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 Refraction, Dispensing Optics
and
Ophthalmic Procedures

Prelims.indd 1 25-09-2012 11:07:55

Prelims.indd 2 25-09-2012 11:07:55
 Refraction, Dispensing Optics
and
Ophthalmic Procedures

Ashwani Kumar Ghai ms

Senior Consultant (Eye Surgeon)
Head, Department of Ophthalmology
Institute of Public Health and Hygiene
Mahipalpur, New Delhi, India

Forewords
JL Goyal
JP Chugh

Prelims.indd 3 25-09-2012 11:07:55

 ®

Jaypee Brothers Medical Publishers (P) Ltd.

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd.
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
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Email: jaypee@jaypeebrothers.com

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Phone: +44-2031708910 Phone: +507-301-0496
Fax: +02-03-0086180 Fax: +507-301-0499
Email: info@jpmedpub.com Email: cservice@jphmedical.com

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© 2013, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any means
without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the author contained
herein are original, and is intended for educational purposes only. While every effort is made to
ensure accuracy of information, the publisher and the author specifically disclaim any damage,
liability, or loss incurred, directly or indirectly, from the use or application of any of the contents
of this work. If not specifically stated, all figures and tables are courtesy of the author. Where
appropriate, the readers should consult with a specialist or contact the manufacturer of the
drug or device.

Refraction, Dispensing Optics and Ophthalmic Procedures

First Edition : 2013

ISBN  978-93-5090-189-2

Printed at

Prelims.indd 4 25-09-2012 11:07:56

 Dedicated to

My late parents for their blessings

and
My wife Dr Reena Ghai and my son Ayush Ghai
for their patience and understanding

Prelims.indd 5 25-09-2012 11:07:56

Prelims.indd 6 25-09-2012 11:07:56
 Foreword

Optics is ever-progressive, continuously advancing facet of

ophthalmology. Not much reading material is available in
ophthalmology written specifically for students of optometry.
Whatever is available that has been written keeping in
mind the needs of undergraduate and postgraduate students
of ophthalmology. Refraction, Dispensing Optics and Ophthalmic
Procedures has been written keeping in mind the needs of students
of optometry and is based on the syllabus laid down by All India
Institute of Medical Sciences (AIIMS), Indira Gandhi National
Open University (IGNOU), Allahabad Agricultural Institute
(AAI) Deemed University, Vinayak Mission University (VMU)
and other prestigious institutes. However, it will be equally
useful for residents of ophthalmology as well. It gives me great
pleasure in writing a foreword for the book authored by Dr
Ashwani Kumar Ghai. The book has been written in a simple
language making each chapter quite easily understandable. I
have no doubt that this book will elicit a lot of appreciation and
acceptance by both optometrists and residents. This will be a
real tribute to the hard work; the author has put into writing
the book.

JL Goyal
Director-Professor (Ophthalmology)
Guru Nanak Eye Centre
Maulana Azad Medical College
New Delhi, India

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Prelims.indd 8 25-09-2012 11:07:56
 Foreword

It gives me great pleasure to write a foreword for Refraction, Dispensing

Optics and Ophthalmic Procedures authored by Dr Ashwani Kumar
Ghai. The book has been written with specific target readers. Not
only the prescription of glasses is important but making and fitting
of glasses is also equally important, otherwise, the very purpose
of prescription is forfeited. The chapter on ophthalmic procedures
and instruments gives a very precise and to-the-point knowledge
required for day-to-day practice. This excellent book will not only
be useful for students of Optometry, Ophthalmic Assistants and
Opticians but also for residents of ophthalmology.

JP Chugh
Senior Professor and Head (Cornea Unit)
Regional Institute of Ophthalmology
Pt BD Sharma Postgraduate Institute of Medical Sciences
Rohtak, Haryana, India

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Prelims.indd 10 25-09-2012 11:07:56
 Preface

Refraction, Dispensing Optics and Ophthalmic Procedures is a book

written to take care of students of optometry, ophthalmic technicians
and practicing opticians. The contents of the book have been
designed taking into account the syllabus laid down by All India
Institute of Medical Sciences (AIIMS), Indira Gandhi National
Open University (IGNOU), Vinayaka Missions University (VMU),
Allahabad Agricultural Institute, and Institute of Public Health and
Hygiene (IPH&H), and other prestigious institutes, for students of
optometry. However, it will be of equal use to students of MBBS
course and ophthalmology residents.
The book has been written in a very simple language and to the
point. Many illustrations have been given to explain the matter in
a better way, wherever, required. All efforts have been made to
explain the significance of the phenomenon in our day-to-day life,
wherever relevant.
I have made all possible efforts to check the correctness of the
text material. Still, I feel such ventures are not likely to be free from
human errors, certain inaccuracies, etc., for which, I apologize
sincerely. Therefore, feedbacks from all those who go through the
material will help improve future editions. An endeavor of this
kind will be highly appreciated and duly acknowledged.

Ashwani Kumar Ghai

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Prelims.indd 12 25-09-2012 11:07:56
 Acknowledgments

I would like to thank Mr Vivek from M/s Appasamy Associates,

Chennai, Tamil Nadu, India and Mr Awadh of Cipla Pharmaceuticals,
for helping me provide relevant photographs for publication.
I would like to thank my students and colleagues for their
continuous encouragement which has made this dream turn into
reality.
I want to express my gratitude to Mr VK Nanglia, Director,
Institute of Public Health and Hygiene (IPH&H), Mahipalpur,
New Delhi, India, for providing me the working environment.
The enthusiastic cooperation received from the team members
of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, needs special mention.
I would also like to thank Dr Varuna Saroha, Dr Alkesh
Chaudhary, Mr Devender Kumar of Kumar Opticians, Rohini,
New Delhi, India, for their timely help and guidance.
I would also like to thank Mr Ivneet Dhingra and Mr Aftab
Akram, for their technical computer support.
I would be failing in my duty, if I do not mention the names
of Er Rajneesh Arora and Er Nancy Sharma, for their technical
academic help.

Prelims.indd 13 25-09-2012 11:07:56

Prelims.indd 14 25-09-2012 11:07:56
 Contents

1. Light........................................................................................ 1
• What is light? 1 • Ultraviolet rays 1 • Visible rays 2 • Infrared
rays 2 • Propagation of light 2 • Speed of light 3 • How do we
see? 3 • Huygens’ principle 4 • Properties of light 4 • Laser
interferometer 11 • Law of inverse square 11
2. Prism..................................................................................... 13
• Prism 13 • Compounding and resolving prism powers 16

3. Refraction of Light............................................................... 18
• Trial set 18 • Combination of lenses 25 • Optics of the eye 32
• Optical aberrations of lenses and eyeball 34

4. Reflection of Light ............................................................... 37

• Mirror 37

5. Visual Angles and Axes of Eye ........................................... 41

• Axes and angles of eyeball 41

6. Refractive Errors ................................................................ 43

• Myopia 44 • Hypermetropia 46 • Astigmatism 49 • Aphakia
52 • Pseudophakia 53 • Anisometropia 55 • Aniseikonia 56
• Amblyopia or lazy eye 57

7. Accommodation and Convergence .................................... 59

• Accomodation 59 • Presbyopia 61 • Convergence 62

8. Retinoscopy and Transposition........................................... 65

• Retinoscopy 65 • Transposition of lenses 70

9. Ophthalmic Lenses ............................................................. 72

• Types of ophthalmic lens materials 72 • Grinding of lenses 73
• Best-form lenses 74 • Pantoscopic tilt 75 • Types of bifocal
lenses 75 • Trifocal lenses 76 • Progressive addition lens 76 •
Anti-reflective coating 78 • Tinting of lenses 79 • Photochromism
80 • Scratch resistant or hard coating 82 • Water-resistant coating
82 • Polaroid lenses 82 • Ultraviolet protective glasses 82

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 xvi Refraction, Dispensing Optics and Ophthalmic Procedures

• Balance lens 83 • Optical center of a lens 83 • Mechanism

of ghost images 84 • Tilting of lenses 85 • Vertex distance 85
• Interpupillary distance 85 • The prescription 86 • Special types
of lenses 86

10.Spectacle Frames.................................................................. 88
• Frames 88 • Box system 90 • Spectacle frame materials 91

11. Headache After Using Spectacles—How to Manage?...... 95

• Headache after using spectacles—how to manage? 95

12.Ophthalmic Procedures and Instruments......................... 97

• Lens and loupe 97 • Slit lamp 98 • Tonometry 101 • Epilation
and electroepilation 104 • Lacrimal syringing 105 • Fluorescein
staining 106 • Corneal scraping 106 • Cauterization of ulcers 107
•Aesthesiometery 107 • Conjunctival swab for culture and sensitivity
107 • Fundus camera 108 • Fundus fluorescein angiography 108
• Placido disk 110 • Keratometry (Ophthalmometry) 110
• Biometry 112 • Corneal topography 112 • Pentacam 114
• Geneva lens measure 114 • Optical coherence tomography
115 • Synoptophore 115 • Ophthalmoscopy 115 • Gonioscopy
120 • Pachymeter 121 • Amsler grid 122 • Visual field charting
(Perimetry) 122 • Contrast sensitivity 126 • Color vision 127
• Ultrasound diomicroscopy 129 • Sterilization and disinfection 130

13.Lasers in Ophthalmology.................................................. 134

• YAG capsulotomy 134 • YAG iridotomy 134 • Laser for
photocoagulation in retinal disorders 134 • Excimer laser and
LASIK laser for corneal refractive surgery 135 • Argon laser
trabeculoplasty (ALT) 136 • Role of laser in trabeculectomy
(under-filtering bleb) 136 • Laser in treatment of malignant
glaucoma 136 • Laser for DCR surgery 136

14.Contact Lens Practice........................................................ 137

• Nomenclature 137 • Anatomy and physiology of cornea 137
• Precorneal tear film 140 • Indications and contraindications of
contact lens 141 • Materials used for manufacturing of contact
lens 142 • Parameters of contact lens 143 • History taking for
contact lens fitting 144 • Fitting of contact lens 144 • How to
insert soft contact lens? 146 • Instructions to the patient 147
• Cleaning of lenses 148 • Post-fitting problems and solution 148
• Complications of contact lens 149 • Contact lens solutions 151

Index......................................................................................... 153

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 Chapter

1 Light

WHAT IS LIGHT?
Light is a form of energy to which human eye is sensitive. The whole
electromagnetic spectrum ranges from cosmic rays on shorter wave length
to radio waves on longer wavelength (Fig. 1.1). Ultraviolet rays, infrared
rays and visible rays are clinically significant from ophthalmic point of
view. Visible white light consists of seven colors ranging from violet
(400 nanometer) to red (700 nanometer). Light with longer wavelength has
lesser energy and light with shorter wavelength has more energy.
Optics is a branch of physics which deals with properties of light
including its interaction with matter and construction of instruments that
use or detect it.

ULTRAVIOLET RAYS
Ultraviolet rays are invisible rays, sunlight being the principal source.
Depending upon their absorption spectrum, UV light has been divided
into three bands:
1. Ultraviolet A rays: This band of UV rays is absorbed by crystalline
lens and thus retina is protected against their bad effects. Prolonged
exposure to these rays causes cataract formation. IOLs implanted
during cataract surgery have chromophores [inhibitors of UV rays]
to protect retina against UV rays.
2. Ultraviolet B rays: This band is responsible for snow blindness and
photo keratitis caused by welding arc. Prolonged exposure to these
rays can cause formation of pingicula and pterigium.
3. Ultraviolet C rays: This band is blocked by the ozone layer of
atmosphere.
Cosmic Gamma X-ray Ultraviolet Visible rays Infrared Micro Radar Radio
rays rays .01- rays rays waves waves waves
10–6 nm 10–3 nm 10 nm C B A VIBGYOR C B A 104 106 109

200 nm → Optical Radiations ← 104 nm

Fig. 1.1: Electromagnetic spectrum of light

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 2 Refraction, Dispensing Optics and Ophthalmic Procedures

VISIBLE RAYS
It consists of Violet, Indigo, Blue, Green, Yellow, Orange and Red
light. Red color has longest wavelength. That is why traffic signals
are made of red light so that it is visible from a long distance. Retina
is most sensitive to yellow light in photopic conditions. In scotopic
conditions it is most sensitive to blue light.

INFRARED RAYS
These rays are absorbed in anterior chamber and cause heating effect.
They are also called as heat rays. They are further of three types:
1. Infrared A rays are responsible for macular burn in solar eclipse
[photo retinitis].
2. Infrared rays B and C can cause corneal opacity and cataract
formation on prolonged exposure.

PROPAGATION OF LIGHT
Light travels in all directions in straight lines from the source of light. It
travels in form of waves which oscillates in all directions and also in form
of tiny particles called photons. A photon is an elementary particle and
the basic unit of light and all other forms of electromagnetic radiation. It
has no rest mass. It shows dual nature, i.e. it exhibits properties of both
waves and particles. For example a single photon is refracted by a lens
and exhibits wave interference with itself. The modern concept of the
photon was developed by Einstein to explain experimental observations
that did not fit the classical wave model of light (Fig. 1.2).
Thus light has dual nature. The term RAY is used for the path along
which the light travels. It is represented by a straight line. A bundle of
rays is called a pencil or a beam of light.
Rays of light may have positive vergence, i.e. when they travel
they converge at a point or negative vergence, i.e. when they travel

Fig. 1.2: Propagation of light

Chapter 1.indd 2 03-08-2012 13:52:00

 Light 3

Fig. 1.3: Vergence of rays

they diverge from a point or they may have zero vergence, i.e. they are
running parallel to each other (Fig. 1.3).
A medium through which light can pass uninterrupted is called
transparent medium. A medium which offers some resistance to the
passage of light is called translucent medium and a medium which does
not allow passage of light through it is called the opaque medium.

SPEED OF LIGHT
Speed of light is the fastest anything has been observed to move.
In vacuum, the speed is three lakh kilometers per second or one lakh
eighty six thousand miles per second. At this speed, it takes light one
ten thousandth of a second to travel around the earth. When light enters
a material, it slows down. The amount depends on the material it enters
and its density. For example, light travels about 30% slower in water
than it does in a vacuum, while in diamonds, which is about the densest
material, it travels at about half the speed it does in a vacuum.

HOW DO WE SEE?
Sun is the natural source of light. When light falls on a nonluminous
body, following things can happen:
1. Light strikes the surface, some part of it is absorbed and some part
is reflected back. This reflected part of light enters our eyeball and
stimulates our rods and cones which generate a visual impulse. This is
carried via optic nerve to visual cortex where the signals are interpreted.
Image formed on retina is very small and inverted which is reinverted
and made of original size in the visual cortex. A red object appears red
because it absorbs colors of all wavelengths and reflects red color which
enters our eye to generate a sensation of red color.
2. Whole of the light is absorbed and no color is reflected back, the
object appears black or opaque.
3. Whole of the light is reflected back and no color are absorbed, the
object appears white.

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 4 Refraction, Dispensing Optics and Ophthalmic Procedures

HUYGENS’ PRINCIPLE
The Dutch physicist Christiaan Huygens and French physicist Augustin
Jean Fresnel were the two scientists who gave this principle. It is used
to analyze problems of wave propagation. According to this principle
every point of a wave front may be considered as the source of secondary
wavelets that spread out in all directions with a speed equal to the speed
of propagation of the waves.
This means that each point of an advancing wave acts as a fresh
source of waves creating a series of circular wave. Thus, as the wave
advances, each advancing wave in turn creates next stream of successive
waves and so on. It can be thought of as an example given below:
If two rooms are connected through an open door and you create a
sound in the extreme corner of one room (farthest from the other room),
to any person sitting in the second room, it will appear as if the sound
has been created from the door (or starting point of the second room)
itself. It is because when a person creates a sound in one room, the
wave travels ahead and the next wave again creates the stream of
waves. This continues and passes the person sitting in the second
room. The person assumes as if the sound is created from the entry of
the door itself.

Applications
1. Diffraction refers to various phenomena which occur when a wave
encounters an obstacle. It is described as the apparent bending
of waves around small obstacles and the spreading out of waves
past small openings. Now, this can be explained through Huygens’
principle. When the wave hits an obstacle, the points where it touches
the obstacle through the slit, start creating waves in all directions.
Waves moving in the same direction are added together. Hence, it
appears as if waves are spreading out of small opening.
2. Reflection and refraction: When a ray (or wave) hits a surface, the
point at which it hits, starts creating waves. If the upper medium has
different refractive index than the lower medium, we see the size
in the waves as different. The tangent of these waves explains the
angle of reflection and refraction.

PROPERTIES OF LIGHT
Until the middle of 1800s, light was taken to be a stream of tiny particles.
This was advocated by Newton. However, by the late 1800s, the particle
theory was replaced by the wave theory. This was because light exhibited
certain properties that could only be explained by the wave theory.
Now the most accepted view is that light exhibits dual nature. Different
properties of light are:
1. Reflection
2. Refraction

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 Light 5

3. Total internal reflection

4. Dispersion
5. Diffraction
6. Polarization
7. Interference.

Reflection
When a ray of light strikes a polished surface, it bounces back in a
particular direction. This is known as reflection of light. Light ray falling
on the surface is called incident ray, the ray that bounces back is called
the reflected ray and a line drawn at right angle to the surface is called
normal (Fig. 1.4). This phenomenon allows us to see images in mirrors.
We see the images in mirrors as apparently coming from behind the mirror
because our eyes interpret it in this manner. But when we see ourselves
reflected in the mirror and raise our left arm, the image apparently raises
its right arm. This is because the image is laterally reversed.
Laws of Reflection
The laws of reflection can be summarized as:
1. The incident ray, the reflected ray and the normal at the point of
incidence, all lie in the same plane.
2. The angle of incidence is equal to the angle of reflection.

Refraction
When a ray of light passes from one medium (say air) to another medium
(say glass) of different optical density, it deviates from its original path.
This is called refraction. When it passes from denser to rarer medium
it deviates away from normal and when it passes from rarer medium
to denser medium it deviates towards normal. The greater the density
difference between the two media, the more the light bends. This
property is used in optical lenses used to correct refractive errors and to
make different ophthalmic instruments (Fig. 1.5).

Fig. 1.4: Reflection of light

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 6 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 1.5: Refraction of light

Refraction Through a Plate of Glass

When a ray of light passes through a denser medium its speed is slowed
down. It does not deviate from its path if it strikes the denser medium at
right angle to it. But if it strikes the medium obliquely, it deviates from
its path as shown in Figures 1.6 and 1.7.
When we look into the surface of a lake or pond while fishing, the fish
we catch seems larger when under the water than when we actually land
it. This is due to refraction. Since the air is less dense than water, the light
bends away from the normal as it emerges out of water to enter our eyes.
This is the reason that stars twinkle and if a wooden stick is half dipped
in water, the underwater portion of stick appears broken.

Laws of Refraction
1. The incident ray and the refracted ray are on the opposite sides of
the normal at the point of incidence and all three lie in the same
plane.
2. The ratio of sine of angle of incidence to the sine of angle of refraction
is constant. This is known as Snell’s Law. The value of this constant is
known as refractive index of the medium. Refractive index of water is
1.33, crown glass is 1.52, flint glass is 1.65 and air is 1.00.

Fig. 1.6: Refraction through plate of glass

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 Light 7

Fig. 1.7: Refraction through prism

Total Internal Reflection

Another property that combines both refraction and reflection is total
internal reflection. If for an incident ray of light angle of incidence is
increased, its angle of refraction also increases. A limit comes when the
refracted ray travels parallel to the surface. This angle of incidence for
which angle of refraction is 90° is known as critical angle. If angle of
incidence is increased further, the refracted ray bends and travels in the
same medium. This is known as total internal reflection (Fig. 1.8). This
phenomenon is made use of in making optical fibers. Diamond shines
even in dark because of this phenomenon. Fiber optics uses this property
of light to keep light beams focused without significant loss, as long as
the bending of the cable is not too sharp. TV and telephone cables use
fiber optic cable more and more since it is much faster and more efficient
than electrons in an electric current.

Dispersion or Polychromatic Effects of Light

It refers to the ability to break white light into its constituent colors.
White light consists of seven colors. If white light enters a prism it splits
into seven colors with violet light having shortest wavelength suffers
maximum deviation and red light with longest wavelength suffers
minimum deviation (Fig. 1.9).
Rainbows are natural phenomena that exemplify all of the above
properties of light. They use refraction, dispersion, and internal reflection

Fig. 1.8: Total internal reflection

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 8 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig.1.9: Dispersion of light

to produce their amazing hues. White light enters raindrops from the sun
it gets dispersed and refracted inside the raindrops. When the dispersed
light hits the back of the raindrop, it gets internally reflected, and when it
emerges it gets dispersed even more.
The color you see most vividly in a rainbow depends on the angle of
your eye. Generally, you must look higher in the sky to see the red, and
lower to see the blue. What you actually see is the red on the top and the
blue on the bottom, with all of the other colors in between. The arc of the
rainbow depends on the angle that your line of sight makes relative to the
sun behind you.

Diffraction
Diffraction refers to the fact that light bends as it goes through an opening.
It is difficult to give an everyday example of this; an easier example is
with another wave form, sound. When someone speaks from in front of
an open door, a person standing way around the corner from the door
will still hear the diffracted sound waves. Phenomenon of diffraction is
more if the size of aperture is small and vice versa. This is the reason that
diffraction is less if the pupil is dilated and it is more when the pupil is
constricted.

Polarization
Polarization is another property of light. Since a light wave’s electric field
vibrates in a direction perpendicular to its propagation motion, it is called a
transverse wave and is polarizable. A sound wave, by contrast, vibrates back
and forth along its propagation direction and thus is not polarizable. Light
is unpolarized if it is composed of vibrations in many different directions,
with no preferred orientation. Many light sources (e.g., incandescent bulbs,
arc lamps, and the sun) produce unpolarized light (Fig. 1.10).
A common example of the use of polarization in our daily life is
found in polarizing sunglasses. The material in the lenses passes light
whose electric field vibrations are perpendicular to certain molecular
alignments and absorbs light whose electric field vibrations are parallel to
the molecular alignments. The major component of light reflecting from
a surface, such as a lake or car hood, is horizontally polarized, parallel to

Chapter 1.indd 8 03-08-2012 13:52:01

 Light 9

Fig. 1.10: Polarization of light

the surface. Thus, polarization in sunglasses, with the transmission axis

in a vertical direction, rejects horizontally polarized light and therefore
reduces glare. However, if you consider a sunbather lying on his or her
side, wearing such sunglasses, the usual vertical polarization (transmission
axis) will now be at 90° and parallel to the surface and will therefore pass
the horizontally polarized light reflected off the water or the land.

Interference
Interference is another property of light. It is a phenomenon that occurs
when two beams of light meet. Depending on both the nature of the
two beams and when they meet, they can either merge and enhance one
another and give a brighter beam, or they might interfere in such a way as
to make the merged beam less bright. The former is called constructive
interference, and the latter is destructive interference (Figs 1.11 to 1.13).
One experiment used to demonstrate how light signals can interfere
with one another is called Young’s double slit experiment after the physicist
who used it for demonstrating the interference phenomenon (Fig. 1.14).

Fig. 1.11: Constructive interference

Fig. 1.12: Destructive interference

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 10 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 1.13: Destructive interference in AR coating

Fig.1.14: Young’s double slit experiment

He set up a screen with two small slits and behind it set up another screen
some distance away. When he subjected the first screen to a single light
source, he found that there were alternate light and dark spots on the
distance screen, corresponding to points where light rays coming from the
two different slits underwent constructive and destructive interference.
This is only possible when we think of light in terms of waves.
One situation that is illustrative of interference is where there is oil
or gasoline floating on the surface of a puddle. Sometimes, you will
see a brilliant pattern of colors given off by the oil or gas, even when
the gas or oil is subjected to white light. What happens is that different
potions of the film cause different colors in the white light to interfere
constructively or destructively, depending on the thickness of the film.
One region of the film might look red because the red light bouncing
off the top of the film interferes constructively with red light passing
through the film and is then reflected back off the water below it.
We can see this more clearly with sound. When you are in the back
of an auditorium, sound can reach you in different ways. It can take a

Chapter 1.indd 10 03-08-2012 13:52:01

 Light 11

Fig. 1.15: Laser interferometer

direct path, be reflected off a ceiling, or walls, or the floor. All of these
will reach you at slightly different times, and sometimes not at all.
They can actually cancel each other out and you hear nothing when you
sit in one area (also called dead zone), and sitting in another, you can
hear an abnormally loud sound. These are examples of destructive and
constructive interference and the reason that modern auditoriums use
sound absorbing materials on ceilings, walls and floors.

LASER INTERFEROMETER
Laser interferometer is an equipment meant clinically (Fig. 1.15) to
determine outcome of a cataract surgery especially where cataract is
mature or hyper mature. In this type of cataract, retinal details cannot
be seen hence in spite of best surgery, outcome may not be rewarding
due to associated macular pathology. Laser interferometry done prior to
surgery, tells us how much vision should be expected. It is based on the
principle of interference. Patient sees stripes whose size can be varied as
desired. Depending upon size of stripe appreciated patient’s vision can
be assessed. However this test is more of academic importance and has
not been able to gain any clinical significance because of its limitations.

LAW OF INVERSE SQUARE

This law applies to light, sound, electricity, gravitation, etc. It states
that the intensity of light, i.e. luminance radiating from a point source
is inversely proportional to the square of the distance from the source.
So an object twice as far away receives only one quarter the energy in
the same time period. In other words, we can say that the intensity of
a spherical wavefront varies inversely with the square of the distance
from the source assuming that there is no loss caused by absorption
or scattering. For example, the intensity of radiation from Sun is 9140
watts per square meter at the distance of Mercury (0.387AU) but only
1370 watts per square meter at the distance of the Earth (1AU), i.e. a
threefold increase in distance results in a nine fold decrease in intensity
of radiation. For a point source, the equation is

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 12 Refraction, Dispensing Optics and Ophthalmic Procedures

E = 1/d2; where E = Energy at one particular point

d = Distance of point from the source of light

Clinical Application
This law is made use of by photographers and theatrical professionals to
determine optimum location of the light source for proper illumination
of the subject. This law can be used only in case of a point source of
light. Fluorescent lamp is not a point source of light. A point source is
like a light from a distant star seen through a small telescope or light
passing through a pinhole or other small aperture viewed from a distance
much greater than the size of the hole.

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 Chapter

2 Prism

We have already discussed in Chapter 1 that when a ray of light strikes a

medium of greater density at right angle to the direction of the separating
surface, the ray does not change its path but its velocity is reduced and
when it strikes a medium of lesser density its velocity is increased. But
when the same ray strikes a medium of different density obliquely, it
deviates from its path. In other words, when a ray of light enters a denser
medium from a rarer medium, e.g. from air to glass, it deviates towards
normal and when it enters from denser to rarer medium e.g. glass to air,
it deviates away from normal.

PRISM

A prism is a refracting medium bound by two plane surfaces which are

inclined at an angle called the apical angle or the refracting angle of
the prism. When a ray of light passes through a prism it gets deviated
towards its base according to Snell’s Law. The image appears to be
deviated towards its apex. It is virtual and erect. The angle of deviation
is the angle between the incident ray and the emergent ray. Deviation is
minimal when the light passes through the prism symmetrically i.e. when
the angle of incidence is equal to the angle of emergence. The angle of
deviation of a prism = Half of the apical angle or angle of refraction.
Thus a prism of refracting angle 10° (a 10° prism) deviates the light
through 5° and has a power of 10 prism diopters.

Nomenclature of Prism

Apex
The point where the two refracting surfaces of prism meet. ‘O’ is the
apex in Figure 2.1.

Base
The side of the prism opposite the apex is called the base of the prism.
AB is the base in Figure 2.1.

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 14 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 2.1: Prism

Angle of Deviation
This is the angle formed between incident ray and the emergent ray. KCE
is the angle of deviation in Figure 2.1.

Prism Diopter
It denotes power of prism. One prism dioptre is that power of a prism
which displaces the image of an object by one cm when object is placed
at a distance of one meter from the prism.
Strength of a prism can also be expressed in degrees and centrads.
Degree is concerned with apical angle.
1° = 2 prism diopters.
Centrad is that strength of a prism which produces a deviation of 1 cm
of arc at a distance of 1 meter.

Apical Angle
It is also called the refracting angle. It is formed between the two
refracting surfaces of prism. AOB is the apical angle in Figure 2.1.
Strength of a prism depends upon different factors namely the
refractive index of prism material, angle of incidence and the apical
angle of the prism. In thin prisms used in ophthalmic practice, angle of
deviation is equal to half the apical angle of prism.

Uses
Diagnostic Uses
a. Objective measurement of angle of deviation
b. Measurement of fusional reserve
c. Diagnosis of microtropia

Instruments
a. Applanation tonometer
b. Indirect ophthalmoscopes
c. Keratometer
d. Operating microscope

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 Prism 15

e. Synoptophore
f. Haidinger brushes

Therapeutic Uses
a. Treatment of convergence insufficiency
b. Treatment of diplopia.

Miscellaneous Uses
a. Low vision aids
b. Hemianopic spectacles
c. Recumbent spectacles

How to Detect and Measure Strength of a Prism?

Manual Method
See a straight line through a prism. It appears broken. Line appears to
be deviated towards its apex (Fig. 2.2). Now place a prism of known
strength in such a way that base is towards apex of test prism. When
prism of correct power is chosen, straight line appears unbroken again.
Another method of detecting prism clinically is that if a prism
is rotated, the image of any object seen through it shows swinging
movements.

With Lensometer?
Place a prism on the platform. Look through eyepiece of lensometer. The
green target appears deviated. If you move the prism to bring the target
in the center, it cannot be brought in the center. This verifies that this is a
prism. The target is deviated towards the apex of the prism.
Now combine a prism of known power with prism of unknown
power placed apex to base. Place this combination on the platform and
see through the lensometer. The target has moved towards the center.
Choose the power of known prism by hit and trial method such that the
combination makes the target move exactly in the center. This is the
power of unknown prism i.e. equal to the power of known prism.

Fig. 2.2: Detection of prism (A straight line appears broken through a

prism and the broken part appears to be deviated towards apex of prism)

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 16 Refraction, Dispensing Optics and Ophthalmic Procedures

Another Method
Check prism by using the Prism Reference Point (PRP), also called the
Prism Compensation Device in the lensometer by noting the displacement
of the mires from the central ring of the PRP. Each ring is marked with a
number, the center is zero. Each ring represents one diopter of prism. If
the mires are located two rings from the center, the prescription contains
2 diopters of prism.

Placement of a Prism
When a prism is used in eye, its position is indicated by its base; like base
out, base in, base up, etc. Base out means that thicker side of prism is towards
the temple. In Figure 2.3 rays from an object O are not only falling on
fovea of one eye but also extrafoveal point of other eye because that eye is
convergent. Patient complains of confusion and diplopia. To relieve diplopia
we place a prism of calculated power with base out (prism is placed with
apex towards deviation), ray of light gets deviated towards base of prism and
falls on fovea. Thus patient is relieved of diplopia.

Rotating Prism
When two prisms are placed apex to base, they behave like a thick plate
of glass. If they are rotated in opposite directions they produce the effect
of a single prism with gradually increasing strength. The strength is
maximum when they lie apex to apex and deviation of this combination
of prisms is equal to the sum of the deviations of two prisms. Rotating
prisms are used to overcome diplopia. One prism may be placed before
one eye and the other before the other eye. Deviation is thus distributed
equally between the two eyes.

COMPOUNDING AND RESOLVING PRISM POWERS

As we know that objects seen through a prism appear to be deviated
towards its apex. Practically orientation of a prism is specified by writing
the direction of its base, i.e. base up, down out and in. Base out and in

Fig. 2.3: Placement of prism

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 Prism 17

means base is towards temple and nose respectively. Oblique prisms are
specified by using 360° scale, e.g. base 40° means base up along 40°
whereas base 230° means base down along 50°.
The process of adding prism powers together is known as compoun-
ding prism powers. If two prisms of power 2 and 3 prism diopters are
prescribed with base in and out respectively, then it is simply prescription
of prism 1 prism diopter base out.
If a prism is to be prescribed in horizontal and vertical meridians both
i.e. at right angles to each other, it can be prescribed as a single resultant
prism by using Pythagoras theorem. Thus if a 3 prism diopter prism
needs to be given with base up and 4 prism diopter prism base in, it can
be prescribed as a single prism of 5 prism diopter at 37° for right eye.
Now if 5 prism diopter at 37° for right eye needs to be broken into its
components, the process is known as resolving prism powers.

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 Chapter

3 Refraction of
Light

TRIAL SET
It is a box containing different types of spherical and cylindrical lenses
along with prisms of different power, trial frame, cross cylinder and
some other things like maddox rod, stenopeic slit, pin hole, occluder, red
green glass, etc. (Fig. 3.1).

