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R EFRACTION Švehlíková G. Department of Ophthalmology LF UPJS v Košiciach Prednosta: prof. MUDr. Juhás T., DrSc.

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Presentation on theme: "R EFRACTION Švehlíková G. Department of Ophthalmology LF UPJS v Košiciach Prednosta: prof. MUDr. Juhás T., DrSc."— Presentation transcript:

1 R EFRACTION Švehlíková G. Department of Ophthalmology LF UPJS v Košiciach Prednosta: prof. MUDr. Juhás T., DrSc

2 H OW THE E YE S EES The process of vision begins when light rays that reflect off objects and travel through the eye's optical system are refracted and focused into a point of sharp focus. For good vision, this focus point must be on the retina, where light-sensitive cells - photoreceptors capture images in much the same way that film in a camera does when exposed to light. These images then are transmitted through the eye's optic nerve to the brain for interpretation.

3 REFRACTIVE ERROR An eye that has no refractive error when viewing a distant object is said to have emmetropia or be emmetropic. An eye that has a refractive error when viewing a distant object is said to have ametropia or be ametropic. Very few people have refraction of exactly 0.0 diopters. Approximately 55% of persons between the ages of 20 and 30 have refraction between + 1 and –1 diopters.

4 REFRACTIVE ERROR The total refractive power of an emmetropic eye is approximately 58 diopters (D), of which 43 D come from the cornea and the remaining 15 D from the lens, aqueous, and vitreous. forms of refractive error: 1. Myopia (nearsightedness) 2. Hyperopia (farsightedness) 3. Astigmatism refractive error - blurred or distorted vision

5 REFRACTIVE ERROR Causes of Refractive Errors The eye's ability to refract or focus light sharply on the retina primarily is based on three eye anatomy features:eye anatomy 1) the overall length of the eye 2) the curvature of the cornea and 3) the curvature of the lens inside the eye

6 Eye Length: If the eye is too long, light is focused before it reaches the retina, causing myopia. If the eye is too short, light is not focused by the time it reaches the retina. This causes hyperopia.

7 Curvature of the Cornea: If the cornea is not perfectly spherical, then the image is refracted or focused irregularly to create a condition called astigmatism. A person can have myopia or hyperopia with or without astigmatism.

8 Curvature of the Lens: If the lens is too steeply curved in relation to the length of the eye and the curvature of the cornea, this causes myopia. If the lens is too flat, the result is hyperopia.

9 MYOPIA Rays of light entering the eye focus in front of the retina The refractive power of the eye is too strong for the lenght of the globe – refractive myopia The eye is too long for the refractive power – axial myopia Epidemiology: Approximately 25% of persons between the ages of 20 and 30 have refraction less than –1 diopters.

10 MYOPIA Forms: Simple myopia: Onset is at the age of 10–12 years Usually does not progress after the age of 20 Refraction rarely exceeds 6 diopters Pathologic ( progressive, malignant )myopia: This disorder is largely hereditary and progresses continuously Overgrowth of the posterior 2/3 of the globe Degeneration at the retinal periphery Special forms: Lenticular myopia - sclerosis of the nucleus of the lens ( cataract) in advanced age ( Spherophakia (spherically shaped lens). Treatment: minus or concave lenses

11 HYPEROPIA Rays of light entering the eye focus behind the retina The refractive power of the eye is too week for the lenght of the globe – refractive hyperopia The eye is too short for the refractive power – axial hyperopia Epidemiology: Approximately 20% of persons between the ages of 20 and 30 have refraction exceeding +1 diopters

12 HYPEROPIA Symptoms: In young patients, accommodation can compensate for slight to moderate hyperopia. However, this leads to chronic overuse of the ciliary muscle. Reading in particular can cause asthenopic symptoms – eye pain or headache, blurred vision,... As accommodation decreases with advancing age, near vision becomes difficult. For this reason, hyperopic persons tend to become presbyopic early. Special forms of hyperopia: Absence of the lens (aphakia) due to dislocation. Postoperative aphakia following cataract surgery without placement of an intraocular lens Treatment: plus or convex lenses

