International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064

Index Copernicus Value (2013): 6.14 | Impact Factor (2013): 4.438

Myopia, Hyperopia and Astigmatism: A Complete

Review with View of Differentiation
Dr. Sanjay Upadhyay
Assistant professor, Department of Ophthalmology, Gujarat Adani Institute of Medical Science, Bhuj, Gujarat

Abstract: Nearsighted individuals typically have problems seeing well at a distance and are forced to wear glasses or contact lenses.
The nearsighted eye is usually longer than a normal eye, and its cornea may also be steeper. Therefore, when light passes through the
cornea and lens, it is focused in front of the retina. This will make distant images appear blurred. There are several refractive surgery
solutions available to correct nearly all levels of nearsightedness. Farsighted individuals typically develop problems reading up close
before the age of 40. The farsighted eye is usually slightly shorter than a normal eye and may have a flatter cornea. Thus, the light of
distant objects focuses behind the retina unless the natural lens can compensate fully. Near objects require even greater focusing power
to be seen clearly and therefore, blur more easily. LASIK, Refractive Lens Exchange and Contact lenses are a few of the options
available to correct farsightedness. Asymmetric steepening of the cornea or natural lens causes light to be focused unevenly, which is
the main optical problem in astigmatism. To individuals with uncorrected astigmatism, images may look blurry or shadowed.
Astigmatism can be corrected with glasses, contact lenses, corneal relaxing incisions, laser vision correction, and special implant lenses.

Keywords: Myopia, Hyperopia, Astignatism

Myopia directly on its surface. Nearsightedness also can be caused by

the cornea and/or lens being too curved for the length of the
1. Introduction eyeball. In some cases, myopia is due to a combination of
these factors.
Nearsightedness (myopia) is a common cause of blurred
vision. It can be mild, moderate, or severe. If you are Myopia typically begins in childhood and you may have a
nearsighted, objects in the distance appear blurry and out of higher risk if your parents are nearsighted. In most cases,
focus. You might squint or frown when trying to see distant nearsightedness stabilizes in early adulthood but sometimes it
objects clearly. View a photo as seen through a normal and a continues to progress with age.
nearsighted eye. Nearsightedness, or myopia, is the most
common refractive error of the eye, and it has become more Etiological Factor:
prevalent in recent years [1].
Because twins and relatives are more likely to get myopia
In fact, a recent study by the National Eye Institute (NEI) under similar circumstances, there must be a hereditary
shows the prevalence of myopia grew from 25 percent of the factor, but because myopia has been increasing so rapidly
U.S. population (ages 12 to 54) in 1971-1972 to a whopping throughout the developed world, environmental factors must
41.6 percent in 1999-2004. Eye care professionals most be more important.
commonly correct myopia through the use of corrective
lenses, such as glasses or contact lenses. It may also be 1) Education[4]
corrected by refractive surgery, though there are cases of A common explanation for myopia is near-work. Regarding
associated side effects. The corrective lenses have a the relationship to IQ, several explanations have been
negative optical power (i.e. have a net concave effect) which proposed. One is that the myopic child is better adapted at
compensates for the excessive positive diopters of the reading, and reads and studies more, which increases
myopic eye. Negative diopters are generally used to describe intelligence. The reverse explanation is that the intelligent
the severity of the myopia, as this is the value of the lens to and studious child reads more, which causes myopia. Myopia
correct the eye. High-degree myopia, or severe myopia, is is more common among students in gifted education.
defined as -6 diopters or worse [2]. 2) Near work hypothesis [5]
The "near work" hypothesis, also referred to as the “use-
Though the exact cause for this increase in nearsightedness abuse theory” states that spending time involve in near work
among Americans is unknown, many eye doctors feel it has strains the eyes and increases the risk of myopia. Some
something to do with eye fatigue from computer use and studies support the hypothesis while other studies do not.
other extended near vision tasks, coupled with a genetic While an association is present it is unclear if it is causal.
predisposition for myopia. 3) Visual stimuli hypothesis
Although not mutually exclusive with the other hypotheses
Cause of Myopia [3]: presented, the visual stimuli hypothesis adds another layer of
mismatch to explain the modern prevalence of myopia.
Myopia occurs when the eyeball is too long, relative to the Modern humans who spend most of their time indoors, in
focusing power of the cornea and lens of the eye. This causes dimly or fluorescently lit buildings are not giving their eyes
light rays to focus at a point in front of the retina, rather than

