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OUTLINE: I. II.

M11 Ophthalmology [MEDICINE]

19 October 2011
Benjamin Cabrera, M.D.

OPTICS & REFRACTION

Review of Optics Refraction A. The Refractive Index B. Prisms C. Diopters The Human Eye A. Accomodation B. Form Sense C. Minimum Visual Angle Refractive Conditions A. Emmetropia B. Ammetropia Treatment

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audio, [2013] upperbatch notes/audio

I. REVIEW OF OPTICS EYE AS AN OPTICAL INSTRUMENT 1. Physical Optics The physical properties of light [2013] Physical optics is concerned with how light, travelling from left to right, hits a lens or an optical system that causes refraction or bending of the light. 2. Geometric Optics The process in which external light energy is focused on the retina The eye is compared to camera. When you look at any source of light, it has no single direction (light goes in all directions); because of the lens system in the eye, the cornea and lens coverge the light, and you end up with a single image on your retina; the image is then converted into the brain. The image is inverted; it is only when it reaches our visual cortex, does it turn right side up EYE AS A SENSE ORGAN 3. Physiologic Optics The biochemical and functional processes that occur in the retina to produce visual energy 4. Psychologic Optics (Neuro- Ophthalmologic Optics) The conduction of visual energy to the occipital visual center [2013] From the retina, everything is perceived as lightwhether it is a mechanical, chemical, electrical stimulus. And as the image gets processed (beyond the optical system) onto the brain, there is going to be a meaning of what that image is. Cognizance of images occurs in the cortex where data is processed PHYSIOLOGY OF THE EYE

[2013] Sometimes you hear, the patient is cortically blind Example: Post stroke patients can see you but could not identify you. They can be aphasic, as they are able to see letters or words but it does not have any meaning to them. If you put these letters or words altogether, it does not make sense to them. They can recognize verbal stimuli but when you put in images or written words, they wont be able to understand it. It is also possible that they can comprehend what the image/words mean but they might have a hard time expressing it. You can identify malingering patients (they say that they cannot see but they actually can) through a visual threat. They will get a little scared when they see you about to hit them. If they are really cortically blind, the pupils will react, but they themselves wont react because their brains cannot interpret the image that they are about to get hit. THERE IS A PROBLEM IN THE VISUAL CORTEX. Ketalar, a sedative for childbirth, can cause transient cortical blindness. A. PHYSICAL OPTICS LIGHT is the basic stimulus for vision o The visible light (rainbow colors) has a prismatic effect o There are light rays that cannot be seen visibly (ex. UV rays) o Hence, there are shades/protectors that reduce these light rays. Light rays are there, but not necessarily needed for vision Visible range: 380-760

Figure 1. Parallel light rays travel, hitting the cornea and lens, causing refraction of light such that light is focused as a single point on the retina (if you are emmetropic). The retina processes the stimulus thanks to the rods and cones, and then sends images to the visual cortex.

Figure 2. ROYGBIV Duochrome test o Red and green side on the charts, since green and red are refracted in different wavelengths o Red falls in front of the retina; red will be dominant for the near-sighted o Green falls behind the retina; green will be dominant for the far-sighted o If both colors are dominant, patient is emetropic; this test has nothing to do with color blindness

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CHARACTERISTICS OF LIGHT *No need to memorize

MEDICINE

VELOCITY = WAVELENGTH X FREQUENCY

1. Velocity or Speed o 3 X 100 cm/sec in vacuum o Slower in clear air and in denser media Wavelength o Size determines the color o Violet (380) the shortest o Red (760) the longest Frequency o Number of complete cycles moving past a specific point over a given period of time

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B. PRISMS Any media whose 2 sides are not parallel will refract light rays Light is deviated towards the base of the prism. o Think that any spectacles or optical system is a prism o If you have 2 prisms converged base to base (biconvex) and light passes through it, light will converge convergent lenses o + lenses used for hyperopes (far-sighted); shorter eyeballs, you would like the image to fall sooner into the retina, you therefore need + lens o 2 prisms apex to apex light will diverge, images move farther away; if you are near-sighted, image falls in front of your retina, you would then like to use diverging lenses (-) lenses Lenses can be viewed as a certain arrangement of prisms (remember that light is deflected towards the base of the prism)

