BRIEF ANATOMY OF THE EYE

The eye is a complex organ of vision that allows us to see the world around us. It
consists of several parts, including the cornea, conjuctiva, iris, pupil, lens, retina,
and optic nerve.

The cornea is the clear outer layer of the eye that helps to focus light. The
conjuctiva is a thin mucous membrane that lines the inside of the eyelids and
covers the sclera (the white of the eye). The iris is the colored part of the eye that
controls the size of the pupil, which is the opening that lets light into the eye. The
lens sits behind the pupil and helps to focus light onto the retina.

The retina is a layer of cells at the back of the eye that contains photoreceptor cells
called rods and cones. These cells convert light into electrical signals that can be
interpreted by the brain. The optic nerve carries these signals from the retina to the
brain, where they are processed into images.
MAJOR CAUSES AND PREVENTION OF EYE PROBLEMS IN NIGERIA

Eye problems are prevalent worldwide, impacting millions of individuals

regardless of age, gender, or socio-economic status. In Nigeria, like many other
countries, various factors contribute to the prevalence of eye disorders.
Understanding the leading causes of eye problems in Nigeria is crucial for
implementing effective preventive measures and providing appropriate healthcare
interventions. From preventable conditions to those influenced by genetic
predispositions and environmental factors, the landscape of eye health in Nigeria is
multifaceted.

SOME OF THE CAUSES INCLUDE:

1. Age related macular degeneration

2. Cornea opacity

3. Refractive errors

4. Ocular trauma

5. Diabetic retinopathy

6. Infectious diseases (such as trachoma and onchocerciasis)

7. Vitamin A deficiency

8. Environmental factors (such as exposure to smoke, dust, and harmful chemicals)

9. Lack of access to quality eye care services and proper eye hygiene practices.

Age related macular degeneration

Age-related macular degeneration (AMD) is a disease that affects a person’s

central vision. AMD can result in severe loss of central vision, but people rarely go
blind from it.

Risk factors for AMD include being 50 and older, smoking, having high blood
pressure and eating a diet high in saturated fat. In AMD, a part of the retina called
the macula is damaged. In advanced stages, people lose their ability to drive, to see
faces, and to read smaller print. In its early stages, AMD may have no signs or
symptoms, so people may not suspect they have it.

The two primary types of age-related macular degeneration have different

causes:
* Dry. This type is the most common. About 80% of those with AMD have the dry
form. Its exact cause is unknown, although both genetic and environmental factors
are thought to play a role. This happens as the light-sensitive cells in the macula
slowly break down, generally one eye at a time. The loss of vision in this condition
is usually slow and gradual. It is believed that the age-related damage of an
important support membrane under the retina contributes to dry age-related
macular degeneration.

* Wet. Though this type is less common, it usually leads to more severe vision loss
in patients than dry AMD. It is the most common cause of severe loss of vision.
Wet AMD happens when abnormal blood vessels start to grow beneath the retina.
They leak fluid and blood, hence the name wet AMD and can create a large blind
spot in the center of the visual field.

The symptoms include:

* Blurry or fuzzy vision

* Difficulty recognizing familiar faces

* Straight lines appear wavy

* A dark, empty area or blind spot appears in the center of vision

CORNEA OPACITY

Corneal opacity refers to a condition where the cornea, the transparent front part of
the eye that covers the iris and pupil, becomes cloudy or opaque. This cloudiness
can vary in severity from mild to severe and may affect a portion or the entire
cornea

CAUSES OF CORNEAL OPACITY.

Corneal Injuries: Trauma or injury to the cornea, such as chemical burns, blunt
trauma, or penetrating injuries, can lead to scarring and opacity.

Corneal Infections: Infections caused by bacteria, viruses, fungi, or parasites can

damage the cornea and cause opacity. Conditions such as bacterial keratitis, viral
keratitis (e.g., herpes simplex keratitis), or fungal keratitis can result in corneal
scarring and opacity if left untreated.

Corneal Dystrophies: Inherited or acquired disorders affecting the structure and

function of the cornea, such as Fuchs' dystrophy, lattice dystrophy, or keratoconus,
can cause corneal opacity as the disease progresses.

Corneal Degenerations: Degenerative changes in the cornea, such as lipid

deposition (corneal arcus) or calcific deposits (band keratopathy), can lead to
opacity.

MEDICAL EYE CONDITIONS THAT CAN RESULT FROM CORNEA

OPACITY:

AMBLYOPIA: Amblyopia resulting from corneal opacity is a condition where the

clarity of the cornea, the transparent front part of the eye, is compromised due to
scarring, injury, or disease. When the cornea becomes opaque, it obstructs the
passage of light into the eye, leading to visual impairment. If this occurs during
childhood when the visual system is still developing, it can lead to amblyopia in
the affected eye because the brain receives unclear visual input from that eye.

STRABISMUS: Strabismus, or misalignment of the eyes, can indeed result from

corneal opacity. When the cornea becomes opaque, it can affect the normal
development of vision, leading to various visual disturbances, including
strabismus. The obstruction of clear vision caused by corneal opacity can disrupt
the coordination between the eyes, leading to a misalignment.

