Clinical optic

Optics of the Human Eye

Important Axes of the Eye

The pupillary axis is the imaginary line perpendicular to the corneal surface and
passing through the midpoint of the entrance pupil.
The visual axis is the line connecting the xation target and the fovea.
The optical axis is the line that best approximates the line passing through the
optical centers of the cornea, lens, and center of the fovea.
The angle alpha (α) is the angle between the visual axis and the optical axis. This
angle is considered positive when the visual axis in object space lies on the nasal
side of the optical axis.
The angle kappa (κ) is the angle between the pupillary axis and the visual axis
Visual Acuity
The following are de nitions of terms used in the measurement of visual function:
 The minimum legible threshold refers to the point at which a patient’s visual ability
cannot further distinguish progressively smaller letters or forms from one another;
Snellen visual acuity is the most common method of determining this threshold.
 The minimum visible threshold is the minimum brightness of a target at which the
patient can distinguish the target from the background.
 The minimum separable threshold refers to the smallest visual angle formed by the
eye and 2 separate objects at which a patient can discriminate them individually.
 Vernier acuity is dened as the smallest detectable amount of misalignment of 2 line
segments
Clinical Refraction

 Most retinoscopes in current use employ the streak projection system developed by
Copeland. The illumination of the retinoscope is provided by a bulb with a straight
lament that forms a streak in its projection.
 The light is re ected from a mirror that is either half silvered (Welch Allyn model)
or totally silvered around a small circular aperture (Copeland instrument) (Fig 3-
1). The lament light source can be moved in relation to a convex lens in the
system. If the light is slightly divergent, it appears to come from a point behind the
retinoscope, as if the light were re ected o a at mirror
Myopia
 There are 2 types of childhood myopia: congenital (usually high) myopia and
developmental myopia, which usually manifests itself between the ages of 7 and 10
years.
 Developmental myopia is less severe and easier to manage because the patients are
older and refraction is less di cult. However, both forms of myopia are progressive;
frequent refractions (every 6–12 months) and periodic prescription changes are
necessary
 The following are general guidelines for correction of signi cant childhood
myopia:
 Cycloplegic refractions are mandatory. In infants, children with esotropia, and
children with very high myopia (>10.00 D), atropine refraction may be
necessary if tropicamide or cyclopentolate fails to paralyze accommodation in
the o ce.
 In general, the full refractive error, including cylinder, should be corrected.
Young children tolerate cylinder well.
 Some ophthalmologists undercorrect myopia, and others use bifocal lenses
with or without atropine, on the basis of the theory that accommodation
hastens or increases the development of myopia. This topic remains
controversial among ophthalmologists.
 Intentional undercorrection of a child’s myopic esotropia to decrease the angle
of deviation is rarely tolerated.
 Intentional overcorrection of a myopic error (or undercorrection of a hyperopic
error) may help control intermittent exodeviations. However, such
overcorrection can cause additional accommodative stress.
 Parents should be educated about the natural progression of myopia and the
need for frequent refractions and possible prescription changes. In older
 children, contact lenses may be desirable to avoid the problem of image mini
cation that arises with high-minus lenses
Hyperopia
 The appropriate correction of childhood hyperopia is more complex than that
of myopia for 2 reasons.
 First, children who are signi cantly hyperopic (>5.00 D) are more visually
impaired than are their myopic counterparts, who can at least see clearly at
near. Second, childhood hyperopia is more frequently associated with
strabismus and abnormalities of the accommodative
convergence/accommodation (AC/A) ratio
The following are general guidelines for correcting childhood hyperopia:
 Unless there is esodeviation or evidence of reduced vision, it is not necessary
to correct low hyperopia. As with myopia, signi cant astigmatic errors should
be fully corrected.
 When hyperopia and esotropia coexist, initial management includes full
correction of the cycloplegic refractive error. Reductions in the amount of
correction may be appropriate later, depending on the amount of esotropia and
level of stereopsis with the full cycloplegic correction in place.
Anisometropia
 A child or infant with anisometropia is typically prescribed the full refractive di
erence between the 2 eyes, regardless of age, presence or amount of
strabismus, or degree of anisometropia.
 Anisometropic amblyopia is frequently present and may require occlusion
therapy. Bilateral amblyopia occasionally occurs when there is signi cant
hyperopia, myopia, and/or astigmatism that occurs in both eyes
Presbyopia
 Presbyopia is the gradual loss of accommodative response resulting from
reduced elasticity of the crystalline lens. Fortunately, appropriate convex lenses
can compensate for the waning of accommodative power.
