REFRACTIVE ERRORS
NORMAL VISION
Light from the objects enter the eye
through the cornea → passing through the hollow
pupil → the amount of light is then regulated by
the iris → hits the lens which focuses the light
rays and projects it on to the retina. The retina
receives the light, converts it into neural signals
and sends this information to the brain for
processing
Embryologically, the retina is derived
from the two layers of invaginated optic vesicle:
with the outermost pigment epithelial layer and
the neural layer (consists of the other 9 strata;
from the rods and cones to the internal limiting
membrane). The retinal pigment epithelium
prevents the light from scattering which
degrades the quality of an image. The outermost
layer of the neural retina, which are the rods and
cones which converts the optical image into
neural activity → flows to the ganglion cells, with
its axons running towards the optic disc in the
nerve fiber layer and leaves the retina as the
optic nerve and transmits the retinal output to
the visual areas of the brain where visual
processing is completed.
(Rods – scotopic <low light levels>; more
numerous and light sensitive, but they can only
register grayscale)
(Cones – photopic <higher light levels>;
detect fine details and color – activated in bright
conditions; density highest at retina)
ELECTROMAGNETIC SPECTRUM
(Frequency – number of waves passing
by a point; Amplitude – maximum displacement
from the equilibrium position)
Light is EM radiation traveling in waves.
So, if in sound, the frequency corresponds to the
pitch while the amplitude to the volume; in light,
the frequency determines its hue while
brightness is regulated by the amplitude.
The VISIBLE LIGHT is the segment of the
EM spectrum that the human eye can view. The
cone-shaped cells act as receivers and are tuned
to the wavelengths in this narrow band of
spectrum.
The visible part of the spectrum to which
the retina is sensitive lies between 380-700 nm
with violet having the shortest wavelength and
red with the longest.
GEOMETRIC OPTICS
Light travels in a straight line but when it
reaches another medium, it will bend.
REFLECTION VS REFRACTION
- When light reaches an optical
interface, some light is reflected and
some is absorbed
- Incident, reflected and refracted
rays all reside in the plane of
incidence
- In the law of reflection, the angle of
incidence and angle of reflection is
equal
o the rays leave the surface at
the same angle at which
they struck it
INDEX OF REFRACTION
n= speed of light in air
speed of light in another medium
Refractive index (n) = c/v
:the higher the n, the slower
the light travels through the medium,
the more the light changes direction
When a ray enters a medium
with an increased index of refraction, it
slows down, the angle of refraction
decreases and bends towards the
normal line, as is in glasses.
CONVEX LENS
▪ As light rays enter the lens,
they turn slightly towards
the axis, as they leave the
lens and move back
through the air, due to the
curvature of the lens, the
rays are angled toward the
central axis and converge
towards the focal point.
(example is a magnifying
glass under the heat of a
sun directed towards a
leaf, the rays will converge
and burn of a single point)
Absolute index of refraction
Ratio of the speed of light in
vacuum : speed of light in the substance
Relative index of refraction
Ratio of speed of light in air :
speed of light in the substance
Convergence in the eyes
▪ cornea has a higher
refractive index
than air
▪ lens higher index
than vitreous
humor
▪ cornea and lens are
both convex in
shape
DIOPTERS
o reciprocal of the distance (in
meters) between a length
and its focus (focal length)
o if focal length is .20 m, its
powers in diopters is 5D =
(1/.20)
SCHEMATIC EYE OF GULLSTRAND
- a model which represents the basic
optical features of the eye
- assumes that the cornea is the only
refractive surface with an index of
1.33
- The refractive index for air is taken
to be 1.000
THREE-LENS CONCEPT
- More accurately conceptualizes the
human eye
- contrary to popular belief, the
CORNEA has almost no power of
refraction but only important in
shaping the anterior curve of the
AQUEOUS LENS
- CRYSTALLINE LENS n varies
throughout its thickness
- VITREOUS LENS major effect on
magnification
ACCOMMODATION REFLEX
At rest, distant objects are focused on
the retina in an emmetropic eye. To focus on
closer objects, increasing the curvature of the
lens allows the dioptric power of the eye to also
increase. The lens is under tension from the
suspensory ligaments.
During accommodation, ciliary muscle
contracts which relaxes the suspensory ligament
to allow thickening of the lens by assuming a
more convex shape suitable for focusing closer
objects.
It is usually accompanied by the
constriction of pupil by the contraction of
sphincter pupillae and the convergent eye
movement of the medial, superior and inferior
recti.
 HOW: Information from the retina
passing to the visual cortex permits the visual
areas to assess the clarity of objects. Cortical
efferent info then passes to the pretectal area,
then to Edinger Westphal nucleus whose axons
travel in the oculomotor nerve and synapse in
the ciliary ganglion. These short ciliary nerves
innervate the ciliary muscle which causes it to
contract.
HYPEROPIA (far sightedness)
VISUAL ACUITY TESTING
- Snellen’s chart can be used to test
visual acuity for people > 6 yo tested
at a distance of 20 ft
- Start by evaluating the vision
without wearing correction lenses
and test one eye at a time
- Start from the biggest letter going
down until he cannot read at least
half of the letters. Repeat the
process this time with the corrective
lenses
- E chart
EMMETROPIA VS AMETROPIA
PRESBYOPIA
Absence vs presence of refractive error
REFRACTIVE ERRORS
Symptoms
o Cardinal sign – decreased visual
acuity
o Asthenopia – easy fatigability of
eyes
o HA
MYOPIA (nearsighted)
- Rays of light converge in front of the
retina, causing a blurred image on
the retina
- Axial myopia
- Refractive myopia – more refractive
lens, greater bending, lesser
distance of convergence
- Corrected with a concave lens which
moves the image back to the retina
o The concave lens refracts
light rays outwards as they
leave the lens before
entering the cornea, thus
allows for correction
Etiology: not clear, genetic factors
- Rays of light from a distant object
focus behind the retina
- Corrected with a convex lens
Causes
1. Decreased refractive power
a. Posteriorly
repositioned lens
2. Decreased effective axial
length – retina is pushed
forward
a. Tumor
b. Orbital mass
- A loss of accommodation that comes
with aging due to a deposition of
insoluble proteins in the lens which
leads to a decrease in its elasticity
- Usually worse in dim light, early
morning and when fatigued
- At 44-46 yo, person will notice an
inability to read smaller prints or
discriminate close objects
- By 55, the degeneration stabilizes
but still persists
- An initially emmetropic – holds the
reading material farther away and
distance vision is unaffected
- Presbyopia occurs earlier in people
with hyperopia
ANISOMETROPIA Correction

