Management of Refractive Errors PDF

MANAGEMENT OF
REFRACTIVE ERRORS AND

PRESCRIPTION OF SPECTACLES
MANAGEMENT OF
REFRACTIVE ERRORS AND
PRESCRIPTION OF SPECTACLES
Yogesh Shukla
MS (Ophthalmology)
Professor
National Institute of Medical Sciences
Jaipur, Rajasthan, India
Fellowship, Anterior Segment
Eye Foundation of America
West Virginia, USA
Fellowship, Pediatric Ophthalmology and Strabismus
Johns Hopkins University Hospital, USA
Director
Rajasthan Nursing Home and Eye Center
Jaipur, Rajasthan, India
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Management of Refractive Errors and Prescription of Spectacles
First Edition: 2015

ISBN: 978-93-5152-884-5
Printed at:
Dedicated to
My parents,
who brought me in this world;
so that I could write this book
to help millions of visually impaired
Preface
This book is for the clinicians. Both for the learning and the learned
ones!
Its aim is to sharpen the judgment and skills. And its goal is to
increase the yield of satisfied patients.
It is really disturbing and unfortunate that with the development
of subspecialties, we have lost touch with many basics of
ophthalmology, gone casual on many aspects, and the so-called
superspecialists in ophthalmology, consider dealing in basics as
demeaning. One of such areas is refraction and treating refractive
errors. So much so that, I have encountered patients lamenting that
they were been sent to an optician for spectacle correction as the
ophthalmologist is very busy for such a small work !
According to very recent studies, 800 million to 2.3 billion people
are affected by refractive errors worldwide. Myopia tops the list,
with 80–90% of population suffering in some countries of Asia. This
mammoth prevalence of refractive errors, speaks for itself about the
ocular disorder. And to add salt to the injury, the incidence of these
errors, particularly myopia, is on the rise.
Proper evaluation of refractive errors and spectacle prescription
are and will remain an integral part of ophthalmic practice.
In a general eye hospital, almost 90% of patients come with
complaints of defective vision, whether due to actual refractive
errors or errors induced by diseases of eyes. Even a patient with
early cataract can be very suitably corrected with spectacles
and continue his daily work for a long-time. And, therefore,
a thorough knowledge as to how to properly correct his induced
refractive error with specs, is paramount.
To meet these ends, the book is laced with clinical points that can
aid in finding the refractive error properly and translating it into the
best possible pair of glasses.
The book is not only a theoretical narration of principles of
refraction, but also enumerates and illustrates a myriad problems
viii Management of Refractive Errors and Prescription of Spectacles
and pitfalls that lie to trap the unwary, the casual and even, at times,
an experienced clinician.
Many a times, it is the fine tuning of the previous prescription
(of some other clinician), which satisfies the disgruntled patient.
Learning these, the book is the hallmark of a skilled refracting
ophthalmologist, one who has mastered the art of prescribing
spectacles!
Though certain relevant refraction tests and procedures are
mentioned or described (which are standard textbook procedures),
the book is not meant to describe the basics of refraction. It is
assumed that the reader has already acquired the basic knowledge
of refraction. The book will further enhance its commitment towards
refraction, the ability to deal with pitfalls and problems faced in
certain patients, and to fine tune his refracting skills.
Also equally important is to have knowledge of the various types
of lenses available in the market, which one to prescribe, suitability
of individual patient, and how to prescribe. The type of frame to be
worn for a particular type of refractive error is also of paramount
importance.
All of these, including the type of lenses to be used, is left to the
fancy of the patient and the whim of the optician.
Therefore, the book will also give an account of what type of
lenses are available in the market, their specific qualities, what is
suitable for a particular refractive error, how to prescribe a particular
type of lens for a particular patient, and more importantly, the type
of frame to be used for optimum comfort to the patient.
A humble, sincere and unbiased effort is made to update the
clinicians, and to revive his interest in treating refractive errors and
to fine tune his abilities and skills.
Yogesh Shukla
Contents
1. Accommodation 1
• How to Test Accommodation 3
• Accommodation and Convergence 5
• Excessive Accommodation Amplitude 6
• Accommodation Spasm 6
• Subnormal Accommodation 9
• Refractive Errors and Accommodation 10
• Pearls 12
2. Cycloplegia 13
• Contraindications 15
• Some Special Situations 15
• Qualities of a Cycloplegic Drug 16
• Cycloplegia and Glaucoma 20
• Clinical Pearls 21
3. Hyperopia 23
• Etiopathogenesis 24
• Children 25
• Presbyopia 30
• Intermediate Vision 31
4. Myopia 33
• Causes and Progression of Myopia 34
• Classification 35
• Management 36
• Quasi-Myopia 40
• Unilateral Myopia 41
• Pseudomyopia 42
• Night Myopia 45
• Presbyopia and Myopia 46
• Pathological Myopia 47
5. Astigmatism 49
• Prescriptions 49
• Ciliary Overtures 54
• Bifocals in Astigmatism 55
• Irregular Astigmatism 57
x Management of Refractive Errors and Prescription of Spectacles
6. Presbyopia 60
• How to Determine near Correction? 62
• Bifocals in Children 63
• Near Correction in Adults 64
• Bifocals in Presbyopia 65
• Bifocals for Reading in Bed 68
• Presbyopia and Contact Lenses 68
• Presbyopia in Myope 69
7. Anisometropia and Antimetropia 74
• Symptomatology of Anisometropia 75
• Aniseikonia 76
• Antimetropia 78
• Anisophoria 81
• Correction in Vertical Gaze 82
• Anisometropia in Children 85
8. Aphakia 92
• Monocular Aphakia 92
• The Bilateral Aphake 93
• Spectacle Management in Aphakia 94
• Refracting an Aphake 96
9. Pseudophakia 98
• Monocular Pseudophakia 98
• Bilateral Pseudophakia 99
• Unusual Cases 100
• Pseudophakia in Children 102
10. Medical Problems and Refractive Error 104
• Effect of Change in Size or Shape of Eye 105
• Glaucoma 105
• Changes in Cornea 105
• Crystalline Lens 106
• Ocular Media and Lens 106
• Changes in Accommodation 106
• Ocular Asthenopia as a Part of Illness 107
11. The Legacy of Spectacles 109
• History 109
• Lenses 110
• Modern Lenses 111
• Plastic Lenses 112
• Polycarbonate 113
Contents xi
12. Types and Quality of Lenses 114

• Refractive Index 114
• Density 115
• Abbe Number 115
• UV Cut-off 116
• Curve Variation Factor 116
• Lens Materials 117
• Summary 119
• Absorptive Lenses 120
• Progressive Power Lenses 126
13. Prescription of Spectacles 129
• Weight, Thickness and Warpage 130
• Decentrations 130
• Pantoscopic Tilt of Frames 132
• Spectacle Fitting in Children 133
• Frames of Spectacles 134
14. Psychodynamics of Spectacles 138
• Ocular Neurosis 140
• The Doctor-Patient Rapport 141
15. The Visually Handicapped 143
• Reasoning for Success Management 144
• Examination and Refraction 146
• Determining the Best Aid 146
• Optical Aids 147
Index 151
Introduction
In my spare time, I often look-up to a quote that says, “It is a terrible
thing to see and have no vision.” It is a quote from a woman whom we
all know and love—Hellen Keller. She was an inspirational woman,
who taught the world to respect people who are blind! Her mission
obviously came from her own life, when she became terribly ill at the
age of 2 years, and lost both—her vision and hearing.
We are very blessed to have the gift of vision and need to embrace
life to the fullest.
The above paragraph comes in context of how people in this
world are getting needlessly visually handicapped and some even
blind, for very simple reasons such as uncorrected refractive errors.
A prominent example is amblyopia, almost 5% of population is
visually handicapped because of amblyopia. Refractive errors are
and will remain a major field where eyecare physicians must properly
understand each refractive error as each patient may be different,
and acquire skills of refraction, especially in young children.
As already stated, global refractive errors have been estimated to
affect 800 million to 2.3 billion people worldwide. In a recent WHO
update, 265 million people are visually impaired (including all causes
affecting vision); 245 million have severe visual impairment (visually
handicapped) and 39 million are blind. Among the major causes of
impaired vision, 43% is due to ‘uncorrected refractive errors’, and
33% due to cataract. Such a magnitude of uncorrected refractive errors
demand a serious and sincere attention, which has unfortunately
waned in the recent years.
You will everyday come across patients who have wandered to
quite few doctors but remained unhappy with their glasses. There
is your test. Dealing conscientiously with these patients and fine
tuning their previous refractions to their satisfaction, will bring out
your clinical acumen and the patient will bless you for whole life.
In this reference, before embarking on the examination of the
patient, remember some tips, as how to proceed. Firstly, take a pro
per history as to the actual complaints of the patients, some may be
relevant while others irrelevant. Ocular asthenopic problems are wide
xiv Management of Refractive Errors and Prescription of Spectacles
and varied, but you have to sort out which may be actually concerned
with eye. One of the most unfortunate things happening in a busy
outdoor is that in patients complaining of headaches, their vision is
first recorded, and finding normal vision of 6/6, they are declared fit, as
far their eyes are concerned, and promptly referred to ENT specialists
or neurophysicians, for further needful. This is where you fall into the
pit. You will be surprised that a large number of these patients have
real ocular asthenopic symptoms and when you do a cycloplegic
refraction, a large number of them will reveal a refractive error.
Therefore, the second pearl is that do not ignore the symptoms
and a normal eyesight does not preclude a refractive error! Each and
every such patient must undergo a proper cycloplegic refraction and
also a careful evaluation of muscle balance.
Thirdly, having done a proper examination and refraction and
once a refractive error has been determined, look for the need of
the patient, the age, the type of vocation, the mental make-up, and
his acceptance for glasses. There are of course ‘rules of thumb’, in
prescribing spectacles, but if you have detected astigmatism for
the first time, the patient may not adjust abruptly to a cylindrical
correction, especially if it is more than 1 diopter or the axis is oblique.
In such cases, a gradual increment with time is advisable.
Another pearl: All patients in presbyopic age are usually advised
regular check-up every 2 or 3 years, as spectacle correction increase
with age. If such a patient comes for check-up at the stipulated time
advised, please check the correction, the person is wearing and
enquire about complaints. If he says that he has no complaints, and
he is happy with his present near correction, do not tamper with it.
There are a number of reasons for happiness, these will be dealt in
chapters ahead, and the patient is best left alone advising politely to
come when symptoms ensue.
Much exercise of thought and research has gone into writing of
the book. It does not only have the standard description of refraction
errors and related conditions, but also relevant examples of long
years of clinical practice.
Your journey through the following chapters should be a pleasant
one, where hopefully you will learn and understand the intricacies of
management of refractive errors and will enlighten yourself to the
fine tuning of spectacle correction and become master of spectacles
rather than getting enslaved by the optician.
1
Accommodation
INTRODUCTION
Accommodation is the ability of the eye to increase its power, by
virtue of which, one is able to see clearly from distance to near. The
accommodation is measured in diopters (D).
It is to be understood that accommodation does not only involve
the change in the shape of the crystalline lens and thus its power,
but the mechanism of accommodation also involves the neuro-
muscular effort to accomplish this change in power. Thus, we have
the accommodation ‘effort’ and the accommodation ‘effect’.
The neuromuscular ‘effort’ involves the nerves supplying the
ciliary muscles and the efficiency of the ciliary muscles themselves.
The ‘effect’ is manifested by the change in curvature of the lens and
its capsule.
It is to be further noted that accommodation also involves the
vergence and the size of the pupil. To be precise, the whole ‘near
reflex’, involving accommodation, convergence and miosis, comes
into play to enable us to focus and see clearly at near. You shall see
in the subsequent pages of this chapter, as to how accommodation is
affected in a number of neuromuscular conditions, of which we do
2 Management of Refractive Errors and Prescription of Spectacles
not usually take cognizance. Let us first, become conversant with a

few definitions.
The amplitude of accommodation (AA) is the maximum dioptric
power attainable by an eye.
The range of accommodation is the linear distance over which
the person can maintain clear vision by virtue of accommodation.
This ‘range’ lies between the ‘far point of accommodation’ and
the ‘near point of accommodation’, which simply means that the
range covers between infinity to the closest point where the object
can be seen clearly.
For clinical practical purposes, what is more important is the range
of accommodation rather than the amplitude of accommodation. In
other words, a person may have perfect amplitude of accommodation
to see clearly close to the eye, but he will not be able to maintain
clear vision at this distance for long and ocular fatigue will ensue.
Thus, he will have to hold the object (a book for example) a little
further away, where he is comfortable. Therefore, in prescribing
presbyopic corrections, one should not rely too much on amplitude
measured by a Prince ruler, but at the distance where the patient can
comfortably accommodate for long.
‘Accommodative insufficiency’ is a term implying the inability of
a person to see clearly at near, at the designated age.
‘Accommodative inefficiency’ is the term specifying a person’s
inability to focus quickly from far to near objects. In other words,
there is a time lag in focusing from distance to near.
The accommodative power or the amplitude of accommodation
slowly but surely, decreases with advancing age. But this decrease
does not follow the ‘rule of thumb’ in each case. There are ample
examples, where a person of age 45 or 48 reads comfortably unaided
while others complain of difficulty in seeing at near before 40 years
of age. This wide physiologic variation is baffling sometimes but we
must not forget the interaction of nerves, muscles and the crystalline
lens in the mechanism of accommodation.
Even the authorities in ophthalmology like Duane and Donders’
differed on the amplitude. Donders found it was 4.5 D at age 40,
while Duane found it to be 5.8 D at age 40.
Chapter 1: Accommodation 3
Examining the observations by a number of authorities, and as

measured by Prince ruler, the following guidelines are recommended:
• At age 40—Average amplitude 5.0 D
• At age 44—Average amplitude 4.0 D
• At age 48—Average amplitude 3.0 D.
Below the age of 40 years, add 1.0 D for every 4 years; above
40 years, subtract 1.0 D for every 4 years. For example, at 36, the
average amplitude would be 6.0 D, at 32 it would be 7.0 D.
Similarly, at age 52, average amplitude would be 2.0 D, and at age
of 56, it would be 1.0 D only. To all the above figures up to the age of
50 years, ± 1.0 D should be considered as range.
These figures become more relevant when a person reaches the
presbyopic age. It is then when the actual clinical test of the doctor
comes into effect. Since the amplitude varies so much, a correct age
for bifocals is difficult to predict.
It is more prudent to know the amplitude, range and the near
requirements of the patient, rather than to follow strictly the above
nomogram.
HOW TO TEST ACCOMMODATION

Three most common tests are narrated here. As accommodation
varies from person to person, so does it varies according to the test
performed. It should be kept in mind, that each test is not foolproof
and accurate. Even with the variables kept constant, chances of
error prevail. At best, these give a fair amount of result which can be
incorporated in prescriptions. The tests are performed monocularly.
Near-point Accommodation Method

In an emmetropic patient, the far point is at infinity. The near point
will then be the dioptric equivalent of the maximum accommodative
capability of the patient. In other words, converting the near point
distance into diopters, will be the measure of amplitude. In this test,
the patient views a near target, say N6 type of letters, which is moved
towards the eye. The distance at which it blurs, is noted as the near
point. Suppose the target blurs at 10 cm (0.1 m), then the amplitude
is 10 D. This is based on a standard law of optics where 1 D increase

in power has focal point at 1 m. It we use a larger target, say N8 or N10
size the near point will be closer as the patient will be able to clearly
even at 6 cm. This means that the near point distance alone does not
determine the amplitude. Target size is an important determinant.
The illumination and speed at which the target is brought closer will
also influence the amplitude.
Prince Ruler
In this, a scaled ruler marked with cm, and equivalent diopters,
having a movable target riding on the ruler is used to measure
the amplitude. It is usually 1/2 m in length, having a reading card
mounted on the scale. A +3.0 sphere is usually added to the distance
correction to pull up the range of accommodation to 40 cm.
The patient holds the prince ruler with one end resting on the
nose and slowly moves the reading card towards and away on the
Prince ruler, to locate both the near and far points of accommodation.
The difference between the far point and near point gives the AA in
diopters.
Spherical Add
This test is also performed monocularly. The patient fixates at a
reading card at a convenient distance of 33 cm or 40 cm. Plus lenses
are then added to relax the accommodation until the target blurs.
Minus lenses are then added to stimulate the accommodation, until
the target blurs again. The difference between the maximum plus
and maximum minus gives the amplitude of accommodation.
The first two tests have a major drawback in the sense that
when the object is moved closer, the angular size of image on the
retina increases, and makes the letters easier to read, requiring less
accommodation.
The spherical add method obviates this problem, but it also has a
fallacy. The incorporation of minus 1.0 D to stimulate accommodation
does not actually stimulate 1.0 D of accommodation and addition of
minus 2.0 D stimulates only 1.8 and minus 3.0 D even less.
Because of these inherent deficits, measurements by all these

methods is only close approximates of amplitude.
In my experience and by other authorities, prince ruler is the
recommended tool used for evaluating amplitude.
There are a few clinical pearls to be kept in mind while measuring AA:
• Accommodative amplitude varies with the position of eyes.
With the eyes down in reading position, the amplitude increases
measurably. If evaluation is done in straight gaze position, which
is normally done and the patients most of the activities are for
near, then the patient will be over corrected for near. The patient
may find working range too close with the correction given.
• The amplitude also is greater when the frontal plane of the face
is down, parallel to the floor. This is due to gravitational forward
shifting of lens owing to relaxed zonules when ciliary muscles are
contracting to induce accommodation. The effect can add 0.5 D
to 1.0 D in elderly to even 3.0 D in younger person.
ACCOMMODATION AND CONVERGENCE

Every individual has a fixed neuromuscular relationship between
the amount of accommodation exerted and the accompanying
convergence. This is accommodative–convergence to accommo
dation (AC/A) ratio.
It is this finely balanced AC/A alliance that keeps the eye in
alignment during all visual tasks at all distances. The alignment
incorporates ‘fusional vergence’ by virtue of which, there is
elasticity in the physiologic bonding between accommodation and
convergence.
These are a few terms which are relevant in context with the
accommodation–convergence relationship. They are more of
academic interest but the clinician must be conversant with them.
‘Relative accommodation’ describes binocular accommodative
function and concerns with the ability to sustain fusion, when
accommodation demands changes. The essence of this is very clear.
In normal physiologic conditions, both eyes accommodate equally
and the demand for convergence and fusion is equally met, but
there are conditions where both eyes do not accommodate equally,
leading convergence and fusion in disarray.
Test for Relative Accommodation

The patients gaze is binocularly fixed on a stationary near target.
Spherical lenses are then simultaneously placed before both eyes till
the target blurs. The maximum plus lens the patient can overcome
to relax accommodation keeping the target clear is called ‘negative
relative accommodation’ and the maximum minus lenses that the
patient can overcome to stimulate accommodation is called ‘positive
relative accommodation’.
EXCESSIVE ACCOMMODATION AMPLITUDE

There are innumerable examples in clinical practice where patients
boast that they can see clearly at near, at even at 50–60 years of age.
Parents, who come for refraction of their children, grumble as
to how come such a small child is requiring glasses while one of
its grandparent is reading newspaper without any glasses! This is a
difficult situation, as the parents may not understand the scientific
oddity behind the grandparents still good near vision.
There are a few clear-cut mechanisms by which the patient has
good uncorrected near vision. Myopes, early nuclear cataracts, early
cortical cataracts (with some clear area having greater diopteric
power), pinhole affect from use of miotics in glaucoma therapy,
are some examples which the clinicians should keep in mind while
giving presbyopic correction.
ACCOMMODATION SPASM
To see clearly at near a person invokes accommodation or relaxes
accommodation to see at far. Some persons, after using their eyes
for long at near work, are unable to relax their accommodation to
view at distance. Over time, this assumes a fixed nature of their
accommodation and presents a ‘pseudomyopia,’ with all the features
of true myopia. Eventually, the patients begins to manifest symptoms
of ocular asthenopia and an excessive near work in this condition,
may result in blurring for near also. This is ‘accommodation spasm’
and refraction in this state, will lead to overestimating a myopic error
or underestimating hyperopic error. Cycloplegic refraction, will

however, uncover the truth.
Accommodation spasm is frequently seen in persons with
psychogenic stress. They are under pressure at school, workplace or
home. Other ailments like spastic colon, duodenal ulcer, or migraine,
is commonly identified in these patients.
Symptoms of this syndrome complex are headaches, blurred
distance vision, abnormally close near point, and most commonly
a fluctuating visual acuity. The hallmark of diagnosis is the marked
difference in manifest and cycloplegic refractions. It would be
understandable that as hyperopes have more accommodation
demand, ciliary spasms should be more common in these patients.
But surprisingly, this is not true. Accommodation spasms are as
common in emmetropes as in byperopes.
When ciliary spasm occurs in a true myope, though uncommon,
it may be easily misread as rapidly increasing myopia. A cycloplegic
refraction again is the best diagnostic tool.
Patients with uncorrected astigmatism tend to make constantly
varying accommodative effort in an attempt to see clearly and
succumb to ciliary spasms.
Management of Accommodation Spasm

Patients with ciliary spasms are not easy to treat but one of the
following can be tried.
Cycloplegia
This is the best and an easy treatment. An appropriate cycloplegic
agent may be used to break the spasm and the patient advised not to
indulge in near work for a few days.
Prescription of Plus Lenses

In a postcycloplegic refraction, the maximum plus tolerated for a
clear distant vision, even if this is fraction of plus found during full
cycloplegic refraction, should be given. Gradually, the spherical
power can be increased in of +0.5 D to +1.0 D, and can be worn for
months or even years.
In Severe Cases
Cycloplegics like cyclopentolate 1%, can be instilled twice daily.
Simultaneously, plus lenses or even bifocals can be prescribed to
ensure clear vision for distance and near. After a period varying from
few weeks to few months, the cycloplegic is discontinued and the
patient continues wearing the distance correction.
Unequal Accommodation
Accommodation amplitudes in the two eyes are usually equal. If a
difference is noticed with glasses, then the difference may be with
refraction done.
A perfect refraction correction means that when two eyes are
working together, the accommodation is equally relaxed in both
eyes. This is known as ‘binocular balancing’ and is one of the most
important and probably least used in routine refractions; a perfectly
balanced refraction provides comfort and satisfaction to the patient.
Following are some useful tests for assessing the binocular
balance. They are simple and quick to perform.
Partial Fogging Method

After giving the correction lenses in the trial from, blur the vision
by inserting +0.75 D in each eye. Instruct the patient to concentrate
on the line he is now seeing which may be 6/9 or 6/12. Alternate an
occluder rapidly between the two eyes. Ask the patient each time
which is better? Then, fog the better seeing eye with +0.25 D and again
ask which is better? Continue this process, with + 0.25 D increments
until both eyes are equally fogged. At this point, the monocular
refractions of the two eyes are balanced and the accommodation is
equally suppressed.
Now, remove the monocular cover to allow the eyes to
see binocularly the line in question, and remove plus lenses
simultaneously from both eyes, in increments of +0.25, until he sees
the 6/6 line clearly with both eyes.
Though the description seems long, it will be found that if the
original refraction is perfect the difference between the two eyes will
not be more than +0.25 D.
Full Accommodation Suppression

In this test +2.0 D lenses are used to fog the vision, instead of + 0.75
D, which reduces the vision instead to 6/60 or 6/36. The rest of the
procedure is same as the partial fogging method.
Though some patients will find it difficult to explain the difference
in vision with so extreme fogging but if the patient is able to feel the
difference in acuity with this test, then it means that the manifest
refraction is grossly faulty with undercorrection in plus or over-
correction in minus.
Prism—Dissociation Test
In this test, vision is fogged with +0.75 D, but the dissociation of
images in the two eyes is accomplished by vertical prisms, rather
than by alternate occlusion. The patient is asked to concentrate on
a single letter with both eyes open. Vertical prisms are introduced
before the two eyes, of usually 4PD to 6PD, which will maintain
vertical dissociation. Then fogging is done by introducing plus
lenses in increments of +0.25 D, to blur the clearer line until both are
equally blurred. At this point, prisms are removed and the extra plus
lenses also.
This test is supposed to be more sensitive and gives more
consistent results.
Causes of Unequal Amplitudes

In spite of best of efforts, if unequal amplitude persists, then reasons
for such situation should be looked for. Uniocular trauma, blunt or
penetrating, is a frequent cause of unequal amplitude. Early cataracts
and early presbyopia, long-standing anisometropia and incorrect
refraction are the other common causes.
SUBNORMAL ACCOMMODATION
Subnormal accommodation is a term used to denote accommodation
amplitude recordably less than for the patient’s age.
Presbyopia is a physiological insufficiency of accommodation
that comes naturally with advancing age. Hyperopia is another
condition, where the amplitude may be normal, but a premature

presbyopia sets in. Therefore, before labeling a person having a
truly subnormal accommodation power, cycloplegic refraction is
mandatory to rule out hyperopia or hyperopic astigmatism. The
following conditions should be kept in mind before labeling a true
subnormal accommodation as idiopathic.
• Previous illness, such as postviral or exanthematous encephalitis
• Present illness, like hypothyroidism, severe anemia, diabetes,
open angle glaucoma
• Drug intake, like anticholinergics, phenothiazines, tranquilizers,
chloroquine, etc.
Complete paralysis of accommodation is rare. But the above
mentioned causes can lead to complete accommodative paralysis
and can be caused by cycloplegic agents, midbrain disorders, Adie’s
syndrome, Panretinal photocoagulation, etc.
The most common causes for unilateral accommodation
paralysis are trauma, uveitis, and acute angle-closure glaucoma.
Accommodation insufficiency may be manifested as poor
amplitude or as poorly sustained accommodation or as accommo
dation ‘inefficiency’. Poorly sustained accommodation most
frequently occurs in uncorrected hyperopes, where accommodation
cannot be maintained for long and either asthenopic symptoms
ensue or frequent blurring occurs in near work.
Accommodation inefficiency is a condition where a patient takes
time to focus at a near object after seeing at a distant object. This may
occur in some of the conditions where ciliary muscles are affected or
can be idiopathic.
REFRACTIVE ERRORS AND ACCOMMODATION

Let us see what relationship exists between refractive errors and
accommodation. An emmetrope differs from an optically corrected
ametrope, whose ametropia has been corrected with glasses or
contact lenses, because each of them have a different accommodation
demand on their ciliary-lens apparatus in performing near tasks.
Here are some examples to be remembered in doing presbyopic
corrections in different refractive errors:
• A 8 D or 10 D myope, who wears a full spectacle correction for

distance will require less accommodation for near viewing than
if he is wearing contact lenses. This is why a 40-year-old patient
has difficulty in reading when he switches to contact lenses from
spectacles
• The 10 D hyperopic person requires more accommodation
for near targets with glasses, than when he switches to contact
lenses. The explanation of this phenomena is based on the optical
effectivity of various corrective lenses, which incorporates the
vertex distance effect, in viewing near objects.
Table 1.1 is a good guide for understanding the vertex distance
effect the various corrections have on accommodation required for
reading:
TABLE 1.1 Accommodation required

With spectacle With contact lens Difference
correction correction
10 D myope 3.0 4.5 1.5 D less
10 D hyperope 6.5 4.5 2 D more
with reading distance at 30 cm, and vertex distance 20 mm
It may be surprising, but this is a true physical phenomena

and the magnitude of the difference in power and magnification,
depends on how far from the nodal point of eye a lens is placed and
whether it is plus or minus.
For a perfect correction of refractive error, a lens would have to be
placed inside the eye, at the nodal point. An intraocular lens subverts
most of these problems; but since it is a pseudolens, the laws of
accommodation does not apply here.
Further, to the above explanation, spectacle or contact lens,
all correct the refractive error and are said to have equal optical
effectivity, but only if the object is located at infinity; the optical
effectivity changes for near objects as it will be imaged at a different
distance by each type of correction, and therefore, the demand for
accommodation will be different in each correction.
PEARLS
As has been seen, accommodation problems are common and
varied. Different ages and different refractive errors have different
demand on accommodation, and therefore, in the process of
correcting a refractive error, the role of accommodation must always
be kept in mind. The following pearls will guide through a smooth
and hassle-free journey of correcting accommodative problems:
• As mentioned in the introduction, an accurate history taking is
paramount. Correlate its relevance and compatibility with the
clinical findings.
• Use an accommodation measuring ruler, especially in presbyopic
correction, where most of surprises are lurking.
• Cyclopegia should be used judiciously.
• Do not rely on manifest refraction alone at any age, especially
when refracting a first timer patient. Always perform cycloplegic
refraction also.
2
Cycloplegia
INTRODUCTION
Cycloplegia, though thought by many clinicians, to be used only out
of necessity, is one of the vital ingredients for solving many clinical
problems. It is not a medicine to be put in a side-table drawer, and
used sparingly. Actually, it is one of the most required diagnostic
tools which must be used judiciously to enable us to learn more
about refractive conditions than is evident by manifest refraction
alone.
To be more emphatic, cycloplegia is mandatory in refracting
children and young adults even up to the age of 21 years! In my
practice, cycloplegic refraction is performed routinely each time
when a young patient comes for the first time and for yearly follow-
up visits. You will be surprised, how often a hyperopia or hyperopic
astigmatism is uncovered. Remember this pearl: Any patient who
complains of headache or other symptoms of ocular asthenopia,
irrespective of his vision, must undergo cycloplegic refraction. You
might be amazed to know that such patients have already gone
from pillar to post, visited all related specialties, but headaches
have persisted. And then, wisdom prevailed in some doctor, the
patient was referred and a good cycloplegic refraction exposed his
refractive error, mostly hyperopia and/or astigmatism. And a simple

spectacle correction alleviated all his problems. The more you
learn from cycloplegia, the more you benefit the patient and will be
overwhelmed to find that such a simple procedure produces such
satisfying results for the patients.
Let us now delve into the pharmacogenics of cycloplegia.
An ideal cycloplegic drug should possess the following charac
teristics:
• Rapid onset of cycloplegia.
• Maximum relaxation of accommodation.
• Short duration of action.
• No residual side effects.
• No toxic effects—locally or systemically.
Till date, whatever drugs we have in our basket, none have the
entire above characteristics.
A cycloplegic drug is then chosen, depending on the age, the
degree of iris pigmentation, the type of refractive error discovered on
manifest refraction, local condition of eye, especially the angle depth,
and any neurogenic disorder, e.g. epilepsy. Further, the dosage and
concentration has also to be titrated according to the patient. It is
to be remembered that all cycloplegic drugs produce mydriasis also.
But a primarily mydriatic drug does not produce cycloplegia, e.g.
neosynephrine or eucatropine, very little cycloplegia.
A cycloplegic agent is used in the eye for following conditions:
• To aid in refraction.
• Paralyze iris and ciliary body postoperatively.
• Relieve ciliary spasm.
• Break iris synechiae.
• To treat anterior uveitis.
As an indispensible aid in refractions, it should be used in the
following conditions:
• In all children, up to 12 years of age, as a mandatory procedure.
• Manifest refraction not compatible with vision, up to 21 years of
age.
• Whenever refraction yields variable results, at any age.
• Symptoms relating to ocular asthenopia, irrespective of vision.
• Suspected extraocular muscle imbalance.
Chapter 2: Cycloplegia 15
• Whenever patient’s complaints are disproportionate to the

manifest refraction. A myope with frontal headaches—may be
overcorrected or headaches in moderate hyperope—may be
undercorrected.
• Early presbyopia, especially when glasses have never been worn.
• In infants and young children, where vision is difficult to assess.
• In bedridden or mentally challenged patients.
• In suspected or actual ciliary spasm.
• In gross anisometropia or antimetropia.
CONTRAINDICATIONS
In the following, cycloplegia should be avoided or used with caution:
• Without or absence of patient’s consent.
• History of drug reactions, like a previous episode in young child
with atropine.
• History of angle closure attacks.
• Critically narrow angles. Here, if necessary, a short-acting
cycloplegic can be used, with informed consent that angle
closure attack may be precipitated.
SOME SPECIAL SITUATIONS

