1. Refractive Errors
Dr.Sucharitha

2. Refraction Def: Method of evaluating the optical state of eye. Or
The process by which the patient is guided through the use of a variety of lenses so as to achieve the best possible acuity on distance and near vision test.
Acc. To the physicist, Refraction is defined as bending of light rays when it passes from one media to other having diff refractive indices.

3. Five Activities Retinoscopy (Objective Refraction)
Cycloplegia / Mydriasis
Refinement (Subjective Refraction)
Binocular Balancing
Prescription Of Spectacle Lenses

4. Ophthalmic Optics Principle of Vergence:
Reciprocal of the distance from the lens to the point of convergence of light.
Divergent:
Light rays that are moving away from each other.
Convergent:
Light rays that are moving towards each other.
Parallel rays have zero vergence

5. Convex Lens Identification of a Convex lens:
Thick at center, thin at periphery.
Object held close to the lens appears magnified.
When it is moved, the object seen through it moves in opposite direction to the lens.
Image formed by a convex lens:
Real, inverted & magnified.

6. Concave Lens Identification of concave lens:
Thin at center, thick at periphery.
An object seen through it appears minified.
When it is moved, the object seen through it moves in the same direction as the lens.
Image formed by a concave lens:
Virtual, erect and diminished.

7. Cylinder lens:
Vergence power is in only one meridian, the one perpendicular to the axis of the cylinder.
Spherico- cylinder (Compound lens, Toric lens):
Focus light in two line foci.
The shape of the light rays as they are focused by the spherico-cylinder lens called the conoid of sturm
Between the two line foci produced by the conoid of sturm is a point called the--
Circle of Least Confusion (point of best overall focus for a sphericocylindrical lens.

8. Strum’s Conoid

9. Refractive State of eye
Emmetropia:
Parallel light rays are focused sharply on retina.
Ammetropia:
Unable to bring parallel light rays into focus.
Types:
Myopia
Hypermetropia
Astigmatism

10. Emmetropia It’s a optically normal eye.
In emmetropic eye, parallel light rays are focused
sharply on sensitive layer of retina with the
accommodation at rest.

11. What happens to the light rays coming from the FP and entering the eye?
In emmetropia the FP is at infinity. So the rays coming from FP, and entering the eye are parallel. They are focused upon the retina (with accommodation at rest) to give a clear image of object at FP.

12. Hypermetropia Definition: Etiology:- Axial Curvatural Index Positional
Absence of lens

13. Clinical types:
Simple
Pathological
Functional
Components:
Total
Latent
Manifest (facultative/ absolute)

15. Signs:
Size of eye ball
Size of cornea AC
Fundus
Complications:
Recurrence, Stye, Blepharitis, chalazion
Convergent squint
Amblyopia
Glaucoma

17. Myopia Definition: Etiology: Clinical types: Congenital Simple
Pathological

18. Pathological Myopia Etiology: Genetic Factors General Growth Process
more growth of retina
Stretching of sclera
Increased axial length
Degeneration of choroid
Degeneration of retina
Degeneration of vitreous

20. Signs: Fundus changes: Myopic crescent Foster fuch’s spots
Peripheral degeneration
Posterior staphyloma
PVD
Complications: RD
Complicated cataract
Vitreous & Choroidal Haemorrhage

21. RK

22. Astigmatism Definition: Types: Regular Irregular Etiology: Corneal
Lenticular
retinal

25. Types:
With the rule
Against the rule
Oblique
Bi-Oblique
Clinical Types:
Simple
compound
Mixed

29. Retinoscopy Objective Refraction Skiascopy or Shadow test
The goal of retinoscopy is to determine the nature of pat.’s refractive error (if any) and approx. lens power that will diminish (neutralize) that error and approach clear vision.
Types : -Manual
-Automated

30. Prerequisites for Manual Retinoscopy
Dark room
Mydriatic / Cycloplegic
Leister’s bulb( 50W / inside Hg, outside black / aperture -1 big, 2 small 2cm)
Retinoscope – Priestly – Smith R.
- Plane mirror R.
- Streak R.
5. Trial Frames / Halberg clip
6. Trial set

31. Commonly used Cycloplegics:
Cyclopentolate Hydrochloride (0.5-1%) - Drops applied 2-3 times at 5 minutes interval. - Retinoscopy is done after 30 minutes. - Effect lasts for 8 hours. Tropicamide (0.5-1%) - Drops applied 2-3 times at 5 minutes interval. - Retinoscopy is done after 30 minutes. - Effect lasts for 8 hours

32. Atropine Sulphate (0.5 – 1%): - lower strength below 5 years of age - Used for cycloplegia in children <7–10yrs of age. - In cases with ciliary spasm and in Convergent
Strabismus. - Effect lasts for 2 weeks.
Homatropine Hydrobromide (1 – 2%) - Drops applied at 15 minutes interval for 6-8 times. - Retinoscopy is done after 1 hour. - Effect lasts for 2 days.

33. Retinoscopes Priestley–Smith retinoscope:
Plane mirror at one end /concave mirror at other end.
Hole- 2.5mm ant. ; 4.0mm post.. Fitted with low polar convex lens.
Projects a circle of light in the patient’s pupil.

