Error of Refraction
HAZEL KAREN N. RAZ
JUNIOR INTERN
D E PA R T M E N T O F C O M M U N I T Y
A N D FA M I LY M E D I C I N E
Refractive errors
(Ametropia)
Symptoms and Signs of Refractive Error
Cardinal sign
decreased visual acuity
Asthenopia weakness
or easy fatigability of the
eyes
Headache discomfort
should be related to the
use of the eyes and
relieved when the eyes
are not in use.
Refractive Errors
Hyperopia Farsightedness
Myopia Nearsightedness
Axial Abnormality in the length of the eye
Abnormality in the refractive power of cornea
Refractive
or lens
Unequal refracting power of the lens in
Astigmatism
different meridians
Presbyopia Decreased accomodation with aging
Aphakia Absence of the crystalline lens
Inequality in the refractive power of the two
Anisometropia
eyes
Hyperopia
Hyperopia
The refractive condition
in which, with
accomodation
suspended, parallel rays
of light are intercepted by
the retina.
Usually due to:
eyeball that is too short
Axial hyperopia
lens system that is too
weak
Refractive hyperopia
The image forms behind the
retina
Signs of hyperopia
Small globe
axial hyperopia
Pseudopapilledema
blurring of the optic disc margin
Papillitis
inflammation of the optic nerve at the level of the disk
Ocular symptoms may originate with excessive
sustained accomodation required for clear vision.
Myopia
Myopia
Optical condition in which
rays of light entering the
eye parallel to the visual
axis come to a focus in
front of the retina.
Usually due to:
eyeball that is too long
Axial myopia
A lens system that is too
strong
Refractive myopia
The image forms in front of the
retina
Type Cause
Onset between 5 10 up to
Axial
Inadequate correlation of the 25 years old.
Physiologic refractive power of the Gradually increases until 18
myopia cornea and lens with the y.o when the eye is fully
length of the globe. grown.
Refractive Seldom exceeds 6 diopters.
Commonly begins as
Axial length of eye is physiologic myopia
Pathologic/
excessive because of > 6 Diopters
degenerative Axial
myopia overgrowth of the posterior The eye continues to enlarge
2/3 of the globe rather than stabilizing when the
globe is adult size.
Occurs in uncontrolled DM,
Due to increasing refractive
Lenticular nuclear sclerosis (aging)
Refractive power of the crystalline lens
myopia Drugs s.a. hydralazine,
(anterior segment).
chlorthalidone, phenothiazines.
Astigmatism
Astigmatism
Optical condition in which
the refracting power of
the lens (or an eye) is
not the same in all
meridians.
This most often results
from too great a
curvature of the cornea
in one plane of the eye.
Parallel rays form an object do
not fall on a single point.
Types of Astigmatism
Meridians of minimal and maximal refraction are at right
Regular
angles to each other
Irregular Meridians are not at right angles to each other
Simple One meridian is on the retina
Simple myopic The other meridian is anterior to the retina
The other meridian is intercepted by the retina before
Simple hyperopic
coming to focus
Compound Both meridians do not fall on the retina
Compound myopic Both meridians in front of retina
Both meridian s intercepted by retina before coming into
Compound hyperopic
focus
One focal line is in front of the retina, the other is
Mixed
intercepted by the retina
Regular astigmatism Irregular astigmatism
The cornea has two Cornea has three or
different radii of more different curvatures
curvature at right angles Causes:
to each other. Corneal scarring
Causes Keratoconus
Biologic variant Variations in radii of
Due to weight of upper curvature of the crystalline
eyelid resting on eyeball lens lenticular
Surgical incisions into the astigmatism (minor
cornea degrees of astigmatism)
Trauma/ scarring of
cornea
Tumors of the eyelid/
chalazion
The cornea
becomes cone
shaped with the
apex of the cone
below and nasal to
the corneal center.
Keratoconus
Symptoms of Astigmatism
A distinct retinal image
cannot form
The changes in
accomodation cause
symptoms
Severe astigmatism may
cause the optic disc to
appear oval rather than
nearly circular.
Presbyopia
Presbyopia
Changes in aging:
Lens capsule less elastic
Lens nucleus becomes
harder
Gradual loss of
accomodation
Starts at about 40 y.o.
