Opticsand Refractive Anomalies AKJain

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Illustrated
Textbook of
Optics and
Refractive Anomalies
Illustrated
Textbook of
Optics and
AK Jain DNB, MNAMS

Assistant Professor
Rama Medical College,
Hapur, Uttar Pradesh
CBS Publishers & Distributors Pvt Ltd

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Illustrated
Textbook of
Optics and
ISBN: 978-93-86310-00-0
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My Beloved Family Members
for their Support, Encouragement and Love
Foreword
O ptics and refraction is the foundation stone of ophthalmology and

comprehensive knowledge of basics is essential in clinical practice.
Majority of patients in ophthalmic practice have refractive errors, hence
every ophthalmic personnel including ophthalmologist must be well
trained to manage the refractive errors perfectly.
I am honoured and feel proud to write the foreword to this book entitled
Illustrated Textbook of Optics and Refractive Anomalies, as I had gone
through the book and found it to be very useful for BSc and MSc optometry
students and equally excellent for medical undergraduates and
ophthalmology postgraduate students. This book is unique in the sense that it not only contains
the basic concepts related to ocular optics and various refractive anomalies but also the live
illustration of refraction methods. These illustrations of refraction give a clear image of real
live reflexes seen during retinoscopy; hence students can understand the exact types of refractive
error and can easily neutralize them when they perform retinoscopy on patients. The chapters
on refractive surgery and low vision are very informative for ophthalmology postgraduate
students. The language and text style is written in a very simple and crispy manner so that
students can understand the basic concepts and reproduce them in examination. Section on
problem-based learning is an exclusive representation in textbook of ophthalmology. Various
footnotes and problem-based learning are the strengths of this book, which make the clear
road for the clinical application of knowledge by the students in their daily practice. I
congratulate the author for this unique endeavour on optics and refraction and wish him all
the success for this book.
Prof DJ Pandey MS
Ex Head, Department of Ophthalmology and
in-charge Eye Bank and Cornea Clinic
SN Medical College, Agra, Uttar Pradesh
UPSOS (Past President), ACOIN (Vice President)
Governor Awarded: Best Teacher Award
Preface
R efractive anomalies are one of the most common clinical problems encountered in the
field of ophthalmology throughout the world and remain one of the difficult challenges
to understand, hence a deep knowledge for correction of refractive anomalies is a prerequisite
for the successful ophthalmic practice. Illustrated Textbook of Optic and Refractive Anomalies has
been written to provide the basic information about optics and refractive errors. This book is
written in simple, concise and lucid manner with supportive illustrations in the form of ray
diagrams, figures and tables so that reader can acquire the profound knowledge about the
subject with the help of diagrammatic representation of the respective topic.
This book comprises five sections including 18 chapters where each section contains the
diagrammatic illustrations related to text for easy understanding of the students. Section one
deals with the basic concepts of optics and lenses including light and its various properties,
refraction and reflection through various surfaces and various types of lenses used in relation
to the human eye. Basic knowledge of light and optics is essential to master the skill of refraction.
This section serves as the foundation stone for correction of refractive anomalies of the human eye.
Section two covers various refractive anomalies associated with the human eye. This section
consists of refractive status of a human eye in relation to not only the refractive errors but also
with convergence and accommodation anomalies. This section also includes chapter on
refractive errors seen with binocular vision anomalies and also the management of such
refractive errors. Section three consists of chapters on vision and all the possible methods to
evaluate the vision in the human eye. Visual status and the possibility in the amount of
improvement in visual status form the basis for refraction. Evaluation of visual status is an art
which requires the thorough knowledge of the examiner about the vision and cooperation of
the patient, hence expressive examination techniques have been explained in this chapter to
make it easy for readers. For mastering the art of refraction, optics of various kinds of
retinoscopes and refraction tools is explained in great detail.
Section four deals with the visual rehabilitation related to the management of different
kinds of refractive anomalies. Detailed retinoscopy methods and various reflexes encountered
during retinoscopy are also explained in simpler and illustrated manner. Chapter on
retinoscopy contains the diagrams representing the actual reflexes seen in patient’s eye, hence
reader can master the technique of retinoscopy by reading this book. Section five at the end
contains problem-based learning, where various problems related to refraction encountered
during practice and the possible solutions have also been discussed in detail.
I hope this book will help teachers, residents, ophthalmologists and optometrists to widen
their knowledge about optics and refraction. The knowledge and information gained from
this book will assist the readers to comprehend the basic concepts of optics and various
refraction anomalies of the human eye.
The author believes that careful review and evaluation can create this book a better one and
there is always scope of improvement. If there are mistakes and printing errors, please mail
your feedback and suggestions to dramitjain75@gmail.com.
AK Jain
Acknowledgments
I t is my great pleasure to express my gratitude to all those, whose blessings and contribution
have made this endeavour possible. First and foremost I would like to thank God, the
‘Almighty’, who has provided me the strength to undertake this work and complete it
successfully.
I would like to express my sincere thanks to Prof D J Pandey for writing foreword for this
book. I take pride in acknowledging the guidance of Prof AK Gupta (formerly Dean, Maulana
Azad Medical College, New Delhi), ICARE Eye Hospital and Postgraduate Institute, Noida
who has been so helpful and cooperative in giving his support at all times to achieve my goal.
I also thank to all my teachers, colleagues and students from Santosh Medical College,
Narinder Mohan Hospital, Ghaziabad, Saraswati Medical College and Rama Medical College,
Hapur, ICARE hospital and Research Centre, Noida and Sharp Sight Centre, Delhi for
their kind cooperation and valuable suggestions to complete this project. I am also thankful to
Dr Sparsh Gupta, Dr Ashish Mehta, Dr Vivek Chhimpa, Dr Vikrant Sharma, Dr Vivek Jain,
Dr Swati Gupta and Dr Amil A for their help and cooperation.
My acknowledgements would be incomplete without thanking all my family members for
their indubitable support, love and encouragement in all my endeavours. I owe my special
thanks to my wife Dr Seema and lovely sweet daughter Harshita Jain for her great patience,
understanding and for giving me unlimited happiness and pleasure.
I would like to thank Mr Satish Kumar Jain, CMD, CBS Publishers and Distributors,
Mr Varun Jain and his management team for their enthusiastic cooperation, professional skills,
and suggestions and to finish this task in an impressive manner. I would like to take this
opportunity to thank Mr YN Arjuna (Senior Vice-President Publishing, Editorial and Publicity), Mrs Ritu
Chawla (AGM Production), Mr Prasenjit Paul (Copyeditor), Mr Ram Murti (Graphic artist), Mr Neeraj Prasad
and Mr Vikrant Sharma for inserting the manuscript in the word processor. My thanks go to
artist Mr Sumit Sharma, whose artistic representations created the magical illustrations.
Last but not the least I thank all my patients who make me
knowledgeable enough to write this book on Optics and Refractive Anomalies.
AK Jain
Contents
Foreword by Prof DJ Pandey vii

Preface ix
Section I: Optics and Ophthalmic Lenses

1. Elementary Optics 3
2. Reflection and Refraction 26
3. Ophthalmic Lenses 38
Section II: Ocular and Refractive Anomalies

4. Optical System and Optical Defects of Human Eye 61
5. Refractive Anomalies 76
6. Binocular Vision and its Anomalies 105
7. Accommodation and its Anomalies 134
8. Convergence and its Anomalies 163
9. Binocular Muscle Co-ordination Anomalies 188
Section III: Vision and Refraction

10. Visual Perception 201
11. Retinoscope and Retinoscopy 248
Section IV: Visual Rehabilitation

12. Spectacles, Spectacle Lenses and Spectacle Lens Fitting 305
13. Contact Lens Optics, Design and Fitting 362
14. Contact Lens Specific Conditions, Complications and Maintenance 409
15. Refractive Surgery 463
16. Low Vision 521
Section V: Problem-based Learning

17. Problems Related to Refractive Errors and Presbyopia 563
18. Problems Related to Refraction, Post-refractive Corrections and Low Vision 582
Index 605
I
Optics and
Ophthalmic Lenses
1. Elementary Optics
2. Reflection and Refraction
3. Ophthalmic Lenses
1
Elementary Optics
Learning Objectives
After studying this chapter the reader should be able to:
• Describe the various theories proposed for light.
• Describe the different properties of light.
• Explain the diffraction, polarization, interference, coherence, scattering, transmission and absorption
phenomenon of light and their applications.
• Explain the fluorescence and photoelectric effect of light.
• Understand and explain various photometry and radiometry terms used for measurement of light.
• Understand the basic mechanism and basic properties of LASER.
• Explain the sensitivity of human eyes for various spectrum of light.
Chapter Outline
• Introduction Transmission and absorbance
– History of nature of light Scattering
• Properties of light Illumination and brightness
– Physical properties Radiometry
Character of light
Photometry
Propagation of light
– Special properties
Intensity of light
Fluorescence
– Optical properties
Photoelectric effect
Diffraction
Polarization LASER
Interference and coherence • Visible light versus human eye
INTRODUCTION History of Nature of Light

Light is an electromagnetic energy. The visible • Particle theory of Newton: In the year
portion of the light which lies in between the 1675, Sir Isaac Newton postulated that light
ultraviolet and infrared wavelengths is the one emits from a source in the stream form and
which gives us the sensation of seeing the is made up of minute particles called
objects. This visible spectrum has seven colors corpuscles. These corpuscles move in the
represented as VIBGYOR, an acronym of air medium unaffected by gravity and give
Violet, Indigo, Blue, Green, Yellow, Orange the feeling of sight when enters the eye.
and Red. To understand the light we need to Newton’s theory was able to describe the
look into the history of nature of light. properties like propagation of light in
3
4 Illustrated Textbook of Optics and Refractive Anomalies
vacuum, reflection and refraction, but was According to dual-nature theory, light
unable to describe the properties like behaves like both wave and photon
diffraction, polarization and interference (particle).
of light.
• Wave theory of Huygens: Subsequently, in PROPERTIES OF LIGHT
the year 1678, Huygens tried to explain
To understand the principles of optics and
phenomenon such as diffraction and
refraction it is essential to know the various
interference of light by proposing that light
properties of the light. Table 1.1 summarizes
moves in the waveform after emitting from
the important and related properties of light
a source. According to this theory, the light
so that readers can understand the various
wave has troughs and crests, which are
clinical applications of the light.
circular in the shape for a given time.
Wavefront is location of various points in
Physical Properties
the same phase at a given particular time
of light wave. Various shapes of wavefront Character of Light
are dependent on the type of light source, Light is a dual natured form of energy, which
e.g. point source produces spherical wave- acts like a wave in a medium and like a photon
fronts, whereas long slit source gives in the vacuum.
cylindrical wavefront. Different medium can be classified as
• Electromagnetic theory of Maxwell: In the • Transparent
year 1873, Maxwell improvised the wave • Translucent
theory by proposing that light wave is not
• Opaque
a mechanical wave but it is an electro-
magnetic wave. Electromagnetic wave When light passes through a medium in
means that light wave has both electric and unchanged form, that medium is called
magnetic fields while travelling in vacuum. transparent medium. If only a part of light is
This theory could partially explain the disturbed when passing through medium, but
scattering phenomenon of light but was still light can pass through a medium, then
unable to explain the photoelectric property that medium is called translucent medium. If
of light. a medium does not allow any light to pass
through it, then that medium is called opaque
• Quantum theory of Einstein: In the year
medium.
1905, Einstein came with a proposal that
light with a given frequency consists of Light moves as an electromagnetic wave in
quanta (photon) with the same energy. It a group and makes an energy spectrum of
can be explained by equation
Table 1.1: Different properties of light
e=h
Physical Optical Special
Here e = energy, h = Planck’s constant properties properties properties
(6.626 × 10–34),  = frequency of light
• Character of • Diffraction • Fluorescence
By this equation we can make out that light • Polarization • Photoelectric
energy (e) is directly proportional to the • Propagation • Interference effect
frequency of light but energy is inversely of light and coherence • LASER
proportional to the wavelength of light; • Intensity of • Transmission
because frequency is inversely proportional light and absorption
to wavelength. • Scattering
• Dual-nature theory is the recent concept • Illumination
and brightness
about light and is accepted universally.
Elementary Optics 5
Table 1.2: Types of rays with their respective ‘’ is the distance between two consecutive
wavelengths crest of light waves and represents wavelength.
Types of rays Wavelength
At any given instance of time the crest (or
trough) of light wave is circular in shape.
Cosmic rays 1 × 10–5 nm
‘E’ represents the electric field of the light
Gamma rays 1 × 10–3 nm
wave at a defined point and this electric field
X-rays 0.14 × 10–1 nm
always remains perpendicular to the direction
Ultraviolet rays 13.6 × 10+1 nm of propagation of light wave.
Visible light (VIBGYOR)
‘A’ indicates the maximum value of electric
Violet ray 385–425 nm
field and it represents amplitude of wave,
Indigo ray 425–445 nm
which determines the intensity of the wave.
Blue ray 445–490 nm
During propagation of light wave there is
Green ray 490–555 nm
no movement of matter rather with the
Yellow ray 555–585 nm
passage of wave the electric field increases,
Orange ray 585–645 nm
decreases and reverses in its direction at each
Red ray 645–750 nm point.
Infrared ray 750 – 1 × 105 nm
Another important characteristic of a wave
Electromagnetic ray More than 3 ×1013 nm
is its frequency, which is defined as number
of crests that pass a fixed point in duration of
different wavelengths and types of rays. one second.
Summary of types of rays and wavelength is
In addition to electric field, light wave has
shown in Table 1.2.
a magnetic field which decreases and increases
Propagation of Light in relation of the electric field. This magnetic
field is a three-dimensional representation
Wave theory: Wave theory is the most popular
which lie perpendicular to the direction of
and widely accepted theory for the propaga-
propagation in one plane and electric field of
tion of light. According to wave theory, once
wave in another plane.
light is emitted from a luminous body and
passes through a homogeneous medium, it Propagation of light in a wave form explains
propagates in all the directions. Although light various properties of light such as
propagate in all the directions but it moves • Diffraction
only in a straight line in the form of a wave as • Polarization
shown in Fig. 1.1. • Interference
‘I’ shows a light wave at particular instance. • Illumination
‘II’ shows a second light wave after a short • Reflection
interval. • Refraction
Photon theory: Interaction of light with matter
results in either emission or absorption of
individual quanta of energy (photon). Photon
is also a form of light because some consider
that light is a stream of particles moving
together. Amount of energy (e) per photon is
calculated by formula
e=h
where  represents frequency of light wave
Fig. 1.1: Motion of light in waveform and h is Planck’s constant
As it is clear from the formula that photon

energy and frequency of light wave are
directly proportional to each other, whereas
frequency of light wave is inversely propor-
tional to the wavelength of light. So, energy
of a photon is also inversely proportional to
wavelength of light, hence photon of
wavelength 400 nm will have double energy
than 800 nm photon. Thus, a red light with
800 nm wavelength is less harmful than
ultraviolet light (< 400 nm) or X-ray (< 350 nm)
which can burn or can severely damage the
tissues.
To explain the photon theory we can
consider the phenomenon of fluorescence as
shown by fluorescein molecule during fundus Fig. 1.2: Law of inverse square
angiography. A single molecule of fluorescein respectively. Since the light is equally
absorbs a single photon of blue light. When distributed on both the spheres, hence
this fluorescein molecule emits light, photon
with lower energy is emitted which lies in the L1 4 πr12 = L2 4 πr22
yellow green spectrum and the remaining L1 4 πr22
energy of photon is used for heat production =
L2 4 πr12
or chemical reaction with fluorescein
molecule. r22
=
Various properties of light can be explained r12
by the phenomenon of photon theory such as So to simplify light intensity at any given
• Scattering of light point on a surface and square of distance from
• Fluorescence the light source are inversely proportional to
• Photoelectric effect each other.
Intensity of Light Optical Properties

As we all know that light travels in all the Diffraction
directions. When light moves from one point All types of waves when pass through an
to other, its intensity rapidly decreases as the obstacle, an aperture or through any form of
distance increases from the point of source of irregularities in the medium get diffracted. It
light. In other words, the intensity of light is means there is a change in the direction of the
inversely proportional to the distance of light waves. Similarly, the light waves also show
source. Light obeys the law of inverse square diffraction phenomenon as they pass through
(Fig. 1.2) means intensity will be more any obstruction or an aperture, means there
(brighter) near the light source and it will is bending and spreading of light waves. This
decrease (dim) far from the light source. change in direction of light wave varies with
Suppose L1 and L2 are amounts of light wavelength of the light and size of the
falling per second per unit area on two spheres aperture. With a given size of obstacle a wave
A and B having radius r1 and r2, respectively of longer wavelength is diffracted more than
(Fig. 1.2). As we know that area of a sphere is wave of shorter wavelength. Hence, light
4r2, hence the amount of light falling on wave with shorter wavelength produces
spheres A and B is L 1 4r 12 and L 2 4r 22 , minimal amount of appreciable change of
Elementary Optics 7
direction. Furthermore, the diffraction is much

more evident when the size of the obstacle/
aperture is small.
Types of diffraction: Two types of diffraction
may occur depending on the distance between
the source and the screen.
• Fresnel diffraction: This type of diffraction
will occur when source of light or screen or
both are present at a fixed distance from the
diffracting material (obstruction or aperture),
i.e. source of light and screen are not far away
from each other. As shown in Fig. 1.3 that Fig. 1.4: Fraunhofer diffraction
incident wavefront is spherical in nature
because point light source is situated at finite Many other optical effects of light like
distance. Similarly, wavefronts emitting interference or refraction may also combine
after getting diffracted from obstacle or with diffraction and may be seen in various
aperture are also spherical in nature. Because forms. Suppose many optical effects are
of the spherical nature of wavefronts, a present together and diffraction becomes
definite diffraction pattern can be produced dominant among them; then we observe the
on screen, without any additional lens. specific pattern of diffraction only. For
• Fraunhofer diffraction: It occurs when the example, if we see the specific pattern of a
light source and screen, or either of them, distant light through a fine woven curtain or
are present at infinite distance from the through a windshield (which is repeatedly
obstruction or aperture, means source of rubbed by the windshield wipers over a car
light and screen are far away from each glass), then in these cases the bending of light
other. As shown in Fig. 1.4, in this type of ray will be perpendicular to the incidence ray,
diffraction the incident wavefronts are hence a diffraction perpendicular to light ray
plane or straight because light source is will be seen. However, in the case of a cross
situated at infinity. Similarly, wavefronts woven curtain, an array of bright spots of two
leaving the obstruction or aperture are also dimensions is seen because in this case the
plane or straight in nature. Because of interference is getting mixed with the
straight wavefronts there is need of a diffraction, and both together are producing
convex lens to converge these wavefronts bright spots of light. If only diffraction could
so that a definite diffraction pattern can be have occurred, then a continuous streak of
produced on the screen. light would have seen rather than spots of
light.
Effect of diffraction on visual acuity: Let us
see the effect of diffraction on visual acuity.
In emmetrope having pupil size of 2.5 mm or
less, the limit of visual acuity is determined
by diffraction. A distant light source forms an
image on retina of the eye. This image has
concentric dark and light rings which are
surrounding a bright central disc of light.
This central bright disc is called airy disc
Fig. 1.3: Fresnel diffraction (Fig. 1.5).
Clinical Applications
Rayleigh criterion is used to set standards in the

fabrication of optical components in optical devices.
more than the shorter wavelength (blue).

Hence, it is clear from the above equation that
an airy disc of larger diameter will be formed
by a wave having longer wavelength (red
light) as compared to a wave with shorter
wavelength (blue light). Diameter of disc (D)
Fig. 1.5: Airy disc is inversely proportional to size of pupil (d)
This can be represented by an equation: so if the size of pupil decreases, the diameter
of central disc increases and vice versa.
λ
D = 2.44 f
d Polarization
Here D = diameter of disc Usually, human eye is not sensitive to perceive
f = focal length of optical system, i.e. eye polarized light except in case of the Haidinger’s
 = wavelength brushes phenomenon where polarized light
d = diameter of aperture, i.e. pupil is perceived as a yellowish bar in the center
When light waves of different wavelengths of visual field. In ophthalmology there are
pass through pupil of the same size, then light several clinical applications of polarized
wave of longer wavelength (red) will diffract light.
Normally visible light has vast number of
Optical Applications waves emitted by molecules of light source,
because each molecule produces a wave
• Various studies concluded that amount of best
resolution produced by an optical instrument or
oriented in its own specific plane. These light
eye is restricted by the phenomenon of waves which are propagating in all the
diffraction. The radius of airy disc is approximately directions and oriented in different planes are
equivalent to the minimal resolvable distance. termed as unpolarized light.
For example, resolution of telescopes can be Hence, an unpolarized light is a haphazard
increased by increasing the aperture of its mixture of polarized beams of light directed
objective lens. in various planes. Mixture of unpolarized light
• Aspherical irregularities of the cornea and and polarized light (plane, circular or
crystalline lens rarely allow the formation of an elliptical) is termed partially polarized light.
airy disc, even if we are looking at a small source
To understand polarization in simpler way,
of light through a very small pupil.
• For any optical system diffraction decides the limit consider a rope which has been tied at one end.
of its finest resolution. Because of this in fabrication Now if we move free end of the rope up and
of optical components a degree of precision is down, then a wave of rope propagate as up
present, after this there will be no improvement in and down oscillations along the length of rope.
the image quality, even if we change the resolution. This oscillation of wave up and down in one
• Rayleigh criterion sets limit of resolution that can plane represents a linear or plane polarized
be produced by an optical system. This criterion light. Suppose if we rotate the free end of this
states that “no further improvement will be seen abovementioned rope in a circular manner,
in the resolution of an optical system, if the optical then a wave will travel along the length of rope
system produces a wave front that lies within one in a circular manner which represents a
quarter wavelength limit of being perfect”.
circularly polarized light.
Elementary Optics 9
Partially polarized light can be produced As discussed the degree of polarizing angle
from a plane reflecting surface by phenomenon of incident light ray varies according to the
of specular reflection. Naturally occurring refractive index of the medium; certain
plane surfaces like water and snow cause materials show differential refractive index
polarization of light on incidence, although a which decides the polarization and direction
polarized light will be produced only when of propagation of light. These materials are
the angle of reflection from these surfaces is known as birefringent (birefractive) material
equal to polarizing angle (Brewster angle ) and exhibit an optical property called as
of medium or surface (Fig. 1.6). birefringence. This birefringence property of
When visible light faces an edge situated a material is responsible for the phenomenon
between surfaces of two refracting media of double refraction, where an incident light
having different refractive indices, some part ray when falls on a birefractive material,
of the light is usually reflected. The part or polarization takes place and single incident
fraction of the visible light which gets reflected ray split into two rays, out of them one ray is
can be expressed by the help of Fresnel fully polarized. These two light rays after
equations. These expressions are dependent polarization do not propagate in the same
upon the polarization of incident light beam direction rather moves into slightly different
and its angle of incidence. For example, paths. Crystal having non-cubic structures like
consider a light ray is reflecting from a glass calcite crystal, and plastic under mechanical
medium (refractive index  1.5) into the air stress are examples of a birefringent material.
medium (refractive index  1), then the polari- Unpolarized light can be transformed into
zation angle is approximately 56°, whereas plane polarized light by passing an
when light ray is reflecting from an air–water unpolarized light beam through a polarizing
interface (refractive index  1.33), then the material like plastic sheet or certain crystals like
Brewster’s angle () to produce polarization tourmaline or calcite crystals. These polarized
is approximately 53°. By these examples we materials or filters allow passing of light wave
can make out that Brewster’s angle () or which is propagating in one particular plane
polarizing angle is not only dependent on the and prevent passing of remaining light waves,
angle of incidence but also dependent on the which are propagating in other planes. So the
refractive index of a given medium. resultant light wave coming out through these
polarized filters propagate in one particular
plane only. As we can see in Fig. 1.7, a tourmaline
crystal C 1 (whose axis is cut parallel to
unpolarized light) has been placed in the path
of light wave. This will produce a polarized
light in the same direction of light beam.
Now, if we place another crystal C2 (whose
axis is also cut parallel to unpolarized light)
after C1, the resultant light wave will also be a
polarized light in the same direction as before
(Fig. 1.8). Now, suppose we keep the axis of crystal
C1 fixed and rotate the axis of crystal C2, then the
light emerging from C2 becomes dimmer and
dimmer in proportionate with amount of
rotation of crystal C2. When the axis of crystal
C2 becomes perpendicular to axis of C1, no
Fig. 1.6: Brewster’s angle () light will come out of C2 as shown in Fig. 1.9.
Fig. 1.7: Phenomenon of polarization, transverse wave passing through crystal C1
Fig. 1.8: No change occurs after placing another crystal C2, which is rotating in same direction
Fig. 1.9: First crystal (C1) kept fixed second crystal (C2) rotate; polarized light vanishes when C2 becomes
perpendicular to C1
Clinical Application surface of oncoming automobiles (during driving)

is also partially polarized, usually horizontally.
• The phenomenon of polarization has been • Clinically Haidinger’s brushes phenomenon can
incorporated in number of ophthalmic instruments be demonstrated by continuously rotating a
like slit lamp, ophthalmoscope, mainly to polarizer in front of a uniform blue field. Normal
eliminate unwanted strong reflex from cornea. individual will observe a rotating structure
• Polarizing sunglasses are very useful in reducing having double ended brush or a propeller. This
glare produced due to reflected sunlight from phenomenon can be used in localization of
natural surfaces like water surface (during fovea during sensory testing or to evaluate the
boating) or snow surface (during skiing). Since retinal nerve fiber layer at macula.
the predominant polarization in natural surfaces • Retinal nerve fiber layer (RNFL) shows
occurs horizontally, these sunglasses are birefringent property, so the thickness of RNFL
designed in such a way that only vertically can be measured by utilizing this property of
polarized light can pass through them. Similarly, birefringence. An instrument scanning laser
light reflected from surface of roads or glass polarimetry (e.g. GDx-VCC) uses polarized light
Elementary Optics 11
and measures the thickness of RNFL by calculating interference is better appreciated when the
the amount of retardation in laser beam. light wave is either monochromatic or its
• Polarizing projection charts are clinically very wavelength lies within narrow bandwidth,
useful because after wearing of specialized although a white light under favorable
polarizing glasses it is possible to test only single conditions can also produce an interference.
eye while the patient is seeing polarizing As shown in Fig. 1.10, waves produced
projection chart binocularly. This test is from a single light source are made to pass
successfully applied on malingering patients to
through a small aperture. This produces a
detect the status of visual acuity. For example,
alternate letters on Snellen’s chart can be
wavefront of light moving in defined
polarized at 90 degree to each other. When a direction. The curved lines in Fig. 1.10 are
patient wearing polarized glasses is asked to see representing crests of waves at a particular
these letters, the letters are seen separately instance. Now let us see what happens when
through each of the eye. Suppose if a patient this wavefront of light is made to pass through
complains that he/she is blind uniocularly, but two small apertures. These light waves
after wearing polarized glasses he/she reads all superimpose with each other and produces
letters from 6/6 line correctly on Snellen’s chart, interference. Two types of interference can
it indicates that this patient is malingering the occur, depending on the way by which these
blindness. waves superimpose with each other.
• Similarly, several other charts based on the
principal of polarization have been designed, Constructive interference: When the crests
which provide sensitivity tests for binocular (maxima) or trough (minima) of two waves
functions or abnormalities. For example, Titmus coincide with each other, the energy of
fly test for streopsis, Mallett card test for fixation electromagnetic fields is added together and
disparity and stereo projector method for a wave of maximum intensity is produced.
aniseikonia. The amplitude of resulting wave will be equal
to the sum of the amplitude of two waves
Interference and Coherence which were superimposing. Hence, they
When two light waves arising from the same produce constructive interference represented
source are bring together, the phenomenon of as light bands in Fig. 1.10(A). As shown in
interference occurs. This phenomenon of Fig. 1.11, when two light waves travelling in
Fig. 1.10: Interference pattern. A: Light band (constructive interference); B: Dark band (destructive
interference)
Fig. 1.11: Constructive interference
Fig. 1.12: Destructive interference
same direction having the same frequency gets

merged in such a way that their crests coincide
with each other then they produce a resultant
wave of maximum intensity.
Destructive interference: When the crest
(maxima) of one wave coincides with the
trough (minima) of other wave, then a wave
of minimum intensity is produced because
energy of two electromagnetic fields is
cancelled by each other. Hence, they produce
destructive interference represented as dark
band in Fig. 1.10(B). As shown in Fig. 1.12, two
waves of the same frequency are superimposing
in such a way that crest of one light wave
corresponds with trough of other light wave,
then a resultant wave is produced with
minimum intensity or zero light intensity Fig. 1.13: Coherence phenomenon
(when amplitude of two waves is exactly Temporal or longitudinal coherence: It is
equal). defined as the ability of one wave of a light
The ability of two light beams, or two beam to interfere with different portion of
different parts of the same beam to produce wave within the same beam. For example, P
interference is termed coherence. The coherence and Q part in Fig. 1.13.
is of two types: A large white light source has coherence
Spatial or lateral coherence: It is defined as almost equal to zero, however when this light
the ability of two different portions of the same passes through a narrow slit (Fig. 1.13), the
light wave to generate interference. For spatial coherence between O and P improves
example, O and P part in Fig. 1.13. and it may approach unity as slit width
Clinical Applications When it is represented as a percentage,

then it is called the percentage transmittance
• The LASER interferometry technique is based on (%T).
phenomenon of interference of laser beams. This
100
laser interferometry is used to evaluate the retinal %T = I ×
function; hence potential vision can be assessed I′
in patients having media opacities due to cataract. Absorbance measures the amount of an
• 3D images in holography are produced by incident light that is absorbed by molecules
phenomenon of interference. of material when it travels through a material.
• During fluorescein angiography excitation and As a result of absorbance the intensity of light
barrier filters of fundus camera are based on will decreases exponentially with distance as
interference. Excitation filter used in fundus the light passes through the material. In other
camera transmits short wavelengths (below words, absorbance increases as path length of
500 nm), which cause fluorescein to fluoresce. light increases. Absorbance is usually expressed
The barrier filter used in fundus camera transmits in terms of optical density (OD) and is measured
only long wavelengths (above 500 nm), hence by using an absorption spectrophotometer. It
only fluorescent emission is received by film,
is based on the principle that every substance
whereas remaining excitation light is blocked.
or medium can absorb or transmits certain
• Based on interference filters, the cold mirrors
are coated in multiple layers. These multilayers
wavelengths of radiant energy but not other
are designed in such a manner that they allow wavelengths. The absorption of a sample or
infrared waves to transmit, whereas visible light material can be calculated from value of
gets reflected. transmittance. It is defines as the negative
• Spectacles glasses having anti-reflection coating logarithm of the transmittance.
works on the principle of destructive interference. 1 100
• OCT (optical coherence topography) is based Absorbance (OD) = log or
T %T
on principles of interference and uses infrared
As clear from formula if transmittance of
rays as light source.
light is 10%, then absorbance (OD) will be 1.
Similarly, if transmittance is 1% and 100%,
approaches to zero. Temporal coherence can then absorbance (OD) will be 2 and 0 (zero),
be improved by using filters, which selects respectively.
only a narrow band of wavelength. Laser light
is an example of highly coherent beam. Scattering
When parallel light beam passes via a
Transmission and Absorption substance or gas medium, a few rays move in
Passing of radiant energy through a medium directions other than the direction of its initial
or space is termed transmission. This is
measured as transmittance which is defined Clinical Applications
as percentage of the light energy that can pass
through a particular medium or substance. For • Absorbed light can excite an electron into a higher
example, if the intensity of the incident light level as seen in fluorescence phenomenon.
falling on a semi-transparent material is I, and • Several optical devices like light filters and
sunglasses utilizes the phenomenon of
the intensity of transmitted light is I, then
absorption to produce effects like polarization.
transmittance (T) would be Birefringent crystals like tourmaline or calcite
I completely absorbs the specific wavelengths of
T=
I′ light, which are not in alignment with their
molecular structures; hence they transmit only
Transmittance is expressed as unitless
a single ray of linearly polarized light.
number between 0 and 1.
Applications of Scattering – Reduction in amount of light: A few ocular

pathologies like cataract, anterior chamber
• Amount of scattering is dependent on two factors, flare and corneal edema cause more scattering
i.e. wavelength of the light and size of particles of light. Large molecules in nucleus of lens in
in atmosphere. the early stages of cataract are responsible for
– Light having shorter wavelengths (blue) will scattering of light and hence multiple images
scatter more as compared to longer wave- of very distinct object like moon are seen in
lengths (red light). Hence, blue light scatters intumescent cataract. Similarly, proteins
more as compared to red light. Due to this molecules in anterior chamber and fluid in
fact the color of sky appears blue. Similarly, cornea will scatter the light and person
red color is used to indicate danger in signals complaints of diminished vision.
because it can be seen from a longer distance
as there is no significant loss of red color due incidence. In other words, the light emerges
to scattering of light. from medium in a different direction from the
– Rayleigh phenomenon occurs due to incident light. This movement of light rays in
scattering of light by smaller size particles in different directions is called scattering of light.
air and is dependent on wavelength of Phenomenon of scattering takes place at
incident light, whereas larger particles like molecular and atomic level, i.e. gas atoms or
dust particles scatter light irrespective of the molecules present in the medium when get
wavelength of incident light. For example, stroked by the incident light rays, electrons of
sky appears blue in mid-day light and appears these molecules absorb energy from the light
reddish during sunset time, because blue light
and then release or re-radiate this absorbed
(shorter wavelength) scatters strongly by
small particles in mid-day time and during energy into various directions as shown in
sunset time only longer wavelengths (red) Fig. 1.14. Due to this reradiation the light
remain (because they scatter less during day- appears as if scattered in the various directions.
time). Scattering due to very small molecules or
• Scattering of light affects vision in two ways, particles present in the atmosphere produces
one by phenomenon of glare and second by a phenomenon called Rayleigh phenomenon
reduction in the amount of light. (Fig. 1.14). Usually this Rayleigh phenomenon
– Glare: Bright sources of light like sunlight or is very weak in nature and it may vary
vehicle headlights when fall on an eye, a according to the wavelength of the incident
fraction of light get scattered inside the ocular light; means shorter is the wavelength, greater
media and then it reaches the retina. As a will be the scattering. For example, sky appears
result, the contrast of fovea decreases due to blue because the blue light (shortest wave-
this scattered light and objects look blur.
length) from the sun is scattered more as
Fig. 1.14: Scattering phenomenon of light

compared to other wavelengths present in the received or emitted from source in the form
sunlight. Larger particles such as dust particles of electromagnetic radiations and it is
in the atmosphere will scatter the light more represented by symbol Q and is measured in
intensely and is less dependent on the unit as joules.
wavelength of incident light ray.
Note: Spectral radiant energy is nothing but the
Illumination and Brightness amount of radiant energy per unit wavelength
In normal physiological state, human eyes interval and its unit of measurement is joules per
respond only to visible light, whereas nanometer.
identification of other spectrum waves require Radiant flux (Radiant power): Radiant
very sophisticated and advance scientific energy measured for each unit time is referred
instruments like radio receivers or scintillation as Radiant power. It means that the energy
counters. For better understanding of transferred, received or emitted per unit time
illumination and brightness, we should be in the form of electromagnetic radiation is
well aware of methods and terminologies radiant power and is measured as joules per
required for measurement of light. Visible second or watts. As we know that light flows
light can be measured by means of through the space so in simpler words, the
• Radiometry flow of radiant energy per unit time can
• Photometry be termed radiant power or radiant flux.
Radiometry: In broader terms radiometry is Radiant flux is denoted as  and is measured
referred as measurement of light in terms of in watts.
power, however, practically radiometry is used Note: Spectral radiant flux is nothing but radiant
to measure the infrared, visible and ultraviolet flux per unit wavelength interval and its unit of
lights with the help of optical instruments. measurement is watts per nanometer.
Following terms are used for the understan-
ding of radiometric measurements: Radiant flux density: It measures the
amount of the radiant flux arriving or leaving
• Radiant energy
at or from unit area of a real or unreal surface
• Radiant flux (radiant power)
in unit time. The amount of radiant flux which
• Radiant flux density is falling on or leaving from the given surface
Radiant energy: Light as such is a form of in unit time is known as Irradiance and
radiant energy and electromagnetic radiation Radiant exitance, respectively.
cause transport of this radiant energy through Irradiance (IR) and Radiant exitance (RE) can
the space. These electromagnetic radiations be calculated as
can be considered as either wave or particle
dω
which is dependent on the fact that in which IR or RE =
form we are measuring these electromagnetic dA
radiations. Light energy is converted into where ‘’ denotes radiant flux received or
another form of energy after getting absorbed released at or from a point on the given
by an object. Radiant energy of visible light surface
which is a part of electromagnetic radiations d = differential derivative
is transferred into electrons of matter in the A = area surrounding the point.
form of kinetic energy. This kinetic or motion Unit of measurement for both Irradiance
energy causes the movement of electrons in (IR) and Radiant exitance (RE) is watts per
the form of an electric current to flow in a square meter.
photographic light meter. Thus in simpler Radiance: Radiance is the amount of
words, radiant energy is the energy transferred, radiant flux incorporated in the light ray
Note: Unit of measurement of spectral radiant controlled conditions they studied the
intensity is watts per steradian per nanometer. response of more than 100 observers who
visually matched the brightness of various
arriving at or leaving a point on a surface in a monochromatic light sources having different
given direction and its unit of measurement wavelengths. Statistical results of study were
is watts per square meter per steradian plotted as CIE photometric curve, which
(steradian is measurement of solid angle of an provided weighing functions to convert
area). radiometric measurement into photometric
Radiant intensity: Radiant intensity is measurements.
referred as the amount of intensity of light Various terms used in photometric measure-
emitted by a given source of light and its unit ments are
of measurement is watts per steradian. • Luminous intensity
Photometry: Photometry is the measurement • Luminous flux
of visible light in terms of units which can be • Luminous flux density
adjusted to a representative value depending
Luminous intensity: Luminous intensity is
on the sensitivity of the visual system. The
defined as light emitted by a given source of
visual system of humans is very complex and
light in a specific direction per unit solid angle
is capable to detect the electromagnetic
and its unit of measurement is candela (Cd).
radiation in the wavelengths ranging from
Measurement of luminous intensity does not
360 nm to 760 nm (commonly referred as
depend on the distance of light source; rather
visible light).
it will depend on the amount of light released
Human eye show variable sensitivity level
in a given angular span. This angular span is
for different wavelengths of light; for example,
represented as steradian. For example, in
a source of light having radiance of one watt
Fig. 1.15 the amount of light (intensity)
per square meter steradian of yellow
received on screen A will be equal to screen
wavelength will appear brighter as compared
A’ (considering that screen A is not obstructing
to a source of light having equal radiance with
the fall of light on screen A’) because both the
red wavelength. In photometry watts of
screens covers the same angle at light source.
radiant energy is not measured, rather the
Luminous intensity of one candela means
subjective impressions are measured which
that source of light is releasing monochromatic
are obtained when human eye visual system
radiation of 540 × 1012 Hertz frequency (or
is stimulated with radiant energy.
Thus, subjective measurement of light is
very complex and variable because along with
wavelength, several other physical and
physiological factors can also influence these
impressions. Various factors like radiant flux,
lightening conditions (whether constant or
flickering), adjustment of the iris diaphragm
and retina, psychological condition of viewer
plays an important role in the measurement
of light during photometry.
Light can be measured as monochromatic
form or in combination form or even as
continuum of wavelengths. In the year 1924,
the Commission Internationale de l’eclairage Fig. 1.15: Luminous intensity on screen A and A’ is
(CIE) performed a study, in which under equal
nearly 555 nm wavelength which corresponds will be emitting one lumen of luminous flux
to maximum photopic luminous efficiency). for each unit solid angle. Hence by simple
It is equivalent to the radiant intensity of mathematic calculations a point light source
1/683 watts per steradian. having intensity of one candela will emit a
One steradian represents the solid angle (s) total of 4 lumens (because area of a sphere is
of one meter square surface area taken from a equal to 4).
sphere having radius of one meter as shown Luminous flux density: Luminous flux
in Fig. 1.16. density is equivalent expression for radiant
flux density measured photometrically and its
Note: Two-dimensional measurement of an angle unit of measurement is lumen per square
is usually done in units like degree and radian.
meter. Similarly, photometric equivalent of
However, a three-dimensional measurement of an
irradiance is illuminance, and that of radiant
angle is expressed in steradian.
exitance is called luminous exitance.
Radiometric measurements can be converted Illumination: Illumination is also referred
into photometric measurements by the use of as illuminance, which in turn is equivalent to
candela along with CIE photometric curve. irradiance. As we know that irradiance is the
Luminous flux (Luminous power): Luminous amount of radiant flux arrived at a surface,
flux is equivalent expression for radiant flux similarly, illumination is amount of light
(watt) measured photometrically and its unit arrived at a given surface and is expressed as
of measurement is lumen (lm). One lumen is number of lumens per square meter (lumen/
equivalent to 1/683 watts of radiant power m2). Earlier illumination was also expressed
at a frequency of 540 × 10 12 Hertz. Thus in units, meter-candle and lux.
luminous power is total flow of light in all Lux (lx): Illumination of a given surface
possible directions after getting emitted from can be measured as lux. The major difference
a light source. between lux and candela is that lux simply
Lumen can be represented as  = E  represents the illumination of a given
where,  = lumen surface, whereas candela actually measures
E = intensity of light illumination in terms of angular span. So
illumination at a given surface in terms of
 = angular span in steradian
lux will depend on the distance between the
As clear from the above equation, a point
light source and surface; whereas in candela
source of light having intensity of one candela
unit, as discussed above, the distance has no
relevance.
As shown in Fig. 1.17, screen A and A’ are
equal in size but screen A’ is less illuminated
as compared to screen A; because farther the
screen from the light source, poorer it will
be illuminated. As we know that sphere of
one meter diameter gives a one meter square
area, which is expressed as one steradian. So
if measuring distance is one meter, then
values of one candela (lumen per steradian)
will be equal to one lux (lumen per meter
square).
Luminance: Photometrically weighted
radiance is referred as luminance. It is defined
Fig. 1.16: Steradian measurement as total amount of light falling or leaving at
The luminance of a perfect diffuse reflecting

surface (Lambertian surface) is equal to the
incident illuminance in foot candles.
Luminance (foot lambert) = Illuminance
(foot candles).
Apostilb: It is an older unit of luminance
and now it is expressed in terms of stilb.
One stilb is equivalent to one candela per square
centimeter or 104 candelas per square meter
(1 stilb = 104 cd/m2). As one apostilb is equal
to 1/ 10-4 stilb, so one candela per square meter
is equal to 3.14 apostilb. An apostilb is defined
as luminance of a Lambertian surface radiating
Fig. 1.17: Illumination at screen A and A is different or emitting one lumen per square meter.
or from a given surface in a specific direction. Lighting efficiency: A surface or a room
It simply means that brightness (viewed from can be illuminated by ample number of ways
a specified direction) of a given surface is such as incandescent lamps, fluorescent tubes,
referred in terms of luminance. electroluminescent sheets, halogen bulbs, etc.
Luminance is commonly represented in All these appliances are compared with each
Candela per square meter (Cd/m2). Various other in their effectiveness of altering electrical
other units used to measure luminance are energy into luminous energy. This conversion
efficiency of an appliance is termed lighting
• Lambert
efficiency and is called luminous efficacy of a
• Foot lambert
source. Luminous efficacy is measured in
• Apostilb lumen per watt (lm/W). In simpler words,
• Bril suppose the power of a light source output in
• Nit watt is known to us, then we can calculate light
• Skot source output in lumen.
Among these abovementioned units the Lighting efficiency is defined in terms of
most commonly used units for measurement percentage which depends on a hypothetical
of luminance are lambert, foot lambert and maximum value of 683 lm/W, at a wavelength of
Apostilb. 555 nm. It simply means at a wavelength of 555 nm
Lambert: This unit was coined by renowned the conversion factor is 683 lumen per watt.
scientist Johann Heinrich Lambert. He defined Radiometric versus photometric measures
lambert as the brightness of a Lambertian
The equivalent term used in radiometry and
surface (means a perfectly diffusing surface)
photometry for the measurement of light is
that reflects or emits one lumen per square
summarized in Table 1.3.
centimeter (lumen/cm2).
Foot Lambert: It is defined as the luminance Applications of illuminance and luminance
of a surface radiating or emitting one lumen Various illumination recommendation levels
per square foot and is more routinely used as are employed by engineers to utilize different
compared to Lambert. types of appliances in routine life, so we all
should be aware of these recommendations.
Note: Lambertian surface are the perfectly diffusing Most commonly recommended illumination
surface which either reflect or emit constant standards are
amount of luminance (radiance) irrespective of the
• Foot lambert is used in motion picture
angle of viewing.
industry to measure the luminance of image
Table 1.3: Equivalent terms in radiometry and photometry

Light measurements Radiometric terms Photometric terms
Term Unit Term Unit
Per unit time rate of flow of Radiant flux Watt Luminous flux Lumen (one
radiant energy Candela = 4
Lumen)
Quantity of light arriving per Irradiance Watt per Illuminance Lumens per
unit area at a point on a given square meter square meter or
surface foot candle
Quantity of light leaving per Radiant Watt per Luminous Lumens per
unit area at a point on a given exitance square meter exitance square meter
surface
Intensity of light emitted per Radiant Watt per Luminous Candela
differential solid angle intensity steradian intensity
Total amount of light emitted Radiance Watt per Luminance Candela per
or reflected per unit area per steradian per square meter
unit solid angle square meter
on a projection screen. A screen luminance • Apostilb unit is used to decide the luminance
of 16 foot lamberts is recommended for of background as well as targets in perimetry
commercial movie theatres. instruments.
• Flight simulation industry also utilizes foot
Special Properties
lambert to measure highlight brightness of
display systems. Generally 3–6 foot Fluorescence
lamberts are recommended for simulation When short wavelength light is absorbed by
devices in aviation industries. an electron (excited electron) present in
• Various panels, switches and displays used specific types of substances, they move to an
in military require illumination even in day- excited state from their ground state. This
light. Luminance levels ranges from 100 foot excited electron can come to a lower level
lamberts in daylight to a few foot lamberts under special conditions. Suppose this excited
in nighttime. electron comes to a lower level, which is still
• Full unobstructed sunlight has an illumi- a level higher than original ground state of
nation of approximately 10,000 foot candle. electrons; then this electron will emit energy.
Normal illumination standards recommen- This energy is emitted in the form of a photon.
dations in foot candles (fc) for various places However, this emitted photon will have less
are energy as compared to the photon which had
– Classroom 50–60 fc absorbed the light energy. Hence the emitted
photon will be of longer wavelength. This
– Lecture hall 100 fc
process of emission of photon with longer
– Nursing station 30 fc
wavelength is known as fluorescence. The
– Hospital corridors 10 fc chemical fluorescein used in fundus angio-
– Operating table 3000 fc graphy works on this phenomenon.
– Reading 80 fc Fluorescein dye when exposed to light by
– Fine job 100–300 fc fundus camera, then unbound fluorescein
– Room 30 fc absorbs light of a wavelength in the range of
– Toilets 10 fc 465–490 nm, which is in bluish green region.
Clinical Applications phenomenon happens inside retinal cells. This

chemical phenomenon generates an electric
Fluorescence property is used in performing fundus impulse. This electric impulse transmits the
angiography and various other angiographies done signals to brain and hence one can see the
for diagnosing ocular, cardiac, cerebral and liver objects. This entire phenomenon of absorption
conditions. of light, formation of chemical substance and
Subsequently, the molecules of dye fluoresce conversion of chemical substance into an
and excited fluorescein molecule re-radiates electrical signal is known as photoelectric
and emits the light with longer wavelength effect.
(520–530 nm), which lies in greenish yellow LASER
region. Hence, a blue light is emitted as green
LASER is all acronyms for Light Amplifi-
light due to fluorescence and details of fundus
cation by Stimulated Emission of Radiation
can be studied easily. Some other chemicals
and represents a very useful and special
like Indocyanine green dye (absorbs 790 nm
property of light. Laser has several unique
and emits 835 nm) shows similar properties.
properties which can be used for diagnostic
Photoelectric Effect and therapeutic purposes in medical science.
Several studies had concluded that when some Elements of a laser
metals are illuminated by specific type of lights All lasers used in ophthalmology consist of
(ultraviolet) or wavelengths, these metals emit the following basic elements (Fig. 1.18).
electrons. This process of emission of energy after • An active medium
illumination is termed photoelectric effect. • Energy input (pumping)
Similar to metals some specific tissues like • Optical amplifier
retinal cells when absorb the light, a chemical • Release of laser
Fig. 1.18: Laser system

Active medium: An active medium in laser Optical amplifier: Third requirement for a
provides an atomic or molecular environment. laser system is optical amplification where
Due to presence of this medium, a large light is amplified by an optical feedback
number of atoms in the active medium (solid, system. The main function of it is to promote
liquid or gas) get energized above their stimulated emissions in the active medium
original ground state on stimulation by a where population inversion had been already
photon of light followed by stimulated achieved. To achieve this, entire laser cavity
emission. It means a photon of the same acts like an optical resonator which means at
wavelength is emitted when the atom comes each end of cavity mirrors are placed to reflect
back to its lower energy state. In ophthal- the light beam to and fro through the active
mology, various active mediums are used to medium so that coherence of light beam is
produce laser beam and are named on the increased and total coherent energy increased
basis of active medium. Some commonly used through stimulated emission. Therefore,
active mediums are: stimulated emission is coherent. Spontaneous
• Gas mediums having gases such as argon emission may also occur from stimulated
(Ar), krypton (Kr), carbon dioxide, argon atoms in active medium. However, this
fluoride (ArF). spontaneous emission occurs randomly in all
the directions, but usually do not strike on
• Liquid mediums used in dye lasers having
reflecting mirror; so there is no optical
dyes such as Rhodamine, Fluorescein and
amplification of spontaneous emission.
Coumarin.
Release of laser: Laser system also contains
• Solid mediums have crystal which is
mechanism to release laser beam from the
activated by an active element, for example,
laser cavity. Releasing of laser is achieved by
neodymium activating a crystal yttrium-
making one mirror fully reflective and another
aluminum-garnet (Nd: YAG) and erbium
mirror partially reflective. Those amplified
activating an yttrium-lanthanum-fluoride stimulated light waves which strike the
(Er: YLF). Semiconductors like diode also partially reflecting mirror gets emitted from
are solid state active medium which the laser cavity as laser beam (Fig. 1.18).
produces laser.
Properties of laser: Laser can also be considered
Energy input (pumping): Laser system also as a type of light energy but has certain unique
requires a source of energy (energy input) to properties compared to ordinary light, like
keep majority of atoms in an energy state
• Monochromaticity
higher than their original ground state in the
• Coherence
active medium. This state is termed popula-
tion inversion as it is opposite of normal • Polarization
situation where majority of atoms remain in • Directionality
their ground energy state. This energy input • Intensity
in the form of optical or electrical energy, Laser systems usually emit light (photons)
which keeps the electrons in population having same energy and thus one particular
inversion state is termed pumping. For wavelength as per requirement. As discussed
example, in gas lasers electrical discharge ordinary visible light is a mixture of seven
between electrodes in gas are source of energy colors having a range of wavelengths,
input while in liquid dye laser energy input is however, a laser light has a only single color
given by other solid or gas laser. Similarly, because laser is produced by the transition of
solid crystal lasers are pumped by an only one atom with a single particular
incoherent light source like Xenon arc flash wavelength. So the laser light is normally very
lamp. pure (not a mixture) in wavelength or has
monochromatic property. However, sometimes Types of laser

these laser systems can emit light which is Laser beam are of two types
combination of multiple wavelengths. These • Continuous wave (CW) laser: This means
light beams having multiple wavelengths can that the laser energy stored in a laser
be easily separated using specially designed material (like ruby crystal) is released as a
instruments. As a result, monochromatic or steady continuous wave.
pure form of light beam consisting of single
• Pulsed laser: This means that the laser
wavelength of light is produced. Another
energy stored in a laser material is released
advantage with laser light is that being
as pulses of light energy.
monochromatic in nature it can be focused
even to a smaller spot as compared to white For continuous wave type laser we need to
light. In addition, it is also not affected by determine the minimum and maximum
chromatic aberration in lens system. power of wavelength for assessment of laser
strength. Wavelength powers can be measured
In case of ordinary light the emitted
by the use of a photodiode or thermocouple
photons have no phase relationship with each
type sensor.
other and are not coherent. Coherence is
another important property of laser light. It For pulsed type of laser a pyroelectric
means the photons emitted from the laser sensor is used. This sensor is designed to
source are “in step” and “in phase” which measure the laser energy at every pulse and
means that the maxima (crest) or minima is able to convert joules into an average power
(trough) of the wave of one photon will occur of laser beam in watts. Repetition of pulse
at same time as on the wave associated with frequency can be measured by combining this
the other photon. It may be temporal coherence sensor with display units. Stability of laser
or spatial coherence and both are utilize to output on every pulse basis can be measured
produce the interference which is used to by use of silicon joule meter probe (type of
produce three-dimensional images (holograms). pyroelectric probe).
Polarization is another important charac- In case where only laser output measure-
teristic of laser light. Many lasers emit linearly ment is required for optical adjustment
polarized light, it means the electric field of purposes, a simpler and cheaper device like
coherent light beam oscillates in a particular thermopile (series of thermocouples) power
stable direction. meter can be used instead of a pyroelectric
Directionality is another important property sensor.
of laser means the laser beams are very narrow In clinical practice effect of laser beam on
and moves together in a beam (highly direc- target tissue is represented by focal point size
tional) and does not spread out or diverge. or spot size (for example, 100 μm)
Lasers cause amplification of only those light Laser types like Argon, krypton delivers
rays (photons) which travel along a very continuous laser wave and hence the power
narrow path between two mirrors of laser is displayed on a panel in unit watt. Whereas
system. It is because of directional property laser type like Nd: YAG is expressed as energy
of laser beam that laser light can be focused per pulse in unit joules on display panel;
on a small spot as it is easy to collect all the because Nd: YAG delivers a pulse of laser not
energy in a simple lens system. a continuous wave of laser. Representation of
Intensity or brightness of laser beam is the energy in joules for pulsed laser type is easier
most important property as it determines the because energy of light beam varies with the
effect of laser on target tissue. Intensity of laser settings of pulse shutter. For example, a laser
beam can be defined as the power emitted per beam of power 50 mW pulsed at time interval
unit surface area per unit solid angle. of 0.1 second will deliver energy of 5 mjoules
per pulse; whereas same laser beam with without opacifying the adjacent corneal tissue
50 mW power pulse for 0.2 second interval will because of the relative absence of thermal
deliver energy of 10 mjoule per pulse. injury. Commonly used lasers for photoabla-
Tissue interactions of laser tion in ophthalmology are excimer ultraviolet
(193 nm), holmium: yttrium-aluminum-garnet
Light energy had been used therapeutically
(Ho: YAG) infrared laser (2060 nm), erbium:
to heat and to alter the target tissue perma-
yttrium-aluminum-garnet (Er: YAG) infrared
nently much before the invention of laser;
laser (2940 nm) and CO2 (10,600 nm) infrared
however, laser does these tissue interactions
laser.
in more controlled and precise way. Various
tissue effects seen by laser beam are Note: Pulsed Nd: YLF (1053) infrared laser is used
• Photocoagulation in plasma ablation of tissue.
• Photodisruption
• Photoablation Clinical Applications
Selective absorption of light energy and Lasers are used extensively in various ophthalmic
then conversion of this light energy into heat, conditions, for both diagnostic and therapeutic
which subsequently produces permanent purposes.
structural changes in target tissue, is termed
photocoagulation. The process of photo-
VISIBLE LIGHT VERSUS HUMAN EYE
coagulation and its therapeutic results are
dependent on laser wavelength and laser Light sensitivity of human eye
pulse duration. At present several lasers • Human eye is very sensitive to a wide range
clinically used for photocoagulation are blue– of light and can see light energy from a few
green (488–514 nm), argon, krypton red (647 nm), photons (5–9) per milliseconds up to bright
dye, diode infrared (810 nm), holmium and sunlight; means a difference of 10 15 in
gallium arsenide. sensitivity.
The process where high peak powered • Visible light is appreciated by human eye
pulsed lasers are used to ionize the target and in the form of pulses or images. These
rupture the surrounding tissue, is termed images or light pulses repeatedly appear
photodisruption. In clinical practice photo- and/or disappear in front of the eyes.
disruptive laser is utilized like a virtual Consider a situation when the repetition
microsurgical scissor, cutting through ocular frequency of these pulses crosses a specific
tissues such as lens capsule, iris, vitreous threshold level; then the eye cannot feel two
strands and inflammatory membranes; pulses as separate, rather feel them as
without disturbing the surrounding tissue. single. The phenomenon where eye feel of
Currently Nd: YAG (1024 nm) laser is used as the pulses of light as single is termed
photodisruptive laser in ophthalmology persistence of eye for light or image.
practice. Persistence of fovea for red light is 0.0209
A laser tissue interaction process where second; for yellow light 0.0179 second; for
high powered ultraviolet laser pulse precisely blue–violet light is 0.0349 second. Hence on
engraves the cornea is termed photoabla- average light persistence time (time interval
tion. During photoablation the energy state between two successive light pulses) is
of only a single photon of ultraviolet light between 0.02 and 0.04 second.
having wavelength 193 nm will exceed the • Daylight vision also called photopic vision,
covalent bond strength of corneal protein. A requires surrounding light levels in high
submicron layer of cornea is removed range (luminance more than 3 cd/m2); vice
precisely by absorption of these laser pulses; versa night time vision also called scotopic
vision, requires surrounding light levels in light increases till observer sees just
low range (luminance less than 0.003 cd/ noticeable difference in light intensity (say
m2). Vision level in between photopic and at 110 units). Then difference threshold is
scotopic vision is called mesopic vision, 10 units (110–100) and Weber’s fraction will
needs surrounding light levels in an be 0.1 (10/100). Now by applying Weber’s
average range (luminance in a range of law the value of the viewer’s difference in
3 to 0.003 cd/m 2 ); hence it is most the threshold for a light spot having any
commonly used for routine activities. other intensity value (say 1000 units) can
• In human eye light sensitive retina has be calculated. As per formula change in
visually sensitive elements: Rod cells and stimulus brightness is constant proportion
cone cells. Rods are more sensitive than equal to Weber’s fraction (0.1 in our
cones; where rods are responsible for example) for spotlight having intensity of
scotopic vision, whereas photopic vision is 1000 unit just noticeable difference would
related to cones. In human eye the photopic be 100 (0.1 × 1000). Weber’s constant for
sensitivity has maximum sensitivity to rods and cones is 0.14 and 0.02 to 0.03
wavelength 555 nm (spectral range of green respectively (lower values of Weber’s
and yellow); whereas peak scotopic sensi- constant indicates high sensitivity to
tivity occurs at range of 507 nm. Similarly a increments).
maximum luminous efficacy (lm /W) of 683 • Fechner’s law: Weber’s law was explained
is also seen at 555 nm range (Fig. 1.19). in detail by statements given in Fechner’s
• Weber’s law: This law is useful to assess law. The initial statement is that only a visual
several sensory functions like brightness, response which exceeds some amount of
loudness, mass, etc. Weber’s law simply threshold is capable of discriminating two
correlates that the just noticeable difference stimuli. The other statement is that
in luminance of stimulus upon luminance logarithmic power for a given intensity (say
of original stimulus is a constant value. E) is equal to visual response (say V) and is
Suppose original luminance is L and represented by equation V = log (E). To
minimal noticeable difference in luminance simplify the Fechner’s law, it means a
is L, then as per Weber’s law subjective sensation is proportional to
logarithm of stimulus sensitivity.
∆L
= K (where K is a constant) Light transmittance of human eye
L
• Normally human eye appreciates electro-
For example, two spotlights have intensity
magnetic spectrum present in natural
of light 100 units each, and intensity of one
environment in a range of 400 to 600 nm.
While considering the ultraviolet light this
UV spectrum is divided as UV-C rays (100–
280 nm), UV-B (280–320 nm) and UV-A
(320–400 nm). UV rays are harmful for eyes,
but majority of these rays are filtered or
absorbed by ocular structures.
• Our natural atmosphere usually gives us
protection from UV rays below 280 nm.
Human eye cornea absorbs 100% of UVC,
90% of UVB and 60% of UVA rays.
Remaining majority of UVA rays are
Fig. 1.19: Eye sensitivity in relation to wavelengths absorbed by crystalline lens, hence only a very
of light and luminous efficacy small fraction of UVA rays reaches retina.
• In normal circumstances majority of high • UV radiations can damage anterior portion

energy visible (HEV) light wavelength of eye, whereas blue light portion (HEV
between 380 and 450 nm (blue light light) can damage retinal structures. This
spectrum) are absorbed by crystalline lens damaging process could be in terms of
in human eye. After surgical removal of photothermal, photomechanical or photo-
crystalline lens (aphakia), HEV light chemical. Photothermal damage is mainly
wavelengths can pass the eye and will caused by longer wavelengths in the visible
reach retina. So these aphakic patients spectrum and also in near infra red region.
usually complain that they are seeing the Photochemical damage is caused by exposure
objects much bluer than before the of retinal structure to HEV spectrum and
surgery. also UV spectrum.
26
2Illustrated Textbook of Optics and Refractive Anomalies
Reflection and
Refraction
Learning Objectives
• Describe the phenomenon of reflection and refraction of light.
• Explain the laws of reflection and refraction.
• Understand and explain the reflection through plane and spherical mirrors.
• Understand and explain refraction through glass plates, prisms and curved surfaces.
Chapter Outline
• Reflection • Refraction
– Laws of Reflection – Introduction
– Reflection Through Mirrors – Refractive Index
Plane Mirrors – Laws of Refraction
Spherical Mirrors – Refraction Through Various Surfaces
Convex Mirror Prisms
Concave Mirror Curved Surfaces
REFLECTION and angle of reflection for a set of parallel rays

When a light ray strikes on a surface or medium, remains same after reflection so there is no
three possibilities may occur with it. A certain scattering of rays.
part of it will be absorbed, a part of ray will be Diffuse reflection: This type of reflection occur
refracted and a part will be reflected. The amount from rough or irregular surfaces, e.g. paper,
of reflection depends on the smoothness and clothing, etc. The rays get scatter in different direc-
polishing of the surface; smoother or well tions because the angle of incident and angle of
polished surface will reflect the light completely. reflection for a set of parallel rays are different.
Basic principles of reflections of light enable
us to understand the laws of reflections from Laws of Reflection
plane and curved surfaces and prisms. • The incident light ray (i), the reflected light
On the basis of nature of surface, reflection ray (r) and the normal (perpendicular line
is of two types: drawn from the surface point, where
Specular reflection: This type of reflection incident ray is meeting at the surface), all
occurs from smooth or regular surfaces, e.g. these elements lie in the same plane as
plane or curved mirrors. The angle of incident shown in Fig. 2.1.
26
Reflection and Refraction 27
Fig. 2.2: Reflection in plane mirror and image formation

Fig. 2.1: Laws of reflection
• The incident light ray and reflected light ray

both lie opposite to each other on either side
to the normal.
• Angle between incident light ray and
normal ( i) is always equal to angle between
reflected light ray and normal (r).
Reflection Through Mirrors

Usually surfaces or mirrors used in various
optical devices are plane, convex or concave.
Let us see the reflection through these various Fig. 2.3: Reflection in plane mirror proving that i’ is
types of mirrors. image of i.
Plane Mirror
Plane mirror is a type of mirror having plane
or flat reflecting surface. Reflected rays from
plane mirror are divergent in nature. Because
these rays are divergent they do not meet with
each other and real image is not formed.
However, after drawing imaginary lines in
opposite direction, a virtual image is formed
behind the mirror (Fig. 2.2). Fig. 2.4: Spherical mirrors
This virtual image formed behind the
mirror is equal in size and is situated at the Spherical Mirrors
same distance as that of the object from mirror The portion of a sphere, in the form of an arc
as shown in Fig. 2.3. The size of image can be is called a spherical mirror. These mirror can
calculated by the formula: be convex or concave (Fig. 2.4), depending on
v the side of surface which is polished.
I=
u Important cardinal points related to spherical
Here, I = size of image mirror:
v = distance between the image and mirror Vertex or pole (Fig. 2.5) of a mirror is nothing
u = distance between the object and mirror but the centre of arc (A).
Centre of curvature (C): It is the centre of the C = centre of curvature

sphere from which the arc has been taken to AF = focal length of mirror
form spherical mirror. Sign convention for spherical mirrors
Principal axis of mirror: The line joining the 1. Various distance like focal point, radius of
centre of arc (A) and centre of curvature (C) is curvature are measured from the pole or
called the principal axis of mirror. vertex, which is a fixed point for all types
Radius of curvature (r) of mirror is the distance of spherical mirrors.
from pole (A) to the centre of curvature (C). 2. When all of these distances are measured
In simpler words, it is the radius value of the in opposite direction as that of the
sphere from which the arc has been taken to direction of the incident ray, then values
form spherical mirror (Fig. 2.6). of these distances are considered as
Focal point: The point where two reflected negative and if these distances are
parallel rays meet on principle axis, either in measured in the same direction as that of
front or behind the mirror is known as focal the incident ray, then values of these
point (F). The distance between this focal point distances are considered as positive as
and pole or vertex of mirror (A) is termed focal shown in Fig. 2.8.
length of that mirror as shown in Fig. 2.7. 3. All those distances which are measured
Here, r1 and r2 = parallel rays perpendicular and above the principal axis
F = focal point are taken as positive (as for erect image),
Fig. 2.5: Spherical mirror showing vertex or pole Fig. 2.6: Radius of curvature in spherical mirrors
Fig. 2.7: Focal length of the spherical mirrors

Fig. 2.8: Measurement of various distances in spherical mirrors. D = direction of measurement of various
distances from pole or vertex
while the distances which are measured Concave mirror When polished (reflecting)
perpendicular and below the principal axis surface of the arc of sphere faces towards the
are taken as negative (as for inverted centre of curvature it behaves as a concave
image). mirror. The focal point of concave mirror lies
Convex mirror When polished (reflecting) in front (towards object) of the polished
surface of the arc is away from the centre of surface of arc. Both the focal point and radius
curvature it becomes convex mirror. The focal of curvature of a concave mirror are represen-
point of convex mirror is behind the polished ted in negative values. The images formed in
surface of the arc. Both the focal point and a concave mirror are dependent on the relative
radius of curvature of a convex mirror are position of the object (Fig. 2.10).
represented in positive values. The image Let us see the various types of images seen
formed in a convex mirror varies in size, in a concave mirror considering that the object
distance and location depending upon the is situated at various positions from pole.
position of object in relation to the focal length • If the object is at infinity then real and
of convex mirror. However, the images pinpoint image is formed at the focal
formed in a convex mirror are always virtual point of mirror (Fig. 2.11).
and erect. Size of image is always smaller than • If the object is between infinity and centre
the object’s size as shown in Fig. 2.9. of curvature, then image formed is real,
Fig. 2.9: Image in convex mirror (virtual, erect and smaller) Fig. 2.10: Image in concave mirror (real, inverted, larger)
ab = object; a’b’ = image ab = object; a’b’ = image
inverted, and smaller in size than that of • If the object is at the focal point of
the object (Fig. 2.12). concave mirror, then image formed is
• If the object is between centre of curvature real and at infinity (Fig. 2.15).
and the focal point, then image formed • If the object is present between the
is real, inverted and bigger than the size focal point and pole of the mirror,
of the object (Fig. 2.13). then image formed is virtual, erect
• If the object lies at centre of curvature and larger than the object size, however,
then image formed is real, inverted and will be situated behind the mirror
equal in size of object (Fig. 2.14). (Fig 2.16).
Fig. 2.11 Fig. 2.12
Fig. 2.13 Fig. 2.14
Fig. 2.15 Fig. 2.16

Figs 2.11 to 2.16: Relationship of images and object, considering object at various positions;
Fig. 2.11: Object at infinity; Fig. 2.12: Object between infinity and centre of curvature; Fig. 2.13: Object
between centre of curvature and focal point; Fig. 2.14: Object at centre of curvature; Fig. 2.15: Object at
focal point; Fig. 2.16: Object between focal point and pole
Note: In concave mirror all images are formed in inside the medium as shown in Fig. 2.17.
front of the mirror except in Fig. 2.16 where object However, once it comes out of the
is situated in between the focal point and pole medium, the speed of the emerging light
(vertex) of concave mirror. ray remains same as before.
2. When light ray enters the substance/
Clinical Applications medium at an oblique angle, then the
retardation in the speed at one edge of
Plane mirrors and concave mirrors are used in various
the light beam will be different as
ophthalmic instruments to magnify the images.
However, convex mirrors are not routinely used in compared to the other edge of the beam.
ophthalmic devices except for analysis of images This is due to the fact that one edge of
formed by corneal reflections and to understand the beam strikes the surface earlier as
principles of Retinoscopy and Keratometry. compared to the other edge. The beam
of light which strikes earlier will retard
before, as compare to the other beam
REFRACTION
which enters later in the medium. The
Introduction light ray which entered first will losses
Light rays once emitted from a light source, its speed first, but will still comes out
travel in all the directions. For all practical first. Similarly the ray which enters last
purposes we consider that the light travels in will also losses its speed in same
a straight line when moving in the space. This proportion and comes out last. In
straight line movement of light ray helps in between these two rays there will be
better way to understand various optical several rays which will enter and comes
systems and its related problems. As explained out as per there angle of incidence. The
earlier that when light ray meets to various resultant light beam will have various
substances while travelling in the space, it gets speeds as the rays will be coming out at
absorbed completely or partially in opaque or different time intervals. (Fig. 2.18)
translucent substances, respectively or may pass This emergent light beam will be not
unabsorbed through a transparent substance. in same plane as before. The direction of
Theoretically, if we consider that there is this emerging beam will be changed due
no resistance in the path of light then it travels to retardation of rays having different
with an approximate speed of 3 × 109 miles/sec speeds. The change in the direction of
in the space but practically every substance light ray or the bending of light beam
gives some resistance, hence speed of light is when it passes through a transparent
retarded when it travels through various medium is termed as refraction.
substances. Due to change in the speed of light,
the path of light also changes as it passes from
one medium to other. The change in speed will
be determined by the refractive index of the
medium. If the speed of light is higher in a
particular medium than in the air, it indicates
low refractive index of that medium.
To understand the phenomenon of refraction
we should consider the movement of light
rays through a transparent medium.
1. When light rays enter a transparent
medium exactly perpendicular to the Fig. 2.17: Light wave moving perpendicular to
surface, then speed of light gets retarded medium
substance indicates the measure of the

bending of light beam when these light rays
passes across one medium to another medium.
For all practical purposes the refractive
index of air is taken as 1.00 and other
substances are compared with air. For
example, water has refractive index of 1.33,
crown glass of 1.5, cornea of 1.376 and
crystalline lens has refractive index of 1.41.
Laws of Refraction
• The incident light ray, the refracted light
ray and the normal all are situated in the
same plane.
Fig. 2.18: Light wave moving oblique to medium • Incident light ray and refracted light ray lie
opposite of the normal.
Refractive Index • Snell’s law states that ratio of sin i (means
sine of incidence angle) and sin r (means
As light travels through a medium it gets
sine of refraction angle) is always a constant
resistance from that medium also. The
for all angles of incidence. Therefore,
retardation of speed of light ray will depend
on amount of resistance exerted by medium. sin i
Constant (K) =
More is the resistance exerted by medium, sin r
more will be decrease in the speed of light. Here i = angle of incidence
This retardation of speed in turn is directly r = angle of refraction
proportional to the amount of bending of light sin i μ′
or = = Constant (K)
ray, means if there is more reduction in the sin r μ
speed of light ray, then emerging light ray will Where, μ is the refractive index of medium 1
bend more acutely. and μ is the refractive index of medium 2.
Property of any substance by which When one of these mediums is air (say μ),
resistance is given to the light ray is called then this constant (K) becomes the refractive
optical density of that substance. In simpler index of second medium (μ); since refractive
terms, if the density of the medium is more, index of air is 1.00.
then this medium will exert more resistance
There are three factors which can influence
on the light ray as compared to less dense
the amount of refraction or degree of bending
medium. For all practical aspects we know
of light beam:
that the light usually travels through the air
which is known as universal medium. Hence • Refractive index of the medium: Through
the optical density of air as a medium is which the light ray is travelling.
considered standard and optical densities of • Angle of incidence of ray (i): Higher is
various substances are compared with air. the value of incidence angle (i), greater
Similarly, the refractive power or bending will be the refraction or bending of the
capacity of any substance is also compared light ray. It means more obliquely the
with refractive power of air. Thus, optical rays strike, more will be bending.
density which determines bending capacity of • Wavelength of light ray: Shorter is the
a substance is called refractive index of that wavelength of light ray, more will be the
substance. In other way, refractive index of degree of its bending. For example, blue
ray will bend more than red ray in any

medium because blue light has shorter
wavelength (380 nm) as compared to red
light (780 nm).
Refraction of light ray occurs at every
interface present between two mediums. For
example, when light passes through a glass
plate from air, it gets deviate at first interface
of air and glass, then deviates at second
interface of glass and air. We know that
incident ray bends towards perpendicular
while passing from rarer (air) to denser (glass)
medium and away from perpendicular when
passes from denser to rarer medium; hence
the incident ray A will emerges out as Fig. 2.19: Refraction of light
refracted ray A’ as shown in Fig. 2.19.
Here, i and i are angle of the incidence at
the air–glass interface, whereas r and r are
angle of the refraction at the glass–air
interface.
Total Internal Reflection

As discussed above when light travels from
denser (glass) medium to rarer (air) medium,
then the angle of refraction (r) is always more
than the angle of incidence (i). The angle of
incidence (i) and the angle of refraction (r)
Fig. 2.20: Critical angle
are inversely proportional to each other. There
is a particular angle of incidence at which the
angle of refraction will become 90° and at this
angle the refracted light ray will just graze at
the interface of two mediums. This particular
angle of incidence at which angle of refraction
is 90° is termed as the critical angle (c) of that
denser medium (Fig 2.20).
Suppose the angle of incidence gradually
increases and becomes more than that of the
critical angle (c), then the refracted ray of light
will not enter into other medium, rather it will
reflect back into the same medium. This Fig. 2.21: Total internal reflection
phenomenon is known as total internal
reflection (Fig. 2.21). Because of this total Clinical Applications
internal reflection phenomenon, we cannot
visualize the angle of the eye directly so we Principle of total internal reflection is used in many
require gonioscope to visualize the angle of optical appliances such as fiber optic lights,
applanation tonometer.
eye.
Refraction Through Various Surfaces Note: In both these situations, the emerging beam
a. Through glass plate of light will be parallel to the incident beam; though
• With parallel sides the path may be changed, if it falls obliquely.
• With non-parallel sides
b. Through prisms • Glass plate with non-parallel sides: When
light falls perpendicularly or obliquely
c. Through curved surfaces
on a glass plate having non-parallel sides,
a. Through glass plate: then there will be both retardation of
• Glass plate with parallel side: speed and bending of emerging beam.
– When light beam falls perpendicu- However, here the path of the emerging
larly on a glass plate having parallel light beam is not parallel to the incident
sides, there will be only retardation light beam rather it is in all different
in the speed of the emerging ray as direction as shown in Fig. 2.24.
shown in Fig. 2.22.
b. Through prism: As discussed above, when
– When light beam falls obliquely on a a light beam is passed through a glass plate
glass plate having parallel sides, then with non-parallel sides, its speed get
there will be both retardation and retarded and the direction of bending beam
bending of light beam as shown in is also different from that of incident beam.
Fig. 2.23. Now let us see what will happen when a
light ray is passed through a prism.
Prism consists of two unparallel plane
refracting sides, meeting at a point called
apex (N) of the prism. These two inclined
refracting sides are connected at the bottom
through a plane surface, called base (LM)
of the prism. The angle between two
refracting surface is called angle of
refraction (r). (Fig. 2.25 A). As per basics of
physics when light ray enters from rarer to
Fig. 2.22: Retardation of speed, when light beam is denser medium, it bends towards the
perpendicular to medium perpendicular and vice versa occurs when
light ray enters from the denser medium to
the rarer medium, i.e. light ray bends away
from the perpendicular. Correspondingly
Fig. 2.24: Refraction through unparallel surfaces

Fig. 2.23: Retardation of speed and bending of light, showing both retardation of speed and bending of
when light beam is oblique to medium light.
• Angle at which the light beam falls on

the prism, i.e. angle of incidence.
• Amount of refracting angle of prism.
Usually the ophthalmic prisms are made
using crown glass and the angle of
incidence of light ray is usually kept
symmetrical. Suppose if these two factors,
i.e. refractive index of the material and the
angle of incidence (which influence the
deviation of light ray through prism) are
Prisms can be used for various diagnostic and

therapeutic purposes in ophthalmology practice.
Fig. 2.25: Refraction through prism I. Diagnostic uses
• Incorporated in ophthalmic instruments such
in case of prism, when a ray (OA) enters as gonioscope, applanation tonometer to
from air (rarer) to glass (denser) medium, it diagnose glaucoma.
bends towards perpendicular and when ray • Used as beam splitter in many ophthalmic
(BE) comes out of prism, i.e. from glass (denser) devices like interferometers, surgical
medium to air (rarer), medium ray bends microscope, slit lamp and keratometer.
away from the perpendicular (Fig 2.25 B). • Can be used as unmounted loose prisms or
Thus, the entire path of incident ray will in combination with other prisms (prism
bar) for either subjective measurement (with
become OABE, because the incident ray
Maddox rod) or objective measurement
(OA) will bend towards perpendicular and
(Prism bar test, Krimsky’s test), of angle of
emerging ray (BE) further bends away from deviation.
the perpendicular means bending again • Clinical evaluation of microtropia (4D
toward base (LM) of the prism. Hence, the prism test) and suppression scotoma
final outcome of an incident ray falling on (induced prism test) is done with the help
a prism is that it bends towards the base of of prisms.
the prism. • Diagnosis of malingering is done by perfor-
The total amount of deviation between ming simulated blindness test using high
incident ray (OA) and emergent ray (BE) is power prisms.
called the angle of deviation. II. Therapeutic uses
Now, we presume that we are observing • In visually impaired patients to enhance the
the object (O) through the prism from visual field special types of prisms called
position E of emerging ray (BE). The object Fresnel prisms are used.
will be seen at position ‘I’ towards the apex • Prisms are incorporated in bifocal glasses
(N) of the prism, though in reality, the object (having high refractive power) to increase
is situated at position ‘O’ near the base of the comfort of wear.
the prism. • In cases of strabismus to correct small degree
Refractive status of prisms deviations, prisms are added in spectacle
The refractive status of a prism depends corrections.
upon three factors: • In cases of convergence insufficiency various
convergence exercises are performed with
• Refractive index of the material by which
the help of prisms.
prism is made.
Fig. 2.26: Prism dioptre
kept constant, then it is only the angle of refraction through curved surface is
refraction of the prism which will decide practically important in ophthalmology.
the amount of deviation of light ray. Let us study Fig. 2.27, where a curved
Various methods had been tried in the transparent refracting surface is represented
past to standardize the refractive status of as XY. Centre of curvature of this curved
the prism but no conclusive way is derived. surface is denoted as ‘C’ and radius of
Most commonly used terminology to curvature as ‘r’ (where r is the distance
express the refractive power of the prism is between C and N). Light ray falling at point
called prism dioptre. One (1) prism dioptre ‘O’ follows the Snell’s law of refraction,
means prism will cause displacement of an hence bend towards the normal. In Fig. 2.27
object by 1 cm which is kept 1 meter away the light ray is travelling from air (rarer) to
from the prism (Fig. 2.26). glass (denser) medium, as a result the
However, in the case of large prisms, the incident ray (OA) is bending towards
measurement of the prism dioptre gives a normal and emerging as OB. Amount of
significant error because measurement is refraction is dependent on the degree of the
done on a tangent scale. To minimize this angle of incidence and refractive index of
error use of a centrad prism unit has been the medium. On the basis of this fact,
recommended where displacement of 1 cm anterior and posterior focus of curved
of the object is measured on an arc instead
of a tangent at one meter distance. However,
prism dioptre is still used normally in our
routine clinical practice. The relationship
between degree of arc and prism dioptre is
expressed as: One degree of arc ~ Two
prism dioptres.
To conclude refraction through prism, the
light ray gets deviated towards the base and
image of the object is displaced towards the
apex when we see through a prism.
c. Through curved surfaces: Cornea, being a
curved surface is most powerful refracting
surface in human eye, hence knowledge of Fig. 2.27: Refraction through curved surfaces
Note: Knowledge of anterior and posterior focus where

will help us to understand various terminologies F1 is anterior focus
like vergence, dioptric power and focal length in F2 is posterior focus
upcoming chapters. μ = refractive index of medium of incident
ray (air in our example)
surface can be calculated by these simple μ = refractive index of medium of emerging
formulas. ray (glass in our example)
μr μ′ r r = radius of curvature of curved surface
F1 = and F2 =
μ′ − μ μ′ − μ (in meter)
38
Ophthalmic Lenses
Learning Objectives
• Describe the types of spherical and cylindrical lenses.
• Explain the image formation through spherical and cylindrical lenses.
• Understand and express the refractive power of ophthalmic lenses and its importance.
• Know the refraction through thick lens and through astigmatic lens.
Chapter Outline
• Introduction • Refractive status of lenses
– Spherical lenses – Role of dioptre
Types – Lens representations
Terminologies related to spherical lenses – Refraction through combination of lenses
Refraction through spherical lenses – Refraction through special lenses
Convex lens Thick lens
Concave lens Astigmatic or cylindrical lens
– Cylindrical lenses Sturm’s conoid
Types – Practical evaluation of lenses

Refraction through cylindrical lenses Convex lens
Convex cylindrical lens Concave lens
Concave cylindrical lens Cylindrical lens
INTRODUCTION deviation or bending of ray is called vergence,

When a bundle of light rays fall on a spherically which is of two types.
curved surface, the individual ray will bend at Convergence: When two parallel rays
different angles. These all bend rays will meet strike a curved refracting surface and both
at a point called focus. The distance of focus will rays bend towards each other after striking.
depend on the curvature of surface, optical den- This phenomenon is termed as convergence
sity of the medium and also on the wavelength (Fig. 3.1A).
of the light falling on this spherical surface. Divergence: If two parallel rays after striking
Convergence and divergence: When a ray a refractive surface get deviated from its path
strikes on a curved refracting surface, it gets and move away from each other. This pheno-
deviated from its path. This phenomenon of menon is termed as divergence (Fig. 3.1B).
38
Ophthalmic Lenses 39
Fig. 3.2: Plano convex lens
Fig. 3.1A and B: Phenomenon of vergence of light rays
These two terminologies, convergence and Fig. 3.3: Biconvex lens

divergence, will be used commonly in upcoming
chapters.
Spherical Lenses
Sphere when cut at certain side can become a
lens; hence the name spherical lens came into
nomenclature. Thus, these lenses have their
(one or both) surfaces curved in the form of
sphere.
As shown in Fig. 3.2 when a part of sphere
is cut, it forms a plano convex lens. Similarly,
if two spheres are combined and a portion is
cut, it will form a biconvex lens (Fig. 3.3).
Types of Spherical Lenses

Various types of lenses can be created from
solid sphere alone or by combining sphere
with various refractive surfaces as shown in
Fig. 3.4.
Common types of lenses are
• Plano convex lens can be formed by cutting
the part of the sphere and it has one plane
surface and the other convex surface. Fig. 3.4: Various types of spherical lenses
• Plano concave lens can be formed by

combining sphere and plane surface and
has one plane surface and other concave
surface.
• Biconvex lenses are produced by combining
two spheres and both refracting surfaces of
these lenses are convex in shape.
• Biconcave lenses are made up by approxi-
mation of two spheres and have both
refracting surfaces of concave shape.
• Meniscus lenses are of two types
– Concave meniscus can be formed from a
sphere and has greater curvature of
concave shape.
– Convex meniscus also can be formed
from a sphere and has greater curvature Fig. 3.5: Terminologies in lenses
of convex shape. XY: Principal/optical axis
O: Optical centre and C: Centre of curvature
Terminologies Related to Spherical Lenses
For better understanding of principal focus
To understand the various types of images points, study Fig. 3.6. As we know that light
formed by these spherical lenses, we should ray can pass through lens from either side of
know various terminologies used in refraction. it, hence lens has two principal foci; one on
Principal axis or optical axis: It is defined as each side of the lens.
the common axis represented by the line joining • First principal focus (F1) is a point situated
centre of curvatures of two refracting surfaces. on the optical axis of lens. Light ray originating
For example in Fig. 3.5, XY is representing from this point become parallel to optical axis,
principal axis or optical axis of the lens. after getting refracted by the lens (Fig. 3.6A).
Optical centre (O): It is the principal point • Second principal focus (F 2 ) is a point
on the optical axis from where the ray of light situated on the optical axis of lens, where
passes undeviated and is also called nodal all the light rays travelling parallel to the
point of lens. In all types of spherical lenses optical axis either converge (in case of
optical point is situated inside the lens, convex lens) or appear to be diverge (in case
however, in case of meniscus lens it lies of concave lens) after getting refracted by
outside the lens. the lens (Fig 3.6B).
Focal length: It is defined as the distance
Centre of curvature: As shown in Fig. 3.5,
between optical centre (O) and principal focus
centre of curvature ‘C’ is nothing but the centre
point, measured along the principal axis of
of sphere, from which the lens is formed.
lens. Two focal lengths f1 and f2 are seen for
Radius of curvature: As shown in Fig. 3.5 it is each lens, because every lens has two principal
the radius (r) of sphere, from which the lens foci on either side.
has been formed. • First focal length (f1) is the distance between
Principal focus: It is defined as the point on optical axis of the lens and first principal
the principal (optical) axis of the lens, where focus (F1) (Fig. 3.6A).
all the parallel rays from infinity either
Note: When lens is situated in air or medium on
converges (in case of a convex lens) or appears
both the sides of a lens is air, then f1= f2.
to be diverge (in case of a concave lens).
Fig. 3.6: Principal focus points in convex and concave lenses
• Second focal length (f 2) is the distance

between optical axis of the lens and second
principal focus (F2) (Fig. 3.6B).
Refraction through Spherical Lenses
To understand refraction through spherical
lenses, we should recall the basics physics
where we learnt the refraction of light ray
through prism in Chapter 2. As we can see in
Fig. 3.7 that an incident ray falling on the
prism will bend towards its base. On the basis
Fig 3.7: Refraction through prism
of this simple fact we can explain the refraction
through various types of lenses. (Fig. 3.9). As it is clear from Fig. 3.9 that the
Convex lens: Convex lenses can also be parallel rays after falling on a convex lens are
considered as combination of two prisms getting converge at focal point, so these types
attached base to base as shown in Fig. 3.8. of lenses are also known as convergent lenses.
As discussed above the light rays will bend Here we also noticed that a central ray of light
towards base of the prism and when both the passes through the lens without any deviation
rays bend towards the base of prism, they will and goes straight through the lens. The line in
meet at certain point; this meeting point of bent which this unaffected ray moves is called the
rays becomes the focal point of the convex lens principal axis of the lens.
Fig. 3.10: Parallel rays from infinity getting converged
Fig. 3.8: Base to base joining of two prisms, making

a convex lens
Fig. 3.11: Divergent rays from point source focusing

farther than focal point
point (I) farther than the principal focus

(F) (Fig. 3.11).
Figures 3.12 to 3.15: Images formed by convex
lenses considering objects at various distances.
• Suppose the point source of light (O) is
Fig. 3.9: Refraction through convex lens
between the focal point (F) and convex
lens, then the image will form behind the
Let us study various images formed by the source of light (O) and will be virtual in
convex lens considering that the object is nature (Fig. 3.12).
situated at various distances from lens: • When an object (AB) is present beyond
• Consider that parallel rays are coming the principal focus (F) at finite distance,
from infinity; then all these parallel rays then a real, inverted and larger size
will converge and focus on a single point. image (A’B’) will form on the other side
This point is called principal focus (F) of of a convex lens (Fig. 3.13).
convex lens. The distance between the • An object (CD) present between principal
convex lens and the principal focus is focus (F) and lens will form a virtual,
termed focal distance or focal length erect and larger image (C’D’) on the same
(Fig. 3.10). side of the lens (Fig. 3.14).
• Now consider that rays are coming from • An object (AB) present at the centre of
a point source (O) which is nearer curvature will form a real, inverted
than the infinity. These rays are diver- and equal size image (A’B’) at centre
gent in nature and when they strike of curvature on the other side of lens
the lens surface, they get focused at a (Fig. 3.15).
Concave lens: Concave lenses can be considered

as combination of two prisms, which are
joined apex to apex as shown in Fig. 3.16.
Again by the rule of refraction through a
prism the light ray bends towards base of the
prism, so in case of a concave lens both the
incident rays bend towards the base of prism
or diverge from each other as shown in
Fig. 3.17.
As we can see in Fig. 3.17, that the parallel
Fig. 3.12: Point light source between focal point and rays falling on a concave lens are getting
convex lens
diverged from each other, thus these lenses
are also called as divergent lenses. Similar to
convex lens a central ray of light also passes
through the concave lens unaffected and goes
straight through the lens. The line in which
this unaffected ray moves is called the
Fig. 3.13: Object AB between centre of curvature

and focal point
Fig. 3.16: Apex to apex joining of two prisms, making

a concave lens
Fig. 3.14: Object CD between focal point and

convex lens
Fig. 3.15: Object AB at centre of curvature Fig. 3.17: Refraction through concave lens
principal axis of the lens. By drawing an

imaginary line in the backward direction of
emerging divergent rays, these rays meet on
the principal axis of lens at a point F. This point
(F) is the focal point of concave lens.
Let us study various images formed by the
concave lens considering the object is situated
at various distances from lens.
Figures 3.18–3.20: Images formed by concave
lenses considering objects at various distances. Fig. 3.19: Object between infinity and focal
• Consider that parallel rays are coming point
from infinity, then the rays will diverge
and do not meet at one point. But if we
move along these divergent rays in
backward direction, then these rays
appears to meet at single point on the
principal axis of lens on the same side of
source of light. This point is called the
principal focus (F) of concave lens as
shown in Fig. 3.18. The distance between
the concave lens and principal focus (F)
is called the focal distance or focal length.
• An object (AB) present beyond the Fig. 3.20: Object between focal point and lens
principal focus (F) will form a virtual,
erect and smaller image (A’B’) on the Note: In a nutshell irrespective of object position
same side of the concave lens. The image concave lens always forms a virtual, erect and
(A’B’) will be situated between focal smaller size image of an object.
point and the lens (Fig. 3.19).
• An object (CD) present between the Clinical Applications
principal focus (F) and lens will form a
virtual, erect and smaller size image • Spherical lenses are used to correct various
(C’D’) on the same side of the lens and refractive errors like hypermetropia and myopia.
this image will be situated between the • These lenses are used in various optical instruments
object (CD) and the lens (Fig. 3.20). and ophthalmic devices, either alone or in
combination.
• Spherical lenses are also used in various low visual
aid devices for improvement in vision.
Cylindrical Lenses
As we had discussed above that spherical
lenses are formed by portion of a sphere or
combination of sphere with other refractive
surfaces. Similarly, the cylindrical lenses can
be produced from a cut portion of solid
cylinder or combination of solid cylinder with
other refractive surfaces; hence the name
Fig. 3.18: Object at infinity cylindrical lenses came in nomenclature.
Types of Cylindrical Lens

Similar to spherical lenses cylindrical lenses
are also classified according to their refracting
status as
• Convex cylinder
• Concave cylinder
Convex cylinder: To form a convex cylindrical
lens a solid glass cylinder having its axis of
rotation as XY is cut vertically via a surface
ABCD along XY axis as shown in Fig. 3.21. Now
when this cut portion is separated from the solid
cylinder, it will work as a convex cylindrical lens.
Concave cylinder lens: Similarly to form a
concave cylindrical lens a solid glass cylinder
having its axis of rotation as XY is combined
with a rectangular plate as shown in Fig. 3.22. Fig. 3.22: Concave cylinder formation
Now when a portion is cut along XY axis and
regular curved surface either convex or concave
separated, then this separated portion will
and gets converge or diverge, respectively.
work as a concave cylindrical lens.
Whereas in cylindrical lenses, one meridian
Cylindrical lenses have only one axis of
is curved while the meridian perpendicular
refraction, i.e. either convex or concave. Rest
to it is plane in nature, hence the rays will bend
of the area of these lenses is non-refracting in
only at one meridian, i.e. on curved one while
nature and thus rays falling in these areas will
the rays will pass unaffected through the
pass unaffected.
meridian perpendicular to it.
Refraction Through Cylindrical Lenses Convex cylindrical lens: As represented in
Refraction through cylindrical lenses is not as Fig. 3.23 portion of the solid glass cylinder is
simple as it occurs through spherical lenses. cut via a surface ABCD. This cut portion
In spherical lenses all the rays strike on a behaves as a convex cylindrical lens. The axis
XY along which the portion was cut is termed
as refractive axis of cylindrical lens. There are
two perpendicular planes (meridians) of this
cylindrical lens, namely LMNO and PQ. As
we can see in Fig. 3.23 plane LMNO is not a
curved surface (rather it is plane surface), so
this surface will not refract the light rays.
Whereas a plane perpendicular to it, i.e. PQ
is having a convex surface; hence the ray
falling on PQ plane will converge at the focal
point of lens. In this convex cylindrical lens
the effective power will be perpendicular to
its axis XY.
Concave cylindrical lens: As represented in
Fig. 3.24, solid glass cylinder ABCD is
combined with a solid glass plate LMNO. The
Fig. 3.21: Convex cylinder formation portion cut from these combined surfaces will
plane perpendicular to it, i.e. PQ is having a

concave surface, hence the ray falling on this
plane will get diverged. In this concave
cylindrical lens the effective power will be
perpendicular to its axis XY.
Refraction Through Convex Cylindrical Lens

A convex cylindrical lens having its axis XY
in vertical direction will focus the divergent
rays coming from a point source ‘O’ as a
vertical line (I) as shown in Fig. 3.25.
Similarly, when light rays perpendicular to
axis XY, passes through a convex cylindrical
lens, these rays get focus at focal plane FF’.
However, the rays which travel in the same
plane as that of axis XY will pass undeviated
as shown in Fig. 3.26.
Fig. 3.23: Convex cylindrical lens
Fig. 3.25: Point source is focusing as line in convex

cylindrical lens
Fig. 3.24: Concave cylindrical lens
form a concave cylindrical lens. The axis XY

along which the portion was cut is termed as
refractive axis of cylindrical lens. As shown
in Fig. 3.24 RSTU and PQ indicate two
perpendicular planes of this concave
cylindrical lens. The plane RSTU is not curved
so it will not refract the light ray. Whereas a Fig. 3.26: Refraction through convex cylinder
Refraction Through Concave Cylinder Lens such a manner that radius of curvature
As shown in Fig. 3.27 when light rays perpendi- (vergence) of the wavefront gradually
cular to cylindrical axis XY passes through a increases as waves move away from the light
concave cylindrical lens, they focus at a virtual source (Fig. 3.28A). This phenomenon of
focal plane FF’; because these rays get increasing vergence of wavefront is known as
diverged when they strike the concave surface negative vergence.
of cylindrical lens. However, the rays which Now if these diverging rays emitting from
are travelling in the same plane as that of a natural light source are merged with the help
cylindrical axis XY will pass undeviated. of a convex lens, then the radius of curvature of
the wavefront will gradually decrease as the wave
moves away from the light source (Fig. 3.28B).
This phenomenon of decreasing vergence of
wavefront is termed as positive vergence.
In a nutshell curvature of wavefront is
dependent on its radius and on the distance
of wavefront from its source of origin. More
is the distance of wavefront from the light
source, lesser will be the curvature of wave
front. In other words, curvature of the wave
front is inversely proportional to the distance
from the light source.
If a light source is placed at infinity then
the curvature of a wave front originating from
this light source will be so flat that the rays
coming out of source are almost parallel to
Fig. 3.27: Refraction through concave cylinder
each other. This phenomenon where waves in
Note: So to simplify and understand refraction a wavefront are parallel to each other is termed
through cylindrical lenses; in both types of a zero (plano) vergence (Fig. 3.28C).
cylindrical lenses the rays which strike In simpler words, refraction means bending
perpendicular to the axis XY of cylinder will deviate of light rays or we can say that refraction alters
and rays which strike the lens at same plane as the vergence of light rays. If the light rays pass
axis XY of cylinder will pass undeviated. straight via a medium, then their vergence is
unchanged and it indicates that no refraction
Clinical Applications has taken place. When light rays while passing
through a medium gets bend or refracted, then
• Cylindrical lenses are used for correction of
refractive error like astigmatism. it indicates that the vergence of light ray has
• Cylindrical lenses are also used in various changed. Lens is such medium that cause
muscular imbalance conditions like heterophoria change in the vergence of light rays.
and heterotropia. Refractive status of a lens determines
• These cylindrical lenses are also used in various • Its power to deviate the image of a given
low visual aid devices for improvement in visual object and
fields. • Its power to either magnify or minify the
image of a given object.
REFRACTIVE STATUS OF LENSES
As we know that any natural light source Note: More powerful lens will refract the light ray
to a higher degree, whereas image size of an object
(usually and almost always) emits rays of
is also more differentiated as compared to the object.
diverging nature. These emitted rays move in
Fig. 3.28: Curvature of the wavefront depends on vergence of rays. A. Negative vergence (divergence);
B. Positive vergence (convergence); C. Zero vergence (source at infinity)
The refractive power (vergence power or distance (focal length) is a convenient and
dioptric power) of lens indicate its ability to practically adoptable method to decide the
converge or diverge light. Refractive power power of the lens.
of a lens is expressed as dioptre (D). For a thin lens calculations of various
In clinical practice the refractive power of distance are based on the formula
the lens is represented in terms of its focal 1 1 1
length and is equal to the reciprocal of the focal = –
F V U
length of the lens Here F = focal length of lens
1 V = distance between the lens and
p=
F image
where p = power of the lens U = distance between the object and
and F = focal length of the lens lens
Refractive power of lens depends upon three Focal point distance is inversely proportional
factors: to the refractive power of the lens; means
• Curvature of the lens surfaces when power of the lens is more, then the
• Distance between two surfaces or thickness distance of the focal point will be less.
of the lens • 1 D powerful lens will have a focal point
• Refractive index of the lens material distance of 1 meter
• 2 D power lens will have a focal point
Note: For all practical purposes lens material is distance of 0.5 meter
standard and practically the thickness of lens is • 0.5 D power lens will have a focal point
very less, hence primarily refractive power of a lens distance of 2 meters
is decided by the curvature of the lens surface.
As we can see in Fig. 3.29A, B, when parallel Role of Dioptre

rays meet at the focal point which is situated Dioptre plays an important role in determining
at 1 meter distance from the optical centre of various properties of the lenses and helps us
the lens, then the power of such a lens is to calculate several data in relation of the
termed 1 Dioptre (D) power. Focal point lenses.
6 meters distance is calculated as zero or nil,

considering that wavefront distance from the
light source is infinite.
Measurement of distance: As discussed above,
we can describe the vergence as either positive
or negative. Similarly, dioptres are also
prefixed with signs of either plus or minus.
Plus dioptres express the convergence
(positive vergence) and minus dioptres
express the divergence (negative vergence).
As shown in Fig. 3.30A when light rays are
diverging from a point source, then they
produce a negative vergence of one dioptre
(–1 D) at 1 meter distance. Now if we decrease
the distance to half from the source, then
vergence gets doubled, i.e. –2 D (because
vergence is inversely proportional to distance
from the light source) and when the distance
from the source remains one-fourth of a meter,
then the vergence become four times, i.e. –4 D.
Similarly, when parallel rays from infinity
Fig. 3.29: Dioptric power of lens. A. Converging are made to converge as a point focus at a
lens; B. Diverging lens distance of one meter by using convex lens,
means a positive vergence of +1 D is
Measurement of vergence: Curvature of a produced. Similarly, when parallel rays are
refracting surface determines the vergence of made to focus at one-fourth of a meter distance
rays and we measure the curvature of from converging lens, means a four dioptres
refracting surface in terms of dioptres (D). (+4 D) positive vergence is produced as
Curvature of refracting surface (wavefront) shown in Fig. 3.30B.
and simultaneously the vergence of light rays
both vary inversely with the distance from the Note: In simpler words, a distance from point of
vergence can be represented either as one-fourth
light source means when shorter is the
of a meter or four dioptre.
distance from source, greater will be the
vergence of ray. Measurement of lens power: Along with
As vergence is inversely proportional to the measurement of vergence and distance,
distance from the light source and as we know dioptre also helps in measurement of power
that dioptres can be used to measure the focal of lens. In other words, dioptre indicates the
point distance so on the basis of this we can ability of any lens in terms of its light bending
correlate the vergence of wavefront in terms capacity. The power of a lens can be described
of dioptres. in terms of dioptric distance (meters) of the
For example, a wavefront present at 1 meter focal point.
distance from its source of origin will have a For example, + 1 D power convex lens will
vergence of 1 dioptre (1 D). Accordingly converge parallel rays from infinity to a point
vergence at 1/2 meter distance will be of 2 D located at the distance of 1 meter from the lens
and vergence at 2 meters distance will be of (Fig. 3.31A). Similarly, a – 1 D power concave
0.5 D. For all practical purposes vergence at lens will diverge the parallel rays from infinity
Fig. 3.30: Measurement of vergence and distance in dioptres
Table 3.1: Equivalent dioptric distances

Dioptric power Focal distance
Nil Infinity or 6 meters
0.5 D 2 meters
1.0 D 1meter
2.0 D 50 cm
3.0 D 33 cm
4.0 D 25 cm
5.0 D 20 cm
10.0 D 10 cm
Fig. 3.31: Effect of one dioptre power lenses on
vergence predominantly at air–lens interface. As the
A: +1 D power convex lens converges parallel rays
curvature of lens surface increases, the degree
at a point situated one meter distance from the
lens
or amount of refraction also increases
B: –1 D power concave lens diverges parallel rays, proportionately; means the lens having a
as if they are coming from a point (focal point) steeper curved surface or a shorter radius of
1 meter distance from the lens curvature will refract incident light rays more
as compared to the lens having flatter curved
which when joined backward will meet at surface or longer radius of curvature.
1 meter distance (Fig. 3.31B).
As discussed above the dioptric power of a Note: The total power of a lens is decided by the
lens is reciprocal to the focal distance (in power of its both refracting surfaces (front and back
meters) means shorter is the distance more curves), but practically it is sufficient to remember
will be the number of dioptres. For example, that front surface of the cornea (convex shape) will
lens of +4 D will converge the parallel rays at produce a positive vergence (plus power) on light
rays passing through it.
a focus distance of 0.25 meter (25 cm); similarly
In relation to refraction, the primary role of the
a –5 D lens will diverge parallel rays and the
eye is to focus all the incident rays of light on the
form a virtual image at focus distance of retina. To achieve this eye must exert a substantial
0.20 meter (20 cm). Equivalent focal distances amount of positive vergence on incident parallel
for routinely used dioptric powers are rays to converge them; so that these parallel rays
summarized in Table 3.1. get focused on fovea situated about 23 mm away
Measurement of curvatures: The light ray from the cornea. Normally total amount of plus
bending capability of a lens is primarily power exerted by both the cornea and crystalline
lens is equal to nearly 60 D.
correlated to the curvatures of lens surfaces,
Lens Representations calculate the effective outcome easily by using

The spherical lenses and cylindrical lenses can the specific formula.
be represented in the following way: 1. If a + 2 Dsph lens is converging the parallel
A symbol of S/sph for sphere and symbol rays, and before these rays reach to the focal
of C/cyl for cylinder are post-fixed the power, point, another diverging lens of – 4 Dsph is
however, the axis of cylinder is also written after placed in the path of these converging rays;
the expression of power separated by a ‘x’ sign. then the effective outcome is calculated as
• For example: Spherical (converging) lens explained below.
and cylindrical lens of 1 D can be represen- To calculate the equivalent power we
ted as + 1 DS (+ 1 Dsph) and + 1 DC (+1 Dcyl) mathematically combine the powers of
× axis of power (e.g. 90° or 180°), respec- these two spherical lenses:
tively. While spherical (diverging) + 2 Dsph + (–4 Dsph) = –2 Dsph
lens of 1 D can be represented as – 1 DS For better understanding we use universal
(– 1 Dsph) and cylindrical lens as – 1 DC representation method of lens power values
(– 1 Dcyl )) × axis of power (say 90° or 180°). in the form of a cross as shown in Fig. 3.33.
Cylinder orientation: This is a universal way The final image formed with combination
to represent the axis of a cylindrical lens. The of these two spherical lenses will be that as
examiner sees the patient’s right and left eyes if a minus 2 Dsph lens is placed, means a
as shown in Fig. 3.32. When the examiner is facing virtual, erect image will be formed at
the patient, the right eye of the patient will be 0.5 meter distance from the lenses.
towards his left side and thus from examiner’s 2. Similarly, when two cylindrical lenses whose
left side the axis representation is started. axis are perpendicular to each other are
Vertically the scale will be read as 90° and placed in contact, then their effective power
horizontally as 180° starting from the left of will be as that of a sphere. For example, if
examiner. Similarly, 45° and 135° are + 1 Dcyl with 90° axis (vertical axis) is
represented at right angle to each other. The combined with another +1 Dcyl having
axis of the cylinders recorded by this universal 180° axis (horizontal axis), then the final
representation is written after the dioptric effective power will be of + 1 Dsph. This can
power of cylinders as described above. also be represented as shown in Fig. 3.34.
Refraction Through Combination of Lenses Note: Effective power of a cylindrical lens is

The practical advantage of dioptre system and actually perpendicular to the represented axis.
signs of plus/minus is that when two lenses
3. Similarly, we can also combine spherical
are used in combination, it became easy to
lenses with cylindrical lenses in various
combinations, so that we can get different
types of images with these combinations.
Suppose if a +2 Dsph is combined with
– 2 Dcyl having axis at 90° , then the resultant
effective power will be of +2 Dcyl at 180°
or horizontal meridian as shown in Fig. 3.35.
4. If a converging spherical lens is combined
with the plus cylindrical lens, then in the
axis of cylinder the effective power will be
combination of both but in the remaining
area of the lens the power will be equal to
Fig. 3.32: Representation of cylindrical orientation spherical lens power. For example, when
Fig. 3.33: Representation of combination of spherical

lenses
Fig. 3.36: Image formation after combination of two

convex lenses
Fig. 3.34: Formation of an equivalent spherical lens

by combination of two cylindrical lenses
Fig. 3.37: Image formation after combination of

concave and convex lens
For example, as shown in Fig. 3.36, a convex

Fig. 3.35: Combination of plus spherical lens and lens (L) will form image at point A, but when
minus cylindrical lens forms a plus cylinder of this lens is combined with another convex lens
opposite axis (M) placed at a distance (d) from the convex
lens (L), then the effective image will be
+2 Dsph is combined with + 1 Dcyl at the formed at focus F. We can also notice that if a
axis 90°, then the resultant effective refrac- convex lens is combined with another convex
tive power at 90° meridian (axis) will be of lens, then the final image formed is real and
+3 D, whereas in all other meridians it will closer as compared to an image formed by
be of +2 D only. single convex lens.
These all calculations which have been Likewise, if a convex lens (M) is combined
discussed above to find out the power of an with a concave lens (L) and placed at a distance
effective lens holds good only when the two (d) from each other, then the final image (F)
lenses are very thin and/or are placed in formed is virtual and situated in between two
contact with each other. However, entire lenses (Fig. 3.37).
calculations to find out the effective power of Thus the calculations from optical system
lenses will change if either the lenses are thick having combinations of lenses is tedious and
and/or are placed at a distance from each difficult, however, this can be done easily if
other. only a few lenses or refractive surfaces are
Clinical Applications have been focused at point F1 (as seen in the

case of a thin lens). However, in the case of a
Combination of lenses leads to discovery of various thick lens the final effective focus became F2
telescopes and forms the optical principle for both in place of F1.
Astronomical and Galilean telescopes. Total power of a thick lens cannot be
obtained by simple addition of the powers of
present and they all lie on the same optical the two refractive surfaces (i.e. R1 and R2 in
axis. Scientist Gauss and Listing worked a lot our example). The formula used to calculate
on mathematics of these combinations, and the total power of a thick lens is:
made the calculations easy for various optical
systems. ⎛t⎞
Total power () = r1 + r2 – ⎜ ⎟ × r1 r2
⎝μ⎠
Refraction Through Special Lenses Here r1 = power of first refracting surface
Thick Lenses of the lens (R1) in dioptre
Till now we studied all calculations r2 = power of second refracting
considering the lens to be very thin (thickness surface of the lens (R2) in dioptre
of lens is negligible) and contain a single t = thickness of the lens in meters
refracting surface. As compared to thin lens, μ = refractive index of the lens material
thick lens have two refracting surfaces For example, consider a 2 cm (0.02 meter)
separated by a glass medium and not by the thick lens having refractive powers +6 D (r1)
air medium as seen in thin lens. Thickness of and +8 D (r2) is made up of crown glass with
thin lenses has no influence on light rays, refractive index (μ) of 1.5, then the power of
hence they pass through thin lens unaffected. this lens will not be just simple addition, i.e.
However, in case of thick lenses it is important 6 + 8 = +14 D, rather it will have total refractive
to know a few additional parameters to power of +13.36 D (calculated by above men-
understand refraction through thick lens. tioned formula). This difference of 0.64 dioptre
In Fig. 3.38, we can see that in thick lens power is due to the change in the vergence
when parallel light ray strikes the refracting happened in light ray while travelling from
surface, i.e. R1 it get converge and then light front to back refracting surface inside the lens.
ray further strikes the second refracting Knowing the calculation for the final refractive
surface, i.e. R2 and finally focused at focal power of a thick lens is very useful in many
point (F2). Suppose, if this light ray had not practical situations.
met at the second surface, i.e. R2 then it could
Clinical Significance
Contact lenses and intra ocular lenses are considered

as thick lenses, although they practically appear very
much thinner than routine spectacle lenses.
Astigmatic or Cylindrical Lenses

In spherical lenses all the meridians have the
same curvature, hence the rays coming from a
point source will focus as a point at focal length
of the spherical lens. But in cylindrical lenses
one meridian is curved (either convex or concave)
and the other meridian (perpendicular to first
Fig. 3.38: Refraction through thick lens meridian) is not curved (i.e. plane), hence the
rays coming from a point source will focus as Sturmís Conoid

a straight line at focal length of the cylindrical Refraction through a compound astigmatic
lens. This type of cylindrical lens which has lens having two meridians can be understood
only one curved meridian is called simple by Sturm’s conoid. As seen in Fig. 3.40 lens
cylindrical or astigmatic lens (planocylindrical has two meridians with different curvatures,
lens). Another type of astigmatic lens which namely LL’ (vertical) and MM’ (horizontal). If
is termed compound or spherocylinder vertical meridian (LL’) of the lens is more
astigmatic or cylindrical lens has both the curved (steeper) as compared to horizontal
meridian curved at different degrees. This type meridian MM’ of the lens as seen in Fig. 3.40,
of lens will never form a point image or a line then the rays from LL’ meridian will focus
image of a point light source. For example, a nearer as compared to rays from MM’, while
spoon which has a steeper curvature from side rays from horizontal meridian (MM’) will
to side (VV’) as compared to the curvature from focus at far point, thus there will be two foci
tip to handle (HH’) (Fig. 3.39). and the distance between these two foci is
known as focal interval (sturm conoid interval).
There is overlapping of light rays in between
these two focal points so that a series of images
of various shapes of the object or source of
light is formed at different intervals. These
images represent the images of object seen by
an astigmatic eye.
If sections are made at different intervals
(points a, b, c, d, e, f and g in Fig. 3.40) in sturm’s
conoid, then the shape of images or shape of
bundle of light rays at these sections will be
as follows
Fig. 3.39: Spoon representing two different curved • Section at point a = both vertical and
meridians horizontal rays are converging at this
Fig. 3.40: Sturm’s conoid

point but vertical rays are converging Practical Evaluation of Lenses

more rapidly than horizontal rays. The parameters of lenses can also be evaluated
Hence, section of light bundle here will without any instrument. We can asses not only
be a horizontally oval-shaped ellipse the type of lens but also their approximate
having more horizontal diameter power to a near accuracy.
• Section at point b = all vertical rays meet Different types of lenses and their approxi-
at this point (first focus), while horizontal mate power can be assessed as follows.
rays are still converging, hence a
horizontal line is seen at this section.
Convex Lens
• Section at point c = the horizontal rays
Hold a convex lens in front of the eye and a
are converging but divergence of vertical
rays has started, hence a horizontal oval distant object is observed through it. Now, if
ellipse is formed at this section. we move the lens side by side, the object image
will move in opposite direction of the move-
• Section at point d = horizontal rays are
ment of lens (Fig. 3.41). This phenomenon is
converging and vertical rays are also
diverging in almost same proportion, due to the fact that the image formed by
hence a circle is formed at this section. convex lens is inverted.
This is the point where least distorted To know the power of this convex lens
image is formed and this circle is called under examination, we can hold a concave
circle of least diffusion or confusion lens of known power in close contact with
which is situated near the middle of convex lens and now observe the movement
interval. of the same object. The opposite directional
• Section at point e = degree of divergence movement of object image will decrease after
of vertical rays is more than convergence addition of concave lens of known power.
of horizontal rays, hence a vertically oval Now gradually change the power of concave
ellipse with large vertical diameter is lens until no movement of image is observed
formed at this section. through both the lenses. At this point of no
• Section at point f = all horizontal rays movement of object the unknown power of
meet here (second focus), hence a vertical convex lens is same as that of the known
line is seen at this point, whereas vertical power of concave lens; although with a plus
rays are still diverging. sign.
• Section at point g = both vertical and
horizontal rays are diverging, hence
vertical oval ellipse is formed.
When in an astigmatic lens the two
meridians are at right angles to each other,
then they produce the regular astigmatism
and if meridians are not at right angle to each
other, then they produce an irregular
astigmatism. The details about astigmatism
and their management will be dealt in
Chapter 5.
Note: Distance between vertical focal point ‘b’ and

horizontal focal point ‘f’ is known as focal interval Fig. 3.41: Opposite movement of an object image
of Sturm. when viewed through convex lens
Concave Lens Test procedure

Similarly, a concave lens is held in front of the • Hold the cylindrical lens in front of the eye
eye and a distant object is observed through and observe the illuminated tube light of
it. Now by moving the concave lens side by the examination room.
side the object image also moves in the same • Rotate the cylindrical lens in either vertical
direction of the movement of lens (Fig. 3.42). or horizontal meridian; while simultaneously
This phenomenon is due to the fact that the observe the movement of tube light.
image formed by concave lens is erect. • We will observe movement of tube light in
To know the power of this concave lens any one of these two meridians. Now note
under examination, we can hold a convex lens the meridian of cylindrical lens where there
of known power in close contact with this is no movement of object (tube light); this
concave lens and now observe the movement is the axis of cylindrical lens because when
of object image. The same directional we move the cylindrical lens in the line of
movement of image will decrease by adding its axis, no movement of object is seen.
convex lens of known power. Continue to • Now slowly rotate the cylindrical lens in
change the power of convex lens till there is any other plane, there will be displacement
no further movement of image in any of object either with or against the movement
direction. At this point of no image movement of the cylindrical lens.
the power of concave lens is the same as that • By this rotational movement of object, we
of convex lens; although with a minus sign. can make out whether it is convex (if against
movement, Fig. 3.43A) or concave (if with
Cylindrical Lens movement is seen, Fig. 3.43B) cylindrical lens.
When we hold a cylindrical lens in front of • Now slowly keep rotating the cylindrical
the eye and view a linear object like tube light lens in the same plane of examination until
through this cylindrical lens, the object image the movement of the object becomes
appears as if it is unequally displaced or maximum, this will be the perpendicular
elongated in one direction (Fig. 3.43). This axis to the axis of the cylindrical lens.
phenomenon happens because of the fact that • Now we can hold another cylindrical lens
cylindrical lenses have power only in one of known power having opposite sign in
meridian. front of the lens in question; so that we can
neutralize the rotational movement of image.
• Keep changing the power of additional
cylindrical lens having opposite sign, until
there is no rotational movement of the
object is seen, this will give the power of
cylinder in question.
In a nutshell remember these points during
evaluation of a given lens
• When we see an object through a lens and
object moves with the movement of lens,
then it is a concave lens and if the object
moves against the movement of lens then
it is a convex lens.
Note: At axis of the cylindrical lens there was no

Fig. 3.42: Same directional movement of object
movement of the object.
image when viewed through concave lens
Fig. 3.43: Movement of object image when viewed through cylindrical lens. A. Convex cylinder; B. Concave
cylinder
• When image movement is only in one plane • Power of cylindrical lens is determined by
along with the rotation of linear object, then using opposite sign spherical lens or
the lens is cylindrical lens. cylindrical lens of known power, until there
• When rotation of linear object is with the is no movement of linear object.
movement of lens, then it is the concave • For neutralization of lenses hold the known
cylinder and if rotation of linear object is power lens in close contact with unknown
against the movement of lens, then it is the power lens keeping their optical axes in the
convex cylinder. single line.
II
Ocular and
4. Optical System and Optical Defects of Human Eye

5. Refractive Anomalies
6. Binocular Vision and its Anomalies
7. Accommodation and its Anomalies
8. Convergence and its Anomalies
9. Binocular Muscle Co-ordination Anomalies
4
Optical System and
Optical Defects of
Human Eye
Learning Objectives
• Understand the refraction through various surfaces in human eye.
• Enlist the main factors affecting refraction through cornea and lens in human eye.
• Describe various theoretical eye models and their comparison in terms of cardinal points.
• Define and understand the visual axes and visual angles of the eye.
• Describe various physiological and pathological optical defects of human eye.
Chapter Outline
• Introduction Spherical aberration
– Refraction through cornea and lens Chromatic aberration
– Theorem of Gauss Oblique aberration
– Gullstrand’s schematic eye Coma
– Listing’s reduced eye Decentring
– Donder’s simplified eye
Distortion
– Retinal image size
• Refractive Status of Eye • Pathological Optical Defects of Eye
– Visual axes and angles of eye – Refractive surface anomalies
– Image formation due to reflection from surfaces – Refractive index anomalies
• Optical Defects of Human Eye – Disposition of optical elements
– Physiological optical defects of eye – Obliquity of optical elements
Diffraction of light – Absence of optical element of eye
INTRODUCTION eye. Various refracting surfaces coming across

Human eye is the most sophisticated optical the light pathways as shown in Fig. 4.1 are
device created by the nature. The eye has • Anterior surface of cornea (C1)
various refracting surfaces and various • Cornea substance (C)
medium through which light rays travel to • Posterior surface of cornea (C2)
ultimately reach at neurological tissue called • Aqueous humor (A)
retina, which sends signals to the brain about the
perceived light ray’s information. This forms • Anterior surface of lens (L1)
the basis of image formation in the brain. Let • Lens substance (L)
us see the structures coming in the pathway • Posterior surface of lens (L2)
of a light ray while passing through the human • Vitreous humor (V)
61
As per various hypotheses crystalline lens

plays a major role in accommodation of the eye
by changing its curvature. During maximum
accommodative state the anterior and
posterior lens curvatures become +5.33 and
–5.33, respectively.
Refraction Through Cornea and Lens

Both cornea and crystalline lens cause
convergence of light rays as both have convex
surfaces. The cornea plays a major role in
ocular refraction with power of about 40–45 D,
Fig. 4.1: Human eye showing various refracting
because there is a huge difference in refractive
surfaces
indices of air (1.0) and cornea (1.376). Whereas
This looks very complicated that a light ray crystalline lens in the eye lies between aqueous
gets refracted at numerous ocular structures and vitreous humor (having same RI), hence
but in reality only the anterior corneal surface refractive power of crystalline lens is about
and crystalline lens act as the effective half compared to refractive power of cornea,
refractive surfaces of the eye, rest of the i.e. nearly 18–20 D.
structures contribute very little in refraction In the eye, cornea mainly works as single
because the difference in their refractive refracting surface. Cornea has homogeneous
indices (RI) is negligible. material with very less thickness; hence cornea
To understand this better it is important to work as single unit. In contrast, lens is thick
know the RI of air and various ocular surfaces and its material is also not homogeneous in
as summarized in Table 4.1. nature. Hence, lens simply does not work as
As we can see that the RI of various ocular two refractive surfaces (anterior and posterior)
structures are more or less similar but there is rather it works as multiple refracting surfaces.
a significant difference in the RI of air and Crystalline lens consists of several layers with
cornea. different refractive indices. For example,
Another important factor which affects the central nuclear portion of the lens has higher
refraction in the eye is radii of curvature of refractive index than peripheral cortical layers.
the cornea and crystalline lens. The values of The curvatures of different layers of the lens
radius of curvatures of different ocular are also different.
surfaces are: As it is clear from Fig. 4.2 that layers of the
• Anterior surface of cornea: 7.7 mm crystalline lens are not concentric as well as
• Posterior surface of cornea: 6.8 mm the curvature of inner layer is greater than the
• Anterior surface of lens: 10.0 mm consecutive outer layers. The curvature of the
• Posterior surface of lens: 6.0 mm peripheral cortical layer is much less than that
of central nuclear layer. Hence, the refractive
Table 4.1: Ocular structures and refractive indices status at different places varies significantly
in the crystalline lens. The refractive index of
Structure Refractive index
peripheral cortical matter of the lens is
Cornea 1.376 approximately 1.386 and refractive index of
Aqueous humor 1.336 the central nucleus of lens is about 1.42, with
Vitreous humor 1.336 an average RI of 1.41.
Crystalline lens 1.41 Greater RI of central nuclear portion of the
Air 1.00 lens as compared to peripheral cortical matter
Optical System and Optical Defects of Human Eye 63
Fig. 4.3: Cardinal points with two refracting

surfaces
Fig. 4.2: Layers of crystalline lens
points are associated with focal planes and
has a great importance biologically; because principle planes, respectively.
variation in the refractive indices helps the Single optical system has one pair of each
crystalline lens to converge the light rays over cardinal point and two optical systems will
the retina. The cortical and nuclear pattern of have six pairs of cardinal points. If these points
crystalline lens also declines the chances of lie on a single plane and we know the value
various optical errors like spherical and of any two cardinal points pairs, then we can
chromatic aberrations; these patterns of calculate the remaining values easily. Similarly
crystalline lens also help in accommodation. the effective outcome of the ray can be
Furthermore, the anterior and posterior calculated in two optical systems by reducing
surface curvatures of crystalline lens are also these cardinal points to a single cardinal point
unequal. Anterior surface of lens is more flat system by using calculations of great
than posterior surface. Thus, the anterior mathematician Gauss.
surface curvature has the power of 10.0 D and In Fig. 4.3, AB is an object, F and F’ are focal
posterior surface curvature has the power of points, P and P are principal points and N
6.0 D only. This difference in power of and N are nodal points for two refracting
curvatures is also responsible for an unequal surfaces R and R’ respectively.
refractive status of lens. Based on the Gauss theorem many models
Thus optical system of human eye is of human eye were proposed. All of these
complex and behaves like a combination of following schematic eye models tried to
lenses or as a thick lens system which makes explain the optics of human eye in as simple
mathematical calculation tedious. Gauss manner as possible.
proposed a simple concept and suggested that
homocentric system of lenses could be treated Gullstrandís Schematic Eye
as a whole rather than in various parts. Any As discussed above, the scientist Gauss put
complicated optical system can be reduced to forward the three pairs of cardinal points, all
a simple system by the application of theorem lying on the principal axis of optical system
of Gauss, which simplify the refraction in eye to understand the multiple optical devices in
and makes the mathematical calculations easy. an easy way. Further, Tscherning and
Helmholtz contributed a lot to understand the
Theorem of Gauss optics of human eye. Ultimately, it was
Each optical system has its own cardinal Gullstrand who presented the most authentic
points, i.e. focal point, principle point and model of schematic eye for better understan-
nodal point. The focal points and principle ding of optics of the eye.
Cardinal data of Gullstrand’s schematic eye • Corneal system 43.05 D and 43.05 D,
is shown in Fig. 4.4. respectively.
Anterior surface of cornea is used as • Lens system 19.11 D and 33.06 D, respec-
reference point for calculation of distance. tively.
• Two principal foci: Anterior (F1) and
posterior (F2) are situated 15.7 mm in Listingís Reduced Eye
front of and 24.4 mm behind the anterior As discussed above Gullstrand’s schematic
surface of cornea, respectively. eye was easy for understanding the optics of
• Two principal points: Anterior (P1) eye; but still it poses some difficulties in
and posterior (P2) are situated 1.35 and performing various calculations. To reduce
1.60 mm away from the anterior surface these difficulties of calculation Listing came
of cornea, respectively forward with his simplified form of
• Two nodal points: First (N1) and second schematic eye, which is popularly called as
(N2) are located 7.08 and 7.33 mm behind reduced eye.
the anterior surface of cornea, respec- In Listing’s reduced eye (Fig 4.5) also, all
tively. the distances of various cardinal points are
calculated from anterior surface of cornea as
Refractive indices of various refracting
reference point.
surfaces when accommodation is relaxed are
• Anterior focal point F1 and posterior
• Cornea—1.376
focal point F2 are situated at 15.7 mm in
• Aqueous humor and vitreous humor— front and 24.4 mm behind the anterior
1.336 surface of cornea, respectively.
• Crystalline lens cortex—1.386 • Principal point P is located 1.5 mm
• Crystalline lens nucleus—1.406 behind the reference plane (anterior
Dioptric power or refracting power of the surface of cornea).
eye while accommodation is minimum and • Nodal points N is placed 7.2 mm behind
maximum is the reference plane.
• Complete eye 58.64 D and 70.57 D, • Anterior focal length of the eye is 17.2 mm
respectively. and posterior focal length is 22.9 mm.
Fig. 4.4: Gullstrand’s schematic eye

Fig. 4.5: Listing’s reduced eye
• Uniform refractive index of ocular readers can remember them easily. He

structures is 1.336. considered the eye as single curved refracting
• Total dioptric power of the eye is 58.2 D surface and reduced the cardinal data as
The total refractive power of the eye is shown in Fig. 4.6.
calculated by formula Reference plane in Donder’s simplified eye
model is situated 2 mm behind the anterior
Refractive index
F= corneal surface of the eye.
Focal length (meters) • Nodal point N is situated 5 mm behind
Hence, by using anterior focal length the reference plane
17.2 mm • Anterior focal length is 15 mm
Refractive index of air • Posterior focal length is 20 mm
F=
Anterior focal length (meters) • Uniform refractive index of ocular
1000 structures is 1.336
=1× • Total dioptric power of the eye is 60 D
17.2
= 58.2
Similarly, by using posterior focal length
22.9 mm
Refractive index of vitreous
F=
Posterior focal length (meters)
1000
= 1.336 ×
22.9
= 58.2
Dondersí Simplified Eye

Scientist Franciscus Cornelis Donders further
simplified the cardinal point data of Listing’s
reduced eye by converting them into round
figures. He oversimplified the data so that Fig. 4.6: Donders’ simplified eye
Retinal Image Size Here, if we consider the angle at nodal point

Due to simplification of cardinal data, it has () of 0.1 radiance and distance from nodal
now become easy to determine the size of point to retina is taken as 17.2 mm, then the
image formed on the retina by an object of size of image according to formula will be
known size. As per simplified eye system the = 17.2 mm × 0.1 radiance
nodal point (N) of the eye is situated at centre = 1.72 mm
of an anterior single curved refractive surface
of the eye. When a light ray starts from top REFRACTIVE STATUS OF EYE
edge of an object and moves in the direction When the entire parallel incident light rays
of nodal point of eye, then it will straightway from infinity meet and form an image on
reach the retina without any deviation. retina (while accommodation is at rest), then
As shown in Fig. 4.7 if a light ray from an the refractive status of the eye is termed
object (AB) top will pass straight via the nodal Emmetropia (E). Other possible destiny of
point (N) of the eye and forms an image (A’B’) incident light rays may be as shown in Fig. 4.8.
in the macular area of retina, then the angle • When all the incident light rays focus in
() formed between the object (AB) and image front of the retina, then it is termed myopic
(A’B’) at nodal point will be equal. The state of the eye (M).
distance between the nodal point (N) and • When all the incident light rays focus behind
image (A’B’) is 17.2 mm, i.e. equal to that of the retina, then it is called hypermetropic
anterior focal length. state of the eye (H).
Angle () is measured in radians and can • When a few light rays meet in front of the
be calculated by simplified formula retina, a few rays meet on the retina or a few
Object size rays meet behind the retina, then this
tan  = condition is termed astigmatic state of the eye.
Distance between the
object and nodal point Visual Axes and Angles of Eye
The size of retinal image (A’B’) can be Visual axes of eye (Fig. 4.9)
calculated by the following formula = • Optical axis: A straight line which passes
Distance between nodal point (N) and retina through the centre of cornea (C), then
(mm) × Angle of image () at the nodal point through centre of crystalline lens (L) and
(radians) then reach the retina at point R is called
optical axis (OR) of the eye. Optical axis lies
nasally to fovea of the retina.
Fig. 4.7: Retinal image size Fig. 4.8: Various refracting status of eye
Note: For all practical purposes center of cornea

(C) is considered corresponding to the center of
pupil.
Clinical Significance
• As it is practically impossible to accurately

determine the optical axis of eye (because of
difficulty in determining the exact center of
cornea), for practical purposes the center of
pupil is determined by seeing the image of light
on cornea.
Fig. 4.9: Visual axes of eye • Angle kappa is used in ophthalmic practice for
measurement of degree of squint.
• Visual axis: A straight line which passes
through fixation point from object (A) via axis (AM) at centre of rotation of eye (M) is
nodal point (N) and meets the retina at its termed angle gamma ().
fovea (F) is called visual axis (AF) of the • Angle kappa (): The angle (OCA) formed
eye. between an imaginary pupillary line (AC)
• Fixation axis: A straight line which passes corresponding to center of the pupil and the
through fixation point on object (A) and optical axis (OR) is called angle kappa.
meets at centre of rotation of the eye (M) is
termed fixation axis (AM) of the eye. Image Formation due to Reflection from
Visual angles of eye (Fig. 4.10) Surfaces
• Angle alpha (): The angle (ONA) formed Purkinje Images
between the visual axis (AF) and the optical In the year 1823, physiologist Purkinje
axis (OR) at the nodal point (N) of the eye discovered that images of a candle gets
is called angle alpha. Normally, it is 5°. This reflected from anterior and posterior surfaces
small degree of deviation between the of cornea and that of crystalline lens, which
visual axis and the optical axis plays an he named them Purkinje’s images. Basically
important role in correcting the chromatic four principal images (Purkinje I, II, III, IV)
aberrations of eye. are seen one each from anterior and posterior
• Angle gamma (): The angle (OMA) formed surfaces of cornea (I, II) and also one each
between the optical axis (OR) and fixation
Phenomenon of Purkinje image is used in

Ophthalmometer (Keratometer), an instrument
which measures the curvature of cornea.
Keratometer utilizes the Purkinje image from
anterior surface of cornea for the calculation of
the radius of curvature of the anterior corneal
surface. Size of the target mires image in kerato-
meter is measured via an observing microscope
using image doubling prisms. The variation in the
image size in relation to curvature of cornea can
be calculated as we already know the size of target
mires and refractive index of cornea.
Fig. 4.10: Visual angles of eye
Table 4.2: Various types of physiological and

pathological optical defects of the eye
Physiological optical Pathological optical
defects of the eye defects of the eye
Diffraction of light Refractive surface
anomalies
Spherical aberrations Refractive index
anomalies
Chromatic aberrations Dispositions of ocular
optical elements
Oblique aberrations Obliquity of the ocular
Fig. 4.11: Purkinje images
optical elements
from anterior and posterior surfaces of Coma Absence of optical
crystalline lens (III, IV). All images formed element of the eye
were upright except the one formed from Decentring
posterior surface of crystalline lens. Images I, Distortion
II, and III were virtual and erect, whereas
image (IV) from posterior surface of lens was
real and inverted as shown in Fig. 4.11. Among
these four images the anterior corneal surface
image was largest in size and brightest in
nature.
OPTICAL DEFECTS OF HUMAN EYE

Above mentioned various cardinal data and
parameters of the eye help us to understand
various optical defects of the eye. Optical
defects of the human eye can be physiological Fig. 4.12: Airy disc
or pathological.
Various types of physiological and Because of diffraction of light even a perfect
pathological optical defects of the eye are lens (aberration free) will not form a sharp
summarized in Table 4.2. point image of a point source of light. Instead
the image of a point light source is formed as
an airy disc. The size of the airy disc depends
Physiological Optical Defects of Eye
on the wavelength of incident light and size
Diffraction of Light of the aperture. Smaller is the aperture or pupil
Sir George Airy, an eminent scientist, reported size, larger will be the diffraction and thus blur
that when light rays pass through an aperture, image will be formed. The shorter is the
the light ray gets diffracted by the edge of this wavelength, less will be diffraction. Hence,
aperture (pupillary margins or rim of even by a clear lens the image formed via an
crystalline lens in human eye). The pattern aperture or circular pupil is in the form of an
which is formed due to diffracted images airy disc with concentric rings of dark and
contains series of concentric rings which have bright light. In simpler words, the best
alternative dark and bright bands along with possible size of smallest focus point is equal
a bright central disc. This central disc is known to an airy disc, due to phenomenon of
as Airy disc (Fig 4.12). diffraction.
Spherical Aberrations Note: The diameter of concentric ring of Airy disc

As we know that refraction of light depends for pupil size of 2.0 mm is 0.01 mm. Spherical
on many factors, among them curvature of the aberration may be more obvious when pupils are
refracting surface is an important factor for widely dilated.
refraction. Crystalline lens of eye has more
curvature at the periphery than the center. Due center and rays from center bend more
to this difference in curvatures of lens the because it is more curved, hence rays
refraction of the peripheral rays of light is from both the portions will meet almost
stronger than the rays falling in the center of at the same point.
lens. As a result, the central rays bend less and • Crystalline lens of eye has more refractive
focus away from lens while peripheral rays index in the center than peripheral cortex
focus near the lens. It means the central and and also the central layers are more
peripheral rays do not focus at a single point curved than peripheral layers. Because
after refraction, thus the image formed is not of this peculiar arrangement of lens
sharp rather it is blur at the edges as shown layers and density of material, the rays
in Fig. 4.13. are refracted more from central portion
Human eye has a dioptric power of about as compared to the peripheral portion of
+60 D which is primarily due to cornea and crystalline lens; hence decreases the
crystalline lens. Theoretically, because of this spherical aberrations.
high dioptric power human eye should • Finally, iris behaves like a diaphragm
produce a great amount of spherical and block the entry of majority of
aberrations, but practically when these peripheral rays into the eye, so that
aberrations of the eye were measured by a only axial and paraxial rays can enter
technique called aberrometry, it was found the eye.
that majority of these aberrations were coma
type aberrations, not the spherical type Chromatic Aberration
aberrations. Light rays when passes through a transparent
There are various ocular structural factors medium the amount of its refraction is decided
which help in decreasing the spherical by the wavelength of incident light ray. As
aberrations of the eye discussed before white light is actually a
• Distinctive curvature of the cornea, i.e. representation of VIBGYOR, where violet
it is more curved in the center and flatter color ray has shortest wavelength and red
at its periphery. Hence, at periphery color ray has longest wavelength. As per the
there is less bending of light rays than law of refraction blue ray will refract more as
compared to red ray of the light. So when
white light passes through the eye, blue light
deviates more strongly and will focus in front
of the red light while the red light being of
longer wavelength will focus at a longer
distance than the blue light. In between these
two color rays other colors of the spectrum
are focused at different distances according to
their wavelengths. In normal circumstances
emmetropic eye is slightly myopic for blue
light (blue rays focusing in front of retina) and
hypermetropic for red light (red rays focusing
Fig. 4.13: Spherical aberration behind the retina) as shown in Fig. 4.14.
be formed in any of the peripheral oblique axis

of eye. So the emergent rays from the
peripheral portion of retina get affected due
to oblique astigmatism of eye. This oblique
astigmatism is more pronounced when either
biconvex or biconcave lenses are used, on
contrary, meniscus lenses or periscopic lenses
show less oblique astigmatism as shown in
Fig. 4.16.
Factor which mainly reduces this oblique
astigmatism is the curvature of retina, which
is adapted to the optical system of eye in such
Fig. 4.14: Chromatic aberration
a manner that the peripheral visual field of
As shown in Fig. 4.14, it is mainly the yellow eye is not affected in practicality. Pupil also
light of spectrum which falls on the retina as reduces the amount of pencil rays to reach the
compared to the blue or red light. Various retina of eye and helps in reduction of oblique
ocular factors that help to decrease these astigmatism.
chromatic aberrations of the eye are:
• Fovea of retina is having very less
number of blue cones, so blue light is not
much appreciated by fovea.
• Long wavelength and medium wave-
length cones in eye have very narrow
band of spectrum of sensitivity. So the
fovea is less sensitive for blue or red color
rays.
• During normal focusing process of the
eye the rays having more intensity (i.e.
yellow color) gets well focused and
forms a sharp image on the retina.
Whereas, blue light rays of shorter wave-
Fig. 4.15: Oblique aberration
length and red light rays of longer
wavelength form lower intensity circles
as compared to the yellow rays; hence
the images formed by blue and red colors
are not sharp on the retina, so get
neglected by the brain.
Oblique Aberrations
An object present in the peripheral visual field
of eye does not focus like central visual field
objects; rather object image is seen as a thin
form of pencil ray due to improper focusing
of the oblique rays.
As shown in Fig. 4.15, a sturm’s conoid is
formed at peripheral portion of spherical lens. Fig. 4.16: Meniscus lenses decreasing oblique aberra-
Due to this conoid two line foci Fa and Fb will tions
Coma
This is again a type of peripheral aberration
because the light rays after getting refracted
from different areas of crystalline lens form
different planes of foci. The peripheral rays
from an object form an image having bright
central portion and a tail having reduced
brightness (similar to a comet). It means point
source of light forms the chief focus along with
an imaginary plane of multiple foci; this effect
is termed coma (Fig. 4.17). This optical aberra- Fig. 4.17: Coma aberration
tion (coma) can be reduced by preventing the
entry of peripheral rays refracting from the
ocular surfaces.
Decentring
Normally incident light rays initially fall on
cornea and then pass through the crystalline
lens to get focus at retina; because practically
cornea and lens are two main refracting
surfaces of the eye. Center of these two major
refracting surfaces do not have a common axis,
rather the crystalline lens of eye is slightly
decentred as compared to the cornea. Axis OA
of crystalline lens L is situated approximately Fig. 4.18: Decentration phenomenon of crystalline lens
0.25 mm above the center of curvature of
cornea C, which in turn is positioned in
common with that of visual axis as shown in
Fig. 4.18. This small decentring of lens does
not functionally affect the vision and hence
usually gets neglected.
Distortion
As discussed above the image size on retina
varies in accordance with change in image
angle at nodal point. This image angle is in Fig. 4.19: Distortion of images pincushion and
turn varies with change in distance between Barrel type
optical axis and object height. In simpler terms
magnification of object is dependent on relative patients or patients wearing high plus power
position of object and optical axis of eye. lenses, a significant pincushion image effect
Suppose peripheral portion of an object is is a matter of concern.
magnified more than the central portion of an Practical aspects of physiological optical
object; then pincushion type of distortion in defects of eye
image is seen. Whereas, if central portion is • In our today’s life these physiological
more magnified than peripheral portion of an optical defects occur normally but they
object, then barrel type of distortion in image do not produce any problem and are not
will occur (Fig. 4.19). For example, in aphakic noticed by us. However, when we see
them together and also when there are However, smaller circles of light will
large amount of refractive errors present; produce clearer image and in turn a good
then these unnoticed aberrations get vision. Thus, human eye tries to produce
clinical importance. these circles of least diffusion to get a
• A single-point light source does not focus clear and sharp image of an object.
as a point on retina; rather it forms a
circle of light which has certain amount Pathological Optical Defects (Refractive
of blurring as shown in Fig. 4.20A. The Errors) of Eye
formation of a blur circle of light happens Parallel rays from infinity when falls on a
due to the combined effects of these physiologically normal eye they get refracted
physiological optical defects in normal and converge to focus on the retina to form a
eyes. This blur circle of light is called circle of least confusion. When this happens
circle of diffusion (circle of least confu- in an eye with the accommodation at rest, it is
sion). When two-point light sources are termed emmetrope state of eye (Fig. 4.22).
kept at close distance they get focused This state of emmetropia is a theoretical
as two overlapping blur circles of light assumption and is difficult to attain in realism
as shown in Fig. 4.20B. because to attain emmetropic state various
• Similarly a line light source which in ocular elements must be perfect in their
reality is combination of multiple point dimensions. For example, to attain emmetropic
sources will form an image of overlapping state in an eye the axial length, corneal
circles and the final image will appear curvature and curvature of the crystalline lens
as a broad band shaped blur image must poses such an accurate dimensions that
instead of a linear image (Fig. 4.21). there is no difference of even fraction of mm
in size. Hence emmetropia is not a common
clinical presentation rather more commonly
small optical errors are seen.
So in other words, a condition where all the
parallel rays of light do not focus on the retina
becomes more common state of eye than
emmetropia. These conditions where all the
parallel rays from infinity do not focus on the
retina and do not form circle of least confusion,
while the accommodation is at rest are termed
ametropia. This ametropic state of eye is
Fig. 4.20: Circle of diffusion. A. Single-point source;
B: Two-point sources
Fig. 4.21: Line of diffusion Fig. 4.22: Emmetropic state of eye

commonly called refractive errors of the eye.

Usually the refractive errors of both the eyes
are of equal degree (isometropia), however,
when the refractive errors of both the eyes
are unequal in amount, it is called Anisometro-
pia.
Refractive errors of eye are broadly classified
as
• Hypermetropia (hyperopia or long
sightedness)
• Myopia (short sightedness)
• Astigmatism Fig. 4.24: Myopic state of eye
Hypermetropia: In emmetropic eye the
principal focus of the eye is formed on the
retina. However, when the parallel light rays
from infinity get focused behind the retina (i.e.
principle focus is formed behind the retina),
while the accommodation is at rest; this state
of eye is termed hypermetropic state of the
eye as shown in Fig. 4.23.
Myopia: When all the parallel light rays from
infinity get focused in front of the retina (or
principal focus of the eye is located in front of
the retina), when accommodation is at rest
then this form of the eye is termed myopic Fig. 4.25: Astigmatic state of eye
state of the eye as shown in Fig. 4.24.
different meridians so a few rays will get focus
Astigmatism: This is the refractive state of eye in front of the retina, a few on the retina and a
wherein the parallel light rays from infinity few behind the retina that is why no single
are not focused at a single focus while the focus is formed.
accommodation is at rest. This state of eye is
Several pathological conditions may lead to
termed astigmatic state of the eye (Fig. 4.25).
refractive errors like hypermetropia, myopia
In astigmatism the refraction of rays varies in
or astigmatism of eye. Pathology may be seen
in dimensions of ocular structures or position
of ocular elements.
Refractive Surface Anomalies

• Curvatural refractive errors may occur
because of too steep or too flat curvature of
either cornea or crystalline lens. These too
flat or too steep curvatures of the refracting
surfaces can lead to curvatural hypermetro-
pia or myopia, respectively.
• Similarly, irregular or different curvatures
of cornea, crystalline lens or retina in
Fig. 4.23: Hypermetropic state of eye different meridians will give rise to
astigmatism of various types, which can be

grouped depending upon the nature of
refracting curvatures in different meridians
as follows:
Myopic astigmatism: It is referred to a
condition where axes of curvatures of both
the meridians are unequal and either one
or both of them are too long. Simple myopic
astigmatism will result when in one of the
axis the light rays will focus on retina while
in other axis rays are focused in front of the
retina (Fig. 4.26A), whereas in compound
myopic astigmatism light rays in both the
axes will focus in front of retina (Fig. 4.26B).
Hypermetropic astigmatism: When axis of
curvatures of both the meridians are
unequal and either one or both the
curvatures are too short they produce
hypermetropic astigmatism. Simple
hypermetropic astigmatism is referred to a
Fig. 4.27: Hypermetropic astigmatism. A. Simple

hypermetropic astigmatism; B. Compound hyper-
metropic astigmatism
condition when rays in one meridian will

focus on retina and in other meridian rays
will focus beyond retina (Fig. 4.27A). In
compound hypermetropic astigmatism
rays in both the meridians will focus behind
the retina as shown in Fig. 4.27B.
Mixed type of astigmatism: If axis of
curvatures of both the meridians are
unequal and one curvature among them is
too long and other curvature is too short,
then they produce a mixed type of
astigmatism. Here light rays falling in one
meridian will be focused in front of the
retina and the rays falling in other meridian
will focus behind the retina (Fig. 4.28).
Refractive Index Anomalies

Fig. 4.26: Myopic astigmatism. A. Simple myopic • If the refractive indices (RI) of crystalline
astigmatism; B. Compound myopic astigmatism lens, aqueous humor and vitreous humor
will focus in front of the retina. This type of

refractive anomaly is termed as axial
myopia.
• If anterio-posterior diameter of the eye is
too short and the retina is situated very near
to refracting optical elements like cornea
and crystalline lens, then the incident light
rays will focus behind the retina. This type
of refractive anomaly is called as axial
hypermetropia.
• In several congenital anomalies crystalline
lens gets dislocate and move forwards near
to cornea, then this condition will cause
Fig. 4.28: Mixed astigmatism
myopia; Whereas, if crystalline lens is
becomes too low (as in diabetes), then it dislocated backward towards the retina,
produces index type hypermetropia. then it will cause hypermetropia.
• When the refractive indices of crystalline
Obliquity of Optical Elements of Eye
lens, aqueous humor and vitreous humor
becomes too high (as in nuclear sclerosis of • Lenticular obliquity: A condition where
lens), then also it will cause index type myopia. crystalline lens is placed either oblique or
• Change in the values of refractive index of subluxated from its original axis. It will
crystalline lens in different meridians can cause an astigmatic type of refractive error.
cause astigmatism. • Retinal obliquity: If posterior pole of the
eye is obliquely placed then it may cause
Note: These index errors are difficult to notice in refractive errors. For example, in
clinical practice and a small change in refractive staphyloma the posterior pole of eye bulges
index of either aqueous humor or vitreous humor backward and will cause high degree of
will not produce much change in the refractive myopia. If its summit is not in alignment
status of ocular system. with the fovea, then rays will fall obliquely
in this region of posterior pole and will
Dispositions of Optical Elements of Eye cause high astigmatic error.
The relative position of optical elements like
cornea, crystalline lens and the retina within Absence of Optical Element of Eye
the eyeball serves an important role in A condition where crystalline lens is absent is
maintenance of refractive status of the eye. termed aphakia. Common causes of aphakic
• If anterio-posterior diameter of eye is too are congenital disorders or post-surgical
long and the retina is situated far away from removal of crystalline lens. Aphakia causes a
refracting optical elements like cornea and refractive error in terms of high degree
crystalline lens; then the incident light rays hypermetropia.
76
Learning Objectives
• Describe the optics of hypermetropia, myopia and astigmatism.
• Discuss various causes and types of hypermetropia, myopia and astigmatism.
• Describe the clinical manifestations and diagnose cases of hypermetropia, myopia and astigma-
tism.
• Manage cases of hypermetropia, myopia and astigmatism.
Chapter Outline
• Hypermetropia Based on etiology
– Introduction Based on degree of error
– Classification of hypermetropia Based on clinical presentation
Based on etiology Congenital myopia
Based on clinical presentation Simple myopia
Based on degree of hypermetropia Pathological myopia
– Normal age variations in hypermetropia Acquired myopia
– Relationship in accommodation and hyper- Nocturnal myopia

metropia Space myopia
Latent hypermetropia Pseudomyopia
Manifest hypermetropia Drug induced myopia
Total hypermetropia – Management
– Clinical tests to find out accommodation based Optical correction
hypermetropia Surgical correction
– Clinical features • Astigmatism
Symptoms – Introduction
Signs – Classification of astigmatism
Sequel of hypermetropia – Regular astigmatism
– Management Classification
Optical correction Clinical features
Surgical correction Treatment
• Myopia – Irregular astigmatism

– Introduction Causes
– Classification of myopia Clinical features
Based on age of onset Treatment
76
Refractive Anomalies 77
HYPERMETROPIA Note: Normal axial length of eye is approximately

Introduction 24 mm.
Hypermetropia is a refractive state of the eye diameter of the eye) of the eyeball is
where the incident parallel rays of light from most common cause of hypermetropia.
infinity get focus behind the retina while the Although there is decrease in total length
accommodation is at rest (Fig. 5.1). Commonly, of the eyeball but the total refractive
it is also known as long sightedness or power of eye remains normal, hence the
hyperopia. In hypermetropia the principal principal focus is formed behind the
focal point (F) is behind the retina so the image retina. About 1 mm shortening of the axial
formed on the retina will be a blurred image. length causes hypermetropia of nearly
3 D.
Classification of Hypermetropia
b. Curvatural hypermetropia: This type of
Depending upon various factors hypermetropia hypermetropia develops when either the
can be classified in to different types as shown curvature of cornea or crystalline lens or
in Table 5.1. both becomes more flat (i.e. corneal plana
or lens plana) as compared to the normal
Based on Etiology
emmetropic eye. It may be congenital or
a. Axial hypermetropia: It is commonest acquired. As a result, the refractive power
etiological type of hypermetropia. Shortening of the eye gets reduced. Generally, a 1 mm
of the axial length (anterio-posterior flattening of the curvature (or 1 mm
increase in radius of curvature) produces
hypermetropia of about 6 D.
Note: Normal radius of curvature of the cornea is

7.8 mm anteriorly and 6.8 mm posteriorly. Normal
radius of curvature of lens is 10 mm anteriorly and
6 mm posteriorly.
c. Index hypermetropia: Reduction in

refractive index of aqueous humor,
crystalline lens material or vitreous humor
may cause index type hypermetropia. For
example, hypermetropia in old age
(physiological) or in diabetic patients
(pathological) is mainly due to decrease in
Fig. 5.1: Hypermetropia the refractive power of crystalline lens.
Table 5.1: Classification of hypermetropia

Based on etiology Based on clinical presentation Based on the degree of hypermetropia
a. Axial hypermetropia a. Simple hypermetropia a. Mild hypermetropia: Having low
b. Curvatural hypermetropia b. Pathological hypermetropia degree error (+0.25 to +2 D)
c. Index hypermetropia c. Functional hypermetropia b. Moderate hypermetropia: Having
d. Displacement hypermetropia medium degree error (+2.25 to
e. Aphakic hypermetropia +5 D)
c. Severe hypermetropia: Having
high degree error (> +5 D).
d. Displacement (positional) hypermetropia: index of the cortex of crystalline lens

Displacement or positional hypermetropia is usually much less than the refractive
occurs due to backward displacement of index of the lens nucleus. It is because
crystalline lens in vitreous cavity towards of this difference in refractive index, a
the retina. For example, in buphthalmos. meniscus type lens is formed inside
e. Aphakic hypermetropia: Congenital the lens and the total refractive power
disorders, surgical removal or traumatic of crystalline lens remains more
posterior dislocation of crystalline lens (Fig. 5.2). While with advancing age
cause a condition known as aphakia (i.e. the cortex of lens undergoes sclerosis
absence of crystalline lens). Aphakia leads and its refractive index increases.
to high degree of hypermetropia. Therefore, the lens turned into more
homogenous in terms of index and
Note: About 1 mm of change in the axial length meniscus lens now act as a single lens.
usually cause 3 D change in the refractive error and Hence, the total converging power of
1 mm change of the curvature usually cause change crystalline lens is decreased as a whole
of 6 D in refractive error. due to sclerosis of lens cortex. This
decrease in converging power of an
Based on Clinical Presentation ageing crystalline lens leads to an
a. Simple hypermetropia: This is the most index type hypermetropia.
common clinical type of hypermetropia. • Positional pathological hypermetropia:
Normal biological variations of ocular May occur due to posterior displacement
structures occurring at the time of develop- of crystalline lens which may occur due
ment, e.g. axial and curvatural hypermetro- to congenital, spontaneous or traumatic
pia may occur due to underdevelopment reasons.
of eye. Hence, the axial and curvatural types • Axial pathological hypermetropia:
of hypermetropia are included in simple Presence of any tumor or inflammatory
type of hypermetropia. mass on posterior pole of the eye or
b. Pathological hypermetropia: Abnormal retinal detachment may cause shortening
variations other than normal biologic of anterio-posterior diameter of eyeball.
variations of the refractive components of
the eye during development may result in
either congenital or acquired problems of
ocular structures. These pathological
variations will lead to the pathological
hypermetropia.
• Senile or acquired hypermetropia: Occur
in advancing age due to change in the
curvature or in index of an ageing
crystalline lens.
1. Curvatural pathological hypermetropia:
Outer lens fibers develop at later age,
hence they have less curvature as
compared to inner younger lens fibers.
This difference in curvatures leads to
hypermetropia in old age.
2. Index pathological hypermetropia: In
younger age group, the refractive Fig. 5.2: Layers of crystalline lens
• Aphakia: means crystalline lens is absent, Note: However, if there is marked nuclear sclerosis
may be due to congenital or acquired of lens as seen in early cataract there will be a
causes. This will give a high degree of refractive error of myopia type instead of
hypermetropia. hypermetropia, because there is an increase in the
• Consecutive pathological hypermetropia: optical density of nucleus also along with cortex
This type of hypermetropia occurs as a of lens.
consequence of either surgical aphakia
or overcorrected myopia or under- This emmetrope refractive status of the eye
corrected pseudophakia. remains stationary after puberty till the old
c. Functional hypermetropia: Functional age (approximately 50 years) and will again
hypermetropia occurs due to paralysis of shift towards hypermetrope in old age due to
accommodation. For example, as seen in sclerosis of lens fibers. An eye which was
patients of oculomotor nerve (III rd nerve) emmetropic at an age of 30 years may have
paralysis or internal ophthalmoplegia. 0.25 D hypermetropia at an age of 55 years
and 0.75 D at an age of 60 years. Similarly, at
Based on the Degree of Hypermetropia an age of 70 years person may have hyper-
a. Mild degree hypermetropia: When the metropia of 1 D and at 80 years may have even
degree of hypermetropia or amount of 2.5 D hypermetropia. This is called acquired
refractive error is in the range of +2.00 D or hypermetropia which is mainly due to
less. In mild hypermetropia the asthenopic continuous growth of the outer layers of cortex
symptoms are generally more pronounced of crystalline lens and also due to the change
in the refractive index of lens material. In old
than visual symptoms because accommo-
age the hypermetropia is mainly of index type
dation in younger age tries to compensate
and occasionally of curvatural type.
for visual difficulties.
b. Moderate degree hypermetropia: When Relationship in Accommodation and
the degree of hypermetropia or amount of Hypermetropia
refractive error is in the range of +2.25 to Hypermetropia either caused by decrease in
+5.00D. Patients having moderate hyperopia the length of eyeball or decrease in the
usually present with difficulty in vision curvatures of refracting surfaces or change in
(mainly in near vision). the refractive index of eye, with all reasons
c. Severe or high degree hypermetropia: the outcome remains same, i.e. the parallel
When the degree of hypermetropia or rays from infinity will focus behind the retina.
amount of refractive error is more than The diffusion circles formed at retina will
+5 D. Patients having severe hyperopia produce blur and indistinct images.
present with difficulty in vision (both Since the eyeball in hypermetropia is short
distance and near vision) along with in anterio-posterior diameter, the retina lies
significant asthenopic symptoms. nearer to the nodal point of eye as compared
to the emmetropic eye. Due to this reason the
Normal Age Variations in Hypermetropia image formed in hypermetropic eyes will be
Normally, the status of human eyes at birth is smaller in size as compared to that formed in
of hypermetropia (approximately 2–3 D), emmetropic eyes.
which may increase a little degree in first year In emmetropic eyes the rays coming from
of infant life. In majority of individuals this a point on retina (R) will leave the eye in
refractive status gradually decreases and by parallel way, whereas the rays from
the age of 5–7 years eye status starts to shift hypermetropic eyes will leave as divergent
towards emmetropia. rays. Hence, in the case of emmetropia the rays
Fig. 5.4: Correction of hypermetropia. A. Accommo-

Fig. 5.3: Emmetropic and hypermetropic eye dation of eye; B. Convex lens
will meet at infinity while in hypermetropia Accommodation is an act where eye tries
they meet behind the retina at a point (A) as to adjust its focal length through the
shown in Fig. 5.3. contraction of ciliary muscle, which is attached
So, theoretically any object present at to the lens capsule. This contraction of ciliary
infinity or practically at any distance of more muscle will increase the refractive power of
than 6 meters will form a sharp and clear lens by changing its curvature (making more
image on the retina in case of emmetropic eyes, convex) and hence certain amount of hyper-
whereas in hypermetropic eye a clear image metropia gets corrected due to accommoda-
will not form on the retina at any distance of tion and person remains asymptomatic. It is
object, keeping accommodation at rest. So, in known that normally physiological tone of
case of hypermetropia the refractive ciliary muscle can cause correction of an
(converging) power of optical system should appreciable amount of hypermetropia, hence
be increased to receive a clear image of object. to know the total degree of hypermetropic
Converging power of the optical system can refractive error, it becomes essential to relax
be increased either by efforts of eye the tone of ciliary muscle by using cycloplegic
(accommodation) or by artificially supporting drugs, e.g. atropine.
the eye (using convex lens). Thus, accommodation has a significant
As shown in Fig. 5.4A during accommo- influence on hypermetropia and on the basis of
dation of eye there is change in the curvature the action of accommodation hypermetropia can
of crystalline lens. This change will increase be represented into various components like:
the converging power of the eye and make • Latent hypermetropia
rays to focus on the retina. On the other hand, • Manifest hypermetropia
a convex lens can be used in spectacles so that – Facultative hypermetropia
convergence is increased and rays get focus – Absolute hypermetropia
on the retina (Fig. 5.4B). • Total hypermetropia
Latent Hypermetropia convex (or plus) lens in front of his eyes. Now,
This is the amount of hypermetropia which we will increase the power of this convex lens
normally gets corrected by the physiological gradually till the person just sees the distant
tone of ciliary muscle. Usually, it is in the range object clearly with weakest convex lens. At this
of about 1 D, but in the children the range of point of correction, the power of convex lens
latent hypermetropia is more than adults and and accommodation of that person are
it progressively decreases with advancement working together and he/she is able to see the
of age. Latent hypermetropia can be revealed object clearly. So, the convex lens used
clinically only by testing refraction after aboli- externally is compensating for only that
shing the tone of ciliary muscle (by use of atro- portion of hypermetropia which is not
pine). It means that if analysis of refraction is corrected by efforts of person’s accommoda-
done in the absence of cycloplegics, then latent tion, hence it is equal to absolute hyper-
hypermetropia can be overcome by accommo- metropia. This absolute hypermetropia is
dation of patient and remains nondetectable. represented by the weakest convex lens which
is giving the maximum visual acuity.
Manifest Hypermetropia
Manifest Hypermetropia
This is the remaining amount of refractive
error from the total refractive error which is Now keep on increasing the power of convex
not corrected by the normal tone of ciliary lens till that person sees the distant object
muscle. It has two components: clearly with the strongest convex lens or we
a. Facultative hypermetropia: This portion of can say note down that power of convex lens
manifest hypermetropia can be corrected by at which blurring of distant object starts. This
the efforts of accommodation exerted by power of stronger convex lens is also
patient. compensating for the accommodation of that
b. Absolute hypermetropia: This is the hypermetrope. Thus, the strongest convex lens
remaining portion of manifest hypermetropia is the measure of manifest hypermetropia by
which cannot be corrected by efforts of which the visual acuity of a person is recorded
accommodation exerted by the patient. as maximum.
Total Hypermetropia Facultative Hypermetropia

It is the total amount of refractive error of eye, The above described process of testing had
which is measured after using cycloplegics also measured that amount of hypermetropia
like atropine which abolishes the tone of which is corrected by accommodation efforts
ciliary muscles. The sum of latent hyper- of a person. The difference in the power of
metropia and manifest hypermetropia strongest and weakest convex lens indicates
indicates total magnitude of hypermetropia. the amount of facultative hypermetropia.
Total hypermetropia = Latent hypermetropia Total and Latent Hypermetropia

+ Manifest hypermetropia (Facultative
Now instill a drop of atropine in the eyes of
hypermetropia + Absolute hypermetropia)
hypermetrope and correct the refractive error
of patient by using stronger convex lens than
Clinical Tests to Find out Accommodation
before by which maximum visual acuity can
Based Hypermetropia
be obtained. The power of this strongest
Absolute Hypermetropia convex lens represents the total hypermetropia,
Assume a hypermetrope person who is unable which will be usually a little more than the
to see the distant objects clearly (vision is not power of that convex lens which represented
6/6) and to correct this we have to place a the manifest hypermetropia.
Note: An apparent increase in hypermetropia is Asymptomatic hypermetropia: In younger

also seen in advancing age after 40 years due to patients a small degree of hypermetropia (i.e.
failure of accommodation. With decrease in the latent hypermetropia) remains corrected by
tone of ciliary muscle, the greater part of latent the action of accommodation of patients and
hypermetropia will become manifest hyper- hence they usually remain asymptomatic.
metropia. This decreases the range of accommo- However, symptoms may appear later on as
dation and with decreased possibility of correction there is increase in the visual stress and
more of facultative hypermetropia will become accommodation fails to overcome the
absolute hypermetropia. In younger age
increased visual stress.
accommodative power can correct most of
hypermetropia and hypermetropia is absolute Symptomatic hypermetropia
only when hypermetropia is of very large degree. Symptoms due to eye strain (asthenopia):
But after an age of 65 years practically all Sometimes hypermetropia gets fully corrected
manifest hypermetropia will become absolute by the efforts of accommodation hence no
hypermetropia because with age there will be
visual symptoms are produced. But in long
gradual weakening of ciliary muscles (decrease
term due to continuous overuse of accommo-
inherent tone of muscle) followed by total failure
of accommodative efforts. As a result both dation (over action of ciliary muscles) to see
facultative and latent hypermetropia becomes distant objects clearly, the patient may develop
nonfunctional. symptoms of accommodative asthenopia (eye
strain). The common symptoms of asthenopia
Difference between the powers of two are watering of eyes, heaviness or dull pain
strongest convex lenses (representing total of eyes, general fatigue, frontal or fronto-
hypermetropia and manifest hypermetropia, temporal headache, mild photophobia or light
respectively) will give the amount of latent sensitivity.
hypermetropia. Usually, patients complaint of worsening
As we can see that whether a person has of asthenopic symptoms as the day progresses
high degree or low degree of total hyper- and more pronounced with prolonged use of
metropia, he will not be able to see the distant near vision. These symptoms get relieved by
objects clearly without using accommodation. giving rest to eyes.
However, if a person has low degree of Diminution of vision with asthenopia: When
hypermetropia within limits of facultative hypermetropia becomes of moderate to severe
hypermetropia, this person can see the distant degree, then it is not fully corrected by effort
objects clearly by using his/her accommoda- of accommodation. So, the patient will
tion power. In one way it is advantageous that complain of visual symptoms along with
accommodation is compensating the hyper- asthenopia. There is more diminution of vision
metropia but constant use of accommodation for near than distance because of continuous
for a long period will lead to stress and various use of accommodation.
convergence anomalies.
Diminution of vision: In high degree of
hypermetropia (usually > 4 D), accommoda-
Clinical Features of Hypermetropia
tive efforts fail to compensate for high degree
Symptoms of hypermetropia. Patient develops diminution
As discussed above active accommodation of vision for near as well as for distance.
tries to compensate the adverse effects of Diminished vision for distance and near is
hypermetropia on vision. This impact of more commonly seen in older individuals who
accommodation on vision may vary according have high degree of hyperopia with more
to age, degree of refractive error and demand visual demanding needs, but have decrease
placed on the visual system. amplitude of accommodation.
Intermittent sudden blurring of vision: than normal, but also eyeball as a whole is
Sometimes there may be spasm of accommo- small in all directions. Rare developmental
dation in hypermetropes which can shift conditions such as coloboma, microphthal-
vision towards myopia (a state of pseudo mos, etc. may be associated with small eyeball
myopia) leading to sudden intermittent and hence predispose hypermetropia.
blurring of vision. Accommodative spasm can • Size or diameter of the cornea is also small
be detected by performing cycloplegic as compared to the normal emmetropic
refraction which discloses underlying eyes. However, the crystalline lens varies
hypermetropia. very little in size even in hypermetropia so
Accommodative convergent squint or in comparison to size of cornea it is
“Crossed-eyes” sensation without diplopia: relatively larger. Thus, the anterior chamber
Excessive accommodation in some patients of eye appears shallower in hypermetropic
can give a feeling that their eyes are getting as compared to an emmetropic eye.
crossed (esotropia or inward deviation of the • Anterior chamber of eye seems relatively
eyes or convergent squint) without producing shallow in hypermetropia and angle of
any diplopia. The eyes cross due to extra- anterior chamber is also narrow as compared
ocular muscle imbalance which happens in an to the normal eye. Due to narrow anterior
attempt to focus near objects requiring the chamber chances of development of primary
excessive convergence. angle closure glaucoma are relatively high.
• On fundoscopy, fundus shows a characte-
Clinical Signs ristic appearance of optic disc and retinal
• Effect of hypermetropia on visual acuity reflex. Optic disc appears of dark grayish
depends on degree of hypermetropia, red color with blur and irregular margins,
accommodation power and age of the which can be sometimes confused with
patients. Low degree of hypermetropia is optic neuritis (papillitis). Since there is no
usually gets corrected by accommodation true swelling of optic disc in hypermetropia,
and patient has normal visual acuity. hence hypermetropic condition is also
Approximate estimation of visual acuity referred as pseudopapillitis. Haziness of the
can be obtained on the basis of degree of disc is sometimes accentuated by a grayish
absolute hypermetropia as shown in areola or by grey striations emerging from
Table 5.2. As the absolute hypermetropia it. Occasionally on examination, an inferior
increases, the visual acuity decreases crescent may be seen around optic disc. Disc
proportionally. vessels may be tortuous and more branching
• On ocular examination hypermetropic in appearance. Retina shows a peculiar
eyeball is usually small in size. It is not only bright reflex effect resembling a water silk
that anterio-posterior diameter is smaller or shot silk appearance. Retinal blood
vessels appear accentuated because of shiny
Table 5.2: Visual acuity relationship with absolute retinal reflexes. These all changes are
hypermetropia accentuated largely due to disturbances in
the reflexes of fundus. Macular reflex is seen
Absolute hyperopia (D) Visual acuity
more eccentric to optic disc and is darker
+ 0.5 6/9 than normal.
+ 1.0 612 to 6/18 • In hypermetropic eyes, macula is situated
+ 1.5 6/24 further away from the optic disc as
+ 2.0 6/36 compared to emmetropic eyes and cornea
+ 3.0 5/60 is more decentred than usual. Due to these
+ 4.5 3/60 two factors the visual axis cuts the cornea
Note: Drugs which cause dilatation of pupil • Gonioscopy may reveal the mild narrowing
(mydriatics) should be administered carefully in of angles in hypermetropic eyes as
hypermetrope because dilation of pupil sometimes compared to emmetropic eyes.
can precipitate an attack of angle closure glaucoma • Ultrasound biomicroscopy (UBM) or
in hypermetrope. anterior segment Optical Coherence
Tomography can detect a shallow anterior
markedly inside towards the optical axis of chamber in hypermetropic eye.
the eye. This gives a large positive angle
alpha and subsequently an apparent Treatment
divergent squint. 1. Asymptomatic patients: There is no need
of any treatment in asymptomatic patients
Sequel of Hypermetropia having
Uncorrected hypermetropia for prolonged • Good general health
duration can lead to various complications • Younger age group with good accommo-
• Recurrent problems related to eyelids like dation
blepharitis, stye or chalazion are common • Small degree of hypermetropia
with uncorrected hypermetropia. Probable • Not complaining about accommodative
reason for occurrence of these problems is asthenopia.
recurrent infections that occur as a result
• Having no muscle imbalance or squint.
of repetitive stroking of eyelids, which is
2. Symptomatic patients: In symptomatic
done by patient to get clear vision and to
patients, hypermetropia should be treated
get relief from fatigue and exhaustion.
by optical and/or surgical correction.
• In some children amblyopia may develop.
For example: Uncorrected binocular high Optical Correction
hypermetropia, unequal high uniocular
The optical correction is done by prescribing
hypermetropia or an accommodative
the convex or plus lenses, which enables the
squint can produce ametropic, anisometro-
rays to get focus on the retina by increasing
pic or strabismic amblyopia, respectively.
the total converging power of optical system
• In very young children (about 2–3 years) an
(Fig. 5.5). These lenses either can be fit in
excessive use of accommodation can
spectacles or can be given in form of contact
produce an accommodative convergent
lens.
strabismus.
• Development of primary narrow angle
glaucoma can be seen in hypermetropes. As
we know that overall eyeball size is small,
with a comparative shallow anterior
chamber and lens size is relatively large in
hypermetropes so these patients are at risk
for an acute attack of angle closure
glaucoma. A precaution has to be taken
while using mydriatics in these patients.
Management of Hypermetropia
Investigations
• Ultrasonography or A-scan biometry can
be done to know the axial length of eyeball. Fig. 5.5: Optical correction of hypermetropia by
It may be smaller or normal in length. convex lens
Basic rules to remember while prescribing in children at an interval of 6 months so

convex lens for hypermetropic patients are as that overcorrection is not prescribed and
follows: if required, amount of correction can be
• Cycloplegic refraction (using atropine for reduced accordingly.
children <6 years and cyclopentolate or • Children who are presenting with
homatropine for older children and symptoms of eye strain (headache, early
adults) should be done in all the cases to tiring, dislike to work, itching or rubbing
know the total amount of hypermetropic of eyes or any combinations of these) and
error. having refractive error of more than 3 D,
• Young children (<6–7 years) have some it is advised them to wear correcting
amount of physiological hypermetropia glasses constantly however, if refractive
and need glasses only when the hyper- error is less than 3 D, then glasses can be
metropia is of high degree or a small worn only at the time of near work.
degree of squint is present along with it. • Full cycloplegic correction has to be
• Suppose, if total manifest hypermetropia given in all cases of accommodative
is of 1 D or lesser degree and the patient convergent squint at all age group.
is asymptomatic, then there is no need • An undercorrection of about 1–2 D should
of correction. be given in those cases where exophoria is
• Younger children (<5 years) if require associated with hypermetropia.
any amount of hypermetropic correction, • Full cycloplegic correction along with
then the full amount of cycloplegic occlusion therapy should be done in
refraction should be prescribed in this cases where amblyopia is associated with
age group because they will accept this hypermetropia.
full correction. However, at school going • Young adult (aged 25 years) may be
age, the amount of refraction may be asymptomatic even with 3 D of hyper-
reduced to a degree of one-third of total metropia but will complaint of difficulty
refraction, keeping in mind that child should in reading at an age of 35 years. This is
not use accommodation of more than because accommodation declines with
2.5 D power for his/her distant vision. age and an additional power of accommo-
• School going children (6–16 years) if dation is required in performing near
having accommodative squint and/or work. In these kind of cases if spectacles
definitive symptoms of ocular fatigue or are not influencing distant vision, then
decreased visual acuity, then even a glasses should be worn only for near
small amount of hypermetropia needs work. As the age advances, accommoda-
correction. tion declines completely and whole
• Older children will not accept full refractive error becomes absolute hyper-
amount of cycloplegic refraction, hence metropia so the person will need glasses
initially they are always undercorrected even for distant vision, thus should wear
up to that amount of refraction which glasses constantly.
they accept comfortably. After this at • For older people glasses are prescribed
every 6 months interval the amount of according to their symptoms and amount
spherical correction should be increased of vision. Manifest hypermetropia
gradually till it reaches to the full amount should be corrected completely and
of cycloplegic refraction. glasses are advised to be worn regularly.
• Hypermetropia in children usually • Optical treatment can be given in the
decreases with the growth of child, hence form of spectacles or contact lenses.
it is mandatory to repeat the refraction Spectacles with convex lenses are most
acceptable, safe and simple method for The prevalence of myopia alters with age
hypermetropic correction. Contact lenses and other associated factors. The prevalence
are often prescribed in unilateral of myopia is more in premature infants than
hypermetropia (anisometropia) to avoid normal and it increases in school-age group
diplopia or amblyopia. and young adult and declines somewhat in
the population above the age 45 years, being
Surgical Correction about 20% in age 60–65 years and 14% in
Various refractive procedures have been 70 years of age. Some studies indicate more
recommended for the correction of hyper- chances of myopia in females than in males.
metropia though the outcomes are not as The chances are also more in those persons
encouraging and reliable as in the case of who work in occupations requiring lots of near
myopia. Various surgical modalities for the work. The prevalence is high (35–60%) in those
correction of hypermetropia are: children whose both parents have myopia
• Hyperopic LASIK than who have one parent with myopia
• Photorefractive keratectomy (25–40%).
• Conductive keratoplasty Optics of myopia
• Thermal laser keratoplasty • Myopic eyes have very powerful optical
• Refractive lens exchange system in relation to the axial length of the
• Phakic intraocular lenses eyeball. The focusing power of the cornea
These refractive procedures are described in and the lens is too great with respect to the
detail in Chapter 15. length of the eyeball so that the parallel rays
of the light focus in front of the retina and
MYOPIA after focusing these light rays start getting
Introduction diverge and eventually fall on the retina
forming a blur image due to circles of
Myopia is the refractive state of the eye where diffusion (Fig. 5.7).
parallel rays of light from infinity get focus in
• In myopic eye, nodal point is situated far
front of the retina while accommodation is at
away from the retina as compared to the
rest (Fig. 5.6). Commonly, it is also known as
emmetropic eye. As a result, the image
short sightedness. In myopic eye, the principal
formed in myopes will be relatively larger
focal point (F) is in front of the retina so the
as compared to emmetrope (Fig. 5.8A). The
image formed on the retina is blurred.
Fig. 5.6: Parallel rays from infinity focusing in front Fig. 5.7: Point light source beyond far point is
of retina in myopia focusing in front of retina in myopia
no or a little value because it may accentuate

his/her visual problems. Thus, generally in
an uncorrected myope accommodation
remains underdeveloped. As we know that
there is a direct relationship between the
effort of accommodation and the effort of
convergence. In myopes this relationship
between accommodation and convergence
is broken. Hence, this disparity may cause
convergence insufficiency, exophoria,
ultimately exotropia and development of
presbyopia at early age.
• In myopes the macula lies slightly nearer
to optic disc than normal eye, leading to
some change in visual axis. As a result the
angle alpha (angle between optical axis and
visual axis) is slightly negative which gives
sense of an apparent convergent strabismus.
Fig. 5.8: Relative positions of retinal images in
Classification of Myopia
myopes. A. Retinal image before correction; B.
Retinal image after correction with lens Depending upon the cause, age of onset,
degree or clinical presentations, myopia can
phenomenon of enlargement of image is be classified as summarized in Table 5.3.
also seen in myopic eyes which are
corrected by the spectacles (Fig. 5.8B). This Based on Age of Onset
enlargement of image provides some a. Congenital or infantile myopia: Congenital
amount of compensation for the decreased myopia may be present where eye is
visual acuity in myopes. myopic (instead of hypermetropic) since
• In myopes the far point of the eye is situated birth, however, this type of myopic
in front of the eye at a finite distance. Any refractive error does not progress and
near object at far point of myopic eye will myopic error remains static throughout
be focused without any effort of whole life. Congenital myopia is usually
accommodation and will be seen easily. associated with systemic disorders or
Thus, use of accommodation in myopes has premature birth.
Table 5.3: Classification of myopia

