REFRACTIVE ERRORS

INTRODUCTION:
Vision is an important sense for normal child development from the moment of birth.
Through sight, the child learns to read, move about the environment and interact with the
world. Impaired vision requires early assessment and intervention to ensure the child’s
optimal development.

Vision is an integral part of effective communication and learning. Because of its

significant impact on children’s life and impairment of vision is an important health problem.

A refractive error is a very common eye disorder. It occurs when the eye cannot
clearly focus the images from the outside world. The result of refractive errors is blurred
vision, which is sometimes so severe that it causes visual impairment.

ANATOMY OF EYE:

The eye is our organ of sight. The eye has a number of components which include:

 Cornea: clear front window of the eye that transmits and focuses light into the eye.
 Iris: colored part of the eye that helps regulate the amount of light that enters
 Pupil: dark aperture in the iris that determines how much light is let into the eye
  Lens: transparent structure inside the eye that focuses light rays onto the retina
 Retina: nerve layer that lines the back of the eye, senses light, and creates electrical
impulses that travel through the optic nerve to the brain
 Macula: small central area in the retina that contains special light-sensitive cells and
allows us to see fine details clearly
 Optic nerve: connects the eye to the brain and carries the electrical impulses formed
by the retina to the visual cortex of the brain
 Vitreous: clear, jelly-like substance that fills the middle of the eye
PHYSIOLOGY OF EYE:

Eye works very much like a camera. Light enters the eye through the cornea, the clear
front surface or “window” of the eye. As the light passes through the cornea, it is bent or
refracted. This bent light then travels through the pupil (the opening in the coloured iris) and
into the natural “crystalline” lens. The lens acts to fine tune the focus of light onto the retina.
The retina turns the light energy into electrical impulses that travel along the optic (eye)
nerve from the eye to the brain, where the image is interpreted. (Actually We see with our
brain, not with our eyes).

WHAT IS A REFRACTIVE ERROR?

Refraction is the bending of light rays as they pass through one object to another.

Refractive error means that the shape of the eye does not bend light correctly,
resulting in a blurred image.

Refractive errors occur when the shape of the eye prevents light from focusing
directly on the retina.

PREVALENCE OF REFRACTIVE ERRORS:

WHO estimates that 153 million people worldwide live with visual impairment due to
uncorrected refractive errors. This figure does not include the people living with uncorrected
presbyopia, which is likely to be quite significant, according to some early evidence.

Uncorrected refractive error is the leading cause of eye problem worldwide and the
second cause of blindness. Worldwide, there are about 2.3 billion people have refractive
error. Out of these peoples, only 1.8 billion have access to eye health care services which are
affordable correction. Children are more vulnerable group, because uncorrected refractive
error can result in to a dramatic impact on learning process and educational capacity.

TYPES OF REFRACTIVE ERRORS:

The four most common refractive errors are:

 Myopia (nearsightedness)
 Hyperopia (farsightedness)
 Astigmatism
 Presbyopia

Myopia or Near-Sightedness:

People with myopia, or near-sightedness, can see close-up objects clearly, but distant objects
are blurred.

 In myopia, light rays are brought to focus in front of the retina, i.e. falling short of the
back of the eye.
 This occurs either because the focusing power of the cornea and lens is very high,
because the eyeball is too long from front to back, or both.

Hyperopia or Far-Sightedness

In contrast, people with hyperopia, or far-sightedness, can see distant objects clearly, but
close-up objects are blurred.
  In hyperopia, light rays are brought to focus behind the retina.
 This occurs either because the focusing power of the cornea and lens is very low,
because the eyeball is short in length from front to back, or both.

Astigmatism:

Astigmatism is a blurring of vision due to an irregular shape in the cornea or lens. In eyes
without astigmatism, the cornea and lens have a more or less similar curvature in all
directions. This allows light to be focused to a single point on the retina.

People with astigmatism have more curvature in one direction, or meridian, than in another
(see Figure below), so that light is not able to focus on a single point on the retina. This
results in blurring of vision at all distances. Normally, the surface of the cornea is rounded,
much like a basketball; with astigmatism, however, the cornea is shaped more a like an
American football.
In the vast majority of cases, astigmatism is a result of the shape of the cornea (and
sometimes the lens) that is present since birth.

Presbyopia:

Presbyopia is the gradual loss of eyes' ability to focus on nearby objects. It's a natural,
often annoying part of aging. Presbyopia usually becomes noticeable in early to mid-40s and
continues to worsen until around age 65.

We may become aware of presbyopia when child start holding books and newspapers
at arm's length to be able to read them.

CAUSES OF REFRACTIVE ERRORS:

Anyone can have refractive errors, but people were at higher risk if they have family
members who wear glasses or contact lenses.

