01 The following are true:

a An IOL overcomes the aneisokonia produced with spectacle correction of aphakia.

b The RSM with an IOL is greater than with a contact lens used to correct the same refractive error.
c An IOL is an equi-convex lens with spherical surfaces.
d A high myope may be rendered emmetropic by aphakic cataract extraction.
e A +12 dioptre contact lens may be suitable for an aphake.

01 a True. Use of an IOL in aphakia overcomes the aneisokonia produced with spectacle correction of
aphakia as the IOL causes minimal magnification effects because it is situated near the natural position
of the crystalline lens.
b False. The relative spectacle magnification with an IOL is 1.0 while with a contact lens it is 1.1.
c False. An IOL is a bi-convex lens, with aspherical surfaces. The anterior surface is normally flatter than
the posterior surface.
d True. Aphakia is equivalent to high hypermetropia, therefore a high myope may be rendered
emmetropic by aphakic cataract extraction.
e True. Contact lens powers in aphakia are normally m the range of + 10 -18 dioptres. In young babies, a
contact lens of the order of +40 dioptres may be required.

02 Regarding spectacle prescription:

a If a change of cylinder axis is found it should always be prescribed.
b Pseudophakes often will not tolerate their full cylindrical correction.
c New bifocal wearers must be warned of difficulty when walking down stairs.
d Patients appreciate minor changes in their prescription.
e The lens form must be discussed with the patient.

02 a False. Only change the axis of the cylinder' if the patient is symptomatic, especially in a myope.
b False.
c True.
d False. There is no need to give a patient new glasses for a minor change in prescription unless there is a
very good reason.
e True. Some patients are intolerant of varifocal glasses etc. So their requirements must be taken into
consideration.
03 The advantages of intra-ocular lens implantation in aphakia include
A binocular single vision
B reduced risk of corneal dystrophy
C reduced risk of cystoid macular oedema
D certainty that refractive error is fully corrected
E minimal aniseikonia

03 A = True B = False C = False D = False E = True

The advantages of intra-ocular lens implantation are convenience, good binocular single vision, improved
peripheral field, and minimal difference in retinal image size between the two eyes (i.e. minimal
aniseikonia). There is a slight risk of corneal dystrophy and cystoid macular oedema, in addition to pupil
block glaucoma, postoperative astigmatism (which may be minimised by removal or insertion of
stitches), post-operative uveitis, posterior capsule rupture requiring vitrectomy, and intra-ocular lens
dislocation.

04 Correction of unilateral aphakia:

a With spectacles causes aneisokonia.
b With spectacles gives a relative spectacle magnification of 1.1.
c With contact lenses gives a relative spectacle magnification of 1.3.
d With an IOL gives a relative spectacle magnification of 1.1.
e Is best with an iseikonic lens.

04 a True. Correction of unilateral aphakia with spectacles gives a RSM of 1.33 in the aphakic eye
causing aneisokonia and diplopia.
b False.
c False. Contact lenses improve the disparity as the RSM is of the order of 1.1
d False. Similarly with an IOL the relative spectacle magnification is 1 allowing binocular vision.
e False. Iseikonic lenses are lenses with no focusing power but which alter the net image size. However,
the maximum magnification achievable is 5% and the lenses are expensive and bulky.

05 A bilaterally aphakic patient can see 6/5 in each eye with + 18 DS contact lenses. The following are
true:
a In place of contact lenses, the patient would require spectacles with lenses of a higher power than +18
 DS for distance vision.
b If the right contact lens could not be worn, the patient would be best corrected with a contact lens of
power +18 DS in the lt eye, and a spectacle lens of between + 8 DS and +18 DS in front of the rt eye.
c The patient's visual field would appear larger in contact lenses than spectacles.
d The patient's visual acuity would be better than 6/5 in spectacles.
e The patient will experience a magnification effect on switching to spectacles.

05 a False
b False. This would cause intolerable aniseikonia (and/or diplopia) due to the relative magnification
effect of the spectacle lens, and the induced prismatic effect when the eyes move into eccentric gaze.
c True. In high hypermetropic spectacle corrections, the visual world is magnified (giving a reduced field
of view) and a ring scotoma is produced.
d True. Although unlikely in real life, due to the aberrations inherent in high lens corrections, the
magnification produced would give an enhanced acuity in this case.
e True.

06 Regarding intra-ocular lenses (IOLs):

A The power of an IOL in air is of the order of 80 D,
b The power of an IOL in the eye is of the order of 20 D.
c The reduced power of an IOL in the eye compared with in air is due to the fact that the RI of air >
aqueous.
d IOL power may be approximated with a ruler.
E IOL power is the reciprocal of its focal length.

