REFRACTIVE ERRORS

Optics of Eye

 Eye is like a photographic camera

 Cornea & Crystalline Lens are two strong
refractive media
 Total Diaoptric Power – +58.6D
 2/3 refraction at cornea, 1/3 at Lens
 Nodal point in posterior part of Lens
 Axial Length 24 mm
Optics of Eye

 Accommodation is a phenomenon which

increases the converging power of eye by
augmenting refractive power of crystalline
lens by increasing its curvature
 Increase in Dioptric Power of Lens
 Constriction of Pupil
 Convergence
Optics of Eye

 Amplitude of Accommodation (A) =

Refractive power of Eye in fully accommodated state
(P) – Refractive power of eye at rest ( R )
A= P – R
 Child with near point 7 cm
A = 100/7 – 1/∞ = 14 - 0 = 14 D
 Amplitude of accommodation decreases with age
Refractive Error

 Emmetropia – Absence of Refractive Error

“is that dioptric condition of eye in which with
accommodation at rest the parallel rays
come to focus on the light sensitive layer of
retina”
 Ametropia- is a condition in which parallel
rays of light do not come to a focus upon
light sensitive layer of the retina.
Refractive Error

Types of Ametropia
 Axial Ametropia – Abnormal axial length of globe
(Too Long – Myopia, Too short – Hypermetropia)
 Curvature Ametropia- Abnormal curvature of
refracting surface of cornea/ lens
 Index Ametropia- Abnormal refractive index of
Lens
 Abnormal position of the lens-
Forward displacement – Myopia
Backward displacement - Hypermetropia
Refractive Errors

Common Refractive Errors

- Myopia
- Hypermetropia
- Astigmatism
Myopia

 Also known as ‘Short Sight’

 Definition
‘Myopia is that dioptric condition of the eye in
which with accommodation at rest incident
parallel rays come to a focus anterior to the
light sensitive layer of the retina’
Myopia

Types of Myopia
 Axial Myopia – Most common
 Curvature Myopia - Keratoconus
 Index – Nuclear cataract
 Abnormal position of Lens – Forward
displacement of Lens
Myopia

Clinical Classification
 Developmental
 Simple
 Pathological
Myopia

Developmental Myopia
 Present since birth
 Uniocular
 High degree Myopia ( – 10 D)
 Does not Progress
Myopia

Simple Myopia
 Usually develops during 5 – 10 yrs of age
 Progresses during adolescence
 Do not progress beyond adolescence
 Rarely progresses beyond 5 – 6 D of Myopia
 No degenerative changes in the fundus
Pathological Myopia

 Pathological Myopia is a progressive myopia

associated with degenerative changes in the fundus
 Appears in childhood usually between the age of
5-10 yrs
 Steadily increases up to the age of 25 yrs or beyond
 Myopia may reach up to -15 to -25 D
 Hereditary
 Racial predilection- common in Jews and Japanese
Pathological Myopia

 Essentially disturbance of growth on which

are imposed degenerative phenomenon
 Condition is genetically predetermined
 Endocrine factors, nutritional factors, debility
excessive near work are incidental
Myopia

 Increase in axial length mainly affects

posterior equator. Part of eye anterior to
equator will be normal
 Elongation occurs mainly due to
degenerative changes of ocular coats
Myopia

Symptoms
 Indistinct distant vision
 In high myopia discomfort after near work
 Disproportion between convergence and
accommodation can lead to exotropia
 Eyes sensitive to light
 Seeing Black spots / Flashes of light
Myopia

 Eyes are prominent

 Anterior chamber appears deeper
 Pupils are large
Pathological Myopia

Fundus Changes
 Myopic Crescent
 Chorio retinal degeneration
 Foster Fuchs spots (Black spots at macula)
 Small haemorrhages at macula
 Breaks in Bruch’s Membrane – Lacquer cracks
 Posterior staphyloma
 Peripheral degenerations like Lattice degeneration
 Vitreous becomes fluid, Floaters seen
 High risk of retinal detachment
Treatment of Myopia

 Spectacle correction (Concave Lenses)

 Contact lens
 Refractive surgery - LASIK
Hypermetrolpia

 Definition
‘Hypermetropia is that dioptric condition of
the eye in which with accommodation at rest
incident parallel rays come to a focus
posterior to the light sensitive layer of the
retina’
Hypermetropia

Types of Hypermetropia
 Axial – Short eyeball Most common
 Curvature Hypermetropia – Cornea Plana
 Index – Old age, cortical cataract
 Abnormal position of Lens – posterior
displacement of Lens
Hypermetropia

 Manifest Hypermetropia
Facultative – That part of manifest hypermetropia
which can be overcome by accommodation
Absolute -That part of manifest hypermetropia which
can not be overcome by accommodation
 Latent Hypermetropia – That portion of total
hypermetropia which can only be revealed under
complete cycloplegia
 Total Hypermetropia – Latent + Manifest
Hypermetropia

 Rarely exceeds 6-7 D

 Have to accommodate both for distant and near –
over action of ciliary muscle – asthenopia- eye strain
 Pain, burning sensation, feel dry, frequent blinking,
redness of eyes, headache
 H/o recurrent stye, chalazia ,blepharitis
 Convergent squint
 In adults early commencement of presbyopia
Hypermetropia

