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In the name of ALLAH, most gracious, most merciful
MYOPIA BY: SUMAYYA NASEEM Internee Optometrist
AIMS & OBJECTIVES OF TODAY’S LECTURE
• Myopia and its etiology• Mechanisms of production• Clinical types• Signs & symptoms• Complications• Diagnosis• Correction• Prevention
HUMAN EYE:OPTICAL CONDITIONS
Emmetropia Ametropia
Index
Axial
Curvature
Myopia
Presbyopia
AstigmatismHyperopia
Parallel incident light is focused in front of the retina
Parallel incident light is focused behind the
retina
We get 2 focal points
• EMMETROPIA
Parallel incident rays come to a
focus on the retina when the
accomodation is fully relaxed so far
point is at infinity.
OPTICS OF EMMETROPIA
• AMMETROPIA
Parallel incident rays do not come to a
focus on the retina when the
accomodation is fully relaxed so far point
is not at infinity.
MYOPIA (short sightedness, hypometropia)
A type of refractive error in which Parallel incident light is brought to a focus in front of the retina when eye is at rest. So far point is at finite distance.
AETIOLOGY
• Hereditary (Genetic Factor)
• Role of diet• Theory of excessive near work• Reading posture• Racial (Chinese and Japanese highest)• Environmental Factors
MECHANISMS OF PRODUCTION
1. Axial myopia • Increased length of eyeball• 1mm=3D
2. Curvature myopia• Increased curve of cornea e.g. conical
cornea• Increased curve of lens e.g. lenticonus• 1mm=6D
3. Positional myopia• Anterior displacement of lens e.g. trauma
4. Index myopia• Increase in ref index of lens e.g. nuclear
sclerosis in diabetes• Increase in ref index of aqueous humor• Decrease in ref index of vitreous humor e.g.
vitreous liquefication
5. Myopia due to excessive accomodation• Patients with excessive accomodation
MYOPIA: REFRACTIVE vs AXIALRefractive Myopia
(Optics of the eye too strong)
Axial Myopia
(Eye too long)
Image of distant object & near object
CLINICAL VARIETIES OF MYOPIA
1.Congenital myopia
2.Simple or developmental myopia
3.Pathological or degenerative myopia
4.Acquired myopia
CLINICAL VARIETIES OF MYOPIA
1. Congenital myopia• Present since birth• Diagnosed at 2-3 years• Common in children born with Marfan’s
syndrome• Mostly unilateral and anisometropic• Rarely bilateral• Usually 8-10 D and constant• May be associated with aniridia,
megalocornea and congenital separation of retina
2. Simple myopia• Commonest• Not associated with any eye disease• Error usually does not exceed 6D• Usually begins at age of 7 to 10 years• Stabilizes around midteens
CLINICAL PICTURE Symptoms• Poor vision for distance
• Asthenopic symptoms (due to dissociation b/w accomodation
and convergence)
• Change in physiological outlook of children
SIGNS• Myopic eyes are large• Anterior chamber is deeper than normal• Pupil is dilated and sluggish• Fundus is normal• Does not exceed 6D• Normal near vision • Defective distant vision
3. PATHOLOGICAL MYOPIA
• Rapidly progressing error• Associated with degenerative changes in
posterior segment• Rapid axial growth of eyeball• Usually Hereditary in nature• Can exceed till 30 D• Ref error increases 4D yearly• Also known as degenerative myopia.
