1

What is aniseikonia?

09/23/20
 What is Aniseikonia?

Aniseikonia: Greek, unequal images 2

-is a binocular condition in which the apparent sizes of the images seen
with the two eyes are unequal.
It is likely that we all have a little of it
It is commonly associated with aniso-metropia, but not always or
exclusively
Anisometropia is iatrogenic, classically, due to unilateral aphakia
(lensectomy)
09/23/20
 Either due to:
Aniseikonia
3
 eye themselves
 Optical
 Can be:
 Physiological (natural)
 Anomalous ( clinically significant)
 Can be:
 Anatomical
 Optical/correcting lenses
Both can be:
symmetrical or asymmetrical
in every meridian progressive increase or decrease
may be meridional

09/23/20
 Classification of Aniseikonia
4

Optical: comes in two types

 Axial: due to differences in axial length
 Refractive: due to corneal differences
Physiologic: appears off primary gaze (looking left, right, up or
down), as in anisometropics wearing specs
Neurologic: due to unequal division of the primary visual
cortex, as in amblyopia

09/23/20
 Patient at risk of aniseikonia
Anisometropia 5

Pseudophakes
Aphakes
Refractive surgery
Retinal conditions like:
Epi-retinal membrane
Retinal detachment( re-attachment)
Macular hole/edema/ retinoschisis

09/23/20
 Symptoms of Aniseikonia
6

(Bannon and Triller, 500 subjects, 1944 study)

Headaches and eye aches (67%)
Photophobia (27%)
Reading Difficulty (23%)
Nausea (15%)
Diplopia (11%)
Dizziness and vertigo (7%)
Depth perception problems (6%)

09/23/20
 Signs of clinically significant
Aniseikonia
7

Apahkia
Anisometropia
Astigmatism
Low Stereopsis
Strabismus
Amblyopia
09/23/20
 Clinically significant aniseikonia values

Usually the symptoms are similar to uncorrected refractive error or oculomotor

imbalance
The difference is before correction and after correction
Aniseikonia seems to become clinically significant at values of 3-5%.   

09/23/20
 9

Sometimes sensitive individuals are suspected to have symptoms with less aniseikonia,
but it is well possible that these symptoms are caused by optically-induced anisophoria
and not aniseikonia. 

09/23/20
 Aphakia & Aniseikonia
Aphakia: 10

 is the classic, but now less common, cause of aniseikonia,

These days, aphakia exists mostly due to:

 injury in adults , and
 congenital cataract removal in pediatrics

For aphakes, spectacles are considered to be a far inferior

treatment to contact lenses, event in very young aphakic Px’s.

09/23/20
 Anisometropia & Aniseikonia
This is the most frequent cause of11 aniseikonia
Since very few of us are truly isometropic, very few of us are
perfectly isokonic as well
How much is anisometropia does it take to cause aniseikonic
symptoms?
 Aniso-Rule of Thumb:2 D or more of spherical equivalent anisometropia is
usually enough to lead to symptomatic aniseikonia
 This can cause vertical diplopia in a bifocal unless you include slab-off
prism

09/23/20
 Astigmatism & Aniseikonia
12
When patients present with high (>2D) difference in astigmatism power in either of their eyes,
they are at risk for amblyopia if uncorrected before age 2

Specifically, high cylinder is a special kind of refractive amblyopia called meriodional

amblyopia in the eye with that refractive error

Aniseikonia results when the cylinder is in one eye because the patient can’t fuse two different
size (and shape) astigmatic images

09/23/20
 Stereopsis & Aniseikonia
13
Recall that a patient with poor depth perception has only a
6% chance to complain of aniseikonia
Despite this fact, you might use threshold stereo-to determine
usefulness of an aniseikonic correction
For example, if an aniseikonic patient has 50” of stereo with an old
Rx, you hope to see as good or better with a new one

09/23/20
 Strabismus & Aniseikonia
Recall that we said there are three kinds of aniseikonia: optical, neurological,
14
and physiological
Physiological aniseikonia can come from strabismus, particularly when
looking left and right through anisometropic spectacles
Think about it: esotropes and exotropes do not move their eyes together when
looking left and right
Combine this with anisometropic glasses and you can have induced
aniseikonia looking off primary gaze
 This phenomenon is called anisophoria

