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**Compound myopic astigmatism – both focal lines are located in front of the retina.
**Compound myopic astigmatism – both focal lines are located in front of the retina.
*Mixed astigmatism – focal lines are on both sides of the retina (straddling the retina).
*Mixed astigmatism – focal lines are on both sides of the retina (straddling the retina).

===Astigmatism throughout the eye===
Astigmatism, whether it is regular or irregular, is caused by some combination of external (corneal surface) and internal (posterior corneal surface, human lens, fluids, retina, and eye-brain interface) optical properties. In some people, the external optics may have the greater influence, and in other people, the internal optics may predominate. Importantly, the axes and magnitudes of external and internal astigmatism do not necessarily coincide, but it is the combination of the two that by definition determines the overall optics of the eye. The overall optics of the eye are typically expressed by a person's refraction; the contribution of the external (anterior corneal) astigmatism is measured through the use of techniques such as [[keratometry]] and [[corneal topography]]. One [[Alpins method of astigmatism analysis|method]] analyzes vectors for planning refractive surgery such that the surgery is apportioned optimally between both the refractive and topographic components.<ref name="AlpinsJan97">{{cite journal |pmid=9100110 |year=1997 |last1=Alpins |first1=NA |title=New method of targeting vectors to treat astigmatism |volume=23 |issue=1 |pages=65–75 |journal=Journal of cataract and refractive surgery}}</ref><ref name="AlpinsDec97">{{cite journal |pmid=9456408 |year=1997 |last1=Alpins |first1=NA |title=Vector analysis of astigmatism changes by flattening, steepening, and torque |volume=23 |issue=10 |pages=1503–14 |journal=Journal of cataract and refractive surgery}}</ref>


==Prevalence==
==Prevalence==
Line 58: Line 61:


Corneal incisions if properly placed can correct astigmatism. These techniques include [[Mini asymmetric radial keratotomy|Mini Asymmetric Radial Keratotomy (M.A.R.K.)]], Astigmatic Keratotomy (AK) and Limbal relaxing incision (LRI). However these techniques are used less often than laser-performed ones.<ref name=azar>{{cite book|last=Azar|first=Dimitri T.|title=Refractive surgery|year=2007|publisher=Mosby Elsevier|isbn=9780323035996|edition=2nd ed.}}</ref>
Corneal incisions if properly placed can correct astigmatism. These techniques include [[Mini asymmetric radial keratotomy|Mini Asymmetric Radial Keratotomy (M.A.R.K.)]], Astigmatic Keratotomy (AK) and Limbal relaxing incision (LRI). However these techniques are used less often than laser-performed ones.<ref name=azar>{{cite book|last=Azar|first=Dimitri T.|title=Refractive surgery|year=2007|publisher=Mosby Elsevier|isbn=9780323035996|edition=2nd ed.}}</ref>

==Dealing with ocular residual astigmatism (ORA)==
A [[Alpins method of astigmatism analysis|method]] of planning and analyzing astigmatism results in [[Cataract surgery|cataract]]/[[Intraocular lens|intraocular lens]], [[Cornea|corneal]], and [[Refractive surgery|refractive]] surgery involves a [[vector analysis]] approach. The vectorial difference between the corneal astigmatism and the refractive cylinder (at the corneal plane) is known as ocular residual astigmatism (ORA), and is expressed in [[diopter|diopters]]. ORA is the astigmatism in the eye not attributable to the anterior corneal surface.<ref name="Alpins2007">{{cite journal |pmid=17397730 |year=2007 |last1=Alpins |first1=N |last2=Stamatelatos |first2=G |title=Customized photoastigmatic refractive keratectomy using combined topographic and refractive data for myopia and astigmatism in eyes with forme fruste and mild keratoconus |volume=33 |issue=4 |pages=591–602 |doi=10.1016/j.jcrs.2006.12.014 |journal=Journal of cataract and refractive surgery}}</ref><ref name="Lyle71">{{cite journal |pmid=5281065 |year=1971 |last1=Lyle |first1=WM |title=Changes in corneal astigmatism with age |volume=48 |issue=6 |pages=467-78 |journal=American Journal of Optometry and Archives of the American Academy of Optometry}}</ref> (Note—ORA is distinct from what is sometimes called residual astigmatism or surgical residual astigmatism, which is the astigmatism remaining after surgery.) ORA is also called intraocular, lenticular, or noncorneal astigmatism. ORA is the minimal amount of astigmatism that can remain in the overall optical system of the eye.

