Refraction &Refractive errors

Competency 1.2
Dr Sushan Shetty
MBBS,MS,FPRS
Assistant Professor
Refraction by the eye
Refractive Index
• Air =1.00
• Cornea =1.376
• Aqueous humor =1.336
• Lens Loading…
=1.386-1.406
• Vitreous humor =1.336
REFRACTIVE POWER
• Cornea - 40-45D
• Lens - 20D
Clinical importance of refraction

• To assess the visual status – refractive errors commonest

cause of defective vision

• Other presentations – head ache, brow ache, pain, redness,

watering, recurrent lid infections

• Important when visual failure is not due to refractive errors

 REFRACTION
• The procedure of determining and correcting
refractive errors

Loading…
• Objective Refraction- Retinoscopy, Refractometry,
Keratometry

• Subjective Refraction
Refractive errors- Pathological optical defects
• Emmetropia (Greek- emmetros =fitting/appropriate)
• Ametropia
● Hypermetropia
● Myopia
● Astigmatism
COMPONENTS OF AMETROPIA
• Corneal power
• Anterior chamber depth
• Crystalline lens power
• Axial length
 ·

Anial
·
Curvature

HYPERMETROPIA Positional
·

Index
-

• DEFINITION: Long-sightedness is the refractive state of the eye

wherein parallel rays of light coming from infinity are focused
behind the retina with accommodation being at rest.
Accomodation
ACCOMODATION

• Our eyes have been provided with a unique mechanism by which we

cam focus the diverging rays coming from a near object on the retina
in order to see clearly

• Change in the shape of the lens

 Loading…
suspensary
↳
ligaments
 D

AETIOLOGY
AXIAL HYPERMETROPIA

• Shortening of anteroposterior diameter of the eye

• About 1 mm shortening 3D of hypermetropia.
• At birth Axial length=18mm
• Rapid growth- By 3rd yr Axial length=23mm
• 3-14 yrs- 1 mm increase
Curvature Hypermetropia
• Curvature of cornea, lens or both - flatter than the normal
decrease in the refractive power of eye.
• About 1 mm increase in radius of curvature results in
6 dioptres of hypermetropia.
• Rare cause
Curvature Hypermetropia
• Curvature of cornea, lens or both - flatter than the normal
decrease in the refractive power of eye.
• About 1 mm increase in radius of curvature results in
6 dioptres of hypermetropia.
• Rare cause
INDEX HYPERMETROPIA
• In old age- due to increased RI of the cortex
relative to the nucleus-Overall refractive power of
the lens reduces

POSITIONAL HYPERMETROPIA
• Results from a posteriorly placed crystalline lens.

ABSENCE OF CRYSTALLINE LENS

• Aphakia
 Total -
L
COMPONENTS OF hatent Manifest S

HYPERMETROPIA
• Total hypermetropia is the total amount of refractive
error which is estimated after complete cycloplegia
with atropine.

• It consists of latent and manifest hypermetropia.

Components of hypermetropia
LATENT HYPERMETROPIA
• The amount of hypermetropia (about 1D) which is normally
corrected by the inherent tone of ciliary muscle.

• High in children and gradually decreases with age.

• Disclosed after abolishing the tone with cycloplegics

u
Manifest hypermetropia

Is the remaining portion of total hypermetropia, which is not

corrected by the ciliary tone.
i. Facultative hypermetropia:
• can be corrected by the patient's accommodative effort.

ii. Absolute hypermetropia:

• which cannot be corrected by the patient's accommodative
efforts.
TOTAL HYPERMETROPIA

TH = Latent + Manifest (Facultative + Absolute)

CLINICAL PICTURE-SYMPTOMS

Asymptomatic

• Young patients have good reserve of accommodation

• Small amount of refractive error
• corrected by mild accommodative effort
Asthenopic symptoms

• Due to sustained accommodative efforts

• tiredness of eyes –aching/burning
• frontal or fronto-temporal headache
• associated with near work
• increase towards evening.
Defective vision with asthenopic symptoms
• Amount of hypermetropia is such that it is not fully
corrected by the accommodative efforts
- More for near than distance

Defective vision only

• Hypermetropia is very high >4D
• Do not accommodate (especially adults)
• Defective vision for near and distance.
far distance
.
 SIGNS
• Size of eyeball small
• Cornea smaller than the normal.
• Anterior chamber shallow.
• Fundus examination small optic disc with ill-defined
margins ( pseudopapillitis).
• The retina as a whole may shine due to increased light
reflections (shot silk appearance).
• A-scan ultrasonography (biometry) short antero-
posterior length of the eyeball.
SHOT SILK APPEARANCE
 COMPLICATIONS
• Recurrent styes, blepharitis or chalazia due to
frequent rubbing.

• Accommodative convergent squint

Age of 2-3 years due to excessive use of
accommodation.
• Amblyopia- Lazy eye
• Predisposition to develop
primary narrow angle
glaucoma due to shallow anterior
chamber

• Due to regular increase

in size of the lens with
increasing age.
TREATMENT

Optical treatment.

• Convex (plus) lenses

• Spectacles

• Contact lenses
RULES FOR GLASS PRESCRIPTION
• Always perform cycloplegic
refraction
• If the total manifest refractive
error is <1 D correction is given
if patient is symptomatic
• The spherical correction should
be comfortable to the patient
• Children <4 years –full
cycloplegic correction
• Older children-first undercorrect
then gradually increase at 6
month interval
• Accommodative convergent
squint-full correction
• Amblyopia-occlusion therapy
Hyperopic LASIK using
excimer laser (upto +4 D)

Loading…
Refractive surgery for hyperopia
Holmium:YAG laser thermoplasty

• low degree of hyperopia.