• Occasionally you may face a situation, where you think that a
cycloplegic examination is a must, but the patient expresses
inability for a return visit. It is prudent not to fall prey to a
manifest refraction only and prescribe spectacles. The patients
may be politely advised to return according to his convenience
for a cycloplegic refraction and a postcycloplegic test. Or you
can suggest a cycloplegic refraction now and a postcycloplegic
final prescription, at his convenient clinic (provided the other
clinician is conversant with what you intend!). In cases, if you
find that the cycloplegic refraction does not differ much from the
manifest, and you can assure the patient that he need not take a
second visit any place, then a final prescription can be written.
• Another similar situation where the patient is unable to return for
a postcycloplegic check.
The following example will obviate your anxiety:

A young man visits clinic with complaints of headaches on
reading and expresses inability to return next day as he is leaving for
abroad next morning and insists on examination as this will bother
him in a foreign city. The manifest refraction yields +0.75 D OU and
Prince ruler, full amplitude.
This small amount of hyperopia should raise suspicion as to
probable more hyperopia which the patient is compensating by
excessive accommodation. Cycloplegic refraction yields OU +3.0 D
hyperopia! The fort has been conquered. But only half! What should
be done now as the person will not come for final prescription. Post-
cycloplegic test in these cases is important, as full correction may not
be tolerated and will cause blurring in distance. Here it will be wise
to give half correction, e.g. +1.5 D and for reading only, as this is what
is causing his main problem; and the patient may be explained about
his error. He will remain symptom free, till his next visit few years
later.
QUALITIES OF A CYCLOPLEGIC DRUG

Effectiveness
The purpose of cycloplegic refraction is to eliminate the variability
created by an unpredictable accommodation. The most effective
drug, therefore should completely suppress accommodation. But
unfortunately most drugs do not. Some residual accommodation is
still left behind. This residual accommodation depends upon again
the age of the patient, the degree of refractive error, the dosage and
the concentration of drug, the iris color, etc.
It is always wise to know the residual accommodation by a Prince
ruler, prior to performing cycloplegic refraction. In young patients,
below 30 years age, a residual amplitude of less than 2 D, can be
considered acceptable; between 30 years and 40 years +1.5 D and
above 40 years, no more than 1.0 D is acceptable. If the residual
accommodation is beyond the above limits, then the dosage is to be
increased or a stronger cycloplegic should be instilled.
Table 2.1 illustrates the drug of choice, dosage, concentration,
mechanism of action, duration, etc. for firsthand knowledge.
Recommended Dosage (Table 2.1)

There is a considerable overlap in the choice of drug to be used in a
particular patient. There does exist rule-of-the-thumb, but the type
of drug to be used depends upon the indications given above, upon
the presenting condition and clinical experience of the physician.
Broadly speaking, atropine is the drug of choice in an infant and
toddler; but here again the concentration varies and the type of
delivery. Atropine ointment is preferred below age 1 year, as its
systemic absorption in slow. Drops can be instilled between 1 year
and 3 years. Homatropine 2% is preferred between 3 years and
5 years age. But in a child of 8 years with strabismus, atropine will be
preferred whereas under other conditions cyclopentolate 1% or 2%
is instilled between 5 years and 12 years. Over 12 years, tropicamide
1–2% suffices in most instances.
As a rule, lesser cycloplegic agent is preferred for children with
normal vision and stronger for children with reduced vision or
muscle imbalance.
Though only specified concentration and dosage should be used,
taking into account the age and suitability of patient, but many times
the desired effect is not produced (This is very easily determined
as the patient’s near vision still remains clear.) In such situations,
there is a tendency by the clinician to instill some more drops. This
practice is to be discouraged, as more instillations may exceed the
safe dosage and liable to induce toxic effects. The patient may be
called another time and a stronger cycloplegic agent used.
Duration of Action
Each cycloplegic agent has a different duration of action. Though
most of the cycloplegic agents have a known duration of effect but
there have been reported cases of effect of cyclopentolate 1% lasting
over 4 weeks. Patients should be warned of such untoward action of
drugs, especially for stronger agents like atropine and homatropine.
If the patient feels alarmed or anxiety overrides his common sense,
then the patient may be called and a drop of 1% pilocarpine instilled.
This may help in cases where tropicamide or cyclopentolate is used
but will not be effective for atropine or homatropine. The effect of
pilocarpine may wane off before the effect of cycloplegia, and the
TABLE 2.1 Characteristics and dosages of cycloplegic agents
Cycloplegic Pharmacologic Concentration Age range Dosage Maximum Duration of Duration of
drug action cycloplegic effect mydriasis cycloplegia
Atropine sulfate Parasympatholytic 0.5 and 1% Below 1 year TDS for 3 1–3 days 10–12 days 15 days
ointment days
Atropine sulfate Para sympatholytic 0.5–1.0% 1 to 3 years 1 drop TDS 1–2 days 10–12 days 15 days
solution for 3 days
Homatropine Parasympatholytic 2% 3–21 years 2 drops 10 60 minutes 24–36 hours 24–36 hours
hydrobromide minutes
solution apart
Scopolamine Parasympatholytic 0.25% 3–10 years 2 drops 10 60 minutes 2–3 days 3–5 days
(solution or minutes
ointment) apart
Cyclopentolate Parasympatholytic 0.5%, 1% Above 25 years 2 drops 45 minutes 16–24 hours 16–24 hours
solution and 2% 3–21 years No repeat
Tropicamide Parasympatholytic 1% 21 years above 2 drops 5 30–45 minutes 6–12 hours 6–12 hours
solution 2% 12 years above minutes
apart
blurriness might return. Sometimes, only mydriasis may wear off but
cycloplegia may persist. At best, it is always prudent to explain to the
patient the consequences of the effect of such drugs and alleviate his
fears. A good idea is to have patient wear dark goggles when going
outdoors as this may give some respite from glare and permit at least
some activity outdoors.
Side Effects
As we know all cycloplegics produce mydriasis also. Thus, photo
phobia and glare are normal side effects. This has to be notified to
the patient before a cycloplegic is instilled and also the duration of
action of each drug. This discomfort can be minimized by advising
the patients to wear dark goggles in daylight, till the effects wanes.
Serious side effects are not common and for the most part, are
dose-related. In any case, the dosage and concentration must never
be exceeded. Before instillation of a cycloplegic, the age, iris color,
presumed type of error, history of any previous untoward action must
be taken into consideration. If the cycloplegic effect has not occurred
with a particular agent, another drug should be tried later or some
more time given to have the full effect, rather than instilling more
drops. Atropine is known to cause maximum side effects. In children,
even normal doses can cause serious side effects. Idiosyncrasy to
atropine can cause alarming side effects and toxicity, but commonly
they result from excessive systemic absorption. Marked flushing of
face, dryness of mouth, hot dry skin, fever, restlessness, rapid pulse,
can all occur. The following hard fact will surprise the reader. A
1% atropine sulfate solution contains 10 mg of atropine per mL; there
are about 10 drops in one mL (milliliter). The instillation of one drop
in each conjunctival sac will yield a dosage of 2 mg (1.0 mg each)
of atropine. This is about four times the usual adult parenteral dose!
Extreme toxicity can occur in idiosyncrasy or in hypersensitive
individuals, such as Down’s syndrome, and can result in halluci
nations, convulsions, delirium, coma and even death. Locally
atropine can cause induration and dermatitis over lids and cheeks
and conjunctival congestion. Homatropine and cyclopentolate
are relatively safer but in young children, care should be observed
regarding dosage and fair skin. Cyclopentolate 1% is known to cause
restlessness, disorientation and delirium. These central nervous

system side effects are pronounced in very young children, especially
with history of epilepsy or related disorders. All water-soluble
cycloplegic drugs are absorbed through conjunctiva, lacrimal and
nasal mucosa. An aqueous preparation placed in conjunctival sac,
will appear in the nose within one minute.
In order to decrease the systemic side-effects, atropine can be
used as an ointment which lessens the systemic absorption. In case
of drops, the medial canthus can be kept pressed for a minute or two,
to prevent the drug entering the lacrimal sac and nasal mucosa.
Treatment
Local skin and conjunctival reactions are best treated by
discontinuing the drug. Fever and flushing can be managed by cold
sponging and antipyretics.
Serious side effects or toxicity may require hospitalization
particularly in children.
CYCLOPLEGIA AND GLAUCOMA

It cannot be overemphasized that strong cycloplegics are not to
be used in a patient with possibility of angle closure. Whenever
it becomes a necessity to use cycloplegics, as a general rule, the
following ground rules should be followed:
• Make an informed consent regarding the reasons and added risk
of using cycloplegia. Also, the patient may be kept in the clinic for
some hours, to immediately institute corrective measures
• Use a mild agent like cyclopentolate 0.5% or tropicamide 0.5%
• If a miotic has been used to counter the mydriasis, then keep
the patient in clinic, till mydriatic effect has subsided. This is to
ensure that miosis itself may not trigger an angle closure attack, a
significant clinical point to be kept in mind in refractions done in
patients suffering from glaucoma.
In case where patients with narrow angles are kept on miotic
therapy as a preventive measure from angle closure attack, the
refraction will vary significantly if a mild cycloplegia is used in
their case; miotics increase the tone of ciliary muscles and thus
accommodation. Such patients may show variable refractions during

miosis and after cycloplegia. If the patient is to be kept for long on
miotic therapy (where laser peripheral iridotomy is not done), then
it is advisable to have the refraction done under miotic conditions.
Open angle glaucoma itself is known to causes changes in
refraction. This change is compounded, when glaucoma therapy
changes with time. But since cycloplegic agents are safe in this type
of glaucoma, it is prudent to use a cycloplegic for refraction.
CLINICAL PEARLS
A pertinent question always haunts the clinician, as what pre
scription to be given after a cycloplegic refraction. Have the patients
to be always called for a postcycloplegic examination?
The answer is as elusive as the question. Following are the cases
where postcycloplegic test in indicated:
Children
Children under 18 or 21 years, who show hyperopia but are
asymptomatic will not require any glasses and need not come for a
second visit.
Myopes will have the same error after cycloplegic refraction and
will not show any discrepancy in a postcycloplegic test and therefore,
do not need another visit. But children showing astigmatism,
anisometropia or demonstrating symptoms, need a postcycloplegic
exam. Children with mixed astigmatism require special attention
during a postcycloplegic test.
Adults
These are a major group manifesting ocular asthenopic symptoms.
Here manifest refraction may not yield any refraction error or may
yield variable error. Cycloplegic refraction now yields hyperopia
or astigmatism. Such patients require a postcycloplegic test for
acceptance. Patients whose manifest and cycloplegic refraction
yield compatible data, prescription can be safely given and post-
cycloplegic test is not needed.
There is another group in the presbyopic or prepresbyopic age. If

the manifest and cycloplegic refraction are same, then prescription
is promptly given. But where a significant difference appears in the
two refractions, a postcycloplegic test is warranted. Cycloplegic
refraction after 50 years of age is rarely needed.
SUMMARY
• Cycloplegia must be used judiciously and kept as an essential
tool in the arena of examination.
• The type of cycloplegic should be not indiscriminately chosen
and indiscriminately used. Selection should be done depending
upon the age of patient, type of error, symptoms of patient, iris
color, any systemic anomaly, local anomaly in eye, etc.
• Patients should be informed (consent taken verbally may suffise)
regarding the effect of cycloplegia and its side effects.
• Postcycloplegic test should be taken seriously, as you may find a
great difference in the cycloplegic refraction and what the patient
accepts.
• Never, in any circumstances, refract a child below 12 years
without cycloplegia. And a young person, who has symptoms of
ocular asthenopia.
3
Hyperopia
INTRODUCTION
Hyperopia or hypermetropia as is usually called, though not as
common as myopia, but still is a perplexing disorder of the eye and
is sometimes difficult to deal with. In myopia or astigmatism, the
patient comes to you with a clear cut, specific complaints of blurred
vision. In hyperopia, on the contrary, the patient’s vision is normal
but comes with complaints which may be vague at times, and can
be overlooked frequently. This is exactly what is happening in a busy
outpatients department. If you start refracting these patients with
cycloplegia, you will be amazed at the number of patients you were
missing. Then there is another pitfall. After successfully finding a
hyperopia, you are in a dilemma as to what and how the plus lens
prescription should be given. You may plunge into depression,
that after all your labor, the patients comes running back that his
vision has now become blurred with the prescription and he is not
comfortable. Thus, hyperopia is not as simple as it appears and you
shall learn to tread carefully as you go through this chapter.
Ch-3.indd 23 06-04-2015 15:08:22

DEFINITION
In hyperopia, the optical power of the unaccommodating eye is weak
to form a clear image of a distant object on the retina. But this is easily
compensated, in most cases, by using the power of accommodation.
In all cases, this may not be possible and if so, at the expense of
so much of an accommodative effort, the patient starts manifesting a
basketful of symptoms.
In a recap, let us go through some basic features of hyperopia.
Some terms used in hyperopia, like total, latent, manifest, absolute
and facultative need to be clarified, as they will be used frequently in
this chapter. It will be simpler if an example is used.
Suppose a male patient comes to the clinic, with complaints of
fatigue and headaches. His vision is 6/9 and refractive error of OU
+4.0 D. Seeing this, a cycloplegic refraction is done, which reveals
+6.0 D of error. The patient is called back for a postcycloplegic test.
Now, putting +1.0 D, each eye, in the trial frame improved is vision to
6/6.
To explain, the total error found with cycloplegia is +6.0 D and
this is the ‘total’ hyperopia. His plain refraction had showed only +4.0
D. This was the ‘manifest’ refraction and the remaining (+2.0) which
revealed only after cycloplegia, is ‘latent’ hyperopia. From +4.0 D of
manifest hyperopia, he is correcting most of it by his accommodation
and needs only +1.0 D addition for further clarity of vision. Thus +1.0
D is the amount he needs as an outside help and is called ‘obsolute’
(which cannot be overcome by accommodation) and remaining +3.0
D is the ‘facultative’, which the patient is compensating by his faculty
of accommodation.
ETIOPATHOGENESIS
A short note on this is mandatory to understand and more
importantly, to make the patient understand. Hyperopia, basically,
as we all know, is due to the defect in the manufacturing of our
eyes—short, small eyes, with sometimes flater corneas. And as this is
since the beginning, it becomes difficult for the patient to make him
accept his problem.
Ch-3.indd 24 06-04-2015 15:08:23

Chapter 3: Hyperopia 25
As age advances, the lens grows in size, the accommodation in

a high hyperope causes the lens to further increase its curvature
(though in some part it is compensated by the stiffness of lens)
and all these mechanisms added together felicitate an attack of
angle closure glaucoma. The clinical pearl here is to motivate the
patient to use specks constantly which will obviate the need for extra
accommodation. Having said that, let us examine when glasses are
necessary, how to personalize them, should they be worn fulltime or
only for near. When closely observed, one denominator stands out
and that is ‘age’. Age is the single largest factor which influences the
management of hyperopia. For convenience of management, let’s
divide age into:
• Up to 5 years
• 6–21 years
• 21–40 years
• Above 40 years.
CHILDREN
Children are born hyperopes. We know that at birth the average
size of an eye is about 17.0 mm. It rapidly attains 20.0 mm by end
of one year, and by 3 years, it has attained around 23.0 mm. Then
very gradually it further grows by 0.5–075 mm by 12 years of age.
The corresponding large hyperopia is easily overcome by more than
adequate accommodation. It is only when something becomes
wrong in this development, that hyperopia results.
So, in what circumstances, will a child come to the doctor! And these
are:
• Diminished vision, in one eye or both, noted accidentally in
routine examination at school or elsewhere
• Strabismus
• Unexplained red eyes or watering
• Nystagmus, or any other sign noted by parent or teacher.
Headaches, a prominent symptom in adults, are uncommon
in children. Since each of above categories have different set of
management, let us study each of them.
Ch-3.indd 25 06-04-2015 15:08:23

• Whenever diminished vision is reported in a child below

5 years and a cycloplegic refraction shows high hyperopia (+5.0
or more), then appropriate specks, according to the subjective
correction which improves vision, is given. Early correction
not only accelerates normal visual acuity development but also
normal development of the eyes.
Where there is anisometropia and unilateral amblyopia, then
in addition to specks, amblyopia therapy has to be initiated.
In children with high hyperopia but ‘normal uncorrected
vision’, need not be interfered with but they should be advised for
regular checkups.
A third group is with high hyperopia, normal vision but
complaining of symptoms like restlessness, fatigue or red eyes.
These children again require cycloplegic refraction and then best
subjective correction.
It is amazing how quickly and comfortably children adapt
to high numbers, so much so that, a child may demand for his
specks on awakening in the morning.
• Child with esotropia: An esotropic child requires a full
cycloplegic refraction with atropine. It is important to know the
total hyperopia. Having determined this, the full cycloplegic
correction is mandatory. Sometimes, after giving the full
cycloplegic correction, there might still remain a small amount
of esodeviation. This is not necessarily a nonaccommodative
component of esotropia. Such children are refracted again
between 1 month and 3 months and you may be surprised to
find that some amount of hyperopia is still remaining. New
prescription is given and now all extra accommodative effort has
been eliminated, the child may become orthotropic.
There is a general tendency to correct little less of hyperopia,
especially if hyperopia is around +8.0 or +10.0. This school of
thought probably generated because of sympathy towards child
or out of fear that the child will not tolerate such high numbers.
It is reiterated that a child’s adaptability is amazing and it is
surprising how well a child tolerates such high numbers. By
correcting, say half of hyperopia, you are not benefitting the
patient. Neither his vision will improve nor his deviation.
Ch-3.indd 26 06-04-2015 15:08:23

• The hyperopic anisometrope child: These are slightly difficult

cases to deal with.
There are two examples to explain:
1. A child of 5 years has the following findings:
Without correction With correction (after cycloplegic Ref.)
OD 6/9 +2.5 6/6p
OS 6/18 +4.5 6/9p
There are two options:
i. First, since the vision is improving in both eyes, to give a full
prescription.
ii. Second, since there is hardly any difference with correction
in OD, it can be left alone and only the difference in
refraction of the two eyes can be given in OS. This
concept stems from the rule that both eyes accommodate
equally. To see clearly OD accommodates by +2.5 D and
simultaneously OS also accommodates by + 2.5 D.
The rest +2.0 D remaining in OS to view 6/9 line, is
compensated by specks. As a general rule, I follow the
second rule in practice.
2. A child of 5 years, has the following findings:
Without correction With correction (after cycloplegic Ref.)
OD 6/9 +2.5 6/6p
OS 6/36 +6.0 6/24
The OS is showing moderate amblyopia. Here you have to
correct the full hyperopia of +6.0 (OU) and initiate occlusion
therapy OD. Since amblyopic eyes do not accommodate, full
correction has to be given in OS. OD can be safely given plain
glasses. Later on, after successful amblyopia treatment of OS,
the prescription can be titrated.
Age 6–21 Years

As the child grows, hyperopia generally decreases. But the decrease
is, as a rule, fixed and constant. One cannot expect a 7.0 D or 8.0 D
hyperopia to vanish when a child goes into teens. Usually a child does
not outgrow his hyperopia after 12 years of age. Even if the hyperopia
Ch-3.indd 27 06-04-2015 15:08:23

which remains may be small, but the demand of a teenager eyes for
reading, writing, computers is so great that what hyperopia did not
show its presence in childhood, it now comes out in full bloom. And
asthenopic symptoms, in varying degrees, now manifest!
High hyperopia, excessive accommodative effort and asthenopic
symptoms, go hand-in-hand. It is again expressed that a young
patient complaining of headaches or lack of interest in studies,
must undergo a full cycloplegic refraction, despite having a 6/6
vision. And a potent cycloplegic like cyclopentolate 2%, should be
used judiciously. The attempt is to expose all the latent hyperopia,
because the extent of latent hyperopia is a measure of the excessive
ciliary tone. The more the ciliary tone, the more the symptoms.
During correction of a hyperope in this age group, the muscle
balance should be simultaneously examined. As there could be
esodeviations like esophoria or the patient may show a manifest
esodeviation at near. This has to be taken into account in context of
abnormal AC/A ratio. Because if you miss this, the patient is likely to
return with complaints. If the esotropia at near is more than 10PD,
then bifocals are recommended, in amount of +2.5 D to +3.0 D, to
suppress the accommodative effort for near.
Age 21–35 Years

It is during 2nd and 3rd decade of life that the patients become
more symptomatic, as the accommodation begins to wane and the
demand for long and close work is most. It is now that more and more
of hyperopes complain of constant headaches and other asthenopic
symptoms.
Manifest refraction in them is shocking. Most of them exhibit
myopia. This is because of strong ciliary tone and excess accommo
dation being used during retinoscopy or on autorefracter. Cycloplegic
refraction reveals the true picture.
Examples to Clarify
Example one: Lady patient of 30 years complained of headaches

on watching TV, which increased on near work. Manifest refraction
(Auto Ref.) showed:
Ch-3.indd 28 06-04-2015 15:08:23

OD –0.5 D/+1.0 cyl. 100

OS –0.75/+1.0 cyl. 90
Cycloplegic Refraction:
OD +1.5/+1.0 100
OS +2.0/+1.0 90
Since the patient is only 30 years with good amplitude of
accommodation (as measured on Prince ruler), she was given full
astigmatic correction only and advised to read at a little further
distance. She became asymptomatic.
Second example: An accountant of 32 years complained of unable
to work at desk for more than 10–15 minutes. The print blurred and
headaches began.
Manifest refraction:
OD +1.5 DS 6/6
OS +2.0 DS 6/6
With this correction, the accommodative amplitude was only 4.0
D. At this age, normal amplitude should be around 7.0 D. Naturally
his total available amplitude was being used for near work and the
fatigued rapidly.
Cycloplegic refraction revealed:
OD +4.0 DS
OS +5.0 DS
As most of his accommodation was being used to correct the
hyperopia, the remaining was not enough for near work, which
he needed most. To be true to rules, the hyperopia should be fully
corrected, so that the accommodation is totally relaxed for distance
and he has all what he needs for near work. But most of the patients
will not accept correction of +4.0 or +5.0, and fogging will occur.
I usually give the best tolerated subjective correction for distance—
not pushing too much—and subjective correction for near work.
Gradually over a year or so, full correction is instituted.
Or if the patient disagrees for distance specks, saying he has no
problem, then give only the appropriate near correction.
It is in the prepresbyopic age, 35–40 years that he actually feels
the impact of his decreasing accommodation. As latent hyperopia
Ch-3.indd 29 06-04-2015 15:08:23

increasingly becomes manifest and compensation by virtue of

accommodation decreases, a mild hyperope finds his reading
difficult. His reading glasses-prescribed few years back, are now
used for distance.
Most of patients complaining now of asthenopic symptoms, are
hyperopes of low degree, who prematurely started having near vision
problems.
These patients, again undoubtedly, need a cycloplegic refraction,
to uncover the total hyperopia. If hyperopia of +2.0 to +3.0 is revealed,
then either reading glasses of +1.0 to +1.5 is given (assuming their AA
is within normal limits) or even single vision glasses would suffice,
because at this age, a moderate hyperope usually begins to have
distance vision problems such blurred TV viewing or disturbance
in distant vision, and would gladly accept full distance correction
which he wears all the time.
PRESBYOPIA
As the hyperope enters into the truly presbyopic age, above 40 years,
a strong need for near as well as distance correction ensues. Patients
who are sufficiently hyperopes, who are already in practice of near
vision glasses, would comfortably start using the distance correction
also. Now a million dollar question faces the clinician as well as
patient and that is adaptation to ‘bifocals’.
Let us face a few scenarios: Firstly, patients who are sufficiently
hyperope and strongly need both distance and near correction would
easily opt for separate pairs. Secondly, if their job demands frequent
distance and near viewing, then bifocals is the better option.
Thirdly, a mild hyperope, with some astigmatic correction needs
distance glasses only for watching TV or during driving, he would
opt willfully for separate glasses, to be used as need demands.
Finally, problems arise in persons working for long hours
on computers. Viewing with the lower segment demands chin
up position which strains the neck muscles. And the problem is
compounded when their work obligates them to see at distance also
frequently.
‘Progressive power’ lenses have emerged to be a boon, for such
persons. Adaptation takes time, so is the high cost, but the advantages
Ch-3.indd 30 06-04-2015 15:08:23

outweigh all deterrents. People who cannot afford progressive power

spectacles or astigmatism makes adaptability difficult, then the lower
segment can be raised to obviate the chin-rise posture or changes in
working module tried.
To summarize the presbyopic effect, assurance to the patient is
required giving him time for adaptation. Proper size of frame and
positioning of segments are equally important.
INTERMEDIATE VISION
As age advances, our accommodative power steadily decreases and
we become more and more dependent on glasses for near work. In a
hyperope person, the latent hyperopia becomes manifest and steadily
more of it becomes absolute, necessitating the use of plus lenses for
distance also. As we become more dependent on bifocals, the distance
and near vision becomes comfortable, but the ‘intermediate’ vision
suffers. A person who was previously comfortable to see things on a
table or work on a desktop computer, now begins to feel the strain.
Some respite is achieved when the distance correction is increased,
as he gets some extra accommodative leverage, but as age further
advances, a hyperope finds intermediate distance working more
difficult. For example, a male person of age 48 years, complains of
unable to work on computers.
Present correction
OU + 1.0 D –6/6
Near add + 1.5 D –N 6
OU + 2.0 D
New prescription
OU + 2.0 DS –6/6
Near +.1.5 D
With this correction, he gets a +1.0 accommodation free to be
used for intermediate working. But at 55 years, his +2.0 D will be
used for distance and +3.0 add for near. Since he has now negligible
amplitude to help at 1 m or so, he will be incapacitated at this
distance where lot of work is done on and around the table.
Ch-3.indd 31 06-04-2015 15:08:23

If he can afford and get used to progressive power lenses, then he

is out of misery. If not, then alternatives are another pair of bifocals
for the distance or the person has to come close at the reading
distance, to view things.
Difficulty at Night
Some hyperopes, with their plus distance correction, complain that
at night, their vision become slightly ‘blurry’ and the coming lights
appear ‘feathery’. The explanation is as follows: Normally we correct
hyperopia at a distance of 6 m which is perfect at this distance. But
when we view at 50 m or 100 m, our eyes are actually over corrected
by +0.5 D. To avoid this problem it is always better to correct a little
less, say from +2.0 to 1.75 (+0.25 D less).
Given this explanation, a question will immediately arise, as why
this problem does not occur in day. In daytime, our pupils are slightly
constricted, the ‘depth of focus’ increases, and images remain clear.
At night with the pupils slightly dilated, the depth of focus decreases
and blurring results.
SUMMARY
• Understand the symptoms of patient, and measure their
compatibility with your findings.
• A normal 6/6 vision does not preclude a refractive error,
particularly hyperopia or hyperopic astigmatism.
• Use cycloplegics judiciously.
• As a rule, do cycloplegic refraction up to 21 years of age.
• Measure amplitude of accommodation where ever necessary.
• Do not force bifocals at first instance, the patient may develop
fear psychosis, and will never in future opt for it. Try with single
vision glasses first.
• Always give full cycloplegic correction in esotrope hyperope, no
matter how high the plus number is!
• Be patient with children in prescribing high plus. Gradually
increase acceptance.
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4
Myopia
INTRODUCTION
Myopia has emerged from ancient Greek word ‘muōpia’ from
myein meaning ‘to shut’ and ‘opos’ meaning ‘eye’. It is also known as
‘nearsightedness’ or ‘short-sightedness’ in layman jargon.
Myopia is the most common refractive error and so prevalent
that it has attracted the maximum number of studies worldwide. A
recent study by National Eye Institute, USA, showed prevalence of
myopia in general population has grown from 25% to 41.6% in last 30
years.
Looking at worldwide figures, a whopping 70–90% prevalence
exists in some Asian countries, 30–40% in Europe and USA and
10–20% only in Africa. Besides this incidence, lurks another
devastating part of myopia—its degenerative or pathological form.
To add salt to the wound, the incidence is on the increase and the
worst, we do not have any measures to prevent its progression. All
these factors have generated a deep interest into its pathogenesis,
prevention and management.
Unfortunately, the progression of myopia by most patients
goes unnoticed. It is only after his or her vision has significantly
deteriorated that treatment is sought. For the most part, it is only
the blurring which is noticed and that too clears quite a bit when
the person comes nearer to the object. Asthenopic symptoms (like
fatigue, headaches, watering and red eyes) usually do not occur is
myopia. Even when patients report these symptoms, they are due
to associated conditions like astigmatism, muscle imbalance or
anisometropia. Since myopia is so important a disorder to affect so
many people, a detail enquiry into the condition is logical.
CAUSES AND PROGRESSION OF MYOPIA

Heredity
Heredity is an unarguably the most significant factor in causation and
progression of myopia. Linkage studies have identified 18 genetic
loci on 15 different chromosomes that are associated with myopia.
That means no single gene(s) are responsible for the disease.
Nutrition
Like so many dietary deficiencies or dietary anomalies linked with
certain diseases, myopia also finds a place in this list. Poor diet
lacking especially in proteins has been implicated in myopia.
Hyperinsulinemia, insulin resistance, insulin-like growth factor,
carbohydrate metabolism disturbances, all have hypothetical
attributions in myopia.
Environmental Factors
The evolution of eyes has been going on for millions of years. Human
eye, as many authorities suggest, was not programmed for so much of
near work. The environment to which the human body was adapted
over millions of years does not match our present environment. Its
function was to view landscapes, mountains and meadows. The
stress of constant near work, compounded by the use of computers
and other gadgets, has increased the prevalence of myopia. Lopsided
reading habits, artificial lighting, reversal of biological clock, all
have contributed to the increase in myopia. There is evidence that
lack of normal stimuli causes improper development of the eyeball.
Chapter 4: Myopia 35
The ‘normal stimuli’ refers to the environment. Modern humans,

who spend most of their time indoor in dimly lighted or fluorescent
lighted rooms, are not giving their eyes the appropriate visual stimuli
and may be contributing to myopia.
Certain races in Africa and Arctic regions who mostly lead a life of
hunting and wandering outdoors, have the lowest rate of myopia.
Intelligence and Myopia

A large number of studies have reported a relationship between
myopia and high IQ. Explanations to this effect point to intensive
near reading by studious children. Another study shows that certain
‘pleiotropic’ gene(s) affect the development of both the brain and
the eye simultaneously.
Some reports suggest that high IQ and myopia co-exist,
independent of excessive reading or near work.
Near Work Hypothesis