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 International Journal of Science and Research (IJSR)
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Index Copernicus Value (2013): 6.14 | Impact Factor (2013): 4.438
the appropriate stimuli to which they had evolved and may the cornea and crystalline lens) or optically too powerful
contribute to the development of myopia. for its axial length.
4) Other risk factors  Degenerative myopia, also known as malignant,
In one study, heredity was an important factor associated pathological, or progressive myopia, is characterized by
with juvenile myopia, with smaller contributions from more marked fundus changes, such as posterior staphyloma,
near work, higher school achievement and less time in sports and associated with a high refractive error and subnormal
activity. Long hours of exposure to daylight appears to be a visual acuity after correction.
protective factor. Researchers at the University of Cambridge  Nocturnal myopia, also known as night or twilight
have found that a lack of outdoor play could be linked to myopia, is a condition in which the eye has a greater
myopia. Another explanation is that pleiotropic gene(s) difficulty seeing in low-illumination areas, even though its
affect the size of the brain and the shape of the eye daytime vision is normal. A stronger prescription for
simultaneously myopic night drivers is often needed. Younger people are
more likely to be affected by night myopia than the
Symptoms of Myopia [1]: elderly.
The main symptom is blurred vision when looking at distant  Pseudomyopia is the blurring of distance vision brought
objects. If you can see well enough to read newspaper print about by spasm of the ciliary muscle.
but you struggle to see things that are farther away, you are  Induced myopia, also known as acquired myopia, results
probably nearsighted. You may have trouble clearly seeing from exposure to various pharmaceuticals, increases
images or words on a blackboard, movie screen, or in glucose levels, nuclear sclerosis, oxygen toxicity (e.g.,
television. This can lead to poor school, athletic, or work from diving or from oxygen and hyperbaric therapy) or
performance. other anomalous conditions.
 Index myopia is attributed to variation in the index of
Your child may be nearsighted if he or she squints or frowns, refraction of one or more of the ocular media. Cataracts
gets headaches often, or holds books or other objects very may lead to index myopia.
close to his or her face. Children who are nearsighted may sit  Form deprivation myopia occurs when the eyesight is
at the front of the classroom or very close to the TV or movie deprived by limited illumination and vision range, or the
screen. They may not be interested in sports or other eye is modified with artificial lenses or deprived of clear
activities that require good distance vision. form vision.
 Nearwork-induced transient myopia (NITM) is defined as
Diagnosis of Myopia [6]: short-term myopic far point shift immediately following a
A diagnosis of myopia is typically confirmed during an eye sustained near visual task.
examination performed by a specialized doctor who is an  Instrument myopia is defined as over-accommodation
expert in refractive conditions of the eye, the optometrist, or when looking into an instrument such as a microscope.
by an ophthalmologist or orthoptist. Frequently
an autorefractor or retinoscope is used to give an initial c) Degree
objective assessment of the refractive status of each eye, then Myopia, which is measured in diopters by the strength
aphoropter is used to subjectively refine the patient's eyeglass or optical power of a corrective lens that focuses distant
prescription. images on the retina, has also been classified by degree or
severity:
Classification of Myopia [7]:
 Low myopia usually describes myopia of −3.00 diopters
or less (i.e. closer to 0.00).
a) By cause
 Medium myopia usually describes myopia between −3.00
Borish and Duke-Elder classified myopia by cause:
and −6.00 diopters.
Axial myopia is attributed to an increase in the eye's axial
length.  High myopia usually describes myopia of −6.00 or
Refractive myopia is attributed to the condition of the more. People with high myopia are more likely to
refractive elements of the eye. Borish further subclassified have retinal detachments and primary open angle
refractive myopia: glaucoma.
 Curvature myopia is attributed to excessive, or increased,
d) Age at onset
curvature of one or more of the refractive surfaces of the
Myopia is sometimes classified by the age at onset:
eye, especially the cornea.
 Congenital myopia, also known as infantile myopia, is
 Index myopia is attributed to variation in the index of
present at birth and persists through infancy.
refraction of one or more of the ocular media.
 Youth onset myopia occurs in the early childhood or
b) Clinical entity teenage, and the ocular power can keep varying until the
Various forms of myopia have been described by their age of 21, before which any form of corrective surgery is
clinical appearance: usually not recommended by ophthalmic specialists
around the world.
 Simple myopia, more common than other types of
myopia, is characterized by an eye that is too long for  School myopia appears during childhood, particularly the
its optical power (which is determined by school-age years. This form of myopia is attributed to the
use of the eyes for close work during the school years.

