OPHTHALMOLOGICO

Error of Refraction:

Refraction
- change in speed that occurs when light passes from one medium
to another is responsible for the bending of light.
- When light passes from a fast medium to a slow medium bends
the light ray toward the normal to the boundary between the two
media.

Diopters:
- reciprocal of focal length measured in meters (1/meters)
- Total Refractive power the eye = 60 diopters
o 40 D: comes from the CORNEA
o 20 D: comes from the LENS
Three –lens system: conceptualization of the optical system of the eye
- Aqueous lens: cornea shapes its anterior curve which has no
refractive power.
- Crystalline lens: its index of refraction VARIES THROUGH ITS
THICKNESS.
Index of refraction (n) - Vitreous lens: important because of its major effect on
- velocity of light in a vacuum / velocity of light in a medium MAGNIFICATION.
- effect of an optical substance on the speed of light
o Absolute: ratio of speed of light in a VACUUM Accommodation
o Relative: ratio of speed of light in AIR - the adjustment of the eye for seeing at near distances
- Varies with: accomplished by changing the shape of the lens through action
o Temperature: (n) increase in cold of the ciliary muscle, thus focusing a clear image on the retina.
o Pressure - Accommodative power is due to the lens elasticity
o Humidity - Loss in accommodation of the lens leads to presbyopia (discussed
- ↑ index  ↓speed  ↑ effect on refraction later)
- Children have strong accommodative power so in order to know
Three rays in trigonometric ray tracing which pass through the spherical lens. the exact or true error of refraction, give CYCLOPLEGIC DRUGS to
relax ciliary body.; sometimes they have 20/20 vision in VA so use
cycloplegic drugs.

Ciliary Zonular Lens effect Diopter

muscles tension
Distant contracted Relax Flatten lens decrease
object
Near object relax Contracted Tout lens Increase

- Marginal ray is refracted more than the paraxial ray (spherical

aberration)
- Chromatic aberration variation of refractive index with frequency
of light (dispersion) greater refraction of blue than red light
o (though this is too much to take in, just adding this since is
spherical lenses such as our crystalline lens can produce
this 2 kinds of aberrations)
- To sum it all up, the parallel rays that enter the lens and converge
to the point of focus because the refractive index of the lens vary
in thickness. Hence marginal rays are refracted more than
paraxial lens since it is thin as compared to the rays entering near
the NORMAL the more refracted the rays are, the severity of
spherical aberration increase (tawag dun sa center dashed line In order to diagnose error of refraction, we should get a good history and PE.
that traverse the axis. ) History:
- Abnormal vision: Central or peripheral vision
Focal length: o Central vision: refractive error, medial opacities and optic
- it is the distance over which initially parallel rays are brought to a nerve or macular disease
focus in one part of the retina (eg: astigmatism, multifocal hence o Peripheral vision: scotomas from glaucoma and visual
blurred image) intracranial visual pathway problems
- the shorter the focal length, the greater the refractive power of - If accompanied by blurring of vision due to a refractive error: ask
the lens since it can bring parallel rays faster into a focus if patient’s vision is clearer when he/ she focuses in near objects
- If the parallel rays converge into a focus, image becomes sharper or far objects.
- Duration/ Timing: acute or chronic.
o Acute: think of a retinal/ macular problem or a vascular
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o If gradual and chronic in progression, think of EORs, - Light rays focus in front of the retina
cataract, open angle glaucoma etc) - Distant vision is blurred; squints to see more clearly
- Is it accompanied by pain? - High degree of myopia increase the incidence of progressing to a
o Sharp or pricking pain may be due to a corneal problem degenerative retinal changes  retinal detachment since the
(cornea is the most sensitive part of the human body globe is longer.
where the nerve endings can be found at the bowman’s - Near-sightedness
capsule - A myopic person has the advantage to read at the far point
o Dull without glasses even at the age of presbyopia
- Is it accompanied by redness? Think of other red eye syndrome. Axial myopia: if eye is longer than average
Maybe the cause of blurring of vision is due to keratitis, or severe, Curvature/ refractive myopia: if refractive elements are MORE refractive
bacterial conjunctivitis or dry eyes. than average
- Any other extra-ocular signs: - Correct myopia:
o Strabismus, deviations, lumps o Concave lenses (since myopic lens are convex)
- Presence of discharge: think of bacterial conjunctivitis o o MINUS lens: myopics have HIGHER diopters
- Increased lacrimation  65 diopter – 5 diopters = 60 diopters. (hehe)
- Is it associated with irritation and itchiness
- Take note of: Hyperopia
o Family history, eye medications, past ocular disorders
which may predispose patient to blurring of vision. - Focus image behind the retina
o Past medical history: HPN, DM, Drug allergies - Globe is shorter
o If patient is taking any diuretics  dry eyes - Far sightedness
PE: - If hyperopia is not too great, a young person may obtain a sharp
Visual Acuity distant image by accommodating, as a normal eye would read.
- Average resolving power of the eye: 1 min of arc; snellen 20-20 = - Hyperope has blurred vision for near and far and requires both
5 mins of arc glasses for near and far
- Far point: point <6m where image is in sharp focus on the retina -
as shown in the picture. Axial Hyperopia: REDUCED axial length
o Myopic correction = reciprocal of far point Refractive hyperopia: REDUCED refractive error
o Eg: -4.0D myope sees at well at 1/4m Curvature hyperopia: lens less convex or curve
- Numerator: testing distance in feet or meters (20ft or 6m)
- Denominator: distance from which a normal eye can read the line MANIFEST:
o For ex: 20/200 - hyperopia is too high and cannot be corrected; can cause
o A letter that the patient can see at 20 feet, a normal deprivation amblyopia and can be bilateral
person can see at 200 LATENT:
o The higher the number in the denominator, the poorer - can be corrected
the visual acuity - detected by instillation of cycloplegic drugs Paralyze ciliary
- Done first before light reflex since if light hits the macula, this will muscles
cause blurring of vision and it will take some time (1-2 mins) for it o important when younger patients complains of eye strain
to return to its normal capacity hence misdiagnosis may occur. after reading; vital in esotropia where full correction of
- Snellen’s chart, illiterate E, near vision chart (uhm, I didn’t include hyperopia may be done.
the details since we have lalala as reference na din) Correction
Pinhole - Biconvex
- It centers/ focuses the light entering the eye allowing only parallel - Plus lens: since hyperopics have (-) Diopters
light to enter the retina
- If (+) patient may have error of refraction Astigmatism
- Central area of the cornea is the area where light hits
perpendiculary  area of best vision since it is less refracted, less - eye produce images with MULTIFOCAL lines or points with
aberration, goes straight to macula  blurring and distortion of images
- Aberration arises if light hits the periphery of the cornea  - causes include:
resulting poor vision o Abnormalities of corneal shape (CORNEAL ASTIGMATISM)
- So in order to differentiate if the cause of blurring of vision is due  Cornea resembles a football shape instead of
to EOR or an organic cause, when using pinhole test, vision will round one  producing multifocal points kasi
not improve mas humaba yung lens resulting in refraction of
rays into different point not just in one focus of
** guys, just so hindi humaba yung discussion about hx and PE dito, ill include the lens but some rays ar refracted to other parts
+1 notes for a complete history and PE. of the retina hence image is distorted.

