Optics Summary 2012

1. Physical/Geometrical Optics
a. Definition and Short summaries 3
b. Ophthalmic Lasers 13
c. Optics of Prisms 17
d. Jackson Cross Cylinder 23
e. Maddox Rod 24
f. Magnification 26
g. Prentice Rule 28
h. Lens Decentration 29

2. Clinical Optics
a. Accommodation 30

b. Visual Testing 36

c. Refractive error
1.Myopia_hyperopia 43
2.Nigh Myopia 49
3.Astigmatism 50
a. Clinical points 52
4.Aphakia 55
5.Anisometropia_aniseikonia_Anisophoria 58
6.Approach to dissatisfied optical patient 62
7.Asthenopia 68
8.Optical considerations in refractive surgery 70
9.Optical considerations in retinal surgery 78
10.Lens based astigmatic management 79

d. Clinical Refraction
1.Retinoscopy (see under optical instruments)
2.Subjective refraction 81
3.Duochrome test 83
4.Bagolini Glasses 84
5.Spherical equivelant 86
6.Overrefraction 87

e. Spectacle Lenses
1.Power and notation of lenses_clinical recognition 88

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 2.Lens Aberrations 90
a. Wavefront aberrations 95
3.Bifocals_multifocals 100
4.Spectacle lens materials 105

f. Contact lenses 109

g. Intra-ocular lenses 122

3. Optical Instruments 129

a. Direct versus indirect ophthalmoscopes 167

4. Previous Questions 168

5. Short Summaries 180

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Discuss the following optical principles
 Fluorescence
 Autofluorescence
 Reflection
 Refraction and Snell’s law
 Diffraction
 Airy Disc / Limits of resolution / Resolving
power
 Refractive index
 Critical Angle
 Total internal reflection
 Schematic eye
 Reduced eye
 Visual acuity
 Contrast sensitivity testing
 Pin Hole
 Keratoscopic patterns in astigmatism
 Birefringence
 Axis of the eye

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 Fluorescence
o Fluorescence is the property of a molecule to spontaneously emit light of a longer
wavelength when stimulated by light of a shorter wavelength
o Common ophthalmic applications
 Ocular fluorescein dye staining
 Fluorescein Sodium dye emits yellow-green light (520-530nm) when
stimulated by blue light (465-490nm)

 Fluorescein angiography
 White light from the camera passes through a blue “excitation” filter
to illuminate the fundus with blue light, causing the fluorescein in
the structures to auto fluoresce and emit a yellow-green wavelength
light
 The camera then filters the reflected blue and yellow-green light
through a yellow-green barrier-filter to only allow the fluorescent
yellow-green light to be captured by the camera
o Titbits:
 FA camera operates similar to indirect
ophthalmoscope principles (not as direct)

 ICG (indocyanine green)

 Fluorescent substance
o Absorbs 805nm infrared radiation and emits 835nm IR
radiation
o The RPE doesn’t absorb this wavelength, but the choroid
does.
o It is thus useful in delineating choroidal lesion’s (where
fluorescein gives less information due to RPE overlying
effect
 Titbits:
 ICG molecule larger than fluorescein
molecule
 ICG best observed with digital imaging
compared to photographic imaging
(because of infrared range)
 ICG contains Iodine
o Unsafe in pt with previous contrast
allergy
o Safe in seafood allergy pt (seafood
allergy related to protein and not
iodine)

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 Autofluorescence
o Autofluorescence occurs when a biological agent spontaneously emits light
o Certain bacteria commonly emit light during autofluorescence
o Ophthalmic application
 Fundus autofluorescence (FAF)
 Certain fluorophores occurs in the fundus
o A2-E in lipofuscin in RPE Cells
o Marker of incomplete degrading of photoreceptor outer
segments
o Fluorescence of these fluorophores are a marker of RPE
strain
o Excitation when using the fundus camera is usually done in
the green spectrum (535 to 580 nm) and emission is
recorded in the yellow-orange spectrum (615 to 715 nm)

 Reflection of light
o When light meets an interface with refractive properties it can be either absorbed,
transmitted with refraction or reflected
 When light meets the interface and is “bounced” back towards the direction
it came, it is said to be reflected
 Laws of reflection
 When light is reflected
o The angle of incidence of light should equal the angle of
reflection

 The image of an object formed by reflection at a plane surface

has the following properties:

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 o the image is upright
o the image is laterally inverted
o the image is virtual
o it is located along a line perpendicular to the reflecting
surface
o It is as far behind the surface as the object is in front of it.

 Refraction and Snell’s law

o Refraction = change in direction of light waves when it passes from one refractive
medium to another one with a differing refractive index
 The more dense the optical medium, the more light is retarded when
passing through it
 Light is bent towards the normal (perpendicular angle related to the surface
of the optical medium

 The incident ray makes an angle of incidence with the ‘normal’

 The angle between the normal and the refracted ray is called the angle of
refraction
 These angles are determined by the refractive indices according to Snell’s
law
 Snell’s law
 States that the incident ray, refracted ray and ‘normal’ all lie in the
same plane and
 The angle of incidence and angle of refraction is related to the
refractive index of the medium through the formula

 Determining the refractive index of the refracting interface

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 o The refractive index of the 2nd medium divided by the
refractive index of 1st medium as in

o E.g when light travels from glass into water, the refractive
interface value (N) = RI (water) / RI (glass)

 Diffraction
o When a wave front encounters a narrow opening/aperture the wave motion spreads
out on the other side of the opening
o The opening / aperture acts a new centre from which secondary waves arise

Titbits:

 Diffraction best explained by wave theory

properties of light
 Occurs due to obstruction in light path
 Constructive and destructive interference occurs
 Increases with wavelength
 Prevents image formation from point source

 Airy Disc / Limits of resolution / Resolving power

o Airy disc
 The diffraction pattern resulting from a uniformly-illuminated circular
aperture has a bright region in the center, known as the Airy disk which
together with the series of concentric bright rings around is called the Airy
pattern
Titbit:

Airy disc is proportional to the wavelength of the

light

is inversely proportional to the diameter of the

pupil

 Limits of resolution / Resolving power

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  These terms refer to the smallest angle of separation between 2
points which allows the formation of 2 discernible images by an
optical system
 The limit of resolution is reached when the 2 airy disc’s are so
arranged that the centre of one falls on the first dark ring of the
other

 Refractive index
o The refractive index of a optical medium gives a measure of its optical density

o Mediums with high refractive mediums slow light waves down

o When entering a high refractive index medium from a low refractive index medium
such as air, the light waves will be bent towards the normal
o The opposite of the above 2 also holds true

 Critical Angle / Total internal reflection

o When light travels from a medium with a high RI to a medium with a lower RI, a
variety of fates can befall it
A) the light wave hits the interface
perpendicular and passes through
undeviated
B) The light wave gets refracted
away from the normal
C) When the angle of incidence (c)
reaches a critical point as here, the
rays are refracted parallel to the
interface  this angle is called the
critical angle
D) When the incident rays enter at an
Angle c = critical angle angle greater than the critical
angle total internal reflection
D = where critical angle is exceded, total internal reflection occurs takes place as demonstrated

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 Schematic eye
o Described by Gullstrand
o The refractive system of the eye is described in terms of its cardinal points
 Measured in mm behind the anterior corneal surface
Distance behind anterior cornea surface

P1 – 1.35mm
P2 – 1.60mm
N1 – 7.08mm
N2 – 7.33mm
F1 - -15.7mm
F2 - +24.4mm
Refractive power = 58.6D

 Reduced eye
o Listing (1853) made the schematic eye easier to use by creating one principle point
midway between the 2 of Gullstrand
o A single nodal point was also created
o The focal points were adjusted for the new principle points
o The result was the reduced eye with a total power still of 58.6D

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 Contrast sensitivity testing
o Can be tested using a sine wave grating
o Optotype testing (Peli-Robson chart) use optotypes with decreasing levels of
contrast to their background

 Pin Hole
o The size of the blur circle on the retina (formed in ametropic eyes) when viewing
objects is related to the pupil size
 If the pupil size increases, the blur circle size also increases
o By placing a pinhole aperture in front of the eye, an artificial small pupil is created,
which diminishes the retinal blur circle
o
o

o A pinhole reduces blurred vision by only allowing para-axial light rays to enter the
eye
o The pinhole measures pinhole visual acuity
o The most useful diameter for a pinhole is 1.2mm (eliminates refractive errors from
-5D to +5d) (pp AAO pg 108)
 If the diameter is made smaller than 1.2mm the diffraction around the
edges will overwhelm the pupil induced image sharpening effects
o Pinhole increases depth of field and depth of focus
o Interpretation
 If the pinhole vision is better than uncorrected vision then a refractive error
is usually present
 If the pinhole worsens vision then macular disease is often present
 A pinhole can also be used after cycloplegic refraction(after BCVA has been
determined)
 If the pinhole vision on top of the BCVA is better than optical
irregularities / irregular astigmatism is likely to be present

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  Keratoscopic patterns in astigmatism
??

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 Birefringence
o An object is said to have birefringence properties if it is able to split light into 2
different light beams both mono-polar (polarised) and with different directions of
travel

 It thus has 2 different refractive indices

o Forms the basis of laser polarimetry

 The machine uses the natural birefringence of the RNFL to measure its
thickeness
o Amyloid when stained with congo red undergoes birefringence

 Axis of the eye

o Angle Alpha
 Angle between optical and visual axis
o Angle Kappa
 Angle between visual axis and trans-pupillary line
o Angle Gamma
 Angle between fixation axis and optical axis

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OPHTHALMIC LASERS
LASERS ANSWER OUTLINE

A) Definition
B) Unique Properties of Lasers
 Monochromaticity
 Polarization
 Directionaltiy
 Intensity
 Coherence
C) Elements of Lasers
 Active medium
 Energy input (pumping + population inversion)
 Optical Feedback System
 Light release mechanism
D) Modes Of Laser Operation
 Continuous wave operation
 Pulse Operated
 Q-Switched
 Mode-Lock
E) Laser Tissue Interaction
 Dependent on
 Wavelength
 Pulse duration
 Tissue charachteristics
 Photocoagulation
 Photo-ablation
 Photo-disruption
F) Surgical Lasers in Ophthalmology
 Argon
 ND-YAG
 Diode
 Excimer
G) Investigational Applications of Lasers in Ophthalmology
 Confocal Optics
 Confocal Microscopy
 Confocal Scanning Laser Ophthalmoscope
 Confocal Scanning Laser tomograph
 Scanning Laser Polarimetry
 Laser Interferometry
 Laser microperimetry
 Laser Doppler Flow-meter 13
A) Definition
 Light Amplified Simulated Emission of Radiation
 Basic mechanism
 Energy source applied to gas/solid or other substance to excite atoms in this
active medium to cause a specific wavelength of light to be emited
B) Unique Properties of Lasers
 Monochromaticity (All light waves has the same wavelength (“single coloured light”)
 Allows a specific tissue with sensitivity specific to this wavelength to be
targeted
 Not affected by chromatic aberrations
 Allows a small spot size to be used
 Polarization (Light emitted linearly)
 Allows maximum transmission through the laser medium
 Minimum loss through reflection due to polarized nature
 Directionaltiy (Collimating effect)
 Light waves travel in same direction in a narrow path
 Makes it easy to collect all the light in lens system and focus it on a small
spot
 Intensity (Power of a laser beam of a given angular size)
 Correlates to the brightness of the emitted beam
 Intensity measured per unit of area
 Determined by spot size and energy output
 Measured in Joules/Watt
 Coherence
 All propagated wave energy in sync (in-phase)
 Emitted light wave all travel in-phase (eliminates destructive interference)
 Improves the focussing qualities
C) Elements of Lasers
 Active medium (Allows large numbers of atoms to be stimulated by so as to emit
light at specific wavelengths)
 Can be
o Gas (argon / Krypton / CO2)
o Solid (ND-YAG)
o Liquid (dye)
o Semiconductor (Diode Laser)
 Energy input (Imparts energy to the active medium to cause emission)
 Done through process called pumping
 This causes population inversion
o Atoms go from resting inactive phase to active state with emission
 Energy input can be from
o Electrical discharge (as in Gas Lasers)
o Other laser beam (as in Dye Lasers)
o Incoherent light (as in solid Crystal lasers)

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  Optical Feedback System (Promotes simulated emission and suppresses
spontaneous emission)
 Laser cavity acts as an optical resonator
o Mirrors reflect and amplify the emitted light
 Light release mechanism
 One mirror is 100% reflective and the other mirror is only partially reflective
 Partially reflective mirror allows some light of only a specific wavelength to
pass out of the laser cavity
 This specific wavelength is then focussed by the aiming beam
D) Modes Of Laser Operation
 Continuous wave operation
 Output of laser is continuous / Constant
 Pulse Operated (high energy is delivered in short bursts only)
 Q-Switched
o A shutter in front of the mirror in the optical cavity
o Energy is allowed to build up to a specific level before the shutter
opens to allow a pulse of energy to be released
o (+- 2-30nanoseconds)
 Mode-Lock
o Various wavelengths in laser tube are synchronised
o Periodically all travel in-phase
o A summated train of very high energy pulses (+- 30 pica seconds per
pulse) is released
o Produces 100% more power versus same energy released by Q-
Switching
E) Laser Tissue Interaction
 Dependent on
 Wavelength
 Pulse duration
 Tissue characteristics
 Photocoagulation
 Light energy heats tissue and alters it
 Target tissue selectively absorbs specific wavelengths of light
o Causes conversion of energy absorbed to thermal energy (heat) and
permanent tissue alteration
 E.g. Argon Laser
 Photo-ablation
 High energy UV light can cause micro-precise tissue splitting/ablation
without damaging surrounding tissue
 No thermal heat created
 Causes splitting of covalent protein bonds in cornea
 Excimer Laser’ photoablation utilizes this principe
 Photo-disruption
 E.g. Yag Capsulotomy
 High peak powered pulse laser ionizes target tissue

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  (photons strip the electrodes from target tissue)
 Causes rupture of target tissue
 Doesn’t damage adjacent tissue
F) Surgical Lasers in Ophthalmology
 Argon
 Argon blue green laser
 (70% blue(488nm), 30% green(514nm))
 Used for PRP, Focal Macular laser, Pre-YAG Pi
 New ones are macular protective
 ND-YAG
 1064nm
 Continous wave or Q-switched
 Used
o Posterior capsulotomies
o Iris disruption (PI)
o Hyloid face disruption
o Subhyaloid hemorhage YAG
 Diode
 810nm
 Continuous wave mode
 Portable /Small
 Little excess heat created
 Only absorbed by Melanin
 Good ocular penetration
 Uses
o Transscleral cyclodiode / retinal photocoagulation
o Transpupillary cyclodiode (internal procedure)
o PDT
 Excimer
 Ag-FL dimer laser medium (193nm)
 Each emitted photon has enough energy to break intermolecular tissue
bonds to ablate tissue without causing excess heat or damage to
surrounding tissue

G) Investigational Applications of Lasers in Ophthalmology

1. Confocal Optics
2. Confocal Microscopy
3. Confocal Scanning Laser Ophthalmoscope
4. Confocal Scanning Laser tomograph
5. Scanning Laser Polarimetry
6. Laser Interferometry
7. Laser microperimetry
8. Laser Doppler Flow-meter

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OPTICS OF PRISMS
1) Definition
2) Physical Optics
 Effect on light rays
 Positions
o Position of minimum deviation
o Prentice position
 Prentice Rule
 3 problems with prismatic effect in bifocals
3) Uses of Prisms
 Diagnostic
o Check VA in preschool children
o Check binocular fusion in children (Base out prism test)
o 4D Test
o Krimsky prism tests
o Prism Cover test
o With Maddox Rod to subjectively measure angle
o Fusional reserve measurement
o Binocular balance
o Simulated blindness test
 Therapeutic
o Building fusional reserve
o Relieve diplopia
o Nystagmus rx
o Forms of therapeutic prisms
 Temporary wear
 Permanent wear
 Prisms in instruments
o Reflectors of light
o Keratometer
o Goldmann tonometer
o Microscope and slitlamp
o Gonioscopy lenses

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1) Definition
 Triangular / Wedge shaped optical medium with 2 plano surfaces inclined at finite
angles
 Orientated according to the base position
 Has specific optical properties
2) Physical Optics
 Properties
o 3 surfaces
 Base
 2 x sides
 Angle between 2 refracting surfaces = apical angle
 Effect on light rays
o Light obeys Snell’s law at every interface
o Rays are deviated towards the base
o Total change in direction of a light ray after exiting the prism = angle of
deviation
o Angle of incidence = the angle at which light rays enter the refractive
surface of the prism
o Angle of emergence = angle at which light ray leaves the 2nd refractive
surface

 Positions
o Position of minimum deviation
 Angle of deviation is least where angle of incidence = angle of
emergence. Also known as the angle of minimum deviation
 The angle of deviation equals half the apical angle

When angle of incidence = angle of

deviation then b=1/2 of a

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 o Prentice position
 In the prentice position one surface of the prism is parallel to the
incoming ray, thus all the light deviaiton takes place on the other
surface

 Prism Diopter
o A prism of 1 diopter produces an apparent displacement of an image of an
object placed 1m away from the prism by 1cm
o 1 prism dioptre produces an angle of apparent displacement of ½ a degree
 1 prism dioptre thus equals half a degree

 Prentice Rule
o Prentice rule gives prismatic power of any point on a lens
 Prism D = h x D
 PRISM POWER = decentration in cm x lens power
 Thick lenses essentially a stack of prism on top of each other
 Increases the peripheral power of the lens, causes more
peripheral deviation of light rays

 3 problems with prismatic effect in bifocals

o Image jump
 When the eyes move from the distance to near vision interface the
prismatic effect causes image jump
o Image displacement

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  Bifocal add induces base down prismatic effect
o Vertical misalignment
 Anisometropic corrective reading lenses may induce different
prismatic effects that could cause diplopia
3) Uses of Prisms
 Diagnostic
o Check VA in preschool children
 Use a 10 diopter vertical prism
 Alternating between targets suggests good VA
o Check binocular fusion in children (Base out prism test)
 20 diopter base out prism in front of 1 eye (e.g. right)
 Displaces image on retina temporally
 Examiner observes for corrective eye movements
 If placed in front of right eye then normal movement would
be adduction of right eye to correct the image shift and
simultaneous left shift of the left eye (according to Herring’s
law). On removal both eyes should shift back to right and
left eye will make a fusional outward movement

o 4D Test
 Differentiates bifoveal fixation from central suppression scotoma
(CSS) in microtropia
 For example
 Patient with L microtropia and CSS (suspected)
4 D base out prism in front of Left (CSS eye)
 Because of CSS no movement to correct
ocular alignment is observed
4 D base out now in front of Right eye
 Temporal image displacement causes right
eye to adduct, and Left eye obeying
Herrings law also shift’s left, removing the
prism causes right recovery movement
o Krimsky prism tests
 Krimsky prism test
 Observing the light reflexes, prisms of increasing strength is
placed in front of the fixating eye until equal light reflexes is
obtained
 Prism reflection test
 Observing light reflexes whilst placing prisms in front of the
deviating eye until equal reflexes (parallax errors common,
not regularly used in practice)

o Prism Cover test

 Alternate Cover uncover tests are performed whilst placing prisms in
front of the fixating eye until no re- fixation movement is noted

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  Use prism base out (apex in direction of deviation)
o With Maddox Rod to subjectively measure angle
o Fusional reserve measurement
o Binocular balance
 During subjective refraction
 Use Riley prisms (total of 6D) to dissociate vertically the 2 eyes
 Binocular balancing can now be performed
o Simulated blindness test
 Prism in front of the seeing eye causes fixation movement
 Placing a prism in front of the “blind” eye will cause refixation
movement where as a truly blind eye will not have a refixation
movement

 Therapeutic
o Building fusional reserve
 Used in convergence insufficiency
 Intermittent use of BO prism to build fusional reserve
o Relieve diplopia
 Use to relieve diplopia in
 Decompensated phoria’s
 Paralytic squints with diplopia in primary position
 Small vertical squints
 Reserved for patients where surgery not indicated
o Nystagmus rx
 Prevents head tilt
 Stimulates convergence (less nystagmus)
o Forms of therapeutic prisms
 Temporary wear
 Fresnel Prisms
i. Plastic sheet of 2 thin prisms with exactly same
refracting angle clipped onto spectacles
ii. Produces effect of single larger prism
iii. Cheap
iv. Minimal chromatic aberration and distortion
 Permanent wear
 Decentering spherical lenses
 Mounted prisms in spectacles

 Prisms in instruments
o Reflectors of light
 Used to cause total internal reflection of light in various instruments
in varies ways
o Keratometer
o Goldmann tonometer
o Microscope and slitlamp (porro prisms)

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o Gonioscopy lenses

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Jackson Cross Cylinder
 Optical Instrument to define cyndrical axis and power of the eye
 Optics
o A sphero-cylindrical lens of which
 The cylindrical power is twice that of the spherical component and of
opposite sign
 The net result is superimposing two cylindrical lenses of equal power but
opposite signs at axis 90 degrees to each other

o Lens is mounted in a handle that can flip between the 2 axis / meridians

 Can be used
o To grossly determine amount of astigmatism present
o To refine the cylinder power and axis during refraction
 The JCC is swung in front of the refracting eye
 If the JCC is placed on axis, the cylindrical power can be determined, by
incrementally increasing the power and offering the patient the choice’s
between the 2 JCC axis’ (which will be of opposite powers)
 If the JCC is place off axis (straddling) the cylindrical axis can be determined,
once again by changing the axis and offering the patient the 2 JCC choices

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MADDOX ROD
 Optical instrument that incorporates a series of fused cylindrical glass rods
o The plano-cylindrical rods converts a white spot of light into a red streak of light

 Optics
o Optical properties of rods  convex cylindrical lens
 Horizontal orientated rods form vertical streak

 Vertical orientated rods form horizontal streak

 Use
 To diagnose extra-ocular muscle imbalance (Phorias)