B. GEOMETRIC OPTICS Events that occur from the moment light strikes the eye and gets focused on the retina o [2013] Without this, every image is like the light coming from the sunscattered, coming from multiple points. It gives the image a focal point. Refraction: Principal basis is the transmission and bending of the direction of travel of light rays Depends on the medias density, i.e. Index of Refraction o [2013] Those with high grades can have their glasses lighter by having lenses with high index of refraction. Why? Because it depends on the material of your glassesthey can make it feel lighter or thinner through the higher index of refraction. You can have the same grade, with thinner glasses thanks to this. In air, light is omnidirectional, and when it hits a transparent medium, if the medium is transparent and vertical, the light goes through it Depending on the medium, it can slow it down or make it faster (index of refraction) II. REFRACTION A. THE REFRACTIVE INDEX (N) A predetermined constant depending on the material It determines the angle of deviation o Air = 1.0 o Water = 1.33 o Glass > 1.40 o This is why we cannot catch fish with our hands if we are above the water. The bending of light goes towards you, making it seem that the fish in the water is below you. It is simply a relative unit compared to air As light passes from one medium to another of a different index of refraction and at a certain angle, there is bending of light, i.e. light is refracted o The bending of the light is dependent on the medias density o A higher refractive index means it can focus more light

HYPEROPIC Converging light rays Positive lens Convex lens Far-sighted Apex-to-apex prisms

MYOPIC Diverging light rays Negative lens Concave lens Near-sighted Base-to-base prisms

Figure 3. Converging lenses biconvex lenses, Diverging lenses biconcave lenses. See how the light would refract based on the structure of the lenses [2013] Hence, with negative lenses, the light rays diverge. For myopic patients, you need to give biconcave lenses because you want to move the image farther back as these patients have longer eyeballs, hence youd want apex-to-apex prisms. For hyperopic patients, you need to give biconvex lenses because you want to move the image forward, as these patients have shorter eyeballs. You want the refraction to come in sooner Negative lenses will make things appear smaller (minify). Positive lenses will magnify.
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Question from the class regarding contact lenses: Contact lenses are still biconcave or biconvex. The thickness of the lens also depends on the grade. Its just the material that varies. Vertex distance is the distance from the spectacles to the apex of the cornea. So if youre myopic, and you move your glasses away from the eye, images would look smaller, because you are increasing the vertex distance. If youre hyperopic, it would look bigger. With contacts, the spectacles are right on top of the cornea. It has the same power, but it is just on top of the cornea, the power on the contact lens seems lower. But in reality, they are just equivalent. To repeat: o MYOPIC: (-) lenses, minifies o HYPEROPIC/PRESBYOPIC/MAGNIFYING LENSES: (+) lenses, magnifies Progressive lenses are graduated bifocal lenses that allow vision at various distances (ie. Near and intermediate). As your eye looks down on the spectacles, the (+) adds up, so it becomes your reading grade. There is a different (+) grade at different points of the progressive lenses (ex. looking down +200, looking up +100). This is important because presbyopic patients have multiple distances of use. Thats why sometimes older individuals would always move their necks and their heads just to read with an arms length. One disadvantage of a progressive lens is there is only one optimal corridor length, meaning there is only one portion where the progression lenses really work. If they look from left to right, they wont be able to see well (remember horses with blinders), because the progressive lenses work really well at the center only. C. DIOPTER A unit of measurement of lens power o The power of the lens will tell you how much it needs to focus the image on the retina. It is a measure of convergence or divergence, and a reciprocal of focal distance (in meters) Depends on the lens curvature and refractive index of the media D = 1/f o Focal point: the sharpest possible image o +1 diopter lens will converge light rays at 1meter away from the lens o 2+ diopter converge light at 0.5m away from the lens o +4 diopter lens will converge light rays at 25cm (0.25meters), i.e., 1/0.25m = 4D o 5+ diopter 20 cm (1/5 of a meter) This means that for a patient with 5+ diopter lens, his eyes would be most relaxed at 20 cm away without wearing his glasses o The higher the grade, the more you want to focus the image o Grade of 500 is a laymans term, but it really corresponds to 5 diopters

