REFRACTIVE STATUS OF

THE EYE

HARSHIT(OPTOMETRY STUDENT)
MANOJ CHANDOLIYA
OPTOMETRIST
Advanced Eye Centre PGIMER
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 REFRACTIVE STATUS OF THE EYE
The relative refractive power of the optical element with respect to the
location of the retina.
ANOMALIES OF REFRACTION
A. Emmetropia : -
 Refractive condition of the eye with accommodation relaxed ,the parallel
rays of light converge to a sharp focused on retina.
 Also called normal refractive condition of the eye
B. Ametropia :-
Condition of eye in which , the parallel rays of light fail to converged to a
sharp focus on the retina ,eye with accommodation relaxed
It is divided as follows:
1. Myopia 3. Astigmatism
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2. Hyperopia
 Emmetropia
• Emmetropia :- incident parallel rays of the light
are brought to focus upon the retina. when the
accommodation in the rest condition

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 Myopia
• Parallel rays of the light are bought to focus in front of layer
of the retina, when the eye is at rest or accommodation is
relaxed .

• Also known as short sightness or Near sightedness.

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Types of Myopia
A. Simple Myopia progressive but some times show mild
::- ;

increase during the year of growth .

Axial Myopia
Refractive Myopia
1. Curvature myopia
2. Index myopia
Functional Myopia:- excessive use of accommodation
According to Sorsby : 35%of myopia remain stationary
: 15% shows slight progress
Occupation, Environmental & Hereditary also play important
role in myopia 5
•Axial :
• Axial length of eye is too long for its normal refractive power .
• Increased axial length may occur in the anterior or posterior parts
of the globe

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 ....conti
•Refractive :
• the refractive component of the eye is more
powerful for the normal axial length of the eye.
• according to Boris refractive myopia further divided
into
Refractive,
• Curvature myopia
• Index myopia
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 ...conti
1. Curvature myopia :-
• Increased curvature of the cornea, lens produce more dioptre
power of the eye.(1mm of increased= 6D increased in power).
2. Index myopia : -
 in which one or more of the refractive indices of the
media are variable.
Myopia related to Anterior chamber deep A/C
depth ,increase refractive power of the eye
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B. Pathological myopia:
Pathological / degenerative/progressive myopia isa a rapidly progressed
starts with childhood(5-10 yr.) to their adult life and changes
particularly in posterior segment of the globe and results in high(> 6D)
degree of myopia such as :-

• Posterior staphyloma , choroidal degeneration and choroidal atrophy

• Pathological or progressive - is marked changes in fundus in case of

posterior staphyloma, tessellated fundus, optic disc is large and pale in color.

• Associated with high refractive error and sub normal VA after correction.
Main causes of visual impairment
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 POSTERIOR
STAPHYLOMA

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 Etiology of pathological
myopia
 Other forms of myopia

1.Nocturnal Myopia
2.Induced myopia
3.Surgical Induced Myopia

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1. Nocturnal myopia
• Generally known as twilight myopia or night
myopia.
• Difficulty seeing in dim light illumination.
• Night myopia caused by pupils dilating to let more
light in which add more aberrations resulting more
near sighted.
• Young people more affected night myopia than
elderly .
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 2.Induced myopia
• Also known as acquired myopia - results from intake of various
pharmaceutical drugs
• Increases the level of glucose
• Nuclear sclerosis
• The encircling bands used in retinal detachments surgery may induce
myopia by increasing the axial length of the eye

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Age of onset of myopia
At Birth, refractive error is approximately +2.50 D
hypermetropia, by the age of 2 or 2.5 yr become
Emmetrope, by the process of Emmetropization
Age of onset of myopia :
Congenital or infantile myopia :- by birth and persists
through the infancy.
Youth onset myopia :- occur early childhood to teenager
with varying refractive power of eye till to the age of 21yrs .
School Myopia :- childhood age particularly school going
age, myopia occurs due to eye used for close work during
school yrs
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 Congenital myopia
• It is associated with an inc. in axial length and overall globe size.
• It is seen in children who were born prematurely or with various birth
defects.
• High degree of error is present (8-10D) and also anisometropia(error
is unilateral).
• It may be associated with congenital convergent squint and other
congenital anomalies.
• It is diagnosed either by routine screening examination or after a
strabismus develops(unilateral). and with bilateral the child will
display some noticeable difficulty in seeing distant objects.
Degree of myopia
• Measured in dioptres by the strength of optical
power of corrective lens that focuses the
distance image on the retina .

