Reporter: Cabriles, Joanna C.

PBL 3
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 • Closely approximates
the human eye
• Cumbersome for some
clinical calculations

AAO 2019-2020 BCSC, Clinical Optics

 • Treats the eye as a
single refractive
element
• Refractive index =
1.333

AAO 2019-2020 BCSC, Clinical Optics

• Process by which the eye focuses on near
objects:
1. Convergence of both eyes
2. Contraction of ciliary muscle -> change in lens
shape (increased curvature)
3. Pupillary constriction
• Average resolving power of the normal human eye = 1
minute of arc
• Snellen letters = made from 5x5 squares
• The letters at 20/20 have a visual angle of 5 minutes of arc
at 20 ft
• = 8.7 mm in width and height
• The eye minimizes an image at 20 ft by ~ 350x  size of
the 20/20 letter on the retina is 0.025 mm  resolution
capacity of 100 lines per millimeter
AAO 2019-2020 BCSC, Clinical Optics
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 Emmetropia Ametropia

• Absence of refractive • Presence of refractive

error error
 • Due to loss of accommodation
that comes with aging
• @ 44-46 y.o = person with
emmetropia will begin to notice
inability to read small print
• Worse in dim light, early AM, or
when fatigued
• @ 55 y.o = symptoms stabilize but
persist
Image source:https://www.eyeglassguide.com/my-eyes/common-
conditions/presbyopia.aspx
• Corrected by the use of convex (plus) lens
• Reading glasses = have the near correction in the entire
aperture of the glasses
• Half glasses = leave the top open and uncorrected
• Bifocals = allow correction of other refractive errors
• Trifocals = correct for distance vision (top), middle
distance, and near distance (bottom)
• Varifocals = progressive change in lens power
 https://www.zennioptical.com/blog/which-eyeglasses-are-right-for-you/

https://i.ebayimg.com/00/s/NTAwWDUwMA==/z/5jsAAOxyaTxTVkRW
/$_3.JPG?set_id=2
https://www.zennioptical.com/blog/which-eyeglasses-are-right-for-you/
 • When the image of distant objects
focuses in front of the retina in an
unaccommodated eye
• Axial myopia = if the eye is longer
than average
• Add. 1 mm = 3 D more myopic
• Curvature/refractive myopia = if
the refractive elements are more
refractive than average
https://bceye.com/lasik-corrects-myopia-what-is-
nearsightedness/
• High degree of myopia -> greater susceptibility to
degenerative retinal changes
• Correction = concave spherical (minus) lenses
http://www.funscience.in/study-zone/Physics/OpticalInstruments/Myopia.php
 • When the image of objects
focuses behind the retina in an
unaccommodated eye
• Axial hyperopia = due to reduced
axial length
• Refractive hyperopia = due to
reduced refractive power (e.g.
aphakia)

https://www.news-medical.net/health/Hyperopia-(Far-Sightedness).aspx
 Hyperopia Presbyopia

• May still be able to • Unable to accommodate

accommodate depending
on degree of hyperopia • Age-related
• Manifest hyperopia = the hyperopia that cannot be
corrected by accommodation
• Latent hyperopia = degree of hyperopia overcome by
accommodation
• Refraction with a cycloplegic = determines the sum of
both manifest and latent hyperopia
• Correction: convex (plus) lenses
 • When the eye produces an
images with multiple focal points
or lines
• Usual cause: abnormalities in
corneal shape
• Crystalline lens may also
contribute

https://healthlifemedia.com/healthy/what-is-an-
astigmatism-in-the-eye/
• Typically, light rays from a single object point are
refracted to form 2 focal lines perpendicular to each
other
• Principal axes = the strongest and weakest meridians
of net refracting power of the anterior segment
refracting surfaces (cornea and lens)
Types of astigmatism accdg to the orientations and
relative positions of the focal lines:
 Regular astigmatism Irregular astigmatism
• there is constant power • power or orientation of
and orientation across the principal meridians
the pupillary aperture changes across the
pupillary aperture
• Corrected with cylindrical
lenses (+ spherical • Usually, can only be
lenses) and rigid contact corrected with rigid
lenses contact lenses
http://www.somertoprak.com.au/astigmatism--keratoconus.html
 Astigmatism against the
Astigmatism with the rule rule

• greatest refractive power • greatest refractive power

is in the vertical meridian is in the horizontal
meridian
• More common in younger
patients • More common in older
patients
 Astigmatism against the
Astigmatism with the rule rule
 Oblique astigmatism

• In which the principal

meridians do not lie at 90
or 180 degrees
 • Difference in the
refractive error
between 2 eyes
• Major cause of
amblyopia

