KELAINAN REFRAKSI (ERRORS OF REFRACTION)

Ametropia (a condition of refractive error), is defined as a state of refraction, when the parallel rays of light coming
from infinity (with accommodation at rest), are focused either in front or behind the sensitive layer of retina, in one
or both the meridians. The ametropia includes myopia, hypermetropia and astigmatism. The related conditions
aphakia and pseudophakia are also discussed here.
HYPERMETROPIA

Hypermetropia (hyperopia) or long-sightedness is the refractive state of the eye wherein parallel rays of light
coming from infinity are focused behind the retina with accommodation being at rest. Thus, the posterior focal point
is behind the retina, which therefore receives a blurred image

Etiology

Hypermetropia may be axial, curvatural, index, positional and due to absence of lens.
1. Axial hypermetropia is by far the commonest form. In this condition the total refractive power of eye is normal
but there is an axial shortening of eyeball. About 1mm shortening of the anteroposterior diameter of the eye results
in 3 dioptres of hypermetropia.
2. Curvatural hypermetropia is the condition in which the curvature of cornea, lens or both is flatter than the normal
resulting in a decrease in the refractive power of eye. About 1 mm increase in radius of curvature results in 6
dioptres of hypermetropia.
3. Index hypermetropia occurs due to decrease in refractive index of the lens in old age. It may also occur in
diabetics under treatment.
4. Positional hypermetropia results from posteriorly placed crystalline lens.
5. Absence of crystalline lens either congenitally or acquired (following surgical removal or posterior dislocation)
leads to aphakia a condition of high hypermetropia.
Clinical types

There are three clinical types of hypermetropia:

1. Simple or developmental hypermetropia is the commonest form. It results from normal biological variations in
the development of eyeball. It includes axial and curvatural hypermetropia.
2. Pathological hypermetropia results due to either congenital or acquired conditions of the eyeball which are
outside the normal biological variations of the development. It includes :
Index hypermetropia (due to acquired cortical sclerosis),
Positional hypermetropia (due to posterior subluxation of lens),
Aphakia (congenital or acquired absence of lens) and
Consecutive hypermetropia (due to surgically over-corrected myopia).
3. Functional hypermetropia results from paralysis of accommodation as seen in patients with third nerve paralysis
and internal ophthalmoplegia.
Nomenclature (components of hypermetropia)

Total hypermetropia is the total amount of refractive error, which is estimated after complete cycloplegia with
atropine. It consists of latent and manifest hypermetropia.
1. Latent hypermetropia is high in children and gradually decreases with age.
2. Manifest hypermetropia is the remaining portion of total hypermetropia, which is not corrected by the ciliary tone.
i. Facultative hypermetropia constitutes that part which can be corrected by the patient's accommodative effort.
ii. Absolute hypermetropia is the residual part of manifest hypermetropia which cannot be corrected by the patient's
accommodative efforts.
Thus, briefly:
Total hypermetropia = latent + manifest (facultative + absolute).

Clinical picture

Symptoms
1. Asymptomatic. A small amount of refractive error in young patients is usually corrected by mild accommodative
effort without producing any symptom.
2. Asthenopic symptoms. At times the hypermetropia is fully corrected (thus vision is normal) but due to sustained
accommodative efforts patient develops asthenopic sysmtoms. These include: tiredness of eyes, frontal or frontotemporal headache, watering and mild photophobia. These asthenopic symptoms are especially associated with near
work and increase towards evening.
3. Defective vision with asthenopic symptoms
4. Defective vision only. When the amount of hypermetropia is very high, the patients usually do not accommodate
(especially adults) and there occurs marked defective vision for near and distance.
Signs
1. Size of eyeball may appear small as a whole.
2. Cornea may be slightly smaller than the normal.
3. Anterior chamber is comparatively shallow.
4. Fundus examination reveals a small optic disc which may look more vascular with ill-defined margins and
pseudopapillitis. The retina as a whole may shine due to greater brilliance of light reflections (shot silk appearance).
5. A-scan ultrasonography (biometry) may reveal a short antero-posterior length of the eyeball.
APHAKIA

Aphakia literally means absence of crystalline lens from the eye. However, from the optical point of view, it may be
considered a condition in which the lens is absent from the pupillary area. Aphakia produces a high degree of
hypermetropia.
PSEUDOPHAKIA

The condition of aphakia when corrected with an intraocular lens implant (IOL) is referred to as pseudophakia or
artephakia.
MYOPIA

Myopia or short-sightedness is a type of refractive error in which parallel rays of light coming from infinity
are focused in front of the retina when accommodation is at rest.