Trial Frame
It is an adjustable frame meant to hold different kinds of lenses during
retinoscopy and refraction of eye. It is designed in such a way that a
combination of spherical lens and a cylindrical lens along with an
occluder or pin hole can be placed in it simultaneously. Temple length
and inter-pupillary distance can be adjusted as per requirements of the
patient. Degree of axis is calibrated on both the rims of trial frame.
Least number of lenses should be placed in the trial frame to create the
desired power. Highest powered lens should be placed closest to the
cornea (in the back lens clamp). Lenses should be replaced as quickly
and accurately as possible (Fig. 3.2).

Fig. 3.1: Trial set (For color version, see Plate 1)

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 Refraction of Light 19

Fig. 3.2: Trial frame

Maddox Rod
1. It is used to detect and measure heterophoria (latent squint) for
distance.

Technique
Patient is made to sit at a distance of 1 meter for smaller scale and
6 meter for bigger scale from tangent scale. He is asked to look at a
point source of light with one eye and through a maddox rod with
other eye. A maddox rod converts a point source of light into a streak.
A normal person with no heterophoria (orthophoria) sees a bulb and
a red streak passing through the center of the bulb. If a person is
suffering from heterophoria, the red streak will pass from right side
or left side or up and down side of bulb depending upon exophoria,
esophoria, hyperphoria and hypophoria. Heterophoria for near is
detected with Maddox wing (Figs 3.3A to C).

A B C
Figs 3.3A to C: (A) Maddox wing; (B) Pinhole; (C) Occluder

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 20 Refraction, Dispensing Optics and Ophthalmic Procedures

Principle
Maddox rod breaks binocularity and latent squint becomes manifest.
2. It is used to detect function of macula when media is not clear, e.g.
before cataract surgery. A person with normal macular function
sees a streak when he looks at a point source of light. This streak
becomes broken if macula is not healthy.

Stenopeic Slit
1. It is used to detect axis of astigmatism. (See Chapter 8)
2. It is used to differentiate between colored haloes of cataract and
glaucoma. This test is known as Emsley Finscham Test. When we
pass a slit from right to left in front of cornea, the colored halo due
to cataract breaks but colored halo of glaucoma remains as such.
This is because; in glaucoma colored halo is due to corneal edema
which is homogeneous. In cataract, it is due to accumulation of
water droplets in lens; which is a heterogeneous phenomenon.

Pinhole
It is like an occluder with a 1 mm hole in the center. In case of refractive
error vision is improved with pinhole. However, if there is a central media
opacity, use of pinhole decreases the visual acuity. If there is macular
pathology, vision does not increase with use of pinhole (Figs 3.3A to C).

Pinhole Improves Vision in Case of Refractive Error. Why?

In case of refractive error, rays of light coming from infinity are focused
either in front of retina (Myopia) or behind the retina (Hypermetropia)
and a blur circle is formed on retina. Bigger is the size of blur circle,
lesser is the visual acuity. With pinhole, size of blur circle is reduced and
thus visual acuity improves as shown in (Fig. 3.4).

Occluder
It is used to occlude the eyeball for testing vision and doing refraction.

Red-Green Glass
1. It is used for diplopia charting. Red glass is put before right eye and
green before left eye by convention.

Fig. 3.4: Pinhole effect

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 Refraction of Light 21

2. It is also used for Worth’s Four Dot

test (Fig. 3.5). This test is done to Red
detect suppression and malingering
(a person lies). Snellen’s chart bears Green Green
two green, one red and one white dot.
Under normal conditions a person White
can see one red and one pink dot (two
Fig. 3.5: Worth’s four dot test
dots) with right eye using red glasses. (For color version, see Plate 1)
With left eye using green glasses he
can see two green and one light green dot (three dots). Red dot cannot
be seen through green glass and vice versa as combination of red and
green becomes black. Patient is asked to wear red glass in front of right
eye and green glass in front of left eye. He is asked to tell how many
dots he can see with right, left and both eyes separately.
The result is interpreted as below:
Right eye suppression—three green dots seen with both eyes open
Left eye suppression—two red dots with both eyes open
Normal person—four dots with both eyes open
Malingerer—Wavering answers
A person having diplopia—five dots, two red with right eye and three
green with left eye.
Prisms of different powers from 1 to 10 prism diopters are there in the
trial set.

Spherical and Cylindrical Lenses

Different powers of convex and concave lenses ranging from 0.25
DS to 20.00 DS and 0.25 DC to 6.00 DC are available in pairs in the
trial set.
Lens and its Types
A lens is a transparent medium bound by two surfaces which are part of
spheres. Lenses are basically of two types; convex and concave.
A convex lens may be biconvex, plano-convex and concavo-convex
or convex meniscus lens. Similarly a concave lens may be biconcave,
plano-concave and convexo-concave or concave meniscus (Fig. 3.6).
A convex lens is considered as collection of prisms placed base to
base and a concave lens is considered as collection of prisms placed apex
to apex.

Fig. 3.6: Different types of lenses

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 22 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 3.7: Concave lens diverges rays of light

Fig. 3.8: Convex lens converges rays of light

A convex lens is a converging lens and a concave lens is a diverging

lens. Why?
A convex lens is made up of prisms placed base to base and a concave
lens is made up of prisms placed apex to apex. We know that power of a
prism is maximum at its apex and minimum at its base. At the same time
a ray, which strikes the prism obliquely, gets deviated towards its base
(Figs 3.7 and 3.8).
Notations of a Lens
Principal axis: It is a line that represents a ray of light which passes
through the lens undeviated.
Optical center: It is that point in the lens through which the ray of light
passes undeviated.
Focus: It is that point on the principal axis of a lens where the parallel
rays of light coming from infinity after passing through the lens get
focused in case of a convex lens or appear to come from in case of a
concave lens.
First principal focus (F1 in Fig. 3.9): It is a point on the principal axis
of a lens such that the rays of light starting from this point in a convex
lens or appearing to meet at this point in a concave lens become parallel
to principal axis after refraction from the lens.
Second principal focus (F2 in Fig. 3.9): It is point on the principal axis
such that the rays of light coming from infinity and hence running paral-
lel to principal axis pass through this point in a convex lens and appear
to come from this point in a concave lens.

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 Refraction of Light 23

Fig. 3.9: First and second principal focus

Center of curvature: It is the center of curvature of the sphere of which

lens is a part.
Focal length: This is the distance between optical center of a lens and
the focus.
Diopter: It is the unit of measurement of power of a lens. It is denoted
by abbreviation D. One diopter power corresponds to a lens of one meter
focal length. Power of lens is inversely proportional to focal length, i.e.
1
D= .
F (in meters)
Back vertex power: The effective power of a lens measured from the
surface towards the eye is known as the back vertex power of lens. The
distance between the back surface of spectacle lens and front surface
of cornea is known as back vertex distance. If this back vertex distance
changes, the back vertex power or effective power of lens also changes.
Depth of focus: The greatest distance through which an object point
can be moved without spoiling the image is termed as the depth of
focus. As the size of aperture of optical system increases, the depth of
focus decreases. Thus, as the size of pupil increases the depth of focus
decreases. Hence, depth of focus is increased during accommodation.

Image Formation by a Convex Lens (Fig. 3.10)

S. No. Position of object Characteristics of image
1. At infinity Image is formed at focus on opposite
side of lens, pinpoint size and real.
2. Away from 2f Image is formed between f and 2f on
opposite side, real, inverted and small-
er in size as compared to size of object
3. At center of curvature Image is formed at 2f on opposite side,
real, inverted and equal in size as that
of object
4. Between f and 2f Image is formed away from 2f on op-
posite side, real, inverted and bigger in
size as compared to size of object
5. At focus Image is formed at infinity, real and
magnified
6. Between f and optical Virtual, magnified and erect image is
center of a lens formed on the same side of the lens

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 24 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 3.10: Image formation by a convex lens

Image formation by a concave lens: Rays coming from infinity are

diverged by a concave lens. The image produced is always virtual, mini-
fied, and erect and on the same side of the lens whatever may be the
position of the object (Fig. 3.11).
Cylindrical lens: A cylindrical lens is a segment of the cylinder cut par-
allel to its axis. These lenses do not have same curvature in all meridians.
Axis of a cylindrical lens is parallel to that of a cylinder of which it is a
segment. In simple words, a cylindrical lens has no power in the direc-

Fig. 3.11: Image formation by a concave lens

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 Refraction of Light 25

tion of its axis but behaves like a spherical lens in a direction at right
angles to its axis.

Uses of Lens
1. A convex lens is used to correct presbyopia, and hypermetropia.
2. It is used as a magnifying lens to see details of an object. It is also
used in low vision aids. It is also used in various types of ophthalmic
instruments like microscopes, slitlamps, ophthalmoscopes, etc.
3. A concave lense is used to correct myopia. It is also used in
ophthalmoscopes and as Hruby lens.

Identification of a Lens
S. No. Convex lens Concave lens
1. It is thick in the center It is thin in the center and thick at
and thin at margins. margins.
2. Convex lens is a It is a minifying lens, objects appear
magnifying lens, smaller in size.
objects appear bigger
in size.
3. If we move a lens, If we move a lens, the image moves in
the image moves in same direction
opposite direction
4. It is denoted by It is denoted by MINUS (-) sign.
PLUS (+) sign
5. It is used to correct It is used to correct myopia.
hypermetropia and
presbyopia.

Both convex and concave lenses are of two types:

S. No. Spherical lens Cylindrical lens
1. Movement of image Movement of image can be seen only
can be seen in all in one direction, i.e. at right angle to its
directions. axis. There is no movement of image
along the axis of lens.
2. If we rotate a lens, If we rotate a lens, there is distortion of
there is no distortion image.
of image.

Compound Lens
It is a combination of spherical and cylindrical lens. If we move a com-
pound lens, the image moves in all directions (due to spherical power).
At the same time if lens is rotated, the image shows distortion (due to
cylindrical power).

COMBINATION OF LENSES
If two thin lenses are placed in contact with each other in such a way
that their optical axes coincides with each other (homocentric system of

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 26 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 3.12: Combination of spherical lenses

lenses) the net power of the combination of lenses will be given by the
algebraic sum of the power of two lenses. However, if the two lenses
are separated together by a distance (d) the net power of combination of
1 1 1
lenses (f) is given by: – = – + – where f1 is the focal lenght of lens no 1
f f2 f1–d
and f2 is the focal length of lens no 2 and d is the distance between two
lenses in meters (Fig. 3.12).
Combination of Cylindrical Lenses (Fig. 3.13)
1. If two cylindrical lenses are placed in contact with each other with
their axis parallel to each other, the net power of the lenses will be
the algebraic sum of the power of two cylinders.

Fig. 3.13: Combination of cylindrical lenses

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 Refraction of Light 27

2. If their axis is at right angle to each other, the net power of the lenses
will depend upon:
a. If they are either concave or convex with equal power—the
combination will behave as a spherical lens with same sign.
b. If their sign is same but power is different –the combination will
behave as a compound lens.
c. If their sign is different and power is same/different, it will
behave as a cross compound lens, i.e. a combination of lens in
which power of cylinder is more than power of spherical lens
with opposite signs.

Decentration of Lenses and Prismatic Effect

When we wear spectacles the visual axis of eyeball must pass through
the optical center of lenses. If it does not happen it introduces prismatic
effect. If prismatic effect is small it may go unnoticed but if it is a marked
decentration, patient complains of eyestrain symptoms. The following
general principles should be kept in mind regarding decentration
of lenses:
1. 1.00 D spherical lens gives 1 diopter prismatic effect if decentered
by 10 mm. Similarly, a +10 D spherical lens gives prismatic effect
of 1 diopter if decentered by 1 mm. This example clearly shows how
important is marking of optical center while fitting of glasses in high
power lenses. The dioptric strength of the prism is calculated by the
following formula:
    Δ=C×D
Where   Δ = Prismatic effect in prism diopters
    C = Decentration in CM
    D = Power of lens in diopters
2. Decentration of a cylindrical lens in its axis produces no prismatic
effect. Decentration of a cylinder at right angle to its axis produces
the same prismatic effect as produced by a spherical lens, i.e. 1.00 D
cylindrical lens if decentered by 1 cm at right angle to its axis;
produces prismatic effect of one prism diopter.
3. If a compound lens is decentered, it produces prismatic effect
of a spherical lens along its axis and algebraic sum of prismatic
effect produced by spherical and cylindrical lens if decentered at
right angles to its axis, e.g. if a +2.00 DS/+1.00 DC*180° lens is
decentered by 1cm along 180° it produces prismatic effect of two
prism diopters but if decentered along 90°, it produces prismatic
effect of three prism diopters.
4. If it is a cross compound lens, i.e. the power of cylinder is more
than the power of sphere with opposite sign, the decentration
produces prismatic effect as below: Suppose a prescription of
+2.00 DS/–3.00 DC*90° is displaced by 10 mm along 90°, it will
introduce prismatic effect of 2 prism diopters but if it is displaced
by 10 mm along 180°, it will introduce prismatic effect of 1 prism
dioptre (+2–3 = –1). Here it is to be kept in mind that a convex lens

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 28 Refraction, Dispensing Optics and Ophthalmic Procedures

if displaced downwards or outwards, it is just like prescribing prism

with base down or base out respectively. Similarly if a concave lens
is displaced downwards or outwards, it is like prescribing a prism
with base up or in respectively, i.e. the convex and concave lenses
have opposite effect.
5. If decentration is required in both horizontal and vertical meridians,
it is produced in oblique meridian.

Clinical Applications of Decentration

Decentration has certain desirable effects also in clinical practice.
1. In lenses for near vision the optical center is displaced inward by
2.5 mm and downward by 6.5 mm on an average so that the optical
center coincides with the visual axis.
2. In order to adapt glasses for an asymmetrical face. Suppose a patient
has left eye displaced downwards as compared to right eye due to
some congenital abnormality. A pair of spectacles with left rim down
and right rim up appears cosmetically unacceptable. So lens of left
rim can be decentered down so that the visual axis passes through
the optical center of glass and there is no prismatic effect.
3. To treat diplopia due to exophoria, esophoria, hyperphoria, etc.
4. To augment exercises for heterophoria.

Prentice Rule
It is a formula used to prescribe prism by decentering the lens. It states that
P = cf; where
P = Prism diopters
c = Decentration in cm
f = Power of lens

Clinical Applications
Sometimes instead of grinding prism into the lens, the lens is decentered
to obtain prismatic effect. Thus the weight and the cost of the glass, both
can be reduced.

How to Check Power of Unknown Lens?

It is by two methods:
1. Neutralization method: Take a lens of known power with opposite
sign. Place the two lenses together and note movement of image
with movement of combination of lenses. Increase or decrease the
power of known lens till the combination of lenses does not show
any movement. Note down the power of known lens. This is also the
power of unknown lens with opposite sign.
  During neutralization always keep the lens close to the eyeball
and see an object, which is far off so that minimal movement of
image in case of small power lens can be easily appreciated.

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 Refraction of Light 29

2. Lensometer and Auto-lensometer (Figs 3.14 to 3.16): It is also

known as Focimeter or Vertex refractionometer.
Lensometer is based on the principle that image of a target; which is
usually a ring of dotted circle, is focused by a standard lens when seen
through a telescope. When an unknown lens is inserted into this optical
system the position of target is changed. The excursion required to bring
target back into focus is directly proportional to the back vertex power
of lens (Fig. 3.14).
First of all when instrument is calibrated the emerging rays are parallel
and image of target T is seen at the focal point of standard lens Fs. When
unknown lens is placed between the standard lens and the telescope with
its back surface facing the standard lens, the image of target T becomes
blurred because it is formed at focal point of unknown lens and the
emergent rays are no more parallel.
In order to see clear image of target T knob has to be rotated so that
the emergent rays again become parallel. The amount of knob rotated to
focus the target is directly proportional to the strength of unknown lens
which can be directly read from the scale.

How to Use?
First of all the instrument should be calibrated. Focus the scale with
eyepiece. Focus the green colored target with knob. Target is seen as

Fig. 3.14: Optics of Lensometer

Fig. 3.15: Lensometer

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 30 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 3.16: Auto-lensometer

a circle of dots. Note down the reading. It should be zero. Now place
the lens with unknown power on the platform of lensometer. Adjust the
knob to refocus the target. Take fresh reading. This gives the power of
unknown lens.
In case of a cylindrical lens after focusing the target, axis of target
should also be noted. This is the axis of the unknown lens. If the unknown
lens is a spherical one, the green colored target is seen as circle of dots.
If it is a cylindrical or compound lens the dots become a series of lines.
The length of lines is directly proportional to the power of the cylinder.
In case of a compound lens after placing the lens, the target is focused
and reading taken. Here the target is focused in form of series of lines with
some particular direction. This is the power of spherical component. Now
refocus the target. Now the direction of lines is at right angles to the previous
direction. Now take second reading. The difference between the first and
second readings is the power of the cylindrical component. The axis shown
at second reading is the axis of the cylinder. In simple words:
First reading = Power of spherical
Second reading—First reading = Power of cylinder
Axis of the second reading = Axis of cylinder.

Uses of Lensometer
1. To check the power of unknown lens
2. To check the axis of unknown lens
3. To mark axis of unknown lens
4. To check and mark optical center of a lens
5. To detect and measure power of unknown prism.
Manual lensometers are of two types. Projection lensometer in which
many persons can see reading at one time and there is no need to adjust

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 Refraction of Light 31

the eyepiece. The other design is the eyepiece lensometer in which only
one person can see the reading at one time and eyepiece needs to be
adjusted every time.

Sources of Error
1. If eyepiece is not adjusted prior to putting the lens on platform. 0.25 D
error can creep in by this mistake.
2. If calibration of instrument is not done.
3. If there is a lag in the movement of knob.
4. If focusing of target is not done properly.
5. If reading is not taken properly. Ideally our eyes should be at the
same level as the level of the scale to avoid error.

How to Mark Axis of a Cylinder With Lensometer?

Place the lens on platform (lens rest). Rotate the lens in such a way that
its axis becomes 180° as seen through eyepiece. Now put some ink or
marker in the slot provided on lensometer for marking axis. Press the
knob to mark on the lens. Three points are marked on lens in this way.
Join these three points; this marks the axis of the cylinder. The central
point is the optical center of the lens.

Effectivity of Lens
If a concave lens is moved away from eyeball or a convex lens is moved
towards eyeball, its effectivity decreases.
If a concave lens is moved towards eyeball or a convex lens is moved
away from eyeball, its effectivity increases (Fig. 3.17).

Fig. 3.17: Change in position of lens produces change in effectivity of lens

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 32 Refraction, Dispensing Optics and Ophthalmic Procedures

Examples
If a minus 10 DS spectacles needs to be replaced with contact lens, its
power has to be decreased to minus 9 DS because when a concave lens
(in form of spectacle) is displaced posteriorly (in form of contact lens)
its effective power is increased and to achieve emmetropia its power has
to be decreased from–10 DS to –9 DS.
During cataract surgery, crystalline lens of eyeball is replaced with
plus 20 DS IOL. If IOL is not implanted and patient is prescribed glasses,
its power would be around plus 10 DS. This is because when plus lens
(in form of IOL) is displaced anteriorly (in form of spectacles), its
effective power is increased and to achieve emmetropia its power has to
be decreased.
Change in position of lens produces change in retinal image size:
If a convex lens is moved away from eyeball (anterior principal focus)
or a concave lens is moved towards eyeball the size of retinal image is
increased. If a concave lens is moved away from eyeball (anterior prin-
cipal focus) or a convex lens is moved towards eyeball the size of retinal
image is decreased (Fig. 3.18).
This is the reason that a patient with aphakic glasses experiences 30
percent magnification of image, with contact lens 5-6 percent and with
IOL only 1 percent magnification of image.

OPTICS OF THE EYE

Human eyeball is compared with a camera. Iris acts as shutter and retina
acts as negative film. The refracting components of eyeball namely

Fig. 3.18: Change in position of lens produces change in retinal image size

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 Refraction of Light 33

cornea, lens, aq. humor and vitreous humor are compared with lens of
the camera. All these components form a homocentric system of lenses.
Thus eyeball acts as a very strong convex lens with power of +60 D,
cornea contributing +42 D and lens +18 D.

Gauss Theorem
Now eye can be considered as a homocentric system of so many lenses
and calculation of power of the whole system becomes very tedious. A
simple method of calculation was devised by Gauss popularly known
as Gauss Theorem. He said that homocentric system of lenses can be
treated as a whole if the object and image distances are measured from
two theoretical planes called principal planes. The whole system can be
resolved into six cardinal points:
1. Two principal planes
2. Two nodal points
3. Two principal foci
According to Gauss concept, the cardinal data of schematic eye is as
follows:
1. Total dioptric power of eyeball is +60 D with lens contributing +18 D
and cornea +42 D.
2. The principal foci lie 15.7 mm in front of and 24.4 mm behind the
cornea respectively.
3. The cardinal points lie in the AC 1.35 mm and 1.60 mm behind the
anterior surface of cornea respectively.
4. The nodal points lie in the posterior part of lens 7.08 mm and 7.33
mm behind the anterior surface of cornea respectively.
The Reduced Eye
To simplify, the cardinal data listing has chosen single principal point
and single nodal point. This is called the Listing’s Reduced Eye. He
presented the following data:
1. Total dioptric power of eyeball is +60 D.
2. The principal point lies 1.5 mm behind the anterior surface of cornea.
3. The nodal point is situated 7.2 mm behind the anterior surface of
cornea.
4. The anterior focal point is 15.7 mm in front of the anterior surface
of cornea.
5. The posterior focal point is 24.4 mm behind the anterior surface of
cornea.
6. The anterior focal length is 17.2 mm and the posterior focal length
is 22.9 mm.
Donder further simplified the data treating eye as a single curved surface.
According to him total dioptric power of eyeball is +60 D. Refractive
index is taken as 1.33. Anterior and posterior focal length is taken as 15
mm and 20 mm respectively. The plane of the curved surface is 2 mm
behind the cornea with a radius of curvature of 5 mm. Nodal point is
situated 5 mm behind the plane.

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 34 Refraction, Dispensing Optics and Ophthalmic Procedures

OPTICAL ABERRATIONS OF LENSES AND EYEBALL

Human eyeball is not a perfect optical system. There are certain optical
aberrations which limit the definition of retinal image.

Spherical Aberration
Rays of light passing from central part of a lens come to a focus that is
slightly away from the point where the peripheral rays are focused. This
is because peripheral part of a lens has more power than the central part
of a lens. Due to this phenomenon definition of retinal image becomes
limited. In a convex lens peripheral rays are focused before the central
rays. This is called Positive Spherical Aberration. In a concave lens,
central rays are focused before the peripheral rays. This is called the
Negative Spherical Aberration (Fig. 3.19).
This phenomenon is little evident in our eyes. This is because nature
has tried to neutralize the effect of spherical aberration by:
A. Providing iris which cuts off the peripheral rays, thus only central
part of lens is used for seeing. When we dilate the pupil spherical
aberration becomes more evident and patient complains of blurring
of vision.
B. Making the peripheral part of cornea flatter than central part of cornea.
This tries to neutralize the effect of aberration produced by lens.
C. Central part of lens (nucleus) is more densely packed hence more
refractive index than the peripheral part of lens.
The spectacle glasses normally used also have this optical defect.
However glasses are available in the markets which are aspheric or
aplanatic but they are costly. Such glasses are grinded in such a way
that their curvature (and hence power) is maximum in the center and
gradually decreases towards periphery. Thus an aspheric lens of +10 DS
has a power of +10 DS at the center and +6 DS at the extreme periphery
(Fig. 3.20).

Chromatic Aberration
White light is made up of seven colors. Each color has different
wavelength and thus suffer different deviation when passed through

Fig. 3.19: Spherical aberration

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 Refraction of Light 35

Fig. 3.20: Aspheric Lens + 10.00 DSph

Fig. 3.21: Chromatic aberration

a lens. Thus red light suffers minimum deviation from its path and
violet light suffers maximum deviation. A spectrum remembered by
VIBGYOR is produced. Thus this effect also compromises the definition
of retinal image. It also increases with increase in size of pupil. Thus a
normal eye is myopic for violet light, emmetropic for yellow light and
hypermetropic for red light. Thus to an emmetropic patient both violet
and red lights appear equally sharp. This forms the basis of duochrome
test (Fig. 3.21).
An achromatic lens can be manufactured by combining two glasses
of different dispersive power and different refractive index. Flint glass
has a refractive index of 1.65 but dispersive power double than that of
crown glass. Ref. index of crown glass is 1.5. Thus if a + 2.00 DS lens of
crown glass with +2d dispersive power is combined with –1.00 DS lens
of flint glass which has –2d dispersive power, a +1.00 DS lens with zero
dispersive power is obtained (Fig. 3.22).

Diffraction
When a bundle of rays of light travels through space, the peripheral
rays tend to deviate away from the center. In simple language, this is
because they do not have peripheral support. This effect is more if the

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 36 Refraction, Dispensing Optics and Ophthalmic Procedures

bundle is narrow thus in a normal size pupil

this aberration is more evident. As the
size of pupil increases, diffraction of light
decreases. Thus different bundles of ray
when pass through a lens do not come to
one focus but form concentric rings. Thus
definition of image is compromised.

Peripheral Aberrations
Certain phenomenon like coma, oblique
astigmatism and distortion of image tend to Fig. 3.22: Achromatic doublet
make the image formed on peripheral part of retina less clearly defined.
But they have little significance due to a peculiar shape of eyeball.
Coma is an aberration which affects light rays falling obliquely on
the lens. Thus rays passing through different parts of lens are focused
at different points and image formed is like shape of a coma. It may be
positive or negative. Aplanatic lens can be used to get rid of this defect.
When rays of light fall obliquely on spherical lenses, they give rise
to oblique astigmatism. This is because spherical lenses show different
power in different meridians if rays fall obliquely on them.
When a grid pattern is observed through a high plus or high minus
lens, the image appears distorted as seen in (Fig. 3.23). This is called
distortion. High power convex lens shows pincushion distortion as seen
by a person using aphakic glasses and high minus lens shows barrel
distortion.
All these types of aberrations can be measured by a test called
aberrometry. This has a clinical application in doing LASIK laser surgery
and making of intraocular lenses.

Fig. 3.23: Distortions

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 Chapter

4 Reflection of Light

MIRROR
A mirror is a part of a hollow sphere whose one side is polished. Mirrors
are of two types:
1. Plane mirror
2. Curved mirror

Plane Mirror
Image formed by a plane mirror is of the same size as the object, laterally
inverted (right side appears towards left and left side appears towards
right), virtual, erect and lies at the same distance behind the mirror as the
object is in front (Fig. 4.1A).

Curved Mirror
It can be of two types: Concave and Convex mirror. Concave mirror
converges parallel rays of light and convex mirror diverges parallel rays of
light. This is in contrast to concave lens which diverges parallel rays of light
and convex lens which converges parallel rays of light (Fig. 4.1B and 4.2).
Center of curvature and radius of curvature of a spherical mirror are
respectively the center and radius of the sphere of which the mirror was
a part. Pole of the mirror is the geometric center of the reflecting surface.

Figs 4.1A and B: Virtual image formed by plane and convex mirrors

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 38 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 4.2: Curved (Concave) Mirror

The principle axis of the mirror is the line joining the pole to the center of
curvature. Principal focus of a concave mirror is the point on the principle
axis where the rays of light travelling parallel to the principle axis get
focused after reflection. In convex mirror, these rays appear to meet but do
not meet actually. That is why convex mirror always gives virtual image.
These images are always erect and smaller than the size of the object
(Fig. 4.1B). Characteristics of image formed by a concave mirror depend on
the position of the object in relation to the mirror. If the object is between
infinity and the principal focus, the image formed is real and inverted. If the
object is between the pole and the principal focus, the image is virtual, erect
and magnified (Fig. 4.3). Focal length of the concave or convex mirror is the
distance between the pole and the principle focus of the mirror. It is equal to
half the radius of curvature, i.e. F = CP/2

Uses of Concave Mirror

1. Concave mirrors are used as reflectors in torch light, film projectors
and search lights.
2. They are also used in telescopes.
3. ENT specialist, dentists use concave mirror as light focusing device.
4. Concave mirror is also used for retinoscopy in hazy media.
5. They are also used as magnifiers.
6. Solar cookers use concave mirror to focus sunlight.
7. They are also used as shaving mirrors. When the face is kept between
the mirror and its focus, its image is magnified and erect.

Uses of Convex Mirror

1. They are used as rear view mirror in vehicles. The image formed by
this mirror is minified and erect, hence bigger area is visible.
2. They are mounted on corners inside and outside the buildings where
corridors and hallways intersect so as to avoid collisions.
3. They are helpful to security personnel to keep a watch on larger
area. Mirrors can be coated and cameras can be mounted inside.

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 Reflection of Light 39

Fig. 4.3: Image formation by a concave mirror

4. They are also used to inspect area difficult to get to. Convex mirror
can be mounted on a rod with light and can be extended underside
the object.
Image formed by a convex mirror is always virtual, minified and erect
irrespective of the position of object.
A real image is one which is formed by actual meeting of light rays
as occurs in concave mirror and convex lens. A virtual image is one in
which rays of light do not actually meet but appear to come from that
point as occurs in convex mirror and concave lens.

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 40 Refraction, Dispensing Optics and Ophthalmic Procedures

Images Formed by a Concave Mirror

S. Position of object Characteristics of Image formed by
No concave mirror (Fig. 4.3)
1. At infinity Image is formed at focus, pinpoint size
and real
2. Away from C Image is formed between F and C, real,
inverted and smaller in size as compared
to size of object
3. At center of curvature Image is formed at C, real, inverted and
equal in size as that of object
4. Between F and C Image is formed away from C, real, invert-
ed and bigger in size as compared to size
of object
5. At focus Image is formed at infinity, real and mag-
nified
6. Between F and pole Virtual, magnified and erect image is
of mirror formed behind the mirror

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 Chapter
Visual Angles
5 and Axes of Eye

AXES AND ANGLES OF EYEBALL

Optical Axis
A line passing through center of cornea, center of lens and posterior pole
of retina is the optical axis of eyeball (ONA in Fig. 5.1).

Visual Axis

A line joining point of fixation with fovea and passing through nodal
point of eyeball is called visual axis. Nodal point of eyeball is just
anterior to posterior capsule of lens. Fixation point is the point which is
being seen with fovea at any particular moment (VNF in Fig. 5.1).

Pupillary Axis

This is a straight line that passes through center of pupil (OPA in Fig. 5.1).

Fixation Axis

This is a straight line that joins center of rotation of eyeball with fixation
point (VC in Fig. 5.1).

Fig. 5.1: Axes of eyeball

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 42 Refraction, Dispensing Optics and Ophthalmic Procedures

Angles (Fig. 5.1)

• Angle Alpha is the angle formed between optical axis and visual
axis i.e. angle ONV
• Angle Kappa is the angle formed between visual axis and pupillary
axis.
• Angle Gamma is the angle formed between optical axis and
fixation axis, i.e. angle OCV.

Purkinje Images (Catoptric imagery)

These were first described by a Czech scientist JE Purkinje to differentiate
between aphakia and normal eye. These are four in number and are
formed as a result of reflection from different ocular surfaces (Fig. 5.2).
First Purkinje Image Formed by reflection from anterior surface
of cornea, situated near pupillary plane. It is
brightest, virtual and erect image. This image
is made use of in keratometry
Second Purkinje Image Formed by reflection from posterior surface
of cornea, situated near pupillary plane. It is
virtual and erect image
Third Purkinje Image Formed by reflection from anterior surface of
lens, situated in vitreous. It is the largest but
dim, virtual and erect image
Fourth Purkinje Image Formed by reflection from posterior surface
of lens, situated within the lens. It is real and
inverted image. It moves in opposite direc-
tion to other images

Clinical Applications
1. To diagnose presence or absence of lens.
2. Keratometry makes use of first Purkinje image.
3. Type of cataract: In MSC and HMSC, Fourth Purkinje image is
absent.
4. Hirschberg test: First Purkinje image is used for estimation of angle
of squint.