Based on age of onset Based on etiology Based on degree of error Based on clinical
presentation
a. Congenital a. Axial myopia a. Low degree error • Congenital myopia
b. Youth onset b. Curvatural myopia < –3 D • Simple myopia
c. Adult onset myopia c. Index myopia b. Medium degree: • Pathological myopia
• Early adult onset d. Positional myopia 3 D to < –6 D • Acquired myopia
• Late adult onset e. Excessive accommo- c. High degree myopia: • Nocturnal myopia
dative myopia > –6 D • Space myopia
• Pseudomyopia
• Drug induced myopia
b. Youth onset (childhood or early or school acuity of myope remains low, which may
myopia): This type of myopia develops deteriorate with advancing age (60–65 years).
during the period of childhood to early Individuals with late adult-onset myopia tend
teenage years (8–14 years). As discussed to present with low to moderate degree
previously, eye is usually hypermetropic at myopia. High degree myopia has been
birth and slowly with the advancement of reported to be less common than in childhood-
age the eye becomes emmetropic (mainly onset myopia, possibly reflecting its later
due to growth and enlargement of the onset.
eyeball). During this change of refractive
status from hypermetropia to emmetropia Based on Etiology
sometimes eye overshoots the emmetropic a. Axial myopia: It is most common cause of
point and becomes myopic in a few myopia. Axial myopia occurs due to
percentage of population. This is termed increase in the axial or anterio-posterior
simple myopia which generally remains length of the eyeball. Although the curva-
asymptomatic till early teenage. However, ture of lens and cornea are normal in axial
in subsequent years the myopic refractive myopia so total refractive power of the eye
error usually progress and may reach up may be the same. About 1 mm increase in
to 5–6 D. This progression of refractive error anterio-posterior length of eyeball will give
usually stops at age of about 18–20 years rise to myopia of nearly 3 D.
and this type of myopic refractive error gets b. Curvatural myopia: Curvatural myopia
stabilized nearly at the age of 20–21 years. occurs when eye has normal axial length
c. Adult onset myopia: This type of myopia but either the curvature of the cornea or
starts usually after 18–20 years of age and crystalline lens or both becomes steeper, as
can be grouped as a result the refractive power of eye is
• Early adult onset: Starts between 20–40 increased. Increase in the curvature of
years of age. cornea is seen in conditions like ectasias or
• Late adult onset: Develops after 40 years in conical cornea (i.e. keratoconus or kerato-
of age. globus). Although, spherical refractive
The prevalence of adult-onset myopia may errors due to increase in the corneal
vary significantly depending on the demogra- curvature are less common than astigmatic
phics of the sample population being studied. errors. Increase in curvature of crystalline
Development of myopia after 18–20 years is lens is seen in rare conditions like anterior
very uncommon, however, if it occurs, it or posterior lenticonus. About 1 mm
indicates either the refractive error was decrease in the radius of curvature of the
neglected for long duration in the previous eye is associated with myopia of nearly 6 D.
years or we have to look carefully for some c. Index myopia: Change in the refractive
other causes of myopia. index of the lens will cause index myopia.
Early adult onset myopia is less likely to be For example, an increase in the refractive
stationary, rather it progresses very fast and index of crystalline lens due to nuclear
sometimes amount of refractive error may sclerosis in advancing age causes myopia.
reach up to 25–30 D. It is usually associated In contrary, decrease in the refractive index
with degenerative changes in posterior of lens cortex (as seen in diabetes) may also
segment of the eye. However, there will be lead to index myopia.
some amount of progression in myopia till old d. Positional or displacement myopia: This
age. Due to this high degree of myopia, type of myopia occurs due to forward
degenerative changes in ocular structures will displacement of crystalline lens towards the
be seen and in later decades of life visual anterior chamber in eye. Probable mechanism
is weakening of zonules which lead to • In cases of bilateral myopia, the child will
displacement of crystalline lens, as occur in have great difficulty in seeing the distant
Ehlers-Danlos syndrome or Homocystinuria. objects so child tries to hold the object very
Displacement of lens is also seen after near to the eyes. This typical symptom
glaucoma surgery. usually gives a clue to the parents about
e. Excessive accommodative myopia: Excessive problem in the vision of child and myopia
accommodation (spasm of ciliary muscle) gets diagnosed.
will relax the suspensory ligaments of • In case of unilateral myopia as child is
crystalline lens capsule and will change the having some useful vision in one eye,
curvature of lens surface. Patients having myopia is detected only during routine
spasm of accommodation develop myopia school eye examinations or when child has
due to this mechanism and presents with an developed strabismus because of aniso-
artificial myopic state of eye (pseudomyopia). metropic amblyopia.
Based on Degree of Error • Timely diagnosis and early treatment of
congenital myopia is very important to
a. Low degree myopia: Have myopia of
restore good distant vision in child.
–3.00 D or less.
Cycloplegic refraction should be performed
b. Medium degree myopia: Having myopia and full correction of myopia with
between –3.00 and –6.00 D. associated astigmatism (if present) is done
c. High degree myopia: Usually myopia of by prescribing spectacles. It is advised to
–6.00 D or more. Persons with high myopia use glasses constantly to prevent any visual
usually may have retinal detachments and deficit; however, it is very difficult to
primary open angle glaucoma. achieve a visual acuity of 6/6 in majority
of cases of congenital myopia.
Based on Clinical Presentation
Congenital myopia Simple myopia
• Congenital myopia is present since birth It is also termed developmental myopia,
and usually manifest at an age of 2–3 years. physiological myopia or school myopia. This
• It is more common in those children who type of myopia is not associated with any
had history of premature births or having systemic disease, hence termed developmental
various systemic disorders like Marfan’s or physiological myopia. It is much more
syndrome, Bardet-Biedl syndrome, Homo- common than the other types of myopia and
cystinuria, Alport syndrome, etc. myopic error seldom goes beyond 6 D. Simple
• Congenital myopia may be associated with myopia usually develops during the
other ocular diseases also like congenital developmental growth of the child. Normally
cataract, microphthalmos, megalocornea, it starts at an age of 5–6 years and progresses
aniridia, posterior staphyloma and congeni- slowly up to an age of 16–18 years. Usually
tal separation of retina. simple myopia starts with a small degree of
refractive error 1–2 D and with the growth of
Clinical features child may reach up to a degree of 4–5 D
• Congenital myopia most commonly pre- (rarely> 6 D). In majority of cases, it becomes
sents as unilateral high degree of myopia stationary up to the age of 18–20 years.
(anisometropia) rarely, it may present as Degree of myopia may vary from low to
bilateral myopia. moderate. About 30% population have low
• Degree of myopia is usually very high degree of myopia (< 2 D), whereas, nearly
(8–10 D) and it generally remains stationary 6% population have moderate degree (2–5 D)
without any improvement. of myopia error.
Causes of simple myopia: Normal biological Table 5.4: Relationship of myopic error with
variations taking place during the develop- distance vision
ment of eyeball will cause simple myopia. Myopic error (D) Visual acuity
These variations may or may not be geneti-
cally determined and may have an autosomal –0.5 6/9
–1.0 6/18
dominant type or autosomal recessive type of
–2.0 6/36
inheritance. Simple myopia may occur due to –3.0 6/60
various factors: –4.0 5/60
• Due to physiological variation in the –5.0 3/60
anterio-posterior diameter of eyeball during –6.0 2/60
development: As a result axial length of
eyeball is increased leading to axial type of • Ocular asthenopic symptoms: These are not
simple myopia. It means eye is an otherwise characteristic of myopia, however, myopes
normal eye but is too long for its optical with small degree of refractive error may
power. compliant of these symptoms. These
• Due to underdevelopment of eyeball symptoms develop due to break in the
during childhood so that eye is too optically relationship of convergence and accommo-
powerful for its axial length. It causes dation. Asthenopic symptoms produced by
curvatural type of simple myopia. either of accommodation or convergence
• Near work hypothesis or “use abuse problem are as follows:
theory”: It states that risk of simple myopia a. Myopic patients use less accommo-
is increased by doing excessive near work, dation to see the near objects clearly,
watching television too long or not using hence they also use less convergence,
corrective glasses. However, this hypo- leading to convergence insufficiency
thesis is supported by only some studies. and eventually exophoria. There may be
• Some advocated that supplementation of suppression of vision in one eye due to
diet with vitamins and minerals have a role exophoria.
in reducing myopia or slowdown the b. Sometimes, to see near objects myopes
progress of myopia. But this thought has may converge and to keep pace with the
not been concluded by any confirmative convergence there is overuse of accommo-
study. dation (ciliary spasm), leading to spasm
of accommodation which may further
• Genetics also play an important role. It has
results in artificial increase in the degree
been found that prevalence of myopia is
of myopia.
increased in those children whom both
parents are myopic as compared to children • Parents of uncorrected myopic children
having one parent myopic, being 20% and sometimes report of developing psycho-
10%, respectively. social symptoms in the child. These children
may be reported as very academic with shy
Clinical features nature and not interested in outdoor
Symptoms activities. Most of these children think that
• Near or short-sightedness: The most common maximum distance vision is what they see,
symptom associated with uncorrected so they mainly concentrate on activities
myopia at any age group is diminished where distant vision is not much needed.
vision for distant objects and it is usually
constant. An approximate estimate of Note: Usual presentation in myopes is the poor
amount of distance vision and degree of convergence due to insufficient use of accommo-
refractive error is shown in Table 5.4. dation; rather than the excessive accommodation.
Signs:
• Poor visual acuity for distance.
• Slit lamp examination of anterior segment
will show
– Eyes look large and prominent because
of large diameter (increase axial length)
of eyeball.
– Cornea may be larger and steeper than
normal.
– Anterior chamber of eye appears deep as
compared to emmetrope.
– The size of crystalline lens is normal as
compared to larger eyeball, hence space
in anterior chamber increases and it
appears deep.
Fig. 5.9: Pathological myopia showing elongation
• Pupil is large in size as compared to of posterior half of eyeball
emmetropes and pupillary reaction is
slightly sluggish. There is increase in ciliary When the posterior pole of eyeball moves
tone which probably keeps the pupil size inward, then the equatorial part of eyeball
larger than normal. comes out of palpebral fissure line and the flat-
• Fundus examination is grossly normal ness of curvature of eyeball becomes prominent.
though mild tessellations of retina and/or a Anterior chamber of the eye is relatively
temporal crescent at optic disc may be seen. deep and the pupillary reaction is sluggish as
• Intraocular pressure is normal; sometimes compare to emmetropes. As we know that
because of thin cornea and/or eyeball coats myopic patients do not need to use accommo-
false raised IOP may be seen. dation to see the near objects clearly, the ciliary
muscle undergoes disuse atrophy (especially
Pathological myopia
circular fibers). This will keep the pupil a little
Pathological myopia is also known as
larger in size with poor light reaction.
progressive or degenerative or high myopia.
Pathological myopia is a rapidly progressing Posterior half of sclera also becomes thin
type of refractive error, usually responsible for due to mechanical stretching of the eyeball and
high degree of myopia along with degenerative sometimes in severe cases sclera may be as
changes in eyeball especially, in retina and thin as ¼th of normal scleral thickness.
choroid. This type of myopia generally starts Fundus examination reveals generalized
in adolescent age (10–12 years) and then atrophic changes in retina as well as in choroid.
rapidly progress till adulthood, may reach up Etiology: Several hypotheses have been
to 25–30 D. postulated to explain the cause of pathological
Clinicopathology: In pathological myopia myopia but till now, no single hypothesis
during the process of development the eye could explain the exact cause of these
gets elongate. This elongation of eye is mainly degenerative changes in choroid or retina.
confined to its posterior half of eyeball while However, the common factors explained in
the anterior half relatively remains normal in many theories show that the pathological
the size as shown in Fig. 5.9. myopia has a definite connection with either
However, due to this elongation the entire genetic factors or environmental factors.
eyeball becomes larger in pathological myopic Genetic factors: Several recent studies had
eyes as compare to the emmetropic eyes. concluded that genetic basis or inheritance play
an important role in causation and progression and pigment epithelium degenerations and
of pathological myopia. This can be confirmed amount of nocturnal myopia is in correlation
by the facts that pathological myopia is with severity of chorioretinal degeneration.
• Usually seen as familial disease (familial Signs:
myopia) • Visual acuity: Visual acuity for distance is
• Geographical and racial variation also seen, severely affected and error is of high degree
more common in population with East Asia than simple myopia. Refractive error increases
than South Asia. gradually every year with an average of
• Studies also indicate that there may be 3–4 D and goes very high up to 25–30 D till
genetic variation in the different chromo- the age of 20–25 years. Sometimes the errors
somes or genes that are linked with the axial may increase progressively for life time.
length of eyeball, various degenerative • Anterior segment:
changes of retina, choroid and vitreous and – The eyes appear large and prominent
refractive error. and may be confused with exophthalmos
Environmental factors: During growth period or proptosis.
there is expansion of eyeball to the proper – Cornea usually appears larger than normal.
length. Posterior pole of eyeball elongates – Anterior chamber appears deep as compa-
specifically during the period of active growth red to emmetrope eyes.
process and various factors like endocrine – Pupils are larger in size and poorly reactive
disorders, diet and presence of disease by to light.
affecting the growth may cause change in axial Fundus examination (Fig. 5.10) will show
length of eyeball, leading to myopia. tilted optic disc with marked degenerative
Clinical features changes in retina and choroid layers and
Symptoms: vitreous of eyeball. It is important to note
• Decreased vision: A profound diminution that degenerative changes observed on
of visual acuity is found in these patients. examination are not necessarily related to
In many cases, because of very high degree of myopia.
refractive error as well as due to associated – Tilted optic disc: The optic disc appears
retinal degenerative changes, the visual large, pale with prominent cups. Tilted
acuity is not correctable to normal by using disc appearance is due to oblique
myopic corrective methods. insertion of the optic nerves into the
• Symptoms due to vitreous degeneration: elongated globe. The tilt is usually
Patients with high myopia may complaints located inferionasal or inferiotemporal.
of seeing black spots or vitreous floaters or – Myopic or temporal crescent: On tempo-
Muscae volitantes in the field of vision, ral side of disc a white sharp defined area
specifically during bright light. The can be seen, which is formed as a result of
degenerated vitreous gel gets liquefy and stretching of eyeball. Backward bulging
the shadows of these liquefied portions of of posterior pole causes separation of
gelatinous vitreous body are appreciated by retina as well as choroid for some dis-
patients as floaters in front of the eye. These tance from the temporal margin of optic
floaters move with the movement of eyeball. disc so that sclera present behind these
• Diminished night vision (Night blindness): layers can be seen directly as a crescent.
Myopes with high degree of refractive error – Peri-papillary atrophy: Hypopigmented
often complain of blurred distance vision finding seen on fundus examination
in dim illumination or night. More common when RPE attenuation surrounds the
in pathological myopes having chorioretinal optic disc.
Fig. 5.10: Myopic fundus
– Choroidal crescent: Can be seen on of eyeball. They appear as yellowish

temporal side of myopic crescent. It is linear lesions and may be associated with
formed due to atrophy of retinal pigment subretinal haemorrhages.
epithelium so that choroidal vessels can – Forster Fuch’s flecks are uncommon
be seen in form of crescent. However, presentation and can occur sponta-
with progression of disease, the choroid neously. They appear as dark red spots
itself get atrophied and the choroidal in macular region probably appear due
vessels become less visible. This appea- to proliferation of retinal pigment
rance of fundus is also called as Tigroid epithelium along with intra-choroidal
Fundus or tesselated fundus. haemorrhages or thrombosis of choroi-
– Supertraction crescent: May be seen on dal vessels.
nasal side of optic disc due to extension – Posterior staphyloma may be seen in
of retina over disc margin, thus blurring high degree of myopia and occurs due
disc margins on its nasal side. to outpouching of scleral tissue while
– Choroidal atrophic patches are present other layers are pushed backwards at
in posterior pole. These white patches are posterior pole of eye. This condition is
surrounded by pigments and sometimes identified on indirect ophthalmoscopic
haemorrhages. Such white patches at examination as sudden kinking of retinal
macula are very common and are main blood vessels where they dip at optic disc
cause of diminished central vision in edge. Staphyloma in the long run can
high myopes. Once these white patches lead to atrophy and loss of vision.
with spots of pigments get accumulated – Cystoid degenerations at periphery of
they get spread widely all over the retina near ora serrata is a very common
posterior pole of fundus. presentation in high myopes.
– Lacquer cracks are formed due to micro- – Lattice degenerations may also be seen
scopic separation in Bruch’s membrane, at the periphery of fundus. They are also
which occurred as a result of overstretching called snail track lesions and may have
small holes which can lead to rhugmato- Acquired or induced myopia

genous retinal detachments. This type of myopia may occur as a result of
– Weiss’s fundus reflex is seen at posterior exposure to various pharmaceutical agents,
pole of eye due to posterior vitreous variation in blood sugar levels, changes in
detachment in high myopes. Vitreous refractive index and position of lens, or other
frequently gets liquefy due to degenera- anomalous conditions. Acquired myopia is
tion and will give symptoms of large often temporary and reversible. Acquired
floaters called Muscae volitantes. myopia may occur due to various reasons
• Visual field defects are seen due to peri- • Change in curvature of cornea or lens:
pheral degenerations. Visual field analysis Increase in the curvature of cornea (in kerato-
may show the ring scotomas or discrete conus or keratoglobus) or lens (lenticonus)
scotomas. may cause curvatural type of myopia.
• A- scan will show large axial length of eyeball • Change in refractive index of lens: May
and B- scan will show posterior staphyloma occur due to
along with posterior vitreous detachments. – opalescent nuclear sclerosis of the central
• Electroretinogram will show subnormal zone of the lens will increase the
wave pattern due to chorioretinal degenera- refractive index of lens and results in
tion. progressive myopia
– In diabetics, refractive index of lens
Sequelae of pathological myopia
cortex is decreased probably because of
• Changes in lens: Lens in high myopes change in carbohydrate metabolism of
shows changes due to nuclear sclerosis. lens, causing myopia.
These sclerotic changes will further increase
• Change in position of cornea or lens:
the amount of refractive error.
Forward displacement (subluxation) of lens
• Development of glaucoma: Primary open as seen in Homocystinuria and Ehlers-
angle glaucoma is commonly associated Danlos syndrome lead to positional myopia.
with myopia probably due to large eyeball.
• Consecutive myopia: May develop due to:
• Development of secondary or complicated – Refractive surgical overcorrection of
cataract: It may occur due to deprivation of hypermetropia
nutrients to the posterior surface of lens as
– The intraocular lens (IOL) implanted for
a result of overstretching of ocular struc-
pseudophakia overcorrects the refraction
tures.
of eye means power of implanted IOL is
• Damage to retina: Retinal tears can occur more than required.
due to lattice degenerations, which may
• Conditional myopia: Various atmospheric
lead to retinal detachment. Retinal haemorr-
situations may induce myopic state for
hages, if occur will give severe vision
emmetropic persons. Some causes are as
related complications.
follows.
• Choroidal and vitreous haemorrhage:
Choroidal haemorrhage and choroidal Nocturnal myopia (night or twilight myopia)
thrombosis is a common complication of Some persons may complaints of greater
high myopes and can give rise to a signifi- difficulty seeing at low level of illumination,
cant loss of visual acuity if it involves the i.e. become symptomatic from increasing
foveal or macula area. Vitreous haemorrhage myopia at night, although, their daytime
may occur along with retinal tear or choroi- vision is normal. This myopia occurs because
dal haemorrhage. In cases of choroidal of increased sensitivity of eye for shorter
haemorrhage the blood may leak into the wavelength of light at low illumination (i.e.
vitreous and can fill the vitreous cavity. modification in spectral sensitivity or Purkinje
Note: Purkinje shift means change in peak sensitivity Note: Instrument myopia may occur due to over-
to light under different illumination condition, from use of accommodation when looking into an
wavelengths close to 555 nanometers (green- instrument like microscope.
yellow) in photopic vision to 507 nanometers (blue-
green) in scotopic vision. • By causing swelling of ciliary process and
its rotation which cause forward displace-
shift). Younger people are more likely to be ment of lens.
affected by night myopia than the elderly. • Use of various drugs like sulfonamide
Such person especially myopic night drivers derived drugs, steroids, cholinergic drugs,
may require increased correction for clear topiramate, etc. can precipitate myopia.
vision at night.
Space myopia Management of Myopia
As we know that when eye receives any visual Myopia can be corrected by:
stimulation from an object situated at some • Optical correction
distance, it will adjust its focus accordingly. • Surgical correction
Although in the absence of any object in the • Supportive and prophylactic measures
visual field (e.g. when looking into empty
space), there is no stimulus for eye for distance Optical Correction
fixation. In this situation accommodative Corrective lens are prescribed in the form of
mechanism of eye adopts a position that eyeglasses and contact lenses.
corresponds to certain amount of accommo- The optical correction is done by prescribing
dation (0.5–1.0 D) so that eye becomes more the concave or minus lenses, which enables
powerful and its focal point is displaced the rays to get focus on the retina by altering
towards lens, leading to myopic state of eye. the total converging power of optical system
This type of myopia is experienced by (Fig. 5.11). Concave lenses will diverge the
fighter pilots or aviators when flying in parallel incident rays and helps in focusing of
cloud or fog. these rays on retina.
Pseudomyopia (false nearsightedness or These lenses either can be fitted in
artificial myopia) spectacles or can be given in contact lens form.
Excessive accommodation or spasm of Basic rules to remember when prescribing the
accommodation may cause intermittent and concave lenses for myopia are as follows
temporary shift of refraction towards myopia. • Unlike hypermetropia, in myopia minimal
Pseudomyopia is usually seen after doing near accepted power, which gives maximum
work for prolonged time, where ciliary muscle visual acuity should be prescribed.
goes into spasm leading to increase in the
power of lens. Occasionally, full correction of
hypermetropia in young children can produce
a state of artificial myopia.
Drug induced myopia
Chronic use of many drugs can produce
myopia of various degrees by allergic reaction.
Drugs can increase the refractive power of eye
by various mechanisms like:
• By causing sustained spasm of ciliary muscles
• By increasing refractive power of lens
through water imbibitions Fig. 5.11: Optical correction of myopia
• Young children below the age of 6–7 years Surgical Correction

should be given full correction and a Various refractive procedures are done for the
constant use of glasses both for distant and correction of myopia. The outcome of these
near work is advised. This constant use procedures are very encouraging and reliable
will help in preventing the deviation of in cases of myopia, hence various newer
eyes as well as will develop a normal procedure has also been introduced for high
accommodation convergence reflex. myopic patients.
Constant use of glasses for near work These refractive procedures have been described
is advised not to improve the near vision in Chapter 15.
but to improve the reading distance and
to maintain the normal eye relationship. Supportive and prophylactic treatment
• In adolescent myopic patients never Various other measures are also advised to
overcorrect or fully correct the refractive decrease the incidence or progression of myopia:
error. These patients usually wants more • Intake of balanced diet: Deficiency of certain
minus power than best corrected visual vitamins and minerals (calcium, magnesium,
acuity power, because this additional vitamin A, vitamin D, etc.) and proteins are
minus power will increase the contrast also associated with progression of myopia.
sensitivity of letters in the vision chart. Intake of these nutrients can slow the
To avoid overcorrection always ask the progression of myopia in children. Though
patient that whether the letters are more this hypothesis has no evidential proof, but
clearer or became small or large in size after still many believe this theory.
adding a little more minus power than • Visual hygiene: To decrease the develop-
before. ment of myopia, it is advised that intensive
• Young adults less than 30 years of age visual near task like reading, computer
usually accept full optical correction. The work, etc. should be done with certain
patients older than 30 years of age who visual hygiene measures like maintaining
were never given a myopic correction proper distance and posture during reading
before, having a refractive error of more and writing, keeping sufficient illumination
than 3–4 D, usually do not accept full and taking break frequently when doing
correction in first sitting. Hence these near work. Research also indicates that
patients are undercorrected initially and children who spent more time outdoors are
advised to step up the correction in further less prone to the development of myopia
sittings. than those who spent less time.
• In high myopes (more than 8–10 D) • Low vision aids can be prescribed for very
always do an under correction irrespec- high myopes to provide some useful vision
tive of the age, because full correction is as they are not getting corrected by
rarely tolerated by these high myopic spectacles or contact lenses. They also have
patients. Try to undercorrect as little as very poor visual acuity due to degenerative
possible, which will give maximum changes of retina and choroid and hence
visual acuity for distance and also is need low vision aids. Details of low vision
compatible for near vision. Generally an aids are described in Chapter 16.
undercorrection of power 1–2 D or more • As genetic has a role in pathological
is required in accordance with the age of myopia, it is recommended that genetic
patient and amount of myopia. This counseling should be done before marriage.
undercorrection will avoid the problems Persons having pathological myopia are
of minification of retinal images and that advised to avoid the marriage with another
of related to near vision. pathological myope.
ASTIGMATISM
Introduction
The word astigmatism is derived from Greek
where “a” means absent and “stigma” means
point. Astigmatism is a refractive state of the
eye wherein the parallel rays of the light from
infinity get focused differently in different
meridians while accommodation is at rest
(Fig. 5.12). In astigmatism, the power of
refraction varies in different meridians and
hence the light rays entering in the eye
undergo unequal refraction so that they are Fig. 5.12: Astigmatic state of eye
not focused at a single focal point rather they
are focused as focal lines (formation of sturm’s example, high prevalence is seen in East Asian
conoid). people, probably due to narrower palpebral
It is a common refractive error accounting apertures and greater tightness of the eyelids.
for about 13% of all refractive errors and
Classification of Astigmatism
occurs with equal frequency in males and
females. Prevalence is very high in first year Astigmatism can be classified in various ways
of life as the curvature of cornea is very steep. as shown in Table 5.5.
Nearly 50% of infants have astigmatism of Before we discuss the types of astigmatism,
about 1D in their first year of life. The degree it is important to know about meridians of
and percentage of astigmatism gradually eyes. Normally these meridians are defined
decrease with age as the cornea flattens. for both eyes in the degrees from 1 to 180 as
Almost half of the population has at least shown in Fig. 5.13. There is no “zero”
0.5 D of astigmatism, while an astigmatism of meridian, nor any angle larger than 180°.
>1 D is seen in nearly 10–15% of adults Generally, astigmatism is of two types:
whereas, only 2% adults have an astigmatic • Regular astigmatism
error of <3 D. Ethnic variations also exist. For • Irregular astigmatism
Table 5.5: Classification of astigmatism

Regular astigmatism Irregular astigmatism
On the basis of On the basis of On the basis of principal focus On the basis of
etiology positions of etiology
meridians
Corneal With the rule Simple Simple myopic Corneal irregular
astigmatism astigmatism astigmatism astigmatism astigmatism
Lenticular Against the rule Simple hypermetro- Lenticular irregular
astigmatism astigmatism pic astigmatism astigmatism
• Curvatural Oblique Compound Compound myopic Retinal irregular
astigmatism astigmatism astigmatism astigmatism astigmatism
• Positional Bi-oblique Compound hyperopic
astigmatism astigmatism astigmatism
• Index
astigmatism
Retinal astigmatism Mixed astigmatism
– Lens may be congenitally tilted or obli-

quely placed or there may be congenital
or traumatic subluxation of lens pro-
ducing a varying degree of astigmatism.
– Refractive index of either cortex or
nucleus of lens may change in diabetic
or cataract patients leading to astigma-
tism.
• Retinal astigmatism is a rare type of
astigmatism. It may occur due to an oblique
Fig. 5.13: Orientation of meridians placement of macula or due to different
curvatures of retina in different meridians.
Regular Astigmatism
Regular astigmatism on the basis of position
In this type of astigmatism only two principal of meridians can be classified into:
meridians (horizontal and vertical) are present Regular astigmatism can also be classified on
having different refractive power and there is the basis of position of its two principal
uniform change in refractive power from one meridians (horizontal and vertical). On the
meridian to another meridian. basis of axis, nature of curvature and angle
between these two principal meridians,
Classification regular astigmatism is classified as follows:
Regular astigmatism on the basis of etiology • With the rule astigmatism (direct astigma-
can be classified into: tism): When two principal meridians (hori-
• Corneal astigmatism: It is one of the most zontal and vertical) are present at right
common causes of regular astigmatism. angle to each other and the vertical
Change in the curvature of the cornea in meridian is more curved (steeper) than the
different meridians leads to corneal astigma- horizontal meridian. This type of
tism. Most of regular astigmatism is corneal astigmatism is termed “with the rule”
in origin. Change in curvature may be astigmatism (Fig. 5.14) because it is like
congenital or acquired like after ocular physiological type of astigmatism seen in
surgery (cataract surgery or excimer laser), normal eye.
trauma to cornea, keratoconus, abnormal
growth of tissue on the cornea (Pterygium),
etc. Change in curvature of cornea due to
acquired factors usually produces irregular
astigmatism.
• Lenticular astigmatism: It is less common
cause of astigmatism. Lenticular astigmatism
may occur due to error in the curvature,
position or refractive index of crystalline
lens:
– Due to congenital abnormality in the
curvature or shape (spherical or oval
shape) of lens. For example, lenticonus
anterior and lenticonus posterior can
produce a significant degree of astigma-
tism. Fig. 5.14: With the rule astigmatism
In normal eye a small degree of physiological As horizontal meridian is steeper than

astigmatic error (0.12 D) exists because the vertical meridian so the refractive power at
vertical meridian of cornea is more curved 180° will be more as compared to 90°. A
(steeper) than horizontal meridian due to convex cylinder at 180 ± 10° or concave
pressure of eyelids on anterior corneal surface. cylinder at 90 ±10° will correct this type of
In other words, horizontal meridian of cornea astigmatism because power of a cylindrical
is more flat as compared to vertical meridian. lens is acting perpendicular to its axis.
That is why this type of regular astigmatism • Oblique astigmatism: When two principal
is named “with the rule astigmatism”. The meridians are present at right angle to each
vertical meridian being steeper in nature other but they are not horizontal or vertical
also has more refractive power than in nature (i.e. tilted). It means two principal
horizontal meridian. A concave cylinder at meridians are not present at usual 90°/180°
horizontal axis, i.e. 180 ± 10° or convex configuration. For example, two principal
cylinder at vertical axis, i.e. 90 ± 10° will meridians present at 45° and 135° or at 30°
correct this type of astigmatism because and 120° (difference in both is still 90°) will
cylinders have their principal meridians cause oblique astigmatism (Fig. 5.16)
perpendicular to each other and power of Curvatures of these oblique meridians may
the cylindrical lens is perpendicular to its be equal or unequal. Oblique astigmatism
axis. may be further sub-classified as
• Against the rule astigmatism (indirect – Symmetrical oblique astigmatism: When
astigmatism): When two principal cylindrical correction required in both
meridians (horizontal and vertical) are the eyes is at symmetrical axis, e.g. at 20°
present at right angle to each other but in both the eyes.
horizontal meridian is more curved (steep) – Complimentary oblique astigmatism: When
than vertical meridian, then this type of cylindrical correction required in one eye
astigmatism is termed “against the rule” is at complimentary axis to other eye. For
astigmatism. (Fig. 5.15). Here the curvature example, 45° in one eye and 135° in the
of meridians are not like of normal eye other eye.
(where vertical meridian is more curved), • Bi-oblique astigmatism: When two
hence named “Against the rule” astigmatism. principal meridians are not at right angle
to each other and also are not horizontal or
Fig. 5.15: Against the rule astigmatism Fig. 5.16: Oblique astigmatism
vertical in nature, this type of astigmatism retina. For example, a plano cylinder
is called bi-oblique astigmatism. For + 1.5 DC × 90° (here horizontal meridian
example, two principal meridians at 20° and rays are focusing behind the retina)
140°. • Compound astigmatism: In compound
Regular astigmatism on the basis of position astigmatism both meridians have same type
of focal lines or type of refractive error in of refractive error with different refractive
two meridians: power and none of the meridians is focused
On the basis of position of the two principal on the retina. Hence, when the light rays
focal lines in relation to retina and type of from both the principal meridians are either
refractive error in meridian, regular astigma- focused in front or behind the retina, it is
tism is classified as follows: called compound astigmatism. It is of two
types (Fig. 5.18A and B):
• Simple astigmatism: When the light rays
from one principal meridian are focused on – Compound myopic astigmatism: When
the retina while rays from other principal rays from both the principal meridians
meridian focused either in front or behind focus in front of the retina. For example,
the retina. Hence, one meridian is emmetro- –2.5 DS × –1.5 DC × 90° (here horizontal
pic while other meridian has refractive error meridian is more steeper)
(myopic or hypermetropic). Depending – Compound hypermetropic astigmatism:
upon the refractive error present in When rays from both the principal
meridian, simple astigmatism can be further meridians focus behind the retina. For
subclassified as follows (Fig. 5.17A and B) example, +2.75 DS × + 1 DC × 180° (here
– Simple myopic astigmatism: When rays vertical meridian is more flat)
from one meridian focus on the retina • Mixed astigmatism: In mixed astigmatism
while rays from other principal meridian both principal meridians have different
focus in front of the retina. For example, types of refractive errors, i.e. the light rays
a plano cylinder –1.75 DC × 180° (here from one principal meridian focus in front
vertical meridian rays are focusing in of the retina while rays from other principal
front of the retina) meridian focus behind the retina. In other
– Simple hypermetropic astigmatism: When words, eye is myopic in one principal
rays from one principal meridian focus meridian and hypermetropic in other
on the retina while rays from other principal meridian (Fig. 5.19). These
principal meridian focus behind the patients are usually asymptomatic because
Fig. 5.17: Simple astigmatism. A. Simple myopic astigmatism; B. Simple hypermetropic astigmatism
Fig. 5.18: Compound astigmatism. A. Compound myopic astigmatism; B. Compound hypermetropic

astigmatism
fatigue or lethargy. These symptoms occur

due to an excessive effort of accommodation
to see the objects clearer. Asthenopic symp-
toms are relatively more common in
astigmatic error as compared to spherical
refractive error. These asthenopic symptoms
are more pronounced in case of
• Small degree astigmatism
• With the rule astigmatism
• Hypermetropic astigmatism
Diminution of vision: Person with astigma-
Fig. 5.19: Mixed astigmatism tism may compliant of blurring of vision
specially when doing work for distant fixation.
Note: Simple, compound and mixed astigmatism Blurring gets increased with increase in the
may be with the rule or against the rule. Remember degree of astigmatism. Transient blurring of
to get a mixed astigmatism cylindrical error is vision get relieved by closing or rubbing of
always more than spherical error with opposite
eyes. To see the object clearly these patients
sign.
try to focus in one meridian clearly which is
the circle of least diffusion falls usually on nearest to emmetrope. Usually these patients
the retina. For example, –2.5 DS × + 3.5 DC × prefer the vertical meridian for clear focus.
180°. Depending upon the type and degree of
astigmatism, objects may appear proportio-
Clinical Features nately elongated in astigmatic patients as
Symptoms: Severity of symptoms mainly follows
depends on the type and degree of astigmatic • Circular objects appears as an elongated
error. oval images (Fig. 5.20)
Asthenopia (eye strain): Astigmatic patients • Line appears as fused elongated blurred
may compliant of tiredness of eyes, mild brow oval images, in succession to each other as
ache or frontal headache or sometimes severe shown in Fig. 5.21. These oval images of a
cephalgia with reflex neurological turbulence line object are seen in both the parallel and
such as irritability, giddiness, light intolerance, perpendicular axis of principal meridian in
Decrease in reading distance: Some high

degree astigmatic patients keep the reading
material closer to their eyes in order to see a
larger image.
Abnormal head posture: In case of high
degree of oblique astigmatism to make the
visual axis straight, patient may tilt their head
to one particular side, in order to reduce the
distortion of blurred image. This habit of tilted
head posture may lead to scoliosis and
Fig. 5.20: Blur vision, circle appearing as oval torticollis in some children.
Signs
• Visual acuity is diminished in direct pro-
portionate with the amount of astigmatism.
Because of distortion of images the patient
will read the letters in Snellen’s chart as
different letter. For example, E as F or Y
as T.
• Retinoscopy or autorefractometry: Will tell
about different powers in two principal
meridians and their axis. They may be
Fig. 5.21: Blur vision, line appearing as elongated perpendicular to each other or may not.
oval images • Keratometry and corneal topography: Can
astigmatic errors, depending upon the type be done to rule out corneal astigmatism. In
of astigmatism. case of corneal astigmatism, two different
corneal curvature in two different meridians
• Point light source appears as blurred point
will be seen.
image with a tail (point of light begins to
tail off). • Jackson cross cylinder test is an important
method to check the power and axis of
Recurrent ocular infection: Patients having astigmatic error.
low degree of astigmatism usually develop a
• Astigmatic fan test or Maddox V test is an
habit of constant rubbing of eyes, probably
older method but is an effective method to
because of itching or burning sensations in
estimate the amount and type of astigmatic
eye. This constant rubbing may result in falling
error.
of eyelashes, hyperemia of lid margins and
frequent stye or chalazion formation. • Stenopic slit or pinhole: Gives information
about the refraction and principle axis in
Half closure of eyes: Like myopes, patients astigmatism. The slit aperture of stenopic
having high degree of astigmatism develop slit allows the entry of light rays only in the
the habit of squeezing or forcefully closing axis of the slit. Suppose the astigmatic axis
the eyes partially. By doing this they make a and slit axis are not in alignment, then the
stenopic slit of eyelids and avoid the rays in
one meridian. This helps them to see the Note: Total astigmatism comprises both of these
object clearer and distinct, but will also factors, i.e. corneal astigmatism (due to anterior
produce significant amount of brow pain; surface of cornea) and supplementary astigmatism
probably because of constant use of eyelid (astigmatism of lens and posterior surface of the
muscles. cornea).
visual acuity will decrease, hence we can

confirm the correct astigmatic axis by use
of stenopic slit.
• Anterior and posterior segments of eye are
usually normal in low astigmatic error.
However, some changes in shape of lens can
be seen in lenticular type high astigmatic
error cases.
• On fundus examination oval or tilted optic
disc may be seen in patients with high
degree of astigmatism. Fig. 5.22: Optical correction of astigmatism
Javal’s rule and its subsequent modifications,
Grosvenor rule, etc. are used to estimate the patient is symptomatic, i.e. there is eye
magnitude of total astigmatism from Kerato- strain symptoms and deterioration of
metry reading vision. It is essential to do a thorough
Javal’s rule formula: At = p (Ac) + K estimation of refraction in these patients
before prescribing the cylindrical lenses.
Here, At = total refractive astigmatism, Ac
If some amount of astigmatic error
= corneal astigmatism; p = about 1.25, K =
remained uncorrected, then patient will
0.50 D against the rule
try to correct it by own efforts and
Or At = 1.25 (Ac) – 0.50 × 90°
symptoms of eye strain may exaggerate.
Grosvenor rule: At = 1.00 (Ac) – 0.50 × 90°.
• High degree astigmatism (>3 D) needs
It has no fudge factor value of 1.25.
full correction irrespective of symptoms.
Astigmatic fan test and Jackson cross cylinder However, full correction in form of
test are explained in details in Chapter 11. cylindrical lenses in first instance may
Treatment of Regular Astigmatism cause distress and discomfort to patient
as object appears distorted and make the
Similar to other refractive errors regular
floor appear to tilt. It is advised that
astigmatism is treated by means of either
when prescribing for first time the error
optical correction or surgical procedures.
should be undercorrected so that the
Optical correction: The optical correction in patient gets habituated to the cylinder.
regular astigmatism is done by prescribing the Gradually, at regular interval the cylindri-
appropriate cylindrical lenses. These may be cal power can be increased until the full
minus or plus cylinders identified after an correction is tolerable in these patients.
accurate retinoscopy (Fig. 5.22). • A change in axis of cylindrical power,
Cylindrical lenses with appropriate axis can especially in adult patients accustomed
be prescribed in form of spectacles or contact to their older axis, is to be done with great
lenses. Hard contact lenses may be prescribed precautions. This change in cylindrical
for correction of low degree (2–3 D) astigma- axis is usually poorly tolerated by older
tism while toric contact lenses (truncated or patients and they may develop astheno-
ballistic to maintain their correct axis) are pic symptoms. Even if it is absolutely
prescribed for higher degree of astigmatism. necessary to change the older axis, then
Basic rules to remember in prescribing the the patient is advised to wear the newer
cylindrical lenses in cases of astigmatism are cylinders in a trial frame and walk
as follows around in examination room for a few
• Low degree of astigmatism (0.5–1 D) minutes. If no symptoms develop, then
needs optical correction only when the newer axis can be prescribed.
• In adults new astigmatic correction is portions of cortex and nucleus. Thus the
avoided, because they poorly tolerate the refractive status of lens varies in different
cylinders, even though there may be a layers, so a cataractous lens may produce
significant improvement in their visual an irregular astigmatism
acuity by these cylindrical lenses. If there • Retinal irregular astigmatism: Various
is significant improvement in both conditions like retinal scarring, tumors of
distance and near visual acuity, then only retina or choroid pushes the macular area
it is advisable to prescribe cylindrical and may cause the distortion of macular
lenses in adults for first time. Brief the area. Thus, the light rays get refracted at
patient that there will be some time different planes due to this distortion of
period requires to get adjusted to these macula. Hence, the astigmatism produced
cylindrical lenses. is of high degree and irregular in nature
• Contact lens is a better option than spec- with poor visual acuity.
tacles to treat bi-oblique astigmatism,
mixed astigmatism or high degree Clinical Features
astigmatism. Irregular astigmatism produces symptoms
• In mixed astigmatism or compound such as
astigmatism the spherical lenses are • Diminution of vision
prescribed as per the guidelines of
• Distorted images of objects
myopia or hypermetropia correction in
various age group patients. • Multiple images or polyopia
Surgical correction: Refractive surgical procedure Treatment

are very effective in correcting astigmatism. • Optical correction: Irregular astigmatism
These refractive procedures are described in detail cannot be corrected by spectacles. It is done
in Chapter 15. by prescribing contact lenses (hard or
semisoft), where contact lens will replace
Irregular Astigmatism the anterior surface of cornea and helps in
Irregular astigmatism is the refractive state of restoration of useful vision.
eye where refractive power of eye changes • Surgical correction is needed in cases where
irregularly in different ocular meridians. In corneal scaring is extensive or optical
irregular astigmatism the principal meridians correction has failed to improve the vision.
are not at right angles and each meridian in Penetrating keratoplasty is usually required
the cornea show separate type of refraction. in severely damaged cornea. Alternatively,
excision of scar and its replacement with
Causes of Irregular Astigmatism
graft can be done. Lenticular irregular
• Corneal irregular astigmatism: A condition astigmatism caused by cataract can be
where the refractive power of corneal corrected satisfactorily by performing
meridians is different in different meridians cataract surgeries and intraocular lens
due to irregular corneal surface. Irregular implantation.
corneal astigmatism may occur due to
keratoconus or widespread corneal scarring. Note: Optical correction of retinal irregular
• Lenticular irregular astigmatism: During astigmatism is not successful, however, surgical
maturation of cataract the crystalline lens correction of various retinal pathologies had been
develops variable refractive index in different tried with variable results.
6
Binocular Vision and

its Anomalies
Learning Objectives
• Understand the mechanism of binocular single vision (BSV).
• Enumerate the various terminologies related to binocular single vision.
• Explain the theories and grades of BSV.
• Understand and evaluate various tests required for assessment of elements of BSV.
• Classify and treat anisometropia.
• Discuss aniseikonia in terms of classification, clinical features and treatment.
Chapter Outline
• Binocular Vision – Tests for SMP
– Introduction – Tests for fusion
– Sensory mechanism of BSV – Tests for stereopsis
– Motor mechanism of BSV – Tests for retinal correspondence
– Central mechanism of BSV – Tests for suppression
– Terminologies in BSV • Anisometropia
Retinal correspondence
– Introduction
Retinal rivalry
– Classification
Suppression
Etiological types
Diplopia
Clinical types
Horopter
– Effects of anisometropia on binocular vision
Panum’s area
– Examination methods
– Theories of BSV
– Treatment of anisometropia
Correspondence and disparity theory
Neuro physiological theory

• Aniseikonia
– Grades of BSV – Introduction
Simultaneous macular perception
– Classification
Fusion Etiological types
Stereopsis Clinical types
– Evaluation of BSV – Clinical presentation

Synoptophore – Measurement of aniseikonia
Stereoscope – Treatment of aniseikonia
105
BINOCULAR VISION corresponding retinal points in temporal

Introduction retina.
• Hemi-decussation of optic nerve fibers at
Binocular vision can be defined as “the
optic chiasma along with integrity of
vision obtained by the synchronized use of
visual pathway: Afferent optic nerve fibers
both the eyes, so that the images formed in
arising from retina hemi-dessucate at optic
each eye separately are appreciated as a
chaisma, which enables these fibers from
single image in the visual cortex of the
corresponding retinal area of two eyes to
brain”.
associate with one another in visual cortex.
Binocular single vision (BSV) is simply not This implies that fibers from corresponding
an inborn characteristic feature, rather it is an retinal points, i.e. temporal retina of one eye
acquired phenomenon developed during the and nasal retina of other eye, travel in same
first few years of life as a gradual developmental optic tract and terminate in same lateral
process. geniculate body where they relay in optic
Various mechanisms involved in the radiation and then to visual cortex.
development of binocular vision and which • Proprioceptive impulses from extrinsic
enable the eyes to function in a coordinated ocular muscles: Extrinsic ocular muscles
manner are described below. give sensory information to the brain in a
proprioceptive nature and this information
A. Sensory Mechanism is essential in establishment of binocular
Factors which constitute sensory mechanisms vision.
in the development of BSV can be grouped
as B. Motor Mechanisms
• Visual acuity value of retinal receptors of Motor factors contributing in development of
each eye: Foveal and macular area of the binocular vision can be grouped as:
retina which mediate central vision has • Anatomical factors: Anatomical factors
high visual acuity value as compared to are the one, which determine the position
rest of the retina which has a low visual of eyes and are concerned with structure
acuity value. Integrity of fovea and macula of bony orbit and its content. These
in each eye is important because there structures are important to ensure that
must be adequate degree of central vision eyes lie in bony orbit in such a way that
for development of binocular vision. their visual axis are aligned correctly with
Difference in the size of two retinal images each other at rest and even during
should not be too great to prevent the movement of eyes.
fusion of images. Peripheral visual acuity • Physiological factors: Physiological factors
also contributes in development of which determines the position of eyes are
binocular vision. of three types:
• Normal correspondence of retinal receptors Postural reflex: These are independent of
of two eyes: Extreme temporal part of visual stimuli and concerned with
peripheral visual field is uniocular, but rest maintenance of two eyes in their correct
of the visual field is binocular. It means the relative positions within the orbit. Hence
visual fields of both the eyes overlap in visual axes of two eyes are aligned to each
majority of portion. Retinal correspondence other despite the change in head posture
is a functional rather than an anatomical relative to body or body to space. Two
phenomenon. Two fovea of each eye may groups of postural reflex are:
be regarded as corresponding retinal points Static reflex: These reflexes are initiated by
and there are numerous other pairs of movement of head relative to body and are
Binocular Vision and its Anomalies 107
controlled by labyrinth and proprioceptive Note: First two factors, the fixation and re-fixation
impulses from neck muscles. reflexes, are uniocular, whereas the other three
Stato-kinetic reflex: These reflexes are factors, conjugate, disjunctive and corrective
initiated by movement of head relative to fixation reflexes, are binocular in function.
space.
Psycho-optical reflexes: These reflexes are Kinetic reflex: These reflexes are dependent
dependent on visual stimuli. Maintenance on a controlled relationship between
of correct position of two eyes within the accommodative and convergence and are
orbit is done by the help of the psycho- related with the maintenance of correct
visual reflexes. In spite of movement of position of two eyes within the orbit.
head relative to body or space the alignment Process of accommodation is followed by
of visual axis of two eyes remain in position an appropriate amount of convergence and
because of visual stimuli which reach the vice-versa; so both of these reflexes are
visual cortex via afferent visual pathway. dependent on each other.
Various components of this reflex are: C. Central Mechanism
Fixation reflex: This reflex is nothing but the
Factors which contribute in development of
ability of each eye to fix a definite object
binocular vision by process of central
independently. Fixation reflex is dependent
mechanism are
on the presence of adequate field of vision
and adequately functioning fovea. • Fusion which is a sensory phenomenon and
Re-fixation reflex: It concerns with the ability referred as proper overlapping of two
of eye to retain fixation on a moving object images from each eye.
(passive re-fixation) or to change fixation • Cortical control of ocular movement which
from one object to another object (active re- is a motor phenomenon.
fixation). This develops shortly after Development of normal binocular vision is
fixation reflex in young age. dependent on these factors such as
Conjugate fixation reflex: This reflex is • Transparent ocular media so that visual
concerned with the application of fixation axes of both the eyes receive uninterrupted
reflex of both the eyes simultaneously to clear vision.
retain the fixation during the conjugate • Retinal and cortical elements of visual
movements. Usually present within system should be capable of working
5–6 weeks of life and is well established by together so that they can fuse the slightly
6 months of age. dissimilar images as single image, means
Disjunctive or vergence fixation reflex: This sensory fusion.
reflex is use of fixation reflex of both the • Two eyes should be accurately coordinated
eyes simultaneously to retain the fixation in all directions of gazes so that retinal and
during the disjunctive movements. Even cortical element of ocular system remain in
though these reflex appear later than a coordinated positions to handle the two
conjugate reflex in life, but is also well images, means motor fusion.
established by the age of 6 months.
Terminologies in Binocular Single Vision
Corrective fusion reflex: This reflex is an
expansion of both conjugate and disjunctive Following terminologies are frequently used
fixation reflexes. Process of fusion reflex in relation to BSV, hence it is important to
enables the eyes to retain fixation and understand them in detail.
function binocularly even during stressful • Retinal correspondence
conditions. It is present since one year of • Retinal rivalry
age but is well established by 5 years of age. • Suppression
• Diplopia elements. These dissimilar objects will

• Horopter stimulate corresponding retinal area together,
• Panum’s area so in place of fusion there is confusion. To
overcome this confusion visual cortex
Retinal Correspondence suppresses the image of one eye. Although by
When visual axes of two eyes corresponding to suppression retinal rivalry is seized but
their respective retinal components (fovea) share constant foveal suppression of one eye will
a common visual direction, then these two cause a total sensory dominance of fellow eye.
retinal points represent retinal correspondence. This dominance of one eye produces a
This retinal correspondence is of two types significant obstruction in the development of
• Normal retinal correspondence (NRC) binocular vision. In these cases restoration of
• Abnormal or anomalous retinal correspon- binocular vision requires return of retinal
dence (ARC) rivalry.
NRC: Retinal correspondence is termed
normal retinal correspondence when these Suppression
conditions are fulfilled When dissimilar objects stimulate two
• Fovea of two eyes must share a common corresponding retinal elements in the eye, then
visual direction. confusion will occur. Similarly, when similar
• The retinal component situated nasally to objects stimulate two non-corresponding
fovea of one eye should correspond with retinal elements, then diplopia will occur. As
retinal component of other eye situated discussed above to remove either the
temporal to its fovea. confusion or diplopia, the image of one eye is
ARC: When fovea of one eye share common suppressed by a central or peripheral
visual direction with an extra-foveal region of inhibitory mechanism. It means to overcome
other eye, then retinal correspondence is the confusion suppression is foveal (central)
referred as abnormal retinal correspondence. and to overcome diplopia, suppression is
Usually ARC is present in low degree extra-foveal (peripheral).
strabismus and condition where foveal and Suppression can be grouped as
extra-foveal points lies very near thus two eyes • Facultative suppression
try to regain binocular vision. Hence, in spite • Obligatory suppression
of manifest strabismus two eyes in ARC may When suppression happens only in binocular
have single binocular vision. During binocular situation with no residual monocular effects,
vision in an ARC situation foveal point of one it is called facultative suppression. Hence,
eye corresponds to extra-foveal point of other monocular visual acuity remains good and no
eye; however, when normal eye is closed, then scotomas in visual field are seen in uniocular
extra-foveal point of other eye has no visual examination.
advantage over fovea of the same eye. So other On contrary, when effects of suppression
eye will regain its original visual direction, is seen even in monocular situation and there
means in monocular conditions the fixation is is residual monocular diminished vision. It is
achieved by fovea. termed as obligatory suppression. This type of
Note: Cover test is based on this principle. suppression will lead to amblyopia.
Retinal Rivalry Diplopia

This is also called binocular rivalry because Diplopia or double vision occurs due to retinal
fusion is not possible when dissimilar shape disparity. It occurs when two non-correspon-
forms are presented to corresponding retinal ding retinal elements (fovea in one eye and
nonfoveal point in other eye) are stimulated several experimental studies concluded that
simultaneously by a point object. As a result many points in the space (not lying on VMH)
image of object is localized in two different also formed single images on retinal elements.
visual directions and the same point object So these researchers discovered another
appears as double when seen in two directions horopter called longitudinal horopter or
simultaneously. empirical horopter curve which has more
radius of curvature (means it is flatter) as
Horopter compared to VMH (Fig. 6.1).
In the year 1613, Aguilonius coined a term
Horopter, which means horizon of vision. Panumís Area
Horopter is the plane of position of all object As discussed above all the points which do
points which forms images on corresponding not fall on horopter can produce physio-
retinal points for a given fixation distance and logical diplopia because these points will be
create single vision. Different models proposed imaged by non corresponding retinal areas,
for horopter are
hence are seen as double. However, in normal
• Geometrical or theoretical horopter ocular conditions we do not appreciate
• Longitudinal or empirical horopter physiological diplopia, which can be explained
When corresponding points from retina has by Panum’s fusional area. Panum’s area is the
a regular horizontal distance, then the zone which surrounds the horopter and in
horopter formed would represent a circle this zone fusion of retinal images occur so
passing through nodal points of the two eyes that stimulus is perceived as single. This is a
and fixation point (O) as shown in Fig. 6.1. narrow band area situated around horopter
This is also called Vieth Muller Horopter and is narrowest at fixation point and
(VMH) and circle in this model becomes broadest in peripheral region as shown in
smaller when fixation points come closer. Fig. 6.2.
A few decades later after invention of
stereoscope by scientist Charles Wheatstone,
Fig. 6.1: Vieth Muller Horopter (VMH) and empirical

horopter Fig. 6.2: Panum’s fusional area
Increased width of Panum’s fusional area simultaneously, a binocular rivalry will

in peripheral visual portion is advantageous occur in brain.
as follows • When single-point object stimulate disparate
• Peripheral diplopia generated during retinal elements in two eyes, diplopia will
fixation of closely held flat targets is occur.
prevented by increased thickness of • When horizontal disparity of image in two
Panum’s area. eyes is limited to Panum’s area, usually a
• Increasing peripheral blurring is in single visual impression is transmitted to
correlation with increased size of brain with an associated depth perception
Panum’s area because visual acuity or stereopsis.
decreases with increase in size of • This depth and quality of perception is in
receptive visual field. correspondence with the amount of
• Increased peripheral extent of Panum’s disparity, means the stereopsis increases,
area potentiates cyclofusion, although whereas perception quality decreases with
cyclovergence of up to 2–3° is present an increase in disparity of image however
between two eyes. after certain limit of disparity the stereopsis
Panum’s area may increase or decrease in quality is very poor and diplopia will occur.
accordance with the size, speed and sharpness Neuro Physiological Theory
of the stimulus. For example, extent of Panum’s
On the basis of physiology of neurons and
area for a slower, dimmer stimulus may be
distribution of cells in nervous system this
ten times wider than that of a faster and
theory tried to explain the mechanism of
brighter stimulus.
binocular vision and stereopsis. Salient
features of this theory are
Theories of Binocular Vision
• Various experimental studies conducted by
Following theories of binocular vision has renowned scientists conclude that nearly
been proposed on the basis of development 80% of total neurons from each eye situated
of various reflexes in early life. in striate visual cortex get stimulated in the
process of visual response to a stimulus.
Correspondence and Disparity Theory • They assumed that an accurate and
This theory gained most popularity and is properly arranged neuronal connection of
considered as best explanation for binocular retina, geniculate body and cortex is present
vision mechanism till now. On the basis of throughout the visual pathway.
following features this theory proposed that • Among these connections nearly one-fourth
a sensory cooperation system consisting of representing binocular responses were
binocular correspondence and disparity of equally stimulated from each eye, whereas
object images in two eyes is responsible for remaining three-fourths represented a
binocular vision. graded response from either right or left eye.
• An assumption is made that the retina and • In these 75% cells which were showing
visual cortex of two eyes has one to one response to the stimulus from either eye,
relationship with each other. the receptive field of vision was found to
• When a single-point object stimulates both be almost equal in size and corresponding
the eyes simultaneously, a single visual the visual fields position in both eyes.
impression is transmitted to brain without • During normal BSV cortical cell gets
any depth perception. stimulated only when an optical stimulus
• When two-point objects differing slightly is simultaneously presented to its two
in character stimulate both the eyes receptive visual fields.
• However, in some cells these two receptive almost equally distinct images can be formed
visual fields may not necessarily be situated by each eye. Once two images are perceived
in the identical anatomical position in on the retina, then an efficient nervous system
retinae of two eyes. is required to receive and interpret these two
• So for a given location in retino-optic clear images as one image. In simpler words,
cortical map there are cells whose visual SMP is the first grade of BSV and is
fields have perfectly corresponding points considered as present when the signals
in two retinal elements and also cells whose transmitted from two eyes are received as one
visual fields have slightly different position by visual cortex of the brain at the same time.
in two retinal elements. Simultaneous perception does not mean that
• This retinal field disparity caused by there is overlapping of the images of the same
difference in direction or distance of field object or pictures rather, it simply means that
in retina of each eye is the basis of Panum’s two dissimilar objects are seen simulta-
fusion area. neously as one. For example, two eyes are
• Sensitive binocular neurons detect this given separate stimuli like picture of a lion
fusion area of Panum and produces and picture of a cage, if simultaneous macular
binocular vision and streopsis. perception is present then the lion will look
inside the cage as shown in Fig. 6.3 while in
Depending on the position of images on
absence of SMP only one image will be seen
retinal elements the BSV can be classified
at one time.
as
• Normal BSV: When the binocular single Fusion
vision is bifoveal in nature and there is no Fusion or second grade of BSV is an ability of
associated manifested squint, it is termed two eyes to compose a single picture from two
normal BSV. similar pictures, each one of them is lacking
• Abnormal or anomalous BSV is seen due
to alteration in the visual direction of Note: Macular dominance is a condition where
retinal elements. In this type of BSV the one eye sees the images of both the objects most
image of fixating object in one eye is of the time. Similarly, if both the images are seen
perceived from fovea while in other eye alternatively by each eye then equal macular
from extra-foveal area. This condition is function is present.
always associated with a small degree of
manifested squint.
Grades of Binocular Single Vision (BSV)

BSV occurs in following stages:
1. Simultaneous macular perception (SMP) or
grade 1
2. Fusion or grade 2
3. Stereopsis or grade 3
Simultaneous Macular Perception (SMP)

Simultaneous perception of objects is most
primitive type of binocular vision which is
developed in a newborn. This ocular function
requires a proper development of an efficient
macula of both the eyes; so that two clear and Fig. 6.3: Simultaneous macular perception
in a small detail. It simply means visual cortex resultant color will be a different color (mixture
combines two almost similar pictures as single of the two presented colors). This process is
complete picture. Facility of an ocular system termed color fusion. For example, when red
to perceive two almost similar images from and yellow colors are presented together,
each eye as one single complete image is termed then an orange color will be perceived by the
as sensory fusion and an ability of system to visual system.
keep the eyes in alignment to maintain a
sensory fusion is termed motor fusion. Stereopsis
Sensory fusion of images occurs only when This is the third grade of BSV and is an ability
two images are situated on their corresponding of two eyes to superimpose to a single picture
retinal area and are sufficiently similar in their from two pictures of the same object, each one
size, brightness and sharpness. Sensory fusion of them are taken from slightly different
is a foveal function and on contrary, motor angles. In horizontal plane eyes are slightly
fusion is an extra-foveal peripheral retinal separated from each other and sensory fusion
function of ocular system. of two slightly separated unequal images in
horizontal plane gives tridimensional
Note: Both sensory and motor fusion occurs in perception. This is also called tridimensional
visual cortex; so purely are central in origin. vision because it gives an effect of depth
For example, if eyes are presented with two perception. Objects lying on horopter are
pictures of rabbits, in which one rabbit is appreciated as flat because they causes zero
missing the tail and another is missing the horizontal disparity, however, objects situated
bunch of flowers. If fusion is present, then only in front or behind the horopter will give rise
one rabbit will be seen having tail and holding to non-zero disparities. When object is in front
a bunch of flowers (Fig. 6.4). Similarly, when of the horopter, it produces crossed disparity
two resembling letters like L and F are because image of object from right eye is
presented, then due to fusion only single letter displaced towards left side and vice versa
E will be seen. from left eye towards right side. Similarly,
Similar to objects, the ocular system can also when object is behind the horopter, it produces
fuse two dissimilar colors when presented to an uncrossed disparity because when viewed
both the eyes at the same time and the monocularly the image of object viewed from
right eye is displaced towards right and in left
eye towards left.
For example, pictures of two buckets kept
at slightly different angles are seen as a single
bucket having three dimensions as shown in
Fig. 6.5. Stereopsis is not synonymous with
depth perception because depth perception is
an assessment of distance of an object from
observer or between two objects, whereas stereop-
sis means appreciation of three dimensions of
an object during binocular vision.
Stereoscopic acuity: Ability of an ocular system
to detect the smallest binocular disparity
present in field of view is termed stereoscopic
acuity (stereoacuity) and represents the mini-
mum amount of disparity beyond which no
Fig. 6.4: Fusion stereopsis effect is seen. Usually a stereoscopic
head leads to an opposite directional

movement of near object image and
same directional movement of distant
object image, as that of head movement.
• Overlapping contours or interposition:
Overlap in images determines the
position of other object. For example,
nearer objects have tendency to conceal
distant objects and appear in front of
distant objects.
Advantages of BSV
• Optical defects of one eye, if present, are
masked by the image of opposite normal eye.
• Defective vision in a part of visual field of
one eye is masked by other eye, because the
Fig. 6.5: Stereopsis same defect may not present in identical
threshold of 20–30 arc seconds is considered parts of two retinae. For example, blind spot
as normal and a distance of about 150–200 meters caused due to optic nerve head is not seen
is considered as critical distance beyond which in binocular visual field because image of the
streopsis effect is not appreciable. Stereoscopic object which falls on blind spot of one eye is
acuity for stationary target is about 2–10 arc seen by retina of other eye and vice-versa.
second, whereas for kinetic target it is in the • Binocular field of vision is larger than either
range of 40–50 arc seconds. field of one eye.
As discussed above for perception of depth, • Mobility of two eyes permits the person to
stereopsis is must, however, several monocular converge the line of sight on a distant object
clues which develop as a result of experience and also helps to see a near object in its
also give spatial orientations such as: absolute distance.
• Geometric perspective: At horizon the two • Stereopsis is most important and only
parallel lines appear as if they are advantage of BSV over monocular vision.
converging and ultimately vanishing. • Second eye is a safety factor against partial
For example: Railway tracks. or complete loss of vision in one eye.
• Apparent size or linear perspective: Large
Evaluation of Binocular Vision
retinal images are interpreted as near
objects while small retinal images are Following instruments are used to evaluate
interpreted as distance objects. So, an binocular vision and also sometimes to correct
object moving away from us appears as visual deficiency, if present.
if progressively decreasing in size. • Synoptophore
• Relative velocity: When a target is moving • Stereoscope
at far distance its image velocity appears
lower as compared to image velocity of Synoptophore
this moving target at near distance. This instrument is used for the assessment of
• Aerial or Atmospheric perspective: Distance the degree of binocular function in terms of
objects appear indistinct due to scattering grades. Synoptophore is very useful for
of light in atmosphere. orthoptic exercises, which are required for
• Motion parallax: When focused at an development of the binocular function in cases
intermediate distance the motion of of defective binocular vision (Fig. 6.6).
Fig. 6.7: Pigeon-cantonment stereoscope
small degree of incomitance deviation, it can

Fig. 6.6: Synoptophore be used for exercises at home because it
facilitates swinging movement in all directions
Synoptophore can also be used in cases of
(fixed stereoscopes cannot be moved). Kinetic
strabismus for
stereoscopes are only stereoscope which can be
• Measurement of subjective and objective
adjusted for both cyclophoria and hyperphoria.
angles of strabismus.
• Diagnosis of latent or manifest strabismus. Variable prism stereoscopes: These instruments
(e.g. Cruise’s stereoscope) are used for both
Stereoscopes testing and training purposes and utilize
In cases of binocular function deficiency, prisms which can be varied in strength as per
stereoscopes are very useful instruments for requirement. Cruise’s stereoscope (Fig. 6.8) is
testing, training and home exercise purposes.
Various types of stereoscopes are
• Fixed stereoscopes
• Kinetic stereoscopes
• Variable prism stereoscopes
Fixed stereoscopes: These instruments (e.g.
Pigeon-cantonment stereoscope and Holme’s
and Whittington’s stereoscope) are used to pro-
mote fusion and to treat uniocular suppression.
Pigeon-cantonment instrument has two boards
fitted with scales for measurement of angle of
deviation. These boards are separated by a
septum placed hinged book-wise and also has
a mirror fixed in upper portion of septum.
Patient has to place his/her nose against
septum and tries to fuse the objects present on
slides as shown in Fig. 6.7. Mirror present on
septum can be covered if not required.
Kinetic stereoscopes: These instruments are
used for fusion and stereopsis. In cases of Fig. 6.8: Cruise’s stereoscope
convenient for home teaching and training of According to the size of target and angle
amplitude of fusion in case of small degree subtended at nodal point of eye, these
strabismus. Prisms available in this instrument simultaneous perception slides are grouped
can be varied in strength up to 20 dioptres and as
can also be added for convergence if required. • Foveal perception slides (1° angle)
One of these prisms can be detached for • Parafoveal perception slides (1–3° angle)
providing vertical adjustment in cases of
• Paramacular perception slides (4–5°
hyperphoria.
angle)
Various tests done for binocular vision are
• Peripheral perception slides (more than
performed to assess
5° angle)
• SMP
• Fusion Tests for Fusion
• Stereopsis Various tests done to evaluate the presence of
• Retinal correspondence fusion are
• Suppression • Synoptophore test
Tests done to evaluate binocular single • Worth four dot test
vision are summarized in Table 6.1.
• Bagolini’s striated glass test
Tests for SMP (Grade 1 BSV) Synoptophore test: Similar to SMP, fusion can
To test this primitive grade one binocularity, be tested by synoptophore using fusion slides.
various slides having dissimilar pictures called These slides have two similar pictures differ
SMP slides, are used in synoptophore. in few details. For example, picture of rabbit
Commonly used SMP slides have pictures of lion in one slide missing tail and in another slide
and cage, parrot and cage, butterfly and net, etc. missing flowers in hand. When such slides are
These slides are projected in synoptophore presented in synoptophore, then in presence
and examine the superimposition of object of normal fusion the person will see a single
images. Suppose superimposition is present rabbit having tail and flower in hand.
for normal SMP slides, then by using SMP Similarly, slides with letter L and with letter
slides having targets of different sizes are F will be fused as letter E when presented in
presented to assess more accurate degree of synoptophore. Amplitude of fusion can be
simultaneous perception. measured by help of synoptophore.
Table 6.1: Various tests done for binocular vision

Tests for SMP Tests for fusion Tests for stereopsis Tests for retinal Tests for suppression
correspondence
Synoptophore • Synoptophore • Lang two pencil • Worth’s four • Bagolini’s test
using SMP slides test test dot test • Red filter test
• Worth four dot • Titmus stereo • Bagolini’s • Worth’s four dot test
test tests striated glasses • Friend test
• Bagolini’s • Random dot test test • Synoptophore
striated glass test • Lang test • Synoptophore method
• Frisby test using SMP slides • Four dioptre base
• Red filter test out prism test
• After image test
• Binocular
visuoscopy test
Table 6.2: Normal fusional amplitudes for different Titmus stereo test and random dot tests
types of vergence require special types of glasses like Polaroid
Vergence Fusional amplitude or red green, whereas Lang test and Frisby test
(in prisms) can be performed with or without special
glasses. These tests can also be grouped under
Horizontal Convergence 35–40
vectographs tests and stereogram tests,
Divergence 5–8
respectively.
Vertical Supravergence 2–3
Infravergence 2–3 Vectographs tests: Principle of vectographs:
Cyclovergence 4–5 The vectographs consist of plates made up of
polarized materials on which target pictures are
Range of normal fusional amplitude in imprinted. These targets are polarized in such
prisms is shown in Table 6.2. a manner that they are at 90° to each other and
For restoration of BSV fusion is must and hence when viewed through special polaroid
assessment of fusion is required to manage glasses they appear as two separate targets.
and evaluate the prognosis of squint. Titmus stereo test: Titmus stereo test is done
by using a booklet made up of two plates
Tests For Stereopsis consisting a three-dimensional polaroid
Based on presentation of targets stereopsis vectographs. One plate on right side of this
tests are booklet is imprinted with a picture of house
• Three-dimensional targets are used in fly, whereas left sided plate is imprinted with
Lang’s two pencil test. Gross stereopsis pictures of animals and circles. Hence, Titmus
(either present or absent) of threshold stereo test consists of three components of
3000–4000 arc seconds can be tested by this examination. This booklet is viewed wearing
method. Examiner and patient both hold polaroid glasses (Fig. 6.9).
the pointed tip pencils in their hand. • Titmus fly test is the first component of test
Examiner holds the pencil vertically in front which can evaluate gross stereopsis of
of the patient and instructs him/her to 3000 arc seconds. Picture of a large housefly
touch the tip of his pencil by the tip of his/ is imprinted on the plate, hence very useful
her pencil; first with both eyes open and in assessing stereopsis in young children.
then with one eye closed. Booklet is kept at reading distance and
Interpretation: When patient touches the polaroid spectacles are worn by patient. To
pencil tip with both eyes open, then gross test instruct the patient to hold the wings
stereopsis is present. However, with one eye of housefly on the plate.
closed patient will not be able to touch the
pencil tip of examiner. In the absence of stereop-
sis even with both eyes open patient will not
be able to touch the pencil tip of examiner.
• Two-dimensional targets are constructed in
such a manner that they stimulate disparate
retinal area and produce the effect of three
dimensions. Following tests utilize this
principle
– Titmus stereo tests
– Random dot tests
– Lang test
– Frisby test Fig. 6.9: Titmus stereo test
Interpretation: If stereopsis is present, the square number from 6 to 9) is considered

patient will reach above the plate and try as excellent.
to hold wings, however, in absence of Advantages
stereopsis the picture appears as flat • Titmus stereo test is simpler and convenient.
housefly. This test can assess only gross
• Useful to assess stereopsis even in young
near stereopsis, distance stereopsis cannot
children
be tested by this Titmus fly test.
• Results can be easily interpreted in terms
• Titmus animal test is the second component
of stereoacuity threshold
of test and consists of three rows of animal
pictures, representing threshold of 100, 200 Disadvantages
and 400 arc seconds, respectively. Each row Require polaroid glasses, sometimes very
has pictures of five animals, among these young child may resist to wear glasses.
five animals one animal is imaged Stereogram tests: Principle of stereogram:
disparately and one animal is outlined These tests utilize a stereogram target. These
darker serving as misleading clue. Patient stereogram tests give no monocular clues to
is asked to select that animal which stands the patient hence, the patient is unable to
out compared to other animals from each presume the type and location of stereogram
row. picture in the test plate. So, these tests are
Interpretation: If stereopsis is present ,then considered as real assessment of stereoacuity
patient will select the animal imaged as compared to Titmus stereo tests. This
disparately and if stereopsis is absent, then principle is used in these following tests.
patient will select the darker outlined
animal. Random dot tests: These tests utilize the random
dot stereogram for testing of stereopsis.
• Titmus circle test is the third component of
Following tests are included in random dot test
test and contain set of nine squares,
arranged three in each row. Each square has • Random dot E test
four circles arranged in the form of a • TNO random dot test
rhomboid as shown in Fig. 6.9. At random, • Lang test
one circle out of four circles in each square Random dot E test: This test is performed by
is imaged disparately, producing a using three test cards having random dots
threshold in the range of 40 to 800 arc patterns. The first card is a model E, second
seconds. card is a stereo E and third card is a blank card.
If the patient has successfully cleared Model E card has letter E with random dot
initial two components of Titmus stereo background and is shown to patient as
test, then ask him/her to push down the reference card for him/her to understand
circle which is standing outwards as what they should look in the coming cards.
compared to other circles in each square. Second card is a stereo E card contains a letter
Remember to start testing from first square E with random dot background, where letter
because threshold gradually decreases from E is visible only with Polaroid spectacles.
first square to last. Third card is a blank card having similar
Interpretation: Amount of stereopsis threshold random dot background as that of stereo E
is represented by the number of circle card (Fig. 6.10).
pushed down correctly by the patient. To test stereopsis, ask the patient to wear
Lowest limit of fine stereoacuity is assumed polaroid spectacles, then show him/her model
as 100 arc seconds and is represented by E card and explain the procedure. Now, from
circle of square number 5. Any stereoacuity 20 inches distance show the stereo E card and
below this limit (represented by circle of blank card at random to the patient and ask
Fig. 6.10: Random dot E test (see text) Fig. 6.11: TNO random dot test (see text)
the patient whether he/she can see the letter Interpretation: If patient see all the stereogram
E or not. figures in first set of three plates then gross
Interpretation: If patient is able to tell correctly stereopsis is present. Quantification of
in which card letter E is present, then stereopsis stereoacuity is done by identification of correct
is present. When stereopsis is present, to stereogram pictures in second set of plates.
quantify the stereoacuity increase the testing Lang test: This test comprises Lang I
distance of card from patient. (Fig. 6.12A) and Lang II (Fig. 6.12B) tests. Both
TNO random dot test: This test is based on these tests are done by the utilization of random
the similar principle as that of random dot E dot stereogram test cards having different sets
test and it provides stereoacuity threshold in
the range of 480 to 15 arc second. In this test
stereoacuity can be quantified without altering
the testing distance.
This test utilizes a booklet having seven stereo-
gram plates, among them first set of three
plates are for screening purposes and second
set of remaining four plates are used to
quantify the stereopsis. First set of plates can
be tested with or without wearing the red
green spectacle and used to assess only the
gross stereopsis. For second set of stereogram
plates red green glasses are required to
visualize the stereogram figure. Each test plates
has stereogram of various shapes like square,
circle, triangles or crosses, made by the help of
random dots in complementary colors (Fig. 6.11).
Patients are first shown the screening
sterogram plates and if patient qualifies then
the second set of stereogram plates are shown.
Patient is asked to wear red green glasses and
from a distance of 40 cm second set of Fig. 6.12: Lang test (see text). A. Lang I test card;
stereogram plates are shown. B. Lang II test card
of stereoscopic images. Lang I test card has wearing of spectacles. Initially these plates are
stereoscopic images of cat (1200 arc seconds), shown from a 40 cm distance starting from
car (600 arc sec) and star (550 arc second); 6 mm thickness and if stereopsis present then
whereas Lang II test cards has stereoscopic it can be quantified by increasing the test
images of elephant (600 arc seconds), car (400 distance to 80 cm.
arc sec) and moon (200 arc sec). These images
Tests For Retinal Correspondence
are embedded in random dots pattern on test
card and are seen disparately by each eye Retinal correspondence can be tested by the
through cylindrical lenses imprinted on following methods
laminated surface of test card; so no special • Evaluate the relationship between retinal
glasses are needed to perform this test. elements of fixating eye and deviated eye
Patient is asked to hold the test card at 40 cm which are stimulated simultaneously.
distance and identify the stereoscopic image Based on this principle following tests are
and its relative position in card. done
Interpretation: If patient correctly identifies – Worth’s four dot test
the image and its location on test card means – Bagolini’s striated glasses test
stereopsis is present. Stereoacuity threshold – Synoptophore method using SMP slides
can be measured by the different size images – Red filter test
identified by the patient. • Evaluate the direction of visual axes in two
Frisby test: In this test three plastic plates of corresponding fovea. Based on this principle
various thickness (6 mm, 3 mm and 1.5 mm) following tests are done
are used as stereogram, and each plate consists – After image test
of four squares in it. Arrow heads of various – Binocular visuoscopy test (foveo-foveal
size and orientations are imprinted on both test of Cuppers)
the sides of these plates in different positions. Bagolini’s striated glasses test: This test utilizes
One of the square in each plate has a hidden Bagolini’s striated glasses and the examiner
circle which can be seen disparately (Fig. 6.13). observes the ocular movements during test
The disparity is produced by the procedure. During this test, eyes are not
displacement of random shape arrow heads dissociated hence it represents normal visual
due to thickness of plastic plates. There is no atmosphere. Bagolini’s glasses are glass plates
need of special glasses for this test and hence which are striated very finely in different
is very useful in young children who resist orientation and are commonly referred as
Fig. 6.13: Frisby test (see text)

Fig. 6.14: Bagolini’s test (see text)
Bagolini’s lenses (without refractive power). Fig. 6.15: Interpretation of Bagolini’s test. A. NRC
These glasses are mounted in a frame so that or harmonious ARC; B. Unharmonious ARC or NRC
with suppression; C. Suppression; D. NRC without
can be used in a trial frame for testing
suppression
purposes. Light spot will appear as fine line
perpendicular to the orientations of striations having unharmonious ARC or suppression
(similar to Maddox rods) and hence forms the with NRC (Fig. 6.15B).
basis for testing the retinal correspondence. • Single line will be seen by patient in case of
• Place two Bagolini’s lenses in trial frame complete suppression. This single line
one in front of each eye, oriented at angles will be seen towards non-suppressed eye
of 45° and 135° as shown in Fig. 6.14. (Fig. 6.15C).
• Patient is asked to fixate at a small bright • Two lines having two light sources, not
point light source shown by examiner from crossing each other will be seen by patient
distance of 20 feet for distance and from having diplopia without suppression in
40 cm for near examination. NRC situation (Fig. 6.15D).
• Ask the patient about the orientation of
lines seen through glasses. Advantages
• Now cover one eye with occluder and again • Simple and easy test
ask the patient about orientation of lines. • No requirement of expensive equipment
• Results are interpret as follows • Eyes are not dissociated, hence resembles
a. A perfect cross of lines passing through with normal conditions during testing.
light at right angle to each other and • Testing can be done for both near and
no deviation on cover test will be seen distance vision.
by a patient in case of NRC as shown
Disadvantages
in Fig. 6.15A.
• Test results are only qualitative. Quantitative
b. Patient with manifest squint will show
analysis (measurement of angle of deviation)
any one of these results.
is not done.
• A perfect cross with crossing lines passing
through central light will also be seen by • Small degree of deviation is not assessed
patient in case of harmonious ARC, because it gets unnoticed.
however, on cover test a deviation will be Synoptophore method: SMP slides are used
seen (Fig. 6.15A). in synoptophore to evaluate the degree of
• Cross of lines where one line is not passing deviation in visual axis by measuring the
through central light will be seen by patient angle of anomaly. Subjective and objective
angles of deviation are calculated by synopto- • Place a red filter in trial frame in front of
phore method and difference between deviating eye and ask the patient about the
these two angles represents the angle of light perceptions. Results are interpreted as
anomaly. follows
• Patient is instructed to look inside the – If only one pink color (mixture of white
synoptophore tubes by placing chin over and red color) light is seen by patient at
chin rest and fixing the forehead against the position of white light, then it indicates
head rest. presence of harmonious ARC. Because in
• Both the arms of synoptophore are adjusted presence of manifest squint single light
at zero mark. with mixed color indicates an ARC.
• Examiner places the SMP slides in their – Two lights (one white and other red) will
respective slots and flashes the light of be seen by patient in case of NRC.
instrument alternately. Simultaneously Suppose if red filter is placed in front of
examiner rotates both the arms of the right eye and the patient see red light
synoptophore till there is no fixation on the right side of white light, then it
movement done by eye of patient. This indicates presence of uncrossed (homony-
serves as alternate cover test. mous) diplopia as seen in case of
• Record the reading of both the arms of esodeviation. In contrary, when red light
synoptophore. Sum of these two reading is is seen on the left side of the white light,
equal to the magnitude of objective angle then it indicates crossed (heteronymous)
of anomaly. diplopia as in case of exodeviation.
• Now slowly move one arm of synoptophore – In above situation when distance
till the patient superimposes the targets (say between two images is measured and
lion and cage). Record the reading on arm found to be lesser than the magnitude
of synoptophore; this is equal to magnitude of deviation of eyes, then it represents a
of subjective angle of anomaly. case of unharmonious ARC.
– Only one light (usually white) is seen by
• Results are interpreted as
patient in case of suppression, however,
– Difference between objective and subjec-
occasionally single red light may be seen
tive angles give the angle of anomaly
by patient depending upon density of
– When subjective angle is equal to red filter and amount of dominance of
objective angle, then patient has NRC other eye.
– When objective angle is more than
After image test: Hering Bielschwsky discove-
subjective angle, then patient has ARC
red an orthoptic test by dissociating two after
– When objective angle is equal to angle
images of two eyes, which is popularly called
of anomaly (means subjective angle is
Hering Bielschwsky after image test. He
zero), then patient has harmonious ARC
utilized two bright glowing filaments having
– When objective angle is more than angle central black spot (to protect fovea), among
of anomaly, then patient has unharmo- them one filament is oriented vertically and
nious ARC another horizontally. These vertical and
Red filter test: This test utilizes a red filter to horizontal filaments produced vertical and
evaluate the status of visual field in cases of horizontal after images, respectively (Fig. 6.16).
manifest strabismus and various responses are • Patient is made to sit comfortably in
interpreted in terms of retinal correspondence. examination room with dim illumination.
• Place a trial frame on patient’s eyes and • Patient is instructed to cover his/her left eye
instruct the patient to fixate on a white point with palm of hand and right eye is
light source situated at distance of 20 feet. illuminated with a horizontal glowing
– Asymmetrical cross is drawn by patient

having ARC, where central blank area
is separated. The distance of separation
of central blank area depends on the
magnitude of angle of anomaly. For
example, in case of patient having left
esotropia with ARC will draw after
images of vertical line towards right side
of horizontal line as shown in Fig. 6.17B.
– Similarly, in case of patient having left
exotropia with ARC will draw after
images of vertical line towards left side
of horizontal line as shown in Fig. 6.17C.
Fig. 6.16: After image test (see text) – Single horizontal line with a central
blank area is drawn by patient having
filament (preferably camera flash light) for
suppression in the left eye as shown in
20 seconds. Patient is instructed to fixate at
Fig. 6.17D.
central black spot of filament.
• Similarly, left eye of patient is illuminated Binocular visuscope test: This test is also
with vertical light for 20 seconds, while known as foveo-foveal Cupper’s test because
patient is fixating the central black spot. invented by eminent scientist Cupper and this
• Patient is asked either to close the eyes or test determines the retinal correspondence by
look at blank screen at distance and draw stimulating fovea of two eyes. In case of
the after images as he/she perceives. eccentric fixation the quantitative analysis of
• Results of patient’s drawing of after images angle of anomaly can be done by assessing the
are interpreted as: visual directions of two fovea.
– Symmetrical cross with blank central • Patient is made to sit comfortably at 15 feet
area (representing fovea) is drawn by distance from a Maddox tangent scale.
patient having NRC. Even if there is a • Examiner instructs the patient to fixate at
presence of either esodeviation or central light on scale with fixating eye
exodeviation with NRC, patient will still while, examiner looks into the macula of
draw a symmetrical cross (Fig. 6.17A). deviated eye by a visuscope.
Fig. 6.17: Interpretation of after image test

• Practically, it is difficult for examiner to look

into visuscope without blocking the view
of patient. Hence, patient is asked to fixate
via looking in a plane mirror or prism
placed in front of his/her fixating eye.
• Now examiner projects an asterisk of
visuscope on the retina of the deviated eye
of patient.
• Once asterisk is focused on retina of the
patient, the examiner asks the patient to
visualize the position of asterisk on tangent
scale in relation to fixating light (Fig. 6.18).
• Results are interpreted as
Fig. 6.19: Interpretation of binocular visuscope test
– When asterisk of visuscope is seen
coinciding with fixation light of tangent
• At this point of examination position of
scale by the patient then it is a case of
asterisk on patient’s retina is seen by
NRC as shown in (Fig. 6.19A).
examiner through the visuscope.
– When asterisk is seen either right or left
• The position of asterisk on the retina in the
of fixation light of scale by the patient
deviated eye of patient indicates the retinal
then it is a case of ARC as shown in
element of this squinted eye corresponding
Fig. 6.19B. The number corresponding
with the common visual direction of
with the position of asterisk on tangent
fixating eye.
scale is equal to the magnitude of angle
of anomaly. Disadvantages
• After confirmation of ARC the correspon- • It is very complex test and cannot be
ding position of peripheral retinal element performed on young children.
in the deviating eye having common visual • This test requires sophisticated instruments
direction with fixating eye can be examined and reasonable amount of practice to perform.
by further modifying this test.
• Examiner moves the visuscope until the Tests For Suppression
patient see the asterisk is coinciding with As discussed to prevent confusion and diplopia
central light of tangent scale. due to unwanted stimuli, the image of one eye
is suppressed by a central or peripheral
inhibitory mechanism. Various tests done to
evaluate the suppression in eyes are as
follows
• Bagolini’s test
• Red filter test
• Worth’s four dot test
• Friend test
• Synoptophore method
• Four dioptre base out prism test
Note: We have discussed Bagolini’s test and red

filter test, on page no 120–121, whereas Worth’s
four dot test and Friend test will be discussed later.
Fig. 6.18: Binocular visuscope test (see text)
Synoptophore method: For diagnosis of Four dioptre base out prism test: This test is
suppression simultaneous macular perception based on the principle of image displacement
(SMP) slides having images of lion and cage and then evaluation of the resultant ocular
and fusion slides having images of rabbit are movements whether binocular or monocular.
used in Synoptophore. This is an easy and fast screening test to
Test with (SMP) slides evaluate the presence and absence of bifoveal
• Patient is instructed to see the SMP slides fusion and suppression of one fovea.
(lion and cage) through tubes of Synopto- • Patient is instructed to fixate a point light
phore. source at 20 feet distance.
• When either lion or cage is seen by the eye • A 4  is placed in front of one eye (say right
of the patient then it is a case of suppression eye) keeping it in a base out position.
of that respective eye. • Examiner observe the binocular movements
• Suppose suppression is present, then to (version) and monocular (left eye in our
quantify it we can modify this method as example) movement (fusional) after placing
follows this base out prism in front of patient’s eye.
– Start with foveal slides and suppose • Results are interpreted as
foveal suppression is present then show – In normal condition a biphasic movement
the macular slides. of left eye (in our example) will be seen
– When patient has suppression in macular by examiner.
slides, then show the Paramacular slides. – In case of central suppression scotoma
– When patient shows suppression even no biphasic movement will be seen,
in Paramacular slides, then it is a case rather only an outward (version)
of total suppression of one eye. movement of left eye will be seen.
Test with fusion slides – Repeat this procedure for other eye (left
• Patient is instructed to see the fusion slides eye in our example) to check the biphasic
(rabbit with tail and rabbit with flower) movement of fellow eye.
placed in Synoptophore slots. Biphasic movement of the eye is elicited due
• When patient sees single image of rabbit with to sudden displacement of a foveal image by
tail holding flowers means NRC is present. the effect of base out prism. This sudden
• When patient sees rabbit is missing either displacement of image leads to a refixating
in tail or flower, then suppression is present movement of eye when image is shifted into a
of respective eye. normally functioning fovea, however, no
movement will be seen if the image is shifted
• Grading of fusion slides can be done by
into a non-functioning (scotomatous) area.
decreasing the size of images similar to SMP
Fellow eye follows the Hering’ law and
slides.
shows a biphasic movement; means first this
By Synoptophore method suppression scotoma eye moves simultaneously and symmetrically
can be mapped in horizontal meridian as in outward direction with the movement of
follows eye under examination. This is termed
• One arm of Synoptophore is moved and version of fellow eye. When eye under
asks the patient at what point the target of examination takes a refixating movement, this
that side disappears and reappears. Record fellow eye will show an opposite slow
the values at this point of disappear and movement to correct image displacement. This
reappear of target on Synoptophore. This is termed duction or fusional movement of
point indicates the position of scotoma in fellow eye. These two movements of version
visual field. and duction in a phasic manner is termed
biphasic movement of fellow eye. However, • Acquired anisometropia may develop as

when a central scotoma is present, the second a result of various surgeries performed on
fusional movement is absent due to an eyeball or other reasons, ultimately
impaired function of fovea and as a result eye causing change in the axial length of the
remains slightly outward rotated. eyeball.
It can be caused by:
ANISOMETROPIA – Uniocular keratoplasty
Introduction – Improper refractive surgery
The optical condition of the eyes where both – Uniocular aphakia, i.e. lens is extracted
the eyes have equal refractive power is called from one eye due to various reasons like
isometropia. Anisometropia or Asymmetropia trauma or cataract.
means that the refractive power in two eyes is – Pseudophakia with placement of inaccu-
not equal so that focus formed are also rate intraocular lens power
different in two eyes. A small amount of – Uniocular traumatic injury
anisometropia is very commonly seen in
population but it has no visual concern. For Clinical Types
example: The difference of 1 D refractive • Simple anisometropia: In this type only one
power in two eyes will produce unequal size eye is affected with refractive error while
and image on the retina of 2% only. the other eye is normal (emmetropic).
A person can well tolerate the anisometro- Depending on the type of refractive error
pic difference of up to 2.5 D at which retinal present in affected eye it can be
images of two eyes have a difference of about – Simple hypermetropic: One eye is normal
5% in size of image. Whereas, anisometropia and the other eye is hypermetropic.
of 2.5 to 4 D can be tolerated by some but the – Simple myopic: One eye is normal and
difference of more than 4 D in both eyes is not the other eye is myopic.
tolerated and produce symptoms.
– Simple astigmatic: One eye is normal and
the other eye is having simple hyper-
Classification
metropic or myopic astigmatism.
Anisometropia can be classified as shown in
• Compound anisometropia: In this type of
Table 6.3.
anisometropia both the eyes have same type
Etiological types of refractive error, i.e. myopia, hypermetropia
or astigmatism, but there is significant
• Congenital or developmental anisometro- difference in their refractive power. It may
pia: It is hereditary in origin and develops be
due to disproportional growth between two
– Compound myopic: Both eyes have
eyeballs.
myopia with different power
– Compound hypermetropic: Both eyes
Table 6.3: Classification of anisometropia
have hypermetropia with different
Etiological types Clinical types power
• Congenital or • Simple anisometropia – Compound astigmatic: Both eyes have
developmental • Compound astigmatism with different degree.
anisometropia anisometropia
• Mixed anisometropia (antimetropia): In
• Acquired or • Mixed anisometropia
this type both the eyes have different types
iatrogenic (antimetropia)
of refractive errors, means one eye is
anisometropia
affected with myopia and the other with
hypermetropia. Similarly, in mixed astig-

matic anisometropia one eye is affected
with hypermetropic astigmatism and the
other with myopic astigmatism.
Effects of Anisometropia on Binocular Vision

Depending on the difference of refractive
power and refractive error in both eyes
binocular vision may be affected in the
following ways:
• Difference of small degree (<2 D) of aniso-
metropia: Binocular single vision take
place.
• Difference of high degree (>4–5 D) of
anisometropia: Binocular vision is lost and
only uniocular vision is present. The eye
which has refractive error of high degree is
suppressed by other eye, and patient
develops suppression amblyopia (termed
anisometropic amblyopia) and strabismus,
leading to poor vision in this eye.
• Different types of refractive error in both
eyes: When one eye is either emmetrope or
low degree hypermetrope while the other
eye is myopic, then alternate vision is
Fig. 6.20: FRIEND test (see text)
present. Person will see the distant object
with emmetropic/hypermetrope eye and Result is interpreted as
the near objects with myopic eye. Usually • If patient read all letters as FRIEND at once,
these patients remain asymptomatic and do then binocular vision is present.
not use any optical correction. • If patient read either FIN or RED letters,
Examination Methods then uniocular vision is present in the
corresponding eye.
• Retinoscopy: Patients complaining of
• If patient read FIN at one time and RED
defective vision either in one eye or both
other time, then alternate vision is present
eyes need retinoscopic examination to
confirm the diagnosis of anisometropia. – Worth’s four dot test: This test comprises
Tests to check status of binocular vision a view box having four lights, i.e. one
red, two green and one white. This view
– FRIEND test: In this test the word
box is placed at 6 meters distance.
FRIEND is incorporated in Snellen’s
Patient is asked to wear diplopia goggle
chart. Letters FIN are written in green
keeping red lens in front of the right eye
color, whereas RED are written in red
and green lens in front of the left eye as
color. Now patient is advised to sit at
shown in Fig. 6.21.
6 meters distance wearing a red green
goggle (diplopia goggle). The red color Patient is asked to see the four dot lights and
lens of goggle is kept in front of the right possible outcomes are interpreted as
eye and green in front of the left eye. Ask • If no manifest squint is present and patient
the patient to read the letters (Fig. 6.20). sees all four lights as they are seen in Fig. 6.21A
difference of 4 D because difference of > 4 D

will not be tolerated by patient and will
produce diplopia. In case of difference > 4 D,
alternate methods like contact lenses must
be prescribed. In children, it is preferred to
give full correction to prevent amblyopia.
In anisometropic adults best correction of
visual acuity can be achieved with some
compromise and usually the eye having
more refractive error is undercorrected. For
example, a patient having best corrected
visual acuity with powers of +4 D and +9 D
and is not able to tolerate these lenses then
a spectacle with power of +4 D and +7 D can
be prescribed.
Anisometropic spectacles are special
types of spectacles used to treat anisometro-
pia. In these types of spectacles to minimize
Fig. 6.21: Worth four dot test (see text) the peripheral prismatic effect (occurring
due to strong lens) the margins of stronger
means this individual has normal binocular lenses are kept weaker (Fig. 6.22).
single vision.
• Contact lenses: Use of contact lens is a
• When squint is manifested and patient sees
better mode of treatment than spectacles as
all four lights where white light is seen as
they are better tolerated and has less
violet as shown in Fig. 6.21B means patient
chances of diplopia. Contact lenses are
has abnormal retinal correspondence.
useful in young children and patients
• Suppose the patient sees only two red color
having high degree of anisometropia.
lights as shown in Fig. 6.21C means the left
eye suppression is present.
Surgical Correction
• When the patient sees only three green color
lights as shown in Fig. 6.21D it means that Various surgical modalities are widely used
the right eye suppression is present. and are very effective for correction of high
• If patient alternately sees two red lights and degree of anisometropia. They include
three green lights as shown in Fig. 6.21E • Intraocular lens implantation in cases of
means an alternate suppression is present. uniocular aphakia.
• Similarly when patient sees five lights, i.e.
two red and three green as shown in
Fig. 6.21E but continuously, it means that
this patient has diplopia.
Treatment of Anisometropia
Optical Correction
Optical correction can be given in the form of
spectacles or contact lens
• Spectacles: Corrective glasses can be
prescribed in anisometropia up to a Fig. 6.22: Anisometropic spectacles
• Corneal refractive surgery for high degree not appreciated of same size and shape due
uniocular myopia, hypermetropia or to unequal distribution of retinal elements.
astigmatism. It may be due to:
• Clear lens extraction in cases of high degree – Displacement of retinal elements (rods
unilateral myopia. and cones) in one eye
– Compression, stretching or edema of
ANISEIKONIA retina
Introduction – Detachment of neuroepithelial elements
of the retina
Aniseikonia (An = not, iso = equal, ikon =
images) is a binocular vision abnormality This type of aniseikonia can be seen in patients
wherein the ocular images presented to the having retinal detachment, macular hole or
visual cortex from both the eyes are unequal macular edema, etc.
in size and/or shape. It is not an uncommon • Cortical or central aniseikonia: It occurs due
condition and can cause distressing symptoms to difference in perception of images on
to patient. visual cortex. If due to any reason the retina
is compressed or stretched in one eye, then
Classification due to this the image formed on retina will
Aniseikonia can be classified as shown in be received by more (in compression) or
Table 6.4. lesser (in stretching) number of receptors
or retinal elements (rods and cones) in that
Etiological Types eye, leading to asymmetrical perception of
The formation of unequal images may be due images from both eyes through visual
to: pathways. The image received by visual
• Optical or dioptric aniseikonia: It occurs cortex would appear smaller (micropsia) if
due to difference in the dioptric size of fewer elements were stimulated and vice
images formed on the retina of two eyes. It versa if more retinal elements are stimulated.
may be inherent (congenital defect in the
dioptric system of eye) or acquired (may Clinical Types
arise due to difference in the power, shape Aniseikonia can also be classified on the basis
or position of the corrective lens worn for of types of images seen by the patient. Suppose
refractive conditions, aphakia or uncorrected if in a patient right eye is affected and he/she
anisometropia). has normal vision in left eye (Fig. 6.23), then
• Anatomical or retinal aniseikonia: It occurs various images seen by him/her can be
due to difference in the distribution of classified as:
retinal elements (rods and cones) in the eye. Symmetrical aniseikonia (Fig. 6.23): It means
Due to this even if the dioptric images of the size of image in one eye differ from other eye
same size are formed on retina but they are in all meridians or in one meridian. It may be
Table 6.4: Classification of aniseikonia
• Spherical or overall: In this type the size of
image is symmetrically increased or
Etiological types Clinical types
decreased in all directions or meridians.
• Optical Symmetrical Asymmetrical • Cylindrical or meridional: In this type size of
aniseikonia • Spherical • Prismatic image is symmetrically increased or
• Retinal • Cylindrical • Pin cushion decreased in one meridian only (may be
aniseikonia • Compound • Barrel horizontal, vertical or oblique).
• Cortical • Oblique • Compound: In this type the image formed is
aniseikonia a mixture of both as spherical and cylindrical.
to difference in image size of more than 1%

between two eyes. Person may complaint
of blurred vision, photophobia, difficulty in
reading, poor fixation and neurological
manifestations such as headache, nausea,
vertigo, nervousness, fatigue, etc. Visual
fatigue is usually precipitated while patient
is watching movies or reading books for
longer duration. Severity of these
symptoms are not related to the amount of
aniseikonia rather depends on individual’s
tolerance to aniseikonia.
• Symptoms due to binocular vision distur-
Fig. 6.23: Right-sided aniseikonia
bances: Most common binocular visual
Asymmetrical aniseikonia (Fig. 6.23) disturbances seen in aniseikonia are
• Prismatic: The image distortion increases pro- diplopia and confusion. If difference in
gressively in one direction or meridian only. image size is of small amount (0.25%), then
• Pincushion: The image difference progressi- it is ignored by the retina, however, as the
vely increases in both the directions (as seen difference of image size is more than 5%,
in aphakia after high plus correction). then diplopia will occur. Younger patients
try to avoid this diplopia by suppressing
• Barrel distortion: It is reverse of pincushion
one eye, hence a uniocular vision will
effect. The image distortion progressively
develop. But in adults once the binocular
decreases in both the directions. For
vision is well established and if there is
example, giving high minus correction.
sudden difference in the image size (e.g.
• Oblique distortion: Here size of images remains unilateral surgical aphakia) then diplopia
same but shape is obliquely distorted. will occur.
• Defect in spatial perceptions: Stereoscopic
Clinical Presentation
visual effect perceived by our eyes in space
Aniseikonia is well tolerated by many patients is obtained due to formation of two slightly
without causing any symptoms; on the incongruent images on the retina. The
contrary, a few patients may develop severe formation of slight incongruent image on
symptoms even with small amount of retina is due to location of two eyes on
aniseikonia. When the difference in size of different lateral position on the head,
retinal images or the distortion of images resulting in physiological aniseikonia. The
reaches the tolerance limit of person these images which are projected in two eyes
symptoms become a clinical entity and need usually differ in their relative horizontal
treatment for aniseikonia. Usually, difference position (horizontal disparity) and this
of more than 1% in image size and meridional horizontal disparity of retinal images is the
distortion of >0.30 is associated with basis for the perception of depth.
symptoms and require corrections. Aniseikonia due to any reason may disturb
the normal incongruity of images on retina
Symptoms and results in anomaly of stereoscopic
Various symptoms of aniseikonia can be visual function (spatial disorientations).
grouped as These spatial disorientations are more
• Subjective symptoms: Manifest in the form pronounced when horizontal meridian is
of asthenopic or eye strain symptoms due involved. Most of time the disturbances in
stereoscopic visual functions are not practical purposes 1% aniseikonia for one
evident because a considerable amount of dioptre of anisometropia is considered as
psychological adaptation for this visual standard and used clinically.
incongruity develops especially if present • Standard method to estimate the degree of
since childhood. However, if the patient is aniseikonia is by using a device space
tired or shifted to the environment where Ekinometer designed by Ogle and Ames.
uniocular perception occurs (e.g. aviation However, being time consuming and
and motoring), then spatial disorientations expensive procedure, it has very less
become very significant and lead to the therapeutic value. In this device the
misjudgement of the actual distances and presentation of the dissimilar objects of the
may result in diplopia, ocular tiredness and same size to the two eyes is made in such a
ultimately accidents. way that disparity between sizes of retinal
Common presentations of spatial disorienta- images can be assessed accurately. This
tions can be explained by these examples: instrument can give information about
– Right hand is larger than left hand following measurements
– Objects present in one-half of visual field – Difference in size of image in horizontal
will appear larger and further away as meridian
compared to other half of visual field; – Difference in size of image in vertical
which has an object of same size situated meridian
at same distance. – Amount of correction needed for inclina-
tion (indicates meridional aniseikonia)
– Face may appear asymmetrical with its
Ekinometer consists of four vertical
left side protruding.
elements (lines A, B, C, and D shown in blue
– Squares become rectangular; circles look color in Fig. 6.24). Two lines (A and B) are in
elliptical and top of table as trapezoid. front and two lines are behind (C and D) a
– Plane ground appears tilted to the cross element (red color in Fig. 6.24). This cross
observer and gives a feeling as if he/she has two cords F and G, lying right angles to
is climbing the hill; although in reality each other. There is a fifth vertical line E (green
the patient is walking on plane surface. color), which passes through the centre of the
– Flat surface of a table will appear as slant cross. This whole system is viewed through a
down on left side and up on the right test lens unit against a uniform black
side. background.
If there is no incongruity of images, then
Measurement of Aniseikonia all the elements in Ekinometer will appear in
Various methods adopted to measure the their normal relationship, and if incongruity
degree of aniseikonia are: of images is present then elements will appear
• Dartmouth studies introduced a method for displaced by an amount proportional to the
measurement of degree of aniseikonia, degree of aniseikonia as well as in the direction
which is well followed by majority of the related to type of incongruity. By neutralizing
practitioners. This method implies a ’rule the displacement using iseikonic lenses, set in
of thumb’ for the rough estimate of degree trial test unit, the elements can be made to
of aniseikonia. This rule states that if appear normal. This will give the degree of
difference in the size of image due to aniseikonia by seeing the reading of test lenses
anisometropia is refractive in nature, then settings. Various appearances of elements on
the amount of aniseikonia produced due to the basis of displacement will be as follows:
this will be approximately 1.5% for every • When all the elements are seen in their
dioptre of anisometropia. However, for all respective position or no displacement
Fig. 6.24: Ekinometer
of elements is seen, it is considered as

normal appearance as shown in Fig. 6.25.
• When front (A, B) and back (C, D)
vertical elements appear displaced and
cross (F, G) appears as if rotated in
vertical axis in the same direction, it
represents the horizontal size difference
in images as shown in Fig. 6.26.
• Correct orientation of vertical elements
(ABCD) with rotation of cross indicates
the vertical size difference in images as
shown in Fig. 6.27.
• As contrary to vertical size difference Fig. 6.26: Horizontal size difference appearance
when there is rotation of vertical lines through Ekinometer
(ABCD) without rotation of cross (F, G)
Fig. 6.27: Vertical size difference appearance

Fig. 6.25: Normal appearance through Ekinometer through Ekinometer
it represents an overall type size correcting the difference in size of the image
difference as shown in Fig. 6.28. formed on retina.
• Tilting of cross (F, G) without discrepan- Iseikonic lenses, when fitted in spectacles,
cies in vertical elements (ABCD) represents cause magnification of images without
meridional size difference as shown in introducing any obvious change in refractive
Fig. 6.29. power.
To understand the functioning of iseikonic
Note: There is no displacement of central cord (E) lenses, study the illustration (Fig. 6.30) on
in any case of size difference. plane parallel glass plate.
As shown in Fig. 6.30 when an object XY is
Treatment of Aniseikonia viewed through a plane parallel glass plate,
Majority of patients with aniseikonia remain the image X’Y’ appears displaced towards
asymptomatic because either the aniseikonia plate. This image X’Y’ is displaced almost
is well tolerated or has no value where equal to one-third of plate thickness along with
uniocular vision is preferred over binocular a small degree of angular magnification.
vision by the patient. Suppose this glass plate becomes curved,
Moderate degree aniseikonia requires then this angular magnification will get
correction by use of iseikonic lenses or contact increased because magnification depends on
lenses which treat the aniseikonia by the refractive power of the front surface and
thickness of glass plate. However, to keep the
image location same as that of the object, the
refractive power of the front surface can be
neutralize by a proportionate refractive power
of back surface; means lens becomes of zero
power. By using this principle image can be
magnified in one or all meridians without
changing the refractive power of lens. These
types of lenses were used by several
researchers with variable results for relief of
visual disturbances seen in aniseikonic cases.
Iseikonic lenses were prescribed in small
Fig. 6.28: Overall size difference appearance number of patients and favorable sympto-
through Ekinometer matic relief from distressing visual disturban-
ces was seen in very limited patients.
Fig. 6.29: Meridional size difference appearance

through Ekinometer Fig. 6.30: Glass plate causing image magnification
Various treatment modalities can be used – Spectacles fitted with iseikonic lenses
for different types of aniseikonia. gives symptomatic relief in some
• Optical aniseikonia: Following modali- selective cases of aniseikonia. However,
ties can be used to correct optical anisei- these lenses are quite expensive and
konia technically difficult to manufacture;
– Implanting of intraocular lenses in hence are not used very commonly
cases of unilateral aphakia. for correction of aniseikonia.
– Contact lenses can be successfully • Retinal aniseikonia: This is quite rare
used to correct anisometropic anisei- cause of aniseikonia and can be corrected
konia and is more preferred than by treating the underlying retinal disease.
spectacles. • Cortical aniseikonia: It is very difficult
– Corneal refractive surgery remains to treat cortical aniseikonia, although
the best treatment choice for all types symptomatic relief can be given by
of optical aniseikonia. prescribing iseikonic lens spectacles.
134
Accommodation and
its Anomalies
Learning Objectives
• Understand asthenopia and its types.
• Understand relation between asthenopia and refractive errors.
• Effects of accommodation insufficiency and convergence insufficiency in relation with asthenopia.
• Enumerate clinical features and management of asthenopia.
• Describe accommodation and its mechanisms.
• Explain various theories of accommodation.
• Explain and calculate range and amplitude of accommodation.
• Describe ocular changes during accommodation and types of accommodation.
• Understand various accommodation anomalies and their management.
• Understand presbyopia and cycloplegia in detail.
Chapter Outline
• Asthenopia • Accommodation Anomalies
– Introduction – Introduction and classification
– Types of asthenopia Increased accommodation
– Refractive error and asthenopia – Excessive accommodation
– Accommodation insufficiency and asthenopia – Accommodative spasm
– Convergence insufficiency and asthenopia
Decreased accommodation
– Clinical features of asthenopia
– Physiological
– Management
Presbyopia
• Accommodation
– Introduction – Pathological
– Mechanism of accommodation Insufficiency of accommodation
– Theories of accommodation Inertia of accommodation

Cramer’s vitreous theory Ill sustained accommodation
Helmholtz theory of relaxation Paralysis of accommodation
Tscherning’s theory of increased tension
– Pharmacological
Coleman theory of accommodation
Cycloplegia
Schachar’s theory of contraction
Atropine
– Physical and physiological accommodation
Homatropine
– Range and amplitude of accommodation
– Refractive status of eye versus far point and Cyclopentolate and tropicamide
near point Scopolamine (hyoscine)
– Ocular changes during accommodation – Fatigue of accommodation
134
Accommodation and its Anomalies 135
ASTHENOPIA Refractive Errors and Asthenopia

Introduction Asthenopic symptoms are usually observed
Most common diagnosis made in ophthalmo- more in persons having mild or moderate
logy practice, especially in patients having degree of refractive errors because patient tries
vague ocular symptoms is asthenopia. to correct this small amount of error by using
Commonly, it is also termed eye strain. The the increased efforts of ocular musculature.
range of symptoms of asthenopia may vary This excessive muscular effort will lead to
from mild ocular discomfort to nonspecific fatigue of ocular muscles and subsequently
headache of any severity, so it can be asthenopic symptoms.
considered as syndrome. Generally patients In persons with high refractive error the
suffering from asthenopia complaint of asthenopic symptoms are not so common
indistinguishable headaches associated with because these persons either develop
ocular symptoms like heaviness of eyelids, monocular vision or adjust their life according
ocular fatigability or sleepiness feeling while to diminished amount of visual acuity.
watching TV or reading books and brow • Myopia: In myopes the far point is at a
ache. Several gastrointestinal disturbances finite distance situated in front of the eye
like nausea, stomach ache and neurological and far point distance is inversely
disturbances like giddiness, depression are proportional to the amount of refractive
also complained by many asthenopic error. Hence, in an uncorrected myope
patients. blurring of letters will occur while they
read a book kept at normal reading
Types of Asthenopia distance from their eyes. Because in
As discussed asthenopia is presented with myopic patients normal reading
vague symptoms so various ocular and/or distance is farther away from their far
systemic conditions may cause this wide range point and also in a myope always a blur
of asthenopic syndrome. However, on the image is formed at any point situated
basis of etiology, asthenopia can be classified beyond the far point of eye. So to read
as shown in Table 7.1. clearly, the myopic patients tries to keep
the book nearer to their eyes (nearer than
Accommodative asthenopia: It is most common far point). This decreased distance of
cause of asthenopia and arises due to strain reading or the greater proximity of near
on ciliary muscles; usually seen in uncorrected object will increase the demand of
refractive errors of the eyes. convergence. Usually positive accommo-
Muscular asthenopia: Arise due to weakness dative convergence reflex (means eye
of extraocular muscles as occur in heterophoria, accommodate when convergence occurs)
intermittent heterotropia or convergence is absent in myopes so these myopic
insufficiency. patients have to exert a positive fusional
convergence to see the near object
Table 7.1: Etiological types of asthenopia clearly and distinctly. This event of
Accommodative Muscular asthenopia excessive exertion of fusional convergence
asthenopia will develop asthenopic symptoms in
uncorrected myopes. Commonly uncom-
• Refractive errors • Heterophoria
pensated myopes develop an accommo-
• Presbyopia • Intermittent
dative response which is lesser than
• Accommodative heterotropia
response seen in an emmetropic
and /or convergence • Convergence
person. It means in uncorrected myopes
insufficiency insufficiency
lower accommodation (as compared to
emmetropes) is produced when eyes • Anisometropia: In anisometropia an

converge to see the near object. So, unequal amount of refractive error is
correction of myopic error in this type present in both the eyes, so an unequal
of patients will force them to use their amount of blurring of images are seen
accommodation (which otherwise was by anisometropic patients. To clear these
poorly used) to see the near objects unequally blur images an imbalance in
clearly hence can produce asthenopic requirement of accommodation will
symptoms. arise. This difference in need of amount
• Hypermetropia: On contrary to myope, of accommodation will produce astheno-
in hypermetrope far point is beyond pic symptoms in some patients having
infinity, so in uncorrected hypermetropes anisometropia.
only blurred images are received by • Presbyopia: Persons doing near work
retina when accommodation is at rest. for long period like tailors, weavers, etc.
To see the clear images hyperopes has may develop premature presbyopia and
to increase their refractive power by will complain of asthenopic symptoms
increasing the activity of ciliary muscle. due to uncorrected presbyopia.
More near will be the object, more ciliary
muscle power will be required to see it Accommodation Insufficiency (AI) and
clearly, so uncorrected hypermetropes Asthenopia
produce significant amount of asthenopic Accommodation insufficiency is a sensory
symptoms due to excessive ciliary motor abnormality of visual system in which
muscle efforts. Similarly, the presbyopic the amplitude of accommodation is less than
patients try to stimulate the accommoda- the expected for patient age. Normally, in the
tion by extra ciliary muscle efforts and patients with accommodation insufficiency
when these attempts become physiologi- the uncorrected visual acuity is not so poor
cally difficult then the asthenopic and refractive error is negligibly small but they
symptoms precipitates. show an inability to focus or sustain focus on
• Astigmatism: Uncorrected astigmatism near objects. So these patients usually
is more common cause for asthenopia complain of headache, blurring of objects,
than uncorrected spherical refractive eyestrain or brow ache after reading
errors especially, a small degree of continuously for a period of 30–40 minutes.
hypermetropic astigmatism produces In presence of accommodation insufficiency
more severe asthenopic symptoms to compensate and to maintain the focus on
because in these cases accommodational near objects these patients either squint or
efforts try to overcome the hypermetropia, frown while reading a near vision chart,
which results in severe asthenopic however, usually they can even read up to N6
symptoms. Patients having “with the line. Following simple clinical tests can be
rule” astigmatism are more symptomatic performed to confirm the diagnosis of AI as
than the patients having “against the well as to differentiate from presbyopia
rule” astigmatism. Although the images • ± 2 dioptre flipper test
formed in patients having “with the rule”
• Positive relative accommodation test
astigmatism is clearer than “against the
rule” astigmatism. Asthenopic symptoms • Monocular estimated method (MEM)
are more severe in patients with low dynamic retinoscopy
degree astigmatic error because the Patients having AI show difficulty in
accommodation efforts exerted by these clearing ± 2 dioptre flipper test, with minus
patients are of greater intensity. lenses both in monocular and binocular
examination. In patients of AI the value of near vision than distant vision because there
positive relative accommodation is usually will be more strain on sensory motor system.
lower than –1.5 D and finding on MEM Furthermore, chances of symptoms are more
dynamic retinoscopy is higher than +1 D. with vertical deviation because of limited
amplitude for vertical fusion.
Convergence Insufficiency (CI) and
Asthenopia Clinical Features of Asthenopia
Convergence insufficiency, a sensory motor Asthenopic symptoms are variable in nature
dysfunction of visual system, which is seen and are dependent on the amount of use of
when patient is unable to converge properly ocular system because the asthenopic
or maintain the convergence to focus the near symptoms are secondary to the muscular
objects. In simpler words, convergence fatigue that may occur due to increased efforts
insufficiency is inability to converge properly of ocular muscles.
while focusing on near objects. Criteria descri- • Pain around orbit and head: Headache is
bed on clinical evaluation for CI includes: most common symptom of asthenopia. The
• Exophoria is more at near than distance exact cause of it is not known but it can be
• Near point of convergence (NPC) is far away considered as a referred pain. Pain in
(more than 3 inches). Normal NPC is 8–10 cm. asthenopia arise due to increased effort of
• Reduced positive fusional vergence ciliary muscle which is then referred into
Convergence insufficiency may occur due those areas which are associated with
to refractive error (as seen in uncompensated cervical segments like superior cervical
myopes, first time corrected hypermetropes), ganglion, bulbo-spinal root of trigeminal
presbyopia, or in patients having accommoda- nerve, and upper cervical nerves. Pain is
tion insufficiency. Systemic diseases or general more noticed in frontal and occipital regions
debility due to chronic illness, metabolic because ophthalmic division of trigeminal
disorders, and toxemia or endocrine disorders nerve is represented most caudally. Pain
may also cause convergence insufficiency. may vary in terms of location and severity.
Most common asthenopic symptoms – An ache may be present locally around
associated with CI are frontal headache, loss eyes or orbit, or may be localized in
of concentration, blurred vision and orbital frontal, temporal, or occipital region or
pain. Sometimes CI patients may complain of may be diffuse in nature. Sometimes
poor stereopsis (depth perception) and also these aches may radiate up to neck or
migraine headache. The episodes of migraine into arms.
headache usually occur after doing excessive – Ache may be limited to any part and
near work, however, these symptoms get may be associated with tenderness over
relived after treatment of CI. that area, e.g. commonly on vertex or
Heterophoria: Asthenopic symptoms in temple of head or in the orbital area near
heterophoria do not appear until there is no eyes (brow ache).
interference with amplitude of motor fusion – Nature of headache may be variable
and deviation. Development of asthenopic from superficial to deep seated.
symptoms in these persons will depend on the – Similarly, headache may be in form of
general health condition of person, state of dull heavy ache or sharp, shooting and
sensory motor system and the type of work piercing in nature (resembling neuralgic
done by person. In heterophoria, frequency of pain).
asthenopic symptoms usually increased – Headache may be intermittent or
following a debilitating disease, even if the permanent type and may be at regular
amplitude is normal. Symptoms are more in or irregular intervals.
• Vague ocular symptoms: General ocular complaint of various vague general

symptoms such as eye strain, ocular fatigue, symptoms in the form of digestive upset
ocular aches, and tired eyes may occur, usually (nausea, dyspepsia), neurotic (dizziness,
seen after doing continuous near work or insomnia, depression, etc.) and abnormal
reading book for more than 30–40 minutes. sensitivity to light, etc.
Continuing near work in spite of ocular
strain can result into actual pain or severe Management
headaches. Normally, these ocular symptoms Management of asthenopia includes identi-
get relived by taking rest or rubbing eyes fication and treatment of multiple causative
or relaxing the eyes by looking at distant factors by means of
objects. However, asthenopic eyes generally • Refraction
have a typical look (watery, suffused and • Correction of accommodation insufficiency
dull) due to continuous status of irritability
• Visual training
and congestion. Rubbing of eyes, especially
in children may lead to development of • Prism therapy
recurrent blepharitis, styes or conjunctivitis • Improvement in general health status
and an accurate cycloplegic refraction must Refraction: Refractive status of every patient
be done to know the refractive status. Once having asthenopic symptoms should be
refractive error is corrected, then these checked by performing cycloplegic refraction
vague ocular symptoms subside automati- and if error is present it should be fully
cally. corrected. Correction of the refractive errors
• Diminution of vision: Visual symptoms will decrease the muscular efforts of eye and
may vary depending on the refractive error thus help to relieve the asthenopic symptoms.
of patient. Most of the time small degree of
refractive errors are fully compensated by Accommodation insufficiency: Patients
the efforts of ocular system of an individual diagnosed with accommodative insufficiency
and thus visual acuity remains unaffected can be prescribed with plus lenses (+1 or +
and patients do not complain of visual 1.25 Dsph power) to decrease motor demand
symptoms. However, in the presence of on accommodation system. These glasses are
stressful conditions (e.g. poor general prescribed as half eye glasses so that near
health, eyes are being used too much like vision is improved without disturbing
for reading book, jobs demanding high distance vision.
degree of visual acuity for long period, fine Eye exercises: Patients having muscular type
tailoring work, etc.), or when refractive of asthenopia are advised for visual training,
errors cannot be compensated by ocular which is given in the form of orthoptic
system, then the visual acuity remains poor exercises like adduction exercise gives best
and visual symptoms (blurring or diminu- results in cases of convergence insufficiency.
tion of vision) will appear. During unusual These exercises help in development of range
strain on eye both the ciliary muscles and of fusion and accommodative efforts.
ocular muscles of eye initially try to Improvement in these factors will be added
compensate it by excessive efforts of for the convergence facilitation and hence
contraction but finally the muscles get tired improves convergence abilities of patient.
and undergo in the state of relaxation, However, the results of these orthoptic
leading to blurring of vision and diplopia, exercises are not visible immediately rather
respectively. these exercises take some time to show the
• Associated symptoms: Sometimes patients desired results perhaps patient perform them
along with visual symptoms may also regularly and judicially.
Note: In selected cases of asthenopia, symptoms may

aggravate in the beginning of orthoptic exercises,
before they show any positive improvement
however, worsening is considered as normal once
improvement in symptoms start.
Prism therapy: If orthoptic exercises do not

work to relieve asthenopic symptoms due to
convergence insufficiency, then prism therapy
in form of base-in (BI) prisms fixed in
spectacles for near work can be prescribed.
Fig. 7.1: Accommodation causes focusing of near
General measures to improve health: For a object on retina
successful treatment of asthenopia an
improvement in general health, management the retina (R). Suppose the object under examina-
of systemic diseases and debility due to illness tion is now brought at point A, when eye is in
is equally important to relieve the symptoms. nonaccommodative state then the conjugate
For severe headaches pain relieving tablets can image will be formed at point A’ which is
be prescribed for immediate symptomatic situated behind the retina and hence a large
relief however, extensive search should be blur circle of diffusion is seen on the retina. Now
done to find the root cause of headache. if by any means we can increase the converging
power of the eye so that the focus A’ is formed
ACCOMMODATION at R, then the object will be seen clearly while
Introduction still keeping the distinct image clear. This
mechanism which causes change in the power
Human eye has developed such a mechanism
of focusing is called accommodation.
by which parallel rays of light from infinity
get focused at macula of the retina. This Various possible mechanisms by which
phenomenon is accomplished by refractive accommodation can be achieved are:
system of an emmetropic eye without exerting • Change in axial length of eye: If eye could
any effort and as a consequence, the objects be made elongated (i.e. its axial length
which are present at a considerable distance increased) so that retina (R) moves out
are seen clearly and distinctly. So, it is obvious to point A’ (Fig. 7.1), i.e. image falls on
that if eye has to function properly it should retina.
be able to vary its focus from distance to near • Curvature of cornea: Another possible
objects in very short interval of time. Hence mechanism is that an increase in
eye needs to adopt its refractive mechanism converging power can be attained by
in such a manner that it allows even near changing (more steep) the curvature of
objects to be seen clearly and distinctly. cornea.
In emmetrope eyes the parallel rays of light • Position of lens: Accommodation could
coming from infinity are focused on the retina be attained by altering the position of
while accommodation is at rest. Human eyes lens and making it to move forwards (i.e.
have a unique mechanism by which it can towards cornea).
even focus the diverging rays coming from However, all these possibilities in
a near object on the retina so that object is human eye are not possible in real life.
seen clearly. This mechanism is known as The most possible mechanism to
accommodation. achieve accommodation is
As shown in Fig. 7.1 that parallel rays • Change in refractive power of lens: There
coming from infinity are getting focused on is increase in the refractive power of
crystalline lens of eye so that converging from far to near and near to far objects,
power of ocular system will increase and without moving their body. Many researchers
the image will form at retina. have presented various theories for the
Accommodation response in human eye mechanism of accommodation in past years.
can be stimulated by various factors including Some popular theories are:
blurring of image, oscillation of accommoda- • Cramer’s vitreous theory
tion, scanning movements of eye, chromatic • Helmholtz theory of relaxation
aberrations, distance and apparent size of • Tscherning’s theory of increased tension
object. The time period between presentation • Coleman theory of accommodation
of an accommodative stimulus and occurrence • Schachar’s theory of contraction
of an accommodation response is known as
reaction time of accommodation. Average Cramerís Vitreous Theory
reaction time for ‘far to near’ and for ‘near to In year 1853, Cramer studied the size of
far’ accommodation is 0.64 and 0.56 second, Purkinje’s image during accommodation
respectively. process. He concluded that size of image
became smaller during accommodation as
Mechanism of Accommodation compared to resting state of eye as shown in
Though there is a considerable amount of Fig. 7.2.
controversy about the precise nature of He also observed change in the anterior
mechanism during accommodation, however, surface of the crystalline lens during
majority of researchers agreed that it is accommodation which became more convex,
essentially the increase in the curvature of whereas there was minimal change in the
crystalline lens (mainly of the anterior surface posterior surface of crystalline lens (which he
of lens) which causes accommodation in concluded because image of candle from
human eye. Mechanism of accommodation anterior surface of lens became significantly
also varies species to species like snakes and smaller as compared to the image of candle
frogs have mechanism by which they can from posterior surface of lens as shown in
move their lens forward to see near objects Fig. 7.2. Based on his observations Cramer
clearly or Mollusc pecten species can elongate proposed a theory called vitreous theory.
their eye to focus on the near objects. Cramer’s vitreous theory for accommodation
There was a long debate since 19th century states that during process of accommodation
that how humans are able to shift the focus there is contraction of ciliary muscle which
Fig. 7.2: Purkinje images (becoming smaller) as seen during accommodation process
acts upon choroid. The choroid in turn causes widely accepted and later on modified by
compression of vitreous gel body against various other researchers like Fincham in the
posterior portion of crystalline lens. As a result year 1937.
pressure on posterior crystalline lens is
Relaxation theory comprises these points:
increased; in response to this the iris tries to
• During rest phase (unaccommodated state
resist this increased pressure, leading to
of eye, i.e. during distant vision), the soft
increase in the curvature of anterior surface
substances of crystalline lens remains
of lens in pupillary area.
compressed inside the lens capsule due to
Points not in favor of vitreous theory increased tension of zonular fibres. Due to
• Later on a few studies concluded that this increased tension of zonules, the lens
accommodation also present in those is pulled backwards towards equator. As a
patients who are not having iris (aniridia), result, the anterior surface of lens is less
hence counter pressure by iris is not the curved means maintain a flat shape to
probable cause for increase in the curvature increase the focal length (as shown in
of crystalline lens. Fig. 7.3). Helmholtz proposed that zonules
• Moreover, accommodation is also possible remain under tension due to pull exerted
in those cases where complete vitrectomy on them by elastic choroid, however, later
has been done. on several studies conclude that zonules
Points in favor of vitreous theory: Subsequent fibers remain in state of tension due to the
studies supported the statement of Cramer’s relaxation of ciliary muscle fibers.
that lens is involved for process of accommo- • During accommodation phase there is
dation. contraction of ciliary muscle and the
choroid is pulled forwards which result in
Helmholtz Theory of Relaxation uniform reduction of tension (relaxation) on
This theory was initially proposed by Thomas all anterior, posterior and equatorial
Young which was further explained in details zonular fibers. Due to relaxation of zonular
by Helmholtz (1885). This theory is also fibers the lens being elastic, mould itself and
known as Young-Helmholtz theory of undergo following changes:
accommodation or capsular theory. This – Increase in the curvature of lens (mainly
theory of accommodation was the most of anterior surface)
Fig. 7.3: Showing accommodation and rest phase

– Increase in the anterio-posterior diameter are thicker in periphery (site of attachment of

of lens zonules) than centre or pole of lens. Due to
– Increase in axial thickness of lens this variable thickness of lens, on application
– Decrease in equatorial diameter of the lens of increased tension of zonules the peripheral
– Forward movement (bulging) of the portion of lens will preferentially become
anterior pole of the crystalline lens flatter than central part, so there is bulging of
– Equatorial edge of lens moved away central part of capsule. On the basis of these
from sclera observations, Fincham concluded that
variation in thickness is responsible for change
Due to all these changes the lens becomes
in shape of lens during accommodation.
more spherical or round in shape and dioptric
Helmholtz theory was modified by other
power of the eye is increased which enable the
researchers also. Gullstrand proposed that
eye to see the near objects clearly (Fig. 7.3).
along with the change in elasticity of lens,
Helmholtz considered that lens capsule and change in the intracapsular forces also play
lens matrix act as an elastic body. In normal role in accommodative process.
state the lens is kept stretched and remains
more flat due to tension of zonular fibers Points against relaxation theory
(suspensory ligaments). Thus, in state of rest • As per Helmholtz hypothesis, with aging
the radius of curvature of anterior surface of the zonules should relax because equatorial
lens is about 10 mm, whereas during state of diameter increases (as crystalline lens and
accommodation it decreases to 6 mm. This equator comes closer to ciliary muscle) with
change in curvature of lens increases the process of ageing. So, the power of crys-
converging power of the eye and focus can be talline lens should increase as age advances
altered as per requirement (Fig. 7.4). for seeing the distant objects during
Helmholtz’s theory was widely accepted. accommodation and person should become
However, this theory could not explain reason more myopic with an unstable lens
for change in shape of lens during accommo- position. But in reality with advancing age
dation. Later on, Fincham suggested that the person becomes hypermetropic and lens
peculiar form attained by lens during process position remains stable.
of accommodation is due to structure of lens • Helmholtz theory could not explain the
capsule. He suggested that thickness of lens decrease in spherical aberrations, which
vary at different places. The anterior surface occurs during the process of accommodation.
is thicker than posterior surface. Both surfaces
Tscherningís Theory of Increased Tension
Tscherning’s proposed a theory of accommo-
dation which was opposite of Helmholtz
theory. According to this theory, during
accommodation contraction of ciliary muscle
directly pulls the zonules and increases
Note: Since majority of anatomical and physiological

evidences were found against this theory;
Tscherning’s view of increased zonular tension is
not accepted widely.
According to Tscherning’s theory, accommodation
results due to increase in the tension in zonules
rather than relaxation of zonules (Helmholtz’s
Fig. 7.4: Helmholtz’s theory showing mechanism
theory).
of accommodation
tension on zonules which in turn will increase anterior chamber is decreased. This pressure
tension on the capsule of lens. Hence, the lens difference creates a hydraulic shift of crystalline
will become more flat at periphery due to lens. As a result, the vitreous applies a force
compression of lens capsule at equator and on the posterior surface of lens and causes
simultaneously it will buldge out from central change in the shape of catenary which in turn
pupillary zone (at pole). changes the curvature of anterior lens (makes
anterior central curvature of lens more steep).
Colemanís Theory of Accommodation
Points not in favor of Coleman’s theory:
In 1970 Coleman proposed a theory for • Later on some studies found that no
accommodation known as the ‘Coleman’s significant difference in the amplitude of
hydraulic suspension theory of accommoda- accommodation is seen in cases having
tion’. Although by the time Coleman’s vitreous body or in cases without vitreous
proposed his theory, already two popular (after vitrectomy), and suggested that
theories were existing, i.e. Helmholtz’s vitreous plays no essential role in accommo-
relaxation theory and Tscherning’s zonular dation process or forward displacement of
contraction theory. However, these theories crystalline lens.
were not able to explain some queries like
• Some studies compared Coleman’s hydraulic
• How convergence potentiate the accommo- suspension theory and Helmholtz’s
dation process? capsular theory to determine changes in
• What is the exact cause of reduction of refractive power during mechanism of
accommodation during presbyopia? accommodation. They found that change in
• What is the relationship of accommodation refractive power during accommodation
process with progression of myopia and process was consistent with Helmholtz’s
glaucoma? capsular theory, not with Coleman’s
• How the optical surfaces of crystalline lens hydraulic suspension theory.
rapidly gains functionality, even in
associated accommodation hysteresis, Schacharís Theory of Contraction
where time is limited? Schachar (1992–1995) gave another theory for
• What is the reason for forward movement the process of accommodation which
of lens during accommodation? resembles with Tscherning’s theory of
• How the zonular ciliary body attachments increased tension. Theory of Schachar’s also
can flatten the lens without involvement of became basis for surgical treatment of
vitreous? presbyopia done to restore accommodation.
Coleman proposed that lens and zonular Schachar suggested that during accommo-
fibers in the eye acts as a diaphragm between dation process the active role is played by
anterior and vitreous chamber of the eye and equatorial zonular fibres, while the anterior
remain in a catenary shape (hydraulic and posterior zonular fibres only provide
suspension bridge), because of pressure passive structural support to lens just like
difference of aqueous and vitreous bodies of supportive ligaments of skeletal joints. Thus,
the eye. The movement of posterior pole of the equatorial zonular fibres are main
crystalline lens is prevented by vitreous gel component to decide the optical power of lens
body. During accommodation when ciliary in the eye. Anterior and posterior zonular
muscle contracts, the pressure in vitreous fibres get tense during distant vision, whereas
chamber is increased while the pressure in they are relaxed during accommodation.
According to this theory, during accommo-
Note: There is no change in curvature of posterior dation there is contraction of ciliary muscle
surface because of vitreous. which leads to increase in the tension of
Fig. 7.5: Schachar’s theory—ciliary muscle contraction causing relaxation of equatorial zonules
Note: Schachar’s theory challenged the classical Note: As discussed there are lots of controversies
and most widely accepted theory of Helmholtz about various theories of accommodation, but Von
where contraction of ciliary muscle caused Helmholtz’s capsular theory is probably the most
decrease in the tension (relaxation) of the zonules widely accepted, because various experimental
and allowed centripetal elasticity of lens capsule physiological studies done in last century provided
to change the shape of crystalline lens. As per enough evidences to prove the fundamental
Helmholtz’s theory the equatorial or coronal elements of mechanism of accommodation still
diameter of lens is reduced and equatorial edge of holds good.
crystalline lens moves away from sclera and entire
lens becomes spherical shape which is just (perilenticular space) is reduced and
opposite to theory proposed by Schachar. contraction of ciliary muscle is not so
effective so that lens become unable to
equatorial zonular fibres (as also suggested in expand coronally. Based on this principle,
Tscherning’s theory) while of tension on Schachar (1992) introduced a new surgical
anterior and posterior zonules is decreased method for correction of presbyopia,
(Fig. 7.5). As a result there is equatorial known as sclera expansion procedure. The
displacement of lens. Biomechanical property scleral expansion will increase the zonular
of crystalline lens is such that, central portion tension and hence should re-establish the
of lens rounds up when equatorial region accommodation in presbyopia. He used
stretches and hence central portion moves bands for sclera expansion with an aim of
anteriorly, i.e. the central surface of lens increasing the distance between lens
becomes more convex and peripheral surfaces equator and ciliary muscle. As per his
become more flat due to more increase in theoretical calculations this increase in
central volume of lens than peripheral volume distance will provide more space for the
(Fig. 7.5). Due to all these changes the equator ciliary muscle to work on zonular tension.
of lens is pulled towards the sclera leading to
• However, various reports had shown
increase in the refractive power of the lens.
conflicting results about sclera expansion
• Schachar’s theory also states that growth in
bands procedure and challenged the
equatorial diameter of crystalline lens with
authenticity of Schachar’s theory of zonular
age results in presbyopia. He proposed that
tension during accommodation.
presbyopia happens due to reduction in the
distance between lens equator and ciliary Comparison of accommodation theories:
muscles. He thought that with aging, the Salient features of various accommodation
area surrounding the crystalline lens theories are summarized in Table 7.2.
Table 7.2: Comparison of salient features among various accommodation theories

Cramer’s vitreous Helmholtz theory Tscherning’s Coleman theory Schachar theory
theory of relaxation theory
Contraction of Contraction of Contraction of Contraction of Contraction of
ciliary muscle ciliary muscle ciliary muscle ciliary muscle ciliary muscle
    
Acts upon choroid Choroid is pulled Directly pulls the Pressure in Increase in the
 forwards zonules vitreous chamber tension of equatorial
Choroid causes   is increased and zonular fibres
compression of Uniform reduction Increases tension in anterior is 
vitreous on in tension on all on zonules decreased (pressure Equatorial
posterior portion zonular fibres  difference) displacement of lens
of lens  Increase tension  
 Lens undergo on the capsule of Creates a hydraulic Central surface of
Pressure on changes: lens shift of crystalline lens becomes more
posterior lens • Increase in the  lens convex and pulling
increased curvature of lens Lens is more flat  of the equatorial lens
 • Increase in the at periphery and Vitreous applies toward the sclera
Iris tries to resist anterioposterior bulge out from force on posterior
this increased diameter central pupillary surface of lens
pressure • Increase in axial zone 
 thickness Changes the
Increase in the • Decrease in curvature of
curvature of equatorial anterior lens
anterior surface diameter
of lens • Forward
movement of
anterior pole
• Equatorial edge
of lens moved
away from sclera
Physical and Physiological if lens substance elasticity is normal. On the

Accommodation basis of these two facts mechanism of
Efficiency of process of accommodation is accommodation has two components:
dependent on two factors: Physical accommodation: The physical
• Ability of lens to change its shape accommodation indicates actual deformation
• Contractile power of ciliary muscle in the shape of lens and is measured in
With advancing age the elasticity of lens is dioptres (D). It means to increase the conver-
decreased and it no longer can change its ging power of eye by 1 D, an expenditure of 1 D
shape as efficiently as in younger age. In this accommodation is needed.
situation accommodation will not be effective Physiological accommodation: The physio-
even if ciliary muscle contracts powerfully. logical accommodation indicates the contrac-
Similarly, a weak or paralyzed ciliary muscle tile power of ciliary muscle and is expressed
will not cause change in the shape of lens, even in myodioptre. One myodioptre unit is the
amount of contractile power of ciliary muscle minimal refraction (eye is focused for far point
which is required to bring a change in the i.e. static refraction) and when eye is in fully
refractive power of lens by 1 D. accommodative state with maximum refrac-
Though these two elements normally tion (eye is focused for near point, i.e. dynamic
correspond to each other during first half of refraction) is called the amplitude of
life (nearly 40–45 years) but they are accommodation.
fundamentally distinct elements. These factors The range and amplitude of accommo-
may dissociate due to various precipitating dation can be calculated by following formula
factors and if this happens they produce as follows:
pathological effects in life. a=r–p
For example, when lens becomes hard in A=P–R
later years of life (nearly 40 years) as in Where,
presbyopia, the physical accommodation gets r = distance of far point (punctum
fail. It is known that alteration in the physical remotum) in meters
properties of lens alone lead to this condition R = refractive power of eye or
and accommodation become difficult in static refraction (dioptres)
presbyopia, however, the ciliary muscle power when accommodated for r.
is unaffected during this phase of early p = distance of near point (punc-
presbyopia. tum proximum)
In contrary, if contractile power of ciliary P = refractive power of eye or
muscle decreased due to any debility in life dynamic refraction (dioptres)
(at any age) also lead to reduced or abolishing when accommodated for p.
accommodation, although lens is being able
a = range of accommodation
to change its shape with normal elasticity.
(meters)
Person may try to overcome this muscle
deficiency by exerting excessive ciliary efforts A = amplitude of accommodation
which may manifest in form of asthenopia or (dioptres).
eye strain symptoms.
Amplitude of Accommodation
Range and Amplitude of Accommodation As discussed above difference in the refractivity
Far point of accommodation (punctum of eye during accommodative and resting state
remotum) is referred as the maximum distance is considered as amplitude of accommodation.
at which an object can be seen clearly when Normally, we have certain amount of
accommodation is relaxed and refractivity of accommodation since birth, which gradually
the eye is at minimum. Near point of decreases with advancement of age. An
accommodation (punctum proximum) is average value of amplitude of accommodation
referred as the nearest distance at which eye according to age has been standardized by
can see the object clearly with maximum effort conclusions drawn from several studies as
of accommodation and refractivity of the eye shown in Table 7.3.
is at maximum. The distance between far point Amplitude of accommodation can be
of accommodation and near point of assessed by measuring the near point of
accommodation is termed the range of accommodation (NPA) which is defined as the
accommodation, i.e. this is the distance over nearest distance till which an eye can see small
which the accommodation of a person is in objects clearly. The tests should be done with
active form. The difference between the both eyes together (binocular) as well as with
refractivity (dioptric power) of eye in these each eye (monocular) separately. Before
two conditions, i.e. when eye is at rest with testing full optical correction of refractive error
Table 7.3: Average amplitude of accommodation As shown in Fig. 7.6 RAF rule has a
at different ages long ruler (50 cm) with a slider which
Age in years Amplitude in dioptres
holds a rotating four-sided cube. A
cheek rest is provided on one end of
6–10 13.5–14.5 ruler which ensures a consistency and
11–15 12–13.5 proper height of target to the patient’s
16–20 10–12 eyes. Other end has a handle to hold the
21–30 8–10 ruler straight while examining the
31–40 6–8 patient. The instrument bar is marked
41–50 4–6 on three sides as follows:
51–60 2–4
• one side is graded in centimeters for
Above 61 years 0.5–1.5
measurement of range of accommoda-
must be done in ametropic or presbyopic eyes. tion
NPA can be measured by three methods. • second side is divided in dioptres
1. The simplest way to measure the NPA for measurement of amplitude of
is by using a linear target (e.g. a line accommodation
drawn on piece of paper). This target is • Third side is marked with number of
brought forwards towards the eye of the years which indicate the standardized
patient and the distance at which the corresponding age of the patient.
target appears blur to the patient, that Similarly, each side of cube has different
point is called NPA. The reciprocal of targets
this distance gives measurement of • First side of cube contains a vertical
amplitude of accommodation. Near line with a central dot for convergence
point of convergence (NPC) is the point fixation.
at which the target appears double to the • Other three sides provide a limited
patient. number of lines of near reading
2. Measurement by using instruments like examples.
prince rule or Royal Air Force (RAF) rule Test procedure
or Livingstone gauge or near point ruler: • Full optical correction of refractive
The instrument consists of a binocular error is provided by spectacles. The
gauge which can be used for measure- cheek rest of the RAF rule is placed
ment of both subjective and objective on cheeks of the patient and a sliding
NPC and NPA. target with 6/9 size letters, numbers
Fig. 7.6: RAF rule

or fine lines are presented towards 3. Measurement by using minus lenses:

eye. Patient is asked to wear his/her full
• Slowly the target is moved towards refractive correction, then test is
the eyes of patient till he/she is able performed first for each eye and then for
to read it clearly. Once the patient both eyes. Make the patient to sit
feels difficulty in reading the 6/9 size comfortably at 6 meters distance from
letters clearly, at this point stop the the Snellen’s chart. Place the trial frame,
movement of sliding. Repeat the occlude one eye and now instruct the
testing procedure first by only one patient to fixate at 6/60 target on
eye (monocularly) and then for both Snellen’s chart. Once patient visualizes
the eyes together (binocularly). the 6/60 target clearly, gradually add
Record the distance of target in minus power lenses with increasing
centimeters. powers till this 6/60 target becomes
• The NPA is value (in centimeters) blur. Power of these added minus lenses
measured at the mark on instrument is equivalent to the amplitude of
bar where target is present. Instrument accommodation.
bar also has measurements on other
side, for amplitude of accommoda- Refractive Status of Eye versus Far or Near
tion in dioptres and a third side which Point
corresponds to the age in years. For Knowledge of relationship between refractive
example, if the patient sees the status of eye and far or near point of eye is
blurring of target objects at a distance important for calculating range and/or
of 25 cm, then the corresponding amplitude of accommodation. The position of
dioptre marking will show +4 D and far point or near point of eye is dependent on
age marking will be at 40 years. refractive status of eye as follows
On the basis of amplitude of accommo- • In emmetropic eye far point (r) is at infinity
dation two situations may arise. If the and near point (p) varies with the age of
patient’s amplitude of accommodation person (Fig. 7.7). As discussed in Table 7.3
is very low (so much so that his/her near at an age of 10 years, the average amplitude
point lie beyond the total length of of accommodation is 14 D, so near point
instrument), then plus lenses should be will be situated at 1 meter (100 cm)/14 D
added with his/her full refractive cm distance (i.e. about 7 cm) in front of the
correction until the near point comes eye. Similarly, at an age of 40 years it will
within the range of length of instrument. be at 100 cm/4 D (about 25 cm) and at an
To know correct value of amplitude of age 45 years will be at 100 cm/3 D (about 33
accommodation deduct these additional cm) from the eye. It means that the
dioptres from the measured amplitude
value (in dioptres) on instrument’s bar.
Secondly, if patient’s amplitude of
accommodation is very high, then
minus lenses should be added to move
away the near point. In these cases to
know the correct value of amplitude
of accommodation add these additional
dioptres with the measured amplitude
value (in dioptres) on instrument’s
bar. Fig. 7.7: Emmetropic eye (far point is at infinity)
refractive power can be compensated with

accommodation of eye; greatest during
childhood and least after middle age.
For example, for a 40 years emmetrope
r = infinity and p = 25 cm
As we know that
Range of accommodation (a) = r – p
Amplitude of accommodation (A) = P – R
So, the range of accommodation (a) =
infinity – 25 = infinity Fig. 7.9: Myopic eye (far point lies in front of eye)
Similarly, R = 0 and P = 100/25, i.e. + 4 D
So, the amplitude of accommodation (A) = • In myopic eye the far point (r) lies in front
4–0=+4D of the eye and is real. Hence, the distance
of far point (r) from the eye is fixed, for
• In hypermetropic eye the far point (r) is a example, 40 cm (for – 2.5 D myopia) (Fig. 7.9).
hypothetical point beyond infinity or Suppose, the near point (p) is at 20 cm for
behind the retina (Fig. 7.8). Hence, to see an adult, then R is 2.5 D and P is 5 D. Now,
the objects clearly at far point, hyper- as per formula
metropic eye has to exert accommodative
Range of accommodation (a) = 40 – 20 =
efforts equal to degree of hypermetropia.
20 cm; and
For example, in +4 D hypermetrope, Amplitude of accommodation (A) = 5 D
hypothetical point (r) lies beyond infinity – 2.5 D = 2.5 D.
or 25 cm behind the retina, whereas the
static refraction (R) is of +4 D power. Ocular Changes During Accommodation
Suppose, for an adult if near point (p) in Ocular changes especially in crystalline lens
front of the eye is 20 cm then P will be +5 D happening during the process of accommo-
(P = 100/20 = +5 D). dation can be summarized as follows:
So, range of accommodation (a) = infinity • Zonular loosening: Normally zonules
–25 = infinity and remain in tension and keep the lens flat.
Range of amplitude (A) = 5 D – (–4 D) = 5 D During accommodation there is contraction
+ 4 D = +9 D of ciliary muscle which causes relaxation of
these zonules.
Note: Distances behind the retina are calculated
• Curvatural change in lens surface: During
as negative.
rest phase, the curvature of anterior surface
of lens is 11 mm and of posterior surface is
6 mm. During accommodative phase the
curvature of posterior surface remains
almost same, i.e. 5.7 mm but that of anterior
surface changes significantly. In strong
accommodative phase the anterior surface
curvature becomes 6 mm in periphery and
nearly 3 mm in central portion of the lens.
Central portion of lens bulges more
probably due to the less thickness of capsule
Fig. 7.8: Hypermetropic eye (far point is beyond in central portion as compared to peripheral
infinity or behind eye) portion of capsule.
• Anterior pole: During accommodation Table 7.4: Classification of accommodation

phase the anterior pole of lens moves anomalies
forward along with the iris, this results in a
Increased Decreased
shallow anterior chamber in centre portion. accommodation accommodation
• Axial thickness: Normally posterior pole (Hyperaccommodation)
of lens shows no movement during
• Excessive • Physiological:
accommodation phase, however, forward
accommodation Presbyopia
movement of anterior pole of lens increases
• Accommodative • Pathological
the axial thickness of crystalline lens.
spasm – Insufficiency of
• Lens sinks down: During accommodation accommodation
as the lens is less firmly held by its zonular – Inertia of
attachments so due to gravitational pull the accommodation
lens sinks downwards within the globe. – Ill-sustained
• Lens substance changes: Along with change accommodation
in curvatures of lens, the change in the – Paralysis of
substance of crystalline lens also produces accommodation
a change in refractivity of lens. Changes in • Pharmacological:
curvature of various portions of lens happen Cycloplegia by drugs
due to internal changes in substances having • Fatigue of
different refractive indices. accommodation
• Pupillary constriction and eye convergence:
During accommodation constriction of Increased Accommodation
pupil and convergence of eyes takes place Excessive Accommodation
almost simultaneously with the above As the name explains this is a situation where
mentioned changes in crystalline lens and an individual apply more than normal
zonules. These all changes occur together accommodation to see the near object
in a bid to see near objects clearly. Pupillary clearly, this situation is termed an excessive
constriction is just a synkinesis reflex (not accommodation. This is under the voluntary
a true reflex) because it is neither dependent control of a person and is discontinuous
on alone accommodation or alone conver- phenomenon, whereas spasm of accommoda-
gence of the eye. tion is nonvoluntary and is a continuous
• Choroid: Ciliary muscle contraction cause process.
forward stretching of the choroid.
Etiology: Under following conditions person
• Ora serrata: Each dioptric power of
may use excess accommodation:
accommodation moves ora serrata forwards
• Refractive errors: Hypermetropia, myopia
to about 0.05 mm.
and astigmatism errors especially in young
person is associated with the use of excessive
ACCOMMODATION ANOMALIES
accommodation. It is a kind of physiological
Introduction and Classification adaptation to see the objects clearly.
As per our previous discussions the amplitude • Presbyopia: Presbyopes in the initial stage
of accommodation varies with age and has of its development use more accommoda-
wide range, which may be considered as variant tion to carry out near work.
of normal range. Any variation above or below • Use of wrong spectacles: Sometimes, use of
of this normal range is not common and is improper or ill-fitted glasses is also associa-
considered as an accommodation anomaly, ted with an excessive use of accommoda-
which can be classified as shown in Table 7.4. tion.
• Prolonged near work: Near work carried • General treatment: Treatment of general
out in presence of poor/excessive illumina- condition is equally important for an
tion for long duration may cause an effective outcome which includes
excessive use of accommodation. In addi- – Near work is stopped completely for
tion, most of the time the general health some period of time. Once the near work
conditions (physical and mental) of these is restarted, the amount, duration and
patients are also poor. conditions in which near work is done
Symptoms should be supervised.
• Diminution of vision: Due to increased tone – General health conditions of these
of ciliary muscles a condition like pseudo patients are taken care because most of
myopia develops so that emmetrope them are in poor health or overworked
becomes myopic, a myope becomes more or neurotic. Hence a plan of holiday or
severe myopic and a hypermetrope may trip with change of weather has a great
appears myope, less hypermetrope or beneficial effect than any medical
emmetrope. There is blurring of vision of treatment.
variable degrees mainly for distant vision.
Accommodative Spasm
• Both the far and near point becomes nearer
to eyes and distant vision becomes blur, so Accommodation spasm is a condition where
concave lenses are prescribed for improve- an individual exerts an abnormally excessive
ment in vision. However, improving the accommodation non-voluntarily.
pseudo myopia by use of concave lenses Etiology: Accommodative spasm may occur
will worsen the situation. due to various functional or organic reasons.
• Near vision usually not affected but in • Spontaneous spasm of accommodation is
advanced cases the near vision is also rarely seen in young children with decrea-
affected and after reading a few pages the sed visual acuity who try to compensate for
print becomes blurred and letters get their refractive error (usually hypermetro-
confused. This condition will improve after pia, may be astigmatism or myopia also)
taking the rest or closing the eyes for some especially when doing prolonged near work
time. in conditions such as poor illumination.
• Ocular asthenopic symptoms like headache, • Use of miotic drugs: Certain strong miotic
fatigue, discomforts in eyes and tiredness drugs like echothiophate and Di-isopropyl
are usually present especially when doing fluoro phosphate (DFP) on instillation may
near work. cause spasm of accommodation. Young
Treatment glaucoma patients using pilocarpine having
It can be treated effectively with a good associated myopic error may also develop
prognostic outcome. accommodative spasm.
• Correction of refractive errors: Refraction • Brain stem lesions such as meningitis,
should be done under full cycloplegia and tabetic crisis and epidemic encephalitis, in
correction of refractive error done by their irritative phase may be associated with
prescribing glasses of power having 1 D less spasm of ciliary muscle.
than the total correction. In recalcitrant • Toxic adverse effects due to some drugs like
cases to ensure absolute visual rest, eyes are sulphonamides, arsenic or even excessive
kept mildly under the influence of atropine smoking may sometimes induce accommo-
for a period of one to two weeks. This will dation spasm.
allow the overexcited ciliary muscle to • Spasm of near reflex is characterized by
recover from its irritable condition. miosis, excessive accommodation and
intermittent convergence strabismus, to physiological deficiency of accommodation,

usually functional in origin (seen in hysteria which leads to a gradual diminution of near
or tense individuals). vision.
• Inflammatory condition of eye: Iridocyclitis Changing pattern of amplitude of accommo-
or other inflammatory condition of eye may dation with age: Age related change in the
cause spasm of accommodation. power of accommodation can be understood
• Other conditions: Trigeminal neuralgia, easily by the graph (Fig. 7.10) composed by
dental wound, sympathetic and parasym- Fisher.
pathetic imbalance are other precipitating This graph is representing average
factors of accommodative spasm. amplitude of accommodation (the ordinate)
Symptoms in relation to advancing age (the abscissa). We
know that far point in emmetropes is at
• Blurred vision for distant objects because
infinity, while near point varies with the age
of pseudo myopia. Near point is shifted
of person. During early childhood (10–12
abnormally close to eye.
years) the amplitude of accommodation is
• Asthenopic symptoms: May be more than
about 14 D, and near point (punctum proxi-
visual symptoms in the form of headache
mum) is at a distance of about 7 cm. Thereafter,
and brow ache.
with advancing age there is gradual reduction
• Macropsia, a condition where objects of the amplitude of accommodation in linear
appear larger than they really are, may fashion and by the age of 30–36 years
appear due to optical delusion. amplitude becomes nearly 50% of original, i.e.
• Sometimes patient may complain of gastric about 7 D while near point moves away at
problems due to reflex mechanism. distance of about 14 cm. By the age of 45 years
Treatment amplitude remains only 4 D and near point
• Medical treatment is done by inducing reaches about 25 cm. At age of 60 years the
relaxation or paralysis of ciliary muscle. amplitude remains only 1 D. Normally, we do
Complete paralysis of ciliary muscle is done near work at an average distance of 28–30 cm
for a long period ( 4 weeks) by using and in emmetropes this final limit to see the
cycloplegic drug like atropine. Sometimes, near objects clearly is achieved at about
spam may reappear, once the effect of 40–45 years of age when the power of
cycloplegic is over. In this situation, it is accommodation remained only of 4 D. Hence
advised to start atropine again for further to work continuously at the near point of
period of time.
• Post cycloplegic optical correction: Glasses
of appropriate power should be prescribed
immediately after the effect of atropiniza-
tion is over.
• General measures should be taken to
prevent spasm as described in excessive
accommodation section.
Decreased Accommodation
Physiological: Presbyopia
Presbyopia or eyesight of old age is not
considered as refractive error; rather it is an Fig. 7.10: Graph showing variations of accommo-
age related decline in visual acuity, occurs due dation with age
25–30 cm at this age, the person has to use the capsule is not able to mold the hardened
whole of the available accommodative power lens. There is also change in size and volume
which puts a substantial strain on the eye and of the lens.
produce asthenopic symptoms. To avoid these • Age related decrease in ciliary muscle
symptoms due to eye strain it is necessary that activity: With increasing age the contractile
about one-third of total accommodation must power of ciliary muscle is decreased and
be in reserve. It is clear that as the near point angle of insertion of zonules on lens
reaches to 25–30 cm, it means presbyopia has changed.
started and the person needs visual aid for Usual age of onset of presbyopia is 40–45 years.
near work at this point. Presbyopia in However, in some situations premature onset
emmetropes usually starts at the age of of presbyopia may occur, like in
40–45 years. However, depending on the
• Uncorrected hypermetropia
refractive status of person also, the age of onset
• Chronic simple glaucoma
of presbyopia may vary. For example, in
uncorrected hypermetrope the symptoms of • General debility and chronic illness: Poor
presbyopia appear at earlier age because in nutrition and more exposure of sunlight
hypermetrope near point is significantly away predispose early changes in lens.
from the beginning of life thus hypermetrope • Premature nuclear sclerosis of lens
person exerts own voluntary effort in the form Symptoms
of increased accommodation to correct the • Difficulty to focus on near objects: As the
error. In contrary, the myopes rarely or never amplitude of accommodation declines, it
develop presbyopia because near point becomes difficult for person to do near
distance of myopes lies within working work at usual distance. In initial stage,
distance. presbyopes feel difficulty in reading of
Age of onset of presbyopia also depends on small fonts or to see finer objects, especially
reading habits and profession of an individual. in dim light (e.g. evening). To get clear
For example, if a person has a habit of reading vision they usually try to hold their head
books more closely, has greater chance to backwards, keeping the book at more
develop presbyopia at early age than who distance and prefer to read in bright light.
maintain some distance while reading. However, with decrease in accommodation
Similarly, the professionals who are musicians, the vision is reduced even in bright light
carpenter, etc. (who do work at 30–35 cm and finally it becomes impossible to do near
distance) will need visual aid for presbyopia work.
at later age as compared to professionals
goldsmiths, compositors , engravers, etc. (work Note: There is less difficulty in bright light because
at small distance of about 20–25 cm). constriction of pupil (miosis) occurs in bright light
which will further increase the depth of focus.
Etiology of Presbyopia
• In more old age, when there is no
Presbyopia occurs due to loss of accommo- accommodative power in the eye but the
dation with advancement of age. This person can see the near objects clearly up
decline in accommodative power may occur to some extent. This is because of decrease
due to in the size of pupil (senile miosis) at this
• Age related changes in crystalline lens and age.
its capsule: With advancing age sclerosis
(hardening) of the lens tissue is increased Note: Presbyopic symptoms are exaggerated by
and there is change in the ratio of elasticity associated systemic illness, fatigue, or debilitating
of lens capsule and lens matrix, as a result diseases.
• Asthenopic (eye strain) symptoms may individual requirement (e.g. working

appear due to decrease of ciliary muscle power distance for an executive will be more,
and its fatigue. Headache and tiredness of so lesser add is required) and correction
eyes are common after reading for a longer should be done on individual basis.
duration or doing near work continuously. A rough estimate of addition power
• Sometimes, person may experience diplopia requires at various age groups especially
due to dissociation between accommodation in emmetropes is shown in Table 7.5.
and convergence. • Power of presbyopic addition is pres-
Treatment of presbyopia cribed as per the need of working
Presbyopia can be treated by: distance required by a particular person.
According to working distance the
• Optical correction
power of addition will change among
• Surgical correction
the patients having similar type of
Optical correction: Glasses should be refractive status.
prescribed after evaluation of static refraction An emmetropic person in his/her
in both eyes (binocular) and in individual eye late 40s has been left with only 4–6 D
(monocular). Convex lenses of suitable power total amplitude of accommodation. For
should be added for clear and comfortable various working distances addition
near vision. The purpose of prescribing given to this person is shown in Table 7.6,
addition is to reinforce accommodation so sparing him/her with a comfortable
that the near point lies into a useful working 50% of accommodation.
distance after addition. Thus, an addition or • In all cases, it is advised that convex lens
add is the difference between distance of weakest power (under correction)
correction and near correction, in terms of with which a person can see the near
power of lenses. object clearly and comfortably should be
Some basic rules which should be followed given. As overcorrection or prescribing
for optical correction in presbyopes are of strong lenses will disturb the associa-
• First do the refraction under cycloplegia tion of accommodation and convergence
and mydriasis and correct the refractive and lead to asthenopic symptoms, i.e.
error for distance, if present. headache.
• After correction of distant vision,
estimate the amount of correction Table 7.5: Presbyopic addition at various age groups
required for presbyopic error in each eye Age in years Addition in dioptre
separately, i.e. find out the working 40–45 +0.75 to + 1.25
distance and amplitude of accommoda- 46–50 +1.5 to +1.75
tion. Add this correction with the 51–55 +2.0 to +2.5
distance correction. 56–60 +2.5 to +3.0
• Presbyopic correction should be given > 60 Variable
in such a way that at least one-third of
accommodation remains in reserve for Table 7.6: Estimated addition in relation to working
symptom free reading and near point of distance
presbyope comes into useful working Working distance Add power (dioptres)
distance.
1/4 meter or 25 cm + 2.5
• However, the limit of accommodation
1/3 meter or 33 cm + 1.75
and working distance vary in individuals
0.4 meter or 40 cm + 1.0
according to profession and age. Hence,
Half meter or 50 cm + 0.5
near point is decided on the basis of
Note: For an intermediate distance vision an

additional correction may be required if patient
wants to see the objects at an intermediate distance.
Addition for intermediate vision: When

amplitude of accommodation decreases the
addition power will increase, so that the range
to see near objects also decreases and it may
produce dissatisfaction in an aging person. In
simpler words, the range of near vision
decreases with increase of addition power.
For example, if we consider a 42 years old
emmetrope who works normally at distance Fig. 7.12: Range of clear near vision with +2.5 D
of 38 cm, will have total amplitude of lenses
accommodation of about 4 D. Suppose if this
person has been prescribed with reading Being an emmetrope even at an age of
glasses of power +1 D bilaterally, then his 62 years this person will see the distant objects
range to see the near objects clearly through clearly without wearing glasses, however he/
these reading glasses will begin from point A she can see near objects clearly in very small
at a distance of 1.00 meter (or 1/1 D) from eye range (as shown in Fig. 7.12) after wearing
and will extend up to point B at a distance of reading glasses.
0.2 meter (1/(4 + 1) D = 1/5 D) as shown in If this person desires to see the objects
Fig. 7.11. situated at an intermediate distance (say at 50–
The same individual after 20 years (about 60 cm) after wearing the reading glasses, then
62 years) will be left with only 1.25 D of total the objects will appear blur because they are
amplitude of accommodation. Suppose , if the situated out of the range of clear vision. To
working distance of this individual is still increase the range of clear vision in this patient
38 cm, and an addition power of +2.5 D has we need to prescribe an intermediate
been prescribed for near vision, then his range additional power, along with near add. These
to see the near objects clearly through these intermediate additions are usually one-half
glasses begins from point A at a distance the power of near correction. Hence, in this
1/ 2.5 D or 0.4 meter from eye and extends up emmetropic patient the range for intermediate
to point B at a distance 1/(2.5+1.25) = 1/3.75 objects can be widened by giving an
or 0.26 meter as shown in Fig. 7.12. intermediate addition of +1.25 D along with
+2.5 D near add. With this prescription person
can see clearly an additional range which
starts from point A at a distance 1/1.25 D or
0.8 meter up to point B at 1/(1.25 + 1.25) =
1/2.5 D = 0.4 meter also. However, the near
add of +2.5 D give total near vision range up
to point C at 0.26 meter as shown in Fig. 7.13.
In a nutshell, near vision range with only
+2.5 D was 0.26 to 0.4 meter, which widened
to 0.26 to 0.8 meter after adding intermediate
power of +1.25 D in glasses.
Modes of prescribing presbyopic correction
Fig. 7.11: Range of clear near vision with +1 D lenses Various types of following optical glasses
Fig. 7.13: Increased range of clear near vision by adding intermediate power +1.25 D with existing near
addition +2.5 D power lenses
• If the patient is emmetrope or having a non-

significant distance error, then single vision
reading glasses are the best choice for near
vision. Because the distance vision becomes
blur through these reading glasses, so to see
the distant objects clearly patient can
remove these glasses or can look from
above these reading glasses. Alternatively,
plano focal or bifocal glasses can be
prescribed. Plano focal glasses have no
power for distance in upper segment and
have suitable near addition power in lower
segment. Bifocal glasses are prescribed to
those who also have refractive error for
distance. These glasses have power both in
distant and near segments.
Fig. 7.14: Various optical glasses for presbyopia • If a presbyopic patient has refractive error
correction in distance vision and also wants to see the
(Fig. 7.14) can be prescribed in presbyopes as intermediate distance objects clearly, then
per the requirements of patient either trifocal or multifocal glasses are
• Monofocal reading glasses prescribed to see the distant, intermediate
• Plano focal glasses and near objects clearly.
• Bifocal glasses Surgical correction: Various refractive surgical
• Trifocal glasses correction procedures of presbyopia are
• Multifocal glasses described in Chapter 15.
Pathological Note: Symptoms of accommodation insufficiency

Insufficiency of Accommodation developing due to lenticular changes usually
remain stable, however, if they occur due to ciliary
When accommodative power of eye is
muscle weakness they may show improvement
significantly less than that of normal
when general and ocular condition of patient is
physiological limits adjusted for his/her age, improved and excessive near work or strain due to
is called insufficiency of accommodation. near work is reduced.
Note: In presbyopia physiological limits of
• Blurring of vision: Occur during near work
accommodation are normal according to the age
and sometimes it becomes impossible to
of person.
perform the near work.
Aetiology • Intermittent diplopia due to disturbance in
• Ciliary muscle weakness or fatigue: May convergence: Usually the accommodation
occur due to insufficiency is associated with convergence
Systemic illness causing muscular fatigue: As failure, but occasionally, if a patient tries to
seen in anemia, malnutrition, diabetes overcome accommodation insufficiency
mellitus, stress, debilitating diseases, then excessive amount of convergence may
toxemia due to infections or chronic occur.
alcoholism, etc. Excessive near work done Treatment
in unfavorable conditions in presence of Treatment of insufficiency of accommodation
ciliary muscle fatigue may lead to failure is done on following guidelines:
of accommodation followed by asthenopic • Proper treatment of the systemic and ocular
symptoms. causes: All the systemic or local causes
Ocular diseases: Ciliary muscle weakness responsible for accommodative failure
may also occur due to ocular causes such should be detected and treated accordingly
as primary open angle glaucoma, sympa- to give improvement in accommodation.
thetic ophthalmia causing mild cyclitis. Work conditions (avoid overwork or
• Lenticular changes such as nuclear sclerosis worry) should also be regulated with
of lens which indicate onset of premature improvement in general health for good
presbyopia and only physical accommoda- results. If the same conditions prevail again,
tion is affected. Hence this is a stable then there are chances of recurrence of
condition and gives rise to no symptoms symptoms.
except those of presbyopia, which sets in • Optical correction for near vision: In every
unusually at early age. case any refractive error for far should be
Symptoms corrected first. If still vision for near work
Symptoms of this condition are similar to is blurred, then spectacle with weakest
presbyopia except that asthenopic symptoms convex lenses is prescribed which give the
are more pronounced than visual symptoms. adequate amount of vision, till there is an
Patients usually present with following improvement in power of accommodation.
symptoms – If an associated convergence insufficiency
• Asthenopic symptoms while doing near is present, then base in prism of adequate
work: Patient may complaints of headache,
irritability, tiredness, early fatigability of Note: In a nutshell any type of refractive error
eyes while making an effort to do near should be fully corrected and when a recovery in
work. Normally, the patients remain accommodation is seen, then the additional power
asymptomatic if they do not perform any for near is made weaker gradually at regular
near work. intervals of time.
power are added to improve the comfort change focus. In inertia of accommodation
of patient. patient takes some time along with some extra
– If an associated convergence excess is efforts to focus a near object, after looking a
present, then full spherical correction is distant object for some period.
done. Symptoms: Typically patients complain that
• Exercises for improvement of accommo- they need some time and some extra efforts
dation: Accommodation exercises are to focus near object after looking a distant
helpful in those cases object for long duration. Some frustration and
– where accommodation insufficiency is trouble may be created by this condition
due to decreased activity of ciliary muscles. although it rarely poses any serious problem.
– who are not having lenticular sclerosis
Treatment
(early cataract) and state of general
• For symptomatic relief optical correction of
debility or has recovered from it
associated refractive error should be done.
Methods to perform accommodation exercises • Accommodation exercises are advised for
are relief for long duration.
• Distance correction glasses should be worn
during accommodation exercises. Ill Sustained Accommodation
• Exercises can be done with the help of a This is also termed condition of accommo-
simple accommodation test-card. The test dation fatigue and mainly refers to a situation
card simply has a black vertical line drawn where range and amplitude of accommoda-
on a white background card. These tion is normal but patient is not able to
exercises should be done at short periods maintain the accommodative efforts for a long
throughout the day. time period. Hence, in an effort to use eyes
• The patient is asked to hold this card at a for a near work over a prolonged period
considerable distance and then bring this weakens the accommodative power so that the
card closer to the eyes until the black near point progressively recedes and blurring
vertical line of card becomes blur and of near vision occurs.
indistinct. Encourage the patient to repeat Causes
this procedure in an attempt to bring his/
Ill sustained accommodation is considered the
her near point as close as possible to eyes.
initial stage of true accommodation insuffi-
Along with this ask the patient to maintain
ciency hence causative factors is same as in
his/her accommodation efforts as long as
true insufficiency. However, accommodation
possible with comfort, while keeping the
fatigue characteristically seen in following
vertical line clear.
situations
• Exercise should be done with both eyes
• Person is recovering (convalescence stage)
simultaneously if there is convergence
from debilitating illnesses.
deficiency. However, in case of convergence
excess only one eye should be used for exercise • Person is in a state of general tiredness
at a time, other eye should be covered. • Person is reading in physically relaxed
situations or in the evening time.
Inertia of Accommodation Symptoms
This is relatively a rare condition, where Patients mainly complain that while
patient feels some difficulty in altering the performing near work they feels tired very
accommodation as per the distance or range soon. Their near point of accommodation
of the desired object. Normally the accommo- gradually recedes, which leads to blurred near
dative response occurs within one second to vision.
Treatment Symptoms
• Patients are directed mainly to reduce the • Near vision blurring: As the near point in
near work within their capabilities and paralysis of accommodation get recedes
limits of duration especially during gradually, the emmetropic or hypermetro-
convalescence and tiredness. pic person complaint of blurring in near
• Improvement in visual hygiene especially vision although it is less marked in myopes.
improvement in illumination conditions • Photophobia or glare: This happens due to
and posture while reading. the dilatation of pupil or mydriasis, which
is generally associated with paralysis of
Paralysis of Accommodation accommodation.
Paralysis of accommodation means the • In cases of paralysis of accommodation,
accommodative system of eye does not respond ocular examination shows an abnormal
to any stimuli, i.e. complete absence of accommo- receding of near point (which approximates
dation. It can be unilateral or bilateral, sudden the far point) and a decreased range of
or insidious in onset and may or may not be accommodation.
associated with palsy of extraocular muscle • Phenomenon of micropsia may also occur
and fixed dilated pupil (paralytic mydriasis). because a delusion of distance may be
Aetiology induced by accommodative anomaly and
Paralysis of accommodation may be due to objects will appear smaller than their actual
• Ocular causes size.
– Exposure of eyes to parasympatholytic Treatment
drugs like atropine, homatropine, etc. • Primarily this condition is resolved once the
– Traumatic injury, glaucoma and cyclitis treatment of its cause is done. For example,
in eye. in drug induced paralysis once the effect of
• Systemic causes drug is over, self recovery occur. Similarly
Systemic causes may cause paralysis of treatment of toxemic conditions like
accommodation by affecting oculomotor diphtheria, diabetes or poisoning, etc. will
nerve, ciliary muscle, sphincter pupillae give favorable results.
and midbrain region. Causes may be • However, in some cases of traumatic
– Infectious diseases may act either injuries, the recovery may be incomplete or
centrally or via peripheral neurotoxin totally absent. Presbyopic spectacles
mechanism includes mumps, herpes (convex lenses) may be prescribed in these
zoster, tonsillitis, infectious mononucleo- cases for near work or for reading purpose.
sis, pneumonia, diphtheria and typhoid. • Photophobia or glare can be reduced by use
– Central neurological disease and of dark glasses.
infections: Vascular disorders, cerebral
syphilis, epidemic encephalitis. Pharmacological Deficient
Accommodation
– Non-infectious toxic conditions like
chronic alcoholism, diabetes mellitus, Cycloplegia
botulism, lead poisoning or belladonna Cycloplegia (cyclo = ciliary and plegia = palsy)
intoxication may also be responsible. means paralysis of the ciliary muscle or
– Intracranial or orbital lesions such as paralysis of accommodation of the eye.
traumatic, inflammatory or neoplastic Cycloplegia can be produced by administra-
conditions causing third nerve paralysis tion of anticholinergic (parasympatholytic)
are also responsible for paralysis of drugs like atropine, homatropine, scopola-
accommodation. mine, etc. (termed cycloplegics) into the
conjunctival sac. These anticholinergic drugs Atropine

also cause mydriasis, i.e. dilatation of pupil Mechanism of action: Atropine is the most
by relaxation of the sphincter pupillae potent cycloplegic agents as compared to
(constrictor pupillae) muscle of iris. Hence, others. After administration into conjunctival
these drugs along with dilatation of pupil also sac, it gets absorbed into the anterior chamber
cause some degree of paralysis of accommo- of eye. Being parasympatholytic drug it blocks
dation. In contrast, the drugs (cholinergic drugs action of acetylcholine on ciliary muscle and
like physostigmine or pilocarpine) which sphincter pupillae muscle of iris. Thus, all the
cause the constriction of pupil, i.e. miosis will muscle fibers in eye which are supplied by
induce some degree of spasm of accommoda- parasympathetic nervous system get paraly-
tion by causing spasm of ciliary muscle. zed resulting in cycloplegia along with
Ideally a cycloplegic agent should have fast mydriasis.
onset of action, short duration of action, must
Duration of action: It causes dilatation of
produce full cycloplegia and should produce
pupil within about 15 minutes but cycloplegic
less or no ocular and systemic adverse effects.
action is slow in onset. Hence, it is advised to
Uses of cycloplegics prescribe atropine 3–4 days prior to
• Both cycloplegia and mydriasis are examination especially in young children so
required for accurate estimation of that full paralysis of accommodation is
refractive errors. Due to cycloplegic action achieved. For young people having strong
the accommodation efforts to see near accommodation, atropine should be given
objects is abolished and the refractive error thrice daily for three consecutive days to
which was latent before gets obvious (latent achieve desired results. Atropine has long
to manifest hypermetropia). It is especially duration of action and complete recovery of
required in children because they have high accommodation occurs in about 7–10 days and
amplitude of accommodation. mydriasis in 9–12 days. Effect of atropine is
• Due to dilatation of pupil (mydriasis) usually not counteracted by miotic drug like
caused by these drugs, the estimation of the pilocarpine, hence it is advised that post
amount of refractive error by retinoscopy mydriatic test should be carried out after
become easier especially in persons having 10 days in atropine treated patient.
small pupil. Dosage: It is available as 0.5% or 1% either in
• Mydriasis is also necessary for detailed the form of drops or ointment. Usually, drops
examination of interiors, i.e. fundus of eye. are watery solution of atropine sulphate,
• Symptoms of asthenopia or eye strain whereas ointment contains a 1% solution of
occurring due to spasm of accommodation alkaloid form with soft yellow paraffin base.
can be improved by using long-acting Drops can be used three times daily for 3 days
drugs, e.g. atropine or homatropine which and ointment is used specially in children once
imparts a state of rest on the eye and thus daily (usually at night) for 3–4 days before
helps it in recovery from the fatigue. examination.
Cycloplegic drugs Clinical effects: Ointment is more preferred
Various cycloplegic drugs of ophthalmic in young children because ointments can be
interest are: rubbed easily into the eyes as children resist
• Atropine strenuously for instillation of drops and fre-
• Homatropine quency of administration of ointment is also
• Scopolamine (Hyoscine) less. Moreover, it is slowly and continuously
• Cyclopentolate absorbed as compared to drops. Sometimes,
• Tropicamide symptoms of atropine intoxication may occur
because of passage of drugs through lacrimal Scopolamine (Hyoscine)

duct. Hyoscine or scopolamine bromide in 0.5%
Precautions: Application of ointment should solution has a similar action as that of atropine.
be avoided a few hours before examination of It has an advantage over atropine because of
eye because being greasy in nature ointment transitory action which lasts only for a period
may remain over the cornea and interfere with of about 4–5 days. It is a suitable cycloplegic
its transparency which in further will affect for children.
the estimation of refractive error.
Note:
Atropine should not be used in patients
• It is important to know that quantity and type of
with closed-angle glaucoma and in hypersen- cycloplegia is not always same for each
sitive patient. individual. The dosage of cycloplegics requires
Homatropine to produce the adequate degree of paralysis of
Mechanism of action of homatropine is similar accommodation may vary significantly in
individuals. Sometimes, even the two eyes of
to atropine, however, onset of action is rapid
same individual may show different degree of
and less potent as compared to atropine.
cycloplegia in response to same dose of a
Duration of action and dosage: As compared cycloplegic drug, a condition called anisocyclo-
to atropine its action starts within 5 minutes and plegia (0.5 D difference in depth of cycloplegia
reaches its maximum within 45–50 minutes is commonly seen, in exceptional cases it may
and also the duration of action is short, its reach up to 10 D)
effects usually last up to 24 hours, however, • It has been recommended that before doing
some residual impairment in accommodation refraction, the depth of cycloplegia should be
may persist for 2–3 days. Homatropine eye tested in each individual. This can be done easily
drops are available as watery solution of by using accommodation cards which is used to
test the remaining amplitude of accommodation.
homatropine hydro bromide in strength of 1%
Normally, after cycloplegia it should not exceed
or 2%. Drops are installed 3–4 times at an 1 D. It means that line on test card should appear
interval of 15 minutes to produce desired blur at a distance of 1 meter, if line is still clear
effect on accommodation for examination at 1 meter then further instillation of cycloplegic
purpose or are given as twice daily dosage for drug is needed.
therapeutic purpose. • Drugs like phenylephrine (directly acting
sympathomimetic) and cocaine (indirectly acting
Cyclopentolate and tropicamide
sympathomimetic) also cause dilatation of pupil
Cyclopentolate and tropicamide (bistropamide)
(mydriasis) but no cycloplegia. It has been
have rapid onset of action, with a satisfactory suggested that combination of sympathomimetic
cycloplegic effect. One drop of drug (0.5% and drugs with atropine or homatropine may cause
1% solutions) instilled in each eye and is synergistic action and helps to produce quicker
repeated every 10 minutes for 3–4 times will cycloplegia.
produce intense mydriasis and cycloplegia in • Instillation of cycloplegics and mydriatic drugs
about 30–45 min. Effect of cyclopentolate may precipitate glaucoma in patients especially
remains for a period of 24 hours but some with shallow anterior chamber. Hence it is
amount of accommodation insufficiency can advised to measure intraocular tension before
persist till 3–4 days. Action of tropicamide administration of these drugs especially in patient
lasts for about 4–7 hours. with more than 40 years of age.
Note: In very young children cyclopentolate due Fatigue of Accommodation

to its irritant action can produce spasm of Usually, in a normal eye fatigue of accommo-
accommodation for a temporary period. In these dation is rare; rather an excessive use of
cases it is better to use atropine for cycloplegia.
accommodation may cause increase in the
amplitude of accommodation in many cases. object to the patient eye till that target
However, when the visual tasks are repeated appears blurred. The details of target
for a long time in the range which lies near movement pathways are recorded on a
punctum proximum, an accommodation drum automatically. The target movement
fatigue can develop even in normal emmetro- pathways should not be diminished for a
pic eyes. The most common symptom is minimum period of 15 minutes, because
asthenopia. Most commonly adopted techni- usually after 15 minutes duration a general
que to measure the fatigability of accommo- fatigue will be noted.
dation was developed by Lucien Howe,
which was further modified by scientist Note: Fatigue responses of two eyes are different
Berens. Test is done by repeatedly and either of the uniocular response again may
presenting a target carrying a dot or small differ from binocular response.
8 Convergence and its Anomalies 163
Convergence and
its Anomalies
Learning Objectives
• Describe convergence and its types in detail.
• Measure AC/A ratio by various methods.
• Explain meter angle and prism dioptre.
• Understand far point and near point in various refractive status of eye and calculate range and amplitude
of convergence by various methods.
• Describe clinical features, diagnostic methods and management of convergence insufficiency.
• Understand convergence spasm and its treatment.
• Enumerate the causes, diagnosis and treatment of convergence paralysis with associated
syndromes.
Chapter Outline
• Convergence Objective convergence
– Introduction Subjective convergence
– Types of convergence Accommodation test
Voluntary convergence – Measurement of amplitude of convergence
Reflex convergence Prism bar method
Tonic convergence Synoptophore method
Accommodative convergence • Convergence Anomalies
– Measurement of AC/A ratio – Insufficiency of convergence
Heterophoria method – Primary convergence insufficiency
Gradient method Causes of convergence insufficiency
Fixation disparity method Symptoms of convergence insufficiency
Haploscopic method Diagnosis of convergence insufficiency
Fusional convergence Differential diagnosis of convergence
Proximal convergence insufficiency
– Measurement of convergence Management of convergence insufficiency
Meter angle – Secondary convergence insufficiency

