01 'With the rule' astigmatism

A is correctable by a plus sphere at 90°

B is correctable by a minus cylinder with the axis at 90°
C is more common in children and young adults
D is frequently 'symmetrical’ in both eyes so that the sum of the cylindrical axes in the two eyes is about
180°
E is a form of oblique astigmatism

01 A = false B = False C = True D = True E = False

'With the rule' astigmatism may be caused by the lid squeezing the globe. It may therefore increase in
curvature vertically. It can be corrected by a plus cylinder at 90o or a minus cylinder at 0°. It appears to
be more common in children and young adults, and tends to become 'against the rule' as age increases.
The astigmatisms are frequently 'symmetrical in that they are mirror images of each other and the sum of
their cylindrical axes approximates 180°. Oblique astigmatism usually refers to astigmatism with the
cylindrical axis more than 25° to the horizontal or the vertical.

02 In the fitting of contact lenses for astigmatism

A the cylinder axis in the toric anterior surface can be oriented by use of a prism ballast lens
B the orientation of the lens is unimportant
C the cylinder axis can be orientated by use of truncation
D the use of a prism ballast lens is ruled out by its strong prismatic effect
E the cylinder axis can be oriented by judging the visual effect when the lens is rotated

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

In the prescription of a toric lens for astigmatism, it is important to align the cylindrical axis of the lens to
the astigmatic axis of the eye. This can be achieved by the prism ballast lens, where a prism is added to
the lower portion of the lens, which will help the lens to be positioned with the prism downwards. Prisms
in the contact lens have little optical prismatic effect as the refractive index from tear to lens is less than
that from air to lens. Truncation involves cutting off one edge of a lens. The truncated edge is heavier and
tends to position itself downwards.

03 Use of contact lenses in the correction of keratoconus

A is contra-Indicated
B reduces the progression of the intrinsic corneal pathology
C tends to create a large area of central touch if ordinary lenses are used
D eliminates any need for corneal grafting
E is often less satisfactory than correction by spectacles

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

Contact lenses are useful in correcting the irregular astigmatic corneal surface in keratoconus, & are
usually more satisfactory than spectacles. However, they don’t reduce the progression of the intrinsic
corneal pathology, and therefore do not eliminate the need for corneal grafting. Keratoconus corneas are
steep centrally and flat peripherally. Hence, fitting an ordinary lens tends either to create a large area of
central touch, or to create an area of central touch with bubbles in the intermediate zone.

04 The following is/are true concerning correction of astigmatism by contact lenses.

A A spherical hard lens Is likely to correct alt posterior corneal surface astigmatism.
B A spherical hard lens is likely to correct all lenticular astigmatism.
C Residual astigmatism is the astigmatism left uncorrected by a spherical contact lens.
D A toric back surface of a hard lens may induce astigmatism.
E A thin soft lens is likely to correct any corneal astigmatism.

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

A hard spherical contact lens corrects most of the anterior corneal surface astigmatism, but leaves the
posterior corneal and lenticular astigmatism uncorrected. A toric back surface (i.e. a lens with spherical
and cylindrical components on the back surface) may induce astigmatism. The astigmatism left
uncorrected by a spherical hard contact lens is called the 'residual astigmatism'. A thin soft lens placed on
an astigmatic cornea will not correct the astigmatism, as the lens may mould onto the cornea. A thick soft
lens may partially correct the anterior corneal astigmatism.

05 The following statements about astigmatism is/are correct

A It can be caused by pressure of the lids on the globe
B In regular astigmatism, the directions of greatest and least curvature are at 45° to each other
C Regular astigmatism can be corrected by a spherical lens
D In 'against the rule' astigmatism, the vertical meridian is more curved than the horizontal meridian
E irregular astigmatism can be corrected by a combination of spherical and cylindrical lenses
05 A = True B = False C = False D = False E = False
Astigmatism is often caused by the curvature of the cornea being abnormal, so that it is no longer
spherical. Regular astigmatism occurs when the cornea has its directions of greater and least curvature at
90° to each other. The most common form is when the vertical meridian Is more curved, probably due to
the pressure of the lids on the globe 'squeezing' it. This is called 'according to the rule' astigmatism.
Conversely, when the horizontal meridian is more curved, it is called 'against the rule* astigmatism.
When the meridians of astigmatism are not at right angle to each other, It is called irregular astigmatism,
and cannot be totally corrected by a spectacle lens. A contact lens may partially correct the defect.

06 The following instruments are useful in the determination of the axis in astigmatism.
A The Maddox rod.
B The astigmatic fan.
C The stenopaeic slit.
D The cross-cylinder.
E The major amblyoscope.

