6 Errors of Refraction

AMETROPIA • Types • Clinical Features

MYOPIA • Clinical Features • Treatment
• Etiology • Treatment ANISOMETROPIA
• Types • Treatment
• Clinical Features ASTIGMATISM
• Treatment • Etiology ASTHENOPIA
HYPEROPIA (HYPERMETROPIA) • Types • Treatment
• Etiology

O VERVIEW (cornea, aqueous and lens) and decrease in the index

of vitreous result in myopia, while the opposite
This chapter will: conditions lead to hyperopia.
• Describe different errors of refraction 4. Abnormal position of the lens—a forward displacement
• Discuss various causes of ametropia of the lens leads to myopia and backward displacement
• Describe myopia, hyperopia, astigmatism, anisometropia to hyperopia.
and asthenopia. There are three types of errors of refraction:
i. Myopia or short-sightedness
When parallel rays of light from infinity come to a focus ii. Hyperopia or long-sightedness, and
on the retina with accommodation at rest, the condition is iii. Astigmatism.
called emmetropia (Fig. 6.1). Conversely, when the parallel
rays of light from infinity do not come to a focus upon the
retina with accommodation at rest, it is known as ametropia.

Ametropia
Ametropia may be due to following causes:
1. Abnormal length of the eyeball—axial ametropia wherein
too long and too short lengths of the globe result in
myopia and hyperopia, respectively. Perhaps, the
change in the axial length of the globe is the most
important cause of ametropia.
2. Abnormal curvature of the cornea or the lens—curvature
ametropia wherein too much and too less curvatures
cause myopia and hyperopia, respectively.
3. Abnormal refractive indices of the media—index ametropia
wherein increase in the indices of the refractive media Fig. 6.1: Emmetropia
30 Textbook of Ophthalmology

Myopia developmental myopia is stationary and progression is

quite rare.
Myopia is that diopteric condition of the eye in which
parallel rays of light from infinity come to a focus in front Simple Myopia
of the retina when accommodation is at rest (Fig. 6.2). Simple myopia is the most common type of myopia which
progresses during childhood and adolescence and seldom
Etiology exceeds 5 to 6 D. It generally stops to progress by the age of
21 years and the best corrected visual acuity is always
At birth most eyes are small and hyperopic, but as the normal (6/6). The fundus may show myopic crescent at
growth proceeds they increase in size (to reach the normal the temporal margin of the disk, tigroid fundus and lattice
adult size of 24 mm) and become emmetropic. degeneration with or without a retinal break.
1. Axial myopia results if the lengthening of the eyeball Transient and acquired myopia may be found following
continues; 1 mm increase in axial length leads to 3 D of trauma to ocular structures, intraocular lens implantation
myopia. (over-correction of aphakia), administration of certain
2. Curvature myopia commonly occurs due to an drugs (acetazolamide, oral contraceptives, tetracycline,
abnormal curvature of the cornea as seen in sulfonamides, etc.) and spasm of accommodation
keratoconus. (pseudomyopia).
3. Lenticonus (0.1 mm = 3D) occurs due to increased
curvature of the lens; it is less frequent. Pathological Myopia
4. Index myopia is found in old age due to senile nuclear
Pathological myopia is essentially a degenerative and
sclerosis.
progressive condition which manifests in early childhood.
The refractive error rapidly increases during the period of
Types active growth and may reach 20 to 30 D by the age of 25
Clinically, myopia may be classified as below: years. The condition has a strong hereditary tendency and
1. Development myopia is more common in women than in men. Autosomal
2. Simple myopia dominant pathological myopia has been linked to genes
3. Pathological myopia. 18p11.31 and 12q2123. The elongation of eyeball occurs
primarily due to degeneration of the posterior half of sclera
Developmental Myopia and is often accompanied with an outward scleral bulge
at the posterior pole—posterior staphyloma.
Developmental myopia is rare and characterized by A myopic eye has its punctum remotum between infinity
an abnormally long eyeball at birth having a refractive and the eye and it accommodates less than emmetropic
error of 10 D. The fundus shows marked choroidal and hyperopic eyes.
sclerosis, hypopigmentation and myopic crescent. The
Clinical Features
The inability to see distant objects clearly and holding the
book too close to the eye while reading are the usual
complaints of parents of the child having simple myopia.
Eyestrain and headache may occur due to an imbalance
between accommodation and convergence in myopia.
Sometimes, the patient sees black spots floating before the
eyes and occasionally flashes of light are noticed.
In pathological myopia, the eyes are unusually
prominent with slightly dilated pupils. There may be an
apparent convergent squint due to a large negative angle
kappa. In spite of the optical correction, the vision is poor.
The blind spot is enlarged and peripheral visual field is
generally constricted.
Ophthalmoscopy may reveal vitreous degeneration
Fig. 6.2: Myopia and opacities, a big optic disk with myopic crescent and
 Errors of Refraction 31