Prism dioptres – Convergence excess
– Range and amplitude of convergence – Convergence spasm
– Measurement of near point of convergence – Convergence paralysis
163
CONVERGENCE Table 8.1: Types of convergence

Introduction Voluntary convergence Involuntary or reflex
When an emmetrope person looks at a distant convergence
object, the position of visual axes is parallel to • Tonic convergence
each other and there is no associated • Accommodative
accommodative effort. However, as the convergence
fixation point change from distant point to a • Fusional convergence
nearer point, then to see the near object clearly • Proximal convergence
there is an effort of accommodation (increase
in refractive power of eye) and also the visual convergent position of eyes even in absence
axes rotate inwards to maintain a defined of fixation object. It is more commonly seen
image formation on the retina or fovea. In in children where it is done in an attempt to
other words, we can say that the angle formed gain attention of their parents. Voluntary
between visual axes of two eyes will increase convergence is centered in frontal lobe of
to maintain image of object at two foveae. This cerebrum. Every person is not skilled enough
change in the relative position or movement of converging at will, but if voluntary
of visual axes is known as convergence. Hence convergence is well developed, then reflex
type of convergence usually becomes more
Convergence means the simultaneous and
automatic and efficient.
synchronous inward rotation of both the eyes to
maintain single binocular vision as the fixation Reflex (Involuntary) Convergence
point alters from more distant to a nearer point.
As the term implies the phenomenon of
Amplitude of convergence is not influenced
convergence is not under voluntary control.
by the process of ageing as seen in case of
Rather it is a psycho-optical reflex controlled
accommodation (decline in accommodation
by peristriate area of occipital cortex and by
occurs with increasing age). Usually, conver-
centre for fixation reflex. It has four elements
gence does not change with progression of
age. However, associated abnormal systemic • Tonic convergence
and ocular conditions may decrease the power • Accommodative convergence
of convergence while various ocular exercises • Fusional convergence
show positive influences on the power of • Proximal convergence
convergence.
Tonic convergence: When a person is awake
and alert, it is the tonic convergence which
Types of Convergence
decides the relative position of visual axes and
Convergence per se is a complex process and helps to maintain the parallelism of the eyes
can be grouped as shown in Table 8.1. at infinity. This tonic convergence is
considered due to presence of intrinsic
Voluntary Convergence innervational tone in extra ocular muscles of
Convergence is the only vergence movement eye which arises because of various excitatory
of the eye that can be exerted at will also. and inhibitory inputs arising to extraocular
Normal type of convergence which occurs muscles from cortex, subcortex or vestibular
during normal visual and ocular activities is center. Normally due to effect of this tone eyes
essentially a reflex mechanism. However, it become more convergent as compared to
can be produced by voluntary rotation of both previous condition, however, anatomically still
the eyeballs also, so that the visual axes of both the eyes remain divergent in relation to each
the eyes intersect to focus on the object. With other. Tonic convergence does not depend on
practice some person can maintain this fusion or location of the object. However,
Convergence and its Anomalies 165
amplitude of tonic convergence deceases with whereas low ratio indicates that eyes are under
advancement of the age and is totally abolished converging for given amount of accommo-
under deep general anesthesia. Emotional dation and may cause more exotropia
status of a person can also affect tonic (divergent squint) and less esotropia on near
convergence. vision. The AC / A ratio states a linear relation-
Accommodative convergence: As the name ship which usually does not change throughout
implies an accommodative convergence is that life.
component of convergence which occurs AC / A ratio is of two types:
along with accommodation of eye. As 1. Stimulus AC / A ratio: When eyes are
discussed above disparity of retinal images is stimulated with lens of different power
responsible for stimulation of fusional or object at different distance (i.e.
convergence. However, stimulus for accommo- stimulus), then there is change in
dative convergence is blurring of retinal convergence capacity of eyes resulting
images, not retinal disparity. As a response to in change in accommodation. Usually,
blur image, the impulse are discharged to eyes the stimulus is presented at distance of
from central system for accommodation and 40 cm which require accommodation of
then the visual system tries to clear the blur about 2.50 D
images by mechanism of accommodation. 2. Response AC / A ratio: It indicates the
Hence we can say that both accommodation response of accommodation which
and convergence are related to each other and occurs due to change in convergence
are in synkinetic relationship along with capacity of eyes. As discussed above the
contraction of pupil (miosis). Thus, the central stimulus for accommodation is of 2.5 D
mechanism to focus the near object is (40 cm) but the accommodative response
governed by a synkinetic near reflex, which is generally 10% less than this stimulus
consists of three elements (2.5 D) and there is accommodation lag
• Accommodative convergence of about + 0.25 D to + 0.50 D.
• Accommodation Measurement of AC/ A Ratio
• Miosis Measurement of AC / A ratio can be done by
The quantitative relationship between following methods
accommodative convergence (AC) and • Heterophoria method
accommodation (A) is denoted as AC / A ratio, • Gradient method
i.e. it is the change in the amount of conver-
• Fixation disparity method
gence due to change in specific amount of
accommodation. The amount of accommoda- • Haploscopic method
tive convergence is measured in prism dioptre Heterophoria method: This test is based on
and that of accommodation is measured in the fact that changes in the accommodation
lens dioptres, hence the ratio can be denoted cause change in amount of convergence and
as number of prism dioptre induced by per accommodation can be altered by changing
one diopter of accommodation. the fixation distance of eyes. In this method
An accommodative convergence of 3–4 the distance and near deviation of eyes are
prism dioptre for 1 D of accommodation is measured which are then compared to find
considered as a normal AC / A ratio. High ratio out AC / A ratio. Deviation of eyes in distance
indicates that eyes are over converging for a vision (d in prism dioptre) is measured at
specific amount of accommodation and 20 feet after giving full optical correction and
responsible for more esotropia (convergent assuming that accommodation is at rest.
squint) and less exotropia on near vision, Deviation of eyes in near vision (n in prism
diopter) is measured at 33 cm (or 3 D) versa a minus lens will increase the

assuming that the convergence applied is requirement of accommodation thus associa-
caused by accommodative convergence solely. ted with increased convergence (eso-shift).
Interpupillary distance (IPD) is measured in This method measures the change in deviation
centimeters by using ruler. of eye due to change in lens induced accommo-
Now AC / A ratio can be calculated by dation.
applying this formula using all these value as Moreover, a +1 D power lens will relax
∆n – ∆d accommodation equivalent to 1 D while –1 D
AC / A = IPD + power lens will increase accommodation
D
Here, equivalent to 1 D, thus the accommodative
response produced due to lenses and
IPD = Interpupillary distance (cm)
accommodative convergence will be in linear
n = Deviation of eyes in near
relationship in a certain range.
vision (prism dioptres)
First, with full optical correction original
d = Deviation of eyes in distance
deviation for near vision of patient is
vision (prism dioptres)
measured using prisms. Then measure
D = Accommodation for near patient’s deviation for near vision after adding
fixation (dioptres) lenses (say +3 D power) in both sides of trial
Conventionally, for calculation purposes frame. AC / A ratio is calculated by using
esodeviation are prefixed with a plus (+) sign following formula
and exodeviation are prefixed with minus (–)
sign. ∆l − ∆O
AC / A =
For example, if a patient has 12 exophoria D
for near and 6 exophoria for distant vision Here
with an IPD of 6 cm, then by formula O = original deviation without
[−12 − (−6)] additional power
AC / A = 6 + l = deviation with additional
3D
(−12 + 6) power of +3 D
= 6+ D = dioptric power of additional
3
lens (here +3 D)
( −6) For example, if a patient has original
= 6+ =6–2
3 deviation of 4 exophoria for a given distance
AC / A = 4 and deviation of 8 esophoria is induced after
Means, 4accommodative convergence is adding +3 D lenses, then AC / A ratio will be
applied for each dioptre of accommodation. 8 − ( −4)
AC / A =
Normal AC / A ratio for heterophoria 3
method is considered as 4:1.
8+4
Gradient method: In gradient method the =
3
stimulus for accommodation is generated by
use of ophthalmic lenses (plus or minus = 4
spherical lens) in place of distance variation. Second way to calculate AC / A ratio is to
Hence, the calculation of AC / A ratio is based measure original deviation (O) for a fixation
on theorem that plus lenses placed before the distance of 33 cm with full optical correction.
eyes will relax (decrease the requirement) the Then add –3 D power lens in front of both the
accommodation and due to less accommoda- eyes and again measure the deviation (l).
tion there will be less convergence and vice Calculate the AC / A ratio as discussed above.
Note: AC / A ratio calculated by Heterophoria • Interpupillary distance (IPD) affects the

method is usually more than AC / A ratio calculated AC / A ratio, because persons having wide
by gradient method, mainly due to the effect of IPD needs more convergence power as
proximal convergence. So, it is considered that only compared to persons having narrow IPD,
gradient method gives a true estimate of AC / A to look at same fixation distance.
ratio because of presence of consistent tonic, • AC / A ratio anomalies play an important role
proximal and fusional convergence. in etiology of strabismus. A high AC / A
IPD measurement is taken in calculation by ratio will cause excessive convergence,
heterophoria method but not in gradient method. which leads to a convergent squint or
Fixation disparity method: This method was esotropia, whereas a low AC / A ratio will
introduced by Ogle and coworkers however, lead to a divergent squint or exotropia,
being a complex method, it is not commonly when patient is focusing a near object.
used in clinical practice. The AC / A ratio is
calculated indirectly on the basis of disparity Fusional (Positive) Convergence
of fixation object. This disparity is induced by Fusional convergence (positive convergence)
changing the accommodative stimulus with is a type of optomotor reflex (involuntary) and
help of ophthalmic lenses in one group while it is stimulated by retinal image disparity. As
in second group forced convergence is we know fusion of two similar object images
induced with help of prism. The data collected is important to achieve binocular single vision.
from these two groups are then analyzed to Whenever there is retinal image disparity, the
find out those accommodation and conver- fusional convergence is stimulated to adjust
gence stimuli which produced same amount the visual axes in such a form that similar
of fixation disparity. retinal images are formed on two fovea of both
the eyes to ensure bifoveal single vision. It is
Haploscopic method: Original haploscope
because of fusional convergence person does
instrument was designed by Herring’s with
not feel diplopia. For example, if a person is
the purpose to study the relationship between
having 4 prism diopter of esophoria then 4 D
accommodation and convergence. In
fusional convergence is required to avoid
haploscope each eye is presented with a
diplopia. During fusional convergence there
separate target to differentiate the visual
is no change in the refractive status of eye.
fields of two eyes. Like fixation disparity
Studies show that fusional convergence is
method it is also not routinely used in
disrupted if one eye is occluded or there is
clinical practice. However, instruments
extreme blurring of image on one eye. Normal
based on this design like Synoptophore are
range of amplitude of fusional convergence is
used clinically to study various conditions
14–20 D for distance and 35–40 D for near. In
of the eyes.
normal circumstances the fusional conver-
Clinical significance of AC / A ratio gence keeps the eyes in orthophoric position
• In presbyopes, the AC / A ratio usually by controlling the lateral divergence of eyes;
remains stable, indicates that it is dependent however systemic illness or ocular fatigue can
on stimulus for accommodation, not on lead to heterophoria and heterotropia. In simpler
amount of accommodation. words, latent divergent squint (exophoria) can
• AC / A ratio is normally higher in majority convert into manifest squint due to decreased
of myopes and lower in majority of hyper- fusional convergence. Hence, fusional conver-
metropes as compared to emmetrope. gence has important role in motor anomalies.
Although, magnitude of AC / A ratio has Orthoptic exercises help in improving the
no association with degree of hypermetro- amplitude of fusional convergence, hence are
pia or myopia. useful in management of heterotropia.
Proximal (Psychic) Convergence present or is placed at infinity. Like accommo-

Usually, during clinical examination the dative convergence an inverse relationship
esodeviation measured by synoptophore is exists between proximal convergence and
found more as compared to the esodeviation observation distance (indicate change in
measured by prism bar and cover test. vergence, i.e. in dioptres). Hence change of
Similarly, if we measure near deviation in a vergence of 1 D means a change in fixation
patient (after full optical correction) by placing from infinity to 1 meter distance. Normally,
equivalent lenses for near distance, then an approximate 1.5 prism dioptre change
theoretically, the near deviation should be occurs in proximal convergence with each
equal to distance deviation because equivalent dioptre change in distance.
lenses had been used, however, actually the
Measurement of Convergence
deviation is found larger for near than
distance. Possible explaination for these two Convergence angle: As it has been discussed
instances is that either accurate full optical above that when eyes are at rest the visual axes
correction was not given or the difference in are parallel to each other but as the eyes focus
deviation is caused by proximal convergence. on a object at a distance then an angle is
Proximal convergence is the convergence formed.
resulting due to proximity of an object or due Convergence angle is an angle formed
to awareness that an object is placed nearby. between two primary lines of vision during
In the above discussed instances the proximal convergence as shown in Fig. 8.1A. Value of
convergence was stimulated because during convergence angle depends on two factors:
measurement of near deviation there was Distance of fixation object from eyes and
proximity (nearness) of an object. While in distance between two pupils, i.e. IPD. Size of
synoptophore the awareness of nearness was angle is decreased with an increase in the
present because in reality object was situated distance of fixation object (Fig. 8.1B) and
near but made to appear optically placed at increased with increase in IPD (Fig. 8.1C). IPD
infinity. Psychological status plays an shows no appreciable effect on convergence
important role in initiation of proximal angle, so practically during measurement of
convergence because even the thought of convergence angle we can exclude IPD.
looking at near object will induce convergence Convergence angle of eyes can be measured
of eyes; although in reality the object is not either as meter angle or prism dioptres.
Fig. 8.1: A. Convergence angle; B. Convergence angle becomes smaller with increasing object fixation
distance; C. Convergence angle becomes larger with increasing IPD
Meter Angle
Nagel introduced unit of measurement for
convergence angle as meter angle. When eyes
are directed to an object situated at distance
of 1 meter (distance measured from a
midpoint of meridian line drawn between two
eyes), then the angle formed by visual axes of
both eyes with the meridian line will be equal
to one metre angle.
The convergence exerted by each eye in
meter angle (ma) depends on the distance
(meters) of object situated in front of eyes and
on IPD. It varies inversely with the distance
of object. For example, convergence will be of
2 ma for a distance of ½ meter and only ½ ma
for a distance of 2 m, as shown in Fig. 8.2. It is
based on the similar comparison for the
dioptre. In an emmetropic eye to see an object
clearly the amount of accommodation in Fig. 8.2: Meter angle
dioptres is equivalent to value of meter angles
exerted by each eye to converge and see the
same object clearly. It means that 1 D of
accommodation is associated with 1ma of
convergence exerted by each eye.
Prism Dioptres
Convergence can be expressed in terms of
prism dioptres () also, which is a tangent
measurement. Consider if an adducting or
converging prism (base out) is positioned in
front of an eye then it will produce diplopia.
Diplopia is produced due to deviation of rays
of light in outward direction (depending on
the strength of base out prism) by the prism
before they enter the eye. In normal situations
to avoid this diplopia, the eye will turn in
inward direction and tries to maintain
binocular single vision. The convergence
(degree of inward deviation) of eye will be Fig. 8.3: Prism dioptric convergence
equal to the degree of outward deviation of
light rays. convergence is approximately equal to 3 prism
The amount of convergence exerted by the dioptre convergence (1 ma = 3).
eyes to see an object (placed at 1 meter distance
from eyes) as single, when base out prism of Range and Amplitude of Convergence
1 prism dioptre power is placed in front of one To understand range and amplitude of
eye, is termed 1 prism dioptre () convergence convergence it is essential to know the far
(Fig. 8.3). On convergence scale, 1 metre angle point and near points of convergence.
Far point (punctum remotum) of conver- plastic ruler or metallic ruler where fixation
gence: It is the farthest point from the eyes, target for test is common objects like tip of
where an object can be seen clearly while pencil or could be specially designed rulers,
accommodation is at rest. It is considered as for example, Livingstone binocular gauge,
the relative position of eyes at rest and in Beren’s rule, Prince’s rule, Krimsky Prince
emmetropes it is usually infinity. However, near point rule and RAF (Royal Air Force) rule.
in complete rest position, the eyes may be Beren’s rule (Fig. 8.4) basically consists of
slightly divergent so the far point of conver- a bar made up of plastic on which a rider is
gence is in negative value, i.e. it lies beyond infinity. fixed with a test chart (fixation target). This
Near point (punctum proximum) of conver- target can be moved back and forth along the
gence (NPC): It is the nearest point from the scale while testing. Sliding target has various
eyes where an object during bifoveal vision targets for measurement of NPC. The bar is
can be seen clearly without any dipolpia and graded for measurements on two sides in
with maximum accommodative effort. In centimeters and dioptres.
other words, it is the point where maximum Prince rule (Fig. 8.5) consists of bar of 2 feet
convergence is exerted by eyes when two lines with 0.5 inch square in size. This square bar
of vision intersect with each other. NPC has different markings on four sides as follows
always lies closer to the eyes as compared to • One side is graded in centimeters for
near point of accommodation (NPA) and measuring NPA and NPC.
normally, it is less than 8 cm. • Second side is divided into inches
Range of convergence: The distance • Third side is graded in dioptres to
between far point of convergence and near measure NPA in dioptres
point of convergence represents the range of • Fourth side of square indicates the
convergence. Positive convergence is that corresponding age of patient in years.
portion of range, which lie between eyes and Krimsky Prince near point rule (Fig. 8.6) is
infinity. Negative convergence (relative a modification where a sliding fixation target
divergence) is that portion of range, which lie is mounted on a board. One end of board has
beyond the infinity (i.e. behind the eyes when a wing like support which rest against lower
eyes are slightly divergent). orbital margins and the other end is closed.
Amplitude of convergence: It is the One side of board is graded in dioptres for
difference in converging powers of eyes which measurement of NPA and NPC and on the
is required to maintain position of eyes at rest
and during maximum convergence (i.e. the
difference of convergence between punctum
proximum and punctum remotum).
Measurement of Near Point of Convergence

Practically all types of convergence, i.e.
fusional, accommodative, proximal and even
voluntary convergence (in later stages when
patient exert voluntary converging efforts) are
stimulated when a person tries to focus on an
object which is actually approaching the eyes
during testing.
A large number of instruments can be used
to measure the near point of convergence.
These instruments can be simple graded Fig. 8.4: Beren’s rule (courtesy: Bernell Corporation)
Fig. 8.5: Prince rule bar
Fig. 8.6: Krimsky Prince near point rule
other side the age (years) is represented. A cheek rest is present on one end of the ruler
Central back portion is graded for distance which ensures a consistency and proper height
measurement in centimeters. Sliding target of target to the eyes. Other end has a handle to
has optotypes for right eye and left eye. hold the ruler straight while examining the patient.
RAF (Royal Air Force) rule consists of a A few studies suggest that measurement of
binocular gauge which helps in measurement NPC with RAF rule provides more consistent
of objective and/or subjective convergence result, compared to the measurements done
and accommodation in 1 mm increments. by means of a pencil or finger.
RAF rule (Fig. 8.7) is made of a metallic bar RAF rule can be used to determine both
of 50 cm length which consists of a slider objective and subjective convergence points,
holding a rotating four-sided cube. Every to observe the accommodation and to
side of this sliding target shows a different determine the master eye. It is also useful as a
target. diagnostic and therapeutic device for detection
• One side of ruler shows a vertical line of convergence or accommodation anomalies.
having a central dot for convergence
fixation. Objective Convergence
• Other three sides have some limited To measure objective convergence, the RAF
number of lines indicating examples of rule box attachment should be positioned at
near reading. distance of 36 cm. Examiner puts face-piece
Fig. 8.7: RAF rule
of ruler on the inferior orbital margins of the The movement of vertical line on the box,
patient, so that patient hold the ruler handle seen by the patient, is always towards the side
in his/her left hand while two fingers of of his/her dominant eye. For example, suppose
examiner’s hands are placed over the small if right eye is dominant eye, then the line will
dot, so that the patient is unable to see this move towards right side of the box. If the line
dot. does not move on either side, rather it is seen
Examiner removes the finger from the dot as double then it indicates that no specific eye
and asks the patient to watch the black section is working as dominant eye.
of dot, while the examiner moves the box Subjective convergence test is more delicate
slowly and gradually towards his/her eyes. as compared to the objective convergence test
The measurement on ruler is recorded at a because element of accommodation plays a
break point where examiner observes that major role in subjective measurement. This test
either one or both eyes get diverge due to tells about that first point at which full
failure of binocular fixation. The distance of binocular vision is not maintained and this
break point recorded in centimeters or point cannot be observed by the examiner. The
millimeters is termed as NPC. As in this test reading of subjective convergence is normally
observations are made by examiner, hence it less than 20 cm, but usually it is always more
is known as an objective convergence. Normal than that of reading in objective convergence.
reading of NPC ranges from 6 to 10 cm in an
emmetrope young adult. Accommodation Test
The positive range of accommodation should
Subjective Convergence
be tested both uniocularly and binocularly. For
For measurement of subjective convergence accommodation test the ruler box is rotated,
the ruler box is kept behind 36 cm mark on so that the text can be shown to the patient.
the ruler end. The position of this ruler box is Keep this ruler box at 36 cm mark while
adjusted in such a way that the patient will be examiner moves the ruler box slowly and
seeing the black vertical line. Now patient is steadily toward the eyes of patient. The patient
instructed to watch the line constantly, as the is instructed to report, when he/she first
examiner moves the ruler box slowly and
steadily towards his/her eyes. Patient is asked Note: A number of near point rulers have been
to report immediately as the line on box moves designed having zero as starting point on their
even slightly, either to the left or right, or it scales at the assumed spectacle point which is 27
becomes double. This distance is recorded mm away from the canthus. In these kinds of rulers
where movement or doubling of line occurs, a value of 27 mm is added in the recorded break
point distance while measuring the distance of NPC.
it denotes the subjective convergence.
notices that letters are becoming blurred. In For distance test patient is instructed to
an emmetrope young adult, normal reading fixate a 6/9 target in a chart placed at distance
distance is about 10 cm or lesser. of 20 feet and prism bar is placed in front of
the eye to record the break point, recovery
Measurement of Amplitude of point and blur point in similar manner as
Convergence described above.
Amplitude of convergence can be measured by
• Prism bar method Synoptophore Method
• Synoptophore method As discussed in Chapter 6 page 120–121 an
objective angle of deviation can be estimated
Prism Bar Method by using grade 1 simultaneous macular percep-
In this method the prism bar is used to tion slides (SMP slides) in Synoptophore. Then
produce blurring or diplopia, either for near grade II fusion slides, i.e. the fusion slides
or distance targets. For convergence test, base having similar kind of targets but an additional
out (BO) prism bar, and for divergence test, a two control marks for each eye, are placed in
base in (BI) prism bar is used. Three cardinal Synoptophore. Suppose patient is able to fuse
points such as break point, recovery point and these targets and see them as single image simul-
blur point are recorded to measure amplitude taneously with both the control marks, means
of convergence. the objective angle is achieved. Now lock the arms
For near test, patient is instructed to fixate of Synoptophore and measure the amplitude
a 6/9 symbol in a chart placed at distance of of convergence or divergence as follows
33 cm. BO prism bar is placed in front of the Measure the amplitude of convergence: As
eye of patient and by sliding the prism bar the discussed above we need to record the
power of prism is increased gradually until breaking point and recovery point for
the eyes are converged to a maximum limit to measurement of amplitude of convergence. To
maintain binocular single vision or the patient record the break point, unlock the arms of
just start to realize diplopia. This point is Synoptophore and gradually converge them
known as break point and reading of this point until the patient report about the disappea-
(power of prism) is recorded. rance of either one or both of the control marks
Now, the power of prism is decreased or appearance of diplopia. This point where
gradually until the patient sees the 6/9 target fusion is broken and patient report of
clearly or diplopia get disappear. This point disappearance of control mark is called break
is known as recovery point and this point point and its value is recorded. Now the arms
reading is also recorded. of Synoptophore gradually moved in
During test before appearance of break backward direction in a less convergent
point, a blur point should also appear because position or divergent position, till the patient
initially the patient consumes fusional again fuses the target as single with both the
convergence to avoid diplopia; however once control marks visible. This is called recovery
this fusional convergence is completely used point and value is recorded.
then the patient will start using the accommo- Measure the amplitude of divergence: On
dative convergence to avoid diplopia. The contrary to convergence, to measure divergence,
point where fusional convergence is fully used diverge the arms of Synoptophore gradually
and accommodative convergence started till the fusion breaks and record the break
indicates blurring of image. This point is called point. Now, move back the arms of Synopto-
as blur point, and it is important to record the phore slowly in a less divergent or convergent
distance of blur point to know about the position until the patient again fuses the target
fusional convergence. as single. Record this recovery point.
Table 8.2: Normal values of various vergence convergence, for any time period without using
Vergence types Distance Near the additional efforts. CI is termed absolute
vergence () Vergence () CI when in absence of presbyopia, the near
(20 feet) (33 cm) point of convergence becomes greater than 11 cm
Convergence 14–20 35–40 from intraocular base line or when the person
Divergence 5–8 15–20 has difficulty in acquiring the convergence of
Vertical vergence 2–4 2–4 30° or more.
Incyclovergence 10–12 10–12 Broadly, we can group CI in two categories
Excyclovergence 10–12 10–12 • Primary or functional convergence
insufficiency
Measure the amplitude of vergence for near: • Secondary convergence insufficiency
Place –3 DS lenses in front of each eye (to over-
Primary Convergence Insufficiency
come power of these lenses, the person has to
apply his/her accommodation in order to see Causes of Convergence Insufficiency
the object clearly, as if fixing an object at 33 cm). • Idiopathic: When the exact cause of
Orthoposition for near fixation is simulated convergence insufficiency is not identified.
by setting the tubes of Synoptophore accor- However, anatomical factors like more inter
ding to a convergent requirement [in prism pupillary distance (IPD) and late develop-
dioptres which is about 3 times of patient’s ment of acquired function may affect the
IPD (cm)] for a target at 33 cm distance. convergence. Several precipitating factors
Now the procedure for testing, near for this type of CI are stress, overwork,
convergence or divergence is similar as that systemic debilities and psychological distur-
for distance, which has been described above. bances.
Normal values for distance and near • Presence of accommodative difficulties or
vergence in various types of vergence refractive errors: Uncorrected high hyper-
conditions are shown in Table 8.2. metropia or myopia may also produce
convergence insufficiency. As we know that
CONVERGENCE ANOMALIES accommodation and convergence acts
synergistically and if accommodation of a
Convergence anomalies commonly seen are:
person suffers due to any reason, then there
• Insufficiency of convergence is also disuse of accommodative convergence
• Convergence insufficiency secondary to mechanism. Uncorrected refractive errors
accommodative insufficiency of high degree may decrease the accommo-
• Convergence excess dative convergence mechanism of person
• Convergence paralysis which ultimately lead to convergence
insufficiency. Mechanism involved in these
Insufficiency of Convergence conditions are
As convergence is valuable in maintenance of – High degree (>+5 D) hypermetropes use
binocular single vision for all distances (which negligible amount of accommodative
are optically nearer than infinity), so its failure efforts, so they develop an associated
can lead to clinically significant problems. accommodative convergence deficiency.
Convergence insufficiency is known for many – Myopes do not require accommodation
years and it is one of the common conditions to visualize the near objects clearly so
responsible for muscular asthenopia. they do not use even the minimum
Convergence insufficiency (CI) is defined amount of accommodation and due to
as inability of ocular system to sustain or disuse of accommodation they develop
acquire an adequate amount of binocular poor accommodative convergence.
– Presbyopia: As discussed before, when Convergence insufficiency symptoms can

a person approaches the presbyopic age, be grouped as a symptom complex of
the near point of eye recedes, so there is asthenopia. Majority of the patients wearing
decreased utilization of convergence. glasses and having convergence insufficiency
Hence, negligence in presbyopic correc- present with complain of asthenopia due to
tion can cause permanent convergence incompatibility of glasses they are using.
insufficiency. On contrary, the patients Asthenopic symptoms complex of conver-
who use the presbyopic correction first gence insufficiency can be grouped as
time in their life can also develop • Symptom due to muscle fatigue:
convergence insufficiency. Proposed Constant use of eye muscles especially
mechanism is that presbyopic correction to perform near work for long duration
gives a relaxation to these patients from will result in muscular fatigue and
a sustained accommodative effort; hence asthenopic symptoms
a decrease in accommodative conver-
– Frontal headache and brow ache
gence can lead to convergence insuffi-
after continuous near work is felt by
ciency.
many patients, which may get
Note: In case of overcorrected hypermetropia the relieved after closing the eyes or
patient may utilize less accommodation and can taking rest for some time. Headache
develop convergence insufficiency. of migrainous type or precipitation
of migraine attack is experienced by
• Prolonged extraocular muscles imbalance: some patients having convergence
convergence insufficiency may be associa- insufficiency which is usually not
ted with conditions like exophoria, inter- relieved by analgesics.
mittent exotropia and imbalances of vertical – Eye strain and feeling of heaviness
muscle if remained uncorrected for long in and around the eyeball is commonly
duration. complained by many patients.
• Consecutive insufficiency of convergence:
– After prolonged near work tender-
As a consequence of squint surgery, i.e.
ness of eyes, burning/itching or
either resection of lateral rectus or recession
hyperaemia with conjunctival conges-
of media rectus muscle can lead to conver-
tion may occur in some patients.
gence insufficiency.
– Sudden changing of focus from near
Symptoms of Convergence Insufficiency to distance after continuous near
The occurrence of symptoms due to convergence work cause difficulty in a few patients
insufficiency (CI) mainly depends on the visual having CI.
requirement of the person. CI is commonly • Symptoms due to breakdown of conti-
seen in those persons who are involved in too nuation in BSV
much reading, or writing work and doing – A periodic closure or covering of
precise near work for longer durations one eye after prolonged book
especially, in young school going children reading is characteristically seen in
excessive school work, long duration reading cases of CI which is usually done to
and writing homework can cause the attain some relaxation from visual
problem of convergence insufficiency. On the fatigue.
other hand, it is uncommon in persons – Some patient may complain of sudden
involved in manual work or field work or in occasional blurring or crowding of
profession not requiring a lot of precise near words while reading books for long
work. duration.
– Intermittent crossed diplopia due to In nutshell salient features of convergence

ocular fatigue is quite commonly insufficiency for diagnosis are
reported by many patients involved • Majority of patients show varying degree
in professions requiring extensive of exophoria for near than distance
near work. • Orthophoria for distance is also not
uncommon
Diagnosis of Convergence Insufficiency
• Proximal fusional convergence amplitude
Convergence insufficiency can be diagnosed for near objects remain poor
by these factors • Decreased adduction of approximately
• Fusional convergence: An absolute conver- 5°–6° (8–10) is seen; but rarely abduction
gence insufficiency is considered if the goes below 10° (18).
patient has a difficulty to achieve a • Prism convergence usually decreased to
30° convergence, when fusional convergence 8°–12° (means lesser than 15–20 prism dioptres)
for near is measured by using Synopto-
• Near point of convergence recedes to
phore. Fusional convergence is decreased
3 inches or 7.5 cm.
for near fixation.
• Near point of convergence (NPC): When • Periodic increase of relative divergence is seen
NPC is more than 11 cm from the intra- when near point is approximately reached
ocular base line or 9.5 cm from the apex of
Differential Diagnosis of Convergence
cornea, in the absence of presbyopia.
Insufficiency
• Prism convergence: When vergences are
measured by ophthalmic prism, the prism As discussed earlier, asthenopic symptoms in
convergence is low, whereas the prism patients can be produced by many other
divergence remains normal. conditions along with convergence insuffi-
• Near point of accommodation (NPC): NPC ciency, so it becomes essential to exclude all
is usually normal and also corresponds other conditions like: accomodative effort
with the age of patient. However, clinically syndrome and convergence paralysis.
it is essential to measure the NPA in every Convergence insufficiency can be differen-
case of convergence insufficiency for tiated from accommodative effort syndrome
diagnostic and treatment purposes. As on the basis of following factors as summari-
there may be combined convergence and zed in Table 8.3.
accommodation insufficney and these Convergence insufficiency can be differen-
patients may require different forms of tiated from convergence paralysis on the basis
therapy. of following factors as summarized in Table 8.4.
Table 8.3: Differences between convergence insufficiency and accommodative effort syndrome
Accommodative effort syndrome Convergence insufficiency
• Patient usually present with esophoria at near • Presents with exophoria in near vision
vision
• Symptoms get improve on adding plus • Symptoms get worse on adding plus lenses
lenses (lenses cause relaxation of the (relaxation of accommodative convergence leads
accommodative convergence and hence to excessive convergence efforts.)
decreases the efforts during accommodation)
• Minus lens test (–3D): patient may develop • Patients feel better because these lenses compensate
diplopia due to sudden induction of deviation for poor fusional convergence found in CI
of eyes due to lens.
Table 8.4: Differences between convergence insufficiency and convergence paralysis

Convergence paralysis Convergence insufficiency
• Eyes are totally incapable to converge, so in • Patient can show convergence ability for several
these cases patient is unable to counter the dioptres of prism
effect of base out prism of any dioptric strength
• On receiving a convergence stimulus, there is • There is pupillary constriction along with conver-
pupillary constriction (miosis) but person is not gence. However, patient is unable to sustain this
capable to converge convergence, so after some time dilatation of pupil
(mydriasis) will occur.
Management of Convergence Insufficiency accommodation in stimulation and hence

In adults many a times convergence insuffi- convergence also stimulated. Under
ciency (CI) remain subclinical or asympto- correction with minus lenses will worsen
matic, so in adults treatment of CI is required the CI in cases of myopia.
mainly in those situations where annoying • Full amount of presbyopic correction as per
asthenopic symptoms are present and patient patients working distance should be done
is uncomfortable. Children, on the other hand, to avoid any exertion on already reduced
having convergence insufficiency may accommodation. Under correction or an
develop poor fusional vergence due to inadequate correction will worsen the CI
constant under use of convergence. These symptoms in presbyopes.
children may have symptoms of exodeviation Orthoptic treatment
and require proper treatment of CI to improve
The main purpose of orthoptic trainings are
the fusional vergence. Prognosis after
treatment is exceptionally good in most of the • Improvement in binocular convergence
cases of CI. • Increase the amplitude of fusional conver-
Various treatment modalities for convergence
gence insufficiency are: Various modalities of orthoptic treatment
• Optical treatment are summarized in Table 8.5.
• Orthoptic/vision therapy Near point of convergence can be improved
• Prism therapy by
• Surgical treatment • Advancement exercises: These are simple
and home based exercise to improve the
Optical treatment: The cycloplegic refraction convergence efficiency in near vision. Basic
should be performed in all cases to find out principle used is to advance the near target
any associated refractive errors. If any and increase the strength of convergence,
refractive error is present, then in cases of hence the name advancement exercises.
convergence insufficiency corrective glasses Patient is instructed to use a near target like
should be prescribed as follows: pictures with some details or fine lines
• Hypermetropes are usually kept under printed on a card. Then patient hold this
corrected so that their accommodative card at an arm length so that the details of
efforts remain stimulated, which in turn target are clear. Now slowly patient will
keep the convergence stimulated. Overcorrec- advance this picture card towards his/her
tion with plus lenses will worsen the CI in nose, so this exercise is also called picture-
hypermetropic cases. to-nose exercise. Once the details of target
• On contrary, myopes should be given full become blur the patient will hold the card
correction with glasses to keep their at that point and try to converge to see those
Table 8.5: Orthoptic treatment for convergence insufficiency

Mode of treatment Type of exercise
To improve near point of convergence • Advancement convergence exercises
• Jump convergence exercises
To improve amplitude of fusional convergence • Convergence card assisted convergence exercises
• Stereogram card assisted exercises for uncrossed
physiological diplopia
• Prism assisted convergence exercises
• Diploscope assisted convergence exercises
• Synoptophore assisted convergence exercises
To improve control over physiological diplopia • Voluntary convergence training
Relaxation exercises • Stereogram card assisted exercises for crossed physio-
logical diplopia
• Prism assisted divergence exercises
• Synoptophore assisted divergence exercises
details clear. If succeed, then patient can and heteronymous physiological diplopia.
advance the card nearer to his/her nose. In Convergence card has three dots which
case patient is unable to see the target gradually reduces in size and are identically
details clearly, then he/she will move back placed on either side of the card. On one
the card away from nose till details become side of card (side A) the dots are blue
clear. This picture-to-nose exercise is colored while on other side of card (side B)
repeated 10–15 times twice daily for the dots are red in color. These dots are seen
improvement in near point of convergence. as large, medium and small size dots by
• Jump convergence exercises: Once some patient as shown in Fig. 8.8.
amount of convergence get improve by Exercise procedure
picture-to-nose exercise, then these – Examiner rests the convergence card on
advanced versions of advancement patient’s nose like a septum so that
exercises should be performed. Usually a patient will see red dots with one eye
month training of basic convergence and blue dots with another eyes;
exercises by advancement method is keeping the large size dot farthest away
required to attain reasonable degree of from nose.
convergence to perform jump exercises. In
these exercises patient is made to learn to
achieve a single binocular vision when there
is a sudden change in the requirement of
convergence.
Amplitude of fusional convergence can be
improved by use of convergence card,
stereogram card, prisms or diploscope.
• Convergence card: This is also called
physiological card because it is based on the
principle of improving the state of physio-
logical diplopia and patient learn to
appreciate the homonymous physiological Fig. 8.8: Convergence or physiological card
– Patient is now asked to focus on large

size dots of red and blue color and then
try to fuse them in each other.
– Once patient is able to do so then ask
him/her to repeat the same procedure
for medium size dots and finally for
small size dots.
– However, these convergence card
evoke a large degree of retinal rivalry
between two eyes, hence many a times
patient is unable to fuse these dots. To
increase the convenience of patient Fig. 8.10: Test results of a convergent card. A. Fusing
these three dots are joined by a black large size dots; B. Fusing medium size dots; C. Fusing
small size dots
line on both sides of the card as shown
in Fig. 8.9.
– Suppose with this modification patient
is able to fuse large size dots on either
sides, then the straight black line will
appear as an inverted V() to the patient
as shown in Fig. 8.10A.
– Once patient is able to fuse the large
size dots and tries to fuse the medium
size dots he/she will see the black line
as X (Fig. 8.10B) and finally when
patient is able to fuse medium size Fig. 8.11: Stereogram card
dots and tries to fuse the small size
dots, then the black line will appear Exercise procedure
as V (Fig. 8.10C). – Stereogram card is held at about one
• Stereogram card: These cards have two meter distance from the patient eyes at
identical pictures with a small variation in the level of glabella.
details (similar to fusion slides of synopto- – Patient is instructed to look at the
phore) as shown in Fig. 8.11. pictures on the card and then place a pen
tip in between the stereogram card and
patient’s eyes.
– Patient is asked to shift the focus on tip
of pen while simultaneously keep
looking at the stereogram card. This will
produce an uncrossed physiological
diplopia and patient will see four pictures
instead of two pictures on the card.
– Now patient is instructed to adjust the
distance of pen tip such that he/she is
able to fuse the two central pictures into
one single and see only three pictures
on the card.
Fig. 8.9: Modified convergence or physiological – Gradually patient is trained in such a
card with black joining line way that he/she is able to see the central
single picture clearly for some duration.

While doing this patient is putting
efforts to converge for near fixation
target (i.e. pen tip) and accommodating
for distance target (i.e. stereogram card
pictures).
– Finally, patient is relatively applying
more effort for converging than that for
accommodating by keeping the central
picture single and clear. This exercise
can be performed at home about 3–4 times
a day for 5–6 minutes.
Fig. 8.12: Diploscope
• Prism assisted convergence exercises:
convergence exercises using prisms are four holes as shown in Fig. 8.12. In presence
simple and effective in improving the of binocular single vision the relative
fusional amplitude of convergence. Initially convergence can be improved by doing the
patient may not be able to learn these exercises with the help of diploscope.
exercises but gradually every patient learn Exercise procedure
and results are satisfactory. – Patient is instructed to hold the handle
Exercise method of diploscope and keep the head rest on
– Patient is presented with a point source his/her glabella or forehead.
target and base-out prisms either loose – Now the convergence exercise is
or mounted in a prism bar are placed in performed by moving the eyes relative
front of the patient’s eyes to card and septum in four different
– Patient is instructed to converge and try positions.
to focus on the target. Check the
– As patient moves his/her eyes in
convergence of patient while he/she is
relative positions of card and septum,
focusing on the target.
he/she appreciates a change in the
– Once patient is able to converge with
relative position of letters and color of
small power prism, slowly and gradually
squares on card from each eye.
the power of prisms are increased and
convergence is checked. – This movement of letters and color
– Repeat the exercise on weekly basis for squares in a definite pattern becomes
a few minutes and measure the conver- basis for training the patient, i.e. how to
gence status on follow-up visits. control and appreciate the various
positions of eyes and direction of their
• Diploscope: It is a simple instrument having
movements.
a metallic bar with head rest at one end and
a handle in the middle. Other end of bar – Hence it helps in training the patient
has a card printed with letters D, O and G how to fixate from a distance vision to a
in the centre and on top and bottom of the near vision or vice versa, which helps
card there are two squares, one red and in improvement of fusional amplitudes
other green in color. In front of card a which is very vital for a contented
metallic septum is attached which contains binocular single vision.
As described in Fig. 8.13 the four positions
Note: During exercise the examiner should observe during training with diploscope are
the eyes of patient and make sure that patient is • Position 1: Patient is instructed to hold
not either diverging or suppressing the eyes.
the diploscope as described above and
may overlap the letters ‘D’ and ‘O’ and

letters ‘O’ and ‘G’ with resultant letter
‘D’ and ‘G’ in each of two horizontal
holes.
• Position 3: Instruct the patient to focus
midway between the septum and his/
her eyes on an object like on tip of a pen.
As patients converge to focus the tip of
pen, the images of letter ‘D’ and ‘O’ of
right eye and letters ‘O’ and ‘G’ of left
eye will fall on a retinal component
nasally to fovea of respective eye; so
these letters are projected temporal to
fovea. Patient sees the letters ‘O G D O’
(as shown in Fig. 8.13). Green square will
shift to right over ‘DO’ letters and red
square to left under ‘OG’ letters.
Fig. 8.13: Various positions during diploscope • Position 4: Examiner asks the patient to
method fixate on an object like a wall mounting
hanged far away from the card on a wall.
fixate on central letter ‘O’ written on the As patients diverge to focus the distant
card. Once the patient focuses on letter object, the images of letters ‘D’ and ‘O’
‘O’, then the letter ‘D’ will fall temporal of right eye and letters ‘O’ and ‘G’ of left
to fovea of right eye (so projected left to eye will fall on a retinal component
letter ‘O’ on card). Whereas, letter ‘G’ temporally to fovea of respective eye; so
will fall temporal to fovea of left eye (so these letters are projected nasally to
projected right to letter ‘O’ on the card). fovea. Patient sees the letters ‘D O O G’
As a result, letters DO are seen by right (as shown in Fig. 8.13). Green square will
eye and OG by left eye. When binocular shift to left over letter ‘O’ and red square
single vision (BSV) is present patient will to right under letter ‘O’.
see three holes in septum having the An unforced convergence and/or diver-
letters DOG, inside them (as shown in gence can be established once patient is well
Fig. 8.13). The color square will be at trained to accomplish and sustain these four
their relative positions, i.e. green above relative positions of diploscopic exercise with
and red below letter ‘O’. effortlessness. These exercises are done for
• Position 2: Now patient is instructed to 3–4 minutes about 3–4 times in a day to achieve
fixate at the midpoint of the two good results.
horizontal holes in the septum. Once • Synoptophore assisted convergence
patient converges to this point of exercises: Synoptophore assisted
fixation the image of letter ‘O’ will fall convergence exercises are very effective
on retinal component nasally to fovea and result oriented even in young
of each eye (instead of fovea of both the children having mild to moderate
eyes). So the letter ‘O’ will be seen in a amount of convergence insufficiency.
homonymous uncrossed diplopia by the
patient as DO and OG in two holes (as Note: For improvement of fusional divergence or
shown in Fig. 8.13). By exercising a huge negative convergence position 4 of diploscopic
amount of convergence power patient exercise is very helpful.
These exercises are carried out by the use

of fusional slides in synoptophore.
During these exercises the arms of
synoptophore are gradually converged
starting at an angle where patient is able
to fuse the pictures on slides. These
exercises are done twice or thrice per
week for a period of 5–6 minutes.
Minimum 15–20 settings are required to
achieve the desired amount of conver-
gence in mild to moderate cases of CI.
Voluntary convergence training: Voluntary
convergence training gives very encouraging
results in motivated and determined patients
to improve voluntary control over relative
positions of both the eyes. By this training the
patient is made to learn, appreciate, maintain Fig. 8.14: Voluntary convergence exercise method
and then control over the physiological (see text)
diplopia developed during the exercise distance light for some time and reintro-
method. duce the finger to appreciate the physio-
Exercise method: logical diplopia.
• Patient is instructed to focus on a bright • Patient is asked to practice this exercise till
light source situated at a distance. he/she is able to appreciate two lights and
• Once eyes are focused on light, ask the can increase or decrease the distance
patient to bring his/her finger in the field of between two lights without the addition of
vision in between the light and eyes (Fig. 8.14). finger in visual field.
A sudden breaking of fusion for distance Relaxation exercises: These exercises are
will produce physiological diplopia. performed to relax the eyes hence are termed
• Patient will see two fingers when he/she is as negative convergence exercises. Various
still focusing on the distant light. Patient is methods are adopted to relax the eyes apart
advised to learn this physiological diplopia. from simple resting.
• Now ask the patient to focus at finger tip • Stereogram assisted relaxation exercise: As
and still looking at distance light. Then discussed before patient is made to learn,
patient will appreciate two distance lights. appreciate and control the crossed
• Instruct the patient to move the finger to physiological diplopia prior to start the
and fro and ask him/her to observe the relaxation exercises for the convergence.
increasing and decreasing distance between Crossed physiological diplopia can be
two distant lights as shown in Fig. 8.14. elicited with the help of a flash light or a
• Patient is advised to maintain the two pen tip, which patient should be able to
distance lights apart and moving with learn and appreciate. Stereogram assisted
finger movement as long as possible. Patient relaxation exercise can be performed once
is asked to remove the finger from field and patient is well trained to handle the crossed
continue to watch the distance lights. physiological diplopia.
• Once the distance light becomes single after Exercise method:
removal of the finger from visual field, then – Patient is instructed to fixate on a distant
patient is instructed again to focus on the object, now place the stereogram card
at about one feet distance from his/her Note: Risley’s rotatory prisms or even loose prisms
eyes. can be used in place of prism bar to perform these
– As patient focuses on stereogram card exercises, though prism bar is most favored because
he/she will see four pictures (instead of of ease of use.
two pictures) on card due to elicitation
of crossed physiological diplopia. at such a distance where focusing will
elicit largest degree of esophoria in
– Patient is instructed to move the card to
patient.
and fro to adjust the relative position of
– Examiner places a prism bar with base-
stereogram card, until the two central
in position in front of one eye of the
pictures fuses and become single. Now
patient and gradually increases the
patient sees only three pictures on
power of prism till two images are seen
stereogram card in total.
by the patient. Thus, the fusion gets
– Tell the patient to maintain clarity of the
dissociated and patient appreciates an
joined central single picture for as long
additional blur image of object (Fig. 8.15).
as possible. While patient is trying to
– Now patient is advised to maintain a
keep the central picture clear and single
single clear image of distant object for
he/she is accommodating for a near
as long as possible. This relaxes the
target (stereogram card) and simulta-
convergence and helps in improvement
neously he/she is converging for a
of symptoms of convergence insuffi-
distant target (flash light). Thus, the
ciency. These relaxation exercises are
accommodation is at work while conver-
done for about 4–5 minutes per week.
gence is relaxing during this exercise.
– After completion of learning and training Prism therapy: If the asthenopic symptoms
patient can practice this relaxation due to convergence insufficiency did not show
exercise at home. any improvement by any of the above
• Synoptophore assisted divergence exercise discussed orthoptic exercises, then prism
therapy should be started to improve
– To elicit fusion, stereopsis slides are
symptoms. Base-in prisms can be incorpora-
used in place of fusion slides in synop-
ted in the near vision glasses or bifocal glasses
tophore; because strongest stimulus for
(here prisms are fitted in lower segments) to
fusion is produced by stereopsis not by
improve the symptoms of CI. These are also
fusion of images.
termed relieving prisms because they relieve
– Patient is asked to fuse both the slides
the asthenopic symptoms.
and once the fusion of two pictures on
slides is achieved, the patient is instruc-
ted to maintain the fusion while slowly
tubes of synoptophore are diverged.
– To maintain the fusion with diverging
tubes of synoptophore patient needs to
relax the convergence.
– These diverging exercises are done for
4–5 minutes in a clinic per week for
improvement in relaxation power of
convergence.
• Prism-assisted divergence exercise
– Patient is instructed to fixate on an
object. If possible object must be situated Fig. 8.15: Prism bar (courtesy: Bernell Corporation)
Note: The relieving prisms or bifocals with prisms • Near point of convergence and near point
are avoided in young patients as they can worsen of accommodation are reduced
the situation because of the associated accommo- • AC/ A ratio is usually negligible or very
dative changes. low.
Surgical management: CI insufficiency is Management
usually a reversible condition, hence decision • Orthoptic exercises
to perform any surgery should be taken only • Optical treatment
when all other therapeutic possibilities have • Prism therapy
failed. Depending upon the amount of • Surgical treatment
exophoria resection of medial rectus in one or
Orthoptic exercises: Orthoptic exercises are
both eyes is considered most effective surgical
done similar to those done in functional
treatment for convergence insufficiency.
convergence insufficiency as discussed above.
Patients must be informed that after surgery
However, the result of orthoptic exercises
he/she may experience double vision for
alone is not very encouraging as compared to
several weeks or months which is more at
the results in primary convergence insufficiency.
distance fixation (consecutive esotropia).
These exercises are advised with an additional
However, this esotropia get resolved sponta-
optical correction using bifocal glasses for a
neously with time.
satisfactory outcome.
Note: In some cases even after surgery recurrence Optical treatment: Reading glasses are
of exophoria for near vision can occur which is prescribed after evaluating the requirements
usually asymptomatic.
of the patient. Minimal plus power lenses
which give comfortable near vision are
Secondary Convergence Insufficiency prescribed. Although prescription of glasses
Patients can have convergence insufficiency for reading purposes alone is less effective,
due to an associated condition such as they need to be combined with prism
insufficiency of accommodation. As discussed therapy.
before, accommodation and convergence
Prism therapy: Fresnel membrane prisms
mechanisms are very closely related to each
(Fig. 8.16A) are used with bifocal lenses which
other; hence it is always advisable to rule out
can be glued in the lower segment of spectacle
any associated accommodation defects before
bifocal lenses because adjustment may be
treating the patient for a convergence problem.
required before determination of final power
A secondary convergence insufficiency
of glasses. Executive bifocals having a
having a primary accommodative insufficiency
decentered plus lens serving as prism in lower
is seen in the following conditions such as
half, is an alternative to Fresnel’s prisms.
• Early Adie’s syndrome Similarly press on bifocal prisms (Fig. 8.16B)
• Infectious mononucleosis are also available, which can simply be glued
• Viral encephalopathy to spectacle lens, produces bifocal adjustment
• Diphtheria of images.
• Following head injury
Surgery: Surgical treatment is rarely
• Thyroid eye disease and Parkinson's recommended to correct secondary conver-
disease are also associated sometimes gence insufficiency however, strengthening of
with CI. medial rectus muscle by resection procedure
Clinical presentation with subsequent prescription of bifocal glasses
• Asthenopic symptoms are similar to those has shown some symptomatic relief in
seen in primary convergence insufficiency recalcitrant cases.
Fig. 8.16: Press on prisms (courtesy: Bernell Corporation). A. Fresnel’s prism; B. Bifocal prism
Convergence Excess commonly seen in hysteric or neurotic

An excessive convergence or spasm of persons.
convergence is not very uncommon. • Organic: Rarely an underlying organic
Etiologically this condition may occur when condition may cause convergence spasm.
• Increased convergence is associated Generally, the convergence spasm due to
with increased accommodation: as both organic origin is associated with other
are synergic in action, hence change in abnormalities and neurologic impairment.
one tends to cause change in other also. It may appear secondary to conditions such
For example, commonly seen in uncorrec- as post head injury, pituitary adenoma, tumors
ted hypermetropes who use excessive of posterior fossa, viral encephalitis, tabes
accommodation, sometimes also in dorsalis, and Arnold-Chiari malformation.
recently corrected myopes or early
Clinical Features
presbyopes.
• Diseases of central nervous system (e.g. Convergence spasm is an intermittent
meningitis or increased labyrinthine condition and patient remains asymptomatic
pressure): Leads to convergence excess in between the attacks of spasm. During attack
because of irritation. following symptoms may occur
• Excessive convergence: This condition
Convergence Spasm resembles to bilateral abducent nerve palsy
It is a condition where intermittent episode since both the eyes remain fixed and
of an excessive amount of convergence inwardly rotated (esotropia) in a state of
occur along with an accommodative spasm extreme convergence spasm.
(ciliary spasm). It is in the form of triad of • Blurred vision: Convergence spasms are
intermittent sustained convergence, spasm usually associated with spasm of accommo-
of accommodation and constriction of dation, hence patient may complaint of
pupil (miosis) because there is synkinesis blurring or loss of vision for near work and
between convergence, accommodation and diplopia.
miosis. • Induced myopic state (pseudomyopia): Patient
may also complaint of decrease vision for
Causes of Convergence Spasm
• Functional: Isolated episode of convergence Note: In abducent nerve palsy size of pupils and
spasm are usually functional in origin. Most visual acuity remain normal.
distance because a state of myopia is also Convergence Paralysis

induced due to spasm of accommodation. Convergence paralysis means patient is
Retinoscopic findings during an attack of unable to converge the eyes even with the
spasm have revealed myopia of as high as strongest stimulus. In other words, an inability
6D contributed due to associated accommo- to overcome the effect of smallest power of
dation spasm. It can be differentiated from base-out prism is termed convergence
true myopia by cycloplegic refraction. paralysis. Although, it is a rare condition but
• Constriction of pupils (Miosis): Being an it may be confused with a very common
inherent component of near reflex, the condition like primary or functional conver-
pupils undergo constriction. gence insufficiency.
• Homonymous diplopia: Patient may experience
an intermittent diplopia during an attack Aetiology
of convergence spasm. Convergence paralysis is rarely primary in
origin and not associated with any significant
Investigations past history. It usually occurs secondary to
Psychiatric evaluation: It is necessary as organic brain lesions situated at corpora
functional spasm is common in hysteria and quadrigemina or at third cranial nerve nucleus
neurosis which can be diagnosed on evalua- region. Some organic brain lesions associated
tion. with convergence paralysis are
Neurological evaluation: Rarely, convergence • Head trauma
spasm may be associated with an underlying • Disseminated sclerosis
organic lesion; hence all patients should also • Tabes dorsalis
be evaluated for presence of any neurological • Encephalitis
condition. • Tumors
Treatment • Narcolepsy
To relieve convergence spasm following
Features
measures are used:
• Treatment of associated cause, if any Convergence paralysis is characterized by
present. features such as
• Perform cycloplegic refraction and presence • An acute onset convergence failure with
of any refractive errors should be treated. total absenteeism of convergence.
• Atropine 1% can be instilled for long term • Exotropia with crossed diplopia will
along with bifocal glasses having plus precipitate when patient tries to fixate a
lenses in the lower segment (used for near near object (due to absence of fusional
work). This therapy may break the spasm convergence).
cycle. • Fusional divergence is not affected. Adduc-
• Monocular occlusion of alternate eyes may tion remains normal.
be tried as an alternative treatment to • Mostly the accommodation remains normal
abolish diplopia. however, in selective conditions accommo-
• Injection of botulinum toxin into medial dation may decrease or even absent. If
rectus muscle for alignment of visual axes accommodation is also affected, then
also tried. symptoms are in more severe form because
• For long-term relief in selected cases of deficiency of associated accommodative
psychiatric evaluation and counseling and vergence.
treatment of any precipitating disease is • Eye movements may also affect when palsy
useful. is due to underlying neurological disease.
Diagnosis Note: Conservative treatment is preferred for

Bielschowsky’s described following criteria convergence paralysis. Surgery on the muscle has
for diagnosis of convergence paralysis: no role in convergence paralysis cases.
In some cases, for temporarily relief botulinum
• Positive history of an acute onset crossed
toxin is used, however, it has no role in long-term
horizontal diplopia for fixation of near
management.
objects.
• Pupillary reflex and accommodation reflex • Monocular occlusion during near work is
remain present during convergence. advised in patients who are unable to regain
• Investigations favoring intracranial lesion. binocular single vision.
• Consistency of these positive findings even
on subsequent examination of case. Associated Syndromes
• Parinaud’s syndrome: Characterized by
Treatment convergence paralysis with a vertical gaze
• The underlying secondary cause should be paralysis.
identified, if present should be treated • Pretectum-posterior commissure syndrome
accordingly. also called dorsal midbrain syndrome. This
• To overcome diplopia for near vision in syndrome results due to a tumor present
presence of normal accommodation in pineal region of brain and is characte-
function, base-in prisms can be prescribed. rized by:
• If patients having weakness of accommo- – Parinaud’s syndrome
dation with convergence paralysis, then – Bilateral fourth cranial nerve paralysis
base-in prisms with plus lenses (minimum – Pupillary reflex is absent with light near
hypermetropic correction) can be prescri- dissociation
bed. – Lid retraction in a few patients
188
Binocular Muscle
Co-ordination Anomalies
Learning Objectives
• Understand orthophoria in detail.
• Describe heterophoria and causes of muscular imbalance.
• Explain esophoria and exophoria.
• Understand hyperphoria and cyclophoria.
• Identify clinical presentation of hyperphoria and its method of management.
• Describe heterotropia in terms of classification, clinical presentation and non-surgical correction.
Chapter Outline
• Orthophoria Cyclophoria
• Heterophoria – Clinical presentation of heterophoria

– Introduction – Treatment of heterophoria
– Causes of muscular imbalance • Heterotropia
– Classification of heterophoria – Introduction
Esophoria – Clinical presentation
Exophoria – Heterotropia classification
Hyperphoria – Treatment of heterotropia
ORTHOPHORIA enter in both eyes and fall on corresponding

In Greek ‘orthos’ means straight or correct and points on the retina (fovea centralis) of each
‘tropos’ means turn or direction. Thus, ortho- eye, subsequently the two images get fuse
phoria represents straight direction of two together psychologically as single image and
eyes and can also be called ‘orthoposition’ as a result binocular single vision is achieved.
which means correct position of two eyes, Normally we can say that both eyes work
where under the effect of fusion two visual simultaneously and are considered by brain
axes intersect at the fixation point. as one, though retinal images formed in both
When eyes are at rest and a distant object is eyes are not same because each eye observes
looked straight ahead, then the visual axes of different aspect of an object. For example, the
both eyes remain parallel to each other. This right eye observes right portion of an object
is known as primary position of the eyes. Thus, more, whereas left eye observes left portion
during primary position of eyes the light rays more. Consequently these two images with
188
Binocular Muscle Co-ordination Anomalies 189
slight disparity are fused together psycholo- Heterotropia or manifest squint/strabismus:

gically. Along with other factors which are It is the condition where the ocular muscle
derived from experience of person this imbalance or deviation of eyes cannot be
psychological fusion allows a person to overcome by fusion reflex and the latent squint
appreciate the solidity and depth of object and turns into manifest squint.
also helps in assessment of the distance of Although heterophoria and heterotropia
object from the eyes. are not directly related to optics but these are
If the position of the object is altered, then essential for knowledge because presence of
the direction of vision will also change, and various refractive errors play an important
as a result, both eyes will occupy different role in the etiology of squint especially in
position, which is called secondary position. concomitant type squint and thus optical
To maintain binocular single vision in correction is required in their treatment.
secondary position also there must be
psychological fusion of two images as single HETEROPHORIA (LATENT SQUINT/
and to achieve this fusion both the eyes must STRABISMUS)
move in a perfectly coordinated manner.
During these coordinated movement of eyes Introduction
both conjugate and disjunctive movements Latent means under cover or hidden, hence
(convergence and divergence) should remain in heterophoria the deviation of eyes during
accurately balanced so that if two eyes move binocular vision remains hidden or covered
or fix any object present at any distance, the due to presence of fusion mechanism. This
primary lines of sight remain directed upon states where the imbalance of extraocular
the fixation point, i.e. macula of each eye muscle is overcome by effect of fusion, so that
remains in the line of vision. proper alignment of eyes is maintained under
It is the perfectly coordinated oculomotor stress is termed heterophoria.
system of eye which allows free mobility of Mechanism: Usually the relative functional
eyes in primary and secondary position insufficiency of one or more extraocular
through six pairs of extraocular muscles so muscle is the main cause of heterophoria. In
that the visual axes of two eyes remain focused order to maintain the parallelism of visual axes
upon the fixation point. in both eyes during binocular single vision,
This coordinated state of the eye where the the weak extraocular muscle remains in the
actions of extraocular muscles are normally state of continuous contraction to maintain its
balanced in such a way that visual axes of two normal tone. Hence, a squint is potentially
eyes remain in alignment and fusion of images present but it is covered/hidden due to
occurs without any efforts is called orthophoria. continuous activity of the muscle. This
The condition where eye gets deviate from constant activity of muscle may produce eye
orthoposition due to ocular muscle imbalance strain and fatigue to the eye which may vary
so that visual axes of two eyes are not in person to person. However, if the person
alignment and do not meet at a fixation point develops state of debility, i.e. stimulus for
is called strabismus or squint. It may be fusion becomes poor or there is a great
Heterophoria or latent squint/strabismus: It difference in visual acuity of two eyes or
is the condition where the tendency of eyes to neurological pathway involved remain
deviate (due to imbalance) can be overcome underdeveloped then latent heterophoria
by fusion, so that proper alignment of eyes becomes manifest heterophoria. Muscular
remains maintained under stress. It means the imbalance may also differ with age of person.
squint remains latent during binocular vision For example, in children and young person,
due to fusion reflex. there is tendency of the eyes to deviate
inwards because of increased convergence, Esophoria

whereas after presbyopic age an outward Esophoria is a common condition and is a type
deviation of the eyes is more common. of heterophoria where visual axis of one eye
has tendency to deviate inwards (nasally)
Causes of Muscular Imbalance
relative to other eye when fusion is broken
Several conditions may disturb the normal (Fig. 9.1). Esophoria may be caused by
muscular equilibrium of eye muscles such as: • Excessive convergence: As convergence is
• Deficiency in the function or tone of muscle more active during near fixation while
may be due to any congenital cause or it divergence is more active in distance fixation,
may occur due to illnesses like generalized hence esophoria due to convergence excess
weakness, anemia, nervous disease, etc. is more pronounced for near vision than
Symptoms of phoria are periodic and distant vision. This is the most common
usually appear when body is fatigued like cause of esophoria but still gives rise to very
in the evening, after doing excessive work few symptoms. As discussed previously
or in the state of anxiety, etc. Symptoms that convergence excess is also associated
tend to disappear after taking rest or with accommodation excess, hence this type
vacation from work for sometime. of esophoria usually coexists with under
• Sometimes, spasm of antagonist muscle or corrected hypermetropic refractive state
an amplification of its tone may lead to the where the excess accommodative effort tend
loss of muscle equilibrium. to stimulate adduction of the eyes. Cases
• Various refractive errors and resultant
accommodation convergence disturbances
may cause muscular imbalance.
• Altered configuration of the orbits and
anatomical variation in the origin and
insertion of muscles may contribute for
muscular imbalance.
• Disturbances in the nerve supply of muscle
which affect the tone of muscles may lead
to imbalance of extraocular muscles.
Classification of Heterophoria
Depending on the involvement of type of extra-
ocular muscle and the direction of deviation
of eyes heterophoria can be classified as shown
in Table 9.1. Fig. 9.1: Esophoria
Table 9.1: Classification of Heterophoria

Types of phoria Type of heterophoria Insufficiency of muscle Latent deviation of eyes
Horizontal phoria Esophoria Lateral rectus muscle Inwards
Exophoria Medial rectus muscle Outwards
Vertical phoria Hyperphoria Hyperesophoria Combination of Upward and inwards
Hyperexophoria extraocular muscles Upward and outwards
Rotational phoria Cyclophoria Incyclophoria Combination of Intorsion
Excyclophoria extraocular muscles Extorsion
of bilateral congenital myopia with increased Hence exophoria is common in those who
convergence may also present with esophoria. utilize less accommodative effort for near
• Deficient divergence: Esophoria due to vision, as seen in uncorrected myopes or
divergence insufficiency is more noticeable first time corrected hypermetropes or
for distant vision as compared to near presbyopes. Exophoria is more marked for
vision. Divergence insufficiency is not so near vision as compared to distance vision.
common cause for esophoria rather in • Excessive divergence: Exophoria due to
normal situations two eyes generally excess divergence is more marked for
remain in slight divergent position. distance vision as compared to near vision.
• Innervational: Disturbances in central • Innervational: Disturbances in central
distribution of innervations of extraocular distribution of innervations of extraocular
muscles may cause esophoria. muscles may cause exophoria.
Exophoria Hyperphoria
Exophoria is referred to a situation where Hyperphoria is referred to a situation where
visual axis of one eye tend to deviate visual axis of one eye is deviated at a higher
outwards relative to other when fusion is level relative to visual axis of other eye, when
broken (Fig. 9.2). Exophoria is the most fusion is broken. It means the deviation occurs
common type of muscular imbalance than any in vertical direction (upwards or downwards).
other types of heterophoria. As discussed It may be left hyperphoria (left visual axis is
before that at rest eyes exist in the position of higher than that on the right) or right
slight divergence, hence when eyes converge hyperphoria (right visual axis is higher than
for a near fixation, then there is tendency of that on the left). In other words, it can be
eyes to diverge for about 3–4 prism dioptres termed left hypophoria (right visual axis is
from point of fixation and this degree of higher than that on the left) and vice versa.
deviation is considered as physiological. Hyperphoria is caused by either weakness in
Exophoria may be caused by superior rectus and inferior oblique muscle or
• Insufficient convergence: As we know that in inferior rectus and superior oblique muscle.
convergence insufficiency is generally As hyperphoria occurs due to involvement of
associated with accommodation deficit. more than one muscle, hence to maintain the
correct position of visual axes, eyes have to
adjust the activity of more than one muscle.
Due to this, even a small deviation of this type
leads to a great discomfort to person. Thus,
the asthenopic symptoms are more pronoun-
ced in vertical phoria than horizontal phoria
(esophoria or exophoria).
Depending on the associated inward or
outward position of eyeball hyperphoria can
be subclassified as
• Hyperesophoria
• Hyperexophoria
Hyperesophoria means where one eye is
deviated in upward and inward direction or
other eye in downward and inward direction.
Fig. 9.2: Exophoria Hyperexophoria is a condition where visual
axis of one eye is in upward and outward

direction or in outward and downward
direction for other eye.
Cyclophoria
Cyclophoria is referred to a condition where
eyes are rotated around the anterior-posterior
axis of eyeball when fusion is broken. Because
of this clockwise or anticlockwise rotation of
the eye the vertical meridian of cornea is
deviated from its normal position. Depending
upon the direction of rotation of eyes the
cyclophoria can be incyclophoria (intorsion)
or excyclophoria (extorsion).
When upper end of vertical meridian of
cornea is deviated nasally, then the movement
is called intorsion (Fig. 9.3) and it is due to
involvement of superior oblique muscle. If Fig. 9.4: Extorsion
upper end of vertical meridian is deviated Essential cyclophoria: The essential cyclophoria
temporally, then the movement is called occurs mainly due to imbalance of superior
extorsion (Fig. 9.4) and it is primarily due to and inferior oblique muscles. Muscular
involvement of inferior oblique muscle. imbalance may arise due to muscular insuffi-
On the basis of clinical presentation, ciency or innervational disturbances. When
cyclophoria can be: there is insufficiency of inferior obliques or
• Essential overaction of superior obliques, then intorsion
• Physiological will occur while with insufficiency of superior
• Pseudocyclophoria obliques and overaction of inferior obliques,
extorsion will occur. Usually essential
cyclophoria presents as low degree and in
majority of cases remain asymptomatic.
However, a large degree of cyclophoria (rare
condition) may produce significant ocular and
even systemic symptoms.
Physiological cyclophoria: Physiological
cyclophoria occurs when eyes try to see a near
object placed closely. When eyes focus on a
near object, then eyes go through convergence
and rotate downwards. Convergence is due
to involvement of medial recti muscles, while
rotation is due to inferior recti muscles of both
the eyes. However, with the downward pull
of inferior recti muscle certain amount of
extorsion of eyes also takes place.
In normal physiological conditions this
extorsion of eyes is neutralized by action of
Fig. 9.3: Intorsion superior oblique muscle (cause intorsion). If
this normal neutralizing action of oblique degree of cyclophoria. Patient sees vertical
muscle is disturbed then some amount of lines as deviated lines and also feels
cyclophoria can occur. This condition is usually difficulty to judge the positions and
asymptomatic and requires no treatment. distance of objects especially of moving
Pseudocyclophoria: Uncorrected oblique objects. There may be associated reflex
astigmatism persons (where principal meridia labyrinthine disturbances leading to
are not vertical and horizontal in nature) vertigo, nausea and occasionally even
sometimes may imitate pseudocylophoria. In vomiting.
astigmatism the image formed on retina will • Reflex symptoms: Headache is very
incline towards the direction of maximal common and may occur even after a short
corneal meridian. Thus to bring this retinal duration of near work, and make near
image in appropriate alignment, the one or work difficult or impossible to continue.
more oblique muscles of eye will act and lead Headache sometimes becomes severe and
to torsion. Patient may have distressing resemble with migraine. Occasionally,
symptoms due to torsion, however, once intermittent diplopia may occur due to
correction of refractive error is done, then all fatigue.
these symptoms will disappear.
Treatment of Heterophoria
Clinical Presentation of Heterophoria Horizontal phoria of small degree is common
but usually asymptomatic, hence do not
Symptoms
require treatment. Heterophoria can be treated
Horizontal phoria (esophoria or exophoria) of as follows
small degree usually does not produce any • General health improvement: As muscular
symptoms and remain compensated by the imbalance is more evident during
residual neuromuscular power of eyes. If associated debility or excessive work or
deviation is of high degree (>6 ), then stress. So in majority of cases it is advised
distressing symptoms may appear. As to take rest from work for sometimes, or
compared to horizontal phoria, hyperphoria change of occupation or improve general
even in small degrees can produce considera- health along with some exercises, instead
ble amount of trouble. Furthermore, cyclophoria of prescribing for optical correction.
produces more significant symptoms than any • Correction of refractive errors: Cycloplegic
other types of phoria. refraction preferably with atropine should
• Visual symptoms: Blurring of vision is be done to determine the degree of
especially more marked after fatigue. refractive error in all the age group patients
Person experiences difficulty in gazing of presenting with heterophoria. Refractive
any object continuously and this discomfort errors are most common and easily
further increases if any attempt is made to treatable conditions associated with phoria,
follow a moving object. Patient may also not hence errors should be corrected fully and
able to judge the exact location of objects in accurately by prescribing the glasses of
the space. The visual symptoms are usually appropriate power. Patients having
improved after closing one eye. heterophoria with refractive errors are
• Abnormal head posture: Patient may have advised to wear the glasses regularly and
unusual head tilt to counteract the deviation constantly, because any negligence in
along with associated blepharospasm and/ optical correction may lead to a more
or wrinkling of forehead. devastating condition of tropia.
• Acute distress symptoms: Acute distress • Orthoptic exercises: If patient shows poor
symptoms are more common with high response with abovementioned measures,
then the orthoptic exercises may be advised • Prism therapy: Prism may also be used to
both for distance and near vision. In relieve the symptoms of phoria if orthoptic
esophoria the aim of exercises is to improve exercises have failed. Both base-out or base-
the amplitude of fusional divergence and in prisms can be used to compensate the
in exophoria is to improve the fusional muscular balance for correction of phoria.
convergence. Divergence exercises to The base of the prism should be positioned
improve fusional divergence can be done in the direction of the action of that muscle
with help of prisms (placed base-in before which need strengthening, whereas the
eye), synoptophore, etc. Similarly, conver- apex should be towards the opponent
gence exercises for exophoria to improve muscle, which needs to be neutralized.
fusional convergence can be done with Hence, for esophoria base-out prisms are
prisms (placed base-out before eye), prescribed because lateral rectus needs
synoptophore, stereograms, etc. For strengthening and medial rectus action
cyclophoria exercises are done by using two needs to be neutralized as shown in Fig. 9.5A.
maddox rods which are placed vertically in Similarly, base-in prisms is prescribed for
front of each eye. Then a point light source exophoria for similar reasons as shown in
is shown to patient. Cyclophoria patient Fig. 9.5B.
will see two horizontal lines appearing at In addition, prism therapy relieves strain
an angle to each other. One of the Maddox and help in maintenance of binocular vision
rods is rotated until two lines get fuse. Then by stimulating fusion. Before prescribing
light source is moved forward and prism therapy it is also necessary to rule
backward and patient is asked to keep two out cause of phoria whether it is type of
lines fused during movement of light. essential deviations (due to anatomical
Maddox rods should be rotated towards anomalies) or dynamic deviations. As
upper nasal quadrants to exercise superior prism therapy may worsen the symptoms
oblique and towards upper temporal in phoria occuring due to dynamic
quadrants to exercise inferior oblique deviations. It is because of this reason full
muscles, respectively. prismatic correction is prescribed in phoria
Fig. 9.5: Prismotherapy for phorias. A. Base-out prisms for esophoria; B. Base-in prisms for exophoria
due to anatomical factors while in of convergent squint. This type of squint

horizontal phoria half correction is given. develops during early life due to loss of fusional
In mixed deviation a vertical prismatic reflexes. As a result the person uses excessive
correction is effective for symptomatic accommodation to correct hypermetropia and
relief. Usually, up to 6–8 prisms can be excessive accommodation causes stimulation
given to patient. of convergence leading to development of
• Surgical treatment: Surgical treatment may convergent squint. Presence of anisometropia,
be required in patients having high degree high astigmatism, general debility, etc. further
of heterophoria or where other treatment aggravate the development of squint.
modalities had failed to relieve symptoms. On contrary, divergent squint is more
Surgery on various muscles has been common in myopes due to dissociation of
recommended to relieve the symptoms of accommodation and convergence synergy.
heterophoria. Resection or recession of Myopes use less accommodation and use their
concerned muscle is advised to correct the convergence in excess as compared to
deficiency or excessive power of muscle. accommodation. Hence, even if they develop
Surgical correction of esophoria or a squint it will be divergent or outward in
exophoria is done by correction of one or nature. In reality, myopes usually do not
more horizontal muscle. In hyperphoria develop a manifest squint commonly; rather
muscle surgery done on either superior or a latent strabismus or heterophoria is more
inferior recti muscle while surgery on common. Divergent strabismus is generally
obliques is done in cyclophoria. most commonly associated with emmetropia
or an astigmatic refractive error.
HETEROTROPIA (MANIFEST SQUINT) The vision of other eye can be easily
Introduction suppressed (to abolish diplopia) if there is any
defect in that eye or fusion is not fully developed.
Heterotropia develops when deviation of eyes However, in those persons where binocular
cannot be overcome by fusion reflex so that vision had already developed, it will not be
parallelism of visual axes is not maintained. easy to suppress the vision of any one eye and
As discussed before to achieve a perfect as a result considerable amount of strain in
binocular single vision there must be dissociating accommodation from convergence
• Formation of two equal size images on the will occur. These are the cases which are
retina of both eyes subject for heterophoria and due to lacking of
• Adequate muscular balance stimulus will result into a case of heterotropia.
• An adequately functioning cerebral
mechanism to interpret and coordinate the Note: In any type of squint it remains tendency of
two sets of images formed on both retina. a person to use better eye than the affected eye so
that vision of other eye is sacrificed in lieu to abolish
Disturbance in any of these three elements
diplopia and heterophoria will not manifest.
will affect the binocular single vision and lead
to deviation of eye from their normal
alignment. Formation of dissimilar images on Clinical Presentations
retina may occur due to refractive errors, • Accommodative convergent squint: This
anisometropia, aniseikonia, etc. Muscular type of squint appears commonly during
imbalance may occur during development childhood (in the age group of 2–8 years)
period or due to paralysis. before full development of fusion. In this
Dissociation in accommodation-convergence age group child develops interest in near
mechanism as seen in some of hypermetropes objects like book, pictures or toys; hence the
is one of the important factors for development accommodation is first time used actively
by the child. The squint appearance is more overcome it or avoid it, but in majority of
often preceded by debilitating illness (e.g. patients disadvantages of diplopia are
measles or whooping cough) in child, overcome either by suppression of images of
leading to reduction in tone of muscles. deviating eye or by a mental reorientation of
• Divergent squint: It is usually associated displaced image so that this image is projected
with myopia but as the myopia is usually in space at a position more near to the image
not present since birth, it usually develops of fixating eye (false projection phenomenon).
with growth of child, hence divergent Suppression of the image of deviating eye
squint is not seen at early age. The squint is is a psychological phenomenon. If this
usually not seen in manifest form until the condition persists for some period then the
fusion is fully established, however, as the visual function is impaired and vision gets
age advances and once near point is receded deteriorated progressively. Cells present in
and convergence is still not much required, visual cortex of occipital lobe receive impulses
a tendency to diverge will increase and then from both the eyes and if impulse from one
become manifest squint. On contrary, if eye excluded for binocular vision shortly after
myopia is since birth (congenital or infantile birth and is not reached on these cells, then
myopia) although accommodation is not the cells will completely loose their capability
required but clear vision to see near object of binocularity.
is attained by efforts of convergence. Due In majority of cases having accommodative
to presence of myopia the distance objects convergent squint (since very young age) this
are permanently out of vision of child suppression of impulse from one eye will lead
(hence are neglected by child), the efforts to a condition called amblyopia ex-anopia. The
of convergence are continuously exercised. vision in this suppressed eye is very poor and
These efforts are rewarded in terms of good if this condition persists for a long time, then
binocular vision. This excessive constant it is difficult or impossible to recover the visual
use of convergence gets established as loss. To prevent the development of this type
esophoria for all distances and which may of blindness due to amblyopia of an untreatable
ultimately leads to a manifest convergent degree it is important to start an early and
squint. effective treatment in every case of strabismus.
• In high degree astigmatism clarity of vision
is not affected by the efforts of convergence Heterotropia Classification
rather there will be a relative blindness for Heterotropia classification is based on the
both distant or near objects. In contrast to direction of deviated eye as shown in Table 9.2.
congenital myope, where clear vision can To understand easily and in convenient
be attained by dissociating convergence way the different hypertropia can be summari-
from accommodation the congenital zed as
astigmatics fails to see clearly by any efforts.
• Esotropia means a convergent squint.
Hence they give up all efforts to see clear
objects by development of divergence • Exotropia means a divergent squint.
initially for near objects and then finally for • Hypertropia and hypotropia mean
distant objects also. vertical squints. Because these terms are
relative, they can further be differentiated
Effect on Vision in Concomitant Squint as
Most cases of concomitant squint develop in – Strabismus sursumvergence wherein
early childhood are usually associated with eye is turned upwards
diplopia. Occasionally, this diplopia persists – Strabismus deorsumvergence wherein
because patient is being unable to either eye is turned downwards
Table 9.2: Classification of heterotropia faced in performing retinoscopy in high

amblyopic eyes because central fixation is not
Plane of Type of Direction of
deviation heterotropia squinting eye
present in these patients. In such cases
retinoscopy is done by occluding the fixating
Horizontal Esotropia Inwards eye so that amblyopic eye can centrally fixate
Exotropia Outwards
and once the retinoscopy is done the fixating
Vertical Hypertropia Upward eye can also be refracted under atropine
(strabismus cycloplegia.
sursumvergence)
If significant refractive error is present then
Hypotropia Downward
(strabismus
full correction should be given by just
deorsumvergence) deducting plus one dioptre power (due to
effect of atropine) from the retinoscopy values.
If child is unable to tolerate the spectacles, then
Treatment of Heterotropia
atropine is prescribed along with spectacles
An ideal treatment approach in case of a for a few weeks until child starts tolerating
strabismus is not only to correct the deviation, the spectacle corrections.
but also to establish a binocular vision. It is It is essential to wear spectacles constantly
very important to start the treatment of squint prescribed for refractive error, i.e. should be
as early as possible once squint is noticed wear from morning and should be removed
because as child’s age advances the reflex at night. If very young children resist wearing
pathway which subserves the function of spectacles or remove them very often, then
binocularity becomes difficult and at an spectacles can be tied with the head of child
adolescent age it becomes impossible. as shown in Fig. 9.6.
Preferably, a strabismus is considered cured
As discussed above the accommodative
only when with treatment person achieve
squint usually develops between the age of
good vision and both eyes are in a perfect
2–8 years and usually a 2–3 years old child
alignment with binocular vision.
can wear spectacles. If child is younger than
Two important steps of treatment which an
ophthalmic expert can perform are
• Accurately determine and correct any
refractive error, if present.
• Maintain and promote the vision in
deviated eye.
Optical Correction
Determination of refractive error is done
under full cycloplegia by atropine given for
three consecutive days (preferably in an
ointment form at bedtime) before examination.
It is better to do retinoscopy for detection of
refractive error and in cases of astigmatic
errors (especially that of deviated eye), a
special consideration is required.
It is possible to do retinoscopy in most of
the cases including young child who can fixate
a light and test lenses can be held in hand at
an arm length. Sometimes difficulty can be Fig. 9.6: Spectacle corrections for young child
this age or not accepting spectacles, then improve its efficacy. A constant watch should
atropine can be given as daily or alternate day be kept as sometimes the occluded eye gets
as ointment, until child is able to wear the deviated and vision gets deteriorate.
spectacles. In some cases atropinisation Result of such a treatment is variable and
rectifies the squint by abolishing the effect of occlusion is tried for a month period and if no
accommodation and further deviation can be improvement occurs, then it can be tried for
controlled by spectacles. another month. In spite of this when no
improvement occurs in deviation and visual
Maintenance of Vision in Squinted Eye acuity, then chances of correction are very less.
Once optical correction has been given, next Suppose there is improvement in visual acuity
step is to improve the vision of squinting eye. then the treatment is continued till there is
Vision is measured as routine and it is re- further improvement in vision is obtained. The
estimated after prescribing the glasses. If the ideal duration of treatment is till the vision of
deviated eye is amblyopic and its visual acuity both eyes become equal or until any further
is very poor, then the fixating eye should be improvement in vision has stopped. In these
occluded to encourage the vision of deviated cases a true equality of vision is maintained
eye. Best method to occlude fixating or better and squinting becomes alternate means a
seeing eye is by applying the surgical plaster condition where one or other eye is used for
(e.g. opticlude) and spectacles can be worn fixation. If child is older, then the outcome is
over it. Alternative method for occlusion is use relatively very poor.
of spectacle having an occluder fixed inside As soon as equality of vision is achieved an
the spectacle or a paper can be applied on one attempt should be made to develop a
lens of spectacles. In cases of dense amblyopia binocular vision by starting orthoptic
this may not be effective and a total occlusion exercises, in which habit of binocularity is
may be needed. However, total occlusion in practiced by training and facilitating a
order to improve vision in amblyopic eye may binocular vision of a degree sufficient enough
destroy remnants of binocular vision to maintain alignment of two eyes.
altogether. Hence, total occlusion of eyes in Preferably once the desire for fusion is
alternating manner is best recommended even obtained by orthoptic exercises, surgical
in cases of dense amblyopia. Cases where treatment is undertaken. However, in cases of
amblyopia is not marked the better eye can accommodative squint operation is postponed
be kept under effect of atropine so that until correcting spectacles has been worn for
distance vision remain indistinct and near some months. For example, suppose the degree
vision is impossible. Hence, the deviated eye of deviation reduced from 25 to 15 degree by
is given an opportunity to work and wearing spectacles, then only correction of
continuous exercise of this eye forces it to 15 degree is required by surgery not of 25 degree.
III
Vision and Refraction
10. Visual Perception

11. Retinoscope and Retinoscopy
10
Visual Perception
Learning Objectives
• Understand perception of light in terms of its all elements like light sense, form sense, contrast sense
and color sense.
• Describe entoptic phenomenon and after images.
• Explain visual acuity in terms of various criteria and factors influencing visual acuity.
• Measure visual acuity for distance and near in infants, children and adults by various available methods.
• Describe the contrast sense, its types and methods of measurement.
• Understand color vision and theories of color vision.
• Explain color vision charts and color blindness.
• Understand potential vision and its methods of measurement.
Chapter Outline
• Light sense Contrast sensitivity curve

– Introduction Arden’s gratings
– Entoptic phenomenon Cambridge low contrast gratings
Floaters FACT chart
Phosphenes Pelli-Robson contrast sensitivity chart
After images • Color sense
• Form sense and visual acuity – Introduction
– Visual acuity (VA) – Theories of color vision
– Factors influencing visual acuity Trichromatic theory
– Types of visual acuity Opponent process theory
– Measurement of ordinal visual acuity
– Color vision charts
VA measurement in infants
– Color blindness
VA measurement in preschool child
Congenital color blindness
VA measurement in school going children
Acquired color blindness
and adults
– Measurement of near visual acuity • Potential vision
• Contrast sense – Introduction
– Introduction – Subjective methods of measurement
– Types of contrast sensitivity – Objective methods of measurement
Spatial contrast sensitivity Potential acuity meter
Temporal contrast sensitivity Laser Interferometer
– Measurement of contrast sensitivity White light interferometer
Historical aspects – Alternate methods of measurement
201
Vision or perception of visual sense is a complex Note: Diurnal animals like squirrel have very few
phenomenon and it involves: or no rod whereas, nocturnal animals like bat have
• Light sense small numbers or no cones. Humans have sufficient
• Form sense number of both rods and cones.
• Contrast sense conditions sensitivity of rods towards the light
• Color sense is much more as compared to cones, hence in
dim illumination, as during early morning or
LIGHT SENSE during evening an individual sees with rods
Introduction and this vision is termed scotopic vision,
Light sense is the sensation of perception of whereas in bright illumination as during day-
light impulses by retina, nerve pathways and light, person utilizes the cones to see the
central nervous mechanism, not only as a objects which is called as photopic vision.
whole but also in all its grades of intensity.
Suppose intensity of light falling upon retina Entoptic Phenomenon
is progressively reduced, then after certain The visual perceptions having their source
level of intensity a point will come when light inside the ocular structures of an observer’s
is no longer perceived by the individual, this eye forms images which may or may not be
point is called light minimum. The light perceived by the observer. These ocular
minimum is not constant at different portion structures which may cause formation of these
of retina. For example, at foveal region it is images may be either normal anatomical
significantly higher as compared to components of the observer’s eye or may be
paracentral and peripheral region of retina. pathological components like opacities
The normal human eye is exposed to a wide present in ocular media. As these images
range of lighting environment, thus to arise from “inside” they are called ‘entoptic’
function properly a very rapid adaptation to phenomenon. Visual perceptions usually filter
these changes in the range of lighting intensity out these images, but if they appear suddenly
is necessary to perform various activities in or become annoying, patients may have
day-to-day life. This ability of human visual symptoms. Several entoptic phenomena are
system which allows a person to see clear in the results of shadows falling on the retina,
different range of lighting intensity, is called due to opaque portions inside the eye.
light or dark adaptation. To understand this Shadows on the retina from a collimated light
in better way, consider a situation when we are sharp irrespective of their position from
suddenly enter from outside (bright sunlight) the screen. For example, when a pinhole is
into movie theatre (dim lighted). Normally, placed near anterior focal point of eye, all the
we feel that objects inside the theatre are not light rays falling on the eye becomes parallel
visible for some time. Once our eyes become and opacities present within the eye will
adapted to that dim illumination, we start produce sharp shadows on retina, irrespective
seeing the objects in theatre. Hence, the of position of objects, i.e. either in anterior or
interpretations about effectiveness of the posterior region of eye (as shown in Fig. 10.1).
process of light minimum can be judged once Though pinhole opacities present in anterior
the retina is stimulated in the same segment of the eye will appear as shadows at
illuminating conditions of dark adaptation, anterior focal point of eye. A small size
which can be achieved by eliminating light for pinhole, a large size pupil, and a very bright
at least 20–30 minutes duration. background will enhance the entoptic effect.
In human eyes retina has two photoreceptors, Various shadows seen in cases of corneal and
i.e. cones and rods. In low illumination lenticular spots are shown in Fig. 10.2. Corneal
Visual Perception 203
Fig. 10.1: Sharp shadows on retina Fig. 10.3: Floaters
They often move with the movements of

eyeball but if someone tries to look them
directly they float away. Floaters are charac-
teristically found in the vitreous cavity as small
opacities and they cast shadows on the retina.
Causes
• Most common cause is liquefaction and
breaking of transparent vitreous gel
occurring with age leading to shrinking of
vitreous and results in detachment of
vitreous from retina (posterior vitreous
detachment). Consequently, the liquefied
material gets chance to move between
vitreous gel and the retina. Collagen fibers
which were initially a part of vitreous now
become loose clumps or debris and begin
Fig. 10.2: Various entoptic appearances. A. Corneal to float into vitreous cavity. The debris in
spots; B. Corneal folds; C. Spots in crystalline lens; vitreous cavity will cast shadow on the
D. Star opacity in crystalline lens
retina and moves around with the
spots or folds will appear as circular shadows movement of eyeball.
of various sizes at anterior focal point of eye,
whereas spots and star opacity in crystalline Clinical Appearance
lens appears as shadows inside the eye which • Depending on the location from retina when
moves with ocular movement. floaters are present very close to retina, they cast
sharp shadows or diffraction pattern (because
Floaters of more obstruction of light) and when these
Floaters [also known as ‘muscae volitantes’ floaters are located away from the retina they
(means flying bugs in Latin) or ’flying gnats’ cast blurry and indistinct shadows.
are shadows which float like cobwebs or • The shadows cast on the retina are visible only
specks in the field of vision. These floaters when they are moving. In resting position
appear as dark, shadowy shapes and may shadows are not seen. Clumps of different sizes
appear as spots, thread-like strands, or some- moves with different speeds and appears as if
an object is moving across our visual field.
times even curved lines as shown in Fig. 10.3.
Clinical Significance the shadows of blood vessels also move

enough and become noticeable. Another way
• Foveal vision may get affected due to the to induce shadows of blood vessels is to direct
presence of very dense floaters and may produce the bright light via sclera. Place a penlight
annoying symptoms in patients, for which source over the closed lid near limbus and
patient may ask for treatment. then move the penlight in small circles, the
• Acute increase in amount of floaters indicates light will penetrate and make the shadows of
the presence of retinal tears, inflammation blood vessels to fall on visual receptors and
(uveitis), infection, hemorrhage, or any ocular
hence Purkinje tree becomes more visible.
injury.
• It is essential to exclude the important conditions Phosphenes
like retinal detachment in every patient
These are vague visual sensations which are
complaining of floaters; before assuring the
patient that these floaters are usually common perceived as flashes of light, originating due
and not harmful. to some internal activity taking place in the
retina or at higher visual system. Phosphenes
• Sometimes remaining materials from break are produced when retina is stimulated by a
down of either hyaloid artery (during third source other than the light, i.e. phosphenes
trimester) or from the retina (during may arise due to stimulation of retina by
vitreous detachment) may cause floaters. mechanical forces (during vitreous detachment)
or electrical forces.
Treatment Various types of phosphenes are:
• Mostly floaters are benign in nature so no • Moore’s lightning streaks: These are most
treatment is required. Patients must be common types of phosphenes observed in
informed that these are due to natural practice and the flashes of light appear as
process of aging and cannot be removed by lightning bolts or streaks. It is more
simple uncomplicated procedures. common in the middle age and elderly
• A few severe cases may require vitrectomy persons and usually seen in temporal visual
which may be associated with complica- fields in vertical direction. Mainly arise due
tions like cataract or retinal detachment. to posterior vitreous detachment which
create more traction on the retina and hence
Note: To resolve floaters a partial vitrectomy can will cause the retinal cells to discharge these
be done called “Floaterectomy”.
lightening streaks.
• Flick phosphenes: These types of phosphenes
Purkinje Tree appear when eyeballs are moved rapidly
Purkinje tree are shadows or images which are and in large and jerky manner. More
produced due to superficial blood vessels of commonly seen by older and dark adapted
retina in the one’s own eyes as vessels lies in patients where probably the incompletely
front of photoreceptors. Normally these or fully detached vitreous might pull retina
images are not visible because of adaptation or bump on the retina.
mechanism in the retina and also they always • Pressure or deformation phosphenes: These
remain in fixed position. The purkinje tree are produced when eyeball is directly
images can be seen when the light source stimulated mechanically by applying
moves at such frequency so that adaptation pressure on the eyeball. To elicit these
mechanism is failed and clear image of blood phosphenes, close the eyelids and move the
vessel can be seen. This can be accomplished eye toward the nose, now pressure is
by viewing through a pinhole pupil. As the applied on the temporal side via eyelid. A
pinhole pupil is moved across natural pupil, bright spot will appear in nasal visual field.
• Electrical phosphenes: Electric current

passing through neural network of retina
or cortex will induce these types of
phosphenes. The magnitude of stimulation
of retina by electric current is decided by
component of current density perpendi-
cular to the surface of the retina. Electrical
phosphenes are commonly observed by
those patients who are undergoing electro-
oculogram (EOG) test where retina is
stimulated when examiners run a small
amount of current through the electrodes
to check the contact of electrodes.
• Cortical phosphenes: These are produced
in a similar manner by electrical stimulation
of cerebral cortex. It has been found that
Fig. 10.4: Afterimage chart
cortical phosphenes can be produced when
there is direct electrical stimulation of cortical only for a fraction of second in the same color
neurons as during brain surgery or during as that of original stimulus color. However,
transcranial magnetic stimulation test. their mechanism of formation is not clear.
Afterimages Clinical Application

Afterimages are produced due to the
adaptation to light patterns. It means if we Afterimages can be used to test for presence of an
look at some object for a long time and then anomalous retinal correspondence.
look away, then an afterimage will be noticed.
As these images are localized to a particular Maxwellís Spot
retinal area so they move with eye movements. Macular pigment (zeaxanthin) present in the
Normally, afterimages are not appreciated by macular area selectively absorbs blue light and
person because eyes move constantly and the retinal area covered by these macular
change the local stimulation, as a result pigments is roughly of the same size as foveal
adaptation not occurs. area. Before reaching the photoreceptors the
The Hermann grid or afterimage chart as light has to pass through these macular pig-
shown in Fig. 10.4 illustrates about afterimage. ments. If a blue filter is placed before the eyes
When eyes are fixed on the tiny black dot at and an evenly illuminated surface is looked
the center of chart for about a minute and then through it, then a circular dark disc is seen in
suddenly eyes are moved to focus on a white macular area around the fovea (Maxwell’s spot).
spot, then afterimage of the grid will be Normally this dark spot is not noticed because
noticed means a dark grid floating over a person is adapted to the difference in color or
white grid will be seen. The afterimages can brightness and also spot moves with the eye.
be of various types like negative afterimage,
positive afterimage or images on empty Clinical Application
shapes. When photoreceptors, i.e. rods and
cones, get overstimulated and loose their Maxwell’s spot can be used to diagnose eccentric
sensitivity they produce a negative afterimage fixation. As described in the above test, patients see
in complementary color of the original the dark spot away from center of fixation point,
means they are not using their central fovea for fixation.
stimulus color. Positive afterimages are produced
Note: Similar technique was used in Haidinger’s cone in between them remain unstimulated.
brushes, where a windmill pattern appears when The two adjacent points (for example, A’ and
viewed through a polarized blue light. If this B’) can be seen distinctly only when they
windmill pattern is not centered on the fixation produce a visual angle (v) of at least one
point, it shows an eccentric fixation. This pheno- minute.
menon appears due to selective absorption of blue The size of visual angle is dependent on two
polarized light by pigment molecules in the fovea. factors:
• Size of the object
FORM SENSE AND VISUAL ACUITY • Distance of the object from the eye
Visual Acuity The average diameter of retinal photo-
Visual acuity deals with measurement of form receptor cone is about 1.5 μ in the macular
sense of visual perception. It measures the region, hence it is seen that these two points
spatial discrimination function of visual A’ and B’ will appear distinctly only when
threshold, i.e. it specifies the limit of discrimina- their retinal image size, i.e. AB is more than
tion of visual sense in space or it determines that of 4.5 μ, means two stimulated cones and
threshold of visual sense. Hence, acuity of one unstimulated cone in between them
vision is decided by the smallest retinal image makes a total of 1.5 × 3 = 4.5 μ.
formed by the smallest object which can be As shown in Fig. 10.6 the objects of same
seen clearly from a certain distance. The visual size are present at different distance will
angle is the most convenient standard to produce image of different sizes and farther
estimate the visual acuity. away is the distance of object from the eye,
smaller will be the image size on the retina.
Visual Angle Hence, size of retinal image is inversely
The angle formed at the nodal point of eye by proportional to the distance of object from the
joining the two lines drawn from the eye, therefore, to see an object clearly either it
extremities of an object is called visual angle should be of large size or should be situated
(v) as shown in Fig. 10.5. The visual angle is a near to the eye. If object AO is of same size
suitable and valuable approach to make out as A’O’ and the object AO is situated at one-
the spatial extent of an object in the desired half the distance of A’O’, then the retinal
visual field. image size (ax) is automatically will be double
To see an object clearly and for discrimination than that of image a’x, hence the retinal image
of size, it is necessary that two individual size for a given visual angle can vary with the
cones should be stimulated whereas, the one change in the viewing distance.
Fig. 10.6: Relation of object distance from eye, with

Fig. 10.5: Visual angle retinal image size
Factors Influencing Visual Acuity affect VA. It is because of these aging changes
Ability to discriminate two spatially separated deterioration of vision is common after age of
targets is termed resolution and it is equivalent 40–45 years.
to ordinary or normal visual acuity. To achieve Retinal eccentricity: Centre of fovea shows
this ordinary visual acuity all ocular elements maximal visual acuity. As the distance from
(which are involved in vision) like anatomical, fovea increases the visual acuity decreases.
physiological and optical show their maxi- Refractive errors: Presence of uncorrected
mum performance. Various physical, physio- refractive errors is generally common cause
logical and psychological factors can influence of reduced visual acuity.
the visual acuity. Psychological factors: Altered mental
Physical factors are the one which mainly status of person due to any disease or any
influences the distribution of light characteris- intoxication may affect visual acuity.
tics like diffraction, aberrations, scattering,
absorption and focus factors. Hence, these Types of Visual Acuity
factors will affect the nature of formed retinal There are different criteria of visual acuity
image. Illumination of the object and contrast which are set for the responses of the observer.
sensitivity are important factors affecting They are
visual acuity. Increase in the illumination • Minimal visible or detection acuity: criteria
causes increase in the visual acuity up to a set for presence of a single feature
point beyond which no improvement in visual • Minimal resolvable or resolution or ordinary
acuity can be elicited. After this point increase visual acuity: Criteria of presence of feature
in the illumination will cause glare. The usual identification in a visible target
range of illumination for optimal visual acuity • Spatial minimal discriminable or hypera-
should be 5–20 foot candles. Reduction in cuity: Criteria set for relative location of
contrast will require more illumination for visible target.
resolution of an object.
• Recognition acuity
Physiological factors affect the processing
of stimulus and are mainly related to the Minimal Visible
observer. These may be Minimal visibility means an ability to detect
Pupil size: Change in the size of pupil also presence of a visual stimulus/object in an
affects visual acuity by altering illumination otherwise empty looking visual field. In other
and diameter of circle of blur on the retina. In words, minimal visible criteria tell about the
persons having pupil size less than 1 mm, ability of a person to see a test object against
visual acuity will decrease because of the background. The maximum limit of
diffraction of light and reduction in illumina- detection acuity indicates absolute threshold
tion of retina. Similarly, large-sized pupil of vision and it can be affected by factors like
(> 6 mm) also decreases visual acuity because size, shape, illuminance and contrast of the
of more chances of scattering of light at the stimulus.
retina. For example:
Accommodation: Accommodation is • A black dot having diameter of 30 seconds
associated with decrease in the size of pupil of arc or more than that can be seen against
(miosis), hence affects VA. Spasm of accommo- a white background from a considerable
dation causes decrease in VA and induces distance.
myopia. • A thin telegraph wire having thickness
Age: With advancement of age changing in of as little as 1 second of an arc can be
the integrity of eye and visual pathways may detected against a uniform sky.
• A black square having diagonal length best focus has a resolution limit between
of 30 seconds of an arc or more can be 30 seconds to 1 minute of an arc, which is
detected against a white or light shade called minimum angle of resolution (MAR).
background from a reasonable distance. Now consider minimum separation
• An illuminated object can be detected between two light bars present in a grid of
from a very long distance in dim light or alternate dark and light bars. As the width of
dark not because of its size rather due to these two light bars increases, the value of
its illuminance intensity. threshold decreases and at limit of nearly
Thus we can say that minimal visual acuity 1 second of arc the width of these light bars
tells about the brightness and detection becomes so thick that observer sees only a thin
discrimination, i.e. it is the ability of an observer black line against a white background as
to determine small differences in the brightness shown in Fig. 10.8.
of two light sources so that presence or Conversely, if the width of two black bars
absence of a target can be determined. is increased, then the stimulus will appear as
thin white line against a black background.
Minimal Resolvable Hence the minimal separation appreciated
(Minimum Separable Acuity) between the two black bars has reduced to a
Commonly considered as an ordinary visual thin white line as shown in Fig. 10.9.
acuity and forms the basis for Snellen’s letters
or Landolt’s C charts. A property of discrimina-
tion of two separated targets in space is called
as resolution and a minimum amount of separa-
tion between these two separated targets
which an observer can appreciate is called
minimal resolvable. Thus minimal separable
acuity tells about the resolution threshold or
smallest visual angles at which two objects can
be discriminated separately (Fig. 10.7).
In other words, we can say that
measurement of resolution threshold is
equivalent to assessment of function of the
fovea centralis. In normal observers the angle Fig. 10.8: Two light bars in a grid appearing as thin
black line (minimal resolvable)
subtended by two targets at the nodal point
of eye gives an idea about the distance
between them. Normal observer in his/her
Fig. 10.7: Minimal resolvable between two-point Fig. 10.9: Two black bars in a grid appearing as thin
objects white line (minimal resolvable)
Hence, in practice visual acuity measures threshold, where only presence or absence of
the minimal separation of target stimulus a target is judged. In normal observers the
through form sense or reading ability of threshold value of hyperacuity is between
observer. To measure visual acuity the tests 2 and 10 seconds of arc.
like Landolt’s C (to detect the gap in a ring)
and Snellen’s optotypes (ability to read a Recognisation Acuity
letter) are used. An individual’s ability is not only to discrimi-
nate the target in spatial characteristics but
Minimal Discriminable also to identify the pattern of target stimulus,
Normal observers are capable of making if he/she is already familiar with that
certain spatial distinctions of a stimulus even particular test pattern. This ability to identify
if the threshold level of stimulus is much lower a pattern or stimulus from a set of similar
than the level of an ordinary visual acuity. This stimuli or patterns is called recognisation,
state is also called hyperacuity and is best hence it is a task which involves not only
represented by an alignment or Vernier acuity. spatial resolution but also has an associated
This simply means hyperacuity test or Vernier cognitive element. For recognisation an
acuity task help to detect whether an observer observer should be well known with the set
is able to judge the alignment or location of of test figures with an additional ability to
two parallel straight lines in relation to each resolve these test figures.
other (Fig. 10.10).
In hyperacuity the observer judges the Visual Acuity Measurement
location of an element of target in relation to Visual acuity per se is a complex ocular
another element of same target, and should function and its components as discussed
not be confused with minimal visible above are
• Ability to judge the presence or absence of
a stimulus, i.e. minimal visible
• Relative judgment of location of one
element of visual target with another
element of same target, i.e. minimal
discriminable.
• Ability to judge presence of feature identifi-
cation in visual target, i.e. minimal
resolvable (ordinary visual acuity).
In clinical scenario measurement of minimal
angle of resolution (MAR) is considered
equivalent to the measurement of visual
acuity, although theoretically as we can see
above, there is a lot of difference. Hence,
various clinical patterns are established to
measure the patient’s threshold for a minimal
resolvable angle.
Based on this principle various types of
visual charts have been developed for clinical
assessment of visual acuity or MAR.
Fig. 10.10: Minimal discriminable showing To define visual acuity in terms of quantity
Vernier’s hyperacuity several eye charts had been developed in early
19th century in Germany. In the year 1836, made in the original Snellen’s eye chart. In the
German ophthalmologist Küchler designed a year 1867, French ophthalmologist Ferdinand
chart using figures (for example, fire arms like Monoyer invented an eye chart and introduces
guns, rifles, canons, farming equipments, a decimal notation method to measure visual
animals, birds, and amphibians) cut from acuity (Fig. 10.12).
calendar, books, and newspapers and pasted In the year 1868, scientist Green proposed
them on the paper in rows of decreasing sizes. an eye chart which has a geometric
As these figures were selected vaguely thus, progression of letter size along with a
the visual design or style was not consistent, proportional spacing in between these letters.
hence this system had its limitations. But Later on in the year 1888, Landolt proposed
Küchler refined his chart and in the year 1843, an eye chart, where he used single symbol of
he published a newer version of his traditional broken ring in different orientations. This
chart. As shown in Fig. 10.11 this chart has 12 solved the problem faced by Snellen’s chart
rows of black letters, which are gradually optotypes, which were not equally recogniza-
decreasing in the size. However, even this ble by all subjects. In the year 1959, Louise
newer version of chart did not gain popularity Sloan designed a new set of 10 nonserif letters.
and hence was published only once in the year Chart to be used at one meter distance and
1843. she also proposed the use of all 10 letters in
The term visual acuity was coined by each row to avoid any recognisation problems
Donders’ in the year 1861 who defined it as and crowding effects between letters.
“ratio between a subject’s performance and a Subsequently, Lea Hyvarinen of Finland,
standard performance in distinguishing Taylor of Australia and Bailey and Lovie
details of a test pattern”. In the year 1862, (1976) all of them designed their eye charts.
Dutch scientist Harman Snellen published his
famous eye chart, as a standardized measure-
ment tool to check visual acuity. Till date only
a few minor variations or improvement are
Fig. 10.11: Kuchler vision chart Fig. 10.12: Ferdinand Monoyer vision chart
Lea use pictorial optotypes like outlines of Measurement of Ordinary Visual Acuity
apple, house, square or a circle to test visual Various tests for measurement of visual acuity
acuity for preschool children. Taylor created in different age groups are summarized in
an eye chart using single optotype, letter E Table 10.2.
(like Landolt’s broken ring) in various
orientations. Bailey and Lovie re-invented the Visual Acuity Measurement in Infants
original Green’s chart and used British letters Subjective Tests
as optotypes. In the year 1982, National Eye Indirect assessment of vision can be done by
Institute combined the Bailey and Lovie layout following tests:
with Sloan’s optotype letters and created an • Historical and observational tests
eye chart called ETDRS chart. In recent years • Binocular fixation preference
many new development has been done to • CSM method
create electronic type charts. An example is a
British-designed Test Chart 2000, which Historical and observational tests: Newborn
became world’s first Window based compu- is responsive to sound and shows awareness
terized test chart. This helps in solving many for surroundings. Parents are usually asked
difficult issues like screen contrast and gives whether child responses to a silent smile, light
an opportunity to change the sequence of letter music or follow objects around the environ-
(so that patient cannot memorize letters). ment. Parental observation also includes
presence or absence of deviation of eyes
Visual acuity can be measured by several
(squint). Suppose one eye is deviated, the
tests based on the various methods of
visual acuity in that eye is likely to be poor,
identification of targets as summarized in
but in case of a constant alternating squint,
Table 10.1.
visual acuity may be normal in both eyes. At
• Detection acuity, i.e. judgment of an age of one month infants develop normal
presence or absence of a target. pupillary reflex, positive blink reflex and eye
• Resolution acuity describes details of popping reflex; presence of these reflexes
spatial characteristics present in a target indicates a good visual acuity. Both pupillary
in full resolution. reflex and blink reflex are learned by 30 weeks
• Recognition acuity means an identifica- of gestation. Unique behavior in babies is eye
tion of a target. popping, and if something else is not elicitable
Table 10.1: Tests for visual acuity measurement based on various acuity methods
Detection acuity Resolution acuity Recognition acuity tests
tests tests Letter identification Direction Picture
tests identification tests identification tests
Boek candy bead Preferential looking Snellen’s letter Arrow’s test Allen’s picture
test test chart card tests
Catford drum Optokinetic HTOV chart Snellen’s E test Pictorial vision
test nystagmus test charts
Dot visual acuity Visually evoked Sloan’s chart Landolt’s C test Miniature toy car
test response (VER) test
Sty car graded Sheridan’s letter Sjögren’s hand test Light house
ball’s test chart picture test
Taylor’s tumbling
E test
Table 10.2: Tests for measurement of visual acuity in various age groups for distance and near vision
In infant Preschool going child School going For near vision
Subjective tests Objective tests 1–3 years age 3–5 years age child and adults
Above 5 years All age group
age and adults
Historical and Visual evoked Marble game Tumbling E test Snellen’s visual Snellen’s near
observational potential (VEP) test acuity chart vision chart
tests test
Binocular Optokinetic Worth ivory Landolt’s C test Landolt’s ‘C’ Jaeger’s near
fixation nystagmus ball test chart vision chart
preference (OKN) test
CSM method Preferential Dot visual Sheridan- ETDRS chart Roman near
looking acuity test Gardiner HTOV vision chart
technique (PLT) test
Coin test Sjögren hand Modified
test ETDRS chart
Bock’s candy Broken wheel
bead test test
Miniature toy Light house
test picture card test
to evaluate visual acuity eye popping reflex

can indicate that infant is able to detect the
change in room illumination. When the light
of room is dimmed suddenly, the upper
eyelids of infant pops open wide for a moment
and infant often closes the eyes once lights are
brought back. This happens again when lights
are dimmed.
Binocular fixation preference test: At an age
of three months fovea gets fully developed
and fixation behavior can be assessed
accurately. Various examples of fixation
behavior assessment are like identifying
mother or fixing eyes on a moving toy. If child
is trying to fixate with only one eye, means
there is poor vision in non-fixing eye and child
will resist violently, if we try to close the
fixating/better eye (left eye in our example)
as shown in Fig. 10.13A. However, when we
close the non-fixating eye (right eye in our
example), child continues to smile as shown
in Fig. 10.13B. Fig. 10.13A and B: Binocular fixation preference test
Suppose visual acuity of child is poor in (see text): A. Closing fixating eye (left eye); B. Closing
both the eyes or child is very irritated or not non-fixating eye (right eye)
Note: On clinical evaluation presence of all

three elements, i.e. CSM indicates visual acuity
of 6/9 to 6/6. Only presence of CS and no M
indicates visual acuity of 6/36 to 6/60 and an
unsteady central fixation indicates vision less
than 6/60.
with either eye when other eye is uncovered

is considered as an evidence of difference in
visual acuity between two eyes.
This test will also help in diagnosing the
underlying squint, if present. At an age of
6 months vergence response to base-in/base-
out prism can be elicited. At this age
vestibulo-ocular reflex induced nystagmus
can also be elicited, which helps in differen-
tiating normal seeing child from a blind
child.
Note: Nystagmus persisting for 5 seconds or more

than 5 seconds duration indicates blindness.
Between 6 and 12 months of age group if a

Fig. 10.14: Binocular fixation preference test (see
response is tried to be elicited by giving forced
text). A. Child resisting closure of right eye; B. Child
resisting closure of left eye choices of object, child will show optimal res-
ponse, because by 9 months of age a habitua-
liking the examiner’s hand over face, then he/ tion phenomenon is developed and an infant
she will resist closure of either eye and will finds it difficult to sustain interest in any type
starts crying or will try to remove the hand of objects.
from eyes as shown in Fig. 10.14A and B.
Objective tests: For assessment of detection/
CSM method: At 3–6 months of age an resolution acuity in infants, various objective
adequate amount of refixation reflex gets tests had been studied, among them most
develop and a cover test or cover uncover significant tests are:
test can be performed. Test is done with one • Visual evoked potential test
eye of baby is fixed on an accommodating
• Optokinetic nystagmus test
target held at 40 cm distance in front of the
baby. • Preferential looking technique
C refers to corneal reflex as the baby fixate • Teller acuity cards test (TAC)
the light held by examiner, normally light • Cardiff acuity test (CAT)
is reflected at center of cornea symmetri- Visual evoked potentials: This technique is
cally. independent of behavioral response of the
S refers to steadiness of fixation by baby infant and is useful in assessing detection/
on the light held by the examiner. resolution acuity in preverbal infants. This is
M refers to the ability of child to maintain the only clinical objective test, which assesses
the alignment of light first by one eye, when the functional status of visual system from
other eye is covered and then by other eye retinal ganglionic cells to occipital cortex. This
when this eye is uncovered. Inability to fixate test is performed in those infants or children
who give unreliable results with other tests. of response is recorded and a rough estimate
Infant is presented with either flash or of visual acuity can be made by these
patterned stimuli and an amplitude values.
electroencephalogram (EEG) is recorded Optokinetic Nystagmus (OKN) Test: In this
from occipital lobe as shown in Fig. 10.15. test presence or absence of an optokinetic
Visual potential responses (VER) recorded nystagmus is assessed by presenting a
by flash stimuli tells only about the integrity patterned rotating drum or a drifting
of visual pathway from macula to occipital stimulus having alternate black and white
cortex. To record reversal VER, alternating strips to infant’s visual field as shown in
black and white stripes or checks (like a Fig. 10.16. The drum is gradually rotated in
checker board) patterns are positioned in front front of the infant and the eyes of an infant
of the child and response of the brain is will follow the stripes with a jerky nystagmus
noticed. To record it, three metal electrodes pattern.
are placed on the head of child which are Interpretation of test: Nystagmus is noticed
connected to a computer. When the child sees with rotation of drum (stimulus) as shown in
the stripes, the signals are transferred from Fig. 10.17. When stimulus with gradually
eyes to the visual cortex; these signals are then decreased width of stripes is presented to the
detected by metal electrodes. Mean amplitude child, the movement of eyes will stop at certain
width of strips. The visual angle subtended
by the thinnest strips of black and white,
which is able to elicit eye movements give a
measurement of visual acuity. Positive
nystagmus response indicate presence of
counting finger vision between 3 and 5 feet in
infant.
Fig. 10.15: Visual evoked potential Fig. 10.16: Optokinetic nystagmus test (see text)
and other patterned with alternate black and

white strips. Child is made to sit in front of
this screen and these two stimuli are presented
with random alterations. The pattern and
position of these two stimuli are altered
randomly so that child moves his/her head
towards the patterned stimulus. Examiner will
observe the head movement of the infant,
through a peep hole present in the screen,
although he is not aware of the position of
patterned stimulus on screen. Examiner will
record the head movement directions as right
or left, in accordance with the presentation of
patterned stimuli.
Thickness of strips in patterned stimuli is
Fig. 10.17: Rotations of eyeballs causing nystagmus gradually reduced along with positional
Various studies reported that newborns change from right to left, till infant stops
moving his/her head; means infant is unable
have an optokinetic acuity of about 6/120,
to resolve the stimulus and hence showing no
which rapidly improves to be about 6/6 at
preference to either a blank or patterned
2 years of age.
stimuli. This minimum thickness of strip,
Preferentially looking test: For assessment of subtend a visual angle and gives an estimate
visual acuity in infants and toddlers the most of visual acuity.
commonly used clinical technique is As this technique employs square wave
preferentially looking test. Principle of this test grating stimuli and estimate psychosocial
is that when two different kinds of stimulus resolution acuity, hence this test can be
(one patterned and another blank) of equal performed on newborn to 5 years of age
brightness are presented to child, he/she group. This method gives best results up to
prefers to look the stimulus with pattern as 6 months of age because older child gets
compared to the blank stimulus. distracted by surrounding objects and hardly
As shown in Fig. 10.18 examiner remains focuses on examination screen.
hidden behind a screen having two stimuli of Teller acuity card test: Most commonly
equal brightness, one homogeneous or blank clinically used method among preferentially
looking test is Teller’s acuity card (TAC) test.
Various test cards are presented to child and
the preference of child to stimulus is
examined.
Visual acuity is estimated by using TAC
grating targets as shown in Fig. 10.19.
These cards consist of alternate black and
white bars or stripes. The distance between
bars varies ranging from widely spaced to
narrow spaced in cards. Each card is presented
to infant initiating from card with larger
pattern and infant’s eye is examined for
Fig. 10.18: Preferentially looking test (see text) fixation. The card with smallest pattern at
Fig. 10.20: Cardiff acuity card (see text)
Fig. 10.19: Teller’s acuity card (see text) group. Further these tests can be grouped as
tests for age from 1 to 3 years and age from
which fixation achieved indicates the measure 3 to 5 years. In children the aim of measurement
of visual acuity. In an infant development of of visual acuity is to screen for high degree
visual acuity is rapid in initial months of age. refractive errors and/or presence of amblyo-
For understanding at one month age visual pia.
acuity seen in infant is about 1 cycle per degree
which increases to about 5 cycles per degree Various tests for age group 1–3 years are
at 6 months of age, however, later on a gradual • Marble game test: Child is encouraged to
increase in visual acuity happens till 5 years place the colorful marbles in holes of a card
of age; which equals to an adulthood acuity or in a box and examiner notices the eye
of 40 cycles per degree. function of child. This test is not to measure
the visual acuity but is done to compare the
Cardiff acuity test: This test is based on
function of eyes and vision is noted as
preferentially looking and on vanishing
useful or less useful. Function of one eye is
optotypes where pictures are used as
compared with other eye by keeping one
vanishing optotypes. Because infants/
eye open and other eye closed and test is
toddlers often becomes bored with gratings,
repeated vice versa.
the pictures of fish, cow, car, train, boat, duck,
house, etc. are presented as targets. These • Worth ivory ball test: Ivory balls of sizes
pictures are so designed that they are of the 0.5–2.5 inches diameter are rolled on the
same size and have two black lines with a floor in front of the child nearly up to
white space in between in such a manner that 10 feet distance. Now child is asked to take
pictures can be seen only at a particular back each ivory ball. Visual acuity can be
distance, i.e. get vanish at particular distance estimated by the smallest size ball retrieve
(Fig. 10.20). Examiner presents the various by child at a prefixed distance.
cards one by one to the child sitting at • Dot visual acuity test: An illuminated box
comfortable distance and notices the fixation printed with black dots of different sizes is
of eyes by child on the cards. shown to the child. Visual acuity is estima-
ted by the size of smallest dot identified by
Visual Acuity Measurement in the child.
Preschool Child • Coin test: Different size coins having two
Children of age group 1–5 years are considered faces on each side is shown to child from
as preschool going and various tests are different distance and asked to identify the
employed to assess the vision in this age faces on the coin.
• Bock’s candy bead test: Candy beads of

1.0 mm size are spread in front of the child.
Child is asked to pick up the candy from a
distance of 40 cm. Snellen visual acuity
equivalent to 6/60 can be estimated by this
test.
• Miniature toy test: Child is shown a minia-
ture form of a toy from 10 feet distance and
now child is asked to name or pick up the
pair of that toy from collection of toys.
Some other tests commonly employed to Fig. 10.21: Snellen’s optotypes with 5 × 5 grid
test the visual acuity in preschool child in the
age group of 1–3 years are For standard vision one grid element of his
• Kay picture test optotype was equal to 1 × 1 minute of arc,
hence the visual acuity can also be considered
• Lea test
as individual’s capability to differentiate the
• Allen test smaller features of optotype separated by
Various tests for the age group 3–5 years are: 1 minute of arc.
• Tumbling E test A ratio of individual’s performance to
• Landolt’s C test standard performance in relation to vision is
• Sheridan-Gardiner HTOV test labeled as 20/20, 20/40, 20/100 and so on.
• Sjögren hand test Snellen arbitrarily choose 20 feet distance for
the measurement of visual acuity. Snellen’s
• Broken wheel test
used nine English letters [C, D, E, F, L, O, P, T,
• Light house picture card test and Z] as optotypes, having serifs.
Visual Acuity Measurement in School Going In the year 1875, Snellen’s modified the
Children and Adults vision charts that was used at 6 meters
distance in place of older 20 feet distance and
Visual acuity in children above 5 years or in visual acuity is noted as 6/6, 6/12 and so on,
an adult can be assessed by Snellen’s chart or instead of 20/20, 20/40 and so on.
Landolt’s C chart.
The size of optotypes is designed in such a
Snellen’s visual acuity chart: Most common manner where for a given distance an angle
and widely accepted method to test the of 5 minute is subtended by each letter at the
distance visual acuity is by Snellen’s chart. nodal point of the eye as shown in Fig. 10.22.
Prior to development of Snellen’s chart most Hence, the patient should be able to read
eye charts were using printed fonts, but topmost letter clearly at 60 meter distance and
Snellen’s invented a new font and called them the subsequent letters at 36, 24, 18, 12, 9, 6, 5,
as optotypes. and 4 meters distances, respectively. The
Principle: Snellen laid out his optotypes on visual acuity is hence denoted as 6/60, 6/36,
a grid of 5 × 5 (Fig. 10.21) and by using 6/24 and so on, where 6/6 is considered as
standard division of a degree into 60 minutes normal limit of acuity.
he defined standard vision. According to These optotypes letters are series of black
Snellen’s definition “standard vision is the capital letters arranged in a line on a white
ability of an individual to recognize Snellen’s board. Size of each letter is progressively
optotypes from a standard distance of 20 feet; decreasing from top line to bottom line. These
at which these optotypes subtend an angle of lines comprising optotypes letters have such
5 minutes of arc”. a width, that each letter subtends an angle of
Fig. 10.22: Various size Snellen’s optotypes subtend same angle at nodal point, kept at specified distance
5 minutes at nodal point of the eye. Snellen’s Landolt’s ‘C’ chart: As all optotypes in
chart commonly used to assess visual acuity Snellen’s chart were not equally recognizable,
is shown in Fig. 10.23. hence in the year 1888, Landolt proposed an
eye chart which has only one prototype, i.e.
symbol of a broken ring or circle. Landolt also
used a grid of 5 × 5 to create the symbol and
each broken circle subtended an angle of
5 minutes at the nodal point of the eye and
the break in circle is representing 1 minute of
arc, which is similar to Snellen’s optotypes as
shown in Fig. 10.24.
Size of symbol ‘C’ is constant of 0.35 inch
with a gap of 0.07 inch, which subtend an
angle of 5 minutes (or 1 minute arc at gap)
when viewed from a 20 feet distance. Break
in the ring was given at the top, bottom, right
and left side of ring with 45 degree position
in between them as shown in Fig. 10.25.
The size of broken circles varies in
proportion to the distance of examination as
shown in Fig. 10.26, similar to that of in
Snellen’s optotypes.
Fig. 10.23: Snellen’s chart (see text) Fig. 10.24: Landolt’s optotype (broken ring)
Fig. 10.25: Various orientations of Landolt’s broken

rings
Fig. 10.26: Various size Landolt’s optotypes subtend

same angle at nodal point, kept at specified distance
Most commonly used design of Landolt’s

vision chart is as shown in Fig. 10.27.
Snellen’s versus Landolt’s vision chart
• In Snellen’s chart the end point of test is
recognition of letter, whereas in Landolt’s
chart test it is determination of the Fig. 10.27: Landolt’s vision charts
direction of the break in the circle, i.e.
whether break is in top, bottom, right or • As circles in Landolt’s chart can have break
left. only in four directions, a possibility of
• Visual acuity is represented by the smallest guessing by patient is always there,
letter read in the Snellen’s chart, whereas whereas letter identification is immediate
visual acuity in Landolt’s chart is and clear in the Snellen’s test, hence it
represented by identification of direction of remains less confusing for both the patient
break in the smallest size circle and is and the examiner.
represented as 6/6, 6/9 and so on. ETDRS chart: ETDRS (Early Treatment
• Although letter targets of Snellen’s chart Diabetic Retinopathy Study) charts are
present a more practical visual test, but in considered as gold standard for measurement
identification of letters literacy along with of clinical acuity. ETDRS type charts have
experience with letters in past will influence similar kind of layout and the prototypes in
the results; even if patient is seeing the these charts can be modified according to
letters blurred. Whereas Landolt’s broken convenience of examiner.
circles eliminate these factors and represent Essential features of ETDRS charts are
a more objective method of testing of visual • Proportional layout: Letter or symbol
acuity. spacing is proportionally designed so
that it is equal to the width of letter and which are substituted by the letters E, P, X, B,
also the spacing of line is equal to the T, Y, and A in theses revised ETDRS charts
height of letters of the lower line. (chart 1 and chart 2 as shown in Fig. 10.29).
• Logarithmic progression Evaluation of visual acuity specially in school
In the year 1959, Bailey and Lovie going children should be done with help of
introduced these two features simultaneously set of both the charts, however, when relative
in the chart; these charts are also called “log difficulty for identification of an individual
MAR” charts. Original ETDRS chart consists Sloan letter is seen then the psychometric
of a set of optotypes having Roman alphabet functions of the patient can be done for
based 10 letters designed on the basis of Bailey assessment.
and Lovie principles. These original ETDRS Testing method for distance visual acuity
charts were available in three test versions OD, Test procedure using eye charts (as discussed
OS and OU. Charts were designed for 4.0 m above) is as follows
distance, hence can easily be used at 2.0 m or • Examiner instruct the patient to sit
at 1.0 m distances. Charts were tested in a comfortably at 20 feet (6 meters) distance
standard illumination (about 200 cd/m2) and facing the eye chart, so that practically
had both front/back lit versions (Fig. 10.28). all the light rays remain parallel and
Revised ETDRS charts were proposed to patient’s accommodation remain at rest.
reduce the differences in reading occurred due • Chart is illuminated properly; about
to the relative difficulty of letter identification 200 Cd/m 2 and patient is asked to
present in between two consecutive lines. identify the optotypes or read the letters
These charts utilizes a new set of letters and in vision chart with one eye while his/
are popularly called modified log MAR/ her fellow eye is closed; alternately a trial
ETDRS charts. In original ETDRS charts the frame can be worn and one side is
Sloan letters C, D, N, R, S, V, and Z were used, occluded by use of occluder.
Fig. 10.28: ETDRS charts (see text)

Fig. 10.29: Modified ETDRS charts
• Visual acuity is recorded by denoting the visual acuity is recorded as 5/60, 4/60,
distance of letters/optotypes, from 3/60, 2/60 and 1/60 depending upon the
patient as numerator and accurately read distance at which the patient see the 60
smallest letter/optotype in the chart as meters line letter/optotype clearly.
denominator. • Suppose patient is not able to read the
• Suppose patient sitting at 6 meters optotype/letter clearly even at 1 meter
distance is able to read all the letters/ distance from chart, then vision is
optotypes correctly up to the line recorded as counting fingers (CF).
representing 6 meters distance, then • Patient is shown fingers at various
visual acuity is represented as 6/6, which distances, i.e. 3, 2 and 1 meter, keeping
is considered as normal. one eye of patient closed; and patient is
• Similarly, depending upon the letters/ asked to count the number of raised
optotypes of smallest line read by patient fingers. Depending upon the examina-
from a 6 meters distance, vision is tion distance at which patient is able to
recorded as 6/9, 6/12 and so on. Patient count the fingers accurately, vision can
can see up to 60 meters line from 6 meters also be recorded as CF 1 meter, CF 2
distance and his/her vision can be meters and CF 3 meters.
recorded as 6/60.
Note: Examiner repeatedly changes the number
• Suppose if patient is unable to see the
of fingers at same distance to avoid any guess by
60 meters line optotype/letter from the patient.
6 meters distance, then to record his/her
vision the patient is instructed to walk • Suppose patient is unable to count
slowly toward the chart at 1 meter fingers very near to his/her face, then
distance intervals, till he/she is able to vision is recorded as hand movement
see 60 meters line optotype/letter and (HM) close to face. Examiner moves his/
her hand with outstretched fingers • Near vision chart consists of lines having
repeatedly in good illumination in front different size fonts, which are arranged in
of the patients eyes and asks whether he/ a decreasing order and are marked with
she is able to perceive the movement of acuity values.
hand; if patient says yes then vision is • Procedure is repeated for fellow eye and
recorded as HM positive (subjective correction with convex lenses is done.
method). • Once both sides the correction for near
• Even if patient is unable to appreciate vision is done, patient is instructed to read
hand movement, then a bright beam of the entire near vision chart with both the
light is thrown over the eye of patient, eyes open with their respective additional
while keeping fellow eye closed with convex lenses in frame.
palm of patient’s hand and patient is
asked whether he/she can perceive the Commonly used reading charts are:
light. Depending upon the response of • Snellen’s near vision chart
patient vision is recorded as perception • Jaeger’s near vision chart
of light (PL) positive or as PL negative. • Roman near vision chart
Note: Patient must be able to perceive the direction Snellenís Near Vision Chart
of light, not a feeling of heat from the light.
On the basis of his distance optotypes, Snellen
• If PL is positive, then to assess the introduced his Snellen’s equivalent for near
integrity of retina, a test called projection vision. He graded the thickness of near vision
of ray (PR) can be done. Patient is shown letters in different lines to be about 1/17th of
a bright beam of light from upper, lower, his distance vision letters. Hence the near
nasal and temporal quadrants and vision letters equivalent to 6/6 lines of
patient is asked to catch the light beam. distance vision were subtending an angle of
If patient is able to catch the beam in all 5 minutes at a distance of 35 cm (average
four quadrants, then a plus sign is used reading distance).
and when patient is unable to identify Available printer’s fonts were unable to
the direction of light in any one construct the unusual configuration of these
quadrant/all quadrants, then a negative letters, hence it was produced only by doing
sign is used to record the visual status. a photographic reduction of standard distance
vision chart to a 1/ 17th of their size as shown
Visual Acuity Measurement for Near Vision in Fig. 10.30.
Near vision test is done monocularly and also Snellen’s near vision chart lost the clinical
binocularly by using a trial frame. Near vision interest, because graded size of charts
test is done by using near vision chart as follows: containing pleasant literature phrases were
• Full optical correction is done for distance available for commercial purposes to record
vision if refractive error is present. One eye the near vision.
is occluded with the help of occluder and
now with full distance correction in place Jaegerís Near Vision Chart
patient is instructed to read the near vision In the year 1867, Jaeger developed a near
chart from a normal reading distance vision chart to measure the near acuity, for this
(usually 30–40 cm). he used the ordinary fonts from printers
• Additional convex lenses are given as per available in that era. These fonts were of
the requirement of patient or at power various sizes and the fonts have changed
where he/she can comfortably read the considerably since then. In original near vision
smallest line of chart. chart Jaeger marked these fonts from 1 to 7
and accordingly the vision of patient was

recorded as J1 to J7 (J goes by the name of Jaeger
himself), which depend on the patient’s ability
to read the smallest print in chart (Fig. 10.31).
Roman Near Vision Chart
In the year 1952, Faculty of Ophthalmologists
of Great Britain came up with a chart
containing ’Times Roman’ type fonts with
standard spacing (Fig. 10.32). This helped in
overcoming the problems faced to make the
Jaeger’s chart in modern fonts. When Jaeger’s
charts were tried to be made in modern day
fonts they were getting significantly deviated
from the original standards of Jaeger’s chart
although for practical purposes they were
quite accurate.
The vision of patient is recorded as number
represented above the smallest line, which he/
she is able to read clearly from a distance of
30–35 cm. For example, suppose patient is
comfortably reading the smallest line of near
vision chart, then his/her near vision is
Fig. 10.30: Snellen’s near vision chart recorded as N5.
Fig. 10.31: Jaeger’s near vision chart

however, in many ocular and systemic illness

it is also important to assess the contrast
sensitivity along with visual acuity. For
example, in conditions like visual pathway
disorders, glaucoma and ocular hypertension
contrast sensitivity gets reduced even though
the visual acuity may be nearly normal.
Types of Contrast Sensitivity

Visual perception in human eye arises from
the light interpretation in terms of space,
wavelength and time. Contrast sensitivity can
be grouped under spatial (space related) and
temporal (time related) interpretation of an
object in varying luminance.
Spatial Contrast Sensitivity

This is an individual’s ability to distinguish
the variations present in luminance across the
bar of a sine wave grating. To check spatial
contrast sensitivity an individual is shown sine
wave grating which contain parallel light and
Fig. 10.32: Roman near vision chart
dark bands with varying luminance. The
CONTRAST SENSE individual is asked to inform at which minimal
level of contrast he/she is able to detect the bars.
Introduction
Spatial frequency defines the width of bars
Contrast sense is more complex function of the and is an expression of pairs of light and dark
retina. Normal sighted individuals are able to bands numbers, which subtend an angle of
see an object and they can process the spatial one minute at nodal point of the eye.
characteristics of the object, if it differs from
As shown in Fig. 10.33 periods (P) of grating
its surrounding in any one of these aspects:
is noted and if the grating has sufficient
• Luminance number of complete cycles (five cycles as a
• Color rule), then spatial frequency is denoted by P-1
• Texture cycles/degree. Hence, a high spatial frequency
• Motion indicates narrow bars and low spatial
• Binocular disparity frequency indicate wider bars. The spatial
An individual’s ability to perceive the frequency of a grating, whose pattern can be
spatial characteristics of an object (not separa- just detected at 100% contrast luminance, is
ted by definite borders with its surroundings) called grating acuity. Normally grating acuity
with slightest change in luminance is called at usual illumination levels is present in the
as contrast sensitivity. Hence in simpler range of 30–50 cycles/degree. For appreciation
words, contrast sensitivity can be defined as of Snellen’s acuity a high grating acuity is
the threshold of an individual to differentiate definitely required.
between the visible and invisible. Spatial frequency discrimination threshold
Snellen’s chart test measures the ability of is a minimal appreciable difference between
an individual about his/her perception of the spatial frequency of two gratings and at high
sharp outline of a small object (visual acuity), contrast levels it remains almost constant.
background, adaptation and eccentricity of

target stimulus.
Critical duration is the maximum time over
which a temporal summation can occur. When
a light is turned on and off for a finite time
interval repeatedly in rapid sessions, this light
appears as a flickering light. If these lights
flickered fast enough, so that they appear as
single light rather than flickering light, then it
indicates that the limit of temporal resolving
ability has reached. This transition from a
flickered to fusion occur over a range of
temporal frequencies and the boundaries
between these two processes is termed critical
flicker fusion (CFF) frequency. Hence, the
upper limit of temporal sensitivity is defined
by CFF frequency.
Testing of spatial and temporal sensitivity
produces a systematic data which is
significantly more complete for status of visual
Fig. 10.33: Spatial frequency system as compared to data collected by
conventional vision testing.
Temporal Contrast Sensitivity
Detection of an object in visual world requires Measurement of Contrast Sensitivity
its presence for a finite time period. A single Historical Aspects
beam of light can evoke a neural response • French Scientist Pierre Bouguer attempted
however, for a reliable visualization numerous the measurement of contrast sensitivity first
quanta of light within a short period are pre- time. He used the ocular structures in the
requisite. This multiple quanta of light form of a null indicator to match the
presented in a short period of time are termed sensitivity and accuracy of the eye.
as temporal summation. • In the year 1956, Schade made the first
Temporal sensitivity cannot be studied attempt to measure contrast sensitivity as
separately because following properties affect a function of spatial frequency. He used a
the ability of a person to detect temporal log scale which was uniformly spaced for
variations contrast detection threshold at spatial
• spatial properties frequencies (about five or so) to measure
• chromaticity the contrast sensitivity function (CSF). Later
• background characteristics on, in the year 1965, Green and Campbell
• surrounding characteristics documented that the CSF is an outcome of
A uniform target field is presented to visual two important factors: Optical and neural.
system for time related processing of • Modulation Transfer Function (MTF) is an
modulated sinusoidal grating to generate optical function which serves to estimate
contrast sensitivity function. In human visual the retinal image quality and is mainly
system, a temporal summation occurs for dependent on size of pupil (simple
about 40–100 milliseconds which depends on measurable factor).
the spatial and temporal properties of the • Subsequently, in the year 1968 Campbell
object and also on other factors such as and Robson revealed that neurally multiple
channels are present in vision and each Clinically contrast sensitivity can be represen-
channel is selective for a different spatial ted in any one form as shown in Table 10.3.
frequency. Variables measured in contrast sensitivity
• Fechner reviewed his own work and also are
considered the measurements done in past • Average amount of light reflected from
especially by Mosson and then concluded the paper (determined by illumination of
that for a wide range of targets contrast paper and density of ink).
threshold is about 1%. This threshold is not • Degree of blackness against whiteness,
dependent on the size and/or luminance means contrast.
of target stimulus; which is an amazing and
• Distance between repetitions of pattern
unexplainable finding till today.
specified in terms of visual angle; means
• In the year 1993, Robson reviewed history number of grating periods or cycles per
of contrast sensitivity measurement and in degree of visual angle.
the year 2003, Owsley reviewed importance
In clinical practice measurement of
of contrast sensitivity measurements for
contrast sensitivity is similar to audiometry
clinical assessment. Contrast sensitivity is
test. Contrast sensitivity curve or visuogram
impaired in several clinical conditions and
tells about the faintest contrasts perceived by
peak contrast sensitivity is found to be redu-
the patient. For a sine wave grating stimulus
ced even when visual acuity was normal.
visuogram curve shows similar function as
Note: Contrast level below which resolution of pure tone audiogram does and for an
grating frequencies of the target is impossible, is optotype stimulus the visuogram resembles
termed contrast threshold. a speech audiogram. Similar to audiometry,
In simpler words, contrast sensitivity is in contrast sensitivity measurement also, the
correlated with contrast threshold in results are depicted as a figure (not as a single
reciprocal manner, means division of one by value).
lowest contrast sense (at which gratings letters
or lines present in stimulus can be recognized) Contrast Sensitivity Curve
is contrast sensitivity. It simply means that A graph is plotted where X axis represents the
suppose a person is able to see details of a visual acuity and Y axis represents the contrast
target at very low contrast, his/her contrast sensitivity. Along horizontal direction of
sensitivity is very high and when person is graph (X axis) the size of symbols gradually
unable to see the target at higher contrast then decreases, whereas along vertical direction
his/her contrast sensitivity is very low. Contrast (Y axis) the stimulus intensity gradually
sensitivity of a person may vary depending becomes paler. All points are drawn for the
on the structure of stimulus (different size target symbols which are perceived by the
gratings or symbols) used for measurement. patient as well as for the target symbols those
Table 10.3: Representations of contrast sensitivity

Contrast sensitivity Formula of calculation Preferred stimulus
Weber contrast (Luminancemaximum– Luminanceminimum) / Letter type stimuli
Luminancebackground
Michelson contrast (Luminancemaximum– Luminanceminimum) / Grating type stimuli
(Luminancemaximum + Luminanceminimum)
RMS contrast Luminance / Luminance Here, Natural stimuli and efficiency
L = mean deviation, L = standard deviation calculations
Fig. 10.34: Contrast sensitivity curve (Visuogram)
were too small in the size or too pale and are Ardenís Gratings
not seen by the patient. In normal conditions In the year 1978, Arden developed a simple
joining of these points form a curve which is and economical technique to assess contrast
popularly known as contrast sensitivity curve sensitivity by sine-wave gratings. The gratings
as shown in Fig. 10.34. are oriented in vertical manner and contrast
Various test methods available for the of grating varies from top (lowest contrast) to
measurement of contrast sensitivity threshold bottom (highest contrast). He introduced a
can be grouped as shown in Table 10.4. booklet having seven photographic plates,
Table 10.4: Types of contrast sensitivity charts

Grating charts Letter charts Computer based charts
• Arden’s grating plates • Regan charts • Cathode rays tubes testing
• Cambridge gratings • Pelli-Robson contrast chart • Freiburg visual acuity and
• Ginsberg’s chart • Mars chart contrast test (FrACT)
• Vistech chart • Holladay automated contrast
• FACT chart sensitivity system
• Vector vision’s CSV-1000 • Medmont AT-20
• Mentor B-VAT II
among them one was screening plate and six parallel lines and the spacing between the two
were diagnostic plates. The spatial frequencies successive lines varied at periodic intervals.
of these plates were gradually increasing from Lines were invisible from 6 meters distance
0.2 to 6.4 cycles per degree (next frequency but still a fluctuation in line density was
being double of previous one; 0.2, 0.4, 0.8 and appreciable. After invention of computerized
so on) as shown in Fig. 10.35. dot matrix these lines were replaced by dots.
Test method: To test contrast sensitivity the Cambridge gratings are set of 11 grating
plates are studied by patients from 57 cm plates present in a spiral bound A4 size
distance with an illumination of 100 foot booklet as shown in Fig. 10.36. This booklet is
candles or a 60 watt bulb about 14 inches hung on a wall at a viewing distance of
above the plates. Each eye is tested separately. 6 meters. These pages are showed in pairs, one
Scoring of plate varies from 1 to 20 depending above the other. In each pair, one page
upon the amount of plate uncovered by comprises the gratings and the other page is
observer. Each plate is slowly withdrawn blank, although the mean reflection of both
upwards from the grey holder until the grating the pages is same.
becomes invisible to patient. Test method: Cambridge booklet is hanged on
Interpretation: Score of all six diagnostic a wall at 6 meters distance from patient’s
plates is summed up and for normal persons sitting position. Examiner turns the pages of
an upper limit of 82 score with an intraocular booklet one by one showing grating of
variation of less than 12 was documented. progressively decreasing contrast, positioned
randomly either on top or bottom page. After
Cambridge Low Contrast Gratings turning each page examiner asks the patient
In the year 1984, Della Sala described the first to choose which page contains the gratings,
version of gratings. A computer graph plotter top or bottom. Gratings are usually shown
was used to generate fine ruling closely spaced with horizontal strips but to increase
sensitivity booklet can be turned to other
direction also.
Fig. 10.35: Arden’s gratings (see text) Fig. 10.36: Cambridge low contrast gratings (see text)
Original testing method was to present a

set of plates three times to each eye and total
number of errors made from weaker eye was
recorded and compared with standard values
obtained from age matched normal indivi-
duals. But this was time consuming, hence the
recommended procedure is to show the pages
in descending order of contrast but stop when
first error by patient is made in identification
of gratings.
Four descending series are shown separately
to each eye and when first error is made or
end of series is reached, a new series is started.
Second or subsequent series are started not Fig. 10.37: Vistech chart (see text)
from the first grating page of that series; rather
the next series is started from four pages Test method
previous to the one at which last error was • The patient is instructed to recognize the
made. For example, if a person does an error orientations (vertical, right or left) of each
on 8th page in first series, then second series sine grating.
is started from 4th page, not from 1st page of • Suppose patient is unable to see the gratings,
second series and so on. then he/she may respond the circle as
blank.
Interpretation: Sum of all four observations are
• The lowest contrast grating recognized by
added and is converted to contrast sensitivity
patient will determine the sensitivity score
by using a table provided with test.
for that spatial frequency.
Note: The grating plate 11 has such a contrast This chart has a wide clinical application in
threshold which is below to level of most of the the measurement of contrast sensitivity especially
normal individuals, thus in clinical practice this in cases of cataract and post-refractive surgery.
grating is excluded from testing and if no error is
found in last grating (number 10), automatically a Note: Step sizes in this chart are irregular; however,
score of 11 is awarded. an average step size of nearly 0.25 log units having
a range of 1.75 log units is present.
Vistech Chart
Vistech chart for measurement of contrast FACT Chart
sensitivity was presented in the year 1984. In Functional Acuity Contrast Test (FACT) is
this chart the sine wave gratings are present modified version of Vistech chart. Chart
as circular photographic plates. There are five format is similar to Vistech chart in terms of
rows of sine wave gratings in total. These sine orientations and spatial frequencies of sine
gratings show increase in spatial frequencies gratings, however, average step size is smaller
(as doubling at every step, i.e. 1.5, 3, 6, 12 and at 0.15 log units against 0.25 log units seen in
24 cycles/degree) from top to bottom of chart. Vistech chart.
Vistech chart in total has nine columns and For better test reproducibility, smaller step
five rows and in each row the contrast of size of 0.15 log units and AFC method of
gratings decreases from left to right. These calculation is used in FACT chart.
gratings are oriented in different directions As shown in Fig. 10.38 chart also contains
such as in vertical direction or are tilted at 15° the blurred grating patch edges and a larger
angle either right or left as shown in Fig. 10.37. patch size. These gratings are smoothed into
Fig. 10.38: FACT chart (see text)
a grey background which helps in represen- Fig. 10.40: Pelli-Robson contrast sensitivity scoring
ting a large number of cycles even at low pad (see text)
spatial frequency.
organized as triplets, there being two triplets
Pelli-Robson Contrast Sensitivity Chart per line (16 triplets over 8 lines). The amount
Pelli-Robson chart is a letter identification of contrast seen among each triplet of letters
chart and is used most commonly in clinical is of same intensity, however, there is a
practice to evaluate the contrast sensitivity. gradual decrease in contrast intensity from
This testing system consists of one triplet to next triplet. Pelli-Robson chart
• Two reading charts is a wall mounted chart to be viewed from 1.0
meter or 40 inches distance.
• One scoring pad
As shown in Fig. 10.39 these two reading Test method
charts are identical but contain different • Patient is instructed to sit at 1 meter distance
sequences of letters. Whereas, the scoring pad facing Pelli-Robson chart.
as shown in Fig. 10.40 is a simple letter pad • Full amount of distance correction (if present)
printed on both sides. Letter sets, similar to is placed in trial frame. If required, add +0.75
two Pelli-Robson reading charts, are printed DS power lenses in front of both the eyes.
on each side of the scoring pad to note down • Chart is uniformly illuminated say with
the correct letter read by the patient during nearly 85 cd/m2 luminance of the white area
examination. Pelli-Robson charts uses 10 Sloan and tries to avoid the glare as much as possible.
letters of constant size and these letters are • Record all the information related to the
patient on the scoring pad and then patient
is asked to name/or read each letter in a
single attempt present on the chart. Patient
is instructed to read the chart lines
horizontally starting from the darkest letter
triplet present on upper left side of the chart.
• Do not allow the patient’s to give up too soon,
rather encourage patient to make guesses,
when they start believing that letters are
absent/or invisible. Give a few seconds for
the faintest letters to appear until they had
Fig. 10.39: Pelli-Robson contrast sensitivity chart guessed correctly 2 out of 3 letters of triplet.
• Test is performed for one eye while the acuity at eight contrast levels. A randomized
fellow eye is kept covered. display of stimulus can be done to avoid the
• Testing of contrast sensitivity is done for memorization of chart by the patient. Along
the fellow eye in similar manner keeping with different contrast sensitivity charts a
the first eye covered. staircase procedure can be used to determine
• In total the test is performed three times to the acuity. Other facilities included in the
measure the contrast sensitivity using Pelli- Medmont AT-20 system is binocular vision
Robson chart. It means each eye is tested test, worth four dot test, Duochrome test,
separately and then both the eyes are tested astigmatic fan and fixation targets for children.
together.
Mentor B VAT II Chart
Interpretation: On scoring pad mark each
letter read correctly by underline or circling it It is a commercially available computer-based
and strike out if any letter read incorrectly. video acuity system used to measure contrast
The faintest triplet in which patient identifies sensitivity, visual acuity and grating acuity.
two out of three letters correctly represents the Here optotypes are letters and visual acuity is
contrast sensitivity. Log contrast sensitivity tested at nine contrast levels.
value for the faintest triplet identified by the Factors influencing contrast sensitivity
patient is represented as number written on • Ophthalmic conditions: Contrast sensiti-
the scoring pad which may be right or left of vity can be impaired in ophthalmic condi-
the triplet. tions like glaucoma, crystalline lens changes
in incipient cataract, ocular hypertension,
Mars Chart amblyopia, age-related macular degenera-
This is designed in a similar way by using tion, retrobulbar optic neuritis, dry eye,
Sloan letters as that of Pelli-Robson chart. Only diabetic retinopathy, etc.
difference is that contrast levels decreases by • Refractive errors: Like myopia, glare can
0.04 log units as compared to adjacent letter affect contrast sensitivity in higher frequen-
(not as triplet as in Pelli-Robson chart). cies.
Contrast range can be tested from 91% to 1.2%. • Age: With advancement of age there is
As these charts are smaller in size they can be decrease in contrast sensitivity, most likely
used for near testing also at 50 cm distance. due to change in spherical aberration of
Test is considered as completed once patient lens.
identifies two consecutive letters wrongly. • Systemic conditions: Contrast sensitivity can
also reduce in various neurological condi-
Regan Charts
tions like multiple sclerosis, Parkinson’s
These charts evaluate visual acuity at different disease, schizophrenia, pituitary adenoma,
levels of contrast, i.e. 96%, 25%, 11% and 4%. and cerebral lesions.
Each letter rows become gradually smaller in • Drugs: Contrast sensitivity may reduce side
size, which enables different spatial effect of some drugs, e.g. ibuprofen,
frequencies to be tested. Disadvantage of test vigabatrin, etc.
is that larger letters are easily seen without
reaching the contrast threshold of the patient. Note: Various available treatment modalities like
optical, medical, surgical, or visual rehabilitation
Medmont AT- 20 Test can produce reasonable improvement in selected
This is a computer-based test unit used to contrast sensitivity deficits. Many a times mere
measure contrast sensitivity by presenting accurate diagnosis of poor vision happening due
variable contrast gratings and Bailey-Lovie to low contrast sensitivity may give satisfaction to
visual acuity charts. This unit can test the visual a large number of low vision patients.
COLOR SENSE • Suppose these three colors or any three

Introduction colors which are sufficiently far apart in
spectrum of visible light are chosen, them
The ability of an individual to differentiate
all other colors including white can be made
between various colors emitted by light of
by mixing them in an appropriate proportion.
different wavelengths is referred as color
• For any given color there is always a
sense. Although color vision is a complex
complimentary color and when these two
process but for understanding purpose
colors are mixed in appropriate proportions
various salient features of color vision are
they will form white color.
• The color appreciation in human eyes is
• Color perception is dependent on the color
entirely a function of photoreceptor, i.e.
of surrounding background. For example,
cones and as we discussed before that cones
if a green color object is placed in green
are related with daylight vision, so color
illuminated background, then person will
vision can happen only in photopic
see the object as white. This green object will
conditions, i.e. color vision characterize the
be appreciated as green if the background
photopic vision.
is illuminated with red or blue color.
• Color vision depends on the wavelength • Three characteristics of color are: Hue,
composition of light entering the eye, intensity and saturation. These attributes
brightness (illumination/luminosity or light decide the nature of color appreciated by
intensity) and saturation or calorimetric the person.
purity (i.e. ratio of mixing with white light).
• Normally an individual can see all colors
• In the presence of moderate or high of visible light spectrum, i.e. violet to red.
intensity illumination (where retina is fully Wavelengths shorter than violet, i.e. ultra-
adopted to light) an individual can violet or longer than red, i.e. infra red are
appreciate colors, whereas in presence of not visible to an individual. However, some
very low intensity of illumination (where blue cones are sensitive to even ultraviolet
eyes are dark-adapted) person will not range of wavelength, so an individual
appreciate colors; rather he/she will see all should have been able to see the UV light
objects as grey having some mild differen- but normal crystalline lens has a property
tiation in their brightness. This phenomenon to block all UV wavelengths. Hence,
of shifting from color appreciation to grey persons undergone cataract surgery are
appreciation in low illuminating condition able to see the UV rays, if UV protected IOLs
is called Purkinje shift phenomenon. are not implanted.
• Color sensation is subjective in nature and
initially all the individuals need to learn Theories of Color Vision
names of different color sensations. Thus, The two most popular theories of color vision
subsequently when the same sensation are
which individuals had learnt initially is felt • Young-Helmholtz theory (trichromatic or
by them then, they can name the color by trireceptor theory)
their past experience. • Hering theory (opponent process theory)
• In retina of eye different types of cones are
present. In these different cones there are Trichromatic Theory
three types of pigments, which preferen- Originally, Young proposed the theory of
tially absorb wavelengths of light in visible trichromacy to explain the process of color
spectrum corresponding to three colors— vision. In subsequent years, Helmholtz did
red, green and blue. Hence, normal color some modifications to explain various other
vision is considered as trichromatic. factors of color vision. Although, the original
form of this theory was unable to give an Opponent Process Theory

adequate explanation of all the phenomena Hering hypothesis has been subsequently
associated with appreciation of color either by improvised by Hurvich and Jameson and is
normal individuals or by individuals having popularly known as opponent process theory.
color defects but none denied the existence of This theory is based on an assumption that
trichromatic stage in color visual process. there are three sets of receptor systems, viz
Young-Helmholtz theory presumes the red-green, blue-yellow and black-white. Each
presence of three types of color receptors of these receptors is assumed to be working
however, each receptors is apparently as antagonistic pair among themselves. It
responding to all wavelengths of light and means that stimulation of one opponent pair
they have various levels of spectral will produce an excitation of one receptor
sensitivities for different light wavelengths. system and will also produce an inhibitory
One receptor has more sensitivity for long effect on other receptor system; hence red light
wavelengths (red color), second for medium will stimulate the red receptors and also will
wavelengths (green color ) and third for short simultaneously inhibit the green receptor.
wavelengths (blue color). All other colors are
believed to be perceived by combinations of Note: Opponent theory was successful in explaining
these three colors in various proportions. For nearly all phenomena of color vision and includes
example, perception of yellow color is a even color-contrast and color-blindness data which
process which simultaneously stimulates red were difficult to be explained by trichromatic
theory.
and green receptors and integrates these
receptors with visual neural pathways and Both these theories helped enormously in
visual cortex. understanding about the system governing
The trichromatic theory was able to explain color vision in human eye. The initial trichro-
the various laws of color mixing but it was matic theory works at the photoreceptor level
unable to explain some basic phenomena and then these visual signals get recorded into
associated with color vision. For example, the opponent process form; which is a higher
theory was not able to explain the pheno- level of neural system of color vision processing.
menon of color defect in dichromate patients Another theoretical representation was
(having confusion in identification of red and proposed by Edwin Land to explain
green color although these patients are able mechanism of color vision. His hypothesis
to see a mixture of these two colors, i.e. yellow explained the presence of three separate visual
color). This theory also had a difficulty in systems responding primarily to different
explaining the phenomenon of complemen- wavelengths of light, are called retinexes. One
tary color after-images. retinex each among these three retinexes
Ewald Hering further expanded the process shows maximum response to long wave-
of color vision and put a hypothetical existence length (red), middle wavelength (green) and
of three oppositional color pigment pairs. short wavelength (blue) of light, respectively.
Trichromatic signals received by cones Each of these visual systems is represented
receptors are not combined at pigment level as an analogue, where black and white
but are passed to the subsequent neural stages picture of an object is taken via a particular
and reveal opponent pairs of color processing color filter.
• Spectrally opponent processes, which
consist of pairs of red versus green and Color Vision Charts
yellow versus blue. Majority of people think that color vision
• Spectrally non-opponent process, which test means the test done by using dotted
consists of a pair of black versus white. pictures or by chart named Ishihara.
Although in reality there are several other Around the same era these two develop-
tests to detect the color defects. Ishihara ments took place which made the way for
test is used since long time and most of modern methods of testing of color defects.
the time it is an incompatible test, however, • John William Strutt Rayleigh invented a
till date it is the most commonly used test test based on perfect matching of various
worldwide. colors. This test is popularly known as
History: During 17th century, Turberville Rayleigh match which is the principle
noticed that some individuals name the behind the development of instruments
colors differently as compared to others and like anomaloscopes. This test also led to
probably this was the first observation related the discovery of conditions such as
to color blindness tests. Nearly hundred dichromatism and anomalous trichroma-
years later scientist John Dalton described the tism.
color vision in detail and he also examined • Dr J Stilling published his famous
several persons by using colored ribbons pseudoisochromatic plates first time to
where color of ribbons has to be named by the world for testing color deficiencies.
persons. During this era most of the color These plates were the antecessor of most
vision deficiency was simply explained by popular Ishihara plates.
subjective means. Color vision and color defects can be
In the year 1837, August Seebeck tried measured by methods shown in Table 10.5.
various advanced technique to explain the
color vision defects. He gave people some Pseudoisochromatic Plates
sample color and asked them to match These plates are most widely and popular
these colors from the most closely related screening test used to assess the color vision.
color in the set of more than 300 colored This test is also known as Ishihara plates test
papers. This test removed the problem after the name of Dr Shinobu Ishihara who
related to naming of color, which vary designed this plate test.
significantly in between persons. This test Principle used in the formation of these
of Seebeck to identify color blindness plates is co-punctual points. Color blind
resulted in identification of condition like person is unable to distinguish colors along
red–green color deficiency. the line of confusion, so in these plates
In the year 1877, Holmgren developed different patterns are used along the confusion
similar type of test by using skeins of wool lines, which are made of different colored dots
having various colors. This Holmgren wool or co-punctual points. Suppose if a person is
test gained popularity worldwide, hence for color blind then he/she will be unable to
more than hundred years it remained identify the colored dots which are represen-
commercially available. ting a pattern across these confusion lines.
Table 10.5: Color vision tests

Pseudoisochromatic Arrangement tests Lantern tests Anomaloscope
plates
• Ishihara plates • Farnsworth • Holmes Wright • Nagel anomaloscope
• HRR plates D-15 tests lantern • Neitz anomaloscope,
• Lanthony desaturated • Farnsworth lantern • Heidelberg Multi Color
D-15 test • Giles-Archer lantern (HMC) anomaloscope
• Farnsworth Munsell • Edridge-Green lantern • Pickford-Nicolson
100 hue test • Williams lantern anomaloscope.
• Hidden digit design: These plates have

hidden designs which can be seen only
by people having color vision defects.
Normal individuals are unable to see any
designs in these plates.
• Classification design: These plates are
specially designed to identify color blind
persons. These plates have vanishing
design on either side of plate, which
helps in differentiation of person having
red green color defects. One side of plate
is used to identify red color defects and
the other side for green color defects.
Standard version of these most popular
Ishihara plates contain a set of 38 plates;
although shorter versions containing 24 plates
and 14 plates are also available (Fig. 10.42).
Fig. 10.41: Patterns of Ishihara plates These Ishihara plates can only identify red-
green color deficiencies. Persons suffering
Various mathematical numerical, english from Tritan defects (blue color deficiency)
letters, curved lines or any other pattern cannot be identified by Ishihara test plates.
can be made invisible inside these dots In the year 1954, other types of plates were
patterns. produced which can be used to classify all
Four different types of plate designs are three color deficiencies; they are called 24 HRR
present in booklet as (Fig. 10.41) plates introduced by Hardy, Rand and Ritter
• Vanishing design: These plates have (Fig. 10.43). There are several more of such
designs which are seen only by the pseudoisochromatic plate tests but none of
persons having good color vision. People them became popular and are not widely used.
with color vision defects are unable to Recently a few electronic color vision test
see any design in these plates. equipment are also available which include
• Transformation design: Different types of certain types of pseudoisochromatic plates.
design are seen by persons having color Although these electronic devices can test color
vision defects as compared to normal vision rapidly, however, none of these equipment
individuals. provide very accurate and reliable results.
Fig. 10.42: Ishihara plates (courtesy: Bernell Corporation)

lines across the white point. Hence, these

persons suffering from color vision defects
will arrange these discs completely in a
different manner as compared to a normal
individual.
In the year 1940 most popular arrangement
test was introduced by Farnsworth and named
as Farnsworth D-15 arrangement test. This test
contains 15 colored plates and patient is
instructed to arrange these colored plates in
Fig. 10.43: Hardy, Rand and Ritter plates for color the correct sequence as compared to pilot plate
vision test (Fig. 10.44).
Arrangement Tests Lanthony desaturated D-15 test is similar
kind of test and is helpful in identification of
Similar to pseudoisochromatic plate test the
color blindness in milder cases.
principle used in identification of color defect
by arrangement test is also based on co- Farnsworth-Munsell 100 hue test. This test
punctual points, however, as compared to comprises 100 plates arranged in a batch of
pseudoisochromatic plates test, an arrangement 20 plates (Fig. 10.45). Patients need to arrange
test is dynamic in nature because here these plates in order as in D-15 arrangement
observer has to arrange a set of color discs or test; results are very encouraging and are
plates in order. Each of these test series contain comparable to other arrangement tests.
a starting pilot plate having various colors and
predefined number of color discs or plates. Lanterns Tests
Patient is instructed to arrange the color discs In Lantern test, colored signal lights are
or plates in the correct sequence as present in presented to observer for identification. These
the pilot plate. Usually color of these discs is tests were primarily used as occupational or
selected close to white color because majority vocational tests especially for persons
of people having color vision defects are employed in railways, airlines, or in transport
unable to differentiate colors along certain workers to identify their color recognition
Fig. 10.44: Farnsworth D-15 arrangement tests for color vision (courtesy: Bernell Corporation)
Fig. 10.45: Farnsworth-Munsell 100 hue test (courtesy: Bernell Corporation)
ability which helps them to identify and

navigate signals. Lanterns tests were useful
in detecting the ability of person regarding
identification of various colors directly,
hence practically it is a useful tool. However,
these tests were unable to detect the type
and severity of color deficiency, hence had
limited value to classify type of color
deficiency. In Lantern test the color signals
are presented to observer either as single
color or in pair and observer asked to
identify and tell the name of color.
Various types of lanterns used to assess the
color vision are
• Holmes-Wright lanterns: These lanterns Fig. 10.46: Holmes-Wright lantern
have five lights (two green, two red and one
white) which are arranged either vertically
or horizontally. Patient needs to identify the
color of lights when these lights are shown
to him/her in pairs of low and high
brightness (Fig. 10.46).
• Farnsworth lantern: These lanterns are
specially designed to pass the people
having milder form of color deficiency.
Results of this test are comparable to
Holmes-Wright lantern, although in severe
deficiencies there are some differences in
results (Fig. 10.47). Fig. 10.47: Farnsworth lantern
Various other types of lanterns were also
popular in past, however, these lanterns were Anomaloscope
gradually replaced by newer techniques of These instruments are based on principle of
color vision estimation. A few examples are either Rayleigh match or Moreland match
shown in Fig. 10.48. system. Anomaloscope can be used to estimate
Fig. 10.49: Nagel anomaloscope
deutan type deficiency will utilize more green

color. The main disadvantage with anomalscope
is that it is expensive instrument and difficult
to use. Examiner must be enough skilled and
trained to do test with anomalscope.
In the year 1907, an eminent scientist Nagel
Fig. 10.48: Various lanterns used in past for color invented an anomaloscope which is popularly
vision assessments. A. Giles-Archer lantern; B. called Nagel’s anomaloscope (Fig. 10.49). This
Edridge-Green lantern; C. Williams lantern instrument is considered as the best instru-
ment to detect color deficiency till date
the degree of color blindness and also clearly although it is not manufactured nowadays.
differentiate between dichromats and
Some other types of widely used anomalo-
anomalous trichromats individuals. In
scope are
Rayleigh match, a color mixing apparatus
• Neitz anomaloscope
consists of narrow spectral bands of red and
green color and observer has to match these • Heidelberg Multi Color (HMC) anomalo-
with yellow color. All types of patients scope
suffering from red green color deficiency can • Pickford-Nicolson anomaloscope
be identified by the matching range of these
Color Blindness
instruments. A number of anomaloscope is
also based on Moreland match where blue Color blindness is also called achromatopsia
green light sources are used in place of red and may be
green light sources. These are used to test the • Congenital
tritan color defects. For example, a dichromat • Acquired
is specifically capable to precisely match the
mixture of red–green color in different ratios, Congenital Color Blindness
whereas anomalous trichromats will not be This is an inherited condition and transmitted
able to recognize normal color match. as X-linked recessive disorder, females are
Difference in the distance of color match usually unaffected and act as carrier. Color
among them will indicate the severity of color blindness is probably due to the absence of
deficiency. On contrary, to match the colors a one or more photo pigments like red, green,
person having protan type deficiency will etc. which are normally found in the foveal
utilize more red color and a person with cones.
Congenital color blindness may present as Note: Theoretically there might be few other cases
• Total blindness having color blindness due to defective or absence
• Partial blindness. of blue sensation, i.e. tritanopes, although these
Total color blindness is very rare and cases are very rare.
generally it is associated with nystagmus and/
Acquired Color Blindness
or central scotoma. Probably a central defect
is responsible for causing the total color blind- It can be presented as partial or as complete
ness. Patient suffering from total color blindness color defect. Partial defect is seen in cases
sees all colors as grey color having different having relative scotoma while complete color
levels of brightness. The entire light spectrum defect is associated with disease of the optic
appears as a grey band, similar to those nerve. Usually most of diseases that affect
patients’ having normal scotopic spectrum. retina and choroid influence the color
Partial color blindness is more common perception, mainly in the blue wavelength
condition than total color blindness and affects range of light spectrum. Although, a slight
about 3–4% of male population (common) and diminution in perception of rays with blue
0.4% female population (rare). Milder cases wavelength is normal because of an increased
suffering from partial color blindness are more physical absorption of blue light. An increase
common in males. Clinically, majority of of amber pigmentation in the nucleus of
patients remain asymptomatic, because they crystalline lens causes increase physical
compensate for their color defect by absorption of blue range wavelengths and this
improving their attention for shade and condition is commonly called blue blindness.
texture of object and combine it with their
POTENTIAL VISION
experience. It is difficult to diagnose partial
color defects, unless and until several special Introduction
color vision tests are performed to detect it. Potential vision means a preoperative
Usually most of these patients have good assessment of visual outcome in cases of
visual acuity but has confusion in identifi- media opacity. In patients having a poor visual
cation of red and green color, hence this defect acuity due to cataract, various tests are
of color identification is a serious problem in employed to know the potential visual
certain occupations like rail engine drivers or outcome after the removal of the cataractous
ship sailors. These red–green color defective lens. Before cataract surgery, it is important
cases are grouped as protanopes and deutera- to know the potential vision to rule out the
nopes. Patients suffering from red color fact that the cause of obvious diminished
defects or protanopes have defective sensation vision is either purely cataractous lens or any
for red wavelength range of light spectrum; other retinal pathology is also contributing in
red color appears much less brighter than that diminution of vision.
seen by a normal individual. In deuteranopes Various subjective and objective methods
or green color defective patients, the sensation are used for assessment of potential vision in
for green wavelength range of light spectrum a patient having media opacity, although all
is defective. These groups have a dichromatic of them have some limitations but still are very
vision; means they see only two out of three useful to predict the potential visual outcome
basic color with maximum brightness. Although after surgery. These methods are summarized
the color defects in both these groups may not in Table 10.6.
be complete, therefore, these cases are also
called protanomalous and deuteranomalous Subjective Methods of Measurement
for red color defect and green color defect, Basic clinical tests were the earliest attempts
respectively. to investigate retinal/neural function behind
Table 10.6: Various methods for assessment of potential vision

Subjective methods Objective methods Alternate methods
Light projection test Potential acuity meter Ultrasonography
Two-point light discrimination test Laser interferometer
Visual evoked potential
Color discrimination test White light interferometer Entoptic imagery test
Maddox-rod test
Trans-illuminated Amsler grid test
ocular media opacities. Various subjective the ‘two-point discrimination’ test. Two bright
tests done to assess the potential vision are pointed light sources of 2 mm size are kept 2
• Light projection test inches away from each other and are shown
• Two-point light discrimination test to patient from 2 feet distance, keeping one eye
• Color discrimination test closed. If patient is able to identify two distinct
• Maddox rod test lights correctly, then grossly his/her retinal
• Trans-illuminated Amsler grid test function is presumed to be intact. However,
this method is unable to give any significant
These tests are simple and can be performed idea regarding macular function of patient, so
quickly; but all of them have several limitations it is not widely used in clinical practice.
and moderate predictive value. However, these
tests are very useful in remote locations, where Color Discrimination Test
newer modern instruments are unavailable. Similar to light discrimination test general retinal
Light Projection Test integrity can be assessed by testing the gross
If surgical removal of cataractous lens has been perception of color. However, this test also gives
decided for visual improvement in an elderly some information about the macular function.
patient, then before planning the surgery, it is This test can easily be performed with the help
necessary to check the presence of light of slit lamp in clinic. Patient is instructed to discri-
perception to execute the cataract surgery. A minate the color (cobalt blue or red- free green
gross and accurate assessment of retinal filters) of lights shown to him/her by slit lamp.
function can be done by simply evaluating the Maddox Rod Test
presence of light perception in the patient eye.
This can be tested by confirming the ability of A clinically reliable and simple method to
patient to perceive the projected light. Directional assess macular function is Maddox rod test.
quality of projected light can get diffuse by A Maddox rod can be held in front of the eye
opaque media but still light perception test gives under examination or can be placed in the trial
a practical clue whether gross retinal and/or frame. With help of occluder one eye of the
optic nerve pathologies like giant retinal patient is occluded and with fellow eye the
detachment or advanced visual field defects are patient is instructed to fixate on a bright light
present or not. Retina is bleached for nearly 20– source held by examiner at one and a half feet
30 seconds by using an indirect ophthalmoscope, distance as shown in Fig. 10.50.
if patient is unable to perceive the light it If the patient sees a continuous red line
implies a significant abnormal retinal pathology. (Fig. 10.50A) it means that the macular
integrity is present. If, patient sees a broken
Two-Point Light Discrimination Test red line (Fig. 10.50B) it means that a macular
Another simple and useful clinical method to lesion is present. To identify retinal detachment
assess potential vision and retinal integrity is or glaucomatous visual field defects, the
Objective Methods of Measurement