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Index Copernicus Value (2013): 6.14 | Impact Factor (2013): 4.438
Treatment [8]: 2. Hyperopia
The goal of treating nearsightedness is to improve vision by
helping focus light on your retina through the use of Farsightedness, or hyperopia, as it is medically termed, is a
corrective lenses or refractive surgery. vision condition in which distant objects are usually seen
a) Corrective lenses clearly, but close ones do not come into proper focus.
Wearing corrective lenses treats nearsightedness by Farsightedness occurs if your eyeball is too short or the
counteracting the increased curvature of your cornea or the cornea has too little curvature, so light entering your eye is
increased length of your eye. Types of corrective lenses not focused correctly. Common signs of farsightedness
include: include difficulty in concentrating and maintaining a clear
 Eyeglasses. This is a simple, safe way to correct vision focus on near objects, eye strain, fatigue and/or headaches
problems caused by myopia. The variety of eyeglasses is after close work, aching or burning eyes, irritability or
wide and includes bifocals, trifocals and reading lenses. nervousness after sustained concentration [9].
 Contact lenses. These lenses are worn right on your eyes.
They are available in a variety of types and styles, In mild cases of farsightedness, your eyes may be able to
including hard, soft, extended wear, disposable, rigid gas compensate without corrective lenses. In other cases, your
permeable and bifocal. Ask your eye doctor about the pros optometrist can prescribe eyeglasses or contact lenses to
and cons of contact lenses and what might be best for you. optically correct farsightedness by altering the way the light
enters your eyes. People experience hyperopia differently.
b) Refractive surgery Some people may not notice any problems with their vision,
Refractive surgery improves vision and reduces the need for especially when they are young. For people with significant
eyeglasses or contact lenses. Your eye surgeon uses a laser hyperopia, vision can be blurry for objects at any distance,
beam to reshape the cornea. This type of surgery has become near or far. It is an eye focusing disorder, not an eye disease.
routine, but it's usually not recommended until the eyes have Farsightedness usually is present at birth and tends to run in
fully developed, in the 20s. families. You can easily correct this condition with
Refractive surgical procedures for nearsightedness include: eyeglasses or contact lenses. Another treatment option is
 Laser-assisted in-situ keratomileusis (LASIK). With this surgery [10].
procedure, your eye surgeon makes a thin, hinged flap in
your cornea. He or she then uses an excimer laser to Causes of Hyperopia [10]:
remove layers from the center of your cornea to flatten its Farsightedness is the result of the visual image being focused
domed shape. An excimer laser differs from other lasers in behind the retina rather than directly on it. It is mainly cause
that it doesn't produce heat. After the excimer laser is used, by two reasons-
the thin corneal flap is repositioned.  Low converging power of eye lens because of weak action
 Laser-assisted subepithelial keratectomy of ciliary muscles.
(LASEK). Instead of creating a flap in the cornea, the  Eyeball being too short because of which the distance
surgeon creates a flap only in the cornea's thin protective between eye lens and retina decreases.
cover (epithelium). He or she then uses an excimer laser to
reshape the cornea's outer layers and flatten its curvature Farsightedness is often present from birth, but children have
and then repositions the epithelial flap. You may need to a very flexible eye lens, which helps make up for the
wear a bandage contact lens for several days afterward to problem. As aging occurs, glasses or contact lenses may be
encourage healing. required to correct the vision. Farsightedness is hereditary.
 Photorefractive keratectomy (PRK). This procedure is
similar to LASEK, except the surgeon removes the Classification of Hyperopia:
epithelium. It will grow back naturally, conforming to your Hyperopia is typically classified according to clinical
cornea's new shape. You may need to wear a bandage appearance, its severity, or how it relates to the
contact lens for a few days afterward. eye's accommodative status.
 Intraocular lens (IOL) implant. These lenses are  Simple hyperopia
surgically implanted into the eye, in front of the eye's  Pathological hyperopia
natural lens. They may be an option for people with  Functional hyperopia
moderate to severe myopia. IOL implants are not currently
considered a mainstream treatment option. Symptoms of Hyperopia [10]:
Symptoms of farsightedness can include:
Some of the possible complications that can occur after  Blurred vision, especially at night.
refractive surgery include:  Trouble seeing objects up close. For example, you can't see
 Undercorrection or overcorrection of your initial problem well enough to read newspaper print.
 Visual side effects, such as a halo or starburst appearing  Aching eyes, eyestrain, and headaches.
around lights
 Dry eye Children with this problem may have no symptoms. But a
 Infection child with more severe farsightedness may:
 Corneal scarring  Have headaches.
 Rarely, vision loss  Rub his or her eyes often.
 Have trouble reading or show little interest in reading.
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 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2013): 4.438
Diagnosis of Hyperopia lenses, and even vision correction procedures are all possible
Visual acuity screening is recommended to detect hyperopia treatment options.
as well as other eye conditions. The gold standard for visual
acuity testing is to use the Snellen chart using manifest and A person's eye is naturally shaped like a sphere. Under
cycloplegic refraction. The difference between Cycloplegic normal circumstances, when light enters the eye, it refracts,
hyperopia and Manifest (Noncycloplegic) hyperopia is Latent or bends evenly, creating a clear view of the object.
hyperopia. However, the eye of a person with astigmatism is shaped
more like a football or the back of a spoon. For this person,
Subjective refraction can be performed with a visual acuity when light enters the eye it is refracted more in one direction
chart at far distance (20ft or 6m) and near distance (1ft or than the other, allowing only part of the object to be in focus
0.33m). These screenings typically are performed by at one time. Objects at any distance can appear blurry and
teachers, primary care physicians (e.g. pediatricians, family wavy[12].
physicians, etc.), optometrists, and/or ophthalmologists. The
charts used for visual acuity screening include, but are not Causes of Astigmatism[12]:
limited to, Snellen, Allen, HOTV, Tumbling E, etc. Astigmatism is a natural and commonly occurring cause of
blurred or distorted vision that is usually associated with an
Objective refraction can be performed using an imperfectly shaped cornea. The exact cause in not known.
autorefraction machine or retinocopy. This first uses rays to
measure at what distance an object is focused on the retina. Symptoms of Astigmatism [13]:
Retinoscopy is the method preferred in babies and children. Although astigmatism may be asymptomatic, higher degrees
It requires a cycloplegic, retinoscope, and a series of lenses of astigmatism may cause symptoms such as blurry vision,
or a phoropter to determine when light rays are focused onto squinting, eye strain, fatigue, or headaches. Some research
the retinal plane. The tester neutralizes the movement of the has pointed to the link between astigmatism and higher
reflected light with one of the lenses in the series. prevalence of migraine headaches.