09/23/20
 Amblyopia & Aniseikonia
15
We all know that amblyopia occurs in the visual cortex
For this reason, amblyopia can coexist with aniseikonia.Why?
The cortex is the same place that eye dominance happens –two-
thirds of patients see images larger in their dominant eye
The effect is called cortical magnification, and explains neurological
aniseikonia

09/23/20
 Predicting Aniseikonia:
16

Ocular Component Analysis

Spectacle Prescription
Keratometry
A-Scan
IOL Status

09/23/20
17

09/23/20
18

09/23/20
 Predicting Aniseikonia from Spectacle Prescription

Remember, the symptoms aniseikonia is nearly always

19

caused by the sign anisometropia

Look for a minimum of 1.50 to 2.00 D to produce
symptoms in patients
The higher the anisometropia, the more likely aniseikonia,
though it is never a guarantee

09/23/20
 Predicting Aniseikonia from Keratometry
The source aniseikonia has treatment implications, from contact
lenses to refractive surgery 20

How do you determine the source of a patient’s aniseikonia? Find where

the anisometropia comes from!
Use your Keratometry readings to measure the optical power of the eye,
as usual
To confirm the source of aniseikonia, compare the K’s OU
For instance, a patient with 3D of aniso-and a 3D difference in K’s OD
and OS has corneal anisometropia exclusively

09/23/20
 Predicting Aniseikonia from A-Scan Axial Length
21

What if all your patient’s aniso-is not all on the cornea?

The next likely suspect is axial length
This can be measured with ultrasound, specifically A-scan
A-scan ultrasound is routinely used in cataract surgery to calculate
IOL power, and IOL’scan cause aniseikonia too

09/23/20
 Predicting Aniseikonia from IOL Status
22

 The far and away most common cause of aniseikonia is unilateral eye
surgery, including LASIK and cataract, with or without an IOL
 In cataract extraction without an IOL (aphakia), expect double-digit
anisometropia
 More common these days is post-surgical anisometropia when the post-
surgical eye is plano, and the other is at least +/-2 D
 Any of you with greater than 2D ametropia? This could be you, after
monovision LASIK

09/23/20
 Treating Aniseikonia
23

Fully occluding one eye

Contact Lenses

Spectacle Lenses

Intraocular Lenses

09/23/20
 Correcting aniseikonia
24

Fully occluding one eye

But no patient is happy about this solution
It is only the last resort
Aniseikonia and its accompanying aniseikonic symptoms can often be reduced by
changing the magnification properties of the auxiliary optics of the patient

09/23/20
 Contact Lenses for Aniseikonia
Unless contraindicated, contact lenses are always the treatment of choice for
aniseikonia when it is caused by anisometropia.
25 Why?
Contact lenses should be offered to all patients with anisometropia, as you want to
be ready if symptoms can arise later in life (with presbyopia)
Of course, LASIK and other refractive surgeries are also an option for the right
patients to relieve aniseikonia caused by anisometropic to spectacles
These corneal plane corrections can reduced aniseikonia by about a third –enough to
make a 3D anisometrope with ~3% aniseikonia asymptomatic

09/23/20
 Spectacle Lenses for Aniseikonia
26
It is classical aniseikonic correction
Optical magnification changes are induced by changing the shape of the spectacles
(curvature, thickness) and or distance of the lens to the eye
This doesn't compromise the central visual acuity
 This is b/c the change in shape of the spectaclelenses, the cosmetics of the glasses might be
compromised (depend on the amount of the aniseikonic to be corrected)
 In optically induced aniseikonia both aniseikonia and anisophoria are often reduced at the
same time.

09/23/20
 Spectacle Lenses for Aniseikonia
27
Spectacle lenses are no longer regularly surfaced, they come in blanks of certain
sphere and cylinder powers
These blanks have a few base curve (BC) choices, and this is where you can ask
for a cheap size lens effect
Ask for the steepest BC for the more minus/least plus lens, and the flattest BC for
the more plus/least minus lens to minimize aniseikonia !
This will net you about two times the dioptric power of the lenses in percent mag
reduction
For example, +2 D reading lenses can be made into 4% magnifiers

09/23/20
 Measure of aniseikonia
28

Aniseikonia values by definition represent how much the right eye should be magnified or
minified to cancel the aniseikonia. 
For example, a measured aniseikonia of -5% means that the image is in the right eye is
perceived as approximately 5% larger than the image in the left eye and
That therefore the aniseikonia is corrected by minifying the image in the right eye by 5% (or
magnifying the image in the left eye by approximately 5%, or a combination of both).