Commercially available instruments to predict
the post-operative visual outcome or to
determine the potential vision are mainly of
two types
• Potential acuity meter (PAM)
• Interferometer
Guyton-Minkowski PAM is an instrument
which projects a miniature Snellen’s chart on
the retina of patient via a pinhole. This
Snellen’s chart is seen through the clear areas
in between the opaque crystalline lens and is
projected over the macular region.
Lotmar and Rodenstock interferometers are
Fig. 10.50: Macular function test using Maddox rod laser-based instruments and utilizes two
coherent beam of helium-neon laser which
Maddox rods are placed in various meridians generates interference patterns and are
and test is repeated. This test also helps in the projected on patient’s retina through pupil.
evaluation of patient’s color sensitivity. Width of the interference fringes corresponds
Sometimes it becomes difficult to perform this to the visual acuity of the patient.
test due to presence of dense media opacities. White light interferometers are similar to
laser interferometers but they use polychro-
Trans-illuminated Amsler Grid matic white incandescent light source instead
In the year 1978 Miller, Lanberts and Perry of laser beam, which produces a large depth
depicted a modified form of the standard Amsler of field grating image in the eye.
test. Instead of standard Amsler grid, a trans-
illuminated grid is used to test the potential Potential Acuity Meter
vision in patients having media opacities. In the year 1980, Guyton and Minkowski
Trans-illuminated Amsler grid is similar in size designed this potential acuity meter (PAM)
as standard Amsler grid but it has 1 mm holes which can be mounted on slit lamp. This
at every intersection of horizontal and vertical device projects a miniature form of Snellen’s
grid lines with a 4 mm fixation hole at its visual acuity chart via a pinhole of 0.15 mm
centre. This grid is mounted on an illuminated diameter, using coherent white light through
light box fitted with 15 W neon tubes. the clear areas present in opaque crystalline
Interpretation: Patients having media lens on patient’s retina (Fig. 10.51A).
opacities (e.g. cataract) are unable to see the Optics of PAM device: As shown in Fig. 10.51B,
lines on the standard Amsler grids, however, a white coherent light from a point source
if they can perceive all the lines joining the passes through an aperture and focuses on
retro-illuminated holes, then the person has Snellen’s chart via a prism. These images are
normal macular function. Suppose the focused on patient’s retina via a condensing
patient sees distortion of illuminated lines lens and a focusing prism. Knob of PAM helps
(metamorphopsia) or dark area (scotoma), in rapid focusing of Snellen’s optotypes by
it implies an abnormal macular function. adjusting the lens (+12 D power) and focusing
However, a significant disadvantage of this prism. These black optotypes on a white chart
test is that majority of patients having dense can estimate a visual acuity ranging from
media opacities are unable to see the grid. 20/20 to 20/400.
Fig. 10.51A and B: A. PAM device; B. Optics of potential acuity meter (see text)
Test procedure
• Test should be done in dimly lighted room
and eyes of patient should not be exposed
to bright lights before test.
• Dilate the pupil by mydriatics for better and
accurate testing.
• Full optical correction is worn by patient
or can be fitted in instrument with the help
of trial lenses.
• Light beam is now projected via clear area
of cataractous lens (window) and patient is
instructed to identify the letters on the
Snellen’s chart. Fig. 10.52: Retinal image of chart in potential acuity
meter (see text)
• Letters on chart will appear and disappear
with the movement of patient’s eye or while • Test chart should be adjusted several times
he/she spell the letters. before confirming the poor macular function.
• Patient may see some disturbing entoptic
images in between letters but slowly he/ Interferometry: Interferometry is a method to
she will adjust to it. predict the potential vision in eyes having
• Patient is instructed to read the lines of mild to moderate media opacities either due
Snellen’s chart until he/she is not able to to cataract or corneal pathology. Devices
read other smaller legible lines. designed on the principle of interferometry are
called interferometers.
• Macular function is considered normal if
patient is able to read an entire line correctly Principle: As we discussed in previous chapter
from the Snellen’s chart (Fig. 10.52). these instruments are designed on the
Clinical Inference are not the usual images, hence are not
affected by optical defects, focus defects, mild
• In mild to moderate degree cataracts having visual to moderate media opacities or imperfect
acuity 20/200 or better; post operative visual acuity refracting ocular system. Observer can see
can be correctly predicted by the PAM in range these fringes purely on the ability of his/her
within 3 Snellen’s line in 100% cases and within retina to conduct signals from photoreceptors
2 Snellen’s line in 90% cases. to visual cortex. Hence, these interference
• In cases having cystoid macular edema, recent fringes become an important tool in distingui-
postoperative reattached retina, serous detach-
shing media opacity from retinal and/or
ments of neurosensory retina, macular hole or cyst,
neurological factors.
very dense cataract, advance glaucoma, geogra-
phical atrophy of macula or dense opacities, PAM Commercially two types of interferometers
can falsely predict an improved or poor visual are available: Laser interferometer and white
outcome. However, amblyopia does not interfere light interferometer.
in accurate prediction by PAM, unlike laser
interferometer. Laser Interferometer
These devices use laser beam to produce
Note: In cases having very dense sub capsular or interference fringe patterns. These devices can
diffuse cortical cataract it is difficult to find a clear
be attached with slit lamp for examination
window for projection of light beam; means least
information is achieved in cases where we need it
purposes.
the most. Instrument design: Light source used for
laser is Helium-Neon, which produces a
property of interference of light. DG Green laser of 632.8 nm wavelength. This laser
and co-workers thought of projecting a beam is splitted into two beams having the
resolution target directly on the retina after same coherent property of laser. Each
bypassing the media opacities for the splitted beam of laser is pulsed with the help
assessment of visual acuity. A set of light of an acousto-optic modulator; which
interference fringes having alternate light and produces 1 msec duration rectangular pulses
dark bands were considered ideal. with frequency of 400 Hz. When these pulses
As shown in Fig. 10.53 a fringe pattern is were alternated there was no overlap and
produced on the retina by interference of light hence no interference was possible. However,
waves generated from two coherent light when pulses arrived simultaneously, the
sources, less than 0.1 mm in diameter. These two beams overlapped and interference
occurred. This overlapping can be controlled
by computer and finer fringe pattern can be
produced.
Optics of laser interferometer: Laser interfero-
meter can be attached to a slit lamp for
examination purpose. Laser is produced and
directed towards the slit lamp mirror via
rotating glass plates and a rotating prism
which allows the axis of gratings to be
changed as per requirement (Fig. 10.54).
Laser devices use low frequency patterns
by using two periodic waves, which produce
Fig. 10.53: Principle of interferometry (fringe pattern interference fringes by moving in-phase and
on retina) out-of-phase with each other. These waves
Electromagnetic wave amplitude decides the

production of fringe pitch not the light intensity,
hence only 20% transmission of each laser beam
is required for reading. Interference fringe
field size varies from 1.5 to 8 degrees and test
is independent of presence of refractive error.
Test procedure
• Patient education is most important before
performing the interferometry procedure.
Various possible fringe patterns are
demonstrated to patient by showing pattern
display cards (Fig. 10.55A). Patient should
also be explained about partial pattern
possibilities due to scotoma in these fringe
patterns as shown in Fig. 10.55B. If scotoma
are seen, then patient is advised to ignore
them and look only at the fringe pattern
direction and orientation.
• Once patient has been explained about
Fig. 10.54: Optics of LASER interferometry (see text) patterns, then laser interferometer is
mounted on slit lamp and patient is asked
pass through the glass plates and rotating to sit in front of the slit lamp by putting his/
prisms to produce fringe pattern on patient’s her chin on chin rest and forehead against
retina via mirror of slit lamp. When both the forehead strip.
these waves are in phase with each other, • For better and accurate examination patient’s
they are seen as white bar and are called pupil is widely dilated by mydriatics and
maxima. On contrary, when out of phase examination room should be dark.
then are seen as dark bar and are called • Highest transparency area of patient’s
minima. The spatial frequency (space crystalline lens is identified by using
between black and white bars) of inter- retroillumination method and laser beam
ference pattern can be adjusted by changing is targeted in this area of lens.
the spacing between two beams. Separation • Scan the pupil until patient starts identifying
between two pin-point beams (i.e. grating the fringe patterns, now an entrance
angle) decides the fringe pattern (i.e. fringe
pitch), increase in grating angle will
produce finer interference pattern or fringe
pitch which requires a greater macular
resolution to identify it.
The grating angle is constantly adjusted till
patient is unable to identify the fringe pattern.
The last perceived grating value is recorded
in decimal system present on the instrument
and an equivalent in Snellen’s visual acuity
can be done by conversion table. Snellen’s Fig. 10.55: Various fringe pattern seen during
equivalent to 6/6 corresponds to a 33 maxima/ interferometry. A. Normal patterns; B. Pattern with
degree of visual angle. scotoma
pupillary area of 1.5 mm is made by jumbled up moving worms, (an effect on inter-
adjusting the knob on instrument. ference fringe produced by media opacities).
• Testing is continued by increasing fringe • Spatial structure of these moving arrays will give
pitch at a step of 0.1 using another knob on an idea about the transparent areas in crystalline
instrument. Patient is asked about the lens, i.e. in relatively clear areas there will be an
orientation (i.e. vertical, horizontal or increase in the size of shooting stars or jumbling
oblique) of fringe pattern at every interval worms. Perfect clear area is the one, where star
of increasing steps. increases in size to cover this entire clear area.
• By adjusting another knob on instrument • Once this clear area is identified now patient is
orientation of fringe can be changed at advised to look inside this area to identify the
fringe direction and orientation, while ignoring
every increasing steps and patient needs to
the other surrounding area.
identify them.
• Finest strip pattern identified by the patient
• Initially, large grating should be used and decides the end point and acuity is recorded as
then grating should be reduced gradually discussed above.
until the patient is not able to detect their • Sometimes patient is able to identify the strips
correct direction. but is unable to identify their pattern and
• Four consecutive correct patterns identifi- orientation correctly; then examiner should
cation by patient is needed to finalize the encourage the patient to pursue further for
acuity reading; a slower patient response identification of the fringe pattern.
indicates an end point of test. In dense media opacities cases
• End point fringe pitch reading is recorded • Patients are unable to see the fringe pattern
from the markings on one of the knobs on because the opacities are very dense and do not
instrument in decimals and is converted to allow even laser beams to penetrate them.
Snellen’s acuity with help of a conversion • In these cases any amount of perseverance is
table supplied with instrument. not going to help and potential vision cannot be
assessed, where it is the most important to know
• In dense media opacity cases, voltage of
the status of potential vision of patient.
instrument can be increased from 5 to
7.5 volts for a convenient examination. False positive results may be seen in following cases:
• Patients of cystoid macular edema having
Note: Prolonged exposure of high intensity light healthy photoreceptors.
like indirect ophthalmoscopic examination should • Patients with viable tilted retinal receptors
be avoided prior conduction of interferometry test. usually give poor Snellen’s visual acuity results,
but can give normal reading in laser interfero-
metry test.
Clinical Inference
• Patients having macular hole or cyst, cystoid
In normal individuals macular edema and geographical macular
atrophy with viable para foveal tissue stimulation
• Normal individuals having no media opacities
can give readings in laser interferometry test.
will see a circular fringe pitch having alternate
light and dark bands as shown in display cards. False negative results may be seen in following cases:
• With breathe of an individual, these patterns • Dense cataract
move because laser spots move, disordered • Dense vitreous hemorrhage
pattern gets replaced by new ordered patterns • Insufficient pupillary dilatation
when settled.
In mild to moderate media opacity cases White Light Interferometer
• Patients having mild to moderate media opacities White light interferometers use polychromatic
will initially report that they are seeing only
white light produced by an incandescent bulb
disordered, moving array of shooting stars or
as source of light beam instead of a laser beam.
Working optics and test procedure of these whereas cortical cataracts are peripherally
white light interferometers is similar to laser located and nuclear cataracts are diffuse
interferometers, however, contrast of gratings in nature.
may be reduced by chromatic aberrations in • Preoperative poor visual acuity: In
white light interferometers against that of laser patients having preoperative VA lower
interferometers (Fig. 10.56). than 6/60; both PAM and interfero-
meters are less effective in predicting
Factors affecting accuracy of test results: Many
visual outcome postoperatively.
factors can influence the outcome of vision
• Ocular diseases: Interferometers overesti-
when tested by either PAM or interferometer.
mates the visual outcome as compared
Hence, it is important to consider these factors
to PAM in patients having poor retinal
during preoperative counseling of patient,
functions due to conditions like macular
while explaining the predicted visual
degenerations, retinal degenerations and
outcome.
retinitis pigmentosa.
Various factors affecting test results are as
follows: Alternate Methods
• Density of cataract: Both PAM and When the abovementioned tests have a
interferometers predict visual outcome questionable response or it is impossible to
in mild to moderate type cataracts perform any test, other alternate methods can
(according to lens opacity classification be employed to assess the visual outcome in
system II). In severe cataracts the media opacities such as
accuracy of potential vision assessment • Ultrasonography
by these tests is poor.
• Visual evoked potential
• Type of cataract: Both PAM and inter- • Entoptic imagery test
ferometer underestimate the visual
outcome in cases of dense posterior Ultrasonography
capsular opacification as compared to Evaluation of ocular structures can be done
cortical cataract or diffuse nuclear using ultrasonography, i.e. B-scan or A-scan.
cataract because posterior sub-capsular Brightness scan or B-scan gives a gross but
cataract is dense and centrally located, accurate assessment of ocular anatomical
status and also rules out pathological
conditions like vitreous hemorrhage, retinal
detachment, and optic disc anomalies. When
B scan is unavailable, then A-scan (amplitude
scan) can be used for assessment of ocular
anatomy.
Test method:
• Entire eyeball is scanned by ultrasono-
graphy in eight meridians which are
divided longitudinally.
• Examiner keeps the ultrasound probe on
the limbal area while patient is instruc-
ted to look into the direction of probe tip.
• Then examiner slowly moves the probe
Fig. 10.56: White light interferometers showing towards fornix covering all eight meridians
fringe pattern and patient simultaneously looks in the
direction of respective meridians under Entoptic Imagery Test

examination. Entoptic images are visual perceptions that
• To obtain detail information about ocular arise from optical structures within the eye.
structures the ultrasound scanning is Many types of entoptic phenomenon are
performed in lower and higher tissue Maxwell spot, Purkinje vascular shadow,
sensitivity settings as compared to blue-field entoptic phenomenon, etc. These
normal. entoptic images are sufficiently reliable and
their accurate description by a patient gives
Note: Ultrasonography gives information about
presumptive evidence that a significant level
anatomical status of macula, not the functional
status of macula. of macular function exists. Usually the
Purkinje vascular shadow and blue-field
entoptic phenomenon are considered most
Visual Evoked Potential
accurate test to check functional status of
The visual evoked potential (VEP) test is retina behind ocular media opacities. It is
considered as more specific because the recommended that an entoptic imagery test
prerequisites for this test is an intact macula, should be performed first in cataractous eye,
optic nerve and visual cortical centre. This is and then in the normal fellow eye (if
a very helpful method to predict potential applicable). If patient perceives entoptic
visual acuity in patients especially in total images by normal eye but not by cataractous
media opacities, where other available tests eye, then it indicates poor visual prognosis in
are not useful to assess visual acuity. cataractous eye.
248
Retinoscope and
Retinoscopy
Learning Objectives
• Describe evolution of retinoscope and historical aspects of retinoscopy.
• Learn principles and theories of retinoscopy.
• Describe various parts of retinoscope and types of retinoscope.
• Understand optics of retinoscope and retinoscopy reflexes.
• Enumerate and perform various techniques of retinoscopy.
• Understand characteristics of various retinoscopy reflexes in all types of different refractive status of eye.
• Neutralize the retinoscopy reflexes and estimate the amount of refractive error.
• Perform objective and subjective refraction by itself.
• Prescribe the power of correction in cases of refractive errors.
Chapter Outline
• History of Retinoscopy – Neutralization of various reflexes
– Introduction Neutralization state
– Pioneers of retinoscopy Rules for neutralization
– Various theories of retinoscopy Interpretation of neutrality
• Retinoscope: An Overview Various neutralization methods
– Retinoscope as a tool – Streak versus corneal meridians

– Parts of retinoscope – Neutralization in astigmatic errors
– Optics of retinoscope – Estimation of cylindrical axis and power
– Various types of retinoscopes – Refining cylindrical axis and power
• Retinoscopy – Neutralization of rare refractive errors
– Principles and techiniques of retinoscopy – Retinoscopy after refractive surgery
– Retinoscopy reflex – Summary of retinoscopy
– Methods of retinoscopy • Objective and Subjective Refraction
– Routine retinoscopy reflexes – Objective refraction
Reflexes in emmetropes – Subjective refraction
Reflexes in hypermetropes Adjustment of refraction
Reflexes in myopia Refinement of refraction
Reflexes in astigmatism Binocular balancing
– Rare retinoscopy reflexes • Prescribing Power for Glasses

– Interpretation of retinal reflexes – Retinoscopy representation
Routine images – Prescription writing
Rare images – Transposition of prescription
248
Retinoscope and Retinoscopy 249
HISTORY OF RETINOSCOPY
Introduction
History of retinoscopy goes back to 1859,
when initial observations about the images
were made by Sir William Bowman which
finally led to the basis of present day clinical
retinoscopy. Sir William Bowman observed a
linear shadow (linear fundus reflex) while he
was doing examination of the fundus of a
patient who had an astigmatic refractive error.
He used a plane mirror ophthalmoscope for
examination of astigmatic eye and illuminated
this plane mirror ophthalmoscope with the
help of a burning candle and this light was
then focused on the patient’s eye. Thus, it was
Bowman who first described this method to
detect astigmatic error in a patient of
keratoconus and he established the basis for
assessment of refractive status by objective
means. Because prior to this observation made
by Bowman, refractive status of patients was
corrected by subjective methods only. Finally, Fig. 11.1: Mirror effects on light. A. Plane mirror
H. Parent in 1880 established the quantitative emits parallel, uncrossed rays; B. Concave mirror
refraction test by measuring refractive error converge rays at a point, from which light rays cross
using lenses and coined the term retinoscopie. and diverge hence produces an opposite reflex or
reversed motion.
Retinoscope used in earlier times had
simple mirrors either plane or concave to
reflect the light coming from of a candle. The Cuignet observed that when the light from
candle light created a “spot of light” which in the plane mirror is moved across the pupil
turn produced shadows instead of linear then the reflexes from the fundus also move
reflection from eye of the patient. Gradually with light movement. Occasionally, the
it was tried and understood by various movements of fundus reflex was in the same
scientists working on this, that a linear streak direction as that of mirror light, but most of
of reflected light can be produced by utilizing the time it was in the opposite direction. He
slit-shaped mirrors as shown in Fig. 11.1. thought that the cornea was responsible for
the production of these reflexes in the eyes and
Pioneers of Retinoscopy hence coined the term for his method as
In the year 1873, French ophthalmologist keratoscopie (‘kerato’ means cornea).
Ferdinand Cuignet compared various reflexes He further observed these reflexes in details
in the eyes by using a simple mirror in terms of the reflex sizes, brightness of reflex,
ophthalmoscope. When he observed through speed and direction of the reflexes in relation
the peephole of his plane mirror he noticed to the movement of projected light. On the
that the reflexes varied in different patients. basis of his observations Cuignet classified
He thought that this phenomenon might be these patients with various refractive errors
happening because every person has different as myopia, hyperopia or astigmatism. Because
refractive status. This became the basis for a of this contribution in field of retinoscopy, he
qualitative test. is known as Father of retinoscopy.
Subsequently, in the year 1878, M. Mengin been done. During this period of development
explained that the source of the reflex the Retinoscope handles and sleeve design
produced during retinoscopy was not the were made handy, compact, more comfortable
cornea (as per Cuignet) but reflexes were and user friendly, with better battery power.
produced from the fundus of the eye. Based
on his postulation Mengin introduced the term Various Theories of Retinoscopy
retinoscopie considering that the reflexes were Though the technique of retinoscopy was put
generated from the fundus (retina) of the eye. to an effective clinical use during the 19th and
H. Parent (1849–1924) in the year 1880 was 20th centuries, however, the principle of
able to produce the quantitative refraction test. retinoscopy was still a debatable issue among
He utilized the lenses to quantify the degree scientists. The most popular theories regar-
of various types of refractive errors suggested ding the principle of retinoscopy emerged
by Cuignet. Parent coined the term retino- during this period were:
scopie which later changed to skiascopie • The far point theory (proposed by Landolt)
(which means shadow) for his quantitative • The observer pupil theory (proposed by
technique. Apart from abovementioned terms Wolff)
various other names were suggested for the • The photokinetic theory (proposed by
techniques done to study the reflexes from Haass)
the eye were Out of these theories the far point theory
• Shadow test (proposed by Priestley proposed by Landolt is most widely accepted
Smith, an Ophthalmologist from Birmin- theory and forms the basis for understanding
gham) the principle of retinoscopy till date. Eminent
• Skiaskopie (Egger translated the word scientists like Priestly-Smith, Donder,
shadow in Greek and coined this term) Gullstrand, Wolff, Haass and others also put
• Pupilloskopie (korescopy) theories for optics and mechanism of
retinoscopy.
• Umbrascopy
In the year 1903, scientist Duane started use
• Scotoscopy of cylindrical lenses in cases of astigmatism.
• Dioptroscopy He developed method to use cylindrical lenses
The electric retinoscopes commonly used while performing retinoscopy to neutralize the
in the beginning of 20th century had spiral reflexes. Most widely accepted far point theory
filament bulb with a rotating sleeve. These of Landolt which still forms the basis for
spiral filaments used to give the spot of light understanding the principle of retinoscopy
which was not in line or very sharp. Later on, was challenged by theories proposed by Wolff
Jacob Copeland introduced a bulb in retino- (observer pupil theory) and Haass (photo
scope which had linear filament. The light kinetic theory).
produced by this bulb was sharp, bright and In initial phases, for illumination of retina
linear. This change in bulb became the basis gaslight was used as a light source. This light
for the discovery of Copeland’s streak source was later on replaced with an
retinoscope which passed many phases of incandescent lamp. Examiner used a mirror
development to reach the present day retino- retinoscope to reflect the rays from the gaslight
scopes. into the patient’s eye, while studying the
Over the last 100 years many improvement fundus reflex through the peephole of mirror
and modifications in the design and retinoscope.
functioning of retinoscope in terms of viewing Gradually, a miniature bulb was developed
system of retinoscope, meridians of bulb which could be placed inside the instrument.
filament and control of light vergence, etc. had This was the model of an early luminous
retinoscope. These small electric bulbs replaced by streak retinoscope in modern era
projected a spot of light to illuminate the retina and designed by many manufactures
much similar to present day’s Ophthalmoscope. commercially. All these brands of retinoscopes
Later on, various designs of retinoscope came have slight difference in their appearance and
with variable vergence. These vergences were design of instrument but the basic principles
produced by the use of either plane or concave remains more or less similar in all commercially
mirror. These mirrors were also fitted in the available instruments.
same instrument.
Over a period of nearly 100 years the Parts of Retinoscope
initially designed spot retinoscopes have not Though from external appearance the
changed much in their design. There were retinoscope looks like a simple instrument
several limitations in function and handling with head and handle. It has several smaller
of these instruments but still they remain in units which are compiled to perform various
use till recently. However, streak retinoscopy functions.
in reality is more accurate, much simpler and To know the retinoscope in better way we
faster than other techniques of retinoscopy. can broadly divide this instrument into two
With time the importance of a linear fundus parts as shown in Fig. 11.2.
reflex as compared to spot reflex especially, • Head piece
in the patients having astigmatism was • Handle piece
recognized. Many researchers stressed on the
Head piece: It is the upper portion of retino-
importance of linear reflex and by using
scope which consists of
various types of slit-shaped mirrors they tried
• A peephole, through which examiner looks
to create a linear beam (or streak) of light,
the retinal reflex.
which lead to development of streak retino-
scope. This streak retinoscope simplified the • A sleeve which rotates the projected streak
procedure of refraction in astigmatism. With of light, hence increases or decreases the
further advancement an electric retinoscope width of projected beam.
which consisted of a rotating slit was produ-
ced which allowed the examiner to compare
various ocular meridians simultaneously.
RETINOSCOPE: AN OVERVIEW
Retinoscope as a Tool
Retinoscopy is also known as skiascopie. This
terminology is more accurate because it
indicates that the shadows (reflexes) from the
fundus are being observed by use of an
instrument.
Retina by itself is a thin and transparent
structures, hence it cannot casts a shadow. So
the structures get illuminated by the light are
retinal pigment epithelium and choroid. These
structures reflect the light and shadows or
reflexes of this reflected light are seen by the
instrument called retinoscope. Previously,
spot retinoscopes were used which are now Fig. 11.2: Retinoscope
• A socket for source of illumination, i.e. bulb by either raising or lowering the sleeve
at its terminal end. according to the convenience of the examiner.
This head piece is fixed by the socket As this condensing lens lies in the path of light
system into the handle. streak, hence it focuses the rays from the bulb
onto the mirror.
Handle piece: It is the lower portion of retino-
scope and has an elongated hollow tube where Mirror: The mirror (mostly plane mirror)
battery is inserted inside. This battery may be causes bending of the light rays which
rechargeable or non-rechargeable. This handle emerges from the bulb, so that it is projected
is fixed with head piece by socket locking system. inside the patient’s eye. The light from bulb
filament emerges in upward direction towards
Internal Components of Streak Retinoscopes the ceiling and has an axis parallel to the floor,
Various commercially designed streak retino- which is then bended and reflected by the
scopes basically have two main components: mirror. Although 100% of the emerged light
from the bulb filament is not reflected by the
• Light projection system
mirror but to a certain extent some of light rays
• Examiner observation system
pass via the mirror. These bypassed light rays
Light projection system: The projection system give an opportunity to the examiner to view
is the one which provides illumination to the retina inside the patient’s pupil. These light rays are
and involve the following major components coaxial to the path of the reflex streak. As this
Light source: In majority of designs a small reflecting mirror is placed at prefixed angle
bulb having a linear filament is used as light inside the head of retinoscope, the path of
source. This filament produces a line or streak emerging light is at right angle to the axis of
of light because the design of this filament is the retinoscope handle.
linear or straight. This bulb is fixed with sleeve Focusing sleeve: Sleeve is a hollow
in such a manner that by turning sleeve up or cylinder, can be mounted in the head or over
down the bulb also moves up and down and the handle of retinoscope. Function of sleeve
as it comes near to the lens the light is is to narrow or widen the width of light streak
divergent and as it goes away from the and it also changes the direction of the light
condensing lens the projected beam is streak by rotation movement. This is used to
convergent. In simpler words, the width of control the amount of light projected inside
projected beam is narrowed or widened by the eye and also controls the direction of eye
moving the bulb up or down using the sleeve. examination. The sleeve when moved up or
Condensing lens: Plus power convex lens down, the distance between the bulb and lens
placed between the light source and reflecting varies, hence it allows the retinoscope to
mirror is called condensing lens. This plus lens project the rays which are either divergent
condenses the light ray, hence named (plane mirror effect) or convergent (concave
condensing lens. Streak of the light which is mirror effect). Because of this function it is also
produced from the bulb (having linear called the vergence control of retinoscope.
filament) is a highly diverging ray, hence a In most of the commercially available
plus lens is used to control the vergence of retinoscopes, the sleeve changes the focus
streak. This condensing lens produces a (vergence) by moving the bulb up or down
positive effect on vergence of the projected keeping the lens at a fixed place. But in some
light rays. The rotating sleeve present between commercially available retinoscopes, the
the head and the handle of retinoscope helps condensing lens (rather than the bulb) is
to change the relative position of the moved up or down to change the vergence.
condensing lens and the bulb and thus The movement of lens can also be done by
vergence of emitted light streak can be altered raising or lowering the sleeve.
As discussed later in this chapter, that patient. The manner in which these reflected
instruments which use a fixed bulb system and rays get affected tells the examiner about the
movable condensing lens, they work just the optics of the patient’s eye.
opposite way as compared to those retino-
scopes which use a fixed lens and movable Optics of Peephole
bulb in up or downward direction. Usually people think the peephole of retino-
In present day retinoscopes, the sleeve scope as the hole which is present on the
controls both the factors, i.e. rotation of the examiner’s side of the retinoscope (we see the
light streak in different axes and vergence of emerging reflected light through it). But in
light focused by the streak. In all types of reality, peephole is the “hole” present in the
retinoscopes, we progressively increase the center of the reflecting mirror inside the
vergence of the light beam from diverging rays retinoscope. As examiner peep (see) through
(plane mirror effect) through parallel rays to this hole it is called peephole. This peephole
converging rays (concave mirror effect), as we can be manufactured in the following ways
move the sleeve from top to bottom or vice • One way is that a small circular portion of
versa. the mirror can be left unsilvered and the
Electric current source: This is provided by remaining area is silvered so that the light
a battery in the handle (e.g. rechargeable single is not reflected from this small unsilvered
battery or replaceable small batteries). There area.
are a few models of retinoscope, which use • Other way is that the mirror is partially
electric connections for providing the current silvered, so that this mirror will act as a
source to the bulb. beam splitter.
Size of peephole is a major contributing
Note: In a nutshell, the projection system is simple
to understand. The retinoscope emits rays of light factor in designing of retinoscope because a
to illuminate the retina. By rotating the sleeve the very large size peephole will reduce the
projected streak is rotated and by moving the sleeve amount of valuable light reflecting into the
up or down the projected ray can be made patient’s eye. To decrease the chances of these
divergent or convergent. internal reflections producing glare and
polarization, some manufactures of retinoscope
Examiner observation system: The observa- have introduce various types of filters which
tion system enables examiner to see the reflex are fixed in between the peephole of the
from the retina. The illuminated retina retinoscope and the true peephole.
reflect back some of the light rays and these This true peephole is the one which allows
few rays then go into retinoscope and pass the observer to see inside the patient’s eye by
through a small hole in the mirror and later maintaining a coaxial relationship between his
on they reach at the back end of the head of eye and the light emerging from the peephole
retinoscope. This small hole in the mirror is of retinoscope. This coaxial (having same
called the peephole. Thus, examiner can see axis) relationship among the observer’s eye
the retinal reflex through this peephole. When and emitted light streak from patient’s eye is
examiner move the retinoscope up or down, very important and prerequisite to view a red
while still looking through the peephole, he/ reflex inside the eye of patient as shown in
she can observe the up and down movement Fig. 11.3.
of the light streak.
Generally, these rays when emerge from the Note: If this coaxial relationship of light is not
patient’s retina, they pass through various maintained, then examiner will see only a black
optical components of the eye and thus get pupillary area inside the patient eye, instead of a
affected by the various eye components of the red reflex.
Fig. 11.3: Observation system illustrating the path

of light through mirror from patient’s retina to
observer’s retina.
Tilting of the retinoscope in sideways will

allow the examiner to see some area of the red
reflex of retina present in alignment with
retinoscope peephole, whereas a few area of red
reflex which are not in line, get cut off. These
cut-off areas will be seen as a dark shadows
inside the patient’s pupil, whereas remaining
area which are coaxial will be seen as red glow. Fig. 11.4: Optics of retinoscope showing positions
of bulb, condensing lens and mirror.
Note: In a nutshell, the observation system of retino-
scope is simply to observe the reflected light ray In our diagrammatic illustration the filament
from illuminated retina through a peephole in mirror. of bulb is considered to be present at the focal
point of convex lens, hence the light rays
Optics of Retinoscope emerging after reflecting from the mirror are
Figure 11.4 is a diagrammatic cross-sectional parallel in nature.
representation of streak retinoscope. Bulb Two types of retinoscope are available
emits light from its filament, which passes • Type I: In this type of retinoscope, the
through a convex lens (condensing lens) and bulb is moved up or down with the
then this light hits the plane mirror. From the movement of sleeve, whereas convex
mirror light rays get reflected outside the lens remain fixed.
retinoscope toward the patient’s eye. The exami- • Type II: In this type of retinoscope, the
ner observes a portion of these reflected light convex lens is moved up or down with
rays via an aperture in mirror called peephole. the movement of sleeve, whereas bulb
The arrows shown in Fig. 11.4 on sides of remains fixed.
retinoscope are representing two types of
movements done by the sleeve of retinoscope, Type I retinoscope
i.e. up or down and rotation. The straight Optics and cross section view of the first type
arrow represents the vertical movement of of retinoscope in which the bulb moves up or
sleeve where upward or downward movement down and convex lens remains fixed is as
will change the vergence of the emitting light follows:
rays by altering the distance between filament As shown in Fig. 11.5A, when sleeve of
of bulb and convex lens. The curved arrow retinoscope is moved in downward direction,
represents the bulb, which can be rotated both the bulb moves downward (away from lens)
clockwise and anticlockwise; to move the and the effect produced is similar to a concave
orientation of reflex either vertical or horizontal, mirror which means emerging light rays will
as per requirement. be convergent in nature.
sleeve of retinoscope is moved in upward

direction.
Opposite effect happens as shown in
Fig. 11.6B, when sleeve is moved down, the
lens moves downward (nearer to bulb) and
produces plane mirror effect and hence
emerging light rays are divergent in nature.
Various Types of Retinoscopes

Retinoscopes took a long revolutionary path
to reach present day’s sleek retinoscope
models. Various types of retinoscopes are
• Simple retinoscopes
Fig. 11.5A and B: Optical effects by the movement • MacNab retinoscope
of retinoscope bulb. A. Bulb moving downwards; • Dynamic retinoscopes
B. Bulb moving upwards
• Spot retinoscopes
As shown in Fig. 11.5B, opposite will • Streak retinoscopes
happen when sleeve is moved up, i.e. the bulb Simple retinoscopes: These were the earliest
will move up (nearer to lens) and produces and oldest instruments used to perform
plane mirror effect, hence emerging light rays retinoscopy. Initially, these were nothing but
will be divergent in nature. simple circular mirrors which had a central
Type II retinoscope perforation or a hole. These mirrors were
Optics and cross section view of the second mounted on a metallic handle. Initially
type of retinoscope in which the lens moves practitioners worked really hard to train
upward or downward and bulb remains fixed. themselves to use these simple plane mirrors
As shown in Fig. 11.6A, when lens is moved along with a source of illumination (present
up (away from bulb), an effect similar to a either on a wall or over the patient’s head by
concave mirror is produced and hence a light mounted on patient’s chair). The
emerging light rays are convergent when practitioners observed the red reflex from
patient’s eye and tried to neutralize these
reflexes with the help of various concave or
convex lenses.
In Fig. 11.7A, three types of simple
retinoscopes are shown, which are collectively
called ‘Orthops’ retinoscope. In Fig. 11.7B the
two reflecting retinoscopes are Lister plain
mirror retinoscope and Priestley- Smith Bright
double mirror. Lister reflecting retinoscope
has a plane mirror, which is mounted on a
handle with central peephole, whereas
Priestley retinoscope has plane mirror on one
side and concave mirror on the other side.
These retinoscopes were manufactured in mid
Fig. 11.6A and B: Optical effects by the movement 20th century and the bright double mirror
of retinoscope lens. A. Lens moving upwards; B. Lens retinoscope is used till date by various institu-
moving downwards tions for teaching and learning purposes.
Fig. 11.7A and B: A. Orthops retinoscope; B. Reflecting retinoscopes
MacNab retinoscope: In year 1909, an Dynamic retinoscopes: In earlier days, when

Ophthalmologist Angus MacNab (1876–1914) performing retinoscopy with simple retino-
had designed a retinoscope for study scopes patients were instructed to fixate on a
purposes. MacNab’s retinoscope was a unique target situated at far distance and their
kind of retinoscope. It has an ivory handle accommodation was kept relaxed. This
with a gilt screw to fix. This retinoscope had method of retinoscopy was called static
an axis indicator wheel (marked from 0 till 180 retinoscopy because accommodation is at rest
degrees) with gear underneath the peephole and no change of refractive status can occur
of retinoscope. This axis wheel was operated due to accommodation during retinoscopy.
by use of gears and had a central peephole as Usually, to relax the accommodation of patient
shown in Fig. 11.8. various mydriatics or cycloplegics drugs were
Once the red reflex is neutralized in one used sometimes, even high convex lenses in
meridian and if there is a movement in other the fellow eye were used to relax the
meridian, then this meridian was neutralized accommodation.
by use of the axis wheel. This was a sophisti- Dynamic retinoscopy was a revolutionary
cated retinoscope and needed continuous thought in the field of retinoscopy. In the year
practice to master this instrument. Actually, 1902 scientist AJ Cross first identified the basic
this retinoscope was an improvement over the principle of this technique. Dynamic retino-
existing simple retinoscope because an scopy is defined as “retinoscopy done when
astigmatism error can also be neutralized by the patient is instructed to fixate on a near
use of this retinoscope. object with both the eyes (binocularly)”.
Initially, any simple object like a reading book
was used as the near object to fixate
binocularly which can be easily held by the
patients at desired distance. Over a period of
time gradually retinoscopes were designed in
such ways that near fixation targets were
incorporated into the retinoscope itself.
The two popular types of dynamic
retinoscopes were present in the era of 1930s.
These were Margaret Dobson retinoscope and
Fig. 11.8: MacNab retinoscope Turville-Pascal Dynascope.
Margaret Dobson retinoscope: As shown

in Fig. 11.9A the Margaret Dobson dynamic
retinoscope had a spiral filament fitted inside
the retinoscope bulb to produce a spot of light
and emerging rays were made slightly
divergent by using a plane mirror before they
were reflected into the eye of the patient. This
instrument was specially designed so that
when patient try to compensate for achieving
the binocular fixation, the working distance
of retinoscope is compensated automatically.
A revolving disc present on the retinoscope
had eight targets; out of these seven targets
were near fixation charts which were designed
to be examined from a reading distance of
30–35 cm. The eighth target designed for
patient was a simple blank chart. This blank
slot of target was designed to decrease the
illumination from all other near targets and Fig. 11.9A and B: Dynamic retinoscopes. A.
hence will convert this dynamic retinoscope Margaret Dobson retinoscope; B. Turville-Pascal
into an old traditional static type of dynascope
retinoscope. The fixation target shown in
above retinoscope picture is that of a horse.
These kinds of pictures were used to perform
retinoscopy in children so that while doing the
retinoscopy the examiner can ask simple
questions to child such as whether this horse
has a tail or can you see the beautiful eyes of
the horse. These simple questions will help
child as well as examiner in fixating the object
and relax their accommodation.
Turville-Pascal dynascope: The Turville-
Pascal retinoscope or ‘Dynascope’ (Dynamic
retinoscope) (Fig. 11.9B) was introduced in the
year 1931. It was designed by the collective
Fig. 11.10: Spot retinoscope
efforts of both scientists, who worked together
with an aim to remove different errors producing the vergence to spot light, either
supposedly introduced by the retinoscope getting reflected from a plane mirror (more
itself in the process of dynamic retinoscopy. common) or a concave mirror (less common).
Spot retinoscopes: In the year 1901, first Streak retinoscopes: The fundus reflexes
electric retinoscope was introduced by Wolff produced in an astigmatic eye are linear, thus
(Fig. 11.10). This newly designed self- for accurate detection of astigmatism it was
illuminated retinoscope was fitted with a better to use a rectangular streak of light than
small bulb which emitted a spot of light inside a spot light. To produce this type of streak
the patient’s eye. In the subsequent years early researchers tried to produce their own
various other vergence models of retinoscopes reflecting mirrors having a slit in the middle
were introduced which were capable of and this helped in conversion of a spot light
into a linear beam. Jack C Copeland (Father of

streak retinoscopy) introduced the first streak
retinoscope having variable vergence around
1920. His streak retinoscope was designed to
produce its own linear light beam which could
have been rotated in all the ocular meridians
by a sleeve. In mid 20th century, Copeland’s
retinoscope popularly called Pulzone streak
retinoscope as shown in Fig. 11.11 was
commercially available in entire European
countries.
Commercially two types of retinoscope are
manufactured such as
• Bausch and Lomb, Copeland and
Copeland-Optec 360: In these retinoscope Fig. 11.12: Heine streak retinoscope
designs convex lens (condensing lens) is the source of light, i.e. bulb is kept fixed,
kept fixed, whereas with the movement whereas the convex lens (condensing
of sleeve the source of light, i.e. bulb can lens) can be moved upwards (towards
be moved upwards (towards the lens) or mirror) or downwards (towards bulb) by
downwards (away from the lens). When raising or lowering the sleeve. When
sleeve present on the retinoscope handle sleeve present on the retinoscope handle
is raised, the light beam is emitted as a is raised, the light beam is emitted as a
divergent beam and opposite occurs convergent beam and a divergent beam
when sleeve is lowered, i.e. a convergent is produced by lowering of sleeve.
beam is produced.
• Retinoscopes made by companies such Note: As these types of retinoscopes need to control
as Welch Allen, Heine (Fig. 11.12), Neitz, two different functions such as moving the
and Keeler: In these retinoscope designs condensing lens upwards/downwards and also
rotate the filament of bulb, their mechanism and
linkage design is quite complex as compared to
retinoscopes manufactured by Bausch and Lomb
Copeland.
RETINOSCOPY
Principles and Techniques of Retinoscopy
The principle is to observe the different kind
of retinal reflections (reflex) obtained from
patient’s eye when light beam produced from
retinoscope illuminates the internal portion of
patient’s eye. The examiner observes the
relative movement of the retinal reflexes when
he/she moves the streak or spot of light beam
either in vertical or horizontal meridians from
corner to corner of patient’s pupil. Then examiner
tries to neutralize these retinal reflexes
manually by placing trial lenses of different
Fig. 11.11: Pulzone streak retinoscope power in front of the eye in a trial frame.
Retinoscopy is a technique used to calculate

the amount of refractive error by an objective
means. Objective refraction test is done by
performing retinoscopy under the effect of
mydriasis. Retinoscopes’ light source is
utilized to illuminate the fundus of patient’s
eye while examiner will observe and measure
the reflected rays of light from the retina.
Retinoscopy may be followed by various
subjective tests to calculate an accurate
amount of refractive correction required for
the patient.
Over many decades retinoscopy has proved
to be an excellent method to evaluate the
refractive status of an eye and is considered Fig. 11.13: Emerging rays pattern and focal point
as a clinically effective method to assess an (FP) for emmetropic (E), hypermetropic (H) and
accurate refractive correction needed by myopic (M) eyes.
patient in very less time without compromising
the quality of result. myopia, assuming that the entering light rays
were parallel in all three ocular states, can be
Retinoscopy Reflex understood by graphic representation as
Various images obtained while performing shown in Fig. 11.13. In an emmetrope, the focal
retinoscopy need evaluation for the calcula- point is at infinity, in hypermetrope it is
tion and estimation of refractive status of the beyond infinity, whereas in myope the focal
eye. As discussed above, when fundus is point is at lesser distance than infinity.
illuminated with the retinoscope light source Consider that examiner is sitting at infinity
and examiner observes the emerging rays distance and looking through the peephole of
coming from the retina (as if retina is retinoscope. Various observations in three
luminous), the optical system of eye exerts basic conditions as mentioned above will be
various types of vergence to these emitting as follows
rays. For example, when retina is illuminated • Retinal reflex moves along with the
with parallel rays (by plane mirror), the rays movement of retinoscope streak (WITH
reflected from the retina will emerge from the motion reflex) in case of emmetrope and
eye according to the refractive status of eye as hypermetrope because emerging light
follows rays are not converging to a focal point
• Reflected light rays will emerge from the as shown in Fig. 11.14.
eye as parallel rays in case of emmetropia. • Against movement of retinal reflex along
• Reflected light rays will emerge from the with the movement of retinoscope streak
eye as divergent rays in case of hypermetro- (AGAINST motion reflex) will be seen in
pia. case of myope because emerging light
• Reflected light rays will emerge from the rays are converging to a focal point (FP)
eye as convergent rays in case of myopia. and then diverging as shown in Fig. 11.14.
The emitting rays will behave differently if Similarly, when examiner is looking
we illuminate the retina with rays which are through the peephole of retinoscope from a
not parallel. finite distance, then the emerging light rays
The optics of retina in different ocular will appear as red reflex inside the patient’s
status, i.e. emmetropia, hypermetropia and pupil (Fig. 11.15A). When examiner moves
practical convenience either one meter or

66 cm distance is advocated to observe the
retinal reflex, from where reflex appears
brighter and examiner can easily add or
remove lenses in/from the trial frame.
When examiner observes from 1 meter
distance, then in case of emmetrope and
hyperopes still the examiner will observe with
movement reflex (Fig. 11.16) because focal
point in both these cases is beyond the
examiner. However, in case of myope (for
example, having one dioptre refractive error)
Fig. 11.14: Different types of retinal reflex considering
following typical reflexes are observed with
that retinoscope is situated at infinity
various positions such as
retinoscope across the eye, the red reflex will • Suppose examiner leans forward with
also move with retinoscope movement. retinoscope: With movement of reflex is
Suppose the emerging light rays are parallel seen
or diverging, then the red retinal reflex will • When examiner goes backward: Against
move in the same direction as of the retinoscope movement reflex will be seen
streak (intercept), this is called with movement • However, with retinoscope exactly at one
(Fig. 11.15B). In contrast, if emerging light rays meter distance no movement of reflex or
meet at focal point and are diverging, then the a neutrality reflex will be seen because
retinal reflex will move in opposite direction, focal point in our example is at one meter
as that of retinoscope streak; this is called distance.
against movement (Fig. 11.15C).
A neutrality of red (retinal) reflex is seen
Note: An interesting way to interpret this condition when peephole of retinoscope coincides with
is that, if we observe against movement we are focal point. This reflex is the one which fills
beyond the focal point and if we see with movement, the entire pupil with light (Fig. 11.17). At this
then focal point is beyond us. point there is no streak of light and also there
is no movement of retinal reflex either with
Practically, optical infinity is considered or against. At this point the retina of eye is in
beyond 20 feet or 6 meters distance but it is conjugate with the peephole of retinoscope. As
impossible for an examiner to sit at this far retinal reflex reverses its direction from with
distance and then observe the retinal reflex or movement to against movement, this focal point
add the correcting lenses in trial frame. For is also called reversal point in retinoscopy.
Fig. 11.15A to C: Red reflex motion with retinoscope streak (intercept). A. In center with streak; B. With
movement; C. Against movement
infinity”. In this technique the patient is

advised to relax his/her accommodation
completely. This state of fully relaxed
accommodation can be achieved either by
providing a distant fixation target to the
patient or by using cycloplegics in cases of
hypermetropes and children.
To obtain the patient’s exact refractive
status, the dioptric power equivalent to
cycloplegic (if used) and also working distance
are mathematically subtracted from the total
amount of retinoscopy. The working distance
lens has power equivalent to the focal length
equal to distance between examiner and
patient. For example, +1.00 dioptre lens equates
for one meter of working distance.
Mohindra near retinoscopy: This technique
is also used to measure distance refractive
Fig. 11.16: Different types of retinal reflex consi- error in a non-accommodative state, however,
dering that retinoscope is situated at one meter this technique differs from dynamic retino-
distance. scopy. This is a very useful technique to assess
refractive state of eye in infants.
Steps of retinoscopy technique are
• The examination room must be dark as
much as possible. Underlying principle
is simple that the dim light emitting from
retinoscope will act as a fixation target
for the child so that accommodation will
not get stimulate.
• Sometimes this technique can be
performed over the shoulder of parents
Fig. 11.17: Neutrality of red reflex while parent is holding the infant or
feeding the infant. The examiner performs
Methods of Retinoscopy retinoscopy from 50 cm distance and two
Retinoscopy methods can be grouped mainly principal meridians of retinal reflexes, i.e.
as horizontal and vertical are neutralized
• Static retinoscopy separately by using spherical or a
• Mohindra near retinoscopy combination of spherical and cylindrical
trial lenses.
• Dynamic retinoscopy
• Originally, Mohindra used a –1.25 D
Static retinoscopy: This is the most widely lenses for adjustment; this dioptric value
and routinely performed retinoscopy of –1.25 D was mathematically added
technique to estimate the accurate amount of with the total neutrality dioptric value
distance refractive error. Static retinoscopy is to get a final result. For example, if
based on Foucault’s principle, which states neutrality is achieved with +4.50 /–1.75
that “the exact refractive status of patient is × 90°, then the final result would be
achieved when the observer create an optical + 3.25/–1.75 × 90°.
• In infants having high degree hyper- target, so that the retinoscopy reflex will
metropic refractive error, Mohindra quickly change back into with motion.
retinoscopy showed less accurate results • Examiner gradually moves nearer to the
when compared with cycloplegic retino- patient and simultaneously instructs
scopy. Although Mohindra technique him/her to sustain their fixation for
remained a unique child-friendly method longer duration on near target. This
as not much cooperation is required with increases the efforts of accommodative
the child. system and helps the examiner to
Dynamic retinoscopy: Difference between estimate about the sustainability of
static and dynamic retinoscopy is that working accommodative efforts.
distance and accommodation are not only • Plus lenses are now added to neutralize
equated with lens power rather convergence the reflex.
and information processing are also considered The results of dynamic retinoscopy can be
in the dynamic retinoscopy. No cycloplegia is interpretated as:
required to perform this retinoscopy. • Normal when reflex seen is rapid,
Simple method to perform a dynamic complete, and steady.
retinoscopy is by using retinoscope and a near • Abnormal when reflex seen is incomplete,
fixation target, say reading chart. sluggish and shows momentary accommo-
Method of dynamic retinoscopy dation and/or accommodative lag.
• Fixation target is held by the examiner Various techniques to execute dynamic
at the nearest possible distance to retinoscopy are:
peephole of retinoscope, without blocking • Bell retinoscopy
the aperture of peephole. • Nott retinoscopy (NR)
• Darken the examination room and a light • Book retinoscopy
is directed towards the reading chart so • Stress point retinoscopy
that patient is able to read this chart.
• Monocular estimate method (MEM)
Examiner holds the reading chart and
retinoscope at the normal reading Bell Retinoscopy
distance. In previous days originally a cat bell was used
• If distant vision correction is present, as the target to perform the technique of
then patient is instructed to wear the dynamic retinoscopy, hence was named as
distance vision glasses. Then patient is Bell retinoscopy. Although nowadays Wolff
instructed to fixate on a distant target wand is used as target to perform this
wearing distance correction (if present) technique. As shown in Fig. 11.18, Wolff wand
and fundus reflexes are observed in both target has a gold or silver metal ball of ½ inch
the eyes, usually with motion is seen. diameter mounted on one or both ends of a rod.
• Now the patient is instructed to suddenly Procedure of retinoscopy
fixate on the reading chart from the • Examiner holds the retinoscope at 50 cm
distance target, while examiner continues distance from the patient and observes the
the retinoscopy. Usually the previously fundus reflex. Now examiner gradually
observed with motion will either swiftly moves the ball towards the patient, while
converts into the state of neutralization patient is instructed to look at the ball
or may appear as against motion. continuously. Simultaneously, examiner
• Suppose neutralization of reflex is continues to perform the retinoscopy and
incomplete, then patient is instructed observe the movements of reflex in relation
again to fixate on the previous distant with the movement of ball target.
• Normal values for bell retinoscopy are an

inward shift, i.e. from with motion to against
motion is in the range of 35–42.5 cm and an
outward shift, i.e. from against motion to
with motion is in the range of 37.5–45 cm.
Note: Suppose lag of accommodation is not

observed within these ranges, then procedure is
repeated by using plus lenses. Lenses which bring
the recordings within these ranges are
acknowledged as near vision prescription.
Nott Retinoscopy
Nott retinoscopy (NR) is a unique method of
retinoscopy. Here an internally-illuminated
cube is used as a target which contains high
contrast cartoon images (usually in black and
white color). This cube is attached on a
retractable tape measure and is viewed from
a 40 cm distance in a dim illumination as
Fig. 11.18: Wolff wand target for bell retinoscopy shown in Fig. 11.19.
(courtesy: Bernell Corporation) The target is kept stationary (D1) and
examiner moves in backward direction
• As the ball moves closer, usually a fast with
holding retinoscope, while observing the
motion is observed, gradually reflex
reflex till it becomes neutralized. This
changes to neutral and then against.
distance between the examiner and the child
• Now when examiner gradually moves the (D2) is recorded and accommodative
ball away from the patient a reverse order response is equal to the inverse of this final
of changes in reflex, i.e. from against to distance.
neutral and then with motion will be
observed by the examiner. Book Retinoscopy
• Firstly record the distance between ball and In book retinoscopy various changes in
the patient’s nose at which a change from retinoscopic reflex are observed depending
with motion to against motion had upon the involvement level or interaction of
occurred while ball was moved towards child, who continuously read a book as target.
the patient. These changes in retinoscopic reflexes could
• Secondly, record the distance between ball be
and the patient’s nose at which a change • A bright, sharp edged pinkish colored reflex
from against motion to with motion had with motion is seen, while child is reading
occurred while ball was moved away from freely and easily.
the patient. • A bright, sharp and dark pink colored reflex
• These two distances are recorded as fraction having fast against motion is seen, while
in centimeters. For example, 36/42 which child is reading on instructions of examiner,
means first recording with motion to means maintain the reading task in spite of
against motion had occurred at 36 cm being stressed.
distance and change from against motion • A dull brick red colored reflex having slow
to with motion had occurred at 42 cm against motion is observed, while child is
distance. reading with frustration.
Fig. 11.19: Method of Nott retinoscopy. D1—fixed distance; D2—final distance
Stress point retinoscopy

Harmon and Kraskin described stress point
retinoscopy. As discussed above, in Bell
retinoscopy a change in motion of reflex was
observed, whereas in stress-point retinoscopy
a change in reflex quality is observed.
Following three types of observations can be
seen when near point stress is observed
• A change in radial pulse of subject
• An inner canthal twitch
• A color change in retinal reflex
Harmon distance: It is measured from the
elbow to the knuckle of middle finger as shown
in Fig. 11.20.
Test procedure
• Examiner initially observes the fundus
reflex, then patient is instructed to focus Fig. 11.20: Harmon distance
on a Wolff ball as near target.
• Now examiner slowly moves Wolff’s ball Interpretation: Normally, in children the
closer to the patient and simultaneously stress point should be 10 cm nearer than
observes that at what distance the Harmon distance of that subject, whereas
patient’s fundus reflex pops. normally in adults the stress point is 20–22.5 cm
away from the face. For example, suppose in
Note: A retinoscopy reflex is called popping reflex a 10 years old child, Harmon distance is
when reflex initially brightens, then becomes dull 22 cm and a stress point is 18 cm. When stress
and again becomes bright. point is measured again with add of + 1.0 DS
lens, the stress point becomes 14 cm, amount obtained at neutralization and if doing
whereas with add of +1.5 DS lens, it becomes from 50 cm, then +2 D is deducted from total
24 cm. In this case + 1.0 DS lens is serving as refractive error.
counterstress lens, whereas +1.5 DS lens is Wet retinoscopy: When mydriatic is used to
inducing a new stress pattern. Hence, we will perform retinoscopy, it is called as wet
prescribe + 1.0 DS lens for near work to this retinoscopy or cycloplegic refraction.
child. Normally in clinical practice tropicamide with
Monocular estimate method phenylepherine drops are used to perform
Monocular estimate method (MEM) is retinoscopy. These drugs produce pupillary
performed in an entirely different way than dilatation but are weak cycloplegics, hence
that from other methods of dynamic retino- when strong cycloplegic effect is needed as in
scopy. Most of the near dynamic retinoscopy cases of very young child or high degree
methods are performed by inserting a lens hypermetropes, then atropine, homatropine or
and its effect on the performance is obser- cyclopentolate is used. Here a correction is
ved. done for both distance and mydriasis, for
MEM is a distinctive method where lenses example, if retinoscopy is done from 66 cm
are principally used to confirm the observa- distance by using atropine, then +1.5 D for
tions done by the examiner. A fixation card is distance and +1 D for atropine is deducted
attached to the retinoscope and under normal from total refractive value obtained by
illumination conditions examiner views neutralization. For homatropine +0.75 D and
retinal reflexes through a central aperture from for cyclopentolate +0.5 D is deducted.
a distance of 40 cm.
Note: No correction for cycloplegic is needed
Techniques of Retinoscopy when tropicamide is used for retinoscopy.
• Dry retinoscopy
Retinoscopy Working Distance
• Wet retinoscopy
If retinoscopy is performed at 25 cm distance;
Dry retinoscopy: Most widely used technique the retinal reflex will be bright and it is easy
to perform the retinoscopy is dry retinoscopy. to reach the patient, but at the same time
Dry simply means that no mydriatic is used chances of the distance error is very high. If it
while performing the retinoscopy. Hence, a is performed at 100 cm distance, the retinal
correction from total refraction is done only reflex will be dim and it is difficult to reach
for distance, for example, if we are doing the patient for changing trial lenses, however,
retinoscopy from 66 cm distance, then simply the distance error is very low.
+1.5 D is deducted from the total refractive
As shown in Fig. 11.21 space (X) of 8 cm
width at 25 cm retinoscopy distance is
Clinical Inference
representing 1 D difference, whereas same
• In low degree hypermetropes dynamic retino- 8 cm space (Y) is representing only 0.09 D
scopy may show a rapid, complete but unsteady difference near 100 cm distance. So when
or discontinuous accommodation which confirms retinoscopy is done at 25 cm distance then an
a diagnosis of an accommodative insufficiency error of few centimeters in distance estimation
and should be treated by prescribing glasses. can bring a large change in results (by 0.50–
• In non-ocular causes a brisk normal dynamic 1.0 D), whereas a distance error of equal
retinoscopy response is present but if symptoms magnitude gives negligible change in results
persist then an addition of reading glasses (small (by 0.05–0.1 D) at 100 cm distance.
power) can be used in cases of a fallaciously Considering these advantages and dis-
normal dynamic retinoscopy.
advantages of near and far working distances,
Fig. 11.21: Retinoscopy distance (cm) with corresponding dioptric power (D)
most of the examiners compromise for a Reflexes in Hypermetropes

working distance of either 66 cm or 50 cm. Various reflexes seen in hypermetrope depend
These are practically convenient distances upon the degree of hypermetropia (Fig. 11.23).
with a suitably bright retinal reflex. 66 cm is In low degree hypermetrope the retinal reflex
nearly an arm’s length and the dioptric value is of small width and fast moving “with
deducted is +1.5 D, whereas 50 cm is a distance motion”, however, as the degree of hyperopia
roughly equal to a bend arm’s length and increases the width of reflex increases and
dioptric value deducted is +2 D. speed of reflex decreases.
This ‘with motion’ can easily be neutralized
Routine Retinoscopy Reflexes
by using a plus lens whose power depends
Reflexes in Emmetropes upon the degree of hypermetropia. For
Normally when retinoscopy is performed example, as shown in Fig. 11.24, a hyper-
from 66 cm distance, an emmetrope will metrope of +1 DS will get neutralize by adding
produce “with movement” in both vertical a +2.5 DS lens when retinoscopy is done from
and horizontal meridians. These reflexes can 66 cm distance (without cycloplegic drug).
be neutralized by small power plus lenses
as shown in Fig. 11.22. For example, with
+1.5 DS lens because retinoscopy was done
from 66 cm.
Fig. 11.23: With motion
Fig. 11.22: With motion getting neutralize with small Fig. 11.24: Neutralization with +2.5 DS lens, in case
power plus lens in emmetropia of +1 DS hypermetropia
Reflexes in Myopia in different meridians. For example, in case of

Similar to hypermetropia various reflexes are simple hyperopic astigmatism the retinal
seen in myopes depending upon the degree reflex may be neutral in 90° meridian and will
of myopia. In low degree myopia the retinal be ‘with motion’ in 180° meridian as shown
reflex is small width and fast moving ‘against in Fig. 11.27.
motion’, however, as the degree of myopia Here the light rays emerging from retina
increases the width of reflex increases and are refracted in a different way by the
speed of reflex decreases, although it still principal meridians of the cornea, hence
remains an against motion as shown in reflexes behave as if there are two eyes
Fig. 11.25. instead of one eye and each of these principal
This against motion can be neutralized by meridians is acting like a separate eye. Once
using a minus power lens whose power the retinoscopy has been performed on the
depends upon the degree of myopia. For eye with one principal meridian, then simply
example, as shown in Fig. 11.26, a myope of repeat the retinoscopy second time on the
–3 DS will get neutralize by adding a –1.5 DS same eye.
lens when retinoscopy is done from 66 cm Several phenomena observed while
distance (without cycloplegic drug). performing retinoscopy in case of astigmatism
are
Reflexes in Astigmatism
• Eye will show two types of reflexes one
Astigmatism is a state of refractive error where
in each principal meridian as shown in
a few rays of incident light focus on the retina
Fig. 11.27.
and a few behind or in front of the retina.
Hence, when retinoscopy is done we get • Retinal reflexes will have different speed,
different kind of movement of retinal reflexes width and brightness in both principal
meridians.
• Movement of retinal reflex will not be
parallel to the movement of retinoscope
intercept; unless scoping along the principal
meridian.
• Both principal meridians cannot be
neutralized by a single correcting lens.
This simply means that there are two
focal points.
Various types of astigmatic error will show
Fig. 11.25: An against motion in myopia following reflexes when retinoscopy is done
Fig. 11.26: Neutralization with –1.5 DS lens, in case Fig. 11.27: Astigmatic reflex. A. Neutral reflex at
of –3 DS myopia 90 meridian; B. With motion reflex at 180 meridian
using working lens of +1.5 DS (compensating

for a retinoscopy distance of 66 cm) in the trial
frame.
• In case of an uncorrected simple hyper-
metropic astigmatism, one focal point
lies at peephole of retinoscope and other
is behind it. For example, a neutral
reflex at 90° meridian and with motion
in 180° meridian will be seen when Fig. 11.28: Uncorrected simple hyperopic astigma-
retinoscopy is done from 66 cm distance tism
using a working lens of +1.5 D as shown
in Fig. 11.28.
• In case of an uncorrected compound
hypermetropic astigmatism both focal
points are behind retinoscope, so ‘with
motion’ in both meridians will be seen
when retinoscopy is done from 66 cm
distance using a working lens of +1.5 D
as shown in Fig. 11.29. However, in our
example, the reflex will be more with
motion at 180° meridian. Fig. 11.29: Uncorrected compound hyperopic
• Uncorrected simple myopic astigmatism astigmatism
cases are similar to simple hyperopic
astigmatism, except that in these cases
one focal point is in the front and another
point is at peephole. Hence, for example,
in these cases ‘against motion’ at
90° meridian and neutral reflex at 180° meri-
dian will be seen when retinoscopy is done
from 66 cm distance using a working lens
of +1.5 D as shown in Fig. 11.30.
• Uncorrected compound myopic astigma-
tism is a state of eye where both focal Fig. 11.30: Uncorrected simple myopic astigma-
points are in front of the retinoscope tism
peephole. Hence, in these cases ’against
motion’ in both 90° and 180° meridians
will be seen when retinoscopy is done
from 66 cm distance using a working lens
of +1.5 D as shown in Fig. 11.31, although
there is more against in 90° meridian in
our example.
Note: Practically during retinoscopy it is very
difficult to judge the degree of against motion.
• In case of an uncorrected mixed
astigmatic one focal point is in front and Fig. 11.31: Uncorrected compound myopic astigma-
other point is behind the peephole of tism
Reflexes of Rare Types

• Scissor movement on retinoscopy means
when one arm of retinal image is moving
in opposite direction to that of other arm of
retinal reflex, like the blades of scissor. Most
of the time these images are difficult to assess,
but on careful examination one can see that
there are two arms of retinal reflex as shown
in Fig. 11.33. Usually one arm is thicker and
show ’with movement’, whereas other arm
will be thin and have ’against motion’.
Fig. 11.32: Uncorrected mixed astigmatism • Oblique movement on retinoscopy means
retinoscope. On retinoscopy ’against movement of reflex is not in coordination
motion’ in one meridian and ’with with our retinoscope intercept. In these
motion’ in other meridian, i.e. 90 degree cases when intercept of retinoscope is
and 180 degree meridians, respectively moved either horizontally or vertically the
(in our example) will be seen when retinal reflex moves oblique to the
retinoscopy is done from 66 cm distance movement of intercept either in ‘with’ or
using a working lens of +1.5 D as shown ‘against’ motion. Retinal reflex in these
in Fig. 11.32. cases will appear as shown in Fig. 11.34.
• No movement on retinoscopy examination
Rare Retinoscopy Reflexes is considered when practically almost entire
pupillary area is filled with reflex and
Reflexes in Pseudophakia examiner cannot see the boundary of retinal
Pseudophakia is a state of eye where an reflex easily. When observer try to move the
intraocular lens is implanted inside the eye streak of retinoscope in any meridian, say
after cataractous lens has been removed horizontal or vertical, no appreciable
surgically. The retinoscopy images seen in movement of retinal reflex will be seen.
these cases are of different types. There may Clinically, these reflexes are very confusing
be ‘with motion’ or ‘against motion’ or may and appear as shown in Fig. 11.35.
have mixed movements of retinal reflex.
Examiner needs to closely observe these
reflexes to neutralize them, a wet retino-
scopy is preferred over dry retinoscopy in
these cases.
Reflexes in Aphakia
Aphakia is a state of eye where cataractous
lens is removed surgically without implanta-
tion of an intraocular lens. The retinal reflexes
seen in these cases are similar to those seen in
high hypermetropic cases. In aphakia very
slow moving, wide width and dull image is
seen, when high plus lenses, say +6–7 D are
added then the speed, brightness of reflex
increases and width decreases (similar to a
hypermetropic case). Fig. 11.33: Scissor reflex
Fig. 11.34: Oblique retinal reflex Fig. 11.36: Centrally dark retinal reflex
the location of focal point relative to the

observer’s eyes, i.e. it is in front or behind
the observer.
• Then it is important to judge the amount of
’with’ or ’against’ movement to decide how
far the observer is from neutrality point.
Certain identifiable characteristics of
moving reflex will help in the estimation of
distance from neutrality.
• Indirectly this will help to decide how much
correcting lens power will be needed to
move the focal point in conjugate to our
retina.
Fig. 11.35: Dim retinal reflex Note: This experience in rough estimation of lens
power will save much trial and error, and will
• Centrally dark reflex on retinoscopy means shorten the time to reach at neutrality.
that a dim retinal reflex is seen only on sides
of pupil margins and the central area of The moving retinal reflex can be characterized
pupil is dark, which shows no reflex. In by three main features
these cases bend the retinoscope streak to Speed: Depending on the distance from focal
study the characteristics of these kinds of point, the retinal reflex moves very slowly
reflexes, also examiner can lean forward to when retinoscope is situated far from the focal
enhance the brightness of reflex (Fig. 11.36). point and it becomes more rapid as
retinoscope gets closer to focal point. When
Interpretation of Retinal Reflexes
neutrality point is reached, the pupil fills with
Routine Images light reflex and no movement of retinoscope
To study the reflex in routine refractive error streak is seen. In simpler words, large degree
cases these steps must be followed by an observer refractive errors will have a slow moving
• First decide whether retinal reflex is ‘with’ retinal reflex and small degree refractive errors
or ’against’ movement which is decided by will have a fast moving retinal reflex (Fig. 11.37).
Fig. 11.37: Speed and brightness of reflex at various intervals in relation to position of retinoscope
Brightness: The retinal reflex will appear refractive error gets neutralized as shown in
dull when retinoscope is situated far from Fig.11.38.
the focal point and it will become brighter However, in clinical practice these
as examiner approaches at the neutrality characteristic of reflex may be sometimes
point. Hence, refractive errors of large misleading in nature. For example, when
degree will have a dull reflex and small retinoscope is situated very far away from
degree refractive errors will have a brighter neutrality point then the retinal reflex appears
reflex (Fig. 11.37). to become widen as if approaching the
neutrality as discussed above. This state is
Note: In Fig. 11.37 against portion is shown as termed pseudoneutrality and is commonly
cross-hatched because against retinal reflex is
seen in very high degree of refractive errors,
dimmer as compared to with reflex at any
comparable distance from the focal point.
means when position of the retinoscope is a
long way from the focal point.
Width: The width band of retinal reflex in the However, with continuous practice of
pupillary area is narrow when retinoscope is retinoscopy it becomes easy for examiner to
situated at a far distance from the focal point, find out the distance of focal point as observer
width of the band broadens as the observer becomes able to judge speed, brilliance and
approaches near the focal point and ultimately width of retinal reflex simultaneously. For
reflex width will fill the entire pupil when the example, when examiner notices enough ’with
Fig. 11.38: Change in width of retinal reflex with distance of retinoscope

movement’ having vast width and moving whether there is any change in the reflex
slowly, automatically he/she will add a lot of movement or not. If it is a case of very
plus lenses to drag the focal point towards high error, then definitely a recognizable
retinoscope. On the other hand, if a little reflex will be seen after adding of strong
‘against’ small width and fast moving reflex lenses.
is seen then he/she will add a little minus • Neutrality disguise. These are also called
lenses to push out the focal point. as motionless reflex (pseudoneutrality)
which covers the full pupillary area,
Rare Images means mimicking as if observer is
Sometimes detection of high refractive errors approaching the neutrality point. To
appears difficult by retinoscopy, however, it confirm this type of disguise simply
is not so difficult. Once the examiner is able move forward about 15–20 cm and now
to identify the type of error and does again assess the movement. If the
retinoscopy after partially correcting them, characteristics of reflex do not change,
then these error starts appearing as routine means we are not near to neutrality, now
small refractive errors and examiner can easily add the strong plus or minus lenses to
neutralize these errors as routine reflexes. For check whether there is any movement.
example, suppose if an aphakic patient is If high refractive error is present, then
presented to clinic for retinoscopy. Patient is there will be a definite reflex movement
already wearing a +11 DS power spectacles after adding the strong power lenses
and still is not able to see clearly. On (Fig. 11.39).
retinoscopic examination, the retinal reflex Various retinal reflexes encountered during
seen in this patient is peculiar and it is little regular retinoscopy examination and their
difficult to assess the movement or margins interpretation is shown in Table 11.1.
of reflex. Simply, add + 8 or +9 D spherical
lens in the trial frame (as the patient is aphakic) Neutralization of Various Reflexes
and again observe the retinal reflex. Now it Neutralization State
will be a nice smooth with reflex which can
Neutralization state is defined as the state
easily be neutralize by adding more plus
achieved when the focal point of the emerging
power lenses gradually.
light lies at the peephole of retinoscope. At this
It is very important to recognize presence
of high spheric error because sometimes they
may remain unrecognizable due to presence
of
• Hazy media disguise: In presence of hazy
media, the high degree errors may
present either as no reflex or a very dull
reflex showing no appreciable movements.
When examiner place either a weak plus
or weak minus lens and notices that there
is no change in the reflex, then probably
it is a case of an opaque media. However,
when these types of situation are
encountered during retinoscopy, then
simply add strong plus lenses or minus
lenses up to the power of 5.0 to 7.0 D
directly. Reassess the retinal reflex Fig. 11.39: Retinal reflex showing neutrality disguise
Table 11.1: Routine retinal reflexes and their interpretations

Retinal reflex Characteristics Interpretation
Small width fast moving bright with Emmetropia or Hypermetropia/Myopia

reflex (less than 1D)
Small width fast moving very bright Myopia

against reflex
Medium width medium speed bright Hypermetropia

with reflex
Medium width medium speed bright Moderate degree myopia

against reflex
Large width slow moving dim with High degree hypermetropia

reflex
Large width slow moving dim against High degree myopia

reflex
Medium width medium speed dim High degree astigmatism usually regular
reflex oblique to retinoscope streak type
Very large width no appreciable High degree hypermetropia or myopia/

movement very dim reflex Aphakia
Two reflexes moving against each High degree irregular astigmatism, e.g.
other like blades of scissor one bright keratoconus
with and one dim against reflex
point the movement of reflex is not seen and retinoscope while simultaneously remains at
is called neutral reflex. Trial correcting lens the working distance.
which is applied by the examiner to achieve Figure 11.40 tells about the approach which
this state of neutralization is the measurement should be followed by the examiner to achieve
of error of refraction. Hence, to achieve the this point of neutralization, while maintaining
state of neutrality the aim of the examiner is the working distance. If the examiner with
to bring the focal point to the peephole of retinoscope is situated in the cone of emerging
Avoid against movement: Practically while

neutralizing any retinal reflex, ‘against
motion’ creates more difficulty than ‘with
motion’ so always try to avoid these against
motions.
Study these following reflexes carefully:
As shown in Fig. 11.41B that ’against
motion’ appears first at the side of pupil
opposite to the streak of retinoscope. When
streak is moved across the pupil, this reflex
moves in a reverse direction across the entire
pupil and finally get disappear on the opposite
side of the retinoscope streak. Because of this
Fig. 11.40: Achieving neutralization state opposite, fast and disappearing property of
‘against motion’, it is difficult to quantify the
light (Fig. 11.40) and the focal point is behind three basic characteristics (speed, brilliance
the examiner (Fig. 11.40A). Now as the and width) of reflex with ‘against motion’. For
examiner adds the convex lens, the focal point example, speed of the reflex cannot be
starts moving towards retinoscope and the assessed easily when it moves in a reverse
retinal reflex gradually gets widened (Fig. direction. Similarly, as the ‘against motion’
11.40B). After adding another plus power lens moves always away from the illuminated
as the focal point reaches to the peephole of retina, its brightness is reduced and hence
retinoscope, then the retinal reflex will fill the reflex margins become hazy. Because of these
entire pupillary area and no movement can blurry reflex margins, the width of the reflex
be appreciated. This is called the neutraliza- is also difficult to appreciate clearly.
tion state of reflex (Fig. 11.40C).
Note: In case of ‘with motion’ plus lenses are added;

because the focal point lies behind the retinoscope
and we need to pull it towards the peephole of
retinoscope. On the other hand, in case of ‘against
motion’ minus lenses are added, because the focal
point lies in front of the retinoscope and we need to
push it towards the peephole of retinoscope.
Although in routine practice of retinoscopy

especially for beginners it is difficult to
approach the neutralization state from ‘against
motion’. To simplify this, one can overcorrect
‘against motion’ by adding extra minus lenses
so that the retinal reflex gets converted into
‘with motion’. Now this ‘with motion’ can be
neutralized by adding plus (means reducing
minus) lenses, in smaller steps, say 0.25 D
power. This approach to achieve neutraliza-
tion is superior and easier as compared to Fig. 11.41: Reflex movement. Compare retinoscope
neutrality achieved by gradually increasing streak with retinal reflex and notice both types of
the power of minus lenses. movements: A. With motion; B. Against motion
Another problem with ‘against reflex can be elucidated with the help of a lens power
motion’ is that it also poses difficulties during wheel (Fig. 11.42) used in a lensometer.
neutralization. The movement of ‘against Rotation of this wheel in clockwise direction
motion’ opposite to streak of the retinoscope from any point will result in increase of minus
appears highly irregular especially, near power or decrease of plus power, while
neutrality state. ‘Against motion’ is usually opposite occurs when rotated in counterclockwise
dull, confusing, difficult to evaluate and direction, i.e. increase of plus or decrease of
measure, hence a general concept is that minus power. The signs and numbers
“when observer is unable to identify the type mentioned on this wheel are irrelevant, only
of reflex, then it is taken for granted that it is the direction of rotation of wheel has value.
against reflex”. Thus, either neutralizing case of myopia or
On the other hand, as shown in Fig. 11.41A a hypermetropia, the basic principle of
‘with motion’ reflex can be identified easily neutralization remains the same. In case of
and is more feasible. The ‘with reflex’ is bright, ‘with motion’ the plus power lenses are added
crispy, rarely confusing and can be assessed to increase the convergence of emitting light
without difficulty. A ‘with motion’ is highly rays until there is no movement of reflex.
dependable, easily agreeable and never contrary, Similarly, in ‘against motion’ minus power
hence one can quickly learn to recognize its lenses are added to increase the divergence of
degree, width and speed which helps to neutra- emitting rays until ‘with movement’ is seen
lize it faster and accurately. Therefore, whenever (then reduce the divergence of rays until
performing retinoscopy always first recognize neutralization state is reached).
‘with movement’ if by chance ‘against motion’ “With motion is key to the neutrality or
is seen, then immediately convert it into ‘with endpoint of retinoscopy and the power of lens
motion’ by adding minus lenses. with which it is achieved is the measure of
“Always work with a WITH and against an refractive error”.
AGAINST”
Interpretation of Neutrality
Rules to be followed to Achieve Neutralization In reality, neutrality is not a point rather it is
Rule 1: Suppose if ‘with motion’ is observed, area or zone created as a result of spherical
then add plus lenses or reduce minus lenses aberrations and many other factors. Size of this
until neutralization is attained. zone varies with the size of pupil and working
distance.
Rule 2: Suppose if ‘against motion’ is observed,
then add minus lenses or reduce plus lenses
until ‘with motion’ is seen and then follow the
rule 1 for neutralization.
Rule 3: For neutralization, always use plane
mirror or keep sleeve up at working distance.
In the abovementioned rules the terms add
plus (or minus) lenses or reduce minus (plus)
lenses have been used. Remember the fact that
“adding plus power is the same as that of
reducing minus power or vice versa”. By doing
this basically we are changing the vergence of
the emerging light rays which depend on the
starting point. This concept can be understood Fig. 11.42: Lens power wheel showing dioptric
by phenomenon of dioptric continuity which continuity
Fig. 11.43: Neutral zone; spherical aberration causes nearer focal point FP1 for axial rays, and a distant
focal point FP2 for peripheral rays
Size of pupil: The width of neutral zone is examiner is unable to assess the movement
directly proportional to the size of pupil. As and position of the reflex within this neutral
the size of pupil increases, the width of this zone. Easiest way to avoid this confusion and
neutral zone also increases. In Fig. 11.43, we stay in a safe (with) zone is to make a judgment
can see that there is no pupil in the eye thus of neutrality just before the doubt of
the zone of neutrality is magnified due to movement begins as shown in Fig. 11.45.
spherical aberration. Axial rays are focused in In a nutshell accurate judgment of a
nearest focal point (FP1) and peripheral rays neutrality state is a skill and basically it is to
on distant focal point (FP2). While doing judge a point just before the zone of doubt
retinoscopy on a dilated pupil, always appears, means there is still a weak ’with
concentrate only on the central pupillary reflex movement’. At this point when observer
and avoid the peripheral aberrations. leans forward with retinoscope a definite and
Working distance: Width of neutral zone is clear ’with motion’ will be seen and if bend
narrowest when the working distance is backwards then in the beginning an uncertain
closer, however, if the neutral zone is very type of reflex movement and on further
narrow, then an accurate estimation of retinal leaning backwards a confusing reflex
reflex and working distance becomes so suggestive of an early ’against motion’ will
significant that even a minor inaccuracy may be seen.
produce a major error in evaluation.
Various Neutralization Methods
As shown in Fig. 11.44, that there is a
significant amount of doubt within the neutral Retinal reflex can be neutralized by either only
zone. Examiner remains indecisive about the spherical lenses (in cases of spherical and/or
presence or absence of reflex, similarly astigmatic errors) or by a combination of
spherical and cylindrical lenses (in case of
astigmatic error).
Fig. 11.44: Doubtful motion within neutral zone Fig. 11.45: Point of judgment for neutrality
Neutralizing with Only Spherical Lenses This can also be represented as gross sphere
To understand the neutralization with use + 4 Dsph × 90° + 6 Dsph × 180°
of only spherical lenses, consider an example Deduction for the working distance (66 cm
where on retinoscopy at 66 cm ‘with motion’ or +1.5 DS in our example) from this gross
at 90° and a larger width slower moving refraction will give +2.5 D × 90° +4.5 D × 180°
‘with motion’ at 180° is seen as shown in net refraction value.
Fig. 11.46.
Note: Always reduce the working distance from
Now place a plus spherical lens (say +4 DS) gross sphere in both the meridian spheres.
at the 90° meridian (having lesser ‘with
motion’) to neutralize this meridian. Now, on It is important to understand that when
doing retinoscopy having +4 DS lenses in neutralization is done using only spheres, it
vertical meridian (90°) no reflex movement is is necessary to measure and record the
seen, whereas horizontal meridian (180°) will spherical value of the first meridian before
still show ‘with motion’. Continue to add plus performing retinoscopy for the second
spheres till this horizontal meridian becomes meridian. Hence, in the above example, when
neutral. Suppose after adding an additional 90° meridian is reexamined after completing
+2 D sphere (above +4 DS) 180° meridian also the neutralization in 180° meridian, this
gets neutralized. These retinoscopy values will 90° meridian will show ‘against motion’
be recorded in the form of a retinoscopy cross because now it is overcorrected by +2 DS. In
as shown in Fig. 11.47. cases of compound refractive errors when
neutralization is done with only spheres both
the meridians will not be seen as neutral at
the same time.
Neutralization with only spheres is a good
technique for children, as they resist wearing
trial frame and it is practically very difficult
to hold the cylindrical lens on its axis or hold
two lenses for a longer duration. A lens rack
as shown in Fig. 11.48 is particularly useful
Fig. 11.46: Retinoscopy showing with motion at 90° while performing this retinoscopy method in
and more with motion at 180°
clinic or when doing refraction under
anesthesia.
Fig. 11.48: Lens racks. Red color racks have minus

Fig. 11.47: Diagrammatic representation of lenses and black color has plus lenses. (courtesy:
neutralization with spheres Bernell Corporation)
Neutralization with Spheres and Cylinders Streak Meridian Versus Corneal Meridian
Consider the same example as discussed In reality, the orientation of retinoscopic
above, where 90° meridian gets neutralized reflexes does not correspond to corneal
with +4D sphere, which is considered as meridians. For example, the reflexes seen at
spherical meridian. As per our previous 180° or horizontally on retinoscopy in reality
discussion, spherical lenses produce power in are produced by the 90° corneal meridians and
all meridians, hence this +4 DS power (in our vice versa. In other words, retinoscope streak
example) is also working in 180° meridian actually tests the power of corresponding
(which is still having ‘with movement’). Add corneal meridian. If retinoscope is scooped
a +2 D cylinder at 180° axis to neutralize this vertically, i.e. retinoscope streak is at 90° and
‘with movement’. By adding + 2 D cylinder at examiner is moving the retinoscope sideways
180° axis (horizontal meridian) there is no to judge the movement of reflex, then actually
change in the reflex movement at 90° meridian examiner is evaluating the refractive power
because cylindrical lenses exert power only in of the eye at horizontal or 180° corneal
one particular axis. This 180° meridian is meridian. Hence, when a cylinder is placed
considered as cylindrical meridian. vertically or at 90°, it is going to neutralize the
After neutralizing the principal meridians power of eye at 180°, i.e. perpendicular to the
independently when the streak of retinoscope cylinder axis which in reality is the corneal
is rotated, both the meridians now appear meridian needed to be corrected in this
neutral and show no movement of retinal reflex. example.
This is more accurate method to neutralize If 90° corneal meridian (say +47 D) has focal
compound refractive errors because both the point at the peephole of retinoscope, then a
meridians can be seen neutral at the same time. neutral reflex will be seen, when the streak is
In our example the gross refraction or lenses horizontal (testing for 90 meridian). If 180°
in front of eye are +4 DS/+2 DC × 180°. corneal meridian has only +44 D, so it will
Always write the spherical power first and show a 3 D with motion when streak is
then the cylindrical power with axis. As this vertical (testing for 180 meridian). Adding
is the gross refraction deduct the working +3 DC at 90°, will in reality add power at 180°
distance of 66 cm, i.e. +1.5 D from spheres only thus it will neutralize the reflex seen at 90°
to get the net refraction +2.5 DS/+2 DC × 180°. (Fig. 11.49).
Although it all looks a little confusing, a
Universally the spherical and cylindrical
simple rule to remember is that “simply place
powers are written in this order hence this net
refraction can also be conveniently written as
+2.5/+2 × 180° (without any power abbrevia-
tions).
Note: No correction for working distance or

cycloplegic is done from the cylindrical power.
Many readers may get confuse that as cylin-

drical power works on an axis perpendicular
to its position, then why a plus cylinder is
added at 180° to neutralize the ‘with motion’
at the same axis rather it has to be applied at
90° so that cylindrical power will be applicable
at 180°. To understand this study the streak meri- Fig. 11.49: Effect of corneal meridians on emerging
dians and corneal meridians are discussed below. rays.
a plus cylinder in the same axis where there is each other, i.e. 90° and 180° and so on.
with movement”. Hence it is very comfortable These can be corrected by cylindrical
to neutralize compound refractive errors with lenses because they also have their
a plus cylinder system. Once spherical principal meridian perpendicular to each
meridian is neutralized, place the cylindrical other. For example, if a plus cylinder is
axis of trial cylindrical lens on the same axis placed with its axis in alignment with
as that of remaining with reflex axis, this will that of most refracting or stronger
correct the corneal cylindrical axis properly. meridian, then it will add power to the
weaker meridian. Hence, when the
Ocular Meridians correcting cylindrical lens placed in
Ocular meridians universally are defined from proper axis, which equals the corneal
1 to 180 degrees in both the eyes as shown in cylinder, then the meridians gets balance
Fig. 11.50, there is no meridian labeled as ‘zero’ and astigmatism gets neutralized, as a
and there is nor any angle larger than 180°. spherical condition of eye had been
Traditionally, right eye is abbreviated as OD created by balancing the corneal cylinder
(oculus dexter) and left eye as OS (oculus with cylindrical lens power.
sinister). • In an irregular astigmatism principal
meridians are not perpendicular to each
Neutralization in Astigmatic Errors other; hence they cannot be neutralized
As discussed before astigmatism is a with cylinders alone. These conditions are
phenomenon when the entire light rays do not usually caused due to corneal irregularities.
refract to a single focal point. In aspheric eye • An oblique astigmatism is simply a
all the ocular meridians refract the light regular astigmatism, where principal
differently because corneal surface is toric in meridians are perpendicular to each
nature. Ocular meridians which refract the other, but are not usual (90°/180°) and it
light maximum and minimum are called should not be confused with irregular
‘Principal meridians’. Each of these principal astigmatism. The principal meridians are
meridians focuses the arriving light rays to a tilted, for example, at 45°/135°. These can
different point of focus at the back of the eye, be neutralized with cylinders similar to
which are called principal foci. These principal a regular astigmatism.
foci may be in front of the retina, on the retina • ‘With the rule’ astigmatism is referred to
or behind the retina; but for retinoscopy it is a condition where correcting plus
immaterial. cylindrical axis is more or less vertical,
Neutralization of various types of astigmatic i.e. between 75° and 105°. ‘Against the
errors is done as rule’ astigmatism refers to a condition
• In regular astigmatism the principal where the correcting plus cylindrical axis
meridians are perpendicular or 90° to is more or less horizontal, i.e. 15° to 165°.
These conditions generally describe the
location of most refracting corneal
meridians and hence the axis of its
accompanying plus cylindrical lenses.
• Symmetrical astigmatism is a condition
where the total axis of correcting
cylinders of both the eyes equals to 180°;
means, for example, OD 70° and OS 110°.
These can be corrected by cylindrical
Fig. 11.50: Ocular meridians lenses easily as in regular astigmatism.
• Asymmetrical astigmatism is a condition

where the axis of cylinders of both the
eyes has no rule, means, for example, OD
75° and OS 25°. These conditions are not
abnormal but are rare, hence whenever
such conditions are encountered try to
reevaluate the retinoscopy.
Note: Usually in younger people the most refracting
corneal meridian is vertical and in older people it is
horizontal, means over the years of age a young
person having ’with the rule’ astigmatism will
develop an ’against the rule’ astigmatic in older age. Fig. 11.52: Simple myopic astigmatism
out the focal point of myopic meridian (90°)

Simple astigmatism whether it is simple
and neutralize it. This minus sphere has also
hypermetropic or simple myopic are in fact
pushed out the focal point at 180° meridian
simple to neutralize because one of the
and converted it into ‘with motion’ which was
principal meridians is already neutral at
initially neutral. Now add plus cylinders at
working distance and second meridian can
180° meridian to neutralize this with move-
easily be neutralized by either plus or minus
ment.
cylinder.
Compound astigmatism is a condition
Figure 11.51 represents example of simple
where neither meridian is neutral at
hypermetropic astigmatism where one
working distance of 66 cm (keeping working
principal meridian, say 90°, is neutral and
lens in position). This could be of following
other principal meridian, i.e. 180°, is showing
types
‘with motion’ at working distance of 66 cm
(keeping working lens in the position). We • Compound hypermetropic astigmatism
simply need to add a plus cylinder at 180° with • Compound myopic astigmatism
gradual increasing in power until with motion • Compound mixed astigmatism
gets neutralize. These conditions seem difficult to neutra-
Figure 11.52 represents an example of lize, but simply the rules of neutralization are
simple myopic astigmatism where 180° followed to convert these three conditions first
meridian is ‘neutral’ and 90° meridian is into simple hypermetropic astigmatism and
showing ‘against motion’ at working distance then neutralize them accordingly.
of 66 cm (keeping working lens in the Compound hypermetropic astigmatism
position). Neutralization in this case is a little (Fig. 11.53) can easily be neutralized because
complicated, first add minus spheres to push
Fig. 11.51: Simple hypermetropic astigmatism Fig. 11.53: Compound hypermetropic astigmatism
both the principal meridians are having a

‘with motion’ although of different amount.
First add plus spheres until the weaker or least
with meridian (spherical meridian) becomes
neutralized. Now add plus cylinder to
neutralize the stronger with meridian
(cylindrical meridian). Now rotate the streak
of retinoscope in both the directions to confirm
that both the meridians are neutral.
In compound myopic astigmatism (Fig. 11.54)
both the principal meridians show ‘against Fig. 11.55: Mixed astigmatism
motion’, and it is difficult to assess which
meridian is more against or stronger. First add To summarise the principles of neutraliza-
strong minus spheres to push out the focal tion
points beyond retinoscope, this gives a • First neutralize the least hypermetropic
friendly ‘with motion’ in both the meridians. or most myopic meridian with appro-
Now simply proceed as in the case of a priate spheres, means first neutralize the
compound hypermetropic astigmatism. meridian having focal point closer to
Slowly reduce the minus spherical powers or patient’s eye.
add plus spherical powers, until first meridian • Now neutralize remaining most hyper-
(more myopic) gets neutralize, add plus metropic or least myopic meridian by
cylinders in the opposite meridian (least using plus cylinders, because this meri-
myopic) to neutralize the remaining ‘with dian will always show ’with movement’
motion’. means fill the remaining astigmatic
Mixed astigmatism (Fig. 11.55) is a interval by using plus cylinders in the
condition where both ‘with and against opposite meridian which has a focal
movement’ are seen in different meridians. point farthest from patient’s eye.
First add minus spheres until ‘against
movement’ becomes ‘with movement’, then Note: However, in these illustrations the actual
slowly reduce the minus spherical power or amount of refractive error is not mentioned,
add plus spherical power to neutralize this because while performing the retinoscopy amount
of refractive error is immaterial. Simply neutralize
meridian. Once this is done, then the
the reflexes in all the meridians and get the gross
opposite meridian having ‘with movement’
refraction, then deduct the values of working
can easily be neutralize by using plus distance and cycloplegic (if used) from gross
cylinders. refraction and one can get the actual amount of
refractive error.
Estimation of Cylindrical Axis and Power

Estimation of Cylindrical Axis
To understand the direction of cylindrical axis
four properties of retinal reflexes are needed
to be studied such as
• Break
• Width
• Intensity
Fig. 11.54: Compound myopic astigmatism • Skew
To follow these properties understanding

of the enhancement phenomenon of retinal
reflex is important. The position or height of
the retinoscope sleeve at which the fundus
reflex seen is brightest, sharpest and narrowest
is called enhancement position. Usually small
cylindrical powers are seen well when
retinoscope sleeve is up, i.e. plane mirror
effect. On the other hand, large cylindrical
powers are best enhanced when sleeve is
down, i.e. concave mirror effect.
Image of retinoscope streak on the surface
of eye is called intercept. In low cylindrical Fig. 11.57: Phenomenon of break
powers the retinal reflex is narrowest when
axis, i.e. on XX’ axis (at 90° in our example) in
intercept is wide, while in high cylindrical
Fig. 11.57B. We will place the correcting
powers the reflex is narrowest when intercept
cylindrical lens on this axis for neutralization
is narrow as shown in Fig. 11.56.
in trial fame. To practice, adjust the retino-
Break: When retinoscopy streak is off axis, i.e. scopy sleeve at enhancement position and
not on the correct astigmatic axis (XX’ in our rotate the sleeve about 15° on either side of
example), then a break is seen. Here, intercept XX’ axis, i.e. at 75° and 105°. A break which
and streak are not parallel, hence a broken line will be more clear at the extremes of this arc
is formed which can easily be observed by (i.e. 75° and 105°) will be seen and it will be
rotating the retinoscopy streak on either less appreciable when examiner approaches
sides of astigmatic fundus reflex as shown near XX’ axis, i.e. 90°; and no break in intercept
in Fig. 11.57A. will be seen exactly at 90°.
This break will disappear when intercept
and retinal reflex become parallel, means Thickness: Thickness of retinal reflex modifies
retinoscope streak is on the correct astigmatic when examiner rotates the streak on either
sides of the correct astigmatic axis. The reflex
is narrowest when the streak of retinoscope is
on the correct axis and becomes wide as it
moves away from the correct axis. For example,
if astigmatic axis is 115° (XX in Fig. 11.58), then
the width of retinal reflex will change as
retinoscope move on either sides of correct
axis or will be narrowest at correct axis.
Note: To practice retinoscopy, enhance the retinal

reflex and rotate the streak on either side of 115°
(in our example for correct astigmatic axis) observe
the change in width of retinal reflex.
Intensity: Retinal reflex intensity varies to

some extent when examiner rotates the streak
off-axis and it will become very bright when
on the correct astigmatic axis. Although, this
observation is indistinct and is useful in
Fig. 11.56: Enhancement and midpoint position patients having low degree astigmatism,
(say 110 degree). Now when examiner moves

his/her head ‘against motion’ of retinal reflex
in comparison to retinoscope intercept will be
seen. This movement of retinal reflex in
comparison to movement of intercept is called
as skewed motion.
Note: All these four characteristics help in

determination of correct cylindrical axis. Break and
thickness of retinal reflex help in high degree
astigmatic errors, whereas intensity and skew
motion help in low degree astigmatic errors.
Fig. 11.58: Change in thickness of reflex Estimation of Cylindrical Power

because small cylinders cannot be enhanced, As discussed before, gradually widening of
whereas larger cylinders can be enhanced to pupillary reflex indicates that the point of
high brightness. neutralization is approaching. To estimate the
cylindrical power, first neutralization of
Skew: Skew is also called oblique motion and
spherical power is done and then the width
is used to refine the cylindrical axis in small
of retinal reflex in the astigmatic axis will give
power cylinders. In this case examiner does
a rough estimate of the amount of astigmatism
not rotate the retinoscope streak rather moves
and hence the power of cylinder requires for
his/her head or wiggle the retinoscope streak
neutralizing. As a general rule width of
in a 30° zone. Notice the movement of retinal
astigmatic reflex is inversely proportional to
reflex in comparison of intercept. Retinal reflex
degree of astigmatism; i.e. thinner the
will move parallel to intercept if streak is on
astigmatic reflex, larger will be the degree of
the correct axis and when the streak is off axis,
astigmatism.
the retinal reflex and intercept will move in
Low degree astigmatism cannot be
different directions.
enhanced, hence width of retinal reflex in
As shown in Fig. 11.59, consider that the
astigmatic axis gives an estimate of amount
correct axis of astigmatism is XX (90 degree),
of cylindrical power require to neutralize it.
but retinoscope streak is at somewhere X’X’
Whereas high degree astigmatic errors can be
enhanced, hence width of retinal reflex shows
a gradual narrowing along with decrease
width of intercept (Fig. 11.60). In these cases
the width of intercept required to enhance the
Fig. 11.60: Narrowing of retinal reflex width with

decreasing intercept width in cases of high cylindrical
Fig. 11.59: Skewed motion power
retinal reflex gives an estimate of amount of

cylinder which is required to neutralize the
reflex.
Note: Once a rough estimate of amount of

cylindrical power is obtained, then astigmatic errors
can be neutralized with routine technique with
keeping sleeve up. “An accurate location of
cylindrical axis cannot be achieved with an
incorrect cylindrical power; an accurate cylindrical
power cannot be achieved with an incorrect
cylindrical axis”.
Refining Cylindrical Axis and Power Fig. 11.61: Straddling meridians and respective
Refining Cylindrical Axis retinal reflex width
The method used to refine the cylindrical axis • In our example as shown in Fig. 11.61
is called straddling. In this technique the widening of reflex is occurring at 145° axis
correcting cylinder is placed in the axis and retinal reflex remains narrow at
obtained by neutralization methods as 55° meridian, then this 55° axis is called guide.
discussed above. Straddling meridians are Now to correct the axis error, turn the
situated at 45° away on either sides of the correcting plus cylinder axis towards 55°
astigmatic axis at which the examiner had (initially in 5° steps) means make 100° as 95°.
placed the correcting cylinders and needs to • Again check the straddling meridians and
be compared at sleeve up position. For example, see if there is any axis error or not.
if correct axis of astigmatism is at 90° and • If still there is an axis error, then slowly turn
examiner had placed the correcting cylindrical the correcting plus cylinder axis towards
lens axis at 100°, then the straddling meridians the narrow reflex axis (guide) in 2° steps
will be 55° and 145° as shown in Fig. 11.61. (means from 95° to 93°) and so on till there
is no difference in width of reflexes.
Refining Method
• Place the entire correction of cylindrical Refining Cylindrical Power
power in the position and perform As a rule an incorrect cylindrical axis will not
retinoscopy while comparing the width of give a correct cylindrical power and vice versa,
retinal reflexes in each straddling meridian. hence by rule first refine the cylindrical axis
• Slowly move back to about 10 cm distance by straddling method and then before refine
keeping retinoscope in the position and the cylindrical power. Once axis is refined the
again compare the width of retinal reflexes power of cylinders can easily be refined by
in straddling meridians by rotating the comparing the neutralization state in principal
sleeve. meridians. First neutralize the spherical
• Repeat this procedure by moving back at meridian and then refine the correcting
10 cm steps till there is widening or cylinder at the refined cylindrical axis.
neutralization in one of either straddling
meridians is seen. Neutralization of Rare Refractive Errors
• Note that whether widening is in 55° or 145° Scissor Reflex
axis. Because there is difference in width of Scissor movement will be considered when
reflex at the same distance, it means there retinal reflex has two arms joined one side
is an axis error. (usually nasally) and open on other side
(usually temporally). These two arms move

in opposite directions to each other when
examiner moves retinoscope streak in either
vertical or horizontal meridians.
• To neutralize this scissor reflex as shown
in Fig. 11.62, first see which arm is moving
in ‘with direction’.
• Then neutralize the movement of the arm
which is moving in ‘with motion’ of scope
by using plus spherical power lenses.
• Now focus on the remaining arm and
observe its movement, whether it moves
‘with or against’ the scope and what is the
meridian.
• If ‘with movement’ is seen then add plus
cylinder in the meridian where motion is Fig. 11.62: Scissor reflex
seen till there is no movement of reflex is
observed.
• If ‘against movement’ is seen, then add
minus cylinder in that particular meridian
of motion till there is no movement of reflex
is noticed.
• Note down the power of spherical lens and
cylindrical lens along with axis.
• Recheck both the arms of reflex for any kind
of movement.
Oblique Reflex
Oblique movement is seen when there is
astigmatism or compound refractive errors.
The reflex will move oblique to the scope.
• To neutralize this oblique retinal reflex (Fig. Fig. 11.63: Oblique retinal reflex
11.63) change the direction of retinoscope
meridian the movement becomes oblique.
intercept parallel to the oblique meridian
In these cases first neutralize the
in which the retinal reflex is moving.
horizontal meridian by plus spheres and
• Notice the movement of retinal reflex with change the scope parallel to other meri-
retinoscope movement. dian and see whether ‘with or against’
• If movement of reflex is ‘with’ streak, then movement. If see ‘with motion’ in oblique
add plus cylinder in that particular meridian, then add plus cylinders and if
meridian, till no movement of reflex is seen. ‘against motion’, then add minus cylinders
• If movement of retinal reflex is ‘against’ the to neutralize this remaining oblique
retinoscope streak, then add minus cylinder retinal reflex.
in the same meridian till no further • Note the spherical and cylindrical power
movement of reflex is noticed. of lenses with axis.
• Sometimes when we scope horizontally the • Recheck all meridians whether there is any
reflex movement is ‘with’ and in vertical residual movement present or not.
No Reflex Note: Sometimes dim reflex can be neutralized by

No reflex or very slow or dim reflex (Fig. 11.64) starting with addition of high plus spherical lenses,
is seen when very high refractive powers are especially in cases where adding quite high power
present. Always try to see the margins of this minus spherical lenses are unable to produce a
kind of reflexes, and if seen try to notice the clearer with motion.
movement of reflex with streak whether ‘with’
or ‘against’. Centrally Dark Reflex
• Suppose slow ‘with motion’ is seen, then Centrally dark reflex (Fig. 11.65) is seen in
add high plus spherical power lenses (say media opacity cases like cataract or corneal
+ 6 D) and again see the movement of reflex. opacities. Always dilate these patients for
Usually the retinal reflex becomes clearer, retinoscopy, because it is very difficult to
thinner and its movement can be apprecia- appreciate any kind of reflex centrally,
ted, if it is a case of high hypermetropia or however, after dilatation one can see some
aphakia. peripheral retinal reflexes.
• Suppose very dim retinal reflex is present • Try to see the sides of reflex motion, which
and no margins are seen, then try high is seen on the periphery of reflex and notice
minus spherical power lens (say–6D) and the movement.
again see the movement. • Suppose if ‘with motion’ is seen in
– If slow movement seen but not a clear periphery, add plus spherical power lenses
‘with motion’, then add more minus and if ‘against motion’ (rarely appreciable)
spherical power lenses, till movement is seen, add minus spherical power lenses.
becomes clearer and crisper with motion. • Neutralize all meridians by rotating scope
– Now add small power plus spherical lenses in vertical, horizontal and other meridians
to neutralize this clearer ‘with movement’. by basic principal of neutralization.
– Check other meridian and suppose ‘with • Note the power of neutralizing lenses and
motion’ is seen, then add plus cylinder recheck the movement.
in that particular meridian or if ‘against
motion’ is seen, then add minus cylinder Note: In majority of these cases even after dilatation,
retinoscopy is not easy and results are variable even
lenses till this movement is neutralized.
in an expert’s hand.
Fig. 11.64: No reflex or very slow or dim retinal

reflex Fig. 11.65: Centrally dark retinal reflex
Retinoscopy After Refractive Surgery for neutralization will be a dilemma for

Retinoscopy method remained constant since the examiner.
day of its origin, however; important advances • By experience one will know that when-
have been achieved in refractive surgery field. ever in doubt always concentrate on the
These new techniques have resulted in new reflex in the center of the pupil; a princi-
challenges by producing various kinds of new pal specifically used after corneal surgery.
retinal reflexes postoperatively. Development • When central reflex is identified and
of newer corneal procedures generated the point of neutralization is reached in the
possible need to re-evaluate the routine center of pupil, examiner may get
retinoscopy techniques. Many a times, after confused by seeing ‘with or against’
corneal refractive surgery, ambiguous reflexes in the surrounding cornea.
retinoscopic reflexes are seen depending on • Make sure to concentrate on the point of
the patient selection, type of procedure, and neutralization or neutrality reflex in the
complications arising after surgery (radial pupillary center because if examiner over
keratotomy, photorefractive keratotomy, refract this point an odd reflex will be seen
penetrating keratoplasty, etc.) which differs from “scissors” movement.
Nowadays, LASIK surgery is the most • This odd reflex becomes wider in one
commonly performed procedure for meridian and becomes narrower in the
correction of refractive errors. Depending on other meridian; and to some observers
various factors like use of different types of will appear as a “Guillotine effect”.
lasers, surgical techniques and instruments • Hence observe very carefully in the center
and patient’s cornea, LASIK surgery can and judge neutrality when central retinal
produce its own set of unique reflexes. reflex is still having a little ‘with motion’.
The optical zone of cornea (laser treated Rarely, surface reflections or glare from the
area) may differ in the geographic location and flat treated cornea may interfere in the
size. Moreover, the position of optical zone interpretation of fundus reflex and produces
may not align with the visual axis of eyes. Due difficulty in assessing the type of reflex. When
to all these variations, a number of possible this becomes problematic, just move the streak
reflexes may be seen in postoperative period. of retinoscope to sideways. This method will
In early postoperative period (say first week) decentre the retinal reflections from the centre
all these variables vary in nature. Continuous of pupil as shown in Fig. 11.66.
change of variables gives challenges to
ophthalmologist and makes their job much
more exciting as well as frustrating.
Refraction in post-LASIK patients is mainly
discussed, however, these principles can be
applied on other refractive surgery also done
on the cornea.
• Usually in first few days after procedure,
the good retinoscopic reflex of any type
is not seen and also no directional
indications are seen.
• Moving the retinoscope forward or
backward will give no result, however, Fig. 11.66: Refractor reflections (A) Glare seen when
sometimes examiner may see two or centered on axis. (B) High reflex on lens indicates
three distinct areas of retinal reflexes. Out that too high. (C) Ideal situation in which reflex is
of these reflexes which one to be used beside pupil.
First post-operative month after LASIK • Pin point the axis on the trial frame marking
appears to be most challenging and it is better by moving sleeve down for enhancing the
to wait till this situation subsides because as retinal reflex.
the corneal edema disappears, the retinal
Step 3: Place cylinder on axis
reflexes become sharper and one can easily
An estimated power cylinder is placed at an
interpret them.
approximate axis (the remaining with
Note: Always be sure to concentrate only on the meridian).
central and treated areas of cornea, while ignore Step 4: Refining of cylindrical axis
the reflexes from the peripheral rim of cornea, as Cylindrical axis is refined by straddling
they vary considerably. Never get confused by
method, i.e. move the sleeve up and then lean
these extra or contra-movements from corneal
periphery, simply focus on the central cornea.
forward, now gradually recede in straddling
meridians. Turn the cylindrical axis as per
Summary of Retinoscopy guidelines.
Any type of refractive error can be neutralized Step 5: Refining cylindrical power
via these six cardinal steps of neutralization. Move the retinoscope sleeve in up position
and lean forward; now recede gradually
Step 1: Use spheres comparing the reflex in principal meridians.
• Keep sleeve of retinoscope in up position, Gradually adjust the plus cylindrical powers
i.e. plane mirror effect, and observe reflexes until these meridians appear equally filled at
in all the meridians to find ‘with motion’. same distance.
• Then place appropriate power spheres to
get ‘with motion’ in all meridians at your Step 6: Refine spheres
working distance. Check the working distance and gradually
• Now neutralize the spherical meridian or adjust the spherical powers (if needed) to get
meridians (first, weakest or least with neutralization at 66 cm distance.
motion) by adding plus spheres or reducing Note: Once the retinal reflexes are neutralized, a
minus spheres. subjective verification of retinoscopy findings are
necessary and a subjective refraction is performed.
Step 2: Estimation of cylindrical axis and power
• Observe the remaining with meridian by
making retinoscope sleeve down, which OBJECTIVE AND SUBJECTIVE REFRACTION
causes enhancement: Objective Refraction
– If no enhancement of reflex means With this enormous theoretical knowledge of
cylindrical power is low, i.e. less than 1 D retinoscopy one can start retinoscopy on the
– If enhancement of reflex seen means patient practically as follows
cylindrical power is high, i.e. more than • A fixation target is presented to the patient
1 D, means need to see the width of and a trial frame is placed, keeping both the
intercept to estimate the cylindrical eyes open.
power. • Advice the patient to fixate on the target
• With sleeve position either up or down with his/her right eye, while examiner
(showing enhancement of reflex) observe scope the left eye of patient as shown in Fig.
the four axis characteristics as 11.67A.
– Break • Study the reflexes and make them ‘with
– Thickness in high cylindrical powers motion’.
– Intensity • Neutralize the retinal reflexes by using six
– Skew in low cylindrical powers cardinal steps.
Fig. 11.67: Retinoscopy method method; A. For patient's left eye; B. For patient’s right eye
• Now scope the right eye while patient is these factors intelligence, emotions, and
fixating the target with his/her left eye as fatigues of patient will also influence the test
shown in Fig. 11.67B. result. Hence in young children and incoherent
• Repeat the same procedure to neutralize, patients it is difficult to perform a subjective
as in right eye. refraction so in these cases glasses are
• Note the gross retinoscopy values in both prescribed only on the basis of objective retino-
the meridians. scopy values.
If a cycloplegic drug had been used to
Subjective Refraction perform retinoscopy, then post-mydriatic test
Once an estimate of refractive error is obtained (PMT) or a subjective refraction should be
by objective retinoscopy as described above, done after some interval, e.g. if homatropine
a subjective verification is done. This is less or cyclopentolate has been used for refraction,
time consuming and not very cumbersome, then post-mydriatic test is done 4–5 days later,
however, when objective refraction is whereas if atropine has been used, then PMT
impossible in conditions like media opacities is done 2–3 weeks later.
or dense hazy media, examiners are Subjective refraction is performed on the
dependent only on this subjective refraction following guidelines
for improvement in visual acuity. • Adjustment of refraction
Here, the patient is asked that which lens • Refinement of refraction
help him/her to see the visual acuity chart • Binocular balancing
best. In subjective refraction, more complex
phenomenon involved like quality of retinal Adjustment of Refraction
image, photoreceptors integrity, visual Although one can perform a totally subjective
pathway up to hindbrain and lastly the refraction but it is always better to do an
occipital cortex response. All these factors objective refraction prior to subjective
decide the response of the patient about the refraction which not only saves the time but
better visualization of the target. Along with also gives an idea where to start.
Patient is made to sit at six meters distance Fogging or Astigmatic Dials Technique
from Snellen’s chart and a trial frame is placed, Astigmatic dial is a chart having radial lines
visual acuity of both the eyes is tested drawn at 30 degree intervals. Before starting
separately and noted. Place the lenses of test it is necessary to make the patient artificially
power obtained from objective refraction in myopic (fogged) by adding a plus (convex)
front of the each eye accordingly. Now a sphere (+0.50 D) before the eye so that all meri-
subjective verification and adjustment of dians are focused in front of the retina, thus the
spherical and cylindrical lenses can be done fogging of the eye eliminates the natural accommo-
by either of two techniques dation response and artificially increases
• Trial and error technique blurring of vision as naturally seen in myopia.
• Fogging or astigmatic dial technique
Test method
Trial and Error Technique • The spherical powers are placed in front of
Different spherical and cylindrical lenses are test eye (e.g. right eye) and the other eye is
tried to get the best corrected visual acuity as occluded, i.e. to obtain a state of compound
follows myopic astigmatism the right eye is fogged
by placing sufficient plus spheres in front
Spherical lenses of it in the trial frame. This brings forward
• Spherical lenses are adjusted first and the all hyperopic meridians, i.e. simple,
patient is asked that with the help of which compound or mixed to get focused in front
lens he/she is able to see clearly and of the retina as shown in Fig. 11.68.
comfortably. Strongest plus lens and • Because of fogging the accommodation will
weakest minus lens which provides the best blur the lines more than normal, hence
corrected visual acuity is noted in case of a patient tries to relax his/her accommoda-
hypermetrope and myope, respectively. tion to prevent the further blurring of lines.
• In myopic patients record the power of that In Fig. 11.68 vertical line (V) on dial
weakest minus lens which makes the letters (appearing darkest), is focusing in front of
of Snellen’s chart clear not that one which the horizontal line (H) on dial (appearing
make them darker and smaller. broken) inside the eye.
Cylindrical lenses • After fogging the eye, now patient is
Cylinders need adjustment both in terms of instructed to look at the astigmatic dial. He/
axis and power and by the rule axis must be she is asked to identify the darkest and
adjusted first followed by the power. sharpest line (V) seen on the dial say at
• Axis verification: Simply rotate the axis of 6–12 o’ clock position or at 90° axis in our
cylinder at a step of 5° in either direction example as seen in Fig. 11.69.
and ask the patient whether visual acuity
improves or detoriate. Although, with small
cylindrical powers patient may not be able
to appreciate the difference in visual acuity,
then high power cylinders can be used to
verify the axis.
• Cylindrical power verification: Once axis
is confirmed power of cylinder can be
adjusted simply by changing the cylindrical
lenses of various powers in the trial frame
and asking patient at every step about the Fig. 11.68: State of compound myopic astigmatism
improvement in clarity of visual acuity. induced by high plus spherical lens
then to get axis of minus cylinder, multi-

plication is done with lower number plus
half, i.e. 2.5 × 30 = 75°.
• Now all the lines on astigmatic dial appear
equally dark but none of them are clearly
focused, because of the fogging of the eye.
• Change the fixation of patient to a Snellen’s
chart and gradually reduce the plus
spherical power either by removing the
plus or adding minus spheres until patient
Fig. 11.69: Astigmatic dial showing darkest line V is able to read the chart clearly (Fig. 11.71).
• Once patient identifies the axis showing
Note: After performing a subjective verification of
darkest line, i.e. 90° (V) in our example, now refraction either by trial and error method or by
gradually add increasing power minus fogging or astigmatic dial method; always refine
cylinders at an axis perpendicular to it (i.e. the refraction subjectively. Like retinoscopy first
180° in our example) till all the lines appear refine the spheres and then cylindrical axis and
equally dark or blur to the patient as shown power.
in Fig. 11.70.
• As shown in Fig. 11.70 addition of minus Refinement of Refraction
cylinder moves the vertical focal line (V) to
Refining spheres
a backward position where horizontal line
Snellen’s distance vision chart is used to refine
(H) is present, hence the interval of Strum’s
the spherical powers along with help of Duo
conoid collapsed and a focal line becomes
chrome test and/or pinhole test.
a point focus (C).
• To calculate the axis of correcting minus Snellen’s chart for refining of spheres
cylinder a ‘rule of 30’ can be applied. • Simple method to refine the spherical
Multiply 30 to the lower number of clock power is that once the cylindrical axis and
hour showing the darkest line, i.e. 6–12 power had been established by fogging
o’ clock in our example. Hence in our example method, then gradually defog by decreasing
the axis of minus cylinder is 6 × 30 = 180°. the spherical power at steps of 0.25 D and
If darkest line is at 3–9 o’ clock position, then ask the patient to read the Snellen’s chart
minus cylinders will be applied at 3 × 30 = after every step.
90° axis. Similarly if this darkest line is seen • Once patient reads 6/6 line comfortably,
between one clock hour, say 2 and 3 o’ clock; stop the changing of spherical power,
Fig. 11.70: Addition of minus cylinder focuses both Fig. 11.71: Final adjustments done in astigmatic dial
line V and H at point C technique
however, near the end point there may be the red letters clearly. Now gradually add
some confusion because patient will minus spheres in a 0.25 D steps, till green
comfortably read at certain point even if letters also becomes clearer.
examiner defog for another 0.25 D power. This test does not give reliable results in
• Accurate assessment of end point is a little patients having visual acuity worse than 6/12
difficult because patient may not be able to because a difference of more than 0.5 D power
read 6/5 line with increasing or decreasing gives difficulty in distinguishing the letters.
spherical power to 0.25 D range, this can
Pinhole test
best be assessed by help of duo chrome test.
Accuracy of optical power correction is
Duo chrome test confirmed by pinhole testing (Fig. 11.73).
Principle: Basic principle of test depends on Test method: After placing the entire optical
the phenomenon of chromatic aberration. correction in the trial frame the patient is
When a target of letters having red and green instructed to look through the pinhole, if he/
background are presented to an emmetropic she reports no improvement in the visual
person then he/she sees these letters equally acuity, it means the total correction given is
sharp and bright because green light rays correct.
focuses slight anteriorly to the retina, whereas Suppose if, the patient reports further
red light rays focuses slight posteriorly to the improvement in the visual acuity with pinhole,
retina (wavelength of green light is shorter then it means that total correction given is
than red light thus green light waves are incorrect. So reconsider the refraction and try
refracted more than red light waves). to improve the optical correction till the
For example, if during subjective refraction patient gives no improvement with pinhole
more minus power lenses are added, then testing.
patient will see the green portion clearer
Refining the cylinders
(Fig. 11.72A) while if too much plus power
Most common employed methods to refine
lenses are added then patient will see red
the cylinders are
letters more clear as shown in Fig. 11.72B.
• Astigmatic fan and block method
This test is simple and reproducible, but the
only disadvantage is that it does not relaxes • Jackson’s cross cylinder method
the accommodation of patient, hence to relax Astigmatic fan and block method
accommodation slight fogging is done with This is an old method to assess the axis of
plus spheres until patient is able to see only astigmatic error and is also called Maddox V test.
Fig. 11.72: Duo chrome test. A. Too much minus power green is clearer; B. Too much plus power red is
clearer
• Instruct the patient to look at the lines on

the fan and ask him/her whether all lines
are equally dark and distinct. If all the lines
appears equally dark or equally blur; then
either there is no astigmatic error or the eye
is fogged in the excess.
• For confirmation of simple myopic state at
this juncture add 0.5 D plus sphere and
again ask the patient whether there is any
change in the darkness on group of lines. If
yes, then state of simple myopic astigmatism
is present and if answer is no, then add
Fig. 11.73: Pinhole another plus sphere at 0.5 D steps, till
patient sees a change in the darkness of lines.
• If patient sees some lines darker than other,
ask him/her which group of lines is clearer
or darker.
• Now instruct the patient to focus on the
Maddox V and ask which limb of V is
blurring. Then examiner slowly rotates the
central panel towards the blurred limb of
V, until both the limbs of V becomes equally
blur to the patient. The tip of V indicates
the axis of astigmatism.
• Once patient observes equal blurring of
limbs of Maddox V then ask him/her to
Fig. 11.74: Astigmatic fan
focus on the blocks of lines and ask him/her
This consists of two components; a fan and a which set of lines or block is darker. Now
block. Fan is nothing but a series of 100 angled add minus cylinders in 0.25 D steps at the
radiating lines appears as the rays from a direction of axis determined as above; until
rising sun. Whereas block is a centrally placed lines in both the blocks appear equally dark.
panel having a letter ‘V’ along with two sets • To confirm this, add plus 0.5 D sphere and
of mutually perpendicular lines. For testing patient should see the lines in both the
purposes this central panel having V and block blocks equally blur. If dark lines are
lines can be rotated up to 100° on either side changed to other block which was
against the dialing fan (Fig. 11.74). originally blur, then we had overcorrected
the cylinders and if the originally darker
Test procedure block lines become more darker then
• Best corrected visual acuity is obtained by initially added spherical power was not
using only spheres; considering the fact that correct.
best corrected spherical powers brings the
circle of least confusion on the retina. Jackson’s cross cylinder method
• Then add plus spherical equivalent of Jackson’s cross cylinder
estimated cylindrical power (spherical power In the year 1887, Dr Edward Jackson discovered
half of cylindrical power is called as spherical the cross cylinder which is essentially a
equivalent to cylinder); this will make the spherocylindrical lens having plus power in
eye in a simple myopic astigmatic state. one meridian and an equal minus power in
• Align the handle of cross cylinder with the

axis of astigmatic error X (Fig. 11.76A);
hence the plus meridian of cross cylinder will
lie at 45° off on one side of astigmatic axis.
• Now flip the cross cylinder by rotation of
handle so that plus meridian will lie on
other side of astigmatic axis (Fig. 11.76B).
• Ask the patient to compare the two images
in these two positions of cross cylinder.
• If both images are equally blur, then
astigmatic axis placed in the trial frame is
accurate.
• When refining the plus cylinder and
suppose if in any one position of two plus
Fig. 11.75: Jackson cross cylinder meridians the image appears clearer to the
patient then rotate the plus cylinder axis
the other meridian. This is used to refine both toward that plus direction.
the axis and power of cylindrical lens and also • Similarly, when refining the minus cylinder
can be used to check the accuracy of spherical then rotate the correcting minus cylinder
power. axis in the direction of clearer image
Jackson’s cross cylinder is effectively a lens towards minus meridian.
having two cylinders of equal power with • Repeat this procedure at steps of 5° rotation
opposite signs placed 90° to each other, which of correcting cylinder until both the images
is mounted on a handle at 45° angles to these appear equally blur after flipping the cross
meridians as shown in Fig. 11.75. In routine cylinder.
ophthalmic practice cross cylinders of power
0.25 D or 0.5 D are most commonly used. Plus
meridian is marked by black/white line and
minus meridian by red line. This cylinder is
flipped by rotation of handle, which shows
two blur images to the patient, then ask the
patient to compare on which side the image
is more blurred. When both the images
become equally blur that is the endpoint of
testing.
Test procedure
This test is performed for refinement of
cylindrical axis and power, and it is
recommended that always refine the axis of
cylinder before the power, because correct
power cannot be found in the absence of
correct axis.
Refining the cylindrical axis
After placing the entire optical correction in Fig. 11.76: Refining the cylindrical axis. A. Alignment
the trial frame cylindrical axis is verified of cross cylinder handle with astigmatic axis X;
uniocularly. B. Flip position of cross cylinder
Refining cylindrical power Binocular Balancing

After placing the entire optical correction in Once the refractive status and best visual
the trial frame and verifying cylindrical axis, acuity has been confirmed uniocularly, then
verify the power of correcting cylinder to confirm the optical correction or balance of
uniocularly. vision under binocular conditions, a binocular
• Align the handle of cross cylinder so that it balancing is needed. This can also be termed
lies at 45° angles with the astigmatic axis an equalization of visual or accommodative
‘X’ and plus meridian of cross cylinder efforts. Binocular balancing provides a ground
align with the astigmatic axis as shown in to focus a simultaneous retinal image in both
Fig. 11.77A. the eyes because an imbalance in images will
• Now when examiner flips the cross cylinder, give rise to asthenopic symptoms.
there is an alternate alignment of plus and Binocular balancing is done for both
minus power with the astigmatic axis of distance and near vision and many studies
correcting cylinder as shown in Fig. 11.77B. were done in past to achieve the accommo-
• Ask the patient in which position of cross dation balance for distance and near vision
cylinder the image is clearer. after refraction. Basic mechanism require to
• Suppose if the image is clearer with perform balancing is done by masking certain
alignment of plus meridian, then we portions of the visual stimulus from either eye
increase the power of plus correcting and this can be achieved by
cylinder, because when we place plus • Alternate occlusion with fogging
meridian over the astigmatic axis we are • Complementary colors
increasing its power. • Prismatic doubling
• On contrary, if image is getting clearer with • Polarization
alignment of minus meridian, then we • Haploscopic presentation
decrease the power of plus correcting
Balancing for distance vision
cylinder or increase the power of minus
correcting cylinder, because when we place This can be done by several methods. Most
minus meridian over the astigmatic axis we commonly used methods are explained here
are decreasing its power. • Alternate occlusion with fogging: Place the
• End point of test is when both the images best corrected optical lenses in the trial
get equally blur. frame and add + 1D sphere in front of both
the eyes. Alternately, occlude one eye and
ask the patient to compare the images from
each eye. If both are equally blur, then add
–0.25 D sphere in front of one eye and again
alternately occlude one eye. Now ask
patient to compare the images from each
eye. He/she will report a clear image from
the eye in front of which a –0.25 D sphere
was added. Suppose patient says no, then
add or subtract spherical power in a 0.25 D
steps till balancing or image clarity becomes
equal in both eyes.
• Turville binocular balance technique: In the
Fig. 11.77: Refining power of cylinder. A. Alignment year 1930, Turville proposed an infinity
of cross cylinder handle at 45° with astigmatic axis X; balance technique for binocular balance of
B. Flip position of cross cylinder refraction. Principle of this method is that
a septum is positioned at the junction point – Project a single row of letters on Snellen’s
of two diagonals from each eyes, which chart of 6/9 (preferably a line better than
were connecting the nodal points and weaker eye). Now place a vertical prism
foveal targets. Various foveal targets or test of 4–5 in front of one eye in the trial
objects shown in original test method are fame. (This will dissociate the images of
shown in Fig. 11.78A. This septum occludes two eyes).
one of the two foveal targets and hence only – With both the eyes open ask the patient
one retinal image from either eye is formed to read the letters of Snellen’s chart. Now
when both the eyes remain open. In case of add plus 0.25 D sphere in front of one
binocular balancing the images will be seen eye and then alternate it with other eye.
as shown in Fig. 11.78B. – If refractive correction in both the eyes
• Bichromatic binocular technique: Cowen is balanced, then patient will see blurring
modified binocular unit in an instrument of letters from the eye having additional
which projects the ring targets (Verhoeff) plus 0.25 D sphere.
in opposition to two halves of red and green – Once balance is achieved in both the eyes
duchrome background, which are cross prism is removed and the patient is
polarized. After placing the best correcting defogged until maximum acuity is
lenses in the trial frame, the ring targets are reached, either with a maximum plus
viewed through appropriate polarized power or with minimum minus power.
filters. Alternately, the eyes are occluded • Fogging with Duo chrome test: In this method
and patient is asked to compare the ring of binocular balancing of refraction, testing
targets. By adjustment of optical correction of corrective power by duo chrome chart is
we can achieve binocular balancing using done along with fogging of one eye.
these duchrome charts. Test method
• Prism dissociation method: It is most – Best corrected optical power lenses are
commonly used and is the most sensitive placed in the trial frame and patient is
method to test binocular balancing. asked to see the red green bars present
Minimum amount of binocularity is a on a vision chart.
prerequisite to perform this method. This – Fog one eye with a plus 2 D sphere and
method is not useful in presence of severe ask the patient to observe the red green
amblyopia or high anisometropia. bar with the other unfogged eye.
Test method – Patient is asked which bar either red or
– Place the best corrected optical lenses in green, he/she sees clearly.
the trial frame and perform uniocular – If both the color bars are equally clear
acuity. then binocular balance is present and no
correction in optical powers is needed.
– If both the bars are not seen equally clear,
then adjust the spheres in front of the
observing eye, until they become equal.
– Repeat the same with fogging the other
eye.
Near vision
Once the patient is fully corrected for distance
vision then test for near vision may also be
Fig. 11.78: Turville infinity binocular balance test. required if patient age is over 40 years, or
A. Test objects; B. Normal results hyperopic, or has any difficulty in reading. In
appropriate illumination in room, ask the

patient to read the near vision chart preferably
at 35–40 cm distance after wearing of full
optical correction for distance vision. Always
check with both the eyes open, do not occlude
either eye.
Examiner asks the patient whether he/she
can read the smallest line with ease or not. If
not, then add plus spherical powers in front
of both eyes together, according to the age or
by assuming till which line patient can read
comfortably as shown in Table 11.2.
If patient is unable to read the smallest letter
Fig. 11.79: Freeman bichromatic polarized modified
line, then add the power as per chart and ring targets
increase gradually in 0.25 D steps till patient
is able to read comfortably. Difference in was used. One area has figured target and
spherical powers for near and distance is other area has undifferentiated targets,
calculated and recorded as ‘Add’ for near however, patient can compare both images by
vision. rapid alteration of bifixation of either views.
For example, if power of distance vision is Freeman near vision unit
plus 1.0 D and near vision is plus 2.5 D then This unit consists of bichromatic polarized
’Add’ for both the eyes is plus 1.5 D. Similarly, modified ring targets (Verhoeff types) along
in myopes if distance power is minus 1.0 D with two cross-polarized letter charts (Fig. 11.79).
and near power is plus 2.0 D then ‘Add’ in
both eyes will be plus 3.0 D. Rodenstock near vision unit
Binocular balancing for near vision Here balancing of accommodation is done by
refraction is done by several methods such as presenting a duo chrome target having letters
and double Verhoeff rings. For balancing of
• Near vision balance with Bisurface reflec-
near vision two cross-polarized letter charts
tors
are also present in testing unit.
• Freeman near vision unit
• Rodenstock near vision unit Osterberg-Bino near vision unit
• Osterberg-Bino near vision unit This consists of a non-polarized duo chrome
Near vision testing by bisurface reflectors reducing number chart along with two cross-
polarized charts, which are separated
In this instrument an angled bisurface mirror
vertically.
is used to separate the right and left eye fields,
whereas in original Turville method a septum Note: These near vision units have similar kind of
purpose. Binocular bichromatic balancing method
Table 11.2: Average addition required by is better than simple duo chromatic principle as it
emmetropes at 35–40 cm reading distance assesses the balancing of monocular accommoda-
Age in years Plus addition in dioptres tion efforts.
40–45 0.75
46–50 1.25 PRESCRIBING POWER FOR GLASSES
51–55 1.75 Retinoscopy Representation
56–60 2.00 Universal method of representation of
60–70 2.50 retinoscopy values are in the form of a cross
71 and above 3.00 as shown in Fig. 11.80.
Similarly, the gross retinoscopy values are

represented along the axis of neutralization.
For example,
• If both vertical and horizontal meridians
get neutralized by plus 5 D power, when
retinoscopy is done at 66 cm distance
with atropine as cycloplegic drug, then
value of 1.5 D for distance and 1 D for
atropine drug is reduced from gross
retinoscopy and net value of retinoscopy
will be represented as shown in Fig. 11.82.
• If vertical meridian is neutralized by plus
Fig. 11.80: Retinoscopy representation (see text) 5 D power and horizontal meridian by
plus 7 D when retinoscopy is done at
66 cm distance with atropine drug then
the gross and net retinoscopy will be
represented as shown in Fig. 11.83.
• Similarly if neutralization occurs by –4 D
power in both the principal meridians
when retinoscopy is done at 66 cm
distance with atropine, then gross and net
retinoscopy is represented as in Fig. 11.84.
• Suppose vertical meridian is neutralized
by –3 D power and horizontal meridian
by minus 5 D, when retinoscopy done at
Fig. 11.81: Retinoscopy representation (see text) 66 cm distance with atropine drug then
Here, X and Y represent the two principal gross and net retinoscopy will be
meridians, i.e. 90° and 180°, respectively. If the represented as shown in Fig. 11.85.
neutralization meridians are not at these angles • In case of oblique astigmatism when
then they can be represented accordingly, for neutralization is at 30° meridian and 120°
example a 40° meridian and 140° meridian, which meridian say with +2 D power and +4 D
will be represented as shown in Fig. 11.81. power, respectively and retinoscopy is
Fig. 11.82: Optical cross in simple hypermetropia

Fig. 11.83: Optical cross in compound hypermetropia
Fig. 11.84: Optical cross in simple myopia
Fig. 11.85: Optical cross in compound myopia
done at 66 cm distance with atropine then lens axis. These values are represented
gross and net retinoscopy will be with the help of net retinoscopy representa-
represented as shown in Fig. 11.86. tion.
Prescription Writing For example, the above net retinoscopy
findings will be written as
In an ophthalmic lens prescription, spherical
lens power is written first, followed by • Figure 11.82: + 2.5 DS
cylindrical lens power and then cylindrical • Figure 11.83: + 2.5 DS/+ 2 DC × 90°
Fig. 11.86: Optical cross in oblique astigmatism
• Figure 11.84: – 6.5 DS maximum power of the cylinder is specified

• Figure 11.85: – 5.5 DS/–2 DC × 90° in a meridian, while the power in remaining
• Figure 11.86: – 0.5 DS/+2 DC × 30° meridian is zero (since the power is zero in
axis meridian of a cylindrical lens).
Plus versus minus cylinder form
These plus or minus cylinder forms represent Note: The power of cylindrical lens is represented
the toric surface and may be grounded either at an axis perpendicular to the one written in net
on the front or back surface of the optical lens, prescription, means when cylindrical axis is written
hence these prescriptions for an optical lens as 90° in the prescription, then the power in the
can be written either as plus-cylinder form or optical cross will be taken at horizontal or 180°
minus-cylinder form. If the front surface of a and vice versa.
lens is grounded it forms a plus cylinder and The optical crosses shown in Fig. 11.87A is
if the back surface of a lens is grounded then representing lens prescription in a minus
it forms a minus cylinder. cylinder form, i.e. –5.5 DS/–2 DC × 90° while
For example, Fig. 11.87B is representing lens prescription
– 5.5 DS/–2 DC × 90° for the same lens in a plus cylinder form, i.e. –
This above prescription is written in a 7.5 DS/+ 2 DC × 180°. We can observe in
minus cylinder form but suppose the cylinder Fig. 11.87A and B that in both examples, the
needs to be grounded on the front surface of optical crosses for total power in the vertical
lens then the same prescription will be written meridian is –5.5 D, whereas in the horizontal
as meridian it is –7.5 D. Furthermore, for a minus
cylinder form the total power of the least
–7.5 DS/+2 DC × 180° minus meridian is selected as spherical power
while for a plus-cylinder form the total power
THE OPTICAL CROSS in most minus meridian is selected as spherical
Optical cross is a graphical representation power.
which explains the relationship between There is another way to write a net power
spherical and cylindrical components of an figure in a prescription form as follows:
ophthalmic lens, also known as power Consider any meridian power as spherical
diagrams. To understand power diagrams power, say vertical or horizontal. Now just
three crosses are drawn; one will represent the subtract the spherical meridian power from
spherical component where power is same in the other meridian power mathematically and
both the principal meridians. Second cross will get the cylindrical power with spherical
represent the cylindrical component where meridian axis as cylindrical axis.
Fig. 11.87: Optical cross representations of same prescription in various cylindrical forms. A. Minus cylinder
form; B. Plus cylinder form
If we consider above discussed example: Transposition of Prescription

If horizontal meridian is considered as spheri- Transposition of a spherocylindrical percep-
cal power (–7.5 D), then subtract the horizontal tion is necessary for a laboratory when they
meridian power, i.e. –7.5 D from the vertical need to manufacture a specific form of lens,
meridian power, i.e. –5.5 D and resultant is i.e. either the front surface cylinder or back
–5.5 – (–7.5) = +2.0, i.e. plus cylinder at 180° surface cylinder lens.
(horizontal/spherical power meridian) Three steps rule for transposition of prescrip-
Hence, the final prescription will be –7.5 DS tion
× +2 DC × 180° This simple 3 steps rule is applied for
Alternately, when vertical meridian is transposition of a spherocylindrical prescrip-
considered as spherical power (–5.5 D), then tion to convert plus (+) cylinder form into a
subtract the vertical meridian power, i.e. minus (–) cylinder form or vice versa.
–5.5 D from the horizontal meridian power,
Step 1: Mathematically, add spherical power
i.e. –7.5 D and resultant is –7.5 – (–5.5) = –2.0,
and cylinder power to get new spherical
i.e. minus cylinder at 90° (vertical/spherical
power.
power meridian)
Hence, the final prescription will be –5.5 DS Step 2: Reverse the sign of cylinder, i.e. from
× –2 DC × 90° plus to minus and vice versa.
So in a nutshell we can consider any Step 3: Rotate the cylindrical axis by 90°.
meridian power as spherical power and to get Cross cylinder form: When a lens is grounded
final prescription just follow this simple rule: as plus cylinder on its front surface and as
“Always spherical powers are deducted minus cylinder on its back surface, having axes
from cylindrical powers mathematically and of these two cylinders at 90° apart, is called as
the resultant power becomes cylindrical cross cylinder.
power, whereas for cylindrical axis use the An example of a cross cylindrical lens is
same axis of spherical power”. + 0.50 DC × 180° combined with –0.5 DC × 90°.
Fig. 11.88: Cross cylinder form representation
Note: In our example the total power of cross prescription by this simple three steps
cylinder lens in the horizontal meridian is –0.5 D, rule
while in the vertical meridian is +0.50 D. Step 1: Consider the first encountered
cylindrical power as the spherical power.
Optical cross representing this prescription is
shown in Fig. 11.88. Step 2: To get cylindrical power, reverse the sign
of this new spherical power and then mathe-
In routine ophthalmic practice these cross
matically add it with second cylinder power.
cylinders are used to refine axis and power
of patient’s best cylindrical correction Step 3: To get the cylinder axis use the same
(Jackson’s cross cylinder) and also can be axis that of second cylinder.
used for near point testing (e.g. in Continuing to the same example of cross
determination of power of a bifocal addi- cylinder as above mentioned, the lens
tion). prescription is + 0.50 DC × 90° combined with
A spherocylindrical prescription can be –0.5 DC × 180° and by applying this three step
formed into a cross cylinder prescription by rule to get a spherocylindrical prescription,
this simple two steps rule: + 0.50 DC × 90° will become as
Step 1: First obtain both the plus cylinder and +0.50 DS/–1.0 DC × 180°
minus cylinder forms of the prescription. Now on applying the original three steps
Step 2: Now combine the two powers rule and this minus cylinder prescription can
mathematically (connect extremes) be transposed into a plus-cylinder prescription
as follows:
For example, if a spherocylindrical lens
prescription is written in a plus cylinder form –0.5 DS/+1.0 DC × 90°
and then in a minus cylinder form, i.e.
Note: Spherocylindrical prescriptions are same in
–0.5 DS/+1.0 DC × 90° and +0.5 DS/–1.0 DC both the methods of transposition of cross cylinder.
× 180°, now if we connect the powers, the Since routinely in our ophthalmic practice we
resultant prescription will be +0.50 DC × 90° encounter transposition between minus cylinder
combined with –0.5 DC × 180°. and plus cylinder forms, hence readers are advised
Similarly, a crossed-cylinder prescription to memorize the original three steps rule for
can be converted into a spherocylindrical conversion of spherocylindrical powers.
IV
Visual Rehabilitation
12. Spectacles, Spectacle Lenses and Spectacle Lens Fitting

13. Contact Lens Optics, Design and Fitting
14. Contact Lens Specific Conditions, Complications and
Maintenance
15. Refractive Surgery
16. Low Vision
12
Spectacles,
Spectacle Lenses and
Spectacle Lens Fitting
Learning Objectives
• Record the historical events of progress during development of spectacle frames and glasses.
• Understand various designs of spectacle frames and mountings.
• Describe the different types of optical material used in spectacle lenses with their special features.
• Explain the terminologies in relation to spectacle lenses and classify the spectacle lenses.
• Understand various types of spectacle lenses and their fitting requirements.
• Describes principles and steps of fitting lenses in spectacle frames.
• Verify and dispense an accurately fitted spectacle glasses.
Chapter Outline
• Spectacles – Classification of spectacle lenses
– History and events of progress – Trifocal lenses
– Frames and mountings – Progressive lenses
– Materials of frames and mountings • Spectacle Lens Fitting
Metals – Interpupillary distance
Plastic frame materials – Frame dimensions
– Bridges and temples – Datum system
• Optical Materials – Boxing system
– Optical glasses – Frame specification
– Optical plastics – Spectacle frame selection
– Spectacle lens materials – Principles of fitting
Glass lenses Pantoscopic tilt
Plastic lenses Temple angle
Absorptive lenses Fitting triangle
• Spectacle Lenses – Lens decentration

– Spectacle lens design – Glazing of lens
Spherical lens design – Verification of spectacles
Spherocylindrical lens design Surface defects
Design of high plus lenses Lens power measurement
– Terminologies in spectacle lenses Frame alignment
305
SPECTACLES help of a strong plano convex lens and

History and Events of Progress he suggested that such device can be
used in those people having poor vision.
Introduction
However, it is not exactly known
Art of glass making is much older than whether he mounted these lenses in any
invention of spectacles. Glasses were used frame or not.
since ages for various purposes, however • The first evidence about invention of
first time glass were used as a visual aid in spectacles has been found in a sermon
the form of a simple magnifying glass (1305) written by the monk Giordano da
called eyeglass. These eyeglasses were Rivalto.
mounted on various materials like wood, • Furthermore, other evidence about inven-
metals, leather, animal horn, bone, etc. and tion of glasses were found in a manuscript
with the help of a handle these mounted and an epitaph written by Alexandria de
eyeglasses were held in front of eye to Spina and Salvino d’Armati of Florence.
visualize the objects.
• Primitive forms of spectacles because of
An optical device used for visual purpose their weight and assembly were difficult
by only one eye is known as an eyeglass, to mount steadily in front of the eyes
however, when two such devices are used for and thus were clamped to the nose
both the eyes together, are called a pair of which was uncomfortable for patient
eyeglasses or spectacles. Initially, only and often interfered with breathing.
eyeglass was invented and used in front of Subsequently, spectacle devices in the
one eye but with trial and error two such form of head bands were produced for
devices were hinged in a manner that one of better comfort.
eyeglasses lies in front of each eye together
• Around 17th century Spanish spectacle
and this leads to a primitive pair of spectacles
makers used loops of silk or cord which
were attached with the outer edges of
It is not exactly known who invented the frames and then loop were extended to
spectacles, but several people had contributed the ears.
in the process of invention to produce the
• In the year 1730, Edward Scarlett
present form of spectacles.
(English optician) developed rigid side
Events of progress pieces (temples) of eyeglasses.
• Roger Bacon, a monk in his famous Opus
Magnus (1267) first described that small Frames and Mountings
letters or objects can be magnified with The devices which act as support for spectacle
lenses can be classified as
• Frames
• Mountings
These two terms are commonly inter-
changeable, though have different meanings.
Frames: Frames can be prepared using metals,
plastics or combination of both metal and
plastic. Usually, metal or a combination frame
consists of an adjustable nose pads for better
comfort, whereas plastic frames has fixed nose
pads or no pads for adjustments as shown in
Fig. 12.1: Primitive spectacles Fig. 12.2.
Spectacles, Spectacle Lenses and Spectacle Lens Fitting 307
mounting and lenses. Two temples are fixed

with end pieces so that a rimless frame can be
worn comfortably.
A typical semi-rimless frame also has three
portions
• A front: Which has both bridge and two
arms
• Two temples
Fig. 12.2: Plastic frame In past, two commercial versions of semi-
rimless mountings were manufactured
Frame mainly consists of three parts
• American Optical Numount was the first
• Front: Encircles the lenses and hold them version which attaches only to the nasal
• Bridge: Keeps the entire front together side of spectacle lens and requires only
and rests on the nose one hole per lens. Numount is a light
• Pair of temples: Rests on the ears and weighted mounting and a tri-flex spring
hold the front in alignment with eyes. is present in mounting at the location
Mounting: A device which holds the two where spectacle lens is attached with the
optical lenses in front of eyes without encir- mounting. Although in look, Numount
cling them completely is called mountings as mounting appears very delicate but
shown in Fig. 12.3. These mountings were presence of tri-flex spring prevents
classically manufactured with gold filled breaking of spectacle lenses during
materials in past and were classified as either pressure and shocks (Fig. 12.4).
rimless or semi-rimless. • Similarly, American Optical Rimway
A typical rimless mounting has three parts was second version of semi-rimless
• Single bridge or center piece: Helps to mountings which attaches to both the
hold the two spectacle lenses together nasal and temporal sides of each
towards nose (nasally). spectacle lenses, thus require two holes
• End pieces: Two in number which hinges per lens for fitting (Fig. 12.5). Although
the spectacle lenses with temples.
• Temples: Two in number, one on each side.
To fit lenses in a rimless frame, two holes
are drilled in each lens, i.e. one hole nasally to
fix the center piece and second hole temporally
to fix the end piece. Center piece consists of
two adjustable nose pads to be placed on the
sides of nose, which carry the weight of entire Fig. 12.4: Numount mounting
Fig. 12.3: Mounting Fig. 12.5: Rimway mounting

Rimway mountings were appearing

tougher than Numount mounting but in
reality temporal corner of this spectacle
lens get easily breaks away on pressure
application.
In addition to these abovementioned
conventional frames or mountings which
contain bridges and temples, the other devices Fig. 12.8: Monocle
were also available which hold either a pair
of spectacle lenses or a single lens in front of worn very often for special motive. The
the eye. muscular pressure of facial and brow muscles
Pincenez or eyeglass was a term used for a hold this Monocle in front of one eye as shown
pair of spectacle lenses, which were held in in Fig. 12.8.
front of eyes by pinching the nose. These
Materials of Frames and Mountings
eyeglasses have no temples and lenses are
fixed in a circular frame like structure as Spectacle frames and mountings can be pre-
shown in Fig. 12.6. pared by using various materials like natural
Similarly, Lorgnette was spectacle which substances or synthetics substances. Materials
indicates that either a pair of spectacle lenses having following properties are considered
(usually) or a single spectacle lens (rarely), ideal for manufacturing spectacles frames
held in front of the eyes with the help of a • Non-corrosiveness
handle as shown in Fig. 12.7. • Adjustability
Monocle which means a single lens, it • Light weighted
appears similar to a trial case lens and was • Non-allergic
• Sturdiness
• Low cost
In older times, naturally available materials
like wood, animal horns, tortoise shell and
leather, etc. were used to make the spectacle
frames for holding the lenses. Nowadays the
commonly used materials are
• Metals
• Plastics
Fig. 12.6: Pincenez • Nylon
Metals
Most commonly and widely used material to
manufacture the spectacles frames are metals;
because use of metal was convenient and
inexpensive to produce the spectacle frames
in large quantity. Most of the metals used were
highly moldable, non-corrosive and non-
allergic and were durable with good cosmetic
looks. Various metals used are
Gold and silver: Initially gold was extensively
Fig. 12.7: Lorgnette used for frames and mountings in western
countries because it meets all the properties petroleum, but with the time various synthetic
of an ideal material except cost. These frames materials were developed in laboratories to
were marked with content of gold percentage produce plastics.
in terms of Karat. Pure gold was too soft, hence Mainly two types of plastics are used for
other metals were added to increase its frames
hardness and durability. Similarly, silver was Thermosetting: These materials convert from
also tried because of its similar properties like a liquid state into a solid state during the
gold, but it was also too soft and needed other process of manufacturing by application of
metals to increase its utilization. heat and pressure. Once the manufacturing
Silver when mixed with nickel forms a had occurred, then even high temperatures or
metal, commonly called German silver which pressure application cannot soften these
became popular for making of frames because materials and in these circumstances they
of its anti-corrosive property, however, the basically decompose. For example, melanines
high percentage of contact allergy due to these used for Melmac dishes, phenolics (Bakelite),
metals discouraged its wide usage in popu- polyesters used for clothing and allyls used
lation. in CR-39 material (very popular as plastic lens
Later on, gold was layered over this material, however, rarely used for manufactu-
German silver by electroplating process, ring spectacle frames).
which not only eliminated its allergic nature
Optyl: Optyl is an epoxy resin containing
but also maintained the properties like
thermosetting plastic material. To manufac-
adjustability and durability. These gold frames
ture frames from optyl, the liquid of it at
remain popular till date because of their
high temperature is poured into a mould
cosmetic reasons, non-allergic nature and anti-
followed by a curing process. After moulding
corrosiveness; still the only hurdle is cost.
different parts of the formed frame can
Stainless steel: This came as an inexpensive easily be dyed using different colors. The
alternative to gold and silver in large-scale optyl material on heating becomes soft and
manufacturing of frames. Steel meet nearly all flexible and thus can be shaped in any
the qualities of an ideal material being very desired form easily.
stable, adjustable, non-corrosiveness, non- Advantages of optyl frames are
allergic and light in weight, and can easily be • Hardness
manufactured in mass productions.
• Dimensional stability
Aluminium: Like steel, aluminium is also • Good shine
inexpensive, noncorrosive, light-weighted • Non-inflammability
material and thus can also be easily used in • Light in weight.
large-scale frame manufacturing. Aluminium
metal also has an advantage over steel that the Disadvantages of optyl frames are that they
frames of aluminium can be dyed easily with need higher temperatures compare to their
different colors which improved its cosmetic counterpart materials to work on; and if any
appearance and sale value. attempt is made to adjust them in cold, frames
will break.
Plastic Frame Materials Thermoplastic: These materials get soft on
A constant search for a better, inexpensive heating and hard on cooling and even basic
material for huge production of spectacle structure of these material is not altered even
frames lead to the discovery of plastic on repeated exposure to this process.
material. Initially, these plastics were either Hence, these materials are widely used for
the derivatives of natural occurring cotton or large-scale production of inexpensive and
durable spectacle frames. Various thermoplas- Both cellulose nitrate and cellulose acetate
tics commonly used to manufacture spectacle are produced by cotton lint and are soluble in
frames are various ketones such as acetone; although
Acrylics: Acrylics are the most common name neither of them is soluble in alcohol. Hence,
for the family of thermoplastic materials, acetone is often used as a polishing or
which include polymethyl methacrylate repairing substance for the frames made up
(mainly used in the manufacturing of hard of cellulose material.
contact lenses and occasionally used for Comparison of cellulose nitrate and cellulose
spectacle frames). Various acrylics used acetate
commercially for spectacle frame manufactu- Cellulose nitrate is superior to cellulose acetate
ring are because
• PMMA • Cellulose nitrate can be easily stretched by
• Plexiglas heat and also shrinks minimally when
• Perspex cooled, so moulding of these frames is
• Lucite comparatively easier than acetate frames.
• Harder surface of nitrate frames is an
Most advantageous features of acrylics are
advantage for better polish and trouble-free
dimensional stability, surface hardness, good
maintenance.
wear resistance, clarity, color fastness, light
• Much thinner frames can be made by nitrate
weight, and non-flammable. Disadvantages of
because it is tougher than cellulose acetate.
acrylics are brittleness and low impact
resistance; due to which these materials are • Nitrates softening point is higher than that
not preferably used for spectacle frames. of cellulose acetate; and its water absorption
is lower, hence better dimensional stability
Polycarbonate: This thermoplastic material is seen in warm and clammy environments.
was used widely in past for manufacturing of
Conversely, cellulose acetate is superior to
spectacle frames. Only disadvantage was that
cellulose nitrate because
it was too hard to work on, so gradually its
use declined over a period of time. • Less production time as compared to
cellulose nitrate.
Presently, mainly two materials are used for
the mass manufacture of spectacle frames, • Frames made are more colorfast compared
cellulose nitrate and cellulose acetate. to cellulose nitrate.
Although both are similar in appearance, but • Cellulose acetate frames are much less
when used for spectacle frames they exhibit flammable compared to cellulose nitrate.
different properties. Cellulose propionate: It is also an ester of
Cellulose nitrate: This is also called xylonite cellulose family. Several properties of
and is commonly known as celluloid in the propionate resembled the optyl material
film industry. Camphor is added as a including the manufacturing by moulding
plasticizer during manufacturing of cellulose process. Frames prepared by cellulose
nitrate, hence when a cellulose nitrate frame propionate are quite tough and light in weight,
is rubbed vigorously with a cloth, an odour so can easily be made into various styles and
of camphor may be noticed. Due to its hard sculpturing effects. However, use of cellulose
nature it retains its shape even in hot climate. propionate frames has decreased in recent
years.
Cellulose acetate: Most commonly used
plastic material to manufacture spectacle Nylon: Polyamides are a generic class of
frames is cellulose acetate because of its less thermoplastic polymers which are commonly
inflammable nature and hardness. known as nylon. Nylon material is very costly
when manufactured in the form of sheet,

hence an injection moulding technique is used
to decrease the cost of manufacturing. Nylon
is very tough and hard in nature but its
brittleness, poor color acceptance, high water
absorption and less transparency has limited
its usefulness in competitive spectacle frame
market. Nylon spectacle frames are currently
available in market, but are less preferred as
Fig. 12.10: Saddle bridge
compared to the cellulose material frames.
Note: Although several materials have been used

for the manufacture of plastic frames; but great
majority spectacle frames are currently made of
thermoplastic material, cellulose acetate.
Bridges and Temples

Following types of bridges and temples can
be used in plastic spectacle frames Fig. 12.11: Keyhole bridge
Bridges: Usually in metallic frames and/or of this kind of bridge, the saddle shape must
rimless or semi-rimless mounting, bridges be a perfect fit with contour of the nose.
make no direct contact with nose; rather Various modified saddle bridges have also
contact is made with the help of adjustable been developed which include built-up areas
nose pads (Fig. 12.9). on either side of bridge in such a way that the
However, in plastic frame there is a direct apparent length of nose looks short.
contact of bridge with the sides of nose. Plastic The keyhole bridges are useful for those
frame’s bridges are either saddle type bridges persons who cannot tolerate pressure on the
or keyhole type bridges or occasionally top of the nose because these types of bridges
modifications of either type. make direct contact only with the sides of
A saddle bridge directly rests on the crest nose, not the top (Fig. 12.11). Fixed,
of nose like a horse back and distributes the nonadjustable pads are made with the frame
weight of spectacles evenly on the top and which make the contact with nose and are
sides of the nose (Fig. 12.10). It has no nose usually of the same material as that of frame.
pads for contact to the sides of nose, hence As compared to saddle bridge, wearing of
suitable for those persons who compliant of keyhole bridge frames usually accentuate the
sensitivity due to nose pads. For proper fitting length of the nose.
Some plastic spectacle frames also contain
other type of bridges which compromise
features between saddle and keyhole types
and are effective in better nose fitting.
Bridge width: For all types of spectacle frames
bridge width remain specified and it defines
as the shortest distance between the two lenses
or in a simpler term, as DBL, i.e. distance
between the lenses, measured in millimeter
Fig. 12.9: Adjustable nose pad unit (Fig. 12.12).
modified skull temples, particular the thinner

styles, contain a wire core to provide added
strength.
Library or spatula temple does not have
any curve like skull temple rather it lays
straight back over the ear (Fig. 12.13D).
Spectacle glasses remains in the position on
the head due to pressure of temples which is
Fig. 12.12: Bridge width specification showing DBL exerted on the sides of skull by temple and
this pressure is not seen with library temple,
Temples: Temples are the part of spectacle hence the fitting of these types of temples is
which holds the front and rests on the ears of difficult. The straight back design of temple
person. Common types of temples available helps the wearer to position the frame on and
are off the face very rapidly thus these temples are
• Skull temple convenient for those who wear glasses
• Library temple irregularly and usually for a brief period of time.
• Riding bow temple Riding bow temple is the one which
• Comfort cable temple. encloses the back and lower part of ear
Skull temple is most commonly used (Fig. 12.13B). Usually these are made up of
temple designs for plastic spectacle frames. plastic material having a central metallic core,
These types of temples remain bent mainly indicated for frames used in children
downward behind the ear and follow the and safety frames.
curve of the ear of person and shape of skull Comfort cable type of temple appears
(hence are called skull temple). Advantage similar to riding bow temple; but the difference
with skull temples is that they do not create is that all and/or part of this type temple
excessive pressure on the mastoid process or (specifically the part encircling the ear) is
ear lobe so are more comfortable for wearer. made up of a coiled metal cable instead of
(Fig. 12.13A). Several modifications of skull plastic (Fig. 12.13C).
temple have been done in terms of width Because of their identical appearance riding
which may vary in different frames from bow and comfort cable temples are used
standard form of skull temple. Most of these synonymously where a comfort cable temple
Fig. 12.13: Showing various types of temples. A. Skull type; B. Riding bow type; C. Comfort cable type;
D. Library type
is considered as a type of riding bow temple. angle of nose is an angle formed between
Metal spectacle frames and mountings usually median sagital plane, i.e. an anterio-posterior
have comfort cable/riding bow temples. These plane passing through the midline of nose and
types of temples because of their structure can line passing by the side of nose as shown in
hold a frame securely in place and thus commonly Fig. 12.14B.
used for children’s spectacles and in some
occupation like by mechanics and electricians. Note: Nose pads are selected in such a way that
they closely match both the frontal angle and
Temple length: Previously, temple length was transverse angle of nose.
calculated by either measurement from length
to bend or overall length from front to tip of
Temple Fitting
temple. Now usually temples are specified as
overall length only. Previously it was Normally, majority of spectacle’s weight is
measured in inches but now represented in borne by the nose but if a person tilt head in
millimeter unit. forward direction, then spectacle weight gets
transfer from the nose to the ears. This weight
Bridge Fitting shift will possess difficulty when patient is
The bridge fitting is an important step during wearing library or skull types of temples,
spectacle fitting because usually most of the because pressure of the sides of temples
weight of spectacles is carried on the nose of against the patient’s head on an area behind
person holding head in erect position. However, the ears maintain the position of the glasses
different styles of frame and positions of head in these types of temple designs. On contrary,
may affect the percentage amount of total riding bow temples encircle the ears and hence
weight of the spectacles which is carried by secures the position of frame by making
the nose. Ideally, bridge fitting should be in contact at the lower arc of the external ear.
such a way that weight of the spectacle frame Important features to remember while
remains distributed over a large area on the fitting the temples of spectacle frames are
nose so that the irritation on the nose is • Relation of angle of external ear to sides
reduced. It is essential to check bony angular of patient’s head.
configuration (i.e. frontal angle and transverse • Shape of mastoid process
angle) of the nose by palpation of nose. Hence, it is important for ophthalmic
As shown in Fig. 12.14A frontal angle of the personnel to inspect the top and back of ear
nose is an angle formed between midline of along with mastoid process; before deciding
nose and a vertical line passing through each upon the type of temple he/she is planning
sides of nose, whereas transverse or splay to dispense to the patient.
Fig. 12.14: Bridge fitting method. A. Frontal angle; B. Transverse or splay angle
OPTICAL MATERIALS • Later on in the year 1876 Ernst Abbe and

Optical Glasses Otto Schott of Germany extended the
use of chemical oxides in manufacturing
History
of glass and produced an extensive
• In the year 423 BC Aristophanes, a Greek range of all new glasses for optical pur-
play writer, mentioned the use of a convex poses.
lens as a burning glass in his play ‘Comedy • Until 1880, optical glasses quality available
of the Cloud’. was either crown or flint. In the year 1880,
• However, early forms of spectacles were Abbe introduced a glass of high refractive
invented in late 13th century and these index without any noticeable rise in its
primary lenses were utilized mainly for dispersive power.
correction of presbyopia. • In the year 1915 Bausch and Lomb Optical
• With the invention of telescope in the year Co. started producing an extensive quantity
1608 by Galileo, demand of high quality of glasses having very good optical quality.
optical glasses rose abruptly. Nowadays Bausch and Lomb, Corning
• English scientist John Dolland developed Glass Works, and Pittsburgh Plate Glass
an achromatic lens in the year 1757. These Company contribute as major optical glass
achromatic lenses were made up of manufacturers in the world.
compounds crown and flint.
Optical glasses have vital properties like
Crown glass: Originally window glasses were • Refraction index: This is identified at the
called crown glass, pieces for these glasses wavelength (589 nm) for Fraunhofer D line
were used to make lenses and were called and is denoted by symbol .
crown lenses. Nowadays crown glasses are the
• Dispersion: This is defined as the variation
one which have silica, soda or potash and lime
in refraction index with wavelength. This
as basic components.
is quantified by Abbe number () and is
Flint glass: In the year 1676, George called nu value.
Ravenscroft used ground flint as silica source
Following characteristics in an optical glass
and added lead as basic component to form
are required to make them useful for ophthal-
brighter, clearer, softer and heavier glass
mic purposes
which was called flint glass. Nowadays flint
glass contains lead oxide primary component • Physical and chemical stability of high
along with other crown glass components. grade
• Transparency of high degree
Events of progress
• In the year 1814 PL Guinand of Switzerland • Homogenecity in both physical state and
revealed that stirring of glass can increase chemical composition.
its homogeneity. • Appropriate refraction index and chromatic
• In the year 1827, Michael Faraday deve- dispersion values.
loped various methods for purification of • Colorless
glass substances. He designed a platinum
melting pot for the purpose of purifying Optical Plastics
the glass substances, which was consi- Introduction
derably resistant to the reaction of melted An organic polymeric material having large
glass. molecular weight which can be shaped by
• In the year 1839, Chance brothers of flow is referred as plastic material. Most of
England started manufacturing of wide these plastics are synthetic materials produced
range of optical glasses. by combination of organic and inorganic
materials such as carbon, oxygen, nitrogen, Spectacle Lens Materials

hydrogen, chlorine, and sulphur. Commonly, Glass Lenses
plastic raw materials are derived from fossil-
As discussed above glass had been used since
formed products such as oil, coal, and natural
old ages to form a spectacle lens for correction
gas. Plastics used for optical purposes are very
of refractive anomalies. Main varieties of
small fraction of total plastics. Materials used
optical glasses are
in fusion of bifocals should be physically
stable; so that no stress occurs along the line • Crown glass
of fusion. • Flint glass
• Barium crown glass
Development of optical plastics: Different
types of plastic materials were available since Crown glass: Glasses having nu value greater
many years but use of plastics for production than 50 are called crown glasses. Basic
of lens increased primarily during and after components of an ophthalmic crown glass are
World War II. Polymethyl methacrylate 70% silica (sand), 14–15% sodium oxide (soda),
(PMMA), also known as Lucite or Plexiglas 11–12% calcium oxide (lime), and small
or Perspex, was one of the major plastic percentages of potassium, antimony, borax,
materials developed during World War II. It and arsenic. These glasses are mainly used in
is a synthetic thermoplastic resin used for single vision glass lenses, and also as distance
production of aircraft windshields. It is more portion in most of the glass bifocal and trifocal
durable than a non-tempered glass but also lenses. Its refraction index is 1.52 and nu value
has a disadvantage of easy scratchability. is 59.
Another plastic material developed Flint glass: Glasses having nu value less than
during World War II was allyl diglycol 50 are called flint glasses. Basic components
carbonate commonly called Columbian are 45–65% lead oxide, 25–45% silica, and
Resin 39 (CR- 39). A large series of 170 clear nearly 10% mixture of soda and potassium
allylic materials were compounded when oxide. These glasses have more refraction
concentrated on a thermosetting in place of index from 1.58 (light flint) to 1.69 (dense flint)
a thermoplastic material. The thirty-ninth and higher chromatic dispersion with a nu
compound among 170 were designated as value of 30–40. They are mainly used for near
CR-39, which was an allyl diglycol carbonate segments in bifocal and also as single vision
monomer. CR-39 was much more scratch lenses where thinner lenses are required due
resistant than PMMA. to high degree of refractive error.
• Robert Graham in 1947 made first
Barium crown glass: Its basic components are
ophthalmic lenses from CR-39.
25–40% barium oxide, along with other crown
• In the year 1957 GE Company developed glass compositions. These glasses have
a new plastic material, a polycarbonate refraction index 1.54 to 1.61 with nu values
resin called Lexan. This material has a from 59 to 55. Barium crown glasses are
great mechanical strength and high mainly used in near segments of fused bifocals
service temperature. In the year 1978, (Nochrome series).
first ophthalmic lenses were produced
from this material. Plastic Lenses
• In the year 1982, Corning Glass Works PMMA lenses: Polymethyl methacrylate is a
came up with a lens called Corlon. This thermosetting plastic material mainly used
was a two-layered glass lens where a to manufacture contact lenses, although
very thin layer of polyurethane is bonded spectacle lenses such as Igard lens were made
to the back surface of glass lens. in Great Britain by using PMMA material.
Lens properties Disadvantages of CR-39 lenses are

• Refraction index: 1.49 • Increased lens thickness compared to glass
• nu value: 57.2 lens due to lower refraction index.
• Specific gravity: 1.19 • CR-39 lenses have relative lower resistance
Advantages of PMMA lenses are than glass lenses for surface aberrations.
• High order transparency • Significant damage to lens surface due to
glazing.
• Shatter proof
• CR-39 lenses loses its photochromatic
• Light weight
property in very less duration, hence are
• Tintability
not used widely as photochromic lenses.
• Optical design versatility
Polycarbonate Lenses: Polycarbonate is a
Disadvantages of PMMA lenses are
thermoplastic material exist in solid state
• Easily scratchability which is melted at about 320°C temperature
• Damage due to glazing and then injected in a mould to form a lens. A
• Unsuitable in extremely hot environment device then squeezes the lens to prevent
CR-39 Lenses: Ophthalmic lenses prepared shrinkage and to ensure the optical accuracy
from material allyl diglycol carbonate mono- of surfaces. Polycarbonate lenses need a hard
mer, popularly called CR-39 (Columbia resin coating of surface to increase scratch resistance
39) were supplied as a yellowish viscous liquid and chemical protection.
from a single western manufacturer. Initially Lens properties
this manufacturer produced CR-39 lenses in • Refraction index: 1.586
a variety of forms, powers and sizes. Some • nu value: 30
manufacturers added substances like UV • Specific gravity: 1.20
absorbers, anti-yellowing agents and mould
releasers to change the properties of lenses for Main advantages are high resistance to
better clinical usage. impact and higher refraction index, so very
thin durable non-breakable lenses can be
Lens properties formed from polycarbonate material. Disadvan-
• Refraction index: 1.498 tages are difficulty in surface molding, lens
• nu value: 58 glazing/fitting and easily scratchability.
• Specific gravity: 1.32
Advantages of CR-39 lenses are Absorptive Lenses
• CR-39 lenses are chemically inert to majority Absorptive lenses have been developed with
of commonly used solvents such as benzene, the purpose to decrease the amount of light
acetone and gasoline. transmission or radiant energy, i.e. lens works
• These lenses are highly resistant to impact. as a filter. The light absorption may be uniform
(absorbs all wavelengths of light) or selective
• CR-39 lenses resist pitting from scatter
(absorbs some wavelengths). These lenses are
particles especially from welding or
not colorless, so they are also called tinted
grinding machines.
lenses.
• Fogging due to sudden change in tempera-
Mainly following types of absorptive lenses
tures is less common than glass lenses
are routinely manufactured for optical
because of lower thermal conductivity of
purposes
CR-39 material.
• Other properties like tintability, light • Tinted glass lenses
weightedness and optical design versatility • Tinted plastic lenses
are similar to PMMA lenses. • Glass lenses with surface coatings
• Photochromic lenses as there are chances of distortion of lens due

• Younger PLS filter lenses to exposure to high temperature. Thus, these
• Polaroid lenses lenses are tinted by dropping them in a
solution having desired organic dye. Resulting
Tinted glass lenses: Tinted glass lenses can
color density of tinted lens depends on two
be produced during manufacturing of crown
factors: Organic nature of the dye and immersion
glass (mixture of silica, soda, lime with small
time.
amounts of potassium, aluminium and/or
barium oxides) by adding one or more metals To achieve a particular type of tint and/ or
or their oxides which results in the formation light transmission; these plastic lens may be
of different types of tinted color lenses as immersed into several kinds of tinted
shown in Table 12.1. solutions. The variation in thickness of lens
from center to periphery does not affect the
Absorptive lenses have several advantages density of tinted lens as penetration of dye in
and disadvantages. the surface of lens is up to a uniform depth.
Advantages Hence, lenses of uniform density are formed.
• Low cost of manufacturing For any reason, if required, the tint color of
• Little surface scratching lens can be changed by dipping the lens in
• Absence of reflection bleaching solution.
• No special equipment needed for surfacing
and lens finishing Glass lenses with surface coatings: Surface
of a glass lens can be tinted by coating it with
Disadvantages
a layer of metallic oxide by evaporation
• Color tint of lenses is permanent in nature.
process under high temperatures in vacuum
• High power tinted lenses had variations in conditions. As discussed above plastic
transmission of light from central portion lenses are unsuitable for this process due to
to peripheral portion of lens. high temperatures. Refraction index of
• Similarly, in patients having high degree metallic oxide is higher than the glass, hence
of anisometropia the transmission of the amount of light reflecting from
light in one eye is variable from fellow absorptive surface is more than that of
eye. uncoated surface of glass lens. To prevent
Tinted plastic lenses: Surface of plastic lenses this phenomenon of higher light reflection
cannot be coated by method of evaporation an anti-reflection coating of magnesium
fluoride is done over and above the metallic
Table 12.1: Metallic oxides and respective tinted oxide coating.
color lenses
Photochromic glass lenses: In the year 1964,
Metallic oxides Lens color
Corning Glass Works company begins the
Iron Green manufacturing of glass lenses having
Cobalt Blue photochromatic properties, means these
Manganese Pink lenses become dark in sunlight and converts
Cerium Pinkish brown back to clarity when sunlight exposure is
Uranium Yellow seized.
Chromium Green
These lenses are composed with silver
Nickel Brown
halide microscopic crystals. Sunlight (ultraviolet
Gold Red
radiation) decomposes these microscopic
Silver Yellow
crystals into silver and halide ions. These ions
Vanadium Pale green
cluster together and when these clusters get
Didymium Pink
larger they become darker. Hence the lens
color appears darker in the presence of • Normally Photolite (fully activated) lens
sunlight, whereas in the absence of sunlight turns into blue color however, it can also
these silver and halide ions again converted be tinted to different colors.
into crystal form. Lens color fades and becomes • Life expectancy of Photolite lenses is
clear in the absence of sunlight. nearly 2 years.
Rate of darkening of lens depends on the Younger PLS filter lenses: In the year 1984
temperature, faster and deeper degree of Younger optics introduced a series of CR-39
darkening occurs in low temperature. lenses, called as Protective Lens Series (PLS).
Degree of darkening of lens depends on These lenses were design to protect the eyes
• Intensity of the radiation by using selective filters for invisible
• Length of exposure ultraviolet and visible blue radiation. PLS
• Surrounding temperature lenses are neither photochromic nor tinted,
Similarly, rate of fading of photochromic lenses rather are manufactured in a specific manner.
depends on Protective additives are added throughout the
lens material uniformly so that these additives
• Glass composition
cannot be bleached or removed.
• Thermal bleaching (higher temperature,
A specific wavelength is nominated to these
faster fading)
PLS filter lenses as product code; below this
• Optical bleaching means exposure to a
wavelength these lenses literally block all of
longer wavelength than that used for
the ultraviolet and blue visible radiations.
darkening
A few specific product code lenses are
Photochromic plastic lenses: Photosensitive summarized in Table 12.2.
plastic for formation of ophthalmic lenses
was introduced by American Optical Note: Using standard methods for cosmetic tint,
Company (1982) and named the plastic the natural color of any of these PLS filter lenses
can be changed without disturbing the lens
photochromic lens as Photolite. These lenses
performance.
were manufactured by the process of chemical
impregnation rather than a usual dye pot Uses
process. • PLS lenses are advised to be used for
Properties of Photolite lenses are protection against ultraviolet and visible
• It shows about 90% transmittance of light blue radiations, because many researchers
in the faded state and about 45% trans- concluded that short wavelength radiations
mission in dark state. such as ultraviolet and blue radiations are
• Within 2 minutes time lens become harmful for eyes.
darker to 45% out of total darkened state. • These lenses are successfully used for protec-
• Similar to other photochromic materials, tion in patients having ocular conditions
less is the temperature of surrounding like cataracts, corneal dystrophies, macular
more will be the darkening of lens. degeneration, and retinitis pigmentosa.
Table 12.2: Various PLS filter lenses and their properties

Product code Natural color of Wavelength designated UV and blue radiation
PLS filter lens blockage (%)
PLS 400 lens Pale yellow color < 400 nm Approx. 100
PLS 530 lens Orange-amber color 530 nm 95–97
PLS 540 lens Brown color lens 540 nm 95–97
PLS 550 lens Red color lens 550 nm 95–97
Polaroid lenses: As discussed in Chapter 1 cellulose acetate butyrate. These laminated

and as shown in Fig. 12.15 normally light beam sheets can be pressed into the desired
is circularly symmetrical and unpolarized curvature to form a lens. To create polarized
(Fig. 12.15A) but when it passes through glass lenses from thin sheet of polarizing
crystals like quartz or calcite it becomes material, the thin sheet is laminated between
polarized (Fig. 12.15C), however, in between two layers of glass which then tinted and
some light rays may also emit as partially surfaced with power according to choice. In
polarized rays (Fig. 12.15B). standard polarized sunglasses lenses, the
To manufacture polaroid filters, a thin sheet tinted layer over lens has a uniform thickness,
of polyvinyl alcohol is heated and then thus density of the lenses is uniform from
stretched so that it becomes about four times center to periphery of lens. Sometimes, to
of its original length. Due to effect of stretching increase the absorptive power of lens for
the molecular structure of polyvinyl alcohol ultraviolet radiations, special additives can be
get aligns in the form of long chain in the added in tint coating.
direction parallel to the stretching. The thin The Corlon lens: Corning manufacturers (1982)
sheet of polyvinyl alcohol is then passed introduced a new specialized type of spectacle
through a solution of weak iodine so that lens known as Corlon or bonded lenses
iodine molecules diffuse into layers of because this lens was manufactured using
polyvinyl and gets attached to chains of long both glass and plastic materials. Corlon lenses
polyvinyl alcohol molecules. Hence, a thin consist of following two layers (Fig. 12.16)
sheet of polarizing filter is formed which is • Front layer of glass: Convex front layer of
then laminated between two layers of coated Corlon lens is made up of a thin glass lens,
using either white crown glass or photo-
chromic glass (photo grey extra). In case of
minus power lenses, this layer has a central
thickness of 1.3 mm when white crown
glass material is used and 1.5 mm when
photochromatic glass material is used.
• Back layer of plastic material: Concave back
layer is made up of a very thin layer of
special polyurethane plastic which is
combined with the glass lens. Thickness of
this polyurethane layer is 0.4 mm.
Fig. 12.15: Polarization of light. A. Unpolarized

rays; B. Partially polarized rays; C. Linear polarized
ray Fig. 12.16: Corlon lens
Advantages of Corlon lens over routine introduced by William Wollaston, and

spectacle lenses are named them ‘periscopic lenses’ because of
• More light in weight (up to 25%) as their property to provide a wider field of
compared to ordinary glass lenses. vision.
• Have thin edges (up to 25%) as compared • Nietzsche and Gunther (German company)
to either ophthalmic crown glass lenses in 1867 developed uniform surface lenses
or plastic CR-39 lenses. of 1.25 D and termed them ‘periscopic lens’.
• Chances of scratches are less than plastic The plus lenses were having –1.25 D back
lenses because front surface is made up surface and minus lenses were having a
of glass. +1.25 D front surface. They also introduced
• More resistant to shock caused by impac- 6.00 D base curve lens where plus spherical
ting object because of its two-layer cons- lenses had the back surface power of –6 D
truction. Impact of an object can break and a minus spherical lens had front surface
the front glass layer but polyurethane power of +6.00 D.
layer remains intact which protects the • Tscherning (1904–1908) first identified the
eyes from injuries due to glass particles. importance of center of rotation of the eye
• Its unique construction design eliminate as a reference point in the lens design. He
the need for tempering because Corlon proposed that an oblique astigmatism
lens is more resistant from back surface might be eliminated by using two forms of
infiltration as compared to both white bent lenses, i.e. deeper and shallower form.
crown glass and CR-39 plastic lenses.
• Moritz von Rohr (1908) worked on spectacle
• Its photochromic layer is thinner compa-
lenses with the aim to eliminate the oblique
red to a regular photogray lens so Corlon
astigmatism and made following conclusions
lenses darken less than regular lens.
• Polyurethane layer of the Corlon lens can – Each lens has a specific thickness.
easily be tinted by technicians in desired – Distance between center of rotation of
solid colors or gradient tints by using eye and back pole of lens was 25 mm.
special types of water based dyes for – Viewing angle for plus lenses was 35° and
better cosmetic looks. for minus lenses was 30° and viewing
distance was infinity.
SPECTACLE LENSES – Sphero-cylindrical lenses can be manu-
Spectacle Lens Design factured in plus toric form.
Spherical Lens Design – He also described the back vertex system
• Most primitive ophthalmic spherical lenses • Subsequently, in the year 1913, Zeiss
were of biconvex type, however, biconcave Optical Company started production of lens
ophthalmic lenses were also produced in based on von Rohr’s lens design as Punktal
later years. Both types of lenses were easy (point-forming) lens.
to manufacture but these lenses had very • In the year 1919, Edgar Tillyer designed
weak surface powers and having same lenses which were flatter than Punktal
curvatures on both the sides. lenses. He considered both oblique
• In subsequent years, with development of astigmatism and curvature of image factors
more manufacturing techniques flat in his design. In the year 1923, American
ophthalmic lenses (flat plus lens with flat Optical Company commercially made these
back surface, minus flat lens with flat front lenses available under the trade name
surface) were also produced. Tillyer.
• Later on, in the year 1804, meniscus (convex • In the year 1920, Kurova corrected curve
–concave or moon-shaped) form of lens was lenses were developed by Continental
Optical Company which were later on Negative and positive toric lenses: Previously,
redesigned by FE Duckwall in 1925. These all corrected- curve spherocylindrical lenses
lenses were having 39 base curves ranging were developed as positive toric lenses but
from +2.5 to +12.5 D powers. many researchers have redesigned them as
• Wilbur Rayton designed Orthogon lenses negative toric lenses also. Advantages of
with the aim to correct oblique astigmatism negative toric lenses are that
like Punktal lens. However, correction of • Most of the multifocal lenses are negative
curvature of image was not included in this toric lenses where bifocal addition is given
design. These lenses were slightly steeper on the front surface.
as compared to Tillyer lenses. In the year • Negative toric lenses play an important role
1928, Bausch and Lomb Optical Company in the spectacle magnification factors. In
initiated production of Orthogon lenses. positive toric lenses two front surface
• On the basis of 14 base curves, Shuron powers and two back surface powers are
Optical Company designed Widesite lenses present, whereas in negative toric lenses
which all were made in a positive toric form. front surface power is the same for both
• In the year 1950, famous Normalsite correc- meridians. Hence, front surface powers
ted curve lens series (designed by Foster contribute in a spectacle magnification
Klingaman) was developed by Titmus difference between two surfaces in
Optical Company. These Normalsite lenses positive toric lenses and not in negative
were flatter as compared to other lenses. toric lenses.
• In early 1964, Univis Lens Company
introduced the Best-form lenses which Design of High Plus Lenses
were negative toric lenses designed by It has been seen that by using ophthalmic
EW Bechtold. lenses with spherical surfaces an oblique
• In the year 1966, Shuron-Continental astigmatism in the range of –23 D to +7 D can
Company developed a negative toric lens be eliminated, however, beyond this range it
series called Kurova Shursite. The bending was impossible to remove oblique astigma-
curvatures of the Shursite negative toric tism. In regular clinical practice, patients
lenses were similar to those of Shuron having refractive error more than –23 D are
Continental Kurova positive toric lenses. rarely seen, however, aphakic patients usually
require more than +10 D power of optical
Spherocylindrical Lens Design correction. Though, contact lenses are good
Astigmatic lenses designed for correction of alternative to spectacles but many of these
astigmatism consist of a spherical surface on patients being old are not comfortable with
one side and a toric surface on the other side contact lens. These persons who required
with two principal meridians. One meridian more than +4D to + 6D correction of oblique
of lens has minimum power and other astigmatism in lens can be prescribed
meridian has maximum power. The total sum aspherical surface lens design instead of a
of powers of two surfaces in each principal routine spherical surface. Aspheric surfaces
meridian remains fixed so that an image of are the one where power of lens gradually
the lens/eye system is aligned with axial decreases toward its periphery. In other
vision. As these lens design have two powers words, an aspheric surface is the one which
so when light ray from a point object situated is axially symmetrical and is formed by the
on the optical axis of the eye falls on a sphero- rotation of a portion of an ellipse, a parabola,
cylindrical lens, it results in formation of an or a hyperbola. David Volk (1958) developed
astigmatic pencil after refraction, which in aspheric spectacle glass lenses known as
succession pass through two focal lines. Conoid lenses. Production cost of aspheric
lenses has decreased greatly due to wide

acceptance of CR-39 plastic lens material
because these lenses could easily be manufac-
tured by a molding process instead of
routinely used grinding process.
Terminologies in Spectacle Lenses

To understand the details of above type of
lenses we need to know these terminologies
related to lenses.
Blanks
Zero powered roughly finished slabs of glass
are called blanks. Commonly, these glass slabs
are available in different diameter sizes of
50 mm, 55 mm, 60 mm and 65 mm, however,
very large size blank, say 70 mm or 75 mm
are also available for specific indications.
Thickness of these blanks range from 4 to
14 mm at 2 mm steps.
All ophthalmic blanks have following two
refractive surfaces with a resultant zero power Fig. 12.17: 6 D Blanks. BC: Base curve having fixed
• Base curve 6 D power CS: combination surface, used to grind
• Combining surface power. A. Minus 6 D blank; B. Plus 6 D blank
Base Curve and a –8 D power is grinded on combining

It is a standard fixed power curve of a blank. surface of the blank to produce a final –2 D
Available base curves are with a standard power lens.
power of zero D, 1.25 D, 2 D, 4 D and 6 D,
Lens Power
however, best form lenses have a base curve
of either 1.25 D or 6 D power. Refracting power of an ophthalmic lens can
be expressed in several ways like
Combining Surface • Approximate power which is also called
This is the other surface of blank on which nominal power when the power of an
desired power is grounded. Net power of the ophthalmic lens is expressed in terms of its
lens is produced by grinding the respective front and back surface powers irrespective
combining surface of a blank provided by of lens thickness.
manufactures. To get a net plus power lens, a • Back vertex power and front vertex power
blank having minus base curve is used and to when ophthalmic lens power is considered
get a minus power lens, a plus base curve in terms of refracting power for emergent
blank is used. rays from its back surface or front surface.
For example, in Fig. 12.17A, to get a lens of • Equivalent power when power of a thick
+ 2 D, –6 D base curve blank is used and a ophthalmic lens or optical system is
+8 D power is grinded on combining surface equated as power of a single thin lens.
of the blank to produce a net +2 D power lens. • Effective power: Here the power of an
Similarly, as shown in Fig. 12.17B, to produce ophthalmic lens is dependent upon its
a –2 D lens, a +6 D base curve blank is used distance from the wearer’s eye.
Note: Among all these expressions of power

specification, practically only back vertex power
is used by optical laboratories and practitioners to
specify an ophthalmic lens power.
Approximate Power
Approximate power of an ophthalmic lens is
calculated by
P = Fa + Fb
Here Fa and Fb represents the powers of
front and back surface, respectively (Fig. 12.18) Fig. 12.19: Back vertex power of lens in air. L1, L2:
and can be measured by lens measure or lens Front and back refractive surfaces of ophthalmic lens
clock. respectively. F’: Secondary focal point. T: Thickness
In this formula for power calculation, of lens
thickness of lens is not considered as it is
Back vertex power is considered important
presumed that a lens has zero thickness.
parameter to indicate the power of an
However, in reality most of the ophthalmic
ophthalmic lens because
lenses cannot be considered to be markedly
thin, thus we need a more accurate expression • As discussed above to measure back
for calculation of lens power which includes vertex power, two points, i.e. back vertex
back vertex power, front vertex power, and of lens and second focal point are
equivalent power. considered. If we select such a power of
lens at which the second focal point of
Back Vertex Power the lens is placed at far point of the eye
This is expressed as the reciprocal of the back then lens can easily be placed at any
focal length [i.e. distance from the back pole position in front of the eye. Hence, an
(vertex) of lens (L2) to the second focal point ophthalmic lens if placed either in a
(F’)]. The second focal point is the actual spectacle plane or on the cornea (contact
distance divided by the refractive index of lens) we can still be able to specify its
ophthalmic lens media. In this Fig. 12.19 back back vertex power to get the expected
vertex power of lens (F’v) in air is expressed optical effect.
as the reciprocal of the distance L2 to F’. • Back vertex power permits an indefinite
utilization in terms of lens form like bend
or cross section shape of ophthalmic
lenses. We can use any form of ophthal-
mic lens either for examination purpose
or fitting process in clinical practice.
What we have to do is just to ensure that
secondary focal point of our ophthalmic
lens coincide with the far point of eye.
Note: Back vertex power can be measured by an
instrument lensometer or vertometer.
Front vertex power or neutralizing power:

The power of an unknown ophthalmic lens
can be measured by neutralizing it with trial
Fig. 12.18: Front (Fa) and back (Fb) powers of lens lens of known power. When these two lenses
are positioned in close contact, these lenses are (equivalent lens) so that it becomes easy to find
considered to neutralize the power of each out object–image relationship of equivalent
other when their measured total refracting lens. It is assumed that this imaginary single
power becomes zero. The neutralization lens will produce the image of a distant object
means that focal lengths of both unknown and of same size and at same position as produced
known lens are equivalent in amount and also by series of lenses of optical system. The focal
the secondary focal point of the known length of this imaginary single lens (equivalent
ophthalmic lens coincides with the primary lens) at which image of same size and at the
focal point of the unknown ophthalmic lens. same position produced similar to those by
Routinely, when we neutralize a spectacle optical system is known as equivalent focal
lens by placing the back pole of a trial lens on length. The reciprocal of this equivalent focal
the front pole of the spectacle lens then we length (meters) is called the equivalent power.
are measuring the front vertex power of Position of this thin equivalent lens with
spectacle lens. Hence, front vertex power is respect to the system is determined by
defined as the negative reciprocal of the locating the principal planes of the optical
reduced distance from the front pole (L1) of system. In symmetrical optical systems only
the lens to its primary focal point (F). a single pair of planes is present; which poses
An expression for front vertex power (Fv) the property of positive unity (+1) magnifi-
can be derived in a similar way as that for back cation (means the object and its image are of
vertex power (F’v). As per above definition same size and image is erect). These pairs of
neutralizing power is the negative reciprocal planes are called principal planes and the
of the distance L1F in Fig. 12.20. points of intersection of optical axis with these
planes are principal points of optical system.
Equivalent Power • Principal plane associated with the object
Many of the optical devices act as a complex space is termed primary principal plane
optical system as they contain a series of lenses and plane with the image space is
which remain separated either by air or by secondary principal plane.
media of different refractive indices. Some- • The distance from the primary principal
times, it is suitable to consider this complex point (P1) to primary focal point (F) is
system of lens as an imaginary single thin lens called primary equivalent focal length
(Fe) as shown in Fig. 12.21.
• Similarly, the distance from secondary
principal point (P2) to the secondary
focal point (F’) is called secondary
equivalent focal length (Fe’). The
reciprocal of the secondary equivalent
focal length is the equivalent power of
an optical system.
Effective Power
An ability of a lens to focus parallel light rays
at a specified plane is termed effective power
of that lens. The term effective power is mainly
Fig. 12.20: Front vertex power of lens in air. L1, L2: considered to define the requirement of
Front and back refractive surfaces of ophthalmic lens change in the power of lens when the lens is
respectively. F: Primary focal point. T: Thickness of moved from one position to another position
lens in front of the eye.
Fig. 12.21: Primary and secondary equivalent focal length. L1, L2: Front and back refractive surfaces of
ophthalmic lens respectively. F: Primary focal point; F’: Secondary focal point, P1: Primary principle plane,
P2: Secondary principle plane, Fe: Primary equivalent focal length, Fe’: Secondary equivalent focal length
Practically we consider that plus lenses are

more effective because when these lenses are
moved farther away from the eyes they
produce more change in vergence than
required. While minus lenses are considered
as less effective because when these lenses are
moved farther away from the eyes, they
produce less change in vergence than required.
Classification of Spectacle Lenses

Spectacle lens classification is summarized in
Table 12.3. The specific features of each type Fig. 12.22: Symmetrical lens
of lens in relation to spectacle fitting purposes
have also been explained. Asymmetrical lenses: Ophthalmic lenses
having different curvatures of both the
Various Lens Forms surfaces are called asymmetrical lenses as
Symmetrical lenses: When curvatures of both shown in Fig. 12.23.
the surfaces of lenses are same, they are called Plano lenses: In these types of lenses one
symmetrical lenses as shown in Fig. 12.22. surface has zero power or plane, whereas
Table 12.3: Classification of spectacle lenses

Based on lens form Based on corrective power
Symmetrical Monofocal lenses
Asymmetrical Plano focal lenses
Plano Multiple focal lenses
Periscopic • Bifocal lenses
Deep meniscus • Trifocal lenses
Lenticular • Varifocal or progressive lenses
Aspheric
Fig. 12.23: Asymmetrical lenses Fig. 12.25: Periscopic lens
Fig. 12.26: Deep meniscus lens

Fig. 12.24: Plano lenses
other surface has curvature. For example,
Plano convex or plano concave as shown in
Fig. 12.24.
Periscopic lenses: These lenses are considered
as best form lens having a base curve of 1.25
as shown in Fig. 12.25 and on combined
surface (+4.25 D in our example) power for
final lens is grinded.
Deep meniscus lenses: These lenses are also
a type of best form lens where base curve is of
6 D as shown in Fig. 12.26 and on its combined
surface (+11 D in our example) power for final Fig. 12.27: Original Myo-disc lens designs
lens is grinded.
Lenticular lenses: These lenticular lenses were in Fig. 12.27. Most of the lenticular lenses
designed by Obrig (1933) for correction of high which were manufactured later on were
degree myopia and named them Myo-disc. A almost similar to this original Myo-disc lens
small concave disc was grinded on the back in their designing.
surface of a Plano lens for formation of this Most of the lenticular lenses contain a
thin and light weight Myo-disc lens as shown powered central portion (optical zone) called
as aperture which is about 30–40 mm in

diameter. This aperture is surrounded by a
carrier lens, having Plano or low plus power.
Initially, these lenses were prepared with the
aim to reduce the thickness of lens, hence in
past for many years majority of the glass
aphakic lenses were made in lenticular form
with some minor percentage of plastic lenses.
Various types of lenticular lenses are
• Solid state lenticular lenses: Here the carrier
is cut in a convex shape from the base lens
as shown in Fig. 12.28 and this design is
mainly used for plastic lenses.
• Fused lenticular lenses: Here aperture is
fused on back surface of plus power lens Fig. 12.30: Plano lenticular lenses. A. Concave
aperture; B. Convex aperture
under high temperatures and then desired
power is grounded on the front surface
• Plano lenticular lenses: These lenses have
(Fig. 12.29). These types of lenses are mainly
either a convex or concave surface aperture and
used for glass lenses.
a plane surface carrier as shown in Fig. 12.30A
and B. Initial Myo-discs are an example of
minus lenticular lenses of these types.
• Cemented lenticular lenses: These lenticular
lenses are made up of a spherical aperture
cemented with a cylindrical carrier by glue.
These lenses are used mainly in patients
having high astigmatic refractive errors.
Advantages of lenticular lenses
– Light weight
– Thin lenses
– Less optical aberrations
– Less spectacle magnification
Fig. 12.28: Solid state one piece lenticular lenses – Correct high refractive errors
Disadvantages of lenticular lenses
– Bull’s eye or fried egg appearance
– Difficult spectacle fitting
Aspheric lenses: The problem encountered
during the use of lenticular design lenses for
correction of high degree refractive anomalies
lead to the development of new design plastic
lenses known as aspheric lens. These lenses
have an aspheric surface (ellipsoid) which
progressively gets flat on the periphery so that
power of lens also reduced gradually towards
the periphery, thus especially useful in
Fig. 12.29: Fused lenticular lenses aphakic patients. In addition, aspheric lenses
also pose the advantages of lenticular form flexible pads. Armorlite multi-drop lens
lenses, i.e. reduced aberrations of lenses along formerly called Welsh four drop lens is one
with reduced thickness and weight. To of the examples of aspheric design lens.
prepare ophthalmic aspheric lens design
mostly conicoid (ellipse, parabola, or hyper- Monofocal Lenses
bola) surfaces were used. These are the lenses used to correct either
Presently to form aspheric surface for an distance vision or near vision problems, hence
ophthalmic lens, two manufacturing approa- are also called single vision glasses. These
ches are used lenses are either spherical or spherocylindrical
• American Optical Fulvue manufactures in nature. Entire surface of these lenses has
aspherical lenses which have a continuous the same corrective power, hence are used to
aspheric surface. The curvature of conti- correct refractive anomalies such as myopia,
nuous aspheric lens decreases constantly hypermetropia, and astigmatism with
from its central portion toward the presbyopia. Various designs of these types of
periphery as shown in Fig. 12.31. Hence, lenses had already been discussed above.
there is a continuous reduction in refractive Plano focal lenses: These lenses are similar to
power towards the edge or periphery due bifocal lenses in the shapes and designs but
to reduction in curvature of the lens. the upper portion of the lens is used for
• Annular pattern arrangement aspheric lens distance vision correction, has no optical
designs: The lens surface consists of series power or plane, whereas the near segment has
of different zones (spherical in shape) an appropriate power to correct presbyopia.
around the center. The surface power of These types of lenses are very useful in
each zone progressively decreases towards patient’s having only presbyopic errors who
periphery, means the farthest zone from the perform continuous near work, if they use
center has least power and the nearest zone single vision glasses they need to remove the
has maximum power. The tangents to glasses very frequently to see the distance
curves of adjacent zones are arranged in objects clearly.
such a manner that they coincide with the
Bifocal Lenses
boundary between the two adjacent zones;
thus eliminating the prominent dividing • Invention of the bifocal lens was done by
lines on aspheric surface. The junctions the scientist Benjamin Franklin in the year
present between two adjacent zones are 1785, to avoid discomfort due to wearing
made smooth by polishing the surface with of two separate spectacles for distance and
near vision; he cuts both the glasses into
halves and fixed them in a single spectacle
frame as shown in Fig. 12.32. The bifocal
lens designed by Franklin has looks similar
to executive single piece bifocal (available
nowadays) with a dividing line on the lens.
Although these bifocals showed excellent
optical property, but the dividing line
across the lens produced reflections and
had a tendency to collect dust, causing
discomfort to wearer. The structural
strength of lens was poor as both portions
Fig. 12.31: Continuous aspheric lens design showing of lens were kept in positions with the help
reduced surface focusing light rays nearer. of eye wire of the frame.
• John Borsch (1889) took another step in

bifocal invention and developed cemented
Kryptok bifocal lenses.
• In the year 1915, Henry Courmettes further
improved the design of fused bifocals; by
fusing a button (segment) into the major
lens, which was made up of two types of
glasses.
• Subsequently, in the year 1931, Watson and
Culver designed and also patented the
bifocal “B” or bar segment bifocal lens
(straight top) as shown in Fig. 12.34.
Fig. 12.32: Original Benjamin Franklin lens design
Almost during the same period four
• In the year 1838, Isaac Schnaitmann inventors filed identical patent applications
developed a type of bifocal lens called solid for the “D” style segment (looks like a letter D,
up-curve bifocal and it was first one-piece lying on its back) as shown in Fig. 12.35.
bifocal lens which gained popularity. This Finally, in the year 1933, NH Stanley got
lens was having good structural strength, the patent, for this D style segment.
invisible dividing line, less chances of chro-
matic aberration and provided wide field of
view for reading than Franklin lens. However,
in the distance portion of lens significant
amount of aberrations were noticed, hence
restricted the field of vision for distance.
Moreover, a strong base down prismatic
effect was seen in the distance part of lens.
• August Morck (1888) developed modified
form of Franklin bifocal and named it
perfection bifocal lenses. Perfection bifocal
contained a curved dividing line. Each glass
piece of lens had beveled edge which led
to more stabilization of lens in the spectacle
Fig. 12.34: Bifocal ’B’ or bar segment lens design
frame as shown in Fig. 12.33. Morck also
invented cemented bifocal design in the
year 1888.
Fig. 12.33: Perfection bifocal lens design Fig. 12.35: Bifocal ‘D’ segment lens design
• Silverman (1932) developed the “R” or

ribbon segment and patented R-compensated
series of lenses; which contain 7 segments
(R4 to R10) designed to compensate for
vertical prismatic effects in the near vision.
• Hammon and Price modified the ‘D’ style
design called as Panoptik (having rounded
corners) and Widesite (having curved-top
version).
• Charles Conner (in 1910) produced a bifocal
lens which was grounded from a single
piece of glass, having a uniform refraction
index. He called this lens Ultex bifocal.
• American Optical Company (in 1954) took Fig. 12.36: Cemented bifocal lens design
the next step for the development and back surface of glass piece was kept less
manufacturing of one-piece bifocal known concave as compared to the back surface of
as executive bifocal. major lens.
Bifocal lenses are broadly classified as
summarized in Table 12.4. Advantages
• Optically acceptable.
Single Segment Bifocals • Cosmetically widely accepted, hence was
Cemented bifocals: In the year 1888, Morck used nearly for a century.
invented the cemented bifocal lens. To Disadvantages
produce cemented bifocal lens, a piece of thin • Chances of dust collection on shoulder
glass (having refractive index similar to major around the dividing line.
lens) was cemented/glued on the back surface • Temperature changes were affecting the
of the major lens as shown in Fig. 12.36. Morck adherence property of the glass piece.
used Canada balsam as cementing or glued • Glass piece had a propensity to fall off easily
material because the refractive index of with long usage.
Canada balsam was equal to glass. The • Cement was getting darken with use and
curvature of both, i.e. front surface of glass time.
piece and the back surface of the major lens In the year 1889, Borsch developed Kryptok
were equal hence no change in refractive (means hidden) cemented bifocal lens. He
power had occurred between these two created a countersink curve, like a depression
surfaces. Power of addition was simply the on the front surface of major lens. Then a wafer
difference between the powers of back or glass piece (flint glass) of refractive index
surfaces of major lens and glass piece; as the 1.67 was cemented into this countersink area.
Table 12.4: Classification of bifocal lenses

Single segment bifocals Double segment bifocals
Cemented bifocals Fused double D segment bifocals
Fused bifocals Double segment executive bifocals
One piece bifocals Mixed double segment bifocals
Special type bifocals
• Minus add bifocals
• Golfers’ bifocals
present. Initially, Kryptok lenses were available

in different segment sizes, but now only
22 mm segment size is available in the market.
Gradually, every lens manufacturer
developed a round segment bifocal lens
having a specific designed company’s
corrected curves. They all used barium crown
glass for the segment instead of flint glass
because barium crown glass has high nu value,
hence chances of chromatic aberrations
decreased significantly. Kryptok lenses are
manufactured by fusing a round segment
inside the groove of major lens as shown in
Fig. 12.37: Kryptok lens design popularly called KT Fig. 12.38.
Normally the segment size in the round
Finally, the surface of entire lens was covered fused bifocal lenses is of 22 mm in diameter,
with a thin meniscus of glass cemented in with the segment optical center located at
place (Fig. 12.37). 11 mm below the segment top in an uncut lens
These were the first bifocal lens where form (Fig. 12.39).
refractive index of reading addition (near
segment) material was higher (1.67) than the
major lens.
Disadvantages
• Difficult to manufacture because six sur-
faces needed to be grounded and polished.
• Lens covering of thin meniscus glass was
very fragile.
• Darkening of cementing material.
• Chances of dislocation or separation of lens
Note: Occasionally, in some special conditions like Fig. 12.38: Manufacturing process for round segment
low vision aid, temporary bifocals or for bifocal (Kryptok) lens
experimental purposes these cemented bifocals are
still used and an Epoxy resin (Araldite) is used in
place of Canada balsam as cementing material for
better stability.
Fused Bifocal Lenses: Most widely used

bifocal lenses are fused types of bifocals and
hence available in several segment styles like
• Round segments
• Straight top segments
• Modified straight top segments
Round segments bifocal lenses: Original
Kryptok bifocal lenses were low in cost but
made of flint glass (small nu value) segment Fig. 12.39: Locations of segment and optical center
so a large degree of chromatic aberration was in round segment bifocal lens
Several lenses belong to this category are

American Optical Tillyer, Univis Unachrome,
Shuron Continental Kurova and Vision Ease
CRF. Round segment size in Univis R and
Vision Ease R bifocal lenses is 22 × 14 mm
segments and in Kurova B is 28 × 14 mm.
Straight top segments bifocal lenses: Most
commonly used types of bifocal are straight
top fused bifocal which was first developed
by the Univis Lens Company of Dayton.
Originally, Univis Sentinel D lens was made Fig. 12.41: Showing Courmettes fusing process.
first by fusing a truncated round high index A. Major lens with counter sink area; B. Button made
segment with small crown glass segment and up of two glasses; C. Finally fused bifocal ‘D’ lens
then fusing this entire segment into a
countersink area of major lens as shown in
Fig. 12.40.
Once the patent of Univis got expired,
straight top bifocal lenses were produced by
many other lens manufacturers like American
Optical Tillyer D, Masterpiece S, Shuron
Continental Kurova D, and Vision Ease D. All
of these lenses are available in various
segment sizes as 22 × 16 mm, 25 × 17.5 mm,
and 28 × 19 mm. Tillyer Masterpiece S bifocal
lens is also available in a 20 × 15.5 mm segment
and Vision Ease D in a 35 × 22.5 mm segment.
Courmettes fusing process of ‘D’ bifocal Fig. 12.42: Final ‘D’ bifocal lens showing 5 mm mark
lens manufacturing involves usage of a button below top edge of segment
made up of two different types of glasses. This
button is fused in a countersink area present centre but finally after fusing the resultant
in the major lens and a finally finished lens is segment optical center came 5 mm below the
manufactured as shown in Fig. 12.41. segment top margin (against 11 mm below top
Initially upper edge of the straight top margin in round segment lenses) as shown in
segment was located 6 mm above the optical Fig. 12.42.
Modified straight top segment bifocal
lenses: Enormous success of Univis straight
top bifocal lenses encouraged other manu-
factures to develop modified forms of straight
top bifocal. Panoptic design by Bausch and
Lomb and Widesite lenses by Shuron were the
earliest modified straight top segment bifocal
lenses (Fig. 12.43).
Panoptic bifocal has a 23 × 15 mm segment
with slightly rounded corners, whereas
Widesite has a slightly curved top. Recently,
Fig. 12.40: Straight top bifocal lens manufacturing Univis F and Vision Ease C bifocals were
process introduced having a similar shape as that of
in most of the round one piece bifocals the near

segment is located on the back surface of the
major lens. Hence, if a cylindrical correction
is needed, then major lens must be grounded
on its front surface or in a plus toric form.
However, very few types of one piece bifocals
are made in a negative toric form, similar to
the fused bifocals.
One piece round segments bifocal lenses:
Fig. 12.43: Modified bifocal ‘D’ segment lens
Original Ultex A and AL type lenses have
designs. A. Panoptic design with rounded edges; B.
Widesite design with curved top large round segments. The lower parts of the
segment have been cut off, hence are also
Panoptic while American Optical Tillyer called hemispherical segments. Both Ultex A
Sovereign and Shuron Continental Kurova CT and AL lenses have segments having 38 mm
as that of Widesite. diameter where in A type lens the segment is
Ribbon Segments bifocal lenses are essen- 19 mm high and in AL type lens it is 32 mm
tially a modified type of straight top segment; high in uncut lens form. Both forms of Ultex
here the lower part is cut off so that wearer lenses have near segment on the back surface
can have distance vision from both below and of the major lens as shown in Fig. 12.45.
above the segment as shown in Fig. 12.44. These Ultex design lenses are manufactured
In all designs of fused bifocal lenses, say by chipping technique as shown in Fig. 12.46.
round, straight top, modified straight top, or
ribbon segments, the bifocal segment is
located on the front surface of the major lens.
As segment side of major lens should have a
spherical surface for fusion process, in these
fused bifocal lenses if a cylindrical correction
is needed, then major lens must be made in a
negative toric form.
One piece bifocal lenses: These lenses are
available in both round and straight top
segment styles. As compared to fused bifocals
Fig. 12.45: One piece round segment bifocal lenses.