Lot of thought has gone into the relationship of near work with the
development of myopia. This hypothesis is also referred as the ‘use-
abuse’ theory, which correlates the progression of myopia with
excessive use of our eyes for near work. This produces excessive
stress on our accommodation-convergence mechanism. There are
two main points to support this hypothesis. Firstly, continuous near
work causes constant convergence, which in turn creates constant
stress on the extraocular muscles, increases their tone and puts
pressure on the globe. Secondly, the continuous accommodative
stress on the ciliary muscles, under constant phase of contraction
slowly builds pressure in the eye, and the eyes of children which are
still developing, may overgrow in size.
CLASSIFICATION
Like hyperopia, myopia can also be classified. The classification is
simple and based on the cause or the clinical appearance:
• Axial—the axial length increase of the eyeball attributes to
myopia
• Curvature—myopia is attributed to an increase in the corneal

curvature
• Index myopia—appears due to an increase in the refractive index
of the refracting elements of the eye, particularly the lens.
Clinically, myopia may be:
–– Simple
–– Degenerative
–– Nocturnal
–– Induced.
MANAGEMENT
Simple Myopia
Every clinician faces a question from every myopic patient that in
spite of constant and religiously using spectacles, why his or her
numbers keep on increasing?
For almost half a century theories on causation and progression
of myopia have abounded the literature. So many controversial
questions, such as: does accommodation influence myopia; how
much outdoor life will benefit; what is the optimum use of eyes for
near work; does any diet or drugs will help to control myopia; how
to prevent pathological myopia; or is there any other measure to
reduce myopic progression?
The answers are as mysterious as the questions! For decades,
there has been a continuous succession of proposed treatments for
myopia. Let us review some of the theories:
Accommodation and Near Work

Strong proponents of “near-use myopia” suggest that since
excessive near work results in progression of myopia, which needs
prolonged accommodation, efforts should be made to minimize
accommodation. These include constant atropinization, under
correction of myopia, removal of glasses during near work, or using
bifocals with +3.0 for near to suppress accommodation. These
measures have been employed for decades, but have these prevented
the progression of myopia? Or does a ‘real’ cause-effect relationship
exist between accommodative effort and myopia? Centuries of

change in the environment of humans, strongly point towards
myopia progression—(this has been discussed in the previous
pages) but even if we agree to the logic of physiologic rationale for
an association, does it truly affect the progression to such an extent
to traumatize that patient, with long-term atropinization or deprive
a clear vision by undercorrection?
Perhaps all authorities agree that myopia and its progression is
genetically determined, but its course can be somewhat influenced
by environmental factors.
Retinal Image Degradation

The work of Wiesel (a nobel laureate) and Raviola showed that
degrading the retinal image in some animals, had a myopia
generating effect. In humans, retinal image degradation might be
associated with myopia development. Corneal scarring, partial
cataracts, partial ptosis, high astigmatism and other image affecting
conditions may in some young eyes, produce myopia. Therefore,
prompt remedial efforts should be made to correct these conditions.
This hypothesis further puts weightage that since undercorrecting
myopia causes loss of clarity of image, this practice should be
abandoned. There is one more inherent problem in atropinization
or suppressing accommodation. Accommodation is not an isolated
phenomenon. By suppressing it, there is a concomitant suppression
of accommodative–convergence also. Thus, a person is now
forced to use fussional convergence to maintain binocularity. This
will gradually lead to asthenopic symptoms or even diplopia. To
summarize, paralyzing accommodation or suppressing it, will only
marginally affect myopia, if at all. The advantage-disadvantage ratio
is so meager, that such remedies are not warranted. Some benefit of
course, can be had by instructing the patient to use accommodation
with ‘care’ and meaning that patient should do reading or similar
near work from a little distance, so that accommodation effort is
at the minimum. Long, continuous hours of near work should be
avoided. ‘Computer vision Syndrome’ is now a known entity for
ocular asthenopia but does it contribute to myopic progression, is
not known yet.
Role of Drugs
Dopamine is a natural neurotransmitter and is abundantly found
in neural tissue. The role of dopamine in rejuvenation of neuron-
synapses in treatment of amblyopia still continues. Dopamine is
found in retinal cells and actively takes part in neural electrical
transmission between amacrine, horizontal and photoreceptor
cells. Dopamine is a product of L-Dopa, which we take in diet. It is
produced and activated in presence of light only. It is also known to
take part in normal development of retina and eye. Darkness or dim
light, hampers the production and normal activity of dopamine. Near
activity like reading and writing in closed rooms with insufficient
or artificial lighting. affect dopamine metabolism and may affect
myopia.
Orthokeratology
Two decades ago ‘orthokeratology’ became very popular. Clinicians
used contact lenses to flatten the corneal curvature in a controlled
manner and maintained the flattening by advising the patient to
continue wearing each day for as long period as tolerated. But
the effect lasted for as long as the lenses were used and was not
permanent.
Surgical Treatments
Radial keratotomy, Lasik and Epilasik are all surgical interventions
in correcting myopia. Lasik and its modifications are the newer
modalities. The ‘remodeling’ of cornea, does not stop at myopia
only but astigmatism and to some extent hyperopia are also treated.
Though Excimer and Femtosecond lasers have revolutionized
the management of myopia but they only cure myopia but do not
prevent its progression, and is therefore, done only after myopia
stabilizes. Like the proponents of Lasik, there are as many opponents
also. Many authorities opine that the center of cornea (visual axis)
should not be tampered with. And they promote flattening of cornea
from the periphery using INTACS.
Spectacles
It should not be misunderstood that spectacle correction has been
introduced last as they are not important. Spectacle was and will
remain the mainstay of myopia correction. An important question
which haunts every clinician is when to prescribe the first glasses.
Most children do not complain in early myopia, as they may start
sitting a little closer to the blackboard in school. In anisometropia
or uniocular myopia, the problem is not recognized till late. It is
only when the myopia has progressed sufficiently or discovered
accidently, that consultation is sought. A routine vision testing in
school, in most cases, is not reliable.
If a distraught parent rushes to an ophthalmologist with a
report from school of diminished vision, a cycloplegic refraction
is warranted. Many a times, no refractive error will be found. If
a small error of –0.5 or –0.75 is indeed discovered and the child is
asymptomatic, then the dilemma arises whether to prescribe glasses
or not!
Most parents would not appreciate glasses at such a tender
age and there are innumerable examples that in later follow-ups,
you would find that the child never wore glasses which you had
prescribed six months or year back.
Consensus is now gathering, that one should not wait for myopia
to progress and cause symptoms, and then prescribe glasses. We
do not have any strong data to guide us to know how myopia will
progress in a patient. There are records that progression in some
cases has been astonishingly rapid.
Therefore, to be on safe side, glasses should be prescribed as
soon as myopia is discovered. The patient can be reviewed every
six months initially to see the mode of progression. If parents are
myopic, then care should be doubled and instruction should be
given regarding reading habits, use of computers and laptops, and
emphasis on optimum outdoor life.
Following are some special situations for spectacle prescription:
• In tropia, particularly exotropia, early glasses are strongly
recommended, as minus correction will stimulate accommo
dative–convergence to help straighten the eyes also.
• In phorias: If the patient has a phoria, the refraction status and

type of phoria should be determined. In case of exophoria, full
correction should be promptly given to facilitate accommodative
convergence, as in exotropia. In case of esophoria, which may be
due to use of excessive fusional convergence or even high AC/A
ratio, care should be taken in the this situation as prescription
of minus lenses will further increase the esodeviation. Therefore,
after giving minus glasses for myopia, muscle balance should be
again evaluated with glasses on. If esodeviation persists, then
patient can be advised to remove glasses for near or use bifocals
with small plus correction for near.
QUASI-MYOPIA
Progressive blurring of vision does not always mean that myopia
is progressing. We know the obvious reason of increasing minus
lenses in adults with nuclear cataracts. But we are more concerned
in children with progressive myopia. There are two important
aspects to be looked into when a young myopic patient comes with
complaints of blurred vision with present spectacles. First the vertex
distance and second, the ‘pantoscopic tilt’ in the frame should be
examined. The first aspect is more important and an example will
clarify the situation.
A child comes to the clinic with complaints of diminished
vision with the present spectacles. Distance vision recorded is 6/12,
both eyes with specks. His vision six months back was 6/6, both
eyes. Cycloplegic refraction showed no deterioration in myopia.
His present glasses were –6.0 OD and –7.0 OS. Fundus picture was
absolutely normal. There was something amiss. The child was called
again (for postcycloplegic test) and was told to put on the present
specks. Astonishingly, the specks had slipped far too low on nose
and that was the place he was keeping the specks, almost 25 mm
from the cornea. Placing the specks back at the original 14 mm made
his vision jump back to 6/6 OU. This is not an exceptional case!
Children are careless about their specks, mishandle them causing
loose frames, slipping down the nose and creating visual disturbance.
Accurate vertex distance is as important in a high myope as is in an
hyperope of +10 D!
Change of vertex distance from 13 mm to 21 or 22 mm causes

under correction in a myope, causing blurring of vision. Similarly.
Pantoscopic tilts in frames of high myopes especially with minus
cylinders would also cause blurring in the vision.
UNILATERAL MYOPIA
Consider the following example: A child of 6 years is discovered with
defective vision, OD, during school examination.
Vision recorded in clinic showed, OD 6/12 and OS 6/6.
Cycloplegic refraction showed:
OD –0.75 D
OS –Plano
Since the child has no complaints and is a simple unilateral
myopia no glasses are prescribed. Even if glasses were given the
child would not have worn them. A year later, he comes back with
complaint of diminution of vision, OD, (Probably, once known his
right eye has numbers, he was cautions and could be closing his left
eye and observing right eye vision.)
Refraction showed: OD (–1.75 D) and OS (–Plano). Now there is the
dilemma. Should glasses be prescribed now? The following point is
to be considered:
• Since early age, he was a mild myope with good vision. The
myopia was not detrimental to his eye. Even now he has good
foveal fixation, as he alternates, fixation for distance and near. He
‘may’ be left alone but strongly advised for six monthly reviews
• Close examination should be done for binocular fusion and
stereo acuity. These children may not fuse well for near and this
is a precursor for exophorias
• Asthenopic symptoms should be enquired. Since accommo
dative–convergence is lacking, the child uses fusional conver
gence to maintain binocularity and invites asthenopic symptoms.
Clinical pearl: As is obvious that his myopia has doubled in six
months, and such trend hints towards progressive myopia, it is
prudent to prescribe spectacles now itself. Psychologically also, the
child is now aware that he sees very blurred with one eye and keeps
on testing his blurred vision while closing the good eye, which upsets
him. Thus, it is better in the interest of the patient to allow him enjoy
normal vision from both eyes.
PSEUDOMYOPIA
What is pseudomyopia? It is a condition where a person complains
of blurred vision at distance and manifest refraction reveals minus
lenses, but a cycloplegic refraction reveals ‘hyperopia’. One of the
most common notion prevailing is that cycloplegic refraction is not
needed in myopia. This is most misleading. Cycloplegic refraction
is as important in myopia as in hyperopia. Although most patients
will have similar manifest and cycloplegic refractions, but it is always
wise to do a cycloplegic refraction, at least the first time.
Example: A 10-year-old boy complains of moderate blurring of vision,
say OU –6/12 and whose manifest refraction reveals only –O.5 D. This
again does not corroborate with the amount of blurring and invites
a cycloplegic refraction, which reveals the presence of a hyperopic
error. Cycloplegia alone unmasks the state of error and what initially
appeared a low grade myopia, is actually ‘pseudomyopia’ created by
excessive ciliary tone.
This is another ‘rule of the thumb’ that in case of any disparity
between vision and manifest refraction, cycloplegic refraction is
mandatory. Now as the patient is symptomatic at distance, what
recourse should be resorted to. Minus lenses are obviously contra
indicated. Usually, single cycloplegia will break the excessive ciliary
tone and the patient will become asymptomatic. If symptom recurs,
the child can be put on cycloplegic drops for a week or so. Since this
is a mild case of excessive ciliary tone, (generated by hyperopia) and
not a true ciliary spasm, the above simple measure will be effective.
To add, the child can be instructed to break from continuous near
work, looking at distance by stopping near work for a couple of
minutes. Also, as a later precaution, he should be encouraged for
some daily period of outdoor activity. If these measures do not
suffice, then lens correction becomes necessary.
‘Full cycloplegic correction’ is given initially for near and then

gradually for distance also. This will relieve the accommodative load
and the patient would remain asymptomatic.
Clinical Pearl
As an extension of use of cycloplegia in a myope, see this situation.
A child of 10 years complains of blurring. His vision OU is 6/12.
Manifest refraction reveals OU –2.5 D. This is a mismatch. Cycloplegic
refraction reveals only OD –0.75, and OS –1.0 O D. If lenses would
have been prescribed according to the manifest refraction, then one
can imagine the consequences. Such examples in clinical practice
are numerous. Although most myopes will reveal the same refractive
error on manifest as well as cycloplegic refractions, but it is always
wise to conduct cycloplegic refraction, at least the first time.
Explanation for the above phenomenon is simple. Most children
have strong accommodative tone. Any stimulus to view objects during
a manifest retinoscopy or on an AutoRef, triggers accommodation
and a false amplification of minus error results.
Overcorrection in a Myope
This is further to what has been narrated in the previous paragraph.
Complaint of asthenopia by a myope is unusual but not rare. If a
myopic person complains of eye strain, then immediately focus on
overcorrection. A minus overcorrection can provoke symptoms by
producing ciliary spasm. The symptoms would exaggerate on near
work, as the patient has to over accommodate to compensate for the
minus overcorrection.
If the current glasses show more minus power than the manifest,
then overcorrection is present and if the manifest shows more minus
than cycloplegic refraction, then ciliary spasm is present.
The suspicion can be cleared by doing a cycloplegic refraction,
which evidently would reveal less minus power. As mentioned
in clinical pearl earlier, that such mistakes of refraction are not
uncommon and therefore it is amply stressed that cycloplegic
refraction is always desired, especially in young persons.
A symptomatic myope, who has been wearing overcorrection for
a long-time, may have so much ciliary spasm, that it is not always
possible to rectify the problem in one stroke. The overcorrection

would have to be weaned gradually in steps. For example, a 30-year-
old computer engineer complains of burning in eyes, watering and
headaches during work. He is wearing a 5 years old prescription,
which shows:
OD –7.0; –1.0 90 6/6
OS –8.0; –1.0 90 6/9
OD –6.50; –1.0 90
OS –7.0; –1.0 90
Cycloplegic refraction:
OD –4.0; –1.0 90
OS –4.0; –1.0 90
Thus, cycloplegic refraction uncovered 3D of difference
between the person’s actual refractive error and the present glasses.
Surprisingly, postcycloplegic acceptance showed reduction of only
–1.0 D, to have clear vision. Obviously the eyes were under the spell
of ciliary spasm and sudden reduction would only lead to blurring.
In such situations, graded reduction in power is advised, say 0.5 D
every couple of months.
A pertinent question will still haunt the reader, that why an
overcorrection of 1.0 or 1.5 D in a myope trigged asthenopic
systems, where as a hyperope of +4.0 or +5.0 of same age remains
as asymptomatic. The explanation is as follows: A hyperope of +4.0
or +5.0 had this condition since early childhood and has adapted to
it. He has learned unconsciously, a comfortable balance between
the accommodation required to see clearly, and the vergence
necessary to maintain fusion. Actually he has to use fusional
divergence to counter the excessive accommodative–convergence,
which accompanies the accommodation. As he grows older, the
hyperopia gradually decreases and so his accommodative demand
and the accompanying vergence. But for a myope who has been
abruptly overcorrected, produces an accommodative convergence,
to which being a myope, he was not accustomed. This in turn,
causes extra effort on convergence and to counteract this he will
have to use extra fusional divergence. These cumulative changes of
overaccommodation and vergence stress occurring ‘suddenly’, is the

root cause of asthenopic symptoms.
NIGHT MYOPIA
During night fall or in dim light, our refractive state shifts towards
nearsightedness. The night myopia has been known for almost two
centuries, but it is only much recently that it has gained importance.
Though its cause is yet not fully explained, but being a distinct clinical
entity that produces symptoms, it should be understood.
Three separate factors operate at night when the pupil dilates:
accommodation, spherical aberration and chromatic aberration.
But for practical purpose, it is the accommodation which contributes
most. At night or in extremely dim light, there is loss of retinal image
contrast. A low contrast of image is incapable of stimulating the
accommodation to focus; so it simply drifts into a resting state. This
resting state is not ‘zero’ accommodation, and hence the myopia.
The symptoms produced are a blurred image with surrounding rings
around lights. These ‘halos’ represent defocused retinal image.
Management
Since the condition occurs typically at night, conditions of that
nature have to be created to measure the amount of night myopia.
Two techniques are in vogue:
1. An accurate laboratory technique is a ‘laser Badal optometer’
which uses a laser speckle to measure myopia.
2. The second is a simple technique of a standard retinoscopy at
convenient distance of one meter in a completely darkened
room. This ‘dark state retinoscopy’ coincides well with the
patient’s night-myopia.
For example, a patient with –3.0 D myopia has problem driving
at night. A fully ‘dark retinoscopy’ is performed with his –3.0 D
correction in place. The dark radioscopy reveals an additional error
of –1.0 D (after correction for 1m distance). He is advised to wear
–4.0 D during night driving. Night myopia is different for different
myopes and the correction has to be individualized.
PRESBYOPIA AND MYOPIA

It is well-known that myopes do not need near corrections, at an age
depending upon the amount of myopia.
Let us recapitulate the reasons:
• Myopes of –3.0 or less can comfortably read by removing their
glasses
• Myopes can ‘slide’ their glasses down their noses to read–an
optical jugglery which reduces their accommodation demand
• The spectacle wearing myope, requires less accommodation than
a hyperope—an optical affectivity of minus correction lenses.
Myopic presbyope tends to delay the use of bifocals for as long
as possible. And he may continue to remove his specks for near as
long as he wants, of course depending on his amount of error! So far
so good, but the problem occurs in myopes of more than –5.0 D or
in myopic anisometropes, (where two eyes are not accommodating
equally for near).
Example
A man of 45 years has –5.0 D of myopia. He started having discomfort
in near vision for last couple of years, with his specks on. On
removing them, his near distance had to be brought to around
20 cm (his far-point being at 20 cm). His usual table work at 40 cm
got disrupted. He tried to read and write at 20 cm, where the vision
became clear but headaches and burning in eyes began. His normal
accommodative–convergence does not come into play here (as he is
not using accommodation), so he uses fusional convergence which
produces the asthenopic symptoms. Thus, such patients require a
bifocal albeit a little time away than an emmetrope.
Effect of Medical Problems on Myopia

Diabetes is the single largest systemic cause affecting the refractive
state of the eye. If a myopic patient in his middle age (as myopia
ceases to progress after this age) complains of sudden blurring of
vision for distance and a refraction reveals more myopia, it important
to take his medical history, rather than jumping to prescribe new pair
of specs. This increase in myopia is due to hydration of the crystalline
lens (Index Myopia) and disappears with the control of diabetes.
Glaucoma, once upon a time, created problems in refraction,
when pilocarpine was used. Though pilocarpine is not used today
for open angle glaucoma but a word of caution is obligatory in
myopia. Pilocarpine produces pinpoint pupils and accommodative
spasm. The accommodation spasm creates pseudomyopia and such
patients who are using pilocarpine, prescribed by some remotely
placed clinician, should be stopped.
PATHOLOGICAL MYOPIA
‘Pathological or degenerative myopia’ and ‘progressive myopia’ are
two different entities and a clear distinction exists between them.
Progressive myopia may gradually progress beyond 8.0 or 10.0 D, yet
is not associated with degenerative changes. Pathological myopia, on
the other hand, is high myopia with choroidal and retinal thinning
and degenerative changes. Both have strong family predispositions,
but their genetic pattern differs.
There is no known treatment for pathological myopia till date. All
the measures employed for restricting the progression of myopia, as
for simple or progressive myopia, do not work here. Surgical measures
like sclera strapping or bolstering the sclera with cadaveric scleral
strips, have yielded negative result. At best, some optical adjustments
can be done like ‘undercorrecting’ the myopia, which enables the
patient to achieve higher magnification by bringing the reading
material closer.
In pathological myopia, the patient is usually visually handi
capped, and needs the assistance of low vision aids. By undercorrect
ing a myope of –15.0, to say, –10.0 gives him advantage of +5.0 D,
and he uses this as a low vision aid. His distance vision is beyond
improvement due to degenerative changes at the macula and thus
a little less correction for distance will not affect him. He may even
remove his glasses to enhance his magnification. This may induce
more magnification but will deprive him of binocularity.
SUMMARY
• Myopia is the most common refractive error. Its increasing
prevalence necessitates a thorough research into its etiopatho
genesis.
• Theories for its causes and progression have generated a great
deal of enthusiasm and to some extent all have their role to
play. An interplay of genetics and environment, has come in the
forefront of our understanding of the disease. Therefore, genetic
counseling is one area where the clinician can focus. Patients
should be warned about menace of excessive near work. Stress
should be laid on outdoor activities and periodic rest to the eyes.
• Asthenopic symptoms is not a prerogative of hyperopia only,
but can occur in myopia also. Myopic patients complaining
of headaches and other asthenopic symptoms, should be
reevaluated with a cycloplegic refraction.
• Myopia should never be undercorrected, as has been the practice
by many clinicians in the past.
• Myopic children and adolescents should always undergo a
cycloplegic refraction each time they come for follow-ups; as
their true refractive error will be revealed only after cycloplegia.
• Night myopia is a real entity; myopes complaining of problems
during at night must undergo a ‘dark refraction’ and the extra
minus be prescribed during night time.
• Self-correction of presbyopia in a myope should not be taken for
granted.
Myopes should be explained of the effect of their refractive state
in presbyopic age, and glasses prescribed in any myope according
to their magnitude of error.
• Systemic diseases like diabetes should be always enquired, in
cases of fluctuating power of lenses.
5
Astigmatism
INTRODUCTION
Astigmatism, as we know it, is ametropia created by meridional
variation in refractive power of the eye. Curiously, it is one of the
most difficult areas of refraction and what adds to the woes is the
dilemma as to what prescription to be given in light of astigmatic
error or mixed astigmatism. Most clinicians give less correction to
begin with. Some do not give any correction in small astigmatic
errors. While others falter in mixed astigmation.
PRESCRIPTIONS
It is none of their fault because whatever correction you give in a
moderately high astigmatic person, he remains unhappy. Either his
vision does not get fully corrected or his asthenopic symptoms do
not vanish. Therefore, a big question looms—whether sharp vision is
more important or alleviation of symptoms.
If given a choice to the patient, he would probably prefer comfort
over sharp vision. But long years of experience recommends that
prescription should be given fully to improve vision, and most of
time the patient adjusts to this correction and becomes comfortable.
If the patient repeatedly complains of asthenopic symptoms, then

correction should be modified. There would be patients, especially
children, who would have no complaints, yet during school vision
testing their vision is subnormal. Again, there are patients with as
little as 0.75 astigmatic errors, yet they suffer from severe asthenopic
symptoms. Adjustment to refractive errors is again a subjective
phenomenon; and younger the patient, his adaptive capability is
better.
In the first instance, where defective vision is incidentally
detected, a cycloplegic refraction should be conducted and his
true refractive status should be unearthed. Here is an eye opener
example:
A child aged 10 years is detected in school examination with
OU vision 6/24. But he has no complaints. Anyway, his manifest
refraction shows:
OD –3.0 D + 3.0 D 180°
OS –3.0 D + 3.0 D 180°
(Symmetrical refractive error)
Cycloplegic refraction reveals:
OD –1.5 D + 4.0 D 180°
OS –1.75 D + 4.0 D 180°
Cycloplegia not only revealed more hyperopic cylinders but less
myopic spheres. How this happens, is already described in previous
chapter.
Vision, with aforementioned full correction, was OU 6/24
at the outset, which very quickly improved to OU 6/6D in a few
weeks. Obviously the child had developed bilateral amblyopia,
which improved on spectacle prescription (being symmetrical and
identical, patching is not required). The above example is only a
sample. The reader will come across scores of such patients in his
practice. One should not be afraid in prescribing full correction
even in higher numbers than what is illustrated above. This serves
two purposes: first, it treats amblyopia automatically, and second,
it obviates the asthenopic symptoms which would arise sooner or
later.
Whenever a person comes with complaints of headaches or
eye aches, a cycloplegic refraction is indicated, and the degree of
Chapter 5: Astigmatism 51
astigmatism should be compared with his symptoms. In a young

patient of 7 or 8 years, a 0.5 D astigmatic error may not be responsible
for the symptoms, but in a 30-year-old with the above symptoms,
correction is indicated. In any case, no hard and fast rules exist and
‘rule of thumb’ should not be followed blindly. Every case should
be treated on its own merits and should be resolved on individual
basis, taking into consideration the amount of error, age, vocation,
amount of near work, and also the personality of the person. High-
strung, stressed patients, with even moderate astigmatic error, may
not benefit with perfect correction! Therefore, an overall situation
should be taken into account.
Astigmatic Refraction for Distance

A proper cycloplegic refraction should be done to unveil the full
refractive-astigmatic error. And then a postcycloplegic subjective
correction instituted. Correction is done for each eye separately, and
then binocularly. In high astigmatic errors, this binocular subjective
testing is even more important. A good idea is to have the patient
walk around your clinic with the correction in place in the trial frame
and the degree of adaptability can be gauged, then and there itself to
quite an extent. If the person feels dizzy or complains of vertigo, then
this is ample indication that the patient will not wear these spectacles
and the prescription should be modified. But a little tilting of objects
or uneven ground appearances, if experienced, is not a deterrent for
the full prescription, as the patient will gradually adjust to this.
Astigmatic Correction at Near

This might be a surprise to the reader. Whenever cylinder power
is substantial (3.0 D or more), it is wise to measure the axis and
power error for near as well. But this is rarely done. Moreover, the
subjective correction should be done binocularly, with the patient
fusing, to take into account the cyclotorsional effect on spectacle
lens correction, when the two eyes converge to view a near object.
This, unfortunately, is never done. If correction for near is done with
one eye closed, then we are neglecting the binocular influences
which tort the eyes to maintain fusion. It should also be understood
that astigmatic change that occurs at near not only involves the axis
position but also change in power too. A simple technique for near
estimations in high astigmatic errors is a follows:
Have the patient fixate binocularly at 35 or 40 cm near target,
with the refracted near correction in place in the trial frame. Fog one
eye with a little plus to slightly blur the print, yet permitting fusion.
Using Jackson cross-cylinders over the unfogged eye, first refine the
axis, then the power. Repeat this similarly on the other eye, with
mildly fogging the first eye. If shift in the axis is more than 5 or power
difference is greater than 0.5 D, then a separate reading glasses are
indicated. But before embarking on this decision, have the patient
wear the original correction of distance in cylindrical power and axis,
with the normal near addition for week or so; if he is comfortable do
not tamper with the prescription. But if he finds discomfort reading
then only modify the near correction. In high cylindrical powers,
if the axis differ for distance and near, then a compromise can be
attempted by prescribing an axis midway between the two.
Changes in Cylinder Power and Axis

It is a general concept that cylindrical power or axis does not usually
change over the years. But the fact is that astigmatism is susceptible
to changes in both power and axis, and this is not limited to cornea
only.
Age-related Changes
The shift in axis occurring with advancing age is well-known. In
presbyopic age the axis moves from “with-the-rule” position to
“against-the-rule” position. The shift in axis is attributed to both the
changes in cornea as well as the crystalline lens.
Myopic or hyperopic changes in refraction are well-known in
cataracts. This may well be accompanied by astigmatic shift also;
modifying the already existing corneal astigmatism. The amount of
astigmatic change by lens can be assessed by routinely following
the corneal curvature by keratometry. The difference between the
refractive and keratometric astigmatic measurements is due to the
lens.
Furthermore, keratometry will evaluate only the ‘anterior’

corneal curvatures. Subtle changes occurring in corneal disorders
or postoperatively in ‘posterior’ corneal surface, also contributes to
astigmatism, which will not be evident on keratometry.
Changes in Children
We all know that the child’s eyes are in a phase of development
up to the age of 12 years. Alterations in length, cornea and lens,
are in process up to that age. Therefore, this is accompanied by
alterations in refractions also. Weaning of hyperopia from childhood
to adolescent’s age is a scientific fact. The following example is self-
explanatory. A child of 6 years comes to the clinic with no complaints
except squinting during watching TV by parents (squinting is not
strabismus!).
OD –0.5 +1.0 180° 6/6p
OS –0.75 +1.5 180° 6/6p
Glasses were prescribed primarily to compensate for mild
astigmatic error to overcome the squinting (squinting is technically
described as voluntary narrowing of palpebral fissure by partly
closing of lids. This is typically seen in astigmatic errors where patient
tries to improve vision by the lid narrowing).
Patient was lost to follow-up but reappeared after 5 years at the
age of 11 years just for routine examination. The child wore specs
for a couple of years but then abandoned them as his squinting
disappeared. Now parents brought the child just for assurance that
the spectacle power has now gone.
OD –0.5, + 0.5 5 6/6
OD –0.25, + 0.5 180 6/6
The above true example demonstrates:
• Reduction in refractive error and astigmatism with time
• Initial spectacle correction should be given for only symptoms
or signs.
Postoperative Change
Induced astigmatism after cataract or glaucoma surgery, are
well-documented proofs. Though the modern phacoemulsion
surgery has dramatically reduced the incidence of postoperative
astigmatism, but no authority can vouch that his or her surgery
has zero astigmatism. Correction of preoperative astigmatism is
being attempted by modifying the incision site or implantation of
Toric IOL’s. But cataract is not the only intraocular surgery; corneal
transplant surgeries are all accompanied by substantial astigmatic
errors. Appearance of these abrupt astigmatic errors to which the
patients has not adapted to, can be very disturbing. It is always wise,
in these cases, to give separate glasses for distance and near; not
bifocals (The pros and cons of bifocals in high astigmatism, will be
dealt later in this chapter).
CILIARY OVERTURES
Ciliary spasms may be a presenting problem in some cases of
astigmatism. This is more pronounced in hyperopic astigmatism,
where the patient is constantly using accommodation to maximize
his visual acuity. Since this does not yield the desired result, he
strains more and more to gain better vision. This in turn, lands the
eye into ciliary spasm.
Clinical experience has shown that manifest refraction in an
astigmatic patient, may not uncover all the astigmatic error. To
uncover the full astigmatic error one must do the cycloplegic
refraction. Many times the cycloplegic refraction may not yield any
extra cylinder than the manifest, but it becomes our bounded duty to
follow the protocol.
If cycloplegia unravels any extra cylinder, then a postcycloplegic
examination becomes mandatory to see the subjective acceptance.
Sometimes the patient may not accept the entire amount, but
eventually gradually with time he will (The best way to ascertain
acceptance is to provide the correction in the trial frame and let the
patient wander around the clinic as narrated earlier).
Case Example
A young female of 16 years, had complaints of headaches and
eye ache, after doing her homework. She was using spectacles for
4 years, which were initially comfortable, but of late, her symptoms
had recurred. Her spectacles showed:
OD –5.0; + 4.0 140 6/9
OS –4.5; + 4.0 60 6/9
Manifest refraction gave identical results. Cycloplegic refraction
showed:
OD –3.0; + 3.5 145
OS –3.0; + 2.5 60
Clearly, the magic of cycloplegia is obvious. The patient was
overminused and the cylindrical error was miscued. It not only
made me wiser, as to what prescription I should give now, but at the
same time, provided relief to the patient also.
The importance of vertex distance has been emphasized in high
minus or high plus lenses. But it is reemphasized that proper vertex
distance should be taken into account in high astigmatic errors also.
BIFOCALS IN ASTIGMATISM
When an astigmatic patient enters into the presbyopic age, a different
set of problems arise. If ones astigmatism is less than 1.0 D, then
adjustment to the new bifocals is easy but in astigmatism of higher
order, difficulty in adaptation arises. In any case, whenever bifocals
are given for the first-time, a fresh refraction is necessary, because
axis tend to change with advancing age. We all know the shift in axis
from ‘with-the-rule’ to ‘against-the rule’ in older persons. If a patient,
who has recently been given bifocals, complains of difficulty, then
the following possibilities should be explored:
• Does the astigmatic axis change, when the patient looks down
and in?
• Has the cylinder been transposed? Patient may have got tested
elsewhere, where transpositioning might have been attempted.
• Have the lenses changed from glass to plastic and vice-versa?
• Is the lower segment of bifocals, in proper position?
• Do the extra plus in the near add causing phorias?