 Method
 Maddox rod placed in trial frame in front of eye
 Patient focuses on white light (point source >6m away)
 The eyes are dissociated now
o The eye with Maddox rod sees a vertical or horizontal red
line
o The other eye sees a single white point source
o By placing prisms in front of the eyes, the 2 images (red line
and white dot) can be brought together until they are
aligned (thus allowing quantification of the deviation

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 o Example:

 Double Maddox Rod Test

o Used to Test and measure CN4 palsies
 Use Maddox Rod in front of both eyes
 One green Maddox Rod and one Red Maddox Rod
 Both eyes observe horizontal lines of different colours which are distinct
from each other
 The eye with the CN4 Palsy will have cyclodeviation and the horizontal ine
will be tilted
 The Maddox rod of that eye can then be rotated until the patient reports
the lines to be superimposed on each other and the angle of cyclo-deviation
can then be quantified

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MAGNIFICATION
 Linear Magnification

 Angular Magnification
o In ophthalmic practise often the actual object size and actual image size not as
important as the angle subtended at the eye
 Subtended angle determines the retinal image size
 Apparent size = ratio of object / image size divided by the distance from the
eye

 Both A,B,C produce the same image on the retina and thus appear identical
in size because they subtend the same angle at the principle point of the eye
 Apparent size = tan a

 Simple Magnifier (Loupe)

o Convex lens allows eye to view an image at much closer distance than would
normally be possible
o Bringing the image closer to the eye causes the angle that the image subtends with
the principle point of the eye to be greater (tan a ↑↑ as above diagram)
o This causes larger retinal image and thus angular magnification

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o Magnifier power
 @ 25cm from the eyes

 Simple formulae (@ 25cm

M = Magnification

F = Lens power in magnifier

4 = Diopter power (1/25cm)

 Thus a commonly used 8x Loupe has a lens power of + 32D

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 Prentice Rule
 All spherical lenses will have induced prismatic effect when viewed through the peripheral
(non-central optical) portions
o The amount of induced prismatic effect depends on the power of the lens and the
distance from the optical centre from whence viewing takes place
o The amount of prismatic deviation can be calculated by the prentice rule

Amount of prismatic effect (prism dioptre) = distance (cm) from optical centre x lens power (dioptre)

∆ = h xD

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LENS DECENTRATION
 Prentice’s Rule
o Prismatic effect of centering lenses
 Peripheral portion of spherical lenses in effect a prism

 Decentration
o Use of non-axial portion of lens to gain prismatic effect (desired or undesired)
o Can occur in poor centration of spectacles
 Causes
 Spherical aberration
 Pin-Cushion effect
 Ring Scotoma
 Jack-in-the-box effect
o Anisometropia Correction Problems
 Distance correction of 2 eyes differ
 Problem with bifocal adds  vertical misalignment of visual axisses cause
image displacement and image jump +- diplopia

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ACCOMODATION
 Definitions
o Accommodation
o Far point
o Near point
o Accommodation Range
o Amplitude of accommodation

 Presbyopia
o Definition
o Hypothesis (causes)
o Treatment

 Accommodative insufficiency
o Definition
o Symptoms
o Causes
 Refractive / Optical
 Systemic
 Mono-ocular
o Treatment

 Paralysis of Accommodation
o Definition
o Causes
o Symptoms
o Treatment

 Accommodation Excess
o Definition
o Symptoms
o Diagnosis
o Causes
 Functional
 Organic
o Treatment

 Accommodation Convergence / Accommodation ration(AC/A Ratio)

o Definition
o How to Measure
 Heterophoria Method
 Gradient method stimulating accommodation
 Gradient method relaxing accommodation

 Convergence insufficiency
o Causes
o Symptoms
o Diagnosis
o treatment

30
 Definitions
o Accommodation
 The ability of the eye to increase its Diopteric power (dynamic optical process)
 Accomplished through a process wherein the crystalline lens assumes a more globular
(convex) shape
 This allows the eye to move its focus from a distant object to one closer to the eye
 Biology
 The crystalline lens is encased in a lenticular bag which is held under tension by the
zonules, which attach it to the ring of cilliary muscles
 Cilliary muscle contraction reduces the tension on the lens, allowing it to conform
to a more convex shape
 Relaxation causes the zonular tension to increase, causing the lens to assume a
more concave (less convex shape)

o Far point
 Far point of distinct vision is the position of an object where its image is located on the retina
during the non-accommodative (relaxed) status of the eye
 Far point for emmetropia is infinity

o Near point
 Near point is the point where an object of close proximity’s image falls onto the retina during
accommodation
 Nearest point where an image can be seen during maximal accommodation

o Accommodation Range
 Distance between near and far point

o Amplitude of accommodation
 Difference in diopteric power of the eye at rest (non-accommodative) and the fully
accommodated eye

 Presbyopia
o Definition
 Gradual decrease / Loss of accommodative amplitude
 Normal age related process (average age = 51yr)
 Normal accommodation amplitude
o 8yr  14D
o 20y  11D
o 40y  4-6D
o 60D  1.5D
 Hypermetropes may present earlier (needs more accommodation to overcome the already
present hyperopic error)
 Myopes may present very late
 Inherent near error allows them to focus clearly on near images
 Might also remove distance correction to read clearly at near

o Hypothesis (causes)

 Lenticular sclerosis
 Harder and less moldable lens with age
 Geometric theory
 With increasing age  lens thicker and anterior zonular shift
o Loss of accommodative effect with zonular relaxation
 Disaccommodative Theory

31
  Gradual failure of lens to be held in unaccommodative position at rest (↓elasticity
of zonules)
 Schachar’s theory
 Continual growth at equator = ↓ resting zonular tension
 (theory fails on many grounds)
 ↓Cilliary muscle function
 ↓Elasticity of lens capsule
 Vitreous syneresis
 ↓support for posterior lens support
 Multifactorial theory
 Incorporates components of all of the above

o Treatment
 Multifocal spectacle lenses
 Formulae (rough guide)
 Surgical
 Multifocal / Accommodative IOLs

 Accommodative insufficiency

o Definition
 Premature loss of accommodative amplitude
 May be early onset presbyopia
 May be inability to sustain accommodative effort

o Symptoms
 Asthenopic symptoms
 Blurred near vision

o Causes
 Refractive / Optical
 High Hypermetropia
 Hypermetropic- or mixed astigmatism
 Anisometropic error
 High myopia
 Exophoria

 Systemic
 Anaemia
 General ill health
 Diabetes
 Stress
 Medication
o Tranquilizers
o Anti-cholinergics
o Beta-blockers
o Many others
 Closed head injury (may be permanent)
 Idiopathic

 Mono-ocular
 Trauma
 Iridocyclitis
 Glaucoma

32
  Lenticular changes (cataract)

o Treatment
 Correction of refraction and or underlying causes
 Prescription of near/reading add

 Paralysis of Accommodation

o Definition
 Complete or significant loss of accommodative amplitude
 May be unilateral or bilateral, complete or partial

o Symptoms
 Blurred near vision
 Asthenopia
 Micropsia
 Because pt needs excessive effort to view near objects, the objects under view is
processed as being smaller and nearer to the eye than they really are

o Causes
1. Cyclpoplegic drugs
2. CN3 palsy
3. Cilliary muscle disease
o Cyclitis
o Glaucoma
4. CVA
5. Encephalitis
6. Head injury
7. MS
8. Old age

o Treatment
 Spectacles with near add
 Management of possible diplopia

 Accommodation Excess

o Definition
 Excessive accommodation due to cilliary muscle spasm
 (spasm of accommodation)

o Symptoms and features

 Headaches (worse in evening/@night)
 Brow-aches
 Variable blurring of distance vision
 Abnormal close reading position
 Pseudomyopia (up to 10D)
 Worsening of existing myopia
 Asthenopia

o Diagnosis
 ↓ range of accommodation
 Weak cycloplegias ineffective
 Discrepancy between refraction with and without cycloplegic agent
 Varying results between subjective and objective refraction

33
 o Causes
 Functional
 Hypermetropia
 Prolonged near work
 Early cataracts
 Early presbyopia
 Anxiety

 Organic
 Drugs
o Miotic use
o Sulphonamides
 Intra-ocular inflammation
 CNS
o Seizures
o Parinaud syndrome
o Head injuries
o Cranio-cervical junction lesions

o Treatment
 Find and treat underlying cause
 Cycloplegia to recover cilliary function
 Atropine or cyclomydril
 Prescribe full cycloplegic refraction (subtract -0.5D if atropinized refraction)

 Accommodation Convergence / Accommodation ration(AC/A Ratio)

o Definition
 The normal accommodative effort is accompanied by a corresponding convergence response
 This ration (AC/A) is expressed in terms of prism diopters of convergence per 1D of
accommodation
 Normal ratio is 3.1 – 5.1
 Important in strabismus
 If AC/A ↓ then ↓Esotropia angle
 If AC/A ↓ then ↑ Exotropia angle

o How to Measure
 Heterophoria Method
 Measurements at 6m and at 33cm
 Patient is asked to fixate at a near object (33cm away) and the convergence angle is
measured. The angle is again measured whilst patient fixates on a 6m target
 Formula

 Gradient method stimulating accommodation

 Measure the convergence angle (∆) for distance (6m)
 Place -1D spheres in front of both eyes (induces a phoria)
 Re-measure now  near induced deivation
 AC/A = difference between 2 measured angles

34
  Gradient method relaxing accommodation
 Measure the convergence angle (∆) for near (33cm)
 Place +3D spheres in front of both eyes (induces a phoria)
 AC/A = difference between 2 measured angles divided by 3

 Convergence insufficiency

o Definition
 Inability of eyes to convergence during accommodation or to sustain accommodative induced
convergence
o Symptoms
 Diplopia for near(prolonged near work)
 Asthenopia
 Fatigue
 Headache

o Diagnosis
 Patient symptoms
 High exophoria at near
 reduced AC/A Ratio
 receded near point of convergence
 low fusional vergence ranges
o Causes
 Primary
 AC/A Ratio abnormalities
 Secondary
 Optical (refractive errors)
 Illness
 Stress
 Drugs

o Treatment
 Small base-in prisms to the spectacles
 2-4∆ split between 2 eyes

 Convergence exercises
 Base-out prism exercises daily (wearing base out prisms for short periods daily to
place more strain on convergence effort, thus “exercising” the convergence system)
 Pencil push-up training
o Child/person exercises daily for 15 minutes using a pencil with a letter on
its back-side
o The patient brings the pencil closer and closer to the eyes until blurring,
aiming to come closer every day (poor evidence for success, though
commonly used)
o Convergence insufficieny treatment trial
 Randomised multicentered trial
 Compared
 office based and home exercise
 home-exercise alone
 computer based
 placebo
o 75% with office based/home exercise group
o Suggests trained orthoptist helping
 Surgery

35
 Bilateral medial rectus resections
o May cause post-operative diplopia (1-3 months)
o CI Can recur
o Should be reserved as last option

36
Visual Testing
 Optical Principles
o Visual testing measures the resolving power of the eye

o The limits of resolution(or resolving power) refers to the smallest angle of

separation between 2 objects subtended at the visual axis, which still allow the
formation of 2 discernible images by the optical system involved
o The maximum limit of resolution is reached when the 2 airy disc’s are separated so
that the centre of one falls on the first dark ring of the other
o MAR
 MAR = minmum angle of resolution
 The smallest angle separating object’s so that the human eye can still
perceive 2 different objects
 1 MAR = objects separated at the eye’s nodal point by the same angle as
that subtended by a photoreceptor cell area on the retina
 Thus if the angle between 2 objects (subtended at nodal point of
eye) is smaller than 1 MAR, then the 2 images will both stimulate a
single photoreceptor cell visual area and the eye will perceive the 2
objects as one

37
o Snellen Optotypes
 Snellen Chart and optotype testing uses optotypes or objects that the
examination subject has to identify

 Snellen
 Snellen chart has lines of progressive smaller optotypes subtending
5MAR
 The “normal” was determined arbitrarily by Snellen by asking his
assistant who he felt had Normal vision to read letters of decreasing
size
 Snellen vision is expressed as a 6/6 or 6/12 or 6/9 etc
o 6/6 means a patient can read the at 6 meters what a person
with normal vision can read at 6m
 Likewise 6/12 means a patient can read t 6 meters
what a person with perfect vision can read at 12m
o Snellen vision utilizes black letters on a white background
and must be measured at 6m distance
o Limitations
 Poor and random progression in MAR of letters
(unlike smooth and equal steps in LogMar charts)
 Not a good test for contrast testing (Black on white
letters = high contrast, and thus patients with poor
contrast sensitivity can still do well)
 Crowding of the letters
 Too few large letters to test poor vision

38
 Bailey-Lovie Charts
 Also uses optotypes
 Regular progression in size of letters
 Also known as logmar charts
o 1 MAR = size of bars of 6/6 Snellen E-optotpye
o = 0 LogMAR
o 1.25MAR = size of bars of 20/30 Snellen E-optotype
o = 0.1 LogMAR
o 1.99MAR = size of bars of 20/40 Snellen E-Optotype
o =0.2 LogMAR

 Constrast Sensitivity Testing

 Contrast of Major importance for vision
o E.g. = cataract patient with good snellen vision and poor
contrast who cannot see well in poor light conditions
o Contrast = Target luminance difference compared to
background

o Contrast sensitivity = reciprocal of the patients contrast

threshold
 E.g 33% contrast threshold = contrast sensitivity of 3
 25% contrast threshold = contrast sensitivity of 4
o Contrast is commonly decreased in optic nerve conditions
and cataract
o Tests
 Peli-Robson Chart
 Measures contrast with series of optotype
letters in decreasing contrast
 The test can be expressed on the line the
patient can reach or the number of letters
read from the top

39
o Factors influencing Vision

1) Refractive Error
 Defocus causes
o ↑Point spread function
o Refractive error =directly proportionate to the amount of
defocus
o Inversely proportionate to the pupil size (due to pinhole
effect)

2) Retinal Ecentricity
 Fovea is the most sensitive area with regards to visual potential
 1° away = 60% reduction in optimal vision

3) Luminance
 VA remains constant over a wide range of luminance

4) Contrast
 ↓contrast = ↓visual resolution
 Stereoscopic vision also ↓ with ↓contrast

5) Pupil size
 Pinhole effect  ↓pupil = ↑VA

6) Exposure duration
 As exposure time to object ↓ so the VA ↓

7) Target and Eye Movement

 VA↓ during saccades / Target pursuit

8) Meridional Variations in Acuity

 Horizontal and vertical meridians is favoured
 Obliquely orientated object are less well resolved visually

9) Crowding
 Targets too close to one another are poorly differentiated (thus
↓VA)

10) Developmental Aspects

 VA will be poorer if visual deprived / inadequately stimulated in
early childhood

11) Age
 ↑light scatter with ↑Age  thus decreased VA with age

40
 o VA Testing

 Babies
 Fixation with eyes NB
o Must be CSM (central steady and maintained)
o Any object for fixation can be used (familiar face good 
mom’s will know if child can fixate on them)
o Aversion to occlusion a good hint at ↓VA
o Features of poor VA in baby
 Aversion to occlusion
 Roving eye
 Eye poking
 Nystagmus
 Infants
 2-5months
 Visual directed reaching
 Children
 Catford drum
 Sty Car
 Optotypes
o Sheridan Gardner test  picture recognition
 Adults
 Optotypes

 Other Optical definitions

o Vernier Acuity
 “Hyperacuity”
 Smallest offset of a line which remains perceptible to the human eye
 Normal = 3-5 seconds of ARC
 (Compared to 1 MAR in snellen vision - normality)

o Minimum legible threshold

 Patients ability to recognize progressively smaller letters/forms
 Snellen commonest test

o Minimum visible threshold

 Minimum brightness of a target optotype so that it still remains visible
against its background

o Minimum separable threshold (also known as Minimum angle of resolution)

 Smallest visual angle at which 2 objects can be discriminated

41
o Snellen Acuity
 Measured with test letters (optotypes) so that the letters subtend as a
whole an angle of 5 minutes of arc and each letter stroke subtends an angle
of 1 minute of arc

42
MYOPIA
1. Definition
2. Classification
1. Axial vs Refractive
2. Degenerative vs Non-Degenerative
3. Pathological vs Simple
3. Functional Manifestation
4. Ocular Findings
5. Systemic Associations
6. Treatment
1. Optical Correction
2. Surgical Correction
3. Principles of prescribing

HYPERMETROPIA
1. Defintion
2. Classification
 Axial vs Refractive
3. Types (NB = explain through example)
 Latent
 Manifest
 Total
 Absolute
 Facultative
4. Pathological Associations
5. Correction (optical vs surgical)
6. Principles in prescribing

43
Myopia
1. Definition
o Where the far point of the eye is nearer than infinity
o Occurs when retinal image is formed in front of the retina
2. Classification
1. Axial vs Refractive
o Axial
 Where the axial length of the eye is longer than normal
 1mm = 3D in phacic eyes, 1mm = 2D in aphakia
o Refractive Myopia
 Increased refractive power of the eye cause image to fall in
front of retina
o ↑ Corneal curvature (e.g. Keratoconus)
o ↑ Lens Curvature (e.g. Lenticonus)
o ↑ Lens thickness (Index Myopia)
2. Degenerative vs Non-Degenerative
o Degenerative myopia occur at > -8D (non-Degenerative < -8D)
3. Pathological vs Simple
o Simple Myopia (“Physiological Myopia)
 <6D, AL < 26mm
 Onset 3-4yr age, slow progression, stable at 21 yr
o Pathological
 >6D, AL > 26mm
 Rapid progression
 Associated ocular pathology
o Pale tessellated fundus
o Focal Chorioretinal atrophy (visible choroidal vessels)
o Lacquer cracks (Ruptures in Bruchs/RPE complex)
o CNV
o Subretinal coin shaped haemorrhages
o Fuch’s Spots (post macular haemorrhage resorption)
3. Functional Manifestation
1. Image minification
2. Anisometropic amblyopia
3. Subnormal vision
4. Visual defects
5. ↓Dark adaptation
6. Abnormal colour discrimination
7. Suboptimal binocularity
4. Ocular Findings
1. ↓VA

44
 2. ↓Ocular Motility (↑Globe size)
3. Pseudo Proptosis
4. Cornea
o Megalocornea
o Keratoconus
o Astigmatism
o Thinning
o Haab striae
5. Iris
o Deep iris processes
6. Lens
o Early onset cataract
o Weak zonules
7. Vitreous
o Vitreous syneresis
o Early synchysis with ↑risk PVD
8. Retina
o Peripheral retinal degenerations
 Lattice↑↑
 Atrophic holes
 Tears
o Rhegmatogenous RD
o Posterior staphyloma
o Foster-Fuch’s spots
o Lacquer Cracks
o RPE attenuation
o Macular holes
9. Disc
o ↑POAG
o ↑Steroid respoders
o ↑Pigmentary glaucoma
o
5. Systemic Associations
1. Albinism
2. Congenital rubella
3. Ehler’s Dahnlos
4. FAS
5. Marfans
6. Sticklers
7. ROP
8. Bardet-Biedl
9. RP
10. Gyrate atrophy
6. Treatment
1. Optical Correction

45
 o Spectacle (Concave negative lenses)
o Contact lenses (negative powered)
2. Surgical Correction
o Corneal
 LASIK (up to 12D myopia)
 PRK (up to 6D)
 RK (out of favour)
 Intrastromal rings
o Lenticular
 Clear lens extraction
 Phacic lens inplantation
7. Principles of prescribing
o Children
 Prescribe full correction if symptomatic / ↓VA distance
 NB not to overminus
o Squint
 In exotropia  minus correction might straighten eyes by
stimulating convergence
o Pseudomyopia
 Excess accommodation by hypermetropes can appear as myopia
 Cycloplegia will unmask
o Overcorrecting
 Stimulates accommodation
 Essentially pushes towards hyperopia
 May cause asthenopia
 Myopes intolerant of overcorrection
 Aim for “red-best” 0.25D undercorrection

46
HYPERMETROPIA
1. Defintion
 Image formation is behind the retina

2. Classification
 Axial
 Short axial length
 Causes light to form image behind retina
 Refractive
 Refractive power of eye inadequate to form image on retina
o Corneal (Cornea plana)
o Posterior lens displacement
o Aphakia

3. Types (NB = explain through example)

 Latent (Residual hyperopia caused by normal resting tone of cilliary body)
 Manifest (maximum plus correction tolerated by patient)
 Total (total amount of hyperopia as measured under cycloplegia)
 Absolute (least amount of plus tolerated without causing vision blurring)
 Facultative (amount of hyperopia that can be overcome by accommodation)

 Example 50yr man

Unaided VA 6/12

Current Specs +1D 6/6

Manifest Refraction +4D 6/6

Cycloplegic Refraction +5.5D 6/6

 This patient has total hypermetropia (after cycloplegic elimination of latent

cilliary tone) of 5.5D
 The most plus he can tolerate without blurring is 4D  Manifest hyperopia
 The latent hyperopia (which is caused by cilliary tone/involuntary
accommodation) is 1.5D  the difference between the manifest hyperopia
and total hyperopia as measured under cycloplegia
 The least plus he can tolerate without blurring is 1D  the absolute
hyperopia, beyond this he will have blurring of vision
 The amount of hyperopia which he can thus overcome with accommodation
is 3D (difference between manifest and absolute hyperopia)  called the
facultative or accommodative hyperopia

47
4. Pathological Associations
 Angle closure glaucoma
 Phacomorphic glaucoma
 Ischaemic optic neuropathies

5. Correction (optical vs surgical)

 Optical correction
 Spectacles
o Plus/convex lenses
 Contact lenses
 Surgical Correction
 LASIK (up to 4D hyperopia)
 PRK in low hyperopics
 Laser thermal keratoplasty
 Phacic lens inplantation