Etiological classification

1. Axial myopia results from increase in anteroposterior length of the eyeball. It is the commonest form.
2. Curvatural myopia occurs due to increased curvature of the cornea, lens or both.
3. Positional myopia is produced by anterior placement of crystalline lens in the eye.
4. Index myopia results from increase in the refractive index of crystalline lens associated with nuclear sclerosis.
5. Myopia due to excessive accommodation occurs in patients with spasm of accommodation.
Clinical varieties of myopia
1. Congenital myopia

Congenital myopia is present since birth, however, it is usually diagnosed by the age of 2-3 years. Most of the time
the error is unilateral and manifests as anisometropia. Rarely, it may be bilateral.
2. Simple myopia

Simple or developmental myopia is the commonest variety. It is considered as a physiological error not associated
with any disease of the eye. Its prevalence increases from 2% at 5 years to 14% at 15 years of age. Since the
sharpest rise occurs at school going age i.e., between 8 year to 12 years so, it is also called school myopia.

Etiology. It results from normal biological variation in the development of eye which may or may not be
genetically determined.
Axial type of simple myopia
Curvatural type of simple myopia is considered to be due to underdevelopment of the eyeball.
Role of diet in early childhood has also been reported without any conclusive results.
Role of genetics. Genetics plays some role in the biological variation of the development of eye, as
prevelance of myopia is more in children with both parents myopic (20%) than the children with one parent
myopic (10%) and children with no parent myopic (5%).
Theory of excessive near work in childhood. In fact, there is no truth in the folklore that myopia is
aggravated by close work, watching television and by not using glasses.
Clinical picture

Symptoms
Poor vision for distance (short-sightedness) is the main symptom of myopia.
Asthenopic symptoms may occur in patients with small degree of myopia.
Half shutting of the eyes may be complained by parents of the child. The child does so to achieve the
greater clarity of stenopaeic vision.
Signs
Prominent eyeballs. The myopic eyes typically are large and somewhat prominent.
Anterior chamber is slightly deeper than normal.
Pupils are somewhat large and a bit sluggishly reacting.
Fundus is normal; rarely temporal myopic crescent may be seen.
Magnitude of refractive errror. Simple myopia usually occur between 5 and 10 year of age and it keeps on
increasing till about 18-20 years of age at a rate of about 0.5 0.30 every year. In simple myopia, usually
the error does not exceed 6 to 8.
Diagnosis is confirmed by performing retinoscopy
3. Pathological myopia

Pathological/degenerative/progressive myopia, as the name indicates, is a rapidly progressive error which starts in
childhood at 5-10 years of age and results in high myopia during early adult life which is usually associated with
degenerative changes in the eye.
Etiology.
1. Role of heredity. It is now confirmed that genetic factors play a major role in the etiology, as the progressive
myopia is (i) familial; (ii) more common in certain races like Chinese, Japanese, Arabs and Jews, and (iii)
uncommon among Negroes, Nubians and Sudanese. The sclera due to its distensibility follows the retinal growth but
the choroid undergoes degeneration due to stretching, which in turn causes degeneration of retina.
2. Role of general growth process, though minor, cannot be denied on the progress of myopia. Lengthening of the
posterior segment of the globe commences only during the period of active growth and probably ends with the
termination of the active growth. Therefore, the factors (such as nutritional deficiency, debilitating diseases,
endocrinal disturbances and indifferent general health) which affect the general growth process will also influence
the progress of myopia.
Clinical picture

Symptoms
1. Defective vision.
2. Muscae volitantes i.e., floating black opacities in front of the eyes are also complained of by many patients. These
occur due to degenerated liquefied vitreous.
3. Night blindness may be complained by very high myopes having marked degenerative changes.

Signs
1. Prominent eye balls. The eyes are often prominent, appearing elongated and even simulating an exophthalmos,
especially in unilateral cases.
2. Cornea is large.
3. Anterior chamber is deep.
4. Pupils are slightly large and react sluggishly to light.
5. Fundus examination reveals following characteristic signs :
(a) Optic disc appears large and pale and at its temporal edge a characteristic myopic crescent is present
(b) Degenerative changes in retina and choroid.
(c) Posterior staphyloma
(d) Degenerative changes in vitreous include: liquefaction, vitreous opacities, and posteriorvitreous detachment
(PVD) appearing as Weiss' reflex.
6. Visual fields show contraction and in some cases ring scotoma may be seen.
7. ERG reveals subnormal electroretinogram due to chorioretinal atrophy.
Complications

(i) Retinal detachment; (ii) complicated cataract; (iii) vitreous haemorrhage; (iv) choroidal haemorrhage (v)
Strabismus fixus convergence.
ASTIGMATISM

Astigmatism is a type of refractive error wherein the refraction varies in the different meridia. Consequently, the
rays of light entering in the eye cannot converge to a point focus but form focal lines.
REGULAR ASTIGMATISM

