Refraction

Refraction
Consists of :
General Optics
The optical system of the eye
Clinical anomalies : refractive errors

Optic
Dioptri (D) : Lens power unit, is an inverse
of focal distance in meters
D = 1/f
1 D lens, parallel light will be directed into
focal spot in 1 meter distance
2 D = 1/f ----> f = ?
If f = 25 cm , ----> D = ?

 Parallel rays will be converged to the focus ---> Plus lens (+)

or will be diverged as if it comes from the focus ----> Minus

Lens (-)

Principles
Rays coming from distance > 5 m
parallel rays
Rays coming from distance < 5m
divergent rays

 Spherical lens
Is a lens with the same curvature diameter in
all meridians

Spherical Convex (+)

Spherical Concave (-)

 A convex lens may be regarded as a series

of prisms bases toward the middle of the
lens
A concave lens may be regarded as a series
of prisms apex toward the middle of the
lens

 Prismatic Effect that occur on eye glasses

explain :
Against motion with (+) Lens
With motion, with (-) Lens

Spherical Lens :
Plus sphere : Convex
characteristic : makes larger and nearer images
+2

+2

Biconvex

+4

Plano K

+5

-1

Concave K

 Minus sphere : Concave

Characteristic : makes smaller and farther images

-2

-2

Bi Concave

Plano K

-4

+1

-5

Convex K

Parallel rays will be centered or diverged

from the focus

Cylindrical Lens
Is a kind of lens that have two
meridians that are perpendicular
to each other
The meridian that has no power
is called the axis
The other meridian, has the
power

 Spherocylindrical Lens
Is a combination between spherical lens and
cylindrical lens
Example :
C + 1.00 D X 90 0

S + 2.00 D
0.00

+ 2.00

+ 2.00

+ 2.00
0.00
+ 1.00

+ 2.00
+ 1.00

+ 2.00

+ 3.00

 Transposition
Methods :
Sphere : Sum with algebra ways SPH + CYL
Cylinder : replace power marks (Neg
Pos),
axis change 90 degrees
Example : S + 2.00 C + 1.00 X 900
S + 3.00

C - 1.00 X 1800

Eye as an Optical Instrument

Refraction media :

Cornea
Humour Aqueous
Lens
Vitreous body

n = 1.33
n = 1.33
n = 1,41
n = 1.33

Haziness on refraction media --> disturbances of vision

 Power of refraction of the eye ball

Totally
Cornea
Lens

: 60 dioptri
: 40 dioptri
: 20 dioptri

 Accommodation Process
Capability of adding the refraction power of the
eye, by increasing the convexity of the lens
normal : rays that come from > 5 m - distance
object regarded as parallel light; the eyes are in
relax position, the images are focused right on
the retina (fovea centralis)

 For object at less than 5 meters

distance, the rays do not come
parallel but divergent. If the eyes
are still in relax position, the
images will be focused behind the
retina. So the object will be seen
blurred. These images must be
moved forward so it will be
focused on the retina by increasing
the convexity of the lens. This
process is called accommodation
process.

 This accommodation
process happens as a
result from the
contraction of M. ciliaris
in the ciliary body

 These reflexes also happen during the

accommodation process :
Accommodation
Miosis
Convergents

Near Reflex

Refraction Anomalies
Normal : Emetropia
Anomalies : (ametropia)
Myopia
Hypermetropia
Astigmatism
Presbiopia

 Emmetropia
Is the condition when the parallel rays focused
exactly on the retina of the eye in relax condition
---> the visual acuity is maximum

 Ametropia
Is the condition when the parallel rays are not
focused exactly on the retina of the eye in relax
condition.
The focal point may be behind or in front of the
retina

Hal 47, 4.2 Duke Elder

 Myopia
Refractive condition in which, with
accommodation completely relaxed, parallel
rays are brought to a focus in front of the retina.
Myopic eye : refractive state over plus power

 Factors that causing myopia :