nasal supertraction due to extension of retina on the nasal Hence, the glasses must be worn constantly. In high
side of the disk. The crescent may run all around the disk myopia, the patient often sees best with under-correction
in an annular ring (Fig. 6.3). Besides, there are chorioretinal as strong concave lenses considerably diminish the size
atrophic patches at the posterior pole as well as in the of retinal image. Sometimes, very bright and clear images
periphery of the fundus. Choroidal sclerosis and Foster- are not tolerated by the patient whose retina has become
Fuchs spot at macula due to choroidal hemorrhage may accustomed to large and blurred images.
be found. A highly myopic eye is prone to develop retinal In high myopia, the normal relationship between
hemorrhage due to complicated posterior vitreous accommodation and convergence is disturbed and if the
detachment, and lattice degeneration with retinal holes glasses are not constantly used, the effort to converge is
and/or tears leading to detachment of retina, and practically abandoned. Thus, the patient uses only one
complicated cataract. eye for near work and the other eye become divergent due
to disuse.
Treatment
Contact Lenses
Optical Lenses Contact lenses are very helpful in many cases of high
The treatment of myopia comprises prescribing myopia. They also eliminate the peripheral distortion
appropriate concave lenses (Fig. 6.4) and paying attention caused by thick concave lenses. At the same time, a minus-
to ocular hygiene. Generally, the myopia should never be edge lenticular design of contact lens decreases the
over-corrected and in practice high myopia is almost discomfort caused by the thickened skirt.
always slightly under-corrected.
Simple myopia up to 6 D may be fully corrected and General Health
the patient is advised to do near work at ordinary reading The general health of a myopic child should always be
distance. If any discomfort is experienced, weaker glasses attended to. Nutritious diet, outdoor activities and regular
may be ordered for near work. exercises should be encouraged. The individual should
The children with uncorrected myopia may lose be advised to do near work in good illumination and
interest in their surroundings owing to blurred vision. continuous reading, particularly at night hours, be
discouraged. Should the patient be ill, all near-sighted
work should be stopped otherwise myopia increases
rapidly. High myopes with progressive degeneration of
the retina should be asked to avoid contact sports or
activities as they increase the risk of blunt ocular trauma
and concurrent retinal detachment.

Low Vision Aid

In pathological myopia, glasses or contact lenses seldom
improve the vision to normal as degenerative changes affect
the retina. Low vision aid may be of some help to the
patient, particularly in reading. There is no treatment to
stop the increase in axial length of the eyeball and arrest
Fig. 6.3: Myopic crescent with chorioretinal degeneration
the progression of pathological myopia. As these patients
invariably develop retinal and macular complications,
routine monitoring for retinal break and choroidal
neovascular membrane formation is required. The only
viable refractive surgery in these cases is either clear lens
extraction or phakic intraocular lens implantation.

Genetic Counseling
Fig. 6.4: Myopic eye: parallel rays are brought to a focus on Genetic counseling may stop hereditary propagation of
the retina by an appropriate concave lens the disease in the family.
32 Textbook of Ophthalmology

Fig. 6.5: Radial keratotomy Fig. 6.6: LASIK: The corneal stroma is ablated by excimer
laser after formation and retraction of corneal flap

Surgical Correction of Myopia 4. Phakic lens implantation involves the placement of