Fig. 5.2: Purkinje images

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 Chapter

6 Refractive Errors

Parallel rays of light coming from infinity are focused on retina under
normal conditions and thus the image of an object is formed on retina.
This condition is known as emmetropia. This image is very small in size
and inverted. From retina, this image is carried to brain via optic nerve
where it is re-inverted and interpreted by visual cortex. Vision of person
is recorded as 6/6 on Snellen’s chart and the power of eyeball is +60
Dioptre. If parallel rays of light coming from infinity are not focused
on retina; the condition is known as ammetropia or a state of refractive
error. Different types of refractive errors are (Fig. 6.1):
1. Myopia
2. Hypermetropia
3. Astigmatism

Fig. 6.1: Different types of refractive errors

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 44 Refraction, Dispensing Optics and Ophthalmic Procedures

MYOPIA
This is also known as ‘Short Sightedness’. It is defined as a condition of
refraction in which parallel rays of light coming from infinity are focused
in front of retina with accommodation at rest. This is because the power
of eyeball is more than +60D.

Types of Myopia
Depending upon mechanism of production, myopia may be of different
types:
1. Axial myopia: Here the axial length of eyeball is more than normal
(>24 mm). One mm increase in axial length causes three dioptre of
myopia.
2. Curvature myopia: Curvature of cornea or lens is more than normal.
One mm increase in curvature causes six dioptre of myopia.
Keratoconus and lenticonus are clinical entities which cause high
curvature myopia.
3. Index myopia: Refractive index of eyeball is more than normal, e.g.
in nuclear sclerosis refractive index of lens is increased causing a
myopic shift.
4. Positional myopia: Anterior displacement of lens in the eyeball
causes a myopic shift.
5. Excessive accommodation as occurs in spasm of accommodation
causes myopia.

Depending upon clinical presentation myopia may be of different types:

1. Congenital myopia: It is present since birth but parents come to
know about the disease at around 2 to 3 years of age. The child
usually requires high concave lens (8-10D) to correct the error. It
may be unilateral or bilateral. The child may develop convergent
squint. It may also be associated with other congenital anomalies
like microophthalmos, microcornea, congenital cataract etc.
2. Simple myopia: This is the most common variety of myopia
encountered clinically. Patient may complain of blurring of
vision, eyestrain while reading, writing or working on computer
and watching television. The school going child may complain of
doing mistakes when he copies matter written on black board. If
error is small, eyestrain symptoms occur more because he tries to
compensate for the error and if error is of high degree, patient is not
able to see distant objects. On examination, myopic eyeball is more
prominent with large pupils. Fundus may show temporal crescent.
Diagnosis is confirmed by retinoscopy.
3. Pathological myopia: This is also known as degenerative myopia.
There is rapid progress of myopia in early adult life associated
with degenerative changes of retina and vitreous. It occurs due to

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 Refractive Errors 45

rapid increase in axial length of eyeball. Heredity plays the main

role because this type of myopia is more common in persons with
family history of high myopia. It is more common in some races like
Japanese, Chinese and it is less common in Negroes and Sudanese.
Due to rapid growth sclera follows the growth of retina but choroid
undergoes degeneration followed by degeneration of retina.
General factors like nutritional deficiency, debilitating diseases,
wrong posture, poor illumination, and working on computer for
long hours play a minor role in progress of myopia.

Symptoms and Signs of Degenerative Myopia

• A patient of progressive myopia complains of rapid deterioration of
vision, vision may not improve to normal status.
• Muscae volitantes (a specific type of vitreous floater) and black
opacities in front of eyes are complained of by many patients.
• Some patients may complain of night blindness due to degeneration
of retina.
• Eyeball may appear proptosed in unilateral cases. Lengthening
occurs mainly around posterior pole.
• Anterior chamber is deep and cornea may be bigger than normal.
• Pupils may be bigger in size and react sluggishly to light.
• Fundus may show big optic disk with temporal crescent or peri
papillary atrophy. Retina becomes very thin and prone to
rhegmatogenous retinal detachment. Foster Fuch’s spot (dark red
spot due to subretinal neovascularization and choroidal hemorrhage)
may be seen. Cystoid degeneration may occur in the peripheral
retina. Posterior Staphyloma may be formed due to ectasia of sclera
at posterior pole lined by choroid and retina. In advanced cases
retinal atrophy may occur and patient may go blind.
• Vitreous becomes liquefied with posterior vitreous detachment and
vitreous opacities.
• Visual fields become contracted and ERG reveals subnormal reading
due to chorioretinal degeneration.

Treatment of Myopia
Myopia is corrected by appropriate concave lenses either in form of
spectacles or contact lens. Surgical correction of myopia can be done by
photorefractive surgery or exchange of clear lens.
Contact lenses are cosmetically better suited with minimal aberrations
and maximum visual field especially in high myopes. However they
need motivation and better care on part of patient.
LASIK laser surgery is gaining popularity day by day. But it has its
own limitations, as very high myopes are sometimes not fit for surgery
due to poor corneal thickness or keratoconus.

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 46 Refraction, Dispensing Optics and Ophthalmic Procedures

Very high myopia can be rectified by lens exchange but patient has to
accept bifocal lenses in young age because accommodation is lost after
surgery.
Recent development in treatment of very high myopia is implantable
contact lens. In this surgery normal lens is left as such and through a limbal
incision an implantable contact lens is fitted over the normal crystalline
lens. This contact lens keeps on floating over the crystalline lens. It is
an alternative to LASIK laser surgery where thickness of cornea is a
limiting factor. Thus patient gets rid of spectacles and accommodation is
also retained. However this surgery is quite costly.
Recently special types of contact lenses have been introduced called
the ortho-k lenses which are to be used by the patient overnight and
removed during day time. This corrects myopia as well as hypermetropia
in a reversible manner. Once the patient stops using them the refractive
error returns back.
Combination of clear lens extraction and LASIK laser can also be
done in very high myopes. However accommodation is lost.
Thus every patient should be individualized for type of treatment.
While correcting myopia the basic rule must be followed everywhere
that myopia is always under corrected to avoid minification and
reading difficulties.

Low Vision Aids are prescribed to patients who cannot carry out their
routine activities even with glasses. These are special types of spectacles,
which are prescribed to patients with very poor vision.
Prevention of progressive myopia can be done at community level
by marriage counseling. A progressive myope should not marry another
progressive myope or they should not bear children.

Complications of Pathological Myopia

These are retinal detachment, vitreous degeneration, and complicated
cataract.

HYPERMETROPIA
This is a type of refractive error in which parallel rays of light coming
from infinity are focused behind the retina with accommodation at rest.
Power of eyeball is less than normal (< +60D).

Types of Hypermetropia
Depending on mechanism of production, hypermetropia can be of
different types:
1. Axial hypermetropia: Here the axial length of eyeball is less than
normal (<24 mm).

Chapter 6.indd 46 03-08-2012 13:59:10

 Refractive Errors 47

2. Curvature hypermetropia: Curvature of cornea or lens or both are

less than normal.
3. Index hypermetropia: Refractive index of eyeball is less than
normal.
4. Positional hypermetropia: Lens is displaced backwards.
5. Absence of crystalline lens: This may be congenital or acquired
due to posterior dislocation of lens. This condition is known as
aphakia.
Depending on clinical presentation hypermetropia can be of different
types:
1. Simple hypermetropia: This is due to normal biological variation
in development of eyeball. This is the most common type of
hypermetropia.
2. Pathological hypermetropia: This is due to certain factors which are
not in the normal biological variations, e.g. posterior subluxation of
lens (positional hypermetropia), acquired cortical sclerosis (index
hypermetropia), under-correction of refractive error (consecutive
hypermetropia) and congenital absence of lens (aphakia).
3. Functional hypermetropia: It results due to paralysis of accommo-
dation, e.g. third nerve paralysis.

Components of Hypermetropia
Total Hypermetropia
Total amount of hypermetropia estimated after complete cycloplegia
with atropine. It has two parts latent and manifest.

Latent Hypermetropia
This part is corrected by inherent ciliary tone. It is usually one dioptre. It
is more in children and decreases with age.

Manifest
This part of hypermetropia cannot be corrected by ciliary tone. It has two
components.
Facultative: This part of hypermetropia can be corrected by accommo-
dative effort.

Absolute: This part of hypermetropia cannot be corrected by accom-

modative effort.

Example
Suppose a patient is put atropine eye ointment and full cycloplegia is
achieved. Now retinoscopy findings at one meter distance show +6.00
DS in both horizontal and vertical meridia. So total hypermetropia in

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 48 Refraction, Dispensing Optics and Ophthalmic Procedures

this patient will be +6–1(distance factor) = +5 DS +1.00 DS is the latent

hypermetropia due to inherent ciliary tone and manifest hypermetropia is
+5–1= +4.00 DS. Now if patient accepts +2.50 DS with 6/6 vision (best
corrected vision), then +2.50 DS is the absolute hypermetropia which
cannot be corrected by accommodative effort and patient needs glasses.
+4.00–2.50 = +1.50 DS is the facultative hypermetropia which patient
corrected with his accommodative effort (Minimum power of convex lens
required to achieve best vision is absolute hypermetropia and maximum
power of convex lens required to achieve best vision is manifest
hypermetropia. Manifest – Absolute = Facultative hypermetropia).

Clinical Features of Hypermetropia

Symptoms depend on the amount of hypermetropia and age of person.
These may be:
1. Asymptomatic: A person who does not have much visual require-
ment and has a small refractive error may not complain of any
problem and refractive error may be detected just by chance.
2. Eyestrain: Patient complains of headache, watering, tiredness of eyes
while working on computer, watching television and doing reading and
writing work. This is due to sustained accommodative effort.
3. Defective vision: When amount of error is very high; patient may not
try to compensate it and complains of defective vision. If patient can
compensate some amount of error by accommodative effort and rest
of the error remains uncompensated; he may complain of eyestrain
symptoms and defective vision both more for near than for distance.
4. On examination size of eyeball appears smaller with small cornea,
shallow anterior chamber and small optic disk with indistinct
margins (Pseudopapillitis). Retina shows more shining called ‘Shot
Silk Retina’. Axial length can be confirmed with A-Scan.

Management of Hypermetropia
Diagnosis is confirmed by retinoscopy under cycloplegia. Fogging test
should be done and maximum acceptance should be prescribed. However,
patient should be comfortable with the prescription. Cylinder should be
prescribed fully. If patient is not comfortable with full correction at first
sitting; under correction may be done with small increment after a gap of
three to six months. Full correction must be given at first sitting if patient
is having accommodative squint.
This error is corrected by prescribing convex lens so that the rays are
converged and focused on retina. Convex lens can be prescribed in form
of spectacles, contact lens, refractive corneal surgery, phakic IOLs and
ortho-k lenses.
Phakic IOL is a type of IOL which is implanted over and above the
normal transparent crystalline lens. However, the surgery is a bit tricky

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 Refractive Errors 49

and should be done by expert hand as it can damage the normal lens
and make it cataractous. This procedure is done to correct very high
hypermetropia.

ASTIGMATISM
It is a type of refractive error in which parallel rays of light coming from
infinity do not come to a focus but form focal lines with accommodation
at rest. This is because the refractive power is different in different meridia.

Types of Astigmatism
Astigmatism is of two types (Flow chart 6.1):
1. Regular astigmatism: Refractive power changes uniformly from one
meridian to another. It has two principal meridia. It can be corrected
by spectacles, contact lens and refractive surgery.
2. Irregular astigmatism: Refractive power does not change uniformly
from one meridian to another. It cannot be corrected by spectacles
and semisoft contact lenses should be advised.

Types of Regular Astigmatism

A. Horizontovertical: Here the two principal meridia are horizontal and
vertical. If the vertical meridian is more curved (hence more power)
than horizontal meridian, it is called ‘with the rule’ astigmatism. This is
called ‘with the rule’ because vertical meridian is generally more curved
due to pressure of lids on eyeball. This type of astigmatism is corrected
by minus cylinder at 180° or plus cylinder at 90°. If horizontal meridian
is more curved than vertical meridian, it is called ‘against the rule’
astigmatism. This type of astigmatism is corrected by minus cylinder at
90° or plus cylinder at 180°.
B. Oblique astigmatism: Here the two principal meridia are not
horizontal or vertical but still they are placed at right angle to each
other, e.g. the two meridia can be 45° and 135° or 10° and 100°.
C. Bioblique astigmatism: Here the two principal meridia are oblique
and at the same time, they do not intersect at right angle to each
other, e.g. one meridian may be at 10° and other at 30°. This type of
astigmatism cannot be corrected by spectacles.

Flow chart 6.1: Types of astigmatism

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 50 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 6.2: Types of astigmatism

Depending upon at which point the rays of light are focused, astig-
matism can be of different types (Fig. 6.2):
1. Simple myopic astigmatism: One meridian is focused on retina
and the other is focused in front of retina, e.g. –1.00 DC at 180°
prescription shows that it is a case of simple myopic astigmatism.
2. Simple hypermetropic astigmatism: One meridian is focused at
retina and the other is focused behind the retina, e.g. +1.00 DC at
180° prescription shows that it is a case of simple hypermetropic
astigmatism.
3. Compound myopic astigmatism: Both the principal meridia are
focused in front of retina, e.g. –1.00DS/–1.00DC at 180° prescription
shows that it is a case of compound myopic astigmatism.
4. Compound hypermetropic astigmatism: Both the principal meridia
are focused behind the retina, e.g. +1.00DS/+1.00DC at 180°
prescription shows that it is a case of compound hypermetropic
astigmatism.
5. Mixed astigmatism: One meridian is focused in front of retina and
the other is focused behind the retina, e.g. +1.00DS/ –2.00DC at
180° prescription shows that, it is a case of mixed astigmatism.
Depending upon etiology, astigmatism can be:
1. Corneal astigmatism: Abnormality lies in the anatomy of cornea
2. Lenticular astigmatism: It may occur due to tilting of lens or
abnormal curvature of lens (lenticonus).
3. Retinal astigmatism: Due to oblique placement of macula as may
occur in scarring of retina.
Clinical Features
1. Patient may complain of eyeache, headache, tiredness of eyes
and sometimes nausea if the error is small. These are known as
asthenopic symptoms.

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 Refractive Errors 51

2. Blurring of vision and distorted appearance of objects may be

complained of by some persons.

Treatment
Astigmatism can be corrected either by glasses or by contact lens or
corneal refractive surgery. Regular astigmatism can be corrected by
spectacles. However if the cylindrical power is high (2-3D) the quality
of vision is better with semisoft contact lens as compared to glasses.
For very high astigmatism toric contact lens can be prescribed. Irregular
astigmatism is corrected by semisoft contact lens, which replaces the
irregular anterior surface of cornea with regular surface of contact lens.
If vision does not improve with contact lens penetrating keratoplasty
should be considered.

Strum’s Conoid
Configuration of rays when they get refracted through a sphero-
cylindrical surface (toric or compound lens) is like the shape of a cone
hence called the Strum’s Conoid. It has the following features (Fig. 6.3):
1. A toric surface has maximum curvature and hence maximum power
in one meridian (suppose vertical) and minimum curvature in other
meridian (suppose horizontal).
2. When parallel rays of light pass through a convex toric lens, vertical
rays get focused at point M and horizontal rays get focused at point
N. Thus these rays have two foci. The distance between the two foci
is called ‘Focal interval of strum’.
3. If these rays are intercepted at different points A, B, C, D, E, and F,
a circular object will appear as shown in the Figure 6.3.
Now if retina is presumed to be present at point A, the condition
becomes compound hypermetropic astigmatism where both the meridia
are getting focused behind the retina.
If retina is at point B, it is simple hypermetropic astigmatism where
vertical rays have come to a focus but horizontal rays are yet to focus.

Fig. 6.3: Strum’s conoid

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 52 Refraction, Dispensing Optics and Ophthalmic Procedures

If retina is at point C, it is a condition of mixed astigmatism where

vertical rays have focused in front of retina and horizontal rays get
focused behind the retina.
If retina is at point E, it is simple myopic astigmatism, where vertical
rays have focused in front of retina and horizontal rays have focused on
retina.
If retina is at point F, it becomes a case of compound myopic
astigmatism where both the meridia have focused in front of retina.

Clinical Significance
It explains why an astigmatic patient complains of seeing distorted
objects. Also that a patient having mixed astigmatism may not complain
of defective vision as the circle of least diffusion falls on his retina and
hence his visual acuity is very good even without glasses.

APHAKIA
It is absence of crystalline lens in its normal position in the eyeball.
It may be congenital absence of crystalline lens or acquired (surgical
removal of lens as after cataract surgery). It creates a high degree of
hypermetropia.

Causes
1. Congenital absence of crystalline lens.
2. Surgical aphakia, e.g. after cataract surgery
3. Traumatic aphakia: Lens is expelled out due to some injury.
4. Spontaneous absorption of lens may occur sometimes producing
aphakia.
5. Posterior dislocation of lens in the vitreous cavity.

Clinical Features
Patient complains of marked loss of vision for distance and near, as there
is total loss of accommodation. On examination:
1. Surgical scar mark may be seen on limbus.
2. Anterior chamber is deep.
3. Iris shows tremulousness (Iridodonesis) on movement of eyeball.
4. Pupil is jet black in color.
5. 3rd and 4th Purkinje images are absent.
6. Fundus shows small disk with indistinct disk margins.
7. Retinoscopy shows high hypermetropia.

Treatment
It can be corrected by glasses, contact lens and intraocular lens
implantation. Usually +10 DS lens along with cylinder for induced
astigmatism is required to correct aphakia in a previously emmetropic

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 Refractive Errors 53

patient. However, each and every patient should be individually assessed

by retinoscopy for the power of glasses required. Aphakic glasses have
the advantage of being cheap, safe and easy method of rehabilitation
of aphakia. However there are a lot of problems associated with use
of these glasses. These are magnification of image by 30% thus totally
unfit for unilateral aphakia as this causes diplopia. It also causes hand
eye incordination, problems of spherical and chromatic aberration
due to thickness of lens. Field of vision is limited. There is prismatic
effect from edges of glass. Objects appear and disappear if the patient
tries to see them by moving eyes, i.e. roving ring scotoma (Jack in box
phenomenon). So patient should be advised to move his head instead of
moving his eyes to look sideways. Cosmetically they are unacceptable
especially in young persons.
Somewhat better method is use of contact lenses. They are
cosmetically acceptable with less magnification (7%), more suited for
unilateral aphakia with wider and better field of vision. Spherical and
chromatic aberrations are absent. However they are costly, difficult to
wear especially for old bilateral aphakes. Very good personal hygiene is
required.
The best method of rehabilitation of aphakia is IOL implantation. It
is fitted on the table during surgery. It can also be implanted later on as
secondary IOL implantation. It has 1 to 2% magnification only, hardly
appreciated by patient, no aberration, no prismatic effect. That is why
they are becoming more and more popular. However special training
needs to be given to the surgeon for good results and costly equipments
are required for surgery.
Another method of rehabilitation of aphakia is refractive corneal
surgery. LASIK laser is the best modality. In this surgery corneal stroma
is ablated with laser to alter its curvature and thus alter the power of
eyeball. Keratophakia and epikeratophakia have still not gained
popularity.

PSEUDOPHAKIA
It is a condition of eyeball when an artificial lens is present in place of
crystalline lens.

Types of IOLs
Depending upon position of IOL they are of different types (Fig. 6.4):
1. AC-IOL (Anterior chamber): It may be angle supported or iris
supported IOL e.g. Iris claw lens.
2. PC-IOL (Posterior chamber): It may be ‘in-the-bag’ IOL, Sulcus
(between iris and anterior capsule of lens) fixated IOL or Scleral
fixated IOL (Fig. 6.5).
‘In-the-bag’ IOL is the best IOL because it is the natural position of lens.

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 54 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 6.4: Types of IOLs

Foldable versus Non-foldable IOL

Foldable IOLs are made from silicone and acrylic and can be folded
without changing its optical properties. Such types of IOLs can be
injected through a very small hole on limbus (2.8 mm or even less).
Inside the posterior chamber they unfold and can be implanted in the bag.
Non-foldable IOL is made from PMMA (poly methyl metha acrylate)
and needs to be implanted through a bigger incision (5.25 mm or bigger)
thus needs more time to heal and there is more astigmatism.
Hydrophobic versus Hydrophilic IOLs
Some IOLs are made from PMMA, which is a hydrophobic material.
Such IOLs are stored dry. Other IOLs are made from hydrophilic
material and stored in solution. There are less chances of after cataract
with hydrophobic material.
Single Piece versus Three Piece IOL
An IOL is made up of two parts
namely central optic and peripheral
parts called haptic. If optic and
haptics are made as a single piece,
this is called single piece IOL. If they
are made separately and joined later,
they are called three piece IOL. Fig. 6.5: Design of PC-IOL

Signs of Pseudophakia
1. Surgical scar mark may be visible on limbus.

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 Refractive Errors 55

2. AC appears slightly deeper than normal.

3. Mild iridodonesis may be appreciated.
4. Pupil is black in color but it gives shining reflex when examined
with torchlight.
5. Visual status depends on refractive status achieved after surgery.
6. Slit-lamp examination with dilated pupil confirms the diagnosis.

Residual Error
Usually, a patient has some spherical and cylindrical error left after IOL
implantation even in the best of hands. Spherical error can be removed by
accurate biometry and cylindrical error can be minimized by decreasing
the size of incision.

ANISOMETROPIA
When refractive status of two eyes is equal, it is known as isometropia.
When refractive status of two eyes is not equal, it is known as
anisometropia. A difference of 1D in refractive status of two eyes creates a
difference of 2% in size of retinal image of two eyes. Up to 5% difference in
retinal image size of two eyes is well tolerated. Thus an anisometropia of up
to 2.5D is acceptable. Anisometropia of up to 4D may be acceptable in some
individuals and more than 4D creates diplopia.

Causes
It may be congenital or developmental or acquired as in unilateral
aphakia.

Clinical Significance
Small degree of anisometropia is of no concern and is quite common.
Patient develops normal binocular single vision. However, if one eye
is emmetropic and other is highly hypermetropic, the later will develop
suppression and amblyopia (lazy eye). Patient will use only emmetropic
eye for vision. If one eye is myopic and other is hypermetropic, then
patient will develop alternate vision. It means that he will use myopic
eye for near vision and hypermetropic eye for distant vision.

Types of Anisometropia
1. Simple anisometropia: Here one eye is normal (vision 6/6 without
glasses) and other eye is myopic e.g. 6/6 vision with–2.00DS. It is
known as simple myopic anisometropia. If other eye is hypermetropic
e.g. 6/6 vision with +2.00DS, it is known as simple hypermetropic
anisometropia.
2. Compound anisometropia: Here both eyes are either myopic (compound
myopic anisometropia; one eye requires–2.00DS and other–5.00DS)
or hypermetropic (compound hypermetropic anisometropia; one eye
requires +2.00DS and other +5.00DS) but one eye has higher refractive
error than the other.

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 56 Refraction, Dispensing Optics and Ophthalmic Procedures

3. Mixed anisometropia: Here one eye is myopic and other eye is

hypermetropic, e.g. one eye requires–2.00DS and other eye requires
+ 2.00DS.
Diagnosis and Treatment of Anisometropia
Patient is diagnosed on retinoscopy. He may complain of defective
vision, headache and other eyestrain symptoms. Different types of
treatment modalities available are:
Spectacles
Care should be taken that patient does not have diplopia or eyestrain
while prescribing glasses. A difference of up to 4D can be tolerated.
Contact Lens
Higher degree of anisometropia can be corrected by contact lenses.
Others
Refractive corneal surgery can be done, IOL can be implanted if there
is unilateral aphakia, and exchange of crystalline lens can be done if
there is high hypermetropia or high myopia. Phakic IOL can be done
in very high hypermetropia. Two procedures can also be combined if
required.

ANISEIKONIA
It is a condition when images projected on visual cortex from two eyes
are unequal in size or shape. Up to 5% aniseikonia can be well tolerated.

Types
It may be optical aniseikonia when image size difference is due to
anisometropia, retinal aniseikonia due to displacement of retinal elements
towards nodal point as a result of retinal edema and cortical aniseikonia
due to abnormality in perception of image. It can be further of two types:
Symmetrical when one image is larger than the other in all dimensions or
in one dimension, e.g. if one eye sees a square then the other eye may see
the square with bigger length and breadth or only length may be larger
(Fig. 6.6). In asymmetrical aniseikonia, image may be distorted in some
degree, it may be progressively larger in one dimension and smaller in
other dimension (Fig. 6.7).

Clinical Features
These are eyestrain symptoms, diplopia if the difference in image size is
more than 5% and there is difficulty in depth perception.

Treatment
Optical aniseikonia can be treated by contact lens, IOL implantation
and corneal refractive surgery. Aniseikonic spectacles which cause

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 Refractive Errors 57

Fig. 6.6: Symmetrical aniseikonia

Fig. 6.7: Asymmetrical aniseikonia

magnification of image without introducing any appreciable power are

also a method of treatment. Retinal aniseikonia needs treatment of cause.
Cortical aniseikonia is very difficult to treat.

AMBLYOPIA OR LAZY EYE

It is a type of functional abnormality of visual system in which one or
both eyeballs are affected. Vision does not improve beyond a certain
limit and no physical abnormality of ocular media or visual pathway can
be blamed for poor vision.
Types of Amblyopia:
It is of three types:
1. Stimulus deprivation amblyopia: If a child has congenital cataract,
corneal opacity or any other opacity in the media so that the rays of
light do not pass and focus on retina, the child will develop amblyopia.
2. Strabismic amblyopia: If a child has squint or strabismus, one eye
dominates over the other causing suppression, which consequently
becomes amblyopic.
3. Anisometropic amblyopia: If a child has anisometropia, i.e. one eye
is emmetropic and other eye is high hypermetropic as in unilateral
aphakia, one eye develops amblyopia.

Treatment of Amblyopia
1. Correction of refractive error: Correct the refractive error either by
spectacles or contact lenses at the earliest possible.

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 58 Refraction, Dispensing Optics and Ophthalmic Procedures

2. Occlusion therapy: Close the normal eye and patient is made to

see with amblyopic eye. Duration of closure depends upon age of
patient. It may be 5:1 or 4:1, i.e. normal eye is closed for five days
and on sixth day amblyopic eye is closed so that the normal eye also
gets chance to see and it may not become amblyopic. This occlusion
is continued for minimum of three months or longer till the eye
shows improvement.
3. Pleoptics: It is a term introduced by Bangerter to include all
types of treatment for amblyopia particularly that associated with
eccentric fixation. This includes exercises like CAM stimulator and
synoptophore exercises.
Treatment of amblyopia is possible before seven years of age.
After that it becomes very difficult. Thus it is very important to
detect amblyopia before this age. It is possible by a compulsory eye
examination of child at the time of admission to school.

Why Myopia should be Slightly Under Corrected?

Myopia is corrected with a concave lens. A concave lens is a minifying
lens. More is the power more is the minification caused by it. Thus
myopia is always slightly under corrected to avoid minification of image
and consequent eyestrain symptoms.

Why Hypermetropia should be Fully Corrected?

Hypermetropia should always be fully corrected so as to relax accommo-
dation and avoid eyestrain symptoms. This is much more important in
case of a squint. However it should be born in mind that correction is not
done at the cost of producing eyestrain symptoms.

Near Objects Appear Clear to a Myopic Patient. Why?

This is because rays coming from a near object are divergent and more
power is required to focus them on retina. As power of a myopic eyeball
is >60 D, hence rays are focused on retina and near objects appear clear
to a myopic patient (Fig. 6.8).

Fig. 6.8: Near vision and myopia

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 Chapter

7 Accommodation
and Convergence

ACCOMODATION
We know that parallel rays of light coming from a distant object are
focused on our retina and we see distant objects clearly. At the same time
when we look at a near object, again we can see it clearly. This is because
our eyeball can increase or decrease its power. This inherent property of
eyeball to increase or decrease its power is known as accommodation.
This happens because when we see at a distant object our ciliary muscle
is in a relaxed state, zonules are stretched apart and lens is less convex.
Power of eyeball is +60D in an emmetropic eye. When we look at a
near object our ciliary muscle contracts, zonules become loose and lens
becomes more convex and thicker. Power of eyeball is increased to more
than +60D. At rest radius of curvature of anterior and posterior surface
of lens is 10 mm and 6 mm, respectively. When we accommodate it
becomes 6 mm on both the surfaces.

Far Point
The farthest point at which the objects can be seen clearly is called the
Far Point of eyeball or punctum remotum. In an emmetropic eye far
point lies at infinity, in hypermetropic eye it is virtual and lies behind the
eye and in myopic eye it is real and lies in front of the eyeball.

Near Point
The nearest point at which the small objects can be seen clearly is called
the near point or punctum proximum. In emmetropic eye near point lies
close to the eyeball depending on age. At 10 years of age, it is 7 cm, and
at 40 years of age, it is 25 cm. Since we keep the reading material at
25 cm distance hence we can read without any aid till forty years of age.
After that the near point recedes back and in order to read it clearly at 25
cm we need plus lenses. This condition of failing accommodation that
occurs with increasing age is called presbyopia. This happens because
the lens becomes less elastic with age hence cannot change its curvature
and weakness of ciliary muscle. Certain conditions like open angle
glaucoma, uncorrected hypermetropia can make the person presbyopic
much earlier.

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 60 Refraction, Dispensing Optics and Ophthalmic Procedures

Range
The distance between the far point and the near point is called the range
of accommodation.

Amplitude

Dioptric power of eyeball required to see at far point is lesser than the
power required seeing at the near point. This difference in dioptric power
of eyeball to see at near and distant object is known as amplitude of
accommodation.

Mechanism
When we look at distant object our ciliary muscle is relaxed, distance
between lens and ciliary muscle is more hence zonules are stretched.
Curvature of anterior surface of lens is 10 mm and posterior surface is
6 mm. Power of eyeball in an emmetropic eye is +60 D. When we look at
a near object ciliary muscle contracts, distance between lens and ciliary
muscle is decreased hence zonules become lax, curvature of anterior and
posterior surface of lens becomes 6 mm. Equatorial diameter of lens is
decreased from 10 mm to 9.6 mm and thickness of lens is increased by
0.50 mm. Total power of eyeball is increased from 60 D to > +60 D. Lens
is displaced slightly anteriorly by 0.30 mm hence AC becomes slightly
shallow (Figs 7.1 and 7.2).

Theories

Two theories of accommodation have been put forward to explain

the mechanism of accommodation namely Young Helmholtz theory
of relaxation and Tscherning’s theory of increased tension. Young
Helmholtz theory is more accepted.

Fig. 7.1: Mechanism of accommodation

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 Accommodation and Convergence 61

Fig. 7.2: (MOA) Lateral view

PRESBYOPIA
It is an anomaly of accommodation in which near point of eye recedes
back due to loss of elasticity of lens with age.

Symptoms
Patient complains of difficulty in reading and writing but distant vision
is good. He may have headache after doing near work or hold a reading
paper at farther distance from eyes.

Treatment
Plus lens is given in form of glasses or contact lens to correct the error.
Presbyopic LASIK laser surgery can also be done however glasses are
the most commonly employed method. Power of lens depends on the age
of patient as shown below:
40 + 1.00
45 + 1.50
50 + 2.00
55 + 2.50
60 + 3.00
Aphakia and Pseudophakia: +2.50DS to 3.00DS
This power is called ‘add’. This is added algebrically to the power for
distance to get the power for near vision.
Always bear in mind that near correction must be given after doing
correction for distance. Both eyes should be checked individually and
minimum possible correction should be given for near. Due consideration
should be given to the profession and habits of the patient while fixing
the near point.

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 62 Refraction, Dispensing Optics and Ophthalmic Procedures

Why Presbyopia Should be Slightly under Corrected?

When we read near objects accommodation and convergence both
are required. Presbyopia is always under corrected so as to encourage
accommodation. Accommodation is accompanied by accommodative
convergence. Thus patient does not complain of eyestrain symptoms.
Full correction of presbyopia causes eyestrain symptoms due to lack of
accommodative convergence.

Paralysis of Accommodation
This condition is known as cycloplegia. It may be caused by use of
cycloplegic drugs like atropine, third nerve paralysis and internal
ophthalmoplegia [paralysis of ciliary muscle and sphincter papillae
muscle]. Patient complains of blurring of vision for near; less marked in
myopic patients and intolerance to light due to associated dilatation of
pupil. On examination pupil is dilated, light reflex is absent and range of
accommodation is decreased. Treatment consists of removal of causative
factor, prescription of plus lens for reading and dark goggles to avoid
photophobia. Effect of drug weans off gradually of its own.

Spasm of Accommodation
This is a condition in which ciliary muscle over contracts and patient
exerts abnormally excessive accommodation. It may be caused by
pilocarpine like drugs. Children with uncorrected refractive error
sometimes go into spasm of accommodation in an effort to compensate
for the refractive error. It may be associated with bad reading habits like
poor illumination, bad posture, mental stress etc. Patient complains of
poor vision due to induced myopia and pain around eyes. If dry refraction
is done at this moment; myopic prescription will be given to the patient
which is wrong. This is the reason that dry refraction should not be done
in children. Refraction under atropine will confirm the diagnosis. Patient
is treated by giving atropine for a few weeks. He is advised to avoid
reading for some time. Removal of associated causative factors such as
poor illumination should also be taken care of.

