REFRACTION

NURCHALIZA HAZARIA SIREGAR

DEPARTEMEN ILMU KESEHATAN MATA
FK USU

Refraction
Refraction is based on the idea that LIGHT is
passing through one MEDIUM into another. The
question is, WHAT HAPPENS?
Suppose you are running on the
beach with a certain velocity when
you suddenly need to run into the
water. What happens to your
velocity?
IT CHANGES!
Refraction Fact #1: As light goes from
one medium to another, the velocity
CHANGES!

Refraction
Suppose you decide to go spear fishing, but unfortunately you arent
having much luck catching any fish.
The cause of this is due to the fact
that light BENDS when it reaches a
new medium. object is NOT directly
in a straight line path, but rather its
image appears that way. The actual
objectThe is on either side of the
image you are viewing.
Refraction Fact #2: As light goes
from one medium to another, the
path CHANGES!

Refraction
What EXACTLY is light doing when it reaches a new
medium? Do you to think ALL of the light refracts?
Some of the light REFLECTS off the
boundary and some of the light
REFRACTS through the boundary.
Angle of incidence = Angle of
Reflection
Angle of Incidence > or < the Angle
of refraction depending on the
direction of the light

Refractive Media
Cornea
Aquos humor
Lens
Vitreous Body (Corpus Vitreous)

Refractive Physiology
Light rays are focused on the retina because they are

refracted by passing through the cornea and lens

(Snells Law)
Corneal refractive power is constant
Lens refractive power is modifiable with
accomodation
Axial length of the eye is constant except under
certain conditions

Accomodation
Emmetropic eye : object closer than 6 m send divergent

light that focus behind retina,adaptative mechanism of

eye is increase refractive power by accomodation
Helm-holtz theory
- contraction of cilliary muscledecrease tension in
zonule fiberselasticity of lens capsule mold lens into
spherical shapegreater dioptic power divergent rays
are focused on retina
- Contraction of cilliary muscle is supplied by
parasympathetic third nerve

Refractive Disorder
Myopia
Hyperopia
Astigmatism

Myopia
NURCHALIZA HAZARIA SIREGAR
DEPARTEMEN I K MATA
FAKULTAS KEDOKTERAN USU

Definition
The common name for this refractive error is near-

sightedness
Patients with myopia are known as myopes
When parallel rays of light enter the eye (with
accommodation relaxed) and come to a single point
focus in front of the retina

Etiology
Axial length

The axial length of the eye is longer than normal due to

imperfect emmetropization
The most common cause of myopia for high myopes

Refractive power

The refractive power of the eye is too strong

Curvature myopia
Cornea or lens has a steep curvature (e.g., keratoconus)
Increased index of refraction (e.g., cornea, lens)
Anterior movement of the lens (e.g., nuclear sclerosis)

Prevalence
Age

At birth: 24 to 50%
As birth weight decreases, the amount of myopia increases in
premature infants
The mean refractive error for full-term infants is +2.00 D
The prevalence of myopia decreases by 1 year old due to the
process of emmetropization
5 to 6 years old: 2% (>-0.50DS)
13 to 14 years old: 15%
In western countries

20 years old: 20%

Prevalence
Gender

In general, there are no significant differences between males

and females
Progression of myopia tends to begin and end earlier in females
High myopia is more common in females

Ethnicity

Higher prevalence in Asians, Arabs, and Jews

Lower prevalence in Caucasians, Blacks, and South Sea Islanders

Urban versus rural communities

Myopia is more common in urban communities than in rural

ones

Progression
Myopia tends to increase linearly until the middle or

late teenage years, at which point, it levels off

The earlier a child becomes myopic, the more rapidly
the condition tends to progress

Juvenile-Onset Myopia
Definition

Myopia in which the age of onset is 8 to 12 years

Etiology

Evidence for genetics influences

Greater similarity of refractive error and ocular structures in

identical twins than in fraternal twins
Increased prevalence of myopia in children of myopic parents
Probability of a child being myopic is:
40% when both parents are myopic
20 to 30% when one parent is myopic
<10% when neither parent is myopic

