REFRACTIVE ERRORS

Dr. victor njom

Lecturer,
Maseno university.
Lenses

POSITIVE or CONVERGING
NEGATIVE or DIVERGING

positive negative
The POWER of a lens , P

The “ DIOPTRE (D ) “
A positive lens of one dioptre
(+1.00D) converge parallel light rays to
a ‘real’ focal point one metre from
(after) the lens.
A negative lens of one dioptre (-
1.00D) diverge parallel light rays as if
they are coming from a ‘virtual’ point
one metre infront of the lens.
ONE DIOPTRE LENS

 P = +1.00 D
 f = +1.0 m or
+100 cm

 P = - 1.00 D
 f = -1.0 m or
-100 cm
The DIOPTRE (D)
 1 Power,
P (D) = ---------------------------
Focal Length, f (metre)

eg. If P = +2.00 D, f = +0.5 m or +50 cm

eg. If P = +4.00 D, f = +0.25m or +25 cm
eg. If P = -2.00 D, f = -0.5 m or -50 cm
eg. If P = -4.00 D, f = -0.25m or -25 cm
Refractive Index (n)
 Velocity of light in vacuum
n=
--------------------------------------- Velocity of
light in the medium
 eg. Air n=1
 eg. Water n = 1.33
 eg. Cornea n = 1.376
 eg. Crystalline lens n = 1.38 to 1.42
 eg. Crown glass n = 1.52
 eg. Flint glass n = 1.6
Refractive Power of a curved
surface ( P )

 n2 - n1
P (dioptre)=
---------------------
r (metre)
where r =
radius of curvature of the
refractive surface in metres
Refractive Power of the
anterior corneal surface

n1 = 1.0 (air) , n2 = 1.376

(cornea) , r = 8mm or 0.008m
(radius of curvature
of cornea)
P = (1.376 - 1) / 0.008 = 47 D
Refractive Power of the
Cornea

The total refractive power of the cornea is

approx. +40 D (ie. less than +47D for the
anterior surface as this is reduced by the
negative power of the posterior surface)
Refractive Power of the Eye
and its axial length
Power of cornea ~ 40 D
Power of the crystalline lens ~ 20D
Refractive Power of the ave. eye ~ 60D
Assuming n = 1.33 for the eye,
ave. length = n / power = 22.22mm
The axial length of most eyes fall between
22 to 24mm (ultrasound scan).
Key Words
EMMETROPIA
AMETROPIA
- Myopia or ‘Short-sightedness’
- Hypermetropia (Hyperopia)
or ‘Long-
sightedness’ - Astigmatism
ACCOMMODATION
PRESBYOPIA
Anisometropia , Amblyopia
EMMETROPIA

Light rays from distant objects

(parallel rays) are focused onto the
retina in a fully relaxed eye
MYOPIA
Light rays from distant objects are
focused infront of the retina in a fully
relaxed eye
Usually too long eyeball length, or
sometimes too high refractive power
Myopia - Far Point

A myopic person can see objects

placed at the far point or nearer.
HYPERMETROPIA
(HYPEROPIA)
Light rays from distant objects are
focused behind the retina in a fully
relaxed eye
Eye too short, or refractive power is
too low (eg. Aphakia where there is no
crystalline lens)
ASTIGMATISM

In many people, the corneal surface

is not perfectly spherical (radius of
curvature the same in all meridians)
like a soccer ball surface.
Many corneas have different
curvature (hence different
power) in different meridian,
like a rugby ball surface.
Astigmatic eye
Any combination of positions of focal
points in relation to the retina is
possible - myopic, hyperopic or
mixed astigmatism
Astigmatism - circle of least
confusion
ACCOMMODATION

Contraction of the ciliary muscles in

the eye allow the crystalline lens to
increase its power. This increases the
power of the eye so that it can focus
at near objects.
It also allows young hyperopes to
overcome the hypermetropia if this
degree is not too high.
AMPLITUDE OF
ACCOMMODATION

The range of accommodation

decreases with age as the crystalline
lens and, to a lesser extent, the
ciliary muscles become less elastic.
Amplitude of accommodation
with age
PRESBYOPIA

By 40 to 45 years of age onwards,

the amplitude of accommodation
may not be sufficient to allow a
person to read at near.
This is PRESBYOPIA.
Additional plus lens power is usually
required.
Anisometropia

