REFRACTION DISORDER

REFRACTION

• Process to measure a patient’s

refractive error
• Determine optical correction needed to
focus light rays from distant & near
objects onto retina
• Provide the patient with clear &
comfortable vision
 REFRACTIVE MEDIA
1. KORNEA
- Contribute ±2/3 of refracting power
of the eye → 43 D
2. THE LENS
- Contribute 1/3 of refractive power of
the eye → 20 D
- Total convergence power of the eye
58,7 D (not 43 ± 20 D) due to the distance between
the cornea & the lens (deep of anterior chamber) that
substract → 4 D ( ±63 – 4 D = 58,7 D)
 REFRACTIVE MEDIA, cont..
3. THE PUPIL
- Reduce amount of light
enters the eye
- Decrease aberrations
- Increases the depth
of focus when costricting
 REFRACTIVE STATES OF THE EYE

• Emmetropia
• Ammetropia
1. Myopia
2. Hyperopia
3. Astigmatism
 EMMETROPIA
• Emmetropia (normal vision) Eye focusing power perfectly
matched to globe length
• Image focused precisely on retina
• Normal vision confers focal length of infinity
 AMMETROPIA
Mismatch between the optical power & length of the eye

Etiology :
Ammetropia Refractive apparatus Axial length is
(cornea and lens) is

Axial myopia Normal Too long

Refractive myopia Too strong Normal

Axial hyperopia Normal Too short

Refractive hyperopia Too weak Normal

MYOPIA
(Nearsighness)

• Focused image in front of the retina

 CAUSE OF MYOPIA
1. Causes Autosomal dominant inheritance
– Mild Myopia (-0.5 to -2.0 D) by age 5 to 8 years
– Moderate Myopia (-2.0 to -5.0 D) by age 8-14
– Severe Myopia (<-6.0 D) by age 20 to 28 years
2. Environmental Cause (Prolonged reading, close
work)
– Mild Myopia (-0.5 to -2.0 D) by age 8-14 years
– Moderate Myopia (-2.0 to -5.0 D) by age 20-28
 CAUSE OF MYOPIA cont..
1. Structural or axial myopia ⇒ Antero-
posterior (AP) diameter longer than
normal (N)
2. Curvature myopia ⇒ AP diameter is
normal, but corneal curvature steeper
than N
3. Increased index of refraction
4. Anterior displacement of the lens
 SYMPTOMS OF MYOPIA
• Blurred vision for distance
• Squint (due to blepharospasm- like action to act
as a pinhole)
• Headache

• Myopic school → usually detected at 9-10 yo,

increase till mid-teens (stable at ≤ S-5,00D)
• Progressive myopia, increase up to -4 D/year,may
reach up to -10 D or – 20 D → predispose to
retinal detachment & primary open angle
glaucoma
 HYPEROPIA

• Hyperopia (Farsightedness) Normal in

infants (+0.50 to +2.50 Diopters)
– Vision normalizes by age 5 to 8 years old
• Light rays focus behind cornea
– Cornea too flat or lens too weak for globe
– Near objects not seen clearly
• Correction: Convex lenses (convergent,
plus power)
 CAUSE OF HYPEROPIA
1. Structural or axial hyperopia → AP
diameter shorter than N
2. Curvature hyperopia
3. Index of refraction hyperopia
• LATENT HYPEROPIA : part of the refractive
error completely corrected by accomodation,
only be measured by cycloplegic refraction &
not manifest refraction
• MANIFEST OR ABSOLUTE HYPEROPIA :
part of hyperopia not corrected by
accomodation
• FACULTATIF HYPEROPIA = MANIFEST
HYPEROPIA – ABSOLUTE HYPEROPIA
 HYPEROPIA
Ex : Patient 25 yo, visual acuity 6/20
- Correction with S + 2,00 D → 6/6
- Correction with S + 2,50 D → 6/6
- Correction with cycloplegik S +5,00 D→ 6/6
So, this patient have :
- Absolute hyperopia S +2,00 D
- Manifest hyperopia S + 2,50 D
- Facultatif hyperopia = S +2,50 – S+2,00 = S+0,5D
- Latent hyperopia S +5,00 D – S +2,50 D =
S +2,50 D
SYMPTOMS OF HYPEROPIA
• Blurred vision for distance
• Frontal headache ⇒ prolonged use of near
vision
• Asthenopia : fatigue, burning eye sensasion &
periorbital pain when fixing at an object for
prolonged periods of time
• Light sensitivity
• Decreased in near visual acuity at a younger
age than in emmetropic eyes
 ASTIGMATISM
• Astigmatism
– Non-spherical
corneal surface
– Parts of surface
(meridians) are
steeper than others
– Objects blurry at any
distance
– The curvature of the optical systrm varies in
different meridians thus refracting the incident
ligth differently in those meridians
 ASTIGMATISM
• With the rule astigmatism : the vertical meridians is
steeper
• Againts the rule : the horizontal meridians is steeper
• Regular astigmatism : Principles meridians are 90⁰
apart
• Irregular astigmatism : Principles meridians are not
90⁰ apart, can’t be completely corrected by
spectacles,
but with contact lens
 REGULAR ASTIGMATISM

