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An exhaustive Medline, Pub Med and Cochrane database internet search was conducted with reference
manager 11. Meticulous Google search using keywords such as refractive errors and ametropia fetched
additional information. Refractive errors being an optical defect in which refracted light rays do not
converge on the fovea of a relaxed eye, corrective interventions are either optical or surgical. These
established modalities of treatment, however, may not always translate into freedom from asthenopia.
Optical impurity imperceptibly degrades quality of best corrected visual acuity. This article considers
aberropia a specific tenacious optical impurity rather than a full-fledged refractive status favoured by its
proponents.
INTRODUCTION
Refractive error (ametropia) is an optical defect in which to unequal refraction of incident light by the dioptric
rays of light from optical infinity fail to converge on the system of the eye in different meridians (Elkington et al.,
fovea in the non-accommodating eye (Waddell, 2000; 1999; Abrams, 1993; Kakuwa and Maiyeku, 2002).This
Elkington et al., 1999; Abrams, 1993). Cornea and lens, article sought to appraise refractive errors and emerging
the main ocular refractive elements, form a relative thick thoughts in ocular optics.
lens refracting complex that operates as functional
syncytium. The outcome of cornea-lens interactions on
incident beam of light are refracted rays destined for the Emmetropization
fovea. However, not all refracted rays will reach the
fovea, some fall short while others exceed it (Waddell, This constitutes intrinsic mechanisms of the eye to
2000; Fred, 1996). achieve emmetropia in childhood. Each refractive
Parallel rays of light come to a focus in front of fovea in component (cornea, lens, axial length) changes in a
the non-accommodating myopic eyes. Abrams (1993) complementary and coordinated manner as the eye
reported that Kepler was the first to give a satisfactory grows in order to minimize refractive error (David and
definition of myopia in 1611 and Plempius was the first to Difford, 2004; Ian et al., 2009; Mutti et al., 2005; Mutti et
examine such eyes anatomically in 1632 while Donders al., 2007). It seems possible that the process of
established its clinical basis in 1866. emmetropization is coordinated by the retina-brain
Hypermetropia, a term suggested by Donders in 1958, complex, which might tune each refractive component of
refracted rays are brought to a focus behind the retina the eye to ensure a sharp image. In what appears to be
when the eye is at rest. Potency of accommodative failed, incomplete or distorted attempt at
efforts determines whether hypermetropia is latent or emmetropization, myopia and hypermetropia ensue
manifests (Elkington et al., 1999; Abrams, 1993; Ebri et owing to ‘naturally occurring’ residual incongruity
al., 2007). between the power of the optical elements of the eye and
In astigmatism, two focal lines, separated by a focal the axial length.
interval and straddling circle of least confusion, form by Various theories have attempted to explain incomplete
the principal meridians to emerge a Sturm`s conoid. emmetropization or secondary ametropia following a
Consequently, there is no point focus on the fovea owing perfect emmetropization.
Megbelayin 022
Genetic theory 89.9%. Medical students are a group of young adults who
spend prolonged periods on reading and close work. With
The refractive state of the eye is contributed by each their intensive study regimen that spans on the average
refractive component of the eye; cornea and lens (David of 6 years, medical students have been reported to be at
and Difford, 2004; Young et al., 2007). With each having high risk for myopia.
a refractive index of 1.34 ((Elkington et al., 1999.), the
contributions of aqueous and vitreous are constant and
hardly change with eye growth. Thus the major refractive Other theories
components of the eye that undergo changes during the
growth period are the cornea, the lens and the axial Socio-economic status, environment, prematurity, height,
length. The size, shape and power of each are nutritional status, levels of education of parents,
determined by inheritance (Young et al., 2007). intelligence, intra-uterine environment and bony orbits are
Many studies have corroborated the familial and other risk factors linked in various ways to the onset and
heritability of ocular components of refractive state of the progression of refractive errors especially myopia
eye (Hammond et al., 2004; Hammond et al., 2007; Biio (Hammond et al., 2001; Saw et al., 2001; Mutti et al.,
and Corona, 2005; Lee et al., 2005). Biio et al. (2005) 2002; Rose et al., 2008).