• Is there only adaptation problem rather than a problem of high
astigmatism?
During prescribing bifocals in high astigmatism particularly
if anisometropia also exist, the patient should be well-counseled
regarding pros and cons of bifocals. In my clinical experience, I have
always advised separate pair for these patients and has relieved me
from lot of disharmony with the patients.
The following example will clarify the situation we are talking
about:
Male patient, aged 50 years, came for periodical checkup for his
specs. He had them for last 8 years but was never happy with them.
Two years back he had his last checkup and the refractionist bluntly
advised that considering his type of refractive error, bifocals was
out of the question. His vocation demanded frequent changing his
vision from distance to near and vice-versa.
His present specks were:
OD –2.0; + 3.0 90 6/9
OS –5.75; +4.0 90 6/9
Near +1.75 add was given. He had separate pair of glasses.
Cycloplegic refraction revealed little change in spherical or
cylinders. Studying his specs showed that OD has a plus cylinder and
OS, minus cylinder. Since he insisted on bifocals (which was a dire
necessity for him), a transpositioning of lenses was attempted. It was
assumed that same sign cylinders would reduce aniseikonia. So the
new prescription was:
OD + 1.0; –3.0 180 6/6p
OS + 1.75; –4.0 180 6/6p
Near add +1.75, as bifocals, with fused segments.
Now the bifocals created another problem. The lower segments
produced ‘anisophoria’ when near work was attempted (This will be
clarified in the chapter on anisometropia). However, this was also
rectified by altering the thickness of cylinders (Slab off technique) to
reduce the phorias. Since, the optician could not do the desired, the
bifocals were abandoned.
Unfortunately, majority of opticians/skilled lens makers are
ignorant about advanced lens fitting techniques, nor is the ophthal
mologist! Nevertheless, this is one of the objectives of this book
to highlight the type of lenses to be used and their modification

techniques.
IRREGULAR ASTIGMATISM
‘Irregular astigmatism’ as is defined, occurs due irregularity of the
anterior corneal surface; but it can also present due to opacities and
irregular refraction from the lens.
In such cases, the basic, primary refractive error of the patient
gets masked owing to the distorted retinoscopic reflexes. Since the
crystalline lens can also be a contributor to irregular astigmatism,
the more appropriate term would be “irregular optical refractive
error.”
Irregular astigmatism commonly occurs in pterygiums, corneal
scars (central or para central), band-keratopathies, kerato-conus.
When astigmatism stems from a large pterygium, refraction is usually
possible and subjective correction given.The same strategy can be
applied for paracentral or peripheral scars. In central corneal scars
of sufficient density which obscures visual axis, refraction can be
attempted from the periphery after mydriasis. If vision improves after
mydriasis and subjective correction, then the mydriatic drops (not
cycloplegic) can be continued along with the subjective correction
prescribed in spectacles. Patient may also use dark goggles in day
light to compliment dilatation and also avoid glare. Science is full of
mysteries, and even in diffuse corneal opacities, some clear area may
remain through which retinoscopy is possible after mydriasis, and
subjective correction possible. It is my clinical experience, that such
cases should not be written off, and a sincere attempt must be made
to refract these patients.
Refracting in Irregular Astigmatism

Refraction in irregular astigmatism requires patience and skill.
Somehow if a mydriatic retinoscopy has revealed a refractive error,
the following steps should be followed:
• Determine and record the best visual acuity. In case of corneal
opacity, use a ‘multiple-hole pinhole’ with a dilated pupil. This
will make it easy for the patient to locate a useful opening through
which he can read a chart. If available, a Guyton-Minkowski

potential acuity meter can be used
• Determine the corneal astigmatism by a keratometer, whatever
help it can afford. This is useful in cases where retinoscopy is not
yielding result
• Refract subjectively in large (1 D) steps to obtain best visual acuity
• Refine the refraction by either using a stenopic slit or a cross-
cylinder.
The stenopic slit is used by rotating it in-front-of the eye to locate
the principal astigmatic meridians, i.e. those yielding the best acuity.
Once the principal meridians are identified, trial lenses can be put in
the frame to arrive at the best visual acuity.
Jackson cross-cylinder can be used directly over the subjective
correction lenses in the trial frame to refine the subjective correction.
Clinical Pearl
Remember that the refraction has been done under cycloplegia.
Hence, a postcycloplegic subjective examination is mandatory. In
cases of corneal opacities where ‘paracentral clear cornea’ will be
used for viewing, the subjective examination has to be done with
pupil dilated, as this will be the permanent state. When such is the
case, the pupil will have to be kept dilated only with mydriatic agents,
not a cycloplegic agent. In clinical practice, the patient is recalled
after a few days when cycloplegic effect has faded, and subjective
correction done with mydriatic drops only. This will be the final
correction, done subjectively under mydriasis.
Important Note
If the cylindrical axis is not at 90 or 180 degree, the effective power
in the vertical meridian can be found according to the following
guidelines (The vertical meridian is significant owing to changes in it
due to the lid pressure).
• When the axis is at 75 degrees, the effective power is same as
90 degree, i.e. 100%
• When axis is at 60 degree (i.e. at 30 or 150 degree) the effective
power at 90 degree will be 75%
• When axis is at 45 degrees from the vertical (45 or 135 degree),

the effective power at 90 degree will be 50% or half of the total
cylindrical power
• When axis ia at 30 degree (i.e. at 60 or 120 degree), the effective
power will be 25%
• When axis is at 15 degree from the vertical, the effective power of
that cylinder at 90 degree is zero.
Systemic and Local Diseases affecting Astigmatism

Diabetes, as is well-known, causes fluctuation in vision and
refractive error, as it waxes and wanes! Not only myopic shifts can
occur, but it is known to produce astigmatism also. Uremia and
related conditions that create large shifts in water balance of the
body, can create large shift in refractive status of the eyes including
astigmatism. Myasthenia gravis is another systemic condition, which
can produce astigmatism which waxes and wanes, with ptosis. Local
conditions of eyes like pterygiums, blepharoptosis and chalazions,
are all known entities to create astigmatism.
6
Presbyopia
DEFINITION
Weakness of eyes for near vision as age advances has been known for
many centuries. It is was not until early 19th century that James Ware
clarified that diminished vision for distance and near are separate
entities. Then 50 years later, Donders described the exact optical
nature of these entities.
Presbyopia is defined as the physiological diminution of the
accommodative power of the eye with advancing age. This results
from natural loss of elasticity of both the lens capsule and the lens
substance. But we have seen in the chapter on accommodation,
that there exists large variation in accommodative amplitude of
individuals. In strict clinical definition, presbyopia occurs when
a person encounters difficulty in near task and has symptoms
of blurring at near and symptoms of eye strain. If this definition
is adhered to, then presbyopia would vary with accommodative
amplitude, refractive errors and type of work of a person. Obviously,
then presbyopia would appear late in a myope and early in a
hyperope. Therefore, the parameter of age takes a back seat, if
presbyopia is discussed in strict clinical sense.
Ch-6.indd 60 06-04-2015 15:52:00

Chapter 6: Presbyopia 61
One other symptom apart from blurring at near and asthenopia is

the inability to relax accommodation. A person experiences blurring
for distance when looking up from a near task. This unfocusing is
another feature of ensuing presbyopia.
Influencing Factors
As already stated above, contrary to the popular notion, 'age' is not
a reliable criteria for the onset of presbyopia. It may begin as early
as 35 years or as late as 50 years. Even in a normal emmetrope
person, the onset at age may vary depending on the amplitude of
accommodation (AA). At age 40, one may have AA between 4 and
6 and the 50 age, between 1 D and 4 D. Since in a literate person,
reading and writing is the main near task, he may choose to read 6
inches away than his normal distance and defer presbyopia by year
or two. An illiterate farmer may never need presbyopic correction.
The bottom line is that presbyopic correction should never be
arbitrarily given relying purely on age even in an emmetropic person.
Amplitude of accommodation should always be measured before
deciding on the prescription. Perhaps nowhere the AA estimation
is as important as in a presbyopic correction. Clinicians have burnt
their fingers in casually giving presbyopic corrections.
Another variable that significantly influences the presbyopic
correction is the amount of accommodation available that a person
can use comfortably. It is a common teaching that 1/3–1/2 of the
available accommodation must be kept ‘in reserve.’
For example, a person of age 45 years has AA of 4.0 D. To read at
33 cm, he is using 3.0 D of accommodation. That leaves only 1.0 D in
reserve, i.e. less than 1/3rd. If he continues to work for long with that
reserve, he may sooner or later face asthenopic symptoms.
Another factor affecting the correction is the illumination at
which a person reads. Good illumination or optimum illumination
increases the contrast and the miosis produced enhances the depth
of focus. Both together complement each other and the person
can read comfortably at a slightly further distance again enabling a
person to defer near correction.
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Influence of Refractive Error

The amount of refractive error whether hyperopic or myopic; how
fully it is corrected, whether corrected by contact lenses or glasses,
if by glasses, then the vertex distance—are several important but
seldom appreciated factors influencing the presbyopic correction.
Note: The following points:
To see clearly at 30 cm, an emmetrope has to exert 3.0 D accommo
dation. A 10.0 D myope corrected by contact lenses exerts almost
the same amount. But if corrected by glasses will need only about
+1.5 D to see at the same near distance. On the other hand, a
10.0 D hyperope, corrected by spectacles will have to exert +5.0 D
of accommodation, while with contact lenses about 3.50 D. This
variation is due to the optical effect of corrective lenses at a specific
vertex distance.
Influence of Height
It has been observed that a short statured person with shorter arms,
will hold the reading nearer that a tall person with long arms, and
will invite presbyopia earlier.
To reiterate, the following influence the onset of presbyopia:
• The amplitude of accommodation
• The proportion of available accommodation that can be used
with comfort
• The type and amount of refraction error
• The working distance of the patient.
HOW TO DETERMINE NEAR CORRECTION

When a patient of presbyopic age comes to the clinic with near vision
problems, the following steps should be considered:
• Make certain that the correction for distance is accurate and
balanced. If doubt exists, then it is useful to do a cycloplegic
refraction. Remember, age is no bar for cycloplegic refraction
• Measure the accommodative amplitude with a prince ruler
• Now, determine the patient’s working distance and working
range. A book or a near chart can be given to a literate person, to
Ch-6.indd 62 06-04-2015 15:52:00

know his reading distance. People working on desk and involved

more in table work should be specifically asked about.
The add then should be placed in the trial frame and patient
asked to read the near chart at his comfortable distance. His range
of near work should then be assessed. Normally, lenses that provide
optional viewing at 40 cm, have a range of 30–60 cm and is satis
factory for near work. But if this person works on a large table and
needs to see material scattered about the table to about 80 cm to
1 m, then this is inappropriate. A similar example is for computer
workers. They may see clearly the reading material at 33–40 cm, but
the reading screen at 1 m, becomes blurred with the near correction.
This is now a universal problem as most of the work is done on
computers. One should always verify the working distance with
the adds in the trial frame, especially in patients whose working
conditions are unusual. A special mention for computer workers
is important. The simplest way is to use separate 'bifocals' for
computers, with the upper segment for screen viewing and the
lower segment for near writing material. Today, we have a wonderful
option of progressive power lenses, which has come as a boon for
persons with unusual working conditions or in bifocal wearers.
BIFOCALS IN CHILDREN
Bifocals in not a commodity of only presbyopes. There are several
indications of bifocals in children.
In cases of ‘accommodative esotropia’ with high AC/A ratio,
bifocals are treatment of choice. The important point to keep in
mind is that the lower segment should be placed a bit high, in line
with lower border of pupil unlike the adult bifocal with the upper
border of lower segment in line with lower border of limbus. Though
this is not a place to discuss esotropia, but still it will be not out of
place to illustrate an example. A young girl of 7 years complained of
intermittent diplopia on doing home work and that her eyes have
started 'crossing' quite frequently nowadays. Her motility evaluation
of eyes with alternate cover tests showed:
Esotropia for distance: –20 PD
Esotropia at near (40 cm): –45 PD
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Cycloplegic refraction showed:

OD + 2.0 + 0.75 180°
OS + 1.75 + 0.75 180°
With this correction in place during postcycloplegic refraction
showed:
At distance, esophoria - 6PD
At near, esotropia - 20 PD
Obviously she had high AC/A ratio. A plus 3.0 add given in trial
frame reduced the esotropia to only a ‘flick’ (of less than 5 PD). She
was promptly given the bifocals as per the norms and the patient is
asymptomatic.
It is surprising but also gratifying that how children readily
adapt to bifocals, despite the high placement of lower segment. The
rationale of placing the lower segment high is that the child should
have full view through the lower segment and also there is a problem
of the specs slipping down the nose-depriving the benefit of the
bifocals.
In pseudophakia in children (who are operated for developmental
cataracts), bifocals are strongly indicated, to maintain clear vision
both for near and distance and sustain binocularity. Bifocals in
children in progressive myopia are controversial. Though many
proponents of the theory of accommodation in causation of myopia
still prefer bifocals, the clinical experience of most authorities have
denied this venture, except in cases of high AC/A ratio in a myope
resulting in esodeviations during near work.
NEAR CORRECTION IN ADULTS

Presbyopia, as we understand it, occurs after 40 years of age. But as
has been discussed earlier, 'age' is not a hard and fast criterion for
onset of presbyopia.
If a person of 30 or 35 years complains of diminished vision or
asthenopic symptoms undetected or undercorrected hyperopia
should be suspected. Reduced accommodation may also result
from central nervous system diseases, diabetes, eye diseases such as
glaucoma, ocular trauma, and systemic medications like tranquili
zers, parasympatholytics, psychotropic drugs, etc. But if no local or
Ch-6.indd 64 06-04-2015 15:52:00

systemic anomaly is discovered and cycloplegic refraction yields

no refractive error, then physiological subnormal accommodation
should be suspected, which is unusual but not rare. It may be simply
a manifestation of an early, but still physiological presbyopia. If a
person in 30’s complains of impaired near vision which cannot be
explained, with exclusion of any refractive error after a cycloplegic
refraction, the accommodative amplitude should be measured.
If the accommodative amplitude is found to be subnormal,
than the following course of action should be taken: (a) A thorough
medical and diagnostic tests should be advised, (b) suitable
bifocals should be prescribed. Such patients always harbor a great
deal of anxiety. The best way to allay their fears is to comfort them
by assuring that this is quite normal in some individuals and give
proper near correction.
BIFOCALS IN PRESBYOPIA
The first sign of advancing age, in majority of cases, is the difficulty
in near vision. What is universal is the resistance to wearing specs,
especially for near sight. And this is a universal truth also that, as
soon as the person begins to use near glasses, he is termed as an
elderly person. People adopt innumerable ways to hide their age and
defer specs for as long as possible. Since near vision problem cannot
be disguised hence patients resistance to bifocals is maximum.
Another problem in bifocals is the line midway joining the upper
and lower segments. This is annoying to the first time bifocal wearer;
and once the patient gets dejected to bifocals, it becomes extremely
difficult to convince him again. Therefore, a wise step is never to
force a patient for bifocals, one may adopt certain other measures
to help him overcome his near vision problem. Increasing the level
of illumination improves the contrast and thus the visual acuity.
Additionally, the miosis induced by light, increases the 'depth of
focus' which further enhances the near vision. There should be what
is called optimum illumination; too much causes glare and retinal
‘irradiation’ by spilling around excess of light. After having exhausted
all these measures the patient is finally ready for bifocals.
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Bifocals, literally means, specs for both distance and near. Let us
now consider the following refractive errors for bifocals:
Hyperopia
A mild hyperopic may not be aware of his disease and may come for
the first time either with difficulty in near vision or headaches, after
working at near for some time. His manifest refraction may show
a small plus error. But this warrants a full cycloplegic refraction to
know his exact hyperopic error. Let us see this example:
A 40-year-old male comes with complaints of headaches and
blurring on prolonged near work.
OD + 0.5D; OS +0.5D
Vision recorded - OU 6/6
OU + 2.0 DS
His accommodation amplitude is +5.0 D. Using his +2.0 accom
modation for distance, he is left with +3.0 D for near work, which
is totally consumed at near. Thus, he is not able to sustain his full
accommodation for long and develops the asthenopic symptoms.
Now there are two options:
1. He may be given full correction for distance which he will wear
all the time. This would correct his hyperopia and have enough
AA in balance for near work. But mind this step; his distance
vision may get blurred and you may land the patient from frying
pan into the fire! One may reduce the correction slightly, say to
+1.0 or +1.5 and this he may adopt in due course of time.
2. The other option is leaving him free for distance and initially
giving him near correction only.
Often such patients are already using some correction for near,
procured some years back when they had astheropic problems
in the prepresbyopic period. So far they were comfortable but
they have come for consultation as their asthenopic symptoms
have resurfaced. Now they need bifocals. After doing a cycloplegic
refraction, the correction should be titrated in the postcycloplegic
test.
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Myopia
Myopia is no exception to bifocals. In mild to moderate myopia of
–1.0 to –4.0 D, the patient is rewarded with 'no' bifocals, or if their
vision so demands of frequent changes from distance and near, a
bifocals of zero power in the lower segment can be given.
It is only in high myopes that their near point comes dangerously
near, that they need plus correction to bring back their near point to
normal workable distance of 30–33 cm.
Astigmatism
As presbyopia approaches in an astigmatic patient, the visual
problems at near may by aggravated than a normal patient. The
diminishing accommodation power, especially in hyperopic astig
matism, compounds the asthenopic problems. Many times, patient
with low degree astigmatism may not be aware of his problem and
had never used glasses. As presbyopia supervenes, and refraction
reveals an astigmatic error, one may not give correction for distance,
but cylinders must be incorporated in near correction.
Clinical pearl: Ideally, whenever a patient already wearing
cylindrical correction, comes for presbyopic correction, a manifest
and cycloplegic correction should be done. It has already been
emphasized that axis changes with advancing age, and therefore, a
reassessment of astigmatism is necessary. Sometimes, a cycloplegic
refraction may yield a slightly different cylindrical axis, but the axis
should be given according to the manifest refraction. This is because
the act of accommodation may cause a shift in cylindrical axis as well
as a slight increase in cylinder power also.
The shift in axis is due to the ‘torsional’ effect of convergence
and increase in power due to influence on lens contour during
accommodation.
In high astigmatic errors, it is scientifically wise to ascertain
the axis for both distance and near separately. And the correction
given according to the demand the eyes are used. If eyes are used
predominantly for near work, then near axis should be incorporated
in specs; if distance work is preferred their correction axis should
be according to distance in correction in bifocals. If both vision is
equally used, a separate glasses for distance and near is advised.
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BIFOCALS FOR READING IN BED

There are some quiet, relaxed moments from a long, busy day when
one wants to lie in bed and read a refreshing novel. But the bifocals
steal away those moments. The chin upright position to read through
the bifocals, strains the neck muscles and after a very short time,
reading becomes a torture.
The solutions for this predicament are:
• The lower segment can be fitted little high up (just as bifocals for
high AC/A ratio children)
• A separate pair of glasses for only reading may be advised.
Progressive power lenses have now solved most of bifocal and
intermediate distance problems. These ‘invisible multifocals’ will be
given special attention in later chapter.
PRESBYOPIA AND CONTACT LENSES

Patients who are already wearing contact lenses, irrespective of
their error, will experience the onset of presbyopia like any other
individual, albeit at a different age than a spectacle wearing person.
Since the 'optical affectivity' of contact lenses and spectacle lenses is
different, the effect of presbyopic correction will also vary.
As already indicated previously, contact-lens-wearing myope
will need more accommodation for a near task than a spectacle
wearing myope, hence they will need presbyopic correction at an
earlier age. On the other hand, a hyperopic contact lens wearer
requires less accommodation for the same near task, and will need
near correction at a later age.
When these persons come with complaints of near vision, they
have the following options:
• A near add may be given over the contact lens.
• A +1.0 can be added to one eye contact lens, so that this can be
used for near viewing and the other for distance vision. A concept
of monocular vision. But keep in mind that this will work for only
a few years; as the presbyopia increases, different approach will
be needed.
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PRESBYOPIA IN MYOPE
The happiest person in the world of spectacles is a low myope. A
myope of –1.0 to –2.0 D myopia will need near correction much later
than an emmetrope or hyperope; only after their presbyopia out
classes their myopia. The simplest and easiest way to read for them
is to remove their glasses for reading. It is only after 45 years of age
or even later, that they start experiencing problems in near vision.
Even then there is a trick, which they learn probably by insinct, that
sliding their glasses slightly low on nose, enhances near vision; and
they continue to do so as long as they can. With all above exhausted,
they finally come for near glasses. The option is now bifocals or
progressive power lenses. The pros and cons of progressive power
will be discussed in a separate chapter. As of now, let us focus our
attention to the more common bifocals. A point to be kept in mind
when prescribing bifocals is to keep the lower segment as small as
possible. We are shifting to a different sign lens from upper to lower,
and abrupt change shift from far to near vision may cause 'image-
jump' and image displacement. Many persons are misled by a wrong
notion that large lower segment are more comfortable in reading.
Large lower segments are advised only for special vocational needs,
not as routine. With the newly acquired near vision, the myopic
presbyope breathes a sigh of relief, but very soon discovers that his
work on and around the writing table or computers, is in absolute
disarray!
This is because of the loss of 'intermediate distance', which was
so important for his day-to-day work. On removing their glasses a
–1.0 or –1.5 D myope, very comfortably worked at 1 meter—the usual
working distance on the table or computers. Their comfort zone
was between 20 cm (near point) and 1 meter (the far point). Even at
2 or 3 meters, they had quite comfortable vision. As their near point
recedes to say 40 cm (with the advent of practical presbyopia), and
they start using the +1.0 correction in bifocals, their intermediate
distance, which was so important for them, has now gone!
With the new bifocals, their distance vision and near vision
become crisp, but loose the advantage of intermediate vision. They
have two options: Either to remove their bifocals during intermediate
work or come 'closer' to view the table work with the near correction.
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Gradually they adapt to the second choice and become habitual to

the circumstances.
In high myopia of more than –5.0 D, the person has been using
spectacles all his life, never taken them out for near work also, as
their near point is too close to the eye for binocular viewing. Hence,
they readily adapt to whatever appropriate near correction is given.
Increasing Myopia in a Presbyope

This is a situation quite commonly encountered as cataract sets
in. The problem surfaces as nuclear sclerosis or cataract develops
in a myope of presbyopic age. This induced index myopia can be
sometimes very difficult to manage. Increasing index myopia may
not result from frank nuclear cataract but even with progressive
nuclear sclerosis, of course, a precursor of eventual cataract. Nuclear
sclerosis can be identified clinically by retroillumination with a
direct ophthalmoscope or a different reflex from center of pupil on
retinoscopy.
Let us see an example:
A 70-year-old gentleman has been a mild myope and has been
wearing –2.0 glasses for distance and usual +3.0 add for near since
10 years. Of late he has started having blurring at distance.
His present glasses:
OU –2.0 D –6/24
Near Add +3.0
Manifest refraction: OU –4.0 6/9
Slit-lamp examination showed early nuclear cataracts.
But his near vision, with present glasses, had become much
sharper in last 6 months and could read small print which he earlier
could not. Why was this happening? The explanation is simple. With
increase in 2.0 D of myopia, he now has an advantage of extra +2.0.
Adding this +2.0 to the already existing +3.0 add in near segment,
gives him near add equivalent to +5.0 D. This brings his near point
to 20 cm, which enhances the magnification of retinal image, and a
better viewing of small print. If one modifies his distance correction
to 4.0 and the usual +3.0 D add for near, he may frown of having lost
his new found near vision.
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To be more dogmatic, it is better to ask the patient what he pre

fers; this will also depend on his way of life! If he is a voracious reader
and confined mostly to near task then new change will suit him.
Most persons are more confined to indoors with less of driving or
other outdoor activities, and hence relish their improved near vision.
Television viewing may become a problem, which can be solved
by inching closer to the set. Nuclear cataracts progress gradually,
and the patient can enjoy the better near sight for quite some time,
but when eventually vision deteriorates, surgical option should be
looked into. Let us look into this situation:
With progression of cataract, say the myopia increases to –6.0 D
and the patient's vision improves to 6/12 or so with this correction
he may not be ready for surgery. A compromise can be struck. The
distance correction may be given –4.0 D which will still give him
distance vision of say 6/18 and near advantage of +4.0 or +5.0 as
before. This will help as near point comes closer and with good
ambient illumination, will continue to benefit in near vision, until he
is ready for surgery.
Unequal Accommodative Amplitudes in Presbyopia

Normally, both eyes have equal accommodative amplitudes. If
during examination for near correction, different near points are
observed, then the error may be that one eye may be overplussed.
The refraction should be repeated carefully, preferably under
cycloplegia, to rule out any discrepancy.
Nevertheless, there may be an occasional case who actually
exhibits unequal near points. This usually happens in the presbyopic
age, say between 35 years and 40 years of age. If refraction shows per
fect correction, then a monocular pathology should be looked for.
The following example will clarify how to go about in a case of
true disparity in accommodation:
A 40-year-old typist complains of blurring on near work.
Present glasses for distance: OU +1.0 6/9
Near point of accommodation (NPA) with glasses:
OD 33 cm (Diop. equivalent to +3.0D)
OS 45 cm (Diop. equivalent to +2.0D)
Manifest refraction: OU +1.5D. –6/9
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NPA with manifest correction:

OD 28 cm (+3.5D)
OS 40 cm (+2.5D)
Accommodation amplitudes with new correction of +1.5 D with
Prince Ruler showed:
OD + 3.5 D
OS +2.5 D
A cycloplegic refraction becomes mandatory, which shows: OU
+2.5 D.
Inference: The above exercise evidently shows that the unequal
accommodative amplitudes are not due to incorrect refraction, as
cycloplegic refraction showed some, latent but equal hyperopia.
Manifest refractive correction was also equal and with equal visual
acuity in both eyes, with all these findings, true unequal amplitude
is disclosed.
Now prescribing the full cycloplegic correction would blur his
distant vision and would not also help near correction. Consequently
distance correction of +1.5 D is to be given (as vision is 6/6 OU, and
an 'unequal near correction' is advised,
i.e. OD + 1.5 Add +1.0
OS + 1.5 Add +2.0
With these bifocals, his near point in both eyes comes around
35 cm, with equal reserves of accommodation.
Thus, contrary to general opinion, if actual unequal accommo
dation amplitudes are found, one should not hesitate to give unequal
near add.
It will be not out of place to mention an important point. If 'equal'
near points are present (i.e. equal accommodative amplitudes),
then equal near correction should be given, irrespective of visual
acuities, meaning equal near add should be given, equalizing the
near ‘distance’, not the acuity line.
Example:
OD –1.0, 6/6
OS –2.0, 6/12
With add OU +2.5 OD can read J1 at 40 cm
OS can read J3 at 40 cm
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What is illustrated here is the distance to be taken into account for

near adds; even if the reading print may be different in the two eyes.
This is because, with both eyes open, the near vision of lesser visual
acuity will not bother the patient but disparity in accommodation
exerted for near will produce asthenopic symptoms.
The pathological reason for unequal AA, as described earlier, is
an ocular pathology like glaucoma, trauma or old iritis. If disease
has affected one eye, prescribe near correction for that eye only. If
binocular pathology exist, with 'unequal AA' then correct both eyes,
albeit unequally. If the patient with monocular pathology has no
near vision complaints, no correction is required.
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7
Anisometropia and Antimetropia
DEFINITION
Anisometropia simply means that refractive errors in two eyes are
different. If both eyes are myopic but disparity exists in the two eyes,
we call it ‘anisomyopia; if the two eyes have different plus numbers,
we call it ‘anisohyperopia.’ There exists another term, though seldom
used, as ‘Antimetropia’, which means one eye is myopic and the other
hyperopic.
Further, we can group anisometropia into the following catego
ries, just as in astigmatism:
• Simple hyperopic anisometropia: One eye hyperopic, the other
emmetropic.
• Compound hyperopic anisometropia: Both eyes hyperopic, but
with different numbers.
• Simple myopic anisometropia: One eye myopic, other emme
tropic.
• Compound myopic anisometropia: Both eyes have different
minus numbers.
• Antimetropia: One eye myopic, other hyperopic.
Having so judiciously classified anisometropia, there still exists
bountiful of uncertainties and confusion regarding its management.
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Chapter 7: Anisometropia and Antimetropia 75
The following points cross the mind on dealing with this subject:
• What is the maximum difference between the two eyes that can
be corrected and tolerated?
• How much difference between the two eyes should be corrected
to maintain balance?
• Can astigmatic anisometropia be resolved by converting into
spherical equivalent?
• What is aniseikonia? How much aniseikonia can be tolerated?
• How can aniseikonia be corrected?
• What is ‘slab-off’ technique? What is its role in lens modification?
• Is the optician trained enough to undertake these techniques?
• How to manage ‘antimetropia’?
• Finally, how much anisometropia is significant to warrant
concentration?
Since these are very relevant questions and faced by every
clinician day in and day out, he must be aware of these atypical
refractive problems and have a know how to deal with them.
Broadly there are two schools of thought, viz. (1) Irrespective of
the difference, prescribe full correction in each eye; and (2) Prescribe
full in the less aberrant eye and then ‘adjust’ the correction in the
more ametropic eye so that the difference is tolerable. There are
fallacies in both the versions; the first idea will outrightly be rejected
by the patient as too large discrepancy will never be tolerated and
in the second, the ‘bad’ eye with less correction will never have full
visual acuity. Therefore, again ‘rule-of-thumb’ cannot be followed.
Each case has to be tested, tried and prescribed on individual basis.
Also it is very difficult to satisfy such patients and sincere effort
should be made to counsel and make them understand their ocular
ailment, and try the best solution applicable.
SYMPTOMATOLOGY OF ANISOMETROPIA
It would have been very helpful if anisometropia could be
quantitatively defined and amount of inequality established to
identify cases that might be clinically significant. But tolerance to
anisometropia is so variable that each case stands on its merit. As
a rule, corrected anisometrope can fuse only if the refractive error
difference is less than 3 D. But there are scores of examples where
Ch-7.indd 75 06-04-2015 15:58:39

difference of 6 D or 7 D has been tolerated, with good fusion and

no diplopia. Refractive difference alone also does not determine the
tolerance for anisometropia. Other factors like type of anisometropia,
patient’s age, fusion capability, presenting symptoms and the psyche
of the person, all play a role. Therefore, what defines a clinically
significant anisometropia, is defined on individual basis. The worst
affected are hyperopes, who may present with any or all symptoms of
ocular asthenopia. Most of these symptoms aggravate on near work.
Myopes and antimetropes, one the contrary, escape asthenopic
symptoms, as they attempt to fuse. But they have visual defects
which bother them.
By and large, most of the patients will come with complaints
of headaches, usually associated with specific visual tasks. Others,
including the majority having headaches, may also have burning,
ocular pain, epiphora, fatigability and limited reading tolerance.
Some tend to have nausea, vertigo, motion sickness associated with
panoramic eye movements.
Symptomatic patients must have their refractive error corrected.
Depending upon the situations described above, the correction
should be wisely done. Small difference anisometropias can be
“fully” corrected, without causing any discomfort. Moderate to high
degrees of anisometropic correction need skill and patience. It is
always prudent to try a full correction in the clinic only and have the
patient wear them for half an hour or so. If they have any problems,
then the difference should be tapered, with the brunt falling on the
more ametropic eye.
Two main problems arise on prescribing high anisometropia.
The image size disparity (aniseikonia) and the induced muscle
imbalance (anisophoria). And to give full benefit to the patient and
relieve these new induced symptoms, ‘compensation’ of speck for
aniseikonia and anisophora will have to be done.
ANISEIKONIA
Aniseikonia is defined as the disparity in size and shape of images
presented by the two eyes to the visual cortex. Most often it has an
optical basis, causing discrepancy in the image sizes formed on the
retinas of the two eyes. Here, the lenses used to correct anisometropia,
Ch-7.indd 76 06-04-2015 15:58:39

are themselves the cause of aniseikonia. This happens because of

magnification or minification of images on the retina. If the two eyes
differ in refractive error, the images formed on the retina when the
error is corrected will also differ. It is primarily the ‘size’ difference
which is a hindrance to fusion. But there is no convenient way to
ascertain the image size difference or how much difference is created
by a given amount of error. We, of course, know the qualities of lenses
used to correct the refractive lenses which create the image disparity
on retina; we also know the ways to modify them. The basis for an
anisometropic difference is exclusively ‘refractive’. For example, in
uniocular aphakia, the magnification difference between the two
eyes is 2% per diopter.
In other words, if the phakic eye is emmetropic, the other aphakic
eye with +12.0 diopter spectacle lens would produce a magnification
difference of about 24%. Physiologically, a magnification difference
of 6–7% can be fused and no diplopia results. Thus, a lens power
difference of 3 D will only produce an aniseikonia of 6% and falls well
within the range of fusion. But there are exceptions to this rule.
On the other hand, if the anisometropia were entirely ‘axial’
and the corrective lens placed at the anterior focal plane of the eye
( 15.0 mm anterior to cornea), the size of retinal image would be
identical to that formed by the emmetropic eye with same corneal
and crystalline lens configuration. This principle, called the Knapp’s
rule, suggests that if the anisometropia is due only to difference in
axial lengths of the two eyes, then correcting for aniseikonia is not
needed.
Lens Manipulation in Correcting Aniseikonia