CONVERGENCE
It is a type of binocular movement of eyeballs in which the two eyes turn
inwards. It may be voluntary or reflex. Reflex convergence is of four
types:
1. Proximal convergence: Psychological awareness of a near object
initiates this type of convergence.
2. Tonic: It means that when the patient is awake there is an inherent tone
in the extraocular muscles.
3. Fusional: It is initiated by a bi-temporal retinal image disparity and
is not associated with change in refractive status of eyeball. It ensures

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 Accommodation and Convergence 63

that image of an object falls on corresponding retinal points in the

two eyes.
4. Accommodative: It is initiated by act of accommodation. It means
that when we accommodate; we converge. It is a part of near reflex.
One dioptre of accommodation is accompanied by 4-5 prism diopters of
accommodative convergence and it remains fairly constant. Abnormalities
of accommodative convergence are associated with squint.

AC/A Ratio (Accommodative Convergence/Accommodation)

It can be defined as accommodative convergence measured in prism
diopters per unit change in accommodation measured in diopters.
Normal value is 4-5 prism diopters. It means that with one diopter of
accommodation, there is 4-5 prism diopter of convergence. It decreases
with age. A high AC/A ratio is associated with convergent squint when
the patient sees a near object. There is no squint if the patient sees a
distant object but when he sees a near object, there is convergent squint. It
is treated by prescribing +3.00DS lens for near along with the correction
of refractive error for distance if any, so that while seeing near objects
he does not need to accommodate. Withdrawal of spectacles for near in
a child with high AC/A ratio depends upon degree of hypermetropia,
AC/A ratio and the amount of associated astigmatism. A low AC/A ratio
is associated with divergent squint when patient sees a near object. AC/A
ratio can be measured by gradient method and phoria method.

Convergence Insufficiency
This is a condition which occurs more commonly in school-going
children. Patient complains of eyestrain symptoms while reading,
working on computer and watching TV. There may or may not be
associated refractive error. This is because when we look at near object
we need to converge. If medial rectii are not strong enough to sustain
convergence it puts strain on eyes hence headache and other symptoms.
It can be confirmed by testing range of fusion on synoptophore. If patient
is not able to sustain 30° convergence he is diagnosed as a patient of
convergence insufficiency. Treatment consists of convergence exercises
after correction of refractive error if any and good nutrition.

How to do Convergence Exercises?

Convergence exercises can be done at home or with the help of
synoptophore. Exercise must be done after using spectacles, if any.

At Home
Hold a pencil or any pointed object at arm’s length. See the tip of the
object with both eyes. Start bringing the object closer to the eyes and
maintain your focus at the tip of the object. When the object is close to

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 64 Refraction, Dispensing Optics and Ophthalmic Procedures

eyes it will appear blurred or there might be doubling of tip of the object.
Stop bringing further closer and try to focus the tip by converging your
eyes. After some time the tip of the object appears clear and single. Bring
the object still closer. Again the tip will get blurred, focus the tip again
and repeat the procedure till you feel headache. At this point, close your
eyes and rest for a few seconds. Bring the object back and again start
bringing closer. This can be done for about ten minutes at one time or till
the eyes get tired.

With Synoptophore
Put slides of fusion in the slot of synoptophore provided for the purpose.
Bring the arms of the synoptophore at zero. Ask the patient to see the
slides through eye piece. Patient sees a single image. Now converge the
arms slightly and see whether the patient maintains fusion. If patient
starts complaining that he is experiencing diplopia, ask him to make the
image single by exercising his convergence capacity. When he again
sees single image, further converge the arms of synoptophore. Again the
patient will experience diplopia. Ask him to exercise his convergence
capacity more and fuse the image. This goes on till his range of fusion
becomes around 35°.

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 Chapter

8 Retinoscopy and
Transposition

RETINOSCOPY
This is also known as Skiascopy or Shadow test. It is an objective method
for determination of refractive error by using principle of neutralization
with accommodation at rest.

Types of Retinoscopy
It is of two types namely wet and dry. When retinoscopy is done with use
of some drug it is called wet retinoscopy. When it is done without use
of any drug it becomes dry retinoscopy. Wet retinoscopy has got certain
advantages that accommodation is relaxed with the use of cycloplegic,
fundus examination is done side-by-side and some hidden disease like
primary open angle glaucoma, diabetic retinopathy can be detected early
in its course and spasm of accommodation is relieved with the use of
cycloplegic. The disadvantage is that patient has to come again for final
prescription and he has to tolerate photophobia, chances of drug allergy
etc. Still wet retinoscopy is the best method.
Depending upon accommodation used it is further divided into two
types; static retinoscopy when patient is looking at distant object and
accommodation is at rest and dynamic retinoscopy when it is done with
patient looking at near object and accommodation is being exercised.
Dynamic retinoscopy is not of much significance.

Retinoscopes
They are of two types:
1. Mirror retinoscopes: This may be a plane mirror or concave mirror
with a hole in the center. A combination of both plane and concave
mirrors is also available known as Priestley-Smith mirror (Fig. 8.1).
2. Self-illuminated retinoscopes: There is an inbuilt source of light in
the retinoscope. These are further of two types—spot retinoscope
and streak retinoscope. Streak retinoscope is more commonly
employed as it is easy to detect axis of astigmatism with this mirror
(Fig. 8.2).

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 66 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 8.1: Priestley-Smith mirror

Principle
This is based on the principle that when light is reflected by a mirror into
the eye of a person, the direction in which the light will travel across the
pupil depends on the refractive status of the eyeball.

Procedure
It is done in a dark room with a retinoscope. Patient is seated at a distance
of six meters from Snellen’s chart and his visual acuity is recorded in
both the eyes separately. Patient is asked to look at infinity so that his
accommodation is relaxed. With the help of a spot or streak retinoscope
light is thrown in his eyes one by one. We appreciate a red fundal glow
in pupillary area. Move the retinoscope up and down, right and left and
notice the movement of glow. There are three possibilities (with plane
mirror retinoscope):
1. Glow moves with the movement Emmetropia, hypermetropia and
of retinoscope myopia less than 1.00 D
2. Glow moves against the move- Myopia more than 1.00 D
ment of retinoscope
3. Glow does not show any Myopia 1.00 D
movement
If concave mirror is used for retinoscopy, e.g. in hazy media the
interpretations are as follows:

1. Glow moves with the movement Myopia more than 1.00 D

of retinoscope
2. Glow moves against the move- Emmetropia, hypermetropia and
ment of retinoscope myopia less than 1.00 D
3. Glow does not show any move- Myopia 1.00 D
ment
Now if the glow shows with movement with plane mirror retinoscope,
add plus lens till the glow stops moving with the movement of
retinoscope and add minus lens
if glow shows against movement
till there is no movement. This is
the point of neutralization. Note
down the power of lens required Fig. 8.2: Streak retinoscope

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 Retinoscopy and Transposition 67

to neutralize the movement of glow. This is the retinoscopy reading.

Note down the distance between the patient and the observer. Movement
of glow is fast if error is of small degree and it is slow when error is of
high degree.
Distance factor = 100/distance between patient and observer in cm.
For example Distance factor for one meter distance = 100/100 cm = 1
Distance factor for half meter distance = 100/50 = 2
Distance factor for two meter distance = 100/200 = 0.5
Drugs Used in Retinoscopy
Retinoscopy done after using drugs is known as wet retinoscopy and
retinoscopy done without drugs is known as dry retinoscopy. Atropine
should be used in children less than 5-years-old. Homatropine should
be used between ages of 5 to 15 years. Cyclopentolate can also be used.
These are cycloplegic drugs (paralyze ciliary muscle and accommodation
is relaxed). Tropicamide and phenylephrine or combination of both
can be used in adult patients. Effect of atropine lasts for one to two
weeks, homatropine for 3 to 4 days, Cyclopentolate for 1 to 2 days and
Tropicamide/ phenylephrine for 3 to 4 hours. During this period patient
finds difficult to do near work and complains of photophobia. So these
side effects should be explained to the patient before putting eye drops
in his eyes.

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 68 Refraction, Dispensing Optics and Ophthalmic Procedures

Drug Factor
Atropine = 1
Homatropine = 0.5
Cyclopentolate = 0.5
Other drugs = none
Now deduct the distance factor and drug factor from the retinoscopy
findings. This gives the objective prescription for the patient.

Subjective Verification
Put the lens of desired power as per the objective findings and ask the
patient to read. Increase or decrease the power of lens by ±0.25 DS.
Prescribe the power of lens with which patient can read the best in terms
of visual acuity and comfort.

Confirmation of Subjective Refraction

Pinhole test: Pinhole is placed in front of prescribed glasses and patient
is asked to read Snellen’s chart. If visual acuity improves with pinhole,
it means still some minor error needs to be corrected. However, if it
is a high astigmatic error vision cannot improve with glasses beyond
a particular limit but still it improves with pinhole. However, if vision
decreases after using pinhole it means some opacity is present in the
medium like central corneal opacity, posterior subcapsular cataract, etc.
Duochrome test: It is based on chromatic aberration. In an emmetropic
person rays of light are focused on retina. As we know that white light
is made up of seven colors namely Violet, Indigo, Blue, Green, Yellow,
Orange and Red (VIBGYOR). All colors have got different wavelength
so they are focused at different points on retina. Red color with maxi-
mum wavelength is focused behind the retina, green color in front of
retina and yellow color on retina. Thus an emmetropic person sees red
and green colors equally sharp. After giving correction patient is asked to
read FRIEND. FIN letters are written in green and RED letters are writ-
ten in red color. If myopia is over corrected or hypermetropia is under
corrected patient will appreciate green letters much better than red let-
ters. On the other hand if myopia is under corrected or hypermetropia is
over corrected patient will appreciate red color much better. Accordingly
change in power of lens should be done so that the patient appreciates
green and red letters equally sharp (Fig. 8.3A).
FIN appears better than RED Overcorrected myopia or under
corrected hypermetropia
RED appears better than FIN Overcorrected hypermetropia or
under corrected myopia

Jackson’s cross cylinder: It is used to verify power and axis of a cylin-

drical prescription. First of all verify power of a sphere if any by some
other method. Then verify power of cylinder followed by axis of cylinder

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 Retinoscopy and Transposition 69

Figs 8.3A to D: Methods for verification of subjective acceptance

by using JCC. JCC is available in powers of 0.50 D or 0.25 D. Any of them

can be used. For confirmation of power of cylinder place the JCC with
axis along the axis of prescribed cylinder and ask the patient which one
is better. Now place the JCC in reverse order and again ask which one
is better. If prescription is correct patient should see better without JCC.
If however one of the positions of JCC is better, increase or decrease
the power of cylinder prescribed and repeat the test till patient sees bet-
ter without JCC. For confirmation of axis place the JCC in such a way
that the two axis of JCC make an angle of 45° with axis of prescribed
cylinder. If patient sees better with JCC rotate the axis of plus cylinder
towards plus axis of JCC and minus cylinder towards minus axis of JCC
till he sees better without JCC (Fig. 8.3B).
Astigmatic fan test: It consists of a dial of radiating lines at an interval
of 10°. Patient is given best suitable combination of lenses and asked to
look at the astigmatic fan with one eye closed. A person with no astigma-
tism sees all the lines equally clear. An astigmatic person sees one line
more sharply defined than the others. Now add +0.50 DS lens over and
above the best combination of lenses already given. This causes fogging.
Now add concave cylinder at axis right angle to the axis of clearest line
visible on astigmatic fan. Power of cylinder should be such that all lines
are equally sharp (Fig. 8.3C).
Stenopeic slit: It is used to verify axis and strength of cylinder. After
doing retinoscopy and subjective acceptance spherical correction is put
in the trial frame. Ask the patient to read with one eye closed. Slit is put
in the trial frame and rotated till the patient sees the clearest vision. This
is the axis of the cylinder required. Now put some spherical power which
gives the best vision with slit still in place. Note down the power of this
spherical (suppose –0.50 DS and slit is at 45°). Rotate the slit by 90°
and again put the spherical power till it gives the best vision. Again note

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 70 Refraction, Dispensing Optics and Ophthalmic Procedures

down this power (suppose –1.50DS with slit at 135°). Now the algebraic
difference of two spherical powers, i.e. –0.50 and –1.50 (–1.00DS) is the
power of cylinder required at 45° (Fig. 8.3D).

Difficulties Faced During Retinoscopy

1. Glow is not visible: This may be because of hazy media due to
corneal opacity, cataract or vitreous opacity. Dilate the pupil and
confirm the diagnosis by slit lamp examination.
2. Movement of glow cannot be appreciated: It may be due to high ref-
ractive errors. Put +10.00 DS or -10.00 DS lens and notice the glow.
3. Scissor shadow: This difficulty is faced with dilated pupil. Constrict
the pupil and do retinoscopy.
4. Conflicting shadows: Different shadows are seen moving in different
directions. This is seen in irregular astigmatism. It cannot be corrected
by prescribing glasses. Semisoft contact lens need to be prescribed.
5. Triangular shadow: It is seen in Keratoconus. Semisoft contact lens
need to be prescribed.
6. Changing retinoscopy findings: It happens if the patient is
accommodating. Ask the patient to look at infinity or paralyze the
accommodation with a suitable drug.

TRANSPOSITION OF LENSES
It means making equivalent forms of prescription. It is required:
1. For manufacturing of glasses.
2. Sometimes refractive error of a patient needs plus cylinder at 90°
in one eye and minus cylinder at 90° in other eye. In such cases we
make the power of cylinder plus or minus in both the eyes to avoid
eyestrain. This is possible by transposition only.
3. Glass in a frame is always fitted in a curved manner. This curve
introduces a definite power in the glass. This is called base curve of
glass. To neutralize this undesired power; transposition is mandatory
in all cases.

Simple Transposition
It is done by observing following rules:
1. Power of new sphere is calculated by algebraic sum of power of
given sphere and power of given cylinder
2. Change the sign of given cylinder keeping power same.
3. Rotate the axis of given cylinder by 90°.
Examples: +1.00 DS/+0.50 DC*90°
Power of new sphere = +1.00+ (+0.50) = +1.50 DS
Power of new cylinder = 0.50 DC with opposite sign (minus) and
axis 180°.
Thus the new prescription becomes +1.50 DS/-0.50 DC*180. This is
called simple transposition.

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 Retinoscopy and Transposition 71

Toric Transposition

For toric transposition a base curve is required. The following rules

should be observed for toric transposition:
1. Sign of cylinder should be same as sign of base curve. If not change
the sign of cylinder by doing simple transposition.
2. Power of new sphere = Power of given sphere minus power of base
curve.
3. Power of cylinder no 1 = Power of base curve with same sign and
axis rotated by 90°.
4. Power of cylinder no 2 = Power of given cylinder + power of base
curve with same axis as of given cylinder.
Example: –2.00 DS/–0.50 DC*90° Base Curve + 5.00
Rule No 1: Sign of cylinder should be same as sign of base curve.
Sign of cylinder needs to be changed by simple transposition.
–2.50 DS/+0.50 DC*180°
Rule no 2: Power of new sphere= –2.50–(+5.00) = –7.50 DS
Rule no 3: Power of cylinder no 1= +5.00 DC*90°
Rule no 4: Power of cylinder no 2= + 0.50 DC + (+5.00 DC) = +
5.50 DC*180°
Thus the new prescription becomes
–7.50 DS/(+5.00 DC*90°)(+5.50 DC*180°)
Some Examples of Transposition
Example 1: +1.00 DS/+3.00 DC*90° Base curve of –6.00
Hence +4.00 DS /–3.00 DS*180° Base curve of –6.00
Net prescription will be
+10.00 DS/(–6.00 DC*90°)(–9.00 DC*180°)
Example 2: –2.00 DS/–1.00 DC*145° Base curve of –6.00
Net Prescription will be
+4.00 DS/(–6.00 DC*35°)(–7.00 DC*145°)

A Practical Problem
Suppose a patient has been prescribed +2.00 DS/–1.00 DC*180° both
eyes with add for near +2.50 DS both eyes. Patient wants glasses to be
made for distance and near separately. What will be the prescription for
near and distance glasses? Answer to this problem is that the patient
should be prescribed +2.00 DS/–1.00 DC*180° both eyes for distance
and +4.50 DS/–1.00 DC*180° for near. Point to be remembered is that
‘add’ is algebraically added to the spherical power for distance and there
is no change in power and axis of cylinder.

How to make a Cross Cylinder of Power 0.50?

Make a glass of –0.50 DS/+1.00 DC*180°. Power of spherical should be
half of power of cylinder with opposite signs.

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 Chapter

9 Ophthalmic
Lenses

TYPES OF OPHTHALMIC LENS MATERIALS

Different types of materials are available for making ophthalmic lenses.
They are:

Glass
This has been the most commonly used lens material. It is colorless,
transparent, resistant to heat and scratch with good optical qualities. It
is available as Crown glass (refractive index 1.523) and Flint (ref. index
1.650). Glasses of higher refractive indices are thinner and lighter than
glasses of lower refractive indices, so more suitable material for high
power lenses.
Photochromatic lenses darken on exposure to light and become
colorless in dark again. This is because silver chloride crystals are
incorporated in the glass material, which on exposure to sunlight become
darker in color. Glasses are also available in different tints, which is a
permanent feature.
Chemical treatment, lamination or heat treatment makes the lens
impact resistant. Chemical treatment is the best method as it gives
optically good quality glasses.

Plastic Lenses or Resin Lenses

These lenses are popularly known as fiber lenses or plastic lenses.
They are transparent, break resistant, impact resistant, lightweight with
good optical qualities but prone to scratches and more costly than glass
lenses. Most commonly used material is CR-39(C stands for Columbia
and R stands for resin). This material can withstand heat up to 100° C.
Its refractive index is 1.498. Chemically it is Allyl Diglycol Carbonate.
Tints can be easily applied and changed if required later on. It is UV
absorbing lens so protects against ultraviolet radiations. Resin lenses
of higher refractive index are also available suitable for high power
lenses. One can easily appriciate that if you come out of air conditioned
envionment, there occurs fogging of spectacle lenses. This fogging of
lenses in response to change in environment is less in resin lenses as

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 Ophthalmic Lenses 73

compared to glass lenses. These lenses can be made scratch resistant by

a special type of coating over the lens. They are also thicker than glass
lenses so the edge of concave lenses becomes prominent.

Polycarbonate Lenses
This material is heat sensitive hence can crack in hot or cold environment,
but highly impact resistant, thinnest and lightweight but prone to
scratches. A special scratch resistant coating is required. Vision around
edges is distorted. Its refractive index is 1.586 thus thinner than resin
lenses. It blocks both UV A and UV B rays. Tinting of these lenses is
difficult. Due to their impact resistance these lenses are suitable for
stuntmen and sportspersons, persons involved in hazardous industries,
children and single-eyed patients.

V-value Constringence or Abbe’s number

The degree to which the material has the same refractive index for
different wavelengths of light. Lenses made with lower V values more
quickly show rainbows, color fringes and degradation of best acuity
when the eye turns towards the periphery of a spectacle lens, the effect
being proportional to the power of lens. In simple language it is a positive
value that indicates the degree of transverse chromatic aberration. High
V-value means low dispersive power and vice versa. Thus Crown glass
has V-value of 59 and CR-39 has V-value of 57.8 and thus patient does
not complain of colored fringes due to their low dispersive power. In
contrast-high index lenses and polycarbonate lenses have a low V-value
thus high dispersive power and cause colored fringing of objects.

GRINDING OF LENSES
It is a procedure by which we convert a slab of glass (blank) into a
spectacle lens with specific power. It is also known as surfacing. This is
done by grinding the blank in such a way that curvatures are produced
on both front and back surfaces. The difference of curvatures on both
surfaces gives us the dioptric power of the lens. A wide range of tools
calibrated for a specific power are required. These tools are made from
cast iron and should be checked from time to time for their accuracy.
Various processes involved in the making of lenses are as under
(Fig. 9.1).
1. Blocking: It is a process by which a blank is fixed to the grinding
machine. Gluing material is heated and applied between the blank and
the platform of grinding machine. Once the material cools down; it
holds the lens very tightly and grinding can be carried out easily.
2. Roughing: It means generating the desired curvature. Surface of
the blank is rotated against tool of specific curvature using sand or
carborundum as abrasive powder. Thus a blank is converted into

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 74 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 9.1: Grinding of lens

a curved piece of glass with rough surface having approximate

desired power.
3. Smoothening: Here a proper tool with specific power is used to give
accurate power to the blank. Fine abrasive material like aluminous
oxide is used to grind the blank. Two grades of abrasive 302 and 303
are used one by one. Surface of the blank is trued with 302 and then
with 303 to make it more smooth. The end product of this process is
the lens with correct power. It is ready for polishing.
4. Polishing: A soft pad of felt cloth or wool cloth or specially designed
polishing pads are attached to the tool of rough use.
5. Deblocking: Polished lens is examined under incandescent bulb and
if found satisfactory, the lens is deblocked from the metal block.
The lens and the block are immersed in cold water and the block is
tapped by a wooden mallet. Ice cubes may also be used to facilitate
the deblocking process. Lens is cleaned with a thinner to remove
any undesired particle over it.
This process is repeated on the other surface of the lens. After each
step lens and the block are cleaned properly. Thickness of the lens is
controlled during grinding of other surface.

BEST-FORM LENSES
An ideal lens should be free from all types of optical aberrations. The
most important is that when we look through a lens obliquely, there
should not be any aberration. A lens form which eliminates all these
aberrations is known as best-form lens. One can easily understand that
for different types of lens powers different types of base curves are
required to achieve very good results. But practically this is not possible
as it requires a huge stock of lenses and tools. Thus we rely upon certain
standard base curves. These base curves are:
From +7D to Plane Base curve of –6.00D is given on back surface
From 0 to –6D Base curve of +6.00D on front surface
From –7D to –10D Base curve of +3.00D on front surface
From –10D to –15D Base curve of +1.25D on front surface
From –15D to –20D Plano front surface
A lens with base curve of 6D is known as deep meniscus lens and with
a base curve of 1.25D is known as Periscopic lens.
Minus base curve is ground on back surface for making up to +7.00D
lenses and a decreasing plus base curve is ground on the front surface
ranging from +6D to plano for making of up to -20D lenses. Beyond +7D

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 Ophthalmic Lenses 75

to-20D powers, it is not possible to neutralize the oblique astigmatism

of lenses. However with newer techniques and advent of computers for
mathematical calculations it is possible to manufacture lenses of best
forms and services have become personalized.

PANTOSCOPIC TILT
It is the angle between the plane of the lens/frame front and frontal plane
of the face. Upper 180° of eye wire is farther from the frontal plane of
face and the lower 180° of the eye wire is nearer to the frontal plane
of face. This is about 10-12°. This is required for proper relationship
of frame front and the eyebrows/cheeks of patient’s face. It also gives
widest view for reading as the vertex distance of the lower half of lens
is minimized.
However, this tilt introduces some astigmatism and changes the
effective power of the lens.
If the tilt is made in such a way that the upper 180° of frame comes
closure to the frontal plane of face as compared to the lower 180°, it is
called the retroscopic tilt.

TYPES OF BIFOCAL LENSES

Depending on design, they are of different types (Fig. 9.2).
1. Kryptok bifocal lenses
2. Straight bifocal or executive bifocal lenses
3. D-bifocal lenses
4. Moon-shaped bifocal lenses
5. Round bifocal
Depending on manufacturing technique, they may be of different
types:
1. Split bifocal: It is also known as two-piece bifocal. Here two separate
pieces of glass of different power are held together in a frame.

Fig. 9.2: Types of bifocal lenses

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 76 Refraction, Dispensing Optics and Ophthalmic Procedures

This bifocal was invented by Benjamin Franklin. It is no more used

now a day.
2. Cemented bifocal: A small plus lens is glued to the back of a
distance prescription with a glue like Canada balsam which has the
same refractive index as glass. This is used today in some low vision
prescriptions which require very high additions.
  The modern variant of the cemented bifocal is the Fresnel lens
which sticks in place with water or alcohol. It is used sometimes as
a temporary bifocal, but it is cosmetically unappealing, expensive,
and optically poor, hence not fit for permanent use.
3. Fused bifocal: This is the most commonly used variety. Here a piece
of glass of higher power with higher refractive index (flint glass) is
fused on the surface of crown glass. This part acts as segment for
near vision. It has good cosmetic appearance as there is no visible
or palpable demarcation. An example of this type is Kryptok which
means hidden in Latin.
  A countersink curve is made on the front surface of crown
glass with refractive index of 1.523. A button of flint glass with
refractive index 1.65 with same curvature is prepared and fused
on the countersink of crown glass at very high temperature of
above 650°C. Since the ref. index of flint glass is higher hence a
round shaped segment can be seen on the front surface without any
palpable demarcation. Size of this round segment is between 22-26
mm. If any cylindrical power needs to be ground on the lens, it must
be done on the back surface of lens.
4. Solid bifocal: This type of bifocal lens is made from a single material
but different segments are ground with different curvatures. The line
between the two segments is visible but can be made to disappear by
joining the two segments with a transition zone. This is also known
as one piece or seamless solid bifocals.

TRIFOCAL LENSES

This lens has three segments for distance, intermediate (e.g. for computer)
and near with different powers. Intermediate segment is 6-8 mm. This
lens is no more used these days.

PROGRESSIVE ADDITION LENS

Progressive addition lens (PAL) lens is made with power for distance
at the top of lens and power for near at the bottom of lens and there is
a gradual transition of power from distance to near in the intermediate
segment but no line is visible so gives better cosmetic appearance.
Person using PAL can view the distant objects from the topmost
segment, can do computer work from the intermediate segment and
do his reading work from the bottom segment. This type of lens is
particularly useful for persons who need to read and type and at the

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 Ophthalmic Lenses 77

same time deal with public e.g. officers working in banks need to read
the cheque no. type it and confirm on monitor and at the same time
deal with the public. Presence of a bifocal segment is taken as a sign
of old age so a PAL without a demarcation appears more youthful.
The disadvantage is that periphery of lens has unwanted astigmatism
hence not good for vision, thus eye movements are restricted. These
lenses are costly and not affordable for every person. Fitting of lens
requires special care. The optical center of lens must match the pupillary
center to avoid difficulty in adjustment, on axis blur and the need to
adopt uncomfortable head positions. Another point to be noted in the
prescription of PAL is that the frame chosen should be of good vertical
height otherwise there will be problem in adjustment. Difficulty faced by
small vertical height frame is that patient has to move his head back and
forth to see clearly on a monitor. This is described as moving one’s head
back and forth as if he is watching a tennis match. This is particularly
important if addition required is higher like +2.00DS or more. Problems
faced by a beginner during adjustment period are headache and dizziness.
Answer to this adjustment problem is removing the lens for some time
and reusing it again once the symptoms are over.
The Varilux lens was the first PAL of modern design. It was developed
by Bernard Maitenaz and patented in 1953.

Designs of PAL Lenses

There are different designs of PAL lenses. They are mono design and
multidesign, asymmetry and symmetry design, and hard and soft design.
In multi design the position for near vision segment goes up as the power
of addition increases. This is because a patient holds the reading material
nearer if the addition is higher. This is not the case with mono design
hence it is considered of inferior quality. In symmetrical PAL design right
and left lenses are identical. Lenses have to be rotated 10° anti-clockwise
in right eye and 10°clockwise in left eye for nasal decentration of near
segments. This causes uneven peripheral optical features and difficulty
in adjustment. Asymmetrical PAL design lenses are made separate for
right and left eyes hence no need for lens rotation. This results in better
optical performance, better BSV and convergence and improved visual
comfort. In hard design PAL, there is small intermediate zone, wide
distance and near zones. It is difficult to adapt. Unwanted cylindrical
power is pushed towards center of the lens therefore intermediate and
peripheral visions are restricted. In soft PAL design distance and near
zones are relatively smaller and intermediate zone is wider. Power
changes gradually from distance to near. Unwanted cylinder power is
pushed towards the periphery. Further modifications are being done to
minimize adaptive problems with PAL lenses (Fig. 9.3).
Bifocal, trifocal and progressive lenses should be better avoided in
old patients who are using glasses for the first time and particularly if the

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 78 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 9.3: Progressive addition lens

addition for near is considerable. This is because there is a considerable

problem while looking down and climbing down the stairs. This problem
is doubled up in patients suffering from vertigo and there are high
chances of patient falling down. A separate pair of glasses for distance
and near is ideal for them.

ANTI-REFLECTIVE COATING
This coating is used to avoid glare faced by computer users and night
drivers. When a ray of light strikes our glass of spectacles most of it
enters the medium of glass but some of it is reflected back from air-
glass interface which creates glare, i.e. the object appears less sharp.
This problem causes trouble to persons who work on computers for long
hours and drive at night.
Anti-reflective coating works on the principle of destructive inter-
ference, i.e. when two light waves meet in such a way that the crest of
one wave falls on trough of other wave (180°out of phase), they cancel
out each other. Glass is coated with a special type of coating in such a
way that the light reflected from air-coating interface and coating-glass
interface form destructive interference as shown in Figure 9.4.

Fig. 9.4: Antireflective coating

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 Ophthalmic Lenses 79

AR coating is done on both the surfaces of lens, i.e. front and back
surface to avoid glare from both the surfaces of lens. It is a multilayered
coating which can be done on almost all types of glasses.
Material (dielectric) for coating is chosen in such a way that its refra-
ctive index is equal to the square root of the refractive index of spectacle lens
and thickness of coating material is one fourth of wavelength of light. Now
because white light is a combination of different wavelengths hence multiple
coatings are required to prevent reflection of light.

Advantages
It improves optical performance of lens, i.e. the wearer sees better and
looks better with AR coated glass. As maximum light passes through the
lens, it improves contrast. It is very useful in persons who drive at night
and use computers for long hours.

TINTING OF LENSES
This is done to decrease transmission of light through lens by making
it appear colored. These lenses are used to avoid bright sunlight and
sometimes for cosmetic reasons.
Different colors and shades are available for this purpose. Shades are
usually expressed as number or percentage. The percentage indicates the
percentage of light transmission blocked. Persons using tinted glasses
are advised not to drive at night.

Some Important Facts About Tinting

1. Tint is a permanent feature in glass lenses. It cannot be changed. In
resin lenses, tint can be darkened or lightened. However if a light
tinted resin lens is darkened, scratches on it become more prominent.
2. It does not change its color from light to dark if exposed to sunlight.
3. Polycarbonate lenses can also be lightened or darkened but with
more difficulty.
4. Tints cause more reflection and transmission of light is decreased.
5. A plane lens where thickness of center and periphery is equal, tint
appears uniform. However in convex lens tint is more prominent in
the center and in concave lens it is more prominent at the periphery.
6. Special care has to be taken if the refractive error on two sides is
significantly different.
7. Tinted lenses attract dust and debris, hence need cleaning more
frequently.
8. Red, green and yellow tints should not be used as they interfere with
traffic signal interpretation.
9. If both antireflective coating and tinting are required, tinting has to
be done first.

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 80 Refraction, Dispensing Optics and Ophthalmic Procedures

10. Silver or chromium coating can be applied on lenses to give effect

of mirror coating so that the patient can see everything but passersby
cannot see his eyes.
11. Tint can be applied in a uniform manner over the whole lens or in a
gradient manner. In gradient manner, the top of the lens is tinted the
darkest and gradually faded to clear at the bottom.
12. The smaller the lens, the lesser are the color shade variations.

Technique of Tinting Lenses

Surface coating: A deposit material is coated on the back surface of the
lens to increase surface reflections. This method is used to tint glass
lenses.
Dye tinting: Resin lenses are tinted by this method. Lens is kept in a dye
chamber bath. The dye penetrates the lens material. Polycarbonate lenses
are difficult to tint. However the hard coat over polycarbonate lenses
takes up the tint.
Solid glass tint: Here the material of the glass itself is being tinted by
adding some special chemical to the raw material of the lenses. Different
tints available in the market are:
A1 = Light blue A2 = Deep blue B1 = Light gray
B2 = Deep gray SP2 = Light pink SP4 = Deep pink
SP9 = Light brown SP10 = Deep brown

Significance of Different Colors

Pink color is cosmetically better because it blends well with the skin
tones. Grey color is considered cool sunglass color. Brown color is taken
as warm cosmetic color. Yellow color is used during skiing, hunting and
shooting to enhance target definition. It enhances contrast during cloudy
and foggy weather.
Tinted lenses for outdoor use should be incorporated with ultraviolet
absorbing material to avoid damage to retina. While indoor tinted lenses
should be such that they absorb blue color and transmit most of other
colors. This is because while working under fluorescent bulb, flickering
of light is there and it is maximum near blue end of spectrum. Blocking
of flicker reduces incidence of headache. While driving tint should not
interfere with traffic signals.