Refractive errors as a cause of eye problem in Nigeria

Refractive errors can cause eye problems and lead to visual impairment in Nigeria
through the following mechanisms:

Blurred vision: Refractive errors, such as myopia (nearsightedness), hyperopia

(farsightedness), and astigmatism, result in the inability of the eye to focus light
properly on the retina, leading to blurred vision. This can significantly impact daily
activities, education, and work performance.
Eyestrain and discomfort: Individuals with uncorrected refractive errors may
experience eye strain, headaches, and discomfort when trying to focus on objects at
various distances. This can lead to fatigue and reduced productivity.
Amblyopia (lazy eye): Children with significant uncorrected refractive errors are
at risk of developing amblyopia, a condition where the brain fails to process visual
information from one eye properly, leading to permanent vision loss in that eye if
not treated early.
Increased risk of eye injuries: Individuals with high degrees of refractive errors
may have difficulty judging distances accurately, increasing their risk of eye
injuries or accidents.
Exacerbation of other eye conditions: Uncorrected refractive errors can worsen
the symptoms and progression of other eye conditions, such as cataract, glaucoma,
and age-related macular degeneration.
Psychological and social implications: Visual impairment caused by uncorrected
refractive errors can negatively impact an individual's self-esteem, social
interactions, and overall quality of life.

OCULAR TRAUMA AS A CAUSE OF EYE PROBLEMS

Ocular trauma refers to any injury to the eye. It can range from mild injuries, such
as superficial scratches on the cornea, to severe injuries, such as penetrating
wounds or blunt trauma causing fractures of the eye socket or even loss of the eye.
Prompt medical attention is crucial for assessing and treating ocular trauma to
prevent long-term complications and preserve vision.

Ocular trauma varies depending on the type and severity of the injury. They
include;

Direct trauma: This occurs when an external force directly impacts the eye. It can
lead to injuries such as corneal abrasions, hyphema (bleeding into the anterior
chamber of the eye), lens dislocation, retinal detachment, or globe rupture (tearing
of the outer layers of the eyeball).

Indirect trauma: This type of trauma occurs when force is transmitted to the eye
from surrounding structures without direct contact. For example, blunt trauma to
the orbit (eye socket) can cause orbital fractures, optic nerve injury, or globe
displacement.

Chemical trauma: Exposure to chemicals, such as acids or alkalis, can cause

severe damage to the ocular tissues. Chemical injuries can lead to corneal burns,
conjunctivitis, and in severe cases, permanent vision loss.

Thermal trauma: Heat or cold exposure can cause damage to the eye tissues.
Thermal trauma can result in corneal burns, cataracts, or retinal damage.

Penetrating trauma: This occurs when a foreign object pierces the eye, causing
damage to the cornea, iris, lens, or retina. Penetrating injuries can lead to
intraocular hemorrhage, infection, or retinal detachment.

Concussive trauma: Sudden changes in intraocular pressure, such as those caused

by explosions or rapid deceleration, can lead to damage to the retina, optic nerve,
or other ocular structures.

Regardless of the type of ocular trauma, prompt evaluation and treatment are
essential to prevent further damage and preserve vision. Treatment may involve
measures such as wound care, antibiotic or anti-inflammatory medications, surgical
repair, or in severe cases, enucleation (removal of the eye).

TRACHOMA

Trachoma is the world’s leading infectious cause of blindness, and is part of a

group of conditions known as neglected tropical diseases (often referred to as
NTDs).

Causes of Trachoma

The disease thrives where there are water shortages, poor sanitation and
infestations of flies. It’s caused by repeated infection with bacteria known as
‘chlamydia trachomatis’, and it spreads through contact with infected flies and via
hands, clothes or bedding that have been in contact with an infected person.

The agony and disability of blinding trachoma can lead to a cycle of poverty,
limiting many people’s access to health services, education and employment.
Effect of Trachoma on the eye

Trachoma is easily spread through direct personal contact such as from fingers,
through shared towels and clothes, and through flies that have been in contact with
the eyes or nose of an infected person. When left untreated, repeated Chlamydia
trachomatis infections in the eye can cause severe scarring on the inside of the
eyelid. This can cause the eyelashes to scratch the cornea (trichiasis). In addition to
causing pain, trichiasis permanently damages the cornea and can lead to
irreversible blindness.

ONCHOCERCIASIS

Onchocerciasis, or river blindness, is a neglected tropical disease (NTD) caused by

the parasitic worm Onchocerca volvulus. It is transmitted through repeated bites by
blackflies of the genus Simulium. The disease is called river blindness because the
blackfly that transmits the infection lives and breeds near fast-flowing streams and
rivers, mostly near remote rural villages. The infection can result in visual
impairment and sometimes blindness. Additionally, onchocerciasis can cause skin
disease, including intense itching, rashes, or nodules under the skin. Worldwide
onchocerciasis is second only to trachoma as an infectious cause of blindness.

The adult worms of the parasite, Onchocerca volvulus, live under the skin and
release microfilariae, which migrate throughout the body. These microfilariae can
invade the eyes, causing a variety of problems, including:

● Keratitis: This is an inflammation of the cornea, the clear outer layer of the
eye. It can cause blurred vision, pain, and sensitivity to light.
● Uveitis: This is an inflammation of the uvea, the middle layer of the eye. It
can cause redness, pain, and floaters (spots in the vision).
● Retinal degeneration: This is damage to the retina, the light-sensitive layer
of the eye. It can lead to vision loss and blindness.