6. Principles in prescribing
 Children < 6yr
 Prescribe when
1. High hypermetropes (>5D) +- Amblyopia
2. Asthenopic complaints
3. Esotropia
4. Hyperopic anisometropia
 No treatment if asymptomatic and Normal uncorrected VA (FU regularly)
 6-20yr
 ↑↑ near work - school
o Often causes symptoms
o NB to do full cycloplegic refraction
o If AC/A ration high then bifocals are NB
 Further relaxes accommodation
 20-40yr
 ↓accomodative reserve due to aging
o Leads to increased cilliary spasm and asthenopia
 NB beware of prescribing bifocals prematurely
o Do full cycloplegic refraction first to determine latent hyperopia

48
Night Myopia
 Spherical aberrations and night myopia
o Spherical aberration exacerbates myopia in low light  night myopia
 In bright conditions the constricted pupil blocks peripheral light rays (which
cause spherical aberrations)
 In dim light the dilated pupil allows peripheral rays to undergo spherical
aberration
 The peripheral rays cause an anterior shift in image formation
o Thus the myopic shift of +- 0.50D at night
 Chromaticity and night myopia
o At night under scotopic conditions the retina adapts and become more sensitive to
the shorter (blue) wavelengths of light
 These are focussed more anteriorly due to monochromatic effect (shorter
wavelengths undergo more chromatic aberration)
 Thus exacerbating the existing night myopia effect

49
 ASTIGMATISM
1. Definition
2. Sturn’s Conoid
3. Classify
 Regular vs irregular
vs oblique
 With the rule vs
against the rule
 Complex vs simple
4. Etiology
5. Optical correction
6. Surgical Correction
7. Prescribing points

ASTIGMATISM
1. Definition
 When refractive indices of 2 main meridians of the eye differ so that image
formation is by the principle of a sturn’s conoid and subsequent non-retinal image
formation

2. Sturn’s Conoid

a = compound hypermetropia astigmatism

b = simple hypermetropia astigmatism

c = mixed astigmatism

d = simple myopic astigmatism

e = compound myopic astigmatism

50
3. Classify
 Regular vs irregular vs oblique
 Regular
o 2 axis’ lie at 90degr to each other and are located near to 90 degrees
and 180degrees
o Includes with-the-rule and against-the-rule astigmatism
o Includes the above compound/simple and mixed types of
astigmatism
 Irregular
o 2 axis’ soes not lie 90 degrees to each other and power in the 2
meridians vary over the cornea from point to point
o Not correctable with optical aids
 Oblique
o Axis’ lie 90 degrees to each other but not near the 90/180 degrees
axis’
 With the rule vs against the rule
 With-the-rule
o Power in the vertical meridian is more than in the horizontal
meridian
 Against-the-rule
o Power in horizontal meridian is more than in the vertical meridian
 Complex vs simple
 See sturns conoid picture

4. Etiology
 Curvature astigmatism
 Anterior cornea
 Posterior cornea
 Combination of above
 IOL decentration
 Lenticular astigmatism
 Refractive astigmatism of normal lens

5. Optical correction
 Spectacles – Toric lenses
 Contacts – Hard / soft
 Surgical
 Toric IOLs

6. Prescribing points
 If small astigmatic error and few or no symptoms don’t prescribe
 In children full prescription to prevent amblyopia
 If cyl error > 2.5D
 Measure Cyl for near and far

51
 o Make allowance for cyclotorsional effects
o Consider 2 pairs of specs (near and far)
 Undercorrect where possible
 Consider adding sphere whilst maintaining near spherical equivalent
 Correction of against-the-rule astigmatism NB
 Period of adaptation to new glasses
 Pt may adapt poorly due to
o Meridional aniseikonia
o Stereoscopic dissociation
o Shifting axis’
 If intolerant
o ↓Cyl and add sphere trying to maintain spherical equivelent

52
Astigmatism Clinical important point
 With-the-Rule refers to the subtype in which the eye has more refractive power along the
vertical axis. The axis stays between 0 to 30 or 150 to 180 degrees.
 Against-the-Rule is another subtype in which the eye has more refractive power along the
horizontal axis. Such people face problems in focusing on objects that are oriented
vertically. The axis varies between 60 to 120 degree range.
 Oblique refers to another subtype in which the axis is between 30 and 60 or 120 and 150
degrees.

In with-the-rule astigmatism, a minus cylinder is placed in the horizontal axis to correct the refractive
error

 Regular astigmatism – principal meridians are perpendicular.

 With-the-rule astigmatism – the vertical meridian is steepest (a rugby ball or American
[2]
football lying on its side).
 Against-the-rule astigmatism – the horizontal meridian is steepest (a rugby ball or American
[2]
football standing on its end).
 Oblique astigmatism – the steepest curve lies in between 120 and 150 degrees and 30 and
[2]
60 degrees.
 Irregular astigmatism – principal meridians are not perpendicular.
In with-the-rule astigmatism, a minus cylinder is placed in the horizontal axis to correct the refractive
error. Adding a minus cylinder in the horizontal axis makes the horizontal axis "steeper" (or better:
makes the vertical axis "less steep") which makes both axes equally "steep". In against-the-rule
astigmatism, a plus cylinder is added in the horizontal axis (or a minus cylinder in the vertical axis).

Children tend to have with-the-rule astigmatism and elderly people tend to have against-the-rule
astigmatism.

Axis is always recorded as an angle in degrees, between 0 and 180 degrees in a counter-clockwise
direction. Both 0 and 180 degrees lie on a horizontal line at the level of the centre of the pupil, and as
seen by an observer, 0 lies on the right of both eyes.

53
54
 APHAKIA
1. Definition
2. Optical Principles
 Effective power of lenses
 Back vertex distance
 Spectacle magnification
3. Optical Correction Problems
 Magnification
 Image distortion
 Ring Scotoma
 Heavy Glasses
 Cosmesis
 Extreme sensitivity to minor
changes
 Base out prismatic effect when
reading
4. Aphakic Refraction

1. Definition
 Optical power of lens of eye absent
 Causes
o extreme refractive hypermetropia
o Loss of accommodation
o Glare
o Possible increased retinal exposure to UV rays

2. Optical Principles
 Effective power of Lenses
o When correcting lens moved closer or further from the eye, the
convergence power of the eye at the principle place changes
o Moving the lens closer or further from the eye moves the retinal image
forward or backwards
o The effective power of the correcting lens need to be changed depending on
the position of the lens
o Back vertex distance thus important especially in aphakic patients
 Back Vertex distance
o Distance between back of correcting lens and the cornea anterior curvature
o Crucially important in any refractive error > 5D
o Position of lens from the eye determines the image magnification
o BVD needs to be measured in all aphakic corrections and taken into
consideration
 Spectacle Magnification
o Spectacle magnification = corrected image size / uncorrected image size

55
 o Relative spectacle magnification
 Corrected ametropic image size / emmetropic image size
 The closer the correcting lens to the eye, the more the image is
magnified
 The further the lesn from the eye, the less the magnification
 Thus contact lenses give +- 1 to 1 image magnification
 Spectacles at normal BVD (12mm) give +- 1.33 to 1
magnification

3. Optical Correction Problems

 Magnification
o Optical correction associated with image magnification
o According to Knapp’s law (2.1% magnification for every dioptre lens power)
 Thus aphakia correction +- 25% magnification (20-35%)
 Thus causes depth perception problems in aphakia – objects appear
closer than they are
 Causes hand-eye coordination problems
 Can lead to enhanced performance on Snellen charts (Aphakic 6/9 =
6/12)
 Aniseikonia
o Mono-ocular aphakic correction with spectacle can cause aniseikonia
 Loss of binocular stereo vision
 Diplopia
o 0.5D difference leads to +- 1% aniseikonia
o Tolerance
 Adults can tolerate up to 5% aniseikonia
 Children can tolerate up to 8% aniseikonia
 Image distortion
o High powered convex correcting lenses prone to aberrations
o Pin-cushion effect
 common in aphakic correcting lenses
 Due to prismatic effect of peripheral lens
 Linear environment appears curved
 Changing shape in different zones and lenses
 Patients can adapt by moving their head (keeping the image through
central lens portion) rather than their eyes

 Ring Scotoma
o Prismatic effect of the lens periphery
 Causes the ring scotoma to form around the edges of the lens
 Jack-in-the-box phenomena
 Direction of scotoma moves as patient moves his eyes
 images move in and out of the scotoma with eye
movements

56
  central 60 degree’s of aphakic lenses surrounded by 10
degree scotoma
 Effective field reduction of +- 20-30% due to prismatic
aberrations
 Often causes falls in the aphakic patients

 Heavy Glasses
 Can slip down the nose
 Uncomfortable

 Cosmesis
o Cosmetic issues due to high optical power
 Produces “fish-egg appearance” of patients eyes to observers
 Eyes appear magnified and displaced

 Extreme sensitivity to minor changes

o High powered lens makes small optical changes into large refractive issues
 BVD changes causes large image size changes and relative refractive
power changes
 Pantoscopic tilt can cause image distortion in different zones

 Base out prismatic effect when reading

o Convergence during reading causes base-out prismatic effect (magnified by
high powered lens)
o Can lead to convergence insufficiency
4. Aphakic Refraction
 Refined refracting skills important
 Difficult to refract aphakic patients on the phoropter due to small changes causing
large errors (pantoscopic tilt/BVD etc)
 Trial frames a good refraction option
 Principles
o Always try to minimize BVD
o PD measurement ++ important
o Measure PD for near and far and adjust bifocal component /position
accordingly
o Eliminate pantoscopic tilt in aphakic glasses

57
 ANISOMETROPIA
1. Definition
2. Classification
3. Problems

ANISEIKONIA
1. Definition
2. Knapp’s rule / Magnification
3. Symptoms
4. Treatment
 Undercorrect refractive error
 Contact lenses
 Iseikonic lenses

ANISOPHORIA
1. Definition
2. Treatment
 Of Horizontal Phoria
 Of vertical Phoria

58
 ANISOMETROPIA
1. Definition
 Refraction of the 2 eyes differ
 Not uncommon to have small refractive difference’s in normal patients

2. Classification
o Simple Anisometropia
 One eye emmetropic other ametropic (myopic or hypermetropic)
o Compound Anisometropia
 Both eyes are ametropic in same direction (i.e. both are myopic or
hypermetropic but to varying degrees)
o Mixed Anisometropia
 One eye is hyperopic and the other myopic
o Simple or Mixed Astigmatic Anisometropia
 One or both eyes have differing levels of astigmatism

3. Problems
1. Aniseikonia
2. Anisophoria
3. Amblyopia
 Hyperopia with > 2D difference (most hyperopic eye will be amblyogenic)
 Myopia with > 4D difference (least myopic eye will be normal)
 Astigmatism with more than 1D difference

59
 ANISEIKONIA
1. Definition
 Unequal size and shape of image formation between the 2 eyes
 In +-20 – 30% of spectacle wearers

2. Knapp’s rule / Magnification

 Knapp’s rule determine’s amount of magnification difference that mounts from
dioptre difference between 2 eye’s
o Every 1D of difference leads to 2x magnification difference
o Hypermetropia
 Image size increases versus other less hyperopic eye (image
magnification)
o Myopia
 Image minification – image formed appears smaller than the fellow
less myopic eye
o Maximum tolerance
 8% in children
 5% in adults

3. Symptoms
1. Visual disturbances
2. Diplopia
3. Squint
4. Asthenopia

4. Treatment
a. Undercorrect refractive error
i. Up to maximum tolerable difference between eyes
b. Contact lenses
i. Especially useful in children where fusion might then be possible
c. Iseikonic lenses
o Magnification of image by lens depends on
 Front curve
 Lens thickness
 Back curve
o Adjusting specs (iseikonic lenses)
 ↑Front curve (↓maxnification)
 ↓Central lens thickness (↓maxnification)
 ↑Back curve (↓maxnification)
 ↓Back vertex distance (↓maxnification in plus lenses and
↓minification in concave lenses)

60
 ANISOPHORIA
1. Definition
 Difference in effective ocular alignment when moving the eyes from the primary
position
 Due to prismatic effect of differing lens powers
2. Treatment
 Horizontal Phoria
 Patients more tolerant of horizontal anisophoria
o Larger fusional amplitude (15-20 diopters) make it less problematic
o Can compensate by moving head and not eyes to look side ways
(this eliminates prismatic effect of peripheral lens portion
 Vertical Phoria
 Patient less tolerant to vertical anisophoria
o Smaller fusional amplitude (3-5D)
o Mx Options
o Can tilt head forward when looking down
o Can drop specs onto nose bridge
o Slab-off Prisms

61
Approach to the Dissatisfied
Optical Patient
 Evaluate source of dissatisfaction
o Exact complaint
o Checklist for spectacle error
 Prescription
 Optical centre/PD
 Base Curve
 Bifocal Segment
 Pantoscopic tilt
 Bifocal type
 Lens material
 Prism
 Frame fit
o Visual performance of eye glasses scenarios

62
 Evaluate source of dissatisfaction

o Exact complaint
 ? unhappy with vision (i.e. refractive error)
 ? performance of lens (e.g. multifocal effect inadequate)
 ? cosmesis
 ? additional optical problems
 ? diplopia
o ?when (prismatic effect of bifocals?

o Checklist for spectacle error

 Prescription
o Is the lens prescription that which was ordered?
 ? Transposition error in cyl /axis (handwriting/misread)
 Lens meter  check the spectacle lens strengths
 Incorrect axis most common error
 Bifocal segments
 Patient commonly complain segments too strong
 Patient expects bifocals to function as trifocals
(wants wider range of near vision)
o Management option could be to make 2
add’s slightly uneven (differ by 0.5D) to give
wider range of focus

 Optical centre/PD
o Are optical centres and PD correctly aligned?

 Optical centres should be aligned with the pupils

 Especially if
o > 2.5D lenses
o Lens material RI > 1.53
 Can mark lens centres (use lens meter) then
recheck the lens alignment on the patient

 Multifocal segments
 If the near-add segments are not correctly
aligned for the near PD (convergence) then a
prismatic effect will cause unwanted
phoria/aberrations
 Check the near PD of the patient and ensure the
near-add segment correlates with this

63
 Base Curve
o Is the base Curve correct?
 Check base curve with the Geneva lens clock
 If base curve ↑then can cause distortion and curvature
peripherally (fish bowel effect)
 Always try to match the new spectacle base curve to the
old base curve to which he/she was used to in the past

 Bifocal Segment
o Is bifocal segment and placement correct?
 Width of segment depends on the patients preference
 Executive bifocals
 Wide horizontal expanse for near view
 Heavier than other bifocals
 Heavy line of demarcation across the lens

 Top edge of bifocal

 Should be +- 6mm below the pupil / +- at the
level of the lower lid margin
 If too high it will distort the distance view
 If too low, the patient will need to tilt his head
to read

 Consideration should be given to round top or flat top

 Flat top has optical centre closer to the top
o Less image jump (especially in myopes)

 Check old bifocals if patient was happy with them

 Pantoscopic tilt
o Specs most commonly use +- 7.5° pantoscopic tilt
o This compromises well between near and distance viewing tasks
o Pantoscopic tilt can induce myopic shift
o Both pantoscopic tilt and lens wrap can cause visual distortion and
asthenopia
 Compare the new specs to the old for gross variation of
tilt / wrap

 Bifocal type
o Patient needing larger near-add segment
 Better suited to executive bifocal
 Poorly tolerant of PALS

64
 o PALS (progressive addition lenses)
 Increasing in popularity
 8-10% of the users don’t adapt and abandon PALS
 Instead
 Use either 2 separate spec’s (near, distance) or
flat-top bifocals
 PALS good choice for first time presbyopic spec wearer
 PALS bad choice for long term bifocal wearer

o Multifocal Change
 Be careful when changing styles (e.g. bifocal to PALS)
 Some pt’s intolerant
 Try to match previous style / parameters (if
patient was happy)

o Patient education
 Reading area smaller than distance area
 Image jump needs an adjustment period to get used to
 Patient can learn to point his/her nose in the reading
direction/position
 More head movement is required for PALS (more than
eye movement)

 Lens material
o Different material (e.g. glass vs plastic) has different characteristics
 Glare
 Chromatic aberration
 Peripheral distortion
o Patient’s used to one material might be intolerant of a new material

 Prism
o Common mistake is to not prescribe prism that was added in the
previous glasses

 Frame fit
o NB to be comfortable, pt to be happy with frame (cosmesis)

o Too small
 Pt may complain of frame edge in visual axis

o Nose pods
 Influences height  thus also influences bifocal
segments height

o Frame selection

65
  Important in myopes with thick lenses (rimless frames
might look cosmetically poor)

 Aspheric lenses
 rimless frame important to minimise
decentration

 PALS
 Should not be placed in oversized frames
o Bifocal segment can then be placed too
low (outside visual axis)

 Visual performance of eye glasses scenarios

o Reading
 Patient’s often complain of over-powered add
 (plan : reduce near segment power)

o Computer work
 Presbyopes often complain about visual discomfort/ asthenopia during work
revolving around computer use
 Arises from constant changing vision from near (computer) to intermediate
(telephone / text material on desk)
 Pt with PALS and whole day computer work
o Often complain of neck strain
o PALS  smaller area of near viewing, thus patient has to do a lot of
head movement to manage near viewing
o PALS poor choice for these patients
 “Computer glasses” reasonable alternative
 Wide area of near vision in lower ½ of glasses
 Wide areas of intermediate vision in upper ½
 NO distance correction though

o Newer presbyope with PALS

 PALS require some head tilt and tilt of the reading material to the correct angle
 Takes time to adjust to

o Nuclear Cataracts
 Index myopia causes myopic shift which can be corrected with specs
 Near point also shifts with glasses, thus difficulty in reading
 Might adjust by slipping distance specs down nose to read over them

o Bifocals and image jump issues

 Near add segment causes image jump due to prismatic effect of the spherical add

66
  Worse in round top segment (because the optical axis is further away from the top of
the segment)
 Especially pronounced in myopic patients
 Flat top styles and executive styles have much less image jump

o Comfort in myopes
 Correcting high myopic errors utilizes heavy lenses (uncomfortable)
 The solution is to utilize thinner lenses with a higher refractive index
 The negative of the thinner lenses are that they cause more reflections
o Can be countered by using anti-reflective coatings

67
 ASTHENOPIA
1. Definition
2. Causes
 Environmental
 Ocular
 Physical
 Functional
3. Symptoms
 Visual
 Ocular
 Referred
 Functional
4. Near Asthenopia
5. Computer vision syndrome

1. Definition
 “Eye strain”
 Vague but real sense of ocular fatigue
 Symptoms derived with strain to maintain clear vision
2. Causes
 Environmental
1. Illumination problems
2. Nature of object (??)
3. Computer vision syndrome
 Ocular
1. Uncorrected ametropia
2. Accommodative difficulties
3. Heterophorias (common cause)
4. Convergence insufficiency
5. Aniseikonia
 Physical
 General ill health
 Stress
 Functional
 Ocular neurasthenia
3. Symptoms
 Visual
 Transient blurring

68
  +- diplopia
 Ocular
 Painful
 tired
 Referred
 Headache
 vertigo

4. Near Asthenopia
 Possible causes
1. Convergence insufficiency (rx with convergence exercises 2minx10)
2. Hypermetropia

5. Computer vision syndrome

 Asthenopic symptoms
 Ocular surface problems / dry eye
 Symptoms
1. Eye strain
2. Tired eyes
3. Irritation
4. Blurred vision
5. Double vision
 Prolonged computer use
1. ↓accomodation power
2. Phoria deviations
3. Transient myopia (“pseudo myopia”-due to accommodation spasm)
 Returns to normal during holidays/weekend
 Treatment
1. Lubricating drops
2. Work breaks (rest eyes)
3. Proper lighting
4. Anti-glare filters

69
OPTICAL CONSIDERATIONS IN REFRACTIVE SURGERY
 Corneal Refractive Surgery types
o Incisional Corneal surgery
o PhotoAblation
o Thermokeratoplasty
o Inlays and onlays

 Lenticular refractive Surgery

o Cataract Surgery
o Clear lens extraction /IOL
o PhaKic intra-ocular lenses
o Toric IOL’s
o Multifocal IOLs
o Accommodating IOLS
o Light-Adjusted IOL’s

 General Consideration in Refractive surgery

o Aim/goal
o Patient selection
 Expectations
 Personality
 Reasons for surgery
o Good refraction
 Cycloplegic refraction vs manifest refraction

 Optical considerations in refractive surgery

o Corneal screening
 Topography
 Wavefront Analysis
o Corneal shape
o Angle Kappa
o Pupil Size
o Irregular astigmatism
 Regular vs irregular
 Causes
 Pre-operative
 Intra-operative
 Post-Operative

70
 Corneal Refractive Surgery types

o Incisional Corneal surgery

 Radial keratectomy (RK)
 Astigmatic Keratectomy (AK)
 Penetrating Keratoplasty (PK)

o PhotoAblation
 Photorefractive Keratectomy (PRK)
 Laser subepithelial keratomileusis (LASEK)
 Laser in situ Keratomileusis (LASIK)

o Thermokeratoplasty
 Laser thermal Keratoplasty (LTK)
 Radiofrequency Conductive Keratoplasty (CK)

o Inlays and onlays

 intacts

 Lenticular refractive Surgery

o Cataract Surgery
o Clear lens extraction /IOL
o PhaKic intra-ocular lenses
o Piggyback IOL’s
o Toric IOL’s
o Multifocal IOLs
o Accommodating IOLS
o Light-Adjusted IOL’s

 General Consideration in Refractive surgery

o Aim/goal
 To improve vision to as close to perfect as possible
 To aim for perfect vision/complete “cure” of underlying error is unrealistic
and might lead to post-operative patient unhappiness

o Patient selection

 Expectations
 Patient needs to understand there is no such thing as a perfect
surgical procedure
 What are the specific needs and requirements of the patient
o Work / leisure visual requirements etc.