The most commonly performed refractive surgical techniques, such as LASIK, change the shape of the anterior corneal surface. When the refractive cylinder differs from the corneal astigmatism in magnitude and/or orientation, there will be some astigmatism remaining postoperatively regardless of how perfectly the LASIK was executed. If the laser treatment is based solely on refractive parameters, as is customary, then all the ORA will remain on the cornea (90° away from the calculated ORA axis, because it is neutralizing the ORA). If the laser treatment is based completely on corneal parameters, then the ORA will remain in the spectacle refraction postoperatively. It is intuitively obvious in that case that people with little or no ORA will have better resulting vision than people with higher degrees of ORA. Studies have confirmed this—LASIK is significantly less effective in correcting astigmatism when astigmatism is mainly located in the internal optics<ref name="Qian2011">{{cite journal |pmid=21739930 |year=2011 |last1=Qian |first1=YS |last2=Huang |first2=J |last3=Liu |first3=R |last4=Chu |first4=RY |last5=Xu |first5=Y |last6=Zhou |first6=XT |last7=Hoffman |first7=MR |title=Influence of internal optical astigmatism on the correction of myopic astigmatism by LASIK |volume=37 |issue=12 |pages=863-8 |doi=10.3928/1081597X-20110629-01 |journal=Journal of Refractive Surgery}}</ref>; and conversely, the efficacy of LASIK is significantly higher in people whose astigmatism is located mainly on the anterior corneal surface.<ref name="Kugler2010">{{cite journal |pmid=20870122 |year=2010 |last1=Kugler |first1=L |last2=Cohen |first2=L |last3=Haddad |first3=W |last4=Wang |first4=MX |title=Efficacy of laser in situ keratomileusis in correcting anterior and non-anterior corneal astigmatism: comparative study |volume=36 |issue=10 |pages=1745-52 |doi=10.1016/j.jcrs.2010.05.014 |journal=Journal of Cataract and Refractive Surgery}}</ref>

The accompanying figures are polar and double-angle vector diagrams from the same patient, whose axes of topographic (SimK) and refractive (R) astigmatism are significantly different. The ORA is the vectorial difference between these measurements.

[[File:Polar_diagram_of_vectors_for_SimK,_refraction,_and_ORA.jpg|thumb|This polar diagram shows vectors for simulated keratometry (SimK), the positive cylinder of the manifest refraction at the corneal plane (R), and the calculated ocular residual astigmatism (ORA). The length of the vectors is represented by the magnitude of the measurements.]]

[[File:Double-angle_diagram_of_vectors_for_SimK,_refraction,_and_ORA.jpg|thumb|In this double-angle vector diagram, the angles from the polar diagram are doubled to convert to Cartesian coordinates, but the magnitude (length) of the vectors remains the same. This view better shows how ORA is the vectorial difference between refractive and corneal astigmatism.]]

The concept of ORA is of fundamental importance to refractive surgeons and their patients, as ORA exposes the impossibility of obtaining optimal results by concentrating only on the shape of the anterior corneal surface or the manifest refractive cylinder. The optics of the entire eye must be taken into account when planning refractive surgery.

===ORA and vision problems===
An overview of LASIK complications can be found [[LASIK#Complications|in the main entry for LASIK]]. About 7% of patients preoperatively have an ORA that could result in an increased post-LASIK astigmatism.<ref name="AlpinsJan97">{{cite journal |pmid=9100110 |year=1997 |last1=Alpins |first1=NA |title=New method of targeting vectors to treat astigmatism |volume=23 |issue=1 |pages=65–75 |journal=Journal of cataract and refractive surgery}}</ref>

It is likely that unrecognized high preoperative ORA is responsible for many unhappy LASIK patients. People with high preoperative ORA can be better managed if their expectations are lowered as to their postoperative results and/or they are treated with vector planning, which optimizes postoperative results.

LASIK patients can report problems to the U.S. [[Food and Drug Administration]] (FDA) through the FDA's MedWatch program.<ref name=MedWatch>{{cite news|title=Report a problem|url=http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm061479.htm|accessdate=23 July 2013|website=US Food and Drug Administration website|date=26 October 2012}}</ref>


==See also==
==See also==

Revision as of 21:17, 27 July 2013

For the more general class of optical aberrations, see Astigmatism.
Astigmatism
SpecialtyOphthalmology Edit this on Wikidata

Astigmatism is an optical defect in which vision is blurred due to the inability of the optics of the eye to focus a point object into a sharp focused image on the retina. This may be due to an irregular or toric curvature of the cornea or lens. The two types of astigmatism are regular and irregular. Irregular astigmatism is often caused by a corneal scar or scattering in the crystalline lens, and cannot be corrected by standard spectacle lenses, but can be corrected by contact lenses. The more common regular astigmatism arising from either the cornea or crystalline lens can be corrected by eyeglasses or toric lenses. A 'toric' surface resembles a section of the surface of a Rugby ball or a doughnut where there are two regular radii, one smaller than the other one. This optical shape gives rise to astigmatism in the eye.[1]

