REFRACTIVE ERROR

EST
AUTHOR (s)
Brien Holden Vision Institute Faculty: Jane Kierath, Sonja Cronjé, Neilsen de Souza, Shoshana Jackofsky,
David Wilson, Mitasha Marolia, Gerd Schlenther, Naomi Freuden, Peter Mohlala Brien Holden Vision Institute,
Sydney, Australia

REVIEWER (s)
Bob Chappell Past President: World Council of Optometry (WCO)

THINK

A woman tells you that she used to read the newspaper everyday, but now she is having a hard time seeing at close
distances.
Why can she no longer see the newspaper? Can you do anything to help this woman?

WHAT YOU WILL LEARN

When you’ll have worked through this unit you should be able to:
 Define the different types of refractive error (myopia, hyperopia, astigmatism, and presbyopia)
 Describe the visual symptoms of hyperopia, myopia, astigmatism and presbyopia
 Describe the different types of spectacle lenses available to correct refractive error
 Instruct people on how to care for their spectacles.

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OPTICS

 Light from an object enters the eye in the form of light rays
 The ocular structures that light passes through are: the tear film, cornea, anterior chamber, pupil, crystalline lens,
vitreous and retina
 Light rays are focused by the cornea and the crystalline lens
 If the light focuses correctly on the retina, a clear image will be formed
 In a normal eye, light that enters the eye is focused on the retina because:
– the cornea and the lens are the correct shape, and
– the eyeball is the correct length
 If an eyeball does not have the correct shape or is not of the correct length, it cannot focus light rays onto the retina
to form a clear image, and is said to have refractive error
 People who have refractive error need spectacles to help them focus light on their retina so they can see clearly.

REFRACTIVE ERROR
 In order for us to be able to see clearly, light needs to focus at one point on the retina (the back of the eye)
(Figure 1)
 When light does not focus on the retina (Figure 2), we cannot see clearly. This is called refractive error.

Focus of light

Retina

Figure 1: Light focussing on the retina (no refractive error)

Focus of 
Focus of light
light

Retina
Retina

Figure 2: Refractive errors – light focussing behind or in front of the retina (not on the retina)

 An eye has refractive error if it is not the correct size and shape
 There are four main types of refractive error:
– Myopia
– Hyperopia
– Astigmatism
– Presbyopia
 A person with a refractive error will have eyes that look normal, but they will not see well unaided
 The symptoms of uncorrected refractive error will be different depending on the type of refractive error, as well as
how big the refractive error is
 A person who has a refractive error will need to wear spectacles (glasses), so that they can see clearly and
comfortably.

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MYOPIA (“SHORTSIGHTEDNESS”)

 Myopia is when light from a distant object focuses in front of the retina
 A person who has myopia is called a ‘myope.’ Myopia is often called “shortsightedness” –
because a person with myopia will have near vision that is better than their distance
vision, no matter what age they are.

Blurry picture on 
WHAT IS MYOPIA? the retina

Distant 
object Light focuses clearly in 
front of the retina

 Figure 3: Light in a myopic eye focussing in front of the retina

 Myopia may be caused by:

WHAT CAUSES – an eyeball that is too long
MYOPIA?
– a cornea and/or a crystalline lens that is curved too much and, therefore,
too strong in power.

HOW DOES A
PERSON WITH
MYOPIA SEE?

Low myopia: Moderate myopia: High myopia:

Distance vision slightly blurred, Distance vision blurred, Both distance and near vision
but good near vision. but good near vision. blurred (distance vision is worse
than near vision).
Figure 4: How a person with low, moderate and high myopia might see

 People with myopia usually complain of blurry distance vision

WHAT WILL  They may tell you that they cannot recognise people who are far away
MYOPES COMPLAIN  They may also tell you (or you may notice) that they see better when they almost close
ABOUT? their eyes (“screw up” or “squint” their eyes)
 Myopic people often find that their vision seems worse at night or in dim light.

 Refraction (to determine the correct spectacle prescription required)

WHAT CAN WE DO
FOR PEOPLE WITH  People with myopia can be given spectacles to see more clearly in the distance
MYOPIA?
 Myopia is corrected with minus spherical lenses.

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HYPEROPIA (“LONGSIGHTEDNESS”)

 Hyperopia is when the light from a distant object focuses behind the retina
 A person who has hyperopia is called a ‘hyperope’
 Hyperopia is sometimes also called “longsightedness” or “farsightedness”.

Light focuses clearly 
behind the retina
WHAT IS
HYPEROPIA?

Distant object

Blurry image at 
the retina

Figure 5: Light in a hyperopic eye focusing behind the retina

 Hyperopia may be caused by:

WHAT CAUSES – an eyeball that is too short
HYPEROPIA? – a cornea and/or crystalline lens that is too flat (not curved enough) and, therefore, too
weak in power.

Hyperopia in young people

 Young people with low levels of hyperopia can change the focus of the lens in their eye
(we call this accommodation) to make an object focus on the retina
 This is similar to changing the focus of the lens of a camera
 See how the lens is thicker in figure 6b than 6a; this is the lens changing its shape
(‘accommodating’) to make the light focus on the retina
 This is how young people with low to medium levels of hyperopia can still manage to have
clear vision at most distances without spectacles. The effort required to do this however, is
often very tiring on the eyes.