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

The axis of astigmatism can be determined objectively by retinoscopy, or subjectively by the stenopaeic
slit, the astigmatic block or fan, and the cross-cylinder. The stenopaeic slit contains a slit mounted on a
trial lens so that light in one meridian only can enter the eye. When the spherical component of the
refractive error is corrected, the vision would be best if the slit aperture is in line with the astigmatic axis
of the eye. Similarly, in the astigmatic fan, the line which appears to be clearest (or darkest) would be in
line with the astigmatic axis of the eye. The major amblyoscope is mainly used to measure squints and
binocular single vision.

07Astigmatism
A. requires optical correction if it is an asymptomatic simple type of 0.25D
B. requires correction if it causes 'eyestrain'
C. should be corrected for distant vision only
D. causes more reduction in visual acuity in compound hypermetropic type than mixed astigmatism
E. can be corrected by contact lenses

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

Astigmatism needs correction if the visual acuity is significantly reduced or if there are symptoms of
asthenopia. An asymptomatic simple astigmatism of 0.25D does not require optical correction.
Astigmatism should be corrected for both near and distant vision, as accommodation cannot correct for
the astigmatism. Compound hypermetropic astigmatism (where the foci for both meridian fall behind the
retina) causes more reduction in visual acuity than mixed astigmatism (where the focus for one meridian
fails behind the retina and the other falls in front). This is because, in mixed astigmatism, the circle of
least diffusion (which lies between the two foci) is likely to be nearer to the retina.

08 The following statements regarding astigmatism is/are true.

A Compound hypermetropic astigmatism may be corrected by a cylindrical lens alone.
B Simple hypermetropic astigmatism may be corrected by a spherical lens.
C Simple myopic astigmatism may be corrected by a cylindrical lens alone.
D Compound myopic astigmatism may be corrected by a combination of concave and cylindrical lenses.
E Mixed astigmatism may be corrected by a combination of spherical and cylindrical lenses.

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

Compound hypermetropic astigmatism occurs when the eye is hypermetropic for both vertical and
horizontal meridians, and requires correction with a combination of a positive spherical (convex) lens and
a positive cylindrical lens. Simple hypermetropic astigmatism occurs when the focus for one meridian is
on the retina, but the eye is hypermetropic for the other meridian. A positive cylindrical lens is required
for correction. Simple myopic astigmatism similarly requires correction with a negative cylindrical lens.
Mixed astigmatism occurs when the retina falls between the two foci, and requires a combination of a
spherical lens and a cylindrical lens of the opposite sign for correction.

09. With regard to astigmatism:

a. regular astigmatism has the principal meridians at 90o to each other
b. oblique astigmatism occurs when the principal meridians do not lie at 90o to each other
c. irregular astigmatism is seen in patients with keratoconus
d. astigmatic eye produces an image known as a Sturm's conoid
e. astigmatic image cannot be fully corrected with a spherical lens

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

Regular astigmatism has the principal meridians at 90 o to each other.
Oblique astigmatism also has its principal meridians at 90 degrees to each other but they do not lie near
to 90 or 180 degrees.
Irregular astigmatism occurs when the principal meridians are not at 90 degrees to each other. An image
known as Sturm's conoid is produced by an astigmatic eye; such image can only be corrected with a
spherocylindrical lens.

10. Regarding the images form by astigmatic eyes:

a. rays in all meridians are focused behind the eye in compound hypermetropic astigmatism
b. ray from one meridian is focused on the retina while the other is focused behind the retina in simple
hypermetropic astigmatism
c. rays in all meridians are focused in front of the eye in compound myopic astigmatism
d. ray from one meridian is focused on the retina while the other is focused in front of the retina in simple
myopic astigmatism
e. ray from one meridian is focused in front of the retina and the other behind the retina in mixed
astigmatism

10. a.T b.T c.T d.T e.T

The definitions of the terms are correct.

11 Which of the following statements is/are true about astigmatism?

A The principal meridians in regular astigmatism may be at 45° to each other.
B If the axes of the principal meridians of each eye are the same, the astigmatism is symmetrical.
C Asymmetrical astigmatism is more common than symmetrical astigmatism.
D Uncorrected asymmetrical astigmatism is more likely than uncorrected symmetrical astigmatism to
cause torticollis.
E Irregular astigmatism can be totally corrected by cylinders.

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

In regular astigmatism, the principal meridians are at right angles to each other, and it can be totally
corrected by cylinders. In irregular astigmatism, the principal meridians are not at right angles to each
other, and it cannot be totally corrected by cylinders. Symmetrical astigmatism occurs when the principal
meridians of each eye are symmetrical with the median vertical line as the axis of symmetry.
In practice, symmetrical astigmatism occurs when the principal meridians of each eye corrected by
cylinders of the same sign add up to about 180°. Symmetrical astigmatism is more common than
asymmetrical astigmatism, and is less likely to cause head tilt or torticollis.

