Refraction

dr Intan Dwi Rahayu SpM

 Refraction

• Consists of :
– General Optics
– The optical system of the eye
– Clinical anomalies : refractive errors
 Optic

• Dioptri (D) : Lens power unit, is an inverse

of focal distance in meters
D = 1/f
• 1 D lens, parallel light will be directed into
focal spot in 1 meter distance
2 D = 1/f ----> f = ?
If f = 25 cm , ----> D = ?
 Parallel rays will be converged to the focus --->
Plus lens (+)

 or will be diverged as if it comes from the focus

----> Minus Lens (-)
 Principles

• Rays coming from distance > 5 m

parallel rays

• Rays coming from distance < 5m

divergent rays
• Spherical lens

– Is a lens with the same curvature diameter

in all meridians

Spherical Convex (+) Spherical Concave (-)

• Spherical Lens :
– Plus sphere : Convex
• characteristic : makes larger and nearer images

+2 +2 0 +4 +5 -1

Biconvex Plano K Concave K

• Minus sphere : Concave
– Characteristic : makes smaller and farther images

-2 -2 0 -4 +1 -5

Bi Concave Plano K Convex K

• Parallel rays will be centered or diverged from the

focus
 Cylindrical Lens

• Is a kind of lens that have two

meridians that are perpendicular
to each other
• The meridian that has no power
is called the axis
• The other meridian, has the
power
• Spherocylindrical Lens

– Is a combination between spherical lens

and cylindrical lens
– Example : S +2.00 D C +1.00 D X 90
+ 2.00 0.00 + 2.00
• 0.00
+
+ 2.00 + 1.00 + 2.00
+ 1.00

+ 2.00

+ 3.00
 Eye as an Optical Instrument

• Refraction media :
– Cornea n = 1.33
– Humour Aqueous n = 1.33
– Lens n = 1,41
– Vitreous body n = 1.33
• Haziness on refraction media --> disturbances of
vision
• Power of refraction of the eye ball

– Totally : 60 dioptri
– Cornea : 40 dioptri
– Lens : 20 dioptri
• Accommodation Process

– Capability of adding the refraction power of

the eye, by increasing the convexity of the
lens
– normal : rays that come from > 5 m -
distance object regarded as parallel light; the
eyes are in relax position, the images are
focused right on the retina (fovea centralis)
 For object at less than 5 meters
distance, the rays do not come
parallel but divergent. If the eyes
are still in relax position, the
images will be focused behind
the retina. So the object will be
seen blurred. These images
must be moved forward so it will
be focused on the retina by
increasing the convexity of the
lens. This process is called
accommodation process.
• This accommodation
process happens as a
result from the
contraction of M. ciliaris
in the ciliary body
• These reflexes also happen during the
accommodation process :
– Accommodation
– Miosis Near Reflex
– Convergents
 Refraction Anomalies

• Normal : Emetropia
• Anomalies : (ametropia)
• Myopia
• Hypermetropia
• Astigmatism
• Presbiopia
 Emmetropia
• Is the condition when the parallel rays focused
exactly on the retina of the eye in relax condition
---> the visual acuity is maximum
 Ametropia
– Is the condition when the parallel rays are not
focused exactly on the retina of the eye in
relax condition.
– The focal point may be behind or in front of the
retina

Hal 47, 4.2 Duke Elder

 Myopia
– Refractive condition in which, with
accommodation completely relaxed, parallel rays
are brought to a focus in front of the retina.
– Myopic eye : refractive state over plus power
 Factors that causing myopia :
•
– Axial : The antero-posterior axis of the eye ball > normal
• in this case, the refraction power of the cornea, lens and the lens position are
normal. The eye usually looks like proptosis
– Curvature :
• The size of the eye ball ---> normal, but there is a increasing of the
cornea/lens curvature
• The change of the lens e.g. : intumescens cataract
– Increasing of the refraction index
• could occur on Diabetic patient
– Changes of the lens location
• changes of the lens position to the anterior after glaucoma surgery
• lens subluxation
 Clinical findings
– Farsightedness are blurred, nearsightedness are normal
– Asthenopia
– On high myopia : hemeralopia occurred caused by
periphery retinal degeneration
– Floating spots visualization caused by vitreous
degeneration
– screw up the eye lids together, in order to get a better
vision
• On high myopia ----> proptosis simulation, deep Anterior
Chamber
• Funduscopy : Tigroid fundus ---> thin retina
and the choroid, myopic crescent arround the
papilla area, sthaphyloma posterior
 Complication

Commonly occurred on high myopia

1. Degenarated and liquefied vitreous
2. Retinal detachment
3. Pigmentation changes + Macular bleeding
4. Strabismus
Myopia classification :
– < 3.00 D = low myopia
– 3.00 - 6.00 D = moderate myopia
– > 6.00 D = high myopia/gravis
 Treatment
Low and moderate myopia : full correction with weakest
spherical lens that give the best visual acuity
• Example :
VOD = 5/60 S -2.50 D = 6/7
S -2.75 D = 6/6
S -3.00 D = 6/6
S -3.25 D = 6/7
The glasses are S - 2.75 D
– On high myopia, usually full correction are not given
due to headache that may occurred. If necessary,
reading glasses can be given ---> bifocal glasses
• Prognosis :
– Simplex/stationer, after puberty will be
constant
– Progressive myopia, the myopia will be
continuously higher and complication may
occurred
 Hypermetropia
• Is a refraction anomaly that without accommodation
parallel rays will be focused behind the retina
• Divergent rays from near object, will be focused
farther behind the retina
 Etiology

– Axial ---> eye ball diameter < N

– Deminished convexity of cornea/lens curvature
– Decreasing Refractive index
– Changed lens position
• Clinical manifestation :