Every spectacle lens introduces some magnification or minification,
depending on its power, shape, its thickness and its distance from
the eye. Since the lens power is fixed by the patient’s refractive
error, the variables left are the shape, thickness and vertex distance.
These can be manipulated in simple approach to compensate for
aniseikonia, as follows:
• Increase in ‘lens curvature’ increases the magnification. For
example, a minus 6 D lens that has a front curve of +3 D and back
Ch-7.indd 77 06-04-2015 15:58:39

curve of –9 D, will generate an image larger than the same power

lens having front curve of +1 D and back curve of –7 D.
• Increase in ‘center thickness’, increases the magnification.
• Increase in the ‘vertex distance’ of plus power lens, increases
the magnification; and increase in the vertex distance of a minus
lens, decreases of magnification.
By controlling the above variables, aniseikonia can be controlled
to quite an extent. The following finer points should also be kept in
mind:
• For each diopter change in power, plus lenses produce greater
size changes than minus lenses.
• This is because the center thickness of plus lenses vary more per
diopter than minus lenses.
• In plus lens, an increase in front curvature adds to the magni
fication. In minus lens, this adds to the minification.
These optical points should be kept in mind when management of
aniseikonia is attempted. Applying these practically in prescription,
this is what should be done:
• In myopic anisometropia, change the lens curvature and vertex
distance, rather than the central thickness.
• In hyperopes, alter the center thickness and vertex distance,
rather than the lens curvature.
• In both myopes and hyperopes, the vertex distance should be
kept as short as possible. With this point in view, a contact lens is
the best alternative.
ANTIMETROPIA
All the above manipulations are most useful in managing antimetro
pia, where one eye is significantly myopic and the other significantly
hyperopic. The problem is compounded when one or both eyes
have cylindrical element. Where ever and whenever feasible, toric
contact lenses are the best choice. Majority of variables contributing
to aniseikonia like lens thickness, curvature and vertex distance are
controlled automatically. For example, a plus contact lens worn on
the eye will produce a smaller image than a spectacle lens, and a
Ch-7.indd 78 06-04-2015 15:58:39

minus contact lens on the other eye will produce a larger image than
minus spectacle lens. As a result, the discrepancy in image sizes,
(aniseikonia) in the two eyes is reduced and fusion is possible.
Consider the following example, to practically understand how
to compensate for aniseikoni:
OD +1.0 D
OS -1.0 D; +4.0 90
This prescription is of antimetropia with mixed astigmatism,
OS. Now, though the spherical equivalents in two eyes are identical
(+1.0 D), the effective lens powers and meridional image-size
difference is not identical. Applying the 1% aniseikonia-per-diopter
rule the image size in OS will be 2% smaller in vertical meridian and
larger in horizontal axis.
Clinical Point
Arthur Links and Robert Brannon have deduced a workable
formula which states 1% image size difference for each diopter of
anisometropia. It is to be noted that this applies to smaller variations
of anisometropia, say up to 5–6 D. As the difference in power increases
to more than 10 D, the lens thickness and curvature variables come
into picture and as stated earlier, in plus lenses the magnification
increases more than 1%. Thus, in aphakie plus lens of more than
10 D, the magnification increases to 2% per diopter.
As we already know that image size disparity up to 7% can be
easily overcome and fusion possible, hence the full prescription can
be given in this case without hesitation.
For academic interest, the following modification can be done.
Reducing the overall magnification in OD lens will narrow
the disparity, in the vertical meridian of OS, but will increase the
disparity in the horizontal meridian. To overcome this, induced
disparity the plus cylinder is grinded on back surface rather than the
front to reduce the magnification (More details are available in the
chapter on spectacle prescription).
Now that we can modify the lens to help compensate for aniseiko
nia, a question arises that should every patient with aniseikonia
should have lens modifications? If not, then when?
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The answers are as follows:

• The clinician already knows the refractive status of the two eyes.
If he finds, by his knowledge, that the aniseikonia is of mild
degree then full correction is advisable. With moderate degree of
aniseikonia, if the correction gives almost equal visual acuity in
both eyes then still full correction is tried and observed. Normally
patients comfortably fuse 1–2% of aniseikonia but if it is between
2% and 5% then still a trial of specs is advisable and differs
from person to person, a reasonable period should be given. If
aniseikonia exceeds 5%, then fusion is difficult and binocularity
will be poor, with spectacles. Such patients are advised contact
lenses. If this is not feasible, then, alterations in the glasses are
done to reduce aniseikonia.
• If the new refractive findings differ little from the older ones and
the patient has no symptoms, no change is necessary.
• If there has been recent change refraction in either eye, and
it appears that the new prescription will create intolerable
aniseikonia, then compensation in the new glasses is required.
• If the correction shows good visual acuity in the more ametropic
eye then compensation is warranted.
Clinical Pearl
A 100% compensation of aniseikonia is not necessary. Also in
compensation for aniseikonia, always try to prescribe minus
cylinders. This produces the maximum reduction in the meridional
size difference induced by that cylinder.
Summary
With all said and done, unusual refractive errors with large
anisometropia, is always difficult to treat. Though a trial in the clinic,
with final prescription in the trial frame, can be helpful but it bears
no guarantee that the tailor-made glasses with all modifications
done will alleviate all problems.
Large lens corrections, spherical or cylindrical, also create
prismatic effect and induce anisophoria.
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This anomaly cannot be assessed with small diameter trial frame

lenses as full ocular excursions are not possible. The crux of whole
issue is, that too much reliance cannot be had during in-clinic trial
of high anisometropic glasses. Best possible modification should be
ordered, not necessarily 100% and the patient warned that if these
glasses do not suit you then reduction in numbers could be done
albeit at the expense of visual acuity.
ANISOPHORIA
Anisopharia is the relative change in heterophoria that occurs as
the eyes move away from the position of primary gaze. Induced
anisophoria results from the prismatic effect produced by spectacles
lenses. It is another barrier to binocularity created by the spectacles
used for correction of anisometropia.
A spectacle lens induces no prismatic effect at its optical center,
so an object viewed through that central portion will not appear
distorted but if the eyes move away from the center in any direction
of gaze, the object will appear displaced, as every lens acts as a prism.
If the two lenses are identical in power, the image displacement will
be equal and there will be no ‘differential’ prismatic effect and thus
no induced phoria.
For example, suppose, two spectacle lenses have identical plus
power and are perfectly centered and IPD aligned. When the gaze
moves to right, the right lens act as base-in prism and left lens as
base-out prism, the displacement is neutralized and no discomfort
felt. Similarly, vice-versa in left gaze. When the eyes move down in
reading position, equal amounts of base-up prisms are introduced,
no ‘differential’ prismatic effect is produced, hence no anisophoria.
But when the two lenses are of unequal power, the prismatic of each
lens will be different at the same distance from the optical center.
And the more the eyes move away from the optical center, the greater
will be the difference in prismatic effects.
How much symptoms are generated by the differential unequal
phoria depends upon the unequality of lens powers, the fusional
amplitudes, and the preexisting phoria if any.
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Management of Anisophoria
The amount of induced phoria, horizontal or vertical, that requires
correction depends upon the patients symptoms, the vergence
capability, and the magnitude of change presented by the new pres
cription. In general, even large anisophorias in horizontal meridians
can be compensated by vergence capability. Since hori zontal
vergence range is variable in individuals, exact quantitative correction
is not possible. Nevertheless anisometropias which generate large
anisophoria for horizontal excursions of eyes will produce even more
disturbing phorias for vertical excursions and then it is the vertical
element that needs compensation rather than the horizontal. As a
general rule, vertical phorias greater than 1.5 PD, should be corrected,
lesser than this, seldom requires correction. As with prism correction
of phorias, it is not necessary to compensate for entire anisophoria,
and allowing patients to use some of their own vergence. Usually
1/2–2/3rds compensation suffices to relieve symptoms. To be more
precise the compensation should be based on actual measurements
taken with glasses on and with horizontal and vertical excursions. For
vertical position the down gaze is more important. Vertical up gaze is
used seldom and mostly associated head turned up.
Correction in horizontal gaze: Though the eyes make much larger
movements than vertical, the version amplitudes are also larger. But
even then, abrupt horizontal movements in higher glass numbers
create sudden change and can be troublesome. Prism correction
can be attempted but usually not practically recommended. Some
simpler ways to deal with the problem are:
• The spectacle and the lens size should be kept smaller. The larger
the lens size, the bigger the problem.
• Encourage head movements in side gazes, rather than eye.
• Reduce the power disparity between the two lenses. This may
compromise vision a bit, but in high ametropias this does not
affect much.
CORRECTION IN VERTICAL GAZE

This is more significant of the two because on looking down for
reading through uncompensated lenses, creates severe asthenopia,
as fusional amplitudes are very limited. The following points should
be noted to overcome the vertical imbalance:
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• In mild anisometropias, the patient may tilt the head slightly

forward, to bring the visual axis as close to the optical center of
glasses.
• The ‘optical center’ of the glasses can be dropped about 3 mm
below their usual position, again to bring the visual and optical
axis as close as possible.
• Smaller frames are recommended because larger the lens, the
more prismatic effect.
• For bifocal users, the problem is ‘intensified’ as they have to look
through the lower segment, far below the distance optical center.
Some of it can be rectified by placing the lower segment little
higher, in line with the lower border of pupil rather than the usual
lower limbus.
• Further, a technique, utilized, for compensation in bifocals, is the
‘slab-off’, over one bifocal segment.
‘Slab-off’ is a process that removes, from the lower portion of
a lens, a piece of glass that is shaped like base-down prism thus
creating a base-up prism effect, without altering the power of the
lens. Since it is the high minus lens that creates a base-down effect,
it is this lens which should have the slab-off procedure. In hyperopic
bifocals, it is the ‘less’ hyperopic lens that receives the slab-off.
A word about cylindrical anisometropia. If cylindrical correction
is only in one axis, (simple myopic or hyperopic astigmatic aniso
metropia) then compensation is obviously needed on the axis the
cylinders are acting. In case of compound astigmatic problems, both
horizontal and vertical prismatic effects need correction. Again here,
it is the down gaze prismatic effect which needs more attention.
Clinical Note
Decentering a 10.0 D lens by 1mm has the same effect as decentering
1 D lens to 10 mm. Both these produce what is defined as ‘1 PD of
deviation’ at 1 meter distance, which translates to 1/2 degree.
Let us see this example:
OD +1.0 D OS +4.5 D
+1.0 +4.5
+1.0 +4.5
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Horizontal excursions of OD even to large amounts would create

negligible prismatic effect. Horizontal movements of OS would
create prismatic effect, but these are easily overcome by fusional
amplitude. The problem will arise in vertical excursion of eyes,
particularly in down gaze for reading, because the vertical amplitudes
are very limited. Taking into account that the eyes move about
8 mm down and 2 mm inside while reading at 40 cms, the following
equation arises:
OD Vertical 0.8 PD (effect) × OD (power) = 0.8 PD Base-up
Horizontal 0.2 PD (effect) × 1 D (power) = 0.2 PD Base-out
OS Vertical 0.8 PD × 4.5D = 3.5 PD Base-up
Horizontal 0.2 PD × 4.5D = 0.9 Base put
Net vertical difference = 3.5 PD - 0.8PD = 2.8 PD
Net horizontal difference = 0.9 + 0.2 = 1.1 PD
(In down gaze, the deviation of image is in the same direction,
hence only the differential amount remains; in horizontal inward
movement the displacement of images are in opposite directions,
hence the increased deviation effect.)
As mentioned, the horizontal deviation will be well taken care of
the by fusional amplitudes, while the vertical needs correction. Of
the 2.8 PD, 2 PD should be corrected by ‘slab-off’ of the right lens
(which has less base-up prismatic effect).
A summary of this complex exercise would indeed be welcomed:
• Single vision lenses creating vertical phoria of more than 1.5 PD
can be slabbed-off, but a simpler solution would be to reduce the
differential prism power by lowering the optical centers by 3 mm.
Or the power of the high ametropic can be reduced to minimize
the difference.
• Bifocal lenses needs slab-off, wherever the vertical phoria is more
than 1.5 PD. One-half to two-thirds correction is acceptable.
• For large difference in horizontal anisophoria, compensation is
not warranted, instead it can be minimized
– By encouraging the patient to turn head instead of eyes.
– Prescribing glasses with minimal vertex distances,
– By having a spectacle frame of smaller diameter.
• If acceptable, reduce the power of the more ametropic lens.
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ANISOMETROPIA IN CHILDREN
Anisometropia in children may be myopic, hyperopic or associated
with astigmatism. Children may be born with refractive errors
or may acquire them with growth. We all know that a child is
born with hyperopia (by virtue of his small eyes) which is aptly
compensated, to quite an extent by crystalline lens and its anterior
shift. As the child grows rapid changes occur both anatomically
and physiologically. Emmetropization is the physiological rule and
occurs as a natural phenomenon. But if this does not occur, then we
have the various types of ametropia. One eye may gallop towards
emmetropia while the other does not and one gets anisometropia.
The rules which govern this disparity are still largely unknown.
As for the pediatric ophthalmologist, the worry for proper vision
development and amblyopia, ends at the beginning of teenage. But
changes in refraction continues well beyond teenage probably up to
21 or 22 years of life. Clinical experience has proved that, in interest
of the patient, one should check vision and refractive errors at least
annually up to the age of 21 years.
Myopic anisometropia: If a child is born with high myopia,
whether simple or compound, the chances of binocularity are slim,
but still glasses should be prescribed to attain as best vision as
possible, even with a difference of 4 or 5 D. Children have remarkable
capability of fusion and even significant amounts of disparity will not
cause trouble. If myopia develops later in childhood, and progresses
with the growth of the child, full correction can be given without
hesitation. Even with the development of ‘unilateral’ myopia during
childhood or adolescence, the child has already acquired good
binocularity, and fusion will be good in mild to moderate myopic
anisometropias. In high degrees of disparity (5 D or more), some
simple compensation may be required.
Clinical Point
Though it may seem odd, but many times, a child can be left without
any glasses, if compound myopic anisometropia is not too great. For
example, a child having error of –1.0 D one eye and –3.0 D in other,
Ch-7.indd 85 06-04-2015 15:58:40

the child happily uses the right eye for distance and left eye for near
work. It is not surprising that these children have no complaints
and they carry on well, until the disparity increases. They also are
unaware of their visual defect until they compare with their follow
students or is discovered accidently.
Hyperopic Anisometropia
Hyperopic anisometropia, simple or compound, is usually present
from birth. If it has gone undetected for long, then the more hyperopic
eye has already become amblyopic. No matter when this is detected,
full spectacle correction, along with antiamblyopia therapy should
be instituted.
Compound hyperopic anisometropia is a developmental
problem. Usually children are born with equal or almost equal
hyperopia, which gradually decreases with age. If it only decreases
in one eye, the child becomes anisometropic. In these cases,
binocularity has already been established and the visual acuities
were normal. The following points need attention:
• If the difference is not too big, say of 1 or 2 D, and the patients
vision is almost equal, and having no complaints, no correction
is needed.
• If the difference exceeds 3.0 D or more, the patient may complain
of diminished vision or asthenopic symptoms, or both.
Such patients need spectacle correction. If such a child goes
uncorrected before the age of 7 or 8 years, he may develop
amblyopic in the more hyperopic eye; if not, then will have
asthenopic symptoms. In the first instance amblyopia treatment
is immediately initiated. In the second instance correction of plus
lenses is given according to the difference of spectacle numbers.
For example,
OD + 1.0 D; OS + 3.0 D
Spectacle lens of + 2.0 will be given in left eye. The rationale is,
that accommodation acts in congruence with the lesser refractive
error, i.e. exertion of only 1 D accommodation. The refractive
error right eye is corrected by virtue of accommodation and since
accommodation acts equally in both eyes, the left eye remains
uncorrected by 2 D. Thus, either the left eye makes no effort for
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correction and becomes amblyopic or if it makes intermittent

effort, asthenopic symptoms result, or even worse, becomes
esotropic.
• If changes in refractive state of the two eyes have gradually
progressed into teenage, and the patient has vision defect and
asthenopic symptoms, full correction with glasses should be
attempted or contact lenses advised. In case, where contact
lenses do not suit, then ‘compensation’ should be done on the
higher number to counter aniseikonia. Here is an example of an
18-year-old student:
OD + 0.5 180° 6/6
OS + 4.0, -1.0 180° 6/9
(The above spectacle the teenager was using for couple of
years, but was never comfortable. In fact, he had to remove
glasses during near work.); the specifications of lenses were:
Front curve : OD + 5.0; OS + 8.0
Center thickness : OD 2.4 mm; OS 4.5 mm
Vertex distance : 13 mm OU
These glasses induced 6.5% larger image in the left eye, and
produced overt aniseikonia.
The following changes were made:
Front curve : OD + 8.0, OS 5.0
Center thickness : OD 4.0 mm; OS 4.0 mm
vertex distance : 10 mm OU
This reduced the aniseikonia to 2.5% only, which was well
within the fusion capability. Since no ‘jumping of reading matter’
(anisophoria) was complained, no slab-off for compensation was
attempted.
The patient has remained comfortable with this.
Presbyopia and Anisometropia

As already discussed in the chapter on presbyopia, what a person
hates most is to show that he is now using reading glasses! This
problem is compounded, when he/she discovers, that as ‘bifocal’ is
needed, with that dreadful demarcation line in between!
Nevertheless, we have two types of patients who come for
presbypic correction, viz. one who has never used glasses, though
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they were anisometropic, and the second, who already were using
anisometropic spectacles. It is the first group of patients who resent
most to bifocals in giving corrective prescriptions to the first time
wearers.
Let us see on example: A stenotypist, age 48 years. comes to the
clinic with complaints of difficulty while working on desk. Refraction
revealed –OD +0.5 D, OS –1.25 D. Obviously so for he never had
distance complaints, nor for near. Now as his reserve AA in left eye
started failing, bifocal glasses were presented as:
OD + 0.75; OS –1.25 D
Add + 2.0 OU
The sudden use of bifocals coupled with disparity of +2.0 in
near work between the near segments made him uncomfortable.
(Remember progressive power lenses are no option as disparity in
reading remains the same.) Compensation is done as below:
OD Base curve + 6.0, center thickness 2.0 mm
OS Base curve + 8.0, center thickness 3.5 mm
Slab-off 1 PD, left segment.
Note: Increasing the front curve and thickness increase the
magnification, without altering the power. The idea is to reduce the
‘difference’ in magnification. Therefore, here the magnification of OS
lens is increased to match with the magnification of OD lens.
The second group of patients who have been using anisometropic
glasses all their life, are already adapted or using compensated
lenses. So the issue of aniseikonia is minimal, but they could be
plagued by anisophoria in near vision.
Suppose a patient of 50 year has been already wearing
anisometropic bifocals all this time and now begins to complain of
difficulty in near vision. If he requires additional near add, then add
for near correction only. If his distance correction has also changed,
then this has also to be corrected keeping in mind the aniseikonia
and ‘anisophoria’, if induced by the new prescription and thus this
will have to be compensated accordingly.
Astigmatic Anisometropia
Astigmatic errors further enhance the anisometropic difficulties,
particularly if the astigmatism is only in one eye or there is difference
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of power and axis meridian between the two eyes. Whatever

the type, it sometimes becomes very difficult to compensate for
aniseikonia or anisophoria or both, because there is a limit up to
which compensation can be done. In such cases, it is advisable to
reduce the power of the more ametropic eye to reduce the difference
in anisometropia. In some cases, separate spectacles for distance
and near are advisable.
Lets see some examples:
1. OD + 1.0 180o 6/6
OS + 0.5, +4.5 90o 6/9
Effective power at 180° meridian:
OD + 1.0, OS +5.0
Here a significant astigmatic anisometropia would produce
meridional aniseikonia and anisophoria also. Such cases are
difficult to compensate and a reduction in cylindrical power of
left eye would be more welcome to the patient.
2. OD - 5.0, –1.0 × 75o 6/6p
OS - 5.0 × 170o 6/9
Here the vertical anisometropia is minimal, but there is a
large power difference in horizontal meridian. In this case, some
compensation can be tried (plus lenses create more magnification
per diopter of power, than minification by minus lenses). Thus,
equalizing the base curves, minimizing the vertex distance and
reduction in center thickness would reduce the aniseikonia from
4% to about 2.5% in horizontal meridian which may be fused
and tolerated. As far as induced phoria is concerned, horizontal
amplitudes being large enough, fusion is not a problem. If this
astigmatic anisometropia would have been in vertical meridian,
compensation would have been difficult.
With all said and done, astigmatic anisometropias are difficult to
treat, compensation is not effective in large differences and patient
has to compromise in vision to avoid diplopia or asthenopias.
Bifocals compound the problem and separate spectacles for distance
and near are a much wiser option.
Antimetropia
‘Antimetropia’ is the term used to denote as one eye myopic and
other hyperopic. Here, correction will depend upon:
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• Severity of disparity
• Symptoms
• Fusion capability
• Visual acuity of the hyperopic eye.
Mild antimetorpia goes unnoticed as again the patient uses
monocular vision. Problems arise in moderate hyperopes, where
either the eye goes into amblyopia or if the patient tries to use the
eye, then asthenopic symptoms ensue.
Consider the following situations:
1. Male child, age: 10 years
Vision:
OD 6/24, OS 6/6.
OD –2.0 D, OS +2.0 D
No problems, OS accommodates for distance and OD is used
for near.
2. Child, age: 10 years
Vision Refraction
OD 4/60 OD –6.0 D
OS 6/6 OS + 0.5 D
The patient is aware of severe visual disability in right eye
and parents demand correction. The best choice would be
contact lenses for right eye. If cannot be handled then, spectacle
correction is the alternative. But beware! –6.0 lenses in one eye
would create aniseikonia and prismatic effect in side gazes.
Fortunately, in a child, the blessing of adaptation does not require
any compensation, but in adults, it does. This will be discussed
later.
3. Child, age: 10 years
Vision: Refraction:
OD 6/24 OD -2.0
OS 6/24 OS +4.0
This is a dicey situation. By the time the child is seen, left eye
is already amblyopic. Since the child had poor vision in both eyes,
why he did not report earlier. It should be remembered that myopia
is a progressive error and as the myopia progressed, the child
learned to see clearer by sitting closer to the blackboard or TV. He
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never used the left eye, which insidiously became amblyopic. Now
the management becomes complicated. As a natural endeavor,
amblyopia therapy (occlusion) is initiated to try to correct left eye
vision as much as possible. Then what? As soon as vision comes to
say 6/6 or 6/6p and occlusion is weaned, what prescription should be
now given to maintain vision and binocularity. Obviously, right eye
is to be corrected fully with –4.0 D to maintain normal vision in that
eye and with +4.0 in left eye, would create a difference of ‘8.0 D’ with
aniseikonia and diplopia. The best option would be contact lenses in
both eyes. If not feasible, then slight “undercorrection” of both eyes,
to say OD –3.0 and OS +3.0, would be tolerable and adaptable at this
early age. The vision in right eye may fall to 6/12 or so, but will not
hamper his normal activities.
Or, to give a theoretically perfect prescription of –4.0 and +4.0,
the lenses would have to alter with changes in front curve, center
thickness, edge beveling, etc. to minimize the aniseikonic effect.
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8
Aphakia
INTRODUCTION
Though aphakia is now an outdated medical terminology, but
occasionally one may come across a patient who had their cataracts
removed 20–25 years back and still living an active life to torment the
ophthalmologist! Thus, knowledge of aphakic correction becomes
a part of every clinicians repertoire and obligatory on my part to
describe it in this book.
Management of aphakia is not easy. Since there are multiple
related optical problems. Distance correction of an aphakic requires
thick, large curvature lenses which have their own inherent problems.
A bilateral aphake is hugely dependent on his aphakic glasses.
The plight of a monocular aphake is even worse, though this condi
tion is rare. But somewhere in your lifetime, you may come across a
patient who is monocular aphakic having lost his other eye in some
accident.
MONOCULAR APHAKIA
An aphakic patient has zero accommodation and is the ultimate state
of presbyopia. If one eye has very immature cataract or no cataract
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Chapter 8: Aphakia 93
and is going along well without any correction with a vision of 6/9 or
6/12, and the other eye is aphakic, what is the correction? To circum-
vent the turbulent waters, advise the patient to carry on. He would
be happier with a monovision system, than an aphakic glasses in the
aphakic eye. The chief obstacle to correction is the large disparity
in image size of almost 25–30%. If the patient insists on using the
operated eye also (as restoration of vision was the purpose of cataract
removal), contact lenses would reduce the aniseikonia to 7% and
this is quite easily acceptable for fusion.
If the phakic eye has reasonably good vision and the patient can
handle contact lenses, than this is the best option. The magnification
in a contact lens wearing aphake can be further reduced by
prescribing a slightly over plussing the contact lens and correcting
the induced myopia by a minus spectacle lens. A contact lens over
correction by + 3.0 D, compensated by a –3.25 D spectacle lens, would
produce an image size almost similar to the phakic eye. An optical
trick! This should be kept in mind for some patients, though most
would manage with a 7% aniseikonia. Near add: Suppose the other
eye has also enough cataract with a very poor unusable vision, then
a monocular aphakic lens correction will be very happily tolerated
by the patient. Then what about the near correction? We have a few
options for the patient. Some clinicians prefer separate glasses for
near, due to obvious problems in an aphakic bifocal lens. The other
simpler option is to advise the patient to slightly slide the spectacle
down the nose. This will enhance the magnification and the small
print will become clearer to read.
THE BILATERAL APHAKE

The best of ophthalmologist will be confused and bothered when
he faces a monocular aphake. And he uses all the talent he has for
convincing both psychologically and optically and reassuring that
this state is temporary and the person will have no problem once the
other eye is operated for cataract and will have similar glasses in both
eyes. But this is not always the case. Let us consider the following
situations:
• A person is monocular aphake for few years, with the other
having nearly mature cataract but did not get operated and got
Ch-8.indd 93 06-04-2015 16:03:05

very well adjusted to the monocular vision. The patient now

gets operated and becomes binocular aphake. Now the issue of
binocular adjustment comes into question. It is true and clinical
experience has proved, that a long time monocular aphake,
does not assume binocularity for quite some time and may be
uncomfortable initially with bilateral aphakic corrections.
• The prolonged occlusion produced by the long-standing cata
racts, can convert a phoria into tropia or a tropia even without
a pre-existing muscle imbalance. Most of times, in such cases,
an exotropia results. And when the cataract is removed and
correction given, diplopia and disappointment results! But the
silver living in the cloud is that it may take a couple of months,
but if preoperatively there was good fusion, then the return to
binocularity is assured. Initially, if the demand to binocularity is
great, Fresnel press-on prisms can be given and weaned gradually.
It must be remembered that binocular aphakic patients also have
a high degree of fusion and all attempts to restore binocularity
must be initiated.
SPECTACLE MANAGEMENT IN APHAKIA

Though a detailed lens design and intricacies of spectacles will be
covered in chapter on ‘Prescription of Spectacles’, but some basic
points can be discussed here.
• Optical centers: When thick plus lenses are advocated for a
bilateral aphake, one of most important point to be kept in mind
is the centration of lenses. Centration means the optical center of
the lens must coincide with the visual axis. A decentered aphakic
lens produces phoria or even a tropia because of incorrect optical
center separation. So during spectacle prescription, attention
must be paid to proper centration.
• Fusion incompatibility for near: Aphakic patients feel no difficulty
in viewing at distance, but get severely disturbed in near viewing.
This is owing to two reasons:
1. Presence of a large ‘exophoria’ for near, common to all
aphakes, because of loss of accommodation and near reflex.
2. Large base-out prismatic effect (of 7–8 PD ) in the reading
position.
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The higher the plus power, the more incapacitating patient

feels in near work. Some simple solutions may avoid above
problems like:
–– If bifocals are used, the near segments should be inset about
3.5 mm.
–– In bifocals, use the minimum amount of add to force the
‘individual to hold reading material farther away, thus
minimizing convergence.
–– Begin with separate distance and near spectacles. Though
the separate glasses are the best alternative, but some
authors prefer bifocals right from the outset, in an attempt to
acclimatize the patients to bifocals with an assumption that
earlier the adaptation, the better!
Temporary Spectacles
A cataract patient who was literally blind for quite sometime,
expects restoration of vision after cataract surgery. This was the
aim of the surgery, the expectation of the patient, and the surgeon
also to give back the lost vision as best as possible. So the patient
after plain cataract surgery finds that there has been a benefit
from the cataract surgery and expects restoration promptly. Since
permanent correction is normally not given before one month, a
temporary slightly low correction is always wise to give. This serves
two purposes: one that the patient immediately gets some vision
and second to encourage early adaptation. Once decision to early
ambulation and adaptation is taken, several points arise as to what
type and style of glasses be given, so that the patient takes it as a
welcome! The following clinical pearls should be looked into:
• Single vision glasses (separate pair for distance and near), vis-
a-vis, bifocals! Without any ego or showing prowess as best
refractionist in town, a candid look into the psychology and
temperament of the patient should be looked into. A person
who has been wearing bifocals all his life, poses no trouble for
bifocals, but who had rejected bifocals very early in presbyopic
age, will again resist it. Hence, in such case, separate glasses are
more comforting to both the patient and the doctor.
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• Size of glasses: Preferably small diameter lenses should be

prescribed as they reduce weight, thickness and certain
aberrations.
• Lens tinting: Aphakic eyes tend to be oversensitive to even
normal levels of illumination and thus some brown or grey
tint is advisable. An affordable patient can straightaway opt for
photochromic lenses.
• Centration: This has been already briefly discussed but it is
reemphasized as this is extremely important. Interpupillary
distance (IPD) should be carefully measured. Remember, pre-
operative IPD may be different to a postoperative IPD, hence
a fresh IPD should always be taken postoperatively. The lenses
selected should align as close as possible to the persons IPD.
• Another clinical point to take into consideration is the
pantoscopic tilt. This is the common tilt of the frame which
occurs from the surface plane, when spectacles are worn on the
nose. Normally this tilt should not be more than 10–15 degree,
but in aphakic spectacles, it should be even less.
Having worn the temporary glasses for month and adjusted
to them, permanent spectacles should be given after careful
refraction.
REFRACTING AN APHAKE
As has been the very idea of this book, that a sincere, serious and
meticulous refraction is the backbone of correction of all refractive
errors. And to err in exposing a refractive error, exposes the crack
in fundamentals of any ophthalmic clinician! Though, I agree, that
aphakia is now almost obsolete, but one may still find some, and not
to forget that it is our bounded duty to doctor our elderly population,
most of them aphakes.
Therefore, let us refresh our refracting skills with an aphakic
patient.
Back to basics: Refraction should be done in the visual axis. All
of us have the habit of instructing the patient to look ‘far’ over the
refractionist’s shoulder. If an autorefracter is used, then this exercise
is deleted.
Ch-8.indd 96 06-04-2015 16:03:05