PHOTOCHROMISM
Photochromic lens changes its color according to light and dark
conditions.
It becomes dark in bright sunlight and again light colored in dim light
conditions. This is because such lenses contain microscopically trapped
silver chloride crystals which change into free silver on exposure to

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 Ophthalmic Lenses 81

sunlight. This free silver forms silver colloids which absorb UV radiations to
cause darkening of lenses. In indoor conditions is silver particles, combined
with trapped halides and silver halide crystals are reformed and lens
appears clear.
Photochromatic lenses are available in glass, polycarbonate and
plastic lenses. Corning was first to manufacture glass photochromic
lenses in 1960s. American Optical Association first introduced plastic
photochromatic lenses in 1980s but it was successful in 1991 when
Transitions Optical introduced them. These lenses darken only in
sunlight but not in artificial light because UV radiations are required
for the darkening effect. Hence car windows which block UV rays also
render these lenses less effective inside the car.
Photochromic lenses should always be replaced in pairs so that there
is no difference of shade in the two lenses. Old photochromic lens has
undergone many light/dark cycles hence its color will be darker as
compared to new photochromic lens. All photochromic lenses have
additional UV absorbing property. Time taken by a photochromic lens to
become dark in sunlight is less than time taken to clear again in indoor
conditions.
Photochromic lenses absorb only UV light. Thus they are not protective
against infrared rays. These lenses become dark on exposure to UV light
hence this may happen even in a room. Darkening performance is poor
on a foggy day. Color change is temperature dependent. They become
darker in winters than in summers. Photochromic lenses are slightly
thicker than other lenses. More is the thickness more is the darkening
effect. These lenses show their optimum darkening effect after 10 dark/
light cycles. More they are exposed to sunlight, the darker they become.
Glass photochromic lenses are available in grey and brown shades.
Photochromism in glass lenses is temperature dependent. They become
darker in cold climate and clear easily in hot summers. So they are more
suitable for snow skiers than beach goers while outside.

Technique
Technique of photochromism in resin lenses is much more difficult.
Photosensitive molecules of Indolino Spironapthoxzine are uniformly
distributed within the front surface of the lens up to a depth of 100 to 150
micrometer. These lenses are also temperature sensitive. This lens becomes
darker in cold temperature. Corning photochromic lenses are also available
in which photosensitive material is present within the substance of the resin
lens. So they have much longer life like glass lenses.
When exposed to light photochromic lenses darken substantially in
response to UV light in less than one minute and then continue to darken
slightly over the next fifteen minutes. The lenses will begin to clear as
soon as they are away from UV light, and will be noticeably lighter
within two minutes and mostly clear within five minutes. However, it

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 82 Refraction, Dispensing Optics and Ophthalmic Procedures

normally takes more than fifteen minutes for the lenses to completely
fade to their non-exposed state.

Advantages and Disadvantages

Photochromatic lenses are never entirely transparent. They do not darken
in artificial light. However they protect against UV light and are useful
for patients who are sensitive to light.

Effect of AR Coating on Photochromism

AR coating decreases reflection of incident light on lens and increases
its transmittance. As the AR coating absorbs ultraviolet rays hence less
light is available for activation of photochromic property of lens. Thus
a photochromic lens with AR coating becomes less dark on exposure to
light as compared to a normal photochromic lens.

SCRATCH RESISTANT OR HARD COATING

This is a very thin coating done over resin lenses and polycarbonate
lenses to protect them from scratches. However it cannot protect them
from scratches from very hard and sharp objects. It also protects tints and
AR coating. Optical effect of this coating is negligible as the refractive
index of this coating and lens material is almost same.
Hard coat may be applied on one or both surfaces of lens. Usually
these coatings are very long-lasting. Tinting of resin lenses becomes
difficult after hard coating. Hard coating also increases antireflective
properties hence transmittance of light is increased.

WATER-RESISTANT COATING
This coating is applied on lens surface to reduce adhesion of water and
oil droplets. Thus the lens can be cleaned easily. It is a special layer of
silicone deposits.

POLAROID LENSES
These lenses remove glare reflected from flat surfaces like water, highways
and snow. They protect against UV rays and improve visibility due to reduced
glare. Polarizing material is nitrocellulose packed with ultramicroscopic
crystals of herpathite. Transmittance of light through the lens is remarkably
decreased. These lenses are available in glass, resin and polycarbonate
materials (Chapter 1, Polarization of light).

ULTRAVIOLET PROTECTIVE GLASSES

These lenses absorb UV rays and protect against their harmful effects.
They are more suitable for persons who have to work outdoors for long
hours. If exposed to UV rays, a person may develop snow blindness,

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 Ophthalmic Lenses 83

pterygium and pinguecula. Ultra violet rays are of three types: UV-A
(200-280 nm), UV-B (280-315 nm) and UV-C (315-400 nm). Ozone
layer in the Earth’s atmosphere absorbs UV-C rays from sunlight. Crown
glass can absorb UV rays up to 300 nm and resin lenses can absorb UV
rays up to 350 nm. Polycarbonate lenses can absorb all harmful UV rays.
UV protective coating applied on resin lenses can also absorb all UV
rays (up to 400 nm). UV coating imparts a very light yellow hue to the
lens. These protective glasses also contain filters which block infrared
rays harmful to human retina (Infrared A rays 700-1400 nm).

BALANCE LENS
This type of lens is used to balance the weight of the other lens in the
spectacle frame where one eye is practically blind. For better cosmetic
appearance, the balance lens power and style should match the other
lens.

OPTICAL CENTER OF A LENS

It is a point in the lens from which rays of light pass undeviated. To
understand the concept it is essential to know that a convex lens is made
up of prisms placed base-to-base. Hence the power is maximum at edges
and zero in the center.

Clinical Significance

Clinical significance of optical center is that fitting of glasses in frame

should be such that the optical center falls against the center of pupil so
that there is no prismatic effect.

How to find optical center of a lens?

It can be done with lensometer and manual method.
By Lensometer
Place a lens on the platform (lens holder) and look through eyepiece.
Looking through the eyepiece move the lens in such a way that the green
circle (target of lensometer) should fall exactly on the center of the black
cross. Mark the point with marker. This is the optical center of lens.

Manual Method
See a bright straight line like image of a tube light through lens. It appears
double. Move the lens up down so that the two images superimpose upon
each other. With a marker mark this line on lens. Repeat the procedure
by rotating the lens 90°. The point where two lines cross is the optical
center of lens.

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 84 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 9.5: Mechanism of ghost images

MECHANISM OF GHOST IMAGES

These are spurious images experienced by some persons usually low
myopes. These are formed as a result of reflections of light from front
as well as back surface of the lens and from the front surface of cornea.
Complaints about ghost images are relatively rare. Most common offender
is the reflection from back and front lens surfaces of a small light source
in front of the patient in a dark area. Patient complains that he sees extra
images of street lights at night. The patient may also complain of seeing
double. A careful history can diagnose the complaint, and counseling
usually takes care of it. Streak reflections may be produced in bifocals
by reflection off the segment tops. Patients perceive vertical streaks or
bars of light (Fig. 9.5).
Different techniques suggested for dealing with ghost image problems
are:
1. Adjusting base curve or pantoscopic tilt: This may move images
slightly, but won’t get rid of them. Adjustment is usually ineffective.
2. Decentration: The idea here is to move ghost images, especially
those formed by objects in front of the patient. It dose not work.
3. Changing base curve: It is completely irrelevant to images of objects
infront of the patient and will make only a negligible difference for
objects behind.
4. Contact lenses: This works perfectly optically, but may not be practical
for some patients like patients who require low cylindrical lens.
5. Counseling: This is the most common and best approach. Once
patients understand the origin and inevitability of the ghost image
problem, they can usually adapt.
6. Change bifocal style: Changing to a fused bifocal or progressive
will help with vertical streaks.
7. Anti-reflective coating: The reduction of reflections with a single
coating is incomplete but multiple layers can help further to reduce
amplitude and to cancel out light at several wavelengths. As many

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 Ophthalmic Lenses 85

as 9 layers may be used cancelling up to 99.5% of reflected light.

Many of these coatings are protective as well. This is a practical and
useful method.

TILTING OF LENSES
Spectacles should be worn in such a way that the lenses lie perpendicular
to the visual axis. Thus the incident light falls upon them normally, i.e. at
an angle of 90°. If a lens is worn in a tilted manner, its spherical power
is increased and cylindrical power is introduced. This change in power is
not significant if power is low but in high powered lenses this becomes
very significant and can cause eye strain symptoms.

VERTEX DISTANCE
This is the distance in mm from back surface of spectacle lens to
front surface of cornea. This is around 12 mm and should be kept
same as change of this distance changes effectivity of lens. Anterior
displacement of convex lens increases its effectivity and anterior
displacement of concave lens decreases its effectivity (Chapter 3
Effectivity of Lens).

INTERPUPILLARY DISTANCE
Interpupillary distance (IPD) is the distance between center of pupil of
one eye and center of pupil of another eye. This is very important for
fitting of every type of spectacle lenses especially progressive addition
lenses. This is to avoid any type of decentration of lenses and thus
prismatic effect. Distance from center of pupil of one eye and midpoint
of nasal bridge is known as monocular pupillary distance. This distance
is of importance for PAL lenses as the face is often asymmetrical. IPD
can be measured with a pupillometer and IPD ruler.

Measurement of IPD with IPD Ruler

Ask the patient to look into the left eye of examiner with his right eye.
Place the zero point of ruler against center of pupil of patient’s right eye.
Now ask the patient to look into right eye of examiner with his left eye
and measure the distance in mm from pupil to pupil. Another way of
measuring IPD is from nasal limbus of one eye to temporal limbus of
another eye in horizontal plane. IPD can also be measured with the help
of a pupillometer.

Monocular Pupillary Distance

This is the distance taken in mm from center of pupil of one eye and
center of nasal bridge keeping zero at center of pupil.

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 86 Refraction, Dispensing Optics and Ophthalmic Procedures

THE PRESCRIPTION
It should bear the following details:

Common abbreviations used in clinical practice:

OD (Oculus Dextur)—Right Eye (RE) OS (Oculus sinister)—Left Eye (LE)
OU (Oculi Uterque)—Both Eye (BE) VR (Visus Remotum)—For Distance
Vision
VP (Visus Proximum)—For Near Vision Add—Near addition power
NAD—No abnormality detected FU—Follow up
WNL—Within Normal Limits
CST—Continue same treatment IOP—Intraocular pressure
BU—Base up Prism BD—Base down Prism
BO—Base out Prism BI—Base in Prism
OE—On Examination PMT—Post Mydriatic Test
ESO—Esophoria ET—Esotropia
EXO—Exophoria XT—Exotropia
RH—Right Hyperphoria LH—Left Hyperphoria
RHT—Right Hypertropia LHT—Left Hypertropia

SPECIAL TYPES OF LENSES

High Index Lenses
Lenses with refractive index between 1.64 and 1.73 are called high index
lenses. Lenses with refractive index more than this are called very high
index lenses. These lenses are available in both glass and resin lenses.

Advantages of High Index Lenses

1. Very thin and light weight
2. Cosmetically better
3. Better optics due to less aberration in high power lenses.
4. More suitable for myopes because edge becomes very thin
However, transverse chromatic aberration is more and there is high
surface reflectance. As a result patient complains of colored tinge around
the object when seen through high index glasses.

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 Ophthalmic Lenses 87

Lenticular Lenses
These types of lenses are made when high power lens is required. The
purpose of making lenticular lens is to reduce its weight. The central
portion of lens is called aperture, which gives dioptric power to the lens.
Lenticular lenses are of two types:
1. Minus/ concave lenticular lenses
2. Plus/ convex lenticular lenses

Aspheric Lenses
These types of lenses are made to neutralize spherical aberration by
reducing the power of lens from center to periphery. Thus a +10 DS
aspheric lens will have +10 D power in the center and +6 D power at the
periphery. This asphericity increases the field of vision with negligible
prismatic effect.
These lenses are available in glass, resin and high index resin lens in
the range of +6.00 DS to –15.00 DS.They are also available as single
vision, bifocal and progressive addition lenses.

Protective Lenses
It is a special variety of lenses advised for children, sportspersons and
industrial workers and all those professionals who are engaged in hazardous
industries. These lenses are impact resistant and minimize the damage
caused to eyeball in case of accidents. Such glasses can be made by:
1. Heat treatment: A polished glass is melted and then cooled by cool
air on both surfaces. Surface of the lens cools faster than the interior
of the lens and brings surface of lens in a state of compression. Such
lenses can be identified by the fact that they unpolarize the polarized
light.
2. Lamination of lenses makes them protective. If such a lens gets
broken there is little chance of injury to the eyeball.
3. Chemical treatment: A finished lens is placed in a hot solution of
potassium for 14 hours. Sodium ions are replaced by potassium
ions. Now this lens is cooled which makes the surface of lens in a
state of compression. It imparts impact resistance properties to the
lens. Such lenses cannot unpolarize the polarized light.
Protective lenses may also be used to protect the eyes from radiations
like photochromic lenses, lenses with antiglare coating, polaroid goggles,
tinted lenses, UV absorbing lenses, etc.

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 Chapter

10 Spectacle Frames

FRAMES
A spectacle frame is a device used to hold the spectacle lenses in position
and put them in front of eyes so that they can be used for seeing. A frame
has broadly two parts: front and sides. Front part of a frame has joints,
rim, bridge, pads and grooves. Eyewire, frame front or rim is that part
of frame which holds lenses. Bridge is the middle part of frame which
joins two eyewires. Pads are synthetic parts which rest on nose. They are
either screwed or snapped into the metal piece. Hinge is the part which
joins sides with eyewires (Fig. 10.1).
A side has again joints, thicker portion of side called Butt, bent portion of
side and sleeves. Certain terms which are commonly used with frames are:
1. Mount: To fix the lenses in eyewire.
2. Dismount: To remove the lenses out of the eyewires.
3. Temple length: It is the length of side in mm.
4. Dowel point: Point where hinge is located for connecting eyewire
and temple.

Shapes of Frames
Commonly used frames are of following shapes (Fig. 10.2):
1. Square
2. Oval
3. Octagon
4. Pilot or aviator

Fig. 10.1: Spectacle frame

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 Spectacle Frames 89

Fig. 10.2: Shapes of Frames

5. Cat eye
6. Round
7. Pantoscopic round oval

Types of Frames
Full Rim
Lens is held in position by a metallic or some other material like plastic
all around.

Half Rim or Supra

Here metallic rim on one side and a fine nylon cord on other side hold
the lenses in position. Nylon cord is attached to the rim. Rim may be on
upper side or lower side. Consequently the nylon cord is on lower or
upper side. Sometimes the rim may surround the lens all around but on
lateral sides where there is nylon cord holding the lenses.

Rimless or Drill Mount

Here there is no rim around the lenses and the lenses are held in position
by screws to the bridge and the temples. This is also known as three-
piece frame because it has a nose bridge and two temples. Screws are
fitted at four places, two temporal and two nasals.
There are certain special types of spectacles like Half Eye. This is a
small sized spectacle used for reading purpose so that distant object can
be seen over top of the spectacles. Certain sports variety goggles are
also available like swimming goggles, squash goggles, divers goggles,
snooker goggles, ski goggles, etc. Some spectacles are used for some
specific occupation like welding spectacles, ptosis spectacles, low vision
aid spectacles, hearing aid spectacles, etc.

Information Available From a Frame

Following types of information is always available from a frame
(Fig. 10.3).
1. Size of rim: Length and width of rim is inscribed on the demo lenses
in mm. It is technically called the Horizontal Boxed Lens Size. It
can also be seen on the inner side of temple.
2. Temple length: It is inscribed on inner side of temple in mm.

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 90 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 10.3: Information available from a frame

3. Bridge size: It is also called DBL (Distance between lenses). It is

inscribed on inner side of temple.
4. Model number: Name of manufacturer and color code of the frame
is also inscribed on the inner side of temple.

Selection of Frame
A good frame should be comfortable. It should sit properly on the nose
and behind the ears. It should be suitable for lenses to be fitted. High
power lenses are thicker and heavy, hence frame should be thicker to
hold the lens. If the lenses are bifocal, the frames should be wide enough
to fit both distance and near powers. It should be of proper size, i.e.
neither too big, too small and nor too heavy. It must suit the face. Color
of frame should compliment skin and age.
A suitable spectacle frame adds charm to one’s personality so one
should wear frames according to their face shapes:
Round face: A narrow frame with high set temples lengthens face.
Oval face: It looks good in most styles.
Long face: A larger square frame gives balance to a long face
Pear-shaped with narrow forehead: Frames with a strong top bar add
width to forehead
Long nose: A low-set bridge tries to shorten it.
Short nose: Choose a high-set bridge.
Close set eyes: A thin and clear bridge adds width between them.
Wide set eyes: A colored bridge makes eyes appear closer.

BOX SYSTEM
This is a new internationally accepted system of frame dimensions.
This has replaced the previous Datum System. Different terms used in
spectacle frames are (Fig. 10.4).
1. Horizontal center line: It is a horizontal line passing through the
geometrical centers of two rims.
2. Vertical center line: It is a vertical line passing through the
geometrical centers of two rims.

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 Spectacle Frames 91

Fig. 10.4: Box system

3. Horizontal lens size: It is distance in mm between two vertical sides

of rim.
4. Vertical lens size: It is distance in mm between two horizontal sides
of rim.
5. Boxed center: It is the point of intersection of horizontal and vertical
center lines.
6. Distance between the lenses measurement (DBL): It is the bridge
size. It is measured from inside nasal point of one to the inside nasal
point of the other rim.
7. Distance between the rims measurement (DBR): It is the distance
between the rims at a specified level.

SPECTACLE FRAME MATERIALS

A variety of materials are available for making frames. An ideal spectacle
frame material should have the following properties:
• It should be rigid enough.
• It should be flexible enough to give it different shapes.
• It should be economical.
• It should be long-lasting.
• It should be resistant to corrosion from sweat.
• It should be easily convertible into different shapes.
• It should be cosmetically attractive and soothing.
• It should be lightweight.
• It should not cause any allergic reaction to tissues it comes in contact
with.
Metal frames usually consist of a number of different materials:
the structural metal of the frame called the base metal and the plating
material, frequently an organic lacquer (coating), and the plastic side
tips and nose-pads. Before coating the wire is drawn through rollers to
change it to the desired configuration. This hardens most alloys. Joints
between the components of metal frames can either be made by soldering
or by welding. Both soldering and welding weaken the heated area.
Many alloys cannot be soldered or welded satisfactorily with the simple
brazing torches used in practice. This is because an oxide layer forms
very rapidly and prevents adhesion. Many metals are toxic and great

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 92 Refraction, Dispensing Optics and Ophthalmic Procedures

care should be taken not to inhale any dust from these alloys. Even safe
metals such as titanium and aluminum can be dangerous if the particle
size is such as to cause lung damage.
Following types of materials are available for manufacturing of
spectacle frames:
Stainless steel: This is a durable material with flexibility. Spring effect
can be given in the frame. It is suitable for patients who are prone
to develop allergic reactions from ordinary frames. It needs to be
electroplated or painted to prevent corrosion.
Aluminium: It is very economic, lightweight, cosmetically attractive
and resistant to corrosion. It is a soft material so sides are made thick.
It is possible to add decorative finish to the material. It is a very good
conductor of heat hence becomes very cold in winters and hot in
summers. So the temple (two long sides) needs to be covered with plastic
sleeves. There are fewer chances of allergic reactions from this material.
German silver: It is corrosion resistant and flexible but needs
electroplating with nickel and is quite allergenic hence can cause allergic
reactions in susceptible individuals.
Titanium: It is most lightweight of all frames, 40 percent lighter than
normal frame materials, highly corrosion resistant from sweat, heat
resistant and non-allergic. Different colors can be added in it to make it
more attractive. But they are very costly. It has very good memory, i.e.
it retains its original configuration. It is available as pure titanium, clad
titanium and a combination of both.
Rolled gold: This is a precious metal frame. The process by which these
frames are made makes the product become harder and springier. This
metal occupies the upper end of the gold frame market.
9 carat gold is also used to make frames. It is very resistant to corrosion,
easily adjustable and convenient to work with.
Nickel silver: This is 12 to 25 percent nickel but mostly copper. It is
mechanically quite a good material for spectacle frames but it becomes
dull very quickly if not plated or coated and rapidly turns green in contact
with body fluids. It is easily worked and soldered and is one of the most
common materials for spectacle frames. Nickel silver is commonly used
for the joints and side reinforcement of plastic frames. Allergy to nickel
and its alloys is common but it only presents a problem where the metal
is in contact with the skin. However this can be prevented by using
plastic side-tips and bridges of inert metal or polymer coatings.
Memory metals: This is a group of alloys which has the common
property of being able to return to their original shape after considerable
distortion. They do snap if repeatedly flexed through sharp angles.
Frames are seldom made from memory metals alone. These materials
are commonly used for temples and bridges with more conventional
materials used for the eye wire screws and other parts. This is because
of cost factor and they are so flexible that they cannot be adjusted
satisfactorily. The best known memory metal is nickel, titanium but it

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 Spectacle Frames 93

is often sold as a titanium alloy with no mention of the nickel. There are
also other memory effect metals like–aluminium, titanium-cobalt and
aluminium-vanadium-titanium etc.
Combination of materials: Sometimes one part of a frame is made
from one material and the other part is made from a different material
for example metals and plastics. This does not include a plastic front
with metal joints, or a metal front with plastic nose-pads. It also does
not include composites. In practice, almost all frames are made from
combinations of materials – plastic fronts commonly have metal sides
and vice versa. Similarly plastic sides usually have metal reinforcement
while metal sides usually have plastic tips.
Plastics: Hawksbill turtle, the source of natural plastic has been declared
endangered species by World Wildlife Fund. Hence natural plastics like
turtle shell, bone, horn, ivory, leather and wood have become obsolete now
a day. Synthetic plastic is of two types: thermoplastics and thermosetting.
Thermoplastics can be re-formed with heat and thermosetting can’t
be reformed with heat because the material breaks up on exposure to
heat. Plastic frames can be made from different materials like cellulose
acetate, cellulose nitrate, cellulose propionate, cellulose acetate butyrate,
PMMA, epoxy resins, polyamides (nylons), polycarbonate, silicone
rubbers, carbon fiber, Kevlar and composite materials.
Cellulose acetate: This is one of the best materials available and prob-
ably the most common plastic spectacle frame material. It is very light,
strong, and mechanically stable at normal temperatures, easily worked
and relatively inert. It is cosmetically attractive and very transparent
material. It tends to whiten where in contact with patient’s body fluids
particularly at the bridge and temples. It is attacked by some common
solvents and dissolves in acetone. Acetate sides usually have full-length
wire reinforcement and any color is usually throughout the material.
It softens at around 50°C temperature so prone to damage by excess
heat.
Cellulose nitrate: Cellulose nitrate is very similar to cellulose acetate
but it catches fire at a temperature little above required to adjust it. It is
strong, convenient to work with and its surface can be polished brightly.
It becomes dark “urine-yellow” color and very brittle with age.
Polyamides (Nylons): These are very rarely called “Nylons”. The ma-
terials are used in sunglasses, sports spectacles, safety spectacles and
temporary aphakic spectacles. They are very strong, but have a very soft
surface, can be very flexible and often cannot be adjusted with ordinary
frame heaters. Frames Carbon Fiber graphite: It is very light, heat re-
sistant, durable and strong. It is one of the favored materials for manu-
facturers of frames.
Carbon fiber graphite: It is very light, heat resistant, durable and
strong. It is one of the favored materials for manufacturers of frames.

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 94 Refraction, Dispensing Optics and Ophthalmic Procedures

Polycarbonate: This is best known as a lens material and is very strong.

Its use as a frame material is uncommon, other than for sports and saftey
spectacles.
Silicone rubbers: These are soft, flexible materials, used for bridges,
side-tips, rim-liners etc. They are extremely stable and typically retain
their elastic properties from –50 to 200°C.
Cellulose acetate butyrate (CAB): It is occasionally used for safety
spectacles. Little information is available on its properties as a spectacle
frame material. Some of the plastic side tips of metal frames may be
made from it.
Polymethyl methaacrylate/Acrylic resins: This is remarkably trans-
parent, cosmetically good looking, highly stable but has low resistance
to impact and not convenient to work with as it is very brittle. This is
almost obsolete as a frame material.
Epoxy/epoxide resins: Epoxy frames are usually translucent, but opaque
colors have also been available (in this case the body of the material is
usually white, and is again colored with a surface dye). These frames
have been claimed to be hypoallergenic. They are usually coated with
a transparent lacquer both to protect them and reduce their allergenic
potential.
Kevlar: This is another material now in occasional use. It is what “bul-
let-proof vests” are made from.

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 Chapter
Headache After
11 Using Spectacles—
How to Manage?

HEADACHE AFTER USING SPECTACLES—HOW TO MANAGE?

This is not a very infrequent complaint. A patient is prescribed glasses
and sent home satisfactorily but a day or two he comes with a complaint
of headache. This is how one can proceed to pinpoint the diagnosis.
Something to be Done on the Part of Optometrist/Ophthalmologist
1. Incorrect Prescription—even slight error of power especially
cylindrical or wrong axis of glass may cause headache. Due care
must be taken while prescribing the power to any patient especially
those who are involved in reading, writing, watching TV for long
hours or working on computer.
2. If refractive error has been over or under corrected, rectification in
prescription should be done accordingly.
Something to be Done on the Part of Optician
1. Power of spectacles does not match the power prescribed –Change
the glasses as per prescription.
2. Even change in size of glasses sometimes makes the patient
uncomfortable. Patient should be explained about the cause and
frame may be selected accordingly.
3. If the glasses are not centered properly they cause discomfort.
Proper centering should be done.
4. Tilting of lenses introduces cylindrical power and changes effective
power of lens, which becomes a source of trouble. Patient should be
advised to wear spectacles properly.
5. If patient complains of glare, prescribe antiglare glasses.
Something to be Done on the Part of Patient Himself
1. If power of glasses is high like in aphakia or high myopia, there is
peripheral distortion of image. Patient should be advised to look
through center of glass and not through periphery of glass.
2. If best-corrected vision is less than required by patient, e.g. due to
ARMD or anisometropia or amblyopia, patient might have some
problem in doing near work for long hours.

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 96 Refraction, Dispensing Optics and Ophthalmic Procedures

3. A beginner takes time to adjust with bifocal and multifocal

[progressive] glasses. He should be advised to wait for some time
and try to adjust with the glasses. However, some patients cannot
adjust in spite of all efforts. It is better for them to use separate pair
of glasses for distance and near.
4. Some patients take time to adjust with new pair of spectacles, so if a
person is well adjusted with previous glasses and there is not much
change in power, advise him to continue with same glass.
5. Sudden change in power causes trouble. Give time for adjustment.
6. Hypermetropes usually take time to adjust with glasses, so wait and
watch for some time.
7. If spectacles are worn in a wrong fashion, i.e. back vertex distance is
changed, e.g. too low or too high on nose, it causes trouble. Patient
should be advised to wear glasses properly.
8. Patient is having exophoria and needs muscle exercises. Such
patients usually complain of headache while doing near work.
Convergence exercises should be advised.
9. Contrast sensitivity of patient is decreased due to cataract or
glaucoma, so he is not satisfied due to fogginess of vision. He should
be explained about the nature of disease and all efforts should be
made to treat the underlying cause.
10. Patient does not like glasses or is not in a habit of using glasses. He
should be explained the advantages of using glasses and should be
encouraged to use glasses.

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 Chapter
Ophthalmic
12 Procedures and
Instruments

LENS AND LOUPE

This is a very handy instrument used to examine structures of anterior
segment of eyeball. It consists of a condensing lens of +13D and a
corneal loupe of power +41D (consisting of two plano-convex lenses of
power +20.5D each) with 10X magnification. It is based on the principle
that when an object is placed between a convex lens and its focus, the
image formed is erect, magnified, virtual and on the same side of the lens
(Figs 12.1 and 12.2).

Technique
Patient is seated on a stool with a light source coming from front and
lateral side from a distance of two feet. Condensing lens is held in one
hand and used to focus light on structure to be examined. Loupe is held
in other hand between thumb and index finger. Little finger and ring
fingers are rested on forehead for stability of hand and upper eyelid is
lifted with middle finger. Loupe is brought close to the eye so that the
cornea comes into focus. By changing the position of condensing lens,
corneal loupe and position of eyes of observer; different structures of
anterior segment can be examined one by one.

Fig. 12.1: Binocular Loupe

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 98 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 12.2: Corneal Loupe

Lens and Loupe has fallen into disrepute with more and more use of
binocular loupe and slit lamp. Binocular loupe has the added advantage
of binocularity but magnification is lesser as compared to uni-ocular
loupe. It is fixed to the examiner’s head hence lesser maneuver is
required.

SLIT LAMP

Uses
1. It is used for detailed examination of anterior segment. It gives a
stereoscopic and magnified view of the part examined.
2. It is required for examination of angle of anterior chamber with
gonioscope.
3. Measurement of IOP with applanation tonometer requires slit lamp.
4. Delivery of laser like YAG, Argon and diode can be done only
through slit lamp.
5. It is used for detailed examination of retina by slit lamp biomicro-
scopy.
6. Vital staining of cornea is observed through slit lamp.

Parts of Slit Lamp

Slit lamp can be divided into two main parts (Fig. 12.3):
1. Illumination system
2. Observation system
Illumination system consists of a light source that can be moved away
from observation system so that a particular angle can be made between
illumination system and the observation system. This is required for
different techniques of slit lamp examination.
Intensity of light source can be increased or decreased as per
requirement by rotating a knob or rheostat. Another knob can change
the height and diameter of light beam. Width of light beam can also be
changed via another knob.
Halogen light is used in most of the examinations. Different filters
like cobalt blue filter are used for fluoresein staining, fitting of rigid gas

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 Ophthalmic Procedures and Instruments 99

Fig. 12.3: Slit lamp

permeable contact lens and applanation tonometer. Red free (green)

filter is used for seeing nerve fiber bundle defects in glaucoma. Blood
vessels, micro-aneurysms and hemorrhages appear dark against a green
background with a red free filter. Vitreous details are also seen better
with blue or green light as they have shorter wavelengths and have more
scattering properties. Yellow filter improves contrast as scattering of
blue light is no more there. All these filters can be introduced using a
knob.
Observation system consists of two eyepieces. Magnification of
image is obtained by multiplying the power of oculars with the power of
the objective lens. Magnification can be changed either by changing the
objective lens or the oculars. This is achieved by flipping a lever located
below the observation system.
Focusing is controlled by a joystick. It is designed to move the slit
lamp laterally and forwards and backwards. Vertical movement is done
by rotating the joystick.

Techniques of Slit-lamp Examination

1. Diffuse illumination
2. Direct illumination
3. Indirect illumination
4. Retro illumination

Diffuse Illumination
It is used to examine different structures of eyeball like eyelids, cornea,
conjunctiva, sclera, iris, pupil etc. It gives general information. A frosted
glass or ground glass is placed in front of the focused light beam to get

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 100 Refraction, Dispensing Optics and Ophthalmic Procedures

diffuse illumination. Magnification is kept low and incident light is projected

into the eyeball obliquely at an angle of 45°.

Direct Illumination
Viewing of structures within the focused light beam is known as direct
illumination. It may be of different types:
A. Optical section: Light beam is in form of a slit. It is projected
obliquely. The angle between the oculars and observation system
is 30-60°. More is the angle, wider is the optical section called
parallelepiped. It gives a cross sectional view of different layers of
cornea. Lens and anterior part of vitreous can also be examined in
a dilated pupil. This technique is applied to locate corneal lesion,
corneal scar, foreign body, depth of AC and type of cataract.
B. Pinpoint illumination: This technique is used to look for aqueous
flare and cells in AC in uveitis. The room should be absolutely dark.
Beam is pin point and focused against pupil in the AC. Aqueous
flare appears as yellowish particles and cells in AC appear as whitish
reflections.
C. Specular reflection: It is used to see corneal endothelium. It is best
seen with one eyepiece only. Angle of illumination system is set equal
to the angle of the oculars and illumination beam is a parallelepiped.
First of all corneal surface is focused with low magnification. Move
the oculars 20 to 30° away from illumination source. Now move
the illumination source 20 to 30° away and in opposite direction
until a bright mirror like reflection is seen through one ocular. Three
reflections are seen. Intermediate reflection is focused finely using
high magnification and endothelial cells can be counted.

