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OPHTHOBOOK-CHAPTERS

Chapter 9: Introduction
to Optics
Timothy Root, MD 45 Comments

Before I started my ophthalmology residency I

didn’t know a thing about optics. It was
embarrassing during my internship year when
friends would ask me to renew their glasses only
to discover I hadn’t a clue as to how to decipher
their prescription!

Optics principles are easy to grasp, but I think

you’ll find it difficult for these concepts to
permanently “sink into your brain“ until exposed
to this stuff on a daily basis. Nevertheless, a
review at this point is useful. These are the basics
I wish I’d known before my first month as a
“prescription-writing resident.”

Myopia and Hyperopia

A myopic eye just means a “nearsighted” eye. If
we draw a picture of this eye, we see that it looks
big (and long) and that light focuses not onto the
retina, but in front of the retina within the vitreous
jelly! To correct this refractive error we use a
minus (concave) lens to diverge the incoming rays
of light. This effectively weakens the overall
refractive power of the eye and pushes the image
back onto the retina where it belongs.

Hyperopic eyes are small, short eyes. The axial

length of these eyes is so short that light focuses
behind the eye. To get that image onto the retina
we have to add power to the overall refractive
power of the eye by using a plus (convex) lens.
These convex lenses are basically your traditional
magnifying glass and can make your patient’s
eyes look enormous at high power.

Near-reading and Presbyopia

Once we get a patient corrected for distance
vision we need to take care of close-up vision.
With distance vision, the incoming light rays are
coming in parallel before entering the eye. A near
object, however, produces expanding divergent
rays of light. When these rays hit the eye they end
up focusing behind the eye.

To get this near object in focus the eye needs

some more refractive power. Fortunately, we are
born with the natural ability to increase the
strength of the lens by making it rounder. This
morphing process is called “accommodation.”

The lens works because it is suspended like a

trampoline by surrounding zonular fibers. These
fibers attach 360 degrees around the lens and
tether the lens to the surrounding ciliary muscle.
When the ciliary sphincter contracts the zonules
relax and the lens becomes rounder. This
rounding of the lens increases its
magnification/refractive power and allows us to
see near objects. With age, the lens becomes
dense and does not easily round out. This
presbyopia presents after age 40 and progresses
with age, explaining the need for near-reading
glasses in this age-group.

FUN FACT
Unlike other
vertebrates,
the
chameleon
has a lens
that is
concave and
actually
diverges
light. This
works like a Galilean telescope that magnifies
the retinal image compared to a traditional
eye. In addition, the chameleon has a large
accommodative amplitude that allows it to
focus on nearby prey that roams within the
field of its elastic tongue.

The chameleon uses its finely tuned

monocular accommodation and evaluation of
retinal size to judge distance. This is very
different than the binocular stereoscopic
clues that we use to judge distance.
Also, the chameleon tongue is sticky, has
suction, and can even grab its prey (kind of
like my leather sofa).

Implanted acrylic/plastic/silicon lenses can’t

change shape at all, meaning that all post-
cataract patients will need reading glasses.
However, new lens are being designed to help
with accommodation. Some have concentric
fresnel rings that create multiple focal points
(one optimized for distance and the other for
near vision). Other designs work by moving
the lens in an anterior/posterior direction like a
telescope. Neat, huh?

Astigmatism
The cornea surface provides the majority of the
refractive power of the eye. In the examples above
we assumed that the cornea surface was
perfectly spherical like a basketball. However,
many patients have some degree of astigmatism,
where the corneal surface is shaped more like a
football. Thus, one axis of the cornea is steeper
than the other.

Spherical correction alone will not work for these

eyes. For astigmatism, we need to add a
cylindrical shaped lens to correct the refractive
aberration along one axis. When we check for
glasses, we determine the amount of cylinder
power, and the exact angle axis this cylinder
needs to be oriented to work. To measure this we
use the foropter.

