2. DEFINITION
Astigmatism by definition is a condition where the
parallel beam of light rays incident on the cornea
after refraction are not focused to form a point image
near or on the retina
5. ETIOLOGY
Irregular curvature or RI in the anterior surface of
cornea
Irregular curvature or RI and also the position of
lens/IOL
The refracting power is not uniform in all meridians
of both lens or cornea
The principal meridians are the meridians of greatest
and least refracting powers
6. Classification of astigmatism
• Based on etiology
• Based on relation between principal meridians
• Based on orientation of meridian or axis
• Based on focal points relative to the retina.
• Based on relative locations of principal
meridians or axes when comparing the
two eyes
8. • When the cornea has unequal curvature on the anterior
surface
Reasons:
• Asymmetric cornea
• Meridional difference in RI
• Varying RI
Corneal astigmatism
9. Lenticular Astigmatism
When the crystalline lens has an unequal
on the surface or in its layers
Reasons:
•Asymmetric crystalline lens
•Asymmetric lens layers
•Tilted crystalline lens
•Varying RI of the lens layers
12. Regular Astigmatism
When the two principal meridians are
perpendicular to each other
Most cases of astigmatism are regular astigmatism
The three types are with-the-rule, against- the-rule,
and oblique astigmatism
Can be corrected with Cyl or Sph- Cyl lens
13. Irregular Astigmatism
When the two principal meridians are not
perpendicular to each other –more than two
principal meridians
Curvature of any one meridian is not
uniform
Associated with trauma, disease, or
degeneration
VA is often not correctable to 20/20
14. • With the rule
• Against the rule
• Oblique
• Bi oblique
Based on orientation of meridian or axis
15. Based on relation between principle
meridian
WTR-With The Rule Astigmatism
Vertical meridian of cornea is more curved
Myopic power is more in vertical meridian
16. With-The-Rule (WTR)
Astigmatism
• When the greatest refractive power is within ±30 of the vertical meridian
(i.e., between 060 and 120 meridians)
• Vertical meridian is more myopic than horizontal
Eg :- -3.0D cyl x 180
• Minus cylinder axis around horizontal meridian
• The most common type of astigmatism based on the orientation of
meridians
18. Against-The-Rule (ATR) Astigmatism
• When the greatest refractive power is within 030 of the horizontal
meridian (i.e., between 030 and 150 meridians)
• Minus cylinder axis around vertical meridian
• Horizontal meridian of cornea is more curved
• Myopic power is more in horizontal meridian
Eg :- -3.0D cyl x 90˚
20. Based on orientation of meridian
OBLIQUE
axis is not on or near 90˚ or 180˚
Range of axis lies in between 120˚-150˚ & 60˚- 30˚
Eg :- -3.0D cyl x 45˚
24. BIOBLIQUE
The meridians are not perpendicular
Eg :- -3.0D cyl x 90˚/ -2.0 D cyl x 110˚
25. Based on focal points relative to retina
Simple astigmatism
One focal point on retina and the other front or behind
Of 2 types simple myopic and simple hyperopic
Compound astigmatism
Both the 2 focal points are in front or behind the retina
Of 2 types compound myopic and hyperopic
Mixed astigmatism
One focal point in front and other behind the retina
26. Simple Astigmatism
• When one of the principal meridians is focused on the retina and the
other is not focused on the retina (with accommodation relaxed)
27. Simple Myopic Astigmatism
• When one of the principal meridians is focused in front of the retina and the
other is focused on the retina (with accommodation relaxed)
28. Simple Hyperopic
Astigmatism
• When one of the principal meridians is focused behind the retina and
the other is focused on the retina (with accommodation relaxed)
34. Mixed Astigmatism
• When one of the principal meridians is focused in front of the retina
and the other is focused behind the retina (with accommodation
relaxed)
35. Based on relative locations of principal meridians
or axes when comparing the two eyes
1. Symmetrical
2. Asymmetrical
36. Symmetrical Astigmatism
The principal meridians or axes of the two
eyes are symmetrical (e.g., both eyes are
WTR or ATR)
The sum of the two axes of the two eyes
equals approximately 180
38. Asymmetrical Astigmatism
The principal meridians or axes of the two
eyes are not symmetrical (e.g., one eye is
WTR while the other eye is ATR)
The sum of the two axes of the two eyes
does not equal approximately 180
39. Asymmetrical Astigmatism
Example:
OD: pl -1.00 x 180
OS: pl -1.00 x 090
One eye is WTR astigmatism, and the other eye is ATR
astigmatism, and the sum of the two axes do not equal
approximately 180
40. Prevalence
Age
Infants are born with ATR astigmatism, where the cornea is the source of the
astigmatism
Preschool children have little or no astigmatism
Teenage children demonstrate a shift towards WTR astigmatism
Older adults show a shift towards ATR astigmatism
43. Incidence
General trend
For older adults, the average rate of change
towards ATR astigmatism is less than or
equal to 0.25D every 10 years
44. Symptoms
Distorted vision at distance and near
Letter confusion
Asthenopia or ocular fatigue
Due to constantly squinting to clear up
distorted vision
Headaches
Squinting
46. Clinical Tests
Visual acuity tests – distance and near
Autorefraction
Keratometry
Retinoscopy
Most reliable source of information for cylinder
power and axis
Monocular subjective refraction, including
Jackson cross cylinder
48. Management
Spectacles
Cylindrical lenses and spherocylindrical lenses in spectacles
Contact lens
Toric soft contact lenses
rigid gas permeable contact lenses
Refractive surgery
Photorefractive keratectomy (PRK)
Laser in-situ keratomileusis (LASIK)
49. Guidelines for optical
treatment
Small astigmatism- treatment is required
In presence of asthenopic symptoms
Decreased vision
• High astigmatism- full correction
• Better to avoid new astigmatic correction in
adults because of intolerable distraction
• Bi-oblique,mixed,high astigmatism arebetter
treated by contact lenses
• Correction of spherical component
50. Residual astigmatism
The amount of astigmatism that still
remains after correction of a refractive error.
In the case of correction of corneal
astigmatism using rigid contact lens
,lenticular residual astigmatism is exposed.