• Radial keratotomy (RK) an anterior chamber lens in a phakic eye. It is a
• Photorefractive keratectomy (PRK) satisfactory procedure to correct high degree of
myopia.
• Intracorneal rings (ICR) or corneal inlays for mild to
5. Removal of crystalline lens corrects high axial myopia
moderate degree of myopia (1-6 D)
of about 21 D. The surgery is not free from
• Laser-assisted in situ keratomileusis (LASIK) for
complications like retinal detachment.
correction of myopia between 1 and 9 D
• Phakic lens implantation
• Refractive lens exchange. Hyperopia (Hypermetropia)
1. Radial keratotomy (RK) corrects the myopia in the
range of 2 to 6 D. In this technique, a central corneal Hyperopia is an error of refraction wherein parallel rays
optical zone (3-4 mm) is spared and 8 or 16 radial of light from infinity come to a focus behind the retina
corneal incisions are placed (Fig. 6.5). Lack of when accommodation is at rest (Fig. 6.7). Like myopia,
predictability of results and glare are its drawbacks. hyperopia may be axial, curvature and index.
With the introduction of better corrective refractive
surgery, radial keratotomy is rarely performed Etiology
nowadays. 1. Axial hyperopia: If the anteroposterior length of the globe
2. Photorefractive keratectomy (PRK) ablates the central is shorter than the normal, it results in axial hyperopia.
anterior corneal stroma with the help of an excimer Hyperopic eye is usually smaller in all dimensions
laser (193 nm) to reduce the corneal curvature. than the normal eye; 1 mm shortening of the eye leads
Corneal haze and glare may occur as complications. to 3 D of refractive error. Almost all eyes at birth are
3. Laser-in-situ keratomileusis (LASIK) is an effective hyperopic and with the growth of the body their
surgical technique for the correction of myopia anteroposterior diameter increases and reaches normal
between 1 and 9 D. A hinged corneal flap is length in adolescence. If an eye remains under-
prepared by using a microkeratome or femtosecond developed, hyperopia is often found.
laser. The laser refractive keratectomy (within the 2. Curvature hyperopia: If the curvature of the cornea or
corneal stroma) is performed using an excimer laser lens is flatter than normal, curvature hyperopia occurs.
after retraction of the flap (Fig. 6.6). Finally, the flap Astigmatism is usually accompanied with curvature
is replaced (see video). hyperopia.
 Errors of Refraction 33

corrects by his accommodation, the facultative hyperopia. It

is determined by the difference between the strongest and
the weakest convex lens, while the strongest convex lens
is the measure of manifest hyperopia. Topical cycloplegic is
used to paralyze the ciliary muscle. Thereafter, the
strongest convex lens is placed with which maximum
visual acuity can be obtained. It represents the total
hyperopia. The amount of latent hyperopia can be worked
out by subtracting the manifest hyperopia from the total
hyperopia.

Clinical Features
Low degree of hyperopia may not cause any symptoms in
young individuals as they have ample reserve of
accommodation. However, symptoms may appear with
the decline of accommodation in later life. In high
Fig. 6.7: Hyperopia hyperopia, the available accommodation may not
adequately cope with the error; hence, blurring of vision
3. Index hyperopia: A decrease in the refractive index of may occur for distance as well as for near. Symptoms are
the lens, as found in cortical cataract, accounts for index often aggravated by long continued close work or reading.
hyperopia. Headache is a common sequel to the excessive
4. Posterior dislocation of lens: A backward dislocation of accommodation needed for near work. The overaction of
the lens produces hyperopia. ciliary muscle is likely to produce eyestrain. The condition
5. Aphakia (absence of the lens) is an example of a high is known as accommodative asthenopia. Heaviness of the
degree of hyperopia. lids, dull pain in the eye and congestion of the eye are the
other symptoms. Young hyperopes are prone to develop
Types latent convergent squint, which further increases the
eyestrain. In general, presbyopia commences at an early
Accommodation has a considerable influence on age than usual in hyperopes. A hyperopic eye is usually
hyperopia. Depending upon the act of accommodation, smaller than the normal, particularly in the axial length.
total hyperopia may be divided into following types: The diameter of the cornea is reduced and the anterior
1. Latent hyperopia; which is corrected by the physiological chamber is often more shallow than usual. Such an eye is
tone of the ciliary muscle. predisposed to angle-closure glaucoma. A bright reflex
2. Manifest hyperopia; which has two components: resembling a watered-silk or shot-silk appearance may be
a. Facultative hyperopia is that part of the error which found in hyperopia on funduscopy. Occasionally, the
can be corrected by an effort of accommodation. margin of the disk may be seen blurred, pseudopapillitis,
b. Absolute hyperopia which cannot be overcome by and the blood vessels may be unduly tortuous.
either accommodation or ciliary tone.
Clinically, the types of hyperopia can be assessed.
Treatment
Generally, a hyperope cannot see a distant object clearly
unless he accommodates. If convex lenses of gradually Optical Lenses
increasing strength are placed in front of the patient’s eyes
until he just sees the object clearly with the weakest convex Hyperopia with asthenopia is corrected by prescribing
lens (convex lens and accommodation both acting to convex lenses (Fig. 6.8). In young children with hyperopia,
provide a clear vision), the amount of hyperopia corrected examination should be conducted under a cycloplegic.
by the lens (not corrected by the effort of accommodation) One diopter is additionally deducted from the retinoscopy
is the absolute hyperopia. Now place convex lenses of to allow for the ciliary tone and the prescribed glasses
gradually increasing strength until the clear vision is still must be used constantly. In these children, hyperopia tends
maintained with the strongest convex lens. This process to diminish with growing age hence, they must be
measures the amount of hyperopia which the patient examined once a year for a possible change in their glasses.
34 Textbook of Ophthalmology