12 The following statements about astigmatism is/are correct.

A It causes eye-strain more often than hypermetropia.
B Regular astigmatism may be congenital.
C Regular astigmatism may occur following cataract surgery.
D Regular astigmatism may follow trauma.
E Corneal astigmatism may be partially corrected by lenticular astigmatism.

12 A = True 8 = True C = True D = True E = True

Astigmatism causes asthenopia (eye-strain) more often than myopia or hypermetropia. Dull ache around
the eye and headaches are common. Regular astigmatism is commonly congenital. However, it may be
caused by trauma or surgical procedures, especially cataract extraction. Astigmatism may be caused by
abnormality in the cornea or the lens. The astigmatism caused by abnormality in the cornea may be
additive to that caused by abnormality in the lens if they are of the same sign and direction, or they may
partially correct each other.

13. The following prescription has oblique astigmatism:

a. PL / -2.00X45
b. +1.00 / -0.25 X85
c. +1.25 / +1.00X175
d. -4.00 / -0.25X35
e. -5.00 / -1.00X130

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

By oblique astigmatism, we mean that the axis of the correcting cylinder is other than near 90 degrees or
180 degrees (other than with or against the rule astigmatism).

14. The following prescription has against-the-rule astigmatism:

a. +1.00 / +0.25 X 180
b. +1.00 / -0.25 X 180
c. +1.00 / -0.25 X 90
d. +1.00 / -0.25 X 135
e. -1.00 / +0.25 X 90

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

In against-the-rule astigmatism, the plus cylinder is at 180o and the minus cylinder is at 90o. In with-the-
rule astigmatism, the plus cylinder is at 90o and the minus cylinder is at 180o.

15. In against-the-rule astigmatism:

a. the horizontal meridian has more power than the vertical meridian
b. a minus cylinder at 180o will correct the astigmatism
c. a plus cylinder at 180o will correct the astigmatism
d. the astigmatism may be reduced with clear corneal incision at the temporal side during cataract surgery
e. the visual acuity is less affected than with-the-rule astigmatism

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

In against-the-rule astigmatism, the horizontal meridian has more power than the vertical meridian. A
minus cylinder will correct the astigmatism if placed at 90 degrees or alternatively a plus cylinder can be
used which is placed 180 degrees. Temporal incision will reduce against-the-rule astigmatism. The visual
acuity is less affected in with-the-rule astigmatism than against-the-rule astigmatism.

16. Simple astigmatism occurs when:

a. one image is focused on the retina and the other is in front of the retina
b. one image is focused on the retina and the other is behind the retina
c. both images are in front of the retina
d. both images are behind the retina
e. one image is in front of the retina and the other is behind the retina

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

Simple astigmatism occurs when one of the images is on the retina. Simple myopic astigmatism occurs
when one image is on the retina and the other in front of the retina. Simple hypermetropic astigmatism
occurs when one image is on retina and the other is behind the retina. Compound myopic astigmatism
occurs when both images are in front of the retina. Compound hypermetropic astigmatism occurs when
both images are behind the retina. Mixed astigmatism occurs when one image is in front of the retina and
the other behind the retina.

17. Oblique astigmatism

a. occurs when light passing through the lens obliquely
b. is more troublesome the higher the power of the lens
c. is most troublesome in the reading section of the varifocal glasses
d. is worse with meniscus lenses than biconvex or biconcave lens
e. of spectacle can be reduced with pantoscopic tilt

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

Oblique astigmatism is worse with stronger lens, biconvex or biconcave lens (as against meniscus lens)
and in the reading section of the varifocal glasses. It can be reduced by using meniscus lens and
pantoscopic tilt of the spectacles.

18 Astigmatism:
a Is termed with-the-rule when a positive cylinder is required at axis 90.
b Is termed against-the-rule when a negative cylinder is required at axis 45.
c Of the order of 0.25 to 1.00 DC is not commonly found in the general population.
d Of l.00 DC will reduce distance vision to approximately 6/9.
e Cannot be corrected with contact lenses if above 3 DC.

18 a True. b False. c False. d True e False

19 A patient with 1.5D dioptre of with-the-rule astigmatism:

a Will usually complain of vision which is more blurred at distance than at near.
b will have a blurred retinal image for objects at all distances.
c Will require a correcting lens with positive axis vertical.
d Cannot be corrected with contact lenses.
e Would be expected to have an uncorrected VA of no better than 6/18.

19 a True. b True. c True. d False. c False.

Although astigmatism theoretically reduces image quality at all distances, the increased depth
 of field of the eye at near means that symptoms are worse at distance.

