Ophthalmology 5th year, 4th lecture (Dr. Tara)

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The lecture has been given on Feb. 14th, 2011 by Dr. Tara.

The lecture has been given on Feb. 14th, 2011 by Dr. Tara.

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  • 1. Refraction by the eye
    • To generate accurate vision by the eye, light must be correctly focused on the retina. This focus is done by refraction of the light.
    • The eye is a compound optical system:
    • The cornea, or actually the air/tear interface is responsible for two-thirds of refractive power of the eye, because of the large difference in index of refraction of both media.
    • the crystalline lens is responsible for one-third of the focusing (refracting) power of the eye.
  • 2. Fig. The eye. C, the cornea. B, in the anterior chamber, filled with aqueous. L, the lens. H, in the vitreous. M, the macula. 0, the optic nerve. FA, the optic axis, meeting the retina at A.. N, the nodal point.
  • 3. Optical system of the eye
    • Fig. Optical system of the eye:
    • a , anterior surface of cornea;
    • b , posterior surface of cornea;
    • c , anterior cortex;
    • d , anterior core,
    • e , posterior cortex;
    • f , posterior core;
    • v and g , anterior and
    • posterior poles of the eye through which the optical axis passes;
    • line jh , visual axis.
  • 4. Fig. The reduced eye. The upper figure represents the normal eye, with the two focal points at F and F' , the two principal points at E and E' and the two nodal points N and N' . The reduced eye, drawn in scale to correspond, with the two principal foci at F and F' , the single refracting surface corresponding to the mean of E and E' , and the nodal point at N , corresponding to the mean of N and N‘ .
  • 5. Fig. The formation of retinal images . The image ab of an object AB is formed by drawing lines from A and B through the nodal point N. cd is the position of the refracting surface of the reduced eye. ANB or aNb represents the visual angle.
  • 6. Visual Acuity
    • Normal VA is 6/6 or 20/20
    • the Snellen test is a test of minimum separable acuity, it is the clinically preferred acuity test.
    • A rating of 6/24 means that a letter that normally should be read at 24 METER has to be brought to within 6 METER before it is recognized by the patient.
  • 7. Visual Acuity
    • Snellen E: An example of a minimum legible (seperable) type test target.
  • 8. Emmetropia & Ammetropia
    • Emmetropia (normal refractive state) :parallel rays of light from a distant object( at infinity) are brought to a focus on the retina when the eye is at rest (not accommodating) so this individual can see sharply in the distance without accommodation .
    • Ammetropia (abnormal refractive state) , parallel rays of light are not brought to a focus on the retina in an eye at rest. A change in refraction is required to achieve sharp vision.
  • 9. Refractive errors
    • Defective vision is most commonly caused by ametropia (errors of refraction) that is why ,when a patient complaints of a visual problem, it is extremely important to ask the question:
    • Is it caused by a refractive error ?
    • The use of a simple “ pinhole ” made in a piece of card will help to determine whether or not there is a refractive error. The vision will improve unless the refractive error is extremely large.
  • 10. Ametropia
    • Means defective refractive status (refractive error) it is divided as follows:-
    • 1-Myopia
    • (short sightedness); the optical (refractive) power of the eye is too high so the parallel rays of light are brought to focus in front of the retina, (when the eye is at rest).
    • C auses: ↑ ant-post diameter of the globe=axial myopia
    • ↑ curvature of the cornea=curvature myopia
    • ↑ refractive index of the lens=index myopia
  • 11.
    • 2-Hypermetropia
    • (long sightedness); the optical power is too low so parallel rays of light converge towards a point behind the retina, (when the eye is at rest).
    • Causes: ↓ A-P diameter of the globe=axial hypermetropia.
    • ↓ curvature of the cornea=curvature hypermetropia.
    • ↓ refractive index of the lens=index hypermetropia.
  • 12. 3-Astigmatism
    • The optical power of the cornea in different planes is not equal. Parallel rays of light passing through these different planes are brought to different points of focus.
    • 1. Simple hyperopic astigmatism.
    • 2. Simple myopic astigmatism
    • 3. Compound myopic astigmatism
    • 4. Compound hypermetropic astigmatism
    • 5. Mixed astigmatism
  • 14. Ametropia
    • All three types of ametropia can be corrected by wearing spectacle lenses. These diverge the rays in myopia, converge the rays in hypermetropia and correct for the non-spherical shape of the cornea in astigmatism.
    • In hypermetropia, accommodative effort will bring distant objects into focus by ↑ the power of the lens so he uses his accommodation that reserved for near objects, if the degree of hypermetropia is more than his accommodation, he cannot see far objects also …
  • 15. Far point & refractive states
    • Far point
    • Is the furthest point of clear vision without accomodation
