Neurobehavior and Special Senses 2017

TUTOR’S GUIDE

Case 6
Decreased Visual Acuity
ec. Refraction Error

Date :
27, 30 November 2017

Senin dan Kamis

Faculty of Medicine
Universitas Padjadjaran Bandung
2017-2018

0
Neurobehavior and Special Senses 2017

TUTOR’S GUIDE

Block Title : NBSS

Week Title : Special Senses ( the eye )
Week Schedule : One week (two times)
Week Theme : Refractive error

Learning Objective

After completing the case, the students should be able to:

1. Describe Anatomy of refraction media (C2)  Anatomy
2. Explain Physiology of Lens (metabolism) and Lens accomodation  Physiology
3. Explain Basic optical system of vision (CN II pathway) (C4)  Physiology
4. Describe anatomy & physiology (pathway) of CN III, IV, VI
5. Describe histology of the eye
6. Describe sign and symptoms of refraction error (C3)  Ophthalmology
7. Explain visual acuity examination and refractive error correction (C4) 
Ophthalmology
8. Describe definition and classification of refractive error (C2)  Ophthalmology
9. Explain management of refractive error (C3)  Ophthalmology
10. Explain early detection for refractive error (C3)  Ophthalmology

Case Synopsis
Andi, a 17 years old boy, came to primary health care with his mother due to Andi’s
teacher report that he had difficulty in distance visual acuity. He has a decreased
vision without any abnormality within the eyeball. After being corrected with
negative lenses he can clearly see the chart. He is having a myopia refractive error
and having a prescription spectacles (minus lenses).

Reffereces
Vaughn. General Ophthalmology. 2005
Tortora. Principles of Anatomy and Physiology. 11th ed. 2006

1
Neurobehavior and Special Senses 2017

Mind mapping

2
Neurobehavior and Special Senses 2017

Page 1 Ocular anatomy

Andi, a 17 years old boy, came to primary health care with his mother due to Andi’s
teacher report that he had difficulty in reading the whiteboard since 6 months ago.
Ocular
His mother also noticed that when physiology
watching the television, Andi always sit near the
television at home.

Instructions : Basic optical system of vision

1. What are Andi’s problems?
2. Generate a list of Hypothesis and state the rationale for each!
3. What further information do you need?
Pathophysiology Refractive error Pathogenesis
Problems :
 17 years old boy
 Gradually difficulty in reading to the whiteboard
 near distance when watching television
Signs & Symptoms
Hypothesis :
Gradually reduce vision because of:
a. Refractive error: myopia, hypermetropia, astigmatism, presbiopia
b. Opacity of the refraction
Eye media, can be due to disorder of:
examination
 the cornea: scar
 the humor aqueous: inflammation reaction, blood
 the lens: cataract
 the vitreous: inflammation,
Diagnosis blood, fibrotic tissue
c. Disease of retina: age related macular degeneration (ARMD), diabetic
retinopathy, hypertension retinopathy
d. Open angle glaucoma
Management
Guiding questions :
1. Which part of the eyes that involved in vision? (refractive media)
Cornea – Anterior chamber – lens – vitreous (review anatomy of the eye)
Each organ have different refraction index

2. Explain how lens accommodate to focus light from object at different

distance (accommodation reflex)!
Far objects :
light from narrow range of angles – ciliary muscles relax, lens stretched – less
convex, less bending of light

Near objects :
light from wide range of angles – ciliary muscles contract, lens recoils – more
convex, more bending of light

3
Neurobehavior and Special Senses 2017

3. Explain the image formation in the eye.

Visual pathway
Basic optical system of vision

Anatomy of the eye

4
Neurobehavior and Special Senses 2017

Retina & optic disc

Visual pathway

1. The axon of retinal ganglion cells in one eye exit the eyeball at the optic disc
and form the optic nerve (N.II)
2. At the optic chiasm, axon from the temporal half of each retina continue
directly to the lateral geniculate nucleus of the thalamus on the same side

5
Neurobehavior and Special Senses 2017

3. Axon from the nasal half of each retina cross the optic chiasm and continue
to the opposite lateral geniculate nucleus of the thalamus
4. Each optic tract consist of crossed and uncrossed axons that project from the
optic chiasm to the lateral geniculate nucleus of the thalamus on one side
5. Axon of thalamic neurons form the optic radiations as they project from the
thalamus to the primary visual area of the cortex on the same side