20. Irregular astigmatism:

a. occurs when there are many radii in one meridian
b. can be corrected with spectacle
c. is usually corneal in nature
d. can be caused by different indices of refraction in different portions of the crystalline lens
e. can be treated with laser refractive surgery

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

Irregular astigmatism occurs when principal meridians are not at 90 degrees to each other. It is commonly
corneal in nature and caused by scar but it can also be lenticular in origin caused by different indices of
refraction in different portions of the crystalline lens. Spectacle cannot correct irregular astigmatism. It is
treated by substituting a new surface and this can be achieved with a contact lens usually RGP lens,
corneal graft or laser surgery.

21 Changes in refractive error. The following are true:

a Children tend to become less hypermetropic in the first few years of life.
b Blunt trauma may cause a sudden change in refractive error.
c Nucleosclerosis causes a myopic shift.
d Diabetic hyperglycaemia may cause a sudden myopic trend.
e Retinal detachment surgery may result in a myopic change".

21 a True. The myopic change occurs with general growth.

b True. Blunt trauma commonly causes a transient change in refractive error.
c True.
d True. In diabetes, the changes in refraction occur bilaterally and suddenly - myopia is associated with
hyperglycaemia and hypermetropia with hypoglycaemia.
e True. The use of encircling bands elongates the axial length, inducing myopia.

22 Regarding initial examination in clinical refraction:

a It does not include checking visual acuity.
b It should include a dilated fundal examination.
c The fellow eye should always be completely occluded while assessing visual acuity.
d It is helpful to do a direct cover test.
e If a manifest squint is presents the fixating eye may need occlusion to achieve fixation with the non-
dominant eye.

22 a False. Visual acuity should be measured for near and distance, both unaided and with current
spectacles.
b False. This should normally be done at the end of the refraction.
c False. In patients with nystagmus a high plus lens should be used as complete occlusion sometimes
increases nystagmus and may reduce acuity.
d True. This detects manifest squint.
e True.

23 History taking in practical refraction. The following are true:

a History taking is irrelevant to the final prescription.
b Previous spectacle wear is important.
c Lens form is not important.
d Past ocular history must be enquired after.
e Hobbies must be enquired after.

23 a False. History is important to ascertain the patient’s age, occupation, and special requirements.
b True.
c False. Myopes are especially intolerant to changes in lens form.
d True.
e True.

24. Asthenopia
A. is caused by continuous accommodative effort
B. is more likely to occur in myopia than hypermetropia
C. is more likely to occur in 2D hypermetropia than 0DS/+2DCx45°
D. doesn’t occur if the amount of astigmatism is small
E. occurs in anisometropic subjects more than pure hypermetropic subjects in general
24 A = True B = False C = False D = False E = True
Asthenopia is caused by accommodative fatigue when there is continuous accommodative effort. It is
more likely to occur in hypermetropia than myopia, as hypermetropic subjects need to exert more
accommodation for near vision. In astigmatism, the image is always blurred, and there is always a
stimulus to accommodative effort. Since accommodation cannot correct astigmatic errors, a small
astigmatic error may continuously stimulate accommodative effort. Similarly, in anisometropic subjects,
the accommodative effort of the two eyes cannot be dissociated. Hence, there is always a stimulus for
accommodation, causing asthenopia

25. Using minus cylinder during refraction:

a. avoids stimulation of accommodation in young hypermetropic patients
b. may overcorrect hypermetrope in the elderly
c. may overcorrect hypermetrope in cycloplegic refraction
d. may undercorrect myope patients
e. is a major cause of spectacle intolerance

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

The use of minus cylinder in young hypermetrope prevents stimulation of accommodation but may
overcorrect hypermetrope in the elderly and when performing cycloplegic refraction.

26. Regarding refraction in children:

a. myopia is more common than hypermetropia
b. refractive amblyopia can occur if there is more than 1.5 dioptre of hypermetropic anisometropia
c. increased accommodation is used by children to overcome uncorrected hypermetropia
d. myopia tends to progress as the child grows older
e. correction of hypermetropia can reduce exophoria
26. a.F b.T c.T d.T e.F
Hypermetropia is more common than myopia amongst UK children. It is recommended that hyperopic
anisometropia of more than 1D should be corrected because of the risk of refractive amblyopia. Increased
accommodation is used by children to overcome uncorrected hypermetropia; as accommodation is
associated with convergence accommodative esotropia can result. As children grow older, the axial
length of the eye increase leading to more myopia. Correction of myopia can reduce exophoria due to
stimulation of accommodation.
27 Regarding hypermetropia:
a It is the most common refractive error in the general population of the UK.
b Hypermetropia results when the posterior focal length of the eye is longer than the axial length.
c Absolute hypermetropia is the amount that cannot be overcome by accommodation.
d Manifest hypermetropia tends to increase with age.
e Latent hypermetropia tends to decrease with age.

