ERRORS OF REFRACTION
HYPEROPIA & PRESBYOPIA
Dr. M. Usman Sadiq
Refraction
Lenses
POSITIVE or CONVERGING (CONVEX)
NEGATIVE or DIVERGING (CONCAVE)
Eye as a Camera
Eyelids- Shutter
Cornea- Focusing System
Lens- Focusing System
Iris- Diaphragm
Choroid- Dark Chamber
Retina-Light Sensitive Film
Emmetropia
43 diopters
AXL = 24-25mm
15 diopters
Accomodation at Rest
Ametropia
A refractive error is present
Myopia • Near Sightedness
Hypermetropia • Far Sightedness
Astigmatism • the curvature of the cornea and/or lens is not spherical
and therefore causes image blur on the retina.
Presbyopia • Loss of accommodative ability of the lens resulting in
difficulties with near tasks
SCENARIO 1
A 16 year old female presented with gradual
decrease of distant vision in both eyes. On
examination Visual Acuity is 6/12 in right eye and
6/36 in left eye which improved with pinhole test.
What is the diagnosis?
Hypermetropia
Hypermetropia
Parallel rays of light coming from infinity are
focused behind the retina and image is blurred.
Etiology
Axial - Decreased AP diameter of Eyeball
Curvature - Flattening of Cornea, Lens or both
Index - old age, diabetics under treatment
Positional - Posteriorly placed lens
Absence of lens - Aphakia
Total Hypermetropia
It is the total amount of refractive error, estimated
after complete cycloplegia with Atropine/Cyclopen.
Latent Manifest
Hypermetropia Hypermetropia
Latent Hypermetropia
Corrected by inherent tone of ciliary muscle
Usually about 1D
High in children
Decreases with age
Revealed after abolishing tone of ciliary muscle
with atropine/cyclopen.
Manifest Hypermetropia
Remaining part of total hypermetropia.
FACULTATIVE HYPERMETROPIA
Corrected by patients accommodative effort
ABSOLUTE HYPERMETROPIA
Residual part not corrected by patients
accommodative effort
Total
Hypermetropia
Manifest Latent
Hypermetropia Hypermetropia
Facultative Absolute
Hypermetropia Hypermetropia
Symptoms
Principal symptom is blurring of vision for close work
Symptoms vary depending upon age of patient &
degree of refractive error
Asymptomatic
Asthenopic symptoms
Defective vision with asthenopia
Defective vision only
Convergent Squint
Signs
VISUAL ACUITY : Defective
EYEBALL: Small or Normal in size
CORNEA : may be smaller than normal. There can
be CORNEA PLANA.
ANTERIOR CHAMBER : may be shallow
LENS: could be dislocated backwards
A Scan Ultrasonography (Biometry) will reveal short
axial length
Normal Age Variation
At birth +2D to +3D Hypermetropia is present.
Gradually diminished by the age 5-10 years.
COMPLICATIONS
Amblyopia (LAZY EYE)
High Hypermetropia
Unilateral Hypermetropia
Treatment
NONSURGICAL
Spectacles – Convex Lens (Plus Lens)
Contact Lens
SURGICAL
Photorefractive Keratectomy (PRK)
Laser insitu Keratomileusis (LASIK) Cornea
Conductive Keratoplasty
PRK v LASIK
PRK LASIK
Young Children (<6 Years)
Some degree of hypermetropia is physiological so
no correction needed.
Treatment required if error is high or strabismus is
present.
In children error tends normally to diminish with
growth so refraction should be carried out every
six month and if necessary the correction should
be reduced, otherwise a lens which is
overcorrecting their error may induce an artificial
myopia.
SCENARIO 2
A 42 year old male patient comes with complaints
of gradual painless visual loss which is for near.
What is the most probable diagnosis?
PRESBYOPIA
Presbyopia
Presbyopia
The physiologic loss of accommodation in the eyes in
advancing age.
Depositition of insoluble proteins in lens in advancing
age leads to decrease in elasticity of lens which
ultimately decreases accommodation.
Around 45 years of age , accommodation become
less than 3D
Reading is possible at 40-50 cm
Difficultly reading fine print , headache , visual fatigue
Increasing Near Point of Accommodation
with Age
Age (years) Distance (cm)
10 7
20 10
30 14
40 20
50 40
Symptoms
The need to hold reading material at arm's length.
Blurred near vision
Headache
Fatigue
Symptoms worse in dim light
Treatment
Spectacles – Covex (Plus) Lens
Only for Near Work
Anisometropia
The optic state of eye where both eyes have equal
refraction is known as Isometropia.
If both eyes have unequal refraction, this condition
is called Anisometropia.
Refractive correction often leads to different image
sizes on the 2 retinas (aniseikonia) which may lead
to diplopia.
Aniseikonia depend on degree of refractive anomaly
and type of correction.
Treatment is done with spectacles (Aniseikonic
Glasses) & Contact Lens.
