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Refractive errors: current thinking

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Wudpecker Journal of Medical Sciences ISSN 2315-7240
Vol. 2(3), pp. 021 - 025, June 2013 2013 Wudpecker Journals

Refractive errors: current thinking

Emmanuel Olu Megbelayin
Department of Ophthalmology, University of Uyo Teaching Hospital, Uyo, Akwa-Ibom state, Nigeria.

E-mail: favouredolu@yahoo.com. Tel: +234-8036670920.

Accepted 12 May 2013

An exhaustive Medline, Pub Med and Cochrane database internet search was conducted with reference
manager 11. Meticulous Google search using keywords such as refractive errors and ametropia fetched
additional information. Refractive errors being an optical defect in which refracted light rays do not
converge on the fovea of a relaxed eye, corrective interventions are either optical or surgical. These
established modalities of treatment, however, may not always translate into freedom from asthenopia.
Optical impurity imperceptibly degrades quality of best corrected visual acuity. This article considers
aberropia a specific tenacious optical impurity rather than a full-fledged refractive status favoured by its
proponents.

Key words: Refractive errors, ametropia, optical impurity.

INTRODUCTION

Refractive error (ametropia) is an optical defect in which
rays of light from optical infinity fail to converge on the
fovea in the non-accommodating eye (Waddell, 2000;
Elkington et al., 1999; Abrams, 1993). Cornea and lens,
the main ocular refractive elements, form a relative thick
lens refracting complex that operates as functional
syncytium. The outcome of cornea-lens interactions on
incident beam of light are refracted rays destined for the
fovea. However, not all refracted rays will reach the
fovea, some fall short while others exceed it (Waddell,
2000; Fred, 1996).
Parallel rays of light come to a focus in front of fovea in
the non-accommodating myopic eyes. Abrams (1993)
reported that Kepler was the first to give a satisfactory
definition of myopia in 1611 and Plempius was the first to
examine such eyes anatomically in 1632 while Donders
established its clinical basis in 1866.
Hypermetropia, a term suggested by Donders in 1958,
refracted rays are brought to a focus behind the retina
when the eye is at rest. Potency of accommodative
efforts determines whether hypermetropia is latent or
manifests (Elkington et al., 1999; Abrams, 1993; Ebri et
al., 2007).
In astigmatism, two focal lines, separated by a focal
interval and straddling circle of least confusion, form by
the principal meridians to emerge a Sturm`s conoid.
Consequently, there is no point focus on the fovea owing
to unequal refraction of incident light by the dioptric
system of the eye in different meridians (Elkington et al.,
1999; Abrams, 1993; Kakuwa and Maiyeku, 2002).This
article sought to appraise refractive errors and emerging
thoughts in ocular optics.
Emmetropization
This constitutes intrinsic mechanisms of the eye to
achieve emmetropia in childhood. Each refractive
component (cornea, lens, axial length) changes in a
complementary and coordinated manner as the eye
grows in order to minimize refractive error (David and
Difford, 2004; Ian et al., 2009; Mutti et al., 2005; Mutti et
al., 2007). It seems possible that the process of
emmetropization is coordinated by the retina-brain
complex, which might tune each refractive component of
the eye to ensure a sharp image. In what appears to be
failed, incomplete or distorted attempt at
emmetropization, myopia and hypermetropia ensue
owing to ‘naturally occurring’ residual incongruity
between the power of the optical elements of the eye and
the axial length.
Various theories have attempted to explain incomplete
emmetropization or secondary ametropia following a
perfect emmetropization.

