REFRACTIVE ERRORS

MYOPIA
•It is a type of refractive error in which parallel rays of light coming from
infinity are focused in front of retina.
ETIOLOGICAL CLASSIFICATION
• Axial myopia
• Curvatural myopia
• Positional myopia
• Index myopia
• Myopia due to excessive accommodation

GRADING OF MYOPIA
• Low myopia: When the power is below or equal to -3D.
• Moderate myopia: When the error is in between -3D to -6D.
• High myopia: When the error is above 6D
Clinical Presentations Of Myopia
1. Congenital myopia
2. Simple myopia
3. Pathological myopia
4. Secondary myopia

1. CONGENITAL MYOPIA
• Present since birth.
• Diagnosed by the age of 2-3 years.
• High degree of error, about 8-10D.
• Convergent squint may develop.
• Other congenital anomalies like cataract, microphthalmos, etc. are present.
2. SIMPLE MYOPIA
• Also called as developmental myopia or school myopia.
• it’s the most common variety.
• Most common in children between 8-12 years of age.

Etiology

• Axial type of simple myopia

• Curvatural type of simple myopia
• Role of diet
• Role of genetics
Clinical Features :
SYMPTOMS
• Poor vision from distance.
• Half shutting of the eyes.

SIGNS:
• Prominent eye balls.
• Anterior chamber is deeper.
• Pupils are large and sluggishly reacting.

Simple myopia usually occurs between 5-10 years of age and it keeps
increasing till 18-20 years of age.
Pathological Myopia
• Degenerative/progressive myopia.
• It is usually rare.
• Rapidly progressive error which starts at 5-10years of age and results in
high grade myopia.
• It is associated with degenerative changes in the eye.

Clinical Features
SYMPTOMS SIGNS:
• Defective vision. • Large cornea.
• Prominent eyeballs. • Anterior chamber is deep.
• Floating black opacities in front of eyes. • Pupils are large.
• Night blindness.
Fundus examination:
• Optic disk appears large and pale and its temporal edge, a myopic crescent
is present.
• Degenerative changes in retina and choroid like chorioretinal atrophic
patches at the macula, foster-fuchs spot (dark red circular patch due to sub
retinal neovascularization and choroidal haemorrhage)at the macula.
• Degenerative changes in vitreous like liquefaction, vitreous opacities,
posterior vitreous detachment appearing as Weiss reflux.

Complications:
• Retinal detachment
• Complicated cataract
• Vitreous haemorrhage
• Choroidal haemorrhage
• Primary open angle glaucoma
Treatment:
Optical treatment of myopia:-
• concave lenses are used.
• contact lenses are prescribed for cases of high myopia.
Surgical treatment of myopia:-
• radial keratotomy.
• photorefractive keratectomy.
• laser assisted in situ keratomileusis(LASIK).
 HYPERMETROPIA
• Hypermetropia or hyperopia or long sightedness

• Parallel rays of light from infinity are focussed behind the retina with
accommodation being at rest.
Etiology
• Axial
• Curvatural
• Index
• Positional
• Due to absence of crystalline lens

Clinical types-
1. Simple or developmental or physiological hypermetropia- commonest
2. Non-physiological hypermetropia.
• congenital
• acquired
3. Functional hypermetropia
Clinical features
SYMPTOMS
• Asymptomatic
• Asthenopic symptoms
• Defective vision with asthenopic symptoms
• Defective vision only
SIGNS
• Decrease in size of eyeball
• Cornea size decrease
• Anterior chamber becomes shallow
• Fundus examination- small optic disc- vascular with ill defined margins, may
stimulate papilitis
• Shot silk appearance of retina
 Treatment
• Optical Treatment – Convex Lenses
• Surgical Treatment-
A. Cornea based procedures
1. Thermal laser keratoplasty
2. Hyperopic PRK
3. Hyperopic LASIK
4. Conductive keratoplasty

