Ophthalmology Optics and Refraction

OPHTHALMOLOGY

Chapter - 1

OPTICS, REFRACTION & Refractive errors

Syllabus:
- Optics, Elementary Optics and Physiological Optics
Measurement of Visual Acuity
- Types of refractive errors (etiology, classification,, clinical
features and treatment):Myopia, Hypermetropia, Astigmatism
- Presbyopia & accommodation

Q.1 Define refractive error. What are the Q. What is ametropia? What are the
different types of refractive errors? (1+2) different types of ametropia? Discuss
briefly the treatment. (1+1+3) [KU 06, 07]
[KU 99, 08]

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Ophthalmology Optics and Refraction
Q. What are the different types of ametropia? Due to decrease in refractive
Outline the management of each one of index of lens e.g. juvenile
them. Enumerate the complication of diabetes, senile cortical sclerosis.
ametropia. (1+2+2) [KU 12, 013] 4. Positional hypermetropia
posteriorly placed crystalline lens
Refractive error (ametropia) is a condition
of refraction where the parallel rays of light 5. Aphakia (absence of lens)
coming from infinity (with accommodation at Condition of high hypermetropia
rest) are focused either in front or behind the a. Congenital
sensitive layer of retina in one or both b. Acquired: due to surgical
meridians. removal or posterior
Types: dislocation of lens
Myopia B. Clinical classification
Hypermetropia 1. Simple/Developmental hypermetropia
Astigmatism may be due to developmental
variation (axial + curvatural)
[For treatment and complication, see
respective Questions] commonest type
2. Pathological hypermetropia
Q.2 What is Hypermetropia? Classify hyper-
a. Index: due to Acquired senile
metropia. Briefly describe treatment of cortical sclerosis
hypermetropia (1+2+2) [KU 98, 02] b. Positional: due to Posterior
Q. Describe briefly the causes of subluxation of lens, aphakia
hypermetropia. (2) [KU 09] c. Consecutive: due to surgically
over
Hypermetropia or long-sightedness is the corrected myopia.
refractive state of eye where in the parallel 3. Functional hypermetropia
rays of light coming from infinity are focused Due to paralysis of accommodation
behind the light sensitive layer of retina when
rd
E.g. 3 nerve paralysis,
accommodation is at rest. internal
Classification: ophthalmoplegia, etc.
A. Etiological classification Treatment:
1. Axial hypermetropia 1. Mild hypermetropia in young (about 0.5D)
does not require treatment.
Commonest type
2. Optical treatment
Normal refractive power
Convex lens of required power, so that
Axial shortening of eye ball the light rays are focused on the retina.
1mm shortening = 3D Rules for optical treatment
hypermetropia Total amount of hypermetropia
2. Curvatural hypermetropia should always be discovered by
Curvature of cornea or lens or performing refraction under complete
both is flatter than normal cycloplegia
1mm increase in radius = 6D Correction should be acceptable to
of hypermetropia the patient
3. Index hypermetropia Gradually spherical correction at