 Symptoms of presbyopia usually begin to appear in patients after the age of 40
years
 Revised guidelines for prescribing cylinders for spectacle correction :
 In children, give the full astigmatic correction.
 In adults, try the full astigmatic correction rst. Give warning and
encouragement. If problems are anticipated, try a walking-around trial with
trial frames before prescribing.
 To minimize distortion, use minus cylinder lenses and minimize vertex
distances.
 Spatial distortion from astigmatic spectacle corrections is a binocular
phenomenon. Occlude 1 eye to verify that this is indeed the cause of the
patient’s complaints.
 If necessary, reduce distortion still further by rotating the cylinder axis toward
180° or 90° (or toward the old axis) and/or by reducing the cylinder power.
Balance the resulting blur with the remaining distortion, using careful
adjustment of cylinder power and sphere. Residual astigmatism at any position
of the cylinder axis may be minimized with the Jackson cross-cylinder test for
cylinder power
 If distortion cannot be reduced suciently by altering the astigmatic spectacle
correction, consider contact lenses (which cause no appreciable distortion) or
iseikonic corrections.
Contact Lenses

Tear Lens
 The presence of uid, rather than air, between a contact lens and the corneal
surface is responsible for another major di erence between the optical
performance of contact lenses and that of spectacle lenses.
 The tear layer between a contact lens and the corneal surface is an optical lens
in its own right. As with all lenses, the power of this tear, or uid, lens is
determined by the curvatures of the anterior surface (formed by the back
surface of the contact lens) and the posterior surface (formed by the front
surface of the cornea).
Correcting Astigmatism
 Because rigid (and toric soft) contact lenses neutralize astigmatism at the
corneal surface, the meridional aniseikonia created by the 2 di erent powers
incorporated within each spectacle lens is avoided.
 For this reason, contact lens–wearing patients with signi cant corneal
astigmatism often experience an annoying change in spatial orientation when
they switch to spectacles. However, refractive astigmatism is the sum of
corneal and lenticular astigmatism.
Correcting Presbyopia
 Correcting presbyopia with contact lenses can be done in several di erent ways:
 reading glasses over contact lenses
 alternating vision contact lenses (segmented or annular)
 simultaneous vision contact lenses (aspheric [multifocal] or di ractive)
monovision
 From an optical point of view, the use of reading glasses or alternating vision
contact lenses is similar to standard spectacle correction for presbyopia.
Simultaneous vision contact lenses direct light from 2 points in space—one
near, one far—to the retina, resulting in a loss of contrast.
Contact Lens Materials and Manufacturing
 Various materials have been used to make contact lenses. The choice of
material can a ect contact lens parameters such as wettability, oxygen
permeability, and deposits on the lens.
 In addition, material choice a ects the exibility and comfort of the lens and the
stability and quality of vision.
Materials
 Contact lens materials can be described in terms of exibility (hard, rigid gas-
permeable [RGP], soft, or hybrid). The rst popular corneal contact lenses were
made of PMMA, a plastic that is durable but not oxygen permeable.
 Currently, most RGP lenses are made of silicone acrylate. This material
provides the hardness needed for sharp vision, which is associated with PMMA
lenses, and the oxygen permeability associated with silicone
Manufacturing
 Several methods are used to manufacture contact lenses. In spin-casting, the
liquid plastic polymer is placed in a mold that is spun on a centrifuge; the
shape of the mold and the rate of spin determine the nal shape of the contact
lens.
 Soft contact lenses can also be made on a lathe, starting with a hard, dry plastic
button; this method is similar to the way that RGP lenses are made.
 Lathes may be either manually operated or automated.
Contact Lens Selection
 Soft contact lenses are currently the most frequently prescribed and worn
lenses in the United States.
Soft Contact Lenses
 Soft contact lenses are comfortable primarily because the material is soft and
the diameter is large, extending beyond the cornea to the sclera.
 Most manufacturers make a specific style of lens that varies in only 1
parameter, such as a lens that comes in 3 base curves, with all other parameters
being the same.
Rigid Gas-Permeable Contact Lenses
 RGP lenses, given their small overall diameter, should center over the cornea
but move freely with each blink to allow tear exchange.