Juvenile-Onset Myopia
Etiology

Evidence for environmental influences

Association between near work, education, and myopia

Children who do a lot of near work, like reading, tend to become
myopic
Myopia is more common where occupations require extensive
near work

Myopia and Visual Acuity

Uncorrected VA

Refractive Error (D)

20/30

0.50

20/40

0.75

20/60

1.00

20/80

1.50

20/120

2.00

20/200

2.50

Symptoms
Blurry vision at distance
Clear vision at near
Squinting
Occasional headaches

Signs
Decreased visual acuities at distance

Clinical Tests
Visual acuity tests - distance
Retinoscopy
Subjective refraction

Management
Divergent or minus lenses in spectacles or contact lenses

Cycloplegics :

Reduce the ability to accommodate

May slow the progression of myopia

Refractive surgery

Pathological Conditions Associated with Myopia

Cataract

Nuclear cataract causes a myopic shift

Diabetes

High blood glucose levels cause increased sorbital levels in the

lens
Water rushes in and dilutes the sorbital in the lens
Lens bulges and results in a myopic shift

Marfans syndrome

Suspensory ligaments break

Subluxation of lens occurs superiorly and temporally and
results in a very high increase in myopia

Hyperopia
NURCHALIZA HAZARIA SIREGAR
DEPARTEMEN I K MATA
FAKULTAS KEDOKTERAN USU

Definition

The common name for this refractive error is far-

sightedness
Patients with hyperopia are known as hyperopes

Definition
When parallel rays of light enter the eye (with

accommodation relaxed) and come to a single

point focus behind the retina

Etiology
Axial length

The axial length of the eye is shorter than normal due to

imperfect emmetropization

Etiology
Refractive power
The refractive power of the eye is too weak

Curvature hyperopia
Cornea or lens has a flat curvature
Decreased index of refraction
Due to decreased density in some parts of the optical system of
the eye
Loss of accommodation
Due to age, drug medications
Aphakia (no lens)
Due to cataract removal

Prevalence
Hyperopia is more common than myopia
Age
The mean refractive error is +2.00D in newborns
The mean refractive error is +1.00 to +0.50D in children at age 6
The mean refractive error is plano in children at age 10
The mean refractive error is skewed toward myopia in children
after age 10
Gender

Hyperopia is more common in females than in males

Ethnicity

Higher prevalence in American Indians, Blacks, Caribbean, South

Sea Islanders, and Eskimos

Compensating Accommodation
Factors

Fatigue general and ocular

Due to continuous focusing of images in and out on the retina

Illness (e.g., cold, fever)

Mental state (e.g., stress)
Alcohol
Drugs and medications (e.g., antihistamines)

Antihistamines may relax accommodation and dilate the pupils

Facultative Hyperopia
Definition

The amount of hyperopia that can be overcome by

accommodation

Absolute Hyperopia
Definition

The amount of hyperopia that cannot be overcome by

accommodation

Manifest Hyperopia
Definition

The amount of hyperopia revealed with a non-cycloplegic

refraction (i.e., when no pharmacological drugs are used to
dilate the eyes)

Latent Hyperopia
Definition

The amount of hyperopia revealed with cycloplegic refraction

(i.e., when pharmacologic drugs are used to dilate the eyes)

Causes

Drugs and progressive near work, resulting in accommodative

spasms so that accommodation may not be relaxed

Total Hyperopia
Definition

The sum of manifest hyperopia and latent hyperopia

Absolute Hyperopia and Visual Acuity

Uncorrected VA

Refractive Error (D)

20/30

0.50

20/40

0.75

20/60

1.00

20/80

1.50

20/120

2.00

20/200

2.50

Symptoms
Asthenopia or ocular fatigue
Frontal headaches
Avoidance of visual tasks, especially at near
Blurry vision at distance and near
Intermittent blurring of vision