The refractive error of the astigmatic eye stems from a difference in degree of curvature refraction of the two different meridians (i.e., the eye has different focal points in different planes). For example, the image may be clearly focused on the retina in the horizontal plane, but not in the vertical plane. Astigmatism causes difficulties in seeing fine detail or blurred vision. Three options exist for the treatment of astigmatism: spectacles, contact lenses (either hard contact lenses or toric contact lenses), and refractive surgery.

Types

Based on axis of the principal meridians

Blur from astigmatic lens at different distances
  • Regular astigmatism – principal meridians are perpendicular.
    • With-the-rule astigmatism – the vertical meridian is steepest (a rugby ball or American football lying on its side).[2]
    • Against-the-rule astigmatism – the horizontal meridian is steepest (a rugby ball or American football standing on its end).[2]
    • Oblique astigmatism – the steepest curve lies in between 120 and 150 degrees and 30 and 60 degrees.[2]
  • Irregular astigmatism – principal meridians are not perpendicular.

In with-the-rule astigmatism, a minus cylinder is placed in the horizontal axis to correct the refractive error (or a plus cylinder in the vertical axis). Adding a minus cylinder in the horizontal axis makes the horizontal axis "steeper" (or better: makes the vertical axis "less steep") which makes both axes equally "steep". In against-the-rule astigmatism, a plus cylinder is added in the horizontal axis (or a minus cylinder in the vertical axis).

Children tend to have with-the-rule astigmatism and elderly people tend to have against-the-rule astigmatism.

Axis is always recorded as an angle in degrees, between 0 and 180 degrees in a counter-clockwise direction. Both 0 and 180 degrees lie on a horizontal line at the level of the centre of the pupil, and as seen by an observer, 0 lies on the right of both the eyes.

Based on focus of the principal meridians

With accommodation relaxed:

  • Simple astigmatism
    • Simple hyperopic astigmatism – first focal line is on retina, while the second is located behind the retina.
    • Simple myopic astigmatism – first focal line is in front of the retina, while the second is on the retina.
  • Compound astigmatism
    • Compound hyperopic astigmatism – both focal lines are located behind the retina.
    • Compound myopic astigmatism – both focal lines are located in front of the retina.
  • Mixed astigmatism – focal lines are on both sides of the retina (straddling the retina).

Astigmatism throughout the eye

Astigmatism, whether it is regular or irregular, is caused by some combination of external (corneal surface) and internal (posterior corneal surface, human lens, fluids, retina, and eye-brain interface) optical properties. In some people, the external optics may have the greater influence, and in other people, the internal optics may predominate. Importantly, the axes and magnitudes of external and internal astigmatism do not necessarily coincide, but it is the combination of the two that by definition determines the overall optics of the eye. The overall optics of the eye are typically expressed by a person's refraction; the contribution of the external (anterior corneal) astigmatism is measured through the use of techniques such as keratometry and corneal topography. One method analyzes vectors for planning refractive surgery such that the surgery is apportioned optimally between both the refractive and topographic components.[3][4]

Prevalence

According to an American study published in Archives of Ophthalmology, nearly three in 10 children (28.4%) between the ages of five and 17 have astigmatism.[5] A recent Brazilian study found that 34% of the students in one city were astigmatic.[6] Regarding the prevalence in adults, a recent study in Bangladesh found that nearly 1 in 3 (32.4%) of those over the age of 30 had astigmatism.[7]

A recent Polish study revealed "with-the-rule astigmatism" may lead to the onset of myopia.[8]

A number of studies have found the prevalence of astigmatism increases with age.[9]

Diagnosis

Symptoms

Although mild astigmatism may be asymptomatic, higher degrees of astigmatism may cause symptoms such as blurry vision, squinting, asthenopia, fatigue, or headaches.[10][11][12] Some research has pointed to the link between astigmatism and higher prevalence of migraine headaches.[13]

Tests

A number of tests are used by ophthalmologists and optometrists during eye examinations to determine the presence of astigmatism and to quantify its amount and axis.[14] A Snellen chart or other eye charts may initially reveal reduced visual acuity. A keratometer may be used to measure the curvature of the steepest and flattest meridians in the cornea's front surface.[15] Corneal topography may also be used to obtain a more accurate representation of the cornea's shape.[16] An autorefractor or retinoscopy may provide an objective estimate of the eye's refractive error and the use of Jackson cross cylinders in a phoropter or trial frame may be used to subjectively refine those measurements.[17][18][19] An alternative technique with the phoropter requires the use of a "clock dial" or "sunburst" chart to determine the astigmatic axis and power.[20][21] A keratometer may also be used to estimate astigmatism by finding the difference in power between the two primary meridians of the cornea. Javal's rule can then be used to compute the estimate of astigmatism.