The severity of eye problems caused by onchocerciasis can vary depending on the
number of microfilariae in the eyes and the length of time they have been there.
Early diagnosis and treatment are essential to prevent blindness.
Vitamin A deficiency

Vitamin A deficiency occurs when the body doesn't receive enough vitamin A,
which is essential for various bodily functions, including vision, immune system
function, and cell growth. When someone lacks sufficient vitamin A, it can lead to
a condition called xerophthalmia, which is characterized by dryness of the
conjunctiva and cornea, night blindness, and ultimately, blindness if left untreated.

1. Role of Vitamin A in Vision: Vitamin A plays a crucial role in maintaining

vision, particularly in low-light conditions. It is a component of the light-sensitive
pigment rhodopsin found in the retina. Rhodopsin helps the eyes adjust to changes
in light intensity and aids in seeing in dim light.

2. Effect on Eye Tissues: Without enough vitamin A, the cells on the surface of
the eye, including those in the conjunctiva and cornea, can become dry and lose
their ability to produce mucin, a substance that helps keep the eye moist. This leads
to dryness and thickening of the conjunctiva and cornea.

3. Night Blindness: One of the earliest symptoms of vitamin A deficiency is night

blindness. This occurs because the retina cannot produce enough rhodopsin,
impairing the ability to see in low-light conditions.

4. Progression to Xerophthalmia: As the deficiency worsens, the dryness of the

conjunctiva and cornea can progress to a condition known as xerophthalmia. In this
condition, the cornea becomes progressively dry, leading to the formation of Bitot's
spots, which are foamy patches on the conjunctiva. If left untreated, xerophthalmia
can progress to corneal ulcers, scarring, and ultimately irreversible blindness.

5. Other Effects: Vitamin A deficiency can also compromise the immune system,
making individuals more susceptible to infections, which can further exacerbate
eye problems.

To prevent vitamin A deficiency and its associated eye problems, it's essential to
consume an adequate amount of vitamin A-rich foods such as liver, fish oil, eggs,
dairy products, and orange and yellow fruits and vegetables like carrots and sweet
potatoes. In some cases, vitamin A supplements may be necessary, particularly in
populations at high risk of deficiency, such as young children in developing
countries. Regular eye exams are also important for early detection and treatment
of any vision problems.

ENVIRONMENTAL FACTORS AS A LEADING CAUSE OF EYE

PROBLEM IN NIGERIA

Environmental factors indeed contribute significantly to eye problems in Nigeria.

Factors such as

1. Air pollution: ways in which air pollution can cause eye problem

a. Irritation: Particulate matter and pollutants in the air can irritate the eyes,
leading to symptoms such as itching, redness, burning sensation, and excessive
tearing.

b. Dryness: Air pollution can contribute to dry eye syndrome by reducing humidity
levels and increasing the evaporation of tears, leading to discomfort, blurry vision,
and a gritty sensation in the eyes.

C. Allergies: Pollen, dust, and other allergens present in polluted air can trigger
allergic reactions in the eyes, causing symptoms like itching, watering, and
swelling of the eyelids.

2. Excessive exposure to UV radiation due to sunlight: UV radiation exposure

has been linked to an increased risk of age-related macular degeneration (AMD), a
leading cause of vision loss in older adults.

3. limited access to healthcare services and education about eye care exacerbate
these issues.

Addressing these environmental factors through public health interventions and

awareness campaigns is crucial for preventing and managing eye problems in
Nigeria

Lack of Access to quality eye care services

Certain forms of blindness can be prevented if the right steps and treatments are
applied at the right times, but this is not always possible due to the challenges
patients face in accessing eye care services. Lack of access to quality eye services
in Nigeria can lead to various eye problems due to several factors:

Delayed Diagnosis: Without proper access to eye services, individuals may not
receive timely diagnosis of eye conditions, leading to progression of diseases such
as glaucoma, cataracts, and diabetic retinopathy, which can result in irreversible
vision loss.

Limited Treatment Options: Inadequate access to quality eye care may restrict
individuals from receiving appropriate treatments such as surgery, medication, or
corrective lenses, exacerbating their eye conditions and impairing vision further.

Increased Risk of Infection: Poor access to sanitation and hygiene practices in

some healthcare facilities can increase the risk of eye infections, such as
conjunctivitis and trachoma, which can cause discomfort and vision impairment if
left untreated.

Lack of Preventive Care: Without access to regular eye examinations and

preventive measures, individuals may overlook early signs of eye problems or
underlying health conditions, leading to undiagnosed issues that could have been
managed or prevented with timely intervention.

Economic and Social Impact: Vision impairment resulting from untreated eye
conditions can significantly impact individuals' ability to work, attend school, or
engage in daily activities, perpetuating a cycle of poverty and limiting socio-
economic opportunities.

POOR HYGIENE

Transmission of Infections: Inadequate hygiene, such as not washing hands

regularly, can lead to the transmission of bacteria and viruses that cause eye
infections like conjunctivitis (pink eye) or bacterial keratitis.
Contamination of Water Sources: Contaminated water sources, often due to poor
sanitation infrastructure, can harbor pathogens that cause serious eye infections
such as trachoma, a leading cause of preventable blindness globally.

