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Refractive error, also known as refraction error, is a problem with
focus Focus, or its plural form foci may refer to: Arts * Focus or Focus Festival, former name of the Adelaide Fringe arts festival in South Australia Film *''Focus'', a 1962 TV film starring James Whitmore * ''Focus'' (2001 film), a 2001 film based ...
ing
light Light or visible light is electromagnetic radiation that can be perceived by the human eye. Visible light is usually defined as having wavelengths in the range of 400–700 nanometres (nm), corresponding to frequencies of 750–420 t ...
accurately on the
retina The retina (from la, rete "net") is the innermost, light-sensitive layer of tissue of the eye of most vertebrates and some molluscs. The optics of the eye create a focused two-dimensional image of the visual world on the retina, which the ...
due to the shape of the eye and or
cornea The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical ...
. The most common types of refractive error are
near-sightedness Near-sightedness, also known as myopia and short-sightedness, is an eye disease where light focuses in front of, instead of on, the retina. As a result, distant objects appear blurry while close objects appear normal. Other symptoms may includ ...
,
far-sightedness Far-sightedness, also known as long-sightedness, hypermetropia, or hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blurred effect is due to incoming light being focused behind, i ...
,
astigmatism Astigmatism is a type of refractive error due to rotational asymmetry in the eye's refractive power. This results in distorted or blurred vision at any distance. Other symptoms can include eyestrain, headaches, and trouble driving at n ...
, and
presbyopia Presbyopia is physiological insufficiency of accommodation associated with the aging of the eye that results in progressively worsening ability to focus clearly on close objects. Also known as age-related farsightedness (or age-related long si ...
. Near-sightedness results in far away objects being
blurry "Blurry" is a song by American rock band Puddle of Mudd. It was released on October 16, 2001, as the second single from the band's debut album '' Come Clean'' (2001). It was 2002's most successful rock song in the United States, topping the ''Bi ...
, far-sightedness and presbyopia result in close objects being blurry, and astigmatism causes objects to appear stretched out or blurry. Other symptoms may include
double vision Diplopia is the simultaneous perception of two images of a single object that may be displaced horizontally or vertically in relation to each other. Also called double vision, it is a loss of visual focus under regular conditions, and is often v ...
,
headaches Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resu ...
, and
eye strain Eye strain, also known as asthenopia (from Greek ''a-sthen-opia'', grc, ἀσθενωπία, ), is a common eye condition that manifests through non-specific symptoms such as fatigue, pain in or around the eyes, blurred vision, headache, a ...
. Near-sightedness is due to the length of the eyeball being too long, far-sightedness the eyeball too short, astigmatism the cornea being the wrong shape, and presbyopia aging of the lens of the eye such that it cannot change shape sufficiently. Some refractive errors occur more often among those whose parents are affected. Diagnosis is by
eye examination An eye examination is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ...
. Refractive errors are corrected with
eyeglass Glasses, also known as eyeglasses or spectacles, are vision eyewear, with lenses (clear or tinted) mounted in a frame that holds them in front of a person's eyes, typically utilizing a bridge over the nose and hinged arms (known as temples ...
es,
contact lenses Contact lenses, or simply contacts, are thin lenses placed directly on the surface of the eyes. Contact lenses are ocular prosthetic devices used by over 150 million people worldwide, and they can be worn to correct vision or for cosmeti ...
, or
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...
. Eyeglasses are the easiest and safest method of correction. Contact lenses can provide a wider
field of vision The visual field is the "spatial array of visual sensations available to observation in introspectionist psychological experiments". Or simply, visual field can be defined as the entire area that can be seen when an eye is fixed straight at a point ...
; however they are associated with a risk of infection.
Refractive surgery Refractive eye surgery is optional eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea ( keratomile ...
permanently changes the shape of the cornea. The number of people globally with refractive errors has been estimated at one to two billion. Rates vary between regions of the world with about 25% of Europeans and 80% of Asians affected. Near-sightedness is the most common disorder. Rates among adults are between 15-49% while rates among children are between 1.2-42%. Far-sightedness more commonly affects young children and the elderly. Presbyopia affects most people over the age of 35. The number of people with refractive errors that have not been corrected was estimated at 660 million (10 per 100 people) in 2013. Of these 9.5 million were blind due to the refractive error. It is one of the most common causes of
vision loss Visual impairment, also known as vision impairment, is a medical definition primarily measured based on an individual's better eye visual acuity; in the absence of treatment such as correctable eyewear, assistive devices, and medical treatment� ...
along with
cataract A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colors, blurry or double vision, halos around light, trouble ...
s,
macular degeneration Macular degeneration, also known as age-related macular degeneration (AMD or ARMD), is a medical condition which may result in blurred or no vision in the center of the visual field. Early on there are often no symptoms. Over time, however, so ...
, and
vitamin A deficiency Vitamin A deficiency (VAD) or hypovitaminosis A is a lack of vitamin A in blood and tissues. It is common in poorer countries, especially among children and women of reproductive age, but is rarely seen in more developed countries. Nyctalopia (ni ...
.