Using the Foropter:

The foropter is the mechanical device we use to
determine glasses prescription. It’s just a big box
full of lenses on dials. When manifesting a patient,
we go through three steps:

1. Figure out the overall spherical error

2. Figure out the extra cylinder to correct for any
astigmatism
3. Tweak the angle of the cylinder correction

When we’re done, the foropter gives us three

numbers to write down on a prescription pad:

Manifesting is a little more complicated then this,

but this is enough to get us started. Let’s analyze
a few sample patients and maybe this will make
more sense.

Patient One
A patient hands us this prescription. He’s an
engineer, and would like us to explain what the
numbers mean.

There are several parts to an eye prescription, so

I’ll go through them one item at a time. The first
number is the spherical error. This patient
requires a +2.50 lens … this tells us that he has a
small, hyperopic eye that focuses images behind
the retina. He needs a little more “oomph” in his
refraction to move everything forward.

The second number is the cylinder. This patient

needs an additional +1.25 diopters of power to
account for the steeper axis of his “football”
shaped eye. The last number is the axis angle of
how to orient that cylinder. His football is tilted at
an axis of 35 degrees.

Patient Two
A 61 year old man presents to you with the
following prescription after cataract surgery. He
wants you to check the numbers to see if they
make sense. What do the numbers mean?

With cataract surgery we go through great pains

to calculate the exact power of intraocular lens for
implantation, with the desire for emetropia so that
the patient doesn’t need glasses for distance. In
this gentleman’s case, he is still a little myopic
with a negative sphere of –1.25. We must have
implanted a powerful lens implant that is focusing
in the vitreous jelly. To offset this powerful
implant, we need to weaken the eye by –1.25
diopters. He also has a little astigmatism of +0.50
with a cylinder angle of 5 degrees. The patient
probably had this astigmatism before, but you can
induce some astigmatic error via corneal incisions
and sutures.

There is another number on this prescription

called the “add.” This is simply the amount of
extra bifocal power needed for reading. This
gentleman has a plastic lens in his eye that can’t
change shape at all, so he needs a +3.00 bifocal
adjustment if he wants to read at approximately
1/3rd of a meter.

Patient Three
A woman brings you this prescription for her child.

As you can see, the child is hyperopic … he must

have small eyes with images focusing behind the
eye. This is a common finding in infants, as their
eyes are still growing. His prescription indicates
he needs some plus power to pull the image
forward onto the retina. In addition, the child has a
little bit of astigmatism. The angle of the
astigmatism is 90 degrees. We call this “with-the-
rule-astigmatism” and this is common with
children. With-the-rule means that corrective
positive-cylinder glasses would place the cylinder
axis at 90 degrees. Elderly patients often have
“against-the-rule astigmatism” with their glasses
having positive cylinder at an axis of 180 degrees.
Here’s a picture to demonstrate what I’m talking
about:

Don’t kill yourself memorizing “with the rule,” as I

just wanted to familiarize you with the subject.
More importantly, notice that this child has a large
difference in prescription power between his eyes.
This anisometropia is concerning because it can
lead to amblyopia if the child begins to favor one
eye over the other.

Minus or Plus Cylinder

As you’ve noticed, astigmatism can be a little
confusing. It also doesn’t help that
ophthalmologists and optometrists like to fix
astigmatic errors differently. Ophthalmologists like
to correct using a positive cylinder (which is
conceptually easier in my mind) while
optometrists prefer using minus cylinder (which is
more useful when grinding glasses). The foropter
machine comes in both flavors and your office
may have both types. They both work and are
conceptually the same, but with an axis that is
written 90 degrees off.

Retinoscopy:
Refracting through that foropter is great, but what
do you do with a child or confused patient who
can’t communicate? You can actually estimate the
refractive power of the eye by examining the
foveal red-reflex (the red-eye you see in
photographs) as you flash a light over the front of
the eye. This technique is important, but tricky to
perform on a child. Don’t worry too much about
retinoscopy until you start your residency and
have to do this yourself.

Fun Fact
The sea nautilus is a great example of eye
evolution. The nautilus has neither a cornea
nor a lens, but instead has a pinhole that it
uses to focus light onto the retina. This
concept is similar to the pinholing technique
we use when checking vision and pinhole
systems that are popular in spy cameras.