Unhygienic Contact Lens Use: Improper cleaning and storage of contact lenses can
introduce harmful bacteria to the eyes, increasing the risk of microbial keratitis, a
potentially sight-threatening condition.

Lack of Cleanliness in Healthcare Facilities: In healthcare settings with poor

hygiene standards, there is a higher risk of surgical site infections following eye
surgeries, leading to complications and poorer outcomes for patients.

Spread of Parasitic Infections: Poor hygiene practices, such as inadequate

handwashing and sanitation, can contribute to the spread of parasitic infections like
onchocerciasis (river blindness), transmitted by blackflies, which can cause severe
visual impairment and blindness if left untreated.

BLINDNESS

Blindness is a condition characterized by a severe impairment or loss of vision that

cannot be corrected with glasses or contact lenses. It can range from partial to
complete loss of sight and can be caused by various factors, including eye diseases,
injuries, or neurological conditions.
Blindness can also be defined as the inability to perceive light or distinguish shapes
and forms, resulting in a total lack of visual perception. This condition can greatly
impact a person's daily activities and independence, requiring them to rely on
alternative senses and assistive devices for navigation and communication.

According to WHO, Blindness is defined as visual acuity of less than 3/60 or

corresponding visual field loss in the better eye with best possible correction

EPIDEMIOLOGY OF BLINDNESS

Globally, at least 2.2 billion people have a near or distance vision impairment and
blindness. In at least, 1 billion or almost half of these cases, vision impairment
could have been prevented.
• Among this, 1 billion people, the main conditions causing blindness are cataract
(94 million), refractive errors (88.4 million), age-related error (8 million), glucoma
(7.7 million), diabetic retinopathy (3.9 million).

• 82% of people living with blindness are aged 50 and above.

• Globally, it is estimated that there are 18 million people affected with

onchocerciasis and 270,000 blinded by the disease mainly in West and Central
Africa, Latin America (like Brazil and Venezuela).

• The prevalence of blindness is more in low- and middle- income regions with
90% from low income settings.

CLASSIFICATION OF BLINDNESS

Blindness can be classified into various types based on the degree of visual
impairment and the cause. Here are some common classifications:

1. Total Blindness:

-No light perception.

-Complete loss of vision.

2. Legal Blindness:

-Visual acuity of 20/200 or less in the better eye with correction.

-Visual field limitation to 20 degrees or less.

3. Low Vision:

-Visual acuity between 20/70 and 20/200 with correction.

-Individuals may have some usable vision.

4. Congenital Blindness:

-Present at birth.

-Could be due to genetic factors, prenatal issues, or developmental abnormalities.

5. Acquired Blindness:
-Develops after birth.

-Result of diseases (e.g., glaucoma, macular degeneration), injuries, or other

factors.

6. Cortical Blindness:

-Caused by damage to the visual processing centers in the brain.

-Individuals may have functional eyes but cannot interpret visual information.

7. Night Blindness:

-Difficulty seeing in low-light conditions.

-Often associated with vitamin A deficiency or certain genetic conditions.

8. Color Blindness:

-Inability or difficulty in perceiving certain colors.

-Most commonly red-green color blindness.

9. Tunnel Vision:

-Loss of peripheral vision, resulting in a narrowed field of view.

-Often associated with conditions like retinitis pigmentosa.

10. Blindness Due to Diabetes:

-Diabetic retinopathy can lead to vision loss.

-Affects the blood vessels in the retina.

11. Functional Blindness:

-Vision is impaired to the extent that daily activities are significantly affected.
Causes of blindness in Nigeria

Blindness in Nigeria can result from various causes, ranging from preventable
conditions to genetic factors. These causes include, but not limited to, the
following factors:

Cataracts: A clouding of the lens in the eye, leading to blurred vision and, if
untreated, blindness. Glaucoma: Increased pressure within the eye, damaging the
optic nerve and causing vision loss.

Age-related macular degeneration: A progressive deterioration of the macula,

leading to central vision loss.

Diabetic retinopathy: Damage to the blood vessels in the retina due to diabetes,
leading to vision impairment.

Trachoma: A bacterial infection of the eye that can cause scarring and blindness if
left untreated

River blindness (onchocerciasis): Caused by parasitic worms transmitted by black

flies, leading to visual impairment.

Vitamin A deficiency: Essential for eye health, deficiency can lead to night
blindness and, in severe cases, blindness.

Retinitis pigmentosa: A genetic disorder causing progressive vision loss due to

degeneration of the retina.

Corneal opacities: Scarring or clouding of the cornea, affecting vision.

Albinism: Genetic condition resulting in lack of pigment in the skin, hair, and
eyes, leading to vision problems.

Trauma: Eye injuries from accidents, violence, or other causes can result in
blindness.

Ocular tumors: Cancerous or non-cancerous growths in the eye can affect vision.

Refractive errors: Uncorrected nearsightedness, farsightedness, or astigmatism can

lead to vision impairment.
 Infectious diseases: Eye infections such as conjunctivitis or keratitis can cause
temporary or permanent vision loss.

Uncorrected refractive errors: Lack of access to eyeglasses or corrective lenses

can lead to visual impairment and blindness.

Prevention of blindness in Nigeria

Preventing blindness in Nigeria requires a comprehensive approach that addresses

both the underlying causes of vision loss and the barriers to accessing eye care
services. Some key strategies that can be applied for preventing blindness in
Nigeria include:

Promoting regular eye screenings: Encouraging regular eye check-ups can help
detect and treat eye conditions early, preventing progression to blindness.

