‫بسن هللا الرحون الرحٍن‬

Level 5
Semester 9
Module (SS931)
Refractive
Errors
•Dr. Ahmed Raouf Amin El-Nafees
Lecturer of Ophthalmology
•Faculty of Medecine – Delta University
•E-mail: [email protected]
•Mobile: 01005290615
 ‫‪Mission and Vision of Faculty‬‬
‫رسالت الكلٍت‪:‬‬
‫تلتزم كلٍت الطب البشري – جاهعت الذلتا للعلوم والتكنولوجٍا بتقذٌن برناهج تعلٍوً تكاهلً هتوٍز ٌقوم‬
‫على الوھـارة والوعرفـت وٌھـذف الى تخرٌج أطبـاء قـادرٌن على الوفـاء بواجبـاتھن الوھنٍـت واألخالقٍـت‪،‬‬
‫والتعلٍن الطبً الوستور والوشاركت الفعالت فً البحث العلوً وخذهت الوجتوع‪.‬‬
‫رؤٌت الكلٍت‪:‬‬
‫تسعى كلٌة الطب البشري ‪ -‬جامعة الدلتا للعلوم والتكنولوجٌا من خالل تطبٌق برنامج التعلم القائم على‬
‫اكتســاب الجدارات أن تكون فً مقدمة المؤسسات الطبٌة التعلٌمٌة المتمٌزة على المستوى المحلً‬
‫والقومى والعالمً‪.‬‬
The normal eye is like a camera with 3 focusing elements:
a: The tear film
b: The cornea
c: The crystalline lens
with the retina acting as the receptive film.

Distant objects are focused by the eye as an inverted image on the retina which is re-inverted in the brain.
Emmetropia:
It is the normal optical condition of the eye → incident parallel rays of light from infinity come to a focus on the retina (fovea
centralis) with accommodation at rest.
There is no error of refraction. An emmetropic eye will have a clear image of a distant object without any internal
adjustment of its optics. The average power of a normal emmetropic eye is + 58 to + 60D & the axial length (AL) is 24mm.

Each image passes from the object of fixation (O)→ through the cornea
to → the fovea (F) in what is called the Visual axis

Through the visual axis is the nodal point (N) which is the optical center of
refraction & it is just behind the lens
There are two significant axes of the eye:

The optical axis (pupillary axis): imaginary straight line perpendicular to → the front of the cornea & extending
through → the pupillary center.

The visual axis (line of sight): imaginary straight line joining the fixation object and the fovea, passing through the
nodal point.

The (fovea) lies temporal to (where the pupillary axis intersects the posterior pole) so → a +ve angle is formed
between the two axes, which is called angle kappa

With change of the antero-posterior diameter of the eye:

The angle kappa ↓ with A-P diameter elongation (myopia) {goes to the –ve side}
↑ with shortening of A-P diameter (hypermetropia) {increase in the +ve side}
 Ammetropia
Ametropia is the state of refraction of in which parallel rays do not come to a focus on the retina (with accommodation
completely relaxed)

Types:
1. Myopia (M).
2. Hypermetropia (HM).
3. Astigmatism.
4. Anisometropia.
5. Aphakia.

Determination & Quantification of refractive errors (Refraction):

a. Manual retinoscopy: can be performed by using a plain mirror and a source of light or a retinoscope projects light directly
into the eye→ produce a red reflex (done after inducing cycloplegia by cyclopentolate in adults or atropine in children).
b. Automated refractometers: for rapidly determining objective refraction.
Etiology:
1. Axial ametropia: There is abnormal length of the eyeball.
Too long→ myopia
Too short→ hypermetropia.
2. Curvature ametropia: There is abnormal curvature of the refracting surfaces of the cornea or lens.
Too strong→ myopia
Too weak→ hypermetropia.
3. Index ametropia: There is abnormal refractive index of the cornea or the nucleus of the lens.
Too high→ myopia
Too low→ hypermetropia.
4. Abnormal position of the lens
Like anterior dislocation of the lens
causing myopia
 MYOPIA (Short Sight)
It is that dioptric condition of the eye in which with the accommodation at rest, incident parallel rays of light come to a focus
anterior to the retina. (most common refractive error worldwide)

It is basically a disturbance of growth on which degenerative changes are superimposed.