reported that estimates of heritability for axial length
range from 40-94% and anterior chamber depth from 70-
94% with linkage to chromosomes 2p24 and 1P32.2 Presbyopia
respectively. Heritability estimates for corneal curvature,
in the same study, was 60 to 92% with linkage to Presbyopia is not considered a refractive error like
chromosomes 2p25, 3P26 and 7q22. Lyhne et al. (2001) in myopia, hypermetropia and astigmatism. Perhaps,
an earlier study among twins aged 20 to 45 years because rays of light emanating from reading distance of
reported 90 to 93% heritability for crystalline lens 33.3cm are not parallel but divergent (i.e. negative
thickness. vergence). More importantly, presbyopia, being a natural
Different modes of Mendelian inheritance are development of sight, results from physiologic failure of
associated with refractive errors including autosomal accommodation due to aging, regardless of eye’s
dominant (AD) and sex-linked (X-linked). Loci for refractive status ab initio. For an eye to be tagged
autosomal dominant high myopia are located on ametropic, therefore, it must be accessed by parallel light
chromosomes Xq28, 18p11.31, 2q37, Xq23-25 and 4q. To rays and its accommodation, if present, should be
date, almost 100% of identified loci for non-syndromic relaxed.
high myopia are either AD or X-linked with high
penetrance (Lyhne et al., 2001; Young et al., 2007). In a
dizygotic twin study, Hammond et al (2004) found that Aberropia
Paired box gene 6 (PAX 6) is strongly linked with
refractive errors. Interestingly, emmetropization was Aberropia, coined by Agarwal et al. (2002), was defined
reported by Mutti (2002) to be largely programmed on as a refractive error that results in a decrease in visual
genetic basis. quality attributable to high order aberrations (HOAs).
Myopia has the strongest evidence for genetic Lower order aberrations are responsible for spherical
susceptibility, although studies have shown different loci and/or cylindrical errors. The availability of aberrometers
between juvenile-onset myopia (low to moderate myopia) of which there are three types; Tschering, Hartmann-
and high myopia. Conversely, hypermetropia and Schack and Ray tracing has enabled wavefronts to be
astigmatism have weaker and less consistent linkage determined and measured thereby unveiling poor vision
with inheritance (Hammond et al., 2001; Lee et al., 2001; due to aberropia. Interesting, aberropia has been linked
Mutti et al., 2002; Young et al., 2007). with residual visual complaints following ametropic
correction. These complaints could arise despite best
corrected visual acuity (BCVA) of 6/6.
The use-abuse theory Although the term aberropia is relatively new, ocular
and spherical aberrations, from which it evolved, have
This theory states that close work causes and contributes been well studied (Megbelayin, 2012). Inherent in ocular
to the progression myopia, as seen in the higher refractive apparatus: tear film, cornea, lens, vitreous and
prevalence of myopia in those with more education and retina are spherical aberrations (Abrams, 1993; Elkington
those who engage in more near-work activities (David et al., 1999). Fortunately, the human eye has various
and Difford, 2004; Karythryn et al., 2008). Woo et al. innate corrective mechanisms that obviate effects of
(2004) conducted a study among Medical students in image imperfections, including the retinal Stiles-Crawford
Singapore reported an alarming myopia prevalence of effect (Elkington et al., 1999). It can then be speculated
023 Wudpecker .J. Med. Sci.
that residual image imperfections occur when these impurity on corrected refractive error tends to zero (become
intrinsic efforts are overwhelmed. infinitesimally small), it effects on corrected vision
Aberropia is possibly a sub-refractive entity rather than becomes negligible because a state of optical unity is
full-fledged refractive error promoted by its proponents. attained. Unity in this context is a state of optical
Because two lens effects (either positive or negative): neutrality, quiescence or noninterference in which the net
positive sphere (for hypermetropia), minus sphere (for effects of optical impurity do not interfere with corrected
myopia) and positive or negative cylinder (for ametropia culminating in BCVA with no residual
astigmatism) influence ocular refractive apparatus to complaints.
focus images on the retina. Since there is no third lens
type, a new refractive error is unlikely. Again, the
established treatments of aberropia introduce a Examples of optical impurity (table 1)
cumulative plus lens or minus lens effects on ocular
optical system signifying that the extra visual improvement
on BCVA was an uncorrected (missed) refractive error. High Order Aberrations (HOAs)
Additionally, based on existing classification of
aberropia, majority of the causes are pathological Patients suffering from HOAs report residual visual
(Agarwal et al., 2002; Agarwal et al., 2003). Refractive complaints despite BCVA of 6/6. The HOAs of major
errors are by definition, non-pathologic, improved with clinical significance are coma (vertical and horizontal)
Pin-hole (PH) and correctable to 6/6 except in amblyopia and spherical aberrations (Weitz and Cummings, 2011).
or pathologic ametropias. The possibility exists that HOAs constitute tenacious sub-
Aberropia appears an optical impurity with unusual dioptric impurity missed during conventional optical
tenacity and dioptric insignificance. Refractive errors are correction. Aberropia has been largely linked with HOAs
corrected within 0.25 diopter spheres (DS) errors and (Agarwal et al., 2002).
patient often cannot improve on numbers or clarity of
Snellen’s charts optotypes read when BCVA is attained
Chorioretinal diseases
with addition or subtraction of 0.25DS (George, 2006).