Having finalized the refraction, lenses should be inserted into

the trial frame and subjective correction should be done. This is
extremely important because the high power plus lenses put in the
trial frame behave differently than the objective refraction. Additions
for near should not be put in the rack in front of distance correction,
but a near lens put separately, as even small variations in ‘vertex’
distance in high power lenses changes the very laws of optics.
After satisfactorily performing the subjective correction, an over-
refraction should be done with fogging method or cross-cylinders, to
verify the accuracy of prescription.
Finally, the frame adjustment is equally important. The frame
should be so adjusted to have minimum vertex distance and a
pantoscopic tilt of not more than 5–7 degree.
So far so good. Having successfully achieved all the above
parameters to the patients satisfaction, some finer adjustments can
be looked into:
• Prescribe the ‘full’ aphakic correction for distance. This will help
the patient in some intermediate distance also.
• Although there is no accommodation in an aphakic patient,
‘binocular balancing’ should still be done, especially during
subjective correction for near.
• In case of bifocals, decentration of the lower segment by at least
3.5 mm OU should be done. A + 10.0 lens, decentred by 1 mm, will
generate phoria of 1 PD and a pair of + 15.0 D lenses, decentered
by 1 mm, will generate phoria of 3 PD. A +10 D, decentered
inward will act as a base-in prism and if decentered out will act as
base-out prism. (This is due to a simple physics law, as a convex
lens behaves as two prisms joined at their bases). Thus, details of
lens design in aphakia will be dealt in another chapter.
Therefore, to summarize, a good aphakic correction with an
optimal visual result will depend on meticulous measurement of
refractive error, the IPD, the vertex distance, the pantoscopic tilt, the
centration and decentration in bifocals, and ultimately how these
are translated into a perfect finished product—the spectacles.
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9
Pseudophakia
INTRODUCTION
Modern day cataract surgery has revolutionized the visual outcome.
Small incision phacoemulsification with high quality aspheric
IOLS and now the toric IOL and multifocal IOL’s have significantly
contributed towards emmetropization of a pseudophakic patient.
But there still remains a sizable population of pseudophakics who
need spectacle correction.
MONOCULAR PSEUDOPHAKIA
This is an area where the surgeon stands for the test. The following
guidelines will assist the ophthalmologist:
In cases of monocular cataracts, where the other eye vision is good,
and surgery of cataract becomes necessary, the final postoperative
refraction should be aimed in such a way that the vertical meridian
anisometropia should be well below 3 D. For example, a patient of
40 years, has emmetropic pseudophakia and other eye normal, for
near work the pseudophakic eye will need +3.0 D correction and
the other no presbyopic glasses. Induced anisometropia of 3.0 D, in
vertical meridians will create both aniseikonia and anisophoria due
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Chapter 9: Pseudophakia 99
to the induced prismatic effect. The patient will be uncomfortable

in upward and downward gazes. Of course, slab-off of the plus lens
can reduce the prismatic effect. Or the correction can be of +2.0,
which will move his near point to 40 cm, but will lessen the prismatic
effect. Another simpler way, which can be preoperatively designed,
is to make the pseudophakic myopic by 1.0 D, which will not much
interfere with is distant vision (the good eye being 6/6) and will
reduce the near correction to only +2.0 D. Age 40, a near correction
of 1.0 D in the good eye will be welcome and will complement the
clinicians effort to reduce the difference in near correction.
Most patients eventually adapt to anisekonia caused by
moderate anisometropia. But this can also be overcome by adjusting
the postoperative final refraction of IOL power, or by modifying the
spectacle lens base curves, thickness, vertex distances, or stabbing-
off. Obviously lesser the postoperative aniseikonia, the more the
comfort to the patient.
Another refractive discrepancy that can occur as a postoperative
complication is the difference between keratometric astigmatism
and refractive astigmatism. Then either there is irregular
postoperative astigmatism or there is tilting of the intraocular lens.
The tilt has to be significant to cause intrusion in binocularity. An
IOL tilted about the horizontal meridian induces plus cylinder with
axis 180°. When a +20 D IOL if tilted 10, 20 or 30 degree, the induced
cylinder power will be 0.5 D, 2.0 D and 5.0 D respectively. A +10 D
IOL will induce half of these amounts and a +30.0 D will generate
one half more. Apparently the tilt will have to be more then 10 degree
to generate clinically significant aberration. A tilt about vertical axis
will create plus cylinder with axis 90°. This will induce astigmatism
in horizontal meridian. To recapitulate, horizontal anisometropias
are well tolerated than vertical anisometropia, hence the tilt about
horizontal axis is clinically more important.
BILATERAL PSEUDOPHAKIA
When one eye is already pseudophakic and its refractive status well
documented, then postoperative adjustments to match the other eye
becomes easy. Also we know how the previous eye has behaved post-
operatively, which makes postoperative predictions more accurate.
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UNUSUAL CASES
There could be instances where high preoperative anisometropia
exists.
Two situations demand discussion:
1. High myopic anisometropia: The following situations may exist:
• The patient may be mild myopic, say around –3.0 to –4.0 OU.
If one develops cataract and made pseudophakic, this
would be conveniently made emmetropic, and the other eye
still having good vision would be used for near. The patient
would be ‘without glasses’—most gladly accepted—working
on the monovision system.
• Unilateral cataract with bilateral high myopia, is the issue.
If the cataractous eye is made pseudophakic emmetropic-
which is preferred, the other eye with –8.0 or –9.0 D, cannot
use glasses and will have to be left as such till it develops
cataract. The only alternative is to operate as early as feasible-
not waiting for the cataract to progress much.
• Myopic anisometropia poses similar problem. If the high
myopic eye develops cataract first, it is a boon; but if the less
myopic eye develops cataract earlier, then again we have to
leave the other eye without specks for some time.
2. Hyperopic anisometropia: Here again we have two situations:
• Moderate hyperopic anisometropia: OD +2.0 hyperopia
and the other OS +5.0 hyperopia. Left eye had existing mild
amblyopia vision 6/12. Patient was using +2.0 OD with
distance vision 6/6 and OS +5. 0 with distance vision 6/12. The
right eye developed cataract and was successfully operated
and made emmetrope with the IOL. With the new scenario,
the disparity between the two eyes has suddenly become of
+5.0 D, both for distance and near. We have already discussed
previously that sudden changes in disparity in refraction
of two eyes at elderly ages is not compatible with adaption.
In such cases, it is prudent to keep the operated eye slightly
hyperopic, may be +1.5 or so. When cataract develops in the
other eye, the IOL power can be matched accordingly.
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If the preoperative disparity is too large, as in high hyperopic

anisometropia, the higher plus number eye is already amblyopic and
the situation of matching does not arise.
Postoperative refraction: The standard practice of correction in
pseudophakia has been to prescribe spectacles after 4–6 weeks
postoperatively. With the advent of MICS phacosurgery and some
opting for temporal incisions, the visual rehabilitation has greatly
improved. In some cases, spectacles can be given as early as two
weeks postoperative.
But clinical experience has shown, that the refraction still
changes after 4 weeks of surgery. It may be a good practice to give at
least the near correction, and subsequent full correction, if needed,
after 4–6 weeks.
Though proponents of multifocal IOL boast of no glasses for
distance, intermediate and near vision, but it is fraught with dangers
and not used routinely. Studies have shown that a large percentage
of multifocal IOL patients who are unhappy with their outcomes
complain of blurry vision due to residual refractive error. A study
reported 30% of eyes had residual refractive error of 0.75 D or more.
Even with best monofocal IOL and surgery in best of hands,
around 90% are corrected with vision around 6/9. But there are
still 10–12% who need glasses. A latest ASCRS report in Eye World
2013, stated that 90% of pseudophakic patients are within 1.0 D of
spherical target and 75% within 0.5 D of target.
The problem lies because we are very accustomed to routinely
exceeding the expectations of cataract patients. The value of
preoperative counseling to set realistic expectations cannot be
overstated. We usually pamper the patient by overstating the surgical
outcome in many ways, be it the surgical techniques or the IOLs.
We emphasize more on the advantages and less on disadvantages
of any procedure. Even if cataract removal and IOL implantation
is done by ‘magic’, without touching the patient, the artificial lens
will not configure to the natural lens and thus naturality cannot be
guaranteed. Therefore, postoperative spectacle correction, whenever
and wherever required, should be given.
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PSEUDOPHAKIA IN CHILDREN
This is perhaps the most controversial and most difficult areas to treat.
Though the implantation of IOL and their strategies is beyond the
scope of this book, but we are still concerned about the visual status
of the children. IOL implantation in children below 3–4 years of age is
not universally practiced, but there are studies where an IOL has been
implanted from age 12 days to 4 years. We all know that the child’s
eye behaves differently than adults, owing to the following facts:
• A child’s eye is still growing, hence IOL calculations are not
predictable. (At birth, the axial length is 17 mm; by 1 year it grows
to 20 mm; from 1 year to 4 years it grows more slowly to about
22.5 mm; from hereon, it continues to grow even more gradually
up to 12 years, attaining the adult size of approx. 23.8 mm).
• There is a tendency of myopisization in aphakic or pseudophakic
eyes. That means, apart from the normal stipulated growth, an
excessive elongation occurs. This makes the calculations even
more difficult.
• The postoperative inflammation is exuberant than adults,
causing undue complications.
• Almost 100% opacification of posterior capsule and anterior
vitreous face, nullifying the very purpose of surgery.
• The IOL will remain in the eye for much longer time than an
adult, hence the surgery has to be modified so that long-term
complications are minimum.
• Most important of all, to provide best possible vision to avoid
amblyopia.
Therefore, the ultimate purpose is to provide and maintain good
distance and near vision, not only for the proper growth of the eyes
but for a normal mental development also. To meet this end, there
are two schools of thought to devise a strategy of cataract removal
and IOL implantation.
• Some believe that the IOL implant should be done according to
the present calculation. The emphasis is that the early ages are
the most critical for visual development and a perfect vision is
mandatory to prevent amblyopia. The only hindrance is that a
child below 3 years is not suitable for spectacles and the parents
find extremely difficult to put contact lenses in such a small child.
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• Others implant the IOL envisaging the future changes in

refraction due to growth of the eye. There are a few formulas
to calculate the prospective IOL, all aiming to undercorrect
the IOL power. Unfortunately, the future anticipated growth is
unpredictable, and ultimately the spectacle correction has to be
given and changed periodically.
A ‘piggyback’ IOL is implanted by some surgeons, with an idea to
fully correct the present ametropia, and later remove as the eye shifts
towards myopia or emmetropization.
With all said and done, the best predictable outcome would
be if surgery is deferred till 4 years of age. But many times, it is
unavoidable- as in unilateral congenital or developmental cataract.
The bottom line is that whatever strategy or line of treatment is
chosen, best possible vision correction is mandatory postsurgically
either by contact lenses or spectacles. Children very easily adapt
to glasses by 3 years of age; and bifocals with a high placed near
segment are preferred. Without saying, plastic lenses are choice for
obvious reasons. In uniocular pseudophakia, amblyopia therapy is
instituted from day one, according to the norms prescribed.
Certain regulations are to be kept in mind when treating young
children:
• As already emphasized, spectacle or contact lens supplemen-
tation is necessary postoperatively, immaterial of whatever line
of treatment is chosen.
• Refraction must be done properly, under sedation if child is
not cooperative (advisably on the operation table succeeding
surgery), in the visual axis.
• Light weight plastics is the material of choice.
• As the child’s eye is fast growing and growth unpredictable,
refraction should be done every six months. The younger the
patient, the more it is in the amblyogenic period, and a lapse of
even a few months, endangers the eye.
• Particular attention should be laid on the frames also. As different
types of frames are flooding the market, a frame which is most
comfortable to the child must be used. Special attention should
be paid on the lens clearance from the lashline, the nosebridge
support, the pressure of sidebars on the back of ears, and most
importantly, on the size of lenses.
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10
Medical Problems and
Refractive Error
INTRODUCTION
In any field where knowledge takes the center court, there are four
types of persons involved: persons who know, that they do not know;
persons who do not know, that they do not know; persons who know,
that they know, and persons who do not know, that they know!
The speed with which medical science is developing, it is
becoming increasingly difficult to keep pace with it. As sub-specialty
and super specialties develop, our area of knowledge gets more
cocooned. As specialists become superspecialists, they know more
and more about less and less until they know everything about
nothing! With increasing stress in life—emotional and physical,
there has been an increase in the psychosomatic problems. And
more often than not, they reflect in visual and asthenopic problems.
Thus, refractive changes reflect the function of the total patient,
not merely that of the eyes alone! There are numerous systemic
problems—medical and pharmacological, that can affect refraction
or accommodation. It is important, therefore, that these associations
are recognized, which help in understanding and managing ocular
conditions.
Chapter 10: Medical Problems and Refractive Error 105
EFFECT OF CHANGE IN SIZE OR SHAPE OF EYE

Anything that changes the size or shape of the eye can induce
refractive error. Orbital masses—usually produce proptosis or ocular
motility changes, but once in a while, it can impinge on the posterior
pole, much before proptosis, and can induce hyperopic changes. An
unexplained, rapid increase in hyperopic refraction should incite
doubt of orbital pathology.
Posterior staphylomas typically occur in pathologic myopia
and induces high myopic astigmatism. Ciliary staphylomas induce
refractive changes by altering the curvature of anterior segment of
eye.
Extraocular Muscles and Lids

These affect the refractive state of the globe. Thyroid ophthalmopathy
known to produce refractive changes. It is not unusual to find a
change in refraction after strabismus surgery. Ptosis, chalazion,
tumors of lids, and even thickened lid by large follicles, all press on
the globe and induce ‘with the rule’ astigmatism.
GLAUCOMA
Glaucoma has been postulated as one cause for increasing myopia.
This may hold true for congenital or developmental glaucoma, but in
adult onset glaucoma, it is extremely rare. Nevertheless, when myopia
progresses in adult years, the intraocular pressure should be monitored.
CHANGES IN CORNEA
Changes in the contour of cornea are most common and take place
from outside influences and the cornea itself. Pterygium can cause
gradually increasing astigmatism. Blepharoptosis and chalazion
have already been enumerated. Keratoconus is a known clinical
entity for progressive myopia and astigmatism.
Contact lenses, although a savior for people disliking spectacles,
itself can cause an astigmatic error, though this is less common now
with high water content soft lenses.
Intraocular surgery, of any type, produces postoperative

refractive error. With the new advanced small incision techniques,
though the severity has greatly reduced but in no way one can
guarantee that glasses will never be required. Diseases of cornea,
usually of epithelium or anterior stroma, where vision is not greatly
affected, will produce some refractive error.
CRYSTALLINE LENS
Cataractous changes in lens are by far most common reason for
change in the refractive state of the eye. Nuclear changes cause a
myopic shift and cortical changes cause a hyperopic shift. Changes
in lens position, whether due to trauma or congenital anomaly,
cause refractive error changes.
OCULAR MEDIA AND LENS

Any disease which causes marked shifts in osmolarity and hydration
of lens and ocular media, cause changes in refraction. Diabetes is far
the most common cause of reversible refractive error.
Uremia, pregnancy, menstruation, dehydration, diarrhea, and
other severe illness where shifts in osmolarity and hydration occur,
can change the refractive state of the eye.
Drugs such as steroids, diuretics, sulfonamides, etc. the list goes
beyond 100, all cause shifts in refractive error, mostly myopia.
Changes in macula: Any disease process that causes on anterior
displacement of macula, will shorten the axial length and produce
hyperopic shift. Central serous retinopathy and submacular
hemorrhage are classical examples of inducing hyperopia. The
refractive changes, in fact, help to follow the progress of disease.
Diabetes and hypertensive retinopathies, when cause macular
edema, induces hyperopia.
CHANGES IN ACCOMMODATION
Complaints of difficulty in reading or seeing, when encountered
in an healthy individual who hitherto had no complaints, a drug
intake history should be sought. Unexpected abnormalities of
Chapter 10: Medical Problems and Refractive Error 107
accommodation can frequently occur by drug effect, local or

systemic. When such a situation is encountered, a detail history of
use of any local drops or any recent change of drops, or any systemic
intake of drug should be enquired. One of the most common
causes of spasm of accommodation is due to use of pilocarpine for
glaucoma. Though not commonly used nowadays but I have seen
patients from peripheral areas, still sticking to such medications
prescribed to them 20 years back.
In contrast to increased accommodation, decreased accommoda
tion is more common side effect of number of systemic drugs like
phenothiazine preparations, chloroquine (now very frequently used
for rheumatoid arthritis), anti-Parkinsonism drugs, anxiolytics,
sedatives, smooth muscle relaxants (Atropine preparations for treating
gastrointestinal problems).
OCULAR ASTHENOPIA AS A PART OF ILLNESS

There are a host of medical conditions that have asthenopia as a
common feature. Hypothyroidism, severe anemia, late pregnancy,
nutritional deficiency, chronic debilitating illness, neurasthenia. In
fact, refractive changes can occur in any patient with prolonged illness
like chronic allergies, chronic respiratory problems, malignancy,
convalescence from a major surgery. The list is endless! Pregnancy
needs more consideration because majority of postpartum females
complain not only of general weakness but vision problems also.
We ignore this, blaming the general weakness. But it is scientifically
documented that in III trimester and thereafter in early postpartum
period, these is some decrease in accommodation. If necessity
demands, a weak plus correction can be given temporarily or to
refrain from near work can be advised. The condition is reversible
and within 2–3 months, the person regains normal accommodation.
Other neurogenic disorders like Parkinsonism, multiple sclerosis,
muscular dystrophies, all manifest symptoms of accommodative
paresis.
A symmetrical impairment of accommodation is characteristic
of central nervous system diseases like neurosyphilis. Head injuries,
intracranial tumors, which affect the III nerve nucleus causing
accommodative and pupillary abnormalities, affecting vision.
It is not possible to enumerate each and every disorder, which

has implications on refractive state of the eye. The list will continue
as newer medications are used or some disease of the body directly
or indirectly, affects the visual system of the eye.
The sole purpose of this chapter is to enlighten the clinician and
advice to keep his eyes open and consider such possibilities in the
workup of every refractive problem.
11
The Legacy of Spectacles
INTRODUCTION
One of the greatest discoveries in the history of mankind is the
development of lenses and spectacles, and they are perhaps the
most useful appliances for a civilized man. Vision, one of the
God’s most precious gift, would be of no use, had not been for the
lenses (spectacles) which provide us clear and comfortable vision
for reading, writing, viewing the wonderful nature and a myriad
of beautiful things around us. Not only have they provided us with
a clear vision, but also aid in treatment of many ocular muscle
imbalances and visual disabilities. Let us pay tribute to a host of
scholars and scientists who contributed to the development of this
wonderful scientific oddity and peep into a glorious history of optical
lenses and spectacles.
HISTORY
The circumstances surrounding the invention of spectacles is
still a mystery! Archives suggest that no visual aid existed at the
time of ancient Romans, the Greeks or Egyptians. About 100 BC,
an influential roman, submitted his resignation to the royal court
expressing his inability to read and write because of his age. 150 years
later, the Roman emperor, Nero, held a large emerald up to his eyes,
to watch the gladiators fight. The Greeks were known to use a glass
bowl filled with water for magnification. It was not until 1000 AD that
the first visual aid was developing. A segment of glass sphere was laid
upon the reading material to magnify and read, by Chinese monks.
The first bonafide spectacle was developed in Venice around
12th century AD. The inventor is unfortunately, lost to history, but
it was here that glasses were made which could be held close to the
eyes to see written material, rather than putting the glass directly on
reading material. The ‘spectacles’ consisted of two convex lenses,
held by a ring of Oakwood, with a handle on one side to hold. For
centuries they were only worn by monks, scholars and the rich and
were regarded as extremely valuable article. During 16th century,
a bridge was developed to hold the two eye pieces, which could be
placed on nose, but still held from the side.
A century later, glass was refined, polished, and shaped in way
to fit on the eye held by the orbicularis oculi muscle. This was the
famous ‘monocle’ and was developed by Baron Von Stock, a German.
Since it used to drop on eyebrow movements, the wearer attached it
to his coat with a string. The monocle was a sign of status and was
worn by men of upper class. It corrected vision only in one eye, and
was used for reading with that eye only.
Modern day spectacle was developed in England in the 19th
century. It consisted of two lenses held in metal frame joined together
by a metal bridge which rested on the nose and side bars on the
temples. It was at this time that women also started using them. This
‘frame’, as we continue to call which holds the lenses, has undergone
very little change, except for the present day newer materials with
which it is made.
LENSES
The ancient Egyptians and the Greeks were familiar with the laws of
reflection and made mirrors, but were unaware of refraction and thus
knew nothing about lenses. About 100 AD, Ptolemy first described the
elementary optics. A century later, Alhazen, an Arabian astronomer,
formulated theories of refraction and knowing the changes that
occur when objects are viewed through glass pieces, pointed out that
vision could be helped with glasses but could not propel his ideas
Chapter 11: The Legacy of Spectacles 111
into practical use. It was not until 1600 AD, when Snell accurately
defined optical laws which govern lenses and refraction. The first
known lenses to correct distant vision (myopia) were developed in
late 16th century and it took another 200 years for lenses for myopia
to be used routinely. The monocle, which is already discussed,
became routine for myopia also, around this time. Between 16th and
18th century, lens making became a separate industry than glass
making. The finished lenses were sold to frame-makers, who fitted
them onto frames and sold them in market. The metal frames were
typically round and made of fixed sizes and had to be modified on
individual basis. It will be not out of place to mention the name of a
16th century genius, Leonardo da Vinci, who became interested in
vision and optics and penned the famous words “Who would believe
that so small a space as the eye, could contain the images of the
whole universe”! He devised a highly thin lens which could fit on the
cornea (a concept of contact lens). The eye was lost and so also the
concept. In 1675, the first completely clear lens was made by Ravens
Croft, a London glassmaker who added flint to the formula of glass
and thus produced the crystalline glass!
In 19th century, lenses and spectacle began in mass production
with companies like Rodenstock started making high quality lenses
for spectacles. By the beginning of 20th century, the Zeiss Company
entered the market of high quality lens making. At the same time,
the laws of refraction governing the refractive errors of eyes and their
measurements were pioneered by names like Purkinje (catoptric
images), Helmholtz (ophthalmometer), Cuignet (Retinoscope), and
Gullstrand (Slit lamp). Gullstrand—an ophthalmologist, later won
the nobel prize for optics.
MODERN LENSES
The last century saw the development of not only high quality lens
materials but designing of lenses to minimize the optical aberrations
and provide more comfortable vision. The 1940s-1950s saw the
advent of ‘High-index’ glass, which was different from the usual
heavy weight crown glass. At the same time, the improved ‘corrected
curve’ lenses used for trial lenses and prescription for high refractive
numbers were tried and then the concept of ‘aniseikonia’ was
realized. Lack of proper understanding and lack of proper correction

of this, the whole idea faded. But nevertheless, high-index lenses
permitted correction of high refractive errors and also resolution of
distortions in peripheral vision.
In 1950s, research by Corning company, brought the wonderful
‘photosensitive’ lenses. They also developed the absorptive ‘sunglass’
uniform coatings, which could be used on both glass and plastic, and
came in many attractive colors.
1960s and 1970s, saw the appearance of ‘aspheric lenses’, which
further reduced the peripheral distortions. 1970s and 1980s gave us
the ‘laminated lens’ a sandwich of glass and polyurethane, which
further reduced the weight of lenses, and were shatterproof. At the
same time, the first generation ‘progressive power lenses’ came into
vogue. They were welcomed with open arms, as they obviated the
dreadful demarcation line of bifocals and trifocals.
In last two decades of 20th century, two innovations took place,
which were not only exciting but of tremendous practical use. First,
the development of plastic lenses, and the second, an endeavor of
optical industry, the innovative ‘ultimate’ ‘progressive power lenses’
(This will be discussed us details in a later chapter).
PLASTIC LENSES
One of the magnificent advancement in optical industry was the
invention of plastic lenses. They possessed many qualities that made
them superior to glass. They were much safer, almost half the weight
of crown glass, for more resistant to fogging than glass, and were
shatter-resistant.
Clear plastic was first developed in 1930s for use in airplane
cockpits. It was named Plexi glass. The material was polymethyl
methacrylate, identical with the material used in hard contact
lenses. It was refined to make more transparent and distortion-free
spectacle lenses, and in 1940s, it became commercially available.
The Pittsburgh Plate Glass Company, USA, further refined the
material, naming it CR-39 (for Columbia Laboratory Resin, the
39th in its line of research products). The greatest advantage of CR-
39 is that it protects the patient’s eyes better than glass. It is more
resistant to breaking and is shatter resistant.
Chapter 11: The Legacy of Spectacles 113
POLYCARBONATE
It was developed in 1970s by Centex Corporation, USA, to be used as
helmets for pilots. Polycarbonate is a magical material composed of
high molecular weight organic noncrystalline material. It has been
termed as ‘thermoplastic metal’ owing to its extremely high impact
strength, which is even greater than many metals.
Other qualities which make it far more superior and its low specific
gravity and higher refractive index. Both these qualities enable
overall weight and thickness of the lens to be less than glass and
CR-39, (Polycarbonate refractive index is 1.58, compared to crown
glass 1.52 and CR-39, 1.49). The lower refractive index of CR-39 made
it unsuitable in higher refractive errors because of its thickness. The
Pittsburgh Company subsequently improved on CR-39 producing
a plastic of refractive index 1.56, which was further improved by a
Japanese company to RI 1.59. One disadvantage of plastic lenses was
its relatively soft and abrasion-prone surface. Now, with excellent
abrasion resistant coating, it is now emerging as a material of choice.
Plastic, especially polycarbonate, when combined with abrasion-
resistant coating, is immune to most chemicals which damage glass.
It also absorbs UV light better than CR-39. Polycarbonate lenses can
also be tinted. Almost any color can be dyed or coated on the surface
and the tint is uniform and free from fading.
The only disadvantage is that they cost two to three times the
ordinary plastic, CR-39 and the latest high index polycarbonate are
even more dearer. With time, more improved plastic materials came
into existence, which will be discussed in other chapter.
To summarize, the journey from the ‘reading stone’ and ‘glass
bowls’ to the present day spectacles has been long and arduous. It
has taken centuries of research by eminent scientists, to bring into
existence of what we cherish as the stylish and beautiful frames
and lenses which keep our vision crisp and clear, beyond our
expectations. The quest for better and more comfortable frames will
continue and alongside the research for better and more aberration-
free lenses. We will continue our journey, as is the rule of life, to
venture the world of more fascinating lenses in later chapters.
12
Types and Quality of Lenses
INTRODUCTION
The quest to discover a spectacle lens with optimal physical and
optical qualities continues where we left in the history of spectacles.
The legacy continues even to this day of writing, where number of
optical companies are striving to invent a lens which would be
light weight, clearer, aberration free, cosmetically acceptable and
provides a crip and clear vision. Also tagged to this is a long list of
added characteristics to protect from sun, glare, reflections, etcetera!
The optimal mechanical and optical properties of any lens
depend primarily on the following characteristics:
• Refractive index
• Density
• Abbe number
• UV-cutoff.
• Curve variation factor (CUF).
REFRACTIVE INDEX
Refractive index expresses the ratio of the velocity of light of a given
wavelength in air, to the velocity of light of same wavelength in the
Chapter 12: Types and Quality of Lenses 115
refracting medium. In practical use, all lens material fall into one of
the following group:
Normal index (nd): 1.48–1.54
Mid Index (nd): 1.54–164
High Index (nd): 1.64–1.74
Very High Index (nd)l: more than 1.74
Clinically used, higher the refractive Index, more the refractive
power of the lens. Disadvantage is that higher the index, the greater
the density of the material and heavier the lens. Other undesirable
side effect is reflections; hence high index lenses need antireflective
coating.
DENSITY
Density tells us how heavy the lens material is and a comparison of
densities indicates the likely change in weight expected in the lens
to be used. The value denoted is ‘the weight in grams per cubic cm
(cm3).’ Densities of high refractive index glass materials are greater
than standard crown glass and are thus heavier than crown glass.
Therefore, to use a high refractive index lens to gain in thickness
would make the spectacle heavier. But this again can be compensated
by an inherent decrease in the curvature factor (CUF).
But, an ultimate ideal lens material would be which boasts of
high index but low density. We will come to that soon.
ABBE NUMBER
Abbe number quantifies the optical properties of the lens material.
It was described by Francis Abbe of Germany, who studied various
chromatic aberrations of a lens. The Abbe number is the reciprocal
of the dispersive power of the material and indicates the degree of
transverse chromatic aberration experienced by the lens wearer.
The effects of chromatic aberration are well known. When light
from a small white object is refracted through a lens (which acts
like a prism), it is dispersed into its monochromatic constituents,
the blue wave-lengths deviated more than the red. To an eye, which
views such an object, the image appears fringed with blue light. This
aberration causes reduction in visual acuity by causing ‘blurring’

effect. The vision through the center of the lens would be fine but
will cause blurring when eyes view from the periphery of the lens
(Prismatic effect.)
Each lens material according to the index and density has a
specific Abbe number. As already stated, higher the Abbe number,
lower the dispersion. Materials classified in terms of Abbe number
are as follows:
Low dispersion: Abbe value (Va) >45
Medium dispersion: Va value—39–45
High dispersion: Va value—less than 39.
UV CUTOFF
An important property of all lens materials, with which we clinicians
are concerned about, is the absorption of UV light. Both ultraviolet A
(320–400 nm) and ultraviolet B (320–280 nm) are harmful to the eyes.
Clear crown glass absorbs 100% of ultraviolet rays below 290 nm and
about 80% in 320 nm range. These rays are abundantly present in
high altitude sunlight. In sufficient intensity, they produce corneal
burn, which absorbs them. Clear crown lens absorbs the UV rays,
and thus helps protect the cornea.
Most of sun’s ultraviolet energy is in the UV-A wavelength band
(97%) and only (3%) is in the shorter wavelength band—the portion
causing maximum damage. Since crown glass absorbs only (80%) of
the UV-A band and allows (20%) to pass, which rapidly increases as
wavelength increases, long exposure to UV rays tend to cause corneal
degenerations and eventually cataracts.
All major varieties of clear spectacle lens materials, whether glass
or plastic, absorb UV rays, with only minor differences.
CURVE VARIATION FACTOR

