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Refractive Errors
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When the refractive power of the cornea and lens matches the axial length of the globe distant light rays are focussed on the retina, a situation known as emmetropia. If a non-accommodating eye is unable to bring parallel light rays from far objects into focus on the retina then it is called ametropia.

There are three basic conditions that produce ametropia:

 

Myopia (Near-sighted)

This arises when there is a mismatch between the refractive power of the eye and the axial length of the eyeball. Excessive convergent power eg cornea too steeply curved (“refractive” myopia) or increased lens refractive index secondary to cataract (“index” myopia) causes distant light rays to be focussed too quickly in front of the retina. The same effect occurs if the refractive power is normal but the eyeball is excessively long (“axial” myopia).

A myopic individual is unable to see distant objects clearly without the aid of a concave lens eg glasses or contact lenses which diverge the light rays to allow the image to be focussed on the retina.

Myopia: Animation demonstrating corneal steepening (refractive myopia) followed by lengthening of the eyeball (axial myopia), both resulting in parallel rays of light being focussed in front of the retina.

 

Hypermetropia (Far-sighted)

This arises when a mismatch results in distant parallel rays of light being inadequately focussed, the image is formed behind the retina. Either the corneal curvature is too flat (“refractive” hypermetropia) or the eyeball is too short (“axial” hypermetropia).

Younger hypermetropic individuals can increase the refractive power of the eye by accommodating (lens fattens) in order to see a distant object clearly. Older hypermetropic people, with no or limited accommodation, may be unable to see distant objects clearly and are likely to have very blurred near vision unless wearing convex lenses which help converge the light.

Hypermetropia: Animation showing corneal flattening (refractive hypermetropia) followed by shortening of the axial length (axial hypermetropia), both resulting in light rays being focussed behind the retina.

 

Astigmatism

The cornea may not have the same radius of curvature (and therefore refractive power) in all directions, a condition known as corneal astigmatism. A rugby ball is an example of an astigmatic surface with two principle curvatures. Uncorrected optically this results in a blurred image on the retina as at least one curvature will be out of focus at any given time. Many myopic and hypermetropic patients will also have a degree of astigmatism.

Astigmatism: This animation initially presents an emmetropic eye where there is no astigmatism. The cornea is spherical and therefore has equal refracting power in all directions (“soccer ball-shaped” eye). The vertical (green) and horizontal (pink) light rays are both brought to a point focus on the retina.

In the second part of the animation the cornea has an astigmatic surface ie two different curvatures at right angles to each other and therefore two different refracting powers (“American football or rugby ball-shaped” eye). In this example the vertical (green) rays are focussed in front of the retina and the horizontal (pink) rays are refracted by a less curved surface to come to a point focus behind the retina.

 

Presbyopia

This is a progressive loss of accommodative ability of the lens (due to loss of lens capsule elasticity) caused by aging. It usually becomes clinically significant around the age of 45yrs onwards as individuals notice difficulty focussing for near tasks. Presbyopia is independent of the distant refractive error and therefore occurs in people with myopia, hypermetropia and astigmatism. It is treated optically with convex reading lenses.

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Core Principles

1. Ocular Anatomy

2. Ophthalmic History

3. Measuring Visual Acuity

4. External Inspection / Eyelids

5. Everting The Eyelids

6. Anterior Segment

7. Pupillary Reflexes (and Dilatation)

8. Ocular Motility

9. Visual Fields

10. Direct Ophthalmoscopy

Ophthalmology in Practice

1. Red Eye Introduction

2. Red Eye Diagnosis

3. Visual Failure Introduction

4. Gradual Loss of Vision

5. Sudden Loss of Vision

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