Indirect Illumination
Here structures not within the focused light beam but adjacent to the
focused light beam are observed. It is of different types:
A. Proximal illumination: A moderately wide beam of light is focused
on the areas adjacent to the areas of interest. The lesion is observed
with scattered light against dark background.
B. Sclerotic scatter: Lesions within the corneal substance can be seen
by this method. A parallelepiped illumination beam is focused at the
temporal limbus. Eyepiece is focused on central part of cornea and
illumination system is set at an angle between 45 to 60° with the
observation system. Light beam enters corneal substance from one
limbus, undergoes total internal reflection and exits from opposite
limbus.

Retro Illumination
In this technique light is reflected from iris or retina to see more anteriorly
located structures. It may be of different types:

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 Ophthalmic Procedures and Instruments 101

A. In direct retro illumination light is focused behind the structure to be

seen and it is angled at 45°. Corneal opacity appears black against
illuminated background. Lenticular opacities appear dark against
red glow of fundus. Thus objects that normally appear bright are
seen as black in this technique.
B. In indirect retro illumination light is focused in such a way that the
background becomes dark. The structure to be seen should not be in
the pathway of light.
There is another technique called trans-illumination. In this technique
iris surface is tested for passage of light. Illumination system and
observation system are positioned coaxially, i.e. click stop position. Red
glow seen through iris confirms hole in the iris.

TONOMETRY
It is a procedure by which we measure the intraocular pressure of
eyeball. The instrument used is known as Tonometer. Normal IOP of
human eyeball is between 10 and 20 mm of Hg. If it is more than normal;
it damages retina and optic nerve and makes the patient blind. This
condition is known as Glaucoma.
Types
It is of two types:
1. Digital tonometry: By this method, we palpate the eyeball with
pulp of fingers and assess how soft or hard it is. This gives us
reasonably reliable information but cannot tell precisely the IOP.
However, it can be done at any time and on every patient. There is
no instrumentation required.
2. Instrumental tonometry: It is done by using an instrument. This
measures IOP more precisely. It is of two types:
(i) Applanation tonometry: It is the best method to measure IOP.
However, it requires costly equipments like slit lamp and applanation
tonometer (Fig. 12.4A) and requires more expertise, e.g. Goldman
applanation tonometer, noncontact tonometer.
(ii) Indentation (Impression) tonometry: This is the most commonly
employed method of measuring IOP. This requires only tonometer which
is very handy and economical, e.g. Schiotz tonometer (Fig. 12.4B). It
measures the depth of impression produced by a small plunger carrying a
known weight. The IOP is determined by correlating scale reading using
a nomogram.

Procedure of Schiotz Tonometry

Make the patient lie down comfortably in bed. Put a drop of local
anesthetic agent like lignocaine or propracaine. Take a clean and
sterilized tonometer. Ask the patient to fix his eyes on his thumb or roof
such that they are exactly at right angle to the earth. Place the tonometer
on his cornea and record the reading on scale. Repeat the procedure

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 102 Refraction, Dispensing Optics and Ophthalmic Procedures

B
Figs 12.4A and B: Applanation tonometer; Schiotz tonometer

in other eye. Convert this scale reading into IOP by seeing conversion
table. This gives the IOP (Fig. 12.5).
Normal weight of schiotz tonometer is 5.5 gm. It can be made 7.5 gm,
10 gm and 15 gm by addition of weight provided with the instrument. If
scale reading is less than three add weight and repeat the procedure. This
increases the accuracy of the tonometer.

Advantages of Schiotz Tonometer

Very simple procedure, easy to do, economical and handy instrumentation
is required.
Disadvantages of Schiotz Tonometer
It can introduce infection in the eyeball. To prevent it, tonometer should
be sterilized prior to use and antibiotic should be instilled in the eye

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 Ophthalmic Procedures and Instruments 103

Fig. 12.5: Procedure of Schiotz tonometry

after the procedure. If patient moves the eyeball during the procedure;
cornea may be injured. To prevent this complication the procedure and
risk should be explained to the patient properly and proper anesthesia
should be achieved before carrying out the procedure.
Goldman applanation tonometry is considered the most reliable and
best method to measure IOP.
Perkin’s tonometer is useful in children and patients under general
anesthesia and those who cannot cooperate on slit lamp.
Noncontact tonometer or (Fig. 12.6) air puff tonometer uses rapid
air pulse to applanate the cornea. An electro-optical system detects the
corneal applanation. Force of air jet required to applanate the cornea
determines the IOP. This is a very quick method and has no risk of
infection as there is no touch with cornea. However it does not give
accurate readings hence it is suitable only for screening purposes.

Fig. 12.6: Noncontact tonometry

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 104 Refraction, Dispensing Optics and Ophthalmic Procedures

Sterilization of Schiotz Tonometer

It can be done by different methods:
(i) Dry heat: Foot plate of tonometer should be heated over flame for
10 seconds, cooled and reused. Repeated heating however will
distort the shape of foot plate and create erroneous readings.
(ii) Use of ultraviolet rays
(iii) Use of tonofilms
(iv) Soak the assembled foot plate in a solution of 1:1000 merthiolate
solution
(v) Clean the foot plate with a swab soaked with ethyl alcohol. This is
the most common method employed clinically.
It is recommended that after each use the tonometer should be
disassembled, barrel should be cleaned with a white pipe soaked with
alcohol followed by another pipe which is dry. The foot plate, plunger
and dummy cornea should be cleaned with swab soaked with alcohol
and allowed to get dry for 60 seconds. Now it is ready to be placed on
another cornea.

EPILATION AND ELECTROEPILATION

Due to certain causes like trachoma, injury and chemical burn eyelashes
become misdirected and rub against cornea. This disturbs transparency
of cornea and ultimately results in corneal blindness. To prevent it
misdirected, eyelashes are removed under slit-lamp examination. The

Conversion table for schiotz tonometry

Scale 5.5 gm 7.5 gm 10 gm 15 gm
Reading weight weight weight weight
0.0 41.5 59.1 81.7 127.5
0.5 37.8 54.2 75.1 117.9
1.0 34.5 49.8 69.3 109.3
1.5 31.6 45.8 64.0 101.4
2.0 29 42.5 59.1 94.3
2.5 26.6 38.3 54.7 88.0
3.0 24.4 35.8 50.6 81.8
3.5 22.4 33.0 46.9 76.2
4.0 20.6 30.4 43.4 71.0
4.5 18.9 28.0 40.2 66.2
5.0 17.3 25.8 37.2 61.8
5.5 15.9 23.8 34.4 57.6
6.0 14.6 21.9 31.8 53.6
6.5 13.4 20.1 29.4 49.9
7.0 12.2 18.5 27.2 46.5
7.5 11.2 17.0 25.1 43.2
8.0 10.2 15.6 23.1 40.2
8.5 9.4 14.3 21.3 38.1
9.0 8.5 13.1 19.6 34.6
9.5 7.8 12.0 18.0 32.0
10.0 7.1 10.9 16.5 29.6

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 Ophthalmic Procedures and Instruments 105

process of removing misdirected cilia is known as epilation. It is repeated

every month because the removed cilia regrow.
If a small galvanic current is passed through follicle of eyelash, the follicle
gets damaged and eyelash can be pulled easily. This process of removing
misdirected cilia by passing galvanic current is known as Electro-epilation.
Because the hair follicle gets damaged, so cilia do not regrow.

LACRIMAL SYRINGING
This is a procedure by which we check patency of lacrimal apparatus.
Sometimes, it is done as a diagnostic as well as curative procedure.

Indications
1. If patient complains of watering from one or both eyes and we
suspect some abnormality of lacrimal drainage system, e.g.
congenital dacryocystitis, chronic dacryocystitis etc.
2. After DCR (dacryocystorhinostomy) surgery; to check outcome of
surgery.
Clinically regurgitation test should be done prior to syringing. It gives
very useful information. It is done by pressing the medial canthus with
finger tip. Regurgitation of discharge confirms blockage of nasolacrimal
duct.

Technique
Examine the patient under slit lamp and rule out agenesis of lacrimal
punctum and punctual atresia. If puncta are normal; make the patient lie
down on an examination table. Put one drop of local anesthetic agent
like lignocaine or proparacaine. Take a 2 ml syringe with lacrimal canula
and fill it with normal saline. Introduce canula into the punctum after
dilating it with punctum dilator. Push saline slowly. Ask the patient if he
feels presence of water in his mouth. If he says ‘yes’; it means lacrimal
drainage system is patent. Saline will come out of the same or opposite
punctum if there is any blockage in the pathway.

Observations
1. Fluid comes out through opposite punctum after initial delay. Site of
blockage is naso-lacrimal duct.
2. Fluid comes out of opposite punctum immediately. Site of blockage
is common canaliculus
3. Fluid comes out of same (lower or upper) punctum. Site of blockage
is lower canaliculus or upper canaliculus.
To know the exact site of blockage another procedure is done known
as dacryocystography. In this procedure Conray 280 dye is used instead
of saline and after doing syringing a radiograph of eye portion is taken.
The level of dye shows the exact site of blockage.

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 106 Refraction, Dispensing Optics and Ophthalmic Procedures

Complications
1. Injury to the lacrimal punctum or canaliculus can occur.
2. Creation of false passage.

FLUORESCEIN STAINING

It is a procedure by which we can stain and visualize all types of micro

or macro abrasions of cornea easily. The name of the stain/dye is sodium
fluorescein. It is available as 10% (5ml) and 20% (3ml) solution in
form of ampoules or strips impregnated with the stain. This dye has an
inherent property of fluorescence, i.e. it absorbs light of one wavelength
(blue) and emits light of another wavelength (green). That is why the
stained area appears green when seen through blue light.

Procedure
Put one drop of fluorescein dye in the eye or put the strip in lower
conjunctival fornix for a few seconds. Ask the patient to blink eyes so that
the stain spreads in the eyeball and then keep the eyes closed for 30 seconds.
Wash excess of dye with normal saline and examine under slit lamp with
cobalt blue filter. The stained area of cornea will appear green.

Uses
1. We can easily visualize small injuries of cornea.
2. Fluorescein dye is also used in some other tests like fluorescein dye
disappearance test, Jones test to check function of lacrimal sac and
fundus fluorescein angiography.

CORNEAL SCRAPING

It is done in cases of corneal ulcer or corneal abscess. This procedure

is carried out either under slit lamp or microscope. One drop of local
anesthetic drug like Paracaine is put in the eye, wait for 30 seconds so
that local anesthesia is achieved. With the help of a hypodermic needle
cornea is scraped and dead tissue is removed and sent for culture and
sensitivity examination. This procedure should be carried out very gently
to avoid corneal perforation.

Advantages of Scraping
1. It removes dead tissue thus drug can penetrate the cornea better that
helps in healing.
2. Along with the dead tissue, the debris is also removed which
contains pathogens. Thus the load of bacteria is also reduced.

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 Ophthalmic Procedures and Instruments 107

CAUTERIZATION OF ULCERS

It is done for better healing of corneal ulcers. After scraping cornea is

washed with normal saline. 1:5 diluted betadine lotion is applied over
the ulcerated area. Carbolic Acid (Phenol) is applied over the margins
of corneal ulcer. One drop of atropine is put in the eye. Pad and bandage
is done with antibiotic eye ointment. This is known as chemical
cauterization. It prevents extension of ulcer.
Instead of carbolic acid heat cautery can also be applied at the margins
of the ulcer.

AESTHESIOMETERY

This is a procedure by which we check the corneal sensitivity. Sensitivity

of cornea is decreased markedly in viral corneal ulcers, neuroparalytic
keratitis. It is decreased to some extent in all types of affections of
cornea. So testing of corneal sensitivity is very important for diagnosis
of corneal diseases. It is done by two methods:
1. Make the patient sit on a stool comfortably. Ask him to keep looking
straight with wide open eyes. Take sterile cotton and make it into a wick
with very fine tip. Bring the cotton wick from behind the patient and
touch the cornea at various points. Note down the blinking. Compare it
with other eye using a different wick. Normally when cornea is touched
with a cotton wick; patient blinks. However if corneal sensitivity is
decreased; blinking is also decreased proportionately. This is the most
common method employed clinically to test the sensitivity of cornea.
2. An aesthesiometer is an instrument with a fine nylon tip (Fig. 12.7).
Instead of cotton wick this is used to test the corneal sensitivity.
Different amount of pressure can be used to touch the cornea and
notice blink reflex. Accordingly more is the pressure required to
elicit blink reflex, lesser is the sensitivity of cornea.

CONJUNCTIVAL SWAB FOR CULTURE AND SENSITIVITY

It is taken in cases of infective conjunctivitis to identify the pathogen and

the antibiotic, which would be effective against the infecting organism.
An autoclaved swab stick is taken and swept in the conjunctival
fornix. It gets soaked in the conjunctival discharge. This discharge is

Fig. 12.7: Aesthesiometer

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 108 Refraction, Dispensing Optics and Ophthalmic Procedures

applied over appropriate agar and incubated at desired temperature.

Any growth seen after 24-48 hours of incubation is tested to identify
the pathogen. Sensitivity of antibiotics is also tested. This is done by
making the bacteria grow on an appropriate agar along with an antibiotic.
Commonly used antibiotics are applied on the agar at different places
along with the bacterial growth. It is incubated at appropriate temperature
for 24 hours. If a particular antibiotic is effective against bacteria, there
will be no growth seen in the area of the antibiotic. Growth of bacteria
in the vicinity of antibiotic shows that the particular antibiotic is not
effective against that bacteria. Treatment of patient can be altered as per
the reports of the test.

FUNDUS CAMERA

A fundus camera is a low power microscope type device used to take

photographs of retina in different conditions (Figs 12.8A and B). It is used
to diagnose a retinal disease and monitor its progression. It works on the
principle of indirect ophthalmoscopy. It gives an upright, magnified view of
the fundus. It views 30 to 50° of retinal area.
Clinical applications:
1. Photograph of retina is taken to diagnose diseases like diabetic
retinopathy, Eales’ disease, primary open angle glaucoma etc.
2. Fundus fluorescein angiography is done to diagnose areas of non
perfusion and any leakage of blood from retinal vessels.
Progress of a disease like glaucoma, diabetic retinopathy can be
monitored by taking serial photographs at different periods of
time.

FUNDUS FLUORESCEIN ANGIOGRAPHY

Fundus fluorescein angiography (FFA) is a procedure, which allows us
to diagnose and manage various types of retinal disorders (Fig. 12.9).

A B
Figs 12.8A and B: Fundus camera; Fundus photograph
(For color version, see Plate 2)

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 Ophthalmic Procedures and Instruments 109

Fig. 12.9: Fundus angiogram

Indications of FFA
1. Diabetic retinopathy
2. Vaso-occlusive disorders
3. Eales’ disease
4. Central serous retinopathy
5. Cystoid macular edema

Technique
Pupils of both eyes are dilated. Patient is seated against fundus camera.
3 ml 20% or 5 ml 10% sodium fluorescein dye is injected aseptically
in ante-cubital vein and serial photography of fundus is done. First
photograph is taken after 5 seconds, then every second for 20 seconds
and then every 2-3 seconds for one minute. Photography is done for both
eyes. Last picture is taken after 30 minutes.

Side Effects
It is a relatively safe procedure. However patient may develop allergic
reaction to dye like nausea, vomiting, rashes and anaphylactic shock. A pre
filled syringe of dexamethasone and chlorpheniramine maleate (CPM)
should be ready to face such emergencies. All patients complain of
yellowish discoloration of skin and urine.
This dye is nephrotoxic. So this procedure should not be done in
nephro compromised patients as the dye is excreted in urine.

Phases of FFA
1. Pre-arterial phase: There is no dye in the circulation.
2. Arterial phase: Dye can be seen in arterioles.
3. Arterio-venous phase: Some dye can be seen in both arterioles and
venules.
4. Venous phase: There is no dye in arterioles. It can be seen in venules.

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 110 Refraction, Dispensing Optics and Ophthalmic Procedures

Abnormalities Detected by FFA

FFA detects two types of abnormalities namely:
1. Hypofluorescence: Various causes are
occlusion of blood vessels, hemorrhage or
exudates.
2. Hyperfluorescence: Various causes are
damage to RPE, pooling of dye as occurs
in CME, CSR and micro aneurysms.
FFA gives a very peculiar pattern in
some diseases like inkblot appearance and
smoke stack appearance in CSR and flower
petal appearance in CME. Thus, FFA is very Fig. 12.10: Placido disk
important tool for diagnosis and management
of fundus disorders.

PLACIDO DISK
It is a disk painted with alternating black and white circles (Fig. 12.10).
It is used to check the regularity of corneal surface. Looking through the
hole in the center of the disk a uniform sharp image of circles is seen on
the cornea. If the corneal surface is irregular, circles appear distorted.
However, with the advent of more sophisticated tests like corneal
topography and pentacam this test is no more used clinically.

KERATOMETRY (OPHTHALMOMETRY)
It is a procedure by which we can measure the curvature of central part
of anterior surface of cornea. The instrument is known as Keratometer
Uses
1. It is used to calculate curvature of central part of cornea on its
anterior surface. This curvature is used to calculate base curve of
contact lens.
2. It is also required to calculate power of IOL to be implanted after
cataract surgery.

Principle
It is based on the principle that anterior surface of cornea acts as a convex
mirror so the size of the image formed varies directly with curvature of
cornea. Thus by knowing the size of image formed curvature of cornea
can be calculated.

Types
Clinically, two of keratometers are used:
1. Javal Schiotz keratometer: In this the target is like a step ladder. Hori-
zontal and vertical curvatures cannot be measured simultaneously.

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 Ophthalmic Procedures and Instruments 111

Fig. 12.11: Keratometer

Fig. 12.12: Autokeratometer

2. Bausch and Lomb: In this the target is in form of a circle and both
horizontal and vertical curvatures can be measured simultaneously.
Depending upon operational technique, keratometers may be manual
or auto-keratometer (Figs 12.11 and 12.12).

Technique
1. Look through eyepiece of keratometer and focus a black cross seen
in the field.
2. Calibrate the instrument for any mechanical error.
3. Make the patient sit on a stool comfortably and ask him to close
the other eye. With the open eye he should see the illuminated
target known as ‘Mires’. An image of circle is formed on his cornea
(First Purkinje Image). If we look through eyepiece we see three
mires; one in the center, one horizontal and one vertical. Focus
the mires by ‘focus knob’ so that they look very sharp. Adjust the
horizontal and verticals knobs to align minus and plus signs (Fig.
12.13). Take reading and adjust mechanical error if any. This gives
curvature of cornea in dioptre and millimeters. Reading in dioptre
is used for IOL power calculation and reading in mms is used for
CL fitting.

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Fig. 12.13: Target of keratometer

Range of Keratometer
Normal range of B and L keratometer is from 36D to 52D. However, the
range can be increased or decreased by placing +1.25D lens or –1.00D
lens in front of keratometer. Use +1.25DS lens in front of the objective
of the keratometer and add +9.00 to the scale reading OR place –1.00DS
lens in front of the objective and substract 6.00 from the scale reading.
This maneuver increases the range of the keratometer. Normal curvature
of cornea is usually around +42D.
Sources of Error
1. If we do not focus the black cross, it can introduce error of about
.25D.
2. Noncalibration of instrument may be a source of big or small errors.
3. Improper focusing and improper alignment of mires can be a source
of error.

BIOMETRY
It is a procedure by which we measure the power of intraocular lens to
be implanted during cataract surgery to achieve desired postoperative
refractive status. It involves two procedures:
1. Keratometry
2. A-scan
First of all, keratometry is done and findings are recorded. For A-scan
paracain eyedrops are instilled in the eye of the patient to achieve topical
anesthesia. Axial length of the eyeball is measured by touching the
scan probe to the center of cornea. Multiple readings are taken and the
reading with good graph is selected. This reading along with findings of
keratometry is fed into the formula and IOL power is calculated. This
also requires ‘A’ constant value which is provided with the IOL by the
company (Figs 12.14 and 12.15).
Manual calculation can also be done by using formula:

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 Ophthalmic Procedures and Instruments 113

Fig. 12.14: A-scan

Fig. 12.15: Procedure of biometry

IOL power = A–2.5L–0.9K; where

A = A constant of IOL
L = Axial length of eyeball
K = Keratometry reading

CORNEAL TOPOGRAPHY
Also known as photokeratoscopy or videokeratography is a noninvasive
technique for mapping the curvature of anterior surface of cornea. This
is a three-dimensional map valuable in the
• Diagnosis of early keratoconus
• Assessing fitting of semisoft contact lens
• In planning lasik laser surgery
• Evaluation of irregular
• Astigmatism especially after penetrating keratoplasty
• Planning of removal of sutures after surgery.
It is an OPD procedure, carried out in seconds and is completely painless.

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Principle
Multiple light concentric rings are projected on the cornea. The reflected
image is captured on a charge-coupled device camera. Computer
software analyzes the data and displays the results in different formats.
Normal cornea flattens from center towards periphery by 2D-4D,
nasal area flattening more than the temporal area. Corneal topography
of two corneas of an individual often shows mirror image symmetry.
Common patterns seen in topography are round, oval, symmetric bow
tie for regular astigmatism, asymmetric bow tie and irregular.

PENTACAM
It is another very important latest technological advancement in the
mapping of both anterior and posterior surfaces of cornea. It is superior
to corneal topography as it gives high resolution images of the entire
cornea including calculation of pachymetry from limbus to limbus.
Corneal topography tells us about the abnormalities of anterior surface
of cornea only but pentacam can detect abnormalities of both anterior
and posterior surface of cornea. It can also provide corneal wavefront
analysis to detect higher order aberrations.
Orbscan is another latest instrument used in clinical practice to analyze
the thickness and the entire posterior surface of cornea.

GENEVA LENS MEASURE

It is a pocket watch-shaped instrument used to measure the power of a

curved surface like a convex or concave lens. Power can be measured
in different meridians. There are three-pointed prongs attached to the
instrument one of them (middle one) is movable and other two being
fixed. When we place the watch on a curved surface, the movable prong
is displaced by the curvature of the
curved surface which is reflected in
the calibrated scale on the watch. The
algebric sum of readings of both the
surfaces gives the net power of the
lens. Thus, power of both spherical
and cylindrical lens along with its axis
can be measured by the instrument.
This instrument is calibrated for lenses
made of crown glass with refractive
index of 1.523 and reading is recorded
in Diopters. Power of lenses made of
other material with different refractive
index can also be calculated from a Fig. 12.16: Geneva lens measure
formula (Fig. 12.16).

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OPTICAL COHERENCE TOMOGRAPHY

It is a noninvasive method clinically used for imaging of retina. Similar
to CT scan of internal organs, OCT uses the optical backscattering of
light to rapidly scan the eye and describe a pixel representation of the
anatomic layers of retina. It is an interferometric technique using near
infrared light. The greater wavelength of light used makes it able to
penetrate better into the scattering medium. All the ten layers of retina
can be differentiated and their thickness can be measured. Confocal
microscopy is another similar technique but with less penetration.
Clinically, certain conditions like age related macular degeneration
and cystoid macular edema can be diagnosed eliminating the need for
FFA. This technique has achieved sub-micrometer resolutions.

SYNOPTOPHORE

This is an instrument used for:

1. Detection and measurement of latent squint (Heterophoria)
2. Detection and measurement of manifest squint (Heterotropia)
3. Convergence and divergence exercises
4. Measurement of subjective and objective angles of deviation
5. Detection of grades of binocular single vision
6. Orthoptic exercises to develop BSV in defective individuals
7. To detect presence and type of suppression
8. Measurement of IPD
9. Measurement of angle alpha
10. To detect retinal correspondence
11. Measurement of range of fusion.
It has one disadvantage that measurement for distance is not accurate
because even when the instrument is set for distance psychic convergence
comes into play and vitiates the measurements.
The instrument consists of base unit with illuminating system, slide
holders, reflecting mirrors and lenses. Separate screws are provided
for adjusting vertical and torsional deviations. Each eyepiece contains
+6.50DS lens to relax the accommodation completely. Interpupillary
distance is adjustable. Tubes can be moved from a convergence position of
50° to a divergence position of 40°. The illuminating system is so constructed
that there is no intense reflection. The intensity of light can be adjusted by
rheostats. Slides are inserted at the ends of the tubes. There is also a slot for
using Haidinger brushes in the two arms of the synoptophore. Arrangement
for putting the light off in front of any of the slide carriers is available. This
system can be utilized for rapid flashing of light for stimulating the under
functioning macula.

OPHTHALMOSCOPY
It is a method by which we see the details of the fundus and detect
opacities in the media. It is of three types:

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Fig. 12.17: Distant direct ophthalmoscopy

1. Distant direct ophthalmoscopy

2. Direct ophthalmoscopy
3. Indirect ophthalmoscopy

Distant Direct Ophthalmoscopy

This procedure should be routinely performed before direct
ophthalmoscopy. This is the best method to detect opacities in the media.
It can be performed by a direct ophthalmoscope or a plane mirror with a
hole in the center (plane retinoscope) or even a concave retinoscope or
indirect ophthalmoscope (Fig. 12.17).

Technique
Throw light on eyeball of patient from a distance of 20-25 cm in a dark
room and observe the pupil. Pupil appears red in color under normal
circumstances.
Clinical applications
1. To detect opacities in the media: Any opacity in the media appears
as a black shadow against red fundal glow. Ask the patient to move
his eye right-left and up-down. Observe the movement of opacity.
Opacities in the pupillary plane show no movement, opacities in
front of pupillary plane (e.g. in AC) move with the movement of
eyeball and those behind the pupillary plane (e.g.in the vitreous)
move against the movement of eyeball.
2. To differentiate between a hole and a mole: A hole in the iris is like
a peripheral iridectomy and a mole on the iris both appear black
in color. On DDO, a red glow is seen through the hole but a mole
remains black in color.
3. To suspect a detached retina/tumor of fundus: A grayish reflex is
seen in the pupil if the retina is detached or there is a tumor arising
from the fundus.

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Figs 12.18A and B: (A) Direct; (B) Indirect ophthalmoscope

Fig. 12.19: Direct ophthalmoscopy

Direct Ophthalmoscopy
It is done with direct ophthalmoscope (Figs 12.18 and 12.19). This
instrument is a handy, self illuminated instrument to view fundus
details. It has two parts, a handle which contains rechargeable battery or
disposable battery and the optical part called the head. Ophthalmoscope
was invented by von Helmholtz in 1850.

Technique
Pupil of patient is dilated. Hold the ophthalmoscope in your right hand
and examine the right eye of the patient with your right eye standing
on the right side of the patient. See the red fundal glow. Now go as
close to the patient’s eye as possible and focus any part of retina by
moving lens wheel with index finger of your right hand. Trace any of the
blood vessels towards its starting point and you will be able to reach the
optic disk. If you ask the patient to look straight ahead, optic disk comes

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into focus. If patient sees the light of the instrument, macula comes into
focus. Other details of fundus like blood vessels and background are
also noted. Similarly, left eye of patient is examined with your left eye
holding the instrument in your left hand and standing on the left side of
the patient. Dioptric power of lens wheel required to examine the retina
of patient depends on clinician’s refractive status, patient’s refractive
status and the distance of the ophthalmoscope from the patient’s cornea.
The field of view depends on the distance of the ophthalmoscope from
patient’s cornea and patient’s refractive status. Field of view is more as
we approach the patient’s eye. It is also more in hypermetropes than
myopes.
Direct ophthalmoscope works on the principle of glass plate
ophthalmoscope introduced by von Helmholtz.
Different apertures and filters are provided in the ophthalmoscope for
performing different functions:
1. Small aperture is to be used to examine the fundus through small
undilated pupil. Similarly, medium and large apertures are used
depending upon the size of the pupil.
2. Visuscope or star or Graticule is used to see type of fixation. Patient
is asked to focus on the light. If he is able to follow the star, it implies
foveal fixation.
3. Slit aperture is used to assess levels of lesions and tumors. It is also
used to differentiate macular hole and macular cyst.
4. Cobalt blue filter is used to see lesions of cornea after fluorescein
staining.
5. Red free filter (green filter) is used to see nerve fiber bundle defects
in glaucoma, improve contrast in viewing retinal blood vessels and
hemorrhages and to distinguish retinal hemorrhage from micro
aneurysm.

Advantages and Disadvantages of Direct Ophthalmoscopy

It is easier to perform and master the procedure. Interpretation is also
very easy as the image formed is erect. Image is 15X magnified, so
minor details can be seen easily. However, it gives a monocular view
and lacks depth perception. Because of high magnification, field of view
is restricted. Examination of retina beyond equator is not possible.

Indirect Ophthalmoscopy
It is done with indirect ophthalmoscope (Fig. 12.20A). This instrument
is used to examine peripheral details of retina. Advantages of indirect
ophthalmoscopy over direct ophthalmoscopy are (Table 12.1):
1. It gives binocular view hence is much better to detect shallow retinal
detachments.
2. Field of view is bigger but magnification is less. Magnification
depends upon power of lens used. With +20D lens 3X magnification
is achieved.

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Table 12.1: Comparison between direct and indirect ophthalmoscopes

Direct Indirect
1. Image characteristics Virtual, erect, 15X Real, inverted, magnified
magnified but field image, field of view
of view is small much larger (about 8
(about 2 disk disk diameters) hence
diameters) hence comparison is easy
comparison of two
eyes is difficult
2. Stereopsis Not present Present
3. Extent of retina Up to equator Up to ora serrata
examined
4. Interpretation Easy as the image Difficult because image
is erect formed is inverted and
laterally reversed
5. Technique Easy to master Difficult to master
6. Examination through Not possible as the Possible as the illumin-
hazy media illumination is lesser ation is much brighter
7. Examination distance As close to the eye of At an arm’s length
patient as possible
8. Condensing lens Not required It is a must

A B
Figs 12.20A and B: Indirect ophthalmoscopy

3. It is easier to compare the retinal details of two eyes.

4. Whole of the retina can be examined; up to ora serrata which is not
possible with direct ophthalmoscope.
The principle of indirect ophthalmoscope is that eyeball is made highly
myopic by interposing a high plus lens between the ophthalmoscope and
the eyeball hence a real, inverted and laterally reversed, magnified image
of retina is formed in the air between the lens and the eyeball.
Technique of Indirect Ophthalmoscopy
Make the patient lie down comfortably on examination table with pupil
fully dilated. Hold the condensing lens in one hand and open the eye with
other hand. Throw the light of ophthalmoscope on eyeball from an arm’s
length. Interpose the condensing lens close to the eye of the patient.
Move the lens away from eyeball slowly till the retina comes into view.
Now focus the view and examine it. Ask the patient to move his eyes
right, left, up and down to examine the periphery. Scleral depression

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is required to examine the extreme periphery of the retina. Findings

can be noted by drawing fundus diagram on paper using color codes
(Fig. 12.20B).

GONIOSCOPY

It is a procedure by which we can see details of angle of anterior chamber

(Figs 12.21A and B). It is an OPD procedure. It is done with an instrument
called gonioscope. Different structures seen with a gonioscope are:
1. Schwalbe’s line: It is the termination of descemet’s membrane. It
appears as a solid, glistening structure.
2. Trabecular meshwork: It gives soft, velvety appearance. It is easy to
identify at 12 o’clock position due to its pigmentation. It has two parts:
Anterior one-third is non-pigmented and posterior two-third parts is
pigmented. Schlemn’s canal is visible only if it is filled with blood.
3. Scleral spur: It is a narrow, solid, whitish band, easily identified
at 12 o’clock position where it is least likely to be covered with
pigments. It is half the width of TM.
4. Ciliary body band: It is as wide as the TM. In angle recession width
of ciliary body band is more than width of TM.
Iris processes can also be seen in young people. They need to be
differentiated from peripheral anterior synichae when present (PAS).
PAS are seen in angle closure glaucoma and are best seen in superior
angles. PAS of inflammatory origin are best seen in inferior angles.

Clinical Application of Gonioscopy

1. It is done to assess depth of angle of anterior chamber. Depth of
angle of AC can be divided into four grades:
Grade 0: Iris is in contact with the corneal endothelium. No structure
of angle can be seen. It is seen in acute angle closure attack. Immediate
treatment is required to save vision.
Grade 1: Only Schwalbe’s line is visible. There are high chances of
angle getting closed hence immediate preventive measures need to be
taken like YAG iridotomy.