The astigmatism is regular when the refractive power changes uniformly from one meridian to another (i.e., there
are two principal meridia).
Etiology

1. Corneal astigmatism is the result of abnormalities of curvature of cornea. It constitutes the most common cause
of astigmatism.
2. Lenticular astigmatism is rare. It may be:
i. Curvatural due to abnormalities of curvature of lens as seen in lenticonus.
ii. Positional due to tilting or oblique placement of lens as seen in subluxation.
iii. Index astigmatism may occur rarely due to variable refractve index of lens in different meridia.
3. Retinal astigmatism due to oblique placement of macula may also be seen occasionally.
Types of regular astigmatism

Depending upon the axis and the angle between the two principal meridian :
1. With-the-rule astigmatism. In this type the two principal meridia are placed at right angles to one another but the
vertical meridian is more curved than the horizontal. Thus, correction of this astigmatism will require the concave
cylinders at 180 20 or convex cylindrical lens at 90 20. This is called 'with-the-rule' astigmatism, because

similar astigmatic condition exists normally (the vertical meridian is normally rendered 0.25 D more convex than the
horizontal meridian by the pressure of eyelids).
2. Against-the-rule astigmatism refers to an astigmatic condition in which the horizontal meridian is more curved
than the vertical meridian.
3. Oblique astigmatism is a type of regular astigmatism where the two principal meridia are not the horizontal and
vertical though these are at right angles to one another (e.g., 45 and 135). Oblique astigmatism is often found to be
symmetrical (e.g., cylindrical lens required at 30 in both eyes) or complementary (e.g., cylindrical lens required at
30 in one eye and at 150 in the other eye).
4. Bioblique astigmatism. In this type of regular astigmatism the two principal meridia are not at right angle to each
other e.g., one may be at 30o and other at 100.
Refractive types of regular astigmatism

1. Simple astigmatism, wherein the rays are focused on the retina in one meridian and either in front (simple myopic
astigmatism) or behind (simple hypermetropic astigmatism) the retina in the other meridian.
2. Compound astigmatism. In this type the rays of light in both the meridia are focused either in front or behind the
retina and the condition is labelled as compound myopic or compound hypermetropic astigmatism, respectively.
3. Mixed astigmatism refers to a condition wherein the light rays in one meridian are focused in front and in other
meridian behind the retina. Thus in one meridian eye is myopic and in another hypermetropic. Such patients have
comparatively less symptoms as 'circle of least diffusion' is formed on the retina.
Symptoms

Symptoms of regular astigmatism include: (i) defective vision; (ii) blurring of objects; (iii) depending upon
the type and degree of astigmatism, objects may appear proportionately elongated; and (iv) asthenopic symptoms,
which are marked especially in small amount of astigmatism, consist of a dull ache in the eyes, headache, early
tiredness of eyes and sometimes nausea and even drowsiness.
Signs

1. Different power in two meridia is revealed on retinoscopy or autorefractometry.

2. Oval or tilted optic disc may be seen on ophthalmoscopy in patients with high degree of astigmatism.
3. Head tilt. The astigmatic patients may (very exceptionally) develop a torticollis in an attempt to bring their axes
nearer to the horizontal or vertical meridians.
4. Half closure of the lid. Like myopes, the astigmatic patients may half shut the eyes to achieve the greater clarity of
stenopaeic vision.

Types of astigmatism : simple myopic (A); simple hypermetropic (B); compound myopic (C); compound hypermetropic (D); and
mixed (E).

IRREGULAR ASTIGMATISM

It is characterized by an irregular change of refractive power in different meridia. There are multiple meridian which
admit no geometrical analysis.
Etiological types

1. Curvatural irregular astigmatism is found in patients with extensive corneal scars or keratoconus.

2. Index irregular astigmatism due to variable refractive index in different parts of the crystalline lens may occur
rarely during maturation of cataract.
Symptoms of irregular astigmatism include:
Defective vision,
Distortion of objects and
Polyopia.
ANISOMETROPIA

The optical state with equal refraction in the two eyes is termed isometropia. When the total refraction of the two
eyes is unequal the condition is called anisometropia. Small degree of anisometropia is of no concern. A difference
of 1 D in two eyes causes a 2 percent difference in the size of the two retinal images. A difference up to 5 percent in
retinal images of two eyes is well tolerated. In other words, an anisometropia up to 2.5 is well tolerated and that
between 2.5 and 4 D can be tolerated depending upon the individual sensitivity. However, if it is more than
4 D, it is not tolerated and is a matter of concern.
ANISEIKONIA

Aniseikonia is defined as a condition wherein the images projected to the visual cortex from the two retinae are
abnormally unequal in size and/or shape. Up to 5 per cent aniseikonia is well tolerated.