ASTIGMATISM

Komal sharma
Assistant professor
CONTENTS
 Definition
 Incidence

 Optics of astigmatism

 Etiology

 Classification

 Signs & Symptoms

 Diagnosis

 Treatment
ASTIGMATISM
 Astigmatism is probably the most misunderstood vision
problem. For starters, it's called "astigmatism," not
"stigmatism." (You don't have "a stigmatism" — you
have astigmatism.)
 Like nearsightedness and farsightedness, astigmatism is
a refractive error, meaning it is not an eye disease or eye
health problem; it's simply a problem with how the eye
focuses light.
DEFINITION :-

 Is type of refractive error In which, light fails to come to

a single focus on the retina to produce clear vision.
Instead, multiple focus points occur, either in front of the
retina or behind it (or both).
 Most astigmatic corneas have two curves, a steeper
curve and a flatter curve.  This causes light to focus
on more than one point in the eye, resulting in
blurred vision at distance or near. 

 The cornea is normally spherical, although in

people with astigmatism, it may be shaped like a
football or oval instead of tennis ball.
 OPTICS OF
ASTIGMATISM
OPTICS OF ASTIGMATISM
In astigmatism, the rays of light from one sector fall
on one point & rays from another sector fall on
another point. In other words, a point focus of light
cannot be formed upon the retina.

The configuration of rays refracted through the

astigmatic surface (toric surface) is called sturms
conoid.
 Thus, there are 2 focal points separated from each
other by a focal interval, called as interval of sturm.

 The length of this focal interval is the measure of

the degree of astigmatism & the correction of the
error can only be accomplished by reducing these
two foci in to one & keep the circle of least
confusion on the retina.
INCIDENCE
INCIDENCE
 No eye is perfectly astigmatic as almost all individuals
have a minor degree of physiological astigmatism.

 About 60% cases of refractive errors have astigmatism

which needs to be corrected.

 Occurs with equal frequency in males and females.

 Approximate distribution according to degree of

astigmatism is:
0.25-0.5 D 50%
0.75-1.0 D 25%
1.00-4.00D 24%
<4.00 1.0%
 The most common type is compound myopic
followed by compound hyperopic, mixed, simple
myopic & simple hyperopic.

 One study reports as:

With the rule 38%
 Against the rule 30%
 Oblique 32%
ETIOLOGY
ETIOLOGY
1.Corneal astigmatism:

 It occurs due to abnormalities of curvature of

cornea
 Most common cause of astigmatism

 Usually congenital

 Acquired is usually irregular

 e.g. keratoconus, pterygium, mild corneal opacities,

chalazion
PTERYGIUM
CORNEAL OPACITY
CHALAZION
2. Lenticular astigmatism:

 It is comparatively rare.
 It may be:

Curvatural….lenticonus
Positional…..congenital tilting & traumatic subluxation of
lens

Index……….developing cataract/nuclear sclerosis/diabetic

cat.
ANTERIOR LENTICONUS
IMAGE DISTURBANCE IN CATARACT
3. Retinal astigmatism:

 Seen occasionally
 Oblique placement of Macula
Classification
CLASSIFICATION

1. Astigmatism - Based on asymmetry of

structure

asymmetric
Corneal astigmatism - astigmatism due to an
shaped cornea

asymmetric
Lenticular astigmatism - astigmatism due to an
shaped lens
2. Astigmatism - Based on axis of the principal
meridians

Regular astigmatism
 Against-the-rule astigmatism (-cyl 90+_20 or +_30)
Or +cyl 180+_20 or 30
 With-the-rule astigmatism (+cyl 90+_20 OR +_30)
OR _CYL 180+_20 OR +_30)

Oblique astigmatism
 Bioblique astigmatism
Irregular astigmatism
Regular astigmatism:
 The astigmatism is said to be regular if there is different
refraction by the eye in two meridian at right angles to each
other.
Can be corrected with spectacles.
Normally, horizontal curvature of cornea is flatter than vertical
& this is attributed to the pressure of lids on the corneal surface.
This is physiological. So, vertical cornea should be more curve
than horizontal.
On this basis, it has two types:
With the rule & against the rule
 With-the-rule (direct astigmatism):
 Principle meridia are at right angle to each other.

 Verticalcurve is more than horizontal.