 Eye is small, AC shallow, Pupil small

 Fundus – Small disc, pseudopapilloedema
Bright reflex
 More prone for angle closure glaucoma
Hypermetropia

Treatment
Spectacle correction- convex lens
Contact Lens
Refractive surgery LASIK
Aphakia

 Absence of crystalline lens (Surgical/Trauma)

 Eye is highly hypermetropic
 No accommodation
 Vision counting finger close to face
Ocular Exam
Operation scar at upper limbus
Peripheral Iridectomy
Iridodonesis
Jet Black pupil
Aphakia

Treatment
 Spectacle correction +10 D
 Contact lens
 IOL implanatation
 Epikeratophakia
Aphakia

Disadvantages of spectacle correction

 Image magnification of 30%
 If opposite eye normal – Diplopia
 Lack of physical coordination
 Spherical aberration Pin Cushion Effect
 Ring Scotoma– Jack in the box phenomenon
 Reduced visual field
 Cosmetic
Aphakia

Advantages of contact lens

 Image magnification 6% Binocular vision
possible
 Full field of vision
Disadvantage
 Difficulty in wearing
Aphakia

Advantages of IOL
 No image magnification
 Full field of vision
 No maintenance
Presbyopia

 Receeding of near point of vision due

reduction in amplitude of accommodation
with age
 Age related
 With age lens becomes less plastic and lens
Capsule less elastic
 Amplitude of accommodation gradually
diminishes with age
Presbyopia

 Difficulty in near vision

 Usually manifests at the age of 45 yrs
 In hypermetrope it may occur early
 Patients report when near point of vision has
receeded beyond comfortable working
distance
 Treatment – convex lens for near vision
Astigmatism

 Astigmatism is that condition of refraction in

which a point of light cannot be made to
produce a punctate image upon the retina by
any spherical correcting lens
Astigmatism

Types
 Regular Astigmatism
Greatest and least curvature of cornea
are at right angles to each other
 Irregular Astigmatism
Corneal surface is irregular and light is
refracted irregularly without any
symmetry
Astigmatism

Regular Astigmatism
 With the rule –Vertical meridian is more
curved
 Against the rule – Horizontal meridian is
more curved
 Oblique – Principle meridians are not at
90ºor180º
Regular Astigmatism

 Simple Astigmatism
- Simple myopic
- Simple hypermetropic
 Compound Astigmatism
- Compound Myopic
- Compound Hypermetropic
 Mixed Astigmatism
Astigmatism: Sturm conoid
Astigmatism

Aetiology
 Regular Astigmatism
Congenital
Cataract surgery
Traumatic wound at limbus
Keratoconus
Subluxation of lens
 Irregular Astigmatism
Corneal ulcer
Traumatic corneal scar
Astigmatism

 Symptoms – Diminished vision

- Asthenopia (Eye Strain)
 Treatment
-Spectacle correction with Cylindrical /
sphero cylindrical lens
-Contact lens
-Refractive surgery
Refractive Surgery

Factors affecting refraction of eye

 Axial length
 Corneal Curvature
 Refractive Index of Lens
Refractive Surgery

Indication
- Job requirement
- Contact sports
- Cosmetic

Disadvantage
Permanent not reversible
Accuracy less
Refractive Surgery

 Corneal Procedure
Radial Keratotomy
Intrastromal corneal Ring
PRK
LASEK
LASIK
Epikeratophakia
Keratophakia
 Phakic IOL
 Clear Lens extraction
Refractive Surgery

Radial Keratotomy
- Radial incisions are given in peripheral cornea
- Peripheral cornea becomes weak and bulges
forwards results flattening of central cornea
- Associated with complications
- Not done these days.
Refractive surgery
Refractive Surgery

Intra Corneal Ring

Intra corneal rings are placed in peripheral cornea
Ant surface of the cornea is lifted over the ring
Results in compensatory flattening of the central
cornea
Refractive Surgery
Refractive surgery

Photorefractive Keratectomy (PRK)

Done for Myopia
Corneal epithelium is scrapped
Excimer Laser applied to ablate the
corneal stroma for desired level
Epithelium is allowed to heal on its own

Painful post op period

Refractive Surgery

Laser Subepithelial Keratomileusis (LASEK)

 18% alcohol is applied to cornea
 Epithelial flap is cut
 Laser ablation done
 Epithelial Flap replaced
Refractive Surgery
Refractive Surgery

Laser in situ Kertaomileusis(LASIK)

Corneal Flap of 150 µ raised
Laser ablation done
Flap is replaced back

Painless, good results. Few complications

Refractive Surgery
Refractive Surgery

 Epikeratophakia- Donor corneal button is

sutured over the anterior surface of cornea
 Keratophakia – Donor corneal button is
placed in the stromal pocket of recipient
cornea
 Done mainly for aphakic correction
 Presently for those patients who cannot be
implanted with IOL
Refractive Surgery
Refractive surgery

Keratophakia
Refractive surgery

 Phakic Intraocular lenses

Anterior Chamber
Iris supported
Posterior Chamber
 Indicated in myopia/ hypermetropia
 Associated with complication like glaucoma,
cataract formation uveitis
Refractive Surgery