 Unlike with soft contact lenses, the parameters of RGP lenses often are not
determined by the manufacturer but are individualized for each patient, making
RGP lens tting more challenging
Base curve
 Unlike soft contact lenses, an RGP lens maintains its shape when placed on a
cornea. As described earlier, a tear layer forms between the cornea and contact
lens (in this case, the RGP lens) that varies in shape, depending on the base
curve and whether there is corneal astigmatism.
Position
A central or interpalpebral is achieved when the lens rests between the upper and
lower eyelids.
Power
The tear lens, as previously noted, is the lens formed by the posterior surface of
the RGP lens and the anterior surface of the cornea. Its power is determined by the
base curve:
 On K. The tear lens has plano power.
 Steeper than K. The tear lens has plus power.
 Flatter than K. The tear lens has minus power
Toric Soft Contact Lenses
 Soft toric contact lenses are readily available in several tting designs. In front
toric contact lenses, the astigmatic correction is on the front surface; in back
toric contact lenses, the correction is on the back surface.
To prevent lens rotation, one of several manufacturing techniques is used:
 adding prism ballast, that is, placing extra lens material on the bottom edge of
the lens
 truncating or removing the bottom of the lens to form a straight edge that
aligns with the lower eyelid
 creating thin zones, that is, making lenses with a thin zone on the top and
bottom so that eyelid pressure can keep the lens in the appropriate position
Contact Lenses for Presbyopia
 Presbyopia a ects virtually everyone older than 40 years.
 Thus, as contact lens wearers age, their accommodation needs must be
considered.
 Three options are available for these patients:
(1) use of reading glasses with contact
lenses,
(2) monovision, and
(3) bifocal contact lenses.
Keratoconus and the Abnormal Cornea
 Contact lenses often provide better vision than do spectacles by masking
irregular astigmatism (higher orders of aberration).
 For mild or moderate irregularities, soft spherical, soft toric, or custom soft
toric contact lenses are used
Gas-Permeable Scleral Contact Lenses
 Scleral lenses have unique advantages over other types of contact lenses in
rehabilitating the vision of eyes with damaged corneas.
 These lenses are entirely supported by the sclera; their centration and
positional stability are independent of distorted corneal topography; and they
avoid contact with a damaged corneal surface.
 Moreover, these lenses create an arti cial tear- lled space over the cornea,
thereby providing a protective function for corneas su ering from ocular
surface disease
Contact Lens Care and Solution
The following are important guidelines:
 Clean and disinfect a lens whenever it is removed.
 Follow the advice included with the lens-care system that is selected; do not
“mix and match” solutions.
 Do not use tap water for storing or cleaning lenses because it is not sterile.
 Do not use homemade salt solutions; they too are not sterile.
 Do not use saliva to wet a lens.
 Do not reuse contact lens–care solutions
 Do not allow the dropper tip to touch any surface; close the bottle tightly when
not in use.
 Clean the contact lens case daily and replace it every 2–3 months; the case can
be a source of contaminants.
 Pay attention to labels on contact lens–care solutions because solution
ingredients may change without warning to the consumer
Intraocular Lenses

 Plano IOLs are available for patients whose eyes require zero (or minimal)
power in the aphakic state (ie, patients with very high myopia). The presence
of an IOL helps maintain the structural integrity of the anterior segment and
reduces the long-term incidence of retinal tears and detachment
The Pentacam
 is a newer imaging system that uses a single Scheimp ug camera to measure
the radius of curvature of the anterior and posterior corneal surfaces, as
well as the corneal thickness, for the calculation of corneal power.
 Early studies have questioned the accuracy of the Pentacam in eyes that have
undergone laser corneal refractive procedures.
Nonspherical Optics
 IOLs with more complex optical parameters are now available.
 It may be possible to o set the positive spherical aberration of the cornea in
pseudophakic patients by implanting an IOL with the appropriate negative
asphericity on its anterior surface
Multifocal Intraocular Lenses
Multifocal IOLs are designed to improve both near and distance vision to decrease
patients’ dependence on glasses.
With a multifocal IOL, the correcting lens is placed in a xed location within the
eye, and the patient cannot voluntarily change the focus.
Types of Multifocal Intraocular Lenses
1. Bifocal intraocular lenses
 Of the various IOL designs, the bifocal IOL is conceptually the simplest.