27 aT bT cT dF eT

28 Hypermetropia
A is most commonly caused by abnormal shortness in the length of the eye
B is commonly caused by abnormal curvature of the cornea
C usually causes reduced visual acuity in children
D may cause 'eye-strain' in children
E may cause convergent squint in children

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

Hypermetropia may be caused by axial hypermetropia, refractive hypermetropia or index hypermetropia.
Axial hypermetropia (caused by abnormal shortness of the eye) is the most common. Hypermetropia
rarely exceeds about 7D. Children have a large amplitude of accommodation so that any hypermetropia is
likely to be compensated by accommodation. Hence, blurring of vision does not occur. However, they
may complain of 'eye-strain' due to persistent tension in the ciliary muscle. This is especially noticeable
after close work. The symptoms may include aching red watery eyes, and headaches. Convergent squint
may occur in children especially those with a high AC/A ratio.

29 In hypermetropia
A the abnormal shape of the eye is usually confined to the post-equatorial segment of the eye
B degeneration of the choroid is common
C fundus appearance may simulate optic papillitis
D it occurs more commonly in females than males
E there is an increased risk of angle closure glaucoma

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

Unlike myopia, the abnormality in the size and shape of the eye is not confined to the posterior segment
of the eye. The diameter of the cornea may be reduced, and the anterior chamber of the eye is usually
shallow. Hence, there is an increased risk of angle closure glaucoma. There is no difference in incidence
between male and female. The optic disc may simulate optic papillitis. Unlike myopia, degeneration of
choroid and retina does not occur.

30 Ametropia
A includes myopia
B includes hypermetropia
C includes emmetropia
D includes astigmatism
E always occurs in both eyes

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

Ametropia means errors of refraction (literally, not according to measure). It includes myopia,
hypermetropia and astigmatism. All these conditions can occur in one eye only.

31. The following are true about hypermetropia:

a. the second principal focus lies in front of the retina
b. accommodation is used to achieve normal vision
c. aphakia is a form of hypermetropia
d. patients require reading glasses earlier than the normal population
e. patients who has hypermetropic refraction following cataract surgery will have problem for both near
and distant reading

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

The second principal focus of hypermetropia lies behind the retina. Accommodation is used to correct the
hyperopia to certain extent. They require reading glasses earlier than the normal population. Aphakia is a
form of hypermetropia. Following cataract surgery, the accommodative ability of the eye is lost.
Therefore, if the patient is render hypermetropic, the vision will be blurred for distant and near. This is
the reason why most patients are made slightly myopic so that they can achieve a reasonable vision
without glasses for distance.
32. The following are true about hypermetropia:
a. manifest hypermetropia is the strongest plus lens the eye can accept for clear distant vision
b. latent hypermetropia is the residual hypermetropia masked by ciliary tone and involuntary
accommodation
c. latent hypermetropia can be unmasked by cycloplegic refraction
d. facultative hypermetropia refers to hypermetropia that cannot be overcome by accommodation
e. absolute hypermetropia cannot be overcome by accommodation

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

Four terms are used to define hypermetropia:
• Manifest hypermetropia refers to the strongest plus/convex lens that the patient can accept for clear
distant vision.
• Latent hypermetropia is the remaining hypermetropia masked by the ciliary tone and involuntary
accommodation. It can be unmasked by cycloplegic refraction.
• Facultative hypermetropia refers to hypermetropia that can be overcome by accommodation.
• Absolute hypermetropia refers to hypermetropia in excess of the amplitude of accommodation.

33. The following is /are true regarding hypermetropia.

A. Total hypermetropia is the total of facultative and absolute hypermetropia.
B. Latent hypermetropia is the difference between total and manifest hypermetropia.
C. Latent hypermetropia is the difference in refraction of the total relaxed eye with and without atropine.
D. It is mostly facultative in an infant.
E. Latent hypermetropia is related to the tone of the ciliary muscle.

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

Latent hypermetropia is the portion of hypermetropia compensated by ciliary muscle tone, which can
only be revealed with cycloplegics such as atropine. The rest of the hypermetropia is called manifest
hypermetropia. Of the manifest hypermetropia, the portion which can be reduced by accommodation is
called the facultative hypermetropia, and the portion which cannot is called absolute hypermetropia.
Total = latent + manifest
Manifest = facultative + absolute
In infancy, the ciliary muscle tone is high, so that most of the hypermetropia is latent. This can only be
revealed by cycloplegics. As age increases, the latent hypermetropia decreases while the manifest
hypermetropia increases. As the amplitude ct accommodation decreases with age, most hypermetropia
becomes absolute at about 60 years.