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6 months interval Fundoscopic signs of Hypermetropia:
Astigmatism should be fully corrected Optic disc: small, more vascular with
Full correction for ill defined margins/pseudopapillitis
accommodative Retina shines due to greater brilliance
convergent squint at first sitting of light reflection (shot silk
For amblyopia full correction with appearance)]
occlussion therapy. Grading of hypermetropia
Modes of optical treatment: Low hypermetropia, when error is + 2D
1. Glass/Spectacles Moderate hypermetropia, when error is
Placed in the position of anterior focal between +2 to +5 D.
point of the eye (15mm in front)
High hypermetropia, when error is +5 D.
2. Contact lens: In unilateral hypermetropia
(anisometropia) Q.3. Give two complications of hypermetropia
in a child if not treated. (2) [KU 2010]
3. Surgical t/t (not as effective as in myopia)
I. Cornea based procedures: If hypermetropia is not corrected for a long time,
following complications may occur:
1. Thermal laser keratoplasty (TLK)
1. Recurrent styes, blepharitis or chalazia-
- For low degree hypermetropia probably due to infection introduced by
- Thallium - Holmium - chromium repeated rubbing of the eyes (which is often
(THC) : YAG laser is used. done to get relief from fatigue and tiredness).
2. Hyperopic PRK using excimer laser 2. Accommodative convergent squint- due to
3. Hyperopic LASIK excessive use of accommodation.
3. Amblyopia (in some cases)- It may be
- Effective in correcting
anisometropic (in unilateral hypermetropia),
hypermetropia upto +4D.
strabismic (in children developing
4. Conductive keratoplasty (CK) accommodative squint) or ametropic (seen in
- Non-ablative and non-incisional children with uncorrected bilateral high
procedure hypermetropia).
- Effective for correcting 4. Predisposition to develop primary narrow
angle glaucoma.
hypermetropia upto +3D.
Q.4. What is Aphakia? Different causes
II. Lens based procedures.
of aphakia. What are the modalities to
1. Phakic refractive lens (PRL) or correct it? (1+2+2) [KU 05]
implantable contact lens (ICL)
Aphakia is a condition in which the lens is
- Surgical option for hypermetropia
absent from the pupillary area, either due to
of more than +4 D.
absence of lens in eye or its dislocation.
2. Refractive lens exchange (RLE)
It produces a high degree of hypermetropia.
- For high hyperopia especially in
Causes:
presbyopic age.
(1) Congenital (rare)- 2 types
Note:
Primary - Failure of
Nomenclature (components of
development of lens
hypermetropia): Total hypermetropia =
Latent + Manifest (Facultative + Absolute) in fetal life

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Secondary - Lens forms, but
gets absorbed in-utero due to some
factors
(2) Surgical - Following cataract surgery
(Needling, ICCE, ECCE)
(3) Aphakia due to absorption of lens
matter- noticed rarely, after trauma in
children.
(4) Traumatic extrusion of lens from the eye.
(5) Posterior dislocation of lens in vitreous.
Treatment:
A. Optical principle: Correct the error by
convex lens of appropriate power, so that
the image is formed on retina
Treatment modalities:
(i) Spectacles
Most commonly employed
Roughly about +10D with cylindrical
lenses for surgically induced
astigmatism
Add +3 to +4D for near vision (to
compensate for loss of accommodation)
Various forms of spectacles:
a. Spherical (usual)
- crown glass with R.I. 1.5
- high index lenses
plastic/glass with R.I. 1.56
1.76
b. Aspherical
i. enticular ii. Full field
(ii) Contact lens: - types
a) Hard
b) Gas permeable
c) Soft
(iii) IOL implantation best method
Usually IOL made from PMMA
(Poly- methyl-meth-acrylate)
Others:
a. Acrylic
b. Flexible PMMA (haptics)
c. Foldable lens made of silicon,
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acrylic
B. Refractive corneal Surgery
Keratophakia
Epikeratophakia
Hyperopic LASIK
Note: In aphakia,
- total power of eye ed to +44D
- total loss of accommodation occurs
- jet black pupil, only 2 Purkinjes images
formed
Q.5. What is myopia? Classify clinical types of
myopia. Describe surgical treatment of
myopia. (1+2+2) [KU 99]
Q. Briefly describe myopia under (a) Types
(b) C/F (c) T/t (1+3+1) [KU 03, 08, 99]
Myopia/Short sightedness is a type of refractive
error of eye in which parallel light rays
coming from infinity are focused in front of
retina when accommodation is at rest.
Classification
A. Etiological types
1. Axial Myopia (commonest type) - due to
increase in length of eyeball
2. Curvatural Myopia - ed curvature
of cornea &/or lens
3. Positional Myopia Anterior
of placement of lens
4. Index myopia - ed refractive index
of lens associated with nuclear sclerosis
5. Myopia due to excessive
accommodation (occurs in patients
with spasm of accommodation)
B. Clinical types
1. Congenital myopia: Present since birth
Diagnosed by age of 2-3 yrs
Usually unilateral
Manifest as anisometropia
Error about 8-10 D, remains
constant
2. Simple Myopia: Developmental Myopia
Commonest variety
Is a physiological error, not
Ophthalmology Optics and Refraction
associated with any disease of eye (a) Prominent eyeballs (elongation of
3. Pathological or degenerative myopia eyeball)
mainly affects the posterior
4. Acquired Myopia which may be
pole & surrounding area
Post traumatic (b) Large cornea
Post keratitic (c) Deep anterior chamber
Drug induced (d) Pupil - Slightly large & react
Pseudomyopia: Due to spasm of sluggishly to light
ciliary muscles (e) Fundus examination:
Space myopia (Night myopia): (i) Optic disc - large & pale
Short wave comes in focus in front Myopic crescent at temporal
of retina, chromatic aberration edge
occurs due to accommodative Peripupillary crescent when
wave choroid & retina are
Consecutive myopia: Due to distracted away from the
surgical over correction of disc margin
hypermetropia
Supertraction crescent on the
C.F.: depends upon the type of myopia nasal side (Retina is pulled
1. Simple Myopia over the disc margin)
Symptoms:
(a) Poor vision for distance (short
sightedness)
(b) Asthenopic symptoms ( eg. Headache)
in pts. with small degree of myopia
(c) Half shutting of the eyes for greater
clarity of stenopaeic vision
Signs:
(a) Prominent eyeballs
(b) Anterior chamber is slightly deeper
than normal
(c) Pupil: Somewhat large & a bit
sluggishly reacting
(d) Fundus: Normal
(e) Usually does not exceed 6-D
2. Pathological Myopia:
Symptoms
(ii) Degenerative changes in retina &
(a) Defective vision
choroid:
(b) Muscae volitantes: floating black
opacities due to degenerative liquefied White atrophic patches at the
vitreous macula
(c) Night blindness: Complained by very Little heaping up of
high myopes having degenerative pigment around them.
changes.
Signs : Foster Fuchs spot at macula
(dark red circular patch due