A. Ultex A type having 19 mm segment; B. Ultex AL
Fig. 12.44: Ribbon segment lens design type having 33 mm segment
Fig. 12.47: Executive bifocal lens design

Fig. 12.46: Chipping technique for manufacturing
of Ultex lenses
Another type of additional hemispherical

one piece bifocal was developed by Robinson
Houchin as Hydray having segment sizes of
either a 40 × 20 mm or a 38 × 33 mm situated on
either the front or back surface of the major lens.
Gross appearance of these lenses is like a
Kryptok or any other round fused bifocal,
however, a feeling in the change of curvature
from major lens surface to near segment is
present in one piece bifocals. Fig. 12.48: Showing manufacturing of executive
bifocal lenses
One piece straight-top segments bifocal
lenses: Straight top one piece bifocal lenses window at top of the lens. These lenses are
are also called Executive bifocals and are rarely used and are prescribed only for
produced by several manufactures under presbyopes in profession like barber or postal
various names like Univis E, Kurova M, Vision clerk, who need a larger near field to work.
Ease Bifield, and Hydray EX. In uncut lenses Solid up curve bifocal lens were the first
the standard height for near segments is introduced minus add bifocal and currently
25 mm in all types (Fig. 12.47) except in an Ultex one piece form called Rede Rite
Hydray lens where the segment is 29 mm high. bifocal is available in the market. Normally,
Manufacturing process of executive bifocal in bifocal lenses the upper edge of the near
lens is simple and involves a rotating device segment is located at lower lid margin of
over which the lenses are glued. Then another wearer but in minus add lenses the edge of
device create groove on this rotating drum as near segment is located above the center of
shown in Fig. 12.48. pupil as shown in Fig. 12.49A.
Another way to obtain an unusually large
Special Types of Bifocal Lenses reading field is by the use of a 28 mm high
Minus add bifocal: These minus add bifocal straight top one-piece executive style bifocal
lenses were especially designed to perform as shown in Fig. 12.49B. Even the standard
near work having only a small distance executive style bifocal lens can be fitted as
For a right hander Golfer this near segment

is placed only on right side of the spectacle
and for a left hander golfer in the left side of
the spectacle frame. This peculiar position of
the near segment remains completely out of
the way, when person is playing however,
enough near vision is present to read score
card or menu card.
Double Segment Bifocals

Bifocal lenses having two addition segments,
Fig. 12.49: Minus add bifocal lens designs. A. Solid i.e. one below the level of pupillary margin
up curve bifocal design; B. Straight top one piece and another above the level are called
design double segment bifocals. These are mainly
used by electricians, painters, and by other
high as 25 mm, this will also bring add professionals, who do close work above the
segment top, well above the center of wearer’s level of the eye. Majority of these lenses are
pupil. of straight top variety which are available
Golfers’ bifocal lenses: A common multifocal in both fused and one-piece forms. Distance
lens can be changed into a special design lens between upper and lower addition segments
on demand of specific occupation simply by is 13 mm in almost all varieties of these types
changing its fitting position in the spectacle of lenses.
frame. The first double segment bifocal lenses
For example, a 50-year-old golfer regularly were introduced by Univis as fused double D
complain about the near segment of his/her (Fig. 12.51A) and is available in either 22 or
multifocal lenses (even progressive lenses) 25 mm add segments widths. Tiyler double
that near segment obstruct the view of golf executive lens designs are also popular as
ball or when he/she tries to line up a hole. To shown in Fig. 12.51B.
solve this problem a special type of bifocal lens Several companies like Vision Ease,
was developed called golfer’s bifocal lens. American Optical, Robinson Houchin and
Here the near segment usually of round shape Shuron Continental make mixed double
is placed in the outer lower corner of just one segment bifocals in various segment combi-
lens of spectacle as shown in Fig. 12.50. nations as shown in Fig. 12.52.
Fig. 12.50: Golfer’s bifocal lens designs. A. For right Fig. 12.51: Double segment lens designs. A. Round
eye; B. For left eye segments; B. Straight top segments
Fig. 12.52: Mixed double segment bifocal lens

showing various types of segments Fig. 12.53: Trifocal lens design
Note: Double segment bifocal lenses are not and Shuron-Continental all these companies
trifocal lenses. manufacture a straight top trifocal lens,
whereas American Optical, Vision-Ease, and
Trifocal Lenses Robinson Houchin manufacture an Executive
style one piece trifocal.
With bifocal lens many presbyopes, wearing
For occupations like computer operator, a
+2 D or more optical correction feel difficulty
special design of CRT trifocal lenses has been
to see an object situated at an intermediate
introduced having a 14 mm high intermediate
distance (say 1–1.5 meters) either via distance
segment as shown in Fig. 12.54. CRT lens is
or near segment of that bifocal lens. It happens
suitable for professions where high percentage
because when the presbyope see the object at
of near work is needed at an intermediate
this distance through the distance portion of
distance.
bifocal lens, his near point of accommodation
lies beyond the object of interest, while when Plastic multifocal lenses: Presently, demand
the object is seen by person through the near of plastic multifocal lenses has increased.
portion of bifocal lens, then the far point of Almost all plastic multifocal lenses are one
accommodation lies too close for the object of piece design where near segment is located
interest. To eliminate this problem trifocal lens on the front surface of lens. These lenses are
were introduced in which another intermediate produced in finished or semi-finished form.
segment having an additional intermediate
power in lens was added. This intermediate
segment is added just above the near segment
of lens. Univis introduced trifocal lenses first
time by name of Continuous Vision lenses.
Originally, in Univis lenses the height of
intermediate segment was kept 6.0 mm, which
later on changed to 8.0 mm occupational
segment, however, nowadays almost all
trifocals have an intermediate segment height
of 7.0 mm as shown in Fig. 12.53.
Trifocal lenses are available in various styles
and combinations in both fused and one-piece
forms. Univis, American Optical, Vision- Ease, Fig. 12.54: CRT lens design having 14 mm segment
Varifocal or Progressive Lenses

These lenses have corrective power for
distance and near vision along with a
progressive power zone or corridor which
extend across the entire width of lens and
connect distance and near portions of the lens.
Central portion of the progressive lens is
the functional area of progressive power zone
and is known as progressive corridor or zone
(Fig. 12.55). Refractive power of varifocal lens
increases progressively from the distance to
the near portion along this progressive Fig. 12.56: Umbilical line and astigmatism in
corridor. All powers lying in between the proportion to displacement. For same amount of
distance and near powers are present in this astigmatism, vertical displacement B is twice the
progressive corridor. No visible reading lateral displacement A
segment and/or no dividing lines are present This designing principle of progressive lens
in this corridor, hence practically there is no developed two approaches of production of
image jump. progressive lenses
The most important factors of a progressive • Hard design: Progressive lenses designed
lens are interconnected and include on this basis give a relatively larger area
• Size of distance and reading areas of high quality images in all areas of lens,
• Types and intensity of aberrations i.e. distance portion, progressive corridor,
• Depth and functional width of corridor and near portion. However, there is an
Various types of progressive lens designs associated high degree of astigmatism in
available differ in high image performance lateral portions of progressive corridor.
and the severity of aberrations. An inherent • Soft design: Progressive lenses designed
astigmatism may be produced either right or on this basis give a smaller area of high
left of the umbilical line (A line at center of quality images in all areas, i.e. distance
progressive corridor as shown in Fig. 12.56) portion, progressive corridor, and near
during creation of an aspherical surface with portion; but has a low degree of astigma-
variable radius of curvatures; this astigmatism tism in lateral portions of progressive
is proportional to the rate of change in the corridor.
curvature. Several types of progressive lenses were
produced till date and some important types
of progressive lenses are
Omnifocal Lens: In the year 1961, David Volk
and Joseph Weinberg introduced first successful
progressive lens known as Omnifocal, which
was manufactured by Robinson Houchin.
These lenses were made of glass and having
aspherical or progressive front surface. Radius
of curvature of aspheric surface of lens (front
surface) progressively reduced in vertical
meridian from top to the bottom, whereas in
the horizontal meridian radius of curvature
Fig. 12.55: Varifocal or progressive lens remained same.
Fig. 12.57: Omnifocal lens designs. A. Plus power

increases downwards from distance optical center and
decreases upwards; B. Functional area of lens decreases
gradually from top to bottom showing distance optical Fig. 12.58: Varilux lens design with central 12 mm
center (DOC) and near optical center (NOC) progressive zone and constant power in distance and
near zone.
The distance optical center of lens lies at a
vertical distance of 25 mm from near optical limited to a 12 mm deep zone, rather than
center of lens. Total amount of plus power extending from top to bottom as in soft design
decreases upwards from distance optical lenses. Varilux lenses are manufactured
center and increases downwards from differentially for the right and left eyes,
distance optical center as shown in Fig. 12.57. because the line of symmetry is inclined
Omnifocal lens was an example of soft nasally toward the bottom of lens as shown
design because the progression of power is in Fig. 12.59. Original Varilux lens were
from top to bottom in entire front surface of available only in glass material.
lens. These lenses are now obsolete but Later on after expire of patent of Varilux 1
mentioned due to its historical importance. progressive lens, the Varilux 2 lens was
introduced by Essel. In this lens not only the
Varilux lens: In the year 1959, Bernard
progressive zone but also entire front surface
Maitenaz developed original Varilux lens and
of lens was of aspherical design. Hence, this
Essel Optical of France introduced them in the
lens was considered as soft design progressive
market. Later on in the year 1967, Titmus
lens. Lateral astigmatism was greatly redu-
Optical Co introduced this lens in the United
ced in Varilux 2 with improvised vision
States, popularly called Varilux 1.
qualities.
Varilux 1 was different in design from
Omnifocal lens. The upper half of Varilux 1
had no progression in power and only 12 mm
deep zone situated in the center of lens had a
progressively increasing refractive power. A
zone of maximum addition with a constant
power having a width of about 22 mm was
situated below progressive corridor of lens as
shown in Fig. 12.58. In original Varilux design
lens, astigmatism free progressive corridor of
5 mm width was also present but on increasing
the power of near addition, the functional
width of the progressive corridor decreased.
Varilux lens is considered as a hard design Fig. 12.59: Nasal inclination of progressive zone in
lens because progressive front surface is right-sided Varilux lens
Once the patent on original Varilux expired • In the year 1986, Seiko Optical Products
several manufactures introduced their own introduced two progressive lenses called
version of progressive lenses. For example, P-2 and P-3.
• In the year 1973, American Optical • Polarite in the year 1986 developed a
introduced Ultravue CR-39 plastic lens. plastic polarized progressive lens by the
A 25 mm wide segment corridor was name of Progressive M. Most recently
present in this lens, hence was renamed Varilux infinity(1988) and Varilux
as Ultravue 25. In the year 1978, another comfort (1993) progressive lens designs
lens with same design called Ultravue 28 were developed to increase the comfort
was introduced with a 28 mm wide of wearer in advancing presbyopic age.
segment. Ultravue lens has an advantage
of a well-defined distance portion, SPECTACLE LENS FITTING
astigmatism-free surface and wide Spectacle lens fitting method: For an ideal
segment area, but at the cost of higher fitting of a lens in the spectacle frame knowledge
rate of progression. This lens was of hard of these following components is essential
design category.
• Interpupillary distance
• In the year 1978, Younger optics
• Frame dimensions
introduced Younger 10/30 CR-39 plastic
• Frame specification
lens. This lens has a 10 mm deep
progressive corridor with 30 mm wide • Spectacle frame selection
functional segment area, hence the name Interpupillary Distance
10/30. This lens was in hard progressive
lens design category. Optical center or major reference point of the
lens, these are two interchangeable terms
• In the year 1980, Silor Optical started
which indicate a point on the lens, where
marketing Super NoLine lens. This impro-
maximum effect of a prescribed prism will be
vised version of original NoLine pro-
seen. Distance between these two points on
gressive lens has a progressive corridor
two lenses of a spectacle lens is called inter-
12 mm deep. This lens has wide distance
pupillary distance (IPD).
and segment area of about 25 mm width,
hence designated in hard design category. Measuring interpupillary distance: First step
NoLine lenses are available in CR-39 for accurate lens fitting in a spectacle frame is
plastic, ophthalmic crown glass, and the measurement of interpupillary distance,
photochromic glass materials. commonly called IPD or PD and both the
Many more companies came up with distance PD and near PD has to be measured.
several types of progressive lenses, although These measurements are defined as distance
list is exhaustive but a few examples are between two visual axes for distance and near
• Cosmetic Parabolic Sphere (CPS) pro- vision, respectively at the level of spectacle plane.
gressive lens by Younger Optics As shown in Fig. 12.60 lines of sight are
• In the year 1982, American Optical parallel for distance vision, hence inter-
introduced Truvision lens. pupillary distance will be the same, whether
• Titmus Optical in the year 1983 started measured at the level of center of rotation
marketing NuVue 75 lens. plane, corneal plane or spectacle plane.
• In the year 1984, Coburn Optical Indus- However, in convergence condition for near
tries started marketing of Progressive R fixation, eyes rotate about their center of
lens. rotation with simultaneous convergence of
• Sola Optical in 1984 introduced a lens lines of sight, hence distance between them
called VIP lens. decrease from center of rotation plane to
(16 inches), holding a millimeter ruler in

one hand at the level of patient’s
spectacle plane.
• Then examiner instructs the patient to
look in his/her left eye, simultaneously
aligning the temporal edge of patient’s
right pupil with the zero mark on
millimeter ruler.
• Then the patient is asked to look at
examiner’s right eye, so that examiner
can record the reading on millimeter
ruler which is aligned with nasal edge
of patient’s left pupil.
Note: Sometimes it is difficult to see the pupillary

border especially in patients having very dark iris,
then the alignment of millimeter ruler is done with
the temporal limbus of right eye and nasal limbus
of left eye.
Fig. 12.60: Measuring interpupillary distance at
Test procedure for near PD measurement
various planes
(Fig. 12.61B)
corneal plane and further at spectacle plane • Examiner sits in front of the patient at a
level as shown in Fig. 12.61. distance of about one and a half feet
Visual axes distance can be measured by (16 inches), holding a millimeter ruler in
using: one hand at the level of patient’s spectacle
• Millimeter ruler plane.
• Elissor Pupilometer • Then examiner instructs the patient to
• AO Grolman device fixate either his/her right or left eye,
• Cal Coast PD ruler
• Bausch and Lomb PD gauge
• Topcon digital PD gauge
• Rodenstock interpupillary gauge
Similarly, pupil center and size can be measu-
red by
• Antique Pulzone hardy rule
• Bishop Harman rule
• Fairbanks facial gauge
• Basic Pupilometer
Simplest and most widely accepted method
to measure both distance and near PD is by
millimeter ruler method.
Test procedure for distance PD measure-
ment (Fig. 12.61A)
• Examiner sits in front of the patient at a Fig. 12.61: Measurement of PD. A. Distance PD
distance of about one and a half feet measurement; B. Near PD measurement
which is accordingly positioned on the The lens decentration is done to control

patient’s midline area by the examiner. prismatic effects, means either to produce a
• Then examiner aligns the temporal edge prismatic effect or to avoid a prismatic effect.
of patients right eye pupil with zero mark
on the millimeter scale, while note down Frame Dimensions
reading corresponding to nasal edge of For measuring lenses, a system of reference
patient’s left eye pupil. points was established for spectacle frames
and spectacle lenses which assist in accurate
Note: Normally at this measuring distance fitting of corresponding optical center and
(16 inches) near PD is usually about 4–5 mm less bifocal segments inside the spectacle frame.
than the distance PD.
Two systems were developed to ease the lens
Due to practical difficulties, it is probably fittings are Datum system and Boxing system.
advisable to measure the distance PD with
accuracy and then find out the near PD by Datum System
calculation with this formula. In the year 1935, Cole and Blackburn introduced
For each eye, difference between distance Datum system (Fig. 12.62) for accurate fitting
PD and near PD (say d) is calculated by of lenses in spectacle frames. Various
d/27 = ½ distance PD/427 or simply d = 27 terminologies used in this system are
(½ distance PD)/427 Datum line (AA): Placing the lens in a
For example, suppose distance PD is 64 mm, position as it should be fitted in a frame, the
then difference d for each eye, will be two horizontal tangents corresponding to
d = 27 (32)/427 highest (UU’) and lowest (LL’) edges of lens
are drawn. A parallel line drawn midway
= 2.02
between these two horizontal tangents is
Hence near PD is 64–2 (2.02) = 59.96 mm
called datum line of reference.
Following conditions can create problems
Datum length (MN): The peripheral
while measuring the PD by using a millimeter
portion of the lens which bound the datum
rule
line in horizontal plane is called datum length
• Difference in patient’s and examiner’s and it represents the horizontal dimensions
PD can introduce a parallax. of a lens.
• Anisocoria or pupil size difference in Mid-datum depth (a): Vertical line joining
both eyes can alter dimensions. upper and lower horizontal tangents from lens
• Asymmetry of the face edges is called as mid-datum depth and it
• Invisible pupil margins represents the vertical dimension of the lens.
• Vertical differences of the two eyes.
• Lateral head or ruler movement while
measuring a PD.
To align the visual axis of eye and optical
axis of spectacle lens sometimes we have to
decenter the lens horizontally depending
upon the frame dimensions and PD. To get
the best possible visual results, it is necessary
to align visual axis and optical center of spec-
tacle lens. However, to get desired prismatic
effect various types of lenses (spherical, plano-
cylindrical or spherocylindrical lenses) can be
decentered. Fig. 12.62: Datum system
called boxing system. In this system the lens

boxing was done by both horizontal (used in
Datum system) and vertical lines (not used in
Datum system). Hence, boxing system is
considered as an improved version of datum
system. Boxing system uses bevel apex of the
edged lens as a constant reference point for
all measurements in millimeters, hence the
chances error in prescription interpretation
were reduced.
Boxed lens: Consider the front and cross
Fig. 12.63: Application of datum system on spectacle section view of a lens as shown in Fig. 12.64.
frame Suppose a square made by the horizontal and
Datum center (O): A cross section point vertical tangent lines touching the lens edges
present midway between the datum length is drawn, which completely surrounds the lens
and a vertical line from upper and lower lens is called boxed lens. Various terminologies
edges is called datum center. used (Fig. 12.65) in boxing system are:
Application of datum system to the frame Eye size (Lens size): Horizontal measure-
(Fig. 12.63) gives the frame dimensions and ment (A) of this box is called eye size for
various additional terminologies are as follows frames and lens size for lenses.
Frame difference: When there is a difference Frame depth: Vertical measurement (B) of
between vertical dimension and horizontal this box represents the frame depth.
dimension of a frame, it is called frame Box center: It is the point where two
difference. Usually it is a few millimeters, as diagonals of box are intersecting with each
both dimensions are also in millimeter. other. It is also called the geometric center
Datum line of frame: It a continuous line (GC) of the frame opening or aperture. It also
joining Datum’s line of both the spectacle represents the geometric center of a lens edges
lenses, i.e. AA. for a given frame.
Datum center distance (B): After fitting the Suppose both the right and left lenses have
two lenses inside the frame, a distance been boxed, as if they were inserted into the
between datum centers (OO’) of these two spectacle frame as shown in Fig. 12.65, then
lenses is called datum center distance.
Distance between lenses (DBL): Distance
between the nasal edges of lens measured at
Datum line plane is called distance between
lenses (C) and is a parameter used in various
calculation of lens fitting.
Due to several technical difficulties this
datum system was not used widely and a
better measuring system known as boxing
system was developed.
Boxing System
In the year 1961, American Optical Manufac-
turers Association introduced a universal Fig. 12.64: Boxing of a spectacle lens, GC: Geo-
system for measurement of lens and frames metrical center.
Fig. 12.65: Application of boxing system on spectacle frame
following parameters are also added in diameter (ED) as shown in Fig. 12.66. It is
existing terminologies as defined as twice the distance from geometrical
DBL: It is the minimum horizontal distance center of lens to the peak of beveled edge of
between two lenses mounted in a spectacle lens situated farthest from geometrical center.
frame. The measuring points are the bevels of Effective diameter is used to determine the
nasal side of two lenses; DBL also represents minimum size of blank. This blank size is
the bridge size of the frame. calculated by doubling the amount of
Distance between centers (DBC): It is the decentration in millimeter and adding the
distance between two geometrical centers of resultant value with effective diameter of
the frame (or lens) and is commonly called lens.
frame PD. This can be represented by the Minimum blank size = ED + 2 × Amount of
following formula decentration in millimeter
DBC = Eye size or lens size + DBL
Segment height (SH): Vertical distance
between top edge of bifocal or trifocal segment
and bottom edge of box is called segment
height.
Segment drop (SD): Vertical distance
between top edge of bifocal or trifocal segment
and datum line is called segment drop.
Frame Specification
Size: Spectacle frames are typically marked
for size, which help in calculating other
dimensions of the frame. For example, marked
as 50–22, where 50 represents the eye size or
lens size and 22 represents the distance
between lenses (DBL) or bridge size.
Effective diameter: Another important speci- Fig. 12.66: Effective diameter (ED) and geometrical
fication provided by manufacturer is effective center (GC) of a lens
Spectacle Frame Selection whether the prescribed lenses can be

Primary function of a spectacle frame is to chipped out from the standard uncut
keep prescribed lenses in such a position that blanks or not.
give an optimum visual efficiency. Also the • To avoid the rejection of spectacles by
frame should be comfortable in wearing and patient always enquire about the
look attractive to fulfill the patient’s expectations. purpose of wearing the spectacles, so that
suitable type of frame can be selected.
For Bifocals and Multifocal Lenses
To fulfill the requirement of optical performance For Progressive Lenses
and comfort expert ophthalmic personnel For a proper and satisfactory dispensing of
should take care of these facts about selection spectacle in case of progressive lenses fitting,
of a spectacle frame the frame selection is an important step. Frame
• Thoroughly consider the factors related to should have these specific features for proper
prescribed lens such as refractive power, fitting of progressive lenses.
lens material, lens centration, base curve • As shown in Fig. 12.67, for fitting of
specification, multifocal type and glass tint. progressive lenses selected frame must have
• Appropriate selection of bridge design that a total vertical measurement of minimum
remains stable, provide the proper weight of 40 mm.
distribution of spectacle frame and also help • Frame must offer a minimum vertical
in maintaining the lenses in a preferred distance of 22 mm between the pupillary
position. center of patient and the horizontal line
• Appropriate selection of temple style and tangent to bottom edge of spectacle lens,
temple length, which adjusts well with the means in a Varifocal lens (having 12 mm
contour of wearer’s ear and to shape of his/ progressive zone) this type of fitting will
her mastoid process. give reading area of 8 mm width, consi-
• Facilitates the lens fitting very near to face dering that progressive zone begins 2 mm
with an appropriate pantoscopic tilt along below the pupillary center.
with corresponding vertical centration of lens. If the distance below pupillary center is less
Improper frame selection may cause than 22 mm, then the remaining depth of
soreness of nose and ears, thus cause discom- maximum near power prescribed for reading
fort to patient and will also affect the visual will be very small.
performance. Hence, for proper frame • The selected frame should fit on patient’s
selection following conditions which influence face very near (maximum 11–12 mm) to
the frame selection should be assessed
properly
• Type of lens, because multifocal or
progressive lenses will need specified
minimum vertical frame dimension for
proper fitting.
• Probable size and exact lens power,
because these factors will affect the
thickness and weight of lenses
• Relationship between patient’s PD and
spectacle frame PD will affect the
resultant appearance of centrality of Fig. 12.67: Spectacle box vertical dimension,
patient’s eyes and also decides that minimum of 40 mm
the back vertex distance, so that a wide is more forward than bottom edge. The inward
lateral field of view and stable near vision tilting of frame improves the cosmetic looks
area can be provided to the patient. of the spectacles, provides a better protection
• Pantoscopic tilt of nearly 12–15° with from flying objects, increases the field of view
slight amount of face forming will help of wearer and decreases effect of oblique
in stabilization of near area and provide astigmatism.
wider view of lateral visual field. Change in pantoscopic angle or tilt helps
• Frames with an adjustable nose pads will in adjustment of spectacle frame. For
permit flexibility in positioning the example, if right-sided lens appears higher
frame, while dispensing and also in on patient’s face as compared to the left-sided
follow-up. lens, then by increasing the pantoscopic angle
for the left lens will make both the lenses in
Principles of Fitting level or one can decrease the pantoscopic
Once the accurate spectacle frame has been angle for the lens which is higher (right lens
selected, the fitting of the lenses into this in our example).
selected frame is an important step. For Sometimes, to achieve a satisfactory fit on
practical purposes proper alignment of wearer’s face we may need to tilt the frame,
spectacle frame is done by the manufacturer. so that lower part of the lens tilted away from
The dispenser should confirm precise fitting the wearers’ face, this is called retroscopic tilt,
of frame or lens on patients according to the used rarely when absolute indications are
following guidelines there.
• Pantoscopic tilt
• Temple angle Temple Angle
• Fitting triangle Temple angle is an angle formed between
front and temple of the spectacle frame in the
Pantoscopic Tilt horizontal plane. Degree of temple angle is
Pantoscopic tilt or angle of a spectacle frame dependent on elements like front width of
means that the bottom edge of the spectacle spectacle frame and patient’s head width, but
lens is tilted away from the vertical axis in majority of the cases, frame temples are bent
(5–8 degrees) in the inward direction (i.e. outwards up to a few degrees (Fig. 12.69).
towards the cheeks of wearer) (Fig. 12.68). In
other words, the upper edge of spectacle lens Note: Recently, very large size spectacle frames
are also used and these frames generated a need
to bend the temples slightly inwards.
Temple angle helps us to check the distance

of two lenses from the patient’s eyebrow
(which should be equal on both sides) and this
can be observed when patient bends his/her
head in downward direction. If the temple
angle on one side is too small, then the patient
will feel an excessive pressure on that side of
head, because the lens on that side extends
outward as compared to fellow lens. The
problem can be solved by increasing the
temple angle on this side, however; in some
cases reduction in temple angle on other side
Fig. 12.68: Pantoscopic tilt can also give good results.
hence it becomes necessary to provide

cushioning effect to the nose to tolerate the
spectacle weight and to prevent pressure
effects. It is done by prescribing spectacle
frames having adjustable nose pads and the
whole surface of these pads should make
contact with the nose. Sometimes frames with
large size nose pads (jumbo pads) can be used
in those having sensitive nose skin. In case of
plastic frames, as there is no adjustable pads
so such a frame should be selected which
provides a large area of contact with nose.
Frame style having a saddle bridge is
appropriate for patients who have a relatively
wide, protruding, high nose crest. However,
Fig. 12.69: Temple angle for patients having narrow and flat crest, a
keyhole bridge is a better choice.
Fitting Triangle Fitting of bifocal lenses: Fitting of a bifocal
Spectacle frame or mounting may be lenses require knowledge of not only of the
compared with a triangle having three points corrective powers of distance and near vision,
of contact; one at the crest of the nose (A) and but also the positions of optical center of the
two on the apex of each ear (B, C) as shown in segment. This placement of optical center of
Fig. 12.70. Normally when head is kept in erect segments is done in vertical and lateral
position, about 65% of total spectacle weight positions of the bifocal lenses.
is taken up by the nose, whereas remaining Vertical position of the segment: In bifocal
(about 35%) of total weight is shared by the lenses the vertical positioning of segment is
ears. However, on bending the head in decided by the following factors
downward direction, the majority of the
• Optical center position of distance portion
spectacle weight gets transfer to the ears.
of lens.
During routine work, mainly the weight of
• Optical center position of the near seg-
spectacles remains on the nose of individual,
ment.
• Reading center which is a point in lens
corresponding to the wearer’s line of sight
during reading or close work.
Optical center position of distance portion
of lens: For best functioning of a lens, the
optical axis of the lens should pass through
the center of rotation of the eye. Level of
distance optical center of a bifocal lens is
decided on the basis of amount of pantoscopic
tilt. To get 2° of pantoscopic tilt, distance
optical center need to be lowered to 1 mm, and
a tilt of 6° is usually cosmetically desired,
hence a lowering of 3 mm of distance optical
center as compared to center of pupil is done
Fig. 12.70: Fitting triangle in a bifocal lens as shown in Fig. 12.71.
Fig. 12.72: Optical center for various bifocal lens

designs from segment top. A. Fused round segment
bifocal (11mm below); B. Fused straight top bifocal
(5 mm below); C. One piece bifocal (19 mm below);
D. Executive bifocal (at segment top)
Fig. 12.71: Lowering (3mm) of distance optical
center to get a 6° pantoscopic tilt.
Optical center position of near segment:

Similarly, position of optical center of various
types of bifocal lens segments is shown in
Fig. 12.72. This clearly gives us an idea about
the fitting of various types of bifocal lenses in
spectacle frames, so that the reading line of
wearer should be in alignment with these
optical centers of near segments.
Reading center: It is considered as a point on
the spectacle lens through which the foveal
line of sight passes during reading. It is
situated about 11 mm below the center of Fig. 12.73: Reading center in bifocal lens is usually
pupil (Fig. 12.73). As discussed above to get a 11 mm below pupillary center
pantoscopic tilt of 6° the bifocal distance position as compared to the distance optical
optical center lies at 3 mm below the pupillary points of bifocal lenses; this is known as
center, hence the reading center of segment is segment inset. Purposes of segment inset
located 11–3 = 8 mm below. On this principle are
bifocal lenses are fitted as shown in Fig. 12.74,
• To make sure that when patient looks with
i.e. segment top is kept in alignment with the
both the eyes, then the field of view of two
lower eyelid margin of wearer.
segments of bifocal glass should coincide.
Lateral position of the segment: Normally • To avoid the horizontal prismatic effects at
segment optical centers are fitted in an inward the reading center.
However, a total segment inset depends on

position of
• Major reference point (MRP)
• Geometrical optical center (GC)
Major reference point: Major reference point
is the difference between frame PD and
distance PD where frame PD is a sum of frame
size and distance between lenses (DBL).
Total displacement of segment inset depends
on the relative position of major reference
point (MRP) and geometrical optical center (GC)
Fig. 12.74: Round segment fitting with reading level of the lens and total displacement may be
11 mm below pupillary center inward, zero or outward as shown in Fig. 12.75.
Proper placement of segment inset is dependent Optical performance of bifocal lenses:

on the following factors Evaluation of properly fitted bifocal lens is
done by observing the optical performance of
• Power of distance correction in horizontal
bifocal lens, which in turn is decided by
meridian.
following parameters
• Interpupillary distance usually called dis-
• Differential displacement at segment top
tance PD.
called image jump.
• Fixation distance of bifocal lens.
• Differential displacement at reading level
• Back vertex distance.
• Total displacement at reading level
The difference of distance PD and near PD • Chromatic aberration
is equally divided in each spectacle lens for
nasal displacement. For example, suppose a Differential displacement at segment top
patient has a distance PD of 66 mm in the (Image Jump): The bifocal lens consists of
primary position of eyes and near PD of three optical centers, i.e.
62 mm in the converging position of eyes, then • Distance optical center
segment inset of 66–62 = 4/2 = 2 mm is done • Segment optical center
for each bifocal spectacle lens. • Resultant optical center
Fig. 12.75: Total displacement of segment reference point (SRP) in relation to geometrical center (GC) and
major reference point (MRP). A. Inward, most common; B. Zero; C. Outward, least common
The prismatic effect in bifocal lens also

exists in the segment and this prismatic effect
at any given point in the segment will be equal
to the sum of prismatic effects caused by both
the distance lens and segment. However, the
image jump occurs only due to segment and
thus the prismatic power of the segment will
decide the amount of image jump. Although
the image jump can occur at any point on the
margin of segment but it is annoying when
occur from top edge of segment which is
considered as zone of confusion. When an
attempt is made by a bifocal wearer to look at
an object through the top edge of segment, he/
she sees two images because a part of bundle
of rays entering the bifocal wearers’ pupil is
passing through the distance lens and
remaining part is passing through the
segment. Images formed by these two bundles
of rays will differ from each other in
• Direction, i.e. differential displacement.
• Focus, because of differences in refractive
power of distance and near portion of
bifocal lens.
• Size, because of differences in magnifica-
tion of images formed by distance and
near portion of bifocal lens.
Differential displacement at reading level:
Relative position of reading level in different
types of bifocal lenses is represented in
Fig. 12.76. These relative positions of reading Fig. 12.76: Prismatic effects of various segment designs
on reading level. A. No prismatic effect; B. Base down
level and position of segment center (solid red
prismatic effect; C. Base up prismatic effect
line) of a bifocal lens determines the differential
displacement at reading level in terms of Total displacement at reading level: Both the
prismatic effect. Various types of prismatic factors, i.e. image jump and the differential
effects produced are as follows displacement at reading level, have no relation
• Reading level and segment center on the with the refractive power of the bifocal lens.
same line, then no prismatic effect produced. However, the total displacement at reading
For example, straight top D bifocal lens as level depends on the refractive power of the
shown in Fig. 12.76A. distance portion and addition power in the
• Reading level is above the segment center, near segment of a bifocal lens.
hence a base down prismatic effect is In case where power of distance portion of
produced. For example, Ultex AL lens as the lens is plus, a base-up prismatic effect is
shown in Fig. 12.76B. added with near segment. However, in case
• Reading level is below segment center pro- where power of distance portion of the lens is
duces a base up prismatic effect. For example, minus, a base-down prismatic effect is added with
executive bifocal lens as shown in Fig. 12.76C. near segment as shown in Fig. 12.77A and B.
Fig. 12.78: Total displacement of reading level both

by distance and near segment.
For example, a bifocal with minus distance

power (means base down prismatic effect
at reading) can be opposed by executive
style segment having base-up prismatic
Fig. 12.77: Effect of power of distance portion of the
lens. A. Plus power lens will add base up effect;
effect; or a plus distance power bifocal
B. Minus power lens will add base down effect needs base-down effect as in an Ultrex A
segment, to oppose base-up prismatic effect
Total displacement of object at reading level by distance portion.
is determined by both the combined effect of Factors required for selection of an ideal
power of the distance lens and near segment bifocal lens include: Segment size, segment
as shown in Fig. 12.78. height and segment shape.
Chromatic aberrations: There are mainly Segment size or width: The size of segment
horizontal chromatic aberrations in high of bifocal lenses has progressively increased
power lenses in the periphery because of in size as the size of spectacle frames has
difference in image sizes of red and blue increased. Earlier available fused round
images. segment bifocals had segment size of 17 mm,
Selection of an ideal bifocal lens: An ideal which has gradually increased up to 22 mm
bifocal segment selection criteria include in recent years, however, segments of as wide
following features as 35 mm are also available in special cases.
• Elimination of image jump: Bifocal segment Decision of segment width is made on the
should not have jump phenomenon. It can basis of patient requirement for near work; if
be achieved by selecting ’no jump’ bifocals more near work is requireds then a wider
(e.g. executive style straight-top bifocal). segment is needed.
• Elimination of differential displacement at Segment height: Initially, many practitioners
reading level: Straight top fused bifocal thought that near segment should be placed
lenses fulfill this criterion, because these as low as possible to avoid the interference in
lenses have the segment pole at reading distance visions however, low placement of
level. segment led to stiff neck problem in many
• Total displacement at reading level: It should patients. An ideal reference point for segment
be zero or nearly zero and it can be achieved height is then decided as the lower lid margin.
in bifocals where segment gives an opposite The top edge of segment is kept at level of
prismatic effect than that of distance lens. lower lid margin or ciliary line in round top
power on the lens surface or by decentering

the spectacle lens. However, in a fully finished
uncut lens whether prism has been grounded
on the lens surface or a decentration is done
to get the prism effect, the resultant prismatic
effect will be the the same. In a fully finished
uncut spectacle lens decentring is generally
more cost-effective as compared to grinding
Fig. 12.79: Fitting of segment height. A. Round top
prism by surface procedure. Decentration is
segment at ciliary margin; B. Straight top segment done when a small amount of prismatic effect
2–3 mm below ciliary margin is needed, or in high power lenses where small
degree of decentration will produce desired
bifocals and 2–3 mm below ciliary line in prismatic effects. However, if prismatic effect
straight top bifocals as shown in Fig. 12.79A is needed in great amount, then prism must
and B. be produced by grinding the lens surface.
Segment shape: Segment shapes are an Decentration of spherical lenses: Relationship
important factor in deciding about the type of between prismatic power and refractive
bifocal needed for various professions. power of the lens is represented by Prentice’s
Advantage of a round fused segment is that it rule. This rule states that on a spherical lens
is less visible than a straight top fused segment, at any given point the prismatic effect is equal
hence for cosmetic reasons it is better preferred to the product of refractive power of lens and
by the patients. Least visible segment is present the distance of that given point from pole of
in Nochrome round segment lens having a the lens.
flesh color tint. For example, Softlite A or Ap = dP
Cruxite A.
Here,
A very small fused round segment of about
Ap = Prismatic power (prism dioptre)
12 mm diameter is called spot or button
d = Distance from lens pole (centimeters)
segment and was preferred by patients
involved in profession related to distance P = Refracting power of lens (dioptres)
vision. Similarly, in case of construction worker, By mathematical calculation, the above
the ribbon or bar segment bifocal lens designs formula can also be represented as
with height of 9 mm was recommended d = Ap/P or
because they do an occasional near work. Decentration (d) = Prismatic power/Refrac-
ting power
Lens Decentration The methods of decentration can be
Lens decentration means displacement of the understood by this example
lens pole from its geometrical center, i.e. lens Consider that the spectacle lens prescription
pole did not coincide with the geometric center as, OD –5 DS/OS –5 DS distance PD = 66 mm,
of the rectangle of boxing system. For proper frame size = 50 mm, DBL = 22 mm.
centration of the lens the geometrical center Suppose, a base in 1 effect is desired in
of the spectacle lens and the geometrical center final spectacle glasses, then two steps
of the rectangle surrounding the lens (boxing calculations are needed for proper fitting of
system) should correspond with each other. this minus power lens in the spectacle frame
However, sometimes decentration is required to produce this desired prismatic effect.
to regulate the prismatic effects. First step: Placement of major reference
The prismatic effect can be added in the lens point (MRP) in alignment with pupillary
prescription by either ground the prismatic center
Second step: Decentration of lens in the So a plano-cylinder having a horizontal

frame to produce prismatic effect. axis, i.e. 180° can only be decentered to
First step: As discussed before, the frame produce vertical prismatic effects like base up
PD is sum of frame size and DBL, i.e. 50 + 22 or base down. On contrary, plano-cylinder
= 72 mm (in our example). having vertical axis, i.e. 90° can only be
Therefore, MRP = Frame PD – IPD, i.e. decentered to produce prismatic effects like
72–66 = 6 mm base in or base out.
Hence, in this case the pole of each lens For example, a spectacle lens prescription
should be moved 6 /2 = 3 mm inward (nasally) has OD +2.5 DC × 90°.
to the center of pupil when no prismatic effect Suppose we need 1 base in or 2 base out
is required. prismatic effects, then decentration of lens to
Second step: According to Prentice’s rule, be fitted in spectacle frame can be find as
the pole of a –5 D lens must be displaced follows
1/5 D = 0.2 cm or 2 mm to produce 1 effect. To produce 1 base in effect, the spectacle
Direction of lens displacement must be lens must be decentered (using Prentice’s rule)
outward (minus lens) to achieve a base in as follows
effect for each eye. d = 1/2.5 D
So, in a nutshell in first step we need to = 0.4 cm inward, because plus
move the lens pole 3 mm inward (nasally) power in the meridian.
from geometrical center and in the second step Similarly, to produce 2 base out effect, the
we need to move the lens pole 2 mm outward spectacle lens must be decentered (using
(temporally) from pupillary center of the each Prentice’s rule) as follows
eye. Hence, the total decentration of this d = 2/2.5 D
prescription lens is 1 mm inward (nasally) = 0.8 cm outward, because plus
from geometrical center of each lens to power in the meridian.
produce a prismatic effect of base in 1. Decentration of spherocylindrical lenses
Rule of thumb in determining the direction of having principal meridians as horizontal and
decentration to produce a desired prismatic effect vertical axis.
is that when a lens or meridian of a lens has For example, a spectacle lens prescription
• A plus power then the lens decentration has OD + 2 DS × –4 DC × 90°
is done in the same direction of the base Calculate the direction and amount of
of prism. decentration to produce 1 base down and 1
• A minus power then the lens decentra- base out prismatic effect.
tion is done in the opposite direction of The first step is to determine the power in
the base of prism. each of the two principal meridians, so that
In the above example we needed a base in we may apply Prentice’s rule to each meridian,
1 effect for a minus 5 D lens, hence we using the rule-of-thumb for the direction of
displaced lens 2 mm in outward direction, i.e. decentration.
opposite to the base of prism. As shown in Fig. 12.80, power in the vertical
Decentration of plano-cylindrical lenses: meridian is +2 D and in the horizontal
Prismatic effect of a cylindrical lens is always meridian is –2 D.
perpendicular to its axis, hence a cylindrical Hence, on applying Prentice rule
lens can be decentered to produce a desired Base down is 1/ 2 D, i.e. 0.5 cm downward
prismatic effect only in cases where the desired displacement
base direction is coinciding with the direction Base out is 1/2 D, i.e. 0.5 cm inward
of power meridian. displacement
Fig. 12.82: Fitting of trifocal lens and comparing with

D bifocal
segment is kept 2–3 mm below the lower lid

margins same as that in a straight top segment
bifocal lens as shown in Fig. 12.82A and B.
Fitting of a progressive lens: Various factors
are considered in proper fitting of a
Fig. 12.80: Application of Prentice rule. MRP: Major progressive lens, because it is not as simple as
reference point; OC: Optical center
that of regular monofocal or bifocal lenses.
Hence, the spectacle lens decentration will Patient selection: For better results a proper
be 0.5 cm downward and 0.5 cm inward in patient selection is an important concern for
the above prescription to produce a 1 base progressive lens fitting. The main purpose of
down and 1 base out prismatic effect. progressive lenses is to provide a continuous
Fitting of double segment bifocals: In most vision for all distances, however, many
types of double segment bifocals separation patients and optician consider it just as an
distance between upper and lower segment invisible bifocals. Hence, it is not a good
is 13 mm, whereas normally cornea is choice for those patients who want only in
vertically 11–12 mm in size. Hence, an ideal invisibility in lens; however, round fused
way of fitting a double segment bifocal lens is bifocal lens is a good choice for these patients
as shown in Fig. 12.81A and B. but intermediate vision remains blur through
these bifocal lenses. Hence, if a patient wants
Fitting of trifocal lenses: Although, trifocal
no visibility and his requirement is for
lenses are not so commonly used nowadays
intermediate vision, then the best choice is
but a proper fitting should be known to every
progressive lenses.
practitioner. Upper edge of the trifocal near
Normally, progressive lenses should not be
prescribed for the patients who are
• Having large interpupillary distance or
very wide nasal bridge.
• Satisfied with their existing bifocals or
trifocals spectacles.
• Comfortable with their present reading
glasses and are satisfied with it.
• Need vertical prism for correction of
Fig. 12.81: Fitting of various double segment lens refractive error, because progressive
designs. A. Double executive design; B. Double lenses are not available with vertical
straight top design prisms.
• Poorly motivated to adopt wearing

conditions.
• Nervous or of highly anxious nature.
Note: To avoid the sensation of blurring or

swimming of objects in lateral visual fields,
progressive lenses wearer must be essentially a
head mover, not an eye mover.
In a motivated and emotionally stable

patient willing to wear progressive lenses,
practitioner needs to evaluate the patient’s
visual requirements and various factors in
relation to his/her work and relaxation. Points
to be considered are
• Pupil size
• Habitual eye and head movements
• Distance correction power
• Near addition power
Fig. 12.83: Temporary and permanent markings on
• Relative usage of near and intermediate progressive lens. A. Temporary markings (DRP—
distance distance reference point, NRP—near reference
• Previous experience with progressive point); B. Permanent markings
lenses
height and PD of fitting cross can be confirmed
Essential fitting measurements for pro-
from manufacturer’s centering or verification
gressive lenses: The measurements require to
chart.
fit progressive lenses differ from conventional
Permanent markings as shown in Fig. 12.83B
bifocal lens fittings in the following ways
are partially visible; consist of two carved
• Interpupillary distance measurement circles which represent the beginning of
should be taken monocularly by pupilo- progressive zone or corridor in the form of
meter so that each pupil aligns with horizontal line. Some manufacturers also put
progressive corridor correctly, however, their identification mark and addition power
single measurement is taken by a ruler on temporal side of lens.
binocularly for bifocal fittings.
A precise fitting of progress lens is
• In progressive lens the reference point in mandatory, because width of progressive zone
vertical meridian (similar to segment in or corridor is limited. Monocular distance PD
bifocal lenses) is the center of pupil, not the measurement is essential to ensure that line
lower lid margins or ciliary line as in of sight of each eye always remains in the
conventional bifocal fittings. progressive zone, while eyes are moving
The progressive addition lenses consist of two downward. Fitting steps of progressive lens
types of markings are
Temporary markings as shown in Fig. 12.83A • The distance PD is marked by corneal
consist of a fitting cross, which corresponds reflection pupilometer or by special
to center of the pupil. A distance reference device provided by lens manufactu-
point (DRP) and a near reference point (NRP) rer.
are used to check the distance and near powers • Then measure the vertical distance (D)
of refractive correction, respectively. The from the center of pupil to a horizontal
Glazing of Lens
Glazing of lens is the fitting process of an uncut
ophthalmic lens inside the selected frame. The
process of glazing has the following steps
• Lens shaping
• Lens cutting
• Lens edging and fitting
Lens Shaping
First of all the shape of lens is measured
Fig. 12.84: Measurement for fitting of progressive optically or mechanically, so that either
lens. A. Vertical distance (D); B.Optical fitting box manually or by a computer controlled lens
line tangent situated at the lowest point grinding machine we can get an exact image
on bottom edge of progressive lens as of the desired lens before cutting begins.
shown in Fig. 12.84A. Lens formers as shown in Fig. 12.85 also
• Now place the temporary marking called patterns are usually supplied by lens
commonly called fitting cross on the manufacturers. These formers have similar
finished lens corresponding to the center shapes as that of desired spectacle lens, and
of pupil as shown in Fig. 12.84B. are used to outline the shape of spectacle lens.
• This center marking should be done on Lens former has a central hole which corres-
the same frame in which the patient’s ponds to the geometrical center and a line
lenses will be mounted. representing 0–180° plane. The geometrical
center of former should be made coincide with
• Once the target spots are centered before
the optical center of lens and by marking the
each pupil, remove the frame and
side holes an axis can be marked accordingly
transfer target spot location on plastic
on uncut lens.
lens using fine point pen.
Manual shaping of desired lens can be
There are two systems which are especially
drawn by using Indian ink keeping the pattern
designed for progressive lens measurements
on a sheet or hard board paper. Cylindrical
are
axis, if present, is marked over the uncut lens
• Grolman fitting system developed by
by lensometer as three dots using greased
American Optical: This system gets
pencil or Indian ink.
directly attach with patient’s spectacle
frame and has horizontal and vertical
scales for marking of various measure-
ments.
• Magna/Mark system: This is a magnetic
based system consists of translucent
targets to mark the various measure-
ments.
In majority types of progressive lenses, the
progressive corridor begins about 2 mm below
the fitting cross; hence fitting techniques are
modified according to the need of patient.
Patients who like to use intermediate distance
vision too much, fitting cross needs to be Fig. 12.85: Lens former showing 0 to 180° line for
placed 1–2 mm above the pupillary center. marking.
Once we had marked the uncut lens with

axis of cylinder and outlined the shape of lens,
the center mark and nasal side of lens is
marked by using specially designed protectors
in relation to cylindrical axis of lens.
Lens Cutting
After proper marking of uncut lens the extra
part of lens is cut, usually a little extra than
the shape marked because some margins are
needed to form the edge of lens for proper
fitting. After cutting the formed rough lens
shape should be matched with size and shape
of the frame.
The lens cutting can be done manually by
using a chipper (before using chipper groove
the outline of lens shape with a diamond
pencil) or alternately a diamond cutter wheel
or fully automated cutting machine can be Fig. 12.86: Various types of lens edges. A. Flat;
used. B. Bevel; C. Mid-bevel; D. Groove
Lens Edging and Fitting Rimless fitting is a little different, it needs

The partial finished lens formed after cutting to make the holes in the lenses and sometimes
also need proper edges so that it can fit grooves are also cut near holes on the sides of
properly inside the frame. Therefore, edging rim. Then the nasal and end pieces are fixed
of lens is done either manually on a rotating with lens with the help of screws and/or
diamond wheel or by fully automatic suction plugs.
machines, although edging by manual way is Finally, prescription and lens power are
more economically viable than automatic matched, quality of lens fit is checked before
machines. For manual edging various types of cleaning and packing for dispensing of
grit wheels are available to grind the lens edges spectacle. With an expert fitter whole glazing
and to make it smooth and shiny. Nowadays process may take 10–15 minutes.
diamond wheels are also present which
produce faster, accurate and smooth edges of Verifications of Spectacles
lens at an economical price. Various edge Sometimes, the patient may complain that the
shapes which can be produced are flat, bevel, lenses prescribed to him/her are not proper
groove and mid-bevel as shown in Fig. 12.86. and there was an error in evaluating the
After formation of well-edged lens, the next degree of refractive error. However, on careful
step is to fit this polished finely shaped lens examination, it may be found that the problem
into the spectacle frame. In metallic frames was due to an error of either dispensing or
usually a bevel-edged lens is fitted by opening fitting of lenses. Hence, it is mandatory to
the frame sides and refitting the side screw, verify the spectacles before dispensing.
whereas in plastic frames the lenses are fitted Spectacle verification means to verify the
by a method called springing in. Frames are lens powers, cylindrical axis, optical center
heated slightly and lenses having beveled and prismatic effect of spectacle lenses along
edges are just pressed inside the frames like a with any surface defects, if present. It is also
spring and it get fit into the frame groove. essential to check the fitting of lens in the
frame along with the frame alignment. Before

dispensing the spectacle we should check
• Surface defects
• Lens power measurement
• Frame alignment
Surface Defects
Sometimes there may be defect in the surface
which may occur during manufacturing
(waves in lens) or during glazing and fitting
(aberrations, chipping or dents) and can be
missed many a times by dispenser.
Note: Surface defects are the most common reason

for rejection of spectacles.
Lens Power Measurement

Lens power and cylindrical axis of a spectacle
lens can easily be measured by lensometer; Fig. 12.87: Downward movement of minus lens,
however, in the absence of instrument manual showing downward movement (same direction) of
neutralization can be done to assess the object from P to P’ position.
parameters of spectacle lens.
Hand neutralization techniques for spectacle
lenses
For spherical lenses
For neutralization of an unknown spherical
spectacle lens the following method is used
• Hold the spectacle lens at about 1 meter
distance while keeping its back surface
towards examiner and then observe an
object at 20 feet distance.
• The object should have both vertical and
horizontal shapes. For example, a large
cross or square or 6/60 size letter A.
• Focus on the image at central zone of the
lens and slowly move the spectacle lens,
both in vertical and horizontal meridians.
• Observe whether the transverse movement
of object appears to be in the same direction
Fig. 12.88: Downward movement of plus lens,
or in the opposite direction in comparison showing upward movement (opposite direction) of
to the movement of the spectacle lens. object from P to P’ position.
• Same direction movement or ‘with motion’
indicates that it is a minus lens as shown in • In plus lenses, ‘against motion’ is seen until
Fig. 12.87. An opposite direction movement the distance between the plus lens and
or ‘against motion’ indicates that it is a plus observer’s eye is less than focal length of
lens. plus lens (Fig. 12.88). If this distance is more
than focal length of the lens, then ‘with For cylindrical and sphero-cylindrical lenses:
motion’ will be seen like minus lenses, but Neutralization of cylindrical or sphero-
the image will be inverted. cylindrical spectacle lens is done by the
• Now take a lens of opposite power from following method
trial lenses and keep its back surface in • Similar to a spherical lens, examiner holds
contact with the front surface of this the spectacle lens at one meter distance
unknown power spectacle lens. keeping its back surface towards him/her
• With more and more experience, the and observes an object, e.g. a plus (+) mark
examiner can closely estimate the required at 20 feet distance.
power of neutralizing trial lens. • Then examiner rotates the spectacle lens
• Now slowly move both the lenses together either clockwise or anticlockwise and
in vertical and horizontal meridians while observes a scissors like motion of the object.
judging the motion of object simultaneou- • When a cross target is observed through
sly. spectacle lens, the displacement of its
• Suppose the power of neutralizing lens is vertical and horizontal lines will be seen
inadequate, then a movement of object will as compared to their original positions
be seen ('with motion’ with low power and present outside the spectacle lens as shown
‘against motion’ with high power) and if in Fig. 12.89A.
power of neutralizing lens is sufficient or • During rotation when spectacle lens gets
equal, then no movement of object image oriented in a way that two limbs of target
will be noticed. For example, if no motion cross become parallel and continuous with
is observed when a +2.5 DS power trial lens principal meridians of spectacle lens, then
is used as neutralizing lens, then the power the displacement of vertical and horizontal
of unknown spectacle lens is –2.5 DS. limbs of cross target disappears as shown
In case of spherical lenses the examiner in Fig. 12.89B.
observes the motion in the same speed and • Once examiner reaches to an orientation
same direction in both horizontal and vertical where both limbs of target cross are parallel
meridians. However, the situation will be and continuous both inside and outside the
different with unknown cylindrical or spectacle lens, then a further rotation of
spherocylindrical type spectacle lenses spectacle lens will show a scissors motion
because the speed and direction of motion either with or against the rotation of
may vary in different meridians. spectacle lens.
Fig. 12.89: Hand neutralization of spectacle lens containing cylindrical power. A. Off-axis cylinder showing
scissor movement; B. On-axis cylinder
Hand neutralization method to determine the representing the axis of neutralization

cylindrical power and axis. inside and outside the spectacle lens. Then
• Observer holds the spectacle lens firmly in examiner marks the axis on unknown
position where the spectacle lines are cylindrical spectacle lens with grease
parallel and continuous with cross target pencil. This axis can be measured with the
limbs both inside and outside the spectacle help of a lens protractor, however, an
lens. approximate ±5° will occur in manual
• Then examiner draws line ABOCD in assessment of axis.
vertical axis as shown in Fig. 12.90A over • After neutralizing each principal meridian,
limbs seen inside the spectacle lens using power and axis are noted and a prescription
grease pencil on the back surface of the of spectacle lens is written in a minus
spectacle lens. cylinder form. For example, if spectacle lens
• Examiner then rotates the spectacle lens and gets neutralized in horizontal meridian
observes the movement of this vertical line with –5 DS trial lens and in vertical meridian
ABOCD. with –3 DS trial lens, it means power of
• Suppose line seen inside the spectacle unknown spectacle lens is +5 DS in the
lens rotates as ‘with motion’ in the horizontal meridian and +3 DS in the
direction of the rotation of spectacle lens, vertical meridian. Prescription for
means that line ABOCD of cross target unknown lens would be written as + 5 DS/
is parallel to the minus cylinder axis as –2 DC × 180°.
shown in Fig. 12.90B. Another difficult task in hand neutralization
• When line inside the spectacle lens rotates method is to mark the optical center or pole
against the direction of rotation of spectacle of spectacle lens.
lens, means that line ABOCD of cross target • To mark the optical center of spectacle
is parallel to plus cylinder as shown in lens, examiner identifies the point where
Fig. 12.90C. the two lines of target cross meet inside
• Once two principal meridians of spectacle and outside the spectacle lens. Then
lens of unknown power are localized, then mark a small dot on the lens while
neutralize each meridian separately using holding the spectacle lens in a position
spherical lenses. where the lines inside and outside are
• Examiner firmly holds the spectacle lens parallel and continuous as described
against the line of cross on trial lens above.
Fig. 12.90: Determination of cylindrical axis. A. Marking of axis line ABOCD over spectacle lens; B. With
movement in case of minus cylinder; C. Against movement in case of plus cylinder
Frame Alignments
As we normally consider that the standard
alignment of frame has been already done by
the manufacturers, so we prefer to fit the lens
directly. However, this is not always true and
often it becomes necessary for dispenser to
check the frame alignment before dispensing.
A proper frame alignment is done by the
following methodology
Fig. 12.92: Examination for vertical alignment of
• Front alignment spectacle frame front
• Temple alignment
In some specific spectacle frame design the
Front alignment: Front alignment is done in
front of frame is arched in outward direction,
two steps with the help of device having
which is commonly called face form. In these
straight border, e.g. a millimeter ruler.
design frames the nasal edges of frame will
First step: examiner places the millimeter
not touch the millimeter ruler as shown in
ruler against the back of spectacle frame below
Fig. 12.93. Mostly aviation types of sunglasses
the end pieces as shown in Fig. 12.91, while
are made in this design. Suppose preferred
spectacle frame is held horizontally. Then
degree of face form or four point touch is
examiner observes whether right and left end
absent, then it can be rectified by adjusting the
pieces are at equal distances above the ruler
frame bridge position.
or not. If they are at equal distance, then no
Sometimes during verification of vertical
adjustment is needed, however, if they are at
alignment, examiner notices that two lenses of
unequal distance, then the frame bridge is either
spectacle frame are in different vertical planes
raised or lowered so that they become equal.
(X-ing of frame), means one side lens is tilted
Second step: Examiner then verifies the
either outward or inward in comparison to
vertical alignment of spectacle frame by
other as shown in Fig. 12.94. Similar to face
placing the ruler along the back surface of
form correction X-ing can also be corrected by
frame underneath or above the nose pads with
adjustment of frame bridge rotation.
temples extending upwards while spectacle
frame is held vertically as shown in Fig. 12.92. Temple alignment: Normally in a properly
In proper alignment situation the ruler should aligned spectacle frame a pantoscopic tilt
touch four points on spectacle frame. Two (generally 6°–10°) and temple angle of 92°–
points are back surfaces of each lens (or eye 95° (a little greater than a right angle) is
wire above each lens) and one point each at present. This procedure is done for the
nasal and temporal edges of spectacle frame. adjustments of pantoscopic tilt and temple
angle in case if they are disturbed. Equality
Fig. 12.91: Examination for front alignment of

spectacle frame Fig. 12.93: Face form in spectacle frame
Fig. 12.94: X-ing of spectacle frame Fig. 12.95: Unequal pantoscopic angles
in pantoscopic tilt of the spectacle frame is of frame has a larger degree of pantoscopic
checked by placing the spectacle frame on a tilt compared to the end piece of the other
glass top table with temples facing side. Similarly, both sides of spectacle frame
downward. Suppose one of the temples does should have the same degree of temple angle.
not touch the glass surface fully as shown in This can be easily assessed by examination
Fig. 12.95, it means that end piece on that side of frame.
362
Contact Lens Optics,

Design and Fitting
Learning Objectives
After studying this chapter the reader should be able to
• Register the historical events of progress during development of contact lenses.
• Understand various concepts and designs of contact lenses.
• Enumerate properties and terminologies of contact lens materials.
• Describe various manufacturing process of contact lenses.
• Explain the various contact lens designs and their classification.
• Memorize indications and contraindications of various types of contact lenses in different clinical situations.
• Describe contact lens fitting methods for soft and rigid types of contact lenses.
• Manage clinical outcomes of soft and rigid contact lens wear.
Chapter Outline
• Contact Lens Optics – Spin casting

– History and events of progress – Cast moulding
– Concept of contact lens forms – Classification of contact lens
– Optical properties of contact lens • Contact Lens Design
Thick lens – Regular lens design
Effective power – Special lens design
Change in retinal image magnification
– Terminologies in contact lens
Effect on refractive status
Contact lens dimensions
Effect on accommodative demand
Contact lens curves and radius
Effect on accommodative convergence
– Indications of contact lens wear
Prismatic effects as compared to spectacles
Aberrations and field of view

– Contraindications of contact lens use
• Contact Lens Materials • Contact Lens Fitting
– Introduction – Patient work up for contact lens fitting
– Terminologies in contact lens material – Soft contact lens fitting
Water properties related to lens – Soft contact lens ordering
Oxygen related contact lens properties – Insertion and removal of soft contact lens
– Rigid contact lens materials – Rigid contact lens fitting
– Soft contact lens materials – Rigid contact lens ordering
• Manufacturing and Types of Contact Lens – Insertion and removal of rigid contact lens
– Lathe cutting – Rigid contact lens related complications and
– Melt pressing management
362
Contact Lens Optics, Design and Fitting 363
CONTACT LENS OPTICS • Nearly for 40 years period (1895–1930) all

Contact lens is a small piece of plastic which contact lenses were made up of glass.
is designed to rest on the cornea and/or sclera Basically of two types
in such a way that they are in direct contact of – Blown glass from Muller
cornea and correct the refractive errors of eye. – Ground glass from Carl Zeiss
Along with optical uses, a contact lens can be • For another decade methods were
used for various other purposes also including developed to take eye cast by using material
therapeutic, cosmetic and diagnostic. like Negocolle, a seaweed extract mainly
used for dental purposes.
History and Events of Progress • In the year 1938, Obrig diagnosed that
Basis aim of several researchers was to contact lens intolerance was due to limbal
neutralize the front surface of cornea with the pressure. He also discovered that fluorescein
help of various devices. solution with blue light can be used to check
• In the year 1508, Leonardo da Vinci came the contact lens fit.
up with an idea that a vision of a person • In the year 1937 Feinbloom first time used
can be altered by immersing head up to ears the plastic material for contact lens. Lenses
with face down in half water filled specially made by him had a glass optic with a plastic
designed bowl. scleral zone.
• In the year 1636, Descartes suggested that – Subsequently, in the year 1943 the
corneal surface can be neutralized by true corneal lenses having diameter of
placing a tube filled with water on the 11–12 mm were introduced, popularly
cornea having a watch glass on the other end. called Tuohy lens.
• In the year 1801, Thomas Young on the basis • During 1950–1960 Gyorrfy revolutionalized
of principle of Descartes tried to neutralize the contact lens manufacturing world by
his refractive power by designing long tube introduction of Polymethyl methacrylate
filled with water, having a lens of 20 mm (PMMA) contact lenses for production of
focal length on the other end. soft contact lenses, which shortly followed
• In the year 1827, John Herschel done by use of hydroxyl methyl methacrylate
experiment with application of animal jelly (HEMA) in the year 1963.
in the form of glass capsule on the eyes in • In the year 1970, rigid contact lenses (made
order to eliminate the astigmatic errors. up of PMMA) were introduced. Later on in
• In the year 1886, first proposal of hydro- the year 1978, rigid gas permeable (RGP)
philic contact appliance came from lenses were also manufactured by using
Galezowsky, who suggested the use of a Cellulose Acetate Butyrate material (CAB).
gelatin disc soaked in cocaine and sublimate • Silicon acrylate material was introduced in
of mercury for post-cataract extraction the year 1975–78. Around the same period,
cases. CIBA Vision Company introduced tinted
• In the year 1887, FA Muller used a glass and bifocal contact lenses.
blown lens to cover the eye of a patient • Later on, in the year 1986, it was Johnson
whose eyelids had been removed. and Johnson Company who manufactured
• In the year 1888, Fick was the first to coin the weekly disposable contact lenses.
the term contact lens and used a non-optical Contact lenses differ from spectacle lenses
corneal contact lens for treatment of in many aspects. Important difference is that
keratoconus. He also suggested the use of the spectacle lenses are worn about 12–15 mm
contact lens for aphakia and cosmetic away from the corneal surface, hence only
purposes. vergence of incident rays hitting the corneal
surface is altered. However, in case of contact

lens, as it remains in contact with corneal
surface, the vergence of the incident rays not
altered, rather vergence of eye itself is altered.
Hence in case of spectacle lens the refractive
power of eye gets an accessory effort and there
is no real change in refractive status of eye, on
contrary, in case of a contact lens, the real
refractive status of eye is changed. This change
in refractive status of eye is contributed by the
fact that when contact lens is in place, the
anterior surface of cornea becomes optically Fig. 13.1: Afocal segment
absent, as it becomes the posterior surface of
a liquid or glass lens. Furthermore, there is a Liquid lens: When two curvatures of contact
chance of independent viewing movement of lens surfaces (both anterior and posterior) are
eyes behind the spectacles which is not seen same like afocal segment but they are different
with contact lens. The prismatic effects are from the anterior surface of cornea, then it
observed more with the use of spectacle lens forms a liquid lens. The elements of refraction
than contact lens. in this kind of system are contact lens, tear film
lens (liquid lens) and anterior surface of
Concept of Contact Lens Forms cornea, which are separated by an invisibly
To understand the function of a contact lens, thin air film. Hence in this system the effective
it is essential to know the concept of glass lens refractive power will be exerted by back vertex
and liquid lens. As we know that tear film play power of liquid lens in the air.
a significant part in corneal integrity to As we can see in Fig. 13.2, the posterior
perform the refractive role, we should know surface of contact lens and anterior surface of
the dynamics of tear film and contact lens the cornea forms a lens filled with liquid (tear
together for functioning of a contact lens as film), called liquid lens or tear lens or fluid
corrective device. lens. The correction of ametropia will be due
Depending upon the curvatures of contact to the refractive power of this lens, which is
lens and corneal surface various lens forms are equal to a sum of anterior and posterior
seen as surfaces of tear lens.
• Afocal segment Glass lens: When curvature of posterior
• Liquid lens surface of contact lens is the same as that of
• Glass lens or focal segment
• Combined lens system
Afocal segment: When curvatures of both the
surfaces of contact lens are the same, then they
form an afocal contact lens. For example,
contact lens having anterior surface of +6 D
and posterior surface of –6 D.
As we can see in Fig. 13.1 that when three
curvatures (two surfaces of contact lens and
one surface of cornea) are same, the contact
lens serves as afocal segment, where anterior
surface of contact lens becomes anterior
surface of refractive system. Fig. 13.2: Liquid lens
cornea, but curvature of anterior surface of

contact lens is different, then they form a glass
lens or focal segment or powered lens.
As shown in Fig. 13.3, a focal segment is
formed due to difference in curvatures of
anterior and posterior surfaces of contact
lens. To understand the refractive power of
this type of system, if we know the power of
posterior surface of contact lens (which is
usually kept fixed), then only task remains is
to know the power of anterior surface of
contact lens (which usually has a relationship
with anterior corneal surface and decided Fig. 13.4: Combined lens
empirically).
Suppose the posterior contact lens surface Optical Properties of Contact Lens
is parallel to anterior corneal surface, then
back vertex power of contact lens will be equal Thick Lens
to ocular refractive status. Although a contact lens physically appears
thin as compared to spectacle lens but for
Combined lens: When the curvatures of three
optical reasons spectacle lens is considered as
elements, i.e. anterior and posterior surfaces a thin lens and a contact lens is considered as
of contact lens and anterior surface of cornea, a thick lens. Because the contact lens is so
are different to each other, then the effective steeply curved, that application of an
power of system is determined by power of approximate power formula, as in case of a
both the liquid lens and glass lens. spectacle lens, will lead to serious refractive
As we can see in Fig. 13.4, that two lenses errors.
are formed: Anteriorly a glass lens and
posteriorly a liquid lens. Refractive status of Effective Power of Contact Lens
this system is a combined power of these two The effective power of a correcting lens
lenses. Although ametropia can be corrected (contact lens or glasses) changes as we bring
by tear lens alone, but in routine practice both it nearer to eye. In case of a contact lens the
the liquid lens and glass lens in combination correcting lens is brought very near to eye, i.e.
are used to neutralize the refractive error. it touches the eyes. Effective lens power is
determined by the relative position of
correcting lens with that of vertex plane. While
in case of spectacles, the lens is placed at
14–15 mm in front of vertex plane, whereas in
case of a contact lens, the lens is placed on
vertex plane. For example, a minus lens
becomes more effective when moves towards
the eye, whereas a plus lens becomes more
effective when moves farther away from the
eye. This means that for a myope a contact lens
must be weaker than a spectacle lens, whereas
for a hypermetrope a contact lens power should
be stronger than a spectacle lens for correction
Fig. 13.3: Glass lens of the same amount of refractive error.
Effective power of a contact lens can be

calculated from spectacle power or lens
prescription by this simple formula:
PO
PA =
1 – d PO
Here PO = power at original position of lens
PA = power at altered position of lens
d = distance the lens has been
moved (in meters), is given a
plus sign if moved towards the
eyes and a minus sign if moved Fig. 13.5: Effective power of a contact lens for a 8 D
away from the eyes. myope; when refracted at vertex distance of 12 mm
To understand this, let us consider a myope
of –8 D spectacle lens power at vertex distance
of 12 mm (12/1000 meters), calculate the
contact lens power (Fig. 13.5).
As per formula
−8
PA =
1 − 0.012(−8)
−8
=
1 + 0.096
−8
=
1.096
= –7.29 D
Similarly, suppose an aphakic patient needs
+12 D spectacle power at vertex distance of Fig. 13.6: Effective power of a contact lens for an
12 mm, then the contact lens power will be aphakic having +12 D power; when refracted at
calculated as shown in Fig. 13.6. vertex distance of 12 mm
As per formula
Note: When refractive errors in eyes are of less
+12 than ±3 D, then the power difference between
PA =
1 − 0.012 (+12) contact lens and a spectacle lens will be about
0.12 D, which can be considered as negligible for
+12 all practical purposes.
=
1 − 0.144
Change in Retinal Image Magnification
+12
= The change in magnification of retinal image
0.856 is another optical effect of contact lens which
= + 14.01 D is due to more closeness of contact lens to eyes.
The abovementioned examples clearly So, when a person shifts from spectacles to
indicate that for myopia the power of contact contact lens, he/she will observe change in
lens will be less than power of a spectacle lens, size of the image of objects.
whereas for hypermetropic eyes it will be It is due to the fact that during calculation
more than a spectacle lens. of magnification by spectacles, the distance
between back of lens and entrance to pupil of demand because the use of minus spectacle
eye is also included. It means if a correcting glasses decreases the accommodative demand
lens is brought near to eyes, the retinal image in myopes. Suppose a myope switch over to
magnification will change which is seen with contact lens from spectacles, then he/she has
contact lens. Therefore, in a myopic person, to exert more accommodative power. On
the contact lens will produce a retinal image contrary, in hypermetropes use of plus
bigger in size than a spectacle lens, hence a spectacle glasses causes increase in the
myopic patient who starts wearing a contact accommodative demand and when they
lenses will usually feel happy by the fact that switch over to contact lens the need of
everything looks larger than before. On accommodative demand is decreased.
contrary, in hypermetropic patient the contact The change in demand of accommodation
lens will produce retinal image smaller in size in contact lens wearer myopes and hyper-
than spectacle lens, hence a hypermetrope metropes as compared to spectacles lens wearer
especially an aphakic will be pleased by the has important role at presbyopic age. In contact
fact that now the objects are looking nearly to lens wearer myopics, the addition power for
their normal sizes. near work will be required at earlier age, whereas
contact lens wearer hypermetrope will need
Note: Usually, aphakics wearing spectacles lens additional power for near work at a later age
have an image magnification of about 22% which as compared to spectacle worn counterpart.
is difficult to adjust binocularly, however, with
contact lens the same person will have an image
An average amount of accommodation
magnification of only 7% which is easier to adjust needed while wearing contact lenses is about
binocularly. 2.5 D irrespective to the amount or type of
refractive error. Consider this fact in example,
a +10 D hypermetrope wearing spectacles
Effect on Refractive Status require 3.29 D of accommodation for a 40 cm
As contact lenses are in direct contact of eyes, reading distance, whereas a –10 D myope
the refractive status of eye may change counterpart needs only 1.8 D for the same
especially with the use of hard contact lens. reading distance. So in this example
On contrary, eyes are also capable to change hypermetrope has to accommodate about
the refractive power of contact lens especially 0.75 D less (i.e. 2.5 – 3.29), while myope needs
of a soft contact lens. These changes in to accommodate 0.75 D more (i.e. 2.5 – 1.8),
refractive power are of important in cases of when these hypermetrope and myope patients
astigmatism. A spherical hard contact lens wear contact lenses instead of spectacles.
usually hide or eliminate the corneal
astigmatism, whereas a spherical soft contact Note: Persons having very high degree myopia
lens remain confine with the toricity of cornea (14 D) will face problems in wearing contact
and produce very little or no effect on corneal lenses, due to a significant increase in demand of
astigmatism. Hence, to correct astigmatism by accommodation.
means of soft contact lenses, toric contact
lenses should be used. Effect on Accommodative Convergence
An increase demand of accommodation in
Effect on Accommodative Demand myopes due to wearing of contact lenses will
Shift of spectacle glasses to contact lens in both lead to use of more accommodative conver-
myopes and hypermetropes also cause change gence. On the other hand, hypermetrope
in accommodative demand. Myopes using wearing contact lens will use less accommo-
minus glasses has an advantage over an dative convergence. As a result, contact lens
emmetropic person in terms of accommodative wearer myope having esophoria will have to
apply more negative fusional vergence than Note: In an aphakic patient due to absence of
glasses wearer myope, resulting in increased crystalline lens, the accommodative convergence
eye strain. While in an exophoric contact does not exist because of lack of accommodation,
wearer myope, increase in the accommodative hence when they switch from spectacle to contact
convergence will decrease the use of positive lenses, there is no change in the demand of fusional
fusional vergence, and thus results in reduced convergence for near vision.
exophoria. Similarly, an exophoric hyper-
metrope contact lens wearer will require more Prismatic Effects as Compared to
positive fusional vergence than glasses. Spectacles
The change in accommodative demand and Spectacles lens induces prismatic effect which
fusional vergence due to contact lens are occurs because line of sight moves away from
practically insignificant for refractive errors of major reference point of lenses as spectacle
small degree, however, the changes may have lens remain fixed and do not move with
significant effects in cases of large refractive movement of eyes, while contact lens moves
errors, especially if there is an associated high with the movement of eyes, hence no
AC/A ratio. significant prismatic effects are produced with
As in the above example, a –10 D myope contact lenses.
and + 10 D hypermetrope both needs more or For example, in case of myopes “base in”
less 0.75 D of accommodation respectively, if effect is produced by minus lenses, while
they wear a contact lens in place of spectacles. “base out” prismatic effect is produced by plus
However, a change in accommodative demand lenses for near vision. Hence, when an
of almost 0.75 D will be accompanied by a exophoric myope switches from spectacles to
change in accommodative convergence. Now contact lenses, he/she will be at disadvantage
if they have an AC/A ratio of 6, then the due to lack of base in prismatic effect for near
change in accommodative convergence at work, whereas an esophoric hypermetrope
40 cm distance will be of 6 × 0.75 which is equal when switches from spectacle to contact
to 4.5 prism dioptres (). Hence, in an lenses, similarly will have disadvantage
exophoric myope, exophoria will be reduced because of lack of base out prismatic effect for
by 4.5 , while in esophoric myope esophoria near work. A vertical prismatic effect during
will be increased by 4.5  at 40 cm distance. It up and down gaze and change in demand of
means an exophoric myope having a refractive vergence during right and left gaze in
error of –10 D will use 4.5  less positive anisometropia is seen with spectacles lenses,
fusional vergence, when uses contact lens in but wearing of contact lenses eliminate this
place of spectacles. On the other hand, an prismatic effect.
esophoric myope in the same situation will use
more negative fusional vergence of 4.5 . Note: Although use of contact lens eliminates many
Similarly, a +10 D hypermetrope when unwanted prismatic effects of spectacles lens but
switch from spectacles to contact lenses, then due to contact lens some beneficial prismatic
an exophoria at 40 cm will be increased by effects are also eliminated. For example, spectacle
4.5  and an esophoria will be decreased by lens can correct a lateral prismatic deviation which
4.5  at the same distance. is lost with contact lens.
Routinely, majority of contact lens wearers
has a refractive error in the range of ±1 D to Aberrations and Field of View
±5 D, hence the change in accommodative Most important types of aberrations which can
convergence, needed with use of contact be experienced with spectacle lens are oblique
lenses instead of spectacles; do not present a astigmatism, curvature of image, and distortion.
significant clinical problem. All of these aberrations are minimized by the
use of contact lenses which move with the Properties required in an ideal contact lens
movement of eyes. material are
Oblique astigmatism and curvature of • Optical property: Lens material should
image aberration happens when spectacle have a good percentage, i.e. 95–98% of
wearer rotates his/her eyes to look through light transmission and have a refractive
the periphery of spectacle lenses, however, index compatible with tears and
contact lens wearers has no such issue to look cornea.
through the periphery. • Ocular compatibility: Material should
Distortion of image occurs due to distance be safe to wear and has no harmful
between aperture of spectacle lens and effects on ocular surface especially
aperture (pupil) of eye. However, in case of cornea.
contact lens, this distance is negligible, hence • Gas permeability: In absence of contact
very minimum distortion of image. lens the cornea receives oxygen through
Field of view is larger in majority of the tears, thus lens material should have
contact lens wearers as compared to spectacle good oxygen transmission through it so
glasses. In a moving eye, contact lens wearer that cornea does not suffocate. Hence gas
has an additional advantage of unlimited permeability through material is a major
macular field of view which is absent in a factor to decide tolerance and duration
spectacle worn person because due to presence of wearing of lens.
of rim of spectacle’s frame the macular field • Physical properties: Specific gravity and
gets restricted as a field of fixation. density of the material are important
properties to keep the contact lens in
CONTACT LENS MATERIALS position because a high density material
Introduction will not stay for a long period on the
History about contact lenses tells us that corneal surface.
initially for manufacturing of contact lens the • Chemical properties: Lens material should
glass material were used, mainly blown glass be easily wettable and water should not
of Muller and ground glass of Carl Zeiss. spread over its surface (hydrophilic), so
However, a constant hunt for an ideal contact that tear film can serve better when
lens material was on, because contact lens of contact lens is in position.
glass material were brittle, heavy and were • Material strength: This property decides
difficult to manufacture in mass. that whether lens will maintain its shape
A revolution in contact lens material took and curvatures after fitting. This is
place in the year 1943 when Kevin Tuohy important to maintain the optical
introduced plastic material for manufacturing property of contact lens.
of contact lens. Although a few years back • Resistant nature: Contact lens material
Obrig had already started the use of methyl should be highly resistant to chemical
methacrylate to produce contact lenses. agents and microbial contamination, so
Subsequently, Gyorrfy introduced PMMA that it will remain sterile during
for lens, and then Wichterle changed the wearing. It should have a property to
picture of contact lens world by introducing easily get sterilized by chemicals or
the hydroxyl methyl methacrylate in the year radiations.
1963. Gradually, acrylic, silicon and cellulose • Moulding: An easy mouldability of lens
acetate butyrate were also introduced as material is a prerequisite to give proper
contact lens materials for mass manufac- shape and curvatures to manufacture
turing. lens in large scale.
Terminologies in Contact Lens Material Clinical Importance

For better understanding of properties of
contact lens material, we should be well versed • Increased in water content of lens improves the
with the following related terminologies. wearing comfort by increasing the transfer of
oxygen through lens. Oxygen permeability of a
Water Properties Related to Lens contact lens doubles with an approximate
increase in 20% water content, which is more
A hydrated contact lens has the following
significant with high absorption property of lens.
water elements
• Increased in water content also enhances the
• Water content mechanical strength of contact lens by
• Water absorption increasing its thickness.
• Wettability • Low wettability increase the wearing duration
Water content: Water content means the and comfort of contact lens by maintaining tear
film stability.
quantity of water present in a lens. We can
measure it in terms of volume or weight. It
can be expressed as: duration and to keep the cornea healthy. This
includes various elements such as
Water content = wet weight – dry weight/wet
weight × 100 • Oxygen permeability
• Oxygen transmissibility
Water content of a contact lens is usually
• Equivalent oxygen percentage
equilibrated in presence of 0.9% saline and
change in conditions like pH and tonicity of • Oxygen tension
solution and temperature can alter the water Oxygen permeability (Dk): It is the property
properties of lens. of a contact lens material, which indicates the
Water absorption: It means the quantity of ability of oxygen to pass through contact lens
water that a contact lens can absorb, means it material without any effort. This is called as
measures the water uptake capacity of lens Dk value of that material, where D means the
and can be expressed as diffusion co-efficient of oxygen and k indicates
the solubility of oxygen in that contact lens
Water absorption = wet weight – dry weight/ material. The value of Dk of a lens material
dry weight × 100 can be calculated by using oxygen electrodes
Wettability: This is important to maintain the in a gas chamber device. Units of Dk are
corneal tear film. Wettability indicates the expressed as Fatt units or Barrer
adherent property of a liquid to a solid surface,
10 −11 (cm 2 × ml O 2 )
despite that the liquid is held by cohesive Dk =
forces. This can be assessed by contact angle sec × ml × mmHg
which is inversely proportional to wettability.
Note: Oxygen permeability (Dk) is a feature of
Thus a lower value of contact angle indicates contact lens material, not of contact lens.
better wettability than a higher contact angle.
On the basis of contact angle various contact Oxygen transmissibility: It is the property of
lens materials can be grouped as a contact lens which indicates the ability of
• Hydrophilic = 0° contact angle oxygen to pass through contact lens of known
• Hydrogel = 20° contact angle thickness. It means it tells about the rate of
• Hydrophobic = > 150° contact angle oxygen transfer across the different contact
lenses of varying thickness. This is represented
Oxygen Related Contact Lens Properties as Dk/L, where Dk is oxygen permeability and
Oxygen related properties of contact lenses L is the central thickness of contact lens in
play an important role in its usage for longer centimeters (cm).
The oxygen transmissibility across a rubber are highly hydrophobic, but due to its
contact lens can be known by formula: other properties these are also grouped as
Dk (Pl − Po ) Filcons. On the basis of different types of
J= substances focons and filcons are grouped as
L summarized in Table 13.1.
Here Pl = oxygen pressure in front of
contact lens Rigid Contact Lens Materials
Po = oxygen pressure behind the Initially all contact lenses were manufactured
contact lens using rigid materials such as glass and
L = thickness of center of contact thermosetting plastics like PMMA. Because of
lens (cm) several clinical drawbacks associated with
Units of oxygen transmissibility is 10–9 (cm these materials subsequently better rigid lens
× ml O2)/(sec × ml × mmHg). materials such as cellulose acetate butyrate
(CAB), silicon and polymers of silicon, etc. for
Note: Oxygen transmissibility is a characteristic manufacturing of contact lens were developed.
of contact lens, not of its material and is inversely Broadly, these rigid contact lens materials
proportional to thickness of lens. It means thinner can be grouped as
is the lens, greater will be its oxygen transmissibility.
• Rigid non-gas permeable materials
Equivalent oxygen percentage (EOP): Cornea • Rigid gas permeable materials
being avascular in nature, receive oxygen Rigid non-gas permeable material: Mostly
mainly from the atmosphere. Presence of the hard contact lenses were made up of
contact lens on the cornea will hamper the thermosetting plastic like spectacle lenses.
supply of atmospheric oxygen to cornea. Thus PMMA was the first commercially available
EOP indicate the amount (%) of atmospheric plastic in this category for mass manufac-
oxygen (in volume) reaching at cornea in turing of contact lenses. PMMA material is
presence of contact lens, for a known thickness not permeable for water or oxygen, hence
of contact lens. For example, as we all know wearers have to depend on a tear pump
that normally about 21% oxygen is present in action of eye for hydration and oxygen
the atmosphere, however, if it is stated that supply to cornea.
EOP is 4%; means that cornea is receiving 4%
Advantages
atmospheric oxygen, instead of 21%.
• It is inert and free of toxic chemicals,
Oxygen tension: It is expressed as partial because PMMA is prepared by a process of
pressure applied by oxygen in a specified annealing (successive heating and cooling),
atmospheric condition. This is an interchan- so does not cause hypersensitivity reactions.
geable term with EOP and helps in deciding • Can be moulded or lathed with high degree
the health status of cornea during usage of of precision.
contact lens for a long period. • Excellent visual properties and safe to wear.
Broadly, contact lens materials are divided as • Requires minimum use of cleaning, soaking
• Focons or wetting solutions.
• Filcons • Can be tinted easily to reduce excessive
Focons: These are hydrophobic material, light sensitivity.
primarily used to manufacture rigid contact • Durable and can be repolished to remove
lenses. minor scratches, hence lasts for nearly
Filcons: These are hydrophilic material, 5–6 years.
primarily used to manufacture non rigid • Economical as compared to any other type
contact lenses. However, elastomers of silicon of contact lens.
Table 13.1: Lens materials and their characteristic properties

Focons Substances Filcons Substances
1a Pure PMMA 1a (hydration = 38) Pure HEMA with <0.2%
(Dk = 0) ionisable chemical (e.g.
methacrylic acid)
1b Copolymer of PMMA 1b Pure HEMA with > 0.2%
(Dk = 0) with 10% other monomer ionisable chemical
2a Pure cellulose acetate 2a Copolymer of HEMA +
(Dk = 2–8) butyrate (CAB) hydroxyalkyl MA +
(hydration = 38) dihydroxyalkyl MA with
< 0.2% ionisable chemical
3 Copolymer of Allyl 2b Same as 2a with > 0.2%
(Dk = 12) methacrylate (MA) + ionisable chemical.
Siloxanyl MA
4 Polysiloxones 3a Copolymer of HEMA + N
(hydration = 71) vinyl lactum with < 0.2%
ionisable chemical
5 Copolymer of Allyl MA + 3b Same as 3a with > 0.2%
(Dk = 71) Siloxanyl MA + 0.5% ionisable chemical
fluroalkyl MA
4a Copolymer of alkyl MA +
(hydration = 79) N vinyl lactum +
alkylacrylamide with
< 0.2% ionisable chemical
4b Same as 4a with > 0.2%
ionisable chemical
5 (Dk = 200) Polysiloxanes
Disadvantages In subsequent years many researchers tried

• Oxygen permeability of PMMA lens is to improve the permeability of contact lens by
negligible, hence cannot be worn for long drilling small holes or fenestration in the lens.
duration, otherwise person will develop Hydrogel (polymers that imbibe water and
dryness, swelling and ocular discomfort. swell) were also added with PMMA to
• PMMA material is very hard in nature so improve its permeability, but still gas
can cause corneal abrasions. impermeability of material remained a major
issue in its wide usage. Because of impermea-
• Because of hydrophobic nature of PMMA,
bility property these lenses are kept light, thin
it has poor wettability. In PMMA lens the
and of small size so that they do not cover a
oxygen transmissibility is very poor so
large portion of cornea. In addition, these
oxygenation of tears depends on renewal
lenses cannot be used for correction of high
of tears due to blinking. As the contact lens
degree of corneal astigmatism because of their
wearer blink, there is slight movement of
light and thin nature.
contact lens over the cornea so that
interchange of tears occurs underneath the Rigid gas permeable lens material: Materials
lens and as a result oxygen is exchanged which are used for production of RGP lenses
and provides necessary oxygen to cornea. maintain the property of PMMA in terms of
rigidity, but unlike PMMA these materials Silicon acrylate: In the year 1974, Norman
have good oxygen permeability, hence became Gaylord produced first siloxane (oxygen and
popular for a long-term usage. Primarily, silicon are combined together) based rigid lens
cellulose acetate butyrate (CAB) and silicon material by cross-linking silicon acrylate with
were used to manufacture these rigid gas per- MMA, resulted in formation of trimethylsiloxy
meable lenses, however, several polymers of (Tris) silane. The presence of silicon provides
silicon and allyl methacrylate later introdu- good oxygen permeability to material while
ced in the market for manufacturing of better MMA provides good wetting and physical
tolerable contact lens. property to material. Many rigid materials
Contact lenses formed from these materials now are used for production of contact lens
are also called semisoft contact lenses because are on the basis of these properties.
of their good oxygen permeability and better Silicon can be added in various proportions
Dk value. with varying Dk value in the range of 15–60
Cellulose acetate butyrate (CAB): It was and oxygen permeability. As silicon increa-
first widely used material to manufacture rigid sed, the oxygen permeability of lens increases
gas permeable contact lenses. This biodegra- but it also alters the surface characteristic of
dable thermoplastic polymer was derived lens.
from yellow poplar wood fiber (YPWF) Fluoropolymers: Fluoropolymers were
having good wettability. Advantages of this discovered during 1930 and are considered as
material over PMMA were good oxygen most desirable material for mass manufactu-
permeability, relative wettability and reduced ring of RGP contact lenses because of their
hardness; however disadvantages as compared high oxygen permeability, wettability and
to PMMA were poor scratch resistance and resistibility to surface deposits. Fluoropoly-
tensile strength. Due to these reasons a mers can also withstand high temperature and
constant search for better material was on, chemical attack. Free radical polymerization
which leads to development of silicon acrylate is basic industrial synthesis method for
material. fluoropolymers. The polymerization process
Styrene: A highly gas permeable, surface is mainly water-based method, which uses
wettable, and relatively hard contact lens either aqueous suspension or aqueous
material used for manufacturing of RGP emulsion polymerization in presence of
contact lenses is styrene (T-butyl dimethyl fluorinated emulsifiers. For manufacturing of
siloxy). This contact lens material is a copoly- contact lenses fluoropolymers can be used
merization product of a reaction mixture either in pure form or in co-polymer forms.
consisting styrene, esters of vinyl alcohol and Flurofocon A is a polymer having high
polyethylene glycol, polysiloxane along with fluorine content which is commercially
a cross-linking agent like divinyl benzene. developed by 3M Company for mass
Initially this material looks promising, production of extended wear contact lenses.
however, due to brittle nature of this material As compared to earlier available fluoropoly-
mass manufacturing became a problem. mers, an excellent wettability and flexibility
Silicon: Silicon is highly permeable to is present in Flurofocon A. This material
oxygen than water. Contact lenses with more has very high levels of oxygen transmiss-
silicon will be more permeable than less silicon ibility and remarkable resistance against
lens. However, silicon has its own problems deposit formation. Hence, combination of
like hydrophobic nature (less wettability) and physical properties and optical stability of
relative stiffness and because of these Flurofocon A makes it the most desirable
properties it is a less friendly material for large new lens material for manufacturing of
production of contact lenses. contact lenses.
Soft Contact Lens Materials • Refractive indices of these lenses is

First monomer material for soft lens, i.e. comparable with cornea, hence quality of
hydroxyethyl methacrylate (HEMA) was vision is better.
introduced by Otto Wichterle in the year • High oxygen permeability is a major
1950. As the name suggests that this material advantage and permeability increases
has a hydroxyl group, in contrast to PMMA proportionally with an increase in the water
where only methyl group was present. These content, whereas decreases with an increase
soft lens materials are also termed hydrogel in the thickness of lens.
because they are cross-linked polymer and • Soft in nature and hence a larger portion of
being hydrophilic absorbs water, get swell cornea can be covered for better field of
and make lens soft and elastic. The cross- vision and correction of refractive error.
linking provides physical stability to lens Disadvantages
material. • Due to high water content and soft material
During production of soft gel materials, nature these lenses are very fragile and get
monomers such as HEMA with the aid of a damaged easily.
catalyst undergo polymerization which results • Swells up due to high water content, hence
in formation of sequence of repeating units clarity of vision is less as compared to rigid
termed Poly hydroxyethyl methacrylate or contact lenses.
P-HEMA. This polymer is made by poly- • Higher incidence of microbial keratitis as
merizing two molecules of hydroxyethyl compared to RGP lenses.
methacrylate (HEMA) monomer and using a Soft contact lenses can be produced by using
cross-linking agent like ethylene glycol several materials either as monomers, polymers
dimethacrylate (EGDMA) or polyvinylpyrro- or co-polymers. Broadly, we can group these
lidone (PVP). The hydrophilic nature of soft hydrogel materials into
P-HEMA is due to the presence of hydroxyl • Conventional hydrophilic hydrogel materials
group (OH) which creates small pores in the • Silicon hydrogel materials
polymers through which fluid can enter.
When more than one type of monomer is Conventional Hydrophilic Hydrogel Material
used in production of the material, then this Conventionally, hydroxyethyl methacrylate
type of material is termed copolymers. A (HEMA) is most commonly used hydrophilic
polymerized HEMA EGDMA lens has water monomer material for manufacturing of
content of about 38–50% and used as daily hydrogel lens. Although nowadays, cross-
wear lens while HEMA-PVP has high water linking polymers are more used because of
content (>50%) and used as extended wear their better stability.
lens. However, by using various different HEMA: HEMA is most widely used, original,
types of monomers different materials can be water insoluble soft contact lens material
produced varying in terms of water contents, which is used as monomer for mass
refractive indices, hardness, and strength and manufacturing of soft contact lenses in our
oxygen permeability. country. Pure HEMA lens has water content
Advantages of about 38–40%. It is mostly copolymerised
• Good hydration equilibrium of material to form various hydrogel which are used for
provides better comfort of wearing. These manufacturing of soft hydrogel contact lenses.
soft lenses can be either low hydration For example, materials such as dimethyl
lenses having water content of 38–50% or acrylamide (DMA), glycerol methacrylate
of high hydration lenses having water (GMA), methacrylic acid (MA), methyl
content of > 50%. methacrylate (MMA) and vinylpyrrolidone
(VP) are used for polymerization in currently MAA-HEMA: To increase the equivalent
available contact lens materials. water content (EWC) of material, a different
HEMA has important properties like it is hydrophilic monomer methacrylic acid
not easily damaged by biodegradation, (MAA) was used to manufacture hydrogels.
chemical or thermal sterilization and by Addition of MAA during formation of soft
enzymes present in tears, hence makes this lens material results in formation of ionized
material most suitable for making contact groups within the matrix of polymer which
lenses used for a long period. increases water absorption property of lens.
Addition of MAA with HEMA usually increases
HEMA-NVP: Subsequently, HEMA copoly-
the water content up to range of 50–60%,
mers were developed to improve water
which in turn results in significant increases
content or hydration of lens material.
in the oxygen permeability through lens.
Copolymerization of HEMA with N-vinyl-
pyrrolidone (NVP) was first commercially The use of MAA in lens material is also
successful contact lens material having associated with some disadvantages such as
equivalent water content of up to 90%. These • The lens containing MAA are very
types of copolymers have rubbery feel as sensitive for changes in the tonicity. For
compared to slippery feel of P-HEMA. In example, in solutions having less tonicity
addition, the amide group present in these (hypotonic like water) the effective water
material bind weakly with water molecule as content (EWC) of lens increased, while
compared to hydroxyl group, therefore, opposite occurs in hypertonic solutions.
evaporation rates of water through these lens • EWC of this type of lens material also
is relatively high leading to chances of change with change in the pH of
instability of lens and discomfort. solution. The EWC of lens decreases in
low pH conditions.
Disadvantages:
• Significant amount of protein depositions
• Sensitive to change in temperature:
can occur on surface of lens and within
Parameters of copolymers of HEMA-NVP
its matrix. However, recently it has been
can change with change in the temperature,
found that these proteins are in non-
hence caution is required during lens fitting
denatured form.
because lens parameters may change after
• During heat-disinfection process the lens
its contact with eye.
may loss its dimensional stability.
• Corneal staining: Use of NVP containing
lenses with solutions which contain MMA-PVD: These are copolymer of polyvinyl
polyhexanide in high amount may cause pyrrolidone (hydrophilic), monomer VP and
staining of cornea and increase level of methyl methacrylate (hydrophobic).
discomfort. Hence, it is essential to keep in Glyceryl methacrylate: Glyceryl methacrylate
mind that if staining occurs, then solution (GMA) monomer consists of two hydroxyl
must be changed which contains negligible groups as compared to HEMA and thus more
amount of polyhexanide. water soluble than HEMA. GMA in combina-
MMA-VP: MMA (methyl methacrylate) and tion with other monomers or hydrogels is used
VP (vinylpyrrolidone) monomers were for manufacturing of contact lens materials.
combined to produce MMA/VP copolymer. Combination of GMA with MMA (Crofilcon
MMA/VP copolymer showed different A) produces a material which is more stiff and
characteristics than HEMA/VP copolymer. strong than P-HEMA as well as contains
MMA/VP copolymers based contact lenses water contents in range of 30–42%. In
may have water content from 60–85% addition, it can be combined with HEMA,
depending upon the composition. which results in formation of non-ionic
material having high water content (up to Several following bulk properties of this
70%). Moreover, the water balance ratio of material are also contributing for manufac-
these types of lens material is excellent because turing of extended wear contact lens.
their rate of rehydration is fast, while • Equilibrium water content and water
dehydration occurs at slow rate. The chances activity; has high percentage of free water,
of deposition are very less and the property bound water and intermediate water.
of material remains unaltered with the change • Oxygen permeability and transmissibility.
in pH in the range of 6–10. • Hydraulic and ionic permeability
Silicon hydrogel material: In the year 1999, Advantages of silicon hydrogels are
silicon hydrogel material was successfully • Less chances of microbial contamination.
introduced in manufacturing of contact lens • Less mechanical interactions to corneal
which within a decade became main type soft surface.
contact lens material representing almost 70% • Less protein depositions over lenses.
of total lens materials. Similar to conventional
• Release of moisture agents like polyvinyl
hydrogels, in silicon hydrogel materials the
alcohol.
main chain consists of siloxane derivates
• Can also be used as drug delivery system.
like polydimethylsiloxane (PDMS), Bis
(trimethylsiloxy) methylsilane, tris-propyl A few disadvantages like sensitivity to lipid
vinyl carbamate (TPVC) and polydimethyl- deposition, hydrophobic surface and non-ionic
siloxy bisvinyl carbamate (PBVC). nature are also present in silicon hydrogel
Initially two silicon hydrogel materials, materials.
Lotrafilcon A and Balafilcon A were available Note: Silicon hydrogels are most desirable material
which were having high oxygen permeability for manufacturing of extended wear contact lenses
but having low water content (25 and 38%, throughout world.
respectively). Hence these materials were
stiffer and hydrophobic than poly-HEMA
MANUFACTURING AND TYPES OF CONTACT LENS
based (water soluble) materials. However,
silicon containing materials are highly oxygen Various processes used to manufacture
permeable. Later on better silicon hydrogel contact lenses are
materials were produced and currently more • Lathe cutting
than 12 different types of materials are • Melt pressing
available having desired relationship between • Spin casting
water content and oxygen permeability. The • Cast moulding
increase in the silicon content increases
permeability of material. The silicon hydrogen Lathe Cutting
materials developed later on have high Dk Earlier this process was used for manufac-
values as well as maintain medium to high turing of corneal PMMA and rigid lenses. Later
water content (> 45%). on, it was also used in the manufacturing of
Following surface properties of silicon soft hydrogel lenses. This process is used for
hydrogels material are desirable for production of both soft and rigid types contact
manufacturing of contact lenses. lenses by using various types of lens materials.
• Topography and roughness Various steps in the process of lathe cutting are
• Friction (less) • Manufacturing of buttons from material
• Wettability (improved by surface treat- • Back surface cutting of a lens blank
ment) • Front surface cutting of a lens
• Surface charge/ionicity (mostly non-ionic) • Wet processing of the lenses
Manufacturing of buttons from material: surface) is fixed on to a mount or chuck, this

Firstly, the monomer material is polymerized process is called blocking. The mount is a
to prepare button-shaped moulds or cylindrical-shaped tool made of metal or
alternatively can be cast in the form of rods plastic, having one end dome-shaped which
from which button can be cut later on. These match with the curve of posterior surface of
buttons act as lens blanks. Polymerization lens blank. At this dome end, hot melted wax
process takes time, hence these button or rods is applied and the posterior or back surface of
are kept in a water bath at a definite lens blank is mounted with the help of this
temperature (depending on the type of wax at dome end and centered carefully. This
material used) for several hours. It is followed assembly is now loaded on the lathe machine
by annealing process of buttons where the for front surface cutting and then centration
material or buttons are heated at high of lens blank is confirmed followed by cutting
temperature followed by cooling at room of surface by diamond tool. The front lens
temperature. Annealing makes the material surface is then polished and deblocked by
soft so that stress is relieved inside buttons. immersing into a deblocking solvent.
In addition, it also prevents grooving of edges Wet processing of the lenses: The processed
or rolling up (like cigarette) of finished lens dry lenses go through hydration and wet
when in hydrated state. processing steps which will vary according to
A soft contact lens is lathed in dry state the type of lens material. For example, non-
means a smaller, steeper lens of greater power ionic lenses are usually first washed with
is prepared by lathe so that when it absorbs deionized water and then with saline.
water it swells and attains required dimensions Ultrasonic baths are also used to increase the
and powers. speed of hydration process. For lenses
Cutting of back surface of lens blanks: The containing MAA, washing is done in tanks
buttons are processed on lathe to cut the back containing sodium bicarbonate to facilitate
surface of lens from the buttons. Nowadays, ionization of the lenses.
computer-based lathe are available which can Advantages
be programmed accordingly to cut buttons • Can be used to manufacture both rigid and
into numerous design and of variable soft type contact lenses.
parameters. Diamond cutting tools are used • Lenses usually have high quality surface
to cut back surface from buttons which is a finishing due to diamond cutting edges on
two-step process. Firstly, a rough cut is given an automated lathe machine.
on buttons to remove excess material. Then a • Variety of lens design, surface curvature to
final cut is given to slice secondary curves and fit for an individual requirement and
slanted edges of lens. Following the cutting, different size diameter lenses can be
the polishing of back surfaces is done on a produced.
polishing machine. Polished materials usually • High quality polishing reduces surface
contain a lanolin base and coarse diamond defects and improves the optical property
dust. During lathing and polishing the of lens having a stable visual acuity which
excessive heating of lens material must be does not fluctuate.
avoided to prevent warpage and errors of • Lathing in dry state of soft lens gives a high
curvature. Prepared semi-finished lenses are dimensional accuracy so even toric lens can
then kept in a solvent to get rid of excessive be designed.
polish.
• Also necessary for production of low
Cutting of front surface lens: The semi- volume and high prescription custom
finished lens blank (buttons with cut back lenses.
Disadvantages: Principle: The cast or mould containing

• Require intense labor, hence it is both mixture of desired monomers (monomer
expensive and susceptible to significant solution + cross-linking agent + initiator) is
human errors. spinned at a controlled speed. During spinning
• It is a slow process. the generated centrifugal forces cause
ascending of the monomer mixture to the walls
Manufacturing errors may occur during lathe
of cast and take the required lens shape, while
process like
simultaneously polymerization also occurs.
• Hydrogel or soft lenses are lathed in dry
This process has the following steps of
state, hence they undergo final step of
manufacturing the contact lens as shown in
hydration which can be a potential manu-
Fig. 13.7.
facturing error.
• Core fractures Manufacturing of inserts: First step is to
• Inclusions, e.g. rust produce inserts of excellent quality which are
• Watermarks, bubbles or holes on lens then used as mould to produce the casts
• Debris, e.g. fibres because the quality of anterior surface and
edges of each lens depend on quality of the
• Lathe rings
inserts prepared.
• Distortion, discoloration and edge defects
of lens Manufacturing of cast: Casts are usually
prepared by using materials like poly
Melt Pressing propylene or polyvinyl chloride. Occasionally,
This method was used to manufacture PMMA
and silicon contact lenses, however, now this
is not widely used and is an obsolete
procedure. Various steps involved in the
process of melt pressing are summarized as
• The monomer is polymerized to produce a
polymer (polymerization).
• This polymer is then converted into sheets,
beads, granules or power.
• Moulds of desired size shape and types are
taken from this polymer material.
• Compression or injection moulding is done.
• Semi-finished lens is then removed from
mould.
• Lens is edged and polished for packing
purposes.
Spin Casting
In the year 1961, Wichterle described a new
method for manufacturing of soft lens and
patented it, which is known as spin casting.
Subsequently, in the year 1971 this method
was further refined by Bausch & Lomb (B&L).
Nowadays, manufacturing of contact lens by
spin casting process is based on the same Fig. 13.7: Contact lens manufacturing by spin casting
principle as developed by B&L. method
the surface treatment of resulting casts is done Advantages

to ensure the wetting of cast material, but this • Generates a homogenous, consistent and
treatment also increases the cost of production properly cross-linked polymer, because a
of lens. thin film of monomer is polymerized.
Spinning process: Most important step of • Produces best quality optical surfaces.
entire process is spinning of the cast which • Accurate spin speed and precise dosing
determines the final power and shape of the produces perfect parameters contact lenses.
produced contact lens. Various other factors, • Minimum surface defects and edging
such as combined effect of gravity, surface errors, because surfaces formed are free and
tension, centrifugal force during spinning, independent to cutting.
quantity of liquid monomer and the rate of • Less expensive and easily reproducible.
spin determine the final outcome. If the radius Disadvantages
of the produced cast is predetermined, then a • Unpredictable fitting.
contact lens of desired central thickness and
• Fitting of lens is not dependent on kerato-
back vertex power can be made by controlling
meter reading of patient.
the speed and dose of monomers. The rate of
spin speed will decide the back vertex power Cast Moulding
while dose will decide the central thickness
Primarily this process was used as cost
of lens.
effective method to manufacture plastic goods
• The anterior surface of lens is spheric and but later on it was also used for production of
curvature of front or anterior surface of contact lenses.
desired lens is provided by the inner surface
of cast or mould. Principle: During the cast moulding
• Back or posterior surface of contact lens is procedure to prepare a contact lens the liquid
aspheric and the curvature of this surface monomer undergo polymerization process
depends on factors like shape and amount between two casts. The formed semi-finished
of speed of mould, physical properties and lens before packaging again processed to
amount of liquid monomers in the cast. produce desired lens.
• It is considered an ideal method for Cast moulding: Cast moulding and its
production of minus power contact lenses modified methods are now commonly used
because the manufactured lens by this for production of high volume soft lenses
process has power of approximately equal because the unit production cost is potentially
to –3 D lens. low by this method. Various steps of this
• However, for manufacturing of positive process as shown in Fig. 13.8 are as follows
powered contact lens, casts with more Manufacturing of inserts: During cast
complicated designs are required. Another moulding process both male and female type
method which has been adopted by inserts along with auxiliary insert housings are
manufacturers to produce the lens of manufactured. Front or anterior surface of
desired power and curvatures is that after final contact lens is formed by using female
the spinning, lathe is also done on spin cast cast which is created by the female insert,
lens. whereas back or posterior surface of the final
• The final lenses are demoulded, either contact lens was created by male cast which
manually or by an automated production line. is formed by the male insert.
• These finished lenses are wet processed in During this process the male inserts are
a similar way to lathed lenses as explained manufactured in less number than female
above. inserts, because contact lens of different
Manufacturing of cast: During manufacturing

by cast moulding both the material used for
cast and design of the casts play a vital role.
The material that is used for development of
cast play an important role in deciding the
dimensional stability. Hence, a careful
selection of chemical structure of the polymer
used to produce contact lens is a vital step
during cast moulding. Previously, the
manufacturers faced some problems related
to stability of casts which lead to low yield of
lenses with correct specification for a specific
manufactured batch.
The design of the cast during manufac-
turing of lens will decide the optical property,
curvatures of surface, pattern of edge and
diameter of final lens, hence resultant lens is
also significantly dependent on the design of
the casts.
Classification of Contact Lenses

Contact lenses can be classified on the basis of
various parameters as summarized in Table 13.2.
Fig. 13.8: Contact lens manufacturing by cast Surface curves
moulding method • Monocurve lens has single curve on both
powers can be produced by altering the female the anterior and posterior surfaces, rarely
insert, as the radii of anterior surface and used nowadays.
altogether thickness profile of lens get change • Bicurve lens has single anterior curve, but
by changing the female cast. two back curves (a central curve and
Table 13.2: Classification of contact lens (CL) on basis of various parameters

Surface Anatomical Physical Chemical Hydration Duration of Clinical uses
curves position properties nature of status lens wear
lens material
Monocurve Scleral lens Soft CL Rigid non-gas Low Long-term or Optical CL
CL permeable CL hydration CL yearly wear
Bicurve CL Corneo- Semisoft CL Rigid gas Medium Monthly Therapeutic
limbal lens permeable CL hydration CL wear CL
Tricurve CL Corneal CL Hard CL Soft CL High Weekly wear Cosmetic CL
hydration CL
Multicurve Daily wear Diagnostic CL
CL
Toric lens Extended Occupational
wear CL
Bitoric lens
flatter peripheral curve), most commonly Hydration status of lens material

used. • Low hydration lenses: Having water content
• Tricurve lenses are similar to bicurve except in a range of 0–38%.
that an intermediate curve is present on • Medium hydration lenses: Having water
back surface. content in a range of 40–60%.
• Multicurve lenses are also similar to bicurve • High hydration lenses: Having water
lenses but have more than one intermediate content more than 60%.
curve.
• Toric lens has a toric back surface, mainly Duration of lens wear
used for highly toric cornea (astigmatic) cases. • Long-term or yearly wear
• Bitoric lens has a cylindrical power on • Monthly wear
anterior surface of lens along with the toric • Weekly wear
posterior surface, mainly used in high • Daily wear
degree of astigmatism with low corneal • Extended wear
toricity like in cases of lenticular astigma-
tism. Clinical uses
Anatomical position in the eye • Optical contact lens
• Scleral lenses are also known as haptic or • Therapeutic contact lens
corneo-scleral contact lenses. These lenses • Cosmetic contact lens
cover the cornea, conjunctiva and sclera and • Diagnostic contact lens
are mainly used for therapeutic purposes, • Occupational contact lens
rarely used for optical, cosmetic or
diagnostic purposes. CONTACT LENS DESIGN
• Corneo-limbal contact lenses cover the
Contact lens can be designed in various ways
entire cornea and limbus to lay over
to achieve the requirement of an optimized
conjunctiva. Mainly used for optical and
contact lens so that it is fit for different clinical
cosmetic purposes.
conditions.
• Corneal contact lenses are entirely confined
• Regular lens designs
to cornea and are mainly used as optical and
diagnostic contact lenses. • Special lens designs
Physical properties
Regular Lens Design
• Soft contact lens
These types of lens are used most commonly
• Semisoft contact lens and usually designed for correction of simple
• Hard contact lens refractive errors, because refractive status of
Chemical nature of lens material eye in simple errors is not affected due to
• Rigid non-gas permeable lenses, usually rotation of contact lens on the cornea. These
hydrophobic in nature made up of PMMA. lenses are designed as
These lenses are also called Focons. • Single cut design
• Rigid gas permeable lenses, made up of • Lenticular cut design
cellulose acetate butyrate and silicon, most Single cut designed lenses may be
commonly used as long-term wear contact monocurve, bicurve or tricurve containing a
lenses. single continuously curved front surface as
• Soft contact lenses, usually hydrophilic in shown in Fig. 13.9. Desired base curve and
nature made up of acrylic and HEMA. peripheral curves are cut from the back surface
These lenses are also called Filcons. of contact lens.
and thickness of contact lens which further

improve the tolerance and centration of lens.
The curve of posterior surface of lens is kept
same.
Prism ballast lenses: These lenses are heavier
at bottom and are indicated for correction of
problems related to binocular vision related
problems as in vertical phoria. As the name
indicates, a prism is given in contact lens for
Fig. 13.9: Single cut contact lens designs
proper orientation and to prevent rotation as
Special Lens Design shown in Fig. 13.11. The vertical base-down
type of prism is prescribed in contact lens.
Several special types of design features are
Usually prisms are prescribed in toric (front
done in lens to optimize the fitting of contact
surface) and bifocal contact lens, in both gas
lens and to prevent rotation of lens in the eye.
permeable and hydrogel material to maintain
These modifications are
orientation.
• Lenticular edge modification
Truncated design lenses: In these design
• Prism ballast lenses
lenses a circumferential zone in contact lens
• Truncated design lenses is present, which is made flat by removing lens
• Fenestrations design material from a circular contact lens as shown
• Blending design in Fig. 13.12, the process is called truncation
Lenticular edge modification: These lenses of lens. Like prism ballast lens, the truncation
have a central optical portion which is
surrounded in periphery by a carrier edge
(either minus or plus powers) as shown in
Fig. 13.10. This carrier edge is supported by
eyelids and prevents the decentring of lens.
These types of modified contact lens are
designed for those persons where the optical
power of gas permeable contact lens
becomes more than –6.00 D or + 4.00 D. The
lenticular edge modification of anterior
surface of contact lens helps to improve the
edge profile as well as also decreases weight Fig. 13.11: Prism ballast contact lens design
Fig. 13.10: Lenticular contact lens design Fig. 13.12: Truncated contact lens designs
of a lens also helps in decreasing the rotation Note: Heavy blending helps in multicurve contact
of contact lens especially with bifocal or toric lenses, to improve the quality of vision.
(front surface) contact lens.
Fenestrations: In these design contact lenses Terminologies in Contact Lens
small holes are present, which are drilled Most important purpose of knowing the
through the surface of a contact lens as details of contact lens design is that the
shown in Fig. 13.13. This design is mainly posterior surface of lens must fit optimally on
used in contact lenses of rigid type, either surface of the cornea because any discrepancy
PMMA or gas permeable types. The in fitting will lead to positional instability of
insufficient oxygen permeability through contact lens on the cornea.
these lens material may cause corneal
edema. The holes help to facilitate the Contact Lens Dimensions
oxygenation of cornea, either directly or by To know specifications of contact lens and to
enhancing tear exchange. improve the fitting of lens on the cornea, it is
Blending: Chances of corneal abrasion or important to know some basic information
trauma can be decreased by smoothing or about lens dimensions which are as follows
blending the junctions between multiple (Fig. 13.14):
curvatures present on posterior surface of Total diameter (TD): It is the linearly measured
contact lenses. Thus, blending increases longest distance between the two boundaries
the tolerance and comfort of wearing. of contact lens and is measured in millimeter.
Blending is generally conducted on gas This is also called overall size, chord diameter
permeable contact lenses. This can be classified or overall diameter and should not be
as confused with a double of radius of curvature
• Light blending: When transformation or of lens. Lenses of various types have different
blending is clearly visible between two total diameters as follows
posterior curves of a contact lens. • Rigid non-gas permeable lenses or PMMA
• Medium blending: When transformation is lenses have a TD of 7.5–8.5 mm.
minimally visible between two posterior • Rigid gas permeable lenses have a TD in
curves of a contact lens. the range of 9–9.6 mm.
• Heavy blending: When transformation is • Soft contact lenses have a large TD in the
invisible between two posterior curves of a range of 13–14 mm.
contact lens.
Back optic zone diameter (BOZD): It is a linear
distance of central optical zone of contact lens
which focuses rays on the retina. It is the
distance between the two junctions or blend
of lens and measured in millimeter. This is also
called posterior optical zone diameter, back
central optic diameter or optic zone diameter.
Normally it should be more than 7 mm for
good vision.
Peripheral curve width: It is the width of
peripheral curve of lens which is flatter than
the base curve and it decides the fitting of lens
on the cornea. This is also called peripheral
Fig. 13.13: Fenestrated rigid contact lens design curve diameter. There may be an intermediate
Fig. 13.14: Dimensions of contact lens
curve width, if an intermediate curve is Contact Lens Curves and Radius

present as in cases of trifocal or multifocal Various contact lens curves and their related
contact lenses. radius as shown in Figs 13.15 and 13.16 are as
Central thickness: It is the thickness of lens follows
measured at optical or geometrical center of a Base curve: It is the curve of back surface of
contact lens. This is also called as geometrical contact lens which rests on the cornea and is
central thickness (GCT). It is an important responsible for good fit. This is also called
factor to decide the hydration and oxygena- central posterior curve or back central optic
tion of lens and is measured in millimeter. The portion. In a given lens design, back curve
value of central thickness of a lens depends radii may be present in a range from 7.5 to
on its posterior vertex power. 9.0 mm, at 0.5 mm intervals.
Fig. 13.15: Various terms and structures of contact lens

Fig. 13.16: Curves in contact lens
Note: “Longer is the radius of curvature, flatter will from boundary of optical curve and goes up
be the base curve”. to the edge of lens is called peripheral anterior
curve, however, in specific cases there may be
Optical curve: It is the curve of anterior a peripheral anterior intermediate curve in
surface of contact lens, in optical zone. Optical between the optical curve and peripheral
power of a contact lens is determined by the anterior curve. In high hypermetropes or high
amount of curvature of optical curve. This is myopes the intermediate anterior peripheral
also called front curve. curve is designed in lens for better visual
Peripheral curves: These curves are present quality.
on the posterior surface of lens and include
Indications of Contact Lens Wear
intermediate curve and peripheral curve.
These curves are concentric to base curve and Contact lens wear can be prescribed for
act as reservoir of tears to facilitate a smooth various indications which can be grouped
lens movement over the cornea. This is also as
called back peripheral optic portion. Simple Optical indications: Contact lenses are used
bicurve lens has a single peripheral curve as an alternative to spectacles for correction
which is larger than optical zone in radius, of various refractive errors like myopia,
although two or more peripheral curves are hypermetropia and astigmatism. Several
present in tricurve or multicurve contact other ophthalmic conditions like aphakia,
lenses. anisometropia, aniseikonia, presbyopia,
Back peripheral radius (BPR): This is also keratoconus, field restrictions as seen in
known as back peripheral optic radius or retinitis pigmentosa are other important
peripheral curve radius. Similarly, in specific indications where contact lens are advised as
cases of high refractive errors, a contact lens a better optical correction device than
with an intermediate curve and its radius are spectacles.
used. Contact lens versus spectacles: Comparison
Peripheral anterior curves: The slope on the of various characteristics of contact lenses with
anterior surface of contact lens which starts spectacles summarized in Table 13.3.
Table 13.3: Comparison of characteristics of contact lenses with spectacles

Characteristics Contact lenses Spectacles
Irregular astigmatism Corrected (hard CL) Not corrected
High anisometropic Binocular vision possible Not possible
Field of vision Larger field obtained Smaller field
Peripheral aberrations Eliminated Not eliminated
Prismatic distortion Eliminated Not eliminated
Wearer skill Reasonable skill No skill
Precautionary wearing measures More Less
Cosmetic acceptability Higher Lower
Cost Expensive Economical
Long duration wearing of contact lens may cause damage of ocular surface
Therapeutic indications: Contact lenses can be • In amblyopia for occlusion therapy

used as curative, supportive, palliative or (opaque contact lenses used).
preventive devices in various ocular conditions. • Post-surgical procedures: Pterygium
a. As curative device: As curative therapy can excision, lamellar keratoplasty, photo-
be used in pathology of cornea, conjunctiva, refractive keratotomy, laser sub-epithe-
etc. lial keratomileusis, C3R for keratoconus.
• Corneal pathologies: Contact lens can be • X-chrome lenses for red green color
used in various disease of cornea deficiency.
including non-healing corneal ulcers, • In lagophthalmos to support the globe.
corneal abrasions, recurrent epithelial
• Leaking conjunctival filtration bleb.
defects, bullous keratopathy, traumatic
epithelial defects, filamentary keratitis, c. As preventive device
small corneal perforations, corneal • Lid conditions like trichiasis, entropion
trauma, exposure keratitis and descemeto- and ptosis to prevent corneal abrasions.
cele. The extended wear type contact • Giant papillary conjunctivitis to protect
lenses are mainly prescribed which are cornea.
also called bandage contact lens (BCL), • In chemical injuries to prevent symble-
because they serve like a bandage over a pharon and to restore anatomy of fornix.
wound. Use of these lenses in corneal • Neuroparalytic keratitis to prevent
pathologies help in decreasing the ocular corneal ulcerations.
pain and discomfort by preventing
• Glare producing iridectomies.
mechanical trauma due to lids, also
improves hydration and drug penetra-
Note: Orthokeratology in high myopia and /or
tion which help in enhancement of the astigmatism rigid contact lens with progressive flat
epithelial healing. fit, believed to mould cornea (technique is now
• Conjunctival melanosis: Lenses are used to obsolete).
deliver high doses of continuous
radiation to conjunctiva. Cosmetic indications
• In glaucoma: Contact lenses are used as • Corneal scars
drug delivery device. • Microcornea
b. As palliative device • Microphthalmos
• Iris pathologies: Coloboma, aniridia and albi- • Heterochromia
nism to avoid excessive entry of light rays. • Deformed eyes
Occupational indications • Iritis

• Actors/Actresses to change looks. Sports • Choroiditis
person involved in archery, football, etc. f. Systemic conditions
• People using telescope. • Diabetes mellitus: There are frequent
• Defense people, in pilots, in shooters. fluctuations in refractive status and
Diagnostic and operative indications corneal erosions heal very slowly.
• Goldman’s three mirror contact lens • Perimenopausal period.
• Fundus photography • Oral contraceptive usage: Lens poorly
• Electroretinography tolerated.
• Fundus examination in irregular astigma- • Pregnancy: Corneal shape can change
tism due to oedamatous swelling.
• A-scan biometry g. Allergies
• Gonioscopy • Contact dermatitis
• For intraocular foreign body localization. • Asthma
• High minus lenses for fundus examination • Atrophic rhinitis
during vitrectomy and endolaser photo- h. Occupational hazards
coagulation.
• Smoky, dusty and hot job environment
• Goniotomy lenses during surgical goniotomy.
• High altitude flyers
Research indications • Construction workers
• Corneal temperature measurement • Automobile mechanics
• Intraocular pressure measurement
i. Poor general and mental health
Contraindications of Contact Lens Use j. Low hygienic patients
a. Diseases of Eyelids k. Old age patient with poor motivation
• Stye l. Arthritis or parkinsonism patient unable
to use hands properly
• Chalazion
• Blepharitis
CONTACT LENS FITTING
• Meibomitis
Contact lens fitting require a protocol to
b. Diseases of conjunctiva achieve the desired results. We need to do a
• Conjunctivitis (bacterial, viral, fungal) good work up in desired patients. Patient
• Chronic hyperemia work up and examination remains constant
• Bulbar conjunctival papillae in all types of contact lenses fitting whether it
c. Diseases of lacrimal apparatus is soft hydrogel contact lens, rigid contact lens,
• Acute or chronic dacryocystitis cosmetic or therapeutic contact lenses.
d. Diseases of cornea Patient Work up for Contact Lens Fitting
• Corneal dystrophies Patient requiring either soft or RGP, and /or
• Dry eyes any other types of contact lenses, thorough
• Tear film abnormalities examination is required to produce a
• Corneal anesthesia as in fifth nerve palsy satisfactory result which can be achieved by
• Pannus following examination
e. Other ocular pathologies History: Proper history plays a major role in
• Episcleritis the outcome of a contact lens wearing results,
• Scleritis whether a patient is new or an old patient
already wearing a contact lens. Patient should • Blink rate is calculated by a time clock. Blink
be evaluated considering these facts rate < 15 and/ or > 30 blinks per minute
• Whether patient is enough motivated to are considered as defective blink mecha-
wear a contact lens or not, and is mentally nism and cause should be established. Blink
prepared to take all necessary precautions characteristics like partial or full blink
regarding contact lens wear. should be noticed because a partial blink is
• Understanding of patient about the unable to wet the contact lens and chances
advantages and disadvantages about of improper tear exchange underneath the
contact lens and with this knowledge contact lens increases.
emotionally he/she is prepared to wear a • Corneal diameter, pupil diameter and
contact lens. interpalpebral width are recorded by using
• History of any chronic systemic illness or a plane transparent ruler. Horizontal visible
systemic allergy is present or not, i.e. to rule iris diameter (HVID) is an important
out presence of any contraindication of parameter to assess the best contact lens fit.
contact lens wear. It is measured from temporal end of limbus
• Previous experience with wearing of to nasal end of limbus by PD ruler. This
contact lens, if present. Details of types and diameter will guide clinicians to select total
methods of wearing schedule of previous diameter of desired lens.
contact lenses. Refraction:
• Occupational history (dust exposure, • Refraction under cycloplegia should be
chemical exposure, etc.) of patient is also done to know the exact amount of refractive
important. error. The recorded refraction value is
Ocular examination: Cycloplegic refraction expressed in minus cylinder form for those
with a detailed anterior segment examination cases where we desire to prescribe only
using slit lamp biomicroscopy should be done spherical contact lens.
to rule any ocular pathology. Detailed • Vertex distance should be measured for
examination includes accurate calculation of power of desired
• General examination contact lens. Refractive errors with more
• Refraction than ± 5 D require a zero vertex distance
• Keratometry correction at cornea because with this much
• Corneal topography refractive error effective power of contact
lens will be significantly different. However,
General examination:
an error of ±2 D or less seldom needed any
• Eyelids should be examined to check force
vertex distance correction at cornea.
of lid closure, and also for any infective
pathology like blepharitis, meibomitis, etc. • Spherocylindrical power should be
converted to spherical equivalent power in
• Conjunctiva is examined using slit lamp to
cases of rigid lenses and in case of soft
rule out any infiltrates, concretions, surface
lenses where either toric lenses are
defects, limbal injection, papillae, follicles
contraindicated or practitioner decides to
and any other infective pathology.
give only spherical powers. Simply half of
• Cornea transparency is noticed and detail
the cylindrical power becomes spherical
examination is done to rule out any opacity,
equivalent power, which is added with
infiltrate and vascularization abnormality
spherical power mathematically.
of surface.
• Tear film status is checked by Schirmer‘s’ Keratometry:
test and tear break up time by using • Corneal curvatures are measured at least
fluorescein dye. in its two principal meridians (vertical or
90° and horizontal or 180°) by using kerato- • Soft lenses are usually bigger in size than
meter either manual or automated. cornea which provides a fit, where the lens
• Keratometry reading is important data edges fall under the upper and lower eye-
which is required to select the base curve lids.
radius in both rigid and soft type contact • These lenses are much more comfortable as
lenses. compared to the rigid contact lens, due to
• Any major difference in keratometry values its softness and an ability to bend with
indicates high degree of corneal astigma- blinking of eyes.
tism and contact lens wearing should be • Most commonly used lenses in routine
avoided in these cases. practice are soft contact lenses because of
Corneal topography: their comfort, flexibility, oxygen permea-
• Corneal topography is performed to locate bility, less glare and minimal over wear
the apex of cornea because centration of lens reaction.
is done according to the central corneal apex Fitting procedures: Recommendations for
not according to geometric center of cornea fitting of soft contact lenses are provided by
which is the central point of pupil. many lens manufactures in their brochures
Displacement of corneal apex will lead to supplied with contact lenses. These brochures
the decentration of contact lens. Hence, give the details of that particular lens series
locating of the apex will help in determining along with desired data and fitting parameters,
the best optical outcome with contact lens. however, a practitioner should be well-versed
• Orbscan can be used to study the curvatures with various parameters and related
and surface characteristics of cornea which nomenclature in the brochure provided with
helps in a proper fit and avoid a flat or steep soft contact lenses.
fitting of contact lens. Usually majority of lens manufactures give
Various types of contact lenses will be three choices for selection of the base curve
considered as follows in detail to understand and the overall diameter (TD) of contact lens.
their uses and fitting methods in a better way Practitioners need to decide the parameters for
selection of contact lens on the following
• Soft contact lenses
grounds to get the best fit of lenses.
• Rigid contact lenses
Fitting steps include
• Extended wear contact lenses
• Trial lens selection
• Disposable contact lenses
• Trial lens fit evaluation
• Scleral RGP contact lenses
• Trial lens ideal fit
• Therapeutic contact lenses
• Ocular factor influencing lens fitting
• Colored contact lenses
• Contact lens factors affecting lens fit
• Contact lenses in special conditions such as
high myopia, aphakia, presbyopia, and Trial lens selection: Trial lens selection is done
high astigmatism on the basis of these following criteria
• Total diameter or overall diameter: It must be
Soft Contact Lens Fitting larger (by approximately 2.5 mm) than the
• Soft contact lenses can be manufactured by HVID of cornea to permit full coverage of
using different types of polymers but cornea. However, this value may be more
mostly hydroxyethyl methacrylate (HEMA) depending upon the limbal sulcus in
is used because of its properties like more particular eyes.
stability, transparent, non-hazardous and • Lens power: To decide the power of contact
non-allergic nature. lens to be prescribed, the refraction for
spectacle should be corrected for vertex flattest keratometry reading, then a low
distance which is distance between the water content contact lens of the same
posterior surface of spectacle glass/contact diameter will require flattening by 1.2 mm.
lens and cornea. Suppose on refraction the Trial lens fit evaluation: Once the trial lens
cylindrical power of spectacles is more than with correct parameters for fitting is selected,
±1.5 D, then toric contact lenses can be used a sterile selected trial lens is inserted into the
or otherwise a spherical equivalent power patient’s eye. A proper fit of trial contact lens
can be used as described above. is evaluated by these parameters
• Back vertex power: To get the benefits from
• Adaptation and patient’s response
contact lens, the back vertex power of
contact lens should be kept as close as – Adaptation period: After placing the soft
possible to the patients’ spectacle prescrip- contact lens in the eye of patient, it is
tion. It also helps to facilitate adaptation. If always necessary to wait for some time
it is not possible to get same power, then it before (settling or adaption time)
is preferred to choose a contact lens of less assessment of the fitting of lens because
power to avoid accommodative spasms. soft lenses have tendency to lose water
For monovision, trial lens should be chosen once they are inserted in the eye. This loss
of power as close to correct power. of water may alter the parameters as well
• Back optic zone radius: Suppose choice of base as fitting characteristics of a soft lens.
curve is available with lens, then manufac- Hence, it is recommended that the lens
turer’s guidelines must be followed fit should be assessed only when the
regarding the selection of trial lens to be contact lens becomes in equilibrium with
tried first. This trial is done without taking the tear film and established in the
the Keratometry readings in consideration. environment of eye. Traditionally, it is
When no choice is available, then a lens advised that about 25–30 minutes should
with base curve flatter than keratometry be given for settling of a lens, however,
reading is chosen. Amount of flattening is some recent studies suggest that initial
decided by the TD and water content of that evaluation of fitting can be carry out after
contact lens which is taken for trial. 5–10 minutes of insertion.
– Although it is difficult to judge the
Following guidelines can be used to decide
physiological response as well as patients
about selection of the trial lens parameters
comfort for lens in five minutes period
• Depending on TD: Principle is that if larger
but its assessment should be based on
the TD of lens, then prefer the flatter lens.
lens sensation and eye movements.
For example, in a lens with TD of 13.0 mm,
a lens having base curve 0.3 mm flatter than – Patients comfort is evaluated by the fact
the flattest keratometry reading should be that lens should feel imperceptible on the
selected. Similarly for a further increase in eye by patient, especially on insertion.
0.5 mm diameter, increase the flattening of Lens sensation should be steady, having
base curve by 0.3 mm, means for a 13.5 mm no appreciable difference in lateral eye
diameter lens a flattening of 0.6 mm is needed movements or blinking.
from the flattest keratometry reading. • Over refraction
• Depending on water content: Principle is that – Normally to check the correct fitting of
lens of high water content usually require contact lenses, examiner should perform
more steep fitting as compared to low water an “over refraction”, means refraction is
content lens. For example, if a high water done while patient is wearing a pair of
content lens with TD of 14.5 mm needs a trial contact lenses. Advantage of an over
flattening of base curve by 1 mm than the refraction is that, rather than depending
on the predictions, whether the given (inferior edge) of contact lens during the
contact lenses are able to correct ametro- blink. Alternatively, if lower eyelid is
pia or not, examiner can determine the obstructing inferior edge of lens, then we
actual refractive status. can observe lens at 4 or 8 o’clock position
– An over refraction is done with binocular for movement. Sometimes, we can displace
balancing. There must be a clear endpoint the lower eyelid using index finger, before
and stable visual acuity. Any disparity assessing the movement. An ideal post-blink
in these factors show poor fit of lens and lens movement should be of 0.5–0.7 mm. If
repeat retinoscopy should be carry out with each blink movement of lens is more
to confirm it. than 1 mm, then it indicates too flat fitting
• Biomicroscopy examination: Subsequent of lens, if it is less than 0.5 mm, then lens
to over refraction, examination by slit lamp fitting is steeper.
using a diffuse, direct illumination under
Note: Recent available contact lenses has more
medium to high magnification (which
water content and are thin with less elasticity as
enable us to visualize the contact lens on
compared to older lenses, which were usually
eye) should be done to check lens fit. thicker and lower in water content; hence they
Trial lens ideal fit: “Fluorescein dye is not show less post-blink movement.
used to assess the lens fit in case of a soft
contact lens”. The fitting is assessed by • Push up test: Many a times it is difficult to
observing following parameters assess lens movement by blink alone, hence
• Coverage of cornea: Contact lens should a better assessment of lens movement can
cover full cornea before, after and during be done by Push up test. It is considered
the blink in the primary position of eye. most useful way to judge dynamic fit of a
Minimum 1–1.5 mm conjunctival overlap contact lens in relation to eye.
should be seen in all movements of eyes. Test procedure: To do this test, the examiner
• Centration: Lens should remain in center applies pressure on the lower eyelid by
of cornea in primary position of gaze and finger to move the contact lens vertically
should retain full coverage of cornea even upwards and then remove the finger to release
during extreme lateral gaze (lens lag) and pressure on the eye so that lens returns to
up gaze (lens sag) as shown in 13.17A and its original position as shown in Fig. 13.18A
B respectively. and B. During this test aim is to observe
• Post-blink movement: Amount of post- how easily the lens displacement occurs on
blink lens movement should be judged in pressure and then how rapidly it returns to
primary gaze, ideally recorded using a its original position on releasing pressure.
reticule marking on slit lamp. Lens Results: These are represented in a percentage
movements are observed at the bottom part grading system where 100% means that lens
Fig. 13.17: Centration of contact lens. A. Lens lag; Fig. 13.18: Push test. A. Finger in position; B. Lens
B. Lens sag moved up
movement is not possible and 0% means in steep fit they become clear immediately
that lens will fall away from the cornea after blinking.
without support of eyelids. A correct and • Conjunctival congestion: On slit lamp the
optimum fit is considered when lens status of conjunctival vessels and scleral
movement recorded is 50%. In addition, indentation should be observed. In case of a
tightness of lens as measured by the push- steep fit limbal vessel nipping, conjunctival
up test shows a linear relationship with congestion and scleral indentation (on long
squeeze pressure (it is the force which exist duration usage) is present.
between posterior surface of lens and front
To summarize these observations and
surface of the eye) and so it can also be
evaluations of a trial lens fit following points
considered in judging lens fit.
to be remembered as shown in Table 13.4.
Effect of blinking is noticed not only
on lens movement but also on visual Ocular factors influencing lens fitting
acuity, retinoscopy reflex and keratometer • Ocular sag: This is determined by corneal
mires. diameter, radius and shape factor and also
• Post-blink visual acuity: Change in clarity by scleral shape and radius and any factor
of vision due to blinking should be among these if altered will affect the lens
checked. In case of an ideal lens fit, no sag, which can only be assessed by a trial
change in visual acuity will be noticed by lens fit.
the patient. However, in a flat fit the • Corneal apex: Position of corneal apex will
patient complaints of blur vision while in affect the centration of lens. Displacement
steep fit, the vision improves immediately of corneal apex will cause the lens
after blinking. decentration, which can be corrected by
• Post-blink retinoscopy reflex: The changes increasing the total diameter (TD). An
in retinal reflex are in correlation with increase in TD will increase the corneal
clarity of vision means in an ideal lens fit coverage, if exposed, while changes in base
the reflexes are sharp, whereas in flat fit curve will not affect centration.
reflex becomes blur and in steep fit, it • Pressure of lids: Too much pressure caused
becomes clear instantly after blinking. by tensed lids may lead to high riding of
• Post-blink keratometer mires: Even the lens and also an excessive movement of
distortion of keratometer mires are in lens. To overcome it a thin lens design
correlation with vision clarity, means in an and/or lens with more diameter can be
ideal lens fit the mires appear crisp and used. Loose lids usually have less effect on
sharp, whereas in flat fit they are blur and lens fits than tight lids.
Table 13.4: Various indicators of loose fit and tight fit of contact lens
Indicators of loose fit of contact lens Indicators of tight fit of contact lens
Too much movement of contact lens No movement of contact lens
Poor centration in primary gaze, usually in Constriction of limbal vessel or ‘nipping’
inferior lag
Buckling of lens edge after wearing Indentation of conjunctiva at lens margins
Presence of lens awareness sensation Conjunctival congestion with redness
Change in vision, especially immediately after Ocular inflammation of low degree
blinking
Blurring of retinoscope reflex and keratometer Visual improvement, immediately after blinking
mires, immediately after blinking
• Tear characteristics: The change in pH and Usually we can specify the total diameter and
osmotic pressure of tear has important part power of lens, to get a proper fit soft contact
to alter the parameters of lens, finally lens from various manufacturers’ guide.
affecting the lens fit. Decrease in the pH of Examination of delivered contact lens:
tear film causes steepening of ionic contact Contact lens delivery received from the lens
lens. Change in osmotic pressure like manufacture should be examined thoroughly
decrease in tonicity of tear will cause tight before inserting it into the eye of patient as
fit of both ionic and non-ionic lenses. Hence shown in Fig. 13.19. Following parameters are
it is important to remember that if an checked for received contact lens:
acceptable fit is not obtained with contact
• Lens total diameter: This is checked by
lens material, then it is necessary to change
using a diameter gauge.
the ionicity or water content of another lens
• Contact lens power: Power of the lens is
material.
determined by using lensometer, specially
Contact lens factors affecting lens fit designed to measure the contact lens
• Total diameter (TD): Variation in the total power.
diameter of lens will affect the fitting of lens. • Lens edges and curves are inspected by
For example, increase in the TD of lens will keeping the lens on the tip of finger and
enhance sag of lens, resulting in tight fit, observing it in bright light for any defect or
while reduction in TD of lens will produce abnormality.
opposite effect. In case of lens with • Lens quality and clarity is also observed
displaced apex, the TD can be increased to while checking for its edges.
improve the corneal coverage by this lens.
Evaluation of ordered lens fit: Once all the
Lens fit is usually more affected by change
parameters of delivered lens are checked
in lens diameter as compared to change in
thoroughly, this lens is ready to use in the
BOZR.
patient’s eye. Following instructions related
• Back optic zone radius (BOZR): Change in the to lens fit along with explanation of methods
base curve of lens cause change in the of lens insertion and removal are taught to the
movement of lens. However, studies patient.
indicate that change in the BOZR does not
cause much effect on lens fit. Contact lens handling instruction to the patient:
Although most of the patients are enthusiastic
• Peripheral design of lens: The peripheral lens
about wearing of a contact lens, but many of
design may also influence the lens fit. The
them are first time wearers. Hence, a detailed
peripheral design indicates correlation
between front and back peripheral curves
of lens. It should be kept in mind that it is
not necessary that lenses with different
peripheral design having same TD and
BOZR will show fitting characteristic in
similar fashion.
Soft Contact Lens Ordering

After a detailed evaluation of the lens
parameters and checking a proper trial lens
fit with these parameters, soft contact lenses
are ordered from a known manufacturers’ Fig. 13.19: Examination of soft contact lens before
series, by specifying the desired power. insertion
instruction about handling and caring of • Soft contact lenses are always stored in
contact lens along with the insertion and normal saline solution because if exposed
removal techniques should be taught to to air, may get dehydrated and breaks
majority of patients. due to brittleness. Rehydrate the lenses
General instructions: Patients should be by placing them in saline solution, and
instructed that contacts should not be wait until they become soft and regain
considered as fashion accessories or cosmetics; their original shape.
rather it is a type of medical devices that need • Old contact lens care solution should not
proper cleanliness as explained and is vital to be reused for cleaning and rinsing purpose
prevent infections of eyes. These infections are and also contact lens solution should not
potentially hazardous for eyes; hence patients be transferred into different container as
are advised to take care of lenses as per solution may loss its sterility and
direction. Cleaning is done both before infection may occur.
insertion and after removal of contact lens • Tip of lens solution container should not
from the eye before putting the lens back in contact any surface. The solution bottle
lens case. should be kept tightly closed after use.
Following instructions are important to be • Contact lens case must be clean and
remembered by patients ideally it should be replaced at least once
• Strictly follow the schedule for insertion in 3 months. Damaged and cracked cases
and removal of lens. should be replaced immediately.
• Daily wear lenses should not be worn at • Over a period of time, contact lenses get
time of sleeping. damage and also its shape can alter due
• To protect from water contact lenses to cornea. Hence, check at intervals that
should be removed before bath, swimming, that lenses fit is proper and the visual
or doing anything, where water can go acuity is perfect, if not report immedia-
inside the eyes. tely to practitioner.
• Never touch contact lens with dirty Insertion and Removal of Soft Contact Lens
hands. Hands should be washed with
Before insertion of contact lenses in the eyes,
soap and water before touching lens.
we should ensure that the lens have not turned
• Never use tap or sterile water and saline inside out, while removing from their blister
solution prepared at home for rinsing or packs or lens case. There are two methods to
storage of contact lens. Use sterile contact check this
lens solution (not tap water) for washing of • Keep the contact lens on the tip of index
case of lens followed by its drying in air. finger and examine its shape and edges as
• For disinfection of lens proper disinfectant shown in Fig. 13.20A. In correct lens an even
solution should be used. Saline solution cup shape is seen, whereas if lens is not
or artificial tear drops should not be used correct, then lens appears shallower with
for disinfection. more pointed at its edges as shown in
• Always use a “rub and rinse” cleaning Fig. 13.20B.
method, before insertion, after removal • Taco test: It is another method to check
or before placing lens in the lens case. The whether lens is proper or in an inside out
contact lenses should be rubbed with position. To do this gently folds the soft
clean fingers followed by rinsing with contact lens in between the index finger and
solution and then soaking. This process thumb. Suppose the lens is in correct
must be done every time for cleaning and position, lens edges should fold inward like
disinfection of contact lens. a Mexican Taco and touches each other
Fig. 13.20: Contact lens checking. A. CL position on fingertip; B. Check position
edges as shown in Fig. 13.21A, whereas if • Place the lens on the tip of the index finger
lens is inside out, then the lens edges will of hand as shown.
curls outward and flips out onto fingertip • Look up while the lower lid is retracted
as shown in Fig. 13.21B. with the middle finger of same hand as
shown in Fig. 13.22A. This is called as one
Note: Important point to be remembered while
hand technique.
testing the position of lens is that the lens should
be held from its center not from its edges. • Alternately, the eye can be spread wide
open with the index and middle finger of
Lens insertion technique: Insertion of a soft left hand and contact lens is placed on the
contact lens is done as follows tip of index finger of right hand, while the
• Wash the hands thoroughly using soap, for middle finger of right hand is placed over
a few minutes and then air dry. cheek bone to avoid any jerky movement
• Remove the lens from its case and clean as of right hand. This is called as two hand
we already discussed above. technique as shown in Fig. 13.22B.
• Rinse the contact lens with cleaning solution. • While looking upward, gently touch the
contact lens to the lower part of eye. Then
slowly remove the finger, when contact lens
is placed on the eye.
• Then very gently and slowly first release
the lower and then upper lids.
• Close the eye and give a gentle massage
over lids, to remove any air bubble in case
if present underneath of contact lens.
• Open the eye and move it gently in all
gazes, to center the lens. Then observe the
correct centration of lens while the other eye
is covered with hand.
• Similar instructions are repeated in other
eye for lens insertion.
Lens removal technique
• Wash the hands thoroughly using soap, for
Fig. 13.21: Taco test for checking correct position a few minutes and then air dry.
of contact lens. A. Inward rolling of lens margins; B. • First turn the eyes upwards and with
Outward rolling of lens margins middle finger retract the lower lid while
Fig. 13.22: Insertion technique of soft contact lens. A. One hand method; B. Two hands method
keeping the tip of index finger on the lower wearing of contact lenses and should be
edge of the lens. advised to follow a strict wearing schedule for
• Disengage the lens slowly by sliding the best visual outcomes.
lens downwards, over to the white portion Generally the wearing schedule is totally
of the eye. dependent on the individual patient's profile,
• Once lens slides downwards, pinch out the however, on an average patients’ are instructed
lens between thumb and the index finger, to wear a soft contact lens for continuous
so that suction created under lens is broken 2–3 hours and then remove the lens for a
by air as shown in Fig. 13.23. minimum period of one hour. They are
• Slowly remove the lens from eye and do advised to follow this schedule for initial
the cleaning with lens solution and place it 10–15 days, or till they become comfortable
in the lens case containing solution. for longer duration wear.
Wearing schedule for soft contact lenses: Follow up: Regular follow up is must to
Normally soft contact lenses are well accepted achieve a comfortable contact lens wearing
and comfortable to wear from day one; hence period without any complications. Patients'
there is tendency in patients that they may are instructed to report immediately if develop
over wear it from day one. Patients should be any discomfort, redness or pain, otherwise can
informed about the disastrous results of over come on a regular follow-up schedule as
below
• Day one
• Day seven
• After a month
• Every six months
On every follow-up visits following evaluations
are performed
• History: Questions are asked in terms of
visual and non-visual symptoms like
change in vision, intermittent blurring,
foreign body sensations, heavy lids or
ocular movements, excessive watering,
discharge or decreased visual fields, etc.
Fig. 13.23: Removal technique of soft contact lens Examiner should be able to differentiate
between physiological/psychological are essentially the same when practitioner

symptoms arising due to adaptation and needs to judge the fitting of either lens.
actual clinical abnormalities. Usually Modern RGP lens designs are available in a
adaptation symptoms are not present with wide range of lenses; which can be fitted easily
soft lenses, however, even if present will in majority of normal ametropic population.
subside on its own within 10–12 days, Nowadays to receive a rigid contact lens,
however, symptoms due to clinical practitioners just need to specify the total
abnormalities will start after 2–3 days and diameter (TD), back vertex power (BVP) and
persist constantly even after 15 days. back optic zone radius (BOZR) of a particular
• Vision: Check the visual acuity with lens in lens design to manufacturer.
position, if visual acuity is less, then do an over Fitting steps include
refraction and recheck vision with a pin hole. • Trial lens selection
• Ocular examination: Detailed ocular exami- • Trial lens fit evaluation
nation is done to record head posture, lid • Trial lens fit interpretation
position, periorbital edema, blinking rate • Corneal factor influencing lens fitting
and conjunctival congestion. • Contact lens factors affecting lens fit
• Slit lamp examination: It is done with contact
lens in the eye, and then after removal of Trial lens selection: The initial trial lens
contact lens. Position of contact lens, cornea should be selected using the following para-
and conjunctiva are examined in detail. meters:
• Total diameter: Selection of total diameter
Rigid Contact Lens Fitting (TD) of lens is decided by the horizontal
Rigid contact lenses are broadly classified visible iris diameter (HVID) and position
as of lid (size of palpebral aperture). Generally,
Rigid non-gas permeable lenses: Mainly a lens having TD 1.4 mm smaller than the
manufactured from PMMA (Plexiglas) and are HVID should be chosen. In addition, on the
rarely used nowadays due to their disadvan- basis of size of palpebral aperture, the lens
tages overweighing the advantages. with smaller TD should be selected if
aperture is small and vice versa.
Rigid gas permeable contact lenses: These are
– Choice of TD according to HVID can be
most widely used contact lenses and are also
made as shown in Fig. 13.24. For small
called semisoft contact lenses. These lenses are
palpebral aperture, rigid lens of
made up of a unique plastic material which
approximately 9.2 mm size, for an
has an ability to permit oxygen to diffuse
average size aperture lens of 9.6 mm
inside and carbon dioxide to diffuse outside
diameter can be chosen, however, for
the lens. Various polymers materials are used
very large apertures 10 mm TD size rigid
to make these lenses such as CAB (cellulose
lens may be required.
acetyl butyrate), silicon acrylate, butyl styrene,
– Choice of lens is also in inverse relation-
polystyrene, fluorine copolymers and polysul-
ship with corneal curvature as summari-
fone copolymers.
zed in Table 13.5. It means flatter the
Fitting procedures: Since PMMA lenses are cornea, larger diameter of RGP lens will
obsolete nowadays, hence we will discuss be required for a proper fit.
fitting of rigid gas permeable (RGP) contact • Center thickness of lens: To enhance the
lenses in detail. oxygen transmissibility contact lenses are
Fitting of rigid contact lens is usually made as thin as possible. In majority of rigid
considered as more difficult than fitting of soft lens materials (available nowadays), the
contact lens, but actually many fitting steps center thickness is kept about 0.14 mm.
Fig. 13.24: Total diameter selection according to HVID and lid positions. A. Small palpebral aperture;
B. Average size palpebral aperture; C. Very large palpebral aperture
Table 13.5: Relationship between corneal curvature vertex power must be approximate to
and contact lens diameter patient’s final prescription. The fit may vary
with minus powered lens and plus power
Corneal curve Diameter of contact lens
lens due to difference in their edge design
40–43 D 9.5 mm and center of gravity. Hence, myopes
43.25–45 D 9.2 mm should be assessed with negatively powered
> 45.25 D 9.0 mm lenses and vice versa with hypermetropes.
• Back optic zone diameter (BOZD): BOZD is
• Calculation of power of trial lens: Refraction
usually kept larger ( 1.0 mm) than average
should be done to determine spectacle
pupil size to avoid flare due to lens. To
power and then power of trial rigid contact
maintain corneal alignment also it is
lens is calculated. First convert the spectacle
necessary to adjust BOZD because as the
lens power into a minus cylinder form, if
flattening of cornea increases, lens of larger
present. Now correct this spectacle power
BOZD will be required to maintain proper
for a zero vertex distance by applying
alignment over the cornea.
appropriate formula or from a ready
• Back optic zone radius (BOZR): Design of back
reference chart provided by the contact lens
surface of rigid lenses could be aspherical,
manufacturer.
spherical or their combination. Spherical
For example, suppose spectacle power is: RGP lenses can be bicurve, tri-curve or
8.5 × + 1.5 × 90°, at 15 mm vertex distance. multi-curve in nature where every lens has
First convert it in minus cylinder form as: different BOZR with different peripheral
–7 × –1.5 × 180° curve design. In case of spherical RGP
Then correct it to a zero vertex distance contact lenses, initial trial lens is selected
as: –5.75 × –1.0 × 180°. on the basis of keratometer readings using
recommendations provided by the manu-
Note: Spherical powers can similarly be corrected
to a zero vertex distance and contact lens of
facturer or using the values as shown in
corrected power is used directly. Table 13.6. In case of an elliptical type of
aspherical contact lenses usually more flat
• Back vertex power: To provide normal vision fitting is required than spherical lenses so
and to decrease probable changes in lens that an alignment across the corneal surface
fit due to difference in lens power, the back is adequately achieved.
BOZR is chosen on the basis of keratometer achieved, patients are advised for a
readings; usually on flattest K- reading (called longer trial period (minimum 30 minutes)
as fit ‘On-K’), especially for spherical RGP which allows them to judge the comfort
lenses or an astigmatism <0.5 D. But for and problems of rigid contact lens. After
astigmatism of > 0.5 D, guidelines as shown trial period the subjective response of the
in Table 13.6 are used to decide about the patient is assessed. Patient must be
BOZR of RGP lenses. comfortable and there must be no reflex
For understanding Table 13.6 values, we tearing. Vision must be stable in all
can take an example, suppose keratometer positions of gaze with the used power of
readings are 45 D/46 D, means having trial lens.
astigmatism of 1 D; then the base curve • Over refraction and visual acuity
selected will be 45.25 D. Similarly if readings – Initially to check the spherical power of
are 46 D/47.5 D, then a base curve of 46.5 D contact lens, an over refraction with
will be selected, however in case where binocular balancing is done. The purpose
readings are 46 D/50 D, then it is better to of binocular balancing is to relax the
choose a toric back optic zone contact lens. accommodation, which might have been
Trial lens fit evaluation: Once the trial lens is induced due to foreign body sensation
chosen, then a sterile trial lens is inserted in of contact lens.
the eye under all aseptic precautions. Just – Visual acuity achieved with contact
before lens insertion, patient is instructed that lenses should be crisp and stable in all
there may be feeling of foreign body sensation gazes. An unstable or improper acuity
after insertion of lens. To reduce feeling of indicates that a cylindrical refraction is
foreign body sensation patient is advised to also needed to correct the refractive status.
look downwards after insertion of lens. – Both by subjective and objective response
“Fluorescein dye is used to assess the lens fit in should be evaluated during refraction by
case of a rigid contact lens”. retinoscope. The results are used to
• Adaptation and patients’ response calculate the tear lens power and to
– Adaptation period: After insertion of lens, adjust the central fit of contact lens, if
as reflex tearing get stop (usually within needed.
5 minutes), lens fit by bare eye and under • Biomicroscopy examination
white light should be examined to check – Dynamic fit of a rigid contact lens can be
the stability and centration of lens during evaluated and measured by using either
trial period. Once an adequate lens fit is a slit lamp or Burton lamp in the same
way as for the soft contact lenses.
Table 13.6: Guidelines for selection of BOZR of – Lens-corneal alignment is assessed by
RGP lenses in astigmatism > 0.5 D help of either white light or a cobalt blue
Astigmatism BOZR light as follows
Spherical to 0.5 D Fit ‘On-K’, means flattest White light
keratometer reading
Using diffuse white light and with
0.5–1.0 D Fit on 0.05 steeper than the an optic section examiner should
flattest keratometer reading make a judgment about centration of
1.0–2.5 D Fit on 0.05–0.10 steeper contact lens in the primary gaze as
than the flattest keratometer well as during lateral movements of
reading eyes.
Over 2.5 D A toric back optic zone is Along with centration, the movement
suggested
of lens with blink is also judged.
Ideally, RGP lens should move dye in small amount is introduced into
downward with each blink, under the conjunctival sac while patient is
the influence of upper eyelid, instructed to blink gently 2–3 times,
however, it returns to cover the pupil which spreads the dye all over the eye.
immediately. – Lens fit should be evaluated using slit
Cobalt-blue light lamp or Burton lamp with a diffuse,
Alignment of posterior surface of direct illumination under medium to
lens with front surface of the eye can high magnification.
be assessed by means of fluorescein – The brightness of fluorescein dye is
because it causes staining of the tear assessed systematically mainly in three
film, which creates a tear lens. On regions of contact lens, i.e. peripheral,
illuminating by appropriate wave- mid peripheral and central. Guillon
length of blue light (cobalt-blue filter) proposed a simple grading scale for the
the fluorescein emits a fluorescent assessment of contact lens fit. According
green color. The intensity of this to grading if fluorescein dye is seen
green color is related to the thickness under the contact lens during assessment
of the fluorescein tear film; means of fit, then it can range from
thicker the tear lens, more yellow will Little amount (0), means in alignment
be the appearance. or minimal apical clearance
As fluorescein dye occupies the tear Moderate amount (+1)
space present between posterior Too much or excessive amount (+2)
surface of lens and front surface of
the cornea. The distance between Trial lens fit interpretation: Now it is
these two surfaces (known as fluores- important to interpret the lens fit to know
cein pattern) can be assessed by whether it is correct or not, which can be done
looking change in the intensity of by
fluorescent light which occurs due to • Patient’s subjective response
excitation by cobalt blue filter. More – RGP lenses usually cause more discomfort
is the intensity (brighter) of color; after insertion as compared to soft
more will be the distance between contact lenses, however, after adaptation
two surfaces. period of 30 minutes, patient should not
Burton lamp feel discomfort. If after adaptation
Burton lamp is used to visualize period also the patient complaints of
various fluorescein patterns. It acts pain and excessive reflex tearing, then
as a source of UV light which is used it indicates that the contact lens is not
to excite the fluorescein dye. However, correct and require modification in
as compared to slit lamp the magnifi- parameters.
cation achieved with Burton’s lamp – By means of correct spherical correction
is less. In addition, it cannot assess the patient must have stable and crisp
pattern when polymer materials visual acuity. However, if vision is not
used in manufacturing of contact lens stable with use of spherical lenses then a
also contain a UV inhibitor where cylindrical overcorrection might be
cobalt blue light with slit lamp is the needed.
choice. – If residual astigmatism is suspected for
• Fluorescein assessment the poor vision, then before prescribing
– In RGP lenses, a fluorescein assessment a toric correction, it is essential to confirm
of the contact lens fit is done. Fluorescein the site of residual astigmatism because
bending or curving of lens may be also visual axis. Various positions of lens may
one of the causes of poor vision. If no site be seen due to these factors.
of residual astigmatism detected on – Corneal opacities, against the rule
examination, then it is most probably the astigmatism and oblique astigmatism
lens bending causing poor vision and may decenter the contact lens either
lens-eye fitting relationship require temporally or nasally. Smaller lens with
modification to correct the vision. a steeper fit will correct this horizontal
• Over refraction decentring.
– Over refraction is done to calculate the – Vertically lens movement is about
tear lens values, i.e. difference in 1–1.5 mm, but sometimes lens may ride
refractive power between the ocular high, means the upper edge of lens
refraction and final contact lens power crosses the upper limbal margin or lens
required to correct ametropia. hook on to upper lid.
– In case of steeper fitting of lens than – Similarly, lens may ride too low or
cornea, a positive tear lens will form as rapidly drop after blink, means lower
shown in Fig. 13.25C and final contact edges of contact lens crosses the lower
lens power will be either less plus or limbal margin.
more minus as compared to the ocular – Some degree of decentration is acceptable
refraction. in case of rigid contact lens fitting.
– In opposite situation, i.e. flatter fitting of Various contributing factors and the
contact lens, a negative tear lens will management of lens decentration are
form as shown in Fig. 13.25A and final summarized in Table 13.7, along with the
power of the contact lens required will available options to improve the centration
be either more plus or less minus than of contact lens.
the ocular refraction. • Fluorescein patterns
– In case of an ideal fit as shown in – Analysis of fluorescein patterns helps to
Fig. 13.25B, a slight central touch is seen. find out the tear lens shapes in relation
Note: Simple guidelines in calculating tear lens
to lens fit. Thus help to confirm the
powers are that if there is 0.5 DS difference in relationship of contact lens and the eye.
over refraction, it means a 0.1 mm difference is For example, steep looking fit will show
present between corneal radius and contact lens positive tear lens pattern while a flat
radius. looking fit will show a minus tear lens
pattern.
• Lens centration and movement: During
lateral gaze and in between blinking, the – Sometimes, even when using the contact
position of lens must be centered over the lens with BOZR which was matched with
keratometer readings of cornea, then also
a steep or flat fit looking fluorescein
patterns may occur. It may be due to
either BOZR of trial lens is inaccurate or
due to difference in the eccentricity of
cornea.
Corneal factors influencing lens fit: Eccentri-
city (e) of cornea decides rate of flattening of
the cornea toward the periphery. Normal
Fig. 13.25: Various tear lenses and over refraction. cornea has average eccentricity value of 0.2 to
A. Flatter fit; B. Ideal fit; C. Steep fit 0.5. If cornea has e value lower (i.e. e <0.5) than
Table 13.7: Various possible causes and management of lens decentration

