Error of refraction

Emmetropia parallel rays come to focus on the retina when the eye at rest
(without accommodation)

Ametropia parallel rays are not focused on the retina when the eye at rest
(without accommodation)

 Types of refractory error

1- Myopia 2- Hypermetropia 3- Astigmatism
4- Aphakia 5- Anisometropia

Myopia Hypermetropia
((Nearsightness)) ((Farsightedness))
Definition parallel rays come to focus in front parallel rays come to focus behind
retina when the eye at rest (without retina when the eye at rest (without
accommodation) accommodation)

Etiology 1- Axial myopia (MCC) 1- Axial Hypermetropia(MCC)

Axial length is longer than average Axial length is smaller than average

2- Refractive myopia 2- Refractive Hypermetropia

If refractive elements are more If refractive elements are less refractive
refractive power than normal power than normal

A-Curvature myopia A-Curvature Hypermetropia

more curved cornea or lens less curved cornea (cornea plana), or
(Keratoconus, lenticonus, subluxation) lens

B- index myopia B- index Hypermetropia

increase of refractive index of lens increase of refractive index of lens
nucleus in senile nuclear cat. cortex in immature senile cortical cat.

3- Anterior dislocation of lens 3-Posterior dislocation of lens

& Aphakia

4-DM (Hyperglycemia) 4- dm (hypoglycemia)

Symptoms 1- Defective vision for far vision 1- Defective vision for near vision

2- Late presbyopia 2- Early presbyopia

3-In pathological myopia 3-Accommodative asthenopia
A- Vitreous floater, Photopsia (due to excess use of accommodation)
B- Defective night vision 4- Asymptomatic in mild case
C- Field defect (overcome by accommodation)

1 Facebook group::- 4th year(ophthalmology)2012-2013

 Signs 1- large globe 1- Small globe
large pupil, cornea, deep A/C, blue sclera, small pupil ,cornea,
Pseudoproptosis shallow A/C

2-Fundus
2-Fundus (VIM)
A- Retinal vessels :-
 1-RETINA tortuous
A-Tigroid (Tessellated) fundus B- Blurred disc margin
(Pseudopapillitis)
B- Myopic crescent
retraction of the retina & choroid from optic disc with
exposure of sclera (give white color) maybe:
-Temporal crescent (temporal to O.D)
-Annular crescent (surrounding O.D)

C- Choroido-retinal degeneration
-white atrophic area surrounded by pigmentation
-it's due to atrophy of retina & choroid showing sclera

D- Posterior staphyloma (temporal to o.d)

E- Lattice degeneration
found commonly in moderate myopes and usually
bilateral and most often located in the temporal and
superiorly, related to RD B/C transform to retinal tear
& hole

F- Lacquer cracks
are ruptures in the RPE-Bruch membrane complex
characterized clinically by fine, irregular, yellow lines,
may lead to Subretinal ‘coin’ hemorrhages

2-MACULA
A-Fuch's spot
black area at macula (due to subretinal hemorrhage)
which lead to loss of central vision

B- Macular hemorrhage

3-VITREOUS

A-Liquefaction & Vitreous floaters

Investigation Autorefractometry & Retinoscopy Autorefractometry

Retinoscopy

2 Facebook group::- 4th year(ophthalmology)2012-2013

Complication 1-Squint (divergent) 1- Squint (convergent)
2- PCAG
 Complication of pathological myopia
1- Primary RD
2- Macular hemorrhage, hole, degeneration
3- Vitreous floaters, liquefaction, PVD
4-Complicated cataract (posterior cortical)
5- POAG & pigmentay glaucoma

Treatment 1- Eye glasses 1- Eye glasses

Spherical concave (negative) lens Spherical Convex (plus) lens

2- Contact lens (soft contact lens) 2- Contact lens (soft contact lens)

3- Refractive surgery 3- Refractive surgery

A- Laser in-situ keratomileusis (LASIK).
B- Extraction of clear crystalline lens
C- Phakic intraocular lens
D- intraocular contact lens (ICL)

Astigmatism

Definition: - parallel rays do not come to point focus as the refractive power of
the eye is not the same in all meridians(without accommodation)

 Types

Regular Astigmatism Irregular astigmatism

Definition It's astigmatism in which It's astigmatism in which

1- Two principle meridians (highest & 1- Two principle meridians (highest &
lowest power) of the astigmatic system lowest power)of the astigmatic system
(cornea mainly) are at right angle (cornea mainly) are not at right angle

2- The change in power is gradual 2- The change in power is not gradual

symptoms Distorted object, uniocular Diplopia, Distorted object, uniocular Diplopia,