06 a True. The power of a standard IOL is much greater than in the eye due to the greater discrepancy in
the air: lens refractive index ratios compared with the aqueous: lens refractive index ratios.
b True.
c False. The refractive index of air is less than that of aqueous, i.e. the ratio nair: nlens is less than the ratio
naqueous: nlens
d True. If parallel light, for example from a light bulb, is brought to focus by an IOL in air, the distance
between the lens and its focal point is its focal length and the inverse of this is the lens power.
e True.
07. An aphakic patient requires a contact lens of +14 D.
A. A spectacle lens of about 11.5D is required if the back vertex distance is 15mm
B. A spectacle lens of about 17.75D is required if the back vertex distance is 15mm.
C. A spectacle lens of 14D is required irrespective of the back vertex distance
D. A spectacle lens of about 12 D is required if the back vertex distance is 12mm.
E. A spectacle lens of about 16.25D is required if the back vertex distance is 10mm.

07 A=True B=False C=False D=True E=False

If a correcting lens of focal length f metres focuses light on the retina, then a correcting lens of focal
length (f +d) metres is required if the lens is placed d metres further away. Since refractive power
=1/focal length, it can be proved mathematically that, Fd=F /1+dF
Where Fd= refractive power of the correcting lens placed d metres away from the eye (negative if moved
towards the eye), F= refractive power of the correcting lens of the original lens in dioptres (+ve for
convex lens, -ve tor concave lens) and d= distance moved away from eye (negative if moved towards
eye).
In general, a weaker convex lens or a stronger concave lens is required if the correcting lens is moved
away from the eye. In the question, for a spectacle lens with a back vertex distance (BVD) of 15 mm
(0.015 m)
F= 14D
d= 0.015 m
Fd= 14/(1 +0.015x14)
= 11.57D
Likewise, for a spectacle lens with BVD of 12 mm (0.012 m),
Fd= 14/(1+0.012x14)
= 12D
For a spectacle lens with BVD of 10 mm (0.01 m)
Fd= 14/(1+0.01 X 14)
= 12.28D.

08 Relative spectacle magnification

A by contact lens of axial myopia is less than 1
B in refractive myopia by a concave lens 15 mm from the eye is than 1
C by contact lens of axial hypermetropia is less than 1
D of aphakics by contact lenses is about 1.1
E is the ratio of corrected image size to uncorrected image size

08 A = False B = True C = True D = True E = False

Spectacle magnification is the ratio of corrected image size to uncorrected image size. Relative spectacle
magnification is the ratio of corrected ametropic image size to emmetropic image size. In refractive
ametropia, the magnification/diminution can be thought of as a system of lenses similar to the Galilean
telescope. The magnification equals the ratio (excessive refractive power of the eye/power of lens used).
In refractive myopia, the power of the spectacle lens used is more than the actual degree of myopia in the
eye, as the lenses are further away from the eye. Hence, there is always diminution unless the lens is at
the nodal point of the eye. The nearer the correcting lens is to the eye, the less the diminution,
Aphakia is an example of refractive hypermetropia of about 15D. If it is corrected by a contact lens, it is
placed about 7 mm in front of the nodal point.
Applying the formula: Fd = F/ (1+ dF).
Where refractive power of the correcting lens placed d metres away from the eye (negative if moved
towards the eye), F = refractive power of the correcting lens of the original lens in dioptres (+ve for
convex lens, -ve for concave lens) and d = distance moved away from eye (negative if moved towards
eye)
Fd= 15/(1 + 0.007 X 15) = 13.6D
Hence, Relative Spectacle Magnification = 15/13.6 = 1.1
In pure axial ametropia, the refractive power of the eye is normal, but the axial length of the eye is either
elongated (in myopia) or shortened (in hypermetropia). If a thin lens is used to correct the ametropia, and
the centre of the lens is in the anterior focal point of the eye, light entering the lens would pass parallel to
the optical axis of the eye. Hence the image size would be the same irrespective of the axial length of the
eye. Knapp's Rule states that in pure axial ametropia, correction by a lens placed at the anterior focal
plane of the eye would produce the same size image as in emmetropia. In axial hypermetropia, moving
the lens towards the eye from the anterior focal point would result in diminution (RSM <1), while
moving away from the eye results in magnification (RSM >1).

