Optics For The New Millennium

Kamran M.
Riaz
G. Vike Vicente
Daniel Wee
Editors
Optics for the New

Millennium
An Absolute Review Textbook
Foreword by Douglas D. Koch
123
Optics for the New Millennium
Kamran M. Riaz • G. Vike Vicente • Daniel Wee
Editors
Optics for the New

Millennium
An Absolute Review Textbook
Editors
Kamran M. Riaz G. Vike Vicente
Dean McGee Eye Institute Clinical Pediatrics and Ophthalmology
University of Oklahoma Georgetown University Hospital
Oklahoma City, OK, USA Washington, DC, USA
Daniel Wee Eye Doctors of Washington

Center for Sight Chevy Chase, MD, USA
Stockton, CA, USA
ISBN 978-3-030-95250-1 ISBN 978-3-030-95251-8 (eBook)

https://doi.org/10.1007/978-3-030-95251-8
© Springer Nature Switzerland AG 2022

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Foreword
I have news for optics lovers and opticsphobes (my nomination for the 2022 word of the year):
this is a new book on this topic. Some will be excited by this news; (most) others will bemoan
it. In fact, all should welcome it, rush to buy it, and keep it handy for easy study and
reference.
Nothing is more fundamental to our field than optics. It’s everywhere, starting of course
with the eye itself, but including glasses, contacts, prisms, lasers, slit lamp, indirect ophthal-
moscope, indirect lens, cameras, goniolens, retinoscope, microscope, and, my personal favor-
ite, intraocular lenses. A basic knowledge of optics is essential for caring for patients, and
greater knowledge helps us do this even better.
Why a new book on optics? My longtime favorite optics book (if there is such a thing) is
Mel Rubin’s Optics for Clinicians, and Benjamin Milder and Rubin’s companion piece The
Fine Art of Prescribing Glasses without Making a Spectacle of Yourself. Both books make
optics understandable for us nonphysicists, and they do so with elegant explanations and a
warm sense of humor. However, both are outdated in that there is so much new material that is
central to ophthalmic practice.
This three-part volume is elegantly organized as an educational and clinically practical
resource. Part I emphasizes the basics: what one needs to study for written board exams. Part
II deals with topics for preparing for oral boards. But don’t be fooled: each is full of practical
information of great value in the clinic. Examples are superb chapters on astigmatism, accom-
modation and presbyopia, and prisms in Part I, and on refraction pearls, contact lenses, vision
testing, and, for those wait-listed for their SpaceX flight, vision in zero gravity.
The third part concerns optics related to surgery, and it is a wonderful compendium of all
kinds of practical information: biometry, corneal measurements, IOL calculations, postopera-
tive optical issues, and optics of refractive surgery, and it includes a chapter listing all available
IOLs, yes, all in one place.
These parts are long, which is a good thing. Each chapter stands alone as a superb resource
on its topic. Each part can serve as a study guide to be read for the task at hand (written or oral
boards, surgical optics), or one can peruse an individual chapter to get a detailed but eminently
readable discussion on nearly any topic in ophthalmic optics.
Optics for the New Millennium is clearly written, elegantly illustrated, and full of that same
warm humor that Mel Rubin employed, updated to 2022. Drs. Riaz, Vicente, and Wee have
pulled off the huge challenge of providing a wealth of information with a highly entertaining
presentation. Read a chapter, and you will be hooked.
Douglas D. Koch
Houston, TX, USA
12/4/2021 Professor and Allen, Mosbacher
and Law Chair in Ophthalmology
Cullen Eye Institute, Baylor College of Medicine
v
Preface
Perhaps the best way for me to start this book would be with an anecdote: as a distracted medical
student, I often found time (and excuses) to read books outside of medicine. In college, I majored
in Middle Eastern History, and I continued to read books related to this subject during medical
school. I came across a fascinating work, The Book of Optics (Kitāb al-Manāẓir), by Ibn al-
Haytham (965–1039), an Egyptian polymath referred to as “the father of modern optics.” In this
text, the author detailed many Optics subjects, including the camera obscura, intromission theory,
refraction, and reflection. He described the first real appreciation of the action of a convex lens to
produce a magnified image of an object - perhaps a precursor to the dreaded U+D=V equations
now studied by ophthalmology trainees. In this seven volume work, he famously contradicted the
prevailing theories of Euclid and Ptolemy, which stated that vision occurs because of rays of light
emanating from the human eye; instead, he correctly asserted that rays originate from the viewed
object and pass into the eye. I was hooked. Reading this medieval Optics textbook was my “a-ha”
moment: I knew I wanted to become an ophthalmologist.
Perhaps the best way for me to continue this introduction would be an admission. Despite my
initial enthusiasm before residency, I hated Optics as a first-year resident. Like many residents,
I found Optics to be abstruse, boring, and unimportant – instead, I thought to myself: Who cares
about this silly incoming light ray and whether it refracts, diffracts, or reflects? How will that
help my patient with this dense cataract see again? And like many trainees, I didn’t care to study
it much during that first year and instead focused on learning “real” ophthalmology conditions
with vision-threatening implications. Unsurprisingly, on my first-year in-service exam, I got a
10th percentile in Optics. Perhaps my score shouldn’t have been so surprising…
After I received my score, I thought to myself, while I am not the most intelligent person in
the world, this subject can’t be impossible to learn. I realized that the “joy” of Optics that led
me to ophthalmology had been lost somewhere along the way. Unfortunately, there weren’t
many subject resources written for people like myself: people with limited brain cells who
ultimately wanted to know and appreciate why they should care about Optics. I took it upon
myself as a challenge: I wanted to (painstakingly and patiently) read every Optics resource
available and teach myself the subject in a way that made sense to me. In my last year of train-
ing, I was fortunate to have my good friend, Daniel Wee, MD, teach our ophthalmology resi-
dency program Optics, and I started to finally understand Geometric Optics. Shortly after that,
I came across a series of outstanding Optics lectures by my other good friend Vike Vicente,
MD, especially regarding Clinical Optics and Refraction. Both of these finally made the sub-
ject matter understandable to me.
When I began to teach Optics to my junior colleagues, I wanted to distill what I learned into
something beneficial to the next generation of ophthalmologists. Therefore, I adopted a teach-
ing style that maintained the academic integrity of the subject matter, but also heavily incorpo-
rated clinical relevance, surgical applicability, and plenty of humor – mainly to keep my
students awake! Over the years, numerous residents and course attendees encouraged me to
write a text, presented in my teaching style, that combined all the knowledge of Optics needed
for certification exams and clinical/surgical practice into a one-stop-shop text. While many
excellent Optics resources are available, I could not find a single, comprehensive resource that
combined all of this Optics material into a single textbook with sufficient practice questions
vii
viii Preface
that could be used during training and in practice, especially one written in a manner and style
that could educate and engage readers.
In September 2019, I finally decided to attempt this ambitious (and slightly audacious) plan
to create such a work. I also knew that I could not accomplish this on my own, especially not
while maintaining a busy cornea and refractive surgery academic practice. I reached out to
Vike and Danny to see if they would be interested (and crazy enough) to join me on this chal-
lenging (and perhaps Quixotic) project to write such a book – an optics textbook for the new
millennium. Amazingly they were crazy enough to agree. Their contributions to this project go
beyond simply writing words and drawing images – while many words can be said regarding
how thankful I am to both of them for saying yes, I can say with all sincerity that this work
would have never been possible without their agreeing to be my partners in crime. Since this
book is our group effort, I will now intentionally switch from the first-person singular tense
into a first-person plural tense for the rest of these opening comments.
What we present here is a textbook that embodies our teaching philosophy toward Optics:
through our irreverence, we hope to show our reverence for the subject matter so that our stu-
dents will similarly appreciate how Optics permeates every facet of ophthalmology and learn
something along the way. We want our readers to learn Optics to pass their certification exams
but, more importantly, to deliver excellent care to their patients. Thus, while there are many
tongue-in-cheek jokes and humor (liberally) sprinkled throughout the text, we have not sacri-
ficed the scientific accuracy of the material. While it may also seem that this book is meant to
entertain (which we freely acknowledge), the primary goal of our work is to educate, espe-
cially through its holistic presentation of “exam-based” and “practice-based” Optics.
In this Optics textbook, we have attempted to maintain the content found in other books
historically, but we have also intentionally changed the context in which it has traditionally
been presented. We want this to be a resource that trainees will use early in their careers, and
one that seasoned practitioners will find useful for their day-to-day care of patients. Thus, we
have intentionally made this book into a relatively large, singular compendium of Optics infor-
mation. We hope that readers will find specific chapters of this “one-stop-shop” book of greater
interest depending on their training level, upcoming exam preparations, and/or primer for
clinical and surgical practice. Whether you are a first-year resident wanting to learn about
U+D=V or an experienced practitioner wanting to know about IOL calculation formulas, we
think this book is valuable for both kinds of readers – and if you read this book carefully, you
will see how both U+D=V and IOL formulas are intimately connected.
We are thankful to a number of people (listed in more detail in the Acknowledgments), but
perhaps, strangely enough, we are especially grateful for our health and opportunity during the
Great Quarantine of 2020 during the COVID-19 pandemic to be able to dedicate time and
effort toward the writing of this book. Since we did not have much to do while bunkered in our
homes, we were able to have an opportunity to work on this Optics textbook. This relationship
between quarantine and Optics is not a first: fittingly, the social distancing during the Great
Quarantine of 1665 allowed Sir Isaac Newton to embark upon a “year of wonders,” including
exploring Optics and experimenting with prisms and refraction. Similarly, Ibn al-Haytham
wrote his Optics magnum opus while under political quarantine (house arrest) for nearly a
decade. We do not suppose our work will be nearly as influential as Newton’s or Ibn al-Hay-
tham’s, but nonetheless, we whimsically observe the historical similarity of our situation
350 years later. We hope that our book is some small measure of good that comes out of this
troubling time. On a more solemn note, it is also why we dedicate our work to the memory of
every single human life lost during the COVID-19 pandemic worldwide.
We hope that you, dear reader, not only enjoy reading this book but can use this knowledge to
better care for your patients. The knowledge that our work may help you improve the vision and
lives of our fellow human beings is comforting. We hope we have continued the legacy of Ibn
al-Haytham and Newton for this new millennium and a new generation of Optics enthusiasts.
Oklahoma City, OK, USA Kamran M. Riaz

Acknowledgments
Through our work, we also hope to show our admiration for our many teachers and mentors
that have taught us Optics through their lectures, papers, and generous mentorship over the
years. We would be remiss not to recognize some of them at the very least: David Guyton, MD,
David Hunter, MD, Constance West, MD, Surendra Basti, MD, and Douglas Koch, MD. We
are also profoundly grateful and thoroughly indebted to the countless students, residents, and
colleagues we have met at various conferences, review courses, academic institutions, and
even online, who have provided feedback, encouragement, suggestions, and criticism (con-
structive and otherwise!) over the years to improve our manuscript.
The following residents and trainees deserve special recognition for serving as beta-testers
and providing valuable suggestions as we wrote the text. They deserve particular recognition
for sacrificing valuable time during training to participate in this work:
1. Karl Becker, MD – Cook County/Stroger Hospital, Chicago, IL

2. Kristen Collister, MD – Dean McGee Eye Institute
3. David A. Murphy, MD – Dean McGee Eye Institute
4. Casey Smith, MD – University of Tennessee
5. Jacob Warmath, MD – Dean McGee Eye Institute
6. Asher Khan, MS4 – University of Oklahoma Medical School
The following colleagues similarly deserve acknowledgment for their critical review and
expertise in improving the text:
1. David L. Cooke, MD – Great Lakes Eye Care, St. Joseph, MI

2. Andrew T. Melson, MD – Assistant Professor, Dean McGee Eye Institute
3. Andrew Hou, MD – Cornea Fellow, Dean McGee Eye Institute
4. Rachel M. Caywood, OD, FAAO – Dean McGee Eye Institute
5. M. Edward Wilson, MD – Medical University of South Carolina
6. Thomas Clinch, MD – Eye Doctors of Washington, MD
7. Belinda Weinberg, OD – Washington DC
8. Suleiman Alibhai, OD – Washington DC
We would also like to thank everyone at SpringerNature Publishing, especially Mariah

Gumpert, Asja Rehse, and Michelle Tam for their editorial assistance with the production of
this work. We also want to acknowledge Jeffrey Taub and Vinodh Thomas (and their respective
teams) for proofreading and typesetting. Most publishers would have rejected and balked at the
idea of this kind of textbook. Some did. Thank you for taking a chance on this crazy project.
Individually, the editors would like to thank:
I would like to thank my teachers and mentors who shared their love of optics and teaching:
Dr. David Hunter, who passed a torch of teaching; Dr. Dave Guyton, who was never tired of
answering my questions at conferences and emails; and Dr. Connie West, for great teaching
gigs. I would like to thank my wife Wendy for supporting me, and my sons Mark and Peter for
allowing me to share the magic of light and physics on the back of many napkins.
ix
x Acknowledgments
– Vike Vicente
I’d like to thank my older brother, Ray (also ophtho), for telling me to get off my butt at the
end of medical school and start learning optics. It gave me a huge head start heading into my
ophthalmology residency. I’d like to thank the various ophthalmology residents and attendings
at the University of South Carolina, Northwestern University, and the University of Arizona for
allowing me to teach. I’m extremely grateful to Kamran and Vike for inviting me to be a part
of this book. Finally, I’d like to thank my wife, Lydia, and my kids, Nolan and Kyla, for their
unconditional love and support.
– Daniel Wee
I am grateful to my family for their support and patience over these past two years, espe-
cially my wife, Sanaa, and my three kids, Rabiyah, Nabeel, and Zaynab, for giving me the
time, freedom, and encouragement (along with peace and quiet) to embark upon, continue, and
finish this laborious project. I am also thankful to the wonderful folks at the Osler Institute for
allowing me to teach at the written and oral board review courses. They took a chance on a
novice lecturer in 2015 and allowed me to develop my teaching style while helping hundreds
of my colleagues pass their certification exams. I suppose I should also be thankful to several
people in the world of ophthalmology who doubted my abilities, questioned if I “belonged”,
and actively sought to hinder my academic career. Thank you for doubting me; I have chan-
neled that into a relentless desire to work harder and have realized that the best revenge is liv-
ing well. Finally, I dedicate this work to my mother, Fahmeeda Begum, MD, who initially
matched into ophthalmology but decided she wanted something more challenging and had a
brilliant career as an endocrinologist. You are the reason why I chose my career path so that
someday I could be as fractionally good, as a clinician and as a person, as you.
– Kamran Riaz
Contents
Part I Ophthalmic Optics for Written Exams
Geometric Optics �� 3

Kamran M. Riaz

Prisms in Ophthalmic Optics�� 15
G. Vike Vicente
Lenses�� 33
Daniel Wee

Mirrors and Combined Systems�� 49
Daniel Wee

Power of Lenses in Different Media �� 69
Kamran M. Riaz
Lens Effectivity�� 77
Kamran M. Riaz
Schematic Eye�� 85
Daniel Wee
Magnification and Telescopes �� 91
G. Vike Vicente
Accommodation and Presbyopia�� 111
G. Vike Vicente
Spherocylindrical Lenses�� 119
Kamran M. Riaz
Astigmatism�� 153
Daniel Wee
Glasses for Written Exams�� 167
G. Vike Vicente

Contact Lenses for Written Exams�� 177
G. Vike Vicente and Kamran M. Riaz

Physical Optics and Advanced Optical Principles�� 185
Part II Optics for Oral Exams and Clinical Practice

Glasses in Clinical Practice �� 219
Kamran M. Riaz
xi
xii Contents

Construction of Glasses (Ophthalmologists as Opticians) �� 229
Kamran M. Riaz

Optical Instruments and Machines�� 243
G. Vike Vicente
Visual Acuity Testing and Assessment�� 277
Kamran M. Riaz
Low Vision and Vision Rehabilitation�� 297
G. Vike Vicente

Contact Lenses in Clinical Practice�� 309
J. Scott Samples and Kamran M. Riaz

Clinical Problems with Optics and Refractive Manifestations�� 323
Daniel Wee and G. Vike Vicente

Optics for Clinical and Surgical Management of Strabismus �� 339
G. Vike Vicente
Pediatric Optics�� 349
G. Vike Vicente
Myopia Control�� 357
G. Vike Vicente

Optics in Micro-Gravity and Zero-Gravity Conditions �� 365
Shehzad Y. Batliwala and Kamran M. Riaz
Part III Optics for Surgical Practice

Preoperative Optics for Cataract Surgery�� 373
Kamran M. Riaz

What’s on the Menu: An Overview of Currently Available IOLs
and Relevant Optics �� 397
Kamran M. Riaz

Intraoperative Optics for Cataract Surgery�� 415
Kamran M. Riaz

Postoperative Optics for Cataract Surgery �� 425
Kamran M. Riaz

Optics for Refractive Surgery �� 439
Kamran M. Riaz
References, Suggested Reading, and Online Sources �� 459
Index�� 461
Contributors
Shehzad Y. Batliwala, DO Department of Ophthalmology, Dean McGee Eye Institute,

Oklahoma City, OK, USA
Kamran M. Riaz, MD Dean McGee Eye Institute, University of Oklahoma, Oklahoma City,
OK, USA
J. Scott Samples, NCLE-AC Contact Lens, Dean McGee Eye Institute, Oklahoma City, OK,
USA
Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, OK, USA
G. Vike Vicente Clinical Pediatrics and Ophthalmology, Georgetown University Hospital,
Washington, DC, USA
Eye Doctors of Washington, Chevy Chase, MD, USA
Daniel Wee, MD Center for Sight, Stockton, CA, USA
xiii
Part I
Ophthalmic Optics for Written Exams
Geometric Optics
Kamran M. Riaz
Objectives lines (linear rays) (Fig. 1).1 This is also referred to as a “pen-

• To define and understand terminology used in Geometric cil” of light rays, even though no actual pencil that you can
Optics regarding: write with exists. The principles we will discuss in this chap-
–– Path of light rays ter will allow us to later discuss other topics, such as prisms,
–– Index of refraction lenses, and mirrors.
–– Divergent, parallel, and convergent light rays Finally, given the amount of time we will spend on this
• To define, understand, and give clinical examples of: world, it may also feel like we will age 20 years while doing
–– Refraction Geometric Optics.
Distortion and dispersion We will also make several other assumptions that we will
–– Reflection (including total internal reflection) point out as we discuss additional topics.
–– Diffraction
Light Rays in Geometric Optics

Introduction
A reality on this planet of Geometric Optics is that these lin-
When we consider Ophthalmic Optics as a universe, we can ear light rays do not like each other: They are naturally diver-
imagine the various types of optics, such as Geometric gent (mathematically represented as having negative
Optics, Physical Optics, and Quantum Optics, as different vergence), trying to get away from their neighbors as fast as
planets within this universe. If you have seen the movie
Interstellar (2014), then you may remember how each planet Chaps. 1-13 “Geometric Optics”, “Prisms in Ophthalmic Optics”,
1
has its unique rules and circumstances. For example, time “Lenses”, “Mirrors and Combined Systems”, “Power of Lenses in
Different Media”, “Lens Effectivity”, “Schematic Eye”, “Magnification
runs differently on the water planet and gravity functions dif-
and Telescopes”, “Accommodation and Presbyopia”, “Spherocylindrical
ferently on the ice planet. Lenses”, “Astigmatism”, “Glasses for Written Exams”, and “Contact
When studying Ophthalmic Optics for the purposes of Lenses for Written Exams” of this book will primarily discuss princi-
written examinations, we will spend the majority of our time ples within Geometric Optics. Chap. 14, “Physical Optics”, will discuss
light in other forms, such as waves and particles. Quantum electrody-
in the world of Geometric Optics. There are several rules we
namics, which is the most comprehensive theory of light, unifying mac-
must follow and several assumptions that we will make on roscopic and microscopic properties of light, is (thankfully) beyond the
this planet, the foremost being that light travels in straight scope of this book.
K. M. Riaz (*)
Dean McGee Eye Institute, University of Oklahoma,
© Springer Nature Switzerland AG 2022 3

K. M. Riaz et al. (eds.), Optics for the New Millennium, https://doi.org/10.1007/978-3-030-95251-8_1
4 K. M. Riaz
can see all three types of light rays when a pencil of light
encounters an aperture (Fig. 2).
When light rays are traveling along peacefully in a
medium, they may do one of the above three actions.
However, when they encounter an object, one or more things
may occur:
• Refraction
–– Distortion
–– Dispersion
• Reflection
• Absorption
• Diffraction
• Scattering
• Polarization
For our purposes in this chapter, we will further discuss

the first four of the above concepts in the next sec-
tions. Discussions pertaining to diffraction, scattering,
and polarization can be found in Chap. 14, Physical
Optics.
Refractive Index
Fig. 1 Light travels in linear rays in all directions in the world of
Geometric Optics Light rays will always travel the fastest in a vacuum (approx-
imately 300,000,000 m/s). We can compare this speed to
they can.2 However, if we operated with this understanding, other common materials, such as water, aqueous, and the
then we could not solve any Geometric Optics problems crystalline lens. The refractive index (n) is simply the ratio of
(which you might argue is a wonderful thing), so therefore the speed of light in a vacuum compared to the speed of light
we have to make another assumption: These divergent light in a given material. Since light travels faster in a vacuum, n
rays are also parallel (when originating from an extremely is always >1.
far away distance, which we refer to as “infinity”), which is We will discuss how changing the index of refraction can
an assumption we will make when we solve problems, such affect the power of lenses in Chap. 5.
as object–lens systems and Prentice’s Rule type of
problems.
Another assumption we will make is that light rays will Refraction
always travel from “left” to “right” when we draw these
problems out. As seen in the candle light figure above, light Refraction simply means that when light rays pass from one
travels in all directions, but for now, we will draw out most medium into another medium, the original path of traveling
problems with light rays coming in from the left side of the gets bent in a different direction. Technically, there is also a
diagram. However, the paths of light rays are reversible, and change in direction in waves as they pass from one medium
we will sometimes need to do this to understand why images into another, accompanied by a change in speed and wave-
form in a particular location, for example. length of the light ray. We are simplifying this phenomenon
Finally, when linear light rays get affected by an external and rebranding this as “bending of light rays.” The quality
source (e.g., a plus power lens), then some of these light rays and quantity of this bending depend on several factors, such
are considered to be convergent (mathematically represented as the type of medium (index of refraction) and the surface or
as having positive vergence) (Fig. 2). For completeness, barrier that the light ray encounters (e.g., a converging lens
external sources may also cause parallel rays to diverge, such vs. a diverging lens).
as when light rays pass through a minus-powered lens. We Snell’s Law of Refraction is a valuable tool to quantify
how strongly a ray of light is refracted (bent) when passing
In other words, light rays are good at practicing social distancing
2 from one material to another. In other words, this law will
guidelines. give us information about the angle at which an incoming
Geometric Optics 5
b c d
Fig. 2 Panel a shows a pencil of light rays as it approaches an opening. At the opening, three different kinds of light rays may be seen: divergent
light rays (Panel b), parallel light rays (Panel c), and convergent light rays (Panel d)
light ray, after passing through the medium, exits that par- two mediums, there will be an increasing amount of refrac-
ticular medium. Snell’s Law is defined as follows: tion when a light ray passes from a medium of lower index of
refraction through a medium of higher index of refraction.
n sin φ = n′ sin φ ′.
Refraction not only occurs throughout Geometric Optics
The above equation simply states that if we know the 1) index but also has clinical relevance. Spherical eyeglasses and
of refraction of the first medium (n), 2) the angle at which the prisms used to quantify strabismus are two examples of
light ray strikes the medium (ɸ), and 3) the index of refraction refraction used in clinical practice. These topics will be dis-
of the second medium (n’), then we can determine the angle at cussed in greater detail in their respective sections.
which the light ray will exit the medium (ɸ’). Of course, we can Two other concepts are related to refraction: distortion
also solve any of the four variables used in the above equation if and dispersion.
we have information about the other three variables. Distortion refers to the visual perception of an observer to
At this point, you may be freaking out because the above refracted light rays. We can see the effects of distortion when
equation brings back awful memories of high school geometry a straw is placed in a glass of water (Fig. 4). To an observer,
and scientific calculators! The good news is that you will never the image of the straw above the water appears to be different
be asked to calculate this equation – remember that you will than the image seen below the water. This “distortion” is how
not be given access to a calculator for exams, so no one will the observer has perceived the refraction occurring at the air–
ever expect you to do this trigonometry math in your head. water interface.
Instead, we can focus on the critical lessons from Snell’s Law. A classic example often used in many optics textbooks is
One lesson is that light rays that travel from a lower refractive the “fisherman scenario.” The unfortunate fisherman is usu-
index medium (e.g., air, n = 1.0) into a higher refractive index ally standing at the edge of a pier (or rock) with a spear (why
medium (e.g., water, n = 1.33) will refract (be bent) toward the a spear, why not a fishing rod and line or even a net like a
norm. The norm is an artificially constructed line perpendicular to normal person?) and sees a fish in the water. Whereas you,
the interface between the two mediums, as seen in Fig. 3. A sec- dear reader, may need to know optics to pass your examina-
ond lesson is that light rays that travel through a medium of higher tions, he must rely on his knowledge of optics so that he can
refractive index and then encounter a medium of a lower refrac- catch his dinner (Fig. 5).
tive index will be bent away from the norm. The question that is typically asked in this scenario is as
The take-home message from Snell’s Law is that with an follows: Where must the fisherman throw his spear to hit the
increasing difference between two indices of refraction of fish? This question also assumes the fisherman is a world-
6 K. M. Riaz
Fig. 3 Light rays entering a material with a higher refractive index will be bent toward the norm (left panel). Light rays entering a material with
a lower refractive index will be bent away from the norm (right panel)
class swimmer and diver because he then has to find his

speared fish in the water, but no one ever seems to ask
these important details on examinations.
Usually, you will be given several options in regards to
where the fisherman should throw his spear (Fig. 5):
• In front of the fish (relative to the fisherman)—i.e., to the

left of the fish (the “left” is relative to you as the reader
observing the diagram) (Choice A).
• Directly at the fish—i.e., at the exact spot in the water
where he sees the fish (Choice B).
• Behind the fish (relative to the fisherman)—i.e., to the
right of the fish (the “right” is relative to you as the reader
observing the diagram) (Choice C).
The key to solving this problem is to recall your knowl-

edge of the previous discussion. Since light rays emanating
from the fish will strike the water–air interface, they are
going from a medium of higher refractive index into one
Fig. 4 Principle of distortion. To an observer, the refraction that occurs with a lower refractive index. Since these light rays will
at the air–water interface will cause the image of the straw above the
water to appear different than the image of the straw below the water refract (bend) away from the normal, for the fisherman, the
(left panel). From a bird’s eye view (right panel), due to the higher actual fish will be “in front” (i.e., to the left to you as the
index of refraction, light rays (red arrow) emanating from the object reader looking at the diagram) of where he is “seeing it.”
(the straw) will reach the air–water interface and will bend away from Therefore, if he wants to catch his dinner, he must use this
the normal. This causes the rays to appear to be coming from further to
the right (left panel) knowledge of optics and throw his spear at point A (Fig. 6).
Geometric Optics 7
Fig. 5 The fisherman is

hungry for his dinner. The
image of the fish is what the
fisherman sees. Where is the
real fish? Should the
fisherman aim at A, B, or C?
Fig. 6 The fisherman catches

his dinner, and you score a
few points in optics. The
fisherman should aim at
A. Light rays coming from
the real fish will refract (bend)
away from the norm as they
enter air (a medium with a
lower index of refraction).
From the fisherman’s point of A B C
view, the image will appear to
be coming from behind the
fish
Real fish Image seen by fisherman
He should also tie a rope to his spear so that it is easily of these lenses will be refracted differently than light rays
retrievable from the water without diving into the lake. that pass through the center of the lens.
Technically, distortion is a subset of optical aberrations, For minus lenses, because the edge of the lens is thicker
which will be discussed later, but it may be helpful to under- than the center, image magnification will decrease further
stand some elementary principles of this concept under the away from the optical center, such that the image at the edge
discussion of refraction. of a minus lens will appear to have been “wrapped” around a
One clinically relevant area (also relevant for test pur- sphere or a barrel (“barrel distortion”) (Fig. 7). For plus
poses) is the concept of barrel distortion and pincushion dis- lenses, image magnification will increase further away from
tortion, which occur with minus lenses and plus lenses, the optical center, such that the image of the edge of a plus
respectively. You can remember this with the mnemonic plus lens will appear to be stretched out toward the periphery
lens = pincushion distortion. We will discuss the differences (“pincushion distortion”) (Fig. 7). We will discuss this topic
between plus and minus lenses later, but for now, you should in greater detail in the section on troubleshooting glasses in
know that the edge of a plus or minus lens is very different patients (see Chap. 16, “Construction of Glasses:
from the optical center of the lens. Specifically, a minus lens Ophthalmologists as Opticians”).
is much thicker at the edges (compared to the center), and a Dispersion occurs whenever light rays undergo refrac-
plus lens is much thinner at the edges (compared to the cen- tion. Specifically, dispersion refers to the change in the angle
ter). Therefore, light rays that pass through the edge of each of refraction of the individual colors of light that comprises a
8 K. M. Riaz
Fig. 7 An observer looking

through a high-powered
minus lens may report a barrel
distortion (left panel),
whereas an observer looking
through a high-powered plus
lens may report a pincushion
distortion (right panel).
Remember, plus
lens = pincushion distortion
retina. Since we have to accommodate (generate plus power)

in order to see any red text (since usually, those light rays
will fall behind the retina), when both red and blue text are
placed side by side, the brain will have to accommodate in
order to see the red and then relax accommodation to see the
blue text. As a result, the brain will falsely think that the red
text is closer than the blue text!
Every material has an amount of dispersion known as the
Fig. 8 Dispersion: When a light ray gets refracted, its individual colors
will also get refracted according to the frequency of that particular Abbe number (aka the V-number). The higher the Abbe num-
color. Therefore, blue light rays will be dispersed more than red light ber, the lower the chromatic aberration in that particular
rays. This concept is a foundation for understanding chromatic material and vice versa. Chromatic aberration has clinical
aberration relevance when discussing the construction of glasses. For
example, it is advantageous to use lens materials with high
“white” light ray. The frequency of a given component of the Abbe number values to minimize the adverse effects of chro-
light ray will determine how much dispersion occurs—the matic aberration. We will discuss this further in Chap. 16,
higher the frequency, the more dispersion of that particular “Construction of Glasses: Ophthalmologists as Opticians”.
color will occur. For example, blue light, which has the high-
est frequency (and therefore the lowest wavelength), under-
goes the most refraction (bending), whereas red light Reflection
undergoes the least. A useful mnemonic to remember is that
blue light rays will get bent the most, whereas red light rays We can begin our discussion on reflection by first introduc-
are rarely bent (Fig. 8). This principle is a useful foundation ing this concept with a plano (flat, not curved) mirror, such as
for understanding the more clinically and surgically relevant the one you used this morning while brushing your teeth and
concept of chromatic aberration, which will be discussed in preparing yourself to study Geometric Optics.4 In a plano
Chap. 14, “Physical Optics”.3 mirror, every single incoming light ray is “bounced back”
If blue text and red text are both placed against a dark or away from the mirror’s surface; none of the incoming light
black background, then an interesting phenomenon known rays are “refracting” through the mirror (and into the wall).
as chromostereopsis occurs. This visual illusion causes the Think of reflection as the term used to describe how some
brain to perceive depth when viewing a two-dimensional incoming light rays will bounce back from the optical
color image, usually blue-red images. Chromatic aberration interface.
effects will cause the brain to view the red portion of the text/ As discussed in the previous section, some light rays will
image as “closer” to you as the observer than the blue. be refracted when they encounter an optical interface.
Remember that the “red” rays normally land “behind” the However, some of the light rays will also be reflected, as in
retina, and the “blue” rays normally land “in front of” the the case of the plano mirror. We can be a bit more sophisti-
cated than simply stating reflection is the “bouncing” back
When incoming light encounters water molecules, for example, dis-
3
persion and scattering help explain why the colors of the rainbow form. See Chap. 4 “Mirrors and Combined Systems” for a more detailed dis-
4
We will discuss scattering more in Chap. 14, “Physical Optics”. cussion of mirrors, including plano and curved mirrors.
Geometric Optics 9
Barrier Surface Normal

Re Reflected light ray
r t f
en
e
Incoming light ray an lect
rri
c i d
Ba
(incident light ray) n l e g e

I ng le d
a
i r
Optical Interface
t
Refracted light ray

Fig. 9 Reflection. An incident light ray (yellow arrow) will bounce off c t ed (transmitted light ray)
fle
the barrier (reflection) at an angle equal to the incoming angle (left Re ngle
A
panel). Reflected light rays (red arrows) from opposite angles may con-
verge at a location known as the focal point (blue dot right panel)
Fig. 10 Whenever reflection occurs at an optical interface (e.g., air–
water), light rays that are reflected (θr) will have the same outgoing
angle as the incoming angle of the incoming light ray (θi). The refracted
action of incoming light rays: reflection refers to the change (transmitted) light ray (θt) will have an outgoing angle less than the
in direction of light rays such that the angle at which incident incoming angle if the second medium is denser than the first
light rays approach a medium will equal the angle at which
they reflect away from the medium (Fig. 9). The second 2
medium is essentially a barrier through which light rays can- n2 – n1
R
not penetrate. In other words, when light rays approach a n2 + n 1
barrier and instead of passing through (refraction), they
bounce off the barrier (reflection). Depending on the barri- Fig. 11 This scary-looking equation, known as the reflection coeffi-
er’s geometry reflected light rays from opposite angles will cient, can be used to calculate the amount of light reflected at an optical
then converge at a single location known as the focal point interface. Believe it or not, it actually has some clinical relevance when
understanding topics such as dysphotopsias!
(Fig. 9).
Furthermore, there are two different types of reflection
that you may wish to know. Specular reflection is when light used acrylic IOLs (n = 1.47–1.55) is significantly higher than
reflects in a single direction (as seen in clinical practice when the index of refraction of aqueous (n = 1.33). Interestingly,
using specular reflection as an illumination strategy during dysphotopsias are almost never seen with silicone IOLs
slit-lamp examination), and diffuse reflection, wherein light (n = 1.39), perhaps because there is less refraction of light as
reflects in many directions off a given barrier. it passes from the aqueous through the silicone IOL.5
The law of reflection states that the incident ray (incom- The concept of reflection may additionally play a role in
ing ray) and the reflected ray (outgoing ray) will lie in the developing dysphotopsias. For example, the reflection coef-
same plane as the surface normal, which means both rays ficient can help us understand one potential contributing fac-
will have the same angle with respect to the surface normal tor to the development of dysphotopsia after cataract surgery,
(Fig. 10). We can compare the angle of reflection to the pre- especially in the current age of acrylic IOLs (that have a high
viously discussed angle of refraction (transmission). index of refraction). We can see this with an example com-
Why do we care about this? The amount of light reflected paring the amount of reflection that takes place with a sili-
from a surface is related to the incoming angle and the two cone IOL (n = 1.43) and an acrylic IOL (n = 1.55).6 Since the
media. We can use the reflection coefficient to calculate the IOLs are bathed in aqueous, we will use n1 for both IOLs as
amount of light transmitted at an optical interface during 1.33. Do not worry about solving the math here; instead,
reflection as follows (Fig. 11) focus on the results from these calculations:
Do the previous discussions on refraction and reflection
have any clinical relevance? Yes.
One area of clinical relevance is the recent interest in the
phenomenon of dysphotopsias after cataract surgery. While
this will be discussed in further detail in the section on post- Masket S, Fram NR. Pseudophakic Dysphotopsia: Review of
5
Incidence, Cause, and Treatment of Positive and Negative Dysphotopsia.

cataract surgery (Chap. 29, “Postoperative Optics for
Ophthalmology. 2020 Aug 12:S0161–6420(20)30787–9.
Cataract Surgery”), one potential contributing factor toward
Depending on the acrylic used in popular acrylic IOLs, the index of
6
dysphotopsias may be explained by Snell’s Law of refraction may range from 1.47 to 1.55, as per manufacturer product
Refraction. The index of refraction for most of the popularly inserts.
10 K. M. Riaz
that approaches the interface with an angle that equals the

 (1.43 − 1.33) 
2
Reflection for silicone IOL =   critical angle will neither get refracted nor get reflected, but
 (1.43 + 1.33)  instead will undergo absorption (which is energy lost as heat,
= 0.001313 = 0.1313% which is negligible for the purposes of Ophthalmic Optics
and you should not waste brain cells on this any further).
 (1.55 − 1.33)  Every material has its respective angle that is unique for
2
Reflection for acrylic IOL =   that material. You may wish to memorize that ordinary glass
 (1.55 + 1.33) 
has a critical angle of 41 degrees, but do not waste time
= 0.005835 = 0.5835% knowing the values of various critical angles for different
media.
The preceding fancy math tells us that an acrylic IOL is Let us use a silly metaphor to drive this home further.
0.5835/0.1313 = 4.44 times more reflective than a silicone Think of light rays as a bunch of senior high school students
IOL. This means that up to 4 times the number of light rays attempting to have a class ditch day. Those students who can
that strike an acrylic IOL are reflected (away) from the IOL approach the school exits and avoid detection by the hallway
compared to a silicone IOL, leading to fewer light rays monitors at less than the critical angle will be able to escape
reaching the retina. The increased reflection may be one rea- (i.e., refraction occurs). However, those students who
son why an acrylic IOL has much higher rates of dysphotop- approach at an angle that the hallway monitors can see them
sia (especially negative dysphotopsia) than a silicone IOL. will not be able to escape and will be made to stay in the
school (i.e., reflection occurs).
Where is this clinically relevant? In clinical examination
Critical Angle and Total Internal Reflection of the anterior chamber angle for most eyes (i.e., excluding
pathologic myopes, megalocorneas, or ectatic corneas), it is
When light rays encounter a barrier, both refraction and impossible to visualize the anterior chamber angle because
reflection will occur, based on the incident angle at which a light rays that emerge from the angle are greater than the
given light ray approaches the barrier. When considering critical angle. These light rays are not refracted and instead
light rays that pass from a medium with higher index of undergo total internal reflection and are reflected into the
refraction (e.g., water) into a medium with lower index of anterior chamber at the air–tear film interface.
refraction (e.g., air), the concept of the critical angle states Gonioscopy allows us to bypass the tear film–air (1.33–
that when incident light rays approach a barrier at any angle 1.00) interface that the emerging light rays from the anterior
less than the critical angle, these light rays will get refracted— chamber angle cannot penetrate by creating a “water–water
i.e., they will pass through the medium, get bent, and emerge interface” (1.33–1.33; the lens also has an index of refrac-
on the other side. When incident light rays approach a barrier tion, but for our discussion we can ignore it) when the lens is
at any angle greater than the critical angle, these light rays placed on the cornea (Fig. 13). Light rays from the angle are
will get reflected—i.e., they will not pass through the medium no longer reflected and instead refracted at this new inter-
and instead will be bent back into the original medium face, thereby reaching the examiner’s eye and allowing for
(Fig. 12). For the sake of completion, an incident light ray examination of the anterior chamber angle structures. For
Fig. 12 Incident light rays

(red arrow) that approach a
barrier at an angle less than
the critical angle will undergo
refraction. Incident light rays
(yellow arrow) that approach
a barrier at an angle greater Refracted
than the critical angle will ray
undergo reflection Air
Water
Reflected
ray
l
tica
Cri le
an g
Geometric Optics 11
The amount of diffraction increases with an increasing

wavelength of light and decreases with a decreasing wave-
length of light. If the wavelength of the waves is smaller than
the obstacle, then no noticeable diffraction occurs.
In clinical practice, diffraction occurs at the circular edges
water of a pupil; in other words, some of the light rays that cannot
air get “through” the edge of the pupil will find a way to re-
water water direct themselves to get through the pupil. When a point
source of light travels through the circular pupil, the image
formed on the retina is a bright central disk known as the
Airy disc (Fig. 15).
Fig. 13 Gonioscopy allows the examiner to replace the air–water inter- The Airy disc will have bright and dark rings (Airy pat-
face with a water–water interface, thereby allowing light from the ante- tern). The diameter of the Airy disc can be calculated by a
rior chamber angle to undergo refraction and reach the examiner’s eye
disgusting looking equation:
d = (2.44 ∗ λ ∗ D) /f
bonus points, you may wish to memorize that the critical
angle between air and aqueous is approximately 48.6°.7 (d is the diameter of the disk; λ is the wavelength of light
Total internal reflection is all around us—it is used in passing through the pupil; “D” is the exit pupil diameter; and
fiber-optic cables, binoculars, and even the slit-lamp. You “f” is the focal length of the optical system (in this case, the
cannot escape optics no matter how much you try. eye)).
If we keep “D” constant, then we can see that longer
wavelengths (λ) of light (e.g., red wavelengths) will have
Diffraction more diffraction through the pupil as compared to shorter
(e.g., yellow wavelengths) of light. Also, diffraction will
Technically, diffraction does not occur in the planet of limit visual acuity if a patient’s pupil size is below 2.5 mm
Geometric Optics, but rather in the planet of Physical Optics due to the Airy disk principle.
(Chap. 14) as it deals with light traveling in waves, rather Diffraction is also applicable when discussing the pinhole
than rays. However, since diffraction bears significant rele- test used in the clinical setting. When a patient looks through
vance in clinical practice, it may be helpful to discuss this the pinhole, we have limited the light rays entering the eye to
concept in light of (pun-intended) the previous discussions only those light rays that enter the eye perpendicular to the
on refraction and reflection. cornea and lens (i.e., we have eliminated light rays that get
In addition to refraction, reflection, and absorption, light refracted (bent)). In theory, a very tiny pinhole would be the
that encounters an opening or barrier in its path will most effective optical opening because it would only allow
also undergo diffraction, which is a change in the direction of unrefracted light rays to reach the eye. However, diffraction
light waves to get through the opening or around the barrier limits the effect of the pinhole because the smaller the pin-
(Fig. 14). The figure below shows light waves that encounter hole, the greater number of unrefracted rays (proportionally)
water droplets (as in a cloud): some of these waves will will hit the edge of the pinhole and undergo diffrac-
refract through (or reflect away from) the water droplet, but tion. Basically, there is a “sweet spot” for the pinhole to have
other waves will find a path around the droplet through the the maximum effect of testing a patient’s visual potential:
gaps between the droplets. 1.2 mm. At this diameter, the beneficial effects of the pinhole
Similarly, light waves that encounter a barrier with a (allowing in only the unrefracted rays) will outweigh the
small opening will pass through the opening and emerge as negative effects of diffraction. If we use a smaller pinhole,
waves (Fig. 14). This happens because some peaks of a light then the negative effects of diffraction will outweigh the
wave will be canceled by the trough of another wave (creat- potential benefits of the pinhole. The pinhole effect also
ing a dark spot), and some peaks of a light wave will be helps explain why undercorrected patients may squint to
amplified by the peak of another light wave (creating a bright increase the number of unrefracted rays that reach their ret-
spot). As a result of this spacing, the waves that leave the slits ina. Finally, we should understand that the pinhole test is
will hit the screen at different times (and arrive at different only practical to assess patients’ visual potential in the pres-
phases). ence of anterior segment opacities (e.g., corneal scar, cata-
ract) and will not be useful in the presence of retinal
pathology (e.g., macular scar). See Chap. 26, “Preoperative
In case, an enterprising reader wants to check the math on this: sin
7
θ = n2/n1 = 1.00/1.33 = 0.75, giving us the angle calculation of sin-1 Optics for Cataract Surgery” for more information on pin-
(0.75), which is equal to 48.6°. hole testing.
12 K. M. Riaz
Fig. 14 Diffraction. Light

waves may find alternate
Wave of
paths around a barrier (left
light
panel) or may emerge as
waves when traveling through
a narrow opening within a
barrier (right panel)
Water
droplets
in cloud
Diffracted light
zones, aka “the rings”) on the optic (depending on the manu-

facturer, these steps may be on the anterior or posterior
aspect of the optic) that split incoming light toward distant
and near focal points based on the height of the microscopic
step. If the step height is one wavelength, the light that hits
that step will be directed toward the near focal point. If the
step height is a smaller fraction of the wavelength, light that
hits that step will be directed toward the distal focal point.
MFIOLs employ a combination of step heights (or a combi-
nation of refraction and diffraction) to split and direct incom-
ing light and to distant, intermediate, or near focal points.8
Practice Questions
1. What is the critical angle when light travels from air to

water?
A. None
B. 13.3°
Fig. 15 The Airy disc pattern shows a series of concentric bright and
C. 28°
dark rings formed by a point source of light passing through a circular D. 42.8°
opening (aperture) E. 56.3°
In surgical practice, we take advantage of diffraction

when we use diffractive multifocal intraocular lenses Optics of MFIOLs are discussed further in Chap. 27, What Is on the
8
(MFIOLs). MFIOLs have microscopic steps (diffractive Menu: An Overview of Currently Available IOLs and Relevant Optics.
Geometric Optics 13
2. If blue text and red text are placed side by side against a Answers
black background for an emmetropic patient, which of
the following statements is true? 1. Answer: This is somewhat of a trick question (sorry). The
A. The blue text will appear to be sharper than the red critical angle only occurs when light travels from a denser
text medium (such as water) into a less dense medium (such
B. The red text will appear to be sharper than the red text as air). There is no critical angle when light travels from
C. The blue text will appear to be closer to the patient a less dense medium into a denser one (Answer Choice
than the red text A). Remember that the critical angle between air and
D. The red text will appear to be closer to the patient than water (aqueous) is approximately 48.6°.
the blue text 2. Answer: In order to see the red text when placed side by
3. Which of the following statements about light rays is side to blue text on a black background, the patient will
true? have to accommodate. As a result, the patient may falsely
A. Light rays that emanate from a point source of light think that the red text is actually closer (Answer Choice
are parallel D). The sharpness of both the blue and red text should be
B. Light rays that get affected by a lens will always be about the same for an emmetropic patient.
convergent 3. Answer: Light rays that emanate from a point source of
C. Light rays that pass through an aperture will either be light are always divergent and must be affected by an
parallel or convergent external source (e.g., a plus lens) to become convergent
D. Light rays must be affected by an external source to (Answer Choice D). We artificially consider them parallel
become convergent in the world of Geometric Optics to gain information
4. What is the most significant refractive interface when about image location, etc. Light rays may be convergent
light passes through the eye? or divergent depending on the type of lens that they pass
A. Tear film–anterior cornea interface through (positive or negative lens, respectively). When
B. Air–tear film interface light rays pass through an aperture, all three types of light
C. Anterior cornea–posterior cornea interface rays (divergent, parallel, and convergent) are formed.
D. Posterior cornea–aqueous humor interface 4. Answer: The air–tear film interface is the most important
5. Which of the following statements is true? refractive interface of the eye (Answer Choice B). This is
A. Refraction describes the process wherein incoming a very important fact to commit to memory.
light rays attempt to pass from one medium into 5. Answer: Dispersion occurs whenever a light ray under-
another medium but instead are refracted back into goes refraction (Answer Choice B). The individual colors
the original medium. that comprise the light ray will also get refracted accord-
B. Refracted light rays will also be split according to the ing to the frequency of that particular color. While both
wavelengths of light that comprise the incoming light barrel and pincushion distortions occur due to light rays’
ray. refractive effects at the edge of a given lens, the former
C. Barrel distortion is experienced by patients who wear occurs in high-minus lenses, and the latter occurs in high-
high-plus lenses, and pincushion distortion is experi- plus lenses. Remember that blue light rays will be dis-
enced by patients who wear high minus lenses due to persed more than red light rays.
the light rays that strike the edge of the lens undergo-
ing different amounts of refraction compared to light
rays that strike the center of a given lens.
D. The law of reflection states that the angle of the inci-
dent ray (incoming ray) is related to the angle of the
reflected ray (outgoing ray) based on the index of
refraction of the second medium.
Prisms in Ophthalmic Optics
G. Vike Vicente
Objectives less. Recall that we previously discussed that the blue com-
• To understand how light rays interact with prisms to form ponent of light rays is bent more when undergoing refraction
images in geometric optics and in clinical practice. (mnemonic: Blue is bent the most).
• To define and understand the concept of prism diopters. In 1666, Sir Isaac Newton showed that prisms can be used
• To apply Prentice’s rule to clinical practice problems. to disperse light into different wavelengths that can be
• To understand how prisms are used in clinical practice in described as the colors of the rainbow (red, orange, yellow,
a variety of settings. green, blue, indigo and violet; recall the “ROY G. BIV”
mnemonic from middle school!). Previously, before Newton,
it was thought that prisms would add color to white light.
Introduction Using two prisms, Newton first separated the incident light
into different colors. Then, he had the red light pass through
This chapter will focus (pun-intended) on prisms used in a second prism showing that no further colors were added
everyday ophthalmic practice. Prisms have flat transparent and that this second light ray remained red (Fig. 2).
surfaces that refract (change the direction of) light rays. Amazingly, Newton is not as famous for this fascinating dis-
They may come in different shapes, but the most commonly covery in the world of optics; instead, he is credited for his
encountered are prisms with triangular shapes, which allows work on gravity and modern physics—as if those things ever
us to have “two” refracting surfaces within the same prism. saved a patient from going blind!
They are usually made of plastic or glass because these An understanding of this principle will be helpful when
materials are transparent to the visible electromagnetic discussing the concept of chromatic aberration in chapter,
spectrum. Plastic prisms are much more commonly used in “Glasses in Clinical Practice” and its clinical applications,
modern clinical practice; glass prisms are relics of days such as the Duochrome test.
gone past. Recall that when incoming light reaches a surface, some
As a side note, glass prisms are calibrated such that they of the light rays may undergo reflection, depending on the
are held with the frontal plane in the direction of the tropia, angle of incidence. In this capacity, prisms may also be used
whereas plastic prisms are held with the frontal plane of the to reflect light using the principle of total internal reflection
prism in the direction of the non-tropic eye (Fig. 1). (see Chap. 1, “Geometric Optics”)
Prisms are usually made of a material that will have a dif-
ferent index of refraction depending on the wavelength that
is going through it. For example, red light will move through Ray Tracing and Prisms
the prism faster than blue light and thus will be refracted
Triangular prisms will refract a real light ray toward its base
as seen by ray tracing (Fig. 3).
The light ray is first bent toward the norm as it enters the
G. V. Vicente (*) prism, which has a higher refractive index. The ray is then
Clinical Pediatrics and Ophthalmology Georgetown University bent away from the norm as it exits the prism and enters a
Hospital, Washington, DC, USA medium with a lower refractive index. The net result is that
Eye Doctors of Washington, Chevy Chase, MD, USA the light ray will be bent toward the base of the prism. Always
e-mail: vvicente@edow.com remember that real light rays love the base of a prism!

16 G. V. Vicente
a b
Fig. 1 Calibration of glass (a) vs. plastic prisms (b). Notice that the glass prism (a) is held such that the frontal plane is perpendicular to the tropic
eye. The plastic prism (b) is held such that the frontal plane is perpendicular to the non-tropic eye
rism Diopters: Definition

P
and Quantification
The amount of refraction can be quantitated by a unit called

a prism diopter (Δ or PD). The technical definition of a prism
diopter is a unit describing the refraction of light by a prism
equal to 100 times the tangent of the angle of refraction.
Since that definition is not very useful; let us rephrase into
something a bit more understandable: If a ray of light is
Fig. 2 Newton’s experiment of refraction with prisms. Notice that after refracted 1 cm at a distance of 1 meter from the prism, then
passing through a prism, a light ray may be separated (dispersed) that prism is said to have 1 Δ of effect (Fig. 4). In other words,
according to its wavelengths with blue light rays undergoing the most
refraction. A second prism can be placed after the first prism to demon-
that prism has a power of 1 PD.
strate that previously refracted light ray will maintain its color because This is one of the few places in geometric optics where
no further significant refraction according to wavelength will occur centimeters are used instead of meters in the actual defini-
tion. A common mistake made here is that many students
may erroneously think that the prism causes the light ray to
no
rm be shifted in millimeters; examinations will often have
(wrong) answer choices that will correspond to making this
mistake.
For example, a 15 Δ prism will refract a ray of light 15 cm
(toward its base) when measured at a distance of 1 m (Fig. 5).
The amount of refraction can be calculated by the follow-
ing formula:
P = 100 tan d

P is the strength of the prism, and d is the angle of devia-
Fig. 3 A real light ray will be refracted (bent) toward the base of a tion of light.
prism
Prisms in Ophthalmic Optics 17
Answer: 8 Δ means that at 1 meter away from the prism,

1m there is an 8 cm shift in the fixation light due to the prism
effect. Therefore, at 7 meters, there is an
8 cm/1 m × 7 m = 56 cm prism effect. So, the images will
1cm appear 56 cm apart.
We could also set it up as a comparative triangle problem
(Fig. 7).
1∆
For these types of problems, we can jump straight to the
math or we can visualize it as similar triangles. As there are
Fig. 4 Prism diopters are defined as the number of centimeters a light no “style points” on an examination, it is useful to figure out
ray is refracted when measured at a distance of 1 m from a prism. The which approach is easier for you and consistently use that
higher the strength of a prism, the greater amount of refraction will approach, so long as you get the right answer.
occur at 1 m
Example #2 If you are given a 20 Δ BD prism and shine a

light through the prism toward a screen located 2.5 m away,
1m where will the light ray hit the screen (Fig. 8)?
Answer: Since we have been given a 20 Δ BD prism, we
know that 1 m away, the light ray will be deflected by 20 cm.
Using the laws of similar triangles, we can calculate that the
light ray will be deflected by 50 cm at 2.5 meters away. We
15cm also are told that this is a BD down prism, and since real light
15∆
rays will be bent toward the base, the light ray will hit the
screen at 50 cm inferiorly (point D). Note that answer choice
A is also 50 cm, which would have been correct if the prism
was a 20Δ BU prism.
Fig. 5 A 15 Δ prism will refract a real light ray 15 cm (toward its base)
when measured at a distance of 1 m to the right of the prism Example #3 If a prism of unknown power deflects a light
ray 6 cm at a distance of 50 cm, what is the power of this
Again, don’t worry about memorizing this formula! We prism?
intentionally did not include it in the list of hi-yield formulas Answer: This problem is again testing our knowledge of
that should be committed to memory. Instead, how the rela- similar triangles but is asking us to use this in reverse. We
tionship between the strength of the prism and amount of can solve this problem by reasoning that since this prism
refraction is related through this equation is observed.1 deflects a light ray by 6 cm at 50 cm, then we must determine
Prism diopters are nonlinear. For example, a 45-degree angle how much it deflects a light ray at 100 cm (1 m).
is equal to 100 prism diopters. However, a 90-degree angle is 6 cm x
equal to an infinite number of prism diopters (not 200!) (Fig. 6). =
50 cm 100 cm
To review, a prism diopter is simply the distance an image
is shifted (measured in centimeters) when measured 1 meter = =
50 x 600, so x 12 cm

away from a prism. Therefore, all prism diopter problems are Therefore, this must be a 12 Δ prism.
nothing more than similar triangle problems. Let us see some In all three of these examples, we have seen how the same
examples of how this can be tested. concept can be tested via three different methods.
Example #1 A patient with a 6th nerve palsy has an 8 Δ dis-

tance esotropia. How far apart do the images of a fixation Oblique Prisms: Vector Forces
light at 7 meters appear to the patient?
When combining two prisms of different directions, we must
consider vector effects of the prism. For example, if we place
A super nerdy way of bringing together Snell’s law of refraction and
1
an 8 Δ base-out and an 8 Δ base-up over the left eye, and we
the concept of prism diopters can be considered here. Recall that using wish to calculate the net effect of these two prisms, we have to
Snell’s law, if we know the index of refraction of the two surfaces and
the incoming angle, we can calculate the outgoing angle: n1 sin θ1 = n2 use vector addition. This will allow us to calculate the magni-
sin θ2. Suppose we are asked to calculate the outgoing angle (θ2), we tude of the vector, ignoring the direction for the time being. We
can then calculate the strength of the prism by first calculating the dif- cannot simply add the two prisms (8 + 8 = 16) or shortcut the
ference between the incoming angle and outgoing angle (θ2 − θ1) and math. In this case, we know that both the BO and BU prism
then taking the tan of this difference. Hopefully, this type of calculation
will never appear on an examination. must be accounted for, and in order to calculate the net effect of
18 G. V. Vicente
Fig. 6 Prism diopters are a b

nonlinear: a 45-degree angle 100 cm 100 cm
is equal to 100 prism diopters,
but a 90-degree angle is equal 45º 90º
to an infinite number of prism
diopters (not 200)
100 ∆ prism
100 cm
Fig. 7 Similar triangles can

be used to solve for x
8cm
1m 7m
Fig. 8 Where will the light

ray hit the screen?
50 cm
20 PD
20 cm
2.5 m 30 cm
20 cm
these two prisms, we have to think back to high school geom- Admittedly, the math on this problem is a bit difficult and
etry and recall the good ole Pythagorean theorem (Fig. 9): may require a calculator:
a 2 + b2 = c2
a 2 + b2 = c 2 64 + 64 = 128 = 11.31 prism diopters base − up and base − out effect.

8∆ BU
BO
&
BU
?∆
Fig. 10 An oblique prism can be used to correct this patient’s double
vision instead of a combination of base-up/base-down prisms
45° 8∆ BO ahead and draw out the diagram of the vector forces if it
helps you to visualize the problem.
Fig. 9 When considering the vector effects of prisms of different direc- a2 + b2 = c2 25 + 144 = √ 169 = 13 prism diopters base-
tions and magnitude, we can use the Pythagorean theorem to calculate up and base-out effect. Of course, you may have remembered
the value of the hypotenuse, which will be our vector force
that this also is one of those “golden triangles” as well. #Pro
tip: You may want to brush up on your Pythagorean triples
Notice that the answer cannot be obtained by simple since test problems have a strong possibility of using golden
addition or subtraction—we can be certain that this “wrong triangle numbers since it makes for easy mental math.2
math” will be a distractor answer choice on an
examination.
We can do an example that is more likely to appear on Effect on Real and Virtual Images
examinations as the math involved does not require a
calculator. At this point, we should clarify some confusing terminology,
depending on whether we are talking about prisms in optics
Example #1 If we measure a 3 PD BU and a 4 PD BO for a vs prisms used in the clinical setting. This is a concept that
patient’s right eye, what oblique prism would we need to pre- can be very confusing if we are not careful about whether we
scribe for this patient? Assume we cannot prescribe anything are discussing REAL light rays (“Optics”) or VIRTUAL
for the left eye (Fig. 10). light rays (“Clinical Setting”).
Answer: We must calculate the vector forces by using the For example, we may hear in clinical practice when using
Pythagorean theorem. prisms that the “image goes to the apex” and the “eye goes to
a2 + b2 = c2 9 + 16 = √ 25 = 5 prism diopters base-up and the base.” The mnemonic “AIBE” may be helpful here to
base-out. Of course, you may have remembered that this is remind us that apex—image, base—eye. For example, for a
one of those “golden triangles” as well. Look at you, you patient with an RXT, we would place a base-in prism over
overachiever, remembering things from high school geome- the right eye to correct this deviation; as examiners, we will
try that the rest of us have forgotten! see the right eye appear to move “nasally” toward the base of
the prism.
Example #2 If we measure a 5 PD BU and 12 PD BO for For ophthalmic optics, the nuance is you have to ask your-
the left eye, what oblique prism would we prescribe to this self if we are dealing with real or virtual light rays. When
patient? Assume we cannot prescribe anything for the right
eye.
A few useful “Pythagorean Triples” values you may wish to memorize
2
For the sake of brevity, we will not draw out the diagram are the following (including multiples of these numbers): 3,4,5; 5,12,13;
for this problem. But if you are just starting out, you can go 8,15,17; 7,24,25; and 20,21,29.
20 G. V. Vicente
solving optics problems, we are dealing with real light rays. have a scenario where a patient looks “x” mm away from the
When treating patients in the clinic, we are dealing with vir- optical center of the lens. It is important to remember to con-
tual light rays—this is because the light rays coming from vert the “x mm’‘ into centimeters before plugging it into the
the patient’s eye are not “real,” the patient’s eye does not above equation. You can be certain that one of the wrong
produce the light rays (unless your patient is Cyclops from answer choices on examinations will include a numerical
the X-Men, in which case you should start running because value obtained by using “x mm’‘ instead of changing it to “x
his laser beams are deadly…). cm.”
Here is how we can keep them separated: #Protip2: Even though it may seem unnecessary, draw out
the lens, especially if you are still getting the hang of prisms.
• Real light rays are displaced toward the BASE of a prism This will help you keep the BO/BI or BU/BD effect orga-
(“optics”) nized visually.
• Real images are displaced toward the APEX of a prism When drawing out lenses, use the following figure to help
(“optics”) you remember how to draw out the lens. Think of lenses as
• Virtual light rays are displaced toward the APEX of a basically a combination of two prisms (Fig. 11).
prism (“clinic”) If we place the same type of prism (with equal quantita-
• Virtual images are displaced toward the BASE of a prism tive magnitude) in front of both eyes, there may or may not
(“clinic”) be a resulting diplopia (Fig. 12). For example, placing BU or
• The light ray that goes INTO the eye is REAL, so it is BD prisms in front of both eyes will move the eyes in the
bent toward the base. For the patient, it appears that the same direction. However, placing BI or BO prism in front of
image is coming from the apex side. The light ray coming both eyes may move the eyes in the same or opposite direc-
FROM the eye (i.e., what you as the examiner see through tions (depending on what part of the lens/prism the patient is
the prism) is VIRTUAL, so those virtual light rays move looking through). For example, if a patient looks nasal to the
toward the apex, but the image of the eye (as you as the optical center of +3D lenses placed in front of both eyes,
examiner see it) moves toward the base as well.
Therefore, the “AIBE” mnemonic is a combination of the a

following: Apex is where real images go toward, and base is
where the eye (virtual image) will go toward.
Prentice’s Rule
Charles F. Prentice (an optician!) developed a formula to

determine the amount of induced prism in a lens. Your one
job is to know Prentice’s rule equation well!
Prentice’s rule determines how much deviation is present b
when one looks away from the optical center of a given lens.
There is no prismatic power at the optical center of the lens.
If everyone would only look through the optical center of
their glasses, then we would never have to worry about the
good Mr. Prentice’s rule!
The formula for Prentice’s rule, which you must commit
to memory, is as follows:
P = ∆ = h X D.

where P or Δ is the amount of prismatic effect in prism diop-
ters, h is the distance in centimeters from the optical center,
and D is the power of the lens. A mnemonic you can use to Fig. 11 Think of lenses as a combination of two prisms. Depending on
the direction of gaze, drawing out the lens in this manner will make it
help you remember this rule is “PhD”:
easier to determine the prismatic effect caused by looking away from
P = hD the optical center. Panel A shows how a plus lens should be drawn in
vertical gaze (top left) and horizontal gaze (top right). Panel B shows
#Protip1: Make sure you convert h from mm to cm!!! This how a minus lens should be drawn in vertical gaze (bottom left) and
is where they mess with you. The question stem will often horizontal gaze (bottom right)
Right Eye Left Eye

a
+3D
Fig. 13 The blue dot represents the line of sight 6 mm below the opti-
cal center of a + 3D lens
Fig. 12 Summary of prismatic effects when a patient looks away from
the optical center of lenses with both eyes. The blue or red dot repre-
sents where the patient’s eye is looking through (instead of the optical
center). Assuming equal magnitude, base-up/base-down over both eyes
-4D
will move the eyes in the same direction (a). Base-in/base-out over both
eyes (b) will move the eyes in the same or opposite directions (depend-
ing on what part of the lens/prism the patient is looking through). For
example, if the patient looks nasal to the optical center (red dots), then
the eyes will move in different directions due to the base-out effects
encountered when looking at this position. However, if a patient looks
to the right of the optical center in both eyes (red triangles), then the
eyes will move in the same direction (toward the patient’s left ear)
there will be a BO prism induced, and therefore, a diplopia

will result. However, if the patient is looking to the “right” of
the optical center of +3D lenses, then for the right eye, there
Fig. 14 The blue dot represents the line of sight 8 mm below the opti-
will be a BI effect, and for the left eye, there will be a BO cal center of this -4D lens
effect; since both eyes are shifted in the same direction (i.e.,
toward the patient’s left), there will be no diplopia.
looks down” or “the patient looks below” and to simply
Example #1 If you look 6 mm below the optical center of assume that this will imply a base-down effect. Drawing out
a + 3D lens with your right eye, what is the induced prismatic the lens as a combination of two prisms helps to avoid this
effect? error.
Answer: Even though this seems like a relatively simple
question, start off by drawing out the lens so that we can Example #2 If you look 8 mm below the optical center
visualize the qualitative deviation (BU or BD) (Fig. 13). of a -4D lens with your left eye, what is the induced pris-
We can see that when we look inferior to the optical cen- matic effect?
ter of this +3D lens, there will be a BU prismatic effect Answer: Again, we can start off by drawing out the lens
induced. Now, we can use Prentice’s rule to solve for the (Fig. 14).
numerical deviation, remembering to convert to cm: We can see that when we look inferior to the optical cen-
ter of this -4D lens, there will be a BD prismatic effect
P = hD = ( 0.6 )( 3 ) = 1.8 prism diopters base − up effect. induced. Notice how this is different from the previous prob-

Note that one benefit of drawing the prism out is that it lem we just did. In both cases, we looked inferior to the opti-
helps with visualizing the BU/BD effect in this eye. For cal center. However, for this problem, we will have to deal
example, a common mistake is to read the phrase “the patient with a BD effect.
22 G. V. Vicente
Right Eye Left Eye Right Eye Left Eye
Fig. 16 The blue dot represents the line of sight of the right and left
eye, respectively, when looking 8 mm to the right of the optical center
of a − 6.0D lens and + 6.0D lens
meaning you are looking to the right of the optical center in both
Fig. 15 The blue dot represents the line of sight of the right and left eyes. This means that the right eye will be looking temporally
eye, respectively, when looking 4 mm inferior to the optical center of and the left eye will be looking nasally (both eyes will be
a − 5.00D lens and a + 2.50D lens directed toward the right ear). Also, this pair of glasses would be
awful to wear even if we were looking through the optical cen-
Now, we can use Prentice’s rule to solve for the numerical ters due to the likely anisometropia/aniseikonia!3 Nevertheless,
deviation, taking care to convert to cm: we can play this game: drawing out the lenses will make the
direction of the deviation relatively simple to figure out (Fig. 16).
P = hD ( 0.8 )( 4 ) = 3.2 prism diopters base − down effect. We can see that there will be a BO prism effect for the

Now we can do some more challenging examples right eye, and a BO prism effect for the left eye—i.e., there
(yippee!). will be diplopia. We can now calculate how much prismatic
effect will be present:
Example #3 If you look 4 mm below the optical center of
OD : P = hD ( 0.8 )( 6 ) = 4.8 prism diopters base − out.
glasses with the following prescription: OD: -5.00D, OS:
+2.50D, what is the net induced prismatic effect?
OS : P = hD ( 0.8 )( 6 ) = 4.8 prism diopters base − out.
First, find the resident that did such an awful refraction
and administer ophthalmic justice: making the resident Since the eyes will be moving in opposite directions, we
refract every VA patient for the rest of the week. Second, have to add the two deviations. The net deviation will be
solve the problem. Again, start off by drawing out the two 4.8 + 4.8 = 9.6 prism diopters (between the two eyes) (XT
lenses (Fig. 15). induced).
Now, we have to calculate each eye separately: Bonus points: how could you correct this deviation?
Answer: We can either give 9.6 PD BI to the right eye or
OD : P = hD ( 0.4 )( 5 ) = 2 PD BD. 9.6 PD BI to the left eye.

Even more bonus points: What is the problem with the
OS : P = hD ( 0.4 )( 2.50 ) = 1PD BU. above answer?

Net (total) effect: 3 PD deviation between the two eyes. Answer: Prisms are only made in whole number values.
Bonus points: How could you correct this deviation? So, we could either give a 9 PD or a 10 PD prism since a 9.6
Answer: Since the right eye is 3 PD “inferior” compared PD is not available. C’est la vie.
to the left eye, we could either give 3 PD BU prism to the Finally, notice that in the above examples, we were only
right eye (to shift it superiorly) or 3 PD BD to the left eye (to asked to calculate the deviation when looking away from the
shift it inferiorly). And yes, it is quite possible that if the optical center of spherical lenses. When dealing with sphe-
patient had normal vertical fusion amplitudes, he/she could rocylindrical lenses, the calculations are a bit trickier,
probably fuse this small induced tropia and we could skip the depending on where the cylinder will have an effect (or not
bonus question(!). have an effect). We will therefore revisit this advanced topic
under “Prentice’s Rule,” in Chap. 10, Spherocylindrical
Example #4 If you look 8 mm to the right while wearing a pair Lenses. Note: Problem #10 in the end-of-chapter questions
of glasses with the following prescription: OD: −6.00 sphere, involves a spherocylindrical lens.
OS: +6.00 sphere, what is the net induced prismatic effect.
Answer: Note the (tricky) wording in the stem of this ques- See Chap. 8, “Magnification and Telescopes” for a detailed discussion
3
tion. It states that you are looking to the right with both eyes, of anisometropia and aniseikonia.
Prisms in Clinical Practice We can review some hi-yield facts regarding dispensing
prisms:
Prisms and Strabismus
• If a patient is suffering from binocular diplopia, and the
In clinical practice, prisms are used to measure a patient’s amount of strabismus measured is less than 18 prism
strabismus. This will allow a surgeon to know how much diopters (PD), then a prism may be prescribed. This may
strabismus surgery to perform or how many prism diopters to serve as a palliative “crutch” and may help avoid
prescribe. Using the alternate cover technique, a prism is surgery.
held with its apex toward the eye deviation. • When the prisms are greater than 3 PD, then the optician
For example, suppose that we have a patient with a LXT will typically split the prism and provide half the strength
(Fig. 17, left panel). Without prism correction, when the over each eye. For example, for an 8 PD LXT, the optician
patient is looking at an object, an inverted real image is pro- may give 4 PD BI for the left eye and 4 PD BI for the right
jected onto the retina (by real light rays); for the right eye, eye.
the light rays strike the fovea, but for the left eye, the light • Typically, about 70–75% of the full deviation measured
rays fall temporal to the fovea. In order to correct this LXT, will be prescribed. This will avoid exacerbating a patient’s
we would place a BI prism over the patient’s left eye with the dependence on prisms. For example, if a patient has 16
apex directed toward the patient’s ear (Fig. 17, right panel). PD of exotropia, a clinician may offer 12 PD base-in for
Since real light rays are bent toward the base of the prism, one eye, or 6 PD base-in each lens over each eye.
this will “bend” the light rays to hit the fovea of the left eye, • With the prescribed prism(s), the patient should experi-
thereby resolving the diplopia. In the alternative cover test, ence relief of diplopia for most of the day. However, even
prisms of increasing strength are used until the patient’s eyes with the prismatic correction glasses on, double vision is
no longer need to re-fixate on the target. This amount of expected at the end of the day when the patient is tired and
prism will be the amount of strabismus present. the strabismus is harder to control.
Before dispensing the measured prism, a prism adaptation • Prescribing partial strength prisms (e.g., giving 8 PD BI
test (PAT) may be performed in the clinic (for a few minutes for the right eye for a patient with 14 PD RXT) will
to few hours) or with trial Fresnel prisms (for several days to compassionately provide some relief to the patient while
several weeks) to allow the patient to get used to the prism still promoting fusion and encouraging them to develop
and bring about any latent strabismus not initially observed. some fusional amplitude by fighting their strabismus.
Some patients may require repeat measurements after a PAT Think of this as sending the patient to the gym to work
in order to titrate the final amount of prism needed, espe- out and get stronger for building up the ability to com-
cially if they have a deviation with both vertical and horizon- pensate for the remaining needed prism. This will also
tal components. hopefully avoid the patient becoming “lazy” and “eating
Fig. 17 Without prism Right Eye Left Eye Left Eye
correction, real light rays will
fall temporally to the fovea of Fovea
Fovea Fovea
the left eye for a patient with
LXT (left panel). When a BI
prism is placed over the left
eye (right panel), real light
rays are bent toward the base
(nasally) such that they will
now fall on the fovea of the
left eye, thereby resolving the
diplopia
Real Real
object image
24 G. V. Vicente
up” their prescribed prism, therefore requiring stronger

prisms in the future.
• If necessary, a second pair of glasses with full-strength
prisms may be provided to use only at night if the patient
really needs it to drive safely or has high demands for
excellent vision at night time. The patient could wear her
partial strength prisms during the day and switch to the
full-strength prisms in the evening.
Clinical Examples of Prism Dispensation.
Example #1 For a patient named Lefty N. Wards with LET

of 20 PD (measured in clinic), 7 PD BO can be given for both
eyes (Fig. 18).
Example #2 For a patient named Lefty Ootward with LXT

of 20 PD (measured in clinic), 7 PD BI can be given for both
eyes (Fig. 19).
Fig. 19 A partial strength split prism: 7PD base-in over both eyes can
Example #3 For a patient named Wright I. Down with LHT be issued for this patient with 20 PD base-out exotropia
of 20 PD (measured in clinic), 7 BU can be given for the
right eye, and 7 PD BD can be given for the left eye (Fig. 20).
Fresnel (Temporary) Prisms
In addition to a ground-in prism in the patient’s glasses, the

clinician may choose instead to give a temporary, inexpen-
sive, plastic Fresnel prism, or a “press-on” prism (Fig. 21).
Fresnel prisms (pronounced as “Freh-NELL”; don’t be a
noob and pronounce it as “FREZ-nel”…) can be easily
attached to the patient’s glasses and can be moved, rotated,
and exchanged (Fig. 22). Basically, a Fresnel prism is a
series of parallel smaller prism surfaces at the same angle. In
Fig. 20 A partial strength split prism: 7PD base-up over the right eye
and 7PD base-down over the left eye can be issued for this patient with
20 PD base-down LHT
patients with diagonal diplopia, Fresnel prisms may also be

rotated to an oblique angle.
Advantages of Fresnel prisms include the following:
1. Useful for the temporary control of diplopia, such as:

• Ischemic diabetic sixth nerve palsy,
• Postoperative diplopia in patients with consecutive
strabismus.
2. Ability to function as experiment (“Trial Prisms”) prisms
when clinical measurements of the deviation are incon-
sistent, and a clinician may therefore use a Fresnel prism
to help titrate the final required prism power, or perform a
prism adaptation test to confirm how much strabismus
Fig. 18 A partial strength split prism: 7 PD base-out over both eyes can
surgery should be performed.
be issued for this patient with 20 PD base-out esotropia 3. Relatively inexpensive (compared to ground-in prism).
3. Higher prism powers will require thicker material, which

may lead to further blurriness of vision.
4. Some level of visual acuity is compromised, mainly due
to negative effects of chromatic aberration.
Convergence Insufficiency
See Chap. 22, “Optics for Clinical and Surgical

Management of Strabismus” for a more detailed explana-
tion of this topic.
Patients with convergence insufficiency (CI) will suffer
from diplopia with near activities. Orthoptic exercises to
increase convergence will often improve convergence insuf-
ficiency, especially in younger patients; however, these may
not work well in older patients, especially in patients with
brainstem pathology or Parkinson’s disease.
Several options exist to help patients with CI. If the patient
is myopic, one option is to simply prescribe them their full
myopic prescription since myopic glasses will have a BI
Fig. 21 8 PD base-down Fresnel prism prior to trimming the size prismatic effect when looking at near. For younger patients,
and this may seem somewhat counterintuitive, another option
may be to do the opposite: intentionally under correct the
needed myopic prescription. This intentional under correc-
tion may stimulate the patient to build up their convergence
abilities. A second option is to prescribe monofocal reading
glasses with a (plus) +2.0 D add. The lower add will increase
the working distance (out to 50 cm) and alleviate some con-
vergence symptoms by forcing the patient to read further
away. If the patient is still diplopic, a third option is to add up
to 7 PD base-in prism to each lens. Remember, BI prism will
cause the eyes to “shift towards the base,” so giving extra BI
prism can “help” these patients who are not otherwise able to
generate the convergence amplitudes needed. A fourth option
involves taping one lens as the last resort to alleviate the
symptoms. A fifth option may be a situation that may require
full correction with base-in prism may be for a patient who
has a time-sensitive need for improved convergence, such as
a young patient with an upcoming prolonged standardized
examination, and thus cannot wait for the convergence exer-
cises to take effect.
In general, younger patients with CI should not be given
the full prismatic correction as they can work to improve
Fig. 22 Rotated Fresnel prisms 8 base-down and base-out, before and
their convergence abilities. For older patients, however, we
after trimming
should be a bit more lenient and merciful; these patients
should be given the full prismatic correction to help alleviate
Disadvantages of Fresnel prisms include:
CI as described above.
1. Fresnel prisms may easily smudge or get dislodged from
the spectacle lens.
2. The Fresnel prism, due to its “press-on” nature, may have Combined Vertical and Horizontal Diplopia
a level of opacity/blurriness of the material, and thus are
less transparent (and more easily noticeable, especially to Say a patient, Wright I. Diagonal (who is right eye dominant)
observers), than ground-in prism. has diagonal diplopia, with an esotropia and a right hypertro-
26 G. V. Vicente
Fig. 23 A 5 base-up and

base-out Fresnel prism over ? PD
the left eye would compensate Z
for this patient with vertical 3 PD Hypotenuse
and horizontal strabismus X
2 2
Z =X + Y
2
2
Z = 9+16=25
4 PD Z = 5 PD
Y
OR 5
4
3
pia, and he requires a 4 PD base-out and a 3 PD base-down

on the RIGHT side. The clinician can prescribe this combi-
nation as ground-in lenses: 4 PD base-out OS, and 3 PD
base-down OD or place a Fresnel prism over the non-
dominant LEFT eye base-up and base-out (Fig. 23). The
amount of a diagonal prism is estimated by calculating the
hypotenuse of the triangle formed (as we discussed in Section
D).
We can now do a few more examples of combined vertical
and horizontal strabismus that may require us to prescribe
prismatic correction.
Example #1 Suppose a patient named I.C. Good presents

with complaints of double vision. You measure a 4 PD RHT
and a 5 PD LET. We can prescribe prisms for both eyes sepa-
rately, using our rule of thumb to give ~75% of the measured
deviation. One option is to give 3 PD BD for the right eye
and 4 PD BO for the left eye (Fig. 24). A second option is to
give a Fresnel prism placed over the left eye of 5 PD placed
base-up and base-out as a trial prism. Fig. 24 Ground-in and Fresnel prism options
Finally, one more advanced point: Patients with cranial
nerve IV palsies will often have a torsional diplopia in addi- induced BO effect when patients look nasal to the optical
tion to a vertical and a horizontal one. The torsional diplopia center of these lenses (Fig. 25).
unfortunately cannot be ameliorated with prisms; however, if To decrease the additional convergence demands in
the horizontal and vertical diplopia can be neutralized with this situation, additional BI prism may be needed in the
prisms, then the patient may find it easier to tolerate and fuse glasses. As a rule of thumb, you should prescribe 2 PD BI
the tilted images. greater than the power of the plus lens. For example, if we
prescribed +8.00D glasses, then we would need to give 10
PD BI for each eye. (Depending on the frame and the pre-
Prisms for High Reading Add Powers scription, most opticians can make ground-in prisms up to
8–9 PD.)
In the clinical management of patients with low vision,
single-vision reading glasses with high-plus power in both
eyes may be necessary to improve functional near vision.4 Prisms and Nystagmus
The high plus lenses will decrease the working distance, but
will also increase the convergence demands due to the Patients with nystagmus will often have a null point in which
they can dampen their nystagmus and improve their best cor-
See Chap. 19, “Low Vision and Vision Rehabilitation” for more
4 rected vision. If the null point is not in primary gaze, they
information. will develop a compensatory head posture to basically arrive
Fig. 26 Prisms and nystagmus with null point in right gaze
Fig. 25 High plus lenses will increase convergence demands when a
patient attempts to focus at near due to the induced base-out prismatic
effects when looking nasal to the optical center. These patients may
fatigue easily if they are not given additional base-in prism to alleviate
the base-out prism due to the high plus lenses
at the null point through the head turn. If the head turn is
small, prisms can be used to “shift the eyes” toward the null
point, thereby reducing the need to turn the head as much.
However, most symptomatic head turns are too large to ame-
liorate with prism. These patients may require surgical inter-
-1sph -1sph
vention, such as a Kestenbaum procedure.
Patients with mild–moderate nystagmus patients may try
prisms in the office in the following way:
• Point the apex of the correcting prism in the direction of the Fig. 27 Prisms and nystagmus with null point in primary gaze and
null zone: For example, if a patient presents with a left head dampening with convergence. Adding extra minus power allows a
patient to use the base-in effect of the minus lens to decrease the
turn and clinical examination reveals a null point in right
demands for convergence
gaze, this means we need to figure out a way to “move” the
incoming image to the patient’s right visual field (Fig. 26). nystagmus with convergence. Therefore, prescribing 5
This will motivate the patient to move the eyes into the null PD BO prisms for both eyes can be used to induce conver-
point (since this is where the image will now appear) so gence at distance and possibly improve their best cor-
that he/she does not have to do a constant head turn any- rected distance vision.5
more. Several options include the following: • It is important to remember that when young patients con-
–– 7 PD BI given to the right eye, with apex of prism verge, they will also accommodate and thus fog them-
toward the right ear. selves. By giving patients extra myopic correction (i.e.,
–– 7 PD BO given to the left eye, with apex of prism additional −1 to −1.5D myopic correction), when the
toward the right ear. patient converges, he/she will look through the “base-in”
–– A combination of the above two options. portion of the myopic lens (Fig. 27). This base-in pris-
matic effect will decrease the amount of convergence (and
Note that all of these options aim to shift the incoming
subsequent accommodation) needed, thereby alleviating
images to the right (i.e., toward the patient’s right ear) and
fogging and asthenopia symptoms.
the patient will move his/her eyes towards the null point.
• If the patient has a chin down posture, this means that This may initially seem counterintuitive: If the patient can dampen the
5
both eyes are hypertropic. A base-down prism may be symptoms with convergence, why are we giving base-out prism, should
given to both eyes to move the eyes “down.” not we give base-in prism (to facilitate convergence)? This can be
• Patients with infantile idiopathic nystagmus will have bet- explained by the idea that giving base-out prism is forcing the patient to
converge (rather than passively converge), similar to the “stick” method
ter vision at near because they are able to dampen their in a “carrot and stick” approach.
28 G. V. Vicente
Miscellaneous Pearls for Prism Dispensation As a rule of thumb, when prescribing prisms to correct
hemispheric defects, place the prism such that the BASE
• The patient should be warned that different prism of the prism is directed TOWARDS the hemianopic visual
strengths may be necessary over time and that their stra- field defect:
bismus may change over time independent of whether –– For a LEFT homonymous hemianopia, orient the bases
prisms were worn. of the prisms placed over each eye in the direction of
• Strabismus surgery may still be necessary despite prisms. the patient’s LEFT ear.
Remember that prisms do not halt or reverse the disease –– For a RIGHT homonymous hemianopia, orient the
process. They are simply a workaround for the pathology bases of the prisms placed over each eye in the direc-
that is present. tion of the patient’s RIGHT ear.
• If the patient has an incomitant strabismus, he/she should
understand that they may still have diplopia in non-
primary gazes. Practice Questions
• Patients should be warned about the optical quality of
eyeglasses with prisms. Specifically, they should be aware 1. A prism of unknown power bends a light ray 50 mm
of seeing rainbows around light sources and heavier when measured 100 cm away. What is the power of the
weight of the frames. prism?
• The patient should be told that it is very difficult to make A. 5 PD
prisms. They should not be surprised if it takes most opti- B. 20 PD
cal shops a few weeks and a couple of tries to get the C. 25 PD
prism lenses just right. D. 50 PD
• Patients should also be told about the higher cost of mak- 2. A prism deflects a light ray 20 cm at a distance of 80 cm.
ing glasses with ground-in prisms. This is why a Fresnel What is the power of the prism?
prism may be a good option as a “test-drive” prism until 3. A prism deflects a light ray 40 cm at a distance of 250 cm.
the patient is happy with a certain prism power that can What is the power of the prism?
then be made permanent. 4. A patient looks 11 mm below the optical center of the
• On that note, it is very difficult, but not impossible to following prescription:
make the following prisms; they will have a high error OD: plano OS: -3.00 sphere
rate at the optical shop and thus should be avoided: What is the induced prism?
A. Progressive lenses and ground-in prisms. 5. A 52 year old patient named I.C. Googly presents to your
B. Diagonal ground-in prisms. office with complaints of double vision when he looks
C. Ground-in prisms stronger than 8–9 PD (they are too down to read. He wears glasses with the following
thick). prescription:
D. Ground-in prisms in only one segment of a bifocal
prescription. OD : −6.00 D sphere
E. Fresnel prisms stronger than 15 PD (they are too
blurry). OS : −4.00 D sphere

• Prisms may also be given to patients with hemispheric
visual field defects (such as those that would occur with a +2.00 add OU ( Executive style )

stroke, for example). By shifting the “missing” visual
What is the induced prism? Assume that the reading posi-
field into the “visible area of vision,” the patient’s symp-
tion is 8 mm downwards and 2 mm inwards to the optical
toms may be partially alleviated. For example, if a patient
center.
presents with a left homonymous hemianopia, one way to
6. A patient presents complaining of vertical diplopia, most
alleviate this patient’s symptoms may involve shifting the
prominent when he wants to read. You note that he has
“missing” visual field toward the right side (i.e., the vis-
a -12D sph prescription for both eyes. In addition, you
ible) visual field. One way to do this would be to place BI
measure a 6 PD RHT. How can you correct his vertical
prism over the right eye and BO prism over the left eye.
diplopia?
Recall that since real light rays will bend toward the base
A. Move the optical center down by 2.5 mm for both
of the prism, incoming light rays would be shifted to the
lenses
nasal retina in the right eye and temporal retina in the left
B. Move the optical center down by 2.5 mm for the right
eye. Remembering our neuroanatomy, we can then deduce
lens only
that these light rays will project into the right visual field.
C. Move the optical center up by 2.5 mm for the right At 100 cm (1 m), the light ray was bent 50 mm (5 cm).
lens and down by 2.5 mm for the left lens Therefore, the unknown prism’s power is 5 PD (Answer
D. Move the optical center down by 2.5 mm for the right Choice A).
lens and up by 2.5 mm for the left lens 2. Answer: We can solve this using the law of similar
7. A patient presents complaining of vertical diplopia, most triangles:
prominent when he wants to read (which is 12 mm below
20 cm ×
the optical center of the glasses). You note that the patient = 80× = (100 )( 20 ) × = 25 cm, so 25 PD
has +8.75D sphere for the right eye and + 6.25D sphere 80 cm 100 cm
for the left eye. You also measure a 4 PD RHT. How can
you correct this vertical diplopia? 3. Answer: We can solve this using the law of similar
A. Prescribe 4 PD BU to the right eye, 3 PD BD to the triangles:
left eye
40 cm ×
B. Prescribe 4 PD BD to the right eye, 3 PD BU to the = 250× = (100 )( 40 ) × = 16 cm, so 16 PD
left eye 250 cm 100 cm

C. Prescribe 4 PD BU to the right eye, 3 PD BU to the
left eye 4. Answer: It may help to draw out the −3.00D lens of the
D. Prescribe 4 PD BD to the right eye, 3 PD BD to the left eye as an hourglass shape as done in the in-text prob-
left eye lems. Doing this will make it clear there will be a BD
8. A patient presents with a history of a left occipital lobe effect when the patient looks inferior to the optical center.
stroke. Which of the following combinations of prisms We can quantify this deviation using Prentice’s rule
will help alleviate his symptoms? (again, take care to convert 11 mm to 1.1 cm!)
A. BI prism for the right eye; BI prism for the left eyes
B. BI prism for the right eye; BO prism for the left eye P = hD = (1.1)( 3 ) = 3.3 PD base down effect

C. BO prism for the right eye; BO prism for the left eye 5. Answer: This is a problem that builds upon some of the
D. BO prism for the right eye; BI prism for the left eye concepts we have already done. In essence, it requires us
9. If a low-vision patient requires +9.00D add for reading, to solve for Prentice’s rule twice (even though we are only
how much total prism power should be given to decrease getting one point on an exam!)
this patient’s convergence demands? First, we need to calculate the effective power of the
A. 9 PD BO prism for each eye glasses when the patient is reading. Since he is wearing an
B. 9 PD BI for each eye executive style bifocal, we can simply add the power of
C. 11 PD BO prism for each eye the distance glasses with the added power to give us the
D. 11 PD BI prism for each eye “effective” power of the glasses when the patient is read-
10. Suppose a patient has the following prescription: ing. So for the right eye, he is basically reading with a -4D
lens (−6 + 2 = -4D), and for the left eye, he is basically
OD : −4.00 D sph reading with a -2D lens (−4 + 2 = -2D).

Since these are myopic glasses, there will be a base-
OS : +1.00 + 4.00 × 90
down effect when looking inferiorly and a base-in effect
The patient presents to your office complaining about ver- when looking nasally.
tical diplopia whenever they wear their glasses. Suppose that Now, we can use Prentice’s rule to determine the
a repeat EOM examination reveals a 5 PD LHT in downgaze deviations:
(when looking through the glasses 1 cm below the optical Inferior gaze
center). Why is this patient unhappy? How can we correct
OD : P = hD ( 0.8 )( 4 ) = 3.2 PD BD
her symptoms?
OS : P = hD ( 0.8 )( 2 ) = 1.6 PD BD

Answers
The net deviation in inferior gaze is 3.2–1.6 = 1.6 PD,
1. Answer: This is a seemingly simple question regarding with the right eye inferior to the left eye (you can think of
prism diopters. The nuance here is that in the in-text prob- this as a small LHT). Since both eyes are shifted inferi-
lems, we were given the deflection in cm. Here, we are orly, we can subtract the deviation between the two eyes.
given the deflection in mm, requiring us to make an addi- Nasal gaze
tional adjustment.
30 G. V. Vicente
OD : P = hD ( 0.2 )( 4 ) = 0.8 PD BI 9. Answer: Patients with high add in their low-vision
glasses will have increased convergence demands. We
OS : P = hD ( 0.2 )( 2 ) = 0.4 PD BI can help decrease these demands by giving additional
BASE-IN power to each eye. As a rule of thumb, we
The net deviation in nasal gaze is 0.8 + 0.4 = 1.2 PD BI should give 2 PD extra base-in compared to the total
(additive effect since both eyes are looking in opposite add. Since we have already given +9.00 add for reading,
directions). the total prism necessary is (9 + 2 = 11): 11 PD BI prism
The total deviation would be 1.6 PD BD effect and 1.2 for each eye (Answer Choice D).
PD BI effect OU. 10. Answer: First of all, we messed up by giving the patient
6. Answer: Since the patient has a 6 PD RHT, we need to glasses that will cause anisometropia and aniseikonia,
“move” the right eye down by either moving the right eye so there is that issue, but since we are in the chapter of
down (by giving this eye a BD prism) and/or moving the prisms, let us apply some of the concepts we have previ-
left eye up (by giving this eye a BU prism) for a net shift ously discussed.
of 6 PD. Second, you may be intimidated by the spherocylindri-
Using Prentice’s rule: P = hD (0.25)(12) = 3. We can cal lens in the left eye. We will deal with spherocylindri-
get a 3 PD BD in the right eye by moving the optical cen- cal lenses and their bearing on Prentice’s Rule in chapter
ter down by 2.5 mm and 3 PD BU in the left eye by mov- “Spherocylindrical Lenses”,: Power Crosses and
ing the optical center up by 2.5 mm (Answer Choice D). Spherocylindrical Notation. But for now, suffice to say
7. Answer: Since the patient has a 4 PD RHT, we need to that +1.00 + 4.00 × 90 means that 4D of cylinder has been
“move” the right eye down by either moving the right eye placed IN the 90-degree (axis) meridian and will exert an
down (by giving this eye a BD prism) and/or moving the effect at the 180-degree (power) meridian; in other words,
left eye up (by giving this eye a BU prism) for a net shift when the patient looks down to read, the +4.00 will not
of 4 PD. have any role in the power of the glasses. We can basically
Currently, the prismatic effect can be calculated using treat the left eye lens as a simple +1.00 D lens.
Prentice’s rule for each eye. Note that since the patient is Applying Prentice’s rule, we can get a better under-
looking inferior to the center of a plus lens, there will be standing of what is happening (Fig. 28).
a BU effect in each eye: Basically, when the patient is reading, she is looking
through a base-down prism in the right eye and a base-up
OD : P = hD (1.2 )( 8.75 ) = 10.5 PD BU.
prism in the left eye (Fig. 29).
Using Prentice’s rule, we can calculate the prismatic
OS : P = hD (1.2 )( 6.25 ) = 7.5D BU.
effect at 1 cm below the optical center as follows:
OD : P = hD (1)( 4 ) = 4 PD BD
The net result is a 3 PD difference between the two
eyes, with the right eye shifted 3 PD BU more than the left
OS : P = hD (1)(1) = 1 PD BU.
eye.
On top of this, there is also an existing 4 PD RHT. So
the total difference between the two eyes is 7 PD. In
essence, when the patient looks downwards to read, the 4
PD RHT will become a 7 PD RHT. The only answer
+1.00 +3.00 x 90
choice that allows us to correct this 7 PD RHT is to pre-
scribe 4 PD BD to the right eye, 3 PD BU to the left eye 1 cm
(Answer Choice B).
8. Answer: As mentioned in the text, when prescribing prisms 1 cm
to alleviate hemispheric visual field defects, we should -3.00 Sphere
place the prisms such that the BASE of the prism is directed
toward the hemispheric visual field defect. In this case, we
have a left occipital lobe stroke, which will cause a RIGHT
HOMONYMOUS HEMIANOPIA. Therefore, we want to
place the bases of each prism to be pointing in the direction
of the patient’s right ear. For the right eye, this will involve
giving a BO prism; for the left eye, this will involve giving Fig. 28 Prentice’s rule can help quantify the prismatic effects in the
a BI prism (Answer Choice D). reading position
Fig. 29 Prismatic effect of reading position (lenses viewed from the side). Because the right lens is a minus lens and the left lens is a plus lens,
there will be a 4 PD base-down in the RT lens and 1 PD base-up in the left lens, respectively
1. Lower the optical center, if “h” is smaller, then the pris-

matic effect will be smaller.
2. Decrease the anisometropia, prescribe values closer to
one another.
3. Consider contact lenses, or refractive surgery to decrease
the anisometropia.
4. Be patient as young patients can develop larger fusional
amplitudes over time and adjust to the induced tropia
from the glasses.
And the last and favorite concept to quiz on the oral
boards is…
5. Write “slab off 5 Δ base down OD” on the prescription. To
4∆ B.D. determine the amount of slab off you can follow the above
Answer:
rule or simply do an alternate cover test to see how much
This patient will have vertical, LEFT. Follow the visual strabismus is being induced in the reading position. In
binocular diplopia when reading. axis from object to eye. general, “SLAB OFF” prism is always placed on the
And feel as if they have 4∆ Left more minus lens (Figure 31). “Reverse slab-off” is always
Hypertropia.
done to the more plus lens. We will discuss more about
slab-off in relation to the construction of glasses in chap-
Fig. 30 Total prismatic effect = 5 PD base-down OD. This prescription ter, “Construction of Glasses: Ophthalmologists as
will induce an annoying vertical, binocular diplopia due to a right Opticians”
hypodeviation. This would be observed in alternate cover only when the
glasses are on
Bonus points (extra question): Again, we will discuss
this concept more broadly in later chapters, but suppose
Therefore, the total prismatic effect will be 5 PD BD in the patient was looking 1 cm to the left of the optical cen-
the right eye. This will induce a right hypodeviation (or ter in both lenses. What would be the new deviation?
left hyper deviation, depending on your preferred frame Horizontal gaze for reading is not as clinically relevant as
of reference), which would be observed on alternate cover the vertical gaze, but in case you were curious5.
testing (Fig. 30). Answer: If our patient was now looking 1 cm to the left
In order to alleviate the problem in downgaze, we have of the optical center in both lenses, then using P = hD, the
a few options at our disposal: right eye would have a 4 PD BI effect. The left eye is a bit
32 G. V. Vicente
4 base in
3 base in
Fig. 32 Total prismatic effect if looking to the left will be 9 PD BI for
the right eye for this patient with OD lens −4.0 sphere and OS lens
+1.00 + 4.00 x 90
180-degree (power) meridian, when looking horizontally,

the left eye lens will now function like a + 5.00D lens.
Since the patient will look to the left of the optical center
4∆ slab-off of this lens, again using P = hD, we can determine that
there will be a 5 PD BI effect. Since both eyes are moving
in opposite directions, there will be additive prismatic
Fig. 31 Slab-off prism to be removed, side view of right lens. “Slab-
effect, so the total deviation will be 4 BI +5I = 9 BI OD
off” is always done to the more minus lens. “Reverse slab-off” is always (Fig. 32).
done to the more plus lens
trickier as we have to account for the full +1.00 + 4.00 × 90.6

Since the +4.00 D cylinder has been placed in the
90-degree (axis) meridian, it will have an effect at the
See Chap. 10, Spherocylindrical Lenses, specifically the section

6
“Prentice’s Rule, Part I” for more information on how to deal with sphe-
rocylindrical lenses.
Lenses
Daniel Wee
Objectives that all the questions on this topic that may appear on written
• To define and understand the concept of positive and neg- examinations will follow the same general format. There is
ative vergence. no groundbreaking research or developments taking place on
• To discuss the concept of objects and images in lens and this topic. Pharmaceutical companies are not spending mil-
mirror systems problems. lions of dollars to develop a new or more efficient way of
• To understand object and image properties (real vs vir- calculating where an image will end up after a light ray
tual, upright vs inverted, magnified vs minified). passes through a convex lens!1
• To understand the common types of lenses (convex and Given that these concepts are unlikely to ever change in the
concave), primary and secondary focal points, and how foreseeable future, this chapter (and the following chapter) will
they function to create images. prepare you to answer questions based on lens and mirror sys-
• To introduce the concept of ray tracing and its usage in tems. While mainly relevant for examinations, we will also
lens system problems. briefly discuss how this may have relevance to clinical practice
• To be able to apply the simple lens formula (and central (such as IOL calculation formulas). This chapter (chapter
ray tracing) to determine image positions; image orienta- “Lenses”) will focus on introductory concepts to object–lens
tion; type of image; and transverse (linear) magnification and object–mirror systems and primarily focus on lenses,
of images formed by both lenses and mirrors. including some advanced concepts for lens systems, such as
• To discuss how lens systems can be affected by different thick lenses. The next chapter (Chap. 4, “Mirrors and Combined
media. Systems”) will introduce mirrors, as well as combined object–
• To apply concepts of calculating vergence along a lens lens–mirror system problems. The usual end-of-chapter ques-
system. tions will therefore appear at the end of chapter “Mirrors and
• To briefly discuss the concept of thick lenses, including Combined Systems”, but will include concepts in both chapters
the thick lens formula. “Lenses” and “Mirrors and Combined Systems”.
One assumption that we will be making for most of this
chapter is that we will only deal with thin lenses (“thin lens
Introduction approximation”). This means that we will ignore the “thick-
ness” of a given lens (until we reach the thick lens section at the
This chapter is the first of two chapters that will cover lenses end of this chapter) and its associated aberrations and disper-
and mirrors in preparation for the purposes of written exami- sion that will take place as the light ray passes through the lens.
nations. Object–lens and object–mirror system problems are For thick lenses, due to the “substance” (thickness) of the
the quintessential tested concepts in geometric optics and are lens, we will have to account for these additional aberrations
often very confusing or boring to trainees. When vague terms and dispersions. Aberration means that light rays that origi-
such as “vergence” are mentioned, the initial reaction for nate from the same point will converge to slightly different
many people is to have glazed eyes in confusion and existen- focal points because of the lens thickness and curvature of
tial angst as to why is this important and necessary to take
care of patients? This does not have to be the case! While this
A second solace is that much of this information has relevance to fun
1
may seem to be a complex and confusing topic, one solace is things in ophthalmology, such as IOL calculation formulas.
D. Wee (*)
Center for Sight, Stockton, CA, USA

34 D. Wee
the front and back surface; dispersion means light rays will curvature of optical wavefronts.” Don’t panic if that doesn’t
get slightly shifted (displaced) as they pass through the lens. make sense! We can come up with another way of under-
Basically, for thick lenses, “three refractions” will actually standing this concept: Vergence is a term used as a descrip-
occur (i.e., the light rays will bend once at the front surface, tion given to light rays that are coming together (converging)
once at the “middle” surface and once at the back surface). If or spreading apart (diverging). For objects, light rays ema-
all of that seems needlessly complicated, we agree! That is nating from the object are almost always diverging (going
why we will stick with thin lenses for the majority of this away from the object), meaning that light rays emanating
chapter—these are much more likely to be tested. from an object have negative vergence. For images, light
Finally, the best way to prepare for these types of questions rays that form the image have passed through a lens (or mir-
is to practice them over and over, so we will present multiple ror) and may be converging or diverging—this means that
examples in the text and at the end of the next c hapter. We will images may have a positive or negative vergence, respec-
share some shortcuts and pearls that may help you avoid mak- tively (Fig. 1).
ing common mistakes made by trainees while solving these In other words, if light rays pass through a lens and come
problems. You may also wish to consult other resources and together in love and harmony, then they will be converging
question databases for more practice problems. (positive vergence). If these light rays are going away from
each other after passing through a lens because they hate
each other, then they will be diverging (negative vergence).2
bjects and Images in Lens and Mirror
O For examination purposes, vergence is simply a number
Systems Problems that we need to calculate the answers. We will later see how
we use vergence as object vergence (U) and image vergence
Conventions and Assumptions (V) in the equations to follow, especially the “Reduced
Vergence Formula (RVF).” Note that when we refer to object
Most of these problems involve the three musketeers: an or image vergence, we will use the capital letters “U” and
object, a lens (or mirror), and the image. Usually, we will be “V,” respectively. This is important because we will later on
given information about two of these musketeers and asked use small “u” and “v” to refer to object distance and image
to calculate the third musketeer. distance, respectively. Note that “U/V” and “u/v” are not
When setting up and solving object–lens and object–mir- exactly interchangeable, especially when it comes to calcu-
ror system problems, we will make several assumptions as lating magnification! When solving these problems, it is cru-
follows: cial that we make sure to keep these letters (capitalized vs.
lower-case) separate.
• Light rays (originating from either an object or an The next two definitions are primarily relevant to objects
unknown “great beyond” distance) travel from left to and images—we will discuss lenses in greater detail in the
right in a formation of parallel rays. next section.
• When light rays encounter a lens, the lens is assumed to
be a thin lens unless explicitly stated otherwise. This Real vs Virtual
allows us to ignore more complex calculations that are In The Matrix (1999), Morpheus famously says: “What is
needed for thick lens problems (which are briefly dis- real? How do you define ‘real’? If you’re talking about what
cussed in the next chapter). you can feel, what you can smell, what you can taste and see,
• When light rays encounter a lens, they will either con- then ‘real’ is simply electrical signals interpreted by your
verge or diverge based on the type of lens. brain.”
• Unless explicitly stated, otherwise, all of these fascinating For ophthalmic optics, we are going to define “real”
object–lens system problems are happening in an air slightly differently. A real object is an object that is not
medium. This will allow us to ignore more complex cal- formed by any other lens system and gives off its own light
culations for index of refraction adjustments until the end rays (diverging light rays). Looking back at Fig. 1, we can
of the chapter. see that both objects are “real” objects.
A real image is formed when light rays converge. A vir-
tual image is an image where light rays actually diverge and
we have to draw imaginary extensions to make them appear
Definitions
to converge. Again, looking back at Fig. 1, the top panel
Vergence
Alternatively, we can think that light rays that have negative vergence
2
Vergence is probably the most confusing thing about this are practicing good social distancing. Remember, we wrote this book
chapter. The official definition of vergence is listed as “the during the Great Quarantine of 2020.
Lenses 35
rays Cov
Divergent light e
(po rging
sitiv li
e ve ght ray
rge s
nce
)
Object
Image
Diverging light rays

(negative vergence)
Object Image
Imaginary extension of
diverging light rays
Fig. 1 Light rays that emanate from an object will always have a negative vergence. Light rays that form an image may have a positive or negative
vergence, depending on the type of lens that affects these light rays
shows a real image (formed by converging light rays) and the agnified vs Minified Images
M
bottom panel shows a virtual image (formed by imaginary A third feature of object–lens (and object–mirror) systems is
extensions of diverging light rays). Did we lose any of you in exclusive to images. Images that are formed by lenses (or
this matrix? Find a phone booth and call us for help—we’ll mirrors) may be either magnified or minified. While ray trac-
get you out of there! ing can give us information about image orientation, it may
For problem-solving, a real image is when the image dis- not be accurate enough to determine magnification or minifi-
tance (v) is a positive number and a virtual image is when the cation of the final image(s). The best way to determine mag-
image distance (v) is a negative number. Note that we are nification or minification is to use the RVF. Again, we will
using lower case “v” to when referring to the image distance. save the math for this concept until the end of the chapter.3
We will discuss this in greater detail when we introduce the
RVF later in the chapter.
Lenses
pright vs Inverted
U
We previously introduced “real” and “virtual” to describe In the previous section, we discussed certain features of
one feature of objects and images. Another important feature objects and images. In this section, we will focus on lenses.
is the orientation of objects and images. Objects and images Note that these concepts are important not only to better
can be upright (erect) or inverted. In general, objects will understand lenses, but also to appreciate how these concepts
always be upright so long as they are real objects. But for are similar and different when dealing with mirrors (Chap. 4,
images, they may be upright or inverted, depending on how “Mirrors and Combined Systems”).
the image is formed. Later in this chapter, we will discuss
how both ray tracing and RVF allow us to determine if the
image is upright or inverted. In Fig. 1, the top panel shows an
inverted (and real) image; the bottom panel shows an upright Note that this refers to linear (transverse) magnification. We will dis-
3
cuss other types of magnification in Chap. 8, “Telescopes and

(and virtual) image. Magnification”.
36 D. Wee
Fig. 2 Primary (F1) and

secondary (F2) focal points
for a plus lens. Light rays that
undergo refraction by the lens
will be focused at the
secondary focal point. The
primary and secondary focal
points can be calculated by
taking the reciprocal of the +4D
lens power
25 cm 25 cm
F1 F2
Positive Lenses Note in Fig. 2 that the inferior light ray from F1 strikes the
bottom portion of the lens, undergoes refraction, and exits
A positive (plus) lens is also known as a converging lens. We with zero vergence.
can represent a positive lens by stacking two prisms together The secondary focal point is the location at which light
such that the bases of each prism are touching each other.4 rays parallel to the optical axis (which have zero vergence),
When we draw them out, it is helpful to maintain this strike the lens, undergo refraction, and come together (con-
“diamond” shape as it will help us to do ray tracings. Recall verge) to the right of the lens (Fig. 2). The secondary focal
from Chap. 2, “Prisms in Ophthalmic Optics” that real light point is extremely important for solving object–lens system
rays will bend toward the base of a prism. Therefore, light problems because it gives the location of light rays that
rays that travel through a plus lens at either end will be bent undergo refraction by the plus lens. Just as we calculated
toward the base. This will give us an idea of where these light the location of the primary focal point for our given +4D
rays will converge (Fig. 1). This will also help us to perform lens, we can use the same reciprocal to calculate the sec-
ray tracings. ondary focal point as 0.25 m (25 cm) located to the right of
Note that we can also draw positive lenses as horizontal the lens.
diamonds. This will be helpful in later sections to under-
stand concepts such as convergence and strabismus. For
lens and mirror problems, however, we will only need to Negative Lenses
use the “vertical diamond” configuration for positive
lenses. We will always draw negative lenses as two prisms stacked
on top of each other such that the apices of each prism are
rimary and Secondary Focal Points
P touching (“hourglass shape”) (Fig. 1, lower panel).
Both plus and minus lenses have a primary and secondary Note that we can also draw negative lenses horizontally
focal point. Let us first define these terms and then discuss in a “bowtie” configuration. This will be helpful in later
why they are important. sections to understand concepts such as convergence and
For a plus lens, the primary focal point is located to the strabismus. For lens and mirror problems, however, we will
left of the lens. This is the location for which a light ray ema- only need to use the “hourglass” configuration for negative
nating from the object passes through until it strikes the lens, lenses.
undergoes refraction, and then exits the lens in a path parallel For a minus lens, the primary focal point is still defined as
to the optical axis (i.e., with zero vergence). the location at which light rays that emanate from the object
The primary focal point can be calculated by taking the will strike the lens and exit the lens with zero vergence (i.e.,
inverse of the lens power. For example, if we are given they remain parallel) (Fig. 3). The key difference for a minus
a + 4D lens, we can calculate the primary focal point as lens is that the primary focal point is located to the right of
1/4 = 0.25 m (25 cm), located to the left of the lens (Fig. 2). the lens. This would mean that the object would have to be
placed to the right of the lens in order to have light rays that
See Fig. 11, in chapter “Prisms in Ophthalmic Optics”, Prisms, for a
4 converge. Thus, light rays that are located to the left of a
review of this concept. minus lens will always diverge away from the minus lens.
Lenses 37
Fig. 3 Primary (F1) and -4D

secondary (F2) focal points
for a minus lens. Light rays
that undergo refraction by the
lens will be focused (via
imaginary extension) at the
secondary focal point. Note
that for a minus lens, the
secondary focal point is
located to the left of the lens. 25 cm 25 cm
The primary and secondary F2 F1
focal points can be calculated
by taking the reciprocal of the
lens power
Therefore, for minus lenses, the secondary focal point is Definitions

still defined as the location at which light rays parallel to the
optical axis (which have zero vergence) come together (to Optical Axis
the left of the lens) after undergoing refraction. The key dif- The “optical axis” used in geometric optics is different than
ference is that for minus lenses, we have to create imaginary the optical axis used for cataract and refractive surgery,
extensions of the refracted rays (note the dotted line in Fig. 3) which is discussed in Chap. 26, “Preoperative Optics for
onto the secondary focal point. The secondary focal point is Cataract Surgery”. For our discussions in this chapter, the
extremely important for solving object–lens system prob- optical axis refers to an imaginary perpendicular line that
lems because it gives the location of light rays that undergo passes through the center of a lens. For example, the optical
refraction by the minus lens. axis is the “thick” blue line in Figs. 1, 2, and 3 presented
The calculation of the primary and secondary focal point earlier. The optical axis is useful when drawing ray tracing
location for minus lenses is still the same: We can use the diagrams for object–lens systems because it primarily serves
same reciprocal calculation for a given -4D lens to calculate as a frame of reference. Note: Some texts may refer to this as
a primary focal point of 0.25 m (25 cm) located to the right the “optic axis” as well.
of the lens and a secondary focal point of 0.25 m (25 cm)
located to the left of the lens. Cardinal Rays
While there are an infinite number of light rays that emanate
from an object, we do not have time to deal with every whiny
Ray Tracing little light ray. Starting with a given object–lens system using
a plus lens, we can focus our attention instead on the cardinal
Before we get into the mathematical problem-solving of rays, which are the three most important light rays that help
object–lens systems, we will first discuss the concept of ray determine the location of the image (Fig. 4), if we know the
tracing as a useful foundation to understand later problems. focal point(s) of the lens. Remember that we can calculate
In the previous discussion of primary and secondary focal the primary and secondary focal points by taking the recipro-
points, we used some elementary concepts of ray tracing. cal of the lens power.
Ray tracing is helpful because it gives us a visual idea of
where light rays will end up after undergoing refraction by a • Cardinal Ray #1: Light ray from the object that starts on
lens (or undergoing reflection by a mirror). a course parallel to the optical axis until it reaches the
Note that ray tracing is not crucial to solving object–lens lens, then undergoes refraction (positive vergence) and
system problems! We can instead use the equations presented continues in a straight line through the secondary focal
in the next section to calculate information such as image point
location, size, and orientation. If this section seems to be • Cardinal Ray #2: Light ray from the object that passes
confusing on a first-time read, you may wish to skip ahead to through the center of the lens and ignores the primary and
the next section and come back to this section on a future secondary focal points altogether. This is also known as
reading. the central ray
38 D. Wee
Fig. 4 The three cardinal

rays (CR1, CR2, and CR3)
can be used with a plus lens
to help determine the image
location. CR1 will undergo CR1
refraction and will be focused
at the secondary focal point CR
2
(F2). CR2 will pass through
the center of the lens without
undergoing any refraction.
CR3 will pass through the CR
primary focal point (F1) until F1 3 F2
it reaches the lens, then exit
the lens with zero vergence
(parallel to the optical axis)
• Cardinal Ray #3: Light ray from the object that passes We can similarly draw the three cardinal rays for a minus
through the primary focal point until it reaches the lens, lens using the same strategy we used with a plus lens (Fig. 5).
then continues on a course parallel to the optical axis The first cardinal ray undergoes refraction away from the
(zero vergence) minus lens (negative vergence)5; therefore, we can draw an
imaginary extension toward the secondary focal point to the
Note that the image can usually be determined by the left of the lens. The second cardinal ray passes through the
meeting point of two out of the three cardinal rays as well. center of the lens, similar to the second cardinal ray for a plus
For the sake of sophistication and showing people we know lens. Finally, the third cardinal ray passes through the sec-
geometric optics, we can draw all three rays whenever ondary focal point until it strikes the lens and continues on a
possible. path parallel to the optical axis (zero vergence). Note that the
image can be determined simply by the intersection of the
first and second cardinal ray (red arrow).
Concepts and Methods of Ray Tracing Finally, the concept of ray tracing is clinically helpful for
understanding concepts used in cataract surgery. For exam-
If we have an object located to the left of a given lens, we can ple, the Olsen formula uses ray tracing (and a thick lens
use the optical axis and the cardinal rays to set up ray tracing model) to help calculate the IOL power. In addition, ray trac-
and determine the location of the image in a given object– ing is helpful to understand postoperative problems such as
lens system. In the previous example, we showed the ray Holladay’s model of negative dysphotopsia.6
tracing for a plus lens.
As an additional note regarding plus lenses, we can use
ray tracing to determine where the image will form based on I mportant Equations for Lens and Mirror
4 potential object locations. You can practice this on your System Problems
own, but we can summarize this as follows:
While ray tracing is helpful to visualize the path of light rays
• Object very far away from the lens (extremely left of the in an object–lens system, it is more likely that one will
focal point): the image will be real, inverted, and encounter examination problems wherein one will be asked
minified to calculate the exact location of the image, its size (magni-
• Object close to the lens (minimally left of the focal point): fied/minified), its orientation (upright/inverted), and its
the image will be real, inverted, and magnified nature (real/virtual).
• Object placed at the focal point: trick question—no image
is formed! Mathematically, the image is located at This is a good time to review a lesson from Chap. 2, “Prisms in
5
“infinity” Ophthalmic Optics”. Notice that this CR1 is hitting the base-up prism
• Object placed to the right of the focal point: image will component of this lens; since it is a real light ray, it will be bent toward
the base.
form to the left of the object (virtual image) and will be
Holladay JT, Zhao H, Reisin CR. Negative dysphotopsia: the enig-
6
upright and magnified. matic penumbra. J Cataract Refract Surg. 2012 Jul;38(7):1251–65.
Lenses 39
Fig. 5 The three cardinal

rays (CR1, CR2, and CR3)
can be used with a minus lens
to help determine the image CR1
location (red arrow). CR1 and
CR2 can be used to determine CR2
that the image will form to the
left of the lens. Ray tracing
can also help determine that
the image will likely be CR
upright and minified (relative F2 3 F1
to the original object)
There are only two key equations we need to know in • (big) V = image vergence: calculated as 1/v (in meters) or
order to solve these object–lens (and object–mirror) prob- 100/v (in cm)9
lems. Neither will be provided on examinations so you must • (little) v = image distance
memorize them!
The reduced vergence formula (RVF) is the bread-and- A few helpful comments regarding this equation10:
butter equation for object–lens system problems.7 It is based
on the principle that the sum of the object vergence (U) and • It may help to convert calculations into “100/x” and work
the power of the lens (D) equal the image vergence (V). The with cm instead of working with decimals. You can
other equation is the magnification formula; in addition, to choose to work with 1/x or 100/x depending on which
giving information about magnification, it can also give kind of math is easier for you to do in your head (or with
information about image orientation and nature (real/ pen and paper).
virtual). • For all of these problems, we will assume that light travels
Let us explore each of these formulas in greater detail. from left to right, unless explicitly stated otherwise.
• If the problem does not state where the light rays are orig-
inating from or use terminology (“light rays from infin-
educed Vergence Formula (Simple Lens
R ity,” “parallel light rays strike a lens,” etc.), then we can
Formula) assume that U = 0. Mathematically, if the light rays are
originating from a (galaxy) far, far away, then the 1/u will
U +D =V be such a small number that we can make it zero in order
to calculate the rest of the problem.
• (big)U = object vergence (almost always negative!): cal- • Finally, remember that the math for these problems should
culated as 1/u (in meters) or 100/u (in cm).8 be relatively easy because they would not allow you to
• (little) u = object distance (almost always negative!) use calculators on the actual examination. If you suddenly
• D = lens or mirror power (may sometimes be written as P find yourself calculating some very ugly numbers, stop
in other texts). We will use D to represent diopters, since and re-assess: You may have flipped the numerator/
the power of the lens is measured in diopters. denominator somewhere, or plugged in the wrong num-
ber for the wrong variable.
We use 1/v (or 100/v) for the majority of these calculations because we
9
We will skip how this formula is derived for the sake of keeping your
7
assume that we are working in air (index of refraction = 1.00). If an
sanity. For those who wish to understand how this formula is derived, object–lens system were immersed into a different medium, such as
consult other texts or Google it if you are extremely bored. This formula water (index of refraction = 1.33), then we would have to accordingly
also has several other names, such as simple lens formula and vergence calculate V = 1.33/v (or 133/v).
formula. The RVF is a modification of Snell’s law of refraction. The full math-
10
We use 1/u (or 100/u) for the majority of these calculations because we
8
ematics for this has been nicely described in other texts and is beyond
assume that we are working in air (index of refraction = 1.00). If an the scope of our discussion. Another confusing aspect of this terminol-
object–lens system were immersed into a different medium, such as ogy is that some textbooks refer to this formula as the lens maker’s
water (index of refraction = 1.33), then we would have to accordingly equation. We will discuss the lens maker’s equation (i.e., a different
calculate U = 1.33/u (or 133/u). equation) in Chap. 5, “Power of Lenses in Different Media”.
40 D. Wee
Fig. 6 If parallel rays +5 D

approach a + 5D lens, where
will the image form?
While many of these reciprocals (diopters and distances) Example #2 If an object is located to the left of a + 7D lens
can be easily calculated, the following table may help serve and forms an image 25 cm to the right of the lens, where is
as a refresher for commonly encountered powers and the object?
distances11: Answer: We can draw this problem out if we would like,
but we can skip to the chase and use our RVF equation. The
Diopter values (D) Distance (in cm) question is asking us to calculate “u,” which is the reciprocal
0.25 400 cm
of U. If we can calculate U, we can easily calculate u. We are
0.33 300 cm
0.50 200 cm given v as 25 cm, so we can calculate V as 100/25 = +4.
1.00 100 cm Therefore: U + D = V, which can be re-arranged so that
1.33 75 cm U = V – D.
1.50 67 cm U = 4–7 → U = −3. Therefore, u = 100/−3 = −33 cm, or
2.00 50 cm 33 cm to the left of the lens.
2.50 40 cm At this point, you may wonder: “Who cares about
3.00 33 cm
U+D=V? I just want to do cataract surgery and help people
4.00 25 cm
5.00 20 cm
see well!” Well, most IOL calculation formulas, including
6.00 16.6 cm some current multi-variable generation formulas, are essen-
7.00 14 cm tially modifications of RVF from the nineteenth century
8.00 12.5 cm adapted to modern technology. In order to calculate the IOL
9.00 11 cm power needed, modern formulas use various biometric mea-
10.00 10 cm surements of the eye to approximate “U” and “V” in order to
calculate “D” (the IOL power). An example of a modern IOL
We can see how the RVF can help us solve commonly formula is shown in Fig. 7. If you do cataract surgery, you
asked questions about object–lens system problems in the have to care about U + D = V!
following examples.
Example #1 If parallel light rays approach a + 5D lens, Magnification Formula

where will the image form (Fig. 6)?
Answer: Since the question stem gives us no information m = U / V or v / u
about the origin of the light rays, we can assume that the light
rays are originating from an extremely far-off distance. The magnification formula does not simply give us infor-
Therefore, if u is an incredibly far away distance, then mation about the linear (transverse) magnification of an
1/u = 0, for the purposes of this problem. object–lens system. It can also be used to determine (1) ori-
So, our U + D = V will become D = V. entation of the image (upright/inverted) and (2) nature of the
V = D = 1/0.05 (or 100/5) = 20; the image will form 20 cm image (real/virtual).
to the right of the lens. In this equation, the following terms are defined as follows:
• m is linear (transverse) magnification.12

We have included this table based on years of feedback from trainees
11
expressing frustration how they had set up the equation correctly but We will discuss other types of magnification in greater detail in
12
goofed the reciprocal calculation and ended up with the wrong answer. Chap. 8, “Magnification and Telescopes”.
Lenses 41
Fig. 7 Modern IOL

calculation formulas are 1336
modifications of the simple
lens formula. Different 1336
variables (e.g., axial length, ELPo
1000
keratometry, central corneal 1336
IOL Power Ko
thickness, white-to-white
ALo–ELPo
ratio, refraction, and anterior 1000
Lens Vergence (D)
chamber depth) are used to V
Image Vergence (V)
enhance the accuracy of “U” DPostRx
or “V” in order to calculate
the IOL power (“D”) Object Vergence (U)
• U is the object vergence. means we have an inverted, magnified image with 5× magni-
• V is the image vergence. fication. Remember that the minus sign denotes inversion,
• u is the object distance (from the lens or mirror). not minification.
• v is the image distance (from the lens or mirror). We can now use a few examples to reinforce some of the
concepts we have discussed so far with both the RVF and
A few helpful comments regarding this equation: magnification equations. These should be fairly easy to
understand at this point. If you are having any difficulty with
• Magnification can be determined by both m = U/V or these examples, re-read the above sections until they make
v/u → a helpful mnemonic is as follows: “big MOVIE, (some) sense.
little VIEW.” “MOVIE” may help you to remember that
the “big U” goes over the “big V,” and “VIEW” may help Convex (Positive) Lens Example #1
you to remember that “little v” goes over the “little u” An object is 20 cm to the left of a + 7 D converging lens.
when you want to calculate magnification. Depending on Where is the image? Is it real or virtual? Is it upright or
the question, you may only be given “U/V” or “v/u,” so it inverted? Is it magnified or minified?
is important to know how to use this equation using both We can walk through this one together step by step. It is
terms. Of course, if given “U,” you can always calculate always helpful for these problems to start off by drawing out
“u” by u = 1/U, etc. a rough sketch of the object–lens system (Fig. 8).
• Positive m is upright; negative m is inverted. You can The object is 20 cm or 0.20 m to the left of a lens. That
always use this to mathematically make sure that you tells us u = −0.2 m.
have correctly determined the orientation of the image. Remember that U and u are almost always negative.
Note that negative m does not mean that the image is min- The exception to U being negative is when we are dealing
ified, it simply means that the image is inverted. This is a with multiple lenses or mirrors wherein the intermediate
common mistake that many trainees make when first image (aka secondary object) appears to the right of the
doing these problems. lens—we will do this example in the end-of-chapter
• For magnification, we will use the absolute value of m. problems.
Therefore, |m| > 1 is magnified and |m| < 1 is minified. In order to reinforce some of the concepts we have dis-
The value of m can be used to determine how large the cussed thus far, we can draw out the ray tracings for this
image will be relative to the original object. problem. While not necessary for every problem, drawing a
• Remember that positive V is a real image, and negative V ray tracing may be helpful because it will give us some infor-
is a virtual image. mation about the image.13
In the previous section, we discussed how to use three car-
For example, suppose we solve an object–lens system dinal rays for ray tracing. We can take a shortcut by simply
using the RVF, and then using the magnification formula, we using the first two cardinal rays (CR1 and CR2): start by draw-
get m = 2. This means we have an upright, magnified image ing a ray from the top of the object that strikes the top part of
with 2x magnification. If our original object is 2 m tall, then the lens—this ray will bend toward the base and pass through
our image is 4 m tall and upright. the secondary focal point. Do not worry if you do not know the
As another example, suppose we use the magnification exact location of the secondary focal point, just draw a line
formula for another object–lens system and we get m = −0.5. that gets refracted by the lens, emerges to the right of the lens,
This means we have an inverted, minified image with 1/2× and bends toward (and through) the optical axis and the
magnification (i.e., the image is 50% the size of the original assumed secondary focal point location. Then draw a ray from
object). If our original object is 2m tall, then our image is 1m
tall and upside down. As a final point, suppose m = −5. This Refer to the previous section for a detailed discussion on ray tracing.
13
42 D. Wee
Fig. 8 Object–lens system +7D

for an object located 20 cm to
the left of a + 7D converging
lens. Where will the image
form?
20 cm
Fig. 9 The first two cardinal +7D

rays can be used to give
information about the
location, orientation, size, and
nature of the image located to
the right of the lens
20 cm
the top part of the object that passes through the central part of From the ray tracing, we can see that the image will be
the lens (the central ray) that does not get refracted. This will located to the right of the lens (real image) and it will be
give you a rough idea of where the image will form. It may inverted. It may also be magnified but we cannot be certain
also give you information about the orientation and size of the of this, so we will have to do put on our hard hats and do
image if you have drawn it correctly (Fig. 9). some real work now using the RVF:
u = −0.2m ( this is the object distance ) or − 20 cm
U = 1 / u = 1 / −0.2m = −5 ( this is the object vergence ) or 100 / −20 = −5
U +D =V
−5 + 7 = V = 2 ( this is the image vergence )
v = 1 / V = 1 / 2 = 0.5m ( this is the image distance ) or 100 / 2 = 50 cm
Now we know the image is 0.5 m or 50 cm to the right of Wonderful! We have a magnified image (2.5×), an inverted
the lens. We know it is a real image because v is a positive image (since m is negative), and a real image because v is
number. positive.
m = U / V = −5 / 2 = −2.5 or m = v / u = 50 / −20 = −2.5
Convex (Positive) Lens Example #2
An object is 10 cm to the left of a + 8D converging lens.
(Note that we can calculate magnification using either
Where is the image? Is it real or virtual? Is it upright or
U/V or v/u; we should get the same number either way).
inverted? Is it magnified or minified?
Lenses 43
Fig. 10 Where will the +8D

image form if the object is
10 cm away from this +8D
converging lens?
10 cm
Answer: Again, start off by drawing out the lens system as We will skip drawing the ray tracing for this problem and
presented in the question stem to get your bearings (Fig. 10). get to the chase:
(
u = −10 cm or − 0.10 m make sure that “u” is negative ! )
U = 1 / u = 1 / −0.1 = −10 ( this is the object vergence ) OR 100 / −10 = −10
U +D =V
−10 + 8 = V = −2 ( this is the image vergence )
v = 1 / V = 1 / −2 = −0.5 m ( this is the image distance ) OR 100 / −2 = −50 cm
v = −0.5 m means the image is virtual (since it is negative) Concave (Minus) Lens Example #1
and 50 cm to the left of the lens. Remember, positive v means A 10-meter-tall object is 50 cm to the left of a − 3 D lens.
there is a real image to the right of the lens and a negative v How tall is the image and is it upright or inverted?
means there is a virtual image to the left of the lens. Answer:
Start off this problem by drawing out a rough sketch of
m = U / V = −10 / −2 = 5 OR v / u = −50 / −10 = 5 the object–lens system and doing the ray tracing. We will
So, we have a magnified, upright image that is 50 cm to draw one ray from the top of the object that strikes the top
the left of the lens. part of the lens and gets bent toward the base—this line will
Suppose the question stated that the original object was have to then have an imaginary extension “backward” to the
8 cm in height. The final image size will be 8 cm × 5 = 40 cm left of the lens. Then, we will draw a ray from the top part of
in height. the object that passes through the central part of the lens
In the previous two examples, we have shown how a posi- (central ray) that does not get refracted (Fig. 11).
tive lens can give an image to both the right and the left of the The point at which the first two light rays will intersect with
lens. As we do more problems, we will see how (a) the loca- the optical axis will give you a rough idea of where the image
tion of the object and (b) the power of the lens can affect will form. It may also give you information about the orienta-
where the image will be located. Do not always assume that a tion and size of the image if you have drawn it correctly. From
convex (plus) lens will always lead to an image on the right! the figure above, it would seem that our image will be upright,
We can solve a few additional examples with minus lenses virtual, and minified. But we should do the actual work here
to reinforce some of the concepts, we have discussed so far. and make sure that our initial conclusions are correct.
u = −0.50m ( make sure U and u are negative !) or − 50 cm

U = 1 / u = 1 / −0.5 = −2 ( this is the object vergence ) OR 100 / −50 = −2
U+D = V
−2 + ( −3 ) = V = −5 ( this is the image vergence )
v = 1 / V = 1 / −5 = −0.2m ( this is the image distance ) OR 100 / −5 = −20 cm to the LEFT of the lens
m = U / V = −2 / −5 = 0.4 ( this is the magnification ) OR v / u = −20 / −50 = 0.4
44 D. Wee
Fig. 11 Ray tracing for an

object (10 meters height)
located 50 cm to the left of
a –3D lens. Note: The
object–lens system is not
drawn to scale -3D
Object
10 m
50 cm
Image
Fig. 12 An object is placed -5D

in front of a −5D lens. The
image is formed at the
midpoint between the object
and the lens. At what distance
from the lens was the object?
image
object
Based on these calculations, our image is upright (since m tal question? No problem! If the examination gives you a
is positive), virtual (since v is negative), and minified (since question with no numbers, make them up!
|m| < 1). The image is 20 cm to the left of the lens. We can make our lives easier by making the numbers
As for the size of the image: 10 m × 0.4 = 4 m image size. easy. Let us make u − 1 and the power of the lens −1D.
u = −1
Concave (Minus) Lens Example #2
U = 1 / u = −1
An object is to the left of a diverging lens. Is the image
upright or inverted? Real or virtual? Magnified or minified? U +D =V
Answer: Do we have enough information to solve this?
−1 + ( −1) = V = −2
We did not get any numbers! Was this a typo? An experimen-
v = 1 / V = 1 / −2 = −0.5m ( our image is 50cm to the left of the lens )

m = U / V = −1 / −2 = 0.5
Therefore, our image will be upright (m is positive), vir- Concave (Minus) Lens Example #3
tual (v is negative), and minified (|m| < 1). If this was an An object is placed in front of a −5D lens. The image is
experimental question, they better give us extra points for formed at the midpoint between the object and the lens.
doing this extra work! Where is the object?
The takeaway from this example is that if a problem has Answer: This is a bit of a trickier question. Let us start off
no numbers, you can make them up in order to determine by drawing out what the problem stem is describing (Fig. 12).
the piece(s) of information being asked. Remember, the We know that the image is between the object and the
basic information for this topic is never going to change— lens; we also know that this is a diverging lens, so it must be
how this concept may be tested, however, may change over a virtual image. Since the image distance is half of the object
time. distance, this means that v = ½ u.
Lenses 45
We can now solve for U and V : V = 1 / v = 1 / (1 / 2u ) . So 2U = V
Now we can use our trusty equation: would be shifted to the right considerably, causing a hyper-
U + D = V → U + D = 2U opic shift. Therefore, the power of the lens needs to be
U + ( −5 ) = 2U adjusted (increased) in order to form an image at the desired
location when considering a medium with stronger index of
So, U = −5, V = 2 × ( −5 ) = −10. refraction.
Therefore, the object distance (u) from the lens is
100/−5 = −20 cm to the left of the lens.
The image distance (v) from the lens is 100/−10 = −10 cm Calculating Vergence Along a Lens System
to the left of the lens.
Another way these concepts can be tested is to ask questions
about vergence along a lens system. We have previously dis-
Lens System with Different Media cussed how vergence can be positive (convergence) or nega-
tive (divergence).
In the previous examples, we assumed that the object–lens For this subtopic, suppose that we are using a positive lens:
system was occurring in air. For example, we were able to We can remember that the vergence of light rays immediately
use 1/u (or 100/u) to calculate U and 1/v (or 100/v) to calcu- as they leave the lens is equal to the power of the lens. As these
late V. However, not all object–lens systems occur in air as light rays approach the focal point (where the image will form),
sometimes the image will form in a different medium. The they will converge until the focal point. Mathematically, this
best example for this is the eye itself: We view objects (in means that their vergence will quantitatively increase until the
air), but the image forms in a water (vitreous) medium. focal point—at this point, they will have joined together in love
Therefore, we have to account for the different indexes of and harmony and the vergence will be infinity.
refraction when calculating the location of an image. The In order to calculate the numerical vergence along a lens
clinical relevance for this concept occurs all throughout oph- system, follow these simple rules:
thalmology; IOL calculation formulas are one example of
why it is important to account for a different indexes of 1. Solve the lens system using U + D = V.
refraction in regards to image location. 2. Calculate the distance from the given point from the
Consider the following example: Suppose we had an image by subtracting the distance between the point and
object that is located 1 m to the left of a + 3D lens that has the location of the final image.
been placed in a water medium. To make the math easier, 3. Divide this distance by 100. This will be the vergence of
assume that the front surface of the lens is in air and the back the light rays at that given point.
surface of the lens is in water. 4. Again, as you move closer to the focal point, the vergence
We can use our familiar U + D = V equation: should continue to increase.
U + D = V → U = −100 / 100 = −1 Let us do an example (Fig. 13). In the lens system below,

−1 + 3 = V = +2 what is the vergence at points A, B, C, D, E, and F?

Let us set up our equation:
At this point, if the system was in air, we can simply use
100/2 = 50 cm to state that the image would form 50 cm to U + D = V → 100 / −11 = −9
the right of the lens. However, we have to account for the
water medium (n = 1.33). −9 + 14 = 5 (V )

Therefore: V = 1.33/v, v = 1.33/V = 1.33/2 = 67 cm. The Therefore, v = 100/5 = 20 cm to the right of the lens.
image will form 67 cm to the right of the lens (in water). At point A: The vergence here should equal V = +5D.
As should be evident, this has implications because the At point B: Point 5 is 5 cm to the right of the lens, but
image is significantly shifted to the right in a water medium more importantly, it is 15 cm from the location of the image.
as compared to an air medium. Suppose we wanted a lens So, vergence at this point will be 100/15 = +6.67 D
(imagine this is an IOL) such that the image formed at vergence.
50 cm.14 If we simply used “in-air” calculations, the image At point C: Point C is 12.5 cm from the location of the
image. Vergence at this point will be 100/12.5 = +8D ver-
Obviously, this would be a giant eye, but just use this example to
14 gence. Notice how our numbers are increasing at each point
understand the concept. as we are approaching the image.
46 D. Wee
Fig. 13 Calculating vergence +14D

along a system: What is the
vergence of light at each of
these locations? A B C D E
Location
11 cm 5 cm of Image
7.5 cm
15 cm
Fig. 14 What is the vergence -2D

U=0
of light at each of these
locations?
10 15 cm 25 cm
A B cm C E
At point D: Point D is 5 cm from the location of the image. At point A: Point A is 0 cm from the location of the image, so
Vergence at this point will be 100/5 = +20D vergence. Again, 100/0 = ∞. Infinite vergence (of the imaginary, extended rays).
our numbers are continuing to increase, so we must be doing At point B: Point B is 25 cm from the location of the
something right! image. Vergence at this point will be 100/−25 = −4.0D
At point E: Point E is 0 cm from the location of the image (because we are dealing with divergent light).
(because it’s right at the image, duh!). Therefore, 100/0 = ∞. At point C: Point C is 35 cm from the location of the
This makes sense because at this point all the light rays have image. Vergence at this point will be 100/−35 = −2.86D
finished converging. (admittedly a yucky number).
For minus lenses, the vergence of all real light rays after At point D: This is the vergence of light rays leaving the lens,
they have passed through the lens will be zero (because they aka the “V” in U + D = V. Vergence at this point will be −2D.
will diverge). We will have to calculate the “vergence” of the At point E: Point E is 75 cm from the location of the
imaginary light rays in a similar fashion to the problem image. Vergence at this point will be 100/−75 = −1.33D.
above. Mathematically, we will use “negative vergence” to In summary, calculating vergence along a lens system is
describe these imaginary light rays, as technically they are simply a wrinkle to the previously discussed concepts. If we
not converging in the same manner as real light rays. Do not first solve the RVF, we can then use this information to cal-
think about this topic for too long lest you get lost in the culate vergence at a given point in the object–lens system.
abyss of vergence… just understand the concept as described
above and the associated calculations.
We can do one more example (Fig. 14). In the lens system Thick Lenses
below, what is the vergence at points A, B, C, D, and E? We
will assume the incoming pencil of light rays are originating A word of caution: We hope this section is low yield. We
from infinity (U = 0). hope that examination makers will not be mean enough to
Answer: We can again start by using our U + D = V equa- put these problems on the examination because the math is
tion. We are told that U = 0, so D = V, so V = −2. Solving for often quite difficult and requires calculators. However, there
v (100/V), we can determine that the image will form 50 cm may be several ways to test this concept.
to the left of the lens at point A.
Lenses 47
Fig. 15 The power of a thick Pant P

post
lens is a sum of the powers of
the anterior surface, posterior
surface, and the “middle
surface.” The middle surface
power is determined by the
lens thickness, index of
refraction, and power of the n = 1.5
anterior and posterior surface:
(Pmiddle = − (t/n)(Pant × Ppost).
In this example, the thickness
of the lens is 10 cm (t = 0.1)
and the index of refraction is Back
Front
1.5 surface power t = 10 cm surface power
“Middle surface” power

Pmiddle = –(t /n )(Pant x Ppost )
We should pause for a moment here and understand why Therefore, the power of a thick lens is as follows:
this has clinical and practical significance. Recall that we Pant + Ppost – (t/n)*(Pant × Ppost).
earlier said we will make a “thin lens approximation” when Note that we did not include this in the hi-yield list of
doing U + D = V problems. In reality, all lenses (e.g., the formulas to know!
cornea, crystalline lens, and spectacle lenses) have both a Let us do some thick lens examples:
front surface and back surface that contributes to the refrac-
tive power of the lens.15 In addition, the thickness of that lens Example #1
(and index of refraction) will also contribute to the refractive If a lens has a front surface power of +8.00D, back surface
power of the lens. This means that there are 3 places of power of −3.00D, thickness of 5 cm, and index of refraction
refraction when light rays pass through a thick lens (Fig. 15). of 1.5, what is the total (net) power of the lens?
In order to calculate the power of a thick lens, we have Answer:
to account for all three places of refraction: the front sur- We can simply plug in the values into our thick lens
face (and its power), the back surface (and its power), and equation:
the “middle surface” (the adjustment for the thickness of Power of Thick Lens = Pant + Ppost – ( t / n ) ∗ ( Pant × Ppost )
the lens). The “middle surface” power relies on the thick-
= +8 + ( –3 ) – ( 0.05 / 1.5 ) ∗ ( 8 × –3 )
ness (t) of the lens (in meters!), the index of refraction (n),
and the power of the anterior surface and posterior surface = 5 – ( 0.033 ) ∗ ( –24 )
(Pant and Ppost). When given a thick lens, usually the front = 5 – ( –0.8 )
surface will be a convex lens (plus power) and the back = +5.8D
surface will be a concave lens (negative power).16 When we
Two other points we can note at this time:
look at Fig. 15, we can see how the shape of the front sur-
face of the cylinder resembles a convex lens, and how the 1. The thicker the lens, the more “power” that the “middle
shape of the back surface of the cylinder resembles a con- surface” will have. This is subtracted from the other two
cave lens. surfaces, leading to an overall decreased power of the
The power of the “middle surface” is as follows: lens.
Pmiddle = − (t/n)*(Pant × Ppost). 2. The higher the index of refraction, the less “power” that
the “middle surface” will have. This is subtracted from
the other two surfaces, leading to an overall increased
This is one (of many) reason(s) that older generation IOL formulas are
15
power of the lens.
often inaccurate as they rely on the thin lens approximation. For exam-
ple, the cornea is reduced to a single refractive surface. While this may
work (relatively) accurately for very normal eyes, these formulas’ accu- Example #2 (Clinical Relevance)
racy drops off significantly in eyes with unique biometric data. See If a cornea has a front surface power of +48D, back surface
Chap. 26, “Preoperative Optics for Cataract Surgery” for more power of −6.00D, thickness of 550 microns, and index of refrac-
information.
tion of 1.376, what is the total (net) power of the cornea?
The cornea is a great example of a thick lens with a convex front sur-
16
face and concave back surface.

Answer: We can again use our thick lens equation:
48 D. Wee
Power of Thick Lens = Pant + Ppost – ( t / n ) ∗ ( Pant × Ppost )

= +48 + ( –6 ) – ( 0.00055 / 1.376 ) ∗ ( 48 × –6 ) → ( ugly math follows )
= 42.12 D
No one would expect you to be able to do the math for this measurements if considering combined cataract surgery with
example. The main learning point is to appreciate how the endothelial keratoplasty. The second learning point is we
“middle surface” of a thick lens has to be accounted for when should appreciate how the back surface of the cornea con-
calculating the total power of the lens. Hence, some of the tributes negative power to the total net power of the cornea.
newer IOL calculation formulas use the central corneal The third learning point is we should be thankful we have
thickness measurement as an additional factor to potentially calculators to solve these problems for real-life, clinical
increase accuracy. We can also see how corneal edema (e.g., purposes.
Fuchs’ endothelial dystrophy) can skew the corneal power
Mirrors and Combined Systems
Daniel Wee
Objectives Mirrors
• To understand common types of mirrors (plano, convex,
and concave) and how they function to create images In order for a smooth surface to function as a mirror, it must
• To understand how mirror systems will share similar fea- reflect as many light rays as possible, while minimizing
tures as lens systems and also have their own unique refraction and absorption. For ophthalmic optics, we will
image characteristics focus our discussion on three kinds of mirrors: plano mir-
• To solve problems with multiple lenses and lens–mirror rors; positive (concave) mirrors; and negative (convex)
combinations mirrors.
• To review common mistakes made when solving lens and
mirror system problems
Plano Mirrors
Introduction Think of plano mirrors as objects that contain a portal to an

entire parallel universe that exists in the mirror. This parallel
In the previous chapter, we primarily focused on (no pun- universe is basically a “mirror image” of the world on the
intended) lenses. In this chapter, we will direct our attention other side of the mirror (see what we did there?). Basically,
toward mirrors. this means that any object located at a certain distance to the
It is important to be comfortable with certain principles left of the mirror (by convention) will have the same distance
and concepts discussed in the previous chapter, such as using to the “right” of the mirror. This is somewhat confusing
the reduced vergence equation/simple lens formula (RVF/ because if you have a mirror on the wall, then there obvi-
SLF), calculating the orientation and magnification of ously is no image that is forming to the “right” of the wall.
images, etc. In general, object–mirror system problems are However, since mirrors reverse the image space, there is the
set up in a similar fashion, and many of the equations and same “space” inside the mirror as there is outside the mir-
concepts we previously discussed have relevance for the dis- ror—if you think about this for too long, your head will hurt.
cussion of mirrors. However, some of the rules we intro- We can understand this by falling back on our good old
duced (and emphasized) in the previous chapter are no longer U + D = V equation. Basically, plano mirrors will have zero
valid. power, so D = 0. Therefore, U = V (and by extension, u = v as
Before you get mad, imagine that the world of mirrors is well). So, if we have an object 50 cm to the left of a plano
a parallel universe wherein some of the rules of our universe mirror, then its image will form 50 cm to the “right” of the
are still valid, but others are not. mirror (in the mirror).
Why is this? With lenses, we previously dealt with Images formed by plano mirrors are always a follows:
refracted light rays. With mirrors, we are primarily dealing
with reflected light rays. This is why we are in the parallel • upright
universe of mirrors. • virtual
• same size
• left–right reversed
We can do some examples to reinforce these properties of

D. Wee (*)
plano mirrors.

50 D. Wee
Fig. 1 Plano mirrors. How far

away will the images formed on
the right be located in relation to
the person and the chair?
4m 3m
Example #1 6 feet
If you are standing (and dabbing) 4 meters behind a chair
that is located 3 meters to the left of a mirror, how far away mirror
is:
(a) the image of the chair from its object (i.e., the chair) 3 feet
(b) the image of the chair from you Virtual
6 feet
image
Answer: Start off as always by drawing out the problem.
This eventually will become easy enough to solve without a
diagram, but it may help initially to draw these diagrams to
get your bearings (Fig. 1). Notice the left–right reversal of
the images compared to the objects, in addition to being Fig. 2 Six-foot ophthalmology resident is on a bit of a budget, so he
upright, virtual, and same size. wants to buy the bare minimum length of mirror in order to see himself
Since the “world” inside the mirror (to the right) is basi- completely. A 3-foot mirror will allow him to be able to do this if he
stands six feet away from the mirror
cally the same as the world to the left of the mirror, then the
image of the chair will be located 3 m to the right of the mir-
ror, and your image will be 4 m to the right of the image of mirror must he stand in order to visualize himself head to toe
the chair (and 7 m to the right of the mirror). completely? (Fig. 2).
The image of the chair will therefore be 6 m from the Since incoming (incident) light rays that hit the mirror at
chair. The total distance between you (in the real world) and a given angle will leave the mirror at the same angle, he basi-
the image of the chair will be as follows: 4 m + 3 m + 3 m = 10 cally needs a mirror length that is half his height. This will
meters. allow the light rays that originate from his toe to be reflected
Recall our previous discussions on reflected light rays toward him if he stands six feet away. Light rays that origi-
(Chap. 1, “Geometric Optics”). We learned that incoming nate from the top half of his body will be reflected back
light rays that strike an optical surface will get reflected at toward him in a straight line. Therefore, he will only need a
an angle equal to the angle of incidence. However, when we 3-foot mirror in order to see his entire body.
have a plano mirror, the brain will think that the light is Note that he must be standing (at least) six feet away from
originating in a straight line from the “image” in the the mirror in order to visualize himself completely. If he
mirror. stands any closer to the mirror, for example, five feet away,
Why is this useful? One advantage of knowing this rule is he will only be able to see five feet of himself (from eye level
that we can determine the “height” needed of a mirror in to approximately knee level).
order to fully visualize the object. This leads us to a second As an aside, a 5-foot ophthalmology resident will only
classically presented example. need a 2.5 foot length mirror; a 7-foot ophthalmology resi-
dent1 will need a 3.5 foot length mirror.
Example #2
Suppose a 6-foot-tall male ophthalmology resident wished to Example #3
see himself (head to toe) in a mirror, but he is on a bit of a Suppose you are standing 10 meters away from a mirror and
budget (residents’ income being what it is these days…). He begin walking toward the mirror at a rate of 0.6 meters/sec-
goes to a mirror store that sells mirrors by foot length. He ond, how fast is your image moving? How close are you and
wants to buy the absolute minimum length of mirror in order your image coming together in one second?
for him to be able to see himself head to toe. However, he has
not been paying attention during his optics lectures and is
confused now at the store. What is the minimum length of This fellow loves ophthalmology so much that he chose it over becom-
1
the mirror that he will need to buy? How far away from the ing a professional basketball player.
Mirrors and Combined Systems 51
Consider this example, the optics equivalent of the age • Optically, r and f are useful because they give us informa-
old “two trains leave separate stations traveling toward each tion about where non-reflected and reflected light rays,
other at x speed at y time” problem. Thankfully, our math is respectively, will pass through.
much simpler. If an object is moving toward the mirror at a • When doing ray tracings with mirrors, draw a reflected
certain speed, then the image is also moving toward the mir- ray that passes through f. Then draw an unreflected ray
ror at the same speed. For example, if you walk toward a from the top of the object that passes through r. The inter-
mirror at a rate of 0.6 meters/second, then your image will section of these two rays (Fig. 3) will give you an idea of
also “walk” toward the mirror at that same speed. Therefore, where the image will form, in addition to its orientation
in one second, it will seem that you and your image have and size.
moved a net distance of 1.2 meters closer together.
alculating the Power of Mirrors
C
With lenses, the only way to calculate their power was to
Important Definitions and Equations take the reciprocal of the focal length: D = 1/F (or 100/F for
cm). With mirrors, we can calculate the power either with the
Before we define our two curved mirrors, positive (concave) focal length (like we did with lenses) or the radius of curva-
and negative (convex) mirrors, we have to pay our dues and ture (both in meters), using the formula as follows:
understand a few definitions. Notice the similarities and dif-
Dmirror = 1 / f OR 2 / r
ferences of these terms compared to how we used them with
lenses (Fig. 3). Note that we have used a positive (concave)
mirror in the diagram below. • Of course, you can use 100/f and 200/r to work in
Therefore, some important definitions and rules regarding centimeters.
mirrors are as follows:
Let us do some warm-up sample problems.
• Focal length (f): It is the point at which incident parallel
reflected light rays intersect (just like lenses). Mnemonic: Example #1 What is the power of a mirror with a radius of
Light rays that hit the mirror will be deFlected and curvature of 4 cm?
FOCUSED onto f.
• Radius of curvature (r): The central ray for mirrors passes Answer: D = 2/r = 2/0.04 (or 200/4) = + 50 D.
through this point. This is always twice the focal length Note: A distractor answer choice may appear as +25D
and is located OUTSIDE the “center” of the mirror. No (which would be erroneously obtained by calculating 1/0.04
light ray will pass through the “center” of the mirror. (or 100/4). Since we are given the radius of curvature, we
Think of this as the “center” of the mirror that is “outside” must use D = 2/r.
the mirror.
• The power of the mirror can be calculated either by Example #2 What is the power of a mirror with a focal
D = 1/f or 2/r (more on this in a minute). Do not confuse length of 10 cm?
“r” and “f” and erroneously calculate 1/r or 2/f. Just
remember that “r” is “later” in the alphabet, so it is the Answer: D = 1/f = 1/0.1 (or 100/10) = + 10 D.
denominator of the “later” number in the numeral system: Note: Again, a distractor answer choice may appear as
1/f or 2/r (mnemonic). +20D (which would be erroneously obtained by calculating
Fig. 3 Focal length (f) of a This “central” light ray does not exist for mirrors
mirror is similar to the length
of lenses: Light rays that get
reflected off the mirror will
pass through this point. The
radius of curvature (r) is
located outside the mirror and
is the location through which
the central ray passes. Note r f
that no light ray passes
through the “center” of the Central ray
mirror (unlike the central ray for mirrors
for lenses)
52 D. Wee
2/0.01 (or 200/10). Since we are given the focal length, we

must use D = 1/f.
Finally, the key to understanding mirrors is to know how
they are similar to lenses and how they are completely differ-
ent. In some aspects, including terminology, everything we
learned with lenses must be (temporarily) unlearned as we
will seemingly tell you the exact opposite. Remember, when
dealing with mirrors, imagine that we are in an upside-down f
universe wherein some of the rules are totally reversed.
Fig. 4 Real images form at the RIGHT of the positive (convex) lens
(where real light rays converge) and at the LEFT of a positive (concave)
Positive (Concave) Mirrors mirror (where real light rays converge)
Positive (plus power) mirrors are known as concave mirrors. lenses or mirrors), you can determine whether the image is
This is different from the terminology we used for positive real or virtual. With mirrors, remember that the light rays are
lenses (aka convex lenses). Remember how we said that we not refracting through the mirror, and they are reflecting
are in an upside-down universe? away from the mirror, so we are still dealing with real light
One mnemonic to remember what a concave mirror looks rays in the above example.
like is to imagine that if you are standing to the left of a con- Here is another spot where people get confused. You may
cave mirror (shown in Fig. 3), it will seem like you are “look- think, “Wait, I thought that if u (or U) is negative because it
ing into a (con)cave.” is to the left of the lens, then anything left of the mirror
Like people, images formed by concave mirrors come in should also be negative!” Well friends, this is again where
all shapes in sizes. They may be as follows: the upside-down world of mirrors has to be acknowledged:
The object is still negative to the left of the mirror, but the
• upright or inverted image is positive even though it forms to the left of the mir-
• real or virtual ror (because it is formed by real light rays).
• magnified, same size, or minified.
“ LOST” Method for Concave Mirrors and Image
The location of the object (i.e., its distance from the mir- Characteristics
ror) will determine which characteristics the image will Since concave mirrors can create a variety of images, the
demonstrate. “LOST” nomenclature system helps us to remember 4 key
For concave mirrors, the radius of curvature point (r) is to characteristics of the image as follows:
the LEFT of the mirror (Fig. 3). Because these mirrors can
give a variety of image sizes and orientations, they are the • L = location of the image
most commonly tested type of mirrors. One example of a • O = orientation (upright or inverted)
concave mirror is a vanity/shaving mirror. If you have one • S = size (magnification or minification)
handy, notice how your image will change in size and orien- • T = type (real or virtual).
tation depending on how far away you are from the mirror.
There is even a point wherein your image will disappear— For a single concave object–mirror system, the object can
rest assured; it is highly unlikely you have also disappeared! be located in 5 potential locations as follows:
We will see this in more detail in the examples below.
When dealing with object–mirror systems, the equations • Case 1: beyond (to the left of) the radius of curvature (r)
are exactly the same as object–lens systems (our friend • Case 2: at the radius of curvature (r)
U + D = V!). Recall that for object–lens systems, a real image • Case 3: between the radius of curvature (r) and the focal
(positive v) is to the RIGHT of a lens and a virtual image is point (f)
to the LEFT of a lens. • Case 4: at the focal point (f)
However, for mirrors, it is the TOTAL OPPOSITE! For • Case 5: to the right of the focal point (f) (between the
mirrors, a real image is to the LEFT of the mirror and a vir- focal point and the mirror).
tual image is to the RIGHT of the mirror (Fig. 4).
What sorcery is this? Remember that real images form as Figure 5 summarizes these 5 possible cases based on the
a result of real light rays converging: If you can determine location of the object.
where the real light rays will converge (whether dealing with We can discuss each of these 5 cases in greater detail.
Case #1 Object located beyond (to the left of) the radius of
curvature (r)
We can use ray tracing for the two chief rays: one ray that
is drawn from the top of the object to the mirror that gets r f
reflected through the focal point (f). The second ray (unre-
flected) will pass through the radius of curvature. The inter-
section of these two rays will form an image that is between
r and f (location); inverted (orientation); minified (size); and
real (type) (Fig. 6). Fig. 7 “LOST” characteristics for an object located at the radius of
curvature (r). The image will form at r (location); it will be inverted
(orientation); same size (size); and real (type)
Case #2 Object located at the radius of curvature distance
(r)
We can again use ray tracing: The first ray will similarly
be reflected off the mirror and pass through the focal point
(f). The second ray basically passes “through itself” since the r f
object is already located at r. So, the image will form at r
(location); it will be inverted (orientation); same size (size);
and real (type) (Fig. 7).
Case #3 Object located between the radius of curvature (r)

and the focal point (f) Fig. 8 “LOST” characteristics for an object located between the radius
of curvature (r) and the focal point (f). The image will always form to
We can again use ray tracing to draw our two rays: one ray the left of r (location); it will be inverted (orientation); magnified (size);
that reflects off the mirror and through the focal point (f) and and real (type)
a central ray (extended backward) through r (Fig. 8). Note
that the image is not drawn to scale and some liberties were to the left of r (location); it will be inverted (orientation);
taken with the object light rays. The image will always form magnified (size); and real (type).
Case #4 Object located at the focal point (f)

Case 2 Case 4
Case 1 Case 5
Using ray tracing, we can see that our two familiar rays
will both pass through f and r, but they will remain parallel.
As a result, they will never intersect and no image is formed.
r f
You can try this with a shaving mirror: If you approach the
Case 3 mirror slowly, you will see that your image will be inverted,
and then as you draw closer, it will disappear before it
Fig. 5 Five potential locations for an object when placed to the left of becomes upright. The point where it disappears is because
a concave mirror. The “LOST” characteristics of the image formed will you are standing at the focal point (not that you have sud-
vary based on these five locations
denly become invisible!) (Fig. 9).
Case #5 Object located between the focal point (to the right
of the focal point) and the mirror
Using ray tracing, we can see that our two familiar rays
(with some liberties taken for the sake of scale and conve-
r f nience) will form an image that is to the RIGHT of the mirror
(location); upright (orientation); magnified (size); and virtual
(type) (Fig. 10). Remember, it is virtual because it is forming
to the right of a mirror. The previous images were all real
Fig. 6 “LOST” characteristics for an object located to the left of the
radius of curvature (r). The image will form between r and f (location), images because they were formed by real light rays that con-
and it will be inverted (orientation), minified (size), and real (type) verge to the left of a mirror. In this case, we are using the
54 D. Wee
bject–Mirror System Examples with Concave

O
Mirrors
Example #1
An object is 25cm to the left of a + 1D mirror. Where is the
r f image? Is it real or virtual? Is it upright or inverted? Is it
magnified or minified?
Answer:
Fig. 9 If an object is located at the focal point (f), no image will form u = −25cm ( make sure U and u are negative!)
because the deflected ray and the central ray will travel parallel to each
other and never converge
U = 100 / u = 100 / −25 = −4 ( this is the object vergence )
U +D =V
−4 + 1 = V = −3 ( this is the image vergence )
v = 100 / V = 100 / −3 = −33 cm ( this is the image distance )

r f f
m = U / V = −4 / −3 = 1.33.
The final image is 33 cm to the RIGHT of the mirror. It is

Fig. 10 When an object is located to the right of the focal point, the virtual (v is negative), upright (m is positive), and magnified
image is to the RIGHT of the mirror (location); upright (orientation); (|m| > 1). We can also see that since the focal length of this
magnified (size); and virtual (type)
mirror is 100 cm, the object is located to the right of the focal
length (Case #5 as discussed above). Our math confirms the
extension of our two light rays (imaginary [dashed] lines).
previous discussion.
For relevance, this is when the vanity/shaving mirror actually
Notice that the equations are exactly the same for lenses
becomes useful and generates an upright and magnified
and mirrors. The only thing that differs is whether the image
image. In other words, when you use a vanity mirror, you are
is to the right or the left of the mirror. If this were a lens,
standing to the right of that mirror’s focal point; this is why
v = −33 cm means the image would have been to the left of
you are able to have a “useful” image of yourself to make
the lens. Since this is a mirror, v = −33 cm means the image
yourself look dapper.
is 33 cm to the right of the mirror.
One other point about Case #5: The object will yield the
largest image when it is immediately to the right of the focal
Example #2
point (f). As the object is brought closer to the mirror, the
An object is 50 cm to the left of a + 8D mirror. Where is the
image size will get smaller (but never smaller than the size of
image? Is it real or virtual? Is it upright or inverted? Is it
the original object). Ultimately, as the object distance
magnified or minified?
approaches zero (to the mirror), the image distance will also
Answer: u = −50 cm (make sure U and u are negative! We
approach zero, and the image height will ultimately become
keep saying this because it is such a common mistake!)
equal to the object height (Fig. 11). You may have noticed
this with the vanity/shaving mirror example. If you stand too U = 1 / u = 100 / −50 = −2 ( this is the object vergence )
close to the mirror, your image will become slightly smaller
until it basically will have the size as yourself. In other U +D =V
words, if you stand extremely closer to a vanity mirror, it will
−2 + 8 = V = +6 ( this is the image vergence )
function like a plano mirror! So, if you want to maximize the
use of your vanity mirror, stand immediately to the right of
the focal point; otherwise, if you forget your optics and stand v = 100 / V = 100 / 6 = 16.7 cm ( this is the image distance )
too close, you are a NooB and you might as well use a plano
mirror. m = U / V = −2 / 6 = −0.33 ( this is the magnification )

Table 1 provides a hi-yield summary of the previous 5
The final image is 16.7 cm to the LEFT of the mirror. It is
cases combined into a single table for review and compari-
real (v is positive), inverted (m is negative), and minified
son purposes
Fig. 11 An object will have the largest image size if it is located imme- equal to the object height. Notice the size and location of the yellow,
diately to the right of the focal point (f). As the object draws closer to green, and purple images in relation to the location of their respective
the mirror, the image size will also decrease. As the object distance to objects. The yellow image is the largest because the yellow object is
the mirror approaches zero, the image height will ultimately become immediately to the right of the focal point
Table 1 Summary of object locations and image characteristics with

concave mirrors
Object
Case location Image characteristics
1 Left of r Image forms between r and f. It will be inverted,
minified, and real.
2 At r Image forms at r. It will be inverted, same size,
f r
and real.
3 Between Image forms to the left of r. It will be inverted,
r and f magnified, and real.
4 At f No image.
5 Right of f Images will be upright and virtual. Image size will
be greatest when the object is located immediately
to the right of f and will continue to decrease in
size. When the object is immediately to the left of Fig. 12 Convex mirrors. All light rays that strike a convex mirror will
the mirror, the image will have the same size as the be deflected away from the mirror
object.
light rays diverge (spread out) since the normal to the surface
(|m| < 1). Note that for this mirror, the focal point (f) is differs with each spot on the mirror.
12.5 cm to the left of the mirror and the radius of curvature
(r) is 25 cm to the left of the mirror. Since the object is wo Rules for Convex Mirrors
T
located 50 cm to the left of the mirror, this is an example of Even though these vexing convex mirrors are vexing us more
Case #1 as discussed above. Once again, our math confirms than anti-vaxxers (drum shot here), in some ways, they are a
the previous discussion. bit easier than concave mirrors. Why? Because there are only
two rules that you need to know for convex mirrors (Fig. 13)
as follows:
Negative Mirrors (Convex Mirrors)
• Rule #1: A reflected ray from the anterior surface of the
Negative mirrors are known as convex mirrors (Fig. 12). convex mirror will have its imaginary extension pass
Think of them as “vexing” mirrors to look at because they through the focal point (f) (to the right of the mirror).
give weird images, such as a funhouse mirror, surveillance • Rule #2: An undeviated ray from the object will pass
mirror (such as used in a convenience store or hospital hall- through the radius of curvature (r), which is also located
way), rear-view mirror (objects in the mirror are closer than to the right of the mirror.
they appear), or the back of a spoon. The radius of curvature
point for these mirrors is located to the RIGHT of the mirror. As a result, concave mirrors will ALWAYS give images
When a light ray from an object hits a convex mirror, the with certain characteristics, no matter how close or far away
56 D. Wee
f r
f r
Fig. 14 As an object approaches a convex mirror, its virtual image will
also shift closer (shift left) to the mirror and increase in size. However,
all images will still remain minified relative to the size of the original
Fig. 13 Convex mirrors. Note that the r and f are located to the right of
object
the mirror. Convex mirrors will always produce images that are Virtual,
ERect (upright), and MINified
always be smaller than the object (Fig. 14). This is different
the object is from the mirror. The images formed by convex than concave mirrors (see Case #5 discussion).
mirrors can be remembered by the mnemonic “VERMIN.” As for the math, convex mirrors will use the same equa-
Convex mirror images are always as follows: tions and principles we discussed with concave mirrors, but
it is important to remember the image characteristics that we
• Virtual can (hopefully) confirm mathematically.
• ERect (upright)
• MINified bject–Mirror System Examples with Convex
O
Mirrors
One other point about convex mirrors is as follows: As an Example #1
object approaches closer to the convex mirror, its virtual An object is 33 cm to the left of a −2D diverging mirror.
image (located to the right of the mirror) will also approach Where is the image? Is it real or virtual? Is it upright or
closer to the mirror and will become larger, though it will inverted? Is it magnified or minified?

u = − − 33cm ( this is the object distance and once again negativee )
U = 100 / u = 100 / −33 = −3 ( this is the object vergence ) We should do the math, now taking into account the index
of refraction (1.33) as follows:
U +D =V u = −33cm
−3 + ( −2 ) = V = −5 ( this is the image vergence ) U = 133 / u = 133 / −33 = −4 ( this is object vergence )
v = 100 / V = 100 / −5 = −20 cm ( this is the image distance ) U +D =V
−4 + −2 = V = −6 ( this is the image vergence )

m = U / V = −3 / −5 = 0.6 ( this is the magnification )
v = 133 / V = 133 / −6 = −22 cm ( this is the image distance )
The final image is 20 cm to the RIGHT of the mirror. It is
virtual (m to the RIGHT of the mirror. It is viis negative),
m = U / V = −4 / −6 = 0.67 ( this is the magnification )
upright (m is positive), and minified (|m| < 1). Note that it
follows our “VERMIN” mnemonic. The final image is therefore 22 cm to the RIGHT of the
Suppose we placed both the object and the mirror under- mirror. It is virtual (v is negative), upright (m is positive), and
water. Will this change our answer.
minified (|m| < 1). Note that it follows our VERMIN +10.00D +6.67D
mnemonic.
8cm
We can observe a few things at this point as follows:
• Notice that the change in index of refraction slightly

5cm 10cm
changed the location of the image (by 2 cm further to the
right).
• Notice that the image magnification slightly increased
underwater, relative to the magnification in air. However, Fig. 15 Lens system for an object (height 8 cm) located 5 cm to the left
both images are still minified compared to the size of the of a + 10D lens which itself is located 10 cm to the left of a + 6.67D lens
original object.
Answer: Start off by drawing out this lens system to get
our bearings (Fig. 15). Note: The figure is not drawn to scale
ptical Systems with Multiple Lenses
O (but who cares!).
and Mirrors We will begin by ignoring the second lens and dealing
with the first lens. We can use our familiar equation:
So far, we have given examples of optical systems with a U + D = V
single lens or mirror. If only lenses or mirrors would just stay U + D = V → U = 100 / −u = 100 / −5 = −20
single—but they sometimes enjoy each other’s company, and
they get together to form a complex lens or complex mirror −20 + 10 = −10 → v = 100 / V = 100 / −10
system. While they may enjoy each other’s company, it = −10 cm to the LEFT of the + 10 D lens
makes our lives more difficult because we have to figure out
m = U / V = −20 / −10 = +2
commonly tested concepts of complex optical systems, such
as the following: V is negative, so our first image is a virtual image; m is
positive, so we have an upright image; and |m| > 1, so our
• Location of the intermediate and final image image is magnified (2×) to a size of 16 cm.
• Orientation of the intermediate and final image Now, we can redraw the lens system using the first
• Total magnification of the lens (mirror) system. image as the “new” object, eliminating the first lens (and
original object) and now dealing with the second lens
These problems are made much easier if we simply tackle (Fig. 16).
one lens (or mirror) at a time: First, ignore the second (or We can again use our U + D = V equation as follows:
third, fourth, etc.) lens and then use U + D = V for the first
lens/mirror to find where the first image will form. Hopefully, U + D = V → U = 100 / −u = 100 / −20 = −5
it will be to the left of the second (or next) lens (or mirror).2
−5 + 6.67 = 1.67 → v = 100 / V = 100 / 1.67
Basically, we should view these problems as two-for-the-
= 60 cm to the RIGHT of the lens
price-of-one types of problems, though unfortunately, on
exams, you will not get double points for getting these prob- m = U / V = −5 / 1.67 = −3
lems correct.
We can do some examples as follows: V is positive, so the second image is a real image. m is
negative, so the second image is inverted. Finally, |m| is >3,
Example #1 An object (height 8 cm) is located 5 cm to the so the second image is 3× the size of the first image.
left of a + 10D lens, which itself is located 10 cm to the left This is where it gets slightly tricky. It is tempting to use
of a + 6.67D lens. Calculate the position of the final image the 2× from the first lens system and add it to the 3× for the
and its magnification (relative to the original object). second lens system for a total of 5× magnification (and apply
that to our 8 cm object for a final magnification size of
40 cm). You can be sure that one of the wrong answer choices
We will do some examples later in this section that deals with a lens
2 will have this number shown!
system where the intermediate image will form to the RIGHT of the
second lens/mirror.
58 D. Wee
Fig. 16 Intermediate image First Image AKA New Object

formed by the first lens will
be located 10 cm to the left of +10.00D +6.67D
the first lens. This lens will be
our “new object” (solid black 16cm
arrow) that is 20 cm to the left
of the +6.67D lens. We can
safely ignore the first object
and the first lens at this time
(dotted arrow and dotted
diamond, respectively)
5cm 5cm
10cm
RIP Old Object
RIP Old Lens
But for the total magnification of a lens system, we have U = 100 / −u = 100 / −10 = −10

to MULTIPLY the individual magnifications of each lens. In
other words, the total magnification is not (2 + 3 = 5×), but U +D =V
rather it is 6× magnification (2×*3×). Therefore, the final
−10 + ( −10 ) = V = −20
image size is 8 × 6 = 48 cm.
v = 100 / V = 100 / −20 = −5 cm to the LEFT of the first lens
Example #2 A 20 cm object is located 10 cm to the left of a
−10D lens, which itself is located 35 cm to the left of a + 15D m = U / V = −10 / −20 = +1 / 2

lens. Calculate the position of the final image and its
magnification. V is negative, so our first image is again a virtual image. m
is positive, so the first image is upright. However, |m| < 1, so
Answer: We can skip to the chase. You can draw out the the first image is half the size of the original object (first
lens system on your own if you wish. But again, we have to image is 10 cm in size).
deal with each lens separately as follows: Now, we can repeat these shenanigans for the second lens
as follows:
u = −10 cm

(
u = −40 cm note,we can also write thisas u’ to keep the two lens systems separate )
U = 100 / −u = 100 / −40 = −2.5
U +D =V
−2.5 + 15 = +12.5
= =
v 100 / V 100 / 12.5 = 8 cm to the RIGHT of the second lens
m = U / V = −2.5 / 12.5 = −0.2
V is positive, so our second image is a real image. m is nega- The total magnification is 0.5 × 0.2 = 0.1× magnification.
tive, so the second image is inverted (relative to both the original Therefore, the final image is 2 cm (aka 1/10th the size of the
object and the first image). Finally, |m| is <1, so we again have original object).
minification of the first image (aka the second object).
Example #3 An object is located 20 cm to the left of discussed that the image from the first lens/mirror becomes
a + 15D lens, which itself is located 20 cm to the left of the object for the second lens and so on. In the examples we
a + 14D mirror. Where is the final image in relation to the did so far, the intermediate images have always ended up to
original object? the left of the second lens/mirror, so we could proceed with
business as usual and continue to use our U + D=V
Answer: Again, take a minute to draw out the lens and equation.
mirror system to get your bearings. We will use the U + D = V But if that first image is to the right of the second lens/
equation (as if there was any other equation to use!) and deal mirror, we have a positive U and a positive u. We can still use
with the lens first and then the mirror second. We must be our U + D=V equation, but we have to account for this object
careful to make sure we follow the rules for lenses and mir- being in the “right spot” (i.e., to the right of the lens/mirror)
rors appropriately as follows: and make sure we keep U/u as positive. Confused? Take a
U +D =V moment to punch a pillow or squeeze a stress ball, and then
we can do some examples.
U = 100 / −u = 100 / −20 = −5 Reminder: U can only be positive if the “object” is formed
by another lens/mirror. Natural objects will always have neg-
−5 + 15 = +10 ative vergence (negative U).
= =
v 100 / V 100 / 10 = 10 cm to the RIGHT of the lens,
10 cm to the LEFT
T of the mirror. Example #1 An object is 25 cm to the left of a + 5D lens,
which is 67 cm to the left of a + 1D lens. Where is the
m = U / V = −5 / 10 = −1 / 2 image?
V is positive, so our first image is a real image. m is nega-
tive, so we have an inverted image. Finally, |m| < 1, so our Answer: We can start off by drawing this out (Fig. 17).
image is minified. For now, ignore the second lens and focus on the +5D lens.
Now, we can deal with the mirror as follows: u = −0.25m ( u is still negative here ) or − 25 cm
U +D =V
U = 100 / −u = 100 / −25 = −4 ( object vergence )
U = 100 / −u = 100 / −10
U +D =V
−10 + 14 = +4
v = 100/V = 100/4 = 25 cm to the LEFT of the mirror (note −4 + 5 = V = +1 ( image vergence )
that this positive V for mirrors means that the image will
form to the LEFT of the mirror!). v = 100 / V = 100 / 1 = 100 cm ( image distance )
m = U/V = −10/4 = −2.5. The image is inverted (relative to the RIGHT of the firsst lens
to this second object/first image, so it is actually upright rela-
So far so good. The image from the first lens is 1 m to the
tive to the first object), has 2.5× magnification (compared to
right of the first lens. But unfortunately, that also means it is
the first image), and is real (positive V).
33 cm to the right of the second lens! Since we have our
The final image is 25 cm to the LEFT of the mirror; there-
object to the right of the lens, our u (and U) for this second
fore, it is 15 cm from the original object.
lens has to be positive. This is the only time u will be a posi-
Just for kicks: The total magnification of this system is
tive number.
1.25× (Total mag = −1/2 * −2.5).
+5D +1D
Advanced Topics
I ntermediate Images to the Right of Lenses

and Mirrors (Positive U)
25cm 67cm
We spent this entire chapter talking about how U and u are

almost always negative. And you, dear, naïve reader, believed
us! Now we are going to give you an exception to this rule in Fig. 17 Lens system for an object located 25 cm to the left of a + 5D
case: If given multiple lens or mirror systems, we previously lens which itself is located 67 cm to the left of a + 1D lens
60 D. Wee
u = +0.33m ( u is positive because the object is to the right of the second lens ) or 33 cm
U = 100 / u = 100 / 33 = 3 ( object vergence )
U +D =V
3 + 1 = V = 4 ( image vergence )
v = 100 / V = 100 / 4 = 25 cm ( final image distance in relation to the second lens )
The final image is 25 cm to the right of the second lens. It U = 100 / −u = 100 / −50 = −2

is 92 cm (67 cm + 25 cm) to the right of the first lens. It is
117 cm to the right of the object (25 cm + 67 cm + 25 cm). −2 + 3 = V = 1 ( image vergence )

The answer could be any of these choices depending on what
= = / V 100 / 1 = 100 cm to the right of the lens
the test gives you as a multiple-choice answer. v 100
Example #2 An object is 50 cm to the left of a + 3 lens, But wait, this is now 25 cm to the RIGHT of the mirror as
which is 75 cm to the left of a + 4 mirror. Where is the image? well!
*Insert moment of screaming into the void here*
Take a minute to draw out the lens and mirror system to This becomes the new object distance for the mirror and
get your bearings. For now, ignore the mirror and start with is a positive number. Once again, this is the rare exception to
the +3D lens only. the rule that U and u are negative.
U +D =V
u = 0.25m ( u is positive because the object is to the right of the mirror ) or 25 cm
U = 100 / u = 100 / 25 = 4 ( object vergence )
U +D =V
4 + 4 = V = +8 ( image vergence )
v = 100 / V = 100 / 8 = +12.5 ( image distance )
The final image is 12.5 cm to the LEFT of the mirror. of that medium as our numerator. For example, if an object
Remember for mirrors, a real image (positive v) is to the left immersed in water is located 66 cm in front of a + 7D lens
of the mirror. whose back surface is exposed to air, where is the image
(Fig. 18)?
u = −66 cm
Index of Refraction Effects
However, U = ( −1.33 / 0.66 OR − 133 / 66 ) = −2
Thus far, when we have done U + D = V problems, and we
have mainly used U = 1/−u (or U = 100/−u) because we U +D =V

have made the assumption that the object is in air. Since air
has an index of refraction of 1.0, we can do the calculation −2 + 7 = V = +5
as such. However, if they are devious enough to give a prob- v = 100/5 = 20 cm to the right of the lens. Note that we can
lem where the object or the image is in a different medium use 100 as our familiar numerator since this image is formed
(such as water), then we have to use the index of refraction in air.
Practice Questions
Water Air
+7D
1. A 2-meter-tall object is 25 cm to the left of a + 3D con-
verging lens. Where is the image? How tall is it? Is it real
or virtual? Is it upright or inverted?
2. Now the 2-meter-tall object is 50cm to the left of the
66 cm
same +3 converging lens. Where is the image? How tall
is it? Is it real or virtual? Is it upright or inverted?
3. Now the 2-meter-tall object is 50cm to the left of a −3D
diverging lens. Where is the image? How tall is it? Is it
real or virtual? Is it upright or inverted?
4. A 3-meter-tall object is 33cm to the left of a +5 mirror.
Fig. 18 If an object immersed in water is located 66 cm to the left of Where is the image? How tall is it? Is it real or virtual?
a + 7D lens whose back surface is exposed to air, where is the image? Is it upright or inverted?
5. Now the 3-meter-tall object is 10cm to the left of the
Similarly, we can do an example if the object was in air, same +5 mirror. Where is the image? How tall is it? Is it
but the image was formed in water: Suppose that an object in real or virtual? Is it upright or inverted?
air was located 25 cm to the left of a + 6D lens and on the 6. Now the 3-meter-tall object is 25cm to the left of a −4D
other side of the lens is water. Where is the image? mirror. Where is the image? How tall is it? Is it real or
u = −25cm virtual? Is it upright or inverted?
7. An object is 33cm to the left of a +6D lens, which is
U = 100 / −u = 100 / −25 = −4 67cm to the left of a +4D lens. Where is the final image?
8. An object is 33cm to the left of a +4 lens, which is 67cm
U +D =V to the left of a +7 lens. Where is the final image?
−4 + 6 = V = 2; 9. An object is 33 cm to the left of a +5D lens, which is
25 cm to the left of a −6D lens, which itself is located
however, v = 1.33/2 = 0.67 m or 67 cm to the right of the lens. 50 cm to the left of a +11D lens. Where is the final image
Note that we cannot simply use 100/2 = 50 cm as the answer. located? What is the orientation of the final image? What
is the magnification of the final image?
10. An object is 10cm to the left of a +15 lens, which is
Common Pitfalls 70cm to the left of a +4 mirror. Where is the image?
What is the magnification of the final image?
A few and somewhat random pieces of advice to close out 11. An object is 20cm to the left of a +6D lens, which is
this chapter are as follows: 75cm to the left of a +6D mirror. Where is the image?
What is the magnification of the final image?
• The nice thing about getting math-heavy optics problems 12. How far from a +60D lens should an object be placed in
is that it is a multiple-choice test. If you make a mistake order to form an image onto a screen that is located 2 cm
converting 1/6 m into 16.7 cm, you will come up with a to the right of the lens?
wrong answer that is not an answer choice and you can go 13. An object is placed to the left of a −5D lens at an
back and fix your problem. The tricky wrong answers are unknown distance. If an image is formed to the left of
the ones where they give you an answer choice that fits the lens at the midpoint between the object and the lens,
your incorrect answer due to a math error. where is the object?
• Make sure U and u are negative unless you are dealing 14. If you are given a +2.00D lens and a +3.00D lens, how
with 2 lenses or a lens and mirror. In this case, check to far apart must they be placed so that an object at infinity
see if the intermediate image (aka the second object) has forms an image 1 meter to the right of the second lens?
a positive or negative U. 15. Suppose you are an emmetrope and you are examining a
• You may want to brush up on your reciprocals. A com- patient who is a −8D myope. If you hold an ophthalmo-
mon mistake made by many trainees is getting the “math” scope 2.5cm from the patient’s cornea, how much addi-
wrong, even though they set up the equations correctly. tional power must be dialed into the ophthalmoscope in
• It is often easier to work in centimeters to do the math. order to allow for inspection of the retina?
However, if the answer choices are given in meters, make
sure you convert centimeters to meters for the Bonus: What if you are a −3D myope? What if you
calculations. are a + 3D hyperope? Assume you are not wearing any
spectacle correction.
62 D. Wee
Answers The image is magnified 2×, so this image is 4 m tall. It

is inverted because m is negative.
1. This is a straightforward question testing our knowledge In the first question, the object was at 25 cm, which is
of the reduced vergence/simple lens formula. Remember within the focal length of the lens (+3D lens would have
that U + D = V and m = U/V. focal length of 33 cm). Notice that by moving the object
outside of the lens’ focal length, we have changed the vir-
u = −0.25m or − 25 cm
tual image into a real image. We are still getting a magni-
U = 100 / −25 = −4 fied image, but this new image will be inverted (compared

to the image formed in question #1).
U +D =V 3. u = −0.50m or − 50 cm
−4 + 3 = V = −1
U = 100 / u = 100 / −50 = −2 ( make sure u and U are negative )
v = 100 / V = 100 / −1 = −100
U + D = V → −2 + −3 = V = −5
The image is therefore 100 cm (or 1 meter) to the
LEFT of the lens. v = 100 / V = 100 / −5 = −20 cm ( or − 0.2m )

It is virtual because v is negative.
The image is 20 cm to the left of the lens. It is virtual
m = U / V = −4 / −1 = 4 because v is negative.
The image is magnified 4×, so this image is m = U / V = −2 / −5 = 0.4

(2 m × 4 = 8) 8 m tall. It is upright because m is positive.
The image is minified 0.4×, so this image is 0.8 m tall.
The resulting object and image would look like Fig. 19.
It is upright because m is positive. The resulting object
2. This again is testing our knowledge of the RVF. You can
and image would look like Fig. 20.
draw the object–lens system out if you wish, but we can
4. This is again a question that tests our knowledge of the
skip to the math as follows:
RVF. However, we are dealing with mirrors, so remember
u = −0.50m or − 50 cm the rules we have previously discussed!

u = −0.33m or −33cm
U = 100 / −u = −2 ( make sure u and U are negative )

U +D =V U = 100 / u = 100 / −33 = −3 ( make sure u and U are negative )

−2 + 3 = V = 1 U +D =V
= =
v 100 / V 100 −3 + 5 = V = +2
The image is 100 cm (or 1 meter) to the RIGHT of the = =
v 100 / V 100 / 2 = 50 cm
lens. It is real because v is positive.
m = U / V = −2 / 1 = −2
Fig. 19 Object–lens system Image

and resulting image for a
2-meter-tall object located
25 cm to the left of a + 3D
lens +3 D
Object
2m
25 cm
100 cm = 1 m
Fig. 20 Object–lens system -3D

for a 2-meter-tall object
located 50 cm to the left of a
−3D lens 2m
20cm
50cm
+5 D mirror
m = U / V = −10 / −5 = 2
Object The image is magnified 2×, so this image is 6 m tall. It
is upright because m is positive. The resulting object/
33 cm image mirror system would look like Fig. 22.
50 cm Notice that the object lies between the focal point (to
the right of the focal point, which is 20 cm) and the mir-
Image ror, this is, Case #5 as discussed in Section C, positive
(concave) mirrors. Our resulting image is formed to the
Fig. 21 Object–mirror system for an object located 33 cm to the left of
a + 5D mirror. The resulting image will be 50 cm to the left of the mirror right of the mirror (location); it is upright (orientation);
(location), inverted (orientation), 1.5× magnified (size), and real (type) magnified (size); and virtual (type).
6. From the question stem, we know that this is a convex
mirror so we can call upon our “VERMIN” mnemonic to
Because we are dealing with mirrors, a positive V (v) help answer some of the questions asked. For image loca-
means that the image will form to the LEFT of our con- tion, we will still need to use the U + D = V formula as
cave mirror. The image is 50 cm to the LEFT of the mir- follows:
ror. It is real because v is positive.
u = −0.25m or − 25 cm

m = U / V = −3 / 2 = −1.5
The image is magnified 1.5×, so this image is 4.5 m U = 100 / −u = 100 / −25 = −4
tall. It is inverted because m is negative. The resulting
( make sure u and U are negative )
object/image mirror system would look like Fig. 21.
Notice that the focal length of this mirror would be at U +D =V
20 cm (100/5 = 20 cm) and the radius of curvature would −4 + −4 = V = −8

be at 40 cm to the left of the mirror, respectively. This
v = 100/V = 100/ − 8 = − 12.5 cm or − 0.125 m.
object is located between f and r (Case #3 as discussed in
Because we are dealing with mirrors, a negative V (v)
Section C, positive (concave mirrors). Our resulting
means that the image will form to the RIGHT of our con-
image follows the “LOST” rules for this case: The image
vex mirror. The image is 12.5 cm to the right of the mirror.
forms to the left of r (location); it is inverted (orientation);
It is virtual because v is negative.
magnified (size); and real (type).
5. Use our familiar U + D = V formula and remember our m = U / V = −4 / −8 = 0.5
rules for mirrors as follows: The image is minified 0.5×, so this image is 1.5 m tall.
u = −0.10 m or − 10 cm It is upright because m is positive. Note that our math
confirms our “VERMIN” mnemonic rules. The resulting
U = 100 / u = −10 ( make sure u and U are negative ) object–mirror system would look like Fig. 23.
7. Since this is our first complex lens system problem in this
U +D =V problem set, we should draw this out (Fig. 24).
It helps to tackle each lens separately. For now, ignore
−10 + 5 = V = −5 the second lens—pretend it does not exist! Let us start
v = 100/V = 100/5 = − 20 cm or − 0.2 m. Because we with the first lens.
are dealing with mirrors, a negative V (v) means that the
u = −0.33m = −33 cm
image will form to the RIGHT of our concave mirror. The
image is 20 cm to the RIGHT of the mirror. It is virtual U = 100 / u = −3

because v is negative.
U +D =V
64 D. Wee
Fig. 22 Object–mirror +5 D mirror

system for an object located
10 cm to the left of a + 5D Object
mirror and its resulting image.
The image is 20 cm to the
right of the mirror (location),
upright (orientation), 2× 10 cm 20 cm Image
magnified (size), and virtual
(type)
Fig. 23 Object–mirror Object

system for a 3-meter-tall
object located 25 cm to the -4 D mirror
left of a −4D mirror. Notice Image
the location of the image
obeys the “VERMIN” rule
25 cm 12.5 cm
Fig. 24 Complex object–lens +6 D +4 D

system for an object located
lens which itself is located
lens
33cm 67cm
−3 + 6 = V = +3 First, we can deal with the first lens.

u = −0.33m = −33 cm
= =
v 100 / V 100 / 3 = 33 cm or 0.33m

The image from the first lens is 33 cm to the right of U = 100 / u = 100 / −33 = −3
the first lens. This means it is roughly 33 cm to the left of
U +D =V
the second lens as well. We could also use 34 cm, but the
math is going to be about the same. This becomes our new −3 + 4 = V = 1
object distance. Now, we can ignore the first lens and deal
with the second lens only (again, they won’t give us dou- v = 100/V = 100 cm or 1m. This means that the image
ble the points for solving this problem on an exam…). from the first lens is 100 cm to the right of the first lens,
which also unfortunately means that it is roughly 33 cm to
u = −0.33m = −33 cm
the right of the second lens. This becomes our new object
U = 100 / u = −3 distance. This is the one of those rare times that u and U

are positive.
U +D =V Now, we have to deal with the second lens, keeping in
mind that u is POSITIVE. It may help to draw a “+” sign
−3 + 4 = V = +1
in front of the u/U to make sure we keep our signs
v = 100/V = 100 cm or 1m. The final image is 1 meter straight.
to the right of the second lens.
u = +0.33m or + 33 cm
Note this question did not ask us anything about the
magnification, orientation, etc., of either image, so we U = 100 / u = +3

will let sleeping dogs lie.
8. We can skip to the part where we just solve the problem U +D =V
for this one. Of course, if you wish, you can take a minute
+3 + 7 = V = +10
to draw out the lenses to get your bearings.
-6 D +11 D
+5 D
33 cm 25 cm 50 cm
Fig. 25 Multiple lens system for an object located 33 cm to the left of a + 5D lens, which itself is located 25 cm to the left of a −6D lens, which
itself is located 50 cm to the left of a + 11D lens. Two intermediate images with unique characteristics will form as detailed in the text
v = 100/V = 100/10 = 10 cm or 0.1m. Since V(v) is As for the orientation, we can name the object as
positive, the final image will be 10 cm to the RIGHT of “Leonardo” to help sort out the resulting mess as follows:
the second lens.
9. Hopefully, this will be as tricky as exam problems will • The image formed by the first lens system was real and
get. This is basically making us solve three U + D = V inverted. We can name this image as “Donatello.”
problems. We will do our usual math, but we can point Donatello is inverted compared to Leonardo.
out a few interesting findings in terms of the image • The image formed by the second lens system was vir-
quality and location (both intermediate and final tual; we will name this image as “Raphael.”
images). –– Raphael is inverted relative to Donatello, so it is
We can draw this one out (Fig. 25) as follows: upright relative to Leonardo.
Now, we have to solve for each lens as follows: • The image formed by the third lens system is real
First Lens System: (because V was positive); we will name this image as
“Michelangelo.”
U = 100 / −33 = −3
–– Michelangelo is inverted relative to Raphael
U +D =V –– Raphael is upright relative to Leonardo
–– Therefore, Michelangelo is inverted relative to
−3 + 5 = +2 Leonardo as well.
v = 100/V = 100/2 = 50 cm to the right of the first lens,
which would be 25 cm to the right of the second lens As a result, the final image is upright relative to the
(yikes—we have to deal with another positive u!). original object. Undoubtedly, that was confusing, so we
Second Lens System (Positive u!) should confirm mathematically using our total magnifica-
tion calculations below because the math never lies.
U = 100 / 25 = +4
Remember that total magnification is the product of
U +D =V the magnification formed by each lens system.