13 ASTIGMATISM Astigmatism is derived from the Greek word stigma (point) and literally means lack of a focal point. parallel light rays do not focus at a point The refracting power in one axis is not the same than that in an axis perpendicular to it Epidemiology: 42% of all humans have astigmatism greater than or equal to 0.5 diopters. In approximately 20%, this astigmatism is greater than 1 diopter and requires optical correction

14 ASTIGMATISM Classification Simple myopic astigmatism – the focus of one meridian is on the retina, other is in front of the retina Simple hyperopic astigmatism- the focus of one meridian is on the retina, other is behind the retina compound myopic astigmatism – both meridians are focused in front of the retina compound hyperopic astigmatism - both meridians are focused behind the retina mixed astigmatism – one is focused in front and the other behind the retina Regular - only two meridians approximately perpendicular to each other Irregular - there are multiple focal points Causes - corneal ulcerations with resulting scarring of the cornea - penetrating corneal trauma - advanced keratoconus - Cataract Treatment: Cylinder lenses Only regular astigmatism can be corrected with eyeglasses irregular astigmatism cannot be corrected with eyeglasses

15 A CCOMODATION Ability of the eye to bring retinal images of objects in various distances into sharp focus Varying the reftactive power of the lens Lens is fixated with elastic ligaments – the zonules – at the ciliary muscle. With contraction of ciliary muscle, the zonules relaxes and the lens takes spherical shape

16 PRESBYOPIA The elasticity of the lens decreases with increasing age, and the range of accommodation decreases Presbyopia - physiologic loss of accommodation in advancing age - begins when the range of accommodation falls below 3 diopters. depending on age presbyopia can be compensated with converging lenses of 0.5–3 diopters

17 A NISOMETROPIA difference in refractive power between the two eyes Where the difference in refraction is greater than or equal to 4 diopters, the size difference of the two retinal images becomes too great for the brain to fuse the two images into one aniseikonia Epidemiology: Anisometropia of at least 4 diopters is present in less than 1% of the population Symptoms : Anisometropia is usually congenital and often asymptomatic. binocular functions may remain underdeveloped when the correction of the anisometropia results in unacceptable aniseikonia, patients will report unpleasant visual sensations of double vision

18 C ORRECTION OF R EFRACTIVE E RRORS the type and degree of refractive error – computerized automated refractometry glassesglasses, contact lensescontact lenses, refractive surgery

19 E YEGLASS L ENSES Monofocal Spherical lenses Toric lenses (cylindrical lenses) refract light only along one axis. Spherical and toric lenses can be combined where indicated Multifocal different areas of the lens have different refractive powers Bifocals : The upper portion of the lens is for the distance correction; the lower portion is for the near- field correction Patients are able to view distant objects and read using one pair of eyeglasses Progressive addition lenses : continuously increasing refractive power

20 CONTACT LENSES quality of the optical image viewed through contact lenses is higher than that viewed through eyeglasses Contact lenses have significantly less influence on the size of the retinal image The cornea requires oxygen from the precorneal tear film. To ensure this supply, contact lens materials must be oxygen- permeable. This becomes all the more important the contact lens moves and permits circulation of tear fluid. Contact lenses may be manufactured from rigid or flexible materials.

21 R IGID C ONTACT L ENSES These contact lenses have a stable, nearly unchanging shape. Patients take some time to become used to them Today, highly oxygen- permeable materials such as silicone copolymers are available correct keratoconus

22 S OFT C ONTACT L ENSES The material of the contact lens, such as hydrogel is soft Patients find these lenses significantly more comfortable. The oxygen permeability of the material depends on its water content, which may range from 36% to 85% Supported by the limbus The lens is displaced only a few tenths of a millimeter when the patient blinks. This greatly reduces the circulation of tear film under the lenses. This requires to be removed at night to allow regeneration of the cornea

23 CONTACT LENSES Contact lenses may also be classified by wearing schedule: - daily wear contacts must be removed, cleaned and stored each night, - while extended wear contact lenses are made from materials which are safe for overnight wear - sometimes " continuous wear" is used for a type of extended wear lens that can be worn for up to 30 days

24 Contacts can also be described by replacement interval Daily, weekly, bi- weekly, monthly or quarterly

25 S PECIAL L ENSES Therapeutic contact lenses: In the presence of corneal erosion, soft contact lenses act as a bandage and thereby accelerate reepithelialization of the cornea. They also reduce pain.