09/23/20
 First pass methods approach
When you think that, Aniseikonia might be a 29
problem but have no clear evidence
Modification of the spectacles (lenses):
 Change base curve
 Lens thickness
 BVD
Different approaches:
 Frame with short vertex distance
 Frame with small eye size
 Use aspheric lens design
 High index lens material

09/23/20
 Directionally correct magnification change
approach
30

 You are fairly certain aniseikonia is present,

High plus Low plus
but no way of measuring, make change to
Flatten the base curve Steeper the base curve
each individual lenses
 This either increase or decrease mag.
 Change will be base curve, thickness and BVD Thin the lens Increase central
 Choose the frame with minimum vertex thickness

distance Decrease vertex distance If the edge is thick move

 Keep eye size small the bevel back
cosmetically

09/23/20
 If both lenses are minus
You are fairly certain aniseikonia is present, but
31
no way of
measuring, make change to each individual lenses
Higher minus Lower minus
 This either increase or decrease mag.
 Change will be base curve, thickness and BVD
Decrease vertex Increase vertex
Minimum vertex distance
distance distance
Small eye size
It is not advisable to change the base curve for minus lens
 Steeping the base curve increase mag Flatten base curve Do not thin
 Increase lens bent => increase vertex distance => more if large mag.
minification Required carefully

09/23/20
 One plus one
32 minus
You are fairly certain aniseikonia is present, but Plus Minus
no way of measuring, make change to each
individual lenses Flatten the base Decrease vertex
 This either increase or decrease mag. curve distance
 Change will be base curve, thickness and BVD
Minimum vertex distance Thin Do not thin
Small eye size

Decrease vertex
distance

09/23/20
 Estimating percent mag. Difference
approach
33

1.5% per diopter of anisometropia when the anisometropia

is refractive in origin.

But anisometropia has at least some axial component, 1%

per diopter is more realistic

09/23/20
 Measuring percent mag. Difference
approach
34

Stereoscopic card
Space Eikonometer
Awaya Test
Aniseikonia Inspector
09/23/20
 Knapp’s Law
35
Knapp’s Law is a mathematical calculation that theorizes
whether contact lenses or spectacles are best for aniseikonia.
According to Knapp:
Use contact lenses for refractive aniseikonia
Use spectacles for axial aniseikonia
What is the flaw in Knapp’s Law?

09/23/20
 Failure of Knapp’s Law
Remember the three kinds of aniseikonia?
36

Knapp’s Law is mathematically true for optical aniseikonia only

Physiologic and neurologic aniseikonia were not taken into account
by Knapp
May be this is why contact lenses are ALWAYS better for
symptomatic aniseikonia clinically
For this reason, Knapp’s Law would better be called “Knapp’s
Suggestion”

09/23/20
 Prognosis for Aniseikonia
37

Patients with anisometropia and no aniseikonic symptoms

can be educated and monitored
Patients with large (double-digit) aniseikonia can often learn to
suppress or alternate fixations
It’s patients with moderate aniseikonia who are most symptomatic,
and whom we can help!

09/23/20
 Vertical imbalance
Mostly for reading and near task.38
Less problem on single vision glasses. Why?
Difficult on various focal lenses
E.g. OD: -7.00Ds and OS: -3:00Ds
What is the prismatic effect when patient look 1cm below OC?
What is the relative prismatic effect to left eye?

09/23/20
 Correction of vertical imbalance
39

Contact lenses
 No problem of vertical imbalance

 Two pair of glasses

 Single vision for near doesn’t correct vertical imbalance but avoid vertical
imbalance
Dropping major reference point
 Not the best to correct

Slab off

09/23/20
 Review Capsule
40
Amblyopia frequently occurs with neurologic aniseikonia

Strabimus frequently occurs with physiological aniseikonia

Up to 2D of aniseikonia can be easily treated with eyeglasses

More than 2D is best managed with contact lenses or refractive surgery, as corneal
thickness allows

09/23/20