 Personality

71
  Will the patient be tolerant of changes / possible side-effects

 Reasons for surgery

o Good refraction
 Cycloplegic refraction vs manifest refraction
 NB to ensure a good refraction is done
 NB to make sure no underlying latent refractive error
 For cylindrical refractive error manifest refraction often more
accurate than cycloplegic refraction

 Optical considerations in refractive surgery

o Corneal screening
 Topography
 Regular versus irregular astigmatism
 Keratoconus
 Forme Fruste
 Pelllucid marginal degeneration
o Corneal tomography such as pentacam can diagnose above
o Pentacam can also provide valuable info on the posterior
corneal refractive properties

 Wavefront Analysis (See separate summary elsewhere)

 Technology that quantifies and graphically presents optical
aberrations
 Most effective current technology to quantify irregular astigmatism
 Based on the fermat principle
o Fermat principle
 Explains how a lens forms stigmatic images
 Rays travelling through the centre have a shorter
path through air but a longer path through the
refractive matter
 Conversely the rays traveling through the periphery
of the lens have a longer air travel and shorter travel
time through the peripheral lens portion
 The fermat priniciple states that the ideal lens will
Fermat principle be shaped so that all light traveling through it, no
matter the path, will be brought to a single point of
focus

 Wavefront Analysis principle (AAO p238)

72
 o A reference sphere is formed centred around the image
point (place where the image is formed on the retina)
 In stigmatic image formation all the light will be
centred and come to point within the reference
sphere
 In astigmatic lenses the optical aberrations will
cause some light to form image at the reference
sphere, whilst some will form image behind or in
front of the reference sphere

o Geometric wavefront
 This is a contour map representing the places where
image formation takes place relative to the
reference sphere at a point in time (“photo finish”
of light waves arriving at the reference sphere)

o Wavefront aberrations
 A wavefront aberration can be quantified by the
difference between the reference sphere and
arriving aberrant light wave (not forming image
within the reference sphere)

o Wavefront aberration is a function of pupil size

 Common Wavefront aberrations

o Defocus
 Positive defocus (myopia)
 Negative defocus (hyperopia)
 Cylindrical defocus (regular astigmatism)

o Spherical aberration
 Peripheral rays focus in front of central rays
 Causes night myopia (common post LASIK)

o Coma
 Light waves at one side of the pupil reach the
reference sphere first, whilst light waves from the
other side of the pupil reach the reference sphere
last
 Image formation in the form of a comet with a tail
 Occurs with decentred keratorefractive ablation

o 85% of aberrations are low order aberrations

 Correctable by spectacle/CL/refractive surgery

73
 o 15% high order with impaired visual acuity
 Difficult to correct
o Zernicke’s Polynomials
 Mathematical formulae used to describe wavefront
surface’s
 Wavefront aberration surfaces are graphs created
from zernicke’s polynomials
 Measured by (few newer techniques also)
 Hartman-Shack wavefront sensor
o Low-powered laser beam focussed
on retina
o Forms image reference sphere
o Emerging rays are deflected to
sensors which determines
aberrations and graphs them

o Corneal shape
 Normal corneal shape is prolate
 Little spherical aberration
 (↑with↑ in pupil size)
 Myopic kerato refractive surgery
 Produces a more oblate shape to the cornea
 (central cornea flattens out compared to the periphery)
o ↑spherical aberration
 Corneal refractive surgery changes shape of cornea
 This usually decreases spherical refractive error
o At the cost of increases spherical aberration
 Aim
o Don’t cause flattening of more than 35D
o Don’t cause steepening of more than 52D
 0.8D of change in K value(pre-OP) = 1D change in refraction post op


o E.g. LASIK pre-op evaluation

 Average pre-op K = 44D
 Refractive error to be corrected = -8.5D
 Predicted post-op K-value
 44 + (0.8 x -8.5) = 37D (acceptable)
 Refractive surgery changes
o Anterior surface of cornea (most powerful refractive
interface)
o Thickness of the cornea (pachymetery)

74
 o Posterior curvature might bulge forward relative to the
changed thickness and changed anterior curvature
 Results in myopic shift
o Important with measurement
 Modern keratometers / tomographers only measure
anterior corneal surface power and assumes a
normal relationship to posterior corneal power
 Thus post LASIK the posterior relationship
changes which might influence future K-
values (as measured by automated
machines)

o Angle Kappa

 Terms

 Large angle Kappa

o Results when the visual axis differs markedly from the
central corneal apex

 Implications in refractive surgery

 If the angle Kappa is large, then centering the excimer ablation over
the geometric centre of the cornea will cause decentred ablation in
effect
 This forms a “second corneal apex” which might cause mono-ocular
diplopia and decreased VA
 Especially of importance in Hyperopic patients

 Thus of importance to identify large angle Kappa’s pre-op

o Pupil Size
 Post refractive surgery patients with pupils > 6mm ↑night vision
problems
 Modern LASIK algorithm’s will compensate for this (thus today less of a
problem

75
  Larger ablation zones are used (minimum 0.5mm/1mm larger than
pupil size
 In myopes large ablation zones not always possible (a smaller
ablation zone is used)
o The smaller ablation zones thus cause nocturnal symptoms
in these patients
 Currently >8mm pupil patients are at risk
o Should be counselled about nocturnal symptoms risk
 Miotics can be used in post-operative problems related to large
pupil size

o Irregular astigmatism

 Irregular astigmatism can occur post-surgery (big challenge)

 Diagnosis made with clinical and imaging modalities

o Typically loss of spectacle BCVA but preservation of BCVA
with CL
o Uncorrected VA not in keeping with refractive error
 E.g. VA unaided 6/9 with +2.00 -3.00 x 060
o Difficulty in determining axis during manifest refraction
o Streak retinoscopy
 Irregular scissor reflexes
o Topographical corneal irregularity

 Management
o If patient is happy with unaided VA despite irregular
astigmatism then leave as is
 Trying to correct surgically may induce large axis
changes without much power change
o LASIK and Astigmatic Keratotomy are unpredictable in
irregular astigmatism

 Causes
 Pre-operative
o Keratoconus
o Pellucid
o Corneal lens warpage
o Dry eye

 Intra-operative
o Decentered ablation
o Cortical islands
o Poor laser optics

76
 o Non-uniform Stromal bed dehydration
o Flap complications
 Dislocation
 Button hole
 Irregular
 Thin
 Torn
 Striae/folds

 Post-Operative
o Flap displacement / Striae
o Post corneal ectasia
o Diffuse lamellar keratitis

77
Refraction Issues in Retinal Surgery
 Scleral Band
o Causes axial myopia

 Radial Plomb
o Neglible on refraction (some astigmatism rarely)

 Air/SF6
o Temporary poor VA
 May be aware of meniscus
 Large Myopic Shift
 ↑refractive power of posterior lens surface(phakic eye)
 Silicone oil
o ↑Refractive index
o Biometry issues
 False long AL
 False low IOL calculation (3-5D)

o Silicone oil : Lens interface

 Phakic
 Forms minus lens (concave)
o Thus adds +- 5D to correction (+5.00DS)
 Pseudophakic
 Forms minus lens (concave)
o Adds +- 5D (+5.00DS)
 Aphakic
 Forms plus lens
o Minuses +- 5D from correction (-5.00DS)

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Management of Astigmatism in lens based Surgery
1. Arcuate Keratotomy
o Method
o How to increase its effect
2. Limbal relaxing incisions
 Method
 Advantages
 Complication
3. On-Axis Cataract Incisions
 Advantages
 Disadvantages
4. Toric IOLs
 Indications
 Designs
 Complications

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1. Arcuate Keratotomy
 Used to correct post –keratoplasty astigmatism
 Arcuate incisions
o In mid-peripheral 7mm zone
o In steep meridian
o @ 95% depth
o Can be combined with compression sutures in flat meridian
 Increased effect
o ↑length of incision
o ↑Depth of incision
o ↑ number of incisions
o Smaller optical zones increases effect
o The older the patient the greater the effect

2. Limbal relaxing incisions

 Used to correct astigmatism during or after cataract surgery
 Incisions
o Curved incisions
o Just anterior to the limbus
o @ 600 micrometer depth
o Single or paired incisions
 Single incision if <1.5D
 Paired if larger
o Placement on steep axis according to the corneal topography

 Advantages over AK
o Heal faster
o Refractive effect stabilised faster
o
 irregular astigmatism
 Flare
 Glare
 FB sensation
o Easier to perform
 Complications
o Under or over- correction
o Wrong axis operated
o Perforation
o Early or late wound leak (especially if combined with cataract surgery)
o Interference with phaco wound construction (if combined cataract surgery)
o Pain or foreign body sensation
o Post-operative epithelial plugging
o Infection

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3. On-Axis Cataract Incisions
 Cataract incision placed in steep axis
 3mm temporal incision causes +- 0.50D of flattening (horizontal meridian)
 The closer the incision to the 90°, the greater the effect of vertical flattening
 Advantages
o Familiar wound construction process
 Disadvantages
o Incisions may have to be made in awkward positions
o Larger wounds might need suturing

4. Toric IOLs
 Indications
o Moderate astigmatism
o Where LRI are not powerful enough
 Designs
o STAAR Toric IOL
 Plate haptic Silicone IOL
 6mm Biconvex optic
 Spherocylindrical anterior surface
 Spherical posterior surface
o Alcon Acrysoft Toric IOl
 6mm biconvex Acrylic Toric IOL
 Spherical anterior surface
 Sphero-cylindrical posterior surface
 Complications
o IOL rotation
 NB to mark patient pre-operatively
 Has to be placed in the bag (cannot be placed in the sulcus or if the
bag compromised (tear etc)
 Might shift post YAG Capsulotomy

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Subjective refraction Outline (Stellenbosch Lecture)
1) Get Objective starting point – Phoropter Retinoscopy
a. Neutralise highest plus first (or least minus)
i. Look for brightest / narrowest light moving with
ii. If only against, add minus until with (then add plus until neutralised)
b. Cylindrical axis
i. Will be perpendicular to the axis of the highest plus
c. Turn axis pointer parallel to the cylindrical axis
d. Neutralise the cylindrical power
e. Check highest plus again (make sure it’s still neutralised)
2) Subjective exam
a. Use 6/9 line or 3 worse than BCVA
b. Occlude one eye
(Red Better  add minus)
c. Do duochrome test
 Leave green best (Green best Add plus)
d. JCC axis
i. On axis
ii. Flip and compare responses  chase the red dot
e. JCC power
i. Off axis
ii. Chase the red dot
iii. Maintain spherical equivelant
 For every 0.50D cylindrical power added, add +0.25D sphere
f. Do duochrome
i. Leave slightly red best or equal
g. Check BCVA and Pinhole again
h. Do other eye
i. Binocular duochrome
i. Leave equal or red best
j. Check BCVA binocularly
3) Near Calculation
a. Near chart at 40cm (remember to adjust PD)
b. Adjust to age and need

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DUOCHROME TEST
 Principle
o The test is based on the principle of chromatic aberration in the eye
 The eye undergoes about 2D of chromatic aberration
 White light entering the eye gets dispersed into its component wavelengths
 The emmetropic eye focusses on the yellow-green spectrum (555nm)
 Red falls behind the retina (+-0.40D)
 Blue falls in front of the retina

 Method
 2 large black snellen letters are
presented to the patient on a split
red-green filter
 One letter is placed on a red background
 One letter is placed on a green background
o Red falls +- 0.40D behind the
emmetropic retina
o Green falls +- 0.40D in front of
the emmetropic retina

 The patient observes the letters and can determine which coloured
letter is more clear
o The eye evaluated is fogged (+- 0.5D)
 The red side should now be more clear
o Add minus sphere until no discernible difference between
red and green can be seen
o (Red best  add minus, green best  add plus)

o If the current refraction he is looking through is myopic, the

red letter will be clearer (closer to the retina)
o Likewise for hyperopia the green will be clearer (closer to
the retina)
 This test is accurate for +- 0.25D discrepancies
 Colour blind persons can also do the test
 Used especially to balance the refraction
 Not useful if VA < 20/30 (cannot discern the 0.5D
difference)

83
Bagolini Striated Glasses
 Optical instrument in the form of spectacle
o Each lens has fine striated lenses similar to the Maddox rod which converts a point
source of white light into a line
o One lens orientated at 45 degrees and the other at 135 degrees (thus 90 degrees to
each other)
o The patient focusses on a near bright white light
o Each eye perceives a single line, orientated at the different angles as above
o Dissimilar images are thus presented to the patient under binocular stereo-vision
circumstances
o Interpretation
 If pt perceives the two lines to intersect each other in the form of an oblique
cross the patient has binocular stereo vision (if eyes are straight or if there is
harmonious abnormal retinal correspondence)

 If pt perceives 2 lines not crossing, then diplopia is present

 If only one line is seen, then suppression is present

84
 If a small gap in one line is seen then a suppression scotoma is present ( as in
microtropia)

 Used to diagnose
 Suppression
 Abnormal retinal correspondence
 BSV
 Interpretation
 Correct interpretation only possible if known whether underlying
strabismus is present or not.

85
Spherical Equivalent
 Definition
o The power of a spherical lens of closest overall effect to a given toric lens.
o Spherical equivalent aims to express a toric lens’s power into a pure spherical
equivalent
 Focal point of spherical equivalent falls in the circle of least confusion of
toric lens’ sturn conoid
o Reveals whether the total power of the eye is essentially hyperopic/Myopic or
emmetropic
o Important in IOL calculations
o Calculated
 Sphere + ½ of the Cylinder
 E.g. +2.00DS / +2.00DC  Spherical equivalent = +3.00DS
 +2.00DS / -2.00DC  Spherical equivalent = +1.00DS

86
Overrefraction
 Reason’s for use
o Pt’s with high anisometropic error difficult to accurately prescribe off the phoropter
findings
 Small changes in BVD and pantoscopic tilt and other variables make
phoropter findings unreliable when converting to the actual spectacle
 Refracting in a trial frame in these settings more accurate
 Another possibility is overrefracting
 This is only useful when the current spectacle frame and BVD and
pantoscopic tilt will be used for the new glasses
o Overrefracting Methods
1. Loose lenses (trial clip lenses)
2. Phoropter in front of the patients current spectacles
3. Using automated refracting instruments
o Calculating the new glasses
 If the patient has only a spherical error, the new sphere is calculated by
simply adding the old sphere to the newly found sphero-cylindrical
correction
 If there is also a cylindrical component which is not at 90 or 0 to the old
script it is more difficult
 Lens meters can be used to add the new correction to the existing
glasses (Cumbersome method, prone to error)
 Manual calculation (difficult)
 Programmable calculators (not commonly available, expensive)
o Overrefraction Uses
1. High Emmetropia (e.g. Aphakia)
2. Soft toric lens needing new refraction for new CL ordering
3. Retinoscopic evaluation of children with existing glasses

87
Power and Notation of Lenses
 Diopter
o Units of lens power
o Unit of vergence power
o Measures and defines the amount of refraction an optical lens causes light rays
entering it to undergo
 1 Diopter = Reciproke of its focal length (meter)
 D = 1 / F (m)

 Lens Prescription
o Nomenclature
 Define the Spherical power first, Followed by Cylindrical power and
Cylindrical axis
 Prisms can be added at the end of the script
 By convention South Africa uses Minus Cylinder scripts
 Example
 +2.00DS / +1.50D x 50°

 Transposition
o Transposition is used to change a prescription from a minus to a plus cylinder script
 The lens is exactly the same, just described in different terms
o Simple transposition
1. Add sphere + Cylinder powers together
2. Change the cylinder sign
3. Change the axis of the cylinder by 90°
 Example
 +4.00DS / +1.50D x 90°

o  +5.50DS / -1.50D x 180°

o Toric Transposition
 Transposition of contact lens based prescriptions
 Method
1. Equalize sign: Change the script so that the cylinder and the base
curve has the same sign (plus or minus)
a. +3.00DS / +1.00DC x 90°  +4.00DS / -1.00DC x 180°
2. Spherical power : Calculate the power of the Spherical surface
(subtract the base curve power from the spherical power given)
a. E.g
i. If the above example had to be converted to a base
curve of -6.00D, then
1. The spherical surface power would be
+4.00DS – (-6.ooD)  + 10DS

88
 3. Specify the axis of the base curve
a. 90° to the calculated axis of the initial script
4. Add the required cylinder (step 1) to the base curve power and
maintain the axis as calculated in step 1
 Example
o +4.00DS / -2.00DC x 90° to +6D cyl
 Equalise sign
 +2.00 / + 2.00 x 180
 Spherical power
 +2.00 – 6.00 = -4D
 Axis base curve
 (90) = 180°
 Required cyl to base curve
 +6.00 + 2.00 = +8.00DC @ 90
o +4.00DS / -2.00DC x 90° to +6D cyl  -4DS / 6DC x 180 / +8.00DC x 90

o Transpose -2.00DS / +3.00DC x 90° to -6D base curve

 (Equalise)+1.00DS / -3.00DC x 180
 (Spherical power) +1 - -6 = +7DS
 (Base curve axis) = 90
 (Cyl required) = -6 + -3 = -9DC x 90
 Answer  +7DS / -6D x 90 / -9Dc x 180
 Identification of lenses
o Plus lenses (image viewed through the lens moves against the lens)
o Minus lenses (image viewed through the lens moves in same direction as lens)
o Astigmatic lenses
 Image rotates as lens is rotated
 When on axis, the image is stabilized (eg at 90 and 180 degrees)

89
 OPTICAL ABERRATIONS
 Definition
 Classification
 Zernicke’s Polynomials
 Low-order aberrations
 High-order aberrations
 Common aberrations
1. Chromatic aberration
 Duochrome test
2. Defocus
3. Spherical Aberration
 How spherical aberration is reduced in the human eye
4. Oblique astigmatism
 How oblique astigmatism is reduced in the human eye
5. Coma
6. Image distortion
7. Curvature of field

 Wavefront analysis (can be included in answer if time)

 Definition
 Defined as imperfections in image formation or distortions of wavefront due to
imperfect optical components
 Deviation of image formation from that of stigmatic (single point) is called an
aberration
 Caused by difference’s in travel time and path that light waves take through the
optical media that contains imperfection
o These difference’s lead to different refraction and irregular image formation

 Classification
 Chromatic aberrations
o Due to the break up of white light into its component wavelengths (see
later)
 MonoChromatic Aberrations
o Aberrations of specific wavelengths of visible light

90
 Zernicke’s Polynomials
 Mathematical formulae to determine aberrations
 Pyramidal representation of aberrations in the eye
 Divides aberrations into
o Low-order aberrations
 Commoner (85%)
 Can be corrected with lenses/refractive surgery
 Most common aberrations
o Astigmatism
o Defocus

o High-order aberrations
 15%
 Commoner post refractive surgery
 More difficult to correct
 Includes
o Coma
o Trefoil
o Spherical aberration
 Common aberrations
1. Chromatic aberration
 Due to dispersion of light into its component wavelengths
 White light is dispersed into its component wavelengths at a
refracting interface
 The shorter the wavelength the more it is deviated during refraction
o Thus blue light (short wavelength) undergoes >> deviation
than red light(longer wavelength)
o

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  Ocular chromatic aberrations
 Light entering the eye is also subject to chromatic aberration
o The total amount of chromatic aberration in the eye = +- 2D
o The emmetropic eye focusses for yellow-green (+-555nm)
 Also the peak wavelength under photopic
conditions (closest to photopic luminosity curve)
o Clinical implications is the duochrome test (see elsewhere
summarised)

2. Defocus
 Spherical error  myopia or hypermetropia

3. Spherical Aberration
 Spherical lenses are prone to prismatic effect in the lens periphery
o Thus light rays passing through the central portion of the lens pass
through without undergoing prismatic deviation
o Light rays passing through the periphery undergo refraction by the
prismatic effect, and are deviated more than the para-axial rays
o This is described as spherical aberration

 How spherical aberration is reduced in the human eye

1. Corneal curvature
o The anterior corneal curvature is flatter in the periphery
than centrally (acts as aplanatic surface)

2. Lens nucleus
o The nucleus of the lens has a higher refractive index than
that of the lens cortex
 The peripheral lenticular zones thus has a weaker
refractive power than the central axial zones

3. Pupil / Iris
o Acts as a stop, in that peripheral orientated light rays gets
blocked by the pupil (only paraxial rays pass into the eye)

4. Retinal Stiles-Crawford Effect

o Retinal cones are more sensitive to light entering the eye
paraxial than light entering through the peripheral cornea

92
 o This directional sensitivity of the photoreceptors limits
residual spherical aberration in the eye

4. Oblique astigmatism
 Occurs when rays of light pass obliquely through a spherical lens
o This causes a toric effect
o Image formation is through a sturn’s conoid with two line foci
formed
 How oblique astigmatism is reduced in the human eye

1. Cornea aplanatic nature

o The aplanatic nature of the cornea reduces both spherical
and oblique astigmatic aberrations
2. Spherical nature of the retina
o The retina is not a plane surface but is spherical
o The circle of least confusion in oblique astigmatism falls on
the retina
3. Astigmatic image forms on peripheral retina
o The astigmatic image in oblique astigmatism falls on
peripheral retina which has poor resolution capabilities
compared to the macula (thus limited effect in visual
dysfunction)

5. Coma
 Coma can be seen as spherical aberration of points not lying on the principle
plane
 Unequal magnification of light rays passing through different parts of the
lens cause unequal image magnification
 The composite image formed is not circular but elongated in the form of a
comet with a tail
 Ocular prevention is similar as to oblique astigmatism
1. Pupil blocks peripheral rays
2. Cornea aplanatic nature reduces peripheral ray aberration

6. Image distortion
 Of importance in high powered lenses (especially aphakia)
 When an extended image is viewed through a spherical lens, the
edges of the object appears blurred due to the prismatic effect of
the peripheral areas of the lens
o Convex lenses cause pin-cushioning effect
o Concave lenses cause barrel distortion

93
7. Curvature of field
 When a plane object is imaged as curved object
 The spherical aplanatic nature of the retina eliminates this aberration in the
eye

94
 Wave-front analysis
 Definition
o Wavefront Aberration
o Wavefront Analysis
o Fermat Principle
o Wavefront principles
 Reference sphere
 Geometric Wavefront
 Aberrations
 Pupil function

 Methods of measurement
o Hartman-Shack
o Tscherning
o Refractometry

 Analysis and interpretation of data

o Zernicke’s polynomials
o Fourier Analysis

 Clinical implications
o After refractive surgery
o Pupil size
o PRK
o LASIK
o Myopic correction profile
o Hyperopic Correction profile