CLINICAL PICTURE
Symptoms• Defective distant vision• Defective near vision if degeneration starts• Muscae volitantes (Flying Flies)• Night blindness
MUSCAE VOLITANTES
SIGNS
• Prominent eyes• Proptosis if error exceeds 20D• Cornea large• a/c deep• Pupil large and sluggish• Sclera is thin
Idiopathic Retinal
Detachment
Open-Angle Glaucoma
Chorioretinal Degeneration
Posterior Subcapsular Cataract
OPHTHALMOSCOPICALLY
Changes in vitreous
• Liquefication• Floaters• Vitreous detachment
POSTERIOR VITREOUS DETACHMENT
VITREOUS DETACHMENT
CHOROIDAL AND RETINAL CHANGES
• Degeneration of choroid• Choroidal hemorrhage• White atrophic patches• Tilted disc• Posterior staphyloma• Myopic crescent (temporally)
• Forster-Fuchs flecks (subretinal neovascularisation & pigmented lesion at or near the fovea)
POSTERIOR STAPHYLOMA
TILTED DISC
CHOROIDAL AND RETINAL DEGENERATIONS
MYOPIC CRESCENT
HIGHLY MYOPIC FUNDUS
COMPLICATIONS
• Retinal tears• Retinal detachment• Hemorrhages• Complicated cataract• Vitreous hemorrhage• Primary open angle glaucoma• Visual field shows contraction• Scotoma can be seen
RETINAL DETACHMENT
RETINAL DETACHMENT
VISUAL FIELD LOSS
4. ACQUIRED MYOPIA
Some causes are as follows:1. Index myopia (diabetic, nuclear sclerosis)
2. Curvature myopia (conical cornea & corneal ectasias)
3. Positional myopia (ant. Subluxation of lens)
4. Consecutive myopia (surgical overcorrection)
5. Night myopia (as pupil dilates)
6. Drug induced myopia (pilocarpine, steroids)
7. Pseudo myopia (excessive & spasm of accomodation)
REFRACTION PROCEDURE
• VA with and without correction monocularly• Pinhole VA• Cover test with and without correction• Quick ophthalmoscopy• Retinoscopy
Subjective verification:
• Duochrome test• Muscle balance- Maddox rod for distance
Bailey-Lovie ChartUniversity of Waterloo
distance VA chart
DISTANCE VA CHART
RETINOSCOPIC FINDINGSDuring retinoscopy of a myopic patient, ‘against’ movement of reflex is seen as compared to retinoscopic light or streak.
Against movement is neutralized by negative or concave lenses.
Reflex motion seen during retinoscopy
“w ith” “neutrality” “against”
Retinoscopy Reflex
RETINOSCOPY: SET-UP
DUOCHROME TEST
Letters Circles
COVER/UNCOVER TEST
MADDOX ROD
PHOROPTER (MANUAL REFRACTOR)
VISUAL FUNCTIONS ASSESSMENT
OPTICAL CORRECTION OF MYOPIAOptions are as follows:• Spectacles and LVD’s• Contact lenses• Refractive surgeries• LaserOthers:• Visual hygiene• Prophylaxis• General measures
SPECTACLES• Minus lenses (CONCAVE) are used to correct
myopia• In high numbers glasses are not cosmetically
attractive and minify actual pt eye size for others
• Myopes are usually kept under corrected so that there accomodation is not stimulated. Otherwise, they will complain of Asthenopic symptoms
EXTREME MYOPIA
CONTACT LENS
Contact lens is a better option for correction of high myopia both optically and cosmetically..
C/L INSERTION & REMOVAL
A SOFT C/L
LOW VISION DEVICES (LVD’s)READING GLASSES
HAND MAGNIFIERS & STAND MAGNIFIERS
DOME/PAPERWEIGHT MAGNIFIER
FILTERS
TELESCOPES
ORTHOKERATOLOGY
• Orthokeratology is defined as, the reduction, modification, or elimination of visual defect by the programmed application of contact lenses
• Orthokeratology uses hard Contact Lenses to remould the Cornea, to reduce or correct Myopic (short-sighted) and Astigmatic (irregular surface) errors of the eye.
• In some ways this is similar to the use of dental braces by an Orthodontist to straighten crooked teeth.
• The main difference is that if a tooth position is corrected for some months it will stay in the new position. However the Cornea is highly elastic, and always returns to its original shape.
• For this reason the lenses are worn nightly or on alternate nights after the ideal Corneal shape has been achieved and removed in the morning giving perfect vision without the need for spectacles or contact lenses.
• Once the desired level of V.A has been achieved a of retainer lens wear is initiated until cornea reaches the level of stability new shape cornea. Lens wear is then gradually reduced to the minimum, required to attain good functional vision through out the day.