Image source: https://www.seevividly.com/info/Lazy_Eye/Amblyopia/Anisometropia

• Refractive correction is complicated by:
• Aniseikonia = differences in size of the retinal image
• Oculomotor imbalance
• Spectacle correction = difference in retinal image size
of 25%
• Contact lens correction = difference of 6%
• Intraocular lenses = difference of less than 1%
• Most babies = slightly hyperopic
• Hyperopia slowly decreases -> decrease accelerates in
the teens -> approach emmetropia
• Corneal curvature
• At birth = much steeper (6.59 mm radius)
• @ 1 y.o. = flattens to nearly adult curvature (7.71 mm)
• Mean axial length
• @ birth = short (16.6 mm)
• @ 10-15 y.o = stable (24 mm)
• Presbyopia = manifests in 5th decade
• Refractive errors
• Mode of inheritance = complex
• Does not need to be present at birth
• Myopia = usually increases during the teens
• Factors influencing progression = poorly defined; probably
involve close work
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 • Safest
• To reduce
nonchromatic
aberrations, lenses
are made:
Image source: https://www.lenspick.com/blog/types-of-eyeglass-lenses-and-coating/ • In meniscus form
(corrected curves)
• Tilted forward
(pantascopic tilt)
 • Glass fluid-filled scleral
lenses = 1st contact lenses
• Caused corneal edema and
discomfort

• Hard corneal lenses = 1st

successful corneal lenses
• Made of
Image source: http://www.baileyeyecare.co.uk/contact-lens-examinations/
polymethylmethacrylate
 Rigid lenses Soft contact lenses
• correct refractive errors • adopt the shape of the
by: patient’s cornea
• Changing the curvature of • Correct little corneal
the anterior surface of the astigmatism
eye -> spherical
• Used for the treatment of
• Overcome corneal corneal surface disorders
astigmatism (control of symptoms)
• All forms of contact lenses are used in:
• refractive correction of aphakia
• Correction of high myopia (produce better image than
spectacles)
• However, majority of contact lenses worn are for
cosmetic correction of low refractive errors.
 • Range of methods for
changing the curvature
of the anterior surface of
the eye
• Expected refractive
effect – derived from
empirical results
In Radial Keratotomy (RK) Surgery, Flattening Perpendicularly to the Radial Incisions
Reduces the Average Refractive Power of the Cornea and Corrects for Myopia
Image source: Correction of Refractive Errors, Bing Chiu and Joshua A. Young,
Ophthalmology, 2.4, 48-55.e1
 • Preferred method of
refractive correction for
aphakia
• Additional (piggyback) IOL
sometimes implanted to
correct residual error
• Occasionally inserted
without removal of the
By Frank C. Müller, CC BY-SA 3.0,
crystalline lens
https://commons.wikimedia.org/w/index.php?curid=23063533
 • May be undertaken for correction
of moderate to high myopia

Image source:
https://healthcare.utah.edu/moran/lasik/clear-lens-
extraction.php
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• Which patients should be refracted?
• Those with subnormal visual acuity
• those with asthenopic symptoms
• Those with decreased visual acuity since last visit
• Post-op patients (e.g. after cataract surgery)
• Asthenopic symptoms = assoc. with accommodative effort
• Fatigue
• Headache
• “eyestrain”
• Double vision
• Fluctuating visual acuity
• Lengthening of the clearest reading distance
• Performed by retinoscopy
• Observes the movement of a retinal reflex (retinoscopic
reflex) created by a beam of light (intercept) through the
pupil and the optical system of the eye
• Parallel alignment of the intercept and the
retinoscopic reflex = presence of spherical error
• If off-axis = astigmatism

Vaughan & Asbury’s General Ophthalmology, 19th ed.

• If reflex moves in the same direction as the intercept =
plus lenses are placed
• If it moves in the opposite direction = minus lenses
• End point = point of neutralization
• Reflex fills the whole aperture and no movement is detected

• Automated refractors = not useful in young children or

adults with significant anterior segment disease
Vaughan & Asbury’s General Ophthalmology, 19th ed.
 • Produces more accurate results in
cooperative patients compared to
objective refraction
• Duochrome test on red and green
backgrounds = uses the normal
chromatic aberration of the eye to
refine spherical correction
• End point = when the black letters
https://www.aao.org/image/duochrome-test of both halves are equally clear
 • Used when it is necessary for
accommodation to be relaxed
• E.g. in hyperopic children
• Cyclopentolate 1%, 1 drop instilled
2x 30 mins prior
• Atropine 0.5% or 1%, applied BID x
https://www.optometry-evolution.com/other- 3 days
ocular-pathology/cycloplegic-refraction-clinical-
tips-and-guidance/
• Myopia
• Optical correction through bifocal or multifocal spectacles
• Removal of distance spectacles when doing close work
• (proposed) low-dose atropine
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