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Eye Optics and

Refractive Errors
By: John J. Beneck MSPA, PA-C
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Case 1
14 year old boy comes to primary care
office c/o inability to see the blackboard in
school
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Case 2
51 year old man presents c/o difficulty
reading the news paper: My arms are too
short!
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Case 3
6 year old girl presents with mom who
states she squints when looking at anything
more than 2 feet away.
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Objectives
Understand the optics of the eye
Understand visual acuity assessment
Understand common refractive errors
Understand color perception assessment

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Objectives (Cont.)
Understand common refractive errors in
terms of:
Etiology/pathology
Clinical presentation
Course and prognosis (when appropriate)
Diagnosis
Interventions/treatments

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Abbreviations
C/o complaining of or complains of
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Visual Acuity
Use Snellen chart
Positioned 20 feet away

Each Eye Alone, Then Together

With Corrective Lenses (If indicated)
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Snellen Charts
http://store6.yimg.com/I/sightmart-eye-care-products_1753_2381891 accessed 9/5/03
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Visual Acuity
Visual acuity is expressed as two numbers
The first indicates the distance of the patient
from the chart
The second indicates the distance at which a
normal eye can read the line of letters
Ex: 20/50
Visual Acuity
20/20
ability to see letters of a given size at 20 feet
20/40
what a normal person can see at 40 feet, this
person must be at 20 feet to see.
20/200
what a normal person can see at 200 feet, this
person must be at 20 feet to see.
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Further Acuity
Assessment/Diagnosis
Optometric examination
Cornea
Anterior chamber
Posterior chamber
Retinal examination and imaging
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Image Reception
Optics/Refraction
Air anterior Cornea
2/3 of the refractive power of the eye
Posterior Cornea aqueous humor
Iris / pupil
Variable aperture
Aqueous humor anterior lens
Posterior lens vitreous humor
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Image Reception
Convex refraction
Refractive index
Convergence
Image reversal
Perception

Blind spot
Refractive Principles of a Lens
Convex lens focuses light rays
Figure 49-2; Guyton and Hall
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The Refractive Principles of a Lens
Figure 49-8; Guyton and Hall

Refractive Principles of a Lens
Concave lens diverges light rays.
Figure 49-3; Guyton and Hall
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Whats next?
Emmetropia (normal vision)
Myopia (near-sighted)
Hyperopia (far-sighted)
Inability of the lens to accommodate adequately
for near vision
Presbyopia
Astigmatism
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Myopia (Near-Sighted)
The patient is able to focus on objects near but not far
away
Typical complaint is difficulty focusing on road signs or
the black board
The lens is unable to flatten enough to prevent conversion
of images before reaching the retina
The image comes into sharp focus in front of the retina
Frequently squinting is compensatory mechanism

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Errors of Refraction
Figure 49-12; Guyton and Hall

Normal vision
Far sightedness
Near sightedness
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Myopia Correction
Corrective concave lens use
Glasses
Contact lenses
Surgical
LASIK (greatest range of correction for myopia)
Laser-Assisted In Situ Keratomileusis
Epithelial flap cut and lifted
Laser applied to deep layers of cornea
Flap repositioned
Squinting?

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Correction of Myopic Vision
Figure 49-13; Guyton and Hall

Myopia corrected with
concave lens
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Depth of Focus
Effect of pupil size on focus in myopic patients
Note the difference in divergence of rays as
they reach the retinal surface
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Hyperopia (Far-Sighted)
The patient is able to focus on objects far away
but not close up
Typical complaint is difficulty reading
The image comes into sharp focus behind the
retina
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Errors of Refraction
Figure 49-12; Guyton and Hall

Normal vision
Far sightedness
Near sightedness
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Hyperopia Correction
Corrective convex lens use
Glasses
Contact lenses
Surgical
LASIK
Laser-Assisted In Situ Keratomileusis
Epithelial flap cut and lifted
Laser applied to deep layers of cornea
Flap repositioned

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Correction of Hyperopic Vision
Figure 49-13; Guyton and Hall

Hyperopia corrected
with convex lens
Presbyopia; The Inability to
Accommodate
Caused by progressive denaturation of the proteins of the
lens.
Makes the lens less elastic.
Begins about 40-50 years of age.
Near point of focus recedes beyond 22 cm (9 inches).

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Astigmatism

Unequal focusing of light rays due to an oblong
shape of the cornea
Presents with relatively stable blurry vision
Patient unable to focus on objects near or far
Near vision is typically better
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Astigmatism
Vertical focal point different from Horizontal
focal point
Cornea lacks discoid continuity
More curved in one plane than another
Unable to correct with a single concavity or
convexity index
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Exaggerated Astigmatic Corneal Shape
Notice the difference in
the degree of curve of the
cornea in 2 planes
Cornea: face-on
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Astigmatism Correction
Cylindrical optical refractive correction
Glasses
Contact lenses
Surgery
LASIK
Laser-assisted in situ keratomileusis

Cataracts
Cataracts
cloudy or opaque area of the lens
caused by coagulation of lens proteins
More to come
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Cataract
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Cataract Correction
Surgical
The lens is replaced
Induces presbyopia
Frequently dramatically improves far vision
Pigment Layer of Retina
Pigment layer of the retina is very important
Contains the black pigment melanin
Prevents light reflection in the globe of the eye
Without the pigment there is diffuse scattering of
light rather than the normal contrast between dark
and light.
This is what happens in albinos
poor visual acuity because of the scattering of
light
Best corrected vision is 20/100-20/200
Color Vision
Color vision is the result of activation of cones.
3 types of cones:
blue cone
green cone
red cone
The pigment portion of the photosensitive
molecule is the same as in the rods, the protein
portion is different for the pigment molecule in
each of the cones.
Makes each cone receptive to a particular
wavelength of light
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Each Cone is Receptive to a
Particular Wavelength of Light
Figure 50-7; Guyton & Hall
Color Blindness
lack of a particular type of cone
genetic disorder passed along on the X
chromosome
occurs almost exclusively in males
about 8% of women are color blindness carriers
most color blindness results from lack of the red
or green cones
lack of a red cone, protanope.
lack of a green cone, deuteranope.
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Eyes & Visual Pathways
Ishihara Test for Color Blindness

The individual with normal color vision will see a 5 revealed in the
dot pattern.
An individual with Red/Green (the most common) color blindness
will see a 2 revealed in the dots.
http://www.toledo-bend.com/colorblind/Ishihara.html, 2001
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Color Vision

Colorblind individuals should see the yellow square.
Color normal individuals should see the yellow
square and a "faint" brown circle.
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How about those cases
Case 1
14 year old boy comes to primary care office c/o
inability to see the blackboard in school
Case 2
51 year old man presents c/o difficulty reading the news
paper: My arms are too short!
Case 3
6 year old girl presents with mom who states she
squints when looking at anything more than 2 feet
away.
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Now, Do You See Things More
Clearly???