Lens location Possible causes Management
Lens riding high or not Flat and wide peripheral zone Steepen the base curve
dropping after blink (superior High minus lens Use plus carrier lenticular design
decentration) Large diameter lens and tight lid Reduce diameter and use prism
Too thick edge lens ballast lens
With the rule astigmatism Reduce Tc and Te of lens
Displacement of optic cap in Use toric peripheral design
upward direction
Lens riding low or dropping Lens too small in diameter Use large lens (increase TD)
rapidly after blink (inferior Lens too thick Reduce Tc
decentration) No lid attachment Add peripheral negative carrier
Displacement of optic cap in
downward direction
Continue to be on one side Corneal apex decentered Increase the diameter of lens and
(lateral decentration) Too small lens use soft lens
Flat contact lens Steepen the base curve of lens
Against the rule corneal Use back surface with toric design
astigmatism or toric periphery design
Stationary Lens Too steep lens Flatten the fit
Excessive decentration Excess lacrimation Correct symptoms
of lens (beyond limbus) Lens too flat Steepen the design
Excess corneal astigmatism Use back surface in toric design
average, means it indicates that cornea has • Cornea with more eccentricity than an average
steepen central cornea (more flat peripheral eccentricity: Means cornea flattens out faster
cornea), while high e value (i.e. e >0.5) indicates towards periphery at faster rate, hence
flatter central cornea than peripheral cornea. spherical contact lens of the same central
Relationship of corneal eccentricity with radius will show central pooling as shown in
contact lens fit is shown in Fig. 13.26. Fig. 13.26C. This lens fit needs a modification,
• Cornea with average eccentricity: Spherical as if dealing with a steep fitting lens.
contact lens will show an ideal lens fit, as
apical appearance, mid-peripheral touch
and peripheral clearance pattern as
indicated by a bright green periphery with
faintly appearing central portion as shown
in Fig. 13.26A.
• Cornea with lower eccentricity than an average
eccentricity: Means cornea steepens out
faster towards periphery at faster rate, hence
spherical contact lens of the same central Fig. 13.26: Corneal eccentricity and respective
radius prescribed for this type of cornea will contact lens fit. A. Average eccentricity, ideal fit;
show peripheral pooling as shown in Fig. B. Lower eccentricity, flat lens fit with peripheral
13.26B. This lens fit will need a modifi- pooling; C. Higher eccentricity steep lens fit with
cation, as if dealing with a flat fitting lens. central pooling
Contact Lens factors affecting lens fit

• Contact lens base curve is flatter than corneal
curvature (flat fitting): Chances of excessive
movement of lens and fluorescein pattern
will show a central black area with
peripheral pooling. Fluorescein pattern in
this case will show a central black area
indicating a direct lens corneal touch
(means there is no tear layer between lens
and cornea) and diffuse green portion in
mid-peripheral and peripheral zone due to
pooling of dye in these areas as shown in
Fig. 13.27.
• Contact lens base curve is steeper than corneal Fig. 13.28: Steep lens fit showing central pooling
curvature (steep fitting): A lens having base
curve steeper than corneal curvature will
show very little or no movement with
presence of air bubbles underneath the
contact lens. Fluorescein pattern will show
a central pooling and bright green band at
periphery, with a broad dark mid-peripheral
zone which indicates intense lens touch in
mid-peripheral zone as shown in Fig. 13.28.
• Contact lens base curve is equal to corneal
curvature (ideal fitting): A lens having base
curve equal to corneal curvature will show
desired movement of lens with rotation of
eyeball. Fluorescein pattern will show an Fig. 13.29: Ideal lens fit showing apical appearance
apical appearance and light green clearance and peripheral clearance
at periphery, with a dark mid-peripheral
zone which indicates that an adequate • Base curve in RGP lenses is an important
amount of tear lens is formed with an ideal parameter to decide about the lens to be
lens fit as shown in Fig. 13.29. ordered. Sometimes, a selected lens of
particular diameter may need change in
diameter due to change in the base curve
as both are directly correlated to each other.
Usually, a large diameter lens should have
a small base curve to produce the same
effect as that of a small diameter lens with
steeper base curve. On an average, a change
of 1 mm in the diameter requires a change
of 0.01 mm in the radius of curvature of
lens.
• Various parameters used for selection of a
rigid lens are dependent on each other, so
to get an ideal lens fit, if one parameter is
Fig. 13.27: Flat lens fit showing central dark area changed, then simultaneously it is also
required to change other parameter. The • Contact lens central thickness should be
fundamental rules which should be measured by a thickness gauge.
remembered to make alterations in lens • Lens edges and curves are inspected by
parameters are as follows. keeping the lens on the tip of finger and
– Modification of 0.05 mm in BOZR of lens observing it in bright light for any defect or
will cause change in power equal to abnormality.
0.25 D considering radius of lens is about • Lens quality and clarity is also observed
7.8 mm. while checking for its edges.
– Similarly, 0.5 mm change in BOZD will Evaluation of ordered lens fit: Once we had
need change of 0.05 mm in BOZR to examined the received lens as per specifica-
retain equal fluorescein pattern. tion, this sterile rigid contact lens is inserted
Rigid Contact Lens Ordering in patient’s eye under all aseptic precautions.
After an extended adaptation period of about
After doing a detailed evaluation about the 25–30 minutes, evaluation of ordered lens is
lens parameters and checking of a proper trial done to check the lens fit on the same
lens fit with these parameters, the rigid contact guidelines as described for trial lens fit
lenses are ordered from a known manufac- evaluations. However, some important points
turer’s series by specifying the desired power. of lens fit for evaluation are as follows
Following parameters are specified in a
• Position of the lens: Well-centered lens
contact lens prescription
indicates an ideal fit. High ride or low ride
• Base curve radius (such as 7.8 mm) lens indicates an abnormal fit.
• Optic zone diameter (such as 7.0 mm) • Movements of lens: 1–1.5 mm vertical
• First peripheral curve radius (such as movement or lateral excursion in horizontal
8.0 mm) gaze indicates an ideal fit. Excessive lens
• Second peripheral curve radius (such as movement in all gazes shows a flat fit and
8.6 mm) less or no movement indicates a steep fit.
• Back peripheral zone (such as up to 8.2 mm) • Fluorescein pattern: As described above the
• Total diameter (such as 9.0 mm) distinctive fluorescein patterns will be seen
in an ideal, flat and steep fit lenses.
• Contact Lens power (such as –5 DS)
• Visual acuity: Should be crisp and clear
Above parameters will typically be written which remain stable before, during and
in a perception form as after the blinks. Over refraction can be done
7.8: 7.0/8.2: 8.0/8.6: 9.0, power –5 DS to rule out any under or over correction of
Examination of the received lens: Contact power.
lens delivery received from the lens manufac- • Psychological and physiological responses:
ture should be thoroughly examined, before Patient should feel comfortable and no
inserting it into the eye of patient. Following foreign body sensation should be present.
parameters are checked for received contact In case of an ideal fit corneal metabolism
lens remain healthy, hence no corneal erosions
• Lens total diameter is checked by using a or edema is noticed after adaptation period.
diameter gauge. Patient education: Once we get a satisfactory
• Contact lens power is determined by using rigid lens fit, patient is educated about
lensometer, specifically designed to the handling and caring of contact lens.
measure the contact lens power. Techniques for insertion, removal and
• Base curve is measured by using a specially recentration of contact lens are also explained
designed instrument called Radiuscope. to patient.
Handling and caring of contact lens: To Insertion Technique

prevent infection, it is essential to educate the • Insertion steps of a rigid contact lens are
patient about proper handling and caring of similar to that of a soft contact lens as
the contact lens. Following instructions are instructed above.
given to the patient at the time of dispensing • Lens is kept on the tip of index finger as
of a rigid contact lens shown in Fig. 13.30A and is inserted in eye as
• Thoroughly clean the hands with soap and described for soft contact lens (Fig. 13.30B).
water and air dry them before inserting, Important point in rigid lenses is identi-
rinsing, cleaning or removing the contact fication of right and left eye lens, especially
lens. in cases where there is a vast difference in
• Never apply excessive pressure while refractive powers of two eyes.
cleaning the lens, because they are very thin
Note: Letter ‘R’ is engraved on the lens periphery
and can easily get fractured.
for right eye lens, hence when patient keeps the
• Clean the lenses after removal and before lens on the tip of finger, he/ she should search for
placing them in lens case, keeping the this mark for right eye.
concave side upwards.
• Always use antiseptic solution or a Removal Technique
commercially available multipurpose Removal procedure for a rigid lens is different
contact lens cleaning solution, to rinse, from soft contact lens removal technique. Here
clean, soak or disinfect a RGP lens, never lens can be removed by two methods as per
heat or use running tap water. convenience.
• These lenses should be disinfected by Method 1 (Fig. 13.31)
chemical treatment at regular intervals for • Head is bended down to make it parallel to
maintaining the sterility. the floor, then patient places the thumb/
• Patients are advised not to sleep or do middle finger of right hand on right lower
underwater swimming, while wearing lid margin and index finger of the same
these lenses. hand over right upper lid margin.
• Cup the left hand under the right eye to
Insertion and Removal of Rigid Contact grasp the falling RGP lens.
Lens • Then patient draw both the eyelids away
Patient is taught to insert the contact lens in from the lens, while pressing them tightly
his/her eyes very comfortably. together and keeping the straight gaze.
Fig. 13.30: Technique of RGP lens insertion. A. Lens placed on index finger; B. Lens insertion
Recentration Technique
• Suppose if lens is beneath the upper lid: Pull
the upper eyelid in upward direction and
look downwards, while firmly holding the
upper lid upwards. Now make rapid
horizontal eye movements, slowly look
straight, and then downwards, now gently
leave the eyelid.
• Suppose if lens in beneath the lower lid: First
widely open both the eyelids by right hand
fingers and locate the contact lens. Slowly
slide the lens upwards by placing the upper
eyelid margin at lower edge of lens. Once
Fig. 13.31: Method 1 for RGP lens removal centered, look straight and then down-
• Suppose lens did not fall by this manoeuvre, wards, while slowly leaving the eyelids,
then alternatively both the hands can be first leave lower lid then upper lid.
used to pull the upper and lower eyelids • Suppose if lens is in the corners of eye: Wide
using right and left hands. open the eyelids as above, now locate the
lens by lateral eye movements. Once lens
Method 2 (Fig. 13.32)
gets centered, look straight and then
• Similarly bend the head down, now place downwards. Now slowly leave the eyelids
index finger of right hand over the upper one by one, first lower followed by upper
lid margin. lid.
• Cup the left hand under the right eye to
grab the falling lens. Wearing schedule
• Look downwards keeping both the eyes • Patients are advised to practice the insertion
wide open, now pull the index finger and removal of RGP lenses for initial
upward and outward. 2–3 days, once they feel confident and
comfortable, regular wearing of lenses
• Suppose lens did not come out, then patient
should be started.
is instructed to blink simultaneously while
pulling the upper eyelid. • Gradually the wearing time is increased, in
• Left hand is used to remove the lens from case of RGP lenses. First wear the lens for
the left eye. 1–2 hours and see the response in terms
of visual acuity, comfort and ocular
symptoms. If comfortable, then wear the
lenses regularly for 2 hours everyday, for
3–4 days.
• When there is no symptom then gradually
the wearing time is increased on daily one
hour basis, at 3–4 days interval.
• Once a constant wearing of 6–8 hours is
reached, say roughly in 30–45 days, then
patient can wear these lenses regularly
during their duty hours.
• Always remember to remove the lenses
after a constant wear for 8 hours and before
Fig. 13.32: Method 2 for RGP lens removal sleeping time.
Follow-up: Regular follow-up is must to avoid • Burning or scratchy eyes: Irritation in eye
the complication of contact lens wear. if occurs immediately after insertion of lens,
Following follow-up visits are mandatory for then it is most likely due to contamination
a comfortable and successful RGP lens of multipurpose cleaning solution or dirty
wearing lens. However, if burning or scratchy
• Day one sensation is felt after 1–2 hours of insertion
• Day three of lens, then it indicates lens has a steep fit.
• Day seven Sometimes dry eyes, poor blinking and
• After a month polluted environment may also give this
• Every three months kind of sensation. Change the cleaning
solution and sterile the lens. Use a flatter
• Every six months
lens if steep fit is found as the cause of
• After one year
irritation.
Follow-up visit evaluations are essentially • Excessive blinking: During adaptation
similar as in case of a soft contact lens, by period frequent blinking is common
taking history, vision and slit lamp examina- however; if it persists even after a few days
tion. of wear, then it is essential to find the cause.
Small size lens or presence of small foreign
Rigid Contact Lens Related Complications
body over lens are the common causes of
and Management
excessive blinking, however, a mucus strand
• Pain: Intolerable pain can be experienced or fogging of lens because of scratches will
after using rigid lenses at various time also induce excessive blinking.
intervals, which gives a clue about the cause • Excessive dryness sensation: Patient may
of pain as follows experience continuous dryness feeling due
– Immediately after wearing rigid lenses to poor lacrimal secretions, inadequate
the pain may be due to improper blinking or tight fit lenses. Treat the cause
insertion technique, foreign body behind for better tolerance of lenses and prescribe
the lens, torn lens edges or due to dry artificial tears eye drops.
lenses. • Foreign body sensation: During adaptation
– Severe pain a few hours after wearing period a little foreign body sensations are
rigid lenses may be due to corneal edema acceptable, however if they present for a
or abrasions caused by steep fitting lens. long duration, then search for the causes of
Replace the lens after evaluating the lens it. Mostly the torn edges or too flat lens
fitting with fluorescein dye. causes these kinds of sensations, although
– Sometimes pain may be felt 2–3 hours too thick, large or scratchy lens with
after removal, which indicates occurrence conjunctivitis may also give continuous
of over wear syndrome due to micro foreign body sensation. Treat the causes
corneal abrasions and edema caused by and change the lens of appropriate fit.
tight lens fitting. Give rest period for • Lens coating in morning: Sometimes in
2–3 weeks and then advice a flatter lens, early morning a milky fluid coating may
once cornea is healed. be seen over the lens. This may be due to
• Watering: Continuous excessive watering collection of Meibomian gland secretions,
may occur due to unfinished lens edges mucus, proteins or epithelial cells debris
which cause mechanical irritation, over the lens. Rarely, in low grade infections
inadequate blinking and corneal edema. abnormal secretions will deposit over lens.
Change the lens and advice to clean the lens Treat with antibiotics and clean the lens
surface properly before insertion. with anti-infective solutions.
• Lid swelling in evening: During adaptation – Blurring in distance vision: Blurring for
period very mild swelling of lids may be distance vision may be seen in early
seen which subsides on its own once patient phase of lens wear. Common reasons are
is accustomed to lens. If lid swelling is excessive watering, improper lens power
present even after adaptation period, then or uncorrected astigmatism, poor quality
probably edges of lens or steep fit lens is lenses or scratched lens surfaces. Do an
the cause. Remove the lens and change as over refraction and examine the lens in
per proper fitting guidelines. white light, check the power of lens with
• Visual disturbances: Several visual distur- lensometer. In late phase blurring of
bances may occur while person is wearing distance vision may be caused by corneal
a rigid contact lens. These symptoms can edema or warpage of contact lens. In
be grouped as both conditions simply change the lens
– Fluctuation in vision: Initial fluctuation in with appropriate fit.
vision may be present during adaptation – Blurring in near vision: In a pre pre-sbyopic
period, which improves on its own. age group, if distance vision is clear and
However, if it appears later then excessive blurring of near vision is present with
watering or small size lens are the causes. contact lens, then the probable causes are
Treat the cause of watering and change improper lens power, decentred lens,
the lens size to achieve a stable clear and poor fluid exchange underneath lens
vision. or severe convergence insufficiency.
– Visual changes with head posture: Flatter Change the contact lens if incorrect
lenses move excessively over the cornea, power or decentration is present. Advice
so patients have tendency to tilt their patient to blink frequently for proper tear
head upwards to keep the lens in the exchange and do convergence exercises
center position for better vision. Change in convergence insufficiency cases.
the lens with smaller diameter for central – Blurring in vision after contact lens removal:
fit and thus decreases the lens movement. Many patients experience blurring of
Sometimes the visual acuity may vision, when they remove contact
improve by head shaking or head lenses and start wearing spectacles
bending, this is due to poorly centered commonly called ‘spectacle blur’.
lens. Change the base curve and TD of Reason for this spectacle blurring are
lens to achieve better centration and corneal edema or lens-induced corneal
stable vision. curvatural changes.
14
Contact Lens Specific Conditions, Complications and Maintenance 409
Contact Lens Specific

Conditions, Complications
and Maintenance
Learning Objectives
• Describe the indications, wearing schedule and complications of rigid and soft extended wear contact
lenses.
• Prescribe disposable contact lenses to patients.
• Understand the indications and management with scleral contact lenses.
• Manage variety of ophthalmic disorders by effective clinical application of therapeutic contact
lenses.
• Prescribe colored contact lenses in various ophthalmic conditions.
• Manage special ophthalmic circumstances like high refractive errors and corneal ectasias specially
keratoconus by the use of specific types of contact lenses.
• Prescribe contact lenses for presbyopes.
• Understand and treat complications related to contact lens wear.
• Describe the efficient methods to maintain, disinfect and preserve the contact lenses.
Chapter Outline
• Specific Contact Lenses Correction of regular astigmatism

– Extended wear contact lens CL fitting in primary corneal ectasias
Rigid extended wear contact lens – Orthokeratology
Silicon hydrogel extended wear contact • Contact Lens Related Complications
lens – Risk factors related to complications with
Soft hydrogel extended wear contact lens contact lens wear
– Disposable contact lenses – Complications and diseases related with
– Scleral RGP lenses contact lens wear
– Therapeutic contact lenses • Maintenance and Care of Contact Lens
– Colored contact lenses – Introduction
• Contact Lenses in Special Conditions – Personal care
– High myopia – Contact lens solutions
– Aphakia – Disinfecting systems
Soft contact lenses in aphakia – Preservative systems
Rigid contact lenses in aphakia – Lens storage system
– Presbyopia – Care of lens cases
Contact lens fitting in presbyopes – Maintenance and lens care regimens
– High astigmatism – Radiuscope
409
SPECIFIC CONTACT LENSES Rigid Extended Wear Contact Lenses

Extended Wear Contact Lenses Almost all types of rigid contact lenses
Since invention of contact lenses, some manufactured for extended wear are gas
patients either desired, or were selected by permeable lenses with medium and / or high
their clinicians to wear contact lenses during Dk values. It is well known that insufficient
sleep also. Hence the need for type of contact oxygen supply to eye may cause edema of
lenses arose which could act for extended cornea. Extended wear contact lenses either
period. In attempt to this, extended wear and RGP or silicon hydrogel allow sufficient
continuous wear contact lenses have been supply of oxygen to the cornea and meet
developed. Extended wear (EW) lenses are the criteria of zero additional swelling.
one, which the patient can wear for six nights Indications: RGP extended wear lenses are
continuously followed by a night of no lens indicated in the following conditions in
wear. Similarly, continuous wear (CW) lenses addition to abovementioned indications.
can be worn up to 30 nights continuously • Patients facing visual problems with toric
followed by a night of no lens wear. extended wear soft contact lenses.
Indications of extended wear contact lenses • Severe metabolic problems such as edema
Ideally every person should be prescribed and hypoxia with soft hydrogel extended
daily wear contact lenses. However, in wear lenses.
following situations extended wear contact • Medical problems like allergies, giant
lens can be used papillary conjunctivitis, or superior limbic
• In certain persons who are engaged in night keratoconjunctivitis associated with use of
duties or irregular working shifts like in soft extended wear contact lenses.
case of doctors and nurses, armed force • Patients having high refractive errors
personnels, security persons and emergency (hypermetropia or myopia) requiring thick
staff members, etc. the use of extended wear lenses or toric bifocals lenses.
contact lens is more convenient. Several studies showed that rigid contact
• Young infant or elderly aphakics may also lens wear is usually associated with greater
benefit from these lenses because they are degree of hypoxia leading to decrease in
incapable or frightened for contact lens corneal epithelial barrier function. Hence,
insertion, thus to overcome complications recommended RGP contact lenses for
related to lens handling and vision limita- extended wear purpose should have the
tions, extended wear can be used. highest oxygen transmissibility and fastest
• When patient is not keen to use daily wear rate of tear exchange so that an adequate
contact lenses, because of convenience of barrier function of corneal epithelium
extended wear lenses. remains maintained.
• Persons habitual of over wearing or sleeping Lens fitting and wearing schedule are
with contact lenses, require extended wear essentially similar to basic RGP lenses of daily
lenses to avoid complications. wear type. Although in some specific cases,
such as papillary conjunctivitis, corneal
Broadly on the basis of material used and decompensation, etc. extended wear RGP
properties, we can group these EW lenses into lenses are not recommended.
• Rigid extended wear contact lenses Initially, patient is advised to wear RGP
• Silicon hydrogel extended wear contact contact lens on daily basis for a week, and then
lenses gradually extend their wear duration,
• Soft hydrogel extended wear contact preferably up to 5–6 nights continuously. For
lenses a successful, uncomplicated extended lens
wear, lens should be removed for one night, Silicon Hydrogel Extended Wear Contact
then after cleaning and rinsing lens can be Lenses
worn again for 6 nights. The silicon hydrogel (Si-Hy) lenses were
Follow-up: Regular follow-up is must to introduced in 1999 with the aim to increase
prevent complications related to extended the oxygen transmission through lens which
wear; a usual follow up schedule is after was main limitation factor with the use of soft
• 24–48 hours of initial lens wear hydrogel lenses. As a result the wearing of lens
• One week of lens insertion for extended period became safer and
• One month or at time of removal, cleaning, comfortable with availability of these types of
disinfecting and reinsertion of lens lens. The Si-Hy lenses contain both properties,
i.e. increase oxygen permeability due to
On every follow-up visit a thorough exami-
presence of silicon and hydrophilic nature of
nation for proper lens fit and clinical signs are
hydrogel lens. However, these lens material
done. Generally during slit lamp examination
demonstrated less wettability and more
a special attention is given for:
chances of lipid depositions than hydrogel
• Contact lens depositions lens materials. As a result to improve the
• Lens adhesion wettability the lenses were surface treated or
• 3–9 o’clock staining added with other materials.
• Persistent corneal striae
• Epithelial microcysts A wide range of Si-Hy material extended
• Contact lens bending or indentation wear lenses are available, for up to 30 nights
of continuous wear and/or for six nights of
Complications of rigid extended wear contact extended wear. These lens materials show a
lenses: Complications and lens related significant advancement in lens design, so that
problems in extended wear lenses are more complications usually associated with lens
common and more pronounced as compared induced corneal hypoxia, such as limbal
to daily wear RGP lenses. redness, epithelial and stromal edema,
Chances of infections are less but caution vascularization of cornea, endothelial poly-
is required in case of lens adhesion because of megathism and myopic shifts are rare.
increased risk of corneal ulceration. Low Although several advantages are present
riding lenses should be avoided because there with Si-Hy lenses, but a few disadvantages
is increase risk of adhesion to cornea. Risk of are
adhesion further increased with use of lens
• Si-Hy materials are more stiff in nature
material having high Dk value, thin lens and
as compared to soft hydrogel material
inadequate edge lift of lens. To avoid adhesion
(HEMA or Etafilcon A), hence during
it is advised to use thick, flatter fitting rigid
blinking can create more negative
lens with medium Dk/t value (~100) with
pressure beneath the contact lens. As a
adequate edge lift.
result, chances of development of
3 and 9 o’ clock staining usually does not
mechanical arcuate lesions and local
cause discomfort but with continuous use of
papillary conjunctivitis are more.
lens severe injection of conjunctiva can occur.
It is more common with use of low riding, • Increased frequency of formation of
thick edge lens as well as in person who blink mucin balls with overnight wearing for
incompletely. Prolonged 3 and 9 o’ clock a long period, especially more common
staining may lead to vascularization in in eyes having steeper corneal curvature.
horizontal meridian. Sometimes, there may be Various hydrogel contact lens materials and
contact lens induced papillary conjunctivitis their respective properties are summarized in
due to hypersensitivity reaction or irritation. Table 14.1.
Table 14.1: Various hydrogel contact lens material and their respective properties
Material Water Max Dk/t Min Dk/t Surface Other technology
content (%) modification
Asmofilcon A 40 161 70 Nanoglass Menisilk
plasma coating
Balafilcon A 33 84 38 Plasma oxidation None
Comfilcon A 48 145 64 None Aquaform technology
Enfilcon A 46 125 55 None Aquaform technology
Filcon II 3 58 86 – None Aquagen process
Galyfilcon A 47 107 37 None Hydraclear technology
lotrafilcon B 36 101 45 Plasma Aqua moisture system
polymerization
Etafilcon A 58 26 8 None None
Narafilcon A 46 118 47 None Hydraclear technology
lotrafilcon A 24 203 68 to 140 Plasma Aqua moisture system
polymerization
Soft Hydrogel Extended Wear Contact eye along with enough tear exchange so that
Lenses debris formed behind lens can be removed
Soft hydrogel extended wear lenses were effectively.
familiarized by John de Carle with Permalens Wearing schedule: Initially it is recommended
and in the year 1981 soft hydrogel extended to wear soft lenses for 24 hours and observe
wear contact lenses got an approval from FDA the symptoms and clinical condition of eyes.
for cosmetic purpose. Soft hydrogel extended If patient is asymptomatic and comfortable,
wear contact lenses can be used continuously then these lenses wear can be extended for
for 30 nights. After 30 days lens should be week period. Gradually, these lenses can
removed, cleaned, disinfected and then be worn for longer durations, usually
reinserted. However, these lenses as compared 25–30 days.
to rigid gas permeable and silicon hydrogel
Follow-up: Regular follow-up is the key to
(Si-Hy) do not allow sufficient oxygen to the
avoid complications such as microbial keratitis
cornea, thus incapable to accomplish the
and lens depositions. Normal follow-up visits
criteria of zero additional swelling with are planned after:
overnight wear.
• Day one
Lens fitting: Instrumentation required for • One month
fitting of extended wear soft contact lenses is • Two–four months or during removal and
essentially same as for all other basic contact reinsertion of lens
lens fitting. History and symptoms are elicited
On every visit a detailed slit lamp exami-
from patient before fitting extended wear
nation for lens fit and corneal condition is
contact lenses, specifically to fully understand
done. In case of any complication lenses are
and to find out the reasons of patient’s desire
removed and reinserted after resolution of
for overnight lens wear. Although, the
problem.
fundamental principles of extended wear soft
contact lens fitting are similar to fitting for Complication with soft EW lens: The EW soft
daily wear, however, most important concern lenses can cause all those complications
is to provide maximum oxygen supply to the related to daily wear soft lenses. However, use
of EW soft lenses carry more risk for develop- • Needs lesser handling and maintenance as
ment of compared to daily wear.
• Ulcerative keratitis: Wearing of lens for exten- • Cost effective.
ded period may alter morphology of corneal However, extended wear lenses has a few
epithelium and predispose to infections. disadvantages such as
• Corneal vascularization • Greater incidence of overall complications
• Deposition of protein and mucus on contact as compared to daily wear lenses.
lens • Increased risk of microbial keratitis, because
• Tight lens syndrome: There is sudden of overnight use.
development of painful red eye. On Patients should be given full information
examination, lens is immobile and regarding associated risks and benefits with
moderately dehydrated. Corneal edema an overnight or extended wear and then asked
develops due to poor oxygenation, also to make the choice of contact lens type. Hence,
flare and cells are seen in anterior chamber. it is important that a discussion should include
To treat this condition, lens should be risk comparison with other lens types and
removed for 1–2 weeks for healing and to wearing modalities even a comparison to
prevent infections. Once the eye is normal, refractive surgery. Once patient accepts this
lens with looser fitting should be prescribed. increased risk with extended wear, then
Rigid versus soft extended wear contact lenses: clinician decide on best course of action.
High Dk/t RGP extended wear contact lenses
have several advantages and disadvantages Disposable Contact Lenses
over soft hydrogel lenses as summarized in These may be grouped as
Table 14.2. • Daily wear disposable contact lenses
Extended wear versus daily wear contact • Extended wear disposable contact lenses
lenses: Extended wear contact lenses have several Daily wear disposable contact lenses: These
advantages over daily wear lenses such as daily wear disposable lenses are sometimes
• Simple and convenient for patients to wear. confused with simple daily wear contact
lenses. The daily wear disposable lenses are
Table 14.2: Various advantages and disadvantages of the one, which are worn during awakening
rigid EW lens over soft extended wear contact lenses time, only for one day. Once removed from
Advantages Disadvantages the eye, these lenses are thrown away and not
Enhanced oxygen Adhesion phenomenon used again, whereas daily wear lenses after
transmissibility removal from the eye can be worn again in
Active tear pump Poor initial wearing comfort the next morning after overnight treatment in
mechanism cleaning solution.
Lesser lens deposits Difficult fitting procedure Over past decade, a significant increase in
the demand of daily disposable contact lenses
Better reproducibility 3 and 9 o’clock staining
has been noticed all over the world because
Superior optical these lenses provide more convenience of
quality
wearing and are associated with decreased
Maintenance of lens risk of complications. Various types of
parameters for a long ‘comfort enhanced’ daily disposable lenses
period
have been developed to decrease the chances
Zero additional of dryness and discomfort among the wearers.
swelling with Selection of daily disposable contact lens for
overnight wear
a patient will depend on the total of
convenience offered by lens to the wearer as lene glycol (PEG), which are present in
well as on the health and compliance of patient packaging saline, further maintain the
for wearing the lens. As compliance is better release of PVA for a long period. For
and risk of complications is less in the teenage example, Focus Dailies Aqua Comfort
group, these lenses are more preferred in this Plus (Nelfilcon A Plus).
age group. For daily wear disposable lenses, maximum
Comfort enhancing daily wear disposable wearing time suggested is summarized in
contact lenses is mainly classified into three Table 14.3.
groups depending on their mechanism of These types of contact lenses are indicated
action particularly for daily disposable wear, hence
• Lens made up of poly HEMA materials and should be discarded after removal from the
co-polymers: The copolymers have eye. As these lenses are disposed of after every
property to retain water. For example, single daily use, risk of developing giant
Acuvue Moist contact lens (Etafilcon A) papillary conjunctivitis is reduced signifi-
has an embedded copolymer called cantly. Daily disposable lenses provide more
polyvinyl pyrrolidone (PVP), which comfort in patient than other contact lenses
works as a water holding agent, hence which are worn for a long period especially,
rate of dehydration of lens is reduced in those patients who feel discomfort and
during lens wear. itching due to allergies.
• Lens made up of poly HEMA materials with
Extended wear disposable contact lenses:
lubricating additives: These are also made
These lenses are also disposed off, once
up of poly HEMA material, although in
removed from the eye, however, these lenses
place of water retaining molecules these
can be worn continuously for either six days
lens materials have lubricating additives
(weekly) or thirty days (monthly), once
coatings. These lubricating additives are
inserted in the eye. Because of their longer
usually present in packaging saline, used
duration of continuous wear, these lenses are
for storage of lens. For example, in case
called extended wear contact lenses. However,
of SofLens daily disposable, a high water
they differ from simple extended wear contact
content material poloxamine is added in
lenses which can be used again after removal
the saline solution which coats the lens
from the eye.
surface and then slowly released into tear
film when these contact lenses are inserted Introduction of weekly replaced disposable
in the eye. lenses has resolved two major issues, i.e.
corneal hypoxia and corneal edema. These
• Lens made from polyvinyl alcohol (PVA):
lenses are worn for six continuous nights and
PVA is a water-soluble non-toxic
then disposed, hence are referred as disposable
polymer, commonly used in lubricating
extended wear lenses.
eye drops and lens solutions. When these
lenses are prepared using PVA, some of Table 14.3: Wearing schedule of daily wear
the PVA remains in unpolymerized (free) disposable contact lenses
form in the matrix of contact lens. After Day Hours
wearing the lens due to blinking this free
1 4–6
form of PVA is slowly released from the
2 7–8
contact lens into the tear film. For
3 9–10
example, Focus Dailies All Day Comfort
4 11–12
(Nelfilcon A). Furthermore, addition of
5 12–14
other substances like hydroxy propyl
6 and afterwards All awakening hours
methylcellulose (HPMC) and polyethy-
Disposable contact lenses are available for hydrogel). A tint (phthalocyanine blue) has
various wearing and disposing schedules such been added, so that the contact lens becomes
as they can be worn either on the daily basis more visible, hence can easily be handled.
or on extended wear basis. These lenses are An additional UV absorbing monomer is
available for daily, weekly, fortnightly or also added in lens to block UV radiation.
monthly disposable schedule. Generally • Various disposable lenses and their
wearing schedule is decided by the treating properties are summarized in Table 14.4.
consultant, however, it vary a little for daily
wear or extended wear disposable contact Scleral RGP Lenses
lenses. RGP lenses when rest over sclera are termed
Patients should be given following scleral RGP lenses. These lenses cover the
warnings related to extended contact lens entire corneal surface and form a fluid vault
wear: for oxygenation of cornea. Majority of newer
• Eye discomfort types of scleral contact lenses are made up of
• Excessive tearing high oxygen permeable materials for better
• Eye redness tolerance.
• Visual changes or diminution of vision Scleral RGP lenses are grouped into
following categories, depending upon overall
Note: Several ocular problems including corneal diameter as
ulcers may develop rapidly which can lead to visual • Corneo-scleral (12.9 to 13.5 mm)
loss.
• Semi-scleral (13.6 to 14.9 mm)
Extended wear disposable hydrogel contact • Mini-scleral (15.0 to 18.0 mm)
lenses as compared to conventional non- • Scleral (>18.0 mm)
disposable continuous wear lenses are found
beneficial only in carefully selected patients Indications
with strict follow-up schedule. However, a Corneal conditions:
significant hypoxia related adverse events and Scleral lenses are indicated in cases of irregular
marked microbial keratitis is noted in many cornea, diseased cornea and healthy cornea.
EW lens wearers as compared to conventional Usually corneo-scleral lenses are used in
non-disposable continuous wear lenses. irregular cornea and healthy cornea, whereas
Examples of disposable contact lenses are scleral lenses are used for scarred and severely
• AVAIRA contact lenses exist in various lens pathological cornea.
designs form such as spheric, aspheric, toric Several conditions where scleral lens can be
and multifocal. These lenses are prepared used are
using material comprising 46% water and • Naturally occurring ecstatic cornea: Like in
54% Enfilcon A (silicon containing young children and adults with keratoconus,
Table 14.4: Various types of disposable contact lenses and their respective properties
Lens series Lens material Water content Lens diameter
Precision UV Varsurfilcon A 74 % 14.5 mm
Actifresh 400 MMA / VP 55% 14.3 mm
Proclear Omafilcon A 62% 14.2 mm
Soflens 66 Alphafilcon A 66% 14.2 mm
Acuvue Genfilcon 48% 14 mm
Dalies Nelfilcon A 69% 13.8 mm
pellucid marginal degeneration and forme • Retract upper and lower eyelids as shown
frusta keratoconus. in Fig. 14.1B with the help of thumb and
• Secondary corneal ectasias: Post-surgery index finger of other hand while keeping
ectasias, post-corneal transplantation, post- the face parallel to the ground.
infarcts corneal cross-linking. • Slowly raise the contact lens onto the eye
Intolerance to corneal RGP or hydrogel lenses in one continuous motion, then slowly
is seen in the following conditions like release the eyelids before lowering the
• Refractive conditions: Lens decentration in supporting suction cup.
high refractive errors • Suppose a large air bubble is seen
• In dry eye underneath lens, either the lens was not
inserted in one continuous motion or the
– Due to ocular disease: Alkali burn, ocular
lens cup was not completely filled with
pemphigoid, Steven Johnson syndrome,
solution.
neurotrophic keratitis, Sjögren syndrome,
filamentary keratitis. • Remove the lens and reinsert as shown in
Fig. 14.1B.
– Due to reduced tear meniscus, decreased
tear production, conjunctival hyperemia— Lens removal technique
as seen in early or contact lens related • Scleral lenses are generally held by the force
dry eye. of suction so always loosen these lenses
before removal.
Scleral Contact Lens Fitting Technique • Put a few drops of rewetting solution and
Insertion technique then inferior peripheral portion of lens is
• To check lens fitting, fill the lens completely gently pushed in repeated motions for some
with isotonic, non-preserved artificial tears seconds.
and add one drop of fluorescein from a • Keep the upper eyelid in steady position
strip. and lower eyelid is used to raise the lower
• Scleral lens is either supported on a large portion of contact lens, away from the eye.
DMV scleral suction cup or a tripod made Otherwise, a medium DMV suction cup can
by using thumb, middle, and index finger, be placed over the lower peripheral portion
as shown in Fig. 14.1A. of contact lens, slowly pull the cup in
Fig. 14.1: A. Tripod of fingers; B. Insertion technique of scleral contact lens

downward and outward direction with reflections from the front and back surface
force directed perpendicular to the lens of contact lens. Now, compare the thickness
surface. of this black layer with the green layer of
Fitting principles: Most important principle tear lens.
for scleral lens fitting is that lens should vault • Suppose, if thickness of black layer (trial
the cornea entirely while lens is aligned to the lens) is 300 microns and on examination
bulbar conjunctiva. To achieve this fit the green layer is appearing approximately
following parameters need to be checked of half thickness than black band, then it
tells that lens is vaulting the cornea by
Overall diameter
125–150 microns which is considered an
• Generally, lenses with large diameter can ideal clearance for a non- fenestrated lens
retain more fluid in the corneal chamber design. Different trial lens are tried until a
thus allow more clearance over the cornea, proper central corneal clearance value is not
hence are more convenient for the user, obtained.
whereas lenses smaller in diameter vault
• Usually all types of scleral lenses take
the cornea more strongly thus they require
30–40 minutes time to settle into the
more accurate central fit.
conjunctiva. Scleral trial lenses showing
• In case of irregular corneas, always choose gross excessive vaulting should be
a lens of larger diameter, although some removed and replaced with a flatter base
lens manufacturers provide guidelines for curve lens.
selecting an overall diameter based on
HVID. Correlation of corneal and peripheral fitting
• Scleral contact lens fit can be considered in
Initial trial lens two parts
• We can follow the lens manufacturer’s – Central fit is over the cornea and
fitting guide to select a trial lens, however, commonly called “corneal chamber”
a simple clinical approach can be tried to
– Peripheral fit is over the conjunctiva.
assess the trial lens base curve.
• Entire corneal chamber should be
• Stand on the side of the patient while
examined with diffuse cobalt blue light in
examining shape and profile of the cornea.
high illumination and medium magnifi-
Suppose cornea appears very steep, select
cation. Observe areas of lens-corneal touch
a steeper base curve similarly, if cornea
(bearing) as in case of a corneal RGP contact
appears flat then select a flatter base curve.
lens.
For an average profile cornea, select an
average base curve. • In an irregular cornea, commonly we
observe a bearing in mid-peripheral or
• Scleral lenses are fit on the basis of sagittal
peripheral regions of cornea however, it is
height, hence clinical assessment is an
acceptable once central corneal clearance is
effective method when properly done.
present. In such a situation an additional
Corneal fit examination clearance is produced in peripheral area,
• On slit lamp optical section is made using without increasing the central corneal
white light and then in high illumination clearance.
with medium magnification, examine the • An excessive lens movement or bubble
central corneal clearance. formation underneath lens indicates that
• Various layers can be observed in cross peripheral curves are too loose. To correct
section, the outermost band of dark black this condition simply tighten the peripheral
color is due to scleral contact lens. This curve by choosing scleral lens of an appro-
dark area is surrounded by two thin priate base curve.
An ideal scleral contact lens fit Therapeutic Contact Lenses

An ideal scleral contact lens fit is expressed Introduction
by the following factors: Therapeutic contact lenses (TCL) or bandage
• Centered lens lenses have emerged as an effective alternative
• Minimum 2 mm larger than limbus for the management of various eye diseases
• Minimum corneal vault especially, in recalcitrant cases which show
• No touch or bearing poor response to other treatment modalities.
• Good coverage to limbus Although TCL is not used as first line
• Edge alignment treatment in majority of ophthalmic disorders
• No movement of lens but it can work as an effective adjunctive
treatment in various ophthalmic disorders.
Over topography
Due to higher risk of development of microbial
• Many a times it is useful to perform a
infections with TLC, the decision to use these
computerized topography, keeping the
types of lens should be taken with great
scleral contact lens in place, once it had
precautions.
settled for about 15–20 minutes. Topography
The most important purposes of prescribing
will show any kind of lens flexure, if
the therapeutic contact lenses are
present.
1. To provide relief and comfort from eye
• Toricity of >0.5 D may be clinically signifi-
pain due to corneal disorders
cant and may affect the vision. It can be
corrected by increasing the central thickness 2. To assist in healing of corneal wound
of contact lens. 3. To provide mechanical support and
protection to cornea
Tear exchange evaluation
4. To maintain proper hydration of corneal
• Before dispensing a scleral lens to patient, epithelial surface
tear exchange evaluation is done. 5. Also used as drug delivery system
• Insert a sterile scleral lens without adding
Types of TCL: Therapeutic contact lenses
fluorescein dye in filling media.
made from both hard and soft lens materials
• Once lens is properly placed, wait for are available, although hydrogels types TLC
settling period of about 10–15 minutes. are more used. Silicon rubber and copolymers
Now instill fluorescein dye with a dye strip are also used to produce specific types of TLC,
over the lens surface. having good oxygen permeability.
• Periodic examination of tear lens is done to
see the presence of dye which moves behind TLC can be classified as
the contact lens into the corneal chamber. 1. Soft hydrogel lens
• In ideal conditions, after 20–30 minutes a • Low water content (38–45%)
small amount of dye should be seen in the • Mid-water content (45–55%)
corneal chamber. Although tear exchange • High water content (67–80%)
underneath contact lens is not so rapid, but 2. Hard (PMMA) and gas permeable scleral
it is significant for a proper lens fit. lenses
• Suppose on examination after sufficient 3. Hard scleral rings
waiting period of 30–40 minutes, no
4. Silicon rubber and silicon hydrogels (38%)
fluorescein dye is observed in the corneal
chamber; means it is a steep fit, hence to 5. Collagen shields having Dk/L = 63% water
correct it either peripheral fit must be content soft lens.
flattened or overall diameter should be Various commercially available therapeutic
increased. contact lenses are summarized in Table 14.5.
Table 14.5: Various types of commercially available therapeutic contact lenses and their properties
Lens type Lens material Water content Total diameter (mm)
Hydrogels
Plano HEMA 38.6% 14
Plano Polymacon 38.6% 13.5 /14.5
Plano ES 70 MMA / VP 70% 15
Troy 85% 15–20
Igel Igel 67/ 77 67% / 77% 14.5
Collagen shields
Bio-Cor type I Porcine
Chiron type I Bovine
Silicon rubber
Silflex Polysiloxane 11.7–13.7
Scleral lenses Scleral sealed ~ 22
Choice of TCL from available TCLs will lens may give rise to discomfort to patient
depend on main purpose for use (as discussed and adhered edges indicate tight lens fit.
above) and on the physiological requirement • It is recommended to keep several lens
of a pathological cornea, etc. designs with similar parameters available
Fitting of a TCL: Fitting of a TCL is very at time of insertion because if one
simple if following guidelines are follows particular lens design fails to produce
which are chiefly for soft TCL because these desired lens fit, then another lens design
are most commonly used TCLs in various may fit well.
ocular conditions. • Generally, the excessive steep or flat lens
• Keratometry is usually of very little help should not be used for fitting. However, in
because due to associated underlying some conditions like corneal edema or
corneal pathology there may be formation cornea epithelium defects, a TCL of flatter
of irregular mires. Thus, a trial lens fitting fitting may be preferred. On the other hand,
is suggested. However, keratometry steeper fitting TLC may be used in patients
readings of other normal eye may be having irregular corneal topography.
helpful. Indications for use of therapeutic contact
• During fitting the use of topical anesthetics lenses: Therapeutic contact lenses are used in
(except in a few conditions) should be various diseases of cornea. In treatment of
avoided because it will mask the pain various ocular conditions which cause
arising due to poor lens fit. abnormalities in epithelium of cornea, the
• Ideally, to check the dehydration effects on relief from pain is the most common and
lens, the fitting must be evaluated at an important part of treatment and these lenses
interval of 20 and 60 minutes. can be used to relieve the pain effectively in
TCL fit should be assessed on slit lamp both these conditions.
in terms of central fit and peripheral fit. Bullous Keratopathy: Use of TCL in following
• An ideal central fit TCL will provide good patients of intractable bullous keratopathy is
corneal coverage with proper mobility very useful
characteristics. • Patient of bullous keratopathy presenting
• Similarly, peripheral lens fit is also with a painful blind eye.
necessary to check because flared edges of • Patient is not fit for graft surgery.
• As a temporary relief measure in those Filamentary keratitis: It is a disease of eye

patient who are waiting for penetrating in which filaments of mucus and degenerated
keratoplasty. epithelial cells get deposit on surface of cornea,
These patients should be prescribed with usually it is self-limiting in most of the cases.
TCL as early as possible. Use of TCL in these The treatment includes topical therapy with
patients is associated with relief in pain as well artificial tears and lubricants. Cases which do
as some improvement in vision. Relief in pain not respond to lubricants alone, low water
is probably due to protection of nerves by TCL content disposable TCLs can be used along
which are exposed due to rupture of bullae. with steroids, topical antibiotics and atropine.
In some patients vision is also improved as Filaments get resolved usually in 4–5 days and
irregular cornea is covered by regular surface within 2–3 weeks a complete disappearance
of contact lens. In bullous keratopathy patients of filaments may be seen; however filaments
the movement of lens should be minimal but may recur after some time.
must be sufficient enough to allow adequate TCL are also effectively used for corneal
tear flow beneath the TCL. Hydrogel TCL of
healing in various recalcitrant cases which are
large diameter having high water content
poorly responding to routine medical
(Duragel 75, Plano ES70, etc.) can be used which
treatment like in the following conditions.
maintain maximum oxygen permeability for
constant wear. For temporary purposes, a thin Recurrent corneal erosion: Disturbance of
high water content TCL can be used to corneal epithelial basement membrane due to
decrease the risk of corneal vascularization. anterior membrane dystrophies (Map dot
Thygeson’s superficial punctate keratitis: finger dystrophy or Cogan dystrophy) or
It is a recurrent and chronic disorder described trauma may result in recurrent breakdown of
by presence of small and oval punctate corneal corneal epithelium causing damage of corneal
opacities of grey white color on cornea. Exact surface (corneal erosions). Majority of patients
cause is not known but may be viral or usually remain asymptomatic throughout
immunological in origin. Corneal opacities their life but nearly 10–15% may develop
cause warpage of corneal epithelial surface recurrent erosion syndrome manifesting in
and reduced visual acuity. High water content form of pain and photophobia and foreign
extended-wear TCL (sometimes low water body sensations. Most patients of recurrent
content) can be used for treatment of severe erosions are treated with lubricants and
cases. The lens acts as a pressure bandage and hypertonic saline, however, a disposable
improves symptoms of pain and foreign body bandage contact lens (usually thick, high
sensation by covering the corneal lesions and water content extended wear type preferred)
nerves. can be used as an extended wear lens for 2, 3
Superior limbic keratoconjunctivitis: It is or even 6 months duration, as per require-
a chronic inflammatory disease involving ment. Before placing TCL, the affected area of
conjunctiva (superior bulbar), limbus and corneal epithelium should be debride
upper part of cornea, characterized by foreign completely and irrigate with saline. Ultra thin
body sensation, photophobia, and ocular pain. TCL are not indicated due to possible chances
Along with other therapeutic modatilities soft of buckling of lens. Corneal abrasion (<5 mm)
TCL especially of large diameter are very due to trauma can be managed by topical eye
effective in relieving the severe pain and drops and eye pad. If the size of abrasion is
symptoms associated with superior limbic more than 5 mm, then it can be treated by the
keratoconjunctivitis cases. TCL with relatively use of TCL, because epithelium heals more
large TD is used till symptoms and signs are quickly with disposable TCL as compared to
disappeared. conventional methods of treatment.
Persistent epithelial defects of cornea: be used if epithelial healing is delayed,

When an epithelial defect of cornea does not epithelial filaments are formed or loose
heal or remain persistent for more than two sutures are present after PK procedure.
weeks, the cornea get highly vulnerable to TCL, in various designs and of different
infection, ulceration, perforation and scarring. materials can also be used to provide
Soft disposables TCL are very useful as mechanical protection and support like in
they protect corneal surface from mechanical cases of corneal thinning, perforation or
trauma by eyelids and gives time to newly corneal trauma so that the need of immediate
formed epithelial to get attach to newly surgery or corneal grafting is delayed or
secreted basement membrane. Soft contact minimized. Various types of lens like
lenses with high oxygen permeability are hydrophilic TCL, scleral lenses or rings and
more preferred to reduce chances of corneal silicon rubber lenses can be used to provide
edema and neovascularization. Collagen mechanical support to cornea.
shields hydrated with acidic fibroblast growth Corneal perforation: Use of a TCL gives
factor (FGF) can be also used to promote structural support and maintains integrity of
healing of epithelial defects. an eye if applied in case of small corneal
Chemical injuries: Chemical injuries to eye perforation (<2 mm) with no loss of tissue.
result in breakdown of collagen leading to Healing rate is faster if lesions are small and
widespread damage to cornea, epithelial noninfected. In addition, lacerations or
surfaces, etc. and formation of stromal ulcer. perforations which lie adjacent to limbus and
The purpose of TCL is to prevent the further in well vascularized area respond faster on
progression of ulcer formation by preventing TCL application. As compared to suturing the
transfer of photolytic enzymes from tear fluid small corneal perforations heal better and with
to corneal stroma. Due to presence of chemosis very less degree of resultant astigmatism.
and epithelium defect, TCLs of small total Thin, low water content soft contact lenses are
diameter (~12 mm) are first choice of usually first choice.
treatment. Hydrophilic lens with high oxygen Corneal wound leakage: Anterior segment
permeability are more preferred because they wound leakage may occur secondary to
help in epithelial migration and promote surgery like post-cataract surgery and
epithelial stromal adhesion. Scleral lens can penetrating keratoplasty, trabeculectomy etc.
also be prescribed if lids are also involved in Majority of leaks are mild and self healing. In
injuries. In case of corneal melting due to moderate wound leakage thin low water
injury cyanoacrylate tissue adhesive can be content soft TCL can be placed. The lens will
applied and then covered with TCL. help in the wound healing by decreasing flow
Epithelial disorders following surgical of aqueous to wound and promotes re-epithe-
procedures: Temporary corneal epithelial lialization and vascularization. Sometimes,
defects may occur after many surgical even collagen shields can be placed in the eye
procedures on eyes like vitrectomy, cataract at the time of surgery and then hydrophilic TCL
extraction, post-penetrating keratoplasty, after 24 hours of surgery. Post-trabeculectomy
epikeratoplasty, kerato-refractive procedures a leaking drainage bleb may form either just
(PRK, LASIK), etc. Soft and/or collagen TCL after procedure or after several days or weeks.
can be used to decrease the chances of TCL of large size (TD = 20 mm) with high
epithelial trauma after surgery which water content (e.g. Mega soft 76.5%) can be
promotes rapid epithelial healing. placed which compress over the leaking bleb
Penetrating keratoplasty: In case of to prevent excessive drainage.
perforation of an existing corneal graft the Thinning of cornea: Patients with a thin
silicon rubber TCL can be used. TCL can also cornea have very high chance of perforation
and usually present with a descemetocele. In TCL as drug delivery devices: TCL can be
such cases, hydrophilic TCL can be prescribed used as drug delivery devices for treatment
which act as a corneal splint and slows down of some ocular diseases. Hydrogel soft lens
the rate of corneal thinning and ultimately impregnated with medications when placed
prevent corneal perforation. If corneal on the cornea usually delivers high levels of
thinning is due to dry eyes, then silicon rubber medication in eyes as compared to topical eye
lenses are better choice. drops. Several drugs such as pilocarpine,
Protection of the cornea: In various condi- corticosteroids, antibiotics, antifungal and
tions of eyes like entropion, trichiasis, eye antiviral, etc. can be delivered through contact
exposure due to lid deformities, cranial nerve lens for treatment of glaucoma, herpes simplex
palsies, etc. epithelium of cornea can easily infections, fungal ulcers, etc. The thickness and
damage due to trivial trauma, hence TCL are water content of lens and molecular weight
used to protect the cornea. TCLs especially may affect delivery of drug through contact
scleral lenses, are very useful to provide lens. The use of TCL for drug delivery for
protection to cornea and comfort in cases of prolonged time may be associated with
trigeminal or facial nerve palsy. increased risks of harmful reactions due to
Various ocular pathologies can lead to direct contact of cornea with drugs.
dehydration of cornea which ultimately leads General instructions to patients: Proper care
to corneal blindness, hence TCL are used to as per following guidelines of therapeutic
maintain corneal hydration in various contact lenses is must to achieve the best results.
conditions as follows • Cleaning and disinfection of TCL are done
Cicatrizing conjunctival disease: Cicatriza- at least once in every 15 days.
tion of conjunctiva with involvement of cornea • Proper size and adequate water content are
may occur in diseases such as Stevens-Johnson prerequisite for good outcome; hence TD
syndrome, ocular pemphigoid, chemical and water content are kept as per the
burns, trachoma and dry eye. In Stevens- requirement in a particular ocular condition.
Johnson syndrome, a thick TCL of low or • Specific suitable prophylactic topical
medium water content having large TD antibiotic drops are used to prevent
(15–20 mm) can be used to prevent formation secondary infections.
of adhesions, however, scleral lenses are more • Never use a TCL for more than 6 months
useful. Alternatively, a silicon rubber lens can duration, however, some TCL requires to
also be effective in selective recalcitrant cases. be changed even at 1 or 2 months intervals.
Chemical burns due to strong alkali lead to • Never apply certain topical drops such as
severe ocular damage. The TCL can be fluorescein, hypotonic saline, phenyleph-
prescribed in the later phase of treatment to rine or gels over TCL.
promote epithelial healing and to protect the • In case of severe burning, irritation, chemo-
fornix from mechanical forces of eyelids. TCLs sis or enhancement of symptoms report
like Mega soft bicurve TCLs or scleral lenses immediately to ophthalmologist.
or scleral rings can be placed to prevent • Always consult before insertion or removal
symblepharon reformation. of a therapeutic contact lens.
Dry eye: It is most commonly encountered Complications of therapeutic contact lenses:
clinical problem in ophthalmology. Dry eyes Although, complications related to TCL are
occurring as a result of secondary causes like similar to those seen with an extended wear
keratoconjunctivits siccca, Stevens-Johnson contact lens. Several complications related to
syndrome, ocular pemphigoid, etc. can be therapeutic contact lens wear are
prescribed lens specially silicon rubber lenses • Microbial keratitis is most serious compli-
which provide hydration to the cornea. cation.
• Ulcers induced by TCL wear. perception, these dark colored lenses are
• Giant papillary conjunctivitis (GPC). used to produce cosmetic relief.
• Neovascularisation. • Visual problems due to photophobia or
For prevention of complications prophy- diplopia need colored contact lenses as
lactic antibiotics with TCL can be beneficial treatment modality. Conditions like
in short term, although role of antibiotic is albinism, aniridia, fixed pupil causes
highly controversial. excessive light entry and macular
complications; here black colored contact
Colored Contact Lenses lenses with small clear central pupillary
Introduction area are needed. Similarly, amblyopia
and diplopia due to any reason need an
Colored contact lenses can be used for cosmetic, occluder contact lens having black
therapeutic, occupational or prosthetic pupillary area.
purposes. Although, by many practitioners,
• Heterochromia is a condition where
all colored contact lenses are considered as
color of iris is different in both eyes.
cosmetic contact lens but soft hydrogel contact
These patients need colored contact lenses
lenses are colored for various clinical
to match the color of both the eyes.
indications also. Generally, hard or rigid
• In young children, colored lenses can be
contact lenses are not colored because it is
used for the treatment of strabismus and
difficult to center them on the cornea and are
amblyopia as occlusion therapy. These
small in size, hence they do not serve the
lenses have black pupil and iris pattern
desired purpose. Several lens manufacturers
with a clear periphery, so that light does
have developed colored soft hydrogel contact
not pass through these lenses.
lenses for cosmetic or prosthetic purposes.
These lenses are also available in various • Specific type of custom colored tinted
refractive powers and thus can be used as an lenses are used as low visual aid where
alternative to the regular soft contact lenses. central pupillary area is tinted with a
specific material to reduce the glare,
Various desirable properties in an ideal
hence patients having poor vision due to
colored contact lens are
macular pathologies or retinopathies gets
• Clarity and purity
benefit by these lenses.
• Quality and safety • X chrome colored lenses are used in color
• Color stability deficiency patients which support in
• Reproducibility identification of colors. ChromaGen
• Variable lens designs tinted color lenses are used to assist in
• Biocompatibility color identification especially, in cases of
• Heat tolerance deuteranopes.
• Colored contact lenses with power can
Indications: Colored lenses can be used in be used in young persons with refractive
various ocular and non-ocular conditions errors, especially during festive seasons
Ocular conditions: As a prosthetic colored and social gatherings to enhance the
contact lenses either to treat or as an adjuvant looks.
treatment modality can be used in the Non-ocular conditions: Colored lenses are
following ocular conditions used by many persons to enhance the look or
• Corneal pathologies like disfigured for occupational requirements
cornea or scarred cornea, either due to • Sports persons use colored contact lenses
disease or trauma. In patients having to decrease the glare while driving or
leucocoria or white opacity with no light playing games.
• Similarly, cinema or television actors – Perform keratometry readings and

need to change the color of eyes obtain base curve by using a trial lens.
according to the demand of role they are – Measure HVID, if not possible of diseased
performing, hence several colored lens eye, then of normal eye.
designs are used for this purpose like – Get photographs of patient for color
having black pupil with white iris or matching of lens.
different shape large pupils with colored Types of colored CL: Various types of colored
iris patterns. lenses have been designed for cosmetic,
• Many persons use colored lenses to prosthetic, and occupational purposes. These
enhance their looks by wearing various lenses can be grouped on the basis of colored
iris patterned contact lenses. These lenses patterns as follows
have clear pupil with different iris • Black pupil with clear mid-periphery and
patterns and tints with a clear periphery. periphery (star burst, Fig. 14.2A): These
Sometimes power is also incorporated in lenses are mainly used to occlude the entry
these lenses if person has associated of light in cases such as amblyopia and
refractive error. diplopia. Sometimes, also used for cosmetic
• ChromaGen custom tinted contact lenses purposes in cases such as inoperable mature
are useful in patients having learning cataract, subluxated lens or in film industry.
disorders such as dyslexia. Generally, lenses are available with pupil
Fitting methods: Fitting guidelines for color size in the range of 2–5 mm and total
lenses are similar to those of a soft hydrogel diameter of 11–14 mm.
contact lens. • Black pupil with iris pattern and clear
• Initially a trial soft lens is tried to record periphery (iris pattern, Fig. 14.2B): These
the fitting parameters; once the lens fitting types of lens are also available in wide range
is checked as per guidelines, same type of of pupil size with various iris patterns to
soft lenses with same parameters, material meet the requirement of different condi-
and design are ordered to get tinted as per tions. Mainly, used for cosmetic purpose in
requirement of patient. disfigured ocular conditions.
• Commercially several lens manufactures • Clear pupil with iris pattern and clear
are providing these tinted colored lens in periphery (limbal rings, Fig. 14.2C): These
series of power and lens parameters in types of lens are available in power (ranging
terms of thickness, total diameter and color from +6 D to –10 D) as these lenses are
pattern. mainly used by patients (having refractive
• In majority of cases where colored lenses errors) during social gathering or special
are indicated as prosthetic lens to cover up occasions to change the colors of eyes.
the corneal deformities. The iris size, color Lenses are available, in various iris patterns
and pattern of normal eye should be taken and colors such as blue, hazel, brown,
as standard to decide the required lens for green, etc. according to different require-
deformed eye. ments. This type of lens can also be used as
• Ideal fitting of color lens is decided not only prosthetic lenses in conditions such as
by the type of fit, i.e. steep or flat, rather aniridia, heterochromia, albinism, polyo-
the color comparison between the two eyes coria, post-iridectomy, and fixed pupil.
is also important. These lenses have a clear pupil size in the
To summarize the fitting requirements of range of 2.5–4.5 mm with iris pattern
colored lenses are: diameter from 9 to 11.5 mm, having a total
– Measure the pupil size in normal illumi- diameter up to 15 mm with a clear peri-
nation pheral zone.
Protein and lipid deposition: Like all other

contact lenses there may be protein and lipids
depositions on colored lenses also, rather
chances are more of depositions because these
lenses are used as prosthetic lenses for longer
duration than routine lenses. Chemical treat-
ment can be done to deproteinize these lenses
as done for other soft contact lenses.
Similar to soft lenses there may be belching
of vessels or discomfort due to tight fit, hence
lenses should be changed with a proper fit
lenses.
In addition, because of color tinting, many
other complications can also occur with these
cosmetic lenses such as
Toxic effects: These lenses are colored by
using various types of dyes or chemicals to
Fig. 14.2: Various types of colored contact lenses. produce the tints and patterns, however, some
A. Star burst; B. Iris pattern; C. Limbal ring; D. Under of these may react with ocular or surrounding
print tissues to produce the toxic effect. There may
• Clear pupil with dark periphery (under be water soluble dye which is poorly hold by
print, Fig. 14.2D): These lenses are mainly polymers and thus slowly dissociates into the
used to cover up the white cornea or surrounding tissues.
disfigured cornea as in cases of leucomatous Discoloration of lens is another common
problem encountered. In most of these colored
corneal opacities or phthiscical conditions
lenses, water soluble dye is used which slowly
for cosmetic purposes.
dissociate with time and thus clear pupil and/
Complications of colored CL: Several compli- or periphery of lens becomes discolor with
cations related to colored contact lenses are time. Strict follow up and timely changing of
similar to those encountered with use soft lens is must to avoid these problems.
contact lenses like: Care of colored CL: Care and handling of
Corneal edema: May be due to decreased colored contact lenses are similar to those of a
oxygen permeability, which in turn is because soft contact lens. These lenses are quite stable
of excessive thickness of colored lenses as and heat tolerable, hence can be worn safely.
compared to the normal soft hydrogel lenses. Lens color withstands the chemical disinfec-
In colored lens, the color coating is done in tant and enzyme cleaning, hence can safely be
between the two layers of polymer to reduce cleaned like regular soft lenses. The tints of
the dissociation of dye in surrounding tissue, lenses are quite UV tolerant, so can be worn
hence the two layers of polymers lead to in hot climate without any additional problem.
increase in the thickness and decrease in the Regular follow up and timely cleaning of
oxygen permeability of colored lens. Although lenses is the key to a successful wearing of
in a large number of patients, the ocular colored contact lenses. Regular follow-up
condition is severely compromised, hence schedule is similar to those of a soft contact
corneal edema is not a major issue to handle, lens. In case any problem like red eye, pain,
however, in selected cases these colored lenses blurring of vision or intolerable foreign body
needs to be discontinued, if corneal edema sensation is felt, report immediately to an
occurs. ophthalmologist.
CONTACT LENSES IN SPECIAL CONDITIONS • Presence of a ring scotoma due to pris-

High Myopia matic effect
Contact lens prescribed in the patients of high • Pin cushion effect due to spherical aberra-
myopia (>–8 D) not only provide optical benefit tions
(retinal image is larger and normal than glasses) • Increased demand on convergence
but also helpful for cosmetic purposes. These problems are eliminated by use of
However, contact lens fitting in high myopes contact lenses, hence are very useful in
needs special attention due to two reasons pediatrics and adult patients. Aphakic contact
• Contact lenses usually ride high due to lenses are specially used in monocular aphakic
larger diameter and thick edges. patients with good results. Both RGP and soft
• Contact lenses base curve should be contact lenses are used in aphakics with
relatively flatter for proper fit. variable results. Majority of aphakic contact
As the degree of myopia increases, the edge lenses are made with a tint to prevent
thickness of contact lens will increase due to excessive light entry and thus reduce glare.
increase in the power of contact lens. As a Usually a grey color tint is given which act as
result, thick edges create a base-up wedge a density filter and protects from UV rays.
effect and lens is pulled up by upper eyelid
and lens tends to rise high. It can be reduced Soft Contact Lenses in Aphakia
by reducing the peripheral thickness and by For correction of aphakia by contact lens, both
using lenticular or aspherical lens design. daily wear and extended wear type soft
These lens design will decrease the irritation contact lenses can be used. The aphakic contact
of lids and will prevent tugging of upper lenses are rarely used in adult because of
eyelid on lens. To minimize the flatness a availability of newer intraocular lens implant
smaller diameter lens can be used with better techniques, however, in pediatric and elderly
fitting, so that flatter edges will not create any patients these contact lenses are still used with
problem. Hence, RGP lenses and lenticular variable results.
design lenses are preferred choice of contact • In young children, an extended wear lens
lenses in case of high myopes. is better choice than daily wear lens,
Aphakia because it is difficult to teach them the
insertion and removal techniques of lens.
Aphakia means absence of crystalline lens,
either due to surgical removal or any • In infants, the contact lenses should be
congenital condition. In surgical extraction prescribed immediately after cataract
placing an intra-ocular lens at the time of extraction because of potential risk of
surgery is an ideal option, however, sometimes developing amblyopia, however, in adults
in very young children or with some associated it is advised to wait for at least two months
conditions surgical implantation of intra- after surgery, so that corneal topography
ocular lens is not possible. To have a clear and keratometry gets stabilized.
vision these patients are dependent either on • There is an increased risk of neovasculari-
spectacles or contact lenses. sation and infection with use of extended
Contact lenses gives far better quality vision wear contact lenses, hence daily wear
as compared to spectacle in case of aphakia lenses should be preferred wherever
because spectacles in an aphakic patient can possible.
produce the following problems • Soft aphakic contact lenses are relatively
• Magnification of retinal image by 20–25% thick and pose discomfort, hence lathe cut
• Reduced field of view and poor eccentric lenticular design lenses are used to increase
acuity the comfort and wearing time.
• For fitting these lenses in pediatric patients • Base curve: Fit steeper than usual to prevent
select the appropriate power, usually the loss of contact lens.
+1–1.5 D more than refraction value in • Material: Usually material having high or
children more than 2 years and +2 D more hyper Dk is used for long-term results.
in children younger than 2 years age. RGP lenses prescribed for aphakia usually
• Try for a steeper fit with good tear exchange ride low because RGP lenses have more central
as compared to flatter fit to minimize the thickness (due to increase plus power) which
lens loss. creates a base down edge effect and the lens
is forced down below by upper lids because
RGP Contact Lenses in Aphakia
of more weight and central thickness. To
Rigid gas permeable contact lenses has eliminate this problem a small lens with
following advantages over soft contact lenses steeper fit is preferred. The single cut lens
in aphakic patients design RGP lenses have a diameter of 7.5–8.5
• Oxygen transmissibility is high mm. However, in spite of small size the
• Optically better as compared to hydrogel centration of these lenses are poor; hence
and/or silicon lenses lenticular design lenses having an anterior
• Flexibility in design central optical zone with a minus power
• Economical carrier (peripheral zone) can be prescribed
• Easy to handle: Can be insert and remove which has better centration.
easily Although RGP lenses have several advan-
• High safety profile: Chances of bacterial tages, but a few disadvantages of these lenses
infection and protein adherence are less are
• More adaptation time
RGP lenses of excellent optical property are
• Poor comfort of wearing
used in aphakia because in aphakic person
• Needs higher skill to fit
strong plus power lenses are required and an
• High chances of lens loss or dislocation
unwanted cylindrical error may present with
• Increased possibility of self trauma
these high spherical powers which is not
corrected by soft contact lenses. Mainly Presbyopia
following lens designs are suitable for aphakic
Contact lenses for presbyopia correction may
patients such as
be considered an effective alternative to
• Single cut lens design
spectacles because they offer faster visual
• Lenticular design adaptation and more freedom of movement
Fitting of RGP in children as well as increase in the quality of vision than
• Total diameter: It is usually kept 1–2 mm ophthalmic lenses. Before prescribing contact
smaller than the corneal diameter but lens it is essential to know the lifestyle,
relatively larger than adult TD to prevent working distances, etc. of patient so that
loss of lens. proper lens design can be selected for every
• Power: Based on the trial lens and over patient depending on the information. For
refraction, also correct for vertex distance. correction of presbyopia, multifocal contact
For example, suppose spectacle power is lenses which contain distance and near vision
+20 D, then give +26.3 D contact lens. in the same lens are used. There are several
Similarly, if spectacle power is –15 D then contact lens options which can be given to
give –12.75 D contact lens. In high power presbyopes including full monovision,
more than 10 D we also need to correct for modified monovision and bifocal or multifocal
tear layer, usually in the range of 2–3 D contact lenses of gas permeable or hydrogel
lacrimal lens. or silicon-hydrogel materials.
One piece back surface hard bifocal contact

lenses are most commonly used to correct
presbyopia. In these bifocal lenses the power
of addition is equal to the difference between
the back surface interface powers in two
portions of contact lens as shown in Fig. 14.3.
Broadly, three classes of lens design can be
used to fit in presbyopes such as
• Non-rotational design lenses
• Rotational design lenses
• Simultaneous vision design lenses
Non-rotational lens designs: Non-rotational
contact lenses are similar to multifocal
spectacle lenses, consist of a distance optic
segment in the upper portion and a near optic
segment in lower portion and are developed
to move vertically on the eye. In addition,
trifocal non-rotational lens design in which Fig 14.4 A to E: Various non-rotational multifocal
half of the add power is incorporated in the contact lens design. A. Straight top non-truncated;
intermediate zone have been also designed B. Straight top truncated; C. Crescent non-truncated;
which moves vertically on the eye. These D. Crescent truncated; E. Trifocal
lenses are manufactured using RGP material
and are in the solid form (Fig. 14.4).
Basically, these non-rotational lenses are
designed in such a manner that movement of
eye is independent from the lens, i.e.
depending on the direction of fixation of eyes
(straight or downward gaze) of person either
a distance or near zone of lens are positioned
in front of the pupil.
As it can be seen in Fig. 14.5A, the distance
portion of the lens lies in front of the pupil
with the primary or straight ahead gaze of the
eyes, whereas near portion comes in front of
Fig. 14.5: Position of non-rotational design contact

lens in various gaze. A. Straight gaze; B. Downward
gaze
the pupil with the downward gaze of the eyes
(Fig. 14.5B). As the gaze is shifted in
Fig. 14.3: One piece back surface bifocal contact downward direction, the lower eyelid pushes
lens. the contact lens upwards. Due to this effect
the lower portion of contact lens (having near zones, hence rotation of the lens over the eye
addition) gets aligns with the pupil. Non- has no effect. Like non-rotational lenses,
rotational contact lens design are similar to mostly these are also RGP lenses, where the
spectacles, i.e. allow an independent move- concentric optical zones may be spherical or
ment with simultaneous alignment with lower aspheric as shown in Fig. 14.6.
eyelids. Base-down prism is usually added in In these lens designs, when the individual’s
the lower portion of the lens so that thickness gaze is focused straight ahead then he/she will
of lower portion of lens is increased as well as observe the distance objects through the center
center of gravity of the lens is lowered. As a of the lens, whereas when his/her gaze shifts
result, lens remains in a lower position on the for reading (downward gaze) then the near
eye and lens rotation also not occurs. vision will be observed through a surrounding
Sometimes, base-down prism alone is annulus as shown in Fig. 14.7A and B respectively.
insufficient to control the lens rotation and its Unlike non-rotational lens, with rotational
position, hence truncating a lens design along lenses there is no need of incorporation of
with lower edge of prism base, enhances the
effect of base-down prism by increasing the
area of contact between contact lens edge and
lower eyelid so that lower lid can push the
lens up during downward gaze.
For example, routine non-rotational contact
lens parameters are lens diameter (8.7–10.5 mm),
BOZR (6.0–9.4 mm), distance power (±20 D),
add power(+0.75 D to +4.5 D), stabilization
prism (1 to 3), stabilization height (1 mm
above to 2 mm below the geometric center)
and truncation (0.4–0.6 mm).
Non-rotational lens designs are more Fig 14.6: Rotational bifocal contact lens design
preferred in presbyopes who are having
• Lower eyelid is just at or above the lower
limbus with moderate to tight lower
eyelid tensions.
• Flat corneal topography.
• Pupil of small size with normal illumina-
tion.
• Persons who need larger optical zones
or back toric or bitoric lenses.
• Persons having residual astigmatism,
with front toric designs.
• If add requirement is higher (>+3.00 D)
means in case of advanced presbyope or
who do frequent close work.
Rotational lens designs: Rotational lenses for
presbyopes are designed in such a manner that
distance or near segments of the contact lens
remain in correct position even when the lens Fig 14.7: Position of rotational design contact lens
rotates. These lenses have concentric optical in various gaze. A. Straight gaze; B. Downward gaze
prism or truncation to stabilize the lens rather Centration based designs: While prescribing
these lenses can rotate due to blinking, but still simultaneous lens designs it is important to
gives continuous optic power for distance as maintain lens centration with minimal lens
well as for near vision. movement because decentration of lens may
Concentric optical zones in a rotational lens result in visual symptoms. Simultaneously,
may have too tight fit has to be avoided to maintain the
• Spherical design in front or back surface proper corneal metabolism. Centration based
• Aspherical design in back surface, or on design is mainly used for soft lenses. The lens
both surfaces designs may be
• Center-near (CN) designs: In center-near
Spherical design: Normally in spherical
design, most of the plus power exists at
design on the front surface of lens, a central
the lens center while most negative
distance zone is present which is surrounded
power at the periphery as shown in
by a transition zone followed by a spherical
Fig. 14.8A. It means the central portion
near zone. The back surface of lens has a
of lens design focuses near objects while
normal tricurve lens design or an aspheric
peripheral portion focuses distance
design.
objects. The center-near based bifocal
Aspherical design: In aspheric design lens
and aspheric lens designs have been
the curvature of back surface changes
developed mainly to deal with problem
progressively so that the add power remains
of contraction of pupil occurring while
limited. If additional add power is required,
working at near.
then it can be obtained by changing the front
• Center-distance designs: In this lens design
surface of these lenses.
the central part is for the correction of
Note: Smaller the distance zone, higher the add distance vision while the peripheral part
power; and steeper the lens must be fit. is for near vision correction as shown in
Fig. 14.8B. This lens designs are mainly
Rotational lens designs are preferred in suggested for initial stage of presbyopia,
those who are requiring add up to +1.25 D.
• Low adds presbyopes Monovision: Monovision contact lenses
• High myopes means where in one eye (usually dominant
• High hypermetropes eye) the full correction is given for distance
• Having steeper corneal geometries vision, whereas the fellow eye ( usually non-
(especially aspherical rotational designs dominant eye) is corrected for near vision,
are used)
Simultaneous vision design lenses: These are
the lens designs where both the distance and
near light rays enter the pupil simultaneously,
i.e. both distance and near vision are presented
to the eyes at the same instant. The distance
or near image is then selected by the brain of
the observer depending on his or her visual
requirements which further depends on the
ability of the brain to distinguish between the
blur and clear image. Contact lenses designed
on this basis may be either center based
(center-distance or center-near) monovision or Fig. 14.8: Rotational center based aspherical contact
modified monovision designs lens design. A. Center near; B. Center distance
using RGP or soft hydrogel contact lenses of Diagnostic criteria to judge regarding
bifocal or multifocal lens designs. Thus, in whether to prescribe monovision, modified
monovision the distance and near images are monovision or multifocal lenses can be done
presented simultaneously to the brain or by performing this simple test. First do an
visual system. After a period of adaptation, assessment to know which eye is dominant
the brain becomes versed to suppress the eye, now try to give over plus lenses in non-
blurred image and thus the object of interest dominant eye which are just enough for good
whether distance or near can be seen clearly. near vision. Suppose patient develops no
However, some patients complain of visual symptoms and is comfortable in near vision,
problems and are intolerant to monovision. In then he/she is a good candidate for prescri-
these cases, multifocal contact lenses or partial bing monovision. On contrary, if the patient
monovision can be tried. Monovision contact feels dizziness or an imbalance with signifi-
lenses are effective way to correct presbyopia cant difference in clarity of vision between two
with low reading addition. As the presbyopia eyes, then avoid monovision and prefer
increases, the adaption to monovision becomes binocular bifocals or multifocal lenses.
difficult for patients. There may be loss of
stereopsis as well as patient experience more Contact Lens Fitting in Presbyopes
difficulty to carry out distance and near tasks. Fitting of rotational lens designs
Furthermore, patients having amblyopia • Examination of the patient to find out the
should not be prescribed monovision contact lens related parameters
lenses, prescribe multifocal contact lenses in – Lens diameter: Size of palpebral aperture
such patients. (PA) and/or HVID can be used to
Modified monovision: Modified monovision calculate the diameter of lens. It is
technique can be used in advanced case of recommended that a lens with slightly
presbyopia where monovision may pose larger diameter should be used to avoid
problem to patient. In this method, the center discomfort to patient except if PA is
distance lens design is used for dominant eye extremely narrow in the size. The
while center near design is used for contra- estimation of lens diameter on the basis
lateral eye. Modified monovision provides the of PA and HVID can be understood by
advantages of monovision while along with Table 14.7.
keeping some multifocal function. However, – Back optical zone radius (base curve):
in modified monovision usually bifocals or Corneal topography/keratometry readings
multifocal contact lenses are used to correct are used, to select the suitable BOZR of
both distance and near vision. the lens as per the manufacturer’s
For example, modified monovision combi- instructions. Rotational lens with front
nation can be as done as shown in Table 14.6. surface spherical design usually has a
tricurve shaped back surface and BOZR
Table 14.6: Various modified monovision combi- is fit to achieve an alignment fitting
nations
Dominant eye Non-dominant eye Table 14.7: Estimation of lens diameter according
Rotational multifocal Simultaneous multifocal to palpebral aperture (PA) and horizontal visible
(center distance) (center near) iris diameter (HVID) in rotational lens design
Rotational multifocal Near single vision lens Lens diameter (mm) PA (mm) HVID (mm)
(center distance) 9.0–9.3 <8 10–11
Distance single vision Simultaneous multifocal 9.4–9.6 8–11 11.5–12.5
lens (center near) 9.7–10.0 >11 >12.5
relationship. However, rotational lens Table 14.8: Estimation of lens diameter according
with back surface aspheric design, to palpebral aperture (PA) and horizontal visible
BOZR is kept steeper than flat K (about iris diameter (HVID) in non-rotational lens design
0.15–0.80 mm) depending upon the total Lens diameter (mm) PA (mm) HVID (mm)
add power required (e.g. for high add
9.0–9.3 <8 10–11
reading it is more steeper).
9.4–9.6 8–11 11.5–12.5
– Calculation of distance power: Distance
9.7–10.0 >11 >12.5
power is calculated according to change
in BOZR, e.g. for every 0.05 mm change with slightly larger diameter should be
of BOZR, 0.25 D is added. used to avoid discomfort to patient except
– Calculation of near power: Calculate as if PA is extremely narrow in the size.
per requirement of patient. – Proper BOZR should be selected for fit
• Select the diagnostic contact lens according alignment. The BOZR should be modi-
to BOZR, calculated power, near/reading fied according to corneal astigmatism, as
add and total diameter. Insert this contact the corneal astigmatism increased, select
lens and allow it to settle for 15–30 minutes. steeper BOZR. If cornea is spherical, then
• Evaluation of lens fit: Assess position of BOZR can be taken equal to flattest
contact lens and assess near vision in keratometry reading.
following terms – Measurement of segment height: Deter-
– Lens centration and diameter: Ensure the mine the distance between lower edge of
centration of lens. lens (or lower eyelid) and lower margin
– Lens movement with blink: 1–2 mm of of pupil. Otherwise, segment height is
lens movement is perfect. kept 1 mm lower than the geometric
– Fluorescein pattern: In spherical rotatio- center of contact lens.
nal lens, the fluorescein pattern should • Stabilization using prism: In the absence of
appear centrally with optimal edge truncation, start stabilization with prism of
clearance (0.5 mm). For aspheric rotatio- 1  in case of minus prescription lens and
nal lens, slightly high riding, with some start with a prism of 1.5  in case of plus
central pooling and a wide band of prescription.
peripheral edge clearance should be seen. • Prism axis: Initially start with prism axis at
• Accuracy of lens prescription is checked by 90°. Suppose there is a nasal rotation of
doing a binocular over refraction for 5–10°, then balance the prism axis, clockwise
distance and then for near, with the patient for right eye and counter-clockwise for left
holding reading material under normal eye, means to 95° or 100°, respectively.
illumination. Suppose the position of inferior prism
marking is rotated towards examiner’s left,
Fitting of non-rotational lens designs: Fitting
then add same degree of rotation to prism
of non-rotational lenses is considered more
axis. On the other hand, if rotated to right
difficult than rotational lenses as more
then subtract the same degree of rotation
parameters are taken into consideration for
from the prism axis (LARS principle means
optimal visual performance.
left add, right subtract).
First lens related parameters are calculated • Assess distance power: Using diagnostic
• Assessment of lens parameters lens, perform binocular over refraction to
– Diameter of lens: Palpebral aperture (PA) calculate distance power.
size and/or HVID are used to calculate • Assess near power: Keeping distance over
the lens diameter as summarized in refraction in position, add an additional
Table 14.8. Like rotational lenses, lens power for reading. Make sure that patient’s
head is tilted slightly downward, with eyes • Lens movement with blink: About 1 mm
set at a down gaze which ensure upward of lens movement is required.
translation of contact lens. • Fluorescein pattern: Should show
• Truncation: If upward translation of contact centered lens with an adequate edge
lens does not happen, then truncation is clearance.
necessary to avoid lower eyelid from sliding Follow-up: On follow-up visits, if required
over the inferior part of lens. alteration in parameters can be done if
• After evaluating lens parameters order of essential for comfortable visual performance
lens can be done and then check the lens fit like
and assessment of ordered lens • If too much lens movement is there, then
– Lens centration and diameter: Lens should TD can be increased or BOZR steepening is
be well centered or slightly low done.
– Lens movement with blink: 1–2 mm of lens • Ensure that a balance exist between distance
movement is ideal and near vision requirements because on
– Lens translation on down gaze: 2 mm of lens adding more minus power to improve the
translation is ideal; which enables the distance vision will affect the near vision
near segment of lens to translate over the on contrary, adding of more plus to improve
pupil. the near vision will affect distance vision.
– Lens rotation: Usually 5–10° generally
nasally, for both distance and near gaze High Astigmatism
– Near segment position: Near segment top Correction of astigmatism by contact lens,
should be present, at or just above lower especially of high degree, needs proper
pupillary margin. selection of contact lens design which may
– Fluorescein pattern: An aligned fluores- vary with each case.
cein pattern should be seen; which Elements responsible for production of
indicates perfect lens centration, lens astigmatism are
translation and movement of lens. • Cornea (mainly)
– Distance/near vision: Should be optimal at • Crystalline lens
working distances. • Retina (rare)
Fitting of center near designs: In these designs, Cornea is considered major refracting
centration and minimal lens movement is surface of the human eye. Even a minor
necessity to attain a good lens fit; because change in the curvature or radius of the
objective is to offer both distance and near corneal surface can induce change in the
vision, simultaneously. The lens fitting steps refractive power of the eye. Different types of
are similar to other lenses, i.e. evaluate the lens astigmatisms usually appear due to toricity of
parameters and select the lens according to the anterior corneal surface. Astigmatisms can
parameters. To get an ideal fit the lens also be induced by the crystalline lens
diameter can be increased and steepening of (lenticular astigmatism) and retina and is
optical zone can be done, i.e. either steepen termed internal astigmatism, however, still
BOZR or increase BOZD and reducing the clinically most significant astigmatism is
axial edge lift. contributed by corneal surface.
Ideal lens fit of center near lens is checked The sum of corneal and lenticular
by astigmatism is termed total refractive
• Lens centration and diameter: Lens astigmatism. Hence, for correction of
should be well centered with good astigmatism by contact lenses, both types of
corneal coverage. ocular astigmatisms should be taken into
consideration. As we know that most of the

astigmatism is contributed due to cornea
but if there is large difference between
corneal and total refractive astigmatism, it
indicates presence of significant amount of
lenticular astigmatism in that individual. For
example, if in a case having higher refractive
astigmatism as compared to corneal astigma-
tism and when a spherical rigid gas permeable
(RGP) contact lens is prescribed to this case,
then a significant amount of residual
astigmatism (lenticular astigmatism) will
remain uncorrected which will affect visual
acuity. These types of cases require fitting of
a RGP contact lens having toric design or Fig. 14.9: Corneal topography showing regular
alternately a toric soft contact lens can also be astigmatism
used.
Types of astigmatism: Depending on the angle
between two principal meridians astigmatisms
are classified clinically in two different types.
The corneal surface can be assessed by perfor-
ming keratometry and corneal topography.
Keratometer is commonly used for measure-
ments of corneal curvature. Corneal topography
is an advance method for corneal assessment
which does complete corneal examination.
Corneal topography is a useful method to
assess and classify corneal astigmatisms.
Broadly, astigmatism can be divided as
• Regular
• Irregular Fig. 14.10: Corneal topography showing irregular
Regular astigmatism: Astigmatism is said astigmatism
to be regular when corneal meridians represen-
ting maximum and minimum refractive irregular astigmatism. Irregular astigmatism
powers are perpendicular to each other. is more commonly seen with keratoconus, after
Further regular astigmatisms can grouped as surgical procedures or in scarred cornea. In
with the rule, against the rule or oblique irregular astigmatism, corneal topography
astigmatism. In regular astigmatism, corneal will show that two principal meridians which
topography appears like a tie, having two are not perpendicular to each other as shown
perpendicular main meridians as shown in in Fig. 14.10.
Fig. 14.9. Contact lens for astigmatism: Various types
Irregular astigmatism: When the principal of contact lens designs can be used to correct
meridians do not lie perpendicular to each astigmatism, however, to avoid rotation of
other and the meridians representing lens during blinking, different systems in the
maximum and minimum refractive powers form of prism ballast, truncation, or thin zones
are not separated by an angle of 90°, it is called are provided.
Correction of Regular Astigmatism then soft toric or spherical RGP contact

General rule for selection of a contact lens is lens should be used. Generally, improve-
that lens choice mainly depends on the amount ment in the visual acuity is observed
of refractive astigmatism as summarized in better with use of spherical RGP lenses
Table 14.9 and shown in Fig. 14.11. as compared to soft contact lenses in
astigmatism. For example, a patient
Soft contact lens correction
having refractive error as –6 DS × –1.25
• Spherical soft contact lenses: Spherical DC, can be corrected with an equivalent
soft contact lens is the first choice to correct soft spherical contact lens, and patient
astigmatism in cases having astigmatic remains comfortable with fair amount of
error up to 1 D and less than 1/3 of the visual acuity. Whereas, a patient having
spherical error. If visual acuity remains refractive error as –2.5 DS × –1.25 DC will
poor with spherical soft contact lenses, be uncomfortable with an equivalent
Table 14.9: Choice of type of contact lens on the spherical soft contact lenses.
basis of degree of astigmatism • Toric soft contact lenses: Patients having
astigmatic error more than 1.25 DC need
Degree of astigmatism Lens of choice
toric soft lenses. In these cases, soft spherical
< 1.00 D Soft or RGP spherical lenses are unable to rectify the error and
lens
RGP lenses may be intolerable, hence soft
1.00 to 4.00 D Soft toric lens or RGP toric contact lenses having different radii
spherical lens are used. These lenses are fitted as per the
> 4.00 D RGP toric lens or custom guidelines provided by the lens manufac-
soft toric lens turer; however, fitter should make sure that
Fig. 14.11: Selection cascade for contact lenses in regular astigmatism

the patients refractive error should correctly Contact lens fitting methods are
match with contact lens parameters. • Empirical fitting method requires spectacle
Soft toric lenses are available as power and K readings adjusted by using
• Standard lenses: Consist of low cylinder type of guaranteed fitting program provi-
amount and are available easily on order. ded by manufacturer, however, eyelid force
• Custom lenses: These lenses have high and interaction between the eyelid and
cylinder amount or nonstandard diameters contact lens is not accounted.
and usually require long time duration to • Diagnostic fitting method requires spectacle
receive from the laboratory. power corrected for vertex distance in both
the meridians (for example, – 4 DS × –2.5
Soft toric contact lens design DC × 180 will become –3.5 DS × –2 DC ×
• Back surface toric (most common, good for 180, at corneal plane where vertex distance
toric cornea) is 10 mm) along with K reading.
• Front surface toric (better for spherical cornea)
Assessment of lens fitting: The overall lens
Stabilization: The soft toric lenses need to
fit as well as rotation of the lens should be
be stabilized, so that rotation of lens does not
assessed in terms of coverage, centration,
occur during blinking. Stabilization can be
movement and rotation. An ideal lens fit is
done by various methods
considered where contact lens remains in a
• By using prism ballast, i.e. in the inferior
stable position and does not rotate markedly
portion of lens additional material is
after blink (Fig. 14.13A). Improper lens fit is
added, generally 0.75 – 2  of ballast
considered when contact lens rotates to an off
added.
axis position which needs compensation at the
• Prism ballast with truncation (usually used time of ordering the lens. If on examination,
in custom designs). lens rotation is found, then it should be
• Truncation, i.e. bottom of the lens is measured in terms of its direction (whether
removed. rotated clockwise or counterclockwise from 6
• By making thin zones (top and bottom of o’clock position) and magnitude (means its
lens are thinned). degree of displacement from expected position).
Systems generally used to stabilize soft toric In this case, during ordering of lens, LARS
lenses are, either thin zones or prism ballast; method should be used to compensate the
these designs can correct astigmatism up to misrotation of lens.
8 D as shown in Fig. 14.12. • Similarly, if trial lens base rotates to left
of observer in 10° (Fig. 14.13B), then add
10° to spectacle power prescription.
• Suppose if trial lens base rotates to right
of observer in 10° (Fig. 14.13C), then
Subtract 10° from spectacle power
prescription.
For example, suppose a trial lens axis is at
180° and it shows
• No rotation, then order a final lens with
axis 180°
• 10° right rotation, then order a final lens
Fig. 14.12: Soft toric contact lens design. A. Thin with axis 170°.
zone toric stabilization system; B. Prismatic • 10° left rotation, then order a final lens
stabilization system with axis 10°.
Fig. 14.13: Assessment of soft toric contact lens fit. A. No rotation, B. Left rotation, C. Right rotation
Stability of contact lens rotation is determi- • Toric RGP contact lenses: To correct mode-
ned by rate to high degree astigmatism mainly toric
• Ask the patient to move eye in different RGP lenses are used. These lenses are
directions of gaze and record the time of available in various designs to fit in
return of lens to its resting position. different types of refractive errors.
• Observe the effect of fast blinks and RGP toric contact lens designs are available as
complete blinks on rotation of lens. • Front surface toric RGP lenses
• Move the contact lens by hand off axis • Back surface toric RGP lenses
and record time of return of lens to • Toric RGP lenses with peripheral curves
resting position. • Bitoric RGP lenses
• Assess the effect of convergence on
rotation of lens. Note: Generally in RGP toric lenses stabilization
is done by creating back toric surfaces, although
Rigid gas permeable (RGP) contact lens RGP front toric lenses needs an additional
RGP contact lenses offer useful choices to correct stabilization system.
regular astigmatism with high quality of
visual acuity. Various RGP lens design can be Front surface toric RGP lenses: Front surface
used depending upon patient's astigmatism. toric RGP lenses are used to correct high
Generally, in cases having low degree of degree residual astigmatism or lenticular
astigmatism, spherical RGP contact lenses are astigmatism in patients having spherical
recommended, however, with high degree of cornea. Stabilization in these types of lenses
astigmatism, a toric RGP lens is recommended is done by an additional system such as prism
to correct astigmatism. Toric RGP contact blast or truncation method. In blast method
lenses can also be required for correction of usually a base down 2 D prism is added on
astigmatism in cases of lenticular astigmatism. the front surface during manufacturing of
contact lens, however, sometimes more
• Spherical RGP contact lens: Primarily used
dioptre prisms may be required to center a
to correct low degree astigmatism, means
very high degree minus power contact lens.
up to 4 D. These lenses are not useful in
correction of moderate to high degree In truncation method contact lens diameter
astigmatic refractive errors. Patients having is reduced in one meridian, usually by cutting
corneal astigmatism to the tune of 4 D can (nearly 0.5–1 mm) an entire edge of contact
be corrected by spherical RGP contact lenses, lens.
although these lenses are made with diameter Back surface toric RGP lenses: Usually stabili-
0.2–0.3 mm smaller than usual diameter. zation of toric RGP lenses is done by creating
back surface as toric. These lenses are usually and pellucid marginal degeneration.
used to correct low degree astigmatism. Keratoconus is characterized by thinning of
Usually Keratometry reading are used for a cornea and ectasias resulting in varying
proper lens fit of posterior curves of contact degrees of irregular astigmatism.
lens, accurately with corneal curvature. Spectacles can be used for management of
Toric RGP lenses with peripheral curves: initial stages of keratoconus, while surgical
Similar to back surface toric lenses, these procedure (most commonly penetrating
lenses are also used to correct low degree keratoplasty) is done only when other
(2–3 D) astigmatism. In these cases of available treatment have failed or there is
astigmatism a spherical RGP lens will fit significant reduction in visual acuity. Majority
improperly, because edge of lens will lift over of keratoconus cases can be managed by
steepest meridian of cornea; which may cause prescribing contact lenses.
decentration and loss of contact lens. Hence, Classification of degree and type of
to correct this problem additional steeper keratoconus is important in making the
peripheral curves are made in steepest corneal decision about type of contact lens fitting
meridians, whereas standard lens curves are method. Position and size of cone in the eye
fitted along the flatter corneal meridian. affect the selection of contact lens fitting
method, hence it is advised to do computerized
Bitoric RGP contact lens: Bitoric RGP contact corneal topography to identify the type of
lens is used in patients who are presented with cone. Basically there may be three types of
moderate degree astigmatism along with a cones as follows
residual astigmatism. Usually, a RGP contact
1. Nipple cones: Mostly these cones are
lens is fitted with a posterior curve, same as
located below the visual axis (sometimes
that of keratometry reading however, when
central), small in size with variable conicity.
this toric back surface RGP lens is placed on
the cornea the interface between contact lens 2. Oval cones: These cones are also located
and tear film forms a toric surface. This newly below the visual axis having larger
formed toric surface causes a state of an induced inferior conical area.
astigmatism and to correct this condition, an 3. Globus cones: These cones are rarely
additional anterior surface toricity is created seen, where about 75% of cornea gets
which forms a bitoric RGP contact lens. affected and clinically Munson’s sign is
present in majority of cases.
Correction of irregular astigmatism: Correction
of an irregular astigmatism using RGP contact Ideal fit in keratoconus: Keratoconic patients
lenses provides a considerable enhancement or other primary corneal ectasias patients require
of visual acuity than spectacle correction. high levels of comfort, because they need to wear
Hence, RGP contact lenses became the first contact lenses for longer duration, hence
choice of management, in some corneal appropriate lens materials should be chosen.
pathology having an irregular cornea such as Cases where steep high minus lenses are
keratoconus, post-keratoplasty, complicated required, lens material having high dimensional
refractive surgery, corneal trauma and post- stability should be prescribed so that chances of
herpetic keratitis. the contact lens distortion are less.
Contact lens of different Dk/t (moderate to
Contact Lens Fitting in Primary Corneal high values for large or flatter lenses, low
Ectasias value for stability and wetting purpose) can
Keratoconus is one of the most common types be used.
of primary corneal ectasias seen in clinical Rigid contact lens fitting: Rigid gas
practice. Others less common are keratoglobus permeable (RGP) contact lenses for correction
of keratoconus are the most common and most correct and improve visual acuity in patients
successful method which provides a new having keratoconus and other corneal ectasias.
anterior surface to cornea. Several contact lens These lens designs are broadly grouped as
designs are available and can be fitted • Multicurve design contact lenses
accordingly at different stages of keratoconus • Aspheric/elliptical design contact lenses
and cone types. Various fitting methods of • Large diameter contact lenses
RGP lenses are summarized as • Combination or Piggy back lenses
Apical clearance method: In this method the
Multicurve lenses Standard form of multi-
contact lens rest on the paracentral cornea and
curve lens designs may be used in persons
vaults the cone. Central cornea is not covered,
having early keratoconus, however, for
hence chances of trauma and scarring of
advanced stage of disease more specific lens
central cornea is reduced. These types of lens
designs are available to use like Woodward
are of small diameter, having less back optic
multicurve lens design. Most important
zone diameter which may result in significant
advantage with these lenses is that practitioner
flare and glare problems. In addition, there
knows all the parameters of this type of lens
may be corneal edema, decreased tear
design which are already provided by
exchange, air bubbles under contact lens (may
manufacturer, hence any modifications in lens
creep into central optic zone, causing poor
can easily be ordered by practitioner. The
visual acuity).
multicurve lenses are designed on the basis of
Apical touch flat fitting method: In this
the fact that in early or moderate keratoconus
method nearly entire weight of contact lens
the periphery of cornea is not much changed,
lies on the cone, with wide edge standoff. The
thus multicurve lenses have normal curves in
lens remains in position due to top lid. Due to
the periphery, but steeper base optical zone
apical touch better visual acuity is obtained
radius (BOZR).
and improvement in visual acuity is noticed
immediately probably because of corneal Central keratometry decides the selection
molding by RGP contact lens. These contact of cone radius and for each cone radius a
lenses can cause to development or progression number of peripheries with different diameters
of apical changes and/or abrasions and scarring are available. For example
of cornea. It is more successful in early • Shepherd NLK (Northern Lenses) also
keratoconus cases, but still can be used in certain called acuity lenses
cases where corneal apices are displaced. • Profile lenses (Jack Allen)
Three-point touch method: It is most • Rose K system
commonly used fitted design for keratoconus Among these lenses the most widely used
especially for multicurve contact lens designs. is Rose K system, which is mainly useful in
The main principle used is to distribute the cases having central cone, however, in cases
weight of contact lens uniformally between having inferiorly displaced cones, Rose K is
the cone and peripheral cornea. Hence, a three- not very useful.
point touch fitted lens will show an apical • Rose K system: On the basis of statistical
contact area of about 2–3 mm and an annulus data collected from keratoconus patient
rim of mid peripheral contact zone. The area by Dr Paul Rose of New Zealand, these
and shape of the contact zones may vary due contact lens designs were developed
to cone asymmetry, e.g. mid-peripheral contact having complex computer generated
zone may assume more crescent shape, if cone peripheral curves. The important
is vertically asymmetrical. characteristic of these lenses are
Contact lens designs for primary corneal 1. To obtain an ideal edge lift of 0.8 mm,
ectasias: Various lens designs are used to these contact lenses include triple
peripheral curve system, i.e. standard, four peripheral curves are 3, 6, 8 and
flat and steep. 10 D more flatter than the base curve of
2. Rose K design lenses are existing in the lens. This lens system contains three
wide range of base curve (4.75–8 mm) diagnostic lens sets, i.e. nipple, oval or
and diameters (7.9–10.2 mm). As the globus types of cones. Fitting principle
steeping of base curve increases, the is to achieve a three-point touch which
optic zone diameter of lens decrea- in turn is dependent on the size of optic
ses. zone in relation to cone size. The optic
3. Toric curves are available on all zone sizes differ from 6 mm for the
surfaces of lens, i.e. front, back and nipple cone to 6.5 mm for the oval cone,
periphery. Traditionally, Rose K and 7 mm for the globus.
lenses are made from Boston ES • Dyna Intra Limbal (DIL): These large
material, however, Boston XO diameter lenses are specifically designed
material was also used by some for cases having inferiorly displaced
laboratories to increase oxygen keratoconus, pellucid marginal degene-
permeability property. ration and post-keratoplasty where
stability of lens is difficult to attain by
Aspheric/elliptic lenses are the one in using smaller diameter lenses. These
which lens flatten in curvature progressively lenses are mainly used to provide
from the center to the periphery. Many stability. These lenses are available in
aspheric lenses designs like Quasar K No 7 various diameters ranging from 10.8 mm
lens, Jack Allen KD lens, and Persecon to 12.5 mm, diameter range. Ideally, the
Elliptical K lens are available for early total diameter of lens is kept 0.2 mm
keratoconus cases. These lenses have large smaller than that of corneal diameter
optic zones thus very useful in patients having because it allows a lens movement of
large pupils and/or oval type cones. Aspheric approximately 0.5–1 mm. Epithelial/
lenses are available in wide variety of stromal scarring may occur with lens due
materials, and can be made in specific material to ‘settle back’ tendency of these lens.
on order. Usually materials having high DK/t are
Large diameter lenses: These contact lenses recommended for manufacturing of
are large in diameter (up to 14.5 mm) having these lenses.
bicurve or multicurve and are available in a • S-Lim lenses (Jack Allen): These semi-
number of lens designs such as scleral contact lenses mainly remain on
• Soper cone design: These contact lenses are the limbus with very little movement.
of bicurve design having two posterior These lenses are mainly designed to vault
curves, one curve is fitted on the central the corneal grafts by changing the sag
cone and the second curve is fitted on the depth according to requirement. For
normal peripheral cornea (like a hat on exchange of tears, 2–4 fenestrations are
the head). Lens has small diameter and present in the lens.
fixed back optic zone. As the base curve • Kerasoft lenses (Ultra vision): Normally
is decreased for a given diameter, the soft lenses, e.g. hydrogels or silicon
vaulting effect of lens get increase. hydrogels are not preferred for correc-
• McGuire lenses: It is a modification of tion of irregular cornea as these lenses
Soper cone lens design and consists of have propensity to drape on the surface
four peripheral curves (primary, secon- of cornea, hence soft lens, e.g. Kerasoft
dary, tertiary and quaternary) instead of have been specially manufactured for
two which are blended together. These treatment of keratoconus which does not
drape over the cornea. Kerasoft lenses manufacture especially in cases of early
(58% water content terpolymer) has a keratoconus and irregular astigmatism. As
back surface cylindrical design and are compared to conventional soft lens, silicon
available as lens series called A, B and C hydrogels have more oxygen transmissibility
with total lens diameters of 14 mm, and rigidity. However, in severe cases of
14.5 mm and 15 mm respectively. Among keratoconus particularly in inferiorly
these lenses series B lenses are most displaced cones, a piggyback combination is
commonly used and has flatter fit as not so successful because silicon hydrogels
compared to series A lens. Kerasoft tend to pucker and do not fit well. Fitting of
lenses are mainly used for early RGP lens should be done first and an apical
keratoconus and for those patients who touch of slight larger area is tolerable.
have difficulty in wearing RGP lens. Problems arising due to lens fitting in kerato-
These lenses offer more comfort and conus
prolonged wearing time in patients who • Peripheral staining: Staining in the form of
cannot tolerate RGP corneal lenses. three and nine o’clock may occur. It usually
• Hybrid soft perm lenses: These lenses are develops due to dryness in the areas
manufactured by using RGP material for surrounding the contact lens. It can be
the center portion of lens and soft 25% managed by using lenses of large diameter,
water content HEMA in the periphery. decrease lens edge lift, performing blinking
The total diameter of lens is about exercises and instillation of ocular
14.3 mm with 8.0 mm of central portion. lubricants.
These lens provide good centration, • Vortex staining: This type of staining is
better visual acuity and less discomfort more common with flat fitting contact
as compared to RGP lens, hence are lenses which may damage corneal epithe-
preferred in RGP intolerant patients. lium. Recommended measures are steepe-
However, these lenses have very less ning of contact lens (causes reduction in
oxygen transmissibility (Dk/t), chances pressure over the cone), and increasing
of giant papillary conjunctivitis and Dk/t of lens material.
corneal neovascularisation are more. • Dimpling: Air bubbles trapped under
Research and advancement in lens contact lens which acts like smooth foreign
manufacturing are coming up with bodies causes dimpling. Usually this
newer versions which give higher happens when normal GP lens designs are
oxygen permeability (Dk 100–105) and used in early keratoconic cases or when an
40–45% water content HEMA skirt. excessive apical clearance is present. In case
Combination or Piggy back lenses As we of dimpling, reduction of BOZD and
know that soft contact lenses are recommen- addition of peripheral curve by using a
ded in cases where patient is sensitive to RGP different multicurve design will help to
lenses or excessive lid sensation to RGP lenses correct the situation.
are present. However, good visual acuity is • Stromal scarring: It is usual in advanced
difficult to attain with use of only soft contact stages of keratoconus which can affect
lenses. Hence, a concept of combination or visual acuity. In cases of significantly
piggy back lenses means fitting a RGP lens decreased visual acuity, graft surgery is
over a soft lens (silicon hydrogels) gained indicated.
popularity so that same level of visual acuity • Thinning: Corneal thinning may occur
can be obtained as with a single lens. which can be managed in a similar manner
Generally, silicon hydrogel with the steepest to stromal scarring. In cases of severe
base curve is preferred for piggy banking lens thinning graft surgery is required.
• Giant papillary conjunctivitis: As kerato- • Cases having large oval or globus cone and
conus is generally associated with atopic inferiorly decentered apex: hybrid design
disease, hence GPC is commonly seen in lenses, intra-limbal, scleral, or piggyback
patient with keratoconus. If develops can lenses are successful.
be managed by preservative free eye drops, • However, most of the lens designs used for
mast cell stabilizers (e.g. sodium cromo- keratoconus needs minimal apical clearance
glycate) in the initial stages, however, in or mild touch; because excessive apical
severe conditions steroids are used to bearing can cause corneal staining and
control the situation. probable corneal scarring while excessive
• Neovascularisation: Most commonly apical clearance can cause peripheral seal
associated with use of Softperms and PMMA off.
scleral contact lenses. It is recommended • Sometimes, when patient is prescribed RGP
that development of neovascularisation lens and there is poor centration, discomfort
should not be allowed in any case because to patient or scarring then piggyback
this will seriously affect the success rate of combination can be tried. For example, soft
corneal graft surgery to be done in the silicon hydrogel contact lens of very low
future. power (0.5 D) is placed under RGP lens,
• Nebulae: Nebulae means a small raised area however, in combination the GP material
of scarring developed in the superficial of hyper Dk (>100) should be used.
corneal stroma due to wearing of flat fitting Sometimes, soft contact lens of moderate
contact lens leading to discomfort and plus power (+6 D) having thicker center can
decreased wearing time. It can be debrided also be used with RGP lens if positioning
by mechanical means (using a scalpel blade) of RGP lens over soft contact lens is low due
or by an excimer laser (phototherapeutic to presence of low corneal apex.
keratectomy).
Orthokeratology
Contact lens fitting in keratoconus
Before fit assessment Orthokeratology or ortho-K is reversible, non-
invasive method used as an alternative to
• Fleischer’s ring and Vogt’s striae are
refractive surgery for correction of visual
hallmark signs of keratoconus.
acuity in low to moderate degree of myopic
• In cases of keratoconus, on doing corneal cases. This approach was known since many
topography the steepest area of cornea years, however, its clinical applications have
usually measures more than 48 D. increased in recent years because of
Furthermore, if eccentricity value  0.8, availability of lens materials having high
then it is more likely to be because of oxygen transmissibility and availability of
keratoconus. better contact lens manufacturing techno-
• In absence of corneal topography facility, logy.
patients having moderate to advance Principle of orthokeratology is that
keratoconus can be assessed by clinical reshaping (change in curvature) of corneal
examination. When a +1.25 D trial lens is surface occurs due to constant wearing of a
placed over patient’s side of keratometer, specially designed RGP contact lens, for longer
then the range of value extends about 8 D period of time. These types of lenses are worn
in case of keratoconus. overnight or on alternate nights, then removed
Contact lens fitting in the morning and not worn during the day.
• In centrally located cone having relatively By orthokeratology there is flattening of the
small apex, usually small diameter RGP cornea so that overall refractive power of the
lenses are used. eye is reduced, however, effects on the shape
of cornea are temporary and cornea regains • Before evaluating lens fit it is advised to
its original shape on discontinuation of lens. wait for 10–15 minutes. Ideally, during
Sometimes, due to compromised corneal evaluation there must be good centration
epithelium, serious complications can occur. of contact lens with a minimum  1 mm lag
Orthokeratology does not affect shape of during blinking.
posterior cornea or depth of the anterior • Again patient must be examined in the
chamber. Reverse geometry design lens have morning as follows
been designed to improve centration and – Check the fitting relationship of lens and
refractive effect which consist of central optic cornea; remove contact lens for assessment
zone more flat relative to cornea while of corneal integrity.
surrounded peripheral zones are more steeper
– If on examination, a consolidated staining
with reverse curves.
of cornea is observed, then it indicates
Assessment before lens fit that contact lens is too flat in central
• Ideal candidates for this technique are portion.
– Myopic having refractive error less than – Do corneal topography which should
5 D. show bull’s eye pattern (central flattening
– Cylindrical error of  1.50 D, in case of with paracentral steepening) in ideal fit.
with the rule astigmatism or  0.50 D in If there is flattening in superior part with
case of against the rule astigmatism. an steepening of inferior arc (smiley face
– Pupillary diameter less than 6 mm. pattern) then it indicates that lens is too
• Important screening tests to be done are flat in fit. If, there is presence of slight
refraction, slit lamp examination and central steepening (central island
corneal topography. Topography provides pattern) then it indicates that lens is too
values of corneal eccentricity and also helps steep. Cases where no obvious topography
to rule out those patients which are having patterns noticed during examination,
irregular cornea. then patients are advised to wear contact
lenses for another 2–3 days, then again
Lens fitting Process
re-evaluate the fitting.
• Base curve radius of RGP lens is determined
by using “Jessen formula”, which uses FAP • On an average, the favorable results are
(flat add plus) tear lens factor. This results obtained in about 10 days of lens wear
in a final contact lens power of +0.75 D, although, duration may vary with degree
which permits regression of corneal surface of myopia, i.e. less for lower myopic and
during daytime. For example, suppose more for moderate to severe myopic
patient has a refractive error of –3 DS × patients.
–0.75 DC × 180 with keratometry values • During treatment period, daily disposable
44.00 D at 180°/horizontal meridian and lenses of progressively decreasing power
44.75 D at 90°/vertical meridian. Base curve should be prescribed to patient and then re-
of contact lens should be, equal to flatter evaluate after one week time.
by 3.75 D (3.00 D + 0.75 D) than K (44 D), • Once treatment period is over, these contact
which becomes 40.25 D (44 D–3.75 D). lenses are worn on a retainer basis; which
• Selection of initial diagnostic lens is based is every night for severe myopic patients
on achievement of bull’s eye fluorescein and once a week for low myopic patients.
pattern (means there is central and mid- These patients can self-monitor their
peripheral bearing with narrow tear retainer wear time, whenever patients
circulation zone and slight peripheral edge notice blurring of vision for distance they
lift). can wear contact lenses overnight.
Precautions during lens wear silicon hydrogel materials proteins

• To obtain optimal lens centration and to deposition is least as compared to other
decrease corneal staining it is recommended materials. The deposition starts as soon as
to use highly viscous artificial tear drops lens is placed in the eye and increases with
before insertion of contact lens. time of wear. Deposition of proteins on
• Lens should not be removed immediately surface of lens appears as thin hazy layer,
after awakening. Rewetting drops should and it is mostly due to deposition of
be applied before removal of contact lens. denatured lysozyme, sometimes due to
• To break the suction (if present), lower albumin and gamma globulin. Lipids
eyelid margin can be used to gently push deposition on surface appears as oily
the lower lens edge. appearance on the lens surface. Sometimes
excessive deposition of lipids and mucin as
jelly bumps may elicit immunological
CONTACT LENS RELATED COMPLICATIONS
reaction in conjunctiva. In daily wear lenses
Contact lenses can cause a wide range of the quantity of deposition on lens also
changes in eye and complications related to depends on factors like water content,
contact lens include inflammatory, mechanical, chemical and ionic characteristics of
or metabolic changes. Although risk of hydrogel lens materials. Generally lenses
complications is low, but poor hygiene and with low water content show less
improper handling of contact lenses can cause deposition than high water content lens.
several complications. Majority of lens related Similarly, deposition of proteins is more
problems are insignificant and without any with ionic lenses as compared to non-ionic
consequences, however, sometimes serious lenses. In addition, the environmental
ocular and vision threatening complications can contaminations and pollutants such as oils,
occur. Recent advancements in contact lens dirt, lotions, make-up, powders, smoke,
materials and multipurpose cleaning solutions aerosols like perfumes and hair sprays can
have reduced several risks related to extended also deposit and contaminate the lens.
wear but some problems still exist today. There may be deposition of bacteria, such
as Pseudomonas aeruginosa and Staphylo-
Risk Factors Related to Complications with coccus epidermidis, along with several fungi
Contact Lens Wear and protozoa on lens surface. Bacterial
Factors related to contact lens itself infection lead to formation of a bio film on
• Materials used for contact lens: Generally lens surface and can penetrate into lens
complications are more frequent in soft material, especially in high water content
contact lens wearer as compared to RGP lens, leading to increase risk of
contact lens users. However, hydrogel and development of bacterial keratitis.
silicon hydrogel lenses are commonly used • Deformation and damage of contact lens:
as daily wearer or monthly/three monthly Contact lens warpage may occur due to
disposable lens. As compared to other soft change in various parameters of lens which
lenses silicon lenses have less chance to can be confirmed by using a spherometer.
develop limbal injections, protein deposi- Change in parameters of lens is indicated
tion, corneal neovascularisation and less by bad lens fit and increased or decreased
damage to epithelium and its functions. lens movement on the cornea, which further
• Various deposition and risk of contamina- lead to injury of corneal epithelium and
tion: A large number of proteins and lipids other complications.
present in the tear film can deposit on the • Cleaning and care solutions for contact lens:
surface of contact lenses, although on Complication may occur due to improper
cleaning of lens. Multi-purpose solutions reduced because due to smoking lipid layer
used to clean contact lenses, must have of precorneal tear film is damaged.
cleaning agents, disinfectants, preserva- • Wearing schedule of contact lens: Generally,
tives and polymers or softeners to make contact lens wearing is associated with
contact lenses wearing more comfortable. some physiological changes like thinning
Regular and proper cleaning of contact of epithelium and decrease rate of
lens is must, however, improper handling epithelium cell exchange in the eye which
of lens or solution can lead to contamina- is further increased with use of continuous
tion of solution itself; which gives wear or extended wear contact lenses.
continuous problems because patients do Silicon hydrogel lens which have high
not change the multipurpose solution oxygen transmissibility may also produce
regularly. these changes but in lesser frequency.
Factors related with contact lens wearer Furthermore, wearing of contact lens
during night is also associated with
• Ocular pathology: Many eye related
increased risk of complications and it is
conditions such as vernal conjunctivitis
assumed that silicon hydrogel lens can be
seasonal and constant allergic conjuncti-
prescribed for night wear if required,
vitis, atypical keratoconjunctivitis, dry eye
because of their high oxygen transmissi-
syndrome or keratoconjunctivitis sicca,
bility.
systemic diseases like thyroid diseases and
dermatological conditions related to • Frequency of replacement of contact lens:
meibomian glands dysfunction act as With continuous wearing there is ageing of
limiting factors for contact lens wearing polymers material of lens and chances of
because the risk of complication due to deposits over lens increased which are not
contact lens wearing is increased in removed completely with regular cleaning
compromised ocular state. and disinfection of lens. Nowadays,
although lens with better materials are
• Blinking pattern: Chances of dryness of lens available which show less deposit forma-
and deposition on lens are increased with tion but it is advised to prefer disposable
less frequent blinking or incomplete or daily wear contact lenses causing less
blinking. There is diminution of tear complications.
exchange between contact lens and cornea • Contact lenses wearing without professional
which may cause retinal hypoxia. To advice: Many wearers buy contact lenses
prevent these complications it is essential without a prescription through internet and
to achieve full blinking by blinking use them irregularly with improper
exercises. handling. Due to poor compliance and
• Intake of medicines: Medicines like diuretics, without professional control a large number
anticholinergics, antihistamines, and of complications related to contact lens
antipsychotic may increase dryness of eye wear may arise.
surface by decreasing production of tears. • Maintenance of lens in hygiene conditions:
Constant use of steroids and other immuno- Appropriate hygiene is very necessary for
suppressant drugs is associated with proper maintenance of contact lenses, lens
alteration in body defense mechanism cases, and cleaning solution bottles so that
leading to increases risk of infections in chances of contamination decreased.
contact lens. Occasionally, contact lens wearers do not
• Smoking: Due to smoking there is change follow hygiene during insertion and
in the stability of tear film as well as removal of contact lens and predisposed to
sensitivity of conjunctiva and cornea is infections.
Complications and Diseases Related with deposits, accumulation of tears behind

Contact Lens Wear contact lens, corneal hypoxia or hyper-
Contact lens related complications are capnia, epithelial erosions specifically at 3
declining gradually because of better lens and 9 o’clock positions, reduction in tear
material, wetting solution, awareness among break up time. Blinking training or exercise
wearer, and better sterility maintenance. In will help to improve blinking and thus
spite of these factors some amount of insult reduction in signs and symptoms.
to ocular tissue is caused by regular wearing • Ptosis: It is commonly seen in RGP lens
of contact lenses. wearers, there may be reduction of
Problems occurring due to contact lens palpebral aperture due to edema of ocular
wear in relation to various ocular structures tissue. Edema may occur due to injury
are summarized in Table 14.10. obtained during frequent insertion and
removal of contact lenses. Other factors
Problems related to eyelids which may predispose it are forced pressing
• Unusual blinking pattern: Blinking of eyelids, extension of lateral eyelid,
abnormality may already be present in papillary conjunctivitis (GPC) and
contact lens wearer however, it may blepharospasm. To treat these conditions
precipitate due to lens wearing. Blinking RGP lenses should not be wear for up to
abnormalities may be in the form of forced three months, treat GPC with proper anti-
blink, partial blink, inadequate number of allergic and lubricants, use soft contact
blinks, and dry eye. These abnormalities lenses and in very severe cases eyelid
may lead to drying of ocular surface, lens surgery shall be performed.
Table 14.10: Contact lens wear complications related to various ocular structures
Eyelid Tear film Conjunctiva limbus Cornea
Epithelium Corneal stroma Endothelium
Unusual Dry eye Conjunc- Limbal Epithelial Edema of CLPU (CL Endothelial
blinking tival redness erosions corneal peripheral bubbles
pattern congestion stroma ulcer)
Ptosis Mucin Papillary Vasculari- Corneal Thinning CLARE (CL Polymega-
balls conjunc- zed limbal microcysts of corneal induced thism/
tivitis keratitis stroma acute red Pleomor-
eye) phism
Meibomian Superior- Epithelial Corneal Infiltrative
glands limbal edema neovascu- keratitis
dysfunc- keratocon- larization
tion junctivitis
External Vacuoles Deep Acantha-
hordeolum stromal moeba
neovascu- keratitis
larization
Internal Corneal
hordeolum stromal
pannus
Squamous
blepharitis
• Dysfunction of Meibomian glands: It is eyelash and toxic punctal epitheliopathy.

due to mechanical blockage of Meibomian Patient will present with diffuse redness,
glands ducts leading to collection of scales at roots of eyelash, sticky eyelashes,
yellowish creamy secretions and drying of along with feeling of warmth, intense
eye. Contact lens does not receive sufficient itching, and photophobia with foreign body
hydration, hence causing dry eye and sensation leading to an intolerance of
intolerance to contact lens. This condition contact lenses. Treatment includes antibio-
can be treated by applying warm compre- tics, corticosteroids (as ointment), artificial
ssions over eyelids, using lubricants eye tears, and improvement of eyelid hygiene.
drops, improvement of eyelid hygiene. In Contact lenses should not be worn during
severe cases antibiotics therapy and eyelid this acute phase, usually variable in
scrubbing can be done. duration, because of periods of remission
• External hordeolum: Commonly known as and recurrence of this condition.
stye. It is characterized by an inflammation Problems related to tear film
of eyelash root tissue or sometimes • Dry eye: Dry eye in contact lens wearer may
associated with inflammation of gland of occur due to increased evaporation of tear
Zeis or Moll. It is an acute infection caused film. In contact lens wearer the tear film
by Staphylococcus common in those having remains compromised and there is limited
associated staphylococcal squamous mobility as well as exchange of lipid
blepharitis. It manifests as infectious deposits on the surface of lens. As a result
swelling of external lid edge and cause disintegration of lipids occurs at rapid rate
discomfort and pain. Treatment includes leading to decrease in lubrication of lens.
removal of eyelash related to that gland Other mechanisms proposed for dryness
along with hot compressions which are decrease production of tears due to
facilitates the spontaneous drainage of increase in osmolality, ocular surface
abscesses outside. Topical and systemic inflammation and lack of biocompatibility
antibiotics are also prescribed for 5–7 days of the lens surface. Treatment measures
period along with other symptomatic include change of contact lens thickness,
drugs. Use of contact lens should be material and design, along with solution
avoided during acute phase, usually about used for caring of lenses. Artificial tear
7–10 days. drops, control of tear evaporation, reduction
• Internal hordeolum: An acute staphylococcal of tear drainage and reduction in time of
infection of meibomian gland is called contact lens wear are other measures to be
internal hordeolum and it is also frequently done to control the dry eye situations.
associated with staphylococcal squamous • Mucins balls: With contact lens wearing,
blepharitis. Patient presents with lid the production of mucus may alter, leading
swelling with eyelid edge inversion and to change in characteristics of tear film and
discomfort, pain and intolerance to contact lens surface. There may be accumulation of
lenses. General treatment includes appli- balls of mucin under the lens surface which
cation of hot compressions and antibiotics appears as tiny grey points on slit lamp
for 5–7 days, along with other symptomatic examination. Normal corneal defense
drugs. Contact lens wearing is not mechanism of cornea and visual acuity may
recommended during this acute phase, compromise due to mucin balls. Usually
usually about seven days. more common with use of silicon hydrogel
• Squamous blepharitis: Infection by contact lenses. This condition can be
Staphylococcus may cause conjunctivitis, corrected by fitting of a flatter contact lens,
staphylococcal infection of follicles of contact lens must be replaced frequently
along with change in lens material. for weeks, months, or even years, hence
Artificial tear drops along with mast cell contact lenses can be worn with control of
stabilizers should be added. A drastic acute phase with all the precautions
improvement in condition will occur soon mentioned above.
after contact lens is taken out of eye. Problems related to limbus
Problems related to conjunctiva • Limbal redness: It is similar to conjunctival
• Conjunctival congestion: Due to presence congestion and may be partial or complete.
of contact lens, toxicity of contact lens There is vasodilatation, contributed by
solution or change in pH may lead to hypoxia, hypercapnia, mechanical irritation,
irritation, immunologic reaction, hypoxia, immunological reaction, infection, inflamma-
hypercapnia and relaxation of smooth tion (acute red eye). Management includes
muscles, causing vasodilatation of con- removal of cause and fitting of a silicon
junctival vessels. This condition is usually hydrogel contact lens.
asymptomatic, however, sometimes • Vascularized limbal keratitis: It is a
itching, slight irritation along with feeling complication usually seen in rigid contact
of hot or cold sensation may be seen. If lens wearer involving cornea, limbus and
severe redness occurs, then contact lenses conjunctiva. On examination, an elevated
should not be used until complete healing vascularised epithelial lesion is seen at
occurs. limbus along with conjunctival oedema and
• Contact lens associated papillary conjunc- corneal vascularization. Corneal infiltrates
tivitis (CLAPC): Due to immunological are present near the limbus, with positive
mechanism, deposits present on contact fluorescein staining around limbus.
lens (especially proteins) act as allergen and Common presentation is discomfort,
causes thickening of conjunctiva. Patients lacrimation and photophobia. Management
having allergic conditions like asthma, hay includes shortening of contact lens wear
fever or general allergies are more prone time and changes in lens design, i.e reduce
for development of papillary conjunctivitis. the overall diameter, increase edge lift and/
Common symptoms are itching which is or more flat base curve. Antibiotic, ocular
more intense at time of removal of lens lubricating and steroid eye drops are given
because of more degranulation of mast cells for 5–7 days and RGP lenses should be
due to handling on eyelids, more mucus removed during this phase; however, soft
discharge (especially in the morning), contact lenses can be fitted later on.
discomfort to contact lens and intense Prognosis is usually good and condition
photophobia and slight blurring of vision. heals within 1–2 weeks time.
On examination, giant papillae on upper • Superior or upper limbal keratoconjunc-
tarsal conjunctiva (like cobble stone) along tivitis: It is another contact lens related
with conjunctival oedema and hyperaemia inflammatory condition, mainly occur due
are seen. Management includes removal of to hypersensitivity to preservatives of
contact lens (until inflammation is over), contact lens solution, especially thiomersol.
reduction in time of lens wear, change of Patients generally complain of foreign body
lens material, reduction in time of lens sensation with redness, itching and
change, change of lens care solution and photophobia. In case of extensive pannus
improvement of eye hygiene. Mast cell there may be an associated diminution of
stabilizers like sodium cromoglycate and visual acuity. On examination limbus,
steroid eye drops are used to treat these bulbar and tarsal conjunctiva, and cornea
papillae for nearly a period of 4–6 weeks. involvement seen in the form of redness on
However, these giant papillae may remain superior limbus with infiltrates, micro-pannus,
and micro-erosions of cornea and/or 1. Erosions at three and nine o’clock position:
conjunctiva are seen. Irregular superior Usually more common in persons using
cornea and epithelial and subepithelial RGP type contact lens and appears
infiltration of superior cornea along with mainly due to interruption of tear flow
hypertrophy of superior bulbar conjunctiva leading to local dehydration and death
also found. Management includes immediate of epithelial cells. Lesions are mainly
removal of lens and application of lubrica- present laterally and inferiorly on the
ting eye drops along with non-steroidal cornea, the sites where upper and lower
anti-inflammatory drugs until inflammation lids are in contact during blinking. Thus,
disappears. Usually redness disappears insufficient or incomplete blinking and
early but epithelium takes time to heal, elevations of lids (due to thick edge of
hence treatment is continued for 3 weeks lens) so that a gap is created adjacent to
to a few months. Later on patient can be lens edge leading to drying of tissue. To
prescribed lens with different design or prevent this it is advised to patient to
polymer which cause less mechanical perform blinking exercises with tears
irritation of limbus. Patients should also be supplements. Fitting of contact lens
instructed about change of lens care having small diameter or reduced
solution, reduction in time of lens wear and thickness can be considered.
use of preservative free contact lens. 2. Superior epithelial arcuate lesion (SEAL):
Problems related to cornea More commonly seen in silicon hydrogel
lens users, wearing lens of improper
Contact lens can affect epithelium, stroma and
design and elasticity. The upper lid
endothelium of cornea leading to various
creates an inward pressure on the contact
complications.
lens and results in excessive mechanical
Effect on epithelium of cornea: Wearing of friction pressure on the epithelium and
contact lens may cause erosion and edema of ultimately its disruption. The lesions
epithelium and formation of microcysts on involve the full thickness of epithelium
epithelium of cornea. and seen in that area which is covered
• Corneal epithelial erosions: The surface by upper eyelid, i.e. within 2 to 3 mm of
defect of corneal epithelium or breakdown superior limbus and parallel to it.
of epithelium in contact lens wearers may Patient usually remains asymptomatic,
present as small lesions or large lesions with however, sometimes may complaint of
different shapes and locations. The lesions slight discomfort in wearing contact
can be identified through fluorescein test lenses for longer duration. To manage
as staining areas because fluorescein dye this contact lens of either less elastic
will enter in the inter-cellular space where material or a hard RGP lens, should be
epithelium is eroded. Healthy epithelium chosen.
remains unstained with fluorescein. Small 3. Inferior epithelial arcuate lesions: The arc-
lesions affecting superficial layer of shaped lesion (smile stain) is present
epithelium generally do not pose any parallel to the inferior limbus, usually
problem to patient and can be treated by associated with soft contact lens with less
prescribing lubricating eye drops. Symptoms mobility. It also results from insufficient
in the form of foreign body sensations, severe blinking causing drying out of contact
pain and rarely photophobia arise when lens and consequent necrosis of
there is involvement of large area and epithe- epithelium. Management includes
lium is affected up to deeper extent. Erosions changing the contact lens with more
may be seen at different areas of cornea thickness with better movability on
corneal surface. Material of soft contact decrease tonicity of precorneal tear fluid.
lens is changed or select a hard RGP Due to this hypotoncity of precorneal tear
lens. film, water get enter in the epithelial cells
4. Central corneal epithelium erosions: More of cornea. Commonly this condition is
common in extended hydrogel lens asymptomatic, however, halo effects can be
wearer. There is complete loss of seen in a few cases. Management includes
epithelium from large area of cornea, changing the adaptation regime for hard
seen as circular staining with fluorescein. contact lens.
Exposure of epithelium to hypoxia for • Vacuoles: Like microcysts these are also
prolonged time results in loss of its small (5–30 micrometer diameter) circular
function and ultimately epithelium get scattered points filled with clear fluid.
completely detached when lens is These vacuoles differ from microcysts in a
removed. It is advised to remove the lens manner that their shadow is formed
for recovery of epithelium which may opposite to the direction of light as
take 7–10 days. Contact lens having high compared to formation of shadow in the
oxygen transmissibility should be same direction of light in case of microcysts.
prescribed later on. Vacuoles are formed due to hypoxia and
Sometimes, any foreign body entrapped are usually asymptomatic. Usually no
beneath hard contact lens can also treatment is required for vacuoles because
damage the corneal epithelial surface, they disappear soon after removal of
seen as irregular lines with fluorescein contact lenses.
stain. Management includes removal and Effect on stroma of cornea: Change in thickness
thorough rinsing of contact lens in multi- and transparency of corneal stroma may occur
purpose solution and then reinsertion. due to chronic hypoxia induced by contact
• Corneal microcysts or microbullae: Micro- lens wearing. Various changes observed in
cysts are small (15–50 micrometer diameter) stroma of cornea due to contact lens wear can
circular or oval-shaped points scattered on be grouped as
the cornea. Usually common with extended • Edema of corneal stroma: Accumulation of
hydrogel contact lens wearers. The fluid into corneal stroma leads to increase
microcysts formation occurs due to chronic in the thickness and distortion of the cornea.
hypoxia, trauma or mechanical irritation The main factor responsible for stromal
caused by lens, poor movement of lens and edema is chronic hypoxia. Due to hypoxic
accumulation of debris in intercellular stress (anaerobic respiration in stroma)
spaces. Microcysts in small number are well there is increased production of lactates in
tolerated and do not need treatment. If the stroma causing elevation of osmotic
present in large numbers and causing pressure within the stroma and ultimately
discomfort and decreased vision, then use tissue swelling or edema. Other factors like
silicon hydrogel or hard RGP contact lenses hypotonic characteristic of tears, hyper-
instead of extended hydrogels. After capnia and low temperatures also
discontinuation of contact lens, the number contribute in edema. Percentage increase in
of microcysts are increased in the first few the thickness of cornea is correlated with
days due to increased metabolic activity, amount of edema. Up to 2% increase in the
however, then they start to decrease and thickness of cornea is not associated with
completely disappear within two months. significant damage and hence no treatment
• Epithelial edema: During adaptive phase is needed. Thickening of cornea up to 8%
of lens wear especially of hard contact lens due to edema is dangerous and on
there is reflex tearing which results in examination striae and folds are seen in
posterior stroma. To manage this condition, layers of stroma, but it is slow in onset.
contact lenses with materials having higher Corneal hypoxia induced by lens especially
oxygen transmissibility, thinner design and by low oxygen permeable lens and thick
better movement on the cornea should be lens results in softening of stroma due to
fitted. In severe edema it is recommended edema. Furthermore, neovascularisation
to remove contact lenses for longer duration can also be precipitated by infection and
( 3–4 months). toxic reactions due to lens solutions. In mild
• Thinning of corneal stroma: Edema of case progression of neovascularisation can
corneal stroma for prolonged period results be stopped by improving the handling of
in decrease of stromal mass which contact lenses, using lens of high dK/L
ultimately become visible as stromal value, reduction in schedule of daily lens
thinning (measured by Pachymetry after wear and careful monitoring of condition.
disappearance of the edema). It is important In severe cases, wearing of lens should be
to treat the cause of stromal edema for completely stopped.
prevention of stromal thinning. This tissue • Corneal vascular pannus: Corneal pannus
loss is irreversible and corneal thickness means growth of fibrovascular limbal tissue
remains permanently the same which and fine blood vessels on the surface of
cannot be recovered to original state before cornea. Hypoxia induced by lens wearing
onset of stromal edema. Management (causing stromal edema) and damage of
includes removal of contact lens perma- epithelium of cornea due to infection are
nently, if not possible, then use contact important precipitating factors for formation
lenses having high oxygen transmissibility. of pannus. Generally, it does not cause
• Corneal surface neovascularization: Surface difficulty to patient, but in extreme cases it
neovascularization may occur due to can cause reduction of visual acuity. In mild
chronic hypoxia or release of inflammatory cases, replace lens material with better
mediators from damaged epithelium. Due oxygen transmissibility, reduce schedule
to hypoxia, accumulation of lactates time of daily lens wearing and careful
promotes softening of stroma which further monitoring of pannus progression. In cases
induces in growth of new vessels. Release of severe pannus, contact lens wearing
of inflammatory mediators also promotes should be permanently stopped and
migration of inflammatory cells which pannus is treated surgically.
stimulate growth of vessels in stroma of • Contact lens peripheral ulcer (CLPU): It is
cornea by releasing vaso-proliferative rare with daily wear, more commonly seen
agents. Usually, in mild to moderate cases with extended contact lens wear. A small
the person remain asymptomatic. In severe (0.5–1.0 mm), distinctive circular ulcer or
case if central cornea is involved, then loss infiltrate with clear defined margin appears
of vision may occur. In severe corneal at periphery of the cornea. It is noninfec-
neovascularisation, the use of contact lenses tious and usually develops due to action of
should be stopped permanently. However, toxins on hypoxic cornea released from
in mild to moderate cases contact lens can gram-positive bacteria. There is redness of
be used with proper care and maintenance, eyes, pain, foreign body sensation and mild
contact lens with higher oxygen transmissi- photophobia. Management includes removal
bility, i.e. more gas permeable lens should of contact lens, start appropriate antibiotics,
be used and daily wearing time of lens analgesics and steroids in topical and
should be reduced. systemic form as per severity of condition.
• Deep stromal neovascularisation: Deep • Contact lens induced acute red eye (CLARE)
neovascularisation can develop in deeper or tight lens syndrome: It is an acute
inflammatory reaction affecting cornea and in contact lens wearer usually persons
conjunctiva, presents in early morning having poor immunologic response are
when patient use an extended wear contact more affected. Infection can occur with any
lens for overnight and eyes remain closed type of lens but more common with soft
for long period. There is hyperaemia of type of lens. Early signs of acanthamoeba
conjunctiva and periphery of cornea. It keratitis appear as dendriform keratitis, sub-
occurs due to release of endotoxins from epithelial infiltrates and diffuse coarse
gram-negative bacteria contaminating punctate epithelial keratopathy. Later on,
beneath lens or in lens care solution. it can invade the stroma also. Treatment
Symptoms are characterized by severe pain, includes removal of contact lenses and
excessive lacrimation, severe photophobia application of topical neomycin and
and severe conjunctival injection. On propamidine isethionate with or without
examination, punctal and diffuse infiltrates oral ketoconazole. After recovery the RGP
are seen in corneal periphery along with lenses with high Dk/t can be fitted with the
signs of inflammation. Management instructions regarding the wearing and
includes immediate removal of contact handling of contact lenses.
lenses, antibiotic treatment and anti-
inflammatory drugs. Once the red eye is Effect on endothelium of cornea: The endothe-
completely settled, contact lenses with high lium of cornea has important role in preven-
Dk/t for daily wear use can be fitted. ting the excessive swelling of stroma. The
various changes may occur in endothelium by
• Infectious keratitis (IK): A unilateral
all types of contact lens but these are more
inflammatory reaction in anterior corneal
common with the use of low gas permeable
stroma is seen where numerous small
lens.
infiltrates of irregular shape are present in
peripheral area along with bulbar redness. • Endothelial bubbles (blebs) response: The
It occurs due to infection of corneal bleb response (focal, circumscribed defects
epithelium and stroma by microbes mainly in endothelium) occurs due to edema of
pseudomonas, leading to inflammatory endothelium which is precipitated by acidic
reaction and necrosis of tissue. There is loss pH change caused by corneal hypoxia. It
of corneal epithelium with stromal infiltration may appear within a few minutes after
and corneal ulcer. Patient presents with insertion of contact lens and is subsides
extreme red eye with surrounding swollen rapidly after removal of lens (i.e. reversible).
and inflammed ocular tissue, severe pain, Endothelial blebs usually do not require
irritation, excessive lacrimation, photophobia, any treatment but development of blebs
purulent discharge diminished visual indicates presence of hypoxia in the eye due
acuity. The incidence of infectious keratitis to lens wearing. Occasionally, blebs are in
is more with extended hydrogel lens than large numbers, then a contact lens with
daily wear RGP lens. Other predisposing higher Dk/t should be prescribed.
factors are warm climate, poor hygiene, • Endothelial cells polymegathism and
non-compliance with contact lens wear and pleomorphism: Endothelial polymegathism
care instructions, swimming with contact (i.e. significant variation in the size of
lenses, hypoxia, mechanical trauma, dry endothelial cells) and pleomorphism (i.e.
eye, smoking, diabetes. Treatment includes variation in shape of endothelial cells) may
immediate removal of contact lens, proper occur due to use of lens of poor oxygen
antibiotics and anti-inflammatory drugs. transmissibility (PMMA wearers or
• Acanthamoeba keratitis: Infection by extended wear lens) for a long period.
protozoa acanthamoeba is not so common Chronic hypoxic stress and hypercapnia
due to contact lens wearing lead to Elements of maintenance and care: The
weakening of junctions between endothelial maintenance and care system of contact lenses
cells followed by change in their shape and consists of following elements to deliver an
size. The cornea in presence of polymega- effective result
thism swells at faster rate than normal • Personal care
cornea. Wearers will complaint of discom- • Contact lens solutions
fort and intolerance with lens. Management • Disinfecting agents
includes fitting of contact lenses with high • Preservative agents
oxygen transmissibility and reduction in • Protein removal process
duration of daily lens wear.
• Lens storage system
MAINTENANCE AND CARE OF CONTACT Personal Care

LENSES Personal hygiene of contact lens wearer
Introduction remains the most important first step in
Maintenance and care of contact lenses by its maintenance and care of contact lens. Person
wearer is most critical step to decide the using contact lenses should keep his/her nails
success rate and satisfaction in contact lens properly trimmed and hands should be
wearer patients. Different regimen can be used washed thoroughly with soap and water prior
for care of lens and choice of regimen will to using contact lenses. Then, dry the hands
depend on many factors including type of lens and use antimicrobial rubs, if possible before
and its material, specific patient needs, lifestyle removal of lenses from lens case. Use of any
or wearing schedule of contact lens. Triad of oil-based solutions like cream or ointments
prescribed good contact lens, patient compliance before handling the contact lenses should be
for lens and monitoring by professional at avoided because, it may cause deposition of
periodic interval decide the outcome of safe lipids over lens surfaces. Hence, foremost impor-
and effective contact lens wear. tant aspect of a good contact lens wear outcome
Aims of care and maintenance of contact starts with a proper handling and caring of
lens are contact lens during insertion or removal.
• Provide comfortable lens wear Contact Lens Solutions
• Minimize and/or prevent contamination Various solutions are used for care and to
by microbes maintain contact lens in good condition and
• Decrease deposits formation on contact for comfortable wear. These solutions are
lens routinely used by the contact lens wearer and
• Maintain availability of contact lenses in purchased by users along with lenses. For
ready wear status convenience of understanding we can group
To achieve these aims, various maintenance these contact lens care solutions as
products are used, which serve following • Cleaning agents
functions to keep the contact lens in wearable • Rinsing solutions
state • Wetting and lubricating drops
• Keep the lens clean • Multipurpose solution
• Maintain wetting/re-wetting of lens
Cleaning agents or solution: Lens surface can
• Prevention of infection be cleaned manually by rubbing and rinsing
• Removal of protein deposits with saline or by using cleaning solutions on
• Maintain physical and chemical state of daily basis. These cleaning solutions generally
contact lens consist of surfactants which act on the contact
lens surface to remove most loosely attached etc. Surfactants are able to remove lipid,
foreign substances like lipids, residues, dirt, inorganic deposits, mucus, etc. however, they
mucus, proteins, microbes or other deposits. are not much effective for removal of proteins.
Cleaning of lens is very important step to remove Enzymatic cleaners: As surfactants cannot
the cysts and trophozoites of acanthamoeba remove protein effectively, hence enzymatic
from surface of lens. The cleaners may be cleaners can be used which contain proteolytic
available in a separate bottle or may be enzymes to break down proteins from surface
combined with disinfecting/soaking solution of lens. However, use of these cleaners is not
in one bottle. Along with surfactants other obligatory and not used on daily basis.
agents can be added in cleaning agent like Enzyme cleaners are usually used for types of
• Different non-ionic or ionic chemical lens which are not replaced frequently and are
substances, added to decrease contact nondisposable.
between lens and the solution Cleaning procedure: Principle is Rub and
• Agents acting against microbes are also Rinse of lens. Contact lenses should be cleaned
added in daily cleaner every time before insertion and after removal
• Agents which maintains osmolality to get a complication free result. Following
• Buffer system to regulate the pH steps are done for cleaning of lenses
• Chelating agents for removal of contami- • Thoroughly wash hands and dry them
nants from lens (avoid moisturizing cream/perfumed
• Abrasive material as adjunct to remove soaps before cleaning)
adherent substances or muco-proteina- • Place the contact lens in palm of hand.
ceous deposits from surface of lens which • Pour 4–5 drops of cleaning agent on each
cannot be removed by surfactant itself. surface of contact lens.
However, use of abrasive material or excessive • Gently rub contact lens using pulp of
rubbing can lead to scratches and may forefinger, for about 15–20 seconds per side
induce change in power to contact lenses. in a circular motion. Slowly roll forefinger
• Agents like polyvinyl alcohol or methyl- in both directions to clean periphery of lens.
cellulose as viscosity enhancers • Rinse well using rinsing solution.
• Alcohol to remove lipids Process of rubbing and rinsing is important
because it significantly helps in removal of
The cleaning agents may be of two types
loose debris and many microbes from contact
Surfactant cleaners: These agents have
lens surface. Cleaning should be done on daily
detergent like action and by reducing surface
basis for all types of contact lenses including
tension act as surface active agent. Surfactants
disposable lenses.
have both hydrophobic and hydrophilic
components and molecules of surfactant Rinsing solutions: Cleaning of lens is
combine with different type of debris or followed by rinsing. The purpose of rinsing is
residues and deposits on lens, as a result, a to remove surfactant cleaners, microorganisms
layer of surfactant molecules is formed over and suspended residues from the surface of
contaminant (micelles formation), surface lens completely, irrespective of the type of
tension get decrease and it causes dispersion cleaning agent. It is advised to rinse all types
of contaminant from contact lens surface of contact lenses and before and after
which get suspend in surrounding liquid and overnight soak. Various types of solutions
finally removed by rinsing. Some common which can be used for rinsing are
examples of surfactants are isopropyl alcohol, • Unpreserved saline
hexylene glycol, polyvinyl alcohol, poloxa- • Preserved saline
mine, poloxamer-407, octylphenoxy ethanol, • Multi-purpose solutions.
Rinsing should not be done with tap water • Polyethylene glycol

due to increase risk of infection with acantha- • Polysorbate 80
moeba. Presence of viscous agents in lubricants
Buffering agents are also added in rinsing helps to increase the contact of solution with
solution and usually buffered isotonic saline lens and also help to decrease the friction.
is more preferred as compared to un-buffered These viscosity agents help to maintain the
saline. relative density of cleaners, soaking solution
Wetting and Lubricant drops: These drops are and lubricants. Usually, cleaners are kept more
used, while contact lens is in the eye and viscous than lubricants while lubricants kept
before insertion of lens in eye where these more viscous than soaking agents.
agents provide lubrication and rewetting of
contact lens surface. Standard wetting drops Note: Viscosity order: Cleaners> lubricants>
soaking agents.
contain following components in a proportio-
nate amount, to increase the comfort and
duration of contact lens wear. Multi-purpose solutions: Most widely used
• Non-ionic surfactant in very low concentra- solution for maintenance and care of contact
tions to promote cleaning of lens lenses is multipurpose solution. As name
• Polymer for lubricating the lens surface suggests this single solution performs functions
of several components of lens care system,
• Buffering agents to compile pH of tears
hence reduces the requirement of actual
• Viscosity agents to reduce friction
number of lens care solutions.
• Preservatives for maintaining the sterility
For patient convenience and ease of
of drops.
utilization, this multi-purpose solution
In patients, who use extended wear or performs a combined function of cleaning,
continuous wear contact lenses, use of these rinsing and disinfection. Moreover, in newer
wetting and lubricant drops are very helpful solutions even protein remover agents are also
for wearers, although drops can also be used added to enhance efficacy of solution and
with daily wear lenses. These are especially reduce another maintenance step in contact
indicated on those patients who have relative lens care.
tear deficiency and use contact lens during
sleeping also, who work in dry atmosphere Disinfecting Agents for Care of Contact
and work for prolonged period on computers, Lens
etc. These wetting and lubricants prevent the Disinfection means removal and/or killing of
contact lens from dryness due to wind microorganisms (microbes, fungi and viruses)
exposure, low humidity and high tempera- from contact lenses and is important step to
tures. Patients facing difficulty in removing be followed after daily cleaning and rinsing
soft hydrogel lenses because of dehydration of lens. In contact lens wearer the natural
or the one who frequently damages his/her defence mechanism of eye remains compro-
lenses on removal will also be benefited by mised, i.e. protective barrier function of
use of lubricants. corneal epithelium affected and there are more
Wetting and lubricating drops are also chances of infection by microorganisms. Thus,
formulated with various viscosity enhancing disinfecting contact lens care solutions are
agents like used to minimize or kill potentially harmful
• Polyvinyl alcohol micro-organisms (bacteria, viruses, amoebas,
• Methylcellulose and hydroxyl methyl- fungi) along with maintenance of contact lens
cellulose hydration. By disinfection the living or
• Hydroxy propyl methylcellulose (HPMC) vegetative microorganisms are destroyed but
not the spores of microorganisms. Sterilization • Hydrogen peroxide-based system

is a process which kills all life form of • Chlorine system
microorganisms including their spores and it Conventional cold chemical disinfectant-
is impossible to achieve sterilization with based solutions: Ideal characteristics required
normal lens care solutions. in chemical disinfectants are
The disinfection for contact lens can be done • Non-toxicity
mainly by two techniques
• Non-irritating
• Disinfection based on heat (thermal
• Compatible with other ingredients
disinfection)
• Stable over time
• Disinfection based on chemical methods
• Effective against a wide range of micro-
(chemical disinfection)
organisms
Disinfection based on heat: As the name Many chemical agents such as chlorhexi-
indicates heat is used to deactivate or kills dine, benzalkonium chloride, thiomersol, and
most of living contaminants from contact lens. sorbic acid are used as disinfectant solution,
Normally sterile thiomersol, persevered (with although with caution because they may cause
potassium sorbate) saline or unpreserved sensitivity reactions.
saline are used as medium to boil the lens.
• Chlorhexidine gluconate (CHG): It is a
Boiling of lens can be done by keeping it in
biguanide antimicrobial agent, mainly
a bowl filled with saline and boiled for
effective against bacteria. It has no
10–15 min in range of 70–90°C. A saline-based
antifungal activity. It can be used as
solution containing thiomersol with EDTA can
preservative and disinfectant with
also be used, where EDTA helps in removal
thiomersol for both soft and hard contact
of calcium from contact lens surface. Thermal
lenses. It can bind with lens materials and
disinfection method should not be used with
with protein deposits and cause allergic
high water content lens.
reactions. Its breakdown product may
Advantages cause yellowish discoloration of lens.
• Very effective method for disinfection
• No associated allergic reactions or • Benzalkonium chloride (BAK): It is a
discomfort quaternary ammonium compound and
can be used as disinfectant and
Disadvantages preservative with ophthalmic solution
• Decreased life span of lens due to for PMMA lenses. It acts as cidal agent
alteration in property of lens against many bacteria and fungi. BAK is
• Discoloration of lens with time due to not used in solution for hydrogel lens
heating (e.g. silicon acrylate and fluorosilicon
• Reduction in water content of lens acrylate) because it binds with lens
especially high water content lens materials, lens being gas permeable also
• Change in optical and physical proper- absorb BAK which can accumulate to
ties of lens due to exposure to heat toxic levels and may cause eye injury.
• Warpage of lens due to denaturation of Additionally, BAK also increases hydro-
proteins phobicity of lens surface, chances of
Chemical-based disinfection systems: Wide deposit formation increased. Normal
varieties of chemical-based disinfection concentration of BAK in contact lens care
systems are present for disinfection of contact solution is 0.001–0.01% and it is more
lenses that can grouped as follows active at alkaline medium (pH = 8). It shows
• Conventional cold chemical disinfectant- synergistic action with EDTA and require
based solution in low dose when combined with it.
• Thimerosal: It is a mercurial compound into saline and oxygen. Disinfection by

having bacteriocidal activity against hydrogen peroxide for bacteria and viruses
many bacteria and fungi. It can be used requires its exposure for about 10–15 minutes
both as a preservative (0.001%) and as a (45 minutes for fungi, 2–3 hours for acantho-
disinfectant (0.0005%) and acts by emaba) followed by neutralization for about
inhibiting the activity of cellular enzymes 30 min–3 hours.
leading to killing of micro-organism. Its The disinfecting solutions based on
activity is maximal at neutral or slightly hydrogen peroxide may contain preservative
alkaline pH and usually used in the or may be preservative free. Depending on the
concentration of 0.001–0.2% in the method adopted to neutralize the peroxide,
solution. It is comparatively nontoxic but two types of peroxide lens care systems can
in some patients it may cause allergic be used for disinfection with hydrogen
reactions especially in persons wearing peroxide
hydrophilic contact lens. It should not be • One-step disinfecting system
combined with EDTA because its activity • Two-step disinfecting system
is reduced with EDTA. When compared One-step system: These systems are
with BAK, it shows less activity against formulated in such a manner that both
some gram-positive and gram-negative disinfection and neutralization of hydrogen
micro-organism than BAK. To achieve peroxides is done in a recommended time
effective antimicrobial action it can be period (30–60 minutes). This is very simple to
combined with other preservatives like use and usually most of the hydrogen
chlorhexidine, etc. peroxide get neutralize in first 30–60 minutes.
• Sorbic acid: Sorbates or sorbic acid act as These systems are either tablet using systems
antibacterial and antifungal agent and is or a disc-based system. In tablet using systems
added in contact lens saline as enhancing delay period is done during neutralization
agent. When used alone it usually does phase, whereas in disc-based systems no delay
not cause any allergic reactions but in is done during neutralization phase. The
formulation with other compound it may effectiveness of this system can be improved
cause burning sensations due to change by controlling the rate of neutralization of
in the pH of solution (as it is acidic in hydrogen peroxide.
nature). It may cause yellow or brown Two-step system: System where neutrali-
discolouration of contact lenses by zation of contact lens is done as a separate step
reacting with amino acids present in tear is called two-step disinfecting system. Thus
proteins. in this system the neutralizing agent in the
Hydrogen peroxide-based system: In this form of tablets is added separately during
system, microorganisms are exposed to disinfection process. These tablets release
oxidative atmosphere by using 3% peroxide catalase enzyme to neutralize the hydrogen
concentration with an acidic pH of 3–4. peroxide so that it reaches to safe residual
Hydrogen peroxide is effective against level. The main advantage with this system is
majority of all microbes responsible for that the neutralization of hydrogen peroxide
infection in contact lens wearer. Residual can be delayed according to requirement so
hydrogen peroxide on lens after disinfection that high peroxide concentration remains
process may cause irritation on eyes, hence it maintained for a long time which will enhance
is necessary to do neutralization of peroxide the antimicrobial effect of solution compared
by using substances like sodium pyruvate, to one-step system. Recommended method for
sodium bicarbonate, sodium thiosulphite, and two-step system disinfection is that contact
catalase. The hydrogen peroxide get decompose lenses are kept in hydrogen peroxide solution
overnight, then neutralize the lenses just Preservative Systems

before their usage. Preservatives are used usually with other
Advantages of hydrogen peroxide system chemical agents. These are used to either kill
• Rapidly kill most types of micro-orga- or inhibit the growth of microorganisms. An
nisms in large numbers ideal preservative present in contact lens
solution
• Takes very short time period, usually a
1. Should provide effective degree of disinfec-
soaking time of 10–20 minutes.
tion in the existing environment
• High anti-microbial efficacy 2. Should be nontoxic
• Decomposition products (oxygen and 3. Should be compatible with lens material
water) are non-toxic in nature. and tear film, i.e. no effect on wettability
Disadvantages of hydrogen peroxide and parameters of lens
system Commonly used preservatives are
• If not neutralized properly, it can cause • Benzalkonium chloride
irritation to eyes • Chlorhexidine
• Once completely neutralized, has no anti- • Thiomerosal
microbial activity • Chlorbutanol
• Occasionally not compatible with contact • Benzyl alcohol
lenses such as high water content, ionic • EDTA
contact lenses; where this system can • PAPB and PHMB
alter (reversibly) lens parameters and • Quaternary ammonium compounds
water content. Chlorbutanol: It is an unstable volatile
preservative with a characteristic smell.
Note: Multi-step hydrogen peroxide systems
although available; but are very complex and can Basically, it is used as chlorinated alcohol
confuse patients. (0.5%) along with other preservatives.
Although it has broad spectrum action on
Chlorine Systems: For disinfection of soft bacteria in acidic pH, however, it acts slowly.
contact lenses anhydrous effervescent tablets Initially, it was used to disinfect PMMA lenses,
of either stabilized halane or halazone benzoic but now it is rarely used. It remains stable at
acid are used in convenient blister pack, where low pH, at high pH it get break into hydro-
both these tablets differ in amount of available carbons and HCl.
chlorine (4–8 ppm). Benzyl Alcohol: It can be used both as a
preservative and disinfectant. Pure benzyl
These chlorine releasing tablets are
alcohol because of its physio-chemical
dissolved in unpreserved saline (~10 ml),
properties is considered as ideal preservative.
which forms a disinfecting solution having pH
It has low molecular weight and can enter
in range of 5.5–7.5. Recommended exposure easily into intermolecular spaces of lens
time is usually four hours, however, polymers. Being bipolar molecule it has low
concentration of undissociated hypochlorous polarity. It is more stable than chlorbutanol,
acid decides the effectiveness of antimicrobial water soluble and can be used to disinfect and
activity. Contact lenses should be rinsed preserve RGP and PMMA lenses. Benzyl
thoroughly before insertion into eyes. alcohol is not suitable for hydrophilic
Dissociated hypochlorous acid produces materials because it can interact with contact
hypochlorite and chlorine which also act as lens and may cause irritation and toxicity to
bleaching agents, hence contact lenses tinted eye. It is converted into aldehydes, leading to
with reactive dyes may change color. hardening and discoloration of soft contact
lens. It is effective against both bacteria and Note: Opti-Free and Opti-Free Express (Alcon):
virus but not active against Pseudomonas contain Poly quaternium-1.
aeruginosa.
EDTA (Ethylene diamine tetra acetic acid): cular structure cannot adhere and enter into
EDTA per se is not a true preservative rather it lens material, thus chances of ocular reactions
acts as a chelating agent, preservative are less.
enhancers and potentiator. It has no antimicro- Protein removal process or enzymatic cleaners:
bial action but it potentiates the antibacterial Enzymatic cleaners contain proteolytic
action of other quaternary ammonium enzymes like papaine, pancreatin, lipase,
preservatives against gram-negative micro- subtilisin, etc. and are included in lens care
organisms especially pseudomonas. In systems for removal of proteins from surfaces
addition, because of chelating property it of contact lens. The enzyme cleaners can be
binds with divalent cations like calcium and used once a week or more frequently
magnesium present in solutions or on the cell depending on the length of lens wear, for
walls of gram-negative organisms which is example: Disposable lens usually do not
necessary to prevent cell growth of microbes. require treatment with enzymatic cleaners
EDTA does not interact with lens material and while soft and some RGP lenses require it
is used in combination with BAK and other because they are not replaced frequently.
preservatives in most contact lens solution. Papaine containing cleaners are not
Poly aminopropyl biguanide (PAPB) and compatible with hydrogen peroxide and
Poly hexamethlene biguanide (PHMB): PAPB thermal disinfection.
and PHMB both are high molecular weight For protein removal, the enzyme tablets are
preservatives, specially developed to avoid the dissolved in saline or distilled water and lens
problem of ocular irritation and hypersensi- is placed in this solution for 4–6 hrs. Lens
tivity occurring due to previous preservatives. should be cleaned and rinsed before and after
PHMB is used in the concentration of 0.001% process of protein removal. This mechanism
and show broad spectrum antimicrobial action of enzyme tablets only loosens the proteins
and less toxicity. hence patients are advised to clean and rub
PAPB which is also known as Dymed their contact lenses after completion of
contains positively charged biguanide group deproteinization process.
which selectively bind to negatively charged
phopsholipids of membrane of micro-organisms, Lens Storage System
leading to disintegration of micro-organism. Storage system for soft lenses and RGP lenses
It is nonirritating, nonsensitive and has more is slightly different because soft lenses are
antimicrobial effect as compared to chlorhexi- stored in a hydrated state, while RGP lenses
dine. It can be used as preservative and are stored in a dry state.
disinfectant in very low concentration of All soft contact lenses once removed from
0.00005–0.0005%. their sterile packing are kept in a lens case
Quaternary ammonium compound (Poly- (filled with rinsing or multipurpose solution)
quad): These high molecular weight cationic in such a manner that entire lens is merged in
polymers like poly quaternium-1, polidro- solution. Normally lenses are removed from
mium chloride, Onamer M are effective the case and cleaned with cleaners before
antibacterial but show less antifungal activity. inserting in the eye. Similarly after removal
Polyquad in the concentrations of 0.001–0.005% from the eyes, lenses are rinsed and kept back
can be used as disinfectant and preservative in the lens case containing multipurpose
for both rigid and soft lenses. Quaternary solution. However, these lenses need to be
ammonium compound being large in mole- treated chemically at least once a week to
prevent contamination and to remove debris Note: Ideally, the lens case should be replaced at
and proteins. regular intervals.
RGP lenses are stored in dry state in a
simple shape (usually flat), fitted inside a lens Maintenance and Lens Care Methods
case which can be kept in purse or pocket.
Newer approach for better lens care is to
After removal from the case these lenses are
simplify the cleaning, storing and disinfecting
cleaned and rinsed before inserting in the eye.
systems required for maintenance and care of
Similarly, after removal from the eyes these
contact lenses which can easily be understood
lenses are cleaned and rinsed with multi-
by patients and they can comfortably adopt
purpose solution before keeping them inside
them. Various lens care methods for better
the lens case.
outcome that are recommended for RGP and
soft contact lens wearers and also for allergy
Care of Lens Cases sufferer patients are as follows
Improper care and maintenance of contact lens
Simplified RGP lens regimens: RGP contact
case may cause contamination of contact
lens solutions usually used are in a sequence
lenses by various microorganisms by
initially for cleaning followed by disinfecting,
formation of a biofilm or glycocalyx on its
then wetting and lastly for conditioning and
surface. Contamination may occur by
cushioning purposes. Most of the commer-
pathogens like Pseudomonas aeruginosa and
cially available solutions serve all these
Serratia marcereens which in turn can produce
function in one solution, however, if patient is
biofilms. The glycocalyx formed on lens
switching to a solution which serves purpose
surface protect bacterial cells from action of
of cleaning, disinfection and conditioning but
chemical disinfectants or preservative and also
not of wetting and cushioning, then an
helps in trapping of nutrient particles for
additional solution should be added to the lens
micro-organism growth. To avoid chances of
care regime.
contamination it is necessary to rinse the lens
case after every use and to discard all used Soft contact lens regimens: Most common
solution from lens case. Thereafter, lens approach adopted by majority of patients
should be stored in fresh solution so that wearing soft contact lenses is to use one bottle
disinfecting efficacy of solution remains lens care system. For example, commercially
maintained which might loss due to mixing available soft lens care products like ReNu
of fresh solution with used solutions. Lens (Bausch and Lomb), Opti free and Opti one
cases should be scrubbed with a toothbrush (Alcon) are very popular. These solutions have
preferably with oil-free soaps or detergents, very low toxicity. Simply a digital cleaning
usually on weekly basis. Then rinse with hot with rinsing (use clean hands) followed by
water and rub thoroughly with clean and dry soaking of lens in a clean case is needed for
tissue. Colonization of microorganisms like maintenance and care a soft contact lens by
protozoa can be prevented by keeping lens these solutions. Although these solutions has
case dry, because protozoa needs moist or wet very low toxicity and allergic reactions
environment for their growth. because they avoid use of preservatives like
CIBA vision has introduced a unique lens thimerosal, chlorhexidine and hydrogen
case called Pro Guard. In this lens case an anti- peroxide exposure, better compliance and
microbial agent is already incorporated which results are still doubtful with these solutions.
prevent contamination of case by micro- Sometimes one bottle lens care systems
organisms. This type of case comprises electri- which contain surfactants can cause Sicca like
cally charged silver ions which help to reduce syndrome. To prevent these patients are
the chances of contamination up to 40%. advised to adopt a saline rinse technique
before insertion of contact lens, preferably target are seen at two different positions as
with sterile saline which may be sorbic acid shown in Fig. 14.14A and B. Radius of
preserved or non-preserved. curvature of contact lens is the distance
between the two positions of Radiuscope,
Care regimes for allergy lens wearers: Patients
where target images are focused clearly.
suffering from allergies should use topical eye
drops of either anti-histaminic or mast cell Main parts of Radiuscope are
stabilizers or non steroidal anti-inflammatory • Compound microscope
drugs before and after lens wear to minimize • Internal illuminated target
the discomfort. • Half-silvered mirror
In a nutshell, care regimen is selected on Radiuscope includes a compound micro-
the basis of patients wearing schedule, type scope having an internally illuminated target,
of lens selected for wearing, ocular sensitivity, such as a radial line target (Fig. 14.14) which
replacement schedule and patient’s convenience. is projected along visual axis of Radiuscope
Patients are advised not to mix different types in such a manner that image of target is seen
of solutions and brands and take advice from clearly through an eyepiece by an observer.
clinician before substituting any solution for Half-silvered mirror is fitted above the
lens care. microscope objective, which is set at an angle
of 45°. When an object is focused (through
Radiuscope Radiuscope), either on its concave reflecting
Measurement of the base curve (i.e. radius of surface or at its center of curvature image of
the curvature of back surface) of a contact lens this target is seen clearly in both the situa-
is done by using an instrument called tions.
Radiuscope. In the year 1900 eminent scientist Procedure: To measure the back radius of a
Drysdale described a principle which is used contact lens following steps are done
in all types of Radiuscope although they may • Place the contact lens (keeping its
vary from each other in design and method of concave surface upward) on the platform
displaying the readings. of Radiuscope, while convex surface of
Principle: When a parallel beam of light is contact lens is kept in downward
directed on center of a concave reflecting direction and float on fluid or wetting
surface, the light gets reflected along the same solution. The fluid helps to reduce the
path as that of incident light. Now if this reflections from the lower (convex)
parallel beam of light is directed to the center surface of the lens when the reflections
of curvature of same concave reflecting from upper (concave) surface of contact
surface; it will again reflect back along the lens are observed.
same path, as that of incident light. • Slowly move the stage of Radiuscope so
As both center of a concave reflecting that illuminated target gets aligned with
surface and center of curvature of the same mirror and a real image is formed at
surface are reflecting incident light along its working plane of objective lens from the
original path sometimes we call these points light reflected through mirror.
as self-reflecting points. It means that center • Once alignment is done, now move the
of curvature and surface of the lens are two microscope downward, toward contact
positions where the object and image coincide. lens surface, until working plane of
Thus the examiner needs to focus the microscope coincides with plane of back
Radiuscope upside and downwards until two surface of contact lens.
clear images (one from center and second from • At this point reflected light (passing
center of curvature of contact lens) of the same through half-silvered mirror) form an
Fig. 14.14: Radiuscope; Zero position (First focus): When microscope objective focuses at back surface of
contact lens. Final position (second focus): When microscope objective focuses at center of curvature, of
back surface of contact lens.
image in focal plane of microscope • At this point concave surface of contact

eyepiece, where it is seen clearly by the lens is again returning the light, along
observer, as shown in Fig. 14.14A. This its own path. This point is called second
point is termed zero point and observer focus point (Fig. 14.14B) and observer
notices the reading on the scale of again notices the reading on the scale of
Radiuscope. Radiuscope.
• Now slowly observer raise the micro- Measure the distance covered by micro-
scope, until a second point is found scope between zero point and second focus
where image of target is in finest focus; point; where images were clearly focused. This
which occurs when working plane of distance denotes real length of radius of
objective lens align with center of curvature of concave surface (base curve
curvature of back surface of contact lens. radius) of contact lens under examination.
15 Refractive Surgery 463
Refractive Surgery
Learning Objectives
• Classify various refractive techniques required to improve the vision.
• Describe various refractive procedures done for correction of myopia.
• Explain the correction of hypermetropia by different types of refractive surgeries.
• Describe refractive procedure for astigmatic errors.
• Explain the presbyopia correction by various surgical techniques.
Chapter Outline
• Refractive Surgery Intrastromal corneal ring segments

– Introduction and Classification Intracorneal lenses
– Lasers in refractive surgeries Gel injection adjustable keratoplasty
Excimer laser • Refractive Procedure for Hypermetropia

Solid state UV laser – Incisional refractive surgery
Femtosecond laser – Laser refractive surgeries
– Selection of an ideal patient – Corneal stromal collagen shrinking proce-
– Preprocedure examination dures
• Refractive Procedures For Myopia Thermal keratoplasty
– Radial keratotomy Conductive keratoplasty
– Keratomileusis • Refractive Procedure for Astigmatism

– Photorefractive keratectomy – Relaxing incisions
– LASIK – Laser-based surgery
– Laser sub-epithelial keratomileusis – Post-PK induced astigmatism
– Epi-LASIK Suture removal
– C-LASIK Relaxing incisions
– Corneal lenticule extraction procedure Corneal wedge resection
– Intraocular refractive surgeries Ruiz procedure
Refractive lens exchange • Refractive Surgeries for Presbyopia

Phakic refractive lenses – Corneal procedures
– Miscellaneous corneal refractive techniques – Lens-based procedures
Orthokeratology – Scleral-based procedures
463
REFRACTIVE SURGERY Lasers in Refractive Surgeries

Introduction and Classification Following lasers are used to perform the
Recently, the refractive procedures done for refractive surgery on the cornea.
correction of refractive errors have become • Excimer laser
very popular especially in younger popula- • Solid state UV laser
tions. To perform the refractive surgery it is • Femtosecond laser
necessary to wait until refractive errors get
stabilize which usually occurs at the age of Excimer Laser
19–20 years in the females and 20–21 years in Excimer literally means excited dimer, where
the males. These refractive procedures took a ‘exc’ part is taken from excited and ‘imer’ part
long curve of evolution and techniques have from dimer. In a molecule, where components
improvised continuously. In recent decades a of that molecule are bounded together in the
steep change has taken place in refractive excited state and not in the ground state, then
surgery techniques which made several older that molecule is termed diatomic molecule. In
techniques obsolete. We will describe only ground state two-component molecules are
those techniques in detail which are presently not bounded, in reality they are repulsive in
in trend. nature. When these component molecules are
Refractive procedures are classified on the excited by electrons they attract each other and
basis of type of incision, laser used or site of become a stable molecule. Hence, in Excimer
refractive correction. The classification of laser when these stable excited molecules
various refractive procedures is summarized dissociate and separates into two molecules,
in Table 15.1. i.e. they come to their ground state level from
Table 15.1: Classification of various refractive surgeries

Incisional refractive Lamellar refractive Laser refractive Intraocular Miscellaneous
procedures surgery surgery refractive surgery refractive techniques
Radial keratotomy Freeze Photorefractive Phakic refractive Conductive
(RK) Keratomileusis of keratotomy lenses (PRLs) keratoplasty (CK)
Barraquer (PRK)
Relaxing incisional Epikeratoplasty/ Laser in situ Refractive lens Orthokeratology
procedures Epikeratophakia Keratomileusis exchange (RLE)
(LASIK)
Astigmatic Non-freeze Laser subepithe- Intrastromal corneal
keratotomy (AK) keratomileusis lial Keratomileusis ring segments
(LASEK)
Hexagonal Keratomileusis Custom laser Intracorneal
keratotomy in situ in situ Keratomi- hydrogel lenses
(BKS technique) leusis (C-LASIK)
Ruiz procedure Automated Epithelial laser
lamellar in situ Keratomi-
keratoplasty (ALK) leusis (E-LASIK)
Femtosecond
LASIK
Small incision
lenticule
extraction (SMILE)
Refractive Surgery 465
their excited state level they emit energy. This short pulse duration (12–15 nanoseconds)
property makes these molecules suitable for which does not allow thermal energy to
laser because ground state is not stable and diffuse into corneal tissue to cause
excited state molecule keep on forming by thermal damage. Thus, it is considered
population inversion (details in Chapter 1). appropriate to carry out surgery on
Majority of these excimer molecules acts as delicate cornea.
an active laser medium (details in Chapter 1) • Secondly, the pulse to pulse energy level
and forms laser by an electric high voltage of excimer laser can be reproduced and
discharge through a gas chamber having noble the variation remains in acceptable
gas mixture. Wavelength of laser coming out limits. The pulses can be repeated (pulse
is determined by the type of gas mixture used repetition rate) in a wide range of
to produce it and a few examples are frequency ranging from 1 to 50 Hz.
summarized in Table 15.2. Usually, Krypton • Thirdly, these excimer lasers have
and Xenon are mixed along with argon, enough energy to produce large beam.
chloride and fluoride. Laser energy typically up to 450 mj is
Excimer system to be used as a medium of obtainable in order to produce large
laser was first defined by Houtermans in beam of laser which can ablate the
1960s, but was extensively used for medical corneal surface effectively. This large
purposes since early 1980s. In medical field laser beam can remove the corneal tissue
these excimer lasers are primarily used for and alters the shape of the central corneal
tissue surface ablation. These excimer laser portion in 4–7 mm diameter area without
system work efficiently in relation to any limitations on pulse energy.
absorption coefficient of tissues and as cornea Most of the continuous wave or pulsed
has high absorption coefficient, it becomes the wave lasers cause ablation of the surface by the
most desirable target tissue for laser ablation. principle of photothermal process, however,
During the year 1980s, frequency doubled excimer lasers ablate cornea by photochemical
organic dye lasers and frequency quadrupled process instead of routine photothermal
Neodymium: YAG lasers were commercially mechanism. The short wavelength (193 nm)
available which were capable of producing a photons are capable of breaking the molecule
laser in the range of 280 nm (UV spectrum), bonds in corneal tissue without producing any
however, these lasers are not used for corneal thermal or acoustic damage to surrounding
surface ablation. Instead excimer laser are tissue. Damage to deeper corneal structures
used for surface ablation because of the like descemet's membrane and endothelium
following characteristics of laser outputs: is mainly prevented by an advantageous
• Firstly, it is considered as ‘cool laser’ property of limited penetration of excimer
because thermal effects of excimer laser laser. Corneal endothelial damage is greatest
are almost negligible because of very by Krypton fluoride laser (248 nm wavelength)
as compared to other excimer laser wavelengths.
Table 15.2: Examples of gas mixture with respective
Similarly, Xenon chloride laser can penetrate
output wavelengths of LASER deeper tissues and damage crystalline lens or
even retina in case of aphakics. Longer
Gas mixture Laser wavelength
wavelength (>280 nm) lasers causes photo-
Argon fluoride 193 nm keratitis, thermal damage, and has mutagenic
Krypton chloride 222 nm properties.
Krypton fluoride 248 nm In a nutshell, Argon fluoride laser with
Xenon chloride 308 nm 193 nm wavelength is the most suitable
Xenon fluoride 351 nm excimer laser for clinical purposes. Argon
fluoride laser is capable of eliminating LaserSoft is a diode pumped solid state laser
microscopic amount (0.1–0.4 nm) of corneal generating 0.2 mm flying spot short pulsed
tissue without producing any thermal injury laser beam with a repetition rate of 4 kHz and
to the cornea. A well-defined exceptionally ablation zone of 1–10 mm diameter.
smooth corneal surface is produced by this For accurate custom ablation (C-LASIK)
laser, because it delivers an accurate amount solid state laser is more preferred to excimer
of energy per pulse and also the precise laser because of various advantageous
numbers of pulses are applied to the specified features as summarized in Table 15.4.
area of the cornea. Excimer laser can produce Introduction of solid state laser (SSL) has
tiny (10 μm wide) corneal incisions even up improved the corneal refractive surgeries as
to 95% depth of corneal thickness. it provides more advantages over excimer laser
Excimer laser machines: Excimer laser machine to the surgeons. The smaller (0.2 mm) spot size
or system had been improved constantly since in SSL helps to obtain an accurate and defined
its advent so that various types of beam are ablation, thus resulting in reduction of corneal
delivered by these machines. These photoabla- microirregularities (i.e. high order abberra-
ting excimer laser machines can be grouped tions) and a smooth and homogeneous corneal
as summarized in Table 15.3. surface is obtained. While, in excimer laser the
large spot size produces more mechanical
Solid State UV Laser stress due to larger acoustic shock waves,
Energy absorption coefficient of cornea is hence there is more damage of collagen
high and relatively stable in the range of structure of cornea. Furthermore, high
190–220 nm, hence laser pulses in the similar repetition rate in SSL causes significant lesser
range (193–220 nm) can be used for corneal collateral damge to surrounding corneal tissue,
surface ablation. Several scientists introduced hence chances of post-procedure corneal haze
fifth node of Neodymium-YAG laser as an is significantly low in SSL.
alternate source of laser for photoablation of
cornea. These solid state UV laser radiations Femtosecond Laser
are generated in a laser crystal by frequency Advancement in research to eliminate the
conversion of an infrared laser light. The collateral damage to surrounding tissue leads
wavelength of this solid state laser radiation to the invention of femtosecond laser. This
is in a range of 208–213 nm. For example, newer improvised medical technology
Table 15.3: Classification of excimer laser machines with properties

Laser types Properties
Broad beam laser These first generation machines produced a wide-ranging beam of laser about
7 mm in diameter. These lasers had high energy per pulse and also beam
irregularities, hence need lower number of pulses but forms the central
corneal islands.
Scanning slit laser To reduce beam irregularities a scanning slit was introduced, which provide
sequential ablation. Formation of central corneal island reduced to a
significant level.
Scanning spot laser In these next generation machines a scanning spot was added to previous
version. The spot passes around the proposed area of ablation.
Flying spot laser These fourth generation machines had wavefront technology and an eye
tracker. While performing the procedure these advanced features
demonstrated to be very useful for patient’s comfort.
Table 15.4: Excimer laser versus solid state laser (SSL)