Classification

An eye that has no refractive error when viewing distant objects is said to have '' emmetropia'' or be ''emmetropic'' meaning the eye is in a state in which it can focus parallel rays of light (light from distant objects) on the retina, without using any accommodation. A distant object, in this case, is defined as an object located beyond 6 meters, or 20 feet, from the eye, since the light from those objects arrives as essentially parallel rays when considering the limitations of human perception. An eye that has refractive error when viewing distant objects is said to have ''ametropia'' or be ''ametropic''. This eye cannot focus parallel rays of light (light from distant objects) on the retina, or needs accommodation to do so. The word "ametropia" can be used interchangeably with "refractive error". Types of ametropia include myopia, hyperopia and astigmatism. They are frequently categorized as spherical errors and cylindrical errors: * Spherical errors occur when the
optical power In optics, optical power (also referred to as dioptric power, refractive power, focusing power, or convergence power) is the degree to which a lens, mirror, or other optical system converges or diverges light. It is equal to the reciprocal of the ...
of the eye is either too large or too small to focus light on the
retina The retina (from la, rete "net") is the innermost, light-sensitive layer of tissue of the eye of most vertebrates and some molluscs. The optics of the eye create a focused two-dimensional image of the visual world on the retina, which the ...
. People with refractive error frequently have blurry vision. **
Nearsightedness Near-sightedness, also known as myopia and short-sightedness, is an eye disease where light focuses in front of, instead of on, the retina. As a result, distant objects appear blurry while close objects appear normal. Other symptoms may include ...
: When the optics are too powerful for the length of the eyeball one has
myopia Near-sightedness, also known as myopia and short-sightedness, is an eye disease where light focuses in front of, instead of on, the retina. As a result, distant objects appear blurry while close objects appear normal. Other symptoms may includ ...
or nearsightedness. This can arise from a
cornea The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical ...
or
crystalline lens The lens, or crystalline lens, is a transparent biconvex structure in the eye that, along with the cornea, helps to refract light to be focused on the retina. By changing shape, it functions to change the focal length of the eye so that it ca ...
with too much curvature (refractive myopia) or an eyeball that is too long (axial myopia). Myopia can be corrected with a concave lens, which causes the divergence of light rays before they reach the cornea. ** Farsightedness: When the optics are too weak for the length of the eyeball, one has
hyperopia Far-sightedness, also known as long-sightedness, hypermetropia, or hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blurred effect is due to incoming light being focused behind, i ...
or farsightedness. This can arise from a cornea or crystalline lens with not enough curvature (refractive hyperopia) or an eyeball that is too short (axial hyperopia). This can be corrected with convex lenses, which cause light rays to converge prior to hitting the cornea. **
Presbyopia Presbyopia is physiological insufficiency of accommodation associated with the aging of the eye that results in progressively worsening ability to focus clearly on close objects. Also known as age-related farsightedness (or age-related long si ...
: When the flexibility of the lens declines, typically due to age. The individual would experience difficulty in near vision, often relieved by reading glasses, bifocal, or progressive lenses. * Cylindrical errors cause astigmatism, when the optical power of the eye is too powerful or too weak across one meridian, such as if the corneal curvature tends towards a cylindrical shape. The angle between that meridian and the horizontal is known as the axis of the cylinder. **
Astigmatism Astigmatism is a type of refractive error due to rotational asymmetry in the eye's refractive power. This results in distorted or blurred vision at any distance. Other symptoms can include eyestrain, headaches, and trouble driving at n ...
: A person with astigmatic refractive error sees lines of a particular orientation less clearly than lines at right angles to them. This defect can be corrected by refracting light more in one meridian than the other. Cylindrical lenses serve this purpose. Other terminology include
anisometropia Anisometropia refers to a condition when two eyes have unequal refractive power. Generally, a difference in power of one diopter (1D) or more is the accepted threshold to label the condition anisometropia. Patients can tolerate 3 D of anisomet ...
, when the two eyes have unequal refractive power, and
aniseikonia Aniseikonia is an ocular condition where there is a significant difference in the perceived size of images. It can occur as an overall difference between the two eyes, or as a difference in a particular meridian. If the ocular image size in both e ...
which is when the
magnification Magnification is the process of enlarging the apparent size, not physical size, of something. This enlargement is quantified by a calculated number also called "magnification". When this number is less than one, it refers to a reduction in si ...
power between the eyes differ. Refractive error may be quantified as the error of a wavefront arising from a person’s far point, compared with a plane, or zero vergence, wavefront compared at an appropriate reference plane. The reference plane may be a real plane such as the spectacle plane or the corneal plane, or an imaginary plane such as the first principal plane or the entrance pupil plane. In diopters, spherical refractive errors can be expressed as K=1/k, where k is the distance in meters from the reference plane to an eye’s far point, and K is the refractive error in diopters. Thus, a person with myopia would have a negative refractive error, a person with emmetropia would have zero refractive error and a person with hyperopia would have a positive refractive error. In the case of regular astigmatism, refractive error needs to be expressed as 3 values: classically as sphere, cylinder and axis. However, it can also be expressed in vector terms, for example, M (mean sphere), J0 (With the rule/Against the rule astigmatism), J45 (oblique astigmatism). Refractive errors containing higher order aberrations (sometimes referred to as irregular astigmatism) can be expressed for a given pupil size using wavefront errors or optical path differences, often as coefficients for Zernike polynomials. A more subjective quantity
visual acuity Visual acuity (VA) commonly refers to the clarity of vision, but technically rates an examinee's ability to recognize small details with precision. Visual acuity is dependent on optical and neural factors, i.e. (1) the sharpness of the retinal ...
(expressed as a fraction) may be used, but there is no direct or exact conversion between the two.