Unaccommodated Light focuses Light focuses 

behind the retina Accommodated 
AGE AND lens
lens
on the retina
HYPEROPIA

Figure 6: The lens changes in thickness from flatter (6a) to thicker (6b) to focus the light onto
the retina (this process is called ‘accommodation’)

Hyperopia in older people

 The lens becomes harder as we become older making it more difficult to change focus
(we lose our ability to accommodate)
 In older people with hyperopia who have lost their accommodation, the light will stay
behind the retina and they will not be able to see clearly without spectacles (Figure 6).

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 The symptoms of hyperopia vary depending on how much accommodation can be used
(how old the person is), and the amount of hyperopia they have
 However, most people with hyperopia complain of difficulty seeing at near – often they tell
you that their near vision is worse than their distance vision
WHAT DO PEOPLE
WITH HYPEROPIA  People with hyperopia may also complain of:
COMPLAIN OF? – Eyestrain (sore, tired, red, dry, or watery eyes)
– Difficulty reading or doing near tasks
– Poor distance vision, especially if they are older and have high hyperopia
– Vision that seems worse at night or in dim light.

HOW DO PEOPLE
WITH HYPEROPIA
SEE?

Low hyperopia: Moderate hyperopia: High hyperopia:

May have good distance and Near vision blurred, Both distance and near
near vision, but may have but good distance vision. May vision blurred (near vision is
eyestrain and headaches with have eyestrain and headaches. worse than distance vision).
prolonged near work.

Figure 7: How a person with low, moderate and high hyperopia might see

 Refraction (to determine the correct spectacle prescription they require)

WHAT CAN WE DO
 People with hyperopia can be given spectacles to see more clearly up close and these
FOR PEOPLE WITH
spectacles may also be prescribed for distance
HYPEROPIA?
 Hyperopia is corrected with plus spherical lenses.

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ASTIGMATISM

 Astigmatism is when the cornea and/or lens is oval in shape, like an egg or a rugby ball
(figure 8) instead of round, like a soccer ball
 A surface that is like that of a rugby ball or egg is called a toric surface
 A toric surface has a different curve in two directions (or meridians): one meridian is
steeper (more curved), the other meridian is flatter (less curved)
 A toric surface causes light entering the eye to focus in two different places, rather than at
one single point.

Basketball or Soccer Ball Rugby Ball

(spherical shape)
(egg shaped)
WHAT IS
ASTIGMATISM?

Flat meridian Steep meridian

Same curvature in all meridians

Figure 8: A soccer ball has a spherical surface.

A rugby ball (egg-shaped) has a toric surface

HOW DO PEOPLE
WITH ASTIGMATISM
SEE?

Moderate astigmatism: High astigmatism:

Distance and near vision blurred. May Distance and near vision more blurred.
complain of eyestrain and headaches.

Figure 9: How a person with moderate and high astigmatism might see

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 People with astigmatism may complain of:

WHAT WILL A
PERSON WITH – Eyestrain (sore, tired, red, dry, or watery eyes)
ASTIGMATISM – Headaches
COMPLAIN OF?
– Blurry vision at both distance and near.

 Refraction (to determine the correct spectacle prescription they require)

 People with astigmatism can be given spectacles for clear distance and near vision to stop
the headaches and eyestrain
WHAT CAN WE DO
 Because the two meridians of an astigmatic eye have different powers, the lens that is
FOR PEOPLE WITH
used to correct it must have different powers in each meridian
ASTIGMATISM?
 This is called a cylindrical or astigmatic lens
 Ready-made spectacles use spherical lenses (not astigmatic lenses) and therefore will
not be suitable for people with astigmatism.

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PRESBYOPIA

 Gradual loss of the ability to focus on near objects (accommodate)

 Caused by a hardening of the crystalline lens due to age
WHAT IS  Both eyes affected
PRESBYOPIA?  Affects everyone over the age of 40–45 years
 Slowly gets worse until about age 60

HOW PEOPLE WITH

PRESBYOPIA SEE?

Presbyopia – early: Presbyopia – later:

May have good distance vision and good near Near vision blurred, but good distance vision
vision, but may have eyestrain and headaches.

Figure 10: How a person with presbyopia might see in the early and later stages

 People with presbyopia will have trouble with near tasks such as reading or sewing
 When presbyopia starts, they may say things like:
– “I can read in good light but not in dim light”

WHAT WILL PEOPLE – “My arms are not long enough”

WITH PRESBYOPIA – “My eyes feel strained when I do a lot of sewing”
COMPLAIN OF?
– “My eyes get tired when I read”
– “The print in the newspaper is too small”
– “I find it difficult to thread a needle”
– “The distance looks blurred when I look up after I have been reading for a long time”.

