VISUAL ACUITY AND

REFRACTION DISORDERS

EKA SUTYAWAN
DEPT OF OPHTHALMOLOGY
UDAYANA UNIVERSITY
INTRODUCTION

■ Refractive errors  most common eye disorders

■ Shufelt et al, 2005:
Uncorrected refractive errors  leading cause of higher
prevalence of visual disorders in the world
■ Farida Sirlan, 1998 :Survei Indera Penglihatan Depkes RI (1996)
refractive errors is the most common of eye diseases (22,1%)
■ Miopia  important cause of refractive disorders
– Miller, 2003: 5,6 % correctable blindness at school age
Optics of the eye

• Eye ≈ camera
■ Lens ≈ lens system, pupil ≈ variable aperture system and
retina ≈ film

■ Refractive interfaces:
– air & anterior surface of cornea
– posterior surface of cornea & aquous humor
– aquous humor & anterior surface of the lens
– Posterior surface of the lens & vitreous humor
(Guyton,2000)
Anatomy of the eye
Accomodation

Ability of the lens to change shape in order to adjust its focus

from the distance objects to near objects

 Contraction of cilliary muscles  relaxes zonular tension

lens shape become more sphericalincreasing dioptric
power to brings the near object into focus

 Ciliary muscles relaxation contract zonular tension  lens

flatten  bringing more distant object into view

 Decreasing with age

(vaughan, 2004)
 Refractive Power of the Eye

■ Cornea  40 Diopters ■ Lens  20 Diopters

Total : 60 Diopters
 Visual acuity

• Clarity or clearness of vision

• Good vision result from a combination of an intact neurologic visual
pathway, a structurally healthy eye, and proper focus of the eye
(Vaughan, 2004)
 Measurement of Visual acuity
■ The measurement requires responses on the part of patient  more
subjective

Measured with Snellen Chart / E chart

at a distance : 20 feet (6 m) or at near : 14 inches away
20/20 or 6/6 or 5/5 or 1.0  normal vision
Distance aquity  always tested separately for each eye

• Uncorrected VA ( UCVA)  measured without glasses/ CL

• Correctred VA (BCVA)  measured with glasses/ CL
(Vaughan ,2004)
 Snellen Chart
■ Composed of a series of progressively smaller
rows of random letters used to test distance
vision
■ Each rows corresponding to the distance
(feet or meters)
■ Acuity  scored as a set of 2 numbers (eg.
20/40)
■ 1st numbers (numerator) testing distance in
feet between the chart and the patient
■ 2nd number (denominator)  the smallest
row of letters that the patient’s eye can read
from the testing distance

(Vaughan, 2004)
■ WHO classification for vision:
– 6/6 – 6/18  normal
– < 6/18 – 6/60  visual impairment
– < 6/60 – 3/60  severe visual impairment
– < 3/60 – NLP  blindness
(WHO,1992)
 REFRACTION

• Procedure by which natural optical error is characterized and quantified

• Necessary to distinguish between blurred vision caused by refractive (ie
optical) error or by medical abnormalities of the visual system
(Vaughan, 2004)
 Methods of refraction

Objective refraction Subjective refraction

 Streak Retinoscopy  Trial and Error method
 Automated Refractors  Fogging technique
 Cross Cylinder technique
 need patient cooperation

Cycloplegic Refraction
Refraction with relaxed accomodation by instillation of
Cycloplegic drugs
Snellen Projector Phoropter

Jackson Cross
Cylinder

Streak Retinoscopy
Jaeger Chart autorefractometer
 REFRACTIVE ERRORS

• Emmetropia  absence of refractive errors

– When image of distant objects focuses in the retina
in the unaccomodated eye
– Naturally optimal focus for distance vision
• Ametropia  the presence of refractive errors
(Vaughan, 2004)
Ametropia

o Myopia
o Hiperopia
o Astigmatism
o Presbyopia
MYOPIA (NEARSIGHTEDNESS)

■ When image of distant objects focuses in front of the retina in the

unaccomodated eye
■ Types of myopia:
 Axial myopia
 Refractive / curvature myopia
 Index refractive myopia
 Myopia caused by change in lens position

(Gracia, 1989; PERDAMI 2006)

■ Cause of myopia: anatomy of the eye, heredity, life styles
■ Simple Myopia (School myopia)  school age, mild to moderate myopia
■ Pathologic Myopia  high myopia with vitreoretinal changes

• Symptom:
– Blurred at distance vision
– Tendency to squint to see distance object
– Like to read / extensive near work activity

(Garcia, 1989)
• Treatment :
– weakest concave spherical ( minus ) lenses that
give maximal correction
• Complication:
– Retinal detachment  high myopia
– Strabismus
– Amblyopia
(Garcia, 1989)
 HYPEROPIA
(FARSIGHTEDNESS)
 When image of distant objects focuses behind the retina in the
unaccomodated eye
 Types of hyperopia:
• Axial Hyperopia
• Refractive / curvature hyperopia
• Index of refraction Hyperopia
• Hyperopia caused by alteration of lens position