Genetic theory
The refractive state of the eye is contributed by each
refractive component of the eye; cornea and lens (David
and Difford, 2004; Young et al., 2007). With each having
a refractive index of 1.34 ((Elkington et al., 1999.), the
contributions of aqueous and vitreous are constant and
hardly change with eye growth. Thus the major refractive
components of the eye that undergo changes during the
growth period are the cornea, the lens and the axial
length. The size, shape and power of each are
determined by inheritance (Young et al., 2007).
Many studies have corroborated the familial and
heritability of ocular components of refractive state of the
eye (Hammond et al., 2004; Hammond et al., 2007; Biio
and Corona, 2005; Lee et al., 2005). Biio et al. (2005)
reported that estimates of heritability for axial length
range from 40-94% and anterior chamber depth from 70-
94% with linkage to chromosomes 2p24 and 1P32.2
respectively. Heritability estimates for corneal curvature,
in the same study, was 60 to 92% with linkage to
chromosomes 2p25, 3P26 and 7q22. Lyhne et al. (2001) in
an earlier study among twins aged 20 to 45 years
reported 90 to 93% heritability for crystalline lens
thickness.
Different modes of Mendelian inheritance are
associated with refractive errors including autosomal
dominant (AD) and sex-linked (X-linked). Loci for
autosomal dominant high myopia are located on
chromosomes Xq28, 18p11.31, 2q37, Xq23-25 and 4q. To
date, almost 100% of identified loci for non-syndromic
high myopia are either AD or X-linked with high
penetrance (Lyhne et al., 2001; Young et al., 2007). In a
dizygotic twin study, Hammond et al (2004) found that
Paired box gene 6 (PAX 6) is strongly linked with
refractive errors. Interestingly, emmetropization was
reported by Mutti (2002) to be largely programmed on
genetic basis.
Myopia has the strongest evidence for genetic
susceptibility, although studies have shown different loci
between juvenile-onset myopia (low to moderate myopia)
and high myopia. Conversely, hypermetropia and
astigmatism have weaker and less consistent linkage
with inheritance (Hammond et al., 2001; Lee et al., 2001;
Mutti et al., 2002; Young et al., 2007).
The use-abuse theory
This theory states that close work causes and contributes
to the progression myopia, as seen in the higher
prevalence of myopia in those with more education and
those who engage in more near-work activities (David
and Difford, 2004; Karythryn et al., 2008). Woo et al.
(2004) conducted a study among Medical students in
Singapore reported an alarming myopia prevalence of
Megbelayin 022
89.9%. Medical students are a group of young adults who
spend prolonged periods on reading and close work. With
their intensive study regimen that spans on the average
of 6 years, medical students have been reported to be at
high risk for myopia.
Other theories
Socio-economic status, environment, prematurity, height,
nutritional status, levels of education of parents,
intelligence, intra-uterine environment and bony orbits are
other risk factors linked in various ways to the onset and
progression of refractive errors especially myopia
(Hammond et al., 2001; Saw et al., 2001; Mutti et al.,
2002; Rose et al., 2008).
Presbyopia
Presbyopia is not considered a refractive error like
myopia, hypermetropia and astigmatism. Perhaps,
because rays of light emanating from reading distance of
33.3cm are not parallel but divergent (i.e. negative
vergence). More importantly, presbyopia, being a natural
development of sight, results from physiologic failure of
accommodation due to aging, regardless of eye’s
refractive status ab initio. For an eye to be tagged
ametropic, therefore, it must be accessed by parallel light
rays and its accommodation, if present, should be
relaxed.
Aberropia
Aberropia, coined by Agarwal et al. (2002), was defined
as a refractive error that results in a decrease in visual
quality attributable to high order aberrations (HOAs).
Lower order aberrations are responsible for spherical
and/or cylindrical errors. The availability of aberrometers
of which there are three types; Tschering, Hartmann-
Schack and Ray tracing has enabled wavefronts to be
determined and measured thereby unveiling poor vision
due to aberropia. Interesting, aberropia has been linked
with residual visual complaints following ametropic
correction. These complaints could arise despite best
corrected visual acuity (BCVA) of 6/6.
Although the term aberropia is relatively new, ocular
and spherical aberrations, from which it evolved, have
been well studied (Megbelayin, 2012). Inherent in ocular
refractive apparatus: tear film, cornea, lens, vitreous and
retina are spherical aberrations (Abrams, 1993; Elkington
et al., 1999). Fortunately, the human eye has various
innate corrective mechanisms that obviate effects of
image imperfections, including the retinal Stiles-Crawford
effect (Elkington et al., 1999). It can then be speculated
023 Wudpecker .J. Med. Sci.
that residual image imperfections occur when these
intrinsic efforts are overwhelmed.
Aberropia is possibly a sub-refractive entity rather than
full-fledged refractive error promoted by its proponents.
Because two lens effects (either positive or negative):
positive sphere (for hypermetropia), minus sphere (for
myopia) and positive or negative cylinder (for
astigmatism) influence ocular refractive apparatus to
focus images on the retina. Since there is no third lens
type, a new refractive error is unlikely. Again, the
established treatments of aberropia introduce a
cumulative plus lens or minus lens effects on ocular
optical system signifying that the extra visual improvement
on BCVA was an uncorrected (missed) refractive error.
Additionally, based on existing classification of
aberropia, majority of the causes are pathological
(Agarwal et al., 2002; Agarwal et al., 2003). Refractive
errors are by definition, non-pathologic, improved with
Pin-hole (PH) and correctable to 6/6 except in amblyopia
or pathologic ametropias.
Aberropia appears an optical impurity with unusual
tenacity and dioptric insignificance. Refractive errors are
corrected within 0.25 diopter spheres (DS) errors and
patient often cannot improve on numbers or clarity of
Snellen’s charts optotypes read when BCVA is attained
with addition or subtraction of 0.25DS (George, 2006).
Hence, whatever is responsible for post correction
residual visual dissatisfaction found in patients with
aberropia despite BCVA of 6/6 could not have been due
to missing 0.25DS to which the eyes were insensitive?
Aberropia should therefore be considered a qualitative
rather than a quantitative phenomenon given that the
dioptric net effects are less than 0.25DS on the ‘clinical
eye’. By clinical eye, it is meant best corrected eye.
Being without significant dioptric effects, optical impurity,
rather than refractive error, appears appropriate to qualify
aberropia in that it sabotages corrected retinal image
fidelity, rendering it less than perfect (‘impure’).
Unity theorem of optical impurity (proposed by this
article)
For BCVA to be faultless, with immaculate fidelity, in
which patients are free from all residual complaints, a
state of optical neutrality appears to exist. Therefore;
1.
Where x is optical impurity
Equation above means the limit of function of x, f(x), as
0
x approaches x is 1. In other words, the function of x can
be made to be as close to 1 (unity), by making x
sufficiently close to x0. This means, as effects of optical
impurity on corrected refractive error tends to zero (become
infinitesimally small), it effects on corrected vision
becomes negligible because a state of optical unity is
attained. Unity in this context is a state of optical
neutrality, quiescence or noninterference in which the net
effects of optical impurity do not interfere with corrected
ametropia culminating in BCVA with no residual
complaints.
Examples of optical impurity (table 1)
High Order Aberrations (HOAs)
Patients suffering from HOAs report residual visual
complaints despite BCVA of 6/6. The HOAs of major
clinical significance are coma (vertical and horizontal)
and spherical aberrations (Weitz and Cummings, 2011).
The possibility exists that HOAs constitute tenacious sub-
dioptric impurity missed during conventional optical
correction. Aberropia has been largely linked with HOAs
(Agarwal et al., 2002).
Chorioretinal diseases
The retina is akin to a film of a camera. It is likely that
certain conditions confer on this ocular “film” poor image
resolution capability. These conditions include epiretinal
membrane, myopic degeneration, occult maculopathy,
retinal folds et cetra. Perhaps, poorly resolved retinal
images do not regain fidelity despite normal cortical
processing and maximal optical corrections.
Accommodation convergence accommodation
(AC/A) anomaly
Convergence insufficiency and paralysis of
accommodation are non-refractive accommodative
entities. Persistence of AC/A anomaly results in a
dissatisfied vision due to altered near synkinesis. It is
likely that a deranged binocular interaction associated
with this condition introduces image-compromising status
on the retina. This could be attributable, at least in part, to
asymmetrical simultaneous retinal perception despite
equal and corrected retinal image sizes. Therefore,
conventional optical corrections are inept in removing the
non-refractive entities (introduced by AC/A anomaly),
christened optical impurity by this article.
Pupillary anomalies
The optimal pupil size is 2 to 6mm, outside this range
miosis or mydriasis ensues. Despite optimal optical
 Megbelayin 024

