REFRACTIVE

ERRORS
Dr. dr. Ariesanti Tri Handayani, SpM(K)
Ophthalmology Departement – Refraction and Contact Lenses Division
Udayana University/Sanglah Hospital – Denpasar

KULIAH BLOK VISUAL SEMESTER 4

2021
 INTRODUCTI
ON
Refraction of light
• occurs when light passes from
one medium to another
different refractive index
(Guyton, 2006)

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REFRACTIVE COMPONENTS OF
THE EYE
Cornea
Refractive index = 1.376
Refractive power = 40 D
Aqueous humor
Refractive index = 1.336
Lens
Refractive index = 1.42
Refractive power = 20 D
Vitreous humor
Refractive index = 1.336
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(Guyton, 2006)
 REFRACTIVE
PHYSIOLOGY
Corneal refractive power is constant

Lens refractive power is modifiable

with accomodation (Harper, 2010)

https://vimeo.com/76393440
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Physiology of the Eye
 LENS
ACCOMODATION
Ability of the lens to change
shape in order to adjust its focus
from the distance objects to near
objects
Contraction of cilliary muscles à
relaxes zonular tension à
spherical lens à focus on near
object
Ciliary muscles relaxation à
contract zonular tension à lens
flatten à focus on distant object
(Vaughan, 2016)
https://youtu.be/1yIpyitm6eE 5
 EMMETROPI
A
Adequate correlation between
axial length and refractive power

Parallel light rays fall on the retina

(no accomodation)

(Harper, 2010)

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AMETROPIA (REFRACTIVE
ERROR)
• The most common eye disorder Depkes RI
(1996) à 22,1%
• Uncorrected refractive error à Leading
cause of higher prevalence of visual
disorders in the world (Shufelt et al, 2005)
• Globally, 153 Million have visual
impairment & 8 Million are blind due to
uncorrected refractive error (Resnikoff,
2008)
• 2050: It is stimated that increased of
myopia prevalence to 49,8% of global
population and 9,8% for high myopia
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(Matsamura, et al, 2020)
 AMETROPIA (REFRACTIVE
ERROR)
Mismatch between axial length Parallel light rays do not fall on
and refractive power the retina (no accomodation)

Myopia Hyperopia
Astigmatism
(Nearsightedness) (Farsightedness)
(Vaughan, 2016) 8
MYOPI
Aearsightedness
N
MYOPIA
(NEARSIGHTEDNESS)
Parallel rays converge at a focal point in
front of the retina (no accommodation)
Epidemiology = global Epidemic,
Asian>>( 50%) (
Predisposing factor = age, ethnicity,
near-work, genetic
Etiology
- Long axial length
- Increase of corneal or lens curvature
(Garcia, 2007; Perdami, 2006, Mehta, 2019)
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 MYOPIA -
CLASSIFICATION
Causes Severity

Axial Myopia Low Myopia

Excessive long globe ≤ 3.00 D
More common
Medium Myopia
Refractive Myopia 3.25 – 6.00 D
Caused by increase of cornea or
lens curvature (Curvature Myopia), High Myopia
or by variation of ocular refractive > 6.00 D
index (Index Myopia) 11
(Ilyas, 2014; Vaughan, 2016)
 MYOPIA -
CLASSIFICATION
Progression

Stasioner Myopia
No progression

Progressive Myopia
Myopia increase, and associated with globe
lengthening

Malignant Myopia
Progressive myopia with complications, such as
retinal detachment 12
(Ilyas, 2014; Vaughan, 2016)
 MYOPIA -
DIAGNOSIS
Symptoms
Blurred distance vision
Squinting/narrowing lids to get
better vision
Headache or eye strain, if
accompanied by astigmatism
(Ilyas, 2014; Vaughan, 2016)
Signs
Thin and more convex cornea
Scleral thinning
Deep anterior chamber
More dilate pupil
Vitreous may collapse prematurely
Fundus = myopic crescent,
tigroid retina
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 MYOPIA -
TREATMENT
Non Surgical
• Glasses (weakest concave lenses
with maximal correction)
• Contact lenses
Surgical
Keratorefractive Surgery
• Laser assisted in situ keratomileusis
(LASIK), Photo Refractive
Keratectomy (PRK)
Refractive Lens Exchange https://vimeo.com/76393440
• Clear Lens Extraction (CLE) Physiology of the Eye
14
• Phakic IOL (Garcia, 2007; Ilyas, 2014; Vaughan, 2016)
 Spectacles
CLE
Contact lens

LASIK Procedure (Keratorefractive Surgery)

Phakic IOL
 MYOPIA -
COMPLICATION
Amblyopia (Lazy eye)
Child age à should be treated before 12 y.o

Strabismus
Can be treated by using glasses or surgery

Retinal detachment
Ocular emergency à Immediate surgery

Glaucoma
Elderly, open angle glaucoma

Other posterior segment abnormality

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(Ilyas, 2014; Vaughan, 2016)
HYPEROPI
Aarsightedness
F
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 HYPEROPIA
(FARSIGHTEDNESS)
Parallel rays converge at a focal point
posterior to the retina (no accommodation)

Etiology
- Short axial length
- Decrease of corneal or lens
curvature à insufficient refractive
power