Refractive errors can be caused by:

 Eyeball length (when the eyeball grows too long or too short)
 Problems with the shape of the cornea (the clear outer layer of the eye)
  Aging of the lens (an inner part of the eye that is normally clear and helps the eye
focus)

SYMPTOMS OF REFRACTIVE ERRORS:

The most common symptom is blurry vision. Other symptoms include:

 Double vision
 Hazy vision
 Seeing a glare or halo around bright lights
 Squinting
 Headaches
 Eye strain (when your eyes feel tired or sore)
 Trouble focusing when reading or looking at a computer

Some people may not notice the symptoms of refractive errors. It’s important to get eye
exams regularly.

HOW IS REFRACTIVE ERROR DIAGNOSED?

 Visual acuity testing by using snellen chart

 Refraction

 Comprehensive eye examination

Visual acuity testing and refraction (determination of refractive error) as needed should be
done every 1 or 2 yr. Screening children's visual acuity helps detect refractive errors before
they interfere with learning. A comprehensive eye examination, done by an ophthalmologist
or an optometrist, should accompany refraction.

Refractive error is diagnosed by an ophthalmologist or

optometrist by using a machine called a phoropter, which is
placed in front of the patient's eyes to trial, or evaluate, various
strengths of eyeglass prescriptions.
The patient participates by informing the doctor which of the various eyeglass strengths
provides the clearest image, which allows the doctor to fine-tune the prescription until the
final correct prescription is reached.

In patients who cannot provide the necessary feedback (including people with physical and
cognitive disabilities and very young children), the doctor can assess the refractive error via a
process called retinoscopy. To do a retinoscopy, the doctor uses a device called a retinoscope
to shine a light into the patient's eye. The doctor then trials the various lenses while observing
the light reflection, or reflex, in the patient's eye to determine the correct prescription
strength.

TREATMENT FOR REFRACTIVE ERRORS:

Refractive error is generally corrected by glasses or contact lenses that help focus the image
correctly on the retina. There are also a variety of refractive laser surgeries. Most of these
work by changing the curvature, and thus power, of the cornea. These include the following:

 photorefractive keratectomy (PRK)

 laser in-situ keratomileusis (LASIK)
 laser epithelial keratomileuisis (LASEK)
 epiLASIK

Non surgical Vision Correction Options:

1. Glasses:

Eyeglasses are the simplest and safest way to correct refractive errors. The eye
doctor will prescribe the right eyeglass lenses to give the clearest possible vision.

Eyeglass lenses work by bending light — just like the lens and cornea in eye. The
eyeglass lens bends light to make it focus correctly on retina (the light-sensitive layer of
tissue at the back of the eye). Different eyeglass lenses can correct different errors caused
by problems with the cornea, lens, or shape of the eye.

Glasses make vision clearer while wearing them — but they don’t change eyes at all.
Wearing glasses doesn’t make eyes weaker or vision worse.
What are the different types of eyeglasses?

People with different refractive errors need different types of eyeglass lenses to see clearly.

 Reading glasses can help people with presbyopia read or see things up close. We can
buy reading glasses at drug stores and convenience stores. Even though we can get
reading glasses without a prescription, it’s important to get regular eye exams to make
sure we’re seeing as clearly as possible.
 Single vision prescription lenses correct near vision or distance vision, but not both.
In nearsightedness, single vision lenses can help to see things far away. In
farsightedness, they can help to see things up close.
 Multifocal prescription lenses correct both near and distance vision. They can help
people who have trouble seeing things up close and far away. For example, people
who have both presbyopia and nearsightedness can use multifocal lenses for reading
and driving.

 Bifocals correct near vision on the bottom and distance vision on the top
 Trifocals correct middle-distance vision in between the near and distance vision
areas
 Progressive lenses are multifocal lenses that don’t have a visible line between
the near and distance vision areas

2. Contacts:

Contact lenses sit on the surface of eyes and correct refractive errors. The eye
doctor will fit for the right lenses and will show how to clean and wear them safely.

Contact lenses are thin lenses that sit on top of the cornea (the clear outer layer of the
eye). They correct refractive errors to make vision clearer — just like eyeglasses.

What are the different types of contact lenses?

When you’re choosing contact lenses, there are 3 main things to know: whether they’re soft
or hard, how long you can wear them, and how often you need to replace them.

Soft or hard
  Soft contact lenses are much more common than hard lenses. Because they’re soft
and flexible, they can be more comfortable and easier to get used to.
 Hard contact lenses can make your vision crisper than soft lenses, and they’re less
likely to tear. But they may take longer to get used to, and they can be harder to clean
and take care of than soft lenses.

Daily wear or extended wear

 You keep daily wear contact lenses in all day and take them out at night. You need
to clean and disinfect daily lenses every night. It’s not safe to sleep in daily lenses —
it can put you at risk for serious eye infections.
 You can leave extended wear contact lenses in overnight. Depending on the brand,
you can wear them for as long as 30 days and nights before taking them out. Extended
wear lenses can be convenient — but they may also make it more likely that you’ll get
a serious eye infection.

Single use or reusable

 You wear single-use contact lenses for one day, then throw them away at night. The
next day, you put in a brand new pair. You don’t need to clean or disinfect single-use
lenses.
 You take reusable contact lenses out at night, clean them, and wear them again the
next day. Depending on the brand, you’ll need to replace them with a new pair after 7
to 30 days.