 Eye examination to check their spectacle prescription

WHAT CAN WE DO  People with presbyopia can be given spectacles for near vision as well as to help with
FOR PEOPLE WITH symptoms of headaches and eyestrain
PRESBYOPIA?  Ready-made spectacles are often used to correct presbyopia
 Presbyopia is corrected with a near addition (or “add”).

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TYPES OF SPECTACLES

 People who have refractive errors need spectacles to see clearly

 There are three types of spectacle lenses available for correcting refractive errors:
─ Single vision
─ Bifocal
─ Progressive.

TYPE OF SPECTACLE FOCUS OF THE WHAT CAN I PRESCRIBE WHAT SHOULD I TELL THE
LENS SPECTACLE THESE FOR? PERSON?
LENS

SINGLE VISION LENS One distance  myopia, hyperopia, Distance spectacles: “You will
astigmatism and presbyopia see clearly when you look far
 either far or away, but
near
(for a person with myopia) you
need to take off the glasses to
see up close.”

(for a person with hyperopia)

you need a separate, stronger
pair of glasses to see up close.

(for a person with astigmatism)

they will also help with your
vision up close

Near spectacles for a person

with presbyopia who does not
have a distance refractive error:
“You will see clearly when you
read, but you need to take off
the glasses to see far away.”

BIFOCAL LENSES Provides clear  Presbyopia where there is “You will see clearly when you
For distance viewing
vision at two also a distance refractive look up close, and when you
distances only error look into the distance. However,
in-between distances may be
 usually at  Or presbyopia where there blurry.”
distance may not necessarily be a
( to 6m) distance refractive error but
For near viewing
the person needs to be able
 and near to see clearly in the distance
(a range where and close up without having
40 cm is the to remove the spectacles to
midpoint) do so

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PROGRESSIVE LENSES All distances:  Presbyopia where there is “You will see clearly when you
also a distance refractive look up close, at intermediate
 distance error distances and when you look
into the distance.”
 near  These lenses are often
preferred over bifocal lenses,
 and in-between as they give the person a
better range of vision
The lens markings can only be (at all distances)
seen when the spectacles are first
received from the laboratory or  Progressive lenses are also
optical workshop better looking (they look
Once these markings are removed, similar to single vision
progressive lenses look like single lenses)
vision lenses.

WHAT TO TELL PEOPLE ABOUT LOOKING AFTER SPECTACLES

 Spectacles can be cleaned with water and soap or dishwashing detergent

 Rinse your spectacles with clean water and dry with a soft cloth
 Do not use very hot water
 Keep spectacles in their case or wrap them in soft cloth or make a small bag for them from cotton material (material
from an old T-shirt is good for this purpose)
 Always use two hands when putting on your spectacles and taking them off
 Do not share your spectacles with another person
 Do not put spectacles face down on the table or any other surface – put them down with the lenses facing up so
they do not get scratched
 Do not leave your spectacles in the hot sun, especially if the frames are made of plastic
 It may take a little time to get used to your spectacles (this is particularly true if the person has not used spectacles
before)
 Go back to your eye care practitioner if your eyes are uncomfortable or your vision is blurry
 You should have your eyes checked regularly (about once every two years).

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COMMON CONCERNS ABOUT WEARING SPECTACLES

Many people when they first start wearing spectacles will have concerns about them.
This section will help you to answer some common questions people have about their spectacles.

Will wearing spectacles make my eyes worse?

 No
 Wearing spectacles that have been prescribed correctly will not make a person’s eyes worse
 A person’s spectacle prescriptions will often get worse over time, however this is not due to the spectacles.

Will wearing spectacles make the muscles in my eye lazy?

 No – wearing spectacles will not make the muscles in your eye lazy
 The muscles of the eye play very little role in myopia and astigmatism
 Correcting hyperopia with spectacles helps the muscles in the eye to do to the same amount of work as the
muscles of an eye that does not have refractive error.

Will doing eye exercises stop me from having to wear spectacles?

 No
 In most cases, doing eye exercises will not prevent a person from having to wear spectacles
 Most refractive error occurs because the eye is not the correct length for the power of the cornea or lens, and this
is something exercises cannot help
 It is still important, however, to look after our eyes and to prevent eyestrain.

Will my high spectacle prescription make me go blind?

 High refractive error usually does not cause blindness
 Although a person with a high prescription does not see very well when they are not wearing spectacles, if they
wear a correct pair of spectacles they will usually see just as well as somebody without refractive error.

Will spectacles cure my refractive error?

 No
 Although spectacles will allow a person with refractive error to see better while they are wearing the spectacles,
they will not ‘cure’ the eyes of refractive error
 A person who wears spectacles for refractive error will always need the spectacles to see clearly.

Can refractive error be cured with medication?

 There are currently no medicines that can cure refractive error.

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TEST YOURSELF QUESTIONS

1. Name and briefly describe the four types of refractive error:

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2. Describe the symptoms a person with a small amount of hyperopia may experience?

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3. A 45-year old tailor complains that he can no longer thread a needle to sew people’s clothes, and he is
worried that he may have to stop working. What condition do you think this man has? Is there anything
that can be done to help this man? What will you tell him?

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4. Name at least 5 things you should tell a person about looking after their spectacles:

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