This pinhole eye is only a step in the evolution

of the visual system: the simplist eye is merely
a light-sensitive patch such as that found on
the plannarium worm. This light-patch can
determine light-and-dark only, with no
directional component.

The next evolutionary step is to curve the eye

into a bowl – since light has to get over the lip
of the bowl and hits only part of the retina,
this conveys some basic directional
information. By closing the bowl into a pinhole
(like our nautilus here) then we get fine
focusing of light. The disadvantage is, of
course, that only a small proportion of
available light is able to get into the eye
through that tiny hole. Our more advanced
lens system allows focusing of much more
light.

PIMP QUESTIONS
1. What bends light more — the cornea or the
lens? What percentage of the eye’s total
refractive power does the lens contribute?
The cornea does the majority of the refractive
power of the eye, because the air-cornea
interface has very different densities. The lens is
only important for approximately one third of the
overall refractive power of the eye.

2. A child has a cataract operation and a lens

implant is inserted. A month after surgery the
child sees 20/20 on the distance Snellen chart.
Will this child need glasses when he returns to
school?
Yes, the child needs reading glasses. An
implanted plastic lens can’t accommodate
(change shape) with near reading, necessitating a
+3 lens or bifocal for close-up vision.

3. Your patient hands you the following

prescription that they got from the optician at
Wal-Mart. The prescription appears to be in
minus cylinder while your favorite foropter is
based on plus-power cylinder. What would be
the equivalent plus cylinder prescription power
for this patient?

To switch from plus to minus (or vice versa) you

add the cylinder to the sphere, change the
polarity of the cylinder, then change the axis by
90 degrees. Thus, the equivalent prescription for
this patient is:
–3.75 + 1.50 at 005

4. A patient wants you to grind his eyeglass

prescription into his SCUBA mask before his
next wreck dive. Your new optical-tech has
never done this before, and asks you whether
she should grind the lens curvature on the
inner or outer surface of the SCUBA mask.
Which one is correct?
You have to grind that mask on the inside of the
mask so that the lens interface is facing the mask
air-bubble. A lens needs a good glass-air
interface if it’s going to bend light according to
Snell’s Law.
Note: this is just an example to illustrate Snell’s
Law. SCUBA masks actually have inserts that are
ground and placed on the inside.

5. When accommodating to view near objects,

does the ciliary body relax or contract? Do the
zonules get tighter or looser?
To see close-objects, the lens needs to become
more powerful and get rounder. To accomplish
this, the circular ciliary muscle, which is a spincter
muscle, contracts. This releases tension on the
zonules and the lens is allowed to become
rounder.

Timothy Root, MD

Dr. Timothy Root is a

practicing ophthalmologist
and cataract surgeon in
Daytona Beach, Florida. His
books, video lectures, and
training resources can be
found at www.TimRoot.com

45 Comments

Fadi Al Awad says:

dear Sir,
I need your help to get a 3 dimentions
explaining about the meaning of
Cylinder,Sphere and Axis.
thank you for your interest
Eng. Fadi Al Awad

Reply

Troy says:

Did anyone spell check these?? Foropter??

PHROPTER correct spelling

Reply

Keith says:

. . .or maybe PHOROPTER . . ?

Reply

yort says:

take it easy.

Reply

MUHAMMAD BILAL says:

great pa ji cha gai ho tussiiii ki kawan twano

hun pai jan

Reply

Katherine says:

Spelling mistakes to note:

Phoropter has a letter o before and after the
r!

Re the Optics Flash Cards. Accommodation

has two letter “c” and two letter “m” (have
omitted the plural s as it looks silly however
I type it) and as I don’t want to imply any
possession, I can’t use an apostrophe!
Obviously something one says rather than
writes.

Reply

MARK IGA ANTHONY says:

Worderful topic i ever enjoy during this

study
Mark iga anthony ophthamology student in
university of juba

Reply

Ilhom says:

i am from Tajikistan. Good jod, Thank u.

