Refraction

Dr.Ani, SpM

Refraction
Consists of :
General Optics The optical system of the eye Clinical anomalies : refractive errors

Optic
Dioptri (D) : Lens power unit, is an inverse of focal distance in meters D = 1/f 1 D lens, parallel light will be directed into focal spot in 1 meter distance 2 D = 1/f ----> f = ? If f = 25 cm , ----> D = ?

 Parallel rays will be converged to the focus ---> Plus lens (+)

or will be diverged as if it comes from the focus ----> Minus Lens (-)

Principles
Rays coming from distance > 5 m parallel rays Rays coming from distance < 5m divergent rays

 Spherical lens
Is a lens with the same curvature diameter in all meridians

Spherical Convex (+)

Spherical Concave (-)

 A convex lens may be regarded as a series of prisms bases toward the middle of the lens A concave lens may be regarded as a series of prisms apex toward the middle of the lens

 Prismatic Effect that occur on eye glasses explain :

Against motion with (+) Lens With motion, with (-) Lens

Spherical Lens :
Plus sphere : Convex
characteristic : makes larger and nearer images

+2

+2

+4

+5

-1

Biconvex

Plano K

Concave K

 Minus sphere : Concave

Characteristic : makes smaller and farther images
0 -4 +1 -5

-2

-2

Bi Concave

Plano K

Convex K

Parallel rays will be centered or diverged from the focus

Cylindrical Lens
Is a kind of lens that have two meridians that are perpendicular to each other The meridian that has no power is called the axis The other meridian, has the power

 Spherocylindrical Lens
Is a combination between spherical lens and cylindrical lens Example :
S + 2.00 D
+ 2.00 0.00

C + 1.00 D X 90 0
+ 2.00 0.00 + 1.00 + 2.00 + 1.00

+ 2.00

+ 2.00

+ 3.00

 Transposition
Methods : Sphere : Sum with algebra ways SPH + CYL Cylinder : replace power marks (Neg Pos), axis change 90 degrees Example : S + 2.00 C + 1.00 X 900
S + 3.00 C - 1.00 X 1800

Eye as an Optical Instrument

Refraction media :
Cornea Humour Aqueous Lens Vitreous body n = 1.33 n = 1.33 n = 1,41 n = 1.33

Haziness on refraction media --> disturbances of vision

 Power of refraction of the eye ball

Totally Cornea Lens : 60 dioptri : 40 dioptri : 20 dioptri

 Accommodation Process
Capability of adding the refraction power of the eye, by increasing the convexity of the lens normal : rays that come from > 5 m - distance object regarded as parallel light; the eyes are in relax position, the images are focused right on the retina (fovea centralis)

 For object at less than 5 meters distance, the rays do not come parallel but divergent. If the eyes are still in relax position, the images will be focused behind the retina. So the object will be seen blurred. These images must be moved forward so it will be focused on the retina by increasing the convexity of the lens. This process is called accommodation process.

 This accommodation process happens as a result from the contraction of M. ciliaris in the ciliary body

 These reflexes also happen during the accommodation process :

Accommodation Miosis Convergents Near Reflex

Refraction Anomalies
Normal : Emetropia Anomalies : (ametropia)
Myopia Hypermetropia Astigmatism Presbiopia

 Emmetropia
Is the condition when the parallel rays focused exactly on the retina of the eye in relax condition ---> the visual acuity is maximum

 Ametropia
Is the condition when the parallel rays are not focused exactly on the retina of the eye in relax condition. The focal point may be behind or in front of the retina

Hal 47, 4.2 Duke Elder

 Myopia
Refractive condition in which, with accommodation completely relaxed, parallel rays are brought to a focus in front of the retina. Myopic eye : refractive state over plus power

 Factors that causing myopia :

Axial : The antero-posterior axis of the eye ball > normal
in this case, the refraction power of the cornea, lens and the lens position are normal. The eye usually looks like proptosis

Curvature :
The size of the eye ball ---> normal, but there is a increasing of the cornea/lens curvature The change of the lens e.g. : intumescens cataract

Increasing of the refraction index

could occur on Diabetic patient

Changes of the lens location

changes of the lens position to the anterior after glaucoma surgery lens subluxation

 Clinical findings :
Farsightedness are blurred, nearsightedness are normal Asthenopia On high myopia : hemeralopia occurred caused by periphery retinal degeneration Floating spots visualization caused by vitreous degeneration screw up the eye lids together, in order to get a better vision

On high myopia ----> proptosis simulation, deep Anterior Chamber

 Funduscopy : Tigroid fundus ---> thin retina and the choroid, myopic crescent arround the papilla area, sthaphyloma posterior

 Complication :
Commonly occurred on high myopia 1. Degenarated and liquefied vitreous 2. Retinal detachment 3. Pigmentation changes + Macular bleeding 4. Strabismus

Myopia classification :
< 3.00 D = low myopia 3.00 - 6.00 D = moderate myopia > 6.00 D = high myopia/gravis

 Treatment :
Low and moderate myopia : full correction with weakest spherical lens that give the best visual acuity
Example : VOD = 5/60 S -2.50 D = 6/7 S -2.75 D = 6/6 S -3.00 D = 6/6 S -3.25 D = 6/7

The glasses are S - 2.75 D

On high myopia, usually full correction are not given due to headache that may occurred. If necessary, reading glasses can be given ---> bifocal glasses

 Prognosis :
Simplex/stationer, after puberty will be constant

Progressive myopia, the myopia will be

continuously higher and complication may

occurred

Hypermetropia
Is a refraction anomaly that without accommodation parallel rays will be focused behind the retina Divergent rays from near object, will be focused farther behind the retina