– H. Manifest ---> is detected without paralazing

accommodation and is represented by the
strongest convex glass needed , the patient sees
most distinctly. It correspons to the amount of
accommodation which he relaxes when a convex
lens is placed before the eye. Devided into two
types :
• Facultative : Can be overcome by an effort of
accommodation
• Absolute : Can not be overcome
– Total Hipermetrop : detected after the
accommodation has been paralyzed with
cylcopegic agents
– Latent Hypermetrop : is the diference of the
total hypermetrop with the manifest
hypermetrop
Hypermetrop

Latent Hypermetrop

Hypermetrop manifest
• Clinical finding :

– Nearsightness are blurred

– High hypermetropia at old age : farsightedness
also blurred
– Astenophia accommodative (eye strain)
– Children : high hypermetropia usually occurring
convergent strabismus (convergent squint)
• Treatment :

– If foria/tropia not present, apply strongest

positive spherical lens that give the best
visual acuity
– If foria/tropia present, total hypermetrop
correction. If necessary : bifocal eye glasses
 Astigmatism

• Refractive condition of the eye

in which there is a difference in
degree of refraction in diferent
meridian, each will focused
parallel rays at a different
point.
• The shape of the images :
– Line, oval, circle, never a
point
• Manifestation :

– Regular astigmatism
• Difference in the degree of refraction in every
meredian.
• Two principles meridian :
– Maximmum refraction
– Minimum refraction Right angle
to each other
– Irregular astigmatism
• Difference in refraction not only in different meridians,
but also in different parts of the same meridian.
 Etiology of astigmatism :
 Corneal curvature disturbances ---> 90%
 Lens curvature disturbances ---> 10%

 Type of Astigmatism :
 Ast. M. Simplex C-2.00 X 90
 Ast. H. Simplex C+2.00 X 45
 Ast. M Compositium S-1.50 C-1.00 X 60
 Ast. H Compositium S+3.00 C+2.00 X 30
 Ast. Mixtus S+2.00 C-5.00 X 180
Ast. M. Simplex Ast. H. Simplex

Ast. M Compositium Ast. H Compositium

Ast. Mixtus
 Presbiopia
• Physiological changes because
accommodation capability is lowering at old
age
Accommodation
16

10

10 20 40 50 60 Age
 Presbiopia correction :
 40 years old S + 1.00 D
 45 years old S + 1.50 D
 50 years old S + 2.00 D
 55 years old S + 2.50 D
 60 years old S + 3.00 D

 Consider the type of previous/history work

 Tailor
 Architect
 Weld engineer
 Refraction Examination Technique

• Subjective :
– Snellen chart/projector, alphabet , inverse E, picture,
Landolt ring
– Trial lens
– Trial frame
• Objective :
– Children, incooperative, difficult correction,
strabismus :
• Ophthlamoscopy
• Retinoscopy
• Refractometer
• Subjective

– Check firstly just one eye : OD

– Distance : 5 or 6 meters
– VOD : …...(basic right eye visus)
a. Trial and error
• apply S + 0.50, better visus , add S+ until visus = 6/6
• S +0.50, lower visus, change to S -, increase S - until
visus = 6/6
• S +/- not working ----> cylindrical
• With astigmatism dial, stenoplic slit, cross cylinder
• astigmatism dial : Blurred line ----> C negative lens axis
• One by one fogging

– S + sp. Lens --> blurred vision, step by step

distracting ---> best sp.

• Nearsightedness/read

– Both eyes at one time at required distance :

use jaeger chart

– Example :
I. AVOD 2/60 S - 3.50 = 6/6 ODS 6/6
headache, eye strain
AVOS 3/60 S - 3.00 = 6/6
II.AVOD 2/60 S - 3.00 = 6/7 ODS 6/6
AVOS 3/60 S - 2.75 = 6/7 w/o headache, eye strain

read ADD S + 1.50

Give Eye Glasses according to II
• Objective

– Use cyclopegic
1. Ophthlamoscopy : papilla clearly seen with
which lens
2. Retinoscopy :
• Ordinary ---> light source outside
• streak -----> light source inside
3. Refactometer
• Computerized
• Lensmeter principal
• Ideally :

– Subjective
– Objective with cyclopegic
– Subjective once more without cyclopegic
• Lens meter
– Measuring lens power
– Measuring focus distance
• Measuring Pupillary Distance

– Drop the flashlight light onto both eyes, the light

is coming from in front of the patient, The
patient look at the observer forehead or the light
----> measure the distance of light spot between
OD and OS ----> as near pupil distance
– Far distance :
• add 2 mm ---> for pupil distance less than 60
mm.
• Add 3 mm ---> for pupil distance more than
60 mm
• Eye Glasses

• Monofocal
• Bifocal
• Progressive
• Eye Glasses Prescription, the components are
– Which eye (OD or OS)
– Power of the lens ( + or - , Power, axis)
– ADD for reading
– Pupil distance far/near
– Name of the patient
 Binocular Optical Defects
• Anisometropia :
– Condition wherein the refractions of the two eyes are an
equal
– variation :
M. E.
H. E.
H. H.
M. H

Antimetropia
• Vision in Anisometrop
– difference < 2.50 D : still get fusion + single
binocular vision
– difference > 2.50 D : fusion difficulties ---->
weak eye suppression ---> amblyopic
– alternans vision : left and right alternate
• Aniseikonia :
– The difference of shape and size of the
images between right and left eye
 Limitation of the eye glasses
– Cannot applied for anisometropia more than 2.50 Dioptri
– Anisometropia causing aniseikonia

• Contact lens : Hard ---> rigid lens

Soft
– Indication :
• High anisometropia
• irregular astigmatism
• Front asymmetry, orbit
• Aniridia
• Descemetocele
• Sports
• Cosmetics
Thank You