For the first lens system: m = U/V = −3/2 = −1.5
+4 + −6 = −2 For the second lens system: m = U/V = 4/−2 = −2
v = 100/ − 2 = 50 cm to the left of the second lens, For the third lens system: m = −1/10 = −0.1
which would be 100 cm to the left of the third lens (still Total magnification = (−1.5) * (−2) * (−0.1) = −0.3
following??) (this math is somewhat difficult, but can be done without
Third Lens System a calculator).
The final image is inverted and 30% the size of the
U = 100 / −100 = −1 original object, thus proving that Michelangelo is inverted
U +D =V relative to Leonardo as well.

If you got this problem correct, congratulations, a wise
−1 + 11 = +10 sensei rat wishes he could give you three points for solv-
ing three U + D=V problems, but unfortunately, we
= =
v 100 / 10 10 cm to the RIGHT of the third lens.
cannot.
66 D. Wee
10. We can solve this problem similar to the previous two Now, we deal with the mirror as follows:
problems that dealt with multiple lens systems. u = +0.25m = +25 cm
We can draw this out if we wish. Otherwise, we can
skip to solving the problem as follows: U = 100 / u = 100 / 25 = +4

First, we start with the lens.
+4 + 6 = V = +10
u = −0.10m = −10 cm
v = 100/V = 100/10 = 10 cm or 0.1m (because V is
U = 100 / u = 100 / −10 = −10 positive, the image will form to the LEFT of the mirror).
The final image is 10 cm to the left of the mirror.
U +D =V The magnification of the final image will be the
−10 + 15 = V = +5 product of the magnification of each lens/mirror system
as follows:
v = 100/V = 100/5 = 20 cm or 0.2m. The image from Lens magnification: m = U/V = −5/1 = −5
the first lens is 20 cm to the right of the first lens. This Mirror magnification: m = U/V = 4/10
means it is roughly 50 cm to the left of the mirror. This Total magnification: (−5) * (4/10) = −2. The final
becomes our new object distance. image will be inverted and double the size of the original
Now, we deal with the mirror as follows: object.
u = −0.5m = −50 cm 12. This is yet another way of asking the same U + D = V

concept. In this case, we are asked to solve for u.
U = 100 / u = 100 / −50 = −2 Since we know that v is 2 cm, we can calculate V as
follows: 100/v = 100/2 = 50.
U +D =V
Now, we can plug this into our U + D = V
−2 + 4 = V = + 2 (because V is positive, the image equation.
will form to the LEFT of the mirror)
U + 60 = 50
= =
v 100 / V 100 / 2
= 50 cm or 0.5m to the LEFT of the mirror U = −10, which means u = 100 / U = 100 / −10 = −10.
The magnification of the final image will be the The object should be placed 10 cm to the left of the
product of the magnification of each lens/mirror system +60D lens.
as follows: 13. This is yet another twist on the U + D = V concept.
Lens magnification: m = U/V = − 10/5 = −2 Since we know that the image is formed to the left at a
Mirror magnification: m = U/V = − 2/2 = −1 location between the object and the lens, this must be a
Total magnification: (−2) * (−1) = +2. The final virtual image. Also, since we are given a minus lens, it is
image will be upright and will be double the size of the more likely that we are dealing with a virtual image.
original object. The image distance (v) is one-half the object dis-
11. We can solve this problem similar to the previous prob- tance (u). This means that v = 0.5u.
lem. Again, if you find it helps, you may wish to draw Now, we have to solve for U and V as follows:
out the object, lens, and mirror. V = 1 / v = 1 / ( 0.5u )
First, we start with the first lens.
u = −0.20m = −20 cm V = 2U

Now, we can use the U+D=V formula, setting
U = 100 / u = 100 / −20 = −5 V = 2 U
U +D =V U + D = 2U
−5 + 6 = V = +1 U + ( −5 ) = 2U

v = 100/V = 100/1 = 100 cm or 1m. The image from
U = −5 and therefore V = −10.
the first lens is 100 cm to the right of the first lens. This
means it is 25 cm to the right of the mirror (oh for crying u = 100/U = 100/ − 5 = − 20. Therefore, the object
out loud!). This becomes our new object distance. This is located 20 cm to the left of the lens. (The image will
is again one of those times that u and U are positive. be located 10 cm to the left of the lens).
14. This problem seems to be a mouthful and a bit confus- = = / V 100 / 2 = 50 cm to the right of the first lens.
v 100
ing. First draw out what the stem is asking (Fig. 26).
This means that given a light source originating
This problem is also confusing because we need to
from infinity, the two lenses should be placed 1 meter
start with the second lens system in order to figure out
(100 cm) apart in order to form an image 1 m to the right
what is happening with the first lens system.
of the second lens.
For second lens system, we know that:
15. The easiest thing to do here is to just get a 90D lens and
U 2 + D2 = V2 use a slit lamp or a 20D lens and use an indirect to exam-

ine the posterior segment. Unfortunately, they are forc-
U + 3 = 1 ing us to use the ophthalmoscope, but we should realize
2
So U2 must be −2, which would make u2 that this is basically a “Vergence Along a Lens System”
100/−2 = −50. This means that the second object, which type of problem.
is the first image formed by the first lens, must be located Let us draw out the description of the question stem
50 cm to the left of the second lens. so that we have a visual understanding of what is hap-
Now, we know that V1 = U2, but this V1 is positive pening (Fig. 27).
because the image is forming to the right of the first lens. For this myopic patient, light rays “leaving” the eye
So, now we will set V1 = +2. will form an image located at the far point of the eye
For the first lens system, the light is coming from where they will converge. This will form a real image of
infinity, so U1 100/∞ = 0. This means that for all intents the eye (that will be so dim that no one can really “see”
and purposes, we can ignore U1 altogether. it) at 100/8 = 12 cm in front of the eye. If we are holding
We can solve now for the first lens system as the scope at 2.5 cm, then the light rays have only trav-
follows: eled 2.5 cm of the total 12.5 cm, so there is still 10D of
vergence that we need to account for. Therefore,
U +D =V
100/10 = −10D dialed into the ophthalmoscope in order
0 + 2 = V = +2 to be able to view the retina.

Fig. 26 How far apart must +2D +3D

a + 2D lens and a + 3D lens
be placed in order to form an
image 1 meter to the right of Image
the second lens?
??? 1m
Ophthalmoscope
-8D myope
Focal Point of
Light Rays
Leaving the
Eye
???
2.5 cm
12.5 cm
Fig. 27 How far from the cornea should an ophthalmoscope be held for a patient who is a −8D myope?
68 D. Wee
As a follow-up, if you, as the examiner, are a −3D moscope. However, if you are a + 3D hyperope and not
myope and not wearing your glasses, you get to use wearing your glasses, you have to compensate for your
your −3D myopia to your advantage. Therefore, you hyperopia. Therefore, an additional −13D will need to
only need to dial in an additional −7D into the ophthal- be dialed into the ophthalmoscope.
Power of Lenses in Different Media
Kamran M. Riaz
Objectives the refractive index when light rays undergo refraction. For

• To understand how a lens may have a different power example, recall from Chap. 1 when we stated that incoming
based on the medium in which it is located light rays undergo refraction at the air-tear film interface.
• To learn how to calculate the power of a refractive Thus, the effective power of a lens depends on the index of
surface refraction of a given medium. By convention, we assume that
• To discuss how different indices of refraction can affect air is the medium for most lenses encountered in Object-
the power of a lens Lens problems; thus, a plus-power lens that has +10D writ-
• To briefly discuss the Lensmaker’s Formula ten on its side will have +10D of power when held in air, but
• To define the Power of a Lens in Different Media the power of this lens will change if placed in a different
Equation (PLDME) and its application to solve medium, such as water, silicone oil, or even chocolate sauce.
problems Fun fact: IOLs are manufactured such that the numerical
power of the IOL written on the box (e.g., +20D IOL) means
that the IOL will have +20D of power when bathed in aque-
Introduction ous (n = 1.33). However, the power of this +20D IOL will be
much different if held in air (n = 1.00). The next time you
Apologies in advance, but the topics discussed in this chapter have a chance to come across a (preferably expired, unus-
are often confusing. Depending on which textbook or resource able) IOL, look through the IOL both underwater and in air.
you consult, you may read a dozen different explanations, The IOL power in air is much stronger (more plus) than its
examples, and even varying terminology used to refer to this power underwater.
concept. Perhaps this is why this topic is confusing to so many We can also apply this concept to another area of relevance
trainees—we cannot even agree on standard terms to discuss in ophthalmic optics. One of the reasons that the cornea has
this!1 In order to make our discussion relevant for examination greater plus power than the crystalline lens is because light
purposes, we are going to use our own terminology (which enters the cornea from the air at the air–tear film (n = 1.00 to
admittedly is adding new terms) that we think is a bit more n = 1.33) interface. The crystalline lens has much lesser “power,”
descriptive and simplified. As always, we will comment on partly because the light passes from an aqueous-to-lens medium
clinical relevance whenever and wherever appropriate. (n = 1.33 to n = 1.409, though much debate exists about the
We can take a minute to recap what we have done so far: exact value, including the central and peripheral regions of the
In the previous two chapters, the reduced vergence formula lens) as it passes from the anterior chamber to the lens.
(aka, the Simple Lens Formula, U + D = V) was used to cal- Before we continue further, an aside is necessary here. In
culate many components of a lens (or mirror) system, includ- Ophthalmic Optics, the term “Lens Maker Equation” may be
ing the power of the lens in question. However, a clinically used to reference the Simple Lens Formula.2 However, in
relevant (and often testable) effect occurs when we change physics optics (the kind you may still have PTSD about
Don’t get us started on the confusion between “meridian” and “axis”

1
when it comes to describing astigmatism. We will save this misery for For example, some texts refer to the lens maker’s equation as a precur-
2
Chap. 10, “Spherocylindrical Lenses”. sor equation used to calculate the simple lens formula.
K. M. Riaz (*)

70 K. M. Riaz
when you think back to your undergraduate physics classes), problem is unlikely to appear on tests. Instead, we should
the term “lens makers’ formula/equation” has an entirely dif- know that the primary determinant of the “functional” power
ferent meaning. In physics optics, the “lens maker’s formula/ of the lens when we change the media is due to the change in
equation” is used to describe the relationship between 4 the indices of refraction.
components of a lens: the radii of curvature (front surface In Ophthalmic Optics, the cornea is a common spherical
and back surface), refractive index, lens thickness, and focal surface that we encounter frequently. Therefore, while we
length. In essence, by calculating the focal length, one can should not waste valuable brain cells on memorizing r values
determine the true effective power of the lens. The equation for different refractive spherical surfaces, one number that
is easier for thin lenses because lens thickness can be ignored; should be committed to memory is that the corneal curvature
however, for thick lenses, the lens thickness is significant and radius is .007 m. This may seem difficult to remember, but
must be taken into account. Clinically, we have to deal with you may recognize that this number (007) is also the code
thick lenses, while in Geometric Optics, we will work with number for the most famous spy in her Majesty’s Secret
thin lenses unless otherwise specified. We will briefly dis- Service.
cuss this version of the Lens Maker Formula at the end of the Nonetheless, we can learn a few key points from the
chapter, and we will use the abbreviation “LMF” when refer- above equation. First, assuming r is constant or relatively
ring to it. It is unlikely that this version will appear on tests small, the power of a refractive surface primarily depends on
because the math required to calculate this is extremely dif- the change between the indices of refraction. Specifically,
ficult to do without a calculator, so you can take some com- the greater the difference between the two indices of refrac-
fort in this fact! tion, the greater the power of the refractive surface. Therefore,
Therefore, for this chapter, we will focus on the a plus power lens will have more power in water or chocolate
ophthalmology-relevant version of determining the power of sauce than its power in air because of the value of (n′ – n).
a lens in different media. To further assist with clarity, we Second, because r is constant (or relatively small), we can
will refer to this as “PLDME” (Power of a Lens in Different combine two of these equations into a Frankenstein equation
Media Equation) when referring to the equation and con- that becomes the PLDME.
cepts necessary for exams and clinical practice. Of course, We can now see how this equation can help us determine
one could argue that this nomenclature is making it even the corneal refractive power in air vs. the corneal refractive
more confusing, but we believe that this terminology is help- power underwater. Again, people, if you decide to submerge
ful for clarity and distinction purposes.3 your head underwater to test your corneas’ power underwa-
ter, be sure to remove any and all contact lenses!
If we want to know the power of the cornea in air vs. the
alculating the Refractive Power
C power of the cornea in water, we can use the above equation
of a Spherical Surface and plug in the following numbers:
Corneal Refractive Power in Air (Air–Tear Film Interface)
The refractive power of a spherical surface can be calculated
n′ − n 1.33 − 1.00
using the wonderfully yucky equation: Ds = = = 47.14D
r 0.007

n′ − n
Ds = Corneal Refractive Power in Water:
r (Cornea–Water Interface)
In this equation, n will refer to the medium with the lower
n′ − n 1.37 − 1.33
index of refraction (usually air), and n’ will refer to the Ds = = = 5.7 D
r 0.007
medium with the higher index of refraction. In addition, r
will refer to the radius of the refractive spherical surface; Even if we use 1.376 as the corneal refractive index, the
however, its value in the equation is represented in meters.4 corneal refractive power in water would be approximately
Usually, the radius of a refractive surface is measured in cen- +6.57D. Would you ever have to calculate this on a test? No!
timeters or millimeters. Therefore when we place that num- The math is too hard. Nevertheless, understanding this helps
ber in the above equation, we will often use a decimal that to explain, for example, why we do not see well underwater:
has a disgusting appearance, rendering the math nearly The cornea has significantly lower refractive power under-
impossible without a calculator. Again, we can sense a theme water as compared to an air medium. In essence, we become
here: Because of the complex math, this type of calculation significantly far-sighted underwater because the cornea can-
not sufficiently refract light to hit the retina as it is able to do
in air. In order to see underwater, we would have to generate
We apologize that we could not come up with a better acronym or
3
mnemonic, however! significant, additional plus power (e.g., by accommodation)

4
Remember, many optics formulas are technically in meters, but we to overcome this barrier; thus, a high/pathologic myope may
often work in centimeters to make the math easier. have an easier time seeing underwater as compared to an
Power of Lenses in Different Media 71
emmetrope or hyperope (the latter would have the most

difficulty).
Suppose the superhero king of Atlantis (whose name we
cannot mention lest we incur the wrath of copyright law-
yers), who is emmetropic underwater, decides to visit us sur-
face dwellers. What will his refractive error be on the
surface?
Answer: Our superhero king of Atlantis likely has incred-
ibly powerful corneas and/or crystalline lenses that can bend
light rays underwater. Therefore, if he is emmetropic
underwater, he will be significantly myopic on the earth’s
surface. He may end up needing −40 to −50D contact lenses
in order to see us surface dwellers. The fact that he does not
Fig. 1 The back surface of the cornea most closely resembles a con-
need glasses or contact lenses on dry land is perhaps, in this cave lens, thereby giving it minus power
author’s belief, the most fascinating of all the superhero’s
powers and should have been explored in the movie’s plot
much more deeply. We can see that the back surface of the cornea has minus
A similarly fascinating real-life example has been docu- power that must be subtracted from the plus power of the
mented and reported among the semi-nomadic Moken peo- front surface of the cornea. Therefore, the net power of the
ple who have lived for generations in boats or stilted cornea will be less than the >47 D of power that we calcu-
dwellings along the coast of Thailand.5 Moken children can lated earlier. This calculation shows the average net refrac-
gather shellfish and other food from the ocean floor as deep tive power of the average human cornea as ~42-43D.
as 75 feet (23 meters). Even though children have more Admittedly, we have employed some shortcuts, so the math
accommodative ability than adults, as optics nerds, we does not exactly match up.7 The main lesson here is that the
should ask ourselves: How are these children able to do this? net refractive power of the cornea is the difference between
Researchers have observed that Moken children can max- the front surface (positive power) and the back surface (nega-
imally constrict their pupils (less than 2 mm-think back to tive power). Clinically, this is important when dealing with
our discussions on diffraction and the Airy disc in Chap. 1) eyes that have undergone previous laser refractive surgery,
and can accommodate past the known limits of human per- especially for correction of myopia. In these eyes, since the
formance (up to 15–16D accommodation). Thus, they can procedure flattens the anterior cornea, keratometry and
overcome the hyperopia encountered by most human beings biometry devices will measure the anterior cornea and
underwater! Interestingly, as these children grow older, they assume a fixed-ratio between anterior and posterior corneal
“age out” of this underwater diving task, as they eventually power when calculating the corneal power. This often leads
lose this ability of “super-accommodation” and the diving to the biometry device measuring falsely steeper-than-real
job is passed on to younger children. With intense training, corneal power measurements, leading to a lower-than-needed
other children of different ethnic backgrounds may similarly IOL power and potential hyperopic surprise.8
achieve this level of underwater vision.6
Returning to the less exciting world of Ophthalmic Optics,
we can use the same equation to calculate the refractive We have intentionally left the math simple here and taken some signifi-
7
cant shortcuts to highlight the more important teaching points men-

power of the back surface of the cornea: tioned in the text. A more strenuous and accurate calculation of this can
Refractive Power of the Back Surface of the Cornea: be done in several ways. One way is to take the Gullstrand eye’s ante-
rior corneal power (approximately 48.8D)—posterior corneal power
n′ − n 1.37 − 1.33 (−5.8D) to arrive at approximately 43D. The magical number of 1.376
Ds = = = 5.7 D
r 0.007 has been used historically for the refractive index of the cornea. With

more accurate methods of measuring the refractive index, we now know
However, we have to ask ourselves is the power of the that the various layers of the cornea themselves have their own refrac-
back surface +5.7D or −5.7D? We can take a closer look at tive index. For example, the epithelium is approximately 1.400,
the back surface of the cornea (Fig. 1). Bowman’s layer is approximately 1.380, the stroma is approximately
1.369, and the endothelium is approximately 1.373. Other methods
have indicated a refractive index of the entire tear-film/cornea complex
ranging from 1.423 to 1.436. In summary, the refractive index of the
tear-film/cornea complex varies significantly from patient to patient,
5
Gislen A, Dacke M, Kroger RH, etc. Superior underwater vision in a but may be actually much higher than previously thought. See Patel S,
human population of sea gypsies. Current Biology Tutchenko L. The refractive index of the human cornea: A review. Cont
2003;13(10):833–6. Lens Anterior Eye. 2019 Oct;42(5):575–580.
6
Gislen A, Warrant EJ, Dacke M. Visual training improves underwater See Chap. 26, “Preoperative Optics for Cataract Surgery”, for more
8
vision in children. Vision Research 2006;46(20):3443–60. information.

72 K. M. Riaz
he Power of a Lens in Different Media

T Example #1
Equation (PLDME) If an IOL made of PMMA (n = 1.49) has a power of +16D
when measured in aqueous, what is the power of this IOL in
The Power of a Lens in Different Media Equation (PLDME) air?
is simply a comparison of the power of a refractive surface
Dmedium1 ( nlens − nmedium1 )
(in this case, a lens) based on the media in which it is placed. =
The PLDME allows us to eliminate the r (and its associated Dmedium 2 ( nlens − nmedium 2 )

complex math) and use the differences in the indices of
refraction to determine the functional power of a lens based Answer
on the medium we are measuring. Begin by using the PLDME:
The PLDME used in ophthalmic optics is as follows: In this case, we can set medium1 as air and medium2 as
aqueous. In general, it is easier to solve these problems by
= having the numerator end up as the larger number, so when-
Dmedium 2 ( nlens − nmedium 2 ) ever possible, set the medium with the lower index of refrac-

tion as medium1.
Dmedium1 = the power of the refractive surface (or lens) in
the first medium Dmedium1 ( nlens − nmedium1 ) Dair ( nIOL − nair )
= = =
Dmedium2 = the power of the refractive surface (or lens) in Dmedium 2 ( nlens − nmedium 2 ) Daq ( nIOL − naq )
the second medium
We can see from the PLDME that if we know the power Dair (1.49 − 1.00 )
=
of a lens in a given medium (e.g., air, with n = 1.00), then we 16 (1.49 − 1.33)
can calculate the power of that same lens in a different Dair ( 0.49 )
medium as long as we know the index of refraction of (1) the = ≈3
16 ( 0.16 )
lens and (2) the new medium.
#ProTip: When setting up this equation, be careful that Dair = ( 3)(16 ) = 48 diopters in air

you match up the power of the lens in a given medium in the
same row as the corresponding index of refraction. For
example, be careful that you maintain the power of the lens Example #2
in medium1 and place the index of refraction of medium2 in If a pair of prescription swimming goggles made from plas-
the same row. The math involved in solving these equations tic (n = 1.44) has −2D of power in air, what is the power of
should be relatively simple for test purposes. If you find the goggles in water? Bonus points: What is the flawed
yourself struggling with the math, pause for a minute and premise of this question?
ensure you have not accidentally placed your numbers in the Answer
wrong spot. Once again, use the PLDME:
The index of refraction of most materials should not be
committed to memory and will likely be given to you on an =
examination. However, you may wish to know a few com- Dmedium 2 ( nlens − nmedium 2 )

monly used indices of refraction as shown in the table below
that we have simplified (rounded) to two decimals for easier As mentioned previously, for consistency, we can set up
memorization9 (Table 1): the PLDME such that the numerator ends up being the higher
Let us do a few examples of typical PLDME questions. number. Therefore, we can place the numbers associated
with the medium with the lower index of refraction in the top
row.
Table 1 Values of common indices of refraction encountered in oph-
thalmic optics
=
D
= air =
( ngoggles − nair )
Medium Index of refraction (n)
Air 1.00
Dmedium 2 ( nlens − nmedium 2 ) Dwater ( ngoggles − nwater )
Water/aqueous/vitreous 1.33 −2 (1.44 − 1.00 ) ( 0.44 )
Cornea 1.376 = =
Crystalline lens 1.386–1.406 Dwater (1.444 − 1.33) ( 0.11)
−2 / Dwater = 4
Dwater = −2 / 4 = −0.5 diopters in water

Source: Emsley HH (ed), Visual Optics, 5th Edition, Volume 1: Optics
9
of Vision, 1953, Butterworth-Heinemann, pp. 336–403.

Dmedium1 ( nlens − nmedium1 ) Daqueous ( nIOL − naqueous )

To answer the bonus portion of the question, we have to
ask ourselves: Does this mean that if we use these goggles = = =
underwater, the −2D goggles will only have a power of Dmedium 2 ( nlens − nmedium 2 ) Dvitreous ( nIOL − nvitreous )
−0.5D? If yes, then why did we spend all this money on 27 (1.69 − 1.33) ( 0.36 )
= =
prescription goggles if they will be underpowered? Moreover, Dvitreous (1.69 − 1.37 ) ( 0.32 )
do we intentionally need to over-minus the goggles to have
D = 27 / ( 9 / 8 ) = 24D of pow
wer ( +3D hyperopicshift )
the required −2D of power underwater? vitreous
This is one of those favorite questions that senior attend-
ings may ask as a rite of passage to younger ophthalmolo- Therefore, during the (hopefully) short time between the
gists. The answer to this is both yes and no. The goggles are initial exam and surgical intervention, the patient will have a
constructed such that the power is on the inside surface of +3D hyperopic shift, and we can take solace that we figured
the goggles. This maintains an air–tear film interface this out using the magical powers of the PLDME.
between the back of the goggles and the swimmer’s eyes.
Therefore, as long as the goggles are properly worn and no
water gets into the space between the back of the goggles Lens Maker’s Formula (Physics Optics)
and the swimmer’s eyes, the goggles will maintain their
−2D of power “underwater.” However, if water gets inside As stated previously, this type of problem is unlikely to appear
the goggles, the air-tear film interface has been replaced on examinations because of the difficult calculations required
with a water-water interface. When the swimmer tries to to solve it. The Lensmaker’s Formula (LMF) is used to con-
use the goggles, they will only have –0.5D of power “in the struct a lens with a specified focal length.10 Since a lens has
water.” Note the semantic difference between “underwater” two curved surfaces (anterior and posterior), if we know the
and “in the water” that makes all the difference on whether index of refraction, lens thickness, and radius of curvature (in
you will correctly answer the senior attending’s question of centimeters) of each surface, we can calculate the focal length
the day. of that particular lens. Basically, a thick lens requires us to fac-
tor in the fact that light rays will get refracted in three different
Example #3 places. Figure 2 shows a typical thick convex lens.
A +27D IOL is constructed of a novel material (n = 1.69). The power of the front surface, back surface, index of
You perform successful cataract surgery on a patient with refraction, and lens thickness can be used to calculate the
silicone oil (n = 1.37) and place the IOL in the capsular focal length.
bag. A few days later, the patient experiences trauma. You We can then take the inverse of the focal length to calcu-
note that the IOL has fallen into the posterior chamber on late the power.
examination. What is the effective power of the IOL at this The LMF is11:
time?
1 1 1
Answer D= = ( n − 1)  − 
First of all, why are we worrying about optics when this f  R1 R2 

patient likely needs surgery to get the IOL out of the poste-
rior chamber and avoid the risk of further problems, includ-
ing retinal detachment and/or blindness? Second, this novel Some texts will refer to this as lens maker’s equation. We have chosen
10
material for the IOL is a terrible choice because the greater to use the term lens maker’s formula since the BCSC also uses the term
the index of refraction, the higher the chances of other prob- lens maker’s equation, albeit as a reference to the simple lens formula.
lems, such as dysphotopsias, though it is likely very thin and All very confusing!
Technically, this is the LMF for a thin lens. The LMF for thick lenses
11
thus easily foldable and injectable through a smaller inci-
in air is even more complicated: D = 1/f = (n – 1) [1/R1–1/R2 + [(n – 1)d]/
sion. Third, let’s go ahead and solve this problem using the [nR1R2]]. That is one disgusting equation, and thus, it is even more
PLDME: unlikely that this will appear on examinations.
74 K. M. Riaz
Lens Thickness 4. What is the radius of curvature of a lens with an index of

refraction of 1.5 and a power of +8D when measured in
air?
Focal Point 5. If a lens is made of a material (n = 1.5) and has a power
of +21D when submerged in acetone (n = 1.35), what is
the power of this lens in air?
6. If a lens made of a material (n = 1.44) has a power of
Front Surface (R1) Back Surface (R2) +40D in air and a power of +20 in an unknown liquid,
what is the index of refraction of this unknown liquid?
7. A lens of an unknown index of refraction is determined to
Fig. 2 In a thick convex (converging, positive power) lens, the power have a power of +80D in air and +20D in water. What is
of the lens is determined by the front radius of curvature, back radius of
curvature, index of refraction, and the thickness of the lens. This can be
the index of refraction of this lens?
used to calculate the focal length, and these variables can be combined 8. Suppose you examine a patient’s biconcave snorkeling
into the LMF equation glasses of unknown power. You note that the front surface
has a radius of curvature of 5 cm, the back surface has a
radius of curvature of 10 cm, and the index of refraction
A convex lens (such as the cornea or crystalline lens) will is 1.5. What is the power of the glasses in air versus
have a positive value for R1 and a negative value for R2. A underwater?
concave lens will have a negative value for R1 and a positive
value for R2. If the question does not explicitly state whether
the lens is convex or concave, looking at the R1 and R2 values
can help determine what type of lens we are encountering. Answers
Hopefully, the LMF will never appear on an examination.
But in case it does: 1. Answer: Use the equation for calculating the power of a
refractive surface, making sure we convert the radius of
Example curvature into meters.
If the refractive index of a lens is 1.6, the front radius of cur-
n′ − n (1.8 − 1.0 ) 0.8
vature is 10 cm, and the back radius of curvature is −15 cm, Ds = = = = +8 D in air
what is the focal length of this lens? What is the power of this r 0.1 0.1
lens? (1.8 − 1.33) 0.47
= = = +4.7 D in water
Answer 0.1 0.11
We will start by writing out the LMF, filling in the given
2. Answer: This is a twist on the familiar equation for calcu-
variables, and solving for the unknown variable:
lating the power of a refractive surface, except this time,
we are asked to solve for n’. We can set up our equation as
1 1 1 1 1 
D= = ( n − 1)  −  = (1.6 − 1)  − 
follows:
f  R1 R2  10 −15 
n′ − n
= ( 0.6 ) × ( 0.1 + 0.00666 ) Ds = n′ = ( Ds × r ) + n = (15 × 0.05 ) + 1
r
= ( 0.6 ) × ( 0.1666 ) = 0.1 = 1.75

So f = 1 / 0.1 = 10 cm ( focal length )
So D = 1 / f = 1 / .1 = +10D 3. Answer: This is a third twist on the familiar equation for
calculating the power of a refractive surface, except this
time we are asked to solve for r. We can use our equation
as before:
Practice Questions
n′ − n ( n′ − n ) (1.66 − 1.33) 0.33
Ds = r= = = = 0.055
r Ds 6 6

1. What is the power of a lens in air with a refractive index
of 1.8 and a radius of curvature of 10 cm? What is the The radius of curvature for this lens would be 5.5 cm.
same power of this lens in water? 4. Answer:
2. What is the refractive index of a lens with radius of cur- n′ − n ( n′ − n ) (1.5 − 1.0 )
vature of 5 cm that has a power of +15D in air? Ds = = r= = = 0.0625m
r Ds 8
3. What is the radius of curvature of a lens with a refractive = 62.5 mm
index of 1.66 that has a power of +6D in water?
5. Answer: This is a relatively straightforward PLDME 8. Answer: This problem requires us to combine our knowl-
question: edge of concepts discussed in the previous chapters (thick
lenses) and concepts from this chapter. We can simplify
the thick lens equation (see Chap. 3) into one that primar-
Dmedium1 ( nlens − nmedium1 ) Dair ( nlens − nair ) ily requires us to compare the power of this lens in air
= = =
Dmedium 2 ( nlens − nmedium 2 ) Dacetone ( nlens − nacetone ) versus underwater. Since the question stem tells us the
Dair (1.5 − 1.00 ) glasses are “biconcave,” we know that we are dealing
= = ( 21)( 0.5 / 15 ) = 21× 3.333 = +70D in air with minus-power lenses: Power of the snorkeling glasses
21 (1.5 − 1.35 )
in air:
6. Answer: This is a bit of a twist on the PLDME equation. D = (n2–n1) * [(1/R1) + (1/R2)]
We are given the two different powers, as well as one = (1.5–1.0) * [(100/–5) + (100/–10)]
index of refraction of a medium, along with the index of = (0.5) * (–30) = –15D
refraction of the lens. We can set it up as follows:
Dmedium1 ( nlens − nmedium1 ) D ( nlens − nair ) Now we can calculate the power of the snorkeling
= = air =
Dmedium 2 ( nlens − nmedium 2 ) Dliquid ( nlens − nliquid ) glasses underwater, using the shortcut that we only have to
account for the difference in the indices of refraction:
40 (1.44 − 1.00 ) 0.44 1.5–1.33 = 0.17. Now we can multiply 0.17 and –30:
= = 1.44 − nliquid =
2 (1.44 − nliquid ) 2 0.17 * –30D = –5.1D (approximately –5D) underwater.
Finally, we have seen several examples of glasses, lenses,
nliquid = 1.44 − 0.22 = 1.22
and IOLs changing from air to water. As a rule of thumb,
the power in air is approximately three times stronger than
7. Answer: The complexity of this problem was admittedly the power of the lens in water.
beyond the scope of what would be encountered on typi-
cal examinations. Nonetheless, we have seen how the
PLDME concept can be tested in various situations. Fun
fact: the index of refraction of silicone is 1.39–1.43, so
maybe this lens is made of silicone-like material?
Dair / Dwater = ( nlens − nair ) / ( nlens − nwater )
80 / 20 = ( nlens − nair ) / ( nlens − nwater )
80 ( nlens − 1.33) = 20 ( nlens − 1.00 )
80 ∗ nlens − 106.4 = 20 ∗ nlens − 20
60 ∗ nlens = 86.4
nlens = ( approximately ) 1.44

Lens Effectivity
Kamran M. Riaz
Objectives is fun and exciting), so his nose is quite long these days.
• To understand how moving a lens closer to the eye and Imagine that if we place glasses on this liar’s nose, we have
away from the eye can change its effective power quite a bit of room to move the lenses forward (down along
• To define the far point and near point for myopic and the nose, away from the eye) and backward (up the nose,
emmetropic eyes closer to the eye). We can visualize this nomenclature in the
• To apply the principles of lens effectivity to clinical following figure – we apologize that we could not fork over
examples of eyeglasses and contact lenses the big bucks to get the actual picture of Pinocchio from his
corporate masters, so instead, we will have to imagine that the
horizontal line in the figure below is his “nose” (Fig. 1).
Introduction When we move lenses toward the eye or away from the
eye, we have “effectively” changed the lens’ power. In other
We have previously discussed that the dioptric power value of a words, the lens is “behaving” like a lens with a different
lens relies on many factors, such as the radii of curvature, index power. We can see how this works for Pinocchio with both
of refraction, and lens thickness. For example, if you hold it in plus- and minus-power lenses.
front of your eye, a +10D lens will have +10 diopters of power
based on these previous factors. One assumption made here is
that the lens is held at a certain distance from the eye (known as Plus Lenses
the vertex distance, which will be important in our discussion on
glasses) to maintain this dioptric power. In other words, we have Moving a plus lens forward (down along the nose, away
to hold the +10D lens at a fixed distance from the eye in order from the eye) will increase its effective plus power. Therefore,
for that +10D lens to behave like a + 10D lens. a +3D lens may “behave” like a +4D lens when Pinocchio
The concept of lens effectivity states that if we hold the moves the lens away from his eye. If we want him to
lens closer or farther away from the eye (i.e., if we change have eyeglasses with +3D of “effective” power, then we will
the vertex distance), that +10D lens may now have “effec- have to decrease the power of the lens if he moves it down
tively” different powers. By altering the vertex distance, we along his nose. This is an important rule for clinical practice:
can cause a lens with a given power to effectively have a dif- in order to maintain the desired distance correction, a plus
ferent power. We will see how this will serve as a foundation lens will have to be decreased in power if it is moved forward
for later discussions on glasses and contact lenses. (i.e., if the vertex distance increases). Or we could just tell
him to stop telling lies so that we do not have to worry about
this effectivity nonsense! (Fig. 2).
Lens Effectivity Moving a plus lens backward (up along the nose, toward
the eye) will decrease its effective plus power. Therefore, our
To understand the concept of lens effectivity, imagine that we same +3D lens may “behave” like a +2D lens when Pinocchio
are dealing with Pinocchio as our test patient. He has been moves the lens closer to his eye. If we want him to have eye-
telling lots of lies recently (such as telling people that optics glasses with +3D of “effective” power, we will have to increase
the power of the lens if he moves it up along his nose. Now
that we told him to stop telling lies, we have to deal with this
K. M. Riaz (*) problem (Fig. 2). This example is a corollary to the above rule
for clinical practice: to maintain the desired distance correc-

78 K. M. Riaz
Fig. 1 Visual representation

of terminology used in
discussions of lens effectivity.
Moving a lens “forward”
means moving it away from
the eye, and moving a lens
“backward” means moving it
closer to the eye
Pinocchio’s “Nose”
Moving a Moving a
lens lens
backwards forward
Fig. 2 Moving a plus lens Behaving Behaving

away from the eye will like a + 2 D like a + 4D
increase its effective plus lens when lens when
power. Moving a plus lens he is he tells a
toward the eye will decrease honest +3D lie
its effective plus power
Pinocchio’s
Moving a Moving a “Nose”
lens lens
backwards forward
tion, a plus lens will have to be increased in power if it is glasses (i.e., adding plus power) and essentially give them-
moved backward (i.e., if the vertex distance decreases). selves “reading glasses” to help with their near vision needs.
Using these two principles, we can understand why a Moving a minus lens backward (up along the nose,
hyperope patient will have to wear higher powered (i.e., closer to the eye) will increase its effective minus power. If
higher number) contact lenses than their glasses. Because we Pinocchio stops telling lies and the −3D lens moves closer to
have moved the lens closer to the eye, we have to increase the his nose, it may “behave” like a −4D lens. If we want him to
power of the needed contact lens. have −3D of “effective” power, then we will have to decrease
the power of the lens if he moves it closer to his eye (Fig. 3).
For real-life purposes, this helps explain why an under-
Minus Lenses corrected myope will often push his/her glasses up along
their nose and closer to the eye – they are (unconsciously)
Moving a minus lens forward (down along the nose, away using the concept of lens effectivity to increase the “effec-
from the eye) will decrease its effective minus power. We can tive” minus power of their eyeglasses.1
think of this scenario as similar to the plus lens in that the
minus lens will also gain more effective plus power the fur-
ther it moves away from the eye. Therefore, a −3D lens will As an additional “why should I care about this” point of relevance,
1
“behave” like a −2D lens if pushed forward down along the understanding the concept of lens effectivity serves as a useful founda-
tion for understanding effective lens position (ELP) for IOL calcula-
nose. If we want Pinocchio to have −3D of “effective” power,
tions. We can deduce that if an IOL sits more anterior (closer to the
we will have to increase the power of the lens if he reverts to cornea), it will have effectively less power, causing a more myopic-
telling lies and the eyeglasses end up further away from the than-intended refractive outcome. Similarly, if the IOL sits more poste-
eye (Fig. 3). riorly, it will have effectively more power, causing a more
hyperopic-than-intended refractive outcome. This concept also has rel-
This example helps explain why presbyopic myopes often
evance for other scenarios, such as why we have to adjust the power of
slide their glasses down along their noses for real-life pur- an IOL if it is placed in the sulcus. See Chap. 28 “Intraoperative Optics”,
poses. By doing this, they weaken their myopic prescription Intraoperative Optics for Cataract Surgery for more information.
Lens Effectivity 79
Fig. 3 Moving a minus lens Behaving Behaving

away from the eye will like a - 4D like a - 2D
decrease its effective minus lens when lens when
power (and give it more plus he is he tells a
power). Moving a minus lens honest -3D lie
closer to the eye will increase
its effective minus power
Pinocchio’s
Moving a Moving a “Nose”
lens lens
backwards forward
This concept can be easily understood for those readers

Far Point
who may be myopic by using themselves as an example.
We imagine a fair number of you reading this book may be
myopic – for you emmetropes out there, sorry! For myopes
who wear both glasses and contact lenses, the power of the Myope
glasses is usually “more minus” than the power of the con-
tact lens. For example, a myope who wears −6D glasses
Far Point
may only need −5.50D contact lenses – because the “lens”
(contact lens) is closer to the eye, less effective power is
needed.
Hyperope
Fig. 4 For myopes, the far point is located in front of the eye. For
The “CAP” Mnemonic hyperopes, the far point is located behind the eye
The “Closer Add Plus (CAP)” mnemonic is useful for both

minus- and plus-power lenses. This mnemonic helps us The far point will be located in front of the eye for a
remember that regardless of the lens (whether it is a plus myope. This intuitively is easier to understand because, in
lens or a minus lens), the closer we move the lens toward these eyes, there is too much plus power present in the eye:
the eye, we must add plus power to the lens to maintain the either the axial length is too long (axial myopia), or the cor-
desired “effective” power of the lens. In both the plus- and neal power is too strong (refractive myopia). Myopic patients
minus-powered lenses examples above, we saw that mov- can see targets located at the far point (or closer) with good
ing the lens closer to the eye requires us to add more plus clarity.
power to the lens. This is easily understood for the plus For a hyperope, the far point will be located behind the
lens: simply add more plus power to the plus lens; how- eye. Admittedly, this is hard to understand or visualize for a
ever, for the minus lens, “adding plus power” means we hyperope, so we should discuss this further. In the hyperopic
have to decrease the minus lens power. You may want to eye, parallel light is refracted (by the cornea and lens) but
read this several times as it may initially seem does not come to a focus at the retina; it will finally converge
counter-intuitive. to a focal point behind the retina (Fig. 4) which we will term
as the far point. Therefore, when the light hits the retina,
since it is still converging, it will produce a blurry image.
The Far Point for Myopic and Hyperopic Eyes The hyperopic eye must generate additional plus power
(accommodation) or use plus-power glasses to “bring the
The far point is a term used to describe “what is the farthest light forward” so that light rays converge on the retina.
point that the eye can see without glasses (and without any For the hyperope, bringing the object closer worsens the
accommodation)”. We will discuss far point and near point blurriness because this creates additional negative vergence
in greater detail in Chap. 9 Accommodation and Presbyopia, at the cornea, which requires additional plus power. This
but we can use this definition for now. explains why young patients with low amounts of hyperopia
80 K. M. Riaz
(e.g., 1−3D hyperopia) don’t need glasses as teenagers and However, for higher refractions and/or unique facial anat-
young adults: they can generate the needed plus power omy, changes in vertex distance can significantly affect the
through natural accommodation. These patients may present patient’s tolerance and satisfaction with the prescribed
in their late 30s/early 40s with complaints of blurry vision glasses.4
worse at near compared to distance as they can no longer If we are given problems that ask us to calculate the power
generate the needed accommodation (latent hyperopia).2 of glasses from the power of contact lenses (or vice versa),
As we will see in the next section, we will need to know we basically have to get the focal lengths of each to match
how to use the far point when dealing with vertex distance up. The trick is to make sure we account for the vertex dis-
problems. tance. Many trainees are confused about whether we should
add or subtract the vertex distance depending on whether we
are dealing with a plus- or a minus-power lens. If we simply
pplying Lens Effectivity to Glasses
A maintain the signed values at all times, we can apply the
and Contact Lenses above rules inclusive of both lenses. We can do some exam-
ples to reinforce these points.
As we hinted at in the previous section, we can use this prin-
ciple to help us understand why the power of glasses and Example #1
contact lenses, especially with higher prescriptions (whether If a patient wears +10D glasses with a vertex distance of
myopic or hyperopic), is often very different. 10 mm, what power contact lenses should be ordered?
When we prescribe glasses, we assume a fixed distance A. +9 D
between the eye and the glasses (known as the vertex dis- B. +10.5D
tance) that is accounted for in the eyeglass prescription. In C. +10.75D
our previous Pinocchio discussions of him telling lies or D. +11 D
being truthful, we were simply changing the vertex distance E. +11.25 D
of the glasses and therefore needing to change the power of Answer: Suppose we are given this problem on an exam,
the glasses.3 and we have a brain freeze, forgetting all the Pinocchio dis-
For clinical purposes, when we change from glasses to cussions and whatnot. We can at least eliminate wrong
contact lenses (and vice versa), we are basically changing the answer choices by simply remembering that hyperopes will
focal length of the lens based on the presence or absence of need “more plus power” in their contact lenses (because of
the vertex distance. Remember that the focal length of a lens the “CAP” mnemonic). Therefore, we can at least eliminate
can be calculated by F = 1/D (or F = 100/D to work in centi- answer choice A and increase our chances of getting this
meters). For example, a +5D lens will have a focal length of problem correct.
20 cm or 0.2 m. But we should not live life by simply guessing. We want
When we change from glasses to contact lenses, we have to actually solve the problem and feel that we have accom-
to subtract the vertex distance. This should make sense plished something meaningful today. In order to solve this
because the contact lens sits on the cornea, so there is no problem, we need to figure out what is the focal length of the
vertex distance to factor. glasses first:
When we change from contact lenses to glasses, we have
f glasses 100
= = / D 100 / 10 = 10 cm
to add the vertex distance because now the lens is away
from the eye, so we have to account for the vertex distance. Since we are going from glasses to contact lenses, we
As an aside, we often assume a given vertex distance (e.g., have to subtract the vertex distance:
12.5 mm) when performing these calculations clinically.
f CTL = f glasses − vertex distance

2
See Chap. 21, Clinical Problems with Optics and Refractive f CTL = 10 cm − 1 cm = 9 cm
Manifestations for more information on latent hyperopia
3
Knowledge of the vertex distance is also helpful surgically. For exam- PCTL = 100 / 9 = +11.1D
ple, the ASCRS IOL Calculator for Eyes with Prior Myopic LASIK/
PRK requires information about the pre-LASIK/PRK vertex distance to
Therefore, we will need to order +11D contact
improve accuracy in some of the generated formulas. If the vertex dis-
tance is unknown, the calculator defaults to 12.5 mm. Of course, this lenses (Answer Choice D).
information is not absolutely necessary for this calculator as other for-
mulas, such as the Barrett True-K No History Method, can generate
relatively accurate predictions without this information. We point this
out to merely emphasize how vertex distance affects our daily practice
as ophthalmologists. See https://iolcalc.ascrs.org/wbfrmCalculator. See Chap. 16 Construction of Glasses: Ophthalmologists as Opticians
4
aspx for more information.

Lens Effectivity 81
Example #2 Practice Questions

What power eyeglasses are needed for a patient who wears
−8D contact lenses? Assume a vertex distance of 14 mm. 1. Suppose Pinocchio is a myope who is fully corrected with
A. −7.50D −8D glasses at a vertex distance of 15 mm. If he were to
B. −8.00D start telling lies again such that his vertex distance became
C. −8.50D 25 mm, what is the power of the new glasses needed?
D. −8.75D 2. Given the same problem above, what if the vertex dis-
E. −9.00D tance was changed to 5 mm? What is the power of the new
Answer: E. Again, suppose we are given this problem on glasses?
an exam, and we forget everything we have previously 3. Given the same problem above, what if we wanted to pre-
discussed. Since we are dealing with minus-power lenses, scribe him contact lenses (i.e., the vertex distance became
the further we move the lens away from the eye, we will need zero)?
more minus power to maintain the effective −8D of correc- 4. Suppose Pinocchio is now a hyperope fully corrected
tion. Therefore, we can safely eliminate answer choices A with +10D glasses with a vertex distance of 10 mm. What
and B. power eyeglasses are needed if the vertex distance is
Now for the actual math here. Since we are going from changed to 20 mm?
contact lenses to glasses, we have to add the vertex distance, 5. Given the same problem above, what if the vertex dis-
making sure that we maintain the signed values at all times: tance was changed to 5 mm? What is the power of the new
glasses?
f CTL = 100 / −8 = −12.5 cm
6. Given the same problem above, what if we wanted to pre-
f glasses = f CTL + vertex distance scribe him contact lenses (i.e., the vertex distance became
zero)?
f glasses = −12.5 cm + 1.4 cm = −11.1 cm 7. What power contact lenses are needed for a patient who
wears +12.5D glasses with a vertex distance of 13 mm?
Pglasses = 100 / −11.1 cm ≈ −9D 8. What power contact lenses are needed for a patient who
wears −6D glasses with a vertex distance of 16 mm?
9. Suppose a patient is fully corrected for her refractive error
Example #3 with a +7D lens with a 10 mm vertex distance; how far in
Suppose a +4D hyperope is given a +3D lens. How far in front of the previous location of the +7D lens should
front of the eye must she hold it to see clearly at a +5D lens be placed in order to fully correct her refrac-
distance? tive error?
Answer:
This question is a repackaging of the concepts we have
discussed thus far: all we have to do is figure out the focal Answers
lengths of the eye and the lens so that this +3D lens can
“behave” like a +4D lens 1. Basically, we have to figure out how the change in vertex
distance will affect the power of the lens that is needed.
f lens 100
= = / 3 33 cm
We can draw this out as shown in Fig. 5.
f eye 100
= = / 4 25 cm Before he started telling lies, Pinocchio’s far point of
the eye was (Fig. 5a)
Now we have to match up the focal distances:
Myopic Far Point = f glasses + vertex distance
Vertex distance = 33 cm − 25 cm = 8cm in front of the eye
= (100 / 8 ) + 1.5 = 12.5 + 1.55 = 14 cm
Now we basically need to find the focal length of the

new glasses: 14 cm – 2.5 cm = 11.5 cm (Fig. 5b).
Power of the new glasses : 100 / 11.5 ≈ −8.7 D (−8.75D glasses since glasses can only be

made in 0.25D steps)
82 K. M. Riaz
Fig. 5 Figure for Practice -8D

a
Problem #1. Calculation of
eyeglass power needed with
increased vertex distance for Far Point
myope. Figure 5a displays the
power of the eyeglasses (-8D)
with 15 mm vertex distance. Myope 15 mm = 12.5 cm
Figure 5b displays the new 1.5 cm
vertex distance (25 mm) that
can be used to calculate the
power of the new glasses
Far Point
Myope 25 mm = 11.5 cm
2.5 cm
Fig. 6 Figure for Practice Hyperope + 10 D

a
eyeglass power needed with Far Point
increased vertex distance for
hyperope. Figure 6a displays
the far point of the eye as 90 mm = 9 cm 10 mm
determined by the +10D = 1 cm
eyeglasses and 10mm vertex
distance. Figure 6b displays 100 mm = 10 cm
the new vertex distance
(20 mm) that can be used to
calculate the power of the
Hyperope
new glasses
b
Far Point
90 mm = 9 cm 20 mm = 2 cm
110 mm = 11 cm
2. We can modify our calculations from the previous prob- 4. Since we are dealing with a hyperope, we need to account
lem to find the new focal length of the glasses: 14 cm – for the far point being “behind” the eye (Fig. 6a).
0.5 cm = 13.5 cm.
Hyperopic Far Point = f glasses − vertex distance
Power of the new glasses : 100 / 13.5 = −7.41D ( ≈ 7.5D ) = (100 / 10 ) − 1 cm = 10 −11 = 9 cm

3. Now we simply have to take the focal length (14 cm) and Now we need to basically find the focal length of the
find the power of the contact lens: new glasses: 9 cm + 2 cm = 11 cm (Fig. 6b).
Power of the contact lens : Power of the new glasses : 100 / 11 ≈ +9D

100 / 14 = 7.14D ≈ −7 D contact lens
5. We can modify our calculations from the previous prob-
lem to find the new focal length of the glasses:
Notice that in problems 2 and 3, as we moved the 9 cm + 0.5 cm = 9.5 cm.
glasses closer to the eye (until it became a contact lens), Power of the new glasses: 100/9.5 = +10.5D. Again,
the “minus” power of the glasses continued to decrease this makes sense as it follows our “CAP” mnemonic. We
(i.e., became more plus) in line with our “CAP” will need stronger “plus” power in the eyeglasses as we
mnemonic. move them closer to Pinocchio’s eyes.
Lens Effectivity 83
6. Now we simply have to take the focal length (9 cm) and 8. We can start off by locating the focal length of the glasses
find the power of the contact lens: (Fig. 8a):
Power of the contact lens : 100 / 9 = +11D f glasses = 100 /D = 100 / −6 = −16.6 cm

7. We can start off again by locating the far point of the eye. Since we are going from glasses to contact lenses, we
In this case, 100/12.5 = 8 cm or 80 mm behind the eye have to subtract the vertex distance, making sure we
(since we are dealing with a hyperope). This also takes maintain the signed values (Fig. 8b):
into account our 13 mm vertex distance (Fig. 7a).
f CTL = f glasses − vertex distance
Now since we are going from glasses to contact lenses,
we can subtract our vertex distance: 8 cm – 1.3 cm = 6.7 cm f CTL = −16.6 cm − 1.6 cm = −18.2 cm
(or 67 mm).
Now we can find the power of the contact lens using PCTL = 100/−18.2 = −5.5D. Again, this follows our pre-
this “new” focal length: 100/6.7 = 14.92D (≈ +15D con- vious examples with minus-power contact lenses and
tact lens) (Fig. 7b). glasses because our contact lens power is “more plus”
Fig. 7 Figure for Practice Hyperope +12.5D

Problem #7. Figure 7a a
displays how using the
Far Point
+12.5D glasses and 13 mm
vertex distance can be used to
find the far point of the eye.
67 mm = 6.7 cm 13 m =
Figure 7b shows the contact
1.3cm
lens power can be calculated
80 mm = 8 cm
b Hyperope
Far Point
67 mm = 6.7 cm
Contact Lens
Fig. 8 Figure for Practice -6D

Problem #8. When given an a
eyeglass prescription power
with vertex distance Far Point
(Figure 8a), the contact lens
power can be calculated
(Figure 8b) Myope 16 mm = 16.6 cm
1.6 cm
18.2 cm
Far Point
Myope 18.2 cm
Contact Lens
84 K. M. Riaz
Fig. 9 Figure for Practice

vertex distance based on
different spherical lens power
(i.e., less minus power) than our eyeglass Far point: 100/7 = 14.28 cm from the lens behind the
prescription. eye (Fig. 9).
9. We can start by first finding the far point for this patient. Next, we need to find the far point for a + 5D lens:
We can ignore the vertex distance because the question 100/5 = 20 cm.
does not ask how far from the cornea we have to place the Finally, we can subtract these two numbers:
new +4D lens, but rather how far from the original 20–14.28 = 5.72 cm in front of where the +7D used to be,
+7D lens. aka 6.72 cm in front of the cornea.
Schematic Eye
Daniel Wee
Objectives Model of the Reduced Schematic Eye

• To understand the history of Gullstrand’s model eye
• To understand how the Reduced Schematic Eye is used to The RSE relies upon certain assumptions to simplify the
calculate problems that test this concept on written exams optical properties of the human eye (Fig. 1). It should be
noted that in modern optics, especially for cataract and
refractive surgery, many of the assumptions of the RSE are
Introduction inaccurate and have since been replaced with other models
and principles. Nonetheless, the RSE remains a useful start-
The schematic eye (“Reduced Schematic Eye” (RSE)) is a ing foundation to later study these advanced topics.
topic that seems intimidating and confusing, but it is actually
a simplified model of an eye used in ophthalmic optics. The • The RSE assumes that the eye only has a single refractive
official definition is that the RSE is a model that represents point (n, the nodal point) that combines the cornea, aque-
the basic optical features of a real eye. This allows us to cre- ous, and lens into a simplified refractive location.
ate ray tracings to determine sizes of retinal lesions, scoto- • Another assumption is that the only two indices of refrac-
mas, or blind spots. In our case, it is a simple geometry math tion are air (n = 1.00) and water/aqueous (n = 1.33).2
problem using two congruent triangles that is a common • The refractive power of the eye is +60D.
question on written exams. • The anterior focal point is 17 mm (determined by
Some useless information that will likely never show up F = 1/60 = 16.7 mm ≈ 17 mm) in front of the cornea.
on exams: the schematic eye was invented by Dr. Allvar • The nodal point is 5.5 mm behind the cornea.
Gullstrand (1862–1930), a Swedish ophthalmologist who • The axial length of the eye is 22.5 mm.
developed the model eye to better study refraction and opti-
cal images in the eye. Fascinatingly enough, he self-taught As stated previously, the nodal point (n) is simply a fancy
himself geometric and physiological optics! He was awarded term used for the point in the eye where all light rays enter-
the Nobel Prize in Physiology or Medicine in 1911 (must ing or leaving the eye do not deviate (Fig. 2). We can see how
have been a slow year) for his work.1 Fun fact: he remains the incoming light rays, regardless of their incoming angle, will
only ophthalmologist to ever receive the Nobel Prize. pass through the nodal point as if the cornea did not exist
Tragically, Dr. Charles Kellman, the inventor of phacoemul- (Fig. 2).
sification technology, never received a Nobel Prize. While For the purposes of exams, just think of the nodal point as
the good Dr. Kellman’s legacy remains inventing a device the part of the eye that allows us to draw two triangles to get
that has restored vision to millions of people worldwide, the our correct answer. The more important number to remem-
good Dr. Gullstrand’s legacy remains inventing a (inaccu- ber is the distance from the nodal point to the retina (F′),
rate) model of the eye that is required learning for ophthal- which is 17 mm. This number has to be memorized because
mology trainees worldwide.
The index of refraction of the cornea is closer to 1.376; aqueous is

2
“Allvar Gullstrand Biographical”. https://www.nobelprize.org/prizes/

1
1.336; crystalline lens is 1.386–1.406 (outer-inner layers); and vitreous
medicine/1911/gullstrand/biographical/. Accessed December 22, 2019. is 1.337.
D. Wee (*)

86 D. Wee
Power = 60D moscope held “x” cm from the eye), then 5.5 mm may need
to be taken into account.
H n=1.33
17 mm
F n F' Ray Tracing with the Reduced Schematic Eye
We can use our RSE model to create another model using our
knowledge of undeviated light rays, the nodal point, and this
magical number of 17 mm to create a simplified model com-
5.5 mm paring two congruent triangles (Fig. 3).
17 mm 22.5 mm Notice that we have eliminated the anterior focal point as
well as the distance from the nodal point to the cornea
(5.5 mm).
Fig. 1 The Reduced Schematic Eye (RSE). Note that the nodal point
(n) that is used for ray tracing is located inside the eye. Also note that
When comparing similar triangles, it is vital that we com-
the distance from the nodal point to F′ is 17 mm. This number must be pare similar parts of the triangle. In other words, how we set
committed to memory up the comparison ratio is extremely important because if we
end up comparing the height of one triangle to the base of the
other triangle, it will lead to some very difficult math – and
more importantly, the wrong answer. We can be reasonably
certain that one of the wrong answer choices given on exams
H n=1.33 will be a calculation obtained by simply setting up the com-
A
17 mm parison ratio wrong!
F n F'
#Protip: If you have started your calculations and encoun-
ter some strange, disgusting numbers, then you may want to
stop and ask yourself if you have plugged in the numbers
5.5 mm
B correctly.
17 mm 22.5 mm
Therefore, set up the calculations as either:
Choice #1 (Math will usually be easier) - Compare the
C
height and base of one triangle to the height and base of the
Fig. 2 Incoming light rays (A, B, and C) will all pass through the nodal other triangle:
point (n) as undeviated light rays as if the cornea did not exist
Height1 / Base1 = Height 2 / Base 2

it will never be given to you on the exam! If you can remem- Choice #2 (Also possible, but math may be trickier) –
ber 17 mm, it is a simple geometry problem.3 It is also worth Compare the height of one triangle with the height of the
noting that the distance from the cornea to the nodal point is other triangle and compare that to the base of one triangle
5.5 mm as that may come up in test questions as well. with the base of the other triangle:
For most RSE problems, we can safely ignore the 5.5 mm
Height1 / Height 2 = Base1 / Base 2
as the distance of the target from the eye is usually in meters;
therefore, the 5.5 mm does not contribute much to the dis- Using this construct, test questions will basically ask us to
tance. For example, if the question states that the tangent determine one of the missing components in this comparison
screen is located 4 meters away, then the true distance from ratio by giving us two numbers; the third number is always
the nodal point is 4005.5 mm, but using 4000 mm is “close 17 mm!
enough” and makes the math easier. However, for problems The other thing to keep in mind is that it will make
wherein the target is much closer to the eye (e.g., an ophthal- things easier to use millimeters as our preferred unit of
measurement. Again, recall that 17 mm (Neurofibromatosis
A useful mnemonic here is to remember that the chromosome for the
3 I chromosome!) is already in millimeter notation, so it will
NF-1 gene in neurofibromatosis is located on chromosome 17. How help to convert the other numbers that will be given to us
does this help you may ask? It is highly likely that you remember “chro- into millimeter notation to keep our calculations consis-
mosome 17” from way back in medical school days, so that number 17
tent. Finally, pay attention to the answer choices as they
is somewhere in your brain. So you can now apply that useful number
to optics (or you can use this optics moment to remember a useful chro- may be given in millimeter, centimeter or even meter
mosome number that may come up on exams!). notation.
Schematic Eye 87
Fig. 3 The RSE can be

further simplified into a
geometry problem comparing Nodal Point Posterior Focal Point
two similar triangles using the Size of
nodal point and its distance to scotoma
the posterior focal point
(17 mm) 17mm
Distance to screen Retinal lesion
?? Answers
n F'
2m Retinal Scar 1. Remember, the 17 mm distance from the nodal point to
1.7mm
the retina is not going to be given to you.
Let us set this up as two congruent triangles and con-
vert 2 mm to 2000 mm. We can redraw the figure as a
Fig. 4 First figure for practice question 1: What is the size of a scotoma
measured 2 m away from the eye caused by a 1.7 mm retinal scar?
comparison of two similar triangles (Fig. 5).
Height1 (Y ) / Base1 = Height 2 / Base 2

Practice Questions
Y / 2000 mm = 1.7 mm / 17 mm
1. What is the size of a scotoma measured 2 m away from Y / 2000 mm = 0.1 mm
the eye caused by a 1.7 mm retinal scar (Fig. 4)? The scotoma is 200 mm or 20 cm or 0.2 m (depending
2. What is the size of a retinal hemorrhage causing a 30 cm on what units the answer choices may have) in size.
scotoma on a screen when measured 1 m from the eye? 2. We can go ahead and set up our congruent triangles, tak-
3. A 3.4 mm retinal scar causes a 40 cm scotoma on a screen. ing care to place the given numbers in their appropriate
How far is the screen from the eye? locations.
4. A patient has a macular lesion of unknown size that cor- Now we can go ahead and plug in the numbers accord-
responds to a blind spot of 2.5 cm when viewed at a screen ingly. This is little trickier because we have units in m,
placed 0.1 m away. How big is the macular lesion? cm, and mm. Let us make the problem a little easier by
A. 4.25 mm converting all the units to mm, as seen in Fig. 6.
B. 0.425 mm
Y / 17 mm = 300 mm / 1000 mm
C. 4.25 cm
D. 42.5 mm Y / 17 mm = 0.3 mm
5. How far away must a tangent screen be placed from a Y = ( 0.3 mm )(17 mm )
patient who has a 1 mm scotoma to manifest 150 times its Y = 5.1 mm
size?
6. Using the model eye, calculate the size of the image The retinal hemorrhage is 5.1 mm in diameter.
formed by a 3 mm retinoscope pinhole on the patient’s 3. By now, we should be in a bit of a rhythm, setting up our
retina if the scope is held 51 cm from the nodal point of familiar congruent triangles (Fig. 7).
the patient’s eye.
7. Using the RSE as a model, suppose we are told that the
location of the second principal plane is 1.6 mm behind This time we are solving for X. Let us convert the
the anterior corneal surface. If a patient views an object at 40 cm to 400 mm.
infinity, how far away from the anterior corneal surface
400 mm / x = 3.4 mm / 17 mm
will the image be formed?
8. What is the size of a 2.55 mm retinal hemorrhage if 400 mm / x = 0.2 mm
viewed by an emmetropic examiner using an ophthalmo- X = 2000 mm or 200 cm or 2 m in front of the eye.
scope held 2 cm from the patient’s eye?
88 D. Wee
Fig. 5 Second figure for

practice question 1: Note the
use of a similar triangles
schematic to solve for the size Size of
of the scotoma scotoma
17mm
2000 mm Retinal lesion = 1.7 mm
Fig. 6 First figure for

practice question 2: What is Size of
the size of a retinal scotoma =
hemorrhage causing a 30 cm 30 cm =
scotoma on a screen when 300 mm 17mm
measured 1 m from the eye?
1 m = 1000 mm Retinal hemorrhage = ??
Fig. 7 The similar triangles

schematic can again be used
to solve for the unknown Size of
variable: the distance of the scotoma =
screen from the eye 40 cm =
400 mm 17mm
Retinal scar = 3.4 mm

Distance of screen from eye = ??
Fig. 8 The similar triangles

to solve for the unknown
variable: the size of the
macular lesion 2.5cm=
25mm
17mm
0.1m=10cm=100mm ???
4. A. This is a great example of a problem where the given 5. This is a convoluted way of asking the same concept we
units are all different (note the centimeter and meter nota- have been doing thus far.
tion in the stem). On an exam, one may be short pressed We can again set up our schematic eye equation as:
on time so we can see how easy it is to make a mistake in
the calculations. This is why developing a habit to work in
the same unit will make our calculations easier. We basically have to solve for Base2:
Again, start by converting everything to millimeter
1 mm / 17 mm = 150 mm / x
notation and drawing out the congruent triangle diagram
(Fig. 8). = =
x 2550 mm 2.55 meters away
6. Start off by converting all the units to mm notation and
Height1 / Base1 = Height 2 / Base 2 draw out our familiar similar triangles diagram (Fig. 9).

X / 17 mm = 25 mm / 100 mm Height1 / Base1 = Height 2 / Base 2

X / 17 mm = 1 / 4 mm This time we are solving for × (Height2)
X = 4.25 mm

Schematic Eye 89
Fig. 9 The similar triangles Retinoscope

to solve for the unknown 17 mm
variable: the size of the 3 mm 3 mm
Eye
retinoscope pinhole cast onto
the patient’s retina when held x mm
51 cm from the nodal point of
the patient’s eye 51 cm = 510 mm
x ( Height 2 ) = ( Height1 / Base1 )( Base 2 ) Thus, v = 1.336/60 = 0.0223 m or 22.3 mm.

Now we can add: 1.6 mm + 22.3 mm = 23.9 mm
= ( 3 / 510 ) ∗ (17 ) = 51 / 510 = 0.1 mm
behind the anterior corneal surface, which is “close” to
Note: we could have used 515.5 mm in place of the typical axial length of an average (emmetropic) eye.
510 mm if we wanted to be more accurate as to the “true” 8. This is a similar problem to the ones that we have done
distance of the ophthalmoscope from the nodal point. before. The one caveat is because the ophthalmoscope is
This would incur a slightly more difficult calculation: held relatively close to the patient’s eye; we have to factor
in the 5.5 mm distance between the anterior cornea and
the nodal point.
This time we are solving for (Height2) We can again set up our schematic eye equation as:
( Height 2 ) = ( Height1 / Base1 )( Base2 ) Height1 / Base1 = Height 2 / Base 2

= ( 3 / 515.5 ) ∗ (17 ) = 0.0989 mm We basically have to solve for Height2; however, Base2

cannot simply be 20 mm. We have to factor in the 5.5 mm
Notice that this answer is essentially the same as and use 25.5 mm instead.
0.1 mm. Now we can solve: Height2 = (Height1 /Base1) * Base2
7. This is a bit of a tricky problem that requires us to com- = (2.55/17) * (25.5) = 3.825 mm.
bine our knowledge of the RSE along with our old friend Had we not factored in the 5.5 mm, we would have
U + D = V. We know that the object is at infinity, so we instead gotten:
can set U = 0. We also know that the index of refraction of
Height 2 = ( Height1 / Base1 ) ∗ Base2 = ( 2.55 / 17 ) ∗ ( 20 ) = 3.0 mm
vitreous is 1.336. This gives us:
U +D =V
0 + 60 = V = 60 Notice that this 0.825 mm difference is significant
V = 1.336/v, as we have to account for the new index of because we are working in much smaller distances as
refraction. compared to the tangent screen problems previously.
Magnification and Telescopes
G. Vike Vicente
Objectives Galilean. Just like pirates, we ophthalmologists are sur-

• To define, understand, and calculate the various kinds of rounded by telescopes in our daily practices.
magnification (transverse[linear], axial, and angular)
• To define and understand how the two main types of tele-
scopes (Astronomical [Keplerian] and Galilean) work Magnification
• To appreciate clinical relevance of magnification of tele-
scopes in clinical and surgical practice Transverse Magnification
Transverse magnification (aka linear magnification) is similar

Introduction to the magnification we discussed when doing lens and mirror
systems.2 We have previously introduced this formula,
Ahoy Optics mateys! To help make this chapter easier to under- M = U/V = v/u (“big MOVIE, little view” mnemonic), when
stand and remember, we will periodically slip into a “pirate discussing object-lens-mirror systems.3 Recall that we can
voice” so that the image of a pirate using a telescope will help use either the sizes or the distances between the object and the
us conceptualize some important concepts and examples. If a image to calculate the magnification.
German spectacle maker in the seventeenth century can under- To continue this discussion, we can use similar triangles
stand telescopes, so can you! (see Hans Lippershey).1 to give us more background to calculating transverse
Argg! Here we go. magnification.
Telescopes work by combining a series of lenses or curved Remember the bilge-sucking law of similar triangles,
mirrors to improve and enlarge our visualization of distant bucko? We can compare the height and the base of a given
objects. Therefore, to understand telescopes we first need to triangle with the height and the base of another similar
understand magnification. There are four types of magnifica- triangle (Fig. 1).
tion we will discuss: Transverse Magnification (aka Linear
Magnification), Axial Magnification (aka Longitudinal X1 X 2
Magnification), Angular Magnification, and Magnification =
Y1 Y2
from a Simple Magnifier.
After discussing magnification, we will then discuss the Suppose we wanted to calculate the height of the image
two main types of telescopes, as well as their clinical, surgi- (X2), we can simply rearrange the above equation as:
cal, and testable relevance: Astronomical (Keplerian) & X2 = (X1∗Y2)/Y1
Technically, linear magnification refers to the magnification of the area

2
Hans Lippershey. https://en.wikipedia.org/wiki/Hans_Lippershey.

1 of an image relative to the area of an object along an optical axis. We
Accessed March 27, 2021. have thus far only addressed the height of an object. But suppose we
had an object that measured 3 cm ×5 cm with 2× transverse magnifica-
tion. This would give us an object with dimensions of 6 cm × 10 cm.
G. V. Vicente (*) Therefore, the linear magnification would go from 15 cm2 to 60 cm2, a
Clinical Pediatrics and Ophthalmology Georgetown University fourfold increase in image area. To keep things simple for the purposes
Hospital, Washington, DC, USA of ophthalmic optics, we will consider transverse magnification and lin-
Eye Doctors of Washington, Chevy Chase, MD, USA ear magnification to be the same thing.
e-mail: vvicente@edow.com See Chaps. 3 and 4, if you need to review this.
3

92 G. V. Vicente
Fig. 1 Using the law of

similar triangles, we can use
object/image height OR
object/image distance from v
the lens to calculate more X1 Y2 i
information about the lens
system, including information o Y1
about magnification X2
u
The vertical height difference between the object (X1) and

the image (X2) (i.e., the transverse magnification) will be
i
proportional to the distance between the object (u) and the o
image (v) from the lens. Notice how a larger (v) or Y2 will 1m 2m
give a larger image, as seen in the dashed arrows to the right.
We can use this relationship between the SIZES of the object
and image to calculate transverse magnification.
Similarly, if we know the DISTANCES of the lens to an Fig. 2 What is the transverse magnification of an object 1 m away from
a convex (+) lens, if the image is 2 m away?
object (u) and from the lens to an image (v), we can calculate
the magnification by using the following formula:
= 1.5m
Transverse Mag image distance / object distance v / u. i
o
3m 9m
On exams, we may be asked to determine the transverse
magnification of a lens system solely based on distances or
sizes, without any information about the lens power. Let us Fig. 3 If a 1.5 m tall object is 3 m from a lens, and the image is formed
do some examples that test this concept. 9 m to the right of the lens, how large is the image?
Example #1 (Fig. 2) Example #3 (Fig. 4)

Transverse Magnification = v/u = 2m/1m = 2× First, we notice that since this is a concave lens system, the
Arrrg!!. See ye landlubbers, magnification is not that image will likely form to the LEFT of the lens. When we
tough! Notice how we did not need any information about enter our distance values into our now-familiar equation:
the object or image height in order to calculate the magnifi- Transverse Magnification = v/u = 0.5/1m = 0.5
cation. Similarly, if we are only given information about the Notice that if the absolute value of the magnification is
object and image heights without any information about less than 1, then the image will be minified. In this case, the
object and image distances, we can still calculate the magni- image is 50% (1/2) size of the object.
fication of the system.
Example #4
Example #2 (Fig. 3) A 2-m tall object is 3 m away from a lens and the image is
Transverse Magnification = v/u = 9m/3m = 3×. 1 m away. What is the size of the image?
The image will be 3 × 1.5 m = 4.5 m tall.
Notice again that we did not need to know the power of Transverse Magnification = v / u = 1m / 3m = 0.33 ×
the lens to solve this equation! Of note, we assumed this was The image will be 2 m x 0.33 = 0.66 m. Notice we did not
a plus lens because the question stem stated that the image draw the object, lens, and image in this example showing
formed to the right of the lens. that you can solve these problems without drawing it out as
well. Initially, it may help to draw them out if you are just
getting your sea legs under you on this pirating adventure of
telescopes in ophthalmology.
Magnification and Telescopes 93
Example #5 Mag1 * Mag2. This is a key point to remember for exam

Shiver me timbers, let us complicate things just a wee bit, purposes because it is very likely that one of the wrong
shall we? answer choices will be one that has the sum of Mag1 and
What if we have more than one lens (Fig. 5)? Mag2, and picking that would be like dancing the hempen
In order to solve these two lens systems, we again will jig!
start off by ignoring the second lens and directing our Start off by solving for the first lens (Fig. 6).
attention to the first lens. We can first calculate the magni- Applying the formulas U = −1/u and U + D = V:
fication of the first lens (Mag1), and then the magnifica-
tion of the second lens (Mag2). The final magnification of
U = −1 / 0.166m ( OR − 100 / 16.6 ) = −6 D.
this lens s ystem will be the PRODUCT (not the sum!) of

U + D = −6 D + 8D = +2 D = V , v = 1 / V = 1 / 2 ( OR 100 / 2 ) = 0.5 m ( or 50 cm )
Magnification of first image = U/V = 6/2 = 3×. (We could After having determined that the magnification from the first
also use Mag = v/u = 50/16.6, which should give us the same lens (Mag1) is 3×, we can now solve for the second lens (Fig. 7).
answer with slightly more difficult math). Applying the formulas U = −1/u and U + D = V:
U = −1 / 0.1m = −10 D.

U + D = −10 D + 14 D = +4 D = V , v = 1 / V = 1 / 4 D = 0.25m = 25 cm.

Magnification of second image ( Mag2 ) = U / V = 10 / 4 = 2.5 ×
Fig. 4 What is the transverse

magnification of an object
1 m away from a concave
lens, if the image is 0.5 m
from the lens?
o i 0.5m
1m
Fig. 5 What is the final +8D +14D

image magnification of an
object that is located 16.6 cm
to the left of a + 8D lens,
which itself is located 60 cm
to the left of a + 14D lens?
16.6cm 60cm
94 G. V. Vicente
Fig. 6 An inverted image is +8D +14D

formed 50 cm to the right of
the first lens
16.6cm
50cm
Fig. 7 An upright image is

formed 25 cm to the right of
the second lens
+8D +14D
50cm 25cm
10cm
Since the first lens system has a transverse magnification change of depth along the axis; it is basically the square of
of 3× (Mag1), and the second lens system has a transverse transverse magnification:
magnification of 2.5× (Mag2), the magnification of the final
Maxial = ( M transverse )
2
image compared to the original object will be the product of
the Mag1 and Mag2: Mag1 × Mag 2 = 3 * 2.5 = 7.5× total
magnification. Note that the sum of Mag1 and Mag 2 (5.5×) Why do we care about axial magnification? Blimey,
is not correct. because clinically, it will cause distortion of 3D images. For
Suppose that the problem had stated that the object was example, it can exaggerate the height of a retinal detachment
10 cm in size and we were asked to calculate the final size of viewed by indirect ophthalmoscopy. This helps offset the
the image, we would calculate the image size as 10 cm × 7.5× loss of some stereoacuity caused by the indirect ophthalmo-
(total magnification) = 75 cm. scope’s effect on pupillary distance (Fig. 8).
We can see how the math works here: if we assume a pupil-
lary distance (PD) of the examiner to be 60 mm, when the
xial Magnification (aka Longitudinal
A examiner looks through the binocular eyepiece, the effective
Magnification) PD is reduced to 15 mm (Fig. 9), thereby reducing stereopsis
by a factor of 4-fold (60/15). Our good matey, axial magnifica-
Now that we have discussed transverse magnification, we tion of the aerial image compensates for this reduction.
can bring a spring upon’er and move onto other types of For example, if we are using a 20D lens (and assume 60D
magnification, such as Axial Magnification (also known as as the power of the eye4), the transverse magnification will be:
the armpit of optics).
Axial magnification describes the magnification along an This is the power of the Reduced Schematic Eye. See Chap. 7,
4
axis between two conjugate points. Simply put, it is the “Schematic Eye” for a review.
From the question stem, we can see that the image dis-
tance (v) from the lens is four times the distance of the object
i from the lens (u). This means that transverse magnification is
o
4×. Therefore, the axial magnification is (4×)2 = 16×
magnification.
Fig. 8 The depth of the object is exaggerated by axial magnification

Angular Magnification
15 mm
This type of magnification is used with objects and images
located at infinity, such as scouring the horizon for friendly
or enemy ships. Recall that an object at any distance will
subtend a certain angle in the observer’s visual field, even
when viewed with the naked eye. In other words, it will
occupy some portion of the observer’s visual field (e.g., a
few arcseconds or arcminutes), even though it may be very
small. When looking at an object through an optical instru-
ment, that object will also occupy some portion of the
60 mm
observer’s visual field. Angular Magnification is simply the
ratio of the image when seen with an optical instrument (e.g.,
telescope, microscope, etc.) to the image when not seen with
an optical instrument. Recall that with any telescope, the ver-
gence of incoming light rays is zero, and the vergence of
Fig. 9 Optics of an indirect ophthalmoscope. Notice how prisms are light rays exiting the telescope is also zero.
used to reduce the effective pupillary distance by a factor of approxi- Although the distances and sizes may be infinitely large
mately four and hard to measure, they have a finite angular size; thus,
angular magnification relies on angles not distances.
Transverse magnification = Power of eye / Power of Angular Magnification = θout/θin, where θout is the angle
lens = 60D/20D = 3× magnification formed with the telescope and θin is the angle formed without
Now, we can calculate the axial magnification: the telescope.
Why bother with angular magnification? Why not just use
Maxial = ( M transverse ) = ( 3 ) = 9 × magnification
2 2
transverse magnification and keep life simple? The problem

is that transverse magnification is only applicable when
As stated above, the eyepieces will reduce the PD and lenses produce real images; when we use an optical instru-
therefore reduce the field of depth by a factor of 4×. ment with eyepiece (such as a microscope, telescope, etc.),
Therefore, the final magnification will be 9×/4× = 2.25×. we are actually viewing virtual images without true “linear
Therefore, the retinal detachment will be magnified by a fac- dimensions”; thus, we have to rely on angular magnification
tor of 2.25× when viewed through a 20D lens, thereby mak- as a workaround. Furthermore, transverse magnification will
ing it easier to see on clinical exam and detect the retinal only give us a small percentage of the size of the object (i.e.,
detachment before our patient heads down to Davy Jones’ minification), whereas angular magnification will give us
locker! true magnification.
Let us do one more example: suppose that an object is For example, suppose we told our coxswain to go up the
located at an unknown distance from an unknown lens and it crow’s nest to look at the moon to calculate our location in
forms an image to the right of the lens at a distance that is the ocean. When he looks up at the moon with the naked
four times the distance of the object from the lens. What is eye, it subtends an angle of approximately 0.5°. When he
the transverse magnification? What is the axial uses his binoculars (we are modern pirates, after all), the
magnification? moon will appear to subtend an angle of 5°. Therefore the
At first glance, me hearties, we may wish to skip this angular magnification is 5/0.5 = 10× magnification, mean-
treacherous island and move on to finding other treasures. ing that the image of the moon formed on the retina when
But if we pause for a moment, we will realize that this prob- looking through the binoculars is ten times larger than the
lem is simply testing previously discussed concepts in a image of the moon formed on the retina when looking with
roundabout (and needlessly complicated) manner. the naked eye.
96 G. V. Vicente
Here is another example: suppose that we now tell our length of the telescope would also become smaller (e.g.,
trusty coxswain (who is still up in the crow’s nest) to look for +40D lens as eyepiece will give 20× magnification and the
neighboring ships on the horizon. He sees a ship off in the length of the telescope would be only 52.5 cm). Our cox-
distance but does not know how far away this ship is, not to swain tells us this is a friendly ship, so we have no need
mention whether this is a friendly or enemy ship. Suppose to hoist the black flag and we can continue our discussions
that he only had a + 2D lens (Fig. 10a). Using the U + D = V on magnification.
equation, we can make U = 0, making D = V; the ship would
therefore cast an image 50 cm to the right of the +2D lens.
This image would be inverted and would have nearly no Magnification From a Simple Magnifier
magnification (M = U/V = ≈0/2 = ≈0). Our coxswain would
not be able to see the ship! A simple magnifier takes advantage of angular magnification
Suppose that we also gave our coxswain an additional by bringing the image of the object closer to the eye (in the
+20D lens and he has been paying attention to our nightly form of an enlarged virtual image) than the eye can normally
optics lectures given after dinner to boost our crew’s focus. The standard close focus distance is taken at 25 cm –
morale (Fig. 10b). He could then hold the +20D lens at a whoever came up with this number and agreed to it should be
distance of 5 cm to the right of where the image is form- made to walk the plank!
ing (50 cm) and create a telescope of 55 cm. Even though We can use trigonometry to compare these two angles:
the image of the ship will be inverted, he will enjoy the Θ lens & Θ 25cm and calculate the angular magnification caused
benefit of magnification 10×, so hopefully he will be able by the lens… but we have no time to do any fancy calcula-
to see the ship! Also note that if we used stronger lenses tions. We can run a rig (use a shortcut) by using our knowl-
for the eyepiece, we would get more magnification and the edge of the lens powers to give us an easier calculation:
Angular Magnification =
Θ lens
=
( )
tan −1 0 / f
=
25 cm D
=
Θ25cm ( −1
)
tan 0 / 25 cm f 4
( For Simple Magnifier )
Fig. 10 (a) Notice the a +2D

transverse magnification
given by a + 2D lens for an
object located close to infinity
is very minimal. (b) When a
second lens is introduced (i.e.,
+20D lens), the first image of
the ship is magnified 10× due
to angular magnification
(Images are not drawn to
scale)
50 cm
b +2D +20D
50 cm 5 cm
Angular magnification for a simple magnifier = D/4. In Telescopes

other words, angular magnification for a simple magnifier
simply relies on taking the power of the lens and dividing it stronomical (Keplerian) and Galilean
A
by 4. If our coxswain was using a + 40D lens and wanted to Telescopes
see his map, he could hold it 25 cm from the map and get 10×
(40/4) magnification. There are two types of telescopes that we must know for
Let us apply this to a clinical, instead of pirating, sce- ophthalmic optics: Galilean and Keplerian (also known as
nario. You are at the hospital doing inpatient rounds, and Astronomical). Each telescope is constructed by putting
your portable slit lamp is out of batteries. If you need to look together two lenses, termed as the eyepiece (i.e., the lens
for infiltrates around the corneal abrasion of a patient, you closest to your eye) and the objective (i.e., the lens closest to
wish that you had a magnifying glass with you. But wait, you the object of interest). Heave ho, and understand the differ-
do have a magnifying glass, the 20D lens! If you used the ences between these two lenses before proceeding further!
20D lens as a simple magnifier, how much angular magnifi- Both telescopes (Fig. 12) will involve using a positive
cation would it have at 25 cm? lens as the objective lens. The two telescopes therefore only
Angular Magnification = D/4 = 20/4 = 5×. This means differ in the type of lens used in the eyepiece. Additionally,
that if you held the 20D lens 25 cm away from the patient’s
cornea, you would be able to take advantage of the 5× mag-
nification to check for a possible infiltrate. Yes, the image
will be inverted, but we can work around that as needed.
It may be helpful to apply this to another scenario: how
much angular magnification is provided by a direct ophthal-
moscope when looking at a patient’s optic nerve? Remember
the direct ophthalmoscope uses the optics of the patient’s eye
as ~60D (assuming that the patient is emmetropic) (Fig. 11).
Angular Magnification = D/4 = 60D/4 = 15×. The optic
nerve looks 15 times larger than the original optic nerve if
the ophthalmoscope was held at 25 cm.
We can now use our understanding of magnification,
Fig. 11 Using the direct ophthalmoscope as a simple magnifier. When
especially angular magnification, to describe the magnifica- held 25 cm from the patient’s eye, the image of the optic nerve will be
tion produced by telescopes. 15 times larger (60/4 = 15)
Fig. 12 Both Keplerian and f2 & f1

Galilean telescopes will use a
a
plus power lens as the
objective. Figure 12a is a
Galilean telescope with a
negative lens as its eyepiece.
Figure 12b is a Keplerian
telescope with a plus lens as
the eyepiece. Telescopic
Magnification = − (Deyepiece
/DObjective) b
f2 & f1
98 G. V. Vicente
both types of telescopes will require that the quantitative • Galilean telescopes will have a negative eyepiece and a
value of the eyepiece is higher than the objective in order to positive objective and will yield upright images.
give any magnification. If the quantitative value of the –– Mnemonic: “Galileo was a good (upright) guy
eyepiece is lower than the objective, then we will inadver- (upright image) despite all the negative people around
tently see a minified image. him (negative eyepiece)”.
A Galilean telescope will use a negative lens as its eye-
piece and it will create an upright magnified image. The pri-
mary focal point of the (minus) eyepiece lens (f1) will align linical Examples of Astronomical and Galilean
C
with the secondary focal point of the (plus) objective lens Telescopes
(f2).5 In our previous example, our coxswain’s telescope (made
A Keplerian (astronomical) telescope will use a positive with a + 20D eyepiece and +2D objective) was an astronomi-
lens as its eyepiece and it will create an inverted magnified cal telescope. One may think that unless we were pirates or
image. The primary focal point (f1) of the eyepiece will coin- astronomers, we do not need to learn about telescopes
cide with the secondary focal point (f2) of the objective. This because we never use them. Wrong...
will be located at a point between the objective and the Fun fact: The slit lamp is basically a Keplerian (astro-
eyepiece. nomical) telescope that uses inverting prisms (Porro-Abbe
To summarize, for both types of telescopes: prism) to re-invert the inverted image (and therefore mak-
ing it upright).6 This means that every time we use the slit
• The secondary focal point (f2) of the objective lens must lamp to examine the patient, we are just like pirates using
coincide with the primary focal point (f1) of the eyepiece telescopes! Similarly, most modern binoculars and even
lens. operating microscopes are advanced, modified Keplerian
• The eyepiece lens will be a higher numerical power value telescopes with similar inverting prisms. Finally, during
than the objective lens. fundus examination with a + 20/+28D lens, we are using an
• They both are examples of afocal systems, meaning that astronomical telescope setup - this is why the fundus image
vergence in = zero, vergence out = zero. is inverted.
• The distance between the two lenses must be the sum of As for Galilean telescopes: most surgical loupes are a
their focal points. type of Galilean telescope as they use a minus powered eye-
piece and a plus powered objective to give us an upright (and
Many privateers often get confused about which telescope magnified) image.7 For fundus examination, if we do not
is which. Avast ye, a helpful mnemonic is as follows: have access to our usual +90D lens, we can use a Hruby
(−55D) lens (which is attached to some slit lamp models) to
• Keplerian (astronomical) telescopes have a positive eye- examine the optic nerve and macula. The lesson here is that
piece and a positive objective and will yield inverted even if we despise the optics of telescopes, we are using tele-
images. scopes daily in clinical and surgical settings.
–– Mnemonic: Write it out as “As + ronomical”:
• The “+” will help you remember that it uses two Magnification of Telescopes
“+” lenses. The magnification for both telescopes can be calculated by
• A will remind you that you will get an “ass- recalling our discussion on angular magnification and mak-
backwards” (inverted) image. ing a small modification. Instead of using the incoming and
outgoing angles, we can simply use the power of each lens to
The location of primary and secondary focal points is always confus-
5
determine the magnification given by a telescope. Therefore,
ing for trainees and is worth a review here. Remember that the primary old salt, our modified formula is:
focal point (F1) is to the LEFT of a plus lens and to the RIGHT of a
minus lens. To be specific, F1 for a plus lens is defined as the location at
which light originates (in a divergent fashion) and strikes the lens such Telescopic Magnification = − ( Deyepiece / DObjective )
that the light rays exit in a parallel fashion (forming an image at infin-

ity). For a minus lens, F1 is defined as the location at which incoming This formula should be committed to memory. Notice
light is directed, via an imaginary extension of incoming light rays, to
the (−) sign, which will create an upright image for the
emerge from the lens in parallel fashion. The secondary focal point (F2)
is to the RIGHT of a plus lens and to the LEFT of a minus lens. To be Galilean telescope and an inverted image for the Keplerian
specific, F2 for a plus lens is the location at which incoming parallel
light rays will converge to form an image. We have been primarily
referring to this F2 as the “focal point” when doing U + D = V problems. See Chap. 17, Optical Instruments for more information regarding the
6
For minus lenses, F2 is the location at which incoming parallel light optics of the slit lamp.
rays, via imaginary extension, appear to converge; recall that these light Surgical loupes that use an astronomical telescope (and inverting
7
rays will actually diverge after striking the minus lens. prisms) are also available.
telescope. So even if you forget the above silly mnemonic onstruction of Telescopes for Exam Problems
C
from the previous section, mathematically, you should be A subtopic of telescope construction, especially for exam
able to determine that Galilean telescopes will give problems, involves knowing how far apart to place the two
upright images and Keplerian telescopes will give inverted lenses in order to construct a useful telescope. As stated above,
images. Finally, notice how this magnification formula the distance between the two lenses must be the sum of their
bears some similarity to, but differs from, the transverse focal points, regardless of whether we are dealing with a
magnification formula. Keplerian or a Galilean telescope:

Flens1 + Flens 2 = distance between the two lenses for construction of telescope
Again, it is helpful to use “cm” notation when calculating For example: if given a + 5D and a − 10D lens, how far
focal points as you will likely be given the power of the apart must the lenses be placed in order to create a functional
lenses in diopter values. Galilean telescope?

Flens1 + Flens 2 = (100 / 5 ) + (100 / −10 ) = 20 + ( −10 ) = 10 cm apart
Notice how a Galilean telescope will often be shorter? It Another example: if given a + 16D lens and a + 4D lens,
would be pretty cumbersome to operate when looking through how far apart must the lenses be placed in order to create a
a long telescope and pretty scary to operate on an inverted functional Keplerian (astronomical) telescope?
image (unless, of course, you are doing retinal surgery).

Flens1 + Flens 2 = (100 / 16 ) + (100 / 25 ) = 16.6 + 4 = 20.6 cm apart
Notice that if we instead used a − 16D lens as the eyepiece Now we have to figure out how far apart these lenses are
and a + 4D lens as the objective, we can form a Galilean tele- before we are made to walk the plank:
scope. The lenses can now be placed 16.6 – 4 = 12.6 cm apart.
We can therefore note that the “length” of a Galilean telescope F + Flens 2 = (100 / 20 ) + (100 / −50 ) = 5 + ( −2 ) = 3 cm
is usually shorter than a Keplerian telescope, especially when lens1
considering lens combinations that differ only in the signed
(positive/negative) value of the eyepiece lens. This is one rea- This “length” of a telescope, 3 cm, may be quite similar to
son why most surgical loupes utilize a Galilean telescope how some surgical loupes may be constructed.
construction.
Example #2
Sample Telescope Problems What is the magnification of a telescope that is constructed
Example #1 with a + 20D lens and a + 4D lens? How far apart must the
What is the magnification of a telescope if one end consists lenses be placed?
of a − 50D lens and the other end consists of a + 20D lens? First, we can determine what kind of telescope this is by
How far apart are the lenses? looking at the values of both lenses. Given that we have two
First, we can determine what kind of telescope this is by plus lenses (+20D and +4D), this must be a Keplerian (astro-
looking at the values of both lenses. Given that we have a nomical) telescope. We can then calculate the magnification
minus lens (−50D) and a plus lens (+20D), this must be a using our formula:
Galilean telescope. We can then calculate the magnification Telescopic Magnification = − (Deyepiece/DObjective) = − (20/4)
using our formula: = − 5 × magnification. The negative value of −5× confirms
Telescopic Magnification = − (Deyepiece/DObjective) = − (−50/20) that the telescope will give us an inverted image.
= + 2.5 × magnification. The positive value of 2.5× confirms Now we have to give no quarter and figure out how far
that the telescope will give us an upright image. apart these lenses must be placed:
100 G. V. Vicente
Fig. 13 What is the power of +XD

the objective lens?
-25D
6cm
F + Flens 2 = (100 / 20 ) + (100 / 4 ) = 5 + 25 = 30 cm

lens1 Remember that the minus sign indicates an inverted image
and does not imply minification.
Example #3 Example #4
A second level type of problem that may be asked based on If we are given a − 25D lens and an unknown power lens to
the above concepts is as follows: if the eyepiece of a func- create a functional telescope such that the lenses are 6 cm
tional astronomical telescope has a power of +10D and is apart, what is the power of the unknown lens? What is the
located 43 cm from an objective lens of unknown power, magnification of this telescope? (Fig. 13)
what is the power of the objective lens? We know that this must be a Galilean telescope since we
We can start off by first calculating the focal length of the are given a minus lens (which must therefore be the eyepiece
eyepiece: Feyepiece = (100/10) = 10 cm. Since the lenses are lens). The focal length of this lens is:
43 cm apart, we can now subtract 10 cm from 43: Feyepiece = 100/−25 = (−)4 cm.
43–10 = 33 cm. The unknown objective lens has a focal The distance between the two lenses is: Flens1 + Flens 2 = 6
length of 33 cm. Therefore, the power of the unknown lens → ‐ 4 + Flens 2 = 6
is: Dobjective = 100/33 = +3 D. For the sake of completion, this
telescope will give a − 10/3 = −3.33× magnification. F = 10 cm → Dobjective = 100 / 10 = +10 D
lens 2

Telescopic magnification = − ( Deyepiece / DObjective ) = − ( −25 / 10 ) = 2.5 × magnification
linical Examples and Scenarios Involving

C may not realize during the refraction that the letters will also
Telescopes become smaller – more likely, he/she may come back to your
office unhappy with the new glasses that you have given them,
While we have previously mentioned some examples of tele- complaining that “everything looks smaller”.
scopes in daily ophthalmic practice, we can focus on several Why is this happening? Recall that young patients, espe-
examples and scenarios that may have significant clinical cially young myopic patients, are able to accommodate
implications on how we care for patients. much easier than older patients.8 This means that they are
able to generate extra “plus” power inside their eyes. As a
he Over-Minused Myope
T result, they will end up requiring more “minus” power in
This is a common clinical scenario, especially when trying to their glasses – hence the common clinical teaching phrase,
refract a young myopic patient. Suppose that we have success- “myopes eat minus”, which means that myopic patients will
fully refracted a young myopic patient down to the 20/15 line. gladly favor more and more minus power during a manifest
When deciding between two lenses at this line, the patient refraction because they are accommodating (and therefore
may favor the more minus lens as he/she may feel that the let-
ters look “clearer or sharper”. However, the patient may or We will discuss accommodation in more detail in the next chapter.
8
generating plus power inside the eye). This is why a cyclo- wearing a hyperopic prescription in his/her glasses is looking
plegic refraction is crucial in young patients, especially when at the world through a regular Galilean telescope – hence, he/
prescribing glasses for significant refractive errors or evalu- she may feel the world is magnified. More on this in the
ating patients for laser refractive surgery. A duochrome test examples below...
can also be used for these patients but does not have the same
impact as a cycloplegic refraction. Aphakic Magnification
Why are we discussing this in the context of telescopes? When wearing glasses, hyperopes will experience a magnifi-
Recall in the previous section we defined a Galilean telescope cation effect because they are looking at the world through a
as having a minus lens as the eyepiece and a plus lens as the Galilean telescope. Aphakic patients, for the sake of this dis-
objective. In the case of our over-minused myope, the patient cussion, are basically extreme hyperopes and therefore will
is generating extra plus power (through accommodation) experience significant magnification.
inside the eye (forming the “eyepiece” of the telescope) and is To understand this better, we should first review internal
looking through a minus lens outside the eye (forming the refractive errors (Fig. 15). It is almost as if patients with
“objective” of the telescope). In other words, the patient is aphakia or high hyperopia have an internal imaginary −12.5D
basically looking at the world through a reverse Galilean lens at their nodal point that diverges light behind the retina.
telescope; therefore, instead of giving the patient a magnified If you want to make a resident more cautious about not
image, as would be seen through a regular Galilean telescope, breaking the posterior capsule during cataract surgery, make
the reverse Galilean telescope will give the patient a minified them see what it is like to have aphakia. To do this you could
image. However, the image will still be upright. The patient remove their crystalline lens or place a secondary −12.5D
may still feel that the image is clear and sharp; however, the IOL in the sulcus. (Make sure the resident signs an informed
minification of the image may be bothersome (Fig. 14). consent first and any other necessary paperwork to ensure
Therefore, by definition, any patient wearing a myopic you do not get sued for this madness). Or ask them to look
prescription in his/her glasses is looking at the world through through a − 12.5D loose lens, which is probably safer and
a reverse Galilean telescope. For the sake of completeness less lawsuit inducing.
(and you may have guessed this, dear privateer!), any patient
Fig. 14 Comparison of magnification for a patient with hyperopia who when wearing glasses, the myope will see the world through a reverse
has an internal negative refractive error (Fig. 14a), an over minused Galilean telescope, whereas the hyperope will see the world through a
patient (Fig. 14b), over minused patient who is accommodating to see regular Galilean telescope. The image seen by the patient is on the far
clearly (Fig. 14c), and a regular Galiean telescope (Fig. 14d). Note that right
102 G. V. Vicente
Fig. 15 Internal refractive

errors for high hyperopes, bad
residents, and aphakic
patients. Figure 15a shows a
A
patient with high hyperopia,
with an imaginary divergent
lens ~ a negative internal
refractive error. Figure 15b
shows a patient with aphakia.
Figure 15c illustrates a bad
resident with an actual
−12.5D piggyback lens.
Figure 15d illustrates same B
resident with a + 10D
spectacle lens
In order to see clearly, both the patient with aphakia and the and the +10D spectacle lens is now the “objective” lens. This
resident with a − 12.5D piggyback lens would need a + 10D lens arrangement would therefore create a Galilean telescope.
spectacle lens. The −12.5D lens is basically the “eyepiece” lens The magnification of this telescope would be:
Telescopic Magnification = − ( Deyepiece / DObjective ) = − ( −12.5 / 10 ) = 1.25× = 25% magnification.
As a side note, this may also have some relevance when because objectively, these patients may test extremely well
performing cataract surgery on a long-standing hyperope. As in the office in terms of visual acuity. These patients may
these patients have been viewing the world through their require extra counseling through the immediate postopera-
“Galilean telescope eyeglasses”, they may have gotten used tive period until they can adjust to the “new size” of the
to the world being larger – in other words, the magnification world, which may take up to 6 months to occur.
caused by the glasses may be “normal size” to them. If plan- Interestingly enough, the same phenomenon is not seen
ning for a postoperative target of plano (or minimal myopic with long-standing high/pathologic myopes who achieve
target), it is important to batten down the hatches before sur- plano after cataract surgery. One would think that these
gery and discuss with the patient that he/she may feel that the patients may complain that the world looks “larger” after
world is “smaller” postoperatively. Many patients eventually cataract surgery, but these patients tend to tolerate the
adjust to this change in size over time, but initially, they may increased size perception of the world much better than their
complain that their perception of their environment is differ- hyperopic counterparts. Perhaps these patients are so happy
ent. This may be frustrating to the scallywag practitioner
that they can see without glasses after cataract surgery that For pediatric patients, this is not a problem to prioritize as
the increased size of objects is a minor issue? compared to correcting the full refractive error in each eye to
prevent amblyopia. Therefore, for young kids, we should
Anisometropia and Aniseikonia always give the full cycloplegic refraction for each eye. For
#Pro tip: These two terms are favorite questions for senior example, a 3-year-old patient who needs +2D OD and −2D
attendings to quiz trainees about, so learn them well, me OS must be given the full cycloplegic refraction; we should
hearties! not worry about anisometropia and aniseikonia in this situa-
In our previous discussions of magnification, we learned tion. Blackbeard and his pirate show mercy to children and
that myopic glasses will minify the world (reverse Galilean only prey upon adults! See Chap. 23, Pediatric Optics, for
telescope) and hyperopic glasses will magnify the world more information about anisometropia and aniseikonia in the
(Galilean telescope). The power of the spectacles will deter- little buccaneer population.
mine how much magnification or minification will take We can highlight these two concepts with two common
place. As a rule of thumb, ordinary spectacle lenses will clinical scenarios:
change the size of the retinal image by approximately 2% per
diopter power at 12 mm vertex distance. Clinical Scenario #1
For example, a hyperopic patient wearing +7D lenses in You have just prescribed a pair of glasses to your 30-year-
both eyes at 12 mm will see images ~14% larger than they old patient two weeks ago. The patient returns complaining
appear to an emmetropic patient. Similarly, a myopic patient about the new glasses: “Doctor, with the new glasses you
wearing −5D lenses in both eyes at 12 mm will see images prescribed, I can see really well with one eye open at a time,
~10% smaller as compared to an emmetropic patient. If you but I cannot tolerate the glasses with both eyes open because
have a significant refractive error and wear glasses, you can I see two images. What should I do? I am a pirate so should
test this yourself by looking at your thumb up close with and I just wear a pirate patch over one eye permanently, or be
without your glasses, and you will see that your thumb will referred to a strabismus expert?”
appear to have a different size (e.g., if you wear a myopic The first thing we should do is to check the previous man-
prescription, the size of your thumb will be slightly larger ifest refraction from two weeks ago and now check the new
without glasses as compared to with glasses). glasses that our pirate patient is wearing. We should also
Despite the extent of the refractive error in both eyes, as check to make sure there is not any undetected strabismus
long as the quantitative value of the refractive error is within (!). Suppose the clinical exam, including EOM exam, is
3 D between each eye, the patient will not experience any unremarkable, and we notice the following:
subjective image size distortions. In other words, both our
+7D OU hyperope and −5D OU myope will not report any • Manifest refraction (two weeks ago): OD −2.00 sph, OS:
major issues with their perception of image sizes when they +3.00 sph.
wear their glasses because the refractive error in each eye is • New glasses (checked with lensmeter): OD: −2.00 sph,
similar. OS: +3.00 sph.
However, problems arise when the quantitative refractive
error between each eye is more than 3D: this is the very defi- Our pirate patient is unfortunately suffering from a mis-
nition of anisometropia. Anisometropia is mainly a problem take that we should have caught two weeks ago. Notice that
on paper: that is to say that simply having a refractive error the refractive error between the two eyes is approximately
difference between two eyes of ≥3 D is not the main prob- 5D (anisometropia); this is likely causing aniseikonia.
lem. The bigger problem is that anisometropia leads to a far We can calculate how much aniseikonia is present using
greater problem: aniseikonia, which is the difference in size our previously discussed rule of thumb for aniseikonia:
perception due to anisometropia. Aniseikonia is a far worse
problem to have. Most adult patients can only tolerate about • Right lens: −2D. Images look 4% smaller.
a 6–7% size difference between the two eyes.9 • Left lens: +3D. Images look 6% larger.
Imagine that anisometropia is an average pirate, but he
works for the dreaded Edward Teach, aka “Blackbeard” him- Total aniseikonia: 10% size difference between the two
self. We should be more afraid of aniseikonia (Blackbeard) eyes. To be specific, when wearing the glasses, the patient
than anisometropia (the average pirate)! will feel that images seen by the right eye will be approxi-
mately 10% smaller than the images seen by the left eye.
This is the classic textbook teaching. The authors have noted patients
9
in their respective clinical practices who could not tolerate even 2D

anisometropia in their glasses, and others who can easily tolerate 6-7D
anisometropia.
104 G. V. Vicente
What can we do for our patient, besides telling him to find What should have been done? Prior to surgery, the sur-
a new line of work because pirating is not really a good long- geon should have discussed with the patient that this may
term career? happen if she elected to target plano in the surgical eye and
There are several therapeutic options in this scenario: delayed surgery (and continued to wear glasses) in the pha-
kic eye. If the patient wished to only have surgery in the right
A. Compromise on Visual Acuity: We can issue lenses for eye, then her options could have been:
each eye that are closer in power. For example, we could
give a − 1D lens OD and +1.5D lens for OS. This will (a) Proceed with surgery in the right eye only with a myopic
make the net refractive error difference between the two target of approximately −2.50D to avoid anisometropia/
eyes as 2.5D, which may be a bit more tolerable. The aniseikonia postoperatively. This target of −2.50 also
patient may not end up 20/20 in each eye with this new allows approximately ±0.50D of inaccuracy in the final
prescription but may be 20/happy as he will not have to refractive error so that the patient may end up between
deal with aniseikonia anymore. −2D and −3D in the surgical eye.
B. Reduce Vertex Distance: By bringing the glasses closer (b) Proceed with surgery in the right eye only and target
to the corneal plane, we can help minimally reduce some plano, but counsel the patient that she will likely need to
of the magnification/minification effects of each lens. wear a contact lens in the phakic left eye to avoid aniso-
This may be hard to do on every patient due to other fac- metropia/aniseikonia issues.
tors such as facial anatomy, deep set eyes, long eyelashes,
etc. It looks like this naughty referring surgeon did not have
C. Contact Lenses: This would probably be the best long this discussion with the patient. What can be done now?
term, nonsurgical option for the patient. By eliminating Given that it has only been two weeks, we have several
any vertex distance, we will also decrease the magnifica- options that we can provide the patient:
tion experienced by the patient.
D. Refractive Surgery: If the patient is a good candidate for (a) Contact lens for the phakic left eye, as discussed above.
refractive surgery, this could be offered, especially after (b) Intraocular lens exchange for the right eye for a more
a contact lens trial. myopic target within the limits of anisometropia, as dis-
E. Tell the patient their brain will adapt over time (at least cussed above. Since it has only been two weeks since the
2–3 months), or until the next resident comes on rotation. first surgery, it should be relatively easy to exchange the
Remember, younger patients can adapt to aniseikonia, so IOL, but this would require an additional, second
it is possible that our young 30-year-old pirate may have (unnecessary) surgical procedure.
success with the tincture of time. (c) Piggyback IOL for the right eye: Since we want to make
the right eye more myopic, we can use a plus power pig-
Clinical Scenario #2 gyback IOL placed in the sulcus to induce myopia.
A 65-year-old patient named Anne Bonny presents to your Assuming that there is a hydrophobic acrylic IOL in the
office for a second opinion. She underwent cataract surgery bag (these are the most popular IOLs available) and
in her right eye with another provider two weeks ago and is there is good capsular integrity (especially of the ante-
extremely unhappy with her vision. She states that she was rior capsule), a three-piece IOL of a different material
told to remove her eyeglass lens from her right eye and con- (e.g., silicone or collamer) can be placed in the sulcus to
tinue to wear the glasses for her left eye’s visual needs. She make the patient more myopic. To determine the power
complains that this is totally unacceptable for her pirating of the piggyback IOL, online calculators or software
career, which she hopes to eventually retire from in a few may be used.10 Otherwise, a rule of thumb for inducing
more years. more myopia after cataract surgery is:
On exam: Visual acuity, OD, sc: 20/20 Visual acuity, • Hyperopic error: Piggyback IOL power = −1.5×
OS, cc: 20/20 desired refraction.
Manifest refraction: OD – plano; OS: −5.00 sph (20/20). • Myopic error: Piggyback IOL power = −1.0× desired
Why is our patient unhappy? refraction.
This is a potentially common clinical scenario that can In this case, we would use the hyperopic error calcu-
happen without proper discussion with patients with signifi- lation (because even though we have ended up plano, we
cant refractive errors prior to cataract surgery. We can see have ended up more hyperopic than needed). So if we
that there are 5D of anisometropia postoperatively that is wanted to now make the patient −3D in her pseudopha-
likely causing aniseikonia, with the pseudophakic right eye
seeing images approximately 10–15% larger than the phakic 10 IOL power calculations piggyback lens. https://www.doctor-hill.com/
left eye. iol-main/piggyback.htm. Accessed March 27, 2021.
kic eye, we will calculate: −1.5× −3D (desired refrac- cant aniseikonia which can decrease binocular and subjective
tion) = +4.5D power for the piggyback IOL. vision.12 In addition, patients may have aniseikonia due to
(d) Proceed with cataract surgery in the left eye to make other functional (sensory), physiologic, and/or neurologic
both eyes have minimal difference of intereye refractive conditions. In clinical practice, contact lenses are almost
error (i.e., target the phakic eye to have the same refrac- always better for all types of symptomatic aniseikonia,
tive error as the pseudophakic eye). Per CMS guidelines, regardless of etiology. A 15–16 mm vertex distance is also a
anisometropia and aniseikonia after cataract surgery of bit longer than the usual vertex distance (12–13 mm), so
the first eye are acceptable indications to proceed with unless our patient was Pinocchio telling lies, this may be a
cataract surgery of the second eye and should be covered difficult pair of glasses to construct and wear.13 Therefore,
by the patient’s insurance.11 Specifically, current guide- while Knapp’s Rule sounds good on paper, we do not see
lines state “if cataract extraction is performed due to “aye to aye” with its clinical performance. Yes, we saved that
anisometropia, the medical record must substantiate the joke for the very end, even though it would have been the
presence of significant aniseikonia secondary to aniso- easiest joke to make throughout the chapter.
metropia arising from the first cataract extraction with We would like to end this telescope chapter with some
IOL implant. The medical record must reflect that the humor and some poetry:
aniseikonia is visually significant to the patient by docu- Patient: “Doctor every time I close my eyes; I see pink
menting the patient’s subjective complaints and must elephants.”
also document that anisometropia is present by determi- Doctor: “Have you ever seen a psychiatrist?”
nation of the refractive error in both eyes after the first Patient: “No doctor, only pink elephants.”
cataract surgery.” In other words, me mateys, even if you “There are stars whose radiance is visible on Earth though
plan to only do cataract surgery after training, you can- they have long been extinct. There are people whose brilliance
not escape knowledge of anisometropia/aniseikonia! continues to light the world even though they are no longer
(e) Offer the patient refractive surgery in the phakic eye to among the living. These lights are particularly bright when the
decrease the intereye refractive error. This may be a rea- night is dark. They light the way for humankind.” — Hannah
sonable option especially with young patients (20– Senesh
40 year olds) who require early cataract surgery due to
trauma or steroids in one eye only, and have a relatively
clear lens in the other eye. The costs of refractive surgery Practice Questions
for anisometropia, however, must still be borne by the
patient and will likely not be covered by insurance. 1. What is the magnification of a Keplerian telescope con-
sisting of a + 2D objective lens that is located 83 cm
from a + 3D eyepiece lens? (Fig. 16)
Knapp’s Rule 2. Where would you place the −10D eyepiece of this
Knapp’s Rule states that if we have a patient with pure axial Galilean telescope? (Fig. 17)
anisometropia (i.e., one eye has a longer axial length than the 3. Where would you place the +10D eyepiece of this
fellow eye), then an equal image size can be achieved on Keplerian (astronomical) telescope if you are given
both retinas (i.e., we can eliminate anisometropia and anisei- a + 4D as the objective lens?
konia) by giving each eye a spectacle lens placed at the ante- 4. If an object is located 50 cm to the left of a + 6D lens
rior focal point of the eye, which is about 15–16 mm in front which itself is 35 cm to the left of a + 12D lens, what is
of the cornea. According to this rule, we would not have to the final transverse magnification? (Fig. 21)
use contact lenses for axial aniseikonia - we can solve all 5. For the previous problem, what is final angular
anisometropia/aniseikonia issues by simply increasing the magnification?
spectacle vertex distance by a few millimeters. 6. What is the axial magnification if we are given a lens
However, in clinical practice, Knapp’s Rule unfortunately system that has an image height of 4 cm and object
does not account for other anatomical factors, such as height of 1 cm?
stretched photoreceptors and reduced retinal element den- 7. A 9-year-old patient presents to your office for low
sity; therefore, these patients will still have clinically signifi- vision consultation. His best corrected visual acuity is
20/350. If the patient needs a telescope to help him see
Local coverage determination (LCD): Cataract extraction (L33954).

11
h t t p s : / / w w w. a a o . o r g / a s s e t s / e 7 b 8 7 2 a d - a 7 6 c - 4 f 1 3 - 8 5 2 5 - Kramer P, Shippman S, Bennett G, Meininger D, Lubkin V. A study

12
d03a622bfb45/636396238727070000/cgs-l33954-cataract-surgery- of aniseikonia and Knapp’s law using a projection space eikonometer.

updated-0 7062017-with-effective-dates-10012016-pdf?inline=1. Binocul Vis Strabismus Q. 1999;14(3):197–201.
Accessed December 4, 2019. See Chap. 6, “Lens Effectivity”.
13
106 G. V. Vicente
Fig. 16 Figure for practice +2 +3

question #1: What is the
magnification of a Keplerian
telescope consisting of a + 2D
objective lens that is located
83 cm from a + 3D eyepiece
lens? O
50 cm 33 cm
f2 f1
8
Fig. 17 First figure for +4
practice question #2: At
which location should
a − 10D lens be placed to
form a working Galilean
telescope?
A B C D
10 cm 15 cm 10 cm 15 cm
the blackboard in school, much magnification is needed Answers

in order for him to be able to read the 20/70 line from
20 feet away? 1. Angular Magnification = − (Deyepiece/DObjective) = −
8. Suppose that you are given the following three lenses: (3/2) = −1.5×. This tells us that we will get an inverted
−9D lens, +3D lens, and a + 2D lens. If you are told you image (minus sign) with 1.5× magnification.
must place two lenses into two slots in a lens stand 2. In order to create a functional telescope, the secondary
(Fig. 23) in order to make a functional Galilean tele- focal point (F2) of the objective lens (the +4D lens) must
scope, which two lenses will you choose and in which coincide with the primary focal point (F1) of the eyepiece
slots will you place these two lenses? −10D lens. For Galilean telescopes, the eyepiece must be
9. Suppose we have three bumbling pirates stranded on a between the objective lens and its secondary focal point.
desert island: Larry (emmetrope), Curly (a + 4D hyper- We can calculate the secondary focal point (F2) of the
ope), and Moe (a − 4D myope). Our three heroes are objective lens: 100/4 = 25 cm.
now shipwrecked on an island with nothing more than We can now calculate the primary focal point (F1) of
a + 16D lens and a + 8D lens. As they attempt to con- the eyepiece lens: 100/10 = 10 cm.
struct a telescope, what folly will ensue? Who will have Now we can add (F1) + (F2) = −10 + 25 = 15 cm dis-
the “best” telescope? tance between the two lenses.
10. Your elderly patient, Cal Icojack, comes in for his annual So we should place the −10D lens at location B (See
exam. He proudly shows you a telescope from his “youth- Fig. 18).
ful days” that he used to sight ships on the horizon. He 3. In order to create a functional telescope, the secondary
now wants to be able to use it to sight his home computer. focal point (F2) of the objective lens (the +4D lens) must
The monitor is 50 cm away from where he sits at his home coincide with the primary focal point (F1) of the eyepiece
office desk. You note that the telescope is constructed with +10D lens. For Keplerian telescopes, the eyepiece must
a − 50D and +10D lens. How can you modify the tele- be to the right of the focal point of the objective lens.
scope length to help him with his home computer needs?
−2 + 6 = 4 = V → v = 100 / 4 = 25 cm to the right of the lens

We can calculate the secondary focal point (F2) of the
objective lens: 100/4 = 25 cm.
We can now calculate the primary focal point (F1) of
Mag1 = v / u = 25 / −50 = −0.5 OR U / V = −2 / 4 = −0.5
the eyepiece lens: 100/10 = 10 cm.
Now we can add (F1) + (F2) = 10 + 25 = 35 cm distance
between the two lenses (Fig. 19). The first image is minified (50% size of the object) and
Notice how this problem is different from the previous inverted (due to the minus sign and also because this is a
one! Be careful to keep your plus and minus signs prop- Keplerian (astronomical) telescope).
erly aligned when doing these calculations (Figs. 20). Next, we must solve for the transverse magnification of
4. First, we must solve for the transverse magnification of the second lens (+12D)
the first lens (+6D). U + D = V → U = 100 / −10 = −10
U + D = V → U = 100 / −50 = −2
Fig. 18 Second figure for +4

practice question #2: By
placing the −10D lens at
f2= f1
location B, the secondary
focal point of the objective
lens will match the primary
focal point of the eyepiece
lens, thereby forming a B
working Galilean telescope
10 cm
25 cm
Fig. 19 First figure for A +4 B C D

practice question #3: Where
would you place the +10D
eyepiece of this Keplerian
telescope if you are given
a + 4D as the objective lens?
10 cm 15 cm 10 cm 10 cm
Fig. 20 Second figure for +4 D

practice question #3: By
placing the +10D lens at
location D, the secondary
focal point of the objective
lens will match the primary
focal point of the eyepiece
lens, thereby forming a
working Keplerian
(astronomical) telescope 15 cm 10 cm 10 cm
108 G. V. Vicente
−10 + 12 = 2 = V → v = 100 / 2 = 50 cm to the right of the second lens
Mag2 = v / u = 50 / −10 = −5 OR U / V = −10 / 2 = −5 6. We may be tempted to simply plug in the values for mag-
nification as m = i/o = 4/1 = 4× magnification. But this
The second image is magnified: it is five times the size would only give us the transverse magnification. In order
of the first image. It is inverted relative to the first image, to calculate the axial magnification, we have to square the
which itself is inverted to the object. Therefore, the sec- transverse magnification:
ond image is UPRIGHT compared to the object.
The final transverse magnification = 4 2 = 16 × magnification.

Mag1*Mag2 = 0.5*5 = 2.5×. Therefore, the final image is 7. When we have a specific line that we want the patient to
2.5 times the size of the original object. Again, note that be able to read, we can determine the magnification
the final magnification is the PRODUCT of the individual necessary by taking the best corrected visual acuity
magnification of each lens system (Fig. 22). (20/350) and dividing that by the desired line of visual
5. Angular Magnification = − ( Deyepiece / DObjective ) acuity:
= − (12 / 6 ) = −2

BCVA 20 / 350 → desiring to see the 20 / 70 line = 350 / 70 = 5 × magnification needed.
Bonus points: we could construct a Galilean telescope The slots are arranged such that the distance between slot
that gives us 5× magnification. For example, we could use A and slot C is 22 cm. Therefore, we will place the −9D lens
a − 20D lens and a + 4D lens to give us 5× magnification. into slot A (eyepiece) and the +3 lens into slot C (objective)
We can then use our formula for calculating the focal to make our Galilean telescope.
length distance between the two lenses: 9. Answer: This is a problem that tests our knowledge of
Flens1 + Flens 2 = (100/ − 20) + (100/4) = − 5 + 25 = 2 constructing telescopes in combination with the observ-
0 cm apart. This would create a Galilean telescope that er’s refractive error. We can have each of our “stooges”
can fit comfortably in a patient’s hand. constructs his telescope and see what happens:
8. Since we are told we need to make a Galilean telescope, For Larry: Since he is an emmetrope, the +16D eye-
we can see we only have one minus lens (−9D), so that piece will function as a + 16D eyepiece. He can use both
lens must be the eyepiece. We can consider using either lenses to make an astronomical telescope: 16/8 = 2× mag-
the +3D lens or the +2D lens as the objective to give us 3× nification. The telescope can be made with the two lenses
and 4.5× magnification, respectively. In order to figure held (100/16 = 6.25 and 100/8 = 12.5) →
out which of these two lenses to use, we can use our for- 6.25 cm + 12.5 cm = 18.75 cm apart.
mula for calculating the distance between the two lenses: For Curly: Since he is a hyperope, he will end up “using”
4D from the eyepiece to correct his refractive error. For him,
Flens1 + Flens 2 = (100 / −9 ) + (100 / 3 ) = −11 + 33 = 22 cm the +16D eyepiece will function as a + 12D eyepiece. Thus,

his astronomical telescope will be: 12/8 = 1.5× magnification.
Flens1 + Flens 2 = (100 / −9 ) + (100 / 2 ) = −11 + 50 = 39 cm The telescope can be made with the two lenses held

(100/12 = 8.3 and 100/8 = 12.5) → 8.3 cm + 12.5 cm = 20.8 cm
Looking at the lens stand we can see that the total length apart.
of the lens stand is 30 cm. Therefore, even though the +2D For Moe: Since he is a myope, he gains an additional 4D
lens would give us more magnification, we cannot use the from his refractive error to “add” to the eyepiece. For him, the
+2D lens for this lens stand. +16D eyepiece will function as a + 20D eyepiece. Thus, his
Fig. 21 First figure for +6D +12D

practice question #4: If an
object is located 50 cm to the
left of a + 6D lens which
itself is 35 cm to the left of O
a + 12D lens, what is the final
transverse magnification?
25 cm 10 cm
50 cm
Fig. 22 Second figure for

practice question #4: The
U + D = V equation can be +6D +12D
used to determine the -2 +4 +2
-10
magnification of each lens
system. The final
magnification is the product
of the individual
magnification of each lens O
system
25 cm 10 cm
50 cm
50 cm
A B C D
10. First, we should realize that this is a Galilean telescope
yielding 5× magnification. In order for him to use this
telescope to sight objects at distance, we can simply cal-
culate the length of the telescope by finding the focal
lengths of the eyepiece (−50D lens) and the objective
Fig. 23 Diagram for practice question #8: Suppose that you are given (+10D). The focal length of the eyepiece is
the following three lenses: −9D lens, +3D lens, and a + 2D lens. If you
are told you must place two lenses into two slots in a lens stand in order 100/−50 = −2 cm; the focal length of the objective lens
to make a functional Galilean telescope, which two lenses will you is 100/10 = 10. The tube length of the telescope is
choose and in which slots will you place these two lenses? −2 + 10 = 8 cm total length.
In order to see objects at 50 cm, the “effective power”
astronomical telescope will be 20/8 = 2.5× magnification. of the objective lens must be modified. In order to see at
The telescope can be made with the two lenses held 50 cm, a + 2D lens will be needed; therefore, we have to
(100/20 = 5 cm and 100/8 = 12.5) → 5 + 12.5 = 17.5 cm apart. subtract 2D from the objective lens. The new objective
Therefore, Moe will be able to construct the “best” lens power effectively will be: 10–2 = 8D. The focal
telescope as it will have the most magnification and the length of the objective lens now becomes 100/8 = 12.5 cm.
lenses can be held the closest together; however, as you Now we can calculate the length of the modified tele-
can imagine, each of our friends will argue and fight over scope by adding the focal length of the eyepiece and
which telescope is the best. “new” objective lens: −2 + 12.5 = 10.5 cm.
Accommodation and Presbyopia
G. Vike Vicente
Objectives
• Describe the anatomical and physiological mechanisms
of the eye during accommodative and nonaccommodative A
states
• Define key concepts such as far point, near point, range of
accommodation, and amplitude of accommodation
• Define and describe presbyopia and how it relates to
accommodation
• Highlight differences in the clinical presentation of
presbyopic myopes versus presbyopic hyperopes B
• Understand how the loss or lack of accommodation can
present in various clinical scenarios
Introduction
C
Accommodation is one of those terms that you may hear
about when older patients and attendings lament about how
much they miss it. For our younger readers, you may not be Fig. 1 In an emmetropic eye (Panel A), no refractive error is present and
able to fully appreciate losing accommodation as you very thus all incoming light rays from infinity will land directly on the retina. In
likely have a great deal of accommodation still present. a hyperope (Panel B), there is an “extra minus lens” that causes incoming
Accommodation allows the eye to maintain a clear image of light rays to fall behind the retina. In a myope (Panel C), there is an “extra
plus lens” that causes incoming light rays to fall in front of the retina
an object of interest as its distance varies.
Before we even define accommodation, let us first discuss
the concept of internal refractive errors as it will serve as a “forward” to fall on the retina. Therefore, a hyperopic patient
useful foundation. An internal refractive error can be thought will have to use accommodation even to see distance objects
of as either an “extra minus” lens in the eye of a hyperope, or (i.e., incoming light rays from infinity). As a basic definition, we
an “extra plus lens” in the eye of a myope. This will cause can think of accommodation as the changes that the eye must
incoming light rays from infinity to fall behind or in front of make in order to bring light rays “forward” onto the retina.
the retina, respectively (Fig. 1). Since we are fancy eye doctors, we should now bring in
For our hyperopic patient (remember our general theme: the formal definition. Accommodation is the ability of the
unfortunate are the hyperopes…), his/her eye will have to eye to change its focus from distant to near objects (and vice
adjust – i.e., accommodate – to bring these light rays a bit more versa) by changing the shape of the crystalline lens through
the contraction or relaxation of the ciliary muscle for near
vision and far vision, respectively.1
G. V. Vicente (*)
Clinical Pediatrics and Ophthalmology Georgetown University
Hospital, Washington, DC, USA
There are several other theories regarding the etiology and mechanics
1
Eye Doctors of Washington, Chevy Chase, MD, USA of accommodation but we are going to skip those academic discussions
e-mail: vvicente@edow.com and use this definition for the bulk of our discussion.

112 G. V. Vicente
When the ciliary muscle relaxes for distance vision, the

zonules will tighten around the crystalline lens. This causes
A the lens to flatten (i.e., the lens becomes shaped like a frisbee
or a tight drum - those of you went to percussion summer
camp, c’mon admit, can appreciate this analogy). The net
result is decreased plus power. The pupil will simultaneously
become larger as accommodation is relaxed.
A potentially useful mnemonic: when we throw a frisbee
in the distance, the lens looks like a frisbee; when we want to
hit a tennis ball that is incoming, the lens looks like a tennis
ball. An animation of accommodation, including changes
B that occur to the shape of the pupil, can be seen in this sup-
plementary online video (LINK HERE: https://gph.is/g/
Z2mJgw8).
Fig. 2 For light rays at near, an emmetropic patient (Panel A) will also
have to accommodate. However, because the myopic patient (Panel B)
Hyperopia and Accommodation
has an “extra plus lens” in the eye, he/she will not have to accommodate
and will be able to easily see near objects as well Let us explore the concept of accommodation a bit further
using our poor hyperopic patient as an illustrative example.
A B There are five types of hyperopia that one should commit
to memory:
• Absolute Hyperopia: The least amount of plus power

(either in glasses or accommodation) that a hyperope has
to have in order to see anything at distance.
• Manifest Hyperopia: The maximum amount of plus
power (either in glasses or accommodation) that a hyper-
ope can accept without experiencing blurring (i.e., becom-
ing myopic). In other words, this is the most plus power
that an undilated hyperope will accept. Remember, he/she
will still be generating some accommodation even when
checking the manifest hyperopia.
Fig. 3 Panel A shows an exaggerated schematic of a contracted ciliary
muscle, relaxed zonules, and a more convex lens (tennis ball shape). • Facultative Hyperopia: Difference between absolute
Panel B shows a relaxed ciliary muscle, stretched zonules, and a flatter hyperopia and manifest hyperopia.
lens with less refractive power (tight drum shape) • Cycloplegic Hyperopia: The total amount of hyperopia
that is actually present in the patient’s eye. When the
Things are a bit different when we are dealing with patient is cyclopleged, he/she cannot generate any plus
incoming light rays from near (Fig. 2). Our poor hyperopic power on his/her own, so the cycloplegic hyperopia will
patient will have to accommodate even more, that is a given, be more than the absolute or manifest hyperopia. Teenage/
but now our emmetropic patient will also have to young adult hyperopes will not be able to tolerate the
accommodate since light rays from a near object will fall cycloplegic hyperopia initially if given as an eyeglass pre-
behind the fovea. Our myopic patient will have an advantage scription (see Chap. 21, Clinical Problems with Optics
here because his/her myopia will function as “extra and Refractive Manifestations). To review, a pediatric
accommodation” and will allow the eye to focus on a near patient must be given the full cycloplegic refraction to
target. avoid the risk of amblyopia.
During accommodation (Fig. 3), the ciliary muscle • Latent Hyperopia: Difference between manifest and
contracts, which in turn loosens the zonules around the cycloplegic hyperopia.
crystalline lens. This increases the convexity of the crystalline
lens (i.e., the lens becomes more spherical like a tennis ball). We can use an imaginary patient example to make this
The anterior surface will be much more spherical than the easier to understand. Suppose a patient requires +2.00D to
posterior surface. The net result is increased plus power. The see at distance; manifest refraction reveals she will tolerate
pupil will simultaneously constrict during the process of up to +3.50D; cycloplegic refraction is +5.00D.
accommodation. In this case:
Accommodation and Presbyopia 113
• Absolute hyperopia: +2.00D • Far Point is the point on the visual axis that is conjugate
• Manifest hyperopia: +3.50D to the retina with accommodation completely relaxed. In
• Facultative hyperopia: Manifest – Absolute → other words, think of this as: “How far can the eye see
+3.50 – +2.00 = +1.50D when not using any accommodation?”
• Cycloplegic hyperopia: +5.00D • Near Point is the point on the visual axis that is conjugate
• Latent hyperopia: Cycloplegic – Manifest → to the retina with accommodation fully active. In other
+5.00 – +3.50 = +1.50D words, think of this as: “How close can the eye see when
fully using accommodation?”
We can see that a hyperope always has to use some • Amplitude of Accommodation (AOA) is the maximum
accommodation to see anything at a distance. Therefore, capacity of the lens to accommodate. The AOA value, in
when he/she wants to focus up close, there is less accommo- addition to measuring how awesome some of you were in
dative ability remaining, explaining why these patients have medical school, is expressed in diopters.2 It can be mea-
problems with near vision. sured by the near point of accommodation, accommoda-
tion rule (aka RAF Rule) or method of spheres.
• Range of Accommodation (ROA) is the extent of clear
Definitions vision when the patient is accommodating. It is expressed
as the distance between the near and far points and there-
For written exams, a few more definitions must be committed fore its value is given in units of measurement (such as
to memory in order to be able to solve accommodation centimeters).
problems.
• Presbyopia is the loss of accommodation due to loss of

lens elasticity. The loss of accommodation continues to Accommodation and Refractive Errors
increase as we age. Several subtypes are of academic
interest: Let us discuss the relationship between accommodation and
–– Incipient Presbyopia: Similar to an “incipient refractive errors. We introduced this concept briefly with the
cataract”, a patient may have some signs/symptoms of theoretical hyperopic patient earlier in the chapter but let us
presbyopia (such as mid-late 30s), but may be able to consider how a given refractive error can affect
function quite well and not need any reading glasses. accommodation.
–– Functional Presbyopia: As the name suggests, this is A useful analogy here is to think of accommodation
when presbyopia begins to cause symptoms to the (which is expressed in diopters) as “money in the bank”.
patient. By definition, patients will benefit from and/or When we want to see up close, we have to spend some of this
require reading glasses for near work. money in the bank.
–– Absolute Presbyopia: With aging, eventually no We can think of myopia as “extra money” in the bank.
accommodative ability remains. Since the myope does not have to accommodate to see at
–– Nocturnal Presbyopia: This may overlap with distance, he/she has extra accommodation (extra money in
incipient presbyopia. Increased pupil size in low-light the bank) to view objects up close.
conditions may cause an apparent decrease in We can therefore think of hyperopia as “less money” in
accommodative ability. When tested during daytime or the bank. Since the hyperope has to accommodate to see at
bright light conditions, these patients function well distance, he/she has less accommodation (less money in the
and have normal accommodative ability. bank) to view objects up close.
• Accommodative Insufficiency has similar symptoms to The emmetropic patient has his/her amplitude of
presbyopia but is due to other factors such as concussions, accommodation to spend – therefore, he/she has no additional
intracranial processes such as meningitis or neoplasms. It or less money in the bank.
may be a transient or permanent process. It may also We can quickly review how the far point and near point
occur in down syndrome around elementary school age. are different for an emmetrope, hyperope, and myope.
• Accommodative Excess is due to ciliary muscle spasm
and may occur in any patient regardless of refractive error. Emmetrope All light rays from infinity will fall directly on
This may be due to excessive near work, uncorrected the retina when the patient is not accommodating. Therefore,
hyperopia or astigmatism, anticholinesterases, or iridocy- the far point is infinity. When the emmetrope fully
clitis. This is also known as spasm of accommodation. accommodates, the AOA is basically the near point.
The clinical implications of this will be discussed in more
detail in Chap. 21, Clinical Problems with Optics and None of the authors were AOA and we still sometimes wonder how we
2
Refractive Manifestations. got into Ophthalmology.

114 G. V. Vicente
Hyperope All light rays from infinity will fall behind the opic friend. In order to see at distance, the myope does not
retina when the hyperope is not accommodating. Therefore, have to dip into the bank account to accommodate at all.
the far point is behind the eye - the exact distance is essen- However, the myope’s far point is limited; it is basically the
tially the refractive error. For example, a + 3 hyperope will refractive error. Therefore, the farthest that the myope can
have a far point of 33 cm behind the retina. The hyperope’s see is 100/4 = 25 cm, which is the far point (Fig. 5). However,
near point is basically the AOA minus the hyperopic refrac- when our myopic friend wants to see up close, he/she not
tive error. only has the full 8D AOA ($8 in the bank account), but also
the 4D of myopia can be thought of as an additional 4D AOA
Myope All light rays from infinity will fall in front of the (additional $4 in the bank account). Therefore, the myope
retina when the myope is not accommodating. Therefore, the actually has 12D AOA ($12 in the bank account). Now when
far point is in front of the eye - the exact distance is the focusing up close, he/she can use all 12D; the near point can
refractive error. For example, a − 3 myope will have a far be calculated as 100/12 = 8.3 cm. The ROA for this patient is
point of 33 cm in front of the eye. The myope’s near point is 25 cm to 8.3 cm, or 16.7 cm.
the AOA plus the myopic refractive error. When our myopic friend wears his glasses, he/she is not
able to use the additional 4D of accommodation; only the 8D
Let us use some examples to further highlight this: AOA is available. Therefore, the near point is 100/8 = 12.5 cm.
When he/she takes off the glasses, the near point is
100/12 = 8.3 cm. This helps explain why presbyopic myopes
The Hyperope might take off their glasses when reading (see the next sec-
tion for more on this topic).
Suppose we have a patient who has 4D of hyperopia and 8D
amplitude of accommodation (AOA). What is the near point?
What is the range of accommodation (ROA)? The Emmetrope
Answer: We are told that the patient has 8D AOA ($8 in
the bank). This patient must spend 4D of accommodation ($4 Suppose we have a patient who is emmetropic and has 8D
from the bank account) just to bring distant light to focus AOA. What is the near point? What is the ROA?
onto the retina. The far point (without using additional Answer: For our emmetropic friend, the far point is
money from the bank account) will be 25 cm behind the eye infinity (Fig. 6). Theoretically, light rays from a distance
(Fig. 4). This means that only 4D of accommodation ($4 left should fall onto the retina without our friend having to dip
in the bank account) is left to see up close. When the patient into the bank account. When focusing up close however, the
uses this remaining 4D, the near point can be calculated as emmetrope can use 8D AOA ($8 in the bank account).
100/4 = 25, or 25 cm. The ROA for this patient is infinity to Therefore, the near point is 100/8 = 12.5 cm. The ROA is
25 cm. infinity to 12.5 cm (Fig. 6).
This patient is able to focus on a page as close as 25 cm.
8.3cm
A.
The Myope B.
Suppose we have a patient who has 4D of myopia and has 8D

25cm
AOA. What is the near point? What is the ROA?
Answer: Things are a bit different for our myopic friend
Fig. 5 A 4D myope with 8D of AOA. The far point will be at 25 cm
here as compared to our previous example with our hyper- (Point A). The near point will be at 8.3 cm (Point B). The ROA is the
distance between the two: 25 – 8.3 = 16.7 cm
A. 25cm 25cm B.
A. B.
12.5cm
Fig. 4 A 4D hyperope with 8D of accommodation. The far point

(without accommodation) will be 25 cm behind the eye at point B. The Fig. 6 An emmetrope with 8D of AOA. The far point will be at infinity
near point (using the remaining 4D of accommodation) will be at 25 cm (Point A). The near point will be equivalent to the AOA: 100/8 = 12.5 cm
(Point A). The range of accommodation is from infinity to 25 cm (Point B). The ROA is from infinity to 12.5 cm
The Cyclopleged Emmetrope assumed that the myope was not presbyopic and therefore
had a healthy amount of natural accommodation left.
Suppose we have a patient who is an emmetrope, has a bit But what happens when our myopic friend ages?
too much time (and curiosity) on his/her hands, and decides Eventually, as with all things in life, there comes a time to
to put in a bunch of atropine drops because of some viral pay the piper.
challenge video he/she saw online. What is the far point, near Suppose we have a 45-year-old patient who is a − 8D
point, and ROA? myope. He has been wearing −9D glasses (let us assume
Answer: In addition to smacking this patient upside the 14 mm vertex distance) for a slight overcorrection, −8D con-
head for doing this silly challenge, we can determine that tact lenses, and presents with complaints of headaches and
the far point is still infinity. However, because of the atro- strain when he wears his contact lenses for reading his cell
pine on board, this patient can no longer accommodate. As phone (at 25 cm) as compared to when he wears his glasses.
a result, the near point will also be at infinity. In order to see Why is this patient unhappy? The short answer: he probably
anything up close, the patient will need, in addition to a has to accommodate more with his contacts as compared to his
lecture about the perils of following online challenge vid- glasses. Whereas previously he could easily generate this addi-
eos, reading glasses to see up close until the atropine wears tional accommodation needed with his contact lenses, now he
off. is struggling to generate that additional accommodation.3
But why is this? Let us compare the amount of
accommodation needed with glasses versus contact lenses.
ccommodation in Presbyopic Myopes
A We can calculate this using our good old friend: U + D = V.
and Presbyopic Hyperopes Do not worry too much about the math: it is highly unlikely
you will have to ever calculate this on an exam, but we
This is a subtopic that deserves its own section because many wanted to show you the math to prove this concept (Fig. 7).
students are often confused when encountering this topic. In
the previous section, we stated that myopia functions as an
We are making an assumption that the patient was not over-minused
3
extra accommodation (“extra money in the bank”). However, his whole life, otherwise a simpler solution would be to give him his
we made a broad assumption that we must now address: we correct (“underpowered”) prescription.
-9D
glasses
-4.24 -13.24
-8D CL
Object
7.6 cm 1.4 cm
25 cm
Fig. 7 Calculation for accommodation needed for a − 8D myope who wears −9D glasses (14 mm vertex distance) and − 8D contact lenses when
wanting to see an object at 25 cm
116 G. V. Vicente
Accommodation Needed with Glasses

U = -100 /u = -100 / ( 25 cm - 1.4 cm ) = -100 / 23.6 cm = -4.24

U + D = V ® -4.24 + - 9 = -13.24 ® v = 100 /V = 100 / - 13.24 = -7.6
Now for the patient to see this object (that has “gone • Wearing single vision glasses for full myopic correction
through” the glasses): (i.e., they get to use the extra accommodation gained with
u = 7.6 + 1.4 = 9 cm the glasses)
• Wearing contact lenses that are slightly underpowered
U = -100 / u = -100 / 9 = 11 D (i.e., he could wear contact lenses such that residual −1D

myopia is remaining in order to gain an advantage for
So, the patient has to generate 11 D of accommodation in near work)
order to see this object at 25 cm. We know that the patient is • Switching to monovision or multifocal contact lenses
basically able to use 8D of myopia as extra accommodation • Using reading glasses for close work activities while
($8D extra in the bank), so he only has to generate 3D of wearing the full contact lens correction
accommodation on his own. • Surgical options for presbyopia (beyond the scope of this
Additionally, a myopic patient wearing minus power chapter)
glasses enjoys beneficial prismatic effects in the reading
position. Recall that minus lenses act like a base-in prism We can add another level of nuance (and possible
when the eyes converge for near tasks; this means less con- confusion). In the previous example, we assumed that our
vergence is required, and near vision tasks are easier. This presbyopic myope friend was wearing soft contact lenses.
advantage is lost when the myope wears contact lenses. However, if he was wearing a rigid gas permeable contact
lens (RGPCL), the mid-peripheral optic zone creates vaulting
Accommodation Needed with Contact Lenses in the mid-periphery through that section due to the tear film.
We can again use U + D = V (Fig. 7): The tear film of a RGPCL has some “plus power” (as com-
pared to clinically negligible power of a soft contact lens tear
U = -100 / u = -100 / 25 = -4 film) that may help a myopic patient with near vision tests.
See Chap. 13 “Contact Lenses for Written Exams”, for more
U + D = V ® -4 + -8 = -12 information.
The patient now has to generate 12 D of accommodation Conversely, unlike presbyopic myopes, presbyopic
in order to see the same object at 25 cm when he is wearing hyperopes may paradoxically enjoy wearing contact lenses
his contact lenses. He is still able to generate 8D accommo- because they will actually have to accommodate less with
dation because of his myopia, but now he has to generate an their contact lenses on as compared to their glasses. The
additional 4D of accommodation on his own. “math” involved in this is the opposite of the math presented
Therefore, he is probably experiencing headaches and above for the myope.
strain because he has to generate an additional 1D of accom-
modation when wearing his contact lenses as compared to
wearing his glasses. This is actually a common clinical sce- ther Miscellaneous Notes About
O
nario that myopes may complain about as they reach presby- Accommodation
opic age, especially if their day job requires a lot of close
work. They may find they do well in situations with contact We can end our discussion on these topics with a few
lenses with mainly distance viewing (such as driving, play- miscellaneous points, in no particular order:
ing sports, and weekend activities not requiring a lot of close
work), but may start to have gradual difficulties with near • Our accommodative ability decreases throughout life; it
tasks. does not start suddenly at 40. Emmetropes notice it
How can we help a contact lens wearing presbyopic around this age because this is usually when it affects
myope? Possible solutions include: our working or reading distance; some patients may
Table 1 Amplitude of accommodation by age Practice Questions

Age (years) Donders Duane (mean) Hofstetter (probable)
10 14 13.4 15.5 1. A + 3D hyperope has 5D of amplitude of accommodation.
15 12 12.6 14 Where is his near point?
20 10 11.5 12.5 A. 0.2 m
25 8.5 10.2 11
B. 0.15 m
30 7.0 8.0 9.5
35 5.5 7.3 8 C. 0.5 m
40 4.5 5.9 6.5 D. 0.3 m
45 3.5 3.7 5
50 2.5 2.0 3.5 2. A hyperopic patient wears +3.0D glasses for driving and
55 1.75 1.3 2 can maintain near focus at 10 cm without glasses. What is
60 1.0 1.1 0.5 her amplitude of accommodation?
65 0.50 1.1 0.5
A. 3D
70 0.025 none none
B. 7D
C. 10D
D. 13D
notice it earlier or later since AOA varies from patient to
patient. Have you ever heard a patient complain: 3. An uncorrected myope has a far point at 1.0 m and a near
“Doctor, ever since I turned 40, I have been using those point at 20 cm. What is her amplitude of
over the counter reading glasses. They ruined my eyes, accommodation?
now I’m 50 and can’t read anything anymore!” You can A. 1D
safely reassure these patients that this is simply a natural B. 4D
process that is taking place: congratulate them on get- C. 5D
ting older and reassure them that this is not a pathologi- D. 6D
cal change.
• As we age, the lens stiffens. The nerves and ciliary 4. A 50-year-old patient presents to your office inquiring
muscles are still working normally but the lens is not as about reading glasses. You measure her AOA as 3D. The
flexible as it used to be. The main reason for the loss of patient wants to be able to read at 33 cm. What power
accommodation is therefore the hardening of the crystal- reading glasses should be given to this patient?
line lens. A. +1.00 D
• Several landmark papers and studies have been published B. +1.50 D
in the literature regarding the AOA expected with changes C. +2.00 D
in age (Table 1).4 However, because the methods used in D. +2.50 D
these papers varied, they cannot be used as a be-all/end-
all guide to definitively “know” the AOA in a given 5. A 65-year-old patient presents to your office inquiring
patient. However, they can be useful guides to appreciate about reading glasses. You determine that with +2.50D
how AOA changes with age. Do not memorize these reading glasses, he can read at 25 cm comfortable. Which
numbers! of the following values is a reasonable estimate of his
• When giving reading correction for presbyopes, in AOA?
general, you want them to still use one-half of their AOA, A. 1.5 D
so you would prescribe them the other one-half of their B. 2.5 D
AOA. For example, if a patient is found to have AOA of C. 3.0 D
3D, you would still want him/her to use 1.5D, so you D. 3.5 D
should prescribe +1.5D reading add. This allows patients
to use some of their AOA while keeping some AOA in 6. An 85-year-old patient comes to your office inquiring
reserve, analogous to splitting the budget between a sav- about reading glasses. She likes to read the newspaper at
ing and spending account. 25 cm but feels that her current +3.00D reading glasses
are inadequate. Her AOA is 0.5D. How much additional
power should you add to her reading glasses?
A. +0.25 D
B. +0.50 D
4
Modified from: Optometric Clinical Practice Guideline: Care of the
Patient with Presbyopia, 2010. https://my.ico.edu/file/CPG- C. +0.75 D
17%2D%2D-Presbyopia.pdf. Accessed July 4, 2021. D. +1.00 D
118 G. V. Vicente
Answers tance: 100/33 = 3D. We are told that she has 3D

AOA. Therefore, we want her to continue using one-half
1. Answer: C. Since the patient has to use 3D of AOA to see of this AOA (1.5D), so we must prescribe an additional
anything at distance, he only has 2D ($2 left in the bank) +1.50D in the form of reading glasses.
of accommodation left to use for near vision. 100/2 or 5. Answer: C. In order to read comfortably at 25 cm, this
1/2D = 50 cm or 0.5 m. patient will need +4D of accommodation through some
2. Answer: D. When the patient is uncorrected, it takes 3D combination of his own abilities and his reading glasses.
for the patient to see clearly far away. The patient is able Currently, he is using +2.50D “help” from his reading
to focus from infinity all the way to 10 cm uncorrected. glasses, so he is using +1.5D on his own. Doubling this
This takes 10D of accommodation to go from infinity to value gives us +3.0D as a reasonable estimate of his
10 cm. Therefore, the patient must have started with 13D AOA. Of course, there are much better ways to measure
of accommodative amplitude, 3D to see at distance +10D AOA objectively – such as Step 1 scores, number of MS3
to bring the near point to 10 cm. clerkship honors, etc. (sorry, we had to!).
3. Answer: B. If the far point is 1.0 m then the patient must 6. Answer: C. In order to read at 25 cm, she will need 4D of
have −1D of myopia. The near point is 20 cm, the help, either from her reading glasses or her AOA. Since
reciprocal of 20 cm = 5D. To go from 1D to 5D they must her AOA is 0.5D, she really can use 0.25D (at most), so
have accommodated another 4D. she will need +3.75D in her reading glasses. Therefore,
4. Answer: B. We can start of by first determining how much her current reading glasses will need an additional +0.75D
add power is needed to read at the desired reading dis- of power.
Spherocylindrical Lenses
Kamran M. Riaz
Objectives This topic arguably causes much angst and stress to train-

• To introduce nomenclature used to describe spherocylin- ees, mainly because no one can seem to agree on terminol-
drical lenses and keratometry measurements ogy and how to speak about a particular teaching point under
• To clarify two key definitions used with spherocylindrical the topic. Even published articles and podium presentations
lenses: meridian and axis are filled with authors and speakers using these terms inter-
• To discuss clinical relevance of these terms as it pertains changeably (and sometimes wrongly!) The problem is astig-
to streak retinoscopy, keratometry measurements, and matism itself1: how do we speak about it related to the cornea,
astigmatism correction lenses, streak refractions, and the surgical correction of
• To understand how to use spherocylindrical notation to astigmatism? The idea of a cylindrical lens, especially in
solve clinical and testable refraction problems regards to “axis” and “meridian”, and how this relates to cor-
• To understand how to use power crosses to solve clinical neal astigmatism and the actual “power” exerted by the
and testable refraction problems cylindrical lens is confusing.
• To revisit Prentice’s Rule to solve advanced problems After figuring out astigmatism and spherocylindrical lens
involving spherocylindrical lenses nomenclature, we may feel trapped with the two additionally
challenging topics of SC Notation and PC Notation. The key
is to realize that both methods are used to arrive at the same
answer. Both methods can determine eyeglass prescription
Introduction power for clinical and testable scenarios, especially based on
streak refraction results. These methods are likely remnants
Dante Alighieri (1265–1321) was a famous Italian poet and of days past when clinicians lacked phoropters, auto-
political theorist of the late Middle Ages who wrote the refractors, and wavefront aberrometers, and perhaps when
Divine Comedy, which is considered one of the greatest liter- these technologies become more mainstream, this topic may
ary achievements of his time. In this epic poem, Dante, pos- lose its relevance. It is also possible that you may find your-
sibly under the influence of recreational substances, describes self in a situation, such as a rare occasion in clinic or while
his imaginary journey through various places of the afterlife, serving in a medical mission, when you may lack access to
including his journey through Inferno (Hell). He reported your favorite toys and may have to rely on these older meth-
that the following phrase is inscribed over the gates of Hell: ods. Alternatively, you may need to know this material sim-
Lasciate ogne speranza, voi ch’intrate (Abandon all hope ply to get through your exams.
ye who enter here). In Dante’s epic story, he eventually finds his way out of
It is fitting that as we embark upon this journey through Inferno. In our story, we hope to do the same.
spherocylindrical lenses, especially when dealing with sphe-
rocylindrical notation (SC notation) and power crosses (PC
The next time your patient tells you, “Doc, I got a huge problem, they
1
notation), we also can imagine that we are passing into a told me I got this here “stigmatism”, what can you do to fix it?” you can
realm through a door with the same quote inscribed above. silently nod to yourself: yes, you and me both, pal.
K. M. Riaz (*)

120 K. M. Riaz
Nomenclature and Definitions at 85°; therefore, the flat meridian is located 90° away (at
175°). This cornea has the shape of a horizontal football such
This topic is often confusing because definitions and nomen- that the center is getting ready to hike it to the quarterback
clature vary among textbooks (and subsequent discussions (with-the-rule (WTR) corneal astigmatism).4
among ophthalmologists!). Studying this can be very frus- For this cornea with 2D keratometric astigmatism, we can
trating because you may find it used differently in another ask the following question: how can we correct this corneal
textbook when you think you have understood a particular astigmatism when using (1) glasses, (2) corneal incisions,
term. This is like standing in line for hours to buy an Apple (3) toric IOLs, and (4) laser refractive surgery. We will deal
iPhone® and then realizing you only have an Android® char- with the first situation in this chapter and the other three situ-
ger (or vice-versa, depending on where your allegiances ations in the next chapter.5
lie!) In order to help this patient (and assuming zero lenticular
We should first discuss a few important terms to help us astigmatism), we will need to prescribe cylindrical correc-
navigate this Inferno. tion to neutralize the corneal WTR astigmatism with a cylin-
drical lens. But how should we orient this eyeglass lens?
Keratometry Measurements
ylindrical Lens: Axis Meridian and Power
C
We need to define several terms that we will use consistently Meridian
throughout this chapter. We can start with our familiar friend,
the cornea, and simplify its shape as a circle. While a circle Before we discuss cylindrical lenses, let us review spherical
has 360 degrees, we need a term to refer to the point of inter- lenses. Recall that a pure spherical lens will focus any incom-
est in this “circle.” The term meridian is simply a term used ing light ray, regardless of its entrance location on the lens
to refer to a location on this corneal circle. Technically, while (i.e., regardless of the meridian of the lens), onto a single
there are an infinite number of meridians in the cornea, we focal point behind the lens (Fig. 1). For example, any incom-
will limit these to 360 meridians.2 Of course, we know that ing light ray that enters a +1D lens from infinity will focus at
the cornea is not an actual circle; most patients have corneas the focal point 1 m behind the lens.
with orthogonal, symmetrical astigmatism, so the corneal A spherocylindrical lens has different powers in different
shape is more like an oval. Thus, there is a flat (longer) side locations (meridians) in the lens. Light rays that pass through
and a steep (shorter) side of this oval, which we can term the this lens will focus on more than one focal point (astigma-
flat meridian and the steep meridian, respectively. As a sim- tism). We will discuss these concepts in greater detail in the
plification, we can consider that the flat meridian is 90° away following sections. The focal point locations for light rays
from the steep meridian in a cornea with regular entering a spherical lens (Fig. 2, Panel a) and spherocylindri-
astigmatism.3 cal lens (Fig. 2, Panel b) differ significantly. For example, a
When we perform keratometry (K) measurements, we are spherocylindrical lens with power of +1.00 + 2.00 × 90 will
generally given two numbers of corneal power – for our pur- focus incoming light at two focal points: 1 m and 0.33 m
poses in this chapter, the corneal power measurements also (33 cm) behind the lens.
give us information about the location of the flat meridian We can describe cylindrical or spherocylindrical lenses
and the steep meridian. For example, suppose we have a by their axis and power. We primarily care about only two
patient with K measurements of 43.00 × 45.00 @ 85. We terms related to these lenses:
know from these readings that the steep meridian is located
• Axis Meridian (AM): This is the degree (meridian) in
which the cylinder’s long side is oriented. We will use the
As a nerdy nomenclature point: the cornea has no “axis”. It is incorrect
2
to use the term, for example, in cataract surgery when deciding to place
a main incision at a given location to reduce corneal astigmatism as See Chap. 11, “Astigmatism”, for a more detailed discussion of these
4
“operating at the steep axis”, which unfortunately has been used in concepts.
numerous published papers and podium presentations. The correct term For those readers who want to anxiously know, we can summarize as
5
is “operating at the steep meridian”. See: Rosen E. Axis or meridian? J follows. Regarding corneal incisions, the main incision can be placed
Cataract Refract Surg. 2011 Oct;37(10):1743 superiorly (at 85°); if using a temporal main incision, paired limbal
This simplification breaks down for irregular corneas such as postre-
3
relaxing incisions can be made centering at 85° – various nomograms
fractive corneal ectasia, keratoconus, and postpenetrating keratoplasty. exist for the degree length for these incisions. Regarding toric IOLs, the
For the purposes of this introductory discussion, we will assume the IOL should be placed with its markings at 85° in order to exert power
cornea has a symmetrical shape (regular astigmatism). For corneas with 90° away (at the 175-degree meridian). Finally, when considering laser
irregular and nonorthogonal astigmatism, one “half” of the cornea is not refractive surgery, given that ablation is typically done in minus cylin-
a perfect mirror reflection of the other “half”. Thus, flat and steep der, the laser will ablate the steeper section of the cornea (along the
meridians are not necessarily 90° away from one another. 85-degree meridian) to flatten it.
Spherocylindrical Lenses 121
Fig. 1 All incoming light

rays that refract through a
pure spherical lens will focus
at a single point. Notice that
the entrance location of the
yellow and red light rays
differs by 90°, but they both
are focused on the same focal
point behind the lens
a b
Fig. 2 Comparison of spherical and spherocylindrical lenses. All spherocylindrical lens (Panel b) will be focused at two distinct focal
incoming light rays that pass through a spherical lens (Panel a) will be points. Notice that light along the vertical meridian (flat meridian) is
focused to a singular focal point. Incoming light rays passing through a less refracted and converges at a further point
term “IN” to indicate the meridian location of this cylin- The AM (green line) refers to the meridian in which the
drical lens. The AM is also the meridian (location) at cylinder is placed “IN”; in this case, this is 90°. The PM
which a line will form by light rays passing through the (red line) refers to the meridian at which the cylindrical
cylindrical lens – this latter quality of the AM confuses power is having an effect “AT”; in this case, this is actually
many trainees. 180°.
• Power Meridian (PM): This is the degree (meridian) at Notice that the AM and PM are 90° apart in the above
which the cylinder is having an effect. We will use the example. This concept works for any cylindrical lens, regard-
term “AT” to indicate the meridian location of where the less of the value of its AM. Even if the lens was placed in an
cylindrical power is “acting at.” oblique orientation, the PM will still be 90° away. For exam-
ple, if we had a plano +2.00 × 45 cylindrical lens, the AM is
AMs and PMs are easier to understand with a pure located in the 45° meridian, and the PM is located at the 135°
cylindrical lens, such as plano +2.00 × 90. Since this is a meridian (Fig. 4).
cylindrical lens, we can envision it like a soda can (Fig. 3).
122 K. M. Riaz
is a slightly different story. In this subtopic, many trainees

get lost in the Inferno.
The first key learning point is that incoming light ray(s)
parallel to the AM will not be refracted. They will not form
any focal point or line!
The second key learning point is that incoming light
ray(s) perpendicular to the AM (i.e., parallel to the PM) will
get refracted by the curvature of the lens (PM). They will
form a focal point/line parallel to the AM (Fig. 5).
As a point of clarification, each individual light ray will
form a focal point. Since numerous light rays enter the lens
at a given location, they will form a focal line. These will
form at a location parallel to the AM (Fig. 6). This concept is
understandably confusing, especially on a first-time read of
this material. Now do you see why we are in the Inferno?
A cylindrical lens could compensate for the corneal
Axis meridian Power meridian astigmatism of a patient with K readings 43.00 × 46.00 @
90 (Fig. 7, Panel a). In other words, a lens with its axis
(meridian) IN 90° will exert power AT the 180-degree
Fig. 3 A cylindrical lens is defined by its axis meridian (green line),
which indicates the orientation of the “longer” side of the cylinder. The (power) meridian to strengthen the 43D at this location by
power meridian indicates where the cylindrical lens’s power is “acting an extra 3D to equal the 46D at the 90-degree meridian
at” (red line). The axis meridian and power meridian are always 90° (Panel a). Supplementary hyperopic sphere (Fig. 7, Panel
apart b) and myopic sphere (Fig. 7, Panel c) can be added to the
cylinder power based on the refractive error of a given
patient.
Axis meridian
Power meridian Please take a minute to re-read the above to make sure
you understand it correctly. As much as we want to escape
the Inferno, there are several important landmarks to concep-
tualize clearly--otherwise, we will get even more lost later.
Eyeglasses: Sphere and Cylindrical Lenses
We can tie the previous discussions together by using eye-

glass prescriptions involving sphere and cylinder correction
as a starting point of reference.
For example, if we are given the prescription for the right
eye: −6.00 + 2.00 × 90.
Fig. 4 Axis and power meridians for a plano +2.00 × 45 cylindrical This prescription notation means that +2.00 D of cylinder
lens. Note that the axis meridian and power meridians are located 90° has been placed IN the 90-degree axis meridian (AM) in
away, despite the lens having an oblique axis meridian order to ACT AT the 180-degree power meridian (PM).
However, because glasses are typically made in minus
cylinder, if we were to write such a prescription, our optical
ylindrical Lenses: What Happens to Incoming
C shop friends would technically make a pair of glasses such
Light Rays? that there is actually a minus cylinder placed in the 180-degree
AM. This cylinder acts at the 90-degree PM to direct incom-
Note: This section, in particular, is often confusing for training light to form a horizontal line at 180°.
ees because it seemingly contradicts what was introduced in There is astigmatism throughout the entire lens, but we
the previous section. can think of there being only −6D of power at the 90-degree
We have just discussed how a cylindrical lens can be used PM. If the patient looks purely up and down from the optical
to correct astigmatism: the lens exerts its power AT the center, only −6D of power must be considered. We have a
PM. However, what is happening with the incoming light ray slightly different story at the 180-degree meridian. Since we
Axis meridian Axis meridian
Focal point
Power
meridian
Fig. 5 Incoming light rays parallel to the axis meridian will not be plane will form a focal point/line, which is parallel to the axis meridian.
refracted, and they will not form a focal point (or focal line). Incoming The figure above could represent a cylindrical lens (plano +2.00 × 90).
light rays perpendicular to the axis meridian (i.e., parallel to the power Incoming light that passes through this lens would be refracted as
meridian) will be refracted by the curvature of the lens. Light at this described above
power at the 180-degree meridian. If that patient looks purely

right or left of the optical center, we have to now consider
−4D of power. Later in the chapter, we will explore this con-
cept further when we revisit “Prentice's Rule, Part II”.
Axis meridian
For a patient who requires the above prescription, we can
assume that her K measurements (assuming zero lenticular
astigmatism) could be: 44.00 × 46.00 @ 90. This means
there are 2 D of cylinder AT the 90-degree meridian (WTR
astigmatism). Therefore, we have to place 2 D of plus-
cylinder IN the 90-degree AM to ACT AT the 180-degree
PM (and make it 2 D stronger to equal the 90-degree
meridian).
Focal line
Streak Retinoscopy
Streaking a patient with purely spherical refractive error is

relatively straightforward. The same power lens can neutral-
ize the reflex in all directions.6 However, most patients will
require some cylindrical correction as well. Different power
Power
meridian
lenses will be needed to neutralize the reflex, primarily in
meridians located 90° from each other.
Note that some texts and resources will use “when you
streak at 90 degrees” when discussing streak results or con-
stantly flip between “at” and “in” nomenclature. In clinic,
senior attendings may say, “when you streak in this 90-degree
axis…” Again, the nomenclature is somewhat confusing.
Some may even argue that having to do 20 streak refractions
in a row is a level of punishment within the Inferno.
Fig. 6 A focal line is formed by light entering the cylindrical lens at the Both expressions are (hopefully) trying to convey the
power meridian
same message: when we place the streak with a hand-held
have placed +2D cylinder in the 90-degree AM to ACT AT See Chap. 15, “Glasses in Clinical Practice”, for a more detailed dis-
6
the 180-degree PM, we have a total of −6 + 2 = −4D of total cussion of streak refraction.
124 K. M. Riaz
a b c
plano +2.00 × 90 +2.00 +2.00 × 90 –6.00 +2.00 × 90
Fig. 7 Corneal (keratometric) astigmatism and cylindrical lens correc- patient with astigmatism see better. In Panel b, a plus-power spherocy-
tion. All three panels have a patient with a cornea that is steeper at 90° lindrical lens (e.g., +2.00 + 2.00 × 90) will help a patient with hyperopic
and flatter at 180°. For example, the keratometry measurements may be astigmatism. In Panel c, a minus-power spherocylindrical lens (e.g.,
43.00 × 46.00 @ 90 for all three panels. In Panel a, an upright cylindri- −6.00 + 2.00 × 90) will help a patient with myopic astigmatism
cal lens (plano +2.00 × 90) with its axis meridian at 90° will help a
–3.00 Streaks 90º (SC) Why is this important? Do we enjoy making new names
–3.00 × 180º (PC)
for things that do not need new names? Hopefully, we will
see how keeping these terms separate will allow us to work
in either spherocylindrical notation (SC notation) or power
cross notation (PC notation) to determine the necessary eye-
glass prescription. Imagine that both SC notation and PC
–4.00 Streaks 180º (SC) notation are two different highways that lead us out of the
–4.00 × 90º (PC) Inferno, so we have to make sure that we get our bearings
and directions straight!7
We can use a streak retinoscopy to compare both of these
highways (SC notation and PC notation). Note that SC nota-
tion requires us to work in the same degree as the orientation
of the streak; PC notation requires us to work at the degree at
Fig. 8 Streak refraction results for the clinical scenario presented in which the streak is exerting its power. We hope the following
the text. Notice the nomenclature used to refer to the degree of the examples make these points clearer.
streak. The streak results can then be used for either SC notation or PC Clinical scenario of streak retinoscopy results (Fig. 8)
notation
• If we move the retinoscope with the streak horizontally

lens of some power in the 90-degree AM (oriented verti- oriented and move it up and down (vertically), and the
cally), we can neutralize with/against motion because the reflex neutralizes with a −4.00 D sphere, we can think of
lens is exerting an effect at the 180-degree power this as “−4.00D STREAKS the 180 degree (SC nota-
meridian. tion)” or “−4.00 × 90 (PC notation)”.
In order to keep things (hopefully) a bit less confusing,
we will use the term “STREAKS the x DEGREE” in order to Over the years, trainees have suggested other shortcuts for each of
7
avoid using the terms of “axis” and “meridian” when dis- these methods that help them arrive at the correct answer(s) as well. We
cussing streak results. In our previous example, we will have chosen here to teach the more commonly employed methods, with
each step spelled out, that we have used to teach this topic over the
instead refer to it as “STREAKS the 90 degree”, and the
years. As you read this, if you come up with shortcuts that work for you,
results of that streak should be clear. that is awesome! As long as you get out of the Inferno, we do not care
which road(s) you take.
• If we move the retinoscope with the streak vertically ori- Returning to our example, −4.00D streaks the 180 degree
ented and we move it side to side (horizontally), the reflex and −3.00D streaks the 90 degree:
neutralizes with a −3.00 D sphere. We can think of this as
“−3.00 D STREAKS the 90 degree (SC notation)” or • SC Lens Power: −4.00D × 180 AND −3.00D × 90
−3.00 × 180 “(PC notation)”. –– Add a “plano” sphere lens in front to further
differentiate
There are several ways to take the results of streak reti- –– Rewrite this as: plano – 4.00 × 180 AND plano – 3.00 × 90
noscopy and translate them into eyeglass prescriptions. We • PC Lens Power −4.00D × 90 AND −3.00D × 180
can now discuss how we can use both SC notation and PC –– For our PC lenses, we are going to write our streak
notation to arrive at the same answer. results showing the meridian at which the lens is exert-
In general, SC notation works well if you feel comforting its power (power meridian).
able (or enjoy) doing math, like seeing every “step” of the
calculation and do not like drawing things out. PC notation In the next section, we will work with SC notation; in the
works well if you do not like doing math and prefer drawing section after that, we will work with PC notation.
things out. We will not judge you on which method you take!
We just want you to get the answer right (i.e., escape the
Inferno). Spherocylindrical Notation (SC Notation)
In order to use either SC or PC notation, we must first
determine how to orient the streak results. One way that may Consider the following example: You perform a streak reti-
be helpful is to think of the streak results as “mini lenses” noscopy on a patient. A +2.00D lens streaks the 80 and
that we can combine to arrive at the “final lens”. If you are −4.25D lens streaks the 170. We will ignore the working dis-
given a streak refraction, think of the “SC Lens” written with tance for this first example (Fig. 9).
the axis meridian (i.e., the same degree in which the streak We can use these results to write out our initial SC nota-
was placed in); the “PC Lens” power is located 90° away tion “mini lenses”. Note: some texts may also refer to these
from the streak results (i.e., at the power meridian). “mini lenses” as cross cylinder notation.
Since + 2.00 STREAKS 80:SC Lens 1 = +2.00 × 80 ( aka plano + 2.00 × 80 )

Since − 4.25 STREAKS 170:SC Lens 2 = −4.25 × 170 ( aka plano − 4.25 × 170 )

Fig. 9 Streak refraction

results: +2.00 STREAKS the +2.0 +2.0
0 0 St
80 and −4.25 STREAKS the reak
s 08
170 0.00 0°
0.00
25
–4.
–4.25
Strea
ks 17
0°
+6.
25
–4.25
126 K. M. Riaz
Now we can convert Lens 1 to minus cylinder format and

Lens 2 to plus cylinder format:
Lens 1: plano + 2.00 × 80 = + 2.00 − 2.00 × 170 ( minus cylinder format )

Lens 2: plano − 4.25 × 170 = − 4.25 + 4.25 × 80 ( plus cylinder format )

Next, we can algebraically combine the two notations Plano – 4.25 × 170
with the same axis; we can use either the two plus cylinder (+) +2.00 – 2.00 × 170
format lenses or the two minus cylinder format lenses. Note, =====================
we must not try to combine two lenses with different axis Final MRx: +2.00 – 6.25 × 170
notation; otherwise, we will get the wrong answer and
remain trapped in the Inferno.
We can convert this result to plus cylinder format to check
If we took the plus cylinder format lenses: plano + 2.00 × 80
our work: −4.25 + 6.25 × 80.
(+) –4.25 + 4.25 × 80 This second calculation confirms that we can use either
===========================
the plus cylinder lenses or the minus cylinder lenses to get
Final MRx: –4.25 + 6.25 × 80
the same final MRx result. Speaking of the MRx, this is cer-
tainly a lot of cylinder! We should make sure our patient does
We would get the same result if we combined the two not have a corneal ectasia, or if this is a post-keratoplasty
lenses in minus cylinder format, and we could check our patient, it might be time to cut some sutures.
work by converting that result to plus cylinder format: Let us do another example, but this time we have to incor-
porate the working distance. We want the patient to be able to
focus at infinity (or at least at a far enough distance to avoid
the terrifying monsters of the Inferno) and not at our retino-

+4.00
results: −7D STREAKS the –7.00 Streaks 90°

90 and +4D STREAKS the
180 with a working distance
of 67 cm
0.00
–7.00
0.00
+4.00 Streaks 180°
+11.00
–7.00
scope (Fig. 10). Suppose that a −7D lens streaks the 90 and a ing distance. We can proceed similarly to the previous
+4D lens streaks the 180. Assume a working distance of 67 cm. example and save the working distance adjustment until the
We can again use SC notation to determine the final eye- end.
glass prescription, but this time, we must consider our work-
SC Lens 1: + 4.00 × 180 = plano + 4.00 × 180 = ( minus cylinder ) + 4.00 − 4.00 × 90

SC Lens 2: − 7.00 × 90 = plano − 7.00 × 90 = ( plus cylinder ) − 7.00 + 7.00 × 180

tion answer into plus cylinder notation. You do not have to

We can then pick the two prescriptions in the same axis
start from scratch all over.
notation and combine them.
We can do one more example using SC notation: a +4.00D
plano + 4.00 × 180 plano – 7.00 × 90 lens streaks the 135 and a +6.50D lens streaks the 45. What
+ –7.00 + 7.00 × 180 +4.00 – 4.00 × 90 is the required prescription if the working distance is 50 cm
================= =============== (Fig. 11)?
–7.00 + 11.00 × 180 +4.00 – 11.00 × 90 Based on these streak refraction results, we can generate
our SC lenses:
Now that we have our initial results, we have to adjust for

working distance (67 cm): Since the working distance is
SC Lens 1: + 4.00 × 135 = plano + 4.00 × 135 = +4.00 − 4.00 × 45
67 cm, we can determine how much “extra” spherical correc-
tion we have to add using the D = 100/f formula, where f is
SC Lens 2: + 6.50 × 45 = plano + 6.50 × 45 = +6.50 − 6.50 × 135
our focal length in centimeters (or working distance, in this
case). Therefore, 100/67 = 1.5. For all these working distance
problems, we have to ADD ADDITIONAL MINUS (SPHERE) Now we can algebraically combine two lenses of our
POWER, so we have to add an additional −1.5D spherical choosing in the same axis notation:
correction; it is crucial that we do not adjust the cylinder or
+4.00 − 4.00 × 45
axis values at this time. Notice the nomenclature that we have
specified above: trainees often get confused by the terminol- plano + 6.50 × 45
ogy used in clinics, such as “subtract sphere from the refrac- = = = = = = = = = = = = = = =
tion” or “take away sphere from the refraction”. +4.00 + 2.50 × 45
When we add an additional −1.5D sphere:
Even though we have calculated the +4.00 + 2.50 × 45,
• Final spectacle prescription: −8.50 + 11.00 × 180 we are not done yet - this may likely be a “distractor” answer
+2.50 −11.00 × 90.8 choice because we have not yet factored in the working dis-
tance. Given that the working distance is 50 cm, we have to
Bonus Tip When solving these problems, you may want to add an additional 100/50 = −2D to the above result. Hence,
look ahead at the answer choices and see what notation (plus the final prescription is +2.00 + 2.50 × 45.
cylinder or minus cylinder) is present. This strategy will help
you to pick which lenses you will combine accordingly.
Alternatively, suppose you chose to combine the two minus
cylinder lenses, and the answer choices are listed in plus cyl- Power Crosses (PC Notation)
inder format; you can just convert your minus cylinder nota-
Just like SC notation, power crosses can be very confusing.
8
Note that this is a very strange refraction and this patient, with signifi- Some texts may refer to this as an “Optical Cross” or “Optical
cant ATR astigmatism seen in the plus-cylinder refraction notation, Power Cross”.9 Power crosses are nothing more than a sche-
may actually have a corneal ectasia causing the ATR such as pellucid
marginal degeneration present! So, while we are monkeying around
matic way of describing trial lenses. It may help to remem-
with this refraction, we should also make sure to get topography on our
fictional patient and ensure we are not missing a vision-threatening cor- Note that a power cross is not the same as an axis cross, which will be
9
neal disease. discussed in the next section.