 Common Aberrations

 Wavefront Analysis

o Definition
 Wavefront Aberration
o This is the deviation of actual light wave-front from the ideal
wave-front @ exit pupil position

95
 o In stigmatic image formation, all the wave-fronts form image at
the same location, on the retina
o In astigmatic image formation, some wavefront (the ideal) forms
image on the retina, whilst wavefront aberrations (non-ideal
light wave’s) form image outside the retina (before or after)
 The aberrant light waves occur due to imperfections of
the optical properties
 Wavefront Analysis
o Automated machine measures and quantifies the wavefront
aberrations
o Can measure for whole eye or only corneal induced aberration
o Measured in dioptre per micrometer

 Most effective current technology to quantify irregular astigmatism

 Based on the fermat principle

o Fermat principle
 Explains how a lens forms stigmatic images
 Rays travelling through the centre have a shorter path
through air but a longer path through the refractive
matter
 Conversely the rays traveling through the periphery of
the lens have a longer air travel and shorter travel time
through the peripheral lens portion
 The Fermat principle states that the ideal lens will be shaped so
that all light traveling through it, no matter their path, will be
brought to a single point of focus

 Wavefront Analysis principle (AAO p238)

o A reference sphere is formed centred around the image point (place where the
image is formed on the retina)
 In stigmatic image formation all the light will be centred and come to
point within the reference sphere
 In astigmatic lenses the optical aberrations will cause some light to form
image at the reference sphere, whilst some will form image behind or in
front of the reference sphere

o Geometric wavefront
 This is a contour map representing the places where image formation
takes place relative to the reference sphere at a point in time (“photo
finish” of light waves arriving at the reference sphere)

o Wavefront aberrations

96
  A wavefront aberration can be quantified by the difference between
the reference sphere and arriving aberrant light wave

o Wavefront aberration is a function of pupil size

o Methods of measurement
 Hartman-Shack wavefront sensor
o Low-powered laser beam focussed on retina
o Forms image reference sphere
o Emerging rays are deflected to sensors which
determines aberrations and graphs them
 Tscherning
 A known pattern or grid is projected onto the retina
 Distortions related to the shape formed can be
observed, measured and analysed

o Refractometry
 Dynamic skiascopy
o Laser beam projected onto the retina
o A set of entrance points at the pupil is
compared to a set of correlating exit points at
the same plane
o This is incorporated with corneal topography
o Differences between entrance and exit points
can be evaluated and analysed
o Analysis / Interpretation of data

o Zernicke’s Polynomials
 Mathematical formulae used to describe wavefront surface’s
 Wavefront aberration surfaces are graphs created from
zernicke’s polynomials

97
 o Fourier Analysis
 Compares actual wavefront to expected normal

o Clinical Implications
 After refractive surgery
 ↑↑higher order aberrations (Coma, spherical aberration)

 Pupil size influence

 Pupil size ↑
 Pre-op coma dominant
 Post-op spherical aberration dominant

 Pupil size ↓
 More coma present
 PRK
 More higher-order aberrations present post-op
 Due to subclinical decentration of ablation pattern
 LASIK
 3rd and 4th order aberrations more common (especially with
↑pupil size)

 Post-Refractive surgery Aberrations

 Directly related to post-op visual problems
 Poor scotopic vision (spherical aberration)
 Low contrast vision
 Glare

 Myopic correction profile

 Pre-op cornea modelled as larger curvature sphere
 Post-op cornea modelled as sphere with treated central zone
 Tissue “subtracted”/ablated
o Creates normal cornea with flat sombrero
pattern

 Hyperopic Correction profile

 Pre-op cornea modelled as curve with less curvature than
desired
 Tissue ablated / “subtracted” from periphery, to form post-
operatively more prolate pattern (↑central curvature)

98
o Common Wavefront aberrations

o Defocus
 Positive defocus (myopia)
 Negative defocus (hyperopia)
 Cylindrical defocus (regular astigmatism)

o Spherical aberration
 Peripheral rays focus in front of central rays
 Causes night myopia (common post LASIK)

o Coma
 Light waves at one side of the pupil reach the reference sphere
first, whilst light waves from the other side of the pupil reach
the reference sphere last
 Image formation in the form of a comet with a tail
 Occurs with decentred keratorefractive ablation

o 85% of aberrations are low order aberrations

 Correctable by spectacle/CL/refractive surgery

o 15% high order with impaired visual acuity

 Difficult to correct

99
MULTIFOCAL LENSES
 Indications for Multifocal Lenses
o Presbyopia
o Accommodative esotropia (> 6D / ↑AC/A)
o Aphakia

 Image displacement
o Spherical lenses are prone to prismatic effect when viewed obliquely through non-
axial portion (according to prentice rule)
o Normal placement of near add is 8mm down and 2mm nasal to centre of distance
lens

o Prismatic effect according to prentice rule

 ∆=hxD
 Thus prismatic displacement horizontally (3D spherical lens)
o 0.2 x +3.00DS = 0.6∆ Base OUT
 “ “ Vertical prismatic effect
o 0.8 x +3.00DS = 2.4∆ Base UP
 Base down image displacement for plus lenses
 Base Up image displacement for minus lenses

o Image displacement and induced Phoria

 If both lenses are of equal power then image displacement due to prismatic
effect will be equivalent (no induced phoria)
 If different strength lenses then an induced phoria will be found
 Plus lenses  Base up vertical prismatic effect  downward image displacement
 Minus lenses  Base down vertical prismatic effect  upward image displacement

o Image Jump
 As above
 When the eyes move downward during reading, they pass through
non-axial portion of distance vision segment of lens
o Thus inducing prismatic effect and image displacement
 Once the near-add portion is reached, the plus near add segment
causes a sudden upward displacement of the image
o This appears as if the image jumps upwards

100
  Plan to counter
o If the optical centre is near the top of the add portion the
jump is less obvious (as in executive styled bifocals)
o Use flat top lens add (especially in myopia)
 The optical centre is closer to the top in flat-top add
segments compared to round top add segment

o Decentration
 During reading the near reflex causes convergence, hence the bifocal near-
add is usually placed more nasally to compensate for this

 Determining the near add

o Requirements to accurately prescribe
 Accurate Baseline refraction
 Accommodative Amplitude
 Occupation / Leisure specific information
o Methods
1. Near Point of Accommodation
 Have patient fixate on a near reading chart (e.g. 5-point or Jaeger
chart)
 Move the chart closer to the patient until the image blurs
 The distance at which blur occurs is the near point
o Convert to dioptre
o E.g. if patient with correction in place blurs at 33cm, the
accommodative amplitude is 3D (1 / 0.33m)
2. Accommodative Rule
 Using a prince rule
o Combines a ruler (in cm / Diopters) and a reading card
o Placing a 3D lens before the emmetropic eye brings both the
far and near point closer, the far point being 33cm from the
eyes

101
 o Amplitude is then determined by subtracting far from near
point
3. Methods of sphere
 Patient fixates at 40cm (reading chart)
 Successively stronger plus lenses are placed until the patient blurs
(relaxing accommodation)
 Successively stronger minus lenses are placed until the patient blurs
(stimulating accommodation)
 The difference between the 2 lenses equals the accommodative
amplitude)
o E.g -3D to blur, +2.5D to blur = 5.5D amplitude
 Selecting the Add
 Once the accommodative amplitude is measured
o Subtract ½ to a ⅓ of this amplitude (patients
accommodative reserve)
o Remaining total = the final add required+-
 Check accommodative range
o Place the add over the distance refractive correction and
measure the far and near point of accommodation in
centimetres (using a ruler)
o Make sure this distance is suitable to the patient’s
occupational and leisure needs
o If the range is too close, add +0.25D incrementally until
 Binocular testing
o Binocular accommodative amplitude is +- 0.5-1D greater
than mono-ocular amplitude
 To prevent over- plussing the add always check the
near add binocularly to ensure comfort
 Types of Bifocal Lenses
o Types
1. Split Bifocals (Franklin style)
 Distance segment flat bottom abuts the flat top of the near segment
(separate lens)
2. Cemented bifocals
 Supplemetary lens (near portion) added to either the concave or
convex side of the single piece distance correcting lens
3. Fused Bifocals
 Depression is created in the distance correcting lens and the near
add lens is heat fused into the depression
4. Solid bifocals (executive style)
 Single lens is utilised
 The front or back segment of the lens in the area where the near
segment will reside is manufactured with a different curvature to
produce the near correcting strength

102
Split bifocals Cemented Fused Solid

 Trifocals
o Top for distance correction
o Bottom for near vision
o Intermediate portion for clear middle distance vision (40cm-1m)
o Poorly tolerated by anisometropic patients
o Typically for
1. Musicians
2. Typists
3. Bridge players

 Progressive addition Lenses (PALS)

o Uniform distance portion, uniform near portion
o Intermediate portion progressive increasing lens strength
o No sudden step in power/prism
o Types
 “Hard” Design
 Narrow intermediate progression corridor
 “Soft” Design
 Broad intermediate progression corridor
o Negatives
 Lateral distortion of field in intermediate portion

o Points of note
 Difficult to get used to (head needs to move more than eyes)
 Patients requiring a broad near portion will struggle with PALS (due to
lateral distortion in near portion)

o Choice of patients for PALS

 Best candidates
 Early presbyopes who haven’t worn bifocals previously
 Patients not requiring wide near-vision fields
 Highly motivated patients

103
 Poor Candidate
 Previous multifocal/bifocal wearer who wants to convert
 (will need adaptation period)

104
 Spectacle Lenses
1. Considerations
2. Lens Properties
 Refractive index
 Abbe Number
(Dispersion)
 Weight
 Durability
 Safety
 Filtration
3. Lens materials
 Plastics
 Glass
4. Lens Coatings
5. Tints/Filters
 Polarised lenses
 Comfort tints
 Photochromatio
tints
6. Lens Design
 Standard
 Asperic
 Atoric
 Best form lenses
o Meniscus
o Toric

1. Considerations
 Clarity/Quality of vision (non-compromisable)
 Comfort
 Cosmetic appearance
 Economy
 Safety

2. Lens Properties
 Refractive index
o Power of the lens

105
  Abbe Number (Dispersion)
o Number depicting the amount of chromatic abberations caused by the lens
o ↓Abbe number peripheral images blurred/colour fringed images
o ↑Abbe number better image quality (less chromatic aberration)

 Weight
o Dependant on
o Material density
o Aspheric designs
o Lens thickness

 Durability
o Ability to resist scratching/ warping / fractures
o Coatings can be protective

 Safety
o Resistance to shattering effect on impact

 Filtration
o Coatings/Tints can block UV-radiation/ possibly Infra-red

3. Lens materials
 Plastics
o High/mid/low index plastics available
o Most common used today
o Standard plastic (e.g. CR-39)
 50% lighter than glass
 UV protective / tints easily
 Easily scratched
o High-Impact Plastic (e.g. Polycarbonate)
 High refractive index  thin lenses with higher power
 Durable
 High velocity shatter resistance
 High degree of chromatic aberration (↓↓ Abbe)
 Easily scratched
 Glass
o Advantages
o Superior optics
o Scratch resistance
o Disadvantages
o Lower impact resistance
o Increased thickness
o Heavy weight
4. Lens Coatings
 Anti-reflective coating

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 o ¼ thickness of wavelength of specific lightwaves to block (destructive
interference)
 “Top Coats”
o Aimed to decrease smudge and static

 Advantages
o Cosmetically better
o Better image quality
o More light transmission
o ↓chromatic aberration

5. Tints/Filters
 Polarised lenses (filters out horizontally polarized light that is reflected)

 Comfort tints (filters out specific colors on demand)

o Red for RP patients
o Orange for ARMD
o Green in Deuteranopic patients
o Brown in protanopia
o Yellow in target shooters

 Photochromatio tints (photo reactive tints)

o Rapidly darken in light, lightens in darkness
o Short wavelength light (300-400nm) causes chemical reaction in
photochromatic lenses
o Silver ions converted to silver
o Reversible process
o Takes longer to turn light than dark
o Doesn’t darken in cars (Windshield filters UV light wavelength spectrums)
6. Lens Design
 Standard
o Spheric front surface (Base curve)
o Toric rear surface
 Asperic
o Flatter anterior curvature
o Flatter and lighter
o ↓apparent magnification of wearers eyes (Cosmetic)
 Atoric
o Front surface is asheric
o Varies in curvature for different meridians
o Decreases aberrations in correcting high astigmatic errors

 Best form lenses (Designed to eliminate oblique astigmatism / peripheral aberrations)

o Meniscus
o Corrects aberrations in spherical ametropia

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o Toric
o Corrects astigmatism in astigmatic ametropia

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Optics of Contact Lenses
1. Definitions and terms
 Base curve
 Diameter
 Power
 Apical Zone
 Corneal Apex
 Optical Zone
 Peripheral Curves
 Sagittal Vault / Depth
 Edge Lift
 Tear Lens
 Wetting Angle
 Fluorescein Pattern
 Lenticular Contact lens
 Dk
 Dk/L
 Radiusscope

2. Types / Classification
 Hard
 Soft
 Medica/Surgical
 Scleral / Corneal

3. Optics
 General
 Difference between CL and Spectacles
 Optical features of note in CL
o Field of view
o Optical Aberration
o Accomodation / Convergence
o Prisms
o Image Size
o Tear Lens
o Soft Contact Lenses
o Rigid Contact Lenses
4. Contact Lens Correction of Astigmatism
5. Contact Lens Correction of Presbyopia
6. Contact Lens for Keratoconus
7. Optical Problems associated with Contact Lens wear
 Fluctuating Vision
 Power
 Corneal Warpage
8. Corneal Changes associated with CL wear
9. Causes of Red eye in CL wearers

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1. Definitions and terms

 Base curve
o The curvature of the central posterior surface of the lens (adjacent to the
cornea)
o Measured by radius of curvature

 Diameter
o Width of the contact lens
 Soft = 13-15mm
 Rigid = 9-10mm

 Power
o Determined by lens shape
o Calculated by Snell’s law
o Expressed in diopters

 Apical Zone
o Steep part of the cornea
o Incorporates the geometric centre
o Typically 3-4mm

 Corneal Apex
o Steepest part of the cornea

 Optical Zone
o Area of front surface of contact lens that carries the refractive power of the
contact lens

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 Peripheral Curves
o Secondary curves in the contact lens found just outside the base curve
o Flatter than the base curve so as to conform to the normal flattening of the
peripheral cornea

 Sagittal Vault / Depth

o Describes depth or vault of contact lens Base curve
o

o Measures the distance from the base curve to the plane connecting the edges
of the contact lens
o Increasing the base curve decreases the sagittal depth and vice versa (if
diameter stays same (see above diagram)

 Edge Lift
o Describes the relationship between the lens and the peripheral cornea
o Adequate edge lift is important to prevent the lens “digging” into peripheral
cornea
o Measured clinically with fluorescein which causes a specific ring to form if
adequate

 Tear Lens
o The optical lens formed by the tear film layer between the cornea and the
contact lens
 Soft CL tear lens usually has plano power
 Rigid lens tear lens power depends on the corneal shape and CL
shape

 Wetting Angle
o Describe the wettability of a CL
 A low wetting angle means water will spread over the surface
 A high wetting angle means water will bead up, decreasing surface
wetting
o A lower wetting angle translates into more comfortable wear and better optics

 Fluorescein Pattern
o Describes the colour intensity of fluorescein staining of the tear lens beneath a
rigid CL
 Areas of contact appear black
 Areas of clearance between CL and cornea appear as green staining

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  Lenticular Contact lens
o A lens with a central optical zone and a non-optical peripheral zone (known as a
carrier)
o Design to improve lens comfort

 Dk
o Describes the oxygen permeability of the CL (how easy O2 passes into the lens)
 D is the diffusion co-efficient for O2 movement in the CL material
 K is the solubility constant of O2 in the material

 Dk/L
o Describes the oxygen transmissibility of the lens (how easy O2 passes through
the lens)
o Dependant on the Dk and the central lens thickness (the “L”)

 Radiuscope
o A device that measures the radius of curvature of CL, such as the base curve of
a RGP lens

2. Classification
 Hard
o PMMA (Gas impermeable-not used anymore)
o Silcone
o Fluorocarbon
 Soft
o Hydroxy-methyl-acrylate
o Poly-vinyl-pyrolidone
 Medical / Surgical
o 3 mirror
o Gonio
o Pan-fundus
o ERG lenses
 Scleral vs Corneal lenses
o Position

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3. Optics
 General
o Common parameters of all contact lenses
 Base curve (posterior surface curvature)
 Power curve (anterior surface curvature)
 Diameter
 Power
o Shape of posterior CL surface designed to fit anterior surface of eye

 Difference between CL and Spectacles

 CL has shorter back-vertex-distance (important in image size)
 Tears and not air form the refracting interface between the lens and
the cornea

 Optical features of note in CL

o Field of view
 CL
o ↑Field of view
CL Closer to principle point of eye
No frame
o Good corrected field of view in all directions
Contact lens moves with the eye
o No spherical aberrations/prismatic effect
Contact lens moves with the eye and para-axial
leght rays never pass through the periphery of the
lens

o Optical Aberration
 ↓oblique astigmatism (as above) because CL moves with eye
 Thus better VA in peripheral gaze compared to specs

o Accomodation / Convergence
 Prismatic effect
o Spectacles
Centered for distance vision
 Convergence as for reading causes prismatic
effect
Base up for hyperopes
Base down for myopes
o Contact lenses
Centered for central and peripheral vision, thus
eliminates prismatic effect during convergence

 Accomodative requirements

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 o CL ↑accomodative requirements for myopes
o CL ↓ accomodative requirements for hyperopes

o Prisms
 Possible to incorporate up to 3D of prism into a CL
 The weight of the prism will rotate the CL to have it come lie
inferiorly
o Thus it can only be used base-down
o Cannot be used to correct horizontal deviations
 Increased amounts of power possible with scleral contact lenses

o Image Size
 Retinal image size dependant on angular magnification and thus
Back-vertex-distance (BVD)
o Contact lenses ↓↓ BVD compared to spectacles
o The image size thus ↓with contact lenses
 Anisometropic aniseikonia
o Best managed with a contact lens irrespective of type of
refractive error
o Avoids the anisophoria which is induced by off axis gaze
through unilateral high powered lens (prismatic induced)

o Tear Lens
 The optical lens formed by the tearfilm and the posterior contact
lens surface
 Power of tear lens determined by
o Curvature of the anterior tear lens (back surface of CL)
o Curvature of the posterior tear lens (front surface of cornea)
 Soft Contact Lenses
o The back surface of the contact lens moulds to the surface
of the cornea
Thus the anterior and posterior curvature of the
“tear lens” in this case is equal
 Thus no resultant power  plano powered
No tear lens effectively is formed
Thus soft contact lenses cannot be used to correct
astigmatism
 Rigid Contact lenses
o Shape of posterior curvature of CL differs from anterior
corneal surface (doesn’t adhere as soft CL)
The tear lens thus formed has optical power
Power of tear lens
 0.25D for every 0.05mm radius of curvature
difference between anterior cornea
curvature and base curve of CL

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  If base curve steeper than corneal K’s
+ powered tear lens
 If base curve flatter than corneal K’s
- power tear lens
o Lens floats on the tear film
The tear lens refractive index (1.336) is almost equal
to that of the cornea (1.376)
 Thus the tearfilm masks > 90% of the
corneal optical power
thus eliminating corneal
astigmatism

4. Contact Lens Correction of Astigmatism

 Rigid Gas Permeable (RGP) CL and soft Toric CL canbe used to correct astigmatism
 The advantage is the elimination of spectacle induced meridional aniseikonia
 Refractive astigmatism has 2 possible components
o Corneal astigmatism
 Can be corrected by CL’s
 CL’s tear lens interface neutralizes corneal astigmatism
o Lenticular astigmatism
 Can NOT be corrected by CL’s
 Usually against the rule (horizontal meridian increased power)
 Can be unmasked by spherical correction over the CL
 Soft Toric Contact lenses
o Soft CL’s with built in weight that rotates CL into specific astigmatic neutralizing
position
o Important to evaluate the rotation of the individual contact lenses to ensure
correct axis alignment

5. Contact Lens Correction of Presbyopia

 Correcting presbyopia with CL can be attempted in several ways

o Reading glasses over CL

o Alternating vision CL
 Segmented or Annular
 Similar to bifocal/multifocal Spectacles
o Simultaneous Vision CL
 Aspheric (multifocal)
 Diffractive
 Similar to multifocal IOL’s
 Causes decreased Contrast
o Monovision

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  Dominant eye corrected for distance
 Fellow eye corrected for near
 Causes Decreased stereopsis

6. Contact Lens For Keratoconus

 5 contact lens options
o Soft / Soft ToriC CL
 For mild to moderate irregular astigmatism

o RGP CL
 For larger irregularities
 Specific KC RGP’s are available that have a steep central posterior
vault to cover the Conus and a flatter peripheral curve to adhere to
more flatter normal corneal shape

o Hybrid Contact lens

 Has a rigid center that has same optical advantage as RGP’s
 Has a soft outer shell  more comfortable

o Piggy-Back lenses
 Soft lens placed onto the cornea and a RGP lens placed over the soft
lens

o Scleral contact lenses

 For severe KC (where other CL not successful)

7. Optical Problems associated with Contact Lens

wear
 Fluctuating Vision
o Possibly due to posterior lens surface being too flat
o This allows the cornea to excessively move across the corneal surface
o Especially with blinking
 With each blink the CL moves across the visual axis causing change
in vision after every blink

 Power
o Quoted CL power denotes power in Saline @ room temp
o Can differ when on pt’s eye

 Corneal Warpage

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 o Corneal curvature can undergo change with extended CL wear
o Regresses in days/weeks after CL removed
o More pronounced
 With extended wear
 Rigid CL
o NB to not do Biometry / Refractive surgery planning before this is addressed

8. Corneal Changes associated with Contac Lens

Wear
 Infectious Keratitis / Corneal Ulcer
o ?poor lens fit underlying
o ?poor contact lens care / hygiene