Curve variation factor (CVF) is the changes in front curve of a lens,
which enables changes in thickness and power of a lens. For example, a
1.7 index material has a CVF of 0.75, which informs that the reduction
in thickness will be about 25%, if this material is substituted for
crown glass. One of the most practical uses of CVF, is to convert the
power of the lens that is to be made into its crown glass equivalent.
This is done simply by multiplying the power of the lens by the CVF
of the material. For example suppose we wish to prescribe a –10 D of
crown lens in 1.70 index material, the crown glass equivalent is 0.75
× –10.0, i.e. –7.5 D. In other words, the use of a 1.70 index material
would result in a lens of –10.0 D, but looks like a –7.50 lens of crown
glass. Similarly, a –10.0 D crown glass lens, made in a material of 1.60
index (having CVF of 0.87) would result a power of –8.75 D lens made
in crown glass, producing a 13% reduction in thickness and weight.
LENS MATERIALS
Since so much depends on the lens material for its optical and
physical qualities, an overview of different optical lens materials
available becomes mandatory.
Glass Material
• White crown glass.
• Flint glass in refractive indices of 1.7, 1.8 and 1.9.
Plastics
• Columbia resin 39 (CR 39)
• Indo Superfin
• Trivex
• Sola Spectralite
• Corning SunSensors
• Polycarbonate
• Polyurethanes.
Of the above lens materials, the ones most commonly used in
day-to-day practice, needs elaboration, so that the clinician should
have a first-hand knowledge as to what material to be ordered and
when.
Optical White Crown Glass (B 270)

This glass material is used in most of prescriptions and has
the following properties: Refractive index (nd) = 1.522; Abbe value
(vd) = 58.5; Density 2.55 g/cm3 (the heaviest material in use today.);
UV cutoff-320 nm. The glass lenses are slowly fading away because of
their weight and danger of shattering. But a resurgence of high index
(1.9) glasses are coming up in the market in certain areas where
high quality vision is desired. Other high quality optical grade glass
material are available, e.g. Borosilicate crown glass, which is used
in telescopes, but due to high cost and precision making, have not
entered the ophthalmic world.
Plastic (CR–39)
CR–39 plastic was the most popular lens material for a long time,
and most commonly prescribed lens due to their safety, low cost,
ease of production and high optical quality. It has the following
specifications: Index-1.49; Abbe value-59; Density-1.3 g/cm3; UV
cutoff-355 nm.
Trivex
Trivex was originally developed for military as visual armor. The
Pittsburg plate glass company (inventors of CR–39) took the initiative
and adapted it for optical industry. Trivex is a urethane based
prepolymer. The word ‘Tri,’ signifies three qualities—superior optics,
ultralight weight and extreme strength. Trivex is relatively newer
plastic that possess UV blocking, good shatter-resistant properties
while at same time offering superior optical quality. The other
advantage over other plastics is that it can be easily tinted.
Its qualities are: Index (nd)-1.53; D; Density-1.1 g cm3; Abbe
value (vd) 45; UV cutoff-380 nm.
Polycarbonate
Polycarbonate is another excellent plastic material. It is very light
weight, blocks UV rays, strong shatter-resistant, and indicated in
children. But since it is a soft material, scratches easily and a scratch-
resistant coating is usually necessary. Since it has a low Abbe value,
as like all other plastic, it may be bothersome in correction of high
refractive errors. Its specifications are: Index (nd)-1.58; Abbe value
(vd) 30; Density-1.2 g/cm3; UV cutoff-385 nm.
Thiourethanes (High Index Plastic)

The material specializes in thinner lenses. They are slightly heavy
(due to high index), and suffer from much higher level of chromatic
aberrations (lower Abbe value). Apart from thin lenses, they have
the advantage of extreme strength and shatter resistance; they
are particularly suitable for rimless glasses. Their specifications
are: Index-1.6–1.74; Abbe value-40; Density-1.3 g/cm3; UV cutoff-
380–400 nm.
SUMMARY
• As lenses become denser and more efficient in bending light
(which is what refractive index means), undesirable effects of
dense material creep into picture. Color aberrations, distortions,
image displacements and reflections, can be very bothersome.
Some of these can be reduced or overcome by high index, low
density and high Abbe value newer plastic lenses.
• Abbe number is the lens’ rating for color aberration. The lower
the Abbe number, the worse the aberration. Most lenses have
Abbe number between 30 and 90, with high index lenses having
between 60 and 70.
• In general, higher the lens index, lower the Abbe number and
worse the distortion.
• High index glass has the worst color aberration properties and
should not be used in precision visual needs or driving. High
index newer plastic, strike a balance between refractive index
and color aberration and are preferred over glass.
• Aberration is always greater in peripheral vision, hence smaller
the lens, lesser will be the peripheral aberration (The patient
instead should turn his head for side viewing.)
• Thicker lenses (for higher numbers) produce worse aberration.
High index produces thinner lenses but creates more chromatic
blur, than slightly thicker, low index lenses.
Therefore, a balance will have to be titrated depending upon
the refractive error, work of the patient, his demand, (single or
bifocals), tolerance, adaptability, cosmesis and other related factors
in dispensing an ideal lens.
ABSORPTIVE LENSES
Human eye has the remarkable ability to adjust to a wide range of
light levels. A healthy eye performs comfortably in illumination
intensities as high as 100,000 Lux (bright sunlight) or as low as
1 Lux (single candle light). Even possessing this immense range of
tolerance where naked eye can perform, why the need arises for
artificial protection. But just as each human body differs, so is the
tolerance of eye to various intensities of light. Then there are medical
reasons, where protection from light is needed for rest and comfort
to the eyes. The other flip side is the exaggerated and inappropriate
use of these type of lenses, many times unnecessary. Whether it is
industry driven or in vogue, absorptive and tinted lenses, constitute
one of the most misunderstood areas in ophthalmic practice.
Therefore, an exploration into the characteristics of these lenses is
necessary.
The purpose of all spectacle lenses is transmission and refraction
of light. In this process, some light is reflected back and some
absorbed, even in clear lenses. Crown glass, the standard clear glass,
from which most lenses are made, loses about 8% at 580 nm (yellow)
by reflection and 5% by absorption. But most of the visible spectrum
is transmitted through the lens. Taking crown glass as standard,
it transmits almost fully the visible spectrum of light, i.e. from
380 nm to 760 nm, and substantial amount of longer wavelength in
the infrared range. As a rule, the visible light is not harmful to the eye
unless its intensity is too high to produce ocular damage.
There will be preceding symptoms of discomfort like redness or
pain, before any serious damage. The longer wavelength infrared
also passes through the cornea as easily as visible spectrum, but the
crystalline lens acts as a barrier, absorbing a significant amount. The
longer the wavelength, the greater the absorption by the crystalline
lens and greater the thermal effect. Hence, long-term exposure to
these rays hastens cataract formation.
The inference derived from the above narration is that all spectacle
lens, glass or plastic, transmit almost all wavelength of light, which
is their primary purpose. As a consequence, constant exposure
can harm the tissues of the eye. It is for this reason, that tinting and
coating of lenses becomes mandatory in certain vocations and in

certain diseases of the eye like aniridia, albinism, etc.
Antireflective Coating
Antireflective (A/R) coating typically consists of an ultrathin layer of
magnesium fluoride on surfaces of lens. For maximum effectiveness,
the coating thickness must be one-fourth of the wavelength of
the incident rays. Since the visible light is composed of different
wavelength of light, it is not possible to have varieties of coating.
Therefore, A/R coating is designed to effectively remove wavelengths
only in blue-green range (mid-spectrum). Properly coated crown
glass lowers one surface reflection by 25%, and if coated on both
surface, then by 50%. An A/R coating can be applied on both
surfaces of lens, be it glass or plastic, and increases in effectivity with
the increase in the refractive index of the material. It is extremely
durable on glass than plastic, and remains stable for long periods.
It can wear off with time, especially on continuous vigorous rubbing
and can be reapplied.
The other advantage of A/R coating is it improves the overall
appearance of the lens making it more cosmetically acceptable.
It also removes the internal reflections from the back surface of
lenses. With high plus lenses, it removes the ‘ghost-images’ from
the periphery of the lens. The nuisance of multiple image reflections
from oncoming headlights are significantly lessened during night
driving.
Tinted Glass Lenses

Tinted glass lenses are manufactured by incorporating various
chemicals into the crown glass mixture. These absorb selected
parts of the spectrum. As the lens material is impregnated with the
coloring chemical, the shade or color density will depend upon the
lens thickness. The thicker the lens, the denser the color. Hence, the
same color will show different hues, with the varying thickness of
lens.
The most commonly used are pink, green, yellow and brown
tints. The cruxite A tint (yellow) absorbs only 12% of light and
transmits 88%, but it absorbs a fairly good amount of UV light, almost

95% radiation below 350 nm. They do not absorb much of visible
spectrum, a property similar to plain crown glass. The more denser
pink shade, cruxite C, absorbs almost 45% of visible light and may be
helpful in cases of albinism. Even postoperative cataract patients can
be benefited since glare is reduced.
Green tinted lenses, which have the transmission properties as
the human eyes have gradually been replaced by neutral grey lenses.
Yellow tinted lenses absorb 100% of the ultraviolet (UV) radiation
and about 17% of visible light, but almost none in the infrared range.
Since they absorb extensively the blue range of visible light, they
serve good purpose as antihaze filters.
Brown tints share similar properties as yellow lenses, are
excellent absorbers in the blue range, hence serve good purpose on
hazy, smoggy days.
Neutral gray (smoky) tints are probably the most satisfactory
as they significantly reduce light transmission. At any density, they
absorb 98% of ultraviolet rays and also infrared. They do not distort
colors as their transmission and absorption is even throughout the
visible spectrum.
Tinted Plastic Lenses

Plastic lenses can be tinted in two ways. Either the dye can be
impregnated in the lens material itself, as in glass lenses, or the
formed lens can be dipped into the desired color solution. Good
quality plastic lenses can be tinted to a uniform density independent
of power or thickness of lens. A drawback of plastic tinted lenses is
they transmit substantial amount of infrared light, but which under
ordinary conditions, causes no harm to the eyes.
Coated Lenses
Lenses of glass or plastic can be coated with the desired color,
instead of being impregnated with the dye (tinted). The procedure is
by application of a metallic oxide to the lens surface in vacuum. The
advantage of coated lenses are that the color can be evenly coated
over the surface of the lens (not variable with the thickness of lens)
and has a uniform color appearance; the color coating can also be
varied with darker towards upper part and lighter in the lower part,
as the upper part is more used for distance for outdoors. The other
advantage is since the color coating is uniform, transmission of visible
light is uniform and no distortion of color occurs. In addition, coated
lenses absorb more of infrared rays. The only drawback is that they
are vulnerable to scratching and with time, the coating fades away.
This can be protected by the application of a harder magnesium
fluoride antireflective coating. Also the lenses, both glass and plastic,
can be recoated. Owing to the drawback that plastic lenses tend to
scratch easily, they are less popular as coated lenses. But of late,
some manufacturers have developed processes for more surface
resilience. These are quartz and diamond film, which makes the lens
surface harder and scratchproof. At the same time, incidentally, they
also serve as a good antireflective coating.
Clinical note: Antireflective is being misunderstood by people.
Though it is true that A/R coating reduces lot of unwanted reflections
from both outer and inner surfaces of lens, but in true sense it reduces
the reflected light which bounces off the lens surface and therefore
improves light transmission by almost 4–5%, so that more light can
reach the eye for good vision.
Polaroid Lenses
Though polaroid lenses have come into vogue only recently as
sunglasses since people have become knowledgeable and concerned
for protection of their eyes from sunlight. The history dates back to
1936, when Edwin Land began experimenting with making lenses
with his patented polaroid filters. It is to be noted that polaroid lenses
used for stereovision are different than the polaroid sunglasses that
we are discussing here. The Polaroid sunglasses have a thin layer of
polarizing material composed of dichroic crystals that are vertically
oriented and laminated between two layers of glass, identical in
the two eye glasses. The vertically oriented polaroid will selectively
absorb those light rays emanating as annoying glare from surface
reflections as often occurs from snow, water, and road surfaces.
Light intensity can be further reduced by ‘coating’ the surface of the
polarized glass. A non-polarized absorptive lens (tinted or coated)

will reduce the general glare by reducing the intensity of light
reaching the eye, but will not effectively reduce glare emanating
from highly reflective surfaces, as snow or water surface. Polaroids
are available in both glass and plastic.
Photochromic Lenses
‘Photochromic’ comes from two Greek words—‘photos’ means
light and ‘chroma’ meaning color. So photochromic simply means
anything that changes color in response to light. Photochromic tinted
glass lenses were first developed by Corning Glass Works in 1964.
The glass contains millions of microcrystals of silver halide, which
decomposes into silver and halogen when exposed to UV and short
wavelength light. As the decomposition occurs, the lens becomes
darker. When the light is removed they revert back to their original
state. Because of the physics of silver halide, the rate of darkening
is little faster, than the rate of fading. Modern photochromic lenses
come in plastic lenses also and instead of silver compound contain
organic carbon-based molecules. Also today’s photochromic lenses
offer different categories of sun protection. For example, there
are lenses which start as clear and change color, which is ideal for
spectacle lenses. There are others which start as a tint and become
progressively darker. They are ideal as sunglasses (goggles.)
Though sunlight is a major factor in their darkening-lighting
process, the lens performance will also be affected by lens thickness,
temperature, and type of tempering used to harden the lens. A
thicker lens will become more darker as it contains more light
sensitive molecules. As the photochromic compounds respond to
thermal changes, higher the temperature, the less effective color
change. Hence, these lenses darken to a lesser extent in hot weather
than in cool weather. Typically, photochromic lenses darken in less
than one minute, and continue to darken in another 10–15 minutes.
They will start getting lighter as soon they are removed from UV light
and clear between 2 minutes and 5 minutes. The following quality of
photochromic lenses are available by different companies:
• Photo Gray II lenses darken in sunlight to about 75% of its
capacity in 30 seconds and take few minutes to lighten.
• Photo Sun II, are available in gray or brown tints, and have an
absorptive component added to it. This has a faster rate of color
change and is more protective from sunlight.
• Photo Gray Extra and Photo Brown Extra are more popular now
as they have wider range of variability. These lenses darken within
10–15 seconds with transmission down to only 20%, and after
assuming their normal state, allow 90% of light transmission.
To summarize, all types of photochromic lenses are wonders
of optical science and take us into a new modern era of spectacle
innovations. With all marvels mentioned above, they have some
disadvantages as well, for example:
• They do not adjust immediately
• For clear start lenses, they do not darken to the proposed levels
• Thicker the spectacle lens, the darker it becomes than the desired
level and leaves a tint, when reverting to original state.
Nevertheless, to monitor the speed of darkening/lightning,
optical companies are coming out with more innovations like the
Julbo’s Zebra lens, which boasts of color transition within 20–25
seconds.
Medical Indications of Absorptive Lenses

• Absorptive lenses are used to protect from photophobia in all
short-term and long-term corneal disorders.
• They also are used to protect from dazzle in corneal scars with or
without mydriasis.
• Patients with vitreous degenerations and retinal dystrophies
often complain of light sensitivity. Tinted coated lenses that
provide relief from visible light are advised for such patients.
• During UV phototherapy for conditions like vitiligo, psoriasis etc.
protection of eyes with full UV absorbing glass is used.
• Following intraocular surgery, particularly cataract.
Nonmedical Indications
Ocular discomfort stems from two illumination factors—intensity
and glare. When illumination levels cross a certain limit, the contrast
between object and its background diminishes and blurring of the
object occurs. This is due to ‘retinal irradiation,’ meaning spillover of
the light on the surrounding retina. Absorptive lenses, by reducing

the intensity of light, create normal viewing conditions.
Glare, scientifically, is a visual interference or annoyance by
unwanted light. Glare is again of two types, i.e. glare from reflected
light or from scattered light. Reflected glare comes from plain
surfaces like glazed paper, polished surfaces, water or snow surface,
etc.
Scattered glare emanates from hazy or foggy environmental
conditions. This can simply be managed by absorptive lenses. Glare
from water or snow surfaces consist of glare as well high intensity
light. In such conditions, absorptive polarized lenses are used.
Tinted lenses are also used for cosmesis to hide an ocular
deformity.
Night reflections are quite annoying but absorptive lenses are not
recommended as they reduce illumination. A/R coated lenses is the
standard recommendation.
PROGRESSIVE POWER LENSES

Progressive power lenses or also known as progressive addition
lenses (PAC) have a long, century old history. The first PPL patent
was granted to Owen Aves in 1907. It consisted of a conical back
surface and a front cylindrical area to produce the progressive
power. It was crude and actually did not have the graded progression
of power. The idea went through several modifications for decades,
when eventually Irving Rips at Younger Optics developed the first
commercially viable blended lens in 1955. The Varilux and Carl
Zeiss companies developed improved, modified modern design and
Essilor in 1959 first started its mass production.
The persistent problems which plague the progressive lenses
are of adaptation and peripheral distortions. Newer improved
manufacturing and metrologic techniques have overcome this
problem to quite an extent. Today, the complex surfaces of progres
sive lenses can be cut and polished on computer controlled
machines allowing “freeform” surfaces as opposed to earlier ‘casting’
process. The better manufactured and freeform surfacing makes the
difference in price of various progressive lenses.
A progressive power lens is a type of multifocal lens that employs

a surface with continuous, smooth increment of plus power. The
curvature of the surface increases from its minimum value in the
distance zone to a maximum value in the near zone.
Characteristics
• Progressive lenses provide the desired plus additions without
any breaks, ledges or lines by ‘blending’ the transition between
the distance and near zones.
• The intermediate corridor between the distance and near zones
incorporates the gradual, graded change in plus power for
intermediate distances.
• The transition from top to bottom is smooth enough to prevent
abrupt changes in prismatic and magnification effects.
Basically, traditional general purpose progressive lenses posses
four structural features:
1. Stabilized fixed power distance zone.
2. Stabilized fixed power near zone.
3. Intermediate corridor of progressively increasing power,
connecting the two zones.
4. Blending region, i.e. peripheral of lens containing nonprescribed
cylinder power of minimal visual utility.
There are more than two dozen companies manufacturing the
progressive type of lenses, and the lenses basically fall into three
groups: Spherical, aspherical and a mixture of the two. Also the
basic design philosophy comprises of ‘hard’ type and the ‘soft’ type
depending upon the abruptness of image jump, more abrupt being
in the hard type.
Spheric Design
In this type, the distance correction has a uniform spherical front
curve, and below it is a 14 mm descending corridor through which
the power increases gradually in linear fashion, equal diopter
increments per mm of descent. Below this corridor is the reading
area, the zone representing the maximum plus power. These lenses
are now outdated being replaced by other designs.
Aspheric Design
Aspheric progressive lenses use the ‘soft’ type philosophy, to
minimize the inherent distortions adjacent to the corridor. The
aspheric front surface grinding of the lower portion of lens permits a
less abrupt optical jump.
Spheric-Aspheric Combination
Manufacturers have combined the best of two designs, using the
aspheric part in the lower and intermediate zones to minimize
distortion and image jump in these and peripheral areas, while
retaining the spherical component in the upper distance part.
A major hindrance in progressive power lenses is the problem
of adaptability. Not only the adaptability curve is long and variable,
but they are unacceptable to many wearers. Therefore, the clinician
must be aware of the numerous designs available in the market and
choose and select the appropriate lens type for a particular person,
as the person may be comfortable with one design and unable to
adapt to another, as the visual requirements may differ from person
to person. Recognizing this manufacturers have come out with
number of options, for example, some progressives maximize the
reading area (Truvision, Unison), while others tend to provide more
intermediate area (Varilux, Younger, CPS).
Therefore, before suggesting and writing a prescription of
progressive lenses a little counseling is always helpful. Also, the types
of progressive lens, which would be most suitable for a particular
type of vocation and need should be prescribed.
13
Prescription of Spectacles
INTRODUCTION
Once the clinician has given prescription of spectacles to the patient,
after duly examining his refractive error, the onus and responsibility
falls on him, though he is not responsible for faulty making by the
optician. Whatever may be the reason, an unsatisfied patient will
ultimately land again to the doctor’s clinic if he is uncomfortable
with the specs. There are two major deficiencies in the doctor-
optician nexus. First, the ophthalmologist is largely unaware of the
many intricacies for proper prescription, viz. type and size of frame,
the type and size of lenses for a particular refractive error, when
bifocals and when single vision prescription, the vertex distance,
pantoscopic tilt of frames, cylindrical error incorporating aniseikonia
and anisophoria induced by large frames and higher numbers, etc.
In most of prescriptions, no such specifications including the IPD,
which is of paramount, is mentioned for the optician; and secondly,
the optician, either out of ignorance or callousness, does not follow
the doctor’s orders, even if mentioned. The ultimate sufferer is the
patient, who runs from doctor to optician, each blaming the other
for the fault!
Therefore, this chapter, will try to enlighten the clinician of some

basic knowledge he must possess regarding lens and spectacle
fitting.
WEIGHT, THICKNESS AND WARPAGE

The higher the myopia, greater the importance of proper lens design.
Large minus lenses not only become heavier but show thick edges
which are unsightly. Plastic lenses overcome this problem, but their
edges are even thicker than glass lenses. There are several ways to
hide the thick edges, e.g. the edges can be beveled; the edges may
also be colored matching the frame; slightly thicker plastic frame
can be used to hide the edges. The other options are to use a high
refractive index plastic lenses, polycarbonate (RI 1.56) or plastic
resin (RI 1.60) which permit the lens edges to be at least 30% thinner
than normal crown glass lens (RI 1.52). Glass lenses of RI 1.70 and
1.80 are now available to permit thinner edges. A problem in large
plastic lenses is the problem of ‘warpage’ by pressure from the
frame. If a youngster insists on large frame for fashion then a high
index glass is preferable. It is to be noted that as the refractive index
increases, there is an increase in the chromatic as well as peripheral
aberrations, creating image distortions. Therefore, a balance will
have to be struck, high refractive error with aberration-free thick lens
and high refractive error with thinner lens.
DECENTRATIONS
A major problem arising out of large frame is centration and
decentration. Ideally the center of pupil (visual axis) and optical
axis should be aligned. If this does not happen then prismatic effect
comes into the picture. To obtain the ideal, large diameter lenses are
‘decentered’ to align with the center of the pupils, which results in
a poor, cosmetically shaped lens, where the temporal edges will be
thicker than the nasal. The higher the power, the more it becomes a
cosmetic blemish. To be in good books of the customer, the optician
does not take this risk and does not decenter the lens.
For large lenses, these are decentered inwards, so that their
optical axis coincides with the visual axis (center of the pupil). If this
Chapter 13: Prescription of Spectacles 131
is not done then the patient fixates through the nasal side of the lens,
and in minus lenses, a ‘base-in’ prismatic effect is induced. Reading
makes the effect even greater as the visual axis shift more nasally.
Decentration can be easily detected by comparing the nasal and
temporal edge thickness. Equal thickness means the lenses have not
been decentered. A patient complaining of asthenopia after a new
prescription is given, the spectacles should be checked not only for
the correct making of numbers but also for decentration. A simple
way in large frames is to compare the edge thickness as stated above
or more precisely, a lensometer can be used to mark the centers of
the lenses; and interpolating this distance with the interpupillary
distance (IPD). In case of discrepancy, the lenses should be remade.
The following example will clarify the point. Suppose, a patient
of OU –5.0 D has lenses mounted them on large colored frame.
The ‘geometrical center’ of lenses measure about 70 mm; the IPD
measures 62 mm. The 8 mm discrepancy produces a base-in
prismatic effect (about 1 PD each eye), amounting to 2 PD esophoria
for distance and 3.5 PD esophoria for near. In hyperopias, the reverse
effect occurs, i.e. large frames, without decentration produce ‘base-
out’ effect. The effect becomes proportionally larger with the increase
in numbers. It is to be noted that plus lenses produce more effect
than minus lenses. Using a high index lens, glass or plastic, does not
change the physics of decentration, they only make the lens lighter
in weight by altering the thickness.
There are two major problems in higher power plus lenses as
compared to minus lenses. Plus lenses being thicker are heavier and
they inherently produce more magnification, than a comparable
magnification by a same power minus lens. The thicker the lens,
more the magnification, steeper the base curve (front curve) higher
the magnification. Any lens of plus power of more than +5.0 or +6.0
induces significant magnification and weight problem. In ordering
spectacles for higher grades of hyperopia, the following points
should be kept in mind:
• A high index lens can be ordered.
• Polycarbonate or other type of plastic lens can be ordered, which
substantially reduces weight.
• ‘Aspheric lens’ design significantly improves the peripheral
vision, with peripheral power drop off of 1 D–5 D. There are
different designs, with common feature being the asphericity.

These lenses are used in very high hyperopes and not routinely.
• Base curve: Keeping the base curves of lenses as flat as possible,
not only reduces the lens induced magnification, it also shortens
the vertex distance, thus further decreasing the magnification.
Note: The lens blanks from which spectacle lenses are ground,
have a base-curve (lens shape) for every given lens power. In
spectacle lens, it is the manufacturer’s standard surface. For
example:
–– For a single-vision spherical lens, it is the lesser curvature,
whether that is on the convex or the concave side
–– For a single-vision cylindrical lens, it is the meridian of least
curvature on the toric surface
–– In a contact lens, it is the curve of the posterior surface of lens.
PANTOSCOPIC TILT OF FRAMES

Pantoscopic tilt is the angulation of the lenses or frame from the
vertical. Careful positioning of the lenses plane can minimize
induced astigmatism and distortions, and maximize visual acuity.
The problem is exaggerated when person looks up or down. The
pantoscopic tilt should not be more than 5–7 degrees from the
vertical. As the tilt increases from more than 10 degree, it induces
cylinders at 180°, in increasing order as numbers increase. Certain
important facts related to lenses and their fitting have been covered
in the previous chapters, but a recap is again presented here:
• The frame size should not be large especially in higher numbers,
as this does not only increase the weight but also produces
prismatic and chromatic aberrations.
• The optical center of the lens must coincide with the pupillary
center, i.e. the visual axis.
• Loose frames which tend to slip down the nose must be corrected
without delay.
• ‘Peripheral beveling’ should be advised to the optician in high
grades of myopia, which will not only improve the cosmetic look
of lenses but will help to fit properly in frame also.
• High plus or high minus lenses, can be made in plastic lenses
(CR 39 or polycarbonate) reducing weight and thickness.
• ‘Vertex distance’ must be carefully monitored. In higher plus or

minus numbers, the distance of spectacle from cornea must be
the same as the distance of trial frame which was used during
subjective refraction. Forward movement (as slippage on nose)
of spectacle frame in plus lens correction magnifies the image,
while in minus lens correction, minifies the image. Not only
that, it changes the line of vision from the optical axis of the lens,
initiating aberrations.
• Bifocals need more precision and care. Higher additions require
‘dropping’ the optical axis few mm down; and ‘slabbing off’ of the
lower segment.
• In anisometropias and antimetropias balancing of disparity of
prescription between the two eyes is important, as it concerns
the aniseikonia and anisophoria.
Most of times, we do not carefully examine the difference
between the two eyes particularly the cylindrical axis; which leads
to off axis distortions and prismatic effects. It has been already
mentioned the off axis cylindrical power effects, which should
be carefully looked into before writing the prescription. Either
the power be reduced or change in axis observed binocularly
subjectively with the trial frame on. Nothing should be left at the
mercy of the optician. Secondly, the glasses should be always
checked by lens meter for their correctness and accuracy, once
they are made.
• Never force a bifocal on a patient or progressive power spectacles
at presbyopic age in a high myope or hyperope. Let the person
first get adjusted and adapted to the two different visual demands
by single vision glasses initially.
• Patients having cataracts, corneal diseases or uveitis, etc. should
be advised absorptive tinted or photochromic lenses for comfort.
• Quality and the type of lens, you would like for the patient, must
by clearly and emphatically inscribed on the prescription. Do not
leave this on the patient or the shopkeeper.
SPECTACLE FITTING IN CHILDREN