128 K. M. Riaz

results: a +4.00D lens .00 +6
STREAKS the 135 and a +4 .5
0
+6.50D lens STREAKS the St
5°
re
13
45. The working distance is ak
s
s
ak
50 cm 0.00 04
re
5°
St
0
.0
+4
+6
.5
0
0.00
+2
.5
0
+4.00
ber that the purpose of power crosses is to ultimately yield an Similarly, if we are given a +3.00 × 180 cylindrical lens,
eyeglass prescription (in addition to making your life miser- we can determine that the lens has been placed such that its
able). Whereas SC notation depends on a fair amount of long side is in the 180-degree AM, but it will exert its power
math, as seen in the previous section, power crosses rely on at the 90-degree PM. We can show this on a power cross
far less math and much more visualization. Depending on (Fig. 14).
your learning style, you may find that power crosses make We can do one more example:
more sense and are easier to work with, so long as your If we are given a cylindrical lens with a power of
drawings are correctly oriented. −3.00 × 90, how can we represent this lens as a power cross?
Since −3.00D has been placed IN the 90-degree AM to
exert power AT the 180-degree PM, we can show this on a
Defining the Power Cross power cross (Fig. 15).
For starters, let us define a power cross. A Power Cross is a

visual representation showing us where a cylindrical lens's Using the Power Cross
power is ACTING at. If we have a +3.00 × 90 lens, its axis
meridian (AM) is 90°, and its power meridian (PM) is 180°. Now that we have defined them, let us do some streak reti-
In other words, this lens will exert power 90° away from the noscopy problems using power crosses (PC). The most sig-
AM. In the figure below, we can map out the orientation nificant difference is how we set up our PC based on
(AM, green arrow) versus the power (PM, red arrow) visu- retinoscopy results, which is the exact opposite of how we set
ally using a power cross (Fig. 12). The power cross basically up our SC notation lenses.
shows us the meridian at which the lens is exerting power
(i.e., where the lens power is acting at). Example #1 A +4.00D lens STREAKS the 135°, and a
Here is another slightly offensive but hopefully unforget- +6.50D lens streaks the 45°. Ignore the working distance (for
table visual mnemonic to help us remember this point. this problem).
Imagine as you are trying to get out of Inferno, you are
encountering all sorts of monsters and demons trying to stop If we want to use SC notation, we will start with
you from escaping. You decide to give them the middle fin- +4.00 × 135 and +6.50 × 45. However, since we want to
ger. Now think of your middle finger as the AM, but the work with PC notation, we have to set it up differently.
“power” (effect) of this gesture is acting 90° away (PM) Remember that the +4.00D exerts its power AT 45°, and the
(Fig. 13). +6.50D exerts its power AT 135.
Fig. 12 Visual representation

(left panel) of a +3.00 90°
cylindrical lens placed in the
90-degree meridian (AM,
green arrow). This lens will
exert its power at the
180-degree meridian (PM, red
arrow). A power cross (right Power
panel) shows us the meridian 180°
at which the lens is exerting +3.00 +3.00
power (PM)
Plano
Plano
help you to avoid choosing the wrong axis in your zeal to get
the answer. There are three steps to this method:
1. Pick a lens as your starting sphere (either one is fine).

Usually, starting with the more “minus” lens will allow
you to work in plus cylinder notation.
2. Then ask yourself, “How much do I have to add/subtract
Power meridian to this lens to “equal” the other lens”. Draw your first
arch to connect the two lenses. This value is the cylinder
portion of the eyeglass prescription.
3. Draw your second arch that connects this second lens to
the adjacent axis. This value is the axis portion of the
eyeglass prescription. Note, because it is a double arch,
you cannot cross over 180° for the axis but must instead
Axis meridian jump over 90° to get the axis. Feel free to celebrate at this
time.
Fig. 13 The middle finger is placed in the 90-degree meridian (axis
meridian, green arrow) but is exerting its power at the 180-degree Going back to our above PC example, we can determine
meridian (power meridian, red arrow)
the eyeglass prescription using the DAM (Fig. 17).
Applying the DAM to our PC:
Our PC must show that the +4.00D is connected with the
45-degree meridian, and +6.50D is connected with the 1. Suppose we selected +4.00D as our starting sphere.
135-degree meridian. We can draw the PC based on these 2. Then we can ask ourselves, “How much do we have to
results (Fig. 16). add/subtract to +4.00 to get to +6.50?” (Arch 1). In this
Once we have our PC, we can now use this diagram to case, it would be +2.50D; this is the cylinder portion of
calculate the eyeglass prescription. There are several ways to the prescription.
do this, but one technique is to use a method we have termed 3. Then draw the second arch to obtain the axis for the pre-
the “Double Arches” (apologies to the world’s largest fast scription (45). The second arch allows us to make sure we
food restaurant chain, please do not sue us…) Method pick “45” instead of accidentally choosing “135”.
(DAM).10 The DAM simply requires you to know how to 4. The final eyeglass prescription is: +4.00 + 2.50 × 45.
draw and do some basic addition and subtraction; it may also
We could have also used +6.50D as our starting sphere
and used the DAM to arrive at the same prescription in minus
This acronym may also represent how you are feeling at this point in
10
cylinder notation (Fig. 18).
the chapter.
130 K. M. Riaz
Fig. 14 Visual representation Power

(left panel) of a +3.00 × 180 +3.00
cylindrical lens. This lens will 90°
exert its power at the
90-degree power meridian. A
power cross shows that the
lens has +3D power at 90°
(right panel)
Plano
180°
Plano
+3.00
DAM applied:
90°
1. The +6.50D is chosen as the starting sphere.
2. Then we ask ourselves, “How much do we have to add/
subtract to +6.50 to get to +4.00?” In this case, it would
be −2.50D for the cylinder portion of the prescription.
-3.00 3. Then draw the second arch to give axis of the prescription
180° (135).
4. The final eyeglass prescription is: +6.50 − 2.50 × 135.
Note: we could have also converted either result into the

opposite cylinder format to get the answer.
plano Example #2 We will factor in the working distance this

time.
Suppose we perform a streak refraction with the follow-
ing results: a +3.00D lens streaks the 150°, and a +5.00D
Fig. 15 Power cross for a cylindrical lens −3.00 × 90. Note that this
lens has zero power at the 90-degree meridian and −3D power at the lens streaks the 60°. If the working distance is 67 cm, what is
180-degree meridian the final refraction?
Fig. 16 Power cross drawn 135° 045°

re 0
from the streak refraction

+6 eak °
St 4.0
5° s
St 045
13 ak
.5 s
r
results: +4.00D lens

+
STREAKS the 135° and a

+6.50D lens STREAKS the
45°
+4.00 +6.50
135° 045° We know that the +3.00D lens exerts its power AT the
2
60-degree meridian, and the +5.00D lens exerts its power AT
the 150-degree meridian. We can draw our PC to show this
relationship (Fig. 19).
We can then use the DAM (Fig. 20).
The steps of the DAM are:
1. Select +3.00D as our starting sphere (the more minus of

the two spheres).
2. Then we can ask ourselves, “How much do we have to
add/subtract to this starting sphere to get to +5.00?” In
this case, it would be +2.00D, which would be the cylin-
+4.00 +6.50
der portion. Draw our first arch.
3. Then we can draw a second arch to the axis (60).
4. The refraction would be: +3.00 + 2.00 × 60, but are not
1 finished yet!
5. Now factor in the working distance of 67 cm (additional
Fig. 17 After setting up a power cross, the Double Arches Method can −1.5D sphere) for the final eyeglass prescription:
be used to calculate the final eyeglass prescription. First, pick one of the +1.50 + 2.00 × 60.
two spheres as the starting lens; it is recommended to choose the “more
minus lens” to work in plus cylinder notation, though this is not a must.
Next, draw the first arch to the second sphere and determine how much Notice that if we had chosen the +5.00D as our starting
we must add or subtract to arrive at this second sphere value. This value lens, we could still apply the DAM, but our result would be
will be the cylinder power. Third, draw a second arch to the adjacent in minus cylinder: +5.00 − 2.00 × 150. Factor in the working
axis for the axis portion of the prescription. Note that it is crucial to
choose a starting lens and proceed in a stepwise fashion taking care to
distance (additional −1.5D sphere), and the final prescription
draw the double arches correctly to avoid picking the wrong axis value would be: +3.50 − 2.00 × 150.
in the final eyeglass prescription
Reconciling SC Notation and PC Notation
We can also prove to ourselves that we can use SC notation

135° and PC notation interchangeably, taking care to follow the
045°
rules of each, and get the same result. Again, we just need to
find any road that will lead us out of the Inferno.
2
pplying SC Notation and PC Notation to Same
A
Streak Refraction
Looking back at the first example we used for SC notation,

we can now use PC notation to get the same result.11
In that example (Fig. 9), the streak results were: +2.00D
STREAKS the 80 and −4.25D STREAKS the 170. When we
+4.00 +6.50 did SC notation, we set the SC lenses as +2.00 × 80 and
−4.25 × 170.
For power crosses, we have to “flip” these lens results
1 since the +2.00D is acting at the 170-degree meridian and the
Fig. 18 The DAM can be used for the previous PC above using the
+6.50D lens as the starting lens. Note that this result will yield an eye- #ProTip. You can use one method and then use the other to “check
11
glass prescription in minus cylinder format your work” for extra practice.
132 K. M. Riaz
Fig. 19 Power cross +

indicating the +3.00D lens is St 5.00 060°
rea
exerting its power at the 06 ks 150°
Stre .00
0°
150 ks
60-degree meridian, and the
a
°
+3
+5.00D lens is exerting its
power at the 150-degree
meridian
+3.00 +5.00
150° 060°
This answer is the same result that we calculated with SC
notation. We will pause here while you celebrate, recover
2
from having your mind blown, or some combination thereof.
Miscellaneous Topics
Another way these problems may be presented is by giving

you two “cylindrical lenses” and asking you to express these
problems in SC notation, PC notation, or as an eyeglass
prescription.
+3.00 +5.00 Example: A patient can see well by combining two trial
cylindrical lenses: +2.00 × 120 and −2.25 × 30. Ignoring the
working distance, determine the needed eyeglass prescription.
1 A. SC Notation: Make the “SC lenses” directly from the

cylinder lens notation
Fig. 20 Double Arches Method applied to the power cross derived in Plano +2.00 × 120 and Plano – 2.25 × 30
Fig. 19
(convert first lens to minus cylinder and second lens to
plus cylinder)
−4.25D lens is acting at the 80-degree meridian. We can use +2.00 − 2.00 × 30 and −2.25 + 2.25 × 120
this information to draw our PC (Fig. 21). (then add either pair of lenses in the same axis
We can then use the DAM to determine the eyeglass pre- notation)
scription (Fig. 22). Eyeglass prescription: −2.25 + 4.25 × 120 OR
+2.00 − 4.25 × 30.
1. Choose −4.25D as the starting sphere. Note: This may also be written as: “−2.25 with
2. Then we have to draw an arch to +2.00 and ask ourselves, +4.25 × 120” OR “+2.00 with −4.25 × 30”. This notation
“How much do we have to add/subtract to −4.25 to get to is a slightly archaic way of speaking about an eyeglass
+2.00?” In this case, it would be +6.25D, which is the prescription, but we will mention it here if it ever shows
cylinder of the eyeglass prescription. up unexpectedly on an examination.
3. Then draw a second arch to yield the axis of the eyeglass B. PC Notation: We know that the +2.00D acts at the 30-degree
prescription (80). meridian and the −2.25D acts at the 120-degree meridian.
4. The final prescription would be: −4.25 + 6.25 × 80. We can generate our PC and use the DAM (Fig. 23).
Fig. 21 Power cross drawn +2.00

Streak 080°
from the streak refraction s 080
°
results used to obtain SC
notation lenses in the example –4.25
from Fig. 9. Notice how the Streak
s
PC will differ from the SC 170°
notation in its setup but
should still yield the same 170°
result
+2.00
- 4.25
080°
2nd 2nd 120°
030°
170°
+2.00
+2.00
1st
–2.25
–4.25
1st
Fig. 22 The Double Arches Method can be applied to the power cross
derived in Fig. 21 Fig. 23 The Double Arches Method can be used on the generated
power cross to determine the final eyeglass prescription
Eyeglass prescription: −2.25 + 4.25 × 120

OR + 2.00 − 4.25 × 30 unfortunately not useful for calling for help to escape the
C. Eyeglass Prescription Inferno). Note that this method may need to be renamed in a
1. Same with either method! Both should yield few years because no one uses telephones shaped like this
−2.25 + 4.25 × 120 (plus cylinder) or +2.00 − 4.25 × 30 anymore!
(minus cylinder). Factor in the working distance as When given a starting prescription, the Telephone Method
needed. can be used as follows:
Finally, we can also use a given eyeglass prescription to 1. Write the given prescription in the opposite cylinder for-
generate a power cross. There is not much usefulness in mat. Thus, write out the minus cylinder format directly
doing this (other than to maybe generate streak refraction underneath if we are given the prescription in plus cylin-
results as a working point to titrate a streak refraction fur- der format.
ther). However, if we were ever asked to do this, the 2. Then draw a “telephone shape” around the sphere and
“Telephone Method” can be used (to derive power crosses, axis values ONLY. Ignore the cylinder values at this time.
134 K. M. Riaz
Fig. 24 If given an eyeglass

prescription, we can use the
Telephone Method to derive a
power cross. This method
involves drawing a telephone
shape around the sphere and
axis values to generate the
power cross. A visual
representation of an “ancient”
telephone has been added for
those readers born after the
year 1990
3. Think of this “telephone shape” between the sphere and not use the DAM to determine the final eyeglass prescription.
axis as the lines of the power cross. Remember, the DAM can only be used for power crosses.
We can do one quick example and move on:
For example, if we are given a starting prescription of Suppose we perform streak retinoscopy on a patient and
−1.50 + 2.50 × 180 (Fig. 24): obtain the following results: a +1.50D streaks the 180° and a
+4.00D streaks the 90°. We will ignore working distance.
1. Start by first writing out the minus cylinder format The critical difference in drawing the axis cross is that we
directly underneath: +1.00 − 2.50 × 90. do not have to flip the streak refraction results. We can basi-
2. Then draw two telephone shapes around just the sphere cally use the SC notation “lenses” as the connections of the
and axis values. These can be connected to make the axis cross (Fig. 25). We have also drawn a power cross next
power cross. to the axis cross for comparison purposes.
3. Now we can draw the power cross. If we choose to use an axis cross, we can still start by
4. Finally, you can use the DAM to check your work and see choosing either sphere as our starting sphere lens. We can
if you can get back to the starting prescription. If we have also ask ourselves our familiar question: “how much do we
made the power cross correctly, we should be able to get have to add/subtract to this lens to get to the other?” In this
back to our starting prescription. case, suppose we chose +1.50D as our starting lens. We
would have to add +2.50 to get to +4.00; therefore, the
+2.50D becomes our cylinder. Now we have to choose our
axis, and here is the crucial difference when using an axis
Axis Cross cross as compared to a power cross: instead of swinging
over to “180” as our axis with a “double arch”, we must
If you have thus far understood SC notation and PC notation remain in the +2.50D axis, which is “90”. In other words,
and do not want to confuse yourself any further, feel free to we do not make a second arch as we do with our power
skip ahead to the next section. However, if you want to learn cross.
of a potential third road that can lead you out of Inferno, then Using the axis cross, our prescription would be:
read on to learn about the axis cross. Admittedly, this method +1.50 + 2.50 × 90.
is not as popular or common, but it can still be used to derive Note that we can use our PC notation as described in the
an eyeglass prescription. previous section, generate our familiar PC, and use the DAM
The advantage of an axis cross (compared to a power to get the same eyeglass prescription (right panel of Fig. 19).
cross) is that we can take the streak refraction results and Most people do not like axis crosses. Again, you do not
draw an axis cross without having to “cross-up” the streak have to work in axis cross notation if you do not understand
results. However, if we choose to draw an axis cross, we can- it. Just find any road to get out of Inferno.
Fig. 25 Axis cross versus

power cross. Streak refraction +4.0 +1.50
results can be used to set up
the axis cross without having
to flip the results. Note that
the DAM cannot be used with
an axis cross
+1.50 180° +4.0 180°
90° 90°
Axis Power
cross cross
eratometry Readings and Eyeglasses

K For example, if we are given keratometry readings pre-
Prescriptions sented with a slightly different notation: 41.50 @ 30 and
44.50 @ 120,12 we can understand these readings as
As we started off the chapter discussing keratometry read- follows:
ings, we can return briefly to this topic to discuss a few addi-
tional details, especially when using these measurements to • The 41.50 @ 30 is the little brother. The 44.50 @ 120 is
generate eyeglass prescriptions. Note that this is not very the big brother. In this case, the big brother is stronger
clinically useful since it assumes all of the refractive astig- than the little brother by 3 D.
matism is contained within the keratometric astigmatism, but • In order to help the little brother, we need to give “him”
this may come up on exams. +3D of cylinder power.
One way to look at keratometry readings is to imagine • We have to place +3D of cylinder IN the steep meridian
that the flat meridian is the “little brother” and the steep (120°) so that it ACTS AT the flat meridian (30°).
meridian is the “big brother”. The little brother is weaker • This “helping cylinder” lens can be written as:
than the big brother. A plus-cylinder lens will give the little +3.00 × 120; the AM is the 120-degree meridian, and the
brother additional power to equal the big brother. Similarly, PM is the 30-degree meridian.
a minuscylinder lens will weaken the big brother to equal the • Alternatively, you could choose to work in minus cylinder
little brother. notation and would need −3D to weaken the big brother.
For example, if we measure a patient’s cornea and the In this case, we could place the −3D of cylinder IN the
keratometry readings are: 43.00 × 45.00 @ 95, the flat merid- flat meridian (30°) so that it ACTS AT the steep meridian
ian (5°) is the little brother, and the steep meridian (95°) is (120°) to weaken it.
the big brother. Now we can ask ourselves: “How much
“help” should we give the little brother, using plus cylinder, If we were asked to dispense an eyeglass prescription to
to equal the stronger big brother?” Since the lower keratom- correct this keratometric astigmatism while maintaining a
etry value needs cylinder “help”, we need to place the plus spherical equivalent of plano, the dispensed prescription
cylinder IN the steep meridian so that it ACTS AT the flat would be:
meridian. In other words, the cylinder’s axis meridian (AM)
has to be parallel to the steep meridian; this will make the
power meridian (PM) parallel to the flat meridian. Remember,
somewhat confusingly, light rays that pass through this Note in this presentation the flat meridian has also been indicated. In
12
the first example, an abbreviated form was used wherein the flat merid-
cylindrical lens will form a line at the AM. ian can be deduced as 90° away from the steeper meridian.
136 K. M. Riaz
Plus Cylinder: − 1.50 + 3.00 × 120 ( or Minus Cylinder: + 1.50 − 3.00 × 30 ) .

We can do another example. If we are given keratometry We can compare the prismatic effect of spherical lenses
values of 42.50 @ 45 and 44.50 @ 135, what is the power of and spherocylindrical lenses at different locations from the
the glasses that we must dispense to maintain a spherical optical center. It is important to note a −5D sphere lens will
equivalent (SE) of −1.00D? have −5D power at all locations when measured with a lens-
meter, but the prismatic effect will be different based on the
• First, identify the little brother (42.50 @ 45) and the big distance from the optical center. For example, Fig. 26 shows
brother (44.50 @ 135). In this case, the big brother is the prismatic effects of a −5D lens when measured in the
stronger than the little brother by 2D. center of the lens as compared to its inferior portion. Notice
• In order to help the little brother, we need +2.00D to be the increasing prismatic power when the lens is measured
placed IN the 135-degree (steep) meridian so that it ACTS at an increasing distance away from the optical center.
AT the 45-degree (flat) meridian: +2.00 × 135. Figure 27 shows a +5D lens with similar increasing prism
• Finally, since we have to maintain the SE of −1.00D, we power when measuring away from the optical center.
have to add additional minus sphere power: Figure 28 shows a spherocylindrical lens (−3.00 +2.00 × 90)
−2.00 + 2.00 × 135 (or: plano – 2.00 × 45). that has the same power throughout the lens, but the pris-
matic effect will be asymmetrical.
Some helpful rules are as follows:
rentice’s Rule, Part II: Spherocylindrical
P
Lenses • Cylinder power placed in the 90-degree axis meridian will
have an effect AT the 180-degree power meridian and
Previously, on “Prentice’s Rule” (see Chap. 2, “Prisms in therefore only play a role if the patient looks to either side
Ophthalmic Optics”), a show that no streaming provider has (left or right) of the optical center.
picked up for a second season, we discussed how this rule –– Ex: −5.00 + 1.75 × 90 = when looking up and down,
applies to the change in the functional power of a lens when only the −5D has “prism power”. So, if a patient looks
one looks away from the optical center. Remember that vertically away (up and down) from the optical center
Prentice’s Rule states that this change can be calculated of this lens, it basically functions as a −5D lens.
using the formula: P = h *D, where h is the distance (in cen- • Cylinder power placed in the 180-degree axis meridian
timeters) from the optical center of the lens, and D is the will have an effect AT the 90-degree power meridian, and
power of the lens. In the previous discussion, all of our therefore only play a role if the patient looks up or down
examples only used spherical lenses. In this section, we will relative to the optical center.
discuss how to use Prentice’s Rule when we are given sphe- –– Ex: −5.00 + 1.75 × 180 = when looking left and right,
rocylindrical lenses. only the −5D has “prism power”. So, if a patient looks
horizontally away from the optical center of this lens,
it basically functions as a −5D lens.
I ncorporating Cylinder Power Based on Gaze
Position Notice that we are conveniently only considering the
sphere power in a chosen gaze direction in each of these
For example, if we are given an eyeglass prescription: examples. However, if the patient looks horizontally or verti-
−3.00 + 2.00 × 180: cally, respectively, we have to account for the cylinder power
This means that +2.00D cylinder power will be placed IN in each of the previous two examples. When considering the
the 180-degree axis meridian in order to act AT the 90-degree cylinder effect at these gaze positions, we can convert the
power meridian. eyeglass prescription from plus cylinder to minus cylinder
With Prentice’s Rule problems dealing with spherocylin- notation and then apply the new “sphere” value to the new
drical lenses, we have to determine the net “prism power” at “axis meridian” to determine how much power is present.
a given meridian, considering the cylinder present. The key Using our two examples from above:
question is, when given a spherocylindrical lens, when must
we incorporate the cylinder power? • For the −5.00 + 1.75 × 90 lens, we can convert to minus
Depending on which part of the lens the patient is “look- cylinder: −3.25 − 1.75 × 180. Therefore, if a patient looks
ing through”, we must account for the cylinder (if present) in to the right and left of the optical center of this lens, it
that gaze position. would basically function as a −3.25D prism lens.
0 prisms
3 base down
10 base down
Fig. 26 How much prism power do different parts of a −5D lens have? ing base-down prism measured. The prismatic effect of the lens
There is no prismatic effect at the center of the lens (left panel). When increases linearly as we increase the distance from the optical center
measuring inferior to the optical center (right panel), there is an increas-
• For the −5.00 + 1.75 × 180, we can convert to minus cyl- (a) If we look 10 mm below the optical center
inder: −3.25 − 1.75 × 90. Therefore, if a patient looked (b) If we look 10 mm temporal to the optical center
vertically up and down relative to the optical center of this
lens, it would basically function as a −3.25D prism lens. If we first look 10 mm below the optical center:
When doing the following problems, it may help to con- • When looking vertically up and down, ONLY the +2.75D
vert between plus cylinder and minus cylinder notation to get is having an “effect” because +1.75D is acting at the
the desired “axis” of the eyeglass prescription depending on 180-degree meridian.
the gaze position. Usually, for these problems, cylinder nota- • We can safely ignore the +1.75 cylinder and draw out our
tion will likely be in 90-degree or 180-degree form, and the “functional lens” as a simple +2.50D in downward gaze
patient will be looking horizontally or vertically. Other (Fig. 29).
degree notations and gaze positions will require vector addi-
tion (and calculators) and will not likely be tested on We can use our familiar Prentice’s Rule equation, remem-
examinations. bering to convert 10 mm to 1 cm: P = hD = 1 cm × 2.5D = 2.5
prism diopters BU.
Now if we look 10 mm temporal to the optical center with
Additional Examples the right eye:
Example #1 • Because we are looking to the side, cylinder power placed

If we are given a right eye lens with a prescription of in the 90-degree meridian will have an effect at the
+2.50 + 1.75 × 90, what is the induced prismatic effect in 180-degree meridian (nasal and temporal gaze), and we
each of the following circumstances? must account for this “prism power”.
138 K. M. Riaz
0 prisms
4 base up
10 base up
Fig. 27 How much prism power do different parts of a +5D lens have? prism is measured. The prismatic effect of the lens increases linearly as
There is no prismatic effect at the center of the lens (left panel). When we increase the distance from the optical center
measuring inferior to the optical center (right panel), increasing base-up
• We can convert to minus cylinder so that we have a new First off, why are wasting time looking off-center on a
“sphere” power to deal with: Minus pair of glasses when we are nearly out of Inferno? Second,
cylinder = +4.25 − 1.75 × 180. let us go ahead and solve this problem anyway.
• We can safely ignore the –1.75D cylinder and realize that Only the –1.5D has to be accounted for in inferior gaze
this lens will basically function as a +4.25D lens when because the +5.00D is placed in the 90-degree meridian and
looking temporally to the optical center. This “new lens” will only have power at the 180-degree meridian.
can be drawn out as Fig. 30.
• In inferior gaze, only the −1.5D has an effect: we can
We can use Prentice’s Rule once more: draw these as two minus lenses with the green dots repre-
P = hD = 1 cm × 4.25D = 4.25 prism diopters BI. Note that senting where we are looking relative to the optical center.
drawing out this lens can help from wrongly thinking there is This will immediately show us a BASE DOWN effect
a base-out effect. We are nearly out of the Inferno, so we do present (Fig. 31). Now we can use our Prentice’s Rule
not want to make any mistakes. equation.
Example #2 • P = hD = 0.8 × 1.5D = 1.2 prism diopters base down.

If we are given a pair of glasses with the same prescription • There is no net prism effect because both eyes have moved
(−1.50 + 5.00 × 90) in each lens, what is the net induced “down”.
prism:
In temporal gaze, if we look 12 mm temporal to the opti-
(a) When we look 8 mm inferior to the optical center (in cal center of this pair of glasses (imagine that the pupillary
each eye) distance of the glasses is much too small for our face), we
(b) When we look 12 mm temporal to the optical center (in can determine the net prismatic power:
each eye)
+ =
x
x
3 base 1 base left

0 prisms down
Fig. 28 How much prism power do different parts of a −3.00 + 2.00 × 90 center of the lens (bottom left panel). The bottom-middle panel shows
lens have? The top panels show a −3.00D sphere lens (blue) combined 3 PD base-down prismatic effect 1 cm inferior to the optical center. The
with +2.00D cylinder lens (green) that has power and prismatic effect bottom right panel shows 1 PD prismatic effect base left 1 cm to the left
along the 180-degree meridian. There is no prismatic effect through the of the optical center
OD OD
+4.25D
Fig. 30 In temporal gaze of the right eye, the +2.50 + 1.75 × 90 lens
will now incorporate the cylinder power and function as a +4.25D lens
• First, figure out how much effect is AT the 180-degree

meridian by converting to minus cylinder:
−1.50 + 5.00 × 90 = +3.50 − 5.00 × 180.
• This conversion means there is +3.50D having an effect at
+2.50D the 180-degree meridian; when we look temporal to the
Fig. 29 In downward gaze, the +2.50 + 1.75 × 90 lens will function as
optical center, we can simplify this spherocylindrical lens
a simple +2.75D spherical lens as a simple +3.50D lens for both eyes (Fig. 32). Notice
that this “minus” lens now functions as a “plus lens” in
horizontal gaze. Now we can use Prentice’s Rule:
140 K. M. Riaz
Fig. 31 In downwards gaze, OD OS

this spherocylindrical
(−1.50 + 5.00 × 90) lens will
function as a −1.50D lens
–1.50D –1.50D
OD OS that incoming light rays will get refracted by the steeper por-
tion of the lens (in this case, the horizontal meridian [power
meridian]) and first form a vertical focal line parallel to the
axis meridian. Incoming light rays that get refracted by the
flatter portion of the lens (in this case, the vertical meridian)
will later form a horizontal line parallel to that axis meridian.
+3.50 +3.50D
However, there are several other shapes and figures formed:
after light rays are refracted by and exit the lens, the following
Fig. 32 This lens will function as a +3.50D lens in temporal gaze. Note lines and shapes ensue, in sequential order:
that both eyes are moving toward the nose (opposite directions)
• Converging light rays (immediately behind the lens)
• P = hD = 1.2 cm × 3.5 = 4.2 prism diopters base in OU. • Vertical focal line
• Net induced prism: 4.2 + 4.2 = 8.4 PD BI. • Vertical oval
• Both eyes move nasally, so an esotropia is induced. • Circle (aka the COLC)
• Horizontal oval
Bonus Wrinkle: what if the question had asked how much • Horizontal focal line
prism would we have to dispense to counteract these glasses’ • Diverging light rays
induced prismatic effect? We would have to place 8.4 PD BO
(rounded to 8.5 PD BO) in either the right or left eye The COLC is basically the halfway point (circular cross-
section) between the two focal lines on the COS (in terms of
diopters, not distance); in practical terms, this is the smallest
The Conoid of Sturm and Circle of Least blur spot (i.e., the “clearest” image) that a spherocylindrical
Confusion lens can make. It is a compromise between the sphere and
cylinder components of a spherocylindrical lens. Thus, we can
One last “circle” to get through before we can escape Inferno: also think of the COLC as the spherical equivalent. Notice
the Conoid of Sturm (COS) and the resulting (and ironically that the COLC may be closer to one of the focus lines. Again,
named) “circle of least confusion (COLC)”. it is NOT the average distance between the two focal points!
We can start with the COS (Fig. 33). The COS is a three- This concept is understandably difficult without visual-
dimensional asymmetrical trumpet shape that we represent as ization, especially in three dimensions. The following exam-
a two-dimensional ray-tracing formed as light passes through ples will hopefully reinforce this discussion.
a (sphero)cylindrical lens. To simplify our discussion, imagine
that we have a spherocylindrical lens oriented like a vertical Example #1 Suppose we have a lens with power
football. From our earlier discussions in this chapter, we know +3.00 + 2.00 × 180. What is the orientation of the first line of
c
a b
Fig. 33 The conoid of sturm can be used to indicate the figure formed COLC is formed at the halfway point, B (in terms of diopters, not dis-
by converging light rays refracted by a spherocylindrical lens. Each tance), between these two focal lines. Converging light has an ovoid
power meridian of the lens forms two sharp focal lines (A and C). The shape between each focal line and the COLC
+3.00 + 2.00 × 180
D= +5D
U= 0 D V2= +5D
D= +3D
U= 0 D V1= +3D
20 cm 25 cm 33 cm
COLC
Fig. 34 Light rays that pass through a +3.00 + 2.00 × 180 spherocylindrical lens will first form a horizontal line at 20 cm (+5D) and then a vertical
line at 33 cm (+3D). The COLC is formed at the halfway point of the diopters (+4D), corresponding to 25 cm right of the lens
focus? Where is the COLC? What is the orientation of the est. Remember that at 20 cm, all the horizontal lines from the
second line of focus? source object will be in perfect focus, but none of the vertical
We can turn to our friend (or enemy), the power cross, to lines will be in focus; similarly, at 33 cm, all the vertical lines
help make this problem a bit easier. Using the spherocylin- will be in perfect focus, but none of the horizontal lines will
drical lens power, we know that this lens has +3D of power be in focus. The COLC is the spot where there is a compro-
acting at the 180-degree meridian and +5D of power acting mise between the vertical and horizontal focus lines.
at the 90-degree meridian. Why is this relevant? Suppose you find yourself on a med-
Light rays that pass through the +5D portion of the lens ical mission trip and a patient with astigmatism needs a pair
(vertical meridian, aka the power meridian) will form a hori- of glasses. Unfortunately, if you only have spherical glasses
zontal line at 100/5 = 20 cm (horizontal meridian, aka the left, then a lens with the spherical equivalent similar to the
axis meridian). Similarly, light rays that pass through the patient’s refraction may be a reasonable option.
+3D portion of the lens (horizontal meridian, aka the power Finally, note that we cannot simply take the average of the
meridian) will form a vertical line at 100/3 = 33 cm (vertical focal points to find the COLC: 20 cm + 33 cm = 53/2 = 26.5 cm.
meridian, aka the axis meridian). The COLC will therefore This approach is incorrect. The COLC is the halfway point in
be determined by the spherical equivalent: terms of diopters, not distance.
+3 + (1/2 * 2) = +4D. The focal point is 100/4 = 25 cm to the
right of the lens (Fig. 34). Example #2 Suppose we place an object 100 cm away from
The horizontal and vertical focal lines will be “equally a spherocylindrical lens with the following power:
blurry” at this location, and thus the image will be the sharp- +2.00 + 3.00 × 180. Where is the COLC?
142 K. M. Riaz
By now, we should know that this lens will function like a rotating the slit in all meridians, we can find the “least lousy”
+ 2.00D at 180° and +5.00 at 90°. Unlike the previous problem, meridian. Compared to the previously mentioned streak
we have incoming light from a finite distance of 100 cm to the refraction, the primary difference with the stenopeic slit
left of the lens.13 This means that since u = −100 cm, U = −1 technique is that the results are transcribed directly in the
(divergent light). Therefore, we have to use U + D = V twice: meridian of the slit to generate a power cross. We understand
that this entire paragraph is confusing, so an example will
−1 + 3 = +2D at 180 ,
hopefully help explain this technique further. For example,
which will create a suppose we placed the stenopeic slit in the 80-degree posi-
vertical line 50 cm to the right tion with a –3.00D sphere. The patient indicates that the

image is still blurry, so we rotate the slit in 10-degree incre-
−1 + 5 = +4D at 90 , ments in both directions until the patient states that the image
which will create a is in the best focus. Suppose the patient says the clearest
horizontal line 25 cm to the right. image is in the 127-degree meridian with the –3.00D lens;
after all, we are dealing with irregular astigmatism. We can
We may be tempted to say that the COLC is the halfway now rotate the slit 90 degrees away to the 37-degree merid-
point between 25 cm and 100 cm, 62.5 cm.14 But we would ian. Suppose now the patient says the clearest image is
be stuck in this last circle of the Inferno because we instead formed with a +4.50D lens. We can interpret our tomfoolery
need to use the spherical equivalent (SE) to calculate the with the steonpeic slit as follows: –3.00D @ 127 and +4.50
COLC (Fig. 35). @ 37. We can construct our power cross such that the –3.00D
is connected to 127-degrees and +4.50D is connected to
The SE of this toric lens is 2 + (1 / 2∗3) = +3.50D. 37-degrees. Now we can use the DAM to get the final refrac-

tion: –3.00 + 7.50 x 127. We do not adjust the working dis-
We can “re-run” the object rays through this lens using tance since we did not perform any streak refraction.
the SE to calculate the COLC. Note that a horizontal oval
will form in between the horizontal line at 25 cm and the
COLC, and a vertical oval will form in between the COLC Practice Questions
and the vertical line at 100 cm:
1. Suppose you are given two cylindrical lenses: +2.50 × 90
−1 + 3.50 = +2.50, 100 / 2.50 = 40 cm. The COLCis
and +1.00 × 180. Express the combined power of these

located 40 cm to the right of the lens. lenses as a spherocylindrical lens.
Congratulations! We have escaped the Inferno (for now). 2. Suppose you perform streak refraction on a patient and
We can finish up with some practice questions and tell the obtain the following results: with the retinoscope streak
stories of our adventures to future generations. positioned vertically and moved horizontally, the reflex
was neutralized with a −6.00 D sphere (“A −6D lens
streaks the 90 degree”). With the streak positioned hori-
Stenopeic Slit zontally and moved vertically, the reflex was neutralized
with a −3.50 D sphere (“A −3.50D lens streaks the 180
Note to the reader: we freely admit that this is a low-yield degree”). Assume your working distance is 50 cm. What
topic, mainly a relic of older textbooks. The stenopeic slit is is the final prescription to be dispensed?
an opaque trial lens with an elongated slit aperture that can 3. If you perform streak refraction on a patient and obtain
be used to find a spherocylindrical refraction. This lens is the following results: a + 5.50D lens streaks the 135°,
likely gathering dust in a drawer in your exam lane. This and a + 2.00D lens streaks the 45°. Assume a working
technique may be helpful in patients with small pupils, len- distance of 67 cm. What is the final prescription?
ticular opacities, and irregular corneal surface (irregular 4. If you perform streak refraction on a patient and obtain
astigmatism). The examiner can place a spherical lens the following results: a − 5.00D lens streaks the 150°,
(minus- or plus-power) with the stenopeic slit in front of the and a + 1.00D lens streaks the 60°. Assume a working
patient’s eye. The slit will minimize refractive blur in the distance of 67 cm. What is the final prescription?
meridian perpendicular to the slit, allowing the examiner to
neutralize the refractive error in the meridian of the slit. By
Strictly speaking, we were using the U + D = V equation in example 1

13
as well, but since the incoming light was originating at infinity, U = 0.
One can be fairly certain that such an answer would be given as a
14
“distractor” answer choice on exams.

Fig. 35 Divergent light rays originate from a source object located vertical line at 100 cm (+1D). The circle of least confusion is formed at
100 cm to the left of a +2.00 + 3.00 × 180 spherocylindrical lens. These the halfway point of the diopters (+2.5D), corresponding to 40 cm right
light rays will first form a horizontal line at 25 cm (+4D) and then a of the lens
5. Draw the Power Cross for the following manifest 10. Using the above example, what would be the net pris-
refractions: matic effect if the pupillary distance was changed to
(a) −2.50 + 1.50 × 90 50 mm?
(b) −6.00 + 2.00 × 180 11. If a patient wears glasses with the following prescription
(c) −10.00 + 3.50 × 45 (−2.50 + 3.50 × 90) in both eyes, how much prismatic
(d) +4.25–2.75 × 20 correction must be dispensed in order to balance possi-
6. If a patient has keratometry readings of 38.50 × 41.50 ble diplopia if:
@ 60, prescribe a pair of glasses that will neutralize (a) The patient looks 6 mm inferior to the optical center
this astigmatism while maintaining a spherical equiv- (in both eyes)
alent of plano. Assume there is no lenticular (b) The patient looks 10 mm nasal to the optical center
astigmatism. (in both eyes)
7. If a patient has keratometry readings of 45.25 × 47.75 @ 12. Suppose that a monocular patient’s refraction in the right
25, prescribe a pair of glasses to neutralize her astigma- eye was −4.00 + 2.00 × 180 prior to cataract surgery. Due
tism while maintaining a spherical equivalent of −2.50. to an error in IOL calculations, the patient ended up with
Assume there is no lenticular astigmatism. postoperative refraction of +2.00 + 2.00 × 90 (hyperopic
8. A light source falls on a spherocylindrical lens with surprise). If this patient was orthoptic in the reading posi-
unknown power. A line is formed at 60° on a screen tion, read 10 mm below the optical center prior to surgery,
placed at 20 cm right of the lens. When the screen is and continues to read 10 mm below the optical center
moved to 33 cm, the line is now at 150°. after the surgery, how much of a postoperative prismatic
(a) At what distance is the circle of least confusion seen deviation is now present? How can you correct this
on the screen? induced prismatic deviation? (The patient adamantly
(b) What is the power of the unknown lens? refuses any further surgery).
9. If a patient wears the following prescription: 13. A cyclopleged 30-year-old patient looks at an Amsler
OD : + 4.00 + 1.50 × 180 grid located 50 cm away. He notices that the vertical
lines are focused sharply when a + 3.00D sphere is held
OS : + 2.50 + 2.50 × 90 in front of the eye, and the horizontal lines are focused

sharply when a + 5.50D sphere is used. What is the dis-
and the original pupillary distance put into the glasses tance correction that should be given to this patient?
is 60 mm, what is the net prismatic effect in horizontal 14. Given a prescription of: −4.00 + 1.00 × 90
gaze if the patient’s actual pupillary distance was (a) Express this prescription in minus cylinder form
70 mm? (b) Draw the power cross for this lens
144 K. M. Riaz
(c) Express the lens power using SC notation lenses

(d) Draw the axis cross for this lens +1.00
(e) What would your streak refraction results be if you
were an emmetrope and had a working distance of
50 cm?
15. A spherocylindrical lens of unknown power refracts

light originating from a source located at infinity. A line
is formed at 45° on a screen placed 25 cm to the right of
this lens. A second line is formed at 135° when the
screen is moved to 67 cm to the right of this lens.
(a) At what distance is the circle of least confusion seen
on the screen? +2.50 180°
(b) What is the power of this spherocylindrical lens?
Answers
1. Answer: We can use either SC notation or power crosses

to calculate the final power.
SC Notation Method
+2.50 × 90 = plano + 2.50 × 90 = +2.50 − 2.50 × 180

90°
+1.00 × 180 = plano + 1.00 × 180 = +1.00 − 1.00 × 90
Fig. 36 Power cross and double arches method for practice question
Algebraically combine either the “90” or “180” #1
lenses. Let us choose the “90” lenses:
Plano + 2.50 × 90
to +2.50D (first arch). Then we draw our second arch to 90
+1.00 − 1.00 × 90 (which will become our axis). The final prescription will be:
================ +1.00 + 1.50 × 90, which is the same result we calculated
+1.00 + 1.50 × 90 using SC notation. We can do the same exercise using +2.50D
as our starting lens. Using the DAM, we would get a minus
If we choose the “180” lenses: cylinder prescription of: +2.50–1.00 × 180.
2. Answer: We can use either SC notation or power crosses
Plano + 1.00 × 180
to calculate the final prescription. Remember that we
+2.50 − 2.50 × 180 need to an additional −2.00D of sphere in order to com-
================= pensate for the working distance.
+2.50 − 1.50 × 180
SC Notation : −6.00 × 90 and − 3.50 × 180

Notice that we could have also derived either result −6.00 × 90 = plano − 6.00 × 90 = −6.00 + 6.00 × 180

by simply converting the first result (in plus cylinder)
−3.50 × 180 = plano − 3.50 × 180 = −3.50 + 3.50 × 90
into minus cylinder and vice versa.
PC Notation Suppose we chose to combine our two “lenses” that
From the cylindrical lens given above, we know that are currently in the 180-degree axis notation:
the +2.50D lens is exerting its power at the 180-degree
−6.00 + 6.00 × 180
meridian, and the +1.00D lens is exerting its power at
the 90-degree meridian. Plano − 3.50 × 180
We can draw the power cross and use the double =================
arches method (DAM) (Fig. 36). −6.00 + 2.50 × 180
If we select +1.00D as our “starting sphere lens”, we will
have to “add +1.50” (which will become our cylinder) to get
in our working distance (additional -2D):

−5.50 – 2.50 × 90.
Add additional − 2D for working distance : −8.00 + 2.50 × 180 We can do the same exercise using −6.00 as our
“starting sphere lens”. Using the double arches method,
If we had used our other two lenses in 90-degree axis we would get a plus cylinder prescription of
notation: −6.00 + 2.50 × 180. We still have to factor in our work-
ing distance (additional -2D): −8.00 + 2.50 × 180.
−3.50 + 3.50 × 90
If we have done our math/drawings correctly, the
Plano − 6.00 × 90 final prescription should be the same regardless of our
================ chosen method.
−3 .50 − 2 .50 × 90 3
. Answer: We can again use either method. Let us do this
question using only SC notation (we will do the next one
only using a power cross).
Add additional − 2D for working distance : −5.50 − 2.50 × 90
SC Notation : +5.50 × 135 and + 2.00 × 45
PC Notation: We know that the −6.00D lens is exert-
ing its power at the 180-degree meridian and the −3.50D +5.50 × 135 = plano + 5.50 × 135 = +5.50 − 5.50 × 45
lens is exerting its power at the 90-degree meridian. We +2.00 × 45 = plano + 2.00 × 45 = +2.00 − 2.00 × 135

can use this information to draw the power cross and use
the DAM (Fig. 37). Suppose we chose the two “lenses” currently listed in
Suppose we chose −3.50 as our “starting sphere lens”, the 45-degree notation:
we will have to “subtract −2.50” (which will become our
cylinder to get to −6.00 (first arch)). Then we draw our sec- +5.50 − 5.50 × 45
ond arch to 90 (which will become our axis). The final pre- Plano + 2.00 × 45
scription will be: −3.50 – 2.50 × 90. We still have to factor ================
+5.50 − 3.50 × 45
Factor in working distance (67 cm), so additional

−1.5D: +4.00 – 3.50 × 45.
–3.50
Suppose instead we chose the two “lenses” currently
listed in the 135-degree notation:
+ 2.00 − 2.00 × 135

Plano + 5.50 × 135
================
+ 2.00 + 3.50 × 135
Factor in working distance (67 cm), so additional

–6.00 180° −1.5D: +0.50 + 3.50 × 135.
Note that if we have done our math correctly, either
final prescription should yield the other final prescription
if we flip between plus or minus cylinder notation.15
4. Answer: We can use power cross notation to solve this
problem.
We know that the +1.00D lens is exerting its power at
the 150-degree meridian; the −5.00D lens is exerting its
power at the 60-degree meridian. We can draw a power
cross that establishes this relationship and then use the
Double Arches Method (Fig. 38).
90°
#2 If you are feeling adventurous, you can try to solve this question using
15
power crosses and should get the same answer.

146 K. M. Riaz
so that it acts at the 150-degree meridian (power merid-

60°
ian): +3.00 × 60.
In order to maintain a spherical equivalent of plano, we
will have to add −1.50D sphere. The final prescription
150°
will be: −1.50 + 3.00 × 60.
7. Answer: We should notice a 2.50D difference between
the two meridians (115 and 25). The 25-degree meridian
is the steep meridian (“big brother”). The 115-degree
meridian is the flat meridian (“little brother”).
In order to help the little brother, we will need to place
+2.50D in the 25-degree meridian (axis meridian) so that
it acts at the 115-degree meridian (power meridian):
+1.00 +2.50 × 25.
In order to maintain a spherical equivalent of −2.50,
we will need to add −3.75D sphere to the final prescrip-
–5.00
tion, yielding: −3.75 + 2.50 × 25.
8. Answer: This question requires us to put together several
topics we have learned thus far. Our knowledge of power
crosses will help us arrive at the correct answer.
First, we know that the lens focuses light at 20 cm at
#4 60°. This means there must be +5D of power (100/20 = +5D)
placed in the 60° meridian (axis meridian) which is exert-
ing its effect at the 150° meridian (power meridian), which
Our prescription from the power cross is: in turn forms a line at 60°. When we draw the power cross,
−5.00 + 6.00 × 60. Alternatively, we could use +1.00 as the +5.00D should be linked to the 150°.
our starting lens, and we would then get: Next, we also know that the lens focuses light at 33 cm at
+1.00–6.00 × 150. 150°. This means there must be +3D of power (100/33 = +3D)
Now factor in the additional −1.5D sphere for the placed in the 150° meridian (axis meridian) which is exert-
working distance: −6.50 + 6.00 × 60. For minus cylinder: ing its effect at the 60° meridian (power meridian), which in
−0.50 – 6.00 × 150. Again, this is a lot of cylinder so turn forms a line at 150°. When we draw the power cross,
make sure we are not missing a corneal ectasia! the +3.00D should be linked to the 60° (Fig. 40).
5. Answer: For each of these prescriptions, we can use the The circle of least confusion (COLC) is the average of
Telephone Method after converting to the opposite cylin- these two powers: 3 + 5 = 8; 8/2 = +4D. The focal length
der notation: distance for +4D is 25 cm. Therefore, the COLC will be
(a) −2.50 + 1.50 × 90 = −1.00 – 1.50 × 180 located at 25 cm.
(b) −6.00 + 2.00 × 180 = −4.00 – 2.00 × 90 For the second part of the question, we can use the
(c) −10.00 + 3.50 × 45 = −6.50 – 3.50 × 135 above information to draw the power cross (Fig. 41).
(d) +4.25–2.75 × 20 = +1.50 + 2.75 × 110 If we choose +3.00 as our starting lens, then when we
Now we can use the telephone method by connecting draw our first arch to the +5.00, we must add +2.00 (which
the sphere and axis of each prescription and setting these will be our cylinder). Then we can draw our second arch
are our four positions of the power cross. over to the 60, which will be our axis. The power of the
The resulting power crosses can be seen in Fig. 39. unknown spherocylindrical lens is: +3.00 + 2.00 × 60 (or
We can check our work using the DAM for each power minus cylinder: +5.00–2.00 × 150).
cross and make sure that we can get back the original Alternatively, we could have used SC notation based
prescriptions. on the question stem with the following “starting lenses”:
6. Answer: We should notice there is a 3D difference
+5.00 × 60 and + 3.00 × 150. We should get the same
between the two meridians (60 and 150). The 60-degree answer.
meridian is the steep meridian (“big brother”). The 9. Answer: To make our lives a bit easier, we need to get
150-degree meridian is the flat meridian (“little both lenses with the same axis notation, regardless of
brother”). whether it is in minus or plus cylinder notation. We can go
In order to help the little brother, we will need to place ahead and change the OS lens to 180-degree notation so
+3D of cylinder in the 60-degree meridian (axis meridian) that we can convert it to minus cylinder:
Fig. 39 Power crosses for 90°

practice question #5. Panels
a b 90°
A-D correspond to the
answers for Practice Question
5, A-D
180° –1.00 –6.00 180°
–2.50 –4.00
c d 110°
020°
135° 045°
+4.25
+1.50
–10.00 –6.50
Unknown lens Screen Screen
20 cm
33 cm
Fig. 40 Diagram for incoming light passing through a spherocylindrical lens of unknown power casting a line at 60° on a screen placed at 20 cm
right of the lens and an additional line at 150° on a screen placed 33 cm right of the lens
looking temporal to the optical centers of the glasses (bot-

OS : + 2.50 + 2.50 × 90 = +5.00 − 2.00 × 180
tom panel of Fig. 42). A base-in effect (additive) will be
For both eyes, we have cylinder power placed in the induced, and Prentice’s Rule can be used to quantify the
180-degree (axis) meridian that is acting at the 90-degree deviation.
(power) meridian (i.e., when the patient is looking up and As the patient is looking temporally to the optical cen-
down). When the patient is looking from side to side, only ter of the lenses in both eyes, there will be an induced BI
the +4.00D is having an effect in the right eye, and only prismatic effect. The prismatic effect is additive since
the +5.00D is having an effect in the left eye. both eyes are shifted nasally (i.e., in opposite directions).
We can draw this change in the pupillary distance and We now have to apply Prentice’s Rule as follows:
its prismatic effect in horizontal gaze (top panel of
OD : P = hD = ( 0.5 )( 4 ) = 2 PD BI
Fig. 42). In the top panel, we can see that if the patient’s
PD was actually 60 mm, the patient would be looking
through the optical center of the lenses, and there would OS : P = hD = ( 0.5 )( 5 ) = 2.5 PD BI

be no prismatic effect to consider. However, since the
patient’s PD is actually 70 mm, the patient will end up Therefore, the net prismatic effect will be 4.5 PD BI.
148 K. M. Riaz
Therefore, the net prismatic effect will be 4.5 PD BO.

60°
11. Answer: For these types of problems, it always helps to
convert the given prescription into the opposite axis
notation to determine the total power in this gaze posi-
150°
tion. Since we have been given 90-degree axis notation
(vertical gaze), we can convert it into 180-degree axis
notation, which would require minus cylinder notation
and give us information about the horizontal gaze.
−2.50 + 3.50 × 90 = +1.50 − 3.50 × 180

We can see that +3.50D of cylinder has been placed in
the 90-degree (axis) meridian and will therefore exert an
+5.00
effect at the 180-degree (power) meridian only. Therefore,
only the –2.50D will have an effect in pure vertical gaze
from the optical center. To solve part a, we can show the
prismatic effects of inferior gaze by re-drawing the sphe-
+3.00
rocylindrical lenses as simple minus lenses, as shown in
Fig. 44 (top panel).
In inferior gaze, the minus lenses will cause a base-
down effect. Using Prentice’s Rule, we can determine the
Fig. 41 Power cross and DAM for unknown spherocylindrical lens for prismatic effects as follows:
practice question #8
P = hD = ( 0.6 ) ∗ ( 2.5 ) = 1.5 PD BD in both eyes.

10. Answer: We can again start this problem by getting both Since both eyes have shifted downwards equally (i.e.,
lenses with the same axis notation: same direction and same magnitude), there is no induced
diplopia. No prismatic correction is needed for part a.
OS : +2.50 + 2.50 × 90 = +5.00 − 2.00 × 180
However, for part b, the situation is slightly different.
For both eyes, we have cylinder power that is placed in When the patient looks nasal to the optical center in both
the 180-degree (axis) meridian that is acting at the eyes (horizontal gaze), we can see that we must incorpo-
90-degree (power) meridian (i.e., when the patient is rate the cylinder power, and these lenses will actually
looking up and down). When the patient is looking function like plus lenses. Therefore, we can show the pris-
from side to side, the +4.00D affects the right eye, and matic effects of nasal (horizontal) gaze by re-drawing the
+5.00D affects the left eye. spherocylindrical lenses as simple plus lenses, as shown
We can draw this change in the pupillary distance and in Fig. 44 (bottom panel).
its prismatic effect in horizontal gaze as follows (top In nasal (horizontal) gaze, nasal gaze to the optical
panel of Fig. 43). In the top panel, we can see that if the center of plus lenses in both eyes will cause a base-out
patient’s PD was actually 60 mm, then the patient would prismatic effect. Using Prentice’s Rule, we can determine
be looking through the optical center of the lenses, and the prismatic effects as follows:
there would be no prismatic effect to consider. However,
since the patient’s PD is actually 50 mm, the patient will P = hD = (1) ∗ (1.5 ) = 1.5PD BO in each eye.

end up looking nasal to the optical centers of the glasses
Since each eye moves in the opposite direction, the net
(bottom panel of Fig. 43).
prismatic effect will be additive: 1.0 PD BO +1.0 PD
Since the patient is looking nasal to the optical center
BO = 2 PD BO total.
of the lenses in both eyes, there will be an induced BO
In order to correct this deviation, 2 PD BI must be
prismatic effect. We now have to apply Prentice’s Rule as
given to either the left or right eye (but not both).
follows:
12. Answer: We can again start by getting both of our pre-
OD : P = hD = ( 0.5 )( 4 ) = 2 PD BO scriptions into the same axis notation. Since we are pri-
marily dealing with inferior gaze, the 90-degree notation
will be helpful since that will allow us to ignore the cyl-
OS : P = hD = ( 0.5 )( 5 ) = 2.5 PD BO
inder portion and focus only on the lens’s spherical
component.
OD OS
60 mm PD
+4.00 +5.00
70 mm PD
5 mm 5 mm
Fig. 42 When the patient looks through the optical center of the to the optical center in both eyes. A base-in effect (additive) will be
glasses, there is no prismatic effect. If the patient has a pupillary dis- induced, and Prentice’s Rule can be used to quantify the deviation
tance of 70 mm (instead of 60 mm), she will end up looking temporally
OD OD
60 mm PD
+4.00 +5.00
50 mm PD
5 mm 5 mm
Fig. 43 When the patient looks through the optical center of the the optical center in both eyes. A base-out effect (additive) will be
glasses, there is no prismatic effect. If the patient has a pupillary dis- induced, and Prentice’s Rule can be used to quantify the deviation
tance of 50 mm (instead of 60 mm), she will end up looking nasally to
150 K. M. Riaz
Fig. 44 Prismatic effects in

vertical gaze (top panel) and
horizontal gaze (bottom
panel) when looking 6 mm
inferior and 10 mm nasal to
the optical center,
respectively, of a
−2.50 + 3.50 × 90 eyeglass
prescription
Preoperative refraction : −4.00 + 2.00 × 180 = −2.00 − 2.00 × 90
Preoperative Postoperative
Postoperative refraction : +2.00 + 2.00 × 90 OD OD
–2.00D +2.00D
We can now redraw these lenses as shown in Fig. 45.
Now we can apply Prentice’s Rule to the preoperative and
postoperative lenses:
Preoperative: P = hD = (1)( 2 ) = 2 PD BD

Postoperative: P = hD = (1)( 2 ) = 2 PD BU 10 mm 10 mm

There is a net deviation of 4 PD BU when we com-
pare the postoperative refraction to the preoperative
refraction. In order to correct this deviation, we will Inferior (vertical) gaze
need to dispense 4 PD BD in the postoperative glasses.
We also need to go back and figure out what went wrong Fig. 45 Preoperative (left panel) and postoperative (right panel) pris-
with the biometry measurements because we made a matic effects induced in the reading position (10 mm inferior to the
optical center)
monocular myopic patient into a hyperopic patient!16
13. Answer: This is yet another twist on asking the same
concepts we have discussed thus far. If the vertical lines focused at the axis meridian (90°). Similarly, if the hori-
are focused sharply with the +3.00D lens, this means zontal lines are focused sharply with the +5.50D lens,
that a + 3.00 × 90 lens is needed; the lens is oriented in this means that a + 5.50 × 180 lens is needed; the lens is
the 90-degree axis meridian, it exerts its power at the oriented in the 180-degree axis meridian, it exerts its
180-degree power meridian, and an incoming light ray power at the 90-degree power meridian, and incoming
(in this case, the vertical lines of the Amsler grid) is light ray (in this case, the horizontal lines of the Amsler
grid) is focused at the axis meridian (180°).
Causes for postoperative hyperopic surprise are discussed in chapter
16 To summarize the above, we can draw a power cross
“Postoperative Optics for Cataract Surgery”. showing that +3D is acting at the 180-degree meridian
and a + 5.50D is acting at the 90-degree meridian. But the Lenses”: −4.00 === 90 and − 3.00 === 180. We can
wrinkle to this problem is that we have to take into account draw the power cross and check our work using the
the location of the Amsler grid at 50 cm. The patient will DAM (Fig. 47).
require +2D of accommodation to see the grid. The (c) Our SC notation lenses should be the opposite of
patient is 30 years old and should be able to generate this our PC components:
amount of accommodation on his own; however, because −4.00 × 180 and − 3.00 × 90.
we have cyclopleged him, we are measuring this extra We can check our work by using the SC method.
plus power that he actually does not need. In other words, We should get the original prescription.
we need to subtract 2D from each lens basically, and then (d) The axis cross is drawn by setting the SC notation
generate our power cross (Fig. 46). Our power cross lenses as connected components and NOT using the
should connect +1.00 === 180 and + 3.50 === 90. DAM. In other words, our axis cross lenses are:
Using this power cross, we can determine the final pre- −4.00 === 180 and − 3.00 === 90.
scription using the DAM : + 1.00 + 2.50 × 180 (or + 3.5 Notice how these are different from our PC
0 – 2.50 × 90). lenses. We can draw the axis cross, and following
14. Answer: the arrows for the axis cross, we should be able to
(a) This one should be fairly easy by now: get back to our original prescription (Fig. 48).
−4.00 + 1.00 × 90 = −3.00 – 1.00 × 180. (e) Our expected streak refraction results will be as fol-
(b) Using the Telephone Method, we can use our plus lows. From our SC notation lenses, we know that
cylinder and minus cylinder notation to get our “PC −4.00 STREAKS the 180 and − 3.00 STREAKS
the 90. But these lenses have already had the work-
ing distance (50 cm = additional -2D sphere) incor-
porated into them. Thus, we must add +2D sphere
+3.50
to determine our streak results: -2.00D STREAKS
the 180° and − 1.00D STREAKS the 90°. In other
words, assuming a working distance of 50 cm, if we
held the streak horizontally (and moved it up and
down [vertically]), a −2D lens would neutralize the
reflex. If we held the streak vertically, a −1D lens
would neutralize the reflex.
+1.00 180°
15. Answer:
(a) The circle of least confusion (COLC) will be formed
halfway between the power of the above two lines.
We can begin by using the information in the ques-
tion stem.
First, we know that the lens focuses light at
25 cm at 45°. This means there must be +4D power
(100/25 = +4D) placed in the 45° (axis) meridian,
which is exerting its effect at the 135° (power)
90°
meridian, which in turn forms a line at 45°. When
Fig. 46 Power cross for practice question #13
Fig. 47 Power cross for –4.00

practice question #14
MRx (plus cylinder): –4.00 +1.00 × 90
–3.00 180
MRx (minus cylinder): –3.0 –1.00 × 180
90
152 K. M. Riaz
we draw the power cross, the +4D should be linked

–3.00
to the 135°.
Next, we know that the lens focuses light at
67 cm at 135°. This means there must be +1.5D
power (100/67 = +1.5D) placed in the 135° (axis)
meridian, which is exerting its effect at the 45°
(power) meridian which in turn forms a line at 135°.
When we draw the power cross, the +1.5D should
be linked to the 45°.
The COLC will be formed at the average power
–4.00 180
of these two powers: (4 + 1.5)/2 = 2.75D. The loca-
tion of this will be 100/2.75D = 36.36 cm to the
right of the lens (admittedly a difficult math number,
which is why this is the last problem in the practice
question set).
(b) From the previous solution, we can draw our power
cross: +4.00 === 135 and + 1.50 === 45.
We can use the DAM to calculate the power
of the unknown spherocylindrical lens:
90
+1.50 + 2.50 × 45 (or +4.00 − 2.50 × 135).
Fig. 48 Axis cross for eyeglass prescription: −4.00 + 1.00 × 90. Note
how this differs from the power cross in Fig. 41. The double arches
method cannot be used with the axis cross
Astigmatism
Daniel Wee
Objectives a refractive state in the eye wherein incoming light rays do

• To understand the concept of astigmatism not fall on the retina at a single point; instead, there is a set of
• To differentiate between various types of astigmatism two focal lines formed by these incoming light rays.2 To
(corneal vs. lenticular astigmatism, refractive vs. ocular review, in an emmetropic eye (without accommodation),
astigmatism, regular vs. irregular astigmatism) incoming light rays should come together in love and har-
• To classify various kinds of corneal astigmatism (with the mony at a single point on the retina. When astigmatism is
rule, against the rule, and oblique) and apply this for clini-
present, there is something evil and sinister happening so
cal and surgical management of astigmatism that these incoming light rays are broken into separate focal
• To understand differences among simple, compound, and lines.
mixed astigmatisms Why does this happen? Because there is no such thing as
• To introduce the concept of pantoscopic tilt and astigma- a perfectly round surface, the asymmetry present in the cor-
tism of oblique incidence, especially in clinical nea and the crystalline lens will cause incoming light rays
situations to be bent differently, depending on the portion of the cor-
• To review the concept and application of a Jackson cross nea (or the crystalline lens) the light rays have passed
cylinder through. Astigmatism is usually always present in conjunc-
• To briefly discuss some additional advanced topics in tion with various amounts of spherical (myopic or hyper-
clinical and surgical management of astigmatism opic) refractive errors. Astigmatism has relevance in both
clinical and surgical practice: we have to correct as many
refractive errors as possible, including astigmatism, in
Introduction order to give the patient his/her best possible vision. We
discussed some of these introductory concepts in the previ-
This chapter is extremely useful for both exam and clinical ous chapter.
purposes. All of us may have found ourselves explaining the So, what is astigmatism? The short answer is that some-
concept of astigmatism to patients several times a day in the times the cornea and/or the lens is shaped more like an
clinic. Some patients may be extremely concerned that they American football than a soccer ball – voila, we have
were told they have “an astigmatism”1 and potentially vision- astigmatism.
threatening consequences of this diagnosis! Other patients The long answer: buckle up. We will cover that in this
may be confused when they see their glass prescriptions look chapter in detail.
more like map coordinates with three different numbers.
Let us define astigmatism: linguistically, astigmatism is
derived from “a” (Greek for “without”) and “stigme” (Greek 2 You may wish to review the discussion in the previous chapter regard-
for “geometric point”). In other words, astigmatism refers to ing conoid of sturm and the circle of least confusion (chapter
“Spherocylindrical Lenses”) that discusses these two focal lines formed
by light rays passing through a spherocylindrical lens – in this case, that
Or, as some patients may call it, “stigmatism”
1
“lens” is the spherocylindrical cornea with astigmatism.
D. Wee (*)

154 D. Wee
Types of Astigmatism ball” are parallel to each other, then both astigmatisms
will team up. For example, if manifest refraction showed
Astigmatism can be classified in several ways: 3D of refractive astigmatism but only 2D is present in
keratometry readings, then it is very likely that the source
• Corneal vs. lenticular astigmatism of the additional 1D of refractive astigmatism is coming
–– Corneal astigmatism itself can be subdivided in several from lenticular astigmatism.
ways, which we will discuss in the next section of this • Lenticular astigmatism can neutralize corneal astigma-
chapter. tism: if the directions of the “corneal football” and “lens
• Refractive vs. ocular astigmatism football” are located 90° away from each other, then len-
• Regular vs. irregular astigmatism ticular astigmatism may offset or neutralize corneal astig-
• Simple vs. compound astigmatism matism. For example, if manifest refraction showed 1D of
cylinder and 2D is present in keratometry readings, then it
is very likely that there is 1D of lenticular astigmatism
Corneal vs. Lenticular Astigmatism located 90° away that is neutralizing the corneal
astigmatism.
This classification is perhaps the easiest to understand. Simply
put, we are describing how much astigmatism is due to the Why is this important? Let us look at a few potential clini-
football shape of the cornea and how much a stigmatism is due cal examples:
to the football shape of the lens. Every patient will have some
amount of both corneal and lenticular astigmatism. For most Clinical example #1 Suppose you are going to do cataract
patients, the amount of lenticular astigmatism may be quite surgery on a patient with a high amount of refractive astig-
minimal. Therefore, the refractive cylinder measured on mani- matism (as evidenced by his/her preoperative glasses) and
fest refraction may be very close to the corneal astigmatism you are deciding what type of intraocular lens (IOL) to place
measured on keratometry. For example, if a patient has kera- in that patient. Patient A has high corneal astigmatism and no
tometry readings of 44.50 × 45.50 at 90 (1D of corneal astig- lenticular astigmatism, while patient B has high lenticular
matism), assuming zero lenticular astigmatism, a possible astigmatism and no corneal astigmatism. Patient A may ben-
manifest refraction for this patient could be −2.00 + 1.00 × 90. efit from astigmatism correction at the time of cataract sur-
In other words, we have to place +2D of cylinder in the gery (e.g., toric IOL or limbal relaxing incision). If this
90-degree (axis) meridian in order to act at the 180-degree patient chooses no astigmatism correction at the time of sur-
(power) meridian.3 For this patient, all of the refractive astig- gery, it is crucial to explain to her that she will require cylin-
matism is coming from the football-shaped cornea. drical correction in the glasses because we will have
However, as you may have gathered, this is not always unmasked the corneal astigmatism after surgery, even if she
the case. Just as the cornea can be shaped like a football, the did not need cylindrical correction in the presurgical eye-
lens can also have an ovoid shape. Lenticular astigmatism glasses! Patient B will likely do well with a non-toric IOL
can therefore also play a significant role in the total amount and will likely do worse with a toric IOL. We will further
of astigmatism present (ocular astigmatism) that may or discuss options for the surgical correction of astigmatism in
may not show up in the refractive astigmatism (next Chaps. 26 and 27 “Preoperative Optics for Cataract Surgery”,
section). and What Is on the Menu: An Overview of Currently
Lenticular astigmatism can be a funny creature that can Available IOLs and Relevant Optics.
have three faces (Fig. 1)
Clinical example #2 Suppose a 24-year-old patient pres-
• Lenticular astigmatism can be so minimal that it has no/ ents to your office for her annual eye exam. She has worn
minimal effect on ocular astigmatism glasses since age 10 but now inquires about wearing con-
• Lenticular astigmatism can amplify corneal astigmatism: tact lenses. Her refraction in both eyes is −3.00D sphere
if the directions of the “corneal football” and “lens foot- (20/15). Keratometry readings are 43.50 × 44.75 at 90
(1.25D) in the right eye and 43.50 × 44.50 at 95 (1.5D) in
See Chap. 10 “Spherocylindrical Lenses”, for a review of this concept
3 the left eye. What type of contact lens would be the best
which is crucial to the rest of the discussion in this chapter. option for this patient?
Astigmatism 155
a b
Fig. 1 There can be three varieties of lenticular astigmatism in relation tive to corneal astigmatism, as shown by the effects of both the cornea
to corneal astigmatism. Panel a shows minimal effect of lenticular and the lens (exaggerated) on an incoming light ray. Panel c shows an
astigmatism, drawn as a “small” lens that does not affect any incoming eye wherein lenticular astigmatism is located 90° away from corneal
light ray. Panel b shows an eye wherein lenticular astigmatism is addi- astigmatism and therefore has a neutralizing effect
This is an example of a patient that likely has the third scenarios of clinical pearls for contact lens fitting in Chap. 20
type of lenticular astigmatism we discussed above. This is “Contact Lenses in Clinical Practice”.
also known as favorable lenticular astigmatism because it is
neutralizing (balancing) all of the corneal astigmatism;
therefore, she only wears a spherical correction in both eyes Refractive vs. Ocular Astigmatism
and has excellent visual acuity. For this patient, she would
probably do well with a soft contact lens. A soft toric contact In some ways, this may be semantics more than a true clas-
lens is likely not necessary to correct this much astigmatism. sification. Both are a combination of corneal and lenticular
Most importantly, a hard contact lens would be the worst astigmatism and are often used interchangeably. Refractive
choice because while it will neutralize the corneal astigma- astigmatism is the total astigmatism that can be detected dur-
tism, it will unmask the lenticular astigmatism and paradoxi- ing a manifest or streak refraction. Therefore, there is some
cally make the patient’s vision worse! We will discuss more dependency on the skill level of the examiner and the coop-
156 D. Wee
eration of the patient. For most clinical setting purposes, (including soft toric) contact lenses. Irregular astigmatism
refractive astigmatism serves as a proxy for ocular astigma- occurs when the astigmatism has variable orientation and
tism, and both are essentially equal. However, ocular amount in both meridians. The principal meridians may or
astigmatism is the total astigmatism that is actually present may not be 90° away from each other: on retinoscopy or plac-
in the eye and may only be detected on wave front aberrom- ido-disk-based keratometry, for example, an irregular streak
etry (see Chap. 14, “Physical Optics and Advanced Optical reflex or irregular mires may be present, respectively. Irregular
Principles”). It is a combination of corneal and lenticular astigmatism usually requires imaging devices such as topog-
astigmatism. Ocular astigmatism may or may not be equal in raphers and/or aberrometers to be quantified; in other words,
magnitude to the refractive astigmatism, but it has relevance irregular astigmatism is the summed total of higher-order
for the purposes of laser refractive surgery, especially for aberrations (see Chap. 14 “Physical Optics and Advanced
wave front-guided and wave front-optimized ablations. Optical Principles”). Irregular astigmatism usually cannot be
In the clinical setting, for example, a patient may have fully corrected with glasses and may account for those annoy-
1.5D of ocular astigmatism, but during manifest refraction, ing patients who objectively can see 20/20 but are incessantly
he may only require 1.25D of refractive astigmatism for complaining about their poor vision in your clinic. For these
20/20 vision. For this patient, the “extra” 0.25D of ocular patients, a rigid gas permeable contact lens may correct most
astigmatism is negligible and clinically irrelevant. However, of the irregular astigmatism present. In recent years, topogra-
on wave front measurement, the full 1.5D of astigmatism phy-guided ablation has emerged as a potentially viable sur-
may be measured. gical option for treating irregular astigmatism.
An additional type of astigmatism can be briefly men-
tioned here. Several terms have been used for this, but
visuoperceptive astigmatism (VPA) may help describe the Simple vs. Compound Astigmatism
fact that a significant component in experienced vision
involved tertiary neuroprocessing – in other words, outside As we stated above, refractive errors with astigmatism result
the eyeball. Thus, in addition to refractive and ocular astig- in incoming light rays falling on the retina as vertical and
matism, VPA refers to underlying neural processes that horizontal focal lines. Depending on where exactly these
mediate retinal defocus and perceptual errors. VPA may neu- lines fall on the retina (in front, directly upon, or behind),
tralize or worsen ocular astigmatism. Don’t worry too much we can further classify refractive astigmatism into five sub-
about VPA, as it’s beyond the scope of exams and clinical types. We will discuss this in greater detail in the section
practice; we introduce it here only for completeness. VPA is “Refractive Errors with Astigmatism: Simple vs. Compound
an area of current and future study that may have greater Astigmatism” of this chapter.
clinical relevance in the future.
Types of Corneal Astigmatism

Regular vs. Irregular Astigmatism
Sutures and Corneal Astigmatism
If the astigmatism has the same orientation and is the same
amount at every point in both the steep and flat meridians A useful starting point for the discussion of corneal astigma-
(which are 90° apart from each other), then we can say that tism (aka keratometric astigmatism) is to use an example that
the patient has regular astigmatism (Fig. 2). Regular astigma- you may be familiar with, based on your experience in clini-
tism can usually be fully corrected with glasses and soft cal and surgical settings. For example, if we place a single
a b c
Fig. 2 Visual representation of no astigmatism (panel a), regular astig- portions of the sphere. In irregular astigmatism (panel c), there is no
matism (panel b), and irregular astigmatism (panel c). Note that in regu- symmetry between any portions of the sphere
lar astigmatism (panel b), there is symmetry between long and short
Astigmatism 157
Fig. 3 Effects of a corneal a

suture on corneal astigmatism.
In panel a, a properly tied
suture will cause negligible
change to the shape of the
cornea and therefore will not
affect the corneal
astigmatism. If the suture is
tied too tight (panel b), it will
cause shortening of the
180-degree meridian and
increased corneal astigmatism
in this meridian. Keratometry
readings will indicate the
180-degree meridian as the
steep meridian, e.g., b
44.00 × 47.00 at 180
suture to close a corneal incision made for cataract surgery of ball. This will be helpful to understand the next sections
the left eye, we can see the effects of the suture on the corneal regarding the subtypes of corneal astigmatism.
astigmatism (Fig. 3). If the suture is properly tied with equal
tension, then its effects on the shape of the cornea (and there-
fore, corneal astigmatism) will be very minimal. However, if With-the-Rule (WTR) Astigmatism
it is your first surgery and you are super cautious to make sure
that this wound won’t leak, you may end up tying it a bit too With-the-rule (WTR) astigmatism refers to corneal astigma-
tight. When this happens (Fig. 3, panel b), we can see that the tism wherein the steep meridian of the cornea is at 90°
suture will cause steepening in the meridian of its placement (±20°): the range for WTR is 70–110°. We can imagine WTR
and flattening of the meridian located 90° away. astigmatism as a football placed down horizontally, as if the
Suppose that our main incision was a temporal clear cor- center is getting ready to snap it to the quarterback (Fig. 4).
neal incision placed at the 0-degree meridian (since this is WTR astigmatism is most commonly seen in younger
the left eye). Now that we tied our suture a bit too tight, we patients. Since the steep meridian is at 90°, the correcting
have induced steepening in this meridian. We would say that cylinder (if using plus cylinder) has to be placed in the
our steep meridian is at 0° (though 180° is preferred, in terms 90-degree (axis) meridian in order to act at the 180-degree
of the nomenclature and style points), and the flat meridian is (power) meridian. An example of an eyeglass prescription
at the 90-degree meridian. The corneal shape has become that may be used to correct WTR astigmatism would be
like a vertical football, as if the kicker is ready to kick a field −1.00 + 1.50 × 90.
goal (against-the-rule astigmatism). In the post-op period, A possibly useful (and silly) mnemonic to remember is
keratometry readings may now read, for example, that WTR astigmatism is more common in younger patients:
44.00 × 47.00 at 180°, and the patient may require a manifest “wittle kids always go wah-wah-wah.”
refraction of −1.50 + 3.00 × 180 to yield 20/20 vision (well,
at least until you remove the suture).4
The suture example can be used as a reference to some Against-the-Rule (ATR) Astigmatism
nomenclature that we will use in following sections. The
steep meridian is the shorter, “more protruding” meridian, Against-the-rule (ATR) astigmatism refers to corneal astig-
the shorter side of the football. The flat meridian is the lon- matism wherein the steep meridian of the cornea is at 180°
ger, “less protruding” meridian, the longer side of the foot- (±20°): the range for ATR is 160–200°. We can imagine
ATR astigmatism as a football placed vertically (Fig. 4).
To review from our discussions in Chap. 10, this refraction is telling us
4
ATR astigmatism is most commonly seen in older, adult
that +3.00D cylinder has been placed in the 180-degree (axis) meridian
in order to act at the 90-degree (power) meridian; it will “help” the 43D patients. This is because of posterior corneal changes that
act like a 46D to equal the 180-degree meridian. occur gradually throughout life so that the net shift of cor-
158 D. Wee
a b
Fig. 4 Simplified representations of with-the-rule (WTR) and against- as a horizontally placed football. In ATR astigmatism (panel b), the
the-rule (ATR) corneal astigmatism. In WTR astigmatism (panel a), the steep meridian is located between 160° and 200° and can be visualized
steep meridian is located between 70° and 110° and can be visualized as a vertically placed football
neal astigmatism for many patients is from WTR to ATR.5 further in Chap. 21 “Clinical Problems with Optics and
Therefore, it is more likely to see ATR in older patients, Refractive Manifestations”.
though ATR may also be seen in younger patients. Since A summary diagram showing WTR, ATR, and oblique
the steep meridian is at 180°, the correcting cylinder (if astigmatism is in Fig. 5.
using plus cylinder) has to be placed in the 180-degree
(axis) meridian in order to act at the 90-degree (power)
meridian. An example of an eyeglass prescription that may efractive Errors with Astigmatism: Simple
R
be used to correct WTR astigmatism would be vs. Compound Astigmatism
−1.00 + 1.50 × 180.
A possibly useful (and silly) mnemonic to remember this As we have previously discussed, in an eye with refractive
is “ancient adults will have ATR.” astigmatism, incoming light rays will not focus at a single
point and instead will produce a set of focal lines. These two
focal lines will basically give the eye two distinct focal points
Oblique Astigmatism (Fig. 6). The five different types of refractive astigmatism
can therefore be classified according to where these two
Oblique astigmatism refers to corneal astigmatism that falls focal points fall in relation to the retina – either in front of,
in between WTR and ATR astigmatism. In other words, the directly upon, or behind the retina.
range for oblique astigmatism is 20–70° and 110–160°. Both Note that both plus-cylinder and minus-cylinder notation
WTR and ATR are typically better tolerated by adult patients can be used to determine the type of astigmatisms we will
as compared to oblique astigmatism. discuss below.
Oblique astigmatism has significant relevance in clinical
practice, especially in prescribing glasses and clinical/surgi-
cal management of oblique astigmatism. We will discuss this Simple Myopic Astigmatism
This will be of significant importance during our discussion of strate-

5
In simple myopic astigmatism, one focal point is anterior to
gies and options for the surgical correction of astigmatism (Chap. 26 the retina, and the other focal point is directly on the retina
“Preoperative Optics for Cataract Surgery”).
Astigmatism 159
Fig. 5 Summary diagram of 90

WTR (green), ATR (orange),
and oblique astigmatism
(blue) locations and ranges
ATR
180 0
Oblique
WTR
Fig. 6 Spherocylindrical lens with ray tracings coming to two separate Fig. 8 Simple hyperopic astigmatism diagram showing two focal
focal points points: one posterior to the retina and one falling directly on the retina
convert it to the opposite cylinder notation. If one of the

resulting spheres is now plano and the other sphere is minus,
then this is a simple myopic astigmatism prescription.
In the example above, note that the first prescription is the
plus-cylinder notation of the second prescription. When con-
verted to minus-cylinder notation, the sphere portion has
become plano. Hence, this refraction is a correction for sim-
ple myopic astigmatism.
Simple Hyperopic Astigmatism
In simple hyperopic astigmatism, one focal point is posterior

Fig. 7 Simple myopic astigmatism diagram showing two focal points:
to the retina, and the other focal point is directly on the retina
one anterior to the retina and one falling directly on the retina (Fig. 8). Examples of manifest refractions that can be classi-
fied as simple hyperopic astigmatism include plano
(Fig. 7). Examples of manifest refractions that can be classi- +2.00 × 90 and +2.00–2.00 × 180.
fied as simple myopic astigmatism include −2.00 + 2.00 × 90 In the two prescriptions above, notice that the first pre-
and this should be: plano + 2.00 x 180. scription is the plus-cylinder notation of the second pre-
When trying to determine if a prescription is simple myo- scription. Since the sphere portion of the first prescription is
pic astigmatism, one method is to take the prescription and plano and the sphere portion of the second prescription is
160 D. Wee
Fig. 10 Compound hyperopic astigmatism diagram showing two focal

Fig. 9 Compound, myopic astigmatism diagram showing two focal points: both posterior to the retina
points: both anterior to the retina
+2.00D sphere, this is a simple hyperopic astigmatism

prescription.
Compound Myopic Astigmatism
In compound myopic astigmatism, both focal points are

anterior to the retina but in two different locations (Fig. 9).
Examples of manifest refractions that can be classified as
compound myopic astigmatism include −4.00 + 2.00 × 90;
−2.00 – 2.00 × 180.
For example, if we consider the first prescription Fig. 11 Mixed astigmatism diagram showing two focal points: one
(−4.00 + 2.00 × 90) and convert it to minus-cylinder notation anterior to the retina and one posterior to the retina
(−2.00–2.00 × 180), we note that both sphere components
are minus sphere; therefore, this is a compound myopic the retina, and one focal point is posterior to the retina
astigmatism prescription. (Fig. 11). What is confusing about the refraction is that sim-
ply looking at the sphere may make you think that it is a
myopic or hyperopic prescription, but when you convert to
Compound Hyperopic Astigmatism minus-cylinder notation, you may get an opposite-signed
sphere.
In compound hyperopic astigmatism, both focal points are Examples of manifest refractions that can be classified as
posterior to the retina but in two different locations (Fig. 10). mixed astigmatism are as follows:
Examples of manifest refractions that can be classified as
compound hyperopic astigmatism include +2.00 + 2.00 × 90 • −1.00 + 3.00 × 180 → convert to minus cylinder,
and +4.00 – 2.00 × 180. +2.00 – 3.00 × 90; SE, +0.50
For example, if we take the first prescription • −2.50 + 3.50 × 40 → convert to minus cylinder, +1.00–
(+2.00 + 2.00 × 90) and convert it to minus-cylinder notation 3.50 × 130; SE, −0.75
(+4.00 – 2.00 × 180), we note that both sphere components • +2.75 – 3.00 × 90 → convert to plus cylinder, −0.25 +
are plus sphere; therefore, this is a compound hyperopic 3.00 × 180; SE, +1.25
astigmatism prescription.
For each of these prescriptions, notice how sphere values
change to an opposite-signed sphere value when we convert
Mixed Astigmatism to the opposite cylinder notation.
As you may have sensed from examples given above, a
Mixed astigmatism is a concept that may be confusing at first commonly tested type of question may be “given the follow-
glance. In mixed astigmatism, one focal point is anterior to ing refraction, what type of astigmatism does this patient
Astigmatism 161
have?” While we have solved some examples above, we will

now present a systematic method to follow to ensure that you
do not make an error in classification:
• Step 1. If the refraction is given in a plus (or minus) cyl-

inder notation, write the opposite cylinder notation next to
it (as we did above).
• Step 2. Look only at the spherical power of each notation.
Ignore the cylinder and axis values:
–– Both spheres are positive: compound hyperopic
astigmatism.
–– One sphere is positive and one is plano: simple hyper-
opic astigmatism.
–– One sphere is positive and one is negative: mixed
astigmatism.
–– One sphere is negative and one is plano: simple myo-
pic astigmatism.
–– Both spheres are negative: compound myopic Fig. 12 Profile view of glasses sitting on a face demonstrating no tilt
astigmatism. (top figure) and the preferred, typical pantoscopic tilt (bottom figure).
Note that the typical amount of tilt is 7–8°; this has been exaggerated in
the diagram for effect
antoscopic Tilt and Astigmatism of Oblique
P
Incidence Theoretically, retroscopic tilt (lower rim of the glasses
tilted away from the cheek) also exists but is very rarely
Pantoscopic tilt (PT) is a confusing topic because, depending used.7 One main drawback of retroscopic tilt is the high
on which textbook you consult, it can refer to two similar yet amount of induced refractive errors based on changes in gaze
slightly different concepts. We can begin our discussion position, much more than those seen with PT. Additionally,
using eyeglasses as an example. faceform tilt (tilt along the vertical axis) is rarely used.
If you look at a pair of single vision lens (SVL) glasses
from the side, you will notice that the lenses are not exactly
vertically aligned. They are usually constructed with an Pantoscopic Tilt: Tilting a Spherical Lens
angle such that the lower edge of the lens is closer to the
face/cheek, i.e., tilted along the horizontal (180-degree) axis Have you ever had a patient tell you that they see better when
(Fig. 12). This makes it easier for a person wearing SVL they tilt their lenses? This is especially common in myopic
glasses to rotate his/her eyes from distance to near (and vice patients due to PT. In our previous discussions on lens effec-
versa) without changing the vertex distance. The range of PT tivity (Chap. 6 “Lens Effectivity”), we discussed how mov-
is 1–12°; the ideal tilt is 7–8° on the lower rim edge. This ing the lens toward the eye and away from the eye can change
will place the optical center of the SVL glasses slightly the effective power of the lens. In this scenario, if we have a
below the center of the pupil (usually around 4 mm). As a spherical lens but tilt the lens around its axis (either 90° or
general rule of thumb, the optical center should be dropped 180 axis), then we will see a resulting increase in lens power
inferiorly about 0.5–1 mm for every 1–2° of PT in order to and induced cylindrical power in that axis. Since PT is typi-
reduce the amount of induced power caused by normal cally used when describing glasses, the tilt will occur in the
PT. Bifocal and progressive glasses have varying amounts of 180-degree axis. If you attempt to tilt around the 90-degree
PT as well. axis, you will probably end up breaking the glasses!
A large degree of tilt, especially on high myopic prescrip- Why does tilting the lens help a patient, mathematically?
tions, will produce considerable amounts of nonuniform This is where we can introduce the concept of Martin’s law
hyperopic shifts, along with peripheral astigmatism and of lens tilt. This law helps us to calculate the power of a given
coma in the visual field.6 Therefore, the amount of PT is even spherical lens depending on how much you tilt it. Note: you
more important for higher prescriptions. will never ever be asked to calculate this on an exam because
For those of you who simply must know, retroscopic tilt can be used
7
See Chap. 14, “Physical Optics and Advanced Optical Principles”, for

6
for patients with unique facial anatomy, such as patients with low-set
a more detailed discussion regarding coma and other higher-order ears and protruding cheeks, or to maximize the amount of the frame’s
aberrations. bridges touching the patient’s nose.
162 D. Wee
a b
Fig. 13 Tilting a plus lens (panel a) induces additional plus cylinder in the axis of tilt, in this case axis 180; tilting a minus sphere lens (panel b)
induces additional minus cylinder in the axis of tilt
the math will be incredibly difficult – if you can do this math We can convert this to plus-cylinder notation,
in your head, then you are wasting your time in ophthalmol- −15.62 + 0.47 × 90.
ogy, and you should have been a Nobel laureate in mathe- When tilted 10°, these glasses will give the myopic patient
matics instead! additional minus sphere power at the cost of some cylinder.
We can see what all the fuss is about when it comes to This explains why an undercorrected myope will tilt his
Martin’s law of lens tilt: glasses – he is gaining some additional minus sphere power.
To summarize PT and Martin’s law of lens tilt:
 (
PT new sphere = Sphere × 1 + ( sin a ) / 3 
2
 )
• Tilting a plus lens → extra plus sphere power and plus
cylinder in the axis of tilt
PT new cylinder = New sphere × ( tan a ) 
2
  • Tilting a minus lens → extra minus sphere and minus cyl-

inder in the axis of tilt
Example #1 +15.00D glasses with 10° of tilt. Remember
that most glasses are tilted about 180-degree axis: Getting back to our clinical example, when a patient says
they see better by tilting their glasses, they probably need
• New sphere, 15 × [1 + ((sin 10 deg)2/3)]: stronger glasses, astigmatic correction, or both (Fig. 13).
–– Sin 10 = 0.17364 → (0.17364)2 = 0.03015 → 0.03015/
3 = 0.01005
–– 1 + 0.01005 = 1.01 Astigmatism of Oblique Incidence (AOOI)
–– 15 × 1.01 = 15.15 D sph
• New cylinder, 15.15 × [(tan 10 deg)2]: Astigmatism of oblique incidence (AOOI) refers to oblique
–– Tan 10 = 0.1763 → (0.1763) 2 = 0.031091 astigmatism that is induced astigmatism from light rays that
–– 15.15 × 0.031 = 0.47 D cyl are not on the principal axis. AOOI can be thought of as the
“unwanted” astigmatism that happens when a patient looks
When tilted 10°, these glasses will function like through the lens at an angle away from the optical center
+15.15 + 0.47 × 180. (i.e., the peripheral portions of the lens). This type of astig-
Notice that these SVL plus glasses have gained additional matism is dependent on the shape of the lens, specifically,
plus sphere and additional plus cylinder in the direction of the relationship between curves of the front surface and back
tilt. surface. While PT assumes that the patient is still looking
through the optical center when the entire lens tilts, AOOI
Example #2 −15.00 D glasses with 10 degrees of tilt → can occur with and without PT, depending on where the
−15.15 − 0.47 × 180 patient is looking. As with many things with glasses, if only
Astigmatism 163
closer to the retina), then the IOL may no longer function as

a + 20.00D IOL. Because it has tilted forward (similar to an
eyeglass lens), it will gain some plus sphere and plus cylin-
der and thus may function as +21.00 + 2.00 × 180 due to PT
(and resulting AOOI). The patient may present with a myo-
pic astigmatism refractive error, such as −1.00 − 2.00 × 180,
which converted to plus-cylinder notation that would be
−3.00 + 2.00 × 90. Note that we used exaggerated whole
numbers in this example to make the math easier for the sake
of reinforcing the concept.
Jackson Cross Cylinders
Edward Jackson (d. 1942) first described the use of the

Jackson cross cylinder lens (JCCL) to determine the power
of astigmatism in 1887.10 Then, in 1907, he described how
the JCCL can be used to refine the axis of the correcting
cylinder. The good Dr. Jackson was a pretty cool and accom-
Fig. 14 Diagram of astigmatism of oblique incidence (AOOI) demon-
plished guy: he established the first graduate course for oph-
strating a light source (green lines) off of the principal axis (red lines).
AOOI may be caused by a spherical lens that has undergone unintended thalmologists, suggested the formation of the instruction
tilting courses of the American Academy of Ophthalmology, and
was the principal founder of the American Board of
patients can be taught to strictly look through the optical cen- Ophthalmology.
ter, then we would not have to worry about these issues! A JCCL is simply a tool used to determine the axis and
When a patient looks through the optical center, spherical strength of astigmatism. It can look like a handheld tool or
lenses induce spherical power, and spherocylindrical lenses can be incorporated into the phoropter (Figs. 15 and 16).
induce both spherical and cylindrical power. However, if the A JCCL is basically two cylindrical lenses placed 90°
light ray is off axis, the spherical lens also induces cylindri- away from each other. One cylinder is plano-convex and the
cal power known as AOOI (Fig. 14).8 other is plano-concave. A JCCL is made by grinding cylinder
PT and AOOI usually occur together; it is difficult to have power on one surface and pairing it with a half-power sphere
a situation where purely one of these is having an effect with- of the opposite sign on the other surface. In other words, the
out accounting for the other. In fact, AOOI can further be spherical equivalent of Jackson cross cylinders will always
broken down into AOOI caused by the cornea and AOOI be zero because the cylinder power in a JCCL is double and
caused by the lens; both of these AOOIs have opposite- of opposite power to the sphere. For example, commonly
signed astigmatism, which produces better image quality for used JCCLs would include −0.25/+0.50 and −0.50/+1.00.
the eye as a whole.9 This may also make more (visual) sense if you imagine
We can conclude this section with a clinically relevant the JCCL as a power cross lens (Figs. 17 and 18).11 In the
example. Suppose we have a patient with a history of pseu- first example, notice the power cross for a JCCL with
doexfoliation syndrome who underwent cataract surgery −0.50/+1.00 power; in the second example, notice the power
with placement of a + 20.00D IOL. His manifest refraction cross for a JCCL with −2.00/+4.00 power.
1 month after surgery was plano (20/20). If this patient came We can use the JCCL to help us answer three commonly
in 3 months later complaining of blurry vision and we see on encountered questions and scenarios:
clinical exam that the IOL has tilted forward around the
180-degree axis (i.e., the superior part of the optic is now Detecting refractive astigmatism If any refractive astigma-
closer to the cornea, and the inferior part of the optic is now tism is present, then using the JCCL to show the patient flip
choices should reveal it because one flip choice should
8
For those of you who wear glasses, especially higher-powered ones,
you can try this by looking obliquely through your lenses in the periph-
ery and trying to read a computer screen, for example. You will notice Newell FW. Edward Jackson, MD – a historical perspective of his
10
that the text is slightly blurry. It is much easier to turn your head and contributions to refraction and to ophthalmology. Ophthalmology 1988;
look at the screen directly (i.e., look through the optical center). 95: 555–58
9
Liu T, Thibos LN. Variation of axial and oblique astigmatism with See Chap. 10, “Spherocylindrical Lenses”, for a review of power
11
accommodation across the visual field. J Vis. 2017 Mar 1;17(3):24 crosses.
164 D. Wee
–0.5
–0.75
+0.5
–0.50 + 1.00 × 90
Fig. 17 Example 1 of power cross showing a Jackson cross cylinder

lens with −0.50/+1.00 held in the 90-degree position
+2
Fig. 15 Picture of a handheld Jackson cross cylinder lens
-2
–2 +4 × 180
Fig. 18 Example 2 of power cross showing a Jackson cross cylinder

with −2.00/+4.00 held in the 180-degree position
always produce less blur than the other choice. However, if

we erroneously have placed the JCCL such that the JCCL
axes are 45° away from the true axis of refractive astigma-
tism, then flip choices may be equally bad, and the patient
may not report a preference for either choice. For example, if
we place the JCCL in the 90°/180° position but the patient
feels that both choices are equally lousy, then we may want
to test at the 45°/135° position to attempt finding any refrac-
tive astigmatism.
What if the patient does not like any of the flip choices? If
the patient does not like any of the flip choices, one or more
of the following may be present: there is no significant
refractive astigmatism; the axis of the refractive astigmatism
Fig. 16 Picture of a Jackson cross cylinder on the phoropter
is 45° away from where we are currently holding the JCCL;
Astigmatism 165
the patient’s vision is too lousy to appreciate any of the blur For example, low amounts (0.50–0.75D) of WTR astig-
choices. matism may be particularly advantageous in pseudophakic
eyes.12 Since there is more plus power at the 90-degree
How much astigmatism can we refine using the JCCL? The meridian, this will help bring in vertical stroke letters at dis-
cylinder power must be reduced if the clinician intentionally tance (such as b, d, h, t, etc.) into better focus. There are
shifts the astigmatic axis, such as may be considered for a more vertically stroked letters in English as compared to
patient who has recently shifted from WTR to ATR, WTR to horizontally stroked letters. WTR astigmatism may also help
oblique, etc. In general, the smaller the amount of cylinder, with English language text because there is “less (vertical)
the more degrees that can be refined. For example, if a patient space” between letters in a sentence as compared to the
only has 0.50D of refractive cylinder, then we can confi- amount of space “between” sentences on a page. Furthermore,
dently refine 15–20° at a time. But if a patient has +2.50D of Javal’s rule states that less cylinder correction is required to
refractive cylinder, then we may only be able to refine 2–5° correct WTR astigmatism in glasses as compared to ATR; in
at a time. An analogy can be drawn from the more familiar other words, 1D of WTR keratometric astigmatism may only
example of toric IOLs: the greater the misalignment for a require 0.75D of refractive cylinder to correct it, as com-
higher-powered toric IOL, the more effect it will have on pared to 1D of ATR keratometric astigmatism.
under−/overcorrecting the patient’s astigmatism. Sawusch and Guyton demonstrated in an elegant model
that the least amount of summated blur exists through the
Example range of object distance 0.5–6 m that is −1.00 + 0.75 (SE,
Which of the following is an example of a Jackson cross −0.63) with WTR astigmatism (as compared to ATR
cylinder? astigmatism) followed by −0.75 + 0.50 (SE, −0.50).13 In
other words, a postoperative pseudophakic refraction of
(a) −0.25 + 0.50 × 180 −1.00 + 0.75 × 90 may be the “Goldilocks” prescription
(b) −0.25 + 0.50 × 90 to give a good range of vision at the above range
(c) −0.50 + 1.00 × 45 distances.
(d) −0.75 + 1.50 × 85 As for ATR astigmatism, the additional plus power at the
(e) All of the above 180-degree meridian helps to bring in vertical stroke letters
at near into better focus; in other words, low amounts of
The answer is (e) all of the above. Notice that in each ATR astigmatism may confer an advantage by improving the
example, the opposite-signed cylinder is double the power of quality of a patient’s reading vision after cataract surgery.14
the sphere. This may be particularly advantageous in patients with
demands for excellent near vision, such as a jeweler or a coin
collector.
Advanced Topics in Astigmatism Finally, in case we have not confused you enough, the
benefits of WTR astigmatism for distance and ATR astigma-
We have thus far spent the bulk of this chapter talking about tism for near work best for languages with vertical stroke
various types and classifications of astigmatism, including a letters. In considering languages with more horizontal
discussion regarding WTR vs. ATR astigmatism. strokes (Arabic, Hebrew, Hindi, etc.), the opposite may be
One question that may seem philosophical but may have true: low amounts of ATR astigmatism may help with dis-
clinical relevance is are there any advantages to retaining tance text, and low amounts of WTR astigmatism may help
some astigmatism in the human eye? In other words, since with near reading vision.
the human eye is imperfectly perfect, should we actively
seek to neutralize all astigmatism and potentially miss out on
some advantages that astigmatism provides, especially in the
pseudophakic eye? While we may pat ourselves on the back
after cataract surgery if a patient has no refractive astigma-
tism on manifest refraction, have we potentially missed out
on certain advantages of mild amounts of WTR and/or ATR Morlet N, Minassian D, Dart J. Astigmatism and the analysis of its
12
astigmatism? surgical correction. Br J Ophthalmol. 2002;86(12):1458–1459

As you may have gathered from the leading nature of the Sawusch MR, Guyton DL. Optimal astigmatism to enhance depth of
13
focus after cataract surgery. Ophthalmology. 1991;98(7):1025–1029

previous paragraphs’ tone, there are theoretical and practical
Trindade F, Oliveira A, Frasson M. Benefit of against-the-rule astig-
14
advantages to low amounts of astigmatism. matism to uncorrected near acuity. J Cataract Refract Surg.
1997;23(1):82–85
166 D. Wee
Practice Questions Answers
1. What kind of astigmatism does a patient with this refrac- 1. Answer: B. Simple hyperopic astigmatism. First, we can
tion have? write the refraction in both plus- and minus-cylinder
Plano + 1.00 × 090: notation:
A. Compound hyperopic
Plano + 1.00 × 90
B. Simple hyperopic
C. Mixed +1.00 − 1.00 × 180
D. Simple myopic Since the sphere in one cylinder notation is plano and
E. Compound myopic the other is plus, then this patient will have simple hyper-
2. What kind of astigmatism does a patient with this refrac- opic astigmatism.
tion have: 2. Answer: E. Compound myopic astigmatism. First, we
−2.00 + 1.00 × 130 can write the refraction in both plus- and minus-cylinder
A. Compound hyperopic notation:
B. Simple hyperopic
C. Mixed −2.00 + 1.00 × 130

D. Simple myopic
−1.00 − 1.00 × 40
E. Compound myopic
3. If a +2.00D sphere lens is tilted forward along its 180 Since sphere values in both cylinder notations are
axis, which of the following prescriptions best approxi- minus, then this patient has compound myopic
mates the “new” power of this lens? astigmatism.
A. +2.00 + 1.00 × 180 3. Answer: C. Remember that tilting a plus-powered spheri-
B. +2.00 + 1.00 × 090 cal lens along its 180-degree axis will add some sphere
C. +2.25 + 1.00 × 180 and cylinder of that same power along the 180 axis. Note
D. +2.50 − 1.00 × 180 that we do not have to use Martin’s law of lens tilt – we
E. +2.25 − 1.00 × 090 could, if we were so mathematically gifted and had access
4. Which of the following statements is true? to a calculator. Instead, we can use the process of elimina-
A. The anterior cornea may have with-the-rule (WTR) or tion. Since we know that the sphere power must increase
against-the-rule (ATR) astigmatism; the posterior with the tilt, we can safely eliminate A and B. Similarly,
cornea usually has WTR astigmatism. we know that the lens should gain plus-cylinder power. D
B. A patient with keratometry readings of 44.00 × 47.00 and E are seemingly an increase in sphere power, but they
at 90 has ATR keratometric astigmatism. also have an increase in minus cylinder so we can elimi-
C. A patient with keratometry readings of 44.00 × 45.00 nate those as well. Only answer choice C gives us a value
at 180 may benefit from a temporal clear corneal inci- with increased plus-sphere and plus-cylinder powers.
sion at the time of cataract surgery. 4. Answer: C. The keratometry readings in choice C are
D. The posterior corneal astigmatism value will increase indicative of ATR keratometric astigmatism; an incision
toward WTR astigmatism with age. at the steep meridian (temporal) may help to reduce this
5. Keratometry readings of 44.00 × 46.00 at 90 are mea- 1D of ATR astigmatism. While the anterior cornea may
sured in a patient 6 weeks after cataract surgery. Which of have WTR or ATR astigmatism, the posterior cornea
the following statements is true (more than one answer nearly always has ATR astigmatism (choice A) that
choice may be correct)? increases toward more ATR with age (choice D). The
A. If there is a tight suture placed in a temporal corneal keratometry readings in choice B are examples of WTR
incision, it should be removed at this time. keratometric astigmatism.
B. The patient may require a manifest refraction of 5. Answers: C and D. The keratometry readings indicated
−1.25 + 2.00 × 180 to correct the refractive WTR astigmatism. A superior suture may be present at
astigmatism. the 90-degree meridian and thus may be removed.
C. The patient may require a manifest refraction of Similarly, a manifest refraction of −1.25 + 2.00 × 90 indi-
−1.25 + 2.00 × 90 to correct the refractive cates that +2D of cylinder placed in the 90-degree merid-
astigmatism. ian will act at the 180-degree meridian (flat meridian) to
D. If there is a tight suture placed in a superior corneal help correct the keratometric astigmatism.
incision, it should be removed at this time.
Glasses for Written Exams
G. Vike Vicente
Objectives Bifocal Construction Types

• To be able to list different types of bifocal segment options
that may be tested on written exams Benjamin Franklin (yes, the kite guy, the hundred-dollar bill
• Define image jump and image displacement guy, and one of the first presidents of the United States...
• Apply lessons from the previous chapter on prisms to only one of those facts is incorrect) is credited with the first
understand how image jump and image displacement can description of bifocals. Whether or not he actually invented
be successfully managed bifocal spectacles is a matter of historical debate; however,
he certainly played a key role in popularizing their usage in
the United States. Shortly after the end of the Revolutionary
Introduction War, the good Mr. Franklin wrote in a letter to his friend
George Whatley about his happiness “…in the invention of
Glass questions on written exams are infrequent. This topic is double spectacles, which serving for distant objects as well
more relevant to oral boards and clinical practice; therefore, as near ones, make my eyes as useful to me as ever they
we will reserve the bulk of our discussion on glasses, includ- were.”1 We know that Franklin was likely a hyperope: there-
ing prescribing, dispensing, and troubleshooting glasses, for fore, his interest in and dependence on presbyopia-correcting
Chaps. 15 and 16 “Glasses in Clinical Practice” and glasses played a role in the popularity and further develop-
“Construction of Glasses (Ophthalmologists as Opticians)”. ment of these glasses.2
We will focus our discussion in this chapter on a few key Bifocals have changed considerably since Franklin’s day.
topics that tend to appear on written exams, such as ques- We can divide types of bifocals available based on how they
tions regarding bifocals’ advantages and disadvantages. are constructed (Figs. 1, 2, and 3):
Since these topics have some overlap and require an under-
standing of prisms (Chap. 2 “Prisms in Ophthalmic Optics”), Fused bifocal A craterlike depression known as a “counter-
we have placed this brief discussion on glasses here in the sink” (panel A) is made in the substance of the eyeglass lens
text. Topics regarding spherocylindrical lenses for distance to allow for a bifocal segment (made of a different material
vision were briefly covered in Chap. 10 “Spherocylindrical with a higher index of refraction, such as flint) to be joined
Lenses”, but are also discussed in terms of clinical relevance (panel B) into the substance of the first lens. This added seg-
in aforementioned Part II chapters. ment is then grounded (panel C) until it is level with the sub-
We will begin by introducing various types of bifocal seg- stance of the rest of this lens. Both round-top and flat-top
ments used in clinical practice and then discuss how bifocals can be made using fused construction designs. In
Prentice’s rule can help us understand (and differentiate) the these eyeglasses, the bifocal segment is attached to the front
two oft-confused (and dreaded!) topics of image jump and part (convex side) of the lens, allowing for any (minus) cyl-
image displacement. inder power to be placed into the back part (concave side) of
the lens.
Taken
1
from https://www.college-optometrists.org/the-college/
G. V. Vicente (*) museum/online-exhibitions/virtual-art-gallery/the-politician.html.
Clinical Pediatrics and Ophthalmology Georgetown University Accessed March 31, 2020
For American history fans, there is another famous story about how
2
Eye Doctors of Washington, Chevy Chase, MD, USA George Washington averted an insurrection by bringing out his reading
e-mail: vvicente@edow.com glasses (see Chap. 9, “Accommodation and Presbyopia”).

168 G. V. Vicente
a b c
Fig. 3 Construction types of bifocals, a split-lens bifocal
Split-lens bifocal (aka executive style, aka “Ben-Franklin”

bifocal) This is the granddaddy of them all. This bifocal
involves two different lenses: the top segment (for distance)
and the bottom segment (for near) are the combinations of
Fig. 1 Construction types of bifocals, fused bifocal
two lenses (regardless of material) that have been cut in half
and joined together in one frame. The optical center of the
bifocal segment is at the top of the segment. Contrary to pop-
ular belief, these are not designed to read secret maps leading
to ancient Masonic treasures.
Solid bifocal this is a one-piece bifocal made from a single

piece of material. During construction, the lens surface is
ground to create two different radii of curvature: the longer
radius of curvature is used for the “distance” portion, and the
shorter radius of curvature (having more plus power) is used
for the “near” portion. A progressive lens (technically not a
bifocal) is an example of a solid construction design.
Remember, a bifocal lens combines two lenses into a sin-

gle lens. The small lens (the segment) is placed into the larger
lens (the carrier). This next part is important: the total power
when a patient looks through the bifocal segment is the sum
of the carrier and the segment lens. For example, if a patient
is wearing a lens in the right eye with the following power,
OD = +1.50 + 0.50 × 90, +2.00D add, then the total power
when the patient is reading will be +3.50 + 0.50 × 90. Note
that the add power does not affect the cylinder power; it only
affects the spherical component of the carrier lens.
As another example, suppose a patient wore a lens with
the following power,
OD = −1.00 + 1.00 × 180, +2.50D add. The total reading
power will be +1.50 + 1.00 × 180. So, this “minus” lens will
function like a “plus” lens when the patient wants to read.
Fig. 2 Construction types of bifocals, cemented bifocal This concept is important for the topics in this chapter
and when solving exam questions (such as Prentice’s rule-
Cemented bifocal The bifocal segment (usually of a differ- type problems) which involve the patient looking through
ent substance with a higher index of refraction) is attached to glasses with bifocal segments with a given power.
the surface of a single vision lens. The lower portion of the Moving on from the construction types of bifocal lenses,
lens will have a greater thickness than the upper portion of we can shift our discussion to the four main designs of
the lens. This is the least commonly employed lens in clini- presbyopia-correcting glasses that we will encounter in clini-
cal practice. cal practice.
Glasses for Written Exams 169
Bifocal Architecture Types center of the carrier lens (Fig. 4, panel b). These are also
referred to as “D” segments (since they look like a D) or a
Round-Top Bifocal “straight top” bifocal segment. Flat tops are excellent options
for myopes – as we will see in the next section!
The round-top bifocal is perhaps the easiest type of bifocal
segment to understand (Fig. 4, panel a). It is basically a
round lens placed into the carrier lens. It is common to Executive-Style Bifocal
remove the inferior portion of the round-top segment just
below its optical center so that the optical center of the seg- As discussed previously, an executive-style bifocal (which
ment aligns with the inferior edge of the carrier. This lens is has many names) is the combination of two lens halves that
commonly used for hyperopic presbyopes – though there is a are joined together into a single frame (Fig. 4, panel c). This
price to pay, as we will see in the next section! bifocal style, while cosmetically awkward (to some), offers
excellent optical clarity because it not only distinctly sepa-
rates the distance and near portions but also allows for suffi-
Flat-Top Bifocal cient “space” or “real estate” that the patient can use for
distance and near vision. Ben Franklin certainly seems to
We can imagine that the flat-top bifocal is basically a round- know what he was doing!
top segment whose head has been cut off (yikes!), which Some patients may complain about the “visible” line in
allows the optical center to be placed closer to the optical the executive bifocal, especially as this bifocal style makes
a b
c d
Fig. 4 Designs of commonly prescribed presbyopia-correcting glasses in clinical practice: round-top (panel a), flat-top (panel b), executive-style
(panel c), and progressive add lenses (panel d)
170 G. V. Vicente
Fig. 5 A progressive addition lens (PAL) can be customized to give the peripheral distortions are more pronounced within the peripheral aber-
patient a larger or smaller area for distance and near vision, depending ration zone. In a “soft design” (right panel), the PAL is designed to
on the patient’s needs. In a “hard design” (left panel), the distance distribute the peripheral distortions over a larger peripheral zone
vision portion is larger, the near vision portion is smaller, and the
the lens considerably thicker, particularly in high-plus lenses. distance and reading at the cost of smaller but much more
This “line” may be undesirable for cosmetic and social rea- severe peripheral distortion zones. Another option is to use a
sons. Furthermore, due to production techniques, some man- soft design PAL (Fig. 5, right panel). The distance and read-
ufacturers may have an unwanted prism at the line or a blur ing portions are slightly smaller in this design, but the larger
zone slightly below it – this in turn may cause undesirable peripheral zones allow for less severe peripheral distortions.
prismatic effects. In other words, we can think of hard design PALs as cram-
ming a week of studying optics into a few days; those few
days are tough (peripheral distortion zone), but other days
Progressive Lens involve no studying. The soft design PAL is like spreading
out studying optics over many days so that the pain is less
A progressive add lens (PAL) is not technically a bifocal intense.3
because it does not contain distinctive or separate segments. PALs are constructed to have a progressive aspheric
We include it here because it is a useful extension of our change in curvature throughout the lens, similar to an
previous discussions. PAL style glasses gradually change aspheric IOL design. This design has the advantage of
power between the top and bottom portions of the lens; they improved vision quality when looking through the optimized
are the most commonly used presbyopia-correcting glasses central portions of the eyeglass (and IOL) but the disadvan-
in today’s clinical practice. As a result of grinding tech- tage of the lens incurring unwanted aberrations when the
niques, a single lens can have multiple zones within the lens: patient looks to the side, similar to a decentration of an
distance, intermediate, and near within a vertical column aspheric IOL.
field of vision (Fig. 4, panel d). PALs have other advantages as well:
The optical lab can further customize pALs to give larger
portions for distance or near vision, based on the patient’s • A PAL functions as a “multifocal” lens that provides a
needs. The best vision with a PAL is achieved when the seamless progression of many lens powers for all viewing
patient looks directly through the lens’s middle “vertical col- distances, especially intermediate vision, which is becom-
umn” (Fig. 5). Think of the vertical column as a “safe zone”: ing increasingly necessary in the modern world for activi-
inside it, the distance and reading optical centers are aligned, ties such as computer vision.
giving the patient the best possible vision for all distances. A • Cosmetic advantages, as no “line” is present as in the
“danger zone” of peripheral aberrations and distortions exists three previous designs.
outside the safe zone. Therefore, all PALs involve a compro- • “Optimal” power in the vertical center for all distances.
mise between the amount of “safe zone” and “danger zone,” • Elimination of image jump and image displacement (see
given that increasing the size of the former will increase sub- section “Prismatic Effects of Glasses”).
jective distortions seen by the patient through the latter.
One option is to use a hard design PAL (Fig. 5, left panel):
this design aims to maximize the distortion-free zones for Authors maintain that studying optics every day is fun.
3
However, as with all things in life, there are disadvantages

as well:
• Some patients may complain that the intermediate zone

(which is usually relatively smaller than the distance and
near portions) is insufficient for their visual needs, espe-
cially if they have high demands for intermediate vision.
• High hyperopes have a difficult time adjusting to PALs.
Low hyperopes, emmetropes, and myopes tolerate PALs I
much better.
• Pupillary distance is extremely important when prescrib-
ing PALs. Since the patient has a narrow “safe zone” ver-
O
tically, any error or change in pupillary distance may
incur an unwanted journey into the “unsafe” peripheral Fig. 6 Image jump is produced by the sudden introduction of prismatic
aberration zone. power at the top of the bifocal (usually round-top) segment when the
• Proper frame size (and eyeglass lens size) is essential. A patient looks down to read. Image jump is momentarily bothersome:
small frame may have a lower amount of starting real once the patient maintains focus through the bifocal segment, the image
stays constant
estate for the optical lab to work within preparing the dis-
tance and near vision parts of the lens.
“image goes to the apex” rule discussed previously. Think of
the round top as a base down prism (Fig. 6): as soon as the
patient looks through the segment, the (virtual) image will
Prismatic Effects of Glasses appear to jump upward toward the “apex of the prism,” which
can be frustrating. However, once the patient looks through
This subtopic is where our previous discussion regarding and maintains focus through the segment, the image will stay
Prentice’s rule will help us understand two concepts that are in its place. Image jump is proportional to the power of the
often challengingly frustrating to understand: image jump add segment: higher-power add segments will cause more
and image displacement. image jump problems.
Remember that when a patient shifts his/her gaze from Image jump is also proportional to the bifocal segment’s
the carrier (distance) lens into the segment portion of the optical center distance from the transition line. For example,
lens, he/she is basically looking through a different lens the optical center of a flat-top segment is approximately
power – recall our examples above. As a result, this new 2–3 mm below the top of the segment; thus, these types of
“reading power lens” will have not only its own power, but bifocals have fewer image jump issues.
depending on how far away from the optical center a patient The most important part of this entire discussion is what
is looking through, prismatic effects will rear their ugly head. follows:
Looking back at Fig. 4, we can see that the optical center Round-top segments will maximize image jump (Fig. 7,
for a round-top segment is the furthest away from the optical panel a), regardless of whether they are given to myopes or
center of the distance lens, especially when compared to hyperopes. We definitely want to avoid giving a round top
optical centers of a flat top and executive style. Appreciating to a myope (see section “Myopes vs. Hyperopes”). Flat-top
this can help us understand why image jump and image dis- segments (Fig. 7, panel b) have their optical center closer to
placement happen in the first place. the distance lens: therefore, there is minimum image jump.
We only have to worry about image jump and image dis- Executive-style segments have no image jump (Fig. 7,
placement problems when dealing with round-top and flat- panel c).
top lenses. With executive style and PALs, we do not have to Even though you can use your knowledge of image jump
worry about image jump or image displacement. to impress people at cocktail parties and social gatherings,
minimizing image displacement is much more crically, theo-
retically, at least on exams.4 In real-world practice, this is
Image Jump quite different, as we will see in section “Myopes vs.
Hyperopes”.
Image jump happens when the eyes move from the carrier
portion into the bifocal segment. As the patient moves his/ 4
You may have gathered by now that none of the authors of this book
her eyes downward to read through the bifocal, the image have much of a social life because we are crazy enough to find things
jumps upward from its anticipated location because of our like image jump and image displacement interesting.
172 G. V. Vicente
a b c
Fig. 7 A round-top segment will act like a base down prism, whereas a flat-top segment will act like a base-up prism. Therefore, image jump will
be the worst for any patient who receives a round-top segment
Image Displacement effects of the segment would somewhat neutralize prismatic

effects of the distance lens. In other words, the flat-top seg-
Image displacement occurs due to the total prismatic power ment will minimize image displacement.
acting in the reading position. In this scenario, the problem
is not a momentary annoyance: it is persistently bothersome
because you will want to look at a particular spot to read, but Myopes vs. Hyperopes
due to prismatic effects, the image will permanently be
shifted elsewhere. The patient will have to constantly Now that we have spent all this time discussing the optical
“search” for the image or look “off-center” to keep the image principles of prismatic effects with bifocals, we can cut to
from moving around. the chase: what kind of bifocal segment will work best for a
We can see what happens with image displacement if we given patient to minimize image jump and image displace-
have a hyperopic patient (Fig. 8) and a myopic patient ment, both theoretically and in actual real-world practice?
(Fig. 9). A simple solution is just to give everyone executive-style
For a hyperopic patient, if we give her a round-top seg- bifocals or PALs! This is perhaps one reason why PALs are
ment, notice that prismatic effects of looking off-center of so popular.
the base up distance lens will be somewhat neutralized by However, if we had to give a flat top or a round top, here
prismatic effects of looking off-center of the base down bifo- is what we need to know:
cal segment (Fig. 8, panel a). In other words, the round top We have previously discussed problems with both image
will neutralize some of the prismatic effects of the hyperopic jump and image displacement. Between the two problems,
distance lens and therefore minimize image displacement. If image jump is the lesser evil, and image displacement is the
we instead gave her a flat-top segment (Fig. 8, panel b), greater evil. Remember image jump is a momentary prob-
notice that the base up effects of both the distance lens and lem, but image displacement is a persistent problem. As a
the bifocal lens would be additive: this would worsen image rule, we will always try to minimize both problems. However,
displacement and, therefore, be a poor choice. if we had to pick our poison, we theoretically want to choose
For a myopic patient, if we were to give him a round-top the option that minimizes image displacement (even if it
segment, notice that prismatic effects (base down) of both maximizes jump).
the distance and the reading lenses would be additive: this How can you remember this? A silly mnemonic is as fol-
would worsen image displacement and, therefore, be a poor lows: suppose a criminal were to break into your home as
choice (Fig. 9, panel a). However, if we instead gave him a you are studying for optics and tell you, “you can either jump
flat-top segment (Fig. 9, panel b), notice that the prismatic up down a few times and I’ll leave or you can be displaced
a b
Fig. 8 A round top segment (panel a) will minimize image displacement for a hyperopic patient, but a flat top segment (panel b) will maximize
image displacement
from your home forever – and no, you can’t take your optics are forced to pick the round top: as a result, we will actually
book with you.” What will you choose? You will choose the maximize image jump for this patient, but at least we will
jump option. Therefore, if you have to pick your poison, minimize image displacement (Fig. 10). The visual mne-
always choose to pay the price of accepting image jump to monic of a happy older hyperopic patient who is bald
avoid image displacement. (“round-top haircut”) will help you remember that a hyper-
For a myope, our solution is quite simple: we can mini- opic patient will benefit from a round-top bifocal.
mize both image jump and image displacement by giving our Another visual mnemonic is to think of the mouth of a
myopic patient a flat top (Fig. 10). The visual mnemonic of a stick figure’s face. An uncorrected hyperope (Fig. 11) has a
happy young myopic patient with his hipster flat-top haircut big upside-down U frowny face because everything is blurry
will help you remember that a myopic patient will benefit up close and far away. That upside-down U frowny face
from a flat-top bifocal.5 looks like a round-top bifocal, which helps us remember:
For a hyperope, unfortunately, we theoretically cannot hyperopes prefer round-top bifocals. Similarly, in our visual
solve both problems – we are forced to pick between the two mnemonic (Fig. 11), we can see that an uncorrected myope
evils. Since we want to minimize image displacement, we has a flat mouth, reminding us that he is neither happy nor
sad: he is doing OK because he can see well at near but not
at distance. This figure can help us remember that his “OK”
You can visually imagine Will Smith from The Fresh Prince of Bel-Air
5
as a young myope with his flat-top hair cut benefiting from some flat- (flat) mouth looks like a flat-top bifocal: myopes prefer flat-
top bifocals. top bifocals.
174 G. V. Vicente
a b
Fig. 9 For a myopic patient, a round-top segment (panel a) will maximize image displacement, but a flat-top segment (panel b) will minimize
image displacement
Fig. 10 Visual mnemonic of

a happy myope with both a
flat-top haircut and flat-top
bifocals and a happy hyperope
with a “round-top” haircut
(bald) and round-top bifocals
Fig. 11 Visual mnemonic of

an even keel myope and an
unhappy hyperope. The
myope is even- keeled
because he can see well up
close but not far away; he
prefers a flat-top bifocal The
hyperope is unhappy because
he cannot see well up close or
far away; the frown helps you
to remember that a hyperope
benefits from a round top
Now for the plot twist, this previous discussion is clas- mizing image jump), real-world applications are a bit more
sic teaching in ophthalmology textbooks of optics. complicated.
However, this all may be a moot point when discussing On one hand, hyperopes that frequently switch between
real-world clinical and optical practice. While we previ- distance and near vision (e.g., a piano player, receptionist,
ously stated that hyperopes should be given a round top to barista, etc.) may be more bothered by image jump. On the
minimize image displacement (even at the cost of maxi- other hand, hyperopes that do long periods of near work
176 G. V. Vicente
(e.g., a computer programmer, secretary, etc.) may be more C. PALs are constructed with a singular spherical design
bothered by image displacement. Therefore, the real-world throughout the lens, in an effort to simulate the shape
dispensation of segment style may vary from patient to of the cornea.
patient based on his/her needs.6 D. The intermediate zone in some PALs may not be suf-
Another plot twist is in real-world optical practice, flat ficient, especially for computer vision.
tops are often given to both myopes and hyperopes because E. High hyperopes tolerate PALs much better than low
they are cheaper to make, and the problem of image dis- hyperopes.
placement is thankfully not as visually debilitating as it theo- 3. Which of the following statements regarding image jump
retically seems. Recent advancements in lens construction, and image displacement is true:
such as “digital lenses” (laser-etched lenses), have further A. Image displacement is more bothersome than image
minimized previous generation image jump and displace- jump.
ment effects. The complete discussion of this point is beyond B. Image displacement is a momentary shift in the per-
the scope of this text; interested readers should consult with ceived image when the patient looks from the dis-
an experienced optician and/or optical lab for more informa- tance portion into the near portion of the eyeglasses.
tion regarding current manufacturing and construction C. Round-top segments will minimize image jump.
standards. D. Flat-top segments will maximize image jump.
1. Which of the following statements regarding bifocals is 1. Answer: B. In a fused bifocal, the segment is made of a
true: material with a higher index of refraction as compared to
A. In a fused bifocal, a countersink is used to place a the substance of the “distance” lens. In a round-top bifo-
bifocal segment made of a lower index of refraction cal, the inferior portion of the round-top segment is
than the substance of the first lens. removed. In a flat-top bifocal, the superior portion of the
B. In an executive-style bifocal, the center of the bifocal round-top segment is removed.
segment is at the top of the segment. 2. Answer: D. In a “hard design” PAL, the distance vision
C. In a round-top bifocal, the superior portion of the portion is larger, the near vision portion is smaller, and the
round-top segment is removed, and the segment is peripheral distortions are more pronounced within the
placed into the carrier lens. peripheral aberration zone. In a “soft design” PAL,
D. In a flat-top bifocal, the inferior portion of the round- peripheral distortions are distributed over a larger periph-
top segment is removed, and the segment is placed eral zone. PALs are constructed with progressive curva-
into the carrier lens. ture changes, similar to modern aspheric IOL designs.
2. Which of the following statements regarding progressive High hyperopes have the most challenging time adjusting
add lenses (PALs) is true: to PALs compared to low hyperopes, emmetropes, and
A. In a hard design PAL, distortion zones are larger but myopes.
have less severity of distortions within these periph- 3. Answer: A. While minimizing both image jump and
eral zones. image displacement is a worthy goal for eyeglass fitting,
B. In a soft design PAL, distortion zones are smaller but whenever possible, clinicians should minimize image dis-
have increased severity of distortions within these placement as it is much more bothersome than image
peripheral zones. jump. Image displacement occurs due to the total pris-
matic power in the reading position; therefore, it is not a
momentary inconvenience to the patient. It permanently
shifts the image away from the patient’s desired or
Again, this is why everyone should simply get a progressive add lens
6
intended reading location. Round-top segments will
(PAL) to make our lives easier. However, a high hyperope may have
problems with a PAL as well, so he/she may ultimately be happiest with always maximize image jump. Flat-top segments will
an executive-style bifocal. minimize image jump.
Contact Lenses for Written Exams
Objectives 20 “Contact Lenses in Clinical Practice”. Topics such as

• To learn how to fit, select, and calculate the power of a multifocal and scleral contact lenses will also be discussed
soft contact lens (SCL) in that chapter.
• To learn how to calculate the power of a rigid gas- Note: topics related to contact lenses may appear on either
permeable/hard contact lens (RGPCL) written or oral exams. Therefore, whether you are preparing
• To understand the concept of the tear lens as it relates to for written exams or oral exams, you may wish to read this
RGPCL fitting chapter and the contact lens chapter in Part 2.
• To introduce concepts of soft toric contact lens (STCL) In this chapter, we will primarily focus on details about
fitting the power calculation of the given type of contact lens.
• To review principles of adjusting the fit of SCLs, RGPCLs,
and STCLs pertaining to written exams
Soft Contact Lenses (SCLs)
Introduction Soft contact lenses (SCLs) are a good option for patients
with mainly spherical refractive errors and low amounts of
You may have opened up this chapter and thought: I am an astigmatism (both refractive and keratometric). They are
ophthalmologist. I do eyeball surgery. I do not need to know considered the “entry-level” contact lenses and likely com-
anything about contact lenses! prise the majority of contact lens patients most ophthalmolo-
Well, that may be true for clinical practice as you may gists will encounter.
rely on your friendly neighborhood optometrist or contact Most of the SCLs used in clinical practice today are
lens specialist for the actual prescription and dispensation silicone hydrogel lenses. These lenses have good oxygen
of contact lenses. However, there are some basics of con- permeability, come in various wear options (replacement
tact lenses that every ophthalmologist should know. This schedules), and are usually well tolerated by most patients.
chapter will primarily focus on how to solve contact lens
problems that often appear on written exams. While we will
discuss some clinically relevant information in this chapter, Features of Soft Contact Lenses
the bulk of information necessary for clinical prescription,
dispensation, and adjustment of contact lenses will be dis- There are three features of a SCL that are important when
cussed in greater detail in Chaps. 6 “Lens Effectivity”, and solving exam problems (and even for clinical practice):
• Base curve (BC) – this is the posterior surface curvature

of the SCL (in mm). A lower BC value corresponds to a
G. V. Vicente (*) shorter radius of curvature and, therefore, a steeper fit of
the SCL. Conversely, a higher BC value corresponds to a
flatter radius of curvature and, therefore, a flatter fit of the
SCL.
e-mail: vvicente@edow.com
• Diameter (DIA) – this is the edge-to-edge width of the
K. M. Riaz
contact lens. SCLs typically range from 13 to 15 mm in
Oklahoma City, OK, USA size. Increasing the DIA will lead to a steeper fit of the

178 G. V. Vicente and K. M. Riaz
SCL. Conversely, decreasing the DIA will lead to a flatter (ii) Use the vertex distance to find the distance to the
fit. far point of the patient.
• Power of the SCL. (iii) Take the reciprocal of that distance in meters to
find the power of the contact lens needed. See
The fit of the SCL can be modified by adjusting either the Chap. 6 “Lens Effectivity”, for a review of cal-
BC or the DIA of the SCL. BC and DIA are inversely propor- culations involved and the examples that
tional to each other. For example, a SCL can be made steeper follow:
by either decreasing the BC or increasing the DIA. 1. For myopes, you will have to add the vertex
distance to the focal point.
2. For hyperopes, you will have to subtract the
Steps for Fitting Soft Contact Lenses vertex distance from the focal point.
6. Place the SCL on the patient’s cornea without fluorescein
We can discuss a step-by-step (simplified) guide to fitting a and assess its fit. An optimum SCL fit will be comfortable
SCL: for the patient and have good centration on the cornea
with approximately 1.0 mm overlapping of the limbus in
1. We first need to select the BC of the SCL. For a SCL, this all directions and 0.25–0.5 mm movement with each
is determined by obtaining keratometry readings and blink in primary gaze:
looking at the average K values: (a) If the SCL fits as described above, congratulations,
(a) If the average K is between 42.5 and 44.5D, use you are done. Make sure to collect your SCL fitting
8.6/8.7 BC SCL (flatter = longer radius of fee.
curvature). (b) However, if the SCL is either too flat (loose) or too
(b) If the average K is between 44.5 and 46.0D, use steep (tight), then proceed to step 7.
8.3/8.4 BC (steeper = shorter radius of curvature). 7. To adjust the fit, we can change either the BC or the DIA:
(c) This relationship explains why many manufacturers (a) In order to steepen the lens, increase the diameter or
now use an 8.5 BC as a one-size-fits-all approach. decrease the base curve.
2. For written exam purposes, we can ignore the SCL “tear (b) In order to flatten the lens, decrease the diameter or
lens (TL)” (the tear film between the back surface of the increase the base curve.
SCL and the cornea) because it has minimal refractive (c) Mnemonic – “call SID if you have a flat tire.” If the
power. The TL will have significance when we discuss lens is flat, we have to steepen it. In order to steepen
RGPCLs. a SCL, you can increase the diameter. You can figure
3. Take the spherical equivalent (SE) of the patient’s mani- out the other three relationships if you can remember
fest refraction if the cylinder present is <1D. If ≥1D, then that nugget.1
vertex correction must be done, as discussed in the next 8. Perform an over-refraction as necessary.
section. For higher amounts of cylinder, an RGPCL or
soft toric contact lens will be necessary.
4. For sphere values below +4.00D/−4.00D, we can simply Sample Problems
use the same eyeglass power as a starting power for the
SCL. Sample Problem #1 What should the power of a SCL be if
5. For sphere values above +4.00D/−4.00D, adjust the SE the patient’s spectacle lens is +12.5D with a vertex distance
value for vertex distance using a vertex table. These are of 13 mm?
available online or in handy reference charts in most
offices. For example, suppose you calculated the SE as Answer. For the contact or glasses to work, we must
−8.50D with a vertex distance of 13 mm; a published ver- remember that the focal point of either lens must match the
tex table chart will give the suggested power for the SCL far point of the eye (Fig. 1). To calculate the far point of the
as approximately −7.75D. Some online calculators will eye, we can take the reciprocal of the spectacle lens,
also do this step for you: 100/12.5 = 8 cm or 80 mm behind the eye (to the right of the
(a) Otherwise, you may have to calculate the new power
using the vertex distance formula:
It is important to only use the SID mnemonic when the lens is flat. Do
1
(i) Calculate the focal point of the given spectacle not use the SID mnemonic if the lens is steep. Remember that the “s”
lens. stands for “to steepen.”
Contact Lenses for Written Exams 179
+12.5D
Far Point
13 mm = 1.3 cm 67 mm = 6.7 cm
80 mm = 8 cm
Fig. 1 Graphical representation for calculating a SCL needed for a far point of the eye. In calculating the power of the required SCL, we
patient wearing +12.5D spectacles with vertex distance 13 mm. When must determine the SCL power such that the focal point of the SCL
the patient is wearing glasses, the focal point of the glasses matches the similarly matches the far point of the eye
-10.00 D
Far Point
10 cm = 100 mm 10 mm
67 mm = 6.7 cm
80 mm = 8 cm
Fig. 2 Graphical representation for calculating a SCL needed for a matches the far point of the eye. In calculating the power of the required
patient wearing −10.00D spectacles with a vertex distance of 10 mm. SCL, we must determine the SCL power such that the focal point of the
When the patient is wearing glasses, the focal point of the glasses SCL similarly matches the far point of the eye
eye). This is both the focal point of the +12.5D lens and the culating the far point of the spectacle lens, 100/−10 = 10 cm
far point of the (hyperopic) eye. to the left of the spectacle lens.
When we move the correcting lens onto the cornea (i.e., a Since we are going from glasses to contact lenses in a
SCL), we have to subtract the vertex distance.2 Remember, myope, we must add the vertex distance,
we are going from glasses to contact lenses in a hyperope, so 10 cm + 1 cm = 11 cm. The power of the SCL therefore
we must subtract the vertex distance, 80 mm −13 mm = 67 mm would be 100/11 = −9D.
(6.7 cm). Now we need to calculate the power of the “lens” Note: these questions may also be given in reverse for
with this new focal point, 100/6.7 (or 1/0.67) = +15D. written exams. In other words, you may be given the SCL
Thus, a + 15D contact lens on the cornea will focus light power and asked to calculate the spectacle lens power.
onto the far point of the eye, just as a + 12.5D lens that is It may also be helpful to remember that when we go from
13 mm further away (vertex distance). spectacles to contacts in myopes, the contact lens power will
be a “lower myopic correction power”; in hyperopes, the
Sample Problem #2 What should the power of a SCL be if power of the contact will be a “higher hyperopic correction
the patient’s spectacle lens is −10.0D with a vertex distance power.” Thus, a − 6.00 myope will likely wear a − 5.50D
of 10 mm? SCL; a + 6.00 hyperope will likely wear a + 6.50D SCL.
Answer. For myopic patients, calculations are slightly dif- Sample Problem #3 A patient complains that his SCL keeps
ferent (Fig. 2). Since this is a myope, the far point will be in falling out. You look at the box and notice the following
front (to the left) of the spectacles. We can again start by cal- numbers:
See Chap. 6, “Lens Effectivity”.

2
8.6 / 13.5 / −4.50 central corneal curvature. What does this mean exactly? It
means that if we take keratometry measurements of the cor-
Which of the following adjustments would most likely nea, we have to convert them to BC measurements. We will
help this patient? look at the two base curves that correspond to the flat and
steep corneal meridians and pick the flatter of these two base
(a) 8.4/13.0/−4.50 curves; we will pick a contact lens with a BC that is slightly
(b) 8.4/13.5/−4.50 steeper than the flatter corneal base curve. Why do we do
(c) 8.6/13.5/−4.75 this? We do this to create some vaulting between the cornea
(d) 8.8/14.0/−4.50. and the RGPCL. Diopter-to-base curve tables are published
references that can easily be found online and in most offices.
Answer. If the SCL keeps falling out, the SCL is likely It is improbable that you would be expected to convert
too loose (too flat). Since we have a flat tire, we can call on between diopters and base curves for test purposes because
our friend “SID” to remind us that we can either increase the math involved is much too challenging to solve without a
the diameter or decrease the BC. Choice D allows us to calculator. It is far more likely that the diopter value and the
increase the diameter, but it also increases the BC, so this corresponding base curve value will be given to you in an
can be eliminated. Choice C involves no change to either exam situation.3
the BC or the diameter and involves increasing the power of For example, suppose that a patient’s keratometry readings
the SCL; that won’t help us, so this choice can also be elim- are 42.50 (BC, 7.95 mm) x 45.00 (BC, 7.50 mm) @ 100. Our
inated. Choice A allows us to decrease the BC, but it also flatter K value is 42.50D (BC 7.95 mm), so we will want to fit
involves decreasing the diameter, so this can also be elimi- a contact lens with a BC that is slightly steeper than this flatter
nated. This leaves us with choice B, decreasing the BC K. Suppose we decide to fit this patient with an RGPCL that
only, while keeping the diameter and the power of the SCL has a BC 7.85 (corresponding to 43.00D). Our chosen BC is
unchanged. 7.95 − 7.85 = 0.10 mm steeper than the flattest K value.
Note: in the above questions, the option to change the con- Therefore, since every 0.05-mm difference between the BC
tact lens diameter was presented. In real-world clinical prac- of the RGPCL and the BC of the cornea will create a +0.25D
tice, however, most manufacturers have a fixed diameter of TL, a 0.10-mm difference will create a + 0.50D TL.
the contact lens (e.g., between 13.8 and 14.6 mm), while Now that we have created a messy situation with this silly
offering several different BC options. Therefore, we are lim- TL, we need to call in another friend. Our second friend for
ited to either increasing or decreasing the base curve when contact lens fitting is “SAM,” which reminds us that if you fit
we want to flatten or steepen the SCL, respectively, in every- steeper than the flattest K, you have to add minus.4
day practice. Technically, this is actually the “SAM-FAP” rule, but fitting
flatter than the flattest K (and therefore adding plus) is
reserved for special situations, such as orthokeratology and
igid Gas-Permeable Contact Lenses
R extreme keratoconus, which is beyond the scope of what we
(RGPCLs) or Hard Contact Lenses need to know for exams. To summarize, we need to know
that since we typically fit steeper than the flattest K, we will
Solving this type of problem is a rite of passage for written have to “add minus” to overcome the effects of the TL.5
exams. We can start by discussing the concept of the tear lens
and what role it plays in our discussion of RGPCLs.
Calculating and Fitting RGPCLs
The Tear Lens in RGPCL Problems We can discuss a step-by-step (simplified) guide to calculat-
ing and fitting RGPCLs:
The tear lens (TL) refers to the tear layer created between the
posterior surface of the RGPCL and the anterior surface of the
cornea. Since we ideally want the center of the posterior For the sake of completeness, the formula to convert between diopters
3
surface of the RGPCL not to touch the central cornea, this will and base curves is as follows: 337.5/diopters = BC (in millimeters).
create a “vault” of the RGPCL over the cornea. This silly little As an added reminder, you can imagine a friend named “Sam” who is
4
TL has (sometimes) significant power that must be accounted always yelling at you to “add minus!”
for when deciding on the power of the final RGPCL. This is a simplification of clinical practice for purposes of ophthalmol-
5
ogy trainees. Contact lens specialists typically choose a base curve cor-
This concept gets slightly confusing for many students: in
responding to a “mid-K” value between the two keratometry values for
general, the power of the TL is + 0.25D for every 0.05-mm a “steeper-than-flattest K and flatter-than-steepest K” fitting strategy.
difference between the BC of the RGPCL and the BC of the The full discussion of this topic is beyond the scope of this text.
1. Obtain a manifest refraction and keratometry readings at the K reading (and a BC conversion table if needed): they
(this should be given to you on an exam). have been helpful enough to tell us that the flattest BC is 7.65
2. Start by thinking like an optometrist: convert the manifest and the BC of the RGPCL is 7.55. Basically, we have a 0.10-
refraction to minus cylinder and adjust for zero vertex mm difference in base curves, so we know that our TL will
distance.6 We can discard the cylinder (and axis) and use have +0.50D power.
this new sphere value as a starting point for the intended However, unlike the SCL example, our job is not done by
RGPCL. simply prescribing the +15.00D into a RGPCL. We still have
3. Now we can look at the K readings and convert them to to deal with our old enemy, the dastardly TL.7 Remember,
BC values, usually using a BC conversion table: this fellow has a power of +0.50D, so we have to call in our
(a) In general, we will want to pick a steeper BC (lower) old friend “SAM” to help us out: SAM tells us we have to
than the flattest K value to allow for some apical “add minus” (add −0.50) to neutralize the TL.
clearance. Therefore, the final power of the RPGCL is
(b) On written exams, BC values corresponding to kera- +15.00 + (−0.50) = +14.50D.
tometry values will usually be given to you.
(c) If no BC values are given, we can choose to fit
0.1 mm steeper than the flattest K (corresponding to Soft Toric Contact Lenses (STCLs)
+0.50D TL power).
4. If we fit steeper than the flattest K, the RGPCL will vault Calculating the Power of STCLs
over the cornea, and the TL will have a convex lens shape.
Hence, the TL will have plus power that we have to addi- We can discuss a step-by-step (simplified) guide to fitting
tionally neutralize when determining the power of the STCLs. We should know that STCLs share some features of
RGPCL. Therefore, we can call upon “SAM” as a SCLs but also have additional steps necessary in the fitting
reminder to “add minus” power to the sphere value process:
obtained in step 2.
5. Now we can use the power of the TL (step 4) and the 1. We first need to select the base curve (BC) of the
power of the sphere (step 2) and add them together to STCL. For a STCL, this is determined by looking at kera-
determine the final RGPCL power. tometry readings and looking at average K values, similar
6. We must assess the fit of the RPGCL at the slit lamp with to our discussion with SCLs.
fluorescein staining. This technique will be further dis- 2. For our next step, we will again think like an optometrist:
cussed in chapter “Lens Effectivity”, Contact Lenses in convert the manifest refraction to minus cylinder just like
Clinical Practice. we did with RGPCL. However, we have to use all three
7. Perform an over-refraction as necessary. values for the power of the STCL:
(a) Adjust the sphere value based on vertex distance as
Example #1 A patient has a refraction of +11.50 + 1.00 × 50 needed for higher sphere powers.
with a vertex distance of 13 mm. Keratometry readings are 3. Select the STCL based on the BC value and the vertex
44.25 × 45.25 at 50, corresponding to BC of 7.63 and 7.46, adjusted minus-cylinder refraction value:
respectively. If the BC chosen is 7.55 (44.75D), what is the (a) For example, if a patient had −3.00 + 2.00 × 90, we
power of the RGPCL needed for this patient? will use −1.00 − 2.00 × 180 as the power of the
STCL.
Answer. This problem seems to have a lot of math, and we 4. Place this STCL on the patient’s eye and check the fit at
may be tempted to simply skip it on an exam. We can sim- the slit lamp (without fluorescein) to ensure that the cen-
plify it step-by-step using the method above. First, we tering mark sits at the 6 o’clock position (as discussed
already have the manifest refraction and the keratometry val- above). Wait at least 5–10 min to allow the STCL to settle
ues. Next, we can think like an optometrist: let us convert the before assessing the axis and rotation:
manifest refraction into minus-cylinder notation, (a) If the centering mark is not at the 6 o’clock position,
+11.50 + 1.00 × 50 = +12.50 − 1.00 × 140. Now we can use then the axis of the prescription needs to be adjusted
the +12.50 and adjust for the 13-mm vertex distance. Note (see next section).
that these are the same numbers we used in Fig. 1. From this
previous example, we have already determined that the
power of the contact lens will be +15.00D. Now we can look
While, in this case, we have facetiously referred to the tear lens as an
7
“enemy” (because of the calculation adjustment that we have to make),

Refer to Chap. 6, “Lens Effectivity”, and the previous examples in this
6
remember that the tear lens is actually our friend because it is mainly
chapter on how to adjust for zero vertex distance. responsible for correcting the corneal astigmatism.
5. Perform an over-refraction to finalize the sphere and cyl- mately one clock hour. Therefore, we have to add to the axis
inder power if necessary. by 30 degrees. The new STCL should be −4.25
6. The fit should be similar to the previous discussions − 2.25 × 120.
regarding optimum fit for a SCL. Adjust the BC or Now suppose we fit a patient with a STCL in Fig. 3, panel
DIA of the STCL if it appears to be too tight or too C, with −4.25 − 2.25 × 90.
loose. In applying the “LARS” rule, we can see that the STCL
has rotated to the right by approximately one clock hour.
Therefore, we have to subtract from the axis by 30 degrees.
Assessing the Fit of STCLs The new STCL should be −4.25 − 2.25 × 60.
Curveball question: What if the STCL has rotated 1.5
Soft toric contact lenses (STCLs) share many similar fea- clock hours. Then we have to adjust by 45 degrees (i.e., the
tures as SCLs. One key difference is that STCLs have a average of 30 and 60 degrees, which would correspond to 1
“line(s),” a “ballast,” or a “black dot” that helps the examiner and 2 clock hours, respectively). If the STCL rotates 2 clock
assess whether the STCL is appropriately positioned or not. hours, we have to adjust by 60 degrees, etc. However, any
Note that the patient cannot see this mark: only you as the excessive rotations should make us recheck the refraction
examiner can see it when examining a patient wearing and consider alternative CL options.
STCLs at the slit lamp. Depending on the manufacturer, the As a final note to the above STCL questions, while these
“mark” may be simply one mark; a combination of three examples have been presented for “test” purposes, in clinical
marks at 6 o’clock; a combination of three marks at 3, 6, or 9 practice, there is rarely a STCL that is stable if it has more
o’clock positions; or even a combination of two marks at 6 than 10–15-degree rotation. In other words, if the STCL has
o’clock and 12 o’clock positions. rotated more than 10–15 degrees, it may be a “steep/flat”
If the STCL has been fit properly, the dot/mark/line issue (i.e., a BC issue) rather than the wrong axis. If the STCL
should be sitting nicely at the 6 o’clock position, regardless is moving “too much,” the BC should be checked as a decrease
of the axis of cylinder correction. Note that the mark on a in BC may fix the problem rather than adjusting the axis.
STCL is unlike the marks on a toric IOL wherein we have to
ensure that the marks on the latter are aligned with the steep Additional Resources Additional information is available
meridian on the cornea intraoperatively. For the STCL, for free online at www.gpli.info, including a contact lens-
regardless the axis meridian of the correcting cylinder, the fitting pocket guide.
mark should be at the 6 o’clock position. If this centering
mark is not exactly at the 6 o’clock position, we have to
adjust the axis of the STCL. Do not change the sphere or the Practice Questions
cylinder based on the mark alone!
At this point, if the mark is not at 6 o’clock, we have to 1. A patient would like to try a soft contact lens (SCL).
call in our third friend in contact lens fitting, “LARS” (We Manifest refraction is −8.00 + 1.00 × 90 with vertex dis-
seem to have some weird friends in the contact lens-fitting tance of 12 mm. Keratometry readings are 44.0 × 45.00
world!). The “LARS” rule tells us that if the mark has rotated at 85.
to the left, we need to add to the axis; if the mark rotated to What K value(s) would you use to determine the BC?
the right, we must subtract from the axis (Fig. 3). As a gen- What power would you use for the final SCL?
eral rule, one clock hour of rotation equals 30 degrees. A. K = 45.0D, PWR = −7.50D
Suppose we fit a patient with a STCL in Fig. 3, panel B, B. K = 44.5D, PWR = −7.00D
with −4.25 − 2.25 × 90. In applying the “LARS” rule, we C. K = 44.5D, PWR = −7.75D
can see that the STCL has rotated to the left by approxi- D. K = 44.0D, PWR = −7.00D
a b c
Fig. 3 The LARS rule for soft toric contact lenses (STCLs). If the fore, we have to add to the axis of the STCL. In panel C, the resting
STCL has been fit correctly (panel A), the centering mark will be seen mark has rotated to the right of the 6 o’clock position; therefore, we
at the 6 o’clock position, regardless of the axis of correction. In panel B, have to subtract from the axis of the STCL
the resting mark has rotated to the left of the 6 o’clock position; there-
zero vertex distance. The focal point of these spectacles is

100/7.5D = 13 cm; since the patient is a myope, we know
that the far point of this patient is 13 cm to the left of the
spectacle lens. Now we have to adjust for the vertex dis-
tance (12 mm or 1.2 cm):
Far point = (13 cm + 1.2 cm) = 14.2 cm to the left of
the cornea. The power of the SCL is the reciprocal,
100/14.2 = −7D. (Watch the decimal places!) A − 7.00D
contact will have the same focal point as a − 7.5D spec-
tacle lens at 13 mm.
2. Answer: C. The SCL is too tight. We have to flatten the
Fig. 4 Rotation of STCL corresponding to practice question #4 SCL by either increasing the BC (to more than 8.5) or
decreasing the diameter (to be less than 13.0). Choice
D seems to allow us to decrease the diameter, but it
2. A patient presents to your office after recently receiving also decreases the BC, so this will not be helpful.
new SCLs from another provider 3 weeks ago. He com- Choice A can safely be eliminated since the only
plains that his eyes start to hurt within a few hours of change is to the power of SCL, so that will not be very
wearing SCLs. Slit-lamp examination reveals significant helpful either. Both B and C increase the BC, but B
pannus in both eyes with several prominent areas of cor- also increases the diameter (which will steepen the
neal neovascularization near the limbus. You look at the SCL). Therefore, C is more likely to help this patient
box and note the following numbers, 8.5/13.0/−4.00. with a tight fitting SCL.
Which of the following adjustments would be most help- 3. Answer: A. For the BC determination in RGP with low
ful for this patient? astigmatism, choose the lowest K, in this case 40.0D. To
A. 8.5/13.0/−4.25 create a tear lens with +0.50D power, we will want to fit a
B. 8.7/14.0/−4.00 half-diopter steeper than the flattest K. Thankfully, they
C. 8.7/13.0/−4.00 have not given us any other BC values here, so we can
D. 8.3/12.8/−4.00 dictate what K values we are going to use.
3. Suppose a patient needs a RGPCL. Her manifest refrac- For the power calculation, convert the manifest refrac-
tion is +10.0 + 1.0 × 180 with vertex distance of 13 mm. tion into the minus cylinder: +10.00 + 1.00 × 180, minus
Keratometry readings are 40.0D x 41.0D at 180. cylinder: +11.00 − 1.00 × 90. We can eliminate the cylin-
Which K would you base your BC on and what power der and axis value and use this “new” sphere to calculate
would you use for contact lens prescription? the power of the lens if the vertex distance = 0. The focal
A. K = 40.0D, PWR = +12.5D point of this “new” sphere is 100/11 = 9 cm or 90 mm
B. K = 40.5D, PWR = +12.5D behind the eye. We are told that the vertex distance is
C. K = 40.0D, PWR = +9.75D 13 mm. Since the patient is a hyperope, the far point of the
D. K = 41.0D, PWR = +13.0D eye will be behind the eye (to the right of the lens and the
4. Suppose you fitted a patient for a soft toric contact lens eye). We can adjust for the vertex distance by subtracting
(STCL). If the power chosen was −5.50 – 1.75 × 150 and it from the focal point to find the far point:
the following pattern was noted on slit-lamp assessment, 9 cm − 1.3 cm = 7.7 cm Now we can find the focal
what would the new power of the STCL be (Fig. 4)? length of this new far point, 100/7.7 = +13.0.
A. −5.50 − 1.75 × 105 Finally, we have to “add minus” due to the tear film
B. − 5.50 – 1.75 × 15 effect, +13.0 − 0.5D = +12.5D.
C. −5.50 – 1.75 × 60 4. Answer: A. The figure shows that the centering mark has
D. −5.50 – 1.75 × 120 rotated by approximately 1.5 clock hours to the right.
We can use the “LARS” rule to remind us that a STCL
that rotates to the right needs to be adjusted by subtract-
Answers ing from its axis. A 1.5-clock hour rotation would cor-
respond to 45 degrees. Therefore, 150 – 45 = 105
1. Answer: B. For the BC determination for SCL, we can degrees. Note that choice B would be wrong because it
simply take the average of K values: (44 + 45)/2 = 44.5D. would be adding 45 degrees instead of subtracting.
For the power calculation, first determine the spherical Choice C is way off because it involves changing the
equivalent −8.0 + ½(+1.0) = −7.5D. Then we have to use axis by 90 degrees. Choice D could be considered, but it
vertex distance calculations to determine the power for does not make enough of an adjustment since it is only
30 degrees (1 clock hour) instead of the needed 45 Acknowledgments Authors would like to thank Rachel M. Caywood,
OD, FAAO, Dean McGee Eye Institute, University of Oklahoma, for
degrees. Again, for real-world clinical purposes, if this
her assistance in the writing of this chapter.
lens has rotated 45 degrees, we may need to assess the
BC before adjusting the axis. This example has been
given mainly for test purposes.
Physical Optics and Advanced Optical
Principles
Objectives research in this arena. More answers will likely be discovered

• To introduce other theories of light, including wave the- in the near future (and in the next version of this book).
ory, particle theory, and quantum electrodynamics. As ophthalmologists, we are masters of the sensory per-
• To understand key topics within Physical Optics, includ- ception of light, and to master it, we must understand it.
ing interference, coherence, polarization, scattering, and
diffraction.
• To review various devices and technology commonly Theories of Light
used in ophthalmology utilizing these concepts.
• To understand how lower-order aberrations (LOAs) and Is light a ray, a wave, or a particle? Well, the answer is all of
higher-order aberrations (HOAs) affect both objective the above – and more. Light cannot make up its mind, so it
and subjective visual acuity. can behave and be described as all three things, often simul-
• To discuss the effect of spherical aberration in the clinical taneous and interchangeably. Thus far, we have primarily
and surgical setting. (and artificially) conceptualized light as rays that travel in
• To understand key principles of spectral sensitivity and straight lines during our discussions of topics in most of
visual pigments. Section I. However, saying that light travels in rays is like
• To understand how lasers used in clinical practice exert saying ophthalmologists only do cataract surgery – it fails to
their effects through principles of photocoagulation, pho- encompass so many other things we do, especially our sub-
todisruption, plasma-induced ablation, photoablation, and speciality colleagues. Therefore, when it comes to light,
photoactivation. Geometric Optics (light traveling in rays) only partially
explains the nature of light. In this chapter, we will explore
some of these other theories.
Introduction to Physical Optics
Wave Theory of Light
Note to the reader: we think this is one of the coolest and most The first additional theory we can discuss is the wave theory
interesting chapters in ophthalmic optics. Though it may have of light. In this model, we can also think of light as propagat-
the least relevance for exams, many of the topics discussed in ing and expanding in three-dimensional space as a wave
this chapter have significant relevance to the current challenges with both wavelength and frequency.1 Waves can interact
and the next frontiers of ophthalmology, especially in cataract with one another by summation or cancellation, and they can
and refractive surgery. Our knowledge as a profession regard- even bend around corners (see interference and diffraction
ing some of these topics remains limited; thankfully, people sections later in this chapter, which is best understood when
much more intelligent than the authors are actively performing imagining light as waves). Imagine you are relaxing after
your board exams sitting on a dock, and you see a ripple on
the surface of a pond. Ripples are only visibly happening in
G. V. Vicente
two-dimensional space (on the surface of the water), but in
Hospital, Washington, DC, USA reality, ripples are happening vertically (underneath the sur-
face of the water) as well (Fig. 1).
K. M. Riaz (*)
Dean McGee Eye Institute, University of Oklahoma, We can visualize this in a two-dimensional space as water waves mov-
1
Oklahoma City, OK, USA ing in a straight line toward the beach.

Waves propagating
on the surface
Waves propagating
under water
Fig. 1 Ripples on the surface of a pond seemingly extend only in a

two-dimensional space on the water’s surface. However, vertical rip-
ples extend underneath the surface of the water, which serves as a foun-
dational analogy to understanding how light can travel in waves
y Fig. 3 We can visualize the Wave Theory of Light by imagining light

as waves traveling in all directions emanating from a light source
Fig. 2 Light can travel as waves in multiple directions. Here, we can

visualize light as waves that travel in the x, y, and z directions for
simplicity
When we extend this to light, we can see that light will

travel as a wave in all three dimensions (x, y, and z direc-
tions). We will refrain from discussing whether light perme-
ates the fourth through tenth dimensions because it is unlikely
to ever be tested on an exam, even as an experimental ques-
tion (Fig. 2).
Under the Wave Theory of Light, we can now imagine
Fig. 4 If a line is drawn connecting all the tangential points to each
that light emanating from a light source will travel as waves wave emanating from our light source, we can find our familiar ray of
in multiple directions (Fig. 3). light
At this point, you might be wondering if we lied to you all
along during Geometric Optics by saying that light can travel
as rays in straight lines previously, and now we are telling familiar friend, the ray of light, hiding and hanging out
you that light travels in waves. We can find our “rays” within within the waves (Fig. 4). We did not lie to you, good sir/
the waves as follows: if we draw a line connecting points that madam, because if light could not be a ray, space villains in
are tangential (at 90 degrees) to each curve, we can see our a galaxy far, far away could not have death rays!
Physical Optics and Advanced Optical Principles 187
Fig. 5 Light particles emanating from a light source are termed photons. The higher the frequency of the light source, the more energy within the
photons
Particle Theory of Light another photon, who are only too happy to connect with
The second theory is the particle theory of light, wherein we another electron.
can think of light as a particle (photon) to help us understand For example, when we discussed refraction in Geometric
how it can carry energy.2 A photon is a discrete packet of Optics, we stated that an incoming light ray will bend toward
light energy; imagine a BB pellet of light filled with energy. the surface normal and emerge on the other side. In the QED
Light with a higher frequency (e.g., the purple spectrum of theory, an incoming light particle (photon) hooks up with an
light) will have more energy than light with a lower fre- electron in the medium and travels a little bit, and then a new
quency (e.g., the red spectrum of light, Fig. 5). We take photon is emitted to the adjacent electron. This hookup-
advantage of this conceptualization of light as photons in breakup routine continues until, eventually, a photon is emit-
developing and applying lasers in ophthalmology. Due to ted at the back surface of the refractive medium as the
time travel paradoxes, we will avoid discussing photon tor- “refracted ray of light.” Interestingly enough, the incoming
pedoes until the twenty-fourth century. photon is not the same photon that emerges from the medium.
We have included QED mainly for the sake of introducing
uantum Electrodynamics (QED)
Q the topic. For the rest of this chapter, we will primarily use
Just as there is one ring to rule them all, the theory of quan- the Wave Theory and Particle Theory to explain some of the
tum electrodynamics (QED) is currently the one theory that following concepts.
unifies all other theories. While you may want to consult
other texts for a more detailed explanation of this theory, we
can simplify it: electrons and photons are like hormonally Interference
amplified young people using a social dating app – they are
constantly hooking up and breaking up. Electrons (matter) Using the Wave Theory of Light, we can imagine two waves
pick up photons (light) for a while and then leave them for meeting and forming a larger wave or two waves meeting
and canceling each other out. Both of these are examples of
interference.
Historically, Newton termed this particle as a corpuscle of light until
2 Suppose that we had a point source of light that passed
Einstein came along and named these individual packets of energy as through a barrier with two openings (Fig. 6).3 We can see that
photons, giving rise to the quantum theory of light. We are intentionally two different “routes” are open for light waves to pass
skipping some of the quantum theory of light principles because it
involves conceptualizing light as both a wave and a particle. It is some-
through the first barrier before reaching the final screen.
what a confusing theory because one is never really sure when to use
the “wave” part of light or the “particle” part of light, so we are going This is our simplified way of explaining Young’s famous “double-slit”
3
to skip it in this text. experiment.

Fig. 6 A light source passing

through a barrier with two
separate openings will
demonstrate both constructive
interference (point B) and
destructive interference (point
A
C)
Z
X
+ =
B
Y C
+ =
There are now three different “flavors” of light waves on the

final screen. As seen at point A, the first kind is light waves
that pass through the superior opening and never encounter
any light waves that have passed through the inferior open-
ing. These loner waves will have the same intensity as the
original light source. The second kind of light wave can be
seen at point B. This location is where light waves from the
superior opening and inferior opening have teamed up
together in love and harmony (“in phase”) to create a more
intensive light pattern – this is known as constructive inter-
ference. Finally, the third kind of light wave is seen at point
C. At this point, light waves from the superior opening and
inferior opening have some deep beef and simply refuse to
join forces. This now creates a less intensive light pattern
than either point A or B, known as destructive interference.
You can demonstrate this to yourself if you have access to
monochromatic light, a barrier with two openings, and plenty
of time to spend on a boring weekend afternoon.
Therefore, the Wave Theory of Light is useful because it
helps to explain how light waves can produce different inten-
sity patterns. If we only assumed that light traveled as rays
and ran those rays through the same barrier-opening setup, Fig. 7 If we only assume that light travels in rays, the resulting pattern
we can see that our diagram will artificially (and falsely) will (falsely) have equal intensity on the final screen
show that the resulting light pattern will be of equal intensity
at all points on the final screen (Fig. 7). 490 nm) to enter the eye. When the fluorescein molecule is
Fluorescein angiography is a good example of a com- excited by the incoming blue light, the molecule will, in turn,
monly used diagnostic tool in ophthalmology that takes emit a yellow-green wavelength (530 nm) of light out of the
advantage of this property of interference (Fig. 8). When fluo- eye.4 This returning “green” light, in addition to other wave-
rescein dye is injected into a patient’s arm, nearly 70–75% lengths of light “emitted” from the eye, now reaches the cam-
will remain bound to serum albumin, and the remaining 25% era a second time, where a green interference filter will block
that enters the circulation will quickly reach the retinal blood all other wavelengths of light and only allow yellow-green
supply. When the camera is first clicked, white light emerging light to be focused onto the film or a digital camera.
from the camera will pass through a blue interference filter,
primarily allowing the blue wavelengths of light (465– Here again, electrons and photons are “hooking up and breaking up”.
4
Incoming
Light
Max absorption Peak fluorescence

at 485 nm at 530 nm
Green interference filter only allows
returning yellow-green light that can then
be focused onto high-contrast film or a
digital camera with imaging software
Excitatory (blue
interference) filter
preferentially sends in
blue wavelengths of light
Fig. 8 The principle of interference is seen with both incoming and cein molecule, which in turn emits green light that “returns” back to the
outgoing light during fluorescein angiography. White light goes through camera. A green filter on the camera allows only the green light to reen-
a blue filter into the eye, and this blue light is absorbed by the fluores- ter the camera
At this point, some of you may think to yourself: “I hate You may have already guessed the answer, but yes, they
optics. I will not order any fluorescein angiograms so that I are relevant and used frequently. Coherence and interference
don’t have to deal with this interference nonsense. I can get are used in various clinical applications, such as OCT, antire-
all the information I need about the retina from OCTs.” Well, flective coatings, and modern optical biometry devices.
you may want to brace yourself for the next section.
Optical Coherence Tomography
One area of considerable relevance is optical coherence
Coherence tomography (OCT) – the word coherence has been hiding in
the “OCT” phrase that you use in the clinic all the time and
Coherence describes the ability of light waves or two parts of you may or may not have even realized it.
the same light wave to produce interference. If someone OCT uses low-coherence interferometry: long-
were to ask you to use “coherence” and “interference” in a wavelength, near-infrared light is used to penetrate into the
coherent sentence, you can puff your chest boldly and scattering medium without damaging any tissue. An optical
declare: “if two light waves can produce an interference pat- beam is directed at the tissue of interest (cornea, retina, etc.).
tern, then they are coherent.” The device’s measuring instruments collect a small portion
of this light that reflects from sub-surface features.
Types of Coherence Interferometry is then used to collect light directly reflected
For completeness, Fig. 6 displays the two types of coher- from surfaces of interest (and reject most photons that have
ence. Temporal coherence is seen with points X and Z. These scattered multiple times that cause “background noise”).
points are on two waves separated by time. If we waited for In time-domain OCT (TD-OCT), if we can time gate the
a few milliseconds, point X would be at the location of point echo train of backscatter from the tissue of interest, we can
Z (though Z would have moved on) and be the same size/ generate an image by varying the path length of the reference
magnitude as point Z. Temporal coherence is the basis for arm in time (the reference mirror is translated longitudinally).
time-domain optical coherence tomography (TD-OCT) By scanning the mirror in the reference arm, a reflectivity
imaging. profile (A-scan) of the sample can be obtained. The device’s
Spatial coherence occurs within the same wave of light. software then amalgamates multiple A-scans to generate a
Two different points on the same wave of light equidistant cross-sectional tomography image (B-scan). Approximately
from the center are considered to have spatial coherence. For 400 A-scans per second can be generated using six radial
example, in Fig. 6, points X and Y have spatial coherence. slices oriented 30 degrees apart, yielding an accuracy down to
Spatial coherence is the basis for spectral-domain optical the level of 10–15 microns.5 Basically, we are comparing
coherence tomography (SD-OCT) imaging. information about point X and point Z from Fig. 6.
xamples of Coherence in Clinical Practice

E Yaqoob Z, Wu J, Yang C. Spectral domain optical coherence tomogra-
5
At this point, one may wonder: is any of this actually used in phy: a better OCT imaging strategy. BioTechniques; 2005 Dec; 39:
ophthalmology? S6–13
With Fourier-domain OCT (FD-OCT), interference com- Antireflective Coatings

ponents are collected simultaneously without using a refer- When light reaches a lens, some of the light will refract
ence mirror to measure the target tissue. FD-OCT through, and some of the light will be reflected (away)
significantly improves acquisition speed without compro- from the lens. However, if we could add a very thin, semi-
mising image quality. There are two subtypes of FD-OCT: transparent material of approximately one-fourth wave-
spectral-domain OCT (SD-OCT) and swept-source OCT length thickness of the incoming light to the lens, we
(SS-OCT). In both subtypes, a sensor within the device ana- would have created a second reflected wave out of phase
lyzes the beam intensity generated by the interference of the with the first reflected wave and caused destructive inter-
reference arm beam and the measuring arm beam – this ference. The two waves would cancel each other out, and
includes constructive, destructive, and partially constructive very little light would be reflected (Fig. 8). The filter’s
interference. troughs and peaks would look similar to the incoming ray.
SD-OCT systems use a spectrometer and high-speed line More importantly, the filter’s peaks and troughs would
scan camera to analyze the reflected light; the SD-OCT mir- neutralize the outgoing reflected ray’s troughs and peaks,
ror is static. Clinically important information can be gath- respectively (Fig. 9).
ered by distributing returning light waves (according to Antireflective coatings are especially useful for high-
different optical frequencies) onto a detector stripe. This index lenses (e.g., some of the newer Crizal®-type materi-
allows information from the full depth scan to be acquired als) since the higher index of refraction also means there is
within a single exposure. SD-OCT takes approximately more reflection of incoming light.
20,000–40,000 scans per second to continuously image a How do opticians or optical labs apply antireflective coat-
6-mm area of interest, yielding an accuracy down to the level ings to lenses? Well, the best thing to do is to visit an actual
of approximately three microns. Basically, we can obtain lab and see for yourself – seriously, it is pretty incredible
information about point X and point Y from Fig. 6 (and all some of the things that can be done with modern technology
points in between) to generate our scan. Since SD-OCT and newer materials. As mentioned above, antireflective
devices utilize lower-wavelength light sources (approxi- coatings are customarily chosen to be approximately one-
mately 820–880 nm) with higher A-scans, they provide fourth the wavelength of incoming light. Given that yellow
images with excellent resolution compared to TD-OCT light (580 nm) is the average wavelength visible to the human
devices, although with limited tissue penetration (decreased eye, most antireflective coatings are chosen to be approxi-
depth). mately 145-nm thick. In order to form this extremely thin
With SS-OCT, the longer-wavelength (1300-nm)-depen- coating, optical labs will allow vaporized particles to slowly
dent reflected light is measured with a single detector. This condense on the lens surface until it forms a layer of approxi-
narrow band light source is then rapidly tuned over a large mately 145 nm.
optical bandwidth. The wavelength is rapidly swept within
the laser, allowing for the use of a point detector. Due to its Optical Biometry Devices
ultrafast scanning system, greater depth range, and less sen- Optical biometry devices are interferometers: they use coher-
sitivity to motion, SS-OCT allows for several million ence and interference to more accurately image the eye
A-scans per second using high-speed swept-source technol- (Fig. 10). A laser light source sends highly coherent light
ogy. Thus, SS-OCT offers deeper tissue penetration (similar toward a beam splitter; this splits half the incoming ray
to TD-OCT devices) and improved image details (improving toward the eye (red line) and the other half toward movable
upon SD-OCT devices). Of clinical relevance, SS-OCT tech- mirrors (blue line). The reflected light, both from the eye and
nology is used in the IOLMaster 700 (Carl Zeiss Meditec, the mirrors, is directed toward a photosensor which deter-
Jena, Germany), a recently introduced biometry device. mines the intensity of the reflected light by measuring both
If we thought OCT devices only dealt with coherence, we the constructive and the destructive interference of the
are in for a surprise: we also have to deal with our good old reflected light (i.e., both red and blue rays in the diagram).
friend, refraction, which distorts the acquired image. Recall The red ray will be affected by ocular structures (due to
that the OCT signal has to pass through different media (air, the change in refractive index [RI] of each structure); con-
cornea, aqueous, crystalline lens, and vitreous) with a wide structive interference will occur when these “returning” red
range of refractive indices. Therefore, the acquired image rays of light arrive at the same time as reflected blue rays.
has to compensate for these refractive effects by applying Mirrors can be moved to coincide with spikes of interest,
several previously discussed optics principles, such as Snell’s such as the anterior corneal surface, posterior corneal sur-
law, power of a refracting surface, and power of lenses in face, etc. The distance between spikes is known as the opti-
different media. cal path length (OPL) of the cornea, aqueous, etc. The length
Fig. 9 Destructive Thin film: 1/4th wavelength thick

interference can be used to a
favorable advantage in the
substrate
construction of antireflective
Glass
coatings. Some of the
incoming light (solid blue Incoming Light
wave) will pass through the
glass substrate (gray
rectangle), whereas some will
be reflected from the surface Weve reflected from glass
of the thin film (blue
rectangle). The two waves
will experience destructive
interference and will not be
seen by the observer
Outgoing Light
with destructive
interference
Weve reflected from film surface
Fig. 10 A commonly used setup for interferometry
of each segment in the eye can be determined by a simple many biometry devices in the United States, or 1.332 as used
measurement of OPL/RI; unfortunately, since we do not in many European countries) or devise one for each segment
know the “true” RI of each ocular structure, we have to either of the eye – this is known as “sum of segments (SOS),”
come up with one for the entire eye (e.g., 1.3375 as used by which is a more accurate way to measure axial length. SOS
axial length differs from the traditional axial length, espe- Polarization
cially in very short and very long eyes. Traditional axial
length tends to “underestimate” the length of short eyes and Polarization (not the political kind) of light is a term used to
“overestimate” the length of long eyes, leading to myopic describe light waves in which vibrations occur in a single
and hyperopic surprises, respectively, especially when using plane. Polarization happens whenever light waves are trans-
older-generation IOL calculation formulas. mitted, reflected, refracted, or scattered. This is another quite
In getting back to our interferometer example, if both the complex topic, and interested readers may wish to consult
red and blue rays have the same OPL, then constructive other texts for more information. We will primarily focus on
interference occurs; if the OPL is <1, then the peak of one linearly polarized light.8
wave will destructively interfere with the trough of another Polarization has many uses outside of ophthalmology. For
wave. The key principle is that we want to see some alternat- example, in addition to its influence on photography, polar-
ing patterns of interference; by using low-coherence light ization is also used to create 3D movies, which are nothing
(instead of white light, which is incoherent), we can create more than two movies filmed from slightly different camera
favorable interference patterns that the photosensor can locations. The two “films” are 90 degrees away from each
measure. other and then broadcast at the same time through two pro-
Partial coherence interferometry (PCI) and optical low- jectors; 3D glasses are basically two lenses with two differ-
coherence reflectometry (OLCR) are two of the most com- ent polarized filters – usually, one is vertical, and the other is
monly used technologies in modern biometry devices, such horizontal – that allow us to visualize “both films” that are
as the IOLMaster 500 (Carl Zeiss Meditec, Jena, Germany) then fused by our brains to give a perception of three-
and the Lenstar (Haag-Streit, Switzerland), respectively.6 dimensionality. A recent area of interest is the use of polar-
With PCI, a dual-beam setup is used: one beam to mea- ization in polarization-sensitive OCT technology (PS-OCT),
sure reflected light from the cornea and the second beam to which can measure the polarization properties of ocular tis-
measure reflected light from the retina. A mirror is used to sues and generate an OCT image by mathematical process-
increase the path length of the corneal signal. When the cor- ing (Jones matrix OCT). Collagen fibers, in particular,
neal and retinal signals are equal, interference is detected. exhibit high phase retardation and birefringence, which can
Then using the index of refraction for the entire eye (usually be used by PS-OCT devices to yield high-resolution images
n=1.3375), the entire axial length (AXL) can be measured. of the tissue of interest. The use of PS-OCT is an area to
OLCR is a bit more complicated,7 so we will instead focus monitor in the future as it continues to develop rapidly.
on the low-coherence interferometry part: low-coherence We will focus our discussion on the four most commonly
light is directed into the eye, and reflected light is measured encountered types of polarization before discussing some
by an interferometer, which interprets this reflected light examples.
from every scan point as an interference pattern and presents
it as a depth profile (A-scan). A cross section (B-scan) can Types of Polarization
also be generated at the same time.
PCI utilizes a multimodal (pulsed) laser diode (infrared Transmission
laser light, 780 nm), whereas OLCR uses a superluminescent Most “naturally” occurring light sources, such as a candle or
(continuous light) diode (820 nm). Because of the “partial” the sun, will emit light that travels in multiple directions with
portion of PCI, every measurement signal will create second- vibrations in multiple planes (unpolarized light). However, if
ary (smaller) peaks on either side of the “measured” peak; in a polarized filter is placed in front of an unpolarized light
other words, the software may falsely measure one of the source, the filter will filter out (i.e., “block”) one-half of the
smaller peaks, such as in the case of a pseudophakic patient, vibrations that pass through the filter. For simplicity, we can
which may lead to an incorrectly measured axial length. assume that all polarization is vertical or horizontal (Fig. 11).
Since OLCR uses continuous, low-coherence light, a full Imagine that the polarized filter is like a bouncer at a
A-scan can be obtained, including axial length, lens thick- nightclub that only lets in the light waves that meet the club’s
ness, corneal thickness, etc. criteria for admission. A vertical filter will only allow in ver-
tical waves, and a horizontal filter will only allow in horizon-
tal waves. Suppose light passes through a vertically polarized
6
See Chap. 26, Preoperative Optics for Cataract Surgery, for a more filter. All the horizontally oriented waves will be excluded,
detailed clinical discussion of these two devices, including the most
recently introduced swept-source OCT (SS-OCT) optical biometry
device (IOLMaster 700, Carl Zeiss Meditec, Jena, Germany).
An internal reference path is used to measure the patient’s eye by using
7
There are other “flavors” of polarization, such as circularly polarized
8
a rotating glass cube system to change the optical path length in the light and elliptically polarized light. Chocolate-chip cookie dough is
reference arm. unfortunately not an available flavor.
Fig. 11 Light waves

emanating from a light source
will have polarization in all
directions (shown only as
vertical and horizontal in the
figure). If a polarized filter is
placed in front of unpolarized
light, only light waves that are
oriented in the direction of the
filter will be transmitted on
the other side. A vertical filter
will only allow vertically
oriented light waves to pass
through
Unpolarized Vertical Vertically
Light polarized filter polarized light
and only the vertically oriented light waves will pass through from the double refraction of light may be seen. A polarized
and be transmitted on the other side. filter may be used to block one of the images and enhance the
other image. The observation of double refraction was a
Reflection foundation to the eventual Wave Theory of Light.
When unpolarized light approaches nonmetallic surfaces As an interesting bit of history, Vikings may have been
(such as asphalt, sand, etc.) and undergoes multidirectional lovers of optics too: they may have used this special crystal
reflection, reflected waves will also undergo partial polariza- as a “sunstone” to identify the sun’s location on cloudy days
tion: some of the reflected waves will be polarized, and some for navigational purposes. Due to the amount of polarization
of the waves will be unpolarized. The amount of polarization of sunlight at the Arctic Circle, the crystal’s “double index of
that happens depends on the angle of incidence of the light refraction” can be used to separate incoming light waves
waves.9 Nonmetallic surfaces will reflect a large concentra- based on the amount of polarization. In other words, on a
tion of waves parallel to the reflecting surface. This reflec- cloudy day, an ancient Viking optics nerd could move the
tion causes glare off the surface of a lake, for example, that crystal along a cloudy sky to find the sun indirectly by
further blocks our fisherman (from Chap. 1, “Geometric observing a yellow entoptic pattern, similar to, of all things,
Optics”) from being able to find his fish underwater.10 For Haidinger’s brush, an example we will discuss in greater
simplification, we can divide polarization of reflected light detail below.11 We have no information on whether the good
into horizontal and other (e.g., vertical, etc.) types. When we Wilhelm Karl von Haidinger (an Austrian physicist) was
consider a surface, such as the fisherman and the lake, much descended from Vikings.
of this reflected light is horizontally polarized. Therefore, a
pair of sunglasses with vertical filters will help our fisherman Scattering
the most; we will discuss this example in greater detail in the When light waves encounter atoms within a material, they
next section. will cause additional electromagnetic vibrations within the
medium that subsequently cause a series of absorption and
Refraction re-emission of light within the medium.12 This is known as
We have previously defined refraction as incoming light scattering. We will discuss scattering further in the next sec-
(rays or waves) bending as they pass from one medium into tion, but for now, we should understand that scattered light
another. We can build upon this understanding by adding that also has significant directional polarization. For example,
the refracted beam will acquire some degree of polarization, the polarization of scattered light is seen on a clear day with
usually perpendicular to the surface. A famous example blue skies as glare in the skies. Photography in these condi-
often used in undergraduate physics classrooms is that of the tions requires a polarizing filter to reduce the glare and
Iceland Spar double-refracting crystal. If an object is viewed increase the “blueness” of the photographed sky. These
by looking through this crystal, two images that have resulted polarizers can be rotated to achieve desired contrast effects
under various lighting conditions.
This is known as the Brewster angle, using the formula, wherein nt and
9
ni are refractive indices of the transmitted and incident mediums,

respectively. Basically, at this angle, all of the reflected light is polar- See also Chap. 26, Preoperative Optics for Cataract Surgery, for addi-
11
ized (linear polarization). tional information.

