Lecture 4 ophthalmology

OCULAR REFRACTION

Visual analyser performances

 Phisical status of refractive components (correct focus on the retina);
 Retinian neurons quality;
 Brain neurons quality.

Ocuar refraction is defined by the anatomical components which contribute on light

array optical modulation

transparent mediums
 lacrimal layer
 cornea
 aqueous humour
 lens
 vitrious

Ocular refraction
 static refraction
 dinamic refraction

Subjects
1. Ametropia
2. Hyperopia
3. Myopia
4. Astigmatism
5. Anizometropia
6. Accomodation
7. Presbyopia

EMETROPIA
 emetropia is that optical condition in which there is no refraction error so that rays
of parallel to the visual axis appear entering the eye are brought to a focus on the
fovea centralis when no accommodation is used

AMETROPIA classification
 spherical or stigmic disorders in which enter:
 myopia
 hyperopia

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  asferical or astigmic disorders in which we include astigmatisms:
 regular
 iregular

HYPEROPIA
 refractive condition of the eye in which (with accommodation suspended) parallel
rays of light are intercepted by the retina before coming to focus

Clasification of hyperopia
 Axial = when the globe is too short to the amount of the refractive power present;
 Refractive = when the power of the cornea and lens is inadequate for the length
of the globe

Type of hyperopia
 Total hyperopia = amount of the hyperopia with all accommodation suspended
(by using the cycloplegic drugs);
 Manifest hyperopia = is the maximum hyperopia that can be corrected with a
convex lens when accommodation is active;
 Latent hyperopia = is the difference between total and manifest hyperopia

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Signs and symptoms
 Visual acuity is reduced when accommodation is not able to fully substitute the
hyperopia;
 Vision is blurred, especially after near work;
 The increased of the accommodation may stimulate an excessive degree of
convergence, manifested as a tendency of for the eyes to deviate inward
(esodeviation);
 The cornea is smaller than normal, and even the globe itself may be smaller;

Oftalmoscopy
optic disk congestive, with indistinct margins and the absence of the physiologic cup
(pseudopapiledema)

Treatment
 convex lenses (glases or contact lenses)
 corneal refractive surgery:
 Laser thermal keratoplasty
 Lamellar keratoplasty
 Photorefractive keratectomy
 Laser in situ keratomileusis (LASIK)
 phakic intraocular lenses using iris-claw IOL;
 clear lens extraction with posterior chamber lens implantation.

MYOPIA
optical condition in which rays of light entering the eye parallel to the visual axis come to
focus in front of the retina

Clasification of myopia

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  Axial = because the refractive power of the cornea and lens is too great for the
length of the eye;
 Refractive = because the eye is to long for the refractive power present

 physiologic myopia
 refractive (lenticular myopia – is refractive myopia related to the lens
power)
 axial
 pathologic or degenerative myopia – is axial myopia

physiologic myopia
 is the most common type
 onset usually between 5 and 10 years of age but may begin as late as 25 years age
 gradually increase until the eye is fully grown about 18 years of age
 seldom exceeds 6 diopters.

pathologic or degenerative myopia

Symptoms
 decreased vision
 axial length of the eye is excessive, primarily because of overgrowth of the
posterior two thirds of the globe

oftalmoscopy
 crescent of the optic disc that begins at the temporal side and progresses to
surround the disc.
 Staphyloma of the posterior pole .
 hyperpigmented spot in the macula (Fuchs spot).
 degeneration of the retinal pigment epithelium
 choroidal sclerosis.
 peripheral retinal thinning with lattice degeneration and retinal breaks.

Treatment
 is neutralized by concave lenses
 contact lenses (in high myopia, anizometropia); highly fitted contact lenses may
temporarily reduce the corneal curvature and thus may show an apparent decrease
in myopia

Refractive surgery
 radial keratotomy acts through peripheral radial incision that flatten the
central cornea
 photorefractive keratectomy (PRK) ablates tissue directly from central
cornea.
 laser in situ keratomileusis (LASIK) excimer application (PRK) after
creation of a hinged flap

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  posterior chamber phakic intraocular lens (implantable ocular lens)
 intracorneal implants

For high myopia

 laser photocoagulation for symptomatic retinal breaks
 extrafoveal or juxtafoveal laser photocoagulation therapy
 combination between LASIK and phakic intraocular lens = “BIOPTIC”
 scleral enforcement to stop or to retard the progression of disease
(controversial and under investigation

ASTIGMATISM
 optical condition in which the refractive power of the eye is not the same in all
meridians.
 variation in the curvature of the cornea or lens at different meridians induces light
rays focusing to more than one point.