B. Lens based procedures

1. Phakic refractive lens(PRL) or implantable contact lens (ICL)
2. Refractive lens exchange (RLE)
 APHAKIA
• Aphakia is a condition in which the lens is absent from the pupillary
area.
• It produces a large degree of hypermetropia.
CAUSES
1. Congenital absence of lens.
2. Surgical aphakia occurring after removal of lens is the commonest
presentation.
3. Aphakia due to absorption of lens matter is noticed rarely after trauma
in children.
4. Traumatic extrusion of lens from the eye also constitutes a rare cause
of aphakia.
5. Posterior dislocation of lens in vitreous causes optical aphakia.
Optics of Aphakic Eye –
Following optical changes occur after removal of crystalline lens:

• Hypermetropia
• Total power of eye is reduced to about +44D from +60D.
• Anterior focal point becomes 23.2 mm in front of the cornea
(Normal: 15.7 mm)
• Posterior focal point is about 31 mm behind the cornea i.e., about
7 mm behind the eyeball (The anteroposterior length of eyeball is
about 24 mm.
• Accommodation is lost fully.
Clinical Features
SYMPTOMS
• Defective vision - Main symptom in aphakia is marked defective
vision for both near and far due to high hypermetropia and absence of
accommodation.

• Erythropsia and cyanopsia i.e., seeing red and blue images. This
occurs due to excessive entry of ultraviolet and infrared rays in the
absence of crystalline lens.
SIGNS OF APHAKIA

• Limbal scar may be seen in surgical aphakia.

• Anterior chamber is deeper than normal.
• Iridodonesis i.e., tremulousness of iris can be demonstrated.
• Pupil is jet black in color.
• Purkinje’s image test shows only two images (normally four images
are seen).
• Fundus examination shows hypermetropic small disc.
• Retinoscopy and autorefractometry reveals high hypermetropia.
Treatment
Modalities for correcting aphakia include -

1. Spectacles
• Was the most common method of correcting aphakia
• Presently, the use of aphakic spectacles has decreased markedly.

DISADVANTAGES –
• Image is magnified by 30%; so its not useful for uniocular aphakia.
• Problem of spherical and chromatic aberations of thick lenses.
• Field of vision is limited.
• Prismatic effect of thick glasses
• Rowing ring Scotoma
• Cosmetic blemish especially in young aphakes
2. Contact lens

ADVANTAGES
• Less magnification
• Elimination of aberrations and prismatic effect.
• Wider and better field of vision
• Cosmetically more acceptable
• Better suited for uniocular aphakia.

DISAVANTAGES
• More expensive
• Cumbersome to wear
• Corneal complications
3. Intraocular lens
• It is the best available method of correcting aphakia
• It is the commonest modality being employed nowadays
• Primary intraocular lens implantation is done during cataract surgery
• Secondary intraocular lens implantation is done during already aphakic
patients.
4. Refractive corneal surgery
• Keratophakia - Lenticule prepared from the donor cornea is placed
between the lamellae of the patient’s cornea.
• Epikeratophakia - Lenticule prepared from the donor cornea is stitched
over the surface of the cornea after removing the epithelium
• Hyperopic LASIK may be used where secondary IOL cannot be
implanted.
 ASTIGMATISM
DEFINITION
• Astigmatism is a type of refractive error wherein the refraction varies in
different media of the eye.
• The rays of light entering the eye cannot converge to point focus but
form focal lines.
TYPES
• Regular - The astigmatism is regular when the refractive power
changes uniformly from one meridian to another.
• Irregular -The astigmatism is irregular when there is irregular change
of refractive power from different meridians.
Regular Astigmatism -
Classification based on the axis and angle between the two meridians-
1. With-the-rule astigmatism-
• In this type the two principal meridians are placed at right angles to one
another but vertical meridian is more curved than the horizontal.
• The correction of this type will require the concave cylinder at 180 ± 20º or
convex cylindrical lens at 90 ± 20º.
• It is termed with-the-rule because similar astigmatic condition exist normally.
2. Against-the-rule astigmatism -
• It refers to an astigmatic condition in which the horizontal meridians are
more curved than the vertical meridian.
• The correction of this astigmatism requires convex cylindrical lens at 180 ±
20º or concave cylindrical lens at 90 ± 20º axis.
3. Oblique astigmatism -
• It is a type of astigmatism where the two principal meridians are not
the horizontal and vertical though these are at right angles to one
another. e.g., 45º and 135º

4. Bioblique astigmatism -
• In this type of regular stigmatism the two principal meridians are not
at right angles to each other. e.g., one may be at 30 and the other at
100.
Refractive types of astigmatism -
1. Simple astigmatism - 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 - The rays of light in both meridians are

focused either on the front or behind the retina and the condition is
labelled as compound myopic or compound hypermetropic
astigmatism respectively.