26 D ISADVANTAGES OF C ONTACT L ENSES Contact lenses exert mechanical and metabolic influences on the cornea. Therefore, they require the constant supervision of an ophthalmologist. Contact lenses require careful daily cleaning and disinfection. This is more difficult, time-consuming, and more expensive than eyeglass care

27 C ONTACT L ENS C OMPLICATIONS Infectious keratitis (corneal infiltrations and ulcers) caused by bacteria,fungi, and protozoans Giant papillary conjunctivitis: This is an allergic reaction of the palpebral conjunctiva of the upper eyelid Corneal vascularization may be interpreted as the result of insufficient supply of oxygen to the cornea Severe chronic conjunctivitis: This usually makes it impossible to continue wearing contact lenses

28 REFRACTIVE SURGERY is surgical (laser or conventional) configuring of the curvatures of the eye (cornea and/or lens) to allow the rays of light to be focused on the retina as a point Categories Corneal refractive procedures Intraocular refractive procedures

29 REFRACTIVE SURGERY laserPRK, LASEK, Epi LASIK LASIK otherincisional keratotomy – radial, hexagoanal intracorneal ring Phacic intraocular lens Clear lens extraction Corneal refractive procedures Intraocular refractive procedures

30 REFRACTIVE SURGERY lower refractive errors (in the range to D) are usually corrected using laser techniques to reshape the cornea higher errors are corrected using lens implant based methods astigmatism and age are also influential in determining the most appropriate technique

31 L ASER R EFRACTIVE SURGERY an eye drop anesthetic is used A portion of the cornea is removed, or creating the flap The eye is then positioned under an Excimer laser which has been programmed to remove microscopic amounts of corneal tissue. Removal of the tissue changes the curvature of the cornea. If the patient has myopia tissue closer to the central part of the cornea is removed to decrease the curvature or flatten the cornea. If a patient has hyperopia tissue in the periphery of the cornea is removed to increase curvature. To correct for astigmatism, selected tissue at certain angles is removed to insure that the cornea curves equally in all directions. After the laser has been used, the flap is returned to its original position.

32 L ASER R EFRACTIVE SURGERY Profile of the cornea after fotoablation for MYOPIA Profile of the cornea after fotoablation for HYPEROPIA If the patient has myopia tissue closer to the central part of the cornea is removed to decrease the curvature - flatten the cornea If a patient has hyperopia tissue in the periphery of the cornea is removed to increase curvature

33 L ASER R EFRACTIVE SURGERY divided into 1. lamellar (LASIK) and 2. surface ( PRK, LASEK, and Epi-LASIK) laser-assisted in situ keratomileusis (LASIK) photorefractive keratectomy (PRK) laser assisted subepithelial keratectomy (LASEK)

34 PRK, LASEK, AND E PI -LASIK methods of surface ablation these procedures do not require a partial thickness cut into the stroma these methods differ in the way the epithelial layer is handled

35 PHOTOREFRACTIVE KERATECTOMY (PRK) In photorefractive keratectomy surgery the epithelium is removed The epithelium might be removed in several ways, including excimer laser destruction, mechanical debridement with a surgical blade, abrasion with a brush, or use of alcohol to loosen the epithelium.