Classifications
 irregular = when the meridian are not at right angle to each other
 regular = when the meridian of minimal and maximal refraction are at right angle
to each other. Regular astigmatism can be:
 with the rule – when the vertical meridian is steepest and a
correcting plus cylinder should be placed at axis 90°
 against the rule – when the horizontal meridian is steepest and a
correcting plus cylinder should be placed at axis 180°
 oblique astigmatism – the principal meridian do not lie at or close
to 90° and 180°

Classifications II
 simple: when one meridian is emetropic and other is ametropic (myopic and
hypermetropic)

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  composed: when both meridian are ametropic
 myopic = both meridian are in front of the retina
 hypermetropic = both meridian are intercepted by retina before coming to
a focus
 mixed astigmatism: one meridian is myopic and other is hypermetropic
Classifications III
 congenital astigmatism
 acquired astigmatism:
 surgical incision o the cornea
 trauma and scarring of the cornea
 tumors of the eyelid pressing upon the globe

Pathogenic aspects
 parallel rays of light do not focus at a point. Each meridian has a focal line; the
distance between these focal lines is the “interval of Sturm”. Between the focal
lines, in the circle of least diffusion (conffusion), the diverging and converging
tendency of the light rays is the same. In this area the image is clear enough to
satisfy the patient

Symptoms and signs

 the image is not clear
 the accommodation is interfered
 severe astigmatism may cause the optic disc to appear oval rather then
near circular

Treatment
 Minor degree of astigmatism with good VA and without symptoms –
correction is not indicated
 Simple astigmatism – cylindrical lens placed in the meridian 90 degrees
away from the axis of the ametropic meridian
 Composed and mixed astigmatism – sphero-cylindric lenses
(combination of a sphere and a cylinder -plus or minus- )

 Hard contact lenses may be used to correct regular astigmatism and

especially the irregular astigmatism
 Surgery
 incisional surgery (relaxing incisions, block resection,
compressive suture) is indicated in congenital regular astigmatism
 excisional surgery (excimer laser – PRK and LASIK) is
recommended both in regular and irregular astigmatism

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ACCOMMODATION
process by which the refractive power of the anterior lens segment increases so that a
near object may be distinctly imaged upon the retina

complex reflex
 the stimulus is a blurred retinal image
 this is coming to brain
 different area of the brain send order to the periphery
 stimulation of the short ciliary branch of the oculomotor nerve constricts or
relaxes the circular ciliary muscle
 the eye almost instantly adjust to provide clear vision.

For near vision

 contraction of the ciliary muscle causes
 the zonulae fibers to relax
 then lens become more convex
 the power is increased
 the focal line is projected onto retina.

For long distance

 ciliary muscle relaxes
 the zonulae fibers are pull and tensioned
 the convexity of the lens surface becomes minimal

amplitude of accommodation
 is distance between far point of the eye and nearest point at which the eye can
maintain focus
 amplitude of accommodation is properly a monocular expression and is measured
for each eye independently

accommodation associated reactions

 convergence of the eyes
 pupilary constriction (miosis)

presbyopia
 with ageing
 lens capsule becomes less elastic
 nucleus becomes harder and less compressible
 this causes a gradual loss of accommodation

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Symptomes
 inability to see near work distinctly
 patient places reding mater farther away from the eyes than previously
 ocular discomfort

Evolution of accomodation
 10 years age - 14Dpt.

 45 years age - 1Dpt.,

 50 years age - 2Dpt. ,
 55 years age - 2.5Dpt. ,
 60 years age - 3Dpt. ,
 70 years age - 3.5Dpt

Special situations
 Myopic patients may compensate for presbyopia by removing the lens that
corrects the distance vision.
 Presbyopia is aggravated in a hypermetropic patients if the lens that corrects the
hypermetropia is removed

Treatment
 convex lenses added to the distance correction;
 Rules:
 the weakest possible convex to permit the individual to carry an vocational
and avocational tasks;
 if a subject requires lenses for distance, bifocal, trifocal or multifocal
lenses should be worn as soon as are indicated

Convergence insufficiency (CI)

 the inability to maintain fusion at near as a result of a reduced amplitude of
fusional convergence power.
 Symptomes:
 eye discomfort
 headache
 blurred vision from reading or doing near work
 Signs:
 reduced amplitude of accommodation
 exoforia

Accomodative insufficiency (AI)

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  symptoms develops after 20-40 min of reading (same as CI) but:
 these patients have normal fusion capacities when a 4 diopters base in prism is
placed in front of the eye while reding
 patients with AI benefit from reading glases

Accomodative spasm (AS)

 inability to relax ciliary muscle (involuntary)
 is associated with stressful situations or functional nevroses
 Symptoms:
 bilateral blurred distance vision
 headache,
 fluctuating vision
 Sings:
 cycloplegic refraction reveals hyperopia
 abnormally close near point of focus
 miosis

ANISOMETROPIA
 condition in which the refractive error of each eye is different
 the different is more than 2 diopter there is a different in image size of the two
eyes named anizeiconia
 total amount of aniseiconia suported by patient must be less then 8%

several problems
 the difference of the power of the two lenses (bifocal lenses) induce a vertical
prism, so that the image from each eye is on a different level (anisophoria);
 severe anisometropia may cause ambliopia because of the developing infant`s
failure to use the eye with greater refractive error;
 failure of central vision leads to strabismus, to absence of binocular vision or to
deficiency of binocular vision

Treatment
 must be done in the first year of life
 must to equalize the size of the retinal image.
When:
 the refractive difference between two eyes is smaller then 4D = full corection with
glases
 this difference is greater we can use:

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 contact lens corection
 specific surgical procedure for each type of refractive error

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