REFRACTIVE ERRORS

Dr. LEOW THYE YNG

BSc (Hons), MB BCh BAO (NUI),
Dip.Opt., MCOptom, MRCOphth,
FRCS (Glasg).
 Lenses

POSITIVE or CONVERGING
NEGATIVE or DIVERGING

positive negative
 The POWER of a lens , P

The “ DIOPTRE (D ) “
A positive lens of one dioptre (+1.00D)
converge parallel light rays to a ‘real’ focal
point one metre from (after) the lens.
A negative lens of one dioptre (-
1.00D) diverge parallel light rays as if they
are coming from a ‘virtual’ point one metre
infront of the lens.
ONE DIOPTRE LENS

P = +1.00 D
f = +1.0 m or
+100 cm

P = - 1.00 D
f = -1.0 m or
-100 cm
 The DIOPTRE (D)

1
Power, P (D) = -----------------------
----
Focal Length, f (metre)

eg. If P = +2.00 D, f = +0.5 m or +50 cm eg. If

P = +4.00 D, f = +0.25m or +25 cm eg. If P =
-2.00 D, f = -0.5 m or -50 cm eg. If P = -
4.00 D, f = -0.25m or -25 cm
 Refractive Index (n)
Velocity of light in vacuum
n=
-----------------------
----------------
eg. Velocity of light
Air eg. n = 1in the
medium n = 1.33
Water
eg. Cornea n = 1.376
eg. Crystalline lens n = 1.38 to 1.42
eg. Crown glass n = 1.52
Refractive Power of a
curved surface ( P )

n2 - n1
P (dioptre)=
---------------------
r (metre)
wherer = radius
of curvature of the refractive surface in
metres
 Refractive Power of the
anterior corneal surface

n1 = 1.0 (air) , n2 = 1.376 (cornea) , r

= 8mm or 0.008m (radius of curvature
of cornea)
P = (1.376 - 1) / 0.008 = 47 D
 Refractive Power of the
Cornea

The total refractive power of the cornea is

approx. +40 D (ie. less than +47D for the
anterior surface as this is reduced by the
negative power of the posterior surface)
Refractive Power of the
Eye and its axial length

Power of cornea ~ 40 D
Power of the crystalline lens ~ 20D
Refractive Power of the ave. eye~ 60 D
Assuming n = 1.33 for the eye,
ave. length = n / power = 22.22mm
The axial length of most eyes fall between 22
to 24mm (ultrasound scan).
 Key Words
EMMETROPIA
AMETROPIA
- Myopia or ‘Short-
- Hypermetropia (Hyperopia )
sightedness’
or ‘Long-
sightedness’ - Astigmatism
ACCOMMODATION
PRESBYOPIA
Anisometropia , Amblyopia
 EMMETROPIA

Light rays from distant objects (parallel rays)

are focused onto the retina in a fully relaxed
eye
 MYOPIA
Light rays from distant objects are focused
infront of the retina in a fully relaxed eye
Usually too long eyeball length, or sometimes too
high refractive power
 Myopia - Far Point

A myopic person can see objects placed at

the far point or nearer.
 HYPERMETROPIA
(HYPEROPIA)
Light rays from distant objects are focused
behind the retina in a fully relaxed eye
Eye too short, or refractive power is too low
(eg. Aphakia where there is no crystalline lens)
 ASTIGMATISM

In many people, the corneal surface is not

perfectly spherical (radius of curvature the
same in all meridians) like a soccer ball
surface. curvature
Many corneas have different r) in
(hence different powe like a rugby
different meridian,
ball surface.
 Astigmatic eye
Any combination of positions of focal points in
relation to the retina is possible - myopic,
hyperopic or mixed astigmatism
Astigmatism - circle of
least confusion
 ACCOMMODATION

Contraction of the ciliary muscles in the eye

allow the crystalline lens to increase its power.
This increases the power of the eye so that it
can focus at near objects.
It also allows young hyperopes to overcome
the hypermetropia if this degree is not too high.
 AMPLITUDE OF
ACCOMMODATION

The range of accommodation decreases with

age as the crystalline lens and, to a lesser
extent, the ciliary muscles become less
elastic.
Amplitude of accommodation
with age
 PRESBYOPIA

By 40 to 45 years of age onwards, the

amplitude of accommodation may not be
sufficient to allow a person to read at near.
This is PRESBYOPIA.
Additional plus lens power is usually
required.
 Anisometropia

Difference in the refractive errors of the

two eyes.
If sufficiently different in both eyes,
amblyopia (“lazy eye”) will occur in the
eye with the more blurred image.
Importance of early detection in children
as correction before 8 to 9 years of age
can prevent amblyopia.
Correction of refractive
errors