34 The following is/are true of hypermetropia.

A Latent hypermetropia is caused by the ciliary muscle tone.
B Total hypermetropia equals the sum of latent and absolute hypermetropia.
C Total hypermetropia equals the sum of absolute and facultative hypermetropia.
D Facultative hypermetropia is that part of hypermetropia that can be relaxed by accommodation.
E Manifest hypertropia increases with age.

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

Total hypermetropia equals the sum of latent and manifest hypermetropia. Manifest hypermetropia equals
the sum of absolute and facultative hypermetropia. Manifest hypertropia increases with age, as the
amplitude of accommodation decreases.

35 The following statements about hypermetropia is/are true.

A In newborn babies, most hypermetropia are manifest,
B In old age, most hypermetropia are absolute.
C In newborn babies, most hypermetropia are latent.
D As age increases, manifest hypermetropia increases.
E As age increases, latent hypermetropia increases.

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

In newborn babies, the ciliary muscle tone is high. Most of the hypermetropia is latent, and is only
revealed by the use of cycloplegics. In old age, the lens nucleus becomes harder, and most hypermetropia
becomes manifest. Also, with increasing of age, the amplitude of accommodation decreases, and most of
the hypermetropia becomes absolute.

36 Which of the following statements about simple myopia is /are correct?

A Degeneration of the fundus occurs.
B Retinal detachments are common complications.
C It does not progress beyond adolescence.
D It frequently exceeds 9D.
E It may be affected by severe illness.

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

Simple myopia can be thought of as normal physiological variations of axial length and curvature of the
cornea. It does not progress beyond adolescent, and it seldom exceeds 6D. Peripheral retinal degeneration
may occur from middle age, but degenerative changes in the fundus do not occur. In severe illness, the
sclera may become stretched. The axial length is increased, and the myopia is made worse.

37. The following are true about myopia:

a. the second principal focus lies behind the retina
b. the presence of posterior staphyloma suggests axial myopia
c. axial myopia may be caused by the cornea having too strong a refractive power
d. nucleosclerosis is a cause of index myopia
e. high myopia may be treated with clear lens extraction

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

In myopia, the second principal focus lies in front of the retina. Myopia may be classified into axial
myopia (in which the eye is abnormally long as in high myopia which can produce staphyloma) or
refractive (index) myopia in which the refractive power of the eye is increased as in keratoconus and
nucleosclerosis.

38 Myopia. The following are true:

a Myopia would be typically termed "axial" in the case of a patient with an axial length of 23 mm.
b "Axial" myopia is more common than "refractive" myopia in teenage patients.
c "Index" myopia is caused when the nucleus of the lens undergoes a reduction in refractive index.
d Myopia can be reduced by flattening the central cornea.
e The far point of an uncorrected -2 DS myope is at a theoretical distance of 20 cm.

38 a False. b True. c False. d True. e False. 50 cm.

39 when refracting myopes:

a They are often intolerant of large changes in their cylindrical axis.
b They are often intolerant of changes in their lens form.
c They generally prefer slight under-correction.
d They may not need a near addition.
e The duochrome test can be used to prevent over-correction.

39 a True.
b True.
c True. This means that they do not have to accommodate for the distance.
d True.
e True, The myopic patient should see the red letters more clearly to ensure under-correction.

40. Myopia
A. is of the axial type in keratoconus
B. may be due to the eye being abnormally short
C. is associated with convergence of parallel rays entering the cornea at a point behind the retina
D. can be corrected by a convex lens
E. requires a stronger lens for correction the further away the lens is from the eye

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

In myopia, light from distant objects (parallel light) enters the eye and converges at a point in front of the
retina. Myopia may be caused by an abnormally short eyeball (axial myopia), or an abnormally strong
refractive medium in the eye (refractive myopia). Axial myopia is the most common cause, and may be
hereditary. Refractive myopia includes conditions caused by abnormally high corneal refractive power
(e.g. keratoconus) or abnormally high refractive power in the lens (e.g. nucleus sclerosis). Myopia should
be corrected with a concave lens. The further the concave lens from the eye, the higher the power of the
lens needed.

41 In pathological axial myopia

A myopia appears from childhood
B it may progress to more than 20D
C degenerative changes of fundus characteristically become widespread in adolescence
D it is more common in Japanese
E it may be genetic in origin
41 A = True B = True C = False D = True E = True
Pathological axial myopia is thought to be genetic in origin, and is more common in some ethnic groups
such as Japanese and Chinese. The refractive error usually appears in childhood and can increase
progressively beyond adolescence to 20D or more. Marked degenerative changes are characteristic
features, although they rarely appear in adolescence.