Another rarely used refraction technique involves the use of a stenopaic slit (a thin slit aperture) where the refraction is determined in specific meridians - this technique is particularly useful in cases where the patient has a high degree of astigmatism or in refracting patients with irregular astigmatism.

Treatment

Astigmatism may be corrected with eyeglasses, contact lenses, or refractive surgery. Various considerations involving eye health, refractive status, and lifestyle determine whether one option may be better than another. In those with keratoconus, certain contact lenses often enable patients to achieve better visual acuity than eyeglasses. Once only available in a rigid, gas-permeable form, toric lenses are now available also as soft lenses. If the astigmatism is caused by a problem such as deformation of the eyeball due to a chalazion, treating the underlying cause will resolve the astigmatism.

Laser eye surgery (LASIK and PRK) is successful in treating astigmatism.[22]

Corneal incisions if properly placed can correct astigmatism. These techniques include Mini Asymmetric Radial Keratotomy (M.A.R.K.), Astigmatic Keratotomy (AK) and Limbal relaxing incision (LRI). However these techniques are used less often than laser-performed ones.[22]

Dealing with ocular residual astigmatism (ORA)

A method of planning and analyzing astigmatism results in cataract/intraocular lens, corneal, and refractive surgery involves a vector analysis approach. The vectorial difference between the corneal astigmatism and the refractive cylinder (at the corneal plane) is known as ocular residual astigmatism (ORA), and is expressed in diopters. ORA is the astigmatism in the eye not attributable to the anterior corneal surface.[23][24] (Note—ORA is distinct from what is sometimes called residual astigmatism or surgical residual astigmatism, which is the astigmatism remaining after surgery.) ORA is also called intraocular, lenticular, or noncorneal astigmatism. ORA is the minimal amount of astigmatism that can remain in the overall optical system of the eye.

The most commonly performed refractive surgical techniques, such as LASIK, change the shape of the anterior corneal surface. When the refractive cylinder differs from the corneal astigmatism in magnitude and/or orientation, there will be some astigmatism remaining postoperatively regardless of how perfectly the LASIK was executed. If the laser treatment is based solely on refractive parameters, as is customary, then all the ORA will remain on the cornea (90° away from the calculated ORA axis, because it is neutralizing the ORA). If the laser treatment is based completely on corneal parameters, then the ORA will remain in the spectacle refraction postoperatively. It is intuitively obvious in that case that people with little or no ORA will have better resulting vision than people with higher degrees of ORA. Studies have confirmed this—LASIK is significantly less effective in correcting astigmatism when astigmatism is mainly located in the internal optics[25]; and conversely, the efficacy of LASIK is significantly higher in people whose astigmatism is located mainly on the anterior corneal surface.[26]

The accompanying figures are polar and double-angle vector diagrams from the same patient, whose axes of topographic (SimK) and refractive (R) astigmatism are significantly different. The ORA is the vectorial difference between these measurements.

This polar diagram shows vectors for simulated keratometry (SimK), the positive cylinder of the manifest refraction at the corneal plane (R), and the calculated ocular residual astigmatism (ORA). The length of the vectors is represented by the magnitude of the measurements.
In this double-angle vector diagram, the angles from the polar diagram are doubled to convert to Cartesian coordinates, but the magnitude (length) of the vectors remains the same. This view better shows how ORA is the vectorial difference between refractive and corneal astigmatism.

The concept of ORA is of fundamental importance to refractive surgeons and their patients, as ORA exposes the impossibility of obtaining optimal results by concentrating only on the shape of the anterior corneal surface or the manifest refractive cylinder. The optics of the entire eye must be taken into account when planning refractive surgery.

ORA and vision problems

An overview of LASIK complications can be found in the main entry for LASIK. About 7% of patients preoperatively have an ORA that could result in an increased post-LASIK astigmatism.[3]

It is likely that unrecognized high preoperative ORA is responsible for many unhappy LASIK patients. People with high preoperative ORA can be better managed if their expectations are lowered as to their postoperative results and/or they are treated with vector planning, which optimizes postoperative results.