May also be due to
decreased strength of
ciliary body musculature
Presbyopia
Chief symptom
Inability to see near work
distinctly which is
aggravated in dim
illumination and with
attempts to read small
print.
There is a need to place
reading matter farther
away from the eyes.
Aphakia
Aphakia
The crystalline lens is
displaced and not in line
with the visual axis.
Causes:
Surgical removal
Marfan syndrome
2o to trauma
Leads to severe
hyperopia and loss of
accomodation
Aphakia
Chief symptom Diagnosis:
decreased vision for both Loss of reflected image
near and far from the surface of the
No symptoms of ocular
lens
discomfort since Excessive movement of
the iris because of the
accomodation is not
loss of support of the
possible. anterior lens capsule
(iridodonesis)
Aphakia
Corrected by means of
intraocular lens
Placed immediately
behind the iris after an
extracapsular cataract
extraction.
An additional convex
lens is required for near
work.
Anisometropia
Anisometropia
Condition in which the
refractive error of each
eye is different (at least
>2 diopters)
Neutralized by
Prescribing the
appropriate prism in the
reading segment
Using separate lenses for
near and far vision
Correction of Refractive
Errors by Use of Lenses
Convex spherical lens Concave spherical lens
Correction of Optical Abnormalities by
Use of Contact Lenses
Held in place by a thin
layer of tear fluid that fills
the space between the
contact lens and the
anterior eye surface.
It nullifies almost entirely
the refraction that
normally occurs at the
anterior surface of the
cornea.
Correction of Astigmatism
Neutralized by cylindrical
lenses which allows a
line of focus to form,
which parallels the axis
of the lens.
Hard contact lenses may
be used to correct
irregular astigmatism.
In keratoconus corneal
transplant should be
considered
Correction of Presbyopia
Treated by convex
lenses addded to the
distance correction
Weakest possible convex
lenses to permit individual
to carry on different tasks.
Trifocal/ Bifocal lenses
If require lenses for
distance without changing
glasses.
The Surgical Correction of
Refractive Errors
Surgical procedures:
LASIK (Laser In Situ Keratomileusis)
PRK (Photoreactive Keratectomy)
Radial Keratotomy
INTACS - implants within the corneal stroma
Phakic intraocular lens implants - lens implants in
the eye
Advantages Disadvantages
In case of high refractive All surgical procedures
errors, the error may be have a statistical failure
brought down to a more rate which may range
manageable level so that from improper correction
it can be corrected by to loss of the eye
other means Costly instrumentation
No need for glasses, and surgery
contact lenses, no Not freely available
maximum wearing time Stringent case selection
LASIK(Laser-Assisted In Situ Keratomileusis)
A surgical procedure
intended to reduce a
person's dependency on
glasses or contact lenses.
Most commonly performed
as a cure for myopia), but
can also be used to cure
hyperopia or astigmatism.
Permanently changes the
shape of the cornea using
a special laser and thus
focusing the light rays
exactly on the retina.
Ambulatory procedure
PRK - Photorefractive Keratectomy
Original excimer laser
procedure for reshaping the
cornea.
Laser is applied to the
surface of the cornea after
the epithelium is removed
Discomfort is greater and
the visual recovery
prolonged compared to
LASIK
Range of refractive errors
which can be corrected by
PRK is also not as wide as
that of LASIK
Radial Keratotomy (RK)
More commonly
performed before the use
of excimer lasers
Surgical procedure used
to decrease myopia by 2
6 diopters
Procedure is less
predictable and less
stable than laser vision
correction.
INTACS
Microthin polymer ring
segments
Placed under the outer edge
of the cornea.
Advantages:
reversibility
tissue is not removed and the
eye is not structurally
weakened
delivers an excellent quality of
vision
Disadvantages:
only approved for low levels of
myopia and does not correct
astigmatism
Phakic Intraocular Lens Implants
Lenses made of plastic or silicone
that are implanted into the eye
permanently to reduce a person's
need for glasses or contact lenses
Phakic refers to the fact that the lens
is implanted into the eye without
removing the eye's natural lens.
During phakic lens implantation
surgery, a small incision is made in the
front of the eye.
The phakic lens is inserted through
the incision and placed just in front of
or just behind the iris.
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