Remember he must throw his spear in front of the fish.
10
The same electron-photon hooking up and breaking up
12
Fig. 12 Polarized light waves

can be simplified as traveling
along the horizontal (x) or the
vertical (y) axis
Examples of Polarization What if we could create a filter to block off light traveling
Within ophthalmology, three common clinical scenarios are along the vertical (y) axis? If we place a horizontal filter in
worth mentioning about polarization. Multiple types of front of the light source, all the vertically oriented light
polarization are present in these examples, but we will try to waves will be blocked by the filter, and only the horizontally
highlight the main type(s) of polarization to reinforce the oriented waves will pass through (Fig. 13A). An observer
previous discussion. standing at point A will see a diminished amount of light
(dimmer light intensity) since the first (horizontal) filter has
Polarized Sunglasses blocked half the light.
Recall our fisherman (it seems we shall never be rid of this Now suppose that we placed a vertically oriented filter as
fellow) who was having difficulty finding fish under the a second filter in this system. This second filter will block out
water’s surface. After we have educated him in Chap. 1 all horizontally polarized light waves, as shown in Fig. 13B.
“Geometric Optics”, suppose he now complains about the As there are a negligible amount of vertical light waves
glare caused by the polarization of reflection (multidirec- remaining at this point, an observer at point B will not be
tional polarization): able to see any light waves from the candle.
Now, back to our fisherman. Instead of giving him
Fisherman: “Doc, can you give me some intensely dark glasses, we can instead offer him polarized
really dark sunglasses that I can sunglasses with a vertical filter that will block out all hori-
use in case I ever get trapped on zontally polarized light waves and only allow in vertically
an island and have to spear fish oriented light. This construction works since most light
again?” reflected from roads, bodies of water, and windshields will
Ophthalmology resident: “Sure, here you go. And don’t be polarized along the horizontal plane. Therefore, a vertical
plan any more vacations because filter will block out these horizontally polarized light waves
you are not very good at fishing and reduce his glare and sensitivity in bright light
if you get trapped on an island conditions.
again.”
Fisherman (puts on “But doc, I can’t see anything.” Crossed Polarizers and Polarized Microscopy
the dark glasses): We can also take advantage of polarization in the ophthalmic
pathology lab, for example, when trying to visualize sub-
At this point, the ophthalmology resident may be tempted stances that demonstrate birefringence, such as amyloid seen
to call in a psychiatry consult. Instead, we should realize that in lattice corneal dystrophy. Birefringence is a unique optical
we can offer this patient a special lens that can significantly property wherein a material can have a different refractive
reduce glare without making lenses too dark. We can take a index depending on the polarization and direction of incom-
step back and remember how polarized light travels: even ing light.13 In other words, such materials can demonstrate a
though polarization happens in all directions, for the sake of “double refraction” of light in a transparent material.
simplicity, we will limit polarization to either the horizontal
(x) or the vertical (y) axis (Fig. 12). Remember the Iceland spar crystal discussed previously?
13
Fig. 13 A horizontal filter

will block all vertically
oriented light waves. An
observer at point A will
perceive this as a dimmer
light source. A second filter
(vertical filter) placed at point
B will block all horizontally
oriented light waves. An
observer at point B will not
perceive any light waves from
the initial light source a b
Anisotropy refers to a non-equal, non-uniform distribu- Polarized light microscopes contain two polarizers: one
tion of properties within a material. Depending on which positioned before the specimen and one positioned after the
direction the material is analyzed, the observed properties of specimen (as shown in Fig. 14). As light passes through the
the material can be quite different. When light enters the true microscope, the plane-polarized light will interact with a
optical axis of anisotropic materials such as amyloid, all the birefringent specimen to create two individual wave compo-
light will pass through at a single speed. However, if light nents oriented perpendicularly to each other. These light
enters in a direction away from the true optical axis of that components are then recombined through constructive and
material, then it will undergo double refraction or destructive interference as they pass through the analyzer.
birefringence. Polarized light microscopy takes advantage of this contrast
Crossed polarizers can be useful in microscopy. A bire- to improve the quality of images of birefringent materials. So
fringent substance placed between both filters will refract even you, ophthalmic pathologists, cannot escape optics!.
light, causing some of the light to no longer be on the hori- The retinal nerve fiber layer (RNFL) is also highly bire-
zontal plane (Fig. 14). This shifts the “horizontal” light to a fringent: incident light undergoes polarization as it passes
slightly different position, allowing it to pass through the through the RNFL. Scanning laser polarimetry takes advan-
second (vertical filter). tage of this polarization to measure the RNFL thickness.
When amyloid is stained with Congo red, it is said to Interestingly enough, the cornea also polarizes some of the
demonstrate “apple-green birefringence” in polarized incident light, so there is a mechanism in the device that
light. You’ve probably memorized that fact from other texts, compensates for the corneal polarization effects. So even
including the Marilyn Monroe mnemonic for corneal dystro- you, glaucoma specialists, cannot escape optics!.
phies, abnormality, and relevant stains. But what does that
mean exactly? The birefringence of Congo red varies with Haidinger’s Brush
wavelength of incoming light waves and includes both nega- This topic is another “rite of passage” type of question that
tive birefringence (blue light) and positive birefringence may come up infrequently. See also Chap. 26, “Preoperative
(yellow light). When mixed together, this will produce green Optics for Cataract Surgery” for more information about this
light. When the polarizer and analyzer are uncrossed, bire- topic. Haidinger’s Brush refers to a technique wherein the
fringence effects are removed, and instead dichroic effects examiner can use a lens (such as a lens from a pair of polar-
appear, changing the observed light from green to red. This ized sunglasses) to rotate polarized light in front of a blue-
asymmetry of effects – the birefringent “green” light and white background to create an entoptic phenomenon that the
dichroic “red” light – can be used by pathologists to confirm patient may perceive as a yellow light. The “spinning” nature
the presence of amyloid. of the yellow light creates a “brush” (rotating yellow and
Fig. 14 Cross polarizers can be used to visualize a material of interest by highlighting its anisotropic optical qualities
blue patterns perpendicular to each other) that can be better presence of EF, the brush can be presented to a suspect
described as a propeller-like phenomenon that the patient patient. If a patient has EF, the brush will appear away from
can visualize as the brush is centered on the fovea.14 the fixation point since the brush will fall on the foveal cen-
The perception of the “brush” of yellow light is thought to ter (Fig. 15, panel B). The brush phenomenon can also be
be due to the dichroism of xanthophyll pigment in the macula used to break EF, as during therapy, the patient may point
as some pigment molecules are arranged circularly. Because to the brush instead of the eccentric fixation point (Fig. 15,
the fovea is not flat, some nerves will run orthogonal to the panel C). Eventually, the goal would be to get the patient to
central fovea, while other nerves will run parallel. be able to superimpose the brush with the fixation point.
This arrangement creates different areas of the fovea that are Finally, Haidinger’s Brush may also be used to diagnose
sensitive to two different degrees of polarization. macular degeneration in older patients, similar to an Amsler
The classic use of Haidinger’s Brush is to assess vision grid. If a patient has macular degeneration, the brush pattern
potential in a patient with dense cataracts. If the patient can would be incomplete or disrupted, raising the suspicion of
see the “brush,” this implies that macular function is present, clinically significant macular degeneration.
and the patient has good vision potential with cataract sur- Basically, no ophthalmologist can ever escape optics
gery. Of course, other instruments such as pinhole acuity and (insert evil maniacal laugh).
potential acuity meter (PAM) may be easier to use for clini-
cal testing purposes. Scattering
This test has two other uses that we can comment upon When light interacts with particles similar in size to its wave-
briefly. First, it may also test for and break eccentric fixa- length, it can scatter (“spread out”) in all directions.
tion (EF) in strabismus patients. In order to confirm the Technically, scattering is due to electron effects on photons
of light, primarily occurring during reflection and refraction;
Note: the “brush” used to describe this entoptic phenomenon can be a
14
we observe these fascinating interactions as the visible
misleading term since it more closely resembles a propeller. appearance of colors.
Nevertheless, since Haidinger described it as a brush, we will maintain
the nomenclature, but it may be easier to understand this as a propeller
There are several types of scattering worth reviewing, as
shape instead. discussed below.
a b c
Fig. 16 The sky appears to be blue at noontime due to effects of

Rayleigh scattering
clouds. You can use a glass bowl filled with water and sprin-
Fig. 15 Haidinger’s Brush may be used to screen for and break eccen-
tric fixation (EF). A patient without EF will have overlap of the fixation
kle in a few drops of milk. Using a flashlight as a proxy for
point (FP, red circle) and the Haidinger’s brush (HB, yellow propeller) the sun at noontime, if you shine it from straight above, you
(panel A). A patient with EF will have an FP that will be either nasal or will see a blue tinge to the bowl; if you shine it from the side
temporal to the HB. Screening for EF (panel B) will be positive if a of the bowl (mimicking a sunrise/sunset), you will see a red
patient points to the FP (arrow) instead of the HB since the HB is falling
on the macula. With therapy to break EF, a patient may learn to eventu-
tinge to the bowl.
ally point to the HB (arrow) instead of the FP (panel C) Fun fact: due to the lack of an atmosphere on the moon, if
we looked up at the “sky” from the moon’s surface, it would
appear black because no scattering occurs due to the lack of
Selective Scattering (Rayleigh Scattering) atmosphere. Similarly, if we were on the surface of Mars, the
This type of scattering occurs when incoming light waves sky would appear pink-red due to the unique combination of
interact with microscopic particles (smaller than the incom- particles in Mars’ atmosphere that cause selective scattering
ing wavelength of light). For example, because air molecules of the red wavelengths.
are extremely small in size, they are more effective at scatter-
ing shorter wavelengths of light (blue and violet) than longer Tyndall Effect
wavelengths (red and orange). Technically, this is not a “pure” form of scattering, but we
This type of scattering also helps us answer the proverbial can group it here because it is a similar concept. The Tyndall
rite of passage question: “Why is the sky blue at noon and effect is restricted to scattering that happens because of par-
red-orange at sunset?” ticles present in a suspension that make the incoming light
Before light from the sun reaches Earth’s surface, it inter- beam “visible.” Again, we can recall that shorter wavelengths
acts with the molecules in our atmosphere (Fig. 16). Since are reflected more due to scattering while longer wavelengths
air molecules are small in size, they are good at scattering are transmitted. We can see two routinely encountered clini-
shorter wavelengths of light; as a result, blue light is scat- cal applications of the Tyndall effect:
tered approximately 16 times more than red light. Since sun-
light includes all colors of the rainbow, violet and blue • Visualization of cell and flare in the anterior chamber –
wavelengths will scatter more and appear to come not just light waves get scattered by white/red blood cells and pro-
from the sun but from all over the sky. There is the highest teins in the aqueous humor, allowing the examiner to
amount of blue light scattering at noontime because longer assess the amount of flare present. The next time you get
wavelengths (red) continue on a straight path without being scolded for incorrectly grading the cell and flare in a
scattered toward an observer’s eyes. The red wavelengths of patient, take solace that at least you know the Tyndall
light are obviously still present, but there is so much scatter- Effect and now must focus on using it clinically.
ing of blue light happening at this time that it is “blocking” • Visualization of blue-green iris – There is less melanin
the red light from being visible. At sunset, we can think of and collagen present in patients with blue/green eyes in
the blue light as having “finished scattering” so now we can the iris stroma. As a result, incoming light waves will
observe longer wavelengths of light (red/orange) at this time. undergo “backscattering” toward the observer. As a result,
If you are incredibly bored on a weekend, you can see the observer will see shorter wavelengths (blue) much
Rayleigh scattering without having to take a trip up to the more prominently as longer wavelengths will get absorbed
by the pigment epithelium. There is a higher melanin con-

centration in the iris stroma in patients with brown eyes.
As a result, a higher percentage of light waves will get
absorbed and not “backscatter” to the observer, giving the
appearance of “brown” eyes.
Mie Scattering
This type of scattering occurs due to particles that are the
same size as the incoming wavelength of light. Another way
of thinking about this type of scattering is that it deals more
with forward scattering as compared to backward scattering.
For example, water droplets in clouds will cause scattering
of incoming light waves, giving a white cloud’s classic
appearance.
Clinically, Mie scattering is relevant both before and after
cataract surgery. For example, lens changes (e.g., cortical
spoking), and associated Mie scattering can be seen as the
“whiteness” of the cataract on clinical exam. For the patient,
because this incoming light is getting scattered by cortical
spokes, there is loss of objective visual acuity and
increased subjective complaints such as increased glare.
After cataract surgery, Mie scattering helps to explain some
of the degradation of visual quality that occurs due to subsur-
face nanoglistenings (SSNGs) that may occur postopera-
tively on particular acrylic intraocular lenses. Light scatter
from off-axis light that strikes SSNGs causes forward scat- Fig. 17 Diffraction can be seen when a light wave passes through an
tering (rather than the previously discussed backscattering). aperture. Longer wavelengths (red) will undergo more diffraction than
The Strehl ratio is used to define the height of a point spread shorter wavelengths (blue)
function compared to an ideal diffraction-limited system for
on-axis (as compared to off-axis) light. A higher Strehl movement, there is a subsequent change in direction as light
ratio is desirable, as this means that there is less Mie scatter- waves seek alternative paths of movement. Seemingly, light
ing. IOLs with low Strehl ratios (secondary to SSNGs) are appears to find a way to bend around corners – what is hap-
more likely to cause subjective degradation of visual acuity, pening, as you might have guessed by now, is that incoming
leading to the classic “20/unhappy” patient. While tempting, light photons are engaging in various shenanigans with elec-
a YAG capsulotomy will not improve visual quality in these trons at the edge of the material.
situations as the cause for decreased visual acuity lies in the This change in direction is known as diffraction. The
IOL itself, not in the posterior capsule. amount of diffraction increases with longer wavelengths (red)
and decreases with shorter wavelengths (blue) (Fig. 17). If
Geometric Scattering the wavelength of waves is smaller than the obstacle, then no
Geometric scattering occurs when incoming light encoun- noticeable diffraction will occur. Note that this is the opposite
ters much larger particles than the incoming light waves. A of refraction, wherein shorter wavelengths (blue) are bent
commonly seen example is a rainbow (or maybe even, wow, much more than longer wavelengths (red).
a double rainbow!) because when light encounters water Diffraction will occur whenever light passes through an
molecules (which are larger than incoming light waves), opening, such as the pupil. Recall that the Airy disk phenom-
scattering that happens during refraction and reflection enon describes the best-focused spot of light that a perfect
accounts for the breakdown of incoming light into colors of lens with a circular aperture can make. When light passes
the rainbow. through any aperture, diffraction will cause a pattern that
looks like a target, a bright central region with a series of
Diffraction concentric rings of decreasing intensity (dimmer rings)
We briefly introduced the concept of diffraction in Chap. 1, around it. A larger aperture will create a smaller Airy disk
Geometric Optics, but will explore it further here. When pattern, whereas a smaller aperture will create a larger Airy
light waves encounter an opening or barrier in their path of disk pattern (Fig. 18).
Fig. 18 Diffraction increases

as the aperture size decreases.
The Airy disk pattern will be
larger and have a noticeably
brighter central region as it
passes through a smaller
aperture (as compared to a
larger aperture)
Large Pupil Airy Disc Pattern
Light Source
Small Pupil
Furthermore, longer wavelengths (red) will create larger Essentially, there must be a compromise in the size of the
Airy disk patterns compared to shorter wavelengths. The size opening to maximize the number of paraxial rays that strike
of the Airy disk (Θo) can be calculated using the equation15: the retina while minimizing the deleterious effects of both
diffraction and spherical aberration.
Θo ≈ 1.22 ∗ ( λ / D )
We can now discuss three common scenarios where the
principle of diffraction may be evident.
In this equation, λ is the wavelength, and D is the size of the
circular aperture. Therefore, the brightest Airy disk pattern will Optical Corona
be produced by longer wavelengths of light that pass through a An optical corona (not the virus!) may be seen due to the dif-
very small aperture. As Airy disk patterns from different points fraction of sunlight or moonlight by small water droplets in
of an object of interest are formed, they may begin to overlap, the atmosphere (similar to scattering) that creates a concen-
causing constructive interference to reduce contrast and even- tric pattern of rings around the object (e.g., moon) with a
tually becoming indistinguishable from each other. bright central area (aureole). The aureole may appear to have
For example, if we consider light that passes through the a circular rainbow appearance, with a blue-white center and
pupil (a circular aperture), light at the edge of the pupil will red-brown peripheral edge – confirming our previous discus-
get diffracted much more than light at the center of the pupil. sions about longer wavelengths of light undergoing more dif-
If we make the pupil smaller, we can increase the theoretical fraction. A similar phenomenon known as “rainbow glory
number of paraxial rays that can reach the fovea, but the final (morning glory)” may also be seen in the atmosphere. The
visual acuity will be limited by diffraction. If we make the glory is caused by multiple optical properties (such as inter-
pupil bigger, the final visual acuity will be limited by higher- nal refraction, wave tunneling, etc.), including diffraction.
order aberrations, predominantly spherical aberration (dis- The next time you are on a plane during a daytime flight, you
cussed in the next section). When the aperture is extremely may be able to see the corona if the sun is above and behind
small, recall that longer wavelengths (red) of light will get the plane and you look down at the clouds – you can consider
diffracted in a higher ratio than in a larger opening. this if the in-flight movie selection is extremely boring.
Pinhole Testing
This is a simplified form of the classic Airy disk diameter equation,
15
In clinical practice, we often employ the pinhole test to mea-
Θo ≈ 2.44λ*(f/D), previously given in Chap. 1, where D is the exit pupil
sure a patient’s potential visual acuity. When the patient
diameter and f is the focal length. The classic equation requires more
math so we can use the simplified one to illustrate learning points from looks through this 1.2-mm hole, we have maximized the
the text. number of undeviated paraxial light rays that strike the retina
while limiting negative effects of diffraction (perceived as instead, this light will form an irregularly shaped blob with
blur by the subject). If we made the pinhole any smaller, then some areas brighter than others. This “blob” is known as the
adverse effects of diffraction would outweigh the increased point spread function (PSF); in other words, the PSF
number of paraxial light rays. Therefore, we can say that at a describes the quality of the image: how light from a single
1.2-mm-sized opening, we have an increased depth of focus point in the object will “spread” out as it forms the image.
and limited negative effects of diffraction. Recall that pin- Therefore, every image we see is a combination of various
hole testing can correct up to 3D of refractive error if due to PSFs from a given object that form the image.
corneal or lenticular pathology but may reduce the visual Paraxial light rays will create relatively small PSFs; how-
acuity if the refractive error is due to retinal pathology. ever, “peripheral” light rays will not focus stigmatically.
These peripheral rays will cast large PSFs – it is these trou-
Diffractive Multifocal IOLs blemaker light rays that cause most optical aberrations.
Diffractive multifocal intraocular lenses (DMFIOLs) and all However, nonparaxial light rays also contribute to image
diffractive-optics advanced technology (presbyopia-brightness and depth of focus.
correcting) IOLs, such as diffractive-optics extended depth A wavefront is a term used to describe the physical trans-
of focus IOLs and trifocal IOLs, take advantage of diffrac- mission or propagation of a ray of light. In other words, a
tion to enhance near and intermediate vision. When light wavefront is what happens to light as it gets affected by com-
waves encounter microscopic steps (diffractive zones) on a ponents of an optical system (such as the cornea and the
DMFIOL optic, parts of the incoming light wave will slow crystalline lens). Wavefront analysis can be used to measure
down, change direction, and instead be directed toward dis- parallel light waves that enter the eye and undergo distor-
tant and near focal points. The height of the step will deter- tions creating aberrations. An aberration is a term used to
mine which focal point the incoming light will be directed describe distortions and deviations of light waves from an
toward. If the step height is the same wavelength as the ideal wavefront pattern. Ideally, we would want the “shape”
incoming light, all incoming light will be directed to the near of the light going into the eye to equal the “shape” of the
focal point. If the step height is a smaller fraction of the light that comes out of the eye, but this (almost) never hap-
wavelength, it will direct more light toward the distance pens because of aberrations.
focal point. Therefore, DMFIOLs use a combination of vary- We can use an analogy to reinforce this concept further:
ing step heights to split incoming light towards the distance, imagine that light rays emanating from an object toward the
intermediate, or near focal points. We will discuss more eye are like Black Friday shoppers departing from the same
about this technology in Chap. 27, “What’s on the Menu: location and headed for the same store (the reference sphere of
Overview of Currently Available IOLs” the eye) that is giving away 80″ high-definition TVs for the first
ten shoppers. Some of these shoppers are faster than others;
others are able to squeeze into the store through side doors, etc.
Optical Aberrations The geometric wavefront is a snapshot of where all these shop-
pers are when the fastest shopper enters the store; the wavefront
Note that throughout this section, we will flip between refer- aberration of each shopper (light wave) is the time at
ring to light as rays and waves because some concepts are which each subsequent shopper enters the store (reference
easily understood using Geometric Optics and other con- sphere) as compared to the first shopper (who got the big TV).
cepts using the Wave Theory of Light. A wavefront, therefore, captures light rays that pass
The human eye is an “imperfectly perfect” system. When through an optical system at a given time (this is known as
a ray (or wave) of light goes into the eye, it will undergo dis- isochronic, or equal-time, surface). In an ideal optical sys-
tortion by the cornea and the crystalline lens; therefore, it can- tem, every point of light from an object would come into
not cannot be focused at a single point on the retina. Some of focus at the same location on the retina. We could place an
these distortions are actually quite helpful, as they may artificial sphere (known as the reference sphere) anywhere in
increase depth of focus and depth perception. Other distor- the optical system to show the uniformity of light. However,
tions may degrade subjective visual acuity and can only be as discussed above when introducing the PSF, this is not the
measured using special imaging devices. Several definitions case: light is unruly, and incoming light, like Black Friday
are important to know before we continue our discussion. shoppers, does not pass through the optical system in a
single-file, orderly fashion. The wavefront is more useful
because it shows where all the “behaving” and “not-
Wavefronts and Aberrations behaving” light (aka aberrations) is at a given point in time
when compared to the reference sphere. Therefore, the wave-
Light emanating from a real object will pass through an aper- front is an irregularly shaped smooth surface that shows
ture (such as the pupil) and not focus in a perfect circle; these aberrations.
We can divide our discussion of optical aberrations into At this point, dear reader, you may be wondering why
two main categories: lower-order aberrations (LOAs) and we care about all this terminology. This is one area of
higher-order aberrations (HOAs). A combination of LOAs Ophthalmic Optics wherein significant recent develop-
and HOAs is usually present in any given eye, and these can ments have occurred. More will undoubtedly occur in the
be further subclassified into distinct entities. We can use a near future, especially regarding cataract and refractive
Zernike polynomial (a mathematical equation) to describe surgery. For example, understanding a wavefront will
and visualize wavefront aberrations (usually arranged in a help one appreciate the significance and differences
hierarchical pyramid shape). The more significant aberra- between wavefront-guided and wavefront-optimized
tions are visually represented at the base of the pyramid, and excimer laser ablation strategies. These topics will be
the less significant aberrations are at the peak of the pyramid discussed in greater detail in Chap. 30, Optics for
(Fig. 19). Zernike reconstruction involves using about 36 Refractive Surgery.
data points to generate a wavefront pattern. More recently, We can measure aberrations using aberrometry.
Fourier reconstruction is another strategy to analyze data Aberrometry measures distortions that a wavefront of light
from any shaped pupil and provides more information to undergoes as it passes through the cornea and the crystalline
treat irregularly shaped corneas using about 240 data points. lens. The most common method of aberrometry, Hartmann-
Even though over 65 total aberrations (up to the eighth Shack aberrometry (HSA), involves using a device (aber-
order) have been identified, the human eye can only perceive rometer) that can send a monochromatic beam of light into
distortion effects from optical aberrations only up to the fifth the eye (Fig. 20). After this light passes through the cornea
or sixth order. We will limit our discussion up to the fourth- and the lens, it will reach the retina and be reflected back
order aberrations. toward the aberrometer. This reflected light from different
Fig. 19 Classification of lower-order aberrations (LOAs) and higher- be corrected with manifest refraction. HOAs can only be measured by
order aberrations (HOAs). LOAs are located toward the top of the pyra- wavefront aberrometry
mid, and HOAs are located toward the base of the pyramid. LOAs can
a b
Charged Coupled
Lenslet array Device
Reflected light
Fig. 20 Aberrometry involves generating a wavefront analysis of the array in the aberrometer and then onto a charged coupled device (CCD)
eye’s optical system to measure both lower-order aberrations (LOAs) (panel B). These data are compared to data from an ideal optical path-
and higher-order aberrations (HOAs). A monochromatic beam of light way and used to map out LOAs and HOAs (panel C)
goes into the eye (panel A), which is reflected back toward a lenslet
points of the optical path is captured by a lenslet array and Ray-tracing aberrometry (RTA) is another method of
then onto a charged coupled device (CCD). The computer in measuring optical aberrations that differs from Hartmann-
the aberrometer uses the CCD data and compares them to an Shack – in this method, ray tracing is used to measure “for-
ideal optical pathway; resulting differences (known as the ward” light rays sent into the eye (rather than reflected) to
optical path difference, or OPD) are then used to map out calculate LOAs and HOAs. These aberrations can be quanti-
both LOAs and HOAs visually. In other words, we are look- fied (in microns) and graphed visually to give the examiner
ing at how the light sent into the eye differs from an ideal an appreciation for the LOAs and HOAs present in the
light path – these differences are LOAs and HOAs. One limi- patient’s eye. RTA can also simulate how a letter will appear
tation of HSA is that because it measures reflected light, we to the patient and show PSF values and a refractive map at
can only measure “reverse” aberrations as a proxy for the various points on the cornea.
“forward” aberrations happening to light waves going into Aberrometry (both HSA and RTA) has a variety of uses
the eye. A helpful analogy is to think that we are measuring in clinical practice, including but not limited to pre-refrac-
the shadow of a tree to measure the height of the tree: the tive surgery assessment of candidates for laser refractive
height of the shadow may vary depending on the sunlight surgery; assessment of LOA/HOA due to the cornea vs. the
(based on the time of day), so this method has some limita- lens; pre-cataract surgery assessment of candidates for
tions in its accuracy. advanced technology intraocular lenses; and postsurgical
While manifest refraction can describe the sphere and assessment of unhappy patients after refractive and/or cata-
cylinder (LOA) present in the eye, it cannot measure HOAs ract surgery.
in the total optical system as a wavefront aberrometry can.
Aberrometry allows us to measure both refractive errors
(such as myopia, hyperopia, and regular astigmatism) and Lower-Order Aberrations
the decreased vision quality due to HOAs. The term “aber-
ropia” is a portmanteau that is rapidly gaining popularity for As discussed previously, lower-order aberrations (LOAs) are
describing this combination of objective and subjective commonly encountered refractive errors seen in clinical
refractive errors. practice, such as sphere and regular astigmatism (cylinder,
including axis). These refractive errors can be easily detected

on manifest refraction and can be adequately corrected with
glasses and soft/toric contact lenses.
Higher-Order Aberrations
Higher-order aberrations (HOAs) cannot be measured during Fig. 21 Spherical aberration – peripheral light rays (blue) will be
manifest refraction. HOAs may contribute up to 20% of a refracted more than paraxial light rays (green). Increased pupil size will
patient’s subjective refractive error and can be a significant increase the amount of spherical aberration noticed by the patient. A
cause of the “20/unhappy” patients – these are patients that patient may report this as glare and halos, especially in mesopic and
scotopic light conditions
objectively may correct to ≥20/25, especially after cataract/
refractive surgery, yet are bitterly unhappy with their vision.
An inexperienced practitioner may be at a loss (or frus- directly on, or even slightly posterior to the retina), SA con-
trated!) in dealing with these patients and addressing their fers increased depth of field and helps with stereo-depth per-
complaints. ception. Thus, having a small amount of “Goldilocks” SA
In the previous section, we discussed how optical aberra- may confer some benefits.16
tions occur due to the deviation of light as it passes through However, drawbacks of SA are many, including, but not
the eye. Patients will usually not report to the examiner: “I limited to:
am experiencing a higher-order aberration.” Instead, patients
may describe HOAs as a combination of glare, halos, star- • Night myopia – More peripheral light rays will fall in
bursts, and ghosting that contribute to subjective complaints front of the retina in an otherwise emmetropic patient
of poor vision. Most HOAs comes from the anterior corneal because of increased pupil size in low light conditions.
surface and the lens; a small, clinically insignificant amount Such patients, especially those with light-colored irises,
may come from the posterior corneal surface (and even the may experience up to −0.50D myopia and may require
retina). spectacle correction, especially in low-light conditions
Risk factors for HOAs include but are not limited to, cor- (such as long periods of driving on dimly lit roads at
neal disease (scars, Salzmann nodules, etc.), large pupil size, nighttime).17
lenticular opacities, increased age, and post-refractive sur- • Point image halos and glare – in addition to the night
gery, especially if done with conventional ablations (i.e., myopia, patients may subjectively experience increased
excluding wavefront-guided and wavefront-optimized spherical aberration as glare and halos, significantly
ablations). worse in low-light conditions.
While there are many HOAs, we will focus our discussion • Decreased contrast sensitivity – this is perhaps the biggest
on the three most important ones: spherical aberration, coma, reason why spherical IOLs (discussed below) are not
and trefoil. commonly used in surgical practice today. Increased
spherical aberration will inversely affect contrast sensitiv-
Spherical Aberration ity18; while the objective vision may still be good, the sub-
Spherical aberration (SA) is the most important of the three jective visual quality in a patient without significant
HOAs that one must know about as it has significant implica- spherical aberration will be much higher than the subjec-
tions on clinical and surgical practice. tive visual acuity in a patient with significant spherical
When light rays pass through the cornea and the lens, they aberration. Furthermore, a patient with pre-existing mild-
are not passing through spherical surfaces; in fact, they are moderate glaucoma who undergoes cataract surgery with
passing through four refractive surfaces (anterior/posterior
cornea and anterior/posterior crystalline lens). Recall that For the sake of thoroughness, this last point is also controversial.
16
both the cornea and the lens are aspherical surfaces: there is Some experts argue that SA, by definition is an “aberration”,
different curvature at the periphery compared to the center. and degrades the image. Whatever increased depth of focus conferred
As a result, peripheral light rays are refracted (bent) more by SA is lost when focusing at near due to pupil constriction (which
will eliminate peripheral rays and only allow in paraxial rays). It is
strongly than paraxial rays. They will thus come into focus beyond the scope of this text to settle this debate, and this point has
slightly closer, that is, in front of the retina compared to their been introduced as a footnote merely for the sake of presenting a sam-
paraxial friends (Fig. 21). pling of this debate. Interested readers are encouraged to consult other
sources for more information.
Advantages and Disadvantages of Spherical See Chap. 21, Clinical Problems with Optics and Refractive
17
Manifestations, for more information on this topic.

Aberration
Piers PA, Manzanera S, Prieto PM, Gorceix N, Artal P. Use of adap-
18
The most significant advantage of SA is that since incoming tive optics to determine the optimal ocular spherical aberration. J
light rays land at different locations (either anterior to, Cataract Refract Surg. 2007 Oct;33(10):1721–6
a spherical IOL may test falsely worse on postoperative Patients may perceive spherical aberration as star-shaped
visual field testing due to the loss in contrast sensitivity. glare or halos around point sources of light (Fig. 23).
On wavefront imaging, spherical aberration gives the Positive Vs. Negative Spherical Aberration
shape of a grapefruit/orange squeezer device (Fig. 22). This Positive spherical aberration means that more peripheral light
image represents how peripheral light rays will come into rays are refracted and come into focus in front of the retina as
focus before central light rays. compared to paraxial light rays, causing a myopic shift; this is
Fig. 22 Visual representation of the three most common higher-order aberrations: spherical aberration, coma, and trefoil
Spherical aberration
Coma
Multiple HOAs
Trefoil
Fig. 23 Patient perception of spherical aberration, coma, and trefoil. Frequently, multiple HOAs are present, leading to a combination of visual
distortions (image credit, https://lasikcomplications.com/hoa.htm)
This observation is admittedly a generalization because

a SA itself is not a static figure: not only does it change with
age but it changes even with pupil size and accommodation.
For example, low-light conditions that increase pupil size will
increase positive SA; however, accommodation by the crys-
talline lens will induce additional negative SA power (approx-
imately −0.05 μm per 1D accommodation). Thus, SA can
+SA
range from slightly positive (e.g., when focusing at a distance
target in low-light conditions) to slightly negative (e.g., when
focusing on a near target in bright-light conditions). The
b
mean net value for spherical aberration in an average popula-
tion is approximately +0.27–0.36 μm (SD = 0.31).20
Recently, SA has gained attention in topics such as myo-
pia control. Some experts have suggested that intentionally
increasing positive SA may help bring even more peripheral
light rays anterior to the retina to reduce image focus poste-
rior to the retina (“hyperopic defocus) and subsequently slow
-SA down axial length increase and myopia progression in young
patients. This topic merits additional discussion, as we will
Fig. 24 Positive vs. negative spherical aberration. In positive spherical see in Chap. 24, Myopia Control.
aberration (panel A), peripheral light rays (red) will focus anterior to
paraxial rays (blue), as seen in myopic eyes. In negative spherical aber- As we age, the net positive spherical aberration increases:
ration (panel B), peripheral light rays (red) will focus posterior to par- we typically develop more positive SA in the cornea, but at
axial rays (blue), as seen in hyperopic eyes the same time, as the crystalline lens undergoes cataract for-
mation, its SA changes from negative to positive as well. This
expressed in microns (Fig. 24). Negative spherical aberration explains why some of the more popular aspheric IOLs have
is the opposite of the above and will cause a hyperopic shift in negative spherical aberration built into the IOL to “restore”
refraction. SA is very much dependent on pupil size: more some of the negative SA present in the natural lens.21
positive SA is present in the eye when pupil size
increases. Furthermore, refractive error may compensate for Corneal Vs. Lenticular Spherical Aberration
SA at larger pupil sizes but may introduce defocus at smaller While it seems redundant, we will repeat this for emphasis:
pupil sizes. For example, a large pupil size (e.g., 6 mm may the cornea has positive SA, and the crystalline lens has nega-
introduce +0.17 to +0.27 μm of SA) that may be neutralized tive SA. However, as the eye accommodates for near targets,
with minimal myopia (-0.25 D) in pseudophakic patients. This the lenticular SA becomes even more negative; with suffi-
may seem counterintuitive, but in such patients, the central cient accommodation, there is so much negative lenticular
part of the pupillary aperture is slightly hyperopic (relative to SA that it reverses the eye’s SA from positive to nega-
the peripheral pupil), balancing mild myopia. Nonetheless, tive. Some authorities propose that having negative SA in
minimizing SA will always yield the best quality of vision. pseudophakic presbyopic patients may help with near tasks
Finally, to further complicate this (confusing) discussion, as the postoperative negative SA may help with reading
some authors have proposed that a small amount of negative vision.
SA in pseudophakic patients may be desirable as this may
increase near vision - in such patients, there is more central Spherical Aberration and Laser Refractive Surgery
power than peripheral, and activation of the synkinetic reflex At this point, we can address a commonly asked question:
(convergence, accommodation, and pupillary miosis) during what happens to SA values of patients who undergo laser
near-vision tasks may make reading-distance letter clearer. refractive surgery? The answer is that it depends on what
The cornea has positive SA, and the crystalline lens has kind of laser refractive surgery was done:
negative SA. The net result is that normal eyes (especially
myopic eyes much more than hyperopic eyes) usually con- Invest Ophthalmol & Vis Science. 1999;40: 203–213; and (2) Glasser A,
tain a low amount of positive SA. The total SA is lowest in Campbell MCW. Presbyopia and the optical changes in the human crys-
our teenage years, with nearly zero SA at age 19 as the posi- talline lens with age. Vision Res. 1998;38: 209–229.
tive SA of the cornea is nearly neutralized by the negative SA Racial demographics of a given population may influence the average
20
of the lens.19 spherical aberration as race and ethnicity have shown to be factors posi-
tively correlated to spherical aberration. The full extent of this variation
is beyond the scope of this text.
See (1) Guirao A, Gonzales C, Redondo M, et al. Average perfor-
19
See Chap. 27 What’s on the Menu: An Overview of Currently
21
mance of the human eye as a function of age in the normal population. Available IOLs and Relevant Optics, for more discussion on this topic.
• Patients who undergo standard (i.e., not wavefront- itself is a “blurred” depth of focus; it is not as sharp or clear
guided or wavefront-optimized) ablations for myopia as a singularly focused spot of light. Remember SA is an
will develop an oblate corneal pattern. In the early days of “aberration,” not an “improvement.” Furthermore, pupillary
laser refractive surgery (LRS), nearly all the treatment constriction may eliminate potentially beneficial peripheral
was limited to the central cornea (usually a 6.5 mm opti- light rays when a pseudophakic patient wants to read. Finally,
cal zone), and the peripheral cornea was left untouched. studies have shown that negative SA may be more beneficial
Thus, the post-myopic LRS cornea would show central to pseudophakic patients: when the patient focuses at near,
flattening with a relatively steep untreated peripheral cor- the synkinetic reflex increases the plus power of the eye and
nea. These patients’ postsurgical wavefronts will show a makes near objects sharper when the pupil constricts.23
significant increase in positive SA, even more than prior Suppose we had two identical twins who underwent cata-
to LRS. A typical wavefront pattern for these patients ract surgery. One twin was left with +0.2 μm SA, and the
may demonstrate emmetropia centrally (green) with other had −0.2 μm SA. Both patients may have a halo from
“annular myopia” in the periphery (red).22 the SA, but the twin with negative SA may be slightly hap-
• Patients who undergo standard ablations for hyperopia pier: when he wants to read, the pupil will constrict, and the
will develop a more prolate corneal pattern (steeper cen- negative SA means that he has more power in the center and
trally). Nearly all the treatment is directed toward the can potentially read better. This comparison has clinical rel-
peripheral cornea (to flatten it) and creates secondary cen- evance before cataract surgery too: a phakic post-hyperopic
tral corneal steepening. These patients’ postsurgical wave- LRS patient may be happier at age 60 as compared to a pha-
fronts will show a significant decrease in SA (they may kic post-myopic LRS patient because the former’s negative
even have net negative SA due to the crystalline lens’ nega- SA may allow her to read at close better than the latter’s posi-
tive SA “overpowering” the weakly positive corneal SA), tive SA.
and the wavefront shape pattern may become inverted. To confuse you further, the previous paragraph can be
argued with a counterpoint: other studies have shown that
Increased positive SA after LRS may lead to an unhappy pseudophakic patients with mild myopia (approximately
patient, especially in a patient with large scotopic pupil −0.25 to −0.50D myopia) may have better uncorrected
size or a patient who needs good distance vision in low-light vision (as measured by contrast sensitivity function and mac-
conditions (such as a long-distance trucker, etc.). These ular threshold studies) if they have some positive SA.24
patients may have increased (and sometimes unbearable) However, this assumes the patient is not wearing any pre-
glare and halos due to increased SA after LRS. scription glasses. If the patient’s myopia is corrected, zero
SA will yield the best quality of vision. Thus, there may be
Spherical Aberration and IOL Options some benefit in leaving behind a small amount of pseudo-
As we have discussed (almost nauseatingly!), one potential phakic positive SA in a patient who is −0.50D in both eyes
advantage of SA is the increased depth of focus: but does and receives monofocal IOLs. However, for patients who
this advantage outweigh the previously mentioned wish to wear glasses or receive presbyopia-correcting IOLs
disadvantages? and desire the sharpest vision possible, the surgeon’s goal
We will discuss spherical vs. aspheric IOLs in greater should be to correct all the refractive error and leave the SA
detail in Chap. 27, What’s on the Menu: An Overview of as close to zero as possible.
Currently Available IOLs and Relevant Optics. For now, We hope that we have not overwhelmed you with this del-
we can summarize spherical IOLs as basically cylinder uge of information. We should appreciate how incredibly
slices of a sphere: they have the same power throughout complex this entire discussion is and how we are still scratch-
the entire optic of the IOL and actually have some positive ing the surface in understanding this topic.
SA themselves. Thus, patients who receive spherical IOLs
will have an increased positive SA after cataract surgery Spherical Aberration and Q-Value
that will function as a poor man’s presbyopia-correcting At this juncture, we can introduce a somewhat abstruse con-
IOL. Patients will not only see well at distance, but the cept that confuses many people, including practicing oph-
increased depth of focus may theoretically confer some thalmologists: Q-value. It is important to note that corneal
additional near vision without the need for reading
glasses.
So why do not we use spherical IOLs and use benefits of Piers PA, Manzanera S, Prieto PM, Gorceix N, Artal P. Use of adap-
23
tive optics to determine the optimal ocular spherical aberration. J

SA to our advantage? The problem is that this depth of focus
Cataract Refract Surg. 2007 Oct;33(10):1721–6
Holladay JT. “Spherical Aberration: The Next Frontier”. Cataract and
24
See Fig. 1 in Chap. 30, Optics for Refractive Surgery, for a topogra-
22
Refractive Surgery Today, November 2006. https://crstoday.com/
phy image of a post-myopic LRS cornea. articles/2006-nov/crst1106_18-php/. Accessed January 10, 2021
SA and Q-value are not the same thing. They are related, the (positive) corneal SA and yield better quality postopera-
but they are also different. Whereas SA measures the effect tive BCVA.
of the optical system on incoming light and is measured in The Q-value may also be combined with keratometry to
microns (as a root-mean-square, RMS), the Q-value back-calculate (approximately) the SA of a given surface. All
describes and measures the shape of the refractive surface of that fancy math is beyond the scope of this text, but if we took
the eye – most notably, the Q-value has no units. Even the average Q-value (−0.26) and average keratometry mea-
though they are not the same thing, it is helpful to discuss surements (44.00D), the calculated corneal SA is approxi-
them side-by-side. mately +0.18 μm. If we simply measured the corneal SA, this
We can think of the Q-value as a way to describe how cor- is approximately +0.27 μm. Most currently-utilized aspheric
neal shape can help to neutralize SA. The Q-value gives us IOLs have about −0.18 to −0.27-μm SA built into the IOL.
information about how much the cornea is flattened in the
periphery compared to its center. A Q-value = 0 will indicate Coma
a perfectly spherical surface, which does not exist in nature. A This HOA occurs due to rays that pass through one edge of the
negative Q-value helps to offset some of the corneal SA. Since pupil coming into focus before or after rays at the opposite
we have stated that most corneas are prolate with positive SA edge (180 degrees away) of the pupil. Coma leads to a varia-
values, most patients (especially myopic patients) will have tion in image magnification. Patients may also perceive this as
corneas with Q < 1. As can be deduced, Q > 1 is typically seen a “comet-like tail” emanating from a point source of light in
in oblate corneas. The Q-value varies among ethnic popula- low-light conditions. This HOA is common in decentered cor-
tions, ranging from −0.20 to −0.27 overall. neas, such as keratoconus (vertical coma due to asymmetry
We can reinforce this with an example. If we have two between the inferior and the superior cornea), irregular pene-
Q-values (e.g., one cornea with a Q-value of −0.45 and trating keratoplasty, and decentered ablations. On wavefront
another with −0.25), we can say that the lower (more nega- imaging, coma gives the shape of a baseball cap (Fig. 22).
tive) Q-value will describe a more prolate cornea. The This figure represents how light rays at one edge of the optical
Q-value is further defined as the best-fit ellipsoid shape to system will come into focus before light rays at the opposite
describe an apical ratio of change. Therefore, different cor- edge – imagine that some Black Friday shoppers have entered
neal curvatures can produce different amounts of SA but still through the one side of the department store, while shoppers
have the same Q-value. In other words, Q-value gives us on the other side are still stuck behind the closed doors.
information about the form of the corneal shape, but the The cornea and lens both have coma; as you might have
spherical aberration gives us information about the function guessed, they both have opposite-signed values of coma.
of the corneal shape. This allows the eye to maintain a good quality of vision
Studies have shown that there is no “perfect” Q-value: despite the “misalignment” of its optical elements – remem-
there is no relationship between the shape of the cornea and ber the human eye is imperfectly perfect.
the eventual best-corrected visual acuity (BCVA). Similarly,
other studies have shown that maintaining a constant Q-value Trefoil
before and after laser refractive surgery, has no significant This HOA occurs due to incoming light that gets “smeared”
outcomes on a patient’s BCVA or even other measures of in three directions. For example, both corneal opacities (cor-
visual acuity, such as contrast sensitivity.25 neal scars, Salzmann nodules, and epithelial basement dys-
Thus far, we have stated that the ideal refractive surface trophy) and lenticular opacities (vacuoles) can smear
will have no imperfections (Q-value = 0). Since the cornea is incoming light. Patients may perceive this as a “peace-sign/
imperfectly perfect, the average human cornea has a Q-value Mercedes-Benz®” symbol emanating from a point source of
of ≈ −0.26. This is where things get confusing: to correct the light in low-light conditions. On wavefront imaging, trefoil
corneal SA, we would actually need a − 0.52 Q-value.26 gives the shape of a “tricorne hat” or “three-person saddle”
Amazingly, the crystalline lens has a Q-value of −0.25, (Fig. 22). Imagine a Colonial American-style hat (kind of) or
which, when combined with the corneal Q-value, results in a saddle upon which three people are sitting but facing three
the neutralization of most of this SA. When we remove the different directions. (Sorry, we couldn’t come up with any-
crystalline lens in cataract surgery, we are now left with addi- thing more clever than this!).
tional positive SA. Hence, some IOL manufacturers add
additional “negative” SA to their aspheric IOLs to neutralize
Spectral Sensitivity and Visual Pigments
Tuan KM, Chernyak D. Corneal asphericity and visual function after
25
wavefront-guided LASIK. Optom Vis Sci. 2006 Aug;83(8):605–10 While many animals can perceive extreme ends of the elec-
26
Ironically enough, at Q-values lower than −0.50 are clues that the tromagnetic (EM) spectrum (including ultraviolet and infra-
patient may have a corneal ectasia present; usually, these corneas have red), the human eye can only perceive a small portion of the
Q-values around −1 or less.
Fig. 25 Spectral sensitivity Rod Green

1.0 Red cone
for rods and cones. Note that (498 cone
Blue cone (564 nm)
spectral sensitivities for each nm) (533 nm)
(437 nm)
photoreceptor are curves. For
example, a red cone will be
stimulated by blue light 0.8
(490 nm) but to a much lesser
degree than a rod
Relative Sensitivity
0.6
0.4
0.2
400 450 500 550 600 650 700

Wavelength (nanometers)
EM spectrum from approximately 300–700 nm. The two Patients have an especially difficult time distinguishing
main types of photoreceptor cells, rods and cones, have peak darker shades of blue from black.
sensitivities to different portions of the EM spectrum. Note A silly (and possibly) useful mnemonic to remember
that these are curves: for example, at 500 nm, cones will still these color deficiencies is as follows: “Protein (meat) is red;
undergo some stimulation even though rods will undergo mountain deu is green; and the tritanic sank in the ocean
much more stimulation (Fig. 25). (blue)” Red-green color vision defects are the most common
Cones themselves can be further divided into three types, forms of color vision deficiency.
each with own peak range of sensitivity (Fig. 25): We will discuss the diagnosis of color deficiency and defi-
• Red cones (560 nm) – technically peak at the yellow por- cits in Chap. 18, Visual Acuity Testing and Assessment,
tion of the EM spectrum. and the clinical management of these patients.
• Green cones (530 nm).
• Blue cones (420–40 nm) – technically peak at the violet
portion of the EM spectrum. Lasers in Ophthalmology
The clinical relevance of these photoreceptors (and their
respective peak sensitivities) can be seen in patients with You may be surprised to know that “LASER” stands for
color deficiency. Color deficiency is prevalent in the general “light amplification by stimulated emission of radiation.” We
population, affecting approximately 5–12% of male patients have been using “LASER” for so long that the acronym has
and 0.5% of female patients.27 A dichromat is when a patient become a word.
lacks one of the three cone systems. Dichromats can be fur- The physics of how lasers emit light is slightly compli-
ther classified as follows: cated and beyond the scope of this particular text. We will
• Protanopia (aka Daltonism) – these patients lack red give you a clue: it involves the same electrons and photons
cones. For these patients, red colors will have a black hooking up and breaking up. The interested reader is encour-
appearance. aged to consult other texts for this information.
• Deuteranopia – these patients lack green cones. For these For ophthalmologists, there are several properties of laser
patients, red and green colors will appear similar. light are worth to memory:
• Tritanopia – these patients lack blue cones. For these • Laser light is monochromatic. All photons emitted by a
patients, blue objects will have a grayish appearance. laser have the same wavelength (color). As a result, there
are negligible aberrations (spherical and chromatic) in
Source, https://ghr.nlm.nih.gov/condition/color-vision-deficiency#
27 laser light. Thus, the laser can be focused onto an
statistics. Accessed March 21, 2020 extremely small spot down to the micron level.
a b
Pump Source (e.g.,
flashlamp)
Laser Medium
(e.g., Nd:YAG)
Optical Resonator
Fig. 26 A laser typically comprises three components: a pump source, bounce hundreds to thousands of times between a highly reflective mir-
gain medium, and optical resonator. As energy flows from the pump ror (b) and a partially reflective mirror (a) before exiting the resonator
source into the gain medium, stimulated emission of photons occurs, toward the intended target
leading to optical gain (amplification). Initially emitted photons will
• Laser light is highly coherent. Photons emitted from a • The power of a laser can be measured in watts or joules.
laser oscillate in the same direction simultaneously like a A watt is 1 joule of energy delivered over 1 second. By
well-choreographed cheer routine (temporal coherence: decreasing the delivery time to less than a second (puls-
“in phase”). As a result, laser light can produce an inter- ing), we can significantly increase the power of the laser
ference pattern – this causes the laser to “speckle” off (i.e., increase the watts). For example, an FSL can deliver
irregular surfaces, such as ripples in a glass of water. approximately 1 quadrillion watts!.28
• Laser light is highly directional and can be polarized. This A laser consists of three main components (Fig. 26):
allows it to be emitted as an extremely narrow beam and • A pulsed power source to supply energy (“pump source”) –
targeted in a specific direction. This is very different from This pump source provides energy to the system. Common
all other previous point sources of light that have negative pump sources include electrical discharges, chemical reac-
vergence as light from these objects will emanate in all tions, flashlamps, or light from another laser. For example,
directions. In addition, even after its emission, laser light is an Nd/YAG laser will usually use light from a xenon flash-
non-spreading with minimal divergence per meter traveled. lamp or a diode laser; excimer lasers use a chemical reac-
A laser beam will spread to less than 1-ft diameter at a dis- tion to provide energy. Lasers are very inefficient light
tance from 1000 ft. from the laser; so even if a laser is sent sources: most of the energy used to power a laser is lost,
from the earth to the moon (approximately 250,000 miles), and only a small amount of energy is emitted from the
it will only spread to cover an area of 2.5 miles on the sur- laser. Going back to our Death Star example, one Optics-
face of the moon (divergence angle = 5 rad). This minimal nerd plot hole in the movie is that no explanation was
divergence allows a laser to deliver a large amount of given for where the energy was coming from to power the
energy to a small, targeted area even if it has to travel a laser. We want answers.
considerable distance to reach it. Think of the Death Star • Gain medium (“laser medium”) – the gain medium is the
(Star Wars Episode IV: A New Hope, 1977) and how a laser primary determining factor of the laser. Energy from the
was able to destroy an entire planet from a far-off distance pump source flows into the gain medium to produce a
as the laser did not diverge much after being fired. Though population inversion, which is basically a complicated
we do not condone the destruction of Alderaan, we cannot way of saying that most of the electrons in the medium
fault the physics in the movie on this point - but don’t get are in higher-energy (excited) states than in lower-energy
us started on the flawed physics of “laser” swords. states. This will cause a spontaneous and stimulated emis-
• Laser light can be continuous (such as an argon laser used sion of photons that will undergo optical gain (amplifica-
for photocoagulation) or pulsed (such as a Nd/YAG laser). tion) in the resonator. Examples of gain media include
Pulsed lasers can be produced by two methods: mode liquids, gasses (CO2, argon, krypton, and helium-neon),
locking and Q-switching. Again, we can skip some of the
physics, but it is worthwhile to know that mode locking is This author has often wondered what kind of pulsed technology and
28
the method used to create extremely short pulses, such as laser components were used by the Empire in the creation of the Death
Star in order to deliver that much energy in such a short time that mil-
those used in femtosecond lasers (FSLs, 10−15 s). lions of voices suddenly cried out in terror and were suddenly silenced.
Table 1 Features of commonly used lasers in ophthalmology 1. Photocoagulation – photocoagulation involves lasers
Type of laser Wavelength Portion of electromagnetic spectrum that use very short exposure times to produce highly pow-
CO2 10,800 nm Far infrared erful light energy absorbed by the tissue. This causes a
Nd/YAG 1064 nm Infrared focal rise in temperature, denaturation of proteins within
Krypton 677 nm Red tissues, and localized destruction (scar formation) of the
Argon 488–514 nm Blue-green
tissue. Most of the laser energy is absorbed by chromo-
Excimer (Ar/Fl) 193 nm Ultraviolet
phores (e.g., melanin, hemoglobin, xanthophyll, etc.) in
tissues that convert the incoming light energy into heat
and secondary destruction of surrounding tissue. These
and solids (such as crystals). Solid host materials, such as chromophores have to be activated by the appropriate
YAG (yttrium, aluminum, and garnet), are usually mixed type of incoming light. For example, argon blue-green
with an impurity (neodymium). (488–514 nm) and krypton yellow (568 nm) can be
• Optical resonator (“laser chamber”) – the optical resona- absorbed by hemoglobin. Xanthophyll preferentially
tor is basically a chamber with two mirrors placed around absorbs 450–500 nm; thus, these wavelength lasers are
the laser medium consisting of a highly reflective mirror used to treat macular disease. Finally, krypton red
and a partially reflective mirror. The light that has under- (647 nm) is not absorbed by hemoglobin, so it may be
gone stimulated emission will pass hundreds (or even used in the presence of vitreous hemorrhage.
thousands) of times between the two mirrors before exit- Photocoagulation laser energy is usually measured in
ing the partially reflective mirror toward the target of watts.
interest. 2. Photodisruption – photodisruption involves lasers that
strike the target tissue and cause an acute formation of
plasma (rapid ionization of molecules). This results in a
ses of Lasers and Light Damage
U shock wave and localized mechanical disruption of the
in Ophthalmology target tissue. Because the laser does not need to be
absorbed by the tissue (as in the case of photocoagula-
We use many lasers in ophthalmology among various spe- tion), these lasers can be highly effective in removing and
cialties that encompass a significant portion of the EM spec- destroying semitransparent membranes. A typical exam-
trum. A list of the most commonly used lasers is presented ple of this is the Nd/YAG laser; when we fire the laser, we
(Table 1). can hear a mechanical “pop” sound. This force destroys the
It is worth nothing that FSLs have not been included in membranous scar tissue during a posterior capsulotomy
this list as they can be made from a variety of materials, and allows you to bill a 66821. Photodisruption laser
such as Nd/glass and Nd/YAG, as the “base material.” It is energy is usually measured in joules.
the mode-locking component that changes their destruc- 3. Plasma-induced ablation – this type of laser damage
tively therapeutic abilities. Thus, while a typical Nd/YAG can be considered a subset of photodisruption. Using a
FSL uses a wavelength of 1053 nm (similar to the Nd/ low-pulse energy laser with a short exposure time (e.g.,
YAG laser, 1064 nm), the former can be used via plasma- femtosecond range), we can gently destroy tissue via
induced ablation to “selectively destroy” target tissue, plasma formation.30 This creates a “wave” of ablation, as
whereas the latter can be used via photodisruption to seen when creating a LASIK flap. Because of its transpar-
“forcefully destroy” tissue.29 Thus, the FSL causes much ency, the cornea can particularly be targeted for plasma-
lower collateral damage than the Nd/YAG laser – this induced ablation with FSLs for precise surgical
allows us to use the FSL to create corneal flaps and inci- maneuvers, such as FSL-astigmatic keratotomy wounds
sions, which you definitely do not want to do with the Nd/ and small incision lenticular extraction (SMILE).
YAG laser! Similarly, the anterior lens capsule and nucleus can be
Ophthalmic lasers can affect tissue in five different surgically targeted using these principles for FSL-assisted
ways: cataract surgery.
4. Photoablation – photoablation involves breaking cova-
lent bonds (carbon-carbon and carbon-nitrogen) in the
target tissue such that it undergoes sublimation (conver-
The Nd/YAG laser has a pulse duration in the nanosecond range
29
(10−9 sec), whereas a FSL has a pulse duration in the femtosecond range

(10−15 sec). Reducing the pulse duration will therefore reduce the To be more specific, ionization (removing electrons from atoms and
30
amount of collateral damage caused by the FSL compared to the Nd/ accelerating them) of atoms causes adjacent atoms to undergo ioniza-
YAG laser – approximately 106 times less damage with the FSL. tion as well.
sion from solid to gas state).31 These lasers create high- as photokeratitis and UV light-induced cataract (“glassblow-
energy photons (range, 193–351 nm) that will be absorbed er’s cataract”). As another example, aphakic patients can
by all layers of the eye, including tears. The cornea should additionally suffer retinal injury due to the loss of
neither be too moist nor too dry during excimer laser sur- UV-blocking properties of the crystalline lens. This is another
gery to avoid an undercorrection or overcorrection, reason why modern IOLs have UV-blocking or UV-filtering
respectively. Photoablation lasers are considered “cold” technology to protect the retina from light damage.32
lasers since minimal heat/force is generated during the Commercially available lasers include class II–IV lasers
tissue destruction process. (Fig. 27). Accidental damage to ocular tissues can occur with
5. Photoactivation – photoactivation lasers involve using any of these lasers. Laser injuries may cause various retinal
laser energy with low energy and long exposure times to changes, including ring-shaped hypopigmented lesions and
convert a chemical from an inert form into an active form pre-retinal/intraretinal hemorrhages. Late-term complica-
to achieve a therapeutic effect. For example, verteporfin tions may occur, including epiretinal membrane (ERM),
(used in photodynamic therapy) is activated by a low- macular hole, choroidal neovascularization (CNV), and scars
power, long-duration (irradiance of 600 mW/cm2 over in the pigment epithelium. Although some pathologic dam-
83 sec) infrared laser (689 nm) and releases free radicals age may improve, permanent and irreversible changes such
that initiate a series of inflammatory events and (subse- as chorioretinal scarring may be responsible for the delayed
quent) anti-inflammatory responses that induce regres- worsening of visual function after the initial improvement.
sion of pathological neovascularization. Another example
that has gained recent interest is corneal cross-linking for • Class I (class 1) – we can safely ignore these lasers as they
mild-moderate progressive keratoconus. In this proce- are too puny to make a difference, and we will not waste
dure, riboflavin, a photosensitizer that can absorb light any brain cells on them.
energy and then cause a chemical change in an adjacent • Class II (class 2) and class IIIa (class 3R) – these lasers
molecule, is first applied to the de-epithelialized cornea (e.g., laser pointer lasers) are considered to be safe for
(Dresden protocol). Ultraviolet-A (UV-A) light is then momentary viewing so long as the total power of the laser
applied to the “riboflavin-marinated” cornea, generating is ≤5 mW. In the USA, the FDA has imposed strict guide-
reactive oxygen species, which induce the formation of lines on the sale of laser pointers and only considers an
covalent bonds between collagen molecules in the cor- output power of less than 5 mW safe.
neal stroma. • Class IIIb (class 3B) – these lasers typically have a
power ≥ 5 mW and may be potentially damaging to the
eye with any suprathreshold level of exposure (in less
ight Damage, Accidental Laser Damage,
L than one-quarter of a second). For example, a handheld
and Laser Safety in Ophthalmology laser pointer (with power ≥ 5 mW) or a military range
finder (range 905–1550 nm) can cause significant and
As with anything in life, too much of something (or the permanent retinal damage similar to solar retinopathy
wrong kind of something) can be dangerous. The intensity of (Fig. 28).33,34 Any laser class 3B (mnemonic, think B for
incoming light (based on its wavelength) and length of expo- bad) and above is damaging to the eye.
sure can damage sensitive ocular tissues, especially the ret- • Class IV (class 4) – this class encompasses most thera-
ina, which has many chromophores that strongly absorb peutic lasers used in ophthalmology, including those pre-
light, and can cause unwanted photochemical injury. The viously discussed.
anterior segment of the eye serves as a protective shield for
the retina. For example, the lens blocks UV-A light (310–
400 nm) while the cornea blocks UV-B and UV-C (<310 nm),
as well as infrared light. UV-A light is used in CXL because As another example, older-generation surgical microscopes were
32
known to cause light-induced retinal injury, especially with prolonged

while it can penetrate the cornea, it is blocked by the crystal- exposure in aphakic eyes or retinal procedures. Modern surgical micro-
line lens and therefore causes no/minimal damage to the scopes contain additional UV filters that have reduced this risk.
retina. However, long-term and repeated exposure to UV Nonetheless, if you are performing intraocular surgery and do not need
light can eventually break down this wall (similar to a noc- the microscope light on the eye (e.g., the circulator nurse has to get
additional viscoelastic, etc.), it is not a bad idea to move microscope
turnal king who rode an ice dragon to break down a magical light away from the eye to avoid potential retinal damage.
wall in the north of a fictional realm), leading to injuries such Mainster MA, Timberlake GT, Warren KA, et al. Pointers on laser
33
pointers. Ophthalmology 1997; 104:1213–14

This is why excimer lasers often have a vacuum fan near the laser that
31
Roider J, Buesgen P, Hoerauf H, et al. Macular injury by a military
34
absorbs the sublimated corneal tissue during the ablation. range finder. Retina 1999; 19:531–35
LASER CLASSES
Class I Class II Class IIIa Class IIIb Class IV Most therapeutic

Class 1 Class 2 Class 3R Class 3B Class 4 lasers used in
ophthalmology
(excimer, YAG,
Argon, etc.) are
class 4 lasers
Consumer, visible - beam lasers
Class 2 lasers are safe for Relatively Safe Hazardous

momentary viewing (ex: laser ALL LASERS IN
pointers, aiming beam of Class 3B and above is
OPHTHALMOLOGY
lasers used in ophthalmology) damaging to the eye (≥5 mW)
Visible laser light: 400 – 700 nm
Fig. 27 Safety profile of commonly used lasers in ophthalmology
a b
Fig. 28 Retinal damage due to accidental damage from lasers. Panel A shows accidental damage due to a military range finder laser. Panel B
shows retinal damage in a child (visual acuity 20/100) due to a handheld laser pointer. (Courtesy of Dr. Yasha Modi, MD)
Since class 3R and 3B lasers can cause accidental eye the power/energy density is also considered. There is no safe
damage, protective eyewear is highly recommended; for NHZ, and therefore laser safety glasses must protect against
class 4 lasers, protective eyewear and other personal safety direct laser exposure.
equipment are an absolute requirement. Laser safety glasses usually involve materials with sig-
In the USA, ANSI Z136 standard requires specification nificant absorptive capabilities, such as polycarbonate or
according to optical densities only and a nominal hazard absorbing glass filters, to increase the optical density and
zone (NHZ) to be determined by the laser safety officer of an decrease light transmittance. The color of the filter also mat-
institution.35 Outside of the NHZ, diffuse viewing eyewear is ters: to protect against ultraviolet/blue wavelengths, a yellow
allowed. In Europe, the standards are a bit more stringent as or orange filter is commonly employed, whereas a red filter
is used to protect against green light. In general, laser safety
https://www.lasersafety.com/wp-content/uploads/2017/08/
35 glasses should be ordered and customized based on the type
LaserSafetyGuide.pdf. Accessed March 22, 2020 of laser to be used.
Practice Questions 8. Which of the following statements about scattering is

true?
1. Which of the following is considered a cold laser? A. Mie scattering is responsible for the degradation of
A. Excimer lasers 193 nm. visual acuity due to subsurface nanoglistenings
B. Argon blue-green 488 nm. (SSNGs).
C. Krypton red 647 nm. B. The Tyndall effect is best characterized by scattering
D. Krypton yellow 568 nm. of incoming sunlight due to atmospheric particles
2. How thick should an antireflective film be in relation to that bend blue wavelengths of light more than red
the wavelength you wish to block? wavelengths of light, leading to the appearance of a
A. ¼ wavelength blue sky at noontime.
B. ½ wavelength C. Rayleigh scattering refers to particles in a suspen-
C. Same wavelength sion that create scattering of light, as seen by cell and
D. 2 X wavelength flare in the anterior chamber.
3. If a patient had a vitreous hemorrhage which laser would D. The Tyndall Effect states that because the melanin
best reach the choroid? present absorbs more of the incoming light in a
A. Excimer lasers 193 nm. patient with a blue iris, the remaining blue wave-
B. Argon blue-green 488 nm. lengths of light are visible to the observer.
C. Krypton red 647 nm. 9. Which of the following statements is true?
D. Krypton yellow 568 nm. A. Currently available multifocal intraocular lenses in
4. Which type of scattering causes the noontime sky to the USA involve the use of refraction to split incom-
look blue? ing light to distance and near focal points and
A. Mie scattering. increase unaided vision at all distances.
B. Tyndall effect. B. The Airy disk is a description of the best focused
C. Rayleigh scattering. spot of light that a lens with a circular aperture can
D. Geometric scattering. make.
5. Which of the following statements about lasers is true? C. Similar to spherical aberration, diffraction increases
A. Laser light is highly divergent and therefore can as the aperture size increases.
deliver a large amount of energy to a large area. D. Pinhole testing involves using a 2.4-mm hole to
B. Laser light is monochromatic, polarized, and tempo- increase the depth of focus and decrease negative
rally coherent. effects of diffraction to assess a patient’s visual acu-
C. Laser light can be diffusely spread out in multiple ity potential.
directions allowing for moderate amounts of energy 10. Which of the following optical aberrations is an example
to be delivered to multiple targets. of a higher-order aberration?
D. Laser light is produced for an efficient use of input A. Sphere.
energy due to properties of the optical resonator. B. Cylinder.
6. Which of the following statements about coherence is C. Piston.
true? D. Coma.
A. Spatial coherence refers to two waves of light that 11. Which of the following statements about spherical aber-
come into focus at the same location at the ration is true?
target. A. Spherical aberration in a myopic patient will
B. Spatial coherence refers to two different points on decrease after conventional excimer laser ablation.
the same wave of light that are equidistant from the B. Spherical aberration decreases the depth of focus
center. and enhances contrast sensitivity.
C. Temporal coherence refers to two different points on C. For most emmetropic patients, the net spherical
the same wave of light that come into focus at the aberration of the eye is a low amount of positive
same time at the target location. spherical aberration.
D. Both temporal coherence and spatial coherence can D. Spherical aberration is worse during the daytime,
be seen on the same given wave of light. especially on a bright sunny day.
7. Which of the following optical principles is correctly 12. Which of the following statements of the Q-value is
paired with its technology? true?
A. Polarization – antireflective coatings on lenses. A. The Q-value is a way to quantify combined corneal
B. Temporal coherence – fluorescein angiography. and lenticular spherical aberration and is measured
C. Polarization – Haidinger’s brush. in microns.
D. Diffraction – rainbow appearance. B. A perfect spherical surface will have a Q-value of 1.
C. The Q-value may be +1 or more in patients with cor- laser to penetrate the hemorrhage and the densely packed
neal ectasias, such as keratoconus and post-refractive hemoglobin chromophore to reach the retinal tissue
ectasia. behind the hemorrhage for photocoagulation.
D. A negative Q-value may help to offset some of the 4. Answer: C. Rayleigh scattering occurs when incoming
corneal spherical aberration. light waves interacts with particles smaller than them-
13. Which of the following color deficiencies has been cor- selves. The Tyndall effect (choice B) is not, strictly speak-
rectly paired with its pathology? ing, a form of scattering but instead refers to scattering
A. Protanopia – lacking red cones. due to particles in a suspension, such as protein or red
B. Deuteranopia – lacking blue cones. blood cells in the aqueous humor in the anterior chamber.
C. Tritanopia – lacking green cones. Mie scattering (choice C), also known as forward scatter-
D. Vivanopia – lacking red cones. ing, explains the appearance of white clouds; clinically, it
14. Which of the following statements about aberrometry is accounts for glare caused by cortical spokes and subsur-
true? face nanoglistenings on IOLs. Geometric scattering
A. Hartmann-Shack wavefront aberrometry involves (choice D) occurs when light encounters particles larger
the use of a lenslet array and a charged coupled than the incoming wavelength of light, such as interaction
device (CCD) to measure optical aberrations on light with water droplets causing rainbow formation.
going into the optical system. 5. Answer: B. This is the summarized definition of a laser.
B. Ray-tracing aberrometry measures reflected light Laser light is highly convergent (choice A) and demon-
emanating back from the retina from 240 points in strates minimal spreading (choice C), even when directed
the optical system. to a target far away. Lasers are actually very inefficient
C. Spectacle glasses and contact lenses are not able to sources of light as much of the input energy is lost in the
correct all the optical aberration measured by “production” of the emitted laser (choice D).
aberrometry. 6. Answer: B. This is the only correct definition listed.
D. A Zernike polynomial can be used to describe wave- Temporal coherence refers to two similar spatial points
front aberrations in a pyramid shape with the most on two separate waves separated by time in terms of
significant aberrations being visually represented at when they come into focus. Spatial occurrence occurs
the top. within the same wave of light; it refers to two different
15. Which of the following types of laser light damage
points on the same wave of light equidistant from the
mechanisms has been correctly paired with its respective center.
laser used in ophthalmic practice? 7. Answer: C. Polarization is used by the Haidinger’s
A. Photoactivation – Nd/YAG laser. Brush technique to cause polarization of incoming light
B. Photoablation – blue-green argon laser. to preferentially stimulate orthogonal and non-
C. Plasma-induced ablation – femtosecond laser. orthogonal photoreceptors (relative to the fovea) to
D. Photocoagulation – CO2 laser. create an entoptic phenomenon and indicate gross macu-
E. Photodisruption – excimer laser. lar function in the presence of a dense cataract.
Destructive interference is used in antireflective coatings
(choice A). Fluorescein angiography uses special inter-
Answers ference filters (choice B) for incoming light (into the
eye) and capturing outgoing light from the eye.
1. Answer: A. Excimer lasers are considered “cold” lasers Geometric scattering accounts for the appearance of
as there is no heat generated when breaking covalent rainbows as incoming light interacts with particles larger
bonds and converting solid tissue into a gas state (subli- than themselves (choice D).
mation). This contrasts with lasers used in photocoagu- 8. Answer: A. Mie scattering, or forward scattering, occurs
lation (choices B–D), wherein incoming light energy is when off-axis light strikes subsurface nanoglistenings
absorbed by chromophores and converted into heat on IOLs, causing a lowering of the Strehl ratio and deg-
energy, causing tissue destruction and scar formation. radation of visual acuity. See the explanation for ques-
2. Answer: A. The antireflective film is a thin, semitrans- tion 4 for information regarding Rayleigh scattering and
parent material of approximately one-fourth the wave- the Tyndall effect.
length of incoming light. This film creates a second 9. Answer: B. Multifocal IOLs (Choice A) use the property
reflected wave that interacts with the first reflected wave of diffraction to split incoming light into near and distance
via destructive interference. focal points. Diffraction is the inverse of spherical aberra-
3. Answer: C. In the presence of vitreous hemorrhage, tion; whereas the latter increases with larger aperture size
using a laser with a longer wavelength (i.e., a different (such as a pupil), diffraction decreases (choice C). Pinhole
color than the the vitreous hemorrhage) will allow the testing involves using a 1.2-mm hole (choice D).
10. Answer: D. Sphere, cylinder, and piston (choices A–C) tion, the most significant aberrations are at the base of
are examples of lower-order aberrations. Other impor- the pyramid (Choice D).
tant higher-order aberrations include spherical aberra-
15. Answer: C. Femtosecond lasers use plasma-induced
tion and trefoil. ablation to make fine cuts and cause changes to corneal
11. Answer: C. Spherical aberration (SA) will increase in a tissue. The Nd/YAG laser uses photodisruption, which
myopic patient after conventional laser refractive sur- occurs when the laser strikes the target tissue and causes
gery. SA increases the depth of focus and worsens con- plasma formation via a rapid ionization of molecules
trast sensitivity (choice B). SA worsens with a large within the tissue. This causes mechanical damage to the
pupil size (choice D). target tissue. The blue-green argon laser involves
12. Answer: D. The Q-value describes the asphericity photocoagulation; in this process, incoming light energy
(shape) of the corneal surface and has no units from the laser causes denaturation of proteins in the tar-
(choice A). A perfect spherical surface will have a get tissue and localized destruction (scar formation)
Q-value = 0 (choice B); most patients will have a within the tissue. The CO2 laser is a far-infrared laser
Q-value ranging from −0.20 to −0.27. The Q-value that cut tissue via flash boiling water molecules within the
becomes increasingly negative in patients with kera- target tissue, effectively sterilizing target tissue and seal-
toconus (choice C). ing adjacent capillaries. The effectivity of the CO2 cut-
13. Answer: A. Deuteranopia means lacking green cones. ting depends on the target tissue’s water content. This
Tritanopia means lacking blue cones. Vivanopia is a laser can also be used for periocular rejuvenation.
made-up term. Thermal effects of this laser cause dermal collagen to
14. Answer: C. Hartmann-Shack wavefront aberrometry
undergo neocollagenesis and tightening of adjacent facial
measures reflected light from the eye (choice A). Ray- skin. The excimer laser works via photoablation: through
tracing aberrometry measures light going into the eye breaking covalent bonds, the laser causes sublimation of
(choice B). In a typical Zernike polynomial representa- target tissue with minimal heat to surrounding tissues.
Part II
Optics for Oral Exams and Clinical Practice
Glasses in Clinical Practice
Kamran M. Riaz
Objectives gery and can help grow your practice in ways you cannot
otherwise imagine.
• To describe how to perform a subjective manifest refrac-
tion, cycloplegic refraction, and streak refraction.
• To appreciate the usefulness of the Duochrome test and Prescribing Glasses in Adults
the optical principles involved.
• To outline presbyopia-correcting options for glasses. Manifest Refraction
• To understand the unique challenges of prescribing, dis-
pensing, and troubleshooting glasses in pediatric patients. While discussing the full theory behind the how’s and why’s
of clinical refraction is beyond the scope of this text, a review
(and summary) of the important steps of subjective manifest
Introduction refraction using a phoropter is important to commit to
memory.
Welcome to Part II! If you are reading this, we hope you have The standard refraction distance is 20 ft. (6 m)1; however,
survived any or all written exams thus far and are ready to most ophthalmology clinic rooms are not this distance unless
take on oral exams and learn something that has clinical specifically designated as “research rooms”. Using a shorter
relevance. room distance, such as 10 ft., will cause the refraction to be
Some of you may believe that glasses are not the purview over-plussed by approximately +0.25 to +0.50D (+0.33D
of ophthalmologists: you may only be partially incorrect in exactly). The patient’s vertex distance (distance between
this assumption and belief. Nevertheless, even if prescribing the back of the eyeglass lens and the patient’s cornea) should
and dispensing glasses are not a significant part of our clini- also be measured. Usually, the vertex distance is 12–13 mm
cal practice, we still need to understand some fundamental for most patients and does not need to be significantly
principles regarding glasses. adjusted for patients with refractive errors between −5.00D
Remember: many times, in clinical practice, your best (or and + 5.00D. However, for patients with large refractive
even only) solution may be to get your patient the best pos- errors, the vertex distance should be carefully measured
sible pair of glasses. And it is a bit more complicated than using a distometer (also known as a vertexometer).2
just sticking your patient in front of an autorefractor, accept- We can begin by positioning the patient correctly at the
ing whatever prescription is generated, and sending your phoropter. Make sure that the patient’s forehead is resting
patient on his/her merry way. At least we think so; all of the securely against the forehead rest, the pupils are centered
authors have had numerous patients who have expressed through the openings, and the leveling bubble is centered.
immense gratitude when they simply receive a good pair of Check to make sure the lenses are free from smudges. Next,
glasses that meets most of their visual needs, even in the we can dial in a starting prescription from any (or a combina-
presence of complex ocular pathology. Please do not under- tion) of the following: streak refraction, autorefraction, or cur-
estimate the power of a good pair of glasses: it can be more
life-changing than the most complex and impressive eye sur-
See Chap. 29, “Postoperative Optics”, for additional discussion regard-
1
ing the relevance of exam room length in performing a refraction after

K. M. Riaz (*) cataract surgery.
Dean McGee Eye Institute, University of Oklahoma, See Chap.17, “Optical Instruments”, for more information regarding
2
Oklahoma City, OK, USA the distometer.

220 K. M. Riaz
rent wearing refraction. Those magical medications known as choices, not two: “is 1 better, is 2 better, or are they both the
artificial tear drops to both eyes before refraction will make same?” If you forget to mention the third choice, some
your life easier for patients with ocular surface disease. Start at patients may become very frustrated as they may feel they
the 20/60 line (assuming the patient has 20/20 vision poten- have to choose between “1” and “2”, when for them, “1
tial). For patients with presbyopia, one eye should be occluded; and 2” are equal for the two choices at a given reading line.
for younger patients with intact accommodation, fogging the The end point is where the patient reports the clearest view
contralateral eye may be a preferable strategy, leading to less of the letter on the chart. Finally, we should always favor
accommodation than occlusion.3 less minus between two sphere choices (especially in
There are four sequential refinements that you should be young adult myopic patients).
able to list out (or summarize) in your own words. Please 2. Find the cylinder axis:
note that when you present choices in each of the following (a) Flip over the Jackson cross cylinder (JCC) such
steps, allow your patient at least 2-3 seconds at each choice that white and red dots are on either side of the 90- or
to have enough time to determine a difference. Moving too 180-degree axis (“straddle the axis”) (Fig. 1).
quickly between the choices may skew the refraction towards (b) Flip the JCC and ask the patient to compare the first
inaccurate results. Bolded words should definitely be com- and second choices, explaining that both choices
mitted to memory, and you may wish to use them as key will be a little blurry, and ask them to choose the
concept words to develop your own checklist on how to per- “less blurry” choice.
form a manifest refraction with the phoropter: (c) Based on which JCC choice the patient prefers, rotate
the axis in the direction of the white dot (“chasing the
1. Adjustment of sphere – begin by dialing in sphere with white rabbit”) toward that choice in 10-degree
choices of +/− 0.50 D apart and asking the patient to read changes.
each line down the chart. We can further refine this in (d) Once the patient prefers the red dot, shift the JCC
0.25D increments as needed. When giving the patient back in the original direction in 5-degree changes.
choices, you must remember there are actually three (e) Repeat in smaller increment steps until the two
choices are reported to be the same.
3. Adjust the cylinder power:
(a) Rotate the JCC so that red or white dot is “on axis”
with the axis determined in step 2 (Fig. 2).
Fig. 1 Finding the cylinder axis – to fine-tune the axis, flip over the
Jackson cross cylinder (JCC) so that the red and white dots straddle the
“arrow” at either the 180-degree or 90-degree axis
Fig. 2 Adjusting the cylinder power correction – to fine-tune the astig-
Similarly, in patients with latent nystagmus, fogging is preferred over
3
matism power, rotate the JCC so that the red and white dots are on-axis.
occlusion in order to determine the BCVA by refraction. This will allow you to dial in cylinder power (blue arrow)
Glasses in Clinical Practice 221
(b) Flip between red and white choices. If the patient Streak Refraction
reports that the white dot choice letters are clearer,
then add + 0.50D cylinder power. If the patient Just as we previously discussed the significant steps for a
reports that the red dot choice letters are clearer, add manifest refraction, knowing the major steps for performing
−0.50D cylinder power. This principle is true for a streak refraction (and how to summarize them) is useful for
plus- or minus-cylinder phoropters. both exams and clinical practice. The following scenarios are
(c) For every +0.50D cylinder power added, add − 0.25D examples of when a streak refraction may be useful (or even
sphere to maintain the spherical equivalent and thus necessary):
maintain the image on the retina.
(d) End when both red-white choices are the same, • Patients who cannot sit at or cooperate with a phoropter:
always favoring the lesser cylinder power. physically disabled patients and pediatric patients,
4. Final sphere adjustment: respectively.
(a) Remove the JCC. Refine the sphere by 0.25D steps • Malingering patient: the faker trying to get you to sign off on
until the patient reports the two choices to be the his unemployment benefits claiming he is blind may actually
same. Again, always favor less minus (“push just need a −1D prescription. A streak refraction can objec-
plus”, especially in young adult myopic patients and tively measure the true refractive error in these cases.
pseudophakic patients with presbyopia-correcting • A streak refraction can serve as a useful starting point
intraocular lenses). before performing a manifest refraction in a patient with
Congratulations, you have just refracted a patient. no previous history of wearing glasses.
Make sure you remember to code CPT 92015 and collect • To determine if patients have irregular astigmatism present
any refraction fee(s) at this time. (such as corneal ectasia) based on the lack of an optimal
streak or the presence of scissored reflex, this will warrant
further imaging and evaluation by a cornea specialist.
Cycloplegic Refraction • To determine if a patient has media opacities, such as oil-
droplet cataract, lenticonus, etc., especially in the pediat-
Cycloplegic refraction (CRx) (also known as wet refraction) ric patient (in whom a prolonged slit-lamp exam may be
involves using anticholinergic agents to pupillary dila- difficult).
tion and, more importantly, to paralyze the ciliary body and
fully relax accommodation temporarily. Since the patient’s For detailed information on best performing a streak
eye cannot generate additional “plus” power (especially in refraction, you may wish to consult other resource texts. For
younger myopic patients), a CRx can be helpful in many now, the bolded words in the checklist below should defi-
situations as follows: nitely be committed to memory, and you may wish to use
them as key concept words to develop your own mini-speech
• To help ensure we are not “over-minusing” a young myo- on how to perform a streak refraction:
pic patient. In these patients, there may be several diop-
ters of difference between the manifest refraction and the 1. The patient should fixate on a distant target. Cycloplegia
CRx. This is especially important for myopic patients pre- may be needed to relax accommodation, especially if per-
senting for laser vision correction. forming a streak refraction in a pediatric patient.
• To diagnose other reasons why the objective dry manifest 2. Calculate your working distance. Usually, 67 cm (1.5D) or
refraction does not provide the patient with good clarity 50 cm (2D) are the standard distances. The working dis-
and comfort in new glasses. tance can vary: some people like to have their arm holding
• To diagnose a patient with latent hyperopia (see Chap. the lenses perfectly straight; others prefer a slight bend. You
21 Clinical Problems with Optics/Refractive should have a colleague calculate your exact working dis-
Manifestations).4 tance once you find your “comfortable” arm position.
• To determine if another pathology is present in a patient 3. Starting with the patient’s right eye, position the streak
with rapidly changing refractions in a short period of vertically and move it side to side to determine whether
time. there is “against” or “with” motion (Fig. 3). Use the
“SPAM” mnemonic (same motion, add plus power;
against motion, add minus power). The streak may need
to be rotated in different meridians to find the one with
the brightest reflex (Fig. 4).
This is particularly relevant if the patient has an esotropia with an
4 4. Keep using SPAM until you have a bright red reflex
accommodative component, even as an adult. without any motion that fills the pupil.
222 K. M. Riaz
a b c
Fig. 3 Several possibilities may occur when moving the streak from strates “with” motion (panel B), plus power needs to be added to the
side to side. If the streak demonstrates “against” motion (panel A), loose lens. The end result should be a neutral reflex that fills the entire
minus power needs to be added to the loose lens. If the streak demon- lens (panel C)
Fig. 4 If astigmatism is a b
present, a streak held in the
vertical position may not
align with the reflex (panel A)
and instead may show oblique
motion. Rotating the streak
(“on axis”) may be necessary
to neutralize the first meridian
(panel B)
5. If the reflex has consistent width and brightness in all astigmatism to correct as well. So, we will have to rotate
directions, there is no astigmatism – congratulations, you the streak 90 degrees away and repeat steps 3–4 for the
have an easy patient. However, there is usually some secondary meridian.
Fig. 5 An incoming ray of light will be bent according to individual

colors that make up the ray of light. Blue rays will come into focus
closer than red rays (intentional exaggeration shown for example TZ VD
purposes)
ED TR
6. Repeat steps 3–5 for the patient’s left eye.

Fig. 6 In an ideal refraction, the yellow component of the incoming
7. Adjust for working distance – remember you must add light will fall directly on the retina. Green components will land in the
additional −1.5D or −2D of myopic sphere correction vitreous, and red components will land in the choroid (intentional exag-
because of the working distance. For example, if -2D geration shown for example purposes)
sphere (without any astigmatism) neutralizes the reflex
and your working distance is 67 cm (1.5D), the final pre- manifest refraction: after optimizing the refraction, each eye
scription will be −3.50D sphere. is tested individually by showing the patient the 20/20 (or
20/25) line with the “red-green” screen (one side of the
screen is green, and the other side is red, as shown in Fig. 6).
Other Tests Used The patient should be fogged by adding about +0.50D sphere
to their measured distance refraction; this will relax accom-
Several other tests may be useful in selected cases to opti- modation and (hopefully) will make the red letters bolder. It
mize manifest refraction. is important to let the patient know you will make it a little
blurry on purpose. (If you forget to do this, they may point
Duochrome Test out your perceived incompetence.)
Note to the reader: we will switch back and forth between At this point, if the patient has been optimally refracted,
referring to light as waves and rays in this section. he/she may report that red and green letters will appear
The duochrome test is one of the most important ancillary equally clear. Congratulations, you are done. You can simply
tests during a manifest refraction, especially when refracting prescribe the glasses, charge the 92015, and move on.
a young myopic patient (even more so if said patient is pre- However, if red and green letters are not equally clear,
senting as a laser vision correction candidate). The test then the “RAM-GAP” mnemonic may be used to refine the
involves taking advantage of chromatic aberration. refraction. This mnemonic reminds us that if the patient
Remember that different wavelengths of light are bent differ- reports that red letters are clearer, the incoming light has
ently by the eye’s optical system: shorter wavelengths (blue) been refracted “too much” and most of the light ray is falling
are bent more than longer wavelengths (red). In other words, in the vitreous. If we consider Fig. 7, we can see that if the
the blue component of a light ray that passes through a plus red portion of the incoming light is on the retina, then yellow
lens will be bent much more than the red component; there- and green portions are in the vitreous. Therefore, if the red is
fore, think that the blue will land in the vitreous and the red clearer, we must add minus (“RAM”) to the refraction.
will land behind the retina in the choroid (Fig. 5). A helpful Similarly, if we consider Fig. 8 wherein the patient reports
mnemonic is blue rays are bent the most. that green is clearer, the yellow and red portions are in the
When we look at the eye, we can imagine that we will be choroid; therefore, we have to add plus (“GAP”) to the
able to get the “yellow component” of the light ray to fall on refraction.
the retina in a perfect refraction scenario directly. Therefore, Several questions are usually asked about the duochrome
in this scenario, the green light components will be slightly test, so pop quiz time, hotshot:
in the vitreous, and the red components will be slightly in the
choroid (Fig. 6). 1. How much is the diopter difference between red and
The duochrome test takes advantage of chromatic aberra- green components of light?
tion to ensure that we have not “over-minused” (or “under- Answer – approximately one diopter. The difference
minused”) a patient. The test is performed as a final step after between red and blue is approximately 1.25 diopters.
224 K. M. Riaz
Fig. 7 Duochrome test. If the

red is sharper, the patient
needs more minus (“RAM”)
TZ VD
ED TR
TZ VD
ED TR
.0
-3
Fig. 8 Duochrome test. If the

green is sharper, the patient
needs more plus (“GAP”)
TZ VD
ED TR
TZ VD
ED TR
.0
+3
2. Should this test be performed binocularly in routine 3. Can this test be used on a patient whose best manifest
patients? refraction yields a vision of 20/50?
Answer – no, we just said above that this should be a Answer – no. This test should only be used on patients
monocular test, so don't be silly and perform it simultane- whose BCVA is ≥20/30 because it realistically can titrate
ously with both eyes.5 about 0.50–0.75D. So, if a patient can only see 20/50,
The duochrome test can be used binocularly to test binocular balance.

5
ensure equal accommodative relaxation between eyes since a young
This is occasionally done with a vertical prism to split screens and patient can still accommodate during monocular duochrome testing.
then the duochrome test will not be “as useful” since the refractive error present. Examples of this technology
difference is likely too small for the patient to include the Nidek AR-2000 objective automatic refractor
appreciate. (Nidek Technologies, Gamagori, Japan).
4. Can a duochrome test be performed on a patient who is
red-green color blind? Answer: Yes! Because the test As discussed in Chap. 14, Physical Optics, a wavefront
involves the patient’s ability to discern between wave- refraction can be performed on inbound (ray-tracing devices)
lengths of light, it can be performed in patients with red- light and outbound (Hartmann-Shack) light from a patient’s
green color blindness. However, the patient may report eye. These devices not only calculate the objective refractive
that the “left” or “right” side of the chart is sharper, so the error but can also give information about higher-order aber-
examiner will have to adjust accordingly. rations. Wave front autorefractors are commonly used for
wave front-guided ablations in excimer laser refractive
utorefraction and Wave Front Refraction
A surgery.
Objective autorefractor devices use low levels of infrared
light to perform refraction. Because this technique does not
involve visible light (as used in subjective manifest refrac- Presbyopia Correction and Glasses
tion), there is an error of approximately 0.75–1.00D between
these two methods. Therefore, autorefractors are used as a See the discussion on presbyopia in Chap. 12 “Glasses for
screening tool or starting point to determine a patient’s Written Exams”, for a detailed discussion regarding correc-
refraction and should not be used as a substitute for actual tion options with glasses.
manifest refraction. However, there may be certain circum- In terms of how to determine the bifocal power, unfortu-
stances when an autorefractor may be more beneficial than a nately, it's a bit more complicated than simply giving every-
subjective refraction, such as in the presence of macular dis- body a + 2.50 add and sending them on their way (even though
ease or lens opacity, to determine the refractive state of a that probably works in real life for ~90% of your patients).
patient’s eye. Several methods can help us determine the needed bifocal
Depending on the type of autorefractor, several popular add power:
methods may be used to calculate the refraction of a patient’s
eye: 1. Use an age approximated add power based on expected
amplitudes of accommodation (AOA), such as Donder’s
• Devices that use automated retinoscopy (dynamic scias- table. Half of the AOA should be held in reserve to avoid
copy) are cost-efficient, integrate well with corneal topog- asthenopia.7 For example, a patient with 3 diopters of
raphy, and rapidly generate a usable refraction (and AOA should be given a + 1.5D add power. This will allow
information about aberrations). Examples of this technol- the patient to use half of their AOA.
ogy include the Nidek OPD-Scan III (Nidek Technologies, 2. Trial and error with different add powers in a trial frame –
Gamagori, Japan). sometimes, you don't have to be elegant as long as you
• The optometer principle can also be used in autorefractor get the correct answer and don’t break anything along the
devices.6 The optometer involves using a standard lens of way.
known power (and focal point) and using the patient’s eye 3. Binocular plus build-up – put the patient in the phoropter
as an “unknown lens” to dial in power such that known with their full manifest refraction for distance. Hold a
lens and unknown lens focal points match. The power reading card at the patient’s preferred distance (33–
needed is used as a proxy for the eye's refractive power. 40 cm). Add +0.25D to each eye until the patient can read
Examples of this technology include the Nikon Auto the lowest line on a near card. Note that this method
Refractometer NR-1000 F (Nikon Corporation, Tokyo, essentially measures the AOA and may induce asthenopia
Japan). if one were to prescribe only the minimum amount needed
• The Scheiner disk principle involves using a lens with two to read the J1+ line without cycloplegia.
small holes vertically oriented with a light source directed 4. Find the patient’s near point by measuring the nearest
into the eye. The top hole is then covered, and depending point that a patient can maintain focus through their full
on the refractive error, the top or the bottom spot of light distance correction. This maneuver can be facilitated by
disappears (for a myope and hyperope, respectively). The using a “Prince rule.” This distance is divided into 100 to
device can then measure the changes that occur when convert it to AOA. For example, if a patient wears −1.75D
blocking both holes in 1–2 seconds to determine the sphere OU and can see up to 33 cm with her glasses on,
The optometer principle is also used in the lensmeter device. See

6
See Chap. 9 “Accommodation and Presbyopia”, for more information
7
Chap. 17 Optical Instruments and Machines, for more details. on this topic.
226 K. M. Riaz
then the AOA is 100/33 = 3D. Therefore, this patient will a child. A more detailed discussion of this topic is presented
need +1.50D reading add in her glasses. in Chap. 23, Pediatric Optics.
5. Fused cross cylinder test (Fig. 9) – place the patient in the The following section will focus on “considerations for
phoropter and dial in his full distance correction. Move the pediatric patients,” apart from the refraction issues discussed
Jacques blur point card (that tic-tac-toe-looking thing gath- earlier in the chapter. In other words, we will discuss the “opti-
ering dust in the corner of the exam lane) to the preferred cian” stuff. Since every child is different, we have to consider
reading distance. Next, dial in ±0.50 on the dial (not the a few additional considerations in this patient population.
JCC dial but rather the dial that we use for “open,” “occlu-
sion,” etc.). Ask the patient: “are the horizontal lines
darker?” If yes, keep adding plus power in both eyes until Special Considerations for Glasses in Kids
horizontal and vertical lines on the Jacques blur point card
have equal intensity. This is the add power required. The following is a list of factors that can increase success
Congratulations on wasting 15 min of your office time while dispensing glasses in pediatric patients:
that you will never get back. You better bill that 92015 if you
did option #5 from that list. • Frame fit – frame fit is equally important as a good
refraction in pediatric patients. Remember that kids have
a weird tendency (compared to your adult patients) to
Prescribing Glasses in Kids grow, especially before 10 years of age. For example, a
child’s head size is approximately 90% of adult size by
As in our previous discussions with adults, a combination of age 10. Kids also have constantly evolving facial, nasal,
refraction strategies may be necessary for optimal refraction and ear anatomy. Factors such as a flat nasal bridge should
in pediatric patients, depending on age and (in)voluntary be considered in frame fit and size. Even if you have the
cooperation of the child (and the parent). We may have to world’s most excellent refraction, if the frames are too
schedule several appointments to optimize the refraction for big, too loose, too small, etc., the child won’t wear them.
Fig. 9 The fused cross cylinder test. After setting the dial to the ±0.50 (right panel). If the patient reports the horizontal lines are darker, the
option (blue arrow) and giving the patient his/her full distance correc- examiner dials in additional plus power until horizontal and vertical
tion, the Jacques blur point card can be used to find the preferred read- lines have equal intensity. The total amount of plus sphere dialed in dur-
ing distance. The patient is asked to look at horizontal and vertical lines ing this process is the reading add required
For example, a head strap may be necessary if the child’s seeing eye in patients with amblyopia and hyperopia
nasal bridge is not large enough to support frames. A spe- (such as with cyclopentolate).8
cial “horseshoe addition” can be placed on the nasal • Cycloplegia – while this may seem like the complete
bridge for added support. opposite of the previous sentence, there may be some sit-
• Lens material – shatterproof materials, such as polycar- uations where cycloplegia of the affected eye(s) is a
bonate, are preferred for lenses because of the higher risk highly appropriate and effective treatment. For example,
of trauma in pediatric patients. if a child has a high hyperopic prescription and an accom-
• Cosmetic reasons – children are fussy creatures with modative ET, cycloplegia may help to relax accommoda-
constantly changing tastes in preferences. A child may tion and accept the full refraction in glasses. See Chap.
pick out blue frames because blue is his favorite color but 22, Optics for the Clinical and Surgical Management of
then 3 months later change his mind that green is his Strabismus, for more details.
favorite color. Aesthetic considerations for color, size,
style, etc., may be prohibitive or motivating reasons for a
child to wear (or not wear) prescribed glasses. Practice Questions
• Psychosocial reasons – other kids can be mean (some of
you may still remember being bullied, or shame on you if 1. Self-assessment – List all the steps of a manifest refrac-
you were the bully!). The child may not want to wear the tion in under one minute in your own words. Practice in
glasses because she gets made fun of at school by her front of a mirror or reciting this to a friend, colleague,
classmates. Similarly, a child may not want to wear her and/or significant other. Apologize to this person and
glasses because her parents picked out the frame, and she offer to buy them a coffee for their troubles.
may feel that she did not have any control over choosing 2. Self-assessment – List all the steps of a streak refraction
the frame color/style. Empowering the child to select his/ in under one minute in your own words. Practice in front
her frames can be extremely effective in convincing the of a mirror or reciting this to a friend, colleague, and/or
child to wear the glasses. Exploring these factors is cru- significant other. Apologize to this person and offer to
cial to ensure that the child will wear her glasses. buy them a coffee for their troubles.
• Family support – unfortunately, we know that some par- 3. Which of the following statements regarding manifest
ents can be... quite difficult. For example, some parents refraction is true:
may not appreciate the need for their child to wear glasses A. A streak refraction is a useful method to determine
and thus may not reinforce glasses wear. Other parents the starting refraction point for a patient with
may be too overbearing regarding the child wearing the aphakia.
glasses. This scenario is where you may have to serve as B. In performing a manifest refraction on a young myo-
a child psychiatrist and counsel the family to provide pic patient, it is preferable to occlude the non-tested
appropriate support for the child to wear his glasses as eye.
much as possible, especially if there is a risk for amblyo- C. During the step of finding the axis using plus cylinder,
pia. Unfortunately, there is no additional ophthalmology if a patient reports the red dot is clearer, move the dial
code (that we know of) that you can use to bill extra for in that direction.
your services as a life coach and therapist. D. When dialing in +0.50D cylinder, one should add
• Reward approach – sometimes, bribery is the best solu- −0.50D sphere to maintain the spherical equivalent.
tion to life’s problems. Kids respond to positive reinforce- 4. Which of the following statements regarding the duo-
ment, so especially with new glasses in pediatric patients, chrome test is true?
it may be necessary to have the parents “motivate” the A. This test can be used in patients with BCVA of ≥20/50
child with candy, TV time, and other rewards to get junior to finalize the refraction.
to wear the new glasses. B. If a patient reports that green letters appear clearer,
• Penalization approach – at other times, if the carrot there may be unintentional overcorrection of the
won’t work, then the stick may need to be employed–not myopia present.
literally, of course! It may be necessary to provide nega- C. Red-green color blind patients may need alternative
tive reinforcement for some patients, for example, to methods of testing, such as a cycloplegic refraction,
“motivate” a pediatric patient with accommodative eso- in lieu of the duochrome test.
tropia to wear glasses to prevent the development of
amblyopia. Strategies such as eyeglass bands (to keep the
glasses on) are relatively benign methods to provide nega-
Note that older texts may discuss the use of phospholine iodide for this
8
tive reinforcement. More aggressive strategies may purpose. In modern practice, this has been essentially abandoned due to
involve using arm splints or cycloplegia of the better- the high side effect risk profile, such as iris cysts, etc.
228 K. M. Riaz
D. This test uses the principle of spherical aberration to move the dial in that direction. If one dials in +0.50D
titrate and finalize the refraction. cylinder, one should add −0.25D sphere to maintain
spherical equivalent.
4. Answer: B. If green letters are clearer, it is likely that we
Answers have over-minused the patient, and we have to add plus
power (using the “GAP” of the “RAM-GAP” mnemonic).
3. Answer: A. A streak refraction may be especially useful This test can only be used in patients with BCVA of
in patients with high refractive errors as a starting point, ≥20/40. Red-green color blind patients can effectively
before placing the patient in the phoropter. In young myo- use the duochrome test, though they may need additional
pic patients, fogging the non-tested eye may be a better guidance on which “side” of the screen they should indi-
method to hinder accommodation during the refrac- cate is clearer. The duochrome test uses the principle of
tion rather than occlusion. When finding the axis using chromatic aberration.
plus cylinder, if the patient reports the white dot is clearer,
Construction of Glasses
(Ophthalmologists as Opticians)
Kamran M. Riaz
Objectives Lens Materials

• To describe the advantages and disadvantages of com-
monly used materials employed in the construction of Commonly Used Materials
glasses.
• To understand the role of lens coatings commonly used in While many materials are used in the construction of lenses
glasses. in glasses, there are several common ones worth discussing.
• To formulate an approach toward diagnosing and improv- These materials are usually a mixture of multiple base com-
ing glasses and bifocals for the unhappy patient. pounds put together in varying concentrations:
• To appreciate how patients’ needs may require the con-
struction of nontraditional or occupational glasses. • Crown glass (n = 1.5–1.6) – this is the most frequently
• To discuss the role of tints in glasses with consideration to used material referred to as “glass” in eyeglasses. It is
patients’ visual needs. somewhat of a misnomer (as are all “glass” materials used
in lenses) as it is actually a composite of silicone dioxide
(sand, ~70%), Na20 (soda, ~15%), and calcium oxide
Introduction (lime, 10–15%); the rest is a mystery like the colonel’s 13
herbs and spices. Crown glass is a relatively durable sur-
Here’s a closely guarded secret for our profession: besides face resistant to scratches and cleans easily. Crown glass
being an ophthalmologist, you also need to know a little bit can be rendered stronger to resist shattering using various
about what our optician friends do in the mystery tower chemical and heat methods.
known as the optical shop (or magical eyeglass-making labo- • Flint glass (aka lead glass, n = 1.66) – this material has
ratory). While we may never have to make glasses ourselves, a high index of refraction (compared to crown glass) and
it is helpful to know some of this information in order to is commonly used as a bifocal segment for fused bifocals.
appreciate better what our optician colleagues do, but also to It is a mixture of sand, soda, and lead oxide. These are
know what kinds of options we can offer our patients who less commonly used today as they are difficult to render
are unhappy with their glasses or are looking for custom- impact resistant.
tailored glasses for their particular visual needs. Before you • Barium glass (n = 1.58) – this material consists mainly of
repeat that refraction for the third time, perhaps you may barium oxide, sand, and other metallic oxides. It is com-
want to think about what could be wrong with the glasses’ monly used for making bifocal segments for fused
construction and design and what options you can discuss bifocals.
with your unhappy patient. • CR-39 (n = 1.498) – a fun historical fact is CR-39 stands
for “Columbia Resins 39”; during WWII, the company
Columbia-Southern Chemical Corporation produced a
variety of polymers, and the 39th polymer was found to
be highly suitable for plastic eyeglass lenses. Today, CR-
39 is among the most popularly used lens materials for
K. M. Riaz (*) most glasses due to several key features:
Dean McGee Eye Institute, University of Oklahoma, • Weight – approximately 50% lighter than crown glass.

230 K. M. Riaz
• Fogging – less likely to fog-up compared to glass Why should we care about this? We ideally want to use
lenses, especially with rapid temperature changes. a lens material that has low dispersion. If a material has low
• Safety – if the lens breaks, it will break into larger dispersion, it will have a low chromatic aberration and
pieces whose edges are not as sharp as broken glass therefore a high Abbe value. Conversely, if a material has
edges. high dispersion, it will have a high chromatic aberration
• Impact resistance – CR-39 requires no additional treat- and therefore a low Abbe value. The Abbe value of the
ment to enhance its natural strength as compared to human eye is 45–50; therefore, lens materials with lower
“glass” lenses. Abbe values can affect the quality of a patient’s vision by
• Chromatic aberrations and reflections – less than increasing the amount of chromatic aberration a patient
“glass” lenses. experiences when looking at the edge of the lens. It is
important to note that objectively, a patient’s visual acuity
However, because CR-39 is “softer” than glass, it does should not be affected by the lens material. However, if you
tend to scratch easier, necessitating the addition of secondary have a “20/unhappy” patient, you should consider these
scratch-resistant coatings. types of things.
Why else should we care about this? If a patient has eye-
• Polycarbonate (n = 1.58) – This material can be used to glasses constructed of a lens material with low Abbe values
make a thinner and lighter lens than other materials. It is (classic example; polycarbonate lenses), then because of
extremely impact resistant, making it a popular choice for chromatic aberration effects, these patients may complain of
safety glasses, children’s glasses, sports glasses, and a “rainbow glare” or “blue off to the side” when wearing
glasses for monocular patients. Polycarbonate is their glasses, especially when he/she looks through the edge
extremely sensitive to scratches and almost always of the lens. This phenomenon is known as “off-axis blue
requires a secondary scratch-resistant coating. However, glare” and is due to transverse chromatic aberration – as if
polycarbonate has an extremely low Abbe value (see next just regular chromatic aberration isn’t bad enough!
section) that can cause significant subjective visual distur- Remember this is an “edge of the lens problem”: there should
bances when the patient looks through the edge of the be minimal/no subjective complaints when the patient is
lens. looking through the optical center of the lens.
• Trivex (n = 1.54) – this is one of the lightest lens materi- Therefore, a desirable lens will have a low chromatic
als available. It offers the same clarity and excellent aberration and a high Abbe value. Ironically, some new
impact resistance as polycarbonate but has a higher (favor- “high-index” lenses have low Abbe values. Abbe values of
able) Abbe value and UV protection. commonly used lens materials are included in Table 1. We
• Hi-index glass (n = 1.7–1.8) – This is a generic term for should emphasize that you should just understand trends in
various glass materials popular for high-power lenses. this figure and not waste time memorizing individual Abbe
Due to their high index of refraction (>1.70), the lens can value numbers for a given lens material. Note the low Abbe
be thinner and lighter, especially at the lens edge, making values for polycarbonate and “high-index” lenses.
them desirable in highly myopic patients. Is there any other reason to care about this? Acrylic is the
most common material used in popularly implanted IOLs
Abbe Value
Table 1 Abbe values for selected lens materials used in eyeglasses
In the previous section, we hinted at some of the pros/cons of Index of Abbe

Lens material Type refraction value
each lens material. One particular property deserves its own
CR-39 Plastic 1.498 58
section because of its high clinical relevance. The Abbe Crown glass Glass 1.523 58
value (aka V-number) measures a given material’s inherent Trivex Plastic – High 1.530 45
dispersion properties. Recall our discussion on dispersion in index
Chap. 1 “Geometric Optics”, dispersion refers to the change 1.7 glass Glass – High 1.701 40
in the angle of refraction of each individual color of light that index
1.8 glass Glass – High 1.802 35
comprises a “white” light ray. In other words, dispersion tells index
us how much the incoming light breaks up into the many High index Plastic – High 1.658 32
colors of the rainbow; we want colors to stick together like plastic index
our favorite band and not break off and try to make it on their Polycarbonate Plastic – High 1.586 30
own. index
Construction of Glasses (Ophthalmologists as Opticians) 231
today, which also have higher indices of refraction (ranging 5. UV-resistant coatings (aka UV 400) – a coating used to
from 1.47 to 1.55) than older-generation IOLs, such as sili- cause destructive interference of incoming UV light
cone IOL, that have much lower indices of refraction (rang- (300–400 nm) can also be used on eyeglasses. Since the
ing from 1.39 to 1.429). These acrylic IOLs also tend to have cornea can absorb UV light, overexposure can cause pho-
low Abbe values (therefore, higher chromatic aberration) tokeratitis and accelerate the development of cataracts in
and higher rates of postoperative dysphotopsia.1 patients with high sunlight exposure (both direct and
indirect), such as skiers. A UV-resistant coating may be
helpful for patients who work (or have fun) in high-UV
Lens Coatings light settings.
Lens coatings can be used to enhance the properties of eye-

glasses further. Some common types of lens coatings include Troubleshooting Glasses
the following:
Imagine the following scenario: you have just spent an hour
1. Antireflection coatings (see Chap. 14 “Physical Optics and a half with your favorite patient, I.M. Grumpyface, per-
and Advanced Optical Principles”) – a clear, thin film forming a meticulous refraction (including a duochrome
(approximately one-fourth the wavelength of incoming test), discussing various presbyopia-correcting options, and
light so that incident light is reflected out of phase, pro- answering his page of questions that he obtained from the
ducing destructive interference of any additional reflected internet “doing his own research” regarding lens materials
light) can be applied to the lens surface that reduces unde- and lens coatings. You finally give him his prescription and
sirable reflections. This coating secondarily increases the are relieved that he walks out of your office, hoping that he
amount of light that enters the eye. These may be particu- never returns (or becomes a patient of your crosstown com-
larly advantageous in high- index and polycarbonate petitor). Your staff gives you death stares because there are
lenses. 20 patients still waiting.
2. Edge coatings – edge coatings are a popular choice for Instead, he returns two weeks later, fuming mad and
high minus lenses with thick edges at the periphery. A unhappy with his glasses.
color coating can be applied to the lens edge that hides Does this sound familiar? This is an all too common sce-
some of the lens edge thickness and reduces some unde- nario, even for ophthalmologists. Let’s explore how we can
sirable lens edge aberrations and reflections. troubleshoot glasses for the unhappy patient before he writes
3. Mirror coatings – using various materials (such as mag- a bad review online.
nesium fluoride or titanium oxide), several layers of con-
structive interference can be added to the outer surface of
the lens in order to create a “mirror effect” similar to a Diagnosing Problems with Glasses
two-way mirror. This coating will decrease the amount of
total light that enters the lens, and the patient may report The following checklist is a (somewhat) logical way to check
a “gray-brown” tint when wearing them. These are espe- why a patient may complain about his/her glasses:
cially popular for patients who desire high visual acuity
in bright light settings, such as police officers and heli- 1. Check the new glasses:
copter pilots. (a) Place glasses in a lensmeter or another device and
4. Scratch-resistant coatings – as discussed in the previous check if the glasses were made correctly (correct
section, “softer” lens materials such as plastic may bene- sphere, cylinder, and axis as the dispensed
fit from a scratch-resistant coating. Many newer materi- refraction).
als, such as high-index glass and Trivex, have inherent (b) Check the base curve of the new glasses with a
scratch-resistant coatings. These coatings may be particu- Geneva lens clock and ensure that the new glasses
larly advantageous in patients (such as ophthalmolo- have a similar base curve as the old glasses.2 Patients
gists!) who constantly rub their eyeglasses against often use the word “fishbowl” or “swimming sensa-
surfaces (such as slit-lamp eyepieces and operating tion” to describe their dislike of a different base
microscopes). curve.
See Chap. 17, Optical Instruments, for a detailed discussion regarding

2
See Chap. 29 for more information regarding dysphotopsias.

1
lens clocks.
232 K. M. Riaz
+
22
+
22
Fig. 1 Centration chart. Top left – a simplified centration chart, with prior to cutting. We can tell it is a left eye lens because the “22” water-
the “+” sign indicating the optical center, the red circle indicating the mark (short for +2.25) etching is located on the right side (temporal to
area for best distance vision, and the dashed circle indicating where the the patient). Bottom figure – lens placed over the centration chart. This
pupillary center should be for reading at near. Horizontal bars addition- will help the optician know how to construct the lens for its final shape
ally help to orient the lens. Top right – a progressive lens with +2.25 add (dotted line)
(c) Check the lens material to see if a different material (a) Check if the new glasses’ frames are too big/too
(different index of refraction) or different/new coat- small for the patient’s face; if the lenses are too thick/
ings or tints are present. too thin; or if the patient has switched to a rim-
(d) Check the glasses to ensure that the cylinder is less frame, especially compared to the older glasses.
ground on the back. This teaching is somewhat a relic (b) Check if the patient is looking through the optical
of older textbooks since most modern glasses, by center of the new glasses; otherwise, there may be an
convention, are made such that the cylinder is ground induced prismatic effect (Prentice’s rule). This can be
on the back surface of the lens. done by marking the pupil center with a dry-erase
(e) Check to ensure that the cylinder power is placed in marker and finding the optical center with a lensme-
glasses in minus cylinder format. Again, this is a ter to ensure that they match.
moot point for modern glasses because essentially, (c) Check the patient’s pupillary distance (PD) and ensure
all glasses are constructed with this arrangement as it that glasses were made such that the optical center
decreases meridional magnification and allows for aligns with the patient’s PD. A centration chart (Fig. 1)
bifocal segments to be placed on the front surface of may be helpful. Have the patient wear the new glasses
the eyeglass lens. and look at a distance target. Using a muscle light,
2. Recheck the patient’s refraction: perform a streak refrac- ensure that the patient is looking through the optical
tion or autorefraction and then recheck the manifest and center of the lenses (as confirmed with a lensmeter).
cycloplegic refraction (especially for myopic patients): (d) Check the fit of the frame, especially with pediatric
(a) Check vision with glasses on both at distance and at patients:
near. (i) Ensure that nose pads and nose bridge fit correctly.
(b) Check the vision with glasses on both in dark and Look at the patient’s facial anatomy and see if
light settings. glasses are sliding down the nose or applying too
(c) If refractions match up, the patient may need addi- much pressure to the nasal bridge.
tional time to adjust to the new prescription, espe- (ii) Ensure that the temples of the glasses are fitting
cially if there has been a significant recent change in snugly over the ears or check if the new frame has
sphere, cylinder, or axis.3 a different temple shape/size than the old glasses.
3. Have the patient wear the glasses: Issues with glasses fitting at the ears may cause an
unwanted tilt of the new glasses, leading to undesir-
#ProTip – have the unhappy glass patient return when the next resident
3
able pantoscopic tilt issues.
is on rotation.
C
A
I H
F
Fig. 2 Visual representation to spatially organize various problems in a problems with bifocals and progressive lenses; (f) problems with pupil-
pair of glasses. (a) Changes in the lens material (index of refraction and lary distance changes, optical center, and induced prismatic effects; (g)
Abbe value issues); (b) problems with the temples causing pantoscopic problems with the bridge of the nose and other facial anatomy; (h)
tilt and fit issues; (c) problems with frames, such as too large/small, too problems with snug pads and other nasal anatomy; i problems at the
thick/thin, and rimless frames; (d) changes in base curve, cylinder edge of the lens, such as chromatic aberration, lens edge glare, etc.; and
ground on the back of the lens, and changes in vertex distances; (e) j problems with glare and lens coatings
(iii) Check if there is any facial anatomy (such as large 4. Bifocals/progressives – see Chap. 12 “Glasses for Written
brow, etc.) affecting the fit of the glasses or causing Exams”, for more details. There are several things worth
issues such as fogging. mentioning here:
(iv) Check to ensure there is no unwanted pantoscopic (a) If this is the first time in bifocals or progressives
tilt or faceform issues that are affecting the patient’s (PAL), the patient may need additional time to adjust.
satisfaction with glasses. (b) Check the type of bifocal/PAL given and see if there
(e) Check the vertex distance: using the distometer, make is a problem with image jump, image displacement,
sure that the vertex distance of the new glasses is the oblique astigmatism, etc.
same as the vertex distance of the old glasses.4 This is (c) Check the position of the bifocal segment, its relation
especially important for higher prescriptions (both myo- to the optical center, vertex distance, and size in
pic and hyperopic), as discussed in Chap. 6 “Lens the context of the frame. For example, a patient who
Effectivity”. has switched to a smaller frame may now have a
(f) Ask the patient about glare and other subjective prob- smaller (proportional) bifocal segment and may be
lems. These patients may benefit from a change or addi- unhappy with this “decreased real estate.”
tion of coating(s). 5. Other miscellaneous issues are as follows:
(g) Ask the patient if he/she notices any subjective visual (a) Scratches and defects.
problems when looking at the edge of the lens. If so, (b) Cost, frame colors, and cosmetic appearance. Patients
there may be issues with the lens edge (such as a thick are sometimes embarrassed to say they changed their
lens edge with high minus prescriptions, chromatic aber- minds about the frames, or perhaps they think they
ration with high index/polycarbonate materials, etc.). will not be charged for a different frame if they com-
plain. Many street-smart opticians may ask, “do you
think you would see better with a different frame?”
It may help to visualize all possible problems on a pair of

See Chap. 17, Optical Instruments, for a discussion on the distometer
4
glasses instead of memorizing a checklist (Fig. 2).
and its clinical usage for vertex distance.
234 K. M. Riaz
Slit-lamp examination of the patient may be helpful if the when looking down, we can slab-off the high minus
above checklist fails to reveal the problem. Specifically, we lens to create a bit of a base-up effect.
can consider the following (not an exhaustive list): (b) “Reverse slab-off” – this is yet another favorite term
for people to throw around in didactic conversations.
• Extraocular motility – new or decompensated phoria and It is basically the opposite of slab-off; therefore, we
convergence insufficiency. can do this to the more plus-power lens to give some
• Eyelids – new ptosis may cause astigmatism; increased base-down effect. In the optician world, reverse
palpebral fissure height may exacerbate ocular surface slab-off is more commonly done in practice because
dryness. it is easier to do in the optical lab.
• Cornea – dry eye syndrome, epithelial irregularity, etc. (c) The lens edge may also be beveled or polished to
• Lens – lens opacity, posterior capsular opacification, etc. improve glare and chromatic aberration issues.
• Retina – worsening of existing retinopathy (diabetes, 3. Change the frame type – if anatomical considerations are
AMD), ERM, etc. the reason, switching to more ergonomically comfortable
frames may solve the problem:
Ancillary testing may also help detect the problem. While (a) Larger frames (especially for high plus lenses) are
we can perform a million-dollar workup, tests that may be usually better than smaller frames, especially if the
the most useful include corneal topography/tomography and unhappiness is due to problems at the edge of the lens
ocular coherence tomography of the retina. (that is noticeable in the field of vision). By making
frames larger, we can shift the problematic edge of
the lens outside the patient’s field of vision.
Fixing Problems with Glasses (b) Somewhat paradoxically, for highly myopic patients,
we can consider switching to a smaller frame to force
Mr. I.M. Grumpyface is still unhappy with this exhaustive the patient to look through the optical center and avoid
list of issues you have just rattled off. He is not impressed looking around toward the edge of the lens. Smaller
with your knowledge and instead wants to know how you frames don’t work well for high plus-power lenses.
can actually fix his glasses. The following is a list of options (c) Rimless/thin frames can be switched to thicker
to fix glasses for the unhappy patient: frames that can better hide the lens’s edge, especially
Always start by repeating the refraction and ensuring that for high minus-power lenses.
it is accurate. Assuming it is, then we can do the following: (d) Adjust the vertex distance as needed. We may not
give much consideration to vertex distance for low
1. Remake the glasses, especially if the prescription has power prescriptions, but this plays a significant role
changed or the new glasses were made incorrectly: in high plus- and minus-power lenses.
(a) Physical changes to the glasses may be necessary; for 4. Astigmatism issues are as follows:
example, changing the vertex distance (usually closer (a) Suppose there has been a significant recent change in
to the cornea), changing the lens material (index of the cylinder correction. We can attempt to decrease
refraction; higher index of refraction will give a thin- the cylinder power while sacrificing some visual acu-
ner lens but may increase aberrations), changing/add- ity (~20/25–20/30) if the patient is not at risk for
ing a lens coating, etc. amblyopia.
(b) Change the base curve back to the old pair of glasses; (b) Suppose there has been a recent change in the axis. We
for high minus lenses, a flatter base curve may be can try to rotate the cylinder closer to 90 degrees or
used for the front of the lens. 180 degrees to avoid diplopia and oblique astigmatism
(c) Grind the cylinder on the back portion of the lenses: issues with the oblique cylinder. However, any change
as discussed in the previous section, this is a relic of in cylinder axis in a patient 20–40 years of age should
days past. warrant a workup for possible corneal ectasia.
(d) Plastic lenses are thinner and lighter than “glass” (c) Some patients may need reassurance to get used to the
lenses. change in cylinder amount and cylinder axis. For pedi-
2. Change the lens edge for high minus or high plus lenses, atric patients at risk for amblyopia, the full correction
especially if there is an induced prismatic effect: (including the axis) must be given; we can’t play
(a) “Slab-off” – this is a favorite term for people to throw around and get all fancy due to the amblyopia risk.
around in didactic conversations. What does it actu- 5. Bifocal issues are as follows:
ally mean? Slab-off is done for high minus lenses (a) Image jump/displacement can be addressed accord-
with thick edges. Basically, we can grind/thin out ingly if a round-top and/or flat-top has been given
the lens edge so it’s not so thick anymore. If a patient erroneously to a patient.
has base-down prism effects in a high minus lens (b) Switch the patient to an executive lens or PAL.
(c) Consider a trifocal pair of glasses for patients with 2. Appearance of glasses (thick lenses, especially at the
high demands for intermediate vision who are will- edges).
ing to sacrifice “real estate” in their glasses. 3. Glare at the edge of lens – chromatic aberration.
(d) Prescribe separate glasses for distance and near 4. Minification – recall that a myope is looking at the world
vision. This solution is beneficial for patients with through a reverse Galilean telescope (see Chap. 8,
convergence insufficiency who need a base-in (BI) “Magnification and Telescopes”), so objects will appear
prism to avoid diplopia at near. These patients can smaller to her (as compared to an emmetrope).
have BI prism for the near glasses and no prism cor- 5. Makes face smaller to others – recall that the temporal
rection in distance glasses. edge of a high minus-power lens is basically a base-out
6. Prescribe separate glasses for distance and reading, night prism; therefore, virtual images will appear to be dis-
and day vision, and indoor and outdoor activities (e.g., placed toward the apex of the prism. For an observer
changing tints or lens coatings). For example, suppose a looking at a patient wearing high minus lenses, the
patient needs glasses for night-time distance needs, such as patient’s temporal face/cheek may appear to be shifted
long-distance driving or playing night-time sports. In that (“smashed in”) toward the nose. High minus lenses may
case, an additional pair of glasses with extra minus power create an undesirable cosmetic effect that the patient may
may be considered to overcome potential problems with be concerned about (Fig. 3).
night myopia.5 6. Cost – to paraphrase a famous rapper from the 1990s,
7. Contact lenses, including monovision and multifocal “More money, more problems.” These lenses may require
contact lenses. a significant financial investment from patients.
8. Refractive surgery may be considered as a last resort after Ten things to consider in improving high minus glasses
all of the above options have been thoroughly discussed. are as follows:
1. Perform a cycloplegic refraction and duochrome test to
make sure the patient is not overminused.
roblems with High Minus- and High Plus-
P
Power Glasses and Potential Solutions
While some of the material in this section may be repetitive,

it may be helpful to separately lump together problems that
may occur with high minus- and high plus-power lenses for
rapid review.
roblems with High Minus-Power Glasses

P
There are six high-yield problems to memorize that may
occur with high minus-power glasses. A useful mnemonic is
“BAG of MMC”:
1. Barrel distortion – light rays that pass through the thicker
edge of a high minus-power lens may cause the patient to
experience a “barrel distortion” (see Chap. 1, “Geometric
Optics”). Remember that real light rays are bent toward
the base (edge of a minus lens), so central rays (passing
through the thinner central portion of the lens) will seem
to come in focus closer to the center as compared to the
peripheral rays that will seem like they are “bent” toward
the edge of the lens. We can also think of distortion as a
disparity in linear magnification for paraxial light rays
versus peripheral rays. The central light rays will be more
minified than the peripheral light rays in myopic glasses.
Therefore, the peripheral rays may appear “pushed out”
towards the periphery.
Fig. 3 An observer looking at a patient wearing high minus-power
lenses may notice that the face appears to be shifted toward the nose
See Chap. 21 Clinical Problems with Optics and Refractive
5
(“smashed in” appearance) due to prismatic effects. Recall that the
Manifestations, for a more detailed discussion regarding causes and image of this patient’s face is a virtual image to the observer; virtual
treatments of night myopia. images are shifted toward the apex of the prism
236 K. M. Riaz
2. Smaller frames – these provide a smaller field of view

but may force the patient to use the pure optical center of
the lens and avoid looking toward the edge of the lens.
3. Larger frames – these push the edge of the lens out of
the field of view. Yes, this is the opposite answer of the
previous choice, but we discussed why both options
might work in the preceding section.
4. Thicker frames – these may help to hide the edge of the
lens better.
5. Polishing the edge of the lens – this may help with glare
and chromatic aberration complaints.
6. Beveling/slab-off – this may help with prismatic effects
encountered at the thick edge of a high minus-power
lens.
7. Plastic (or lighter lens material) – this decreases the
weight of the lens.
8. Flatter base curve for the front of lens.
9. Decrease the vertex distance.
10. Non-glasses options – contact lenses and refractive sur-
gery. Again, for exam purposes, save this answer as the
last option after you have thoroughly discussed the pre-
Fig. 4 An observer looking at a patient wearing high plus lenses may
vious options.
notice that the face appears to be shifted out toward the ear (“bug-eyed”
appearance) due to prismatic effects. Recall that the image of this
roblems with High Plus-Power Glasses
P patient’s face is a virtual image to the observer; virtual images are
There are ten high-yield problems to memorize that may shifted toward the apex of the prism
occur with high plus-power glasses. We apologize, but we
could not come up with a clever mnemonic to help you 6. Magnification – recall that a hyperope is looking at the
remember this: world through a Galilean telescope, so objects will
1. Ring scotoma – secondary to prismatic effects. See appear larger to her (as compared to an emmetrope).
below for a more detailed explanation. 7. Cosmetic considerations – recall that the temporal edge
2. Jack-in-the-box phenomenon – this goes hand in hand of a high plus lens is basically a base-in prism; therefore,
with ring scotoma. See below for a more detailed virtual images appear to be displaced toward the apex of
explanation. the prism (the patient’s ear). For an observer looking at a
3. Pincushion distortion – light rays that pass through the patient wearing high plus lenses, the patient’s temporal
thinner edge of a high plus-power lens may cause the face/cheek may appear to be larger and shifted toward
patient to experience a “pincushion distortion.” the ear (“bug-eyed appearance”). This may create an
Remember that real light rays are bent toward the base undesirable cosmetic effect (Fig. 4).
(in this case, the center of a high plus-power lens), so 8. Increased convergence demands – when the patient
the central rays will reach the retina first. The peripheral wants to read, he will look through the nasal portion of
rays will seem to focus much further away than the cen- the high plus lens, which creates an unwanted base-out
tral rays – they will seem to be pulled away from the prismatic effect. The patient will therefore have to con-
central visual axis. We can also think of distortion as a verge more in order to compensate.
disparity in linear magnification for paraxial light rays 9. Weight of high plus glasses.
vs. peripheral rays. In hyperopic glasses, central light 10. Cost. Again, more money, more problems.
rays will be more magnified, and peripheral rays will be It is helpful to discuss two problems mentioned above in
less so, seemingly “pulled” out toward the periphery. a bit more detail. It is helpful to view these problems together
4. Spherical and chromatic aberration issues – due to opti- as each helps explain the other.
cal effects at the edge of the lens.
5. Field of vision reduction – because of the four above Ring Scotoma (aka “Roving” Ring Scotoma) As dis-
issues, the edge of the lens is an optically problematic cussed above, the edge of a high plus lens has base-in pris-
area for a hyperope. As a result, only the “center” of the matic effects (for the patient). Real light rays are bent toward
lens is functional, so the patient may report a reduction the base of a prism. As the power of the lens increases, there
in the field of vision. is increased refraction of incoming light rays towards the
“base” of the two prisms that comprise the lens (known as 4. Reverse slab-off: this can help with prismatic effects
angle alpha). Due to a large angle alpha, we can observe that encountered at the edge of the lens.
light rays that hit the edge of the lens are bent so significantly 5. Non-glasses options – contact lenses work extremely
toward the center of the lens (the base of the prism) that they well in hyperopic patients, especially those with presby-
never reach the retina, and thus the patient never “sees” them. opia, as they decrease the accommodative demand.
Since the edge of the lens is shaped like a ring, this is per- Excimer laser refractive surgery has a lower rate of suc-
ceived by the patient as a “ring scotoma.” It is sometimes cess in hyperopes than myopes. A secondary IOL may be
called a “roving ring scotoma” because the sco- an extremely effective option if a patient has hyperopia
toma blocks objects of interest in the peripheral visual field, secondary to aphakia.
so the patient tries to look “around” it, but the scotoma also
constantly moves; this can be very frustrating for the patient.
This is why using a larger frame (such that the edge of the Custom Glasses
lens is outside the field of vision) may alleviate this
problem. Mr. I.M. Grumpyface was so pleased with your abilities to
troubleshoot and finally get him a pair of glasses that work.
He has been telling everyone he knows about your skills, and
Jack-in-the-Box (JITB) Phenomenon The JITB phenom- your busy ophthalmology practice has now turned into a
enon is easy to understand in the context of the previous dis- thriving optical shop. One of his referrals is Ms. Tara Daktyl,
cussion on ring scotoma. Basically, when a patient wearing reportedly a “lady friend” of Mr. Grumpyface, looking for
high plus-power lenses wants to look at an interesting object some custom glasses. She is a middle-aged female who is an
located in the peripheral visual field, he may move his eyes electrician during the day and a concert pianist at night. Her
toward the object. As the eye moves toward the object, the hobbies include golfing, hunting, and fishing. She was told
image may momentarily land in the ring scotoma area and that you are the best in town and is eager for your advice on
disappear; but then, as the patient continues to move his eye what kind(s) of glasses can help her visual needs.
further, the image is no longer in the scotoma, so it appears Using Ms. Tara Daktyl as our starting point, we can dis-
in the visual field again. This sudden disappearance and cuss some options for “custom glasses” – creative, nontradi-
reappearance of objects in the peripheral visual field is tional ways to construct glasses with particular requirements
known as the JITB phenomenon. Like the childhood (or for specific visual activities.
creepy!) toy, the object disappears and appears. JITB can be
very frustrating for the patient, especially when considering
peripheral vision needs for activities such as driving (e.g., ontraditional Bifocals (Occupational
N
seeing street signs, cars in parallel lanes, etc.). Again, this is and Recreational Bifocals)
why using a larger frame (such that the edge of the lens is
outside the field of vision) may alleviate this problem. While we often assume that bifocals have to be made with a
reading segment in the bottom portion of each lens, there are
several options for nontraditional bifocals:
Improving High Plus-Power Glasses As you may have 1. Glasses with bifocal segment(s) placed superiorly or
sensed a theme in this entire textbook, it is no fun being a superonasally. This option may be suitable for patients
hyperope. There are a limited number of things we can do to with occupational requirements (e.g., electricians, car-
improve high plus lenses: penters, car mechanics, etc.) for near work that involves
looking upward (rather than downward for reading);
1. Change frame design and size: as discussed previously, these patients may therefore require near-vision correc-
larger frames work exceptionally well for hyperopic tion when looking up rather than down. An add segment
patients because they can hide the edge of the lens, mainly placed in the superior or superonasal portion of the lens
to decrease problems such as ring scotoma and (in one or both eyes) may help the patient with her near-
JITB. Unlike their myopic counterparts, using a smaller vision needs when she is looking upward. Basically, these
frame will not work well. patients would have a “reverse bifocal” as the bottom por-
2. Change frame design: wraparound-style frames may also tion would be for distance vision.
work because they may shift the edge of the frame out of 2. Glasses with a single bifocal segment placed inferiorly.
the field of vision. This option may be viable for patients for activities
3. Switch to a high-index or lighter-weight material to requiring maximum field of vision for distance with a
decrease the weight. Usually, high plus-power lenses are reduced bifocal area for quick, minimal near-vision
heavier than their high minus-power lens counterparts. needs. In other words, these patients may want a bifocal
238 K. M. Riaz
segment for short periods of near vision, rather than pro- Tints in Glasses
longed periods of reading. For example, an avid presby- Tints in glasses are a somewhat controversial and evolving
opic golfer (or a hunter) may only need to look at her subject. The basic principle is to use tints (colors) in eyeglass
scorecard momentarily to record her score; she may lenses to preferentially block specific wavelengths of light to
therefore want to maximize her distance vision during improve patients’ subjective vision. For example, blocking
her recreational golf outings. Therefore, an add segment shorter wavelengths (blue) may help reduce eyestrain and
placed only in the inferonasal aspect of one lens (prefer- headaches in patients with extreme photosensitivity. It is
ably the nondominant eye) will allow her to look down known that blue wavelengths may additionally trigger spe-
for quick near-vision needs while maximizing distance cial cells (intrinsically photosensitive retinal ganglion cells,
vision, especially in the dominant eye. IPRGCs) besides rods and cones that may be abnormally
3. Bifocals with modified near segments. Some patients may activated in patients with severe photophobia.6 It has been
need a bifocal for assistance with intermediate vision (such shown that increased activation of IPRGCs may exacerbate
as a concert pianist or stock trader looking at computer photophobia. Among various tints, the FL-41 is a reddish-
screens) rather than near vision. Therefore, a modified bifo- pink tint that has been used since the 1990s that has been
cal can be made with the inferior add segment set for one- shown to have usefulness in treating certain patient popula-
half the required reading add power. For Ms. Daktyl, if she tions with photosensitivity and eyestrain.7
wears +2.50D for near vision, we can construct her a pair of Historically, tints have been used to treat patients w ith
glasses when she plays the piano such that the bottom “add” various ophthalmic, neurological, psychological, and psy-
is instead +1.25 (allowing her to look at sheet music), and chiatric diseases with varying degrees of success. More rel-
the top portion of the glasses have the full distance vision evant to routine ophthalmic practice, removing a cataract
correction (e.g., to look at the conductor). Such glasses may (and the patient’s intrinsic light filter) may be one reason
not be helpful for near-vision needs. why some patients report photophobia immediately after
We have now given Ms. Daktyl three additional pairs of cataract surgery. Some authors have reported successful
glasses for her various occupational and recreational needs. usage of tints in patients with ophthalmic diseases such as
She is thrilled and purchases three $1200 frames to go with blepharospasm, achromatopsia, and cone dystrophies.
each prescription you have given her. At this rate, you may While a variety of options exist, there are several tint col-
never need to see patients with actual pathology or do eye ors that we should be familiar with: FL-41, dark gray
surgery ever again. (smoke), brown (amber), and yellow. Dark gray and brown
tints can be interchangeable for all intents and purposes:
Other Modifications for Glasses • FL-41 (boysenberry color) tints – as previously men-

tioned, these tints block blue wavelengths of light and
Like the gift that keeps giving, Mr. Grumpyface’s referral may be especially useful in patients with clinically sig-
patients keep coming in. A young man named Jed I. Knight nificant photophobia and photosensitive neurological dis-
(dressed in a brown, hooded robe) comes in asking for a eases (e.g., epilepsy, etc.).
pair(s) of glasses that will help with the following activities: • Dark gray (smoke) tints are meant for daytime wear in
bright sunlight conditions. They may help to decrease
• Optimizing vision at dawn and dusk when he performs brightness, especially from sunlight, without compromis-
specific training exercises, such as handstands. ing color quality.
• Optimizing vision in low-light conditions as he navigates • Brown (amber) tints are meant for daytime wear on
through an unknown swamp searching for a little green man. cloudy days or sunset/sunrise type of lighting conditions.
• Optimizing vision while running back and forth between • Yellow tints are controversial as they are purported to
indoors and outdoors – because who knows? enhance depth perception and visibility in low-light condi-
• Reading a novel while sunbathing – it could happen? tions – this is why they are a preferred color for safety
• Optimizing vision while sailing on his yacht – yeah, we glasses used in dim-light conditions, such as coal-mining
also don’t know why he does this. safety glasses. However, they may filter out a large portion
of blue wavelengths of light, subjectively giving patients
As you contemplate telling him to go elsewhere, he
responds: “If you send me out, I shall become more powerful Raabe J, Kini A, Lee AG. Optical lens tinting – a review of its func-
6
than you can possibly imagine.” tional mechanism, efficacy, and applications. US Ophthalmic Review
His list of demands serves as a helpful starting point to 2019; 12: 85–87
introduce a few other things we can do for glasses: tints, gra- Wilkins AJ, Wilkinson P. A tint to reduce eye-strain from fluorescent
7
dients, and polarization. lighting? Preliminary observations. Ophthalmic Physiol Opt.

1991;11:172–5
Fig. 5 Photochromic lenses are not recommended for outdoor activi- and polar bears encountered during such activities. Of note, no animals
ties in cold settings, such as snowmobiling, as the lenses may become were hurt in the production of this book, and yes, we know polar bears
too dark for the user and obscure vision. This is not good for penguins and penguins would not be found in the same location
the impression of improved contrast vision in bright-light because windows may block some of the incoming light that
settings. Even more controversial, they are said to help stimulates the lens to change color – the photochromic tint may
“soothe strained eyes” from computer vision syndrome. take several minutes to work. This delay may lead to frustration
However, research performed in simulated settings such as for the patient. As a final warning, lenses may become too dark
nighttime driving conditions has not demonstrated in a cold outdoor setting, such as during skiing or snowmobil-
improved performance in subjects. At the time of this writing (Fig. 5). A variety of photochromic tint options are com-
ing, there is no substantial evidence to suggest that yellow mercially available.
tints in standard glasses have anything more than a placebo
or “cool-guy” fashion sense effect in patients.8 radient Modification for Glasses
G
A gradient modification can be added to sunglasses such that the
Photochromic lenses are a separate category of tints that top of the lens is the darkest while the bottom of the lens has a
can be lumped into this discussion. These lenses have mole- very minimal tint (or even no tint). A gradient allows the patient
cules within the lens substance that automatically adjust to have the full benefit of sunglasses at the top of the glasses
the color based on light exposure; they can “transition” between while allowing for better visibility in the lower portion of the
darker tints outdoors and lighter/no tint indoors. A significant lens. For example, this may be a valuable modification for
advantage of these lenses is that they allow a patient to use one patients who enjoy reading while sunbathing: the top portion of
pair of glasses for both indoor and outdoor needs. They also the glasses will provide sunlight protection and good distance
block nearly 100 percent of incoming UVA/UVB light. One vision, while the bottom portion of the lens has a minimal tint to
disadvantage is that these lenses do not function as well as provide greater visibility for near vision and reading.
actual sunglasses outdoors; an actual pair of sunglasses may be
optimal for prolonged outdoor activities. Another disadvantage Polarization for Sunglasses
is that these lenses may not work as well in bright environ- We have previously discussed polarization filters in Chap. 14
ments with windows that block UV light (such as car windows) “Physical Optics and Advanced Optical Principles”. To
review, vertically oriented polarization filters are commonly
Hwang AD, Tuccar-Burak M, Peli E. Comparison of Pedestrian
8 used in polarized sunglasses. A vertical filter will block most
Detection With and Without Yellow-Lens Glasses During Simulated of the horizontally scattered light (such as incoming light off
Night Driving With and Without Headlight Glare [published online the surface of a lake) while allowing in vertically oriented
ahead of print, 2019 Aug 1]. JAMA Ophthalmol. light, making them an excellent choice for sunglasses used
2019;137(10):1147–1153
240 K. M. Riaz
outdoors (e.g., when captaining a yacht on a bright sunny whereas dark brown/smoke-gray tints may be helpful for
day). outdoor activities.
Returning to our friend, Jed I. Knight, we can therefore 3. Due to nystagmus issues, contact lenses may give better
prescribe the following tints, gradients, and other vision than glasses. Soft toric and rigid gas-permeable
modifications: lenses may especially help neutralize moderate-severe
corneal astigmatism.
• Prescribe brown (amber) tints for dawn/dusk activities. 4. Handheld telescopes may be useful for school-age
• Prescribe yellow tints for his swamp (low-light condition) patients (see Chap. 5 “Power of Lenses in Different
activities. Media”, Chap. 19 “Low Vision and Vision
• Prescribe photochromic tints for his indoor-outdoor Rehabilitation”).
activities. 5. Other strategies to reduce glare include screen tints on
• Prescribe sunglasses with a gradient tint for reading while computers and yellow paper (instead of white paper) for
sunbathing. classroom work.
• Prescribe polarized sunglasses for his yacht sailing 6. We must also remember that due to a limited BCVA,
activities. some patients with albinism will not appreciate the effect
of glasses. A trial frame in the office is often helpful
After you write him prescriptions for each pair of these before finalizing the prescription.
specialized glasses and as you begin to tally his hefty bill at
checkout, you notice him waving his right hand and softly Glasses for a Patient with Achromatopsia (aka “Rod
say: “These are not the dollars you are looking for.” You Monochromatism”) Recall that only the rods are function-
don’t remember much of what happened after that. ing in these patients, and no cones are functioning. Rods are
tolerant to red light because bright light will bleach out the
rods. Therefore, using a dark-red tint on glasses will transmit
Glasses in Special Circumstances red wavelengths of light, protect the rods, and allow the
patient to utilize the rods’ abilities for maximum vision.
We can conclude this chapter by discussing strategies for
glasses for patients in special circumstances. Usually, this is As an added wrinkle, a subset of achromatopsia patients is
addressed by a skilled optometrist or a low vision specialist blue-cone monochromats. In these patients, both the rods and
in real life. While we may never actually have to do this in blue cones are functioning. If we only used a red tint, we would
clinical practice, an understanding and appreciation for our lose out on the potential function of the healthy blue cones.
colleagues’ thought processes and strategies are worthwhile. Therefore, using a magenta tint will allow the patient to use
Many vision pathologies may benefit from customized both rods and blue cones to maximize vision potential.
glasses, but there are also numerous ways to help a patient
depending on the disease. A full review of all potential Glasses for a Patient with Congenital Stationary Night
glasses options for every ophthalmic disease is beyond the Blindness (CSNB) CSNB refers to a group of nonprogres-
scope of this text. sive retinal disorders characterized by an abnormal or absent
Consider three sample patients and different types of function of the rod system; basically, only the cones are func-
glasses that can benefit each. tioning. In these patients, using yellow tint glasses will maxi-
mize the peak sensitivity of yellow (560 nm) among red
Glasses for a Patient with Albinism There are several cones (which peak technically at the yellow portion of the
factors to consider for a patient with albinism: high inci- electromagnetic spectrum; see Chap. 14 “Physical Optics
dence of refractive errors, astigmatism, nystagmus, and and Advanced Optical Principles”) and partially among
glare issues. Strategies for prescribing glasses to these green cones. Using a yellow tint/filter may interfere with
patients include: color discrimination but maximize visual acuity potential in
these patients.
1. Due to these patients’ photophobia/glare issues, polar-
ized sunglasses for outdoors (along with headgear with a
visor) can be extremely beneficial. Sunglasses may be
accordingly tinted and/or have a mirror coating. Practice Questions
2. Photochromic lenses with dark tint outdoors and light tint
indoors (as opposed to clear lenses indoors) may also be 1. A 50-year-old patient (−4.00D myope) states she gets
helpful for a single pair of glasses. Different tints may be new headaches with her new single vision distance
helpful based on the activity, for example, light blue tints glasses when she uses them for driving and while she is
may be helpful for indoor lighting (school, workplace), binge-watching her favorite TV series.
You check the lenses and measure that both are −4.00 D • Complaints of peripheral objects in the distance “sud-
sphere. You check her visual acuity with glasses at dis- denly” appearing – ______.
tance as 20/30 and at near as 20/60. A repeat refraction 5. Which of the following statements is true?
shows −4.00D sphere OU (20/20) in the phoropter. When A. For a patient with a − 8.00D sphere prescription OU,
you perform the duochrome test, she states that green let- a flatter base curve for the front of the lens may be
ters are bolder than red with glasses on. Which of the fol- helpful.
lowing is the most likely cause of this patient’s B. Reverse slab-off means to grind or shave down edges
symptoms? of a high minus lens.
A. The new frames have a shorter vertex distance. C. Switching to a smaller frame is a very effective way to
B. The new lenses have a different base curve. solve problems of a ring scotoma and Jack-in-the-box
C. There is Jack-in-the-box (JITB) effect caused by the effect in patients with hyperopic prescriptions.
new frames. D. Spherical and chromatic aberration effects are more
D. She is experiencing problems because of unmet likely at the center of a pair of glasses.
accommodative needs in the new glasses; she should
switch to a progressive or bifocal lens.
2. A 14-year-old patient presents with subjective com- Answers
plaints of poor vision after recently getting a new pair of
glasses. He states: “It looks like I am looking through a 1. Answer: A. Results of the duochrome test indicate that the
fishbowl.” On exam today, his vision is 20/20 with glass patient has been overminused (“green add plus” from the
prescription +2.00 + 1.00 X 090 OU. Repeat manifest “RAM-GAP” mnemonic). However, the dilemma appears
refraction is the same, yielding 20/20 corrected visual to be that glasses’ power and repeat refraction are the
acuity OU. The patient is ortho without correction at both same, yet the patient demonstrates signs of “extra” minus
near and far. Which of the following is the most likely power. Due to lens effectivity, a minus-power lens will
cause of this patient’s symptoms? gain power if it is closer to the eye. In this scenario, it is
A. The patient likely has latent hyperopia and should likely that a shorter vertex (answer choice A) is causing
have a cycloplegic refraction. the −4.00D lens to behave like a −5.00D lens (approxi-
B. The vertex distance may be too large and should be mately). Restoring the old vertex distance should alleviate
checked with a distometer. the problem. A different base curve (choice B) may cause
C. The patient is probably describing a ring scotoma problems such as a “swimming sensation,” but would not
given his hyperopic prescription. cause a decrease in BCVA. The JITB effect (Choice C) is
D. The problem is due to new lenses with a different base seen in patients with high plus-power glasses for objects
curve. in the distant peripheral field of vision, not with reading
3. Which of the following statements is true regarding the vision. Patients who are overminused may also experi-
construction of specialty glasses? ence problems with unmet needs of accommodation
A. A gradient modification is an effective substitute for (choice D). However, the patient does not seem to be
polarized sunglasses for a patient who is an avid complaining about these issues in the question stem.
sailboater. 2. Answer: D. When a new base curve is introduced, the
B. FL-41 tints may be useful for patients with clinically patient will often complain of a “fishbowl” effect (choice
significant photophobia. D). The remaining findings on the exam, including the
C. Most modern polarized sunglasses are made with lack of a tropia or phoria, further reinforce that the prob-
horizontal filters in order to effectively block horizon- lem seems to be coming from the new glasses. Latent
tally scattered light. hyperopia (choice A) may cause blurred near vision and
D. A photochromic tint works equally well for outdoor headaches, and usually manifests in patients after age 30.
activities and driving. A longer vertex distance (choice B) would cause blurred
4. For each of the following complaints, indicate whether it distance vision. A ring scotoma (choice C) would be
is more likely to be reported by a patient wearing −10.00D expected in high hyperopia and mainly with peripheral
OU glasses (A) or + 10.00D OU glasses (B): vision at distance.
• Roving ring scotoma – ____. 3. Answer: B. The FL-41 tint (boysenberry color, answer
• Pincushion distortion – ____. choice B) preferentially blocks shorter wavelengths (blue)
• Minification of viewed objects – _____. of light and may decrease activation of specialized cells
• Barrel distortion – _____. (IPRGCs) that may be “overactivated” in patients with
• Magnification of viewed objects – _____. significant photophobia. A gradient modification (choice
A) consists of a “dark tint” at the top of the lens with a
242 K. M. Riaz
gradual decrease toward the bottom of the lens that has roving ring scotoma (A), pincushion distortion (A), mag-
almost no tint at all. It can be useful for patients who nification of viewed objects (A), and sudden appearance
enjoy activities such as outdoor reading in sunlight, as it (A) of peripheral objects in the distance (“Jack-in-the-
provides some “sunglasses” like protection at the top of box” effect).
the lens while allowing for a relatively clear “inferior” 5. Answer: A. For high minus-power prescriptions, a flatter
reading portion. However, it does not offer the same ben- base curve for the front of the lens, as compared to the
efits of a polarized pair of sunglasses that would more back of the lens, may improve subjective comfort and
effectively block horizontally scattered light throughout visual acuity. Slab-off (choice B) is a modification cus-
the entirety of the lenses. Modern polarized sunglasses tomarily done to high minus lenses: as these lenses have
(choice C) contain vertically oriented filters that block thick edges (compared to the thinner center), grinding/
horizontally scattered portions of incoming light, thereby thinning out the edge of the lens may help alleviate prob-
allowing the vertically scattered (a minority portion of lems at the lens periphery (prismatic effects) and lens
incoming light) to pass through the filter. A photochromic edge (spherical/chromatic aberration). In modern optical
tint (choice D) may not work as well during driving as practice, reverse slab-off is more frequently done: in this
compared to outdoor activities. During outdoor activities, strategy, the edge of the plus lens is modified to give less
there is more “incoming light” to better activate the pho- base-down effect. In general, switching to a larger frame
tochromic tint. The tints may not effectively or efficiently (especially one such that the edge of the lens is outside the
activate in a “dim-bright light” condition such as driving patient’s field of view) can be helpful for both myopic and
inside the car on a sunny day (due to light-blocking effects hyperopic prescriptions. For the hyperope, a larger frame
of the car roof, windshield, etc.). (choice C) can help minimize negative effects of ring sco-
4. Answer: The patient with −10.00D (pathological myope) toma and JITB effect. Spherical and chromatic aberra-
is most likely to complain of a barrel distortion (B) and tions (choice D) mainly occur at the peripheral edge of the
minification of viewed objects (B). The patient with lens.
+10.00D (high hyperope) is most likely to complain of a
Optical Instruments and Machines
G. Vike Vicente
Objectives • New fellow- Oh! I’ve seen prism glasses before, but my
• To understand the optical principles involved in the devel- residency program never taught us how to measure the
opment and usage of commonly encountered instruments prisms.
in ophthalmic practice • Chairman – In three years, they never taught you? Shame
• To know the components of the retinoscope and how to on them!
perform retinoscopy • New fellow – Yes sir!
• To know how to use the lensmeter to measure the power • Chairman – In three years, you never asked?
of single-vision, bifocal, and progressive glasses
• To review the various components of the phoropter Since we have all these interesting ophthalmic gadgets in
• To discuss advantages and disadvantages of trial frames our clinics, we owe it to ourselves to understand what optical
• To survey the optics involved in the construction and clin- principles went into their development and implementation.
ical usage of the direct and indirect ophthalmoscopes Most importantly, we must learn how to use them properly.
• To review important components of the slit lamp, includ- Let’s start the tour.
ing correlation with previously discussed concepts, such
as the telescope and prisms
• To discuss how to use the manual keratometer, as well as Retinoscope
review advantages and disadvantages of this device
• To be able to assemble the optical instruments required by Technical Components
an eye care professional in a worst case/zombie apoca-
lypse scenario A retinoscope is a portable, handheld instrument that allows
the clinician to measure a patient’s refractive error, detect
regular/irregular astigmatism, assess the red reflex, and
Introduction quickly screen for intraocular pathology (e.g., cataract, len-
ticular/retinal tumor, etc.)
We would like to start this chapter with a true anecdote about Retinoscopy (a.k.a. skiascopy) is a technique wherein the
ophthalmic instruments. On the first day of his fellowship, retinoscope is used to objectively measure the refractive error
one of the authors had the following conversation: present in a patient’s eye(s). This is especially useful for pedi-
atric, non-verbal, and physically handicapped patients who are
• Chairman – Please go measure the prism in this patient’s unable to undergo subjective refraction at the phoropter.
glasses. Retinoscopy may also be employed during an exam under
• New fellow – I’m sorry I do not know how. anesthesia to assess refractive error in the operating room. A
• Chairman – You’ve never seen prism glasses before? skilled retinoscopist may even be able to successfully refract
patients with large spherical and cylindrical errors, such as
patients with keratoconus, even when autorefractors and
wavefront aberrometers fail! Retinoscopes produce a streak of
G. V. Vicente (*)
Clinical Pediatrics and Ophthalmology Georgetown University light that reflects from the posterior fundus back through the
Hospital, Washington, DC, USA eye toward the observer. By observing both the streak of light
Eye Doctors of Washington, Chevy Chase, MD, USA and the red reflex coming out of the eye simultaneously, the
e-mail: vvicente@edow.com observer is able to determine both the patient’s refractive error

244 G. V. Vicente
(myopic, hyperopia, and astigmatism) and accommodative

a
ability.
The retinoscope is one of the oldest instruments still used
in modern ophthalmic practice. This instrument was invented
c
in the 1800s using candles to produce a spot of light. These
spot retinoscopes have largely been replaced by streak reti- b
noscopes so we will focus on the latter. Today, all retino-
scopes have similar components (Fig. 1):
Several notes about the retinoscope are as follows:
• The crossed polarizing filter is helpful to cut down on

reflections and allows retinoscopy to be performed closer
to the axis of the correcting lens. It is rarely used in clini-
cal practice but may be used in special situations, such as
corneal ectasia, wherein the reflex may be skewed and
may require an additional filter. d.
• The streak retinoscope may be converted into a spot retino-
scope with a special bulb. Some practitioners may find a
spot retinoscope to be easier to use for large vision screen- e
ings and assessing pediatric patients as this technique can
help detect refractive error quickly without relying on
patient fixation. In addition, a spot retinoscope may func-
tion as a poor man’s keratometer/topographer and yield
information about the tear film, corneal power, etc.
• The retinoscope sleeve can be moved up or down. f
Depending on the manufacturer of the retinoscope, “sleeve
up” or “sleeve down” will correspond with a divergent light
(“thick beam,” a.k.a. “the fat guy”) or a convergent light
(“thin beam,” a.k.a. “the thin guy”) (Fig. 2). In general, we Fig. 1 Streak retinoscope components: (a) Crossed polarizing filter to
will want to use “the fat guy” to perform retinoscopy.1 reduce glare. (b) Examiner eyepiece. (c) Semitransparent mirror allows
examiner’s view to be coaxial to the streak. (d) (+) Condensing lens. (e)
Linear filament bulb creates a linear streak of light. (f) Sleeve can rotate
If “the fat guy” (diverging light) is used 95% of the time, the filament and change the distance between the light and the lens
why do we need two sleeve settings? In other words, is there making the light convergent or divergent
ever a time to use “the thin guy”? Yes, dear reader, using a
narrow beam is advantageous in certain situations, such as If the patient’s far point is at the peephole, then the pupil
determining the exact axis of astigmatism in the phoropter or will fill with a round red reflex as soon as the intercept
trial frame (Fig. 3). reaches the pupil.
The sleeve can also rotate, making it easy to rotate the streak While doing retinoscopy. The observer should record his/
to check for astigmatic power at different degrees (Fig. 4). her working distance from the patient. By convention, 66 cm
is considered as the standard working distance (WD); how-
ever, if you are taller or shorter, or prefer for your arm to be
Principles of Retinoscopy more extended or more flexed, your working distance may
need to be adjusted accordingly. A fixed WD allows for a good
In order to perform retinoscopy, we need to determine if the view of the pupil and makes the math easier when determining
red reflex is filling the pupil (“neutralization”), moving in the the final prescription to be dispensed. In general, we can take
same direction as the streak (“with motion”), or in the oppo- the reciprocal of the WD and add additional myopic sphere
site direction as the streak (“against motion”) (Fig. 5). power to the dispensed refraction. For example, if we set
66 cm as our WD, we would add an additional −1.5D sphere
The thick beam means that the emitted light rays are slightly divergent
1 to the streak refraction; if we set 50 cm as our WD, we would
and the instrument acts as a plano mirror. The thin beam will focus the add an additional −2D sphere to the streak refraction. Note: do
emitted light and the instrument acts with a concave mirror effect not add any additional power to the cylinder or adjust the axis
wherein the light rays cross and then diverge. Therefore, because this
light has already crossed, performing retinoscopy with the thin beam based on the working distance!
means that the examined eye’s reflexes will move in the opposite direc- Here are some examples of streak refractions and dis-
tion as compared to when using the thick beam. The thin beam may be pensed refractions with an assumed WD of 66 cm:
helpful in certain situations, such as determining the astigmatic axis off
the phoropter of trial frame.
Optical Instruments and Machines 245
a b
c
Fig. 2 Streak retinoscope sleeve settings. Never miss an opportunity to lens, u becomes small, U = D and V = 0. The light is at the focal point
remember U + D = V. In panel A, the sleeve is down and the bulb is far of the lens making the rays exit in parallel fashion. Panel C, the sleeve
from the lens. Thus, V (+) light will be converging and form a streak is up producing more diverging light, V (−). The light streak will be
that is in focus at 33 cm. In Panel B, as the light moves closer to the slightly out of focus
Fig. 3 A thin intercept “converging light” setting is used to better see where the oblique astigmatism is located. A wide intercept with diverging
light would make it difficult to tell if the axis was 120, 135, or 150 degrees
246 G. V. Vicente
Fig. 4 By rotating the handle, the filament is rotated, which in turn rotates the streak vertical, horizontal, or oblique
Neutralization achieved with trial lens: Final dispensed refraction: While we are discussing positioning, the examiner should
−1.00 sphere −2.50 sphere
sit in front of the patient but without blocking their view of
−1.00 + 1.00 × 90 −2.50 + 1.00 × 90
the eye chart. Performing retinoscopy from too far to the side
Plano 1.50 sphere
Plano +2.50 × 90 −1.50 + 2.50 × 90
will cause false astigmatism to be observed.
+3.0 sphere +1.5 sphere It is also important to remember that because young
patients can generate significant accommodation, it may
Suppose you are performing retinoscopy and you want to falsely affect the retinoscopy.3 Therefore, especially with
avoid having to adjust for the WD, there are two other pediatric patients, it is necessary to perform cycloplegic reti-
options. The first option, which is only theoretically possi- noscopy. Moreover, it is also easier to perform retinoscopy
ble, is to perform retinoscopy from far away (beyond optical through a dilated (large) pupil than a small one. Older
infinity). However, this has two main disadvantages: you patients can be relied upon to simply fixate at a distant target,
would need a very strong light, and it would be hard to see a though a cycloplegic retinoscopy will always yield a “purer”
tiny pupil from far away.2 The second and more practical result.
option is to add a + 1.50D trial lens throughout the measure- We have previously discussed that hyperopic patients
ment and then remove it for the final prescription. The “R” have a far point behind the retina. When conceptualizing reti-
setting in many phoropters places a + 1.50 D lens in your line noscopy, it may be helpful to understand that the “mirror
of sight; you can then do retinoscopy adjusting the phoropter image” of this far point will be behind the examiner (Fig. 6).
lenses until the pupil fills in. When neutralization is reached, As the intercept comes down, it does not fill the pupil, so the
then the “R” is removed and the “O” open setting is placed red reflex forms a bar; the first red rays (A and B) to reach the
without the need to subtract any value from the readings on
the phoropter.
Retinoscopy in this situation may be falsely myopic or hyperopic. It is
3
not uncommon for an undilated pediatric patient to scope with +1.00D

sphere at one moment, and then a few seconds later, scope with −4.00D
Socially distanced streak refraction may be quite difficult.
2
sphere.
Fig. 5 With vs. against movement. When the far point (blue dot) is at the peephole, the patient’s pupil will instantly fill with a red reflex as the
yellow intercept comes down and reaches the pupil. This is known as neutralization
examiner’s pupil come from the top of the pupil and move in shows the examiner’s view of neutralization (top row), with
the same direction as the intercept (“with motion”). motion (middle row), and against motion (bottom row).
When “with motion” is observed, plus power lenses are This is a lot easier to understand with animation, but the
added with increasing power in order to bring the far point editors decided against turning this textbook into a giant flip
to the retinoscope peephole and achieve neutralization. book. What happens when we neutralize the reflex on one
Patients who are nearsighted will have a far point between axis but we see with motion at another axis? This means
them and the examiner (Fig. 7). As the streak comes down astigmatism is present. If you are working with plus cylinder,
and reaches the top of the patient’s pupil, the first red rays (A it is easier to first neutralize the most minus axis and then add
and B) to reach the examiner will appear to be coming from plus power 90 degrees away until that reflex is neutralized as
the inferior pupil. The red reflex will move in the opposite well. Let’s look at a few examples:
direction (“against motion”) as the intercept. Example #1 (Fig. 10): Suppose that when the streak is
When “against motion” is observed, minus power oriented horizontally (top left panel), neutralization is
lenses are added with increasing power in order to bring the observed. When the streak is oriented vertically (top right
far point to the retinoscope peephole and achieve panel), with motion is observed. Using the “SPAM” mne-
neutralization. monic, we know we must progressively add plus power in
A useful mnemonic to remember this is “SPAM”: Same order to neutralize this reflex. We note that this reflex finally
(“with motion”) requires Plus power, and Against motion neutralizes with the addition of +4.00D (bottom panel). To
requires Minus power. We can compare retinoscopy for determine the patient’s required prescription, we can adjust
hyperopes and myopes in the following two figures. Figure 8 for WD and dispense: −1.50 + 4.00 × 90.
depicts how adding minus lenses and plus lenses for myopic Example #2 (Fig. 11): Suppose that when the streak is
patients and hyperopic patients, respectively, will shift the oriented vertically (top right panel), neutralization is
far point to align with the examiner’s peephole. Figure 9 observed. When the streak is oriented horizontally (top left
248 G. V. Vicente
a
A a
b b
B
B
Fig. 6 With vs. against movement for hyperopes. When the far point motion.” Notice the red rays emanating from “A and B” enter the peep-
(blue dot) is behind the observer, as in a hyperope, a red reflex will hole and are visible. The black rays emanating from “a and b” do not
move in the same direction as the intercept. This is known as “with enter the peephole and do not reach the observer
panel), with motion is observed. Using the “SPAM” mne- Example #4 (Fig. 13): In this scenario, suppose we note
monic, we know that we must progressively add plus power that there is with motion in both the 90-degree and 180-degree
in order to neutralize this reflex. We note that this reflex fully meridians, but more so along the 90-degree meridian when
neutralizes with the addition of +4.00D (bottom panel). To the streak is moved left to right. In this case, the 180-degree
determine the patient’s required prescription, we can adjust is the “more minus” meridian (top left panel), so we can neu-
for WD and dispense: −1.50 + 4.00 × 180. Note the key dif- tralize that with the addition of plus lenses until neutraliza-
ference with this example compared with the previous one. tion with +2.00 D sphere (bottom left panel). We can then
Example #3 (Fig. 12): In this scenario, neither meridian is direct our attention to the 90-degree meridian (top right
successfully neutralized without additional lenses. Since we panel) and progressively add plus lenses until neutralization
want to neutralize the against motion meridian first (top left with +4.00D cylinder (bottom right panel). After adjusting
panel), we will use the “SPAM” mnemonic to add progres- for WD, the dispensed refraction will be +0.50 + 4.00 × 90
sively add minus lenses until the reflex is neutralized, in this Example #5 (Fig. 14): What happens if we have a patient
example, with a − 1.50D lens (bottom left panel). We can with oblique astigmatism? In this case, we notice the reflex
then direct our attention to the vertical meridian that has with is neutralized with the streak held horizontally (top left
motion (top right panel) and progressively add plus lenses panel). Suppose that when we hold the streak vertically, we
until the reflex is neutralized, in this example, with a + 4.00D notice with motion but with a tilted red reflex (top right
lens (bottom right panel). We may be tempted to simply dis- panel). This indicates the location of the steep axis at approx-
pense −1.50 + 4.00 × 90, but we must remember to adjust for imately 70 degrees (oblique astigmatism). We will then pro-
the WD. Therefore, the dispensed refraction should be gressively add plus lenses until neutralization with +4.00D
−3.00 + 4.00 × 90. cylinder to act at the 160-degree axis (bottom panel). After
a
A
A
a
b
B
B
b
Fig. 7 With vs. against movement for myopes. When the far point “against movement.” Notice the red rays emanating from “A and B”
(blue dot) is in front of the observer as in myopes, a red reflex will move enter the peephole and are visible. The black rays emanating from “a
in the opposite direction as the yellow intercept. This is known as and b” do not enter the peephole and do not reach the observer
adjusting for the WD, the dispensed refraction will be • Keratoconus scissoring (Panel A): This can be an effec-
−1.50 + 4.00 × 70. Notice that this patient has mixed astig- tive screening tool to warrant further investigation with
matism, and corneal topography may be in order to assess for topography, pachymetry, etc.
corneal ectasia! • Bull’s eye motion (with motion in the middle, against
There are two other types of retinoscopy findings that motion in the periphery) (Panel B): In young patients with
may be discussed here. Skew phenomenon occurs when the large pupils, we may notice a bull’s eye pattern where the
reflex is tilted because it is off axis with low cylinder powers. central part of the lens shows with motion and the
Break phenomenon is similar to skew but occurs with peripheral part of the lens show against motion due to the
higher cylinder powers. peripheral rays converging more (i.e., our good friend
By now we can all agree retinoscopy is amazing: you can spherical aberration). In this case, the examiner should
measure anything! Well, there are several challenges and focus on neutralizing the central reflex and ignore the
noteworthy exceptions (Fig. 15): peripheral reflex.
250 G. V. Vicente
Fig. 8 For a myopic patient (top panel), the near point (blue dot) is toward the peephole. For a hyperopic patient (bottom panel), a plus
between the observer and the patient. A minus (red) lens would add (black) lens will converge the red light and bring the far point onto the
divergence to the red light coming from the eye and push the near point peephole
Fig. 9 Examiner’s view of with vs. against movement (summary). Light intercept moves from left to right. Top row shows neutralization, middle
row with motion, and bottom row against motion
In addition to the movement of the red reflex, three char-

acteristics of the red reflex may be observed if retinoscopy is
far from neutral:
• The Speed of the reflex will be slower (it might not even
seem to move at times giving a false sense of filling the
pupil).
• The Brilliance of the reflex will be lower.
• The Width of the reflex will be narrower.
We mentioned earlier that young patients should be

dilated prior to retinoscopy. The one exception to this rule is
if you are concerned the child may have an accommodative
deficiency, which should be assessed in any child having
reading difficulties. This can also occur in young patients
.0
+4
(approximately 6–8 years of age) with Down syndrome or in

any post-concussion patient. In these situations, dynamic
Fig. 10 Plus cylinder power placed in the 90-degree meridian is retinoscopy may be more useful. A full discussion of this
required to neutralize with motion observed (to act at the 180-degree technique is beyond the scope of this book, but in brief, the
axis). After adjusting the WD, the dispensed refraction will be examiner should have the child focus on an accommodative
−1.50 + 4.00 × 90
target (such as a sticker) at the peephole in an undilated
state. If the examiner observes with motion, while the patient
is trying to focus on the near target, then the patient may
need additional plus power.
Summary: How to Perform a Streak Refraction
See Chap. 15 Glasses in Clinical Practice, for a seven-step,

“to be memorized and summarized,” method on how to per-
+4
.0 form a streak refraction.
Geneva Lens Clock
Dear reader: the Geneva lens clock (GLC) is not a steam

punk doomsday device, but we’re glad that crossed your
mind. The GLC is an adapted spherometer that allows the
observer to measure the curve of a spectacle lens and the
Fig. 11 Plus cylinder power placed in the 180-degree meridian is location of the curve (front or back). If the lens material and
required to neutralize with motion observed (to act at the 90-degree its index of refraction are known, it can then also be used to
axis). After adjusting the WD, the dispensed refraction will be determine the refractive power of that surface. A given GLC
−1.50 + 4.00 × 180
is constructed and calibrated to a specific index of refraction
(and therefore a specific lens material) and can therefore
• Posterior capsular opacity (Panel C): Posterior lenticonus only be used to assess that particular lens material. If the lens
may also demonstrate this type of reflex. is made of some other material, the reading must be adjusted
• Lenticular/retinal opacity or extremely high refractive to correct for the difference in the refraction index. Different
error (Panel D): A dull pink (or even white) reflex may be GLCs can be made based on the measured lens material.
caused by nuclear sclerosis, high myopia, or high hyper- The most commonly used index of refraction for GLCs is
metropia (e.g., −10 or +10 D, respectively). 1.53 (crown glass). Suppose we have a crown glass GLC,
252 G. V. Vicente
Fig. 12 A −1.5D sphere (red

trial lens) is added to
neutralize the against motion
first (top left and bottom left
panels). Then, a + 4.0D
cylinder lens is used to
neutralize with motion
observed on the 90-degree
meridian. After adjusting for
WD, the dispensed refraction
should be −3.00 + 4.00 × 90
-1
.5
-1
.5
.0
+4
Fig. 13 When there is with
motion in both meridians, +2
.0
begin with neutralization of
the “more minus” meridian.
Suppose there is more “with
motion” along 90 degrees
when the streak is moved left
to right. A +2.00 D sphere
lens neutralizes the
180-degree meridian, but
there is still with motion
along the 90-degree meridian.
Thus, more plus cylinder +2
.0
(+4.00D) power is added to
+2
the 90-degree meridian until .0
neutralization is noted. After
adjusting for WD, the final
dispensed refraction will be
+0.50 + 4.00 × 90
0 .
+4
and we used it on a different lens material. If we measure a

lens with index of refraction >1.53, the GLC will read the
lens power LOWER than actual; if we measure a lens with
index of refraction <1.53, the GL will read the lens power
HIGHER than actual.
The GLC is used to measure the back surface of a given
lens (Fig. 16). Three probes make contact with the surface of
the lens. The outer two probes are fixed, while the center one
moves (straight blue arrow), retracting as the instrument is
pressed down on the lens’s surface. As the probe retracts, the
hand on the face of the dial turns (curved blue arrow) by an
amount proportional to the distance of the central probe
+4.0 movement.
In our previous discussions with Geometric Optics (Chap.
1), we described minus lenses as simple meniscus concave
shaped objects (Fig. 17, left panel). The shape of a minus
lens in a spectacle frame may surprise some readers (Fig. 17,
Fig. 14 The reflex is neutralized moving the intercept up and down
along the 180-degree axis (top left panel). However, when the streak is right panel).
placed in the 90-degree meridian, there is with motion with a tilted red What’s the surprise? Notice that the spectacle minus lens
reflex indicating oblique astigmatism (top right panel). With additional is actually a thick lens that has a weak plus lens power on the
plus cylinder placed in the 70-degree meridian (acting at the 160-degree
front surface and a stronger minus lens power on the back.
axis), neutralization is observed (bottom panel). After adjusting for
WD, the final dispensed refraction will be −1.50 + 4.00 × 70 The net result is still a minus power lens. There are many
Fig. 15 Four atypical cases: a b

(a) Keratoconus scissoring.
(b) Bull’s eye with motion in
the middle, against motion in
the periphery. (c) Posterior
capsular opacity. (d) Nuclear
sclerosis or very high
refractive error
c d
254 G. V. Vicente
4 4
0-
0-
+0
+0
8
8
8
8
4 4
Fig. 16 Geneva lens clock (GLC). The central prong is on a spring and surface, it reads: −5.5D refractive power (on the red scale) along
will be pressed differently depending on the curve of the crystal. When 180-degree axis of these glasses. The black scale is used for the front
the GLC is placed on the optical center perpendicular to the posterior surface
Different manufacturers may use different front surface

and back surface base curves in their lenses. Modern labora-
tories will typically choose between a limited range of base
curves for a given power range in order to minimize periph-
eral aberrations.5
By convention, modern eyeglasses are constructed such
that the cylinder is ground onto the back surface.6 The front
surface is therefore usually spherical.
The GLC can help identify different problems with
glasses:
Fig. 17 A theoretical minus lens (used in geometric optics; left panel)
and a minus lens used in eyeglasses (right panel) A. Suppose a patient is unhappy with a new pair of glasses
that he received at his last visit 1 month ago. When the
reasons for this complex construction, such as considerations old glasses and new glasses are measured using a lens-
for manufacturing, historical practices, and the architecture meter (see next section), they both read −3.0D total
of the eyeglasses.4 The approximate power of the lens can be refractive power. At this point, we may be tempted to
calculated by adding the front surface to the back surface. simply reassure the patient that the glasses were made
For example, a lens with a + 8D curve on the front surface correctly and send them out of the office. However, if we
and a −10D curve on the back surface will have a net power use a GLC, we may then find that there was previously
of +8 + (−10) = −2D. a − 5.5D posterior curve on the old glasses, but the new
We can also see how varying combinations of front sur- glasses have −7.0D D posterior base curve. In this case,
face and back surface base curves can be used to construct the glasses were made “correctly,” but the patient
eyeglasses with similar or different powers. For example, the
same power of eyeglasses (−1.00D) can be constructed using “Lens Form: Sphere, Cylinder, and Axis”. https://www.laramyk.com/
5
two different combinations of front surface and back surface resources/education/lens-form-and-theory/lens-form-sphere-cylinder-

base curves (Fig. 18). and-axis/. Accessed June 7, 2020.
Historically, this was not always the case. Older texts may reference
6
the idea of “checking to see if the cylinder power was ground into the
front surface” when troubleshooting glasses. This is a moot point in
For example, having a protruding front surface would make for a cos-
4
modern times since, by convention, modern optical laboratories con-
metically undesirable lens, in addition to requiring thicker frames. struct lenses with the cylinder ground into the back.
4
+4.5D - 5.5D
+0
+0
0-
0-
8
8
8
8
4
4
+2.25D - 3.25D
4
+0
0 -
+0
8
0 -
8
8
8
4
Fig. 18 Graphical example of two potential (and different) ways to construct −1.00D spectacles. In the top panel, a + 4.5D curve on the front and
a − 5.5D base curve on the back is used. In the bottom panel, +2.25D curve on the front and a − 3.25D curve on the back is used
describes a fishbowl effect with the new glasses and is the lens by constructing a power cross to determine that
unhappy. The solution here would be to rewrite the pre- the power of this spherocylindrical lens is −1.00 + 2.00 ×
scription with instructions given to the optical lab to 180.7
maintain the old back surface base curve.
B. If assessing an old pair of glasses, the plus cylinder
power may have been ground on the front surface or the Lensmeter
lenses were placed backwards. This would also have the
similar strength on the lensmeter, but the distortion Introduction to the Lensmeter
would be noticeable to the patient. and the Optometer Principle
Specially constructed GLCs can also be used to determine Fun fact: “Lensmeter” is the name given for the device used
the thickness of a gas permeable contact lens. to measure the power of a spectacle lens; the “Lensometer®”
Finally, when trying to measure the power of a sphero- is a trade name for a particular brand of lensmeter. You can
cylindrical lens, remember that the posterior surface will win friends and be the highlight of social parties by knowing
contain the cylinder, so we must adjust accordingly when this type of information.
using the GLC (Fig. 19). Suppose when measuring the All lensmeters work on the optometer principle: if we
back surface of the lens, the GLC reads −6.00D along the have a single converging lens with a known power (and
90-degree axis (top left panel) and −8.00D along the known focal length), we can take advantage of this property
180-degree axis (bottom left panel). Assume that the
front surface is +7.00D. We can calculate the power of See Chap. 10 “Spherocylindrical Lenses”, to review this concept.
7
256 G. V. Vicente
+7.0 - 6.0
+7.0 - 8.0
Front surface Posterior surface
+1.0
4
0-
- 1.0
Fig. 19 Determining the power of a spherocylindrical lens. In the top surface is +7.00 D sphere. A power cross may then be used to combine
left panel, the GLC reads −6.00D along 90 degrees. In the bottom left the power of the front surface and back surface to determine the power
panel, the GLC reads −8.00D along 180 degrees. Assume that the front of the spherocylindrical lens: −1.00 + 2.00 × 180
90 180
0
+10
-10
+20
a b c d e f g h
Fig. 20 Lensmeter. (a) Adjustable eyepiece. (b) Reticle (with prism scale and axis scale). (c) Keplerian telescope (green box). (d) Spectacle lens.
(e) Standard lens. (f) Power drum. (g) Target mire and Axis Dial. (h) Lamp collimator (blue box)
by placing an unknown lens and adjusting it until the In a typical lensmeter (Fig. 20), the known lens (a.k.a.
unknown lens’ focal length matches up with the known lens’ standard lens) is inside the machine, and a light source illu-
focal length. We can then back-calculate the power of the minates a target behind it. The unknown lens (eyeglasses; we
unknown lens once the focal lengths of the known lens and will discuss positioning in a minute) is placed in front of the
the unknown lens match up. known lens – that is, closer to the examiner’s eye. The exam-
iner can dial in power into the lensmeter until the unknown 5. Read the axis from the axis wheel.
lens “matches up” (has the same focal length) as the known
lens. If you want to further summarize this: (1) Rotate the axis
A typical lensmeter will also have an astronomical so that the thin guys are parallel (thin lines are parallel). (2)
(Keplerian) telescope that allows for precise detection of Rotate the drum so that the thin guys are in focus (sphere
parallel rays at neutralization. This prevents the examiner’s power). (3) Rotate the drum so that the fat guys (thick triple
refractive error from causing significant measurement error. lines) are in focus. (4) The difference between the fat guys
and thin guys is the plus cylinder power.
ow to Use the Lensmeter: Single Vision

H
Lenses Bifocal Lenses: Measuring Add Power
There are several key steps to follow when using the lensme- Suppose we want to measure a pair of bifocal lenses: the
ter. We can break them down as follows. Let’s suppose we biggest thing to remember is that for the distance portion of
are measuring a simple pair of single-vision lens (SVL) the lens, we must still position the glasses so that the temples
glasses with distance correction only for starters: are facing away from you. However, if you want to measure
the bifocal add power very precisely, especially in high
1. Focus the eyepiece: before placing the eyeglasses, turn power lenses, you have to turn the glasses around so that the
the power drum until the mires are out of focus to eventu- temples are facing toward you. Why is this? Recall that the
ally bring them into focus (this avoids error potentially bifocal power is ground on the front surface of the glasses, so
caused by your accommodation). Then, turn the eyepiece we want this portion to be closer to the lensmeter aperture.
in a counterclockwise (CCW) (to add plus power) direc- Then, we can follow these steps:
tion to fog the target. Then slowly move the eyepiece in a
clockwise (CW) (to add minus) power until the target is 1. Center the bifocal add and refocus the thin triple lines
clear. This helps to prevent your refractive error from 2. The difference in the triple lines power measured for the
“skewing” the results. Then, adjust the power drum to bifocal add and the power measured when measuring the
focus the mires at a drum reading of zero (plano). distance portion is the add power.
2. Position the eyeglasses: for SVL glasses, position them 3. If we are dealing with a trifocal lens, we can repeat this
with the temples facing away from you. Remember that same procedure with the intermediate portion: refocus
since the majority of the eyeglass power is ground on the the triple lines for the intermediate segment; the differ-
back surface, it is closer to the lensmeter aperture. Align ence between the distance portion power and the inter-
the SVL lens so that the mires cross in the center of the mediate segment power is the actual “intermediate add”
target. power.
3. Measure the sphere: 4. Progressives are a bit more of a challenge to measure and
(a). Focus the single lines by rotating the drum CCW add in. That is why many manufacturers will etch a small
while simultaneously rotating the cylinder axis (~1 mm) two-digit number in the margin of the lens
wheel so that the single lines are perpendicular to the (Fig. 21). Spectacles with +1.75 add will have a “1.7”;
triple lines (widely spaced triple mires). spectacles with +3.0 add will have a “3.0.”
(b). If the single lines and triple lines come into focus at
the same time, then the SVL glasses only have
spherical correction. Pat yourself on the back and
move on.
(c). However, if only the single lines focus, record this as
the sphere power, and we must now measure the
cylinder.
2.2 2.2
4. Measure the cylinder:
(a). Move the power drum further CCW (adding more
minus) to bring the triple lines into focus.
(b). Calculate the difference: the power at which the tri-
ple lines focus – the power at which the single lines
Fig. 21 Progressives lenses will have a small two-digit number (in this
focus – this is the plus cylinder power for the SVL
example, “22”) etched. This is an example of spectacles with 2.25 add
glasses.
258 G. V. Vicente
of the mires. For example, if the mires are displaced

upward, then this is a base-up prism, etc. In Fig. 22,
notice the central thick mire (among the three thick mires)
is used to count the downward displacement circles.
Since this intersection point is “two-circles down,” this
indicates there is 2 PD base-down in this lens. In Fig. 23,
notice the intersection of the mires has been shifted to the
right (relative to the examiner) when measuring the right
lens of a pair of glasses. Since the shift is relative to the
examiner, we can determine that there is 2 PD base-in
(not base-out). If the mires had been shifted to the left
(relative to the examiner, not pictured), then we can deter-
1 mine that there is 2 PD base-out in the right lens.
2 Other fun facts about the lensmeter: there is a knob at the

top of some lensmeters that you can spin and rotate in any
3 direction to measure up to 15 PD of prisms (Fig. 24). If no
knob is present, a trial prism can be placed between the spec-
tacle and the telescope to compensate for the deviated image.
The dark rings can also help determine if the pupillary
Fig. 22 View through a lensmeter demonstrating a spectacle lens with
BD prism. In a patient with 2 BD prism, regardless of whether this is a
center does not match the optical center in patients without
right lens or left lens, no matter how the spectacle lens is moved, the ground in prisms. In this situation, if the lens spectacle is
intersect of yellow lines remains at the 2nd dark ring. There are two placed on the lensmeter so that the pupillary center mark is
additional dark lines (blue arrows), not circles at 12 and 6 o’clock rep- centered, the yellow lines would be off center. The view
resenting 4 and 5 PD, respectively
would be similar to Fig. 23, but moving the spectacle would
actually move the yellow lines to the center.
Measuring Ground-In Prism
What happens if you have a fancy pants patient with prism in

his/her glasses? Send them to your local neuro-
ophthalmologist colleague?8 Sure, but you can also follow
these steps to measure the prism power and orientation:
1. Mark the pupillary center (position on the glasses through

which the patient is viewing while looking straight ahead)
using an erasable marker. Center this mark on the lensme-
ter target. This assumes that the glasses were made cor-
rectly with the optical center of the glasses at the center of
the pupillary axis. Most manufacturers have markings on
the eyeglass lenses that can be used in conjunction with
stencils to find the true optical center of the eyeglass
lenses.9
2. Count the number of black concentric circles from the
central cross of the lensmeter target to the center of the
vertical and/or horizontal cross mires. Each circle is
equivalent to 1 PD.
3. Record the direction of the thick portion (base) of the
prism by determining the direction of the displacement
Fig. 23 View through a lensmeter with a right lens spectacle with 2 PD
This is a surefire way to lose your favorite neuro-ophthalmologist
8
base-in ground in prisms. Note that the orientation of the prism (base-in
accepting your other referrals. vs. base-out) is determined by the shift relative to the examiner. No mat-
9
See Chap. 16 Construction of Glasses: Ophthalmologists as Opticians, ter how the spectacle is moved, the intersect of yellow lines remains at
for further details the 2nd dark ring
Fig. 24 Prism knob on a

lensmeter (white arrow) can
be spun and rotated to bring
the displaced image (top right
panel) to the middle of the
target mires (bottom right
panel)
1
2
3
1
2
3
Phoropter
Fun fact: the phoropter also relies on the optometer principle.

In fact, “phoropter” is actually a contraction of “phoro-
a
optometer.” The history of how this device came into origin b
and its evolution over the years is a fascinating rabbit hole 65 70

c d e f
that you can read about online on your own time.
The phoropter allows the clinician to quickly assess the g
refractive error of a patient but may also be used to detect
heterophoria, horizontal/vertical vergences, and accommo- . I.
dative amplitudes. The main usefulness of the phoropter is . .