Difference in the refractive errors of

the two eyes.
If sufficiently different in both eyes,
amblyopia (“lazy eye”) will occur in
the eye with the more blurred image.
Importance of early detection in
children as correction before 8 to 9
years of age can prevent amblyopia.
Correction of refractive errors
Spectacle lenses
Contact lenses
Intraocular lens implants esp. after
cataract removal
REFRACTIVE SURGERY -
Excimer Laser (“LASIK” or “PRK”)
- Intracorneal ring implants
- Intraocular ‘contact lens’ (“ICL”) or
Phakic Intraocular lens
Myopia - correction with a
minus lens
Hypermetropia - correction
with a positive lens
Astigmatism requires a
spherocylindrical lens
Spherocylindrical lenses have
different powers in different
meridians
Presbyopia - spectacle
correction

Two pairs of glasses - one distant, one

near
Bifocals lenses

Multifocals or Progressive lenses

EXCIMER LASER
EXCIMER = “ Excited Dimer “
193 nm (ultraviolet)
Breaks the intramolecular bonds of the
corneal tissue (photoablation )
PRK - “Photorefractive Keratectomy”
LASIK - “Laser in-situ keratomileusis”
Flatten the corneal curvature ie.reduce the
refractive power of the cornea in myopia
may also correct hyperopia and astigmatism
PRK – Photorefractive
Keratectomy
LASIK – Laser in-situ
keratomileusis
Lasik 1
Lasik 2
Lasik 3
Lasik 4
Lasik 5
Lasik 6
Lasik - Complications
Corneal stromal flap complications
Infections
Corneal melting, corneal haze, corneal
ectasia
Dry eyes
Glare - esp. night driving
Loss of visual acuity or constrast sensitivity
Retinal detachment
Epi-LASIK

Epithelial Flap instead of Corneal

Stromal Flap i.e. more
superficial cut
Excimer laser as in PRK
Said to be safer than LASIK
Intraocular Contact Lens / Phakic
Intraocular Lens
Phakic IOL
Phakic IOL
CONDUCTIVE KERATOPLASTY
(CK) for presbyopia
 Radiowaves
applied to corneal
periphery to alter
the shape of the
cornea i.e. steepen
the corneal
curvature
 Reduce
hypermetropia /
increase myopia
Visual Acuity

Minimum angle of resolution of the

eye ~ 1 min. of arc (60 sec)
The normal eye can discriminate two
points as separate if they subtend at
least an angle of 1 min. at the eye
Snellen Charts
The Snellen “ E “

 D
( D - distance m. this letter subtend 5 min.
eg. 60, 36, 24, 18, 12, 9, 6, 5 metres)
Snellen Acuity
 Recording Visual Acuity
(Snellen Acuity)
 Test Distance (m.) Snellen
Acuity = ------------------------------
Distance (m.) at which
the smallest visible letter
subtend 5 min. of arc
Test Distance is usually at 6 m.
eg. 6/5, 6/6, 6/9, 6/12, 6/18, 6/24, 6/36,
6/60 ; 5/60, 4/60, 3/60, 2/60, 1/60 ; CF
(Counting fingers), HM (Hand movements), PL
(Perception of light), NPL (No PL)
Determination of Refractive
Errors

OBJECTIVE - does not require a response

1) Infants and young children requires
retinoscopy under cycloplegia
(Cyclopentolate 1% or rarely atropine 1%
eyedrops are used to immobilise the ciliary
muscles and hence block accommodation
2) AUTOREFRACTORS (computerised)
SUBJECTIVE - patient asked to choose
between lenses
Importance of vision checks
on young children
In addition to manifest squints, high
degrees of anisometropia, astigmatism,
hyperopia and myopia can cause
amblyopia (lazy vision) due to blurred
image on the fovea of one or both eyes.
A sharp retinal image is essential for
development of a normal visual acuity
Importance of early detection of visual
problems for early treatment
Treatment of Amblyopia

Optical correction of refractive errors

(with or without patching of the better
eye) before 8 to 9 years of age is crucial.
The younger the age at commencement
of treatment, the better the results.
Results are generally disappointing after
9 to 10 years old.
Change of refractive errors
with age
Low grade hyperopia (ave.~ 2D) at birth
Slight increase in hyperopia during first 7
years
Gradual decrease in hyperopia
throughout primary school
Trend to drift into myopia by end of
primary/early secondary, and increase in
myopia throughout secondary school
Change in refractive errors
If hyperopia of about +2.50D at 6 years,
tend to be emmetropic at 14 years; if >
+2.50D at 6 yrs., some hyperopia will
remain at 14 yrs.
Myopia tend to increase through secondary
school till early 20’s, then level off
Some drift towards hyperopia esp. after 40
yrs., but hardening of the lens nucleus cause
a shift into myopia esp. in the older age.
Factors in development of
myopia
Genetic - family, uniovular twins, race
- Japanese, Chinese, Jews,
Germans
Environment - close work - indoors
?Pre-existing astigmatism
?Lack of exercise, ?food
?Role of parasympathetic system - ?Use of
parasympathetic blocker like atropine
eyedrops.
THANK YOU!