LIESA ZULHDYA

Optics of human eye

Eye as acamera

Components

Schematic eye and reducedeyes

Axes and visualangles

Optical aberrations
Eye as a camera

Eyelids- shutter

Cornea- focusing system

Lens- focusing system

Iris- diaphragm

Choroid- dark chamber

Retina-lightsensitive
film
Components
The cornea
The anteriorchamber

The iris and pupil

The crystalline lens

The retina
Cornea
 Reasons of refraction:
 Curvature.
 Significant difference in refractive indices ofair
and cornea.
 Vertical diameter slightly less than horizontal
 Front apical radius 7.7 mm K= 48.83 D
 Back apical radius 6.8 mm K=-5.88 D
 Actual refractive index cornea= 1.376
 Power of cornea +43D (2/3 of total eyepower)
 Not optically homogenous (ground
substance)=1.354, n(collagen)=1.47
The anterior chamber
 Cavity between cornea and iris
 Filled with aqueous humor.
 Depth of AC – about 2.5-4.0 mm
 Change in AC depth change the total power. 1mm
forward shift of lens- increase about 1.4D inpower
 Refractive index of aqueous humor= 1.336
Iris and Pupil
•Regulate amount of light entering theeye
•At 2.4mm pupil size, best retinal imageobtained,
as aberration and diffraction arebalanced.

Average • 2-4mm
size:
• depth of focus increases
Small pupil • Concept used as pin hole test in refraction

• Retinal image quality improves

Large pupil • Size of blue circleincreases
The crystalline lens
• Birth 3.5 – 4 mm
Thickness
• Adult life 4.75 – 5 mm

• Ant surface 10 mm
Radius of curvature
• Post surface 6 mm

• Nucleus 1.41
Refractive index of lens • Pole 1.385
• Equator 1.375

Total power • 15 -18 d.

• At birth- 14-16 D
Accommodative power • At 25yrs- 7-8D
• At 50yrs- 1-2D
 Lens accounts for about one third of the refraction
of the eye.
 ACCOMODATION
 Provides a mechanism of focusing atdifferent
distances.

 OPTICAL CHANGES IN CATARACTOUS LENS

 Visual Acuity reduction.
 Myopic shift.
 Monocular diplopia.
 Glare.
 Color shift.
Vitreous
 Refractive index same asaqueous.
Retina
 Maximum resolving power at fovea.
 A concave spherical surface with r =-12 mm.
 Advantages of curvatureof retina over plane image
forming surfaces of cameras and optical
instruments:
 The curved images formed by the opticalsystem
is brought in the rightorder.
 A much wider field of view is covered by the
steeply curved retina
Emmetropia

43 diopters

24-25mm

18 diopters

Accomodation atrest
 REFRACTIVE ERRORS
• Ametropia: a refractive error is present

• Myopia: Near sightedness

• Hyperopia(Hypermetropia): Far sightedness

•Presbyopia: Loss of accommodative ability of the lens resulting in

difficulties with near tasks

• Astigmatism: the curvature of the cornea and/or lens is not spherical and
therefore causes image blur on the retina
 REFRACTIVE ERRORS

• Anisometropia: a refractive power difference between the 2 eyes (> 2D)

•Aniseikonia: a difference of image size between the 2 eyes as perceived

by the patient
• Aphakia: (Phakos=lens), aphakia is no lens

• Pseudophakia: artificial lens in the eye

Myopia
 A form of refractive error in which parallel rays of
light entering the eye are focused in front of retina
with accommodation being atrest.
Etiological types
 Axial(MC)-increased AP length of eyeball
 Curvatural-increased curvature of cornea, lensor
both
 Index-increased refractive index of lenswith
nuclear sclerosis
 Positional-anterior placement of lens
 Myopia due to excessiveaccommodation
Clinical types of myopia
 Congenital