 Corneal abrasions
o Can result from
 Underlying FB
 Poor insertion/removal technique
 Damaged contact lens
o Higher risk for infectious keratitis due to contact lens over abrasion
 Rx with abX, no patching, discontinue CL until healed

 Punctate Keratitis
o Related to
 Poor lens fit
 Toxic reaction to lens solutions
 Dry eyes

 3®clock / 9®clock staining

o Specific SPK staining pattern seen in RGP use
o Related to
 Poor wetting in horizontal meridian
 Due to
o Abortive reflex blink pattern
o Insufficient lens movement
o Inadequate tear meniscus
o Thick peripheral lens
o Attempt
 Refitting CL
 Lubrication

 Sterile Infiltrates
o Typically peripheral corneal infiltrates

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 o Intact overlying epithelium
o Rx
 Short course ABx (?infective component)
 Discontinue lens use

 CLSLK (contact lens superior limbic Keratoconjunctivits)

o Superior bulbar conjunctival injection
o Upper lid palpebral changes
o Rx
 Discontinue lens wear

 Dendritic Keratitis
o Looks like dendritic epithelial defect
o Less intense fluorescein stain
o RX
 Discontinue Contact lens wear
 Follow up for resolution
 (non-infectious cause)

 Corneal neovascularization
o Sign of hypoxia
o RX
 Refitting
 Higher DK material lens
 Looser fit
 Fewer hours daily CL wear
 Switching to disposable lenses

 Corneal Warpage
o Both soft and RGP lenses can induce corneal topographic changes
o More common with rigid
o Rx
 Discontinue use

 Spectacle blur
o Patient notices spectacle blur after CL wear
 Related to corneal warpage
o Rx
 Refit CL or
 Discontinue wear for period

 Giant papillary Conjunctivitis

o Typical in established lens wearers (no pre-existing allergic changes)
 New onset
o Red/itchy eyes

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 o Increased lens awareness
o Mucus discharge
o Palpebral papillae
o Rx
 Immediate resolution with discontinuation
 If pt prefers to keep on CL wear
o New cleaning solution
o Mast Cell stabilizers
o NSAIDs topically

 Ptosis
o ?dehiscence of levator aponeurosis due to extended RGP wear

9. Red eye Causes in Contact lens wearer

 Poor Fit
o Either too loose or too tight (noted on slight lamp)

 Hypoxia
o Findings
 SPK’s
 Microcysts
 Corneal edema
 Corneal neovascularization

 Corneal Deposits
o Can lead to GPC

 Damaged contact lens

o Can cause pain on insertion

 Toxic Reaction (lens care solution)

o Pain worse after insertion and gets better after a while
o Conjunctivitis / sterile corneal infiltrates can be seen occasionally
o Diagnosed by resolution with change in solution

 Ocular Allergy
o if pre-existing allergic changes, may worsen with CL wear
o GPC

 Dry eye
o Defer CL wear in a patient with moderate to severe dry eyes (check pre-fitting)

 Infectious Keratitis

119
o Consider always in diagnosis

120
INTRA-OCULAR LENSES
1. Classification
a. Material Types
 Rigid
 Foldable
 Filters
b. Position/ Site
 AC-IOL
 PC-IOL
 Phacic IOL
 Piggy-Back IOL
c. Optical Properties
 Monofocal IOL’s
 Multifocal IOL’s
 Accomodative IOL’s

2. IOL Power Calculations

a. IOL Formulae
b. Biometry
c. Keratometry
d. IOL calculations in Special circumstances
 Piggyback IOL’s
 IOL Exchange
 Silicone Oil
 Corneal Refractive Surgery
 Sulcus lens placement
 Anterior Chamber lens placement

121
INTRA-OCULAR LENSES
1. Classification
a. Material Types
 Rigid (PMMA, used for ECCE’s)
 Foldable
 Silicone
 Acrylic
 Hydrogel
o Suitable for small incision insertion
 Filters
 UV filters
 Newer also Blue light filters (theory to prevent AMD, unproven
efficacy)
b. Position/ Site
 AC-IOL (within AC, haptics in angle of eye)
 PC-IOL (behind iris, in capsular bag or in cilliary sulcus)
 Phacic IOL
 Placed in either AC or PC with crystalline lens left insitu
 Piggy-Back IOL
 Supplementary IOL placed in bag or in sulcus with existing PC IOL
 Used to correct post-IOL refractive surprises
c. Optical Properties

 Monofocal IOL’s
 Single powered IOL, no accommodative power
 Improved VA allows patient clear vision across spectrum of
distances
 Especially true if myopic astigmatism is achieved
o One meridian on sturn’s conoid corresponds to distance
vision allowing patient to see distance
o Other meridian on conoid lies within myopic spectrum,
allowing patient to have good range of near-vision
 Monovision
o One eye corrected for distance
o Other eye corrected for near (+- 1- 2D myopic)
 Advantages
o Cheaper
o Better contrast sensitivity
o Less nocturnal/glare problems
 Disadvantages
o ↓depth perception

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 o Need for spectacles (distance)
o No accommodative function

 Multifocal IOL’s
 Provides both near and distance correction in one lens
 2 types : Diffractive / Refractive
 Works by
o Has more than 2 apical foci and thus more than 2 co-axial
Diopteric powers
 Creates 2 superimposed images
 One is sharpy focussed
 One is blurred
 Eventually brain “learns” to distinguish and
ignore the blurred image
 This Causes
 ↓Contrast sensitivity
 ↑Glare
 ↓illumination
 Distant and near dominant IOL portions change
position based on pupil size (convergence/miosis
during accommodation)
o Centration of critical importance due to nature of IOL design
 Patient selection
o Dependant on visual demands of patient
o Activities of pt
o Personality and expectations
o Pupil diameter and size in different light conditions
o Ocular co-morbidities
 Dry eye/ocular surface disease – poor choice
 Low myopia (not ideal)
o Emphasize risks / alternatives
o Downplay benefit’s
 Design Types
o Refractive IOL
 Has different radii of curvature arranged in
concentric rings
 Central zone corresponds to desired near power
 Concentric surrounding zones correspond to desired
distance power
o Diffractive


 Advantages
o Spectacle independent

123
  Disadvantages
o Poor contrast sensitivity
o Glare / Haloe’s at night
o Adaptive period post operatively


 Accomodative IOL’s
 Design incorporates changes in IOL focal point in response to
changes of IOL position…
 Change in IOL position occur with forces generated during
physiological near reflex
 Disadvantages
o Decentration
o Unwanted distortion
o Capsular bag contraction

2. IOL Power Calculations

 Aim of calculation is to provide an IOL that fits specific needs and desires of
the individual patient
 IOL calculation formula uses
 Central Corneal power
 Visual axis length
 Target post-operative refraction
 Estimated vertical IOL position (ELP estimated lens position)
 Generally safer to aim just on Myopic,
 In multifocal IOL’s emmetropia is NB

a. IOL Formulae
 Theoretic Formulae
 Modern IOL power calculations use theoretical formulae
o Based on gullstrand theoretical eye model
 Regression Formulae
 Include SRK1, SRK2
o Simple to use
o Not always accurate
o Largely replace by modern theoretical formulae
b. Geometric Optics
a. Used to create basic theoretic formulae
b. IOL power calculation formulae

124
c. Biometry
a. Axial Length
 The most important factor in IOL calculation
 1mm error = 2.35D error in 23mm eye
 Measurement
1. A-scan Ultrasonography
a. Cheap and commonly used
b. Can be applantation or immersion
c. Applanation unpredictable and often artificially
shortens the axial length due to corneal indentation
d. Immersion more accurate
2. Optical measurement
a. Zeiss IOL master uses partial coherence laser
b. The machine measures time taken for Infrared light
to reach the retina and return via light interference
methods
c. Advantages
 More accurate than US AL measurement
 Ideal for staphyloma and in silicon oil eyes
(US poor capabilities in these settings)
 Non-contact (eliminates corneal indentation
errors)
d. Disadvantages
 Needs patient cooperation, patient needs to
fixate on the target
 Not useful in dense cataracts (needs foveal
fixation on target)

d. Keratometry
a. Second most NB in calculation
b. 1D error = 1D post op refractive error
c. Measurement by
 Keratometry
1. Measures only small central corneal area (3.2mm)
2. Only measures anterior corneal surface power, makes
assumptions regarding the posterior corneal power
 Corneal topography
1. Pentacam
2. Rotating scheimpflug camera
3. Measures front and back corneal power and corneal
thickness
4. Good in post corneal surgery/Laser cases

e. Estimated Lens Position (EPL)

125
 a. Formulae used to calculate EPL uses AL
b. Based on pachymetric studies on PCIOL’s
c. Anterior chamber depth important (ACD)
 Initially used in 1980’s
 Later incorporated in A-Constant for formulae like SRK
 Still in existence but not recommended anymore (more accurate
formulae now)
 ACD calculation
1. ACD = 2.93 x AL – 2.92
2. Most accurately measured with optical pachymeter
3. IOL master also good accuracy
d. Modern IOL formulae use
 ACD calculated of A-constant
 Surgeon factor
 ACD calculated with instrument
 Haigis uses 3 factors
f. Formulae choice (Based on multiple studies and incorporated in Royal college
guidelines)
a. Short eyes (<24.5mm)
 Hoffer Q most accurate
b. Average eyes (24.5-26mm)
 Holiday most accurate
c. Longer eyes (>26mm)
 SRK/T
d. Haigis
 May be more accurate than all of the above but requires 3
personalized a constants to be calculated of 500-1000 individual
cases with single IOL type

g. IOL calculations in Special circumstances

 Piggyback IOL’s
 Calculated
o Myopic surprise : Piggyback power = 1.0 x Error
o Hyperopic surprise : Piggyback power = 1.5 x error
 IOL Exchange
 As with piggyback if error less than 5D, else HolidayR
 Silicone Oil
 Difficult to calculate AL accurately
o Slower sound velocity
o Artificially long eye measured
 Optical coherence biometry (Zeiss) more accurate
 Corneal Refractive Surgery
 Difficult IOL calculation post refractive surgery due to
o Instrument error

126
  Instruments struggle to measure accurately post
refractive surgery
 Manual keratometers measure central 3.2mm area
 Misses the surrounding flatter cornea
 Underestimates true optical power
 Topographers overestimate the power
 Causes hyperopic surprises
o Index of refraction(IR) error
 IR based on relationship between anterior and
posterior corneal curvature relationship
 Relationship changes during PRK, LASIK/LASEK
 Relationship stays the same in RK (changes both
anterior/posterior curvature equivelantly)
 Manual keratometers only measures the anterior
and not posterior curvature
 For every 7D corrected 1D corneal power
overestimation takes place
o Formula error
 Most formulae rely on AL and keratometry to
determine IOL prediction
 PRK/RK/LASEK all change the keratometry without
changing ACD/EPL thus causing IOL calculation
errors
 Methods of calculation post refractive surgery
o Double K method (Aramberri)
 Uses pre-Lasik K’s in the formulae to determine EPL
(if known), uses 43.5D if unknown
 Uses Post-Lasik K’s for the final calculation
o Clinical History Method (old)
 K = K(pre-op) + R(pre-op) – R(post)
 Corneal power to use in final formulae =
current K-readings + pre-op refractive error
(from patient history) – current refractive
error
o Contact lens method (Archaic)
 K = B + P + R(cl) – R(bare)
 Corneal power = base curve of hard PMMA CL + CL
power + refraction with CL on eye – bare refraction
without CL
o Computerised Calculation tools
 Multiple other methods available, non-proven

 Sulcus lens placement

 Can subtract 0.75D to 1.25D to compensate for anterior shift in EPL

127
 Anterior Chamber lens placement
 Best to calculate AC IOL strength pre-operatively using automated
formulae
 In emergency the A-Constant can be used also roughly subtracting +-
3D to 3.5D from the calculated PC-IOL

128
Optical Instruments
1) Direct Ophthalmoscope 130
2) Indirect ophthalmoscope 133
3) Gonioscope 135
4) Retinoscope 137
5) Slit-lamp Biomicroscope 140
6) Applanation tonometer 142
7) Focimeter 144
8) A-Scan Ultrasound 145
9) Keratometer 147
10) Simple magnifiers 148
11) Operating microscope 149
12) Low vision aids_telescopes 150
13) Autorefractors 152
14) Endothelial specular microscope 153
15) Confocal microscopy 154
16) Placido’s disc 155
17) Pachymetry 156
18) Optical AC depth measures 156
19) Corneal topographers 157
20) Fundus cameras 158
21) Scanning laser ophthalmoscopes 159
22) Optical Coherence Tomography 160
23) Pentacam 164
24) Lens meter 165

129
1) Direct Ophthalmoscope
 A simple handheld optical instrument used to examine the ocular structures of a patient
 Invented in 1851by Von Helmholtz
 Optics
o If a person’s retina was made to be luminous, the image formed from the retina could
be projected out through the pupillary aperture and with the correct instrument
(which has to be nearly perpendicular to the light source) viewed by an observer
o The basic features of a direct ophthalmoscope are a light source which is directed by a
system of lenses and mirrors into the patient’s eye to illuminate the retina.
o The image formed is projected out of the subjects eye and viewed through a viewing
aperture set coaxial to the projected light

o Illumination system
 Incandescent bulb used as light source
 Light directed through a converging primary lens
 Focussed by a 2nd lens onto a 45° mirror
 Light passes from mirror into eye through the pupil
 The aperture between Lens 1 and Lens 2 allows different shapes or
colours of illumination.
 Cobalt blue
 Red-free
 Slit
 Half moon

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  Small/large circular white
 These apertures are mounted on a horizontally oriented thumb-wheel
so that different ones can be used at different times.

 Viewing system
 Aperture
Set either above the mirror or in the mirror
Allows the observe to view the projected retinal image at an
almost co-axial angle to the light that enters the pupil

 Compensating lenses
Small set of lenses house in a vertical thumb-wheel
In front or behind the aperture
Focusses the image onto the observer’s retina
 Optical principles
o Only illuminated retina can be viewed
o Amount of retina illuminated depends on
 Working distance (nearer to the pupil the larger the retinal size illuminated)
 Pupil size (more dilated, more illumination)
o Retina can be viewed up to the equator
 By viewing obliquely through the pupil (limited by direct line of sight (unlike
indirect)

o Refractive errors in direct ophthalmoscope exam

 Light emerging from an emmetropic eye will emerge parallel and be focussed
onto the retina of an emmetropic examiner

 Light emerging from a myope will converge and fall in front of examiners
retina (correct by rotating minus (converging) lens into place on direct)

 Light emerging from hyperope will be diverging, falls behind the retina of
examiner (correct by dialling in converging plus lens on direct)

o Magnification in direct ophthalmoscopy

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  Magnification determined by simple magnifier formula (using angular
magnification)
 Magnification = optical power eye (+- 60D) x image distance ( 0.25m)
 = 15 x (compared to x4 in indirect)
 Magnification in refractive error
 -10D Myope = 17.5 x { (60-+0) x 0.25 }
 +10D Hyperope = 12.5x { (60-10) x 0.25 }
o Technique
 Systematic approach NB
 Patient and examiner comfortable
 Dimmed light
 Well dilated patient
 Use right eye to examine right eye, left eye for left
 Patient fixated on distant target
 Examiner finds red-reflex first
 Approaches with light aimed slightly towards nasally whilst entering the pupil
 Once optic disc is found, the fundus can be systematically examined

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2) Indirect ophthalmoscope
 Optical device with a head-mounted light source used in conjunction with a high power
optical lens to examine the fundus of a patient

 Optical principles based on a astronomical telescope

o The patient’s optical system/hand-held lens acts as the telescope’s objective lens
o The indirect’s condensing lens acts as the telescopes eye piece

 5 fundamental principles in all indirect’s

o Fundus Imaging Formation
o Aerial Image
o Conjugacy of pupils
o Fundus Illumination
o Binocular Observation

 Fundus image formation

o A bright light is used to illuminate the retina
o An image of the retina is projected outwards
o The image is first refracted by the patient’s own lens and cornea before being
captured by the handheld optical lens (e.g. 28D or 22D lens)
o A new image is then formed behind the lens (+-5cm)

 Aerial image
o This aerial image is
 Real
 Inverted
 Has depth characteristics (3D)

o The examiner simply focusses on the formed image to view the retina

 Conjugacy of pupils
o The pupils of the patient and examiner must be in line with each other and the optical
lens to ensure maximal light passage from one retina to the other

 Fundus illumination
o The light leaving the indirect head set has to pass through the same lens onto the
patient’s retina as the light leaving the patient’s retina enroute to the examiner
o This creates obvious problems with reflections
o Modern lens designs has highly anti-reflective coatings to minimize this problem

 Binocular observation
o To view the object in 3D the examiner must receive the image to both eyes
o This is accomplished by mirror’s located in the head set

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o A mirror splits incoming light into 2 beams which is directed by porro prisms to the
examiner’s eyes

o Field of View : Direct versus indirect

 Direct
 Limited field of view (only up to equator)
 Field of view limited by most oblique light rays that can pass between
patient pupil and examiner

Light beams 1 and 4 are diverging beyond

the examiners pupil, resulting in the small
field of view

 Indirect
 The indirect utilizes a condensing lens to refract the oblique rays
emerging from the patients eye onto the examiners retina

 This offers a wider field of view

o Choice of lens
 The stronger the lens the more the image magnification, but the smaller the
field of view
 Thus a 28D (wider field of view, less magnification) is good to “scan”
the fundus and examine the far periphery, whilst a 20D lens is good to
examine specific lesions with due to the greater magnification
 Magnification is thus inversely proportionate to the lens strength
 13D lens gives +- 5x magnification
 20D lens gives +- 3x magnification
 28D lens gives +- 2x magnification

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 3) Gonioscope
 A specific optical lens used to examine the structures of the anterior chamber angles
 Optical principles of total internal reflection
o The anterior chamber angle is hidden from direct observation with a slitlamp or other
direct viewing source due to the principle of total internal reflection

o Light emanating from the AC angle exceeds the critical angle at the cornea and total
internal reflection occurs
o To view these structures, the gonio-lens is needed

 Gonio-lens optics
o Gonio-lenses modifies the air-fluid interface by incorporating the cornea and the
contact lens into a single optical unit
 The steeper curved outer surface of the gonio-lens replaces the air-fluid
interface
 Internal reflection is abolished due to the change in critical angle

fluid bridge between the cornea and the gonioscopy lens,

which links them functionally into a single optical system

The steeper radius of curvature of the gonioscopy lens is

substituted for that of the cornea, permitting direct
visualization of the angle recess

 Types of gonio-lenses

o Direct Gonioscopy Lenses

 Direct imaging of the angle is performed using a magnifying device
(loupes/microscope)
 A true image is seen with true spacial orientation
 E.g. Koepe Lens
Direct gonio-lens
o Indirect / Mirrored Gonio-lens
 The optical power of the front surface of the cornea is eliminated by the lens
interface
 an angulated mirror is placed within the lens
 The mirror reflects the light rays originating from the chamber angle recess to
the line of vision of the viewer

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Mirrored-goniolens
 The image seen is inverted and is projected 180° away from where it
originates
 Typically Used in conjunction with a slit-lamp
 E.g. zeiss type

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4) Retinoscope
 An optical instrument used to determine the refractive status of the eye
 2 types
o Streak retinoscopes (almost only used now)
o Spot retinoscope (rarely used today)

 Components

o Light source
 The retinoscope has a light source that form a streak projection of the light
 It uses a straight filament
 The filament can be moved in relation to a convex lens sysem in the
retinoscope
If the light is slightly divergent, it appears to come from a
point behind the retinoscope (as if off a plano mirror)
 Plano mirror setting
If the light is slightly convergent, it appears to come from a
position between the examiner and the patient (as if from a
concave mirror)
 Concave mirror setting
Plano mirror setting most commonly used (sleeve down on
welch-allen)
 The axis of the light streak can be rotated
o Mirror
 Light is focussed onto a mirror (half or totally covered with silver)
 The streak of light is projected into the eye by the mirror
o A viewing aperture is set directly behind the mirror to allow the observer to view the
patients reflex
 Technique
o Positioning and alignment
 As with direct ophthalmoscope exam, left eye to examine left eye and right
for right
 Lens reflections make retinoscopy difficult to impossible if attempting to do it
para-axial
 The ideal alignment is just off-center (not too far as to induce spherical
aberations, but not too central to suffer from lens reflections)

o Fixing and fogging

 Patient must have accommodation relaxed
 Either cycloplegic dilated or fogged or focussing on a distance target

o The retinal reflex

 the projected streak illuminates areas of the patients retina, which causes
light to be reflected back to the examiner

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  observing the characteristics of the reflections allows the examiner to
determine the refractive status
 Light reflexes emanating from the eye
 If emmetropic, light emerges parallel
 If myopic, light emerges converging
 If hyperopic, light emerges diverging
 Peephole position and far point
 If the peephole of the retinoscope (and the viewing examiner) is placed
at the focal point of the emerging light rays, the light reflections will fill
the whole peephole and produce a uniform illumination
 If the far point of the light is in front of the examiner, it will create an
‘against motion’ in relation to the movement of the streak
 If the far point is behind the examiner, it will create a ‘against
movement’ in relation to the streak movement (Hyperopia)
 Neutrality
 If the light fills the entire peephole uniformly and does not move,
neutrality is reached
Moving forward when neutrality is reached causes a with
movement again (far point is then placed behind the
examiner again)
Moving backwards…against movement
 Correcting lenses is used to bring the far point to the peephole

o Character of the reflex

 Speed
 Slow moving reflex far from neutrality, increase in speed as closer to
neutrality
 Large refractive errors produce slow moving reflexes
 Brilliance
 Reflex is dull when far from neutrality and becomes more brighter the
closer to neutrality
 Large refractive errors have dull reflexes
 ‘Against’ reflexes are usually dimmer than ‘with’ reflexes
 Width
 The reflex streak seen is narrower the further from neutrality and
becomes broader as neutrality is approached
 Large refractive errors have thin reflexes
 At neutrality the reflex is so broad as to fill the entire pupil

o The correcting lenses

 The examiner places correcting lenses in front of the patient until the for
point of the reflex is brought to the peephole
 Working distance
 The working distance is the distance the retinoscope is held from the
eye