Differential diagnosis of Hyperopia: Diagnosis of Astigmatism [13]:

Orbital tumors, serous elevation of the retina, posterior Astigmatism can be diagnosed through a comprehensive eye
scleritis, presbyopia, hypoglycemia, cataracts, and/or post examination. Testing for astigmatism measures how the eyes
refractive surgery may present in a similar fashion to focus light and determines the power of any optical lenses
hyperopia. needed to compensate for reduced vision. This examination
may include:
Management of Hyperopia [11]:  Visual acuity—As part of the testing, you'll be asked to
The standard, and safest, treatment for symptomatic read letters on a distance chart. This test measures visual
hyperopia is corrective lenses. Mild hyperopia does not need acuity, which is written as a fraction such as 20/40. The top
treatment. Hyperopic correction can be achieved by glasses number is the standard distance at which testing is done,
lenses, contact lenses, or refractive surgery. The lenses twenty feet. The bottom number is the smallest letter size
required to correct hyperopia are convex lenses that converge you were able to read. A person with 20/40 visual acuity
light rays entering the eye to bring the focal point of the eye would have to get within 20 feet of a letter that should be
onto the retina. Glasses lenses are tolerated better in babies seen at forty feet in order to see it clearly. Normal distance
and children. Contact lenses are typically not preferred until visual acuity is 20/20.
adolescence or later, however the decision is based on the  Keratometry—A keratometer is the primary instrument
responsibility level of the patient or caregiver. A survey of used to measure the curvature of the cornea. By focusing a
practitioners revealed a common threshold for treatment circle of light on the cornea and measuring its reflection, it
intervention of hyperopia was 3.00D to 5.00D of is possible to determine the exact curvature of the cornea's
asymptomatic hyperopia in children at age. surface. This measurement is particularly critical in
determining the proper fit for contact lenses. A more
Refractive surgery is typically not preferred until the sophisticated procedure called corneal topography may be
refractive error of the eye has stabilized and growth of the performed in some cases to provide even more detail of the
eye has stopped, which typically occurs in the third decade of shape of the cornea.
life. Surgical options for hyperopia include thermal laser  Refraction—Using an instrument called a phoropter, your
keratoplasty (TLK), conductive keratoplasty (CK), spiral optometrist places a series of lenses in front of your eyes
hexagonal keratotomy, excimer laser, clear lens extraction and measures how they focus light. This is performed using
with intraocular lens implantation or phakic intraocular lens a hand held lighted instrument called a retinoscope or an
implantation. automated instrument that automatically evaluates the
focusing power of the eye. The power is then refined by
Astigmatism patient’s responses to determine the lenses that allow the
Astigmatism is a common eye condition that's usually clearest vision.
corrected by eyeglasses, contact lenses, or surgery. Using the information obtained from these tests, your
Astigmatism is caused by an eye that is not completely round optometrist can determine if you have astigmatism. These
and occurs in nearly everybody to some degree. findings, combined with those of other tests performed, will
For vision problems due to astigmatism, glasses, contact allow the optometrist to determine the power of any lens

