REFRACTION DISORDERS

COKORDA DEWIYANI PEMAYUN

DEPT OF OPHTHALMOLOGY
UDAYANA UNIV 2015
 INTRODUCTION

• Refractive errors  most common eye disorders

• Uncorrected refractive errors  leading cause of higher
prevalence of visual disorders in the world
(Shufelt et al, 2005)
• IndonesiaSurvei Indera Penglihatan Depkes RI (1996)
– refractive errors is the most common of eye diseases (22,1%)
(Farida Sirlan, 1998)
• Miopia  important cause of refractive disorders
– 5,6 % correctable blindness at school age
(Miller, 2003)
 REFRACTIVE ERRORS
• Emmetropia  absence of refractive errors
– When image of distant objects focuses in the retina in the
unaccomodated eye
– Naturally optimal focus for distance vision
• Ametropia  the presence of refractive errors
• Ametropia:
– Myopia
– Hiperopia
– Astigmatism
– Presbyopia
(Vaughan, 2004)
 MYOPIA (NEARSIGHTEDNESS)
• When image of distant objects focuses in front of the retina in
the unaccomodated eye
• Types of myopia:
– Axial myopia  the anterior – posterior eye diameter is
larger than normal
– Refractive / curvature myopia  the refractive elements
are more refractive than average
• Cause of myopia: anatomy of the eye, heredity, life styles
• Simple Myopia (School myopia)  school age, mild to
moderate myopia
• Pathologic Myopia  high myopia with vitreoretinal changes
• Symptom:
– Blurred at distance vision
– Tendency to squint to see distance object
– Like to read / extensive near work activity
• Treatment :
– weakest concave spherical ( minus ) lenses that give
maximal correction
• Complication:
– Retinal detachment  high myopia
– Strabismus
– Amblyopia
(Garcia, 1989)
 HYPEROPIA (FARSIGHTEDNESS)
 When image of distant objects focuses behind the retina in the
unaccomodated eye
 Types of hyperopia:
• Axial Hyperopia  the anterior – posterior eye diameter is
smaller than normal
• Refractive / curvature Hyperopia  the refractive elements
(cornea & lens) are less refractive than average
 Types of hyperopia based on the accomodation:
1. Latent hyperopia : hyperopia that completely corrected by
accomodation and is not apparent or measurable by
manifest refraction when no cycloplegic is used
• Types of hyperopia based on the accomodation:
2. Manifest hyperopia : hyperopia that is apparent or
measurable by manifest refraction
• Facultative hyperopia may be corrected by convex
lenses but also may be corrected by accomodation in
absence of lenses
• Absolute hyperopia  hyperopia that is not
compensated for by accomodation & need convex
lenses
• Symptoms of hyperopia:
– Blurred vision at near  noticeable if the person is tired,
indistinct printing and inadequate lightning
– Distance vision is impaired  for high hyperopia (>3.00D)
or older patients
• Symptoms of hyperopia:
– Headache in the frontal region  exaggerated by
prolonged use of the eye for near vision
– Uncomfortable vision called asthenopia
– Increase sensitivity to light
– Spasm of accomodation  cramp of cilliary muscle
accompanied by intermittent blurred vision. The blurred
vision clears if the patient is given minus lens
• Treatment of hyperopia:
– Strongest convex ( plus ) lenses that give maximal
correction
• Complication:
– Glaucoma ( shallow anterior chamber)
– Esotropia ( high hyperopia )
– Amblyopia ( especially in children, could be bilateral )
(Garcia, 1989, Vaughan 2004)
 ASTIGMATISM
• Term astigmatism  from Greek, means: without a point
• Condition in which rays of light are not refracted equally in all
meridians
• Astigmatic eye have 2 principal meridians that is usually at
right angles to each other
• Cause of astigmatism: abnormalities of the corneal shape
• Forms of astigmatism:
1. Regular astigmatism: two principal meridians with
constant power and orientation across the pupilary
aperture resulting in two focal lines  can be corrected
with cylinders
Focal points in astigmatism
 Forms of astigmatism:
2. Irregular astigmatism: the principal meridians are not
90° apart because of irregularity of the corneal
curvature  cannot be corrected with cylinders