Increasing awareness: Education campaigns on the importance of eye health,

common eye conditions, and the availability of treatment options can help raise
awareness and encourage people to seek timely care.

Improving access to eye care services: Ensuring that eye care services are
available, affordable, and accessible to all segments of the population, especially in
rural and underserved areas, is crucial for preventing blindness.

Addressing underlying health conditions: Managing chronic conditions such as

diabetes and hypertension can help prevent diabetic retinopathy and other vision-
related complications.

Promoting healthy lifestyle choices: Encouraging healthy habits such as a

balanced diet, regular exercise, and avoiding smoking can help prevent eye
conditions like age-related macular degeneration and cataracts.

Providing vitamin A supplementation: Ensuring that children and at-risk

populations receive adequate vitamin A supplementation can prevent conditions
like night blindness and xerophthalmia.

Preventing eye injuries: Implementing safety measures in workplaces, homes,

and schools can help reduce the risk of eye injuries that can lead to blindness.
 Treating infectious diseases: Addressing conditions like trachoma and river
blindness through mass drug administration, sanitation improvements, and health
education can prevent blindness caused by these diseases.

Supporting research and innovation: Investing in research on eye health,

treatment options, and technological advancements can lead to improved
prevention and management of eye conditions.

Prioritizing eye health as a public health concern: This involves allocating

resources, implementing preventive measures, integrating eye care into healthcare
systems, collecting data, and advocating for policy changes. By recognizing the
importance of vision care and taking proactive steps, Nigeria can effectively
prevent blindness and improve the overall eye health of its population.

DIAGNOSTIC INVESTIGATIONS

The diagnostic investigations for blindness aim to identify the underlying causes
and severity of visual impairment. Here are some common diagnostic tests and
procedures:

1. Visual Acuity Testing:

- Measures the clarity of vision using an eye chart.

- Typically involves reading letters or symbols at various distances.

2. Refraction Test:

- Determines the need for corrective lenses to improve visual acuity.

- Helps diagnose refractive errors such as myopia (nearsightedness) or hyperopia

(farsightedness).

3. Ophthalmoscopy/Funduscopy:

- Examines the retina, optic nerve, and blood vessels at the back of the eye.

- Can identify conditions like diabetic retinopathy or macular degeneration.

4. Tonometry:
- Measures intraocular pressure to screen for glaucoma.

- Elevated pressure may indicate increased risk of optic nerve damage.

5. Visual Field Testing:

- Assesses the full extent of peripheral vision.

- Useful for detecting conditions like glaucoma or optic nerve disorders.

6. Slit-Lamp Examination:

- Provides a magnified view of the eye's structures.

- Helps diagnose conditions affecting the cornea, lens, and anterior segment.

7. Electroretinography (ERG):

- Records electrical activity of the retina in response to light.

- Useful in evaluating retinal function and identifying disorders like retinitis

pigmentosa.

8. Optical Coherence Tomography (OCT):

- Produces high-resolution cross-sectional images of the retina.

- Assists in diagnosing macular diseases and monitoring retinal thickness.

9. Visual Evoked Potential (VEP):

- Measures brain responses to visual stimuli.

- Helps assess the integrity of the visual pathway, useful in conditions affecting the
optic nerve or brain.

10. Blood Tests:

- Screen for systemic conditions impacting vision (e.g., diabetes, autoimmune

disorders).

- Assess nutritional status and detect deficiencies related to vision loss.

11. Genetic Testing:

- Identifies hereditary factors contributing to congenital or genetic-related
blindness.

12. Magnetic Resonance Imaging (MRI) or Computed Tomography (CT)

Scan:

- Imaging studies that assess the brain and optic nerve for abnormalities or tumors.

13. Fluorescein Angiography:

- Involves injecting a dye into the bloodstream to visualize blood flow in the retina.

- Useful for detecting vascular abnormalities.

A comprehensive evaluation often involves a combination of these tests to

diagnose the specific cause of blindness and guide appropriate management and
intervention.

MEDICAL MANAGEMENT OF BLINDNESS

The medical management of blindness depends on the underlying cause of the

vision loss

1. Ocular Conditions: If the blindness is due to ocular conditions such as

cataracts, glaucoma, diabetic retinopathy, or age-related macular degeneration,
treatment options may include medications, laser therapy, intraocular injections, or
surgical interventions like cataract surgery or retinal detachment repair.

2. Refractive Errors: Refractive errors such as myopia, hyperopia, or

astigmatism can be corrected with prescription glasses, contact lenses, or refractive
surgery to improve vision.

3.Infections: Blindness caused by infectious diseases like trachoma or

onchocerciasis may be managed with antibiotics or antiparasitic medications to
treat the underlying infection.

4. Injuries: Traumatic injuries to the eyes may require immediate medical

attention, including surgical repair or other interventions to preserve or restore
vision.
5. Neurological Conditions: Blindness resulting from neurological conditions
like optic neuritis, stroke, or brain tumors may require medical management
targeting the underlying neurological disorder.

6.Inherited Disorders: Genetic conditions causing blindness may not have

curative treatments, but supportive care, low vision aids, and genetic counseling
can help manage the condition and provide resources for individuals and families.