In axial myopia The part anterior to the equator is normal. The increase in AL affects the posterior pole.
Index myopia: refractive index of the nucleus in nuclear cataract
Curvature myopia: lens→ lenticonus
cornea→ keratoconus or corneal ectasia
Types:
Simple High or Degenerative Congenital
Onset 14-16 years 5-10 years At birth
Progression Till 20 years Continues after 20 Stationary
Degree ↓6D ↑10D Around 10D
Degenerative changes absent present absent
Symptoms:
1. Indistinct far vision.
2. Mid closure of eyelids to simulate a pinhole which increases the depth of focus.
3. Defective night vision (in progressive myopia).
4. Musca volitantes.

Signs:
1. Apparent convergent squint (-ve angle alpha) may be present.

2. Fundus examination: (in degenerative myopia)

i. Optic Disc: Temporal crescent: The retinal pigment epithelium fails to extend up to the temporal border of the disc. This leads
to exposure of choroidal pigment.
Posterior staphyloma: The sclera may bulge out at the posterior pole due to thinning.
ii. Macula:
Chorioretinal degeneration is often present.
Foster Fuch’s spots: These are dark pigmented circular areas following old choroidal HGEs.
iii. Peripheral Fundus:
Tesselated (tigroid) fundus may be present even in simple myopia.
Weiss ring may be seen due to posterior vitreous detachment.
Complications:
1. Vitreous degeneration (liquefaction), opacities and detachment are commonly seen.
2. Tear (BREAK) and hemorrhages occur in the retina due to chorioretinal degeneration.
3. Retinal detachment (rhegmatogenous) due to retinal break through which fluid seeps in, detaching the retina from its bed.
4. Complicated cataract (posterior cortical) is due to the disturbance to the nutrition of the lens.
5. High myopia is sometimes associated with chronic simple glaucoma.
6. Consecutive optic atrophy.
Management:
1. Spectacles→ prescribing suitable correcting spherical concave lenses.
2. Contact Lenses: minus (concave) lenses are obtained through entering
the obtained refraction in a special conversion table
3. Operative:
1) Radial keratotomy: Multiple peripheral cuts are made in the cornea in
order to flatten the increased curvature of the cornea.
2) Photorefractive keratectomy (PRK)
Excimer laser: It reshapes & flattens the central part of the cornea
3) LASIK (Laser-assisted in situ keratomileusis)
It corrects myopia of –0.5D to –9.00D (according to recent guidelines)
4) Femtolaser (lasik & smile): allows surgeons to treat patients with thinner
corneas and prescriptions higher than -10.0 D.
5) Phakic IOL or clear lens extraction or exchange:
for very high myopia.
 Hypermetropia (Far Sight)
It is that dioptric condition of the eye in which with the accommodation at rest the incident parallel rays of light come to a
focus posterior to the light sensitive layer of the retina.
Most newborns are hypermetropic at birth (about +2D) & this hypermetropia vanishes with eye growth.

Etiology:
1. Axial hypermetropia: Due to decrease of the axial length the eye.
2. Index hypermetropia: Due to decrease of refractive index of the cornea or nucleus of the lens.
3. Curvature hypermetropia: Due to decreased curvature of the cornea or lens.
4. Abnormal position of the lens: e.g. Posterior dislocation of the lens.
5. Aphakia.

