OPTICS and REFRACTION

Professor Marianne Shahsuvaryan

Department of Ophthalmology
Yerevan State Medical University
 The Eye as an Optical System:

(A) REFRACTIVE MEDIA :

1. The Cornea

2. The Aqueous Humor

in the Anterior Chamber

3. The Lens

4. The Vitreous
THE CORNEA:

Most of the bending of the light rays

(refraction) occurs at the cornea.

The cornea contributes to approximately

2/3 of the refracting power of the eye along
with the tear film.
It contributes ± 43 diopters.
2. THE LENS.
The lens contributes to 1/3 of the refractive
power of the eye (± 20 diopters). By itself it is
more powerful than the cornea as a convergent
surface but because of less difference in indices
of refraction between the aqueous versus the
cornea, less convergence exists at the level of
the lens.

The total convergence power of the eye is 58.7d

and not 43±20=63d due to the distance between
the cornea and the lens (depth of the anterior
chamber) that will subtract approximately 4d.
3. THE PUPIL.

The pupil reduces the amount of light that

enters the eye.

It decreases the aberrations.

It increases the depth of focus when

constricting.
(B). ACCOMODATION:

It is the process by which the eye changes

its refractive power to focus on near or far
objects. It results from increased curvature
of the lens due to contraction of the ciliary
muscle. The stimulus to accomodation is a
blurred retinal image.
When the ciliary muscle is relaxed, the choroid acts like a spring
pulling on the lens via the zonule fibers causing the lens to become
flat.

When the ciliary muscle contracts, it stretches the choroid, releasing

the tension on the lens and the lens becomes thicker.
When looking at an object that is far away the lens is kind of skinny.

When looking at nearby objects the lens gets fatter, causing the
image of the object to be focused on to the retina in the fovea.
(C). REFRACTION and REFRACTIVE ERRORS:

Refractive errors are the most common

cause of poor vision. They are the easiest
to treat. Refraction is a term applied to the
various testing procedures employed to
measure the refractive error of the eye in
order to provide the proper correction.
TYPES OF REFRACTION
(a) Subjective refraction

(b) Automated refraction

(c) Cycloplegic refraction

Cycloplegic refraction is done by applying a cycloplegic

agent to the eye (atropine, cyclopentolate or tropicamide)
to paralyze the ciliary muscle so that the absolute refractive
error can be measured. it is helpful to detect latent hyperopia
in children compensating their hyperopia by accomodation.
REFRACTIVE ERRORS:
Emmetropia: Normal eye. No
refractive error.

Anisometropia: A refractive
error is present.

1. Myopia

2. Hyperopia

3. Astigmatism Emmetropia

4. Presbyopia
1. Myopia (nearsightedness)
– if cornea is too steep or anterior-posterior (AP)
axis is too long.

The focused image is formed in front of the retina.

TYPES OF MYOPIA
a. Axial myopia:

The AP axis is longer than normal.

Patients may have pseudoproptosis due to the larger globe.

b. Curvature myopia:

The eye has a normal AP axis but at the corneal level the curvature
may be steeper than normal ex: congenital, or keratoconus.
MYOPIC SHIFT
At the lens level: lens curvature is increased ex in
intumescent cataract.

c. Increased Index of refraction:

Occurs with nuclear sclerosis making the eye myopic

d. Anterior displacement of the lens:

Occurs after trauma or after glaucoma surgery.

 Symptoms of myopia:

I. Blurred vision for distance

2. Squint (due to blepharospasm - like action to act as a

pinhole)

3. Headache (rare)

Myopia is usually detected at the age of 9-10 years and keeps

increasing till mid-teens when it stabilizes at -5d. or less
 Progressive myopia:

- rare form of myopia

- may increase at a rate of up to -4d. per year

- is associated with chorioretinal degeneration and vitreous floaters

and liquefaction

- usually stabilizes at the age of 20 years but can progress until mid
30’s

- may reach up to -10 or -20d.

- high myopes (more than -7d) are predisposed to retinal

detachment and POAG.
Congenital myopia:

- more than —10d. in infants

- generally not progressive

- should be corrected as soon

as detected.

Treatment:

Always give full correction with

(-) lenses.
I. HYPEROPIA (Hypermetropia, farsightedness)
– if cornea is too flat or anterior - posterior (AP) axis is too short

The focused image forms behind the retina. Most children are born
with some hyperopia (maximum up to ±3d. ) but this usually resolves by
12 years of age.
a. Axial hyperopia:

- It is the most common cause of hyperopia

- AP diameter of the eye is shorter than normal.
- These eyes are more prone to angle closure glaucoma because of
shorter anterior segment with crowding of the angle structures.
- The optic nerve is also smaller
- It may be associated with pseudopapilledema:
- usually occurs with more than +4d.
- swollen discs but no other signs of true papilledema such as
blurring of the disc margins, hyperemia of the disc, hemorrhages.
b. Curvature hyperopia:

When either the lens or cornea has a weaker than normal curvature,

lower refractive power or convergence occurs.

c. Index of refraction hyperopia:

Occurs due to a decrease in the index of refraction (and density) in

any part of the optical system of the eye.

