Refraction

Refraction

• Consists of :
– General Optics
– The optical system of the eye
– Clinical anomalies : refractive errors
 Optic

• Dioptri (D) : Lens power unit

D = 1/f

D = Dioptri
f = Focus (m)

Eg : D = 1/0,25  D = 4 D
 Principles

• Rays coming from distance > 5 m

parallel rays

• Rays coming from distance < 5m

divergent rays
 Lenses
• Spherical lens
• same curvature diameter in all meridians
• Cylindrical lens
– two meridians that perpendicular to each other
• Spherocylindrical lens
 Lenses

• Convex  plus (+) lens

Parallel rays will be converged to the focus

Spherical Convex (+)

 Lenses

• Concave  Minus (-) lens

Parallel rays will be diverged as if it comes
from the focus

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
• Characteristic of Spherical Lens :
– Plus sphere : makes larger and nearer images
– Minus sphere : makes smaller and farther images
 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 C + 1.00 D X 90 0
+ 2.00 0.00 + 2.00
0.00

+ 2.00
+ + 1.00 + 2.00
+ 1.00

+ 2.00

+ 3.00
 Eye as an Optical Instrument

• Refraction media :
– Cornea n = 1.33
– Humour Aqueous n = 1.33
– Lens n = 1,41
– Vitreous body n = 1.33
• Haziness on refraction media --> disturbances of vision
• Power of refraction of the eye ball
– Totally : 60 dioptri
– Cornea : 40 dioptri
– Lens : 20 dioptri
• Accommodation Process
– Lens capability to increase convexity
– M. ciliaris Contraction in the ciliary body
– Effect  adding the eye refraction power
 Rays from > 5 m
distance = parallel light; eyes in
relax position  images focused on
the retina (fovea centralis)
Rays from < 5 m
Rays  divergent. Images
focused behind the retina. So
the object will be seen blurred.
images must be moved forward
to focused on the retina by
increasing the convexity of the
lens. This process is called
accommodation process.
• Near Vision Reflex:

– Accommodation
– Miosis
– Convergents
 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

– Curvature : cornea, lens curvature
– Increasing of the refraction index : DM patient
– Changes of the lens location : lens subluxation
• Clinical findings :
– Farsightedness blurred, nearsightedness normal
– Asthenopia
– Squinting eye lids  better vision
• High myopia  proptosis, deep Anterior Chamber
• Funduscopy : Tigroid fundus ---> thin retina and
the choroid, myopic crescent arround the papilla
area, staphyloma posterior
• Complication :
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
• 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  detected without paralazing
accommodation and is represented by the
strongest convex glass needed , Divided 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  convergent
strabismus
• 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 :
– Maximum refraction Right angle
– Minimum refraction 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 :
0
– Ast. M. Simplex C-2.00 X 90
– Ast. H. Simplex C+2.00 X 45 0

– Ast. M Compositium S-1.50 C-1.00 X 60 0

0
– Ast. H Compositium S+3.00 C+2.00 X 30
0
– Ast. Mixtus 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

10 20 40 50 60 Age
• Presbiopia correction :
– 40 years old S + 1.00 D
– 45 years old S + 1.50 D
– 50 years old S + 2.00 D
– 55 years old S + 2.50 D
– 60 years old 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 :
I. AVOD 2/60 S - 3.50 = 6/6 ODS 6/6
headache, eye strain
AVOS 3/60 S - 3.00 = 6/6
II.AVOD 2/60 S - 3.00 = 6/7 ODS 6/6
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
• Eye Glasses
• Monofocal
• Bifocal
• Progressive
• Eye Glasses Prescription, the components
are :
– Which eye (OD or OS)
– Power of the lens ( + or - , Power, axis)
– ADD for reading
– Pupil distance far/near
– Name of the patient