Fig. 6.8: Hyperopic eye: parallel rays are brought to a focus Fig. 6.9: Keratoplasty tip is inserted at the marked spots
on the retina by an appropriate convex lens (Courtesy: Dr Ted T Du)

In young patients with active accommodation, hyperopia 4. Conductive keratoplasty: It is a nonlaser procedure that
should be undercorrected but in advanced age, when all involves neither cutting nor removal of tissue. It does
the manifest hyperopia becomes absolute and not cause pain and dry eye postoperatively. It is
accommodation is poor, a full correction is advised. recommended for the treatment of mild to moderate
hyperopia between +0.75 D and +3 D and also for the
Contact Lenses correction of presbyopia. Conductive keratoplasty is
Contact lenses are often prescribed in unilateral hyperopia preferred over LASIK and PRK due to its better safety
(anisometropia) to avoid diplopia or subsequent margin.
amblyopia. Conductive keratoplasty is a minimally invasive
hyperopic procedure that delivers high-frequency, low-
Surgical Correction of Hyperopia energy electrical current to a depth of 500 μm in
peripheral corneal tissue. When the temperature
In prelaser era, thermokeratoplasty, hexagonal keratotomy
reaches 65°C, collagen fibers shrink, flattens the
and epikeratophakia were used to correct hyperopia. These
peripheral cornea and therefore, steepens the central
operative procedures were either difficult to perform,
cornea. The keratoplasty tip (Fig. 6.9) is inserted in a
unpredictable, unstable or caused irregular astigmatism.
circular fashion at 6 mm, 7 mm or 8 mm zone in a spot-
Therefore, these procedures are no longer in clinical
practice. The new methods to correct hyperopia include: by-spot manner, determined by normogram. Extra
1. Laser thermal keratoplasty (LTK): It involves the use of spots can be added to the flat meridian in order to
holmium laser to reshape the cornea for correction of correct astigmatism.
hyperopia. The holmium laser is an infrared laser that 5. Intraocular lens (IOL) implantation: It is the most popular
shrinks the corneal stromal collagen fibers. and safe method for correction of aphakic
2. LASIK: It produces steepening of the central cornea and hypermetropia. Primary IOL implantation is done at
is a surgical procedure for hyperopia up to 4 D. Mid the same time after the removal of cataract. Suitable
peripheral ablation is performed under a corneal flap cases of aphakia can be managed by secondary lens
to achieve a refractive correction that may be more stable implantation.
and predictable than that obtained by PRK or LTK. 6. Keratophakia: It is a procedure in which a donor corneal
3. Refractive lensectomy: Hyperopic patients are the best lenticule is placed in to intralamellar pocket fashioned
candidates for refractive lensectomy because the risk in the corneal stroma. Currently, a new lens called
of retinal detachment in them is not significant and Perma vision lens, made of permeable hydrogel
keratorefractive procedures are not still producing substance, is under clinical trial for correction of
consistently good results. hypermetropia from 1 to 6 D.
 Errors of Refraction 35

the vertical. The most common cause of astigmatism

against-the-rule is cataract surgery from superior corneal,
limbal or corneoscleral section in which the vertical
meridian flattens due to the scarring.
Broadly speaking, astigmatism is divided into two
categories—regular and irregular. When the two principal
meridians of greatest and least curvature are at right angles
to each other, the condition is called regular astigmatism.
Occasionally, the axes are not at right angles but are crossed
obliquely; this condition is known as bioblique astigmatism.
If the two meridians do not lie in the principal planes (that
is near to 90° or 180°), but remain at right angles to each
other, this type of regular astigmatism is termed as oblique
astigmatism.