42 Index myopia
A is caused by increased curvature of the cornea
B may be caused by an abnormal refractive index of the lens
C may precede senile cataracts
D is the commonest cause of myopia
E can be corrected by a concave lens

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

Index myopia is caused by abnormal refractive indices of the media. This can be caused by an
abnormally high RI in the cornea, aqueous, or the nucleus of the lens. Alternatively, it may be caused by
an abnormally low refractive index in the vitreous (reducing the difference of refractive indices between
the lens and the vitreous). An example of index myopia is nucleus sclerosis prior to the development of a
nuclear cataract.

43 The following statements about myopia is/are true.

A The image is In front of the retina.
B It is always caused by an abnormally long eyeball.
C It can be corrected by a concave lens.
D It can be corrected by accommodation.
E The visual acuity is improved by screwing up the eye.

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

Myopia can be caused by either an abnormally long eyeball (axial myopia) or excessive refractive power
of the eye (refractive myopia). Excessive refractive power of the eye can be due either to increased
curvature of the cornea or Increased refractive index of the lens. The image is formed in front of the
retina. It can be corrected by a diverging (concave) lens. One can see more clearly by screwing up the
eyes, due to the pinhole effect.
44 Myopia can be caused by
A excess shortening of the eye
B changes in the refractive index of the lens
C changes in the curvature of the cornea
D reading too closely for too long
E backward displacement of lens

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

Myopia can be caused by excessive lengthening of the eyeball. There is no evidence that the length of
time spent in reading is associated with development of myopia. The forward dislocation of lens is
associated with myopia, as the effective power of the convex lens increases when it moves forward from
the nodal point. Conversely, a concave lens is more effective the more it moves towards the nodal point
of the eye.

45 The following statements about pathological axial myopia is/are true

A The anterior pole of the eye is most affected
B Posterior staphyloma may be a complication
C Myopic crescent is characteristically present
D Degeneration occurs in the central part of the fundus
E Degenerative changes in the vitreous are common

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

In pathological axial myopia, the posterior pole of the eye is much more affected by the increase in the
length of the eye than the anterior pole. This is probably due to degeneration of the sclera. In severe
cases, the sclera may bulge out at the posterior pole to form a posterior staphyloma. Degeneration occurs
both in the central and the peripheral parts of the retina. Degeneration in the periphery of the retina leads
to retinal tears and detachment. Degeneration changes in the vitreous are common, causing 'floaters'.

46 In the correction of ametropia

A a stronger concave lens is required for myopia if the lens is placed further away from the eye
B a stronger convex lens is required for hypermetropia if the lens is placed further away from the eye
C the retinal image is larger than in an emmetropic eye if a convex lens is placed 25 mm away from the
eye to correct axial hypermetropia
D the retinal image is larger than in an emmetropic eye if a concave tens is placed 25 mm away from the
eye to correct axial myopia
E the retinal image is larger than in an emmetropic eye if a concave lens is placed 7 mm from the eye to
correct axial myopia

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

When the spectacle lens is moved away from the eye, the image also moves forwards. In uncorrected
myopia, the image is formed in front of the retina, and hence if the lens is moved forwards, a stronger
concave lens is required to move the image back onto the retina. Conversely, in uncorrected
hypermetropia, the image is behind the retina, and the convex lens for correction attempts to bring it
forwards onto the retina. Hence, if the correcting convex lens is moved forwards, the image also moves
forwards, and a weaker convex lens is needed. Relative spectacle magnification is the ratio of corrected
ametropic image size to emmetropic image size. In axial myopia or hypermetropia, the corrected
ametropic image size is equal to the emmetropic image size. (The relative spectacle magnification is 1.)
In axial myopia, if the spectacles are worn nearer to the eye than the anterior focal point (about 15 mm
from the cornea), the image size is increased. Conversely, if they are worn more than 15 mm from the
cornea, the image size is reduced. The opposite is true for hypermetropia.

47. The back vertex power:

a. is the reciprocal of the back vertex distance
b. of a convex meniscus lens can be calculated from its second focal length
c. of a convex meniscus lens is stronger than its front vertex power
d. gives the equivalent power of a lens
e. is used to grade spectacle lenses

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

The concept of back vertex power is used in the calculation of a thick lens. The back vertex power is the
reciprocal of the posterior vertex focal length expressed in dioptres. The posterior vertex focal length is
different from the focal length of a thick lens. In the case of a convex meniscus lens, the posterior vertex
focal length is shorter than both the second focal length and the anterior vertex focal length. As a result,
in a convex meniscus lens, the back vertex power is stronger than its front vertex power.
The equivalent power of thick lens is calculated from the two surface powers and a correction for
vergence change due to lens thickness. Spectacle glasses are graded according to its vertex power
because its back vertex power is the one that is used to correct the ametropia.