 Simple ordevelopmental

 Degenerative orpathological

 Acquired
Congenital myopia
 Common in premature babies or with birth defects
 Stationary(8-10D)
 Associated with
 Increase in axial length
 Esotropia
 Other congenital anomalies of eye
Early and full correction under cycloplegia
Poor prognosis in unilateral caseswith severe
myopia and anisometropia
Simple myopia
 Physiological/school myopia
 Commonest type
 Results due to normal biologicalvariations
in development of eye
 Age of onset- 7-10yrs
 Moderate severity-<5D,neverexceeds8D
 No degenerative changes
Degenerative myopia
 Progressive in nature
 Related to heredity, general growthprocess
 Heredity linked growth of retina
 Factors affecting general growthprocess
 Age of onset-early adultlife
 Severe->6D
Pathophysiology
Genetic factors

More growthof
retina

Degenerative Stretching of General growth

changes in sclera sclera process
Increased axial
length
Decrease Degeneration of
d vision choroid
Degeneration of
retina
Degeneration of
vitreous
Myopic
Crescent
Lacquer Cracks
Breaks in Bruch’s membrane
Sub retinal neovascularization
Sub retinal hemorrhage
Foster – Fuchs's spots
Posterior staphyloma
Complications
 Macular hemorrhage
 Retinal tears, detachment
 Vitreous hemorrhage
 Choroidal hemorrhage
 Complicated cataract
 Nuclear sclerosis
 Primary open angleglaucoma
Clinical features - Symptoms
 Distant blurred vision
 Half shutting of eyes
 Asthenopic symptoms
 Muscae volitantes
 Night blindness
 Divergent squint
Signs
 Prominent eyeballs
 Large cornea
 Anterior chamber isdeep
 Large & sluggishly reacting pupil
 Fundus examination-changes seen onlyin
pathological myopia
Optical treatment
 Concave lenses
 Children
 Adults

 Contact lenses
Optical treatment
 Minimum acceptance providing maximumvision
 Low myopia(<6D):
 Young children : glasses required onlyif

Isometropia
<2years ≥ -4.0D
2-3years ≥ -3.0D
Anisometropia:
≥ -2.5D
Give full correction undercycloplegia
Avoid overcorrection
 Adults:
 <30years-full correction
 >30years-less than full correction with which patient is
comfortable for nearvision.

HIGH MYOPIA
 under correction is done to avoid
near vision problem
minification of images
contact lenses are better(toavoid image minification)
Surgical treatment
 Radial keratotomy
 Lamellar corneal refractiveprocedures
 Laser based procedures
 PRK
 LASIK
 LASEK
 C-LASIK
 E-LASIK
 Miscellaneous corneal refractiveprocedures
 Orthokeratology
 Intracorneal contact leses
 Intra stromal corneal ring segments
 Gel injectable adjustable keratoplasty

 Intraocular refractive procedures

 Phakic refractive lenses
 Refractive lense exchange
 Hypermetropia

 It is the refractive state of eye where in parallel rays of

light coming from infinity are focused behind the
sensitive layer of retina with accommodation being at
rest
Etiological types
 Axial(m.c)-decreased AP diameter of eyeball
 Curvatural-flattening of cornea, lens orboth
 Index –old age, diabetics undertreatment
 Positional-posteriorly placed lens
 Absence of lens-aphakia
CLINICAL TYPES
 SIMPLE HYPERMETROPIA
 PATHOLOGICAL
 FUNCTIONAL HYPEROPIA
SIMPLE HYPERMETROPIA
 Commonest form
 Results from normal biological variations inthe
development of eyeball
 Include axial and curvatural HM
 May be hereditary
PATHOLOGICAL HYPERMETROPIA
 Anomalies lie outside the limits of biological variation
 Acquired hypermetropia
 Decrease curvature of outer lens fibers in old age
 Cortical sclerosis
 Positional hypermetropia
 Aphakia
 Consecutive hypermetropia
FUNCTIONAL HYPERMETROPIA
 Results from paralysis of accommodation

 Seen in patients with 3rd nerve paralysis &

internal ophthalmoplegia
TOTAL HYPERMETROPIA
 It is the total amount of refractive error,estimated after
complete cycloplegia withatropine