09 Problems in correction of aphakia by contact lenses include

A the inability of contact lenses to correct astigmatism
B infective corneal ulcers
C papillary conjunctivitis
D intolerance of contact lenses
E glaucoma

09 A = False B = True C = True D = True E = False

Problems in correction of aphakia by contact lenses include intolerance of foreign bodies feeling, oedema
of corneal epithelium from prolonged wear, papillary conjunctivitis, peripheral corneal vascularisation,
recurrent corneal erosions and infective corneal ulcers. Pupil block glaucoma is a complication of intra-
ocular lens implantation.

10 An aphakic subject requires a spectacle correction of +12D. The BVD is 15 mm, and the anterior
chamber is 5 mm deep.
A A contact lens of 10.75D results in under-correction.
B A contact lens of 12,75D results in over-correction.
C A contact lens of 16D results in over-correction.
D A posterior chamber intra-ocular lens of 14.75D results in under correction.
E A posterior chamber intra-ocular lens of 15.75D is required.

10 A = True B = False C = True D = True E = True

𝐹
Applying the general formula Fd = 1 + 𝑑𝐹

Where Fd = refractive power of the correcting lens placed d metres away from the eye (negative if moved
towards the eye), F = refractive power of the correcting lens of the original lens in dioptres (+ve for
convex lens, -ve for concave lens) and d = distance moved away from the eye (negative if moved towards
eye).
If a contact lens is used F = 12D
d = -15 mm (-0.015 m)
Fd = 12/(1 +-0.015x12)
= 14.63D

If a posterior chamber intra-ocular lens is used F = 12D

d = -20 mm (-0.02 m)
Fd = 12/(1+-0.02.x 12)
= 15.79D
11 The following statements about aphakia is/are true
A Removal of the lens in an emmetropic eye requires correction by a spectacle convex lens of about 11D
B Removal of the lens in an emmetropic eye requires correction by a contact lens of less than 11D
C The retinal image of an aphakic eye is about 30% smaller than the emmetropic retinal image
D Unilateral aphakia is best corrected by spectacles
E It may be accompanied by astigmatism

11 A= True B = False C = False D = False E = True

Correction of aphakia after surgical removal of a tens in an emmetropic eye by spectacles requires a
convex lens of about 11D, although it would require a higher correction by a contact lens or IOL. In
hypermetropia, the image is behind the retina. Hence, the further forward is the correction lens, the
further forwards would be rays of light brought onto the retina. The retinal image of an aphakic eye is
about 30% larger than an emmetropic eye. Astigmatism is sometimes present due to the surgical section
in cornea or the corneoscleral junction. Unilateral aphakia is best corrected by an intra-ocular lens if
binocular single vision is desired.

12 Advantages of contact lenses over spectacles in monocular aphakia include

A increased visual field
B less spectacle diminution
C increased binocular single vision
D less ring scotoma
E less image distortion

12 A = True B = False C = True D = True E = True

The advantages of contact lenses over spectacles in monocular aphakia includes increase in visual field,
less spectacle magnification, increased binocular single vision, less spherical aberration with ring
scotoma and image distortion, less prismatic effect, and of lighter weight.

13. Regarding the correction of aphakia with glasses:

a. there is an increasing image magnification as the correcting glasses is moved forward from the position
of the natural crystalline lens
b. reduction in visual field is a common problem
c. “pincushion” distortion of the visual field
d. ring scotoma of aphakia is created by the prismatic effect of the lens
e. using head turning rather than eye movement to change gaze direction can prevent 'Jack-in-the-box'
phenomenon

13. a.T b.T c.T d.T e.T

There is an increasing image magnification as the correcting glasses is moved forward from the position
of the natural crystalline lens. Therefore, aphakia is best corrected with either contact lens or secondary
lens implant. The problem with aphakic glasses include:
• large image magnification
• “pin-cushion ” distortion of the visual field
• a ring scotoma, which has the “jack-in-the-box” effect of objects
• suddenly appearing from the edge of the scotoma.
• reduction of visual field

14 Problems associated with spectacle correction of aphakia include:

a Discomfort.
b Misjudgment of distances due to aneisokonia.
c Reduced performance on visual acuity tests.
d A ring scotoma.
e A small field of vision.

14 a True. Aphakic spectacles are heavy and tend to slip.

b True. Uneven image magnification causes aneisokonia and misjudging of distances, which can be
dangerous.
c False. Image magnification may lead to an enhanced performance on visual acuity tests.
d True. The ring scotoma, or jack-in-the-box effect, are caused by the prismatic effect of the lens.
e True. Magnification, and the distortion in the peripheral field.