A B
Figs 12.21A and B: Gonioscope and its optics

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 Ophthalmic Procedures and Instruments 121

Grade 2: Schwalbe’s line and TM is visible. There are less chances of

angle getting closed.
Grade 3: Schwalbe’s line with TM and scleral spur are visible. It is an
open angle and there are no chances of angle closure.
Grade 4: Schwalbe’s line, TM, Scleral spur and ciliary body band are
visible. It is a wide open angle and there are no chances of angle closure.
2. Angle recession can be diagnosed only by doing gonioscopy.
3. Gonioscopy is a must for diagnosis and treatment of congenital
glaucoma.
Gonioscopy is of two types; namely direct and indirect gonioscopy. In
direct gonioscopy structures are seen directly but in indirect gonioscopy
mirror images of structures are seen, i.e. inferior angle is seen superiorly
and right sided angle is seen on left side and vice versa. Koeppe, Barkan,
Swan-Jacob and Thorpe goniolenses are examples of direct gonioscope
and Goldman three mirror gonioscopes, Zeiss 4-mirror goniolens are
examples of indirect goniolens. Direct goniolens is more suitable for
surgical procedures like goniotomy. Indirect goniolens is more com-
monly used for classification of glaucoma.

Technique
Make the patient sit against slit lamp. Explain him the procedure
properly. Put one drop of 2% xylocaine eye drop. Take the goniolens,
put some coupling fluid like 2% HPMC and insert it over cornea. Using
slit-lamp beam different angle structures can be seen. Examination of
360° angle can be done by rotating the goniolens 360° gradually. While
using Goldman three-mirror gonioscope dome-shaped mirror is used for
gonioscopy. Structures can be seen more easily if during the procedure
patient is asked to look towards the mirror of the goniolens.
PACHYMETER
It is an instrument used to measure the thickness of cornea. It is
required prior to lasik laser surgery, screening of keratoconus and
monitoring of glaucoma. There are two types of pachymeters: Optical
pachymeter and ultrasonic pachymeter. Ultrasonic pachymeters are the
latest ones used clinically. It works by way of corneal waveform. It
is just like A-scan of eyeball. It is accurate and can detect structures
within corneal substance like micro bubbles created in the cornea
during femto-second laser flap.

Procedure
Patient is seated on a stool. One drop of local anesthetic agent is put in
the eye. Wait for 30 second for proper anesthesia. Take the probe and
touch the central part of cornea gently. Corneal thickness is displayed on
monitor in micrometers.

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Fig.12.22: Amsler grid

AMSLER GRID
This is a chart devised by Marc Amsler to detect slight abnormalities of
central 20° of visual field. Most commonly used chart consists of a white
grid of 5 mm squares on a black background with a central white fixation
point (Fig. 12.22).

Technique
Patient is seated comfortably in a well lit room. Patient should see this
chart with best corrected vision, i.e. after using spectacles if required.
Chart is held at a distance of 25 cm. No medicine should be used prior to
this procedure so that accommodation is intact and there is no change in
pupillary size. Patient is instructed to look at the fixation point of chart
with one eye, other eye being closed. Ask the following questions:
1. Are you able to see the fixation point? If not it is due to presence of
central scotoma.
2. With eyes seeing at fixation point can you see whole of the chart
or any portion of chart is missing? It may be due to para-central
scotoma.
3. Is there any waviness in the horizontal or vertical lines? This may
indicate metamorphopsia. It occurs if distance between two cones is
altered as in macular edema.
4. Is there any blurred or distorted area in the grid? These changes
appear prior to appearance of a definite scotoma.

VISUAL FIELD CHARTING (PERIMETRY)

This is a procedure by which we estimate extent of visual field. Visual

field is a three-dimensional area around an object of regard (fixation
point). Extent of visual field is 90° temporal, 60° nasal, 70° inferior and
60° superior with a white object of 5 mm size. Perimetry is of two types:

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 Ophthalmic Procedures and Instruments 123

1. Kinetic perimetry: Here the stimulus is moved from periphery to

center like confrontation method, tangent screen etc.
2. Static perimetry: Here stimulus of known luminance is presented
at preset positions for a preset duration. Automated perimetry is an
example of static perimetry.
Central field can be charted with scotometry, Goldman perimetry
and automated field analyzer. Peripheral field can be charted with con-
frontation method, Lister’s perimeter, Goldman perimeter and automated
perimeters.

Confrontation Method
Here visual field of examiner is compared with visual `field of patient
presuming that the visual field of examiner is normal. It is a very easy
method and can be done anytime, anywhere without any instrumentation.
Patient sits in front of the examiner at a distance of one meter. Patient
closes his right eye and examiner closes his left eye. Thus visual field of
left eye of patient is compared with visual field of right eye of examiner.
Patient is asked to look into the right eye of examiner with his left
eye. The examiner brings his finger from periphery to center midway
between patient and himself. Both patient and examiner must see the
finger simultaneously to consider the visual field of patient as normal.

Lister’s Perimeter
It is used to estimate the extent of peripheral field. It consists of a metallic
semicircular arc with a scale and a white dot for fixation. The arc can
be rotated in different directions. Patient is asked to sit in front of the
perimeter such that the chin is rested on the chin rest. One eye of patient
is occluded at one time. He sees the fixation point with open eye. An
object is moved from periphery to center till he starts appreciating the
object. This point is noted on the scale. Similar recordings are done in
different directions. Size and color of object is noted (Fig. 12.23).

Scotometry
It is used to estimate central 30° field. The Bjerrum’s screen is practically
used for this purpose. It may be of one meter or two meter square size.
Patient is seated at a distance of one and two meters respectively. Screen
consists of a central fixation point around which are concentric circles
from 5-30°. Patient is asked to fixate at the central dot with one eye,
other eye being occluded. First of all, blind spot is charted with one eye.
Then a white target of 10 mm size is moved from periphery to center
in different directions and any point where the target becomes invisible
is recorded. Blind spot is located about 15° temporal in the horizontal
meridian. Central and para-central scotomas can be found by this method
(Fig. 12.24).

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 124 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 12.23: Lister’s perimeter

Fig. 12.24: Bjerrum’s screen

Automated Perimeter
This is the current gold standard. Patient is seated against a concave dome
with presbyopic correction if required. One eye of patient is occluded.
Patient sees the central target with the open eye. Computer shines light at
predetermined positions and of particular intensity. Patient is instructed
to press a button whenever he sees a light at any point without loosing his
fixation. Computer records this and compares it with the normal value
for the age already fed in its software (Figs 12.25 and 12.26).

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 Ophthalmic Procedures and Instruments 125

Fig.12.25: Automated perimeter

Fig. 12.26: Visual field chart

Scotoma
It is an area of partial alteration in the field of vision which consists of a
partially diminished or entirely damaged visual acuity surrounded by a
field of relatively normal vision. In simple words it is a partly or totally
blind area in the visual field. It is of different types:
1. Physiological scotoma: It is present in each and every individual,
e.g. blind spot.

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 126 Refraction, Dispensing Optics and Ophthalmic Procedures

2. Pathological scotoma: It indicates some abnormality of retina or

optic nerve, e.g. arcuate scotoma, paracentral scotoma, central
scotoma, etc.
3. Negative scotoma: This type of scotoma cannot be appreciated by
the patient himself but can be charted on perimetry. Blind spot is
a negative scotoma. Thus this type of scotoma is a sign and not a
symptom.
4. Positive scotoma: This type of scotoma can be appreciated by
patient himself. It is usually late stage of a disease. Patient says that
he sees a black spot in his visual field

CONTRAST SENSITIVITY
Contrast is the difference in visual properties that makes an object
distinguishable from other objects and the background. Contrast
sensitivity is the ability of the eye to see objects that may not be
outlined clearly or that do not stand out from their background,
e.g. ability to appreciate a gray object against a white background.
Contrast sensitivity is maximum at 20 years of age and at spatial
frequencies of about 2-5 cycles/degree. It decreases with age, in
cataract, and diabetic retinopathy (Fig. 12.27).

Clinical Features of Low Contrast Sensitivity

1. Difficulty in seeing traffic lights or vehicles at night.
2. Not able to see a burning flame on stove.
3. A very good illumination is required to read or write.
4. Not able to see spots on cloths or dishes.
5. Feeling of tiredness while watching TV.

Fig. 12.27: Contrast sensitivity chart

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 Ophthalmic Procedures and Instruments 127

Testing of Contrast Sensitivity

This test measures the degree to which this ability has been lost. Large
objects can be seen easily even with low contrast sensitivity but smaller
objects can be seen only if contrast is of high degree.

Clinical Significance

A patient with good visual acuity but low contrast sensitivity may be
suffering from diabetic retinopathy. Similarly a difference of contrast
sensitivity between two eyes should be seen seriously.

COLOR VISION
There are two types of photoreceptors in retina namely rods and
cones. Rods work in dim light and are distributed more in peripheral
retina. Cones work in bright light and are distributed more in macular
area. Cones are also responsible for color vision. According to Young
Helmholtz theory color vision is Trichromatic, i.e. it is combination of
three primary colors namely red, blue and green. All other colors can
be made by combination of these three colors. There are three different
pigments in our retina which perceive these colors. A person who cannot
perceive colors properly is said to be partially color blind and another
one who cannot see colors at all is said to be totally color blind. A person
who is totally color blind perceives all colors as grey. This is known as
Purkinje shift. Colorblindness is of two types namely congenital and
acquired.

Congenital Color Blindness

It is transmitted from parents to children and till today has got no cure
(Figs 12.28A and B). Males are more commonly affected (3-4%) than
females (0.4%). It may be of different types:
Anomalous Trichromatic color vision: Patient can appreciate all the
three primary colors but one or two colors cannot be appreciated without
some error. It may be of three types:
a. Protanomalous: Here red color perception is defective.
b. Deuteranomalous: Here green color perception is defective.
c. Tritanomlous: Here blue color perception is defective.
Dichromatic color vision: Mechanism to perceive one of the three
primary colors is totally absent. Only two colors can be perceived. It
may be of three types:
a. Protanopia: Here red color perception is absent.
b. Deutranopia: Here green color perception is absent.
c. Tritanopia: Here blue color perception is absent.
Monochromatic color vision: Only one of the three primary colors can
be appreciated. It is a very rare condition.

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 128 Refraction, Dispensing Optics and Ophthalmic Procedures

B
Figs 12.28A and B: Inheritance of color vision defect

Achromatic color vision: It is an extremely rare condition due to

congenital absence of cones. It is associated with day blindness and
nystagmus. Patient is totally color blind.

Acquired Color Blindness

Due to damage to macula or optic nerve red green discrimination
becomes defective. In nuclear sclerosis, blue color appreciation becomes
defective. It is because increased levels of amber color pigment in
nucleus absorbs blue color.

Methods of Color Vision Testing

1. Pseudo-isochromatic plates, e.g. Ishihara charts (Fig. 12.29)
2. Fornsworth Munsell 100 hue test
3. City University color vision test

Fig. 12.29: Ishihara charts (For color version, see Plate 2)

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 Ophthalmic Procedures and Instruments 129

4. Edridge green lantern test

5. Nagel’s anomaloscope
6. Holmgren’Wool Test.

ULTRASOUND BIOMICROSCOPY
Ultrasound biomicroscopy (UBM) is a technique used to analyze anterior
segment with the help of a high frequency ultrasound transducer. It is
performed with a 50 MHz probe. It gives a resolution of 40 micron and a
depth of 4 mm. The first commercially available machine was developed
by Zeiss in 1991. The machine has three essential components:
1. Transducer
2. High frequency signal processing
3. Motion control
Transducer has a piezoelectric crystal which produces a radio-
frequency pulse of 50 MHz. This radiofrequency travels the body tissues
and is reflected back to the transducer. The reflected radio frequency is
processed by signal processing unit and the signals are displayed on the
monitor. There is a motion control device which is meant to ensure subtle
movements of transducer during the procedure.

Technique
UBM is done in supine position with the eyes open. The transducer
cannot come in direct contact with the cornea as there is a special cup
between the eyelids to keep them open. The eyecup is filled with normal
saline or sterile methylcellulose. There is approximately a distance of
2mm between the cornea and the transducer. It prevents injury to cornea.
Eyeball is scanned in each clock hour from centre of cornea to ora-serrata.
Images produced by UBM have a resolution of 40 microns hence each
and every detail of different structures of anterior segment is visible.
Uses
1. It helps to study angle details even in the presence of opaque medium.
2. It is helpful in the study of uveitis. Presence of pars planitis, supra-
ciliary effusion, cyclitic membrane can be seen on UBM.
3. In case of trauma with hyphema, it helps to study the status of iris,
lens, ciliary body, etc.
4. It helps study anatomy of anterior segment in case of dense corneal
opacity so that surgical intervention can be planned.
5. It helps study entire extent of tumor of anterior segment.
6. It helps differentiate between scleritis and episcleritis.

Limitations
1. It cannot visualize structures beyond 4 mm of depth.
2. UBM cannot be performed in the presence of an open corneal or
sclera wound.

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 130 Refraction, Dispensing Optics and Ophthalmic Procedures

Flow chart 12.1: Methods of sterilization

STERILIZATION AND DISINFECTION

Sterilization is a process which kills or removes all types of living
micro-organisms including bacterial spores from an article, surface or
medium.
Disinfection is a process which kills or removes all types of disease
causing organisms but does not kill bacterial spores.

Sterilization of Instruments
Different methods of sterilization of instruments have been depicted in
the (Flow chart 12.1). These are:
1. Physical Methods: These may be natural like sunlight and artificial
like drying, heat, filtration and radiation etc.
2. Chemical Methods like use of phenol, gases, halogen compounds etc.
Sunlight is the natural method of sterilization. It contains ultraviolet
rays which have lethal action against all types of microorganisms. Water
in lakes, rivers and tanks are sterilized by this natural method.
Some more commonly employed methods of sterilization are:
Heat Sterilization: It can be both dry and moist. Dry heat causes
dehydration of cells, denaturation of proteins and oxidative damage to
cells. Moist heat causes denaturation and coagulation of proteins.

Ways of Dry Heat Sterilization

1. Drying in air causes dehydration of bacteria but it is an unreliable
method and is of academic interest only.
2. Flaming: Tips of forceps, hypodermic needles, scraping spatulas and
tips of AC canula can be sterilized by this method. The instrument is

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 Ophthalmic Procedures and Instruments 131

made red hot by keeping on the flame of a spirit lamp and allowed to
cool before reusing. It kills all types of organisms including spores.
Any organic material sticking to the tip should be cleaned properly
before exposing to flame. However the sharpness of the instrument
is blunted.
3. Incineration: It is used to destroy soiled dressings, blood stained
cotton, beddings and pathological material.
4. Hot air oven: It is used for forceps, scalpels, glass syringes,
scissors etc. The article must be double wrapped and kept at 150° C
temperature for 2 hours.

Ways of Moist Heat Sterilization

1. Boiling: This method kills all organisms but spores. All types of
instruments can be boiled except rubber and plastic materials.
Sharpness is blunted by boiling. Boiling is done for 30 minutes.
Hard water should not be used as it leaves a layer of residues on all
instruments and the container.
2. Steaming: Almost all types of instruments can be steamed. It also
does not kill spores. Instruments are kept over a shelf above water
level and are sterilized by steaming for 30 minutes.
3. Autoclaving: It is the best and most common method employed to
sterilize all types of metallic instruments. It kills all types of micro-
organisms and spores. It is done at 121° C temperature, 15 lb/inch
square pressure for 20 minutes.

Sterilization Control
Spores of Bacillus stearothermophilus are enclosed in an envelope and
kept in autoclave. Once the process of sterilization is over, these spores
are inoculated on suitable medium and checked for any growth.

Chemical Sterilization is Done by Different Ways

1. Savlon: It is composed of cetrimide and chlorhexidine. It is a surface
active agent. It is effective against Gram +ve bacteria and is used to
sterilize various instruments, catheters, knives and scissors etc. It is
also used for cleaning of skin for dressing.
2. Spirit: 95% Alcohol: It does not kill viruses but is effective against
bacteria and spores.
3. Methylated Spirit: It is 70% isopropyl alcohol. It is used to sterilize
schiotz tonometer.
4. Formaldehyde: 10% formalin is used to sterilize cryoprobes, and
heat sensitive instruments. Formaldehyde gas is very toxic and
irritant and is used to sterilize sick rooms, wards and O.T.
5. Glutaraldehyde: It is commercially available as ‘Cidex’ solution

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 132 Refraction, Dispensing Optics and Ophthalmic Procedures

and is widely used to sterilize endoscopes, rubber tubings, catheters.

It is very effective against tubercle bacilli, fungi and viruses.
6. Hydrogen peroxide: 3% solution is very effective against HIV and
Herpes. It is commonly used to clean dirty wounds, prisms, lenses
and applanation tonometers
7. Ethylene oxide gas: It is used to sterilize IOLs, DCR tubings,
disposable plastic items like catheters, syringes etc. It is very
effective against bacteria, spores and viruses.

Sterilization by Radiation
X-rays, Gamma rays, cosmic rays are ionizing radiations. They are lethal
to DNA and kill all types of microorganisms. They penetrate tissues
without raising the temperature. They are used to sterilize plastic items
like syringes, catheters, etc.
Infrared rays are nonionizing radiations. They are absorbed by the
surface and temperature of the article is raised. They are used for rapid
mass sterilization of syringes, and hospital wards, virus laboratories etc.

Sterilization of Operation Theater

The process of sterilization of operation theater (OT) is known as
fumigation.
First of all OT is cleaned nicely and washed with soap and water
thoroughly. All the walls should be thoroughly mopped. Once the room
has been air dried, it is fumigated with formalin solution.

Availability of Formalin
Formalin is commercially available as 40% solution. When it is heated
vapors of formaldehyde are produced. It is best done at 20°C temperature
and 65% of relative humidity. The quantity of 40% formalin required is
0.50 ml per cubic foot.
For an area of 1000 cubic foot 500 ml of 40% formalin solution is
added in 1000ml of water in an electric boiler. Boiler is switched on after
sealing the door. After about one hour when whole of the solution has
vaporized, the boiler is switched off from outside the OT.
Formaldehyde vapors can also be produced by automatic vaporizing
unit operated electrically.
Alternatively for 1000 cubic foot area of OT, 450 gm of potassium
permanganate is added to 500 ml of 40% formalin solution. This causes
auto-boiling and generates fumes. This is an exothermic reaction and
takes place vigorously hence must be carried out by an expert technician.

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 Ophthalmic Procedures and Instruments 133

OT is closed for 24-48 hours. After opening the OT after 48 hours, AC

is turned on and residual vapors are allowed to escape in a proper way
so that there is no problem with the other hospital staff. To neutralize the
residual formalin 150 ml of 10% ammonia is taken in a bowl for 500 ml
of formalin used and kept in the centre of the OT for three hours.
Example: For an OT of 20*15*10 size = 3000 cubic foot area, 1500
ml of 40% formalin will be required for fumigation and 450 ml of 10%
ammonia will be required for neutralization of residual fumes.

Procedure
Seal all the possible outlets of OT through which formaldehyde
gas can leak. Place spore strips in OT at appropriate places to check
decontamination. Place the vaporizing unit in the room and close the
door from outside. Seal this door from outside. Put the unit on and wait
for about one hour till whole of the solution is used up. The OT is kept
locked till 24 hours. After 24 hours, the air conditioner is put on, the door
is opened and the gas is allowed to leak out in a proper way. Nobody is
allowed to enter the room till the gas has been allowed to escape. Levels
of residual gas are checked with a suitable air monitoring equipment. It
should be as low as 2 ppm. Formaldehyde gas is a scheduled chemical
and is very harmful for humans. Its maximum exposure limit is 2 ppm.
Thus the fumigation must be carried out by a trained paramedical staff as
per the described procedure.
Caution: Hydrochloric acid and chlorine containing compounds
must not be present in OT as formaldehyde gas can react with these
compounds to form a lung carcinogen (Chlormethyl).

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 Chapter

13 Lasers in
Ophthalmology

LASER stands for Light Amplification for Stimulated Emission of

Radiation. There are different types of clinical applications of different
types of laser systems. Commonly employed procedures are:

YAG CAPSULOTOMY
YAG stands for ‘Yttrium Aluminium Garnet’. This type of laser
is used for treatment of ‘After Cataract’. After ECCE or SICS or
Phacoemulsification posterior capsule becomes thick and opaque. Patient
starts complaining of blurring of vision. On slit lamp examination with
dilated pupil thick posterior capsule can be easily appreciated. With the
help of YAG laser a hole is made in the posterior capsule in front of
pupil. It is an OPD procedure and patient is sent home immediately after
the procedure. Usually, 1.6 to 3.2 mJ of energy is required to make a hole
of 2 to 3 mm just opposite the pupil. 2 to 4 shots are sufficient to serve
the purpose. Too big or too small holes should be avoided to prevent
CME [cystoids macular edema].

YAG IRIDOTOMY
In patients who are prone to develop narrow angle glaucoma peripheral
iridotomy can be done by using YAG laser to prevent attack of acute
congestive glaucoma.

LASER FOR PHOTOCOAGULATION IN RETINAL

DISORDERS
Neovascularization of retina, e.g. in diabetes, Eales’ disease, BRVO,
BRAO, etc. can be taken care of by photocoagulation otherwise it
can cause vitreous hemorrhage or neovascular glaucoma leading to
blindness. Here Argon laser or diode laser is used. The purpose of laser
is to decrease the oxygen demand of retina. The part of retina which is
lasered becomes dead hence no oxygen is required by that part. At the
same time that part of retina becomes non -seeing. Macular area and
hence central vision is spared in this procedure so that patient can see
and carry out his routine activities (Figs 13.1 and 13.2).

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 Lasers in Ophthalmology 135

Fig. 13.1: Laser for retinal photocoagulation

Fig. 13.2: Laser spots on retina

EXCIMER LASER AND LASIK LASER FOR

CORNEAL REFRACTIVE SURGERY
This surgery is used widely now a day to get rid of spectacles. In excimer
laser epithelium of cornea is abraded, laser is applied on the bed, soft
bandage contact lens is put and patient is sent home with the advice to
come back after five days when all the epithelium is regenerated and
there is no refractive error left. In lasik laser, a flap of cornea is raised
with a microkeratome, laser is applied on the bed, flap put in its position
and patient is allowed to go home. Advantage of this type of laser over
excimer laser is that the patient does not complain of pain, redness, etc
because epithelium remains intact.

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 136 Refraction, Dispensing Optics and Ophthalmic Procedures

ARGON LASER TRABECULOPLASTY (ALT)

Patients suffering from glaucoma who are not fit for surgery and IOP
cannot be controlled even with maximum medical therapy, ALT is
the answer. Laser shots are applied on trabecular meshwork through
gonioscope. This causes localized burning of meshwork. Scarring
follows, which has a pulling effect on meshwork that opens up the pores
of trabeculum, thus aqueous outflow is increased. This procedure can
control rise in IOP for a couple of years.

ROLE OF LASER IN TRABECULECTOMY

(UNDER-FILTERING BLEB)
After this surgery if bleb is not well formed and IOP is high due to under-
filtering bleb, aqueous outflow can be increased by breaking one of the
sutures with the help of laser.

LASER IN TREATMENT OF MALIGNANT GLAUCOMA

In this glaucoma aqueous pockets are formed in the vitreous cavity due to
misdirection of aqueous humor. Specific treatment consists of breaking
vitreous phase with the help of laser and letting the aqueous humor come
out of these pockets.

LASER FOR DCR SURGERY

Endolaser DCR is gaining popularity now a day as this procedure
does not require any incision, so it is more acceptable cosmetically as
compared to conventional DCR.

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 Chapter

14 Contact Lens
Practice

A contact lens is a small plastic wafer designed to rest on cornea or

sclera and is used to correct refractive errors. It may be of three types
(Fig. 14.1):
1. Soft contact lens
2. Semisoft contact lens
3. Hard contact lens.

NOMENCLATURE

1. Overall diameter: The dimension across the physical boundary

of contact lens in mm. It may be 13 mm, 13.5 mm or 14 mm in
case soft contact lens. It varies according to size of cornea and type
of lens. Overall diameter of semisoft contact lens is smaller than
overall diameter of soft contact lens.
2. Optic zone: It is the central part of contact lens used to focus rays of
light on retina. It is decided as per size of pupil and overall diameter.
3. Base curve: It is the curvature of posterior central part of contact
lens which rests on anterior surface of cornea. It is decided by K.
4. Peripheral curves: These are 2-3 depending on make of lens and
help to stabilize contact lens on cornea.
5. Edge: It is union of anterior and posterior curves at the periphery.
6. Power: It is decided by anterior central curvature of contact lens and
varies according to refractive error of patient.
7. Thickness: It is measured at the central part of lens in mm.
8. Tint: It is the color of lens.
9. K refers to the flatter of the two meridians of cornea (Higher reading
of keratometery in mm) (Fig. 14.2).

ANATOMY AND PHYSIOLOGY OF CORNEA

Cornea is transparent, avascular structure present on anterior surface of
eyeball. Its diameter on anterior surface is 11.7 mm horizontally and

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 138 Refraction, Dispensing Optics and Ophthalmic Procedures

Fig. 14.1: Soft and semisoft contact lens Fig. 14.2: Parts of contact lens

11 mm vertically. Its thickness is 0.54 mm in centre and power is +45 D.

Radius of curvature is 7.94 mm. It has got five layers (Fig. 14.3):
1. Epithelium: It is the most anterior, metabolically most active layer
of cornea. It is made up of many layers of cells. Each cell is richly
supplied with nerves from ophthalmic branch of trigeminal nerve.
Thus it causes pain when a cell is damaged. It has a very good repair
capacity.
2. Bowman’s membrane: This is the layer which does not have
regenerative capacity. Damage to this layer may leave corneal opacity.
3. Stroma or Substancia propria: It constitutes 90% thickness of
cornea. It is made up of multilayered lamellae. Metabolically, it is
less active. Its peculiar arrangement makes the cornea transparent.
4. Descemet’s membrane: It is very resilient and does not give way
easily.
5. Endothelium: It is second most active layer of cornea. It has hexagonal
cells, each cell has Sodium Potassium ATPase pump which keeps on
pushing water out of cornea that enters its substance and keeps it
transparent. Any damage to these cells is repaired by enlargement of
neighboring cells. Normal endothelial cell count is 3000 per cubic
mm. Damage to this layer results in loss of transparency. Cell count
decreases with age. Cornea decompensates if cell count decreases
less than 300 per cubic mm.

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 Contact Lens Practice 139

Fig. 14.3: Microscopic structure of cornea

Oxygen Supply of Cornea

Cornea gets oxygen in different ways:
1. Most important source is atmospheric oxygen dissolved in tears
(precorneal tear film). When a person wears contact lenses, this
supply of oxygen is decreased. Now the supply depends on two
factors. Firstly, the material that may or may not allow oxygen to
pass through its substance. This depends on DK value of the material.
Higher is the DK value, more oxygen can pass through the substance
of cornea. Secondly, the movement of contact lens on cornea that is
directly related with tear exchange. More is the blink rate, more is
tear exchange and more oxygen is available to cornea. Steep (tight)
fitting causes less movement of contact lens, thus less tear exchange
and lesser oxygen is available to cornea. Thick contact lens also
impairs oxygen supply to cornea. High water content of contact lens
also increases oxygen supply to cornea.
2. Peri-limbal capillaries also supply oxygen to cornea.
3. Oxygen dissolved in aqueous humor is also available to inner layers
of cornea.
During sleep oxygen supply to cornea is decreased remarkably. If
we sleep with contact lens on our cornea, the oxygen supply is further
decreased leading to corneal hypoxia. Cornea becomes edematous, with
microcysts. Eyes become red and person may complain of blurring of
vision. Thus it is strongly recommended that one must not sleep with
contact lens on cornea.

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 140 Refraction, Dispensing Optics and Ophthalmic Procedures

PRECORNEAL TEAR FILM

A very thin layer of tears covers the cornea known as precorneal tear
film. It has three layers (Fig. 14.4):
1. Mucin layer: It is secreted by mucin secretory glands of conjunctiva
namely Goblet cells, Crypts of Henle and Glands of manz. It
converts hydrophobic surface of cornea into hydrophilic surface
thus stabilizing the aqueous layer of tear film on cornea.
2. Aqueous layer: It constitutes main bulk of tear film. It is secreted
by accessory lacrimal glands namely Glands of Krause and Glands
of Wolfring. It forms the Basic tear secretion. The main lacrimal
gland secrets tears during hours of emotional crisis known as Reflex
tear secretion. This layer keeps the cornea and conjunctiva moist,
flushes away the metabolic waste products from conjunctiva. This
layer contains sodium chloride, sugar, and urea. It is alkaline in
nature and saltish to taste. It also contains antibacterial substances
like Lysozyme, Betalysin and Lectoferrin.
3. Lipid layer: It is secreted by Meibomian glands. It spreads over the
aqueous layer and prevents its evaporation. It also lubricates the
eyelids to facilitate blinking.

Functions of Tear Film

1. It supplies oxygen to cornea.
2. It keeps the cornea and conjunctiva moist.
3. It contains antibacterial substances.
4. It flushes away the metabolic waste products from conjunctiva and
cornea.
5. It facilitates blinking. Normal blink rate is 12 per minute.
Tear production is decreased in old age, during hours of fatigue. Use of
certain drugs like Timolol, Pilocarpine, Oral contraceptives, Antihistaminics

Fig. 14.4: Precorneal tear film

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 Contact Lens Practice 141

decreases tear production. Thus such medicines should not be used by a

contact lens wearer. Pregnancy also decreases tear production.

INDICATIONS AND CONTRAINDICATIONS

OF CONTACT LENS
Contact lenses can be used for different purposes such as:
1. Optical indications: Myopia, Hypermetropia, Astigmatism, Kerato-
conus (Cone-shaped cornea), Anisometropia and anisekonia, Aphakia,
Presbyopia, Aniridia (Absence of iris) and albinism (Absence of
melanin pigment). Refractive errors are better corrected with
contact lenses as compared to spectacles because of larger field,
little peripheral aberrations and no rim interference. It has been
found that axial length is slightly decreased by using contact lenses
in myopia due to its flattening effect. Thus it slows down progress of
myopia. Hypermetropes exert less accommodation and convergence
with contact lenses as compared to spectacles. It is due to base out
prism effect of spectacles during convergence. Irregular astigmatism
can be corrected by contact lenses only. In Anisometropia and
anisekonia spectacles cause disparity of image size leading to
diplopia. These conditions can be rectified by using contact lenses.
In Aniridia and albinism patient cannot tolerate light (Photophobia).
A cosmetic contact lens can be used to avoid photophobia.
2. Cosmetic indications: Unsightly cornea or eyeballs can be hidden
by tinted or painted contact lenses. Pupil can be left clear in contact
lens if eye has got some useful vision. Color of underlying iris can
be changed by cosmetic contact lens as is required by some actors.
3. Occupational indications: Sports persons get an advantage of getting
less serious injury with contact lens. News casters and television
actors can avoid reflections by using contact lens. Fogging of
spectacles can be avoided while shifting from cold or hot and humid
atmosphere.
4. Therapeutic indications: Soft contact lenses have been found
useful in treatment of non-healing corneal ulcers, impending
corneal perforation, Bullous keratopathy, Trichiasis, prevention
of symblepharon, recurrent corneal erosions, etc. Medicines like
Pilocarpine have been found more effective when they are instilled
over contact lens or incorporated in contact lens.
5. Diagnostic indications: Procedures such as Gonioscopy, Fundoscopy
and electro diagnostic procedures like ERG are done taking help of
contact lens.
6. Research indications: Contact lenses can be used for research
purposes like occlusion of eye in animals, stimulating accommodation
and relaxing accommodation.

Contraindications of Contact Lens

1. Infective conditions of eye: Stye, Chalazion, Blepharitis, Conjunctivitis,
Keratitis, etc. Use of contact lens in such circumstances can spread
infection.

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 142 Refraction, Dispensing Optics and Ophthalmic Procedures

2. Allergic eye conditions like spring catarrah, simple allergic

conjunctivitis. Symptoms may be exaggerated.
3. Abnormalities of lid margin like entropion and ectropion, trichiasis
and diseases of conjunctiva like pterigium, limbal dermoid (due to
surface irregularity fitting is not proper).
4. Paralysis of fifth nerve causes loss of corneal sensations and contact
lens can damage the cornea without awareness of the patient.
5. Exophthalmos causes improper blinking and tear exchange becomes
inadequate.
6. Ocular conditions like scleritis, episcleritis, uveitis, bleb of
trabeculectomy, uncontrolled diabetes.
7. Non-medical conditions: If patient is not motivated failure is likely
to occur. Failures are more in males than females, hypermetropes
than myopes, high astigmatism, better vision with glasses and
patients with large pupils.
8. Tear film disturbances: contact lenses themselves cause dry eye, so
should not be used in dry eye conditions.