      • Emmetropia: at infinity
      • Myopia: between Infinity & his eye (in front of his eye)
      • Hyperopia: behind the eye or behind the infinity.
  • 16. Spectacle correction of myopia BY SPHERICAL MINUS LENS CORRECTION
    • This requires a lens at the eye that will diverge collimated light so that it appears to come from the far-point. Such a lens is a minus lens and if collimated light strikes this lens, it will appear to be focused at the second focal point of the lens.
    • Minus lenses cause image minification and “ barrel ” distortion in addition to prismatic image displacement.
  • 17. Spectacle correction of myopia.
    • Fig. a. Rays from the far point are focused on the retina. b. A negative lens whose second focal point coincides with the far point forms a virtual image of rays from infinity at the far point. c. Rays from the infinity strike the eye with a vergence as if from the far point and are focused on the retina.
  • 18. Spectacle correction of hyperopia BY PLUS SPHERICAL LENS.
    • a. The far point lies behind the eye. Rays converging to the far point lies behind the eye. Rays from the far point are focused on the retina. b. A plus lens focuses rays from infinity at its second focal point, which is coincient with the far point. c. Convergent rays strike the eye and are focused on the retina.
    • Cylinders, have a maximum curvature along their circumferential direction and zero curvature along their length, that is, parallel to the cylinder axis. The zero curvature is 90 degrees to the maximum curvature. A cylindrical refracting surface will form a line image of a point parallel to the cylinder axis
  • 20.  
  • 21. Irregular Astigmatism
    • In the previous examples of types of regular astigmatism, the axes were at 90 and 180 degrees. In reality, the axes may be at any meridian. If the maximum and minimum curvatures are 90 degrees apart, the astigmatism is regular — for example, 45 degrees and 135 degrees, or 65 degrees and 155 degrees.
    • If, however, the two principal meridians of curvature are not 90 degrees apart or the corneal curvature is not axially symmetric, the condition is irregular astigmatism. This may be due to injury, corneal diseases that leave scars, keratoconus, or congenital abnormalities
    • Anisometropia is the condition in which the refractive error of one eye differs from the other. It may be characterized by unequal amounts of myopia or hyperopia, or one eye may be myopic and the other hyperopic, to which the special term anisometropia is applied.
  • 23. After cataract extraction … ?
    • The lens provides one-third of the refractive power of the eye so that after cataract extraction (the removal of an opaque lens) the eye is rendered highly hypermetropic, a condition termed aphakia. This can be corrected by;
    • • the implantation of an intraocular lens (IOL) intra-operatively [pseudophakic] ;
    • • contact lenses;
    • • aphakic spectacles (eye glasses).
  • 24.  
  • 25.  
    • The optical benefits of contact lenses over spectacle correction in high myopia include:
      • image magnification, (when the optical correction in myopia is brought closer to the corneal surface, image magnification  s.)
      • the elimination of prismatic object displacement with its attendant “ barrel ” distortion.
      • elimination of image degradation caused by the spherical aberration of spectacle lenses with off-axis viewing (coma).
    • The rays of light from closer objects, such as printed page, are divergent, can be seen well only by the process of accommodation, at which the circular ciliary muscle contracts, allowing the naturally elastic lens to be more globular shape = greater converging power, the eyes also converge.
    • With age the lens gradually hardens and the lens no longer becomes globular, so the accommodation ↓,reaching a critical point after age of40years.
    • close work becomes gradually more difficult . Objects have to be held away to reduce the need for accommodation.
  • 28. Convex lenses in the form of reading glasses therefore are needed to converge the light rays from close objects. This occurs earlier in hypermetropes than myopes. The physical part is related to hardening or sclerosis of the crystalline lens that reduces the elasticity of the lens capsule and the plasticity of the lens core. The physiologic part of accommodation is the innervation and contraction of the ciliary muscles. Some hold that sclerosis of the ciliary body reduces its ability to constrict, and the lens does not sufficiently obtain the conditions required for changing its shape
    • Although refractive errors are most commonly corrected by spectacles or contact lenses, laser surgical correction is gaining popularity.
    • The laser & non laser surgeries either modify the shape of the cornea or do an open eye surgery as in phaKic IOL , clear lens extraction.
    • The excimer laser precisely removes part of the superficial stromal tissue from the cornea to modify its shape. Myopia is corrected by flattening the cornea and hypermetropia by steepening it.
  • 30. References
    • 1. Duke Elder ’ s Optics & refraction
    • 2. Lecture notes ophthalmology
  • 31. Thank you