15. Difficulties of correction of aphakia by spectacles include

A. prismatic errors from displaced optical centers
B. spherical aberration
C. image diminution
D. incorrect prescription due to inaccurate estimate of vertex distance
E. reduced visual fields

15 A = True B = True C = False D = True E = True

Correction of aphakia by spectacles may cause numerous problems, due to the strength of the lens and
the absence of accommodation of the eye. Examples are as following:
a. prismatic effects, causing ring scotoma and the 'jack in the box' effect:
b. spherical aberration;
c. image distortion with pin-cushion effects;
d. reduced visual fields;
e. magnification of the retinal image of about 30%;
f. loss of binocular single vision;
g. sensitivity of the power of spectacle correction required to small changes of the back vertex distance.

16 Ring scotoma
A is caused by prismatic deviation of high-power spectacle lenses
B consists of an area of central scotoma
C is particularly associated with correction of aphakia
D is stationary when the eye moves around
E results in 'jack in the box' phenomenon

16 A = True B = False C = True D = False E = True

Ring scotoma may occur when high-powered spectacles are worn, especially in aphakia. Light entering
through the lens undergoes prismatic deviation, while light entering outside the lens is not deviated.
Hence, there is a ring of visual field just outside the lens where It cannot enter the eye and be seen by the
subject. This is the ring scotoma. The location of the scotoma moves with the movement of the eye, and
results in the 'jack in the box' phenomenon.

17. The increasing prismatic effect of the more peripheral parts of a spherical lens is responsible for:
a. ring scotoma
b. chromatic aberration
c. spherical aberration
d. jack-in-the-box effect
e. image distortion
17. a.T b.F c.T d.T e.T
The increasing prismatic effect of the more peripheral parts of a spherical lens is responsible for:
• spherical aberration
• ring scotoma
• jack-in-the-box effect
• image distortion so that a thick plus lens gives a pin-cushion effect and a thick minus lens gives a
barrel effect.

18. Iseikonic lenses

A. are expensive to make
B. can have magnifying power without refractive power
C. are an example of an afocal lens with magnification
D. can have a magnification up to 15%
E. can be made to have magnification in one meridian only

18 A=True B = True C = True D = False E = True

Iseikonic lenses are lenses with magnification power but no refractive power. They produce angular
magnification by utilising the effect of the lens thickness and the refractive power of the front surface,
which is neutralised by the refractive power of the other surface. They are examples of afocal lenses. Due
to limitations on the thickness of a lens, the maximum magnification produced is about 5%.
They are expensive and require special equipment to be manufactured. They can either be made with
equal magnification in all meridians, or with magnification in one meridian only.

19 Which of the following statements about Worth's four-dot test is/are true?
A It can be used to test for squint.
B It can be used to test for suppression.
C If the subject sees four lights with a manifest squint, abnormal retinal correspondence is present.
D If the subject sees three green lights, normal fusion is present.
E If the subject sees five lights, diploplia is present.

19 A = False B = True C = True D = False E = True

Worth's four-dot test is used to test for abnormality of fusion. If the subject sees four lights with a
manifest squint, fusion appears to be present. (The image of the white light is fused.) The presence of a
squint means that the subject must be fixating with the extra-foveal area of one eye. Hence, ARC is
present. If three green lights are seen, all the images are perceived by the left eye. Hence, there is right
eye suppression. If the subject sees five lights, both eves are used, but the images are not fused. There
must be diploplia.

20. Anisometropia:
a. occurs when the two eyes have different refractive errors
b. of more than 1D in hypermetropic patients can usually be controlled through accommodation of the
more hypermetropic eye
c. is a common cause of amblyopia in patients with uncorrected low myopia
d. of recent onset may be caused by the development of posterior subcapsular cataract
e. may result from unilateral central serous retinopathy

20. a.T b.F c.F d.F e.T

Anisometropia refers to different refractive errors between the two eyes. Anisometropia of more than 1D
in hypermetropic patients cannot be controlled with unilateral accommodation because accommodation is
a binocular process. Therefore the image in one eye is often blurred and is a cause of amblyopia. On the
other hand, anisometropia in low myope does not usually cause amblyopia because the near vision is
normal. Unilateral nucleosclerosis and not posterior subcapsular cataract can lead to index myopia.
Central serious retinopathy can cause hypermetropic shift.