MEDICINE

III. THE HUMAN EYE Can be thought of as a series of lenses whose main goal is to focus light rays from the external world unto the retina: o Cornea, aqueous, lens, vitreous The average human eye has a total converging power of about 60 diopters. The main refractive components are as follows: o Cornea ~ +40 Diopters o Lens ~ +20 Diopters o 1/60= .016 (around 17 mm focal point) Eye as a refractive system The retina is not a refractive surface Lens has less refractive power than the cornea even if it is thicker than the cornea because the lens is between aqueous to vitreous, which has a lesser change in index of refraction compared to air to cornea [2013] The cornea has greater refractive power than the lens due to the higher index of refraction in going from air to the cornea, as compared to going from the lens to the vitreous. (These are different media, so index of refraction would differ). [2013] Because the cornea has a greater refractive power, the clinical implication of this is that refractive surgery is more effectively done on the cornea. [2013] The total converging power is 60 diopters. This corresponds to a focal point of 17 mm, meaning light rays will converge at 17mm away from the lens given 60 diopters. This tells us that to have normal vision, the length of the eyeball should be about 2224 mm. The distance from the apex of the cornea to the lens is about 5mm. Add this to 17mm and you get 22mm. [2013] Asians are generally myopic, perhaps because learning the idiographic characters (ie. Chinese, Japanese, Korean etc.) requires more visual effort (more concentration on a small image/detail just to read) Caucasians are generally hyperopic. IV. REFRACTIVE CONDITIONS A. EMMETROPIA A condition wherein parallel light rays fall into a pinpoint focus ON the retina However, this doesnt mean that axial length of the eyeball is at its ideal 23mm. It just means that the lens system as a whole focuses directly on the retina. All light rays fall on the retina without spectacles At 60 diopters, F= 1/60, focal point is roughly 16 mm or 0.16m If that were correct then from the back of lens to retina would be 16 mm Add 8 mm for anterior chamber, cornea Total would be 22-24mm ideal eye

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B. AMMETROPIA A condition wherein parallel light rays DO NOT fall into a pinpoint focus on the retina: Question: If I am far-sighted, does that mean I can see far clearly? No. Hyperopes need + lenses; Some hyperopes can still see without using glasses/refuse to wear glasses The image lies behind the retina; the person can make it fall on the retina through accommodation; when lens increases in anteriorposterior diameter, it increases its convergence power As the years go by, accommodation wanes and you will become more and more dependent on your glasses (eventually far-sighted will be more dependent than near-sighted people because their far and near vison will not be clear) If a hyperope wears their glasses early on, then they can be less dependent on their glasses later on because their accommodation will be preserved Near-sighted people, as the years go by, they find it more comfortable reading with near vision 1. MYOPIA Commonly known as nearsightedness Parallel light rays focus at a point IN FRONT of the retina o Axial where the eyeball is longer than average o Refractive where the corneal curvature is steeper than average Corrected by a biconcave, negative, diverging lens to push the converging light rays or image farther back Myopia: Your eye can be 22-24 mm long, but your lens power or corneal power is steeper, images fall in front of your retina

MEDICINE

Figure 5. How light rays focus in a hyperopic eye. In hyperopic eyes the light rays fall behind the retine [2013] Latent hyperopia Patients who are far-sighted usually do not require spectacles while they are still young. This is because they have a lot of accommodation. This can produce spasm of the ciliary muscles, increasing the biconvexity of the lens, thereby allowing light to focus directly on the retina. However, when they get older, they lose much of their accommodation, so they become increasingly far-sighted. They are unable to increase the AP diameter. Since younger hyperopic patients can accommodate, we have to be careful when prescribing spectacles because we may get the wrong reading. 3. ASTIGMATISM A condition where the curvature of the cornea or lens is not the same in different meridians o Since the curvatures are different, there is no single point of focus. Parallel light rays focus on 2 SEPARATE LINES OR PLANES o Spherical o Cylindrical Corrected by cylindrical lenses each with a power in two different meridians/axes o Ex: -2.00 sph with 1.5 x 90 degrees o [2013] It is possible that when an astigmatic person gets new glasses and they get a headache right away, the lenses were not placed on the correct axis due to laboratory errors (Sanayin mo lang!) o [2013] Pupillary Distance Your pupillary distance is measured, and when it is not correct by 1 mm on the glasses, the axis would not be proper anymore. Hence, they try to move their glasses left and right for things to become clearer Comes from the Greek word stigma, meaning point When you have astigma, you have no single point of focus Curvature of the eye is like a ball/sphere and is expected to have one point of focus In astigmatism, the eye is a little ovoid, (almond/American football) 2 curvatures: One will be focusing on your retina, and the other will not The axis indicated in prescription is the axis that is not focused Types of Astigmatism: Simple myopic: one image on the retina and one image in front of the retina Simple hyperopic: one image on the retina and one image behind the retina Compound myopic: both images in front of the retina Compound hyperopic: both images behind the retina Mixed: one in front of the retina and one image behind the retina