Hence, whatever is responsible for post correction
The retina is akin to a film of a camera. It is likely that
residual visual dissatisfaction found in patients with
certain conditions confer on this ocular “film” poor image
aberropia despite BCVA of 6/6 could not have been due
resolution capability. These conditions include epiretinal
to missing 0.25DS to which the eyes were insensitive?
membrane, myopic degeneration, occult maculopathy,
Aberropia should therefore be considered a qualitative
retinal folds et cetra. Perhaps, poorly resolved retinal
rather than a quantitative phenomenon given that the images do not regain fidelity despite normal cortical
dioptric net effects are less than 0.25DS on the ‘clinical processing and maximal optical corrections.
eye’. By clinical eye, it is meant best corrected eye.
Being without significant dioptric effects, optical impurity,
rather than refractive error, appears appropriate to qualify Accommodation convergence accommodation
aberropia in that it sabotages corrected retinal image (AC/A) anomaly
fidelity, rendering it less than perfect (‘impure’).
Convergence insufficiency and paralysis of
accommodation are non-refractive accommodative
Unity theorem of optical impurity (proposed by this entities. Persistence of AC/A anomaly results in a
article) dissatisfied vision due to altered near synkinesis. It is
likely that a deranged binocular interaction associated
For BCVA to be faultless, with immaculate fidelity, in with this condition introduces image-compromising status
which patients are free from all residual complaints, a on the retina. This could be attributable, at least in part, to
state of optical neutrality appears to exist. Therefore; asymmetrical simultaneous retinal perception despite
equal and corrected retinal image sizes. Therefore,
conventional optical corrections are inept in removing the
1.
non-refractive entities (introduced by AC/A anomaly),
christened optical impurity by this article.
Where x is optical impurity
corrections, abnormal pupil size tends to create problems spectacle by patients poses an enormous threat to
with image clarity. Perhaps, diffraction with resultant airy maximizing the corrective potentials offered by optical
disc (seen with miosis) and excessive peripheral option. Spectacle phobias or hatred of this magnitude
aberrations (with mydriasis) introduce a non-refractive should be isolated as non-refractive impediments (optical
entity (optical impurity) irresponsive to refractive impurity) that attenuate benefits derivable from optical
corrections. correction.
Despite accurate refraction and dispensing of appropriate Glaucoma, corneal facet scar, incipient cataract and poor
refractive correction, ametropic patients may still express ambient light create contrast problems. In severe forms of
dissatisfaction with BCVA. Patient’s emotional state and these conditions refractive spectacles may not be helpful.
unwillingness to accept refractive spectacle create As each condition evolves, however, a stage is reached
invisible barriers between refractive lenses and the when contrast between objects and their environment is
objects they are meant to see. Morbid rejection of severely affected. Often objects are identified but clarity
025 Wudpecker .J. Med. Sci.
is jeopardized. It is being considered that conditions Orthoptic exercises may be useful in convergence
associated with reduction in contrast add a sub-refractive insufficiency. Clinico-pathologic conditions like incipient
moiety (optical impurity) that thwarts the full benefits of cataract, macular pucker and glaucoma et cetra should
ametropic corrections. be looked for and treated using established means.
Multidisciplinary approach is advocated for patients with
emotional disturbances. Other modalities of managing
Emotional lability and stressors nagging residual asthenopia in patients with normal
BCVA would include psychotherapy, nutritional
There are myriads causes of emotional instability, assessment, improving on ambient light, counseling,
ranging from mind boggling worries ignored by the relaxation and internists’ review.
patients to manifest conditions. Examples will include
anxiety disorders, pregnancy and puerperal anxieties,
menstrual anxieties in adolescents, general debility, Conclusion
anemia, malaria, malnutrition, drug-related, chronic
alcoholism, excessive near work, etc. These stressors Aberropia is not a full-fledged refractive error but a
are occasional non-refractive accomplices of ametropia. plausible optical impurity that sabotages retinal image
Unlike the latter, however, they subsist despite refractive fidelity following conventional refraction.
corrections. These optically unyielding sub-refractive
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