessary : bifocal eye glasses

astigmatism

astigmatism • Refractive condition of the eye in which there is a difference in degree of

Refractive condition of the eye in which there is a difference in degree of refraction in diferent meridian, each will focused parallel rays at a different point. The shape of the images :

Line, oval, circle, never a point

astigmatism • Refractive condition of the eye in which there is a difference in degree of
• Manifestation : – Regular astigmatism
• Manifestation :
– Regular astigmatism

Difference in the degree of refraction in every meredian.

Two principles meridian :

Maximmum refraction Minimum refraction

• Manifestation : – Regular astigmatism • Difference in the degree of refraction in every meredian.

Right angle to each other

Irregular astigmatism

Difference in refraction not only in different meridians, but also in different parts of the same meridian.

• Etiology of astigmatism :
• Etiology of astigmatism :

Corneal curvature disturbances ---> 90% Lens curvature disturbances ---> 10%

Type of Astigmatism :

Ast. M. Simplex

Ast. H. Simplex

Ast. M Compositium

Ast. H Compositium Ast. Mixtus

C-2.00 X 90

0

0

C+2.00 X 45 S-1.50 C-1.00 X 60 S+3.00 C+2.00 X 30 S+2.00 C-5.00 X 180

0

0

0

Ast. M. Simplex Ast. H. Simplex Ast. M Compositium Ast. H Compositium Ast. Mixtus
Ast. M. Simplex
Ast. H. Simplex
Ast. M Compositium
Ast. H Compositium
Ast. Mixtus
Presbiopia
Presbiopia

Physiological changes because accommodation capability is lowering at old age

Accommodation

16 10 6 2 10 20 40 50 60
16
10
6
2
10
20
40
50
60

Age

• Presbiopia correction : – – 45 years old 40 years old S + 1.00 D
• Presbiopia correction :
– 45 years old
40 years old
S + 1.00 D
S + 1.50 D

50 years old 55 years old

60 years old

S + 2.00 D S + 2.50 D

S + 3.00 D

Consider the type of previous/history work

Tailor Architect Weld engineer

Refraction Examination Technique

• Subjective :
• Subjective :

Snellen chart/projector, alphabet , inverse E, picture, Landolt ring

Trial lens Trial frame

Objective :

Children, incooperative, difficult correction, strabismus :

Ophthlamoscopy Retinoscopy Refractometer

• Subjective – Check firstly just one eye : OD – Distance : 5 or 6
• Subjective
– Check firstly just one eye : OD
– Distance : 5 or 6 meters
– VOD : …
...
(basic
right eye visus)

a. Trial and error

apply S + 0.50, better visus , add

S+ until visus = 6/6

S +0.50, lower visus, change to S -, increase S - until visus = 6/6

S +/- not working ----> cylindrical With astigmatism dial, stenoplic slit, cross cylinder astigmatism dial :

Blurred line ----> C negative lens axis

• One by one fogging – S + sp. Lens --> blurred vision, step by step
• One by one fogging
– S + sp. Lens --> blurred vision, step by step distracting

---> best sp.

Nearsightedness/read

Both eyes at one time at required distance : use jaeger

chart

– Example :
– Example :

I. AVOD 2/60 S - 3.50 = 6/6 AVOS 3/60 S - 3.00 = 6/6 II.AVOD 2/60 S - 3.00 = 6/7

AVOS 3/60 S - 2.75 = 6/7

– Example : I. AVOD 2/60 S - 3.50 = 6/6 AVOS 3/60 S - 3.00

ODS 6/6 headache, eye strain

ODS 6/6 w/o headache, eye strain

read ADD S + 1.50 Give Eye Glasses according to II

Objective

– Use cyclopegic 1. Ophthlamoscopy : papilla clearly seen with which lens
– Use cyclopegic
1. Ophthlamoscopy : papilla clearly seen with
which lens
  • 2. Retinoscopy :

Ordinary ---> light source outside streak -----> light source inside

  • 3. Refactometer

Computerized Lensmeter principal

• Ideally :
Ideally :

Subjective Objective with cyclopegic Subjective once more without cyclopegic

Lens meter

Measuring lens power Measuring focus distance

• Measuring Pupillary Distance – drop the flashlight light onto both eyes, the light is coming
• Measuring Pupillary Distance
– drop the flashlight light onto both eyes,
the light is coming from in front of the

patient, The patient look at the observer forehead or the light ----> measure the

distance of light spot between OD and

OS ----> as near pupil distance Far distance :

add 2 mm ---> for pupil distance less than 60 mm.

Add 3 mm ---> for pupil distance more than 60 mm

• Eye Glasses • Monofocal • Bifocal • Progressive
• Eye Glasses
• Monofocal
• Bifocal
• Progressive

Eye Glasses Prescription, the components are :

Which eye (OD or OS)

Power of the lens (

+ or - , Power, axis)

ADDE for reading Pupil distance far/near Name of the patient

Binocular Optical Defects • Anisometropia :
Binocular Optical Defects
• Anisometropia :

Condition wherein the refractions of the two eyes are an equal

variation :

Myopia

M

M.

E.

H.

E.

H.

H.

M.

H

Binocular Optical Defects • Anisometropia : – Condition wherein the refractions of the two eyes are

Antimetropia

• Vision in Anisometrop – difference < 2.50 D : still get fusion + single binocular
• Vision in Anisometrop
– difference < 2.50 D : still get fusion + single
binocular vision

difference > 2.50 D : fusion difficulties ---->

weak eye suppression ---> amblyopic alternans vision : left and right alternate

Aniseikonia :

The difference of shape and size of the images between right and left eye

Limitation of the eye glasses

– cannot applied for anisometropia more than 2.50 Dioptri – anisometropia causing aniseikonia • Contact lens
– cannot applied for anisometropia more than 2.50
Dioptri
– anisometropia causing aniseikonia
Contact lens :

Hard ---> rigid lens Soft

Indication :

High anisometropia irregular astigmatism Front asymmetry, orbit Aniridia Descemetocele Sports Cosmetics