Risk factors


Genetics

There is evidence to suggest genetic predilection for refractive error. Individuals that have parents with certain refractive errors are more likely to have similar refractive errors. The Online Mendelian Inheritance in Man (
OMIM Online Mendelian Inheritance in Man (OMIM) is a continuously updated catalog of human genes and genetic disorders and traits, with a particular focus on the gene-phenotype relationship. , approximately 9,000 of the over 25,000 entries in OMIM ...
) database has listed 261 genetic disorders in which myopia is one of the symptoms. Myopia may be present in heritable connective tissue disorders such as:
Knobloch syndrome Knobloch syndrome is a rare genetic disorder presenting severe eyesight problems and often a defect in the skull. It was named after the ophthalmologist William Hunter Knobloch (1926 - 2005), who first described the syndrome in 1971. A usual occur ...
(OMIM 267750);
Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with long arms, legs, fingers, and toes. They also typically have exceptionally flexible joints a ...
(OMIM 154700); and Stickler syndrome (type 1, OMIM 108300; type 2, OMIM 604841). Myopia has also been reported in X-linked disorders caused by mutations in loci involved in retinal photoreceptor function (
NYX Nyx (; , , "Night") is the Greek goddess and personification of night. A shadowy figure, Nyx stood at or near the beginning of creation and mothered other personified deities, such as Hypnos (Sleep) and Thanatos (Death), with Erebus (Darkn ...
, RP2, MYP1) such as: autosomal recessive
congenital stationary night blindness Congenital stationary night blindness (CSNB) is a rare non-progressive retinal disorder. People with CSNB often have difficulty adapting to low light situations due to impaired photoreceptor transmission. These patients may also have reduced visua ...
( CSNB; OMIM 310500);
retinitis pigmentosa Retinitis pigmentosa (RP) is a genetic disorder of the eyes that causes loss of vision. Symptoms include trouble seeing at night and decreasing peripheral vision (side and upper or lower visual field). As peripheral vision worsens, people may ...
2 (RP2; OMIM 312600); Bornholm eye disease (OMIM 310460). Many genes that have been associated with refractive error are clustered into common biological networks involved in connective tissue growth and extracellular matrix organization. Although a large number of chromosomal localisations have been associated with myopia (MYP1-MYP17), few specific genes have been identified.