• The amount of ametropia that can be corrected using orthokeratology is: –1 to –6 D myopia with 1.5 D of WTR astigmatism and 0.75 D of ATR astigmatism.
ORTHOKERATOLOGY CONTACT LENS
SURGERYClear lens extraction:• For myopia of greater than 15-20 D,
cataract surgical procedure is applied and non-cataractous lens is removed and intra ocular lens of calculated power is inserted.
Phakic IOL:
• IOL is also placed in A/C or P/C of phakic eyes to correct the refractive error.
CATARACT SURGICAL PROCEDURE
LASER AND SURGERIES
Photorefractive keratectomy PRK:• Uses Excimer laser to change ant. curvature
of cornea.• Tissue is ablated centrally 3.5-4mm and
surface curvature is reduced.• After scarring, haloes, glare and reduction of
best VA are the complaints of patient.
PHOTOREFRACTIVE KERATECTOMY PRK
• A mechanical keratotome is used to dissect through the superficial corneal stroma and fashion a lamellar circular flap of uniform thickness.
• The bared corneal stroma is reshaped using Excimer laser and hinged flap is replaced.
• Better than PRK because of little scarring and better correction predictability.
LASER ASSISTED IN SITU LASER ASSISTED IN SITU KERATOMILEUSIS KERATOMILEUSIS LASIK
LASER ASSISTED IN SITU LASER ASSISTED IN SITU KERATOMILEUSIS KERATOMILEUSIS LASIK
Flap creation
Laser interventionFlap repositioning
CORRECTION WITH LASIK & PRK
Myopia•-1D to -6D --------- PRK•-6D to -12D -------- LASIK
(better to wait till the patient reaches the age of 21 years)
EXCIMER SYSTEM
LASIK
EPIKERATOPHAKIA
• This uncommon surgical technique creates a new corneal surface with a different surface curvature by attaching a lenticule of pre- shaped donor corneal stroma to the surface of host cornea.
• The eye is not entered and procedure is easily reversed by removal of lenticule.
EPIKERATOPHAKIA
KERATOMILEUSIS
• It is the use of microkeratotome to remove lamella of ant. corneal stroma which is then reshaped on a cryolathe before being replaced.
• High degrees of myopia till 15D can be corrected in this way.
• Keratophakia is developed as a modification of keratomileusis and is used for aphakia.
KERATOMILEUSIS
PREVENTION & CONTROL OF MYOPIA
• Many people believe that too much close work, such as reading or sitting too close to the television, causes nearsightedness. But there was little evidence to support this belief. However, one study suggested that people in professions that involve extensive reading have higher degrees of nearsightedness.
• With regular instillation, topical 0.05% atropine is an effective agent for controlling myopia progression in a majority of school aged children.
• Nutritional Factors
• Since the eye has a collagenous structure, it seems likely that the same nutrients which strengthen collagen might also be helpful in keeping the eye from becoming elongated. Calcium, magnesium, boron, silica, selenium, manganese and vitamin D all come to mind, as well as vitamin C. A strong ocular structure would likely be less prone to becoming elongated, as occurs in myopia. Low levels of calcium, fluoride and selenium were found to be related to increased risk of progressive myopia in an exploratory study.
• Vitamin E, can slow the progression of myopia in children. Myopia in children was also significantly related to lower consumption of protein, fat, vitamins B1, B2 and C, phosphorus, iron, and cholesterol.
• We should insist that our children use good lighting and good posture when reading, take frequent eye rest breaks during long study periods, and encourage them to be physically active.
• Environmental visual stress may be lessened by taking these precautions while reading: frequently stretching and moving the eyes and looking away from the reading material at distant objects, removing distance eyewear(-) or using reading glasses for near tasks.
• As it is usually hereditary in nature, so family marriages should be avoided.
VISUAL HYGEINE
REFERENCES• Theory and practice of optics and
refraction by A K Khurana• Duke Elder's Practice of refraction
(Tenth edition)• Clinical Optics by Elkington, Frank and
Greaney (Third edition)• www.visionlaser.com• www.orthokeratology.com
and many other websites.