Types of Defective Vision: Astigmatism

The Mico University College Department of Language and Literacy

Brief Early History of Vision and Optics

One of the earliest ideas about vision is that it depends on light that streams out of the eye and detects surrounding objects. This is known as extramission theory. Pythagoras (5th Century B.C.) - Understood the eye to have a fire within that was emitted forth from the eye to create an image.

Wang. M (2008). Irregular Astigmat

Empedocles (b. ca. 492BC), - claimed that when you looked at a candle flame, the flame and your eye were both sending out some kind of mysterious stuff, and when your eyes stuff collided with the candles stuff, the candle would become evident to your sense of sight.

Crowell, B. (2000), Optic

Plato (428 to 347 B.C.) Expounded on this view and postulated that the visual fire emanated from the eye and fused with daylight to form a single body to allow the eye to directly connect with the object.

Wang. M (2008). Irregular Astigmat

Galen (129 to 200 A.D) - furthered these ideas by proposing that a psychic spirit traveled through the optic nerve and out of the eye where it formed a projection of rays that fell upon objects and made them visible. The crystalline lens was the main receptor for the sensations created by these projected rays. The visual spirit then traveled from the crystalline lens, through the optic nerve and ultimately to the brain. This extrammission theory of vision dominated European thought for centuries.

Wang. M (2008). Irregular Astigmat

Vision that involves something entering into the eye is known as intromission theory. Theorists who held this view believed that isomorphic images streamed off objects and entered the eye where they were sensed.

Gross, C. (1999). Nueroscientis

Aristotle (384 to 322 B.C) -felt that a transparent medium existed between the eye and the object. This medium was transformed by the object, and directly connected to the water inside the eye where the image was recreated. Epicurus (341 to 270 B.C.) -believed that an object transformed the air between the object and the eye into a replica of the object which could be seen once it came in contact with the eye. He perceived the reflection on the cornea as the actual object existing within the humor of the eye.

Wang. M (2008). Irregular Astigmat

Alhazen (965 to 1039 A.D.) -believed that light was created from a source such as the sun and that it was reflected from an object of interest to the eye. Johannes Kepler (1571 to 1630) -described the refracting properties if the cornea and lens and the image that formed on the retina. Once the importance of the curvature of the refractive surfaces of the eye was well established, measurement of these curvatures could begin.

Wang. M (2008). Irregular Astigmat

Optics Today

Some light energy is turned into heat while some are reflected by objects. Some people would disagree if you told them that light was reflected from a book to the eye, because they think of reflection as something that mirrors do, not as something that a book can do.

Optics Today

Light is the visible portion of the electromagnetic radiation spectrum. It lies between ultraviolet and infrared portions, from 400 nm at the violet end of the spectrum to 700 nm at the red end. The white light consists of seven colours denoted by VIBGYOR (violet, indigo, blue, green, yellow, orange and red). Light ray is the term used to describe the radius of the concentric wave forms. A group of parallel rays of light is called a beam of light.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Optics Today
The behaviour of light rays is determined by ray optics. A ray of light is the straight line path followed by light in going from one point to another. The knowledge of geometrical optics is essential to understand the optics of eye, errors of refraction and their correction.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Optics Today
Reflection of light is a phenomenon of change in the path of light rays without any change in the medium (air, water, lens). Refraction of light is the phenomenon of change in the path of light, when it goes from one medium to another. The basic cause of refraction is change in the velocity of light in going from one medium to the other. A lens is a transparent refracting medium.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Optics Today

As an optical instrument, the eye is well compared to a camera with retina acting as a unique kind of 'film'. The focusing system of the eye is composed of several refracting structures which include the cornea, the aqueous humor, the crystalline lens, and the vitreous humor. These constitute a homocentric system of lenses, which when combined in action form a very strong refracting system of a short focal length.

Crowell, B. (2000), Optic

Anatomy of the Eye

How the Eye works

Discovery of Astigmatism

The description of astigmatism was presented independently by two members of Londons Royal Society who interestingly both suffered from uncorrected astigmatism- Thomas Young M.D. (1773 to 1829) who was the first to describe the condition present in the human eye and Sir George Biddell Airy (1801 to 1892) who coined the term astigmatism after it was suggested by a colleague.