P
that instead of an examiner having to slowly take out one j .

lens at a time, as if you are trying to pick the right wand for 0 n
90
a young wizard, multiple lenses can quickly be dialed in and k 3

4
13
5
45
L. m
out during the course of a clinical refraction. 5
15
15
18 0
0
Let’s review some phoropter anatomy: 45

13
5
90
We have previously discussed how to use the phoropter
.00 90
during the course of a routine subjective manifest refraction R
s135 45
in Chap. 15 “Glasses in Clinical Practice.” 180 0

q r
+ .50
-
o p
RMH
The phoropter may be considered as an optical Swiss

135
.
army knife because it has so many functions and capabilities.
45
.12
90
Of course, we rarely use them, but there are several features

we can point out about the phoropter that may be useful in Fig. 25 Phoropter. (a) Leveling knob. (b) Rotation adjustment knob.
certain select situations: (c) Pupillary distance knob. (d) Pupillary distance scale. (e) Near rod
holder. (f) Level bubble. (g) Convergence setting. (h) Jackson cross cyl-
• The vertex distance can be measured through the vertex inder. (i) Vertex distance forehead rest knob. (j) Sphere power dial. (k)
Vertex distance mirror. (l) Sphere power scale. (m) Risley prism. (n)
distance mirror, and it can be adjusted by moving the Cylinder axis scale. (o) 3D sphere power change. (p) Auxiliary lens
patient’s forehead rest (see Fig. 25, I). The distometer (see knob. (q) Cylinder power knob. (r) Cylinder axis knob. (s) Cylinder
Sect. VII, Distometer) can also be used. power scale
260 G. V. Vicente
• Setting the auxiliary lens knob on “R” places a + 1.5D ful in binocular balance and in patients who might be
lens in the patient’s view. This would allow retinoscopy to malingering. A full discussion regarding binocular bal-
be done without having to subtract a working distance. It ance is beyond the scope of this text. For a brief discus-
will also fog the patient. sion on malingering, see Chap. 21 Clinical Problems with
• The sphere power can be adjusted +/– 0.25D at a time Optics and Refractive Manifestations.
using the sphere power dial (see Fig. 25, J.) or the large • 0.12 setting may be used only on picky “type A” patients,
dial (Fig. 25, O.) around the auxiliary lens knob to change who would like to see if additional −0.25D is better than
3D at a time. −0.12D after their 4th LASIK surgery. It is not used very
• We can look at the auxiliary dial (for the left eye) in often because most patients may not be able to tell a
closer detail (Fig. 26): 0.12D difference. For practical purposes, most optical
laboratories are unable lenses in powers smaller than
Note: The right auxiliary dial is similar to the left auxil- 0.25D steps.
iary dial with the following notable differences. First, instead • RL (red lens) is on the patient’s right, and GL (green
of a 10ΔI there is a 6ΔBU option. Second, instead of a GL lens) is on the patient’s left. This can be used in W4D test-
(green lens), a RL (red lens) option can be used to simulate ing to look for suppression scotomas or diplopia. It is
glasses used in Worth 4 Dot (W4D) testing. Finally, instead important that the color of the W4D matches the colors of
of WMH/WMV options, a RMH/RMV (red Maddox rod the lens filters; otherwise, this may lead to false “fusion”
horizontal/red Maddox rod vertical) option is present. readings.
The following features are present in the auxiliary dial: • The Maddox rods RMH, RMV (on the patient’s right)
and WMH, WMV (on the patient’s left) can help test the
• The fused cross cylinder (±0.50) setting can be used to patient for torsional diplopia, but they do not rotate so
measure the required add power. See Chap. 15, Glasses in they cannot be used to quantify the amount of torsion. For
Clinical Practice, for more information on how to use the example, a patient with a right superior oblique palsy with
fused cross cylinder setting to determine the required right hypertropia and right excyclotorsion looking through
reading-add power. RMH and WMH would describe a tilted red line going
• The 10ΔI on the right dial and a 6ΔBU on the left dial from her right shoulder down to her left hip; the red line
can be used to dissociate the patient’s vision. This is use- will be below the white line.10
• If you can’t find those plastic polarized glasses that came
with the stereoacuity book, the polarized filters P in the
phoropter are useful when checking binocularity.
R
O The final tool is the Risley prism with a range from 0 to 20
P
PD that can be found on both sides (Figs. 25, H, and Fig. 27).

Each consists of two wedge prisms inside the cylinder that can
be rotated to be used as horizontal or vertical prisms. With the
OC
V
WM
“0” in the horizontal position, up to 20 PD BU and BD prism

can be dialed in (indicated by a black arrowhead); with the “0”
in the vertical position, up to 20 PD BI and BO can be dialed
+
WMH
-.50
in. This is a very useful tool to measure phorias, tropias, and

vergence amplitudes in patients with diplopia and strabismus.
Patients can even adjust the small dials (green double-ended
arrow) to find the prism power they like best.
6∆B
GL
PH
Trial Frames
Trial frames allow the patient to try their refraction prior to

.12
purchasing lenses. They should be considered in certain clin-

ical situations, such as:
Fig. 26 Auxiliary lenses for the left eye: R, Retinoscopy. O, Open.
OC, Occluded. + − 0.50, Jackson cross. 6ΔBU, 6 Diopter base-up
prism. PH Pinhole, 0.12 0,12 D lens, GL Green lens, WMH White
Maddox rod horizontal, WMV White Maddox rod vertical, P Polarized This is somewhat counterintuitive, but we assure you that we have
10
lens checked this in the clinical setting and is not a typo.

6
Fig. 27 A Risley prism combination consists of two wedge prisms Risley prism on the right side of the figure has 9 PD base-out setting.
inside the cylinder (top left panel). In this example, the phoropter Risley The small dark triangles on the silver ring show the base of the prisms
prism on the left side of the figure shows a 6 PD base-up setting, and the is “up” on the left and “out” on the right side
• To help decide on whether or not it is worth changing axis can be adjusted accordingly. Finally, low power sphere
their glasses lenses (e.g., −0.50D and +0.50D) or prisms can be placed in
• If the new manifest refraction reveals a significant change the front cell. This allows for easy swapping in and out of
in the axis of astigmatism low sphere power to titrate the final refraction while mini-
• If the new manifest refraction is a borderline anisome- mizing effects of longer vertex distance.
tropic prescription (approaching ~3D between the two
eyes)
• To appease very picky, highly demanding patients Distometer
• To trial prism lenses for correction of diplopia prior to
dispensing The vertex distance is the distance from the cornea to the
• To be used for double Maddox rod testing back surface of the spectacle lens. For most low-moderate
refractive errors, a standard distance of 12.5 mm vertex dis-
If a patient is taking an excessive amount of time in tance is used. For higher powers (both high minus and high
deciding between lens options during a manifest refrac- plus), changing the vertex distance will affect the power of
tion, the trial frames allow for patient flow as well. We may the lens (See Chap. 6 Lens Effectivity).
give the new prescription in a trial frame and tell the When dispensing glasses, and especially for higher power
patient to walk around for a bit as we continue to see other prescriptions, we must ensure that the vertex distance is the
patients. same as the old prescription. This can be measured using the
Trial frames have several disadvantages, including but not phoropter or a device known as the Distometer (Fig. 29).
limited to not fully simulating dispensed spectacles, having Notice that the distometer is used with the patient’s eyelid
difference in base curves, and limited field of vision. closed – this is a nice way to prevent iatrogenic corneal abra-
When using trial frames, we can take note of three “slots” sions! In terms of accuracy, the device is calibrated to assume
(cells) (Fig. 28). In general, the highest sphere power an upper eyelid thickness of 2 mm so that the measured ver-
obtained during manifest refraction should go in the rear tex distance does not need to be further adjusted by the
cell. The cylinder power should go in the middle cell, and the examiner.
262 G. V. Vicente
Fig. 28 Trial frames will

have three cells. High power
trial lenses should go in the
most posterior cell (yellow). +2
Cylinder power is placed in 0
the middle slot (blue), and +1.
0
low spherical power (e.g.,
−0.50D and +0.50D) is +0
placed in the front slot (green) .5
to allow for easy exchange
180
0
5
13
45
90
Fig. 29 This distometer is used to measure the vertex distance. Notice ing therefore does not need to be further adjusted to calculate the cor-
that the patient’s eyelid is closed. The device is calibrated to assume rect vertex distance
approximately 2 mm thickness of the upper eyelid. The measured read-
a b c
? ? ?
-
-
d e
? !
Fig. 30 In ambient light conditions (a), the examiner is unable to visu- combination can be used to project light onto the patient’s retina while
alize the patient’s retina. If a light source is placed between the exam- allowing for the examiner to simultaneously observe the illuminated
iner and the patient (b), the light will illuminate the patient’s retina but posterior segment. If the examiner is too far away from the patient (d),
would cause glare to the examiner and preclude his/her view. If the he/she will not be able to examine the patient properly. When the exam-
examiner sits in front of the light (c), then the light is effectively useless iner is viewing the patient’s eye from close range (e), he/she will be able
and creates a situation similar to (a). A 45-degree mirror and prism to examine the patient’s retina
Direct Ophthalmoscope preferably on the observer’s retina (Fig. 30). If the observer

sits behind the light, the light blocks the observer’s view and
The direct ophthalmoscope: a neuro-ophthalmologist’s sec- produces a lot of glare. If the observer sits in front of the
ond favorite instrument for viewing the optic nerve. (The light, then the observer blocks the light.
−55D Hruby lens attached to some slit lamps is the pre- The ophthalmoscope overcomes this problem by having
ferred.) This instrument uses the built-in optics of the an internal light source perpendicular to the examiner that is
patient’s own eye. Remember that an emmetropic human eye then redirected to the patient. Originally, a 45-degree mirror
acts as a + 60D lens (see Chap. 7 “Schematic Eye”). We can with a small opening in the center was used, and later a prism
also take advantage of angular magnification to visualize was added to modify the original design. This construction
the posterior segment (see angular magnification section allows the examiner to project light into the patient’s eye par-
below). axial to the examiner’s line of sight without blocking the
The humble ophthalmoscope has quite the history in oph- view or causing glare.
thalmology. It was first developed in the 1800s by Cambridge Modern ophthalmoscopes will have a light source that is
mathematics professor Charles Babbage (1791–1871) and coaxial to the observer’s line of sight (without blocking it)
then by German physicist Hermann von Helmholtz (1821– and small diameter compensating lenses to focus a virtual
1894) in 1915. Later, William Noah Allyn (yes, the same of upright image of the patient’s retina onto the observer’s
the company fame) developed the world’s first handheld retina. In contrast, an indirect ophthalmoscope (see next sec-
direct illuminating ophthalmoscope.11 tion) will form an aerial inverted image in front of the
Let’s think of this as a superhero origin story! The device observer.
overcame a simple problem of how to look through a dark This simple model works as long as the patient and the
pupil as no one had been able to do this before. Since the examiner are emmetropes (Fig. 31). However, if either one
posterior segment is relatively dark, an observer would need has a significant refractive error (hyperopia or myopia), then
a light source that was bright enough to illuminate the retina the compensating lens power must be dialed into the oph-
while simultaneously allowing enough reflected rays to exit thalmoscope accordingly. Multiple compensating (plus and
the eye and create a conjugate retinal image outside the eye, minus) lenses can be placed into a dial (similar to the
phoropter) (Fig. 32). The aperture size can be varied, and the
Ophthalmoscopy.
11
https://en.wikipedia.org/wiki/Ophthalmoscopy. source of light can be made to seem as if it originates at the
Accessed June 7, 2020 45-degree two-way mirror.
264 G. V. Vicente
a b
c d
Fig. 31 Direct ophthalmoscope compensating lens. (a) If the patient nate the retina and create a bright image on the observer’s retina. (c) If
and the observer are emmetropes, then a conjugate image of the the patient is ametropic, the conjugate image will be out of focus. (d) If
patient’s retina will form on the observer’s retina, but a stronger light is a small compensating lens is dialed in, then a focused image can be
needed to see it. (b) A bright light source and a two-way mirror illumi- formed on the observer’s retina
Fig. 32 Direct b
ophthalmoscope components:
(a) Lens wheel with
compensating lenses. (b) a c
Peephole. (c) 45-degree -
two-way mirror. (d) 2nd
condensing lens. (e) Aperture
wheel. (f) 1st condensing
lens. (g) Light source
The second converging lens (Fig. 32, D) will focus the light dilated pupil will also allow more light into the patient’s eye
source on the mirror. If this light source were far away, then the and increase the illuminated area to 3 mm. The power of the
light rays entering the eye would be parallel and focused on a compensating lens will depend on the patient’s refractive error
single point on the retina. Since a wider area of illumination is and the distance to the patient. The examiner may use the oph-
desired, a diverging ray is preferred. A pharmacologically thalmoscope and continue to wear his/her glasses as a result.
-6 +5
Fig. 33 Left panel shows a plus-power internal refractive error in a minus-power internal refractive error in a hyperopic patient and a plus-
myopic patient and a minus-power lens dialed into the ophthalmoscope power lens dialed into the ophthalmoscope which creates a minified
which creates a magnified image through a Galilean telescope (minus- image through a reverse Galilean telescope (plus-power eyepiece and
power eyepiece and plus-power objective lens). Right panel shows a minus-power objective lens)
The direct ophthalmoscope will use the optical properties ing that if one has excellent clinical exam skills, one
of the patient’s eye to magnify the image as well.12 While ray doesn’t always to have order an OCT of the macula!
tracing would show no magnification, angular magnification
causes a 15-fold magnification (60D/4) in an emmetropic
patient. When examining myopic patients, the examiner will PanOptic Ophthalmoscope
notice extra magnification due to the Galilean telescope
formed by the minus-power compensatory lens dialed into The PanOptic™ is a modified ophthalmoscope (Welch-
the ophthalmoscope and the plus-power internal refractive Allyn, Skaneateles Falls, NY, USA) that provides good visu-
error of a myope. Similarly, when examining a hyperopic alization of the posterior segment and may be preferred by
patient, a reverse Galilean telescope is formed, and the both examiners and patients.13 Using a longer working
patient’s retina may be less magnified (though this may give distance, it provides a larger, 25-degree field (similar to a
a secondary advantage of increased field of view). As always, binocular indirect but maintains an upright image of the pos-
you cannot escape geometric optics! (Fig. 33) terior pole) through an undilated pupil (Fig. 34). The exam-
Several miscellaneous notes to finish this section: iner can also stand further away from the patient, which is
handy in the era of social distancing! The simplified internal
• To avoid touching noses with the patient, the examiner optics includes 3 plus-power lenses and a light source that is
should use his/her right eye to examine the patient’s right focused on the cornea.14 This allows illumination through a
eye and vice versa. small pupil and avoids reflections from other anterior struc-
• To better see the optic nerve, the examiner should position tures. A light aperture that is conjugate with the pupil blocks
himself/herself approximately 15 degrees to the temporal extra reflections as well.
side of the patient.
• The ophthalmoscope may also be used to compare the red
reflex of both eyes simultaneously from a distance.
• The ophthalmoscope may also be used to test for eccen- Petrushkin H, Barsam A, Mavrakakis M et al., Optic disc assessment
13
tric fixation as well as use the slit feature to perform a in the emergency department: a comparative study between the
PanOptic and direct ophthalmoscopes. Emerg Med J. 2012;29(12):1007–
Watzke-Allen test to assess for macular pathology – prov-
1008. https://doi.org/10.1136/emermed-2011-200038
If you pay close attention to the diagram, you can see this is a modi-
14
For a review of angular magnification, see Chap. 8 “Magnification

12
fied astronomical telescope with an additional plus power lens to “re-
and Telescopes” invert” the inverted image.
266 G. V. Vicente
a b c d e f
g
Examiner
h Patient
Fig. 34 PanOptic™ ophthalmoscope. The top panel shows the Mirror to reflect light source. (e) Objective lens ~ + 40D. (f) Soft exten-
Illumination system, the bottom panel shows the viewing system. (a) sor to block other light sources. (g) Focus dial to move eyepiece. (H)
Eyepiece. (b) Imaging lens ~ + 40D. (c) Incoming light aperture. (d) Condenser lens focuses light onto the mirror
Binocular Indirect Ophthalmoscope (BIO) Massachusetts Eye and Ear Infirmary. His name: Professor
Charles L. Schepens, MD.15
While the direct ophthalmoscope has its many advantages, Compared to the direct ophthalmoscope, the BIO has cer-
the examiner is limited by a small, two-dimensional view of tain notable features:
the patient’s fundus. Wouldn’t it be even better to have an
instrument that allowed us examine a patient’s eye, confers a • Larger field of view (25 degrees vs. 7 degrees).
three-dimensional view, and also frees up our hands? By • Allows examination of the peripheral retina.
now you can tell that we enjoy giving a historical context to • Decreased magnification from 15× to 3× (when using a
the instruments we use. 20D lens) (60/20 = 3×).
In the 1930s, a young Belgian medical student was trained • Better view of the fundus in patients with media
as an ophthalmologist at Moorfields Hospital in England. He opacities.
saw his life upended by the German invasion of Belgium • The line of sight of both of the observer’s pupils enters the
during War World II. First, he joined the Belgian air force patient’s pupil in a paraxial fashion but through a slightly
and then joined the resistance. After his second capture, he different path than the illumination. This reduces reflec-
fled to France with his wife and two children and joined the tions and back scatter.16 The narrower new pupillary
resistance there. Posing as a lumber mill operator, he helped
smuggle over 100 refugees across the Pyrenees while under
the nom de guerre Jacques Pérot. After being discovered by “Charles L. Schepens, MD”. https://eye.hms.harvard.edu/charless-
15
chepens. Accessed June 7, 2020

the Gestapo, he fled to England where he began work on the
This reflex-free system was designed by Gullstrand. Yes, the same
16
binocular indirect ophthalmoscope (BIO). In 1947, he emi- optics genius who won a Nobel Prize for the reduced schematic eye
grated to the USA and started the first retina service at the (See Chap. 7, “Schematic Eye”).
d e
15 mm
60 mm
20D
a b c
Fig. 35 Binocular indirect ophthalmoscope (BIO). The binocular eye- faceplate, and an image of the faceplate will form on the patient’s pupil.
piece reduces PD to about 15 mm. Using a 20D condensing lens, an (e) shows the image of the observer’s pupils (gray circles) and the light
aerial, inverted, real image will form 5 cm anterior to the lens. (a), (b), source (yellow square) that are formed on the patient’s cornea, within
and (c) planes are conjugate. (d) The faceplate and (e) the patient’s the pupil. Light rays and image rays between the 20D lens and the cor-
cornea are conjugate; an image of the patient’s pupil will form on the nea will be parallel
d istance will reduce stereoacuity, but this is compensated lens. We can use the laws of similar triangles to determine
for by axial magnification (Fig. 35). the magnification of the image (Fig. 36). The focal length of
• The BIO is more useful in a wiggly pediatric patient than the lens is 1/20 = 50 mm; the focal length of the eye (using
the direct ophthalmoscope. Clinical pearl: animal crack- the RSE) is 17 mm.18 We can convert the focal length into
ers have been used by our authors for years to improve power to make the math easier:
cooperation of young patients. Transverse magnification = power of the eye/power of the
lens = 60D/20D = 3×
We can examine the construction of the BIO in greater Therefore, a 20D lens would magnify the retina
detail (Fig. 35). The BIO’s binocular eyepiece reduces the 60/20 = 3×; a 30D lens would have a larger field but less
examiner’s pupillary distance (PD) to approximately 15 mm. magnification 60/30 = 2×. The 20D lens is the most com-
When examining an emmetropic eye, an inverted, real image monly used lens for BIO in adults. For examination of pedi-
will form 5 cm anterior to the 20D lens. Notice that examin- atric patients, especially patients with retinopathy of
er’s eyes, 20D lens, and patient’s eye will form a conjugate prematurity (ROP), a 28D lens is preferred as zones 2 and 3
plane. An image of the examiner’s eyes and light source will will be easier to see.
form on the patient’s cornea (Fig. 35, E). Earlier, we stated that the BIO reduces the pupillary dis-
The power of the condensing lens will determine three tance from +60 mm to 15 mm. One would expect normal
things: stereopsis to be reduced as well by 4×. However, as men-
tioned above, axial magnification compensates for this.
• Viewing distance Using a 20D lens, we can calculate the axial magnifica-
• Field of view tion = (transverse magnification)2 = (3×)2 = 9×. Now apply-
• Magnification ing the reduction of PD (4×), we can calculate the final
magnification obtained when using the BIO as:
Thanks to the laws of similar triangles,17 an easy rule of Final magnification with BIO = 9/4 = 2.25×.
thumb when it comes to magnification of the handheld lens
is to divide the refractive power of the eye (60D) by the
power of the lens. Let’s use a 20D lens as our examining
See Chaps. 7 and 8 “Schematic Eye” and “Magnification and

17
We could also divide the focal length of the lens by the focal length of
18
Telescopes”. the eye: 50 mm / 17 mm = 3.

268 G. V. Vicente
X1
f eye
20D
f lens
X2
Fig. 36 The laws of similar triangles help us determine the magnification of the image
Operating Microscope Gullstrand’s reflex-free system is used to our benefit. A

nearly collimated light beam or a focused light beam may
Here’s another instrument we couldn’t live without. If we be used.21 (For those of you who are too embarrassed to
approach this tool from a problem-based perspective, we ask, collimating means to make rays parallel, close to
would need an operating microscope with the following zero vergence.)
features: • Binoculars to allow stereoscopic vision.
• Magnification changer and a collimating lens.
• Provides adequate and adjustable magnification • Beam splitter allows a second person or camera to have a
• A light source that provides sufficient illumination with- view as well.
out causing thermal and photic injury to the patient’s eye • Foot pedal to control X/Y/Z axes, magnification, focus,
• Makes all rays parallel and paraxial to avoid shadows, and lighting.
glare, and other optical aberrations
• Maintains binocularity and stereoacuity while magnify- From an ophthalmic optics standpoint, we should appre-
ing a very small area ciate that many of the previously discussed concepts are used
• Hands-free control of magnification, focus, light, and in the modern operating microscope, such as lenses, mirrors,
X-Y-Z axes total internal reflection, Galilean telescope, and magnifiers.
• An observer scope to help first-year ophthalmology resi- Further subtopics regarding the operating microscope, such
dents lubricate the cornea with just the right amount of as optimizing visualization, avoiding photic damage, etc.,
BSS are beyond the scope of this text. You may wish to consult the
• Cup holder (optional) and music player (advanced models operating manual of a given microscope and/or consult other
only) available resources for more information.
While there are many brands of operating microscopes

currently available, all of them are built upon the following Slit Lamp Microscope
optical principles that address surgeons’ needs (Fig. 37)19:
Built upon similar principles as the ophthalmoscopes, the slit
• A light source is located in the floor stand far away enough lamp has three main components: an illumination system, a
to not heat up the surgeon’s forehead. A fiber optic cable stand, and an observation system. We can use the schematic
can be used to bring the light onto the field.20 As with used in the commonly encountered Haag-Streit slit lamp
other microscopes, the light is coaxial – parallel to the (Haag-Streit, Switzerland) as an example (Fig. 38).
line of sight, but not in the same spot. Once again,
Cordero I. Understanding and caring for an operating microscope.

19
Community Eye Health. 2014;27(85):17 Cionni RJ, Pei R, Dimalanta R, Lubeck D. Evaluating Red Reflex and
21
Fiber-optic cables use total internal reflection (TIR) to transmit light.

20
Surgeon Preference Between Nearly-Collimated and Focused Beam
See Chap. 1 “Geometric Optics”, for more on TIR. Microscope Illumination Systems. Transl Vis Sci Technol. 2015;4(4):7
Fig. 37 Operating binocular

microscope. (a) Binoculars
include eyepieces, objective
lenses, and mirrors to narrow
the pupillary distance. (b)
Beam splitter uses a
45-degree two-way mirror. (c)
Magnification changer using a
Galilean microscope. (d)
Main objective lens with a
fixed working distance
15–20 mm (dark arrow). Gray
areas show parallel rays.
Assistant’s bottle of BSS not
included a
BSS
Again, notice the many familiar components we have pre- quiet, dark cabin with a curtain slightly open and a ray of
viously discussed, including mirrors, Galilean telescope, and sunshine illuminating the dust particles floating in the air as
prisms. the observer ponders the secrets of optics.22 To form an
evenly illuminated slit beam, an occluder with a thin linear
opening is placed between a condenser lens and an objective
Illumination System lens (Fig. 39). This is known as the Kohler illumination prin-
ciple, wherein the occluder is analogous to the diaphragm
A beam of light in the shape of a thin slit coming in at an aperture in a camera.
angle will allow the observer to see small details and depth
better than a wide beam of light aimed straight on. Imagine a Who said that optics can’t be poetic?
22
270 G. V. Vicente
Fig. 38 Haag-Streit slit lamp

microscope schematic. (a)
Illumination source. (b)
Patient’s eye. (c) Tilted
mirror. (d)+10D objective
lens. (e) 16× Galilean
telescope. (f) Porro-Abbe
prism. (g) Adjustable a
eyepiece. (h) Observer
b c d e f g h
a b c d e
Fig. 39 Kohler illumination principle within a slit lamp. (a) Image of Occluder with slit opening. (d) Condenser lenses. (e) Light source.
slit/optical section over the common pivot point of the viewing and illu- Notice a and c are conjugate planes (dark lines) as are b and e (red
minating arms. (b) Objective lens with an image of the filament. (c) dashed lines)
Due to the refractive power of the cornea and the lens, vide an upright image of the patient’s retina (mnemonic:
light does not reach the fundus without a diverging lens Hruby = upright)
such as a handheld lens (+90D, +60D) or the attached The incoming light may be located below the examiner
Hruby lens. The Hruby lens is a −55D lens that is found (as in the Zeiss slit lamps) or above the examiner (as in the
as an attachment on some slit lamps that can be slid into Haag Streit slit lamps). The light and viewing systems may
view in order to examine the fundus. Note that it will probe arranged in a parfocal setting with both systems focused
a b
Y
X
X
Fig. 40 Parfocal vs. non-parfocal settings. Panel A shows an example point “X” and the illumination system is rotating about point “Y.” This
of the viewing system and the illumination system in a parfocal setting, may be helpful in certain clinical situations, especially if the examiner
both focused at the same location of interest. Panel B demonstrates a wishes to evaluate peripheral corneal or anterior chamber angle
non-parfocal setting wherein the viewing system is rotating around pathology
on the same plane on the eye or non-parfocal setting (Fig. 40). Stand

A non-parfocal setting may be useful to examine pathology
located in the far periphery of the anterior segment (cornea, The stand may include:
angle anatomy).
Using different techniques (with varying angles and illu- • Comfortable and stable rest surface for patient and
minations), clinicians can examine the anterior segment with observer
various illumination methods, including direct focal illumi- • Joystick to control X, Y, Z axis
nation, diffuse illumination, specular reflection, transillumi- • Control of illumination and magnification
nation, indirect lateral illumination (retroillumination), and • Power source
sclerotic scatter. A full discussion regarding the appropriate • Applanation tonometer
application and advantages of each technique are beyond the • Fixation lights (select models)
scope of this text. However, there are several optical princi- • Protective shield (very important in a post-COVID
ples we can appreciate: world!)
• Cell phone charger (deluxe models only)
• Specular reflection relies on a non-parfocal setting in
order to examine the peripheral endothelium. As we mentioned previously, the observer should be care-
• Sclerotic scatter involves aiming intense light at the lim- ful with their posture to avoid chronic cervical problems
bus from an incoming angle that is greater than the critical from repeated use.
angle. The cornea will reflect this light according to the
principle of total internal reflection. This also requires a
non-parfocal setting. Observation System
• Several light filters are selectable with each viewing
method. For example, the red-free (green) filter can be The observation system of a slit lamp is very similar to an
used to visualize the nerve fiber layer and intra-retinal operating microscope (see Fig. 37); it will have several
hemorrhages by filtering out undesirable wavelengths of familiar optics devices:
light. The cobalt blue filter (450–500 nm) will function
similar to the excitatory blue filter used in fluorescein • Stereoscopic eyepieces
angiography to improve visualization of topical • Magnifying Galilean telescope
fluorescein.23 • Objective lens
• A Porro-Abbe prism is used to reinvert the image. This
unique glass prism is constructed such that four
Refer to the discussion in Chap. 14 “Physical Optics and Advanced
23
right-
angled prisms are joined face-to-face fashion.
Optical Principles”.
272 G. V. Vicente
Incoming light undergoes total internal reflection four

times (ensuring no loss of right-left orientation) within
the prism before exiting in the same orientation as the
incoming light.24 The image is rotated 180 degrees as a
result – in some ways, this functions as an astronomical
telescope to “re-invert” the returning image to the
examiner.
The aforementioned Galilean telescope component there-

fore maintains the “re-inversion” caused by the Porro-Abbe
prism, yielding an overall upright image with maintained
left-right orientation.
Keratometer Fig. 41 Purkinje images seen on slit lamp examination. The first and
second Purkinje images (P1 and P2, blue arrow) usually appear as a
superimposed figure in the superior pupillary space. The fourth Purkinje
Purkinje Images image (P4, red arrow) is usually seen in the inferior pupillary space. P4
is inverted relative to the other images. P3 is not shown in this figure.
Before discussing the construction and application of the
keratometer, it is important to first discuss the concept of
Purkinje images. There are four main Purkinje images – each reflected light may be “reflected back into the eye” from
image is a reflection of incoming light from an internal struc- the posterior corneal surface creating an entoptic phenom-
ture within the eye: enon. Finally, P3 and P4 in a pseudophakic eye come from
the anterior and posterior optic of the IOL; these can vary
• P1 (aka corneal reflection or glint): Reflection of light widely from case to case based on the IOL size, material,
from the anterior corneal surface. This is the brightest of toricity, and other factors. A more detailed discussion of
the four images and used in keratometry and topography. Purkinje images and their intraoperative role in cataract
• P2: Reflection of light from the posterior corneal surface. surgery can be found in Chap. 28, Intraoperative Optics for
This is the dimmest of the four images. Cataract Surgery.
• P3: Reflection of light from the anterior crystalline lens
surface. This is the largest of the Purkinje images.
• P4: Reflection of light from the posterior crystalline lens Manual Keratometer
surface. This is the only “inverted” image and has a
brighter intensity than P3. For cataract surgeons, this is of Also known as an “ophthalmometer,” the manual keratome-
significant importance because the position of P4 (com- ter measures the curvature of the cornea and its refractive
pared to P1) can be used for intraoperative assessment of power. This is useful in various clinical settings, including
IOL position and pseudophacodonesis (Fig. 41). but not limited to contact lens evaluations, quantifying kera-
tometric astigmatism, evaluating the health of the tear film,
For all intents and purposes, we can combine P1 and P2 determining the source of a patient’s astigmatism, and detect-
into a single image since they are almost completely super- ing irregular astigmatism.
imposed. P1 and P4 are usually used to determine eye posi- Some limitations of the manual keratometer include:
tion, though some devices may use the third image as well.
As an aside, in modern surgical microscopes that use • Limited to two-point measurements at 3–4 mm central
three lights, P1, P3, and P4 may appear as a triangular corneal zone.
cluster of lights (P1 and P3 would appear like an upright • Does not provide any information about the peripheral
pyramid whereas P4 would appear as an inverted pyra- cornea.
mid). Interestingly enough, under certain lighting condi- • Does not account for spherical aberration.
tions, you may be able to visualize P3 and P4 as this • Susceptible to misalignment and focusing errors.
• Though distortion of mires indicates irregular astigma-
Porro-Abbe
24
prism. https://en.wikipedia.org/wiki/ tism, the presence of distorted mires precludes a quanti-
Porro%E2%80%93Abbe_prism. Accessed June 7, 2020 fied, accurate measure of keratometric astigmatism.
• User skill and experience: as automated devices, includ-

ing corneal topographers, have become popular; per-
forming manual keratometry is quickly becoming a lost
art!
The most commonly used manual keratometer uses two O I

formulas to derive the dioptric power of the cornea.
r
The first formula is our good friend from Chap. 5, Power
of Lenses in Different Media, the equation used for deter- d
mining the refractive power of a spherical surface:
D = ( n′ − n ) / r

where n’ is the index of the cornea, n is the index of refrac- Fig. 42 Keratometry formula. r = 2 * d (I/O), r radius of curvature of
tion of air (1.0), and r is the radius of curvature. Though the the central cornea (blue arrow and blue circle). d Distance between the
keratometer measures the anterior corneal surface, it uses an object and the image, O Radius of the object, I Radius of the image.
Note that the Purkinje image of the ring forms posterior to the patient’s
assumed index of refraction of 1.3375 rather than the actual cornea (inside the eye)
1.376.
The second formula is used to find the radius of curvature.
If we consider the anterior surface of the cornea as a convex est to 90 degrees). The difference between the two
mirror, we can apply the following formula: readings is the amount of keratometric astigmatism (in
plus cylinder) present in the patient’s cornea (Fig. 43).
r = 2∗ d ( I / O )

where “d” is the distance from the object to the 1st virtual
Purkinje image formed within the eye. Note that this Purkinje Practice Questions
image is different from the previously discussed Purkinje
images of the cornea and crystalline lens. In this scenario, a 1. Which of the following is the most likely cycloplegic
ring is placed in front of the keratometer light source that refraction if, during streak retinoscopy (at the standard
ends up creating a virtual image of this ring posterior to the working distance), you observe neutralization while mov-
corneal surface (inside the eye). Because the distance from ing the intercept left to right across the 90-degree axis and
the mirror (cornea) to the image (v) is so small (4 mm), “d” with motion when moving up and down across 180-degree
can be approximated to just (u), which is the fixed distance axis? (Fig. 44)
between the keratometer and the cornea. “I” is the image A. Plano +1.00 × 180
size, and “O” is the object size (the size of the illuminated B. −1.50 + 2.00 × 180
ring(s)) (Fig. 42). C. Plano +1.00 × 90
D. −1.50 + 2.00 × 90
How to Use the Manual Keratometer 2. If the Geneva lens clock measures the following:
What will be the most likely strength of this spectacle
When performing keratometry, the goal is to focus the mires lens? (Fig. 45)
and center the reticle in the bottom right circle (known as the A. −1.00 + 2.00 × 090
focusing circle) (Fig. 43): B. −6.00 + 2.00 × 180
C. +1.00 + 6.00 × 090
1. Measure the horizontal meridian. Turn the horizontal D. +1.00 + 2.00 × 180
drum (left drum) to superimpose the plus signs (Fig. 43,
Panel B). 3. Where would you place the spectacle lens in this lensme-
2. Measure the vertical meridian. Turn the vertical drum ter? (Fig. 46)
(right drum) to superimpose the minus signs (Fig. 43, A. Location A
Panel C). B. Location B
3. Record the values of the horizontal drum (meridian clos- C. Location C
est to 180 degrees) and the vertical drum (meridian clos- D. Location D
274 G. V. Vicente
a - b c
-
+ +
- - + +
-
+ + + + -
- -
- -
+ + +
+ + + + + +
-
- -
Fig. 43 Sequences for performing manual keratometry. (a) The focus- meridian can be assessed by superimposing the minus signs by rotating
ing circle (bottom right circle) is used to quantify the amount of kerato- the right drum. The difference in the recorded values is the amount of
metric astigmatism. (b) The horizontal meridian can be assessed by keratometric astigmatism present (in plus cylinder)
superimposing the plus signs by rotating the left drum. (c) The vertical
5. Using a direct ophthalmoscope, the examiner must dial

additional −6.00D compensating lens power to see the
patient’s uncorrected eye fundus clearly. Will the optic
nerve appear more or less magnified than a zero setting in
an emmetrope?
A. More minification
B. More magnification
Answers
1. Answer: B (−1.50 + 2.00 × 180). If neutralization is

achieved across 90 degrees with zero sphere and with
motion is observed along 180, then we know that this
patient requires a corrective cylinder placed in the
180-degree meridian (in order to act at the 90-degree
axis). Though we are not given the amount of cylinder
Fig. 44 This patient has a light streak that moves with motion across power used, we can see from the answer choices that we
the 180-degree axis and neutralizes across the 90-degree axis
can safely eliminate C and D as the correcting cylinder in
these choices is placed in the 90-degree meridian (which
4. What kind of ground in prism is present in this lens would act at the 180-degree axis, which is 90 degrees
(Fig. 47)? away from where we need the corrective cylinder).
A. 3 PD base-down Looking at answer choices A and B, we know that we
B. 4 PD base-down must add an additional −1.50 sphere once the working
C. 4 PD base-up distance is subtracted. The trial lens used is likely a + 2.00
D. 5 PD base-down. × 180 cylindrical lens.
a b
c d
4
4
0+
8
8
0
Fig. 45 GLC measurements. (a) On the back surface the GLC reads −6.00D along 90 degrees and −4.00D along 180 degrees. The front surface
is +5.00D along both meridians
2. Answer: A (−1.00 + 2.00 × 90). We know that the 3. Answer: Location B. The spectacle lens should be placed
power of the front surface is +5.00D. For the back sur- where the rays are parallel.
face, we basically have −6.00D @ 90 and −4.00D @ 4. Answer: C. Notice that the yellow lines intersect the 1st
180. We can write this as a power cross as seen in bar above the 3rd circle representing the amount of prism
Fig. 48 (top right panel). We can then combine the (4 PD) and location of prism (base-up) relative to the cen-
front surface and back surface power crosses to gener- tering circle.
ate the combined power cross (bottom panel). Then 5. Answer: B. Dialing a minus lens within the ophthalmo-
using the double arches method, we can determine that scope will create a Galilean telescope when we take into
the power of the spherocylindrical lens is −1.00 + 2.00 account the (+) refractive error within the patient’s eye.
× 90 (Fig. 48). This will create a magnified image.
276 G. V. Vicente
90
180
a b c d
Fig. 46 Cross-section of a lensmeter
+5.0 -6.0
+5.0 -4.0
Front surface Posterior surface
-1.0
+1.0 -1.00+2.00 x 090
Fig. 48 The front surface is a spherical lens of +5.00D represented by

the first power cross. The posterior surface is represented by the 2nd
3 power cross. Adding the two-power crosses produces the power cross
on the bottom. This can be used to determine the power of the measured
spectacle lens
Fig. 47 Observed lensmeter results of measuring an eyeglass lens with

unknown prism power
Visual Acuity Testing and Assessment
Kamran M. Riaz
Objectives that what you learn from this chapter will be helpful your
• To define and understand the various methods of visual daily practice.
acuity testing. As ophthalmologists, we rely on visual acuity as our main
• To know the differences between various terms used in “vital sign” when examining a patient; interestingly enough,
visual acuity threshold measurements. the actual testing of visual acuity is a relatively neglected
• To understand important principles regarding the Snellen topic. We hope this chapter will clear up some of the key
visual acuity and ETDRS visual acuity charts. concepts about visual acuity testing, make it less painful to
• To be able to discuss alternative methods of visual acuity understand, and maybe even teach you something along the
testing in common clinical scenarios. way. Let’s get in line.
• To understand the role of color vision testing and binocu-
lar testing.
• To describe how contrast sensitivity and defocus curves Tests for Visual Acuity
play a role in visual function and clinical practice.
• To memorize the definition of legal blindness in the The Four “Targets” of Testing Visual Acuity
United States.
Before we even get to our familiar Snellen visual acuity
chart, there are some definitions of visual acuity tests that we
Introduction have to (unfortunately) introduce at this time. We fully
understand that some of these terms are abstract and nebu-
Visual acuity testing is like going to the DMV: no one par- lous. Hence, we have listed each term and then given a ques-
ticularly enjoys doing it, but it seems like it is something we tion (in parenthesis) that you can use to help understand what
all have to do regularly. Even you retina folks may acciden- exactly a given test is trying to accomplish:
tally check visual acuity (which is okay, don’t feel guilty;
you may have even enjoyed it).1 Just like at the DMV, we will • Target Detection: Do you notice this test object at all?
see many “lines,” be given forms to fill out and encounter • Examples of this type of testing include the “Tumbling
confusion at nearly every step of the way. Also, similar to Es” and “Landolt Cs” test. In this type of testing, we
visiting the DMV, you may be forced to set aside a Saturday rely on the patient’s ability to visually detect the loca-
morning when nothing else is going on to read this chapter. tion of a gap or break in the test object (either the E or
Make sure you are well-caffeinated because you may be here the C). This type of test can be used on a nonliterate
for a few hours. However, unlike going to the DMV, we hope English or illiterate adult patient. The patient can be
easily instructed to tell the examiner the orientation of
the letter, which in turn is an indirect test used to deter-
mine whether or not the patient is noticing the gap or
On a side note, the authors are working on patenting a light switch and
1
break in the letter.
marketing it as “The Retinal Surgeon’s Phoropter.” Phase III clinical • Target Recognition: Can you tell me what this test object is?
trials are pending… just kidding; we love our retina colleagues!
K. M. Riaz (*)

278 K. M. Riaz
• You are probably most familiar with this type of test- Snellen visual acuity chart. If the patient can read the
ing, such as the Snellen and ETDRS Visual Acuity line without any glasses correction, we can pat ourselves on
charts. In this test, the patient has to not only “see” the back for a job well done with cataract surgery. However,
the letter, but he/she must recognize the letter as what exactly is this 20/20 letter “E” doing? The letter “E”
well. The choice of letters, design of the chart, and subtending an angle (casting an image with a specific size)
spacing between the letters are crucial factors to onto the patient’s retina. We are, in turn, testing the patient’s
ensure that the letter recognition difficulty is equal ability to recognize and read it.
for different letter sizes and chart working distances. If we break this down further, the letter “E” on the 20/20
The ETDRS chart standardizes and fills in the gaps line is constructed so that the whole letter subtends an angle
of the Snellen chart – more on this in the sections of 5 arcmins when viewed by an observer standing 20 feet (6
below. This type of visual acuity testing is the most m) away; however, the letter “E” is constructed with 5 unique
common method used in clinical and research “strokes”. Each “stroke” on the letter “E” subtends 1 arcmin
settings. as well (Fig. 1).
• Target Resolution Threshold: Do you notice the separa- For an observer viewing the Snellen chart at 20 feet, larger
tion between these objects? letters will accordingly subtend larger arcmins proportional
• This type of testing requires patients to discriminate to their size compared to the 20/20 letter “E.” For example,
the separation between elements of a stimulus pattern. since the 20/200 line is 10 times the size of the 20/20 line, we
We are testing the visual angle (see next section), so it can determine that the 20/200 letter “E” will subtend 10
does not require the patient to “recognize” a letter but times the arcmins as well: 10 x 5 arcmins = 50 arcmins sub-
rather the separation or space between a patterned ele- tended by the 20/200 letter “E” when viewed by an observer
ment. It differs from Target Detection because the at 20 feet (Fig. 2). Similarly, the 20/60 letter “E” will subtend
stimulus pattern fills up most of the testing screen. 3 x 5 arcmins for a total of 15 arcmins when viewed by an
Examples of this type of testing include acuity grating observer at 20 feet.
testing (such as Teller acuity testing) and checkerboard We will discuss the Snellen visual acuity chart in the
pattern testing. next section, but what we need to understand at this point is
• Target Localization: Do you notice any difference between that each letter on the visual acuity chart will subtend a
these test objects? certain angle (measured in arcmin) onto a patient’s retina.
• This type of testing requires patients to tell the differ- When we test a patient’s visual acuity, we are basically test-
ence in spatial positions of a segment of a test object. ing whether or not the patient recognizes these subtended
The most common example is Vernier acuity testing angles.
(see next section). A patient is shown lines and asked With this background, we have four more definitions to
to point out where exactly he/she notices a misalign- review. Notice that there is some overlap between these
ment or discontinuity in the line. and the ones we previously introduced – remember, this
entire chapter is like being at the DMV: it seemingly defies
all logic and usefulness, but you just have to get through it.
Degrees, Minutes, and Seconds of Arc Four other terms are used in the measurement of visual
function. We will group the first three together, and the fourth
Before we continue further, we have to define some key
terms and principles used in visual acuity testing:
• 1 degree is 1/360 th part of a circle.

1 arcmin
• 1 minute is 1/60 th of a degree: this is the most important
one to know. 1 arcmin
• 1 second is 1/60 th of a minute.
5 arcmin
1 arcmin
Why is this important? Because all visual acuity testing
methods rely on a test object/letter casting a certain angle 1 arcmin
(referred to as “subtending an angle”) onto the patient’s ret-
ina. The test object/letter is constructed so that each individ- 1 arcmin
ual component can be related to some fraction of our above
circle, usually in minutes of arc (also known as arcmin).
Fig. 1 Each “stroke” on the 20/20 letter “E” subtends 1 arcmin,
Let’s use a more familiar example: suppose we ask a whereas the entire letter will subtend 5 arcmins (when viewed from
patient to look at the letter “E” on the 20/20 line on the 20 feet away)
Visual Acuity Testing and Assessment 279
Fig. 2 The 20/20 letter “E” 20/200 “E”

will subtend 5 arcmins to an
observer viewing the Snellen
eye chart at 20 feet. Using this 50 minutes
as a reference, we can
determine the arcmins
subtended by larger letters as
proportional to the 20/20
letter (5 arcmins). For
20/20 “E” 5` minutes=
example, the 20/200 letter “E”
(5/60) degree
will subtend 10 times the
arcmins for a total of 50
arcmins when viewed by an
observer at 20 feet
E E E E E Minimum legible (resolvable) threshold

20/40 line (and can’t read any letters on the 20/30 line), we
will record the visual acuity as “20/40”. This notation is
simply a numerical way of saying, “this 20/40 line is the
patient’s minimum legible threshold.”
Minimum visible threshold
.
Minimum Visible Threshold
Minimum visible threshold (MVT)3: In some ways, this is a
Minimum separable threshold
weird definition because we aren’t really testing the patient’s
ability to see letters. Instead, we are testing his/her ability to
distinguish a target from a background. Typically, a target
(or letter) of varying brightness levels against a background
Vernier acuity (hyperacuity) is presented to the patient; the patient is asked to indicate
which target s/he can no longer see. In this test, we ascertain
the viewing angle within which the patient’s eye can detect
the presence (or absence) of a stimulus. Testing at this level
Fig. 3 Depiction of minimum legible (resolvable) threshold, minimum is at seconds of arc (arcsec) and only stimulates a few photo-
visible threshold, minimum separable threshold, and Vernier acuity. receptors. Lea Symbols (discussed later in this chapter) are
Minimum legible (resolvable) threshold involves testing at the arcmin
an example of MVT testing.
level. Minimum visible threshold involves testing at approximately 10
arcsecs. Minimum separable threshold (MST) similarly involves test-
ing at the arcsec level (<10 arcsecs). Vernier acuity, a subset of MST, is Minimum Separable Threshold
the most sensitive form of visual acuity testing and involves testing at Minimum separable threshold (MST)4: In this kind of test-
approximately 2–3 arcsecs
ing, two objects are presented to the patient with progres-
sively smaller space in between them; the patient is asked
(Vernier acuity) can be thought of as a subset of the third to indicate at which point he/she cannot distinguish
category (minimum separable threshold) (Fig. 3). between the two objects (such as dots or bars) sepa-
rately because they will seem like the same object. Testing
inimum Legible (Resolvable) Threshold
M at this level is also at the level of arcsecs. Teller Acuity
Minimum legible threshold (a.k.a. minimal resolvable Cards (discussed later in this chapter) are a form of MST
threshold) (MLT/MRT)2: This refers to the point at which a testing.
patient cannot further distinguish between progressively
smaller subtended angles (using letters or forms) from one Vernier Acuity
another. In this type of testing, we usually test patients on the Vernier acuity (a.k.a. hyperacuity): As discussed above,
arcmin level. The Snellen visual acuity chart is the most Vernier acuity may be thought of as a subset of MST. However,
commonly used tool to determine the minimum legible Vernier acuity is much more specific than MST as this type of
threshold. For example, if a patient can only read up to the testing involves asking the patient to notice “breaks” within
Some texts may refer to this kind of testing as detection acuity.

3
Some texts may refer to this kind of testing as recognition acuity.

2
Some texts may refer to this kind of testing as resolution acuity.
4
280 K. M. Riaz
a line or misalignment of line segments. Vernier acuity is

the most sensitive type of testing because we are testing at
the level of 2–3 arcsecs as the break in the line will cast an
angle smaller than a photoreceptor. For example, Fig. 4
shows eight different lines constructed with segments that
are “closer together” and “farther apart” than their neighbor.
If you zoom (not the teleconference application) in closer,
you can start to see each segment; but when you step back far
enough, all the lines will seem to be straight lines, and the
segments will disappear. When you are physically closer to
the lines, the segments are casting angles “large” enough to
be noticed by your photoreceptors; when you step back, the
angles are too small to be noticed by your photoreceptors, so
the lines appear to be completely straight lines.
Vernier acuity is used throughout ophthalmology: the
keratometer, lensmeter, applanation tonometry, and even
the Amsler grid all make use of Vernier acuity! For exam-
ple, we ask patients to use an Amsler grid because very
early retinal neovascularization or an epiretinal membrane
that affects a few photoreceptors may not cause enough
changes for a patient to incorrectly read letters (because
the other photoreceptors may detect the visual stimuli and
hide the flawed information from the damaged photorecep-
tors). However, when we present the familiar checker-
board/grid lines, we can test at the photoreceptor level to
detect early pathology. Vernier acuity can therefore detect
Fig. 4 Vernier acuity tests a patient’s ability to discriminate between
visual acuity changes before it affects the MLT/MRT,
segments within a line or breaks within a line. When you look at the
MVT, and/or MST. lines close-up, the lines will appear to be jagged or irregular because the
For example, suppose you are looking at the image of two angles cast by each segment are large enough to be noticed by your
lines separated by a space of 3 mm (x) from 40 meters away photoreceptors. As you begin to step back, each line will look like a
clear, straight line until all the lines appear to be straight lines
(y) (Fig. 5). We can use similar triangles if we want to deter-
mine how large this space will be on the retina. Recall our
discussions from Chap. 7 “Schematic Eye”, we can use the Snellen Visual Acuity Chart
“17 mm” rule as the distance from the eye’s nodal point to
the retina (y’). For exact numbers, we can add the 5.5 mm The Snellen visual acuity chart is like your driver’s license:
(distance from the nodal point to the cornea) to y, so that 40 you use it every day and don’t really think much about it
meters can be rewritten as 40,005.5 mm. We can then solve unless you have to use it for a photo ID to get through a secu-
for x’ as follows: rity line at the airport or appease the exam center proctor to
x/y = x’/y’ let you into the testing center to take your board exam.
x’ = (x/y)*y’ = (3 mm / 40005.5 mm) * (17 mm) = 0.0013 mm. Similarly, we use the Snellen chart all the time in clinical
The width of a retinal cone is approximately 0.004– practice and may not give much thought to its development,
0.005 mm, so the image can easily be captured by a retinal usefulness, and, most importantly, why it is used to assess a
cone. In other words, Vernier acuity allows this image to be patient’s visual function.
perceived by a single retinal cone when viewed from 40 Herman Snellen (1834–1908) was a Dutch ophthalmolo-
meters away! gist who introduced a visual acuity chart that could easily
Fig. 5 Vernier acuity allows

the observer to spot a small
40m
break in the line from 40 m
away. The break is magnified
in the bottom panel, where
similar triangles show the
space between the dark lines
as a red line projected onto 3mm
the retina. The retinal image
size of a 3 mm break in a line
40 m away is smaller than a
single retinal cone
x y’
y x’
1.75 mm
1.75 mm
1.75 mm 1.75 mm
Fig. 6 Snellen letters are actually optotypes: using a 5x5 grid pattern of alternating black and white squares (each measuring 1.75 mm), letters can
be generated with standardized heights and lengths, corresponding to a fixed number of arcmins
and quickly assess subtended angles (arcmins).5 While other the Snellen chart tests a patient’s ability to recognize an
charts had been previously introduced, the Snellen chart was optotype when it subtends 5 arcmins, which can only be
revolutionary. It was the first to use optotypes: using a 5x5 appreciated if the patient can recognize a letter with a spatial
grid pattern, alternating black and white squares could gen- pattern separated by a visual angle of 1 arcmin. Snellen’s
erate letters within this grid (Fig. 6). chart included a 7-step sequence (minimum angle of resolu-
Fun fact: Snellen’s first chart actually had symbols instead tion: 10, 5.0, 3.5, 2.5, 2.0, 1.5, and 1.0 arcmins).
of letters; another early version had the letter “A” (rather We can now measure visual acuity in terms of the visual
than the familiar “E”) and numbers as well. The letters are angle perceived by a patient using optotypes. Notice that it
arranged so that the critical detail within each letter (stroke would be extremely cumbersome and awkward to use the pre-
of the letter and gap width) will subtend approximately one- viously mentioned arcmins to relay information about a
fifth of its total height; the height and width of the optotype patient’s visual function: “Mr. Jones is able to see the optotype
is approximately 5 times the thickness of a stroke. Therefore, that subtends 5 arcmins at 20 feet.”6 As stated previously, the
Parker P. Heritage of ophthalmology. Herman Snellen, 1834–1908. J

5
The next time you want to tease a junior resident, you can use this
6
Ophthalmic Nurs Technol. 1988 Jan-Feb;7(1):38 nomenclature to indicate that a patient has 20/20 vision.
282 K. M. Riaz
20/20 optotype is constructed so that each stroke of the letter Table 1 Approximate heights for letters (optotypes) found on the
subtends 1 arcmin and the entire letter subtends 5 arcmins Snellen visual acuity chart
when viewed at 20 feet (or 6 meters). Snellen letters serve as a Line on Snellen
chart 20/15 20/20 20/30 20/40 20/50 20/60 20/70
proxy that allows us to measure the patient’s perception of the
Height of letter 7 9 13 18 22 27 31
visual angle based on his/her ability to read the optotype that (mm)
accordingly subtends that particular visual angle.
Similarly, each letter on the Snellen chart is designed so
that any letter on a given line will subtend 5 arcmins when Notice that letters on each consecutive line increase in
viewed from that distance. For example, the 20/60 letter will size by approximately 4–5 mm, though from the 20/20 to
subtend 5 arcmins when viewed from 60 feet; similarly, the 20/15 line, the size goes from 9 mm to 7 mm. Thus, there
20/100 letter will subtend 5 arcmins when viewed from isn’t a fixed ratio or pattern of how the height of each line
100 feet. To determine the number of arcmins for every letter compares to the line before or after it. On most Snellen
larger than the 20/20 line when viewed at 20 feet, the inverse charts, this progression is irregular and can vary significantly,
of that line can be multiplied by 5 as follows: especially when considering larger letters. For example,
there is a 100 percent size increase when comparing the
• 20/40 line: inverse = 40/20 = 2 x 5 = 10 arcmins 20/100, 20/200, and 20/400 letters. This non-uniformity
• 20/80 line: inverse = 80/20 = 4 x 5 = 20 arcmins (lack of geometric progression) of letter sizes is one major
• 20/200 line: inverse = 200/20 = 10 x 5 = 50 arcmins. limitation of the Snellen chart – this would lead to the devel-
opment of more uniform charts, such as the ETDRS chart,
You may want to grab another cup of coffee and re-read which we will discuss in the next section.
the previous three paragraphs a few times to let all that amaz- Other disadvantages of the Snellen chart include:
ing information soak in.
When we say that a patient has “20/40” visual acuity, for • The use of black and white squares to create optotypes
example, we are actually saying that at the standard testing dis- also creates nearly 100% contrast of each letter, further
tance (20 feet), the patient can only perceive the optotypes on amplified when testing in a dark room and using a white
the 20/40 line that subtend 10 arcmins. The denominator can computer monitor or background. Thus, we are (poten-
also be considered the distance at which that size letter subtends tially) artificially enhancing a patient’s actual visual func-
5 arcmins. If a patient only has 20/40 vision (i.e., able to per- tion by adding 100% contrast into the equation. In most
ceive only 10 arcmins from 20 feet away), then when we com- everyday visual situations, 100% contrast is nearly non-
pare this vision to a patient with 20/20 vision (i.e., able to existent. This may explain why some patients test several
perceive 5 arcmins from 20 feet away), we can compare these lines better on a Snellen chart but may have worse “func-
two patients’ perception of visual angles: the 20/20 patient has tional vision” with their everyday visual tasks in typical
double the perception as the 20/40 patient. Finally, another way lighting situations. See the discussion on Contrast
to think of this (and a way to explain this to patients) is that a Sensitivity toward the end of this chapter for more
patient with 20/40 vision needs to be 20 feet away to see the information.
20/40 line, whereas a patient with 20/20 vision can see the 20/40 • Different rows have different numbers of letters, ranging
line from 40 feet away. from 1 to 8 letters per row.
Enough about visual angles, let’s talk a bit about the letter • Not every line is of equal legibility or difficulty as they
size on a Snellen chart. If we look at the letter “E” on the may not contain an equal number of “easy letters” and
20/20 line, the total length of each stroke is approximately “hard letters.” Easy letters are considered those letters that
1.75 mm; therefore, the total height of the letter is approxi- don’t have many other letters with similar shapes in the
mately 9 mm (Fig. 6).7 Recall that a “stroke” refers to both English alphabet – for example, the letters A, J, and Z are
the shaded portion and the space within a letter. Table 1 considered easy letters. Hard letters may have one or
shows the height for each letter on a given line on the Snellen more letters with similar shapes – for example, the letters
chart – please note that this has been given for illustrative C, D, G, O, Q, U, V, and W share many similar fea-
purposes only and should not be committed to memory.8 tures and are more likely to be confused.
• Memorization bias may play a role when using non-
The BCSC Clinical Optics (Clinical Optics: Basic and Clinical
7 computerized Snellen charts. This bias is more of an issue
Science Course. American Academy of Ophthalmology, 2020) gives when using printed or projected Snellen charts wherein the
the height of the 20/20 letter “E” as 8 mm. Other sources vary, including
examiner cannot present multiple varieties of the same line
8.73 mm.
to assess whether the patient can genuinely see the line or
International Society for the Enhancement of Eyesight, January 28,
8
2005. http://www.i-see.org/eyecharts.html. Accessed February 23, has “memorized” the line because he/she has done the test
2022.
Table 2 Snellen visual acuity can be readily converted into other strokes under the two legs of the letter “A”, additional strokes
nomenclature systems used to report visual acuity, including visual
in the letter “E”, etc.), may create additional difficulty for a
angle (arcmin) notation, decimal (Visus) notation, and logMAR
notation patient to recognize correctly. Thus, vision scientists realized
Decimal
that sans-serif, simplified letters (e.g., DEFHNPRUVZ -
Snellen Snellen Visual Angle notation Gesundheit!) could be easily recognized with “similar” dif-
(feet) (meters) (arcmins) (Visus) logMAR ficulty. Charts that sought to improve on the limitations of
20/15 6/4.5 0.75 1.33 −0.12 the Snellen chart had been developed prior to the ETDRS
20/20 6/6 1.00 1.00 0.00 study. Louise Sloan (1898–1982) had developed optotype
20/25 6/7.75 1.25 0.80 0.10 fonts (Sloan letters) to give letters of consistent difficulty that
20/30 6/9 1.5 0.67 0.18
established standards for future clinical studies.10 Ian Bailey
20/40 6/12 2.00 0.50 0.30
20/50 6/15 2.50 0.40 0.40 and Jan Lovie-Kitchin at the National Vision Research
20/60 6/18 3.00 0.33 0.48 Institute (Australia) had also previously designed a “log-
20/80 6/24 4.00 0.25 0.60 MAR visual acuity chart” built upon the geometric progres-
20/100 6/30 5.00 0.20 0.70 sion of optotypes to standardize visual acuity testing in
20/200 6/60 10.00 0.10 1.00 1976.11 Basically, the ETDRS took the Bailey-Lovie chart
20/400 6/120 20.00 0.05 1.30 and made some additional modifications, such as using a 4 m
testing distance (instead of 6 m) and Sloan letters (instead of
so many times.9 Ironically, as Snellen’s original chart ( with British Standard letters). As the ETDRS had significant
the E, FP, TOZ, etc. at the top) became a staple in medical implications for the clinical management of diabetic patients,
offices worldwide, it became so recognizable that some the associated chart also became popular among clinicians
authorities felt it needed to be redone into something less and vision research scientists. Today, LogMAR charts, such
recognizable to avoid unwanted memorization bias. as the Bailey-Lovie and ETDRS charts, are considered the
Computerized charts have eliminated this bias since we can gold standard for clinical research studies in
show the patient many varieties of the same line. ophthalmology.
Why on earth did they use this chart? Think of the ETDRS
Nevertheless, the Snellen visual acuity chart remains the as improving on the flaws of the Snellen chart; in other
most commonly employed method of visual acuity testing in words, it’s like one of those new “REAL-ID” driver’s licenses
clinical practice outside of the research setting. Snellen acu- that have advanced features compared to the older driver’s
ities can be converted to other commonly used methods of licenses. Key features and advantages of the ETDRS include:
reporting visual acuity, including Snellen in metric notation,
visual angle (Arcmins) notation, decimal (Visus) notation, • Sans-serif optotypes of letters are used in each line of the
and logMAR. LogMAR notation is particularly useful for chart; this is thought to make each letter equally legible
comparing the mean Snellen visual acuity in a series of (and equally challenging) when compared to other letters
patients and comparing across populations (Table 2). LogMAR on each line.
notation is commonly used to report visual acuities and • The ETDRS has the same 10 letters introduced by Sloan:
refractive outcomes in clinical research publications. CDHKNORSVZ (almost seems like the world’s worst
vanity license plate!).
• Each line also has the same number of test letters (5) per
The ETDRS Visual Acuity Chart line.
• The size of every letter on a given line is the same as its
The Early Treatment Diabetic Retinopathy Study (ETDRS) fellow letters; each letter is further separated by a white
is one of those landmark studies in ophthalmology that you space equal to the size of the letter itself. This arrange-
should definitely know about. While the study sought to ment helps to minimize any unwarranted consequences of
assess the efficacy of scatter and focal photocoagulation to crowding.
halt the progression of retinopathy, the study also gifted us • Each letter has a value of 0.02 log units, so the total value
with the standardization and popularity of the ETDRS visual of each line is 0.1 log units. Hence, each line decreases in
acuity chart – thanks retina people! 0.1 log unit increments, so each line varies from the line
As discussed in the previous section, the Snellen chart has
considerable limitations and drawbacks. For example, letters
with serifs, or extra strokes at the edges (e.g., underline
Finkelstein D, Masoff R. Louse Littig Sloan, pioneer in clinical vision
10
research 1898–1982. Arch Ophthalmol 1982; 100: 1347

Admit it, many of you nerds have (subconsciously) memorized that the
9
Bailey IL, Lovie JE. New design principles for visual acuity letter
11
20/30 line is OFLCT and the 20/25 line is APEOTF. charts. Am J Optom Physiol 1976; 53: 740–745
284 K. M. Riaz
above and the line below in a logarithmic (geometric, though it is possible that they may need to remove the
fixed pattern) fashion. rotary telephone symbol because kids may no longer rec-
• Therefore a three-line change (gain or loss of vision) will ognize it! The Lea Symbols test involves giving the
correspond to doubling or halving, respectively, of the patient a sheet with four reference “images” (house,
visual angle. This relationship makes comparisons of square, circle, and apple) that are then shown as optotypes
visual acuity across studies more straightforward and on a screen; the patient is asked to match what he/she sees
more comparable. on the screen with the symbols on the reference sheet. The
• LogMAR notation is actually a measurement of vision Handy Eye Chart involves a picture of nearly universal
loss (Table 2). In other words, like golf, the lower the hand gestures and positions as a proxy for optotypes that
score, the better. Notice that 20/20 vision corresponds to the patient can then demonstrate using his/her own hand –
a logMAR score of zero. Loss of vision will correspond to and before you ask or ponder, no, “flipping the bird” is not
positive logMAR scores. considered a universal hand gesture and therefore is not
• Visual acuity measurements using a logMAR chart are part of the chart.
twice as repeatable as those from a Snellen chart12 and • Letter Position Methods: Tumbling Es, Landolt Cs, etc. In
over three times more sensitive to interocular differences this test, the patient is shown a letter in different positions
in visual acuity.13 and then has to report the letter’s position as a proxy for
“seeing” the letter. In the Tumbling Es test, the “E” can
ETDRS charts are available for various test distances be placed in one of four positions (facing up, down, left,
ranging from 20 feet (6 meters) to 2 meters (6.5 feet). or right), and the patient can similarly use his/her hand to
Potential limitations of this chart include its size (physical display three fingers up, down, left, or right. The Landolt
footprint in an exam lane), cost, and increased testing time Cs test involves showing the letter “C” in one of 8 possi-
(compared to the Snellen chart). On this last point, we can ble positions; as a result, there is less chance that the
see that the ETDRS chart has 55 letters, whereas the Snellen patient “guesses right,” as can happen with only four
chart has 36 letters; this explains why it takes longer for a choices on the Tumbling Es test.15
patient to complete the ETDRS.14 • Internet Visual Acuity Charts: Thanks to the magical
power of the Internet, several readily available visual acu-
ity charts (especially for near vision) are available in most
ssessing Visual Acuity in Nonliterate or
A languages that can be printed out and placed at the recom-
Illiterate Adult Patients mended testing distance.
For clinical practice and exam purposes, you may need to be

familiar with some methods of testing visual acuity in Assessing Visual Acuity in Pediatric Patients
patients who are nonliterate in English or altogether illiterate
(in any language). Several potential testing methods include: We should also be familiar with various testing methods that can
be used in pediatric patients. Remember that the bulk of vision
• Arabic numerals (0–9) are the most popular number sys- development occurs after birth. A more detailed discussion of
tem used worldwide, regardless of a patient’s native lan- vision development from birth to adulthood is presented in
guage. Most visual acuity charts have a “numbers” option Chap. 23 “Pediatric Optics”. Starting from birth (chronologi-
to generate optotype numbers as a proxy for letters. cally), the following test(s) may be used at the discretion of the
• Picture Methods: Allen pictures, Lea Symbols, Handy examiner and based on the clinical setting:
Eye Chart, etc. In each of these methods, picture opto-
types are used so the patient can easily recognize them. • Blinks to light reflex and pupillary light reflex: These two
These are especially popular among pediatric patients. reflexes should be present (almost) immediately after birth.
You are already probably familiar with the Allen pictures • Pattern stimulus: By one week of age, infants can distin-
commonly used in pediatric ophthalmology clinics – guish between a gray-shaded stimulus and a black-shaded
stimulus at 1 foot away. The examiner can ascertain this
Lovie-Kitchin JE. Is it time to confine Snellen charts to the annals of
12 acuity by observing if the infant will look (even for a few
history? Ophthalmic Physiol Opt 2015; 35: 631–36 moments) longer at the patterned stimulus.
McGraw PV, Winn B, Gray LS, et al. Improving the reliability of
13
visual acuity measures in young children. Ophthalmic Physiol Opt

2000; 20: 173–84
Shamir RR, Friedman Y, Joskowicz L, et al. Comparison of Snellen
14
Or as can happen on a multiple-choice exam with four answer choices
15
and Early Treatment Diabetic Retinopathy Study charts using a com- and you are completely clueless. There’s a 25% chance that you may
puter simulation. Int J Ophthalmol 2016; 9: 119–23 just guess right!
Fig. 7 Teller Acuity Cards.

The examiner stands behind a
screen and presents cards with
varying contrast patterns to
the child, observing through a
central viewing hole if the
child preferentially looks
toward the area of the card
with the pattern. This
indicates that he/she can see
the pattern on the card. This
response is then translated
into an approximate visual
acuity
• OKN drum: A nystagmus will be induced if the baby can intermittent strabismus, it would be labeled “UM.” More
see stripes and follow the OKN drum. This response indi- specifically, the child’s vision can be described as “holds
cates the vision is at least 20/200. This ability can be seen fixation for 2 seconds” or “holds fixation until
at 6 weeks or earlier. blink”, before reverting to fixation with the dominant eye.
• Equal behavior with either eye covered. If a child cries • A 10–15 PD base-down prism or 20PD base-out prism
and fights occlusion when the right eye is covered but can be used to induce a deviation. If no movement is
does not react when the left eye is covered, they will likely observed, then the vision in that eye is likely poor.
have poor vision in their left eye. This is the child’s way • Teller Acuity Cards (preferential looking): We will dis-
of saying, “Stop doing that, I can’t see when you cover cuss this in more detail later in the chapter (“Contrast
my only good eye!” Sensitivity”). In brief, this test involves presenting cards
• Fix, follow, and maintain and central, steady, and main- with high contrast gratings on one side and no grating
tain (FFM and CSM): The “fix and follow” are monocular (and equal luminance) on the other side. The examiner
tests wherein the examiner tests if the child can maintain views the child through the central viewing hole to deter-
fixation and follow an object of interest. The smiling face mine which side of the card is “preferred” by the child. If
of a quiet examiner will get their attention (no fancy toys the child has good visual function, he/she should prefer-
are necessary). Similarly, the “central and steady” por- entially look toward the side of the card with more con-
tions are monocular tests to see if the child can use his/her trast (more pattern) to indicate that he/she can “see it”
central vision to fixate on an object of interest and keep (Fig. 7).
the eye steady (i.e., no nystagmus or strabismus eye • Picture optotypes (Allen cards, etc.)
movements). If an eye is uncentered due to constant stra- • Letter optotypes with matching (Lea Symbols, “HOTV”
bismus or eccentric fixation, it would be labeled “UC.” If testing). Most 2.5-year-old kids can play a matching game
the eye is unstable due to nystagmus, it would be labeled with HOTV letters. Even if they are shy or don’t know the
“US.” By covering the dominant fixating eye, the exam- letters yet, they can understand the concept of match-
iner forces the child to fixate with the other eye; then, the ing letters. A single letter is shown at 10 or 20 feet while
dominant eye is uncovered, and the child is allowed to see the child sits on his/her parent’s lap and holds a small
with both eyes open. If he/she can maintain central and sheet with the HOTV letters. For the sake of the examiner,
steady fixation on the object with both eyes, then we can animal crackers are an indispensable part of this exam.
say that the child has the “maintained” portion as well. If Families can also practice the matching game at home
the eye drifts off and alignment is unmaintained due to prior to the appointment.
286 K. M. Riaz
Age Pupillary Blink to OKN drum Following Fixation Visual

light light movements Acuity
reflex
At birth 20-1000
2-4 weeks
6 weeks
3 months
6 months 20/400
Fig. 8 Chronological summary of visual acuity from birth to six months. It is clinically relevant to remember this figure when an anxious new
parent comes in because their 1-week-old is not fixating on faces yet
• Tumbling E, Landolt C. 2. It is likely that young patients will at times want to get the
• Electroretinography (ERG) test: This test can determine correct answer desperately and will cheat around an
retinal functionality. It gives no information about the occluder whenever possible. The examiner has to be alert
anterior eye or the post-retinal visual pathway. Younger and ensure the eye is adequately occluded.
kids would have to be sedated to perform this test. 3. While this may seem to be a direct contradiction to the pre-
• Visual evoked potential (VEP) test: This test can be used vious point, in recent times (“post-hipster era”), it is not
in patients from infants to young kids. Recall that the VEP uncommon to have a pediatric (grade-school or junior-
tests the function of the visual pathway from the retina to high) patient who is eager to receive glasses such that he/
the occipital cortex (i.e., “behind” the eye). It does not she intentionally misses the line. This type of malingering
necessarily give information about the eye per se but more may be easily missed if the clinician is unaware of these
about the functionality of circuitry behind the eye. It can psychosocial factors. These patients can usually be diag-
help quantify optic nerve pathology and amblyopia. nosed by “bottom-up visual acuity testing,” i.e., starting at
the 20/10 line and then increasing to the 20/15, 20/20, etc.,
A chronological summary of visual acuity from birth to lines as needed. Similarly, confrontational visual fields
six months is shown in Fig. 8. may also help detect this subset of patients. Please see
Several other principles and pearls may be discussed here Chap. 21, “Clinical Problems with Optics and Refractive
regarding checking visual acuity in pediatric patients. Manifestations”, for a complete discussion of malingering
1. As clinicians, we must appreciate that while all patients and its relationship with optics.
are concerned about their children’s health, if a parent 4. Young (and adult) patients with amblyopia may experi-
has amblyopia, he/she may be even overly concerned. ence a crowding phenomenon during visual acuity testing
One of the authors (GVV) had a patient who could do (a.k.a. contour interaction). This phenomenon is due to
HOTV matching at 15 months of age with a recorded abnormally large receptive fields of neurons in the visual
vision of 20/30 on each eye. It turns out that the child’s system of the amblyopic eye. The affected eye may score
mother had dense amblyopia, and was told that amblyo- 20/30 on a Snellen chart with one letter at a time and
pia could run in families and that it was best caught 20/50 when a line of letters is presented. When recording
early. Feeling guilty, she went online and found HOTV this patient’s vision, should we record it as 20/30 or
and taught her daughter each of the figures in sign lan- 20/50? Well, both are correct – it depends on how the
guage(!). The author thanked the mom, reassured her visual acuity is recorded. For this reason, it is vital to
that her daughter was fine and also explained that we record the visual acuity with single letters and a line of
could have detected amblyopia at this age even without letters during a visit in order to be able to compare
sign language. The learning point here is that we should sequential vision measurements. Some visual acuity
be cognizant of parents’ concerns and, therefore, be devices have crowding bars which enable the examiner to
familiar with various types of visual acuity testing for present one letter at a time with these crowding bars to
pediatric patients. minimize the crowding phenomenon.
a b c
d e
Fig. 9 Worth Four Dot: Patient perceptions. (a) Normal binocularity. (b) Suppression of the left eye. (c) Suppression of the right eye. (d) Diplopia
due to exotropia. (e) Diplopia due to esotropia. (f) Diplopia due to right hypertropia
ssessing Visual Acuity in Patients

A Binocular Vision Testing
with Nystagmus
Worth Four Dot
Suppose we have a patient with 20/30 vision when tested bin-
ocularly and 20/80 vision when tested left eye only. In most This simple test requires a Worth Four Dot (W4D) flash-
patients, we would expect the right eye to test 20/30 because light and red/green glasses (red lens goes over the right
we often assume that the patient’s vision is as good as his/her eye). The W4D is constructed with a red light at the top,
best eye under binocular conditions. However, what if a patient two green lights in the middle, and a white light at the bot-
has 20/40 vision with both eyes open and 20/70 with one eye tom (Fig. 9). The test is performed at 33 cm (near) and at
at a time? This seemingly paradoxical finding is a common 6 m (distance). Remember that the red lens will only allow
situation in patients with Congenital Idiopathic Nystagmus in red light; the green lens will only allow in green light.
(CIN). If vision is tested monocularly, the latent nystagmus Patients with normal binocularity should see two green
will worsen the monocular recorded vision in these patients. lights, one red light, and one pink light at near and distance
To avoid this pitfall and measure a more accurate monocular (Fig. 9, Panel a).
vision, the examiner has three choices: If the patient is suppressing one eye, he/she will only
see one set of color dots. For example, if the left eye is
• Fog one eye with a lens that is +5.00 D sphere greater suppressed, the patient will report seeing only 2 red dots
than their refractive error instead of occluding it. (top light and bottom light) (Fig. 9, Panel b); if the right
• Have the patient hold the occluder at arm’s length. This eye is suppressed, the patient will see only 3 green dots
distance may allow enough peripheral vision to prevent (the two middle lights and the bottom light) (Fig. 9,
the latent nystagmus from emerging while still only test- Panel c).
ing one eye at a time. If the patient has diplopia, he/she will report seeing 5 dots
• Use a combination of Duochrome letters with red-green (Fig. 9, Panel d and e). The alignment of the dots may not be
filters or polarized lenses. Unlike the standard Duochrome intuitive but much like the Maddox rods, crossed diplopia
test (which is a monocular test). will cause uncrossed images – what the right eye sees will
appears on the right and what the left eye sees appears on the
Clinically, this has significant implications as it could left. However, and this may seem counterintuitive, a right
affect whether a patient can pass a vision screening exam, hypertropia will make the images the right eye sees appear
obtain a driver’s license, etc. lower than they really are (Fig. 9, Panel f).
288 K. M. Riaz
Patients with monofixation syndrome will have a small yet? Pseudoisochromatic refers to colored plates that appear
tropia (<8 PD), peripheral fusion, and a small central sco- to be the same colored (isochromatic) to patients with color-
toma. They will be able to see all four dots at near when a vision abnormalities and multi-colored to patients with nor-
large image falls on the peripheral macula; however, when mal color vision. The Ishihara and HRR color plates are
they stand further away from the lights, a small image is two commonly used methods of pseudoisochromatic color
formed on the fovea, and their small suppression scotoma plate testing.
may impede the patient seeing one of the colors. Four commonly used methods for color vision testing are
the following:
Testing of Stereo Acuity 1. Ishihara color plates: Developed in 1917 by Dr. Shinobu
Ishihara, these color plates are perhaps the most popu-
Stereo acuity testing relies on polarization to help to quan- larly used plates for color vision testing. The plates
tify a patient’s binocular depth perception. See the involve using confusion lines among spots with common
“Polarization” section in Chap. 14 “Physical Optics and points (copunctal points) to build patterns of differently
Advanced Optical Principles”, for a full discussion on colored spots (usually in the form of a number or a line).
polarization. There are four different types of plates used:
Stereo acuity is measured routinely by pediatric and stra- (a) Vanishing design plates: patients with color vision
bismus specialists as it can help monitor eye suppression and defects will not see anything at all, whereas color-
intermittent strabismus. Typically, two slightly disparate normal patients will see a sign on this plate.
images are presented to the retina and integrated in the occip- (b) Transformation design plates: patients with color
ital cortex. Finer stereoacuity is necessary to discern between vision defects will see a different sign as compared to
images as they are presented closer and closer to each other. color-normal patients.
Stereoacuity can be measured at near and distance. Some (c) Hidden digit design plates: patients with color vision
tests may have false positives from monocular cues patients defects will see a sign on this plate, whereas color-
can see. One of the most commonly used tests is the stereo normal vision patients will not see anything.
fly test. The figure is shown horizontally and slowly rotated (d) Classification design plates: a vanishing design is
to an upright position. As the image of the wings “pop up,” a used on either side of the plate – one for green vision
child with intact stereo acuity should be able to reach out and defects, the other for red vision defects. It can further
try to grab them. differentiate between red and green color vision
Other tests of similarly constructed objects (animals, defects.
raised dots among a series of dots, etc.) may be used for finer Ishihara plates are available in books of 14 plates (most
discrimination of stereo acuity. commonly used), 24 plates, and 38 plates. Basically,
you should know that individuals with defective color
vision may see nothing at all, something different, or
Color Vision Testing something “present” that differs from color-normal
patients, depending on the plate being used. As a result,
Before proceeding, you may wish to review the section on this is a test with good sensitivity for screening color-
“Spectral Sensitivity and Visual Pigments” in Chap. 14 deficient patients, but it does not specify the deficiency.
“Physical Optics and Advanced Optical Principles”. Finally, a fun fact: the first plate is considered to be the
Color vision defects can be classified into two catego- control plate, so both color-normal and color-deficient
ries: congenital and acquired. Acquired defects are usually patients should be able to see it. If a patient says that
blue-yellow defects, whereas congenital defects are usually they can’t see the first plate, you may have a malingerer
red-green, though they can also include blue-yellow. on your hands!
Historically, there were several iterations of color vision 2. Hardy, Rand, and Rittler (HRR) test: This book has 24
testing beyond the scope of this text. Several commonly- color plates; the first four are “instruction plates”; the fol-
used tests can be used to screen, assess, and quantify color lowing six plates are “screening plates” that present the
vision defects. most challenging targets for finding one of the three pri-
Let’s get a definition out of the way: pseudoisochromatic. mary color vision defects (deuteranopia, protanopia, and
You have probably used this and not given much thought to tritanopia) – if a patient clears these six plates, then he/
the word because it sounds intelligent; we suspect that most she is unlikely to be color deficient. The next 14 plates are
people in ophthalmology don’t know what this word means used to diagnose the exact type of color deficiency and
but use it anyway because everyone else uses it, not knowing the extent (mild, moderate, or severe). One of the main
that most everyone else may also not know it… confused advantages of the HRR test is its speed: a patient has to
only clear six plates (rather than 14 or more) in order to refraction. In this case, we will want the accommodation to
have “normal” color vision. be <1/8 D to avoid a rounding error and incur the additional
3. Farnsworth D-15 test: This type of test involves active −0.25D. Therefore, we should apply the reciprocal of 1/8 = 8
participation from the patient to arrange 15-colored discs meters (which is equivalent to 26.25 feet).
or patterns in the correct order. If you are feeling incred- Again, most patients would probably not notice this, but
ibly bored at the DMV, you can also try the Farnsworth- suppose your patient is a smart-aleck optics nerd who comes
Munsell 100 hue test, which involves 100 different plates in for a refraction and scoffs at your 20-foot exam lane as
to be arranged in groups of 20 plates – this test is very inadequate to test at “optical infinity.” You would then have
time-consuming and fatiguing! The color difference to test this smart-aleck at 26.25 feet if possible – otherwise,
between adjacent plates is approximately 1–4 nm, which send him to your enemy across town and move on with your
is considered as the near- minimum level for an observer day. Or ask them to take another step back from the chart,
to distinguish. Thus, this test is much more specific in another step back, until they are standing in your least favor-
classifying which color deficiency a patient is likely to ite partner’s room.
have. The D-15 is also useful to determine if a patient has
a congenital or acquired color deficiency. An individual
who fails the Ishihara test but passes the D-15 test will ontrast Sensitivity and Contrast Sensitivity
C
probably not have significant color discrimination prob- Function (CSF)
lems for most visual tasks and vocations.
4. Anomaloscope: This instrument is the most accurate for Contrast sensitivity is a visual function that is separate from
testing color-deficiency severity and distinguishing visual acuity, even though it plays a role in a patient’s “tested”
between dichromats and anomalous trichromats.16 As you visual acuity. Simply stated, contrast sensitivity is a patient’s
may have gathered, it’s mainly used for research purposes. ability to differentiate between bright (“white”) and dim
Basically, the patient is asked to match red and green light (“black”) components of a target object. When we test a patient’s
sources with a yellow light source. This allows for good visual acuity using black letters against a white background, we
detection of all types of red-green color vision deficiency. are artificially supplying the patient with near 100% contrast
Some anomaloscopes may also have b lue-green matching sensitivity. For example, suppose we had a patient with 20/20
capabilities. Patients with protanopia will use more red vision but presented her with two visual acuity charts at the
light to match the colors compared to patients with deuter- same distance, one with high contrast and the other with low
anopia, who will use more green light to match the colors. contrast. She would likely perform better on the high contrast
This instrument can also indicate the severity of the color visual acuity chart than on the low contrast visual acuity chart.
deficiency based on how a patient performs. In real-world scenarios, a patient with poor contrast sen-
sitivity may have poor visual function due to difficulty see-
ing the edges of objects, reading black print on colored paper,
Miscellaneous Topics driving on a “cloudy” day, etc. Similarly, in target objects
with low lighting (low luminance), we are more likely to dis-
Concept of Optical Infinity tinguish between shades of gray (as compared to bright lumi-
nance conditions) because the subtle differences in shade
We previously stated that the standard testing distance for may be easier to appreciate. In bright luminance conditions,
visual acuity is 20 feet (6 meters). However, even at this dis- the extra light “washes out” the shades of gray, so we cannot
tance, there is technically some accommodation present. We distinguish as easily until the contrast increases (i.e., the tar-
can calculate this accommodation: 100/600 cm = 1/6 D. This get object is closer to having distinct black and white pat-
is unlikely to be significant to most people, but we may still terns). The contrast threshold is the minimum amount of
theoretically over-minus a patient, due to rounding the 1/6D contrast needed for the patient to distinguish between the
to 1/4D, by approximately −0.25D. “light” and “dark” components of an object; the lower the
Optical infinity is the distance at which accommodation is threshold, the better a given patient’s contrast sensitivity.
so negligible that it can’t affect the measured refraction. At We can now build upon this by briefly discussing spatial
this point, you might be worried that you will have to find a frequency.17 Imagine we have a grating pattern (basically,
super-long exam lane to test a patient’s visual acuity at “opti- think of this as an object with alternating black and white
cal infinity”. Thankfully, we can find a workaround to limit bars), as shown in Fig. 10. Spatial frequency is simply a
the accommodation to have a negligible effect on the final
Tutorial on Spatial Frequency Analysis. http://www.psy.vanderbilt.
17
As the name suggests though, it is so anomalous that it’s never used…

16
edu/courses/hon185/SpatialFrequency/SpatialFrequency.html.
see what we did there. Accessed April 19, 2020
290 K. M. Riaz
a b c
Fig. 10 A sine-wave grating is a pattern of alternating black and white original object. Panel B shows how decreasing the contrast while main-
bars that can be used to understand contrast sensitivity and spatial fre- taining a high spatial frequency can affect the image quality. Panel C
quency better. In Panel A, the object has been imaged with high spatial shows an image of low spatial frequency and high contrast
frequency and high contrast, thereby giving a good estimation of the
fancy way of saying: when we look at this object, how many between frequency and contrast isn’t totally inverse. Instead,
pairs of bars will be imaged within one degree of the visual the relationship better approximates a curve: up to a certain
angle on the retina (approximately 0.3 mm). For example, (high) level of spatial frequency, we can maintain relatively
viewing your index fingernail at arm’s length will cast an high contrast sensitivity, but after a certain level of spatial
image that occupies one degree of the visual angle on the frequency, the contrast sensitivity decreases significantly
retina. If you move your arm closer or further away, a larger (Fig. 11).
or small visual angle will be cast, respectively. A grating pat- Wake up, you probably dozed off. Any image that we
tern with high spatial frequency will cast many narrow bars perceive of an object, whether taken by a camera or the
onto the retina (Fig. 10, Panel A); a grating pattern with low human eye, will only capture a certain amount of detail
spatial frequency will cast fewer bars (“fatter bars”) onto the of the object. We discussed this previously with the point
retina (Fig. 10, Panel C). spread function (PSF) in Chap. 14 “Physical Optics and
Several possibilities may occur when we view this object: Advanced Optical Principles”. We can take this one step
ideally, we would want to visualize the object with high spa- further by including contrast in this idea: there will
tial frequency and high contrast (Panel A). However, there is always be a ratio of the image contrast compared to the
always a tradeoff between spatial frequency and contrast. If actual object contrast. This ratio is called the transfer
we image the same object using high spatial frequency and factor, a proxy for contrast sensitivity – in other words,
lower contrast (Panel B), the image quality suffers. Similarly, how much of the actual contrast we are actually “see-
if we image the object using low spatial frequency and higher ing,” which we will discuss in more detail in the next
contrast, the image suffers (Panel C). This relationship section.
a
10
b
a
c
1
Contrast sensitivity c
0.1
0.01
0.001
1 3 10 30 100
Spatial Frequency (cpd)
Fig. 11 The highest level of contrast sensitivity (vertical axis) is seen for low (Panel A) to medium (Panel B) levels of spatial frequency. Contrast
sensitivity decreases significantly once spatial frequency reaches higher levels (Panel C)
When we view an object, contrast can either enhance or are much more difficult to detect.18 Specific eye pathologies,
diminish the perception of that object for a given spatial fre- such as retinal and optic nerve disease, may asymmetrically
quency number. In other words, an object may have low spa- affect contrast sensitivity more than visual acuity.
tial frequency, but with good enough contrast, we may be We take advantage of contrast sensitivity and spatial fre-
able to see it better (e.g., white text on a black page as com- quencies when performing Teller Acuity testing. We can alter
pared to black text on a white page). Suppose that by the time both the spatial frequency (number of bars) and the contrast
we are finished at the DMV, it’s nighttime as we are driving to see if the child will prefer the grating pattern as a proxy
home: in low light conditions (with only street lights on), we measurement for the patient’s visual function. A typical CSF
may not be able to make out high spatial frequencies (such as is shown for an infant vs. an adult in Fig. 12. We can see that
individual leaves on a tree). However, we can still make out infants cannot see high spatial frequencies and require more
low spatial frequencies (the tree itself) just as well as we can contrast, even for low-intermediate spatial frequencies.
during daytime. But if we turned off our headlights and drove Thus, an infant’s visual system is best suited for seeing
on a road without any lights, it would be difficult to see any- objects very close with good lighting and high contrast
thing, even trees, because both the spatial frequency and the (which makes sense because his/her entire world is located
contrast have become relatively low. Please note that this up close). As he/she gets older, the CSF will continue to
author does not endorse driving without your headlights improve. This CSF improvement, along with the develop-
turned on at nighttime. ment of the optical system (cornea, lens, retina, etc.), allows
We can formally test contrast sensitivity using charts such for healthy vision development.
as the Pelli-Robson chart that presents various optotypes Finally, as we age, the CSF at high spatial frequency
over a range of contrasts. The patient is shown parallel bars decreases for various reasons, such as those mentioned above.
(known as sine-wave gratings) of varying widths (spatial fre- However, even in the absence of retinal pathology, factors such
quency) and contrasts. Medium-level angular frequency
(approximately 5–7 cycles/degree) is the sweet spot for opti- Leguire LE, Algaze A, Kashou NH, et al. Relationship among fMRI,
18
mal detection by most patients; lower and higher frequencies contrast sensitivity and visual acuity. Brain Res 2011; 1367: 162–69
292 K. M. Riaz
Fig. 12 Contrast sensitivity 0.001 1000

function (CSF) curves for an
infant vs. an adult. Notice that
the infant cannot see high
spatial frequencies very well Adult
and requires much more
contrast, even for low-
intermediate spatial
Sensitivity (1/threshold contrast)

frequencies 0.01 100
Threshold contrast
0.1
10
Infant
1 1
0.1 1 10 100
Spatial frequency
(cycles/degree)
as decreased pupil size also decrease the CSF. Therefore, older such as a sheet of white paper with two black bars), the MTF
patients may need higher contrast for visual objects with high for any lens should be quite high. This high MTF value makes
spatial frequencies (such as small print). sense because there is not much detail in the object that needs
to be captured by the lens. Therefore, for boring, uninteresting
objects with low spatial frequency, the MTF of most lenses
Modulation Transfer Function (MTF) should be quite high. If we lived in a stick figure world (such
as the two-dimensional world from Edwin Abbott’s novel,
Recall that the transfer factor will decrease as the spatial fre- Flatland (1884), then, the MTF would be quite high.
quency increases: there is only so much contrast that the eye However, we live in a world with complex objects having
can faithfully transfer at higher spatial frequencies. Therefore, significant details. When we test visual acuity in the clinic
the modulation transfer function (MTF) is a graph that using a Snellen acuity chart, we use high-contrast black and
shows how we perceive contrast based on the spatial fre- white figures that lack significant complexity. In other words,
quency. It can be used for any optical system, such as a camera our assessment of a patient’s visual acuity can instead be
or (especially) an IOL.19 By convention, we refer to this as the thought of as: how well does this patient see a simple image
contrast sensitivity function (CSF) when referring to the with high contrast?20
human eye: a person with high CSF requires very little con-
trast to see an object and vice versa. Basically, you want to Some boring nerdy stuff: think of optical images (perceptions of a
20
have a high CSF because it will give you “better” vision. given object) analogous to our perception of sounds: what we hear is a
fractional amount (with varying quantity and quality) of the “true
Let’s simplify the MTF definition: the MTF is simply a
sound” of a bird or a Mozart symphony, for example. Similarly, optical
way to describe the CSF for a lens system, whether it is the images are fractions of the true image: we can represent this mathemati-
eye, glasses, or an IOL. A perfect lens would have an MTF of cally using a sine-wave grating (SWG). The SWG contrast is indicated
1 (or 100%); this means that the lens is so amazingly perfect by the brightness difference between the brightest and darkest parts of
an image. SWGs usually show a gradual change of dark/light ratios. A
that every single object is faithfully represented in the image.
variant of SWGs involves arranging black and white bars with an abrupt
If we have an object with low details (low spatial frequency, change instead. These are known as Ronchi rulings, which are based on
a square wave pattern rather than a sine-wave. Snellen visual acuity
letters are basically Ronchi rulings: high-contrast black and white let-
The MTF is extremely important when considering favorable optical
19
ters are used to assess a patient’s vision without any real assessment of
properties of an IOL, especially presbyopia correcting IOLs such as patients’ ability to perceive contrast; in other words, these black-and-
multifocal IOLs and extended depth of focus IOLs. See Chap. 27 white visual acuity charts are poor ways to assess a patient’s functional
What’s on the Menu: An Overview of Currently-Available IOLs and visual acuity. See “Modulation Transfer Function (MTF)” by Warren
Relevant Optics. Hill, MD, for more information: https://bit.ly/2MSkNYF
Since objects in the real world have both details (fre- fied by dividing the area below the measured MTF curve by the
quency) and modulation (contrast), a faithful image of that area below the diffraction-limited MTF curve; a more desir-
object should ideally have as many details and contrast as able IOL will have higher MTF values indicating its perfor-
possible. This is where the MTF helps: for a given frequency, mance for a given distance. Overall, monofocal IOLs will have
we want to know how much modulation (contrast) is present high MTF values at distance and low MTF values at near.
in the image of the object. Mathematically, the MTF is Presbyopia-correcting IOLs, especially those that rely on dif-
described by the following equation: fractive optics (e.g., multifocal, diffractive extended depth of
focus, and trifocal IOLs) will usually have lower MTF values
MTF ( u ) = Mi / Mo
at distance but better MTF values at intermediate and
near. Wavefront-modifying presbyopia-correcting IOLs, while
where MTF(u) is the MTF at a given frequency, Mi is the offering a different philosophical approach to improve interme-
modulation of the image, and Mo is the modulation of the diate- and near-vision, have very low MTF values.
object. Thus, the concept of MTF has even greater significance
If you are ever nerdy enough to look at IOL insert sheets for advanced technology IOLs. Again, if you are nerdy
(or FDA approval materials online), you may notice that enough to look at the inserts for these presbyopia-correcting
many IOLs will include these MTF graphs. The MTF of a IOLs (which you should be if you truly want to be a “refrac-
perfect IOL would be 1 (Mi/Mo = 1), but again, no such IOL tive cataract surgeon”), you may notice the inclusion of MTF
exists. Also, at some (low or high) frequencies, no image of curves tucked away in the device specifications sheet.
the object can be captured, whether by the eye or an IOL. Depending on the technology of the presbyopia-correcting
Remember our discussions on spherical aberration – we IOL, the MTF values for distance, intermediate, and near
warned you that you could never escape this concept in will vary. For example, multifocal IOLs with higher add
Ophthalmic Optics!21 The net spherical aberration of the eye powers will have better MTF values at near (compared to
is slightly positive, which increases as we age. When we do monofocal and trifocal IOLs). In contrast, trifocal IOLs will
cataract surgery, we remove whatever negative spherical have better MTF values at intermediate (compared to mono-
aberration the (cataractous) lens provided, so we further focal and multifocal IOLs).23 Ideally, a desirable presbyopia-
increase the spherical aberration of the patient’s eye. This is correcting IOL will have high “average” MTF values for all
one reason why aspheric IOLs (with negative spherical aber- distances and pupil distances. However, finding this
ration) are popular as they seek to “replace” the (cataractous) “Goldilocks” IOL remains elusive as all presbyopia-
lens’ negative spherical aberration. correcting IOLs will have better and worse performances for
Suppose we instead placed a spherical IOL (which has certain distances and pupil sizes.24 Finally, MTF values can
positive spherical aberration) during cataract surgery. The also be affected by IOL design, material, architecture, and
increased net positive spherical aberration will worsen the technology platforms. Nonetheless, despite its imperfec-
MTF and subjective visual quality. Higher power IOLs will tion, it is one “standardized” metric that can be used to assess
disproportionately worsen the MTF compared to routinely the playing field of presbyopia-correcting IOLs. Future ver-
used power IOLs; for example, a + 36.0D IOL will cause 4 sions of presbyopia-correcting IOLs will likely seek to
times worse spherical aberration than a + 18.0D improve MTF values, especially at distance, to improve
IOL. Monofocal aspheric IOLs will either improve or not patients’ subjective visual acuity.
worsen the net positive spherical aberration; therefore, the
MTF values of aspherical IOLs are much higher than the
MTF values of spherical IOLs. Defocus Curves
MTF is a popularly used and validated metric to quantify
the optical performance of an IOL.22 By using optical bench Defocus curves are of particular interest in the current cli-
equipment and an aberration-free model cornea, MTF values mate of cataract surgery, especially with presbyopia-
for given spatial frequencies (e.g., 50 and 100 lp/mm, equiva- correcting IOLs. To simplify, a defocus curve is an objective
lent to 20/40, and 20/20 Snellen letters) can be used with fixed measurement of how well a multifocal or extended depth of
pupil sizes (e.g., 3.0 mm and 4.5 mm to simulate photopic and
mesopic conditions). The IOL’s optical quality can be quanti- 23
Son HS, Tandogan T, Liebing S, Merz P, Choi CY, Khoramnia R,
Auffarth GU. In vitro optical quality measurements of three intraocular
lens models having identical platform. BMC Ophthalmol. 2017 Jun
See Chap. 14 “Physical Optics and Advanced Optical Principles”, for 29;17(1):108. https://doi.org/10.1186/s12886-017-0460-0. PMID:
21
more information regarding spherical aberration. 28662629; PMCID: PMC5492950

Pieh S, Fiala W, Malz A, Stork W. In vitro strehl ratios with spherical, 24 Santhiago MR, Netto MV, Barreto J, Gomes BA, Schaefer A, Kara-
22
aberration-free, average, and customized spherical aberration- Junior N. Wavefront analysis and modulation transfer function of three
correcting intraocular lenses. Invest Ophthalmol Vis Sci. 2009 multifocal intraocular lenses. Indian J Ophthalmol. 2010
Mar;50(3):1264–70 Mar-Apr;58(2):109–13
294 K. M. Riaz
focus IOL (MFIOL/EDOF-IOL) is correcting presbyopia by It is important to commit this to memory because patients
measuring visual acuity at a range of distances. Thus, both may sometimes ask you to write a letter regarding the legal
defocus curves and MTF curves are complementary, like status of their vision. You want to make sure that in your
peanut butter and jelly, in assessing IOL performance. noble efforts to help a deserving patient use local and federal
A defocus curve is set up by first correcting the patient’s government assistance programs for low-vision patients, you
refractive error and giving him/her whatever refractive cor- don’t inadvertently help an “undeserving” patient. Another
rection is needed to give the best possible distance visual takeaway from this definition is that a monocular patient is
acuity. This helps to eliminate any positive or negative effects not necessarily “legally blind” if he/she still has good BCVA
induced by residual refractive errors. For example, residual in the better eye. However, a patient with end-stage glau-
myopia may artificially make a given IOL test better for coma with central visual acuity of 20/50 with a peripheral
near-vision in a pseudophakic patient. After the patient is visual field ≤20° in both eyes is considered legally blind.
best corrected for distance, a consecutive sequence of
increasing minus-power lenses (starting from +1.0 to −4.0,
in 0.5D) is presented to the patient, and he/she is asked to Tests for near Vision
read the smallest line possible.
When the examiner presents these lenses, we can simulate The Jaeger chart is the most commonly used eye chart to
the patient’s vision at that particular distance. This concept is assess near visual acuity. Other charts include the Nieden
easier understood with the minus lenses: for example, the and Parinaud near charts. Depending on the model/type of
−1.0D lens will simulate vision at 100/1 = 100 cm, the card, the testing distance may vary. Letter heights are not
−2.5D lens will simulate vision at 100/2.5 = 40 cm, and the standardized, and there is no logarithmic progression of
−4.0D lens will simulate vision at 100/4 = 25 cm. letters.
In general, we see that MFIOLs with higher add powers For this purpose, a variety of standardized near-reading
(e.g., +4.0 add) will often give excellent vision at 33 cm and charts are available to serve as a better proxy for modern
closer; however, patients may lose 1–2 lines of vision (rang- optotypes distance acuity measurements, such as the Bailey-
ing from 20/30 to 20/40) when testing between 50 to 40 cm. Lovie Word Reading Chart and the Colenbrander English
Conversely, lower add MFIOLs (e.g., +2.5 or + 3.0 add) will Continuous Text Near Vision Cards, and the RADNER
often give better vision in the 33–50 cm range, while causing Reading Charts. These charts also have logarithmic progres-
1–2 lines of loss of visual acuity at 33 cm and closer. sion of letters with validated chart design, optotype size, and
Given that MFIOLs/EDOF-IOLs with different add pow- specified test distance. Moreover, these charts have continu-
ers have different defocus curves, some surgeons take advan- ous text with typeset material used such that the distance
tage of this disparity by employing a “mix-and-match” height of lower-case letters subtends 5 arcmins.
approach with presbyopia correcting IOLs. This approach Congratulations, you have just completed the visual acu-
involves placing a lower add MFIOL or EDOF-IOL in the ity chapter. It’s time to leave the DMV and never return.
dominant eye (therefore giving the patient better intermedi-
ate vision, theoretically) and a higher add MFIOL or EDOF-
IOL in the non-dominant eye (therefore giving the patient Practice Questions
better near vision, theoretically). This combination allows
the “strengths” of one MFIOL/EDOF-IOL to cover up the 1. Which of the following measurements of visual acuity is
“weaknesses” of the other. the most sensitive assessment method?
A. Vernier Acuity.
B. Minimum Separable Threshold.
Legal Blindness C. Minimum Visible Threshold.
D. Minimum Legible Threshold.
There are some definitions that you simply have to memo- 2. Which of the following statements is CORRECT?
rize. The definition of legal blindness in the United States (at A. There are 60 arcdegrees in a visual circle.
the time of this writing, April 2021) is that the best-corrected B. 360 arcdegrees make up one arcmin
vision in the BETTER eye is ≤20/200 OR the field of vision C. 5 arcmins is equivalent to 1/12th of one arcdegree
in the better eye is ≤20°. These requirements do not vary by D. 60 arcsecs is equivalent 10 arcmins
state. Driver’s license requirements do vary depending on the 3. For an observer standing at 20 feet, how many arcmins
state, so do not waste time memorizing every state’s require- are subtended by an optotype found on the 20/60, 20/100
ment for exams. However, you should know your state’s par- and 20/200 line? How many arcmins are subtended by the
ticular requirements for daytime only and unrestricted 20/15 and 20/10 optotypes?
driving for clinical practice.
4. If patient 1 (who has 20/15 vision) is looking at an object 3. Answer: Remember that for an observer at 20 feet, each
in full focus from 100 feet away, where does patient 2 optotype on the 20/20 line will subtend 5 arcmins. To
(who has 20/20 vision) have to stand to see the same determine the number of arcmins for every letter further
object in full focus? up the chart, we can take the inverse of that line and mul-
5. Patient 1 (who has 20/30 vision) can view an object when tiply it by 5 (which is the number of arcmins subtended by
standing 20 feet away from the object. From how far the 20/20 line). In this case:
away can patient 2 (who has 20/20 vision) view the same • 20/60 line = 60/20 = 3 x 5 = 15 arcmin
object? • 20/100 line = 100/20 = 5 x 5 = 25 arcmin
6. Suppose that a patient’s BCVA is 20/80 when tested on • 20/200 line = 200/20 = 10 x 5 = 50 arcmin
the Snellen eye chart in a standard exam lane. How far • 20/15 line = 15/20 = 0.75 x 5 = 3.75 arcmin
must the patient move toward the chart to see the 20/20 • 20/10 line = 10/20 = 0.5 x 5 = 2.5 arcmin.
line? 4. Answer: We can take the reciprocal of Patient 1’s vision
A. 5 feet and multiply it by the desired distance. In this case, Patient
B. 10 feet 1 has 20/15 vision, so: 15/20 x 100 feet = 75 feet away.
C. 15 feet 5. Answer: Similarly, we have to take the reciprocal of
D. 17.5 feet Patient 1’s vision and multiply it by the desired distance.
7. Which of the following statements is TRUE about the In this case, Patient 1 has 20/30 vision, so: 30/20 x
ETDRS visual acuity chart? 20 feet = 30 feet away.
A. The space between each letter on a given line is 6. Answer: These types of problems may seem confusing, as
approximately half the size of the letter, thereby there are several ways to solve them. We recommend
reducing the unwarranted effects of crowding. thinking of these problems as complicated ways of asking
B. The ETDRS uses 15 letters that have been chosen to you to solve ratio problems.
be equally difficult in viewing ability to ensure that no Since we know that the patient’s BCVA is 20/80 (when
one line is easier than the other. tested at the standard testing distance of 20 feet), we need to
C. Testing a patient’s visual acuity with the ETDRS calculate how many arcmins this patient can perceive:
chart takes less time (when compared to the Snellen 80/20 = 4 x 5 = 20 arcmins. We have to determine how close
visual acuity chart), making it the gold standard for the patient has to be in order to basically see 5 arcmins. “X”
clinical research studies. feet is the distance the patient actually needs to be at:
D. Each line on the ETDRS differs from its neighboring
line by 0.1 log units. • 20 feet/x feet = 20 arcmin / 5 arcmin
• 20x = 100, x = 5 feet
Answers At this point, we may see that we calculated 5 feet,

glance up at the answer choices, rejoice that we see “5 feet
1. Answer: Vernier acuity is the most sensitive form of (answer choice A),” and think we have solved our prob-
visual acuity assessment; by asking a patient to notice lem. But this is where these types of problems are devious.
breaks in a line segment, we can test down to the level of Notice that the question said how far the patient must
2–3 arcsecs (Answer Choice A). Minimum Separable move toward the chart. In other words, we know that the
Threshold is at a level of >3–5 arcsecs; in this method, patient needs to be 5 feet away from the chart; since he is
two objects are presented to the patient with progressively currently 20 feet away, he must actually move 15 feet
smaller space until he/she can’t distinguish any separation closer (Answer Choice C) to be 5 feet away.
between the two objects. Minimum Visible Threshold is 7. Answer: As mentioned in the text, there are several fea-
similarly at multiple arcsecs level; in this method, a target tures of the ETDRS chart worth committing to memory.
with varying brightness levels is presented to the patient The space between each letter on a given line is equal to
until the patient cannot detect the stimulus any further. the size of the letter, thereby reducing the unwarranted
Finally, the Minimum Legible Threshold is tested at the effects of crowding. The ETDRS chart uses 10 letters
level of arcmins; in this method, a patient is asked to dis- (CDHKNORSVZ). As there are 55 letters on the ETDRS
tinguish between smaller subtended visual angles (such (compared to 36 letters on the Snellen chart), visual acu-
as using letters to test visual acuity). ity testing will take longer on the ETDRS chart compared
2. Answer: A visual circle is made up of 360 degrees of arc to the Snellen chart. The biggest advantage of the ETDRS
(arcdegrees); each arcdegree can be further broken down chart is that each line differs from a neighboring line by a
into 60 arcmins; each arcmin can itself be further broken fixed logarithmic value of 0.1 log units (Answer Choice
down into 60 arcsecs. 1 arcmin is equivalent to 1/60th of D). A 3-line change is equivalent to doubling (or halving)
an arcdegree, so 5 arcmins is equivalent to 1/12th of one the visual angle, making it easier to compare visual acuity
arcdegree (Answer Choice C). across research studies.
Low Vision and Vision Rehabilitation
G. Vike Vicente
Objectives other strategies that can be offered to patients to improve

• To understand how low vision can affect patients’ lives their functional vision for activities of daily living (ADLs).
• To have a familiarity with currently available options, The authors recommend that ophthalmology trainees
including devices and training, on how to improve func- should spend at least some time (even for a few days at some
tional vision in both adult and young patients with low point in training) to first-hand observe and appreciate what
vision your local vision rehabilitation specialists do.
• To know how clinical skills, considerations, and nuances Finally, we would like to give a special thanks to Drs.
best measure vision and refract low vision patients Belinda Weinberg, OD, and Suleiman Alibhai, OD, of
• To familiarize the reader with optical and non-optical Washington, DC, for teaching us how to help our low vision
aides for near and distance tasks patients (LVPs). We could not have written this chapter with-
out their help.
Introduction
Definitions
Despite our numerous successes with clinical and surgical
rehabilitation of patients, we will inevitably be faced with There are several definitions that must be committed to
patients whose eye condition(s) cannot be improved. While memory as they are often used extensively (and sometimes
we ourselves may not be able to help them further, we should interchangeably) in the magical world of low vision
be familiar with what our low vision specialist colleagues are rehabilitation:
able to do for these patients. The skillset required for and
routinely employed by these saints is truly remarkable and • Vision disorder: This implies progressive, irreversible
inspiring – it really takes a special set of skills to patiently vision loss due to ophthalmic pathology, such as nystag-
work with this patient population. mus, aniridia, and macular degeneration. Vision disorders
As ophthalmologists, we may not be personally involved can cause vision impairment, vision disability, and vision
in the low vision rehabilitation of patients. However, we will handicap.
inevitably be the ones to diagnose and determine when • Vision impairment: This term refers to permanently
patients may not benefit from any further clinical and/or sur- reduced acuity, loss of visual field, presence of central
gical treatment. Thus, we may be the “gatekeepers” that can scotoma, and/or best corrected visual acuity (BCVA)
appropriately refer these patients to our low vision specialist <20/40 in the better seeing eye.
colleagues. While important for exams, this knowledge is • Vision disability: This term refers to a less severe form for
also extremely valuable for clinical practice. We should have vision impairment. Patients with visual disabilities may
a good understanding of various devices, tools, training, and have difficulty with vision-intensive tasks, such as seeing
the board, reading a book, bubbling a Scantron sheet, and
finding a bus.
• Vision handicap: This term refers to vision impairment or
G. V. Vicente (*)
vision disability that require low vision assistance, such
Hospital, Washington, DC, USA as preferred seating in classrooms and books on tape.
• Legal blindness: This term is perhaps the most important
e-mail: vvicente@edow.com to know. It is a standard definition for the entire United

298 G. V. Vicente
States and does not vary state by state.1 A patient is con- • Psychosocial status (including depression, anxiety, hallu-
sidered to be legally blind if the best corrected vision is cinations (e.g., Charles Bonnet syndrome, etc.), and other
<20/200 or less in the better seeing eye or if the widest psychiatric conditions)
diameter of the visual field around a point of fixation is
≤20°. For example, if a monocular patient has 20/25 On this last point, we should appreciate that vision loss
vision in his functional eye, he is not considered legally can be profoundly depressing for many patients (or exacer-
blind. As another example, a patient with end-stage bate already-existing depression). Some patients with vision
glaucoma with visual acuity 20/40 in both eyes but a cen- loss may experience hallucinations, both with insight
tral visual field of 15° in both eyes is considered legally (Charles Bonnet syndrome) and without recognition (e.g.,
blind. dementia, Parkinson’s disease). Appropriate referral to a
mental health specialist, psychiatrist, and/or neurologist may
be life-changing or even life-saving.
The Low Vision Patient (LVP)

Activities of Daily Living (ADLs)
Sometimes, the eye disease wins. As much as we ophthal-
mologists pride ourselves in treating cataract, glaucoma, While we use visual acuity to assess visual function in rou-
macular degeneration, and a myriad of other eye diseases, tine ophthalmic clinical practice, a more accurate and com-
we are painfully aware that we cannot win all eye battles. prehensive assessment of visual function of LVPs includes
This doesn’t mean that we throw in the towel when we their ability to perform everyday activities.
can’t improve a patient’s objective visual acuity. A patient Thus, activities of daily living (ADLs) is a broad term
with a vision disorder (as described in the previous section) used to describe functional vision required to perform every-
not amenable to further clinical or surgical therapy is a low day tasks of living such as cooking, grooming, reading mail,
vision patient (LVP). Note: This does not mean this is a no and using a telephone. It is difficult to correlate a visual acu-
vision patient! We can still help a LVP with correct diagno- ity in the office to the effect it has on a given patient’s ADLs
sis, empathy, discussion of further treatment options, and as other factors, such as comorbid non-ophthalmic condi-
appropriate referrals to low vision rehabilitation resources. tions, must also be considered. In order to best help a given
A LVP isn’t simply someone with <20/400 visual acuity. LVP, we must understand what specific ADLs are impaired
There are several additional factors that should be consid- due to their decreased vision. In assessing an LVP, a detailed
ered as well: history regarding specific ADLs will help us know what
devices and treatments may be offered. For example, an
• Visual field loss (central and/or peripheral scotomas) assessment of ADLs requiring distance vision and near
• Loss of contrast sensitivity vision may be a good starting point:
• Loss of color discrimination
• Glare and photophobia Near Vision ADLs:
• Reading vision for mail, books, and newspapers
While some of these can be assessed with objective tests • Near vision for household tasks such as sewing, fixing
(such as visual acuity testing, visual field testing, etc.), a sub- appliances, and cooking
jective assessment is also required. Specifically, five key • Near vision for personal grooming, shaving, and applying
(and subjective) areas should be further assessed in LVPs: make-up
• Near vision for recreational tasks such as using a fishing
• Difficulty with reading tasks (newspaper, email, financial hook or playing cards
documents, mobile phone, etc.) • Near vision for social tasks such as reading a menu at a
• Activities of daily living (see next section) restaurant
• Safety issues (reading prescription bottles, house safety • Near vision technological tasks such as using a computer,
assessment, etc.) cellphone, or handheld device
• Barriers to social participation (driving, transportation,
etc.) Distance Vision ADLs:
• Vision required for mobility, such as using public trans-
portation, walking in urban areas, reading street signs,
Driver’s license requirements for both unrestricted and daytime-only
1
train times, and (most importantly for many patients)
driving vary state by state. These should not be committed to memory
driving
for the sake of exams, but you should know your state’s requirements
for clinical practice. • Vision for watching television and movies
Low Vision and Vision Rehabilitation 299
• Vision for other recreational tasks, such as golfing, bird- Table 1 Comparing Snellen visual acuity and the corresponding
watching, etc. “count fingers” distance
Snellen equivalent Count fingers (CF) distance
Other classifications include assessing daytime/nighttime 20/8000 CF @ 1’
ADLs, color discrimination, contrast sensitivity, and glare 20/4000 CF @ 2’
20/2666 CF @ 3’
assessment. These last two items are noteworthy because
20/2000 CF @ 4’
they have an inverse relationship: if a patient has decreased
20/1600 CF @ 5’
contrast sensitivity, we may be tempted to increase the light- 20/1333 CF @ 6’
ing – but this may worsen the glare! Similarly, if a patient 20/1143 CF @ 7’
complains of glare and we intervene with decreased lighting 20/1000 CF @ 8’
or tinting, this may worsen contrast sensitivity. Finding the 20/800 CF @ 10’
Goldilocks zone between these two conditions may be an
additional challenge for the low vision specialist. calibrated for 10 feet. This can lead to more precise visual
acuity measurement.
Computer-driven tests, such as the Grating Acuity Test
Measuring Visual Function in LVPs and Grating Contrast Sensitivity test, may better evaluate an
LVP’s ability to see both the direction of a grated pattern and
Before discussing low vision aids, we must first discuss sev- its contrast, allowing objective visual acuity measurements
eral principles for measuring visual acuity and visual field in as low as 20/4000, compared to 20/1600 with current low
LVPs. vision eye charts.5
A few other methods and definitions are useful to better
evaluate visual acuity and function in LVPs:
Visual Acuity
• Contrast sensitivity (CS) is a qualitative measurement that
Given that many LVPs may have BCVA <20/400, simply may be a better predictor of visual performance than tra-
writing “<20/400” is not very helpful. While terms such as ditional BCVA. Examiners must watch for CS issues
count fingers (CF) (at a given distance), hand motions (HM), when the symptoms are worse than expected given the
and light perception (LP) provide everyday functionality, visual acuity. For example, LVPs may report needing
they too lack specificity. Remember that linear or reading stronger lighting than previous, difficulty with street
visual acuity is more useful than single letter acuity. curbs, finding dark objects on dark backgrounds, etc.
For this reason, LVPs may require a different eye chart; • Threshold print size is the absolute smallest size the
many such charts are available.2 The standard Snellen or patient can read.
ETDRS chart can also be moved closer to the LVP in order • Target acuity is the patient’s goal visual acuity (“I want to
to measure a given letter at a lesser distance. For example, be able to read this newspaper,” etc.) that may or may not
CF can be converted into Snellen visual acuity using the fol- be the same as the objective BCVA
lowing table (Table 1):3 • Critical print size is the size the patient can read fluently
Low vision specialists prefer the ETDRS visual acuity for brief periods.
chart over the Snellen as the former allows assessment of • Enlargement ratio (ER) = critical print size/target acuity.
visual acuity using logMAR notation as well as provides This is how much bigger the print needs to be for the
backlighting.4 Distance visual acuity may also be tested both patient to be able to read it.
with and without single and/or multiple pinholes, especially • Acuity reserve (AR) is the low vision specialist’s goal. A
in patients with good central retinal/optic nerve function patient’s critical print size may be 20/80, but we should
(e.g., end-stage glaucoma). A Feinbloom number chart is provide enough assistance so the patient can be an over-
commonly used as it comes in a portable spiral book and is achiever and be able to read 2–3 lines smaller. This way
they will be able to read the critical print size for pro-
longed periods of time (e.g., reading a novel, etc.)
2
For example, the Berkley Rudimentary Vision Assessment is popularly • Metric print size (M) is a common unit among low vision
used as it allows the examiner to test the LVP’s vision at 25 cm for an specialists. 1.0 M = 20/50; Snellen = newspaper print;
objective visual acuity measurement as low as 20/16,000. 2.0 M = 20/100 Snellen.
3
Modified from “How Visual Acuity is Measured,” https://lowvision.
preventblindness.org/2003/10/06/how-visual-acuity-is-measured/.
Accessed July 19, 2020 Bittner AK, Jeter P, Dagnelie G. Grating acuity and contrast tests
5
4
See Chap. 18 “Visual Acuity Testing and Assessment”, for a discussion for clinical trials of severe vision loss. Optom Vis Sci. 2011;
on the Snellen and ETDRS charts. 88(10):1153–1163
300 G. V. Vicente
• Continuous text cards may be used to measure near visual help patients as they await their low vision referral.
acuity rather than the traditional near vision card. Alternatively, some patients may not be able to access a low
Remember that linear or reading acuity is more useful vision specialist due to distance or financial barriers.
than single letter acuity. Therefore, there are some simple things that we can offer to
provide some functional benefits:
How can we put all these definitions into practice?
Let’s say a patient’s measured acuity or critical print
size, where they are able to read fluently, is 2 M (metric Illumination
print size units) at 40 cm with a +2.50D add, but their goal
(target acuity) is 0.8 M. Thus, the actual AR would be For most LVPs, simply increasing their ambient lighting
0.5 M, 2–3 lines smaller than the target. The enlargement (home or office environment) is a simple and effective way
ratio (ER) would be: to improve functional vision. A simple low vision assess-
ER = measured acuity/acuity reserve = 2 M/0.5 M = ment should include a lighting assessment and demonstra-
4X. The add power that should be offered is +2.50D × 4 = tion. Don’t panic at this physics discussion, but recall that
+10.00D. light intensity is the inverse square of distance (1/r2); simply
stated, patients may benefit from lighting sources with
incoming light that is closer and more directed toward their
Visual Field visual area of interest, especially books. For example, goose-
neck lamps are better than regular lamps as they create a
We should be quite familiar with objective peripheral visual focused “spotlight” effect (Fig. 1). Ideally, the lampshade
field testing, such as Humphrey and Goldmann visual fields. will be lower than eye level and tilted at 45° to reduce glare.
For LVPs, central visual field testing devices as macular High intensity light bulbs such as LEDs may be more useful
microperimetry may be useful to objectively locate central than traditional bulbs; however, in some patients, it may have
scotomas and the patient’s retinal point of fixation (preferred a paradoxical effect of “too much brightness.”
retinal locus, or PRL). Recall that these patients may either For a small subset of LVPs (mainly those with glare prob-
spontaneously or interventionally develop new (or even mul- lems such as patients with oculocutaneous albinism (OCA)),
tiple) PRLs. In other words, while these patients may have dimmer light bulbs with less intensity may be indicated.
poor exactly-in-the-center central vision, they may have new Remember that there is often a trade-off between glare and
PRLs slightly adjacent to the central scotoma that can be contrast sensitivity.
used advantageously for low vision rehabilitation.
Tints
Simple Interventions for LVPs
For some LVPs, as mentioned above, glare can be more
While most LVPs will benefit from a formal consultation problematic as scattered light will decrease contrast and
with a low vision specialist, there are some simple interven- visual acuity and cause discomfort from photophobia. In
tions that we can offer as ophthalmologists to immediately addition to modulating the intensity of ambient lighting,
Fig. 1 Preferred lighting. The

lamp on the right would
provide better illumination for 45°
a low vision patient
Learning optics can be fun and Contrast sensitivity (CS). Is a

improve the quality of life of our qualitative measurement that
patients. A Typoscope is a may be a better predictor of
-0.25
-1.00
simple reading shield that can visual performance than visual
help block glare from the surface acuity. Examiners must watch
of the page and help the reader for CS issues when the
stay on the correct line. help symptoms are worse than
block glare from the surface of expected given the visual
the page and help the reader acuity. Patients will report
stay on the correct line. needing stronger lighting than
they used to, trouble with
Tints curbs, finding dark objects on
For some patients, glare can be dark backgrounds.
more problematic. Light scatter
will decrease contrast, visual V.Illumination
acuity and cause discomfort. Brighter lighting is simple and
Tints can reduce disability glare effective. A low vision
by Fig. 3 0.25 D vs. 1D Jackson cross cylinder
Fig. 2 A typoscope may be helpful for patients who enjoy reading. It

functions as a masking device to block glare from the white paper on a cylinder (JCC) with +/− 1D options (instead of the usual +/−
page. In addition, it helps patients to focus on the text area of interest by 0.25D options) would be potentially more useful, whether
minimizing potentially negative effects of crowding used in a phoropter or a trial frame (Fig. 3).
When trying to refine the sphere, rather than agonizing
additional tints can reduce disability glare, for example, by over +/− 0.25D sphere increments, adding −1/+1D sphere at
selectively blocking blue light.6 Yellow, orange, and amber a time may be more effective. One clinically useful pearl to
tints may be more useful than simple dark glasses in certain determine how much sphere to add at a time may be to con-
patient populations. vert the patient’s BCVA at 20 feet to 10-feet visual acuity
and then divide the denominator by 100. For example, if a
patient’s BCVA is 20/400:
Typoscope 20/400 → 10/200 (10-feet visual acuity) →
200/100 = 2D. This patient should be offered +/− 2D sphere
Another useful tool for patients with glare is known as a
typoscope. This simple reading shield can help block glare during manifest refraction.
from the surface of the page and help the reader stay focused Remember that reassurance, patience, and compassion
on the correct line by minimizing potential effects of crowd- are needed in abundance. When scheduling these patients,
ing (Fig. 2). additional time for refraction should be planned for during
their clinic visits.
We can now divide our remaining low vision tools/strat-
Refraction in LVPs egies as “optical” (requiring glasses, lenses, etc.) or
“non-optical.”
Many LVPs may have difficulty in answering questions (“1
or 2”) during a subjective manifest refraction as they may not
be able to appreciate the differences between the presented Optical Tools and Strategies
options. For example, a patient with 20/200 due to AMD
may not appreciate 0.25D of additional cylinder presented – Near Vision and Reading Aids
one would be wasting his/her time trying to fine tune a mani-
fest refraction in such a scenario. For many LVPs, optimizing functional near visual acuity is
As a result, several considerations must be considered in even more important than distance visual acuity. As many
this unique patient population. For example, a Jackson cross LVPs may spend more time indoors/at home, improving
functional reading vision may be considered as the most
important goal of the low vision specialist. Several options to
See Chap. 16 “Construction of Glasses (Ophthalmologists as
6
consider include the following:
Opticians)”, for a detailed discussion regarding the usage of tints in
glasses.
302 G. V. Vicente
igh Power Plus Single Vision Lenses

H in prism (12 PD BI to both eyes) to decrease convergence
and Kestenbaum’s Rule demands with high power plus lenses.
High power plus single vision lenses (think “Coke-bottle” If one wants to further understand how/why Kestenbaum’s
glasses) are an excellent option as they are hands-free and rule works, read the rest of this paragraph; otherwise, skip to
provide a wide field of view for near vision tasks. These are the next section. Basically, in order to read newsprint (8
available in a range of approximately +4 to +20D lenses; point), a patient needs to have at least 20/50 linear BCVA to
higher powers may need to be custom-ordered. These lenses read at 40 cm. Note that this is linear, not single letter, BCVA
may be placed as a full-frame or half-frame (similar to a (remember the previous discussion about the importance of
bifocal) in one or both eyes. linear visual acuity measurements in LVPs). At 40 cm, a
Remember that any plus lens will exert base-out prismatic patient lacking any accommodative ability will require a
effects when patients look nasal to the optical center.7 When +2.50D lens (100/40 = 2.5). A patient with 20/100 linear
using high power plus lenses, a significant base-out effect BCVA at 40 cm will be able to read 20/50 letters at 20 cm. At
may require the use of base-in prism to decrease conver- this distance, the non-accommodating patient will need a
gence demands at near. +5D lens for assistance, (100/20 = 5), which would be the
A rule of thumb for dispensing base-in prisms: add 2 PD same power as the one determined by Kestenbaum’s rule.
more than the reading portion (whether a single vision high
power lens of a bifocal (see next section)) of the glasses. For igh Add Bifocal Segments
H
example, if an LVP is requiring a +6.00D add, we would As the term suggests, some LVPs may require additional
need to give approximately 6 + 2 = 8 PD base-in for each add power in a bifocal segment beyond what we could cus-
eye. A patient with a +10.0D add would require 12 BI prisms tomarily dispense. In general, because these patients often
over each eye. have plus-power distance vision glasses as well, round top
A downside of this option is that these glasses have a or executive style bifocal segments work best. Flat-top seg-
very short working distance and are extremely heavy. ments may not be the best choice for patients with hyper-
Furthermore, recall that when dealing with higher power opic glasses due to the debilitating effects of image
prescriptions (both myopic and hyperopic), the effects of displacement and image jump.10 If an LVP requires a myo-
vertex distance may be more impactful; a careful measure- pic prescription, a flat top bifocal segment (available up to
ment and maintenance of vertex distance is necessary, espe- +5.00D) would be a reasonable choice. Progressive add
cially when changing frames or updating an LVP’s lenses may not be well tolerated due to the “transition zone”
refraction. Finally, these types of glasses are quite and oblique astigmatism that would be increased with higher
expensive. powers; these may be considered for add powers up to
When discussing high power plus lenses, we can intro- +3.5D.
duce a favorite topic of exams (and senior attendings): The following table is a starting point reference for how
Kestenbaum’s rule. In 1953, the good Dr. Kestenbaum, in a much add power should be given to a LVP with the following
very appropriately named paper (“Reading Glasses for “starting” BCVA at 40 cm.
Patients with Very Poor Vision”),8 described how the clini-
cian can estimate the strength of a high power plus lens Required Add Chart
needed to read newspaper without accommodation.9 This
elegantly simple rule requires the clinician to measure the VA @ 40 cm with +2.50 Add needed for 20/40 Working distance
20/50 +3.00 33 cm
distance Snellen acuity for the better seeing eye, take the
20/60 +3.75 27 cm
reciprocal, and use that as the required add power for both 20/70 +4.25 22 cm
eyes. 20/80 +5.00 20 cm
For example, if the BCVA in the right eye is 20/200 and 20/100 +6.25 16 cm
left eye is 20/300, then we would apply Kestenbaum’s rule to
the right eye: 20/200 → 200/20 = 10. We would give both Remember that higher add powers will create a shorter
eyes a +10D lens, NOT a +10D, for the right eye and a +15D working distance and increase binocular strain due to the
for the left eye. Of course, we would need to give some base-
See Chap. 12 “Glasses for Written Exams”, for a discussion on bifocal

10
types, image jump, and image displacement. Recall what we have said
7
See Chap. 2 “Prisms in Ophthalmic Optics”, for a review of this topic. regarding flat-top bifocals: traditionally, it was taught that flat-top bifo-
8
Clearly, it was much easier to publish academic papers without fancy cals should not be placed in hyperopic glasses. However, in modern
and creative titles in the 1950s. optical practice, flat-top bifocals are cheaper to make, and thanks to
9
Kestenbaum A. Reading glasses for patients with very poor vision. Am advancements in laser-etching technology (edge-to-edge power), flat-
J Ophthalmol. 1953;36(8):1143–1144 top bifocals are nonetheless commonly dispensed in plus-lens glasses.
increased convergence required. Base-in prisms, as dis- will take practice – so don’t be surprised if your AMD patient
cussed previously, should be given in these cases. learns how to use loupes more effectively than you do!
“Computer” low vision glasses can also be constructed
with an intermediate add as the top portion of the bifocal and ideo Magnification and Electronic Displays
V
the near add as the bottom portion of the bifocal. (Tablets, CCTVs)
Though these devices may have traditionally been quite
igh Power Handheld Lenses (Handheld
H expensive, they have become more affordable in recent times
Magnifiers) due to cheaper technology and government assistance for eli-
Think of these as monocles for the modern age as patients gible patients. These devices can be very effective and help-
can hold them up to their eye(s) when needed (variable eye ful in this patient population. Older versions of this
to lens distance). They can also hold them near to the page or technology involved the device scanning, digitizing, and
object of interest – visualize Sherlock Holmes using a mag- reformatting written text. Due to recent advancements, this
nifying glass. These lenses are available with or without illu- process is made much faster and faithfully reproduces writ-
mination. They allow for different working distances based ten text. These devices can also be connected to the Internet,
on the power of the lens but require a steady hand. Their desktop, or phone to allow patients to read electronic texts/
narrow field of view can be increased by holding the lens newspapers, etc. Patients can customize their magnification
closer to the spectacle plane. These are available in ranges and/or desired contrast levels.
from +5 to +20D. They are especially advantageous in patients with sco-
One optics-nerd point: We have previously discussed how tomas or eccentric fixation who need high magnification
angular magnification and using a lens as a simple magnifier during reading tasks as these patients often have difficul-
(held at 25 cm from the object of interest) can be used to ties with beginning and ending of words (Fig. 4).
provide magnification.11 For most modern magnifying Remember that patients with eccentric fixation would have
glasses, because it is difficult to hold the magnifier at 25 cm, worse linear visual acuity than single letter acuity due to
it is much easier to hold it closer to the object of interest. crowding effect (this is similar to patients with amblyopia)
Therefore, magnifiers are given a “trade magnification” (Fig. 5).
power that modifies the previous “simple magnification for- Electronic devices can also incorporate speech-to-text
mula (D/4)” as follows: software both as “input” (from the patient) and “output”
(from the device) to allow patients to use their voice to
Trade magnification = ( power of the lens / 4 ) + 1
accomplish computer-related ADLs. For example, thanks to
For example, trade magnification of a +8D lens is the magic of speech-to-text software, both you and your
(8/4) + 1 = 3× magnification. 86-year-old AMD geographic atrophy patient can tell
Alexa® to download a song, order pizza, or set an appoint-
Stand Magnifiers ment on your calendar.
A stand magnifier can be placed over a text or newspaper and Commonly used electronic devices, such as computers
may work better than handheld lenses, especially for patients and tablets, now have additional built-in features for
with tremors. Advantages of these devices include availabil-
ity of extra illumination and various sizes. Disadvantages
include a fixed working distance. These are available in
power up to +50D.
Loupes for Near Vision

Close focus telescopes may be worn by patients for reading
activities. Like surgical loupes, they have a longer working
distance than reading spectacles but allow the patient to use
his/her hands for holding the reading material. Disadvantages
include a small field of view, limited depth of focus, and pre-
cise head positioning. If one recalls how long it took to learn
how to effectively work with surgical loupes during resi-
dency, now try applying that to an 85-year-old patient with
end-stage AMD learning to use loupes. It can be done, but it
11
See Chap. 8 “Magnification and Telescopes”. Fig. 4 Handheld magnifier
304 G. V. Vicente
Patients with scotomas Keplerian (astronomical) telescopes may be considered as

may benefit from they can gather more light rays; by using inverting prisms,
magnification
images can be made upright as well. The magnification is
Fig. 5 Patients with central scotomas benefit from magnification of the somewhat smaller (2–4×) and the focal length is longer.
object. Notice both gray scotomas are the same size Furthermore, they are heavier and more expensive than
Galilean telescopes, especially the inverting-prism portion.
However, the image quality is usually much better than
Galilean telescopes.
Some telescopes may have a fine-tuning dial for adjust-
able focus, similar to the operating microscope. One disad-
vantage is that the magnification provided is inversely
proportional to the field of view: higher amounts of magnifi-
cation will decrease the field of view, making them subopti-
mal for tasks that require good peripheral vision such as
driving. Another disadvantage is the decreased contrast sen-
sitivity by both kinds of telescopes.
Reverse Telescope
Fig. 6 Low vision telescope If an LVP has good central vision but significantly reduced
peripheral vision, then an off-center reverse Galilean tele-
enhanced magnification, speech-to-text, and contrast scope can be mounted on the peripheral part of the eyeglasses
adjustment. to increase/widen the peripheral field of view. Though the
use of a reverse Galilean telescope will minimize objects, it
may confer the advantage of increased peripheral vision to
Distance Vision Aids allow an LVP, for example, to go through doors more easily.
A high power (10–30 PD) base-out prism can be placed on
Distance activities of daily living to consider for LVPs the temporal portion of each lens to shift the outer field
include seeing street signs, crossing signals, wall-mounted inward (relative to the patient).13
menus, television, theater, and public transportation (bus
numbers, train times). In rare circumstances, driving may be ioptic Telescopes with Driving Glasses
B
considered depending on local state requirements for a driv- LVPs can use small, bioptic telescopes mounted on eye-
er’s license. Each state has its own minimum requirements of glasses (usually the superior portion) to help them drive
BCVA and peripheral visual fields for restricted and unre- safely. Similar to the previous option, the small telescope
stricted licenses. portion is placed away from the optical center and used
Some simple devices include binoculars and handheld intermittently when driving to improve perception of the
monocular distance vision lenses. A few other devices peripheral visual field, similar to how a rearview window is
include: used by all drivers intermittently. Though this device
requires considerable training and practice, a magnification
Telescopes of 2–6× is possible. For example, a patient may only see
Telescopes can be very effective for distance vision, me mat- 20/200 BCVA with glasses, but if they can achieve 20/70
eys.12 They can be handheld or placed in the glasses and may through the bioptic portion, this may qualify him/her for a
be placed in one or both lenses. They can be especially effec- restricted (daytime only) driving in some states. This option
tive for indoor distance activities, such as viewing a TV may be especially useful in patients with nystagmus as
screen or reading the chalkboard (e.g., a school-age patient most states allow for restricted drivers licenses with the use
with hereditary retinal disease) (Fig. 6). of bioptics (Fig. 7).
Galilean telescopes are generally preferred for LVPs: they
provide an upright, magnified (2–10×) image with a shorter
focal length. The field of view is wide and the weight of the
telescope is quite light. Additionally, they are cheaper to
make as compared to astronomical telescopes.
“Vision Aids for Impaired Peripheral Vision or Tunnel Vision,” https://
13
Recall Chap. 8 “Magnification and Telescopes”, for a discussion on

12
www.schepens.harvard.edu/images/stories/nire/peripheral_vision.pdf.
telescopes and all things related to pirates. Accessed July 21, 2020
• The device itself is quite large (4.4 mm long and 3.6 mm

in diameter) and requires a 9 mm sclerocorneal incision
(similar to an extracapsular cataract extraction wound).
At this time, there is no significant evidence to assess the

effectiveness of the IMT in improving visual acuity in
patients with late or advanced AMD.14
Another option is to create a “poor man’s” version of the
surgical IMT by creating a Galilean telescope at the time of
cataract surgery. For example, one can plan for a postopera-
tive IOL target of +10D in order to create roughly a −10D
eyepiece inside the eye (focal length 10 cm).15 The patient
can then use +5D lenses (focal length 20 cm) held 10 cm
away from the eye for 2× magnification.
Future technologies may include retinal implants and cor-
Fig. 7 Bioptic telescope
tical visual prosthetic devices; none of these devices are
available for widespread use at the time of this writing.
Surgical Options
I mplantable Miniature Telescope (IMT) Non-optical Tools and Strategies

The IMT was FDA approved in 2014 as a surgically
implanted device to potentially improve vision in LVPs with There are dozens of non-optical (think: “not glasses”) methods
end-stage AMD. The IMT was designed to enlarge objects in that can be used to help LVPs. The following is a non-
the central visual field and “project” them onto the mid/ comprehensive list of tools and strategies that can be consid-
peripheral (and presumably healthy) retina in order to ered in addition to the previously mentioned optical tools:
improve these patients’ functional vision. While the device
offers a potentially surgical option and may be improved • Devices to help with everyday tasks, such as bold ink
upon in the future, there are numerous hurdles that prevent pens, large print books, large print playing cards, large
its widespread use: print phone dials, etc.
• Services from local institutions, such as requesting utility
• On-label use of the device requires implantation at the companies to send large-print bills; requesting banks to
time of cataract surgery. Most patients with end-stage issue large print statements and checks with raised lines.
AMD are usually pseudophakic for many years (many • Referral to state agencies, assisted-living services, occu-
with open posterior capsule due to YAG capsulotomy). As pational therapy, social work, and support groups to help
a result, many potential patients don’t qualify due to their improve quality of life and independence in LVPs.
prior history of cataract surgery. While one may consider • Signature guides for legal documents.
using an IMT in a phakic patient with pattern dystrophy • Guide dogs.
or other central macular disease (North Carolina macular • Learning braille.
dystrophy, etc.), this would be an off-label use of the • Prisms (with eccentric fixation): while theoretically this
device. may make sense (shift the image out of the scotoma into
• A skilled low vision specialist trained in the rehabilitation an area of “usable” retina), use of prisms is considered
exercises necessary after implantation is crucial to a suc- controversial and not frequently used (due to conflicting
cessful visual outcome. Given the scarcity of these sorcer- evidence).
ers/sorceresses of vision rehabilitation, it may be difficult
to find a skilled and experienced practitioner. Patients
must undergo preoperative training with an external tele-
scope to determine whether they qualify or whether ade- Gupta A, Lam J, Custis P, Munz S, Fong D, Koster M. Implantable
14
quate vision can even be obtained. miniature telescope (IMT) for vision loss due to end-stage age-related
• The fellow eye must have good peripheral vision. Most macular degeneration. Cochrane Database Syst Rev.
2018;5(5):CD011140
patients with end-stage AMD usually have significant dis-
We realize that an IOL target of +10D breaks every rule of cataract
15
ease in the fellow eye as well.
surgery.
306 G. V. Vicente
• Scanning training: training patients to “find” moving It may be more difficult to assess the visual potential and
objects or objects of interest in the peripheral visual field visual field of a young child with low vision than an adult.
and indirectly focus on them. Some studies have shown A low vision evaluation may provide useful information
scanning training to be quite effective, especially for for teachers. Simple questions may include:
patients with stroke-related hemianopia visual field loss.16
• Eccentric fixation training: this strategy can be especially • What size print can the child see on the board from the
useful for young patients with central vision loss and front row (2-inch-tall letters?).
preserved peripheral retina, such as patients with Best’s • What is the child’s reading speed at 10- or 14-point letter
disease. size?
• Does the young patient have a visual diagnosis that would
Just like a certain superhero who cannot see but relies on cause them to need more time for certain visual tasks,
his heightened sense of hearing to fight evil,17 sometimes we tests, etc.?
can take advantage of the preserved sense of hearing to com- • Can reading be sustained into college years or will audio
pensate for the loss of vision.18 substitution or braille become necessary?
Auditory strategies include National Library Service for
the Blind and Physically Handicapped (NLS). Some cities The clinician should be familiar with what services the
have services wherein volunteers read the local papers and county or state can offer young patients. For example, are
LVPs can call into a toll-free local number to listen to the there pediatric low vision specialists (“vision teachers”)
news being “read aloud.” available in the local area that can work with the child? Is
Other devices and apps that have optical character recog- there an infant and toddler’s program that may help?
nition (OCR) and can read aloud to LVPs include: All of the previously mentioned options may be consid-
ered for pediatric LVPs. A few particularly effective strate-
• Stand-alone devices that can perform text to speech (e.g., gies and useful considerations in children include:
ClearReader+).
• Closed circuit TV (CCTV) e.g., Clearview+ Speech. • Glasses: the full cycloplegic refraction should always be
• Apps (e.g., Seeing AI) that will describe in audio what is given.
seen on the phone screen that includes currency, bar • Telescopes for distance with a goal of 20/40 should be
codes, faces, and emotions. considered. These may be especially useful for classroom
• Wearable – Orcam. This is a small standalone device with situations. Patients with albinism and other congenital
a camera and a speaker that is attached to frames and can retinal diseases may benefit significantly from
recognize text and faces. The user would point to a word telescopes.
on a menu and the device will read the text. • Glare control: additional modifications, such as polarized
lenses, specialized color tints, and mirror coatings may be
effective.19 Photochromic lenses may also be considered
ow Vision Rehabilitation of the Pediatric
L for select patients.
Patient • School activity modifications: for example, using yellow
paper to reduce glare or having a specialized computer
While vision loss in any patient is difficult for both the clini- monitor.
cian and the patient, it can be even more devastating in pedi- • Just like fitting glasses with kids, frequent follow-ups,
atric patients. Fortunately, vision loss in the pediatric patient adjustments. and alternate devices may need to be used as
may be especially amenable to low vision therapy. When we the child grows older.
work with pediatric patients, we need to keep in mind the
child’s understanding, apprehension, determination, and
acceptance, not to mention the parents’ attitude which may Practice Questions
range from helpful-motivated, denial, anger, to not-helpful.
1. Which of the following trial frame choices (“number 1 or
number 2”) should be offered during a refraction to a
Rowe FJ, Conroy EJ, Bedson E, et al. A pilot randomized controlled
16 patient with 20/100 best corrected vision?
trial comparing effectiveness of prism glasses, visual search training A. −1.00 D sph vs. −1.25 D sph
and standard care in hemianopia. Acta Neurol Scand. 2017; 136(4):
310–321
Again, we cannot name this superhero lest we incur copyright
17
19
infringement. Opticians)”, for additional information on glasses modifications, such

Apologies to patients with Usher’s syndrome
18
as polarized lenses, tints, and coatings.
B. −1.00 D sph vs. −1.50 D sph Answers

C. −1.00 D sph vs. −2.00 D sph
D. −1.00 D sph vs. −2.50 D sph. 1. Answer: B. Convert BCVA to 10 feet by dividing the
2. Let’s say a patient’s measured acuity (critical print size) BCVA by 2: 20/100 = 10/50. Now divide 50 by 100 = 0.5.
at which he/she is able to read fluently is 3 M (metric This represents the amount of “sphere” difference choices
print size units) at 40 cm with a +2.5D add. However, the that should be offered to the patient. A 0.25D change may
goal (target acuity) is 1.0 M. Thus, the acuity reserve not be appreciated as much by the patient. A full 1D
(AR) would be 0.6 M, which is approximately 2–3 lines change in choices may end up causing an inaccurate
smaller than the target. What add would this patient refraction. In general, the worse the patient’s best cor-
require to be able to read in a sustained, fluid manner? rected vision, the wider the choices that should be offered.
A. +2.5D add 2. Answer: D. +12.5 D add. The enlargement ratio (ER)
B. +5.0D add would be ER = measured acuity/acuity
C. +10.D add reserve = 3 M/0.6 M = 5×. The add power that should be
D. +12.5D add offered is +2.50D × 5 = +12.50D. Additional base-in
3. How much base-in prism would you include if the patient prism (14–15 PD BI) should also be given.
requires a +5.0D add? 3. Answer: C. 7 PD base-in on each lens. The amount of
A. 4 PD base-in on each lens prism required to ease extra convergence demands due to
B. 4 PD base-out on each lens very short working distance = 2D + add D (+5.0) = 7 PD
C. 7 PD base-in on each lens BI on each lens.
D. 5 PD base-in on each lens 4. Answer: C. The IMT is a potentially effective option for
4. Which of the following statements regarding optical tools phakic patients with end-stage AMD. At this time, there is
and strategies for low vision patients is TRUE? no significant evidence to assess the effectiveness of the
A. The implantable miniature telescope is an effective IMT in improving visual acuity in patients with late or
option as an IOL exchange surgery in pseudophakic advanced AMD (see Reference 14 cited in the text). A
patients with end-stage AMD. handheld telescope may be difficult to use in patients with
B. A handheld telescope magnifier is an effective option significant hand and/or resting tremors, such as in
for a patient with Parkinson’s disease. Parkinson’s patients. When dispensing high plus power
C. Glasses with telescope magnifiers are an effective lenses, base-in prisms should be given to decrease conver-
option for school-age low vision patients. gence demands.
D. When giving high plus power lenses (either as a sin- 5. Answer: B. According to Kestenbaum’s rule, the recipro-
gle vision lens or a bifocal segment), giving a patient cal of the vision 100/20 should give you the starting point
additional base-out prism is helpful to decrease the of what to offer the patient. In this case +5.0D reading
increased convergence demands for near vision. glasses. Again, the clinician should strongly consider giv-
5. If a patient has a best corrected vision of 20/100, what ing additional base-in prism (in this case, 7 PD BI prisms).
reading glasses should be offered according to 6. Answer: B. Macular microperimetry is helpful to map the
Kestenbaum’s rule? location of the central scotoma and assess the location of
A. +2.0 new PRLs in patients with central retinal disease. The
B. +5.0 definition of legal blindness in the United States as visual
C. +8.0 acuity less than or equal to best corrected visual acuity of
D. +10.0 20/200 or a visual field ≤20° around central fixation. Use
6. Which of the following statements is TRUE? of prisms has not been shown to be more effective than
A. The definition of legal blindness is defined as the scanning training in patients with hemianopias. In gen-
vision in the better-seeing eye <20/250 or visual field eral, treatment strategies to improve contrast sensitivity
<25°. involve increasing illumination; this usually worsens
B. Macular microperimetry is helpful in assessing pre- glare symptoms. Thus, treatment of both entities involves
ferred retinal locus in a patients with Best’s disease. a compromise.
C. Use of prisms to rehabilitate patients with scotomas
and/or hemianopias has been shown to be as effective
as scanning training.
D. Treatments to improve contrast sensitivity will also
help with glare symptoms.
Contact Lenses in Clinical Practice
J. Scott Samples and Kamran M. Riaz
Objectives skill, experience, and patience required to be an expert con-

• To understand commonly used terms in contact lens tact lens specialist.1
design and architecture.
• To understand the advantages, disadvantages, and trou-
bleshooting strategies for soft contact lenses, soft toric Important Definitions
contact lenses, and rigid gas permeable contact lenses.
• To have an introductory understanding of advanced con- We can group several terms used in contact lens fitting into
tact lens designs available for patients with specific visual the following categories based on architecture, materials,
needs. and surface properties.
Contact Lens Architecture

Introduction
We had so much “fun” with contact lenses in Chap. 13 that • Base curve (BC) (Fig. 1): The curvature of the posterior
we felt it was necessary to have a contact lenses chapter in surface of the contact lens, usually expressed in millime-
Part II. ters. Corneal keratometry measurements (in diopters) can
In Chap. 13 our discussion on contact lenses primarily be converted into BC notation to select an appropriately
focused on calculating the power of three types of commonly sized lens. Remember this fundamental rule: the lower
used contact lenses: soft contact lenses (SCLs), soft toric the BC value, the steeper the CL, allowing for more vault-
contact lenses (STCLs), and rigid gas permeable contact ing over the corneal surface and avoidance of the central
lenses (RGPCLs). You may wish to review this previous corneal apex.2
chapter (or consult it) as you proceed through this chapter. • Diameter (DIA): The total edge-to-edge length of the
Instead, this chapter will focus on the role of contact contact lens. SCLs will generally have a longer DIA than
lenses in clinical practice, with minimal discussion on prin- the corneal diameter as they will encompass the entire
ciples and steps of fitting a given type of contact lens. We cornea (range 13–15 mm). On the other hand, RGPCLs
will survey the various kinds of available contact lenses, will have a shorter DIA as they will be fit within the cor-
including clinical applicability, strengths, and weaknesses of nea (range 9–10 mm).
each lens. Some of you may look at this topic and think to • Peripheral curve: This curve is the secondary (peripheral)
yourself: but I don’t even dispense contact lenses! I refer curve of the contact lens that is different from the
them to an optometrist or a contact lens specialist! While BC. Given that the cornea is flatter in the periphery than
that may be true, a basic understanding of contact lenses is the center, the peripheral curve will also be (generally)
essential for board exams and clinical practice. If nothing
else, hopefully, this chapter will make you appreciate the As a cornea specialist, this author (KMR) certainly appreciates the
1
skill of expert contact lens specialists like the co-author (JSS) in dra-
matically improving visual acuity in complex corneal and anterior seg-
J. S. Samples (*) · K. M. Riaz ment pathologies.
Dean McGee Eye Institute, University of Oklahoma, Recall our discussions of the “SID” rule in Chap. 13 “Contact Lenses
2
Oklahoma City, OK, USA for Written Exams”.

e-mail: Scott-Samples@DMEI.org

310 J. S. Samples and K. M. Riaz
f • Resistance to foreign body/deposits forming on the con-

tact lens.
e • Transmit oxygen (and nutrients) to the cornea.
• Allow for adequate exchange of tears between the contact
lens and the cornea.
Several materials may be used in the construction and

design of contact lenses, including:
b • Glass: Leonardo da Vinci was the first to describe the idea

of using a glass lens with a funnel for pouring water (and
c therefore altering its power) to be placed on the sclera.
Later, Sir John Herschel (1823) described the idea of
a grinding a glass lens to be fit onto the surface of the cor-
nea using the patient’s eye as a model and using a gel to
create a protective barrier between the contact lens and
d the patient’s eye. Through the late nineteenth century, this
concept began to be refined and used primarily to protect
diseased eyes rather than for refractive correction. In
modern times, these facts are interesting for historical
appreciation only. If you ever encounter a patient with a
glass contact lens, he/she may be a time-traveler from the
past (or the future?).
Fig. 1 Contact lens architecture terms: (A) Peripheral curve; (B) base
curve; (C) sagittal depth; (D) peripheral curve width; (E) optical zone; • Plastic (polymethylmethacrylate, PMMA): PMMA con-
(F) diameter tact lenses, though highly durable, are relatively imper-
meable with essentially no oxygen permeability or
transmissibility. The tear pump underneath the lens is the
flatter than the BC. The peripheral curve is usually not only source of oxygen to the cornea with these lenses.
considered in standard fitting, given that the BC will pri- These, too, have fallen out of use in modern times.
marily determine the fit of the given contact lens. The • Hydrogel polymers (hydroxyethylmethacrylate [HEMA]
peripheral curve may need to be adjusted to ensure a good and silicone hydrogel): These are the most commonly
fit in advanced cases. used materials for SCLs, especially silicone hydrogels
• Optical zone: The central portion of the contact lens – this (introduced in 1998), given several factors:
is where all the refractive action happens as the curvature –– Favorable oxygen permeability (silicone atoms create
of the anterior surface primarily determines the refractive pores favoring movement of oxygen)
power of the contact lens. –– Less water content (within the SCL) that allows for
• Sagittal depth (a.k.a. vault): Technically, this refers to the better lubrication of the ocular surface3
distance from the center of the posterior contact lens to a –– Improved patient comfort
line drawn perpendicular to the edge of the lens. For –– Resistance to deposits forming on the SCL
SCLs, the vault is negligible, but for RGPCLs, the vault –– The ability for extended-wear in select patients
must be considered in the context of the resulting tear lens • Cellulose acetate butyrate (CAB): Used primarily in
(and its power). RGPCLs, this material has better oxygen permeability
than PMMA but is still much lower than silicone hydro-
gels. Several modifications can be made:
Contact Lens Materials –– Addition of silicone acrylates: PMMA/silicone can
increase oxygen permeability
An ideal contact lens material should incorporate certain
favorable qualities:
This may seem counterintuitive but if there is less water within the
3
• Comfortable for patient wear yet durable and resistant to SCL, then the SCL will be much thinner and much more comfortable.
A higher water content SCL will draw out the eye’s tears, thus making
tearing and scratching.
them more prone to dehydration; they are also much more prone to
• Surface should allow for optimal lubrication. evaporation from air conditioning and periods of low blinking (com-
• Minimal movement with blinking. puter use, reading this entertaining optics book, etc.)
Contact Lenses in Clinical Practice 311
a b c
Fig. 2 Visual representations of oxygen diffusion coefficient (D) and low solubility coefficient, while Panel c shows a material with high
solubility coefficient (k). Panel a shows the speed of oxygen molecules solubility coefficient. The Dk value is a measurement of oxygen perme-
through a material. The solubility coefficient (k) can be understood as ability in a given material. A favorable contact lens material will have a
the volume of gas dissolved in a material. Panel b shows a material with high Dk value
–– Fluorosilicone acrylates: Addition of fluorine increases very high Dk/t values (usually >100) compared to other
oxygen permeability but renders the RGPCL more materials, including other types of hydrogels.
fragile. Additionally, fluorine allows mucin to form on • Wetting angle: This term refers to how water can effec-
the RGPCL, thereby attracting tears and enhancing tively spread over a lens surface (wettability). Therefore,
surface lubrication. a favorable contact lens should have a low wetting angle
because it means that water can more easily “flow” across
the entire lens surface.
Contact Lens Surface Properties
In the previous section, we discussed several favorable prop-

erties of contact lens materials. These materials are espe- ommon Contact Lens Types: Clinical
C
cially advantageous because of specific properties of the Applications and Troubleshooting
contact lens surface(s):
Soft Contact Lenses (SCLs)
• Dk: Oxygen permeability of a lens material (Fig. 2). D is
the oxygen diffusion coefficient for a given material, and In clinical practice, soft contact lenses (SCLs) are the most
k is the solubility coefficient of oxygen for a given mate- commonly prescribed contact lenses. Advantages of SCLs
rial. In general, these terms are used together as a single include comfort, cost, disposability (especially with daily
entity. A favorable contact lens should have a high Dk wear SCLs), availability, and adaptability for patient usage
value. (ranging from refractive to therapeutic). Disadvantages
• Dk/t: Oxygen transmissibility of a lens material, where t include the inability to correct significant astigmatism, fra-
is the thickness of the lens material. We can see that low- gility, and potential for misuse.4
ering the thickness of the lens will therefore increase the SCLs are usually the first-line choice for most contact
Dk/t value (Fig. 3). By convention, Dk/t values are calcu- lens wearers. Overall, the Dk (and Dk/t) values of SCLs are
lated for a −3.00D power contact lens and listed for each quite high (70–140), and thus they offer significant advan-
lens brand. Myopic contact lenses will generally be thin-
ner in the center compared to hyperopic contact lenses;
thus, even if both are made of the same materials, a Though, theoretically, all contact lenses may be abused if in the wrong
4
hands. The popularity and ease of availability of SCLs may falsely skew
−4.00D SCL will have a higher Dk/t value as compared to
the “abuse” potential, though any cornea specialist will attest that SCL
a +4.00D SCL. Thus, a favorable contact lens should abuse is the number one cause of clinically encountered corneal
have a high Dk/t value. Modern silicone hydrogels have infections.
a b
Fig. 3 Dk/t measures the oxygen transmissibility of a lens material. If given two lenses made of the same material, the thinner lens (Panel b) will
have a higher Dk/t value than the thicker lens (Panel a). A favorable contact lens material will have a high Dk/t value
tages in patient comfort and ocular surface lubrication. tion will help the practitioner choose and adjust an SCL’s BC
Different models have varying amounts of the previously and DIA.
discussed features (such as Dk, wettability, etc.). However, The most commonly available power ranges for SCLs are
what works in one patient may not work well in another as follows:
patient. Therefore, different models may be tried before the
final prescription in a patient. The brand name of the contact • −6.00D to +6.00D in 0.25D steps
lens is a vital part of the prescription! In addition, clinicians • −6.50D to −12.00D in 0.50D steps
may find that certain brands work well for certain patients, • +6.50D to +8.00D in 0.50D steps
while another brand may work well for another type of
patient. Contact lens practitioners often have to adopt a Additional power ranges may be custom ordered from a
“trial-and-error” approach when fitting a patient with SCLs. given SCL manufacturer if needed to correct extreme refrac-
A complete discussion about every available SCL brand/ tive errors.
model is beyond the scope of this text.
SCLs may be worn as daily wear (disposable, removed at ssessing and Troubleshooting SCLs
A
night time), 1–2 times weekly, or monthly types, depending After performing necessary calculations for the SCL power5
on the SCL manufacturer and model. In modern practice, and selecting an SCL model, further assessment is done as
daily disposable SCLs should be recommended to patients to follows:
avoid risks associated with improper storage, cleaning, and
disinfection associated with extended wear SCLs. The 1. Place the SCL on the patient’s cornea without fluorescein
price point of daily disposable SCLs has dramatically and assess the fit. An optimum SCL fit will be comfort-
dropped in recent years, making them comparable to other able for the patient, have good centration on the cornea
SCLs. Monthly wear SCLs are still the most commonly pre- with approximately 1.0 mm overlapping of the limbus on
scribed type of SCL. However, given the high risks associ- either side, and 0.25–0.5 mm movement with each blink
ated with extended wear SCLs (and patient abuse of CLs!),
daily disposables are rapidly increasing in popularity as a
lens of choice for most practitioners in recent years. This was discussed in Chap. 13, “Contact Lenses for Written Exams”.
5
Additionally, a number of online calculators and mobile phone apps are

Most SCLs are available in select stock BC and DIA
also available to make this calculation of converting the MRx with ver-
sizes. As discussed in Chap. 13 “Contact Lenses for Written tex distance adjustment to SCL power easier in clinical practice (unfor-
Exams”, keratometry measurements and slit-lamp examina- tunately, not allowed for exams).
in primary gaze. This is sometimes described as “light Additional power ranges may be custom ordered from a
3-point touch” as the SCL lightly touches the corneal given STCL manufacturer if needed to correct extreme
apex and the limbus at both sides. refractive errors.
(a) The SCL may be either too flat (loose) or too steep Recall that STCLs are designed so that the contact lens
(tight). has minimal movement while on the patient’s cornea. If the
2. To adjust the fit, we can either change the base curve or STCL moved significantly, the cylinder correction would be
the diameter: lost or negatively affected.
(a) In order to steepen the lens: increase the diameter or Several additional features of an STCL (as compared to
decrease the base curve. an SCL) include:
(b) In order to flatten the lens: decrease the diameter or
increase the base curve. • Prism ballast and extra weight on the STCL: This allows
(c) Mnemonic: “Call SID if you have a flat tire”: If the better alignment and stability of the STCL, especially in
lens is flat, we have to steepen it. In order to steepen the presence of significant corneal astigmatism.
an SCL, you can increase the diameter. If you can • Thinned out upper and lower edges of the STCL: this
remember that silly mnemonic, you can figure out the allows better contact with the upper and lower eyelids to
other three relationships. provide a more secure and comfortable fit.
Other factors to consider during the evaluation include:

ssessing and Troubleshooting STCLs
A
• Assessing vision: If the visual acuity with the SCL is not Similar fit/comfort/movement parameters that we discussed
acceptable, over-refraction may be necessary. If you have for SCLs can be applied to STCLs.
done the calculation correctly, the chosen SCL power Several other factors to consider include:
should be within ±0.75D of the calculated power. If not,
further examination or repeat calculation is necessary to • Note that the refractive cylinder is a combination of
account for the discrepancy. corneal (keratometric) and lenticular cylinder. If a
• Comfort: The patient should barely feel the SCL, if at all. patient is fit with an STCL but still demonstrates refrac-
For first-time SCL wearers (or switching to a new brand), tive cylinder, there is likely an additional (uncorrected)
the patient may benefit from leaving the office and return- lenticular cylinder present. For the sake of complete-
ing in a few hours to “test drive” the SCL before ness, it is also possible that the STCL has rotated “off
committing. axis.” For example, if a patient has MRx: -2.50 + 1.50
• Wetness: There should be an even tear film distribution of x 90 and is fitted with an STCL, but over-refraction
the SCL surface. Sometimes changing brands may be shows an additional 1D cylinder, there is likely lenticu-
necessary. If multiple brands are inadequate, we must lar cylinder that neutralizes the corneal cylinder to a
evaluate for dry eye syndrome/ocular surface disease. certain degree. In this case, the patient may be better
off with a simple SCL (rather than an STCL or an
RGPCL).
• It may take longer for a patient (especially a first-time
Soft Toric Contact Lenses (STCLs) wearer) to adjust to STCLs compared to SCLs. Additional
hand-holding and return visits may be necessary before
STCLs are available in daily, 2-week, and monthly wear abandoning a particular STCL model.
options. They are an excellent option to correct 1–2.5D kera-
tometric astigmatism.6 In addition to choosing an appropri-
ate BC and DIA, the most commonly available power ranges
for STCLs are as follows: Rigid Gas Permeable Contact Lenses (RGPCLs)
• −6.00D to +6.00D in 0.25D sphere steps; cylinder Please see Chap. 13, “Contact Lenses for Written Exams”,
options: −0.75D, −1.25D, −1.75D, −2.25D. for a full review of the calculations involved in converting
• −6.50D to −9.00D in 0.50D sphere steps; cylinder a patient’s manifest refraction with vertex correction to
options: −0.75D, −1.25D, −1.75D, −2.25D. RGPCL power selection. You may especially want to
• STCLs axis values are available in 10° increments. review the concept of the tear-lens and the “SAM-FAP”
rule.
For astigmatism greater than this, an RGPCL or scleral lens may be
6 RGPCLs predate the widespread popularity of SCLs.
required. RGPCLs fixed a flaw in previous iterations of hard contact
a b c
Fig. 4 RGPCL fluorescein staining patterns, Part I (frontal view and contact with the peripheral cornea allowing for pooling of the fluores-
cross-section view). Panel a shows a good fit with uniform distribution cein peripherally (green pooling). Panel c shows a steep fit: the contact
of fluorescein staining underneath the RGPCL. Panel b shows a flat fit: is extremely tight on the peripheral cornea, preventing peripheral pool-
notice that the RGPCL is resting on the central cornea with minimal ing and leading to fluorescein pooling in the middle
lenses. While these lenses (usually made of PMMA) patterns may be observed. Figure 4 shows commonly-
improved patients’ vision, the near-complete lack of oxygen encountered RGPCL staining patterns.
permeability led to significant ocular surface issues. The
“gas permeable” modification to hard (rigid) lenses allowed • An ideal staining pattern will confirm a good fit with min-
them to be worn without unwanted side effects. Thus, the imal apical clearance (Panel a). As fluorescein will freely
term RGPCL is somewhat of a misnomer because SCLs also diffuse under the RGPCL, a uniform “sea of green”
allow for oxygen permeability and transmissibility (the should be observed without any significant intensely
previously discussed Dk and Dk/t). In fact, the contact lens green or black areas.
community usually refers to “rigid gas permeable” contact • If the RPGCL fits too flat (Panel B), then this means that the
lenses as simply “gas permeable (GP)” lenses given the neg- center of the RGPCL and the center of the cornea are making
ative perceptions, historically, with the term “rigid.” extreme contact such that no fluorescein can enter under-
Nonetheless, we will use RGPCLs as a term that encom- neath the lens (central black area). Instead, the fluorescein
passes all hard contact lenses. can freely coat the cornea's peripheral ring where the RGPCL
The beauty of RGPCLs lies in their ability to reshape the does not fit well. This staining pattern appears like a “green
tear film, especially in the presence of an astigmatic or irreg- donut,” with a peripheral green ring and central black hole.
ular cornea, into a spherical shape on the corneal surface. As • If the RGPCL is fit too tight/steep (Panel c), then this means
we have discussed previously (and extensively), the role of that the center of the RPGCL is so far away from the center
the tear film in visual acuity cannot be understated. RGPCLs of the cornea that all the fluorescein is pooling centrally;
can normalize the corneal surface and effectively neutralize since the peripheral cornea and RGPCL are making
corneal astigmatism. All else equal, RGPCL wearers often extreme contact, no fluorescein accumulates peripherally.
prefer these contact lenses over SCLs, as RGPCLs usually This staining pattern appears like a “black donut,” with a
provide sharper and clearer vision. peripheral black ring and central green hole. This pattern is
RGPCLs are generally smaller than SCLs; as a result, they the opposite of the pattern seen in Panel b.
allow for more exchange of tears under the lens with each
blink. Modern RGPCLs are made from a firm plastic with Additionally, several unique staining patterns may be
minimal water content; as a result, they are much more dura- seen in specific patient populations (Fig. 5):
ble and long-lasting than SCLs. Somewhat paradoxically, a
good fitting RGPCL can be much more comfortable than an • In patients with significant against the rule (ATR) astig-
SCL, especially in patients who have worn them for years.7 matism (Panel a) and with the rule (WTR) astigmatism
One critical step in fitting RGPCLs is assessing RGPCL (Panel b), the steep meridian is horizontal and vertical,
fit with fluorescein staining at the slit lamp. Several staining respectively. Fluorescein will accumulate in the steep
areas: thus, it will accumulate horizontally in a “green
bowtie” pattern in ATR astigmatism and vertically in a
Think back to all those times in the clinic when you have seen an
7
elderly patient who presents for cataract surgery but has worn RGPCLs “green hourglass” pattern in WTR astigmatism.
for 30+ years. These patients are usually quite happy and then unhappy • In patients with oblique astigmatism (Panel c), the
when you tell them that they have to stay out of the RGPCLs for at least RGPCL will primarily “rest” on the flat meridian; there-
3 weeks prior to biometry measurements (with some practitioners rec-
fore, the fluorescein will pool in the areas of the steep
ommending an additional week for every decade of RGPCL use).
a b c
Fig. 5 RGPCL fluorescein staining patterns, Part II. Panel a shows a based on the location of the steep and flat meridians. Panel c shows a
patient with ATR astigmatism: since the steep meridian is along 180 patient with oblique astigmatism with the steep meridian at 70°: thus,
degrees, the RGPCL is making contact with the cornea along the verti- the RGPCL will rest on the flat meridian (160°). Panel d shows apical
cal meridian (black) where no fluorescein accumulates. This allows for compression in a patient with keratoconus. The RGPCL is touching the
pooling in the steep horizontal meridian (green). Panel b shows WTR bowed-out cornea inferiorly (black area) as the fluorescein pools in the
astigmatism: an opposite staining pattern is seen (compared to Panel a) rest of the cornea
meridian. For example, if a patient with oblique

astigmatism (steep meridian 70°) was fit with an RGPCL,
the staining pattern in Panel c may be seen.
• In patients with corneal ectasia, the area of maximal cor-
neal protrusion will make contact with the RGPCL and
prevent staining in this area. Panel D shows a typical
staining pattern in keratoconic cornea (inferior steepen-
ing) fit with an RGPCL.
In addition to the previously discussed rules on fitting the

RGPCL (remember, we usually want to fit slightly steeper
than the flattest K), we also have to consider how the RGPCL
physically fits with the eyelid(s). An ideal fit is known as an
apical alignment fit (Fig. 6), wherein the upper edge of the
RGPCL fits entirely underneath the upper eyelid.8 This type
of fitting allows the patient to comfortably blink without
“touching” the edge of the lens with each blink.
Several modifications can be made for extreme powers of
RGPCLs. For example, a high minus-power RGPCL may
have a considerable thickness at the edge that may interfere
with eyelid movement (e.g., the patient may complain that
the RGPCL gets “stuck” to the upper eyelid constantly). In
this case, we can ask the optical lab to bevel the lens edge
(grind the thick lens edge into a thinner) into a shape known
as a “lenticular bevel” (Fig. 7). Similarly, a high plus RGPCL
may be too thin at the edge of the lens (compared to its cen- Fig. 6 An ideal fit for an RGPCL is to have an apical alignment fit
ter), and thus, the RGPCL may not make enough contact wherein the upper edge of the RPGCL fits comfortably underneath the
upper eyelid
Some practitioners may also refer to this type of fit as “upper lid
8
attachment” fit.
a b
Fig. 7 A high minus RGPCL may be modified with a lenticular bevel to decrease friction with the upper eyelid (Panel a). A high plus RGPCL that
rides low on the patient’s cornea may be modified with a flanged lenticular cut to increase contact with the upper eyelid (Panel b)
with the upper eyelid. In this case, we can ask the optical lab Patient Education
to thicken the lens edge into a shape known as a “flanged
lenticular cut” (basically make the lens more minus (thicker) This section may seem unnecessary because most of this is
at its edges). “common” sense information learned during training.
Rarely, an interpalpebral (or central) fit may be necessary: However, especially for exams, this section serves as a con-
in this option, the RGPCL will have an extremely small solidated, comprehensive laundry list of information that is
diameter and rest in between the upper and lower eyelids useful for fitting any type of CLs:
(without any contact with either eyelid). This fit is slightly
more uncomfortable than an apical alignment. It may be con- • Educate the patient regarding proper contact lens hygiene:
sidered in special situations, such as extreme hyperopes or Discussion of simple factors such as washing hands thor-
unique anatomy (e.g., high upper eyelids [blepharoplasty oughly before touching contact lenses; disposal of contact
gone wrong!]). lenses cases at periodic intervals; not reusing (or “topping
An RGPCL should be sufficient to correct corneal astig- off”) contact lens solution; use of hydrogen peroxide
matism most of the time. However, there may be situations solution for extended-wear soft contact lenses; etc.
where residual astigmatism is detected on an over-refraction • This cardinal rule of contact lens hygiene deserves empha-
even after placing an RGPCL. This “unruly” residual astig- sis: Patients should be strongly educated NOT to sleep or
matism may be due to the posterior corneal surface or len- swim with contact lenses! Even if the contact lens box (or
ticular astigmatism. For these situations, special RGPCLs another eye care provider) tells them it is OK to wear the CL
with a “back surface toric” (to match the corneal surface) and overnight, we should always remind patients that removing
a spherical anterior surface may be warranted. Furthermore, the contact lens is always the safest and recommended
“bitoric” RGPCLs (wherein both the anterior and posterior action. Remember, we are allowed to break this rule to treat
surfaces of the RGPCL have cylinder power) may be needed corneal disease (such as epithelial defects, etc.), but this
in advanced cases. requires topical antibiotics for infection prophylaxis.
• Another cardinal rule: Patients should NOT use their own significant than the anterior segment pathologies, and
saliva to “re-wet” the contact lens!9 “Homemade” and additional surgery may not yield many benefits.
“organic” contact lens solutions are also a definite
no-no. Using tap water is even more of a no-no.
• Educate the patient on proper insertion and removal of
contact lenses. A demonstration is usually required for Advanced Contact Lens Designs
first-time contact lens wearers.
• Remind the patient regarding contact lens replacement Presbyopia Correcting Contact Lens Options
schedules. SCLs should be changed per manufacturer rec-
ommendations. RGPCLs should be replaced yearly. Recall from our previous discussions that contact lens-
• Review signs and symptoms of contact lens-related eye wearing patients may face additional advantages or disad-
emergencies. vantages as they approach presbyopic age. For example,
• Arrange for regular follow-up appointments. Well-fitting myopic contact lens wearers may struggle to read due to
SCLs can be evaluated on a schedule determined by the pro- increased accommodative demands while wearing SCLs.
vider. RGPCLs, STCLs, and specialty lenses (discussed Conversely, hyperopic contact lens wearers may report an
below) should be evaluated on the eye at least annually. easier time reading in contact lenses (compared to their
glasses) due to decreased accommodative demands.
A simple solution to presbyopic contact lens wearers is
Miscellaneous Troubleshooting to simply give them reading glasses, march them out of
your office, and tell them to return only when their cata-
A few other points may be considered: racts have worsened. However, two other options may be
considered:
• Contact lenses are described by their rear vertex power.
Usually, the power of a contact lens may be found on the Monovision with contact lenses With monovision, the
manufacturer’s box. In certain situations, however, the idea should be to ascertain the dominant eye first and cor-
clinician may need to determine the power of a given con- rect it fully with a contact lens. The non-dominant eye can
tact lens. RGPCLs are easily checked by placing the back be set for residual -1.50 to -2D myopia, depending on a
of the lens in the nose cone of a lensmeter (See Chap. 17 patient's intermediate/near vision needs. Remember never
“Optical Instruments and Machines”). This can also be to assume that the right eye is the dominant eye and the left
done for SCLs/STCLs but requires an additional liquid eye is the non-dominant eye: you must ascertain eye domi-
chamber with an adjustment for the index of refraction nance using simple in-office tests. Several monovision con-
• An RGPCL may also be used for diagnostic purposes. The tact lens trials may be necessary before finding a
tear lens can fill in corneal irregularities for patients with combination that works for each patient. Remember that
irregular corneas (corneal ectasia, corneal scars, corneal monovision will cause a loss of binocularity and decreased
thinning, etc.) as the anterior surface of the RGPCL is depth perception, so this option may not work for all
evenly coated with tears to create a more stable air-tear patients. Patients with intermittent strabismus and stereo-
film interface. Over-refraction can then be done to deter- acuity should avoid monovision as this can worsen their
mine whether the cause of decreased visual acuity is due to ability to fuse. Patients who do not have binocularity may
the cornea or other pathology. RGPCL over-refraction is be good candidates for monovision.
especially useful when multiple ocular pathologies (e.g.,
aphakia, retinal scarring, etc.) are present, and the clini- One trick used by some practitioners to calculate the start-
cian is deciding whether anterior segment surgery may ing power of the contact lens for the non-dominant eye is as
benefit the patient. If RGPCL over-refraction significantly follows: add the spectacle near power to the sphere power
improves a patient’s vision, then further surgery (e.g., cor- and then add additional −0.50D to get the final contact lens
neal transplant, secondary lens implant, etc.) may be con- power. For example, if a patient wears glasses of −4.00D
sidered as it confirms that the cornea/ocular surface is sphere with +2.00D add, then we can calculate the near eye
causing the decreased vision. If RGPCL does not improve contact lens power as follows: −4.00 + 2.00 + (−0.50):
the vision, lenticular or retinal pathologies may be more −2.50 D. We realize this basically leaves the patient with
approximately −1.50D myopia, which is what we stated at
the beginning, but this rule makes it sound official and
One of the authors may or may not have done this during his high
9
sophisticated. Of course, the final power of the CL (for both
school years and amazingly never developed an eye infection until he
learned about contact lens basics during an ophthalmology rotation and eyes) can be adjusted as needed depending on the
realized how lucky he had been his entire life. patient’s reading distance preferences.
a b
Fig. 8 Multifocal (bifocal) contact lenses, alternating vision style. (a) Inferior near add segment. (b) Central near add segment
Multifocal contact lenses (MF-CLs) several options may MF-CLs may also be found in daily and monthly varieties
be considered for this patient population: in a similar range of distance powers as previously discussed
SCLs. The add power may be described as “low/medium/
• Multifocal (bifocal) contact lenses, alternating vision style high” or may be numerically listed: +1.00D, +1.50D,
(Fig. 8): One option involves placing the add power as a +2.00D, +2.50D add. Some designs may incorporate addi-
“segment” in the inferior portion of the lens (Panel a). When tional ring(s) with additional near/distance powers in the
the patient looks down to read (similar to bifocal segments center. MF-CLs usually require multiple visits and adjust-
in glasses), he/she will look through the bottom portion of ments. A significant number of patients will not tolerate
the contact lens. Another option is to place the add power in MF-CLs for various reasons: it is important to warn patients
the central portion of the lens so that when the patient wants during the “test-drive” phase that this may occur.
to read, the pupil will constrict, and they can focus through
the central (“near”) portion of the contact lens. The pupil
will dilate when the patient wishes to see in the distance, Scleral Contact Lenses (ScCLs)
and they can focus through the outer ring (“distance”) por-
tion of the contact lens. A variant of this option involves Recently, ScCLs have gained much interest due to their ver-
reversing the concentric portions (i.e., the central portion for satility and effectiveness in various clinical situations. This
distance vision, the peripheral portion for near vision). remains an area to monitor closely as future developments
• Multifocal contact lenses, simultaneous vision style with this technology are very likely. ScCLs are made of a
(Fig. 9): These can be used in both SCLs and RGPCLs. rigid gas permeable material; thus, they are technically
Like a multifocal intraocular lens, there is a continuous RGPCLs, just as the corneal RGPCLs we discussed ear-
range of near powers present at various portions of the lier. If we wanted to be very specific, we could call them
lens. As a result, the patient will experience some blur due scleral RGPCLs, but since we refer to them as “scleral con-
to incoming images from both distance and near. Different tact lenses” in clinical parlance, we will refer to them as
add powers may be considered as well, with lower add ScCLs in our discussion as well.
powers for the dominant eye (to give more distance and Think of ScCLs as giant corneal RGPCLs with similar
intermediate vision) and higher add powers for the non- materials and polymers. They are beneficial for the following
dominant eye (to give more near vision) in a “mini- situations:
monovision” strategy.
Optic
Haptic Haptic
Transitional Transitional
Fig. 10 Components of a scleral contact lens: central optic, peripheral

haptic, and transitional zone
allow for some vaulting of the ScCL over the cornea to

allow for an adequate tear film reservoir
• Peripheral haptic (outer edge design): rests with the
scleral surface
• Transitional zone (limbal zone): connects the central
optic with the peripheral haptic and vaults over the
limbus
Fig. 9 Multifocal contact lenses, simultaneous vision style. Different
add powers are found throughout the contact lens yielding simultaneous
near and far vision ScCLs typically have a large diameter (18–24 mm);
smaller variants, known as semi-scleral lenses, are also avail-
able. However, fitting is much more difficult because the
• Corrections of high quantities of regular and irregular practitioner has more parameters to consider. A complete
astigmatism (e.g., corneal ectasia, post-penetrating kera- discussion of nuances of ScCL fitting is beyond the scope of
toplasty, etc.) this text and is best left to an experienced practitioner.
• Visual rehabilitation in the presence of corneal scars (post However, several considerations should be kept in mind:
RK scars, post-infectious scars, etc.)10
• Treatment of ocular surface disease requiring continuous • There is no one-technique-fits-all method for fitting
lubrication (advanced dry eye disease, etc.) ScCLs can ScCLs. Every manufacturer has a guide for their design,
treat the disease and improve the vision for some patients and not every ScCL can be adjusted similarly among the
with advanced dry eye disease. various manufacturers.
• Protection of the ocular surface (e.g., non-healing epithe- • A well-fit ScCL does not move much, if at all. Most
lial defects, neurotrophic keratopathy, distichiasis/ designs involve a sealed off edge with no tear flow under
trichiasis) the ScCL. This requires a “Goldilocks” fit of the ScCL:
• Management of limbal stem cell pathology: as the ScCL tight enough to avoid movement but not too tight to cause
vaults over the cornea, it can protect the limbal niche conjunctival ischemia and blanching. If the ScCL is too
microenvironment, provide lubrication, and improve flat, the ScCL will have excessive movement with blink-
patients’ vision11 ing, cause physical irritation, and allow for unwanted
• Treatment of Type A personalities: patients who are tear-fluid exchange.
unhappy with both SCLs and RGPCLs • The patient will have to “fill” the ScCL with sterile saline
or specially approved solutions (e.g., ScleralFil [Bausch
An ScCL consists of three main components (Fig. 10): and Lomb] and Nutrifill [Contamac Solutions]).
• The ScCL itself has a toric profile: when fitting the ScCL,
• Central optic: The size and shape of the central optic will a specific portion of the ScCL may require additional
determine corneal clearance. The base curve is chosen to steepening while flattening the portion 90° away.
• While a well-fit ScCL can help treat limbal pathologies,
an ill-fitting ScCL can cause compression on the limbus,
For these two reasons, ScCLs are a cornea specialist’s best friend.
10
leading to unwanted limbal stem cell deficiency and/or
Grodsky JD, Doshi R, Riaz KM. Medical management and visual
11
rehabilitation of limbal niche dysfunction. J Cataract Refract Surg. corneal neovascularization. Similarly, if the ScCL is too
2020;46(2):312–316 loose at the limbus, it may inadvertently cause conjuncti-
val prolapse underneath the lens and onto the corneal sur- • Intralimbic contact lenses: These are specialized
face. This is usually painless for the patient but may affect RGPCLs with large optical zones (>11 mm).
the vision and drain the fluid reservoir prematurely. • Hybrid contact lens: these custom lenses have a cen-
• The central optic should similarly vault the cornea enough tral RGPCL portion and a peripheral SCL skirt. This
to create an adequate fluid reservoir but not too much to arrangement combines the optical superiority of an
prevent comfortable blinking. Different practitioners have RGPCL with the comfort of an SCL.
different patterns and preferences for the ideal vault; fre- • Piggyback contact lenses: The patient will first wear
quently, scleral lens fitters will rely on the manufacturer- an SCL for comfort and protection of the ocular sur-
recommended ideal vault as a target (usually face/cornea. Then, an RGPCL is worn on top to com-
200–400 microns) and adjust as needed. One important bine the optical benefits of an RGPCL and comfort of
distinction is that the vault is measured from the highest an SCL. Some practitioners have even used an SCL to
(steepest) point on the cornea, not necessarily the corneal facilitate wearing an ScCL or other advanced geome-
center. This detail is crucial when assessing the vault in try contact lenses.
patients with ectatic disease where the steepest part of the
cornea is usually shifted away from the center. After the 2. Use of Contact Lenses as Bandage Contact Lenses
lens is worn for several hours, some of the fluid reservoir Contact lenses, usually SCLs, may help facilitate cor-
may decrease, and the lens may only vault ~100 microns. neal epithelial healing in the presence of a corneal epithe-
• If the ScCL is too thick and the vault is too much, this lial defect (e.g., post-PRK, post-superficial keratectomy,
may artificially affect the “functional” Dk/t of the ScCL, treatment of recurrent corneal erosion syndrome, treat-
leading to problems such as corneal hypoxia and edema, ment of bullous keratopathy, etc.). Usually, an SCL with
as shown by mathematical Dk/t models. high Dk/t approved for extended wear is used and kept in
• ScCL fitting often requires multiple visits with adjust- place for 1–4 weeks. The power of the bandage SCL is
ments. Though time-consuming, it can be gratifying for negligible (usually plano or −0.50D). Topical antibiotics
the patient to experience improved visual acuity and ocu- are usually given as prophylaxis.
lar surface comfort with a well-fit ScCL. Often, a well-fit 3. Orthokeratology (Ortho-K)
ScCL can obviate the need for surgery, including corneal Ortho-K is a controversial topic.12 The basic premise
transplantation. While corneal surgeons enjoy performing of Ortho-K involves using RGPCLs for overnight wear to
transplant surgery, they also enjoy their patients’ seeing cause corneal flattening, thereby secondarily treating
better, especially without surgery! myopia temporarily (up to 24 hours). Ortho-K is primar-
ily used to correct myopia in children, and this theoreti-
cally allows patients to use Ortho-K during the night to
avoid having to use glasses during the day. Previously, it
Contact Lens Fitting Considerations in Select was thought that this strategy is not effective as it does not
Situations treat axial myopia: however, newer research has shown
that Ortho-K may prevent myopic progression in pediat-
Several commonly encountered situations may benefit from ric patients.13
contact lens fitting by a skilled and experienced However, as with any type of overnight contact lens
practitioner: wear, there is a significant increase of potential infectious
keratitis, corneal abrasions, corneal hypoxia, etc. This