Table 1. Causes of optical impurity.

High order aberrations (Weitz and Cummings, 2011)

 DUE TO OPTICAL IMPERFECTIONS
 Spherical aberrations from high-powered lenses
 Coma
 Curvature of field
 Pin-cushion or barrel shaped
 POST SURGICAL
 Post penetrating keratoplasty
 Post refraction surgery
 IOL-induced aberrations(inherent in IOL or IOL malposition)
 Aberrations due to post-op capsular abnormalities
 MISCELANEOUS CAUSES
 Keratoconus and other corneal ectasias
 Corneal trauma, scars
 Other causes of irregular astigmatism
 Incipient cataract
 Lenticonus
 Subluxated lens, coloboma lens
 Vitreous opacities
Other non-refractive causes
 CHORIORETINAL DISEASES
 Macular Epiretinal membrane (ERM)
 Myopic degeneration
 occult maculopathy
 Chorio-retinal folds involving macular
 AC/A ANOMALY
 Convergence insufficiency
 Paralysis of accommodation
 ABNORMAL PUPILLAY SIZE
 Mydriasis (causes peripheral aberrations)
 Miosis (causes diffraction)
 DECREASED CONTRAST SENSITIVITY
 Glaucoma
 GLARE
 Occult incipient cataract
 Corneal facet scar
 SPECTACLE INTOLERANCE
 QUALITY OF AMBIENT LIGHT
 EMOTIONAL STATE