In addition to medical interventions, rehabilitation services such as orientation and

mobility training, vocational counseling, and assistive technology can help
individuals adapt to living with blindness and maintain independence in daily
activities. It's important for individuals with vision loss to work closely with
healthcare professionals, including ophthalmologists, optometrists, and
rehabilitation specialists, to develop personalized management plans tailored to
their specific needs and goals.

REFRACTIVE ERORS

INTRODUCTION

In a healthy eye, Light enters the eye through the cornea, then passes through the
pupil, controlled by the iris. The lens focuses the light onto the retina, which
contains photoreceptor cells called rods and cones. These cells convert light into
electrical signals, which are transmitted through the optic nerve to the brain. In the
brain, the visual cortex processes these signals, allowing us to perceive images and
shapes.

Refraction is the eye’s ability to bend light rays so that they fall on the retina. In
the normal eye, parallel light rays are focused through the lens as a sharp image on
the retina. When the light does not focus properly on the retina, it is called a
refractive error.
Refractive errors are common vision problems caused by an irregular shape of the
eye, which affects how light is focused on the retina. These errors lead to blurry
vision and can occur in varying degrees. The main types of refractive errors
include myopia (nearsightedness), hyperopia (farsightedness), astigmatism, and
presbyopia. They can affect people of all ages. Most refractive errors can be
corrected using eyeglasses or contact lenses, refractive eye laser surgery, or
surgical implantation of an artificial lens

TYPES OF REFRACTIVE ERRORS

MYOPIA

Myopia (nearsightedness) is an inability to accommodate for objects at a distance.

It causes light rays to be focused in front of the retina.

This means the person can see near objects but objects in the distance are blurry.

Myopia may occur because of excessive light refraction by the cornea or lens or
because of an abnormally long eye.

Myopia is the most common refractive error as about 30% of Americans have this
disorder.

There is strong evidence that many people inherit myopia, or at least have the
tendency to develop myopia.

HYPEROPIA

Hyperopia (farsightedness) is an inability to accommodate for near objects

It causes the light rays to focus behind the retina and requires the person to use
accommodation to focus the light rays on the retina for near objects.
The person with hyperopia can see distant objects clearly.

This type of error occurs when the cornea or lens does not have adequate focusing
power or when the eyeball is too short.

PRESBYOPIA

Presbyopia is the loss of accommodation associated with age. One usually begins
to notice this condition in the early to mid-40s. As the eye ages, the lens becomes
larger, firmer, and less elastic. These changes, which progress with aging, result in
an inability to focus on near objects

ASTIGMATISM

Astigmatism is an uneven or irregular curvature of the cornea. The irregularity

causes the incoming light rays to be bent unequally. Thus, the light rays do not
come to a single point of focus on the retina, which results in visual distortion.

Astigmatism can occur in conjunction with any of the other refractive errors.

Causes of Refractive Errors

1. Eyeball Length: The length of the eyeball can affect refraction. A too long or too
short eyeball alters the focal point of light, causing myopia (nearsightedness) or
hyperopia (farsightedness), respectively.

2. Corneal Shape: The cornea, the eye's outermost layer, refracts light as it enters
the eye. An irregularly shaped cornea can lead to astigmatism, causing distorted or
blurred vision.

3. Lens Changes: The eye's natural lens undergoes age-related changes, impacting
its flexibility. This can result in presbyopia, making it difficult to focus on close
objects, especially as people age.it typically occurs at the age of 40.
4. Genetics:

Family history plays a significant role in the development of refractive errors. If

parents have myopia, hyperopia, or astigmatism, their children may be more prone
to these conditions.

5. Environmental Factors:

Prolonged near work, such as reading or using digital devices for extended periods,
may contribute to myopia development, especially in children.

6. Disease or Injury:

Eye diseases, injuries, or conditions affecting the cornea, lens, or retina can lead to
refractive errors.

7. Systemic Diseases:

Conditions like diabetes can cause changes in the shape and structure of the eye,
leading to refractive errors.

Signs and symptoms of refractive errors

The Primary symptom of refractive errors is blurred vision for distant objects, near
objects, or both.

Sometimes the excessive ciliary muscle tone can cause headaches.

Prolonged squinting and frowning with ocular use can also lead to headaches.

Occasionally, excessive staring can lead to ocular surface desiccation, causing eye
irritation, itching, visual fatigue, foreign body sensation, and redness.
Frowning and squinting when reading and excessive blinking or rubbing of the
eyes are symptoms of refractive error in children

Prevention

1.Regular Eye Exams:

Schedule comprehensive eye exams regularly, even if you don't experience

noticeable vision problems.

Early detection of refractive errors allows timely intervention and proper corrective
measures.

2. Balanced Diet:

Consume a diet rich in eye-friendly nutrients like vitamins A, C, and E, as well as

minerals like zinc.

Foods such as leafy greens, carrots, citrus fruits, nuts, and fish contribute to eye
health.

3. Proper Lighting and Reading Habits:

Ensure well-lit work and reading environments to reduce eye strain.

Position screens or reading materials at a comfortable distance, typically about

arm's length.

4. Proper hydration

Stay adequately hydrated, as dehydration can affect eye function and contribute to
dry eyes.
5. Quit Smoking:

Smoking is linked to an increased risk of cataracts and macular degeneration,

which can impact vision.

