Refractive
disorders
Basak Bostanci MD FEBO
AIMS
• refractive elements of the eye
• emetropia and accomodation
• types of refractive disorders
• the risk factors and frequency of refractive disorders
• symptoms and findings of refractive disorders
• correction methods of refractive disorders
• contact lens use
• Refractive errors occur when
the optical system of the eye
fails to focus an object onto
the retina.
• The optical components of
the eye are:
• the cornea
• the lens
• the length of the eyeball
(axial length)
• anterior chamber depth
Refractive
elements of
the eye
•The eye functions like a
camera – it has an optical
system (the tear film,
cornea, aqueous humor,
lens and vitreous humors)
and a light-responsive film
(the retina).
Refraction is
calculated in
diopters (D)
1D is the power of a
convergent lens to
focus parallel light at
its focal point (f) 1 m
behind the lens
• On average babies are born with
+3.00 D hyperopia
• All refractive components change as
the eye grows
Normal refraction
Emmetropia: Normal
sight; light from a distant
object is focused
perfectly on the retina
As the object comes
closer to the eye, the
lens increases in power
by altering its shape to
become more convex
This active process of
accommodation is
stimulated by
parasympathetic fibres
in the oculomotor nerve.
Normal refraction
• Cornea is the most powerful
focusing element but only the
lens is naturally adjustable.
• The total refractive power of
the human eye is
approximately 60D; of which
43D is contributed by the
cornea and 19D by the lens.
• With maximum
accommodation the
refractive power of the lens
increases to aproximately
33D.
Emmetropia and accomodation
Accomodation is the mechanism
by which the eye changes
refractive power by altering the
shape of its lens
• An imbalance of the optical components of the eye leads to a
refractive error= ametropia
Hyperopia
• In long-sightedness (hypermetropia or hyperopia), the refractive power
of the eye is inadequate so that light from distant objects is focused
‘behind’ the eye. An additional convex lens is required
Hypermetropia
• Hyperopia occurs due to
• A cornea that is too flat
• A short eyeball
both cause the distant targets focus
behind the retina
Hypermetropia
• Asthenopia
• Headache
• Difficulty seeing near
• Diffuculty seeing far (if >
+4.00 D)
https://www.easyoptic.cz/eye-health/what-
are-the-most-common-types-of-eye-defects
Myopia
• In short-sightedness (myopia), distant targets are focused in front of the
retina. This is corrected by a concave lens.
• However, objects close to the myopic eye may be focused directly onto
the retina: hence the term ‘short-sightedness’
Myopia
• Myopia may occur due to:
• a long eyeball (axial myopia)
• highly curved cornea
(curvature myopia)
both cause the distant targets
focus in front of the retina
Myopia
• Blurry distance vision
• Asthenopia, eye strain
• Headaches
• Feeling fatigued when
driving or
playing sports
• Squinting
https://www.easyoptic.cz/eye-health/what-
are-the-most-common-types-of-eye-defects
Juvenile onset: 7-16 years of age,
progression may continue into 20s
and 30s
Adult onset: about 20 years of
age – extensive near work is a risk
factor
Genetic and enviromental risk
Myopia factors
Higher educational achievement
Poor nutrition
In Turkey: 24.5% among
school age children (%15-
%38)
In US: 25% among
Myopia adolescents aged 12-17
years
In Taiwan: 84% among
adolescents aged 16-18
years
There are rare cases in which
the myopia may progressively
get worse, leading to severe
visual impairment.
Myopia
This rare condition called
degenerative myopia which
increases the risk of retinal
detachment, cataracts and
other degenerative changes in
the back of the eye
Degenerative myopia
Representative 3-dimensional (3D) magnetic resonance
imaging (MRI) scan of emmetropic eyesis ϩ 0.5 diopter
(D), and the axial length is 23.3 mm.
22.0 diopters (D) and an axial length of 34.3 mm
Nasal view of 3D MRI of the right eye. The globe is elongated in the
anteroposterior direction.
In an eye with
a= without astigmatism, light fails
to come to a single
stigmos: point focus on the retina to
produce clear vision
Astigmatis
m Multiple focus points
Astigmatism may occur
occur, either in front of
in addition to myopia
the retina or behind it
and hypermetropia.
(or both).
Astigmatism
• The power of the cornea is
unequal in different
meridians with one
meridian being significantly
more curved than the
others
• The steepest and flattest
meridians of an eye with
astigmatism are called the
principal meridians
• the eye behaves like a rugby
ball instead of a soccer ball
Types of astigmatism
• Regular astigmatism: Flat and
steep meridians (principal
meridians) are 90 degrees
apart from each other
• Irregular astigmatism: the
principal meridians are not
perpendicular, corneal
surface is scarred or
degenerated
Astigmatis
m
•Regular astigmatism:
• Myopic astigmatism. One or both
principal meridians of the eye are
nearsighted. (If both meridians are
nearsighted, they are myopic in differing
degree.)
• Hyperopic astigmatism. One or both
principal meridians are farsighted. (If
both are farsighted, they are hyperopic in
differing degree.)
• Mixed astigmatism. One prinicipal
meridian is nearsighted, and the other is
farsighted.