Environmental

In studies of the genetic predisposition of refractive error, there is a correlation between environmental factors and the risk of developing myopia. Myopia has been observed in individuals with visually intensive occupations.
Reading Reading is the process of taking in the sense or meaning of letters, symbols, etc., especially by sight or touch. For educators and researchers, reading is a multifaceted process involving such areas as word recognition, orthography (spell ...
has also been found to be a predictor of myopia in children. It has been reported that children with myopia spent significantly more time reading than non-myopic children who spent more time playing outdoors.
Socioeconomic status Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family's economic access to resources and social position in relation to others. When analyzing a family's ...
and higher levels of education have also been reported to be a risk factor for myopia.


Diagnosis

Blurry vision may result from any number of conditions not necessarily related to refractive errors. The diagnosis of a refractive error is usually confirmed by an
eye care professional An eye care professional (ECP) is an individual who provides a service related to the eyes or vision. It is any healthcare worker involved in eye care, from one with a small amount of post-secondary training to practitioners with a doctoral level ...
during an
eye examination An eye examination is a series of tests performed to assess vision and ability to focus on and discern objects. It also includes other tests and examinations pertaining to the eyes. Eye examinations are primarily performed by an optometrist, ...
using a large number of lenses of different optical powers, and often a retinoscope (a procedure entitled '' retinoscopy'') to measure objectively in which the person views a distant spot while the clinician changes the lenses held before the person's eye and watches the pattern of reflection of a small light shone on the eye. Following that "objective refraction" the clinician typically shows the person lenses of progressively higher or weaker powers in a process known as '' subjective refraction''.
Cycloplegic Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. This results in sim ...
agents are frequently used to more accurately determine the amount of refractive error, particularly in children An
automated refractor An autorefractor or automated refractor is a computer-controlled machine used during an eye examination to provide an objective measurement of a person's refractive error and prescription for glasses or contact lenses. This is achieved by measuri ...
is an instrument that is sometimes used in place of retinoscopy to objectively estimate a person's refractive error.
Shack–Hartmann wavefront sensor A Shack–Hartmann (or Hartmann–Shack) wavefront sensor (SHWFS) is an optical instrument used for characterizing an imaging system. It is a wavefront sensor commonly used in adaptive optics systems. It consists of an array of lenses (called ...
and its inverse can also be used to characterize eye aberrations in a higher level of resolution and accuracy. Vision defects caused by refractive error can be distinguished from other problems using a
pinhole occluder A pinhole occluder is an opaque disk with one or more small holes through it, used by ophthalmologists, orthoptists and optometrists to test visual acuity. The occluder is a simple way to focus light, as in a pinhole camera, temporarily removing ...
, which will improve vision only in the case of refractive error.


Management

The management of refractive error is done post-diagnosis of the condition by either optometrists, ophthalmologists, refractionists, or ophthalmic medical practitioners. How refractive errors are treated or managed depends upon the amount and severity of the condition. Those who possess mild amounts of refractive error may elect to leave the condition uncorrected, particularly if the person is asymptomatic. For those who are symptomatic,
glasses Glasses, also known as eyeglasses or spectacles, are vision eyewear, with lenses (clear or tinted) mounted in a frame that holds them in front of a person's eyes, typically utilizing a bridge over the nose and hinged arms (known as temples ...
,
contact lenses Contact lenses, or simply contacts, are thin lenses placed directly on the surface of the eyes. Contact lenses are ocular prosthetic devices used by over 150 million people worldwide, and they can be worn to correct vision or for cosmeti ...
,
refractive surgery Refractive eye surgery is optional eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea ( keratomile ...
, or a combination of the three are typically used.