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Ophthalmology Optics and Refraction
to sub - retinal Modes of Optical treatment:
neovascularization &
Glasses / spectacles: Simple Myopia
choroidal hemorrhage)
Contact lens: esp. in High Myopia
Cystoid degeneration at
Intraocular lens
periphery
(b) Surgical treatment
Total retinal atrophy in
central area in advanced case Indications:
Pt. who does not wish to use spectacles
Intolerance to contact lens
Age >20 yrs
After error has established
Cornea based procedures:
1. Radial keratotomy (RK):
- For low to moderate myopia (2 to 6
D)
2. Photorefractive keratectomy (PRK)
- Gives very good correction for 2 to 6
D of myopia
(iii) Posterior staphyloma - due to
ectasia of sclera at posterior pole 3. Laser in-situ keratomileusis (LASIK)
(iv) Degenerative changes in vitreous - Refractive surgery of choice for myopia
of upto - 8 D
- Liquefaction,vitreous opacities
& posterior vitreous detachment 4. Intercorneal ring (ICR) implantation : into
(PVD) appearing as Weiss peripheral cornea.
reflex 5. Orthokeratology
f) Visual field contraction, ring - For correction of myopia upto 5D.
scotoma in some cases II. Lens based procedures:
g) ERG subnormal due to 1. Refractive lens exchange
chorioretinal atrophy
- For myopia of 16 to 18D,
Treatment of Myopia especially in unilateral cases.
(a) Optical treatment 2. Phakic refractive lens (PRL)
Principle: Using appropriate concave lens so - Being considered for correction of
that the rays are diverted & the image forms myopia of >8D.
on retina (c) General Measures
Balanced diet rich in vitamin & protein
Early management of associated
debilitating factor
(d) Low Vision Aids (LVA) - In pts with
progressive myopia with advanced
degenerative changes.
(e) Prophylaxis (Genetic counseling)