Laser features Excimer laser (193 nm) Solid state UV laser (213 nm)
Beam quality Require beam forming elements No beam forming element needed,
and is multimode in nature hence produces Gaussian bean of
single mode
Flying spot size 0.8–1 mm 0.2 mm (five times smaller)
High order aberrations Not treated Treated
Eye tracking system Speed 150 Hz Speed 1 kHz
Repetition rate 50–500 Hz 1 kHz
Thermal effect Temperature rise in corneal stroma Temperature rise in corneal stroma
during procedure is up to 7°C during procedure is 0.8°C
Corneal drying Required during transepithelial Not required
treatment
Damage due to acoustic Minimal Almost nil
shock waves
Post-procedure corneal haze Present Significantly less
Post-procedure visual recovery Slower Faster
Post-procedure scarring Minimal Almost nil
Maintenance cost Higher because require gas Lower
storage system
initially came for the creation of accurate and bubble where, the force generated in
precise corneal flaps, however, its use creation of cavitation bubble separates
expanded slowly in field of other ocular the target tissue. Thus, laser energy is
surgeries especially cataract, lamellar kerato- converted into mechanical energy and
plasty and penetrating keratoplasty. this process is called photodisruption.
Presently, Femtosecond laser systems • Femtosecond laser system literally
utilize photodisruptive laser of 1053 nm produces no collateral damage to the
wavelength in infrared spectrum. Various surrounding tissue, hence it is used as
types of femtosecond lasers are an effective tool to create tissue planes
• Solid state bulk lasers, for example, diode and flaps in LASIK surgery.
pumped lasers like neodymium-doped • Earlier FS laser systems had repetition
or ytterbium-doped and Titanium- rate of 30 kHz (excimer has up to 500 Hz
sapphire lasers. and SSL has 1 kHz) which gradually
• Fiber lasers reached to the present stage of 160 kHz,
• Dye lasers thus FS laser can create corneal flaps
• Semiconductor lasers within a few seconds duration.
• Free electron lasers • FS laser has pulse frequency in the range
Femtosecond laser has several advantages of 50–160 kHz, pulse duration 400–800
and specific features as follows: femtosecond (fs, where 1 femtosecond =
• Femtosecond (FS) laser system works on 10–15 second) and energy range 1–50 in
the principle of photodisruption. Target microjoules (μj, where 1 microjoule = 10–6
tissue absorbs the femtosecond laser joule)
energy to form plasma state. This plasma • Due to these specialized features FS laser
quickly expands to create cavitation can be focused at 2–3 μm size spot within
a range of 5 μm in cornea and high speed • Desire or expectation of patient towards

delivery of laser abolishes the possibility procedures: Enthusiasm of patient plays an
of damage to the surrounding target tissue. an important role in effective and desirable
• Excimer laser and solid state laser can be outcome of any refractive procedure because
used only for surface ablation, whereas an unmotivated patient will usually remains
femtosecond laser can be focused very unhappy and unsatisfied with the outcome.
accurately in transparent medium like Those patients who have a strong desire to
cornea and due to high speed this laser have good visual acuity without spectacles
can be used to cut deep within the target or contact lenses as found in actor/actresses
tissue without damaging the surroun- or in other occupations, show satisfaction
ding tissues. after surgery. Generally the patients think
In a nutshell, femtosecond laser technology that laser is a full proof and 100% accurate
produces high speed, microscopic accuracy and precise method for correction of
and precise photodissection of target tissue. refractive errors. This thought will increase
The effective outcome of various refractive their expectations about refractive
surgical procedures mainly depends on the outcomes very high, which eventually is a
following factors major cause of dissatisfaction. Hence,
• Proper selection of patient counseling before procedure should be done
• Proper evaluation of patient before to inform patients that a second procedure
procedures (preoperative) may be required in selected cases to achieve
the desirable visual acuity and also there may
Selection of an Ideal Patient be a few procedure related complications
Criteria for good patient selection include the after surgery. It is also important to inform
factors such as that the refractive procedure will not
• Age of patient: Patients less than 18 years eliminate the requirement of near correction
of age are not considered suitable for for presbyopia.
refractive surgery because the refraction • Associated eye diseases: Various ocular
below 18 years generally remains unstable. conditions where refractive procedures are
If refractive status is corrected before this absolutely or relatively contraindicated are
age, then any further change in refractive summarized in Table 15.5.
status later on will destroy the whole • Informed consent: It is also essential to
purpose of refractive procedure. Usually obtain a written informed consent from
procedure is performed on those patients patients before surgery. Patients must be
who are having stable refraction over a aware of the type of refractive procedure
period of one year. These procedures and its possible complications. Detailing
preferably should be done up to 45 years about the outcomes and individual varia-
because presbyopia will develop after age tions along with risks and benefits of
of 40–45 years and again the patient will proposed refractive procedure is done in the
need glasses for correction of presbyopia, language which the patient best understands.
however, this is not the rule that refractive
surgery cannot be done after 45 years of age. Preprocedure Examination
• Occupation of patient: The procedure like In motivated patients who are selected for
radial keratotomy is avoided in the persons refractive procedure following examination is
having profession like night driving job or must to improvise the visual outcome.
sportsman or security personnel. After RK, • Systemic examination: Elaborative systemic
the chances of glare or eyeball perforation examination is done to rule out any
is increased in this kind of jobs. systemic debilitating illness like connective
Table 15.5: Ocular condition where refractive attention is given to retinal lattice degenera-
surgery is contraindicated tions or small retinal holes which can lead to
Absolute Relative retinal detachments during or after refrac-
contraindications contraindications tive procedures in high myopes. These lesions
if present must be treated before performing
Corneal ectasias like Dry eye
the refractive procedures and patient must
keratoconus
be kept well-informed about them in detail.
Herpes keratitis Chronic blepharitis
• Pupil size assessment: Measurement of the
Thin cornea Large size pupil
size of pupil before refractive procedure is
Connective tissue Ocular surface disorders an important aspect to avoid many post-
diseases (OSD) procedure complications especially intole-
Chronic use of Monocular (one-eyed) rable glare. Ideally pupil should be measure
steroids or antimeta- individual in non-accommodated state under mesopic
bolite in autoimmune conditions at low intensity light. Pupil size
disorders can be measured by the following methods
Blepharophimosis Diabetes mellitus
– Rosenbaum card method
Glaucoma Uveitis
– Colvard pupillometer
Corneal aberrations Pregnancy
– Procyon pupillometer
due to contact lens
usage – Aberrometer
Ocular infections – Pupilscan
(recent onset) – Neuroptic devices
Normally, in scotopic conditions average
tissue disorders, juvenile diabetes, chronic pupillary size in a young individual is
asthma, etc. considered as 6 mm however, a larger pupil
• Visual examination: Both distance and near size more than 6 mm, is not necessarily an
visual acuity are measured using standard abnormality because pupil is a dynamic
charts, with and without glasses. Ideally a structure. Total ablation zone is kept larger
cycloplegic refraction is done to evaluate than pupillary size to prevent any post-
the exact amount of refractive error so that operative complications like glare, halos or
an accurate amount of correction will be poor visual acuity.
done by refractive procedure. • Intraocular pressure measurement: Most
• Ocular examination: Detailed ocular important examination step in refractive
adnexal examination is done to rule out any surgery is to record the intraocular pressure
squint, nasolacrimal blockage or other (IOP) preferably by applanation tonometer.
orbital anomalies. Glaucoma is an absolute contraindication
• Anterior segment examination: Thorough for refractive surgery hence in case of any
anterior segment examination is done with doubt a complete evaluation of glaucoma
slit lamp to rule out any ocular disorders is done before procedure.
which are contraindicated for refractive • Corneal examination: A detailed corneal
procedures. examination is done by performing:
• Fundus examination: Meticulous posterior – Tear film status: Schirmer’s test and tear
segment examination is done by dilating the film break up time test using fluorescein
pupil and using an indirect ophthalmo- dye is done to rule out any dry eye
scope with scleral indentation technique, to situation, which is a relative contraindi-
exclude any condition which can create any cation for LASIK procedure. There are
complication pre- or post-procedure. Special high chances of developing severe dry
eye post-LASIK in patients, who are at Note: Commercially available topographic systems
borderline dry eye state. are Orbscan and Pentacam. Keratometry, Rasterste-
– Keratometry: This gives a gross idea about rography, and Interferometry are other methods to
the corneal curvatures and any irregu- evaluate the corneal surface irregularities.
larities in corneal surface.
– Pachymetry: Corneal thickness is measu- – Aberrometry: Measurement of any optical
red by Pachymetry. This is an important deviations (aberrations) is called aberro-
data to be known before performing any metry. There may be low order or high
refractive procedure to rule out thin order aberration in the eye. Nowadays
cornea, which is an absolute contraindi- even aberrometry is done before refrac-
cation for corneal refractive surgeries. tive procedures so that these optical
The most preferred way of corneal deviations can be abolish during laser
thickness evaluation is ultrasonic pachy- ablation of cornea. Important types of
metry because it is easy to perform and aberrometer having the same basic
quite accurate method to evaluate the principle are:
corneal thickness. Hartmann-Shack aberrometry
– Corneal topography: This is the method to Tscherning aberroscopy
study the shapes of corneal surfaces and Ray tracing aberrometry

is generally called keratoscopy. Different
types of keratoscopy are: REFRACTIVE PROCEDURES FOR MYOPIA
Placido-disc keratoscopy Refractive surgeries for myopia have
Photokeratoscopy developed very fast as compared to hyper-
Videokeratoscopy: This is most metropic or astigmatic refractive surgeries. A
widely used method to evaluate the few procedures are now obsolete but mentioned
corneal surface abnormalities and is for historical values. Various refractive
useful in detecting borderline cases of surgeries done for myopia are summarized in
keratoconus. Table 15.6.
Table 15.6: Various refractive procedures for correction of myopia

Refractive lamellar Refractive laser surgery Refractive intraocular Miscellaneous techniques
surgery surgery
Freeze Keratomileusis Photorefractive Phakic refractive lenses Orthokeratology
of Barraquer for keratotomy (PRK) (PRLs)
myopia (MKM)
Non-freeze Laser in situ Refractive lens exchange Intrastromal corneal ring
keratomileusis Keratomileusis (LASIK) (RLE) segments
Keratomileusis in situ Laser sub-epithelial Intracorneal lenses
(BKS technique) keratomileusis (LASEK)
Automated lamellar Epithelial laser in situ Gel injection adjustable
keratoplasty (ALK) keratomileusis (E-LASIK) keratoplasty
Custom laser in situ
keratomileusis (C-LASIK)
Corneal lenticule extrac-
tion procedure (SMILE)
Refractive incisional procedure (e.g. Radial keratotomy) and refractive lamellar procedures are now obsolete.
Radial Keratotomy (RK) flatten cornea has less refractive power and
The idea of radial keratotomy for myopia was hence myopia gets corrected. Most popular
initiated by Japanese scientist Tsutomu Sato hypothesis is that due to normal intraocular
(1939) who performed surgery for correction pressure the weak peripheral cornea (due to
of myopia by creating 40 radial incisions in incisions) is pushed and thus central cornea
Descemet's membrane (posterior layer) and becomes flatter as shown in Fig. 15.2. A
40 radial incisions in anterior surface of moderate degree (2–7 D) of myopia can be
cornea. Subsequently, this procedure was not corrected by this method.
accepted by many because it was associated Advantages
with increase chances of bullous keratopathy. • There is rare possibility of central corneal
During 1970s and 1980s, many Russian haziness because the central 4 mm zone is
scientists mainly Fyodorov and his colleagues not incised.
improved the technique by making incisions • Very economical as compared to PRK or
only on the anterior surface of cornea and thus LASIK
reducing the chances of bullous keratopathy. • Post-operative wound healing is earlier in
After this many attempts have been taken to RK as compared to PRK.
refine the method of incision for RK and
availability of better microsurgical instruments Disadvantages
and advancement in corneal topography • Chances of eyeball rupture following even
measurements played an important role in a trivial injury are very high after RK as
improvement of RK-based surgeries. compared to PRK or LASIK, because cornea
Procedure: In RK, under topical anesthesia is weakened by multiple incisions in RK.
using Neumann corneal marker eight radial • Significant glare and halos especially
lines are marked on the cornea. Then eight during night time is experienced by large
centripetal radial corneal incisions of nearly number of patients.
90% corneal depth are made by diamond knife • Improper healing of corneal incisional
in the peripheral part of cornea. A central wounds can produce high degree irregular
optical zone of nearly 4 mm is left clear as astigmatism.
shown in Fig. 15.1. • Overcorrection or undercorrection of refrac-
These incisional corneal wounds while tive error is not very uncommon with RK.
healing, contracts the peripheral cornea and
flattens the central cornea. Thus, the RK Note: Newer, safer, effective refractive procedures
procedure provides a new shape to cornea, i.e. with predictive outcome, like LASIK and LASEK,
flat in central and steep in periphery. This have made RK procedure obsolete.
Fig. 15.1: Radial keratotomy Fig. 15.2: Myopia correction by radial keratotomy
Keratomileusis epikeratomileusis. In this procedure in place

It is a lamellar corneal refractive procedure of a corneal wafer, a portion of corneal
which was first described by scientist Jose epithelium is removed. Under the edge of
Barraquer who is known as Father of all the remaining epithelium, a pocket is created and
lamellar corneal refractive surgeries. a cryolathed donor homograft is inserted
Keratomileusis term is derived from Greek inside this pocket. Sometimes, a preserved
words (Kerato = cornea and mileusis = carving material is used instead of homograft.
or chiseling) which means chiseling of the Non-freeze keratomileusis: In the year 1983,
cornea. In lamellar keratoplasty, the refractive Krumiech and Swinger described this technique.
power of cornea is altered by placing a lenticule Keratomileusis in situ (Barraquer-Krumiech-
on or within the cornea. This procedure Swinger technique): In the year 1985 a
became the milestone for all the recent corneal modification and combination of both
refractive procedure. techniques was developed by these three
Freeze myopic Keratomileusis of Barraquer scientists popularly called BKS technique.
(MKM) and hyperopic Keratomileusis of Automated lamellar keratoplasty: In late
Barraquer (HKM): This technique is similar 1980s, Ruiz introduced the technique of
for correction of both myopia and hyper- automated lamellar keratoplasty. In this
metropia. A thin lamellar button or disc of technique two keratectomies are done with
corneal tissue is removed from its superficial help of automated microkeratome. This
surface with a microkeratome as shown in lamellar procedure revolutionalized the
Fig. 15.3. This corneal button is then reshaped corneal refractive surgery and laid a ground
into a new desired shape for correction of for recent laser baser keratectomies.
myopia or hypermetropia after freezing it as
shown in Fig. 15.3. This corneal tissue is Photorefractive Keratectomy (PRK)
freezed and then cryolathe reshapes it. This Photoablation of corneal stroma by use of
newly shaped corneal disc is then stitched to excimer laser is called photorefractive
the patient’s corneal stromal bed at appropriate keratectomy. PRK is used to correct myopic,
place. hypermetropic and astigmatic refractive
Epikeratomileusis or Epikeratophakia or errors, though it is very successful in myopic
Epikeratoplasty: In the year 1979, scientist cases.
Kaufman developed this technique of Excimer laser for medical purposes was
available since early 1980s, however, it was
Trokel and colleagues in the year 1983 who
used excimer laser to perform PRK for myopic
correction. They proposed that an excimer
laser can be used to ablate the corneal surface
without damaging the surrounding tissue.
Excimer laser ablation produced an
exceptionally even corneal surface, which was
not possible even by the latest existing
microkeratome used in lamellar refractive
surgeries. PRK similar to RK is effective in the
correction of low to moderate degree myopia
(1.5 to 7 D).
Fig. 15.3: Barraquer Keratomileusis. A. Myopic Principle: For correction of refractive error a
correction; B. Hypermetropic correction selected optical zone of anterior corneal
Fig. 15.5: Surgical steps of photorefractive

Fig. 15.4: Photorefractive keratectomy (see text)
keratectomy. A. 20% Ethyl alcohol drop for
stroma is photoablated with excimer lasers. epithelial loosening; B. Mechanically removal of
epithelium; C. Laser treatment; D. Bandage contact
This ablation causes the remoulding of cornea
lens placement
and hence leads to change in the refractive
status of the cornea. For example, in case of zone is removed to avoid any procedural
myopia central optical zone of anterior corneal accidents.
stroma is ablated as shown in Fig. 15.4, which • Once epithelium is removed and Bowman's
causes flattening of the central cornea and thus membrane is visualized, the patient is
decrease in the refractive power of cornea. instructed to focus on the target light, while
This decrease in corneal refractive power leads surgeon adjusts the centration of micro-
to the correction of myopic error. scope with the treatment area of cornea.
Surgical steps (Fig. 15.5) • Without any delay the laser treatment is
• PRK is a day care surgery and can be started with the use of eye tracker system
performed comfortably under topical to safeguard against eye movements.
anesthesia, however some surgeons prefer Surgeon should try to minimize the time
to give additional mild sedatives. gap between epithelium removal and laser
• Corneal epithelium removal: To deliver the delivery to prevent excessive drying or
excimer laser at corneal stromal bed, wetting of corneal stromal surface.
removal of corneal epithelium is a • Once laser ablation is complete the corneal
prerequisite. This can be done by any one surface is irrigated and simple antibiotic
of the following methods ointment is applied. The eye is patched for
– Mechanically: Using microsurgical blade an overnight period. Alternately, some
or rotating brush. surgeons apply bandage contact lens and
– Chemically: Using cocaine or 20% ethyl start preservative free antibiotics in high
alcohol (for about 25–30 seconds) frequency dosage.
– Laser method: By use of excimer laser Important surgical aspects of PRK
• Normally, epithelium in 0.4–0.8 mm area • Ablation zone: To prevent complications like
larger than the calculated central ablation halos around vehicle lights and intolerable
glare after PRK surgery, the diameter of – Topical steroids is started (once the
ablation zone plays an important role. For healing of corneal epithelium occurs) as
example, small zone give more halos and eye drops 4–6 times a day initially for
glare during night driving because ablation 7–8 days and then gradually reduced
area boundaries are within scotopic size over one month period.
pupil. Ideally, on an average, ablation – Topical preservative-free lubricants/
zone diameter for myopia is considered as artificial tear drops are instilled every
6–6.5 mm and for hypermetropia 8.5–9.0 mm. 2 hourly initially and then reduced to
• Centration of ablation: Proper centration of 3–4 times a day for a period of 2–3 months.
laser beams during PRK procedure is the
key for the successful surgical outcome. To Note: In those cases where delay in corneal
achieve good centration proper fixation of epithelial healing is observed, a Bandage contact
the eyeball is perquisite. Fixation of globe lens should be applied to promote the rapid
can be done by operating surgeon using a corneal healing. Use of topical steroids and
frequent use of preservative-free lubricants help
hand held suction ring or by patient using
in better corneal healing as well as decrease the
self fixation during ablation. Fixation light chances of corneal haze and corneal regression
on operating microscope should be coaxial postoperatively.
with line of vision of patient and surgeon
during ablation. Surgeon instructs the Complications: Various complications can
patient that during procedure this fixation occur during photorefractive keratectomy
light will become dim but still remain which can be grouped as follows.
visible, so keep on trying to fixate the light. • Intraoperative complications
Fellow eye is patched to prevent any cross – Photoablation zone decentration: It can occur
fixation during procedure. Laser beam is due to improper alignment of the laser
always centered to the pupil of patient. beam in relation to the central fixation
Decentration of ablation should never occur or may occur because of the sudden
during treatment. accidental ocular movements by the
Post-surgical treatment patient during delivery of laser. Decen-
• Once surgery is complete, eye patching for tration of photoablation will produce
overnight period is done after applying the symptoms like glare, diplopia, halos and
topical plain antibiotics ointment and also the residual astigmatism associated
cycloplegic drops (atropine). with poor visual acuity. In majority of
• Next day the eye patch is removed and cases, over a period of time gradual
complete ocular examination is done and corneal remoulding will decrease the
then to prevent infection and to reduce the effect of decentration, however, in
post-operative pain and inflammation remaining cases where symptoms are
following topical medications are prescribed significant and no improvement is
– Topical preservative-free antibiotics are noticed with time then a computer
started 4–6 times a day to prevent any assisted analysis of the center of pupil
infection for 7–8 days and then are and center of ablation zone is performed.
reduced to three times a day for 2–3 weeks Suppose an ablation zone of irregular
duration. orientation in relation to the pupillary
– Topical non-steroidal anti-inflammatory center is found, then to neutralize the
eye drops 4–6 times a day to reduce post effect of decentration a second ablation
operating pain and inflammation for at 180° to first ablation is done. The center
8–10 days and then frequency can be redu- of this second ablation zone is decenterd
ced over one and a half month duration. from the pupillary center by the same
amount as the first ablation is decentered myopia can be managed by using specta-
from pupillary center, but at 180 degree. cles or contact lenses, however, it is
This process will make the average center advisable to wait at least for six months
of two ablations in a line which passes before prescribing contact lenses because
through the pupillary center. use of contact lens can further cause
– Sub-retinal hemorrhage: It can occur regression.
during surgery due to rupture of fragile – Central islands: Postoperatively, small
retinal vessels. In PRK a shock wave of central elevations may be seen on the
high amplitude disrupts the tissue of corneal surface during analysis with
stromal bed and this shock wave can corneal topography (usually cornea
cause the retinal hemorrhages. shows a central area having high refrac-
• Postoperative complications tive power than its adjacent paracentral
– Overcorrection: Usually, a slight amount area). Several hypotheses have been
of overcorrection is desired in PRK postulated to explain this phenomenon
because in majority of the cases of island formation. Some considered
regression (about 0.5–1.0 D) will occur that corneal tissue hydration may vary
after a few months of procedure. Suppose in different corneal areas. For example,
a patient presents with greater degree of there may be increase in the hydration
hypermetropia even after more than a in central stromal area of cornea. In
month postoperatively, then it is advised addition, the abnormal profile of laser
to taper the corticosteroid rapidly so that beam also affects the ablation in different
the process of wound healing is areas. For example, exposure to flat
increased. Due to tapering of corticoste- ablation beam cause ablation of central
roids there are chances of additional hydrated corneal tissue at a slower rate,
remodeling of stroma and as a result the hence a lesser amount of corneal tissue
amount of hypermetropia will decrease. may be removed from the central zone.
However, this rapid tapering of steroids Sometimes during procedure discharge
may cause increase amount of corneal of a cloud of gaseous and particulate
haze, which require close monitoring of debris may occur which leads to lesser
the patient. Generally, improper healing delivery of laser energy and formation
of wound during postoperative period of central islands. Laser beam may have
is common cause of overcorrection of the inconsistent energy distribution and
refractive error, hence it is suggested to undesired optical properties which will
do scraping of epithelium and stroma cause these islands. Occasionally, non-
after procedure to enhance the process homogeneous corneal epithelial healing
of wound healing. will result in larger epithelial hyperplasia
– Undercorrection: Residual myopia due to in central area.
undercorrection can occur commonly – Corneal scar: Any kind of corneal insult
because of increased rate of wound will lead to formation of corneal haze or
healing or in some cases due to thickened scar. Corneal haze after PRK is specifi-
hyperplastic epithelial layer. Topical cally more observed in patients who are
steroids can be started in mild to having high degree myopia (>8 D).
moderate degree residual myopia to During process of epithelial healing there
delay the wound healing, however, long is increase in the amount of activated
term usage of steroids can cause potential keratocyte in the corneal tissue. Thus,
complications like glaucoma or cataract newly formed collagen and proteogly-
in otherwise normal eyes. Residual cans get deposit into the corneal tissue
leading to corneal haziness. The corneal – Infectious keratitis: This may cause corneal
haze characteristically appears in the first scaring and diminished visual acuity.
month of procedure, however, maximum Proper antibiotic coverage is required to
amount of corneal haze is seen typically treat this condition. Sometimes, excessive
in first 3 months of post-operative period. use of anti-inflammatory drops without
The haze gradually decreases over a proper coverage of steroids may cause
period of 1–2 years. Clinical grading of excessive migration of leukocytes as
the corneal haze is summarized in corneal infiltrates. These infiltrates are
Table 15.7. sterile and usually appear a few days to
weeks after the procedure. Treatment of
Regular use of topical steroids decreases
choice is to discontinue the anti-inflamma-
the corneal haze and improves the
tory drops and start the topical steroids
refractive status of eye. If corneal haze
for appropriate time duration.
persists even after six months of surgery,
then an excimer laser treatment may be • Delayed postoperative complications
required to improve the visual status of the – Delayed epithelial healing: Various factors
eye. like dry eye, larger epithelial debridement,
excessive topical anti-inflammatory
Note: Corneal haze until grade 1 is clinically not drops or prophylactic topical antibiotics
a major issue and resolves with topical steroids. and early withdrawal of steroids may cause
Corneal haze of more than grade 2 is considered delay in epithelial healing of corneal wound.
as scar and additional treatment is required to – Visual aberrations: The visual aberrations
correct the scar.
like night glare or halos are not very
– Recurrent erosion syndrome: After PRK, common after PRK, however, a small
map dot fingerprint type of changes may ablated area of about 3.5–4.0 mm can
take place outside the ablation zone in cause night glare or halos because in dim
the surrounding epithelial defect areas. or scotopic illumination pupil get dilated
Due to these epithelial changes, recurrent and the light rays which passes across
epithelial erosions can occur in the the mid-peripheral area causes halos of
neighboring area of ablation zone or very light. In low contrast conditions these
rarely even in the treatment zone. glare may persist for longer duration and
Excimer laser phototherapeutic keratec- will cause difficulty in night driving. To
tomy (PTK) is the treatment of choice solve this problem retreatment with
to manage this recurrent erosion synd- increase ablation zone diameter of 6.0 mm
rome. is done because halos are usually not
seen with an ablation area of 5.0–6.0 mm.
– Corneal ulceration: Sometimes, patients
Table 15.7: Clinical grading of corneal haze
presenting with delayed wound healing
Grade Clinical presentation are prescribed bandage contact lens for
Grade 0 Transparent cornea long periods after surgery. The cornea in
Grade 0.5 Minimally identifiable haze these cases may suffer from poor
Grade 1 Mild haze with normal visual oxygenation which may further delay the
acuity process of wound healing. These types
Grade 2 Moderate haze with decreased of cases have more chances of developing
visual acuity corneal ulcers.
Grade 3 Marked haze with unclear iris Various advantages and disadvantages of
details photorefractive keratectomy in comparison to
Grade 4 Severe haze with no iris details radial keratotomy are summarized in Table 15.8.
Table 15.8: Various advantages and disadvantages simultaneously also consists of precision of
of photorefractive keratectomy in comparison to excimer laser ablation. LASIK can correct a
radial keratotomy high degree of myopia, i.e. up to 12 dioptres
Advantages Disadvantages and hypermetropia or astigmatism up to 6
dioptres. Though, LASIK has several
Eyeball integrity is Pain and soreness
advantages over PRK or RK, but limitations
well maintained experienced by patients
are that LASIK requires fine surgical skills and
as compared to the for several weeks
very costly pieces of equipment to perform
radial keratotomy
this procedure. Residual refractive errors after
No diurnal variations As postoperative epithelial PRK, RK or cataract surgery can be corrected
in refractive status or healing is slow, it may by LASIK but variable results are seen.
night glare as compared delay the regain of good
to radial keratotomy. visual acuity. LASIK Set up
In moderate myopia Visual acuity may also be The complete set up of LASIK includes
(2–8 D) excellent affected by residual • Automated microkeratome
results are seen with a central corneal haze • Excimer laser machine
high accuracy of 95%
Automated microkeratome: Microkeratomes
cases achieving ±
are the instruments which create a smooth,
0.5 D correction.
uniformly planar, precise and desired
More expensive
thickness corneal flap to perform LASIK. All
procedure than radial
these microkeratomes are motor driven and
keratotomy
hence are called automated microkeratome.
Various models of microkeratome have been
In cases of significant undercorrection of
developed since advent of LASIK and are
refractive error, repeat PRK can be carried out
mainly mechanical or laser types. Some
with reasonable safety, however, majority of
microkeratome models are designed for the
patients do not require a second procedure.
creation of corneal flaps both for LASIK and
PRK retreatment should not be done in the
epi-LASIK. A few microkeratome are designed
following conditions
to create both types of flaps, i.e. the hinged
• Postoperative refractive status is changing flaps and free corneal caps. The development
regularly. of microkeratome was gradual since advent
• Undercorrection of refractive error is of LASIK and various types and designs of
clinically not significant. microkeratome have been invented by several
• Patient was on steroid therapy till manufactures. These microkeratome can be
recently. mechanical or non-mechanical in the design
• First procedure was done before lesser and may be disposable or non-disposable in
than six months duration. usage. On the basis of their design and usage,
• Corneal complications like corneal haze microkeratomes can be broadly classified as
or corneal islands are present. • Mechanical microkeratome
LASIK • Hydrokeratome
LASIK is considered as most popular • Epikeratome
refractive procedure done for correction of all • Laser microkeratome
three refractive errors, i.e. myopia, astigma- Mechanical microkeratome were developed
tism and hypermetropia. Unlike PRK, this in early era to create corneal flaps and
procedure keeps the Bowman’s capsule as primarily they had cutting head which was
well as corneal epithelium intact and advanced either manually by surgeon or
automatically by an electric motor. Initially, diameter (about 35 micron) is injected at a very

to cut the corneal flap diamond blades or high speed (nearly 2000 kph) to cleavage the
metallic (steel) blades were used, however, in cornea. This waterjet beam is angled 0° with
advance designs water jet under high pressure cornea and a fixed thickness hinged flap is
(hydro blades) or laser beam is used to create created by this waterjet beam. An image
the flap. tracking system is present to monitor the posi-
Various mechanical microkeratome designs tion of water pressure and beam of waterjet.
can be grouped as manual, automatic and Epikeratome is similar to microkeratome in
disposable types. Commonly available almost all features, except that it creates an
mechanical types of microkeratome and their epithelial flap instead of a corneal flap.
salient features are summarized in Table 15.9. Epikeratome moves below the epithelial plane
Hydrokeratome design is based on waterjet (excluding Bowman’s membrane) under
principle technique where high pressure fluid suction and cut the corneal epithelial layer
beam is used to break the collagen bonds for surface in smooth and homogenous manner.
corneal lamellae. The corneal dissection with The advantages of epikeratome over alcohol
this technique produces smoother planar or rotating brush de-epithelization techniques
surface with less tissue damage. Under are
extreme high pressure (more than 15,000 psi) – Smoother and linear corneal surface after
continuous saline beam of very narrow procedure
Table 15.9: Various mechanical types of microkeratomes

Manually advanced microkeratome
Microkeratome types Salient features
Turbokeratome Fixed head produces 150 m thickness flap, 20° angled
with cornea, oscillating speed 10,000 to 24,000
cycles per minute (cpm).
Microlamellar keratome Corneal flaps from 0 to 450 m thickness, 9° angled
with cornea, 20,000 cpm oscillations speed
Lamellar microkeratome Flap thickness 120,140,160 and 180 m, 21.5° angled
with cornea, oscillating speed 15,000 cpm
Automatic advanced microkeratome
Universal microkeratome Single unit fixed thickness plate create hinged flap,
0° angled with cornea, oscillating speed 14,000 cpm,
pendular movement
Eye-tech microkeratome Teflon coated steel blades, 26° angled with cornea,
oscillating speed 8000 to 14,000 cpm.
Hansatome Fixed depth 160 and 180 m thickness flaps,
disposable metal blade, left and right eye adapters
Disposable microkeratomes
Automated disposable microkeratome Moulded plastic, preassembled, single use unit with
130 m and 160 m thickness flaps, metal blade with
10,000 rpm speed
Flipmaker disposable microkeratome Similar to automated disposable microkeratome with
oscillation speed 12,500 cpm.
– Avoids surface toxicity of alcohol the remaining corneal thickness should be

– Epithelial layer can be replaced after more than 250 μm, hence patients having
surface ablation central corneal thickness less than 550 μm
– Less postoperative pain because surface are not ideal candidates for LASIK.
nerves are preserved. Surgical technique: Surgical technique of
– Less postoperative corneal haze because LASIK is simple and effective in an ideal
less corneal inflammation surgical atmosphere. It is a day care surgery
Laser microkeratome are latest version like other refractive procedures and in an
microkeratomes and utilize femtosecond laser expert hands require less than 15–20 minutes
beam to create the corneal flap. Femtosecond operating time.
laser is discussed in detail on page 266. The Preoperative requisites are meticulous
corneal flaps created by femtosecond laser are evaluation of refractive status, corneal
of precise thickness, extremely smooth, thickness, corneal topography and IOP
homogeneous, well centered and significantly measurement on the day of surgery. Patient
stable. is advised to use topical preservative free plain
Excimer laser machine: Excimer laser machine antibiotic drops 3–4 times/day for two days
is required to ablate the corneal bed as per prior to procedure. Once everything is set
precalculated data. Basic principle and surgeon check the microkeratome and suction
functioning of various design excimer laser unit before commencing the procedure and
machine have been discussed in detail at take up the patient for LASIK. Surgical steps
page 264. are as follows:
Preoperative evaluation for LASIK • In majority of cases, topical anesthesia
Ideal patient selection and preoperative (xylocaine or proparacaine) is used
evaluation for LASIK includes all points as 2–3 times in 15–20 minutes duration prior
discussed in detail on page 268. However, to start the surgery.
there are a few specific points in relation to • Careful cleaning of ocular area and proper
preprocedure consideration for LASIK. draping to cover every eyelash is done
• Patients with sunken eyeball and narrow similar to any other refractive surgery.
palpebral apertures are not ideal candidate • Proper exposure of globe is achieved by
for LASIK. In these patients placing of use of lid speculum (preferably self-
suction ring and passing of microkeratome retaining speculum).
is difficult because of inadequate eyeball • Corneal marking: Cornea is marked by
exposure. using a corneal marker dipped in gentian
• As majority of high myopes is contact lens violet. Several designs of corneal marker
wearer, they are advised to discontinue the for LASIK are available, for example,
use of contact lens wear before LASIK. Hoffer corneal marker, Mendez corneal
Contact lens wearing is discontinued 15 marker, and Lu corneal marker. For centra-
days prior in case of soft contact lens wear tion of suction ring and precise realignment
and one month prior in case of rigid contact of corneal flap specially designed corneal
lens wear. marker such as Lu marker (Fig. 15.6A) is
• Central corneal thickness should not be less used to mark the cornea. This marker has
than 500 μm for LASIK procedure because an external circle of 10.5 mm diameter
on an average 100 μm thick corneal flap and with an internal circle of 3 mm diameter.
nearly 160–180 μm stromal bed is ablated These two circles are joined by two
to correct refractive error. To keep the integ- pararadial lines in an asymmetrical
rity of eyeball and avoid corneal complication manner as shown in Fig. 15.6B. The inner
Note: An accurate IOP reading by Barraquer

tonometer is obtained when both tonometer and
corneal surface are dry.
• Preparation of corneal flap: After applying

the suction ring and increasing the IOP, the
cornea is moistened with balanced salt solu-
tion (BSS) and microkeratome cutting head
is inserted inside the suction ring track.
Then microkeratome is advanced
manually or automatically (depending
on design of the microkeratome) to create
either superiorly or nasally hinged
smooth corneal flap as shown in
Fig. 15.7A. Cornea is continuously kept
Fig. 15.6: Corneal marking in LASIK. A. Lu corneal moist with BSS during the movement of
marker; B. Markings on cornea microkeratome to prevent any thermal
damage to the corneal flap.
circle is aligned concentrically with the
Always follow the rule ‘wet cutting: dry
patient’s pupil for accurate centration, ablation’
whereas external circle is aligned to fix
Care is to be taken to prevent the
the suction ring. In case of an accidental inadvertent formation of a free flap.
free flap condition, the asymmetrical Initially superiorly hinged flaps were
pararadial lines will help in precise considered superior against the nasally
realignment of corneal flap. hinged flaps. Recent studies had shown
• Suction ring application: Once the corneal that superiorly hinged flaps damages the
marking is done, suction ring of selected majority of corneal innervations, hence
size is placed according to marking with the recent studies recommend the nasally
slight decentration towards the hinge. hinged flap creation superior to
Then the suction is started by attached superiorly hinged flap. Reason being that
pump and on an average an IOP of most of the corneal nerve fibres enter the
65 mmHg is achieved. Surgeon instructs cornea nasally and a nasally hinged flap
the patient that there will be transient saves majority of innervations of the
blurring but he/she should try to keep cornea. Only disadvantage of nasally
the focus on the target light. Proper level hinged flap is that the flap may be
of IOP attained can be checked as displaced by the movement of upper lid,
follows whereas in a superiorly hinged flap
– Significant blurring of vision/no chances of displacement is less.
vision
– Dilatation of pupil Note: Majority of LASIK experts recommend
– Barraquer’s tonometer measurement releasing of suction pressure immediately after
creation of corneal flaps, however, some suggest
– Reading in pressure gauge continuing the pressure until completion of
It is important to achieve an IOP of ablation. The explanation is that the amount of
about 65 mmHg because it is needed for damage to optic nerve is the same in both the
creation of corneal flap of an accurate situations but by keeping pressure, better centration
thickness and diameter. for ablation can be achieved.
To achieve a smooth, linear and – Central ablation should be done for

precise cut following points must be better visual outcomes. Latest version
remembered while creating the corneal LASIK systems have an eye tracker
flap facility which continuously follows
– An adequate exposure of eyeball is the eyeball movements during
necessary. ablation. Alternately, globe fixation
– Continuously maintain IOP between ring can be used to stabilize the
60 and 65 mmHg during cutting eyeball during ablation.
because a lower IOP will make – Do not ablate the hinge of corneal
eyeball soft and will produce a flap flap, it may cause free flap or poor
of variable thickness and diameter. healing post procedure.
– Keep cornea well irrigated by using – Complete the ablation process within
BSS during cutting. This will prevent 30 seconds after flap creation to avoid
the damage due to friction produced excessive dehydration of corneal
by microkeratome plate. surface.
• Corneal stromal ablation: Lift the corneal • Corneal flap repositioning: Once ablation
flap using micro spatula towards the is done, the corneal bed and flap are
hinge and then dry the corneal stromal irrigated with BSS to remove any
bed using cellulose sponge. Then centra- interface debris. Corneal flap is allowed
tion of laser is done and surface corneal to settle on the corneal bed, and then it is
ablation is started by excimer laser on the slightly distended and aligned properly
basis of pre-calculated fixed data feeded using golf club spatula. Excess fluid is
in laser machine by the surgeon as shown dried by wet Weckcell sponge and finally
in Fig. 15.7B. To achieve better results using wet spear sponge or Johnston
these points should be followed while applanator, the flap is repositioned on
doing the ablation the stromal bed. After repositioning the
– Apply the rule ‘wet cutting and dry flap it is allowed to get dry for 5 minutes
ablation’, i.e. keep the corneal bed as shown in Fig. 15.7C. This will adhere
constantly dry during the ablation the flap firmly over the corneal bed.
process. Confirmation of adherence of flap to
Fig. 15.7: Surgical steps of LASIK procedure

stromal bed is done by performing the • Preventive measures: Patient is advised to

striae test. Periphery of the cornea is follow these instruction along with
pressed by wet spear sponge to produce medication for better and faster visual
striae and these striae can be seen recovery after LASIK
radiating on the flap. – Take complete rest for a day or two and
• Speculum removal: Removal of lid then can perform routine daily activities,
speculum and drape is the most crucial but still to avoid strenuous work.
part of LASIK procedure because a minor – Avoid rubbing or touching of the eyes
negligence can lead to major troubles like and contact with water for 7–10 days
epithelial defect or flap displacement. To period.
avoid this gently remove the lid specu- – Avoid direct sunlight exposure and use
lum and drape under direct microscopic of eyes for long duration for 2–3 weeks.
observation. After removal of lid – Do not drive especially, during night
speculum and drape patient is instructed time.
to blink gently, while the position of flap – No sport activities or swimming for
is observed under microscope. In spite 6 weeks duration after LASIK.
of blinking the flap must remain firmly – In case of visual symptoms like pain,
adhered and properly aligned. excessive redness or diminished vision
Postoperative treatment report immediately to LASIK center.
• Ocular protection: Majority of surgeons in Follow up: Meticulous corneal examination
uncomplicated cases advice goggles after and measurement of visual acuity is done on
procedure for protection. following visits
• Systemic medications: Oral broad spectrum • First postoperative day
antibiotics (cephalosporins or fluoroquino- • One week after surgery
lones) and long acting analgesics (diclo- • One month after surgery
fenac or acelofenac) are prescribed for • Six months follow-up
prevention of infection and pain reduction, • Yearly follow-up visits
respectively for minimum duration of 3–5
On every follow up visit check the position
days.
and alignment of flap, corneal transparency
• Topical medications: To reduce pain, for and anterior chamber status.
better wound healing and to decrease
foreign body sensation following eye drops Complications of LASIK
are prescribed after LASIK surgery: Although LASIK is considered a very safe and
– Topical broad spectrum preservative free effective treatment for correction of refractive
antibiotics eye drops usually fluoro- errors in expert’s hands, however, there are
quinolones are given in a frequency of several complications which can occur during
every two hours for initial 3 days and or after LASIK. Several studies concluded that
then 6–8 times/day for a total period of complication rate of LASIK done by experien-
2–3 weeks in reducing dosages. ced surgeons is less than 0.5–1%. Various
• Topical steroids usually prednisolone complications of LASIK are summarized in
acetate is started 6–8 times/day for Table 15.10.
2 days and then gradually reduced for a Prevention and management of LASIK
total period of 3–4 weeks. complications
– Preservative free lubricating eye drop or • Holding of globe for placement of suction
artificial tears eye drop is prescribed ring may result in temporal sub-conjunc-
4 hourly for a period of 6 weeks. tival hemorrhage which can be easily
Table 15.10: Various complications of LASIK

Related to Microkera- Related to Associated Early post- Delayed post- Refraction
suction ring tome related photo with flap operative operative related
fixation ablation handling
Sub Incomplete Decentered Flap Epithelial in Halos and Over and under
conjunctival flap ablation hydration growth glare correction
hemorrhage
Conjunctival Variable Interrupted Flap interface Diffuse Interface Induced
chemosis thickness flap ablation debris lamellar haze astigmatism
keratitis
Ocular Free flap Flap ablation Flap Flap striae Recurrent Regression of
hypotony wrinkling epithelial refractive error
erosion
Button hole Central Poor flap Flap loss Corneal Poor contrast
or flap tear islands adherence ectasias sensitivity
Infectious Dry eye Diplopia
keratitis
prevented by using blunt holding forceps. and check the position of blades for proper
During application of suction ring fit. Maintain the IOP above 65 mmHg
complication like conjunctival chemosis during microkeratome movement and use
may occur which can obstruct the pressure newer blades in every case to prevent these
of suction ring. Always check the pressure flap complications.
rise and flow before application of suction • Photoablation is an important step of
ring. Rarely, severe ocular hypotony may LASIK surgery, hence it is important to
occur due to sudden vacuum created by the maintain the centration of ablation and
suction ring, hence to prevent this hypotony check the program entered in computer
the pressure in the suction ring should be data. Decentration of ablation can cause
raised gradually. irregular astigmatism and poor visual
• Improper motor functioning, presence of outcome. To prevent decentration newer
debris in the cutting interface or suction loss machines have an eye tracker system and
during cutting can result in creation of an also patient cooperation is must. Decentra-
incomplete flap. Microkeratome components tion once occurred it is difficult to treat,
as discussed above should be checked hence prevention is the only treatment.
before inserting into the track of suction Sometimes, technical error in laser system
ring. Always check the IOP before starting can interrupt the ablation process. In this
the cutting of corneal flap because low IOP situation, instead of being panic, discontinue
can cause variable thickness flap or free flap the process and reposition the flap after
(especially in small or flat cornea). In thoroughly irrigating with BSS. Repeat the
addition, the pressure should be checked process on later date once technical problem
intermittently to confirm the constant is solved. Accidental ablation of flap hinge
maintenance of IOP during flap cutting. or base of flap can happen because
Poor suction mechanism or poor blade centration for photo ablation and corneal
quality can cause button hole or tear flap are two different points. To avoid flap
(especially, in steep cornea) in corneal flap. ablation some surgeons purposely decenter
Always remember the handling instructions the suction ring about 0.6–0.8 mm, so that
photo ablation center and flap center do not surface. However, in majority of cases they
coincide. Central islands are mainly related stabilize without any associated compli-
to PRK procedure but they regress with cation. In rare incidences, the epithelial
time. However, in LASIK central islands growth is symptomatic and requires
rarely occur but once occur, they hardly treatment in terms of lifting of flap and
regress with time. Latest version scanning removal of epithelium using spatula.
laser beams and preprocedure programming Repositioning of flap is done with extreme
data entries have almost abolished the concern to prevent the recurrence of
occurrence of central islands nowadays ingrowth.
after LASIK. • Diffuse lamellar keratitis (DLK) is also
• Repositioning of flap is a crucial step in called Sands of Sahara syndrome, due to
LASIK because rough handling of flap can its appearance similar to sand. It may occur
cause damage, dislocation or destruction of as nonspecific diffuse intrastromal or
corneal flap. Excessive time gap (> 30 seconds) intralamellar keratitis in early postoperative
between creation of corneal flap and laser period. Clinically majority of the patients
ablation can cause hydration or desiccation present with severe pain, photophobia, and
of corneal stromal bed. Surgeon must be an diminished visual acuity, usually within
expert to reduce this time gap and avoid 3–5 days after procedure. On slit lamp
flap hydration. Intraoperative contamina- examination on the basis of location of
tion of corneal surfaces/interface debris white granular cells, DLK can be graded as
can happen due to friction in microkera- – Grade I Peripheral cells
tome blades. To prevent interface debris – Grade II Central cells
during procedure, following steps are – Grade III Clumps of cells in center with
advised clear periphery
– Appropriate and thorough cleaning of – Grade IV Stromal melting
instruments must be done and keep them In Grade I and II cases intensive steroids,
on plastic surface to avoid the contact anti-inflammatory and antibiotic eye drops
with fibres. are prescribed for 5–7 days. If no improve-
– Powdered surgical gloves should be ment is seen in infiltrate or if DLK is in
replaced. Grade III and IV, then it is suggested to lift
– Minimize the use of topical anesthetics the flap and irrigate the stromal bed with BSS
to prevent epithelial defects. solution then drying with Merocel sponge
– Meticulous corneal flap irrigation with should be done to prevent stromal melting.
BSS solution should be done. • Trivial trauma in early postoperative period
– Never touch the posterior surface of can lead to flap loss due to poor adherence
corneal flap. of flap and the most effective treatment is
Repositioning of flap is done properly to prevent trauma by wearing the protective
and golf club spatula is used to remove the goggles in early postprocedure period.
wrinkling and striae from flap. Striae test Usually, corneal lamellar grafting is not
is done as described on page 282. Poor required in case of flap loss because corneal
adherence of corneal flap will occur if there epithelium will grow over the residual
is flap hydration or wrinkling. corneal stromal bed and fill the area so that
• In early postoperative period (a few days cornea will function normally with minimal
to week) corneal epithelial cells may pro- haze. Flap striae may be seen in immediate
liferate under the corneal flap due to postoperative period. These striae are either
excessive topical anesthesia or flap handling macrofolds or microfolds seen in corneal
or betadine scrub contact with corneal flap.
– Macrofolds are large folds involving erosions are also uncommon and in these
entire corneal flap thickness and can be cases bandage contact lenses can be
seen easily on slit lamp. Large folds may prescribed with variable results. Dry eye
occur due to the corneal flap slipping remains the most common complication
from stromal bed and will cause full after LASIK especially, in patients having
thickness flap pouching along with borderline dry eye before surgery.
diminished visual acuity. Common hypothesis is that during corneal
– Microfolds are present within the corneal flap creation superficial corneal nerves are
flap and are occur due to wrinkling in cut as they are coming from nasal side of
either Bowman’s membrane or epithelial the cornea. This damage to corneal nerve
membrane. These microfolds occur due leads to the decreased corneal sensation and
to problem in flap adherence. reduced blinking rate which ultimately cause
Flap striae can be managed by lifting the appearance of significant clinical dry eye.
flap and repositioning it carefully to avoid • Improper entry of program in computer is
any wrinkling or slipping from stromal bed. the commonest cause of under or over-
Infectious keratitis though very rare but a correction of refractive error. However,
potentially hazardous condition which nowadays these errors are very rare because
necessitate immediate and effective refinement in program and improvised
treatment to save useful visual acuity. nomogram are available in laser systems.
• Most common complications of small Difference of more than 2 dioptres can be
optical zone, subclinical decentration of corrected by repeat laser treatment if
ablation and poor repositioning of flap are desired, within a period of 2–4 months
halos and intolerable glare especially, because corneal flap can be lifted effortlessly
during night drive. Pupillary dilatation within this duration. Decentration of
during mesopic conditions, high order ablation and improper corneal flap healing
aberrations due to decentration and irregu- can cause astigmatism of regular and
lar astigmatism due to flap complications irregular types. To prevent astigmatism
are the causes of these halos and glare after precise ablation and proper healing of
LASIK. To prevent the glare and halos, keep corneal flap is must. Regression in refractive
the optical zone diameter larger than status in early follow up period has also
pupillary size and avoid decentration been showed in several studies. These
during ablation. studies reported that initially 0.5–1.0
• Interface haze which can be observed after dioptre hyperopia and then low degree
LASIK surgery is not similar to corneal haze myopia is seen in majority of cases during
(seen after PRK), relatively a minimal first 2–4 months period of follow-up
haziness is seen at the interface of corneal however, the refractive status remained
flap and stromal bed in LASIK. Generally, stable after six months follow-up in majority
the interface haze disappears within of cases. Decreased contrast sensitivity is a
3–6 months duration, leaving a grey circular troublesome complication seen in many
scar at the edge of corneal flap. There are cases. The probable cause of diminished
no symptoms due to interface haze, hence contrast sensitivity is central flattening of
require no treatment. Corneal ectasias is a cornea in comparison to periphery of
rare complication and may result if too thin cornea.
corneal base is left which may result due to • In a few selective cases LASIK can lead to
formation of a thick corneal flap. It can be the decompensation of latent squint and
managed by penetrating keratoplasty or patient will experience diplopia after
lamellar keratoplasty. Recurrent epithelial surgery. Many a times, in high refractive
error patients the spectacle lenses are fitted Table 15.11: Various advantages and limitations
with slight decentration to induce the of LASIK compare to RK and PRK
prismatic effect or even sometimes prisms
Advantages Limitations
are incorporated in spectacle lenses to
compensate for squint. In these cases when Negligible or no pain Very expensive
after surgery
LASIK is done this delicate compensation
for prismatic effect is lost and patient feels No post procedure Not done in patients
diplopia. To avoid such diplopia it is better residual corneal haze with inadequate corneal
thickness
to give contact lens trial prior to surgery.
– Recent studies reported a psychological Minimal or no risk of Potential risk of corneal
globe perforation during flap related
complication after refractive surgeries and
surgery complications
termed it Refractive Surgery Shock Syndrome
(RSSS). Many patients experienced depression, No risk of globe rupture Requires commendable
due to trauma surgical skills
acute stress or anxiety and post-traumatic
syndrome features after refractive surgery. Early visual recovery
Common causes reported for this are Effective in correcting
improper counseling and surgical consent high degree myopia
for disturbing visual symptoms like halos, up to 25–30 dioptres
glare, starburst, and poor contrast sensi-
tivity. These symptoms hampered the tonometer gives an erroneous low values.
routine activities of younger generation, Therefore, to diagnose glaucoma these IOP
especially at night time. The RSSS condition value needs correction according to the new
is still under research process but is a corneal thickness.
significant complication if occur.
Laser Subepithelial Keratomileusis (LASEK)
• An unknown origin GAAP (Good Acuity
Plus Photophobia) syndrome is associated In the year 1999, Camellin introduced the
with uneventful femtosecond laser technique of LASEK which has combined
treatment. Usually after 4–6 weeks of advantages of both PRK and LASIK. LASEK
LASIK procedure a transient increase to similar to PRK avoid the corneal flap related
light sensitivity is reported, hence it is also complication because in LASEK an epithelial
called TLS (transient light sensitivity). Short flap is created after loosening the epithelium
duration topical steroid treatment completely by using alcohol and like LASIK it offers
resolves this condition without any minimal postoperative pain and faster visual
remnant long-term effects. recovery. LASEK can be considered an
alternative option in those patients where
LASIK has several advantages and a few LASIK is contraindicated like patients having
limitations as compared to RK and PRK, large pupils, thin, steep or flat cornea, deep-
which are summarized in Table 15.11. set eyes, glaucoma, etc.
Sequel of LASIK Surgical technique (Fig. 15.8): LASEK surgical
• Imprecise calculation of IOL power: Post- technique is almost similar to PRK (described
LASIK the cornea takes an oblate shape, on page 472) except the following steps
hence the mean keratometry readings used • Formation of epithelial flap: Unlike PRK
in IOL power calculation formula will give epithelium is not removed rather a hinged
an inaccurate emmetropic IOL power. epithelial flap is created by these surgical
• Imprecise IOP measurement: Central corneal steps
thickness is decreased after LASIK and – Flap trephination: Under topical anesthesia
hence the IOP measured by applanation using calibrated (70 μm depth) blade an
epithelial incison is given with a

microtrephine (8 mm in diameter) placed
centrally over the cornea. Microtrephines
are available in various sizes from
8–10.5 mm diameter and have a blunt
4 mm segment which spares the intact
corneal epithelium to provide a flap
hinge. Gentle pressure is applied on the
microtrephine to cut the corneal epithelium,
leaving a 4 mm flap hinge.
– Chemical de-epithelization: An alcohol cone
of the same diameter as microtrephine
is placed centrally over the cornea in
marked groove. 20% ethyl alcohol
prepared in cold water is then instilled
inside the alcohol cone (Fig. 15.8A). After
30 seconds, the alcohol is sucked out of
the cone with cellulose sponge. The Fig. 15.8: Surgical steps of LASEK. A. Chemical de-
entire corneal surface and conjunctiva is epithelization; B. Creation of flap; C. Surface
irrigated generously with BSS. At the ablation; D. Repositioning of epithelial flap
time of alcohol application it is recommen- • Therapeutic soft contact lens is applied over
ded to check the light reflex on the the cornea for a period of 6–7 days.
alcohol surface regularly, any movement Postoperative management is similar to
of reflex indicates the leakage of alcohol. PRK or LASIK as described on page 482.
– Creation of flap: Wait for another Differential favorable features of LASEK in
30–40 seconds so that alcohol treated comparison to PRK and LASIK are summarized
epithelium get released from Bowman’s in Table 15.12.
membrane. Margin of the epithelium is
then lifted with the help of a microhoe Epipolis Laser in Situ Keratomileusis (epi-
and epithelial debridement is started. LASIK)
Once epithelium is detached from In the year 2003, Pallikaris commenced a newer
Bowman’s membrane, then epithelial flap technique for correction of refractive errors
is smoothly assembled and slowly rolled which had all the advantages of LASEK and
towards the hinge with the help of also avoided the flap-related complications of
hockey stick spatula (Fig. 15.8B). LASIK. This recent technique is called epipolis
• Surface ablation: After rolling of epithelial LASIK (epi-LASIK or superficial LASIK),
flap, clear Bowman’s membrane is seen and where ‘Epipolis’ is a Greek word which means
then surface ablation is done by excimer ‘superficial’. Principle of this technique is that
laser within precalculated ablation zone to an epithelial flap is prepared by using an
correct the refractive error (Fig. 15.8C). epikeratome, rather than using alcohol (as in
• Repositioning of epithelial flap: Generously LASEK). Thus, in epi-LASIK the epithelial
irrigate the ablated corneal surface with BSS cells remain preserved and hence better
so that all the debris is removed completely healing and less postoperative complications
from corneal surface. Then epithelial flap occur. Less postoperative pain and corneal
is rolled gently and slowly over the haze along with quicker wound healing are
stromal bed using repositioning spatula some of the advantages of epi-LASIK seen
(Fig. 15.8D). over LASEK.
Table 15.12: Various advantages of LASEK in automated and disposable types of epikerato-
comparison to PRK and LASIK mes are available. A few examples of
commercially available epikeratome are
Over PRK Over LASIK
Morias Epi-K, Centurion Epiedge, Amadeus
Postoperative pain is Lower chances of II, Gebauer Epilift, etc. Epi-LASIK became the
less corneal ectasias procedure of choice in high degree myopes
Postoperative corneal Absence of corneal flap (>10 D) or in patients having thin cornea (<530
haze is less related complications μm), because there is an additional corneal
like free flap, button thickness of nearly 100 μm which is available
holing, etc. for ablation (similar to LASEK).
Improved epithelial Superior option for thin
healing, hence an cornea (at 480 μm Custom Laser In situ Keratomileusis
early recovery thickness > 6–7 D (C-LASIK)
myopia can be corrected) Conventional excimer laser surgery is the most
Postoperative Additional 90 μm cornea common refractive surgery for correction of
complications are available for ablation, refractive error, since, the visual outcome after
limited (additional 5 D myopic standard LASIK was not satisfactory in terms
correction) of high order optical aberrations like contrast
High order aberrations sensitivity and glare (specially, in night).
are excluded Various studies had concluded that a
Postoperative dry eye is proportionate increase in the spherical
less as corneal nerves are aberrations was seen in relation to corneal
preserved asphericity after conventional LASIK surgery.
Large zone treatment is In normal conditions anterior surface of
possible cornea gradually becomes flatter from center
towards periphery means cornea is prolate in
Surgical technique: Preoperative prepara- shape normally. After conventional LASIK,
tions and intraoperative steps of epi-LASIK the central cornea becomes flatter and
are similar to that of LASEK (as discussed on peripheral cornea becomes steeper means
page 486) however, the only difference is in become oblate shape. This causes an oblate
the formation of an epithelial flap. shift, which is directly proportional to the
amount of ablation. This change in corneal
Epithelial flap formation asphericity causes remarkable inconvenience
• For formation of an epithelial flap an in the quality of vision, although the visual
advance version of microkeratome called acuity remains well within normal range. To
epikeratome is used. This epikeratome improve the quality of vision and to maintain
create an epithelial flap (similar to corneal the corneal asphericity (i.e. reduction of high
flap) of precise thickness. order aberrations) the constant search to
• Commonly epikeratome consists of a blunt overcome these problems continued. In the
blade or a plastic or stainless steel separator. year 1999, Theo Seiler successfully treated one
This epikeratome moves slowly (as of his patients by customized laser ablation
compared to microkeratome) over the surgery and now C-LASIK is one of the
cornea inside a track controller, while preferred refractive procedures for correction
simultaneously it pushes away or slices a of errors. Various cases having high degree
much even epithelial flap. irregular astigmatism due to penetrating
As the epi-LASIK procedure has gained injuries, penetrating corneal grafts or
popularity in recent years, various types of extensive peripheral corneal scars cannot be
corrected by the conventional laser treatment, are required to correct the high order aberra-
hence they are treated by customized LASIK tions also.
technique. • Measurement of optical aberrations: All the
C-LASIK is also called ‘customized ablation’ aberrations of the eye are measured
LASIK, named because custom ablation is a using corneal topography and wavefront
pattern of ablation. This ablation pattern aberrometry devices. These devices are
includes the patient’s requirement and is so accurate and precise that a refractive
based on individual eye’s optical system and error of submicron level, i.e. 0.01 D can
anatomy. This customized pattern of laser be measured. This data is utilized to
ablation utilizes variety of treatment patterns design a customized ablation pattern
for spherical, cylindrical, aspherical and which is feeded in the laser machine.
asymmetrical errors and then the optical • Linking of data: All the measured data is
system of the eyes are optimized to remove combined with the help of software
them. For easy understanding we can compare which download this data on a floppy
the conventional LASIK procedure with a disc. This disc is inserted into laser
‘Readymade shirt’ present in cloth store as machine computer to guide and perform
ready to buy stock and customized LASIK ablation pattern.
with a ‘Tailor made shirt’ stitched by a tailor • Laser ablation: Customized ablation is
on order according to the exact fit for a done with a flexible laser delivery system
particular person. which can deliver small size laser spots
An exact evaluation of an individual eye’s (<1–2 mm size). This system is also
optical system is done with corneal topogra- equipped with an excellent eye tracking
phy and aberrometry. Thus, customized system or an eye stabilizing system. To
ablation selectively corrects all orders of achieve an accurate ablation, registration
aberrations present in an individual’s eyes. of wavefront data with laser machine
Customized optical ablations can be done and eye tracking system to eye is a
by using any one of the following techniques challenging step for surgeons. Any
discrepancy in entry of data will give an
• Corneal topographic guided ablation
unfavorable outcome.
• Wavefront guided ablation
Advantages of C-LASIK
As the name suggests the corneal topo- • High quality vision: As compared to standard
graphy guided ablation is done on those LASIK, C-LASIK gives a high quality vision
aberrations which are identified during with reduced risk of night glare and halos.
corneal topography. In this the laser treats the Contrast sensitivity is better with C-LASIK.
corneal irregularities as an integral part of the • Less invasive: Comparatively C-LASIK is a
treatment plan. less destructive technique than conven-
Similarly, the wavefront guided ablation tional procedure. It ablates a lesser amount
works on the aberrations which are produced of corneal tissue to achieve the desired effect.
by the entire human optical system and can • Correction of irregular astigmatism: As
be detected by the wavefront measurement discussed before, cases following penetra-
devices. ting injuries, penetrating corneal grafts or
Technique of C-LASIK: As discussed peripheral corneal scars can be treated by
above the C-LASIK is an advancement C-LASIK. Nearly 40% of eyes have some
procedure of standard LASIK, hence majority degree of corneal irregularities. These eyes
of steps are same as that of a standard LASIK can also be treated by customized procedure
procedure. However, for customized ablation and shows better results than conventional
in C-LASIK technique a few additional steps method.
• Achievement of super-vision: As compared to – Third plane (c) is created from central to

conventional LASIK, the visual acuity up peripheral cornea about 0.5 mm more
to 6/4 or 6/3 can be achieved. The visual than posterior surface of lenticule. This
acuity of human retina is usually reduced represents the anterior surface of
due to presence of high-order aberrations lenticule.
and diffraction of light. It is seen that chances – Final incision (d) is made at 30–50 degree
of high-order aberrations are more with angle usually superior or superotempo-
conventional LASIK than custom-LASIK. ral (to preserve the nasal and temporal
corneal nerves and surgical ease) in
Corneal Lenticule Extraction Procedure peripheral cornea from edge of anterior
The most recent advancement in the correction lenticule surface to entire thickness of
of myopia is corneal lenticule extraction corneal surface to access the lenticule.
popularly called SMILE (small incision • The entire femtosecond laser procedure
lenticule extraction) procedure. takes about 25 seconds and then the suction
Principle: Four photoablative incisions are is switched off automatically. Patient eye
made in a sequence by femtosecond laser is repositioned after releasing the contact
which creates a corneal stromal lenticule and glass interface underneath the operating
corneal incision. This corneal lenticule is then microscope.
extracted by either creating a flap (similar to • Corneal incision is opened using a sharp
LASIK) or from a corneal incision with the tipped delicate instrument and then the
help of a blunt forceps. anterior surface of lenticule is separated
gently and uniformly by using a blunt
Surgical technique
spatula.
• Procedure is performed under topical
• Using the same sharp tipped instrument the
anesthesia after cleaning and draping the
posterior surface of lenticule is opened and
eye similar to other refractive procedures.
• The positioning of eye is done under a
curved contact glass interface and proper
positioning of the head of patient is done
to avoid nasal contact of the interface.
Centration of the eye is done by instructing
the patient to look at fixating light.
• Suction is started so that cornea will be held
adjacent to the contact glass interface. Now
the femtosecond laser is applied to create
various photoablative incisions to create
intrastromal lenticule and corneal incisions
– First incision plane (a) is made from
peripheral cornea to central cornea
creating the posterior lenticule surface of
predetermined diameter depending on
the size of optical zone.
– Vertical 360 degree edge (b) is created Fig. 15.9: Photoablative incisions of SMILE. a. First
along the perimeter of lenticule according incision plane; b. Vertical incisions 360 degrees;
to the precalculated depth equivalent to c. Third incision for posterior lenticule surface;
the thickness of lenticule. d. Corneal incision for lenticule extraction
then using blunt spatula the posterior remove the lenticule because it gets stuck
surface is separated uniformly from the to overlying cornea.
corneal stromal bed. Postoperative complications: These are very
• Once these two planes of lenticule are less compared to other corneal refractive
separated, then using blunt microsurgical procedures. However, following complications
forceps the lenticule is manually extracted can occur in small percentage of cases
through the small corneal incision. • Fine scarring with interface inflammation
• Balanced salt solution is used to flush the can occur at the edges of corneal incision
corneal pocket with the help of a fine blunt site or lenticule, however, it is not in
tipped cannula. pupillary area, hence no visual symptoms
• Postoperative treatment is similar to LASIK are seen.
procedure as described on page 482. • At incision site there may be epithelial in-
growth, which is usually self limited and
Complications require no additional treatment.
Intraoperative complications: Rarely, some • Occasionally corneal microstriae are seen.
intraoperative complications can occur during • Complications like dry eye, night glare or
SMILE procedure as follows. decreased contrast sensitivity are seen in
• Sudden loss of suction can occur during lesser magnitude compared to other
femtosecond treatment either due to refractive procedures.
patient's errors like sneezing or moving Comparison with Femtosecond LASIK
head or due to machine faults like gas • Intrastromal lenticule is created within the
bubble migration, fluid entry between corneal substance, hence SMILE is
suction ports. Once the suction is lost, the independent of treatment factors like
laser system automatically goes into restart corneal hydration, depth of ablation,
mode. Depending upon the timing of atmospheric temperature and humidity.
suction loss the procedure can be restarted. • Total procedure time in SMILE is markedly
For example, suppose if suction is lost at short because only single laser platform is
the time of posterior lenticule surface required unlike femto LASIK where two
creation (<10%) then restart the SMILE platforms (one to create corneal flap and
procedure and if suction loss occurs when second for photoablation) are required.
>10% posterior lenticule creation is done • SMILE is cost effective in terms of capital
then switch over to LASIK procedure. When investments, maintenance and consumable
suction is lost during side cut stage of either costs.
posterior or anterior surface of lenticule, • Higher order aberrations, especially spherical
then repeat the side cuts with decreasing are appreciably less in SMILE.
the lenticule diameter by 0.2–0.4 mm. • Amount of corneal tissue requirement per
• Microepithelial abrasions at corneal incision dioptre correction is less compared to
site may occur during laser treatment. excimer LASIK because the peripheral loss
• Minute corneal tears at incision site during of energy fluence is not present with
opening of corneal incision may occur. femtosecond laser.
• Selection of wrong tissue plane during • Corneal nerve arcades are relatively well-
separation of anterior lenticule surface from preserved during SMILE because no
overlying corneal plane. Sometimes, the corneal flap is created.
posterior lenticule surface plane is • Postoperative wound healing is faster and
separated instead of anterior surface of better because very small corneal incisions
lenticule and then it becomes difficult to are made during SMILE procedure.
Intraocular Refractive Surgeries is the procedure of choice with high power

• Refractive lens exchange (RLE) foldable IOL implantation. Sometimes in
• Phakic refractive lenses (PRLs) myopes only removal of crystalline lens will
achieve emmetrope status means the IOL
Refractive Lens Exchange power requires to achieve emmetropic state
History: In earlier time even before the is zero but still it is advisable to implant a zero
invention of IOLs, in the year 1890 extraction power IOL rather than keeping the patient
of clear crystalline lens was advocated to treat aphakic, since IOL implantation decreases the
unilateral cases of high myopia of –15 to chances of retinal complications and posterior
–20 dioptres, which was commonly called capsular opacification.
Fukala’s operation. However, due to high Refractive lens exchange is an intraocular
incidence of post procedure retinal detach- surgery, hence the complication of the
ment, this procedure never gained popularity. procedure is similar to any other intra-
In last century the ophthalmic surgery had ocular surgery. Therefore, the surgeon
continuously improvised with invention of must choose RLE procedure weighing
better techniques and equipment for between the surgical complications and
extraction of crystalline lens and IOL insertion. expected visual outcome. Various inclusion
These recent innovation encouraged the and exclusion criteria for RLE are summari-
surgeons to consider the refractive lens zed in Table 15.13.
exchange (RLE) procedure for correction of As RLE is a refractive procedure and not
high degree myopia or hypermetropia in cases the routine conventional cataract surgery
which were not fit for correction by laser certain specific preprocedure evaluations
surgeries. along with routine examination are recommen-
Significantly high myopia (25–30 D) is ded for better visual outcome and patient’s
treated by clear lens extraction by phacoemulsi- satisfaction.
fication and an appropriate power foldable Detailed preoperative evaluation: Majority of
IOL is implanted. Similarly, in high hyper- patients planned for clear lens extraction are
metrope (+8 to +14 dioptres) phacoemulsification myope, hence the meticulous evaluation of
Table 15.13: Various exclusion and inclusion criteria for refractive lens exchange
Inclusion criteria Exclusion criteria
High degree myope or hypermetrope in Young moderate to high degree myopic patients are
presbyopic age, because complete loss of better treated with phakic IOLs.
accommodation occurs after RLE.
Correction of regular high degree astigmatism Young hyperopic patients are included only when
not getting corrected by corneal refractive phakic IOL is contraindicated because of shallow
surgeries. Toric IOLs can be successfully anterior chamber, otherwise they are excluded from
implanted in these cases. RLE.
Very high degree refractive error (myopes > Patients having retinal conditions like macular
12 D and hyperopes > 7 D) not getting degenerations, peripheral degenerations, retinoschisis
corrected by corneal refractive surgeries or and retinal tears or holes are not included because
where phakic IOLs are contraindicated. the potential visual outcome is unfavorable after RLE.
Borderline presbyope with high degree hyper- Young patients having very high expectations of
metropia can be included for multifocal IOL visual outcome or very apprehensive about RLE.
implantation.
following retinal lesions are mandatory along Postoperative complications: In RLE the
with measurement of IOP immediate or late postoperative surgical compli-
• Examination for vitreous degeneration cations are similar to any conventional cataract
• Examination for retinal degeneration surgery but there may be some additional
• Lattice degeneration with or without hole. intraoperative and postoperative complica-
All these lesions should be looked prior to tions due to high refractive ocular status.
surgery, as high degree myopes are prone for In high myopes
these retinal changes. If these lesions are • Capsular bag is unstable so capsulorr-
present they should be treated by photocoagu- hexis is a little risky and in some cases
lation or cryotherapy before RLE procedure. capsular tension rings are required to
Generally, patients having macular degenera- perform capsulorrhexis.
tion will have poor visual outcome, however, • Large axial length is a risk factor for
they may get better field of vision after RLE, increased percentage of subchoroidal
hence should be informed to patient before hemorrhage.
procedure. • Eyes having axial length >25 mm are at
IOL power calculation: Calculation of IOL more risk for capsular bag syndrome.
power should be perfect to achieve good • Increased postoperative complications of
visual outcome after RLE. IOL power is retinal detachment due to longer axial
dependent on axial length of eye, keratometry length, vitreous and retinal degeneration,
reading of cornea and formula applied for posterior vitreous detachment and
power calculation so following points are retinal holes.
advised In high hypermetropes
• Immersion technique for measurement of • Shallow anterior chamber gives poor
axial length is superior to contact technique. surgical space for phacoemulsification
• Automated keratometry is superior over and IOL insertion.
manual keratometer. • Small axial length is a risk factor for
• Optical interferometry based IOL power increased percentage of choroidal
calculation by use of IOL master gives effusion syndrome.
perfect readings. RLE has a high potential to correct even
• Several studies concluded that most appro- high degree refractive errors but its clinical use
priate formula for IOL power calculation is limited in patient’s having clear lens,
in case of myopia is Haigis formula and in because of these specific complications not
case of hypermetropia is any one formula seen in routine cataract surgeries. Recently, a
among Hoffer Q, SRK/T, Haigis or huge progress has been done in the field of
Holladay. IOL power calculation, IOL designing and
Surgical technique microsurgical instrumentation so gradually
• Phacoemulsification with foldable IOL RLE is also getting a wider acceptance as
implantation is the procedure of choice. refractive surgery.
• Continuous circular and curvilinear
capsulorrhexis is prerequisite. Keep the size Phakic Refractive Lenses
of capsulorrhexis a little smaller than optic Earlier in the year 1954, Strampelli introduced
of IOL for better centration. the idea of correction of high degree refractive
• Meticulous flawless phacoemulsification of errors using refractive lenses, but only in last
crystalline lens with minimum surgically two decades these photorefractive lenses
induced astigmatism is done because RLE gained popularity as an indispensible tool in
is a refractive surgery. refractive surgery. Usually, the refractive
power of eye is modified by altering the power

of two refracting surfaces, i.e. cornea and lens.
The refracting power of cornea and crystalline
lens can be altered using laser corneal surgery
and refractive lens exchange, respectively.
There is another possibility to change the
refracting power of eye by introducing third
refracting surface without touching cornea or
natural crystalline lens, which can be done by
using phakic refractive lenses (PRL). High
degree refractive errors either myopic or
hyperopic can be corrected by PRL with
precise predictable surgical outcome. PRL is
mainly indicated for correction of high degree
refractive errors in young patients having
healthy eyes and stable refraction. Patients of Fig. 15.10: Acrysof Cache phakic intra-ocular lens
more than 50 years age having diabetic
retinopathy and/or glaucoma are contraindi-
cations for PRL procedure.
Depending on the intraocular position these
phakic IOLs can be broadly classified as
shown in Table 15.14.
• Acrysof Cache phakic IOL: This lens is
made up of hydrophobic acrylic material
having an optic of 6 mm and four haptics
to fit exactly in anterior chamber as
shown in Fig. 15.10. Lens is available in
sizes 12.5 mm, 13 mm, 13.5 mm or 14 mm
with power range from –6 to –16 D.
Fig. 15.11: NuVita MA phakic intra-ocular lens
• NuVita MA phakic IOL: Kelman designs
IOLs were modified by Baikoff who IOL having an optical zone of 4.5 mm
designed angle fixated anterior chamber and optical diameter of 5 mm. Long legs
IOLs. These original lenses had of this lens engage the angle of eye and
25° angulations with 4.5 mm optics. In optic remains in front of pupillary area
second modification Baikoff's reduced as shown in Fig. 15.11. Power range
angle to 20° at the cost of reduced optical available for myopia correction is –6 D
diameter. Later on other modifications to –20 D. Several modifications are done
in the design leads to NuVita MA phakic in past 10 years to decrease the endothelial
Table 15.14: Various designs of phakic IOLs

Anterior chamber phakic IOLs
Posterior chamber Phakic IOLs
Angle supported Iris supported
Acrysof Cache IOL Artisan ICL (Implantable contact lens)
Nuvita MA IOL Artiflex PRL (Phakic refractive lens)
Kelman duet IOL
Vivarte IOL
Note: Foldable anterior chamber angle fixated

phakic IOLs are Vivarte IOL and Kelman duet IOL.
damage and iris damage by this lens.

Glaucoma and intraocular inflammation
are main long-term problems with this
lens.
• Artisan: This lens is made up of PMMA
material having an optic of 5 mm/6 mm
and two claw-shaped haptics to grasp the
iris muscle in mid-periphery as shown
in Fig. 15.12. Total size of the lens is
8.5 mm and as this lens is fixed in mid-
Fig. 15.13: Artiflex IOL phakic intra-ocular lens
periphery of iris there is no need of
different sizes for various length of myopia in power range of –2 to –14.5 D
patient’s eye. 5 mm optic artisan is and myopic astigmatism up to –7.5 D.
available in power range of –2 to • ICL: These posterior chamber phakic
–23 D, +2 to +12 D and up to 7.5 D for IOLs (ICL and PRL) are also known as
myopic, hypermetropic and astigmatic implantable contact lens. ICL is made up
patients, respectively. However, 6 mm of hydrogel collagen co-polymer having
optic artisan is presently available a plate design haptic with 4.5 to 5.5 mm
only for myope in power range of size optic. This foldable lens design can
–2 to –15.5 D. be inserted through 2.5 mm incision and
• Artiflex: This lens has a 6 mm optic, made its four haptic design plate facilitates
up of polysiloxane material and two claw proper fixation in the ciliary sulcus.
shaped haptics made up of PMMA Haptic plate has a forward vault to
material as shown in Fig. 15.13. Overall minimize the IOL crystalline lens touch
diameter is 8.5 mm and is available for as shown in Fig. 15.14. Available in
power range of –3 to –23 D, + 3.0 to
Fig. 15.12: Artisan IOL phakic intra-ocular lens Fig. 15.14: Visian ICL
+ 21.5 D and up to –6 D for myopia, • Posterior segment examination: Indirect

hypermetropia and myopic astigmatism, ophthalmoscopy is done for detail fundus
respectively. Various sizes of ICL for examination with sclera depressor to see the
myopia and astigmatism are 11.5 –13 mm periphery. Any retinal lesions should be
and for hyperopia are 11 –12.5 mm, in recorded and if needed should be treated
0.5 mm steps. before surgery.
• PRL: These lenses are made up of silicon • Intraocular pressure is measured accurately.
material and require no fixation to ciliary Along with these routine examination some
sulcus. These lenses float on the surface important assessments are also done for PRL
of crystalline lens by their unique insertion such as
hydrophobic material and aqueous flow • Anterior chamber depth: This is an
dynamics. Width of ICL is 6 mm for both important parameter to be measured from
myopic and hypermetropic patients, corneal endothelium to anterior surface
however, thickness of lens varies with of crystalline lens. Anterior chamber (AC)
the dioptric power to a maximum of depth can be measured by use of Orbscan,
0.6 mm as shown in Fig. 15.15. ICL is Pentacam, IOL master or OCT. Although
available in power range of –4 to –22 D UBM can also measure AC depth but are
and +3 to +16 D for myopia and hyper- not preferred because the corneal
metropia, respectively. thickness is also added in the total
Preoperative evaluation: Similar to routine measurement value. Normal desirable
preoperative evaluation as in other intraocular safe AC depth is 3–3.2 mm for PRL
surgery following examinations are done in insertion, AC depth less than 2.8 mm is
case of PRL. considered as unsafe. In shallow AC
• Vision and refraction: Uncorrected and best chances of endothelial cell loss after PRL
corrected visual acuity should be recorded insertion is very high.
and meticulous objective, subjective and • Anterior and posterior chamber size:
cycloplegic refraction is done to assess exact Measurement of anterior chamber size is
refractive status of eye. prerequisite for implantation of an angle
supported PRL because in improperly
• Anterior segment examination: Detailed
matched measurements chances of PRL
slit lamp examination must be done.
rotation and decentring are higher.
Similarly, posterior chamber size is
important in case of sulcus fixating PRL
because any miscalculation will lead to
either occlusion of AC angle (large size
PRL) or crystalline lens touch and cataract
formation (small size PRL). These
measurements can also be done with
Pentacam or Orbscan, however, OCT gives
quite accurate measurement of anterior
chamber size.
• Pupil size and configuration of iris:
Measurement of pupil size is done in
mesopic conditions and for a successful
PRL implantation the criteria is that
difference of more than 1 mm in pupil size
Fig. 15.15: PRL phakic IOL intra-ocular lens and PRL optic in mesopic conditions is
unacceptable. Normal individuals has flat be used through side port to support the
configured iris, whereas high hypermetro- correct unfolding of lens. Slowly pull the
pes has convex-shaped iris configuration. cartridge outside while trailing IOL
For implantation of iris fixating PRL the haptic is inserted into the eye. Wash the
eyes with convex configured iris are not viscoelastic thoroughly using irrigation/
suitable. Accurate evaluation of iris configu- aspiration (I/A) cannula manually.
ration is done by OCT. – Iris fixated anterior chamber IOL: For
• Endothelium profile: Normal healthy example, Artisan IOL insertion is done
endothelium having low polymegathism through a large corneal or scleral incision
and/or pleomorphism with a cell count of of 5.5–6.5 mm length. Two sides are
minimum 2400 cells per cubic mm is needed made at 10 o’clock and 2 o’clock positions
for a successful PRL implantation. with a main incision of 5.5–6.5 mm size,
superiorly. Inject viscoelastic preferably
Surgical techniques
high density in anterior chamber. Insert
• Phakic IOLs can be implanted in topical, the IOL in anterior chamber holding with
peribulbar or general anesthesia depending lens holding forceps and rotate it in
upon the surgeon’s choice and situation. horizontal position. Fixate the IOL in
However, for nonfoldable IOLs (for midperipheral region of iris by using a
example, NuVita or Artisan), peribulbar or blunt needle through side port and
general anesthesia is recommended. pressing the lens optic through main
• For anterior chamber IOL (either angle port. Each claw of IOL must be grasping
fixated or iris fixated) miosis is required, at least 1 mm of iris tissue. Wash the
hence 2% pilocarpine drops are instilled viscoelastic thoroughly using I/A
15–20 minutes prior to surgery. However, cannula manually.
posterior chamber IOL insertion requires – Posterior chamber phakic IOL: For example,
well dilated pupil so topical tropicamide ICL insertion is done through clear
(1%) with phenylephrine (1%) drop is corneal 3.2 mm incision made temporally.
instilled 2–3 times at an interval of 10 minutes Two side ports at 6 and 12 o’clock
prior to surgery. position with a clear corneal 3.2 mm
• Cleaning and draping of eye is similar to temporal main incision are made. Inject
other refractive procedure, however, the viscoelastic preferably high density in
following surgical steps are different for anterior chamber. Most crucial and
various design phakic IOLs. important part is proper and precise
– Angle fixated anterior chamber IOL: For loading of the ICL in the cartridge. Once
example, insertion of Acrysof cache IOL loaded cartridge inserted in the anterior
is done through clear corneal main chamber and ICL is injected slowly into
incision of 2.8 or 3.2 mm. Side port of the anterior chamber while surgeon
0.8–1 mm is made at 9 o’clock position keeps an eye on the mark on leading and
and main incision is made superiorly, trailing haptic. Leading haptic mark
while taking care of anterior lens capsule. must be on right side and trailing haptic
Inject viscoelastic preferably of high mark on left side of operating surgeon.
density in the anterior chamber. IOL is Once ICL is placed in anterior chamber,
loaded inside the cartridge and then slowly press the tip of haptic using a soft
cartridge is inserted through main tip lens manipulator to posterior chamber.
incision. Now slowly and constantly Never press the optic of ICL. Wash the
inject the lens while keep a check on viscoelastic thoroughly using I/A cannula
correct unfolding of lens. Blunt dialor can manually.
Note: In case of Acrysof cache IOL, iridectomy is • Occasionally, postoperative decentration of

not essential, however, in rest of phakic IOLs IOL in case of iris fixated phakic IOLs has
iridectomy must be done during surgery or been reported.
preoperatively using YAG laser. • In small percentage of patients giant
granular cell deposits are seen on IOL
Postoperative treatment surface, after Artiflex IOL insertion.
• Topical antibiotics/steroids eye drops for • Variable percentage of cataract formation
6–8 times/day for a period of 2–4 weeks with ICL lens insertion has been reported
with gradually decreasing the frequency of by many studies. However, it can be
instillation. prevented by proper assessment of
• Topical lubricants 4–6 times/day for a posterior chamber depth and accurate ICL
period of 4–6 weeks and later on as and length calculations.
when needed.
Several studies have compared the
• Precautions to be taken as after LASIK advantages and disadvantages of phakic IOLs
surgery described on page 482. in relation to other refractive procedures
• Follow-up is similar to LASIK as described specially PRK and LASIK. These advantages
on page 482. and disadvantages are summarized in
Complications of phakic IOLs: In a planned Table 15.15.
and well-executed surgery there are literally
no complications seen with phakic IOL Miscellaneous Corneal Refractive
insertion, however, a few complications can Techniques
occur during phakic IOL insertion or post • Orthokeratology
procedure as follows • Intrastromal corneal ring segments
• Possibility of reverse implantation, i.e. • Intracorneal lenses
upside down insertion of foldable phakic • Gel injection adjustable keratoplasty
IOLs is present. This can be avoided by
carefully monitoring the mark on IOL while Orthokeratology
leading haptic is opening inside the eye. Orthokeratology means reshaping of the
• A few cases of iris bleeding during iridectomy cornea by applying pressure and flattening of
has been reported. This can be prevented the central portion of the cornea. In ancient
by using high density viscoelastic or China, a concept of correction of distance
performing YAG laser iridectomy. vision was to apply the weight over eyelids
Table 15.15: Advantages and disadvantages of phakic IOLs in comparison to LASIK and PRK
Advantages Disadvantages
Correct very high degree of refractive errors not Intraocular procedure, possibilities of intraocular
suitable for other procedures infection is higher
Maintain accommodation Early cataract formation, specially in ICL
Not associated with regression (wound healing) Endothelial decompensation, specially with anterior
chamber phakic IOLs
Reversible procedure with expected outcome Intraocular hemorrhage due to iridectomy
Maintain prolate shape of cornea hence better Iris atrophy and pupil deformation with iris fixated
vision quality IOLs
Add on procedure can be done to correct Chronic anterior uveitis with anterior chamber IOLs
residual refractive error
during sleeping. Considering this concept first • Corneal surface mapping is done by corneal
time in the year 1962, George Jessen used topography method with four recordings
PMMA contact lenses of zero power (Plano in each eye.
lenses) flatter base curve than the central • Calculate the average apical curvature and
corneal curvature for correction of myopia. eccentricity of cornea from these mappings.
After introduction of rigid gas permeable Usually patients having steep apical
contact lenses in year 1980s and a progressive curvature (more than 44 D) and high
development in the field of corneal topography, eccentricity (more than 0.55) are good
a leap change occurred in orthokeratology. In candidates for orthokeratology because
modern days, orthokeratology or Ortho-k maximum correction is possible with these
fitting has become a valuable non-surgical corneal parameters.
technique to treat the refractive errors • Measure the horizontal visible iris diameter
specially myopia (mild to moderate degree) (HVID) and record the value separately for
and astigmatism. each eye.
Indications: Orthokeratology has been tried • Once these parameters are calculated then
to correct all types of refractive error and even the parameters of corrective contact lens are
presbyopia, however, it is a useful technique calculated using these data to correct the
to temporarily reshape the cornea in these desired amount of refractive error.
following conditions • Alternately, a trial lens of similar para-
• Progressive myopia in young child meters can be tried for one night wear and
• Low to moderate degree myopia (–2.5 to next day morning the evaluation of trial
– 6 dioptres) and/or low degree astigmatism lens fit can be assessed by recording visual
(up to 2.5 dioptres) for any age group. fluorescein pattern, corneal topography
• Younger myopes (< 18 years), who cannot mapping and unaided visual acuity.
be considered for LASIK. • Suppose if trial lens fit evaluation is
• Patients having unstable or frequently satisfactory then individual corrective
varying amount of refractive error. (custom ordered) contact lens with specific
• Sports persons having restrictions in parameters is ordered to lens manufacturers.
wearing spectacles or contact lenses. • Therapeutic schedule for majority of
• Early presbyopes (still under evaluation) custom ordered contact lens designs is that
Orthokeratology technique wear the lenses daily for 6–8 hours duration
• Cycloplegic refraction is done to record the continuously in daytime (awake) and in
accurate values of spherical and cylindrical some specific designs, wear even during
powers. However, spectacle power can also nighttime (sleep).
be taken with vertex distance correction • Usually, custom ordered contact lenses
without compensating for spherical takes 8–10 days to reflect the full effect of
equivalent. correction so patients should keep patience
• Anterior segment examination with slit to wait for improvement in unaided visual
lamp is done to rule out any corneal acuity.
pathology or epithelial defects. • Once satisfactory visual acuity and expected
• Tear film evaluation by Schirmer’s test and correction in corneal reshaping has been
tear break up time (TBUT) test is done to achieved, then wearing schedule is modified
rule out dry eye and tear film instability into maintenance schedule.
because unstable tear film may cause • Maintenance schedule require wearing of
difficulty in fitting of corrective contact corrective lenses for a few hours in a day
lens. during awake usually for 2–3 days a week
or as needed just to maintain the corrected cause the flattening of cornea. Principle of this
corneal shape and continued to have good technique is that a vaulting effect is produced
unaided visual acuity. after insertion of intrastromal corneal ring
Complications: Orthokeratology is a non- segments in the cornea which shortens the
surgical technique hence complications are central arc of the cornea. This helps in correction
very less, however, symptoms of foreign body of myopia and astigmatism. The diameter of
sensation, glare and ocular discomfort had ring is related in inverse manner to the amount
been reported by small percentage of patients. of flattening of cornea, hence smaller the
Rarely, potential complications like microbial diameter of ring, more will be the flattening
keratitis can occur due to continuous wear of and higher degree of myopia gets corrected.
contact lenses. Regular follow up and early Keratoconus is characterized by increased
treatment is the only effective method to curvature and thinning of the cornea. In
prevent microbial keratitis. keratoconus, the coefficient of elasticity of
Various benefits and limitations of ortho- cornea is reduced, as a result, the resistance
keratology are summarized in Table 15.16. offered by cornea to prevent deformation of
cornea is reduced which in turn causes
Intrastromal Corneal Ring Segments increased stress on the cornea and forward
projection of it. Stress is the force applied per
Earlier in the year 1978, Fleming and
unit area means stress is focally more in apical
associates developed synthetic intracorneal
area causing corneal thinning in keratoconus.
implants in the shape of complete ring
When the area is large with the same amount
termed intracorneal rings. They inserted these
of force the stress can be decreased on per unit
intracorneal rings in the eye through a
area. In keratoconus intracorneal rings
peripheral corneal partial thickness incision.
redistribute the corneal curvature which
However, difficulties occurred during
causes redistribution of stress in apical area
insertion of these rings lead to modification
and hence break the biomechanical disease
in the shape of rings. The complete rings were
progression.
later modified and made into two ‘C’-shaped
segments and renamed intrastromal corneal Intrastromal corneal ring segment designs:
ring segments. Currently two types of intrastromal corneal
Principle: Barraquer and Blavatskaya ring segments are available
hypothesized that intracorneal rings behave • Intacs segment
like tissue additives, which when placed will • Ferrara ring segment
Table 15.16: Benefits and limitations of orthokeratology

Benefits Limitations
Reversible non-surgical alternative correction Offers temporary correction of refractive error
method for refractive errors
Safe and reproducible procedure Require longer duration to get desired visual outcome
All age group patients can be treated Repeatedly needs to wear the corrective lenses to
maintain the correction
Require no costly equipment or advanced Only low degree refractive errors mainly myopia and
surgical skills, hence cost effective astigmatism can be corrected
Easy acceptance and faster patient adaptation
Effective and desirable visual results without
any visual aids.
Intacs segment: Intacs segments are available • External diameter is 6.6 mm and inner dia-
in pair which are made up of PMMA material, meter is 5.4 mm as shown in Fig. 15.16B.
each with an arc length of 150° as shown in • Arc length is 120° and 160°.
Fig. 15.16A. External diameter of ring is • Thickness of segment range available
8.1 mm and inner diameter is 6.77 mm with a from 150 to 350 μm in 50 μm increments.
positioning hole diameter of 0.28 mm. • Cross-sectional shape is triangular due
Transverse section of ring is hexagonal shape to this shape a prismatic effect is created
and longitudinal section is conical shape with which eliminates the halo phenomenon.
thickness ranging from 250 μm to 450 μm in
Various indications and contraindications
50 μm increments.
of insertion of intrastromal corneal ring
Note: Currently new design Intacs segments are segments are summarized in Table 15.18.
introduced for correction of myopia called Intacs
Preoperative evaluation: Depending on the
SK. This segment has oval shape transverse section
and inner diameter is 6 mm. amount and type of correction, the number and
thickness of intrastromal corneal ring segments
Nomogram for Intacs: Amount of refractive is decided. Routine systemic and ocular exami-
error correction is dependent on the thickness nations are done as in other refractive surgeries.
of Intacs ring selected for surgery and is Following evaluations are important to achieve
summarized in Table 15.17. good visual outcome in selected patients.
Ferrara ring segment: In the year 1986, • Uncorrected visual acuity (UCVA) and best
ophthalmologist Ferrara introduced modified corrected visual acuity (BCVA)
PMMA rings for correction of moderate degree • Spherical and cylindrical power
of myopia. Subsequently in 1994 he developed • Manifest refractive spherical equivalent
a procedure to implant this ring segment in an (MRSE)
intrastromal corneal tunnel and then in the year • Corneal pachymetry for thickness
1996 he substituted the single ring with a pair of
• Keratometry (K) value
ring segments. These rings are popularly called
• Corneal topography
as Keraring and can correct higher degree of
myopic error compared to Intacs segments. • Examination of anterior segment
Characteristic features of Ferrara ring Surgical implantation method for rings
segments (Keraring, Fig. 15.16B) are • Anesthesia: Commonly rings are implanted
• Rings are made up of PMMA CQ-acrylic under topical anesthesia with or without
material. oral sedation.
Fig. 15.16: Intracorneal ring segments. A. Intacs segments; B. Keraring segments

Table 15.17: Nomogram for correction of refractive widened manually using 270° dissection
error gliders and spatula. Alternately, these
corneal pockets can also be made by
Intacs Myopia Average
thickness correction correction
femtosecond laser.
(in μm) dioptres (D) dioptres (D) • For insertion of Intacs segments an
instrument is required which generates
250 1.0–1.5 1.3
vacuum in the suction ring and also has
300 1.6–2.3 2.0
lamellar dissector to create stromal
350 2.4–3 2.7
channels. Suction ring is applied much
400 3.1–3.9 3.5
similar to LASIK procedure and pressure
450 4.0–4.5 4.2
is checked. At an appropriate pressure the
• Corneal marking: For Intacs, marking of lamellar dissector is placed inside the
geometric center of the cornea is important corneal pockets, which create two semicir-
which can be done by 11 mm zone marker cular stromal tunnels at 180° apart by
using Sinskey hook. For Keraring, marking dissecting the corneal stroma using
of pupillary center is required which can rotational movement of dissector.
be done preoperatively. • Femtosecond laser can be used instead of a
• Corneal thickness: Intraoperatively thick- lamellar dissector or manual dissector to
ness of cornea is measured at incision site create stromal channels for insertion of
and an average of five readings is recorded. segments. Photodisruptive infrared wave-
• Corneal incision: A 1.8 mm radial corneal length femtosecond laser is used to create
incision is made by using a calibrated the tunnels at predetermined stromal depth
diamond blade (for nearly 70% of average ranging from 120 to 400 μm. This laser pro-
corneal thickness). Usually incision is made duces smooth walled and of precise depth
at an axis perpendicular to steepest corneal and diameter tunnels once the required
meridian at inferior position (6 o’clock) and parameters like incision length, width,
in superior position (at 12 o’clock), about inner and outer diameter with depth of
7 mm away from the optical zone. Incisions tunnel had been entered properly in the
are made in such a manner that implants database.
can be placed nasally and temporally. • Ring insertion: Once the appropriate
• Corneal pockets: On either side of incisions tunnels are created either manually,
corneal pockets are made (nearly 70% of mechanically or by laser, two ring segments
corneal depth) using modified microspatula are inserted inside the tunnels, one segment
in clockwise and anticlockwise directions. clockwise and another segment anticlock-
For Keraring insertion these pockets are wise. Rings are placed in such a manner that
Table 15.18: Various indications and contraindications of intrastromal corneal ring segments
Indications Contraindications
Low to moderate degree myopia High (>45 D) mean K-reading
Progressive keratoconus Collagen vascular diseases
Pellucid marginal degenerations Recurrent corneal erosion syndrome
Myopia/astigmatism in thin cornea Corneal dystrophy
Corneal irregularities after PK or trauma High degree astigmatism after PK
Corneal ectasias after LASIK Chronic treatment with drugs like amidarone,
isoretinoin or sumatriptan
Postradial keratotomy Pregnant and lactating women
a gap of about 15–20° nasally and 35–40° Note: Femtosecond laser assisted procedures has
temporally is left. Ends of rings are inserted very less complications specially the microbial
to a length in such a way that about 2 mm keratitis and ring displacement.
and 1.5 mm distance is left from inferior and
superior incisions, respectively. • Corneal neovascularization around channels
• Wound closure: Once rings are placed • Visual symptoms, e.g. glare and halos
properly at desired depth and length, the Comparative benefits and limitations of
incision wounds are closed by one or two intrastromal corneal ring segments over laser
interrupted 10–0 nylon suture. These sutures ablative refractive procedures are summarized
are usually removed after 12–15 days time in Table 15.19.
to prevent any associated infections.
Intracorneal Lenses
Postoperative treatment
Intracorneal hydrogel lenses: In the year 1967,
• Topical antibiotic eye drops are prescribed
first hydrogel lens was developed for
for 7–10 days in a frequency of 4–6 times/day.
refractive keratoplasty to correct the high
• Steroids eye drops are prescribed for one
myopia, hypermetropia or aphakia. These
month period in gradual decreasing
implants were initially prepared of hydroxy
frequency starting with 4–6 times/day.
methyl methacrylate (HEMA) having
• Lubricating eye drops preferably preser-
refractive index similar to cornea (1.37). The
vative free drops are given 6–8 times/day
properties of intracorneal hydrogel lens
for a period of 4–5 weeks.
material are
Complications: In expert hands with proper • Water content is high in range of 70 to 80%
precautions complications of intracorneal ring • Lens diameter in the range of 5.0–6.5 mm
segments are negligible, however, following • Lens thickness differs as per the type of lens,
complications can occur in small percentage e.g. for myopia the peripheral thickness is
of cases more, whereas for hypermetropia the
• Improper refractive correction central thickness is more. Moreover, after
• Deposits in tunnels implantation the thickness of lens increases
• Superficial microbial keratitis because it absorbs the water and permits
• Migration or expedition of segments. the nutrients to flow across.
Table 15.19: Advantages and limitations of intracorneal ring segments in comparison to laser ablative
refractive procedures
Advantages Limitations
Better anterior corneal surface is preserved Only mild to moderate degree myopia can be
compare to photo ablative procedures corrected
Central corneal tissue or optical axis remain Frequency of over or undercorrection is higher
surgically unaffected
Natural corneal shape (prolate shape) is Effect is regressed due to displacement or expedition
maintained of segments
Reversible procedure where rings can easily be Complications like tunnel deposits and neovascu-
removed if desired larization are great hurdles.
Superior visual outcome in mild to moderate
degree keratoconus cases.
Maintains the strength of cornea because no
ablation of stroma
Surgical procedure Intracorneal polysulfone lenses: Similar to

• Procedure is performed under topical hydrogel lenses, lenses of high refractive index
anesthesia after cleaning and draping the material polysulfone were also tried by several
eye similar to other refractive procedures. scientists as intracorneal lens implants.
• By means of mechanical microkeratome a However, the initial trials were not successful
corneal flap of about 8.5–9.0 mm diameter and results of polysulfone lens implants
is created with inferior hinge (about 3.5–4.0 caused significant clinical problems. Under
mm). Thickness of corneal flap may vary topical anesthesia, using diamond knife a
in range of 180–300 μm depending upon the 5.5–6.0 mm size clear corneal incision was
choice of surgeon. made near limbus. Using blunt spatula a
• Hydrogel lens is implanted underneath the corneal pocket was created and polysulfone
corneal flap over stromal bed in pupillary zone. lens was implanted and centered. Incision was
• In a few selected cases, corneal suturing is closed using nylon suture. Postoperative
required for stability. treatment was similar to other refractive
• Postoperative treatment is similar to other surgeries. Severe postoperative complications
refractive procedures, i.e. topical antibiotics like stromal melting, wound scarring, anterior
(thrice daily × 3 days) and topical steroids chamber perforation, wound dehiscence,
(thrice daily with gradual tapering over irregular astigmatism and neovascularization
15 days). were reported by several studies conducted
on polysulfone intracorneal lens implants.
Note: In this procedure, irrigation of flap interface Due to these sight threatening complications
should not be done after giving cut with this lens never gained any acceptance in
microkeratome or implantation of hydrogel lens. clinical practice.
Complications: Limited number of intracorneal Gel injection Adjustable Keratoplasty

hydrogel lens implantation cases and their
This is a reversible procedure proposed by
studies are available to establish the clinical
Simon G. in the year 1985 for correction of
complications related to the procedure, however,
moderate degree of myopia by altering the
following complications after hydrogel lens
curvature of cornea. Principle used is that a
implantation have been reported in a few studies
gel material is injected inside the corneal
• High order corneal aberrations are increased channel which causes change in the anterior
after intracorneal hydrogel lens implanta- curvature of the cornea and hence correct the
tion, especially in cases of high degree refractive error. Several gel materials had been
hypermetropia or aphakia. tried for this purpose, however, most
• Intrastromal epithelial cyst and opacifica- commonly experimented gel material is
tion is reported in a few cases. polyethylene oxide.
• Complete regression of refractive error is seen
in many cases which require a second correc- Surgical technique
tive surgery to correct the refractive error. • Procedure is performed under topical
• In some cases formation of membrane around anesthesia after cleaning and draping the
the lens is seen at intrastromal plane. eye similar to other refractive procedu-
res.
Note: Many studies reported that predictability of • Pachymetry is done at the site of injection
surgical outcome and stability of refractive status and an optical zone 7.0 mm is marked using
is very poor after intracorneal hydrogel lens corneal marker.
implantation, hence this procedure is not widely • Radial incision of about 1.0 mm size, of
accepted.
nearly 75–80% corneal thickness is made by
using a diamond knife. Blunt spatula is metropia correction can be broadly grouped
used to separate the stromal lamella and a as
lamellar plane guide is placed inside the • Incisional refractive surgery
corneal pocket. • Laser refractive surgery
• Then a specially designed helicoids spatula • Corneal stromal collagen shrinking
is inserted in corneal pocket in lamellar procedures: Conductive keratoplasty and
plane and 360° annular dissection is done thermal keratoplasty
to create the intrastromal channel.
• Gel material (polyethylene oxide) is injected Incisional Refractive Surgery
into intrastromal channel in gradual Hexagonal keratotomy is an incisional
manner and simultaneously epithelial refractive procedure which can be performed
massage is given to equally distribute the to correct mild to moderate degree of
gel inside the channel. An intra-procedural hypermetropia. In the year 1985, Mendez
keratometry is done to observe the change performed this procedure to correct
in the curvature of cornea happening due hypermetropia. This procedure is now
to injection of gel. This curvatural change obsolete but is discussed because of its
will decide the amount of gel to be injected. historical importance. Originally, in this
• Once the desired change of corneal method, circumferentially connecting
curvature had occurred, then stop the gel peripheral cuts in hexagonal shape were
injection. No sutures are required to close created around 4.5–6 mm clear optical zone
the incision. as shown in Fig. 15.17A. This causes the
buldging of central cornea and hence
Gel injection adjustable keratoplasty is a
correction of hypermetropia occurred. Later
simple cost effective procedure for correction
on, Jensen and Mendez improvised the
of myopia and astigmatism. This procedure
technique by creating shorter, non-connecting
has an advantage of reversibility without
incisions in hexagonal shape as shown in
affecting the visual axis and easy adjustability
Fig. 15.17B. In spite of this modification, the
of refractive correction intraoperatively.
complications like higher amount of aberra-
Postoperatively negligible amount of corneal
tions, corneal scarring, irregular astigmatism,
scar or haze are the additional benefits of this
corneal perforation on trivial trauma, and
procedure. Limitations of this procedure are
keratitis were observed in high percentage of
quantification of amount of gel require to
cases. Hence, due to high risk of complications
correct the error and slight opaque nature of
over advantages this procedure is not
gel. To avoid visual symptoms gel is injected
preferred.
in relatively larger optical area.
REFRACTIVE PROCEDURES FOR

HYPERMETROPIA
In majority of refractive procedures done for
correction of hypermetropia, the principle
used is similar to that used in the refractive
procedure for myopia correction. However,
the major difference is that in myopia the
central corneal ablation (thinning) is done,
whereas for hypermetropia correction the
peripheral corneal ablation (thinning) is done. Fig. 15.17: Hexagonal keratotomy. A. Original
Various refractive procedures for hyper- method; B. Modified method
Laser Refractive Surgeries zone photoablation produces corneal

Similar to myopia the laser systems can also thinning in peripheral area and hence
be used to correct hypermetropia and various buldging of central cornea occurs.
laser refractive surgeries for correction of • Nearly three times of laser energy is
hypermetropia are required in hyperopic PRK to ablate the
• Hypermetropic photorefractive keratec- equivalent amount of corneal stroma as
tomy (PRK) compared to myopic PRK. For example, to
• Hypermetropic LASIK correct 2 D hypermetropic error amount of
• Hypermetropic epi-LASIK laser spots require to ablate cornea are
• Hypermetropic LASEK equivalent to the spot require to correct
6 D myopic error.
• Hypermetropic customized LASIK
• Increased amount of laser ablation increase
Hypermetropic PRK: Prerequisite and initial the chances of corneal dehydration and
surgical steps of hypermetropic PRK centration.
technique are same as that of myopic PRK.
Centration of optical zone is an important
Under topical anesthesia excimer laser is
step in hypermetropic PRK, hence proper
applied to correct the hypermetropic refractive
patient alignment and target fixation is must.
error, however, the preparation of stromal bed
In hypermetropic PRK the epithelial healing
and pattern of laser delivery is entirely
is also delayed because of
different from myopic pattern.
• Large size epithelial defect is created.
• In hypermetropic PRK a large diameter
(about 9 to 9.5 mm) optical zone is prepared • Longer duration of photoablation is
by removing corneal epithelium, against required
smaller area in myopic PRK. • More amount of laser energy is delivered
• Then large dough-nut shaped laser Postoperative treatment and complications
photoablation is done as shown in Fig. 15.18, of hypermetropic PRK are similar as that of
whereas in myopic PRK the central optical myopic PRK (discussed on page 474–477).
zone photoablation is done. This peripheral Hypermetropic LASIK: Principles and
surgical technique of hypermetropic LASIK is
same as that of described for myopic LASIK
on page no 479–482. A refractive error of +1
to +8 D can be corrected by this method.
Hypermetropic epi-LASIK: Prerequisite and
surgical steps of this technique are same as
that of described in myopic epi-LASIK on
page 487–488. Epi-LASIK for correction of
hypermetropia (especially, moderate to high
degree error) is preferred to PRK or LASIK
due to several advantages as described in
myopic epi-LASIK on page 488.
Hypermetropic LASEK: This procedure has
its specific advantages over LASIK and can
correct high degree of refractive error. Basic
principle and surgical steps of hyperopic
LASEK are same as that of myopic LASEK
Fig. 15.18: Hypermetropic photorefractive keratectomy (described on page 486–488).
Hypermetropic C-LASIK: Most recent proce- After the invention of lasers this procedure
dure to correct moderate to high degree of again gained some attention because of better
hypermetropia is customized LASIK. It has an control over the delivery of thermal energy to
edge over conventional LASIK in terms of cornea by use of laser energy. A wide range
visual outcome and postoperative comfort to of anterior corneal curvature changes can be
patient. Basic principle and surgical steps of brought by using several treatment
hyperopic C-LASIK are same as that of myopic parameters like laser wavelength, pulse
C-LASIK (described on page 488–489). duration, pulse energy, number of laser spots,
pattern of spots, and size of laser spots.
Corneal Stromal Collagen Shrinking Originally, Holmium: YAG laser was used to
Procedures deliver the thermal energy and this procedure
Principle: Anterior curvature of cornea can be is termed laser thermal keratoplasty (LTK).
altered using various energies like thermal Ho: YAG laser penetrates cornea up to depth
(heat) energy, radiofrequency energy or laser of about 480–520 μm which is considered
energy which cause shrinkage of the corneal perfect depth range to provide heat to stroma
stromal collagen structure. This change in the without causing damage to adjoining tissue.
anterior corneal curvature will cause the In addition, Thermal footprint produced by
correction of refractive error. laser is conical shape (whereas, a hot needle
Correction of hypermetropia or presbyo- produces cylindrical thermal profile). As
pia can be done by various procedures compared to cylindrical thermal profile, these
based on this principle and can be grouped conical shape profiles or footprints produces
as shrinkage of stromal collagen more in the
anterior stroma than posterior stroma, hence
• Thermal keratoplasty
better correction in refractive error is achieved
• Conductive keratoplasty
with long lasting results.
Thermal Keratoplasty (TK) Mainly two types of laser delivery systems
are studied widely
In the year 1898, Lans applied thermal energy
on the cornea through heat or thermal cautery • Contact probe LTK
for correction of astigmatism. The exposure • Non-contact type LTK
to heat caused change in the curvature of These two types of system delivers different
anterior cornea due to the shrinkage of corneal amount of temperature, spot size, space
stromal collagen, which corrected the distribution and time of laser delivery.
refractive error. Later on, thermal energy was Contact laser thermal keratoplasty: In this
delivered using a radiofrequency probe type of delivery system a sapphire probe is
instead of heat cautery. This procedure is used to deliver the thermal energy at an angle
termed thermal keratoplasty, however, with of 120°. The solid state infrared range laser of
use of simple heat cautery or probe the control 2060 nm wavelength at 0.3 millisec pulse rate
of thermal energy delivery was difficult, hence is emitted as electromagnetic radiations by this
this original nonlaser thermal keratoplasty probe to treat about 700 μm diameter spot size
procedure was widely abandoned because of corneal area at 450 μm depth.
these reasons
Surgical technique
• Poor predictability of refractive outcome
• Procedure is performed under topical
• Corneal scarring anesthesia after cleaning and draping the
• Delayed epithelial healing eye similar to other refractive procedures.
• Stromal necrosis • Under topical anesthesia along with 1%
• Corneal vascularization pilocarpine the cornea is marked with a
specifically designed marker to denote the important role in Ho: YAG laser tissue
probe placement. interaction effects.
• Then probe is placed perpendicular to • Once the corneal surface is ready for laser
corneal surface and typically eight to then either 8 or 16 treatment spots are
sixteen spots are applied in peripheral applied in single or double ring patterns as
cornea either in single ring or double ring shown in Fig. 15.19. Diameter of treatment
pattern. After procedure, remove the spot ring can be in the range of 4–8 mm
coagulated epithelium with a cotton tip depending upon the type and amount of
applicator. refractive error correction required. Double
• Postoperative management is similar to ring pattern can be either staggered or
other refractive procedures. radial as shown in Fig. 15.19B, C.
Non-contact thermal keratoplasty: In this • Postoperative treatment includes topical
type of delivery system the slit-lamp is used antibiotics and anti-inflammatory drops
to deliver the laser energy to cornea. Ho: YAG 4–6 times a day for one to two weeks duration.
laser of 2130 nm wavelength at 0.25 millisec In both these methods the laser treatment
pulse rate is emitted by a slit-lamp laser causes the thermal contraction of stromal
delivery system to create a spot size of 600 μm collagen matrix, which in turn creates a
having nearly 90% of energy per spot. constriction band in peripheral cornea. This
peripheral constrictive band causes the
Surgical technique steepening of central cornea and hence the
• Before starting the procedure topical correction of hypermetropia.
anesthesia is administered 4–5 times in each Several studies on laser thermal kerato-
eye at 5 minutes intervals and then patient plasty have been done for correction of
is made to sit on laser delivery slit-lamp hypermetropia and astigmatism. Majority of
system. these studies concluded that LTK is useful in
• Patient is instructed to focus the fixation red correction of low to moderate degree (range
light source and a self-retaining lid specu- of 1–4 D) of hypermetropia and is an effective
lum is applied to keep the eyes wide open. alternative in conditions like monovision
• Corneal surface is dried either by waiting induction or to improvise the overcorrected
for 5–10 minutes or using a moist cellulose LASIK/PRK patients. LTK is very economical
sponge because corneal hydration plays an and has low maintenance cost, hence it is an
Fig. 15.19: Laser thermal keratoplasty ablation patterns. A. Single ring pattern; B. Double ring radial pattern;
C. Double ring staggered pattern
effective way to treat hypermetropia. Several delivers radiofrequency energy directly to

studies also concluded that nearly one-third cornea and has a cuff, which ensures the
of the total patients in presbyopic age group correct depth of delivery.
corrected by LTK retained functional near • Foot pedal to control the release of radio-
vision with hyperopic correction. No frequency energy.
significant postoperative complications have Preoperative assessment
been reported after LTK.
• Near and distance vision
Conductive Keratoplasty • Refraction for far and near
In an approach to develop a procedure having • Keratometry
combined advantages of theromkeratoplasty • Corneal topography to rule out keratoconus
and uniform heat application to corneal or other irregularities
stroma with better predictable outcome, • Pachymetry
Mendez and colleagues introduced a non-laser • Anterior segment examination by slit lamp
refractive procedure for correction of • Monovision tolerance assessment using
hypermetropia and presbyopia, called contact lenses
conductive keratoplasty (CK). In place of laser, Procedure of CK: CK is done under operating
radiofrequency energy is used to reshape and microscope as following steps
steepen the cornea in conductive keratoplasty. • Topical anesthesia using xylocaine or
In CK, current of low energy and high proparacaine drops.
frequency (350 kHz) is given to heat the • Self-retaining lid speculum is applied for
corneal collagen tissue in the periphery which adequate corneal exposure and also to serve
results in shrinking of peripheral and as ground electrode.
paracentral stromal collagen. This shrinking
• Corneal marking is done using a corneal
results in flattening of cornea in the periphery
marker dipped in gentian violet ink. Marker
and steepening in the central part. Thus
is placed exactly in center of cornea to avoid
hypermetropia and/or presbyopia is corrected
any postprocedure astigmatism.
by this method.
• Delivery of radiofrequency energy is done
Indications: CK is preferred in patients of by keratoplasty tip insertion at defined
hypermetropia with age more than 40 years spots in a ring pattern marked over cornea
with a stable refractive error as more benefits as per nomogram as shown in Fig. 15.20.
are seen with CK in this age group than
Nomogram in CK: Important points to be
younger patients.
remembered during delivery of radiofre-
• Hypermetropia of +1 D to +3.5 D, with or quency energy are
without astigmatism of up to +1 D.
• Keep keratoplast tip exactly perpendicular
• Presbyopia to corneal surface to get full depth penetra-
CK equipment: Primarily CK system consists tion of energy.
of following components • Avoid high touch, i.e. more pressure on
• CK console: This is a radiofrequency energy cornea during procedure, use light touch
generating device. technique, i.e. minimum pressure while
• CK Hand piece (probe) this is a pen shaped delivering the energy to form a spot size of
reusable part which is attached to console 0.5–1 mm.
system with a removable cable and connector. • Smooth and even size spots are applied
• Keratoplast tip this is a disposable stainless using 350 kHz with 60% power.
steel needle attached to probe. Needle • 0.6 seconds treatment time is required per
length is 450 μm and diameter is 90 μm. It spot.
require with respective spherical correction

is summarized in Table 15.20.
Postoperative management
• Topical antibiotic/anti-inflammatory eye
drops 3–4 times per day for one week.
• Lubricating eye drops 4–6 times per day for
4–6 weeks.
• Follow up is done after CK on
– One day
– One week
– Three weeks
– Six weeks
– Three months
Various advantages and disadvantages of
CK are summarized in Table 15.21.
Fig. 15.20: Nomogram for conductive keratoplasty REFRACTIVE PROCEDURE FOR ASTIGMATISM
Various surgical techniques have been
developed for correction of simple astigmatic
error or compound astigmatic error in
association with spherical refractive errors or
high degree astigmatic error associated with
post-penetrating keratoplasty. These astigmatic
corneal refractive procedures can be grouped
as shown in Table 15.22.
Relaxing Incisions
Astigmatic refractive error is quite common
and is usually treated with spherical refractive
Fig. 15.21: Spots placement order in conductive error through various laser based or lens based
keratoplasty corrective procedures. Astigmatism correction
based on corneal relaxation principle is
• Start treatment from 12 o’clock position and performed with limbal relaxing incisions and
move as per sequence shown in Fig. 15. 21. astigmatic keratotomy. Basic principle of
• Second and third ring treatment spots are correction in both the procedure is same.
applied in relation to first ring in such a According to the depth of cornea two or more
pattern that they do not touch each other. peripheral corneal incisions (transverse or
• Number of treatment spots is dependent on arcuate shape) are created perpendicular to the
the amount of error needed to be corrected. steepest meridian. Once these incisions heal
Number and placement of treatment spots due to biomechanical characteristic of cornea
the steeper meridian becomes flat and the
Note: Shape of CK footprint is cylindrical, whereas flatter meridian becomes steep, hence the
after LTK it is conical. Footprint is nearly up to 80% astigmatic error gets corrected. The effect of
depth of cornea because corneal tissue receives incision is directly related to the position
same temperature from surface till bottom. Visual (distance from the central cornea), length and
recovery is seen after one week time.
depth of incision.
Table 15.20: Number of treatment spots required in relation to spherical equivalent correction of error
Spherical equivalent (D) Number of treatment spots
correction First ring (6 mm) Second ring (7 mm) Third ring (8 mm) Total spots
0.75–0.875 – 8 – 8
1.0–1.625 8 8 – 16
1.75–2.25 8 8 8 24
2.375–3.0 8 16 8 32
Table 15.21: Advantages and disadvantages of conductive keratoplasty

Safe and effective in hypermetropia and Ineffective in high degree (>4 D hyperopia and 1 D
presbyopia astigmatism) refractive error
Minimal invasive technique Not reversible
Stereopsis or depth perception remains Regression can occur at rate of 1 D per 2–3 years
maintained duration. Hence repetition of procedure may be
required every 2–3 years time period
BCVA is improved after procedure Complications rarely seen are
• Corneal perforation
Contrast sensitivity remains maintained • Corneal erosions
• Iritis
• Decreased BCVA
Table 15.22: Various refractive surgeries for correction of astigmatism

Post-penetrating keratoplasty
Simple and compound astigmatic errors
induced astigmatism
Relaxing incisions Laser based surgery Suture removal
Limbal relaxing incision Astigmatic PRK Relaxing incisions
Corneal relaxing incisions Astigmatic epi-LASIK Relaxing incisions with
(Astigmatic keratotomy) compressing sutures
Astigmatic LASIK Corneal wedge resection
Astigmatic C-LASIK Ruiz procedure
Astigmatic LASIK
Limbal relaxing incision: Astigmatic error of acuity and optical quality of cornea is minimal.
more than 0.5 dioptre can be appreciated by Thus, LRI is the primary indications for low
sensitive patients and may influence optical degree astigmatic error correction.
quality of vision in these patients. Low degree
residual astigmatism (0.5–2.5 dioptre) after Corneal relaxing incisions (astigmatic
cataract surgery or refractive lens exchange or keratotomy): The concept of astigmatic
phakic IOLs (without toric lenses) can be keratotomy (AK) was introduced by Lans in
corrected by limbal relaxing incisions (LRI). 1898. This procedure is similar to limbal
This procedure can be performed along with relaxing incision, however, it is used to correct
cataract surgery for an effective correction. As high degree astigmatic errors (3–8 dioptres)
these incisions are peripherally placed and which may appear following penetrating
heals very fast their influence on the visual keratoplasty or post-cataract. In this method
to correct high degree astigmatism the nomogram for relaxing incision. Alternately,
incisions are given on the cornea. Basic laser can be used to make incisions in more
principle of this procedure is same as described précised way with accurate length and depth
above. of incisions. On an average in case of ‘with
In AK two or more transverse or arcuate the rule’ type astigmatic error (up to 2 dioptre)
shape incisions of predetermined depth and two incisions are given, whereas for same
length are given on corneal mid-periphery amount of error only one incision is given in
region perpendicular to the steepest meridian the case of ‘against the rule’ or oblique astigma-
as shown in Fig. 15.22. The incision on the tism. These incisions are ideally made in
steep meridian will lead to flattening of that 2.5–3.5 mm radius around the pupillary center
meridian while steepening of unincised (flat) or the center of cornea as shown in Fig. 15.22.
meridian 90 degree away (called coupling Two types of incisions can be given in AK
effect). Incisions short in length cause more • Transverse (T-cut) incisions: Usually, two
flattening of steeper meridian than steepening incisions of 3 mm length are given as a pair
of unincised meridian (coupling ratio >1). on the steepest meridian on mid-peripheral
Generally the transverse incisions of 3–5 mm cornea as shown in Fig. 15.23A. In specific
and arcuate incisions of 30–90° causes cases to increase the effect of incisions,
coupling ratio of one. Too deep or too long sometimes another pair of incision is added
incisions must be avoided as there are in the same meridian adjacent to previous
increased chances of globe perforation, incisions as shown in Fig. 15.23B. As the
induction of irregular astigmatic error and length of these transverse incisions
overcorrection of astigmatic error in post- increased their flattening effect decreases
surgical period. because these transverse incisions are made
Surgical method: Corneal incisions are made tangentially to optical zone of cornea.
depending on the amount and type (with the Incisions which are deeper, longer and
rule, against the rule or oblique) of astigma- more centrally located will produce greater
tism using a diamond knife, as per the existing effect.
• Arcuate incisions: Usually these incisions
are made at a fixed distance from pupil
center at any length in an arcuate shape in
pair as shown in Fig. 15.24. For any length
or any given optical zone size these arcuate
Fig. 15.23: Transverse (T-cut) incisions in astigmatic

Fig. 15.22: Incisions made in astigmatic keratectomy keratectomy. A. Single pair incisions; B. Double pair
procedure incisions
refractive error of myopia and astigmatism,

then an elliptical ablation pattern is used to
correct both these errors together. Marking of
astigmatic axis on patient’s cornea must be
done while patient is in sitting position
because in lying down position the axis mark
will shift from the original position.
Astigmatic epi-LASIK: Astigmatic epi-LASIK
procedure is similar to the epi-LASIK
procedure described in detail on page 487–488.
This procedure is a better choice for correction
of moderate to high degree astigmatism as
Fig. 15.24: Arcuate incisions in astigmatic keratectomy
compare to PRK because of the advantages as
incisions are more effective as compared to described on page 488.
transverse incisions. The reason is that with Astigmatic LASIK: Astigmatic LASIK is a
increasing the length of incision (maximum similar procedure to conventional LASIK as
up to 90°), flattening effect of arcuate described on page 477–480 , except in terms
incision increases. of laser ablation pattern. Astigmatic LASIK
can effectively correct an astigmatic error in
Laser-based Surgery the range of 2–10 D with minimal complications.
Astigmatic PRK: Astigmatic photorefractive This procedure has an edge over PRK in terms
keratotomy (PRK) is similar to photoablation of visual outcome and safety.
procedure (describe on page 472–474) done for
Astigmatic C-LASIK: Currently, astigmatic
correction of spherical errors like myopia or
C-LASIK especially, wavefront guided is
hyperopia except that the ablation pattern
considered as first choice refractive proce-
created by laser in astigmatic PRK is
dure for correction of moderate to high
cylindrical, not spherical as done in myopia
degree astigmatism with negligible compli-
as shown in Fig. 15.25. If patient has combined
cations and satisfactory visual results.
Technique of C-LASIK is same as described
on page 488–489.
Postpenetrating Keratoplasty (PK)-induced

Astigmatism
High degree of astigmatism (5–30 D) may be
induced after penetrating keratoplasty.
Various methods advocated to manage this
astigmatism are:
Suture Removal
Suture removal is the most effective, easiest
and fastest way to correct the astigmatism
induced due to penetrating keratoplasty. This
can be done as follows
• Examination of central and peripheral
portion of the corneal graft and measure-
Fig. 15.25: Photoastigmatic refractive keratectomy ment of central corneal graft curvature is
done by using keratoscope and keratometer, induced astigmatism, then any other procedure
respectively. These parameters will help the described below can be tried to correct the
examiner to decide exactly which suture astigmatism.
should be removed to correct the astigma- Astigmatic LASIK: As discussed before
tism. Keratoscopic mires become closer and astigmatic LASIK can correct astigmatism of
exhibit a ‘V’ pattern indentation near a tight up to 10 D and currently wavefront guided
suture as shown in Fig. 15.26A. Alternately, C-LASIK is the procedure of choice to correct
in case having no induced astigmatism, no astigmatism produced after penetrating
such indentation pattern will be seen on keratoplasty.
keratoscopy as shown in Fig. 15.26B.
• Once the indentation pattern is seen and Relaxing Incisions Post PK
suture is identified by the examiner, • As described earlier the arcuate relaxing
removal of selected sutures present in most incisions are given on the steepest meridian
steep meridian will correct both the regular to correct the astigmatism. Normally, a pair
and the irregular type of astigmatism. of arcuate incision about half millimeter
• Depending on the degree of induced inside the donor graft junction is given on
astigmatism usually in case of interrupted the donor cornea. These relaxing incisions
sutures surgeon can remove the selected can correct astigmatism in the range of 2.5
suture after 3 months duration of surgery. to 8 dioptres.
Whereas, in case of continuous sutures, the • Under topical anesthesia these arcuate
selected sutures are ideally removed after incisions are created with a diamond knife
one year duration of surgery. or femtosecond laser beam as described on
Penetrating keratoplasty induced astigma- page 466. Pair of arcuate incision (180°
tism is initially corrected by suture removal apart) are made deep up to 70–75% of
technique only. However, once all the sutures corneal thickness. Length of incisions can
are removed and patient has a stable refractive be extended in a range of 60° to 100°
status with a significant amount of residual- according to the degree of astigmatism.
Fig. 15.26: Post-penetrating keratoplasty astigmatism

Relaxing incisions with compression sutures

• High degree astigmatism (6 to 15 dioptres)
can be corrected by applying compression
sutures along with relaxing incisions.
• Relaxing incisions are given on the cornea
at desired angle in a manner explained
above. Two or three interrupted suture by
10–0 nylon suture are given on each side at
graft-host junction, perpendicular to the
steepest meridian as shown in Fig. 15.27.
Corneal Wedge Resection Fig. 15.27: Relaxing incisions with compressing
For very high degree astigmatism (16 to 25 D) sutures
before attempting a repeat penetrating • Then about six to seven interrupted
keratoplasty, corneal wedge resection or Ruiz compressing sutures by 10–0 nylon or
procedure can be tried to correct the residual prolene are applied to close the gap as
astigmatism. shown in Fig. 15.28C.
• Retrobulbar or peribulbar anesthesia is • These compression sutures should be
given and under complete aseptic precau- applied tight enough to attain an over
tions corneal wedge is removed from the correction by nearly 1/3 amount of the
recipient cornea. present astigmatism.
• Usually a 1–1.5 mm wide base and approxi-
mately 90° in extent from the flattest Ruiz Procedure (Trapezoidal Keratotomy)
meridian of recipient cornea is selected near Ruiz procedure is performed in the following
host graft junction as shown in Fig. 15.28A. cases such as
• Using fine microsurgical blade the selected • Failure of wedge resection
corneal wedge is removed from the donor • Highly equivalent spherical myopic refractive
cornea as shown in Fig. 15.28B. error
Fig. 15.28: Corneal wedge resection. A. Corneal wedge selection; B. Removal of corneal wedge;
C. Interrupted compressing sutures
• Significant anisometropia after keratoplasty, Note: After penetrating keratoplasty when corneal
for example, one eye with post-keratoplasty wedge resection and/or Ruiz procedure get fail to
status and fellow nonoperated eye is highly correct the residual induced astigmatism, a repeat
myopic eye. penetrating keratoplasty should be performed.
Ruiz procedure can correct about 10–12 D
Modified Ruiz procedure (rectangular
astigmatism with simultaneous shift in
incision pattern) has also been described
spherical equivalent towards hypermetropia.
where the radial incisions are made
Surgical steps of procedure are as follows
perpendicular to the horizontal incisions. This
• Under suitable anesthesia deep horizontal modification helped to obtain full correction
corneal incisions along the steepest of astigmatism band in the periphery.
meridian are made by using a guarded
diamond knife, in a step ladder manner as
REFRACTIVE PROCEDURE FOR PRESBYOPIA
shown in Fig. 15.29.
• Two sets of horizontal (transverse) corneal Presbyopia is not a refractive error rather it is
incisions (keratotomy) are performed an ageing process which ultimately affects
opposite to each other. The depth of every individual. Presbyopia usually happen
incisions must be 80% of corneal thickness. around 40–42 years of age and many people
• Each set of horizontal keratotomy are consider it a sign of old age, hence resist
bordered by two radial incisions in such a wearing of bifocal or progressive spectacles.
manner that they do not cross with the A large number of people do not want to wear
horizontal incisions. glasses or due to professional reasons wants
correction of presbyopia by surgical procedures.
• Cross connection of horizontal and radial
Various procedures to correct presbyopia by
incisions can result in wound gaping,
surgical means are summarized in Table 15.23.
delayed wound healing, and epithelial
microcystic dystrophy. Corneal Procedures
Results of Ruiz procedure are significantly
Monovision procedure: Monovision simply
variable though it can correct penetrating
means one eye (usually dominant) is fully
keratoplasty induced astigmatism along with
corrected (made emmetropic) and fellow eye
spherical myopic error. It can be performed
(usually non-dominant) is made myopic of
following penetrating keratoplasty for
about 1.5–2.5 D as per patient requirement.
correction of primary astigmatism as well as
This can be done safely and effectively with
following cataract extraction.
excimer laser in myopes and with conductive
keratoplasty or thermokeratoplasty in
hypermetropes. Even monovision can also be
achieved with intraocular lens implant. In one
eye the IOL power is kept for distance
correction, whereas in the fellow eye IOL
power is adjusted for near vision. This
procedure can be done in presbyopic having
high refractive error by doing clear lens
extraction and IOL implant or after cataract
extraction and IOL implant.
Note: Disadvantage of monovision is that an

intermediate distance vision usually remains
uncorrected.
Fig. 15.29: Ruiz procedure
Table 15.23: Classification of various presbyopia corrective surgeries

Corneal procedure Lens-based procedures Sclera-based procedures
Monovision procedure Multifocal Intraocular Lenses Anterior ciliary sclerotomy
Laser procedures Accommodative IOLs Sclera spacing procedures
Corneal implants Refractive lens exchange Sclera expansion with laser
Laser procedures: Excimer laser can also be • Multifocal excimer laser: Most recent and
used for correction of presbyopia similar to effective treatment to correct presbyopic
refractive errors. myopes, hypermetropes, or emmetropes is
• Laser thermal keratoplasty can be done but multifocal LASIK. In this method a
CK is more preferred than laser thermal multifocal cornea is created by giving
keratoplasty. multistep, independently calculated,
• Monovision LASIK can be performed. In ablation zones using flying spot excimer
this method, one eye is corrected for distance laser. Surgical steps are as follows
vision and the other eye for near vision with – Cornea is anesthetized by topical
the help of epi-LASIK or C-LASIK. anesthesia.
• Presbyopic bifocal LASIK this is also called – Under aseptic precautions hinged
as LASIK-PARM (presbyopia by Avalos corneal flap of size 8.5 to 9.5 mm is made.
Rozakis Method). In this method, instead – In next step, central multifocal LASIK is
of one zone as created with routine LASIK performed where central ablation of
two concentric ablation zones are created cornea for correction of distance refrac-
on the cornea. This changes the shape of tive errors is done.
cornea at two places, which enable the – Peripheral multifocal LASIK is the last
patient to have distance vision from one step where multiple paracentral ablations
zone and near vision from another zone. in several optical zones of cornea are
Surgical steps of this laser are as follows done to correct the near and intermediate
– Cornea is anesthetized using topical vision defects.
anesthesia.
Corneal implants or inlay: Various implants
– Under aseptic precautions hinged to correct presbyopia were tried in past but
corneal flap of size 8.5 to 9.5 mm is made. failed due to several disadvantages. Recently
– Hyperopic ablation of cornea is perfor- after the development of microkeratomes,
med to make it steeper centrally (prolate femtosecond laser and better biosynthetic
shape) which will facilitate for near material this idea of presbyopic implants has
vision. revived. A few examples are
– Myopic ablation of cornea is performed • Kamra inlay (AcuFocus): This implant is a
over central 4 mm zone to make cornea polyvinylidene fluoride material ring which
flatter centrally (oblate shape) which will has an outer diameter (3.8 mm) and inner
facilitate the distance vision. or central opening of 1.6 mm, with a
– At the end of laser, cornea is of oblate thickness of 10 μm. This is implanted
shape or flatter in center for distance uniocularly (non-dominant eye) under a
vision and a surrounding ring of prolate corneal flap as created in LASIK. The central
shape or steeper periphery for near opening of inlay is positioned in such a way
vision. that it remains in front of the pupil of eye
– Repositioning of corneal flap is done as and produces a ‘pinhole camera’ effect, thus
described on page 481. increases depth of focus. It is first corneal
inlay which has been approved by FDA in

2015.
• PresbyLens (raindrop near vision inlay):
This is a hydrogel material implant having
1.5 mm diameter with an edge thickness of
10 μm, which progressively increases up
to 24–40 μm towards center. This implant
is similarly placed in non-dominant eye
after creating a corneal flap by LASIK.
This implant alters the curvature of cornea.
It was approved by FDA in 2016 for
presbyopia. Fig. 15.31: Refractive multifocal intra ocular lens
• SDICL: Recently, an intracorneal inlay lens
of small diameter has been produced for lens optic. The effectiveness of these IOLs
correction of presbyopia. This lens is depends on the surgical centration of lens
inserted in a intrastromal pocket created via and size of patient’s pupil.
a 3–4 mm circumferential corneal incision • Diffractive IOLs: These IOLs have two
made in periphery as shown in Fig. 15.30. focus points, one point for near and another
No suture is required to close the incision. for distance vision. There are diffractive
Main advantage of these implants is that concentric rings on anterior and posterior
they can be removed if not tolerated or if a surface of IOL optic to diffract the incoming
cataract surgery has to be done in later stage. light rays and focus them either to near or
distance focal point of IOL as shown in
Lens-based Procedures Fig. 15.32. The effectiveness of this type of
IOL is independent to surgical centration
Multifocal intraocular lenses: These lenses
and patient’s pupil size.
can be implanted either after cataract surgery
or refractive lens exchange procedure. Mainly Accommodative IOLs: These IOLs are
two types of lenses are present: Refractive and designed in such a way that movement of
diffractive multifocal lenses. ciliary muscle is transformed into an ocular
• Refractive multifocal IOLs: These IOLs dynamic change in terms of dioptric power.
have two or more ring-shaped spherical
zones of different refractive powers as
shown in Fig. 15.31. Near power zone is
usually situated in the central portion of
Fig. 15.30: Small diameter intracorneal implant Fig. 15.32: Diffractive intraocular lens
Presently available accommodative IOL

designs are
• Humanoptic 1CU: It is a single piece IOL
made up of hydrophilic acrylate material
and has four wide haptics with a flexible
haptic-optic junction as shown in Fig. 15.33.
Optic is 5.5 mm in diameter and haptics is
9.8 mm in width. These haptics are so
designed that they get compressed by
capsular bag with accommodation and
move the optic forwards.
• AT-45 Crysta lens: This IOL has an optic of
high refractive silicon material with a
modified plate haptic design. Optic is of
5.0 mm diameter with a groove at optic
haptic junction. There is a pair of arch-
shaped stabilizing polymide haptic at the Fig. 15.34: AT-45 intraocular lens
end of each plate haptic as shown in
Fig. 15.34. This mechanism helps in moving Refractive lens exchange: Rarely, to correct
the lens forward when a pressure gradient presbyopia in emmetropes the clear lens
is generated between vitreous cavity and extraction with IOL implantation is done.
anterior segment during accommodation However, in cases having high degree
due to ciliary muscle movement. refractive errors clear crystalline extraction
• Visogen synchrony: This IOL design has with multifocal IOL implantation can be done
two optics, i.e. the anterior is convex with 32 D at presbyopic age. Detailed surgical procedure
power and other with posterior concave optic. with associated complication is explained on
These two optics are connected by a spring page 492–493.
mechanism. During accommodation process
the anterior optic moves inside the capsular Scleral Based Procedures
bag and posterior optic remains constant. Anterior ciliary sclerotomy: Various accommo-
dation theories assumes that
• Outward movement of equator of crystalline
lens during near accommodation causes
increase in the diameter of lens.
• In ageing process due to natural lenticular
growth, the equatorial diameter of crystalline
lens increases.
• Decreased space between lens equator and
ciliary body resists the outward movement
of crystalline lens during near accommo-
dation, hence causes presbyopia.
Aim is to increase the space between lens
equator and ciliary body, hence an anterior
ciliary sclerotomy has been tried to stretch and
enlarge the eyeball with variable results. This
procedure is performed to facilitate extra
Fig. 15.33: Humanoptic 1CU intraocular lens space for ciliary muscle to contract and force
forward movement of vitreous body, so that Majority of studies reported that presbyo-
accommodation can improve the near focus. pic correction of moderate degree can be
Surgical procedure steps are achieved by anterior ciliary sclerotomy. Post-
• Under suitable anesthesia four radial operative complications include subconjunc-
incisions in the conjunctiva in each tival hemorrhage, photophobia, and ocular
quadrant of eyeball are made starting irritation.
from limbus up to pars plana. Sclera spacing procedures: As discussed
• Then about 600 μm deep radial incisions above to correct presbyopia various scleral
of about 3 mm length are created in the implants have been tried to increase the
sclera in four quadrants of globe using circumferential space of globe. PMMA
microsurgical blades. Care must be taken segments scleral implants commonly available
to avoid deeper and too posterior as PresView implants are used to increase the
incisions to prevent accidental injury of scleral space. Posterior scleral tunnels are
ciliary body and retinal detachment. made in four scleral quadrants. PMMA
• Now with the help of a specially designed segments are implanted over ciliary body in
microsurgical forceps these incisions are these sclera tunnels in four quadrants by using
separated very minimally to create an automatic microsurgical instrument.
desired scleral space. Be careful about Results of this procedure are yet to be
globe perforation or ciliary body injury. expected.
• No sutures applied for scleral incision Scleral expansion with laser: This is an
but conjunctiva is cauterized to avoid advancement of anterior ciliary sclerotomy
ocular infections. where partial thickness radial incisions are
In spite of good initial surgical outcome in made on sclera over ciliary body region to
majority of cases the incisional wound regress increase the circumferential space by using
and space gets decreased. So to maintain the Erbium: YAG laser instead of a routine
space, silicon expander plugs are used to be microsurgical blade. This facilitates the
placed in incision wounds. Normally, silicon outward movement of crystalline lens to
expander of 0.6 mm width and 2.5 mm length provide increased focal power and focal
are used based on the estimated dimensions depth during accommodation. This proce-
of incisional wound and expected circum- dure is in experimental stages with variable
ferential expansion of globe. outcome.
16 Low Vision 521
Low Vision
Learning Objectives
• Evaluate and classify the low vision with the prevalence of visual problem.
• Describe the diagnostic guidelines for a low vision patient.
• Understand the management strategies for low visual acuity.
• Understand the treatment strategies for central and peripheral visual field defects.
• Describe strategies required to manage reduced contrast sensitivity and glare in cases of low vision.
• Prescribe the optical and non-optical visual aids in patients having visual impairment.
Chapter Outline
• Low Vision Evaluation – Optical and non-optical low visual aids

– Introduction – Improvement of diminished visual acuity
– Definition and classification of low vision Magnification for distance
– Epidemiology of low vision Magnification for near
– Etiological factors for low vision – Enhancement in contrast sensitivity and

• Management of Low Vision reduction of glare
– Diagnosis of low vision – Approach for central visual field defects
– Detailed history – Approach for peripheral visual field defects
– Ocular examination – Non-optical visual aids
Visual status • Prescription of Low Vision Devices
Refractive status – Objectives in prescribing a low vision device
Visual field evaluation – Supportive services in low vision management
Binocular vision assessment Training/Instructions to patient
– Supportive evaluation Patient education
• Treatment Approach for Low Vision – Prognosis and follow-up visits
LOW VISION EVALUATION explained in relation to low vision, however,

Introduction low vision never implies visual blindness. Low
Low vision can simply be considered as the vision person can present with functional
poor utilization of eyes or visual system. ocular defects like poor distance and/or near
Various similar terms like visual impairment, visual acuity, suppressed visual fields,
visual disability or visual handicap are decreased contrast sensitivity and excessive
521
glare. Low vision symptoms also include Definition and Classification of Low Vision
distortion of image, diplopia or difficulty in World Health Organization, International
visual perceptions. Visual impairment can Classification of Impairment, Disabilities, and
cause significant visual disability which in Handicaps (ICIDH) system, define and
turn restricts the daily routine activity of an classify various vision related conditions as
individual and also hampers his/her ability follows
to carry out any work independently. • Visual disorder means an ocular condition
Thus, low vision or visual handicap regardless of its origin (such as trauma,
condition confines the personal, economical disease or any anomaly) which can cause a
and social independence of an individual. The considerable damage to visual structures.
person suffering from visual impairment is
• Visual impairment is any loss or anomaly
unable to independently perform several
in an ocular structure causing reduction of
personal and social activities like reading,
physiological or psychological ocular
writing, moving in public transport, identify
functions such as vision, visual field,
people or attend social gatherings moreover,
contrast sensitivity or color.
these people are economically dependent on
relatives or others. • Visual disability means any restriction or
inability (due to visual impairment) to
Young children having visual impairment
since birth or soon after birth will develop perform routine ocular functions. For
delayed physical and mental milestones, example, reading, writing, moving around
especially in the area of coarse and/or fine independently or recognize familiar faces.
motor abilities. Similarly, students suffering • Visual handicap is a condition which shows
from low vision are unable to read books with that a person is having an unfavorable
standard sized font, unable to see blackboard status in society resulted from visual
or screen projection or computer. Hence, these impairment and/or visual disabilities.
students face a huge loss of their educational Visual impairment or low vision can be
development. In these cases parents and considered as the functional restriction of
teachers should be aware about visual abilities visual system caused by visual disorder that
of student and they must apply various can lead to visual disability or visual handicap.
possible techniques to make best use of the For better understanding consider the
remaining useful functional vision of student. example of age-related macular degeneration
Visual impairment fundamentally means (ARMD). In an individual, ARMD (visual
that the concern person is not blind, although disorder) will lead to decrease visual acuity
the vision is markedly less as compared to the (visual impairment); which in turn causes
normal individual and cannot be corrected by inability to read small size font (visual
regular optical devices, medical or surgical disability), hence, finally a limitation of
methods. Hence, these patients are best personal, social and economical independence
corrected by low vision devices such as large (visual handicap) will occur.
print, image magnifiers and increased
Note: In a nutshell, low vision is referred as an
illumination. insufficient amount of vision unable to fulfill the
Several ophthalmological and/or neuro- routine requirements of a person.
logical disorders can also lead to a wide range
of visual impairment starting from moderate Worldwide, low vision or visual impair-
visual loss to total blindness. It means that ment is classified in different manner, but here
visual loss is not all of a sudden rather it occurs we are considering the classification and
over a range from poor visual acuity to definitions given by World Health Organi-
complete blindness. zation (WHO), International Classification of
Low Vision 523
Diseases (ICD) categories and Indian National Note: Clinical significance of legal blindness is
Programme Control of Blindness (NPCB). mainly for legal benefits.
Various low vision conditions as defined by
WHO are summarized in Table 16.1. Classification of Diseases) is summarized in
• Advantage of these functional definitions Table 16.2.
is that patients who have vision < 3/60 In India, according to National Programme
are included for low vision services, Control of Blindness (NPCB), definition of
which help these patients to utilize their visual impairment is as follows
remaining useful vision to its maximum • Low vision refers to a state when an
prospective. individual has the following conditions
• Functional visual impairment may result – Visual acuity not more than 6/18 (20/
in the following conditions such as 60) and less than 6/60 or 20/200 in better
– Inadequate visual resolution eye (with best refractive correction).
– Insufficient field of vision – Limitation of visual field  20° and up
– Decreased peak contrast sensitivity to 40°.
Inadequate visual resolution and/or peak • Low vision means an individual having
contrast sensitivity in high or low illumination poor visual function in spite of receiving
causes difficulty in performing routine daily standard treatment or full refractive error
activities. correction; however, still is able to utilize
For several health management purposes the remaining vision for planning and/
and clinical uses ICD is the international stan- or performing an assignment with
dard diagnostic classification body. Diseases suitable supportive instruments.
and other health-related problems recorded on • Blindness refers to a state of complete
various types of health and vital records such absence of visual perception or visual
as death certificates and other health records acuity  6/60 (20/200) in better eye (with
are mainly classified by ICD. Classification best refractive correction) and/or visual
of low vision as per ICD-10 (International field of  20º.
Table 16.1: Various low vision conditions with their definition (WHO)
Visual conditions WHO definition
Visual impairment A condition which range from partial sight to total blindness
Low vision Visual acuity in range of 3/60 to <6/18 (after best possible correction)
and visual field < 20° from the point of fixation in the better eye
Functional visual impairment Significant reduction of visual capability resulting from some pathological
conditions which cannot be corrected or treated
Functional low vision A person with low vision having an impairment of visual functioning
even after treatment, has a visual acuity in range of <6/18 to light
perception and /or a visual field of <10° from point of fixation but who
is potentially able to use his /her vision for planning and/or execution of
a task
Blindness Visual acuity <3/60 (after best possible correction) and visual field
<10° in better eye from the point of fixation. This can also be simplified
as no usable vision with exception of light perception
Legal blindness Visual acuity 6/60 or 20/200 (after best correction including contact
lenses) with a visual field of 20° (in the widest meridian) in better eye
Table 16.2: Classification of low vision according to ICD

Type Visual acuity
Maximum Minimum
Low Vision
1 6/18 (20/60) 6/ 60 (20/ 200)
2 6/60 (20/200) 3/ 60 (20/ 400)/Finger count at 3 meters
Blindness
3 3/60 (20/400)/ Finger count at 3 meters 1/ 60 (20/ 1200)/Finger count at 1 meter
4 1/60 (20/1200)/ Finger count at 1 meter Light perception (PL)
5 No perception of light (NPL)
9 Undecided or unspecified
Epidemiology of Low Vision young adults is insufficient, however, this is

Incidence: An accurate estimation of people an important population which needs timely
having low vision or visual impairment is visual rehabilitation related care and services.
difficult to assess because the study outcome Risk factors: Various factors can increase the
will differ according to the norms used to risk of visual impairment in a person, which
calculate the population affected. Prevalence includes various ocular pathologies along with
of low vision increases with rise of ageing trauma and systemic illnesses. Most common
population; hence when an increasing risk factors for low vision in adults are
population and an ageing population are • Cataract
grouped together they result in a considerable • Diabetic retinopathy
rise in total number of people suffering from • Glaucoma
low vision.
• Age-related macular degeneration
People more than 50 years age: About 20% of
world’s population is in the age group 50 years Etiological Factors for Low Vision
or above, whereas nearly 65% people out of Several congenital or inherent, acquired,
total low vision sufferers belong to this age ocular or systemic conditions can lead to low
group. In many developed countries prevalence vision however, conditions causing irreversi-
of low vision is increasing because of a rising ble damage to ocular structures or visual
percentage of population falling in this age pathway remain the major cause of low
group of 50 years and above. vision. Most common conditions causing low
Children less than 17 years of age: Worldwide, vision in various age groups is summarized
children below 17 years of age suffering from in Table 16.3.
low vision are estimated to be about 2 crores
in number. Out of these children nearly 1.2 crore MANAGEMENT OF LOW VISION
children have uncorrected refractive errors Visually impaired patients present a big
causing low vision. These refractive errors can challenge to practitioners in terms of diagnosis
easily be screened and corrected by routine and treatment, although management of low
evaluation methods. Approximately, 15 lakh vision in these patients is complicated and
children are suffering from irretrievable require a thorough knowledge of science but
blindness, because of various congenital an accurate diagnosis will lead to a satisfactory
pathologies for their remaining life. Exact treatment. In most of the cases both patient
analytic records of visual impairment and doctor feel that nothing can be done for
prevalence in school going children and very improvement in vision but a positive
Low Vision 525
Table 16.3: Etiological factors for low vision in • Supportive evaluations

various age groups – Contrast sensitivity testing
Age group Etiological factors – Color vision testing
Children Nystagmus (congenital), cortical – Glare testing
visual impairment, congenital – Electroretinogram (ERG)
cataract, albinism, Leber’s optic – Visually evoked potential (VEP)
atrophy, retinitis pigmentosa, – Electro-oculogram (EOG).
optic atrophy, retinoschisis
(juvenile) Detailed History
Younger Malignant myopia, traumatic Most important aspect in diagnosis of a case
brain injury, keratoconus, histo-
of visual impairment is to obtain an elaborative
plasmosis, toxoplasmosis, solar
and precise history of illness from the patient.
retinopathy
When detailed history cannot be elicited from
Elder or older Age-related maculopathies,
cataract, diabetic retinopathy, the patient then we can ask for help from family
glaucoma (primary open angle), members. Sometimes, history can also be
cerebrovascular accident, central obtained from health care personnel, therapists
retinal vein occlusion, macular or supportive personnel. History should include
hole, central retinal artery occlu- • Chief complaint regarding visual and
sion, angioid streaks professional activities.
• Character and extent of chief complain.
approach should be kept by the practitioner. • Visual problems in terms of more for
An accurate diagnosis and several treatment distance or near vision.
strategies will definitely help the visually • Systemic illness history including previous
impaired patients in performing the routine diagnosis and treatment
activities of their life. • Related ocular problem history in family
Management of low vision can be broadly members
grouped as • Medication usage and medication allergies
• Diagnosis of low vision • Social history and psychological framework
• Treatment strategies for low vision of patient.
• Vocational, educational and professional
Diagnosis of Low Vision visual requirements of patient
Diagnosis of etiology of low vision is very • Related medical history of family member
challenging and sometimes may require other in support to patient’s visual difficulties.
procedures or steps in addition to following
steps mentioned below Ocular Examination
Guidelines for diagnosis of a low vision case: Detailed evaluation of ocular system is a
Following components are important to prerequisite to achieve an accurate diagnosis
diagnose a case of low vision especially in cases of low vision patients.
• Detailed history Ocular examination includes
• Ocular examination • Structural examination by using slit lamp
• Structural ocular examination • Functional ocular examination which
• Functional ocular examination includes
– Visual status – Visual acuity
– Refractive status – Refractive status
– Visual field – Visual field
– Binocular vision – Binocular vision
Ocular structural examination: Gross ocular

asymmetry or periorbital structural anomalies
like ptosis, lid lesions or significant orbital
lesions should be looked for and are recorded
in examination sheet. Detailed anterior and
posterior segment examination is done using
slit lamp biomicroscopy.
Any corneal, lenticualr or anterior segment
pathology should be examined by using slit
lamp. Similarly, examination of fundus is done
using indirect ophthalmoscope to rule out any
posterior segment pathology.
Functional Ocular Examination Fig. 16.1: Multi pinhole occluder

Visual Status correction. Suppose an improvement in visual
Estimation of amount of visual acuity (VA) is acuity occurs, it means this patient VA can be
an important part of low vision evaluation and improved by further correction of the
is used to calculate the degree of high contrast refractive power, however, if no improvement
visual losses. For practitioners visual acuity in visual acuity is seen it means refractive
measurement helps to correlate the chief power prescribed is best correction.
complaint of patient and actual visual Distance and near visual acuity is checked
impairment status, hence this VA assessment by using either of these following specially
is utilized in designed charts.
• Monitoring the steadiness or progression of Distance vision charts: Distance vision assess-
visual detoriation ment in low vision patients is done with
• Monitor the changes in visual performance specially designed charts which are portable,
with the advancement of rehabilitation having large numbers of optotypes, high
• Evaluate typical head positions due to contrast and wide range (100–800 foot size) of
eccentric viewing optotypes size. Along with these features low
• Judge the amount of motivation in patient vision charts poses variable ambient illumi-
• Demonstrating the basic approach and nation to evaluate minimum lighting condi-
techniques related to rehabilitation process. tions that can cause glare and also to decide
In low vision patients visual assessment is about the requirement of filter to reduce
done after placing best correction (spectacle photophobia and glare.
or contact lenses) in trial frame using various Various distance vision charts (Fig. 16.2)
techniques. Initially check Snellen’s visual commonly used to record visual acuity in
acuity after putting the best corrective patient’s having low vision are
appliance, but to confirm the accuracy of best • Sloan’s chart
corrected vision pinhole test is performed. • Feinbloom charts
Pinhole test: Primarily this test is performed • Bailey-Lovie Log MAR chart
to assess whether visual acuity can be further
improved by refraction or changing the Note: Most of these low vision charts are designed
existing best correction or not. After placing to test visual acuity at non-standard testing
full optical correction lenses in trial frame, distances of 10 feet, 2 meters, 1 meter or closer,
pinhole glasses or a multi pinhole occluder as against standard 20 feet or 6 meters distance for
Snellen’s distance visual acuity chart.
shown in Fig. 16.1 is placed over this
Low Vision 527
Fig. 16.2: Distance vision chart for low vision Fig. 16.3: Near vision chart for low vision (courtesy:
(courtesy: Bernell Corporation) Bernell Corporation)
• Modified ETDRS (Early Treatment Feinbloom charts: William Feinbloom designed

Diabetic Retinopathy Study) chart both distance and near vision charts for
• SOHS (Student Optometric Services to partially sighted patients popularly called
Humanity) charts. Feinbloom’s low vision charts (Fig. 16.4).
Distance vision chart originally designed by
Near vision charts: Similar to distance vision
Feinbloom is a thirteen page spiral bound
charts various near vision charts are designed
book consisting of number optotypes (based
to record not only the near vision but also the
on Snellen’s optotypes and Sloan’s letters).
amount of magnification require to see the
This chart was designed to be tested from
near letters clearly. For measurement of near
10 feet distance and covers 10/10 to 10/700
visual acuity different types of acuity charts
visions, although it can be tested from any
have been designed especially for visually
distance but conversion for distance is done.
impaired patients. Commonly used near
For example, suppose if a patient read 100 size
vision charts (Fig. 16.3) in low vision patients
letter from 2 feet distance clearly then vision
are
is recorded as 2/100 (equivalent to 20/1000
• Sloan’s M charts or 6/300).
• Feinbloom charts Feinbloom near vision test cards are different
• Modified ETDRS charts from distance vision charts because on one
• Lee charts side they contain numbers optotypes with
seven levels (3.2 M to 0.5 M size), whereas
Note: These low vision charts are designed with other side of test card provides continuous
special features such as single letters, isolated reading lines in five levels (3.2 M to 0.8 M size).
words or short sentences.
Graded continuous text lines provide more
Fig. 16.4: Feinbloom distance and near vision charts for low vision
accurate measurement of reading ability as Similarly, it also helps in assessment of the

compared to a number optotypes measurement. amount of magnification required to improve
Main advantages of these charts are large the near vision by simply multiplying the size
optotypes size, easy portability and can be of letter clearly read by patients.
measured at any examination test distance, Suppose if, a patient read 8 M size letter
however, disadvantages are inconsistent clearly at 40 cm distance, then to read 1 M size
width to height ratio and irregular progression letter from same distance he/she will require
of optotypes sizes. 8 times magnification of letters.
Sloan’s M chart: In low vision patients visual
assessment using Sloan’s M system is widely Refractive Status
used because it gives equivalent Snellen’s As discussed above uncorrected or under
values which can be compared with distance corrected refractive errors remains major
visual acuities of normal person. For example, cause of diminished visual acuity all around
letter sizes present at 1 M or 2 M in Sloan’s the world, thus full correction of refractive
chart indicate the distance similar to Snellen’s error is mandatory in low vision cases because
chart print for angular size of 6/6 optotype. it is the deciding factor for further addition of
Here an angle of 5 minutes of arc is subtended low visual aids. Although pinhole test remains
by 1 M print optotypes at 1 meter distance, the standard in decision of performing
hence visual acuity can be calculated by this refraction, however, in cases of low vision (less
simple formula as than 6/18 after correction) cycloplegic
Test distance in meters/M size letter read refraction is done irrespective of pinhole test
by patient results.
Suppose a patient read 8 M size letter clearly Objective and subjective refraction is
from 40 cm distance, then performed in a routine manner as discussed
VA = 0.4/8 in Chapter 11, when pupil size is normal and
= 20/400 clear media is present, however, when retinal
Low Vision 529
reflex is dull, small size pupil or media opacity vital role when a patient’s independent
are present, then radical retinoscopy is perfor- travelling is concern. Central, peripheral, or
med to assess the refractive status of the eye. both visual field assessments is done to
Radical retinoscopy simply means perfor- evaluate the existence and position of the
ming a retinoscopy from a closer distance than relative or absolute field losses. These field
usual distance (50 or 66 cm). This may be assessment findings are then interrelated with
helpful to detect high refractive errors like visual functioning of the low vision patient.
pathological myopia, high hypermetropia, or Following tests are used to evaluate visual
astigmatism. fields in low vision patients
Just noticeable difference (JND) simply • Confrontation test
means a minimum amount of change in lens • Amsler grid test
power, appreciated by the patient which is • Automated static perimetry
expressed in denomination Snellen’s acuity • Goldmann kinetic perimetry
equivalent of 20 foot distance. For example, • Tangent screen testing
just noticeable distance of 2 dioptres is nearly
equivalent to a visual acuity of 10/100 or Central visual field evaluation using low
20/200 in a retinoscopy range of +1 D. This vision field charts (Fig. 16.5) or kinetic
simply means that examiner needs to starts perimetry is done to look for the presence of
his/her subjective refraction by placing +1 D relative or absolute scotoma in all the cases of
power lens, over existing retinoscopy lenses low vision. In these patients having poor
or patient’s present spectacle prescription. visual acuity or visual function the supportive
Effects produced by various ocular patho- assessment with Amsler grid test and static
logies like irregularities of cornea, irregular perimetry is done to rule out the presence of
astigmatism or lenticular changes on quality metamorphopsia and decreased sensitivity.
of retinal images can be determined with the This evaluation will help in determining that
help of a stenopic slit or pinhole as discussed whether a patient having low vision can be
above. improved with low visual aids or not, because
• Size and position of an absolute scotoma
Visual Field Evaluation will have an effect on near vision
Many studies had confirmed that visual field specially in reading capability in spite of
evaluation, especially in cases of low vision is an improvement in the image magnifica-
equally essential like the assessment of visual tion and visual acuity of patient with the
acuity or reading ability. Visual fields play help of visual aids.
Fig. 16.5: Central visual field charts for low vision (courtesy: Bernell Corporation)
• Significant image distortion (if present) particular disease, or other unexplained

will require nearly twice more magnifi- findings. These supplementary tests are as
cation as compared to an estimate done follows
only on the basis of visual acuity measure- • Contrast sensitivity
ment. • Color vision
• In patients having field losses in • Glare
peripheral areas the amount of field loss • Electroretinogram (ERG)
in terms of area and depth and amount • Electro-oculogram (EOG)
of presence of vision specially in peri- • Visually evoked potential (VEP)
pheral islands is assessed to decide
whether patient having low vision is a Contrast sensitivity: Newer studies had
good contender for visual field expander concluded that to correct the same amount of
devices or not. visual acuity, patients having low contrast
sensitivity require nearly thrice the lens power
Binocular Vision Assessment as compared to patients having normal
Treatment options or visual performance in contrast sensitivity. Hence, contrast sensitivity
low vision patients are greatly affected by appears to be an important parameter of visual
visual deficiencies such as nystagmus, squint, function especially, in low vision patients.
ocular motility defects, imperfect binocular Contrast sensitivity in low vision patients
vision, or diplopia. To assess binocular func- can be measured by specially designed
tion following procedures can be done contrast sensitivity charts (Fig. 16.6), which
• Hirschberg corneal reflex test for coarse helps in detection of certain range of spatial
judgment of ocular alignment frequency losses. Because
• Worth four dot, stereo fly test, etc. for • Mid-frequency range loss of contrast
testing of sensor-motor function sensitivity affects the independent
• Amsler grid test mobility of person.
• Contrast sensitivity assessment tests • High frequency range loss produce
difficulty in reading and identification of
Note: Both Amsler test and contrast sensitivity tests familiar faces.
are done monocularly versus binocularly to identify
the dominant eye and hence the requirement of Color vision: Presence of color vision abnor-
occlusion therapy. malities many a times helps in the diagnosis
Mostly low vision patients have one eye as
their favorite or better eye, hence requirement
for a binocular prescription is insignificant.
However, following possibilities for improve-
ment in binocular vision must be considered
• possible utilization of binocularity or bino-
cular use of low vision optical devices
• possibility of an improved ocular func-
tion by occluding the non-preferred eye
Supportive Evaluation
Various supplementary tests may be required,
especially in unsatisfied patients, insufficient
improvement in magnification, education or
work-related necessities, occurrence of Fig. 16.6: Contrast sensitivity charts for low vision
Low Vision 531
of specific conditions and may considerably TREATMENT APPROACH FOR LOW VISION
influence the professional, educational, day- Every patient of low vision requires an
to-day activities and independent movement individualized treatment approach. Based on
of an individual. In patients having low vision, the following factors clinician can plan various
tests like Holmgren wool test and Farnsworth strategies for low vision therapy.
dichotomous test are commonly used to • Chronological age and mental development
evaluate the practical inferences for loss of of patient
color vision. For example,
• General, physical and ocular health condi-
• Hereditary or congenital retinal dystro- tion of patient
phies such as Best vitellifrom disease,
• Primary cause of low vision and its final
Stargardt disease, central areolar choroidal
outcome
dystrophy, they all cause red green color
• Extent of visual loss or visual disability or
deficiency,
visual handicap
• Acquired conditions like ARMD, diabetic
• Visual necessities, aim and objectives of the
retinopathy and hypertensive retinopathy,
treatment
usually causes blue–yellow color defi-
• Patient’s hopes and amount of inspiration
ciency.
• Mental aptitude of the patient to take part
Glare sensitivity: Glare can disable the low in the process of visual rehabilitation
vision patients because it may cause increased • Associated physical handicap which can
risk for slipping and difficult movements while obstruct visual rehabilitation
walking independently. Glare sensitivity of an • Existing optical systems or low vision aids
individual may be evaluated by environmen- • Accessible supportive treatment modalities
tal stress testing procedures or specific devices
available in market. Evaluation of glare These treatment strategies are planned
sensitivity of low vision patient helps in presuming that patient’s refractive error has
quantifying the amount of problem and gives been fully corrected before evaluating the
a clue for the requirement of special glare expected amount and type of magnification
filters. or else refractive status is not contributing in
to the optics of correcting visual aids. Devices
Various conditions such as cataract,
used to improve various elements of low
posterior capsular opacification, corneal
vision are called low visual aids.
edema or macular edema can cause variation
Low visual aids are the devices which make
in glare sensitivity. These conditions are
objects to appear larger, brighter or clearer,
treatable, hence low vision can be improved
even an improvement in contrast sensitivity
in these cases by proper surgical treatment.
with reduction in glare also happens. These
Several special filters such as ultraviolet light
low visual aids work on the following strategies
blockers, contrast enhancers or low intensity
filters can be incorporated in glasses to protect • Object enlargement
from glare. • Optical magnification
Supportive exhaustive and specific electro • Contrast improvement
diagnostic tests such as ERG, EOG and VEP • Electronic magnification
are important to establish diagnosis, especially Broadly, we can group these low vision
when clinical information and routine tests are devices as
insufficient or incompatible to produce results. • Optical devices
Moreover, if the patients having low vision • Non-optical devices
are very young and/or handicapped, these Both types of optical and non-optical low
tests are useful to establish the diagnosis. vision devices use abovementioned strategies
to provide improvement in low vision

elements. Magnification or enlargement of the
objects remains the key approach among all,
whether an optical or non-optical low vision
device is used to improve the vision.
An increase in angulations of objects
relative to eye’s optical system provides the
desired magnification for patients having low
vision. Most commonly used magnification
methods are
• Relative size magnification Fig. 16.8: Relative distance magnification by an
• Relative distance magnification optical system
• Angular magnification original standard or reference distance
• Projection magnification (typically 40 cm or 25 cm) and RDM is
Relative size magnification: Relative size expressed as
magnification (RSM) is simply the magni- tan a
fication in the size of the object at same RDM =
tan a′
position as shown in Fig. 16.7. For example,
outsized print books, magazines and p
=
newspapers use this principle of magnifi- q
cation. For example, if an object of the same size is
Relative size magnification is calculated by moved from 25 cm (p) distance to 5 cm (q)
keeping the fixation distance (d) similar for distance, then
both object sizes. For example, an object of
height H (say 1 mm) kept at 25 cm distance 25
RDM = = 5 times magnification.
has been magnified to height H’ (say 3 mm) at 5
same distance (25 cm), then Angular magnification: Angular magnification
3 (AM) of an optical system refers to the ratio
RSM = = 3 times magnification. between angle formed by an object image
1
when viewed via optical system and the angle
Relative distance magnification: Relative formed by the object when viewed directly as
distance magnification (RDM) refers to the shown in Fig. 16.9. Here, both these angles are
amount of magnification produced by altering measured presuming that both these angles
the distance between an object and the are formed at pupillary center of eye (C).
observer’s eye as shown in Fig. 16.8. To denote
the amount of RDM, it is essential to use an
Fig. 16.7: Relative size magnification by an optical Fig. 16.9: Angular magnifications by an optical
system system
Low Vision 533
Angular magnification (AM) = angle Improvement of Diminished Visual Acuity

formed by image of an object/angle formed Initially it is important to identify the most
by same object when viewed directly. suitable magnification system for low vision
q patient having diminished best corrected
AM = visual acuity with routine refractive correc-
p
tion. Improvement in the distance and near
Hence in an angular magnification the
visual acuity is done on the basis of specific
comparison of an apparent increase in the
requirements of the patient. Mostly this
object size is done with optical system and
required level of magnification for either
without optical system in place.
distance or near vision is characteristically
Projection magnification: Projection magni- work oriented, means it is distinctively
fication simply means formation of an enlarged different for various activities.
image of an opaque or transparent object on a
screen. Projection magnification system can be Magnification for Distance
optical magnification system or electronic Determination of the expected amount of
magnification system such as a closed circuit magnification for improvement in distance
television (CCTV) system. A high amount of visual acuity is simply calculated by taking a
magnification at the observer’s suitable ratio of denominators of both the existing best
distance is possible, by using projection corrected visual acuity (BCVA) and the
magnification. This system has an additional desired visual acuity level.
advantage that, it can be used in combination For example, suppose existing BCVA is
with relative distance magnification for high 10/240 and desired visual acuity is 10/60, then
amount of magnification as shown in Fig. 16.10. simply the magnification required is 240/60
= 4 times.
Optical and Non-optical Low Visual Aids
Devices commonly used for enhancement
Low vision optical devices: For easy under- of distance magnification are telescopes or
standing of low vision treatment, various head mounted electronic devices, however, it
management approach using low vision is important to consider these following
optical devices are factors before prescribing a distance magnifi-
• Improvement of diminished visual acuity cation system
• Enhancement in contrast sensitivity and • Visual requirements for specific work
glare • Need of variation in amount of magni-
• Management of central visual field defects fication
• Management of peripheral visual field • Extent of visual field required for specific
defects task
Fig. 16.10: Relative distance magnification combined with projection magnification by an optical system
• Amount of brilliance/contrast at work compared to the angle produced by the

place incident rays.
• Use of binocularity Telescope designs: Most commonly used
telescopes as low vision devices are classical
Telescopes
afocal telescope designs such as
Optical system: An optical system which
• Galilean telescope
offers an angular magnification without
causing alteration in vergence is termed afocal • Keplerian telescope
telescope. These afocal telescopes have two Galilean or terrestrial telescope
basic optical elements, i.e. an objective and an Optics: In Galilean telescope objective lens (O)
eyepiece. In all types of telescopes the is of convex (plus power) and eyepiece (E) lens
objective lens is of plus power to obtain an is of concave (minus power). Incident rays
angular magnification and is kept facing the when falls on convex objective lens then a
object, whereas an eyepiece is either a plus or virtual image of height (H) is produced and
minus power lens (significantly larger in the central light ray after passing through the
power as compared to objective) and is kept optical center of objective lens subtend an
nearer to the observer’s eye. angle (A) with optical axis of system as shown
Principle: Basic optical principle in all types in Fig. 16.11. Another light ray passes via
of afocal telescope is that the secondary focal optical center of the eyepiece lens which forms
plane of objective lens and primary focal plane the tip of virtual image and emerges out from
of eyepiece lens coincides with each other. The eyepiece lens without any deviation, forming
parallel rays falling on objective lens will form an angle A’ with the optical axis of system.
an image at the secondary focal plane of this Hence, in this optical system bundle of parallel
objective lens and this image now acts as an rays enters an objective lens at an angle A,
object for the eyepiece lens. Since the object whereas a similar bundle of parallel rays emerges
image is situated at the primary focal plane of out from the eyepiece lens at an angle A’.
eyepiece lens, the emerging rays from this D = distance between the objective and
optical system are again parallel in nature. eyepiece lens; Fo = secondary focal length of
However, these emerging rays form a larger objective lens, Fe = primary focal length of
angle with the optical axis of the system as eyepiece lens.
Fig. 16.11: Optics of Galilean telescope

Low Vision 535
Here, the ratio of angle A’/A represents an per principle, the primary focal plane of
angular magnification, which can also be eyepiece lens coincides with secondary focal
expressed as plane of objective lens, thus the emerging rays
tan A′ from eyepiece lens are parallel, forming an
M= angle A’ at optical axis of system.
tan A
Magnification provided by this telescope
Fo system is also
=
Fe M = –Pe/Po here Po is power of objective
Consider that Po is power of objective lens lens and Pe is power of eyepiece lens
and Pe is power of eyepiece lens, then by Since secondary focal length of the objective
simple calculation lens is positive and primary focal length of
− Pe eyepiece lens is negative, sum (D) of them is
Magnification = equal to total length of telescope.
Po
In a nutshell since for a Galilean telescope In a nutshell since for a Keplerian telescope
Po is always a positive lens and Pe is always a both Po and Pe are always a positive lens,
negative lens hence, magnification formula, hence magnification formula, (M = –Pe/Po)
(M = –Pe/Po) will have a positive sign which will have a negative sign which means that
means that image formed will be always erect. image formed will be always inverted.
Keplerian or astronomical telescopes is Galilean versus Keplerian telescope: Various
combination of two convex lenses means a features of Galilean telescope and Keplerian
plus power (convex) objective (O) lens and a telescope are compared in Table 16.4 and the
stronger plus power (convex) eyepiece (E) lens image formed in a standard telescope is shown
as shown in Fig. 16.12. When parallel rays falls in Fig. 16.13.
on the objective lens at an angle A passing Types of telescopes: Telescopes for low vision
through the optical axis of system, it will patients are available as hand-held or head-
produce a real image of height (H) at the borne (spectacle mounted) telescopes, either
secondary focal plane of the objective lens. As in monocular form (as shown in Fig. 16.14) or
Fig. 16.12: Keplerian telescope

Table 16.4: Galilean telescope versus Keplerian telescope

Telescope features Galilean telescope Keplerian telescope
Telescope design Simpler Complex
Telescope weight Lighter Moderately heavy
Telescope length for a given Shorter Longer
amount of magnification
Image formed Erect Inverted (hence needs an additional
erecting system, to be used as a low
vision device).
Quality of image and brightness Lower Better
of view field
Image magnification Lesser usually up to 4X Higher usually up to 20 X
Observer’s fields of view Smaller Larger
Exit pupil Virtual, falls inside the telescope Real, situated at short distance
(between objective and eyepiece behind the eyepiece very close to
lens), present usually at some entrance pupil of eye
distance in front of entrance
pupil of eye
Position and size of exit pupil are two important factors which determine the degree of field of view in a telescope.
Fig. 16.13: Image seen through telescope
Fig. 16.14: Monocular telescopes: A—Hand held, B—Spectacle mounted (uniocular)

Low Vision 537
binocular form (as shown in Fig. 16.15). Table 16.5: Various telescope designs and their
Spectacle mounted telescopes can be either power range
center mounted (full diameter) devices or off Telescope Design Power range (X)
center mounted (bioptic, or reading/surgical) type
devices. Among off centered devices bioptic
Galilean Full diameter 1.3–2.2
are superiorly off centered to view the distance
telescope telescope
objects, whereas reading/surgical devices are
inferiorly off centered. Bioptic 2.2–4
telescopes
Headborne telescopes (fixed in spectacle
frames) are available as full diameter telescopes Keplerian 2–8
and the telescope engages the total aperture telescopes
of the spectacle lens. Similarly, bioptic telescopes Clinically most useful Galilean Bioptic telescopes are 2.2X
are small diameter telescopic unit, mounted power and Keplerian telescopes is 3X or 4X power.
in the upper portion of carrier lens fitted in • Headborne telescope (spectacle mounted)
the spectacle frame as shown in Fig. 16.15. systems are indicated where viewing is
Various design telescopes are available for desired for long duration such as watching
low vision patients. These telescope designs television or sports event.
and their power range is summarized in • Spectacle mounted telescopes are prescribed
Table 16.5. depending on the need of patient, mobility
Indications of telescope and head posture. For example, a bioptic
• Hand held telescopes are very useful for version is preferred when patient mainly
purpose of viewing for short period such needs telescope for distance or mobility,
as to read the bus numbers or street signs, however, a full diameter version is advised
can also be used to view blackboard work when patient needs telescope mainly for
in classroom or wall mounting. watching television or computer work.
Fig. 16.15: Binocular telescopes: A. Hand held; B. Spectacle mounted (bioptic); C. Spectacle mounted
(full diameter)
Head mounted electronic devices: Recently, Most commonly used low vision optical
various head mounted video devices or devices to correct near vision are
electronic magnification systems have been • Microscopic lenses or spectacle mounted
developed, having features such as changeable reading glasses
autofocus magnification, and/or contrast • Telemicroscopes
enhancement. Although electronic devices can • Image magnifiers
be used for correction of both near and • Electronic magnifier appliances
distance low vision but still are not suggested
for mobility tasks such as driving or ambula- Microscopic lenses or spectacle mounted
tion. reading lenses: Microscopic lenses are most
commonly used low vision devices in majority
Magnification for Near of patients for improvement of near vision.
Visual outcome and comfort of wear is very
Unlike distance magnification no simple
satisfactory in most of the wearers because
formula is present for near magnification
these devices are suitable for both near and
hence, various calculation processes were
intermediate distance vision.
employed in the past to determine the
Optical system: Simple magnification
minimum addition power, required for near
system is present, where object magnification
magnification in low vision cases. Most of
is achieved by bringing the object (O) within
these calculation processes required an
the focal length (f) of high powered convex
assessment of best corrected distance visual
lens. Hence, a virtual, erect and magnified
acuity using maximum lens power and then
image (I) is formed behind the object. Object
estimation of additional near power to
forms an angle ‘a’ at point C, whereas image
visualize the smallest object clearly. To
forms a larger angle ‘b’ at the same point C
evaluate the amount of near magnification
(Fig. 16.16).
required, this calculated near power is placed
in the trial frame and the patient is asked to Types of spectacle magnification glasses:
read only the letters initially and then entire Mostly these glasses are mounted in a
line in gradual decreasing font size. Assess conventional spectacle frames either as
not only the reading capacity but also the monofocal or bifocal glasses.
flow of reading because continuous reading Broadly, these spectacle mounted glasses
usually requires higher magnification than are grouped as
mere identification of words. • Single vision spectacle magnifiers
This initial calculated power of lens for near • Bifocal spectacle magnifiers
vision can be further modified, depending
upon the results of Amsler grid or contrast Single vision spectacle magnifiers: In cases
sensitivity testing. Using these methods the where no distance correction is needed
examiner should reach to an end point where usually, a single vision or half eye glasses are
patient is able to continuously read the preferred because of convenience of wear in
smallest possible size font text. For this end terms of spectacle weight, lens thickness and
point examiner can use singlet or doublet lens size. Commercially aspheric lenses are
magnification lenses (for example, hybrid available in power range +4 D to +20 D.
lenses) as discussed later in this chapter. Once (Fig. 16.17), whereas microscopic and hybrid
the maximum power for near magnification diffractive double lenses are available in the
is calculated, then an equivalent powered lens power range of +24 D (6X magnification) to
systems (listed below) are searched for the +60 D (15X magnification).
correction of near vision in visually impaired Hybrid diffractive lenses or double lenses:
patients. Hybrid diffractive spectacle lenses or double
Low Vision 539
Fig. 16.16: Microscopic lenses produces image magnification, here D’ = distance between image and
magnifying lens and H = distance between eye and magnifying lens.
Fig. 16.17: Spectacle magnifier with aspheric lenses

(see text)
lenses consist of two elements, one in front and

Fig. 16.18: Hybrid diffractive lens
another in the back portion of lens. Front
element consists of an aspheric curve front Bifocal spectacle magnifiers: To work as an
surface and multi-order diffractive (MOD) effective low vision aid, power of additional
back surface. Similarly, back element also has microscopic lens must be extremely high. Semi
a first order refractive front surface and a finished bifocals usually present in ready stock
plano back surface. by many ophthalmic laboratories, rarely have
These two elements are separated by an air an addition power more than +4 D, even on
interface and are assembled in such a manner special order addition available for fused
that diffractive surfaces of each element faces bifocals are usually just up to +4.5 D.
each other as shown in Fig. 16.18. However, on special order single piece bifocals
Clinical Applications Table 16.6: Various advantages and disadvantages

of spectacle mounted lenses
• These microscopic lenses are commercially Advantages Disadvantages
available in a wide range of equivalent power up
to +80 D although, some patients can have Relatively economical Very close working dis-
binocularity even with a near addition power of tance (decreases with
+10 D, but convergence demand is significantly increase in power of
higher when working distance is less than 16 cm. additional lens)
Hence, greatest challenge for low vision patients Hands free High spherical aberra-
in using microscopic lenses is adaptation to this magnification tion in high plus lenses,
close working distance produced due to very high although aberrations are
power additional lenses. reduced by use of asphe-
• Working distance (meters) is simply the reciprocal rical or diffractive lenses.
of equivalent addition power, means working Wider field of view Require high illumina-
distance for a +20 D lens is 1/20 meters, i.e. tion, because of close
0.05 meter or 5 cm. To work optimally in such a working distance
close working distances the appropriate use of
Simultaneous distance
illumination is important.
and near vision
• These patients are advised to use a reading stand
which will help in maintaining of accurate focal Cosmetically better
distance and lessen the postural fatigue. accepted
• Usually the reading speed is very slow as word to
word reading because of close working distance
and illumination. Patients are advised to keep
patience and slowly learn to read at this close
distance. Once patients are accustomed to this
close working distance, the reading speed with
microscopic lenses or double lenses is usually
faster compared to other lens systems having
equivalent power.
with addition power as high as +20 D can be

obtained from some selected ophthalmic
laboratories. Fig 16.19: Telemicroscope
Microscopic lenses or spectacle mounted
Note: In nutshell, combination of an afocal telescope
lenses has several advantages and disadvan-
and a reading cap is called as a telemicroscope.
tages (summarized in Table 16.6), when com-
pared to their equivalent power magnifiers. working distance is predetermined by the
Telemicroscopes: These are popularly called power of reading cap added above the
reading telescopes which are particularly telescope. For example, reading cap of +2.5 D
designed for near work by using afocal power will produce a 40 cm working distance,
telescopes (also used for distance magnifi- similarly for 10 cm working distance, reading
cation) and modified reading caps. In these cap must have +10 D power.
telescopic systems usually a reading cap is Optical system: As discussed above a
fitted in the front portion of an afocal telescope telemicroscope has two elements, i.e. an afocal
which can easily be removed and carried microscope and reading cap, hence the total
separately by the patient as shown in Fig. 16.19. amount of magnification by a telemicroscopic
This reading cap can easily be worn when system is represented by multiplying the
patient needed to perform near work. Near angular magnification of afocal telescope with
Low Vision 541
Clinical Applications relative distance magnification of the reading

cap. This total magnification is in turn can be
This simple relationship that equivalent power of equated with the amount of relative distance
a telemicroscope is equal to the product of reading magnification produced by the equivalent single
cap power and angular magnification of afocal plus power lens. This simply means that different
telescope is very useful in selecting various telemicroscopes having same equivalent power
combinations of reading cap and afocal telescope will produce same amount of magnification
for a predetermined magnification with desired
for wearer but working distances will be
working distance.
different in different telemicroscopes depen-
For example, consider following three telemicro-
ding upon the power of reading cap.
scopes, each of them providing the same amount
of equivalent power, say 24 D with same magnifi- Advantages
cation as shown in Fig. 16.20. • Provides magnification of similar amount
• Telemicroscope A has 4X telescope with a at a greater working distance when compared
+6 D reading cap to microscopic lens of an equal power.
• Telemicroscope B has 8X telescope with a • Can be useful for those patients, who are
+3 D reading cap incapable (because of specific working
• Telemicroscope C has 12X telescope with a
distance requirements) or unwilling to
+2 D reading cap
regulate closer working distance of micro-
However, working distance for these three
scopic lenses, although desires a hands free
telemicroscope is different depending upon the
power of reading cap, i.e. 16.7 cm (1/6 meter) for magnification.
A, 33.34 cm (1/3 meter) for B and 50 cm (1/2 meter) Disadvantages
for C telemicroscope with variable field of view. • Size of field of view is reduced because an
Whereas, an equivalent microscopic lens of the same increased working distance is achieved at
power (+24 D) will have only 4.17 cm (1/24 meter) the cost of decreased field of view, this can
working distance as summarized in Fig. 16.20.
cause a reduced reading speed.
Fig. 16.20A to C: Various power telescopes, having equivalent power of +24 D, showing different working
distances. D: Equivalent power microscopic lens showing very less working distance
Image magnifiers: Various image magnifiers The amount of magnification for a

used to improve near vision in a low vision particular hand-held magnifier can be denoted
patient can be grouped as by using the formula mentioned below which
• Hand-held magnifiers is based on two assumptions, i.e. the standard
• Stand magnifiers reference distance for an unaided vision is
• Paper weight magnifiers 25 cm and another is that an object is situated
at primary focal point of the magnifier lens.
Hand-held magnifiers: Hand-held magnifier
Magnification = Primary focal point of
are common in use as they provide magni-
magnifier lens/4
fication at variable working distances, hence
Hence the emerging light rays from the
are especially useful in seeing objects within
object will be parallel from magnifier lens
reading distance or during spotting tasks such
(Fig. 16.21) and these parallel rays will fall on
as seeing the expiry date on medicine package.
the observer’s eye irrespective of the distance
By use of this type of device a larger field of
between magnifier and observer’s eye.
view is achieved due to shorter distance
between the lens and eye. Types and designs: Various types of hand-
held magnifiers are shown in Fig. 16.22
Optical system: Hand-held magnifier is
comparatively a simple device although optical • Conventional hand-held magnifiers
principles used in this device are relatively • Pocket or foldable hand-held magnifiers
complex because magnification is not in terms • Self-illuminating hand-held magnifiers
of a specific number. Magnification depends These magnifiers are available in the power
on two factors, i.e. equivalent power of the range of +4 D to +60 D with variable range of
device and position of the magnifier, hence magnification; because field of view varies with
both distances, i.e. from lens to the observer’s distance between the position of object and
eye (either d1 or d2) and distance from the focal length of magnifier lens. These magni-
object to magnifier lens (D) affects the amount fiers are selected according to individualized
of magnification. According to desire of need of patient and their working distance.
magnifier’s user, each of these distances can Various advantages and disadvantages of
easily be changed independently over a wide hand-held magnifier in relation to other
range of field of view as shown in Fig. 16.21. magnifiers are summarized in Table 16.7.
Fig. 16.21: Optics of hand-held magnifier

Low Vision 543
glasses. Because equivalent power is greater

with bifocal than without it, hence bifocal can
be used for maximum magnification.
• Where magnifier lens to object distance is less
than focal distance of magnifier lens, divergent
light rays emerge from the system, hence an
addition power lens or patient’s accommodation
or both in combination are used.
Table 16.7: Various advantages and disadvantages

of hand-held magnifier
Simple and economical Users require great
device practice to maintain
proper lens to object
distance.
More working distance Field of view is reduced
compared to micro- compared to micro-
scopic lenses scopic lenses.
Eccentric viewing is Hands are engaged
easy
During reading no Tiring and cumbersome
Fig.16.22: Various types of hand-held magnifiers.
accommodation is to hold the lens at fixed
A. Conventional; B. Foldable; C. Self-illuminated
needed position from object
Difficult to use by
Clinical Applications patients suffering from
systemic illness like
Suppose patient’s already wearing bifocal Parkinsonism, or
spectacles require the magnifier along with their neurological deficiency.
spectacles, then they should be guided by
practitioner about the maintenance of distance Stand magnifiers: Stand magnifiers provides
between eye and magnifier lens. These patients a larger working distance compared to
must be guided that from which portion of bifocal
spectacle magnifier glasses having equivalent
glass the maximum magnification will be achieved
at desired object distance. power; however, the relative field of view
• Suppose patient holds the object at focal becomes smaller than spectacle glasses.
distance of magnifier lens, where magnifier lens Optical system: Stand magnifier forms an
to eye distance is greater than focal length of image at infinity when plane of reading matter
magnifier lens, then patient is instructed to view overlaps with primary focal plane of magnifier
through distance portion of his/her bifocal lens. Normally for magnification reading
glasses. Because viewing through the reading matter is placed a little inside the focal plane
power of bifocal glasses would actually reduce of magnifier lens, so that image is formed at a
overall equivalent power to less than magnifier position between infinity and plane of reading
power alone. matter. This object image is virtual, larger and
• Suppose patient held the object at focal distance erect in nature and is located behind the
of magnifier lens (as shown in Fig. 16.21), where magnifier lens as shown in Fig. 16.23A.
magnifier lens to eye distance is less than focal
While prescribing the stand magnifiers for
length of magnifier lens, then patient is instructed
a visually impaired person, practitioner must
to view through reading portion of bifocal
be in a position to locate the image plane of
Majority of patients prefer a stand magnifier for

reading purposes, because lens to object distance is
predetermined and fixed. In addition, self illuminated
stand magnifiers are useful in situations where lighting
control is difficult. Usually, the optical parameters
provided by the magnifier manufacturers’ are
insufficient for clinical uses, hence practitioner needs
to evaluate equivalent power of magnifier with the
position of object image and prescribe the specific
type of stand magnifier to match the requirements of
patient.
Fig. 16.23: Optical system of stand magnifier. A. Image
plane shown in a stand magnifier; B. Optical power types. Fixed focus type magnifiers has a fixed
of neutralizing lens determines the position of image object to lens distance, whereas focusable type
plane by making emergent light rays parallel magnifiers require fixing of distance between
lens and object to see the image clearly. The
that particular stand magnifier because magnifier support is placed directly upon
instructions can be given to the patient reading material so that both object distance
regarding proper viewing distance, and also and image distance are constant. Several fixed
practitioner can estimate the amount of focused designs are fitted with self-illumina-
accommodation or power of near addition tion which has an additional advantage of
needed by the patient to observe the object glare free light source. Power range of these
image clearly. Location of image plane is magnifiers is +4 D to +80 D.
determined by calculations done after Various advantages and disadvantages of
neutralizing the emerging divergent rays with stand magnifier in relation to other magnifiers
an appropriate power plus lens. This plus lens are summarized in Table 16.8.
will make the emerging rays parallel and
Paperweight magnifiers: Paperweight magni-
image will form at infinity as shown in
fiers are very popular low vision aids, because
Fig. 16.23B.
of convenience and availability. These aids can
Types and design: Stand magnifier as
be used in very old people who have tremors
shown in Fig. 16.24 are available both as fixed
focus (common) and focusable (less common)
Table 16.8: Various advantages and disadvantages
of stand magnifiers
Simpler to use, because Field of view is smaller
object distance is pre- as compared to specta-
determined and cle magnifying glasses
magnifier lens is
mounted on a stand
Can easily be used Cannot be used for non-
by patients suffering planar object surface,
from systemic illness because lenses will not
and who are unable focus equally at different
to use hand-held levels of planes.
magnifiers
Fig. 16.24: Stand magnifier design
Low Vision 545
or are unable to hold objects for longer

durations. These are thick planoconvex lenses
kept directly on the reading matter and person
slowly slides this magnifier across the page
while reading the printing matter. Hence,
paperweight magnifiers can be considered as
modified version of stand magnifiers.
Optical system: Magnification power of a
paperweight magnifier can be calculated by
locating the image position and applying a
simple linear magnification formula usually,
used for a single spherical refracting surface.
Fig. 16.26: Magnification through paperweight
Magnification = ’ h’/ h magnifier where R = T
Where,  = refractive index of air, ’ =
Types and designs: Various types of paper-
refractive index of magnifier lens material, h
weight magnifiers are commercially available,
= central thickness of paperweight magnifier
but most commonly used paperweight design
and h’ = object distance from top of magnifier.
are bar, dome shaped and LED illuminated
This can further be simplified as
Magnification = ’ h’/h (because refractive Various advantages and disadvantages of
index of air is 1) paperweight magnifier in comparison to other
Here, in Fig. 16.25, A = object location, A’ = commercially available magnifiers are
image location h = central thickness of summarized in Table 16.9.
paperweight magnifier and h’ = object distance
Electronic magnifying appliances: Several
from top of magnifier, R = radius of curvature
electronic magnifying appliances like closed
of sphere, C = center of curvature
circuit television systems (CCTV), head-
Similarly, if a paperweight magnifier has mounted devices (HMD) and computer-based
equal amount of radius of curvature (R) and adoptive softwares are available for visually
central thickness (T) means it is in the form of
a hemisphere, then magnification will be equal
to refractive index of lens material, i.e. ’ as
shown in Fig. 16.26, because here h = h’ and
image will be located at object plane.
Fig. 16.25: Magnification through paperweight Fig.16.27: Various types of paperweight magnifiers.
where T < R A. Bar design; B. Dome shaped; C. LED illuminated
Table 16.9: Various advantages and disadvantages These devices are explained in detail
of paperweight magnifiers later in this chapter in non-optical
devices.
Good light gathering Low magnification
In a nutshell final selection of a distance or
power power near magnification system to correct low
vision is based on the following factors
Easy to handle and Restricted field of view
maintain
• Comfort in utilization of magnifier espe-
cially in relation to the field of view,
Very economical Difficult to read
scanning or focusing the object.
continuous text
• Patient’s need of mobilization or driving
Can also be used in old vehicle after wearing low vision aids.
age patients, with
• Contrast or image brightness required by
unsteady hands
the patient especially for reading.
• Lightness of magnifier.
impaired persons. Unlike abovementioned
• Social acceptance or cosmetic appearance
magnifiers majority of these appliances are
with device.
bulky and non-movable, hence recently
• Expenditure for purchase and mainte-
compact designs of electronic magnifying
nance of low vision device.
appliance like HMD devices are manufactured
so that they can be easily carried to different Enhancement in Contrast Sensitivity and
places by the patient. Reduction of Glare
Salient features of various electronic
Change in contrast and glare sensitivity are
magnifiers are
two important associated factors along with
• These electronic magnifying appliances amount of visual acuity which influences the
magnify the object image and also various routine works especially in a low
provide binocular presentation with a vision patient. The routine activities such as
contrast enhancing system. reading, writing, moving around and other
• Patients using these appliances can day-to-day living activities are adversely
control the image size magnification and affected due to reduced contrast sensitivity,
amount of contrast. whereas excessive sensitivity to glare will
• Some of the advance appliances have a cause the defective functional abilities in
reverse contrast control system also visually impaired patients. In cases of low
where printed matter can be displayed contrast sensitivity or altered glare sensitivity
in reverse contrast, means as white letters the practitioner should concentrate on the
on a black background. following approaches to improve the comfort
• In many designs working distance and and visual effectiveness in low vision patients.
functional field of view can also be • Significant enhancement in the amount of
changed with the willingness of patient. magnification.
• CCTV is designed for patients desiring • Recommendations of specialized lens
an extended reading or writing schedule. designs like biconvex aspheric lens, hybrid
lenses, achromatic doublets.
Note: The choice of an appropriate magnification • Add special designed lenses like lens
system for improvement of near vision in a coatings, tinted lenses, UV filter lenses,
particular person require several visits by the absorptive lenses.
patient as patient has to learn the use of these • Best possible lighting condition during
complicated lens system according to their required routine activities by using illuminated
working distance and posture.
appliances.
Low Vision 547
• Advice to use the non-optical supportive contrast sensitivity conditions. Low vision
articles like eye shades, sunscreen, peak patients suffering from significantly decreased
hats, signature guides, typoscopes. contrast sensitivity require only increased
Several studies had concluded that low amount of magnification over and above the
vision patients show higher degree of estimated visual acuity. Visibility of low
sensitivity to alteration in lighting conditions, contrast print materials can be improved by
hence to achieve comfort at work and using tinted lenses or acetate superimpose. A
maximum visual performance these visually variety of regulatory filters and lens tints are
impaired patients need particular amount of available to increase contrast in surroundings
illumination. In general to improve visual or decrease glare sensitivity. Some studies
performance, modifications in lighting concluded that yellow and orange tints
conditions at house or at job place are strongly increased contrast sensitivity in patients
recommended. In visually impaired patients having age related macular degeneration
reduced near visual acuity is commonly similarly, dark red tints has conventionally
associated with reduced contrast sensitivity, being used in patients having albinism and
hence image magnification alone is not retinitis pigmentosa.
sufficient to improve the reading capability, Altered sensitivity to glare can be evaluated
rather special illumination adjustments should inside the house or outdoor at public places
be searched during reading or performing in different problematic lighting atmosphere
other near activities for better visual such as LED bulb lighting in job place or
functioning. shopping mall. Non-optical aids like peak hats
Best suitable illumination for house or job and shades either used single-handedly or in
place can be decided by simply comparing the combination with sun filter glasses reduces
illumination between various light sources significant amount of annoying glare.
like LED bulbs, fluorescent lamps, halogen Reflected glare from printed matter
bulbs, gas tube lights, or assemblage of these produced due to additional illumination done
light sources. Distance of the light source from for contrast enhancement can be markedly
the target and angle of the light rays on the decreased by using typoscope, because it cuts
object are also essential parameters. Visibility down the surrounding light area during
comfort is assessed with the alteration of reading.
illumination because an excessive illumination In low vision patients having decreased
will produce intolerable glare (sensitivity to contrast sensitivity electronic devices (e.g.
glare is reduced in low vision patient). CCTV or head mounted devices) remain a
In critical lighting situations illuminated, better option because they help in handling
optical appliances play a major role in of contrast, brightness, and magnification
enhancement of contrast, however, some of especially when illuminated magnifiers are
these appliances are incapable to produce increasing the amount of glare.
uniform illumination, hence may require an
additional supplementary light source. Approach for Central Visual Field Defects
Low vision patients suffering from mild to Visual field defects in terms of either relative
moderate amount of decreased contrast or absolute scotomas which are located
sensitivity require specialized type of reading centrally produce significant amount of
glasses fitted with lens designs having hybrid deterioration in basic visual task such as
doublets, or aspheric lenses with antireflective reading or writing. Moreover, the size, position
coatings. These lenses transmit an increased and the depth of these central field defects
amount of light and hence produce sharper influence the outcome of near magnification,
object images, so they are useful in poor hence in several cases in spite of a suitable near
magnification various factors like size of supplemented magnification and non-

printed matter, understanding of material, complimented reading conditions. Prism
reading speed and duration gets compro- relocation technique is very useful in shifting
mised. the image closer to new preferred retinal
In patients having macular scotoma the location.
positive stimulus to focus the object on fovea Patients can be explained the advantages
may be present, hence with duration and of these approaches, however, success with
proper training these patients will learn to reading systems can hamper the growth of this
observe the target eccentrically. However, vital ability of eccentric viewing. Patient’s
eccentric viewing of the target needs to build motivation play a major role in final result of
up a new preferred retinal location (preferably eccentric viewing training, although size and
near to macular scotoma) to which the patient’s site of scotoma greatly affects and poses
eye treat as a new fovea. difficulty in controlling eccentric viewing and
In spite of a relatively superior visual acuity reading speed even after good training in a
and magnification response, scotoma situated highly motivated patient.
right side of fixation will make continuous
reading of text matter very difficult. Similarly, Approach for Peripheral Visual Field
scotoma situated left side of the fixation will Defects
make judgment of the text matter in subse- Patients having peripheral visual field defects
quent line difficult. face more difficulty in moving around
Learning of an eccentric viewing (EV) independently compared to persons having
becomes difficult in scotoma (situated in the only decreased visual acuity. Various training
surrounding area of an absolute scotoma) methods like scanning approach or organized
having areas of relative sensitivity loss and/ searching technique will improve understan-
or distortion. Many patients learn EV with ding of surrounding and independent
their own efforts, but proper training is more travelling ability, especially in patients having
advantageous for an improvised reading skill. incapacitating peripheral visual field defects.
Training of EV is usually done for improve- After completion of an estimation of visual
ment of reading by using suitable magnifi- field loss, both factors, i.e. patient’s appre-
cation devices. Eccentric viewing (EV) training ciation about field loss and his/her capability
comprises these approach to cover the defect are investigated by proper
• Patient is taught to become responsive questioning and observing the functional
for scotoma. abilities. Following devices are used as field
• Develop improvised reading techniques expander to enhance visual fields in low vision
like moving of the reading matter (not patients
the head), read single letter, read large • Reverse telescopes
print matter in lower magnification. • Concave lens
• Learn to adjust the image relocation • Prisms
happened due to the use of prisms. • Mirrors
Once patient develops responsiveness to
• Field expanders
scotoma then they can learn to locate this
• Honey Bee lens systems
scotoma with ocular movements. Control of
head and eye movements can be achieved in Reverse telescopes: Reverse telescopes are
a gradual guided practice manner, using nothing but reversely fitted telescopes, which
above threshold objectives like large printed shorten or diminish (in place of magnify) the
matter or television screen. Various types of whole visual field either in one meridian or
printed matter have been developed both for all meridians. As a result of diminution of
Low Vision 549
visual field, more objects can condense in a

smaller area but at the cost of decreased visual
acuity. In these telescopes the objective lens is
kept near the eye, hence image formed is
minified. Similar to distance magnification
telescopes, these reverse telescope designs are
also commonly available as hand-held or
spectacle mounted design as shown in
Fig. 16.28. Good visual acuity is a prerequisite
to use these reverse telescopes, because Fig. 16.29: Prism segments fitted in spectacle frame
minification effect occurs at cost of visual
acuity. the prism. Prisms are very useful in cases of
Concave lenses or minus lenses: Minus lenses constrained visual field conditions like
are placed a little away from the eyes and they hemianopia or generalized field constriction.
will also minify the entire field of view, hence Various designs of prisms are available as
can be used as field expanders in cases of low • Fresnel prisms also called press on
vision patients. These minus lenses help in prisms
direction purposes, especially to find objects • Simple prisms grounded or cemented
or locate people or view a large print matter. segmentally into any part of lens.
Prisms: Prisms are basically used to reallocate Fresnel prisms: Fresnel prisms are used to
an image toward its apex and to produce this move an image from non-seeing area to seeing
prismatic effect prisms are incorporated or functional retinal area. Majority of the
segmentally in the desired section. For patients suffering from homonymous
example, prisms are fixed on spectacle lens in hemianopia will be benefited by use of these
such a manner that the prism base remain prisms.
toward the field defect. Usually this prism Fresnel prisms are press on spectacle lenses
segment is fixed away from the central portion (Fig. 16.30) in direction of field loss in a position
of the lens (like in temporal side to right or in front of the eye, these prisms bends light at
left eye, or in upper part as shown in Fig. 16.29) nearly half dioptric value. Stronger dioptric
so that prism does not obstruct the view of prisms form larger blind spot which creates
patient when he/she is looking straight ahead. image jump, hence patient feel more image
When patient look through these prisms,
the objects can be detected in non-seeing area
of the eye with very less ocular movement as
compared to the movement required without
Fig 16.28: Spectacle mounted reverse telescope Fig. 16.30: Fresnel prism
shifting when uses higher dioptre prisms.