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  The diopteric power of this distance must be brought into the final
equation
 Commonly 67cm working distance (+- arm’s length) is used – dioptre =
1.5D (must be subtracted from the final findings)

o Finding neutrality
 By observing the reflex, appropriate correcting lenses are brought in front of
the eye until neutrality is reached
 If ‘against’ motion is seen, negative lenses are used in progressive
power until neutrality is reached
‘against’ reflexes are often dimmer, thus it is useful in
‘against’ motion to add minus lenses until against motion is
seen, and then progressively decrease until neutrality is
reached
 If ‘with’ is seen, plus lenses are used until neutrality is reached

o Finding the cylindrical axis

 Specific reflexes related to the axis

 Break
The reflex is seen to be not aligned with the light streak
The line appears broken
 Skew
An off-axis streak will move differently to the reflex

 Intensity
The reflex will be dim if non-alligned and brighter when well
aligned
 Width
The reflex will become narrower as the alignment improves,
and wider as the alignment worsens

o Finding the cylindrical Power

 Identify the 2 axis’ as above, and neutralize each separately
 The powers can be noted on a power cross

 Subtract the one from the other

o = 0.5 DC = cylinder
 Correct working distance (-1.50D)
 Final
o +1.5DS x -0.50DC @ 10°

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5) Slit-lamp Biomicroscope
 High powered binocular microscope used to examine the eye
 Utilizes a combination of lenses arranged in such a way to create a magnified erect and
sharp image
 All slitlamps are characterised by the following inherent principles
o Astronomical Telescope
o Inverting Prism
o Galilean Telescope
o Objective Lens
o Illumination System
o Binocular Viewing System

 Astronomic telescope
o System of 2 convex lenses one in front of the other.
o Produces a high magnification and minimal aberrations (compared to a single lens
system)
o Typically makes up the microscope “eye-piece

 Inverting prisms
o Incorporated in the slit-lamp to create an erect image from the magnified inverted
image
o Commonly uses a porro-prism type
 2 triangular prisms arranged so as to reflect light several times and eventually
form an erect image
 (Minimal light loss and no magnification)

 Galilean telescope
o This system utilizes 2 lenses set apart from each other at exactly the difference of
their respective focal lengths
 One concave and one convex lens
o Creates more magnification
o Maintains the erect image

 Objective lens
o a strong convex lens
o used to bring the working distance of the slit-lamp from infinity to a distance of +-
10cm from the eye
o close enough to focus the optical system onto the eye

 Illuminating system

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 o A system of apertures allow the light beam used in the examination to be changed in
size and shape and color
 A slit beam of varying size, width and rotation can be used to view ocular
media
 The illumination and aperture system can be rotated around the eye to study
it from various angles

 Binocular viewing system

o Prisms are used to split the image formed into 2 separate images
o This allows depth perception

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6) Applanation tonometer
 The gold standard of IOP measurement is applanation, using the goldman slitlamp mounted
applination tonometer

 Optical principles

o Based on Imbert-Fick law:

 pressure within a sphere (P) is roughly equal to the external force (f) needed
to flatten a portion of the sphere divided by the area (A) of the sphere which
is flattened:

 P=f/A

 applies to surfaces which are perfectly spherical, dry, flexible, elastic and
infinitely thin
 The human eye however
 Not dry
 Not thin walled
 The effect of this with regards to Imbert-Fick law:
 Scleral rigidity produces a counter pressure force
 Tearfilm causes a globe direct force due to surface tension
 Goldmann Calculated
 If enough force is applied to the globe to produce a circular area of
flattening of 3.06mm then the counter force of scleral rigidity cancels
out the tear film globe directed forces
 Therefor:
The force applied to a human eye that causes circular
flattening of 3.06mm of cornea is directly proportional to
the intra-ocular pressure of that eye.
Force needed to flatten cornea (dynes) x 10 = IOP (mmHg)

o Mechanics
 Mounted on a slitlamp(magnification)
 Split prisms in head of instrument
 Mounted with bases in opposite directions
 These create 2 images situated 3.06mm from each other…
 Pressure exerted through the device onto the cornea cause the 2
semicircle’s diameter to enlarge (owing to a larger area applanated).
 Once the circles touch, the area applanated is 3.06mm (and the IOP
can be read)

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o Measurement
 When the cornea is applanated
 Tearfilm surrounding the area of applanation appears to the observer
as a circle
 The split prisms built into the tonometer cause two exact images of the
circle to be formed exactly 3.06mm from each other.
 By adjusting the pressure exerted on the cornea, the clinician finds the
pressure where the 2 semi-circles formed are just touching each other,
and this corresponds to the IOP.


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7) Focimeter
 Device used to measure the power of spectacles and contact lenses
 Consists of
o Illuminated target
o Platform for the unknown lens
o Eye-piece
o A standard lens
 The device uses the ‘standard lens’ to shorten the focal point of the introduced lens
o By placing the standard lens so that it’s focal point coincides with the posterior vertex
of the introduced spectacle/CL lens, then the diopteric scale of the instrument
becomes clear. (Badal principe)
o The Spectacle lens is introduced and adjusted/rotated until the brightest set of
perpendicular lines are found
o The target is then moved back or forth to find the second perpendicular bright lines,
to measure the second axis
o The difference is the cylindrical component
o The axis can be read from the wheel setting

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8) Ultrasound
 A diagnostic instrument that utilizes sound waves to produce echo’s from optical media to
produce sonograms that can be graphically represented and interpreted

 Principles
o Sound is produced by an oscillating piezoelectric crystal @ 8-15mHz
o Utrasound travels in the form of wavefronts
o These wavefronts pass through the ocular media and back to the probe where they
are processed and displayed graphically

o The wavefronts are attenuated by 3 factors in the ocular tissue

 Distance travelled from the probe
 Absorption amount by different tissue
 Acoustic interference in different tissue (scatter, reflection, refraction)
 Thus different ocular tissue will absorb, scatter,reflect,refract US in
different amounts compared to different tissue
 The US measures these differences and can produce graphical evidence
of the differences

o 2 Commonly used ultra sound methods

 A-Scan
 B-scan

o A-scan
 Uses parallel non-focused beam emanating from a stationary 8mHz
piezoelectric crystal
 Reflectivity versus time is graphically displayed for a single direction (in which
the probe is orientated)
 Values can be converted to mm
 Uses
 IOL calculations
 Muscle thickness measurements (TED)
 Measure of tumor height (choroidal melanomas)

o B-scan
 Uses a focussed piezoelectric crystal in an oscillating probe
 Image displayed as a 2 dimensional slice (similar to CT)
 Usefull information is also gained by using it in dynamic fashion, rather than
stationary images

o Uses of Ultrasound in ophthalmology

 Detection of and differentiation of intra-ocular and orbital lesions
 Location of IOFB’s

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  Biomicroscopy
 Biometry

o Specific useful clinical settings

 Opaque media
 Pre-vitrectomy evaluation
 Choroidal mass lesions
 Intra-orbital and Intra-ocular foreign bodies
 Proptosis
 Optic nerve dysfunction
 Extra-ocular muscle abnormalities

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9) Keratometer
 Instrument used to measure the diopteric power of the Cornea
 Determines the refractive power of the cornea
 Optical principles
o Assumes the cornea acts as a high powered convex mirror and thus measures the
radius of curvature of the central corneal “mirror” effect to determine the power
o In essence it measures reflecting power and enfers refractive power
 Cornea as a convex mirror
o The cornea act as a high powered convex spherical mirror (+- 250D powered)
o If an object is placed at a known distance from the cornea and the reflected minified
image size can be measured, the radius of curvature can be calculated mathematically
 R = 2 x u (I /O)
 R = radius of curvature
 U = object distance to cornea (machine pre-set)
 I = size of image
 0 = size of object
 Thus corneal radius directly proportionate to size of reflected image
 Inversely proportionate to size of the object
 The challenge is to measure the very small image reflection
 Keratometer uses a built in magnifier to enlarge the image
 Second problem is to combat eye drift (patient)
Doubling principle counters this
 2 prisms are placed base to base to split the
object image in 2 fields
 The observer sees the object as 2 distinct
images one above thither in the pupil plane
 Any object movement will cause the image to
move equal distance from each other, making
measurement still possible
o 2 types of keratometers

 Von Helmholtz keratometers

 Image size is varied to achieve a known object size

 Javal-Schiotz Keratometer
 Object size is varied to achieve a known image size

o Technique
 Examiner finds 2 images
 Align the horizontal split images to get the one K-value
 Same process to align the vertically split images to get 2nd K-value
K-values are read off the instrument knob

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10) Simple magnifiers
 Use of high powered convex lens (as in simple magnifier /Loupes)
o Enables eye to view object at much shorter distance than possible unaided
o As the object is nearer the eye  the angle subtended at the eye is nearer
 Causes increased retinal image size (magnification)

 When working at 25cm (normal assumed working distance) then



 Thus commonly used loupes

 8x Loupes  32DS lens

 4 x Loupes 16DS lens

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11) Operating microscope
 A low-powered binocular compound microscope linked to an adjustable light source

 Same optical principles as the slitlamp

o Astronomical Telescope
o Inverting Prism
o Galilean Telescope
o Objective Lens
o Illumination System
o Binocular Viewing System

 Difference’s
o Uses a diffuse light, not a slit
o Long working distance between the observer and the eye
o Zoom lenses are used to maintain focus during the surgery

 Working distance
o Adjustable lenses with specific focal lengths are used
 Commonly 150,175,200mm lenses

 Magnification
o Specific to each microscopes component lenses
o Varies typically 6x  40x
o 12.5x eyepieces common
o Smooth zoom focus in modern microscopes

 Illumination system
o Various
o Coaxial illumination
 Specifically useful for posterior capsule visualization and vitrectomy

 Fibre-optic delivery systems to reduce heat

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12) Low vision aids_telescopes

 Indications
o Pt’s with low vision/partial sight
o Certain diseases are amendable to low vision correction, other’s not
 Approach
o Legal blindness
 <3/60 or <5° field both eyes (V2020 = 10°)
o Patient
 What are his requirements/expectations

 Mechanism of improved vision

o Enlarged retinal image
o Ellimination of anterior corneal irregularities
o Sharper retinal image
o Increased illumination

 Classification of low vision aids

o For near
 Large type books
 Projection magnifiers
 Spectacles
 Strong convex lenses
 Best form lens
 Telescopic spectacles
 Spectacle modifications
 Head-borne loupe
 Auxiliary convex lens
 Clip on telescopic lens
 Non-spectacle magnifiers
 Hand held
 Stand held
 Paperweight
 Strong light
 Ruler
 Black paper with cut out line

o For Distance
 Spectacles
 Conventional
 Telescopic
 Pinhole
 Telescopic contact lens

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  Spectacle modifications
 Pinhole

o For increasing field of vision

 Selwyn cross – vision aid
 Peripheral vision glasses

o Optics in low-vision aids

 Galilean telescope
 2 lens system
One convex lens + one concave lens
Separated from each other by respective focal lenghts
Magnifies retinal image (↑subtended angle at eye)
+- 3x magnification
 Only for near vision(Decreases depth of focus)

 Convex Lens magnifier

 Forms magnified virtual image
 Magnification = +- ¼ the diopteric power
2-20x
 Only for near vision (Decreases depth of focus)

 Selwyn Cross
 Presents the field on the blind side to the upper field of the seeing eye
 2 fields are synthesised to produce a full field

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13) Autorefractors
 Different optical principle from manual lensmeters (focimeter)
o Uses principle of spherical aberration /prismatic decentration (prentice rule)
o When light passes para-axial through a lens, the rays pass without deviation
o When passing through the periphery, they are refracted, depending on the distance
from the optical centre and the power of the involved lens (prentice rule
o The autorefractor calculates the power of the lens based on the amount of light
deviation it measures
o Briefly
 The instrument causes parallel light beams to enter the eye, and it has
detectors that measure the light reflected back from the eye
 It measures the deviation the light underwent when passing through
the eye
 It thus determines the centre point and the distance the light beam
passed from this point and the amount of deviation it underwent
 Based on the prentice rule it can then deduce the lens’ power
 The instruments commonly shine 4 light beams (5 x 5mm) to gain these
measurements

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14) Endothelial specular microscope
 Specular microscopy is a technique used to view and photograph endothelial corneal cells
o Utilizes specular reflections from the interface between the endothelial cells and the
aqueous humour
 Can be done through contact or non-contact methods
 Optics
o Instrument separates illumination and viewing paths so that reflections from the
anterior corneal surface do not obscure weaker reflections from posterior corneal
surface
 Slitlamp specular microscopy
o If viewing and illuminating paths are symmetrically displaced on either side of the
normal line to the cornea
o Must use narrow illumination beam  narrow field of view
o Monocular technique with slitlamp beam decentred and placed at 45-60° with the
eyepiece

 Contact specular microscopy

o Special microscope with one side touching the cornea
o Higher magnification possible

 Video specular microscopy

o Makes documentation of larger areas possible

 Wide-field specular microscopy

o Employs special techniques to eliminate reflections from anterior corneal interface

 Cell evaluation
o Assessment of cell morphology
o Special abnormalities
 Guttatae
 KP’s
o Cell counts
 Normal 3000cells/mm² (young people)
 Normal 2500cells/mm² (older people)

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15) Confocal microscopy
 Confocal microscopy is an optical imaging technique
o used to increase optical resolution and contrast of a micrograph
o Uses point illumination and a spatial pinhole to eliminate out-of-focus light in
specimens that are thicker than the focal plane.
 It enables the reconstruction of three-dimensional structures from the obtained images
 Images are acquired point-by-point and reconstructed with a computer, allowing three-
dimensional reconstructions
 Optical principle
o a single point of tissue is illuminated by a point light source and simultaneously
imaged by a camera in the same plane, ie, it is “confocal”
o This produces an image with a very high resolution but it has virtually no field of view
due to a single point of illumination and detection.
o To solve this problem, the instrument instantaneously illuminates and synchronously
images, ie, scans, a small region of tissue with thousands of tiny spots of light which
are reconstructed to create a usable field of view with high resolution and
magnification

 In a confocal laser scanning microscope

o a laser beam passes through a light source aperture and then is focused by
an objective lens into a small focal volume within or on the surface of a specimen
o Scattered and reflected laser light as well as any fluorescent light from the illuminated
spot is then re-collected by the objective lens.
o A beam splitter separates off some portion of the light into the detection apparatus,
o After passing a pinhole, the light intensity is detected by a photodetection device
transforming the light signal into an electrical one that is recorded by a compute

 It provides images which are comparable to in-vitro histochemical techniques delineating

o corneal epithelium
o Bowman’s layer
o Stroma
o Descemet’s membrane
o corneal endothelium

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  Clinical Uses
o Corneal Pathological processes (diagnosis/management)
o corneal dystrophies and ecstasies
o contact lens induced corneal changes
o pre and post surgical evaluation (PRK, LASIK and LASEK, flap evaluations and
Radial Keratotomy)
o To monitor penetrating keratoplasty

16) Placido’s disc

 Instrument used to manually study the corneal topography
 Can be used during surgery to evaluate suture placement/effects on astigmatism (meloney
keratometer)
 Measures anterior 7mm of cornea (periphery not well evaluated)
 Optics
o Flat disc with concentric black and white rings arranged on its one side
o Contains a central viewing aperture at the centre of the rings
o A convex lens is built into the aperture
 Method
o The observer places the disc in front of the cornea and observes the reflection of the
rings off the cornea through the magnified aperture
 Astigmatism can be seen as the rings being closer formed to each other in the
steep meridian
 Regular astigmatism can be seen as bow tie patterns of oval steepening
 Irregular astigmatism can be seen as asymmetrical patterns of
steepening
 Steeper cornea can be seen where smaller images are formed with tighter
arranged circles

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17) Pachymetry
 Thickness of cornea and or Anterior chamber depth can be measured with a pachymeter
 Method
o Optical measurement using Purkinje Sanson images
 Difference between anterior and posterior corneal surface  corneal
thickness
 Difference between posterior corneal and anterior lenticular  ACD
o Ultra-sound using a-scan (applanation / immersion)

18) Optical AC depth measures

 Methods

o Optical Pachymetry
 uses images I and II of Purkinje-Sanson's images to
measure the corneal thickness and AC depth
 Contact and non contact

o Scheimpflug imaging (Pentacam)

 Rotating slit light and camera creates multiple slit images of the AC which is
computerized into a 3D volumetric map
 Non-contact

o partial coherence interferometry (PCI)

 dual laser beam PCI(Zeiss IOL master)
 Uses partial coherence interferometry principles
 Based on michelsons interferometer
 Laser light beam aimed at fovea is reflected back and on basis of interference,
axial calculations including axial length and AC depth measurements are
made
 Non-contact

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 o Scanning slit-tomography (Orb-scan)
 Non-scheimpflug imaging system
 Rotating camera takes slit images and can reconstruct data to produce
information on many parameters including AC-depth

o Anterior Segment OCT

 Based on optical coherence and interference principles
 Also uses michelson’s interferometer principles
 Non-contact

19) Corneal topographers (see placido’s disc )

 Corneal topographers can be

o Placido disc based (multiple concentric ring’s shone into the cornea)
o Standard keratometer based
 Directed to multiple different areas (off-centre)

 Computerized videokeratoscopes
o Enables image analysis of multiple rings (16-32)
o Produces colour coded topographic maps of the cornea
o Uses
 Monitor for contact lens warpage
 Keratoplasty monitoring
 Keratoconus/globus monitoring
 Terriens
 Pellucid

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20) Fundus cameras
 Camera’s used to take images of the fundus
o Can be
 Black/white
 Colour
 FA
 FAF
 ICG
 Same optical principle as indirect ophthalmoscopes

 Optics
o Bright light source gives flash illumination of retina which is captured by the camera
 Multiple condensing lenses/mirror’s and beam splitters achieve this
o The retinal image is projected outwards, and refracted by the patient’s own optical
media
o An aerial image is formed by the camera’s objective lens
o The camera can then capture this image
o Multiple filters allow different wavelength of light to pass into the camera (depending
on type of photo required (e.g. FA, FAF)

 Non-Mydriatic camera’s
o Uses infra-red light in conjunction with an automatic/semi-automatic focussing
device to align and focus the camera on the retina
 The infra-red light does not cause pupil dilatation
o The flash is triggered and the image captured before the pupil has time to constrict

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21) Scanning laser ophthalmoscopes
 Laser based imaging devices based on the principle of confocal microscopy principles
 The scanning laser ophthalmoscope (SLO) provides a high-quality image of the retina
 A laser beam scans across the fundus, and light is collected only from one retinal point at a
time
 This laser beam is then passed through a spatial pinhole to eliminate all light not at the same
focal plane, thereby created microscopic crisp sections

 The instrument then analysis and produces retinal tomogram’s

 Procedure
o A laser is collimated and then reflected off of a beam-splitting mirror.
o As in confocal SLO, light must pass through both a horizontal and a vertical scanning
mirror before and after the eye is scanned to align the moving beam for eventual retinal
raster images of the retina.
o The laser enters the eye through the pupil to illuminate the region it has been focused
onto and light reflected back leaves the same way
o The light is focused through a confocal pinhole to remove light not reflecting off of the
plane of interest and then recorded
 Uses
o Glaucoma-RNFL evaluation (e.g. Heidelberg retinal tomograph( HRT))
o Retinal dystrophies / Degenerations (especially cone dystrophies and RPE related
retinal degenerations/dystrophies)

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22) Optical Coherence Tomography

Optics of OCT
 Definition
 Optical Principles
o Coherence
o Michelson interferometer
 Optical Components
o Light Source
o Light Detector
o Beam Splitter
o Movable Mirror
o Computer Analyser
 Types
o Time Domain
o Fourier (spectral) Domain
 Applications in Ophthalmology
o Retina
o Glaucoma
o Anterior Segment

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 Definition
o Optical Coherence tomography
 An OCT is a modern high-technology instrument used to take cross-
sectioned image of microscopic tissue in the eye
 Commonly used in retinal and glaucoma based diagnostics
 Based on light properties similar to Ultra-sound reflectivity
 Creates a cross-sectioned image of tissue by taking advantage of the
interference properties of temporal coherent light

 Optical Principles
o Coherence
 Is a property of light that enables interference
 Constructive interference
 When 2 waves travel together in such a way that they are in-phase
o The super-positioning of the waves causes doubling of light
intensity (creates a larger wave)
 Destructive interference
 When 2 waves are out-of-phase, their amplitudes subtract from
each other with resultant decrease in light intensity

o Michelson interferometer
 Interprets the properties of 2 waves by studying the pattern of interference
created by their superposition
 Detects light intensity and compares this to the 2 waves’ properties

 Optical Components
o Light Source
 Super luminescent diode
 Near infra-red (850nm)
 Non-visible
o Light Detector
o Beam Splitter
o Movable Mirror
o Computer Analyser

 Schematic
o Light reflected from the movable mirror (reference beam) will cancel out most of
the light coming from retinal tissue (object beam) except the light which
corresponds to the position of the movable mirror
o Light in this fashion is plotted against the position of the movable mirror, allowing a
‘A-scan’ like image to be generated
o By using a tilting mirror between the retina and the beam splitter, a 2D ‘b-scan like’
image can be generated
o OCT thus creates a digital volumetric contour model of an ocular structure by
reconstructing images made from the light travelling through the object

161
 o Similar to an optical equivalent of ultrasound

o OCT is non-invasive, non-contact

o Modern OCT can delineate ocular structures up to 2-3μm

 Types
o Time Domain
 The reference mirror is moved
 The change in interference pattern of the reference arm is
translated longitudinally in time by a photometer
 Average resolution 10μm
 +- 400 A-scans/Sec
 Negatively influenced by eye movement
 Reliable
 Affordable

o Fourier (spectral) Domain

 Reference mirror remains stationary
 Different optical frequencies are distributed onto a high speed
spectrometer
 Depth information is acquired through analysis of interference
patterns in a spectrum of mixed reflected lights
 Ultra-high resolution 3-6μm
 20 000  52 000 A-scans/sec (ultra-high speed)
 Not as negatively influenced by eye drift
 Retinal structures can be registered allowing exact re-scan of same areas
with accurate comparative data

162
  Expensive++

 Applications in Ophthalmology
o Retina
 Macular oedema
 Vitreo-macular traction
 Macular holes
 Serous chorioretinopathy
 ARMD (leakage, early drussen
 CNV
 Shaken baby syndrome

o Glaucoma
 RNFL thickness analysis
 Ganglion cell analysis
 Optic nerve head scans / comparison
 Cup to disc ratio’s (volume based / area based)

o Anterior Segment
 From tear-film to the iris plane
 Independent of corneal opacity
 Pachymetry
 K-Values
 3D Corneal topography
 Imaging of LASIK flaps
 Imaging of the AC angle
 Tube position evaluation
 Lens position
 Iris /Ciliary body Masses

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23) Pentacam
 An optical device used to image the anterior segment and produce contour like exact
volumetric 3D reconstruction images
 Combined device consisting of
o Slit-illumination
o Scheimpflug Camera (which rotates around the eye)
 A thin layer in the eye is illuminated through the slit-light
o The cells scatter the light
o Creates a cross-sectioned image which is photographed side-ways by the pentacam
 The camera creates a sharp image from the anterior surface of the cornea to the posterior
surface of the lens
 Point clouds are allocated to the various tissue layers
o Ray tracing determines exact tissue boundaries
 A set of 3D measurements is determined
o Precise geometrical maps of the anterior eye segment
o Various maps can be generated
 Clinical Applications
o Functions
 Corneal topography
 ACD / AC-volume
 Lens topography
 Lens densitometry
 Zernike analysis (aberrations)
 Angle structure analysis
 IOL calculations (parameter’s quantification)

164
24) Lens Clock

A lens clock is a mechanical dial indicator that is used to measure dioptric power of
a lens. A lens clock measures the curvature of a surface, but gives the result as an
optical power in diopters, assuming the lens is made of a material with a
particular refractive index.