Signs
Miotic pupil
Enables accommodation and increased depth of focus
Esophoria
Inward deviation of the eyes
With accommodation, eyes tend to converge
Decreased visual acuities at distance and near,

especially the latter

Occasional diplopia or double vision

Clinical Tests
Visual acuity tests distance and near
Binocular vision tests (e.g., cover test)
Accommodation tests
Retinoscopy
Subjective refraction

Management
Accommodation training (especially in young

patients)
Convergent or plus lenses in spectacles or contact
lenses

Refractive surgery

Management
Spectacles

Single vision glasses

Contact lenses

Soft contact lenses

Rigid gas permeable contact lenses

Refractive surgery

Photorefractive keratectomy (PRK)

Laser in-situ keratomileusis (LASIK)

Astigmatism
NURCHALIZA HAZARIA SIREGAR
DEPARTEMEN I K MATA
FAKULTAS KEDOKTERAN USU

Definition
When parallel rays of light enter the eye (with

accommodation relaxed) and do not come to a single

point focus on or near the retina

Optics
Power in the horizontal plane projects a vertical focal

line image
Power in the vertical plane projects a horizontal focal
line image

Optics
Refraction of light taking place at a toric surface:

the conoid of Sturm

Etiology
Cornea

The cornea has an unequal curvature on its anterior surface

Lens

The crystalline lens has an unequal curvature on its surface or

in its layers

It is due to a distortion of the cornea and/or lens

The refracting power is not uniform in all meridians
The principal meridians are the meridians of

greatest and least refracting powers

The amount of astigmatism is equal to the
difference in refracting power of the two principal
meridians

Classification
Based on etiology
Based on relation between principal meridians
Based on orientation of meridian or axis
Based on focal points relative to the retina
Based on relative locations of principal meridians or

axes when comparing the two eyes

Corneal Astigmatism
When the cornea has unequal curvature on the

anterior surface

Lenticular Astigmatism
When the crystalline lens has an unequal on the

surface or in its layers

Total Astigmatism
The sum of corneal astigmatism and lenticular

astigmatism

Regular Astigmatism
When the two principal meridians are perpendicular

to each other
Most cases of astigmatism are regular astigmatism
The three types are with-the-rule, against-the-rule,
and oblique astigmatism

Irregular Astigmatism
When the two principal meridians are not

perpendicular to each other

Curvature of any one meridian is not uniform
Associated with trauma, disease, or degeneration
VA is often not correctable to 20/20

With-The-Rule (WTR) Astigmatism

When the greatest refractive power is within 030 of

the vertical meridian (i.e., between 060 and 120

meridians)
Minus cylinder axis around horizontal meridian
The most common type of astigmatism based on the
orientation of meridians

With-The-Rule (WTR) Astigmatism

Against-The-Rule (ATR) Astigmatism

When the greatest refractive power is within 030 of

the horizontal meridian (i.e., between 030 and 150

meridians)
Minus cylinder axis around vertical meridian

Against-The-Rule (ATR) Astigmatism

Oblique (OBL) Astigmatism

When the greatest refractive power is within 030 of

the oblique meridians (i.e., between 030 and 060 or

120 and 150)

Simple Astigmatism
When one of the principal meridians is focused on

the retina and the other is not focused on the retina

(with accommodation relaxed)

Simple Myopic Astigmatism

When one of the principal meridians is focused in

front of the retina and the other is focused on the

retina (with accommodation relaxed)

Simple Hyperopic Astigmatism

When one of the principal meridians is focused

behind the retina and the other is focused on the

retina (with accommodation relaxed)

Compound Astigmatism
When both principal meridians are focused either in

front or behind the retina (with accommodation

relaxed)

Compound Myopic Astigmatism

When both principal meridians are focused in front

of the retina (with accommodation relaxed)

Compound Hyperopic Astigmatism

When both principal meridians are focused behind

the retina (with accommodation relaxed)