Various advantages and disadvantages
of Fresnel’s prisms are summarized in
Table 16.10.
Mirrors: To improve visual field in a low
vision patient having a temporal field defect
can be given plano mirror which is attached
in the rim of spectacle frame on the nasal side.
These mirrors are angled toward non-seeing
area in such a manner that by looking into this
mirror (just like the review mirror of a jeep)
the patient can easily detect the targets or Fig. 16.31: Gottlieb field expanders
objects lying within the field defect. Honey Bee lens system: These are nothing but
As discussed before the image formed in a spectacle mounted triple telescopic systems,
plane mirror is reversed, hence the patient like a honeycomb, hence the name of system.
should learn and understand left to right This type of visual system offers largest visual
reversal of the object image seen in the mirrors. field to low vision patients in their present
These mirrors are available in two designs, i.e. respective powers.
a removable hook-on form or a permanently Three telescopes of similar power are
fixed form, however, both the types has their optically aligned in one housing, which is
merits and demerits. Mainly these mirrors are fitted on a spectacle frame as shown in
recommended for right or left hemianopic Fig. 16.32. Special wedge designed prisms are
field defects. placed over the outer telescopes, angling in a
Field expanders: Although the field expanders manner such that visual fields of outer
are similar to prisms but contain high powered telescopes direct towards middle telescope.
lenses fused in the temporal aspect of a This mechanism results in filling the blind
spectacle lens which helps in improving the spots of both the eyes, hence this system
field of view. For example, Gottlieb field provides a larger continuous horizontal field
expanders (Fig. 16.31) are easily available in of view.
various power ranges. In a nutshell proper training to utilize these
visual field enhancement aids is very
important before deciding the actual outcome
Table 16.10: Various advantages and disadvan-
tages of Fresnel’s prisms
of their success. Usually low vision patients
Light weight Creates significant image
distortion
Very thin Chromatic aberrations
are increased
Economical Not stable on glasses, fall
off easily
Easy to use, simply press Increases photophobia
on spectacle glasses
Available in wide range Decreases acuity and
20–60  contrast sensitivity
Fig. 16.32: Honey Bee lens system
Low Vision 551
are not familiar to these complex lens systems lights, rather patients suffering from albinism,
and their optical features, hence for an effective cataract or maculopathies feel relaxed in low
utilization of these lens systems patient must intensity yellow lights.
have a basic knowledge of optics involved in Typoscopes: It is a reading tool, which helps
these systems. So the low vision patients must in fluent reading through a small rectangular
develop these basic visual proficiencies in box; shows only 2–3 lines at a time as shown
• Object spotting especially for using in Fig. 16.33. Surrounding dark background
reverse telescopes and minus lenses. cuts the glare from page and facilitates an
• Scanning the surroundings for using the easier reading of selective text, hence also
prisms and/or mirrors. considered as contrast enhancer.
• Development of techniques to utilize Script aids: Many script aids (writing aids) are
these complex lens systems. available for visually impaired persons such
as felt tip pens, signature guides, envelope
Non-optical Visual Aids
guides, witting templates as shown in
Visual aids which do not utilize the lenses for Fig. 16.34. These aids help the visually impaired
improvement in amount and quality of the person to write routine important matter
vision, especially in visually impaired persons inside a guided box like signing the bank
are called as non-optical visual aids. Various cheques or writing the postal address. Even
types of non-optical visual aids have been Braille or Moon method of writing is also an
developed on the basis of magnification of example of writing aid.
object’s size, improvement in the contrast
sensitivity or providing the sensory clues like Auditory aids: Several auditory aids like
touch or hearing. Aim of these non-optical talking watches or clocks, large print auditory
visual aids is to discover the possibility to calculators, speech synchronized computers,
assist low vision persons so that they can use help enormously in severely poor visual acuity
their residual vision more efficiently or patients.
perform some specific jobs non-visually.
Following are non-optical aids used in
specific situations in a low vision patient
• Reading aids
• Script aids
• Auditory aids
• Object magnification aids
• Orientation and mobility aids
• Sight substitution aids
Reading aids: Low vision patient can be
benefited by the use of either highly illumi-
nated reading surface or contrast enhanced
reading area. This can be achieved by use of
reading stands or typoscopes.
Reading stands: Maximum illumination
(avoiding eyes) on reading material is helpful
in majority of low vision patients. This
purpose is served by use of a reading stand
with lighting facility. Many patients feel
uncomfortable in high intensity fluorescence Fig. 16.33: Typoscope
Fig. 16.34: Writing aids
Object magnifications aids: Increase in the

size of object helps low vision patients to Fig. 16.35: Closed circuit television
identify various things. For example, large
print books or playing cards, high contrast Table 16.11: Various benefits and limitations of
clock dials or telephone dials. Similarly, closed circuit television
various electronic devices are also available Benefits Limitations
for magnification of object size. Instantly convert any Very expensive
Electronic devices: Electronic devices magni- material into large print
fies the objects for easier visibility in low vision Only device which Not easily available
patients and are available as follows provides binocularity at
• CCTV very high magnification.
• Large print computers Provides larger field of Non-portable
• Electronic head mounted magnification view with distortion free,
devices highly magnified image.
CCTV: Closed circuit television is an electro- Provides high illumi- Long learning curve
nic device, which helps in reading and writing nation and contrast
activities in patients having very poor vision. enhancement
In these devices a camera pick the picture of Make reading of conti-
concern object and project it on a TV screen nuous text easier at
which is several times magnified (up to 40 high magnification
times) as shown in Fig. 16.35. Enable the patient to
CCTV provides more comfortable reading/ perform writing tasks
writing posture, increased work duration and such as writing cheques
faster reading speed than any other similar
type of optical devices. which provides large size prints with
Various benefits and limitations of CCTV movement of objects towards viewer’s eyes.
are summarized in Table 16.11. Sometimes this software is also incorporated
Large print computers: A few computers with an auditory facility which provides
are available with specially designed software speech along with the printed text. Although
Low Vision 553
this system has several advantages but is very • Not suitable for patients having head
cumbersome and difficult to master this tremors
device. • Difficult to navigate
Electronic head mounted magnification Orientation and mobility aids: Various non-
devices: In the year 1992, scientists from John optical devices are designed to support a
Hopkins Wilmer Eye Institute introduced a visually impaired person for better orientation
unique low vision system aid, called low of objects and mobility. A sighted person
vision enhancement system (LVES) which was holding hand of a visually impaired person
later on marketed as low vision imaging and guiding the path was a traditional method
system (LVIS). employed for many centuries. Gradually,
Examples of various commercially available devices were developed to aid the mobility of
head mounted electronic devices are low vision patients.
• LVIS Mainly following methods are used to
• V-max guide slightly impaired persons
• Jordy system • Guide dogs
• MaxPort • White sticks and canes
• NuVision • Electronic devices
In LVIS, a video camera (monocular) is Guide dogs: Very small percentage of
mounted on a binocular head-mounted visually impaired persons uses guide dogs
display system which provides enhanced for mobility, however, they can be referred
contrast with changeable degree of magni- by health workers, clinicians or ophthal-
fication. This head mounted system is mologists to rehabilitation centers for proper
connected with a control device. Maximum training. Dog owner must be in a physical
magnification is about 10 times with field of health status to direct the dog for a desired
view about 50° horizontally and 40° vertically. route of walk.
V-max is next generation LVIS which has a White sticks and canes: To guide impaired
color video camera and magnification up to sighted persons these white sticks or canes are
about 20 times, however, field of view reduced available
to half than previous generation LVIS, i.e.
• Symbol cane: This is specially designed to
about 25° horizontally and 20° vertically. Its
symbolize that consumers of this cane are
control device is more simple compared to
visually impaired persons and need
LVIS.
special attention usually in a crowded
Jordy system came with more advanced place such as market, shops or roads.
features than V-max, like zooming magni- This cane is made up of multiple sections
fication of objects as high as 30 times and of foldable hollow light weighted tubes.
variable viewing options such as color view, Some amount of training is required to
black and white view, high contrast images, use this kind of cane.
positive and negative contrast images and
• White walking stick: Visually impaired
reverse contrast imaging systems.
patient use this cane as a symbol cane
Although several advantages are present in
rather using it for mobility or finding the
these devices but main disadvantages are
directions. It is primarily used by low
• Very expensive vision patient to take support while
• Field of view is reduced walking. Occupational counselor and
• Not easily available physiotherapist commonly recommend
• Complex operating system these types of canes for visually impaired
• Difficult mobility patients.
• Guide cane: Mainly used by people who of a magnifier for reading newspaper and
have some useful vision to identify using an auditory device for novel or
various routine objects such as footsteps storybook.
and staircase, doors or furniture. It is a Mainly two senses, i.e. hearing and touch,
longer and sturdier cane compared to substitute the sight; hence various devices are
symbol cane. designed for sight substitution is as follows
• Long cane: Primarily used by virtually • Hearing substitutes: These devices are
blind people to scan the ground in front based on the principle that when a
of them for the recognisation of the desired work is complete, an indicating
obstructions or some risks ahead of them. sound like beep or siren will blow so that
It is a long light weighted cane having a
a visually impaired person can notice
rubber grip with a roller ball tip on one
that desired work is complete. For
end.
example, fluid or water level devices
Electronic devices: Several electronic
which beep when water or fluid has
devices are available for orientation and
reached the desired level in a coffee mug.
mobility aid for visually impaired persons.
Similarly, several popular movies or
These devices can be used in addition to canes,
videos are available with audio described
for localization of various obstructions in
routine surroundings such as ceilings, narrations. Talking microwaves, talking
corridors, turning roads, small bushes. books, clocks, watches are also available
Commonly available electronic devices for so that the visually impaired person can
visually impaired patients are perform routine activities. At some
• Sonic aids: These devices use sound places annual subscription of talking
waves to detect the presence or absence newspaper, magazine and books are also
of an object similar to Radar. Hence, available.
when an obstacle comes across, the user • Touch substitute: These are touch-based
receives an auditory warning or reading and writing methods and are
vibratory signal so that person can move popularly called Braille or Moon. Braille
away from hazard. is considered as most popular and most
• Global positioning system: Commonly widely accepted method of touch related
called GPS and are similar devices used reading in writing by blind people whole
in automobiles or mobiles for finding the over the world. Specific combination of
directions of desired destination. These six raised dots are arranged like numbers
devices give a voice command to visually on various surfaces such as charts, dice
impaired person once the patient or board; which produces each of 63
specifically feed the desired route in GPS symbols of letters as shown in Fig. 16.36.
device. Mostly people use this technique to tag
Sight substitution aids: As we know that sight short text matter or read small paragraphs.
is the most important sense in individuals Reading and writing using Braille
because nearly two-thirds of information require a significant amount of training,
around us is received by sight. A significantly by professionals. Moon is simpler than
visually impaired or practically blind person Braille both in terms of practice and
uses his other sense of hearing or touch more learning because shapes of symbols
efficiently than better sighted people. resemble the routine letters, however this
Although person may be literally blind but method is not used widely because
many still like to use their visual sense in a limited trainers and books are available
mixture with other senses. For example, use on Moon technique.
Low Vision 555
person to person even if their visual status

may be similar.
• Prescribe simpler, portable, economical and
light weighted devices because complex
devices are not very user friendly.
• Before finalizing the prescription, attempt
similar types of low vision aids having
comparable designs and /or magnification.
• Always try to prescribe binocularly, where
magnification difference is not significant.
However, in cases where complex
electronic devices are required or patient is
single eyed, it is better to prescribe the best
low vision device (telescopes or hybrid
double glasses) for better seeing eye.
• Avoid prescribing low vision devices for
very young children or very old people
mainly because both are not competent
enough for accepting a low vision device.
For better understanding of the patient’s
requirement and before prescribing the low
Fig. 16.36: Braille visual aids which satisfy the objectives of our
prescription, following elements are determi-
PRESCRIPTION OF LOW VISION DEVICES ned
Introduction • Distance vision correction requirement
As discussed an accurate diagnosis and • Near vision correction requirement
magnitude of visual problem is assessed. Once • Peripheral visual field enhancement
the visual status of patient is evaluated, then requirement
the appropriate low vision aid is prescribed Distance vision correction requirement
which fulfill the objectives of prescription of • For improvement of distance vision in a
low visual aids. visually impaired person primarily we need
to magnify the distance object so that
Objectives in Prescribing a Low Vision person can see the object clearly. Amount
Device of object magnification required by a
While prescribing a low vision device clinician particular patient is simply calculated by
should consider following objectives dividing the denominator of their present
• Primary objective of prescription is to give visual acuity with the denominator of the
maximum visual acuity, contrast and visual desired visual acuity, considering that the
field with minimal influence on the numerators of both the acuity are the same.
movements of the patient. For example, suppose if present visual
• Keep an appropriate balance between acuity is 10/120 and desired visual acuity
amount of magnification, field of view and is 10/20, then
working distance. Amount of magnification required for
• Individualize the requirement of low vision distance correction = 120/20 = 6 times.
devices in different persons because • Spectacle mounted magnifiers or head
motivation and mental status varies from mounted electronic magnifiers are selected
on the basis of expected amount of visual acuity is measured at 6 meters

magnification and contrast enhancement distance and then desired near visual acuity
requirements. is converted into Snellen’s equivalent at
• Appropriate telescopic system either 40 cm. Now denominator of distance visual
Galilean or Keplerian is decided on the basis acuity is divided with denominator of
of desired amount of magnification, extent desired near visual acuity (Snellen’s
of field of view, contrast in image quality, equivalent at 40 cm) and the product is
and position of exit pupil. multiplied by 2.5 (for near distance).
Near vision correction requirements For example, suppose distance visual acuity
Near vision correction requirements in low is 20/240 and desired visual acuity is
vision patients is not as simple as distance 20/40, then starting addition is 240/40
requirements, where simply the magnification multiplied by (2.5)
of object is sufficient to improve the distance = 6 × 2.5 = 15
vision. For near vision we need to assess Means +15 D power lens is required as
• Starting addition with distance correction starting addition.
• Refine the starting correction • Kestenbaum’s rule: It is very simple where
the distance visual acuity represented in
• Equivalent power calculation
Snellen’s fraction is reversed. Final product
Starting addition is the power of lens requires of this reversed value represents the
to be added initially with the calculated starting addition in dioptres.
distance power. This starting addition is For example, suppose distance visual acuity
assessed using single letter charts and can be is 20/240, and then the reverse represen-
calculated by using any one of following tation is 240/20 = 12
methods Hence + 12 D starting addition is required
• Starting addition calculation depending on in this case.
starting near visual acuity with proper
accommodation: The M system is used to Refining the starting correction is done by
measure near visual acuity and stated as a using near vision charts having continuous
fraction (means testing distance/M letters reading text matter. As discussed above the
read). Suppose if the expected target for starting addition power for near vision is
near visual acuity is 1 M, then simply calculated by different methods using single
equating it in fraction representation with letter charts, however, refinement in near
the present near acuity will give the amount power is done with considering the contrast
of near correction. sensitivity and Amsler grid results along with
near acuity require to read the text matter
For example, suppose 6 M size letter is
(newspaper, textbook, etc.) effortlessly and
read at 30 cm (0.3 meter) distance. This
uninterruptedly from the desired distance.
can be represented in a fraction as 0.3/
The refined power required for near correction
6 M.
is usually greater than the starting addition
When equate this power because continuous reading of text
0.3/6 M = X/1 M, matter require more magnification and better
X = 0.3/6 M or 0.05, contrast.
Which means this patient require 100/5 Equivalent power is nothing but the power
(+20 D) dioptre addition power to read 1 M of a single lens which is equating the power
size letter, from 30 cm distance. of entire optical system required for
• Another method to calculate the starting magnification. Formula used to calculate the
addition power is that Snellen’s distance equivalent power has the power of low vision
Low Vision 557
device (say P1) and power of accommodation In a nutshell, prescription of a low visual aid
or addition (say P2) and the distance between is done in the following sequence
P1 and P2 (say d). • First of all try a spherical convex lens in
For spectacle magnifiers, equivalent power spectacle frame to correct distance vision
(say Pe) is simply the addition of two powers, then add an appropriate power of near
i.e. P 1 and P 2 . It means for spectacle addition as calculated by various methods
magnification the equivalent power is (as discussed above), either in the form of
Pe = P1 + P2 monocular or binocular glasses.
For hand-held magnifiers, the distance (say • Suppose field of view is not adequate then
d) between the low vision device and patient’s add a converging prism in the above
eye also come into calculation, hence equiva- prescription.
lent power for hand-held magnifier is • If no improvement with spectacle glasses
calculated by formula is seen then advice hand-held magnifier
Pe = P1 + P2 – d (P1 P2) with an appropriate magnification, whereas
no improvement with hand-held magnifiers
Formula required in calculating the
will be followed by the prescription of a
equivalent power for electronic magnifiers or
stand magnifier.
CCTV is complex but this is also based on the
• Telescopes, and electronic devices are
above mentioned parameters.
complex to use and expensive hence are
Peripheral visual field enhancement kept as reserved and are rarely prescribed
requirement: Majority of low vision patients in some cases showing no improvement
has an associated reduced peripheral visual with conventional devices.
field, hence while calculating the distance and
near vision requirement we should also Supportive Services in Low Vision
consider the requirements to enhance the Management
peripheral visual field in these cases. To Visual rehabilitation is an important and
increase the peripheral visual field an integral part in the management of low vision
appropriate optical system is selected and then patients. It consists of education, training,
patient is trained to use this system. To assistance and support or provides means
enhance the peripheral visual field in a low which may benefit a visually impaired person.
vision patient, various optical systems can be In addition to low vision, many patients
used as follows especially in older age group may develop
• Prisms: As discussed above prisms can be depression due to hazardous effects of visual
incorporated in spectacles by keeping the impairment. Following supportive services
base towards the visual field defects, so that and their recommendations can be done with
when patient sees through prism the object the help of several governmental and non-
image will shift towards the apex of prism governmental organizations
and will be seen by the patient. • Medical condition related counseling
• Mirrors: Use of mirrors is another method (psychiatric or psychological)
of shifting the object image from non-seeing • Nutritional counseling (especially, for
area to seeing area by placing the mirror diabetics)
angle towards the field defects. • Genetic counseling
• Reverse telescopes and minus lenses: Both of • Employment related training
these optical systems enhance the field of • Supportive medical/ocular services
view in low vision patients by minifying the • Procurement of supportive devices such as
image so that more information is seen in a talking books or computer softwares from
particular visual field. public library
Training/Instructions to Patient • Interpretation of blur images

Training of the patients about the uses and • Target scanning and identification
drawbacks of prescribed optical system is an • Fixating the eyes during saccadic eye
important part while dispensing the visual aid movements
device. Individually patients must be taught • Identify the pursuit movements
about the best way of utilization and • Memorize the target and recognize it on
maintenance of that particular low vision aid. reappearance
Optical systems which are complex in nature
will need harder and longer training for Patient Education
optimal usage of device, however, in majority Patient education is equally important as that
of cases regular practice, improves the of an effective treatment, hence after the
handling and usage of even a complex optical completion of clinical evaluation all practi-
devices. Regular practice and proper training tioner must analyze and should discuss about
of low vision aid has shown good reading their examination findings with the patients
speed and even longer duration wear of and their concern relatives. This discussion
complex devices in majority of cases. with patient and their family members give a
Following instructions and training about comprehensive understanding of the eye
the prescribed low vision device are given to disease, natural course and prognosis of
the patients at the time of dispensing or during present ocular disease with various functional
successive meetings for better outcome limitations. This healthy discussion and
• Type of low vision aid. patient education will help in a successful
• Functioning of low vision device. management and rehabilitation of visually
• Coordinating usage of prescribed low impaired person.
vision aid such as distance maintenance, For successful treatment these following
proper lighting and proper timing of factors evaluated during examination should
usage. be discussed with patients and their family
• Timely maintenance, i.e. changing the members, while dispensing the visual aids
battery or recharging the device and • Amount of motivation evaluated in the
proper care of device. patient.
• Avoid any hazardous situation by using • Benefits and limitations of the treatment
the device at improper timing like during offered.
driving or coming down from staircase • Description of treatment strategies with
with head mounted devices. probable prognosis for success of offered
Apart from abovementioned routine and treatment.
general instruction, many visually impaired
• Expected time required for training of
patients also need some additional training to
use of device and desire of compliance
utilize their remaining vision more profi-
for successful rehabilitation.
ciently.
Various specialized training procedures are Patient counseling and education elements
advised on individualized pattern based on include these strategies
remaining visual acuity, category of prescri- • Establish the relationship between
bed low vision appliance, size and position of patient’s visual status and visual signs/
scotoma (if present), and specific objectives. symptoms evaluated during examination.
Specialized training requires to use remaining • Select the best possible rehabilitation
vision include the following strategies strategy with its decisive factors and
• Eccentric viewing expected outcomes in terms of achieve-
• Recognition of the sentence from words ment of treatment objectives.
Low Vision 559
• Prepare the evaluation facts and/or • Whether the ocular status of patient is stable
directives for patient in detailed written or deteriorating
document. When desired aims and objectives of
• Discuss in detail about importance of the therapy are achieved then follow-up visits to
regular follow-up and patient obedience assess various aspects related to treatment
in relation to the prescribed low vision should be done on a regular basis. The follow-
management. up visit schedule can be decided by both the
• Time framing for re-evaluation and practitioner and the patient. These routine
follow-up advices. follow-up visits should be done to evaluate
the patient’s
Prognosis and Follow-up Visits
• ocular health status
Overall prognosis and visual outcome in low • visual condition
vision therapy depends on several factors such
• visual performance
as
• Primary cause of poor visual acuity • low vision aid adaptation
• Category and amount of visual impairment Although patient’s requirements and visual
• Physical and mental status of patients condition may change over time period, but
it is essential for a visually impaired patient
• Aims and objectives of rehabilitation
to realize the necessity of re-evaluation.
• Patient’s approach, enthusiasm and hopes
Patients should know that there will be a
towards low visual aids
gradual change in visual condition, however,
• Practitioner’s mindset and impulse towards they should not presume that sudden drop in
visual outcome vision is normal for their ocular condition.
Frequency and duration of follow-up visits Similarly, practitioner should also be aware
will be decided by these aspects that if there is a sudden change in the patient’s
• How well the patient is reacting to the requirements, re-evaluation is necessary to
prescribed low vision treatment resolve their recently developed visual status.
V
Problem-based
Learning
17. Problems Related to Refractive Errors and Presbyopia

18. Problems Related to Refraction, Post-refractive Corrections and
Low Vision
17
Problems Related to
Refractive Errors and
Presbyopia
MYOPIA • Duo-chrome test (Chapter 11 Page 292)

should be done to know if more minus
Problem 1: A young person aged 17 years, power is given or not.
having mild asthenopic symptoms was • Finally, if we are not satisfied with above
presented to clinic. On examination, distance mentioned methods then cycloplegic
visual acuity was found relatively normal, refraction or wet retinoscopy (Chapter
however, on performing a subjective refraction 11) can be done to relax the accommo-
patient is accepting minus spherical power of dation. This gives us the accurate
reasonable degree. refractive status of this young patient
1. Why patient is accepting minus power? who is accepting the significant degree
2. How do you manage such cases? of minus power.
Solution: Note: In young asymptomatic patients accepting
1. While performing a subjective refraction it minus power spheres for distance vision, always
is very important to keep in mind that the perform cycloplegic refraction specifically with
patient should not be corrected with too atropine to know the correct refractive status.
much minus power. Many a times, young
patients use accommodation during Problem 2: A 60 years old lady presented
subjective refraction, hence they accept with complain of fluctuation in distance vision
minus power lenses. Usually young since 3–4 years. She had a history of radial
patients prefer extra minus power because keratectomy done about 40 years back and
when compensated by accommodation, since then she had problem of glare and poor
letters on acuity chart look smaller and contrast sensitivity. Recently, since 15 years
darker which patient think as better vision. her power of glasses for distance and near had
2. For managing such situation following increased regularly and abruptly.
methods can be used during refraction 1. What are the causes of symptoms and
fluctuation in refractive error?
• Patient must be trained to compare only
2. How would you manage this case?
the clarity of letters on vision chart.
Inform the patient that if letters become Solution:
smaller and darker, then they should be 1. Most probable cause of symptoms like glare
considered as same choice, not as better and poor contrast sensitivity may be
choice. • Radial keratectomy (RK) especially, with
• Fogging or astigmatic dial technique smaller treatment zone and deeper
(Chapter 11 Page 290) should be incisions to correct higher degree
performed where patient begins with a myopia. Size of pupil plays an important
choice from plus power lenses. role for manifestation of glare because if
563
size of pupil is larger than optical zone acuity with glasses, if BCVA is satisfac-
(especially during nighttime) then glare tory, prescribe glasses and if not, then
will increase. advice for cataract surgery with possible
• Formation of cataract is another possi- visual outcome.
bility for increased glare at nighttime at
Problem 3: An elderly person of age about
the age of 60 years.
68 years presented to clinic with diminished
• Fluctuation in refractive error may also distance vision with existing spectacles (fitted
be due to change in refractive status post- with two years old prescription). On examina-
radial keratectomy because contraction of tion, an additional –1.5 D change was found
incisional wound usually causes refrac- in each eye.
tive shift mostly towards hypermetropia.
1. What are the probable causes for this
• Similarly, the corneal irregularities, acquired myopia?
scarring and smaller optical zone are
2. How you will prescribe a new spectacle
causes for fluctuation in refractive errors.
power in this case and what all possibilities
Moreover, formation of cataract especially
you will consider in management of this
nuclear sclerosis will also contribute to
case?
the change in refractive status.
2. Management of this case includes detail Solution:
evaluation of 1. Probable causes for acquired myopia at an
• Pupil size in daylight and dim light age of 68 years may be
• Status of cornea in terms of optical zone, • Cataract (most probably nuclear sclerotic
scarring and keratometry type)
• Cycloplegic refraction twice in daytime • Diabetes mellitus of recent onset or with
and evening poor glycemic control
• Assessment of cataract if present • Recent retinal detachment surgery
• Detailed fundus evaluation (scleral buckling)
• Suppose the size of pupil is large, then • Medications (e.g. chloroquine, anti-
advice the pharmacological treatment depressants, sulfa drugs, chlorthalidone,
using pilocarpine to induce miosis which etc.)
will reduce the glare, especially during 2. Prescription of new spectacle power requi-
nighttime. Perform meticulous cyclo- res consideration of following possibili-
plegic refraction to know the amount and ties
type of refractive error and prescribe • Suppose cause of acquired myopia is
glasses accordingly. Majority of these cataract, then patient must be described
post-RK patients will have irregular type in details that change in power in
of astigmatic refractive errors, hence they spectacles will improve the vision but
may require refractive surgical proce- will not solve the problem of cataract.
dures for correction of refractive error. • New prescription power should be
• Hypermetropic refractive shift (due to placed in trial frame and shown to the
radial keratectomy) and presbyopia (due patient binocularly to check the distance
to progressive age) will cause difficulty and near vision. Suppose there is an
in near vision, hence she may require improvement in the distance visual
higher additional power than usual to acuity with new prescription power but
see the near objects. the near vision get more adverse due to
• Suppose cataract is present, then decide increased myopic shift, then more add
according to the best corrected visual power should be prescribed.
Problems Related to Refractive Errors and Presbyopia 565
• Consult with the patient whether the Solution:

change in prescription will allow them 1. An ideal way to manage this case is that
to carry out their daily activities adequa- show the amount of change in vision
tely or not. Suppose outcome is that they quality to the patient, first by placing the
can perform their daily activities comfor- older prescription and then the newer
tably with glasses, then offer new prescription. Now ask the patient whether
prescription. However, if they feel he/she would like to wear a new pair of
difficulty in performing daily activities glasses (contact lenses) or not depending on
with new prescription, then advice the improvement in vision noticed by him/
cataract surgery for vision improvement. her during examination. This methodology
When patient is unclear about outcome, (i.e. let the patient decide about the change)
then prescribe the new glasses and wait should be followed in every case presenting
for the outcome in follow-up visits. for any probable change in prescription.
• If cause of acquired myopia is uncon- 2. To reduce the accommodative demand we
trolled diabetes, then first it is necessary will advice use of spectacles for correction of
to stabilize the blood sugar level. Once myopia because in myopes spectacle glasses
the sugar level is stabilized, then do not only increase the retinal image size but
cycloplegic refraction again and pres- also reduce the efforts of accommodation,
cribe new glasses. which is very useful in person approaching
• If cause of acquired myopia is exposure the age of presbyopia (Chapter 13, Page 367).
to medications, then first of all disconti-
Note: As this patient is approaching the age of
nuation of medications is required. In
presbyopia any amount of increase in minus power
addition, also discuss with patient about
will affect the near vision significantly, hence it is
the duration of exposure to medications advisable to evaluate the patient both for distance
which will decide whether patient and near vision if we are correcting the myopic
requires change in prescription or not. error at this age.
• Myopia secondary to retinal detachment
surgery is usually astigmatic error and Problem 5: 40 years old male presented
will improve when scleral buckle is with diminished distance vision with
removed after some time, however, until monocular diplopia from left eye since one
that period appropriate power glasses month. He had undergone an encirclage band
with prisms should be prescribed to buckle surgery in left eye for large retinal tear
maintain the visual acuity and avoid about one month back. The retinal tear was
monocular diplopia. located in the periphery and was not involving
the macular area. After scleral buckle surgery
Problem 4: An adult aged 38 years having
the unaided visual acuity was 6/6 in the right
moderate degree myopia appeared for
eye and 6/60 in the left eye, however, with
routine eye checkup to the clinic. This patient
pinhole the visual acuity in left eye improved
was habitual of wearing contact lenses in
to 6/9. On further evaluation left eye showed
office and outdoor activities. On examination,
12 exotropia with 4 hypertropia.
a small increase in the myopic correction was
1. What are the causes for his symptoms?
found.
2. Outline the effects of lenses on tropia.
1. What should be further course of manage-
3. How would you mange this case?
ment in prescribing new refractive power?
2. How will you reduce the accommodative Solution:
demand and also increase the retinal image 1. Scleral buckling causes myopic shift due to
size in this 38 years old patient? elongation of posterior segment of eye. This
myopic shift leads to diminution of distance • Another possibility is that patient is

vision in this case. Simultaneously, the wearing glasses for myopia, but almost
pressure effects and changes in corneal certainly his/her myopic refractive error
curvature after scleral buckling lead to is not fully corrected.
irregular astigmatic error which causes • Sometimes, a myopic person might be
monocular diplopia in some cases. These reading after taking off their spectacles,
symptoms are more pronounced in those a condition called natural near sighted-
cases where encirclage buckle is applied ness.
compared to partial buckle. 2. Various possible modes of management in
2. As per the rule the minus lenses show more this patient are
deviation than plus lenses, hence with • Suppose patient is low degree myope
minus lenses the tropia appears more and and is satisfied with his/her distance and
with plus lenses the tropia appears less. near vision, then there is no need to
Simple formula ‘percentage difference = 2.5 prescribe glasses either for distance or
× deviation’ can be used to calculate the near vision.
prismatic effect of lenses on tropia. • In the situation where patient is wearing
3. As significant amount of increase in visual myopic glasses but is undercorrected,
acuity is seen with pinhole test, the dimi- then the best way is not to prescribe an
nished distance vision and also the diplopia additional minus power to fully correct
can be managed by correction of refractive the distance refractive error because
error alone. Cycloplegic refraction is done patient is not complaining about distance
to estimate the complete amount of vision and also is comfortably seeing the
refractive error and glasses are prescribed. near objects. Moreover, keeping them
To correct exotropia prisms (base in) are under-corrected allows them not to move
added, this will also eliminate the mono- for a bifocal or progressive addition lens
cular double vision. immediately. However, correction of
myopic prescription may be required
Note: If diplopia is not improved with correction
of refractive error with glasses and prisms, then along with addition of a bifocal or
the cause of diplopia is probably muscular progressive addition lens if patient
misalignment. This needs correction in scleral performance for distance is not satisfac-
buckle or removal of buckle once retina is settled. tory.
• In case of natural near sightedness where
Problem 6: A 46 years aged person is patient is comfortable, then there is no
reading book comfortably without using need to prescribe for a bifocal or pro-
reading glasses or bifocals or progressive gressive glasses because these patients
glasses at routine reading distance. are used to read from a nearer distance
1. What are possible reasons for clear near vision than normal reading distance and
at this age in this patient (normally we prescription of bifocals or progressive
expect symptoms of presbyopia at this age)? lenses will disturb their routine reading
2. What sort of management is needed in this distance.
case?
Problem 7: An elderly person aged
Solution: 52 years having high degree myopia, wearing
1. Various possibilities of this patient reading progressive glasses regularly arrived to clinic
comfortably without using glasses are for eye check up with desire to remove heavy
• Patient may be having low degree myopia progressive glasses. Ocular examination
and not using glasses for distance vision. reveals that spectacle power is accurate,
needs no correction and eyes are also in good such as contact lenses of suitable designs
health. (rotational non-spherical contact lenses)
1. What kind of advice we should give to this and aspherical high index lenses (reduces
patient considering that he/she has no the weight and thickness of glasses) can
systemic illness? be offered to this patient.
2. What other alternatives we can offer to this Problem 8: An adult aged 36 years having
patient to get rid of heavy glasses? moderate degree myopia, presented with
Solution: complaint of difficulty in reading while using
1. Considering the age of patient and high existing glasses. However, the reading fluency
degree of myopia following advices can be is increased when glasses slides down on the
given to this patient: patient’s nose.
• Usually high degree myopes have 1. Can we consider this as presbyopia and
increased chances of development of what is the possible diagnosis for near
posterior segment complications like vision problem?
lattice degenerations, retinal holes or 2. How will you manage this case?
tears and macular degenerations. In this Solution:
patient a detailed fundus examination
1. For an individual of 36 years of age,
should be done to rule out any posterior
presbyopia is very unlikely diagnosis for
segment lesion and the patient should be
difficulty in near vision. Most strong
informed about potential complications
possibility is that patient was over corrected
of high degree myopia.
for myopic error with minus lenses for
• We must advice the patient to report distance vision since starting of glasses
immediately if he/she develops symptoms wear. This is further confirmed by the fact
of retinal damage in the form of change that reading ability improves with sliding
in temporal vision, floaters or flashes. down the glasses on nose, because with
• On every regular follow-up visit increase in vertex distance the minus power
including present visit a detail dilated decreases. At a younger age, the patient’s
fundus examination is done to rule out accommodation power was able to
any pathological myopic changes. If compensate for this extra minus power
changes are present an immediate treat- prescribed in glasses. However, with
ment should be done to prevent any advancing age (at 36 years) the accommo-
devastating outcome like retinal detach- dative ability is decreased gradually which
ment. is now not sufficient to overcome the
2. Various alternatives to high power myopic excessive minus power in the present
glasses can be offered to this patient after glasses. So this myopic patient is not left
performing the corneal keratometry and with enough accommodation to be use for
corneal topography reading purposes and developed symptoms
• Suppose patient is fit for refractive of near vision.
surgery, then the best possible alternative 2. Best method to mange this patient is to
to glasses is laser correction of myopic perform a cycloplegic refraction (preferably
error. Considering the age of patient and using atropine) and estimate the accurate
degree of myopia, the best possible laser degree of myopia. Once the exact amount
treatment is with Femtosecond Lasik of myopic error is determined, then the
surgery (Chapter 15, page 477). patient may be prescribed with the new
• If the patient is not fit for refractive prescription, which most likely will have
surgery, then other optical alternatives less minus power.
Note: It is necessary to advise patient that new to compensate for 2 dioptre myopia while
glasses prescribed to him may take some time to reading a book so he needs to remove the
adjust for distance vision because accommodative myopic glasses to read the book comfor-
tone may take a little time to relax or to return to tably. As patient does not want to remove
normal tone. his glasses to read, then the best option for
him is to use either bifocal or multifocal
Problem 9: A 38 years old asymptomatic glasses so that he can see both the distance
patient walked in clinic for routine eye check- and near targets without removing the
up. He had never used spectacles for either glasses. Suppose patient works on computer,
distance or near vision and presently working then options are trifocals, computer glasses
comfortably on computers. However, after or progressive glasses.
ocular examination and post-cycloplegic
2. In case of bifocal lenses the common
refraction, a small degree of myopia is revealed.
prismatic effects (discussed in Chapter 12,
1. What should be our course of management page 348) are
in this case?
• Differential displacement at segment top
Solution: (image jump): This image jump occurs
1. On discussion and examination, following due to near segment in bifocal lens and
advices can be given to this patient is more problematic than other prismatic
• If patient feels that his/her distance vision effects of bifocal lens. When person sees
is adequate and on examination only a suddenly from distance portion to near
slight myopic correction is needed, then portion the image of the object appears
it is better for the patient to continue his/ as if jumped from its place, which take
her routine work without distance glasses. some time for adjustment.
• At the age of 38 years avoid any kind of • Differential displacement at reading level
near correction, especially when we (image displacement): This occurs due to
found a small degree of myopia. the relative reading position in near
segment and is minimum with straight
• Manage this patient just by Counseling
top D bifocal lenses design.
and advice of regular follow-up.
• Total displacement is the sum of both
Problem 10: A 48 years old –2 DS myopic these prismatic effects and is dependent
patient presented to clinic with the complain on the refractive power of distance and
that he has to remove the distance vision near addition portion.
glasses off and on to read the books or Note: Progressive lenses are the best choice
newspaper. Presently patient’s near vision because they have least amount of image jump and
without glasses is satisfactory at routine image displacement, hence the total displacement
reading distance, however, the patient desires is also least in progressive lenses.
to prescribe new glasses so that he needs not
to remove the glasses either to see the distance Problem 11: A 40 years old office executive
or near targets. having moderate degree (–3.5 DS) myopia
1. Describe the problem with possible solutions. presented to clinic with a desire of corrective
2. Explain the various prismatic effects asso- refractive surgery for myopia. There is history
ciated with bifocal or multifocal glasses. of wearing contact lenses during family
functions or gatherings. No history of medical
Solution: illness is present.
1. The patient is presbyopic at the age of 1. What advice would you give to this patient?
48 years and his accommodation is 2. Compare refractive surgery and progressive
completely exhausted. Hence he is unable glasses in relation to this case.
Solution: cortical lenticular changes are seen on dilated

1. As this patient is approaching the presbyo- fundus examination.
pic age and might not have been aware 1. How will you counsel the patient?
about the fact that refractive surgery will 2. What is line of management in this case?
correct only distance refractive error in his
case, our prime duty is to counsel this Solution:
patient about the pros and cons of myopic 1. Before counseling the patient clinician must
corrective refractive surgery. Patient should confirm about
be well informed that after surgery the • Status of anterior segment specially
distance vision will be alright and there is cataract.
no need to wear optical correction for • Posterior segment status
distance vision ever, however, as the person • Corneal surface status and related
is nearing presbyopic age there will be problems like dry eye or scars.
requirement of reading glasses in coming • Pupillary assessment in bright and dim
years. The patient will also loose the light conditions
advantages of natural near sightedness Once these evaluations are recorded and
after laser surgery. Moreover, compli- found to be within normal limits, then
cations related to laser surgery should be explain the patient regarding their refrac-
explained in detail before performing the tive status, stating that the patient needs
surgery. refractive correction both for distance and
2. Considering the age of patient and work near vision and counsel the patient with
profile, progressive glasses are also very these options.
good alternative for his problem because • Suppose distance vision is corrected fully
the patient can have quality vision with less in both the eyes by refractive surgery,
accommodative demand in progressive then he/she will need to wear glasses for
glasses. For cosmetic reasons patient can near vision.
occasionally use contact lenses of bifocal or • There is no option that only near vision
multifocal design (Chapter 14, page 428). gets corrected by refractive surgery.
Post-LASIK surgery patient needs to wear • Rate of progression of cataract or any
glasses for near vision and moreover there other ocular condition will not be
are chances that intermediate vision may affected by refractive surgery and patient
also get affected after LASIK, hence will eventually require cataract surgery
progressive glasses are very good choice at when it will mature.
age of 40 years. • With gradual maturity of cataractous
Note: Many moderate degree myopes feel comfort changes there will be slight changes in
in reading without glasses during presbyopic age refractive status specifically for distance
and do not want to lose this natural nearsightedness vision.
at presbyopic age. 2. Management of this particular case is
slightly on different line compared to routine
Problem 12: 56 years old moderate degree refractive surgery case because practitioner
(–2.75 DS) myopic patient presented to clinic needs to correct both the distance and near
with a desire of myopic corrective refractive vision in an elderly patient by corneal
surgery. Patient is already wearing progressive refractive surgery. Following treatment
glasses since 14 years and having a vision of options can be given to the patient
6/6 and N6 in each eye with glasses. There is • Monovision LASIK can be done which
no history of medical illness or symptoms of means one eye is corrected fully for
cataract, however, grade one peripheral distance vision and fellow eye will be
fully corrected for near vision, so that no will appear as manifest hypermetropia. In
spectacles are required for both distance this case also prior to age of 47, the person
and near vision. used accommodation to correct distance
• Multifocal LASIK is another good option vision and as the age increased his/her
to correct both distance and near vision latent hypermetropia has now turn into
simultaneously in both the eyes. manifest hypermetropia.
• Alternately multifocal intraocular lenses 2. This patient requires correction for both the
can be advised in both the eyes one after near and distance vision after performing
the other. the cycloplegic refraction. The correction
• Monovision with IOL, where in one eye can be given in the form of bifocal or
the IOL of distance power correction and progressive addition lenses or if the patient
in fellow eye IOL of near power is comfortable with two pairs of glasses
correction can also be done to correct (used separately for distance and near), then
both the distance and near vision. it is another economical option. Moreover,
over the counter available reading glasses
Note: In adult patients having 6/6 and N6 vision can also be used if patient is having low and
in each eye, the multifocal LASIK is good option binocularly equal degree of hypermetropia
for correction of refractive error. without astigmatism. For example, +1 D
pair for distance and +2.75 D pair for near.
HYPERMETROPIA
Note: In these types of cases it is mandatory to
Problem 1: An elderly person aged 47 years perform a cycloplegic refraction preferably using
presented in clinic with difficulty in distance atropine drops to evaluate the exact degree of latent
vision, although there was no such complaint and manifest hypermetropia.
in the past. The patient is wearing half eye
reading glasses for near work comfortably Problem 2: A 21 years old college student
without a prescription since 10 years. Recently presented to clinic with history of ocular
the power of half eye glasses was increased strain, frontal headache and brow ache since
by the optician. 2 years. His symptoms are exaggerated with
1. Describe the probable cause of difficulty in continuous reading or studying in classroom.
distance vision? Past history revealed that he had been
2. How will you manage the case? prescribed spectacles for distance and reading
Solution: purposes about 3 years back, which he used
off and on to relieve the symptoms of
1. The most probable cause of difficulty in
headache. Patient has no history of medical
distance vision at this age is uncorrected
illness.
latent hypermetropia. The latent hyper-
metropia usually remains uncorrected 1. What all additional evaluation you would
because young healthy person does not like to perform to reach the diagnosis in this
experience any difficulty in distance vision case?
since they have sufficient reserve of 2. On cycloplegic refraction of this patient, the
accommodation and can use his/her error found in right eye is +0.75 DS (6/6)
accommodative power to overcome the and left eye is +0.25 DS (6/6), and orthoptic
defect in distance vision. However, as the examination showed orthophoria for
age advances, the ability of person to distance and 4 exophoria in near. Discuss
accommodate get deteriorate and no the differential diagnosis of this case.
enough accommodation is left to overcome 3. Outline the management strategies for this
the latent hypermetropia, which ultimately case.
Solution: 36 years is very unlikely. Most possible

1. To establish diagnosis in this case we should diagnosis is that the hypermetropia of this
perform cycloplegic refraction, orthoptic patient was not corrected completely with
assessments and measure the range and the glasses prescribed to him, i.e. latent
amplitude of accommodation. This additional hypermetropia persisted in spite of
information will help us to confirm the correction for hypermetropia. This latent
diagnosis like hypermetropia, and/or hypermetropia was getting compensated
muscular imbalance in this young patient. by the excessive accommodation efforts of
2. Various possible diagnoses in this patient the patient till age of 36 years. As the age
are hypermetropia, convergence insuffi- advanced the accommodation ability
ciency or accommodation insufficiency. As decreased gradually, as a result an inadequate
for distance there was orthophoria and amount of accommodation is left for
exophoria for near and the range and ampli- reading so this patient experienced
tude of accommodation was also normal, difficulty in near vision. Most likely
thus this case may be of low degree hyper- diagnosis in this case is under corrected
metropia with convergence insufficiency. hypermetropia, where only the manifest
3. Management of this patient is mainly done part was corrected and latent part was not
by advising orthoptic treatment of corrected by glasses.
convergence insufficiency (discussed in 2. Management strategies for this under-
Chapter 8, page 177). Optical correction of corrected hypermetropic patient are
low degree hypermetropia should not be • The latent hypermetropia can be
recommended because it may worsen the revealed by doing cycloplegic refraction
asthenopic symptoms in case of conver- or retinoscopy, i.e. testing refraction after
gence insufficiency. As the amount of abolishing the tone of ciliary muscle so
exophoria is small there is no need of that hypermetropia cannot be overcome
additional prism therapy in this case, by accommodation of patient. If latent
however, sometimes for rapid and effective hypermetropia of high degree is detected
results base in prisms can be added. on refraction with cycloplegia, then it is
Surgical treatment of convergence insuffi- recommended to do post-cycloplegic
ciency will not be required in this particular refraction to confirm that the additional
case. plus power prescribed to patient during
cycloplegic refraction is adequate for
Problem 3: Young adult male, aged
patient without cycloplegia also, because
36 years wearing hypermetropic correction
as the accommodation tone of the eye
was having no problems with distance and
returns to normal, the visual acuity may
near vision with prescribed glasses since last
alter.
12 years. Now this patient is presented to clinic
• On the other hand, a push plus technique
with difficulty in near vision with his present
can be performed during non-cycloplegic
glasses, however the distance vision with
refraction to know the maximum plus
these glasses is comfortable and clear.
power which the patient can tolerate.
1. Whether this patient became presbyopic
During testing, the plus spherical power
and if not, what is the likely diagnosis?
is added progressively until the patient
2. What sort of management is required to
notices slight blurring or discomfort.
correct near vision problem?
This plus power indicates full hyper-
Solution: metropic correction to be given and it
1. As we have discussed on page 567 that should be corrected in stages to avoid
appearance of presbyopia at the age of intolerance because tone of ciliary
muscle (accommodation) returns to strabismus or amblyopia, then other

normal gradually. therapies like occlusion therapy, etc. are
• Alternately, contact lenses can be prescri- also required with optical correction.
bed to this patient, because the mechanism
Problem 5: An elderly male aged 70 years
of relaxation of accommodation is much
wearing bifocals since 28 years is presented
gradual and also the tolerance to high
to clinic with recent onset of diminution of
plus power is better.
vision for distance and near. On examination,
Note: Many a times patients of younger age group a change in refractive power suggestive of
having quite well distance and near vision without recent onset hypermetropic shift was found.
any glass may also complain the problem in near 1. What are the possible causes for this recent
vision when they approaches the presbyopic age onset hypermetropic shift?
because of latent hypermetropia. 2. How would you mange this case?
Problem 4: A 5 years old child having Solution:

history of occasional mild deviation of eyes 1. Diminution of both distance and near vision
was brought by parents to the clinic for along with refractive shift towards hyper-
detailed evaluation. There is no past history metropia in this age may probably occur
of any systemic illness. On examination no due to
manifest squint was seen, however, cycloplegic • Diabetes mellitus: Recent onset diabetic
refraction has revealed a refractive error of mellitus having poor glycemic control or
+1.75D in both the eyes. fluctuations in glucose levels due to long
1. Explain the probable cause of deviation of standing diabetes mellitus may cause
eyes. hypermetropic shift.
2. What should be the course of management? • Cortical cataract in some cases may cause
mild hyperopic shift in older age patients,
Solution:
however, majority of cortical cataract
1. Most probable causes of occasional causes an associated astigmatic error
deviation of the eyes in young child are which can lead to the difficulty in distance
mild degree of hypermetropia or muscular and near vision.
imbalance due to systemic illness. As there
• Anterior shifting of retina due to retinal
is no history of systemic illness in this child
edema or central serous chorioretino-
then the most probable diagnosis for
pathy will lead to hyperopic shift because
deviation of eyes is hypermetropia.
of the defective focusing of light rays on
2. There is no need of any optical correction
the retina.
in this case. Usually, young children
presenting with low to moderate degree of 2. The management of this patient includes
hypermetropia, with no strabismus and no detailed posterior segment evaluation and
visual difficulty do not require any sometimes even assistance of advance diag-
correction for refractive error because child nostic instruments like optical coherence
has enough amount of accommodation to topography, fundus angiography to establish
overcome the hypermetropia which is the cause of hyperopic shift.
elicited without any conscious effort by the • If poorly controlled diabetes mellitus is
child, i.e. without any symptoms of eye the cause of change in refractive status,
strain. However, if hypermetropia is more then the patient should be referred to physi-
than 3 D and child also having symptoms cian for better control of blood sugar.
of eye strain then optical correction should • In case of cataract if change in glasses
be prescribed. If there is associated gives satisfactory vision, then we can
prescribe new power of glasses and if AC/A ratio (discussed in Chapter 9, page 197).
vision is not satisfactory with glasses The power of bifocal lenses is gradually
then patient should be advised to adjusted as the age of child advances, where
undergo the cataract surgery. add power is gradually decreased because
• If posterior segment lesions are the cause accommodation efforts are slowly compen-
of hyperopic shift, then treatment of the sated with plus lenses. Follow-up of child
lesions is advised. should be done strictly at 6 months interval
to evaluate the amount of visual acuity and
Problem 6: Parents of a 3½ years old child deviation of eyes.
brought him with complaint of deviation of
eyes and inattentiveness of surroundings Note: Accommodative esotropia with high AC/A
while playing with toys. Parents noticed ratio remain the only ophthalmic condition where
deviations of eyes when child tries to focus bifocal glasses are advised for very young child
(2–8 years age group).
the near objects, however, the deviation was
less marked when child watches the television.
The birth history is normal and child is Problem 7: An asymptomatic young adult
showing normal developmental milestones. aged 24 years presented to clinic for routine
1. What is the probable diagnosis? ocular examination. On cycloplegic refraction
2. If on refraction moderate degree of hyper- and examination a diagnosis of latent
metropia found in the child, how will you hypermetropia was made for which plus
manage the case? power glasses were prescribed to the patient.
After a few days the patient again came to the
Solution: clinic with complaints of intolerance to newly
1. Most probable cause of deviation of the eyes prescribed glasses to him.
in young child having no other ocular 1. What could be the causes of these symp-
abnormalities is uncorrected refractive toms?
error specially hypermetropia. To confirm 2. How we should manage this case?
the diagnosis cycloplegic refraction should
be done using atropine ointment. Suppose Solution:
the refractive error found in this case was 1. In this case the most probable causes of
moderate degree hypermetropia (say intolerance to the prescribed glasses may
+6.5 DS in each eye). Thus, the diagnosis of be
this case is accommodative squint due to • Imperfect cycloplegic refraction
high degree hypermetropia with high • Post-mydriatic test (PMT) was not perfor-
AC/A ratio. med
2. Management of the case includes correction Most probably the refraction performed
of hypermetropia by plus power glasses. In was not correct (see the guidelines in
this case the full correction is given in Chapter 11 for refraction techniques) and
spectacle power and parents are advised to either an overcorrection or undercorrection
make sure that the child must wear the of hypermetropia has been done. In both
glasses regularly. Due to defective these situations accommodation ability of
accommodation and high AC/A ratio the patient will affect which lead to asthenopic
child may show deviation in near vision in symptoms or intolerance to glasses.
spite of using hyperopic glasses. Suppose Moreover, a post-mydriatic test was also
after full correction this child shows not performed to assess the tolerance of the
deviation of eyes (esotropia) in near vision, plus power lenses, because this patient was
then the bifocal glasses are advised, where going to wear the plus power spectacles
an add is given to compensate for high first time in his life. In these patients the
ciliary muscle tone had been used to Solution:

overcome the latent hypermetropia since 1. The various possible options for this high
long duration and this increased ciliary tone hyperopic patient to get rid of glasses are
is difficult to get relaxed all of a sudden by • Contact lens wear: As the power of
use of plus power lenses. glasses is only spherical, she can comfor-
2. To manage the condition of intolerance this tably wear contact lenses and get rid of
patient should be advised to come for a glasses. Advantages of contact lenses are
repeat cycloplegic refraction to check the better cosmetic appearance and lesser
accuracy of prescription. spherical aberrations compared to the
• If cycloplegic refraction is found accurate spectacles. Efforts on accommodation are
and significant amount of plus sphere also reduced due to decreased vertex
power is detected then advice the patient distance in the contact lenses (Chapter 13,
to come again for a post-mydriatic page 367).
test. Post-cycloplegic refraction gives • Refractive surgery: Her hyperopia can be
an accurate assessment of patient’s permanently corrected by refractive
tolerance of new plus power prescribed procedures specially C-LASIK or
to him so it is mandatory to perform this Femtosecond LASIK (discussed in
test before writing the final prescription. Chapter 15, on page 489). Advantages of
In first prescription it is recommended refractive surgery are lifetime correction
to prescribe less plus power lenses than of refractive error, however, a few
the total power required to correct the disadvantages are dry eye, glare and
entire hypermetropic error. Gradually, in decreased contrast sensitivity (discussed
subsequent follow up visits the plus in Chapter 15).
power can be increased as the tolerance 2. Considering her age and amount of the
of patient increases to plus power refractive error the best possible advice for
spectacles. this young lady is to undergo the refractive
• Suppose the refraction was incorrect and procedure for correction of high degree
an undercorrection or overcorrection had hypermetropia. Using contact lenses for
been done, then simply perform a PMT long period are very cumbersome and also
and write a new prescription with not complication free, hence refractive
accurate power of lenses. surgery is a better choice in this case.
Note: Once the plus power lenses are started to Problem 9: Young college student aged
be used by the patient then this increased ciliary 25 years presented with difficulty in reading
muscle tone will gradually decline. Now gradually for some duration continuously. There is no
the power of plus lenses can be stepped up to history of wearing glasses and previous ocular
correct the entire degree of hypermetropic error. examination. This student tries to read in
installments and get relief when take rest in
Problem 8: A 21 years old high hyperopic between reading.
(+7 DS in each eye) female patient presented 1. Discuss the possible diagnosis in this case.
to the clinic with dissatisfaction of wearing 2. How will you manage the problem?
thick lenses and she wants to get rid of her Solution:
spectacles. 1. At 25 years of age presbyopia is not a
1. What all possible options are available for diagnosis so reading difficulty might be due
her to get rid of her glasses? to these following situations
2. What best advice you will give to this • Latent hypermetropia: A large amount
patient? of latent hypermetropia may cause
difficulty in near vision in young adult accepting a larger degree of cylindrical

because at this age, the accommodation power.
ability of person is unable to compensate 1. What could be the possible reasons for this
the hypermetropic error and the hidden change in cylindrical power?
refractive error will manifest. 2. How would you prescribe new power?
• Convergence insufficiency: Patients
having convergence insufficiency face Solution:
difficulty in reading for longer duration 1. Various possible reasons for sudden
and develops asthenopic symptoms. acceptance of large cylindrical power in this
Normal near point of convergence case are
should not be farther than 8 cm, however, • Firstly, the reason of increase cylindrical
a receding in NPA will cause reading power may be increase in the astigmatic
difficulty. power of the patient. Though it is very
• Drugs: Several pharmacological agents unlikely that there is only increase in the
used to treat condition like common cold, astigmatic error of patient’s present
migraine, motion sickness or some prescription; thus it becomes necessary
central nervous system disorders may to recheck for inaccuracy of earlier
affect pupillary sphincters. This causes prescription.
faulty accommodation and leads to • Another possibility is that the patient is
difficulty in reading. A detailed treatment using too much minus spherical power
history is must before concluding the which will ultimately lead to increase in
cause of reading difficulty in a young cylindrical power. In this case chances of
adult. over minusing are high, because for
2. Management of this case depends on the every half dioptre of over-minused
cause of near vision problem prescription, the cylinder plus power
• Suppose the latent hypermetropia is the needs an increase by one dioptre to
cause, then perform cycloplegic refraction maintain the spherical equivalent.
and prescribe the full correction in first For example, suppose the exact refractive
sitting. error of patient is: –2 × +1.0 × 90°; means
• Suppose convergence insufficiency is the the spherical equivalent is –1.5 D.
cause of problem, then the convergence • If spherical power of this patient gets
exercises (discussed in Chapter 8) are wrongly overcorrected by –0.50 dioptre
very effective in relieving the symptoms. sphere, then to maintain a spherical
• Suppose the patient is on any drug equivalent of –1.5 D an additional
causing difficulty in near vision then the +1.0 D cylinder power is needed to
best option is refer the case to physician equalize this spherical overcorrection. So
and ask the opinion about discontinuing the resultant final prescription will
the drug. become –2.5 × +2.0 × 90°.
• Suppose this patient is overcorrected by
ASTIGMATISM –0.75 D spherical power then to maintain
a spherical equivalent of –1.5 D, an
Problem 1: Young adult of age 20 years, additional +1.5 D cylinder power is needed
having mixed myopic error came for routine to equalize this spherical overcorrection.
follow-up visit. The patient is presently So the resultant final prescription will
wearing a small cylindrical power lenses, become –2.75 × + 2.5 × 90°.
whereas now on subjective refraction 2. In this patient repeat cycloplegic refraction
suddenly the patient was found to be is done to know the exact power of spherical
and cylindrical errors. Post-mydriatic test prescribing the final total correction in
(PMT) is done to know the minimum power cylindrical power and axis. Initially place
of minus sphere and maximum power of trial lenses of changed cylindrical power
plus cylinders acceptance by the patient. and axis in a trial frame and ask the patient
After PMT the power must be prescribed to look around in the clinic or walk around
for spectacle lenses. wearing this trial frame. Suppose patient
feels discomfort, then immediately remove
Problem 2: Middle-aged patient having a
the trial frame. Suppose the visual acuity is
mixed astigmatic refractive error was
showing significant improvement with new
presented to clinic for routine follow-up.
prescription, then the change in cylindrical
Previous prescription of glasses was –5.5 DS
power is first prescribed. Once patient is
× + 1.5 DC × 90° in both the eyes. After cyclo-
adjusted to new power of cylinder, then
plegic refraction the new glasses prescription
gradually change in axis of cylinder is
came out to be –5.25 DS × + 2 DC × 95° for right
prescribed till the total power and axis of
eye and –6 DS × + 2.75 DC × 85° for left eye.
cylinder gets corrected.
After wearing this new prescription for
2–3 days, this patient came back with a Problem 3: In our routine village camp
complaint of severe asthenopic symptoms like 26 years old person presented with complain
sloping of computer screen, and rising of of gradual diminution of vision for distance
ground on walking with nausea. and associated frontal headache, since few
1. What could be the cause of these asthe- years. This patient has no medical illness and
nopic symptoms? also no history of wearing glasses in the past.
2. How does the corneal topography will In our camp set up there is no facility for
appear in this case? retinoscopy or autorefraction.
3. How would you manage this case? 1. What are the methods to determine an
accurate astigmatic error (if present),
Solution: without these facilities?
1. The strongest possibility of these asthenopic
Solution:
symptoms is the modification done in new
prescription for improvement in refractive 1. When a young adult presents with gradual
error. Among all types of refractive errors diminution of vision for distance and we
the most sensitive part of a prescription is do not have facility of autorefraction or
corrections in the astigmatic portion of retinoscopy; perform accurate subjective
entire prescription. Usually a change in refraction as per guidelines described in
> 0.5 D power and >5 degree of axis in astig- Chapter 11. Many a times young adults
matic error can cause asthenopic symptoms, have uncorrected astigmatic errors of mild
especially in patients who are already to moderate degree. As the accommodation
wearing the astigmatic glasses with different gradually diminishes with age, these
power and axis of cylindrical lenses. astigmatic errors produce symptoms of
diminution of vision and asthenopia. After
2. In this case the corneal topography will
subjective refraction patient can be
show a typical bow and tie appearance in
prescribed the glasses to be used constantly
vertical orientation. This patient has the
for distance and near work.
regular with the rule type of astigmatism,
where topography shows a plus astigmatic Problem 4: A young female aged 19 years
power in vertical direction. undergraduate student of college presented
3. This case can be managed by performing a with complain of difficulty in seeing the letters
trial screening of prescription before on whiteboard in classroom and also reading
book for long duration, since a few months. refraction this patient is well accepting a
There is history of associated frontal headache +1.5 DS × –0.5 DC + 180° for near correction.
and brow ache off and on with occasional blurring 1. What is the probable diagnosis of this case?
of letters in book. She has no history of medical 2. What should be our prescription?
illness or wearing of glasses in the past.
1. Outline the evaluation method to reach the Solution:
proper diagnosis. 1. The most probable diagnosis of this case is
2. How will you manage the case? recent onset presbyopia, because the small
degree with the rule astigmatism is very
Solution: common and produces no clinical symp-
1. Complete anterior segment examination on toms. Usually these small degrees with the
slit lamp with unaided visual acuity is rule astigmatism require no correction for
recorded. Fundus examination with optic distance vision.
disc evaluation is done to rule out retinal 2. As per the past history patient was
pathology and glaucoma. Cycloplegic comfortably seeing at distance till now and
refraction is done to assess the refractive would simply require correction for
status of the patient. Blood tests to rule out reading. A prescription of +1.25 D sphere
systemic conditions like anemia, thyroid is advised depending on the spherical
disease or microelement deficiency (e.g. equivalent calculated from the subjective
calcium) are ordered. refraction of +1.5 DS × –0.5 DC × 180°. In
2. Suppose all the medical investigations and this particular patient there is no need to
ocular examination came out to be normal; prescribe an additional astigmatism
then probably the cause is refractive error. correction; however, astigmatic addition
Cycloplegic refraction in these sorts of cases can be prescribed if patient feels an
usually show a simple or mixed astigmatic improvement in either reading or distance
error of mild to moderate degree. To acuity with the addition of cylindrical
manage the case complete amount of power, or patient prefers to use bifocal or
astigmatic error is recorded and initially progressive additional glasses.
glasses are prescribed after performing
Problem 6: A 11 years old class 6th student
PMT, so that patient can tolerate the new
was brought by the parents with complaint of
prescription. Once the patient is comfor-
difficulty in seeing the letters properly on
table with glasses, then complete amount
blackboard. History revealed that child
of astigmatic error can be advised. After a few
usually sits in front row in the class and never
months of comfortable wear of glasses she
worn glasses; also there is no previous history
can be advised to go for toric contact lenses.
of refraction done. Subjective refraction of this
Once the refractive error becomes stable she
child is OD –1.75 DS (6/12), OS – 1.5 DS × +
can go for astigmatic refractive surgery to
0.75 DC × 70° (6/6).
get rid of glasses or contact lenses.
On detail examination no ocular pathology
Problem 5: An adult aged 44 years was was found, and VA in right eye was improving
presented with complaint of difficulty in to 6/6 with pinhole.
reading small fonts since a few months. On 1. What is the cause of low visual acuity in
examination along with signs of presbyopia right eye?
he also had a plano-astigmatic error of 2. How it should be managed?
–0.75 DC × 180° for distance vision in each eye.
There is no history of using distance vision Solution:
glasses in the past and also the patient is 1. Most probable cause of low visual acuity
asymptomatic till recently. On subjective in right eye is improper refraction, because
young children may have different degree 2. Any case of diplopia should be thoroughly
of ciliary tone in each eye and hence subjective investigated in terms of blood parameters
refraction may not give accurate amount of (complete blood count, blood sugar, thyroid
refractive error. Secondly, in majority of profile, lipid profile, etc.), MRI brain and
patients astigmatic correction is symmetrical, ocular B-scan. Clinically a detail posterior
so it is better to search for this possibility. segment evaluation is also necessary to rule
2. To manage this case we need to perform a out any intraocular lesion.
cycloplegic refraction with atropine eye 3. For the management of this case perform a
drops. On PMT a complete symmetry in meticulous cycloplegic refraction to determine
astigmatic error would have been indicated the exact refractive power and cylindrical axis.
when refractive error for the right eye is • Suppose new prescription eliminates the
–1.5 DS × + 0.75 × 110°, so a repeat subjective symptoms of diplopia, then the cause was
refraction for the right eye can be done established and patient will be alright in
considering this symmetrical prescription. a few days after wearing the new glasses.
• However, if symptoms of monocular
Note: When there is significant improvement is
diplopia are still present and investiga-
seen in visual acuity with pinhole and no ocular
tion data shows some deviations from
pathology is found on examination; then the most
common cause of low visual acuity is inaccurate normal, then search for other causes of
refraction. monocular diplopia. Then the line of
management is either medical or surgical.
Problem 7: A middle aged 52 years old
Note: In cases of monocular double vision suppose
patient presented with complain of diplopia
pinhole test abolishes the diplopia, then the cause
since few days. Ophthalmic history revealed is either refractive error or cataract.
that the patient was wearing a sphero-
cylindrical correction of moderate degree in PRESBYOPIA
each eye since many years. On clinical evalua-
tion monocular diplopia was discovered in Problem 1: A 44 years old office employee
right eye; however there was no deviation of eyes started facing difficulty in performing the
and extraocular movements were free and full. routine desk work. He has no difficulty in
There is no history of medical illness like diabetes distance vision and was not wearing any
mellitus, hypertension or thyroid disease. glasses. On his own he purchased an over the
1. Whether refractive error can cause this counter reading glasses for near vision, but
recent onset diplopia? after advise from colleagues he presented to
2. How will you investigate this case? clinic for ocular evaluation. This patient asks
3. Outline the management of this problem. following question during examination
1. Whether using over the counter reading
Solution: glasses are correct for my eyes?
1. Few selective refractive errors especially 2. What are the advantages and disadvantages
irregular astigmatism of moderate to high of over the counter reading glasses?
degree can cause severe blurring of vision 3. What is the problem with my vision and using
with distortion of images; which occasio- over the counter glasses will affect my vision?
nally can manifest as monocular diplopia.
4. How would you treat me?
In this particular case the moderate degree
astigmatic error was wrongly corrected either Solution:
in terms of spherical power, cylindrical 1. Usually when the patient of 44 years age
power or axis; hence the symptom of are asymptomatic and have good distance
monocular double vision was appearing. vision without glasses, the near vision
problem is due to presbyopia. For this usual for distance and then check the near vision
presbyopic condition over the counter monocularly then binocularly. Suppose
(OTC) glasses are good alternative, when distance vision retinoscopy is normal, then
given by trained ophthalmic personnel. In near vision is corrected using plus power
this particular case the OTC glasses were spherical lenses monocularly and then
purchased by patient under no supervision, binocular balancing is done as discussed in
so chances of overcorrection or under- Chapter 11, page 297.
correction are high. Problem 2: A 50 years old presbyope using
2. Most common advantages of OTC glasses over the counter reading glasses since 8 years
are economical, easily accessible and presented with difficulty in seeing the fine
immediately available to use. near objects. On examination it was found that
Disadvantages of OTC glasses are patient needs an increase in the strength of the
• These glasses have equal power on both existing over the counter reading glasses. On
sides, however, majority of person have declaring that patient needs to increase the
some amount of difference in refractive power of their existing reading glasses the
status of both the eyes. patient asked these routine questions:
• OTC glasses are available in common 1. Can I still use my old reading glasses which
size small frames, whereas facial anatomy are less strong?
2. Will the old glasses harm my eyes?
of people are quite different; hence the
3. Write an appropriate solution with explana-
optical center and reading center may not
tion.
properly align in OTC glasses.
• Quality of lenses used in OTC glasses is Solution:
usually poor because of mass produc- 1. The patient can continue to use his/her old
tion; hence proper refractive correction reading glasses as long as patient feels that
is not possible. the glasses are providing satisfactory vision
for reading.
Note: Indirect disadvantage of OTC glasses is that 2. Suppose these old reading glasses are not
patient does not feel like visiting an ophthalmologist causing any eyestrain; means they are also
at presbyopic age; hence the chances of missing
not doing any harm to patient’s eyes, by
potentially blinding conditions like glaucoma and
using them. However if there is difficulty in
cataract increase.
seeing small objects or performing fine work,
3. Problem in this case is simple presbyopia then change of glasses is recommended.
due to decreased accommodation ability at 3. Best option for this patient is to perform a
44 years of age. Using OTC glasses prescribed cycloplegic refraction to record the exact
by ophthalmic personnel will not weaken amount of refractive error. Suppose there
the eyes, however, in this case the patient is no refractive error for distance vision,
had purchased OTC glasses without any then the power of near vision is determined
prescription so these glasses may not be and balancing is done as discussed in
correct for him. Many a times due to Chapter 11, page 297. It is always better to
unproven concern of weakening of eyes, wear the glasses of exact power rather than
occasionally patients report that despite of OTC reading glasses for the reasons
having difficulty in reading they avoided explained in the above solution. Suppose
using the recommended reading glasses; to patient is an office employee and do
keep their eyes strong. computer work, then it is better to use the
4. To manage this case we will perform dry progressive glasses rather than OTC
retinoscopy to evaluate any refractive error reading glasses.
Problem 3: A 55 years old moderately high reading book for some time. Patient is not
myope successfully using progressive wearing glasses for distance or near and has
addition lenses for normal reading recently no medical illness. Presently patient feels that
discovered that now she is facing difficulty in it takes a few seconds for his vision to become
threading a needle. There is no history of clear when he looks across the room after
medical illness and the power of her present reading for some duration. He also feels that
glasses is nearly one and a half year old. words overlap when he read the book
1. What might be the cause of her problem? continuously for some duration.
2. How will you solve the situation? 1. Explain the etiology of this off and on blurring
of vision both in distance and near?
Solution: 2. How you will manage this case?
1. The most probable cause of her difficulty are
• Change in refractive power. Solution:
• Beginning of cataractous changes. 1. This symptom is classical presentation of
• Power of addition used since beginning presbyopia, especially in an emmetrope.
was less (means just sufficient to read). The remaining accommodation at 42 years
2. Various possible solution for her problem of age is functioning very strongly so that
are dependent on the cause this patient can read for some duration;
• In case of change in refractive power it however due to this extra efforts of accommo-
is better to perform retinoscopy and dation patient’s eye takes a few seconds for
prescribe new glasses having sufficient the accommodation to relax when patient
near add to see very small objects like look distance objects. Similarly while reading
needle hole or thread margin. for some duration the small amount of
accommodation gets exhausted and patient
• Perform a dilated examination to see the
feels that words are getting overlapped.
lenticular changes and if the cataract is
only in grade one or two and patient is 2. To manage this case the options are depen-
achieving N5 with near add then dent on the amount and severity of symptoms
prescribe glasses and if the vision is not • If these symptoms of blurring off and on
improving up to the patient’s satisfaction, are accidental findings by the patient and
then perform cataract surgery. are not causing any major inconvenience
or difficulty; reading glasses can be
• Alternately in moderate degree myopes
deferred for some more period of time.
the simplest solution to this problem is
• However, suppose patient has also
just take off the present glasses and
noticed some difficulty with small print
thread the needle; because by doing so
or would like to eliminate this problem;
they are using their natural nearsighted-
then reading glasses are recommended.
ness to see close, hence no accommoda-
• Suppose patient has to perform work on
tion or additional plus power is needed.
computers and also desire to have crisp
Note: This strategy will also be useful when patient intermediate vision then progressive glasses
try to read very small print, or when it is necessary are recommended as the first choice.
to read while at the same time patients require Problem 5: A 44 years old emmetrope not
distance vision. However the reading material needed
wearing any glasses for near presented to the
to be held closer than the normal reading distance.
clinic with complaints of difficulty in reading
newspaper inside the room especially during
Problem 4: A 42 years old asymptomatic early morning or evening time; however, he
emmetrope presented with the complaint of is able to read the newspaper in balcony in
difficulty in focusing the distance objects after daylight without any glasses. This patient also
feels that he faces difficulty in reading the satisfactorily. Patient can wear these glasses
magazine in bed during nighttime; however, during reading work by keeping them
the same magazine he can read easily while slightly in front over the nose, so that he can
sitting on table in daylight. see the distance objects above the glasses.
1. Explain the causes of this problem along
with the diagnosis. Note: In bright sunlight reading is much easier for
an emmetropic early onset presbyope because of
2. How would you manage this patient? the pinhole effect. The pinhole effect can be
Solution: produced either by stimulating the eye with bright
light or squinting the eyes.
1. The most probable cause of these symptoms
is weakning of accommodative power of
eyes, due to onset of presbyopia at the age Problem 6: A 52 years old emmetropic
of 44 years. These symptoms are occurring presbyope was using half eye reading glasses
because since 8 years for reading purposes. He has no
• Normally when accommodation power history of medical illness or any other ocular
decreases the pinhole effect helps in the problem. This patient walked into the clinic
ability to read clearly by producing miosis overwhelmed saying that he is capable of
of eyes. Hence this patient was able to reading magazines without his reading glasses
read newspaper in daylight. On contrary, on tour, especially when he lay down on
normally pupils dilate when surrounding seashore.
illumination decreases, which cause loss 1. Write an appropriate explanation of
of the pinhole effect; hence this patient improvement in near vision.
was unable to read inside the room. 2. Is this problem require any additional treat-
• In normal circumstances accommodation ment?
is achieved by contraction of the ciliary Solution:
muscle, which in turn relaxes the zonules 1. When this elderly emmetropic presbyope
and allows the crystalline lens to become is on a tour and lay down on seashore in
more convex. During early morning bright sunlight his eyes get the pinhole
period the ciliary muscles are mildly effect as discussed in the above problem.
slower and until late night the muscle Normally on seashore the bright sunlight
gets fatigued; so this patient has diffi- causes miosis of pupil to produce a signifi-
culty in reading the newspaper especially cant pinhole effect and this pinhole permits
during early morning and late nighttime. only the central rays (coming from an
• Usually inside the bed person holds the object) to enter the eye. This effect neutrali-
magazine closer as compared to sitting zes the refractive error and also compensate
position during daytime; this decrease in for the demand of accommodation. Hence
reading distance demands more accommo- this patient is able to read the magazine
dation power, which this 44 years old without wearing his reading glasses.
patient do not have. Hence this patient 2. As this pinhole effect is a normal pheno-
faces difficulty in reading the magazine menon and causes no harm to the eyes of
in bed during nighttime. patient, no additional treatment is
2. As this patient is having an early onset recommended in this case. However, patient
presbyopia and has on official work we can can continue to wear his reading glasses in
manage this patient by prescribing the all other situation while reading. Patient must
reading glasses. For an emmetrope at be counseled and explained about the pheno-
44 years of age, usually a +1.25 DS power menon of pinhole effect for improvement of
half eye reading glasses will work very his near vision in sunlight.
582
Problems Related to
Refraction, Post-refractive
Corrections and Low Vision
REFRACTION with the old glasses. During re-evaluation

examine these points
Problem 1: A 65 years old patient having
• Check the power of old glasses.
pesudophakia in both eyes came for routine
follow-up without any significant complaints. • Compare the visual acuity with both the
A meticulous cycloplegic refraction was old and new spectacles and note down
performed on this patient and glasses were the difference and comfort level (some-
prescribed. After a week this patient again times patient may have better visual
came to the clinic with complaint that new acuity and comfortable feel with new
glasses prescription given to him are not good glasses).
and he is facing a lot of difficulties in seeing • Perform a repeat refraction (preferably
with new spectacles compare to his old with cycloplegic drug, e.g. cyclopentolate)
spectacles. This patient has no history of 2. Manage the patient according to outcome
systemic medical illness. of examination as follows
1. What could be the possible cause of non- • Suppose a change in prescription of
acceptance of new prescription? glasses is must, then advice the patient
2. How will you manage this case? for new glasses (give complimentary
consultation) and also explain him the
Solution: cause of his difficulty in vision.
1. To find out the cause of discomfort and non- • Suppose the glasses power prescribed
acceptance of glasses ask the following were correct but there was an error in
leading questions to this patient making of glasses by optician; handle the
• Whether problem of seeing is in one eye situation gently and consult with
or both the eyes? optician for arrangement of new
• Is their difficulty in seeing at distance, complimentary spectacles.
near or both with new glasses? • Suppose the power of new prescription
• Is there any associated symptoms like is accurate and also the glasses made are
ocular strain, tilting of edges of plane correct then counsel the patient that some-
object, nausea, sudden blurring? time a change in power requires adjust-
ment period of one to two weeks, hence
• From where these new spectacles were do not panic and continue to wear the
made? new prescription.
Suppose the patient answers that he is
having difficulty in seeing both at distance Problem 2: Two 75 years old patients came
and near and has no associated symptoms together to clinic with complaint of gradual
of eye strains then re-evaluate the patient painless diminution of distance visual acuity
582
Problems Related to Refraction, Post-refractive Corrections and Low Vision 583
since few months. A meticulous cycloplegic • As patient B having cataract is not

refraction is done and on subjective refraction satisfied with distance vision with
best corrected visual acuity with glasses was glasses then cataract extraction with IOL
recorded for both the patients as follows implantation is the treatment of choice.
• Patient A: Distance visual acuity 6/24 and
Problem 3: A young patient having mixed
near visual acuity of N12 in each eye.
refractive error came for follow-up after a
• Patient B: Distance visual acuity 6/24 and period of two years with complain of slight
near visual acuity of N6 in each eye. difficulty in distance vision with existing
Considering these abovementioned visual glasses. Two years back an excellent refraction
status, explain was performed by you and patient is wearing
1. What is the possible diagnosis of each the same power glasses since then.
patient? 1. What type of refraction should be perfor-
2. How will you manage them? med to resolve the present problem?
2. Describe the management in this case.
Solution:
1. Considering the disparity between distance Solution:
and near visual acuity 1. As this patient is having a mixed refractive
• Patient A is more likely to have age- error and was comfortably wearing the
related macular degeneration, because in previously prescribed glasses since two
case of age-related macular degene- years, it means the cylindrical power and
ration, distance and near acuity are axis determined during previous cycloplegic
comparable. After correction with refraction was accurate. This time as the
glasses both the distance and near visual patient is having slight problem in distance
acuity rarely get fully corrected in case vision with existing glasses, means there is
of ARMD. no need of changing the cylindrical power
• Patient B is more likely to have a cataract, or axis in this patient and simple over
because in an early to moderate grade refraction for correction of spherical power
cataract usually a disparity between is required to correct the distance vision
distance and near acuity is seen where problem. In over refraction the patient is
near acuity is always better than distance asked to wear the present glasses and a dry
acuity. After correction with glasses the retinoscopy is performed to neutralize the
near acuity is usually corrected in normal reflexes. New power is recorded and
range, however, the distance acuity is difference in power is considered for
rarely get fully corrected in case of prescription.
cataract. 2. New prescription is dependent on the
2. Management of these patients include visual outcome after over refraction.
• In case of patient A having ARMD the Suppose over refraction produces an excellent
treatment of choice is best correction with vision in distance, then only a change in the
glasses and also by low visual aids sphere is prescribed along with the existing
(discussed in Chapter 16). cylindrical power and axis. Thumb rule of
prescription is that do not change the
Note: Suppose a patient present with gradual astigmatic error frequently. Difficulty in
painless diminution of vision and has both cataract adjusting to the new prescription will be
and macular degeneration; then the discrepancy less in cases where astigmatic power was
in improvement of distance and near visual acuity kept same as compared to the cases where
can be helpful in deciding which condition is more cylinder power (especially cylindrical axis)
responsible for the reduced visual acuity.
was changed in new prescription.
Note: Additional advantage of performing an over- Note: There is no role of auto-refractor in these
refraction is that there is no need to adjust vertex kinds of cases.
distance (distance between the lens and cornea)
in new glasses. Since the new glasses will be fitted the axis of cylindrical lens is shifted in steps
in same plane as existing and adjustment of new of 15–20 degrees, not as 2–5 degrees as done
glasses will be easier for patient. Remember that in routine refraction method.
larger the prescription power, the vertex distance
becomes more relevant. Problem 5: An elderly 86 years old patient
came to the clinic with complaint of having a
Problem 4: An elderly patient of 85 years lot of confusion about spectacles he needs
age presented to clinic with low distance during daily activities. He has no history of
vision (6/60 in each eye). He is a diagnosed medical illness; however, both eyes cataract
case of age-related macular degeneration extraction with IOL implantation was done
(ARMD) and is on medical management. about 10 years back. On further investigation
There is no history of medical illness; however, four pairs of spectacles were found in a carry
both eye cataract extractions with IOL bag, which he is wearing for various daily
implantation was done about two years back activities.
in right eye and one year back in left eye. 1. How will you proceed in this case?
1. Whether routine type of refraction technique 2. How will you solve the problem of multiple
will help in improving the visual acuity in spectacles?
this case? Solution:
2. Describe an appropriate type of refraction
1. Primary aim of consultation is to reduce the
method to improve the visual acuity in this
number of spectacles in this patient which
case.
are being used for various activities and
Solution: simplify the things. Following questions are
1. Routine type of dry or wet retinoscopy will asked to the patient to understand the real
not help in this particular case, because the requirement in his daily activities
reflexes seen are not very bright and also • Which pair of spectacle he wishes to wear
the patient is not able to appreciate the most of the time?
small changes during subjective refraction. • For what kind of activities he requires
Hence we need to modify the refraction other pair of glasses?
method to improve the visual acuity.
• How long he wear other pairs of spectac-
2. Most appropriate refraction technique is to
les?
perform the objective refraction under
cycloplegia (specifically homatropine) and • Since how long he is using these four
selecting large steps of lens power pairs of spectacles?
correction in ARMD patients having low Answers to these questions will help the
vision. Once the objective refraction is done practitioner to understand the real require-
and estimated amount of refractive error is ment of multiple pair of glasses. Based on
recorded then the subjective refraction the answers clinician can decide and
power measurement and comparison of accordingly reduce the spectacles which are
spherical and cylindrical powers are done not really needed by this old man.
in larger steps like 0.75 to 1 dioptre; not in 2. Management of this problem depends upon
routine smaller steps of 0.25 D. After the outcome of evaluation of patient and
changing the power of lenses at every step all four pairs of glasses
the patient is asked to compare the visual • Suppose prescription of all glasses is very
acuity and then proceed accordingly. Even old and patient wear most of these
spectacles for very short duration then it improvement in near vision is nuclear
is better to perform a cycloplegic refrac- sclerosis of crystalline lens. Cataract
tion and prescribe new pair of glasses especially of nuclear sclerosis type causes
preferably separate spectacles for a condition commonly called second sight
distance and near vision. This will reduce of nearness because the patient again starts
the number of glasses to only two pairs seeing the near objects without reading
from four pairs. Alternately a pair of glasses after wearing the near vision glasses
bifocal glasses having distance and for 20–25 years.
intermediate power and second pair of 2. To manage this case first evaluate the
glasses having only near power can be distance vision with best optical correction
prescribed. and following options are available for this
• Suppose patient is using these four pairs elderly patient
of glasses regularly and comfortably • Suppose the distance vision improves
during various daily activities, then it is significantly by optical correction and
advisable to continue all pairs of spectac- patient is also satisfied with the amount
les as before, because change in pattern of vision, then it is better to recommend
may create newer visual problems. the progressive glasses for some more
Problem 6: A 65 years old male patient year with regular six monthly follow up.
presented to clinic overwhelmed that since a • Suppose there is not significant improve-
few months he does not require near vision ment in distance vision or patient is not
glasses to read newspaper, although he was satisfied with the amount of distance
using half eye reading glasses since 22 years vision with glasses, then it is better to
for reading purpose. He has not undergone recommend the cataract surgery.
any medical check up since 6–8 years and also Problem 7: An elderly 85 years old patient
has no symptoms of illness. presented to clinic with visual symptoms due
1. What are the possible etiologies for to excessive scratches on present spectacle
improvement in near vision at such an lenses. On examination the refractive power of
elderly age? present glasses was accurate and a new prescrip-
2. How will you manage this case? tion of same glass power was prescribed.
Solution: After a few days patient came with complain
of intolerance to new glasses and exaggeration
1. Most common phenomenon causing an
of visual symptoms.
improvement in reading ability in elderly
age group patients is due to acquired 1. How will you evaluate the case?
myopia. As discussed before the common 2. What will be the next step of management?
causes for acquired myopia are Solution:
• Nuclear sclerosis of crystalline lens 1. First we check the power of old glasses on
• High blood sugar levels in a diabetic lensometer and also compare the new
(recent onset) patient. prescription with the old power of glasses.
• Retinal detachment surgery (recent) Once the power of both the old and new
• Chronic use of medications. prescriptions are checked then
As this particular patient has no history • Suppose the power of old and new
of recent ocular surgery (specially retinal glasses are different, then ask the optician
detachment with scleral buckling), drug to correct the power of new glasses.
intake for longer duration or high blood • Suppose both the power of glasses are
sugar levels; the probable cause of the same, then the most likely cause for
this problem of intolerance is that the • Examiner then alternately occludes one
new lenses have a different base curve eye by an occluder while patient is still
than that of the old lenses. Change in looking to the distance object.
base curve will affect the accommodation • Patient must be able to see the distance
efforts of eye and refractive power of object clearly with one among two eyes.
lens, hence will cause intolerance to the The eye which sees the distance object
patient. clearly is termed dominant eye.
2. Most preferred method to solve this 2. For a successful monovision contact lens
problem is to ask the patient to carry the fitting, the recommendations are
old lenses to the optician along with new • Determine the dominant eye and prescribe
prescription of glasses with specially the distance correction contact lens for
mentioned note for optician. In this note this dominant eye. A monofocal contact
request the optician to simply duplicate the lens of near power is prescribed in fellow
old prescription including the base curve eye (non-dominant eye).
of lenses. • Alternately bifocal contact lens can be
prescribed in both the eyes.
Note: Suppose patient is wearing prisms in old
prescription then simply write a note to the optician POST-REFRACTIVE CORRECTION
to duplicate the existing prisms in new lenses.
Problem 1: A 70 years old presbyope was
Problem 8: A 41 years old moderate degree comfortably wearing flat top bifocal glasses
myope recently developed presbyopia since 26 years. He developed difficulty in
presented to clinic with a desire of monovision visualizing the TV caption from an inter-
contact lens fitting. He has no medical illness mediate distance with his present glasses.
and contraindications to contact lens fitting. After cycloplegic refraction his glasses were
1. How will you evaluate the case for mono- changed from flat top bifocal to progressive
vision? type of glasses elsewhere. Now this patient is
presented to our clinic with discomfort in
2. What will be your recommendations in this
vision both at distance and near.
case?
1. How will you evaluate this case?
Solution: 2. What will be the solution to this problem?
1. All the basic evaluations for fitting of Solution:
contact lens are done as discussed in 1. For evaluation of problem
Chapter 14, page 430. In case of monovision • First inquire when the patient has been
contact lens fitting we need to establish changed from a standard bifocal to
which eye of patient is dominant for a progressive glasses or since how long
successful prescription. Easiest clinical patient is wearing these new progressive
method to determine the dominant eye of glasses. Usually there is an adjustment
patient is as follows period for progressive glasses; some
• Instruct the patient to outstretch both the individuals may take approximately
arms keeping hands one on top of other. 2–3 weeks time period for adjustment of
Tell the patient to create a small gap bet- progressive glasses.
ween two thumbs of outstretched arms. • Following problems are asked to decide
• Then patient is asked to look at a fine the cause of patient’s difficulty in using
object like quotation on wall through this progressive glasses:
small gap between the thumbs (keeping – Troublesome inbuilt blur at the sides
both the eyes open). of progressive glasses
– Necessity of any abnormal head Solution:

posture for seeing the distance or near 1. Various situations can cause the reading
objects difficulty in this case.
• However, if there is a significant need for • To reach a proper diagnosis some more
the correction of intermediate distance, information is required in this case. Ask
for example, to see the television; it was the patient whether changing the reading
reasonable to make the change in glasses distance (means either keeping the book
from bifocal to progressive. a little away from eyes or bringing the
2. To solve the problem book a little closer to eye), affects the clarity
• Suppose the patient feels inbuilt blur or of reading. Suppose the answer to any
require abnormal head posture to see one of these situations is yes, means the
clearly, then check the proper pantosco- reading addition given was improper.
pic tilt (described in Chapter 12, page Always keep in mind that in the making
345). of bifocal lenses, near power is always
• Check the power of new progressive added with the distance prescription.
lenses by automatic lensometer (to be Suppose the distance prescription is
sure about the fitting of correct prescrip- incorrect, then the reading segment
tion). prescription will automatically be wrong
• Counsel the patient that usually pro- and patient will have difficulty in reading.
gressive lenses require some amount of • Classically position of the upper line for
training in viewing the target and also D-bifocal segment is fitted at the level of
viewing through progressive lenses takes lower lid margin as described in Chapter 12,
some time for adjustment. page 350. Suppose on inspection the
• Suppose no problem is identified or it is reading segment is found to be fitted too
confirmed that patient is unable to low or too high, then the problem is not
tolerate progressive glasses, best option in addition power rather the cause is
is to change back to standard bifocal flat improper fitting of lens in the spectacle
top glasses. frame.
• Spectacles are verified whether the lower
Note: Generally when patient is doing perfectly portions of the lenses are fitted with an
well with standard bifocal and has no complaints, inwardly angled position (pantoscopic
it is better to continue the same type of glasses in tilt) or not. Proper pantoscopic tilt is
new prescriptions. mandatory to read comfortably as
described in Chapter 12, page 346.
Problem 2: A 55 years old patient was 2. Management of problem
refracted and prescribed new glasses for both • Suppose if an improper addition was
distance and near vision. This patient was given in new prescription, then re-
previously wearing the D-bifocal glasses and examine the patient and give proper
hence made the new prescription in same lens addition power.
design. After 2–3 days the patient came back • Suppose patient feel more comfortable
with the complaint of having difficulty in in reading by pushing the glasses up or
reading with the recent prescription received lifting the chin up, then reading difficulty
from us; although the distance vision is fine is because of improper fitting of glasses
with the new prescription. in spectacle frame. In these cases the
1. What are the probable causes for difficult opticians are advised to fit the bifocal
near vision with new prescription? segment properly in spectacle frame as
2. What should be the line of management? described in Chapter 12.
Note: In some individuals spectacle frame slides half eye reading glasses; then he/she can
down from nose while person lowers the head to wear two glasses one above the other for
read a book; so the working position of bifocal near this kind of fine near work.
segment is fitted slightly lower than the usual
position (i.e. at lower lid margin) in these cases. Problem 4: A 48 years old an office executive
who was wearing D-bifocal glasses since
• Suppose improper pantoscopic tilt was many years comfortably is now presented
noticed in this case then correction of the with difficulty in performing the excel work
pantoscopic tilt will enhance the comfor- on his computer wearing glasses. The
table reading ability of this patient. prescription of his bifocal glasses was recently
changed about 3 months before and he is
Problem 3: A 47 years old emmetrope was having crisp distance and near vision with the
presented to clinic with the complaint of D-bifocal glasses.
recently developed problem in viewing the 1. What could be the probable cause for this
labels of medicines with his near vision half problem in computer work?
eye glasses. He was using +1.75 D power half 2. Write down the possible solutions for this
eye reading glasses without any prescription difficulty in intermediate vision.
very successfully since one year. He used to 3. Describe the tips to remember while
purchase the reading glasses from the prescribing a computer glasses.
opticians without any prescription. He has no
history of medical illness and also presently Solution:
has no complaint for distance vision. 1. Most common cause for difficulty in
1. What are the possible causes for this diffi- viewing computer screen clearly is the
culty in near vision with reading glasses? distance of monitor. The desktop computer
2. Outline the solutions to this problem? monitor is usually situated at a further
distance than the normal reading distance.
Solution: This distance is referred as the intermediate
1. Possible causes for difficulty in reading the distance of vision; where person is unable
labels of medicine with present near vision to visualize the objects clearly either from
half eye glasses are the distance portion or near portion of his/
• Whether patient is attempting to see the her standard bifocal glasses.
medicine labels in bright sunlight. If yes, 2. To correct this problem possible solutions
then the probable reason is that signifi- are
cant miosis in sunlight will cause • Prescribe a trifocal lens as discussed in
difficulty in near vision with reading Chapter 12, page 336. Patient is able to
glasses because pinhole effect increases view the computer screen clearly and
the near vision. perform excel work comfortably when
• Is there any history of purchase of see through the intermediate segment of
different reading glasses for fine near trifocal lens. However a small amount of
work, because fine near work requires chin lift is required to position the
higher addition power at nearer working intermediate segment of trifocal lens in
distance. visual line of eyes.
2. Best possible solutions for this problem are • Alternately progressive lenses can be
• Advice the patient to purchase different prescribed, where multiple power will
half eye glasses with stronger power for take care of intermediate distance;
this kind of fine near work. however a slight chin lift is recommen-
• Suppose patient requires seeing of medi- ded even for a progressive addition
cine labels regularly and have multiple glasses.
• When patient is not agreeing for either Problem 5: A 62 years old professor is
of the above two solutions, then prescribe presented with the complaint of difficulty
a separate computer glasses having in reading book during taking a class
intermediate correction in top portion standing against the classroom dice; although
and near correction in bottom portion of professor is wearing the D-bifocal glasses
lenses. For distance vision patient is since many years and has clear distance and
advised to use a separate spectacle. near vision with glasses. Professor has no
Patient will see the computer monitor history of medical illness or not on any
while looking straight ahead, because the drugs.
intermediate power is fitted in top 1. What could be the possible cause for this
portion. These computer glasses also problem?
eliminate the necessity of chin lift to see
2. How would you manage this problem?
the computer screen, hence are useful in
patients having neck problems. Solution:
3. Remember these points while prescribing 1. Strongest possibility is that the height of
the computer glasses reading dice is such that professor need to
• Never prescribe single vision glasses read the book at an intermediate distance,
having intermediate power, because which is beyond the reading distance and
patient also needs to see near fonts while nearer than distance vision. So professor is
trying in computer key board. unable to read either from distance segment
• Always prefer progressive glasses as or near segment of his/her present D-bifocal
computer glasses, because jumping of glasses.
images is negligible in progressive glasses. 2. This problem can be solved by following
• When only computer bifocal glasses are methods
advised, then the near addition look very • Prescribe the progressive additional
unusual, because nearly half of near glasses or trifocal glasses and replace
power is required to be fitted in top present D-bifocal glasses.
portion of glasses as intermediate power • Prescribe a separate pair of glasses (on
and only remaining half power will be patient desire) with full distance correc-
fitted in near segment. tion in the upper portion and add of
• To avoid this unusual looking situation intermediate correction in the lower
a convenient method to calculate the portion of D-bifocal glasses; so that
intermediate power is by use of a near professor can see the classroom students
vision test card and slit lamp. Fix the near from upper portion of spectacles and
vision test card in chin rest position of book with the near segment simulta-
slit lamp; this test card will serve as neously, while taking the class.
computer screen. Now gradually change
the power of lenses in trial frame until Note: Similar management is useful for various
patient comfortably read the smallest line professions where person needs distance vision
clarity with intermediate correction to read the
on near test card. This will give the desired
subject matter kept on the dice.
intermediate vision with minimum lens
power.
Problem 6: Patient of age about 45 years
Note: Suppose patient is suffering from a significant working as vegetable vendor presented to
neck problem and feels difficulty in maintaining a clinic with problem in near vision. This
chin lift position then both trifocals and progressive patient requires glasses which he can wear
glasses are not suitable as computer glasses.
continuously during the work. Explain which
type of glasses you will prescribe to this the eyes converge and hence the reading
patient. segment lie in front of pupillary center in
1. Whether a bifocal glass that is fitted with normal circumstances. In case of golfers
too weak power of addition and why? they view the score card from temporal side
2. Whether a bifocal glass that is fitted with and hence they face difficulty because near
too strong power of addition and why? segment is fitted nasally.
2. Management of the problem in special cases
Solution: like golfers near add is required on opposite
1. To this presbyopic patient working as side of corner of glasses, i.e. temporarily,
vegetable vendor we will prescribe either so that they can read score card while
the half eye reading glasses or bifocal aiming for golf ball straight down. The
glasses fitted with weak addition power. golfers are fitted with special type of
Because weaker addition glasses will golfer’s lenses in one eye and normal fitting
produce a wider and longer range of in fellow eye as per requirement of golfer
reading. This patient does not require (described in Chapter 12, page 335).
reading of book or fine matter, hence
weaker addition will work better. Note: Similarly several other professionals like
2. Usually bifocal glasses fitted with too electricians, musicians specially French horn
strong power are not prescribed because players and watch makers, require near add in top
they will create more problems than a too portions of glasses. These bifocal glasses are
weak fitted bifocal glass. A closer and commonly called occupational bifocals (discussed
in Chapter 12 on page no 334).
narrower range of reading produced by too
strong bifocals is less tolerated as compared
to longer and wider range of reading UNCOMMON REFRACTIVE CONDITIONS
produced by weaker bifocal glasses. Study these following clinical refractive
scenarios which are not so common in routine
Note: Suppose half eye glasses are prescribed then
patient needs to advise to keep these glasses slightly
clinical practice. Plan the strategies to manage
lower on the nose so that he can see the distance these uncommon clinical refractive problems.
objects from top of glasses. Problem 1: A 22-year-old boy came to the
clinic for consultation regarding maintenance
Problem 7: A 55 years old golf player of his eyes. Presently the boy has no ocular
presented with the complaint of difficulty in complaints. He had past history of ocular
seeing the score card, since few months. trauma and on examination had no perception
However, the player is comfortably wearing of light (PL) in right eye and left eye was
flat top D-bifocal glasses since 12 years. emmetropic.
1. What could be the cause for difficulty in 1. What advice you will give to this patient?
viewing the score card?
Solution:
2. How will you mange this case?
1. It is most important to protect the left eye
Solution: as this patient is having only one visually
1. Cause of problem in this case is that usually useful eye. Following advice can be given
bifocal addition power is fused in lower to look after the eyes
segment of glasses and near segment is • Wear protective goggles while playing
placed in bottom nasal portion of lens contact games like football, cricket or
during fitting of spectacles. So normally badminton.
people read from nasally fitted lower near • Wear Plano power anti-reflex coated glasses
segment of glasses, because while reading specifically made from polycarbonate
material (non-breakable) for regular two eyes (anisometropia) of less than

work, which give continuous protection 2.5 dioptres is present, it will not produce
from minor ocular injuries. clinical significant difference in image size
• Use preservative free lubricants, because (aniseikonia). Hence in this particular case
this boy is working on computers for we can prescribe the glasses without
more than 7–8 hours per day. producing any new clinical symptoms.
• Regular six monthly ocular examinations. Problem 3: A 50 years old asymptomatic
Problem 2: 28 years old patient working on patient walked into the clinic for consultation.
computers for 5–6 hours daily came for an On examination when left eye was occluded
ocular examination to the clinic. Apparently the distance vision was affected and vice versa
patient is having no visual symptoms, when right eye is occluded the near vision gets
however he occasionally feel foreign body affected. However, patient is comfortably
sensation in both the eyes. On detailed seeing both the distance and near targets
examination and after cycloplegic refraction without any glasses binocularly. On perfor-
the patient had 6/6 visual acuity in each eye ming the refraction patient had –2.25 DS
with –1.75 DS power in right eye and plano refractive error in right eye and plano power
power in left eye. He also has mild dry eye in in left eye for distance. Also patient is
both the eyes. accepting + 4 DS in right eye and +2 DS power
1. How will you prescribe this patient? in left eye for near vision.
2. Will there be any clinical symptoms if we 1. What is the diagnosis of this condition?
prescribe glasses for this patient? 2. What kind of consultation you will give to
this patient?
Solution:
1. As we can see that there is significant Solution:
difference in amount of refractive status of 1. This particular patient is asymptomatic
both the eyes in this patient, so it is better because of phenomenon called natural
to leave the decision on patient whether he monovision, where patient is comfortably
wants to wear glasses or not. Prescription seeing distance objects clearly with one eye
of glasses can be done as follows (left eye in our example) and vice versa near
• Normally patient is asymptomatic and objects with fellow eye (right eye or myopic
seeing the distance objects clearly with eye in our example).
both the eyes open, because left eye is 2. Depending on the requirement of patient
emmetropic. At the age of 28 years with we can give following advise to this patient
one eye having moderate degree myopia having natural monovision
the patient is comfortable in reading • Suppose patient require full correction of
from any distance. Some of patients feel distance as well as near vision in each
that correcting one eye will not produce eye then we need to advice either bifocal
any significant improvement in distance or progressive glasses for this patient,
vision and hence refuses to use the glasses. where right eye glasses will have both
• On contrary some patient may feel that distance and near powers, whereas left
correction of refractive error in one eye eye glasses will have only near correction
will improve the quality of vision by power.
depth perception and also will not • Suppose patient is happy with present
hamper the vision of better eye, so they visual status and desire not to wear
agree to wear the glasses.
2. As discussed in Chapter 6, page 125 when Note: In natural monovision cases it is always
better not to prescribe any glasses.
the difference in refractive error between
glasses, then patient will do extremely Problem 5: An elderly 85 years old patient
well even without glasses for some more presented with complaint of reading difficulty
years. with the present bifocal glasses. On examina-
Problem 4: An elderly 60 years patient tion the distance visual acuity was 6/18 in
presented to clinic with difficulty in seeing the right eye and 6/12 partial in left eye with
distance and near objects since last few present glasses. Patient is wearing an addition
months. Patient is wearing glasses for distance of +2.75 DS in both eyes and is having a near
since few years and has no history of medical vision of N36 with present bifocal glasses.
illness. On examination right eye has a Patient is a diagnosed case of dry age related
refractive error of –2.5 DS × –1.5 DC × 90° with macular degeneration (ARMD) and is on
a near add of +3 DS, whereas left eye has only medical treatment.
perception of light. 1. Describe the management outline in this
1. What type of advice you will give to this case.
patient? 2. What will be your prescription for this
patient?
2. Does this patient require some special type
of prescription for making of glasses? Solution:
1. Normally in emmetrope at this age the
Solution:
maximum near addition given is in the range
1. As discussed above on page 590 protec- of +2.5 to +3.0 DS. As this patient is having
tion of eyes specially the right eye having ARMD we can consider managing this case
useful visual acuity is most important in on the guidelines of low vision rehabi-
this kind of patients. So we will advice litation (discussed in Chapter 16). This
the patient in similar manner as dis- patient can be managed by using various low
cussed. vision optical aids at this stage of disease.
2. As the distance refractive power is signifi- 2. Prescription for this elderly ARMD patient
cant in right eye and left eye has no useful include
vision, we will prescribe the patient with
• A higher addition of +3.5 to +4.0 DS can
the prescription having fully corrected
be prescribed when patient is getting a
power for refractive error on right side
significant improvement in near vision
column and a balance written in left side
and also is mentally prepared to keep the
column. The optician will understand the
reading objects little nearer than usual
meaning of balance and fix an almost
reading distance.
matching power of glass in front of left eye
• Suppose a higher addition more than
also, so that cosmetically both the glasses
+4.0 DS is required in this case to
appear equal and more acceptable. This left improve the near visual acuity then we
eye lens is commonly called balance lens can prescribe separate near vision glasses
which appear almost equal in thickness and having high plus power.
style to its fellow lens. This patient can
manage the near vision by simply removing Note: Suppose near vision further deteriorates, then
the glasses and keeping the object a little consider magnification for near objects by using
nearer than usual reading distance. low vision optical aids as described in Chapter 16.
Suppose the patient is not comfortable in
removing the glasses too often and require Problem 6: 17 years old young college
near addition, then he can be prescribed student presented with complain of difficulty
bifocal glasses with +3 D addition in both in seeing letters on blackboard, especially
eyes. when he/she sit on last bench in classroom.
There is no history of wearing glasses or any Note: Unlike monovision cases always correct the
eye examination in past. On examination after young anisometric patients to prevent amblyopia
cycloplegic refraction the right eye has –5.5 DS and other vision related symptoms.
refractive error and left eye has –0.5 DS
refractive error. also improved after correction, refractive
1. Describe this condition in detail. surgery on right eye is done to correct
2. Outline the management strategy for this the anisometropia in this case.
patient. Problem 7: An elderly couple, husband of
3. Write the management of this patient in 65 years age and wife 63 years of age presented
follow-up visits. to clinic with recent onset difficulty in seeing
Solution: the distance objects from their present glasses.
1. The difference between refractive status of On examination husband had a large
both the eyes is considerably high; hence chalazion in right upper eyelid and wife had
this condition is called anisometropia ptosis of left eye. Both of them had no
(described in Chapter 9). The difference in significant history of systemic medical illness.
degree of refractive error is of 5 dioptres, On performing the refraction a change in
hence when right eye is fully corrected there spherical power and cylindrical axis was
will be significant amount of aniseikonia found in respective eyes of both the patients.
(described in Chapter 9), where patient will 1. Explain the cause of change in refractive
see the significantly smaller size images status on one eye.
from right eye after full correction of 2. Describe the course of management in both
refractive error. the cases.
2. To manage this patient initially we need to
Solution:
prescribe trial corrective lenses, means
correct the right eye refractive error partially 1. Explanation for change of refractive status
by giving lesser power (say –2.25 DS) lenses in one eye having ocular pathology are
than total power (–5.5 DS in our example). • In both these cases pressure changes on
Patient is instructed to wear these trial cornea due to mechanical push of lesion
lenses and report after some time about the will be seen.
quality of vision and associated symptoms • In case of husband the large upper eyelid
(if any). chalazion is mechanically pushing the
3. In follow-up visit this patient can be cornea due to its weight on eyelid and
managed as follows hence a refractive error especially
• Suppose patient remains asymptomatic astigmatic type will occur.
with trial run lenses, we can gradually • Similarly in case of wife the left eye ptosis
increase the power of right side lenses will cause the change in corneal
(until tolerated by patient) to improve curvature. These changes in cornea can
the visual acuity in right eye. produce astigmatic error (usually
• Suppose patient shows symptoms of irregular astigmatism) due to distortion
aniseikonia, then we can prescribe of cornea.
contact lens for right eye which will • Hence in both the cases these conditions
improve the visual acuity and also are responsible for recent onset change
eliminate the aniseikonia symptoms by in refractive status of one eye.
abolishing the vertex distance factor. 2. Management of problem
• Later on when refractive status of right • Surgical removal of chalazion is the treat-
eye becomes stable and visual acuity has ment of choice, to relieve the mechanical
pressure on cornea in case of husband. Solution:

This will automatically correct the 1. Low vision evaluation: Low vision evalua-
refractive status of right eye; because tion is done according to following headings
once the chalazion is removed the cornea as discussed in Chapter 16
will come back to its original shape • Detailed patient history
within a short period of time. • Visual acuity assessment
• Similarly in case of wife correction of • Refractive status
ptosis will eliminate the indentation of • Visual field assessment
cornea by left upper eyelid and hence • Color vision
will correct the refractive status of left eye
• Contrast sensitivity and glare
gradually over period of time.
Detailed history in terms of various target
Note: In these cases correction of refractive error related activities is taken from the patient
by glasses or other optical means is not helpful. and his keen (relative accompanying the
patient). He is unable to move alone in
known or unknown places or identify the
LOW VISION
people meeting him in surroundings. With
Study these following low vision cases very existing glasses he is unable to read the bus
carefully and explain the low vision evaluation numbers or read a sign board on railway
methods along with management strategies stations or roads, hence is not able to move
in each specific condition. in the common crowd without any
support.
Problem 1: An 85 years old patient walked
into the low vision clinic with the support of This elderly patient had difficulty in
his grandson. He was teacher by profession reading, writing and also watching
and presently is unable to read or write since television. He is also not able to sign on
a few months. Nearly 6 months ago patient cheques or documents and also faces great
was examined by retina specialist for gradual difficulty in identifying the labels of his
painless diminution of vision and was routine medicines. However, he is able to
diagnosed as a case of dry ARMD both eyes eat from his plate, wear clothes, identify the
where right eye is affected more than left eye. currency notes and take bath on his own.
Presently patient is unable to move around • Visual acuity assessment is done both for
alone and facing difficulty in performing daily distance and near vision using low vision
activities. distance and near charts with best
Past history revealed that in both eyes possible optical corrections. Visual acuity
cataract extraction with intraocular lens in right eye (OD) is 3/60, in left eye (OS)
implantation was done, about 12 years back 4/60 and OU 5/60
in right eye and 11 years back in left eye. Since • Near visual acuity OD is 8 M, OS is 6 M
post cataract surgery patient is wearing bifocal and OU 5 M
glasses and his present power of glasses is • Refractive status OD –2.25 × +1.75 × 90°
nearly two years older. Patient has no medical and OS –3.5 × –1.5 × 160°
illness and no surgical history in the past. • Acceptance OD is –2.5 × +1.5 × 90° (5/
In this case of dry ARMD 60) and OS is –3.5 × –1.5 × 160° (6/60)
1. Outline how you will evaluate the low • Low vision device trial for near vision
vision status of this patient. done and near visual acuity improved to
2. Write down in detail about the manage- 1.6 M with +10 D half eye spectacle
ment for this ARMD patient having magnifier at 8 centimetres distance in
significant visual impairment. normal illumination, whereas with
+12 D hand-held magnifier the binocular had history of osteoarthritis for which she
near visual acuity improved to 1.2 M. takes oral anti-inflammatory medications off
• Color vision testing done with color and on as per her requirements. Treatment
plates and was found to be within history revealed that twice she had received
normal limits. Visual field assessment retinal laser treatment in both the eyes in last
with low vision visual charts showed OD 3–4 years.
moderate superior suppression and OS Presently she complains of gross diminution
mild temporal field suppression. of distance and near vision in spite of wearing
• Contrast sensitivity showed diffuse progressive multifocal glasses. The prescrip-
reduction in both eyes where right eye tion of present progressive glasses is about
was more affected than left eye. Glare 8–10 months old and she is using separate near
was markedly reduced with the usage of glasses for reading books. Her history of
photochromic glasses. diabetes is about 40 years old, initially she was
2. Rehabilitation and management only on oral hypoglycaemic and gradually she
• Complete distance vision correction was came to the present status of insulin with oral
prescribed. Patient was advised to get hypoglycaemic usage since 10 years. With
these glasses in photochromic lenses and insulin she is maintaining her blood sugar
wear the spectacles regularly for daily levels well in control and rarely have
activities. fluctuation in blood sugar levels. Presently she
• +10 D half eye magnifying near is not using any low vision aids or any other
spectacles in white lenses were prescribe supportive visual aid.
for near work. 1. Outline how you will evaluate the low
• Use of signature guide and envelop vision status of this patient.
guide to sign the cheques and write 2. Write down in detail about the manage-
letters are advised along with usage of ment for this diabetic retinopathy patient
magnifying near glasses. However, to having significant visual impairment.
search near objects hand-held magnifier
Solution:
of +12 D power can be used occasionally
by the patient. 1. Low vision evaluation: Elaborated history
• Use of peak cap and dark goggles was in terms of various target related activities
advised while patient goes out in is taken from the patient and her husband.
sunlight and advised to avoid going out She is facing difficulty in identifying the
alone in nighttime. numbers of channel on television and also
in reading books with present glasses. She
• To watch TV patient was counselled the
feels very uneasiness while coming down
role of approach magnification.
from the staircase especially during night-
• Regular monthly visits till three months time. She has great difficulty in writing
and then every three months were notes or any letter and also found conti-
recommended for follow-up. nuous reading of novel very tiresome.
Problem 2: A 70 years old female came with However she is able to do her routine
her husband to the clinic for low vision activities like bathing, prayers, walking in
evaluation. She was referred by her family house and eating food, etc. independently.
physician and is a diagnosed case of bilateral • Visual acuity assessment is done both for
diabetic retinopathy with left eye affected distance and near vision using low vision
more than right eye. She also had history of distance and near chart (Feinbloom’s
associated hypothyroidism for which she is chart) with best possible optical
taking oral medications since 15 years. She also corrections. Best corrected visual acuity
(BCVA) in right eye (OD) is 6/60, in left • She was advised to avoid going out in
eye (OS) 5/60 and OU 6/24 sunlight, however, if required she was
• Refractive status of respective eyes were advised to wear peak cap with dark
OD –1 × –2.5 × 90° and OS – 2.5 × –2 × 90° goggles or take umbrella while goes
• Near visual acuity with present near out in sunlight. However, she was
vision glasses OD is 3.2 M, OS is 2 M and advised to avoid going out alone in
OU 1.5 M nighttime.
• Low vision device trial for near vision • To watch TV patient was counselled to
done and near visual acuity improved to use distance glasses with the application
0.8 M with +6 D half eye spectacle of the approach magnification by
magnifier at 30 cm distance in normal reducing the viewing distance of
illumination, whereas with +8 D hand- television and also enlarging the screen
held magnifier binocular near acuity was size of TV.
0.5 M. • Regular monthly visits are must till initial
• Color vision testing done with color plates three months and then every three
and was found that she is able to identify months to observe the adjustment of low
the normal colors within normal limits. vision devices and then a regular follow-
• Visual field assessment with low vision up is recommended to watch for any
visual charts showed no suppression of deterioration in visual acuity.
visual fields either in right eye or left eye. Problem 3: A 57 years old patient walked
• Contrast sensitivity showed mild diffuse into the clinic with holding the hand of his
reduction in both eyes where left eye was wife and straightway sat on the examination
more affected than right eye. Glare was chair when asked to take a seat for evaluation.
marked reduced with the usage of He is a diagnosed case of open angle glaucoma
antireflex coated polarized glasses. since 28 years and using anti-glaucoma
2. Rehabilitation and management medication since then. Treatment history
• Complete distance vision correction was revealed that right eye trabeculectomy was
prescribed and patient was advised to get done about 8 years back and left eye
these glasses in antireflection coated trabeculectomy was done 5 years back. Both
polarized lenses. She was instructed to eyes cataract extraction with IOL implantation
wear these spectacles regularly for her was done one after the other in last 3 years.
routine household activities. No associated history of medical illness is
• +6 D half eye magnifying near spectacles present.
either in high index aspheric lenses or in Presently patient is wearing progressive
hybrid lenses were also prescribe for near glasses and having satisfactory visual
work. She was instructed to remove the acuity for distance and near, however, his
distance glasses and wear these near visual fields done one month back is
spectacles for reading writing purpose showing significant peripheral scotoma
only. with ring scotoma in both the eyes. He is
• Use of signature guide and envelop using anti-glaucoma medications latano-
guide to sign the cheques and write prost with brinzolamide and brimonidine
letters are advised along with usage of combination eye drops regularly in both the
magnifying near glasses. However, to eyes.
search near objects hand-held magnifier At present patient is unable to identify large
of +8 D power can be used occasionally furniture in room and need to move the head
by the patient. to see the various objects present in room. He
is unable to watch the entire TV screen in one • Visual field assessment with low vision
view and also not able to perform continuous visual charts showed significant
reading in computer screen or textbook. suppression of visual fields in both the
However, patient is able to perform routine eyes, where right eye was affected more
daily activities independently and can walk than left eye. Right eye showed ring
alone in garden. scotoma with presence of only 8 degrees
1. Outline how you will evaluate the low central visual field and left eye has
vision status of this patient. inferior and superior arcuate field defects
2. Write down in detail about the manage- with presence of only 12 degree central
ment for this advance glaucoma patient field.
having significant visual impairment. • Contrast sensitivity showed marked
diffuse reduction in both eyes where
Solution: right eye was more affected than left eye.
1. Low vision evaluation: Detailed history in Glare sensitivity was not much affected.
relation to various task related activities are 2. Rehabilitation and management
taken from the patient and his wife. Patient
• Complete distance and near vision
is able to identify the distant objects very
correction was prescribed and patient
clearly, however, is unable to see the entire
was advised to get these glasses in
object in a single view, hence is facing
progressive lenses. He was instructed to
difficulty in identifying the numbers of
wear these spectacles regularly during
channel on television and also in reading
his routine activities.
books. He feels difficulty and uneasiness in
• Central visual field expanders as
crowded places because he often bumps up
discussed in Chapter 16 are prescribed
with people walking around him. He is
to improve the visual field. Patient was
unable to enjoy any tour or scenery places
instructed to wear these field expanders
because of limited view of visual field.
during daily activities or reading,
However he is able to perform daily
however, try to avoid them wearing in
activities like bathing, clothing and eating
public places.
independently. He is also able to sign the
• He was advised to avoid going out alone
documents and read the letters.
in crowded places and if absolute
• Visual acuity assessment is done both for necessary then he has to take support of
distance and near vision using Snellen’s a sighted person.
distance and near chart with best • To watch TV patient was counselled to
possible optical corrections. Best use distance glasses with the application
corrected visual acuity (BCVA) in right of the field expanders specially the
eye (OD) is 6/9, in left eye (OS) 6/6 and reverse telescopes or minus lenses, so
OU 6/6 that larger field of view is seen.
• Refractive status of respective eyes were • Patient and relatives are explained the
OD – 1 DS and OS – 0.75 × –0.5 DC × prognosis of advanced glaucoma disease
90° and patient is encouraged to learn some
• Near visual acuity with +3DS power near additional skills like Braille or Moon for
vision glasses, OD is 0.8 M, OS is 0.8 M future survival as there are chances of
and OU is 0.5 M further deterioration in visual field.
• Color vision testing done with color • Regular follow-up at two months interval
plates and was found that he is able to is advised to observe the adjustment of
identify the normal colors within normal low vision visual field expanders and
limits. assessment of visual fields.
Problem 4: Retina specialist referred a especially during nighttime. He is not

36 years old patient having the diagnosis of much educated but has great difficulty in
retinitis pigmentosa (RP) with optic atrophy, signing the bank cheques or any other
for low vision evaluation and management. documents. However, still he is able to
This patient came to the clinic with holding perform his day-to-day activities like
the hand of his brother and was searching the bathing, clothing, identifying house furni-
examination chair when asked to take a seat ture and eating food, etc. independently in
for evaluation. Present and past history was bright daylight.
explained by his brother because patient was • Visual acuity assessment is done both for
not very comprehensive and also was not distance and near vision using low vision
precise in answering the leading questions. He distance and near chart (Feinbloom’s
had no significant contributory birth or past chart) with best possible optical correc-
history related to the present illness. About at tions. Visual acuity in right eye (OD) is
the age of 19 years he was diagnosed as a case 4/60, in left eye (OS) 4/60 and OU 5/60
of RP and since then the patient is on irregular • Near visual acuity OD, OS is 6 M and
follow up due to social and financial OU 5 M
constrains. Patient is third child among five • Refractive status of respective eyes were
children and two of his siblings had similar OD –2.5 × –0.75 × 110° (5/60) and
kind of problem. One of his paternal uncle and OS –1.5 × –0.5 × 70° (5/60) and OU with
grandfather also had problem of poor night glasses 5/60.
vision. He has no associated systemic illness • Low vision device trial for near vision
and there is no history of consanguineous done and near visual acuity improved to
marriage in his family. His present complaint 1.8 M with +8 D half eye spectacle
is diminution of distance and near vision since magnifier at 30 centimetres distance in
7–8 years and was unable to go around in the normal illumination, whereas with
night time since past 22 years. Patient is a +10 D hand-held magnifier binocular
vegetable seller and now he is unable to near acuity was 1 M.
identify the currency or weight of vegetables • Color vision testing done with color
at night time, so he closes down his vegetable plates and was found that he is able to
sale in the evening time only. He is presently identify basic colors, however, he fails to
not using spectacles for either distance or near, identify the specific design color plates.
although elsewhere he had been prescribed • Visual field assessment with central low
distance glasses about 4–5 years before which vision visual field charts showed that
he hardly worn in past few years. There is no only 15 degrees central vision in both the
history of any previous low vision evaluation eyes is present.
or prescription of any kind of low vision • Contrast sensitivity showed moderate
devices. degree of reduction in both eyes where
Solution: left eye was slightly more affected than
1. Low vision evaluation: Detailed history in right eye. Glare was marked reduced
terms of various target related activities is with the usage of amber tint glasses.
taken from the patient and his brother. He 2. Rehabilitation and management
is facing difficulty in identifying the • Complete distance vision correction was
currency and weight of vegetable sale prescribed and patient was advised to get
especially during nighttime. Patient is these glasses in amber tint lenses for
unable to search the road for home or move better visibility in daylight. He was
around independently in market place instructed to wear these spectacles
regularly during his routine vegetable was normal and he is younger among two
business timings. sons. He had almost normal developmental
• +8 D half eye magnifying near spectacles milestones except that since 2–3 months he
preferably in high index aspheric lenses started difficulty in identifying the faces,
were also prescribe for near work. He reading the books and also started watching
was instructed to remove the distance the television from very closer distance.
glasses and wear these near spectacles for Presently he is a college graduate student in a
identifying the currency and reading the regular college and sits in second row of
weight of vegetables on weighting classroom, however, his professors complains
machine. that he is very restless in classroom and is not
• Use of signature guide to sign the doing well in studies.
cheques and documents was advised Presently the chief complaint is that he is
along with usage of magnifying near unable to see the distant objects clearly and is
glasses. However, to search any specific not able to read the book from normal reading
vegetable items or small coin hand-held distance. This diminution in distance and near
magnifier of +10 D power can be used vision has occurred since 2–3 months and
occasionally during business hours. visual acuity markedly decreased in right eye
• He was advised to avoid going out alone and then after 3–4 weeks into the left eye.
in nighttime and if absolute necessary, There is no history of consanguineous
then he has to take support of a sighted marriage in his family and his elder brother is
person. absolutely normal with no such complains,
• To watch TV patient was counselled to however, one of his paternal uncle had similar
use distance glasses with the application kind of ocular problem. No systemic or other
of the field expanders specially the ocular complains are present. Patient is not on
reverse telescopes or minus lenses, so any chronic use of drugs and also there is no
that larger field of view is seen. previous history of ocular examination or
• Genetic counselling and examination usage of glasses or any other optical aids for
of other family members for visual poor visual acuity.
status and disease identification is
advised. Solution:
• Patient and relatives are explained the 1. Low vision evaluation: Detailed history in
prognosis of disease RP and patient is terms of various target related activities is
encouraged to learn some additional taken from the parents. Patient is facing
skills like Braille or Moon for future difficulty in reading/writing and also was
survival as there are chances of further unable to see the distance objects clearly.
deterioration in distance and near vision. His behaviour and eye contact was normal
on gross evaluation and has no difficulty
• Regular follow-up at three months inter-
in moving around in market places,
val is advised to observe the adjustment
however, was uncomfortable in bright
of low vision devices and assessment of
sunlight in daytime and with vehicle
visual fields.
headlights in nighttime. He faces difficulty
Problem 5: A 22 years old young male was in identifying the friends and relative faces
diagnosed as a case of Leber’s hereditary optic from some distances and also is unable to
neuropathy (LHON) in both the eyes by retina read the school bus number or road sign-
specialist recently. This patient was presented boards. He is also unable to read the book
to our clinic with his parents for low vision continuously in fluency even if he changes
evaluation and management. Birth history the reading distance frequently. Patient is
able to perform daily activities like bathing, was instructed to wear these spectacles
clothing and dining independently. regularly throughout the day.
• Visual acuity assessment is done both for • 8X telescope (monocular type) is fitted
distance and near vision using low vision with his distance spectacle power and he
distance and near charts. Distance visual is trained to read the text on blackboard
acuity in right eye (OD) is 3/60, in left wearing these telescopic lenses. Specific
eye (OS) 4/60 and OU 5/60. instructions were given to the professor
• Near visual acuity OD, OS is 4M and OU to cooperate in terms of seating arrange-
3 at 20 cm distance. ments and training of patient to see with
• Refractive status of respective eyes were telescopic spectacles. Once patient is
OD + 1.75 Ds and OS + 1.5 × + 0.5 × 90° accustomed to these telescopic spectacles,
• Acceptance OD and OS + 1.75 DS, 5/60. then he is advised to wear them regularly.
Near visual acuity 2.6 M at 18 cm. • To watch TV patient was counselled to
• Color vision testing done with Munsell use approach magnification by reducing
100 hue test and was found that he is not the viewing distance of television and
able to identify basic colors; especially also enlarging the screen size of TV.
had difficulty in identifying red color. • Parents are explained about the prognosis
• Visual field assessment with peripheral of Leber’s hereditary optic neuropathy
and central low vision visual field condition and are instructed to promote
charts was attempted but patient is the patient to adjust the low vision device
unable to complete the test accurately, and to learn some additional skills where
because he is not fixing the central vision is not much hurdle.
visual target of charts. His visual field • Regular follow-up at two months interval
charts showed centrocecal scotoma in is advised to observe the adjustment of
both the eyes and in right eye the low vision devices and assessment of
scotoma was extending on both sides retinal status with visual fields.
of vertical meridian.
Problem 6: A 9 years old female child
• Contrast sensitivity testing showed 15%
presented to clinic with her father for low
moderate degree of diffuse reduction in
vision evaluation and management. She is an
both eyes where left eye was slightly
established case of Oculo-cutaneous albinism
more affected than right eye.
with rotatory nystagmus having very poor
• Distance low vision aids 8X telescope visual acuity. History was presented by the
(monocular type) was tried with latest father because child was unable to focus on
distance correction glasses. He was able questions and was not able to maintain the eye
to read 6/36 size letters comfortably from contact. Birth history reveal normal hospital
6 meters distance fluently. Overall delivery and she is the elder among two
response for distance and near vision daughters.
improved and both the parents and
She had almost normal developmental
patient were accepting the final visual
milestones except that since early childhood
acuity when telescope was added with
she used to keep the things very close to her
spectacle lenses.
face and watches television from very near
2. Rehabilitation and management distance. She also was not able to maintain the
• Complete distance vision correction was gaze and had constantly moving eyes
prescribed and parents were advised to especially in rotatory movements. Her skin
get these glasses in photochromic grey color is also very fair, whereas her parents and
lenses for better visibility in daylight. He sister are having normal brownish colored
skin. Presently she is a class third student and • Color vision testing done with HRR color
sits in front rows of classroom, however, her plates and was found that she is able to
teacher complains that she is very less identify basic colors, however, she fails
attentive in class and do not copy the subject to identify the specific design color
matter correctly from the blackboard. plates.
Presently she is unable to see the distant • Visual field assessment with central low
objects clearly and is not able to fix her eyes vision visual field charts was attempted
on any target. She also read and writes from but child is unable to complete the test
very close distance. No systemic or other because of her rotatory nystagmus.
ocular complains are present. There is no • Contrast sensitivity testing done with
history of consanguineous marriage and her chart showed moderate degree of diffuse
younger sister is absolutely normal with no reduction in both eyes where left eye was
such complains. slightly more affected than right eye.
Solution: Glare was markedly reduced with the
1. Low vision evaluation: Detailed history in usage of photochromic glasses and
terms of various target related activities is shades.
taken from her father. She is facing • Nystagmus evaluation shows the pre-
difficulty in reading/writing and also sence of rotatory nystagmus with null
unable to see the distant objects clearly. zone in primary gaze and exaggeration
She needs support to move in crowded in lateral gazes.
places and also feels irritation in bright • Cover uncover test revealed left exopho-
sunlight. She has right-sided head tilt while ria with nystagmus.
try to focus the distance objects or speak to • Low vision aids tried for distance vision
some person. This head tilt is more with use of 6X telescopes over distance
significant when she focuses on specific correction glasses. She was able to read
tasks like watching television, or sees the 6/9 size letters comfortably from
blackboard in classroom. She is able to 6 meters distance fluently. She was also
move around in the house independently able to identify the near objects and
and also is able to perform her daily locate various objects in the examination
activities like bathing, clothing, eating and room.
moving around without any support. 2. Rehabilitation and management
• Visual acuity assessment is done both for • Complete distance vision correction was
distance and near vision using low vision prescribed and parents were advised to
distance and near chart (Feinbloom’s get these glasses in photochromic brown
chart) with best possible optical correc- tint lenses for better visibility in daylight.
tions. Distance visual acuity in right eye She was instructed to wear these
(OD) is 3/60, in left eye (OS) 2/60 and spectacles regularly during her routine
OU 3/60. activities.
• Near visual acuity OD, OS is 3.2 M and • 6X telescope (monocular type) is especially
OU 3 M at 8 cm distance. designed with her spectacle power and
• Refractive status of respective eyes were she is trained to see the blackboard
OD – 6.5 × – 0.75 × 90° and OS – 7.5 × – wearing telescope lenses. Specific written
0.5 × 90° instructions were given for school
• Acceptance OD –6.× –0.75 × 90° (6/18) teacher to arrange the front row seat for
OS –6.5 × –1.0× × 90° (6/24), with head child and cooperate in training the child
tilt towards right. Near visual acuity to see with telescopic spectacles.
2 M at 15 cm. Gradually once she is accustomed in
using telescope mounted spectacles, then • Genetic counselling and examination of

she should wear these telescopic other family members for visual status
spectacles regularly. and systemic disease identification is
• She was advised to avoid going out in advised.
sunlight and if absolute necessary then • Patient and relatives are explained the
she has to cover the body with proper prognosis of oculo-cutaneous albinism
clothing and wear dark shade spectacles disease and parents are instructed to
with peak cap. For additional protection promote the child to learn some addi-
from sunlight she can use UV protection tional skills where vision is not much
sunscreen lotions (SPF > 12). hurdle.
• To watch TV patient was counselled to • Regular follow-up at three months inter-
use approach magnification by reducing val is advised to observe the adjustment
the viewing distance of television and of low vision devices and assessment of
also enlarging the screen size of TV. visual fields.
Bibliography 603
Bibliography
1. AK Khurana. Theory and Practice of Optics and 6. John M. Corboy, David J. Norath, Richard Reffiner,
Refraction. Elsevier (A division of Reed Elsevier Ron Stone. The Retinoscopy Book. An Introductory
India Private Limited); 2008. Manual for Eye Care Professionals. SLACK
incorporated; 2003.
2. David Abrams. Duke-Elder’s Practice of refraction.
Elsevier (A division of Reed Elsevier India Private 7. Myron Yanoff, Jay S Duker. Ophthalmology.
Limited); 1983. Mosby international ltd; 1999.
3. George L. Spaeth, Helen V. Danesh-Meyer, Ivan 8. Norman S. Jaffe, Mark S. Jaffe, Gary F. Jaffe.
Goldberg, Anselm Kampik. Ophthalmic Surgery Cataract Surgery and its complications. Harcourt
Principles and Practice. Elsevier; 2012. Asia PTE. Ltd;1999.
4. Gholam A. Peyman, Donald R. Sanders, Morton 9. Paul L. Kaufman, Albert Alm. Adler’s Physiology
F. Goldberg. Principles and Practice of Ophthal- of The Eye, Clinical Application. Mosby Inc;
mology. Jaypee Brothers; 1987. 2003.
5. Gunter K. von Noorden, Emilio C. Campos. Binocular 10. Troy E. Fannin, Theodore P. Grosvenor. Clinical
Vision and Ocular Motility. Mosby inc.; 2002. Optics. Butterworth-Heinemann; 1996.
603
Index 605
Index
Aberrometry 470 clinical presentation 129

Absorptive lenses 316 measurement 130
photochromic lenses 317–318 treatment 132
polaroid lenses 319 Anisometropia 125–128
the Corlon lens 319 classification 125
tinted glass lenses 317 effects on binocular vision 126
tinted plastic lenses 317 treatment 127
Younger PLS filter lenses 318 Anomaloscope 237
AC/A ratio 165–167 Heidelberg multi-color (HMC) 238
measurement of AC/A ratio 165–167 Nagel’s 238
types of AC/A ratio 165 Neitz 238
Accommodation 139–162 Pickford-Nicolson 238
accommodative spasm 151 Aphakia 269, 426
decreased 152 Apical clearance method 439
excessive 150 Apical touch flat fitting method 439
fatigue of 161 Apostilb 18
ill-sustained 158 Approximate power 323
inertia of 158
Arden’s gratings 227
insufficiency of 136, 138, 157
Arrangement tests 236
mechanisms and theories 140
Farnsworth D-15 arrangement test 236
ocular changes during 149
Farnsworth-Munsell 100
paralysis of 159
hue test 236
pharmacological deficient 159
Lanthony desaturated D-15 test 236
physical and physiological 145
range and amplitude of 146 Artiflex 495
refractive status of eye versus far or near point 148 Artisan 495
Accommodative IOLs 518 Aspheric /elliptic lenses 440
Acrysof cache phakic IOL 494 Aspheric lenses 327
Advancement exercises 177 Asthenopia 135–139
Afocal segment 364 clinical features 137
After image test 121 management 138
Airy disc 7, 8, 68 types 135
Amsler grid test 241, 529, 530, 538 Astigmatic fan and block method 292
Angle fixated anterior chamber IOL 497 Astigmatism 73, 74, 97–104, 136
Angular magnification 532 contact lens for 434
Aniseikonia 128–133 irregular 104, 434
classification 128 refractive procedures 510
605
regular 98, 434 grades of 111

classification 98 mechanisms for development of 106
clinical features 101 terminologies 107
treatment 103 tests for fusion 115
Asymmetrical lenses 325 tests for retinal correspondence 119
AT-45 Crystalens 519 tests for SMP 115
Atropine 160 tests for stereopsis 116
tests for suppression 123
Back optic zone diameter (BOZD) 383, 398 theories of 110
Back optic zone radius (BOZR) 393, 398 Binocular visuscope test 122
Back peripheral radius (BPR) 385 Bitoric RGP contact lens 438
Back surface toric RGP lenses 437 Blanks 322
Back vertex power 323 Bock’s candy bead test 217
Bagolini’s striated glasses test 115, 119 Book retinoscopy 263
Base curve 322, 384 Boxing system 342, 343
Bell retinoscopy 262 Braille or Moon 554
Benzyl alcohol 458 Bridges and temples
Beren’s rule 170 bridge fitting 313
Best-form lenses 321 comfort cable temple 312
Bifocal lenses 156, 328–335 keyhole bridge 311
cemented bifocals 330 library temple 312
D style segment 329 riding bow temple 312
double segment bifocals 335 saddle bridge 311
fitting of bifocals 346, 353 skull temple 312
fused 331
temple fitting 313
Golfers’ 335
temple length 313
minus add bifocal 334
Burton lamp 400
One piece 333
ribbon segments 333 Cambridge low contrast gratings 228
round segments 331 Cardiff acuity test 216
selection of ideal lens 350 Cast moulding 379
single segment bifocals 330 CCTV 552
solid up curve 334 Characteristic of retinal reflex 270
straight top segments bifocal lenses 332 brightness 271
ultex bifocal 330 speed 270
Bifocal spectacle magnifiers 539 width 271
Binocular balancing 295 Chemical injuries 421
alternate occlusion with fogging 295 Chlorbutanol 458
bichromatic binocular technique 296 Chlorine systems 458
fogging with duo chrome test 296 Choroidal crescent 93
Freeman near vision unit 297 Chromatic aberration 69
near vision testing by bisurface reflectors 297 Cicatrizing conjunctival disease 422
Osterberg-Bino near vision unit 297 CK equipment 509
prism dissociation method 296 Cobalt blue light 400
Rodenstock near vision unit 297 Coherence 11
Turville binocular balance technique 295 spatial 12
Binocular fixation preference test 212 temporal 12
Binocular vision (BSV) 105–125 Coin test 216
advantages of 113 Coleman’s theory of accommodation 143
evaluation of 113 Color discrimination test 240
Index 607
Color vision 232–239, 530 Contrast sensitivity 224–231, 530

color blindness 238 charts 227
color vision charts 233 curve 226
theories 232 factors influencing 231
Colored contact lenses 423 measurement 225
complications of 425 spatial 224
fitting methods 424 temporal 225
indications 423 Contrast threshold 226
types of 424 Convergence 38, 164–187
Coma 71
accommodative 165, 367
Combined contact lens 365
angle 168
Combining surface 322
card 178
Conditions causing refractive errors 73–75
convergence excess 185
absence of optical element of eye 75
convergence paralysis 186
dispositions of optical elements of eye 75
convergence spasm 185
obliquity of optical elements of eye 75
refractive index anomalies 74 fusional (positive) 167
refractive surface anomalies 73 insufficiency of 174
Conductive keratoplasty 509 measurement of amplitude of 173
Contact lens 363–461 measurement of 168
care of lens cases 460 measurement of near point of 170
classification of 380 proximal (psychic) 168
colored 423 range and amplitude of 169, 170
complications and diseases related with contact reflex (involuntary) 164
lens wear 446 tonic 164
concept of 364 voluntary 164
design 381 Convergence insufficiency 174-184
in special conditions 426 primary 174
materials 369–371 secondary 184
related complications 444 Corneal edema 425
solutions 453 Corneal implants or inlay 517
contraindications of 387 Corneal lenticule extraction procedure 490
disinfecting agents for care of 455 comparison with femtosecond Lasik 491
disposable 413
complications 491
extended wear 410
surgical technique 490
history and events of progress 363
Correspondence and disparity theory 110
indications for 385
Cramer’s vitreous theory 140
lens storage system 459
CSM method 213
maintenance and care of 453
Custom laser in situ keratomileusis (C-Lasik) 488
maintenance and lens care methods 460
advantages of 489
manufacturing of 376
optical properties of 365 technique of 489
oxygen properties related to 370 Cyclopentolate and tropicamide 161
preservative systems 458 Cyclophoria 192
rigid contact lens fitting 397 essential 192
scleral RGP lenses 415 physiologicala 192
soft contact lens fitting 389 pseudocyclophoria 193
terminologies in 383 Cycloplegic drugs 160
therapeutic 418 Cylindrical lenses 44
water properties related to 370 types of 45
Daily wear disposable contact lenses 413 FACT chart 229

Datum system 341 Far point of convergence 170,
center 342 Fechner’s law 24
length 341 Feinbloom charts 526, 527
line 341 Ferrara ring segment 501
Mid-datum depth (A) 341 Filamentary keratitis 420
Decentring 71 Filcons 371
Deep meniscus lenses 326 Fitting triangle 346
Diffraction 6, 68 Fixation disparity method 167
Fluorescence 19
Fraunhofer 7
Focons 371
Fresnel 7
Fogging or astigmatic dials technique 290
Diffractive IOLs 518
Forster-Fuchs flecks 93
Dioptroscopy 250
Four dioptre base-out prism test 124
Diplopia 108
Frame and mounting materials 308
Diploscope 180
acrylics 310
Discoloration of lens 425 cellulose acetate 310
Distortion 71 cellulose nitrate 310
Divergence 38 cellulose propionate 310
Donders’ simplified eye 65 optyl 309
Dot visual acuity test 216 Friend test 123, 126
Dry eye 422 Frisby test 119
Dry retinoscopy 265 Front surface toric RGP lenses 437
Duo chrome test 292 Front vertex power or neutralizing power 323
Dyna intra limbal (DIL) lenses 440 Fusion 111
Dynamic retinoscopes 256
Dynamic retinoscopy 262
Glare sensitivity 531
Glass contact lens 364
Eccentricity 401 Gradient method 166
EDTA (ethylene diamine tetra acetic acid) 459 Guide dogs 553
Effective power 324 Gullstrand’s schematic eye 63
Ekinometer 130
Hand-held magnifiers 542
Electronic head mounted magnification devices 553
Haploscopic method 167
Electronic magnifying appliances 545
Harmon distance 264
Entoptic imagery test 247
Head mounted electronic devices 538
Entoptic phenomenon 202
Helmholtz theory of relaxation 141
afterimages 205
Hermann grid or afterimage chart 205
floaters 203
Heterophoria (latent squint/ strabismus) 137, 189–195
Maxwell’s spot
causes 190
phosphenes 204
classification 190
Purkinje tree 204 clinical presentation 193
Epikeratome 478 treatment 193
Equivalent oxygen percentage 371 Heterophoria method 165
Equivalent power 324, 556 Heterotropia (manifest squint) 195–198
Esophoria 190 classification 196
ETDRS chart 219 clinical presentation 195
Examiner observation system 253 maintenance of vision in squinted eye 198
Exophoria 191 treatment 197
Extended wear disposable contact lenses 414 Historical and observational tests 211
Index 609
Homatropine 161 Lambert 18

Horopter 109 Lathe cutting 376
Humanoptic 1CU 519 Landolt’s ‘C’ chart 218
Hybrid diffractive lenses or double lenses 538 Lang test 118
Hybrid soft perm lenses 441 Lang’s two pencil test 116
Hydrogen peroxide-based system 457 Lanterns tests 236
Hydrokeratome 478 Farnsworth 237
Hypermetropia 73, 77–86, 136 Holmes-Wright 237
absolute 81 Laser 20, 464
classification 77 elements of 20
clinical features 82 excimer 464
facultative 81 femtosecond 466
latent 81 in refractive surgeries 464
management 84 properties of 21
manifest hypermetropia 81 solid state UV 466
normal age variations 79 tissue interactions of 23
refractive procedures 505 types of 22
relationship with accommodation 79 Lasik 477
sequel of 84 automated microkeratome 477
total 81 complications of 482
Hyperphoria 191 preoperative evaluation for 479
sequel of 486
Illumination 17
surgical technique 479
Illumination and brightness 15
Lens
Image jump 348
cutting 356
Intacs segment 501 decentration 351
Interference 11 edging and fitting 356
constructive 11 lag 391
destructive 12 power 322
Interferometer 242 representations 51
Laser 243 sag 391
white light 245 shaping 355
Interpupillary distance 339 Lenticular lenses 326
Iris fixated anterior chamber IOL 497 Light 4
Iseikonic lens 132 character of 4
intensity of 6
Jackson’s cross cylinder 293
propagation of 5
Javal’s rule 103
Light projection system 252
Jordy system 553
Light projection test 240
Jump convergence exercises 178
Light sense 202
Just noticeable difference (JND) 529
Light sensitivity of human eye 23
Kerasoft lenses (ultravision) 440 Lighting efficiency 18
Keratoconus 438 Liquid contact lens 364
CL designs for primary corneal ectasias 439 Listing’s reduced eye 64
contact lens fitting in 442 Low vision 521–559
ideal CL fit in 438 approach for central visual field defects 547
Keratoscopie 249 approach for peripheral visual field defects 548
Kestenbaum’s rule 556 binocular vision assessment 530
Krimsky’s Prince near point rule 170 definition and classification 522
diagnosis 525 Mohindra near retinoscopy 261

enhancement in contrast sensitivity and reduction Monocular estimate method 265
of glare 546 Monofocal lenses 328
epidemiology 524 Monovision 430
functional ocular examination 526 Monovision procedure 516
magnification for distance 533 Monocle 308
magnification for near 538 Multicurve lenses 439
non-optical low visual aids 551 Multifocal intraocular lenses 518
optical and non-optical low visual aids 533 Multi-purpose solutions 455
prescription of low vision devices 555 Myopia 73, 86–96, 135
supportive evaluation 530 acquired 94
classification 87
supportive services in low vision management 557
congenital 87, 89
training/instructions to patient 558
contact lens fitting 426
treatment approach for 531
drug induced 95
visual field evaluation 529
management of 95
Lorgnette 308
nocturnal (twilight) 94
Luminance17 optics 86
Luminous pathological 91
flux (luminous power) 17 pseudomyopia 95
flux density 17 refractive procedures 470
intensity 16 simple 89
Lux (lx) space 95
LVIS 553
Nature of Light 3
M system 556 dual-nature theory 4
Mac-nab retinoscope 256 electromagnetic theory of Maxwell 4
Maddox rod test 240 particle theory of Newton 3
Magnification for near 538 quantum theory of Einstein 4
electronic magnifying appliances 545 wave theory of Huygens 4
hand-held magnifiers 542 Near point of accommodation 146, 176
microscopic lenses 538 Near point of convergence 170, 176,
paperweight magnifiers 544 Near vision charts 222
stand magnifiers 543 Jaeger’s 222
telemicroscopes 540 Roman 223
Major reference point 348 Snellen’s 222
Marble game test 216 Neuro physiological theory 110
Margaret Dobson retinoscope 257 Nomogram in CK 509
Mars chart 231 Non-optical low visual aids 551
McGuire lenses 440 auditory aids 551
Medmont AT-20 test 231 electronic devices 552
Melt pressing 378 hearing substitutes 554
Mentor B VAT II chart 231 object magnifications aids 552
Meter angle 169 orientation and mobility aids 553
Michelson contrast 226 reading aids 551
Miniature toy test 217 scripts aid 551
Minimal angle of resolution (MAR) 209 sight substitution aids 554
Minimal discriminable acuity 209 touch substitute 554
Minimal resolvable acuity 208 Nott Retinoscopy 263
Minimal visible or detection acuity 207 Nuvita-ma phakic IOL 494
Modified monovision 431 Numount 307
Index 611
Oblique aberrations 70 Posterior staphyloma 93

Omnifocal lens 337 Potential acuity meter 241
Opponent process theory 233 Potential vision 239
Optical cross 300 alternate methods 246
Optical curve 385 objective methods of measurement 239
Optical defects of eyes 68–75 subjective methods of measurement 239
pathological (refractive errors) 72–75 Practical evaluation of lenses 55
physiological 68–72 concave lens 56
Optical materials 314 convex lens 55
Barium crown glass 315 cylindrical lens 56
CR-39 lenses 316 Preferentially looking test 215
crown glass 315 Prentice’s rule 351
flint glass 315 Presbyopia 152–156, 427
PMMA 315 contact lens correction 427
polycarbonate 316 etiology 153
Optokinetic nystagmus (OKN) test 214 refractive procedures 516
Orthokeratology 442, 498 symptoms 153
Orthophoria 188 treatment 154
Orthoptic exercises 138, 177, 184 Prince rule 170
Oxygen permeability 370 Prism-assisted convergence exercises 180
Oxygen transmissibility ( Dk) 370 Prism bar method 173
Prism dioptre 36, 165, 169
Pantoscopic tilt 345 Prism therapy 139,183,184, 557
Panum’s area 109 Prismatic effects 368
Paperweight magnifiers 544 PRL 496
Pelli-Robson contrast sensitivity chart 230 Projection magnification 533
Peripheral visual field defects 548 Protein and lipid deposition on CL 425
concave lenses or minus lenses 549 Pseudoisochromatic plates 234
field expanders 550 HRR 235
fresnel prisms 549 Ishihara 234
mirrors 550 Punktal lens 320
reverse telescopes 548 Pupilloskopie 250
Periscopic lenses 320, 326 Purkinje images 67
Persistent epithelial defects of cornea 421 Purkinje shift phenomenon 232
Photocoagulation 23 Push up test 391
Photodisruption 23
Photoelectric effect 20 Quaternary ammonium compound (poly-quad) 459
Photometry 16
Radical retinoscopy 529
Photorefractive keratectomy (PRK) 472
Radiometry 15
delayed postoperative complications 476 radiance 15
intraoperative complications 474 radiant energy 15
postoperative complications 475 radiant flux 15
Piggy back lenses 441 radiant flux density 15
Pinhole test 292, 526 radiant intensity 16
Pincenez 308 Radiuscope 461
Polarization 8 RAF rule 147, 171
Poly amino propyl biguanide (PAPB) 459 Random dot E test 117
Poly hexa methlene biguanide (PHMB) 459 Rare images 272
Posterior chamber phakic IOL 497 Reading center 347
Reading stands 551 corneal wedge resection 515

Recognisation acuity 209 relaxing incisions post PK 514
Recurrent corneal erosion 420 Ruiz procedure 515
Red filter test 121, 123 suture removal 513
Reflection 26 radial keratotomy (RK) 471
diffuse 26 refractive lens exchange 492
laws of 26 Regan charts 231
specular 26 Regular contact lens designs 381
Reflection through mirrors 27 Relative distance magnification 532
concave 29 Relative size magnification 532
convex 29 Relaxation exercises 182
plane 27 prism-assisted divergence 183
Refraction 31 stereogram assisted 182
Laws of 32 synoptophore assisted divergence 183
Refraction through Retinal correspondence 108
astigmatic or cylindrical lenses 53 Retinal rivalry 108
combination of lenses 51 Retinoscope 251
concave cylinder lens 47 components of streak 252
concave lens 43 optics of peephole 253
convex cylindrical lens 46 optics of 254
convex lens 41 parts 251
cornea and lens 62 various types of 255
glass plate 34 Retinoscopy 249
prism 34 adjustment of refraction 289
thick lenses 53 after refractive surgery 287
Refractive index 32 binocular balancing 295
Refractive multifocal IOLs 518 estimation of cylindrical axis and power 281
Refractive procedure for presbyopia 516 history 249
corneal 516 interpretation of neutrality 275
lens-based 518 interpretation of retinal reflexes 270
scleral-based 519 methods of 261
Refractive status of eye 66 neutralization in astigmatic errors 279
Refractive status of lenses 47 neutralization of rare refractive errors 284
Refractive surgery 464–520 neutralization of various reflexes 272
corneal lenticule extraction procedure 490
objective and subjective refraction 288
corneal stromal collagen shrinking procedures 507
prescribing power for glasses 297
custom laser in situ keratomileusis (C-LASIK) 488
prescription writing 299
epipolis laser in situ keratomileusis (epi-LASIK) 487
principles and techniques of 258
gel injection adjustable keratoplasty 504
refinement of refraction 291
incisional refractive surgery 505
cylinders 292
intracorneal lenses 503
cylindrical axis 294
intrastromal corneal ring segments 500
cylindrical power 295
keratomileusis 472
spheres 291
laser refractive surgeries 506
laser sub-epithelial keratomileusis 486 refining cylindrical axis and power 284
LASIK 477 reflex 259
phakic refractive lenses 493 rules for 27
photorefractive keratectomy (PRK) 472 techniques of 265
post-penetrating keratoplasty (PK) induced theories for 250
astigmatism 513 transposition of prescription 301
Index 613
various neutralization methods 276 Soft contact lens fitting 389

working distance 265 contact lens factors affecting lens fit 393
Retinoscopy reflexes (rare) 269 insertion and removal of soft contact lens 394
aphakia 269 ocular factors influencing lens fitting 392
centrally dark 270, 286 wearing schedule for soft contact lenses 396
dim or no 270,286 Soft contact lens materials 374
oblique 270, 285 Glyceryl methacrylate 375
pseudophakia 269 HEMA 374
scissor 269, 284 HEMA-NVP 375
Retinoscopy reflexes (routine) 266 MAA-HEMA 375
astigmatism 267 MMA-PVD 375
emmetropes 266 MMA-VP 375
hypermetropes 266 silicon hydrogel material 376
myopes 267 Soft contact lenses in aphakia 426
Reverse telescopes 548 Sonic aids 554
RGP contact lenses in aphakia 427 Soper cone design 440
Rigid contact lens 397 Special contact lens designs 382
contact lens factors affecting lens fit 403 blending 383
insertion and removal of 405 fenestrations 383
materials 371 prism ballast lenses 382
truncated design lenses 382
cellulose acetate butyrate (CAB) 373
Spectacle 306
fluoropolymers 373
bridges and temples 311
silicon 373
classification of spectacle lenses 325
styrene 373
frame alignments 360
ordering 404
frame and mounting materials 308
recentration technique 406 frame specification 343
related complications and management 407 frames and mountings 306
Rinsing solutions 454 frame selection 344
RMS contrast 226 glazing of lens 355
Role of dioptre in relation of lenses 48 history and events of progress 306
Rose K system 439 lens power measurement 357
lens design 320
Sands of Sahara syndrome 484 lens fitting 339
Scattering 13 lens materials 315
Schachar’s theory of contraction 143 principles of fitting 345
Scopolamine (hyoscine) 161 terminologies in spectacle lenses 322
Scotoscopy 250 verifications of 356
Segment shape 351 Spherical aberrations 69
Segment size or width 350 Spherical lenses 39
Shadow test 250 terminologies related to 40
Simple retinoscope 255 types 39
Spin casting 378
Simultaneous macular perception (SMP) 111
Spot retinoscopes 257
Single vision spectacle magnifiers 538
Stand magnifiers 543
Skew 283
Static retinoscopy 261
Skiaskopie 250 Stereogram card 179
S-Lim lenses (Jack Allen) 440 Stereogram test 117
Sloan’s M chart 528 Stereopsis 112
Snell’s law 32 Stereoscopes 114
Snellen’s visual acuity chart 217 Stereoscopic acuity 112
Streak retinoscope 257 Tscherning’s theory of increased tension 142

Stress point retinoscopy 264 Turville-Pascal dynascope 257
Sturm’s conoid 54 Two-point light discrimination test 240
Suppression 108 Typoscopes 551
Symmetrical lenses 325
Synoptophore 113 Umbilical line 337
Synoptophore assisted convergence exercises 181 Umbrascopy 250
Synoptophore test 115
fusion slides 115, 124,173
Varifocal or progressive lenses 337
SMP slides 115,120, 124,173 fitting of 353
Varilux lens 338
Taco test 394 Vectographs tests 116
Telemicroscopes 540 Vernier acuity 209
Telescopes 534 Videokeratoscopy 470
Galilean or terrestrial 534 Visogen synchrony 519
Keplerian or astronomical 535 Vistech chart 229
Teller acuity card test 215 Visual acuity (VA) 206–224
Temple angle 345 factors influencing 207
Theorem of Gauss 63 measurement in infants 211
Therapeutic contact lenses 418 measurement of distance 220
complications 422 measurement in preschool child 216
fitting of a 419 measurement for near vision 222
indications 419 types of 207
types of 418 measurement 209
Thermal keratoplasty (TK) 507 Visual angle 206
contact laser 507 Visual axes and angles of eye 66
non-contact laser 508 Visual evoked potential 213, 247
Three-point touch method 439 Voluntary convergence training 182
Tilted optic disc 92
Titmus stereo test 116
Weber contrast 226
TNO random dot test 118 Weber’s law 24
Total diameter (TD) 383, 393 Weiss’s fundus reflex 94
Total internal reflection 33 Wet retinoscopy 265
Transmission and absorption 13 Wettability 370
Trial and error technique 290 Wetting and lubricant drops 455
Trichromatic theory 232 White sticks and canes 553
Trifocal lenses 156, 336 Wolff wand target 262
CRT 336 Worth ivory ball test 216
fitting of 353 Worth’s four dot test 115, 119,123, 126
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Optics and Refractive Anomalies AK Jain

Book · July 2023

Amit Kumar Jain

The user has requested enhancement of the downloaded file.

AK Jain DNB, MNAMS

CBS Publishers & Distributors Pvt Ltd

First Edition: 2017

Published by Satish Kumar Jain and Produced by Varun Jain for

• Kochi: Ashana House, No. 39/1904, AM Thomas Road, Valanjambalam,

O ptics and refraction is the foundation stone of ophthalmology and

Foreword by Prof DJ Pandey vii

Section I: Optics and Ophthalmic Lenses

Section II: Ocular and Refractive Anomalies

Section III: Vision and Refraction

Section IV: Visual Rehabilitation

Section V: Problem-based Learning

Interference and coherence • Visible light versus human eye

INTRODUCTION History of Nature of Light

As it is clear from the formula that photon

Intensity of Light Optical Properties

direction. Furthermore, the diffraction is much

Rayleigh criterion is used to set standards in the

more than the shorter wavelength (blue).

Fig. 1.7: Phenomenon of polarization, transverse wave passing through crystal C1

Clinical Application surface of oncoming automobiles (during driving)

Fig. 1.11: Constructive interference

Fig. 1.12: Destructive interference

same direction having the same frequency gets

Clinical Applications When it is represented as a percentage,

Applications of Scattering – Reduction in amount of light: A few ocular

Fig. 1.14: Scattering phenomenon of light

The luminance of a perfect diffuse reflecting

Table 1.3: Equivalent terms in radiometry and photometry

Clinical Applications phenomenon happens inside retinal cells. This

Fig. 1.18: Laser system

monochromatic property. However, sometimes Types of laser

• In normal circumstances majority of high • UV radiations can damage anterior portion

Concave Mirror Curved Surfaces

REFLECTION and angle of reflection for a set of parallel rays

Fig. 2.2: Reflection in plane mirror and image formation

• The incident light ray and reflected light ray

Reflection Through Mirrors

Centre of curvature (C): It is the centre of the C = centre of curvature

Fig. 2.7: Focal length of the spherical mirrors

Fig. 2.11 Fig. 2.12

Fig. 2.13 Fig. 2.14

Fig. 2.15 Fig. 2.16

substance indicates the measure of the

ray will bend more than red ray in any

Total Internal Reflection

Fig. 2.24: Refraction through unparallel surfaces

• Angle at which the light beam falls on

Prisms can be used for various diagnostic and

Fig. 2.26: Prism dioptre

Note: Knowledge of anterior and posterior focus where

Concave lens Astigmatic or cylindrical lens

– Cylindrical lenses Sturm’s conoid

Types – Practical evaluation of lenses