3. Mixed astigmatism – The light rays in one meridian are focused in

front and in one meridian it is focused behind the retina; thus in one
meridian eye is myopic and the in the other it is hypermetropic.
CLINICAL FEATURES –
SYMPTOMS-
• Asthenopia- characterised by difficulty in focussing, transient
blurred vision, dull ache in the eyes, frontal headache, sometimes
nausea and drowsiness; is especially marked in low astigmatism ≤
1D.
• Blurred vision and defective vison
• Elongation of objects proportionate to the degree and type of
astigmatism is noticed in high astigmatism.
• Keeping the reading material close to the eyes may be needed to
achieve large but blurred retinal image.
SIGNS-
• Half closure of the lid - astigmatic patients may half shut the eyes
to achieve the greater clarity if stenopaeic vision.
• Head tilt – astigmatic patients may develop a torticollis in an
attempt to bring their axes nearer to the horizontal or vertical
meridians.
• Oval or tilted disc may be seen on ophthalmoscopy in patients with
high degree of astigmatism.
• Different power in different meridians is revealed on retinoscopy
autorefractometry.
INVESTIGATIONS -
1. Retinoscopy - reveals different power in two axes.

2. Keratometry - Keratometry and computerised corneal topography

reveal different corneal curvature in two different meridians in
corneal astigmatism.

3. Astigmatism fan test

4. Jackson’s cross cylinder test

TREATMENT -
1. Optic treatment of regular astigmatism comprises the prescription of
appropriate cylindrical lenses, discovered after accurate refraction .

 Spectacles with full correction of cylindrical power and appropriate

axis should be used for distance and near vision.
 Contact lenses –
• Rigid contact lenses may correct upto 2-3D of regular
astigmatism, while soft contact lenses can correct only little
astigmatism.
• For higher degrees of astigmatism toric contact lenses are
needed.
• In order to maintain the correct axis of toric lenses, ballasting or
truncation is required.
2. Surgical correction of astigmatism –

• Astigmatic keratotomy (AK) refers to making transverse cuts in the

mid-periphery of the steep corneal meridian.

• Photo-astigmatic refractive keratotomy (PARK) is performed using

eximer laser.

• LASIK procedure can be adopted to correct astigmatism upto 5D.

• SMILE procedure can also be adopted to corrected astigmatism.

IRREGULAR ASTIGMATISM -
DEFINITION-
The astigmatism is irregular when there is irregular change of refractive
power from different meridians.

ETIOLOGICAL TYPES –
1. Curvatural irregular astigmatism is found in patients with
extensive corneal scars or keratoconus.
1. Index irregular astigmatism is due to variable refractive index in
different parts of the crystalline lens may occur rarely in patients with
cataract.
CLINICAL FEATURES -
SYMPTOMS of irregular astigmatism include -
• Defective vision
• Distortion of objects, and
• Polyopia

SIGNS depicted on investigations are -

• Retinoscopy reveals irregular pupillary reflex.
• Slit-lamp examination may reveal corneal irregularity or keratoconus.
• Placido’s disc test reveals distorted circles.
• Photokeratocopy and computerised corneal topography give
photographic record of irregular corneal curvature.
TREATMENT -
1. Optic treatment of irregular astigmatism consists of contact lenses
which replaces the anterior surface of the cornea for refraction.

2. Phototherapeutic keratectomy (PTK) performed with eximer laser

may be helpful in patients with superficial corneal scar responsible for
irregular astigmatism.

3. Surgical treatment is indicated in extensive corneal scarring (when

vision does not improve with contact lenses) and consists of
penetrating keratoplasty or deep anterior lamellar keratoplasty
( DALK).
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