Mixed Astigmatism
When one of the principal meridians is focused in

front of the retina and the other is focused behind

the retina (with accommodation relaxed)

Symmetrical Astigmatism
The principal meridians or axes of the two eyes are

symmetrical (e.g., both eyes are WTR or ATR)

The sum of the two axes of the two eyes equals
approximately 180

Asymmetrical Astigmatism
The principal meridians or axes of the two eyes are

not symmetrical (e.g., one eye is WTR while the

other eye is ATR)
The sum of the two axes of the two eyes does not
equal approximately 180

Prevalence
Age

Infants are born with ATR astigmatism, where the cornea is

the source of the astigmatism
Preschool children have little or no astigmatism
Teenage children demonstrate a shift towards WTR
astigmatism
Older adults show a shift towards ATR astigmatism

Prevalence
Gender

In general, there are no significant differences between males

and females

Ethnicity

Higher prevalence in North Americans, Latinos

Asian infants tend to be WTR astigmatism
Caucasian infants tend to be ATR astigmatism

Incidence
General trend

For older adults, the average rate of change towards ATR

astigmatism is less than or equal to 0.25D every 10 years

Visual Acuity
Theoretically, at NO distance does an uncorrected

astigmat have a sharp retinal image

Clinically, if astigmatism is small (less than 0.50DC),
the patient may not notice blur

Visual Acuity
Simple or compound myopic astigmatism

Accommodation may make the retinal image even more

blurry

Simple or compound hyperopic astigmatism

Accommodation may improve VA to some extent

Mixed astigmatism

VA is relatively good
May not need much accommodation

Spherical and Astigmatic Ametropia

Uncorrected VA

20/30

Spherical
Astigmatism (D)
Refractive Error
(D)*
0.50
1.00

20/40

0.75

1.50

20/60

1.00

2.00

20/80

1.50

3.00

20/120

2.00

4.00

20/200

2.50

>4.00

Symptoms
Distorted vision at distance and near
Letter confusion
Asthenopia or ocular fatigue
Due to constantly squinting to clear up distorted vision
Headaches
Squinting

Signs
Decreased visual acuities at distance and near

Clinical Tests
Visual acuity tests distance and near
Autorefraction
Keratometry
Retinoscopy

Most reliable source of information for cylinder power and axis

Monocular subjective refraction, including Jackson

cross cylinder

Management
Cylindrical lenses and spherocylindrical lenses in

spectacles and contact lenses for simple

astigmatism and compound astigmatism,
respectively
Refractive surgery

Presbyopia
NURCHALIZA H.SIREGAR
DEPARTEMEN I K MATA
FAKULTAS KEDOKTERAN USU

Definition
Latin definition

Presbyopia = old mans eye

Decrease in the amplitude of accommodation or loss

of accommodative ability with age

Etiology
Natural part of the aging process
Onset at approximately 40 years of age and over

though may be earlier in low hyperopes

Progression
Once presbyopia occurs, it increases over a period of

10 to 12 years, after which it stabilizes

Symptoms
Blurry vision at near
Difficult or impossible to accommodate sufficiently

for near work

Increasing Near Point of Accommodation with Age

Age (years)

Distance (cm)

10

20

10

30

14

40

20

50

40

Amplitude of Accommodation and Age (Donders Table)

Age (years)
10
15
20
25
30
35
40

Amplitude
(D)
14.00
12.00
10.00
8.50
7.00
5.50
5.00

Age (years)
45
50
55
60
65
70
75

Amplitude
(D)
3.50
2.50
1.75
1.00
0.50
0.25
0.00

Near Work
Comfortable vision at near uses less than or equal to

half of the available amplitude of accommodation

Near work becomes difficult when the amplitude of
accommodation is less than 5.00D

Management
Converging or plus lenses for near work only

in spectacles or contact lenses

Changes in prescriptions are required every two to

three years for presbyopia

Surgery

Thank You