Symptoms:
(These are noticed specially in the evenings after close work)
1. There is blurring of vision for near work.
2. There may be frontal headache and eye strain (asthenopia).
3. Early presbyopia
Signs:
1. There is typical small eye as a whole. It is prone to cause primary closed angle glaucoma due to the shallow anterior chamber
and narrow angle.
2. Accommodative convergent squint may be present (esophoria or esotropia).
3. Apparent divergent squint with high hypermetropia (high +ve angle alpha).

Management:
1. Glasses: Using convex spherical (plus) lenses.
2. Contact lenses: Less tolerated than in myopia.
3. Refractive surgery (LASIK): Is less satisfactory than in myopia.
Definition:
Astigmatism
Astigmatism (a=not; stigma=point) is the error of refraction in which, with accommodation completely relaxed, parallel rays
come to many foci at different distances from the retina not to a fixed point. Astigmatism occurs when either the front surface
of the eye (cornea) or the lens inside the eye has mismatched curves→ the eye has different refractive powers in different
meridians.
Etiology:
Corneal astigmatism: is the most common and is usually congenital. It may be induced by surgical or traumatic scars. It may also
occur due to ectatic diseases of the cornea such as keratoconus.
Lenticular astigmatism: as in subluxation of the crystalline lens or tilted IOL.
 Classifications of Astigmatism
(Regular or Irregular), (with or against the rule), & (simple, compound, & mixed)

a) Regular: When strongest meridian and the weakest meridians are perpendicular and the meridians in between are
regularly arranged.

b) Irregular: When strongest meridian and the weakest meridians are not perpendicular and the meridians in between are
irregularly arranged. It occurs in keratoconus and corneal scars.

a) With the rule: The vertical meridian → more curved

b) Against the rule: The horizontal meridian ↗

a) Simple:
One meridian is emmetropic and the other is ametropic, i.e. simple myopic or simple hypermetropic astigmatism.
b) Compound:
Both meridians are ametropic but of the same type, i.e. compound myopic or compound hypermetropic astigmatism.
c) Mixed:
One meridian is myopic and the other is hypermetropic.

The rule is the ↑ curvature of the vertical meridian →thought to be d.t pressure of the lids on the cornea
Symptoms:
1. Blurring of vision.
2. Accommodative asthenopia.
3. The letters in the book appear to be “running together”.

Signs:
1. The patient reads some types on the visual acuity charts and cannot read other types on the same line.
2. Refraction
3. Special tools as placido disc keratoscope & corneal topography.
Correction of Regular Astigmatism:
1. Glasses using cylindrical lenses.
2. Soft toric contact lenses.
3. Refractive surgery: LASIK (less satisfactory than in myopia).

Correction of Irregular Astigmatism:

1. Rigid gas permeable (RGP) contact lens→ These stable contact lenses essentially act as a second surface for the eye,
compensating for the irregularities of the cornea and functioning as the eye's new reflective surface

2. Keratoplasty is the end-stage treatment

 Anisometropia
Definition: Anisometropia (an=not, iso=equal) is a difference of ˃1D in refraction between the two eyes. Patients may have up
to 3D of anisometropia before the condition becomes clinically significant due to headache, eye strain, double vision or
photophobia
Types
1.Dating since birth
2. Acquired → in cases of aphakia or asymmetrical keratoconus

Symptoms:
1. Asthenopia.
2. Diplopia on wearing full power correcting glasses.

Correction of anisometropia:
1. Glasses can be used with under correcting the eye with a higher error at the expense of good vision to avoid anisekonia
(usually a maximum of 4D difference can be tolerated).