6. Protective Eyewear:

Wear appropriate eye protection during activities that pose a risk of eye injury,
such as sports or construction work.

7. Manage Chronic Health Conditions

Conditions like diabetes can affect eye health. Manage chronic health issues to
reduce the risk of associated eye problems.

Diagnosis of Refractive Error

1. Visual acuity testing

Visual acuity testing measures the sharpness of vision. It's typically done using an
eye chart, where the patient reads letters of various sizes from a distance.

2. Refraction: Refraction is the process of determining the correct lens prescription

to improve vision. This is done by assessing how light bends (refracts) as it enters
the eye and focusing it properly on the retina.

3. Comprehensive eye examination: A comprehensive eye examination is a

thorough evaluation of the eye's health and visual function. It includes tests to
assess visual acuity, eye pressure, eye muscle movement, peripheral vision, and the
health of the retina and optic nerve. It may also involve checking for refractive
errors and evaluating the need for glasses or contact lenses.
4. Visual acuity testing and refraction (determination of refractive error) as needed
should be done every 1 or 2 years. Both tests help diagnose refractive errors like
myopia (nearsightedness), hyperopia (farsightedness), and astigmatism.

A comprehensive eye examination, done by an ophthalmologist or an optometrist,

should accompany refraction.

Treatment of Refractive Error

Treatments for refractive errors include :

1. Corrective Eyeglasses

2. Contact Lenses

3. Refractive surgery

Myopia and hyperopia are corrected with spherical lenses. Concave lenses are
used to treat myopia; they are minus or divergent. Convex lenses are used to treat
hyperopia; they are plus or convergent.

Astigmatism is treated with cylindrical lenses

Corrective Glasses

The right corrective lenses can enhance vision in those with myopia, hyperopia,
presbyopia, and astigmatism.

Glasses for presbyopia are often called “reading glasses” because they are usually
worn only for close work.

Presbyopic correction may be combined with a correction for another refractive

error, such as myopia or astigmatism.
In these combined glasses, the presbyopic correction is in the lower part of the
spectacle lens. A traditional bifocal or trifocal has visible lines.

However, most lenses today that correct vision at various distances do not have
visible lines.

The prescription varies throughout the lens, allowing distance focusing in the top
two thirds and near focus in the bottom one third of the lens

Contact Lenses

Contact lenses are another way to correct refractive errors. Contact lenses are made
from various plastic and silicone substances. They are highly permeable to oxygen
and have a high water content. These features allow for increased wearing time
with greater comfort. If the oxygen supply to the cornea is decreased, it becomes
swollen, visual acuity decreases, and the patient has severe discomfort

In general, you need to know whether the patient wears contact lenses, the pattern
of wear (daily versus extended), and care practices. Shining a light obliquely on the
eyeball can help visualize a contact lens.

Contact lenses are associated with microbial keratitis, a severe sight-threatening

complication.

Risk factors for keratitis include poor hand cleaning, poor lens case hygiene, and
inadequate lens cleaning.

Teach the patient the importance of following recommended cleaning practices and
reporting redness, sensitivity, vision problems, and pain to the eye care provider.
Teach the patient to remove contact lenses at once if any of these problems occur.

Surgical Therapy

Surgery can eliminate or reduce the need for eyeglasses or contact lenses and
correct refractive errors by changing the focus of the eye.

Surgical management for refractive errors includes

laser surgery and

IOL implantation.

STRABISMUS

Crossed eyes, or strabismus, is a condition in which both eyes do not look at the

same place at the same time. It usually occurs in people who have poor eye muscle

control or are very farsighted. Six muscles attach to each eye to control how it

moves. The muscles receive signals from the brain that direct their movements.

Normally, the eyes work together so they both point at the same place. When

problems develop with eye movement control, an eye may turn in, out, up or

down. The eye turning may occur all the time or may appear only when the

person is tired, ill, or has done a lot of reading or close work. In some cases, the

same eye may turn each time. In other cases, the eyes may alternate turning.
Proper eye alignment is important to avoid seeing double, for good depth

perception, and to prevent the development of poor vision in the turned eye.

When the eyes are misaligned, the brain receives two different images. At first,

this may create double vision and confusion. But over time the brain will learn

to ignore the image from the turned eye. Untreated, eye turning can lead to

permanently reduced vision in one eye. This condition is called amblyopia or

lazy eye.Some babies' eyes may appear to be misaligned, but they are actually

both aiming at the same object. This is a condition called pseudostrabismus or

false strabismus. The appearance of crossed eyes may be due to extra skin that

covers the inner corner of the eyes or a wide bridge of the nose. Usually, the

appearance of crossed eyes will go away as the baby's face begins to grow.

Strabismus usually develops in infants and young children, most often by age 3.

But older children and adults can also develop the condition. People often

believe that a child with strabismus will outgrow the condition. However, this is

not true. In fact, strabismus may get worse without treatment. A doctor of

optometry should examine any child older than 4 months whose eyes do not

appear to be straight all the time.

Classification of Strabismus
Strabismus is classified by the direction the eye turns:

 Esotropia: inward turning.

 Exotropia: outward turning.

 Hypertropia: upward turning.

 Hypertropia: downward turning.

Other classifications of strabismus include:

 The frequency with which it occurs (either constant or intermittent).