- Condition in which the two eyes o Cylindrical lenses which

have an unequal refractive power allows a line of focus to
- Major cause of amblyopia (lazy eyes) form, which parallels the
as the eyes cannot accommodate axis of the lens
independently and the more o Rigid lenses
hyperopic eye is blurred o In keratoconus – corneal
- A difference in power of 2 diopters is transplant should be
an acceptable threshold to label the considered
condition as such ▪ A degenerative non-
inflammatory
ASTIGMATISM
disorder where
- Treatable imperfection in the cornea thins and
curvature of the eye that causes change to amore
blurred distance and near vision conical shape than
- Light rays aren’t refracted uniformly its normal gradual
in all meridians due to non-spherical curve
shape of cornea or lens, parallel rays ▪ Typically diagnosed
passing through these different in adolescence and
planes are brought to different severe state in 20s-
points of focus. 30s
- Occurs when either cornea or lens
SPECTACLES
has mismatched curves, parallel rays
of light focuses in multiple focal - Safest method of correction
points rather than a single one
CONTACTS
Classification
- Higher quality of optical image and
1. Regular astigmatism (2 lesser influence on the size of retinal
meridians) image than the spectacles
a. Power and
KERATOREFRACTIVE
orientation are
constant - Changing the curvature of the
b. Principal meridians anterior surface of the eye
are perpendicular
to each other LASIK
2. Irregular astigmatism Surgical procedure which reduces a
(different meridians) person’s dependency on glasses or contacts
a. Power and
orientation across 1. Laser is focused on one eye while
the pupil changes covering the other eye
2. Tiny marks made on the cornea to
indicate proper alignment for
creation of corneal flap
 3. Flap created through
microkeratome or femtosecond
laser and folded out of the way
4. Ablation of stromal blade with
excimer laser
5. Corneal flap put in place

ADVANTAGES: Mostly painless,

immediate 20/20 vision,

DISADVANTAGE: flap can fall down

Contraindications:

1. Unstable refractive error

2. < 21 yo
3. Ongoing active
inflammation of external
eye (conjunctivitis)
4. Pregnancy
5. Pacemaker
6. Keratoconus

LASEK

- Similar procedure with LASIK, but

instead of creating a flap, the outer
layer of cornea is loosened, moved
and reattached

PRK

- First corrective surgery to use laser

instead of a blade for the removal of
corneal tissue
- Similar to LASIK but there’s no flap
creation, instead the epithelial cells
on the eye surface is removed,
excimer laser is then used to
reshape the cornea then the
epithelium will grow

DISADVANTAGE: Recovery period is much longer

because the epithelium is completely removed