36 L ASER ASSISTED SUBEPITHELIAL KERATECTOMY (LASEK) LASEK – epitelial flap Epi-LASIK - microkeratome In LASEK and Epi- LASIK surgery the epithelial flap is folded back after the ablation, this epithelial flap is placed back into its original position the epithelial alignment is protected from blinks and eye movements by the addition of a bandage contact lens

37 LASEK No stromal flap - much fewer serious potential complications ( Lamellar Keratopathy, Interface infections.) Minimal or no induction of optical aberrations Quicker recovery of corneal sensation and the blink reflex (4 months vs. 1 1/2 years with LASIK) Higher amounts of refractive errors can be corrected More discomfort Recovery time is longe r final results for LASIK and surface treatments are similar The AdvantagesThe Disadvantages

38 LASER - ASSISTED IN SITU KERATOMILEUSIS (LASIK) a partial-thickness corneal flap made with a microkeratome depths of 100–200 µm femtosecond laser has been developed, provides more accuracy in flap thickness

39 LASIK Rapid visual recovery Less postoperative discomfort Induces more optical aberrations Induces more complications If there is a complication, it is usually due to the flap Only used for mild to moderate myopia Much longer time for recovery of blink reflex when the eye is dry The AdvantagesThe Disadvantages

40 Corneal scarring/haze (<1-2%) Although LASEK may carry a decreased rate of corneal haze relative to PRK, it may still develop secondary to an inflammatory response to the surgical manipulation of the corneal surface. The inflammation leads to the formation of an opacified cellular layer that appears as a white haze and restricts light from transmitting to the back of the eye, thus causing a defect in vision The risk of scar formation increases with increasing ablation depth, and scars are common when treating more than 8 D of myopia. Keratitis (0.5-1%) Postoperative infection is more likely when epithelial coverage is incomplete or when the surgical duration is longer than average. Additionally, contact lenses may serve as a source of infection, as they may be contaminated with microorganisms. Likely, because contact lenses are not used postoperatively in LASIK, LASIK has a lower incidence of keratitis (about 0.2%). C OMPLICATIONS

41 Corneal scarring/hazeKeratitis

42 C OMPLICATIONS Dry eye syndrome associated with recurrent erosions This complication is secondary to decreased corneal sensation due to corneal denervation. It may last from a few weeks to 1 year, although, on average, it lasts 1-4 weeks. Although this complication occur in LASEK and LASIK, it is more likely to be associated with a longer duration in LASIK. Overcorrection (1%, incidence similar to LASIK and PRK) Undercorrection (10-15%, incidence similar to LASIK and PRK) Macular cyst formation (<0.1%) Irregular astigmatism (<1%): This complication is secondary to decentration of the laser optical zone or uneven healing, leading typically to a wavy corneal surface.

43 I NTRAOCULAR REFRACTIVE PROCEDURES Clear lens extraction range: myopia/hypermetropia at any level Principle = replacement of the natural lens with an intraocular lens (IOL) multifocal IOLs can be implanted to reduce spectacle dependence for near vision is identical to modern cataract surgery

44 I NTRAOCULAR REFRACTIVE PROCEDURES Phacic intraocular lens implantation - range: up to - 17D myopia; up to +10D hypermetropia Principle = implantation of a soft flexible artificial lens is particularly suited to younger patients who are out of range for laser refractive surgery

45 I NDICATIONS The major indications for refractive surgery include astigmatism, myopia, and hyperopia, specifically in patients who are intolerant of or who desire to be free from glasses or contact lenses

46 C ONTRAINDICATIONS Unstable refractive error Refractive error outside the range of correction (The range varies according to the surgeon's experience, the laser used, and the laser strategy; however, it is typically approximately 9-14 D of myopia, 4-6 D of hyperopia, and 2-6 D of astigmatism.) Keratoconus Pellucid marginal degeneration Significant dry eye syndrome Active inflammation of external eye Autoimmune disease History of or active herpes simplex keratitis, risc of the reactivation of the virus Active collagen vascular disease Uncontrolled diabetes Uncontrolled glaucoma Pregnancy or breastfeeding

47 Q UESTIONS AND DISCUSSION

48 T HANK YOU FOR YOUR ATTENTION !


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