48. True statements about the correcting lens include:

a. when a correcting lens is moved forward in a hypermetrope the image is moved forward
b. when a correcting lens is moved forward in a myope the image is moved backward
c. the effectivity of the lens is increased in a myope if the correcting lens is moved backward
d. the effectivity of the lens is increased in a hypermetrope if the correcting lens is moved forward
e. a hypermetrope with early presbyopia may be able to read clearly by pushing his glasses closer to his
eyes

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

The image is moved forward when a correcting lens is moved forward irrespective if the lens is concave
or convex. The effectivity of the lens is increased in hypermetrope when the lens is moved forward
(which is expected of a convex lens) but in the case of the myope, the effectivity of the lens is decreased
if the lens is moved forward as the lens fails to achieve its expected function which is to move the image
backward. A hypermetrope with early presbyopia may be able to read clearly by moving his glasses away
from the eyes.

49. BVD. The following are true:

a. the back vertex distance is the distance between the back of a correcting lens and the cornea
b. the back vertex distance is not required if the correcting lens is less than 5 dioptre power
c. the contact lens for a myope is usually stronger than the glasses
d. the contact lens for a hypermetrope is usually stronger than the glasses
e. contact lens magnifies the image in a patient with axial myopia

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

The position of the correcting lens affect its effective power. The back vertex distance is important if the
power of the correcting lens is more than 5 dioptres. The contact lens for a myope is usually weaker than
the glasses but for a hypermetrope it is usually stronger than the glasses. Contact lens magnifies the
image in a patient with axial myopia.
50. Relative spectacle magnification:
a. is defined as the ratio of corrected image size to uncorrected image size
b. is 1.0 in axial ametropia if the correcting lens is placed at the anterior focal point
c. is 1.0 in index or refractive ametropia if the correcting lens is placed at the anterior focal point
d. is about 1.33 in aphakia corrected with spectacle
e. is 1.0 in aphakia corrected with contact lens

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

Relative spectacle magnification (RSM) is defined as the ratio of corrected ametropic image size to
emmetropic image size. The definition in ‘a’ is spectacle magnification. In axial ametropia if the
correcting lens is placed at the anterior focal point, the RSM is 1.0. In index or refractive ametropia if the
correcting lens is placed at the anterior focal point, the RSM is >1.0 for hypermetropia and <1.0 for
myopia. Aphakia is an index/refractive ametropia and the RSM is about 1.33. With contact lens, the RSM
approaches unity but still measures about 1.1. In order to achieve RSM = 1, a secondary lens implant is
the treatment of choice.

51 Correction of myopia by contact lenses compared with spectacles

A has an increased field of vision
B requires presbyopic correction later
C reduces image distortion
D reduces retinal image
E reduces the effort of accommodation

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

The advantages of correction of myopia by contact lenses include reduced prismatic effect and spherical
aberration, increased image size, and increased field of vision. However, if the subject has a limited
amplitude of accommodation, it may not be well tolerated. This is because there is more demand for
accommodation if contact lenses are used than if spectacles are used.

52. Back vertex distance

A. is the distance between the front and the back of a spectacle lens
B. is the distance between the piano side of a spectacle lens and the cornea
C. is especially important to be measured accurately in aphakia
D. should be measured for myopia of 1.5D
E. is the same for every subject

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

Back vertex distance is the distance between the eye and the back surface of the spectacle lens. It is
different for each individual and for different spectacle frames, owing to different facial contours. In
practice, the difference in back vertex distance makes a significant difference to the power of the lens
prescribed only if the power of the lens exceeds 5D. It is especially important in aphakia. as the power of
the lens prescribed is likely to be around 11D.

53 The back vertex power

A is synonymous with back vertex distance
B is the most important factor determining the power of a spectacle lens
C can be calculated from the posterior focal length of the lens
D is equal to the effective power if placed at the anterior focal plane of the eye
E is higher the longer the posterior focal length of the lens

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

The back vertex power equals the refractive power of the back surface of a spectacle lens, and can be
calculated from (1/ posterior focal length in m). The effective power of the lens depends mainly on the
back vertex power, and the distance between the cornea and the back surface of the lens. If it is placed at
the anterior focal plane of the eye, the effective power equals the back vertex power. The back vertex
distance is the distance between the back surface of the lens and the cornea.

54 The relative spectacle magnification in axial ametropia

A when corrected by a lens placed at the anterior focal plane of the eye, is always 1
B when corrected by a lens placed at the anterior focal plane of the eye, is governed by Knapp's Rule
C when corrected by a lens placed behind the anterior focal plane of the eye, is less than 1 in myopia
D when corrected by a lens placed in front of the anterior focal plane of the eye, is more than 1 in myopia
E is the same as in refractive ametropia

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