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Advising against marriage between two Classification:
individuals with progressive myopia.
A. Regular astigmatism
Note:
B. Irregular astigmatism
(i) Radial Keratotomy - Linear radial
incision (80% depth) are made in periphery A. Regular astigmatism: It occurs when the
in the cornea sparing a central optic refractive power changes uniformly from one
zone.The incision are allowed to heal meridian to another (i.e. there are two
spontaneously leading to paracentral principal meridia).
relative ectasia & resulting flattening of I. Depending on the axis and the angle
cornea. between two principal meridia:
(ii) ICR are inserted in a paracentral stromal
a. With the rule astigmatism
packets which leads to paracentral bulging
& central flattening. 2 principal meridia at right angles
(iii) PRK Excimer laser ablation of superficial Vertical meridian curvature greater
layer of cornea after removing the than horizontal
epithelium. Similar condition exists normally
(iv) LASIK - First the flap of 130-160 micron (about 0.25D), due to pressure of
thickness of ant. corneal tissue is raised. eyelids
Then midstromal tissue is ablated directly
b. Against the rule astigmatism
with an excimer laser beam.
Grading of myopia : [American optometric 2 principal meridia at right angles
association] Horizontal meridian curvature
Low myopia, when error is 3d. greater than vertical
c. Oblique astigmatism
Moderate myopia, when error is
between 3D to 6D 2 principal meridia are not
horizontal or vertical
High myopia, when error is 6D.
But are at right angles (e.g. 45o
Q.6. What is Astigmatism? Classify o
and 135 )
astigmatism. Describe the treatment of
Astigmatism (1+2+2) [KU 03] can be symmetrical or
complimentary
Q. Define Astigmatism. What is regular an d
irregular astigmatism? What is with the d. Bi-oblique astigmatism
rule and against the rule? (1+2+2) 2 principal meridia are not at right
o
angles (e.g. one at 30 and other at
[KU 07] o
100 )
Q What are the clinical features,
II. Depending upon refraction
investigation and treatment of
astigmatism? [TU] a. Simple astigmatism
In one meridian- rays focused on retina
A refractive error in which refraction varies
in different meridian due to which rays of In other meridian- rays focused either
light entering the eye cannot converge to a i. in front of retina Simple myopic
point focus but forms focus lines is called astigmatism, or
astigmatism. ii. behind the retinaSimple
hypermetropic astigmatism

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Ophthalmology Optics and Refraction
b. Compound astigmatism (v) In irregular astigmatism, signs of
Rays in both meridia focused either causative factor
i. In front of retina Compound Scarring of cornea
myopic astigmatism Decentration of lens
ii. Behind the retinaCompound Investigation
hypermetropic astigmatism For regular astigmatism:
c. Mixed astigmatism (i) Retinoscopy- reveals different powers
Rays in one meridian focused in in two different axis
front of retina (myopic) (ii) Keratometry- to measure corneal
curvature
Rays in other meridian focused
(iii) Jackson's cross cylinder & astigmatic
behind the retina (hypermetropic)
fan test
B. Irregular astigmatism to confirm the power & axis of
occurs when the refractive power cylindrical lens
changes irregularly from one meridian For irregular astigmatism
to another (i.e. there are multiple (i) Astigmatic dial
meridia) (ii) Placido's disc distorted circle
Types: (iii) Computerised corneal topography &
i. Curvatural photokeratoscopy
ii. Index Irregular corneal curvature
Symptoms Treatment
(i) Defective vision A. Regular Astigmatism
(ii) Blurring of objects (i) Optical treatment
a. Spectacles: Full cylindrical
(iii) Elongated objects based on type and
correction with perfect axis should
degree of astigmatism
be used for distant and near vision
(iv) Asthenopic symptoms, marked esp. in small b. Contact lens: Rigid lens 2-3D
amount of astigmatism
Soft contact lens for only little
- Dull ache in the eye astigmatism
- Headache Toric contact lens for higher
- Early tiredness of eyes degree
- Sometime nausea & even drowsiness (ii) Surgery
a. Astigmatic keratotomy by giving
(v) Polyopia in irregular astigmatism cuts in the direction of more
Signs curved axis.
(i) Different power in two meridia b. Removal of suture in
- on retinoscopy or autorefractometry. astigmatism following cataract
(ii) Oval or tilted optic disc may be seen in surgery or keratoplasty.
ophthalmoscopy in patients with high c. Photoastigmatic refractive
degree of astigmatism. keratotomy (PARK) using excimer
(iii) Head tilt - in an attempt to bring their laser.
axes near horizontal or vertical d. LASIK can correct upto 5D
meridian. (iii) Laser - Excimer laser is useful to
(iv) Half closure of eyelids - to achieve resharpen the cornea in particular
greater clarity of asthenopic vision. meridian.
B. Irregular Astigmatism