• Low myopia - 0 to -3.00 dioptres

• Medium myopia - -3.00 to -6.00 D
• High myopia - More than -6.00 D
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OPTICAL CONDITIONS
 In the myopic eye parallel rays of light come to
focus in front of the retina.
Distant object can’t seen clearly .
In myopic eye the far point is in front of the eye at
finite distance (depending on the degree of myopia).
Farthest point at which object seen distinctly is
called far point ( punctum remotum).
Degree of myopia depends upon the distance of
Punctum Remotum.
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 Role of Accommodation

• Distance Objects are blur as point

focus forms before retina
• While Near Objects remains In focus,
because of accommodation
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 EPIDEMIOLOGY

• The global prevalence of refractive errors

estimated from 800 million to 2.3 billion.
• Incidence of myopia in population often
varies with age ,country, sex ,race ethnicity ,
occupation environment and other factors.
• The prevalence of myopia has been reported
as high as 70–90% in some Asian countries.
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 SIGNS
• Prominent eye balls
• Anterior chamber –deeper than normal
• Pupils –large sluggishly reacting
• Fundus –normal rarely temporal myopic crescent may
be seen( retina pulled over disc margin).
• Magnitude of refractive error
• Increase at rate of -0.5 to -0.30/year
• Does not exceed 6 to 8
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 SYMPTOMS
• Blurry distance vision most common symptom, but near
vision good .
• If any degree of myopia present become serious problem
• In high myopia both near and distance vision affected ,
object bring too close to eye to see clear.
• Asthenopic symptoms .
• Half shutting of eye .

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 TREATMENT
• Optical treatment of myopia
• Concave Lenses
Mode of prescribing concave lenses
• Spectacle
• Contact lenses

(Basic rules : Minimum acceptance Maximum vision

)
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 Surgical Treatment
• LASIK( Laser in situ keratomileusis)
• PRK( Photorefractive keratotomy)
• Femto second laser .
• Intracorneal contact lens(corneal implants)
• Phakic refractive lenses(PRLs)
• Orthokeratology(corneal tissue moulding) 24
 Hyperopia
• Hyperopia : parallel rays of light are brought to focus
behind the retina.

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HYPEMETROPIA
• Hyperopia :- is form of the refractive error in which
parallel rays of light are brought to focus behind the
retina when the is at rest.
• The Image in the form of circle of least diffusion and
blurred .
• Such condition suggested by Krasner (1755), Donders
in (1858) give term hypermetropia.
• It is also known as long sightedness.
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Ray Diagram Of Hypermetropia

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CLASSIFICATION
Simple: it is produced by normal biological variations, i.e. Axial and
curvatural.
Pathological : congenital and acquired
Functional : due to paralysis of accommodation
Curvature hypermetropia :-
Curvature of any refracting surface is small.
 congenitally Flattening of cornea or by result of trauma or disease.
 1 mm change in radius of curvature of the cornea
=6 .0 dioptres hypropia

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Anatomical features

• Degree of Hyperopia
• Physiological and pathological Hyperopias
• Action of accommodation

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Pathological Hyperopia
• It results due to abnormal development of the eyeball, which
is outside the normal biological variations of the
development.
• It is seen in following conditions
1. Microphthalmos
2. Microcornea
3. Congenital aphakia
4. Congenital posterior subluxation of lens
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ROLE OF ACCOMMODATION IN
HYPERMETROPIA
• The Contraction of ciliary muscles in the act of
accommodation increase refractive power of lens to correct
the certain amount of hypermetropia
• Physiological tone of ciliary muscle normally correct is called
latent hypermetropia
• The remaining portion of uncorrected is called manifest
hypermetropia
• Summation of both is called total hypermetropia

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Role of Accommodation in
Hyperopia
• Latent Hyperopia-Hyperopia that is masked by
accommodation and is not revealed by noncycloplegic
refraction. A cycloplegic agent is necessary to uncover
the full amount.
• Manifest Hyperopia-Hyperopia indicated by the
maximum plus lens that provides the optimum
distance visual acuity

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 TOTAL HYPERMETROPIA

1. Latent hypermetropia :- (amount only 1 dioptre ) it is

overcome physiologically by the tone of the ciliary muscle
2. Manifest hypermetropia
1. Facultative :- overcome by efforts of accommodation
2. Absolute :- which can not be overcome by accommodation

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Example:-
Suppose patient has 3D absolute hypermetropia
Patient able to see 6/5 even with 5 D of hypermetropia by relaxing
accommodative effort. Thus +2 D of hypropia was corrected by
voluntary accommodative efforts.
Hence +2D is value of facultative hypermetropia and +5D represent
manifest hypermetropia.
Now under cycloplegic refractive error detected +6.5 D is called total
hypermetropia.
The diff 1.5 D is corrected by inheritance tone of ciliary muscles of
the eye , this is called latent Hypermetropia.
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Summary of above example
a) Absolute Hypermetropia +3D
b) Facultative hypermetropia +2D
c) Manifest hypermetropia +5D
d) Latent hypermetropia +1.5D
e) Total hypermetropia +6.5D

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 Why Hypermetropia
happens??