 regular astigmatism:
• With the rule  the greater refractive power is in the
vertical meridian
• Against the rule  the greater refractive power is in the
horizontal meridian
• Oblique astigmatism  the principal meridians are more
than 20° from the horizontal and vertical meridians
Types of regular astigmatism
• Refractive types of astigmatism :
– Simple hyperopic astigmatism  one meridian is
emmetropic, the other is hyperopic
– Simple myopic astigmatism  one principal meridian is
emmetropic, the other is myopic
– Compound hyperopic astigmatism  both principal
meridians are hyperopic to different degree
– Compound myopic astigmatism  both principal
meridians are myopic to different degree
– Mixed astigmatism  one principal meridian is hyperopic,
the other is myopic
• Symptoms of astigmatism:
– Blurred vision  high astigmatism
– Good VA but asthenopia & frontal headache especially
while patient is doing precise work at a fixed distance with
prolonged periods low grade astigmatism
– Transient blurred vision at near, relieved by closing or
rubbing the eyes
– Tilting / turning of the head  high degree of oblique
astigmatism
– Squint to achieve a pinhole effect at distance and near
 The letters seen by astigmatic
patients

The uses of Jackson Cross

Astigmatic Clock Dial Cylinder for Astigmatism
• Test for astigmatism:
– Astigmatic Clock Dial
– Jackson Cross Cylinder

• Treatment of astigmatism:
– Cylinders lenses
– Rigid Gas Permeable (RGP) contact lens
– Toric Contact lens

(Garcia, 1989, Vaughan 2004|)

 PRESBYOPIA
• Loss of accomodation that comes with aging
• A person grows older, the lens larger & thicker  becomes
less elastic  decrease the ability to change shape
• Clinically noted after age of 40, usually around 44 or 45
years
• Symptoms:
– Receded distance for reading
– Inability to do close work (eg: Reading newspaper or
telephone directory)
– Excessive light required for reading
• Near Vision Test:
Jaeger Chart
• Treatment of presbyopia:
Convex (plus) lenses
• 40 years  + 1.00 Dioptri & Increase 0.50 D of every 5 years
of age

• Types of glasses for presbyopia:

– Reading glasses
– Bifokal lenses
– Trifokal lenses
– Progressive lens
(Garcia, 1989, Vaughan 2004,Guyton,2000)
 ANISOMETROPIA
• A difference of refractive error between the two eyes.
• A major cause of amblyopia because the eyes cannot
accommodate independently and the more hyperopic eye is
chronically blurred
• Difficult to give refractive correction due to aniseikonia and
oculomotor imbalance
• Aniseikonia  differences in size of retinal image
• Spectacle lenses 25 % aniseikonia  rarely tolerable
• Choices:
– Contact lens  6 % aniseikonia
– IOL  < 1 % aniseikonia
(Vaughan, 2004)
 CORRECTION OF REFRACTIVE ERRORS
• Spectacle lenses  safest method
• Contact lenses  soft CL, RGP, Toric CL
• Refractive Surgery
– Keratorefraktif surgery, eg: LASIK
– Refractive Lens Exchange
• Phakic IOL
• Clear Lens Extraction

(Vaughan, 2004)
 CONTACT LENS PROBLEM
Mild iritation,discomfort,corneal aberration ..>
Seriously potential Infection
Symptoms of this infection include irritation,
pain, redness, watery eyes or discharge from
the eye. A person may also become sensitive
to light and experience blurred vision..>blind
 CL PROBLEMS
• Predisposing factors
• Dry eye.
• Blepharitis.
• Atopic or allergic conjunctivitis.
• Poor lens care or inexperienced CL user.
• Prolonged lens wear including overnight wear.
• Smoking.
• Immunosuppression.
• Trauma
• Systemic disease.
spectacles
CLE
Contact lens

LASIK Procedure (Keratorefractive Surgery)

Phakic IOL
Thank You