Reply

John says:

You should all be thanking Mr. Root for his

amazing site, not nitpicking the spelling of
terms. Great work!

Reply

Makoto says:

Actually, isn’t the engineer’s “football”‘s

axis at 125 degrees, necessitating the plus
cylinder at 35 degrees?

Editors Note: Yep, but I didn’t write this out

explicitly as it would sound confusing. My
focus with that “example” was that
astigmatism occurs at different angles than
90 and 180. I don’t find it useful for
beginners to think about the shape of the
eyeball “football” in too great detail, as this
gets very confusing. You are technically
correct, though, and I may reword this next
edition.

Reply

priyanka says:

wonderfull book short review of

ophthalmology really very nice book

Reply

bharatsingh says:

Thank”s for http://www.opthobook.com

Reply

judith says:

How accurate and specific is the calculation

for intraocular lens implants?
Can the patient expect to get specific
results?

My partner, after much discussion with his

surgeon, opted for a lens “just off infinity”
(the surgeon’s words)so that he would be
able to see extremely well in the 20-50 foot
range (he’s an athlete, plays basket ball,
baseball)

2 weeks following surgery, his focal length

appears to be just about a meter and a half,
fuzzy any further distant than 20-25 feet.

Monovision with a distance lens implanted

in the second eye is NOt a good option…he
needs good acuity, and most important,
good depth perception.

?thoughts?

Reply

Dr Ogbonna maerkson says:

The website is very educative and i will like

people from Nigeria to benefit for it.
Thank you for ur good work of inform and
educating world esp. the 3rd world
countries.

Reply

gajendra nagar says:

sir, this site is very nice n very special for

learning and educating to people. nice nice
nice ya its nice

Reply

Hiran says:

i´m from brazil, resident of oftalmology

this site is very nice, learned so much, thing
that i couldn´nt understand just on books !
THANKS!

Reply

Francisca Gracia says:

hi I am optometrist and I have been learning

to do biometry.
for the calculation of the IOL.
I order to do this we need the prescription
of the glasses of the patient, keratometry
and then the axial lens. then, the calculation
of IOL can be made.
when patien has cataract usually the
prescription changes and i have been
reading that the appropiate prescription use
for the calculation should be the one before
cataract.
I feel confused how to get that prescription.
my manager at the hospital say that we
should use the prescription available on the
clinical notes that we have at the hospital.
however I think that if we do this we will
always consider precription of the glasses
when the patient has develop cataract.
As i have been working now in both in
private practice at the community and the
hospital I think that the prescription before
the patient developed cataract could be
requested at the practice and then have a
more accurate information. what are the
consequences of considering the
prescription of glasses when the patient
has develop cataract already?
many thanks

Reply

pp says:

1.IOL calculation formula do you use? (

please show me the
equation)

2.cataract can cause myopic shift.

thanks.

Reply

NITIN SAGAR says:

dear Sir,
I need your help to get a 3 dimentions
explaining about the meaning of
Cylinder,Sphere and Axis as requested else
where.

interested in learning optic basics

Reply

sazzadreal says:

great article, thank you sir for this

Reply

alpesh says:

hello! sir
how we can get -1.0 D against the rule
astigmatism post operatively? kindly
request reply.

Reply

glenn c says:

Great info., I now know what the

Prescription means! Thanks!

Reply

DR.EHIKPENMI says:

this site is quite awesome.’tis a good site for

the populace to know more about their eyes
and eyes condition. DR.ROOT,you have
done a great job. more power to your elbow.
DR.EHIKPENMI O.D. (Nigeria)

Reply

Paul Nenani Banda says:

this site is awesome,two thumbs up.i would

like to find out what is binocular vision,what
tests would one perform if the px has no
binocular vision.how to perform streak
retinoscopy,highlight mix astigamatism,high
myopic astigmatism and aphakia.
PAUL NENANI BANDA(optometry
student,zambia)

Reply

llongoria says:

can severe astigmatism be corrected by the

Intralase and Ziemer systems?