Axial : The antero-posterior axis of the eye ball > normal
in this case, the refraction power of the cornea, lens and the lens
position are normal. The eye usually looks like proptosis

Curvature :
The size of the eye ball ---> normal, but there is a increasing of the
cornea/lens curvature
The change of the lens e.g. : intumescens cataract

Increasing of the refraction index

could occur on Diabetic patient

Changes of the lens location

changes of the lens position to the anterior after glaucoma surgery
lens subluxation

 Clinical findings :
Farsightedness are blurred, nearsightedness are normal
Asthenopia
On high myopia : hemeralopia occurred caused by
periphery retinal degeneration
Floating spots visualization caused by vitreous
degeneration
screw up the eye lids together, in order to get a better
vision

On high myopia ----> proptosis simulation, deep

Anterior Chamber

 Funduscopy : Tigroid fundus ---> thin retina and

the choroid, myopic crescent arround the papilla
area, sthaphyloma posterior

 Complication :
Commonly occurred on high myopia
1. Degenarated and liquefied vitreous
2. Retinal detachment
3. Pigmentation changes + Macular bleeding
4. Strabismus

Myopia classification :
< 3.00 D
= low myopia
3.00 - 6.00 D= moderate myopia
> 6.00 D
= high myopia/gravis

 Treatment :
Low and moderate myopia : full correction with
weakest spherical lens that give the best visual acuity
Example :
VOD = 5/60
S -2.50 D = 6/7
S -2.75 D = 6/6
S -3.00 D = 6/6
S -3.25 D = 6/7
The glasses are S - 2.75 D

On high myopia, usually full correction are not given

due to headache that may occurred. If necessary,
reading glasses can be given ---> bifocal glasses

 Prognosis :
Simplex/stationer, after puberty will be constant
Progressive myopia, the myopia will be
continuously higher and complication may
occurred

Hypermetropia
Is a refraction anomaly that without accommodation
parallel rays will be focused behind the retina
Divergent rays from near object, will be focused farther
behind the retina

 Etiology :
Axial ---> eye ball diameter < N
Deminished convexity of cornea/lens curvature
Decreasing Refractive index
Changed lens position

 Clinical manifestation :
H. Manifest ---> is detected without
paralazing accommodation and is represented
by the strongest convex glass needed , the
patient sees most distinctly. It correspons to the
amount of accommodation which he relaxes
when a convex lens is placed before the eye.
Devided into two types :
Facultative : Can be overcome by an effort of
accommodation
Absolute : Can not be overcome

 Total Hipermetrop : detected after the

accommodation has been paralyzed with
cylcopegic agents
Latent Hypermetrop : is the diference of the
total hypermetrop with the manifest
hypermetrop

Hypermetrop

Latent Hypermetrop

Hypermetrop manifest

 Clinical finding :
Nearsightness are blurred
High hypermetropia at old age : farsightedness
also blurred
Astenophia accommodative (eye strain)
Children : high hypermetropia usually
occurring convergent strabismus (convergent
squint)

 Treatment :
If foria/tropia not present, apply strongest
positive spherical lens that give the best visual
acuity
If foria/tropia present, total hypermetrop
correction. If necessary : bifocal eye glasses

astigmatism
Refractive condition of the eye in which there is a
difference in degree of refraction in diferent
meridian, each will focused parallel rays at a
different point. The shape of the images :
Line, oval, circle, never a point

 Manifestation :
Regular astigmatism
Difference in the degree of refraction in every
meredian.
Two principles meridian :
Maximmum refraction
Minimum refraction

Right angle
to each other

Irregular astigmatism
Difference in refraction not only in different
meridians, but also in different parts of the same
meridian.