Accommodative asthenopia Accommodative asthenopia

Etiology 1- Corneal astigmatism: - 1- Corneal astigmatism: -

congenital, post-operative (after cataract Keratoconus, corneal opacity , pterygium
extraction, keratoplasty)

2- Lenticular astigmatism:- rare 2- Lenticular :- immature cataract

3 Facebook group::- 4th year(ophthalmology)2012-2013

Treatment 1- Eyeglasses (TTT under lying cause)
Cylindrical lens in simple astigmatism

Sphero- Cylindrical lens in compound &

Mixed astigmatism

2- Contact lens Hard contact lens

3-refractive surgery

Types of regular astigmatism

Depending upon position of the two principles meridian in relation to retina

1. Simple astigmatism

A- simple myopic astigmatism

In this type the rays are focused on the retina in one meridian and either in
front the retina in the other meridian.

B- simple hypermetropic astigmatism

where in the rays are focused on the retina in one meridian and either behind
the retina in the other meridian.

2. Compound astigmatism

A- compound myopic astigmatism

In this type the rays of light in both the meridia are focused in front the retina

B- compound hypermetropic astigmatism

In this type the rays of light in both the meridia are focused behind the retina

3. Mixed astigmatism
refers to a condition wherein the light rays in one meridian are focused in front
and in other meridian behind the retina Thus in one meridian eye is myopic
and in another hypermetropic

4 Facebook group::- 4th year(ophthalmology)2012-2013

 Anisometropia
Definition
It's difference in refractive power between the two eyes more than 4 diopter.

Etiology: congenital, acquired (unilateral Aphakia)

Symptoms: double vision.

Treatment:

Contact lenses and intraocular lens.

Anisometropia cannot be corrected with glasses because lead to aniseikonia.

Presbyopia
Def ::- It’s loss of accommodation comes with aging (Physiological)

Cause ::-Maybe due to lens sclerosis & decrease of elasticity of capsule

A person with emmetropic eyes (no refractive error) will begin to notice
inability to read small print or discriminate close objects at about age 44–46.
- Presbyopia come late in myopia after 46
- Presbyopia come early in Hypermetropia before 44

 Clinical feature Premature presbyopia

1- Difficulty in near work (Pathological presbyopia)
2- Patient hold book at greater distance 1- Anemia
2- POAG
3- Cycloplegic
 Treatment
Presbyopia is corrected by use of a plus (convex) lens

Aphakia (studied in LENS chapter)

TTT:-
Unilateral ::- IOL - C.L (C/I Glasses)>> due to (Anisometropia, Aniseikonia)
Bilateral ::- IOL - C.L – Glasses (convex)

IOL P/C = +20D IOL A/C = +18D Glasses = +10D

5 Facebook group::- 4th year(ophthalmology)2012-2013

 Laser in-situ keratomileusis (LASIK).
In this technique flap of anterior corneal tissue is raised.
After creating a corneal flap mid stromal tissue is ablated directly with an
excimer laser beam, at last flattening the cornea
Currently this procedure is refractive surgery of choice for myopia up to 12 D

Patient selection criteria are:

1- Patients above 20 years of age,
Befor any LASIK surgery we done
2- Stable refraction
3- Absence of corneal pathology. 1- Topography to exclude Keratoconus
2- Pachymetry to measure corneal thickness
Advantages of LASIK.
(i) Minimal or no post-operative pain.
(ii) Recovery of vision is very early
(iii) No risk of perforation during surgery or due to trauma

Disadvantages.
1. expensive.
2. requires greater surgical skill
3. Flap related complications
(i) intraoperative flap amputation,
(ii) wrinkling of the flap on repositioning,
(iii) postoperative flap dislocation/subluxation,

Extraction of clear crystalline lens

has been advocated for myopia of –16 to –18 D

Phakic intraocular lens(Artisan lens)

considered for correction of myopia of >12D. In this technique, a special type
of intraocular lens is implanted in the A/C

intraocular contact lens (ICL)

considered for correction of myopia of >12D. In this technique, a special type
of intraocular lens is implanted P/C anterior to crystalline lens.

How to differentiate between CONVEX & CONCAVE lens?

Convex lens (plus) (convergent) Concave lens (minus) (divergent)

Thick at center more than peripheral Thick at peripheral more than center
Objects appear larger Objects appear small
Objects looked at move in opposite direction Objects looked at move in same direction to
to movement of the lens movement of the lens

6 Facebook group::- 4th year(ophthalmology)2012-2013