 Concave cylinder is prescribed in horizontal axis
(180) and convex are prescribed in vertical axis (90).
 Normally the vertical meridian is rendered 0.25 D
more convex than horizontal by the pressure of
fleshy upper eyelid.
 +CYL 90+_20 OR +_30

 -CYL 180+_20 OR +_30

 Against-the-rule (indirect astigmatism):
 Principle meridia are at right angle to each other.

 Horizontal curve is more than Vertical.

 Convex cylinder is prescribed in horizontal axis
(180) and concave are prescribed in vertical axis
(90).
 Usually associated with old age.

 -CYL 90+_20

 +CYL 180+_20
 Oblique astigmatism:

 A type of astigmatism in which principle meridia

are not horizontal or vertical but are at right angle to
each other (45 & 135).
Usually symmetrical in both the eyes (cylinder
required at 30 in both the eyes)
Or complementary (cylinder required at 30 in one
eye & 150 in other eye)
 Bioblique astigmatism:
 In this type of astigmatism, the two principle
meridia are not at right angle to each other.
 e.g. one may be at 30 & other at 100.
 Irregular astigmatism:
It is characterized by an irregular change of
refractive power in different meridia.
There are multiple meridia which admit no
geometrical analysis.
 In this type of astigmatism, the two principle
meridia are not at right angle to each other.
 e.g. one may be at 30 & other at 100.

Cannot be corrected by spectacles.

It occurs due to corneal scars, during maturation
of cataract, scarring or tumours of retina.
3. Astigmatism - Based on focus of the principal
meridians
Simple astigmatism

Simple hyperopic astigmatism
 Simple myopic astigmatism

Compound astigmatism
 Compound hyperopic astigmatism

 Compound myopic astigmatism

Mixed astigmatism
SIMPLE ASTIGMATISM

In simple astigmatism, one of the foci falls on retina & other focus
falls in front or behind retina.
This leads to one meridian being emmetropic & other being myopic
(one focus on the retina & other focus falls in front of retina) or
hyperopic (one focus on retina & other focus behind retina), so called
as simple myopic astigmatism & simple hyperopic astigmatism
respectively.

It can be with-the-rule or against-the-rule.

-2 D cyl at 90 is example of simple myopic astigmatism.

+2 D cyl at 90 is example of simple hyperopic astigmatism.

SIMPLE HYPEROPIC ASTIGMATISM
SIMPLE MYOPIC ASTIGMATISM
COMPOUND ASTIGMATISM

Neither of the two foci fall on the retina.

The condition is known as compound hyperopic
if both foci are at back of retina.
The condition is known as compound myopic if
both foci are at front of retina.
It can be with-the-rule or against-the-rule.
-3 DS with -2DC at 90 is example of compound
myopic astigmatism.(ATR)
+3 DS with +2DC at 90 is example of compound
hyperopic astigmatism.(WTR)
COMPOUND HYPEROPIC
ASTIGMATISM
COMPOUND MYOPIC ASTIGMATISM
 MIXED ASTIGMATISM

 In mixed astigmatism, one of the two foci lies at back while

other at front of the retina.

It can be with-the-rule or against-the-rule.

-3 DS with +8DC at 90 is an example of mixed astigmatism.

MIXED ASTIGMATISM
 :NOTE

If cyl power is less than spherical power, then it is

not mixed but compound astigmatism.

For example, -3DS with +1DC at 180 sounds as if it

is mixed astigmatism, but actually is compound
astigmatism, as cyl is less than sphere.
 RESIDUAL ASTIGMATISM

The largest element of the total astigmatism is due to

anterior corneal surface.
While the other components like:
 Posterior corneal surface
Lens
Refractive indices
constitute the residual astigmatism.

RESIDUAL ASTIGMATISM= TOTAL – CORNEAL ASTIGMATISM

SIGN AND SYMPTOMS
 TYPE OF THE SYMPTOMS PRODUCED, DEPENDS
UPON THE TYPE OF ASTIGMATISM:
1. BLURRING OF VISION:
 Transient blurring of vision in low astigmatism.
 Relieved by closing/rubbing the eyes.
 Circles elongate into ovals.
 A point of light appears tailed off.
SIGNS & SYMPTOMS
2. Asthenopic symptoms:

 More marked in patients with low astigmatism

(more accommodative effort)
 Severe in hyperopic astigmatism
(more accommodative effort)

 Tirednessof eyes
 Headaches (from mild frontal ache to explosions of
pain)
 Nervous disturbances:
 Dizziness
 Fatigue
 Irritability
 SIGNS & SYMPTOMS
3. Tilting of the head:
Some patients with high oblique astigmatism, may
hold the head tilted to one side to reduce image
distortion.
Some children may even develop scoliosis.
(The condition of side-to-side spinal curves is called scoliosis. On an X-
ray, the spine of an individual with scoliosis looks more like an "S" or a
"C" than a straight line.)
 SIGNS & SYMPTOMS

4. Half closure of the lids:

Seen in patients with high astigmatism.