2. Contact lenses reduce the difference in retinal image size to about 6%.

3. Refractive surgery: LASIK or IOL implantation produces a difference of less than 1% (most convinient)
Definition: Asthenopia (eye strain)
A group of symptoms noticed with fine visual tasks as close work, especially in artificial illumination conditions.
Symptoms:
1. Headache and eye ache.
2. Burning sensation and frequent blinking.
3. Lacrimation.
4. Hyperemia of the conjunctiva and lid margin.
5. Recurrent styes, chalasia and blepharitis.
Causes:
A. Accommodative asthenopia:
1. Hypermetropia.
2. Astigmatism.
3. Presbyopia.
4. Anisometropia.
B. Muscular asthenopia:
Due to heterophoria (latent squint).
C. Nervous asthenopia:
Due to vitamin deficiency and liver diseases.
Definition:
Presbyopia
Presbyopia is difficulty in near vision due to progressive weakness of accommodation with aging (after the age of 40)
Mechanism:
1. Crystalline lens fibers → sclerosed with age.
2. Ciliary muscle →weaker with age.
Symptoms:
1. Difficult near vision around the age of 40 in a previously emmetropic eye.
earlier in hypermetropic patients.
later in myopic patients.
2. Accommodative asthenopia.
Correction of presbyopia:
1. Glasses:
*A pair of glasses (Plus lenses added to the far correction).
* Bifocal & Multifocal glasses.
2. Accommodative Intra-Ocular Lenses:
May be used during cataract extraction.
3. Multifocal Intra-Ocular Lenses:
May be used during cataract extraction.
 Contact Lenses
Principle: contact lens rest on the corneal surface→ changes the power of the anterior corneal surface

Types:
1. Hard lens (historical)
It consists of PMMA (Polymethyl methacrylate) a plastic, non-toxic material.
Advantage: It is durable, firm and inert.
Disadvantage: a. The corneal hypoxia leads to corneal oedema.
b. It may cause foreign body sensation.

2. Soft lens
It consists of HEMA (hydroxyethyl methacrylate) or related polymer and is hydrophilic in nature.
Advantage: It is comfortable and stable.
Disadvantage: It is delicate and has a short lifespan.

3. Gas permeable lens (the new hard lens)

It consists of mixture of hard and soft material, e.g. CAB (cellulose acetate butyrate), silicone, silicone with PMMA.
Advantage: It causes minimum corneal hypoxia.
Disadvantage: It tends to scratch and break.
Indications:
They are mainly refractive, therapeutic, occupational and cosmetic.
1. Refractive
i. In bilateral errors of refraction→ patient not accepting glasses or glasses lenses are too thick or heavy in high errors.
ii. Unilateral high errors (aphakia, myopia) →It prevents diplopia as there is no retinal image magnification.
iii. Regular astigmatism→ toric CL
iv. Irregular astigmatism or Keratoconus → RGP provides regular corneal surface and mechanical support.
2. Therapeutic
i. It has epithelial healing effect, e.g. as in corneal ulcers, filamentary keratitis.
ii. It is used as a vehicle for drug delivery, e.g. soft hydrophilic lens.
iii. It prevents symblepharon formation, e.g. as in chemical burn.
iv. It encourages natural healing process, e.g. as in descemetocele and wound leaks.
3. Occupational
In athletes—There is less chances of serious injury, better optics and wider field.
4. Cosmetic
a. Colored CL
b. Cosmetic CL for anirdia
c. Cosmetic CL for corneal opacity
Advantages:
1. The size of the retinal image is near to normal.
2. The field of vision is larger than spectacles as it moves with the eye and not restricted with a frame.
3. No spherical or chromatic aberrations.
4. Cosmetic.

Disadvantages:
1. Special care is required for its cleanliness and storage.
2. Some people do not tolerate them (foreign body sensation) and others develop allergy to contact lens solutions.
3. Traumatic corneal abrasions may occur during manipulation.
4. Infection is always a risk with bad hygiene or lens contamination (acanthamoeba keratitis → catastrophic)
5. Economic burden in poor patients

Complications:
1. Conjunctiva: Allergic (giant papillary) or infective conjunctivitis may occur occasionally.

2. Cornea: Corneal epithelial edema → due to corneal hypoxia.

Vascularization →due to hypoxia or infection.
Ulcer →due to improper hygiene and infection by a high virulent organism (Remember Acanthamoeba).