Astigmatism

Walter Huang, OD Yuanpei University Department of Optometry

Definition
When parallel rays of light enter the eye (with accommodation relaxed) and do not come to a single point focus on or near the retina

Optics
Power in the horizontal plane projects a vertical focal line image Power in the vertical plane projects a horizontal focal line image

Optics
Refraction of light taking place at a toric surface: the conoid of Sturm

Etiology
Cornea
The cornea has an unequal curvature on its anterior surface

Etiology
Lens
The crystalline lens has an unequal curvature on its surface or in its layers

Etiology
It is due to a distortion of the cornea and/or lens The refracting power is not uniform in all meridians The principal meridians are the meridians of greatest and least refracting powers The amount of astigmatism is equal to the difference in refracting power of the two principal meridians

Classification
Based on etiology Based on relation between principal meridians Based on orientation of meridian or axis Based on focal points relative to the retina Based on relative locations of principal meridians or axes when comparing the two eyes

Corneal Astigmatism
When the cornea has unequal curvature on the anterior surface

Lenticular Astigmatism
When the crystalline lens has an unequal on the surface or in its layers

Total Astigmatism
The sum of corneal astigmatism and lenticular astigmatism

Regular Astigmatism
When the two principal meridians are perpendicular to each other Most cases of astigmatism are regular astigmatism The three types are with-the-rule, against-therule, and oblique astigmatism

Irregular Astigmatism
When the two principal meridians are not perpendicular to each other Curvature of any one meridian is not uniform Associated with trauma, disease, or degeneration VA is often not correctable to 20/20

With-The-Rule (WTR) Astigmatism

When the greatest refractive power is within 030 of the vertical meridian (i.e., between 060 and 120 meridians) Minus cylinder axis around horizontal meridian The most common type of astigmatism based on the orientation of meridians

With-The-Rule (WTR) Astigmatism

Against-The-Rule (ATR) Astigmatism

When the greatest refractive power is within 030 of the horizontal meridian (i.e., between 030 and 150 meridians) Minus cylinder axis around vertical meridian

Against-The-Rule (ATR) Astigmatism

Oblique (OBL) Astigmatism

When the greatest refractive power is within 030 of the oblique meridians (i.e., between 030 and 060 or 120 and 150)

Oblique (OBL) Astigmatism

Simple Astigmatism
When one of the principal meridians is focused on the retina and the other is not focused on the retina (with accommodation relaxed)

Simple Myopic Astigmatism

When one of the principal meridians is focused in front of the retina and the other is focused on the retina (with accommodation relaxed)

Simple Hyperopic Astigmatism

When one of the principal meridians is focused behind the retina and the other is focused on the retina (with accommodation relaxed)

What Patient Sees

One meridian is out of focus

Compound Astigmatism
When both principal meridians are focused either in front or behind the retina (with accommodation relaxed)

Compound Myopic Astigmatism

When both principal meridians are focused in front of the retina (with accommodation relaxed)

Compound Hyperopic Astigmatism

When both principal meridians are focused behind the retina (with accommodation relaxed)

What Patient Sees

Both meridians are out of focus

Mixed Astigmatism
When one of the principal meridians is focused in front of the retina and the other is focused behind the retina (with accommodation relaxed)

Symmetrical Astigmatism
The principal meridians or axes of the two eyes are symmetrical (e.g., both eyes are WTR or ATR) The sum of the two axes of the two eyes equals approximately 180

Symmetrical Astigmatism
Example
OD: OS: pl -1.00 x 175 pl -1.00 x 005

Both eyes are WTR astigmatism, and the sum of the two axes equal approximately 180

Asymmetrical Astigmatism
The principal meridians or axes of the two eyes are not symmetrical (e.g., one eye is WTR while the other eye is ATR) The sum of the two axes of the two eyes does not equal approximately 180

Asymmetrical Astigmatism
Example:
OD: OS: pl -1.00 x 180 pl -1.00 x 090

One eye is WTR astigmatism, and the other eye is ATR astigmatism, and the sum of the two axes do not equal approximately 180

Prevalence
Age
Infants are born with ATR astigmatism, where the cornea is the source of the astigmatism Preschool children have little or no astigmatism Teenage children demonstrate a shift towards WTR astigmatism Older adults show a shift towards ATR astigmatism

Prevalence
Gender
In general, there are no significant differences between males and females

Prevalence
Ethnicity
Higher prevalence in North Americans, Latinos Asian infants tend to be WTR astigmatism Caucasian infants tend to be ATR astigmatism

Incidence
General trend
For older adults, the average rate of change towards ATR astigmatism is less than or equal to 0.25D every 10 years

Visual Acuity
Theoretically, at NO distance does an uncorrected astigmat have a sharp retinal image Clinically, if astigmatism is small (less than 0.50DC), the patient may not notice blur

Visual Acuity
Simple or compound myopic astigmatism
Accommodation may make the retinal image even more blurry

Simple or compound hyperopic astigmatism

Accommodation may improve VA to some extent

Mixed astigmatism
VA is relatively good May not need much accommodation

Spherical and Astigmatic Ametropia

Uncorrected VA Spherical Astigmatism (D) Refractive Error (D)* 0.50 1.00

20/30

20/40
20/60 20/80 20/120 20/200

0.75
1.00 1.50 2.00 2.50

1.50
2.00 3.00 4.00 >4.00

Spherical and Astigmatic Ametropia

Spherical refractive error (D)*
Myopia or absolute hyperopia When multiplied by a factor of two, it equals astigmatism (D)

Symptoms
Distorted vision at distance and near Letter confusion Asthenopia or ocular fatigue
Due to constantly squinting to clear up distorted vision

Headaches Squinting

Signs
Decreased visual acuities at distance and near

Clinical Tests
Visual acuity tests distance and near Autorefraction Keratometry Retinoscopy
Most reliable source of information for cylinder power and axis

Monocular subjective refraction, including Jackson cross cylinder

Management
Cylindrical lenses and spherocylindrical lenses in spectacles and contact lenses for simple astigmatism and compound astigmatism, respectively Refractive surgery

Management
Spectacles
Single vision glasses with cylinder

Management
Contact lenses
Toric soft contact lenses Toric rigid gas permeable contact lenses

Management
Refractive surgery
Photorefractive keratectomy (PRK) Laser in-situ keratomileusis (LASIK)