21 Iseikonic lenses
A are used to correct astigmatism
B are always effective in aniseikonia
C can be clipped on to the present spectacles for a trial period
D can be combined with lenses with refractive correction
E can be combined with bifocal lenses

21 A = False B = False C = True D = True E = True

Iseikonic lenses are afocal lenses with magnification but no overall refractive power. They are used to
correct aniseikonia (difference in image magnification between the two eyes), but are not always
effective. As they are expensive to make, they are sometimes clipped on to the present spectacles for a
trial period. They can be combined with lenses for correction of refractive error, or with bifocal lenses.
22 The following statements about anisometropia is/are true.
A It occurs when both eyes are equally highly myopic.
B It occurs when one eye is highly myopic and the other emmetropic.
C Binocular single vision is impossible If anisometropia exceeds 1D.
D Correction by spectacle lenses often causes aniseikonia.
E An tseikonic lens is always effective.

22 A = False B = True C = False D = True E = False

Anisometropia occurs when the refractive errors of the two eyes show a significant difference. Some
binocular single vision is possible for low grades of anisometropia, but eye-strain is a common
complaint, and binocular single vision becomes impossible in high grades of anisometropia. Correction
with spectacles usually causes differences in retinal image size (aniseikonia), and correction with
iseikonic lenses are not always effective. Contact lenses may be more effective.

23 In Worth's four dot test

A a red lens is placed in front of the subject's left eye
B a plane untinted lens is placed in front of the subject's right eye
C the subject views a box containing two red lights
D the subject views a box containing two green lights
E the subject views a box containing one white light

23 A = False B = False C = False D = True E = True

Worth's four-dot test is used to test for abnormality of fusion and ARC. A red lens is placed in front of
the right eye and a green lens is placed in front of the left eye. The subject views a box with one red, two
green and one while light. Since only red light can pass through red lens, and only green light can pass
through green lens, the red light must be seen by the right eye, and the two green lights by the left eye. If
both eyes are used to see the white light, the light will be seen as white. However, if the right eye is
suppressed, the white light will be seen as green by the left eye.

24 Compared with spectacle prescription, treatment of anisometropia by contact lenses

A reduces the prismatic effect in axial anisometropia
B reduces the phsmatic effect in refractive anisometropia
C reduces the aniseikonia in axial anisometropia
D reduces the aniseikonia in refractive anisometropia
E increases the monocular visual acuities

24 A = True B = True 0 = False D = True E = False

Contact lenses have less prismatic effect than spectacles In all kinds of anisometropia, as prismatic power
= power x decentration, and decentration is less if contact lenses are used.
In axial anisometropia, the image size at the retina is the same as emmetropia (i.e. RSM is 1) if the lens is
at the anterior focal plane of the eye. Hence, the spectacles are more likely to achieve this. In refractive
anisometropia, the image size at the retina approaches that of emmetropia the closer the lens is to the
nodal point of the eye. Hence, a contact lens is more likely to cause less aniseikonia.
In practice, however, anisometropia is likely to be a mixture of axial and refractive anisometropia. Hence,
a trial of contact lenses is justified in all cases of anisometropia.
Use of contact lenses does not increase the monocular visual acuities, although the binocular visual
acuity may be increased.

25 Spectacle intolerance is commonly associated with:

a Anisometropia.
b A difference of 40 degrees between the cylindrical axes of the two eyes.
c High refractive errors. .
d Amblyopia.
e Bifocals.

25 a True. In anisometropia, unequal magnification and unequal prismatic effects give rise to spectacle
intolerance.
b True. Where the axes of the cylinders vary by more than 20 degrees, spectacle intolerance is more
common.
c True. In high myopic or aphakic corrections, the marked prismatic effect at the lens periphery often
causes intolerance.
d False.
e True. In a bifocal lens, the prismatic effect at the junction of the near and distance segments may
initially give rise to some discomfort.
26 When prescribing spectacles;
a It is not necessary to note the BVD unless the prescription is above 8DS.
b The optical centres of spectacle lenses should always be at the patient's IPD.
c A maximum of 2 D of anisometropia can be tolerated.
d Plastic lenses are the lens of choice for children.
e Glass lenses are always heavier than plastic lenses of the same prescription.

26 a False, The BVD should always be measured and recorded if one meridian of the prescription is 6 D
or more. It is good practice to do this for powers of 4 D.
b False. This depends on the prescription. For low powers, a negligible prismatic effect is induced by
slight decentration. In cases where a prism is prescribed, decentration is often employed to deliberately
create a prismatic effect.
c False. Much higher levels of anisometropia than this may be tolerated in practice, although there is a
large individual variation between patients.
d True,
e False. For high minus prescriptions, for example, the lighter lens may be a glass lens of high RI.