 Etiology :
Axial ---> eye ball diameter < N
Deminished convexity of cornea/lens curvature Decreasing Refractive index Changed lens position

 Clinical manifestation :
H. Manifest ---> is detected without paralazing accommodation and is represented by the strongest convex glass needed , the patient sees most distinctly. It correspons to the amount of accommodation which he relaxes when a convex lens is placed before the eye. Devided into two types :
Facultative : Can be overcome by an effort of accommodation Absolute : Can not be overcome

 Total Hipermetrop : detected after the

accommodation has been paralyzed with cylcopegic agents Latent Hypermetrop : is the diference of the total hypermetrop with the manifest

hypermetrop

Hypermetrop

Latent Hypermetrop

Hypermetrop manifest

 Clinical finding :
Nearsightness are blurred
High hypermetropia at old age : farsightedness also blurred Astenophia accommodative (eye strain) Children : high hypermetropia usually occurring convergent strabismus (convergent squint)

 Treatment :
If foria/tropia not present, apply strongest positive spherical lens that give the best visual

acuity
If foria/tropia present, total hypermetrop correction. If necessary : bifocal eye glasses

astigmatism
Refractive condition of the eye in which there is a difference in degree of refraction in diferent meridian, each will focused parallel rays at a different point. The shape of the images : Line, oval, circle, never a point

 Manifestation :
Regular astigmatism
Difference in the degree of refraction in every meredian. Two principles meridian :
Maximmum refraction
Minimum refraction
Right angle to each other

Irregular astigmatism
Difference in refraction not only in different meridians, but also in different parts of the same meridian.

 Etiology of astigmatism :
Corneal curvature disturbances ---> 90% Lens curvature disturbances ---> 10%

Type of Astigmatism :
Ast. M. Simplex
Ast. H. Simplex Ast. M Compositium Ast. H Compositium Ast. Mixtus

C-2.00 X 90
C+2.00 X 45

0 0

S-1.50 C-1.00 X 60 0 S+3.00 C+2.00 X 30

0 0

S+2.00 C-5.00 X 180

Ast. M. Simplex

Ast. H. Simplex

Ast. M Compositium

Ast. H Compositium

Ast. Mixtus

Presbiopia
Physiological changes because accommodation capability is lowering at old age
Accommodation 16

10 6

2
10 20 40 50 60

Age

 Presbiopia correction :
40 years old 45 years old 50 years old 55 years old 60 years old S + 1.00 D S + 1.50 D S + 2.00 D S + 2.50 D S + 3.00 D

Consider the type of previous/history work

Tailor Architect Weld engineer

Refraction Examination Technique

Subjective :
Snellen chart/projector, alphabet , inverse E, picture, Landolt ring Trial lens Trial frame

Objective :
Children, incooperative, difficult correction, strabismus :
Ophthlamoscopy Retinoscopy Refractometer

 Subjective
Check firstly just one eye : OD Distance : 5 or 6 meters VOD : ...(basic right eye visus) a. Trial and error
apply S + 0.50, better visus , add S+ until visus = 6/6 S +0.50, lower visus, change to S -, increase S - until visus = 6/6 S +/- not working ----> cylindrical With astigmatism dial, stenoplic slit, cross cylinder astigmatism dial :
Blurred line ----> C negative lens axis

 One by one fogging

S + sp. Lens --> blurred vision, step by step distracting ---> best sp.

Nearsightedness/read
Both eyes at one time at required distance : use jaeger chart

 Example :
ODS 6/6 I. AVOD 2/60 S - 3.50 = 6/6 headache, eye strain AVOS 3/60 S - 3.00 = 6/6 ODS 6/6 II.AVOD 2/60 S - 3.00 = 6/7 w/o headache, eye strain AVOS 3/60 S - 2.75 = 6/7 read ADD S + 1.50 Give Eye Glasses according to II

 Objective
Use cyclopegic 1. Ophthlamoscopy : papilla clearly seen with which lens 2. Retinoscopy :
Ordinary ---> light source outside streak -----> light source inside

3. Refactometer
Computerized Lensmeter principal

 Ideally :
Subjective Objective with cyclopegic Subjective once more without cyclopegic

Lens meter
Measuring lens power Measuring focus distance

 Measuring Pupillary Distance

drop the flashlight light onto both eyes, the light is coming from in front of the patient, The patient look at the observer forehead or the light ----> measure the distance of light spot between OD and OS ----> as near pupil distance Far distance :
add 2 mm ---> for pupil distance less than 60 mm. Add 3 mm ---> for pupil distance more than 60 mm

 Eye Glasses
Monofocal Bifocal Progressive

Eye Glasses Prescription, the components are :

Which eye (OD or OS) Power of the lens ( + or - , Power, axis) ADDE for reading Pupil distance far/near Name of the patient

Binocular Optical Defects

Anisometropia :
Condition wherein the refractions of the two eyes are an equal variation : Myopia M
M. H. H. M. E. E. H. H

Antimetropia

 Vision in Anisometrop
difference < 2.50 D : still get fusion + single binocular vision difference > 2.50 D : fusion difficulties ----> weak eye suppression ---> amblyopic alternans vision : left and right alternate

Aniseikonia :
The difference of shape and size of the images between right and left eye

 Limitation of the eye glasses

cannot applied for anisometropia more than 2.50 Dioptri anisometropia causing aniseikonia

Contact lens :
Indication :

Hard ---> rigid lens Soft

High anisometropia irregular astigmatism Front asymmetry, orbit Aniridia Descemetocele Sports Cosmetics