 Whether it always involves the same eye (unilateral).

 If the turning eye is sometimes the right eye and other times the left

eye (alternating).

Causes & risk factors

Strabismus can be caused by problems with the eye muscles, the nerves that

transmit information to the muscles, or the control center in the brain that

directs eye movements. It can also develop due to other general health

conditions or eye injuries.

Risk factors for developing strabismus include:

 Family history. People with parents or siblings who have strabismus

are more likely to develop it.

 Refractive error. People who have a significant amount of

uncorrected farsightedness (hyperopia) may develop strabismus

because of the additional eye focusing they must do to keep objects

clear.

 Medical conditions. People with conditions such as Down Syndrome

and cerebral palsy or who have suffered a stroke or head injury are at

a higher risk for developing strabismus.

Many types of strabismus can develop in children or adults, but the two most

common forms are below.

Accommodative esotropia

Accommodative esotropia often occurs because of uncorrected farsightedness

(hyperopia). The eye's focusing system is linked to the system that controls

where the eyes point. People who are farsighted are focusing extra hard to keep

images clear. This may cause the eyes to turn inward. Symptoms of
accommodative esotropia may include seeing double, closing or covering one

eye when doing close work, and tilting or turning the head.

Intermittent exotropia

Intermittent exotropia may develop when a person cannot coordinate both eyes

together. The eyes may point beyond the object being viewed. People with

intermittent exotropia may experience headaches, difficulty reading and eye

strain. They also may close one eye when viewing at distance or in bright

sunlight.

Symptoms

Symptoms of Strabismus include:

1. Eyes that look misaligned.

2. Eyes that do not move together.

3. Frequent blinking or squinting, especially in bright sunlight.

4. Tilting the head to look at things.

5. Faulty depth perception

6. Double vision
Diagnosis

A doctor of optometry can diagnose strabismus through a comprehensive eye

exam. Testing for strabismus, with special emphasis on how the eyes focus and

move, may include:

 Patient History. A doctor of optometry will ask the patient or parent

about any current symptoms. In addition, the doctor will note any

general health problems, medications, or environmental factors that

may be contributing to the symptoms.

 Visual Acuity. A doctor of optometry will measure visual acuity to

assess how much vision is being affected. For the test, you will be

asked to read letters on reading charts that are near and at a distance.

Visual acuity is written as a fraction, such as 20/40. The top number is

the standard distance at which testing is done (20 feet). The bottom

number is the smallest letter size you were able to read at the 20-foot

distance. A person with 20/40 visual acuity would have to get within

20 feet of a letter that should be seen clearly at 40 feet. "Normal"

distance visual acuity is 20/20. Your eye doctor has other methods of
 measuring vision in young children or patients who cannot speak or

comprehend the visual acuity test.

 Refraction. A doctor of optometry can conduct a refraction to

determine the appropriate lens power you need to compensate for any

refractive error (nearsightedness, farsightedness or astigmatism).

Using an instrument called a phoropter, the doctor places a series of

lenses in front of your eyes and measures how they focus light using a

handheld lighted instrument called a retinoscope. Or the doctor may

use an automated or handheld instrument that evaluates the refractive

power of the eye without the patient needing to answer any questions.

 Alignment and focusing testing. Your doctor of optometry needs to

assess how well your eyes focus, move and work together. To obtain a

clear, single image of what you are viewing, your eyes must

effectively change focus, move and work in unison. This testing will

look for problems that keep your eyes from focusing effectively or

make it difficult to use both eyes together.

 Examination of eye health. Using various testing procedures, your

doctor of optometry will observe the internal and external structures

of your eyes to rule out any eye disease that may be contributing to
 strabismus. This testing will determine how the eyes respond under

normal seeing conditions. For patients who can't respond verbally or

when some of the eyes focusing power may be hidden, your doctor

may use eye drops. The eye drops temporarily keep the eyes from

changing focus during testing.

Using the information obtained from these tests, along with the results of other

tests, your doctor can determine if you have strabismus. Once testing is

complete, your doctor can discuss treatment options.

Treatment

Treatment for strabismus may include eyeglasses, prisms, vision therapy, or eye

muscle surgery. If detected and treated early, strabismus can often be corrected

with excellent results. People with strabismus have several treatment options to

improve eye alignment and coordination. They include:

 Eyeglasses or contact lenses. This may be the only treatment needed

for some patients.

 Prism lenses. These special lenses are thicker on one side than the

other. The prisms alter the light entering the eye and reduce how
 much turning the eye must do to view objects. Sometimes the prisms

can eliminate the eye turning.

 Vision therapy. Your doctor of optometry might prescribe a

structured program of visual activities to improve eye coordination

and eye focusing. Vision therapy trains the eyes and brain to work

together more effectively. These eye exercises can help problems with

eye movement, eye focusing and eye teaming and reinforce the eye-

brain connection. Treatment can occur in your doctor of optometry's

office as well as at home.

 Eye muscle surgery. Surgery can change the length or position of the

muscles around the eyes so they appear straight. Often, people who

have eye muscle surgery will also need vision therapy to improve eye

coordination and to keep the eyes from becoming misaligned again.

Prevention

Strabismus cannot be prevented. Complications can be prevented if detected

early enough. At the minimum children should be screened for eye health

before 6 months of age and again between 3-5 years.