Latent hyperopia: is that part of the refractive error completely

corrected by accomodation. It can only be measured by cycloplegic
refraction and not manifest refraction

Manifest or absolute hyperopia: is the portion of the hyperopia not

corrected by accomodation.

With aging, the accomodative power of the eye decreases. This will
shift a hyperopic patient from latent hyperopia to greater degrees of
absolute hyperopia.
Symptoms of hyperopia:

1. Blurred vision for distance

2. Frontal headache aggravated by prolonged use of near vision.

3. Asthenopia: fatigue, burning eye sensation and periorbital pain

when fixing at an object for prolonged periods of time.

4. Light sensitivity

5. Decrease in near visual acuity at a younger age than in

emmetropic eyes.
Treatment of hyperopia:

Convergent or (+)lenses.
3. ASTIGMATISM:

The curvature of the cornea varies in different

meridians thus refracting the incident light
differently in those meridians.
TYPES OF ASTIGMATISM
With-the-rule astigmatism: the vertical meridian is steeper

Against-the-rule astigmatism: the horizontal meridian is

steeper

Regular astigmatism: Principle meridians are 90 degrees

apart

Irregular astigmatism: Principle meridians are not 90

degrees apart. This type of astigmatism cannot be
completely corrected by spectacles and may need contact
lenses ex: corneal scarring, keratoconus.
Symptoms of astigmatism:

1 - blurred vision for far and near

2 - squint (for pinhole effect)

3 - asthenopic symptoms

4 - frontal headaches

5 - tilting of the head (for oblique

astigmatism)

The diagram on the right has been fudged

to illustrate how it might appear to a
person with astigmatism.
Treatment is with cylindrical lenses
or contact lens.
4. PRESBYOPIA:

It’s the physiologic decrease in the amplitude of

accommodation associated with aging.

There is less bulging of the lens with

accommodation due to a change in the crystallins
of the lens that result in decrease in the elasticity
of the lens fibers or hardening of the lens.
Symptoms include:

- larger reading distance required

- inability to focus on close work.

- Excessive illumination required for close work.

Treatment: Add positive lenses to far correction according to age .

5. AMBLYOPIA:

It is decreased visual acuity of one eye

(uncorrectable with lenses) in the absence of
organic eye disease insufficient enough to explain
the level of vision.

It is caused by visual deprivation due to any

cause (congenital or acquired) during the critical
period of development (up to age 8-9 yrs) that
prevents the establishment of normal vision in the
involved eye.
Causes include:

- strabismus (most common cause)

- anisometropia

- high hyperopia

- opacities: corneal scars, cataract

- optic nerve disease

- retinal disease
REFRACTIVE ERRORS CORRECTION

1. Corrective Lenses – Glasses

2. Contact Lenses
3. Surgery
A. Photorefractive Surgery
B. Intraocular Contact Lenses – phakic IOL
C. Intraocular anterior chamber Lenses with
iris fixation (Artisan)
D. Refractive Lens Exchange
1. TYPES OF CORRECTIVE LENSES:

(a). Spherical lenses:

All have equal curvatures in all meridians.

(i). Convex, (-F) lenses or convergent lenses are used for

the correction of hyperopia, presbyopia and aphakia.
They make objects look larger in size.

(ii). Concave, (-) lenses or divergent lenses are used for the
correction of myopia. They make objects look smaller in
size.
(b). Cylindrical or toric lenses:

One meridian is curved more than all the other ones.

They are used to correct astigmatism.

A cylinder lens is different than a spherical lens which is what one normally sees in
spectacles. Although a cylindrical component my be built in to that which appears
spherical.

As can be seen in the above diagram a cylinder lens has power only in one axis. In the
above it is the horizontal axis. This lens does not refract light in the vertical direction.
c .Prisms:

A prism is an optical device composed of 2 refracting

surfaces that are inclined toward one another.

It has an apex and a base. It refracts light toward its

base whereas an object seen through a prism appears
deviated toward the apex of the prism.

It does not change the size of an object.

Prisms are used to correct strabismus.

2. Contact Lenses
Many people wear contact lenses to help image light properly on to
the retina.
 3. Surgery
Photorefractive surgery
The EXCIMER LASER
causes photoablation

photorefractive
corneal epithelium
keratectomy (PRK)
of tissue
corneal stroma Lasik
(laser in-situ keratomilesis)

and is used for:

a photorefractive surgery to change the surface of the cornea in
order to correct errors of refraction