Fig. 6.10: Astigmatism Regular Astigmatism

Regular astigmatism may be classified into the following
7. Phakic intraocular lenses: Phakic intraocular lens (PIOL) types:
implantation has given good results in correction of 1. Simple astigmatism, where one of the principal
hyperopia and it has overcome some of the problems meridians is emmetropic and the other is either
associated with refractive corneal surgery. Three hyperopic or myopic. The former is known as simple
currently available PIOL designs are angle supported, hyperopic and the latter simple myopic astigmatism.
iris supported and lens placed in the posterior chamber 2. Compound astigmatism, where both the principal
in front of the crystalline lens. Phakic intraocular lens meridians are either hyperopic or myopic, the former
surgery shares complications common to routine is known as compound hyperopic and the latter compound
cataract surgery. myopic astigmatism.
3. Mixed astigmatism, where one of the principal meridians
is hyperopic and the other myopic.
Astigmatism
Clinical Features
Astigmatism is that condition wherein the refraction varies
in different meridians of the eye. Hence, a point focus Generally, small astigmatic errors do not give any ocular
cannot be formed upon the retina (Fig. 6.10). discomfort. However, severe symptoms are found in cases
of hyperopic astigmatism wherein the accommodation is
Etiology brought into play to overcome hyperopia. Higher degrees
of astigmatism often cause poor visual acuity but vision is
Astigmatism is most commonly caused by abnormalities not much impaired in mixed astigmatism as the circle of
in the curvature of the cornea (curvature astigmatism). least confusion falls upon or near the retina. The
Abnormalities in the curvature or centering of the lens can continuous strain of accommodation may cause symptoms
also cause astigmatism. A small amount of astigmatism of asthenopia. The optic disk appears oval or blurred in
occurs due to inequalities in the refractive index of different one sector in astigmatism on direct ophthalmoscopy.
sectors of the lens (index astigmatism). An astigmatic fan, consisting of horizontal and vertical
lines, may help to detect the regular astigmatism. The
Types patient sees distinct lines of the fan in one direction (vertical
or horizontal) and they appear tailed off or blurred in the
Theoretically, no eye is stigmatic as the vertical curvature
other direction.
of the cornea is greater than the horizontal by about 0.25 D
owing to the pressure of the upper lid upon the eye. This is
Irregular Astigmatism
accepted as physiological and termed as astigmatism with-
the-rule. When the curvature and refractive power of the refractive
As age advances, astigmatism with-the-rule tends to media are markedly irregular leading to multiple focal
disappear or even gets reversed to astigmatism against-the- points, that produce completely blurred images on the
rule wherein the horizontal curvature becomes greater than retina, such a condition is called irregular astigmatism.
36 Textbook of Ophthalmology

The irregular astigmatism is caused by corneal scar,

penetrating injuries of the eye, keratoconus, lenticonus and
immature cataract. The patient with irregular astigmatism
often suffers from distorted vision and headache.

Treatment
Optical Lenses
A small degree of astigmatic error may not require any
optical correction. But in all such cases, if the error causes
asthenopic symptoms, a full optical correction by
cylindrical lenses should be advised for constant use. All
forms of regular astigmatism can be corrected by
cylindrical lenses or spherocylindrical combinations. In
contrast, irregular astigmatism cannot be corrected by
spectacle lenses due to irregularities in the curvature of
meridians.