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Best treatment by contact lens (5) Compound astigmatic anisometropia
Phototherapeutic Keratectomy (PTK) Both eye astigmatic but of unequal degree
excimer laser may be helpful for
Symptoms:
superficial corneal ulcer responsible for
May be:
irregular astigmatism
i. Binocular single vision- in small
Surgical t/t: Penetrating keratoplasty i n
degree of anisometropia (<3D)
extensive corneal scarrring
ii. Uniocular vision one eye suppressed
Q.7. What is anisometropia? What are the due to its high refractive error
symptoms? How will you manage the case (anisometropic amblyopia)
(1+2+2) [KU 00] iii. Alternate vision
Q. What is anisometropia? What are its one eye is hypermetropic and
other myopic
types?
hypermetropic eye is used for
How will you manage? (1+2+2) [KU 04] distant vision & myopic for near
The optical state when the total refraction vision
of two eyes is unequal is called Management
anisometropia. (i) Diagnosis - by Retinoscopic examination
A difference upto 5% (2.5D) in retinal (ii) Treatment
images of 2 eyes is well tolerated. (a) Spectacles - Upto 4D
However some can tolerate upto 2.5 to 4D - If > 4D there occurs diplopia
but > 4D is not tolerated. (b) Contact lens - for higher degree
Note: Optical state with equal refraction in 2 eyes (c) Aniseikonic glasses
is called isometropia (d) Other modalities are
Types (i) IOL implantation for U/L aphakia
(ii) Refractive corneal surgery for
(1) Simple Anisometropia
U/L high myopia, astigmatism
One eye - Normal (Emmetropic)
& hypermetropia
Other eye - Myopic (Simple
myopic anisometropia) or (iii) Fucala's operation for U/L very
hypermetropic (simple hypermetropic high myopia.
anisometropia) - Removal of clear crystalline
(2) Compound Anisometropia lens
Both eyes either - Myopic Q.8. What is accommodation? Write about
(Compound Myopic anisometropia) or
range and amplitude of accommodation
hypermetropic (compound
hypermetropic anisometropia) and theories of accommodation. (1+2+2)
Refractive error in one eye is higher [KU 02, 03]
than in other.
(3) Mixed Anisometropia Q. Mechanism of accommodation. (4)
(antimetropia): Q. What is accommodation? How does
One eye - myopic accommodation affect the vision (2+3)
Other - hypermetropic
[KU 05]
(4) Simple astigmatic anisometropia
One eye- emmetropic Adjustment of the eye for various
Other eye- either simple myopic distances whereby it is able to focus the
or hypermetropic astigmatism image of an object on the sensitive layer of
retina is called accommodation.

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This is achieved by various adjustments
made in the eye. i.e.
Convergence of eye balls.
Constriction of pupil.
Increase in the anterior curvature of lens
Range of Accommodation (ROA):
The distance between near point
(punctum proximum) & far point
(punctum remotum) is called ROA.
Near point - Nearest point at which
small objects can be seen clearly
Far point - Farthest point at which eye
can see clearly.
Amplitude of Accommodation (A):
The difference between the
diopteric power needed to focus at near
point (P) & far point (R) is called
amplitude of accommodation.
Mathematically A=P-R.
P = 1/Distance of n e a r point of eye
(metres)
R = 1/Distance of far point of eye
(metres)
Theories of Accommodation:
(1) Young Helmholtz theory describes how the
anterior curvature of lens increases during
accommodation.
During near vision ciliary muscles
contract & draw the choroid forward. The
suspensory ligament relaxes and hence
the tension on the lens is released. The
lens due to its elastic property, bulges
forwards & hence the anterior curvature
of lens increases greatly.
(2) Besides increase in the anterior curvature
of the lens, two more adjustments are made
in the eyeball during accommodation for near
vision.
(i) Convergence of both eyeballs: to
bring the retinal images on the
corresponding points.
(ii) Constriction of pupil in order to
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(a) visual acquity by decreasing lateral
chromatic & spherical aberration.
(b) Reduce quantity of light entering
the eye &
(c) Increase the depth of focus through
more central part of lens as its
convexity is increased.
Pathway of Accomodation reflex :
Retina occipital cortex (area 17) Association fibres
Mid brainInternal capsuleFrontal eye field (area 8)
Third nerve nucleus of both sides
Contraction of Medial rectus Parasympathetic pathway
Convergence of eye ball
Edinger - Constriction in ciliary ring
westphal nucleus - Forward pull on ciliary body
Constriction of Increase in anterior
sphincter pupillae curvature of crystalline
lens.
Constriction of pupil.
Effects of accommodation in vision:
Accomodation helps to see the near
objects clearly by focusing the diverging light
rays coming from the near object on the
sensitive part of retina which is mainly
brought upon by accommodation reflex.
Accommodation reflex:
1. When the eye is at rest (unaccommodated),
the ciliary ring is large & keeps the
zonule tense. Because of zonular tension, the
lens is kept compressed (flat) by the capsule.
Ophthalmology Optics and Refraction
2. In accommodation a) Presbyopia : Difficulty in near vision in
(i) Contraction of ciliary muscles old age. Asthenopic sympoms due to fatigue
of ciliary muscles.
shortening of ciliary ring suspensory
ligament relaxes Elastic capsule of b) Insufficiency of Accommodation
lens acts unstrainedly to deform the (accommodative power less than normal for
lens the patients age)
substances lens alter its shape to All symptoms of presbyopia present.
become more convex (conoidal) Asthenopic symptoms more marked
than blurring of vision
c) Paralysis of accommodation (Cycloplegia)
Complete absence of accommodation
Blurring of near vision
Photophobia due to dilated pupil
d) Spasm of accommodation
(abnormally excessive accommodation)
Defective vision due to induced myopia
Asthenopic symptoms more marked
than visual symptoms
Q.9. What is Presbyopia? What are its
symptoms? How will you manage it?
(1+2+2=5) [KU 02, 07, 09]
Q. Describe briefly the t/t of Presbyopia. (2)
[KU 03]
Q. Pathophysiology of Presbyopia (1) [KU 08]
Presbyopia (eye sight of old age) is not an
(ii) Constriction of sphincter pupillae
error of refraction but a condition of
constriction of pupil
physiological insufficiency of
(iii) Contraction of medial rectus accommodation leading to progressive fall in
convergence of eyeball
near vision.
The resultant change in the shape of the
lens will even focus the diverging rays OR
coming from a near object on the retina in a A condition of falling near vision due to age
bid to see clearly. related decrease in the
amplitude of accommodation or increase in
punctum proximum
Occurs after 40-45 years of age.
Pathophysiology
There is diminution of accommodative
power of eye with age. The causative factors
Anomalies of accomodation: are:
Results in various problems which are: i. Lens matrix is harder & is less easily
moulded.