1. Emmetropia – absence of refractive error

2. Anisometropia – difference in refractive error between two eyes
- Major cause of amblyopia because the eyes cannot accommodate
independently
- The more the hyperopic eye is, the chronically blurred it gets
3. Ametropia or refractive error – an optical defect that is brough about
by the inability of the lens to focus an image directly to the retina due
to a change in eyeball length.
- Combination of three of any of the ff:

Myopia

o Lenticular astigmatism.
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 Not corrected by hard CL. 6. Laser Subepitherlial keratomileusis (LASEK)
Correction: - Flap, but up to epithelium (NO stromal involvement)
- Cylindrical lens 7. Corneal ring
Presbyopia
Myopia Hyperopia Astigmatism Presbyopia
- No refractive error Axial longer reduced No change
- Loss of accomodaation associated with aging length in axial
- Loss of the lens power of accommodation eithr through length
o Hardening or sclerosis of the lens Light rays IN FRONT of BEHIND the Multifocal Loss of
o Loss of ciliary muscles or choroidal elasticity focus the retina retina points accomodation
o Decrease focusing ability for near objects  eye strain  Near sighted Farsighted
headache Diopters >60 (+1, +2, <60 (-1, -2, -
- Starts at age 40 – 46 years, inabi;lity to read small printing (earlier +3) 3)
in women >35 years) Correction Concave Biconvex Cylindrical Spherical
- Worse in dim light, early in the morning and when patient is lens (-) diopter (+) diopter lens hard contact
stressed, fover fatigued or very happy. lens
Correction:
- Bifocals: far and near Causes/ - Axial Axial Cylindrical Football
o Higher portion for distances Etiology: - Curvature/ Refractive lens shaped
o Lower portion is for reading refractive (in aphakia) cornea:
- Trifocal: far, near and middle Curvature correctiabe
o Correct for distance vision: top Lenticular/
o Midldle distance: middle residual
o Near distance by lower segment astigmatism:
- Progressive (varifocal): far, near, middle distance without step
change
o Lens are blended into one

Correction of refractive errors:

1. Spectacle lenses
- Safest method of refractive errors
2. Contact lenses
a. Hard and gas permeable lenses
o Correct refractive errors by changing the
curvature for the anterior surface of the eye
o Indicate for the correction of irregular
astigmatism such as keratoconus
b. Soft contact lenses
o Adopts the shape of the cornea minimal
correction of the cornea aberration
o Used for the treatment of corneal surface
disorders but for the control of symptoms rather
than refractive reasons
Surgical Techniques
1. Astigmatic Keratotomy
2. Photorefractive Keratotomy
3. Laser insitu Keratectomy (LASIK)
- Combined microsurgical and excimer laser to correct
myopia, hyperopia and astigmatism
- A highly specialized instrument (microkeratome) is used to
cut thin flap in the cornea
- 90% stroma (flap)
- Advantage:
o Surgery is performed under a protective layer of
tissue
o There is less surface area to heal, less risk of
corneal haze
o Less post-op discomfort
o Less need for post op medications
o Vision returns within a day or so.
4. Intraocular lenses
5. Clear Lens Extraction for myopia Sources:
Vaughn Basic Ophthalmology
LALALA
Others, “stuck” knowledge