 Divided into latent & manifest

LATENT HYPERMETROPIA
 Corrected by inherent tone of ciliarymuscle
 Usually about 1D
 High in children
 Decreases with age
 Revealed after abolishing tone of ciliary muscle with
atropine
 Facultative
hyper metropia
Manifest hyper
metropia
Total hyper Absolute hyper
metropia metropia
Latent hyper
metropia
 SYMPTOMS
 Principal symptom is blurring of vision for
close work
 Symptoms vary depending upon age of patient
& degree of refractiveerror
 Asymptomatic
 Asthenopic symptoms
 Defective vision withasthenopia
 Defective vision only
SIGNS
 VISUAL ACUITY : Defective
 EYEBALL: small or normal insize
 CORNEA : may be smaller than normal. There can be
CORNEA PLANA
 ANTERIOR CHAMBER : may be shallow
 LENS: could be dislocated backwards
 A Scan ultrasonography (biometry) reveal short axial
length
FUNDUS:
A) DISC: Dark reddish color, irregular
margins ,confused with Papillitis sotermed
as PSEUDO-PAPILLITIS
B) MACULA: Situated further from the disc
than usual, large positive angle
alpha, apparent divergentsquint
C) BLOOD VESSELS: Show undue tortuosity
& abnormal branchings
D) BACKGROUND: SHOT- SILK RETINA
COMPLICATIONS
 Recurrent styes,blepharitis orchalazion
 Accomidative convergentsquint
 Amblyopia
 Anisometropic
 Strabismic
 Uncorrected bilateral high hypermetropia
 Predisposition to develop primary narrowangle
glaucoma
Care should be taken whileinstilling
mydriatics
TREATMENT
BASIS FOR TREATMENT
 No Treatment
 Error is small
 Asymptomatic
 Visual acuity normal
 No muscularimbalance
Young children(<6 or 7yrs)
Some degree of hypermetropia is physiological so no
correction
Treatment required if error is high or strabismus is
present
working in school small error may require correction
In children error tends normally to diminish with
growth so refraction should be carried out every six
month and if necessary the correction should be
reduced, ortherwise a lens which is overcorrecting
their error may induce anartificial myopia
 No deduction of tonus allowance instrabismus
Adults
If symptoms of eye-strain are marked,we correct as
much of the total hypermetropia as possible,trying
as far as we can to relieve the accommodation
When there is spasm of accommodationwe
correct the whole of theerror
Some patients with hypermetropia do not initially
tolerate the full correction indicated by manifest
refraction so we under correct them
Exophoria hyperopia should be under correctby 1
to 2D
Patients with absolute hypermetropia are
more likely to accept nearly the full
correction because they typicallyexperience
immediate improvement in visualacuity

In pathological hypermetropia the

underlying cause rather than the
hypermetropia is chief concern
MODE OF TREATMENT
 SPECTACLES
OPTICAL TREATMENT

 CONTACT LENS

 SURGICAL
SPECTACLES
Basic principle
Prescribe convex lenses (Plus lenses) so thatrays
are brought to focus on theretina
Advantages
 Comfortable
 Easier method
 Less expensive
 Safe idea
CONTACT LENS
ADVANTAGES
Cosmetically good

Increased field of view

Less magnification

Elimination of aberrations & prismaticeffect

REFRACTIVE SURGERY
 Refractive surgery is not as effective as in myopia
TYPES
 Hexagonal keratometry
 Laser thermal keratoplasty
 Photo refractive keratectomy
 LASIK
 Photorefrctive keratectomy
 Phakic IOL and clear lensextraction
 PRESBYOPIA
The physiologic loss of
accommodation in the
eyes in advancing age
 Physiologic loss of accommodation in
advancing age
 deposit of insoluble proteins in lens in
advancing age-->elasticity of lens
progressively decrease-->decrease
accommodation
 around years of age , accommodation
become less than D-->reading is possible at
- cm-->difficultly reading fine print
, headache , visual fatigue
Increasing Near Point of Accommodation
with Age
Age (years) Distance (cm)

10 7

20 10

30 14

40 20

50 40
 SYMPTOMS
The need to hold reading material at
arm's length.