It is called as Geneva Lens Gauge, Lens measure or Lens Clock

Appearance
The lens clock has 3 legs

 · The 2 outside legs do not move

 · The center one moves in and out
 · The difference in height position of the center leg and the 2 outside leg is sag
for the arc of a circle

**Doesn’t show the actual sag measurement but shows the dioptric value for the surface
power

Using The Lens Clock

 · Place the clock on a flat surface, so that all 3 pins are equal, your clock
should measure zero– If not, your lens clock is defective
 · The lens clock must be held perpendicular to the surface of the lens
 · Tilting the clock by 10° from the perpendicular, can create as much as 2
diopters of error in your reading.

Base Curve Determination

 · Defined as the beginning curve upon which the net power is based
 · The lens clock can be used to measure this
 · Modern lenses have spherical front surfaces (F1)– The base curve will be the
lens clock reading of the front surface of the lens
 · Back surface is called (F2)

 · When measuring the F1 of the lens, you will need to read the black scale

165
  · When measuring the F2 of the lens, you will need to read the red scale

 · If there are more than 1 curve on the front surface, the lens is either warped
or is a plus-cylinder lens form
 · The base curve is the least curved of the 2 readings

Index

 · The lens clock is designed for materials where n = 1.53 (crown glass)
 · Measuring a lens where n > 1.53 – The lens clock will read too LOW
 · Measuring a lens where n < 1.53 – The lens clock will read too HIGH

Nominal Power of a Lens

Since the lens clock directly measures the surface values of a lens, we can use it to
approximate the power of lenses
– Only works for materials with index of refractions close to 1.53

 · F1 measures +6.00D
 · F2 measures -4.00D
 · Ft = +2.00D (Power)

Power Determination
The lens clock can be used to measure sphere and cylinder power
1. Hold the lens clock so that the center leg is at the center of the lens and perpendicular
to the lens surface
2. Rotate the lens clock around the center leg
3. If the needle on the lens clock remains unchanged, the surface is spherical
4. If the needle shows a change in value, the surface is toric with 2 separate curves
5. Read the maximum and minimum values
(The orientation of the three legs where the maximum and minimum readings are will
correspond to the major meridians of lens power)

· Modern lenses are of Minus cylinder form. So while measuring the power of the lens you
might find cylinder in F2 and the F1 will always be SPHERICAL

1. When rotating the lens clock on the front surface of a lens, all meridians read +4.00D.
On the back surface, the clock reads -6.25D Then the power will be
(+4.00) + (-6.25) = -2.25D
2. When rotating the lens clock on the front surface of a lens, all meridians read +6.50D.
On the back surface, the clock reads -7.50D when the 3 legs are along the 180°
meridian, and -6.00D when the 3 legs are along the 90°meridian. Here you can
calculate the nominal power of the lens if the lens made in minus cylinder form as given
below.

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Direct versus indirect Ophthalmoscope
Direct Ophthalmoscope Indirect Ophthalmoscope
Image Erect Real Virtual, inverted
Field of View 6° (limited) 25° (wide)
Magnification 15x 3-4x
Stereopsis Mono-ocular non-3D Binocular 3D view

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2012 May MMED Stellenbosch optics

Discuss

 Over refraction (5)

 Binocular balancing (5)
 Fogging technique (5)
 Pinhole (5)
 ???(5)

 Cylinders and uses in ophthalmology (25)

 MCQ’s (50)

Mmed 2007 Stellenbosch

Write notes on

 Laser properties (10)

 Types of laser tissue interaction (10)
 Anti-reflective coatings (10)
 Knapp’s law (10)

Discuss your approach to the dissatisfied optical patient (40)

Discuss the optics of prisms and their uses in ophthalmology (40)

Discuss the choice of IOL and Biometry in the following settings

 The Long eye (8)

 Short eye (8)
 Silicone Oil filled eye (8)
 Aphakic paediatric eye (8)
 Post Lasik Eye (8)

MMED 2006

Discuss optical aberrations (40)

Discuss non-surgical correction of presbyopia (40)

Discuss the optics and uses of prisms (40)

Discuss the following spectacle scripts (40)

 OD +3.50D / -2.50D x 48 Prism 2.5PD Base down (add +1.00)

 OS -3.00D / -1.00 x 120 Prism 2PD Base up (add 2.50D)

168
MMED 2005 Sbosch
Discuss the IOL calculations in patient with previous refractive surgery (40)
Discuss the following
 Asthenopia (10)
 Anisometropia (10)
 Aniseikonia (10)
 Ametropia (10)

Discuss optical aberrations (40)

Discuss (short notes)

 Inplantable Contact Lenses (ICL’s) (10)

 OCT (10)
 Jackson Cross Cylinder (10)
 Back vertex distance (10)

MMED Sbosch 2002

Discuss the following spec (40)

 OD +3.50D /-3.00D x 48 Prism 2.5PD Base down (add +2.00)

 OS -4.00D / -2.00 x 120 Prism 2PD Base up (add 2.00D)

Discuss your approach to the patient who complains of asthenopic symptoms shortly after you
prescribed him a new spectacle (40)

Discuss the IOL calculation in the post-refractive surgery patient (40)

Write short notes on (4 x 10)

 Optics of the lensmeter

 Aneisokonia
 Anti-reflective layers
 Chromatic aberrations

MMED 2000 (160 marks)

Discuss optics of IOL’s (40)

Discuss astigmatism and its correction (40)

Discuss the optics of prisms (and applications) (40)

What is the spherical equivelant of

-3.5/+2.00 x 130 (3)

Change the plus notation of the following to a minus cylinder form

-5.50/+3.00 x 180 (3)

169
Post cataract surgery the patient has a refraction of +1.00/+3.00 x 100

Is the astigmatism against or with the rule (4)

Name thick lens aberrations (10)

What is the most effective pinhole diameter (3)

If your patient becomes more hyperopic after repeated refractions in the past, what will you look for
(7)

Define hyperopia (latent…manifest…facultative…absolute) (10)

MMEd 1998

Discuss the clinical optics of bifocals/multifocals (40)

Discuss the optical problems associated with aphakic glasses (40)

Discuss astigmatism (40)

Discuss the optics and uses of prisms (40)

170
Optics & refractive surgery
1. Surgical treatment of presbiopia
2. 45yr old man requests refractive surgery. His refraction is as follows
OD +0.75/-1.50 x 5° OS -1.75/-1.25 x 175°'
discuss and motivate your advice to him and your management of his case
3. Discuss the modern management modalities of astigmatism
4. Discuss the types, indications and complications of refractive surgery
5. Notes on IOL calculation in post refractive surgery patients
6. Current opinions to correcting presbiopia
7. Current surgical correction in hypermetropia
8. Approach to a patient who presents with asthenopic symptoms shortly after receiving new spectacles
9. Describe the optics of the retinoscope
10. A 20yr old soft contact lens user presents with a unilateral keratitis. Discuss the most likely ddx,
investigations and management of this patient
11. Discuss the management of a 65yr old patient with metamorphopsia
12. Discuss the refractive needs of
a 48 year old church organist
a presbiopic professional game hunter
a 55 year old
golfer
13. Describe current management options in a patient of 42 years with a spectacle correction
of -1.75 sphere with a silinder of -0.5 x 180 degrees in both eyes who wants to eliminate spectacle wear as far as po
14. Discuss
IOL's
15. Discuss the use of the following
Jackson cross cylinder
Maddox Rod
Pachymeter
16. Discuss the basic optics of contact lenses, the indications for contact lens wear and possible comlications
17. Examination and treatment of a post op phaco pt with double vision (local )
18. Discuss AC/A ratio
19. Discuss the complications of contact lens use
20. Classify and discuss the clinical pathology of high myopia

171
Pathology
1. Short notes on apoptosis
2. Pathology of lacrimal gland tumours
3.Clinical pathology of sabaceous gland carcinoma of the eyelids
4. Approach to patient with red eye
5. Notes on pathology of various ophthalmic lesions occuring in the phacomatosis
6. Pathology of ocular melanomas
7. Pathology of lacrimal gland tumours
8. Discuss Herpes simplex infections of the eye and the treatment thereof
9. Discuss the pathology of tumours of the lacrimal gland
10. Discuss the genetics of retinoblastoma
what factors, clinical and pathological, have a bearing on prognosis
11. Discuss the pathology of
Choroidal melanoma
Basal cell carcinoma of the eyelid
Tumours of the caruncle
Pleomorphic adenoma of the lacrimal gland
12. Discuss the current state of the art in the pathology and management of
uveal malignant melanoma
13. Discuss the pathology of orbital and optic nerve sheath meningioma and
orbital pseudotumour
14. Notes on the clinical and radiological features and pathology of
optic nerve glioma
optic nerve sheath meningioma
15. Wound and response to injury of the cornea and sclera
16. Describe the pathophysiology of a cataract
17. Describe the genetics of glaucoma
18. Discuss the pathology of malignant tumours of the eyelid
19. Discuss the melanotic tumours of the uvea and retina
20. Short notes on Tuberous sclerosis
21. Discuss the pathology of open angle glaucoma including congenital glaucoma
22. Discuss the histology and clinical pathology of Malignant melanoma of the choroid
23. Discuss phaco-anaphylactic glaucoma
24. Discuss the pathology of anterior scleritis
25. Discuss briefly ectopia lentis
26. Describe the pathology of ROP
27. Discuss the pathology of SCC and Granulomatous uveitis
28. Describe the pathology of a congenital tilted disc. What are the common signs
ssosiated with this condition. Discuss the differential diagnosis.
29. Discuss the pathology of peripheral corneal ulceration and thinning
30. Notes on the pathology of choroidal tumours
20. Classify and discuss the clinical pathology of high myopia

172
 Pathology – Dylan notes
1. Discuss the pathology of the tumours of the eyelids
2. Discuss the pathology of tumours of the optic nerve
3. Discuss the pathology of
a. Coats disease
b. Rhabdomyosarcoma
c. Sturge Weber syndrome
d. Angiomatosis retinae
e. Pseudoxanthoma elasticum
4. Discuss the pathology of uveal tumours
5. Discuss the pathology of retinoblastoma
6. Discuss the pathology of malignant conjunctival tumours
7. Write notes on the following
a. Adenoid cystic carcinoma of the lacrimal gland
b. Orbital rhabdomyosarcoma
c. Chalazion
d. Mucormycosis
e. Trachoma
8. Discuss the pathology of malignant melanoma of the uvea
9. Discuss the pathology of phacomatoses
10.Discuss the pathology of the following conditions
a. Meningioma of the optic nerve
b. Nanophthalmos
c. Coat’s disease
d. Phacoanaphylactic endophthalmitis
e. Squamous cell carcinoma of the conjunctiva
11.Write short notes on
a. Ocular manifestations of AIDS
b. Syphilitic uveitis
c. Neurofibromatoses (already discussed)
d. Coat’s disease (already discussed)
e. Sturge-Weber syndrome (alread discussed)
12.Discuss the pathology of melanocytic tumours of the eye
13.Discuss the pathology of lacrimal gland tumours

173
14.Write short notes on
a. Ocular manifestations of AIDS (already discussed)
b. Tuberculous uveitis
c. Ocular sarcoidosis
d. Molluscum contagiosum (already discussed)
e. Xeroderma pigmentosum (already discussed)
15.Discuss the pathology of ocular inflammation
16.Discuss the congenital anomalies and pathology of the lens
17.Discuss the hereditary retinal dystrophies
18.Discuss the pathology of
a. Pseudotumour of the orbit
b. Rhabdomyosarcoma (already discussed)
c. Pleomorphic adenoma (already discussed)
19.Discuss ocular granulomatous inflammation
20.Discuss the pathology of ocular malignant melanoma
21.Discuss the pathology of malignant tumour of the eyelids
22.Describe the macroscopic and microscopic pathology of the following
a. Fuch’s dystrophy
b. Chalazion (previously discussed)
c. Conjunctival melanocytiv naevi (already discussed)
d. Rosai-Dorfman disease
e. Orbital meningioma (already discussed)
f. Dermoid tumour of the conjunctiva
g. Sympathetic uveitis (already discussed)
23.Discuss the pathology of corneal degenerations and corneal dystrophies
24.Write short notes on the following
a. Keratoacanthoma (already discussed)
b. SCC of the eyelids (already discussed)
c. Basal cell ca of the eyelids (already discussed)
d. Glioma of the optic nerve (already discussed)
e. Leukocoria (can also be phrased as discuss pathology of
pseudoglioma)
25.Make short notes on the following
a. Angiomatosis retinae (already discussed)
b. Sarcoidosis (already discussed)

174
 c. Phacolytic glaucoma
d. Juvenile xanthogranuloma
26.Write short notes on the following
a. Tuberculous sclerosis (already discussed)
b. Behcet’s disease
c. Leprsoy (already discussed)
d. Corneal lattice dystrophy (already discussed)
e. Pterygium
27.Discuss the pathogenesis and pathology of diabetic retinopathy
28.Discuss the pathogenesis of
a. Thyroid eye disease
b. Proliferative vitreretinopathy
29.Discuss the pathology of diabetes mellitus in the eye
30.Write short notes on
a. Histology of optic neuritis
b. Pigmented lesions of the conjunctiva (already discussed under
melanocytic tumours of the eye)
31.Write short notes on
a. Fungal infections of the cornea
b. Synchysis scillitans and asteroid hyalosis
32.Write short notes on pigmented lesions of the cornea
33.Discuss viral infections of the cornea
34.Write short notes on
a. Ocular rosacea
b. Retinal macroaneurysm
35.Write short notes on the ocular and/or orbital involvement of the
following
a. Toxoplasmosis
b. Toxocara infestations
c. Chlamydial infections
36.Describe the pathology of glaucoma
37.Write short note on ocular rhinosporidiosis
38.Write short notes on pseudotumour of the orbit as well as a differential
diagnosis thereof

175
39.Discuss the pathogenesis of and morphological abnormalities in the
lacrimal gland in Sjogrens disease
40.Discuss the pathogenesis and histopathological findings of fungal
infections of the eye and orbital tissue
41.Discuss the pathology of iridocorneal endothelial syndrome
42.Discuss the pathology of orbital lymphomas and leukaemias
43.Write short notes on
a. Peter’s anomaly
b. Axenfeld/Axenfeld-Reiger anomaly
44.Discuss the pathology of pseudoexfoliation syndrome
45.Discuss the pathology of ectopia lentis
46.Discuss the pathology of
a. Anterior ischaemic optic neuropathy and
b. Demyelinating disease
47.Discuss the pathology of hordeolum
48.Discuss the pathology of
a. Fuch’s heterochromic iridcyclitis
b. Wegener’s granulomatosis
49.Discuss the pathology of central retinal and branch vein retinal occlusion
50.Discuss the pathology of collagen diseases of the skin
51.Discuss the pathology of Ehlers-Danlos syndrome
52.Discuss the pathology of cysts and pseudoneoplasms of the conjunctiva
53.Discuss the pathology of hypertensive and arteriosclerotic,
haemorrhagic and exudative retinopathy
54.Discuss the pathology of central serous retinopathy
55.Discuss the pathology of drusen
56.Discuss the pathology of AMD
57.Write short notes about optic disc oedema
58.Write short notes on the pathology of mitochondrial myopathies
59.Discuss the pathology of tumours of the reticuloendothelial system
60.Discuss the pathology of developmental abnormalities of the bony orbit
61.Discuss the pathology of congenital defects of the optic nerve
62.Discuss the pathology of episcleritis and scleritis
63.Discuss the pathology of acute and chronic conjunctivitis
64.Discuss the pathology of conjunctival amyloidosis

176
65.Discuss the pathology of retinal inflammation
66.Discuss the pathology of retinal degenerations
67.Discuss the pathology of idiopathic macular holes
68.Discuss the pathology of congenital anomalies of the neural retina
69.Write short notes on the pathology of the following
a. Congenital rubella
b. Pars planitis
c. Vogt-Keyanagi-Harada syndrome
70.Discuss congenital anomalies of the eye
71.Discuss the pathology of iron and copper in the eye
72.Discuss the meaning of the following terms
a. Orthokeratosis
b. Parakeratosis
c. Acanthosis
d. Dyskeratosis
e. Acantholysis
f. Bulla
g. Atrophy
73.Discuss the pathology of congenital abnormalities of the skin
74.Write short notes on the pathology of
a. Senile ectropion and entropion
b. Blepharitis
c. Toxic epidermal necrolysis
d. Epidermolysis bullosa
75.Write short notes on the pathology of
a. Acanthomoeba
b. Choroideremia
c. Fibrous histiocytoma
76.Make short notes on the pathology of optic atrophy
77.Discuss the pathology of vitreous opacities
78.Write short notes on the pathology of vitreous haemorrhage
79.Write short notes on the pathology of the following
a. Cysticercosis
b. Echinococcus
c. Schistosomiasis

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 d. Ophthalmomiasis
e. Congenital stationary night blindness
80.Discuss the pathology of the follwowing primary orbital tumours
a. Teratoma
b. Haemangioma
c. Arteriovenous communication
d. Lymphangioma
e. Glomus tumour
81.Discuss the pathology of benign cystic lesions of the eyelid
82.Discuss the pathology and sequelae of endophthalmitis
83.Write short notes on the pathology of xanthelasma
84.Write short notes on the pathology of pingueculae
85.Write short notes on Goldenhar-Gorlin syndrome
86.Write short notes on the pathology of iris neovascularisation
87.Write short notes on the pathology of choroidal folds
88.Discuss the pathology of congenital and developmental defects of the
pigment epithelium of the uvea
89.Write short notes on the pathology of choriocapillary atrophy
90.Write short notes on the pathology of commotio retinae
91.Write short notes on the pathology of anterior segment necrosis
92.Write short notes on the pathology of Lyme disease
93.Discus the pathology of the follwing chromosomal abberations
a. Trisomy 13
b. Trisomy 18
c. Trisomy 21
d. Chromosome 47 deletion defect
94.Discuss the pathology of melanocytic tumours of the pigment epithelium
of the iris, ciliary body and retina

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Pathology
1. Short notes on apoptosis
2. Pathology of lacrimal gland tumours
3.Clinical pathology of sabaceous gland carcinoma of the eyelids
4. Approach to patient with red eye
5. Notes on pathology of various ophthalmic lesions occuring in the phacomatosis
6. Pathology of ocular melanomas
7. Pathology of lacrimal gland tumours
8. Discuss Herpes simplex infections of the eye and the treatment thereof
9. Discuss the pathology of tumours of the lacrimal gland
10. Discuss the genetics of retinoblastoma
what factors, clinical and pathological, have a bearing on prognosis
11. Discuss the pathology of
Choroidal melanoma
Basal cell carcinoma of the eyelid
Tumours of the caruncle
Pleomorphic adenoma of the lacrimal gland
12. Discuss the current state of the art in the pathology and management of
uveal malignant melanoma
13. Discuss the pathology of orbital and optic nerve sheath meningioma and
orbital pseudotumour
14. Notes on the clinical and radiological features and pathology of
optic nerve glioma
optic nerve sheath meningioma
15. Wound and response to injury of the cornea and sclera
16. Describe the pathophysiology of a cataract
17. Describe the genetics of glaucoma
18. Discuss the pathology of malignant tumours of the eyelid
19. Discuss the melanotic tumours of the uvea and retina
20. Short notes on Tuberous sclerosis
21. Discuss the pathology of open angle glaucoma including congenital glaucoma
22. Discuss the histology and clinical pathology of Malignant melanoma of the choroid
23. Discuss phaco-anaphylactic glaucoma
24. Discuss the pathology of anterior scleritis
25. Discuss briefly ectopia lentis
26. Describe the pathology of ROP
27. Discuss the pathology of SCC and Granulomatous uveitis
28. Describe the pathology of a congenital tilted disc. What are the common signs
ssosiated with this condition. Discuss the differential diagnosis.
29. Discuss the pathology of peripheral corneal ulceration and thinning
30. Notes on the pathology of choroidal tumours
20. Classify and discuss the clinical pathology of high myopia

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