Contact Lenses
The visual acuity does not improve in cases of irregular
astigmatism with spectacle correction; here toric contact Fig. 6.11: Acrysoft toric IOL
lenses are of immense value. Soft or rigid gas permeable
toric lenses are prescribed.
5. Conductive keratoplasty: When conductive keratoplasty
Surgical Correction of Astigmatism is used to correct astigmatism, the spots are applied to
the flatter meridian to induce steepening.
Moderate to large degrees of astigmatism can be managed 6. Corneal transplantation: Penetrating keratoplasty may
by surgical correction. Astigmatic keratotomy, relaxing be required to manage patients with irregular
incisions in the cornea or limbal relaxing incisions can astigmatism, corneal scarring and ectasia.
correct moderate degree of astigmatism.
1. Photoastigmatic keratectomy: Astigmatism can be
corrected with excimer laser by performing an elliptical Anisometropia
ablation to flatten the steeper meridian.
2. Incisional correction of astigmatism: Transverse Anisometropia is that condition wherein there is relative
keratotomy, arcuate keratotomy and limbal relaxing difference in the refractive status of the two eyes. It is
incisions have been used to correct astigmatism. In significant when the difference between the refraction of
these surgical procedures, a diametrically opposite the two eyes exceeds 2.5 D. A minor difference of
linear incision is made in the steep corneal meridian to refraction between the two eyes is not uncommon and it
flatten it. In all these techniques, the closer the incision seldom gives any symptom. Binocular vision is usually
to the center of the cornea, the greater the correction of maintained if the difference between the two eyes does not
astigmatism. However, the technique has been replaced exceed 2.5 D. In some cases, when one eye is emmetropic
by LASIK and PRK. or moderately hyperopic and the other is myopic, the
3. Toric intraocular lenses (Fig. 6.11): They can correct patient falls into the habit of using emmetropic or hyperopic
astigmatism and are currently quite popular. eye for distant vision and the myopic for near work. The
4. LASIK: Toric LASIK ablations are used to correct simple binocularity is disrupted in high degrees of error, as the
or compound astigmatism. The overall results of LASIK patient tends to suppress the image in the more ametropic
are not predictable as the procedure often under eye. It ultimately leads to amblyopia ex-anopsia (amblyopia
corrects the cylinder. It is reported that wavefront due to disuse). High degree unilateral myopia, hyperopia
guided laser ablation may correct refractive error up to and uniocular aphakia are important causes of
7 D sphere and 3 D cylinder. anisometropia.
 Errors of Refraction 37

Treatment Key Features

Anisometropia must be corrected in childhood to prevent • Emmetropia is when parallel rays of light from infinity
the development of amblyopia ex-anopsia. The optical come to a focus on the retina with accommodation at
correction is not readily acceptable to the child due to rest
difference in the size of the retinal images (aniseikonia) in • Ametropia is when the parallel rays of light from infinity
the emmetropic and the corrected eye. The use of contact do not come to a focus upon the retina with accomm-
lens eliminates this defect. If the eye has become amblyopic, odation at rest
the emmetropic eye is patched and the patient is • Myopia is that diopteric condition of the eye in which
encouraged to use the ametropic eye with optical correction. parallel rays of light from infinity come to a focus in front
Later, orthoptic exercises should be given to develop of the retina when accommodation is at rest
• Hyperopia is an error of refraction wherein parallel rays
binocularity. Laser in situ keratomileusis has been tried
of light from infinity come to a focus behind the retina
with satisfactory results in cases of anisometropia. when accommodation is at rest
• Astigmatism is that condition wherein the refraction
Asthenopia •
varies in different meridians of the eye
Anisometropia is that condition wherein there is relative
Asthenopia is characterized by ocular or periocular difference in the refractive status of the two eyes
discomfort, heaviness of eyelids, sleepiness, tired eyes, • Asthenopia is characterized by ocular or periocular
discomfort, heaviness of eyelids, sleepiness, tired eyes,
brow ache and headache associated with prolonged ocular
brow ache and headache associated with prolonged
use especially for near. Occasionally, the patient complains
ocular use especially for near.
of throbbing headache often accompanied with nausea.
The main causes of asthenopia are:
1. Uncorrected refractive errors—hyperopia and
astigmatism Bibliography
2. Incorrect glasses or misplacement of the optical center
of a corrective lens 1. Abrams JD. Duke-Elder’s Practice of Refraction. Edinburgh:
3. Heterophorias Churchill Livingstone; 1978.
2. Curtin BJ. The Myopias: Basic Sciences and Clinical
4. Anisometropia Management. Philadelphia: Harper and Row; 1985.
5. Presbyopia
6. Convergence deficiency.

Treatment Review Questions

The causes of asthenopia must be identified and should 1. What are the common errors of refraction?
be treated promptly. The corrective measures include 2. How do you treat myopia?
correction of refractive error, replacement of inappropriate 3. What are the types of hyperopia?
glasses, orthoptic exercises and/or surgical correction of 4. How do you classify regular astigmatism?
muscle imbalance. 5. What are the causes of asthenopia?