Refraction

Dr. Lakshmi Thaufiq, SpM (K)

DR. Shanti F Boesoirie, SpM.,MKes

Refraction

The optical system of the eye

Dioptri (D) : Lens power unit, is an inverse
of focal distance in meters
D = 1/f

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 (-)

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

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

Lens (-)

 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

 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

-4

Plano K

+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

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

 For object <5 meters distance

rays do not come parallel but
divergent.

If eyes still in relax position, the

images will be focused behind the
retina. So the object will be seen
blurred. images must be
moved forward focused on the
retina by increasing the convexity
of the lens. This process is called
accommodation process.

A
C
C
O
M
O
D
A
T
I
O
N

 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

 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 -2.75 D = 6/6
S -3.00 D = 6/6
S -3.25 D = 6/7
The glasses are S - 2.75 D

S -2.50 D = 6/7

On high myopia, usually full correction are not

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

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.

 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

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

Irregular astigmatism

Right angle
to each other

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

 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

 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