Refractive Errors
Dr. Hassenien S. Shuber
13 November 2022
Emmetropia (with accommodation relaxed)
is the refractive state in which parallel rays of light from a distant
object are brought to focus on the retina .
The far point
(posision of an object such that its image falls on the retina of
relaxed eye)of the emmetropic eye is at infinity, and infinity is
conjugate with the retina .
Ametropia :
• presence of a refractive error.
• 65% of the population have refraction of 0.00 to +0.75 and can therefore regarded
emmetropic,
• 25% are low Hypermetropic (+1.00 to+3.75D)
• 8% are low myopes(-0.25 to -5.00D).
• High myopia and high hypermetropia each make up 1% of the population in western
countries.
In axial ametropia,
the eyeball is either unusually long (myopia) or short (hyperopia).
In refractive ametropia,
the length of the eye is statistically normal, but the refractive power of the eye is abnormal:
excessive in myopia or inadequate in hyperopia. Aphakia is an example of extreme refractive hyperopia.
An ametropic eye requires either a diverging or a converging lens to focus a distant object on the retina.
Myopia:
The myopic eye possesses too much optical power for its
axial length. In myopia light rays from an object at infinity
converge too soon and thus focus in front of the retina .The
main symptom is blurring of vision esp. for far.
Aetiology :
1.Axial Myopia :
2.Refractive Myopia :e.g. nuclear sclerosis and keratoconus .
Classification:
According to the degree of refractive error (measured in Diopter), myopia can be
classified into:
1.Simple myopia (5-6 D)
2.Pathologic myopia ( more than 6D):-associated with progressive excessive
elongation of the globe often followed by degenerative changes involving the
sclera, choroid, Bruches membrane ,RPE and the sensory retina . these may
include :
1. Tilted optic disc with surrounding area of chorioretinal atrophy.
2. Chorioretinal atrophy involving the posterior pole and / or the retinal
periphery .
3.Macular changes
Myopic fundus Normal fundus
4.Retinal detachment may result from peripheral retinal degenerations , retinal
breaks and vitreous degeneration.
5.Cataract (PSC and early onset nuclear sclerosis)
6.increased prevalence of primary open angle Glaucoma and steroid
responsiveness.
7.Posterior staphyloma which is an out bulging of the thinned sclera at the site
of exit of the optic nerve which in turn worsen the refractive state
Treatment:-
Patients with pathological myopia should have their Fundi routinely
examined with well dilated pupils and their visual symptoms taken seriously.
Optical correction include:
1.Concave (minus lenses)
2.contact lenses
3.Radial Keratotomy (old method almost
obsulete)
4.Clear lens extraction :gives very good visual
results but small risk of retinal detachment.
5.Photorefractive percedures:
6. Phakic intraocular lens implantation e.g. ICL
photorefractive Keratectomy (PRK) and Lasik
• the procedure performed with excimer Laser which can accurately ablate corneal tissue to
an exact depth with minimal distruption of the surrounding tissue.Ablasion of the central
cornea 10 micrometers can correct 1D myopia. Up to 6 Ds of myopia can be corrected
with this procedure.
• Laser in-situ Keratomileusis (LASIK) : can correct myopia up to 12 D and is currently the
most frequently performed procedure.
6. Intraocular collamer lens (ICL)
What is accommodation?
Hyperopia:
The Hyperopic eye does not possess enough optical power
for its axial length .
In hyperopia ,an object at infinity focuses behind the
retina .
Aetiology:
1. Axial Hypermetropia.
2. Refractive Hypermetropia:
e.g. when the cornea is flatter than normal for that particular eye
(curvature hypermetropia) which may be congenital (cornea plana) or acquired
(trauma to the cornea with subsequent scar formation )
Hypermetropia can be classified into:-
a. Total hypermetropia: is the amount of hypermetropia after all accommodation is
suspended (using cycloplegic drops e.g. atropine or cyclopentolate).determination of
total Hypermetropia is important in management of children with strabismus.
b.Manifest Hypermetropia: is the strongest convex lens accepted for clear distant
vision.
c.Latent Hypermetropia:is the difference between total and manifest hypermetropia.
At birth 90-95% of new born eyes are hypermetropic to the extent of 2.5-3D
because they have a short axial length .Thus , in the absence of strabismus such
children rarely need spectacles .
Clinical Features:
Blurring of vision esp. for near and symptom of eye strain like headache and
ocular pain due to excessive accommodation.
Treatment :
after determination of the degree of R.E. , treatment options include:
1.Convex (plus) lenses to bring the image from behind the retina a new focus on
it.
2. Contact lenses
3. Photorefractive Keratectomy (PRK): can correct low hypermetropia by ablating
the corneal periphery.
4. LASIK: correct up to 6 D.
Astigmatism
In astigmatism, variations in the curvature of the cornea or lens at different
meridians prevent the light rays from focusing to a single point I.e. the refractive
power of the eye varies in different meridians and a focus line rather than point is
formed .
Types of Astigmatism:
1) Regular Astigmatism :
the tow principal meridians are at right angle to each other and is correctable with
cylindrical spectacle lenses. it is further subdivided into:-
▪Simple myopic: one line focus lies on the retina and the other lies in front of the
retina.
▪Simple Hypermetropic: one line focus lies on the retina and the other lies behind
of the retina.
▪Compound Myopic: Rays in all meridians come to focus in front of the retina.
▪Compound hypermetropic: Rays in all meridians come to focus behind of the
retina.
▪Mixed: one line focus lies in front of the retina and the other lies behind the
retina.
2) Irregular astigmatism:
If the orientation of the principal meridians changes from point to point across the pupil,
Or if the amount of astigmatism changes from one point to another, the condition is Known as
irregular astigmatism.
Cylindrical lenses can do little to improve Vision in these cases, although rigid contact lenses may
be useful.
Treatment:-
1. Cylindrical lenses
2. Soft contact lense may be used if astigmatic error is less than 2 D, while rigid
contact lenses may be used for higher degrees.
3. Photorefractive surgery weather PRK or LASIK.
4. Intraocular collamer lens (ICL)
5.Advanced Keratoconus may benefit from intrastromal (corneal ) rings .
Presbyopia