Wang. M (2008). Irregular Astigmat

Etymology
A spherical lens focuses a single object source into a single corresponding point or stigma. An astigmatic lens is one that does not focus light into a single point. However, separate lines corresponding to a single point object are created in the image space. This results from the unequal distribution of the refractive power of the astigmatic lens.

Wang. M (2008). Irregular Astigmat

Astigmatism

Astigmatism might be the most misunderstood vision problem. Even the name is challenging to many people, who incorrectly call it "stigmatism. Like nearsightedness and farsightedness , astigmatism is a refractive error, meaning it is not an eye health problem; it simply is a problem with how the eye focuses light. In an eye with astigmatism, light fails to come to a single focus on the retina to produce clear vision. Instead, multiple focus points occur, either in front of or behind the retina (or both).

Types of Astigmatism
Broadly speaking, there are two types of astigmatism: regular and irregular. REGULAR ASTIGMATISM -The astigmatism is regular when the refractive power changes uniformly from one meridian to another (there are two principal meridia).

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

CAUSATION:

1. Corneal astigmatism is the result of abnormalities of curvature of the cornea. It constitutes the most common cause of astigmatism. 2. Lenticular astigmatism is rare. It may be: i. Curvatural due to abnormalities of curvature of lens. ii. Positional due to tilting or oblique placement of lens. iii. Index astigmatism may occur rarely due to variable refractve index of lens in different meridia. 3. Retinal astigmatism due to oblique placement of macula may also be seen

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Vertical and Horizontal Meridia

Types of regular astigmatism -Depending upon the axis and the angle between the two principal meridia, regular astigmatism can be classified into the following types : 1. With-the-rule astigmatism. In this type the two principal meridia are placed at right angles to one another but the vertical meridian is more curved than the horizontal. This is called 'with-the-rule' astigmatism, because similar astigmatic condition exists normally. 2. Against-the-rule astigmatism refers to an astigmatic condition in which the horizontal meridian is more curved than the vertical meridian. Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

3. Oblique astigmatism is a type of regular astigmatism where the two principal meridia are not the horizontal and vertical though these are at right angles to one another (e.g., 45 and 135). Oblique astigmatism is often found to be symmetrical or complementary. 4. Bioblique astigmatism. In this type of regular astigmatism the two principal meridia are not at right angle to each other e.g., one may be at 30o and other at 100. The configuration of rays refracted through the astigmatic surface (toric surface) is called Sturms conoid and the distance between the two focal lines is known as focal interval of Sturm.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Astigmatism Eye

Depending upon the position of the two focal lines in relation to retina, the regular astigmatism is further classified into three types: 1. Simple astigmatism, wherein the rays are focused on the retina in one meridian and either in front or behind the retina in the other meridian.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

2. Compound astigmatism. In this type the rays of light in both the meridia are focused either in front or behind the retina and the condition is labelled as compound myopic or compound hypermetropic astigmatism, respectively. 3. Mixed astigmatism refers to a condition wherein the light rays in one meridian are focused in front and in other meridian behind the retina .Thus in one meridian eye is myopic and in another hypermetropic. Such patients have comparatively less symptoms as 'circle of least diffusion' is formed on the retina. Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Symptoms and Signs

Symptoms of regular astigmatism include: (i) defective vision; (ii) blurring of objects; (iii) depending upon the type and degree of astigmatism, objects may appear proportionately elongated; and (iv) asthenopic symptoms, which are marked especially in small amount of astigmatism, consist of a dull ache in the eyes, headache, early tiredness of eyes and sometimes nausea and even drowsiness. Signs 1. Different power in two meridia is revealed on retinoscopy or autorefractometry. 2. Oval or tilted optic disc may be seen on ophthalmoscopy in patients with high degree of astigmatism. 3. Head tilt. The astigmatic patients may (very exceptionally) develop a torticollis in an attempt to bring their axes nearer to the horizontal or vertical meridians. 4. Half closure of the lid. Like myopes, the astigmatic patients may half shut the eyes to achieve the greater clarity of stenopaeic vision.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Investigation
1. Retinoscopy reveals different power in two different axis 2. Keratometry and computerized corneal topography reveal different corneal curvature in two different meridia in corneal astigmatism 3. Astigmatic fan test 4. Jackson's cross cylinder test. These tests are useful in confirming the power and axis of cylindrical lenses.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Treatment
1. Optical treatment of regular astigmatism comprises the prescribing appropriate cylindrical lens, discovered after accurate refraction. i. Spectacles with full correction of cylindrical power and appropriate axis should be used for distance and near vision. ii. Contact lenses. Rigid contact lenses may correct up to 2-3 of regular astigmatism, while soft contact lenses can correct only little astigmatism. For higher degrees of astigmatism toric contact lenses are needed. In order to maintain the correct axis of toric lenses, ballasting or truncation is required. 2. Surgical correction of astigmatism is quite effective.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Irregular Astigmatism