1. Corneal Ectasias (Keratoconus, Pellucid Marginal treatment, including determining patient candidacy and
Degeneration, etc.) appropriate lenses, is best left to experienced
While many patients with corneal ectasia may require practitioners.
and benefit from RGPCLs or ScCLs, other options may
be necessary:
• Reverse geometry RGPCLs (RG-RGPCLs): This

design may be considered for patients with extremely See Chap. 24 “Myopia Control”, for additional information about this
12
topic.
oblate corneas (excessive central flattening with steep
VanderVeen DK, Kraker RT, Pineles SL, et al. Use of Orthokeratology
13
periphery). RG-RGPCLs have a flat central zone com-
for the Prevention of Myopic Progression in Children: A Report by the
pared to the peripheral curve, allowing for a better fit American Academy of Ophthalmology. Ophthalmology.
with oblate corneas. 2019;126(4):623–636
Practice Questions D. A “mix-and-match” strategy for multifocal contact

lenses may involve giving a higher add power to the
1. Which of the following statements is CORRECT? dominant eye and a lower add power to the non-
A. The base curve of a contact lens refers to the edge-to- dominant eye.
edge length of the contact lens.
B. The peripheral curve of a contact lens is usually
steeper than the base curve as the peripheral cornea is Answers
generally steeper than the central cornea.
C. The sagittal depth refers to the distance between the 1. C. This is the definition of sagittal depth. The base curve
posterior contact lens and a line drawn perpendicular of a contact lens is a measurement of the curvature of the
to the edge of the lens. posterior surface of the contact lens (expressed in milli-
D. The diameter of an RGPCL will usually be longer meters). The peripheral curve of a contact lens is usually
than the diameter of a SCL. flatter than the base curve, as the peripheral cornea is usu-
2. Which of the following materials is most commonly used ally flatter than the central cornea. An RGPCL is usually
in the construction of modern-day SCLs? smaller than an SCL and, therefore, will usually have a
A. Hydroxyethylmethacrylate (HEMA) smaller diameter as well.
B. Silicone hydrogel 2. B. HEMA was the most commonly used material in SCLs
C. PMMA until the 2000s.
D. Acrylic 3. C. While both a high Dk and high Dk/t are preferred, a
3. Which of the following combinations of values is the higher Dk/t is preferable to only a high Dk value. A low
most ideal for a SCL? wetting angle allows for the effective spread of water over
A. High Dk value, high wetting angle the lens surface (“wettability”).
B. High Dk/t value, high wetting angle 4. C. This is the description of a tight-fitting RGPCL. The
C. High Dk/t value, low wetting angle described staining pattern gives no information about the
D. High Dk value, low wetting angle type of corneal astigmatism present.
4. If after placing an RGPCL, there is a noted staining pat- 5. A. Monovision may be an excellent option for patients
tern of a black peripheral ring and a central green zone, who are okay with sacrificing some binocularity in
which of the following conclusions can be made? exchange for a range of vision and avoidance of glare/
A. The patient has WTR astigmatism. halos. In general, multifocal CLs (MF-CLs) take a sig-
B. The patient has oblique astigmatism. nificant time for adjustment, and multiple attempts may
C. The RGPCL is too tight. be necessary to find the ideal add power for a given
D. The RGPCL is too loose. patient. All MF-CLs have some compromise of visual
5. Which of the following statements regarding contact lens clarity in exchange for a range of visual acuity. A mix-
use in presbyopic patients is TRUE? and-match strategy involves giving a lower add to the
A. A monovision contact lens strategy may give good dominant eye (for distance and intermediate vision) and a
range of vision with some compromise of binocular- higher add to the non-dominant eye (for distance and near
ity and depth perception. vision).
B. Multifocal contact lenses are generally tolerated and
accepted by patients in a short time after first fitting.
C. Multifocal contact lenses offer crisp vision at all dis- Acknowledgments The authors are grateful to Rachel M. Caywood,
tances: distance, intermediate, and near. OD, FAAO, for her critical review of this chapter.
Clinical Problems with Optics
and Refractive Manifestations
Daniel Wee and G. Vike Vicente
Objectives develop an effective treatment plan. While one may think of

• To recognize causes of commonly encountered acquired “optics” as merely limited to updating a patient’s glasses,
refractive errors (myopic, hyperopic, and astigmatic) in there may be scenarios where the clinician must think criti-
clinical practice, including vision-threatening and life- cally. As we will see in the next sections, there may be sce-
threatening etiologies narios where new or changing refractive errors may not only
• To understand the effect of corneal sutures on the devel- blind a patient but may even (gulp) kill a patient.
opment of refractive errors and appropriate clinical In each section, you may notice that while we have given
management a differential diagnosis (“laundry list”) of etiologies to know,
• To recognize clinical presentations of acquired diplopia, we have also created clinical scenarios of high-yield etiolo-
including options for clinical management and alleviation gies in each category that will hopefully reinforce some of
of symptoms these critical teaching points.
• To define asthenopia, recognize its symptoms, and iden-
tify potential causes and treatment strategies
• To become familiar with problems experienced by aphakic Acquired and Clinical Myopia
patients and clinical options for the treatment of aphakia
• To effectively diagnose and treat malingering, including While there are many causes of acquired myopia, there are
medicolegal considerations two broad categories to consider in the clinical setting: (1)
increased refractive power of the eye (refractive myopia)
and (2) increased axial length (axial myopia). The following
Introduction classification tree lists common reasons for each category:
This chapter will cover common and uncommon clinical • Increased refractive power of the eye:
problems that may present with primary or secondary issues –– Increased corneal power, such as corneal ectasia (kera-
related to optics and refractive errors. While many of these toconus, etc.), though this will usually be accompanied
disease entities may have other pathognomonic signs and by a concurrent increase in astigmatism
symptoms, optics and refractive error symptoms may be the –– Lens shape changes
primary (or only) presenting symptoms. The topics discussed Cataract, diabetes, ROP, lenticonus
in this chapter are not only high-yield for clinical practice but –– Lens repositioning (forward shift)
are also especially useful to know for certification exams. Drugs (chlorthalidone, sulfonamides, tetracycline,
As ophthalmologists, we rely on clinical exam skills, carbonic anhydrase inhibitors)
imaging, and ancillary tests to make a correct diagnosis and Toxemia of pregnancy
Anterior lens dislocation
–– Ciliary muscle tone/excessive accommodation
D. Wee (*) Students, spasm, inadequate fogging by examiner
Center for Sight, Stockton, CA, USA Drugs (antihistamines, miotics, sulfa, tetracycline,
G. V. Vicente topiramate)
Clinical Pediatrics and Ophthalmology Georgetown University • Increased axial length
Hospital, Washington, DC, USA –– Posterior staphyloma
Eye Doctors of Washington, Chevy Chase, MD, USA –– Congenital glaucoma

324 D. Wee and G. V. Vicente
–– Scleral buckle into a strong suspicion for type 2 diabetes. A typical exam-
–– Idiopathic progressive myopia ple of this is a 40–50-year-old patient who presents over
the course of several months with increasing myopic cor-
Let’s discuss some high-yield clinical scenarios to high- rection in glasses as described above. The patient may
light a few important items from our above “laundry list”: report that the glasses work for a few months before requir-
ing a higher myopic correction. Exam findings may be
Scenario #1: The Unhappy Middle-Aged Patient with completely normal, especially in the early stages prior to
Frequent Glasses Prescription Changes the development of any diabetic retinopathy. Recall that
A 55-year-old man comes in to the clinic and the following hyperglycemia may cause swelling of the crystalline lens,
scene ensues: which leads to increased refractive power of the lens and
progressive myopia (usually with minimal change in astig-
Patient: “Doc, I do not want to see a resident today. I matism). Anatomical conditions are unlikely to cause
want to talk to the boss doctor.” bilateral refractive changes. In this setting, as an ophthal-
Resident: “Ok, can I just ask what is going on?” mologist, we can treat the eye (glasses, dilated fundus
Patient: “Every time I come here, I get a new doctor, and exam) but should order the initial workup for diabetes,
a new glasses prescription, and after two months arrange for prompt evaluation with an internist/endocri-
the glasses do not work anymore! This is the nologist, and counsel the patient about the need for regular
third time this year!” eye exams.1
Resident: “No problem, I’ll get the attending, let me just In other cases, acquired myopia is expected, such as
take a look at your glasses and our notes for a post scleral buckle (as the buckle causes axial compres-
minute.” sion along the equator), leading to increased axial
myopia.
March:
Glasses worn: OD: −1.00 sph (20/25) OS: −1.50 sph (20/30)
Manifest refraction OD: −1.25 sph (20/20) OS: −1.75 sph (20/20)
Scenario #2: The 1-Year-Old with Constant Tearing
Glasses issued: OD: −1.25 sph OS: −1.75 sph A 12-month-old child is referred by her pediatrician for tear-
June: ing in both eyes with the working diagnosis of likely naso-
Glasses worn: OD: −1.25 sph (20/30) OS: −1.75 sph (20/30) lacrimal duct obstruction (NLDO). Family history is
Manifest refraction OD: −1.75 sph (20/20) OS: −2.25 sph (20/20) negative.
Glasses issued: OD: −1.75 sph OS: −2.25 sph
October (present • Slit lamp exam: high tear film noted OU
day)
Glasses worn: OD: −1.75 sph (20/40) OS: −2.25 sph (20/40)
• Cycloplegic refraction: +0.50sph OU
Manifest refraction OD: −2.50 sph (20/25) OS: −2.75 sph (20/25) • Dilated fundus exam: normal
Exam findings are unremarkable other than trace nuclear The patient undergoes uncomplicated NLD probing and
sclerosis. irrigation under anesthesia. Postoperatively, the patient con-
tinues to experience epiphora and undergoes another NLD
Resident: “Sir, I think I know what is going probing procedure. This too fails, and the patient has a third
on. Can I ask you two quick procedure to place an NLD stent. The stent is eventually
questions?” removed at age 2.5 years, and at this time, the patient’s
Patient: “Fine.” mother states her child has been holding objects rather close
Resident: “Have you been thirstier lately? lately.
Do you have to urinate more
frequently?” • Repeat exam (patient age 3) including dilation reveals:
Patient: “Yes, why do you ask?” • Cycloplegic refraction −7.00D sph OU
Resident: “In addition to correcting your • Dilated fundus exam: C:D 0.8 OU
glasses, I think it is important that
we set up an appointment for you to In this case, the patient had an atypical cause of infantile
see your primary care doctor soon.” glaucoma which usually causes buphthalmos. However, this
Boss Doctor Attending: “Good job being a real doctor in child was not light-sensitive nor did the corneas appear large
addition to being an eye doctor, or cloudy. A significant bilateral myopic shift occurred in a
young apprentice. Now go fetch
me a coffee.” Order a fasting blood glucose, HbA1C, CBC, and BMP so that by the
1
Remember that a progressive, binocular myopic shift in time the patient presents to the internist/endocrinologist, he/she is
a middle-aged patient in a few months’ time should clue us impressed that you as an ophthalmologist actually remember real doc-
tor stuff.
Clinical Problems with Optics and Refractive Manifestations 325
relatively short period of time. Ideally, the optic nerve pathol- Acquired and Clinical Hyperopia
ogy would have been appreciated during the first two NLD
probing procedures. The learning point here is that infantile As a rule, hyperopic shifts are much more concerning than
glaucoma may present with rapidly increasing myopia and myopic shifts as they can be vision (and life) threatening – as
accompanying epiphora – diseases don’t read textbooks! such, they are a favorite topic for exam purposes.
Similar to the previous discussion on myopia, there are
Scenario #3: The Young Adult with a Recently Started two broad categories to consider in the clinical setting when
Medication encountering acquired hyperopia: (1) decreased refractive
A 28-year-old patient presents with complaints of difficulty power of the eye (refractive hyperopia) and (2) decreased
driving over the past 10 days after she was started on a recent effective axial length (axial hyperopia). The following clas-
medication. The patient reports she never wore glasses sification tree lists common reasons for each category:
previously.
Exam today: • Decreased refractive power of the eye
–– Lens changes
Visual acuity, sc OD: 20/50 OS: 20/50
Aphakia (crystalline lens or IOL dislocation)
Manifest refraction: OD: −2.50 sph (20/20) OS: −2.50 sph (20/20)
SLE: unremarkable OU
Pregnancy (both myopic and hyperopic changes are
possible)
Upon further questioning, she cannot recall the name of –– Poor accommodation
her new medication but states she was previously taking gab- Tonic pupil and Adie’s syndrome
apentin for control of her seizures. A call to her neurologist Third nerve palsy
reveals that she was recently started on topiramate. Trauma
This clinical case scenario is a curveball on the more Drugs (chloroquine, phenothiazines, antihistamines,
well-known phenomenon of acute angle closure glaucoma anticholinergics, benzodiazepines, marijuana)
(AACG) secondary to topiramate. In this example, the topi- Pregnancy.3
ramate induced anatomical changes that stopped just short of • Decreased effective axial length
inducing AACG (drug-induced myopia). Recall that while –– Tumor (choroidal or orbital)
the exact mechanism of topiramate’s evil effects on the eye is –– Central serous retinopathy
unknown, the prevailing theory is that the drug induces –– Severe papilledema
changes in the membrane potential leading to abnormal fluid
movements: a combination of uveal effusion and ciliary Let’s discuss some high-yield clinical scenarios, includ-
body edema lead to myopic shift, anterior chamber shallow- ing ones that should definitely not be missed on exams:
ing, and eventual AACG.
What should we do as ophthalmologists? Should we stop Scenario #1: The Happy 50-Year-Old with Miraculously
the medication? No, remember we are not real doctors! Improved Vision
Instead, we must immediately contact the primary care pro- Patient: “Doctor, I did not come in the last couple of
vider and advise immediate cessation of the drug and con- years because my eyes have been doing so well.
current alternate medications. If we simply stopped the drug I stopped wearing the glasses you gave me, and
without this discussion with the primary doctor, it is possible my eyesight has gotten better. I don’t even need
that the patient may undergo a severe seizure attack such that those lousy bifocals anymore!”
by saving the eyeball we ended up sacrificing the patient her- Doctor: “Really?”
self.2 We should not stop the medication without having an
alternative treatment plan in place with the primary provider. Examination today:
In terms of the eye, we must educate the patient about AACG
Previous manifest −1.50 sphere OS: −0.75 sphere
symptoms and advise her to come in immediately if such refraction OD: 20/20 (20/20)
symptoms develop. We should do a daily follow-up with a +2.00 add OU
low threshold for prophylactic laser peripheral iridotomy if Today’s manifest refraction −1.50 sphere OS: plano (20/20)
the angle doesn’t deepen. Usually, with prompt cessation of OD: 20/20
the drug, AACG can be avoided and the vision recovers in a
few weeks’ time.
Note that pregnancy can cause myopic changes (as discussed in the
3
previous section) and hyperopic changes. The latter changes can hap-
pen both due to crystalline lens changes as well as accommodation
Obviously, not good to save the eyeball at the cost of killing the patient
2
changes.
On first glance, we can see that this patient is likely happy Thankfully, we did not sign up this patient for LASIK!
because he has basically developed monovision. Should we Instead, this is a classic presentation of central serous cho-
pat him on the head, thank him for coming in, and send him rioretinopathy (CSCR). You may wish to review the full
on his way? pathophysiology, diagnostic tools, and treatment options
No, while the patient may be happy with his monovision, from other sources, but suffice it to say that this disease can
a closer look at his current refractive error indicates that he classically present with a unilateral hyperopic shift.
has had a hyperopic shift in his left eye that has made him Finally, if a bilateral hyperopic shift were to occur, the
plano. This warrants further clinical examination, including clinician should have a strong suspicion for medication-
possible imaging. induced retinal edema.6 A full list of medications is beyond
For this patient, suppose during the dilated fundus exam the scope of this text, but some common and high-yield med-
of the left eye, we observe posterior choroidal folds in a cen- ications include thiazolidinediones, fingolimod, tamoxifen,
tripetal pattern around the fovea. A CT of the orbits shows an niacin, MEK inhibitors, and ketamine. This type of edema
orbital mass (metastatic tumor) pushing against the posterior usually presents like a CSCR type of macular edema.
pole.4 This is a life-threatening diagnosis. The patient will Treatment options range from simple observation to intravit-
require a multidisciplinary approach with referral to oncol- real injections, and long-term visual effects range from tran-
ogy and neurosurgery, among other “real-doctor” specialists. sient to sight-threatening.
As ophthalmologists, we can continue to assist the team by
continuing to perform timely exams and ocular imaging, Scenario #3: The 36-Year-Old with Miraculously
especially for monitoring the (currently) unaffected eye and Improved Vision after Trauma
treating any ocular involvement in the future. Patient: I joined a special club two days ago with other
like-minded individuals where we beat each other
Scenario #2: The Case of the Unhappy 58-Year-Old up for fun. I wish I could tell you more about it,
Attorney but the first rule is that we do not talk about this
Patient: “I can’t read my legal briefings anymore! I have to club. It was my first night, so I had to fight. I’m
close my left eye and simply use my right eye not sure what happened because the other guy
lately. I used to just take my glasses off and read. knocked me out pretty badly, but I realize that I
Sign me up for LASIK now!” don’t need glasses for my left eye anymore. I told
Doctor: “Oh really?” you this club is amazing!
Doctor: Oh really…?
Examination today:
Examination today:
• Previous manifest refraction (3 months ago): −3.00
sphere OU (20/20) • Previous manifest refraction: −14.00D sphere OU
• Today’s manifest refraction: OD: −1.25 sphere (20/40), • Today’s manifest refraction: OD (cc) 20/20 (−14.00D
OS: −3.00 sphere (20/20) sphere); OS (sc) 20/20 (plano)
Similar to the last patient, this patient has had a unilateral Has this patient miraculously improved his vision by get-
hyperopic shift in his right eye. Unlike the last patient, this ting into this mayhem-filled fight? We should investigate fur-
patient is unhappy; presumably, because of his −3.00D myo- ther. Suppose that slit lamp exam is significant for a totally
pic error, he was able to take off his glasses to read previ- subluxated crystalline lens into the vitreous with resulting
ously but now is unable to do so. Again, a thorough exam, aphakia in the left eye. While aphakia typically causes a
including dilated fundus exam and potential ophthalmic hyperopic shift, in this patient, the aphakia has caused a
imaging is necessary. Suppose that the exam of the macula hyperopic shift of his pre-existing myopia such that he is
shows an elevated, dome-shaped ring of fluid surrounding now basically plano.
the central fovea. OCT of the macula shows a collection of Obviously, we cannot simply pat him on his head and
subretinal fluid below the neurosensory retina.5 send him on his way. In addition to counseling him about not
partaking in underground boxing clubs, this is a surgical
emergency that needs prompt vitrectomy, lensectomy, and
possible secondary IOL placement.
4
Note that a choroidal melanoma (another favorite exam question) may
appear with similar exam findings, though the clinical appearance of a
gray-green mass may be seen on fundus exam.
And yes, we could obtain an FA/ICG to confirm the “smokestack” pat-
5
Makri OE, Georgalas I, Georgakopoulos CD. Drug-induced macular
6
tern here as well, but none of the authors are retina specialists. edema. Drugs. 2013;73(8):789–802
Acquired and Clinical Astigmatism Today’s manifest refraction: OD: −2.00 + 4.00 × 075 (20/25)
OS: −2.50 + 0.50 × 180 (20/25)
We previously discussed various types and classifications of
astigmatism in Chap. 11 “Astigmatism”. When formulating a We should note from comparing the two refractions that
differential diagnosis for causes of acquired astigmatism, we the patient has experienced a significant shift in refractive
can divide it into corneal or lenticular astigmatism. Retinal cylinder (and axis) in the right eye. This acquired astigma-
astigmatism, while theoretically possible, is nearly tism must be coming from either the cornea or the lens.
non-existent. Corneal topography or keratometry should be pursued next:
Topography/keratometry: 44.00 × 44.50 @ 180 OU. This
confirms that the acquired astigmatism isn’t coming from the
Differential Diagnosis of Clinical Astigmatism cornea.
Suppose we now proceeded with the slit lamp exam.
One way to classify corneal and lenticular astigmatism is to Gonioscopy reveals a pale, fleshy lesion in the angle, and a
think anatomically: start from the front of the eye and work sectoral cataract is present in the right eye. Before dilating
your way backwards. the patient, we can get ocular imaging (such as AS-OCT or
A partial differential diagnosis for acquired astigmatism UBM). Suppose that the UBM confirms a ciliary body tumor
is as follows: in the right eye.
Along with the previous case regarding choroidal mela-
• Corneal noma, this diagnosis should definitely not be missed as it can
–– Lid/adnexa (compressive etiology) lead to blindness or even death. You may wish to review how
Ptosis to diagnose ciliary body tumors (gonioscopy, UBM,
Blepharophimosis AS-OCT, or anterior segment FA) and their treatment (irido-
Chalazion or lid masses cyclectomy, etc.). Remember that a multidisciplinary
Congenital fibrosis of extraocular muscles approach is necessary, including neuroimaging, oncology
–– Conjunctival surface consultation, and systemic workup/imaging.
Pterygium, ocular surface tumors
–– Corneal
Lesions/masses: pterygium, dermoid, CIN Suture Management
Dystrophies: EBMD, keratoconus, pellucid mar-
ginal degeneration, etc. In a perfect world, every eye surgeon would be able to place
Latrogenic: post-LASIK ectasia corneal sutures that are robust enough to ensure wound closure
Degenerations: Terrien’s, Salzmann but also delicate enough to not cause any astigmatism whatso-
Scarring secondary to trauma or infections ever. Obviously, this never happens. Recall that a tight suture
–– Congenital placed on or close to the cornea can induce astigmatism (best
Fetal alcohol syndrome, albinism, Alport syndrome, understood by conceptualizing this as inducing plus-cylinder)
infantile nystagmus syndrome, retinopathy of pre- by warping the corneal curvature at that location (Fig. 1). Tight
maturity, Kabuki syndrome, Ehlers-Danlos syn- sutures located closer to the central cornea will induce more
drome (EDS) type 1, Down syndrome, sclerocornea astigmatism than sutures located closer to the limbus.
• Lenticular Topography/keratometry can be very useful to quantify
–– Compressive: ciliary body tumors (watch for sectoral suture-induced astigmatism that may be difficult to detect on
cataract!) clinical exam alone. For example, in this topography-obtained
–– Anterior polar cataracts post-penetrating keratoplasty (Fig. 2), there are tight sutures
–– Cortical cataracts (Panel a, left panel) causing 20.37D of astigmatism at 8°. After
removing multiple tight sutures, the astigmatism has decreased
Let’s discuss some high-yield clinical scenarios, includ- to 7.75D (Panel b, right panel). Additional sutures can be
ing ones that should definitely not be missed on exams: removed to further reduce the astigmatism as needed.7
Scenario #1: The Middle-Aged Female Who Is Unhappy

While corneal surgeons’ preference for the timing of suture removal var-
7
with Her Glasses ies, most surgeons would remove tight sutures starting at 3 months post-
A 45-year-old female complains that she can’t see well near operatively after penetrating or deep anterior lamellar keratoplasty.
or far with the glasses you gave her 2 years ago Removing too early may lead to instability of the graft-host junction,
including wound rupture and graft dehiscence. Waiting too late (e.g., after
Current prescription: OD: −2.00 + 0.50 × 180 (20/50) 12 months) may reduce the potential benefits of suture removal due to
scarring and fibrosis. Most surgeons will continue removing sutures until
OS: −2.50 + 0.50 × 180 (20/25)
the astigmatism is <2D and/or the BCVA is acceptable to the patient.
a
b
Fig. 1 Tight sutures and astigmatism. A tight suture will induce plus suture that flattens the periphery and steepens the central curvature.
cylinder in the meridian in which it is located. Panel a shows an ideal Notice that the interlimbal distance does not change in either situation
suture that does not distort the corneal curvature. Panel b shows a tight
Fig. 2 A tight suture(s) can induce significant amounts of astigmatism. (Panel b, right panel), the astigmatism has reduced to 8.47D. Additional
In Panel a (left panel), tight sutures are causing 16.7D of astigma- suture removal can be done as needed at this time
tism(!). After suture removal and repeat topography 6 weeks later
Sutures placed at the time of cataract surgery can simi- been getting by with my left eye for a few weeks now. Will I
larly cause significant amounts of astigmatism. For example, finally get my glasses prescription today?”
suppose that a 70-year-old patient presents for her one-month Manifest Refraction today (1 month after ECCE):
postoperative visit after planned extracapsular cataract
OD : −2.00 + 4.00 × 135 ( 20 / 40 )
extraction (ECCE) requiring a wide superior limbal incision.
The patient is now pseudophakic in both eyes. OS : −1.00 sphere ( 20 / 20 )

She asks: “I would really like to get my glasses prescrip- A (cartoon) clinical exam and topography are shown in
tion today for my right eye because it’s still very blurry. I’ve Fig. 3. It appears there is a steep suture (marked in red) that
a b
+ +
Fig. 3 Topography of the patient’s right eye (panel a) shows steepen- suture is cut, repeat topography taken 1 month later shows steepening
ing along the 135-degree meridian, which corresponds to the refractive 90° away of approximately 1 diopter
cylinder and location of the tight suture seen on clinical exam. After the
corresponds to the corneal astigmatism seen on topography the IOL has dislocated (tilted) causing lenticular (pseudo-
at 135°, which also matches the refractive cylinder values. phakic astigmatism).8 Depending on the situation, treatment
Notice that the spherical equivalent of the manifest refraction options at this time range from simple observation, glasses,
of the right eye is plano, which suggests that the patient has contact lenses, IOL repositioning, and/or IOL replacement
excellent vision potential once the astigmatism is reduced. (with appropriate fixation).
Suppose we determine that the suture at 130° is tight and
we decide to remove it. We reassure the patient that addi-
tional time is needed for healing, and we schedule the patient Acquired Causes of Poor Accommodation
for a return visit in 4–6 weeks.
At the following-up visit 6 weeks later, we can repeat the Similar to the previously discussed acquired refractive errors,
manifest refraction: poor accommodation can have a variety of causes. A sample
list follows:
OD : − 0.50 + 1.00 × 45 ( 20 / 20 ) .

Repeat topography now corresponds to Panel b in Fig. 3, • Age, normal presbyopia
indicating approximately 1D of astigmatism at the 45-degree • Latent hyperopia
meridian. Depending on the needs of the patient, we can • Medications (parasympatholytics, phenothiazines, tran-
either dispense the glasses at this time or consider additional quilizers, chloroquine, antihistamines)
suture removal. • Systemic illness (hypothyroid, anemia, myasthenia gra-
Notice that spherical equivalent is still plano, which is the vis, diabetes)
same as the spherical equivalent noted at the previous visit. • Prior encephalitis or meningitis
Recall that the principle of coupling applies for suture • Tumor
removal as well: flattening in a given meridian will cause • Head trauma – post-concussion syndrome.9
steepening of the meridian located 90° away. • Tonic pupil
In certain situations, the presence of sutures should not • Topical and systemic medications.10
preclude other previously discussed causes of acquired astig-
matism. Let’s see an example of this:
An 80-year-old patient underwent ECCE 1 month ago
and was found to have 3D astigmatism at the 135-degree See Chap. 11 “Astigmatism”, for a discussion on how a tilted/dislo-
8
meridian. Suture removal was done and the patient now pres- cated IOL can induce refractive and astigmatic errors.
ents 6 weeks later. Repeat manifest refraction today shows Raghuram A, Cotter SA, Gowrisankaran S, et al. Postconcussion:
9
the same amount of refractive cylinder at the 135-degree Receded Near Point of Convergence is not Diagnostic of Convergence
Insufficiency. Am J Ophthalmol. 2019;206:235–244
meridian. What else could be going on (Fig. 4)? 10
Smith JL, Buncic JR. Drugs which can affect near vision: a useful list.
In this situation, the suture removal didn’t improve the https://uwpress.wisc.edu/journals/pdfs/AOJ_49_178.pdf. Accessed
astigmatism. We have to probe further: dilation reveals that August 10, 2020
a b
Fig. 4 After suture removal (Panel a), there is still refractive cylinder present in the meridian of the removed suture. Dilated exam (Panel b) shows
a dislocated IOL causing lenticular (pseudophakic) astigmatism
• Ocular trauma This confirms our suspicions regarding the diagnosis of

• Down syndrome around 6 years of age.11 latent hyperopia. The patient has been hyperopic his entire
life, but he was managing when younger because he was able
Let’s discuss some high-yield clinical scenarios: to generate the necessary accommodation. However, now
that he is getting older, his AOA is decreasing and he is not
Example #1: The Unhappy Bank Teller able to generate the accommodation that he needs; thus, he is
A 39-year-old bank teller complains of poor vision, espe- fatiguing quickly, especially given his high demands for
cially for near tasks, for more than a year. Previously, he near-vision tasks given his profession. Recall that patients
reports he never had to wear glasses. For the past year, he has can comfortably use one-half their AOA.12 Therefore, he can
been given several pairs of glasses by various providers, but comfortably generate 3D of accommodation at this time but
none of these seem to be working more than a few months. it is likely that he will continue to lose his AOA over the next
few years. Eventually, he will require the full cycloplegic
Exam today: Uncorrected distance visual acuity: 20/20 OU
refraction but will likely not tolerate the full refraction at this
Uncorrected near visual acuity: J7 OU
Manifest refraction today: +1.75 sphere OU (20/20)
time.
One approach is to give these patients one-half the cyclo-
At this point, we may be tempted to dispense the glasses plegic refraction (e.g., +2.00D sphere OU) and slowly
prescription and send the patient on his merry way because increase this over time to allow the patient to “adjust” to the
he can see 20/20. However, we should remember that his prescription.13 We could also consider atropinization to force
main complaint is with his near vision tasks, especially given him to use the full cycloplegic refraction, but we should con-
his profession. Furthermore, he was already 20/20 at dis- sider the side effects. Another option is to use bifocal glasses
tance without any glasses; a manifest refraction today simply or even contact lenses – recall that presbyopic hyperopes
revealed that he had a mild hyperopic correction.
What else could be going on? This is a potentially classic
presentation of a patient with latent hyperopia who is now See Chap. 9 “Accommodation and Presbyopia”, for a review of this
12
topic.
having problems with accommodation due to aging. At this
A silly (but hopefully useful) analogy for the latent hyperope is to
13
time, we need to perform some additional, not-commonly- consider them like a heroin addict: you can’t stop them “cold turkey”;
performed tests, such as measuring the amplitude of accom- you have to transition them off the heroin (accommodation) with a less-
modation (AOA) and performing a cycloplegic refraction. harmful substitute, such as methadone (one-half the cycloplegic refrac-
Suppose the AOA is 6D in each eye, and the cycloplegic tion, in this analogy). Eventually, the goal is to wean these patients off
their “love for accommodation” by slowly building up the hyperopic
refraction is +4.00D sphere OU. correction over a period of several months or years. We apologize for
this analogy as drug addiction is a serious problem in real life, and we
don’t wish to make light of it as it affects many people. Over the years,
Cregg M, Woodhouse JM, Pakeman VH, et al. Accommodation and
11
we have found that students respond well to this analogy because it is a
refractive error in children with Down syndrome: cross-sectional and “memorable” one. We should emphasize that our intent with this anal-
longitudinal studies. Invest Ophthalmol Vis Sci. 2001;42(1):55–63 ogy is to educate, above all else.
have decreased needs of accommodation when using contact our discussion on asthenopia to etiologies related to refrac-
lenses. tive errors and glasses. Several useful categories of ques-
tions/tests to perform include:
Example #2: The Unhappy Social Media Influencer
A 32-year-old female who has built her career on being a A. Asthenopia due to errors in refraction:
“social media influencer” presents with complaints of read- (a) Was the patient over-minused causing the need for
ing her cellphone over the past week. She reports that if she excessive accommodation, especially in a young
closes her left eye, she can still read with her right eye only. myope? A duochrome test or cycloplegic refraction
She is extremely unhappy as her cellphone is her primary may be helpful.
means of “letting her followers know what to buy and what (b) Is there latent hyperopia present that can only be
is trending.” measured after a cycloplegic refraction, as discussed
in the previous section?
• Distance visual acuity (uncorrected): 20/20 OU B. Asthenopia due to poorly made/functioning glasses:
• Near visual acuity (uncorrected): OD: J1 OS: J10
For example, suppose a 55-year-old engineer comes in for
How should we proceed? In this case, the clinical exam his third refraction in 2 months.15 He states that “something
will shed light on the diagnosis. Suppose that in room light is wrong with these glasses.” You perform another long
conditions, the right pupil is 2 mm whereas the left pupil is refraction until your shoulder hurts, but the repeat manifest
8 mm. When we shine a light into both eyes, the left pupil refraction today is exactly the same as the prescription
minimally reacts, but when asked to read the near card, the ground into the patient’s current (new) glasses. Before label-
left pupil constricts to approximately 6.5 mm with a slow ing this patient “difficult” and referring them to your least
re-dilation. favorite colleague, you may want to review the differential
This is a classic presentation of Adie tonic pupil. A full for this problem.16
review of this entity is beyond the scope of this text, but it If the repeat manifest refraction matches the current
should be remembered that decreased near vision in one eye glasses’ prescription, then a summary list of what to do next
may often be the presenting symptom to the clinician. includes:
Hopefully, you can make the correct diagnosis and treat her
symptoms so that your social media accounts will also gain 1. Pupillary distance (PD): Mark the location of the pupil-
thousands of followers. lary axis on the lenses, and check the optical center
through a lensmeter.17 Does it line up with the pupils? Is
the new glasses’ PD the same as the old glasses or the PD
Asthenopia used in the phoropter during today’s repeat refraction?
2. Base curve: Using a Geneva lens clock, check the old ver-
Sometimes in ophthalmology, when we want to sound intel- sus new base curves.
ligent, we come up with fancy sounding words to describe 3. Is the cylinder ground onto the back surface of the lens, or
symptoms and problems that can be easily described in is the lens backwards?
everyday English.14 Asthenopia is no different: it simply 4. Is the progressive or bifocal segment height okay? Is it
means eyestrain, usually due to excessive accommodation, affecting chin posture?
that manifests as subjective, episodic, and often vague symp- 5. Is the frame alignment okay? Is the pantoscopic tilt >7°?
toms of eye fatigue, discomfort (including intraocular and 6. Does the vertex distance of the glasses match the vertex
extraocular), headaches, photophobia, intermittently blurry distance used in the phoropter? This may particularly be
vision, and difficulty keeping the eyes open. It can be consid- a problem with higher power lenses.
ered a diagnosis of exclusion but also a concurrent diagnosis 7. Has there been a large change in the axis of the
(with other more readily diagnosed conditions). Asthenopia astigmatism?
can results from a combination of etiologies, including
excessive accommodation, imbalance of extraocular mus-
By now, you should have gathered that anytime an engineer comes in
15
cles, organic nervous system disease, and/or improper illu- for an eye exam in these hypothetical clinical cases, you should buckle
mination. It can be a frustrating condition for both the patient up because it’s going to be a while.
and the examiner. Similarly, you may wish to review Chap. 15 “Glasses in Clinical
16
Clinically, we can work up the various symptoms of Practice” and Chap. 16 “Construction of Glasses (Ophthalmologists as
Opticians)” for a full discussion on the topics of prescribing, dispens-
asthenopia by ruling out/in common causes. We will focus
ing, and troubleshooting glasses.
Consult Chap. 17 “Optical Instruments and Machines” for a review on
17
For example, we use the term “ocular straylight” to refer to “glare.”

14
how to use the lensmeter and Geneva lens clock.
8. Has there been a change in lens material? High index home involves more than an hour drive through dimly lit
lenses are thinner and lighter, but they have more chro- roads.
matic aberration and a smaller sweet spot.
9. Finally, does the patient not like the frame design but is Exam: Distance vision (uncorrected) 20/20 OD and OS
Manifest refraction: −0.50D sphere OU (20/20)
too embarrassed to say they changed their mind? “Do you
think you might see better with a different frame?” What else could be accounting for her symptoms?
This is a classic presentation of night myopia. When con-
Of note: This question is one of the most common clinical sidering this diagnosis, ophthalmic diseases, such as retinitis
scenarios asked by senior attendings! Other educational pigmentosa, vitamin A deficiency, and congenital stationary
instructions to patients include ensuring adequate lighting, night blindness, can be determined by basic exam and clini-
limiting screen time (especially with cell phones/tablets), cal testing. If no organic pathology is found, then five differ-
and keeping a diary of symptoms to elicit triggering/alleviat- ent reasons may account for these findings.
ing factors. The key feature of all these therapies is to reduce
the amount of accommodation done by the patient. The clas- 1. Pupil dilation under scotopic light conditions (Fig. 5):
sic trifecta of warm compresses, lid scrubs, and tears may Recall that as the pupil dilates, more light rays will pass
also be used for management of non-vision-threatening through the peripheral cornea and lens in low-light condi-
symptoms. tions as compared to bright-light conditions. These light
As mentioned above, non-glasses-related causes of asthe- rays will be bent more strongly than central light rays
nopia are numerous, including undiagnosed strabismus, dry (spherical aberration), leading to a myopic shift.19 Wave
eye, screen fatigue, and CNS issues. If adjusting the refrac- front testing or ray-tracing imaging may further quantify
tion and/or glasses fails to improve the patient’s symptoms, the amount of spherical aberration present.
additional testing, imaging, and lab workup may be 2. Limitations of the refraction lane: The standard lane is
necessary. 20 feet (6 m) long which is shorter than the distance to
test optical infinity.20 In order to correct for infinity, we
have to add an additional −0.25D to the final refraction to
ther Commonly Encountered Clinical
O avoid under-correction.
Problems with Refractive Considerations 3. Purkinje shift: in low light conditions, shorter wave-
lengths of light will converge more. Simultaneously, as
There are a few additional scenarios that don’t fit nicely into the rods take over at night time, these photoreceptors are
one of the previously mentioned categories but warrant addi- more sensitive to blue light. Thus, there is a tendency for
tional discussion. the peak luminance sensitivity of the human eye to shift
toward the blue end of the color spectrum in scotopic-
mesopic light conditions.
Night Myopia 4. Loss of accommodation targets: since the patient has a
lengthy commute in dimly lit roads, there may be no tar-
Night myopia is the tendency for most people to develop gets to “anchor” accommodation, such as street lights or
myopia in low illumination settings. Interestingly, soldiers road signs. As a result, she may be generating additional
experiencing night myopia during World War II brought accommodative (plus) power and inadvertently “fog-
additional attention to this topic as observers noticed that ging” herself while driving.
additional minus-powered lenses were needed for sighting 5. Spasm of accommodation due to daytime activities: as
stars and other objects of interest during nocturnal mis- the patient is a medical student trying to ace her STEP
sions.18 While a variety of historical theories have been pro- exams to get into ophthalmology, she may be spending
posed for this phenomenon, we will instead focus our most of her day accommodating while reading.
attention to how a patient might present to your office with
complaints of night myopia symptoms. We can help the patient by any of the following methods:
Suppose that a 24-year-old medical student presents to
your office complaining of poor night vision. She feels that 1. Additional myopic correction for “nighttime” glasses to
while she can see well during the day, her vision is particu- use while driving. For example, instead of simply dis-
larly worse when she drives home at night time. Her route
See Chap. 14 “Physical Optics and Advanced Optical Principles”, for

19
Otero JM, Plaza L, Salaverri F. Absolute thresholds and night myopia.

18 a review of spherical aberration.
J Opt Soc Am. 1949 Feb;39(2):167–72 See Chap. 18 “Visual Acuity Testing and Assessment”.
20
Fig. 5 Spherical aberration contributes to night myopia. Pupillary dila- will be refracted much stronger than central rays and will “land” in
tion under mesopic lighting conditions will allow more peripheral rays front of the retina, inducing a myopic shift
to pass through the cornea and crystalline lens. These peripheral rays
pensing −0.50D sphere OU, we can give −1.00D sphere cation with contact lenses is less pronounced as compared
OU that the patient can wear during her commute home. to the magnification experienced with glasses. This may
2. Advise the patient to take study/rest breaks during the decrease the negative effects of aniseikonia.
day. The “20/20/20” rule can be used to remind patients 3. IOLs: both ACIOLs and fixated-PCIOLs may be consid-
that every 20 minutes, they should look at a target 20 feet ered, especially if the previous two options are
away for at least 20 seconds to break accommodation. intolerable.
3. A mild pupil constrictor, such as dilute brimonidine/pilo-
carpine, can be given before her commute home to Patients with spectacles for unilateral aphakia will experi-
decrease myopic shift from spherical aberration. ence similar problems as patients who wear hyperopic
glasses:22
Management of Aphakia • Ring scotoma secondary to prismatic effects of the lens

periphery
We have previously discussed how hyperopia/aphakia causes • Jack in the box phenomenon: sudden appearance of
problems with magnification leading to anisometropia and objects that jump out of the scotoma
aniseikonia.21 Several options exist for the management of • Magnification (Fig. 6)
aphakia, ranging from clinical to surgical: • Pincushion distortion (Fig. 7)
• Extra weight of the aphakic lens, which can make the
1. Glasses: for one eye or both eyes. If given for both eyes, spectacles lopsided and difficult to wear
the patient may do just fine. However, if only one eye is • Higher cost
aphakic, certain issues may occur with aphakic spectacles
(see below).
2. Contact lenses: contact lenses may be an excellent option
for patients with unilateral aphakia. Recall that magnifi-

22
See Chap. 8 “Magnification and Telescopes”.

21
Opticians)”, for a more detailed review of these topics.
Fig. 6 A high plus-powered

lens given to the aphakic eye
(right eye) will cause
significant magnification and
extra weight and induce a ring
scotoma. The ring scotoma is
caused by light rays that strike
the peripheral edge of the lens
never reaching the visual axis
due to the effects of refraction
stroke given the child is blind and the eyes appear normal.
The child is then referred to a university hospital ED for a
stat MRI of the brain.24 The patient’s mother is charged
$4000 on her credit card because they cannot obtain an insur-
ance referral. The MRI is normal and the on-call ED attend-
ing calls you, asking, “What should we do now?”
This scenario was a real case experienced by one of the
authors recently.25 We will first discuss an increasingly
common entity known as nonorganic visual loss (NOVL).
NOVL includes both volitional (e.g., malingering) and
non- volitional (e.g., factitious disorder, hysteria, etc.)
causes. In other words, sometimes the patient is intention-
ally faking it, but other times, the patient may not be pur-
posely faking it.
NOVL is defined as a decrease in visual acuity or visual
field without an identifiable organic cause. It may be pres-
ent in 0.5–5% of the patient population, and early teens
and middle age patients may be the most affected.26 We
have personally observed a 1–2% prevalence in our pediat-
Fig. 7 Pincushion distortion induced by an aphakic lens
ric practice, with the highest rate among 7-year-olds who
would like to wear glasses because it’s “the cool thing to
Nonorganic Visual Loss (NOVL)23 wear.”
An in-depth review of NOVL is out of the scope of this
A 7-year-old wakes up on a fine Sunday morning frantically text, though it is important to distinguish between those con-
telling her parents that she cannot see: “I think I’ve gone ditions in which the patient is consciously aware (volitional)
blind.” Her family takes her to a local optometrist who agrees
the child is blind but cannot tell why. They refer her to a
general ophthalmologist who diagnoses a likely occipital Of course, modern medical practice is that any patient that enters a
24
university ER must get a CT and/or MRI…just kidding.

We will disclose how this case was handled in the end-of-chapter
25
Many thanks to Robert W. Enzenauer, MD, MPH, MSS, MBA,
23 questions.
Professor of Ophthalmology and Pediatrics, Chief of Ophthalmology, Lim SA, Siatkowski RM, Farris BK. Functional visual loss in adults
26
Children’s Hospital of Colorado for his assistance and contributions and children patient characteristics, management, and outcomes.
to this section. Ophthalmology. 2005;112(10):1821–1828
of his/her deception and those in which the patient believes are therefore diagnoses of exclusion. Knowing which tests to
their signs and symptoms are caused by a real condition order may limit unnecessary testing without missing a subtle
(non-volitional). degenerative condition such macular dystrophy, inherited
optic nerve pathology, or amblyopia.
(a) Volitional: malingering, Munchausen syndrome, etc. It is more difficult to diagnose NOVL patients who
A patient may pretend to have or exaggerate complain of seeing “blurry” rather than those patients with
symptom(s) in order to achieve some tangible or intan- profound vision loss. Similarly, it is difficult to separate
gible gain. For example, a young child may intentionally NOVL patients who are exaggerating a symptom with a
fail a vision test because he wants to wear glasses. true underlying organic pathology. In a young patient, it
Another common example is a soldier who intentionally may be easier to diagnose malingering by simply asking
fails a vision test in order to avoid active combat duty.27 “What do you think would help?” They will often tell you:
Munchausen’s syndrome is a particular type of voli- “Glasses!”
tional (factitious) disorder in which the person wants to The following combination of clinical exams, tools, and
assume the role of the sick patient, often for tangible imaging may be utilized in the diagnosis and management of
gains such as disability insurance. Munchausen by proxy NOVL patients. Some of these tests may not only be diag-
is a variant of the classical Munchausen’s syndrome; in nostic but may be therapeutic as well.
this scenario, someone else (a parent) may make the In the following examples, let’s assume the patient states
patient intentionally sick in order to seek attention. his/her RIGHT EYE is blind.
These cases may also involve child abuse; a high degree
of clinical suspicion and tact is therefore necessary when Monocular Blindness Tests
encountering these patients. A. Red-Green Glasses and Worth Four-Dot (W4D) Testing
(b) Non-volitional: conversion disorder, hysteria, etc. Test setup: The red lens goes over the right eye; the
Patients with a conversion disorder or functional green lens goes over the left eye. The W4D light is held
somatic syndrome truly believe their symptoms are real 3 feet away.
and are caused by a medical problem. These patients are (a) If the right eye is truly blind, the patient would only
not necessarily “faking” as they may even have had an see 3 green dots, i.e., the three lights perceived by
injury (minor or in the past) that they believe is affecting the left eye.
their eyes. For example, one of the authors had a patient (b) A patient with normal vision would see 4 dots: one
who had minor eye injuries after an oil-rig explosion in red, two green, and one that is red/green.
the recent past. The patient had no findings on the exam (c) Even a patient with amblyopia or monofixation syn-
and visual acuity was 20/20 in both eyes. However, the drome with a suppression scotoma should be able to
patient was totally convinced that his eyes were dam- see the dots at near, but miss one of the colors at
aged from the traumatic injury. He was not seeking any distance.
disability insurance or filing a lawsuit. He continued to B. OKN Drum
work at the oil-rig but was convinced that he was going Test setup: The “blind” right eye is open and the
blind. For these patients, validation and reassurance “healthy” left eye is covered. The drum is rotated along
without judgment is extremely crucial (along with lots its vertical axis in front of the right eye.
of preservative-free tears as in the case of the oil-rig (a) If the right eye is truly blind: no nystagmus is
patient). Ultimately, a psychiatry consultation or cogni- observed.
tive behavior therapy may be necessary, along with (b) If a horizontal nystagmus is induced, this indicates at
patience and the tincture of time, for resolution of least 20/200 vision or better.
symptoms. C. Base Down 4 Diopter Prism
Test setup: This can be tried under monocular or bin-
Regardless of volitional/non-volitional causes, all NOVL ocular conditions. A 4 PD base-down prism is moved in
patients must have thorough workups to rule out organic front of the affected eye.
causes. While it may seem like a waste of time, money, and (a) If the right eye is truly blind, then no movement will
resources, there are medicolegal considerations as well: we be observed.
cannot simply pass off someone as a “faker” only to find out (b) A patient with normal vision will move their eye
that a true organic pathology exists! All variants of NOVL upward to maintain fixation on a target. Again, recall
that a virtual image is moved toward the apex so the
eye will “move” up to “catch” the virtual image if it
Broderick KM, Ableman TB, Weber ED, Enzenauer RW, Wain HJ,
27
Wroblewski KJ. Nonorganic Vision Loss in the Afghanistan and Iraq has normal vision (this movement is relative to the
Conflicts. Neuroophthalmology. 2017;41(4):175–181 examiner).
D. Mirror Test sively larger lines on the Snellen chart: for example,
Test setup: The “blind” right eye is open, and the starting with the 20/10 line, the examiner can dial in
“healthy” left eye is covered. A handheld mirror is aimed “strong” plano lenses and then show the 20/15 or 20/20
at the patient so he/she can see his/her own reflection and line. The patient will think he/she is getting stronger
is then moved around as the examiner says, “I’m going to lenses and will read the larger lines.
reflect some light onto your eye”: D. Confrontation visual field testing: This is also particu-
(a) If the right eye is truly blind, it will not follow the larly effective in young malingering children; they may
mirror. lie that they can’t see the fingers. If a patient’s vision is
(b) A patient with normal vision will follow himself. worse than count fingers, then he/she should also have
You can try this at home: it is really hard not to fol- trouble ambulating and recognizing faces.
low the mirror. Since human vanity is second only to E. Averse light reaction: If a patient is truly blind, then sud-
human stupidity, a malingering patient will involun- denly shining a bright light should not cause him/her to
tarily look at the mirror to see his/her own suddenly flinch away from the light.
reflection. F. Autorefraction/streak refraction: If a patient intention-
E. Fogging ally performs poorly on subjective manifest refraction,
Test setup: Both eyes are open in the phoropter, and then an autorefraction or streak refraction can be per-
successive lenses are changed over either eye until the formed to detect the true refractive error of the eye. For
normal eye is fogged with plus lenses and the “bad” eye example, if the patient pretends that he/she cannot see
is not. any better despite any combination of lenses you display
(a) If the right eye is truly blind, then the patient will not on the phoropter, but the autorefraction and streak refrac-
be able to see through the phoropter. tion show a refractive error of −1.00D sphere OU, then
(b) A patient with normal vision should still be able to you may have a faker on your hands!
see well even if the opposite eye is fogged. G. Corneal topography: Similarly, this may help to show
F. Stereoacuity how much corneal astigmatism is present and whether
Test setup: With the patient’s near correction refrac- this matches the refraction.
tion in place, both eyes are kept open, and a set of stereo- H. OCT macula: This may help rule out any retinal
acuity lenses (polarized or red/green) is held over each pathology.
eye.
(a) If the right eye is truly blind, the patient cannot dis-
cern the 3D images. Visual Field Loss Tests
(b) A patient with normal vision should be able to see I. Visual field testing (Humphrey): A clover-leaf pattern
the 3D images under binocular conditions. indicates inattentiveness, which may be intentional.
G. Color Vision Testing: The first plate in the Ishihara plates Patterns inconsistent with logical scotomas and high
is considered to be a control so that both color-normal false-negatives may also be seen on testing. Remember
and color-deficient patients should be able to see it. If a that central scotomas are extremely rare in NOVL and
patient states he/she can’t see the first plate, then you warrant further evaluation.
may have a malingerer on your hands. J. Tangent screen tests and Goldman visual fields at differ-
ent distances: Watch for spirally enlarging visual fields
Binocular Blindness Tests (“spiraling isopters”), overlapping isopters, or visual
A. Simple observation of the patient ambulating the room, fields that become smaller as the screen is placed further
missing obstacles: away.
(a) If acute loss of sight is reported, the patient would be K. Visual evoked potential (VEP) testing: While this may be
expected to be in an anxious state or bumping into a fantastic waste of healthcare resources, VEP testing
objects. may be needed in certain cases for medicolegal purposes
B. Bringing fingertips together from opposite hands across to confirm the diagnosis of NOVL. It is not practical to
the torso or finger-to-nose testing: Since this relies on use VEP testing as a primary diagnostic tool.
proprioception, even patients with actual blindness
should be able to do these tasks. If a patient is unable to Once NOVL is diagnosed, reassurance may be the best ini-
do these tasks, there may be volitional NOVL present. tial remedy for many of these patients, as up to 50% of patients
C. Using plano trial lenses and rechecking vision (“bottom- may have improvement of symptoms over time. For some
up visual acuity”): This is particularly effective in young patients, especially young children, it may not be helpful to be
children around age 7 years who would like to try glasses. confrontational (other than the visual fields, see what we did
This can be combined with showing the patient progres- there) with them as there may be underlying psychological or
social factors present. A separate discussion with parent(s) RIGHT EYE

may be necessary as well. One option may be to offer over the C
B D
counter reading glasses and ask the parents to inform them if A E
the vision gets worse despite the placebo glasses. This is rele-
vant, as up to 2% of patients in one study went on to be diag-
nosed with an organic illness, and up to 40% of adults may
have a concurrent psychiatric illness.28 If a patient is reaching
out for medical attention, it may be because they are afraid of
complaining about what really bothers them. A multidisci-
plinary approach may at times be necessary.
Practice Problems
1. If a patient with Marfan syndrome is found to have the

right crystalline lens dislocated superotemporally on clin- Fig. 8 Which of the following sutures should be cut if the postopera-
tive manifest refraction shows +4.00D cylinder at 80°?
ical exam, which of the following refractive errors is most
likely present?
the eyes look normal. The child is then referred to a uni-
A. −2.00 + 2.00 × 90
versity hospital ED for a stat MRI of the brain. The
B. −2.00 + 2.00 × 120
patient’s mother is charged $4000 on her credit card
C. −2.00 + 2.00 × 60
because she cannot obtain a timely insurance referral
D. −1.0 sphere
because it’s a Sunday. The MRI is normal. The child is
2. A 30-year-old professional tennis player complains that
happily chatting with her mother in the ED room. The ED
she cannot see the ball that well while playing outside at
doc calls you, asking “what should we do next?” (You
nighttime even when outdoor lights are on. Vision with
may recall this is the clinical scenario presented in the
−2.00 D sphere OU contact lenses is 20/20 OD and OS. A
chapter text.)
manifest refraction, including Duochrome test, over the
A. Order an MRA-angiogram.
contacts is plano. What is the appropriate next step?
B. Observe the child: are they ambulating okay; are they
A. Reassure patient nothing is wrong, her best corrected
in any stress?
vision in 20/20.
C. Ask the child what she thinks is wrong or may help.
B. Order an ERG to rule out nyctalopia.
D. Order an OCT of the macula.
C. Try −2.50D sphere contacts for nighttime sports
E. B and C
activities.
5. Which of the following conditions is the LEAST likely
D. Try −1.50 D sphere contacts for nighttime sports
cause of acquired unilateral hyperopia:
activities.
A. Adie’s tonic pupil
3. A patient comes in for a 4-week postop appointment after
B. Choroidal melanoma
his planned ECCE. Manifest refraction OD shows +4.00D
C. Diabetes
cylinder at 80° (Fig. 8). Which suture can be considered
D. Central serous retinopathy
for removal at this time? The suture at:
E. Ciliary body tumor
A. A
B. B
C. C
D. D Answers
E. E
4. A 7-year-old wakes up on a Sunday morning blind in both 1. Answer: B. A dislocation (and presumed tilt) of the crys-
eyes. Her family takes her to a local optometrist who talline lens superotemporally of the right eye will induce
agrees the child is blind but cannot tell why. The patient plus cylinder (and associated myopic sphere to compen-
is then referred to a general ophthalmologist who diagno- sate) in the direction of the tilt. Correcting cylinder (plus
ses a likely occipital stroke, given the child is blind and cylinder) will be needed in the meridian corresponding to
the dislocation/tilt that will act at the axis located 90°
away (at 30°).
Enzenauer R, Morris W, O’Donnell, T, Montrey J. (2014). Functional
28
2. Answer: C. The patient is likely experiencing night
ophthalmic disorders: Ocular malingering and visual hysteria. https://
myopia and may appreciate a little stronger myopic pre-
doi.org/10.1007/978-3-319-08750-4
scription just for her nighttime outdoor sports. As dis- response was “Glasses!” It turns out that the child wanted
cussed in the text, a clinical examination and thorough to wear glasses because her friends all wore glasses. A
history should be sufficient to rule out organic causes of very expensive workup could have been avoided by ask-
nyctalopia. However, if the patient has a peripheral ing the right questions and keeping the diagnosis of
visual field defect or complains of seeing very poorly for NOVL (whether intentional or unintentional) in the back
all activities in the dark, then an ERG may be of one’s mind when encountering acute bilateral vision
considered. loss.
3. Answer: D. A tight suture at approximately location “D” 5. Answer: C. While diabetes can cause acquired bilateral
corresponds to 80°. Cutting the suture at C (approxi- myopia, it is an uncommon cause of acquired hyperopia,
mately 90°) or E (approximately 60°) may also be consid- especially unilateral hyperopia. Adie’s tonic pupil and
ered in the future, but at this time, cutting the suture at central serous retinopathy are both (relatively) benign
location D may have the most therapeutic effect. causes of unilateral hyperopia. Choroidal melanoma is a
4. Answer: E. As a follow-up from the clinical scenario pre- vision-threatening (and potentially life-threatening) cause
sented in the text, the child was sitting happily on her of unilateral hyperopia. A ciliary body tumor is more
mother’s lap in the ED room. When asked by the clini- likely to cause astigmatism with compensatory myopic
cian, “What do you think would help?,” her excited sphere.
Optics for Clinical and Surgical
Management of Strabismus
G. Vike Vicente
Objectives cally significant esotropia (20–30Δ). It can occur with any

• To apply previously discussed optics principles necessary refractive error including myopia or emmetropia, though
for the proper dispensation of spectacle correction to moderate hyperopia (approximately +4D) is most
patients with strabismus common.1
• To troubleshoot glasses in patients with strabismus The differential diagnosis must include infantile esotropia
• To understand the effect of refractive errors on the mea- (primary esotropia), cranial nerve six palsies, Duane’s syn-
surement of strabismus prior to surgery drome, and neoplastic causes, such as posterior fossa tumors.
Patients with AET usually will have full ductions but may
have inferior oblique overaction.
ptical Dispensing for Clinical Management
O There are several clinical examination considerations
of Strabismus with optics relevance when evaluating AET patients:
While many patients with clinically significant strabismus • Prior to dilation, the strabismus should be measured at
may ultimately require surgery, initial treatment consists of near and distance and with a + 3.0 D lens.
various nonsurgical strategies, including glasses, patching, • Dynamic retinoscopy should be performed while focusing
and use of therapeutic prisms. Examples of clinical prisms on an accommodative target at near (e.g., a small sticker).
are addressed in further detail in Chap. 2 “Prisms in The examiner should watch for with motion which may
Ophthalmic Optics”. Patching and other occlusion therapies help quantify the amount of hyperopia present.2
are beyond the scope of this optics text. Therefore, we will • It is crucial to fully cycloplege the patient in order to mea-
focus our attention on clinical management using glasses sure the full amount of hyperopia as the eventually dis-
and other optics principles previously discussed. pensed glasses should match the full cycloplegic
Note that there may be some overlap of material in this hyperopic refractive error. For example, if +3.00D sphere
chapter and the next chapter, given that many patients with OU is measured during the cycloplegic refraction, then
strabismus will inevitably be pediatric patients. These two +3.00D glasses should be issued. Do not reduce or adjust
chapters should be read consecutively so that the material the power of the glasses for AET patients.
from one chapter complements your understanding of the • Dilation of AET patients involves using three sets of
material from the other chapter. cyclopentolate drops given every five minutes and waiting
at least 40 minutes for its full effect. Be wary of the over-
zealous resident who dumps an entire bottle of dilating
Accommodative Esotropia (AET) drops while doing a half-nelson wrestling choke on a
screaming 2-year-old!
Accommodative esotropia (AET) usually presents around • Watch for anticholinergic effects of the administered
2–3 years of age (range 6 months to 7 years). AET can be drops (psychosis, tachycardia, gastroparesis, dryness,
familial, present acutely or slowly, and demonstrate clini- flushing).
G. V. Vicente (*) American Academy of Ophthalmology. Basic and Clinical Science

1
Clinical Pediatrics and Ophthalmology Georgetown University Course, Section 6 Pediatrics, 2020–2021. San Francisco, CA: American
Hospital, Washington, DC, USA Academy of Ophthalmology, 2021
Eye Doctors of Washington, Chevy Chase, MD, USA Recall the “SPAM” mnemonic from Chap. 15 Glasses in Clinical
2
e-mail: vvicente@edow.com Practice: “Same (with) motion, add Plus; Against motion, add Minus”

340 G. V. Vicente
a b
+5D
+2D
+3
c d
+3 -2D +5D
+5D
Fig. 1 Panel A represents a + 5D hyperopic eye with relaxed accom- to accommodate +3D. Therefore, initially, with the +5.0D glasses and
modation (i.e., no accommodation generated by the patient). Note the generating +3.00D accommodation, she will see like a − 2.0D myope
significant uncorrected refractive error. Panel B represents the child and complain of blurry distance vision. In panel D, atropine has been
generating 3D of accommodation constantly, decreasing the refractive given so that the child is no longer in a constant accommodative state
error to approximately +2 D. Blurry vision still remains. In Panel C, and is able to see clearly at distance with the +5.0D glasses
suppose that this child is given +5D glasses, she will initially continue
It is important to discuss the following points with the acuity. If AET is not treated, then a non-accommodative
parents of the child: surgical esotropia may develop in addition to the existing
AET.
• It may take some time for the child to adjust to the • Educate the parent that over the next few months, it is
glasses. The child who has been constantly accommo- normal to see worsening of eye-crossing when the glasses
dating will continue to do so, even with the glasses in are not worn.
place, causing an initial period of blurry distance vision. • If the glasses do not control the AET, then strabismus
The child may initially (and correctly) observe, surgery may be necessary within 6 months. Reassure the
“Mommy, everything far away is blurry with these parents that it is not their fault that this condition
glasses on!” In turn, the mom (or dad) may think to her- occurred. It wasn’t screen time or dim light or anything
self/himself, “Well, the glasses do seem rather thick and the parents did.
might be too strong, and the eye doctor seemed very • Some kids may outgrow this condition over the next
young… Maybe they gave my child the wrong prescrip- ten years, especially if one of the parents is a high
tion or maybe the optical lab messed up the glasses?” myope. Kids who do not tolerate weaning the glasses
To avoid this scenario, a short course of cycloplegic may wear contacts or undergo excimer laser refractive
drops may be helpful: 1 drop of atropine 1% OU once a surgery (ELRS) as adults if they are suitable
day for 1–3 days. Some doctors even recommend plac- candidates.
ing the atropine drops on the same day the child comes • The doctor may need to try several different strengths of
back to pick up the frames. Fig. 1 graphically displays glasses even after the initial dispensed glasses, including
the effects of immediate, persistent accommodation of a potentially prescribing bifocal glasses (especially in the
child with +5D hyperopia after receiving the full cor- presence of high AC/A ratio, which is discussed in the
rection glasses. next section).
• Remind the parent that wearing the glasses cannot harm • Historically, the teaching was that glasses do not affect
the child. However, not wearing the glasses will perma- the amount of hyperopia; the hyperopia may fluctuate
nently harm the child by worsening amblyopia and stereo until age 7 and then slowly decreases, regardless of
Optics for Clinical and Surgical Management of Strabismus 341
whether the child wears the glasses or not.3 However,

recent studies have called this teaching into question.4
After the initial dispensing, the child will need to be fol-

lowed up within 4–6 weeks. At this visit, in addition to mak-
ing sure the frames fit the child well, several other
considerations should be kept in mind:
• If the strabismus is fully controlled at near and distance

when the glasses are worn, then the patient should con-
tinue wearing glasses full time and follow up every
6 months to continue to check for amblyopia, strabismus,
and change in hyperopia. A cycloplegic refraction is typi-
cally performed every other visit to measure the latter.
• However, if there is still crossing at distance and the child
Fig. 2 A bifocal segment that is too low (bottom figure) will not help
has been diligently wearing the glasses, then a second control the esotropia in patients with high AC/A. The bifocal line must
cycloplegic refraction with atropine (instead of cyclopen- intersect the pupil
tolate) should be performed to try to unmask any latent
hyperopia not detected during the original visit. If the pre- (+3.00 add) that intersects the pupil.7 Unfortunately, a very
vious refraction is confirmed, then the patient may have common error is for the optical shop to make the glasses with
partially accommodative esotropia (see below) and the usual “short” bifocal segments given to adults (Fig. 2).
require glasses and strabismus surgery. If additional Long term, if the child is now a tween and still needs an
hyperopic refractive error is found, then the stronger add at near to control their AET, then a progressive style lens
glasses should be issued. could be used but with great care. The progressive add should
• If the patient is orthophoric at distance but still has esotro- be fitted 4 mm higher than an adult lens. Is the child still
pia at near when the glasses are on, then the patient has a ortho and with good stereoacuity at near with the new glasses
high AC/A (accommodative convergence/accommoda- on? Is accommodation and reading okay?
tion ratio).
artially Accommodative Esotropia (Partial AET)
P
If esotropia at near or distance persists despite glasses with
atients with High Accommodative
P the full “cycloplegic refraction,” a second cycloplegic refrac-
Convergence/Accommodation Ratio (High AC/A) tion (including potential use of atropine 1%) should be con-
This type of patient is a subset/variant of AET. In brief, if the sidered. During this repeat refraction, if significant diplopia
patient is orthophoric at distance but still has intermittent ET or crossing (>8PD) persists at near and distance, then partial
at near, then it is likely that a high AC/A ratio exists.5 These AET is likely present, and strabismus surgery may be neces-
patients often have an average of +2.25D hyperopia6 but sary in addition to glasses. Most surgeons base the amount of
over-converge for a given amount of accommodation, espe- surgery on the near deviation present with glasses, while oth-
cially when compared to the previously discussed AET ers may base their amount of surgery on the distance mea-
patients. Therefore, our goal should be to reduce the patient’s surement and use a Faden procedure if the crossing at near is
exuberant convergence that happens during accommodation greater than the crossing at distance. A full discussion of the
by giving additional plus power for near vision tasks. High preferred surgical technique is beyond the scope of this text-
AC/A patients will benefit from a flat top bifocal prescription
As you read this, you may be wondering if we are violating our rule
7
Atkinson J, Anker S, Bobier W, Braddick O, Durden K, Nardini M,

3 from Chap. 12 Glasses for Written Exams, wherein we said to avoid
Watson P. Normal emmetropization in infants with spectacle correction giving flat-top bifocals to hyperopes whenever possible. However, there
for hyperopia. Invest Ophthalmol Vis Sci. 2000 Nov;41(12):3726–31 are several important considerations when considering pediatric
patients. First, image displacement is better tolerated by kids as com-
4
Chang JW. Refractive error change and vision improvement in moder- pared to adults. Second, prevention of amblyopia supersedes subjective
ate to severe hyperopic amblyopia after spectacle correction: Restarting visual complaints. Finally, in real-world optical practice, flat-tops are
the emmetropization process? PLoS One. 2017 Apr 19;12(4):e0175780 more commonly prescribed, regardless of refractive error, because they
A mild degree of esophoria is acceptable at near with the glasses on,
5
are cheaper to make and the problem of image displacement is thank-
but there should be no actual esotropia or intermittent esotropia. fully not as visually debilitating as it theoretically seems. Recent
This is a key difference between AET patients and AC/A patients. AET
6
advancements in lens construction, such as “digital lenses” (laser-
patients usually have higher amounts of hyperopia, whereas AC/A etched lenses), have further minimized previous generation image jump
patients have low-moderate amounts of hyperopia. and displacement effects.
342 G. V. Vicente
book. Instead, you should know that a percentage of patients activation of the near triad due to uncorrected accommo-
will likely fail nonsurgical interventions as described above dative needs.8 This may occur either due to poor compli-
and may eventually need strabismus surgery. ance with reading glasses or because their progressive
glasses are not meeting their accommodative needs. As
dults with Accommodative Esotropia
A such, the increased accommodative demand can lead to
It is not uncommon for AET to recur or worsen in patients in worsening esotropia. These adult ET patients may be told
their late 20s. These patients may require a bifocal or readers by initial providers that reading glasses should be worn as
at a younger age than their peers. Advanced cases of recur- needed for reading; however, if there is any esotropia
rence may ultimately require surgery as well. present, then they must be encouraged to wear dedicated
reading glasses (single vision reading glasses), bifocal or
ther Considerations for Patients with AET
O progressive with a high add, and a segment of proper
There are several other considerations for patients with AET, height.
especially as they get older and present for contact lenses,
ELRS, and/or cataract surgery.
Convergence Insufficiency (CI)
• Avoid monovision, whether through contact lenses,
ELRS, or cataract surgery, in patients with good stereo- Convergence insufficiency (CI) has a bimodal distribution,
acuity and intermittent strabismus. The difference in affecting both young and old patients. In younger patients,
refractive error between the two eyes induced by the inter- CI may not become symptomatic until 7–10 years of age,
vention may impair fusion and worsen their control on the when convergence demands for near tasks (such as reading
intermittent strabismus. However, if the patient has a his- in school) exceed the patient’s ability to converge. In older
tory of suppression, amblyopia, and/or well-controlled patients, CI may occur as a result of natural aging but also
strabismus, monovision may be an option. It is crucial for with pathological disease such as brainstem disorders and
the non-strabismus ophthalmologist to be aware of these Parkinsonian neurodegenerative disorders.
conditions prior to any surgical intervention to avoid an CI can be diagnosed in the office with a good history and
unhappy patient (and eventual referral to a neuro- two simple tests. Important questions to ask during the his-
ophthalmologist or strabismus specialist)! tory include:
• It is important to avoid prolonged postoperative blurry
vision in patients with intermittent strabismus. For exam- • Asking the patient about fatigue or binocular diplopia
ple, if an unexpected refractive error occurs after first eye during reading
cataract surgery, the patient may need temporary glasses • Asking about asthenopia symptoms (see Chap. 21 Clinical
or contact lenses until the appropriate intervention (e.g., Problems with Optics and Refractive Manifestations)
IOL exchange, piggyback IOL, staged ELRS, or second • Asking the patient if he/she tends to close one eye when
eye cataract surgery) can take place. Additionally, pro- reading.
longed corneal edema may worsen strabismus control – • Asking the patient and/or parent how long does it take for
surgeons may wish to use additional topical steroids and/ the symptoms to occur. For example, if little Suzy is able
or hypertonic saline to accelerate resolution of corneal to play a game she enjoys on her mom’s cellphone for two
edema. hours but then complains of “reading problems” after
• In myopes with a history of AET, it is important to avoid 5 minutes, then maybe it’s not her eyes.
even slight hyperopic over-corrections with ELRS and/or • Obtaining a good medical history (e.g., asking about hand
cataract surgery. Postoperative hyperopia may lead to tremors) and family history (e.g., history of relatives with
greater accommodative demand and recurrent Parkinson’s disease, etc.)
ET. Therefore, erring for slight myopia (−0.25 to −0.50D)
may be a safer surgical option, even for ELRS surgery. Two in-office tests are especially useful:
1. The easiest is the near point of convergence (NPC) test,

Adult Esotropia (Adult ET) which is not the same as the optical near point. The NPC
can be found by first having the patient wear his/her
While there are many causes of adult esotropia (adult ET), habitual near correction; the examiner can then move an
we will focus on those related to optics.
For example, some strabismologists have noticed an
Guyton DL. The 10th Bielschowsky Lecture: Changes in strabismus
8
increased prevalence of adult ET in early presbyopes. One over time: The roles of vergence tonus and muscle length adaptation.
possible explanation is that some patients have a chronic Binocular Vision & Strabismus Quart 2006; 21:81-92
accommodative target (e.g., a target with small print) working distance and actually made the convergence symp-
slowly closer to the patient until one eye drifts out or the toms worse!
patient reports seeing double. Most patients can sustain So what should the “non-novice” practitioner do? Some
converging their eyes up to 5 cm from their nose; patients additional palliative options for this patient can be tried, in
with CI may report symptoms (or you may notice eye the following order:
drift) at a longer distance (range 10–30 cm).
2. The second test is the convergence amplitude (CA) test. 1. Offer a lower + 2.00 add which will create a longer work-
The CA test is performed by using a base-out horizontal ing distance. You can reassure the patient he/she can still
prism bar (in a pinch the rotary prisms in a phoropter may read larger font but may have difficulty with extremely
work too). The prism bar’s 2 PD segment is held in front fine print: “You may not be able to read the stock pages
of either eye, while the patient is focusing on a near target but you will see less double.” This may be especially use-
using their normal reading correction. The bar is then ful in current times since many older patients are using
slowly raised up to 35 PD. Most patients should be able to electronic tablets and reading devices to make the font
maintain a single object up to this prism. Patients with CI larger.
will have one eye drift out and see double when the bar 2. Try 5–7 PD base-in prisms OU in single vision reading
reaches 10 or 15 PD base-out. glasses in the office in trial frames; if helpful, the patient
can then purchase the glasses.
Here are two real scenarios in which optics may be help- 3. Try 8–12 PD Fresnel base-in prisms that are cut in such a
ful for patients with CI: manner so as to only cover the reading segment over the
non-dominant eye (for more on prisms please see Chap. 2
Scenario #1 A 22-year-old cramming for the LSAT exam “Prisms in Ophthalmic Optics”).
reports: “Doctor, I see double when I read more than 30 min- 4. Taping one bifocal segment with opaque tape. This should
utes. I have my exam in 3 weeks, I do not have time for eye be the last resort.
exercises to work.”
Additional CI treatment options consist of convergence
In this scenario, in order to meet the immediate, time- exercises using stereograms that can be performed by the
sensitive needs of the patient, we can prescribe a pair of patient at home. It is important to note that pediatric CI
monofocal reading glasses with 5–7 PD base-in prism OU in patients respond better to exercises as compared to adult CI
order to help alleviate his symptoms in the short term. The patients – as the saying goes, “you can’t teach an old dog
patient can try these “reading glasses” in a trial frame in the new tricks.” These can be provided by an orthoptist, an oph-
office. We can first have the patient read for ten minutes with thalmologist, a developmental optometrist, or a pediatric
their usual correction and then offer the trial frame with addi- optometrist. For pediatric CI patients, convergence exercises
tional prism power to see which strength is preferred. can be done as “outpatient therapy” in the office; as these are
Another option may be to give a reading add, though this quite expensive, they should be reserved primarily for
may be difficult for a non-presbyope to adjust in a short patients with poor home compliance.9
period of time. Finally, habitual modifications, such as advis- This last point is somewhat counterintuitive but bears
ing the patient to hold books further away, may additionally worth mentioning. Some specialists may actually prescribe
help decrease convergence demands for near. base-out glasses (as compared to the previously discussed
base-in prisms) in order to treat pediatric CI. While the base-
Scenario #2 A 78-year-old with a hand tremor complains, out glasses do not help the symptoms (they may initially
“Doctor, I’m having a hard time reading the paper. Closing worsen the symptoms), they may force the patient to con-
one eye helps but my face gets tired after a while so I gave up verge and develop larger fusional amplitudes. Think of this
reading.” approach like sending the patient to the gym: you have to
break down muscles in order to build them up. Similarly,
In this scenario, novice practitioners would simply hear “I base-out glasses will force the pediatric patient to develop
can’t read” and give an additional reading add (e.g., a + 3.00D “stronger” convergence abilities. This approach is not very
add instead of the +2.50D they had). But you, dear reader, helpful with adult CI patients.
are no novice! Suppose that the patient returns 1 week later,
now complaining: “Doctor, with these new glasses I have to
hold the paper closer and the double vision is worse!”
What happened? Closing one eye is a sign of diplopia; it 9
Convergence Insufficiency Treatment Trial Study Group. Randomized
is possible that the +3.00D add essentially shortened the clinical trial of treatments for symptomatic convergence insufficiency
in children. Arch Ophthalmol. 2008 Oct;126(10):1336–49
344 G. V. Vicente
Exotropia and Over-Minus Lenses onsiderations for Strabismus Surgery

C
in Patients with High Refractive Errors
As with many things in life, we are initially taught certain
rules should never be violated, only to later learn that there For patients with minimal refractive errors, strabismus mea-
are exceptions to this rule. For example, as first-year resi- surements taken while a patient is wearing his/her glasses
dents, you may recall being taught that you should never may not be significantly different from measurements taken
over-minus a patient; this is a sin second only to sleeping without glasses. However, in the setting of high refractive
with contact lenses overnight.10 errors, especially myopia, measurements with glasses may
However, there are two notable exceptions to this rule. significantly vary from measurements without glasses.
The first exception is “extra-minus” correction given to night Recall that both plus and minus lenses can be thought of as
time athletes or for the treatment of night myopia, as dis- two prisms arranged together; the prismatic effect is espe-
cussed in Chap. 21 Clinical Problems with Optics and cially pronounced when patients look away from the optical
Refractive Manifestations. The second exception is for a center (Fig. 3).
young patient with intermittent exotropia (XT) who already Consider a high myope patient wearing his/her glasses
wears minus glasses. without strabismus. When this patient looks through the
As residents we are taught to never ever over-minus a optical center of the glasses, there is essentially no prismatic
patient. However, there are two exceptions to this rule. The deviation induced. However, now consider the same high
first, night time athletes, night time pilots, or truckers are myope patient with either an esotropia (ET) or exotropia
addressed in the Night Myopia section. The 2nd exception is (XT); given that the patient will look nasal or temporal to the
a young patient with intermittent exotropia who already optical center, respectively, this patient will have additional
wears glasses.11 prismatic deviation as mentioned in previous discussions on
For example, consider an 8-year-old patient who is Prentice’s Rule.
a − 1.00D sphere who also has intermittent XT. This patient Now suppose our myopic patient had a significant XT:
may be given 2–4D of “extra” minus power in both eyes. this means that our patient will basically be looking
This “base-out” effect at distance caused by the over-minused through the temporal portion of the minus lens, which
glasses may then stimulate increased convergence to combat will cause additional base-out effect and worsen his
the induced worsening of the XT to neutralize the divergent XT. If we measure this patient’s deviation with his glasses
strabismus. It is important to note that this approach will usu- on, we will not only have to neutralize the pre-existing
ally work only with younger patients; patients after age 20 XT but also have to neutralize the “additional” XT caused
may get headaches and may not be able to generate the by the glasses. Therefore, if we measured his XT with the
needed convergence to combat the worsened XT. glasses on, we will falsely over-measure this patient’s
As for hyperopic young patients with XT, they should be XT.
given partial strength glasses (approximately 2.0D less than This leads us to a simple but important rule: “Minus mea-
the hyperopic cycloplegic refraction if they have >4.0D of sures more.” In other words, if a patient is wearing his/her
hyperopia or 1.5D of hyperopic anisometropia). This is myopic correction glasses and we measure the strabismus
another one of those rare situations where less than the full with the glasses on, we will falsely over-measure the patient’s
cycloplegic refraction is given to a hyperopic patient with true deviation.
strabismus. Forgetting this rule may lead to the following scenario:
Dr. Ima Havingabaday gets a call from his 1-day post-op
myopic patient who had a bilateral lateral rectus recession
se of Prisms for Clinical Management
U for 60 PD of intermittent XT. The patient frantically exclaims
of Strabismus over the phone: “Doc, I am seeing a lot of double vision. You
said that could happen but I look very crossed-eyed!” Dr.
Please see Chap. 2 “Prisms in Ophthalmic Optics”, for addi- HBD, as she is known around these parts, agrees to have the
tional discussion of using prisms in clinical practice to man- patient come in urgently. Repeat examination today confirms
age strabismus. that the patient now has 12Δ of consecutive esotropia and
will likely need to go back to the OR. The patient appears
crestfallen and reaches for his phone to start an angry online
review…
Actually no, sleeping with contact lenses is the only unforgivable sin
10 What may have happened? When Dr. HBD reviewed the
in ophthalmology. Everything else is negotiable. chart, the optics mistake became all too clear. The patient’s
Watts P, Tippings E, Al-Madfai H. Intermittent exotropia, overcorrect-
11
strabismus was measured while the patient was wearing her
ing minus lenses, and the Newcastle scoring system. J AAPOS. 2005
−10 D glasses. For example, consider that our patient actu-
Oct;9(5):460-4
Fig. 3 Prismatic effects of plus and minus lenses. Note that the prismatic deviation increases as the patient looks further away from the optical
center of the lens.
Fig. 4 “Minus Measures

More.” In this example, the
−10 D sphere glasses confer a
base-out effect given the
pre-existing exotropia that
causes the patient to look
temporal to the optical center.
Therefore, the measured 48∆ LXT
exotropia (approximately 60
PD) is significantly more than
the actual exotropia (48 PD)
-10.00 60∆
60
ally had approximately 48 PD of exotropia without his Prismatic effect = ( 2.5 ) ∗ ( D ) %

glasses on. However, when wearing his −10D glasses, the
measured exotropia increased due to the base-out effect of where D = spectacle power. We can see that higher refractive
the high minus lenses (Fig. 4). errors will cause a higher prismatic effect. For our previous
The 60 PD that were measured were therefore “too patient, these −10D sphere lenses will have a 25% prismatic
much” – instead of performing surgery for 48 PD XT, Dr. effect on the measurement. We can then calculate:
HBD accidentally did surgery for 60 PD XT, leading to the 0.25∗ 48∆ = 12 PD
surgical over-correction, consecutive esotropia, and a poor
online review. This minus lens will measure 12 PD additional XT on top
So far, we have said that “minus measures more.” But of the actual 48 PD XT, leading to the erroneous measure-
how much more? A detailed discussion on this quantification ment of 60 PD XT.
is best left for a strabismus text, but for now, we can use the Interestingly, minus lenses will have the same effect
following approximation: whether the patient has an XT or ET! For our second exam-
346 G. V. Vicente
ple, let’s suppose a new myopic patient has a 48 PD the left lens, which would confer a b ase-in effect (Fig. 6).
LET. Given her LET, our patient will look nasal to the optical This would actually reduce the measured prism to approxi-
center of the left lens (Fig. 5). However, in this example, mately 48 PD. The examiner must realize that there is a pris-
there is additional base-in effect from the minus lens. It will matic effect due to the glasses in addition to the actual
appear to the viewer and the patient that there are 60 PD ET LXT. If the “glasses-on” measurements were used, there
instead of the true 48 PD ET. This would lead to a similar would be a surgical under-correction of the LXT.
surgical overcorrection of this patient as well. In order to avoid this problem, we can either apply the
Plus lenses have the opposite effect of minus lenses. For above formula (preferred) or measure the strabismus without
our third example, suppose we have a hyperopic patient glasses. However, this might not be possible in patients with
wearing +10D sphere glasses with a 60 PD LXT. Due to the large refractive errors, especially hyperopic refractive errors,
LXT, our patient will look through the temporal portion of because without glasses, the patients may accommodate and
Fig. 5 “Minus Measures

More.” In this example, even
if the same left eye were
esotropic, the patient would
be looking through the
base-in prism portion of this
myopic lens. This would
similarly lead to a false over
measurement of their
strabismus 48∆ LET
-10.00
60∆
60∆ XT
+10.00
48∆ XT
48
Fig. 6 Effect of plus lenses on measured strabismic deviation. In a hyperopic patient with LXT, the left eye will look through the temporal portion
of the lens. The induced base-in prism will cause an underestimation of the true amount of XT
converge, further muddying the measurements. A third strat- • VA sc 20/25 OD and OS

egy may be to measure the strabismus while having patients • VA cc 20/40 OD and OS
wear contact lenses as a compromise between maintaining • He is orthophoric with his glasses on and has 25 PD of
correction of refractive error while avoiding unwanted pris- Esotropia at near and distance without glasses. Your next
matic effects. step should be:
A final note on this subject: even though minus lenses A. Re-refract the patient and confirm if the previous
measure more strabismus, it is important to note that the cycloplegic refraction was correct.
minification effect of high minus lenses will minimize the B. Tell the parents to insist on the child wearing the
appearance of strabismus. Hyperopic lenses will exaggerate glasses.
the appearance of strabismus due to their magnifying effect, C. Consider bilateral medial rectus recession because the
while decreasing the amount of strabismus measured. glasses are not working.
D. Give a drop of atropine 1% OU to help relax his accom-
modation and transition into his hyperopic correction.
Practice Questions
1. If a −16D sphere OU esotropic patient measures 42 PD

ET with her glasses on, what angle of deviation would Answers
you operate for?
A. 54 PD ET 1. Answer: B. Prismatic effect % = (2.5) * (D) %, 2.5 X
B. 30 PD ET 16D = 40%; thus, a −16D will have a 40% increase in the
C. 32 PD ET measurement. Therefore, the true measurement was 30
D. 25 PD ET PD, 40% of 30 = 12PD, Minus Measures More,
2. If a + 10D aphakic OU patient measures 15 PD XT, what 30 + 12 = 42 PD.
amount of deviation would you operate for? 2. Answer: A. 2.5 X + 10D = 25% prismatic of under-
A. 20 PD XT measurement. If the true deviation was 20PD, then 20 X
B. 25 PD XT 0.25 = 5PD prismatic effect. (Plus Measures Less)
C. 10 PD XT 20−5PD = 15 PD measured XTcc.
D. 12 PD XT 3. Answer: D. The child is fogging himself by chronically
3. A 3-year-old comes back for a 6-week follow-up after accommodating; one or two doses of atropine 1% should
purchasing his first pair of glasses for accommodative help. Re-refract if this does not work or if there is still
esotropia. His parents state he refuses the glasses. You crossing at distance with the glasses on. Strabismus sur-
measure the glasses and they are made correctly: +3.50 D gery is NOT indicated because the glasses are controlling
sphere OU and are equal to your last cycloplegic refrac- the esotropia when they are worn.
tion. The frame appears to fit the child well. You measure
the child’s vision:
Pediatric Optics
G. Vike Vicente
Objectives ncorrected Ametropia and Risks

U
• To discuss the importance of treating refractive errors, of Amblyopia
including hyperopia, myopia, and astigmatism to prevent
amblyopia in pediatric patients Adults with refractive errors (ametropias) may primarily
• To review several special circumstances wherein extra complain of blurry vision; usually, with successful refraction
consideration for the construction of glasses may be (glasses or contact lenses), the refractive error is neutralized
needed, such as bifocals for aphakia, accommodative and patients have excellent vision, even if they have gone
insufficiency, and treatment of accommodative esotropia months or years without glasses. In children, especially from
• To highlight important features of constructing and dis- birth to puberty, significant ametropias (especially uncor-
pensing glasses in children rected unilateral refractive errors) may lead to permanent
• To introduce key principles of contact lens dispensation in visual loss in the form of amblyopia or loss of stereoacuity.
pediatric patients As with the rest of medicine, doctors should intervene if
• To briefly discuss advanced topics, such as myopia con- something is bothering or harming the patient. This applies
trol, which are of significant interest among practitioners to issuing glasses in children. Most adults wear glasses
currently because the uncorrected refractive error bothers them. With
children, we must be aware that uncorrected refractive errors
can cause permanent harm to a child’s sight in the form of
Introduction amblyopia or loss of stereoacuity.1 Thanks to the use of
photo-screeners and primary care vision screening, many
One of the most common questions from my comprehensive children with amblyopia risk factors are found early enough
ophthalmology colleagues is: If a child has “x” cycloplegic to treat successfully.2 Children with a diagnosis of amblyo-
refraction, what prescription should I actually give? Is it “x” pia, or with significant risk factors for amblyopia, should be
or do I need to change it to “y”? While the dispensation of treated without delay in order to prevent any or additional
glasses and contact lenses has been previously discussed in irreversible vision loss.
Chap. 15, “Glasses in Clinical Practice”, this chapter will
instead focus on a very cute, very unique (and occasionally
frustrating!) segment of the human population that is not old
enough to drive but makes it all worthwhile if you can suc-
cessfully improve their vision.
G. V. Vicente (*) DeSantis D. Amblyopia. Pediatr Clin North Am. 2014 Jun;
1
Clinical Pediatrics and Ophthalmology Georgetown University 61(3):505–18.
Koo EB, Gilbert AL, VanderVeen DK. Treatment of Amblyopia and
2
Eye Doctors of Washington, Chevy Chase, MD, USA Amblyopia Risk Factors Based on Current Evidence. Semin
e-mail: vvicente@edow.com Ophthalmol. 2017;32(1):1–7

350 G. V. Vicente
riteria for Unilateral Versus Bilateral

C Table 1 Guidelines for refractive correction in infants and young
Amblyopia children
Refractive error (diopters)
Amblyopia can occur in one eye or both the eyes. Unilateral Condition < 1 year 1–2 years 2–3 years 3–4 years
Isometropia
amblyopia is defined as patients with an amblyogenic factor
Myopia −5.0 −4.0 −3.0 −2.5
and:
Hyperopia without +6.0 +5.0 +4.5 +3.5
esotropia
• Asymmetrical objection to monocular occlusion or Hyperopia with +2.0 +2.0 +1.5 +1.5
• Failure to initiate or maintain fixation or esotropia
• Interocular difference of two or more octaves with Teller Astigmatism 3.0 2.5 2.0 1.5
fixation preference cards or Anisometropia without
strabismus
• Interocular difference of two or more lines in visual acu- −4.0 −2.5
Myopia −3.0 −3.0
ity charts.3 Hyperopia +2.5 +2.0 +1.5 +1.5
Astigmatism 2.5 2.0 2.0 1.5
Bilateral amblyopia is defined as: Reproduced with permission from the American Academy of
Ophthalmology Pediatric Eye Evaluations Preferred Practice Patterns
• Limited best corrected visual acuity <20/50 in patients 2017 Guidelines
3–4 years old
• Worse than 20/40 in patients 4–5 years old and intervention (such as patching and use of cycloplegics) may
• Worse than 20/30 in patients older than 5 years old be necessary.
Risk Factors for Refractive Amblyopia Dispensing Glasses in Children
The type and quantity of refractive error increases the risk of Please review the section in Chap. 15, “Glasses in Clinical
amblyopia depending on the patient’s age. Some types of Practice”, that discusses considerations for prescribing
refractive errors are more dangerous than others! Table 1) glasses in children, such as principles of frame fitting and
below lists cut-off values and guidelines for which clinicians sizing. In this section, we will discuss several additional key
should be concerned about a significant risk of amblyopia. principles.
Note that these values are based on consensus as there are
not many rigorous published data for guidance. Ultimately,
the clinician should use these guidelines and customize mon- Visual Acuity Needs in Children
itoring and therapy based on each individual patient. For
example, the cut-off values should be lower if a child has For children without amblyopia or strabismus, there are no
anisometropia with strabismus. set guidelines regarding how much or what kind of refractive
The key point here is that if refractive amblyopia is caught error merits glasses correction. Most clinicians will dispense
early (when the vision is better than 20/80), it can often be glasses if a child’s refractive error is causing symptoms, such
treated with glasses alone.4 Therefore, it is important to as blurred uncorrected near or distance vision <20/40.
remind patients that glasses are primarily treating (and pre- Wearing glasses is optional as long as the uncorrected refrac-
venting) amblyopia, not just the refractive error. If the tive error is not harming the child’s vision or affecting their
amblyopia does not improve with glasses alone, then further learning.5 This threshold may change with time; for example,
an older child may be more discerning than a younger one, as
they may have to read smaller print on a classroom board or
Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA,
3 a page.
Christiansen SP; American Academy of Ophthalmology Preferred In kindergarten (age 5–6 years), most activities are hands
Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric on and up close; this keeps the child’s attention primarily for
Eye Evaluations Preferred Practice Pattern®: I. Vision Screening in the
near vision tasks. Patients with low myopic refractive errors
Primary Care and Community Setting; II. Comprehensive Ophthalmic
Examination. Ophthalmology. 2018 Jan; 125(1):P184–P227. may not complain of any difficulty with these tasks (espe-
4
Cotter SA; Pediatric Eye Disease Investigator Group, Edwards AR, cially if given the chance to play with mom or dad’s cell
Wallace DK, Beck RW, Arnold RW, Astle WF, Barnhardt CN, Birch
EE, Donahue SP, Everett DF, Felius J, Holmes JM, Kraker RT, Melia
M, Repka MX, Sala NA, Silbert DI, Weise KK. Treatment of anisome- Interestingly, as discussed in Chap. 21, these days there may be a fair
5
tropic amblyopia in children with refractive correction. Ophthalmology. number of school-age children who present actually wanting glasses
2006 Jun;113(6):895–903 because it is the “cool” thing to wear in school...
Pediatric Optics 351
phone!). However, when the child is presented with distance Table 2 Comparison of measured in-office cycloplegic refraction for
vision tasks, such as looking at the teacher or blackboard, he/ hyperopic pediatric patients and glasses dispensed
she may complain of blurry vision. Also, objects in the Patient age Cycloplegic refraction OU Glasses to be
periphery may distract the child. (Years) (D) dispensed
Langford et al. showed that most distance visual acuity 2, no strabismus +4.0 None
2, with +4.0 +4.0
demands in KG through second grade are comparable to strabismus
20/200 vision; in grades 3–5, 20/80 visual acuity is needed.6 2, no strabismus +7.0 +5.5
For near activities (approx. 16 inches) in this age range, the
visual acuity demand ranges from 20/100 to 20/500. This is
helpful not only for dispensing glasses, but also vision reha- enough accommodation to compensate for his/her hypero-
bilitation needs. For example, most low vision specialists pia. As children can accommodate easily, most physicians
will try to achieve at least 20/40 vision for the patients will “shave off” 1.5–2.0D from the cycloplegic refraction
through optical aids, such as loupes or telescopes for patients when dispensing glasses. If patients have concurrent hypero-
in this age range. Please refer to Chap. 19, Low Vision and pia with accommodative esotropia (AET) then the full cyclo-
Vision Rehabilitation for more information on this topic. plegic hyperopic refraction is issued. See Chap. 22, “Optics
As children continue to grow older (after age 10), visual for Clinical and Surgical Management of Strabismus”, for a
acuity needs are approximately the same as adult patients. more detailed discussion regarding AET.
A child who appreciates the glasses will confirm the phy- Table 2 may be helpful to illustrate the in-office cyclople-
sician’s suspicion that the benefit in vision outweighs the gic refraction (CRx) vs. the dispensed glasses. Note that in
nuisance caused by the frames. However, there may be a sig- patients without strabismus, the CRx is adjusted; however, in
nificant number of pediatric patients that do not accept wear- patients with strabismus, the full CRx is given.
ing glasses for other reasons as discussed in Chap. 15, Remember that a young patient without strabismus, who
“Glasses in Clinical Practice”. To summarize, if the refrac- is incorrectly issued the full cycloplegic refraction will
tion is accurate and the child refuses to wear the glasses, (unintentionally) continue to accommodate and fog them-
other factors to consider include the following: selves by 1.5–2D, thus seeing blurry at distance with the
glasses just like an uncorrected −1.5D myope. See Fig. 1 in
• An error in the lenses Chap. 22, “Optics for Clinical and Surgical Management of
• Poor fitting frames Strabismus”, for a detailed illustration of this concept.
• Cosmetic reasons If a child with strabismus needs to wear his/her full CRx
• Psychosocial reasons glasses, then a drop of atropine 1% may be placed in both
• Poor parental compliance and/or parental support eyes at the time he/she receives the glasses to help relax
• Somewhat simple, but paradoxical: the child may feel that accommodation and transition into the full-strength hyper-
his/her uncorrected blurred vision is not bothering him/ opic glasses. Arm splints have fallen out of favor
her that much (thankfully!).
Finally, it is important to reassure the parents that it may
take a few days for the child to get used to wearing glasses,
regardless of whether or not the child has any concurrent
Hyperopic Refractive Errors strabismus.
Most children are born with low levels of hyperopia: this

may be benign and asymptomatic, especially as the eye con- Myopic Refractive Errors
tinues to grow.7 As discussed above, kids with moderate
hyperopia or anisometropic hyperopia should be given While common in teens and adults, myopia in young chil-
glasses to prevent amblyopia. Children older than 4 years dren (including toddlers and infants) is less common; these
may require hyperopic correction if they have symptoms patients should undergo a comprehensive workup to rule out
with near vision. Checking near vision and dynamic retinos- any lens, glaucoma, collagen, and/or retinal abnormalities,
copy (See Chap. 17, “Optical Instruments and Machines”) especially if there is no family history of early myopia. As
prior to dilation is very useful in assessing if a child has the world of young children is mainly focused at near, low to
moderate myopia is often asymptomatic, well-tolerated and
does not merit glasses. If the child is symptomatic, if the
6
Langford A, Hug T. Visual Demands in Elementary School. J Pediatr
Ophthalmol Strabismus. 2010;47:152–156. refractive error exceeds −1.0D, or the child has <20/40
The commonly heard phrase, “Johnny grew out of his glasses,” may
7 uncorrected vision in the better eye, glasses may be strongly
apply here. considered.
352 G. V. Vicente
Table 3 Comparison of measured in-office cycloplegic refraction for Table 4 Comparison of in-office refraction versus the recommended
myopic pediatric patients and glasses dispensed dispensed refraction based on different refractive errors
Cycloplegic refraction Glasses to be Patient age Cycloplegic refraction OU Glasses to be
Patient age OU (D) dispensed (years) (D) dispensed
3 −10.00 −8.00 1 +1.00 + 1.00 × 90 None
4 −0.50 None 1 +1.50 + 3.00 × 90 Plano +3.00 × 90
5 (with intermittent −2.00 −4.00 1 Plano +3.00 × 90 −1.50 + 3.00 × 90
XT) 1 −2.00 + 3.00 × 90 −2.00 + 3.00 × 90
6 −1.25 −1.25
As discussed in Chap. 22, “Optics for Clinical and Astigmatic Refractive Errors
Surgical Management of Strabismus”, young patients with
intermittent exotropia (XT) may be given extra-minus (“over In general, younger patients tolerate glasses with the full
minused”) power glasses to help control the strabismus.8 astigmatism correction (regardless of type and/or quantity)
Wearing an additional -2D more than the myopic refractive better than adults. Recall that with adults, it is acceptable to
error will stimulate the patient to accommodate and induce reduce the astigmatism correction to ensure better tolerance,
convergence. For example, if a child with intermittent XT especially with high amounts of astigmatism and/or oblique
has −1.5D of myopia, −3.5D lenses may be tried. Studies astigmatism.
have shown that wearing this “extra” minus power did not With kids, it is a different story: we want to ensure that
accelerate or worsen myopia in these patients.9 amblyopia does not set in, so it is crucial to give the full
For most patients, the full amount of myopia measured astigmatism correct, regardless of the cylinder amount or the
with a cycloplegic refraction is issued. However, in patients axis of astigmatism. One rule of thumb recommended in
<4 years old with severe myopia (e.g., > -6D sphere), the these scenarios: if the spherical equivalent (SE) is plano or
final dispensed refraction can be reduced by 1–2D since hyperopic, then we can reduce the sphere by 1.5D (i.e., addi-
most of the child’s attention is at near, not distance. For tional minus sphere correction).
example, a 2-year-old child who is a -10D may be issued a -8D Table 4 may be helpful to illustrate the in-office refraction
glasses instead of the full -10D glasses. vs. the recommended dispensed refraction in an imaginary
Table 3 may be helpful to illustrate the in-office refraction pediatric patient (age 1 year) with significant astigmatism
vs. the recommended dispensed refraction in myopic and various spherical refractive errors.
patients.
Now for some controversy: there is much debate among
pediatric ophthalmologists regarding whether or not to inten- Prescribing Bifocals in Children
tionally under correct myopia with the long-term goal of
slowing myopic progression – sort of a short-term pain for Bifocals are rarely required in young patients. If a bifocal is
long-term gain approach. The idea behind this thinking is prescribed, the reading segment should intersect the pupil.
that intentional under-correction of myopia will limit accom- See Chap. 22, “Optics for Clinical and Surgical Management
modative demand and accommodative lag at near. The other of Strabismus”, for a detailed discussion regarding when
school of thought advocates an approach to intentionally bifocals may be needed.
over correct the myopia with glasses so that they last longer. The following types of pediatric patients may benefit
Some studies have shown an increased myopic shift when from bifocals:
young myopic patients are under-corrected.10
• Patients who have aphakia or pseudophakia (see the
below sections for more information on these special
situations).
• Accommodative esotropia (AET) with high AC/A
(accommodative convergence over accommodation). In
8
Rowe FJ, Noonan CP, Freeman G, DeBell J. Intervention for intermit- some patients with AET, spectacles with the full cyclople-
tent distance exotropia with overcorrecting minus lenses. Eye (Lond). gic refraction will help control the strabismus for dis-
2009 Feb;23(2):320–5 tance, but they will not work as well at near and a residual
9
Kushner BJ. Does overcorrecting minus lens therapy for intermittent esotropia may be present. In this case, a + 3.00D sphere
exotropia cause myopia? Arch Ophthalmol. 1999 May;117(5):638–42 add OU may be required.
10
Vasudevan B, Esposito C, Peterson C, Coronado C, Ciuffreda KJ.
• Accommodation Insufficiency (AI). This can be checked
Under-correction of human myopia--is it myopigenic?: a retrospective
analysis of clinical refraction data. J Optom. 2014 Jul-Sep;7(3):147–52. with a near vision card, and/or dynamic retinoscopy
where the undilated child is trying to focus on a near This patient will be fixating with his right eye (likely the
accommodative target next to the retinoscope. If “with dominant eye based on the refractive error) and generating
motion” retinoscopy is present, then accommodation is +1.00D accommodation in both eyes; this is the bare mini-
insufficient at that distance and a bifocal should be mum accommodation needed to see clearly with the right
included in the glasses. eye without any correction. As such, the “effective” uncor-
–– Patients with Down’s Syndrome may experience early rected refractive error in the left eye is actually +3.00D. This
AI around the time they reach school age.11 has a high risk of causing refractive amblyopia.
–– Patients who have had a concussion may as well have Therefore, we can dispense glasses with the following
AI.12 prescription:
OD : plano

Anisometropia and Aniseikonia in Children OS : +3.00 D sphere

Note that the dispensed glasses prescription for the left
See Chap. 8, “Magnification and Telescopes”, for addi-
eye is not equal to the CRx because of the principles we dis-
tional discussion regarding anisometropia and aniseiko-
cussed above.
nia. We will refrain from making any more pirate jokes
in this chapter even though, deep down me hearties, we
Example #2
all enjoy such humor.
Suppose we have an 18-month-old child without strabismus
Recall that anisometropia is when the quantitative refrac-
with the following CRx:
tive error between each eye is more than 3D. Anisometropia
leads to aniseikonia, which is the difference in size percep- OD : +4.00 D sphere

tion due to anisometropia. Most adult patients can only toler-
ate a 6–7% size difference between the two eyes. OS : +7.00 D sphere

In pediatric patients, anisometropia and aniseikonia are The following glasses prescription should be issued:
not as significant as they are in adults; remember that uncor-
OD : +2.50 D sphere
rected refractive errors, especially unilateral ones, may lead
to amblyopia. In addition, kids tend to tolerate the subjective OS : +5.50 D sphere
difference between the two eyes much better than adults. For
example, we can assume that a pediatric patient with aniso- Note that this patient has anisometropia. However, since
metropia (e.g., OD: +1D, OS: +4.50D) will fixate with the the patient does not have any strabismus, we can reduce the
better seeing eye (OD). Since accommodation is usually CRx by approximately 1.5D in both eyes with the assump-
simultaneous and bilateral, we can also assume that the non- tion that the child can easily generate this accommodation on
dominant eye will be accommodating as well. his own. The patient still has anisometropia, which is accept-
We can use some examples to highlight this concept: able to leave as is in this age group.
Example #3
Anisometropia without Strabismus Suppose we have (yet another) 18-month-old child without
strabismus with the following CRx:
Example #1 OD : +1.00 + 1.00 × 90 ( SE : +1.5D )
Suppose we have an 18-month-old child without strabismus
with the following CRx: OS : +4.00 + 1.00 × 90 ( SE : +4.5D )

OD : +1.00 D sphere This patient is likely to fixate with her right eye and is

used to accommodating +1.5D with both eyes to see clearly
OS : +4.00 D sphere
at a distance without correction. As such, the effective uncor-
rected refractive error in the left eye is +2.50 + 1.00 x 90 (SE:
+3.00), which will cause refractive amblyopia.
de Weger C, Boonstra N, Goossens J. Effects of bifocals on visual
11 Therefore, we should issue glasses with the following
acuity in children with Down syndrome: a randomized controlled trial. prescription:
Acta Ophthalmol. 2019; 97(4):378–393.
Green W, Ciuffreda KJ, Thiagarajan P, Szymanowicz D, Ludlam DP,
12 OD : −0.50 + 1.00 × 90
Kapoor N. Accommodation in mild traumatic brain injury. J Rehabil
Res Dev. 2010; 47(3):183–199. OS : +2.50 + 1.00 × 90
354 G. V. Vicente
Anisometropia with Strabismus In older (school age and beyond) patients, contact lenses
may be prescribed on a case-by-case basis. Several important
Example #4 questions to consider:
Suppose we have a 24-month-old with 25 PD LET with the
following CRx: • Is the child responsible enough to remove and clean
the contacts nightly? Remember the cardinal sin of
OD : +1.00 + 1.00 × 90
ophthalmology: sleeping with contact lenses. A good
OS : +4.00 + 1.00 × 90 question to assess whether the child is ready for this
responsibility may be, “Can the child brush his teeth
For this patient, we have two choices: (1) Dispense the nightly without being nagged?” If a child demon-
full CRx (because the patient has a significant LET) and (2) strates good compliance, motivation, and responsibil-
adjust the dispensed CRx with the assumption that the patient ity, CLs can be cautiously tried in these patients.
can comfortably accommodate +1.5D on her own: Ironically enough, corneal ulcers due to irresponsible
Therefore, our two choices are: use tend to occur in older patients, not responsible
Choice # 1 : OD : +1.00 + 1.00 × 90, OS : +4.00 + 1.00 × 90 9-year-olds!14
• Similarly, it is important to not force a child who is not
Choice # 2 : OD : −0.50 + 1.00 × 90, OS : +2.50 + 1.00 × 90 motivated to wear CLs.
This scenario is a bit more complicated because we did • Affordability: CLs are (usually) more expensive than
not specify if the LET was an accommodative ET (AET) or spectacles. Some clinicians encourage older children to
sensory ET. If further examination revealed that the patient raise some of the money required to instill a sense of
had an AET, then the full cycloplegic refraction should be responsibility towards CLs.
given. However, if we were certain that this is a sensory • CLs may also be used for myopia control. This has
(refractive) ET, then it is acceptable to reduce the prescrip- become a very popular topic in recent years and will be
tion to allow the patient to accommodate and see if that is discussed in greater detail in the next chapter.
enough to control the esotropia.13 • Since CLs decrease the negative effects of anisometropia
and aniseikonia, stereoacuity may be significantly
improved with CLs vs. glasses. School age patients who
onsiderations for Dispensing Contact
C play sports that require fine motor skills and rapid hand-
Lenses in Children eye coordination (e.g., baseball and hockey) may benefit
from CL use during these activities.
Contact lenses (CL) may be required for children with apha-
kia after cataract surgery without IOL placement, as in the
case of infantile cataracts or trauma. Practice Questions
In infants and toddlers with unilateral aphakia, while
inserting the CL may be initially challenging, the CL may 1. An 18-month-old patient without strabismus has a
provide better compliance and vision than glasses alone. As cycloplegic refraction (CRx) of: +7.00 D sphere
we have mentioned several times in the chapter (intention- OU. What glasses should be dispensed?
ally), a young child’s attention is primarily focused at near. A. +7.00D sphere OU
The refractive goal with a CL should therefore aim for inten- B. +5.50D sphere OU
tional low-myopia, approximately −1 to -3D in both eyes. C. +2.00D sphere OU
For example, if the CRx of the left eye of an aphakic D. No glasses at this time.
1 year old is +20D, then a + 23D CL can be dispensed to 2. A 24-month-old patient with 20 PD of esotropia at near
yield approximately -3D “corrected” refractive error. This and distance has a CRx of: +3.50 D sphere OU. What
allows the child to maintain some myopia to focus on objects glasses should be dispensed?
at near. A. +3.50D sphere OU
B. +2.00D sphere OU
Admittedly, you may need to read this example a few times to fully
13
appreciate and understand the nuances behind it. One suggested way: Chalmers RL, Wagner H, Mitchell GL, Lam DY, Kinoshita BT, Jansen
14
try to teach this to your significant other or a group of friends – if they ME, Richdale K, Sorbara L, McMahon TT. Age and other risk factors
can understand it, you probably understand it well! We do not take any for corneal infiltrative and inflammatory events in young soft contact
responsibility for your popularity level plummeting as a result of this lens wearers from the Contact Lens Assessment in Youth (CLAY) study.
nerd maneuver, however. Invest Ophthalmol Vis Sci. 2011 Aug 24; 52(9):6690–6.
C. +3.50D sphere OU with +3.00D add bifocal OU C. OD: +4.00D, OS: +4.00D
D. The patient will not benefit from any glasses at this D. OD: Plano, OS +4.00D; with +3.00D bifocal add
time and will instead need to undergo strabismus OU
surgery. 9. A 5-year-old patient without strabismus has a CRx:
3. A 24-month-old patient is wearing +2.00D sphere −2.00 + 4.00 × 180 OU
glasses OU and has a CRx of +2.00D sphere OU. She is What glasses should be dispensed OU?
orthophoric at distance but has 20 PD of esotropia at A. −3.50 + 4.00 × 180
near with her glasses on. What is the appropriate next B. −1.00 + 2.00 × 180
step? C. −2.00 + 2.00 × 180
A. Continue with the current glasses full time D. −2.00 + 4.00 × 180
B. Plan strabismus surgery 10. A 6-month-old is aphakic in her right eye. She is wear-
C. Schedule MRI and further neurological workup to ing a + 20 D contact lens in her right eye. A cycloplegic
rule out intracranial mass. over-refraction over her contact lens shows +1D sphere
D. Change current glasses to a + 2.0 sph with a + 3.0 OD. What contact lens power should be prescribed?
bifocal add OU. A. +19 D
4. A 24-month-old patient with 30 PD of esotropia at dis- B. +20 D
tance is orthophoric at near. He has a cycloplegic refrac- C. +21 D
tion of +2.00D sphere OU. What is the appropriate next D. +24 D
step?
A. Observe for now, continue to watch for amblyopia.
B. Plan strabismus surgery. Answers
C. Schedule MRI and further neurological workup to
rule out intracranial mass. 1. Answer: B. If the child has >5D of hyperopia and no eso-
D. Try +2.00D sphere glasses. tropia is present, then 1.5D sphere can be reduced
5. A 10-month-old patient has a − 3.00D sphere OU CRx. (“shaved off”) off the measured CRx. Note that this would
What glasses should be dispensed? not apply if the child had any tropia on exam.
A. None 2. Answer: A. If the child has a hyperopic refractive error
B. −1.00D sphere OU and esotropia is present, then the full CRx is prescribed.
C. −3.00D sphere OU 3. Answer: D. This patient has residual esotropia that is
D. −4.50D sphere OU worse at near. This is likely a case of accommodative
6. A 3-year-old patient has a CRx: esotropia (AET) with high AC/A ratio, which means
OD: +3.00D sphere (VA 20/25) that the distance power is not enough to control the eso-
OS: +5.00D sphere (VA 20/70) tropia when focusing at near. Thus, a + 3.00D bifocal
Examination reveals that there is no strabismus pres- add OU would be a reasonable choice at this time.
ent. Which of the following choices represents a reason- 4. Answer: C. This patient has divergence insufficiency,
able choice for the dispensed prescription glasses? where the esotropia is worse at distance. This patient is at
A. +3.00D OD, +5.00D OS high risk of a cranial six nerve palsy and should have a
B. +1.50D OD, +3.50D OS neurological workup.
C. +3.00D OU 5. Answer A. The myopia present in this infant is not high
D. +5.00D OU enough to cause amblyopia or significant symptoms at
7. A 5-year-old patient has a CRx: this time. However, a patient with this amount of myo-
+1.00 + 4.00 × 90 OU. pia at this age is concerning. A thorough workup is indi-
Examination reveals that there is no strabismus pres- cated though to rule out causes of high early myopia
ent. What glasses should be dispensed? such as infantile glaucoma. The patient should be moni-
A. +1.00 + 4.00 × 90 tored at frequent intervals and may need glasses in the
B. −2.00 + 4.00 × 90 future.
C. −0.50 + 4.00 × 90 6. Answer: B. Because this hyperopic patient does not have
D. +1.00 + 2.00 × 90 strabismus, 1.5D should be reduced (“shaved off”) from
8. A 3-year-old patient without strabismus has a CRx: both lenses.
OD: Plano, OS: +4.00D sphere 7. Answer: C. Because this hyperopic patient does not have
What glasses should be dispensed? strabismus, 1.5D should be reduced (“shaved off”) from
A. OD: -1.50D, OS: +2.50D both lenses. It is important to note that the full cylinder is
B. OD: Plano, OS: +4.00D prescribed.
356 G. V. Vicente
8. Answer: B. This patient will be fixating with the right eye 10. Answer: D. The +1D over-refraction tells us this infant
without having to generate any accommodation. has +21D of hyperopia but is only corrected for
Therefore, the left eye will have an “effective” uncor- +20D. Since the infant’s world is mostly at near, the goal
rected refractive error of +4.00D sphere that will cause should be to leave this patient with a small amount of
amblyopia. Issuing a prescription that covers the uncor- myopia with the contact lens in place. The ideal over-
rected amblyogenic error is appropriate. Given the age of refraction would be −3.0D. This can be achieved by
the patient, we do not have to worry about any anisome- a + 24.0 D contact lens.
tropia or aniseikonia issues; preventing amblyopia super-
sedes any other considerations. Acknowledgments Special thanks to Ann Yen, Mara Robinson, and
9. Answer: D. The spherical equivalent of this patient’s Mike Robinson for their insights on early elementary classroom learn-
ing and Dr. Suleiman Alibhai, O.D, F.A.A.O, for his help in understand-
CRx is plano. The full CRx should be offered. ing the needs of low vision students.
Myopia Control
G. Vike Vicente
Objectives risk increases if one or both parents are myopic.3 However,

• To discuss current ideas regarding established and recent no known single gene or particular mutation directly causes
etiologies of myopia in children. juvenile-onset myopia.
• To understand the concept of peripheral defocus and its However, even with the strong evidence of genetics,
role in the myopia control. myopia prevalence has dramatically increased in the recent
• To discuss various philosophical approaches towards halt- years, suggesting environmental factors may play a stron-
ing myopia progression, including glasses, contact lenses, ger role than previously recognized.4 Furthermore, ethnic
pharmacological therapies, and surgical intervention. and geographic variations may play a supplemental or
• To discuss which methods have been shown to produce separate role in the development of myopia among chil-
positive results, especially in light of recently published dren. For example, ethnic Chinese children in Australia
literature. have a lower prevalence of myopia than in East Asia.5 This
suggests that environmental factors, such as the amount of
time spent indoors or performing tasks with high near-
Introduction vision demands, may be environmental factors contribut-
ing to the rise of myopia.6 Further studies may be able to
Genetics and Environment explain why children who spend more time outdoors (per-
forming tasks with high distance-vision demands) have a
In the last 30 years, childhood myopia rates have increased lower rate of myopia development.7 Perhaps high-intensity
by approximately 66% in the United States; this rate may be outdoor light leads to higher retinal dopamine secretion or
even higher in other countries. Myopia is believed to have focusing on distant objects “trains” patients to avoid using
both a genetic and environmental component.1 For example, excessive accommodation required for near-vision tasks?
studies in twins have shown high rates of myopia regardless
of twin type. Identical twins usually have very similar refrac-
tive errors, whereas the magnitude of refractive error may
vary among fraternal twins.2 Additionally, pediatric myopia Mutti DO, Mitchell GL, Moeschberger ML, Jones LA, Zadnik
3
K. Parental myopia, near work, school achievement, and children’s

refractive error. Invest Ophthalmol Vis Sci. 2002 Dec;43(12):3633–40.
1
Dirani M, Shekar SN, Baird PN. Adult-onset myopia: the Genes in
Kleinstein RN, Sinnott LT, Jones-Jordan LA, Sims J, Zadnik K;
4
Myopia (GEM) twin study. Invest Ophthalmol Vis Sci. 2008
Collaborative Longitudinal Evaluation of Ethnicity and Refractive
Aug;49(8):3324–7.
Error Study Group. New cases of myopia in children. Arch Ophthalmol.
2
Lyhne N, Sjølie AK, Kyvik KO, Green A. The importance of genes and 2012 Oct;130(10):1274–9.
environment for ocular refraction and its determiners: a population
French AN, Morgan IG, Burlutsky G, Mitchell P, Rose KA. Prevalence
5
based study among 20–45 year old twins. Br J Ophthalmol. 2001
and 5- to 6-year incidence and progression of myopia and hyperopia in
Dec;85(12):1470–6.
Australian schoolchildren. Ophthalmology. 2013 Jul;120(7):1482–91.
Guo Y, Liu LJ, Tang P, Lv YY, Feng Y, Xu L, Jonas JB. Outdoor activ-
6
ity and myopia progression in 4-year follow-up of Chinese primary

G. V. Vicente (*) school children: The Beijing Children Eye Study. PLoS One. 2017 Apr
Clinical Pediatrics and Ophthalmology Georgetown University 27;12(4):e0175921
Tasks with high near-vision demands include use of hand-held elec-
7
Eye Doctors of Washington, Chevy Chase, MD, USA tronic devices, video games, etc. Perhaps your mom was right after all:
e-mail: vvicente@edow.com too much TV will ruin your eyes and you should go play outside more!

358 G. V. Vicente
Fig. 1 The emmetropization mechanism is present in many animals. Infantile hyperopia will stimulate axial length growth; myopia will slow
down axial length growth. This is why you may not see many baby chickens or baby monkeys wearing glasses other than the figure above
At present, our current understanding of myopia can be previously discussed Optics principles with the hopes that
simplified to the following: A significant number of patients you, dear reader, can further appreciate the relevance of these
have a genetic predisposition towards myopia, but environ- principles in our profession!
mental factors accelerate or attenuate development of dis-
ease severity.
Optical Interventions
Importance of Slowing Myopia Progression Non-pharmacological and non-surgical interventions are

considered as first-line therapy for myopia control. Several
High myopia is not a benign condition in the pediatric popu- “glasses” and “contacts” options include the following:
lation. It is associated with increased risk for glaucoma, cata-
racts, retinal detachment, and myopic maculopathy in
adults.8,9,10,11 Therefore, it is important to explore ways in Emmetropization
which high myopia and axial length elongation can be pre-
vented or at least halted: not only can this help patients see Here is a fun fact: Cute little baby animals also have refrac-
better during childhood, but it can also prevent late-term, tive errors, but since there are not a lot of pediatric veterinar-
adult-onset visual pathology as well. Since the fastest myo- ian optometrists, nature has found a way to help these
pic shifts in humans tend to occur in ages 8–12, most clinical animals out. For example, studies in monkeys and chickens
studies are aimed at slowing the growth in this have shown that eye growth in these animals’ eyes responds
demographic. to the refractive error over time; for example, if the baby
The topic of slowing myopia progression (“myopia con- monkey or chicken is hyperopic (near images are consis-
trol”) has garnered significant clinical and research interest tently focused behind the retina), then a visual feedback loop
in recent years. This topic also allows us to connect some causes the eye growth to adjust by increasing axial length
proportionally such that there is emmetropization over time
(Fig. 1).12,13
Wong TY, Klein BE, Klein R, Knudtson M, Lee KE. Refractive errors,
8
intraocular pressure, and glaucoma in a white population. While this may make for unemployed pediatric veterinar-
Ophthalmology 2003;110:211–7. ian optometrists, it does raise a fascinating observation: kids’
9
Leske MC, Wu SY, Nemesure B, Hennis A. Risk factors for incident
nuclear opacities. Ophthalmology 2002;109:1303–8. Schaeffel F, Howland HC. Properties of the feedback loops control-
12
10
Saw SM, Gazzard G, Shih-Yen EC, Chua WH. Myopia and associated ling eye growth and refractive state in the chicken. Vision Res 1991;
pathological complications. Ophthalmic Physiol Opt 2005;25: 381–91. 31:717–34. 66.
11
Risk factors for idiopathic rhegmatogenous retinal detachment. The Hung LF, Crawford ML, Smith EL, III. Spectacle lenses alter eye
13
Eye Disease Case-Control Study Group. Am J Epidemiol 1993;137: growth and the refractive status of young monkeys. Nat Med 1995;
749–57. 1:761–5
Myopia Control 359
eyes can also potentially respond and adjust to infantile peripheral images that are currently blurry, so thou must
refractive errors. Basically, there is plasticity in the eye such comply immediately.17
that the eye wants to move towards emmetropia by adjusting We will discuss three strategies that hold some promise
axial length, both increasing and decreasing it, to respond to based on clinical trials below. In the past, several other strate-
infantile hyperopia and myopia, respectively. gies, including (1) rigid gas permeable lenses; (2) bifocal or
These vision-dependent mechanisms can operate in a progressive spectacles; and (3) under-correction of myopic
very regional manner. When a refractive error is created for spectacles have not shown consistent clinical benefits to
only a portion of the visual field in animal studies, the vitre- reduce of myopic shift or prevent axial elongation.18,19
ous axial length of the corresponding retina was most affect-
ed.14 This effect was present even when the fovea was ablated ultifocal Contact Lenses
M
with a laser. These animal studies would support the theory A multifocal contact lens (MF-CL) can be used to create a
that affecting the peripheral refractive error can influence the therapeutic peripheral defocus. This type of MF-CL would
shape of the eye independent of central vision.15 involve an architecture design, in which the central portion
This entire discussion raises a more fundamental (and was set for distance and a peripheral portion had an add
hopefully clinically relevant) question: Can clinicians power—again, this intentionally created peripheral myopic
actively intervene to initiate or accelerate emmetropization image could slow down axial length growth.
in pediatric refractive errors? We can further explain this point using the concept of
“image shells” (Fig. 2). In an uncorrected myope (Panel A),
central rays fall in front of the retina while peripheral rays
Peripheral Defocus fall behind the retina. Suppose we have corrected this patient
with a standard contact lens (Panel B): now the central rays
As the name suggests, the philosophy behind peripheral are in focus on the fovea, but the peripheral rays continue to
defocus is as follows: By correcting the central visual field fall behind the retina—this is known as a peripheral hyper-
(for distance), the clinician can intentionally cause periph- opic shell. In this situation, distance objects of interest are
eral defocus with the “noble” intention of slowing axial visualized with good clarity; therefore, there is no significant
length elongation and halting progression of myopia. For stimulus to arrest axial length growth. Now suppose, we fit
example, in children with myopia, it is common to see myo- this myopic child with a contact lens with full distance cor-
pic defocus centrally with a hyperopic defocus peripherally; rection centrally, but intentionally added extra plus power in
this hyperopic defocus on the peripheral retina may be a risk the periphery (Panel C). Peripheral light rays will now come
factor for worsening myopia.16 Therefore, therapeutic periph- to focus in front of the retina (peripheral “myopic shell”). By
eral defocus strategies for the treatment of myopia aim to causing peripheral myopia, the brain may be able to signal to
cause a peripheral myopic defocus in order to slow down (or the eye to arrest additional axial length growth. Finally, as
reverse) myopia. discussed in the next section, orthokeratology (Panel D)
The idea behind this is elegantly simple: While continu- lenses can similarly be used to intentionally create a steeper
ing to provide the child with sufficient refractive correction peripheral cornea and a myopic peripheral image shell.
centrally (for distance vision needs and preventing amblyo- In 2019, the US Food and Drug Administration approved
pia), we can also maintain enough peripheral blur in the ret- the use of the MiSight® soft contact lens (CooperVision,
ina so that the brain can signal to the eye: Dear Mr. Eyeball, Inc., Pleasanton, CA) after prospective studies showed they
I beseech thee to cease and desist all axial length growth. Do reduced the rate of myopia progression and the rate of axial
you know that the images you are sending me from the elongation in children 8–12-year-olds. These MF-CLs are a
periphery are extremely blurry—bang up job with the cen- single use, disposable soft contact lens with concentric
tral images, by the way old boy, but the peripheral images peripheral add power. The BLINK study (published in
are quite lousy. This child needs to see these interesting August 2020) was a randomized, prospective, and double
masked, 3-year clinical trial that compared monovision dis-
tance soft contact lenses and soft multifocal contact lenses
Smith EL, III, Huang J, Hung LF, Blasdel TL, Humbird TL, Bockhorst
14
KH. Hemiretinal form deprivation: evidence for local control of eye

(Biofinity Multifocal D from Cooper Vision) in 7–11-year-
growth and refractive development in infant monkeys. Invest
Ophthalmol Vis Sci 2009;50:5057–69. This is how we imagine the brain and the eye communicate, and we
17
Smith EL, III, Hung LF, Huang J, Blasdel TL, Humbird TL, Bockhorst
15 dare you to prove us wrong.
KH. Effects of optical defocus on refractive development in monkeys: WSPOS – World Society of Pediatric Ophthalmology and Strabismus
18
evidence for local, regionally selective mechanisms. Invest Ophthalmol WSPOS Myopia Consensus Statement −2019
Vis Sci 2010;51:3864–73 Walline JJ, Lindsley K, Vedula SS, Cotter SA, Mutti DO, Twelker
19
Hoogerheide J Rempt F Hoogenboom W. Acquired myopia in young

16
JD. Interventions to slow progression of myopia in children. Cochrane
pilots. Ophthalmologica. 1971; 163: 209–215. Database Syst Rev.; 2011. CD004916
360 G. V. Vicente
a b
c d
Fig. 2 Image shells. Panel A shows an image shell formed by light rays in the periphery. Panel C shows a contact lens with an extra plus add
in an uncorrected myope with an oblate globe. Central rays fall in front power in the periphery, which would form a myopic image shell in the
of the retina but peripheral rays fall behind the peripheral retina. Panel periphery while still maintaining the central rays in focus on the fovea.
B shows a myopic patient with a typical contact lens correction, central Panel D shows a cornea after orthokeratology with steeper peripheral
rays are in focus on the fovea but peripheral rays form a hyperopic shell cornea and a myopic peripheral image shell
old myopic children.20 It showed a slower progression of • When should treatment be started and ended?
myopia and axial elongation in patients with a + 2.50D • How much do age, genetics, ethnicity, and amount of
peripheral add, compared to +1.5D or monovision (Biofinity) myopia affect the results?
distance contact lenses.21 • Which is the best demographic to treat?
In this emerging field, every new clinical answer leads to • How much of a rebound effect will occur once treatment
additional questions such as: is stopped? (A second 3-year BLINK study is underway
which includes a crossover and a wash out period).
• How many hours per day should a contact lens be worn to
Walline JJ, Walker MK, Mutti DO, Jones-Jordan LA, Sinnott LT,
20
Giannoni AG, Bickle KM, Schulle KL, Nixon A, Pierce GE, Berntsen be effective?
DA; BLINK Study Group. Effect of High Add Power, Medium Add • Will a contact lens with different peripheral add (increased
Power, or Single-Vision Contact Lenses on Myopia Progression in depth of focus) work better than a contact lens with a sin-
Children: The BLINK Randomized Clinical Trial. JAMA. 2020 Aug gle peripheral add?
11;324(6):571–580.
• Would a stronger peripheral add (i.e., > +2.5D) work
Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D,
21
Young G. A 3-year randomized clinical trial of MiSight lenses for myo- better?
pia control. Optom Vis Sci. 2019;96(8):556–567. • Does an add at different meridians work better?
Myopia Control 361
• How are patients with astigmatic myopia different? Spectacles

• How can we help patients with smaller pupils? Many different types of spectacles have been tried to reduce
• Would combining low dose atropine and peripheral defo- myopic progression without consistent effects. Bifocals, pro-
cus have an additive effect? gressives, and under-correction lenses have been tested with
• Does a mild to moderate reduction in myopic progression the hope that reducing an accommodative lag during near
in a child reduce the probability of developing retinal tasks would help prevent emmetropization and axial elonga-
detachments, glaucoma in the future? tion to no avail.
A full discussion as to why spectacles have failed is
This is certainly a topic that will likely need to be updated beyond the scope of this text. One potential reason is that
in the future versions of this text. For now, the concept of peripheral defocus is difficult to achieve with glasses as com-
peripheral focus should be appreciated. pared to contact lenses. We encourage you, dear reader, to
read about this in other texts to learn more about the various
rthokeratology Contact Lenses
O works that have been done on this topic.
This is a somewhat controversial topic among ophthalmolo-
gists, but bears worth mentioning given recently published
data. As introduced above (Fig. 1, Panel D), a peripheral Spherical Aberration
hyperopic defocus can also be achieved with orthokeratol-
ogy (Ortho-K) contact lenses. These specially designed As introduced in Chap. 14 “Physical Optics and Advanced
lenses can be worn overnight to cause peripheral corneal Optical Principles”, spherical aberration (SA) plays an
steepening. A major convenience of Ortho-K is that the child important role in various facets of Optics. For the purposes
does not have to wear glasses or contact lenses during the of myopia control, SA has recently gained attention as it
day, as the peripheral defocus created overnight can last for has been suggested that SA can be intentionally manipu-
most (if not all) of the child’s waking hours. Of course, infec- lated to slow down axial length growth and myopia
tious keratitis, especially in the pediatric population is a valid progression.
and significant concern. We previously discussed how the eye may grow in
Other factors to consider, include difficulty in evaluating response to the hyperopic defocus present at birth: since
the purported effect of the Ortho-K intervention: a cyclople- incoming light rays fall behind the retina, the eye may
gic refraction would not be useful in evaluating the effect of increase its axial length to “catch” these posterior light rays.
Ortho-K on patients as the goal is for patients to have uncor- Since SA provides depth of focus, we can potentially
rected, central emmetropia during the day. Measurement of increase positive SA by increasing the peripheral refractive
axial length has been suggested as a better indicator of suc- power of the system to cause more peripheral light rays
cess or failure, though this can also be temporarily affected (which previously were landing behind the retina) to now
by corneal flattening and anterior chamber shortening. land onto or even slightly anterior to the retina (while main-
Therefore, axial length must be measured after a washout taining paraxial rays). In sophisticated terminology, we
period of no Ortho-K lens wear, similar to contact lens- would say increasing the depth of focus helps to offset the
wearing patients undergoing preoperative refractive or cata- problems of accommodation lag in a child’s hyperopic eye.
ract surgery measurements. Furthermore, it is unknown how In more simpler terms, since the eye is sending both cen-
long Ortho-K lenses must be worn to be effective. In the gen- trally focused and peripherally focused light rays to the
eral population, it is known that the cornea often resumes its brain, the brain is happy and does not feel the need to signal
pre-Ortho-K shape with recurrence of myopia. the eye to increase axial length.
A recent report in Ophthalmology reviewed the published As with all things in life, there is a balance in the perfect
evidence on this topic and concluded that this strategy may amount of SA for these cases. For example, much SA will
be cautiously considered in select patient populations.22 degrade the quality of the central image and decrease the con-
Again, this remains a topic that will similarly need to be trast sensitivity. At this time, no clear evidence exists to sug-
updated in the future versions of this text. gest that this is a standard therapy; indeed, we are not sure
whether positive SA or peripheral myopia (peripheral defo-
VanderVeen DK, Kraker RT, Pineles SL, Hutchinson AK, Wilson LB,
22
cus) is more important in slowing the progression of myopia.
Galvin JA, Lambert SR. Use of Orthokeratology for the Prevention of
However, this is a topic that will likely continue to be studied
Myopic Progression in Children: A Report by the American Academy
of Ophthalmology. Ophthalmology. 2019 Apr;126(4):623–636. and deserves attention for the future developments.
362 G. V. Vicente
harmacologic Interventions: Low-Dose

P Surgical Interventions
Atropine
There are currently no proven surgical techniques to slow
Topical atropine has long been considered as a tool for myopic progression. Future studies may involve scleral cross
myopia control since it can decrease accommodation and linking to stiffen the sclera or refractive corneal surgery to
bind to scleral muscarinic receptors. Muscarinic receptors steepen the peripheral cornea.28
are found in the sclera but their influence on the scleral
matrix is not understood.23 Multiple studies have shown a
positive clinical effect with low-dose topical atropine, but Practice Questions
the mechanism of action is still unclear. Paradoxically,
low dose atropine has little effect on accommodation, yet 1. A 10-year-old patient has been using Ortho-K at night
it can prevent myopic progression (and increased axial time for myopia control for 2 years. She returns for a
length).24 12 month follow up. What is the most appropriate way to
The ATOM2 study in 2012 reported that using 0.01% determine if a therapy is having any long term effect for
atropine drops once a day reduced the progression of myopia myopia?
by 50% and did not have the rebound regression observed A. Autorefractor.
after cessation of 1% and 0.5%.25 More recently, the LAMP B. Manifest refraction.
phase 2 study in 2020 showed 0.05% atropine was more C. Cycloplegic refraction.
effective than 0.01%.26 D. Measurement of axial length.
As with peripheral defocus, multiple therapy questions E. Answers A and C.
remain for the future: 2. You wish to offer myopia control therapy to the family of
a 10-year-old, avid daily swimmer, with a − 3.00 D refrac-
• What is the ideal demographic patient? tion and strong family history of myopia. Which of the
• At what age should atropine be stopped or tapered? following myopia control therapies should be avoided?
• Is it useful to combine low-dose atropine with other inter- A. Multifocal contact lenses.
ventions, such as multifocal contacts or Ortho-K with B. Ortho-K.
atropine? Some early data suggest that Ortho-K with atro- C. Atropine 0.01%.
pine may be effective in slowing axial elongation in chil- D. Atropine 0.05%.
dren with low myopia.27 E. None of the above.
3. A 7-year-old patient started using one drop of Atropine
0.05% OU 1 week ago. He complains of having trouble
reading since starting the drops. Examination of the
Barathi VA, Beuerman RW. Molecular mechanisms of muscarinic
23
patient with his distance glasses on reveals:
receptors in mouse scleral fibroblasts: prior to and after induction of Vision at distance 20/20 OU.
experimental myopia with atropine treatment. Mol Vis.
2011;17:680–692
Vision at near 20/50 OU.
Pineles SL, Kraker RT, VanderVeen DK, Hutchinson AK, Galvin JA,
24 Dilated pupils and with motion at near during
Wilson LB, Lambert SR. Atropine for the Prevention of Myopia retinoscopy.
Progression in Children: A Report by the American Academy of What options can you offer this patient?
Ophthalmology. Ophthalmology. 2017 Dec; 124(12):1857–1866. A. Remove distance glasses while reading
Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the
25
B. New bifocal glasses
Treatment of Myopia 2: Myopia Control with Atropine 0.01% Eyedrops.
(ATOM2) Ophthalmology. 2016 Feb;123(2):391–9 C. Switch to 0.01% atropine
Yam JC, Li FF, Zhang X, Tang SM, Yip BHK, Kam KW, Ko ST,
26 D. Consider multifocal contacts or Ortho-K if the patient
Young AL, Tham CC, Chen LJ, Pang CP. Two-Year Clinical Trial of the is mature and responsible enough
Low-Concentration Atropine for Myopia Progression (LAMP) Study: E. All of the above
Phase 2 Report. Ophthalmology. 2020 Jul; 127(7):910–919.
Kinoshita N, Konno Y, Hamada N, Kanda Y, Shimmura-Tomita M,
27
Kaburaki T, Kakehashi A. Efficacy of combined orthokeratology and

0.01% atropine solution for slowing axial elongation in children with Zhang X, Tao XC, Zhang J, et al. A review of collagen crosslinking in
28
myopia: a 2-year randomised trial. Sci Rep. 2020 Jul 29; 10(1):12750. cornea and sclera. J Ophthalmol. 2015; 2015: 289467.
Myopia Control 363
Answers 3. Answer E. All options would help this patient have

accommodation problems due to likely pharmacologic
1. Answer: D. In patients using Ortho-K, measuring axial cycloplegia.
length progression is the best way to determine how the
patient’s myopia may be changing since the corneal Acknowledgements The author would like to thank Dr. Gary Gerber,
effects can last for weeks and affect the refraction. OD, Co-Founder, Chief Myopia Eradication Officer, Treehouse Eyes;
Dr Rachel M. Caywood, OD, FAAO, Dean McGee Eye Institute /
2. Answer A. In a patient who is an avid swimmer, it may University of Oklahoma; and Dr. Ashley Wong, OD, Eye Doctors of
not be feasible to wear contacts during swim practice. Washington for their guidance in this subject.
This patient could wear Ortho-K lenses at night or use
atropine drops.
Optics in Micro-Gravity
and Zero-Gravity Conditions
Shehzad Y. Batliwala and Kamran M. Riaz
Objectives ision Standards and Criteria for Astronaut

V
• To review historical vision standards and criteria for Selection
astronaut selection and their evolution over time.
• To review various methods of vision correction in astro- Historically, all NASA astronauts were military test pilots
nauts and potential candidates. and thus were required to meet strict vision standards as
• To describe vision changes astronauts experience both determined by the military. These standards eventually were
during training and in microgravity. relaxed as the demand for astronauts increased in the post-
• To describe terrestrial-based benefits stemming from Apollo era, and the effects of spaceflight on vision were bet-
NASA-led optics research. ter understood.1
Uncorrected distance visual acuity (UCDVA) require-
ment for pilot astronauts must be better than 20/100; for non-
Introduction pilots, UCDVA must be better than 20/200. Best-corrected
distance and near visual acuity (BCDVA and BCNVA) must
Imagine this: You have spent the last seven months traveling reach 20/20 in each eye.1
through space as the pilot of your three-member spacecraft, However, these serve as historical trivia. NASA has
and the red glow of Mars emerges brighter, larger, and closer now waived any UCDVA requirement for all astronaut
through your window. As your crew activates the Mars selection categories and primarily set modern vision
Landing System to enter the atmosphere and begin your requirements based on the BCDVA and BCNVA. At pres-
descent, you realize something is different as you view the ent, astronaut candidates may not have a cycloplegic
Red Planet. Your vision has gotten progressively blurrier spherical refractive error that exceeds +5.50D or − 5.50D,
over the past few months: You now have difficulty reading while astigmatism cannot exceed 3 diopters in any merid-
the landing checklist, and you are uncertain if you have the ian. These criteria are even more stringent for pilots, with
visual acuity to nail this landing! What do you do? Why is cycloplegic spherical refractive error not to exceed +3.50
this happening? or − 4.50D, and astigmatism not to exceed 2 diopters in
If you thought Ophthalmic Optics only had relevance on any meridian.
planet Earth, remember we have warned you since the begin- Does this mean that anyone with a mild refractive error
ning: You cannot escape Optics no matter where you go in has to wave goodbye to their astronaut dreams? Not exactly.
the universe. NASA has approved laser refractive surgery (LASIK and
Before we figure out how to land this multi-billion-dollar PRK) for astronaut selection (meaning any individual apply-
spaceship, let’s first review current vision standards for ing for the selection process, including pilots and non-pilots)
astronaut selection and the various ways to correct vision in as of 2007. Pre-op cycloplegic refraction must be between
this unique patient population. +4.00D and − 8.00D sphere with 3.00D or less of (minus)
cylinder.1 This roughly aligns with criteria used for “safe”
S. Y. Batliwala (*) laser refractive surgery in the general population.
Department of Ophthalmology, Dean McGee Eye Institute,
e-mail: shehzad@drbatliwala.com
K. M. Riaz Manuel, K, Mader, T.H. Ophthalmologic Concerns: Vision Standards
1
Dean McGee Eye Institute, University of Oklahoma, and Selection Testing. Principles of Clinical Medicine for Space Flight,
Oklahoma City, OK, USA edited by Michael R. Barratt, Sam Pool, Springer, 2008, 535–545.

366 S. Y. Batliwala and K. M. Riaz
However, the upper limits for both myopia and hyperopia aspect of the lens to allow the astronaut to see small nearby
with current lasers for civilians are a bit higher.2 objects in the far periphery while wearing the extravehicular-
Regarding extraocular muscle function, testing must not activity helmet.5
reveal any evidence of microtropia, suppression, or diplo- It should be noted that “space glasses” must fit exception-
pia.3 Disqualifying factors include the presence of any tropia, ally well. Spectacles in space are especially prone to fog-
10PD or more of horizontal phoria, and 1.5PD or more of ging; astronauts may also require a headband-type secure
vertical phoria. connection due to the effects of microgravity not being
Stereopsis of less than 25 arc-seconds with Optec testing “strong” enough to secure the glasses to the nose and ears.
is disqualifying.3 Color vision testing requires a score of at
least 10 of 14 plates with the 14-plate Dvorine pseudoiso-
chromatic test.4 Contact Lenses
In summary, visual assessment for astronaut candidacy
includes measurement of refractive error, color vision, bin- A 1989 study by NASA evaluated spherical soft, toric soft,
ocular vision, and stereopsis – obviously, there are all essen- and rigid gas-permeable contact lenses (RGPCLs) on simu-
tial things for a potential astronaut! lated weightlessness parabolic flights and found that
RGPCLs had a tendency to be displaced superiorly.6 The
official recommendation is to avoid RGPCLs, but nearly all
Vision Correction Options other types of contact lenses are approved for spaceflight.
There have been no reports to date of visual degradation or
As stated in the previous section, a mild refractive error does permanent corneal injury due to wearing contact lenses.
not exclude a potential astronaut candidate. More than half Given the increasing prevalence of soft contact lenses
of astronauts wear glasses and (even) contact lenses during among astronauts, extensive preflight training regarding
flight missions. Furthermore, many astronauts may undergo the use of caution to remove contact lenses before sleep is
surgical vision correction, including laser refractive surgery. provided.7 Extended wear contact lenses are discouraged
because the high concentration of carbonaceous particles in
the spacecraft air leads to an increased risk of ocular foreign
Spectacles body injury and subsequent bacterial keratitis and
conjunctivitis.
Several changes can be made to standard spectacles to make
them more operational and safer in both the simulated and
actual spaceflight environment. Given the close confines of Refractive Surgery
spacecraft, astronauts must carry out a majority of their
vision-intensive tasks in the near-to-intermediate range of Several refractive surgery procedures may be considered for
vision. As such, modified executive-style trifocal spectacles astronauts:1,3,4
with 11-mm (rather than the standard 7-mm) vertical separa-
tion between the bifocal and trifocal lines are well suited to 1. Radial keratotomy (RK) was a common procedure per-
this environment. formed worldwide during the 1980s8 to treat myopia.
Additional modifications include using a slightly longer However, later research demonstrated a progressive
bifocal focal length calculation (optimized for a 51 cm focal hyperopic effect in most patients over time due to a weak-
distance) to accommodate the cockpit seating and instrument ened cornea.9 This effect is exacerbated at altitudes above
arrangements of the T-38 aircraft, which is used for astronaut
training purposes. Interestingly, it is not uncommon to use Recall the discussion for occupational/recreational bifocals in
5
spectacles with a vertical bifocal segment in the temporal Chap. 16 Construction of Glasses
Manuel, K, Mader, T.H. Ophthalmologic Concerns: Vision Standards
6
and Selection Testing. Principles of Clinical Medicine for Space Flight,

2
See Chap. 30, Optics for Refractive Surgery for a more detailed discus- edited by Michael R. Barratt, Sam Pool, Springer, 2008, 535–545
sion on upper and lower limits of refractive error amenable to laser In other words, probably not a good idea to get a corneal ulcer due to
7
refractive surgery. overnight contact lens wear during your flight to Mars. However,
3
Reschke, M, Clement, G, Thorson, S, Mader, T.H. Neurology: Visual microbial keratitis has occurred in space: https://www.escrs.org/
Impairment. Space Physiology and Medicine, edited by Nicogossian, Publications/Eurotimes/08Feb/NASAapprovesalllaser.pdf
A.E, Williams, R.S., Huntoon, C, L., Doarn, C.R., Polk, J.D., Schneider, The 1980s were certainly a strange era… see Chap. 30 Optics for
8
V.S. Springer, 2016, 245–283 Refractive Surgery for more information regarding RK and other his-
Wright, P, Scott, R.A.H, Ophthalmology. Ernsting’s Aviation and
4 torical refractive procedures.
Space Medicine, fifth Edition, edited by Gradwell, D.P, Rainford, D.J, Gwon A. Prospective Evaluation of Radial Keratotomy (PERK) Study
9
2016, CRC Press: Taylor and Francis Group. 10 years after surgery. Arch Ophthalmol. 1995; 113(10):1225–1226.
Optics in Micro-Gravity and Zero-Gravity Conditions 367
9000 feet because the hypoxic cornea expands astronaut who had undergone bilateral cataract surgery
circumferentially in the periphery, leading to significant was found to have stable vision during a 2-week space-
flattening of the corneal cornea and a hyperopic shift. flight. Talk about a sweet grandfather deal (see what we
This refractive shift is obviously a significant risk factor did there).12 More recently, an astronaut with an IOL in
for spaceflight as even virgin eyes may develop a hyper- only one eye successfully completed a six-month mission
opic shift. Therefore, any candidate with previous RK is to the International Space Station without any issues.13
not allowed by NASA for further consideration as an The NASA Study of Cataracts in Astronauts (NASCA)
astronaut (disqualifying procedure). was a cross-sectional study that looked at the progression
2. Photorefractive keratectomy (PRK): As of 2007, NASA of nuclear, cortical, and posterior subcapsular cataracts in
allows PRK for astronauts. Studies initially showed that a veteran astronauts. This 5-year study revealed a statisti-
mismatch between optical zone diameters and the size of cally significant and dose-dependent association between
the entrance pupil could lead to significant glare and space radiation and posterior subcapsular cataracts.14 An
halos, leading some to believe that PRK would also be a aging astronaut population and the association between
potentially disqualifying procedure. However, this stance space radiation and cataract formation will certainly
has been mitigated by modern wavefront-guided treat- increase the demand for cataract surgery in this special
ment modalities, which cause a lower incidence of glare, population of patients in the future!
halos, and other higher-order aberrations. Studies have
shown that individuals who have undergone PRK are not
susceptible to altitude-related refractive shifts as those
experienced by patients after RK surgery. Vision Changes during Space Travel
Astronauts with previous PRK have successfully trav-
eled to the International Space Station, suggesting that This topic brings us back to our scenario in the introduction,
PRK is a well-tolerated procedure during space flight.10 which is a genuine possibility in the near future, given NASA’s
Interestingly in this patient, during the 12-day space recently announced plans of landing the first woman and sec-
flight, a hyperopic shift ≥1.00D did not occur during the ond man on the surface of the Moon in 2024, and a potential
flight. Ocular surface dryness, photophobia, and other Mars landing projected for 2033.15 We are coming even closer
symptoms were not significant throughout the flight, sug- to accomplishing such audacious goals thanks to the efficien-
gesting that PRK is stable for short space flights. After cies and streamlined use of resources by private space compa-
returning to earth, the refractive error and ocular exam nies such as SpaceX, which accomplished the first commercial
were relatively the same as compared to the pre-space crewed mission to the International Space Station on the
flight exam. Demo-2 Crew Dragon, launched on May 30, 2020.
3. LASIK: NASA also allows LASIK for astronaut selec- When NASA began to conduct post-flight surveys of
tion and retention as of 2007.11 Findings from high- astronauts in 1989, they observed that 29% of astronauts on
altitude studies of patients who have undergone LASIK short missions (approximately two weeks) and 60% on long-
have shown mixed stability results in one case and myo- duration missions experienced a degradation in distance and
pic shifts in other cases. This may affect aviators, but it is near visual acuity.16 NASA escalated vision research activity
unknown how it may affect astronauts who are consis- in response, leading to additional data collection such as pre-
tently exposed to normal atmospheric pressures and oxy-
gen concentration during an extra-terrestrial flight but Mader TH, Koch DD, Manuel K, Gibson CR, Effenhauser RK,
12
experience significant pressures (as described in the pre- Musgrave S. Stability of vision during space flight in an astronaut with
vious section) at the time of liftoff. To date, no astronaut bilateral intraocular lenses. Am J Ophthalmol 1999; 127:342–343
has flown in space following LASIK. Mader TH, Gibson CR, Schmid JF, Lipsky W, Sargsyan AE, Garcia K,
13
Williams JN. Intraocular Lens Use in an Astronaut During Long

4. IOL replacement: Interestingly, NASA considers prior Duration Spaceflight. Aerosp Med Hum Perform. 2018 Jan 1;
cataract surgery a disqualifying procedure for astronaut 89(1):63–65.
selection, but not retention, even though a pseudophakic Chylack LT Jr., Feiveson AH, Peterson LE, Tung WH, Wear ML,
14
Marak LJ, Hardy DS, Chappell LJ, Cucinotta FA. NASCA report 2:
Longitudinal study of relationship of exposure to space radiation and
Gibson CR, Mader TH, Schallhorn SC, Pesudovs K, Lipsky W, Raid
10 risk of lens opacity. Radiat Res. 2012 Jul;178(1):25–32.
E, Jennings RT, Fogarty JA, Garriott RA, Garriott OK, Johnston 15
https://www.space.com/spacex-crew-dragon-demo-2-test-flight-
SL. Visual stability of laser vision correction in an astronaut on a Soyuz explained.html
mission to the International Space Station. J Cataract Refract Surg. Nicogossian, A.E, Williams, R.S., Huntoon, C, L., Doarn, C.R. Living
16
2012 Aug; 38(8):1486–91. and Working in Space: An Overview of Physiological Adaptation,

“NASA approves all-laser LASIK for astronauts.” https://www.escrs.
11
Performance, and Health Risks. Space Physiology and Medicine, edited
org/Publications/Eurotimes/08Feb/NASAapprovesalllaser.pdf. by Nicogossian, A.E, Williams, R.S., Huntoon, C, L., Doarn, C.R.,
Accessed January 17, 2021 Polk, J.D., Schneider, V.S. Springer, 2016, 95–137.
and post-flight dilated fundus exams, MRIs, optical biome- fter Return to Earth and Spaceflight
A
try, visual fields, and cycloplegic refractions. Associated Neuro-Ocular Syndrome (SANS)
Although the exact cause of vision changes is still

During Lift-off and Initial Exposure unknown, current thinking suggests that the cephalad fluid
to Micro-Gravity shifts induced by microgravity lead to increased intracra-
nial pressure. As NASA began to study vision and vision
Astronauts experience a variety of forces during space travel. changes in astronauts meticulously, they identified seven
For example, even during the initial lift-off, astronauts expe- astronauts who exhibited a “constellation” of unexplained
rience increased gravitational (G) forces that push the globe findings including optic disc edema (5/7), globe flattening
towards the optic nerve,17 which stops as soon as the astro- (5/7), choroidal folds (5/7), cotton wool spots (3/5), rNFL
naut leaves Earth’s atmosphere and now experiences micro- thickening on OCT (6/7), and decreased near visual acuity
gravity. As blood rushes towards the head, this causes an (6/7).22 Collectively, these findings have been described as
increase in IOP upon exposure to microgravity, along with Spaceflight Associated Neuro-ocular Syndrome
facial edema and increased sinus/periocular pressure.18 (SANS). In response to decreased near visual acuity, astro-
Fascinatingly enough, the eye can quickly adapt to neutralize nauts over the age of 40 are prescribed “Space Anticipation
this initial IOP spike, causing glaucoma specialists every- Glasses” if they experience a hyperopic shift, which can be
where to breathe a sigh of relief.19 greater than +0.50D between pre- and post-mission spheri-
cal equivalent refraction in one or both eyes (range + 0.50D
to +1.75D).23
During Space Flight (Micro-Gravity and Zero- Several hypotheses may be offered to explain the ana-
Gravity Conditions) tomical changes seen in SANS, but our focus here will be
on the hyperopic shift. While posterior globe flattening can
In the introductory scenario, we assumed you were an emme- partially explain this refractive change, the etiology of flat-
trope. A spaceflight-induced hyperopic refractive error most tening may be multifactorial. Increased intracranial pres-
likely caused the blurry vision at near distance due to the flat- sure (ICP) with resultant increases in subarachnoid
tening of the posterior aspect of the globe that has been pressure could lead to various degrees of posterior globe
described in long-duration fliers (at least six months duration). flattening.8 Alternatively, cephalad fluid shifts may elevate
Interestingly enough, we may entertain the thought experi- optic nerve sheath cerebrospinal fluid (CSF) pressure
ment that a myope may experience an improvement in UCDVA without an overall rise in CSF pressure. This causes the
due to the hyperopic shift. This “favorable” refractive shift for subarachnoid compartment to exert an anterior force that
myopes may create a new market in the future for space tour- indents the posterior sclera resulting in posterior globe
ism combined with myopic vision correction (non)surgery! flattening.
Other considerations during actual space flight include Another mechanism leading to hyperopia may involve a
increased reports of glare among astronauts and reduced weakened corneal refractive power after exposure to changes
contrast sensitivity.20 Astronauts also experience lighting in atmospheric and oxygen partial pressure. However,
conditions ranging from extreme darkness to intense sun- research thus far has not revealed any definitive evidence
light – astronauts experience much more solar radiation than supporting this mechanism. Indeed, our previous discussions
their earth-bound friends.21 regarding the stability of PRK in short-term space travel sug-
gest that corneal refractive power is relatively stable during
Similar to a nervous first/second-year resident pushing down on the short-term flights; however, effects during long-term flights
17
globe during cataract surgery, much to the chagrin of the teaching are still unknown.
attending… Finally, choroidal expansion could theoretically lead to a
Mader TH, Gibson CR, Caputo M, Hunter N, Taylor G, Charles J, hyperopic shift. The choroid is a highly vascular, spongy tis-
18
Meehan RT. Intraocular pressure and retinal vascular changes during

transient exposure to microgravity. Am J Ophthalmol 1993; sue that is usually approximately 0.3 mm in thickness,
115:347–350 drained by the vortex veins, and thus could be congested as a
Mader TH, Taylor GR, Hunter N, Caputo M, Meehan RT. Intraocular
19
pressure, retinal vascular, and visual acuity changes during 48 hours of Lee AG, Mader TH, Gibson CR, Tarver W, Rabiei P, Riascos RF,
22
10 degree head-down tilt. Aviat Space Environ Med 1990; 61:810–813 Galdamez LA, Brunstetter T. Spaceflight associated neuro-ocular syn-
Ginsburg AP, Vanderploeg J. Vision in space: near vision acuity and
20
drome (SANS) and the neuro-ophthalmologic effects of microgravity: a
contrast sensitivity. NASA Interim Report: Space Shuttle Medical review and an update. NPJ Microgravity. 2020 Feb 7;6: 7.
DSOs. Houston, TX, Johnson Space Center, 1986 Bacal, K, Romano, J. Radiation Health and Protection. Space
23
Parker DE, Reschke MF, Aldrich NA. Performance. In: Nicogossian

21
Physiology and Medicine, edited by Nicogossian, A.E, Williams, R.S.,
AE, ed., Space Physiology and Medicine, second ed. Philadelphia, PA, Huntoon, C, L., Doarn, C.R., Polk, J.D., Schneider, V.S. Springer, 2016,
Lea & Febiger, 1989 chapter “Accommodation and Presbyopia” 197–227
Optics in Micro-Gravity and Zero-Gravity Conditions 369
result of cephalad fluid shifts. Stagnant choroidal blood vol- surgery. The eye-tracking device was initially developed
ume can expand, resulting in a shortening of the distance via contractual relationships between NASA and the
between the macula and the lens by 0.3 mm, leading to an U.S. Department of Defense’s Ballistic Missile Defense
approximately 1D shift toward hyperopia. Office (BMDO). The concept was to use LADAR tech-
nology for autonomous rendezvous and docking of space
vehicles to service satellites. The science behind this
Terrestrial-Based Benefits Stemming work was later applied to aid in developing the
from NASA’s Optics Research LADARVision eye-tracking system. Alcon eventually
acquired the technology via a series of mergers in 2000.
Thus far, we have focused on how astronauts may undergo LADAR technology was utilized in millions of excimer
vision changes during space travel. However, in addition to laser procedures in the early 2000s.
the space-flight relevance of NASA’s Optics research, we ter- D. iDesign ® Advanced WaveScan Studio (Johnson and
restrial bound folk have also benefited from these efforts in Johnson Vision, Santa Ana, CA, USA).: This wavefront
numerous areas. We will discuss a few of these contributions technology27 is now used in mapping the cornea in prepa-
below: ration for laser vision correction and stems from invest-
ments made to develop the James Webb Space Telescope
A. Welding Industry24: Arc welding emits potentially (JWST). This next-generation space telescope will
harmful UV light and poses significant risks to the replace the Hubble Space Telescope (HST) after its
observer in terms of retinal damage, especially if launch in March 2021.
viewed for long periods and from ultraviolet radiation As an aside, the JWST will offer infrared technology
and blue light. In the 1980s, NASA’s Jet Propulsion to allow it to observe the first galaxies that formed in
Laboratory scientists James Stephens and Charles the early universe. To allow for the viewing of such
Miller began studying birds of prey whose eyes pro- large distances, it requires extremely large mirrors.28
duced tiny oil droplets that filter out harmful radiation The primary mirror is more than two stories in diameter
and transmit only specific visible wavelengths of light, and consists of 18 separate segments. Each segment
protecting and enhancing vision. These brilliant NASA must be perfect in terms of smooth contour, flatness,
scientists used light filtering dyes and small zinc oxide and completely scratch-free to cover astronomical
particles to create a protective welding curtain, which viewing distances. To ensure high fidelity and quality,
has now been successfully commercialized and utilized each mirror segment must be measured, ground, pol-
in occupational welding glasses. ished, and repeatedly tested. The grinding phase is one
B. UV protection in sunglasses25: The same research pro- of the most time-consuming steps, so one wonders what
cess described above by Drs. Stephens and Miller also kind of optical lab does this service and whether they
applied to a vast lineup of UV blocking sunglasses com- can polish the author’s glasses to be truly scratch
mercially marketed as Eagle Eyes Optics (Calabasas, resistant.
California). The technology has now evolved into ski In order to save time, the infrared Hartmann-Shack
goggles and astronaut helmet visors applications. More Scanning System was developed to immediately test the
recently, this technology has been inducted into the mirrors after grinding and obtain a detailed map on how
Space Foundation’s Space Technology Hall of Fame. to do the next step of the grinding.29 By introducing this
C. LADAR technology : The LADARVision 4000 (Alcon
26
new step of instantaneous feedback after grinding, the
Laboratories, Fort Worth, TX, USA) was an early- polishing and testing steps were optimized efficiently
generation laser that utilized a laser radar (LADAR) eye- until the mirror was ground to the desired levels of near-
tracking device to enhance accuracy during refractive perfect optical purity.
This same technology spun off into the Complete
Ophthalmic Analysis System (COAS), which provided a
NASA Technical Reports Server. Welding Curtains. 2002. ntrs.nasa.
24
gov/archive/nasa/casi.ntrs.nasa.gov/20020091940.pdf. Accessed June

4, 2020. See Chap. 14 “Physical Optics and Advanced Optical Principles”,
27
Bryan, William. NASA Spin-offs. Scratch-Resistant, UV-Reflecting

25 Physical Optics and Chap. 30 Optics for Refractive Surgery, for more
Lenses. 2016. https://spinoff.nasa.gov/Spinoff2006/ch_6.html. information regarding wavefronts and their usage in refractive surgery.
Accessed June 6, 2020. And you thought Mirrors were only there to make your life miserable
28
NASA Technical Reports Server. The Right Track For Vision

26 on exams…
Correction. 2003. ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa. See Chap. 14 “Physical Optics and Advanced Optical Principles”,
29
gov/20030099657.pdf. Accessed June 5, 2020. Physical Optics for a discussion about Hartmann-Shack technology
detailed map of the eye’s front surface to detect pathol- efficient reusable rocket launch systems, as demonstrated by
ogy such as keratoconus.30 COAS was later acquired by the recent Demo-2 Crew Dragon launch. A collaboration
Advanced Medical Optics (now Johnson and Johnson between government and private industries appears to be the
Vision, Inc., Santa Ana, CA, USA), who incorporated only way forward for more discoveries and applications. As
this technology in their iDesign Advanced WaveScan such technologies evolve and the cost to launch is reduced,
Studio. The technology allows for accurate laser vision high-fidelity terrestrial equivalent research in microgravity
correction planning, working within 3 seconds to obtain will become more accessible to scientists, and opportunities
four different measurements of the eye’s refractive errors for additional spin-offs that benefit life on Earth (as dis-
and higher-order aberrations. The technology initially cussed in the previous section) will be numerous.
used to optimize the JWST has led to increased effi- Finally, we can end this chapter with a more fundamental
ciency in mapping the human eye for laser vision and slightly philosophical question: Why bother with
correction. research in space? Don’t we have more pressing needs, espe-
cially as ophthalmologists, right here on Earth?
It is our opinion that, in addition to space ophthalmology
Future Considerations research having the potential for creating technologies that
can benefit humanity on Earth, another reason to continue
Space is the final frontier.31 While we have discussed some learning about ophthalmic applications in microgravity is a
Optics related features of space travel and microgravity con- philosophical one.
ditions, we are still scratching the surface of all the informa- Since the advent of time, humanity’s mandate has been to
tion and knowledge about future space travel. explore, push the boundaries of possibility, and discover the
As we have discussed thus far, the long-term conse- next frontier. This same spirit allowed unwavering explorers
quences of microgravity-induced changes to ocular anatomy of the past to discover novel lands and resolute scientists to
and vision before, during, and after spaceflight may be a sig- discover novel cures. Exploration is a mindset, and it is this
nificant barrier to future space travel. Perhaps, for this rea- mindset that clinicians and scientists must engage in collec-
son, NASA has specifically labeled SANS as one of the top tively in order to solve humanity’s most pressing challenges.
five high-priority risks to mitigate to allow for further space It is not every day that physicians and other professionals
exploration. In the near future, we hope to learn more infor- who specialize in and study the human eye can contribute to
mation from currently ongoing research as the idea of long- the inspirational endeavors embodied by NASA and the
term space flights is becoming more and more of a reality. spirit of exploration that it represents. By understanding the
This discussion leads us to another reality: The need to history of this unique niche within ophthalmology, we can
address current limitations and barriers to much-needed learn from the past and aspire to impact future developments
research in space ophthalmology. Access to space is one of within the field. It is possible that in future editions of the
the primary limitations in conducting high-fidelity research book, we may have much more to share in this constantly
for pathologies related to the microgravity environment. One evolving and seemingly-unknown super-subspecialty within
of the best ways to conduct research in this realm is to do it ophthalmology.
in the appropriate environment, which currently exists on the
International Space Station. Private space companies are cru- Editors’ Note This chapter was included in the textbook as
cial in helping NASA address the current stagnant status it covers some exciting and recent developments in the field
quo. Their efforts have led to the advent of highly cost- of Optics, including areas that likely will see even more
research and findings in the near future. These novel con-
cepts are not part of “standard” Optics curricula, so they are
NASA Technical Reports Server. Telescope Innovations Improve not likely to be tested on exams. We have intentionally not
30
Speed, Accuracy of Eye Surgery. 2013. https://ntrs.nasa.gov/api/cita- included any “Practice Questions” in this chapter. Interested
tions/20130009008/downloads/20130009008.pdf. Accessed June 21,
2021 readers may wish to consult other texts for additional reading
What? You didn’t think we’d finish the chapter without that reference, or review questions, including some of the sources cited in
31
did you? this chapter.

Part III
Optics for Surgical Practice
Preoperative Optics for Cataract
Surgery
Kamran M. Riaz
Objectives relate to the most exciting part of ophthalmology: cataract

• To understand various methods of assessing vision poten- surgery.1
tial before cataract surgery. This chapter will review important Optics principles that
• To review introductory principles of optical biometry. every cataract surgeon should know before surgery.
• To understand the role of angle alpha and angle kappa in
cataract surgery.
• To compare and contrast the differences between spheri- Assessing Visual Potential
cal and aspheric IOLs.
• To discuss considerations for cataract surgery in special While some may argue that the best way to assess visual
situations, such as patients with long axial length, silicone potential in the presence of a cataract is first to take out the
oil, and previous refractive surgery. cataract and then figure out the vision… This is neither
• To appreciate various strategies for correcting astigma- appropriate surgical practice nor the correct answer on board
tism at the time of cataract surgery, including advantages exams. Before performing cataract surgery, we should famil-
and disadvantages of currently available options. iarize ourselves with the proper preoperative workup, includ-
• To review optical principles of advanced technology ing assessing a patient’s visual potential after cataract
IOLs. surgery. In addition to good clinical practice, this also helps
the surgeon and patient have reasonable (and similar) expec-
tations for the upcoming cataract surgery.
Introduction This may not be of much concern in the presence of mild-
moderate visually significant cataracts. Currently, there are
Greetings and welcome to Part III: Hooray, you made it no absolute requirements for determining a “visually signifi-
through the (boring) fundamental stuff so that we can finally cant cataract” for billing and documentation purposes.
discuss real-life applications of the Ophthalmic Optics that Patient complaints of decreased visual function, including
we have discussed so far. In Part III, we hope you will better glare/halos at nighttime, difficulty with night driving,
appreciate our previous discussions when we see how it they impaired reading, and other subjective visual complaints,
can be sufficient documentation, though this author wonders
if health insurance companies will make us all fill out 1000-
page forms for every cataract surgery in the future.
There is no one-method-fits-all strategy regarding when
to do cataract surgery. We should tell our patients, barring
any significant medical urgency (e.g., phacomorphic/phaco-
lytic glaucoma), that the correct time to do surgery is when
the patient feels the decrease in vision quality is hindering
their ability to perform activities of daily living. Visually sig-
nificant can mean different things to different people. An air-
line pilot may have different visual needs compared to
K. M. Riaz (*)
Dean McGee Eye Institute, University of Oklahoma, With due apologies to those of you who don’t perform cataract surgery
1
Oklahoma City, OK, USA anymore…

374 K. M. Riaz
someone who simply wants to pass the vision screening • Assessment of contrast sensitivity (see Chap. 18,
requirements for a driver’s license. “Visual Acuity Testing and Measurement”): decreased
Previously, a BCVA <20/40 was required for billing pur- contrast sensitivity may be present even with good
poses; this requirement has changed. Some clinicians objec- visual acuity.
tively score the cataract using classification systems such as • A thorough examination of the anterior segment and lens
the LOCS II grading system. Devices to measure glare, such with attention given to the cataract type, density, sublux-
as a straylight meter (C-Quant, Oculus, USA), may also be ation presence, zonular integrity, etc.
utilized. Recently, ray-tracing aberrometry devices such as • Dilated fundus exam with attention given to the macula
the iTrace (Tracey Technologies, Houston, TX, USA) have and optic nerve.
incorporated features such as the dysfunctional lens index
(DLI) to objectively “grade” light rays passing through the In the presence of extremely dense cataracts that preclude
crystalline lens to determine cataract severity. The DLI may examination of the fundus, a B-scan (ultrasound) is vital to
be helpful in situations when clinical examination of the ensure that there is no retinal detachment, retinal mass, or
cataract may suggest a visually insignificant cataract, but other posterior segment pathology that may preclude imme-
objective assessment of light rays passing through the cata- diate cataract surgery or warrant referral to other specialties,
ract may indicate otherwise. both within and outside of ophthalmology.
Standard Techniques
Assessing Vision Potential in Dense Cataracts We can now focus on some specific “standard” testing strate-
gies and devices that can be used to assess a patient’s vision
Several other principles must be kept in mind in the presence potential. We previously discussed some of these in Chap. 14
of long-standing, dense, and visually-incapacitating cata- “Physical Optics and Advanced Optical Principles”.
racts. We will focus our discussion on this type of patient.
• Pinhole testing (PHT): When a patient looks through the
History and Exam 1.2 mm pinhole, we have maximized the number of unde-
A thorough history is the first step in the preoperative assess- viated paraxial light rays that reach the retina while limit-
ment of patients with dense cataracts. Important questions ing diffraction. This increased depth of focus allows us to
include the following: correct upto 3D of refractive error in the presence of len-
ticular pathology. If the lens opacity is minimal, PHT will
• How long has the patient noted the visual decline? Is it in improve the visual acuity. However, if the lens opacity is
one or both eyes? dense centrally (e.g., posterior subcapsular (PSC) cata-
• Is there a known history of amblyopia? ract), then the visual acuity may not improve (or even
• Is there a history of trauma, steroid use, or medications2 worsen).
associated with the development of cataracts? • The retinal acuity meter (RAM; AMA Optics Inc., Miami,
• Any history of ocular surgery, especially laser refractive FL, USA) is similar to PHT as it is also helpful in deter-
surgery? mining macular function.3 It is beneficial to distinguish
• Did the patient wear glasses or contact lenses during their between cataractous and retinal causes of visual dysfunc-
lifetime? Specifically, is there a high refractive error pres- tion. While it relies on a pinhole aperture similar to PHT,
ent, especially pathologic myopia and hyperopia? it has an additional + 2.50D lens allowing for testing at
• Does the patient have (or have access to) any old eye 40 cm from the patient. RAM can compensate for both
examination records? spherical and astigmatic refractive errors and may predict
postoperative visual acuity better than the potential acuity
During the preoperative exam, in addition to performing a meter (see below).
detailed slit-lamp with dilated fundus exam, several areas • Potential Acuity Meter (PAM; Haag-Streit, Switzerland):
should be given additional attention: This device can project a visual acuity chart directly onto
the retina to allow an estimate of visual acuity. However,
• Assessing pupillary function, including the presence or the PAM might be unwieldy for most patients as it has a
absence of an afferent pupillary defect. learning curve and carries a larger physical footprint. In
• Extraocular motility exam, especially for the presence of addition, PAM relies on a skilled examiner to accurately
exotropia that may indicate long-standing visual decline.
Airiani S, Braunstein RE. “The Retinal Acuity Meter.” CRST Europe

3
Cumming RG, Mitchell P. Medications and cataract. The Blue

2
2007. https://crstodayeurope.com/articles/2007-oct/1007_08-php/.
Mountains Eye Study. Ophthalmology. 1998;105(9):1751–1758 Accessed June 21, 2020
Preoperative Optics for Cataract Surgery 375
direct incoming light through the patient’s pupil. Finally,

the PAM only corrects for spherical refractive errors.
• Laser interferometry (aka retinometry): Two laser light
beams (red helium-neon) can be used to create a diffrac-
tion fringe pattern on the patient’s retina to assess retinal
function. By varying the widths of the fringe patterns,
visual acuity can be determined on a range (20/600 to
20/20).
• Projection of color or light through colored gel films: This
can be used to create an entoptic phenomenon to estimate
gross retinal function. This technique does not quantify
potential visual acuity compared to the previously dis-
cussed tests.
• Maddox rod orientation: A gross evaluation of retinal
function to detect a scotoma can be determined by asking
the patient whether s/he can “see the red line” – inability
to see the red line suggests macular pathology.
• ERG and VEP testing: These two tests can assess retinal
function and optic nerve/brain function, respectively. Fig. 1 Haidinger’s brush appears as a propeller shape with blue and
These two tests are also a spectacular waste of time/ yellow “dumbbells” oriented 90 degrees from each other. The brush
money and are best used for extreme circumstances and phenomenon can be best visualized against a white background or blue
research purposes... sky. Due to the dichroism of xanthophyll pigment in the macula, the
observer perceives incoming polarized light with two distinct colors
• On mission trips without fancy technology and severe and locations. The size of the brush is approximately the size of the
long-standing white cataracts, we can use a muscle light macula. A patient’s ability to perceive the brush, even in the presence of
gently pressed and moved against the closed lid to simi- dense media opacity, indicates gross macular function. The brush may
larly create an entoptic phenomenon. The retina is pre- also be used to aid patients undergoing eccentric fixation training
sumed to function if the patient sees a dark branch pattern
with a red background. You can try this in the clinic or at yellow and blue patterns perpendicular to each other) shape
social functions (though we cannot be held responsible that can be better described as a propeller-like phenomenon
for your declining popularity among your friends and that can be visualized by the patient as the brush is centered
associates if you choose to go full Optics Nerd in all on the fovea.5
aspects of your life). The perception of the “brush” of yellow light is
thought to be due to the dichroism of xanthophyll pig-
Haidinger’s Brush ment in the macula, as some pigment molecules are
Finally, the rite of passage test that merits its own section: arranged circularly. Because the fovea is not flat, some
Haidinger’s Brush. Note, the authors fully confess that we nerves will run orthogonal to the central fovea while
have never used this test, nor do we ever plan on using this other nerves will run parallel. This creates different areas
test, and we pray for the souls of those who have used this of the fovea that are sensitive to two different degrees of
test.4 polarization. The size of the brush is approximately the
Haidinger’s brush refers to a technique wherein the exam- size of the macula. Basically, this test can detect that the
iner can use a lens (such as a lens from a pair of polarized macula is functioning correctly to justify to the surgeon
sunglasses) to rotate polarized light in front of a blue-white and patient that some visual function can be expected
background to create an entoptic phenomenon that the after surgery.
patient may perceive as a yellow light (Fig. 1). The “spin-
ning” nature of the yellow light creates a “brush” (rotating
Note: the “brush” used to describe this entoptic phenomenon can be a
5
misleading term since it more closely resembles a propeller.