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Ophthalmology Optics and Refraction
ii. Lens capsule is less elastic i. Monovision LASIK
iii. Progressive increase in the size of lens ii. Monovision conductive
iv. Weakening of ciliary muscles keratoplasty (CK)
Symptoms iii. Presbyopic bifocal LASIK or
(1) Difficulty in near vision. LASIK-PARM.
Starts in evening & in dim light i.e. LASIK by presbyopia Avalos
Later even in good light Rozakis method.
It is progressive II. Lens based procedures
(2) Asthenopic symptoms due to fatigue of i. Bifocal or multifocal or
ciliary muscles accomodating IOL implantation.
Tiredness of eyes, frontal or fronto- ii. Monovision with intra occular
temporal headache, watering, mild lenses.
photophobia
III. Sclera based procedures
Seen after reading or doing near work.
i. Anterior ciliary sclerotomy (ACS)
(3) Inability to perform near work meticulously
e.g. sewing, threading a needle with tissue barriers.
(4) "Arms are not long enough" is a ii. Scleral spacing procedures and
common experience. scleral ablation with erbium.
Treatment Q.10.How will you measure visual acquity of a
(1) Optical treatment 45 years old lady? Outline the method in
Appropriate convex glasses for near work stepwise manner? (2+3) [KU 2000]
(Unifocal, Bifocal, Multifocal)
Age Correction in Diopter spherical
Q. How will you measure distant acquity of
a person visiting your OPD? If the
45 1Ds visual acquity improves when you use a
50 5 Ds pin hole what do you infer? (3+2) [KU01]
55 Ds
Visual Acquity (VA) is the estimation of
60 5 Ds
eye ability to discriminate between two
Add 0.5 Ds every 5 years points.
Basic principles for presbyopic correction:
Distant and near visual acquity should be
1. Always find out refractive error tested separately.
for distance and first correct it.
First visual acquity for right eye is tested,
2. Find out the presbyopic correction then left eye.
needed in each eye separately and add it
(1) For Distant Visual Acquity
to the distant correction.
The distant central visual acquity
3. Near point should be fixed by taking
is usually tested by
consideration for profession of the
patient. Snellen chart - for literate patients
4. The weakest convex lens with which E-chart & Landolt c-chart for
an individual can see clearly at the near illiterate patients
point should be prescribed. Simple picture / Toy chart -
(2) Surgical treatment for children
I. Cornea based procedures: The chart should be read at the distance