It is characterized by an irregular change of refractive power in different meridia. There are multiple meridia which admit no geometrical analysis.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Irregular Astigmatism

Irregular astigmatism causes light to be distorted from the uneven surface of the cornea, which typically manifests as multiple images from a single object.

1. Curvatural irregular astigmatism is found in patients with extensive corneal scars or keratoconus. 2. Index irregular astigmatism due to variable refractive index in different parts of the crystalline lens may occur rarely during maturation of cataract.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Irregular Astigmatism Symptoms

Defective vision, Distortion of objects and Polyopia.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Investigations
1. Placido's disc test reveales distorted circles 2. Photokerotoscopy and computerized corneal topography give photographic record of irregular corneal curvature.

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

Treatment
1. Optical treatment of irregular astigmatism consists of contact lens which replaces the anterior surface of the cornea for refraction. 2. Phototherapeutic keratectomy (PTK) performed with excimer laser may be helpful in patients with superficial corneal scar responsible for irregular astigmatism. 3. Surgical treatment is indicated in extensive corneal scarring (when vision does not improve with contact lenses)

Khurana. A. K. ( 2008). Comprehensive OPHTHALMO

How Common is Astigmatism?

Both regular and irregular astigmatism can be hereditary. Therefore, parents with the condition should have children checked periodically. Many experts believe that everyone is born with some level of astigmatism; however, it is just a matter of whether it increases over time causing a moderate to severe condition, or remains the same as in the case of mild astigmatism.
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How Common is Astigmatism?

Astigmatism often occurs early in life, so it is important to schedule an eye exam for your child to avoid vision problems in school from uncorrected astigmatism. In a recent study of 2,523 American children ages 5 to 17 years, more than 28 percent had astigmatism of 1.0 diopter(D) or greater. Also, there were significant differences in astigmatism prevalence based on ethnicity. Asian and Hispanic children had the highest prevalences (33.6 % and 36.9%, respectively), followed by whites (26.4 %) and African-Americans (20.0 %). In another large study of more than 11,000 eyeglass wearers conducted recently in the UK, 47.4 % of wearers had astigmatism of 0.75 D or greater in at least one eye, and 24.1 % had this amount of astigmatism in both eyes. The prevalence of myopic[Link] astigmatism (31.7 %) was [Link] approximately double that of hyperopic

Astigmatism and Literacy

Being able to properly align the eyes and focus clearly are important motor aspects that accompany our binocular vision. This ability also develops significantly over the first 6 months of life. When we are young and shift our eyes from viewing something far away to something close, a clear and flexible lens within our eye changes its focus through a process called accommodation. The alignment of the eyes must also adjust to the changing depth of the object, and this process is called mergence. Newborns have some ability to change the alignment of their eyes, but it is very basic and limited; however, this ability becomes much more accurate over the first 3 months of life based on the maturation of their binocular vision capacity. Accommodation is also limited in newborns and similarly shows significant increases to adult-like [Link]

Like eye alignment, this improvement relates more to their increased capacity to see objects more clearly which leads to a more active focusing response. However, accommodative accuracy is better when objects are close (75cm) vs. distant (150cm) until the infant reaches 6 months of age. Infants probably prefer closer objects because they have limited attention spans, and closer objects capture their attention. A person who suffers from astigmatism has problems trying to focus an image and is constantly trying to compensate. Trying to focus all these images without distinction is called accommodation. When children are younger their capacity to compensate is greater, however, as the work load increases with age, this becomes more difficult and accommodation decreases, this is when astigmatism becomes [Link] more obvious.

Because of decreasing accommodation the child may develop wrong postural habits brought on by constantly tilting the head in an attempt to focus vision. When a child with astigmatism reads, they jump lines or the letters appear to be moving. Persons suffering from astigmatism experience:

Visual strain and feelings of sleepiness Headaches Photophobia Frequent conjunctivitis