 Blurred near vision

 Headache

 Fatigue

 Symptoms worse in dim light.

CORRECTION
 SPECTACLES

Plus lens
(or)
Convex lens
 Surgery
 Monovision LASIK

 Monovision & CK

 IntraCor

 Refractive lens exchange

 Corneal Inlays & Onlays

ASTIGMATISM

A defect of an optical
system causing light rays
from a pointsource to fail
to meet in a focal point
resulting in a blurred and
imperfect image.
 Focal interval of Sturm :-
Distance between 2 focal
lines

 Circle of leastdiffusion
At the dioptric mean of focal lines the cross section of
sturms conoid appears as circular patch of light rays –
best overall focus
Regular Astigmatism :
 Correctable by Spherocylindrical lenses
Etiology :
1. Corneal - abnormalities of curvature [common]

2. Lenticular is rare. It may be:

i. Curvatural - abnormalities of curvatureof
lens as seen in lenticonus.
ii. Positional - tilting or oblique placementof
lens , subluxation.

3. Retinal - oblique placement of macula [rare]

• Symptoms :
Blurring of vision
Asthenopic symptoms
Tilting of head
Squinting [Half closure of eyelid]
Investigations:
 Retinoscopy
 Keratometry
 Computerized corneal Tomography
 Astigmatic fan test
 Jackson crosscylinder
Treatment
 Optical treatment
 Spectacles
 RGP contact lenses
 Toric contact lenses
 Surgical correction
Guidelines for optical treatment
 Small astigmatism- treatment is required
 In presence of asthenopicsymptoms
 Decreased vision
• High astigmatism- full correction
• Better to avoid new astigmatic correctionin
adults because of intolerable distraction
• Bi-oblique,mixed,high astigmatism are better
treated by contact lenses
• Correction of spherical component
Irregular Astigmatism
• Etiology :
Corneal -[ Scars , Keratoconus
, flap complications,
marginal degenration ]

Lenticular -[Cataract maturation]

Retinal-[scarring of
macula,tumours of retina,choroid]
Symptoms :
Defective vision
Distorsion of objects
Polyopia

Investigations:
- Placido's disc test reveals distortedcircles

- Computerized corneal topography

Treatment :
 Optical treatment :
- RGP contact lenses
-Hybrid contact lenses
-Scleral lenses
- Piggyback lens

 Surgical treatment:
- penetrating keratoplasty
 Astigmatism correction requires prescription of
convex cylindrical lenses at 180 +/- 20 deg or
concave cylindrical lenses at 90 +/- 20 deg withthe
rule and viceversa
Contact lenses
 Toric contact lenses
Soft lenses [SL]
Rigid gas permeable lenses
[RGP]
RGP do not conform to the asymmetry of corneal
surface but replaces it totally and also provides
clarity of vision ,moredurable.

Soft lenses are more comfortable to wear ,easy to

fit, adhere more tightly to cornea.
Refractive surgeries
 Astigmatic Keratotomy
 Photoastigmatic refractive Keratectomy [PRK]
 Relaxing incisions with compressionsutures
 LASIK surgery
Residual astigmatism :

 The amount of astigmatism that still

remains after correction of a refractive error.

 In the case of correction of corneal

astigmatism using rigid contactlens
,lenticular residual astigmatism isexposed.
Anisometropia
 Difference in refractive power between eyes
 refractive correction often leads todifferent
image sizes on the retinas( aniseikonia)
 aniseikonia depend on degree ofrefractive
anomaly and type of correction
 closer to the site of refraction deficit the
correction is made-->less retinal image
changes in size
 Anisometropia
 Glasses : magnified or minified 2% per 1D
 Contact lens : change less thanglasses
 Tolerate aniseikonia ~ 5-8%
 Symptoms : usually congenital and often
asymptomatic
 Treatment
 anisometropia > D-->contact lens
 unilateral aphakia-->contact lens or intraocular
lens
THANK YOU