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of 6 meters or 20 ft. Visual acquity is written as Numerator/
Denominator
Denominator is the distance at which
the person is able to read.
Procedure
i. Pt. is seated at a distance of 6m from the
Snellens chart so that the light rays are
practically parallel, and the pt. exerts
minimal accommodation. The chart
should be properly illuminated. The pt.
is asked to read the chart with each eye
separately
ii. When the pt. is able to read upto 6m
line, the visual acquity is recorded as
6/6 (Normal). Similarly, depending
upon the smallest line which the pt. can
read from the distance of 6m, his vision
is recorded as 6/9, 6/12, 6/18, 6/24, 6/36
and 6/60 respectively.
iii. If he cannot see the top line from 6m, he
is asked to slowly walk toward the chart
till he can read the top line. Depending
upon the distance at which he can read
the top line, his vision is recorded as
5/60, 4/60, 3/60, 2/60 and 1/60
respectively.
iv. If he is unable to see the top letter when
close to it, he is asked to count the
extended fingers of the examiners hand
held up at about 1m against a dark
background. His vision is recorded as
CF- 3, CF-2, CF-1 or CF close to face,
depending upon the distance at which
the pt. is able to count fingers
v. If he cannot count fingers, the examiner
moves his hand close to the pt.s face. If
he appreciates hand movements (HM),
VA is recorded as HM +ve.
vi. If he is unable to see these, he is taken
into the dark room and a light is focused
on his eye and he is asked to say when
the light is on and when it is off. If
he succeeds in doing this, VA = PL +ve
(perception of light) and he may be able
to give some indication of the four
directions from which the light is
directed up, down, right and left.

IIIrd MBBS [An Easy Approach] / 13

Ophthalmology Optics and Refraction
This is recorded as projection of rays
(PR), light, accurate or inaccurate in
each quadrant. If he fails to see the light,
his vision is recorded as VA = PR -ve
(2) For Near Visual Acquity
Pt is asked to read the near vision
chart kept at distance of 35 cm in good
illumination with each eye separately.
In near vision chart, a series of
different sizes of printer types are
arranged in increasing order & marked
accordingly.
Commonly used near vision chart are:
1) Jaeger's chart: 7 print marked as
J1 to J7
2) Roman test types: Near vision is
recorded as N5, N8, N10, N12
3) Snellen's near vision test chart.
Pin Hole Test
The initial measurement gives the VA of
the eye unaided by the lenses.
If the vision is subnormal, VA is
again determined by asking the pt. to read
the letters through a pin hole.
If visual acquity improves by
using pinhole, it indicates an underlying
refractive error.
Hence, pin hole test helps in
confirming whether the optical
correction in the trial frame is correct or
not.
It is necessary in all cases to determine
the function of the macula in best
optical conditions.
Note:
Listings reduced eye- is the simplified schematic
eye taking single principle point and single nodal
point, midway between two principle points and
two nodal points, respectively.