Spectacle lenses Contact lenses

Intraocular lens implants esp. after cataract
removal
REFRACTIVE SURGERY
-Excimer Laser (“LASIK” or “PRK”)
-Intracorneal ring implants
-Intraocular ‘contact lens’ (“ICL”) or
Phakic Intraocular lens
Myopia - correction with a
minus lens
Hypermetropia - correction
with a positive lens
Astigmatism requires a
spherocylindrical lens
Spherocylindrical lenses have different
powers in different meridians
 Presbyopia - spectacle
correction

Two pairs of glasses - one distant, one near

Bifocals lenses

Multifocals or Progressive lenses

 EXCIMER LASER
EXCIMER = “ Excited Dimer “ 193 nm
(ultraviolet)
Breaks the intramolecular bonds of the corneal
tissue (photoablation )
PRK - “Photorefractive Keratectomy” LASIK -
“Laser in-situ keratomileusis”
Flatten the corneal curvature ie.reduce the
refractive power of the cornea in myopia
may also correct hyperopia and astigmatism
PRK – Photorefractive
Keratectomy
LASIK – Laser in-situ
keratomileusis
Lasik 1
Lasik 2
Lasik 3
Lasik 4
Lasik 5
Lasik 6
 Lasik - Complications

Corneal stromal flap complications Infections

Corneal melting, corneal haze, corneal ectasia
Dry eyes
Glare - esp. night driving
Loss of visual acuity or constrast sensitivity
Retinal detachment
 Epi-LASIK

Epithelial Flap instead of Corneal Stromal

Flap i.e. more superficial cut
Excimer laser as in PRK Said to be safer than
LASIK
Intraocular Contact Lens /
Phakic Intraocular Lens
Phakic IOL
Phakic IOL
CONDUCTIVE
KERATOPLASTY (CK) for
presbyopia
Radiowaves applied to
corneal periphery to
alter the shape of the
cornea i.e. steepen the
corneal curvature
Reduce hypermetropia /
increase myopia
 Visual Acuity

Minimum angle of resolution of the eye

~ 1 min. of arc (60 sec)
The normal eye can discriminate two points
as separate if they subtend at least an angle
of 1 min. at the eye
Snellen Charts
 The Snellen “ E “

D (D
distance m. this letter subtend 5 min. -
eg. 60, 36, 24, 18, 12, 9, 6, 5 metres)
Snellen Acuity
 Recording Visual Acuity
(Snellen Acuity)
Test Distance (m.) Snellen
Acuity = -------------------------
-----
Distance (m.) at
which the smallest visible letter subtend
5 min. of arc
Test6/18,
eg. 6/5, 6/6, 6/9, 6/12, Distance
6/24,is 6/36,
usually at 6; m.
6/60 5/60, 4/60, 3/60, 2/60, 1/60 ; CF
(Counting fingers), HM (Hand movements), PL
(Perception of light),
Determination of
Refractive Errors

OBJECTIVE - does not require a response

1)Infants and young children requires retinoscopy
under cycloplegia
(Cyclopentolate 1% or rarely atropine 1%
eyedrops are used to immobilise the ciliary
muscles and hence block accommodation)
2)AUTOREFRACTORS (computerised)
SUBJECTIVE - patient asked to choose
between lenses
Importance of vision
checks on young children
In addition to manifest squints, high
degrees of anisometropia, astigmatism,
hyperopia and myopia can cause
amblyopia (lazy vision) due to blurred
image on the fovea of one or both eyes.
A sharp retinal image is essential for
development of a normal visual acuity
Importance of early detection of visual
problems for early treatment
 Treatment of Amblyopia

Optical correction of refractive errors (with

or without patching of the better eye) before
8 to 9 years of age is crucial.
The younger the age at commencement of
treatment, the better the results.
Results are generally disappointing after 9 to
10 years old.
Change of refractive errors
with age

Low grade hyperopia (ave.~ 2D) at birth

Slight increase in hyperopia during first 7
years
Gradual decrease in hyperopia throughout
primary school
Trend to drift into myopia by end of
primary/early secondary, and increase in
myopia throughout secondary school
Change in refractive errors
If hyperopia of about +2.50D at 6 years, tend to
be emmetropic at 14 years; if > +2.50D at 6 yrs.,
some hyperopia will remain at 14 yrs.
Myopia tend to increase through secondary
school till early 20’s, then level off
Some drift towards hyperopia esp. after 40 yrs.,
but hardening of the lens nucleus cause a shift
into myopia esp. in the older age.
Factors in development of
myopia
Genetic - family, uniovular twins, race
-Japanese, Chinese, Jews,
Germans
Environment - close work
-indoors
?Pre-existing astigmatism
?Lack of exercise, ?food
?Role of parasympathetic system - ?Use of
parasympathetic blocker like atropine