MATERIALS USED FOR MANUFACTURING

OF CONTACT LENS
Different materials used for manufacturing of contact lenses are:
1. Polymethyl methacrylate (PMMA): PMMA has good optical
properties, inert, non-toxic having excellent moulding and
machining qualities but practically impermeable to oxygen. Thus
the lenses made from it can be used only for a limited time. It has
transmission of 90% ref. index of 1.49, hardness of 4.5 as compared
to 10 of diamond. Its softness makes it vulnerable to scratches. It has
1.5% water content after immersion in solution for several days. A
thin coating of silicon tetrachloride increases its wettability.
2. Polycarbonate: It is transparent, tough with high refractive index,
more prone to scratching than PMMA. It is used for high power
contact lenses.
3. Cellulose acetate butyrate (CAB): It is hard, strong with good
machining and moulding properties.
4. Silicone rubber: It is also a good material. However, it is hydrophobic
in nature and a hydrophilic coating needs to be done on the surface
of contact lens.
5. Hexa ethyl methacrylate (HEMA): HEMA and its copolymers are
commonly used to make soft contact lenses.
6. Fluorocarbons: These are newer materials with very good oxygen
permeability.

Properties of Contact Lens Material

Materials used in manufacturing of contact lens should have following
properties:

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 Contact Lens Practice 143

1. It should be biologically inert, i.e. it should not react with tissues it

comes in contact with.
2. It should have high gas permeability.
3. It should have little friction effect between contact lens and
eye tissues.
4. It should not change its properties when subjected to different pH.
5. It should not take part in enzymatic activities.
6. It should not absorb metabolites and toxins.
7. It should not show strong adhesive molecular forces.
8. It should not show excessive electrophoretic osmotic properties.
9. It should not excite inflammatory response even if it remains in
contact with the tissue over a long duration of time.

PARAMETERS OF CONTACT LENS

1. Power: It is determined by curvature of anterior surface of optic zone
of contact lens. It is not related directly with thickness of lens. It is
calculated by doing refraction and taking help of conversion table.
2. Base curve: It is decided by curvature of anterior surface of cornea
as determined by keratometery. Base curve of soft contact lens is
made flatter than flat K of cornea because the overall diameter of
soft contact lens is always greater than greatest diameter of cornea.
However diameter of semisoft/hard contact lens is smaller than
diameter of cornea so its base curve is kept same as flat K of cornea.
3. Overall diameter: It depends upon diameter of cornea which can be
taken either by a caliper or a simple scale.
4. Thickness: More is the thickness of lens lesser will be the oxygen
permeability. In addition it makes the lens heavier and it tends to
fall thus making the fit flatter. Most of the manufacturing companies
keep this parameter of contact lens constant.
5. Optic zone diameter: It is usually kept constant, however it can be
increased or decreased depending upon size of pupil.
6. Edges: They should be smooth.
7. Water content: More is the water content, more is the oxygen
permeability so that person can wear the contact lens for a longer
duration. However, it becomes thicker, heavier and more pliable
with increasing water content. Accordingly, parameters have to be
set to have alignment fitting.
8. Oxygen permeability: It depends on DK value of material,
thickness of lens and water content of lens. Higher DK value
means more oxygen permeability. More thickness of lens means
lesser oxygen permeability. High water content means higher
oxygen permeability. High oxygen permeability increases
wearing period of contact lens.

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 144 Refraction, Dispensing Optics and Ophthalmic Procedures

HISTORY TAKING FOR CONTACT LENS FITTING

1. Why do you want contact lens? Weather the reason is cosmetic,
optical, occupational or any other.
2. Any history of ocular surgery. Contact lens should not be prescribed
immediately after glaucoma surgery to avoid injury to bleb.
3. History of diabetes? Weather taking any medicines? Weather blood
sugar levels are within normal limits? Contact lens should not be
prescribed to uncontrolled diabetics. Pregnancy can also trouble the
patient who is already using contact lens due to water logging.
4. History of drug intake? Drugs like antihistaminic (cetrizine, avil),
oral contraceptives, decongestants, beta-blockers interfere with
contact lens wear. It is advised that no drug should be used over
contact lenses except preservative free lubricating eyedrops.
5. History of any previous contact lens failure, if yes try to find out the
cause to avoid repeated failure.
6. History of ocular allergy or infection or dryness. If yes, treat the
cause first.

Examination
1. Vision with and without glasses and with pin hole should be
recorded.
2. Any evidence of disease of conjunctiva, cornea, lids, etc. like
blepharitis, pterigium, vascularization of cornea, etc.
3. Any evidence of dry eye.
4. Any evidence of recent ocular surgery.
5. Keratometery, corneal diameter, diameter of pupil, corneal sensation,
tear film break-up time (BUT) and blinking.
Aircrew members are not allowed to use contact lens, however,
air hostess can do so. Contact lenses are not allowed in mining, sand
blasting and drilling.

FITTING OF CONTACT LENS

If patient is a beginner, she must be given a trial of contact lens. Different
types of fittings are (Figs 14.5A to C):
1. Alignment fitting: This is the ideal fitting in which contact lens
floats on precorneal tear film. There is neither pooling of dye (tears)
anywhere nor the contact lens touches the cornea. Movements of
contact lens with each blink are sufficient enough to enable tear
exchange required by cornea.
2. Steep (Tight) fitting: Here the contact lens touches the cornea at
periphery and there is pooling of dye (tears) at the center of cornea.
Contact lens shows very little movement with each blink so that
tear exchange is inadequate and cornea is at risk of hypoxia (lack

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 Contact Lens Practice 145

A B C
Figs 14.5A to C: Types of fitting. (A) Alignment fit; (B) Steep fit; (C) Flat fit

of oxygen supply). However, due to very little movement patient

feels quite comfortable immediately after wearing contact lens but
starts having problem after some time due to hypoxia. Steep fitting
is dangerous and should be avoided.
3. Flat (Loose) fitting: Here the contact lens touches the cornea at
centre and there is pooling of tears at the periphery. Movements
of contact lens on cornea are more than normal. There is adequate
tear exchange and no risk of hypoxia at all. However excessive
movements of contact lens give foreign body sensation and patient
feels uncomfortable and takes more time to adjust with lenses.

How to Start Contact Lens Fitting?

1. Find power of contact lens by doing refraction. Power of spectacles
needs to be converted into power of contact lens by consulting
conversion table. Power of cylinder needs to be made half (called
spherical equivalent) and added algebraically to power of sphere,
e.g. if power of spectacles is +1.00 DS,+2.00 DS, +3.00 DS or –1.00
DS, –2.00 DS, –3.00 DS; the power of contact lens will remain same.
If power of spectacles is +4.00 DS, +10.00 DS; power of contact
lens needs to be increased. If power of spectacles is –5.00 DS, –8.00
DS; power of contact lens needs to be decreased as is evident from
the Table 14.1.

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 146 Refraction, Dispensing Optics and Ophthalmic Procedures

Table 14.1: Conversion table

S No. Power of Power of Power of Power
spectacles {DS} of CL {DS} spectacles {DS} of CL {DS}
1. +1.00 +1.00 –1.00 –1.00
2. +2.00 +2.00 –2.00 –2.00
3. +3.00 +3.00 –3.00 –3.00
4. +4.00 +4.25 –4.00 –3.75
5. +5.00 +5.50 –5.00 –4.50
6. +6.00 +6.75 –6.00 –5.50
7. +7.00 +7.75 –7.00 –6.25
8. +8.00 +9.00 –8.00 –7.00
9. +9.00 +10.25 –9.00 –7.75
10. +10.00 +11.75 –10.00 –8.75
11. +12.00 +14.50 –12.00 –10.00
12. +14.00 +17.75 –14.00 –11.50
13. +16.00 +21.00 –16.00 –13.00

If power of spectacles is –4.00DS/–1.00DC*180 degree, the power

of contact lens will be (–3.75DS) + (–0.50DS) {spherical equivalent of
cylinder} = –4.25DS
2. Base curve of contact lens is calculated by doing keratometery and
adding 0.70 to flat K reading (for soft contact lens), e.g. if K readings
are 7.80 and 7.90, base curve of soft contact lens will be 7.90 +0.70
= 8.60. Base curve of semisoft contact lens is taken as flat K reading
i.e. 7.90.
3. Diameter of contact lens is calculated by adding 2.00 to greatest
diameter of cornea measured by scale or caliper for soft contact
lens and by deducing 2.00 from minimum diameter of cornea for
semisoft contact lens. However, every manufacturer keeps diameter
of its make fairly constant and alignment fitting is achieved by
changing base curve.
4. Tint of contact lens and its water content can be decided in
consultation with the patient.

HOW TO INSERT SOFT CONTACT LENS?

There are different ways of inserting soft contact lens (CL):
1. Wet the tip of right index finger. Put soft contact lens on finger tip.
Pull the upper eyelid of right eye with other hand and lower eyelid
with middle finger of right hand. Put contact lens by looking directly
onto the contact lens.

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 Contact Lens Practice 147

Fitting Technique
1. Ask the patient to wash her hands and eyes with soap and water.
Shake excess water.
2. Take contact lens and check inside out and right left.
3. Wet contact lens should be put on finger and introduced in the eye.
Ask the patient to move her eyeball so that the lens settles on cornea.
4. If patient experiences foreign body sensation ask her to close the
eyes for 15-30 minutes.
5. Do slit-lamp examination for type of fitting. Base curve of contact
lens or diameter of contact lens can be adjusted to achieve alignment
fitting. Following points should be looked for:
a. Centration: Contact lens should be nicely centered on cornea.
Cornea should be properly covered by contact lens.
b. Movements of contact lens: With each blink contact lens should
move 0.5-1.00 mm, lesser movements indicate steep fit and
greater movements indicate flat fit.
6. In semisoft and hard contact lens fitting, fluorescein stain is used.
By this method pooling of dye (Green area) and corneal touch (Blue
area) can be easily appreciated.

Fluorescein stain is never used in soft contact lens fitting as the soft
contact lenses absorb dye and become unfit for use.

Advantages of Semisoft Contact Lens Over Soft Contact Lens

1. Visual acuity is better with semisoft contact lens.
2. High astigmatism can be corrected better with semisoft contact lens.
3. Irregular astigmatism and Keratoconnus can be corrected only with
semisoft contact lens.
4. Semisoft contact lens can be worn for a longer duration as compared
to soft contact lens.
5. Oxygen supply to cornea is much better with semisoft contact lens.
6. They are more durable and require lesser care.
7. Modification can be done in semisoft contact lens after manufacturing
but it is not possible in soft contact lens.
However their fitting technique needs to be mastered. They take more
time for adaptation because their edge rests on cornea (Very sensitive)
while in soft contact lens the edge rests on sclera (Less sensitive).

INSTRUCTIONS TO THE PATIENT

Always
1. Wash your hands before inserting or removing CL.
2. Clean CL after removing and before inserting.
3. Store them in CL solution.
4. Wear CL according to wearing schedule.
5. Carry your specs and CL kit with you while traveling.

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 148 Refraction, Dispensing Optics and Ophthalmic Procedures

6. Cosmetics (Kajal, Surma) should be applied after putting the lens.

7. Perfumes should be sprayed well before putting the CL because these
are alcohol based chemicals and remain in air as aerosols for some time.
They are absorbed by contact lens, which can damage the cornea.

Never
1. Wet your CL by placing in mouth.
2. Rub your CL with tissue paper.
3. Sleep with CL on. One can have a nap.
4. Wash your CL in tap water. It can cause infection of acanthoemeba.
5. Put them in hot water. They can get warped.
6. Insert over a sink. Many lenses are lost down the drain.
7. To begin with CL should be used for a short period. Wearing period
can be increased gradually.

CLEANING OF LENSES
Contact lenses should be cleaned after and before every use.
Deproteinization of lenses should be done every 15 days. Protein content
of tears gets deposited on contact lens due to opposite charge and alters
the optical quality of contact lens. Contact lens should be placed in a
clean vial along with CL solution and an enzyme tablet. The vial should
be closed and kept for 4-6 hours. Protein deposits are dissolved by action
of enzyme. CL is taken out and the CL solution of vial is discarded. After
cleaning with fresh CL solution the contact lenses are ready for use.

Disinfection of Contact Lens

There are two ways of disinfection:
1. Thermal: Contact lenses must be deproteinized before disinfection.
The CL should be put in a vial with CL solution and cap tightly
closed. Put this whole vial in boiling water for 30 minutes. Let the
water cool and CL is ready for use. This procedure can also be done
with the help of Soft Lens Aseptor-Patient Unit
2. Chemical: This is a less commonly employed method.

POST-FITTING PROBLEMS AND SOLUTION

1. Foreign body sensation: Some amount of foreign body (FB)
sensation is common after initial contact lens use. This is a part of
adaptation. However, if this sensation lasts for long following things
should be looked for:
a. Excessive movements of lens
b. Bad finish of edge
c. A low riding lens which strikes the lower lid
Solution: Excessive movements can be appreciated on slit lamp
examination. Bad finish of edge can be felt by tip of index finger. A

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 Contact Lens Practice 149

low riding lens can be easily seen even on torch light examination.
Excessive movements are due to loose/flat fit. To rectify decrease
the base curve of contact lens, increase the overall diameter of
contact lens or decrease the thickness of lens. A bad finish of edge
can be corrected by refinishing the contact lens. A low riding lens
can be rectified by steepening the base curve or increasing overall
diameter or making the lens thin. Similarly an up riding lens can
be rectified by increasing the overall diameter, steepening the base
curve, increasing the thickness of optic zone or decreasing the
thickness of periphery.
Sometimes while traveling patient complains of some foreign
particle going inside the eye and creating FB sensation. Remove
the lens; wash the eye with clean water. If FB sensation is no more,
reinsert the lens after cleaning it with CL solution. If still the FB
sensation persists, consult the nearest eye surgeon.
2. Edge in the pupil: Patient complains of transient but frequent blurring
of vision. This is due to non-optical area of lens coming in and going
out of pupillary area. This problem can be dealt by increasing the
optic zone diameter of contact lens or overall diameter of contact
lens and steepening the base curve if it is flat fit.

COMPLICATIONS OF CONTACT LENS

1. Hypoxic complications: With soft contact lens there is only 1-2 %
of tear exchange with each blink. It is 10-20% with RGP (Rigid
Gas Permeable) or semisoft contact lens. This is known as adequate
tear exchange. If contact lens is steep fitted or the DK value is very
low, or lens is very thick, oxygen supply to cornea is hampered
and cornea starts becoming edematous with decreased sensations,
superficial and deep vascularisation, micro cysts formation and
superficial punctuate keratitis. Patient complains of redness in eyes,
watering, blurring of vision and pain in eyes. Most common causes
of hypoxia encountered clinically are overwear, steep fitted lens or
patient sleeps with contact lens in eyes. So, patient must be advised
not to sleep with contact lens in eyes.
Treatment: Remove the contact lens immediately and try to find out
the cause, e.g.
• Steep fitting, incomplete or inadequate blinking, patient slept
with contact lens on, thick lens and poor quality material of
contact lens with low DK value
• Remove the cause and prescribe lubricating eye drops and topical
antibiotics and
• Call the patient after 3-4 days.
2. Infective complications: Cornea may become infected with
contaminated solution, lack of personal hygiene, use of tap water
for contact lens storage or cleaning or from adjoining structures of
eye. Staphylococcus aureus, Acanthamoeba, Pseudomonas are the

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 150 Refraction, Dispensing Optics and Ophthalmic Procedures

common microorganisms which infect cornea. Patient complains

of redness, watering, blurring of vision, pain in eyes. On slit lamp
examination conjunctival congestion with purulent discharge may be
seen. Cornea may show some infected lesion. Lack of compliance to
instructions and delayed reporting predispose the patient to develop
vision threatening complications.
Treatment: Ask the patient to discontinue use of contact lens till
further instructions. Take conjunctival swab and send for culture and
sensitivity. Take history of using tap water for contact lens cleaning.
Start antibiotics and lubricating eye drops and change the treatment
if required as per culture report.
3. Allergic complications: Patient may develop allergy to preservatives
of contact lens solution. Very rarely he becomes allergic to contact
lens material. He starts complaining of itching, redness, watering
etc. He may develop Giant Papillary Conjunctivitis, follicular
hypertrophy and hyperemia of conjunctiva.
Treatment: Ask the patient to discontinue using contact lens for
some time. Prescribe topical antihistaminics and diluted steroids.
Once the symptoms are settled ask the patient to change the contact
lens solution or the material as the case may be. He can also change
the wearing schedule or lens design. He should be advised to use
lubricating eye drops and clean his lenses regularly.
4. Giant Papillary Conjunctivitis: It is papillary hyperplasia in the
upper tarsal conjunctiva and occurs in 10-15 % cases of soft contact
lens users and 1-3% users of semisoft contact lens. Patient becomes
aware of lens, complains of burning sensation, blurred vision,
intolerance to contact lens, mucinous discharge and drooping of
upper eyelid.
Treatment: Stop using contact lens for at least a few months. Use
lubricating eye drops and diluted steroids, sodium chromoglycate
eye drops and vasoconstrictor eye drops.
5. Traumatic complications: Patient may sustain injury with contact
lens edge or finger nail while inserting or removing the contact lens.
This may cause redness of eyes, watering and FB sensation of eyes.
Treatment: Fluorescein staining should be done and area of injury
should be drawn on prescription slip for future reference. Stop using
contact lens for some time. Remove any eyelash or foreign body
from eye if any. Prescribe antibiotics and lubricating eye drops for
4-5 days.
6. Deposits: They are most common with soft contact lens, more
with extended wear than daily wear and least common with hard
contact lens. Deposits consist of calcium and proteins from tears and
cleaning solutions. Deposits impair oxygen permeability, interfere
with vision. Lens surface becomes irregular and invites infection.
Treatment: Patient should be advised to clean and disinfect contact
lens regularly. Deposit prone patients should be advised to use

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 Contact Lens Practice 151

semisoft lenses instead of soft contact lens and daily wear contact
lens instead of extended wear contact lens.
7. Dessication of cornea: This is due to tear film disturbance caused
by contact lens. Cornea may show 3-9 o’clock and 6 o’clock
staining or dimple staining. Patient complains of redness, irritation,
photophobia and intolerance to contact lens. 3-9 o’clock staining is
caused by thick lens and 6 o’clock staining is caused by incomplete
blinking. Dimple staining is due to tight fitting of contact lens.
Treatment: Use a large lens of less thickness or a soft contact lens.
Stress the need of complete blinking. Fitting of contact lens should
be reassessed.
8. Toxic complications: Certain drugs and preservatives of contact lens
solution like Benzalkonium chloride, Thiomersal, etc. get deposited
on contact lens surface and manifest as toxicity of cornea and
conjunctiva. Patient complains of irritation, photophobia, watering,
pain, etc.
Treatment: Stop using contact lens for sometime. Change contact
lens solution, clean and disinfect contact lens and use lubricating
eye drops.

CONTACT LENS SOLUTIONS

Both soft and semisoft contact lenses require proper solutions for wetting,
soaking and cleaning. Soft contact lens cannot be kept dry and must be
stored in soft contact lens solutions. A contact lens solution is constituted
by three agents namely wetting agent, soaking agent and cleaning agent.
1. Wetting agent: It converts hydrophobic surface of contact lens into
hydrophilic one. It acts as a cushion between lids and contact lens
and contact lens and cornea. It stabilizes CL on finger tip due to
capillarity action. Wetting agent is formed by:
a. Cushioning agent like polyvinyl alcohol
b. Preservatives like benzalkonium chloride and chlorbutanol
c. Wetting agent like polyvinyl alcohol
2. Soaking agent: It keeps the lens in a state of hydration, maintains its
sterility and removes mucus from surface of lens. Soaking agent is
mainly constituted by preservatives like benzalkonium chloride. It
prevents growth of gram +ve and gram –ve bacteria.
3. Cleaning agent: A lens may get contaminated by oil, cosmetics,
dried mucus, foreign body, etc. These things make the lens unfit for
wearing because they irritate the eyes, blur the vision and act as a
nidus for bacterial growth. Thus such a lens needs cleaning by:
a. Friction rubbing: Put the lens on palm with a drop of wetting
agent and rub with finger tip. It can scratch the lens.
b. Spray cleaning: It is done by a specially designed kit.
c. Hydraulic cleaning: It is done by pumping action of water on
contact lens in a special container.
d. Ultrasonic cleaning: It is done by passing ultrasonic waves in a
fluid containing contact lens.

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Index

Page numbers followed by f refer to figure and t refer to table

A Auto-lensometer 30f
Automated perimeter 124, 125f
Absence of Axes
crystalline lens 47 and angles of eyeball 41
iris 141 of eyeball 41f
melanin pigment 141 Axial
Achromatic hypermetropia 46
color vision 128 myopia 44
lens 35
Acquired color blindness 128 B
Advantages of
high index lenses 86 Bacillus stearothermophilus 131
Schiotz tonometer 102 Back vertex power 23
scraping 106 Balance lens 83
semisoft contact lens over soft Base curve 137, 143
contact lens 147 Binocular loupe 97f, 98
Aesthesiometery 107 Bioblique astigmatism 49
Air puff tonometer 103 Bjerum’s screen 124f
Alignment fit 145f Blurring of vision 51
Aluminium 92 Bowman’s membrane 138
Amblyopia 57 Box system 90, 91f
Amsler grid 121, 122f
Anatomy and physiology of cornea C
137
Angle of deviation 14 Carbolic acid 107
Carbon fiber graphite 93
Aniridia 141
Cat eye 89
Aniseikonia 56
Cauterization of ulcers 107
Anisekonia 141
Cellulose acetate 93
Anisometropia 55, 141
butyrate 94, 142
Anisometropic amblyopia 57
Center of curvature 23, 37
Anomalous trichromatic color vision
Central serous retinopathy 109
128 Chromatic aberration 34, 35f
Anti-reflective coating 78, 78f, 84 Ciliary body band 120
Aphakia 52, 61, 141 City university color vision test 128
Apical angle 14 Cleaning of lenses 148
Applanation tonometer 14, 102f Clinical application of
Aqueous layer 140 decentration 28
Argon laser trabeculoplasty 136 gonioscopy 120
Aspheric lens 35f, 87 Color vision 127
Astigmatic fan test 69 Combination of
Astigmatism 141 cylindrical lenses 26, 26f
Asymmetrical aniseikonia 57f lenses 25
Autokeratometer 111f spherical lenses 26f
154 Refraction, Dispensing Optics and Ophthalmic Procedures

Complications of Defective vision 48

contact lens 149 Depth of focus 23
pathological myopia 46 Descemet’s membrane 138
Components of hypermetropia 47 Designs of PAL lenses 77
Compound Dessication of cornea 150
anisometropia 55 Detection of prism 15f
hypermetropic astigmatism 50 Diabetic retinopathy 109
lens 25, 27 Diagnosis of microtropia 14
myopic astigmatism 50 Dichromatic color vision 128
Concave Different types of
lens 24f lenses 21f
diverges rays of light 22f refractive errors 43f
mirror 39f Diffraction 5, 8
Condensing lens 119 Digital tonometry 101
Cone-shaped cornea 141 Dioptre 23
Conflicting shadows 70 Direct
Confrontation method 123 illumination 99, 100
Congenital ophthalmoscopy 115, 116, 117f
color blindness 127 retro illumination 101
myopia 44 Disinfection of contact lens 148
Contact Dispersion 5, 7
lens 48, 53, 56, 84, 141 of light 8f
fitting 144, 145 Distant direct ophthalmoscopy 115,
practice 137 116, 116f
solutions 151 Duochrome test 68
sensitivity 126 Dye tinting 80
chart 126f
Convergence insufficiency 63
E
Conversion table 146t
for Schiotz tonometry 104 Eales’ disease 109
Convex Edridge green lantern test 128
lens 24f Electromagnetic spectrum of light 1f
converges rays of light 22f Endothelium 138
mirrors 37f Epithelium 138
Corneal Ethylene oxide gas 132
astigmatism 50 Executive bifocal lenses 75
scraping 106 Extent of retina 119
topography 113 Eyestrain 48
Cortical aniseikonia 56
Cross compound lens 27 F
Curvature
hypermetropia 47 Far point 59
myopia 44 Fitting
Curved mirror 37, 38f of contact lens 144
Cylindrical lens 24, 27 technique 146
Cystoid macular edema 109 Fixation axis 41
Flat
D fit 145f
fitting 145
Dacryocystography 105 Fluorescein staining 106
D-bifocal lenses 75 Fluorocarbons 142
Decentration of lenses 27 Focal length 23
 Index 155

Foreign body sensation 148 Indirect

Formaldehyde 131 illumination 99, 100
Fornsworth Munsell 100 hue test 128 ophthalmoscopy 115, 118, 119f
Friction rubbing 151 retro illumination 101
Functional hypermetropia 47 Infrared rays 2
Functions of tear film 140 Inheritance of color vision defect 127f
Fundus Insert soft contact lens 146
angiogram 109f Instrumental tonometry 101
camera 108, 108f Interference 5, 9
fluorescein angiography 108 Interpupillary distance 85
photograph 108f IOL implantation 53
Irregular astigmatism 49
G Ishihara charts 128, 128f

Geneva lens measure 114, 114f J

German silver 92
Giant papillary conjunctivitis 150 Jackson’s cross cylinder 68
Glutaraldehyde 131 Javal Schiotz keratometer 110
Goldman applanation tonometry 103
Gonioscope 120f K
Grinding of lens 73, 74f
Keratoconus 141
Keratometer 14, 111f
H Kinetic perimetry 122
Haidinger brushes 15 Kryptok bifocal lenses 75
Hard contact lens 137
Heat L
sterilization 130
Lacrimal syringing 105
treatment 87 Laser
Hemianopic spectacles 15 for DCR surgery 136
Heterophoria 19 for photocoagulation in retinal
Hexa ethyl methacrylate 142 disorders 134
High index lenses 86 for retinal photocoagulation 135f
Hirschberg test 42 in ophthalmology 134
Hot air oven 131 in treatment of malignant glaucoma
Huygens’ principle 4 136
Hydraulic cleaning 151 interferometer 11, 11f
Hydrogen peroxide 131 spots on retina 135f
Hydrophilic IOLs 54 LASIK laser surgery 45
Hyperfluorescence 110 Latent hypermetropia 47
Hypermetropia 20, 43, 46, 48, 141 Laws of reflection 5, 6
Hypofluorescence 110 Lazy eye 57
Left eye suppression 21
I Lenses measurement 91
Lensometer 29f
Identification of lens 25 Lenticular
Illumination system 98 astigmatism 50
Implantable contact lens 46 lenses 87
Incident ray 5 Lipid layer 140
Indentation tonometry 101 Lister’s perimeter 123, 123f
Index Long
hypermetropia 47 face 90
myopia 44 nose 90
156 Refraction, Dispensing Optics and Ophthalmic Procedures

Low Ophthalmoscopy 115

contrast sensitivity 126 Optic 1
vision aids 15, 46 of eye 32
zone diameter 143
M Optical
aberrations of lenses and eyeball
Maddox 34
rod 19 aniseikonia 56
wing 19, 19f axis 41
Management of hypermetropia 48 center of lens 83
Materials used for manufacturing of coherence tomography 114
contact lens 142
Optics of lensometer 29f
Measurement of
Orbscan 114
fusional reserve 14
Ortho-K lenses 48
IPD with IPD ruler 85
Oval face 90
Memory metals 92
Overall diameter 137
Methods of
color vision testing 128 Oxygen
sterilization 130 permeability 143
Methylated spirit 131 supply of cornea 139
Microscopic structure of cornea 139f
Mirror retinoscopes 65 P
Mixed
Pachymeter 121
anisometropia 56
Pantoscopic tilt 75
astigmatism 50
Pantoscopic round oval 89
Moist heat sterilization 131
Paralysis of accommodation 62
Monochromatic color vision 128
Parameters of contact lens 143
Monocular pupillary distance 85
Parts of
Moon-shaped bifocal lenses 75
contact lens 138f
Movements of contact lens 147
Mucin layer 140 slit lamp 98
Myopia 20, 43, 44, 141 Pathological
hypermetropia 47
myopia 44
N scotoma 125
Nagel’s anomaloscope 129 Pentacam 114
Near vision and myopia 58f Peripheral
Negative spherical aberration 34 aberrations 36
Neutralization method 28 curves 137
Nickel silver 92 Periscopic lens 74
Nomenclature of prism 13 Perkin’s tonometer 103
Noncontact tonometer 103 Phakic IOLs 48
Notations of lens 22 Pinhole 20
test 68
O Pinpoint illumination 100
Placement of prism 16, 16f
Oblique astigmatism 49 Plane mirror 37
Observation system 98 Plastic lenses 72
Occlusion therapy 58 Polarization of light 9f
Operating microscope 14 Polaroid lenses 82
Ophthalmic Polyamides 93
lenses 72 Polycarbonate 94, 142
procedures and instruments 97 lenses 73
 Index 157

Polymethyl methacrylate 94, 142 Role of laser in trabeculectomy 136

Precorneal tear film 140, 140f Rolled gold 92
Presbyopia 61, 141 Rotating prism 16
Priestley-Smith mirror 66f Round face 90
Principal axis 22
Prism 13, 14f S
diopter 14
reference point 16 Schiotz tonometer 102f
Procedure of Schwalbe’s line 120, 121
biometry 113f Scissor shadow 70
Schiotz tonometry 101, 103f Scleral spur 120
Progressive addition lens 76, 78f Sclerotic scatter 100
Propagation of light 2, 2f Scotoma 124
Properties of Scotometry 124
contact lens material 142 Second principal focus 22
light 4 Selection of frame 90
Protective lenses 87 Semisoft contact lens 137
Proximal Shapes of frames 88, 89f
convergence 62 Short
illumination 100 nose 90
Pseudo-isochromatic plates 128 sightedness 44
Pseudopapillitis 48 Shot silk retina 48
Pseudophakia 53, 61 Signs of pseudophakia 54
Pupillary axis 41 Silicone rubber 94, 142
Purkinje images 42, 42f Simple
anisometropia 55
R hypermetropia 47
hypermetropic astigmatism 50
Radius of curvature 37
Range of keratometer 111 myopia 44
Recumbent spectacles 15 myopic astigmatism 50
Red green glass 20 transposition 70
Reduced eye 33 Slit lamp 98, 99f
Reflected ray 5 Snell’s law 6
Reflection 4, 5 Soft
Reflection of light 5f, 37 and semisoft contact lens 138f
Refraction 4, 5 contact lens 137
of light 6f, 18 Solid glass tint 80
Refractive Spasm of accommodation 62
corneal surgery 48 Special types of lenses 86
errors 43 Spectacle 48, 56
Regular astigmatism 49 frames 88
Resin lenses 72 Specular reflection 100
Retinal Speed of light 3
aniseikonia 56 Spherical aberration 34, 34f
astigmatism 50 Spray cleaning 151
Retinoscopes 65 Stainless steel 92
Retro illumination 99, 100 Static perimetry 122
Right eye suppression 21 Steep fit 145f
Rims measurement 91 Stenopeic slit 20, 69
 158 Refraction, Dispensing Optics and Ophthalmic Procedures

Stereopsis 119 IOLs 53, 54f

Sterilization 129 lens 21
of instruments 130 myopia 44
of operation theater 132 ophthalmic lens materials 72
of Schiotz tonometer 104 regular astigmatism 49
Stimulus deprivation amblyopia 57 retinoscopy 65
Strabismic amblyopia 57
Straight bifocal 75
Streak retinoscope 66f U
Strum’s conoid 51 Ultrasound biomicroscopy 128
Substancia propria 138 Ultraviolet
Symmetrical aniseikonia 57f A rays 1
Synoptophore 15, 115 B rays 1
C rays 1
T protective glasses 82
Target of keratometer 112f rays 1
Tear film disturbances 142 Uses of
Technique of concave mirror 38
indirect ophthalmoscopy 119 convex mirror 38
slit-lamp examination 99 lens 25
tinting lenses 80 lensometer 30
Temple length 89
Testing of contrast sensitivity 126 V
Titanium 92
Vaso-occlusive disorders 109
Tonometry 101
Vergence of rays 3f
Toric transposition 71
Vertex distance 85
Total
Vertical
hypermetropia 47
internal reflection 5, 7, 7f center line 90
Trabecular meshwork 120 lens size 91
Translucent medium 3 Visual
Transposition of lenses 70 axis 41
Traumatic aphakia 52 field chart 125f
Treatment of V-value constringence 73
amblyopia 57
convergence insufficiency 15 W
diplopia 15
myopia 45 Water
content 143
Trifocal lenses 76
resistant coating 82
Types of
Worth’s four dot test 21, 21f
amblyopia 57
anisometropia 55
astigmatism 49 Y
bifocal lenses 75, 75f YAG
cataract 42 capsulotomy 134
fitting 145f iridotomy 134
frames 89 Young’s double slit experiment 9
hypermetropia 46 Yttrium aluminium garnet 134

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