REFRACTIVE ERRORS

EMMETROPIA
• State of refraction wherein the parallel rays of
light coming from infinity are focused at the
sensitive layerof retina with the accomodation
being at rest.
 AMETROPIA
a state of refraction wherein the parallel rays of
light coming from infinity (with accomodation
at rest) are focussed either in front or behnd
the sensitive layer of retina , in one or both
meridia.
It includes
Myopia
Hypermetropia
Astigmatism
 Components of ametropia
Refractive state of eye is determined by
• corneal power- 40 to 45D
• anterior chamber depth-mean 3.4mm
• crystalline lens power-15 to20D in its non
accomodative state
• axial length- mean 24mm
Refractive index of each component of eye as
an optical system
REFRACTING MEDIUM REFRACTIVE INDEX

AIR 1.000

TEAR FILM 1.357

CORNEA 1.376

AQUEOUS HUMOUR 1.336

LENS (CORTEX- CORE) 1.386 – 1.406

VITREOUS HUMOUR 1.336

 HYPER METROPIA
• Hypermetropia( hyperopia) or long
sightedness refers to the refractive state of the
eye wherein the parallel rays o f light
comingfrom infinity are focussed behind the
retina with accomodation being at rest
 Aetiological types
• Axial hypermetropia – reduced AP diameter
• Curvatural hypermetropia – flatter cornea or lens
• Index hypermetropia – change in RI of lens in old age
• Positional hypermetropia - posteriorly placed lens
• Absence of crystalline lens – congenital or trauma
• Consecutive hypermetropia – overcorrected myopia,
underpowered IOL
 Clinical types
• Congenital hypermetropia- unilateral, present since
birth
• Simple hypermetropia – axial or curvatural
• Pathological hypermetropia – seen in
microphthalmos, microcornea, congenital posterior
subluxation of lens, cong. aphakia
• Secondary hypermetropia(acquired)
- senile hypermetropia( curvatural, index),
positional,aphakia, consecutive, acquired axial,
aquired curvatural, functional
 symptoms
• Asymptomatic
• Asthenopic symptoms – headache, tiredness
of eyes, watering, mild photophobia
• Defective vision with asthenopic symptoms
• Defective vision only
• Intermittent sudden blurring of vision
• Crossed eye sensation – due to excessive
accomodation
 Signs
• Visual acuity- varies with degree of
hypermetropia and degree of refraction
• Size of eye ball- normal or small
• Cornea- slightly smaller or cornea plana
• Anterior chamber- shallow , angle- narrow
• Fundus- optic disc – small, reddish,
pseudopapillitis. BGR- shine. Vessels- tortuous
• A scan- short anteroposterior length of eyeball
 Grading of hypermetropia
• American optometric association has defined
three grades :
• low hypermetropia, ≤ +2D
• moderate hypermetropia, +2 to +5D
• high hypermetropia, ≥ +5D
 Complications
• Recurrent styes, blepharitis or chalazia
• Accomodative convergent squint – develop by
2-3yrs of age, due to excessive use of
accomodation
• Amblyopia
• Predisposition to develop PACG
 TREATMENT
1.OPTICAL TREATMENT:
Prescription of convex (plus) lenses-
spectacles, contact lenses.
2.SURGICAL TREATMENT:
conductive keratoplasty/ corneal refractive
therapy, laser thermal keratoplasty, hyperopic
LASIK or PRK, phacic IOLs, RLE.
3.VISUAL HYGIENE:
 MYOPIA
• Myopia or short sightedness-parallel rays of
light coing from infinity are focussed in front
of retina when accomodation is at rest.
 Aetiological types
• Axial myopia – increased AP diameter
• Curvatural myopia – increased curvature of
cornea or lens
• Positional myopia – anteriorly placed lens
• Index myopia – increased RI of lens associated
with nuclear sclerosis
• Myopia due to excessive accomodation
 Clinical types
• Congenital myopia
• Simple or developmental myopia
• Pathological or degenerative myopia
• Secondary myopia
 CONGENITAL MYOPIA
• Aetiology- associated with increase in axial length and
globe size. Frequently seen in children who were born
prematurely or with birth defects such as marfan
syndrome and homocystinuria
• Clinical features- unilateral, high degree of error, may be
associated withcongenital convergent squint, cataract,
microphthalmos, aniridia,megalo cornea, congenital
separation of retina
• Treatment- early diagnosis and full cycloplegic refractive
errorwith astigmatic correction to be prescribed
 SIMPLE MYOPIA
• Simple/ developmental/ physiological-
commonest variety
• Onset- school going age( 8 to 12)- school
myopia
• low myopia, ≤2D
• moderate myopia, 2 to 6 D
 Aetiology
• Axial
• Curvatural
• Role of genetics – autosomal dominant
• Role of diet
• Theory of excessive near work
 CLINICAL PICTURE
SYMPTOMS:
Poor vision for distance
Half shutting of eyes
Asthenopic symptoms
Change in psychological outlook
SIGNS:
predominant eyeballs
AC- deep
pupils- large
fundus- temporal myopic crescent
 PATHOLOGICAL MYOPIA
• Pathological/ degenerative/ progressive
• Starts in childhood at 5-10 years of age and
results in high myopia ( 7-6D) during early
adult life
• Usually associated with degenerative changes
in the eye
 CLINICAL PICTURE
SYMPTOMS:
defective vision
muscae volitantes and floating black
opacities- due to degenerated liquified
vitreous
night blindness
 signs
• Prominent eyeball
• Cornea- large
• Ac-deep
• Pupils- large, react suggishly to light
• Magnitude of error- may progress to 30-40D
• FUNDUS- pale,large optic disc with characteristic temporal
crescent
degenerative changes in choroid and retina-
tigroid fundus, forster-fuchs spot, cystoid degeneration,
lattice degeneration , snail track lesion, retinal tear,
hemorrhages, retinal detachment
 Cont...
• Posterior staphyloma
• Degenerative changes in vitreous-
liquefaction, vitreous opacities, posterior
vitreous detachment
• Visual fields- contraction, ring scotoma
 complications
• Retinal tears
• Retinal detachment
• Complicated cataract
• Nuclear sclerosis
• Vitreous hemorrhage
• Choroidal hemorrhageand thrombosis
• Primary open angle glaucoma
 SECONDARY MYOPIA
• CAUSES:
• Index myopia- nuclear sclerosis, incipient
cataract, diabetic myopia
• Curvatural myopia
• Positional myopia
• Consecutivemyopia- surgical overcorrection of
hypermetropia, pseudophakia with
overcorrecting IOLs
 Cont...
• Pseudomyopia – excessive accomodation
• Space myopia – when there is no stimulation
for distance fixation
• Night myopia or twilight myopia – increased
sensitivity to shorter wavelength of light
• Drug induced – cholinergic drugs such as
pilocarpine, echothiophate . Steroid induced.
Sulphonamides.
• Myopia of prematurity
 TREATMENT
• OPTICAL: prescription of appropriate concave (
minus) lenses
• PREVENTIVE MEASURES – prevent progress of
myopia. Atropine , pirenzipine 2 % gel
• VISUAL HYGIENE
• LOW VISION AIDS- useful in progressive
advanced degenerative changes
SURGICAL TREATMENT OF MYOPIA
• Methods to induce flattening of central
cornea:
• Excimer laser photorefractive keratotomy
• Excimer laser – assisted insitu keratomileusis
(LASIK)
• Laser assisted epithelial keratomileusis
(LASEK)
• Femtosecond laser assisted LASIK
 ASTIGMATISM
• Refraction varies in different meridia
• Rays of light entering the eye cannot converge
to a point focus but form the focal lines.
• Broadly 2 types of astigmatism: regular and
irregular
 REGULAR ASTIGMATISM
• When the refractive power changes uniformly
from one meridian to another( i.e. There are 2
principle meridia)
• Risk factors:
• family h/o
• preterm birth/ low birth weight
• advancing age
• corneal scarring due to injury
• Corneal thinning
• Pre existing myopia or hypermetropia
• Severe allergies resulting in constsnt rubbing
of eyes
• Diabetes
 Aetiological types
• Corneal astigmatism- most common, usually
congenital
• Lenticular astigmatism- curvatural, positional,
index
• Retinal astigmatism – due to oblique
placement of macula
 TYPES OF REGULAR ASTIGMATISM
Depending upon the axis and angle b/w the two principal
meridia:
1. With the rule astigmatism – vertical meridian is more
curved
2. Against the rule astigmatism – horizontal meridian is
more curved
3. Oblique astigmatism – two meridia are not horizontal
and vertical, but right angle to each other
4. Bi-oblique astigmatism- two meridia not at right angle
Refractive types of regular astigmatism
• Simple myopic astigmatism
• Simple hypermetropic astigmatism
• Compound astigmatism
• Mixed astigmatism

Symmetric astigmatism- principal meridia in

each eye have similar but opposite axes.
 Clinical features
• Blurring of vision
• Asthenopic symptoms
• Tilting of head
• Squinting
• Reading material may be held close to eyes
• Burning and itching
 Irregular astigmatism
• Irregular change of refractive power in
different meridia
• Aetiological types:
• corneal- extensive corneal scars or
keratoconus
• lenticular – variable RI in different parts of
crystalline lens
• retinal- macular area scarring
 Clinical features:
• Defective vision
• Distortion of objects
• Polyopia( seeing multiple images)
 Treatment
• Optical – contact lenses
• Phototherapeutic keratectomy with excimer
laser- useful in superficial corneal scar
• Surgical – penetrating keratoplasty- indicated
in extensive corneal scarring
SURGICAL INDUCED ASTIGMATISM
• Usually following cataract surgery
• Induced by incision or suture
• Caused by some degree of flattening of the
corneal meridian at right angle to the
direction of the incision
THANK YOU