Figure 4. How light rays focus in a myopic eye. In myopic patients, the focal point lands way in front of the retina such that beyond that point, light rays diverge again. So when they finally land on the retina, the image is still not focused. 2. HYPEROPIA Commonly known as farsightedness Parallel light rays focus at a point BEHIND the retina o Axial where the eyeball is shorter than average o Refractive where the corneal curvature is flatter than average (Note that these are the opposite of the definitions of the types of myopia) Corrected by a biconvex, positive, converging lens to push the image forward Your eye can be 22-24 mm long, but if cornea is flat, image may still fall behind retina

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If youre wearing spectacles and youre still squinting means you are still pinhole-ing, there is a lack of correction o Astigmatic people squeezing their lids trying to make eye more spherical; can see better From the time we were born to when we reach adulthood, our eyeballs also grow. For myopics, as their eyes grow, they will be more myopic o It is often said that wearing soft contact lenses can retard the grade progression; however, soft contact lenses, do not change the contour of your eye, it will not stop the growth of your eye nor keep it from being more myopic/hyperopic. 3. Figure 6. Astigmatism [2013] Astigmatism the shape of the cornea is not spherical, but almond shape (American football shape), there are two different axes, and one of them is steeper. The end result is, since the light is diffused, image borders become fuzzy. When prescribing glasses for astigmatic patients, aside from the degree of myopia/hyperopia, there are also numbers indicating the amount and the degree and the orientation for astigmatism Example: - 1.75 1.25 x 90 o First number (-1.75) main spherical correction (myopic/hyperopic correction) o Second number (01.25) extent of astigmatism in diopters o Third number (90) the axis of the cylinder required to bend the light rays to compensate for the almond-shaped cornea. Refractive surgery

Radial keratotomy (RK)

o [2013] Incisional surgery on the cornea (like a sunburst appearance) to make the cornea collapse such that a longer eyeball will be somewhat shorter o Incisions haVE to be deep o Done by hand! o Fell into ill repute because patients ended up needing corneal transplant because the single layer of corneal endothelial cells got destroyed Photorefractive keratectomy (PRK) o [2013] No flaps are created on the cornea. The epithelium of the cornea is denuded instead. o Need days weeks for the epithelium to heal LASIK (Laser Assisted In Situ Keratomilieusis) o [2013] A flap of tissue is created. Laser fires underneath the flap to eliminate stromal tissue, effectively flattening the cornea. After firing, the flap is put back on o Shorter time for healing because the only healing portion is around the flap (not the entire epithelium) o This procedure disproves the classical teaching that if you fire beyond the membrane, you will produce scarring. This procedure removes stromal tissue below the membrane and yet there is no scarring. o Uses cold laser which disrupts the covalent bonding in the stroma. This would make the molecules move and expand in the same space. This does not produce burns (as we think of lasers in the movies) Others like lens exchange (replace with proper corrected lens) o In refractive lens exchange, an implant placed to replacement the eye, just like cataract surgery. o A Femtosecond laser can now make the flap for you and remove intrastromal tissue.

Figure 7. Cross-section of an astigmatic eye V. 1. 2. CORRECTION OF AMMETROPIA Spectacles Contact lenses o Soft, rigid gas permeable, hard, etc. o Multifocal Will not make your grade lower; For grades of 400 and below, if you place the lens nearer the eye the grade will naturally be lower because you need to accommodate less, but if you put the lens farther away (as in spectacles) the grade will be higher because you will accommodate more; but essentially your grade is still the same/axial length is still the same
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Figure 8. LASIK
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VI. REFRACTIVE LENS EXCHANGE/EARLY CATARACT SURGERY Sample case BS, 42 M, teacher who wants to get rid of glasses completely o CVA OD 20/70 OS 20/160 o REF OD +4.25 ~ -0.75 X 95 20/25 (AL 20.76mm) o REF OS + 6.25 ~ -0.50 X 35 20/25 (AL 20.07mm) Options: o Contact lenses o LASIK (including presbyopic LASIK) o Monovision o CK o Refractive lens exchange with multifocal intraocular lens (IOL)implantation Multifocal IOL: OD +27.OD OS +30.OD Option for post-phaco LASIK enhancement of residual error [2013] For this case, we have to take into account the limitations of LASIK. LASIK can only take away hyperopia of about 500 and myopia of about 1000. If the patients grade is a little beyond this, what do we do? Try refractive lens exchange In refractive lens exchange, a 2.2mm incision is made. Ultrasound is used to disintegrate proteins. Lens are then inserted. *Bringing your vision down to 20/20 for hyperopes will depend on how hyperopic you are Refractive Surgery Touches the cornea to permanently change the optics of the eye while glasses and contacts are temporary Radial keratotomy Hand-made incisions using diamond knives to change the curvature of the eye; was very common in Russia o Was common for myopes; wanted to shorten eye; incisions on the cornea will weaken it, will flatten cornea and will make the eye shorter; o Problem with this: in high altitudes, grade changes because cornea is weakened o Late 80s: PRK o Trying to flatten the cornea of myopes, trying to steepen corneas of hyperopes o PRK did not create a flap; take away epithelium via blunt dissection, then laser is fired into the cornea o You will have to heal epithelium all around LASIK Nowadays, criteria is based on the functional status of the patient Functional vision is 20/40; 20/20 is said to be normal simply because a long time ago, somebody said so The LASIK effect for your error of refraction does not involve your lens; but your lens continues to grow (presbyopia is not a refractive error, but an error of accommodation); so effect of LASIK is still there but by the time you reach about 40, you will still need reading glasses o For hyperopes: fire around the cornea to steepen it; o For myopes: fire at the center of the cornea to flatten it