34. Streak retinoscope Self illuminating, projects a streak.
We can rotate the streak in diff angles.

35. Trial Frame

36. Trial Set Typical “Trial Set” will have:-
Spheres - every quarter of a diopter to 4D, every half to 6D, every diopter to 14D, every 2D to 20D.
Cylinder – every quarter of a diopter to 2D. Every half to 6D.
Prism – upto 10 PD, additional 15 & 20 PD.
Plano lenses
Opaque disc
Pin hole
Stenopaeic discs
Maddox rods
Red & Green glasses

37. Principle Of Retinoscopy
Retinoscope illuminates an area of the retina, the image of this area formed at the pat.’s far point.
- observer views rays of light emanating from the illuminated retina through pat.’s pupillary area from a working distance.
-Depending upon the behavior of reflex the observer knows whether emerging rays are –
- Convergent, Divergent or Parallel.
Lenses from the trial set are used to neutralize the movement (neutralization point = subject’s far point coincides observer’s nodal point.)

38. Optics of Retinoscopy
In retinoscopy an illuminated area of retina serves as an object, & the image at the far point of the eye located by moving the illumination across the fundus & noting the behavior of the luminous reflex in the pupil.
The observer does not see the illuminated area of the pat.’s fundus, but only the rays emanating from it to form an illuminated area of the pupil.

39. Working Distance
The distance between the examiner and the patient’s eye is measured and converted to diopter.
Usually, most examiners uses a working distance of a arm length i.e, approx. 66cm / 2/3m / 26 inches.
D=1/f i.e, D=1/2/3 i.e, D=3/2 i.e, D=1.5D
This power is then substracted from the final dioptric amount that is measured.
The working distance must remain constant through out the examination.

40. Far Point
Far Point (FP) is the furthest point at which objects can be seen clearly by the eye. Object kept at FP of the eye can be seen clearly with accommodation at rest.
Position of FP depends on the optical state (static refraction) of the eye.
In emmetropia it is at infinity.
In myopia it is at a finite distance.
In hypermetropia it is a virtual point behind the retina.

41. If the image is formed between pat. & observer- Against movement.
Seen in- 1. Myopia > 1.5 D
If the image is formed either behind the pat.’s eye or behind the observer’s- With movement.
Seen in- 1. Emmetropia
2. Hypermetropia
3. Myopia < 1.5 D
The point of reversal or neutral point of retinoscopy is reached when the subject’s far point coincides with the observer’s nodal point & examiner see a diffuse bright red reflex in the pat.’s pupil & no movement of the reflex is discernible.

42. Retinoscopy Reflex
Clues we get from features of retinoscopy reflex Intensity: In high refractive errors we get a faint reflex and in low refractive errors we get a brighter reflex. 2. Speed: In high refractive error we get a slow movement, and in low refractive error a rapid movement of the reflex. As the neutral point is reached the movement of the reflex is fast. 3. Size: In high refractive error we get a narrow reflex. Reflex will fill the pupil when the neutral point is reached. In very high refractive errors we may not get a reflex or may get a faint reflex with negligible movement. We will not get a good reflex with low power lenses in these cases. So try with high plus or minus lenses

43. Steps in Retinoscopic Procedure
Set the retinoscope so that the light rays emanating are parallel.
Adjust the pat. In appropriate testing position & distance.
Direct the pat. To look at a specific distant target, (optotype). If cycloplegia has been used, pat. Can directly look into the light.

44. 4. look through the examiner’s eye piece of the
retinoscope & direct the light into the pat.’s
pupil.
- If refraction from the pat.’s pupil is not easy to
see then reason are---
Retinoscope bulb can be dim, dirty or turned off.
The pat. May have very high refractive error.
The room light may not be sufficiently dim.
Media opacity.
-Extra reflection can be- Cornea, Trial lens, Extra
light in examining room.

45. 5. Streak horizontal – Move up & down.
Streak vertical – Move right & left.
6. Note the motion of the reflex-
Against- Add “-” minus lenses in 0.5 diopter
increment until the against movement lost.
With- Add “+” plus lenses in 0.5 diopter until it
becomes difficult to tell the direction of
movement.

46. 7. Smaller sweeps are helpful as the reflex band
appears widen. When the movement of the
reflex fills the pupil and can not be ascertain-
- The reflected light rays coming from the eyes
are parallel.
-The lens combination used to reach this point
(with the dioptrc equivalent of working distance)
is the objective measurement of the refractive
error of the eye.
- This is referred to as neutrality.

47. 8. Confirmation of neutrality: If our assessment is correct we will get the following
results–
After reaching the neutral point (end point) in Retinoscopy (with plane mirror) we move slightly towards the subject, then we will get a ‘with movement’ (because the Far Point is now behind the Observer).
If we move slightly away from the subject we will get an ‘against movement’ (because now the Far Point is between the observer and the subject).

48. 9. Note the power of the lenses used.
Substract the dioptric equivalent of working distance = Refractive error in the axis of
sweeping.
10. If there is different reflexes from the horizontal
& the vertical orientation of the streak =
Astigmatism.
- Need cylindrical eye glasses.

49. Automated retinoscopy
Alternative method, takes less time.
Optical Principle:
The Scheiner Principle
The optometer principle
Types - Based on operational method used:
Analysis of image quality: Dioptron, Canon Autorefractometers, Hoya Autorefractometers.
Retinoscopic Scanning: Ophthalmetron, Humphrey Autorefractor, Nikon 5000 & 7000.
Sceiner disc refraction: 6600 Autorefractor, Nidek &Topcon Autorefractor.

50. THANK U