See also Chap. 14 “Physical Optics and Advanced Optical Principles”
4
Nevertheless, since Haidinger described it as a brush, we will maintain
for other uses of Haidinger’s brush testing in clinical practice besides the nomenclature, but it may be easier to understand this as a propeller
pre-cataract surgery. shape instead.
376 K. M. Riaz
Table 1 Optical biometry axial lengths versus immersion ultrasound If USB measurements are misaligned, especially in long
biometry and 3 axial length adjustment formulas AXL eyes where perpendicularity may be more challenging
Wang-Koch Wang-Koch to obtain, then the AXL may be falsely overestimated. Thus,
modified modified the probe must be accurately placed on the patient’s eye and
Optical IUS Holladay Holladay Sum-of-
biometry (Recalc) 12011 12018 segments
relies on the presence of a skilled examiner.
20.00 20.00 20.14 • Sound waves travel through the various structures in the
25.00 24.89 24.91 24.95 eye differently. For example, sound travels faster through
26.50 26.35 26.23 26.35 26.40 the lens and cornea (approximately 1640 m/s) as compared
30.00 29.78 29.31 29.21 29.76 to the aqueous and vitreous (approximately 1530 m/s).
34.00 33.69 32.84 32.48 33.61 • Sound waves will travel through short AXL eyes at a faster
rate as compared to average AXL eyes, and at a slower rate
for longer AXL eyes. One way to understand this concept
Principles of Biometry is to realize that the longer AXL has “more vitreous” com-
pared to the shorter AXL eye. This may further increase
A full review of every detail regarding biometry is beyond the inaccuracy in measured AXL in these eyes, further
the scope of this text. We will instead focus on several confounding accurate IOL power calculations.
Optics-relevant principles of biometry. • USB additionally relies on the examiner putting in the
correct sound velocity at the time of obtaining measure-
ments. If a wrong velocity is entered, the measurement
Ultrasound Biometry (A-Scan Techniques) will be inaccurate. While it is good clinical practice to ask
the patient to return for a repeat measurement with the
Ultrasound biometry (USB) is the old-school, original correct sound velocity, this may not always be possible
method of determining the axial length (AXL). While optical logistically. Therefore, some authors recommend adjust-
biometry (OB) has become more popular (see next section), ing the AXL measurement using the following equation:
there may still be situations when USB is necessary, such as AXLc = AXLi ´ (Vc / Vi )
in the presence of dense cataracts, mission trips, and/or the
need for intraoperative biometry due to patient inability to sit
for preoperative biometry. where AXLc is the “correct” (desired) AXL, AXLi is the
USB can be done in two ways: 1) contact applanation or incorrect AXL, Vc is the correct sound velocity, and Vi is the
2) immersion. Contact applanation requires corneal contact: incorrect sound velocity.
this can indent the cornea and artificially shorten the Several authors have reported that AXL measurements
AXL. Immersion requires more examiner skill but is more obtained by USB are consistently different from those
accurate than contact applanation. In general, immersion is obtained by OB; specifically, OB-AXL measurements are
preferred over contact applanation despite the limitations of falsely longer-than-real in long AXL eyes and shorter-than-
both methods. Several points about USB are as follows: real in short AXL, when compared to USB-AXL measure-
• USB is especially advantageous in the presence of dense ments (Table 1).6 This has significant implications: if we use
cataracts. Since this technique relies on measuring the OB-AXL measurements in long eyes, then the AXL is “too
transit time of the ultrasound signal, it can measure AXL long” and we may end up inadvertently using a lower-than-
through an extremely dense cataract when OB may be needed IOL power and causing an undesirable more-than-
unable to get a reliable measurement. intended hyperopic postoperative refractive error. You may
• The USB technique relies on certain assumptions, such think: “fine, let’s just use USB-AXL measurement in all
as the presence of “normal” amounts of aqueous and vit- patients with long AXLs to avoid this problem with
reous, as each of these ocular structures has its own index OB-AXLs”. This sounds like a good idea, but lens constants
of refraction. The device relies on the average velocity of for modern IOLs have been optimized for OB and not for
the ultrasound signal to calculate AXL. This is not a sig- USB. You may want to read the preceding paragraph few
nificant problem in normal eyes. However, in the pres- times because it is confusing on the first read! Table 1 lists
ence of silicone oil, for example, the signal will slow AXL values obtained by OB when compared to immersion
down, leading to an abnormally long AXL. We will dis- USB and three commonly used AXL adjustment formulas.
cuss silicone oil in greater detail later in this chapter. Currently, we are searching for methods to make the USB-
Similarly, the AXL may be falsely skewed in a pseudo- AXL usable with current IOL constants (which are optimized
phakic eye if the machine is not adjusted accordingly.
• USB is prone to measuring the AXL in a non-central line to
Cooke DL, Waldron R, Savini G, Riaz KM, Taroni L, Murphy DA,
6
the fovea. To ensure a coaxial reading, there must be good Guaraldi F. Immersion ultrasound biometry vs optical biometry. J
“spikes” from the retina and anterior/posterior lens surfaces. Cataract Refract Surg. 2022 Jul 1;48(7):819–825.
for OB, such as those found on online user-group databases7) Table 1, if you perform a USB and OB on a given patient, the
for increased accuracy. Some authors suggest (1) either modi- AXL measured by OB will likely be slightly longer than the
fying the USB-AXL with an adjustment factor to calculate an AXL measured by USB.11
“adjusted AXL” that can be entered into OB devices so that Since the USB-AXL is (usually) slightly shorter, the calcu-
the OB-optimized lens constants can be used or (2) adjusting lated IOL power may be slightly stronger-than-required, lead-
the lens constant and using the measured USB-AXL data as ing to a potential myopic surprise – not the end of the world,
is. The latter option requires an easier calculation. This author but something to keep in mind in these unique situations.
recommends subtracting 0.23 from the lens constant so that Hence, an adjustment to the USB-AXL or the lens constant, as
the USB-AXL can be used.6 For example, if the online lens described in the previous section, can help overcome this
constant for a given IOL is 119.0 and one is using USB-AXL potential limitation.
measurements, then a “new” lens constant of 118.77 can be OB uses partial-coherence interferometry (PCI) (infrared
used in one’s IOL formula of choice and no further adjust- laser light, wavelength 780 nm), optical low-coherence reflec-
ments to the USB-AXL are needed. tometry (OLCR) (wavelength 820 nm), or swept source opti-
cal coherence tomography (SS-OCT) (wavelength 1300 nm)
to measure reflected light from the tear film and the RPE.12
Optical Biometry (OB) One significant advantage of OB is that since it relies on
patient fixation, it allows us to measure the true visual axis
Optical biometry (OB) is the newer, most commonly used rather than the optical axis (we will discuss these concepts
type of biometry in modern day cataract surgery. OB was later in the chapter).13 Additional advantages include
developed as a more straightforward, non-contact method of increased measurement speed; less measurement error from
obtaining measurements to yield results similar to USB.8 the tear film; user-group optimized IOL constants for OB;
One interesting modification is the measurement of AXL: and, perhaps most importantly, better corneal power measure-
When Haigis calibrated the original optical biometer, he cali- ment. Ancillary staff (or residents at the VA) performing
brated OB AXL measurements to be equivalent to US AXL biometry measurements usually find performing OB easier
measurements with a necessary adjustment.9 Since this origi- than USB.
nal device could only locate two points on the eye (anterior OB not only measures the AXL, but also measures other
corneal surface and retinal pigment epithelium), Haigis biometric parameters such as keratometry, anterior chamber
mathematically adjusted the image-side reference position depth (ACD), lens thickness (LT), corneal thickness (CCT),
from the retinal pigment epithelium (RPE) to the internal and horizontal white-to-white diameter (HWTW); thus, it is a
limiting membrane (ILM). Most biometers have since magical all-in-one device. With USB (and even some PCI OB
adjusted their devices to produce similar values.10 devices), we may have to get these other measurements from
Nonetheless, as discussed above and demonstrated in other devices. As stated above, one limitation of OB is the pres-
ence of dense cataracts, corneal scars, or vitreous hemorrhage
7
For example, the User Group for Laser Interference Biometry (ULIB): that may prevent the partial-coherence signal from accurately
http://ocusoft.de/ulib/c1.htm. Accessed January 19, 2021. More measuring the eye. Newer OB devices, such as the Lenstar LS
recently, IOLCon has replaced ULIB: https://iolcon.org/lensesTable. 900 (Haag-Streit, Switzerland) and IOL Master 700 (Carl Zeiss
php. Accessed February 25, 2022
Meditec, Dublin, CA) use strategies such as OLCR and
8
Haigis W, Lege B, Miller N, Schneider B. Comparison of immersion
ultrasound biometry and partial coherence interferometry for intraocu- SS-OCT, respectively, to further improve accuracy through
lar lens calculation according to Haigis. Graefes Arch Clin Exp dense lens opacities.
Ophthalmol. 2000 Sep;238(9):765–73 Studies have shown that while the AXL measured by OB
9
Haigis W, Lege B, Miller N, Schneider B. Comparison of immersion and USB may be similar in normal AXL eyes, OB is better at
ultrasound biometry and partial coherence interferometry for intraocu-
lar lens calculation according to Haigis. Graefe’s Arch Clin Exp
Ophthalmol 2000; 238:765–73.
10
A potentially more accurate method of measuring AXL has been pro-
posed known as “sum-of-segments AXL” (SOS-AXL). In SOS-AXL,
the individual segment lengths of each structure (cornea, aqueous, lens, This is particularly true for long AXL eyes, where the OB-AXL may
11
vitreous, etc.) is measured according to both incoming wavelength of be ≥0.2 mm longer than the USB-AXL.
the device and the individual refractive index of the structure, rather This is why we spent all that time discussing interference and coher-
12
than using an assumed index of refraction (e.g., 1.3375) for the entire ence in Chap. 14 “Physical Optics and Advanced Optical Principles”!
eye. Using SOS-AXL may further improve the preciseness of AXL Among the three types of OB, there are additional features/advantages
13
measurement, and therefore improve the function of many IOL formu- to consider. For example, PCI is the “oldest” of these three methods, yet
las. See (1) Cooke DL, Cooke TL. Approximating sum-of-segments it gives an accuracy to the level of 0.02 mm. OLCR and SS-OCT have
axial length from a traditional optical low-coherence reflectometry recently been introduced and each have their distinctive features. For
measurement. J Cataract Refract Surg. 2019 Mar; 45(3):351–354 and example, SS-OCT uses lasers of variable wavelength to obtain multiple
(2) Cooke DL, Cooke TL, Suheimat M, Atchison DA. Standardizing B-scans during the imaging process. The integrated OCT may also help
sum-of-segments axial length using refractive index models. Biomed assess retinal pathology – a rudimentary OCT can be done at the time
Opt Express. 2020 Sep 25; 11(10):5860–5870. of biometry!
378 K. M. Riaz
predicting the final refractive outcome (likely due to its abil- We have previously discussed how a traditional keratom-
ity to better measure the corneal power).14 eter works.16 Recall that this device primarily measures the
anterior corneal curvature and assumes the power of the pos-
terior cornea by using a fixed ratio between the anterior and
Biometry in Special Situations posterior cornea. For example, if the device reads “43D” for
an average K measurement, this is likely the combination of
While there are many situations where additional consider- approximately +48.8D from the anterior cornea and − 5.8D
ations have to be made (such as a physical handicap prevent- from the posterior cornea. The measurement does not
ing the patient from sitting for biometry measurements), account for corneal thickness or variation of posterior cor-
these are beyond the scope of our discussion. One critical neal toricity.
situation has Optics relevance: the contact lens wearer who The IOL Master 700 (Carl Zeiss Meditec) uses telecentric
presents for cataract surgery. keratometry for anterior keratometry measurements and
If a patient uses contact lenses, the following should be swept-source acquired pachymetry to define a toric posterior
kept in mind: surface model (incorporating corneal thickness) for posterior
• Always measure both eyes, even if one eye is corneal measurements. The resulting total keratometry (TK)
pseudophakic.15 value is constructed to work with established IOL formula
• Patients who wear soft contact lenses should be out of lens constants and offers the surgeon a measurement of the
their lenses for a minimum of 3–7 days (textbooks vary) anterior and posterior corneal radii that can potentially be
before biometry. This is to avoid inaccuracies that may used for more accurate IOL calculations. Large data sets
happen due to corneal warpage from the lenses that may evaluating the superiority of TK over K measurements have
falsely skew keratometry measurements. not been reported; however, TK values may be used in post-
• Patients who wear rigid gas permeable contact lenses refractive surgery eyes to improve the accuracy of older for-
(RGPCLs) should be out of their lenses for at least 2–3 weeks mulas, such as Haigis, to be equal to the accuracy of other
(again, textbooks vary) prior to biometry. Some authorities modern post-refractive IOL calculation formulas.17 TK mea-
recommend a minimum of two weeks with an additional surements (specifically posterior keratometry (PK) measure-
week for every 10 years of RGPCL use for a maximum of ments) may also improve accuracy of KCN-specific formulas
6 weeks out of RGPCLs. For example, patients who have (e.g, Kane-KCN, Barrett True K KCN, etc.) in KCN corneas
worn RGPCLs for 20 years should be out of their lenses for with K values > 50D.
at least 4–5 weeks before biometry. Serial measurements In general, the anterior cornea acts like a plus lens (with
may also be taken every two weeks after RGPCL removal to either with-the-rule (WTR) or against-the-rule (ATR) astig-
ensure the stability of corneal measurements, especially if matism, while the posterior cornea acts more like a minus
planning for a toric or presbyopia-correcting IOL. lens (usually steep in the vertical axis and having ATR
astigmatism, ranging from −0.26 to −0.78D).18 This means
that depending on the anterior corneal astigmatism (ACA)
Principles of Keratometry measurement, the posterior corneal astigmatism (PCA) may
neutralize, increase, or have no effect on ACA. In younger
While a complete discussion of this topic merits a whole patients with WTR, the ATR of the posterior cornea will
other textbook, several essential principles should be kept in compensate for some of the WTR (of the anterior cornea); in
mind when obtaining, assessing, and compensating for kera- older patients, the posterior cornea’s ATR will increase the
tometry (K) measurements as an estimation of corneal power. total corneal astigmatism.
Along with AXL, accurate K values are highly desirable and As we age, total corneal astigmatism will shift toward
weighted heavily in all IOL formulas (see next section). ATR as ACA shifts from WTR to ATR. Since the PCA remains
constant, it may seem that we are gaining ATR, but this is
mainly due to the ACA changes. This relationship is even
Levison AL, Han Y, Chiu CY. Comparison of Refractive Results
14
more skewed in post-refractive patients.
between IOL Master and Immersion A-scan Ultrasonography. Invest.
Ophthalmol. Vis. Sci. 2011;52(14):5686
This is a good rule for all patients, even those who do not wear con-
15
tacts. For most patients, the measured AXL should be similar in both
eyes (excluding patients with pathologies, such as amblyopia, or previ- Please see Chap. 17, Optical Instruments and Machines
16
ous trauma/surgeries, such as scleral buckles). The authors are anecdot- Wang L, Spektor T, de Souza RG, Koch DD. Evaluation of total kera-
17
ally aware of at least one lawsuit that resulted due to a -10D myopic tometry and its accuracy for intraocular lens power calculation in eyes
surprise that occurred because the other (pseudophakic) eye was not after corneal refractive surgery. J Cataract Refract Surg. 2019 Oct;
measured. Further review led to the realization that the AXL measure- 45(10):1416–1421.
ment was inaccurate; had the other eye been also measured, then the Koch DD, Ali SF, Weikert MP, et al. Contribution of posterior corneal
18
discrepancy in AXL measurement would have (potentially) been astigmatism to total corneal astigmatism. Journal of Cataract and
detected before surgery. Refractive Surgery 2012; 38: 2080–87.
Why is all of this (confusing) discussion so important? In For example, the Fyodorov formula, upon which many
addition to the inherent inaccuracy of K measurements, this modern IOL power calculation formulas are based on, sought
understanding of ACA/PCA is essential when we consider to calculate the “D” as such:
surgical options, such as toric IOLs (discussed in the next D = V – U
chapter), to correct corneal astigmatism. If we only relied on
D = (1336 / [ AL - ELP ]) -
ACA (and ignored the PCA) for a toric IOL, we would
potentially end up over-correcting WTR and under-correcting
ATR. For this reason, it is recommended to intentionally
(1336 / éë1336 / {1000 / ([1000 / DPostRx ] - V ) + K} - ELP ùû )
under-correct WTR astigmatism in a young patient (<60 years
old) to allow the increased ATR (that will happen in the where K is net corneal power, AL is Axial length, ELP is
future) to correct the residual WTR astigmatism remaining effective lens position (ELP), DPostRx is desired refraction,
after toric IOL surgery.19 and V is vertex distance.
Various devices and methods have been employed to Don’t be scared by the above formula. You will never
measure the true corneal power (i.e., measure PCA). We can have to calculate this on an exam. We have included it above
broadly group them into direct methods and indirect so you can (1) appreciate the complexity of IOL calculation
methods: and (2) appreciate how U + D = V impacts so many things in
• Direct methods to measure PCA: Scheimpflug devices, ophthalmology!
SS-OCT biometry (e.g., the previously discussed TK),
and slit-scanning devices.
• Prediction methods (formulas) to estimate PCA: Modern Theoretical and Regression Formulas
IOL formulas and toric calculators (available online) use
complex algorithms to estimate the PCA. Examples of Theoretical formulas (e.g., Binkhorst, Colenbrander,
these include the Baylor nomogram, Abulafia-Koch Fyodorov) are IOL formulas derived by applying geometric
regression transformations, and the Barrett toric IOL optics to the reduced schematic eye.22 Many of our “old
calculator. friends” we met in Part I were used historically: thin-lens
However, no single instrument, device, method, or for- formulas, thick-lens formulas, and ray-tracing models. In
mula is considered the be-all/end-all accuracy method. This modern surgical practice, these formulas have been essen-
field remains rapidly evolving (and confusing!) for cataract tially abandoned due to their inaccuracy, especially at
surgeons. extreme AXL and K measurements.
Regression formulas (empirical or statistical formulas)
were based on actual measurements rather than assump-
Intraocular Lens Formulas tions made by the theoretical formulas. The grand-daddy
of these formulas is the SRK Formula. Even though we
A complete discussion of all available IOL formulas, includ- do not use this anymore, this formula must be committed
ing the history, applications, and limitations of each formula, to memory and serves as a useful model to understand
is beyond the scope of this text. Advanced level Optics nerds advanced concepts that we will discuss later. Why is this
may wish to consult several texts on this subject.20 For the formula still important? For example, you may wonder
rest of us mere mortals, we will focus on a few key principles why some cataract surgeons are always freaking about
under this topic. the “correct” lens constant for a new IOL: we can see that
In general, all IOL formulas are essentially trying to accu- a higher or lower “A” will lead to a higher- or lower-than-
rately capture the “D” value from our good old friend “U + needed IOL power, causing myopic or hyperopic sur-
D = V”!21 prise, respectively.
The SRK Formula is:
IOL Power for emmetropia ( Po ) = A - 2.5 L - 0.9 K

This intentional under-correction of WTR is slightly controversial.
19
Some authorities recommend leaving behind approximately 0.3–0.5D where A is the a-constant according to the IOL (determined
residual WTR in these patients, which this author favors. Other sur- by the manufacturer usually by ultrasonic measurement)23; L
geons recommend correcting as much astigmatism as possible, even if
it involves a small flip in the axis.
An excellent resource is Bissen-Miyajima, H, Weikert M, Koch DD
20
Yet another old friend (enemy) returns! See Chap. 7, “Schematic
22
(eds). Cataract Surgery: Maximizing Outcomes Through Research Eye”.

(2014). Springer Publishing. This is why we must ensure the correct a-constant is being used for a
23
A good nerdy mathematics review of this can be found here: Olsen,

21
given IOL if we use optical biometry since the manufacturer a-constant
T. Calculation of intraocular lens power: a review. Acta Ophthalmologica (i.e., what is written on the box) is usually for ultrasound biometry,
Scandinavica 2007; 85: 472–485. unless specified otherwise.
380 K. M. Riaz
ments of true corneal power since we are actually measuring

the size of the image reflected by the tear film (which is a
P = A –0.9K –2.5L
convex mirror, another old friend!).25 These measurements
Fig. 2 Understanding the SRK formula is helpful for understanding also make assumptions about the index of refraction, poste-
commonly encountered advanced topics. For example, both falsely rior corneal power, and corneal spherical aberration, further
elevated keratometry measurements (e.g., post-myopic PRK/LASIK) causing additional potential errors.26
and falsely elongated AXL measurements (e.g., long AXL and silicone After these “first-generation” formulas, several “second-
oil) will call for a lower-than-required IOL power, leading to potential
postoperative hyperopic surprise generation” formulas (such as SRK II and Binkhorst II) were
introduced. These formulas mainly sought to estimate the
is the AXL (as measured by ultrasound); and K is the average postoperative IOL position based on the AXL measurements
keratometry readings (using an index of 1.3375). in long and short eyes. Unfortunately, while they performed
The SRK formula has several limitations. First, it is not slightly better, they too faced the same limitations as the
recommended for extreme AXLs because the formula first-generation formulas.
assumes a linear relationship between IOL power and As a result, newer formulas have been developed to ame-
AXL. This relationship is not linear in short and long AXL liorate the deficiencies of older-generation IOL formulas.
eyes. A similar assumption is made with corneal power caus-
ing a limitations when dealing with flat/steep corneas.
Second, the A-constant itself is an “estimate” made by the Estimated (Effective) Lens Position
manufacturer that needs to be adjusted if OB is used, for
example. To overcome these limitations, surgeons ideally The estimated (effective) lens position (ELP) is simply a way
need to back-calculate postoperative results to personalize of asking: Where does the IOL eventually sit in the eye so
their individual A-constants. that we can use this position as the principal plane of refrac-
What else do you need to know about the SRK formula? tion. Historically, the ELP was also called the anterior cham-
A favorite question that you may encounter about this for- ber depth (ACD) when ACIOLs were standard practice.
mula is: Which measurement error is more devastating when Since we now place IOLs in the posterior chamber, the term
using the SRK formula: keratometry or AXL? ELP is used instead. When we perform biometry, we are
This is relatively simple to understand when we see that the attempting to use preoperative measurements to estimate the
formula “weighs” the AXL by a factor of 2.5 and the keratom- postoperative (pseudophakic) state of the eye, including a
etry measurements by a factor of 0.9. Therefore, a 1 mm AXL prediction of the ELP.
error will affect IOL power by approximately 2.5D (especially Third-generation formulas (discussed below) sought to
in short AXL eyes, up to 3D error), whereas a 1D keratometry calculate a more accurate ELP. For example, the Holladay I
error will affect IOL power only by about 1D. formula uses the AXL and K measurements to calculate an
Understanding the SRK formula is also helpful for under- ELP value, termed the “surgeon factor” (SF). As another
standing some of the advanced topics later on (Fig. 2). For example, the Haigis formula uses the preoperative ACD
example, in post-myopic LASIK/PRK eyes, the measured measurement (and does not include K measurements at all)
K values are falsely higher than real even though the cornea to calculate the ELP. A complete discussion of the “nuts and
has undergone flattening from the refractive surgery.24 This bolts” in each formula is beyond the scope of our discussion.
causes the formula to suggest a lower power IOL than We should appreciate the concept of ELP and understand
needed, leading to the dreaded hyperopic surprise. Similarly, how emerging IOL formulas seek to improve their accuracy
in patients with long AXL or SO in the vitreous cavity, the by primarily improving the ELP value (either directly or
measured AXL is falsely longer; this again causes the for- indirectly).
mula to suggest a lower power IOL leading to the dreaded In the next section, we will discuss how the newer-
hyperopic surprise. generation formulas account for this ELP. By accounting for
While most biometry devices can measure AXL accu-
rately, the real challenge lies in obtaining accurate K mea- 25
See Chap. 17, Optical Instruments/Machines for a discussion regard-
surements. The cornea accounts for about 2/3rd of the total ing keratometry.
An additional comment can be made about the index of refraction
26
refractive power of the eye. Thus, while an error in AXL is
(1.3375) used by most biometry devices. If one uses online calculators
certainly impactful numerically, an error in corneal power (e.g., online multivariable IOL formulas or online toric IOL formulas),
measurements is more commonly encountered clinically. As it is important to make sure that the formula is using the index of refrac-
discussed previously, K measurements are indirect measure- tion used by the biometer. For example, the popularly used Barrett Toric
Calculator has two options for index of refraction: 1.3375 and 1.332. If
we accidently clicked on 1.332, it can create 0.5–1.0D hyperopic error
For example, if keratometry readings from the optical biometer sug-
24
by calling for a lower-than-needed IOL power. Thus, it is important to
gest 40/41 (at a given axis), it is likely that the real K values are even make sure that the formula(s) used has the correct index of refraction
flatter than these measurements. entered.
(or calculating) the ELP, third-generation formulas seek to which the empty capsular bag will encapsulate and fixate
improve the accuracy of previous-generation formulas, espe- an IOL following in-the-bag implantation. This formula
cially in long/short AXL and steep/flat K eyes. While we primarily predicts ELP as a function of ACD and LT.
may think that the ELP is basically the ACD, it turns out that • The recently popular Barrett Universal II formula
this is not an accurate assumption. Remember the old saying accounts for ELP by relating ACD to AXL/K and a rela-
about what happens when you assume… tionship between the A-constant and a separate “lens fac-
tor.” This formula also utilizes LT and WTW values when
available to improve accuracy further, though it can be
Third-Generation and Multivariable Formulas run solely off of AXL, K, and ACD measurements.29
• The Hill RBF is like a Tesla ®: Technically, there is no
These formulas represent a return to the theoretical formulas math in the formula as it relies on pattern recognition AI
(first generation) with additional modifications made to to review the inputted biometry measurements and deter-
account for the previously discussed limitations. mine the IOL power needed.30
Third-generation formulas (Holladay I, Hoffer Q, and • The Kane formula uses theoretical optics, regression, and
SRK/T) still primarily rely on AXL and K measurements. AI components to calculate the IOL power.31
However, they also attempt to predict ELP (as it relates to Several of these formulas have been integrated into com-
AXL) using the original datasets from which the formulas monly used biometry devices, while others are freely avail-
have been derived. The actual “secret recipe” of each for- able online. You may wish to keep your eyes on several other
mula is beyond the scope of this text. The take-home mes- formulas as authors publish their results, including the K6,32
sage is that these formulas are much more accurate than EVO 2.0, Pearl DGS, VRF, Castrop, Næser, and OKULIX
previous-generation formulas, especially for eyes with formulas.
unique biometric data. However, when dealing with extreme To date, when considering eyes with relatively average
AXLs, these formulas too suffer from the limitations of AXL and K values, there is no clear evidence that a single
their predecessors. formula is leaps and bounds superior to other formulas. This
The Ladas Super Surface Formula (LSSF) was recently author recommends that each surgeon uses several multivari-
introduced to combine the strengths of these third-generation able formulas with optimized lens constants for your pre-
IOL formulas to improve refractive accuracy. Think of the ferred IOL in a comparative fashion, with the inclusion of
LSSF like a Megazord-formula that combines all these third- your surgeon-induced astigmatism (SIA), to ensure relative
generation formulas (the power rangers, in this analogy) into agreement and similarity for the calculated IOL power. In
a real-time AI-influenced formula that adjusts based on sur- other words, if 3−4 multivariable formulas all agree that a
geons’ data via crowdsourcing.27 While LSSF seeks to given IOL power will cause similar postoperative refraction,
improve the results of third-generation formulas, it has not then go with that IOL power and hope for the best.
proved to be superior to multivariable formulas, especially For eyes with unique biometric data (e.g., long/short AXL
for extreme AXL eyes. and flat/steep K’s), this author strongly recommends that sur-
Multivariable formulas (aka “fourth-generation formu- geons avoid using “traditional teaching” methods that favor
las”) primarily seek to better calculate the ELP by including third-generation formulas (e.g., SRK/T for long eyes and
other biometric measurements such as ACD, LT, CCT, Hoffer Q for short eyes). Instead, surgeons should utilize
HWTW, age, refraction, and retinal thickness.28 For multivariable formulas whenever possible. In addition,
example: simultaneous comparison of several multivariable formulas
• The Haigis formula attempts to measure ELP by includ- should be strongly considered. Though it may require time
ing ACD and three different IOL constants (a0, a1, and and effort (for which you can’t bill for, unfortunately), this
a2). author recommends using online multivariable formulas for
• The Holladay 2 formula uses seven different measure- eyes with unique measurements. In the future, a centralized
ments to predict ELP, including HWTW, refraction, and online repository for multiple formula calculations with
patient age. simultaneous comparison, similar to the ASCRS IOL power
• The Olsen formula uses thick-lens geometric optics and calculator in eyes with previous refractive surgery may
ray-tracing, and factors in preoperative ACD, corneal
diameter (WTW), and LT. A key feature is the 29 “Barrett Universal II Formula.” http://calc.apacrs.org/barrett_univer-
“C-constant,” which can be conceptualized as a ratio by sal2105/. Accessed June 21, 2020
“Hill-RBF Calculator Version 2.0.” https://rbfcalculator.com/.
30
Accessed June 21, 2020

Ladas Super Surface Formula available at www.IOLcalc.com.
27
“Kane Formula” https://www.iolformula.com/about/. Accessed June
31
Accessed June 21, 2020 21, 2020

“IOL Calculation Formulas Explained.” https://cataract-community.
28
Cooke Formula (K6). https://cookeformula.com/. Accessed January
32
zeiss.com/iol-calculation-formulas-explained. Accessed June 21, 2020 9, 2021

382 K. M. Riaz
f urther help surgeons to effectively and efficiently select an Well, the answer to this question is a bit more complicated
appropriate IOL power in short and long AL eyes. Ideally, a and requires us first to understand the various “axes” relevant
collaborative, multinational effort to amalgamate formulas for cataract and refractive surgery.
for extreme AL eyes is needed to create a resource that is Note: the following discussion of the various axes inten-
freely available to all surgeons. There is no one-size-fits-all, tionally does not use the term “line of sight”, which other
Swiss-army-knife type of formula that can be used for every authors have discussed extensively as a distinct entity from
single eye at this time. Future studies may shed further light the visual axis. As most cataract and refractive surgeons
on ideal formulas for a given biometry device and a given today use the term “visual axis”, we will use this term in
IOL platform. place of, but also inclusive of, the “line of sight”. While we
It seems there is a new IOL formula released every few will briefly introduce the “line of sight”, interested readers
months – in future versions of this book, we may have to add may wish to consult other texts on this topic.34
much more information about each. It is beyond the scope of The three most important axes are as follows (Fig. 3):
this text to say which IOL formula is best for which situa- • Optical Axis: The optical axis (OA) is an imaginary line
tion.33 We have mainly included the previous discussion for that connects the optical center of the cornea and the optical
you, dear reader, to appreciate how Optics plays a role in center of the lens. We may additionally draw an extended
your life as a cataract surgeon and how all the “boring” stuff imaginary line to the optical center of the retina for visual-
we discussed earlier actually has relevance! ization purposes only. In optical biometry, the midpoint of
the HWTW is used as a presumed location of the OA.
• Pupillary Axis: The pupillary axis (PA) is an imaginary
Optical Angles and Axes line perpendicular to the corneal surface that passes
through the midpoint of the pupil, similarly extended to
We may assume that when we look at an object in the dis- the retina. The PA has no relationship to the visualized
tance, we can draw a straight line from the center of the fovea object or the foveal center.
that goes through the center of the pupil and leads to the • Visual Axis: The visual axis (VA) is an imaginary line
object of interest. However, this is not the whole story… that connects the visualized target and the foveal center. It
there are three axes and two angles relevant to cataract sur- has no relationship (necessarily) to the cornea, pupil, or
gery, especially when considering advanced technology lens. As stated previously, we will refer to the VA as inclu-
IOLs (ATIOLs) for presbyopia correction. sive of the “line of sight” as well.
In addition, some authorities defined OA as a line that con-
nects the four Purkinje images that originate from a coaxial
Optical Axis, Pupillary Axis, and Visual Axis light source.35 They have added the term (also referred to as the
“line of sight”) to refer to the line formed from the fixation
A theoretical scenario can serve as an introduction to what is point to the center of the entrance of the pupil. Therefore, by
arguably a confusing topic: suppose you just performed per- this classification, the line of sight can be considered the previ-
fect LASIK surgery on a + 3.50D OU hyperopic patient. You ously discussed OA, making the OA a separately defined axis
centered your treatment zone in the center of the pupil and altogether. Hopefully, you can see now why we have tried to
pat yourself on the back for a job well done. You are imagin- minimize our discussions on the “line of sight”.
ing that she will return in a few days thrilled with your exper- Getting back to our hyperopic patient: In our good-
tise and will name her first child after you. intentioned efforts to center the ablation on the center of the
Instead, the patient returns a week later, furious that she pupil (PA), we may not have centered it on the VA. Though
has disabling glare, halos, and starbursts that worsen with the objective visual acuity is good, the decentration is caus-
low-light conditions. Her objective visual acuity is 20/25, but ing significant higher order aberrations (such as coma).
she is bitterly angry. Especially since this patient was a hyperope, there may have
What may have happened? Everything should be perfect, been a difference between the PA and VA, creating a visual
right? We centered our treatment in the exact center of the angle. We will discuss these two angles in the next section.
pupil and that’s the spot that all patients look through…
right?
This is currently an area of significant interest among researchers,

33 For example, see Azar DT (ed.), Refractive Surgery, third Edition.
34
with many new formulas and papers being introduced every few Elsevier Publishing, 2019.
months. The reader is directed to https://www.doctor-hill.com/iol-main/ In addition to the below discussion on Purkinje images, see Chap. 28
35
formulas.htm for a useful summary overview of when to use each Intraoperative Optics, for a more detailed discussion on the 4 Purkinje
formula. images seen through an operating microscope
Fig. 3 Three axes (optical VA VA

axis, pupillary axis, and visual PA OA
axis) are relevant for cataract α
and refractive surgery. The
optical axis (OA) is an
imaginary line that connects
the optical center of the
x
cornea and the optical center
of the lens. The pupillary axis
(PA) is an imaginary line
perpendicular to the corneal
surface that passes through x
the midpoint of the pupil. The
visual axis (VA) is an
imaginary line that connects
the visualized target and the
foveal center. These three
axes create two important
angles: (1) Angle Alpha (α):
this is the angle formed by the
OA and the VA and (2) Angle
Kappa (κ) (aka chord mu):
this is the angle formed by the K
PA and the VA
Angle Alpha and Angle Kappa
The VA would be the same as the OA and PA in a perfect

eye. However, since this is not the case, we can use these
three surgically relevant axes above to establish two addi-
tional surgically relevant angles (formed by these axes)
(Fig. 4):
• Angle Alpha: This is the angle formed by the OA and
the VA. The normal eye has about 5.2° horizontal and
++ 1° vertical tilt of angle alpha. Angle alpha is especially
+
important for refractive IOL surgery as it measures the
degree of anatomical tilt of the eye relative to the opti-
cal axis. If there is a significant (>0.5 mm) angle alpha,
the OA (which is the center of the capsular bag where
the IOL will usually center) may not match the VA. This
may not be an issue for a monofocal IOL, but when con-
sidering an MFIOL/EDOF-IOL, a patient with signifi-
cant angle alpha may end up looking through the “rings”
(through which the VA passes through) rather than the
Fig. 4 Angle alpha and angle kappa are of significant interest when center of the IOL optic, despite a well-centered IOL
considering MFIOL/EDOF-IOLs. The first Purkinje image (red cross)
(Fig. 4).36
represents the visual axis. The optical center (blue cross) is the center of
the HWTW and is where the IOL will center. The pupillary axis (green • Angle Kappa (aka chord mu): This is the angle formed
cross) is the pupil center. In this example, the patient has a significant by the PA and the VA.37 It is supposed to represent the
discrepancy between the visual axis (red cross) and the optical axis two-dimensional displacement of the entrance of the
(blue cross), causing a significant angle alpha (>0.5 mm). The patient
also has a large difference between the visual axis (red cross) and pupil-
lary axis (green cross), indicating a large angle kappa as well. This Some authors believe that the ideal location for a MFIOL/EDOF-IOL
36
patient is a poor candidate for an MFIOL or EDOF-IOL. Of note, the is halfway between the VA and PA. Usually, the VA is slightly nasal to
green circle represents the pupil (used to measure the pupillary axis), the PA. When placing a MFIOL/EDOF-IOL, gently nudging the IOL
and the blue half-circles represent the horizontal white-to-white (used nasally may help better land the IOL in this “sweet spot.” See “Hidden
to measure the optical axis) Figures,” https://crstodayeurope.com/articles/2018-apr/hidden-figures/.
Accessed June 21, 2020
A (questionably) useful mnemonic is “AOV” (alpha, optical, visual)
37
and “KPV” (kappa, pupillary, visual)

384 K. M. Riaz
pupil center from the subject-fixated, coaxially-sighted lary axis. By applying the Pythagorean formula, the chord
corneal light reflex. The normal eye has about a 2.6° tilt of mu (C) can be calculated as: C = (x2 + y2). To simplify mat-
angle kappa. Large angle kappa is commonly seen in ters, one can simply add the absolute values of x and y and
hyperopes, indicating that the center of the pupil is not the yield a “close enough” measurement of chord mu. Before
true visual axis.38 Angle kappa is especially important in you do your next cataract surgery, take a minute to look at the
excimer laser refractive surgery. The pupil-tracker will biometry printouts (which we cannot include due to copy-
use iris landmarks to center the ablation, assuming that rights) to see if you can find the chord mu. Again, this num-
the pupillary axis is essentially the visual axis. Since this ber should be less than 0.6 mm if one plans to implant an IOL
is not the case with hyperopes, ablation performed with with diffractive optics.
pupil-tracking may inadvertently cause a decentered abla-
tion since the patient’s VA is not the same as the PA. In
these situations, it may be helpful to align the ablation Considerations for Special Situations
with the VA (as per the Purkinje image) rather than the
PA. For ATIOL surgery, a patient with large angle kappa Long and Short Axial Length Eyes
(>0.6 mm) may experience a central light ray to similarly
hit the edge of the ring outside the central optic, thus Third-generation formulas may calculate a lower-than-
increasing the unwanted effects of glare and optical aber- required IOL power in patients with long AXL (>25.5 mm).
rations. With modern biometry devices, the pupil bary- In these eyes, compared to normal AXL eyes, there is “more
center values can be added together (ignoring positive or vitreous”; as a result, the optical signal spends more “time”
minus values) as a proxy for the angle kappa; this mea- traveling through the vitreous in a long AXL compared to a
surement should be less than 0.6 mm.39 normal AXL. As the index of refraction of vitreous is slightly
Getting back to our clinical vignette, we can tie this all higher than aqueous (1.337 vs. 1.336, which we previously
together by the following: Because the patient was a hyper- ignored), this plays a role in long AXL eyes. As a result, the
ope, she likely had a significant angle kappa. When we cen- measured AXL is falsely long, leading to hyperopic sur-
tered the ablation on the PA, we did not center it on the actual prise. This would be devastating for any patient, especially
VA. As a result, the patient is looking “off-axis” from the those with long AXL, as they have presumably been myopic
ablation and likely has significant higher-order aberrations, their whole lives and would be extremely unhappy if they
including coma and irregular astigmatism.40 became hyperopic after surgery. As always, being a hyperope
Overall, patients with abnormal angle alpha and/or angle stinks…
kappa would also be poor candidates for diffractive ATIOLs A landmark paper in 2011 was the first to describe a
(MFIOLs, EDOF-IOLs, and TF-IOLs). These patients would method for adjusting the AXL (popularly known as the
be better off with an aspheric, monofocal IOL. If they are “Wang-Koch” modification) if working with third-generation
interested in presbyopia correction, monovision, or an formulas (Holladay I, Hoffer Q, and SRK/T) and the Haigis
accommodating IOL would be better choices. formula.41 Basically, the measured AXL (by OB) would need
As a final aside: Recently, there has been significant dis- to be adjusted and re-entered as a modified AXL back into
cussion among refractive cataract surgeons regarding angle the biometry device for a more accurate calculation of the
kappa and chord mu. Again, angle kappa is the angle formed required IOL power. A follow-up paper from the same
between the pupillary axis and the visual axis; chord mu is authors in 2018 included updated AXL factors for each for-
defined as the distance between the pupil center and the mula.42 This AXL modification improved the outcomes of
subject-
fixated, coaxially-sighted corneal light reflex. these four popularly used formulas. In recent times, as sur-
Modern IOL biometry devices, such as the IOL Master 700 geons have shifted toward favoring multivariable formulas,
(Carl Zeiss Meditec, Jena AG, Germany), can generate a this modification has become unnecessary as the formulas
chord mu value which serves as a proxy for angle kappa. have a built-in mathematical mechanism to compensate for
Other biometers, such as the Lenstar (Haag- Streit, long AXL. In other words, if you use Barrett, Hill RBF,
Switzerland), can show the x and y coordinates of the pupil- Kane, etc., you do not have to worry about manually making
this adjustment. Additionally, the Wang-Koch modification
should not be used in patients with a history of laser refrac-
There are many other conditions besides hyperopia that are associated
38
with large angle kappa, such as cicatricial ROP, toxocariasis, and con- tive surgery.
genital retinal folds. These patients may present to the pediatric oph-
thalmologist for evaluation of (pseudo)strabismus and exotropia.
These are the PCX/PCY and Px/Py values on the Lenstar® and IOL
39
Wang L, Shirayama M, Ma XJ, et al. Optimizing intraocular lens
41
Master®, respectively. power calculations in eyes with axial lengths above 25.0 mm. J Cataract
Some of you may wonder, what should be done for this patient?
40 Refract Surg. 2011;37(11):2018–2027.
Therapeutic options now include a RGPCL/scleral contact lens or Wang L, Koch DD. Modified axial length adjustment formulas in long
42
topography-guided ablation. eyes. J Cataract Refract Surg. 2018 Nov; 44(11):1396–1397.

There is an even greater risk for inaccurate AXL measure- ference!. In this scenario, we are assuming that the SO will
ments for short AXL eyes – again, it stinks to be a hyperope. be removed in the future (more on this below).
Due to the math involved in the available IOL formulas, When we use a modern OB device, we can select the
inaccurate AXL measurements in short AXL eyes will more “phakic silicone oil” mode, which similarly attempts to cor-
profoundly affect the calculated IOL power than long AXL rect the potential error in AXL measurement. This setting
eyes. One reason may be that the IOL is “closer” to the retina again assumes that the SO will be removed in the future and
in these eyes (as compared to normal AXL eyes), and even a will calculate an IOL power accordingly. Suppose we used
small change in ELP may cause more of a refractive effect – this setting, but then the SO permanently stays in the eye;
we also know that these eyes are prone to significant varia- this will cause a 4–6D more-than-desired hyperopic refrac-
tion in post-operative ELP. In addition, current IOL tive error because the SO will mold to the posterior surface
manufacturing standards for tolerance in higher powers of the biconvex IOL (recall the discussion in the previous
(>30D) allow for greater variability: in other words, it may section), thereby decreasing the effective power of IOL. Of
be that a +32D IOL is not really +32D. Finally, the ACD in course, we can reduce this effect by using a convex-plano
these eyes is also quite shallow, either due to anatomical IOL, but this type of IOL is no longer available in the USA.
variation or thickness of the cataract; this also skews the cal- If the patient was emmetropic before retina surgery, the
culated IOL power. AXL of the eye without SO can be used by those of us who
Thankfully, the most commonly encountered refractive forgot all the other pearls.
error in short AXL eyes is a postoperative myopic surprise, To summarize: If the SO will never be removed, then
likely due to a more anterior ELP of the IOL than predicted, use non-adjusted measurements because the SO is the new
especially in patients with shallow ACDs. As most of these vitreous. Even then, because the SO may mold to the back
patients are usually hyperopes prior to cataract surgery, they of the IOL, we will have to increase the power of the IOL
actually may be quite happy with a myopic outcome as they by 4–6D to account for this hyperopic shift. If the SO can
may be able to finally read without reading glasses! be removed in the future, then use the “phakic silicone
As mentioned previously, this author recommends that oil” setting on the biometry device to calculate the needed
surgeons utilize multivariable formulas (either biometry- IOL power.
integrated or online calculators) in a side-by-side compari- Of course, this is all a moot point since most of these eyes
son for formula agreement when calculating the desired IOL have lousy vision potential anyway, but we digress.
power in these extreme AXL eyes.
ilicone Oil and IOL Choices
S
As discussed previously, a convex-plano IOL would be ideal
Silicone Oil for these eyes. Since we do not have this type of IOL, we are
forced to use a biconvex IOL (unless we planned for inten-
This is the one section that drives many trainees crazy – it is tional convex-plano ACIOL implantation, which is not rec-
no surprise that it is also a topic that senior attendings may ommended). A biconvex IOL can lose up to one-third its
love to quiz you on. This is a confusing yet high-yield refractive power due to SO molding; if the SO can never be
discussion. removed and biometry calls for a + 20.0D IOL, one may go
ahead and place a + 25–26.0D IOL to account for this loss of
ilicone Oil and Biometry
S IOL power.
A foundational rule for this discussion is that any signal In terms of IOL material, acrylic, collamer, or PMMA
(USB more than OB) that travels through silicone oil (SO) IOLs are reasonable choices. Silicone IOLs should be
(index of refraction: 1.40–1.52, depending on the type and avoided in these eyes due to the risk of silicone IOL-SO
weight of the SO) will be slowed down compared to the interaction leading to visually significant opacities. As light
signal traveling through vitreous (index of refraction: passes through the IOL (which has a higher index of refrac-
1.337). As a result, it will take longer for the signal to return, tion; for example, acrylic IOLs have an index of refraction
leading to an erroneously high AXL measurement (often 1.47–1.55) into the vitreous (1.337), it is refracted to a cer-
>30 mm!). tain degree. However, if it now passes through SO (1.40), it
If we are using USB, we can adjust the machine settings will be refracted much less, thanks to our good old friend
(from 1532 m/s to 980 m/s) so that the measurement taken Snell’s Law(!). Therefore, the IOL must be strong by approx-
through SO will be as if taken through vitreous. For example, imately 4−5D if the SO remains in the eye.
if we measured an eye with USB without signal adjustment,
we may measure an AXL of 33.85 mm (falsely long). ilicone Oil and Cataract Surgery: Hi-Yield
S
However, when we measure that same eye with the adjusted Summary
velocity (980 m/s through SO of 1,000 cSt), we may get a If one has to ever explain this, the following summary may
more accurate measurement of 25.07 mm - this is a huge dif- suffice and should be committed to memory:
386 K. M. Riaz
• First, we must understand that the optical issue with SO in like the dark side of the moon: We do not have a good way
the eye is the potential inaccuracy in IOL calculation, to measure it, so we measure the anterior surface and make
leading to a high risk of hyperopic surprise. assumptions about the posterior surface. This works (usu-
• The million-dollar question: does the SO need to remain ally) well in virgin corneas, but this anterior-posterior rela-
in the eye? There are three possible scenarios: tionship is no longer the same after refractive surgery. As
• First Possibility: The SO can be removed immediately. If a rule of thumb, the corneal power is over-estimated by
so, remove the SO, perform routine biometry, perform approximately 1D for every 6D of treated refractive error.
cataract surgery, and move along: nothing more to see • Limitation of IOL formulas: Older-generation formulas
here. primarily rely on AXL and keratometry measurements to
• Second Possibility: The SO can be removed in the distant calculate the ELP. If the keratometry measurements are
future, but the cataract needs to be removed now. This inaccurate (and not adjusted), the formula will call for a
itself has three potential answers: lower-than-required IOL power, and the patient will have
• Measure the SO filled eye and aim for -5D myopia to a hyperopic surprise. Therefore, we have to use “modi-
account for potential postoperative hyperopia. fied” formulas to adjust for the keratometry measurement
• Use a biometry machine with SO settings, but remem- inaccuracies.
ber that the suggested IOL is for an eye with no In normal corneas, we assume a constant ratio (called the
SO. Therefore, if we use this SO setting and place an Gullstrand ratio from the Gullstrand schematic eye43)
IOL aiming for emmetropia, we will end up with between the posterior and anterior curvatures, which is
approximately 5D of hyperopia if the SO is not approximately 0.883 (6.8/7.7, respectively, or 88.3%) or, as
removed. more recently suggested, 0.813 (81.3%).44 Do not get too
• Assuming that the refraction and keratometry of the bogged down by these numbers. After refractive surgery, the
two eyes are similar (before placement of SO), we can anterior curvature will change (e.g., become flatter after
consider using the measurements of the non-SO-filled myopic correction), and the Gullstrand ratio will increase. In
eye to calculate the IOL. addition to looking at the front surface K values, one pearl to
• Third Possibility: The SO will never be removed. In this determine whether a patient has had refractive surgery is to
case, use the non-adjusted measurements because the SO use Scheimpflug tomography to measure the posterior and
is the new “vitreous.” However, we should still aim for anterior corneal curvatures (in mm). If the posterior-anterior
an additional +5.0D in the calculated IOL power to cornea ratio is higher than 0.82, there is a high likelihood that
account for SO molding to the posterior surface of the the patient has undergone myopic laser vision correction.
IOL. For example, if the non-adjusted measurement calls In summary, the keratometry measurements are inher-
for a 22D IOL for target plano, use a 27D instead. ently inaccurate because refractive surgery alters the corneal
If you can rattle this off coherently, please take a bow curvature. Therefore:
before moving to the next section. • In post-myopic laser refractive surgery patients, the kera-
tometry measurements are falsely steeper-than-real.
This causes an underestimation of the IOL power, lead-
Previous History of Refractive Surgery ing to potential hyperopic surprise. For example, we can
see from Fig. 1 that if we falsely increase the value of
When determining accurate IOL power in patients with a “K,” we will decrease the value of the calculated IOL.
previous history of refractive surgery, there are two main • In post-hyperopic laser refractive surgery patients, the
issues: corneal power measurement inaccuracy and spherical keratometry measurements are falsely flatter-than-
aberration issues. real. This causes an overestimation of the IOL power,
Corneal Power Measurement Inaccuracy: Corneal power leading to potential myopic surprise (which is not a ter-
measurements after refractive surgery may be inaccurate due rible outcome, one may argue).
to (a combination of) three reasons:
• Instrument errors: Keratometers only measure the central An old friend (enemy) returns! See Chap. 7, “Schematic Eye”
43
zone (3.2 mm) of the cornea, which is smaller than the Dubbelman M Van der Heijde GL Weeber HA Vrensen GF . Radius
44
effective central zone. This is especially important in and asphericity of the posterior corneal surface determined by corrected
patients with a previous history of high myopia. These Scheimpflug photography. Acta Ophthalmol Scand. 2002; 80:379–383.
The anterior and posterior corneal radii can be used to calculate the
corneas tend to be much flatter than virgin corneas, thus APR (anterior corneal radius/posterior corneal radius ratio) or P/A
causing even more of a measurement error. (posterior/anterior corneal radii) ratio. Previous authors have reported
• Index of refraction: The corneal index of refraction the APR ratio (range 1.19–1. 23) and P/A ratio (approximately 0.83) in
(1.3375) used by most keratometry devices assumes a a normal population is significantly different from the ratio in post laser
vision correction (LVC) patients. As the APR and P/A values are
fixed ratio between the anterior and posterior corneal sur- inversely related, post-myopic LVC eyes will have lower APR and
faces. Remember, the posterior surface of the cornea is higher P/A values, respectively.
Several methods have been proposed to measure corneal • An aspheric IOL with negative spherical aberration
power more accurately (both via indirect and direct methods).45 may be advantageous due to these eyes’ increased posi-
Modern OB machines may include formulas (e.g., Haigis-L) tive spherical aberration. An aberration-free IOL is also
that make specific adjustments for more accurate keratometry be a good choice, especially if the patient desires some
measurements for post-refractive surgery eyes.46 As mentioned additional near vision (i.e., leaving behind some positive
previously, TK values can be used with an older formula, such spherical aberration). A spherical IOL would be the worst
as the Haigis formula. Most surgeons currently use a free online choice.
calculator hosted by the American Society of Cataract and • Thoroughly discuss with the patient the potential for post-
Refractive Surgery (ASCRS) that offers multiple formulas that operative refractive error (especially hyperopic surprise)
can be used in a side-by-side comparison fashion; each of these and the need for potential postoperative adjustment(s) of
formulas, such as the Wang-Koch-Maloney, Shammas, Potvin- these errors (e.g., glasses, contact lenses, piggyback IOL,
Hill, and Barrett True K formulas, attempt to calculate the true IOL exchange, or additional excimer laser surgery).
corneal power depending on available data to calculate the For post-hyperopic refractive surgery patients:
required IOL.47 Notably, some of these formulas require addi- • Use available post-refractive IOL formulas, including the
tional measurements, such as corneal power from topography, ASCRS online calculator, to calculate the IOL
tomography, or AS-OCT devices. power. Given the increased risk of myopic surprise, we
Spherical Aberration Issues: If you thought we were done can safely target close to emmetropia.
with spherical aberration, guess again! • A spherical IOL with positive spherical aberration or
• Traditional myopic laser treatments (i.e., prior to an aberration-free IOL is a good choice. An aspheric IOL
wavefront-guided (WG) and wavefront-optimized (WO) with negative spherical aberration would be the worst
treatments) primarily treated the central cornea and left choice.
the peripheral cornea relatively untouched. As a result,
these traditional myopic laser treatments typically Previous Radial Keratotomy (RK) Surgery
increased corneal spherical aberration. In retrospect, it remains unclear who was the bigger idiot: the
fool under the microscope or the fool behind the microscope
• In contrast, traditional hyperopic laser treatments (source unknown).
decreased the corneal spherical aberration due to
mainly treating the peripheral cornea and leaving the Radial keratotomy (RK) was introduced in the late 1970s as an
central cornea relatively untouched. With WG/ incisional procedure to correct myopia. A guarded blade was
WO treatments, the SA theoretically remains rela- used to make radial cuts (approximately 90% corneal thick-
tively unchanged because of peripheral blend zone ness) to cause secondary corneal flattening based on the num-
treatment. ber of incisions. For a while, RK worked; however,
The two most common types of post-refractive patients complications such as progressive hyperopia, irregular astig-
presenting for cataract surgery are patients with previous his- matism, and corneal scarring rendered this procedure in mod-
tory of PRK/LASIK and previous history of radial keratot- ern times as an abandoned and obsolete surgery.48 Please see
omy (RK). Chap. 30, “Optics for Refractive Surgery”, for more informa-
tion about RK.
revious Laser Refractive Surgery: PRK
P Cataract surgeons must know about RK because these
and LASIK post-RK patients may now require cataract surgery. There
We can summarize our strategy for these patients as are several considerations for these patients:
follows:
For post-myopic refractive surgery patients: Preoperative Considerations
• Use available post-refractive IOL formulas, including the • Corneal measurements are even more inaccurate in post-
ASCRS online calculator, to calculate the needed IOL RK eyes than post-PRK/LASIK eyes. Again, the kera-
and err on the side of additional myopia (i.e., aim for tometry measurements are falsely steeper-than-real
−0.50 or − 0.75 instead of emmetropia). (similar to post-myopic laser refractive surgery), leading
to an inaccurately low IOL power and increased risk of
A good summary of these strategies may be found at: https://eyewiki.
45 hyperopic surprise. The current post-RK IOL formulas
a a o . o rg / B i o m e t r y _ f o r _ I n t r a - O c u l a r _ L e n s _ ( I O L ) _ p ow e r _
calculation#After_Refractive_Surgery. Accessed June 21, 2020. For example, the PERK Study (1982–83) evaluated the safety and
48
Recall from our previous discussions above that the Haigis formula
46
efficacy of RK. Ten-year results showed that 53% of patients ≥20/20
does not rely on the K values to determine the ELP, and instead relies vision. However, the biggest finding was the instability of the proce-
on ACD measurements and 3 constants (a0, a1, and a2). The Haigis-L dure: a hyperopic shift (≥1 D) was seen in 43% of the study patients.
is a modification of this Haigis formula. See Waring GO third, Lynn MJ, McDonnell PJ. Results of the prospec-
“IOL power calculation in eyes that have undergone LASIK/PRK/
47
tive evaluation of radial keratotomy (PERK) study 10 years after sur-
RK.” https://iolcalc.ascrs.org/. Accessed June 21, 2020. gery. Arch Ophthalmol. 1994; 112(10):1298–1308.
388 K. M. Riaz
are even less accurate than post-PRK/LASIK IOL formu- Phakic IOL
las. As such, surgeons should target more myopia (-1D or A few Optics related considerations should be kept in mind
more) to account for a postoperative hyperopic surprise. when performing cataract surgery in patients with existing
Post-RK formulas can be found on the ASCRS website phakic IOLs:
like the post-LASIK formulas. • The phakic IOL does not have to be removed before per-
• Patients should be strongly counseled regarding the chal- forming preoperative biometry measurements. It can be
lenges associated with accurate biometry measurements removed (obviously) at the time of cataract surgery.
and should have reasonable expectations. They should not • When using OB for preoperative measurements, we do
expect perfect vision immediately after cataract surgery. not have to make any additional adjustments because the
phakic IOL’s effect on low-coherence light is minimal,
Intraoperative Considerations especially for collamer phakic IOLs, which are the most
• Depending on the number of wounds (usually 8 RK inci- commonly implanted phakic IOLs in the United States.49
sions were made, though up to 50 incisions have been • If we have to use USB, we should keep in mind that the
seen!), the old RK incisions may splay open with a stan- AXL measurement will likely be inaccurate. The least
dard clear corneal incision. If the RK cuts are minimal, amount of inaccuracy is with collamer phakic IOLs. If the
using a smaller blade (≤2.2 mm) with strategic placement patient has a silicone phakic IOL (especially a hyperopic
of the incision may be sufficient; otherwise, a scleral tun- one, which is not available in the United States), there is a
nel may be the safest option. greater chance of inaccurate AXL measurement.
• Surgeons should have suture available in case the RK • To calculate the “correct” AXL, the following formula
incisions splay open during surgery. Use low flow settings can be used50:
to minimize stress to the incisions. Move slowly but effi-
AL ( corrected ) = AL (1555 ) + ( X ´ T )
ciently during every step of the procedure. This should
not be a 10-minute cataract! • where X = +0.42 (0.41–0.42) for poly (methyl methacry-
• Avoid any diffractive ATIOLs (MFIOLs, EDOF-IOL, and late), −0.59 (0.56–0.59) for silicone, +0.11 (0.10–0.12)
TF-IOLs). Stick with aspheric monofocal IOLs as the saf- for collamer, and + 0.23 (0.23–0.24) for acrylic; and T is
est option. This is somewhat controversial as some sur- the central thickness of the phakic IOL.
geons maintain that EDOF-IOLs can be used in these
patients without difficulty. For exam purposes, a conser-
vative approach is recommended; thus, aspheric monofo- Biometry in Undilated Versus Dilated States
cal IOLs are the safest option. An accommodating IOL or
monovision may be considered if that patient desires Performing biometry on patients without dilation (and other
presbyopia correction. diagnostic drops, such as topical anesthetics) is ideal clinical
practice. Multivariable formulas factor in other biometric
Postoperative Considerations measurements, such as ACD, in calculating the IOL power. It
• The RK incisions may swell after cataract surgery, causing is also well known that ACD increases after dilation, and
corneal flattening and immediate postoperative (transient) multivariable IOL formulas incorporate ACD measurements
hyperopia. Do not panic! Wait at least 6–8 weeks with differently.51
serial refraction and examination before jumping into In real-world clinical settings, patients with visually sig-
doing additional piggyback IOL or IOL exchange nificant cataracts may be examined by a clinician after dila-
surgery. tion, and the decision for surgery may follow. In this setting,
• Patients should be counseled that the postoperative refrac- while it is ideal for the patient to return and undergo undi-
tion may vary considerably. These patients should not lated biometry measurements, it may be convenient to per-
expect immediate 20/20 vision like routine cataract sur- form post-dilation biometry so that the patient does not have
gery patients – they have to atone for their past sins by to return for an additional visit for biometry testing. If using
being patient postoperatively. Some patients may require first- to third-generation formulas, post-dilation biometry
up to 3 months to allow for stabilization of the refractive
error. Sanders DR, Bernitsky DA, Harton PJ Jr., Rivera RR. The Visian
49
• Patients may require glasses or contact lenses (including myopic implantable collamer lens does not significantly affect axial
RGPCLs for irregular astigmatism) to manage postopera- length measurement with the IOLMaster. J Refract Surg. 2008 Nov;
24(9):957–9.
tive errors. Surgical intervention may include piggyback
Hoffer KJ. Ultrasound axial length measurement in biphakic eyes. J
50
IOL (especially for confirmed, persistent hyperopic sur- Cataract Refract Surg. 2003 May; 29(5):961–5.
prise), IOL exchange, or cautious PRK. LASIK is highly Rodriguez-Raton A, Jimenez-Alvarez M, Arteche-Limousin L, et al.
51
discouraged(!) in these patients as flap creation would be Effect of pupil dilation on biometry measurements with partial coher-
extremely challenging and risky. ence interferometry and its effect on IOL power formula calculation.
Eur J Ophthalmol. 2015;25:309–14
measurements are essentially the same as undilated biometry • Use an assumed K-reading of 44-45D, aim −1 to −2D
measurements. However, if using multivariable IOL formu- myopic, and proceed with cataract surgery.
las, post-dilation biometry measurements may favor a • Use the K-readings from the fellow eye (if available),
higher-power IOL in a significant portion of cases, increas- especially in cases of unilateral disease (e.g., corneal scar
ing the likelihood of a myopic surprise.52 Again, not the end from infection). This may not work well if the other eye
of the world, but not an ideal situation, nonetheless. also may soon need PKP (e.g., bilateral advanced
keratoconus).
• Multiple-regression analysis with surgeon-specific values
Combined Cataract and Corneal Surgery and individualized a-constants can also be applied – this
also requires a lot of historical data and meticulous effort.
For some patients, combined cataract and corneal transplant For real-world purposes, one should aim for additional
surgery may be needed. While there is seemingly an alphabet myopia; this author routinely uses a -2D target in these situ-
soup of corneal transplant surgeries these days, we will focus ations. Alternatively, you may consider referring these cases
on two types of combined cataract-corneal surgeries. Again, to a corneal surgeon with experience dealing with this
the common theme is the risk of the dreaded hyperopic scenario.
surprise…
ndothelial Keratoplasty (EK)
E
enetrating Keratoplasty (PKP)
P The field of EK has undergone significant advancements,
As expected, the major drawback to combined cataract/PKP with a variety of new procedures now being routinely per-
surgery (“the old triple procedure”) is the inaccuracy of IOL formed, including Descemet’s stripping (automated) endo-
power prediction given the unpredictable power of the cornea thelial keratoplasty (DSEK/DSAEK), Descemet’s
after PKP. Unless one is a superhero corneal surgeon who can membrane endothelial keratoplasty (DMEK), and Pre-
consistently predict “x” keratometry readings (and astigma- Descemet’s endothelial keratoplasty (PDEK). EK proce-
tism) after PKP, inaccuracies in IOL selection are likely. dures are much more amenable to being combined with
Therefore, some authorities recommend performing the cataract surgery. While some surgeons advocate staging
PKP first, waiting at least a year for the cornea to stabilize procedures whenever possible, combined cataract and EK
(including astigmatism management with suture removal), surgery may be necessary given the clinical scenario and
and then performing cataract surgery using the post-PKP patient expectations.
corneal measurements (that presumably have stabilized and DSAEK is a tissue additive procedure (40–150 μm of tis-
are accurate). While this is an ideal approach, it may not sue, including endothelium, Descemet’s membrane, and
always be possible to delay the cataract surgery, especially some stroma. This leads to changes in posterior corneal cur-
in trauma or rapid progression cases. Others recommend vature as well as corneal deturgescence. The net result of this
performing the PKP with cataract removal only, waiting magical symphony is a hyperopic shift after DSAEK, ranging
until the keratometry measurements have stabilized, and from 0.5 to 2.0D. As a result, the refractive target should be
placing a secondary IOL 6−12 months later. This also may about −1 to −1.5D with combined cataract/DSAEK to com-
be less-than-deal, as the capsular bag may fibrose, prevent- pensate for potential hyperopic shit.
ing in-the-bag IOL placement. This also requires an addi- DMEK is a 1:1 tissue replacement surgery. Since there is
tional surgical procedure with potential risks and setbacks. significantly less transplanted tissue, the amount of postop-
There may be various postoperative refractive errors, erative hyperopic shift is less than DSAEK. As a result, the
especially high/irregular astigmatism and the dreaded hyper- refractive target should be about −0.5 to –1D to compensate
opic surprise. For exam purposes, if one has to do combined for potential hyperopic shifts. Alternatively, using an IOL
cataract/PKP, several strategies for keratometry readings power +1D higher than the biometry print out values can
may be considered, including but not limited to the also help achieve emmetropia. For example, if a given IOL
following: formula predicts that a +19.0D will get a –0.50D final
• Reviewing his/her previous historical post-PKP astigma- refraction, surgeons can instead use a +20.0D IOL to obtain
tism values (at least 10 cases), a surgeon may use the the desired –0.50D refraction in such a scenario.
average of these K-readings as a reasonable estimate for Preoperative considerations include the presence of sig-
postoperative K-readings. nificant corneal edema that may confound biometry mea-
surements. To obtain better keratometry measurements,
one may consider using topical glycerin before biometry or
Simon NC, Farooq AV, Zhang MH, et al. The Effect of Pharmacological
52
Dilation on Calculation of Targeted and Ideal IOL Power Using

performing a superficial keratectomy to “debulk” astigma-
Multivariable Formulas [published online ahead of print, 2020 May tism. Intraoperatively, surgeons should avoid placing a
27]. Ophthalmol Ther. 2020; https://doi.org/10.1007/ hydrophilic IOL as the concurrent use of air or gas may
s40123-020-00261-x
390 K. M. Riaz
cause opacification of the IOL. A smaller (4.5–5.0 mm) hyperopia and long-term BCVA 20/200 due to dense
capsulorrhexis is also useful, to ensure that the IOL remains amblyopia.
in the bag during the EK procedure, especially during A published model in the literature recommends using
moments of iatrogenic anterior chamber flattening for graft axial length and age to predict a long term postoperative
manipulation. Finally, patients should be counseled about axial length55:
the risk of refractive error after cataract/EK surgery, includ- Postoperative AXL = 1.93 + 0.91 x (baseline AXL) – 0.07 x
ing hyperopic surprise and the need for glasses. (baseline age) + 0.14 x (age at follow-up) – 0.005 x (base-
line age) x (age at follow-up).
For example: A 3-year-old child with an AXL of 21.95 mm
Cataract Surgery in Pediatric Patients may be expected to have an axial length of 24.19 mm at
age 20 years.
Biometry measurements in kids have a potential for inaccu- Postoperative AXL = 1.93 + 0.91 x (21.95) - 0.07 x (3) + 0.14
racy for a variety of reasons. For example, USB is usually x (20) - 0.05 X (3) X (20) = 24.19 mm.
performed after induction of general anesthesia in the OR This predicted AXL can then be used in the surgeon’s IOL for-
rather than OB in the clinic. There are also increased errors mula of choice to plan for emmetropia at age 20.
in AXL measurement (due to the short AXL). Finally, the The takeaway from this discussion is not to debate the
biggest question: What IOL power should be selected to bal- merits of whether or not you should place an IOL in a pedi-
ance good vision and allow the child to “grow”? atric patient. Instead, keep in mind the Optics-related details,
This is a controversial topic. At present, fewer surgeons especially due to changing refractive errors in this patient
are placing primary IOLs in infants since the 5-year results population.
of the Infant Aphakia Treatment Study were published.53
This study reported that infants who received an IOL had the
same vision as those left aphakic and used contact lenses.54 Cataract Surgery in Keratoconus Patients
The patients with an IOL tended to need more follow-up sur-
geries than those who were aphakic. Many keratoconus (KCN) patients may require cataract sur-
However, placing an IOL at the time of the cataract surgery without concurrent or future corneal transplant surgery.
gery may be preferred for patients who cannot afford the Recall that KCN progression tends to plateau in middle-age
contact lenses. Pediatric cataract surgeons will place an IOL years, and these patients may have good vision with glasses
that causes initial hyperopia (under-correction) to allow the or contact lenses until they develop visually significant
child to “grow into” the IOL and avoid potential later myopic cataracts.
shift. This makes sense because kids can usually wear glasses As a simplification, we can classify KCN patients into
or even contact lenses for low hyperopia. Recently, several two groups:
tables for postoperative refractive targets based on age have • KCN patients who are accustomed to wearing glasses
been published, with a range from +5D at age 2yrs to +1D at only
age 10. For older kids, emmetropia may be targeted. Age of • KCN patients who are accustomed to primarily wearing
the child, compliance with patching and spectacles, and uni- contact lenses (e.g., soft toric contact lenses (STCLs),
lateral vs. bilateral cataracts are also factors that should be rigid gas permeable (hard) contact lenses (RGPCLs), and
considered in deciding which refractive goal is best. scleral contact lenses (ScCLs))
Uncorrected postoperative hyperopia is more amblyo- We can further divide these groups into subgroups:
genic than uncorrected myopia. Patients with the latter will patients who desire astigmatism correction at the time of
at least be able to see at near uncorrected. In other words, if cataract surgery and those who do not. Since many of these
post-op spectacle and patching compliance are expected to patients are significantly myopic their entire lives, the last
be poor, then a goal of post-op emmetropia (and increasing thing we want is to make them hyperopic after cataract sur-
myopia later in life) may be preferable than +5D uncorrected gery. The crux of the problem in KCN corneas is that the
steeper the cornea, the greater the risk for postoperative
hyperopia.
VanderVeen DK, Drews-Botsch CD, Nizam A, Bothun ED, Wilson
53
Measurement of corneal power remains challenging in
LB, Wilson ME, Lambert SR; Infant Aphakia Treatment Study.
Outcomes of Secondary Intraocular Lens Implantation in the Infant KCN patients. One area of confusion for many surgeons is
Aphakia Treatment Study. J Cataract Refract Surg. 2020 Sep 7. that given the numerous devices to obtain keratometry (K)
Infant Aphakia Treatment Study Group, Lambert SR, Lynn MJ,
54
Hartmann EE, DuBois L, Drews-Botsch C, Freedman SF, Plager DA,

Buckley EG, Wilson ME. Comparison of contact lens and intraocular Trivedi RH, Barnwell E, Wolf B, Wilson ME. A Model to Predict
55
lens correction of monocular aphakia during infancy: a randomized Postoperative Axial Length in Children Undergoing Bilateral Cataract
clinical trial of HOTV optotype acuity at age 4.5 years and clinical find- Surgery with Primary Intraocular Lens Implantation. Am J Ophthalmol.
ings at age 5 years. JAMA Ophthalmol. 2014 Jun; 132(6):676–82. 2019 Oct; 206:228–234.
measurements, which K values should we use if different (a) Use the regular K values from the biometry device.
devices give us different K measurements? In addition, (b) Do not use the TK values from the IOL Master 700 or
should one device’s K values be given preference over the EKR65 values on the main page. Why not? Since
another? this formula inherently adjusts for the posterior cornea,
As a broad simplification, we can classify devices that using either the TK or EKR65 will cause us to inadver-
give K measurements into the following categories: tently “double-dip” in the posterior cornea adjustment.
• Biometry devices: e.g., IOL Master, Lenstar, etc. These However, the website offers surgeons the option to use
are usually preferred because IOL formulas are primarily the “predicted PCA”, which means the formula does the
based on K measurements from biometry devices. “hard work” of calculating the posterior corneal power;
• Topography devices: e.g., Atlas, Antares, etc. These or “measured PCA”, which requires us to separately
devices are helpful to check for irregular astigmatism and input the posterior Pentacam or posterior keratometry
axis skew. (PK) values (NOT the TK values!) and central corneal
• Ray-tracing devices: e.g., iTrace. thickness. The measured PCA may give better out-
• Tomography devices: e.g., Pentacam, Galilei. These comes, especially in KCN eyes with K values > 50 D.
devices are helpful to assess anterior and posterior eleva- (c) Current results indicate that this formula gives slightly
tion changes. The Pentacam can generate two maps that more than-intended myopic results, which may not be
may be of interest: (1) Holladay EKR Detail Report (which bad for KCN patients who are likely accustomed to
has the EKR65 mean at 4.0 mm values) and (2) Power myopia.
Distribution Map (which has the True Net Power (TNP) at 2. Kane KC: make sure to choose the keratoconus option
4.0 mm values). We should avoid using the SimK values and aim for approx. -0.75 to −1 D. This formula can be
for IOL calculations, such as those shown on the default 4 found at: https://www.iolformula.com
Maps Refractive screen, because these values were not (a) Like the previous formula, use the regular K values
designed for IOL calculation purposes! This is a common from the biometry device.
mistake made by many well-intentioned surgeons. (b) Current results indicate that this formula gives slightly
Some surgeons have suggested that the mean of five val- more than-intended myopic results, which may not be
ues obtained on different devices give sufficient accuracy to bad for KCN patients who are likely accustomed to
predict the appropriate IOL power. Alternatively, to derive myopia.
this “synthesized keratometry,” one can average the K1, K2, 3. Barrett Toric Calculator (note this is different from the
and axis values to derive this “synthesized keratometry.” first Barrett formula in this list). This formula can be
Still, five or more values seem to be the magic number if one found at: https://calc.apacrs.org/toric_calculator20/
has access to this many devices(!). Toric%20Calculator.aspx
After obtaining K measurements, we can choose which (a) This formula can use modified K values. Therefore,
IOL formula(s) to use. Most formulas tend to produce more- use TK or the ERK65K values for this formula.
than-intended hyperopic postoperative refractive errors. (b) This formula is beneficial if you want to put in a toric
Older-generation IOL formulas tend to be inadequate for IOL in KCN patients (more on this below).
eyes with unique biometric measurements. However, and 4. Other multivariable formulas such as Barrett Universal 2,
somewhat fortuitously, good old SRK/T can work well in Olsen, and Hill RBF have internal mechanisms to account
KCN eyes because it produces myopic errors in non-KCN for posterior corneal power. However, in KCN eyes (espe-
eyes with steep K measurements (Melles RB, Holladay JT, cially if both K’s are < 50D), one may cautiously use the
Chang WJ. Accuracy of intraocular lens calculation formu- TK or EKR65 values instead of the K values. As men-
las. Ophthalmology. 2018;125(2):169–78). If we use SRK/T, tioned previously, some surgeons prefer using the EKR65
we can aim for approximately −2D myopia and expect some Km value (for both K1 and K2) with the Holladay I for-
“hyperopic shift” such that we end up with a close-to-plano mula (with AXL adjustment, if needed).
refractive error. We can also use the Holladay I formula with When considering IOL options in KCN patients, we should
the mean ERK65 values taken from the Pentacam for both avoid diffractive-optics IOLs for presbyopia correction (see
the flat and steep K in a given IOL formula. Remember to Chap. 27 What’s on the Menu: An Overview of Currently
use the WK adjustment for AXL in both formulas since many Available IOLs and Relevant Optics, for more information on
KCN eyes are longer than 26 mm. IOL options). Our two IOL options are as follows:
When we examine currently available multivariable IOL Monofocal IOLs: Recall that many KCN corneas have
formulas, we have several options: serendipitous multifocality and significant HOAs.
1. Barrett True K KC: make sure to choose the keratoconus Paradoxically, many KCN patients may be accustomed to
option and aim for approx. -0.75 to −1 D. these higher amounts of HOAs, especially spherical aberra-
This formula can be found at: http://calc.apacrs.org/ tion (SA), which confers some depth of focus and enhanced
Barrett_True_K_Universal_2105 intermediate-near vision. Thus, while it may be tempting to
392 K. M. Riaz
use a monofocal, aspheric IOL with high amounts of nega- gery. You will have an upset patient if they have paid out-of-
tive SA correction (e.g., ZCB00 platform (Johnson and pocket fees for a toric IOL only to have worse vision
Johnson Vision, Jacksonville, FL, USA) and AcrySof plat- postoperatively. In other words, to paraphrase a famous rap-
form (Alcon Laboratories, Inc., Fort Worth, TX, USA)), it ping DJ, congratulations, you just played yourself.
may be advisable to use an aberration-free IOL (e.g., Envista Some under-correction of WTR astigmatism may be
IOL (Bausch and Lomb, Tampa, FL, USA)) so that these desirable. See Chap. 27, What’s on the Menu: An Overview
patients can maintain their “favorable” HOAs for intermedi- of Currently Available IOLs and Relevant Optics, for more
ate and near vision tasks. information regarding toric IOLs in the general population
Toric IOLs: Most KCN patients presenting for cataract that can also be used for KCN patients.
surgery will have already “cross-linked” themselves as a
result of aging – it is unlikely that their KCN will progress.
Thus, we can consider astigmatism correction with toric IOLs stigmatism Correction and Cataract
A
in a select group of KCN patients with central, regularly sym- Surgery
metrical, and bowtie-shaped keratometric astigmatism with a
non-skewed axis in the central 3 mm. During the preoperative Upto 50% of patients may have visually significant kerato-
examination, we should also consider the following: metric astigmatism at the time of cataract surgery. The full
• The patient’s refraction should demonstrate stability over discussion of this rapidly changing topic is beyond the scope
the past 18–24 months. The refractive astigmatism axis of this text, but a brief summary follows.
should also be within 10 degrees of the keratometric
astigmatism axis.
• The ideal KCN patient should have keratometric astigma- Incisional Procedures
tism that can be mostly corrected with the toric IOL alone.
Avoid any corneal incisions (such as limbal relaxing inci- Incisional options to correct astigmatism include the following:
sions or femtosecond laser-assisted arcuate keratotomies) • Operating on the steep meridian: This was a popular strat-
in these corneas! egy in older times when surgeons routinely made large
• While we will primarily rely on the K measurements incisions (>3.0 mm) that caused flattening in the meridian
obtained by optical biometry to calculate the toric IOL of the incision and steepening 90 degrees away. Historically,
power, it is imperative to get topography, and ideally, most surgeons sat superiorly so it was quite easy to use this
tomography, to ensure no irregular astigmatism is present. strategy to correct low amounts of WTR astigmatism. In
Topography and tomography maps can also help ensure recent times, as more surgeons are sitting temporally and
the astigmatism shape is symmetrical without axis skew. shifting toward smaller incisions (≤2.4 mm), the astigma-
The “pencil test” can be used on the topography map to tism impact of the main wound (surgically induced astig-
ensure that one can draw a straight line within the steep matism) has become less (≤0.5D). This may still be
meridian of the cornea such that the superior and inferior considered for patients with <1D astigmatism (especially
corneal meridians can be connected with a line within the ATR, allowing for surgeons to sit temporally).
central 3-4 mm. If there is any break or skew, irregular • Opposite clear corneal incision (OCCI): Some authors
astigmatism is present, and a toric IOL should be avoided. have discussed using an OCCI along with operating on the
• During the preoperative exam, we must ask the patient if steep meridian to correct astigmatism. The most signifi-
a) they wear contact lenses (of any kind) and b) they wish cant disadvantage of this technique is the (unnecessary)
to wear contact lenses after surgery. If a patient is happy creation of an additional full-thickness corneal wound.
wearing contact lenses postoperatively, avoid a toric IOL • Limbal relaxing incision (LRI) (manual): A guarded
and place a monofocal IOL so that the patient can con- blade targeted for 80–90% depth of the peripheral cornea
tinue contact lens wear. may be used to cause corneal flattening in the steep merid-
• Be very cautious (and probably avoid altogether!) when ian (along with steepening of the flat meridian 90 degrees
considering a toric IOL in a patient who wears RGPCLs or away). Advantages of LRIs include effectiveness for
ScCLs. Suppose we place a toric IOL and pat ourselves on mild-moderate astigmatism (1-2D), low cost, and the
the back for doing a good job correcting the patient’s astig- availability of nomograms (published and online) to plan
matism. In that case, we may be dismayed to realize that the the LRI. The most significant disadvantage of LRIs is the
patient is angry postoperatively, especially if they have paid inevitable regression (up to 50% or more of the intended
for the toric IOL when they attempt to wear their contact correction) that occurs over time, along with perforation,
lenses. Why? When the patient wears their contact lens bleeding, and induction of irregular astigmatism. Please
(which corrects keratometric astigmatism), the toric IOL see Chap. 29, “Postoperative Optics for Cataract Surgery”,
will essentially serve as unmasked iatrogenic lenticular for further discussions regarding the use of LRIs outside
astigmatism. This is a critical discussion to have before sur- of cataract surgery.
• Femtosecond laser-assisted arcuate incisions: This is a trainees are taught to put in an arbitrary value, ranging from
highly controversial topic as no large data sets have been 0.25D–0.50D (or more), rather than actually calculating it
published at the time of this writing to demonstrate sus- based on their individual surgical outcomes. Accurately cal-
tained effectiveness of this approach.56 Based on the pub- culating one’s SIA can be done, but it requires a bit of effort,
lished papers thus far, we can say that this technique is, at planning, and postoperative vigilance (and additional
best, similar to manual LRIs at this time in terms of effec- testing).
tively correcting astigmatism. They are definitely inferior Fortunately, several online tools and spreadsheets can make
to toric IOLs. These incisions have several disadvantages, this seemingly arduous task more manageable. This author
such as cost to the patient and potential for irregular astig- recommends downloading the freely-available Surgically
matism because they are placed much closer to the cor- Induced Astigmatism Calculator developed by Warren Hill,
neal center. Many post-surgical complications have been MD,58 which allows surgeons to input their individual data and
reported from poorly placed incisions of this type. generate accurate SIA values, even down to SIA for right eye
Extrapolating the lessons learned from the days of inci- vs. left eye surgeries; temporal vs. superior incisions; incision
sional refractive procedures close to the corneal center size; and even incision style (such as clear corneal, near-clear
(AK, RK, Hex-K), it seems unwise to stir the sleeping corneal, and scleral). This tool requires not only preoperative
giant known as the corneal center. Further published stud- keratometry measurements (e.g., manual or automated kera-
ies are needed to validate this technique. tometry values) but also postoperative keratometry values.
Many surgeons do not routinely obtain the latter, so interested
surgeons must ensure that additional keratometry measure-
Calculating Surgically Induced Astigmatism ments are taken at least one month after the surgery, ideally
after the patient’s refraction has stabilized and they are eter-
Surgically induced astigmatism (SIA) is the amount of kera- nally grateful for the wonderful cataract surgery you
tometric astigmatism (and secondarily refractive astigma- performed.
tism) caused by you, the wonderful cataract surgeon, either For surgeons who genuinely wish to master refractive
intentionally or unintentionally. This is not necessarily the cataract surgery, especially those who want to use premium
same as the amount of astigmatism that one intends to cor- IOLs, assessing one’s unique SIA is essential. As should be
rect at the time of cataract surgery, either with the main inci- evident by now, there is more to cataract surgery than simply
sion or LRIs; this is known as target-induced astigmatism being able to finish a case in 10 minutes!
(TIA). In an ideal situation, the TIA and SIA are equal; for
example, if the surgeon wanted to correct 0.75D of
keratometric astigmatism at the time of cataract surgery with Toric IOLs
a combination of a main incision at the steep meridian and a
limbal relaxing incision 180-degrees away, and the net result See Chap. 27, “What’s on the Menu: An Overview of
was the patient postoperatively had 0.0 D of keratometric Currently-Available IOLs and Relevant Optics”, for more
astigmatism, then the TIA will equal the SIA. Of course, this information regarding toric IOLs.
never happens in real life, so the SIA is nearly always differ-
ent from the actual TIA.57
Most toric IOL calculators and even LRI nomograms Practice Question
require the surgeon to input his/her habitual SIA. Many
1. Which of the following statements is TRUE?
For example, the Roberts et al. paper only reported 1-month data after
56 A. Visual acuity will typically improve when performing
femtosecond laser arcuate incisions. Roberts HW, Wagh VK, Sullivan pinhole testing in a patient with PSC cataract.
DL, et al. Refractive outcomes after limbal relaxing incisions or femto- B. The retinal acuity meter (RAM) has a built-in +3.00D
second laser arcuate keratotomy to manage corneal astigmatism at the
time of cataract surgery. J Cataract Refract Surg. 2018;44(8):955–963
lens allowing for testing at 33 cm.
For those readers interested in a more advanced, mathematical analy-
57 C. The potential acuity meter (PAM) is especially useful
sis of astigmatism, the Alpins Method, developed by Noel Alpins, is because it can account for both spherical and astig-
recommended for additional information. This approach further breaks matic refractive errors.
down success of astigmatism correction by metrics such as the correc- D. When performing Maddox rod test, a patient who is
tion index (CI): how much astigmatism was actually corrected as com-
pared to the intended correction (basically the SIA/TIA); the magnitude
unable to discern a red line may have macular
of error (intended correction (D) - actual correction (D) and the index of pathology.
success. See (1) Alpins NA, Goggin M. Practical astigmatism analysis
for refractive outcomes in cataract and refractive surgery. Surv
Ophthalmol. 2004 Jan-Feb; 49(1):109–22. and (2) Alpins NA. Practical Available at https://www.doctor-hill.com/iol-main/toric_sia_calcula-
58
Astigmatism: Planning and Analysis, Slack Incorporated; New Jersey, tor.htm. Also available as an online-only database at: https://sia-calcu-
2018. lator.com/. Accessed March 21, 2021.
394 K. M. Riaz
2. Which of the following statements regarding the B. Optical biometry tends to underestimate axial length
Haidinger’s brush test is TRUE? because of the corneal changes after LASIK.
A. The test involves rotating polarized light to assess C. Corneal topography underestimates true central cor-
whether the patient can detect an entoptic phenome- neal curvature and power in corneas with previous
non as a proxy for visual potential. LASIK surgery.
B. The perception of the brush/propeller of yellow light D. Corneal topography overestimates true central cor-
is due to the parallel arrangement of xanthophyll pig- neal curvature and power in corneas with previous
ment in the macula, allowing for light to interact with LASIK surgery.
photoreceptors equally. 7. Which of the following statements concerning optical
C. This test can be used to test the gross retinal function angles and axes is TRUE?
of both the central and peripheral retina. A. Angle kappa is the angle formed between the optical
D. When performing this test, the optical principle of axis and the visual axis.
diffraction is employed to improve depth of field by B. Angle alpha is the angle formed between the pupil-
limiting negative effects of diffraction. lary axis and the visual axis.
3. Which of the following statements regarding biometry is C. Angle kappa is an important consideration for laser
TRUE? refractive surgery in a hyperope.
A. Immersion biometry has a major limitation due to D. A patient with high angle kappa would not be a good
potential indentation of the cornea by the immersion candidate for an accommodating IOL.
shell device. E. Modern biometry devices can calculate angle alpha
B. Optical biometry (OB) AXL is typically longer than with good accuracy.
USB AXL.
C. OB is more effective at assessing AXL in the pres-
ence of dense cataracts as compared to USB AXL. Answers
D. OB uses ultraviolet wavelengths of light (193 nm) to
penetrate lens opacities better, allowing for more 1. D. Maddox rod testing can be performed as a gross evalu-
accurate measurement of AXL. ation of retinal function to detect a scotoma. If a patient
4. Which of the following statements regarding corneal cannot see the “red line,” this suggests macular pathology.
astigmatism is TRUE? Visual acuity will typically worsen with pinhole testing in
A. The majority of patients <40 years of age will have the presence of a PSC cataract as the lens opacity primar-
much more ATR as compared to WTR. ily involves the (central) visual axis. The RAM has a built-
B. Consideration should be given for intentional under- in +2.50D lens to allow for testing at the given reading
correction of WTR in a 45-year-old patient. distance of 40 cm. The PAM only corrects for spherical
C. Consideration should be given for intentional under- refractive errors and thus may feel to improve vision in
correction of ATR in an 80-year-old patient. patients with additional astigmatic errors.
D. Direct measurements of posterior corneal astigma- 2. A. In this technique, the examiner uses a polarized lens to
tism (PCA) will usually yield better refractive out- rotate (polarized) light in front of a blue-white back-
comes than estimated measurements of PCA. ground to create an entoptic phenomenon – perceived as
5. Which of the following statements regarding IOL formu- “spinning yellow light” by the patient (in the shape of a
las is TRUE? “brush”). Dichroism of xanthophyll pigment means that
A. The SRK formula weighs the K measurements much some molecules are parallel while others are circular;
more significantly than the AXL measurements. similarly, some nerves will run parallel to the fovea while
B. Third-generation IOL formulas incorporate other bio- others will run orthogonal. Hence, two different orienta-
metric measurements such as WTW, CCT, LT, and tions of nerves and molecules in the fovea will be sensi-
HWTW to measure the ELP better. tive to two different degrees of polarization. This test only
C. Multivariable formulas have internal mechanisms to assesses the central retina. Diffraction is not employed in
compensate for long/short AXL and steep/flat Ks. this test.
D. Third-generation IOL formulas are as accurate as 3. B. USB measures the AXL from the anterior corneal sur-
multivariable IOL formulas for long AXL eyes. face to the ILM (neurosensory retina), whereas OB mea-
6. Which of the following statements concerning IOL calcu- sures the AXL from the anterior cornea to the RPE. This
lation in patients with a previous history of LASIK sur- means that OB measurements may be slightly longer as
gery to correct myopia is TRUE? compared to USB. Suppose USB measurements are used
A. Optical biometry tends to overestimate axial length in an OB device (without adjustment). In that case, there
because of the corneal changes after LASIK. is a risk of (slight) myopic surprise, which is typically
not that devastating for patients with dense lens opaci- than inaccuracy in K measurements. Third-generation
ties. Contact biometry utilizes a probe to contact the cor- formulas primarily rely on the AXL and K values to esti-
nea physically; this potentially may indent the cornea mate the ELP and do not consider the
(especially if done by an inexperienced practitioner), biometric variables.
falsely yielding a shorter-than-real AXL. USB is more 6. D. Optical biometry measurements of AXL are not sig-
effective than OB in the presence of dense media such as nificantly affected by LASIK (choice A or B). However,
infrared laser light (wavelength 780). the true central curvature tends to be overestimated
4. B. As we age, the total corneal astigmatism will shift (choice D) in these patients, leading to a lower-than-
towards ATR. Therefore, leaving younger patients required IOL power and potential hyperopic surprise.
with some WTR may be advantageous to compensate 7. C. Angle kappa is a critical consideration for laser refrac-
for the inevitable shift towards ATR with aging. In tive surgery. If the treatment is centered on the pupil, it
older patients, it is best to correct the ATR fully. At may not be centered on the visual axis, leading to a decen-
present (June 2021), there is no consensus regarding tered ablation and higher-order aberrations. Angle kappa
the superior accuracy of using directly measured PCA is the angle formed between the pupillary and visual axes;
vs. estimated PCA. angle alpha is the angle formed between the optical and
5. ANSWER: C. Multivariable formulas improve the errors visual axes. Patients with high angle kappas may inadver-
made by older-generation formulas that assumed a fixed, tently look through the rings of a diffractive MFIOL/
linear relationship between IOL power and AXL values. EDOF-IOL/TF-IOL; if these patients desire presbyopia
When using third-generation formulas (without the Wang- correction, monovision and/or an accommodating IOL
Koch adjustment) in long AXL eyes, the risk of hyperopic may be a better choice. Modern biometry devices can
surprise is much more significant than using multivariable measure chord mu, an approximation for angle kappa.
IOL formulas, which have internal mechanisms to adjust
for long (and short) AXL measurements. The SRK for- Acknowledgments The author is very grateful to David L. Cooke, MD
mula weighs the AXL measurements by a factor of 2.5 vs. (Great Lakes Eye Care, St. Joseph, MI), for his editorial assistance and
critical review of the material presented in this chapter.
the K measurements (factor of 0.9); thus, inaccuracy in
AXL measurements is much more “devastating”
What’s on the Menu: An Overview
of Currently Available IOLs
and Relevant Optics
Kamran M. Riaz
Objectives IOL should be used in a given situation?1 In some ways, the

• To discuss clinically relevant information regarding IOL cataract surgery itself has become the easy part. Determining
materials, architecture, shape design, and structure which IOL to use in a given situation, especially to meet a
• To provide a brief overview of currently accepted IOL given patient’s visual goals after surgery, has now become
power standards the hard part.
• To discuss optical properties of the most-commonly This chapter is intended to provide the novice surgeon
implanted single- and three-piece IOLs in the United with an overview of all currently available IOLs in the
States United States. Knowledge of these IOLs, and their advan-
• To present options for surgeons encountering eyes requir- tages and disadvantages, is useful for surgeons to provide
ing extreme IOL powers their patients with the best possible outcomes. While we
• To review optical properties of toric IOLs have intentionally glossed over some super-nerdy Optics
• To survey currently available advanced technology IOLs, details, we have kept the essential details in the chapter.
including relevant technology and features Disclaimer: This chapter is meant to highlight the features
• To provide the reader with an understanding of modular of commonly used IOLs as a singular compendium refer-
transfer function curves as a method of assessing IOL ence, especially for trainees. It is not our intent to promote or
performance disparage a given IOL. None of the authors have any finan-
cial interests in any of the IOLs discussed in this chapter.
Introduction
Optics of IOLs
Modern cataract surgery is a combined therapeutic and
refractive procedure, as many patients are increasingly moti- IOL Materials
vated to decrease dependence on glasses after surgery. Even
for standard cataract surgery cases with monofocal intraocu- The material used to make an IOL will have optical and clin-
lar lenses (IOLs), patients may have certain vision goals that ical implications. Old-school, first-generation IOLs were
may or may not be achieved when using a given IOL as com- made of polymethylmethacrylate (PMMA) and hydrogels.
pared to another. Recent years have also seen a significant While they had excellent optical quality, these IOLs required
number of advanced technology IOLs (ATIOLs) that can
correct astigmatism and presbyopia.
The “menu” of IOLs is quite large, seemingly larger than This may be especially difficult for trainees to keep up with. After
1
even the menu of a popular chain restaurant that is a “fac- finishing training in 2013, this author himself has seen the introduction
of multiple monofocal IOLs; two new toric IOLs; three new diffractive
tory” for cheesecakes but makes a hundred other items as
multifocal IOLs; two extended depth of focus IOLs (one using diffrac-
well. The abundance of IOL choices seems to have created a tive optics and the other using wave front modification optics); one tri-
“paradox of choice”: with so many IOLs on the menu, which focal IOL; and one monofocal-plus IOL.
K. M. Riaz (*)

398 K. M. Riaz
large incisions as they could not be folded (think of modern- hydrophobic IOLs can adhere to collagen membranes better,
day ACIOLs).2 resulting in better apposition of the IOL to the posterior cap-
sule.6 Another reason may be that hydrophilic IOLs have
Acrylic, Silicone, and Collamer IOLs “less sharp” edges than hydrophobic IOLs, thereby allowing
In modern times, a variety of materials are utilized in IOLs. lens epithelial cell migration.7 Finally, the hydrophilic sur-
Some of the more popular choices include acrylic (index of face itself may promote epithelial cell migration and
refraction range: 1.47–1.55), silicone (index of refraction: increased PCO.8
1.43), and collamer (index of refraction: 1.44). The index of Hydrophobic IOLs are more popularly implanted in the
refraction chosen for the IOL involves a bit of a trade-off: A United States at the time of this writing. Most of the monofo-
higher index of refraction means that the IOL optic can be cal IOLs that discussed in the next sections are hydrophobic
thinner (especially for higher diopter powers), which allows acrylic IOLs. Most sources define hydrophobic IOLs as hav-
for easier folding and insertion at the time of cataract sur- ing less than 1% water content.9
gery. However, a higher index of refraction may also lead to Hydrophilic IOLs have their unique advantages. For exam-
higher rates of both positive and negative dysphotopsias.3 ple, because of the “slippery” material, the IOL can be folded
Acrylic IOLs became popular not only for their relative and inserted into a very small incision (<2 mm) with rapid
ease of insertion through smaller incisions but also for the opening once inside the eye. Additionally, hydrophilic IOLs
decreased rates of posterior capsular opacification (PCO) are gentler to the uvea/angle structures as they may induce less
noted with these IOLs (more on this below). Studies have inflammation in the eye. Hence, some surgeons prefer using a
shown that acrylic is a “stickier” material that adheres to the hydrophilic IOL like the Akreos AO60 (Bausch and Lomb,
capsular bag. A “sandwich” like structure accumulates Inc., Tampa, FL, USA) for four-point scleral fixation with
between the IOL surface and the capsule, further hindering sutures for the treatment of aphakia. Hydrophilic IOLs are
the growth and proliferation of PCO.4 While single-piece very popular outside the United States.10
acrylic (SPA) IOLs are currently the most commonly Hydrophilic IOLs have a water content ranging from 18%
implanted IOLs in the United States, the other two IOL to 38%, depending on the particular manufacturer and model.
materials have their unique advantages as well. For example, For example, the aforementioned Akreos IOL has a water
silicone IOLs are often preferred for IOL exchanges in content of 26%. Hydrophilic IOLs have several limitations
patients with intractable dysphotopsias. In addition to having that may explain why many US surgeons prefer hydrophobic
a low incidence of dysphotopsia, collamer is the preferred IOLs. First, because the square edge of these IOLs is made
material for phakic IOLs. via a lathe-cut or drill-cut in a dry state, when exposed to
aqueous, the IOL will swell and the square edge becomes
Hydrophobic Versus Hydrophilic Acrylic IOLs much rounder—this may explain why the square edge of a
We can further subclassify acrylic IOLs into their biomate- hydrophilic IOL is less effective than the square edge of a
rial properties: hydrophobic and hydrophilic variants. Both hydrophobic IOL in preventing PCO. Second, while contro-
are associated with lower PCO rates than other IOL materi- versial, some reports have suggested that bacterial biofilms
als, though hydrophobic IOLs have lower PCO and YAG may more easily form on these IOLs than their hydrophobic
rates compared to hydrophilic IOLs.5 One reason may be that counterparts.11 Finally, and perhaps of most relevance,
2
It is said the idea of implanting an intraocular lens came to Harold
Ridley after an intern asked him why he was not replacing the lens he Heatley CJ, Spalton DJ, Kumar A, Jose R, Boyce J, Bender
6
had removed during cataract surgery. The acrylic plastic material was LE. Comparison of posterior capsule opacification rates between
chosen because Ridley noticed it was inert after seeing RAF (Royal Air hydrophilic and hydrophobic single-piece acrylic intraocular lenses. J
Force) pilots of World War II with pieces of shattered canopies in their Cataract Refract Surg. 2005 Apr;31(4):718-24.
eyes. See Williams HP. Sir Harold Ridley’s vision. Br J Ophthalmol. Iwase T, Nishi Y, Oveson BC, Jo YJ. Hydrophobic versus double-
7
2001 Sep;85(9):1022-3. square-edged hydrophilic foldable acrylic intraocular lens: effect on

3
See Chap. 1, Geometric Optics for a discussion of how the index of posterior capsule opacification. J Cataract Refract Surg. 2011
refraction (and good ole Snell’s Law) may affect the incidence and Jun;37(6):1060-8.
severity of dysphotopsias. Dysphotopsias are additionally discussed in Dorey MW, Brownstein S, Hill VE, Mathew B, Botton G, Kertes PJ,
8
Chap. 29, Postoperative Optics for Cataract Surgery El-Defrawy S. Proposed pathogenesis for the delayed postoperative
4
Linnola RJ, Werner L, Pandey SK, et al. Adhesion of fibronectin, vit- opacification of the hydroview hydrogel intraocular lens. Am J
ronectin, laminin and collagen type IV to intraocular lens materials in Ophthalmol. 2003 May;135(5):591-8.
human autopsy eyes. Part I: histological sections. J Cataract Refract Of note, the Envista MX60/MX60E (Bausch and Lomb, Tampa, FL,
9
Surg 2000; 26:1792-180 USA) has approximately 5% water content.

5
Zhao Y, Yang K, Li J, Huang Y, Zhu S. Comparison of hydrophobic and
10
For example, the Rayner C-flex and Superflex (Rayner Intraocular
hydrophilic intraocular lens in preventing posterior capsule opacifica- Lenses, Ltd., West Sussex, United Kingdom)
tion after cataract surgery: An updated meta-analysis. Medicine 11
Qiu X, Wu Y, Jiang Y, Ji Y, Zhu X, Yang J, Lu Y. Management and
(Baltimore). 2017 Nov;96(44):e8301. Microbiological Characteristics of Membrane Formation on a
What’s on the Menu: An Overview of Currently Available IOLs and Relevant Optics 399
hydrophilic IOLs may undergo opacification when exposed IOL Architecture: Optic Design
to intraocular air or gas. Thus, patients who may subse-
quently undergo retinal surgery or endothelial keratoplasty While the optic design options and variations of modern
(DSAEK/DMEK) requiring air or gas may develop vision- IOLs are quite lengthy, we will focus on a few salient issues
limiting opacification on the IOL optic that may require IOL with Optics relevance.
exchange. Therefore, these IOLs should therefore be cau-
tiously used in patients with increased risk for these future Haptic-Optic Planarity
surgeries (e.g., Fuchs endothelial dystrophy). While you may not have scrutinized it during your cata-
There is no perfect IOL material. All currently available ract surgeries at the time of IOL insertion, as you were
materials have their optical and clinical advantages and dis- undoubtedly more focused on getting the IOL into the eye
advantages. The surgeon ultimately determines the final safely before anything went wrong, there are subtle vari-
choice of IOL. While most trainees are primarily exposed to ances in the design of SPA IOLs, especially in regards to
acrylic IOLs, it is important to be aware of other IOL mate- the plane in which the haptics and optic are located. In
rial choices as well. broad terms, the haptics and optic can be in the same
plane, or the haptics may be slightly anterior to the optic
(Fig. 1). The planarity of an IOL should minimally affect
IOL Architecture: Edge Design its optics, but it may affect its functionality inside the eye.
For example, an offset planar design may theoretically
The edge of the IOL optic also has interesting optical and reduce the risk of PCO formation by creating additional
clinical implications. The two broad classifications of edge contact between the IOL and the posterior capsule. The
design are rounded edge and square edge (also known as a Tecnis platform (Johnson and Johnson, Jacksonville, FL,
ridged or truncated edge). While a rounded lens edge more USA) is an example of a SPA with offset planar design;
closely approximates the shape of the natural crystalline the Acrysof platform (Alcon Laboratories, Fort Worth,
lens, the “lens edge barrier” theory proposes that a square- TX, USA) is an example of a SPA with “uni-planar” hap-
edge design creates a better mechanical barrier at the capsu- tics-optic design.
lar bag equator, decreasing the risk of PCO formation.12
This should mean that square-edged IOLs are great, right?
Well, it is not that simple. In the valiant efforts to decrease
PCO, several authors have noted that the square edge may
create an additional plane of refraction and reflection, which a b
may contribute to unwanted positive and negative dysphotop-
sias.13 This may explain why in the “old days” of non-square
edge IOLs, dysphotopsias were rarely ever a problem.
Some manufacturers have attempted to combine the best
of both worlds in edge design. For example, the Sensar AR40
series (three-piece) IOL platform (Johnson and Johnson,
Jacksonville, FL, USA) utilizes a rounded anterior edge and
a square posterior edge. The IOL is designed to maintain the
favorable optics of the rounded edge at the anterior optic sur-
face (where most of the incoming light undergoes refrac-
tion), while also maintaining the benefits of a square edge at
the posterior optic edge to reduce PCO formation.
Hydrophilic Acrylic Intraocular Lens: A Clinical Case Series and

Material Comparative Study of Different IOLs. J Ophthalmol. 2019 Feb Fig. 1 Haptic-optic planarity can vary among commonly used SPA
3;2019:5746186. IOLs. Panel a shows an offset planar design in which the haptics are
Some may argue that PCO formation is a good thing because it allows
12
located slightly anterior to the optic. This design potentially allows for
you to do another billable procedure. Don’t be that guy or gal! more contact between the posterior aspect of the optic and the posterior
See Chap. 29, Postoperative Optics for Cataract Surgery, for a detailed
13
capsule and may reduce PCO formation. Panel b shows a uniplanar
discussion on dysphotopsias design in which the haptics and optic are located in the same plane
400 K. M. Riaz
dge-to-Edge Power and Inert Carriers

E getting yelled at by your supervising attending and causing
Another thought that you may not have given much consid- him/her gray hairs, what is the net refractive effect of this
eration during the stresses of cataract surgery: When we backward IOL?
place a SPA IOL, how much of the IOL contains refractive Since the front surface (which has more plus power) is
power? In other words, does the entire optic (usually 6 mm now on the back surface, the +21.0D IOL will lose some plus
for most SPA IOLs) have refractive power, or do some por- power, it may now act like a ~ +20.0D IOL and cause a hyper-
tions not have any power? opic surprise. If the optic and haptics are in the same plane
The Acrysof IOL platform is a SPA with full edge-to-edge and/or utilize a 1:1 curvature design, this should cause a mini-
power. The Envista platform (Bausch and Lomb, Tampa, FL, mal refractive effect, even if the IOL is placed upside down.
USA) has a minimal inert carrier ring that increases in The situation with three-piece IOLs is slightly different.
size with higher diopter powers. Notably, the Tecnis platform While they also utilize a biconvex design, historically, three-
has a peripheral 0.5 mm inert carrier ring, essentially giving piece IOLs had a 5- or 10-degree slant from where the hap-
it a 5.0–5.25 mm functional optic. This inert carrier makes it tics inserted into the optic; this led to more effective power on
easier to fold the IOL, allowing it to go through a smaller the posterior surface of the IOL. If these IOLs were placed
incision. The peripheral carrier is also slightly depressed backward, they would cause a myopic surprise. Since three-
compared to the central optic when viewed in cross-section, piece IOLs were routinely used, older texts (and attendings)
making it easier to remove in cases of IOL exchange. One may state that if an IOL is placed backward, it will cause a
drawback of an inert carrier is that it renders peripheral reti- myopic surprise. Many popularly used 3-piece IOLs con-
nal examination a bit more difficult, as the optics of the inert tinue to utilize a “slant” design in modern practice. The
carrier affect visualization. In patients with large pupils and Tecnis ZA9003 (Johnson and Johnson, Jacksonville, FL,
complex retinal history, using an IOL with full edge-to-edge USA) and AcrySof MA60AC/MA60BM/MA60MA (Alcon
power may be a better choice. Another reported drawback is Laboratories, Fort Worth, TX, USA) are examples of three-
a unique combination of positive-negative dysphotopsia and piece IOLs with slant design optic.
“night halos” when incoming light passes through the inert Suppose a senior attending asks you, “What is the refrac-
carrier portion of the optic. tive effect of placing an IOL backward?” In that case, you
should first inquire whether he/she is referring to a SPA or
Biconvex IOLs 3-piece IOL before giving your answer for both types of
Most modern-day SPA IOLs are biconvex lenses, meaning IOLs. Hopefully, this will win you some bonus points for
they have dioptric power on the front and back surfaces. One the day.
advantage of using a biconvex configuration is minimiz- As stated previously, a biconvex configuration with a
ing unwanted spherical aberration caused by the IOL. The more rounded posterior surface allows the optic to have bet-
net result of this configuration means the effective power is ter contact with the posterior capsule. Thus, a backward
actually “inside” the IOL rather than either of the optic sur- placed biconvex IOL may also increase the risk of posterior
faces. Historically, biconvex IOLs were designed with a 1:2 capsule opacification.
curvature (not power) distribution. The posterior optic had a You can avoid this problem if you check to make sure that
larger curvature, but this is no longer valid as there is signifi- the leading haptic of the C-haptic IOL (one-piece or three-
cant variation in modern IOLs. Each IOL’s specification piece) is facing to the left; if the IOL looks like an “S” with
sheet may have information regarding the type of biconvex the leading haptic facing to the right, then you should STOP
curvature configuration (e.g., 1:2, 1:1, or 2:1), but this is only because the IOL is backward (Fig. 2).15
for average IOL powers (between 15-25D). When consider-
ing lower and higher power IOLs, the shape configuration Convex-Plano IOLs
may change.14 This type of IOL is somewhat of a relic to days gone by since
Note that the above ratios refer to the radius of curva- there is no currently available one-piece posterior chamber
ture, not the actual power. For most modern SPA IOLs, the convex-plano IOL in the United States at the time of this
majority of the power is on the front surface of the IOL optic. writing (September 2021).16 Older texts may mention this
If we place a + 21.0 D IOL in the capsular bag in its cor- IOL, including recommending using this IOL for eyes with
rect orientation, we can safely assume it will behave like a
+ 21.0D IOL. However, if we inadvertently place the IOL
backward (assume it has an offset haptic-optic design with Another, more memorable mnemonic is if you see the “S”, then “you
15
need to fix it, stupid.”

more power on the anterior optic surface), in addition to
The last of this type of IOLs was the MC70CM 3 piece convex-plano
16
PMMA IOL (Alcon Laboratories, Fort Worth, TX, USA) with a 7.0 mm
Personal communication, Thomas Olsen, MD and David L. Cooke,
14
optic. Currently available anterior chamber IOLs, such as the MTAXUO
MD, March 7, 2021. series, are convex-plano IOLs.
a b IOL Sphericity
IOLs can be either spherical or aspheric; each of these shapes

has its advantages and disadvantages. At present, most of the
commonly implanted SPA IOLs are aspheric IOLs.
Spherical IOLs
Recall our previous discussion regarding spherical aberra-
tion in Chap. 14, “Physical Optics and Advanced Optical
Principles”. As a quick review, the cornea has positive spher-
ical aberration, the crystalline lens has negative spherical
aberration, and the net result of the visual system is slightly
positive spherical aberration, wherein peripheral light rays
fall slightly in front of the retina. We gain more positive
spherical aberration with age.
Spherical IOLs are older-generation IOLs that do not cor-
rect for spherical aberration.17 As a result, patients with
Fig. 2 The leading haptic of a C-haptic IOL (one-piece or three-piece)
should be facing to the left (Panel a) so that the IOL looks like a back- spherical IOLs will have increased (positive) spherical aber-
ward letter “S.” If the leading haptic is facing to the right (Panel b), the ration (due to loss of negative spherical aberration from
IOL will look like the letter “S,” indicating that you should stop imme- removing the crystalline lens and the positive spherical aber-
diately and adjust the IOL orientation ration of the IOL added to the already-existing positive
spherical aberration of the cornea) after cataract surgery.
Comparatively, spherical IOLs have similar objective dis-
tance visual acuity to aspheric IOLs.
Advantages of spherical IOLs include an increased depth
of focus secondary to increased spherical aberration (pseudo-
accommodation). It is not uncommon to see these patients
read well uncorrected at near without any reading glasses.
Two situations in which spherical IOLs are especially advan-
tageous include the following:
• Cataract surgery in the setting of high decentration risk

(e.g., pseudoexfoliation syndrome, loose zonules, eccen-
tric pupils): Even if the IOL shifts slightly, the effective
power of the IOL remains the same.
Fig. 3 Convex-plano IOLs compared with biconvex IOLs. Convex- • Post hyperopic laser refractive surgery: These eyes tend to
plano IOLs contain all the effective refractive power in the front surface have increased negative spherical aberration, so using an
of the optic. These IOLs induce significantly higher amounts of spheri- IOL with positive spherical aberration can help “shift” the
cal aberration
eye’s spherical aberration back toward zero.
silicone oil. This inevitably creates confusion among train- Spherical IOLs sound great, right? Well, not exactly.
ees because no such mythical IOL exists at this time (at least Their numerous disadvantages are why we have shifted
available for on-label use in the United States)! towards aspheric IOLs. The biggest disadvantage is signifi-
A convex-plano IOL is configured such that all the refrac- cantly decreased contrast sensitivity due to increased spheri-
tive power is on the front surface of the optic, and the back cal aberration. While patients may objectively have good
surface has no dioptric power (Fig. 3). One advantage of this distance/near visual acuity, the subjective visual quality,
configuration is that if placed in an eye with silicone oil, especially in low-light conditions, may be suboptimal.
there is minimal effect on the IOL power because the sili- Remember that spherical aberration is ultimately an imper-
cone oil does not have a “curve” to mold itself upon and
cause a refractive change. However, one major disadvantage Currently available models of spherical IOLs include the SN60AT/
17
is the significant spherical aberration caused by this type of SA60AT (SPA) (Alcon Laboratories, Fort Worth, TX USA) and Sensar
IOL shape. AAB00 (SPA) and AR40 (three-piece) series (both from Johnson and
Johnson Vision, Jacksonville, FL, USA)
402 K. M. Riaz
Table 1 Increasing the spherical aberration will correspondingly Table 2 Comparison of spherical and aspheric IOLs
increase the effective power of the IOL
Spherical IOLs Aspheric IOLs
For SA of 20 μm, this corresponds to an A-constant change of 0.3. Potential 20/20 20/20
This equals a refraction change of objective visual
ΔRef = 1.3375*ΔA-constant; acuity
ΔRef = 0.4 D more myopic Near (reading) Good uncorrected reading Poor uncorrected
ΔRef ≈ 0.75*ΔIOL Power vision ability acuity (~J4/J5) reading acuity
0.4/0.75 = 0.54 D ≈ increase in IOL Power caused by SA of 20 μm. Decentration Minimally affected Visual acuity may
For SA of 26 μm, this corresponds to an A-constant change of 0.41. be mildly to
This equals a refraction change of: severely affected
ΔRef = 1.3375*ΔA-constant Contrast Poor Good
ΔRef = 0.55 D more myopic sensitivity
ΔRef ≈ 0.75*ΔIOL Power Spherical Increased; proportionally Neutral to
0.55/0.75 = 0.73 D ≈ increase in IOL Power caused by SA of 20 μm. aberration more with higher power IOL decreased (better
Special thanks to David L. Cooke, MD, for his assistance with the cal- (e.g., +30D spherical IOL subjective visual
culations displayed in the examples will increase spherical acuity)
aberration much more than a
+ 10D IOL)
fection in the visual system; therefore, whenever possible, Example of Post-hyperopic laser Routine patients;
reducing spherical aberration is preferable to upholding it for patient wherein refractive surgery; post-myopic laser
its purported advantages. In addition, glaucoma patients may this IOL may be pseudoexfoliation; post- refractive
especially trauma (zonular instability) surgery;
artificially test worse on visual field testing with a spherical preferred mild-moderate
IOL due to this decreased contrast sensitivity. Another disad- glaucoma
vantage is the amount of spherical aberration induced due to For patients with Discouraged due to Preferred
the power of the IOL. For example, a + 30D spherical IOL large pupils worsening of spherical
aberration
will cause much more spherical aberration than a + 10D
True power of Slightly higher than labeled As labeled
spherical IOL. Furthermore, the negative effects of spherical the IOL
aberration are amplified by pupil size: patients with large
pupils (or in low-light conditions) will experience much
more spherical aberration than patients with small pupils.
Finally, due to spherical aberration effects, the “true” popularly implanted IOLs—we should emphasize that this
power of a given spherical IOL is higher than its “labeled” table should not be committed to memory and is not inclu-
power and higher than the same power aspheric IOL with sive of all available IOLs.
negative spherical aberration. Thus, a + 21.0D spherical IOL Each manufacturer has a different strategy toward spheri-
(labeled) may have the same effective power as a + 21.50 cal aberration correction, ranging from no correction to
or + 21.75D (labeled) aspheric IOL, depending on the amount (attempted) full correction. These differences lead to a philo-
of asphericity. The math involved is a bit advanced (yet fasci- sophical discussion that enraptures many optics nerds: What
nating), and is shown in the following table (Table 1). is the ideal spherical aberration for a pseudophakic patient?
While not exhaustive, Table 2 can be used to compare What is the “perfect” amount of “imperfection” to leave in a
monofocal spherical IOLs with aspheric IOLs as you read pseudophakic eye?
the next section. As with many things in life, the answer is quite compli-
cated. We discussed some of these principles in Chap. 14,
Aspheric IOLs Physical Optics. While the full scope of this particular dis-
Aspheric IOLs are currently the most popular type of IOL cussion is beyond the scope of this book, to give you an idea
implanted in the United States at the time of this writing. As of the complexity of this question, we have to consider mul-
the name suggests, an aspheric IOL optic has a different tiple factors. For example, the refractive error can compen-
peripheral curvature than the central curvature. Furthermore, sate for residual spherical aberration. Again, recall that
these IOLs are designed to avoid adding any positive spheri- positive spherical aberration causes a myopic shift while
cal aberration to the patient’s optical system. Most aspheric negative spherical aberration causes a hyperopic shift. For
IOLs have negative spherical aberration built into the IOL example, refractive myopia may be assisted by some nega-
(range − 0.18 to −0.27 μm).18 Table 3 lists the amount of tive spherical aberration (which causes a hyperopic shift).
negative spherical aberration present in some of the more We also know that pupil size should not affect the refractive
error, but it does affect the spherical aberration, especially
for larger pupils. Putting these three factors together (refrac-
An exception to this is the Envista MX60(E) series (Bausch and
18
Lomb, Tampa, FL, USA) which is a zero-aberration (aberration-free) tive error, pupil size, and spherical aberration), we can see
aspheric IOL. that refractive error may compensate for induced spherical
Table 3 Spherical aberration correction profile of commonly used aspheric IOLs in the United States
Acrysof Tecnis Envista and Akreos Lenstec Nanoflex Hoya
Aberration correction of IOL −0.20 μm −0.27 μm 0 μm 0 μm −0.019 μm −0.18 μm
Targeted residual spherical aberration of the pseudophakic eye +0.07 μm 0 μm +0.27 μm +0.27 μm +0.251 μm +0.09 μm
Note: This assumes that the crystalline lens (cataract) had approximately +0.27 μm before cataract surgery
aberration due to larger pupil sizes but may worsen defocus This example may help provide an additional explanation
due to smaller sizes.19 for why IOL calculation in short AXL eyes is challenging.
The biggest advantage of aspheric IOLs is the “restora- Recall that IOL powers in higher power ranges are usually
tion” of the spherical aberration equilibrium previously pres- produced in 1.0D steps. Thus, if you use a + 33.0D IOL, for
ent in the “youthful” crystalline lens. Correction of spherical example, there is a chance it may be closer to 32.5D or
aberration leads to better contrast sensitivity20 (especially in 33.5D! This may be another reason why refractive outcomes
low-light conditions), better subjective visual acuity, and in hyperopic and short axial length eyes may be inaccurate.
avoidance of artificially worsening visual field testing in Even if we have the most accurate measurements, the “true”
glaucoma patients. In addition, most younger cataract sur- IOL power for these high-diopter power IOLs may be differ-
geons, including those of you in training, likely have more ent than labeled. Most manufacturers usually keep track of
experience with these IOLs. the “true” IOL power for every IOL produced based on the
As can be expected, there are disadvantages with these serial number. Suppose you ever encounter a situation
IOLs as well. The biggest disadvantage is its single focal wherein your postoperative refraction is strangely and totally
point (usually distance vision) with loss of depth of focus; different from what you expected. In that case, you may want
most patients with aspheric IOLs set for distance vision can- to put on your detective hat and contact the manufacturer and
not read well at near. In addition, decentration of an aspheric ask what that IOL’s power was based on its serial number.
IOL (>0.8 mm) and tilt (>10°) will degrade visual acuity. This task may be a quality improvement type of project for a
trainee if such a situation arises.
See Chap. 26, “Preoperative Optics for Cataract Surgery”
IOL Power Standards for more information regarding other challenges in obtain-
ing accurate IOL calculations in short axial length eyes.
When we place a SPA IOL of a given power, we assume that
the true power of the IOL is the same as what is written on
the box. For example, we assume (and should hope!) that a Monofocal IOLs
+ 22.0D IOL should behave like a + 22.0D IOL inside the
eye. However, some “acceptable” inaccuracy is allowed by A detailed discussion of every available monofocal IOL is
the American National Standards Institute (ANSI). In gen- beyond the scope of this book. We will limit our discussion
eral, IOL powers <25D are supposed to be within ±0.4D; to the most popularly implanted monofocal IOLs.
IOL powers 25-30D are supposed to be within ±0.5D; and Before we proceed further, we would like to strongly
IOL powers >30D are supposed to be within ±1.0D. emphasize that this section is meant to serve as an overview
The manufacturing process of IOLs is too detailed for about monofocal IOLs. While we will highlight certain fea-
this text, but one key point is that after production, the actual tures of a given IOL, we do not intend to promote or dispar-
power of a given IOL is measured down to the decimal point age a given IOL; as educators, it is not our intent to influence
of power. Each IOL is placed in a “bin” closest to the cor- your IOL choices.
responding “box label” power. For example, suppose we All of the IOLs discussed below have a good track record
measured two IOLs targeted for 24D of power immediately of optical performance. We are assuming that you, as the
as they emerged from the magical IOL-making machine. reader, are an adult and can conscientiously choose the IOL
One IOL is measured as 23.7D of power, and the other is that works best for you and your patients using your best
measured as 24.1D. Assuming 0.5D power steps, the first clinical judgment.
IOL will be placed in the 23.5D bin and the second in the
24.0D bin.
Single-Piece Acrylic IOLs
Don’t worry if you don’t understand this paragraph on the first read. It
19
AcrySof Platform
takes several readings to fully digest this material.
The AcrySof platform (Alcon Laboratories, Fort Worth, TX,
Recall the inverse relationship between spherical aberration and con-
20
USA) includes the SN60WF (yellow), SA60WF (clear), and
trast sensitivity: reduction of spherical aberration will improve contrast
sensitivity. See Chap. 14, “Physical Optics and Advanced Optical AU00T0 (preloaded) models. This same platform is used in
Principles” for more information. this manufacturer’s toric and presbyopia-correcting IOLs
404 K. M. Riaz
(discussed later). At present, it is the most popularly sify this IOL as it is neither a pure monofocal nor an ATIOL
implanted IOL in the United States. (discussed in the later sections). However, its indications for
This single-piece IOL is a hydrophobic, acrylic, biconvex, use designate this IOL as a monofocal IOL. While it utilizes
aspheric, square-edged, C-haptic IOL. The optic c ontains a the same Tecnis platform as the ZCB00, the Eyhance fea-
copolymer of phenylethyl acrylate and phenylethyl methacry- tures a continuous change in power from the periphery to the
late, cross-linked with butanediol diacrylate, which leads to center of the IOL. In other words, by using a higher-order
the highest fibronectin adhesion among SPA IOLs. In English, asphere, additional plus power is located in the central por-
this means that this IOL “sticks” well to the capsular bag with tion of the lens, allowing for a modest improvement in inter-
minimal rotation and low rates of PCO formation. mediate vision while maintaining distance vision quality
The optic size is 6.0 mm and features a square-edge comparable to an aspheric monofocal IOL. The IOL optic
design with full edge-to-edge power. Available powers are has no “architectural” modifications, such as diffractive
+6 to +30D in 0.5D steps. The SN60AT features an anterior rings. Under the microscope, the IOL appears to be similar to
asymmetric biconvex design goes from +31.0 to +40.0D in a standard monofocal IOL, though a subtle donut-ring can be
1.0D increments. The index of refraction is 1.55, which is the seen under certain light conditions intraoperatively.
highest among its fellow SPA IOLs. In late 2021, the Clareon Data from clinical trials report MTF values in low-light
platform was introduced as an updated hydrophobic acrylic conditions superior to other monofocals; in addition, defocus
material in the USA. curves comparing the Eyhance to the ZCB00 suggest a slight
Advantages of this IOL include low rates of PCO, excel- improvement (1–2 lines) in intermediate and near vision.
lent in-the-bag stability, UV light blocking (SN60WF) and Thus, while it is not a true ATIOL in terms of its intermedi-
filtering (SA60WF), and familiarity among most surgeons. ate/near vision, it also avoids the unwanted glare and halos
Disadvantages of this IOL include the cosmetic yellow associated with diffractive-optics ATIOLs. This IOL may be
glint (cat’s eye reflex noticed by observers), glistenings, sub- a suitable option for patients who desire improved intermedi-
surface nanoglistenings, anterior optic membranes,21 and ate vision but may not be ideal candidates for an ATIOL with
high rates of dysphotopsias. out-of-pocket fees. Given the modest improvements in inter-
mediate and near vision, we can think of this as a “pseudo-
Tecnis Platform ATIOL”, as awkward as that term sounds. A toric version of
The Tecnis platform (Johnson and Johnson, Jacksonville, FL, this IOL (DIUxxx) is also available. As this is a relatively
USA) includes the ZCB00 PCB00, and DCB00 (preloaded) new IOL to the US market, long-term clinical performance is
models. This same platform is used in this manufacturer’s toric, unknown at the time of this writing.
monofocal “plus” (Eyhance), and presbyopia-correcting IOLs.
This single-piece IOL is a hydrophobic, acrylic, bicon- Envista Platform
vex, anterior aspheric with square optic edge C-haptic The Envista platform (Bausch and Lomb, Tampa, FL, USA)
IOL. As mentioned previously, the haptics have a slightly includes the MX60 and MX60E models. The optical func-
anterior offset from the optic plane. tion of both IOL models is the same; however, the MX60E
The optic size is 6.0 mm with an inert carrier ring of features a modification in the IOL material that allows for
approximately 0.5 mm, yielding a functional 5–5.25 mm faster unfolding than the MX60. Recently, a preloaded model
optic. The inert carrier ring allows for a higher power range. (MX60PL) has been introduced to market. This same plat-
Available powers are +5 to +34D in 0.5D steps. The index of form is used in this manufacturer’s toric IOL models.
refraction is 1.47, which is the lowest among its fellow This single-piece IOL is a hydrophobic, acrylic, bicon-
hydrophobic SPA IOLs. vex, aspheric, square-edged, C-haptic IOL. The haptics are
Advantages of this IOL include the offset haptics-optic notable for prominent eyelets (“loops” or “holes”) at the
design, which causes low rates of PCO. The optic is a rela- haptic-optic junction, which facilitate IOL rotation within
tively “clean” optic with minimal glistenings. The inert car- the bag at the time of insertion.
rier ring makes IOL exchange easier as the anterior rhexis The optic size is 6.0 mm with edge-to-edge power. The
does not adhere tightly to the anterior optic. optic has slight posterior vaulting, but the haptics and optic are
Disadvantages of this IOL include the previously dislocated within the same plane. Available powers are the highest
cussed issues with the inert carrier ring, as well as a rela- among the IOLs discussed thus far in this section: 0 to +34D,
tively slow IOL unfolding time intraoperatively. with +10 to +30D in 0.5D steps and 0 to +10D and +30 to
In February 2021, the Eyhance (DIB00) was introduced +34D in 1 D steps. The index of refraction is 1.53. As noted in
as a “monofocal plus” IOL. It is difficult to accurately clas- the previous section, while this is an aspheric IOL, no spherical
aberration correction (aberration-neutral) is built into this IOL.
Advantages of this IOL include an optic without glisten-
Riaz KM, Williams BL, Safran SG, Gallardo MJ. Proliferative
21
Anterior Optic Membranes in Hydrophobic Acrylic Intraocular Lenses. ings and low rates of PCO. Additionally, the angulation of the
Clin Ophthalmol. 2020 Oct 22;14:3451-3455. haptics (55-degrees) is higher than the previous two IOLs,
Table 4 Summary of commonly used monofocal IOL features

IOL model AcrySof Tecnis Envista Softec iSert Nanoflex
Architecture Biconvex aspheric Biconvex aspheric Biconvex aspheric Biconvex aspheric Biconvex aspheric Plate haptic
shape with C-shaped with C-shaped with C-shaped haptics with C-shaped with C-shaped
haptics haptics haptics haptics
Material Acrylic Acrylic Acrylic Acrylic Acrylic Collamer
Hydrophobic / Hydrophobic Hydrophobic Hydrophobic Hydrophilic Hydrophobic Hydrophilic
hydrophilic
Index of 1.55 1.47 1.53 1.43 1.52 1.442
refraction
Power range 6–30D in 0.5D 5–34 in 0.5D steps 0–34D: 10–30 in 0.5D 5–36D, see text 6-30D in 0.5D 10.5–30.5D in
steps steps, 0–10 and for additional steps 0.5D steps
30–34 in 1D steps details
Optic size 6.0 mm 6.0 mm with inert 6.0 mm 5.75 mm 6.0 mm 6.0 mm
carrier
Diameter 13.0 mm 13.0 mm 12.5 mm 12.0 mm 12.5 mm 10.8 mm
Spherical −0.20 μm −0.27 μm 0 μm 0 μm −0.18 μm −0.019 μm
aberration
correction
which allows for more capsular bag contact and potential sta- In 2013, an older version of this IOL was recalled due to
bility as it has a pseudo-capsular tension ring effect. This may high rates of inflammation.
be advantageous when using the toric version of this IOL. Table 4 summarizes the highlights of these commonly
Disadvantages include a relatively high index of refrac- used monofocal IOLs.
tion with associated dysphotopsias. The MX60 model
unfolds the slowest among these three IOLs.
Three-Piece IOLs
Softec Platform
The Softec platform (Lenstec, Inc., St. Petersburg, FL, USA) Knowledge of three-piece IOLs remains an invaluable tool for
includes the Softec HD, Softec HDM, and Softec HDO any cataract surgeon, despite many surgeons favoring the use
models. of SPA IOLs. First, no matter how “excellent” a cataract sur-
This single-piece IOL is a hydrophilic, acrylic, bi- geon you may be, there will come a day when you encounter
aspheric, C-haptic IOL. The optic size is 5.75 mm with edge- our dear friend Mr. Vitreous, and you may have to forego a SPA
to-edge power. Available powers include +5.0 to +36.0D, IOL in favor of a three-piece IOL. Second, recall that you must
with +15.0 to +25.0D in 0.25D steps; +10.5-14.5 and +25.5- never place an SPA IOL in the sulcus (despite some surgeons
29.5D in 0.5D steps; and +5 to +10D/+30 to +36D in 1.0D saying otherwise), due to the risk of postoperative complica-
steps. This IOL is available in 0.25D steps in the most com- tions such as UGH syndrome.22 In addition, there are certain
monly used IOL power ranges. Among SPA IOLs, this has situations in which a three-piece IOL is favored, such as:
the lowest index of refraction at 1.43.
The main difference between the HD and HDM models is • Patients with moderate-high risk of late-term dislocation
that the latter can be inserted through a sub-2.2 mm incision. due to zonular weakness or instability (e.g., pseudoexfo-
Interestingly, while the HD and HDM models are “circular,” liation syndrome), wherein a three-piece IOL (with or
the HDO features an “oval” shaped optic that can be placed without a capsular tension ring and/or capsular tension
with the haptics in the horizontal position to decrease the segment), might be a safer option
incidence of dysphotopsia. • Patients requiring high or low IOLs powers that are not
available in SPA IOLs (e.g., high myopia)
iSert Platform • Patients requiring piggyback IOLs for correction of
The iSert platform (Hoya Surgical Optics, Inc., Chino Hills, refractive surprise (see Chap. 29, “Postoperative Optics
CA, USA) includes the iSert 250 (clear) and iSert 251 (yel- for Cataract Surgery” for more information)
low) models. • Patients requiring iris or scleral-fixation of IOL in cases
This single-piece IOL is a preloaded, hydrophobic, acrylic, of aphakia
bi-aspheric C-haptic IOL. The optic is 6.0 mm with edge-to-
edge power. The index of refraction is 1.520. Available pow-
ers include +6 to +30D in 0.5D steps. One interesting feature
See Chap. 28, Intraoperative Optics for Cataract Surgery, for addi-
22
about this IOL is that the haptics have a mixture of PMMA tional information regarding sulcus IOLs (e.g., sulcus IOL power calcu-
added to increase adhesion to the capsular bag. lations, types of placement, etc.)
406 K. M. Riaz
While you may not use these IOLs often, you should be Caution should be exercised when considering silicone
comfortable with using them when the situation demands. IOLs for patients who may need silicone oil in the future. In
Remember that many of these IOLs usually will require a addition, a “bimanual” insertion is required as the IOL
larger (≥2.8 mm) incision than SPA IOLs. unfolds quite suddenly inside the eye compared to com-
For situations requiring common IOL powers, available monly used SPA IOLs.
acrylic choices include the following:
• AcrySof MA60AC (clear)/MN60AC (yellow) (Alcon Extended Range IOLs

Laboratories, Fort Worth, TX USA): Both of these
acrylic IOLs are available from +6 to +30.0D in 0.5D Occasionally, you may encounter a patient (such as a high
steps. The MA50BM (clear) is similar but features a hyperope or pathologic myope) who requires an IOL power
larger 6.5 mm optic, making it useful for large eyes or that you did not think existed. It is helpful to know what IOL
suture fixation as it offers a bit more forgiveness in terms options are available for these unique patients in these situa-
of decentration. tions. We hope this section will make IOL selection a bit
• Tecnis ZA9003 and Sensar AR40e models (Johnson and easier—of course, surgery in these patients can be an adven-
Johnson, Jacksonville, FL, USA): The ZA9003 is avail- ture, so we wish you good luck in advance on that!
able from +10 to +30.0D in 0.5D steps, and the Sensar
AR40e is available from +6 to +30.0D in 0.5D steps. xtreme Low Power IOLs
E
These acrylic IOLs have PMMA haptics with a rounded A few options exist for these extremely myopic, insanely
anterior edge optic and square posterior edge optic. long axial length eyes. Recall that one of the SPA IOLs
• CT Lucia 602 (formerly EC3-PAL) (Carl Zeiss Meditec (Envista) goes down to 0D, as does the Akreos IOL (Bausch
Inc., Dublin, CA): This hydrophobic acrylic IOL has and Lomb, Tampa, FL, USA).
recently gained significant attention among surgeons The following options are three-piece, hydrophobic
who perform scleral fixation IOL surgery. The polyvi- acrylic IOLs:
nylidene fluoride (PVDF) haptics are robust, nearly
indestructible, and useful for intraocular gymnastics, • AcrySof MA60MA (clear) and MN60MA (yellow)
making this IOL an ideal choice for transconjunctival (Alcon Laboratories, Fort Worth, TX, USA): Available in
intrascleral haptic fixation (Yamane technique) in cases minus 5.0 to plus 5.0D in 1D steps.
of aphakia. This IOL is available from +4 to +34.0D in • Sensar AR40M and AR40e (Johnson and Johnson,
0.5D steps. The refractive index (1.49) is similar to Jacksonville, FL, USA). The AR40M is available in minus
PMMA. The optic has an inert carrier which may con- 10 to + 1.5D, and the AR40E is available in +2 to + 5.5D
tribute to dysphotopsias. powers; both models are available in 0.5D steps.
• MZ60PD and MZ60MD (Alcon Laboratories, Fort Worth,
Silicone IOLs are mainly available as three-piece IOL TX, USA): These obscure PMMA IOLs are available in
models. The two most popularly used are as follows: minus 10 to minus 4D in 1.0D steps (MZ60PD) and minus
3 to + 3.0D in 1.0D steps (MZ60MD). The 6.0 mm optic
• SofPort Li61AO (Bausch and Lomb, Tampa, FL, USA): size will require an extremely large incision as this is a
This silicone optic IOL is available from 0 to +4D in non-foldable IOL.
1.0D steps, +5.0 to +30.0D in 0.5D steps, and + 31 to
+34D in 1.0D steps. This zero-aberration IOL has PMMA In addition, some surgeons have discussed using the pha-
haptics attached to the silicone optic with a rounded ante- kic collamer IOL (Staar Surgical, Monrovia, CA, USA) as
rior edge and square posterior edge. It has a very low an off-label IOL. This IOL goes from −3 to −20.0D. The
index of refraction (1.429), which is the lowest among all cost of this IOL may also make it prohibitive for routine use.
available IOLs, and thus has the lowest reported inci- Again, we cannot endorse this as an on-label use for this IOL
dence of dysphotopsia. This IOL can be inserted in inci- in this situation.
sions as small as 2.4 mm in its dedicated cartridge and
inserter. xtreme High Power IOLs
E
• Tecnis Z9002 (Johnson and Johnson, Jacksonville, FL, Similarly, a few options exist for these extremely hyperopic,
USA): This silicone optic IOL is available from +5.0 to very short axial length eyes:
+30.0D in 0.5D steps. The IOL has PMMA haptics with a
rounded anterior edge and square posterior edge. It has an • AcrySof SA60AT (clear) and SN60AT (yellow) (Alcon
index of refraction of 1.46. This IOL requires a 3.0 mm Laboratories, Fort Worth, TX, USA): This SPA IOL is
incision in its dedicated cartridge and inserter. available in commonly used powers but is also available
from +31 to + 40.0D in 1D steps. Recall that this is a a highly biocompatible material with a very low index of
spherical IOL. refraction (1.442). This material is also used for the pha-
• P359UV (Bausch and Lomb, Tampa, FL, USA): This kic IOL (Visian ® ICL). Collamer’s unique properties
PMMA IOL is a spherical IOL with a 5.5 mm optic. It is allow for good adherence to the lens capsule, incite mini-
available from 0 to + 45.0D in 1.0D increments. Note that mal inflammation and reduce the risk of calcification. The
it cannot be folded and will require a large incision. optic is 6.0 mm with edge-to-edge power. Nanoflex IOLs
are available from +10.5 to +30.5D in 0.5D steps. One
Additionally, some surgeons recommend a “double” IOL unique feature of this IOL is its ability to “mend itself” if
approach in these eyes. With this strategy, the highest avail- damaged during the course of a YAG capsulotomy (such
able power SPA is placed in the capsular bag, and the remain- as when done by a first-year resident). The IOL has
ing needed IOL power (usually a three-piece IOL of a approximately −0.019 microns of negative spherical
different material, such as silicone) is placed in the sulcus or aberration. Unlike previous-generation plate-haptic IOLs,
even in the capsular bag. Some additional IOL calculations there have not been reports of late-term dislocations,
are required, such as calculating the resulting hyperopia with including after YAG capsulotomy.
the SPA IOL and then using the piggyback IOL calculation • CZ70BD (Alcon Laboratories, Fort Worth, TX, USA):
for a hyperopic surprise (Piggyback IOL power = 1.5 × hyper- This UV-absorbing, single-piece PMMA IOL is popu-
opic refractive error) to place the second IOL, either at the larly used in secondary IOL surgery due to its uniquely
time of the initial surgery or as a staged procedure for pig- designed haptics that facilitate suture passing for scleral
gyback IOL (secondary IOL) placement. fixation. It has a low index of refraction (1.49) and is
available from +4.0 to +34.0D in 0.5D steps. The less
commonly used MZ60MD/PD models go down to –3.0D
Anterior Chamber IOLs and –10.0D, respectively. This is the only IOL available in
the USA with a 7.0 mm optic, making it ideal for scleral
In the United States, at the time of this writing, there are two fixation by allowing some “wiggle-room” for decentra-
main ACIOL model types available, both made of PMMA tion. Because of its size and material, a large (≥7 mm)
and with equally comparable long-term visual outcomes23: incision (e.g., scleral tunnel) is required.
• The Kelman Multiflex III ACIOL (MTA2UO-MTA7U0

models; Alcon Laboratories, Inc., Fort Worth, TX, USA) Toric IOLs
features a 5.5 mm optic. The model numbers (2–7) increase
in 0.5 mm overall length sizes, corresponding to a range of Most trainees are familiar with toric IOLs and usually have
12.0–14.5 mm. This ACIOL has a convex-plano design. gratis-access to these IOLs during residency. All three major
• The S122UV/L122 UV (Bausch and Lomb, Tampa, FL, IOL manufacturers in the United States make monofocal
USA) types (12.5/13.5 mm lengths) feature a 6.0 mm toric IOLs that can correct up to 4.5D of corneal astigma-
optic and a biconvex design. tism.24 The terminology for a given toric IOL power varies
slightly among manufacturers, but the range of correctable
See Chap. 28, “Intraoperative Optics for Cataract corneal astigmatism is the same. The cylinder power is
Surgery”, for more discussion on ACIOLs, including calcu- mainly in the posterior aspect of the toric IOL. The meridian
lating the needed IOL power in unplanned situations. of the correcting cylinder is usually denoted by circular
marks or a dashed line that helps the surgeon place the IOL
in the correct meridian (steep meridian, aka the axis merid-
Miscellaneous IOLs ian); recall that the cylinder power will then act at the (power)
meridian 90-degrees away.
Several other IOLs may be significant in certain situations: A full discussion of the pros/cons and variations of each
toric IOL model is beyond the scope of this text. Overall,
• Nanoflex CC4204A (Staar Surgical, Monrovia, CA, they are quite similar to their monofocal counterparts in
USA): This hydrophilic plate-haptic IOL is made of col- terms of material, index of refraction, etc. Reports in the lit-
lamer, which has a high water content (40%). Collamer is erature vary regarding the superiority of one type of toric
IOL over another.
Suelves AM, Siddique SS, Schurko B, et al. Anterior chamber intra-

23
ocular lens implantation in patients with a history of chronic uveitis: IOLs that combine presbyopia- and astigmatism-correction are dis-
24
five-year follow-up. J Cataract Refract Surg. 2014;40(1):77-81. cussed in the next section.
408 K. M. Riaz
Advantages of toric IOLs include superior accuracy in tifocal IOLs (MFIOLs), extended depth of focus IOLs
astigmatism correction, avoiding additional corneal inci- (EDOF-IOLs), trifocal IOLs (TF-IOLs), and accommodative
sions, improving UCVA/BCVA, and sustained reduction of IOLs (AIOLs). One key point: All MFIOLs, EDOF-IOLs,
astigmatism, as shown in numerous studies. Disadvantages and TF-IOLs “purchase” this greater range of vision by pay-
include cost, inability to correct high(>4.5D)/irregular ing the currency of contrast sensitivity. In other words, espe-
astigmatism, late-term rotation, and inadvertent under-
cially when compared to monofocal IOLs, patients with
correction/overcorrection of astigmatism. MFIOLs/EDOF-IOLs/TF-IOLs will experience reduced
This last point merits some additional discussion. Recall contrast sensitivity. In addition, patients may have visually
our discussions in the previous chapter on total corneal astig- significant glare, haloes, starbursts, and other subjective
matism, including anterior and posterior corneal astigma- visual disturbances. AIOLs do not incur these subjective
tism. For example, if we have a young patient (40-50 years) visual disturbances but tend to not perform well for near
with WTR astigmatism and we fully correct the WTR astig- vision needs.
matism, then as the patient gets older, s/he may gain addi- Furthermore, this is an area that is rapidly changing and
tional ATR. For these patients, it may be prudent to leave evolving with new ATIOLs available seemingly every few
some residual WTR astigmatism (approximately 0.5D) so months like smartphones. We will limit our discussion to
that they can “grow into” their ATR astigmatism. We can ATIOL models and technologies available in the United
safely correct the full WTR astigmatism in older patients States at this writing (September 2021). Technologies on the
because they may not have much time left to “grow into” horizon, such as newer EDOF IOLs and light-adjustable
their ATR astigmatism.25 For ATR patients, most surgeons IOLs, are topics to watch for in the peer-reviewed literature.
would feel comfortable correcting the full astigmatism, Again, before we proceed further, we would like to
regardless of age. strongly emphasize that this section is serves as an overview
Finally, it may be preferable to avoid “flipping the axis” of ATIOLs. While we will highlight certain features of a
as much as possible when correcting astigmatism, especially given ATIOL, we do not intend to promote or disparage a
for WTR astigmatism. However, some surgeons argue that given ATIOL. We are assuming that you, as the reader, are an
reducing astigmatism to the lowest possible quantitative adult and can conscientiously choose the ATIOL that works
amount, even if one has to flip the axis, is preferable for all best for your patients using your best clinical judgment.
types of preoperative astigmatism. We suggest that under-
correction of WTR astigmatism has two unique advantages.
First, residual WTR allows patients to “grow” into their ATR Diffractive Multifocal IOLs
astigmatism with age. Second, residual WTR confers an
optical advantage for viewing letters with vertical strokes at Diffractive MFIOLs rely on the principle of diffraction to
a distance. Additionally, we recommend that surgeons correct intermediate and near vision. Recall that in the prin-
aggressively correct ATR astigmatism regardless of patient ciple of diffraction, light waves slow down and change direc-
age. Patients with preoperative ATR astigmatism who have tion when they encounter an obstacle (aka the “diffractive
mild postoperative WTR astigmatism are better able to toler- zone”). MFIOLs utilize a combination of microscopic steps
ate this “axis flip” than their WTR counterparts. (diffractive zones) to split light toward distance and near
focal points.
Incoming light rays will be directed towards a near and
Advanced Technology IOLs distance focal point depending on the step height they
encounter. If the step height is the same wavelength as the
If you have made it this far, now comes the real fun stuff. incoming light, all the particles are directed towards the near
Please take a minute to stop and play Abba’s “Money, Money, focal point. If the step height is a small fraction of the incom-
Money” (1976) in the background before continuing.26 ing light wavelength, more light particles are directed
Advanced technology IOLs (ATIOLs), aka presbyopia- towards the distance focal point. Therefore, MFIOLs utilize
correcting IOLs, allow surgeons to correct distance, interme- a combination of step heights to split incoming light into
diate, and near vision (presbyopia correction) for patients “distance,” “intermediate,” and “near” focal points.
who are motivated to decrease the need for spectacles post-
operatively. We will focus our discussion on diffractive mul- Apodized Diffractive MFIOLs
Do not be scared by the word “apodized.” It simply means
that there is a gradual reduction (apodization) in step height
Yes, that sounds morbid so apologies in advance!
25
from the center to the periphery. Apodization allows incom-
Remember how we spent time discussing refraction and diffraction
26
back in Chap. 1, “Geometric Optics?” It may be worthwhile to review ing light to be directed toward far and near points in a grad-
these definitions before proceeding further. ual pattern, rather than an abrupt split between far and near.
An example of an apodized diffractive MFIOL is the This MFIOL features 18 rings on the posterior aspect of the
Restor (+3.00 add (SN6AD1) and + 2.50 add (SVT25T0); optic extending to the periphery. The non-apodized rings
custom order +4.00 add available (Alcon Laboratories, Fort direct an equal amount of incoming light to the near and dis-
Worth, TX USA). Technically, this lens combines a refrac- tance focal points. As a result, this MFIOL performs better
tive (monofocal) and diffractive MFIOL. The central 3.6 mm for distance and near vision with some compromise of inter-
of the optic contains an anterior apodized diffractive region mediate vision. Patients who desire good distance/intermedi-
and a refractive (monofocal) peripheral portion. When the ate vision with some compromise of near vision may be
patient’s pupil size increases (e.g., distance vision), more dif- good candidates for a lower add power model. As a corollary,
fractive zones with small step heights (and the periph- patients who desire good distance/near vision with some
eral refractive zone) are exposed, thereby directing more compromise of intermediate vision may be good candidates
incoming light towards the distance focal point. This combi- for a higher add power model. Since the rings encompass the
nation of a “central” apodized diffractive region with a entire optic, patients with large scotopic pupils and/or
peripheral “donut” of a refractive region allows for good patients who enjoy reading in low-light conditions may be
near and distant vision, respectively. well-suited for this MFIOL.
The SV25T0 (+2.50D add) is a MFIOL model with 7 rings Given the three models with varying add power options,
and is better suited for distance vision (due to an extra dis- patient height and reading distance preference can similarly
tance and intermediate vision zone). The SN6AD1 (+3.00D be considered as discussed in the previous section.
add) model features 9 rings and has more rings dedicated for Remember, using a lower add power may be advantageous
near vision; it is better suited for distance and near vision. in patients who naturally read at a longer distance when
Patients who desire good distance and intermediate vision holding reading material. For example, a retired profes-
(computer vision) may prefer the +2.50D add, whereas sional basketball player may prefer +2.75D add power in
patients who desire good distance and near may prefer the both eyes, while a 4′11″ grandmother may prefer +4.00D
+3.00 D add in both eyes. Surgeons should consider patients’ adds in both eyes. A similar “mix and match” strategy has
height and preferred reading distance as well. For example, been advocated by some surgeons, such as using a +3.25D
taller patients or patients who like to hold reading material add in the dominant eye and a +4.00D add in the non-dom-
farther away may be happier with a lower add power than inant eye. As discussed with apodized MFIOLs, the strat-
shorter patients. Finally, “mix and match” options have also egy to utilize the strengths of the lower add MFIOL to
been used, such as placing a +2.50 add in the dominant eye compensate for the weaknesses of the higher add MFIOL
and a +3.00 add in the non-dominant eye. This combination and vice versa.
allows the patient to utilize the dominant eye for distance- In September 2020, toric versions (ZKUxxx with +2.75
intermediate vision and the non-dominant eye for distance- add and ZLUxxx with +3.25 add) that can correct 2.5–3D of
near vision. The idea is that with both eyes open, the “gaps” corneal astigmatism were made available.
created by one MFIOL model can be filled in by its counter-
part MFIOL model.
Toric versions of both models (SV25Tx and SND1Tx) Refractive IOLs (Historical)
can correct up to 2.5–3.0D corneal cylinder.
One potential disadvantage of this MFIOL is the 3.6 mm Refractive IOLs are no longer available in the USA and are
diffractive zone: patients with large pupils, especially those mainly of historical interest. The ReZoom (Abbott Medical
who enjoy reading in low-light conditions, may have reduced Optics, Santa Anna, CA, USA) refractive IOL was an exam-
near vision since more incoming light is directed towards the ple of this technology.
refractive distance zones as compared to the central diffrac- These ATIOLs were constructed by incorporating two dif-
tive zones. ferent powers into multiple circular refractive zones.
Because each “donut” of the IOL has a different effective
on-apodized Diffractive MFIOLs
N power, distance/near vision primarily depended on the
As you may have guessed, non-apodized diffractive MFIOLs patient’s pupillary response to light. The ReZoom featured
utilize rings of uniform step height (1 wavelength) to direct a five refractive zones to provide a range of vision: Zones
significant percentage of incoming light toward the near 1(central zone), 3, and 5 (far peripheral) were set for distance
point. while Zones 2 and 4 were set for near vision. The “transi-
The Tecnis MFIOL is available in three versions: ZKB00 tion” lines between each zone offered intermediate vision.
(+2.75D add), ZLB00 (+3.25D add), and ZMB00 (+4.00D Theoretically, this sounded like a great idea for an
add) (Johnson and Johnson Vision, Jacksonville, FL USA). ATIOL. However, due to the extremely high rates of glare,
410 K. M. Riaz
halos, and subjective visual dysfunction, it was discontinued odified Wavefront Extended Depth
M
in 2011. of Focus IOLs
Wavefront modification is used in the “new kid on the block”
EDOF IOL; the Vivity IOL (DFT015/DAT015) was released
Extended Depth of Focus (EDOF) IOLs in January 2021 and included a toric option (DFT315/415/515
and DAT315/415/515 models).
One optics nerd note: Diffractive optics (Symfony IOL; Compared to diffractive IOLs, this EDOF IOL contains a
Johnson and Johnson Vision, Jacksonville, FL USA and AT modification of the central aspect of the anterior optic to
LARA 829 MP IOL; Carl Zeiss Meditec, Dublin, CA, USA) “stretch and shift” the wavefront of incoming light to give
is one method to create an EDOF-IOL. Other EDOF-IOL depth of focus.28 In layman’s terms, this essentially allows
strategies include stretching the wavefront (as used in the the IOL to have a + 1.5D reading add with similar distance
Vivity IOL (Alcon Laboratories, Fort Worth, TX USA), pin- visual acuity as a monofocal IOL, but with better MTF val-
hole optics (IC-8 IOL; Acufocus, Irvine, CA, USA), and ues than diffractive IOLs (both diffractive MFIOLs and dif-
opposite spherical aberrations (Mini Well IOL; SIFI S.p.A., fractive EDOF IOLs). Furthermore, the absence of rings
Catania, Italy). As the name suggests, the goal with EDOF is allows this EDOF-IOL to be pupil independent for scotopic
to shift or extend the focal point (rather than split incoming and mesopic vision needs.
light into distinct focal points) to increase intermediate and Surgeons may still choose to do a modified mini-
near visual function. We will focus primarily on the two monovision (dominant eye plano, nondominant eye approxi-
EDOF-IOLs available in the United States at the time of this mately −0.5 to −0.75D) to allow for improved near vision.
writing. This IOL also has negative spherical aberration to compen-
sate for corneal spherical aberration. Patients can expect
Diffractive Optics Extended Depth of Focus IOLs good distance and intermediate vision, but near visual tasks
Diffractive EDOF-IOLs contain ring structures in the optic may still require reading glasses. Due to the stretched and
termed as “echelettes.”27 Instead of arriving at two distinct shifted wavefront, there are minimal “gaps” between dis-
focal points, incoming light is redirected towards an elon- tance, intermediate, and near vision. Since there are no
gated focal point shaped like a cylindrical column of “rings”, some surgeons have suggested that this ATIOL may
light (“the depth of focus”). The Symfony EDOF-IOL be used effectively in post-refractive surgery patients.
(ZXR00) and a toric option (ZXTxxx) were approved in the Subjective visual disturbances, including glare and halos,
USA in August 2016. The Symfony has a posterior achro- have been reported in the FDA clinical trials.29 As with many
matic diffractive surface with 9 echelettes. things in life, we have to lose something to gain something.
In addition to correcting spherical aberration, this EDOF- With this IOL, there is approximately 50% MTF reduction at
IOL also corrects chromatic aberration. Theoretically, if we distance, but better MTF at near. In other words, we are sac-
corrected both spherical aberration and chromatic aberra- rificing contrast sensitivity at distance to gain near vision.
tion, we could get 20/12 or 20/10 vision at distance. However, There have been reports of subjectively blurry vision at all
using echelettes means we are still relying on diffractive distances due to loss of contrast sensitivity. Long-term real-
optics, so this slightly reduces the range of vision correction world results of this IOL remain to be seen at the time of this
to the level of 20/20. Again, we are paying for presbyopic writing. However, this IOL offers a different philosophical
correction with the currency of enhanced distance vision. and technological approach to previous generations of
Benefits of this ATIOL include better subjective vision presbyopia-correcting IOLs.
and better intermediate vision. However, glare/halos are sim-
ilar to MFIOLs (despite initial claims to the contrary), and
patients may lose some near vision while gaining more inter- Combined EDOF-MFIOLs
mediate vision.
Some surgeons have described using an EDOF-IOL set The Tecnis Synergy (Johnson and Johnson Vision,
for emmetropia in the dominant eye and an EDOF-IOL set Jacksonville, FL, USA) was launched in June 2021 as a com-
for –0.50D in the non-dominant eye to improve binocular bined EDOF-MFIOL. The EDOF portion of this ATIOL is in
near vision. “Mix and match” strategies to use an EDOF-IOL
in the dominant eye (distance/intermediate) and an MFIOL 28 One way to understand “stretching and shifting” is to understand that
in the non-dominant eye (distance/near) have also been a transition element in the central part of this IOL stretches the incom-
reported. ing wavefront in the X-Y direction; a second transition element shifts
the incoming wavefront in the Z direction. The combination of this
“stretch and shift” creates EDOF optics.
A useful rule in life: whenever you want to sound intelligent, use a
27
“Patient Information Brochure”. https://www.accessdata.fda.gov/
29
French-origin word and people will think you are a genius. cdrh_docs/pdf/P930014S126D.pdf. Accessed January 9, 2021.
the near to intermediate range (approximately 33 to 80 cm). incoming light to be split into the dedicated intermediate
The MFIOL portion has two distinct focal points at approxi- focal point. Toric versions of this IOL (T3-T6) are
mately 33 cm (near) and infinity (distance). This ATIOL is available.
basically a combined Symfony and Tecnis MFIOL; it has 15 Advantages of this ATIOL include a good range of vision
rings (compared to the 9 echeleettes of the Symfony and the with dedicated zones for all three distances. Potential disad-
18 rings of the Tecnis MFIOL). By using the strengths of one, vantages include compromise of near vision, worse halos/
the limitations of the other can potentially be mitigated. photic phenomena (even compared to older-generation
The Synergy is available in both a spherical (DFR00V) MFIOLs), and reduced MTF (20%) at distance and near.30
and toric models (DFWxxx). Like the Symfony, this ATIOL
corrects both spherical and chromatic aberration. One distin-
guishing feature is its champagne-like color, which confers Accommodative IOLs (AIOLs)
both UV and violet-light filtering. In addition, surgeons
should target closest to plano in their refractive target, even if While AIOLs allow for presbyopia correction, their mecha-
that incurs slight hyperopia (less than +0.25D). A 0.5D myo- nism of action is totally different from the previously dis-
pic “miss” with this IOL can cause a 1-line vision drop com- cussed ATIOLs. There is no use of diffractive optics, so there
pared to a 0.5D hyperopic miss, which only causes a half-line are no rings/echelettes in an AIOL.
vision drop. We can think of AIOLs as monofocal IOLs with elon-
When looking at the defocus curve for the Synergy (as gated haptics on hinges that allow the IOL to move (to simu-
compared to a monofocal Tecnis IOL), patients can expect late accommodation) forwards and backward, allowing for
≥ 20/25 vision until 33 cm. Similarly, MTF values are only the full range of vision. For example, when the patient wants
modestly decreased compared to a monofocal IOL and much to read, ciliary muscle contraction will move the optic for-
higher when compared to other diffractive ATIOLs. Given its ward, inducing a myopic shift and allowing for near vision.
relatively recent introduction to the market, long-term real- The Crystalens AO1UV/AO2UV (Bausch and Lomb,
world data are needed to determine other advantages and Inc., Tampa, FL, USA) is the only AIOL available in the
limitations of this ATIOL. United States. A toric option (TruLign; BL1UT125/200/275)
is also available.
Advantages of this AIOL include no glare/halos, good
Trifocal IOLs range of vision at distance and intermediate, and a zero-
aberration profile. It may be especially useful in post-
TF-IOLs are the “old new kid on the block.” Approved in refractive cataract surgery patients who desire presbyopia
August 2019, they represent a variant of MFIOLs as they correction but want to avoid glare/halos.
have distinct zones for distance, intermediate, and near Disadvantages of this AIOL primarily include a “locking”
vision. of the IOL after some time that prevents good near vision,
In the United States, the PanOptix TFNT00/TFAT00 though patients still maintain good distance and fair interme-
(Alcon Laboratories, Fort Worth, TX, USA) is the only cur- diate vision. Patients may also have to do “eye training”
rently available TF-IOL. The PanOptix is an upgraded exercises after cataract surgery to enhance their near vision.
SN6AD1 with several changes. First, the apodized platform Finally, a rare complication known as “Z-syndrome” may
has been replaced with a non-apodized platform that basi- occur. Due to exuberant capsular fibrosis and contraction,
cally contains a + 3.25D add and a + 2.17D add for near and haptic-hinge issues can cause an asymmetric vaulting of the
intermediate vision, respectively (corresponding to a + 1.65D AIOL so that it looks like a “Z” (one portion tilted anteriorly,
and + 2.35D add power at the corneal plane). Second, the the other portion tilted posteriorly), usually requiring laser or
3.6 mm diffractive zone of rings has been expanded to surgical intervention. This author has anecdotally noted that
4.5 mm, thereby limiting the monofocal refractive zone to an placing a capsular tension ring at the time of surgery may
outer 1.5 mm peripheral “donut.” Third, this ATIOL contains help reduce the incidence of Z-syndrome.
14 rings, as compared to the SV25T0 (7 rings) and SN6AD1 Several additional AIOL designs are awaiting FDA
(9 rings). Finally, the peripheral monofocal “donut” and cen- approval at the time of this writing.
tral “button” within the rings are maintained for good dis-
tance vision.
The construction of the TF-IOL creates three distinct
focal points: distance, intermediate (60 cm), and near Lee S, Choi M, Xu Z, et al. Optical bench performance of a novel
30
trifocal intraocular lens compared with a multifocal intraocular lens.

(40 cm). The intermediate diffractive split allows for light to Clin Ophthalmol. 2016;10:1031-1038.
412 K. M. Riaz
Additional Comments About ATIOLs useful: Imagine that the ATIOL is like the federal govern-
ment. The government initially collects taxes and then dis-
As stated previously in the chapter, no single ATIOL has tributes the revenue to various projects in varying amounts.
demonstrated consistent superiority over its counterparts or The ATIOL similarly collects incoming light but cannot
can be thought of as a “one ATIOL to rule them all” type of distribute all of it.31 Since it only has a fraction of the incom-
option. The ultimate choice of which ATIOL to use for a ing light, it must now decide how much to allocate toward its
given patient is for the surgeon to decide after a meticulous three biggest projects: distance, intermediate, and near
preoperative exam, including appropriate diagnostic test- vision. Imagine that the ATIOL has $100 (after the squan-
ing, and lengthy preoperative discussion about vision goals dered incoming revenue). It must now distribute that $100 to
after cataract surgery. While tempting, it is crucial to not these three areas. Most ATIOLs will spend most of that $100
promise patients “complete independence” from glasses. It toward distance vision. After all, patients still prioritize good
is better to under-promise and (hopefully) over-deliver. It is distance vision. Therefore, when we look at the MTF and
also important to carefully parse through the bravado of defocus curves for ATIOLs, we notice that the highest peak
“refractive IOL” surgeons who speak on behalf of a given (highest area of spending) is for distance vision. Thus, when
company that regale audiences with tales of their patients compared to monofocal IOLs, the distance peak is lower, but
who are “universally happy 20/15 vision at all distances.” that is because monofocals spend the entire $100 toward dis-
Peer-reviewed clinical studies, rather than hype and show- tance vision.
manship, is the ultimate arbiter. Be wary of the surgeon The MTF curves for ATIOLS become more interesting
who boasts an “80 percent premium IOL practice!” Also, for intermediate (40–75 cm) and near vision (<40 cm). When
be wary of the surgeon who implants “tons of ATIOLs” but we look at the literature on ATIOLs that report MTF values,
cannot explain the optics involved in each of the ATIOLs. we should focus on where the secondary high peaks for each
As previously discussed in Chap. 18, “Visual Acuity are located; this is where the ATIOL is spending the remain-
Testing and Assessment”, optical systems, including IOLs, der of the $100 budget. For example, we can observe that
are incapable of full 100% transmission of the object’s low-add power diffractive MFIOLs and EDOF-IOLs spend
details. The modular transfer function (MTF) is a mathemat- most of the budget on distance and intermediate vision; thus,
ical graphic representation of how we perceive contrast these ATIOLs may not function well for near vision. One the
based on the spatial frequency emanating from an object. A other hand, high-add power diffractive MFIOLs spend most
perfect IOL would have an MTF of 1. this means that every of the budget on distance and near vision; thus, these ATIOLs
single detail of the object is faithfully captured and may not function well for intermediate vision. Trifocal IOLs
transmitted. seem to have three prominent peaks for distance, intermedi-
Since we live in a world with intricate details, the MTF is ate, and near vision as they spend the budget a bit more
a way to measure the accuracy of image transmission based equally in these three areas compared to other ATIOLs.
on how much modulation (contrast) is present in the trans- However, there are significant gaps in between these three
mitted image. Thus, the MTF is a way to assess how well the areas that patients may report as “dead zones” in their vision.
IOL performs: a more desirable IOL will have a higher MTF In summary, there is no perfect ATIOL. However, under-
value at the measured distance. standing MTF curves may give the surgeon additional insight
When we look at MTF curves for a monofocal IOL, for on which ATIOL functions better for a given visual distance
distance visual acuity, the monofocal IOL will have a very and what compromises are made. It will also allow trainees
high peak for distance (test distance infinity) and very low to critically read literature regarding ATIOLs, rather than
peaks for intermediate and near vision. This makes sense as blindly follow a (paid) speaker on the platform, and under-
it confirms what we already know: Monofocals do well for stand the pros/cons with each IOL. This knowledge will
distance vision and not-so-good for intermediate and near allow the surgeon to set reasonable expectations with the
vision, so patients will have to use reading glasses for these patient and hopefully achieve a favorable surgical outcome
tasks. for all parties involved.
When it comes to ATIOLs, the MTF and defocus curves
are one way to assess how well a given ATIOL performs at
A certain percentage of incoming light is lost with an ATIOL due to
31
the various test distances. Recall that ATIOLs redistribute
absorption and destructive interference: think of this as “wasteful” gov-
incoming light to various target distances to give the patient ernment spending in the above analogy. This should not be interpreted
better intermediate and near vision. One analogy may be as a political statement of any kind.
Practice Questions 5. Which of the following patients is comparatively the

worst candidate for a toric IOL?
1. Which of the following patient examples represents the A. A 65-year-old mild hyperope with ATR astigmatism
best candidate for ATIOL surgery? B. A 40-year-old patient with scarring from severe
A. 65-year-old patient with refractive error plano in the keratoconus
dominant eye and − 1.75D sphere in the nondominant C. A 55-year-old moderate myope with WTR
eye astigmatism
B. A 65-year-old patient with refractive error of −16.00D D. A 75-year-old patient with forme-fruste keratoconus
in both eyes 6. Which of the following statements regarding IOL materi-
C. A 65-year-old patient who desires to see at 20/15 als and design is TRUE:
vision across all distances and fervently desires to not A. Square-edge IOLs are associated with lower rates of
use glasses for any visual activities PCO formation
D. A 65-year-old patient who is +1.50D sphere in both B. Square-edge IOLs are associated with lower rates of
eyes dysphotopsias after cataract surgery
E. A 65-year-old patient with extra money in their flex C. Square-edge IOLs are associated with late-term
spending account who wants to use it before the end dislocation
of the calendar year D. Square-edge IOLs have fallen out of favor as rounded-
2. Which of the following is TRUE in regards to spherical edge IOL designs are primarily used in the construc-
IOLs? tion of single-piece acrylic IOLs
A. Spherical IOLs will yield a much lower objective best 7. Which of the following statements regarding hydropho-
corrected visual acuity when compared to aspheric bic and hydrophilic IOLs is TRUE?
IOLs A. Hydrophilic IOLs have sharper optic edges as com-
B. The amount of spherical aberration induced by a pared to hydrophobic IOLs
spherical IOL is independent of the dioptric power of B. Hydrophilic IOLs require a larger incision for inser-
the spherical IOL tion as compared to hydrophobic IOLs
C. Spherical IOLs are a poor IOL choice in patients with C. Hydrophilic IOLs may undergo opacification if
a history of pseudoexfoliation syndrome exposed to intraocular gas or air
D. Spherical IOLs may confer better near vision to D. Hydrophilic IOLs confer better visual acuity as com-
patients when compared to aspheric IOLs pared to hydrophobic IOLs
3. Which of the following statements about multifocal intra- E. Hydrophilic IOLs are only available in limited power
ocular lenses (MFIOLs) is TRUE: ranges as compared to hydrophobic IOLs
A. MFIOLs can correct higher-order aberrations of the
cornea
B. An apodized diffractive MFIOL is an IOL, wherein Answers
the optic has abrupt, discrete steps from the center to
the periphery, allowing for splitting light into distinct 1. D. Among the options, a low hyperope may be the best can-
focal points didate for ATIOL surgery. In choice A, the patient has natu-
C. A non-apodized diffractive MFIOL has diffractive rally occurring monovision and may be best left with
steps of uniform height, located on the posterior postoperative monovision, especially to avoid potential glare/
aspect of the optic that encompass the entire optic halos with an ATIOL. In choice B, an ATIOL power may not
D. A refractive MFIOL has significantly less glare and be available in the power needed for a pathological myope; in
haloes as compared to a diffractive MFIOL addition, these patients may not do well with an ATIOL due
4. Which of the following statements about modular trans- to demands for reading and potential movement of the ATIOL
fer function curves is TRUE? (due to large capsular bag). In choice C, a patient with unrea-
A. A monofocal IOL has an MTF of 1.0 sonable expectations (“type A personality”) may not be best
B. The highest MTF peaks for a diffractive MFIOL are suited for ATIOL as all current ATIOLs involve some com-
at intermediate (40 cm) and near (25-33 cm) promise of visual acuity and contrast sensitivity for increased
distances range of vision. In choice E, do not be greedy: no information
C. TF-IOLs have the highest peak at distance with nearly was given regarding the clinical candidacy.
similar peaks at near and intermediate ranges 2. D. Spherical and aspheric IOLs both confer similar

D. Higher add MFIOLs will have better MTF peaks at objective visual acuity. However, the subjective visual
intermediate as compared to near ranges acuity with an aspheric IOL is usually much better due to
414 K. M. Riaz
improved (retained) contrast sensitivity. Higher powers ease is unlikely to progress at this age, a toric IOL is a
of spherical IOLs (e.g., +30D) will induce much more reasonable option. The 40-year-old patient with corneal
spherical aberration than their lower power counter- scarring is the worst candidate as there is likely irregular
parts (e.g., +10D). Spherical IOLs may be advanta- astigmatism present that cannot be corrected with a toric
geous in patients prone to IOL decentration, such as IOL. The patient may eventually need corneal transplant
patients with pseudoexfoliation syndrome, traumatic surgery in the future as well. If the patient needs to
cataract, etc., because of the consistent power through- undergo cataract surgery, a monofocal IOL is the safest
out the IOL. Because of increased depth of focus, option. In this scenario, the patient may benefit from spe-
spherical IOLs will usually confer better near vision cialty contact lenses (e.g., scleral contact lenses) for addi-
than aspheric IOLs. tional vision correction.ANSWER: A. Square-edge IOLs
3. C. Choice C is the definition of a non-apodized diffractive have been shown to decrease lens epithelial cell migration
MFIOL. An apodized diffractive MFIOL (choice B) has a and development of PCO, regardless of the IOL material
gradual reduction of steps from the center to the mid- used. However, they are also associated with higher rates
periphery (3.6 mm). MFIOLs cannot correct any higher- of dysphotopsia (both positive and negative) compared to
order aberrations. A refractive IOL (no longer available) rounded-edge IOLs. There is no evidence to suggest that
has much higher rates of glare/halos compared to square-edge IOLs can dislocate in the long-term, in the
MFIOLs. absence of exacerbating factors such as pseudoexfoliation
4. C. As there is no perfect lens system, there is no IOL that syndrome or trauma. Square-edge IOLs are the most pop-
has an MTF of 1.0 (100 percent transmission of contrast). ular design for SPA IOLs.
All monofocal IOLs will have a higher MTF than 6. C. Hydrophilic IOLs may undergo opacification if

ATIOLs. Regardless of technology, the highest MTF exposed to intraocular air or gas, making them a poor
peaks for all ATIOLs will be at distance. Peaks for near choice in patients who may need endothelial keratoplasty
and intermediate vision will vary, depending on the tech- and/or retinal surgery in the future. Hydrophilic IOLs
nology and add power in the ATIOL. TF-IOLs have the have smoother optic edges than hydrophobic IOLs, which
highest peak at distance with comparatively equal peaks may be why they are associated with slightly higher PCO
at near and intermediate to yield three focal points of formation rates than hydrophobic IOLs. Hydrophilic
vision. Higher add MFIOLs will have better MTF peaks IOLs may be inserted via smaller surgical incisions (1.8–
at near; lower add MFIOLs will have better MTF peaks 2.2 mm) compared to hydrophobic IOLs. Both hydropho-
at intermediate ranges. bic and hydrophilic IOLs confer equal visual acuity and
5. B. The other three patients are all good candidates for a are available in similar power ranges.
toric IOL. Elderly patients with forme-fruste keratoconus
may benefit from a toric IOL to reduce refractive astigma- Acknowledgments The author is very grateful to David L. Cooke, MD
tism. However, they should be counseled that glasses and/ (Great Lakes Eye Care, St. Joseph, MI) for his editorial assistance and
critical review of the material presented in this chapter.
or contact lenses may still be needed. As their corneal dis-
Intraoperative Optics for Cataract
Surgery
Kamran M. Riaz
Objectives Optics of Sulcus and Anterior Chamber IOLs

• To understand to adjust the power of sulcus and/or ante-
rior chamber IOLs, and why this adjustment is necessary Congratulations, you just broke the posterior capsule. While
• To understand the potential usefulness of intraoperative you may feel awful in the immediate moment, you can take
Purkinje images, especially when placing diffractive solace that you have now joined a fellowship of elite cataract
ATIOLs surgeons (read: every cataract surgeon alive) who have done
• To discuss potential advantages and current limitations of the exact same thing.1 While the usual steps of vitreous man-
intraoperative aberrometry agement are important, we will focus our discussion on the
• To review intraoperative aspects of toric IOLs and ATIOLs optics involved with intraocular lenses (IOLs) not placed in
the capsular bag.
First, it is important to follow the Boy Scouts’ motto: be
Introduction prepared. Surgical planning should include having biometry
printouts available for review (e.g., by a circulating nurse)
In the previous chapters, we discussed the considerable and ensuring that one has access to backup IOLs at the surgi-
thought processes and planning a good cataract surgeon must cal facility.
perform before to the day of surgery. As for the actual day of Remember that single-piece IOLs are one-trick ponies:
surgery, we may have (false) ideas of surgery day being a they can only be placed in the capsular bag. On the other
time to turn our brains off, fire the phaco machine and crank hand, 3-piece IOLs are the Swiss army knives of IOLs: they
out a bunch of ten-minute cataracts. Alas, it is never that can be placed in multiple locations and fixated in various
simple. techniques: in the capsular bag, in the sulcus, via optic cap-
Careful preoperative planning should make the actual ture, iris-fixated, and/or scleral fixated. Remember that plac-
intraoperative process fun. In some ways, modern cataract ing a 3-piece IOL requires additional maneuvers, such as
surgery, especially when using advanced technology intra- ensuring proper injector style, enlarging the surgical inci-
ocular lenses (ATIOLs), requires cataract surgeons to spend sion, and taking care during injection to unfold the IOL prop-
more time planning and designing the surgery than it takes to erly. Some residents never experience injecting a 3-piece
perform the actual surgery. However, there are certain situa- IOL during training because of the regular use of single-
tions and considerations we should keep in mind piece IOLs; if so, please spend some time in a wet-lab setting
intraoperatively. learning how to load and insert 3-piece IOLs. Politely asking
This chapter will discuss a few optics-related things a sur- your surgical facility manager for expired IOLs is a great
geon should keep in mind as he/she performs cataract place to start.
surgery.
Some people argue that if you do not have complications, you are not
1
operating enough. The authors know of a fellow trainee who went

through all of residency without breaking a capsule. He then went into
private practice and immediately broke a capsule and had no idea what
to do. He tried calling his former attendings during surgery. Do not be
that guy/gal.
K. M. Riaz (*)

416 K. M. Riaz
a b
Fig. 1 If a 3-piece IOLs optic is placed in the capsular bag (Panel a), power will need to be reduced accordingly, depending on the power of
then no adjustment to the planned IOL power is necessary. If a 3-piece the intended IOL
IOLs optic is placed in the sulcus (Panel b), then the planned IOL
Depending on where we place a 3-piece IOL, we may power should be made if placing a 3-piece IOL in the
need to make certain adjustments to the power of the sulcus:
IOL. The following principles should be applied: –– For IOL powers >26D: decrease the IOL power by
1.5D.
• A 3-piece IOL may be placed safely in the bag (Fig. 1) if –– For IOL powers 17-26D: decrease the IOL power by
the capsular defect is minor, either entirely or via optic 1.0D.
capture (where the optic is placed in the capsular bag and –– For IOL powers <17D: decrease the IOL power by
the haptics are placed in the sulcus). In this case, no IOL 0.5D.
power adjustment is necessary compared to the biometry
printout because the IOL optic has been placed in the cap- What happens if we, ruh-roh, destroy the capsular bag
sular bag. For example, if the biometry sheet calculated a and cannot place a 3-piece IOL?3 In this case, we may have
+ 18.0D 3-piece IOL, an +18.0D IOL can be placed with- to place an ACIOL. Several considerations must be made
out additional adjustments. when using these ACIOLs—it is worthwhile to review these
• A 3-piece IOL may be placed in the sulcus (Fig. 1) for periodically, even though the need for them should be (hope-
various reasons. Sulcus placement can involve either fully!) very infrequent:
placing the entire IOL in the sulcus (more common) or via
reverse-optic capture, wherein the haptics are placed in • When placing ACIOLs, the horizontal white to white
the capsular bag and the optic is placed in the sulcus.2 In (WTW) measurement is crucial to ensure that the ACIOL
either case, we have to adjust the calculated IOL power:
because the IOL will now sit more anterior to the retina, It is this author’s opinion that whenever possible, an ACIOL should be
3
we have to decrease the power of the 3-piece IOL. If we avoided due to the increased risks of UGH and corneal edema/bullous
did not do this, we would have a myopic surprise—which keratopathy. It would be better to close the eye at this point and return
for a planned scleral fixation IOL procedure (e.g., Yamane technique,
some may argue is not that bad of an outcome, and we Aggarwal glued IOL technique, or Gore-Tex® fixation of IOL) or iris-
would not argue too much either. However, for the sake of fixation of 3-piece IOL (less-preferred) along with a thorough pars
accuracy, the following adjustment to the calculated IOL plana vitrectomy. However, reports in the literature have found that
there are no-long term differences in the visual outcomes and complica-
tions when comparing ACIOL and secondary scleral-fixated IOL eyes.
See Chan TC, Lam JK, Jhanji V, Li EY. Comparison of outcomes of
Reverse optic capture has been advocated by some surgeons as a tech-
2
primary anterior chamber versus secondary scleral-fixated intraocular
nique to alleviate pseudophakic dysphotopsia, either as a primary tech- lens implantation in complicated cataract surgeries. Am J Ophthalmol.
nique or postoperative adjustment of an already-placed IOL. 2015 Feb;159(2):221–6.e2.
Intraoperative Optics for Cataract Surgery 417
is appropriately sized. The biggest reason for problems Purkinje Images and IOLs
with ACIOLs is not due to the proximity of the ACIOL to
the cornea but due to the ACIOL movement (pseudo- You may wish to review the previously introduced concept
phacodonesis) that causes chronic, low-grade mechanical of Purkinje images and their application in keratometry in
irritation of the iris and anterior chamber angle structures. Chap. 17, “Optical Instruments and Machines”.
This leads to glaucoma, recurrent hyphema, and corneal As we have shifted into the era of aspheric IOLs, even a
edema (bullous keratopathy). As a rule of thumb, we must 0.4 mm decentration of a monofocal aspheric IOL may
size the ACIOL 1.0 mm larger than the measured WTW. decrease visual performance.6 When using diffractive
• When placing an ACIOL, we must ensure that the ACIOL ATIOLs (MFIOLs, EDOF-IOLs, and TF-IOLs), the centra-
is correctly oriented with the haptic resting in the scleral tion of the IOL becomes even more critical. A decentered
spur, away from any iris defects/iridectomy, and away ATIOL may lead to higher rates of glare, halos, and decreased
from any vitreous. The wound size will need to be subjective visual acuity postoperatively. Intraoperatively,
enlarged (approximately 6 mm) and closed accordingly centration relying on the pupil alone may be challenging as
with sutures. studies have shown that the pupil may shift ≥0.5 mm after
• Some surgeons will recommend placing an intraoperative dilation.7
peripheral iridectomy to reduce the risk of pupillary Only the P1, P3 and P4 Purkinje images are seen during
block. surgery (remember that P2 is “hidden” within P1 and does
• In the United States, there are two main ACIOL model not relevance to our discussion).8 We can begin with how
types available, both made of PMMA and with equally these images appear on the slit-lamp exam in the clinic as a
comparable long-term visual outcomes4: starting frame of reference (Fig. 2, Panel a). Notice that we
–– The Kelman Multiflex III (MTAXUO models; Alcon primarily see “two” Purkinje images easily (P1 and P4, blue
Laboratories, Inc., Fort Worth, TX, USA) features a arrow and red arrow, respectively). Notice the “inversion” of
5.5 mm optic and is available in 12.0–14.5 mm lengths. the P4 image. During surgery (Fig. 2, Panel b), three Purkinje
This ACIOL is a convex-plano design.5 images are present. Starting from anterior to posterior, we
–– The S122UV/L122 UV (Bausch and Lomb, Tampa, will (ironically enough) first see P4 (inverted pyramid-
FL, USA) types (12.5/13.5 mm lengths) feature a shaped red dots) form on the cornea, even though this reflex
6.0 mm optic and a biconvex design. originates from the posterior surface of the lens (or IOL)
• When adjusting the power of the ACIOL, the following (more on this in the next section). Next, we will see P1
calculation is used: (upright pyramid-shaped blue dots),9 which originates from
Power of planned PCIOL – (PCIOL A-constant – ACIOL the anterior cornea. Finally, we will see P3 (upright pyramid-
A-constant). shaped green dots), which originates from the anterior sur-
–– For example, if we had planned to place a + 23.0D face of the lens (or IOL).
PCIOL with A-constant 119.0 and our ACIOL (e.g., Additional intraoperative features of each image are
L122UV) has A-constant 116.0: described below. You may wish to refer to Fig. 3, which rep-
Power of ACIOL = 23 – (119–116) = +20.0D. resents a graphical illustration in the cross-section of each of
–– During surgery, if we panic and forget the above calcu- these Purkinje images. Specifically, note each image’s struc-
lation, we can simply decrease the ACIOL power by
2.5–3.0D as compared to the planned PCIOL.
–– You may wish to have the ACIOL power calculated in
advance of the surgery day using your biometry device,
especially for trainee surgeons or if planning high-risk Wang L, Koch DD. Effect of decentration of wavefront-corrected
6
cataract surgery. intraocular lenses on the higher-order aberrations of the eye. Arch
Ophthalmol. 2005;123(9):1226–1230.
Yang Y, Thompson K, Burns SA. Pupil location under mesopic, phot-
7
opic, and pharmacologically dilated conditions. Invest Ophthalmol Vis

Sci. 2002; 43:2508–2512.
One weird thing about the Purkinje images is that the numbering sys-
8
4
Suelves AM, Siddique SS, Schurko B, et al. Anterior chamber intra- tem has no relationship with where the image is actually located. For
ocular lens implantation in patients with a history of chronic uveitis: example, one would think P1 is located most anteriorly and P4 is
five-year follow-up. J Cataract Refract Surg. 2014;40(1):77–81. located most posteriorly. In reality, even though the source of P4 is the
5
See Chap. 27, “What Is on the Menu: An Overview of Currently posterior lens/IOL, it is located on the corneal surface
Available IOLs and Relevant Optics” for more information regarding Note that P2 is “contained” within P1, thus making P1 the brightest
9
IOL optic shape and architecture. intraoperative Purkinje image.