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(Vaughan, 2016)
 HYPEROPIA -
CLASSIFICATION
Causes Severity

Axial Hyperopia Low Hyperopia

Shorter globe ≤ 2.00 D

Refractive Hyperopia Medium Hyperopia

Caused by decrease of cornea or 2.25 – 5.00 D
lens curvature (Curvature
Hyperopia), or by variation of ocular High Hyperopia
refractive index (Index Hyperopia) > 5.00 D
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(Ilyas, 2014; Vaughan, 2016)
 HYPEROPIA -
CLASSIFICATION
Role of Accomodation Cycloplegic

Facultative Hyperopia Manifest Hyperopia

Can be overcome by accomodation Determined with noncycloplegic
refraction

Absolute Hyperopia Latent Hyperopia

Cannot be overcome by Determined with cycloplegic refraction
accomodation

Total Hyperopia = Facultative + Absolute Hyperopia magnitude = Manifest + Latent

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(Ilyas, 2014; Vaughan, 2016)
 HYPEROPIA -
DIAGNOSIS
Symptoms

Blurred near vision

Eye strain à strained ciliary muscle

to maintain accommodation
Headache à accommodative
asthenopia
Young children à convergent
squint
21
(Ilyas, 2014; Vaughan, 2016)
 HYPEROPIA -
TREATMENT
Non Surgical
• Glasses (strongest convex lenses
with maximal correction)
• Contact lenses

Surgical
No significant result

https://vimeo.com/76393440
Physiology of the Eye
22
(Ilyas, 2014; Vaughan, 2016)
 HYPEROPIA -
COMPLICATION
Amblyopia (Lazy eye)
Occurs at child-age
Should be treated before 12 y.o

Strabismus
Can be treated by using glasses or
surgery

Glaucoma
Closed angle
23
(Ilyas, 2014; Vaughan, 2016)
ASTIGMATIS
M
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 ASTIGMATIS
M
Parallel rays focus on multiple focal
points near or/and on the retina
(no accommodation)

Etiology
• Asymetric lens/corneal curvature
• Variable refractive index in
different meridian

25
(Vaughan, 2016)
FOCAL POINTS IN
ASTIGMATISM

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 ASTIGMATISM -
CLASSIFICATION
Regularity
Regular Astigmatism
Principal meridians are perpendicular
Can be corrected with cylinder
lenses
Irregular Astigmatism
Principal meridians cannot be
defines, eg. Corneal scars.
Cannot be corrected with cylinder
lenses
(Ilyas, 2014; Vaughan, 2016)
Meridian
With the rule Astigmatism
Vertical meridian is steeper
Against the rule Astigmatism
Horizontal meridian is steeper
Oblique Astigmatism
The principal meridians are more
than 20° from horizontal and vertical
meridians 27
ASTIGMATISM -
CLASSIFICATION

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ASTIGMATISM -
CLASSIFICATION

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 ASTIGMATISM -
DIAGNOSIS
Symptoms

Distortion, Sensitive to light and blurry vision

Asthenopic symptoms
Head tilting and turning

Examination

Placido disc
Astigmatism fan & Jackson Cross Cylinder
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(Ilyas, 2014; Vaughan, 2016)
 ASTIGMATISM -
DIAGNOSIS
Placido Disc Astigmatism Fan Jackson Cross Cylinder

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 ASTIGMATISM -
TREATMENT
Non Surgical
• Glasses (Cylindrical lenses)
• Contact lenses ( Toric or rigid gas
permeable – RGP )

Surgical
• Photorefractive keratectomy (PRK)
• Laser assisted in situ keratomileusis RGP Soft contact lens
(LASIK)

32
(Ilyas, 2014; Vaughan, 2016)
PRESBYOPI
A
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 PRESBYOPI
A
Physiologic loss of
accommodation in older
age due to degenerative
process (begin at 40s)
Etio-pathogenesis
- Deposit of insoluble proteins
in lens
- Decrease of lens elasticity
- Decrease of accommodation

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(Guyton, 2006)
 PRESBYOPIA -
DIAGNOSIS
Symptoms

Blurred near vision

Eye strain while doing near-work

Need to keep things farther to

focus on them properly
Headache

35
(Vaughan, 2016)
 PRESBYOPIA -
DIAGNOSIS
Examination

Near vision examination after

subjective refraction

Jaeger Chart

36
(Ilyas, 2014; Vaughan, 2016)
 PRESBYOPIA -
TREATMENT
Non Surgical
• Glasses (convex lenses) à reading
glasses
• Based on patient’s age
40 y.o = +1.00 D
45 y.o = +1.50 D
50 y.o = +2.00 D
55 y.o = +2.50 D
≥ 60 y.o = +3.00 D

(Ilyas, 2014; Vaughan, 2016)

 ANISOMETROP
IA
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

(Guyton, 2006)
ANISOMETROP
IA
 ANISEIKONI
A
Differences in size of retinal image

Spectacle lensesà 25 %
aniseikonia à rarely tolerable

Choices:
– Contact lens à 6 % aniseikonia
– IOL à < 1 % aniseikonia

(Guyton, 2006; Vaughan, 2016)

THANK
YOU
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