SIMPLE ASTIGMATISM

Lens correction C - Lens correction C +

 REGULAR ASTIGMATISM

COMPOUND ASTIGMATISM

Lens correction S (-) C (-) Lens correction S (+) C (+)

 REGULAR ASTIGMATISM

MIXED ASTIGMATISM

Lens correction S (-) C (+)

S (+) C (-)
 SYMPTOMS OF ASTIGMATISM

• Blurred vision for far and near

• Squint (for pinhole effect)
• Asthenopic symptoms
• Frontal headaches
• Tilting of the head
TRANSPOSITION OF SPHEROCYLINDRICAL
NOTATION
TRANSPOSITION OF SPHEROCYLINDRICAL NOTATION
New sphere = old sphere + old cylinder
New cylinder = old cylinder, but with opposite sign
New axis = old axis changed by 90⁰

Ex : - 0,75 + 0,50 x 180 -0,25 -0,50 x 90

Ex :
MANAGEMENT REFRACTIVE ERROR

1. Management: Refractive Error Correction

Non-Surgical Options (Myopia : concave
lens, hyperopia : convex lens, Astigmatism :
cylinder lens)
- Eye Glasses
- Contact Lenses
2. Refractive surgery
- Laser In Situ Keratomileusis (LASIK)
- Intrastromal corneal ring (ICR)
- Phakic Intraocular Lenses
 AMBLYOPIA
• Decreased visual acuity of one eye (uncorrectable
with lenses) in the absence of :
- Organic eye disease insufficient enough to
explain the level of vision
- Caused by visual deprivation due to any cause
(congenital or acquired ) during the critical
period of development (up to age 8-9 yo) that
prevents the establisment of normal vision in
the involved eye
 CAUSES OF AMBLYOPIA
• Strabismus (most common cause)
• Anisometropia
• High hyperopia
• Opacities : corneal scars, cataract
• Optic nerve disease
• Retinal disease
 LOW VISION

Impaired visual function

Full remediation, not

possible :

Conventional spectacles,
contact lens,
medical intervention

RESTRICTION EVERYDAY
LIFE
 LOW VISION (WHO)
Impairment visual function
After R/ Standart refractive correction

Visual acuity < 6/18 – 1/~

Visual field < 10⁰

Potentially able to use

Planning Execution task
 CAUSE OF LOW VISION
• Children : Optic atrophy, Congenital, cataract,
Congenital idiopathic nystagmus, Congenital
abnormalities of the brain & nerv system
• Early adult life : Stargard’s disease, Retinitis
pigmentosa
• Working years: Diabetic retinopathy (>>),
Myopia,Uveitis,
Corneal dystrophies, Degenerative condition
(cataract & macular disease)
• Retirement : Cataract, AMD, Glaucoma, Retinal
detachment
 SYMPTOMS OF LOW VISION
• Difficulty in : - reading
- recognize people’s face
- task → fine detailed vision

• Color vision deficits

• Contrast sensitivity variably affected
• Mobility not affected
 LOW VISION AID

• OPTICAL DEVICES :
- Microscopic glassess
- Hand magnifiers
- Stand magnifiers
- Telescope
- Closed-circuit Television
(CCTV)
 LOW VISION AID

• NON OPTICAL DEVICES

- Typoscope
- Standing reading book
- Writing frame
- Sunglassess lens
- Large print
- Contrast
 ACCOMODATION
• Accomodation ⇒ mechanism the eye
changes refractive power by altering the
shape of its crystalline lens
• The posterior focal point is moved
forward in the eye during
accommodation so far point moves
closer to the eye
 ACCOMODATION
• It is the process by the eye changes its
refractive power to focus on near
objects. It results from increased
curvature of lens due to contraction of
the ciliary muscle. The stimulus to
accomodation is a blurred retinal image.
 PRESBYOPIA
• It’s physiologic disease in the amplitude
of accommodation associated with
aging
• There is less bulging of the lens with
accommodation due to a change in the
crystalline lens that result in decrease in
the elasticity of the lens fiber or
hardening of the lens
 SYMPTOMS OF PRESBYOPIA

• Larger reading distance required

• Inability to focus on close work
• Excessive illumination required for close
work
 TREATMENT OF PRESBYOPIA

• Add positive lenses correction

according to age
- 40 yo : S + 1,00 D
- 45 yo : S + 1,50 D
- 50 yo : S + 2,00 D
- 55 yo : S + 2,50 D
- 60 yo : S + 3,00 D
- > 60 yo : S + 3,00 D