418 K. M. Riaz
a b
Fig. 2 During routine slit lamp exam (Panel a), two Purkinje images b), three distinct Purkinje images are seen and depicted in cross-section.
(P1 and P4, blue arrow and red arrow, respectively) are easily recogniz- From anterior to posterior, these are P4, P1, and P3. See the text for
able. Note the inverted light reflex caused by P4. Intraoperatively (Panel additional details regarding the origin and location of each image
tural origin and location as this is somewhat counterintuitive, • In cases where the patient does not fixate on the micro-
especially for P4!10 scope light, P1 may not be helpful. If this occurs, P3 and
P4 can also be used to determine fixation. Ideally, P3/P4
• P1 is formed by the anterior corneal surface and is can be used to “capture” P1 into a superbright, solitary
located on the anterior aspect of the crystalline lens (or image (Fig. 6, Left Panel). P3 can also be placed at the
IOL). It is the smallest yet brightest image seen on the nasal edge of the IOL and P4 at the temporal mid-
anterior lens/IOL (even though the source is the anterior periphery of the IOL to generate P1 and approximate the
cornea). During cataract surgery, it has an upright orienta- patient’s fixation (Fig. 6, Right Panel).
tion (see Fig. 4, blue dots) of three dots forming an upright
pyramid shape (i.e., two dots at the bottom, one dot at the Figure 7 provides a summary diagram that shows the
top). The main illumination light forms the larger top dot cross-section location of the three most important Purkinje
while the bottom two dots are coaxial to the surgeon’s images (without inclusion of their structural origin).
oculars. It is particularly appreciable in an aphakic eye A few additional, advanced optical principles may be fur-
(Fig. 5). When centering a diffractive ATIOL, P1 is the ther discussed in regards to the surgical Purkinje images as
most critical image because of the characteristics men- the IOL index of refraction and power changes:
tioned above and serves as a proxy for the visual axis. In
addition, it moves minimally with patient eye movement. • When considering IOLs with a high index of refraction
• P3 is formed by the anterior surface of the crystalline (e.g., acrylic IOLs), a more intense P3 and P4 image may
lens/IOL and is located in the vitreous. It is the largest be seen compared to IOLs with lower indices of refraction
image, has an upright pyramid shape, and can vary in (e.g., silicone IOLs). The AcrySof IQ IOL (Alcon
brightness (Fig. 4, green dots). Laboratories, Inc., Fort Worth, TX, USA) has an index of
• P4 is formed by the posterior surface of the crystalline refraction of 1.55; the intensity of the P3 image seen with
lens/IOL and, oddly enough, is actually located on the this IOL helps to explain the “cat’s eye glimmer” that is
corneal surface. It has a medium size but has an inverted seen by observers.
pyramid shape orientation (Fig. 4, red dots) (i.e., two dots • Recall that as IOL power increases, the anterior surface of
at the top, one dot at the bottom; the bottom dot is hidden the IOL will become more convex as well. As a result, as
with the brighter dot of P3). It is located very close to P1 IOL power increases, the P3 usually becomes smaller
and may be hidden in certain fixation positions. while the P4 size remains the same (for example, while
the anterior portion of a biconvex IOL increases in power
when going from a + 21.0D to a + 31.0D IOL, the poste-
rior power of the biconvex IOL is minimally changed).
In order to maintain consistency, we have attempted to “color-code”
10
• Similarly, as the IOL power decreases, the P3 becomes
the images in both the figure diagrams as well as the intraoperative
images: P1 = blue, P3 = green, and P4 = red larger; the P4 also becomes larger depending on the IOL
P1 P2
P3 P4
Fig. 3 Cross-section diagram representing the structural origin and within the P1 image. P3 (green) originates from the anterior lens cap-
image location for the four Purkinje images. P1 (blue) originates from sule and forms the “deepest” image behind the lens. P4 (red) originates
the anterior corneal surface and forms on the anterior aspect of the lens from the posterior lens capsule and forms on the anterior corneal sur-
(or IOL). P2 (yellow) originates from the posterior corneal surface, and face. It is the only image to have an inverted image orientation
while it also forms on the anterior aspect of the lens, its image is hidden
brand (Fig. 8). As the IOL power decreases to ≤10.0D, • A fun surgical “parlor” game is to predict the power of the
the P3 may actually invert and appear like an inverse pyr- IOL by looking at the size and orientation of the P3 and
amid shape, similar to P4 (Fig. 9). P4 IOL, similar to guessing the power of a patient’s eye-
• The IOL shape becomes a meniscus in the minus IOL glasses by looking at the amount of indentation (or distor-
power range (rather than a biconvex shape). As a result, the tion) of the patient’s temporal face/cheek through the
P4 will also invert (i.e., become upright) in minus power edge of the spectacle lens. Optics nerds are the epitome of
ranges while the P3 remains like an inverted pyramid. nerds.
420 K. M. Riaz
Fig. 4 Intraoperative view of Purkinje images during cataract surgery (red circles) is seen as an inverted pyramid located close to P1. Note
using a diffractive ATIOL. P1 (blue circle) is seen as an upright pyra- that the lowermost dot of P4 is hidden by the bottom-right dot of P3. In
mid; P3 (green circles) is also an upright pyramid but much larger; P4 this image, the P1 is used to center an EDOF-IOL effectively
IOLs, P4 will be located relatively close to P1. With low

cylinder power toric IOLs, P4 will be slightly further
apart from the P1 image (Fig. 9). P4 will be extremely far
from the P1 image as the cylinder power increases.
• Diffractive MFIOLs may have unique P3 and P4 image
quality patterns. Recall that non-apodized MFIOLs (e.g.,
Tecnis multifocal IOL; Johnson and Johnson Vision,
Tampa, FL, USA) have diffractive rings on the posterior
surface of the MFIOL; as a result, the P4 image may have
a “banded (ringed)” pattern. Apodized MFIOLs (e.g.,
ReStor; Alcon Laboratories, Fort Worth, TX, USA) have
diffractive rings on the anterior surface of the MFIOL; as a
result, the P3 image may have a “banded” pattern (Fig. 10).
Intraoperative Aberrometry
Fig. 5 P1 (blue arrow) is easily observed in the aphakic eye. P4 may Please refer to Chap. 14, “Physical Optics”, for basic prin-
also be seen as a dim light behind P1 ciples regarding the usage of wavefront analysis and aber-
rometry in ophthalmology.
Finally, here are a few more fun facts regarding Purkinje Intraoperative aberrometry (IOA) refers to the intraopera-
images in toric and diffractive MFIOLs: tive use of wavefront aberrometry to measure the refractive
state of the aphakic and pseudophakic eye. Surgeons can use
• For toric IOLs, recall that the cylindrical power is mainly this tool to refine the preoperatively calculated IOL power
in the posterior aspect of the toric IOL.11 In non-toric further. Currently, a “whole-eye” assessment of the eye’s
refractive power can be done for a range of -5D to +20D in
the aphakic state. Measurements are performed in under a
See Chap. 27, “What Is on the Menu: An Overview of Currently
11
Available IOLs and Relevant Optics” for more information regarding

minute. Corneal data is limited to the central 4 mm, and the
toric IOLs. results are extrapolated to calculate an IOL power.
Temporal Incision
Fig. 6 Left Panel: P3 and P4 can be superimposed upon P1 to create an at the nasal edge of the IOL and P4 (green arrow) at the temporal mid-
extremely bright reflex that can further help centration, especially when periphery to further approximate the patient’s fixation (P1, blue arrow)
placing a diffractive ATIOL. Right Panel: P3 (red arrow) can be placed
Fig. 7 Cross-section diagram of the eye showing the intraocular loca-

Fig. 8 As the IOL power decreases, the P3 (green arrow) becomes
tions of the three most important Purkinje images; P1 is blue, P3 is
much larger than P1 (blue arrow). P4 also slightly increases in size while
green, and P4 is red
remaining relatively close to P1. The top two spots (red arrows) of P4
can also be seen in this image
This technology may be beneficial in cases wherein pre-

operative IOL calculations are potentially inaccurate, such as including optimal measurements, treatment of ocular surface
in post-refractive surgery and patients with a wide range of disease, and other good surgical measures. Just because
preoperative corneal astigmatism. Note that IOA should not the technology exists does not mean that surgeons should
replace meticulous and thoughtful preoperative planning, switch off their brains and let the technology do the work—
422 K. M. Riaz
this is how Skynet may one day come to power and wage war
on the human race.12
IOA is primarily performed after cataract removal and
prior to placement of the IOL. The technology is dependent
on patient fixation to obtain a line-of-sight aphakic refrac-
tion, in addition to physiological IOP and a clear ocular sur-
face. Thus far (June 2021), there have been no definitive
reports in the literature proving the superiority of IOA in rou-
tine cataract surgery or post-refractive surgery when com-
pared to modern preoperative biometry, use of multivariable
formulas, and meticulous surgical technique.
IOA may also be performed after placing a toric IOL to
confirm the correct axis meridian location. The aphakic read-
ing will give a potential meridian of placement, whereas
post-IOL placement IOA can confirm alignment, including
real-time information to the surgeon for the need to rotate the
toric IOL intraoperatively. The implementation of good pre-
operative measurements, surgical planning, and usage of
Fig. 9 In a low-power IOL, the appearance of P3 may invert (green
arrows) and look similar to P4 (red arrows). In this intraoperative pic-
multivariable formulas for toric IOLs have been reported to
ture of a + 6.0D (Toric) IOL placement, notice P1 (blue arrow) main- be as good or better than results obtained with IOA.13
tains its upright pyramid shape. P3 and P4 are nearly superimposed in IOA is an evolving technology. In addition to the limita-
an inverse pyramid shape; the P3 light spots are larger than the P4 light tions mentioned above, other factors such as globe changes
spots. The yellow arrow indicates a light spot wherein P3 and P4 are
overlapped, and it is difficult to distinguish the two. Author’s note:
secondary to tight speculum placement; accuracy of “supine”
apologies for the air bubbles that may make it challenging to appreciate refraction with likely cyclotorsion (as compared to seated
P1 clearly refractions which are customary clinical practice); subopti-
mal ocular surface (post-dilation drops, viscoelastic, corneal
edema from phacoemulsification, etc.) and other limiting
factors must also be further studied. Finally, IOA does not
incorporate multivariable formulas at this time.
I ntraoperative Considerations for Toric IOLs

and ATIOLs
Several intraoperative considerations for toric IOLs and

ATIOLs include:
• It is essential to place the toric IOL on the intended merid-

ian (or as close to humanly possible) due to decreased
astigmatism correction due to wrong-meridian placement.
It has become a commonly accepted teaching that
1-degree misalignment of a toric IOL leads to a 3.3%
reduction in cylinder correction effect.14 However, recent
Shame on you if you did not get the Terminator 2: Judgment Day
12
(1992) reference.
Solomon KD, Sandoval HP, Potvin R. Evaluating the relative value of
13
intraoperative aberrometry versus current formulas for toric IOL

Fig. 10 Toric IOLs have cylindrical power on the posterior surface of sphere, cylinder, and orientation planning. J Cataract Refract Surg.
the IOL. A low-power toric will have a P4 image (red arrow) relatively 2019;45(10):1430–1435.
close to the P1 image (blue arrow). In this apodized toric diffractive The source of this claim, which has in turn been repeated by many
14
MFIOL, the rings are located on the anterior surface of the optic. As a authorities, is this paper from 1994(!): Shimizu K, Misawa A, Suzuki
result, the P3 image may appear as a “banded (ringed)” pattern (green Y. Toric intraocular lenses: correcting astigmatism while controlling
arrow) instead of the usual pyramidal shape axis shift. J Cataract Refract Surg 1994; 20: 523–26. In this paper, the
findings suggest that the amount of toric IOL rotation and Practice Questions
effect on visual acuity is nonlinear.15 For example, a rota-
tion ≤10 degrees is far more tolerable than a rotation ≥10 1. During cataract surgery, posterior capsule rupture occurs
degrees. The most significant “devastation” happens so that the intended single-piece +20.0D IOL cannot be
between 10 and 20 degrees; if there is a ≥ 45-degree rota- placed in the bag. Assuming the A-constant of the 3-piece
tion, the toric IOL essentially has no correction. In other IOL is similar to the planned IOL, which of the following
words, instead of 30 degrees, it seems that only a IOL powers is the best choice for sulcus placement?
≥ 45-degree rotation leads to the total effect-loss of cylin- A. +19.0D
drical correction.16 B. +19.5D
• Toric IOLs usually have a marking (three dots or a line) to C. +20.0D
indicate the meridian of the corrective cylinder to help D. +20.5D
alignment with the intended marked corneal location. E. +21.0D
• There is an increased risk of toric IOL rotation in patients 2. During cataract surgery, the surgeon experiences a severe
with large capsular bags (e.g., high myopes). Placing a case of indigestion in the middle of lens removal. The
capsule tension ring/segment may help stabilize the IOL- entire bag-zonule complex is lost and a thorough vitrec-
capsular bag complex and reduce the risk of future tomy is performed. A + 17.0D single-piece IOL
rotation. (A-constant: 119.0) was planned for the capsular bag.
• There is no sulcus-toric IOL available in the United States Which of the following anterior chamber IOL powers
at the time of this writing. should be placed, assuming the ACIOL A-constant is
• The ideal placement of an IOL is centration on the visual 115.5?
axis and pupillary axis, which is not possible unless angle A. 15.0D
kappa (chord) is zero. However, every eye has some B. 14.5D
amount of chord. While we discussed the usefulness of C. 14.0D
centering an IOL on the P1 image previously, recent D. 13.5D
reports suggest that the optimal centration of a diffractive E. 13.0D
ATIOL is to place it at the midpoint of the pupillary center 3. Which of the following statements is TRUE?
(pupillary axis) and visual axis (P1).17 In other words, A. P1 is the brightest and largest of the four Purkinje
after centering the ATIOL upon P1, surgeons may con- images
sider nudging the haptics so that they are closer together B. P2 is best seen in an aphakic state
nasally; simply pushing the optic nasally is inadequate. C. The size of P3 increases as the IOL power decreases
• Several additional surgical steps are essential for surgical D. P4 will always have an inverted pyramid shape
success with accommodating IOLs: careful polishing of 4 . Which of the following statements regarding Purkinje
anterior capsule and removal of lens epithelial cells; posi- images in toric and diffractive optics ATIOLs is
tioning the IOL with posterior vault intraoperatively TRUE?
(anterior vault may cause unintended myopic surprise); A. For high cylinder power toric IOLs, P4 will be
meticulous wound closure; and appropriately sized extremely close to P1, and the brightness of P1 may
capsulorrhexis. obscure P4
B. For all toric IOLs, the Purkinje images appear similar
to Purkinje images of a non-toric model of that same
IOL platform
authors only studied 47 patients, used 5.7 mm incisions (with sutures), C. In non-apodized diffractive MFIOLs, P3 may appear
only corrected ATR astigmatism, and used an early model 3-piece toric
IOL. to have a banded (ridged) pattern
Tognetto D, Perrotta AA, Bauci F, et al. Quality of images with toric
15 D. In apodized diffractive MFIOLs, P3 may appear to
intraocular lenses. J Cataract Refract Surg2018; 44: 376–81. have a banded pattern
Németh G. One degree of misalignment does not lead to a 3.3% effect
16
decrease after implantation of a toric intraocular lens. J Cataract

Refract Surg. 2020;46(3):482
“Multifocal IOLs: Patient selection and optical performance”. https://
17
www.healio.com/news/ophthalmology/20170125/multifocal-iols-
patient-selection-and-optical-performance. Accessed June 29, 2020
424 K. M. Riaz
Answers the 4 Purkinje images, it is not the largest—P3 is the

largest Purkinje image. P2 is rarely, if ever seen, as it is
1. ANSWER: A. For IOL powers between 17 and 26D, the usually hidden in the brightness of P1. While P4 usually
3-piece IOL power for sulcus placement should be has an inverted pyramid shape, it can appear as an
decreased by 1.0D. If this IOL is placed via the optic- upright pyramid shape when using minus-powered
capture method, the planned +20.0D IOL can be safely IOLs.
placed. 4. ANSWER: D. In non-toric IOLs, P4 will be located rela-
2. ANSWER: D. The formula for calculating the power of tively close to P1. With low cylinder power toric IOLs, P4
the needed ACIOL is as follows: ACIOL power = power will be slightly further apart from the P1 image (Fig. 9).
of planned PCIOL – (PCIOL A-constant – ACIOL A P4 will be extremely far from the P1 image as the cylinder
constant) = 17.0 – (119.0–115.5) = 13.5D power increases. The Purkinje images of a toric IOL will
3. ANSWER: C. The size of P3 increases as the IOL differ from non-toric IOLs based on the amount of cylin-
power decreases; conversely, the size of P3 will decrease der power present. In non-apodized diffractive MFIOLs,
as the IOL power increases. While P1 is the brightest of the P4 image may have a banded (ridged) pattern.
Postoperative Optics for Cataract
Surgery
Kamran M. Riaz
Objectives Postoperative Myopic Surprise

• To understand potential optics-relevant problems after
cataract surgery, including myopic surprise, hyperopic If we had to select between two options, postoperative
surprise, and issues related to astigmatism. hyperopia or postoperative myopia, one might argue that the
• To identify reasons contributing to patients’ subjective latter is not necessarily a bad thing. A patient might be
complaints after cataract surgery, including issues related quite happy with −1.00D postsurgical refractive error as they
to dysphotopsias. may be able to read, use their cellphone, and read from their
• To appreciate various non-surgical and surgical options tablet device with minimal need for glasses.1
for correcting problems after cataract surgery. Nonetheless, we should understand common reasons for
unexpected myopic errors after cataract surgery. Some of
these reasons, such as short axial length (AXL) and using
Introduction post-dilation biometry measurements with multivariable for-
mulas, were previously discussed in Chap. 1, Preoperative
Imagine the following scenario: you have just completed Optics for Cataract Surgery.
second-eye cataract surgery on Mr. C.M. Burns and are
examining him at his one-week post-op visit. In all of your
previous interactions, he has been an extremely grouchy cur- Commonly Encountered Scenarios
mudgeon, criticizing you, your staff, and his meek assistant
as being “incompetent peasants.” Today, however, he is Among the various reasons for an unexpected myopic sur-
delighted: he can see 20/20 at all distances and even has a prise after cataract surgery, some of the most commonly
smile on his face. He tells you that you have done an “excel- encountered (and important for exams) reasons include the
lent” job with his cataract surgery. He tells you that he is so following:
happy with your work that he henceforth names you the sole • Error in IOL power placed (too strong of an IOL power
inheritor of his multibillion-dollar fortune. You exit the room placed): For example, if a + 24.0D of a given IOL model
similarly happy, wondering what tropical island you should was inadvertently placed instead of a + 22.0D IOL)
purchase and how soon you can retire from ophthalmology. • Backward placement of 3-piece IOL IOL: Recall from
Despite our best efforts, not every patient ends up this Chap. 26, Preoperative Optics for Cataract Surgery, that
happy in real life. This chapter deals with troubleshooting most 3-piece IOLs have a biconvex design with slant hap-
and managing various optics-related postoperative issues tics insertion, meaning that there is slightly more power
that may arise after cataract surgery. on the posterior aspect of the optic as compared to the
The least amount of summated blur that exists through the range of
1
object distance 0.5–6 m is approximately −1.00 + 0.75 (SE: −0.63)

with WTR astigmatism, followed by −0.75 + 0.50 (SE: −0.50). In other
words, having some myopic sphere and cylinder power is potentially a
good thing! See: Sawusch MR, Guyton DL. Optimal astigmatism to
K. M. Riaz (*) enhance the depth of focus after cataract surgery. Ophthalmology.
Dean McGee Eye Institute, University of Oklahoma, 1991;98(7):1025–1029.

426 K. M. Riaz
anterior aspect. If such an IOL was inadvertently placed to be within ±0.5D; >30D are supposed to be within
backward in the capsular bag, then the effective power of ±1.0D. The latter helps to provide an additional explana-
the IOL will increase, causing a myopic surprise. Single- tion for why IOL calculation in short AXL eyes is chal-
piece IOLs wherein the haptics and optic are in the same lenging: Even if you put in a + 33.0D IOL, for example,
plane should have minimal change if the IOL is acciden- there is a chance it may actually behave like a + 32.5D
tally placed upside down. or + 33.5D IOL!
• Error in biometry measurements and/or A-constant:
Recall from our discussions with the SRK formula, a
myopic surprise may occur in any of the three following Capsular Block Syndrome (CBS)
errors: (1) use of a (falsely) higher A-constant; (2) use of
flatter-than-actual keratometry (K) measurements; and Though a favorite for exam scenarios, this complication is
(3) use of shorter-than-actual axial length (AXL) mea- thankfully a rare complication in modern practice. Capsular
surements. In all three scenarios, a higher-than-required Block Syndrome (CBS), also known as Capsular Bag
IOL power may be falsely calculated. Distension Syndrome, is thought to occur in the setting of
• (Inadvertent) sulcus placement of IOL: If a given power uncomplicated cataract surgery with a relatively small
IOL was meant to be placed in the capsular bag but ends (<4 mm) capsulorrhexis combined with incomplete removal
up in the sulcus, the effective lens position (ELP) will be of viscoelastic, especially behind the IOL (Fig. 1). Clinical
more anterior-than-expected, thus causing a myopic shift. examination characteristically shows a small rhexis such that
Depending on the IOL that was implanted, surgical inter- the edge(s) may be visible even in the undilated state. Using
vention may be necessary. If a single-piece IOL intended a thin slit technique, one may be able to appreciate a “milky”
for in-the-bag placement ends up in the sulcus, then surgi- fluid behind IOL, along with a notable gap between the pos-
cal intervention to either reposition the IOL in the bag (if terior optic border and the posterior capsule. The IOL may
safe) or remove the single-piece for a 3-piece IOL should appear extremely bright with white-yellowish material
be undertaken promptly. Recall that if a single-piece IOL behind the IOL causing distension of the capsular bag
is in the sulcus, the thick haptic edges may cause mechan- (Fig. 2). Anterior segment imaging (such as AS-OCT) may
ical iris chafing, leading to chronic inflammation or a be additionally helpful to visualize the turbid fluid-IOL com-
uveitis-glaucoma-hyphema (UGH) syndrome. Nearly all plex in cross-section view (Fig. 3).
authorities maintain that a single-piece IOL should not be
left in the sulcus. If a 3-piece IOL that was intended for
in-the-bag placement ends up in the sulcus, it may be
managed with nonsurgical options.
• Anterior dislocation of IOL: This may occur in cases of
postoperative hypotony, large rhexis, and anterior capsule
compromise, to name a few common scenarios. Similar to
the previous example, the ELP will be more anterior-
than- expected, similarly causing a myopic shift.
Management options are essentially the same as the pre-
vious example. Of note, assuming the same distance of
displacement, anterior IOL displacement will require a
greater magnitude of (minus) sphere correction as com-
pared to the (plus) sphere correction required for posterior
IOL displacement.2
• IOL labeling error: Recall from the previous discussions
in Chap. 26, Preoperative Optics for Cataract Surgery,
some “acceptable” inaccuracy is allowed by the American
National Standards Institute (ANSI). IOL powers <25D
are supposed to be within ±0.4D; 25−30D are supposed
For example, when comparing a 2 mm IOL anterior vs. posterior dis-
2
placement, the former may require up to −5D sphere to correct, whereas Fig. 1 Capsular block syndrome (CBS) may occur in the presence of a
the latter may only require +0.5D sphere correction. See: small, intact capsulorrhexis (<4 m) and retained viscoelastic material
Lakshminarayanan V, Enoch JM, Raasch T, Crawford B, Nygaard behind the IOL. This creates an osmotic gradient drawing fluid into the
RW. Refractive changes induced by intraocular lens tilt and longitudi- space between the IOL and the posterior capsule, eventually causing a
nal displacement. Arch Ophthalmol. 1986 Jan;104(1):90–2 forward shift of the IOL and myopic refractive error
Postoperative Optics for Cataract Surgery 427
see if a spontaneous resolution occurs. Of course, this

assumes the IOP and inflammation are acceptable, and
daily examination (and parking validation for their visits to
your fancy downtown office) of these patients may be
required.
If CBS is seen after 7 days, further interventions may be
necessary. If there is excess inflammation and increased
IOP, then topical steroids/NSAIDs and hypotensive medica-
tions, respectively, may be utilized. Otherwise, YAG capsu-
lotomy or surgical disruption of the posterior capsule can be
both diagnostic and therapeutic. A posterior capsule open-
ing will allow the retained fluid to fall back into the vitreous
and (hopefully) shift the IOL back into its intended
position.
Treatment Options
Depending on the etiology of myopic surprise, various

treatment options may be considered. Conservative options
Fig. 2 CBS may cause the IOL to appear extremely bright on examina-
tion. Whitish-turbid material can be seen behind the IOL causing fluid
such as glasses and contact lenses (including monovision
to accumulate between the IOL and the posterior capsule. Image Credit: and/or multifocal options) may be considered for cases that
William Trattler, MD, Miami, FL are not surgical emergencies. Surgical interventions include
IOL exchange (with the new IOL placed in the capsular
bag, if possible, or in the sulcus, with appropriate power
modification) and excimer laser refractive surgery (LASIK/
PRK).
Another approach that may be considered is the place-
ment of a secondary IOL (“piggyback” IOL) on top of the
already existing IOL. This latter approach involves placing
a minus-powered 3-piece IOL in the sulcus, assuming that
the in-the-bag IOL is left in place or too dangerous to
remove (e.g., capsular compromise and post-YAG capsu-
lotomy). For example, if a single-piece acrylic (SPA) IOL
is placed in the bag, a 3-piece non-acrylic IOL (such as sili-
cone or collamer IOL) is preferred for the sulcus to treat the
residual refractive error. While there are several nomo-
Fig. 3 Anterior segment imaging (AS-OCT or UBM) may be extremely grams available to calculate the power of the piggyback IOL
helpful to visualize the anterior shift of the IOL caused by milky/turbid
fluid behind the IOL causing the posterior capsule distension a simple rule of thumb is that a 1:1 ratio of IOL power:
refractive error can be used to correct a myopic refractive
error. For example, if a patient has an unintended −2.00D
The small capsulorhexis and retained viscoelastic combi- sphere after cataract surgery with a SPA IOL placed in-the-
nation create an osmotic gradient drawing fluid into the bag but post-YAG capsulotomy, then one acceptable
space posterior to the IOL optic and anterior to the posterior approach may be to place a − 2.0D 3-piece IOL in the sul-
capsule. The fluid gradient causes a circumferential adher- cus to treat the refractive error.
ence between the anterior capsule opening and the anterior In the previous paragraph, we stated that a non-acrylic
optic of the IOL. As the capsular bag behind the IOL dis- 3-piece IOL is preferred. A 3-piece acrylic IOL can be cau-
tends, the IOL is pushed forward, causing a myopic shift. In tiously placed in the sulcus as well, though there is a small
addition, there may be increased IOP and low-grade risk for intralenticular opacification (ILO). While ILO has
inflammation. been previously reported for acrylic-on-acrylic IOLs placed
If CBS is seen in the early-postoperative phases in the capsular bag, it has not been reported for 3-piece
(1–4 days), it may be acceptable to cautiously observe to acrylic placed in the sulcus with a SPA acrylic IOL in the
428 K. M. Riaz
bag.3 ILO may cause a visually significant loss of vision In addition to embarking upon the walk of shame, we
(similar to corneal scarring) that cannot be treated with addi- should also understand common reasons for unexpected
tional YAG capsulotomy. Surgical removal of both IOLs may hyperopic error after cataract surgery. Some of these reasons,
be required for cases of visually significant ILO.4 such as long axial length and post-refractive surgery, were
While the above discussion about using piggyback IOLs previously discussed in Chap. 26, Preoperative Optics for
to treat postoperative myopic refractive errors sounds lovely, Cataract Surgery.
in the United States, surgeons have limited options when
considering this technique. At this time, there are no minus-
powered silicone or collamer IOLs available in the United Commonly Encountered Scenarios
States; only minus-powered acrylic IOLs are currently
available.5 Among various reasons for an unexpected hyperopic sur-
Finally, for the sake of completion, a collamer phakic IOL prise after cataract surgery, some of the most commonly
(Visian ICL; Staar Surgical, Monrovia, CA, USA) may tech- encountered (and important for exams) reasons include the
nically be used in this setting as a piggyback IOL (range following:
−3.00 to −20.0 D); however, the cost for this IOL may be • Error in IOL power (too weak of an IOL power placed):
prohibitive for most patients. In addition, this is an off-label For example, if a + 20.0D IOL was inadvertently placed
use of this IOL. instead of a + 22.0D IOL.
• Error in biometry measurements and/or A-constant:
Recall from our discussions with the SRK formula, a
Postoperative Hyperopic Surprise hyperopic surprise may occur in any of the three follow-
ing errors: (1) use of a (falsely) lower A-constant; (2) use
In contrast to our previous discussions on postoperative of steeper-than-actual keratometry (K) measurements (as
myopic surprise, overall, a postoperative hyperopic surprise in post-myopic refractive surgery); and (3) use of longer-
is far less tolerated by patients, especially for myopic patients than-actual axial length (AXL) measurements (as in long
prior to cataract surgery. Remember that while postoperative AXL eyes and eyes with silicone oil). A lower-than-
myopia may help with some near-intermediate vision tasks, required IOL power may be falsely calculated in all these
postoperative hyperopia is good for absolutely nothing other scenarios causing the unwanted hyperopic surprise.
than an angry patient who may decide to “release the hounds” • Backward placement of a SPA IOL: This only applies to
on you. SPA IOL models with offset haptic-optic designs, as dis-
cussed in Chap. 26, Preoperative Optics for Cataract
Surgery.
There is considerable debate on this point. Some surgeons argue that
3
• Corneal ectasia: The measured K values may be extremely
ILO has been reported only in the context of acrylic-on-acrylic IOLs high (often >50D) for patients with stable corneal ectasia
both placed in the capsular bag, and the risk of ILO with a three-piece
acrylic IOL in the sulcus and a single-piece acrylic IOL in the capsular not requiring corneal transplant surgery. Most IOL for-
bag is extremely low. For hyperopic surprises, this author advises using mulas, especially third-generation formulas, do not
three-piece silicone IOLs as piggyback IOL options and avoiding account for the nonlinearity of higher K measurements in
acrylic IOLs as much as possible. For myopic surprises, a three-piece the formulas.6 As a result, the high K values may lead to a
acrylic IOL may be placed as a piggyback option after thorough discus-
sion with the patient. However, laser refractive surgery (PRK or LASIK) lower-than-required IOL power and increase the risk of
might be a better option in these cases to avoid additional intraocular hyperopic surprise.
surgery. Financially, piggyback IOL for myopic surprise would likely • Outlier biometry measurements such as increased lens
incur out-of-pocket costs for the patient anyway, so they might as well thickness (LT) (>5 mm) and decreased anterior chamber
pay for a more predictable and safer refractive procedure.
depth (ACD) (<3 mm) when using multivariable formulas.
4
In this case, if both IOLs are removed with preservation of the capsular
bag, then a “correctly-powered” IOL can be placed, either a one-piece Recall that multivariable formulas incorporate ACD and
or three-piece IOL. The latter can be placed in the bag or sulcus (includ- LT measurements when calculating the IOL. When these
ing optic capture). More often than not, these cases will involve signifi- values are abnormal, the calculated ELP may be signifi-
cant scarring of the IOLs to the capsular bag, and therefore amputation
cantly different from the actual postoperative ELP. While
of the embedded haptics or removal of the entire bag-IOL complex may
be necessary. This may require additional vitreous management and a complete discussion of this math is beyond the scope of
subsequent placement of an iris- or scleral-fixated IOL
The last available minus-powered silicone IOL in the United States
5
was the AQ5010V (Staar Surgical, Monrovia, CA USA), and it was More recently, the online Barrett true K and online Kane formulas
6
discontinued in August 2016. At present, the two most commonly avail- have a “keratoconus” option that makes internal adjustments for high K
able minus-powered acrylic IOLs are the MN60MA (Alcon values to minimize the risk of postoperative hyperopic surprise. Still
Laboratories, Fort Worth, TX USA) and AR40m models (Sensar; most surgeons will aim for additional myopia to adjust for a hyperopic
Johnson & Johnson Vision, Sarasota, FL USA) surprise.
the text, suffice it to say that this may increase the risk of • IOL tilt: A rotational tilt of the IOL, not perpendicular to
hyperopic surprise. In such scenarios, it may be helpful to the visual axis.
look at “older” generation formulas (such as Holladay I or Both IOL decentration and IOL tilt will negatively impact
SRK/T) side-by-side with newer formulas (such as Barrett) visual acuity postoperatively as they both will induce myo-
to see if there is agreement. Alternatively, one may choose pic sphere and astigmatism to the clinician’s refraction. IOL
to aim extra myopic (−0.75 or −1.00D) to compensate for tilt, defined as an increased angle between the IOL axis (i.e.,
the likely postoperative hyperopic surprise. the axis in which the optic is oriented) and the reference axis
(which can be either the optical axis or the visual axis), is
discussed in the next section. As a rule of thumb, approxi-
Treatment Options mately 1 mm IOL decentration is equivalent to 7° IOL tilt.
IOL decentration is defined as an increased distance in the
Depending on the etiology for hyperopic surprise, several lateral direction between the center of the IOL and the refer-
treatments may be considered. Conservative options, such as ence axis. Several risk factors, such as long axial length,
glasses and contact lenses (including monovision and/or mul- thicker lens, capsule fibrosis, an incomplete overlap of
tifocal options), may be considered for cases that are not surgi- the optic by the rhexis, and large/poorly constructed capsu-
cal emergencies. Surgical interventions include IOL exchange lorrhexis have been shown to increase the risk of IOL decen-
(with the new IOL placed in the capsular bag, if possible, or in tration. Aspheric IOLs are much more negatively affected by
the sulcus, with appropriate power modification) and excimer IOL decentration than spherical IOLs. Similarly, the efficacy
laser refractive surgery (LASIK/PRK). It should be noted that of toric IOLs is affected both by decentration and by tilt.
hyperopic excimer laser correction is significantly less effec- ATIOLs using diffractive optics are severely affected by even
tive than myopic excimer laser correction. For example, treat- minute amounts of IOL decentration. Patients who have paid
ing a −2.50D refractive error with laser refractive surgery is a small fortune for these IOLs will be extremely unhappy
much easier than a +2.50D refractive error. with IOL position errors. IOL decentration and tilt happen
In contrast to treating myopic errors, placing a secondary more frequently than we realize; thankfully, these shifts are
IOL (“piggyback” IOL) on top of the already existing IOL is minimal. Clinical studies have shown that 2–3° tilt and 0.2–
a much more viable option. Silicone and collamer IOLs, 0.3 mm decentration are common and clinically insignificant
such as the Li61AO (SofPort; Bausch and Lomb Inc., Tampa, for most IOL types.7 However, >1 mm decentration and ≥ 5°
FL USA) and CQ2015 (Staar Surgical, Tampa, FL USA), tilt may be visually significant.8
can be employed, especially when removing the original Lateral IOL decentration, in the absence of the other two
IOL may be challenging or risky. The Li61AO, in particular, IOL position errors, nearly always adds myopic astigmatism
is a useful option as it is available in a wide range of powers to the eye’s refractive error. IOL decentration negatively
(full range: 0 to +34.0D). impacts visual function more than IOL tilt, especially when
While several nomograms can be used accurately calcu- evaluating aspheric IOLs, toric IOLs, and diffractive optics
late the power of the IOL to correct the postoperative refrac- ATIOLs. In one study, the best-corrected visual acuity (BCVA)
tive error, a simple rule of thumb is that a 1.5:1 ratio of IOL decreased from approximately 20/15 with perfect centration to
power: hyperopia can be used for the piggyback IOL approximately 20/25 with 0.4mm decentration.9
power. For example, suppose a patient’s refractive error is Treatment of IOL decentration includes nonsurgical
+2.00D sphere after cataract surgery with a SPA placed in- options such as glasses and contact lenses. Surgical options,
the-bag (additionally, assume the enterprising referral sur- such as IOL repositioning, placement of capsule tension
geon has already performed a YAG capsulotomy!). In that ring, capsule tension segments, IOL exchange, and/or laser
case, one acceptable approach may be to place a +3.0D refractive surgery, can be considered if clinically necessary.
3-piece silicone IOL in the sulcus to treat the refractive error. If the IOL decentration happened because you made a lousy
capsulorrhexis, then an apology letter (along with a box of
candy) may be required.
IOL Decentration
Ale JB. Intraocular lens tilt and decentration: a concern for contempo-
7
There are three types of IOL position errors: rary IOL designs. Nepal J Ophthalmol. 2011 Jan-Jun;3(1):68–77.
• IOL displacement (or IOL shift): A longitudinal shift of Korynta J, Bok J, Cendelin J, Michalova K. Computer modeling of
8
the IOL either toward or away from the retina. This shift visual impairment caused by intraocular lens misalignment. J Cataract
is the most important IOL position error, and is also the Refract Surg. 1999 Jan;25(1):100–5.
simplest one to understand as it mainly causes a hyper- Madrid-Costa D, Pérez-Vives C, Ruiz-Alcocer J, Albarrán-Diego C,
9
opic or myopic shift, respectively. Montés-Micó R. Visual simulation through different intraocular lenses
in patients with previous myopic corneal ablation using adaptive optics:
• IOL decentration: A lateral shift of the IOL, perpendicu- effect of tilt and decentration. J Cataract Refract Surg. 2012
lar to the visual axis. May;38(5):774–86.
430 K. M. Riaz
Postoperative Astigmatism Issues tally oriented alphabet (e.g., Arabic, Russian, and Hindi)
may use ATR astigmatism advantageously for distance
Astigmatism issues arising after cataract surgery can be vision (in such patients, residual WTR astigmatism may help
divided into two broad categories: expected postoperative with near vision tasks).
astigmatism and unexpected postoperative astigmatism. The takeaway from this entire discussion is this: the
human eye is imperfectly perfect. Astigmatism is an “imper-
fection” that we attempt to treat and reduce whenever possi-
Expected Astigmatism ble, but it may not be necessary (or even beneficial) to fully
treat this “imperfection.” Some “imperfection” may actually
The first category is straightforward: A typical scenario lead to a subjectively happy patient. Do not be hasty to treat
would include a patient with moderate astigmatism (1.5-2D low amounts of pseudophakic astigmatism with additional
of keratometric astigmatism) measured before cataract sur- surgery (especially laser refractive surgery): you may end up
gery who opts for a monofocal IOL due to financial limita- causing more harm than good!
tions.10 Dealing with this situation is quite simple: prescribe
the patient glasses and/or contact lenses and move on with
life. Both the surgeon and the patient are usually quite happy Unexpected Astigmatism
with this situation because this possibility was discussed and
managed appropriately after surgery. The second category (unexpected postoperative astigma-
While we may be trained to think that astigmatism is tism) is more complex and requires a detailed discussion
“bad,” there are some optics-related merits of residual astig- with specific examples.
matism after cataract surgery, especially when comparing Three potentially common examples of this scenario
pseudophakic with-the-rule (WTR) and against-the-rule include the following:
(ATR) astigmatism types. We previously discussed some of
these concepts in the previous two chapters, but we can IOL Tilt
expand that discussion here. Continuing our previous discussions on IOL displacement
Residual pseudophakic WTR (greater plus power at the and IOL decentration, IOL tilt primarily causes induced
90-degree meridian) will bring in vertical stroke letters (such as astigmatism. Risk factors for IOL tilt include short AXL eyes,
b, d, h, k, p, t,) at a distance into better focus.11 WTR astigma- previous history of PPV, and exuberant capsule fibrosis.
tism also helps reading languages (such as English) that have As previously discussed in Chap. 11, Astigmatism, if a
less “space” in-between individual letters as compared to the + 20.0D monofocal IOL undergoes tilting around the
“space” between lines of text on a page (such as this engross- 180-degree axis (e.g., suppose that the superior part of the
ingly entertaining optics book you are reading right now). optic is now closer to the cornea, the inferior part of the optic
Furthermore, according to Javal’s Rule, WTR astigmatism is now closer to the retina), then the IOL may no longer func-
requires less cylinder correction in glasses than ATR. As mention as a + 20.0D IOL. The IOL will gain some plus sphere
tioned previously, the Sawusch and Guyton model suggests power and plus cylinder power in the 180-degree (axis)
that 0.50–0.75D WTR astigmatism allows for the least amount meridian.
of summated blur from 50 cm to 6 meters, which is where most This next part is slightly confusing, so it may take several
distance vision occurs. Finally, recall that we “gain” ATR as we readings to comprehend this concept fully. The amount of
get older, so having some residual WTR astigmatism allows us “gained” sphere and cylinder depends on both the power of
to “grow into” our eventual ATR later in life. the IOL and the degree of tilt.12 We previously stated that
Residual pseudophakic ATR (greater plus power at the 1 mm of decentration is equivalent to 7° tilt; to make the math
180-degree meridian) will bring vertical strokes at near into easier, let’s assume we are dealing with a + 19.0D IOL with
better focus. Thus, it may be beneficial to leave intentional a 15° tilt. Assuming no longitudinal displacement, this IOL
ATR in a patient with high demands for near work, such as a
jeweler and coin collector, especially if the patient wants to
perform these activities without glasses. Additionally, Specifically, we can think of IOL tilt in lower power IOLs as more
12
“devastating” in terms of their equivalence to 1 mm of IOL decentration

patients whose primary language revolves around a horizon- as compared to higher power IOLs. The previous sentence is under-
standably awkwardly worded and counterintuitive. For example, a
+ 15.0D IOL only requires 5.55 degrees of tilt to equal 1 mm of decen-
Perhaps we should have asked Mr. CM Burns to donate the costs of a
10
tration, whereas a + 21.0D requires 7.79 degrees of tilt to equal 1 mm
toric IOL for this fictional patient prior to cataract surgery. of decentration. An elegant article that discusses this in more detail:
Morlet N, et al. Astigmatism and the analysis of its surgical correc-
11
Erickson P. Effects of intraocular lens position errors on postoperative
tion. Br J Ophthalmol 2001; 85:1127–38. refractive error. J Cataract Refract Surg. 1990 May;16(3):305–11.
will function like a + 19.50 + 1.00 × 180. On clinical refrac- Keratometry measurements

tion, assuming the patient’s refraction was previously plano, OD : 43.00 / 45.00 @ 170
we may now obtain a − 1.50 + 1.00 × 90 (corresponding to OS : 43.25 / 45.25 @ 10

−0.50 − 1.00 × 180). Note that because the IOL has gained
plus sphere power, the clinician will note increased minus Treatment options at this time include first educating the
sphere power in the refraction. However, though the IOL has patient about what has happened and informing her that she
gained more plus cylinder power in the 180-degree (axis) does not have any ophthalmic disease. We can reassure her
meridian, the clinician will either note a refraction of increased that she can still see very well with glasses at this time and
minus cylinder power in the 180-degree (axis) meridian, or overall has had an acceptable surgical result. Contact
because we are ophthalmologists and prefer plus cylinder, a lenses, including a soft toric, rigid gas permeable (RGPCL),
refraction of increased plus cylinder power in the 90-degree and/or scleral lens (ScCL), may also be offered. Surgical
(axis) meridian. options include limbal relaxing incisions (which can be
Depending on the stability of the IOL, single-piece vs. done in the office or minor operating room), IOL exchange
3-piece, presence of vitreous, etc., this may be managed con- (replacing both monofocals with toric IOLs, if safe and the
servatively (glasses or contact lenses) or require surgical patient is financially able), and/or excimer laser refractive
intervention (IOL repositioning/fixation or IOL exchange surgery.
with or without vitreous management). As an aside, this vignette also highlights the impor-
tance of a thorough preoperative discussion with patients
nmasked Corneal Astigmatism
U prior to cataract surgery. Patients at risk for unmasked
Suppose a patient presents to your office 2 months after corneal astigmatism after cataract surgery should be coun-
uneventful cataract surgery in both eyes by a provider in seled about options for astigmatism correction before
another state. She reports ghosting and blurred vision when deciding to proceed with cataract surgery. The surgeon
she does not wear the glasses prescribed after surgery. As should document that astigmatism correction options
your curiosity is piqued, you ask her if the ghosts ever talk to were offered to the patient. They should also be informed
her. She says “No,” but is concerned because she was told about the need for glasses/contact lenses after surgery to
after surgery that she has “astigmatism” in her glasses, which correct unmasked astigmatism; most importantly, they
she reports she never had before surgery. should understand that the cataract surgery did not cause
the astigmatism.
Exam: Distance visual acuity without correction: 20/40 OD, 20/40
OS oric IOL Rotation
T
Today’s Manifest Refraction: Suppose a 68-year-old male patient presents for his postop-
OD : − 1.50 + 2.00 × 170 (20/20) erative one-week visit to your office. You had previously
OS : − 1.00 + 2.00 × 10 (20/20)
performed cataract surgery in his left eye and placed a toric
Slit lamp exam: WNL, including PCIOL well-centered
OU. DFE normal. IOL. At his postoperative one-day visit, he saw 20/25 and
was quite happy with this vision. Today, he reports decreased
She then shows you her old (presurgery) glasses: −1.00D vision, especially noting “ghosting” around images. He
sphere in both eyes. fears that something terrible has happened and will lose his
What happened? Did the surgery go wrong? Did our vision.
patient magically develop astigmatism after cataract
surgery? Exam ( today ) Visual acuity without correction OS : 20 / 60
This vignette is a classic scenario of favorable preopera- Manifest refraction OS : −1.50 + 4.00 × 95 ( 20 / 25, slow )
tive lenticular astigmatism counteracting the (signifi- Preoperative keratometry : 42.25 × 44.25@ 94
cant) corneal astigmatism. Hence, the patient only needed to
wear glasses with spherical correction. A review of your operative report reveals that you placed a
After cataract surgery, the outside provider likely placed toric IOL at the 94-degree meridian.
a monofocal IOL in both eyes. Since the cataracts (and the Slit-lamp exam today reveals the following (Fig. 4).
favorable lenticular astigmatism) were removed, she now What happened? Will our patient lose his vision?
has prominent corneal astigmatism, aka unmasked corneal Unfortunately, it appears that the toric IOL was initially
astigmatism, that requires glasses correction. placed at the correct meridian (approximately 95 degrees) but
We can confirm this by obtaining keratometry measure- has since rotated approximately 70 degrees in the past few
ments today: days. This undesirable rotation has worsened the preexisting
432 K. M. Riaz
much has (thankfully) changed with cataract surgery since

that time. Recent findings suggest that the amount of toric
IOL rotation and effect on visual acuity is nonlinear.14 For
example, a rotation of ≤10 degrees is far more tolerable than
a rotation of ≥10 degrees. The largest loss-of-effect (propor-
tionally) occurs between 10 and 20 degrees; only if there is a
≥ 45-degree rotation, then the toric IOL has a total effect-loss
of astigmatism correction.15
Getting back to our patient, we can begin by validating his
concerns with reassurance and explaining what has hap-
pened. Thankfully, refraction improves his vision (albeit
with more cylinder than he would have liked), so the vision
potential remains quite good. Nonsurgical options at this
time would include glasses and/or contact lenses (soft toric,
RGPCL, and/or ScCL) to manage the astigmatism. Since it is
still early in the postoperative period, a reasonable option
would be to return to the operating room and rotate the IOL
back into its intended location with meticulous surgical tech-
nique to remove viscoelastic and ensure IOL stability. A cap-
sular tension ring can be placed to stabilize the IOL-bag
complex. A sutured capsular tension segment may also be
required if there is any zonular compromise. If the toric IOL
is defective or compromised, replacing it with a new toric
IOL may also be necessary.
Suppose our patient had surgery performed by another
surgeon 18 months ago and presents with the same findings.
At this time, it may be difficult to rotate the IOL due to fibro-
Fig. 4 Slit-lamp exam today showing a toric IOL with markings sis and scarring that have likely occurred postoperatively.
located at approximately 165 degrees
Rotating the IOL may cause additional damage to the IOL-
bag complex, including potential vitreous loss. Similarly, an
corneal astigmatism from 2D to approximately 4D (refractive IOL exchange may be difficult, especially if a YAG capsu-
cylinder). lotomy was performed after surgery. For these situations,
When placing a toric IOL, surgeons should make every glasses/contact lenses remain a good option. Finally, excimer
attempt to place the IOL in the correct meridian. Recall that if laser refractive surgery can be offered to treat the refractive
a toric IOL rotates away from its appropriate location, there is error and may be the safest surgical option for these late-term
a reduction in its effect. The classic teaching (which has rotation situations.
recently been called into question, see next paragraph) is that a
1-degree rotation causes a 3.3% reduction in astigmatism cor-
rection effect. Extending this, we can see that if the IOL rotates Correcting Postoperative Astigmatism
30 degrees, there is a 100% reduction of effect. Finally, if the
IOL rotates more than 30 degrees, it can worsen astigmatism, We have discussed some of these options before, but for the
which happened in our example. sake of completion and a compiled source of options, the
As discussed in the previous chapter, this 1-degree rotation following are potential strategies to manage and correct post-
equaling a 3% reduction rule has become a commonly operative refractive astigmatism.
accepted fact. The source of this claim, which in turn has been Nonsurgical Options
repeated by many authorities is a paper from 1994(!) which • Glasses
reported the results of 47 patients with ATR astigmatism, • Contact Lenses, including toric, RGPCL and ScCLs
used a 5.7 mm incision (with sutures), and used an older-gen-
eration 3-piece toric IOL with an oval optic.13 Of course,
Tognetto D, Perrotta AA, Bauci F, et al. Quality of images with toric
14
intraocular lenses. J Cataract Refract Surg 2018; 44: 376–81.

Shimizu K, Misawa A, Suzuki Y. Toric intraocular lenses: correcting
13
Németh G. One degree of misalignment does not lead to a 3.3% effect
15
astigmatism while controlling axis shift. J Cataract Refract Surg 1994; decrease after implantation of a toric intraocular lens. J Cataract
20: 523–26. Refract Surg. 2020;46(3):482
Surgical Options correction with contact lenses (e.g., a −5D CL would make the
• Exchanging a monofocal IOL for a toric IOL or a patient effectively a + 5D hyperope) with glasses (+5D) can
wrongly-powered toric IOL for a correctly-powered give them back their preoperative hyperopia. Surgically, if a
toric IOL patient continues to be unhappy, an IOL exchange for restoring
• Rotation and stabilization of a previously placed toric hyperopia may be considered. This author has had to resort to
IOL this option for one memorable patient who insisted on going
• Incisional procedure(s) in the office or operating room, back to her preoperative hyperopia.
such as limbal relaxing incision and manual/femtosecond
laser-assisted arcuate keratotomy
• Laser refractive surgery
Unmasked Tropia
Troubleshooting Other Postsurgical Issues As much as we pride ourselves in making a patient objec-
tively see 20/20 after cataract surgery, we should be cogni-
Several other problems may also present after cataract sur- zant of certain patients who may have been dependent on
gery as a combination of objective and subjective refractive glasses for correcting both refractive error and tropias.
issues. For example, suppose a 67-year-old male patient presents
to your office for an unscheduled visit 2 months after uncom-
plicated surgery in both eyes. At his postoperative 1-month
Magnification and Minification Issues surgery, he was 20/20 in both eyes with a plano refractive
error. You advised him to use +2.50 OTC readers and patted
One would think that patients with high myopia and/or yourself on your back so much that you pulled a neck mus-
hyperopia who become emmetropic after cataract surgery cle. Today, he bitterly complains that while he would read
should be delighted to get rid of their glasses. Usually, that is with glasses prior to surgery, now he cannot read for more
the case with most of these patients, especially with high than a few seconds before his eyes feel extremely tired and
myopes, though they may complain about needing reading the words “seem to move all over the page.”
glasses as they previously may have been able to read with- Suppose that a repeat exam today shows 20/20 vision
out correction – though they likely had to hold the reading uncorrected in both eyes with plano refractive error in both
material extremely close! eyes. When each eye is tested individually with a + 2.50D
However, a minority of these patients may complain about lens, he can read the J1 line without any problems. However,
subjective size distortions with their new emmetropia.16 binocularly, he cannot read for more than a few seconds.
Recall that high myopes experience minification effects as What happened? Is he malingering? What if he is a friend
they view the world through a reverse Galilean telescope; of Mr. Burns and tells him to remove you from his will?
conversely, high hyperopes experience magnification effects At this time, we should suspect that the old glasses may
as they view the world through a Galilean telescope. For these have been helping more than the refractive error. Suppose
high myopes and high hyperopes, emmetropia may now when we test his old glasses, we note the following
cause them to view the world as much larger or much smaller, prescription:
respectively, compared to their perception prior to cataract OD : −1.50 + 0.75 × 95, +2.50 add, 3 PD BD
surgery. Myopes usually tolerate this postoperative “magnifi-
cation” quite well: they probably are so happy to get rid of OS : −1.25 + 0.75 × 85, +2 50 add

their glasses that they may not want to complain any further!
However, our high hyperope friends may complain about Suppose we test his motility and note a 3 PD RHT
postoperative “minification” or a “Lilliputian” perception of (comitant).
the world: they may subjectively feel that everything around By now, we should realize that this patient had a signifi-
them looks much smaller. When performing cataract surgery in cant RHT that was successfully treated with his old glasses
a high hyperope, it is vital to discuss postoperative “minifica- that had a 3 PD BD in the right lens. Now that he does not
tion” with emmetropia prior to cataract surgery. Thankfully, need glasses for distance (or near vision, when each eye is
most patients will eventually learn to adjust over time, so in the tested individually), he was not given his previous prism cor-
immediate postoperative period, one can employ the magical rection. In other words, he may objectively read 20/20 with
treatment of “MICLO”: mindful inaction with cat-like observa- each eye, but when trying to read (looking down) with both
tion. If the patient is persistently unhappy, then a myopic over- eyes, he experiences diplopia and adverse effects of the
RHT. We can simply prescribe glasses with the required
See Chap. 8, Magnification and Telescopes to review this concept.
16
prism correction for this patient.
434 K. M. Riaz
We can also ask him not to tell Mr. Burns about this unfor-
tunate oversight. The learning point here is to ensure that PD.
preoperative correction of tropia is documented and main-
tained postoperatively.17
Dysphotopsias
Suppose a meek, mild-mannered, constantly fearful fellow

named Mr. W.J. Smithers comes in for a second opinion after
cataract surgery in both eyes with another provider. He
reports a shimmering crescent-shaped light seen in the tem-
poral field of his right eye and a banana-shaped temporal
shadow in his left eye. What’s going on?
ND.
This clinical scenario may be one of the more fascinating
(and frustrating) recent developments in postoperative issues Fig. 5 Simplified schematic diagram representing etiology of positive
after cataract surgery. A full review of this condition, includ- and negative dysphotopsia (PD and ND). Both involve incoming tem-
ing etiology and treatment, is beyond the scope of this text.18 poral light creating either an edge reflection (PD) or edge scotoma (ND)
Dysphotopsias are aberrant, unwanted, and frustrating
optical phenomena subjectively experienced by patients after may be easier seen with smaller pupils as this leads to
uncomplicated cataract surgery that may affect nearly 20% increased contrast between the ND shadow and adjacent
of patients, with varying symptoms intensity and duration rays, similar to the pinhole effect. In other words, with a
levels. There are two main types of dysphotopsias: positive larger pupil, enough rays that get through may “hide” the
dysphotopsia (PD) and negative dysphotopsia (ND) (Fig. 5). ND, but the ND becomes more noticeable with a smaller
We still do not fully have a grand unified theory that pupil.20
explains the etiology of dysphotopsias. However, some theo- • Positive angle-kappa
ries and observations include the following: • Smaller axial distance of the IOL behind the iris
• There is a higher incidence of PD and ND with high- • Nasal anterior capsule overlying the anterior nasal aspect
refractive index acrylic IOLs with square-edge optics of the IOL (controversial)
(the most common type of 1-piece IOLs implanted in the • High dioptric power of a biconvex IOL
USA today, regardless of manufacturer).19 • Hydrophilic IOLs
• The nasal retina extends more anteriorly than the tempo- • History of previous refractive surgery
ral retina. If areas of the nasal retina are stimulated by • FLACS corneal incision
light postoperatively that were previously not, this may • Smaller IOL optic (<6.0mm)
contribute to PD. Similarly, if areas of the nasal retina • Type A personality
are no longer stimulated by light postoperatively As we can see, that is quite the laundry list and can theo-
(whereas they were receiving light preoperatively), this retically include a significant number of patients. We should
may contribute to ND. understand PD and ND further before delving into potential
• Small pupil size: This is somewhat counterintuitive as one treatment options.
may think that a larger pupil size would be more of a cul-
prit. However, studies have shown that the ND shadow
Positive Dysphotopsia (PD)
Another example of “new” diplopia may occur in a patient who devel-
17
oped a sensory exotropia due to a long-standing white cataract; fittingly PD is usually reported as a temporal light streak, hazy glare,
enough, the patient may not have complained about the double vision or arc induced in bright light conditions from an oblique
because he could not see out of the affected eye. After the cataract is
removed, the patient may now “see” the exotropia as the pseudophakic light source; this distinguishes it from retinal pathology (e.g.,
eye still deviates. vitreous traction) that usually occurs in dark light conditions.
An excellent and comprehensive review article may be found here:
18 While many etiologies and risk factors may cause PD, the
Masket S, Fram NR. Pseudophakic Dysphotopsia: A Review of likeliest reason is that incoming, oblique light rays strike the
Incidence, Etiology and Treatment of Positive and Negative
Dysphotopsia [published online ahead of print, 2020 Aug 12].
Ophthalmology. 2020;S0161–6420(20)30787–9. Hong X, Liu Y, Karakelle M, Masket S, Fram NR. Ray-tracing optical
20
See Chap. 27, What’s on the Menu: An Overview of Currently-

19
modeling of negative dysphotopsia. J Biomed Opt. 2011
Available IOLs. Dec;16(12):125001
nasal edge of the optic-anterior capsule-pupil complex and light is blocked. On the other hand, unlike PD, ND symp-
undergo a combination of refraction, scattered and internal toms are worse with pupil constriction. ND may occur more
reflections, striking portions of the nasal retina, especially frequently in women and in the left eye. ND may occur with
those regions not previously stimulated by light in the phakic non-acrylic and non-square edge IOL as well.
state, and creating a PD in the patient’s temporal field. At present, the likely explanation for the “enigmatic pen-
For example, one major contributing factor is the popularity umbra” of ND is that incoming light rays that previously illu-
of square-edge acrylic IOLs with a high refractive index. While minated the nasal retina no longer do so after cataract surgery.
a square-edge IOL may reduce the incidence of PCO, it may also This “illumination gap” can be eliminated by restoring illu-
create unwanted refractions and reflections at the anterior optic mination to the dark band of the nasal retina, or at least shift-
edge, redirecting incoming light onto a smaller area of the retina; ing this gap beyond the noticeable areas of the nasal retina.
this is typically not seen with a round-edge IOL, which spreads Other factors contributing to ND include high angle kappa,
incoming light onto a larger area of the retina. Therefore, a theo- high hyperopia, short axial length, overlying nasal anterior
retically “ideal” IOL may have a rounded anterior edge and a capsule, increased posterior chamber depth of the pseudo-
squared posterior edge to both reduce PD and PCO.21 Similarly, phakic eye, and position of in-the-bag 1-piece IOL haptics.
a high refractive index may contribute to PD as well.22 The latter factor is somewhat controversial as evidence for
Other factors contributing specifically to PD include a placing the haptics in a horizontal inferotemporal position
lenticular design optic (which allows for a consistent optic showed benefit for transient ND rather than late-term ND; in
thickness across a range of IOL powers), thickness of the this study, the treatment group actually had a higher rate of
square edge, and placement of more IOL “power” in the pos- ND at 1-month when compared to the control group (silicone
terior optic versus the anterior optic. For this last factor, it IOLs).26 Further complicating these factors is the recent
has been reported that high-index IOLs with a flat anterior proposition that CNS components may also contribute to
radius of curvature cause central light flashes from backward ND.27
reflections of the optic.23 If you are confused after reading the previous paragraphs,
join the club: it includes most cataract surgeons in the world,
indicating that there is still much to learn about ND. ND is a
Negative Dysphotopsia (ND) topic that we will hopefully learn more about in the coming
years, including practical strategies to prevent and treat this
ND is usually reported as a dark, temporal crescentic shadow unwanted temporal shadow.
seen in bright light conditions. ND may occur slightly more
frequently than PD (15–20% of patients) and may be seen
much earlier in the postoperative period. However, compared Treatment Strategies
to PD, patients may be much less bothered by ND through
neuro-adaptation at 1 year after surgery, though this is con- Numerous treatment strategies have been described for PD
troversial as others believe ND is worse than PD.24 The etiol- and ND. When too many treatment options exist, it usually
ogy of ND is slightly more hallenging to understand than indicates that no single option is perfect or effective in every
PD.25 There are some similar inciting factors as PD and as situation. The following is a list of the most commonly
some different ones as well. employed options, with notation given for whether an option
For example, similar to PD, ND symptoms are due to may be more effective for PD, ND, or both (B).
incoming temporal light and can be reduced if the temporal Nonsurgical Options
• Validation/reassurance until neuroadaptation occurs (B):
this is probably the strategy most cataract surgeons use.28
For example, the ZA9002 (silicone IOL; Johnson and Johnson,
21
Thankfully, most PD/ND eventually resolves: whether it
Sarasota, FL USA), AR40 platform (acrylic IOL; Johnson and Johnson, truly goes away or whether patients learn to deal with it is
Jacksonville, FL, USA), and the CQ2015A (collamer IOL; Staar
Surgical, Monrovia, CA USA) have a rounded anterior edge and
subject to debate.
squared posterior edge optic.
See the discussion in Chap. 1, Geometric Optics
22
Henderson BA, Yi DH, Constantine JB, Geneva II. New preventative
26
Erie JC, Bandhauer MH, McLaren JW. Analysis of postoperative

23
approach for negative dysphotopsia. J Cataract Refract Surg.
glare and intraocular lens design. J Cataract Refract Surg. 2016;42(10):1449–1455.
2001;27(4):614–621. Masket S, Rupnik Z, Fram N, Vikesland R. Binocular Goldmann
27
Osher RH. Negative dysphotopsia: long-term study and possible

24
Visual Field Testing of Negative Dysphotopsia. J Cataract Refract Surg.
explanation for transient symptoms. J Cataract Refract Surg. 2020;46(1):147–148.
2008;34(10):1699–1707. This option may/may not include another strategy: wait until the
28
An appropriately titled paper that deals with this concept: Holladay

25
patient becomes mad at you and then refer them to your across-town
JT, Zhao H, Reisin CR. Negative dysphotopsia: the enigmatic penum- competition. Please do not refer such patients to the authors! What did
bra. J Cataract Refract Surg. 2012;38(7):1251–1265. we ever do to you, other than try to teach you optics?
436 K. M. Riaz
• Treatment of refractive error (B): Glasses, especially diffractive optics (e.g., MFIOLs, EDOF-IOLs, and trifocal
frames with thick edges, may help reduce symptoms, IOLs). While there is some overlap with the previous PD/
especially with PD. ND discussion,29 these phenomena are due to the more
• Treatment of ocular surface disease (B): As with many central portion of the optic rather than the optic edge causing
problems in ophthalmology, give them the magical potion multiple focal points. The subjective glare/halos are due to
known as preservative-free artificial tears. the forward light scattering (Mie scattering) and other
• Pupillary dilation (ND). higher-order aberrations. Some risk factors, such as ocular
Non-incisional Surgical Options surface disease, IOL decentration, and type A personality,
• YAG capsulotomy to remove the nasal aspect of the ante- have been previously well described in the literature. More
rior capsule (ND) recently, there has been an understanding that aberrant
• Not polishing the nasal anterior capsule at the time of angle-kappa and angle-alpha may contribute to these issues
cataract surgery to promote early nasal capsular clouding as well.30
and contraction (ND > PD) Ideally, with good screening, diagnostic imaging, applica-
Incisional Surgery Options tion of optical principles, meticulous surgical technique, and
• Repositioning vertically oriented haptics horizontally appropriate patient selection, we can minimize the number
while keeping the IOL in the capsular bag (ND). of unhappy ATIOL patients.31
• Placing the IOL in the bag such that the haptic-optic junc- Postoperatively, there are not a lot of good options for
tion is horizontally inferotemporal (useful for short term, these patients. In the immediate postoperative period, the
no evidence for post 1-month symptoms) (ND). See above best strategy may be a healthy dose of reassuring the
for why this may not truly be an effective strategy. patient that surgery went well and writing a prescription
• Reverse optic capture (ND > PD): This strategy involves for observation/hand-holding. If there is any residual
placing the haptics of the IOL in the bag and then lifting refractive error, it may be tempting to treat with excimer
the optic out of the bag such that it is anterior to the cap- laser surgery as ATIOLs rely on minimal refractive error.
sulorrhexis edge. This maneuver can be combined with a However, photic phenomena may worsen with overaggres-
horizontal haptic orientation. sive treatment. Therefore, temporary treatment of refrac-
• Truncation of the nasal-edge of the IOL haptic has been tive error with glasses and contact lenses may be helpful to
reported. However, this may create a sharp optic edge that see if that resolves the photic phenomena. If so, laser
can secondarily damage critical capsule structures. refractive surgery may be employed; if these do not work,
• IOL exchange: Exchanging a square-edge acrylic IOL for then laser refractive surgery may not help or worsen the
rounded-edge and/or non-acrylic (silicone, collamer) IOL symptoms. If intractable glare/halos remain even after a
(both, but especially PD). period of observation, an IOL exchange with a monofocal
• Implanting a secondary non-acrylic plano-power piggy- or accommodating IOL may be offered, which usually
back IOL (ND > PD): this may be particularly useful fixes the problem definitively. IOL exchange surgery must
post-YAG capsulotomy and/or in situations where an IOL be carefully considered in general, but even more so in the
exchange may be risky. presence of an open capsule (post-YAG capsulotomy), as
• Primary sulcus placement of 3-piece IOL (ND > PD): This the IOL exchange may necessitate concurrent vitrectomy.
can be done at the time of original cataract surgery (i.e., not It can be frustrating for the ATIOL patient to undergo addi-
placing an IOL in the bag at all and instead placing a 3-piece tional incisional surgery, especially if he/she has previ-
in the sulcus) or at the time of IOL exchange (i.e., removing ously spent a significant amount of out-of-pocket money
the in-the-bag IOL and placing a 3-piece IOL in the sulcus). for the “upgraded” IOL.
This is a similar strategy to reverse optic capture in that the
IOL optic is anterior to the capsulorrhexis edge.
• Primary placement of an IOL with frosted edges (ND):
currently in clinical trials.
• Primary placement of an IOL with grooves within the
optic to allow for “tucking” of the capsulorrhexis edges
“behind” the edge of the anterior optic while keeping the
In fact, some authorities refer to these as “diffractive dysphotopsias”
29
IOL in the capsular bag (ND): currently in clinical trials. are they are seen only in ATIOLs that use diffractive optics to create
multiple focal points; this is compounded by the glare that results from
forward light-scatter (Mie-scattering) from the diffractive optics ele-
Photic Phenomena with ATIOLs ments (rings or echelettes)
See Chap. 26, Preoperative Optics for Cataract Surgery, for a review
30
of these topics.
Photic phenomena (glare, halos, starburst, streaks of lights)
In other words, be wary of the surgeons that boast of a >50% ATIOL
31
can cause frustration for patients who receive ATIOLs with surgical practice…
ostoperative Refraction: Room Lengths

P for developing lens constants) 6 meters (20 feet) instead of
and Optimizing Lens Constants infinity. This standard reference distance has merits for sev-
eral reasons. First, we can generally get the lens constants
Author’s Note: A special thanks to David L. Cooke, MD with this distance as in the ULIB database.32 Second, if we
(Great Lakes Eye Care, St. Joseph, MI), for his assistance get the room distance to 20 feet, the refraction is “close
and instruction in the material presented in this section. enough” that we do not need to further extend it to 26.25 feet.
We can comment on one last point for postoperative The second option is an elegant proposal by Simpson
refraction that is slightly technical and definitely nerdy. et al. to move the refraction reference distance, regardless of
When we perform postoperative refractions, we simply mea- one’s exam lanes, to equal 6 meters33; in other words, use
sure the patient’s visual acuity on the screen in the room, some math instead of renovating your entire office:
become very happy if the patient is 20/20, and move on with

life. However, as with many things in Optics, this is not
Refraction at 6 m = (1 / 6 D − 1 / 4 D ) = −0.08333D ≈ −0.08D
entirely accurate for the actual refractive error, which may be
necessary for some clinically-relevant things, such as opti-
mizing one’s unique lens constant(s) so that one can have an Returning to our previous fictional refraction of −1.00 + 0.50
even higher percentage of 20/20 patients. × 90, we would need to add an additional minus sphere
We must refer to a common reference point for our final power (−0.08D) for the final refraction of −1.08 + 0.50 × 90.
refraction. And no, that reference point does not mean refer- Note that this is obviously theoretical because we cannot
ring to an optometry colleague to finalize the refrac- write this as an eyeglass prescription unless you are trying to
tion. When we finish our perfect manifest refraction in pull an April Fool’s joke on your optician friends. Moreover,
whatever room we are using, we must adjust the final refrac- only a few refractions will be wrong because we cannot dial-
tion to give the “perfect” correction at some distance, either in 0.08D into the phoropter. However, on average, the refrac-
at optical infinity (for perfect distance vision) or 20 feet (6 tion of one’s surgical patients, when looked at as a group,
meters) - the latter is the standard refraction distance for IOL will be overplussed by 0.08D. This adjusted refraction value
clinical studies. will be significant when calculating one’s own unique lens
When testing at room lengths less than 20 feet/6 meters constant.
(most ophthalmology offices), we have to account for non- If one has shorter rooms, this will be even more impor-
parallel (overly divergent) light rays. For example, suppose tant. Suppose the testing distance between the phoropter and
our room was 4 meters: a person without accommodation the chart/screen was 9.5 feet (2.9 meters). Using the ideal
(e.g., a dilated patient or your pseudophakic 80-year-old) IOL power prescription adjustment:
will be slightly “over-plussed” in the manifest refraction at
this distance. Remember that at 4 meters, incoming light has
(1 / 6 − (1 / 2.9 ) ) = −0.18D
a divergence of approximately −1/4D; to account for this
extra −1/4D, our refraction has an “extra” +1/4D sphere This means that our patient’s refraction for infinity is
(compared to what we would get if we refracted at optical actually −1.18 + 0.50 × 90. We can see how this can skew the
infinity). Therefore, we have to add approximately −0.25D to data set’s average refraction and, in turn, affect the calculated
the final refraction to adjust for the room distance. value of one’s unique, surgeon-optimized lens constant.
We can use an example to make this point a bit clearer. In conclusion, it is obviously very difficult and nearly
Suppose that our patient’s refraction after cataract surgery impractical to do this adjusted refraction for every single
was −1.00 + 0.50 × 90 (20/15) when refracted at 4 meters. patient in a busy surgical practice. However, if one is genu-
However, we have inadvertently included an “extra +0.25 D” inely interested in determining one’s individual lens con-
in this measurement, so the manifest refraction at infinity stant, then taking the time to perform this in 50–100 eyes
should actually be −1.25 + 0.50 × 90. Remember that optical with one’s preferred IOL platform will be invaluable to find-
infinity requires a room of at least 8 meters (26.25 feet) - who ing an individualized lens constant to achieve even more pre-
among us can afford to renovate all of our exam lanes to have cise surgical outcomes.
this distance?!
Therefore, we have to find a happy medium between opti-
cal infinity and a typical ophthalmology exam lane (usually
ULIB User Group for Laser Interference Biometry. http://ocusoft.de/
32
ranging from 8 to 10 feet for most offices, as measured as the ulib/c1.htm. Accessed January 10, 2021.
distance from the phoropter to the visual acuity chart). One Simpson MJ, Charman WN. The effect of testing distance on intra-
33
option is to make the reference distance for IOL studies (i.e., ocular lens power calculation [letter]. J Refract Surg 2014; 30:726
438 K. M. Riaz
1. Which of the following statements concerning myopic 1. B. Most 1-piece IOLs have a biconvex design with the
surprise is TRUE? posterior aspect of the optic having more power than the
A. A myopic surprise can occur if the surgeon planned to anterior aspect. A myopic shift may occur if the IOL is
place a + 23.0D IOL in the capsular bag but acciden- inadvertently placed upside down in the capsular bag. If
tally placed a + 20.0D in the capsular bag a lower IOL power is accidentally placed (choice A), a
B. A myopic surprise can occur if the planned 1-piece lower-than-actual A constant is used (choice C), or if the
IOL is inadvertently placed inverted down in the cap- IOL-bag complex shifts posteriorly (choice D), then a
sular bag hyperopic surprise may occur.
C. A myopic surprise can occur if a lower-than-actual 2. B. Placing a plus-powered 3-piece IOL as a piggyback
A-constant is used IOL in the sulcus will worsen the refractive error. All of
D. A myopic surprise can occur if the IOL-bag complex the other options can treat postoperative myopia to vary-
shifts posteriorly after cataract surgery ing degrees.
2. All of the following treatment strategies may be used to 3. C. CBS seen immediately after surgery may be carefully
treat myopic surprise EXCEPT: monitored with topical hypotensive and/or steroids with the
A. IOL exchange: replacing the existing in-the-bag IOL hopes that it may self-resolve. Imaging of the IOL-bag
with a lower power in-the-bag IOL complex will show an anteriorly shifted IOL (choice A)
B. Placement of a plus-powered 3-piece silicone/collamer within the capsular bag with posterior distension of the
IOL in the sulcus posterior capsule due to the built-up fluid. A large IOL
C. Laser refractive surgery (LASIK or PRK) optic and small capsulorrhexis (choice B) are risk factors
D. Repositioning an anteriorly dislocated 1-piece IOL for CBS. A YAG capsulotomy may be both diagnostic and
from the sulcus back into the capsular bag therapeutic for this condition (choice D)
3. Which of the following statements about capsular block 4. D. Patients who receive IOLs based on a higher-than-
syndrome (CBS) is TRUE? actual A constant may end up with a higher-than-required
A. AS-OCT and/or UBM will typically show a posterior IOL power causing a myopic surprise, not a hyperopic
shift of the IOL-bag complex surprise. All of the other patients (choices A, B, and C)
B. Risk factors for CBS include a small diameter optic are at risk for a more hyperopic-than-intended refractive
(<6 mm) and a large capsulorrhexis error. This does not mean a hyperopic refractive error nec-
C. CBS seen in the first few days after surgery may be essarily (e.g., +1.00D) but may mean that if −1.00D was
observed if IOP and inflammation are acceptable targeted with the surgery, the patient may end up −0.25D
D. A YAG capsulotomy is often ineffective at treating instead.
CBS 5. A. PRK/LASIK for hyperopic refractive errors tends to be
4. All of the following patients are at risk for postoperative less predictable and less effective than myopic treatments;
refractive error more hyperopic-than-intended EXCEPT: in other words, it is far easier to treat a patient with
A. Patients with a previous history of myopic LASIK/ −2.00D refractive error as compared to a patient with
PRK surgery +2.00D refractive error. All of the other treatments (B, C,
B. Patients with ACD < 3 mm and LT > 5 mm when and D) may be effectively used in this setting.
using the Barrett formula
C. Patients with corneal ectasia
D. Patients who receive IOLs based on a higher-than-
actual A constant
5. Which of the following treatment options is LEAST
effective for a hyperopic surprise?
A. Excimer laser refractive surgery
B. Placement of plus-powered 3-piece sulcus (“piggy-
back”) IOL
C. IOL exchange with a higher-powered IOL
D. Glasses and/or contact lenses
Optics for Refractive Surgery
Kamran M. Riaz
Objectives who does not perform refractive surgery needs to know for
• To understand optics concepts previously discussed con- community-based practice and/or exam preparation.
cerning modern refractive surgery. The other purpose of this chapter is to hopefully string
• To identify refractive reasons and concepts important in together some of the previous optical concepts we have dis-
determining suitable laser refractive surgery (LRS) cussed, especially advanced topics such as higher-order
candidates. aberrations (HOAs) (Chap. 14, Physical Optics), which may
• To diagnose and troubleshoot postoperative problems have initially overwhelmed a first-time reader with its seem-
after LRS in the context of previously discussed optics ingly irrelevant nature. Instead, we hope to show how these
principles. concepts are clinically and surgically relevant and reinforce
• To survey other types of incisional refractive surgeries their understanding and appreciation.
currently in practice. For this chapter, we will assume that the reader knows the
fundamental procedural aspects of LRS. If you are unfamil-
iar with how photorefractive keratectomy (PRK), laser in
Introduction situ keratomileusis (LASIK), and small incision lenticule
extraction (SMILE) are performed, please consult other
Before we start this chapter, let’s get something important resources for this information.2
out of the way: by no means should this chapter be consid-
ered a primer, replacement, or even supplement for a text-
book on refractive surgery, especially excimer laser refractive eview of Relevant Corneal Anatomy,
R
surgery (LRS). The purpose of this chapter is not to make the Biomechanics, and Function
reader a refractive surgeon. Ideally, a fellowship in cornea/
refractive surgery and tutelage under experienced, skilled In a simplified model of relevant anatomy, the cornea has 5
refractive surgeons should be completed before embarking main layers; for the purposes of refractive surgery, the major-
on refractive surgery in actual patients.1 ity of these procedures occur in the corneal stroma.3 The
Instead, the purpose of this chapter is to primarily serve as stroma primarily consists of collagen fibrils arranged in
an introduction for the reader to understand how some of the approximately 200 parallel lamellae; each fibril is oriented
previously discussed optics principles are used in refractive angularly to fibrils in adjacent lamellae, leading to increased
surgery, especially in preoperative screening and postopera-
tive management. This chapter is intentionally designed to
For the purposes of this chapter, we will use the term “PRK” to refer to
2
present the basics of what a comprehensive ophthalmologist any type of surface ablation procedure, including variations of PRK
such as epi-LASIK, LASEK, and anterior surface ablation (ASA). The
Please also see the recommended reading list for Refractive Surgery
1 full discussion of the nuances and differences of these procedures is
resources for those who wish to understand this subject further, includ- beyond the scope of this text.
ing advanced preoperative, postoperative management, and intraopera- Recently, a sixth layer, known as the pre-Descemet’s layer (Dua’s
3
tive principles. Layer), has been introduced.
K. M. Riaz (*)

440 K. M. Riaz
biomechanical strength of the cornea. Fibrils are densely As a vastly simplified principle, most refractive surgical
packed in the anterior two-thirds of the cornea; this means procedures on the cornea involve altering the corneal curva-
that there is less likely to be swelling within the anterior two- ture to alter the eye’s refraction favorably.
thirds of the stroma than the posterior one-third. When the Finally, a rudimentary knowledge of higher order aberra-
cornea is healthy or edematous, the anterior lamellae take up tions (HOAs) is vital for refractive surgery.7 Among HOAs,
most of the strain; when the cornea is dehydrated, the poste- spherical aberration (SA) is perhaps the most important one
rior lamellae take up more. Strain is also related to intraocu- to keep in mind, especially regarding the effects of LRS on
lar pressure and other external mechanical factors. SA. Prolate corneas usually have positive SA; oblate corneas
Why should we care about all of this? The lack of unifor- usually have negative SA. Since most emmetropes and
mity in the biomechanics of the cornea explains the variation myopes have prolate corneas, most patients usually have low
in corneal response to various refractive procedures. For amounts of positive SA. While the crystalline lens has nega-
example, LASIK and SMILE both have a more significant tive SA, the cornea has a greater positive SA magnitude,
effect on the total corneal biomechanical load because of the leading to a mean net value of approximately +0.36 μm
flap (with LASIK) as well as ablation in the “deeper” areas (SD = 0.31 μm). As we get older, we typically develop more
of the stroma (LASIK and SMILE) as compared to PRK. As positive SA.
another example, procedures that weaken the cornea, such as In regards to LRS, the following considerations can be
radial keratotomy (RK) or limbal relaxing incisions (LRIs), kept in mind:
have different refractive effects than a procedure wherein tis- • Patients who undergo standard (i.e., not wavefront guided
sue is removed, such as LASIK or PRK. (WFG) or wavefront optimized (WFO)) ablations for
Recall that the air-tear film interface is the most important myopia will develop an oblate corneal pattern (central
refractive surface of the eye.4 Therefore, any refractive sur- flattening with a relatively steep untreated peripheral cor-
gery will require a healthy and optimized air-tear film inter- nea). These patients’ postsurgical wavefronts will show a
face to optimize surgical results. significant increase in positive spherical aberration. A
The eye’s optical power derives primarily from the anterior typical wavefront pattern for these patients may demon-
surface of the cornea (+48.0 D). The posterior surface contrib- strate emmetropia centrally (green) with “annular myo-
utes a NEGATIVE power (−6 D), yielding an overall corneal pia” in the periphery (red) (Fig. 1a).
power of ~ +42.0 D. Even though the posterior cornea is a • Patients who undergo standard ablations for hyperopia
convex surface, since light rays travel from a medium of higher will develop a more prolate corneal pattern (steeper cen-
refractive index (stroma) into a medium of lower refractive trally). These patients’ postsurgical wavefronts will show
index (aqueous humor), the posterior cornea can be assumed a significant decrease in spherical aberration (they may
to function as a minus lens. even have net negative spherical aberration), and the
The normal cornea flattens from the center to the periph- wavefront-shaped pattern may become inverted (Fig. 1b).
ery (by approximately 4D); the nasal cornea is flatter than
the temporal cornea.5 A prolate cornea is one wherein the
central cornea is steeper than the peripheral cornea; this type reoperative Considerations for Excimer
P
of cornea is usually found in patients with myopic refractive Laser Refractive Surgery
errors.6 An oblate cornea is one wherein the central cornea is
flatter than the peripheral cornea; this type of cornea is usu- Selected Ophthalmic Considerations
ally found in patients with hyperopic refractive errors. We
can use this foundation to understand how LRS can advanta- Laser refractive surgery (LRS) is performed on healthy eyes
geously change the shape of a prolate or oblate cornea and in patients with excellent vision potential. LRS is primarily
correct refractive errors. For example, by flattening a prolate used for myopes to flatten the central cornea with minimal
cornea, we can make it more oblate-like and treat myopic treatment of the periphera cornea. For hyperopes, LRS is
refractive errors. used to primarily flatten the peripheral cornea to steepen the
central cornea secondarily. This summary is a gross simplifi-
cation but is a primary concept that can be kept in mind as we
discuss LRS procedures such as PRK and LASIK.
4
See Chap. 1, Geometric Optics and Chap. 5, Power of Lenses in Remember that any refractive surgery will not “improve”
Different Media for a more detailed explanation of the air-tear film a patient’s vision potential; the primary goal of LRS is to
interface. achieve vision comparable to a level with glasses and/or con-
The mnemonic “flat nasal bridge” may help to remember that the nasal
5
tact lenses. If a patient cannot achieve 20/20 vision prior to
cornea is flatter than the temporal cornea.
A useful mnemonic is to think of a prolate cornea as being “too profes-
6
sional” of a cornea: it does such a professional job of refracting incom- See Chap. 14, Physical Optics, for a more detailed explanation and
7
ing light rays that they don’t reach the retina. review of higher-order aberrations.
Optics for Refractive Surgery 441
a b
90 90
105 75 105 75
120 60 120 60
45 45
135 135
30 30
150 150
165 15 165 15
180 + 0 180
+ 0
Fig. 1 Typical wavefront appearances of post-LRS corneas. In Panel a, post-hyperopic LRS cornea shows a steep surface centrally (red) and
a typical post-myopic LRS cornea shows a flat surface centrally (green) ring-shaped flatter area peripherally (green)
and ring-shaped steeper area peripherally (red). In Panel b, a typical
LRS, this must be conveyed to avoid creating unrealistic • Ocular Conditions

expectations. Even if a patient gives you a briefcase of cash, –– Mild-moderate ocular surface disease/dry eye
it’s not worth it. syndrome
–– Controlled glaucoma: LASIK requires increased intra-
Patient History ocular pressure for suction during flap creation, so
In order to select appropriate candidates for LRS, refractive PRK may be preferable
surgeons must carefully evaluate preoperative data (such as –– Epithelial basement membrane dystrophy (EBMD)
keratometry measurements to exclude steep and flat corneas, and recurrent corneal erosion syndrome (for LASIK;
etc.) and anatomical considerations, such as unusual orbit PRK may serendipitously help improve these patients’
and lid anatomy, severe ocular surface disease, and corneal pathology and refraction simultaneously since the
sensation. “PTK” portion is part of the PRK)
There are several absolute contraindications for LRS that –– Presence of cataract
can be elicited in the patient history that should be commit- From an optics perspective, several important consider-
ted to memory: ations from the patient’s history and medical records that can
• Systemic Conditions help determine whether a patient is a good candidate for LRS
–– Pregnancy include:
–– Collagen vascular diseases • Age of Patient: Unless part of a clinical study, LRS can
–– Uncontrolled diabetes only be performed on 18 years of age or older patients in
• Ocular Conditions the United States. Many surgeons may wait until a patient
–– Corneal ectasia (keratoconus, pellucid marginal degen- is at least 21 years of age to ensure refractive stability and
eration, etc.) reduce the risk of exacerbating subclinical corneal
–– Severe ocular surface disease/dry eye syndrome ectasia.8
Additionally, there are a few relative contraindications • Stability of Refractive Error: A patient’s manifest refrac-
for LRS that may be helpful to know: tion should be stable for at least 12 months before
• Systemic Conditions LRS. Every refractive surgeon and/or a given laser plat-
–– Diabetes (even if controlled): these patients are at form may have different cutoff rules. Most surgeons
increased risk for poor epithelial healing, so photore-
fractive keratectomy (PRK) may be less desirable than A useful resource for patients written in non-technical language can be
8
laser in-situ keratomileusis (LASIK) found at: https://www.aao.org/eye-health/treatments/lasik. Accessed

February 15, 2021.
442 K. M. Riaz
would agree that a sphere or cylinder change of >0.50D However, the importance of a skilled examiner, ideally the
should warrant repeat examination in 4–6 months until refractive surgeon him/herself, performing a meticulous
the refractive error is reproducibly stable. manifest refraction cannot be overstated. Hence the previous
• Magnitude of Refractive Error: while there are many discussions in Chap. 15, (Glasses in Clinical Practice) and
available laser platforms available in the United States, a Chap. 18, (Visual Acuity Testing and Assessment) are rele-
complete discussion of the parameters of each manufac- vant for all you aspiring LASIK surgeons.
turer’s laser is beyond the scope of this text. Currently, Important preoperative candidacy exam considerations
excimer lasers in the USA can correct up to −11/−12D include the following guidelines. If a patient does not meet
myopia, +5/6D hyperopia, and + 5/6D astigmatism.9 these requirements, the measurements can be repeated in
• Contact Lens History: patients should be out of SCLs 3–7 3–4 months until stability or normalcy is noted.
days and out RGPCLs 3 weeks with an additional one • Reproducibility and agreement of refractive error: For
week for every decade of wear prior to any exam for LRS myopic candidates, the sphere and cylinder components
candidacy. Suppose the initial candidacy exam reveals of the manifest refraction should not differ from the
abnormal topography (also known as “corneal warpage”) cycloplegic refraction by more than 0.5D. The astigma-
due to contact lens wear. In that case, the patient should tism axis should be within 15 degrees as well. For hyper-
be advised to remain out of contact lenses for an addi- opes, the sphere and cylinder components of the manifest
tional 1–2 months until repeat examination is consistently and cycloplegic refraction should differ no more than
stable, especially with reproducibly acceptable corneal 0.75D, whereas the astigmatism axis should be within 15
topographies.10 degrees.
As an aside, in the early days of LRS, sequential treat- • Keratometric (corneal) astigmatism and refractive astig-
ment of both eyes was the norm. As a result, patients often matism: for an ideal LRS candidate, the keratometric
had considerable, temporary anisometropia (and aniseiko- astigmatism should approximate the refractive astigma-
nia) between the two procedures requiring short-term contact tism. For example, if a patient has keratometry of
lens use. If sequential LRS is performed and a contact lens is 43.50/45.00 @ 90 in the candidate eye, a reassuring mani-
needed after the first procedure, the patient should be out of fest refraction would be −3.00 + 1.50 × 90 (20/15).
contact lenses at least one week prior to any (first or second) However, if the keratometric astigmatism significantly
laser treatment. differs from the refractive astigmatism (and the patient
still achieves good vision), there is likely lenticular astig-
Examination Considerations matism. Using the previous example, if the patient’s
While a full discussion of the preoperative exam is beyond refraction was instead −3.00D sphere (20/15), there is
the scope of this chapter, there are a few important candidacy likely lenticular astigmatism that neutralizes keratometric
considerations related to optics. First, both manifest refrac- astigmatism. Therefore, as a general rule for all LRS
tion and cycloplegic refraction are essential parts of the pre- patients, the laser treatment should be based on refractive
operative exam. An autorefraction or streak refraction may astigmatism rather than keratometric astigmatism; other-
be useful starting points, but neither can replace subjective wise, we may inadvertently unmask lenticular astigma-
manifest refraction. If you want to do refractive surgery, you tism to an undesirable post LRS refractive outcome (and
should be an expert at manifest refraction. The sharpest probably a very unhappy patient!).
visual acuity with the least amount of minus (“pushing plus”) • Corneal measurement values: Corneal topography is an
should be the final endpoint, especially in young myopic absolute requirement for any LRS candidacy examina-
patients; the Duochrome test and/or cycloplegic refraction tion. Modern topography devices can give additional
can be especially useful to ensure we are not inadvertently information regarding irregular astigmatism and potential
overminusing these patients. ectasia. As a general rule, approximately 0.75-8D of cor-
Second, most refractive surgeons also obtain a wavefront neal flattening occurs for every 1D of myopic ablation.
assessment preoperatively to assess pre-existing higher order For example, if we had a patient with a preoperative −4D
aberrations and assist with custom treatments (wavefront sphere refractive error, then LRS would cause approxi-
guided/wavefront optimized treatments). Aberrometry can mately 3–3.25D of corneal flattening. Similarly, if we had
further identify whether a patient’s refractive error has cor- a patient with a preoperative +3D sphere refractive error
neal (or indirectly, lenticular) causes for aberrations. with average K’s of 42D, then the postoperative K’s
would be: 42D + (1*3D) = 45D. While different surgeons
have different cutoff parameters, most would agree that
A mnemonic to remember this is the “10/5/5” or “12/6/6” rule.
9
These same principles apply to biometry in contact lens wearers prior

10 excessive flattening of the cornea (<35D) is undesirable
to cataract surgery as it may cause issues such as decreased corneal integrity,
irregular astigmatism, and higher order aberrations a

(HOAs). Conversely, approximately 1D of central c orneal
steepening occurs for every 1D of hyperopic ablation.
Most would agree that excessive steepening of the cornea
(>50D) is undesirable with a similar risk of inducing
irregular astigmatism and HOAs. b
• Flat and steep corneas: In addition to calculating postop-
erative corneal shape, preoperative corneal measurements
can be used to determine potential intraoperative risks,
especially with LASIK. For example, a flat cornea (<40D)
increases the risk of small flaps and free caps (especially
in the days of microkeratome-based LASIK). Similarly, a
steep cornea (>48D) increases the risk of a buttonhole flap Fig. 2 Beneficial prismatic effects of myopic and hyperopic glasses. In
(especially in the days of microkeratome-based LASIK).11 Panel a, a myopic patient with exophoria may enjoy a base-in advantage
Such patients may be better candidates for PRK or no when converging, especially for reading. In Panel b, a hyperopic patient
with esophoria may enjoy a base-out advantage when converging, espe-
LRS at all.
cially for reading
• Pupil size: It is crucial to measure pupil size in both
light and dark conditions. Patients with light-colored
irises, especially women, are more likely to have sig- an unhappy patient.13 For example, suppose we have a
nificantly large pupil sizes (>7 mm) under mesopic, young myopic patient with exophoria who wears
low light conditions. Remember from our previous dis- glasses; when the patient wants to read, the eye will
cussions that larger pupil sizes will incur more glare converge nasally, and he will enjoy some base-in help
and HOAs. In the previous days of LRS, myopic treat- with the glasses (Fig. 2a). If we treat the patient with
ment patterns were limited to the central 6–6.5 mm of LRS, the favorable base-in effect is lost and the patient
the cornea. Therefore, these patients had a “donut- may be unhappy with the decompensated exophoria.
shaped” untreated peripheral cornea that increased the Similarly, a hyperope with an esophoria may be happy
severity of HOAs, especially spherical aberration, in glasses because of the base-out effect of the glasses
leading to unhappy patients. We have learned from enjoyed by the patient during convergence (Fig. 2b).
these early days as newer lasers, primarily wavefront These patients can still undergo LRS but must under-
guided/optimized treatment strategies will treat stand they may need strabismus surgery or prisms post
(“smoothen”) additional portions of the peripheral cor- LRS. Another situation to avoid in patients with inter-
nea to limit the severity of HOAs. Therefore, patients mittent strabismus is prolonged monocular blurred
with large mesopic pupils may benefit from custom- vision from corneal haze or uncorrected refractive error
ized laser treatments to minimize these subjective post- after LRS as this can break their fusion and worsen their
operative causes of unhappiness and poor online strabismus.
reviews. Finally, we have left corneal thickness for last because it
• Ocular motility: Who would have thought that refrac- deserves a slightly longer and separate discussion. Under
tive surgeons had to remember some skills from their this topic, several important concepts include:
residency days doing neuro-ophthalmology and pediat- 1. While optical pachymetry (obtained by topography and
rics? Preoperative examination for both tropias and Scheimpflug tomography) is helpful for thickness mea-
phorias is necessary as some patients may have con- surements in various parts of the cornea, ultrasonic
trolled motility problems when wearing their glasses.12 pachymetry is much more accurate and necessary for the
If we simply treat the refractive error and pat ourselves candidacy examination. Thus, the decision for LRS is
on the back for making a patient glasses-free, we may based on ultrasonic pachymetry measurements.
inadvertently unmask a compensated phoria and create 2. Since LRS involves the removal of corneal tissue, it is
imperative to ensure that we are not leaving behind a
“thin” cornea that may be prone to ectasia (or even perfo-
A potentially useful mnemonic for remembering this: steep corneas
11
ration with minimal trauma). Historically, the Munnerlyn
cause buttonhole flaps (two e’s = two t’s). formula has been used to estimate the ablation depth for
A patient with existing phoria compensated with glasses may be
12
unhappy after surgery because the beneficial effects of glasses (base-in/

base-out effects and/or decreased needs for convergence) may be lost This can happen after cataract surgery as well, as discussed in Chap.
13
after LRS. 29, Postoperative Optics

444 K. M. Riaz
myopic corrections.14 While this formula remains useful, microns) is still the same, not 90% of 140–150 microns.
most surgeons use a rule of thumb of approximately Please consult a refractive surgery text for the finer details
14–15 microns of tissue removed for every 1D of myopic on this point.
ablation. For example, if we had a patient with a preop- When considering LRS in presbyopic and pre-presbyopic
erative refractive error −4D sphere, we can use patients, they should be counseled that they may need read-
Munnerlyn’s formula to calculate that approximately ing glasses immediately (or shortly) after LRS if they opt for
56.33 microns of corneal tissue will be removed. distance vision only. Therefore, it is necessary to have a pre-
Similarly, we can “shortcut” the math by multiplying the operative discussion regarding potential monovision treat-
refractive error by 14 and getting 56 microns. ment to allow for some near and intermediate vision after
3. The “Residual Stromal Bed (RSB)” is a key measurement LRS. With this strategy, the dominant eye is corrected for
for LRS. Recall that with PRK, the epithelium (approxi- plano while the nondominant eye is left slightly myopic
mately 50 microns) is removed prior to laser ablation of (range: −1.5 to −2D myopia). Remember that some loss of
corneal tissue. With LASIK, a flap (thickness range binocularity will result with monovision, so the following
90–140 microns) consisting of epithelium, Bowman’s additional considerations are necessary:
layer, and some anterior stroma is lifted prior to laser 1. Eye dominance: during the preoperative exam, we can
ablation of corneal tissue. The RSB is considered the ascertain eye dominance in patients through questions or
amount of corneal tissue that is neither ablated nor part of simple tests. For example, the patient can be asked to
the flap. The absolute lowest amount of RSB is 250 make a circle (“OK” sign) with his/her thumb and index
microns, though many refractive surgeons ideally prefer finger and look at a distance target; the preferred eye is
an RSB > 300 microns. likely the dominant eye. Additionally, the patient can be
4. The Percent Thickness Altered (PTA) is a relatively new asked to make a “diamond sign” using both hands’ thumb
measurement that measures the relationship between the and index finger to look at a distance target. Other ques-
flap thickness and ablation depth compared to the preop- tions include asking a patient which eye they would pre-
erative corneal thickness.15 The PTA is calculated as the fer to sight through a telescope, aim a gun (depending on
sum of the flap thickness (FT) and ablation depth (AD) where you practice, this may be very useful clinically) or
divided by the preoperative corneal thickness (CCT): take a picture through a camera. Never assume that the
PTA = (FT + AD)/CCT. If the PTA is greater than 40%, right eye is the dominant eye, even if the patient is
there is an increased risk of ectasia even with normal pre- right-handed.16
operative topography. Most refractive surgeons use PTA 2. Monovision contact lens trial: for patients who seek out
as an additional criterion in determining LASIK candi- LRS and have already been wearing monovision contact
dacy rather than a solitary exclusion criterion. Other sur- lenses, surgical planning is easy. We can simply main-
geons may consider a high PTA to be an indication for tain their monovision. However, for those patients who
PRK over LASIK, assuming all other measurements are have not previously experienced monovision, a 1–2-
normal. week trial with monovision contact lenses can be an
5. Custom-based ablations remove slightly more tissue than invaluable “test-drive” experience for that patient to
standard ablations. The full amount varies per laser and determine whether or not he/she likes the monovision.
the target treatment. The computer-based calculations Recall that patients with high demands for binocular
done by a given laser platform will usually give the exact vision, type A personalities, and extensive periods of
number of microns to be removed for the proposed treat- near-vision activities may be poor candidates for mono-
ment. Usually, this is not significantly more than what is vision LRS to begin with, so a simple monovision con-
calculated by the Munnerlyn or 1D:15-micron rule but tact lens trial can clinch the surgical decision. If a patient
may be important for higher treatments. undergoes a monovision contact lens trial and is some-
6. Advanced point: even if you reduce an ablation for higher what lukewarm about how much he/she liked it, one
myopes (for example, 10% reduction for −10.0D myope), option is to perform monovision LRS with the idea that
the amount of tissue ablated (approximately 140–150 the non-dominant eye can be “touched up” for emmetro-
pia in the future if the patient truly does not acclimate to
The Munnerlyn formula: t = S2*D/3, where t = thickness of the tissue
14 the monovision.
ablated (in microns); S = diameter of the optical zone (in millimeters);
and D = dioptric correction. The spherical equivalent can be used for D
for cases with significant astigmatism. Lawsuits have occurred wherein a right-handed patient underwent
16
Santhiago MR, Smadja D, Gomes BF, Mello GR, Monteiro ML,

15
monovision LRS with the right eye assumed to have been the dominant
Wilson SE, Randleman JB. Association between the percent tissue eye (when in reality the left eye was the dominant eye) without preop-
altered and post-laser in situ keratomileusis ectasia in eyes with normal erative confirmation using the tests and questions mentioned in the
preoperative topography. Am J Ophthalmol. 2014 Jul;158(1):87–95.e1. text. A monovision contact lens trial is extremely helpful in these cases.
Fig. 3 Representative Ablation Diameter

treatment profile algorithm
for a blend zone with variable
spot size treatment. Notice
that additional treatment is 8.0 mm
done for the peripheral cornea
to reduce potential
postoperative HOAs
1.0 mm 1.0 mm
0.8mm
Optical zone – 5 to 6 mm
Transition
zone
Ablated area – 9.0 mm

Optical Zone
(6.0mm)
Conventional Versus Custom Treatments ablation, depending on their preferred practice patterns
As discussed in Chap. 14, Physical Optics, recall that all and/or surgical results (range 1.5–10 Hz)
LRS procedures involve photoablation, wherein laser energy • Comparatively, the treatment dimensions for hyperopia
is used to break covalent bonds (carbon-carbon and carbon- are larger than the dimensions for myopia. In order to pro-
nitrogen) to vaporize collagen polymer chains into individ- duce a steeper central cornea with hyperopic ablations,
ual atoms. The target tissue undergoes sublimation the bulk of the treatment is directed in a ring-shaped pat-
(conversion from solid to gas). Photoablation lasers are con- tern to the peripheral cornea.
sidered “cold” lasers since minimal heat/force is generated • Astigmatism is corrected by focusing the laser treatment
during the tissue destruction process. to steepen the flatter axis, which may seem counterintui-
In the early days of LRS (the early 2000s), conventional tive at first glance.
treatments (also known as standard or traditional treatments) In contrast, custom LRS treatments use wavefront
were used for all patients. Again, as a simplification, conven- refraction and aberrometry measurements to design an
tional treatments were primarily based on the subjective individualized treatment profile for each patient. The most
refraction without a measurement (or consideration) of opti- significant feature of custom LRS treatments is the addi-
cal aberrations, especially HOAs. We have the benefit of tional treatment done to the peripheral cornea. For exam-
hindsight, but at that time, it was not known how much ple, if a custom LRS treatment is done (using a blend zone)
impact HOAs had on post LRS outcomes. While conven- for a patient with 6.00D myopia, then different portions of
tional treatments objectively treated the refractive error, they the cornea will be treated with varying amounts of treat-
treated a small central zone of the cornea (approximately ment. Within the central 6 mm optical zone, the laser will
6–6.5 mm) and created a mostly postoperative oblate corneal treat the full −6D. A blend zone will be additionally treated
shape. This in turn increased HOAs and decreased subjective outside this central zone: −5.00D will be treated at 6.5 mm
post-LRS vision, especially in patients with large pupils.17 and −1.00D at 8 mm (Fig. 3). Basically, a gradual slope
A few other (advanced) points regarding standard treat- will be created from the optical zone to the extreme periph-
ments, which also apply to custom treatments (discussed in eral untreated cornea.
the next section), include: One type of custom LRS treatment is wavefront guided
• Myopic treatments are typically done at lower rates treatments (WFG). In WFG treatments, information from the
(~6 Hz) than hyperopic treatments (~10 Hz). However, wavefront map guides the laser to customize the treatment
surgeons can choose how slow or how fast to perform the pattern so that irregularities can be corrected, leading to a
reduced incidence of glare, haloes, contrast sensitivity, and
difficulty with night vision. One potential limitation of WFG
These are the patients that end up going on nationally syndicated talk
17
is potentially dynamic (or inaccurate) measurements that
shows hosted by quack doctors to bad mouth LASIK.
446 K. M. Riaz
vary depending on age, patient accommodation, and pupil • Depending on a surgeon’s practice, custom treatments
diameter. The VISX Star S4 laser (Johnson & Johnson may incur additional financial costs to the patient com-
Vision, Santa Ana, CA, USA) is an example of a commonly pared to conventional treatments.
used WFG laser platform. More recently (FDA approval 2016), topography-guided
Another type of custom LRS treatment is wavefront opti- ablation treatments (TGA) have been introduced as a third
mized (WFO) treatments, which seek to correct potentially type of LRS. This technology seeks to improve outcomes of
reduced treatments on the peripheral cornea. While the full custom LRS and treat corneas that previously may have been
physics discussion is beyond the scope of this text, we can considered poor candidates for other types of LRS. In other
simplify this concept by realizing that because laser energy words, by adding corneal topography measurements (such as
directed to the central cornea comes in from a different direc- areas of elevation and irregularity), TGA may effectively
tion than laser energy directed to the peripheral cornea, there treat irregular corneas (aka “funny looking corneas”) to min-
is some unwanted reduction of treatment effect to the periph- imize postoperative aberrations. TGA treatments may be
eral cornea. In turn, this may worsen HOAs, especially especially useful for treating post-LRS complications, such
SA. With WFO, more energy is directed to the peripheral as decentered ablations and irregular astigmatism. The supe-
cornea (transition zone) to compensate for this loss. WFO riority of TGA in routine cases remains to be seen at the time
utilizes preoperative measurements and the attempted cor- of this writing.
rection, compares it to a normative database of patients, and
then selects an ablation pattern to minimize optical aberra-
tions (especially HOAs) after surgery. The WaveLight Selected Psychosocial Considerations
Allegretto Wave Eye-Q Laser (Alcon Laboratories, Fort
Worth, TX, USA) is an example of a commonly used WFO Refractive surgeons usually also have to moonlight as psy-
laser platform. chiatrists: when considering an LRS candidate, while the
Both WFG and WFO are two different philosophical previously mentioned ophthalmic considerations are essen-
treatment algorithms that seek to improve patients’ objective tial, there are additional psychosocial considerations that can
and subjective vision after LRS. WFG primarily seeks to benefit both the surgeon and the patient:
reduce pre-existing HOAs, while WFO seeks to minimize the 1. Reasonable postoperative visual expectations: As stated
induction of new (post-LRS) HOAs. While debate among previously, the primary goal of LRS is to provide patients
refractive surgeons may be as intense as the debate between with the same type of vision achieved with glasses and
Apple ® and Android ® users about which one is better, suf- contact lenses. LRS does not enhance or increase a patient’s
fice it to say that both WFG and WFO produce comparable preoperative vision potential. If a patient can only achieve
postsurgical visual outcomes. Most refractive surgeons 20/30 in a given eye due to amblyopia, for example, the
currently employ either WFG or WGO treatments for most patient should be counseled that he/she may never achieve
LRS patients. 20/20 vision; thus, surgery should be cautiously considered
A few other (advanced) points regarding conventional and only after extensive preoperative discussion in such
custom treatments are as follows: patients. If a patient demands unattainable vision through
• As mentioned previously, custom laser treatments remove LRS, it’s probably best to punt the patient to the local
slightly more corneal tissue than conventional laser treat- LASIK factory and avoid yourself the headache.18
ments. This additional tissue removed is negligible for 2. Understanding the healing process and appropriate time
most patients but may have additional considerations for to achieve the desired vision: Patients should be coun-
higher refractive errors. seled that despite the advances in LRS, it is still a surgical
• While upper limits of treatment vary depending on a procedure, and sufficient healing time (especially with
given laser’s capabilities, conventional LRS can treat PRK) must be given to achieve the desired result. If a
slightly higher amounts of myopia as compared to cus- patient demands instantaneous vision improvement
tom LRS. The amount of hyperopia that can be treated is through LRS or does not want to allow for the natural
about the same for both custom and conventional healing process to occur, it’s again probably best to punt
treatments. the patient to someone else and avoid yourself the
• For patients with mixed astigmatism (defined as a patient headache.
with refractive error with more cylinder than sphere, such
as −2.00 + 4.50 × 90), conventional LRS treatments may
allow for higher amounts of treatment than custom One would then hope that the referral provider would have the knowl-
18
edge and wherewithal to tell the patient he/she is not a good LRS
treatments. candidate.
3. Visual acuity does not equal visual function: Many LRS ectasia also merits further reading of appropriate texts, espe-
candidates may psychologically feel they have to read a cially in the current era of increased awareness and corneal
certain line on the eye chart (20/20, 20/15, or even 20/10) cross-linking.
to feel they had “successful” surgery. It is necessary to
discuss the difference(s) between measured visual acuity
and practical visual function. For example, a patient who Regression Versus Progression
can see 20/10 may overaccommodate to achieve good
distance vision and may suffer from reduced near vision. This is a favorite discussion point as many surgeons
4. The ideal LRS patient should have an easy-going nature, (wrongly) interchangeably use these terms when discussing
reasonable expectations, willingness to follow surgeon post-LRS refractive misses.
instructions, and understand that glasses/contact lenses It may be helpful to start with a dictionary definition
may still be needed in the near or distant future. After see- of each term. Regression is a return to a former or less
ing others’ misleading advertisements guaranteeing per- developed state. Progression is a movement towards a
fect vision, some patients may come in and expect you to more advanced state, especially gradually or in stages.
provide the same guarantees and outcomes. Any candi- Regarding LRS, both regression and progression may
date who does not meet these criteria should be punted occur, though both are more frequently seen with myo-
to… well, you get the theme here. pic LRS.
Regression may occur in the early weeks after myopic
LRS due to asymmetrical epithelial hyperplasia; basi-
ostoperative Optics Issues After Excimer
P cally, the eye tries to revert to its original curvature by
Laser Surgery filling in part of the ablated areas with epithelium. For
example, a patient who was −4.00D prior to LRS might
Every patient after LRS will sing your praises, refer 20 be 20/20 (plano) at post-op 1 week, but after 2–3 weeks,
friends and family members to see you for surgery, give you may be 20/25 with −0.75D refractive error. If such
a large briefcase of cash, and commission a statue in your regression occurs, prolonging or increasing topical ste-
honor. Of course, nothing in the previous sentence is true. roids (+/− topical cyclosporine) may help to reverse the
With modern technology and current techniques, LRS is regression. Increasing steroids is the same strategy used
generally a well-tolerated surgical procedure with excellent to treat early under-correction, and indeed there is likely
results. However, as with any surgery, complications may overlap between regression and under-correction (see the
occur and may be encountered by ophthalmologists who do following section). Even in normal postoperative cor-
not routinely perform LRS. While we will focus on the neas, long-term regression without significant clinical
optics-relevant postoperative issues after LRS, we would be refractive shift may occur (approximately 0.06D of
remiss not to mention that the most common (and usually, regression may occur per year).
thankfully, transient) adverse effect of LASIK is dry eye Patients with proven regression of refractive error may
syndrome. As LASIK involves the creation of an anterior need additional LRS treatment if medical therapy and obser-
flap, corneal nerves may be damaged during flap formation, vation fail to improve the symptoms.
leading to or exacerbating dry eye syndrome. PRK only Progression usually refers to a significant refractive shift
ablates the superficial nerve fibers and leaves the deeper that occurs years after LRS. For example, a patient who
nerves intact—therefore, after re-epithelialization, there are undergoes LRS at age 19 may have additional myopia
significantly fewer dry eye issues with this procedure. The 10 years later. In this case, it is unlikely that the laser treat-
effects of dry eye syndrome on refractive error and vision ment has “regressed” significantly; it is more likely that
quality should be evident by now.19 myopia progression is the more significant factor here. These
We will discuss a few potential postoperative ophthalmic patients may need a “touch-up” procedure years later to treat
optics issues after LRS below. Please review the discussions this progression. Therefore, younger LRS patients should be
on higher order aberrations in Chap. 14.20 Post-LRS corneal counseled about this potential late-term problem.
Additionally, patients who underwent LRS 10–15 years ago,
Please consult other refractive surgery resources for detailed discus-
19
especially during the early days of LRS, may present later in
sion of post-operative dry eye syndrome, as well as other postoperative life with myopia due to progression.
issues such as striae, flap dislocation, and diffuse lamellar keratitis
(DLK; aka “Sands of Sahara”)
As an advanced topic, some surgeons intentionally over-
You were warned previously that you would not be able to escape
20 treat young myopes to cause postoperative hyperopia (rang-
knowing the higher-order aberrations. ing from 0.50 to 0.75D hyperopia). The idea here is that these
448 K. M. Riaz
patients can comfortably accommodate a bit (which they may mize haze risk. When performing a retreatment for LASIK,
have been doing before LRS as well) to neutralize the hypero- one can either lift the flap for additional ablation or perform
pia; having this hyperopic “buffer” may allow the patient to PRK (“PRK over the top”) and avoid flap lift.
have some progression of their myopia with aging and “grow”
into emmetropia. Think of this as similar to your parents buy-
ing clothes 1–2 sizes bigger when you were younger. Similarly, Haze
some surgeons may welcome late progression in myopes
>40 years old because this progression may help with presby- Any disruptive injury requiring corneal epithelium regrowth
opia symptoms (which may not be a bad thing!). can activate fibroblasts and an inflammatory cascade. In
PRK, the corneal epithelium is mechanically or chemically
removed prior to laser ablation; successful surgery requires
Under-Correction Versus Over-Correction regrowth of healthy corneal epithelium. Aberrant tissue
growth during this re-epithelialization process can cause cor-
As a follow-up to the previous topic, a refractive “miss” may neal opacity and scar formation (haze). Patients at risk for
occur for various reasons, leading to (early) postoperative haze formation include higher refractive errors (>−6D),
under-correction or over-correction. Higher preoperative keloid formers, younger age, darker irises, and increased UV
refractive errors are more likely to be associated with under−/ light exposure after surgery.
over-corrections. As with many postoperative problems, Haze appears in the subepithelial layers, ranging from a
both of these issues may resolve themselves especially if the lacy, reticular opacity to dense scar-like fibrosis. Haze can
magnitude of unintended refractive error is relatively small present several weeks after PRK, peaking at 1–3 months, and
(up to 0.75D). then regressing or disappearing over 6–12 months. Patients
Under-correction occurs much more frequently with higher with poor epithelial healing history or tendency (e.g., EBMD,
degrees of myopia and hyperopia, especially with smaller diabetes, recurrent corneal erosion syndrome, etc.) may be at
optical zones of treatment (<6.0 mm diameter). If seen early in increased risk for developing visually significant, non-
the postoperative period, one option is to increase steroids to clearing haze. Why should you care about haze for clinical
decrease epithelial hyperplasia and reverse under-correction.21 and exam purposes? Haze can cause regression of the refrac-
This treatment is the same strategy for early regression if you tive correction and astigmatism (including irregular
have been paying attention. Indeed, there may be some over- astigmatism).
lap between early regression and under-correction, but that’s a In terms of prevention, mitomycin-c (MMC; concentra-
bit of a chicken-egg argument as well. tion 0.02–0.04%, treatment time range: 12–120 seconds) has
Over-correction of more than 1.0D at 1 year after LRS been effectively used to decrease the incidence and severity
occurs much less frequently, and it may also happen more of haze after PRK. Many refractive surgeons advise patients
frequently with PRK procedures than LASIK. Younger after PRK to use UV light protective sunglasses (3–12 months
myopes might not notice over-correction because they may after surgery) and/or oral vitamin C to further decrease the
be able to accommodate (generate plus power) to neutralize risk of haze. Persistent, visually debilitating haze may
the unintended hyperopia. If over-correction becomes prob- require phototherapeutic keratectomy (PTK) and/or mechan-
lematic, intentionally stopping steroids may cause some exu- ical scraping (with additional MMC) for removal.
berant healing and reduce the over-correction. Topical
NSAIDs may also help.22
For persistent under/over-correction, additional laser Central Island
treatment may be necessary. It is far easier to treat under-
correction than over-correction; think of getting a haircut at A central island can be considered as a focal area of untreated
the barber: it is far easier for the barber to cut more hair (treat corneal tissue within the intended treated zone. Basically,
the under-correction) than “add” hair (treat the over- think of this as an area that has been “missed” by the laser. It
correction). One advantage of LASIK compared to PRK is is defined as an elevation of at least 1D measuring more than
that since refractive stability occurs earlier, this allows for 1 mm compared to the surrounding treatment area (Fig. 4).
earlier enhancements (within 3 months). For PRK, one Central islands were more frequently seen with older broad-
should wait >3–6 months to stabilize the refraction and mini- beam lasers. They may resolve independently (within 6–12
months) but may require additional treatment (PTK or TGA)
to remove and improve refractive error.
A mnemonic to remember this: “ISTU” = increase steroids, treat
21
under-correction. Central islands can cause unexpected myopia or hypero-

A mnemonic to remember this: “NSAIDS may help NEGATE the
22 pia, astigmatism (including irregular), and higher order
correction”. aberrations.
105
90
75 LRS, we can introduce the concept of the “line of sight”:
120 60 because of the non-centered optics of the eye, the line of
45 sight isn’t necessarily equivalent to the visual and/or optical
135
axes. Therefore, the ideal ablation should be centered on the
150 30 area of the cornea that overlies the line of sight (i.e., the
entrance pupil).
15 A decentered ablation may appear on topography as a
165
“shift” of the central treatment area to a peripheral sector of
the cornea with a larger area of untreated cornea (Fig. 5).
180 ++ 0 Decentration was more frequently seen with older lasers that
lacked the ability for real-time eye-tracking. In the early days
of LRS, patient fixation on the operating microscope was
crucial for proper centration; if the patient’s eye drifted dur-
ing the procedure (or the surgeon did not position the
patient’s head at the beginning) and the surgeon did not re-
adjust, the ablation would instead be centered on a peripheral
area of the cornea—obviously, this is not a good thing.
Precise centration on the visual axis, rather than relying on
Fig. 4 Central island after LRS. Notice the focal area of elevated cor-
the pupillary axis, is much more critical for hyperopic than
nea (orange) within the treatment zone (blue-green) myopic treatments, as these eyes may have a significant
angle kappa.
90 Decentration up to 0.5 mm may be asymptomatic and
105 75
120 60 observed. However, decentration of ≥1.0 mm is usually
symptomatic. A decentered ablation may cause objective
135 45
refractive errors (myopia, hyperopia, and astigmatism) and
30
subjective glare, haloes, and other HOAs. Patients with
150
larger pupils may experience more symptoms with even
smaller amounts of decentration. RGPCL use or TGA treat-
15
165 ment may be necessary for persistent issues with
decentration.
180 ++ 0
Other Types of Refractive Surgery
While LRS is a significant component of Refractive Surgery,

there are several additional procedures that we can briefly
discuss.
Historical Procedures
Fig. 5 Decentered ablation. Notice the displacement of the treatment
zone (blue-green) with a large crescent-shaped area of untreated cornea
(red) While the history of refractive surgery includes many proce-
dures, ranging from ingenious to downright scary, we will
focus our discussion on two historical procedures that may
Decentered Ablation still be encountered in patients who present for routine eye
care with a remote history of refractive surgery: radial kera-
As a summary of our previous discussions on the three totomy (RK) and hexagonal keratotomy (HexK).
important axes,23 we can understand the importance of cen-
tering the ablation such that the patient looks through the adial Keratotomy (RK)24
R
treated area. The differences between the visual axis, optical RK was a procedure introduced in the late 1970s as a proce-
axis, and pupillary axis are negligible for most patients. For dure to treat myopia by making near-full thickness
See Chap. 26, Preoperative Optics for Cataract Surgery.

23
See also the discussion on RK in Chap. 26, Preoperative Optics
24
450 K. M. Riaz
Fig. 6 Radial keratotomy (RK) was an incisional procedure utilizing near-full-thickness radial incisions from the peripheral to central cornea. The
resultant corneal flattening would treat the myopic refractive error
a b c
Fig. 7 Radial keratotomy (RK) was an incisional procedure utilizing shows a T-cut (modified astigmatic keratotomy) used to treat astigma-
near-full-thickness radial incisions to cause corneal flattening and sec- tism. Panels b and c show 8 and 16 cut RK, respectively
ondary treatment of myopia. An increasing number of cuts (4, 8, 16, or
more) could be made to treat higher amounts of myopia. Panel A also
(approximately 90% corneal thickness) radial incisions to of myopia, though surgeons certainly pushed the boundaries
weaken the cornea’s mechanical strength and cause corneal in those days (Fig. 7).25
flattening (Fig. 6). Fun fact: excimer lasers were first invented to create more
An increasing number of incisions, ranging from 4–16 accurate and reproducible RK incisions rather than perform
cuts (or even more cuts, making you wonder what the sur- ablations!
geon was thinking at the time), could treat increasing
amounts of myopia. RK was primarily used to treat up to 4D
We’ve made this joke before, but wow, the 1980s were really an inter-
25
of Cataract Surgery. esting time.

While many RK clinical studies were done, the PERK exagonal Keratotomy (HexK)
H
Study (1982–1983) is a landmark study that merits a brief Hexagonal keratotomy (HexK) was a procedure wherein a
discussion.26 This study evaluated the safety and efficacy of series of paracentral incisions were made in a hexagonal pat-
RK for treatment of −2.00 to −8.75D of myopia. The 10-year tern to induce central corneal steepening and secondary
results showed that 53% of patients achieved ≥20/20 treatment of hyperopia (Fig. 8a). Fittingly enough, HexK
vision—pretty good! However, the biggest drawback of the was sometimes used to treat sequential hyperopia caused by
procedure was the unpredictability and instability of the PRK (Fig. 8b), with varying levels of success.
treatment effect. For example, a hyperopic shift (≥1D) was HexK was abandoned due to many problems and compli-
seen in 43% of the study patients—not pretty good! cations, such as glare, photophobia, corneal ectasia, fluctuat-
As RK could only treat spherical myopia, for patients ing vision, and diplopia/polyopia. Again, these post-HexK
with astigmatism, additional transverse incisions (“T-cuts” or patients may now present for cataract surgery with skewed
modified astigmatic keratotomy (AK) incisions) were placed corneal measurements making IOL calculations challenging.
as seen in Fig. 7, Panel A.
Other complications included diurnal fluctuation of
vision, glare, corneal scarring, higher order aberrations and Current Incisional Corneal Procedures
irregular astigmatism. In modern times, this is an abandoned,
obsolete procedure. However, you should know about RK Corneal incisional procedures are mainly used in the current
for exams and clinical practice, as many of these post-RK era of refractive surgery to reduce corneal (keratometric)
patients may now present for cataract surgery. See Chap. 26, astigmatism. These can be performed manually (with a
Preoperative Optics for Cataract Surgery, for additional guarded steel or diamond blade) or with the assistance of a
information on preoperative assessment and cataract surgery femtosecond laser (FSL). They can be combined with cata-
planning. ract surgery or performed outside of cataract surgery to cor-
rect naturally occurring and postsurgical astigmatism.
As previously discussed, when treating astigmatism with
incisional procedures, the main idea is to “flatten” the steeper
meridian of the cornea while “steepening” the flatter merid-
Waring GO 3rd, Lynn MJ, McDonnell PJ. Results of the prospective
26
evaluation of radial keratotomy (PERK) study 10 years after surgery. ian 90-degrees away to create a more uniform cornea with
Arch Ophthalmol. 1994;112(10):1298–1308. reduced corneal astigmatism. This concept of “coupling”
a b
Fig. 8 Hexagonal keratotomy (HexK). Panel a shows 6 paracentral cuts in a hexagonal pattern to cause central corneal steepening. Panel b shows
HexK performed after sequential hyperopia from RK (with T-cuts)
452 K. M. Riaz
states that flattening in one meridian will cause steepening in that occurs over time. LRIs are especially effective for reduc-
the meridian 90-degrees away; the amount of coupling ing ≤1.5D keratometric astigmatism.
depends on how close the incision is placed in relation to the
corneal center. A coupling ratio of >1.0 (meaning more flat-
tening occurs in the incisional meridian as compared to Intrastromal Corneal Ring Segments (ICRS)
steepening occurring in the meridian 90-degrees away) is
seen with procedures closer to the corneal center, such as While various intrastromal corneal ring segments (ICRS)
astigmatic keratotomy (AK). A coupling ratio closer to 1.0 is devices are available in other countries, INTACS (CorneaGen,
seen with procedures closer to the corneal limbus, such as Seattle, WA, USA) corneal ring segments are the only device
limbal relaxing incisions LRIs. available in the USA at the time of this writing. Historically,
Both of these procedures may cause under-correction or ICRS were developed around the same time as LRS (the early
over-correction of astigmatism, as well as corneal scarring 2000s) to treat low amounts of myopia by displacing corneal
and irregular astigmatism (corneal ectasia). Corneal perfora- lamellar bundles and shortening corneal arc length. Semi-
tion may occur as a rare complication. circle PMMA ring segments are placed in the mid-peripheral
corneal stroma (at approximately 70–80% depth) in a lamel-
stigmatic Keratotomy (AK)
A lar channel created mechanically or with an FSL. More cor-
Astigmatic keratotomy (AK) procedures refer to tangential neal flattening can occur by using thicker and asymmetric
incisions made in the mid-peripheral cornea. By definition, segments. For example, a commonly used ICRS strategy for
AKs are closer to the corneal center than LRIs and thus incur keratoconus involves placing a thicker segment (450
higher risks. We can further divide AKs into manual and microns) in the inferior cornea and a thinner segment (210
FSL-assisted AKs (FSL-AKs). microns) in the superior cornea. Several nomograms and
Manual AKs refer to incisions made with a guarded blade treatment strategies are utilized by surgeons performing
(steel or diamond) at approximately 95% depth in the cor- ICRS implantation.
neal mid-peripheral zone. A variety of nomograms have been While INTACS were initially developed to treat low
proposed regarding the length, location, and number of AKs amounts of myopia, the success of LRS quickly led many
to correct higher amounts of astigmatism. Historically, AKs refractive surgeons to abandon ICRS in favor of LASIK and
were often (and still) used to treat high amounts of corneal PRK, similar to BlueRay ® winning the competition against
astigmatism after PKP. Manual AKs usually cause a cou- HD-DVD ®. INTACS fell out of favor but then were re-
pling ratio > 1.0. purposed when surgeons began to use them to reduce astig-
FSL-AKs have recently been introduced as an alternative matism in keratoconus and corneal ectasias. It seemed that
method to correct lower amounts of corneal astigmatism (as INTACS now had a second life! However, while INTACS
compared to manual AKs), primarily at the time of cataract reduced astigmatism in ectatic corneas, they did not slow
surgery. As previously discussed in Chap. 26, Preoperative disease progression. Thus, keratoconus patients who received
Optics for Cataract Surgery, this is a highly controversial INTACS experienced a return (or even increase) of their pre-
topic as no large data sets have been published at the time of existing astigmatism. Some refractive surgeons again aban-
this writing to demonstrate superiority of this approach. doned INTACS because what was the point of a surgical
procedure if the potential benefits could not be sustained?
imbal Relaxing Incisions (LRIs)
L With FDA approval of corneal cross-linking (CXL) in 2016,
Please see Chap. 26, Preoperative Optics for Cataract INTACS have now made their second comeback. Corneal sur-
Surgery, for a review of limbal relaxing incisions (LRIs) in geons now use INTACS for patients with mild-moderate kera-
conjunction with cataract surgery. Outside of this setting, toconus with CXL to “flatten and freeze” an ectatic cornea.
LRIs may be used to treat corneal astigmatism, including Thus, INTACS can be placed to reverse corneal steepening,
post-cataract surgery astigmatism. and CXL can be used to halt disease progression. Several strat-
A guarded blade (550–600 μm depth) is used to create a egies have been proposed, including combining INTACS with
partial thickness (approximately 80–90%) circumferential CXL as a single procedure or staging the two procedures by
(aka “circum-limbal”) incision(s) in the peripheral cornea to several months. Some surgeons prefer CXL followed by
cause corneal flattening in the steep meridian and reduction INTACS, while others prefer the opposite when staging.
of corneal (keratometric) astigmatism. LRIs can be per- Finally, INTACS can also facilitate contact lens fitting as a
formed in the office or operating room setting. They produce result of corneal flattening.
less astigmatism correction than AKs, but are generally Complications with all ICRS procedures include inadver-
much safer; low-cost to perform; and carry a lower risk of tent corneal perforation, infection, and extrusion of the ring
glare, perforation, and irregular astigmatism than AKs. The segment. Other problems include reduced corneal sensitivity,
most significant disadvantage of LRIs is the inevitable induction of additional astigmatism, and night vision prob-
regression (up to 50% or more of the intended correction) lems (glare, haloes, and HOAs). ICRS does not stop disease
compared to LRS. There is significant interest among refrac-

LASIK
tive surgeons about the future of SMILE.
Surgical Treatment of Presbyopia
While we have thus far focused on treating myopia, hypero-

pia, and astigmatism, several surgical techniques and devices
may be considered for the treatment of pure presbyopia in
SMILE
select patient populations.
As an extension of LRS, monovision LASIK or PRK can
be used in this patient population in the presence of other
Fig. 9 Comparison of LASIK and Small Incision Lenticule Extraction refractive errors. Similarly, as an extension of cataract sur-
(SMILE). In LASIK, a flap (blue dotted line) composed of epithelium gery, monovision IOLs or advanced technology IOLs
(~50 μm) and stroma (~50–80 μm) is created prior to the ablation (light
blue area). SMILE involves using an FSL to create a stromal lenticule
(ATIOLs) for presbyopia can also be offered.
(light blue area) that can be removed via a side-cut incision. The ante- For pure presbyopia, several additional procedures can be
rior surface of the cornea is not violated with this technique offered. These procedures haven’t really gained widespread
popularity either due to lack of sustained effect and/or post-
progression, so if CXL is not done, the disease process may operative complications.
continue, especially in younger patients.
resbyopic LASIK (Multifocal Laser Ablation)
P
Presbyopic LASIK involves combining myopic LASIK with
Small Incision Lenticule Extraction (SMILE) modified laser treatment to create a steep central area in the
cornea—essentially creating a “bifocal” cornea. Since then,
Small Incision Lenticule Extraction (SMILE) is the latest additional modifications of this “PresbyLASIK” procedure
procedure to join the refractive surgery party, achieving have been used. For example, in peripheral presbyLASIK,
excellent postoperative results similar to other LRS proce- the central cornea is treated for distance vision, whereas the
dures.27 Inclusion and exclusion criteria are similar to LASIK peripheral cornea is treated to induce negative spherical
and PRK. Currently, SMILE can treat up to −10D myopia aberration and secondarily increase the depth of field for
and up to 3D astigmatism. near vision. In central presbyLASIK, a central hyperpositive
In this procedure, an FSL is used to create a stromal lenti- area is created for near vision, and the peripheral cornea is
cule that is then extracted through a small side cut incision treated for distance vision.
(Fig. 9). After removing the lenticule, corneal flattening and As with many refractive surgery procedures, PresbyLASIK
the desired refractive change occur. No excimer laser abla- hasn’t achieved widespread popularity due to problems such
tion is performed, so you can “smile” because the anterior as decreased contrast sensitivity and some compromise of
surface of the central cornea is not violated. visual acuity at all distances.28
Advantages of SMILE compared to LASIK and PRK
include preservation of the anterior corneal surface which onductive Keratoplasty (CK)
C
decreases the risk of dry eye syndrome, induces less biome- Conductive keratoplasty (CK) is another one of those proce-
chanical stress to the cornea, and possibly reduces the sever- dures where, with the benefit of hindsight, one wonders if
ity of induced aberrations. Other benefits include less patient this was ever a good idea. CK is a radiofrequency-based col-
pain and less refractive regression than LASIK and lagen shrinking procedure performed in the peripheral cor-
PRK. Furthermore, because the anterior corneal surface is nea in a ring pattern to treat 0.75–3D of hyperopia. A series
maintained, PRK or LASIK treatment for further reduction of 8–32 spots can be placed in a concentric pattern to induce
of refractive error is still possible. peripheral tightening (flattening) and secondary steeping of
The main disadvantages of SMILE include potential the central cornea to correct hyperopia and improve near
problems with FSL technology, limited range of treatment vision. CK may be performed in an office setting in one or
for myopic astigmatism, and unknown long-term results both eyes in a modified monovision (“blended vision”)
approach.
Zhang Y, Shen Q, Jia Y, et al. Clinical Outcomes of SMILE and

27
Alio JL, Chaubard JJ, Caliz A, et al. Correction of presbyopia by tech-
28
FS-LASIK Used to Treat Myopia: A Meta-analysis. J Refract Surg. novision central multifocal LASIK (presbyLASIK). J Refract Surg
2016 Apr;32(4):256–65. 2006; 22(5): 453–460.
454 K. M. Riaz
Unfortunately, CK had many side effects, including non- Disadvantages of pIOLs include the following:
clearing corneal edema, irregular astigmatism, and corneal • Additional cost due to use of an operating room (approxi-
scarring. Clinical evidence suggests that CK has transient mately 2–3× the cost of LRS) that is not covered by medi-
effects; significant regression of refractive effect may occur cal insurance
within 4–8 weeks of treatment. At present, some surgeons • Potential surgical complications for any incisional proce-
29
are utilizing CK in conjunction with CXL in keratoconus dure, such as infection, bleeding, etc.
patients. • Potential damage to iris, anterior chamber angle, and cor-
neal endothelium.
Corneal Inlays • Pupillary block and angle closure glaucoma. pIOLs
A variety of corneal inlay devices have been introduced require placement of at least 2 (generous) peripheral iri-
(and then subsequently withdrawn from the market) in dotomies to reduce the risk of this complication.
recent years to treat presbyopia. These devices involve cre- • Secondary induction of cataract (ASC cataract) due to
ating a corneal flap (similar to LASIK) and placing a pin- mechanical damage to the anterior crystalline lens.
hole-style biocompatible polymer inlay designed to increase As an advanced topic, for extremely high myopic refrac-
the depth of field to improve near and intermediate visual tive errors (more than -20D myopia), patients may benefit
acuity without affecting distance vision.30 Inlays may be from a staged procedure of pIOL followed by LRS for resid-
combined with LRS. Thus far, results from these surgical ual refractive error.
devices have not been significantly convincing for wide- While not all ophthalmologists may place pIOLs, these
spread adoption. patients may later present for cataract surgery. Some addi-
tional optics-related considerations for these patients
include:
Phakic IOLs • Preoperative biometry considerations: no additional
adjustments are needed on modern optical biometry
While not as popular in the USA, phakic IOLs (pIOLs) are devices to measure the eye and calculate the needed IOL
commonly used as a primary refractive surgery technique in power. You don’t have to adjust for the phakic IOL as you
other countries. Currently, the Visian ICL (Staar Surgical, would have to adjust for a patient with a previous history
Monrovia, CA, USA) is the only pIOL available in the of PRK or LASIK. A presbyopia-correcting ATIOL can
USA. Whereas previously, pIOLs could only treat myopic be considered as the corneal HOAs are similar to a non-
refractive errors, a toric pIOL was recently approved by the refractive surgery patient population.
FDA in August 2018. • Intraoperative considerations: at the time of cataract sur-
While older pIOLs were placed in the anterior chamber or gery, the pIOL has to be carefully removed prior to initiat-
affixed to the iris, current pIOLs are placed behind the iris ing the capsulorhexis, so a surgeon experienced with
and directly in front of the crystalline lens (in the sulcus pIOLs may be better suited for performing cataract sur-
space). Like cataract surgery, a pIOL requires a corneal inci- gery in these patients.
sion and is usually performed in the operating room.
Advantages of pIOLs include the following:
• Ability to correct −3.00 to −20.0D myopia with up to 4D Refractive Lens Exchange (RLE)
of cylinder
• Reversible procedure with no change to the cornea, Refractive Lens Exchange (RLE), also known as clear lens
including maintenance of anterior corneal surface exchange, can be considered “early” cataract surgery wherein
integrity. a non-cataractous crystalline lens is removed and replaced
• Lower incidence of glare, haloes, and HOAs with a presbyopia-correcting ATIOL. A lengthy discussion
• Lower incidence of dry eye syndrome of RLE is beyond the scope of this text as this is a controver-
• Better contrast sensitivity compared to LRS procedures sial topic even among ophthalmologists. RLE may be a
• Similar patient satisfaction to LRS procedures potential surgical option for patients with refractive errors,
• Because the cornea is not altered, IOL calculations for especially presbyopia, who are unsuitable for LRS or other
pIOL patients at the time of cataract surgery can be per- refractive surgical options.
formed as per routine (see below) For example, a potential RLE candidate may be a hyper-
opic patient with presbyopia who has developed contact lens
intolerance. RLE may be offered with the placement of
Rojas MC, Manche EE. Comparison of videokeratographic functional monofocal IOLs for monovision or presbyopia-correcting
29
optical zones in conductive keratoplasty and laser in situ keratomileusis

for hyperopia. J Refract Surg 2003; 19(3): 333–337. ATIOLs.
See the discussions regarding Diffraction and Depth of Field in Chap.
30 While high myopes may be thought of as another good
14, Physical Optics and Advanced Optical Principles. candidate population, in the presence of a formed vitreous,
there is a very high risk of retinal detachment even with What potential surgical options, if any, exist for this
successful surgery. Please consult other texts and resources patient?
for more information. We have included it here for the sake
of completeness and for readers to have a cursory awareness Scenario #3
of this procedure for exam purposes. A 22-year-old patient recently underwent uncomplicated
LASIK with you 2 weeks ago. Prior to surgery, she was
−7.50D sphere OD and −8.00D sphere OS with 20/20 vision
Practice Questions in her glasses. The patient reports that the vision has been
intermittently blurry since her surgery, especially at a bdis-
The following scenarios presented as practice questions will tance, and progressively worsens throughout the day. She is
hopefully connect some of the themes, procedures, and strat- a computer analyst and spends approximately 10 hours a day
egies discussed thus far in this chapter. in front of the computer and other handheld electronic
devices. She is highly concerned about an under-correction
Scenario #1 and wishes to schedule a touch-up enhancement procedure
A 25-year-old male presents to you to discuss surgical as soon as possible.
options to correct his myopia.
Visual OD : 20/25 OS : 20/30
Visual acuity, sc: OD : HM OS : HM acuity, sc
Manifest Rx: OD : − 23.50 + 2.00 × 85 (20/15) (today):
OS : − 24.00 + 2.25 × 95 (20/15) Manifest Rx OD : − 2.00 sphere (20/15)
(today)
Topography: OD : 44.00 × 46.00 @ 85
OS : − 2.25 sphere (20/15)
OS : 44.00 × 46.25 @ 95
Exam, Unremarkable OU. Well-healed LASIK flaps OU.
No ectasia or inferior steepening in both eyes
including
Pachymetry: OD : 540 OS : 550 DFE:
Exam, including DFE: unremarkable OU Cycloplegic OD : plano (20/15) OS : − 0.25 + 0.25 × 80 (20/15)
Rx (today)
What potential surgical options, if any, exist for this
patient? What potential options, including nonsurgical and surgi-
cal, exist for this patient at this time?
Scenario #2
A 36-year-old patient presents to your office after moving Scenario #4
into town a few months ago. She reports that she had LASIK A 60-year-old patient is highly motivated to have refractive
in both eyes approximately 18 years ago at a provider else- surgery to improve his vision as you successfully performed
where. Prior to surgery, she was −8.50D sphere in both eyes. LASIK on his 30-year-old son 6 months ago. He does not
She reports difficulty with glare and halos, especially at night currently wear glasses or contact lenses for distance, though
time. She states that she was told that her LASIK might wear occasionally uses some reading glasses for long periods of
off after then years, and she may need a “touch up” proce- near work. He works as an accountant and is an avid golfer
dure. She is very eager to proceed with a LASIK enhance- during the weekends, and he reports some glare while driv-
ment and has an unmarked envelope full of $100 bills that ing at night.
she casually places on the countertop.
Visual acuity, sc: OD : 20/25 + , J12 near OS : 20/100 distance,
Visual acuity, sc: OD : 20/20 OS : 20/25 + 1 J2 near
Visual acuity, cc: OD : 20/15 OS : 20/15 Manifest Rx: OD : − 0.25 + 0.50 × 180 (20/20)
Manifest Rx: OD : − 0.50 + 0.25 × 90 (20/15) OS : − 1.75 (20/20)
OS : − 0.50 sphere (20/15) Cycloplegic Rx: similar to manifest
Pupils: Light : 4.5mm OU Dark : 8.5mm OU Topography: Unremarkable OU. No evidence of ectasia.
Exam, including Unremarkable in both eyes. Well-healed LASIK Pupils: Light : 4 mm OU Dark : 7 mm OU
DFE: flaps OU. Exam, including Unremarkable OU
DFE:
Topography: consistent with post-myopic ablation with What should be discussed and offered to this patient?
central flattening changes; no abnormalities or ectatic
changes.
456 K. M. Riaz
Answers unwanted peripheral light rays during bright-light condi-

tions. The Stiles-Crawford effect states that the light
1. There is no single surgical procedure currently available entering the eye near the edge of the entrance pupil pro-
that will correct his entire refractive error. A staged duces a lower photoreceptor response than light of equal
approach for myopia correction can be discussed. Given intensity entering near the center of the pupil. In other
that the patient is beyond the approved limits for LRS, words, the brain gives more “preference” to photorecep-
PRK/LASIK is not possible as a primary procedure. tors that receive central light rays in photopic conditions,
However, a cycloplegic refraction and dilated fundus but when more peripheral photoreceptors are activated in
exam should be performed nonetheless prior to any surgi- mesopic conditions, the brain can’t help but notice the
cal decision in any patient with this amount of myopia peripheral, defocused light rays.Back to our patient: treat-
due to the high incidence of p eripheral retinal pathology ment and reassurance would be the best option at this
in this patient population. RLE would incur arguably time. The mild myopia may also help the patient delay the
unacceptable risks (e.g., retinal detachment) in a young need for reading glasses for a few years. Additional LRS
myope, including loss of accommodation postoperatively. to treat the minimal myopic refractive error may help the
Therefore, one potential option is to first place a toric objective vision but is unlikely to help her main com-
pIOL to correct approximately 20D of myopia (recall that plaints of glare and halos at night time. A mild pupillary
pIOLs can correct −3 to −20D myopia, with up to 4D of constrictor (for example, dilute brimonidine) may be
cylinder) with full correction of the 2D and 2.25D of offered for the reduction of symptoms at night time.
refractive astigmatism, respectively in each eye, which Glasses and/or contact lenses are also reasonable
corresponds to the keratometric astigmatism. After allow- options. As a final (advanced) point, topography-guided
ing sufficient time for healing and stabilizing the refrac- ablation (TGA) could be offered if the topography showed
tion, PRK or LASIK can be performed for the residual abnormalities.
refractive error. It is important to inform the patient that 3. This scenario is a classic example of postoperative LRS
temporary glasses may be needed for the residual refrac- refractive error seen in the early postoperative period. The
tive error while the eyes heal from the pIOL surgery. main causes of postoperative LRS refractive error include
2. This vignette is a typical example of a post-LRS patient the following 6 potential reasons:
(who likely received a standard ablation based on LASIK • Development of corneal ectasia
history 18 years ago) with visual decline due to subjective • Development of cataract
rather than objective issues. The manifest refractive shows • Progression of myopia
a minimal refractive error that is unlikely to cause her pri- • Regression of corrective effect
mary issues of glare and halos. In other words, her prob- • Deliberate or unintentional under-correction
lems are not due to regression or progression of myopia. • Spasm of accommodation
The more likely explanation for her subjective complaints It is unlikely that the patient developed corneal ectasia
is due to HOAs, especially spherical aberration, based on or a cataract within 2 weeks of LASIK. Similarly, it is
the history and the scotopic pupil size.Problems with unlikely that progression or regression of myopia occurred
HOAs are more likely with higher amounts of laser abla- within such a short time. We should definitely check the
tions and smaller optical zones used in the days of stan- LASIK op-notes to ensure that there was no deliberate or
dard (conventional) LRS. Recall that in standard LRS, the unintentional under-correction. However, looking at
peripheral cornea is essentially left untouched. During the today’s manifest refraction, we notice that she requires a
daytime, her pupil is 4.5 mm and therefore smaller than lot of myopic correction for minimal refractive error; this
the likely optical zone (6–6.5 mm), so only the incoming disappears with the cycloplegic refraction. We also notice
light refracted by the treated central cornea reaches the that she is a young myope who spends a considerable
fovea and a relatively clear (stigmatic) image is formed. amount of time focusing at close due to her job require-
However, in low-light conditions, the pupil dilates consid- ments. Therefore, it is most likely that spasm of accom-
erably larger than the optical zone; therefore, incoming modation is the culprit in this situation.In this case, getting
light will pass through the treated central cornea and the a cycloplegic refraction is the key to solving the puzzle.
peripheral ring of untreated cornea to cause a myopic Initially, reassurance is the mainstay of treatment, along
defocus secondary to spherical aberration, which the with education regarding methods to break accommoda-
patient perceives as glare and halos at night-time.As an tion such as frequent breaks and focusing at distance
aside, the Stiles-Crawford effect may also help negate objects during work hours. For persistent symptoms, a
short course of cycloplegia may be offered. Eventually, reous separation, etc.) are normal, then RLE with pres-
she should break out of her accommodation so it is cru- byopia-correcting ATIOLs may be offered. For exams,
cial that we do not enhance this patient at this time. conservative options should always be discussed prior
4. Answer:This patient has naturally occurring monovision. to surgical treatments.
Despite his enthusiasm for LRS based on his son’s excel-
lent outcome, he may not be the best candidate for LRS
because he likely functions well without any refractive Recommended Additional Reading
correction. We may be tempted to correct the left eye, but
he would lose his near vision that may hinder his job as an The following is a recommended, but not comprehensive, list
accountant, even if his vision was 20/15 in the left eye. of additional resources for learning more about refractive
The right eye spherical equivalent is basically surgery:
plano.Additionally, he is starting to have some glare and 1. Feder RS, Rapuano CJ (eds). The LASIK handbook: a
has relatively large (especially for a male) scotopic pupils. case-based approach. Philadelphia: Lipincott, Williams,
LRS may further worsen these subjective symptoms.The & Wilkins; 2007.
safest option at this time is to offer him “night-time 2. Azar D, Gatinel D, Ghanem R, Taneri S (eds). Refractive
driving” glasses with anti-glare reflective coating that surgery, 3rd edn. Elsevier; 2019.
corrects distance vision in both eyes. Currently, he does 3. Randleman JB. Refractive surgery: an interactive case-
not have a visually significant cataract but might be on based approach. Slack Incorporated; 2014.
his way to developing one in a few years. If the patient 4. Sinjab MM. Corneal topography in clinical practice
is highly motivated and additional exam considerations (Pentacam System): basics & clinical interpretation.
(such as normal axial length, presence of posterior vit- Jaypee Brothers Medical Publishers; 2012.
References, Suggested Reading,
and Online Sources
Modern Optics Textbooks Classic Optics Textbooks

1. American Academy of Ophthalmology. Basic and clinical sci- Benjamin WJ. Borish’s clinical refraction. 2nd ed. Waltham:
ence course, section 3: clinical optics, 2020-2021. San Francisco: Butterworth-Heinemann; 2006.
American Academy of Ophthalmology; 2021. Campbell CJ. Physiological optics. New York: HarperCollins; 1974.
2. Babbetts RB. Bennett and Rabbett’s clinical visual optics. 4th ed. Duke-Elder S, Abrams D. System of ophthalmology – ophthal-
Philadelphia: Elsevier; 2007. mic optics and refraction, vol. 5. Maryland Heights: CV Mosby
3. Bennett ES, Henry VA. Clinical manual of contact lenses. 5th ed. Company; 1970.
Philadelphia: Lipincott, Williams & Wilkins; 2019. Fry GA. Geometrical optics. Boston: Chilton Book Company; 1969.
4. Brooks CW, Boorish IM. System for ophthalmic dispensing. 3rd Garcia GE. Handbook of refraction. 4th ed. New York: Little, Brown
ed. Oxford, UK: Butterworth-Heienemann; 2006. and Company; 1989.
5. Corboy JM. The retinoscopy book: an introductory manual for eye Guyton DL, West CE, Miller JM, Wisnicki HJ. Ophthalmic optics and
care professionals. Thorofare: Slack Incorporated; 2003. clinical refraction. Baltimore: Prism Press; 1999.
6. Dowaliby M. Practical aspects of ophthalmic optics. 4th ed. Oxford, Henson DB. Optometric instrumentation. Oxford, UK: Butterworth-
UK: Butterworth-Heinemann; 2000. Heinemann; 1983.
7. Elkington AR, Frank HJ, Greaney MJ. Clinical optics. 3rd ed. MacInnis BJ. Ophthalmology board review of optics & refraction.
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8. Hunter DG. Last-minute optics: a concise review of optics, refrac- Michaels DD. Basic refraction techniques. New York: Raven Press;
tion, and contact lenses. 2nd ed. Thorofare: Slack Incorporated; 1988.
2010. Milder B, Rubin ML. The fine art of prescribing glasses without mak-
9. Kaschke M, Donnerhacke KH, Rill MS. Optical devices in ophthal- ing a spectacle of yourself. 3rd ed. Gainesville: Triad Publishing
mology and optometry: technology, design principles and clinical Company; 2004.
applications. 1st ed. Weinheim: Wiley-VCH; 2014. Rubin ML. Optics for clinicians. 2nd ed. Gainesville: Triad Publishing
10. Katz M. Introduction to geometrical optics. 1st ed. Hackensack: Company; 1974.
World Scientific Publishing Company; 2002. Reinecke RD, Herm RJ. Refraction: a programmed text. Norwalk:
11. Keating MP. Geometric, physical, and visual optics. 2nd ed. Oxford, Appleton-Century-Crofts; 1976.
UK: Butterworth-Heinemann; 2001.
12. Shukla AV. Clinical optics primer for ophthalmic medical person-
nel: a guide to Laws, formulae, calculations, and clinical applica-
tions. 1st ed. Thorofare: Slack Incorporated; 2009.
Online Resources: Texts and Lectures
American Academy of Ophthalmology OKAP and Board Review, sec-
tions on “Basic Optics”, “Lens/Cataract” and “Refractive Surgery”.
Modern Ophthalmology Textbooks with Optics https://www.aao.org/okap-study-presentations.
Sections Ophthalmology Oral Board Review Course. Recorded lectures for writ-
ten exams and oral exams for optics. www.osler.org/ophthalmology.
Chern KC, Saidel MA. Review questions in ophthalmology. 3rd ed.
Philadelphia: Lipincott, Williams & Wilkins; 2018.
Chern KC, Saidel MA. Ophthalmology review manual. 2nd ed.
Philadelphia: Lipincott, Williams & Wilkins; 2011. Online Resources: Question Banks
Friedmann NJ, Kaiser PK, Trattler WB. Review of ophthalmology. 3rd
ed. Philadelphia: Elsevier Saunders; 2017. Basic and Clinical Science Course Self-Assessment Program. https://
Luviano DM. Ophthalmology oral board review. 1st ed. Philadelphia: store.aao.org/basic-and-clinical-science-course-self-assessment-
Lipincott, Williams & Wilkins; 2018. program.html.
Pemberton JD, Daniels A, Fay A. Ophthalmology clinical vignettes Ophthalmology Question Bank. www.Ophthoquestions.com.
Oral exam study guide II. Little Rock: Crimson House Publishing;
2015.
Tamesis R. Ophthalmology board review: pearls of wisdom. 2nd ed.
New York: McGraw-Hill; 2005.

K. M. Riaz et al. (eds.), Optics for the New Millennium, https://doi.org/10.1007/978-3-030-95251-8
Index
A clinical relevance, 165

Abbe value, 230, 231 compound hyperopic astigmatism, 160
Aberrations, 200 compound myopic astigmatism, 160
Aberrometry, 201, 202, 215 corneal astigmatism
Absolute hyperopia, 112 ATR, 157, 158, 165, 166
Absolute presbyopia, 113 oblique astigmatism, 158
Accommodation, 117 sutures, 156, 157
ability, 116 WTR, 157, 158, 165
AOA, 117 corneal vs. lenticular astigmatism, 154, 155
ciliary muscle contracts, 112 definition, 153
definition, 111, 113 JCCL, 163–165
distance vision, 112 mixed astigmatism, 160, 161
emmetropic patient, 112 pantoscopic tilt
Frisbee, 112 AOOI, 162, 163
hyperopia, 112, 113 single vision lens, 161
hyperopic patient, 111 spherical lens, 161, 162
internal refractive errors, 111 refractive vs. ocular astigmatism, 155, 156
nerves and ciliary muscles, 117 regular vs. irregular astigmatism, 156
presbyopic myopes and presbyopic hyperopes, 115, 116 simple vs. compound astigmatism, 156
refractive errors, 113–115 simple hyperopic astigmatism, 159
Accommodative esotropia (AET), 339–341, 347, 355 simple myopic astigmatism, 158, 159
Accommodative excess, 113 Astigmatism of oblique incidence (AOOI), 162, 163
Accommodative insufficiency, 113 Astronomical (Keplerian) and Galilean telescopes
Achromatopsia, 240 clinical examples, 98
Acrylic, 398 construction, 99
AcrySof platform, 403 eyepiece, 98, 105
Activities of daily living (ADLs), 297–299 magnification, 98, 99
Adult esotropia (Adult ET), 342 negative lens, 98
Advanced technology IOLs (ATIOLs), 415 positive lens, 98
Against-the-rule (ATR), 157, 158, 165, 166, 430 sample telescope problems, 99, 100
Air-tear film interface, 13, 440 types, 97, 98
Airy disc, 11 Auto-refraction, 225
Albinism, 240 Axial length, 376
Amplitudes of accommodation (AOA), 113, 225, 226 Axial magnification, 94, 95, 105
Amsler grid, 143, 151
Angular magnification, 95, 96, 105, 263
Aniseikonia, 103–105, 356 B
Anisometropia, 103–105, 353–354, 356 Barium glass, 229
Anisotropy, 195 Biconvex, 417
Anterior chamber depth (ACD), 428 Bifocal architecture types
Anterior chamber IOLs, 407, 415 executive-style bifocal, 169, 170
Anterior corneal surface, 418 flat-top bifocal, 169
Anterior lamellae, 440 PAL, 170, 171
Antireflective film, 213, 214 round-top bifocal, 169
Aphakia, 333–334 Bifocal construction types, 167, 168
Aphakic magnification, 101–103 Bifocal lenses, 257
Apodized diffractive MFIOLs, 409 Binocular blindness tests, 336
Aspheric IOLs, 387, 402 Binocular indirect ophthalmoscope (BIO), 266–268
Asthenopia, 331, 332 Binocular vision testing, 287–288
Astigmatic keratotomy (AK), 452 Bioptic telescopes, 304
Astigmatism Break phenomenon, 249

K. M. Riaz et al. (eds.), Optics for the New Millennium, https://doi.org/10.1007/978-3-030-95251-8
462 Index
C Critical angle, 10
Capsular block syndrome (CBS), 426 Crown glass, 229
Cellulose acetate butyrate (CAB), 310 Custom LRS treatments, 445
Cemented bifocal, 168 Cyclopleged emmetrope, 115
Central island, 448 Cycloplegic hyperopia, 112
Central serous chorioretinopathy (CSCR), 326 Cycloplegic refraction (CRx), 221
Chord Mu, 384
Choroidal melanoma, 338
Choroidal neovascularization (CNV), 211 D
Chromatic aberration, 223 Decentered ablation, 449
Chromophores, 210 Defocus curves, 293, 294, 412
Ciliary body tumor, 327 Demo-2 Crew Dragon launch, 370
Circle of least confusion (COLC), 140–142, 146 Destructive interference, 188
“Closer adds plus (CAP)” mnemonic, 79 Dichromats, 208
Coherence, 213, 214 Diffraction, 11, 12
antireflective coatings, 190, 191 Diffractive multifocal intraocular lenses (DMFIOLs), 200, 408
OCT, 189, 190 Diffuse reflection, 9
optical biometry devices, 190–192 Diopters, 16–18, 29
types, 189 Direct ophthalmoscope, 263–266
Cold laser, 213, 214 Dispensation, 24
Collamer, 398 Dispensing contact lenses, 354
Collamer IOL, 428, 438 Dispersion, 7, 8, 13
Color deficiencies, 214 Distometer, 219, 261, 262
Color vision testing, 288–289 Distortion, 5–7
Columbia resins 39 (CR-39), 229, 230 Double arches method (DAM), 144, 151
Combined vertical and horizontal diplopia, 26 Duochrome test, 101, 223–225, 287, 337
Complete ophthalmic analysis system (COAS), 369 Dysphotopsias, 9, 10, 398, 434
Compound hyperopic astigmatism, 160
Compound myopic astigmatism, 160
Conductive keratoplasty (CK), 453 E
Congenital idiopathic nystagmus (CIN), 287 Early treatment diabetic retinopathy study (ETDRS), 283
Congenital stationary night blindness (CSNB), 240 Eccentric fixation (EF), 196
Conoid of sturm (COS), 140–142 Echelettes, 410
Constructive interference, 188 Edge-to-edge power, 400
Contact lenses (CL), 182, 183, 354, 366 EDOF-IOLs, 417
architecture, 309–310 Effective lens position (ELP), 426
materials, 310–311 Electronic displays, 303–304
patient education, 316–317 Electroretinography (ERG) test, 286
presbyopia correcting, 317–318 Emmetrope, 113, 114
RGPCLs, 180, 181, 313–315 Emmetropia, 448
ScCLs, 318–320 Emmetropization mechanism, 358, 359
SCLs, 311–313 Endothelial keratoplasty (EK), 389
clinical practice, 177 Enlargement ratio (ER), 307
features, 177, 178 Entoptic phenomenon, 375
sample problem, 178–180 Esotropia, 354, 355
select situations, 320 ETDRS visual acuity chart, 283, 284
STCLs, 181, 182, 313 Excimer laser refractive surgery, 439
surface properties, 311 Executive-style bifocal, 169, 170
troubleshooting, 317 Extended depth of focus (EDOF) IOLs, 410
Contrast sensitivity, 289–291, 445 Extracapsular cataract extraction (ECCE), 328
Contrast sensitivity function (CSF), 291, 292 Extreme high power IOLs, 407
Conventional treatments, 445 Extreme low power IOLs, 406
Convergence insufficiency (CI), 25, 342, 343 Eye dominance, 444
Converging lens, 36
Convex-plano, 417
Convex-plano IOLs, 401 F
Corneal astigmatism, 154, 155, 408 Facultative hyperopia, 112
ATR, 157, 158, 165, 166 Far point, 113
oblique astigmatism, 158 Femtosecond laser, 215
sutures, 156, 157 Flat-top bifocal, 169
WTR, 157, 158, 165 Flint glass, 229
Corneal cross-linking (CXL), 452 Focusing circle, 273
Corneal incisional procedures, 451 Fourier-domain OCT (FD-OCT), 190
Corneal surgery, 389 Fresnel (temporary) prisms, 24, 25
Corneal thickness, 443 Functional presbyopia, 113
Index 463
G risk factors, 203

Gain medium, 209 spherical aberration
Galilean telescopes, 304 advantage of, 203
Geneva lens clock (GLC), 251, 253–256, 273, corneal vs. lenticular spherical aberration, 205
275, 276 disadvantage of, 203, 204
Geometric optics, 4 implications, 203
diffraction, 11, 12 IOLs options, 206
light rays, 3, 4 laser refractive surgery, 205, 206
reflection, 8–11 negative spherical aberration, 205
refraction, 4–8 peripheral light rays, 203
refractive index, 4 positive spherical aberration, 204, 205
Geometric wavefront, 200 Q-value, 206, 207
Glare, 443, 445 trefoil, 207
Glasses, 227, 228, 240–242 Hybrid contact lens, 320
abbe value, 230, 231 Hydrophilic acrylic IOLs, 398
albinism, 240 Hyperopes, 114, 172, 173, 175, 176
auto-refraction, 225 Hyperopia, 112, 113
bifocal architecture types Hyperopic refractive errors, 351
executive-style bifocal, 169, 170 Hyperopic surprise, 380, 428
flat-top bifocal, 169
PAL, 170, 171
round-top bifocal, 169 I
bifocal construction types, 167, 168 iDesign® Advanced WaveScan Studio, 369
CRx, 221 Implantable miniature telescope (IMT), 305
CSNB, 240 Incipient presbyopia, 113
custom glasses Interference
activities, 238 constructive interference, 188
gradient modification, 239 destructive interference, 188
non-traditional bifocals, 237, 238 fluorescein angiography, 188, 189
polarized sunglasses, 239, 240 intensity patterns, 188
tints, 238, 239 light source, 187, 188
duochrome test, 223–225 Interstellar (2014), 3
in kids, 226, 227 Intraocular lenses (IOLs), 206, 397
lens coatings, 231 advanced technology, 408–412
lens materials, 229, 230 monofocal, 403
manifest refraction, 219–221 optics, 397–401, 403
presbyopia, 225, 226 toric IOLs, 407
prismatic effects Intraoperative aberrometry (IOA), 420
image displacement, 172, 174, 176 Intraoperative optics
image jump, 171, 176 anterior chamber IOLs, 415
myopes vs. hyperopes, 172, 173, 175, 176 intraoperative aberrometry, 422
streak refraction, 221–223 IOLs, 422, 423
troubleshooting Purkinje images, 417–420
diagnosing problems, 231–234 sulcus, 416
fixing problems, 234, 235 Intrastromal corneal ring segments (ICRS), 452
high minus glasses, 235, 236 Irregular astigmatism, 156
high plus glasses, 236, 237 iSert platform, 405
wavefront refraction, 225
J
H Jack-in-the-box (JITB) phenomenon, 237
Haag-Streit slit lamp microscope, 270 Jackson cross cylinder (JCC), 220
illumination system, 269–271 Jackson cross cylinder lens (JCCL), 163–165
Haidinger’s brush, 195–197, 213, 214, 375 Javal’s rule, 430
Haloes, 445
Haptic-optic planarity, 399
Hard contact lenses, 180, 181 K
Hartmann-shack wavefront aberrometry, 215 Keplerian (astronomical) telescopes, 304
Haze, 448 Keratometer
Hemianopic visual field defect, 28 manual keratometer, 272–274
Hexagonal keratotomy (HexK), 451 Purkinje images, 272
High index of refraction, 230 Keratometry readings, 143
Higher-order aberrations (HOAs), 447 Kestenbaum’s rule, 302, 307
coma, 207 Knapp’s rule, 105
overview, 203 Kohler illumination principle, 269, 270
464 Index
L MFIOLs, 417
LADAR technology, 369 Micro and zero-gravity
Laser in-situ keratomileusis (LASIK), 439 NASA’s optics research, 369
Laser refractive surgery (LRS), 440 RGPCLs, 366
Lasers, 213, 214 several refractive surgery procedures, 366, 367
accidental damage, 211, 212 space travel, 367–369
components, 209, 210 spectacles, 366
light damage, 210–212 vision standards and criteria, 365–366
properties, 208, 209 Mie scattering, 198, 213, 214
safety, 211, 212 Minimum separable threshold (MST), 279
uses, 210, 211 Minimum visible threshold (MVT), 279
Latent hyperopia, 112, 330 Minus lenses, 78–79
Law of reflection, 9 Mirrors and combined systems
Left homonymous hemianopia, 28 concave mirror, 54, 55
Legal blindness, 294, 297 convex mirror, 55–57
Lens effectivity -8D myope, 67
dioptric power value, 77 focal length (f), 51
far point, 79, 80 index of refraction effects, 60, 61
minus lenses, 78–79 location of intermediate, 57
plus lenses, 77–78 LOST method, 52–55
+10D lens, 77 multiple lens system, 65–67
vertex distance calculation, 84 90D lens, 67
Lensmeter, 273, 275, 276 object–lens system, 62, 63
bifocal lenses, 257 object–mirror system, 63, 64
ground-in prism, 258, 259 orientation of intermediate, 57
optometer principle, 255, 256 plano mirrors, 49–51
SVL glasses, 257 positive (plus power) mirrors, 52
Lenticular astigmatism, 154, 155 positive U, 59, 60
Limbal relaxing incisions (LRIs), 392, 440, 452 power of, 51, 52
Linear magnification, 91–94 radius of curvature (r), 51
Longitudinal magnification, 94, 95 reduced vergence/simple lens formula, 62
Low-dose atropine, 362 -3D myope, 68
Low vision and vision rehabilitation U + D = V equation, 57, 59
ADLs, 298–299 U+D=V formula, 63
definitions, 297 Mitomycin-c, 448
illumination, 300 Mixed astigmatism, 160, 161
LVP, 298 Modulation transfer function (MTF), 292, 412
non-optical tools and strategies, 305–306 Monovision contact lens trial, 444
optical tools and strategies Multifocal contact lens (MF-CL), 359–361
distance vision aids, 304–305 Multifocal IOLs, 214
near vision and reading aids, 301–304 Multivariable formulas, 381
surgical options, 305 Munnerlyn’s formula, 443, 444
refraction in, 301 Myopes, 114, 172, 173, 175, 176
rehabilitation of pediatric patient, 306 Myopia control
tints, 300–301 genetics and environment, 357–358
typoscope, 301 low-dose atropine, 362
visual acuity, 299–300 MF-CL, 359–361
visual field, 300 orthokeratology contact lenses, 361
Low vision patient (LVP), 298 peripheral defocus, 359
Lower-order aberrations (LOAs), 202 spherical aberration, 361
surgical techniques, 362
Myopic surprise, 425, 426
M
Macular microperimetry, 307
Magnification, 433 N
angular magnification, 95, 96, 105 NASA’s optics research, 369
axial magnification, 94, 95, 105 Near point, 113
formula, 40–45 Negative dysphotopsia (ND), 434, 435
simple magnifier, 96, 97 Newton’s experiment of refraction, 16
transverse magnification, 91–94, 105, 108 Night myopia, 332
Manifest hyperopia, 112 Nocturnal presbyopia, 113
Manifest refractions, 143, 219–221 Nodal point, 85, 86
Marfan syndrome, 337 Nominal hazard zone (NHZ), 212
Mars landing system, 365 Nonorganic visual loss (NOVL), 334–337
Martin’s law of lens tilt, 161 Nyctalopia, 338
Medication-induced retinal edema, 326 Nystagmus, 26, 27
Index 465
O refractive surgery, 386–388

Object–lens and object–mirror system short axial length eyes, 384
conventions and assumptions, 34 silicone oil, 385, 386
magnification formula, 40–45 Orthokeratology (ortho-K), 320, 362, 363
magnified vs. minified images, 35 Orthokeratology contact lenses, 361
minus lens, 38 Over-minused myope, 100, 101
negative lenses, 36, 37
plus lens, 38
positive lenses, 36 P
ray-tracing PanOptic™ ophthalmoscope, 265, 266
cardinal rays, 37, 38 Pantoscopic tilt (PT), 430
optical axis, 37 AOOI, 162, 163
real vs. virtual, 34, 35 single vision lens, 161
reduced vergence formula (RVF), 39–41 spherical lens, 161, 162
thick lenses, 46–48 Parkinson’s disease, 307
upright vs. inverted, 35 Partial AET, 341
vergence, 34, 35, 45, 46 Partial coherence interferometry (PCI), 192
with different media, 45 Partially accommodative esotropia (Partial AET), 341–342
Object-lens-mirror systems, 91 Particle theory of light, 187
Oblate cornea, 440 Pediatric optics
Oblique astigmatism, 158 anisometropia and aniseikonia, 353–354
Oblique prisms, 17–19 astigmatic refractive errors, 352
Ocular astigmatism, 155, 156 dispensing contact lenses, 354
Operating microscope, 268, 269 dispensing glasses, 350–353
Ophthalmic optics, 3 hyperopic refractive errors, 351
Optical aberrations, 213 myopic refractive errors, 351–352
aberrometry, 201, 202 prescribing bifocals, 352–353
HOAs refractive errors, 349
coma, 207 risk of amblyopia, 350
overview, 203 unilateral vs. bilateral amblyopia, 350
risk factors, 203 visual acuity, 350–351
spherical aberration, 203–207 “Pencil” of light rays, 3
LOAs, 202 Penetrating keratoplasty (PKP), 389
trefoil, 207 Percent thickness altered (PTA), 444
wavefront, 200, 201 Phakic IOLs (pIOLs), 454
Optical axis, 382 Phoropter, 259–261
Optical biometry (OB), 376, 377 Photic phenomena, 436
Optical coherence tomography (OCT), 189, 190 Photoablation, 210, 445
Optical infinity, 289 Photoactivation, 211
Optical low-coherence reflectometry (OLCR), 192 Photochromic lenses, 239
Optical path length (OPL), 190 Photocoagulation, 210
Optical resonator, 209, 210 Photodisruption, 210
Optics and refractive manifestations Photorefractive keratectomy (PRK), 367, 439
acquired and clinical astigmatism Phototherapeutic keratectomy (PTK), 448
differential diagnosis of, 327 Physical optics
suture management, 327–329 coherence
acquired and clinical hyperopia, 325–326 antireflective coatings, 190, 191
acquired and clinical myopia, 323–325 OCT, 189, 190
acquired refractive errors, 329–331 optical biometry devices, 190–192
aphakia management, 333–334 types, 189
asthenopia, 331, 332 diffraction
binocular blindness tests, 336 airy disk phenomenon, 198, 199
imaging and ancillary tests, 323 aperture, 198
monocular blindness tests, 335, 336 DMFIOLs, 200
night myopia, 332 optical corona, 199
NOVL, 334, 335 pinhole testing, 199, 200
poor accommodation, 329–331 interference
visual field testing (Humphrey), 336 constructive interference, 188
Optics, cataract surgery destructive interference, 188
astigmatism correction, 392–394 fluorescein angiography, 188, 189
biometry, 388 intensity patterns, 188
corneal surgery, 389 light source, 187, 188
intraocular lens formulas, 379–381 particle theory of light, 187
keratometry, 378, 379 polarization
optical angles and axes, 382, 384 crossed polarizers, 194–196
pediatric patients, 390 example, 192
principles of biometry, 376–378 Haidinger’s brush, 195–197
466 Index
Physical optics (cont.) Presbyopia, 113, 225, 226, 453

polarized microscopy, 195 Presbyopic hyperopes, 115, 116
polarized sunglasses, 194 Presbyopic LASIK, 453
reflection, 193 Presbyopic myopes, 115, 116
refraction, 193 Primary and secondary focal points, 36
scattering, 193 Prismatic effects, 143, 147, 148, 150
transmission, 192, 193 image displacement, 172, 174, 176
QED, 187 image jump, 171, 176
scattering myopes vs. hyperopes, 172, 173, 175, 176
geometric scattering, 198 Prisms
Mie scattering, 198 combined vertical and horizontal diplopia, 26
selective scattering, 197 convergence insufficiency (CI), 25
Tyndall effect, 197, 198 description, 15
wave theory of light, 185, 186 diopters, 16–18, 29
Piggyback contact lenses, 320 dispensation, 24
Piggyback IOLs, 405 effect on real and virtual images, 19, 20
Pinhole testing (PHT), 11, 374 for high reading add powers, 26
Plano mirrors, 49–51 for low-vision patient, 29, 30
Plasma-induced ablation, 210 Fresnel (temporary) prisms, 24, 25
Plus lenses, 77–78 glass prisms, 15, 16
Point spread function (PSF), 200 index of refraction, 15
Polarization left occipital lobe stroke, 29
crossed polarizers, 194–196 Newton’s experiment of refraction, 16
example, 192 and nystagmus, 26, 27
Haidinger’s brush, 195–197 oblique prisms, 17–19
polarized microscopy, 195 plastic prisms, 15, 16
polarized sunglasses, 194 power of, 28
reflection, 193 Prentice’s rule, 20–22, 29, 30
refraction, 193 prismatic effect of reading position, 31
scattering, 193 ray tracing, 15
transmission, 192, 193 right homonymous hemianopia, 30
Polarization-sensitive OCT technology (PS-OCT), 192 shapes, 15
Positive dysphotopsia (PD), 434 and strabismus, 23, 24
Posterior capsule opacification, 400 vertical diplopia, 28–30
Posterior lamellae, 440 Progression, 447
Post-LASIK, 388 Prolate cornea, 440
Postoperative optics Pump source, 209
astigmatism issues, 430–433 Pupillary axis, 382
capsular block syndrome, 426, 427 Pupillary distance (PD), 232
hyperopic surprise, 428, 429 Purkinje images, 272, 382, 419
IOL decentration, 429 Pythagorean theorem, 18, 19
myopic surprise, 425–427
refraction, 437
troubleshooting, 433, 435, 436 Q
Potential acuity meter, 374 Quantum electrodynamics (QED), 187
Power crosses (PC notation), 144 Q-value, 215
definition, 128, 130
using, 128–132
Power of a lens in different media equation (PLDME), 70, 72 R
Power of lenses Radial keratotomy (RK), 366, 440, 449
air–tear film, 69 Range of accommodation (ROA), 113
+8D in air, 74 Rayleigh scattering, 197, 213, 214
+15D in air, 74 Ray-tracing aberrometry (RTA), 86, 202
+40D in air, 74 Reduced schematic eye (RSE)
index of refraction, 69 anterior corneal surface, 87, 89
lens maker’s formula/equation, 69, 70, 73, 74 definition, 85
PLDME, 70, 72, 75 development, 85
reduced vergence formula (U+D=V), 69 macular lesion, 87
refractive power, 70, 71 model of, 85, 86
simple lens formula, 69 ophthalmoscope, 87
+6D in water, 74 ray tracing, 86
+20D IOL, 69 retinal hemorrhage, 87
+27D IOL, 73 retinal scar, 87
in water, 74 retinoscope pinhole, 87, 89
Prentice’s rule, 20–22, 29, 30, 136–139, 148–150 scotoma, 87
Index 467
Reduced vergence equation/simple lens formula (RVF/SLF), 49 Spectacle minus lens, 253
Reduced vergence formula (RVF), 39–41 Spectacles, 361, 366
Reflection, 8–11 Spectral-domain OCT (SD-OCT), 190
Reflection coefficient, 9 Spectral sensitivity, 207, 208
Refraction, 4, 5 Specular reflection, 9
Refractive astigmatism, 155, 156 Spherical aberration (SA), 213, 361, 400, 440
Refractive errors (ametropias), 113–115, 349 advantage of, 203
Refractive index (RI), 4, 191 disadvantage of, 203, 204
Refractive IOLs, 409 implications, 203
Refractive lens exchange (RLE), 454 IOLs options, 206
Regression, 447 laser refractive surgery, 205, 206
Regular astigmatism, 156 negative spherical aberration, 205
Residual stromal bed (RSB), 444 peripheral light rays, 203
Retinal hemorrhage, 87 positive spherical aberration, 204, 205
Retinal nerve fiber layer (RNFL), 195 Q-value, 206, 207
Retinal pigment epithelium (RPE), 377 Spherical IOL, 387
Retinoscope Spherocylindrical lenses
accommodation, 246 astigmatism, 119
challenges, 249, 251 axis cross, 134
components, 243–246 COS and COLC, 140–142
dispensed refractions, 244 eyeglasses prescriptions, 135, 136
mirror image, 246, 248 history, 119
myopes, 247, 249, 250 keratometry readings, 135, 136
neutralization, 247, 248, 250–252 net induced prism, 138–140
oblique astigmatism, 253 nomenclature
red reflex, 251 axis meridian and power meridian, 120–122
streak refractions, 244, 247 eyeglass, 122, 123
working distance, 246 keratometry measurements, 120
Reverse Galilean telescope, 101 light rays, 122–124
Reverse geometry RGPCLs (RG-RGPCLs), 320 power crosses, 128–132
Reverse telescope, 304 prismatic effect, 137
Right homonymous hemianopia, 30 streak refraction, 131–134
Rigid gas-permeable contact lenses (RGPCLs), 180, 181, streak retinoscopy, 123–125
313–316, 366 Spherocylindrical notation (SC notation),
Rounded edge, IOL, 399 125–128, 144
Round-top bifocal, 169 Split-lens bifocal, 168
Square-edge IOL, 398
SRK formula, 379
S Stand magnifier, 303
Scleral contact lenses (ScCLs), 318–320 Stereo acuity testing, 288
Several refractive surgery procedures, 366, 367 Strabismus, 23, 24
Silicone, 398 accommodation ratio, 341
Simple hyperopic astigmatism, 159 accommodative convergence, 341
Simple myopic astigmatism, 158, 159 adult ET, 342
Single piece acrylic (SPA), 398 adults with accommodative esotropia, 342
Single vision lens (SVL) glasses, 257 AET, 339–341
Skew phenomenon, 249 clinical management of, 339–344
Slit lamp microscope, 270 convergence insufficiency, 342, 343
illumination system, 269–271 exotropia and over-minus lenses, 344
observation system, 271, 272 minimal refractive errors, 344–346
stand, 271 patients with AET, 342
Slowing myopia progression, 358 Streak refraction, 131–134, 142, 151, 221–223
Small incision lenticule extraction (SMILE), 439, 453 Streak retinoscopy, 273, 274
Snell’s law, 5, 190 Strehl ratio, 198
Snellen visual acuity, 299 Subluxated crystalline lens, 326
Snellen visual acuity chart, 280–283 Sulcus IOL, 415
Soft contact lenses (SCLs), 309, 311–313 Sum of segments (SOS), 191
clinical practice, 177 Surgically induced astigmatism (SIA), 393
features, 177, 178 Swept-source OCT (SS-OCT), 190
sample problem, 178–180
step-by-step guide, 178
Soft toric contact lenses (STCLs), 181, 182, 309, 313 T
Softec platform, 405 Tear lens (TL), 180
Spaceflight associated neuro-ocular syndrome (SANS), 368 Tecnis platform, 404
Spatial coherence, 189 Telephone method, 146
468 Index
Telescopes, 304 Vision handicap, 297

anisometropia and aniseikonia, 103–105 Vision impairment, 297
aphakic magnification, 101–103 Visual acuity testing
astronomical (Keplerian) and Galilean telescopes binocular vision testing, 287–288
clinical examples, 98 color vision testing, 288–289
construction, 99 contrast sensitivity, 289–291
eyepiece, 98, 105 CSF, 291, 292
magnification, 98, 99 defocus curves, 293, 294
negative lens, 98 DMV, 277
positive lens, 98 ETDRS chart, 295
sample telescope problems, 99, 100 ETDRS visual acuity chart, 283, 284
types, 97, 98 four “targets” of, 277–278
Knapp’s rule, 105 legal blindness, 294
over-minused myope, 100, 101 MST testing, 279
+2D objective lens, 105 MTF, 292, 293
Temporal coherence, 189 MVT testing, 279
Thick lenses, 46–48 non-literate or illiterate adult patients, 284
Three-piece IOLs, 406 patients with nystagmus, 287
Time-domain OCT (TD-OCT), 189 Snellen visual acuity chart, 280–283
Topography guided ablation treatments (TGA), 446 stereo acuity testing, 288
Toric IOL rotation, 431 subtended angles, 279
Toric IOLs, 420 tests for near vision, 294
Transverse magnification, 91–94, 105, 108 Vernier acuity, 279–281
Trial frames, 260–262 Visual evoked potential (VEP) testing, 286, 336
Trifocal IOLs, 411 Visual field testing (Humphrey), 336
Tyndall effect, 197, 198 Visual pigments, 207, 208
Typoscope, 301 Vitreous hemorrhage, 214
U W
Ultrasonic pachymetry, 443 Wave theory of light, 185, 186
Ultrasound biometry (USB), 376 Wavefront aberration, 200
Ultraviolet-A (UV-A), 211 Wavefront guided treatments (WFG), 445
Uncorrected distance visual acuity (UCDVA), 365 Wavefront optimized (WFO), 446
Under-correction, 448 Wavefront refraction, 225
Undilated biometry, 388, 389 Wet refraction, 221
With-the-rule (WTR) astigmatism, 157, 158,
165, 430
V Working distance (WD), 244, 246
Vernier acuity, 279–281, 295 Worth four dot (W4D) flashlight, 287
Vertex distance, 219
Vertexometer, 219
Video magnification, 303–304 Z
Vision disorder, 297 Zernicke polynomial, 201

Optics For The New Millennium

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Optics For The New Millennium

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Kamran M.

Optics for the New

Foreword by Douglas D. Koch

Optics for the New

Daniel Wee Eye Doctors of Washington

ISBN 978-3-030-95250-1 ISBN 978-3-030-95251-8 (eBook)

© Springer Nature Switzerland AG 2022

Oklahoma City, OK, USA Kamran M. Riaz

1. Karl Becker, MD – Cook County/Stroger Hospital, Chicago, IL

1. David L. Cooke, MD – Great Lakes Eye Care, St. Joseph, MI

We would also like to thank everyone at SpringerNature Publishing, especially Mariah

Part I Ophthalmic Optics for Written Exams

Part II Optics for Oral Exams and Clinical Practice

Part III Optics for Surgical Practice

Shehzad Y. Batliwala, DO Department of Ophthalmology, Dean McGee Eye Institute,

Objectives lines (linear rays) (Fig. 1).1 This is also referred to as a “pen-

Light Rays in Geometric Optics

© Springer Nature Switzerland AG 2022 3

For our purposes in this chapter, we will further discuss

class swimmer and diver because he then has to find his

• In front of the fish (relative to the fisherman)—i.e., to the

The key to solving this problem is to recall your knowl-

Fig. 5 The fisherman is

Fig. 6 The fisherman catches

Real fish Image seen by fisherman

Fig. 7 An observer looking

retina. Since we have to accommodate (generate plus power)

Barrier Surface Normal

(incident light ray) n l e g e

Refracted light ray

Incidence, Cause, and Treatment of Positive and Negative Dysphotopsia.

that approaches the interface with an angle that equals the

Fig. 12 Incident light rays

The amount of diffraction increases with an increasing

Fig. 14 Diffraction. Light

zones, aka “the rings”) on the optic (depending on the manu-

1. What is the critical angle when light travels from air to

In surgical practice, we take advantage of diffraction

© Springer Nature Switzerland AG 2022 15

 rism Diopters: Definition

The amount of refraction can be quantitated by a unit called

Answer: 8 Δ means that at 1 meter away from the prism,

Example #2 If you are given a 20 Δ BD prism and shine a

Example #1 A patient with a 6th nerve palsy has an 8 Δ dis-

Fig. 6 Prism diopters are a b

Fig. 7 Similar triangles can

Fig. 8 Where will the light

a 2 + b2 = c 2 64 + 64 = 128 = 11.31 prism diopters base − up and base − out effect.

Therefore, the “AIBE” mnemonic is a combination of the a

Charles F. Prentice (an optician!) developed a formula to

Right Eye Left Eye

there will be a BO prism induced, and therefore, a diplopia

Right Eye Left Eye Right Eye Left Eye

up” their prescribed prism, therefore requiring stronger

Clinical Examples of Prism Dispensation.

Example #1 For a patient named Lefty N. Wards with LET

Example #2 For a patient named Lefty Ootward with LXT

Fresnel (Temporary) Prisms

In addition to a ground-in prism in the patient’s glasses, the

Oklahoma City, OK, USA Kamran M. Riaz

Part I Ophthalmic Optics for Written Exams

Part II Optics for Oral Exams and Clinical Practice

Part III Optics for Surgical Practice

Light Rays in Geometric Optics

rism Diopters: Definition

Fresnel (Temporary) Prisms

Therefore, for minus lenses, the secondary focal point is Definitions

Example #1 If parallel light rays approach a + 5D lens, Magnification Formula

Introduction Think of plano mirrors as objects that contain a portal to an

bject–Mirror System Examples with Concave

I ntermediate Images to the Right of Lenses