(Garcia, 1989; PERDAMI 2006)

 Types of Hyperopia based of accomodation

Latent hyperopia completely corrected by accomodation and

is not apparent or measurable by manifest refraction when no
cycloplegic is used
Manifest hyperopia  apparent or measurable by manifest
refraction
 Facultative hyperopia may be corrected by convex
lenses but also may be corrected by accomodation in
absence of lenses
 Absolute hyperopia  not compensated for by
accomodation & need convex lenses
(Garcia, 1989)
Symptoms of hyperopia:
 Blurred vision at near  noticeable if the person is
tired, indistinct printing and inadequate lightning
 Distance vision is impaired  for high hyperopia
(>3.00D) or older patients
 Headache in the frontal region  exaggerated by
prolonged use of the eye for near vision
Symptoms of hyperopia:
– Uncomfortable vision 
– Increase sensitivity to light
– Spasm of accomodation  cramp of cilliary muscle
accompanied by intermittent blurred vision and its
clears if the patient is given minus lens
(Psudomyopia)
– Sensation of eye crossing without diplopia
■ Treatment of hyperopia:
– Strongest convex ( plus ) lenses that give maximal
correction
■ Complication:
– Glaucoma ( shallow anterior chamber)
– Esotropia ( high hyperopia )
– Amblyopia ( especially in children, could be bilateral )
(Garcia, 1989, Vaughan 2004)
 ASTIGMATISM

■ Term  from Greek, means: without a point

■ Condition in which rays of light are not refracted equally in all meridians
■ Astigmatic eye have 2 principal meridians that is usually at right angles to
each other
■ Cause of astigmatism: abnormalities of the corneal shape
 Forms of Astigmatism

Regular Astigmatism Irregular Astigmatism

two principal meridians with the principal meridians are

constant power and not 90° apart because of
orientation across the irregularity of the corneal
pupilary aperture resulting in curvature
two focal lines cannot be corrected with
 can be corrected with cylinders
cylinders
Focal points in astigmatism
 regular astigmatism:
• With the rule  the greater refractive power is in the
vertical meridian
• Against the rule  the greater refractive power is in the
horizontal meridian
• Oblique astigmatism  the principal meridians are more
than 20° from the horizontal and vertical meridians
Types of regular astigmatism
■ Symptoms of astigmatism:
– Blurred vision  high astigmatism
– Good VA but asthenopia & frontal headache especially
while patient is doing precise work at a fixed distance
with prolonged periods low grade astigmatism
– Transient blurred vision at near, relieved by closing or
rubbing the eyes
– Tilting / turning of the head  high degree of oblique
astigmatism
– Squint to achieve a pinhole effect at distance and near
 The letters seen by astigmatic
patients

The uses of Jackson Cross

Astigmatic Clock Dial Cylinder for Astigmatism
■ Test for astigmatism:
– Astigmatic Clock Dial
– Jackson Cross Cylinder

■ Treatment of astigmatism:
– Cylinders lenses
– Rigid Gas Permeable (RGP) contact lens
– Toric Contact lens

(Garcia, 1989, Vaughan 2004)

PRESBYOPIA

• Loss of accomodation that comes with aging

• A person grows older, the lens larger & thicker  becomes less elastic
 decrease the ability to change shape
• Clinically noted after age of 40, usually around 44 or 45 years
• Symptoms:
– Receded distance for reading
– Inability to do close work (eg: Reading newspaper or
telephone directory)
– Excessive light required for reading
– Near Vision Test: Jaeger Chart
– Treatment of presbyopia:
Convex (plus) lenses
40 years  + 1.00 Dioptri & Increase 0.50 D of every 5 years of
age

■ Types of glasses for presbyopia:

– Reading glasses
– Bifokal lenses
– Trifokal lenses
– Progressive lens
(Garcia, 1989, Vaughan 2004,Guyton,2000)
ANISOMETROPIA

• A difference of refractive error between the two eyes.

• A major cause of because the eyes cannot accommodate
independently and the more hyperopic eye is chronically blurred
• Difficult to give refractive correction due to aniseikonia and oculomotor
imbalance
(Vaughan, 2004)
• Aniseikonia  differences in size of retinal image
• Spectacle lenses 25 % aniseikonia  rarely tolerable
• Choices:
– Contact lens  6 % aniseikonia
– IOL  < 1 % aniseikonia
(Vaughan, 2004)
 CORRECTION OF REFRACTIVE
ERRORS
■ Spectacle lenses  safest method
■ Contact lenses  soft CL, RGP, Toric CL
■ Refractive Surgery
– Keratorefraktif surgery, eg: LASIK
– Refractive Lens Exchange
■ Phakic IOL
■ Clear Lens Extraction

(Vaughan, 2004)
spectacles
CLE
Contact lens

LASIK Procedure (Keratorefractive Surgery)

Phakic IOL