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 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2013): 4.438
correction needed to provide clear, comfortable vision, and
discuss options for treatment.

Treatment of Astigmatism [13]:

Astigmatism may be corrected with eyeglasses, contact

lenses, or refractive surgery. Various considerations
involving eye health, refractive status, and lifestyle determine
whether one option may be better than another. In those
with keratoconus, certain contact lenses often enable patients
to achieve better visual acuity than eyeglasses. Once only
available in a rigid, gas-permeable form, toric lenses are now
available also as soft lenses.

Laser eye surgery (LASIK and PRK) is successful in treating

astigmatism. Corneal incisions if properly placed can correct
astigmatism. These techniques include Mini Asymmetric
Radial Keratotomy (M.A.R.K.), Astigmatic Keratotomy
(AK) and Limbal relaxing incision (LRI). However these
techniques are used less often than laser-performed ones.

References
[1] Hornbeak, D.M. and T.L. Young, Myopia genetics: a
review of current research and emerging trends. Current
opinion in ophthalmology, 2009. 20(5): p. 356.
[2] Kohnen, T., Refractive surgical probleml. Journal of
Cataract & Refractive Surgery, 1997. 23(5): p. 698-702.
[3] Chehab, K., A.H. Shedden, and X. Cheng, Lens
incorporating myopia control optics and muscarinic
agents. 2012, Google Patents.
[4] Ip, J.M., et al., Role of near work in myopia: findings in
a sample of Australian school children. Investigative
Ophthalmology and Visual Science, 2008. 49(7): p.
2903.
[5] Angle, J. and D. Wissmann, The epidemiology of
myopia. American journal of epidemiology, 1980.
111(2): p. 220-228.
[6] Silvertown, J., et al., Environmental myopia: a diagnosis
and a remedy. Trends in ecology & evolution, 2010.
25(10): p. 556-561.
[7] Grosvenor, T., A review and a suggested classification
system for myopia on the basis of age-related
prevalence and age of onset. American journal of
optometry and physiological optics, 1987. 64(7): p. 545-
554.
[8] Hara, T. Treatment of Myopia. in Third International
Conference on Myopia Copenhagen, August 24–27,
1980. 1981. Springer.
[9] Eisner, F., An Introduction to Vision Training.
[10] SHAGAM, J.Y., Diagnosis and Treatment Of Ocular
Disorders. Radiologic technology, 2010. 81(6): p. 565-
589.
[11] Cotter, S.A., Management of childhood hyperopia: a
pediatric optometrist's perspective. Optometry & Vision
Science, 2007. 84(2): p. 103-109.
[12] Read, S.A., M.J. Collins, and L.G. Carney, A review of
astigmatism and its possible genesis. Clinical and
Experimental Optometry, 2007. 90(1): p. 5-19.
[13] Wang, M.X. and T.S. Swartz, Irregular Astigmatism:
Diagnosis and Treatment. 2008: SLACK Incorporated.

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