This is to make a sort of stenopaeic slit & cutting
out the rays from one meridian..
This also causes Asthenopic symptoms.
 SIGNS & SYMPTOMS

5. Reading material is held too close:

Reading material is held too close to the eyes by

the patient to achieve blur but large image just like
a myope.
 SIGNS & SYMPTOMS
6. Burning & itching:

May be seen in patients with low astigmatism

B/c of rubbing the eyes
 Falling of eye lashes
 Hyperemia
 Styes& chalazia
DIAGNOSIS
 DIAGNOSIS

VA with and without correction monocularly

Pinhole VA
Retinoscopy
Keratometry
Keratoscopy with placido’s disc
Computerised corneal topography/videograph

Subjective verification:
Jackson cross cylinder
Astigmatic fan & block
Trial & error technique (axis then power)
Maddox V
Stenopaeic slit
VISUAL ACUITY & PINHOLE VA
JACKSON CROSS CYLINDER
JAVAL SCHIOTZ KERATOMETER
PLACIDO’S DISC
TOPOGRAPHY
 THE TYPICAL SPIRAL PATTERN OF KERATOCONUS
PROGRESSION. IN COLOR-CODED TOPOGRAPHIC
IMAGES, RED REPRESENTS STEEPER CORNEAL
CURVATURE, AND THE SPECTRUM OF YELLOW,
GREEN, AND BLUE REPRESENTS PROGRESSIVELY
FLATTER CURVATURES.
TREATMENT
MODES:
1. SPECTACLES
2. CONTACT LENS
3. LASER
4. REFRACTIVE SURGERY
5. KERATOPLASTY
1. SPECTACLES
ASTIGMATISM IS CORRECTED OPTICALLY WITH A
CYLINDRICAL LENS. 
A COMBINATION OF A SPHERICAL LENS AND A
CYLINDRICAL LENS (SPHEROCYLINDRICAL LENS) IS
USED TO CORRECT A SPHERICAL ERROR WITH AN
ASTIGMATIC ERROR.
CYL HAS POWER (CURVATURE) IN ONE MERIDIAN
AND NO POWER IN THE OTHER MERIDIAN.
THE AXIS OF THE CYLINDER IS LINED UP WITH THE
AXIS OF ASTIGMATISM TO CORRECT THE
ASTIGMATIC POWER DIFFERENCE.
 INSTEAD OF A FOCAL POINT, THE
SPHEROCYLINDRICAL LENS CREATES TWO
FOCAL LINES PERPENDICULAR TO ONE
ANOTHER AND AT DIFFERENT FOCAL
DISTANCES DEPENDING UPON THE
PARTICULAR CURVATURES. HALF WAY IN
BETWEEN THE TWO LINES A BLUR CIRCLE IS
FORMED CALLED THE "CIRCLE OF LEAST
CONFUSION". 
 2. CONTACT LENSES
VARIOUS TYPES OF CONTACT LENSES ARE USED:

SOFT
HARD
RIGID GAS PERMEABLE
HYBRID (HARD CENTER & SOFT PERIPHERY, USED IN
KERATOCONUS)

DEPENDING UPON THE DEGREE OF ASTIGMATISM:

SPHERICAL
TORIC
BITORIC
EUGENE KALT, MD, FIRST TO PROPOSE THE USE OF
A CONTACT LENS FOR KERATOCONUS.
3.LASER & REFRACTIVE SURGERIES
PHOTOREFRACTIVE KERATECTOMY PRK
RELAXING INCISIONS (TRANSVERSE & ARCUATE
KERATOTOMY)
WEDGE RESECTION
COMPRESSION SUTURES
CONTINUOUS SUTURES ( ASTIGMATISM LOW)
INTERRUPTED SUTURES (ASTIGMATISM HIGH)
ORTHOKERATOLOGY (HARD LENS)
KERATOPLASTY (KERATOCONUS)
Thanks