 Etiology of astigmatism :
Corneal curvature disturbances ---> 90%
Lens curvature disturbances ---> 10%

Type of Astigmatism :
Ast. M. Simplex

C-2.00 X 90

Ast. H. Simplex

C+2.00 X 45

Ast. M Compositium

S-1.50 C-1.00 X 60

Ast. H Compositium

S+3.00 C+2.00 X 30

Ast. Mixtus S+2.00 C-5.00 X 180

0
0
0
0
0

Ast. M. Simplex

Ast. M Compositium

Ast. H. Simplex

Ast. H Compositium

Ast. Mixtus

Presbiopia
Physiological changes because accommodation
capability is lowering at old age
Accommodation
16

10
6

2
10

20

40

50

60

Age

 Presbiopia correction :

40 years old
45 years old
50 years old
55 years old
60 years old

S + 1.00 D
S + 1.50 D
S + 2.00 D
S + 2.50 D
S + 3.00 D

Consider the type of previous/history work

Tailor
Architect
Weld engineer

Refraction Examination
Technique
Subjective :
Snellen chart/projector, alphabet , inverse E, picture,
Landolt ring
Trial lens
Trial frame

Objective :
Children, incooperative, difficult correction, strabismus :
Ophthlamoscopy
Retinoscopy
Refractometer

 Subjective
Check firstly just one eye : OD
Distance : 5 or 6 meters
VOD : ...(basic right eye visus)
a. Trial and error
apply S + 0.50, better visus , add S+ until visus = 6/6
S +0.50, lower visus, change to S -, increase S - until visus
= 6/6
S +/- not working ----> cylindrical
With astigmatism dial, stenoplic slit, cross cylinder
astigmatism dial :
Blurred line ----> C negative lens axis

 One by one fogging

S + sp. Lens --> blurred vision, step by step distracting
---> best sp.

Nearsightedness/read
Both eyes at one time at required distance : use jaeger
chart

 Example :
ODS 6/6
I. AVOD 2/60 S - 3.50 = 6/6
headache, eye strain
AVOS 3/60 S - 3.00 = 6/6
ODS 6/6
II.AVOD 2/60 S - 3.00 = 6/7
w/o headache, eye strain
AVOS 3/60 S - 2.75 = 6/7
read ADD S + 1.50
Give Eye Glasses according to II

 Objective
Use cyclopegic
1. Ophthlamoscopy : papilla clearly seen with
which lens
2. Retinoscopy :
Ordinary ---> light source outside
streak -----> light source inside

3. Refactometer
Computerized
Lensmeter principal

 Ideally :
Subjective
Objective with cyclopegic
Subjective once more without cyclopegic

Lens meter
Measuring lens power
Measuring focus distance

 Measuring Pupillary Distance

drop the flashlight light onto both eyes, the
light is coming from in front of the patient,
The patient look at the observer forehead or
the light ----> measure the distance of light
spot between OD and OS ----> as near pupil
distance
Far distance :
add 2 mm ---> for pupil distance less than 60
mm.
Add 3 mm ---> for pupil distance more than 60
mm

 Eye Glasses
Monofocal
Bifocal
Progressive

Eye Glasses Prescription, the components are :

Which eye (OD or OS)

Power of the lens ( + or - , Power, axis)
ADDE for reading
Pupil distance far/near
Name of the patient

Binocular Optical Defects

Anisometropia :
Condition wherein the refractions of the two eyes are
an equal
variation :
Myopia
M
H.
H.
M.

M.
E.
H.
H

E.

Antimetropia

 Vision in Anisometrop
difference < 2.50 D : still get fusion + single
binocular vision
difference > 2.50 D : fusion difficulties ---->
weak eye suppression ---> amblyopic
alternans vision : left and right alternate

Aniseikonia :
The difference of shape and size of the images
between right and left eye

 Limitation of the eye glasses

cannot applied for anisometropia more than 2.50
Dioptri
anisometropia causing aniseikonia

Contact lens :

Hard ---> rigid lens

Soft

Indication :

High anisometropia
irregular astigmatism
Front asymmetry, orbit
Aniridia
Descemetocele
Sports
Cosmetics