MEDICINE

Risk and complications of LASIK: any surgery has potential risks and complications (e.g. potential for infection) o Risk is much lower in LASIK than contact lens o Wearing contact lens: contact lens is a foreign body and is not sterile, touching the eye all the time has a potential risk for infection vs. LASIK, wherein after the operation, you will not need to touch the eye anymore Creates only a flap of tissue, then flap is put back in place, leaving only a small circle of epithelium in place healing area is less Classic LASIK: create flap of epithelium with a microkeratome (oscillating blade), fire laser, under topical anesthetics LASIK may not always be the best solution for all o Refractive lens exchange: Doing early cataract surgery in the absence of a cataract, replacing your natural lens with a multifocal lens o Phacoemulsification o 40% near; 40% far; 20% mixed Can LASIK be done while asleep? o Done in pediatric patients o However, we rely on the patients to look at the light to determine the visual axis since the center of the pupil may not necessarily be the center of the visual axis Femtosecond laser o Paired system: flap is created within 6 seconds with a LASIK machine, where everything can be visualized (in the oscillating blade, it cannot be visualized while it creates a flap); excimer laser projects the laser in many points in the eye o Laser for cataracts has never been available until now o Can specify EXACT measurements for incisions o Crack pattern is created without any blades; quadrants created are aspirated o CT scan guided o Faster for the patient o <35 installations worldwide; available here in American Eye Center VII. OTHER TOPICS *Not emphasized by sir A. ACCOMMODATION To focus on a nearby object, the brain sends out signals to contract the smooth muscles of the ciliary body This enables the zonules to loosen up, which in turn increases the lens curvature (the lens thickens), thus increasing its converging power, and making it a positive lens Presbyopia o Occurs with aging (around 40) o Loss of focusing or accommodative power of the human eye o One would need plus lenses (presbyopic glasses or reading adds) to make up for the lost automatic focusing power of the lens

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Figure 10. Construction of the Snellen Chart for consistency

Figure 11. Optotypes. Optotypes are the letter, symbols and figures found on the charts. All optotypes have to subtend an angle of 5 minutes. D. RECORDING VISUAL ACUITY USING THE SNELLEN CHART Measured at 20 ft (60 m) o For visual acuity tests that use a projector, the minimum distance is 10-11 feet. Numerator distance between chart and patient Denominator smallest row of letters that the patients eye can read Ex: A visual acuity of 20/40 simply means that the patients eyes can only read from 20 ft. what a normal (emmetropic) eye can read at 40 ft Feet 20/200 20/100 20/70 20/50 20/40 20/30 20/25 20/20 Meters 6/60 6/30 6/21 6/15 6/12 6/9 6/7.5 6/6

Figure 9. How progressive lenses work for presbyopic individuals B. FORM SENSE Visual acuity Discriminates between stimuli or allows us to see 2 stimuli separately as two instead of fusing them into 1 Minimum amount of separation between 2 light sources at a given distance from the eye so that they can still be seen as 2 These 2 lights subserve an angle at the nodal point of the eye called the minimum visual angle C. MINIMUM VISUAL ANGLE Experimentally the smallest detectable line subtends one minute of an arc The big E on the Snellen chart subtends an angle of 5 minutes Letters are constructed so that they subtend the same visual angle when viewed at distances of up to 200 ft

Table 1. Equivalent Snellen Chart readings in feet and meters When testing visual acuity, improvement of vision with a pinhole indicates an error of refraction. A pinhole eliminates peripheral light rays. When youre testing near vision, youre testing accommodation so a pinhole would be useless.

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Figure 12. Cataract surgery

Figure 13. Lens replacement

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