•??

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 ....conti
• Decrease in the length of eyeball
• Decrease the curvature of cornea and/or lens
• Change in the refractive index the optical media.

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Clinical Features
General stress & fatigue while doing near works.
Dim vision
Asthenopia- due to sustained accommodative efforts
Ocular stress leads to Headache-frontal or frontotemporal region.
Tearing congestion
Photophobia
Nausea
Recurrent styes and chalazia
Itching & burning sensation
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 Cont…..
• Hypermetropia in children associated with
convergent squint due to an alteration of
AC/A ratio
• High Hyperopia the eye is small.
• Aqueous chamber shallow

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Visual Acuity

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 Treatment
• Prescribing convex lenses in full correction with best visual
acuity outcomes, the form of spectacle and contact lenses
• Surgery treatments –
1. Hyperopic LASIK or PRK
2. Conductive keratoplasty(CK)
3. Laser thermal keratoplasty(LTK)
4. Phakic IOLs(ICL)

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Correction of the
Hyperopia

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Anisometropia
The significant difference in the
spherical refractive error for the
two eyes , the individual is called
anisometropia.
Refractive error difference by 1 or
more than 1 D
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 Astigmatism
• Astigmatism is a type of refractive error wherein the
refraction varies in different meridian. The rays of light
entering the eye cannot converge to a focal point but
form the focal lines.
Diagram:
 Types Of Astigmatism:
(1) Regular Astigmatism
(2) Irregular Astigmatism
 Regular astigmatism
• The astigmatism is regular when the refraction power changes
uniformly from one meridian to another(i.e there are 2 principal
meridian).
• Aetiology : astigmatism may be defined as
1. Corneal astigmatism- result of abnormalities of curvature of cornea.
It constitutes the most common cause of astigmatism.
2. Lenticular astigmatism - small amount of astigmatism due to
congenital abnormalities of curvature of lens (curvatural), due to
congenital tilting or oblique placement of lens or traumatic subluxation
of lens(positional), due to variable refractive index of lens in diff.
meridian like in nuclear sclerosis, and in cataract(index).
3. Retinal astigmatism – due to oblique placement of macula may also
be seen.
 Types of regular
astigmatism
• Depending upon the axis and the angle b/w the two principal meridia.
1. With the rule astigmatism – the two principal meridian are placed at right
angles to one another, but the vertical meridian is more curved than the
horizontal. Thus, correction of this type will require the concave cylinders at
180 or convex cylinders lens at 90. Myopic power more in vertical meridian.
(e.g -3.00dc*180)
2. Against the rule astigmatism- in which horizontal meridian is more curved
than the vertical meridian. Thus, correction will require the convex cylindrical
lens at 180 or concave cylindrical lens at 90. Myopic power more in horizontal
meridian. (e.g -3.00dc*90)
3. Oblique astigmatism- in which two principle meridian are not horizontal and
vertical but at right angles to one another.(e.g 45 and 135 degree.)
4. Bi- oblique astigmatism- the two principle meridia are not at right angle to
each other (e.g. 30 and 100 degree.)
 Refractive types of regular
astigmatism
• Depending upon the position of the two focal point in relation to
retina.
1. Simple astigmatism – rays are focused on the retina in one
meridian and either in front(simple myopic astig.) or behind (simple
hyperopic astig.)
2. Compound astigmatism – rays of light in both the meridia are
focused either in front(comp. myopic) or behind the retina(comp.
hyperopic).
3. Mixed astigmatism- condition where the light rays in one meridian
are focused in front and in other meridian behind the retina.
 Irregular astigmatism
• It is characterized by an irregular change of refractive power in diff.
meridia.
• Aetiological types-
1. Corneal irregular astigmatism – is found in patients with extensive
corneal scars or keratoconus.
2. Lenticular irregular astigmatism – due to variable refractive index in
different parts of the crystalline lens and may occur rarely during
maturation of cataract.
3. Retinal irregular astigmatism- due to distortion of the macular area
due to scarring or tumors of retina.
Symptoms- squinting, tilting of head , asthenopic
symptomsetc.
 TREATMENT
• Optical treatment – for regular astigmatism prescribing the appropriate
cylindrical lens. It may be in the form of spectacles and spherical hard
contact lens( correct upto 2-3D of regular astig.). For higher degree of
astig. toric contact lens needed.
• And for irregular astigmatism prescribing contact lens, which place the
ant. Surface of the cornea.
• Surgery treatment- required for corneal scarring and consists of
- Penetrating keratoplasty(PK)
- Phototherapeutic keratectomy(PTK)