Physiology of vision (transformed light energy into impulse)

Basic optical system of vision

6
Neurobehavior and Special Senses 2017

Page 2
The PHC doctor examination showed the visual acuity on the right eye (RE) was 6/20
ph 6/9 and the left eye (LE) was 6/12 ph 6/9. The eye movement was normal. The
palpation pressures of the eyes were normal. The external eye examination with
flashlight examination showed normal bulbus conjunctiva, clear cornea, normal
depth anterior chamber, normal pupil reaction, and clear lenses in both eyes.
Funduscopy examination revealed within normal limit in both eyes.

Instructions :

1. What are Andi’s problems?

2. Do your hypotheses change?
3. What further information do you need?

7
Neurobehavior and Special Senses 2017

Problems :
1. Distance Visual acuity

Hypothesis :
1. Refraction error:
a. Myopia
b. Hypermetropia
c. Astigmatism

Guiding questions :
1. What is the meaning of vision 6/20 ph 6/9 or 6/12 ph 6/9 (visual acuity
interpretation)?

2. What is the function of pinhole examination?

3. What is refractive error? Emmetropia? Ametropia?

4. What is classification of refractive error and give explanation (distance

vision).
Myopia, Hyperopia, Astigmatism

5. What is refractive error for near vision?

1. Visual acuity
Normal vision is 20/20 (feet) 6/6 (meters)
Visual acuity is always tested separately for each eye
The first number represents the testing distance in feet (meters) between the chart
and the patient. The second number represents the smallest row of letters that the
patient can read.
Ex: 20/40 (6/12)  The patient’s eye can only read from 20 feet (6 meters) letters
large enough for a normal eye to read from 40 feet (12 meters).
Tools: Snellen chart
Visual acuity notation:
PH : pin hole
CF or FC (1/60 – 5/60) : counting finger or finger counting
HM (1/300) : hand motion
LP (1/) : light perception with or without projection (4 quadrants)
NLP : no light perception

2. Pinhole Examination
If the patient needs glasses or if his or her glasses are unavailable, the corrected
acuity can be estimated by testing vision through a “pinhole”. Refractive blur is
caused by multiple misfocused rays entering through the pupil and reaching retina.
This prevents formation of a sharply focused image. Pinhole prevents nost of the
misfocused rays entering the retina  only a few centrally aligned focused rays will
reach the retina, resulting in a sharper image.

8
Neurobehavior and Special Senses 2017

3. Refractive error
Refractive error is optical abnormality which needs corrective lenses to be in proper
focus for distance.
Emmetropia  naturally in optimal focus for distance vision
Ametropia  myopia, hypermetropia, astigmatism  need corrective lens

4a. Myopia
When the image of distant objects focuses in front of the retina in the
unaccommodated eye  myopia (nearsightedness)
If the eye is longer than average  axial myopia
If the refractive elements are more refractive than average  curvature myopia or
refractive myopia.

4b. Hyperopia (hypermetropia/farsightedness)

Unaccommodated eye would focus the image behind the retina.
If the is shorter than average (reduced axial length)  axial hyperopia
If the refractive elements are less refractive than average  refractive hyperopia

4c. Astigmatism
The eye produces an image with multiple focal points or lines.
The usual cause of astigmatism is abnormalities of corneal shape. The crystalline lens
may also contribute.

5.Presbyopia
The loss of accommodation that comes with aging to all people. A person with
emmetropic eyes (no refractive error) will begin to notice inability to read small print
or discriminate fine close objects.

Page 3
The PHD doctor gave the correction for refractive error and gave the glasses
prescription.
VOD: 6/20 S-1.50 = 6/6
VOS: 6/12 S-1.00 = 6/6

9
Neurobehavior and Special Senses 2017

Instruction :
1. Explain the management of refractive error.
2. Give patient education about the refractive error.

1a. Myopia
Concave spherical (minus) lenses are used to correct the image in myopia. These
lenses move the image back to the retina.

1b. Hyperopia
Convex spherical (plus) lenses are used to correct the image in hyperopia. These
lenses move the image back to the retina.

1c. Astigmatism
Astigmatic errors can be corrected with cylindrical lenses, frequently in combination
with spherical lenses.

10