REFRACTIVE

ERRORS
-ROSHINI.M
3rd yr MBBS
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 LEARNING OBJECTIVES
Hypermetropia
What is refraction? Myopia
Astigmatism
Types of refractive errors Anisometropia
Aniseikonia
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WHAT IS REFRACTION?

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 Refraction is the bending of light as it passes through
one object to another. Vision occurs when light rays are
bent (refracted) as they pass through the cornea and
the lens. The light is then focused on the retina.

The retina converts the light-rays into messages that

are sent through the optic nerve to the brain. The brain
interprets these messages into the images we see.

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 EMMETROPIA (optically normal eye)

a state of refraction, where in the parallel rays of light

coming from infinity are focused at the sensitive layer
of retina with the accommodation being at rest

AMETROPIA (a condition of refractive error)

a state of refraction, when the parallel rays

of light coming from infinity (with accommodation at
rest), are focused either in front or behind the sensitive
layer of retina, in one or both the meridians.
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REFRACTIVE ERRORS

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HYPERMETROPIA

Hypermetropia (hyperopia)
or long-sightedness
is the refractive state of the eye
wherein parallel rays of light coming from
infinity are focused behind the retina
with accommodation being at rest.

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 ETIOLOGY
[Link] hypermetropia
The most commonest form. [Link] hypermetropia
It occurs due to axial
Results due to due to posteriorly
shortening of the eyeball.
placement of crystalline lens

[Link] hypermetropia
[Link] of crystalline
It occurs due to comparatively flatter
lens
curvature of the cornea or lens or both
Either congenitally or
acquired leads to aphakia
[Link] hypermetropia
— a condition of
Occurs due to change in the high hypermetropia.
refractive index of the lens 8
 SYMPTOMS
[Link]
[Link] symptoms SIGNS
tiredness of eyes,
frontal or fronto-temporal
1. Size of eyeball may appear small
headache,
watering [Link] may be slightly smaller
mild photophobia
[Link] chamber is comparatively
[Link] vision with asthenopic shallow.
symptoms.
[Link] examination reveals
4. Defective vision only. a small optic disc

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 COMPLICATIONS

1. Recurrent styes, blepharitis or chalazia

2. Accommodative convergent squint

[Link]

4. Predisposition to develop
primary narrow angle glaucoma.

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A. Optical treatment B. Surgical treatment

Prescribe convex (plus) lenses

Intraocular lens implantation
Refractive corneal surgery
i. Keratophakia
ii. Epikeratophakia
iii. Hyperopic Lasik

Modes of prescription of convex lenses

1. Spectacles 2. Contact lenses
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MYOPIA

Myopia or short-sightedness
is a type of refractive error in which
parallel rays of light coming from infinity
are focused in front of the retina when
accommodation is at rest.

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 CLASSIFICATION
Etiological
Clinical
1. Axial myopia
1. Congenital myopia
Increase in antero-posterior length of the eyeball.
2. Simple or developmental myopia
2. Curvatural myopia 3. Pathological or degenerative myopia
Increased curvature of the cornea, lens or both. 4. Acquired myopia
(i) post-traumatic
3. Positional myopia
(ii) post-keratitic
Anterior placement of crystalline lens in the eye.
(iii) drug-induced
4. Index myopia (iv)pseudomyopia
Increase in the refractive index of crystalline lens (v) space myopia
associated with nuclear sclerosis. (vii) night myopia
(viii) consecutive myopia.
5. Myopia due to excessive accommodation
Occurs in patients with spasm of accommodat 13
SYMPTOMS SIGNS
1. Prominent eye balls.
1. Defective vision 2. Cornea is large.
3. Anterior chamber is deep.
2. Muscae volitantes
4. Pupils are slightly large and
react sluggishly to light.
3. Night blindness
5. Visual fields show contraction and in
sometimes ring scotoma is seen.
6. ERG reveals subnormal electroretinogram
due to chorioretinal atrophy.
Contd...
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 7. FUNDUS EXAMINATION

(a) Optic disc appears large and pale and its temporal edge
has a characteristic myopic crescent.

(b) Degenerative changes in retina and choroid.

These are characterised by Foster-Fuchs' spot

(c) Posterior staphyloma

d) Degenerative changes in vitreous include:

liquefaction,
vitreous opacities,
and posterior vitreous detachment (PVD)
appearing as Weiss' reflex
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 COMPLICATIONS

(i) Retinal detachment

(ii) complicated cataract
(iii)vitreous haemorrhage
(iv) choroidal haemorrhage
(v)Strabismus fixus convergence.

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 TREATMENT
1. Optical treatment of myopia constitutes
prescription of appropriate concave lenses.

2. Surgical treatment of myopia.

3. General measures empirically include

balanced diet rich in vitamins and proteins.

4. Low vision aids (LVA)

5. Prophylaxis (genetic counselling)

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 ASTIGMATISM

Astigmatism is a type of refractive error

wherein the refraction varies in the different meridia.

Consequently,the rays of light entering in the eye

cannot converge to a point focus
but form focal lines.

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 Refractive types of regular astigmatism
CLASSIFICATION Depending upon the position of the two
focal lines in relation to retina.
REGULAR ASTIGMATISM
the refractive power changes uniformly
from one meridian to another.
TYPES-Depending upon the axis and the angle
between 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
Principle meredians perpendicular to each other
but not at 180° and 90°
4. Bioblique astigmatism.
Two principal meridia are not at right angle
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to each other
 IRREGULAR ASTIGMATISM
irregular change of refractive power in different meridia.

TYPES
1. Curvatural irregular astigmatism
Found in patients with extensive corneal scars or keratoconus.

2. Index irregular astigmatism

due to variable refractive index in different parts of the crystalline lens
may occur rarely during maturation of cataract.

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 TREATMENT

1. Optical treatment
prescribing appropriate cylindrical lens
i. Spectacles ii. Toric contact lenses

2. Surgical correction of astigmatism 21

 ANISOMETROPIA
When the total refraction of the two eyes is unequal
the condition is called anisometropia.

anisometropia up to 2.5 is well tolerated

between 2.5 and 4 D can be tolerated depending upon the individual sensitivity.
However, if it is more than 4 D, it is not tolerated and is a matter of concern.

ETIOLOGY TREATMENT
1. Spectacles.
1. Congenital and developmental
2. Contact lenses
anisometropia.
3. Aniseikonic glasses
2. Acquired anisometropia 4. Other modalities of treatment
Intraocular lens implantation
Refractive corneal surgery 22
Removal of clear crystalline lens
 ANISEIKONIA
Aniseikonia is defined as a condition wherein the
images projected to the visual cortex from the two retinae
are abnormally unequal in size and/or shape.

TREATMENT
1. Optical aniseikonia may be corrected by
aniseikonic glasses, contact lenses or intraocular
lenses depending upon the situation.
2. For retinal aniseikonia treat the cause.
3. Cortical aniseikonia is very difficult to treat.

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 The End

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