• laser spots- ring at the periphery
to produce peripheral flattening
and central steepening..
 Conductive Keratoplasty
• Nonablative
• Nonincisional procedure
• By collagen shrinkage
through radiofrequency
waves
• Peripheral corneal
stroma in a ring pattern.
PHAKIC IOLs/ Implantable Contact lens
• Phakic IOLs (+6 to +10 D)
Refractive errors 2
Myopia
Competency 1.2
Dr Sushan Shetty
MYOPIA
 Asked
.
&

Frequently
AETIOLOGICAL CLASSIFICATION
Axial myopia
• Increase in anteroposterior length of the
eyeball

Curvatural myopia
• Increased curvature of the cornea, lens
or both.
 Aetiological classification
Positional myopia
• Anterior placement of crystalline lens in the eye.

Index myopia
• Increase in the refractive index of lens

nuclear cataract, DM

Myopia due to excessive accommodation

• In patients with spasm of accommodation
Grading of myopia
• Myopia >6D- High Myopia

• Myopia 3-6D- Moderate Myopia

• Low myopia
 CLINICAL VARIETIES OF
MYOPIA
1. Congenital or developmental myopia
2. Simple myopia
3. Pathological or degenerative myopia
4. Acquired myopia
• Drug-induced- Sulfonamides, Hydrochlorthiazide, Indapamide,
Triamterene etc
• Pseudo-myopia-Spasm of accommodation
• Consecutive myopia- Consecutive to an IOL implantation
CONGENITAL MYOPIA
• Present since birth, usually diagnosed by 2-3yrs
• Error - 8 to -10 D
• Remains constant, Progression rare
• Convergent squint in order to preferentially see clear at the far point
• Cataract, aniridia, microphthalmos
• Full cycloplegic refraction should be prescribed
 SIMPLE MYOPIA
• Commonest

• Not associated with any disease of the eye.

• Usually starts in the early teens

• Gradually progresses

• Refractive error does not generally exceed 6-8 D

• Finally stabilizes by 20-25 yrs

• No degenerative changes

SIMPLE MYOPIA
• Symptoms:
- Poor vision for distance
- Asthenopic symptoms rare
- Half shutting of the eyes

• Signs:
- Large prominent eyeball
- Deep anterior chamber
- Pupil slightly large
- Fundus- Normal; rarely Myopic crescent
PATHOLOGICAL/DEGENERATIVE/
PROGRESSIVE MYOPIA
• Rapidly progressive error

• Starts in childhood at 5-10 years of age

• Increases steadily up to 25 yrs

• Reaching -15 to -25D

• Associated with degenerative changes in the eye.

• Strongly hereditary- females, Jews, Japanese, Chinese

Degenerative myopia

Increase in axial length- mainly affects

the posterior pole

Due to degeneration of the coats

SYMPTOMS
• Low myopia- Blurred vision for distance
• High myopia- Discomfort after near work
• Divergent squint – Exophoria/ tropia (latent/ manifest)
• Floaters/ Muscae volitantes- due to vitreous liquefaction in
myopes
• Night blindness: due to marked degenerative changes in the
fundus
SIGNS
• Prominent eyeball

• Anterior chamber: deep

• Pupil: slightly large

• Lens- Complicated cataract may be present

Fundus changes:
• Vitreous Floaters, PVD( posterior
vitreous detachment)
• Optic disc: large, pale, tilted
• Myopic temporal crescent/
peripapillary atrophy
• Peripheral retinal degenerations-
retinal thinning, holes, tears
MYOPIC CRESCENT

Bulging backwards of the post pole

Separation of the retina and choroid from temporal
margin of the disc- white sclera can be seen.
On the nasal side- supertraction crescent
Degenerative changes
• Chorio retinal atrophic patches
in retina and choroid :
• Foster-Fuchs' spots/ flecks- Bright red patches due to bleeding from
CNVM ( Choroidal neovascular membrane)
 POSTERIOR STAPHYLOMA
Due to ectasia of sclera at posterior pole- may be
apparent as an excavation with the vessels bending
backward.

RETINAL DEGENERATIONS

Lattice degeneration
Pigmentary degeneration
White without pressure
Retinal holes
Pathological myopia
• Breaks in Bruch's membrane and choriocapillaris, resulting in lines
across the fundus called "lacquer cracks"
• Visual fields: may show constriction due to retinal degenerative
changes

• A-scan: high axial length

 Complications
• Retinal detachment
• Complicated cataract
• Vitreous haemorrhage
• Choroidal haemorrhage
 TREATMENT
• Optical :
- Concave lenses as spectacles
- Contact lenses
- LVAs- Low Visual Aids in high myopia
• Orthokeratology- the cornea is molded
by overnight use of special rigid gas
permeable (RGP) contact lenses
Spectacles
• Never over correct – give minimum power needed
• Advice constant use for children – to prevent exo deviations, normal
mental development
• High myopia-
undercorrect for distance
avoid contact sport
genetic counselling
Refractive surgeries
- LASIK- LASER assisted epithelial keratomileusis

- SMILE- Small incision lenticule extraction- A small lenticule

of corneal stroma is extracted with Femto laser

- Intracorneal rings (1-6D)

- Clear lens extraction/ refractive lens exchange

- Phakic IOLs/ Intra ocular contact lenses/ ICL(>12D)

Intacs – intra corneal rings
 Other measures
• General measures
Balanced diet
Visual hygiene
Avoidance of excessive near work
More outdoor activity
• Therapeutic interventions
Atropine drops in low strength (0.01%)- reported to prevent progression
of myopia.
Atropine 0.01% drops
• ATOM Study
• Atropine in treatment of myopia Study
• LAMP Study
• Low-Concentration Atropine for Myopia Progression (LAMP)

• Once daily dose in children with documented myopia progression

• Prevents progression of myopia
THANK YOU