14 / III rd
MBBS [An Easy Approach]
Ophthalmology Optics and Refraction

Multiple Choice Questions

1. The refractive power of emmetropic eye is 11. Myopia and Hypermetropia are corrected by:
a. +50D b. +55 D a. Convex and concave lens respectively
c. +60 D d. +65 D b. Concave and convex lens respectively
2. Condition of eye with refractive error is: c. Cylindrical lens
a. Ametropia b. Emmetropia d. None
c. Anisometropia d. Anisokonia 12. When light passes through prism it
3. At birth eye is: deviates towards
a. Hypermetropic b. Myopic a. Apex b. Surface
c. Emmetropic d. Aniseikonic c. Sides d. Base
4. Refractive power of lens is 13. In Against- the-rule astigmatism:
a. +20 Diopters b. +40 Diopters a. Vertical meridian is more curved than
c. +30 Diopters d. +60 Dipters horizontal
5. The most common type of refractive error b. Horizontal meridian is more curved than
is: vertical
a. Hypermetropia c. Both meridia are equally curved
b. Myopia d. None of the above
c. Astigmatism 14. VA is expressed in fractions, It has a
d. None of the above numerator and denominator. Normally
6. In myopia, axial length is: numerator is
a. Shorter than normal a. 1 meter b. 3 meter
b. Longer than normal c. 6 meter d. 20 meter
c. Pupil is smaller 15. Accomodation is the function of:
d. Optic nerve head is larger a. Cornea b. Iris
c. Crystalline lens d. Vitreous
7. In high Hypermetropia,
16. A person is blind, when his better eye has
a. Distance vision is blurred
vision:
b. Near vision is blurred a. Less than 6/60 b. Less than 5/60
c. Both near and distance vision can be c. Less than 3/60 d. Less than 4/60
blurred 17. Pathological changes in fundus are
d. Usually the condition is asymptomatic commonly seen in:
8. One millimeter decrease in axial length of a. Hypermetropia b. Myopia
the eyeball leads to hypermetropia of: c. Astigmatism d. Presbyopia
a. 6 dioptres b. 2 dioptres 18. Presbyopia is mostly seen after:
c. 3 dioptres d. 4 dioptres a. 30 years b. 35 years
9. The standard power of an IOL implanted c. 40 years d. 49 years
in posterior chamber is: 19. Pin hole improves vision in case of:
a. 18 dioptres b. 25 dioptres a. Optic atrophy
c. 20 dioptres d. 23 dioptres b. Hypermature cataract
10. Near vision correction may be needed in: c. Myopia
d. RD
a. Myopia
20. Myopia of >6D should be:
b. Hypermetropia a. Under corrected
c. Astigmatism b. Not corrected
d. Presbyopia c. Over corrected
d. Fully corrected

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Ophthalmology Optics and Refraction
21. Myopia is seen in: 24. Hard contact lens are made up of:
a. Larger axial length a. Silicon b. Glass
b. Posterior staphyloma c. PMMA d. HEMA
c. Keratoconus 25. Aniseikonia refers to:
d. All a. Difference in corneal diameter
22. When there is difference in refractive b. Difference in image size retinal image
power of the various meridians of the eyes, c. Difference in refractive power
the condition is called: d. Difference in image colour
a. Hypermetropia 26. An image is focused 50 cm to the right of a
b. Myopia lens. The object is located 12.5 cm to the
c. Anisometropia left of the lens. The object is located 12.5
d. Astigmatism cm to the left of the lens. What should be
23. Soft contact lens is made up of: the power of lens?
a. Silicon b. PEMMA a. +7 D b. +3 D
c. HEMA d. Plastic c. +8D d. +10 D
Answers :

1.c 2.a 3.a 4.a 5.c 6.b 7.c 8.c 9.c 10.b
11.b 12.d 13.b 14.c 15.c 16.c 17.b 18.c 19.c 20.a
21.d 22.d 23.c 24.c 25.b 26.d

PBQs
1. A 26 years old student has presented in Reasons:
your OPD room with chief complaint of i. Problem with distant vision
difficulty in reading letters in blackboard
during class for last 3 years. On ocular ii. Vision improved with pinhole
examination unaided visual acquity of both iii. Deep anterior chamber (AC)
RE and LE is 6/36 and with pinhole visual
acquity is 6/6 in both eyes, EOM- full, iv. Fundoscopy: temporal myopic
Anterior chamber deep. Direct fundoscopy crescent
reveals large oval pink disc with temporal c. What are the treatment modalities?
crescent in both eyes.
Refer to previous questions.
a. Write differential diagnosis.
2. A 10 years old boy presented to OPD with
D/D complaints of blurring of vision for
Myopia distance both eyes sinces months. There
Corneal degeneration was no history of redness or pain. On
examination of VA, unaided VA was 6/60 in
Developmental cataract the RE and 6/36 .. he LE. On doing
Corneal dystrophy refraction, it improved to 6/6 in BE. His
b. What is the most likely diagnosis? acceptance in RE was -2.0 Dsph/-1.0 Dcyl
Give reasons. @ 90 and in was -2.0 Dsph.
Most likely diagnosis is : Myopia 4+6=10

16 / III rd
MBBS [An Easy Approach]
Ophthalmology Optics and Refraction
a. Write provisional diagnosis of Right b. What are the various treatment options
eye and Left eye separately. of this condition?
= compound myopic astigmatism in rt. Eye
and simple myopia in lt eye

IIIrd MBBS [An Easy Approach] / 17