Reply

Jean says:

Am wondering … how much spherical

power does the cylindrical portion of an Rx
have? If have been told 50%.
If that’s true, then -1.00 +1.00 would be a
net spherical power of -.50.

So, I’m wondering 1) if that is actually true,

and 2) if the 50% would change depending
on where the axis is … ?

Reply

drcris says:

First, Spherical Equivalent of a cylinder

component is always equal to half of its
value in addition to the spherical
component. For example: -0.50 -4.00 x 165
will give us a Spherical Equivalent of
-2.50D.

Second, it doesn’t matter what’s the axis,

the value of the Spherical Equivalent won’t
be affected.

Reply

darcy says:

Phoropter.

darcy

Reply

William says:

Dr. Root this is a wonderful training tool you

have provided for students in all fields of
Optometry, I am an Optician and your break
down of phoria and tropia for example
made it so easy to understand and absorb
the topic. Thank you for your help in guiding
us to become better providers to all our
patients.

Reply

Shivam says:

Hello Dr. Root ,

I am a 4th year medical student and your

website helps a lot in studying the basics .
I was wondering if you could tell us
something about the different angles in the
eye –
The alpha , kappa , gamma and lambda
angles , its too confusing .

Thankyou – your follower .

Reply

Julia says:

This website was of great help sir, it’s so

hard to find detailed information such as
yours that doesn’t make me want to sleep.
This truly helped a lot, thank you sooo
much!

Reply

Claudio AGMFilho says:

hi there i am a resident in opthalmology

how are you?
thank you so much for sharing all of this
information with us.
i am from Recife-Pe,
brazil in south america. and i love this
channel.
this website i meant to say.
well
don’t ever change anything in here.
this website is wonderful. and i am about to
buy your book at amazon.
when are you coming to south america to
visit us down here?
look me up
Facebook
claudioagmfilho
best of luck.
and come to brazil to visit.

Reply

c. crow says:

I have a question about hyperopia. 40 yr.

old uncorrected Va distance OD 20/100 OS
20/60 but his Uncorrected near Va is
OD 20/40 OS 20/30

M OU +5.50 range Wavescan shows him

+8.00 range OU

How can his near VA be this good?

Reply

michael says:

I AM AN OPTOMETRIST FROM NIGERIA I

MUST COMMEND THE AUTHOR. WHAT A
WONDERFUL BOOK. WRITTEN WITH ALL
SIMPLICITY YET INCISIVE. THANKS DOC

Reply

dr sarita says:

hello,I am final year MS student ,you make

ophthal very easy.

Reply

Trilok says:

Awesome explanation…Just got what I

needed. Thanks!

Reply

Mnj says:

Thx for the great job but I need to learn the

steps of refraction , any suggested books
or websites that might help?

Reply

drm says:

Thank u

Reply

stephen nguku says:

great info

Reply

Sutira says:

Thank you so much for such a simple

explanation for a difficult subject. You have
truly helped me so much.

Reply

Kathleen Harrell says:

Thank you so much, I have been looking for

a site that explains all of this in much
simpler terms. I feel I have a much better
understanding!!!

Reply

Tran says:

Hi Dr. Root,

I’ve heard of the term “spherical equivalent”

and I know how it’s calculated. However, I
don’t know what it is and I have a vague
understanding that it’s used to calculate
soft lens power and spherical glasses
power. Please clarify. Thanks!

Reply

Tran says:

I’ve heard of the term “spherical equivalent”

and I know how it’s calculated. However, I
don’t know what it is and I have a vague
understanding that it’s used to calculate
soft lens power and spherical glasses
power. Please clarify. Thanks!

Reply

Lars says:

I simply love it all! Thanks a lot

Reply

Julissa Rodriguez says:

Hi, Dr. Timothy Root

My name is Julissa and I am an Ophthalmic

Technician here in Orlando. I am from
Puerto Rico and got a job as Oph Tech and I
am having some problems with the
refractions. Can you do a video lecture of
How to Recract as the ones of Tropias vs.
Phorias, Retinoscopy, and Slit lamp? There
where awesome.

Thanks

Reply

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