corrections, abnormal pupil size tends to create problems
with image clarity. Perhaps, diffraction with resultant airy
disc (seen with miosis) and excessive peripheral
aberrations (with mydriasis) introduce a non-refractive
entity (optical impurity) irresponsive to refractive
corrections.
spectacle by patients poses an enormous threat to
maximizing the corrective potentials offered by optical
option. Spectacle phobias or hatred of this magnitude
should be isolated as non-refractive impediments (optical
impurity) that attenuate benefits derivable from optical
correction.

Spectacle intolerance Decreased contrast sensitivity

Despite accurate refraction and dispensing of appropriate
refractive correction, ametropic patients may still express
dissatisfaction with BCVA. Patient’s emotional state and
unwillingness to accept refractive spectacle create
invisible barriers between refractive lenses and the
objects they are meant to see. Morbid rejection of
Glaucoma, corneal facet scar, incipient cataract and poor
ambient light create contrast problems. In severe forms of
these conditions refractive spectacles may not be helpful.
As each condition evolves, however, a stage is reached
when contrast between objects and their environment is
severely affected. Often objects are identified but clarity
025 Wudpecker .J. Med. Sci.
is jeopardized. It is being considered that conditions
associated with reduction in contrast add a sub-refractive
moiety (optical impurity) that thwarts the full benefits of
ametropic corrections.
Emotional lability and stressors
There are myriads causes of emotional instability,
ranging from mind boggling worries ignored by the
patients to manifest conditions. Examples will include
anxiety disorders, pregnancy and puerperal anxieties,
menstrual anxieties in adolescents, general debility,
anemia, malaria, malnutrition, drug-related, chronic
alcoholism, excessive near work, etc. These stressors
are occasional non-refractive accomplices of ametropia.
Unlike the latter, however, they subsist despite refractive
corrections. These optically unyielding sub-refractive
entities can be isolated as optical impurities because they
influence BCVA quality.
Spurious
Functional visual loss seems to form an invisible non-
refractive barrier (optical impurity) between spectacle
corrections and objects they are meant to see. Malingers
and hysterics could report dissatisfaction with optical
correction at a BCVA of 6/6. Malingers complain to get
compensations but hysterics complain subconsciously. If
unidentified, these conditions could pose serious
challenges because no action seems to resolve the
problems.
OPTICAL IMPURITY
Principles of treatment
Optical impurity being non-refractive could be sieved from
ametropias to which they are often tenaciously
associated. It is possible that the determination of
wavefronts unveils tenacious optical impurity. Correction
of aberropia takes into cognizance ocular optical
aberrations and corneal topography which are pre-
determined by aberrometry. Consequently, wave front
guarded laser ablation of pre-determined cornea will
bring about hair-line refractive correction that engenders
retinal image fidelity as seen in treatment of aberropia.
Pilocarpine, a cholinergic agonist, can be instilled into
the eyes to constrict an abnormally dilated pupil. The
resultant pin-hole effect allows only paraxial rays of light
into the eye. These rays of light are not affected by ocular
aberrations, thus improving the vision of patients.
Diffraction is the main impediment to the use of induced
miosis as a therapeutic option.
Orthoptic exercises may be useful in convergence
insufficiency. Clinico-pathologic conditions like incipient
cataract, macular pucker and glaucoma et cetra should
be looked for and treated using established means.
Multidisciplinary approach is advocated for patients with
emotional disturbances. Other modalities of managing
nagging residual asthenopia in patients with normal
BCVA would include psychotherapy, nutritional
assessment, improving on ambient light, counseling,
relaxation and internists’ review.
Conclusion
Aberropia is not a full-fledged refractive error but a
plausible optical impurity that sabotages retinal image
fidelity following conventional refraction.
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