Astigmati
sm –
symptom
s
• Blurry or distorted
vision
• Headache
• Asthenopia
• Head tilt
• Squinting
https://www.easyoptic.cz/eye-health/what-are-the-most-common-types-of-eye-
defects
Accomodati
on
•ability to change focus for
close-up objects is
called accommodation
Stimulated by
parasympathetic
innervation
When the ciliary muscles contract the tension lessens on the ligaments and the lens
thickens, enabling the eye to focus on near objects
When the ciliary muscles relax, the ligaments tighten, the lens
becomes stretched and thin and focuses on far objects
Accomodation
• At age 8 years: accomodative power: 14 D
• At age 28 years: 9 D
• At age 64 years: 1 D
• Causes of this power loss:
• Increased size of the lens
• Altered mechanical relationships
• Increased stiffness of the lens nucleus
Presbyopia
• With increasing age (particularly after age 40
years), the flexibility of the lens reduces,
accommodation begins to fail and the point of
closest focus falls further and further from the
eye
• This natural phenomenon is known as
presbyopia.
• It is overcome by a convex lens (reading glasses)
Spectacles
(glasses)
Correcti
ng
Contact lenses
refractiv
e errors
Refractive surgery
Spectacl
es
Spectacles – corrective lenses
• Spherical lens: equal curvature in all meridians
• Concave (minus) lens:
• Used to correct myopia.
• Refracts light rays, making them more divergent.
• Objects seen through a minus lens look smaller
• Convex (plus) lens:
• Used to correct hypermetropia, presbyopia and aphakia.
• Refracts light rays to make them more convergent
• Objects seen through a plus lens look larger
• Toric (cylinder) lens
• Used to correct astigmatism
• Shaped like a section through a rugby ball with one meridian more curved
than the other (at right angles to each other)
Correction of myopia
- (minus) power spherical lens; for example: - 2.00 D
Correction of hyperopia
+ (plus) power spherical lens; for example: +2.00 D
Correction of astigmatism
- power cylindrical lens; for example: - 2.00 D at 90 degrees (axis of
astigmatism on a 180-degree rotary scale)
Spectacle lenses
Two lens powers for both near
and distance vision can be
inserted into a single frame
Three lens powers for
distance, intermediate and
near vision
Smooth, seamless progression
of many lens powers for clear
vision across the room, up
close and at all distances in
between
Correcting refractive errors
Contact • CLs are superior in severe refractive errors and anisometropia
• Also used therapeutically in corneal disease as bandage CLs or
lenses as prosthetic lenses for the scarred cornea or iris abnormality
Indications for contact lenses
• Cosmetic (e.g. To avoid glasses).
• For sport (e.g. tennis and skiing for wider field)
• Severe refractive errors:
○ High myopia (e.g. >6D myopia): a patient with
high myopia depends on contact lenses for visual acuity
and a wider visual field
○ Aphakic children without an intraocular lens
after congenital cataract surgery
○ Irregular astigmatism (e.g. rigid contact lenses
for corneal scarring and keratoconus)
Cosmetic / prosthetic contact lenses
This person has a defect in his left iris (top
photo). After a fitting with a prosthetic contact
lens, the eye has a more natural appearance
(bottom photo). Images: Orion Vision Group.
Therapeutic bandage contact lenses
• Protection of normal epithelium
• i.e: To protect the cornea if there are sutures on the
lid margin or under the eyelid, abrading the cornea.
Use until sutures dissolve or can be removed.
• Healing abnormal epithelium
• i.e: corneal abrasions and erosions
• Pain relief
• i.e: Bullous keratopathy—CL help to alleviate pain by
covering exposed nerve endings
Complications
• Punctate corneal erosions
secondary to epithelial
ischaemia
• Corneal vascularisation
• Allergy to or toxicity from
preservatives
• Giant papillary conjunctivitis
(undersurface of upper lid –
resembles hay fever)
• Corneal ulceration and infection
Advice for patients
• Maintain a high standard of CL hygiene
• Lenses should be cleaned and disinfected each
time they are removed
• Avoid overnight wear
• Have back-up spectacles
• Leave lenses out when adverse symptoms or a red
eye develops
• Remove soft lenses while administering
preservative containing drops
Refractive surgery: Excimer laser
• Reshaping the cornea using an
excimer laser, allowing light
entering the eye to be properly
focused onto the retina for clear
vision.
• Have a high success rate so that
PRK: Photorefractive keratectomy patient satisfaction is high, but
LASIK: Laser-Assisted in Situ Keratomileusis complications, though rare, can
SMILE: Small inciison lenticule extraction occur
Complications: Corneal haze / Over-
correction, under-correction / Regression
of effect / haloes / starburst phenomena
PRK vs LASIK
PRK LASIK
• Epithelium is removed and • A thin flap is created on the
discarded prior to reshaping the cornea with a microkeratome or a
underlying corneal tissue with an femtosecond laser
excimer laser • The flap is lifted to expose the
• The epithelium repairs itself within underlying corneal tissue and is
a few days after surgery. replaced after the cornea is
• Recovery takes longer than reshaped with an excimer laser
recovery from LASIK • Less discomfort, faster recovery
• Slightly increased risk of eye • Vision stabilizes more quickly
infection and haziness of vision in
the first few days after surgery
• Suitable for patients with a thin
cornea
Thank you
[email protected]
İnstagram: doc.dr.basakbostanci