What are the benefits of contact lenses?

Some people prefer to wear contacts instead of eyeglasses.

Contacts stay in place and improve peripheral (side) vision, so they can be easier to wear
when being active or playing sports. They don’t fog up the way glasses do, so they may also
be more convenient for people who work or spend a lot of time outdoors in cold weather —
or indoors in places that are very cold, like a walk-in refrigerator or freezer.

If you wear contacts, you can wear non-prescription sunglasses to protect your eyes from UV
rays. You can also wear contacts with UV protection built into the lenses.
What are the risks of contact lenses?

Contact lenses are not risk-free. If you don’t use them the right way, you can get serious eye
conditions, including corneal ulcers (sores) and infections.

You can lower your risk by:

 Disinfecting and storing your contacts correctly — every time

 Only wearing your contacts for the amount of time your doctor recommends
 Taking out your contacts before you shower, swim, or go in a bath or hot tub

When to get help

Take out your contacts if you have any of these symptoms:

 Eye pain
 Red eyes
 Light sensitivity (when light hurts your eyes)
 Sudden blurry vision
 Unusually watery eyes
 Discharge (unusual fluid leaking out of your eyes)

If the symptoms don’t go away or they get worse, call your eye doctor.

Refractive Surgical Procedures:

Refractive surgical procedure intended to reduce a person's dependency on glasses

or contact lenses. The most common refractive surgical procedures performed today are:

LASIK (Laser In-Situ Keratomileusis):

It is a surgical procedure intended to reduce a person's dependency on glasses or

contact lenses. In this procedure a thin hinged flap of cornea (the cornea is the transparent,
dome-shaped window covering the front of the eye) is created and lifted to one side in order
to allow laser treatment to the deeper part of the cornea. The flap is then repositioned in its
original position.
 This is an outpatient procedure that usually takes 10 - 15 minutes per eye. The actual
laser treatment usually takes a few seconds.

EpiLASIK ( Epithelial Laser-Assisted In-Situ Keratomileusis:

EPI LASIK) – it is a procedure, which combines the advantages of PRK and LASIK,
Epi lasik involves the use of a microkeratome, similar to LASIK, however only the
superficial epithelial layer of cornea is separated as in PRK and this flap is replaced following
the reshaping of the cornea using the Excimer Laser.

PRK ( Photorefractive Keratectomy ):

Which was the original kind and is still sometimes used. It involves gently scraping
some surface cells off the cornea and then using a laser beam to re-shape it.

Post-Refractive surgery instruction:

 Mild / Moderate tearing is expected after the procedure.

 A sense of foreign body presence and irritation are common.
 Small red spots on the white surface of the eye – occasionally appear.
 Sensitivity to bright light / corneal Haze – on the day of the procedure.

Do’s

 Instillation of eye drops as per the prescriptions.

 Cleaning of the lid margin gently with sterile tissue from the following day.
 Have normal food / no restrictions.
 Can have below neck bath from the following day.
 Blink your eyes gently & frequently on the day of treatment.
 Can read, watch TV and use computer, couple of days after the treatment.
 Use sunglasses when you go out and plastic shield while sleeping for 2 weeks.

Don’ts

 Do not expose your eyes to dust / pollution.

 Do not touch or rub your eyes.
  Do not take head bath or splash water into the eye and face for 2 weeks.
 Do not keep your eyes open for long duration.
 Do not clean the eye on the day of your treatment.
 Do not swim for one month.
 Do not use eye cosmetic /eyeliner for 2 months.
 Avoid exercises for 1 week.
 Avoid self-driving for 1 week.

COMPLICATIONS OF REFRACTIVE ERRORS:

Uncorrected Refractive Error is one of the leading cause amblyopia that exposes children to
poor school performance. It refrain them from productive working lives resulting in severe
economic and social loses in their latter adulthood lives.

Uncorrected refractive error is the leading cause of eye problem worldwide and the second
cause of blindness.

PREVENTION OF REFRACTIVE ERRORS:

Refractive errors cannot be prevented, but they can be diagnosed by an eye

examination and treated with corrective glasses, contact lenses or refractive surgery. If
corrected in time and by eye-care professionals, they do not impede the full development of
good visual function.

SUMMARY:

Refractive error is an eye disorder, in which the patient has a distorted eye shape and vision.
This eye disorder is not a preventable condition but is treatable. A simple eye test can help in
the diagnosis of this condition, and timely correction will save the patient from any additional
medical complexities.

REFERENCES:

 https://www.sankaranethralaya.org/lasik-corner.html
 https://www.visionaware.org/info/your-eye-condition/guide-to-eye-
conditions/refractive-error-and-astigmatism/125
 https://www.umkelloggeye.org/conditions-treatments/refractive-errors
 https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-
diseases/refractive-errors
 https://www.who.int/features/qa/45/en/
 https://www.medanta.org › refractive-error