Glasses

These are the most effective ways of correcting the refractive error. However, the availability and affordability of eye glasses can present a difficulty for people in many low income settings of the world. Glasses also pose a challenge to children to whom they are prescribed to, due to children's tendency to not wear them as consistently as recommended. As mentioned earlier refractive errors are because of the improper focusing of the light in the retina. Eyeglasses work as an added lens of the eye serving to bend the light to bring it to focus on the retina. Depending on the eyeglasses, they serve many functions. ; Reading glasses: These are general over-the-counter glasses which can be worn for easier reading, especially for defective vision due to aging called presbyopia. ; Single vision prescription lenses: They can correct only one form of defective vision, either far-sightedness or near-sightedness. ; Multifocal lenses: The multifocal lenses can correct defective vision in multiple focus, for example: near-vision as well as far-vision. This are particularly beneficial for presbyobia.


Contact lenses

Alternatively, many people choose to wear contact lenses. One style is hard contact lenses, which can distort the shape of the cornea to a desired shape. Another style, soft contact lenses, are made of silicone or hydrogel. Depending on the duration they are designed for, they may be worn daily or may be worn for an extended period of time, such as for weeks. There are a number of complication associated with contact lenses. Typically the ones that are used daily. If redness, itching, and difficulty in vision develops, the use of the lenses should be stopped immediately and the consultation of ophthalmologists may be sought.


Surgery

Laser in situ keratomileusis (LASIK) and photo-refractive keratectomy (PRK) are popular procedures; while use of laser epithelial keratomileusis (LASEK) is increasing. Other surgical treatments for severe myopia include insertion of implants after clear lens extraction (refractive lens exchange). Full thickness corneal graft may be a final option for patients with advanced kerataconus although currently there is interest in new techniques that involve collagen crosslinking. As with any surgical procedure complications may arise post-operatively Post-operative monitoring is normally undertaken by the specialist ophthalmic surgical clinic and optometry services. Patients are usually informed pre-operatively about what to expect and where to go if they suspect complications. Any patient reporting pain and redness after surgery should be referred urgently to their ophthalmic surgeon.


Medical treatment

Atropine has believed to slow the progression of near-sightedness and is administered in combination with multifocal lenses. These, however, need further research.


Prevention

Strategies being studied to slow worsening include adjusting working conditions, increasing the time children spend outdoors, and special types of contact lenses. In children special contact lenses appear to slow worsening of nearsightedness. A number of questionnaires exist to determine
quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...
impact of refractive errors and their correction.


Epidemiology

The number of people globally with refractive errors that have not been corrected was estimated at 660 million (10 per 100 people) in 2013. Refractive Errors are the first common cause of Visual Impairment and second most common cause of visual loss . The assessment of Refractive Error is now done in DALY ( Disability Adjusted Life Years ) which showed an 8% increase from 1990 to 2019. The number of people globally with significant refractive errors has been estimated at one to two billion. Rates vary between regions of the world with about 25% of Europeans and 80% of Asians affected. Near-sightedness is one of the most prevalent disorders of the eye. Rates among adults are between 15-49% while rates among children are between 1.2-42%. Far-sightedness more commonly affects young children, whose eyes have yet to grow to their full length, and the elderly, who have lost the ability to compensate with their accommodation system. Presbyopia affects most people over the age of 35, and nearly 100% of people by the ages of 55-65. Uncorrected refractive error is responsible for visual impairment and disability for many people worldwide. It is one of the most common causes of
vision loss Visual impairment, also known as vision impairment, is a medical definition primarily measured based on an individual's better eye visual acuity; in the absence of treatment such as correctable eyewear, assistive devices, and medical treatment� ...
along with
cataract A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colors, blurry or double vision, halos around light, trouble ...
s,
macular degeneration Macular degeneration, also known as age-related macular degeneration (AMD or ARMD), is a medical condition which may result in blurred or no vision in the center of the visual field. Early on there are often no symptoms. Over time, however, so ...
, and
vitamin A deficiency Vitamin A deficiency (VAD) or hypovitaminosis A is a lack of vitamin A in blood and tissues. It is common in poorer countries, especially among children and women of reproductive age, but is rarely seen in more developed countries. Nyctalopia (ni ...
.


Cost

The yearly cost of correcting refractive errors is estimated at 3.9 to 7.2 billion dollars in the United States.


References


External links

{{DEFAULTSORT:Refractive error Vision Disorders of ocular muscles, binocular movement, accommodation and refraction Refraction Wikipedia medicine articles ready to translate Wikipedia neurology articles ready to translate Corrective lenses