Since this is a special area, it needs special mention.
• Children have a high degree of adaptability and therefore, one
should not refrain from giving as high numbers as required.
There have been personal experiences, where the optician

has returned back the prescription telling the patient that the
numbers are too high for a small child and should be reviewed.
Counsel the parent’s right at the outset regarding the necessity of
prescription, allaying fears of high numbers.
• The frames should be well fitting not too large, with optical center
well-aligned with pupil. The most important point is that since
children have the tendency to peep over the frames, hence the
top arm of the frame should be well-covering the eye.
• Where bifocals are advocated in any tropia with high AC/A ratio,
the upper line of lower segment should preferably bisect the
pupil. This is to ensure that when the child reads, it is effectively
viewing through the near segment.
• Plastic lenses should be advised in children for obvious reasons.
• If the frames become loose too often or child tries to remove the
spectacles, a plastic band may be tied at the back of head with the
two arms of the frame for steady positioning.
• Rimless or thin frames are not recommended for children,
especially with astigmatism, as they tend to tilt causing change in
axes. Reasonably thick but light weight, plastic frames and lenses
should be advised. ‘Trivex’ which is a high index, shatterproof
best plastic is the ideal lens material for children.
It is clinical experience that children who suffer from asthenopia,
strabismus or severe vision defects, not only very readily adapt to
glasses but ‘demand’ for their glasses and wear them gladly.
FRAMES OF SPECTACLES
Since this whole chapter discusses about fitting of spectacles, it is
of paramount importance to briefly discuss the frames which is the
backbone of spectacles. No matter how much or for how long you
counsel a patient regarding the type of frame most suitable and
advisable for him/her, one is engulfed in the glitter and glamor of
the wide array of frames in the optical shop and mesmerized by the
charming talk of the optician, buys the latest and costliest one! But
the clinician has do his part and to the best of his talents.
There are a few things which must be emphasized to the patient,
when a prescription for glasses is handed:
• The frame should not be too small or too large, looking to the
facial symmetry. Higher numbers should have smaller and
lighter frames.
• High minus numbered patients should be advised to wear thicker
but lighter plastic frames, as edge visibility would be masked.
• Advise the patient to go for proper fitting and size of frames rather
than design and style.
• Most importantly, the ‘geometric center’ of the frame should be
as close as to the ‘optical center’ of the lens. This would entail
minimum decentration and will have minimum prismatic effects
in straight gaze also.
• The pantoscopic tilt should also be seen while putting the frame
on the table and viewing from the side.
Though some frame does tend to become loose with time, but
too much reliance should not be put on shopkeeper regarding the
fit. A tight fit frame will cause pressure on temples and headaches,
which would be misunderstood for wrong prescription? A frame, if
becomes loose overtime, can be tightened any time.
In spite of the clinician best counseling and making the patient
understand the type of frame he would need, the patient following
your instructions has now procured the spectacles. But after
wearing for a few days, he returns with one or many of the following
complaints:
• The frame hurts on the nose.
• Feels pressure and discomfort behind the ears.
• Glasses keep on sliding down the nose.
• Glasses get foggy and dirty.
• Family and friends comment on glasses being too thick.
• Lenses fall out frequently.
• Eyes feel ‘strained’ with new glasses.
• Vision reads better with ‘older’ glasses.
• Troubled by glare/reflections.
• Objects seem different with progressive lenses.
Every ophthalmologist, novice or experienced, must have faced
with such Pandora’s box of complaints.
At the outset, listen carefully to the exact complaints of the
patients. Examine the spectacles: Is the frame exactly what you had
envisaged for the patient? The frame itself may be faulty! Recheck
your refraction and before that check whether the glasses are
correctly made.
Remember, the patient has already worn the spectacles for
same days and then has come with complaints. According to the
complaints, follow this check list:
• Noses come in different shapes, sizes and varieties! And so the
'bridge' of the frame has to be adjusted accordingly. If the bridge
of the nose is broad, a broader bridge of frame should have been
selected for comfort. The 'nose-pads' should also be examined.
Most of times, they can be adjusted to provide comfort.
• The 'arms' of the frame should be gently and snugly resting on
the back of ears, over ear cartilage. They may press tightly there,
causing pain. The frame arms may be loosened or a new frame
should be advised.
• Sliding of glasses down the nose is a common problem. If the
lenses are heavy, plastic lenses should be advised. If the frame is
loose, obviously a tighter frame is needed.
• Fogging or dirty lenses is the most commonly encountered
hindrance to clear vision, especially in children and the elderly.
There are solutions available commercially to clean lenses or
simply soap and water would suffice. Simultaneously, position of
lenses with respect to eye lashes and cheek should be examined.
If the eye lashes touch the back of lenses, it may smog the upper
part of lens. Similarly, oil from cheeks may smog the lower part
of lens. This can be overcome by changing the pantoscopic tilt of
frame, or by increasing the vertex distance (by adjusting the nose
pads itself ).
• If complaints of ocular asthenopia ensue from the new pair, the
refraction should be rechecked. If vision appears less sharp, then
the vertex distance should be checked along with the pantoscopic
tilt.
• Complaints of 'better vision' particularly for near, needs redres
sal. In bifocals, where the power has been increased, may not be
commensurate with the habitual reading distance; or the bifocal
segment is not properly placed causing discomfort in reading.
This is more pertinent in higher grades of refractive errors.
• Glare and reflections from new spectacles, (which was not

present previously) emanates from poor quality lenses. Poor
quality lenses, glass or plastic, fog easily when person comes out
from cold room or come, out into the hot, humid atmosphere.
Glare is expressed differently by different people. Scientifically
it is uncomfortable excessive illumination from a bright light
source. Reflections are images seen from internal reflections
from outer and inner surfaces of the lens or the cornea.
A dirty, smoggy lens creates more of these annoying reflections.
• Progressive power lenses differ from manufacturer to manu
facturer and as already stated, may not suit everybody. A high
quality lens, where transition from the central corridor to
periphery is gradual, is best suited but equally very costly and out
of reach of many patients.
In summary, complaints of discomfort from a new pair should
not be brushed aside and force the patient that he will eventually
adjust, which he may not because of inappropriate frame and
spectacles must be patiently and carefully looked into. Many times,
simple adjustments of nose-pads or arms of frame may alleviate his
problems.
14
Psychodynamics of Spectacles
INTRODUCTION
This chapter is basically designed to understand the psychology of
a person who resists or refrains from wearing spectacles. From the
days of Hippocrates and Socrates, the concept of holistic medicine
has been promulgated. And throughout the annals of medicine,
the mind and body analogy has been amply stressed. Not only this
concept has stood the test of time, but also the evidence-based
medicine also strongly supports the view.
In spite of best, correct refraction, done by a conscientious
clinician, there are a certain group of patient who simply will keep
on complaining, grumbling and will refuse to wear glasses. Let us
open the window of a house filled with these disgruntled, unhappy
patients and peep into their problems:
• Emotional factors: There are some patients, who have had a bad
childhood history. They were sickly, emotionally disturbed by
family conflicts, or other emotional responses, which have grown
to hostility and anger. When they grow up, they try to cope with
their stress by rejection. They are so called 'difficult' individuals
and will not cooperate for anything in the beginning. When
these adolescents and young adults develop refractive errors,
they come to the doctor for help for their vision or asthenopic
Chapter 14: Psychodynamics of Spectacles 139
complaints. It is at this time that if they are not handled in a

satisfying manner and the responses of the clinician have been
rude and rough, they simply resent and refuse to cooperate.
Most of times, these individuals are not cooperative, and
therefore, may somewhat irritate the busy clinician. It is here
that the rapport misfires, and the patient may never undergo
any examination in future. This is very common with children
and therefore, what Kenneth Wright, an authority in pediatric
ophthalmology has rightly coined that “refraction in a child
requires patience, skill and some talent”!
It may also happen that the attitude of previous refractionist
was hostile, and the person simply reacts by not accepting any
glasses from the subsequent clinic.
• Inhibition influences:
a. Self-image: Every individual has its own personality and
is conscious of his body look in society, especially the
face. It is very common to see persons rejecting glasses
because it changes their looks. Not only they seem to look
absurd, particularly with thick glasses, but are subject to
many comments from onlookers. But thanks to the prolific
development of optical industry where frames of different
shapes and colors have enchanted the young and the old
alike. We also have new ways and means to hide thick glasses
or advocate thinner lenses.
b. Parental attitude: Some parents just do not accept that their
child has got a refractive error and needs glasses. They argue,
as no other member in their family has glasses then why
only this child. Even where strongly indicated, they refuse
spectacles, and fall prey to misconceptions generated by
elderly family members that this problem will disappear with
age; or keep on overstuffing their child with green vegetables
and fruits.
c. Age-related factors: In young child, as already mentioned, the
parent's attitude of denial and delay makes them not wear
glasses. Another condition of strabismus in children is also
not addressed by the parents. Most of time, the misconception
that this will subside as the child grows still persists in illiterate
and uneducated classes.
Yet another common problem is of frequent breaking of

spectacles by children; the parents get fed up of continuously
buying new glasses and decide to let the child group up when
he would learn to care for glasses. As the child grows into
teens, another set of problems crop in. He/she now becomes
conscious of spectacles,and the mockery by fellow students
who are not using them, creates rejection to wearing glasses.
The adolescent may not wear glasses for some months, but
then realizes that vision is getting impaired and has difficulty
in seeing clearly on blackboard, and frequent complaints by
teachers, again brings the patient to the clinician. It is then
you must make the person and parents realize that spectacles
are necessary part of life and without them the child will not
be able to study and progress in class.
As the person crosses teens and goes into adulthood, one major
resentment to spectacles occurs, that is, marriage. In no way, a boy
or a girl would tolerate spectacles in marriageable age. Of course,
alternative to spectacles are contact lenses and Lasik surgery. But
there still remains a sizable group who worry about surgery and
would continue with glasses. But here there are certain motivational
factors, which by choice or chance; compel the patient to wear
glasses. Firstly, relief from symptoms, i.e. without spectacles cannot
move around. Secondly, ‘economic need’, i.e. without glasses the
person cannot work, his earning and lively hood is at stake, and
finally, ‘competitive compulsion’, i.e. to progress in career, the person
needs good vision. No matter how much the person dislikes the
glasses, but the above compulsions necessitates wearing of glasses.
The reasons listed above, probably work throughout the earning
years, and the person, willingly or unwillingly, keeps the spectacles
proudly mounted on the nose.
OCULAR NEUROSIS
There are two disorders which do not have any physical or organic
basis but are important entities which every ophthalmologist must
be aware of.
The stresses and tensions of life sometimes become so intense,
that they no longer can be kept under control and become converted
Chapter 14: Psychodynamics of Spectacles 141
into signs and symptoms of almost any type. Sometimes they are
directed towards eyes or vision and may manifest as asthenopia or
so severe as total blindness, and are clinically identified as ‘ocular
neurosis’. Two most common entities which comprise ocular
neurosis are ‘neurasthenia’ and ‘ocular hysteria’.
Neurasthenia: The symptoms of ocular asthenopia like headaches,
fatigue, burning, watering, reading intolerance are all exaggerated
in neurasthenia. Before labeling a person as ocular neurotic, it is
mandatory to do a thorough checkup with cyclopegia to rule out an
actual refractive error.
Ocular hysteria: In this type of disorder, the patient unconsciously
converts a psychic conflict into some type of vision problem, i.e.
visual loss, blurred vision, reduced field, etc. A unique feature of
this hysteria is the patient's conspicuous lack of concern about
the ocular defect. Another significant feature, the findings tend to
remain constant. The fields characteristically are tubular, severely
constricted which does not conform to any neuroanatomic defect.
Nevertheless, such patients complaints should always be looked into
professionally and any organic cause discovered.
THE DOCTOR-PATIENT RAPPORT

Patients usually begin their relationship with the doctor on faith,
and it is the responsibility of the doctor for augmenting this sense
of confidence. Each clinician develops his own techniques of having
a rapport with the patients. This involves patients of all ages, but
more relevant for children and younger group. Children are sensitive
and need to be dealt with caution. They are apprehensive to even
putting drops in their eyes. Having had bad experience in some
other clinic, some cycloplegic drops produce a stinging sensation,
and a forceful application, further alienates the child. Such patients
need first a little counseling or polite talk, assuring that such drops
are to be put only once and not for regular use, and will help to find
problem in the eyes. Clinical experience has shown that a single
drop of proparacaine 1%, instilled first, will anesthetize the eyes.
This helps into ways; firstly, the reflex watering caused by irritation
of drops (which dilutes the drops) will not occur and secondly, the
child will not resist for instillation of more cycloplegic drops. Having
overcome the first hurdle, now surfaces the problem of motivating
the child to wear spectacles, if refractive error is discovered. Never
push the parents or the child over the brink for wearing spectacles. If
the child is very young, a toy spectacle may be encouraged for some
time before embarking on actual numbers. For a school going child,
if the child and parents resist, the glasses may be deferred for some
time. Small myopic errors, for example, may not do any harm. In a
few months, when numbers slightly increase and classroom work
becomes difficult, the child will be self-motivated towards glasses.
The first and second decades of life when refractive errors emerge
and grow, patients should be reassured, persuaded, explained about
wearing glasses and their refractive errors. They should be explained
politely about the consequences of not wearing specs but not in a
threatening way which may unnecessarily alarm the patient and
parents. Something akin to a 'golden handshake' should be attempted
where the patient fully complies with the doctor’s instructions and
gladly wears spectacles with a broad smile, not a broad grin!
15
The Visually Handicapped
INTRODUCTION
This book would be incomplete and morally unjustified, if we leave
a sizable population who, in spite of best of refractive correction and
best of glasses, do not achieve useful vision. These ‘partially sighted
persons’ are also part of society and unfortunately very little effort
has been made by the optical industry to help them.
These ‘visually handicapped’ persons are those whose vision in
the better eye does not improve beyond 6/60; or field of vision is less
than 20 degree. And in this is a subgroup of ‘legally blind’ persons
whose vision does not improve beyond 3/60 in both eyes. No doubt,
lot of visually handicap problems does stem from severe refractive
errors, but those which have pathological disease, can also be
benefitted from suitable visual aids.
If even half the percentage of low vision population can do their
daily routine with some visual aid, then it is worth the time of any
clinician. Why this apathy then? Low vision problems are typically
at the bottom of the list of priorities. Understandably, the potential
failure with them is considerable. The amount of time spent on them is
not commensurate with success of providing good vision. Therefore,
most clinicians are reluctant to treat such patients. But basically,
there are no intricacies or mysteries, in refracting these persons with

which the doctor cannot be conversant. There are simple guidelines
which are available for more than half a century, but for reasons well
known to clinicians, these patients remain neglected.
REASONING FOR SUCCESS MANAGEMENT

Motivation
Above all, the patient himself should be strongly motivated with a
strong positive attitude. Knowing the handicap and determined to
overcome it, the patient should listen and follow all the instructions
of the doctor and should try to make the best use of it. It is advisable
to refer the patient to a clinic which specializes in dispensing low
vision aids.
History-taking
The potential success of the optical aid would depend upon the
type of disorder and the history associated with it. It is always wise
to politely ask the patient and relatives certain relevant questions.
Firstly, enquire about actual visual problem, whether inability to
see clearly the details or side vision is affected. Blurring of details
would indicate a macular problem and side vision impairment
would indicate retinitis pigmentosa, for example. Or the patient
may complain of better vision in bright light and severely decreased
vision in dim light—a contrast sensitivity issue. Also enquire about
the duration of visual impairment. Is it progressive or static. In early
stages or when impairment is progressive, the patient will not accept
that he is disabled; will try all that is possible for a cure and such
patients are poor candidates for low vision aid.
Visual Background
Patients who are visually handicapped from childhood, have learned
through the Braille materials. For them other types of visual aids
would not work and attempts on them would be futile.
Chapter 15: The Visually Handicapped 145
Customized Visual Aid

Low vision aids are tools for specific tasks. They are not like spectacles
or contact lenses which are all purpose. Identify the specific need
of the patient, viz. whether more need for reading (near work) or
more interested in watching TV and passing time. Thus visual aid is
basically customized.
Experience with Previous Aid

Clear information of the aid used previously should be obtained. If
the earlier aid was unsatisfactory, there is no use trying similar type
again. Also, the patient’s priority might have changed, so aid should
be devised according to it.
Other Handicap
Another important aspect is to observe for any other handicap other
than visual. Patient with severe arthritis or stroke may not be able to
use certain type of aid.
Baseline Visual Acuity

Low vision studies and the guidelines have underlined the level of
visual acuity as a determinant of success or failure of visual aid. The
nature and site of pathology causing the visual defect did not matter
for the benefit from the aid; it was the acuity level that correlated
with reading ability from the visual aid.
Clinical Point
A poor distance acuity does not undermine near acuity also. Children,
who are severely handicapped for distance vision, surprisingly can
read quite well at near by bringing the reading material close to
their eyes, creating magnification by utilizing their accommodation.
Similarly, patients who have central scotoma have satisfactory
distance vision but poor near vision. Therefore, a low visual aid is
determined in these patients according to their situation.
EXAMINATION AND REFRACTION

Every low-vision patient must undergo a careful examination and
refraction. The cause of the diminished vision must be ascertained,
because this has a bearing on the usefulness of visual aid. The best
distance correction should be achieved. The refraction should be
meticulous, performed slowly and with patience, because even small
cylindrical changes which produce a difference of even one line, has
bearing on comfort in a visually handicapped person.
Suppose in a patient, the vision does not increase beyond 6/60
with best lens correction possible then an increment of 1 D should be
tried, because changes of 0.25 or 0.5 will not yield useful difference
in visual acuity.
Another important point is that subjective correction should
be carried out with the chart at 3 m or even less; because at 6 m,
the patient may get confused and also practically the best corrected
vision makes him comfortable in and around that area of 3–4 m.
Even the correction is more predictable at 3 m or even less, as a
visual acuity of 6/24 at 3 m, would interpolate to 6/60 at 6 m. There
are low vision charts available in the market with larger optotypes
to be viewed at 3 m and 6 m. Low vision aids can be tried according
to the need of the patient, e.g. if the person likes to go to the park for
walks and needs visibility at distance then visual-aid should be given
according to that distance (6 m) or the person needs to walk in the
house only then correction should be done according to 3 m.
DETERMINING THE BEST AID

Low vision, technically, relates to diminished visual acuity of central
vision and occurs due to damaged macula. Peripheral vision loss is
less disturbing to the person at least in terms of his/her reading and
near work. Therefore, most of our efforts and of the optical industry
are directed towards enhancing the central vision, by magnifying the
image and increasing the available light.
The following steps should be followed in evaluating and
determining the type of low vision aid:
• The first step is to ensure that the distance is corrected to the best
possible level.
• Then, the near vision correction should be dealt with. A set of

reading cards, with simple, continuous material in graded print
sizes, should be used. Simple letter cards are not helpful, as they
do not represent the continuous text.
• Next, the exact distance at which the patient is comfortable to
read should be determined. Additions of plus lenses are done
till the patient is able to read. The smallest print size the person
can comfortably read and the distance at which the card is
held, will determine the starting magnification. A simple way of
determining the magnification is to divide the print size in mm
(can be measured to be exact) by the reading distance in cm,
and multiplied by 40 (assuming this to be the standard reading
distance). Having determined the magnification, the spectacle-
borne low vision-aid is ordered. Usually this will fall between
2x and 5x magnification. If the acuity is severely depleted, then
larger magnifications are provided by handheld or other type of
magnifiers.
OPTICAL AIDS
Aids for Distance
Optical aids for distance include telescopes and absorptive lenses.
Telescopes are the hallmark as visual aids for distance. There are two
basic types available:
1. Head-borne monocular or binocular telescopes, mounted on a
spectacle frame or clipped onto existing glasses
2. Handheld monocular or binocular telescopes. When selecting a
telescope, its specifications should be well-understood.
Very powerful units have inability to focus at near. Monocular
telescopes have the advantage of being focused as close as a few
inches and available in various strengths. Other features to be looked
upon are the size and weight of the telescope. Higher power ones are
heavy and difficult to hold on spectacles.
Both head-borne and hand-held telescopes are available in a
variety of strengths, from approximately 2x up to 30x. But higher
than 10x are not of practical use being too heavy and difficult to
hold steady. Two major limitations of all telescopes are that they
reduce the field of vision and they produce ‘motion magnification.’

The telescope magnification also magnifies the motion of wearers
retinal image, so with the movement of eyes or head, the entire field
seems to move rapidly or swim, producing a distressing vertigo type
sensations. Because of these drawbacks, distance magnifiers have
best utility in viewing static objects or field.
Aids for Near Vision and Reading

Optical aids for near include hand held magnifiers, stand magnifiers,
a variety of head-borne devices, pocket or foldable magnifiers and
electronic pocket or desktop CCTV magnifiers.
Commonly used are handheld or stand magnifiers. The handheld
are excellent devices for reading and come in illuminated and non-
illuminated types. But persons with arthritis and parkinsonism
type disorders have difficulty in using them. For such patients, the
stand or fixed focus magnifiers are more useful. They also come in
illuminated and nonilluminated varieties.
Dome and bar magnifiers are another variety of near magnifiers.
They are one of the easiest aids to use and arguably the most
important for those with albinism. They have a modest ability to
magnify print and in combination with short viewing distance, many
reading tasks can be easily accomplished.
A general purpose magnifiers used are pocket or folding type.
The lens swivels out of a protective case, which doubles as a handle.
They come in power from 1.5x to 10x.
The 21st century era has ushered innumerable new inventions
and innovations. When traditional optical aids do not accomplish
the desired task, electronic visual aids (EVA) are a good alternative.
Reading can be done on electronic TV screens, with a CCTV system.
This system also allows the viewer to adjust the brightness and
contrast of the magnified image. The user can read white letters
on a black ground to enhance contrast or different backgrounds to
decrease glare.
Nonoptical Aids
There are some ancillary nonoptical devices or methods, by which
the benefit of an optical aid can be enhanced.
Illumination is a variable of greatest importance. Partially

sighted individual’s visual performance increases immensely with
increase in illumination. As a standard, illumination levels of 100
to 200 foot candles is essential with persons having retinal or optic
nerve diseases, glaucoma, etc. (A 100 watt frosted bulb at one foot,
will provide illumination of 100 ft candle.)
Excessive illumination is counterproductive. Hence, care should
be taken, when illumination levels are provided, as excessive diffuse
intensity is disturbing to patients with corneal opacities, cataracts, or
vitreous opacities.
Other things which can help a visually handicapped person are
modifying the devices of his daily use like, large print telephone
pushbuttons, large print indicators on doors of bathrooms and
kitchens, keeping optimal illumination in rooms all the time, easy
operating remote control devices for CCTV devices, which the
patient can easily access and operate.
Nonmagnifying Optical Devices

Magnifiers are not the only devices for the partially sighted. There are
devices for people having visual disability of severely restricted field
of vision. The so called ‘field expanders’ range from sophisticated
prismatic spectacles to a simple ‘reverse telescope’. In effect, they
squeeze a large spatial image onto a smaller segment of retina. The
simplest and most frequently used expander is a low power telescope
with the viewing done ‘inversely of normal’.
Fresnel press-on prisms are used to expand the visual field of a
patient with retinitis pigmentosa or advanced glaucoma. The prisms
are applied with the base directed towards the blind field, in the
direction of desired expansion.
Several specialty lenses are in the market to enhance the contrast.
Their primary aim is to absorb light and reduce the short-wavelength
light ( the UV, blue and blue-green).
There is also something for nightblindness. ‘Starlight viewers’
and ‘infrared detectors’, are telescopic-type instruments that increase
the apparent brightness of objects viewed in dim light. These are
also known as ‘night vision glasses’ and are extensively used by
army personal to see in dark. But these are very expensive and not
commercially marketed.
SUMMARY
Most of the diseases which cause severe visual handicap are
progressive in nature and eventually the optical devices may not
work. Nevertheless, this must not deter the clinician of not making
efforts to provide visual aids.
In providing the aid, the patient and family members should
be explained about the benefits and shortcomings of the aid. The
patient may take some time in adjusting to the new visual scenario,
and patience should be observed.
In selecting the aid, find which will suit and satisfy the patient’s
specific visual need, and start with the weakest lens or telescopic
power.
Carefully explain to the patient and demonstrate the proper use
of the visual aid. If possible, a trial period of some days may be given
to the patient before outright purchasing it. Every optical low visual
aid is restrictive and one may need several devices for different tasks.
Also these devices must be complimented by variety of ‘nonoptical
devices’, so that full advantage of the aid can be achieved. Arguably,
dealing with a visually compromised person is cumbersome,
time consuming and may result in failures, but as a conscientious
clinician it becomes our moral responsibility to provide the best of
vision to every individual. A sincere effort should be made to provide
as best as possible some useful vision to a visually impaired person.
Unfortunately, the availability of low vision aids is not always at
hand and what the doctor has perceived and evaluated is not always
available. Moreover, what has been received may not comply with
the clinician’s order and such obstacles demoralize the doctor and
the patient. Nevertheless, even if you have shared his misery with
some counseling and assurance and helped him gain some useful
vision with your efforts in providing a suitable visual aid, you have
attained sainthood!
Index
Page numbers followed by t refer to table.
A B
Abbe number 115 Band-keratopathies 57
Accommodation and convergence Baseline visual acuity 145
5 Bifocals for reading in bed 68
Accommodation required 11t Bifocals in
Accommodation spasm 6 astigmatism 55
Accommodation, changes in 106 children 63
Accommodation, test 3 presbyopia 65
for relative 6 Bilateral aphake 93
Aniseikonia 76 Bilateral pseudophakia 99
Anisohyperopia 74 Binocular aphake 94
Anisometropia and antimetropia 74 Blepharoptosis 105
Anisometropia in children 85
Anisometropia, symptomatology of
75
C
Anisomyopia 74 Candle light, single 120
Anisophoria 56, 81 Ciliary overtures 54
management of 82 Ciliary spasm 43
Antimetropia 74, 78, 89 Cornea, changes in 105
clinical pearl 80 Curve variation factor 116
clinical point 79 Cyclopentolate 19
Antireflective coating 121 solution 18
Aphakia 92 Cycloplegia 7, 13
Aspheric lens 131 and glaucoma 20
Astigmatic anisometropia 88 pharmacogenics of 14
Astigmatic correction at near 51 Cycloplegic agents, characteristics
Astigmatic refraction for distance 51 and dosages of 18t
Astigmatism 49, 67 Cycloplegic drugs, qualities of 16
irregular 57 duration of action 17
prescriptions 49 effectiveness 16
systemic and local diseases recommended dosage 17
affecting 59 side effects 19
Atropine sulphate treatment 20
ointment 18 Cycloplegic refraction 13, 16, 29, 53
solution 18 revealed 29
Cylinder power and axis, changes Hyperopic anisometrope child 27

in 52 Hyperopic anisometropia 86, 100
compound 74
moderate 100
D simple 74
Decentrations 130 Hyperopic astigmatism 67
Density 115
Determine near correction 62
Determining best aid 146
I
Doctor-patient rapport 141 Interpupillary distance 96, 131
Duane and donders 2
J
E Jackson cross-cylinders 52
Epilepsy 14
Esotropia, child with 26
Excessive accommodation
K
amplitude 6 Keratoconus 57
Extraocular muscles and lids 105 Knapp’s rule 77
Eye, effect of change in size or shape
of 105
Eyes, weakness of 60
L
Lens 110
F absorptive 120
coated 122
Full accommodation suppression 9 contact 105
Fusion incompatibility for near 94 crystalline 106
curvature 77
manipulation in correcting
G aniseikonia 77
Geometric center 135 material glass 117
Glasses, near point of material optical white crown
accommodation with 71 glass (B 270) 117
Glaucoma 47, 105 material plastic (CR–39) 118
material plastics 117
material polycarbonate 118
H material thiourethanes (high
Homatropine hydrobromide index plastic) 119
solution 18 material trivex 118
Human eye 120 materials 117
Hyperopia 23, 66 medical indications of absorptive
children 25 125
etiopathogenesis 24 modern 111
or hypermetropia 23 photochromic 124
Index 153
progressive addition 126 high 100

progressive power 126 simple 74
aspheric design 128 Myopic or hyperopic changes 52
spheric design 127 Myopic patients 48
spheric-aspheric
combination 128
tinted glass 121
N
tinted plastic 122 Near correction in adults 64
types and quality of 114 Near-point accommodation method
3
Neosynephrine or eucatropine 14
M Neurasthenia 141
Macula, changes in 106 Neuromuscular effort 1
Malignancy 107 Night, difficulty at 32
Monocular aphakia 92 Nonmagnifying optical devices 149
Monocular pseudophakia 98 NPA with manifest correction 72
Mydriatic drops 57
Myopes 6
and antimetropes 76
O
Myopia 33 Ocular asthenopia as part of illness
causes and progression of 34 107
classification 35 Ocular asthenopia, symptoms of 6,
effect of medical problems on 46 13
environmental factors 34 Ocular hysteria 141
heredity 34 Ocular media and lens 106
high 70 Ocular neurosis 140
in presbyope, increasing 70 Optical aids 147
index 47 for distance 147
intelligence and 35 for near vision and reading 148
management 36 Optical centers 94, 135
near work hypothesis 35 Optical nonoptical aids 148
near-use 36 Overcorrection in a myope 43
night 45
management 45
nutrition 34
P
orthokeratology, simple 38 Pantoscopic tilt of frames 132
pathological 47 Partial fogging method 8
role of drugs, simple 38 Pearl, clinical 43
simple 36 Pearls 12
surgical treatments, simple 38 clinical 21
treatment for pathological 47 adults 21
unilateral 41 children 21
Myopic anisometropia 85 Phakic eye 77, 93
compound 74 Plastic lenses 112
Polaroid lenses 123 Respiratory problems, chronic 107

Polycarbonate 113 Retinal image degradation 37
Postcycloplegic test 15, 21, 40
back for 24
Postoperative refraction 101
S
Presbyopia 30, 60 Scopolamine (solution or ointment)
advent of practical 69 18
and anisometropia 87 Spasm, management of
and contact lenses 68 accommodation 7
and myopia 46 Spectacle 39
in myope 69 fitting in children 133
influencing factors 61 frames of 134
unequal accommodative legacy of 109
amplitudes in 71 lens 114
Presbyopic age 62 psychodynamics of 138
Prescription of plus lenses 7 temporary 95
Prescription of spectacles 129 Spherical add 4
Prince ruler 4 Subnormal accommodation 9
Prism—dissociation test 9 Sunglass 112
Pseudomyopia 6, 42
Pseudophakia 98
in children 102
T
Pupil, center of 130 Thumb, rule of 2
Tropicamide solution 18
Q
Quasi-myopia 40
U
Unequal accommodation 8
R Unequal amplitudes, causes of 9
UV cutoff 116
Reasoning for success management
144
Refracting aphake 96
V
Refracting in irregular astigmatism Vertical gaze, correction in 82
57 Vision glasses, single 95
Refraction, examination and 146 Vision, intermediate 31
Refraction, good cycloplegic 13 Visual acuity, baseline 145
Refractive error clinical point 145
and accommodation 10 Visual aid, customized 145
influence of 62 Visual axis 38
medical problems and 104 Visual background 144
Refractive index 114 Visually handicapped 143

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MANAGEMENT OF

REFRACTIVE ERRORS AND

The Health Sciences Publisher

© 2015, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Management of Refractive Errors and Prescription of Spectacles

First Edition: 2015

12. Types and Quality of Lenses 114

not usually take cognizance. Let us first, become conversant with a

Examining the observations by a number of authorities, and as

HOW TO TEST ACCOMMODATION

Near-point Accommodation Method

is 10 D. This is based on a standard law of optics where 1 D increase

Because of these inherent deficits, measurements by all these

ACCOMMODATION AND CONVERGENCE

Test for Relative Accommodation

EXCESSIVE ACCOMMODATION AMPLITUDE

or underestimating hyperopic error. Cycloplegic refraction, will

Management of Accommodation Spasm

Prescription of Plus Lenses

Partial Fogging Method

Full Accommodation Suppression

Causes of Unequal Amplitudes

condition, where the amplitude may be normal, but a premature

REFRACTIVE ERRORS AND ACCOMMODATION

• A 8 D or 10 D myope, who wears a full spectacle correction for

TABLE 1.1 Accommodation required

It may be surprising, but this is a true physical phenomena

refractive error, mostly hyperopia and/or astigmatism. And a simple

• Whenever patient’s complaints are disproportionate to the

SOME SPECIAL SITUATIONS

The following example will obviate your anxiety:

QUALITIES OF A CYCLOPLEGIC DRUG

Recommended Dosage (Table 2.1)

restlessness, disorientation and delirium. These central nervous

CYCLOPLEGIA AND GLAUCOMA

accommodation. Such patients may show variable refractions during

There is another group in the presbyopic or prepresbyopic age. If

Ch-3.indd 23 06-04-2015 15:08:22

Ch-3.indd 24 06-04-2015 15:08:23

As age advances, the lens grows in size, the accommodation in

Ch-3.indd 25 06-04-2015 15:08:23

• Whenever diminished vision is reported in a child below

Ch-3.indd 26 06-04-2015 15:08:23

• The hyperopic anisometrope child: These are slightly difficult

Age 6–21 Years

Ch-3.indd 27 06-04-2015 15:08:23

Age 21–35 Years

Example one: Lady patient of 30 years complained of headaches

Ch-3.indd 28 06-04-2015 15:08:23

OD –0.5 D/+1.0 cyl. 100

Ch-3.indd 29 06-04-2015 15:08:23

increasingly becomes manifest and compensation by virtue of

Ch-3.indd 30 06-04-2015 15:08:23

outweigh all deterrents. People who cannot afford progressive power

Ch-3.indd 31 06-04-2015 15:08:23

If he can afford and get used to progressive power lenses, then he

Ch-3.indd 32 06-04-2015 15:08:23

CAUSES AND PROGRESSION OF MYOPIA

The ‘normal stimuli’ refers to the environment. Modern humans,

Intelligence and Myopia

Near Work Hypothesis

• Curvature—myopia is attributed to an increase in the corneal

To be more dogmatic, it is better to ask the patient what he pre