 The bifocal concept is based on the idea that when there are 2 superimposed images on the
retina, the brain always selects the clearer image and suppresses the blurred one
2. Multiple-zone intraocular lenses
 To overcome the problems associated with pupil size, ophthalmologists developed a 3-zone
bifocal lens .
 The central and outer zones are for distance vision; the inner annulus is for near vision.
 The diameters were selected to provide near correction for moderately small pupils and
distance correction for both large and small pupils.
Second-generation di ractive multifocal intraocular lenses
 Currently, 3 second-generation di ractive multifocal IOLs are available.
 The first of these IOLs, the AcrySof ReSTOR IOL , is an apodized di ractive
lens .. This IOL is now available in an aspheric design.
 The second design, the ReZoom has 5 anterior surface zones for distance and
near vision; grading between the zones provides intermediate vision.
 The third IOL, the TECNIS ZM 900 lens (AMO), adds an aspheric surface,
whereas the ReZoom lens does not.
Clinical Results of Multifocal Intraocular Lenses
 Some multifocal IOLs perform better for near vision; others, for intermediate.
Studies have shown a bene t to using a combination of these lenses in the same
patient.
 The best-corrected visual acuity may be less with a multifocal IOL than with a
monofocal IOL; this di erence increases in low-light situations. However, the
need for additional spectacle correction for near vision is greatly
 reduced in patients with multifocal IOLs. Some patients are quite pleased with
multifocal IOLs; others request their removal and replacement with monofocal
IOLs.
Optical Considerations in
Keratorefractive Surgery
Optical Instruments and Techniques Used in Ophthalmic Practice
 Direct Ophthalmoscope
 Indirect OphthalmoscoFundus Camera
 A fundus camera
is nearly identical to the indirect ophthalmoscope; the aerial image is
simply reimaged onto the camera’s lm or sensor arrape
 Slit-Lamp Biomicroscope
In a slit-lamp biomicroscope, a system of lenses and apertures (known as
Koehler illumination) is designed to collect the light from the device’s bulb
into a beam of homogeneous brightness, giving good contrast and minimal
glare
 Auxiliary lenses for slit-lamp examination of the retina
The cornea and lens together provide so much convergence that we cannot
look through them with the slit lamp and see the retina
 Gonioscopy
Unless a gonioscopy lens is placed on the eye, the anterior chamber angle is
hidden from view by total internal).
This problem is solved by use of a contact lens with a mirror or a contact
lens
 allowing direct viewing at an angle less than the critical angle
 Surgical Microscope
The viewing optics of an operating microscope are similar to those of the slit
lamp. The illumination is “coaxial,” running near the viewing paths.
 Geneva Lens Clock
The Geneva lens clock uses 3 pins to measure the curvature of a spectacle
lens.
 Lensmeter
To measure the power of a lens using a lensmeter, we place the lens on a nose
cone at the top of a cylinder. Optical Pachymeter
With the optical pachymeter, the thickness of the cornea or the depth of the
anterior chamber is measured by lining up prism-split images in the focused
slit lamp’s optical section through the eye
 Applanation Tonometry
The head of the applanation tonometer contains a prism that splits the image
of a uorescing circle of tears to determine when that circle is precisely a
certain size
 Specular Microscopy
Specular microscopy is a modality for examining endothelial cells that uses
specular re ection from the interface between the endothelial cells and the
aqueous humor.
 Keratometer
The keratometer is used to measure the curvature of the central outer
corneal surface by measuring the size of a re ected image in each meridian
(or only in the meridians of greatest and least curvature)
 Topography
Computerized computations of measurements of the re ected image of a
Placido disk of concentric circles painted inside a concavity enable corneal
topography instruments to produce a detailed map of the shape of the entire
outer corneal surface
 Ultrasonography of the Eye and Orbit
 Macular Function Tests
 Scanning Laser Ophthalmoscopes
In a scanning laser ophthalmoscope, a rapidly scanning laser illuminates a
small spot of retina, while a luminance detector measures the light that is
reacted.
 Confocal scanning laser ophthalmoscopes and microscopes
Optical imaging devices may include a confocal aperture, a small opening
through which pencils of light must pass in order to contribute to the device’s
image.
 Scanning laser polarimeter
 Wide- eld scanning laser ophthalmoscope
 Scheimp ug Camera
In a Scheimp ug camera, the image and object planes are tilted with respect
to the instrument’s optics
 Autorefractors