LASIK patients can report problems to the U.S. Food and Drug Administration (FDA) through the FDA's MedWatch program.[27]

See also

References

  1. ^ Astigmatism at MayoClinic.com
  2. ^ a b c "Astigmatism at Buzzle.com". Buzzle.com. Retrieved 21 June 2008.[self-published source?]
  3. ^ a b Alpins, NA (1997). "New method of targeting vectors to treat astigmatism". Journal of cataract and refractive surgery. 23 (1): 65–75. PMID 9100110.
  4. ^ Alpins, NA (1997). "Vector analysis of astigmatism changes by flattening, steepening, and torque". Journal of cataract and refractive surgery. 23 (10): 1503–14. PMID 9456408.
  5. ^ Kleinstein, R. N.; Jones, LA; Hullett, S; Kwon, S; Lee, RJ; Friedman, NE; Manny, RE; Mutti, DO; Yu, JA (2003). "Refractive Error and Ethnicity in Children". Archives of Ophthalmology. 121 (8): 1141–7. doi:10.1001/archopht.121.8.1141. PMID 12912692.
  6. ^ Garcia, Carlos Alexandre de Amorim; Oréfice, Fernando; Nobre, Gabrielle Fernandes Dutra; Souza, Dilene de Brito; Rocha, Marta Liliane Ramalho; Vianna, Raul Navarro Garrido (2005). "Prevalence of refractive errors in students in Northeastern Brazil". Arquivos Brasileiros de Oftalmologia. 68 (3): 321–5. doi:10.1590/S0004-27492005000300009. PMID 16059562.
  7. ^ Bourne, R; Dineen, BP; Ali, SM; Noorul Huq, DM; Johnson, GJ (2004). "Prevalence of refractive error in Bangladeshi adults*1Results of the National Blindness and Low Vision Survey of Bangladesh". Ophthalmology. 111 (6): 1150–60. doi:10.1016/j.ophtha.2003.09.046. PMID 15177965.
  8. ^ Czepita, D; Filipiak, D (2005). "The effect of the type of astigmatism on the incidence of myopia". Klinika oczna. 107 (1–3): 73–4. PMID 16052807.
  9. ^ Asano, Kazuko; Nomura, Hideki; Iwano, Makiko; Ando, Fujiko; Niino, Naoakira; Shimokata, Hiroshi; Miyake, Yozo (2005). "Relationship Between Astigmatism and Aging in Middle-aged and Elderly Japanese". Japanese Journal of Ophthalmology. 49 (2): 127–33. doi:10.1007/s10384-004-0152-1. PMID 15838729.
  10. ^ Astigmatism[unreliable medical source?]
  11. ^ Astigmatism symptoms and treatment on MedicineNet.com
  12. ^ http://www.hipusa.com/eTools/webmd/A-Z_Encyclopedia/astigmatism%20symptoms.htm[dead link] HIPUSA Astigmatism symptoms
  13. ^ Harle, Deacon E.; Evans, Bruce J. W. (2006). "The Correlation Between Migraine Headache and Refractive Errors". Optometry and Vision Science. 83 (2): 82–7. doi:10.1097/01.opx.0000200680.95968.3e. PMID 16501409.
  14. ^ http://www.hipusa.com/eTools/webmd/A-Z_Encyclopedia/astigmatism%20treatment.htm[dead link] HIPUSA Astigmatism treatment
  15. ^ http://www.stlukeseye.com/eyeq/Keratometry.asp[dead link] Keratometry
  16. ^ Corneal Topography and Imaging at eMedicine
  17. ^ Graff, T (1962). "Control of the determination of astigmatism with the Jackson cross cylinder". Klinische Monatsblatter fur Augenheilkunde und fur augenarztliche Fortbildung. 140: 702–8. PMID 13900989.
  18. ^ Del Priore, LV; Guyton, DL (1986). "The Jackson cross cylinder. A reappraisal". Ophthalmology. 93 (11): 1461–5. PMID 3808608.
  19. ^ Brookman, KE (1993). "The Jackson crossed cylinder: Historical perspective". Journal of the American Optometric Association. 64 (5): 329–31. PMID 8320415.
  20. ^ Basic Refraction Procedures[unreliable medical source?]
  21. ^ http://www.nova.edu/hpd/otm/nbeo/refract1.htm[dead link] Introduction to Refraction
  22. ^ a b Azar, Dimitri T. (2007). Refractive surgery (2nd ed. ed.). Mosby Elsevier. ISBN 9780323035996. {{cite book}}: |edition= has extra text (help)
  23. ^ Alpins, N; Stamatelatos, G (2007). "Customized photoastigmatic refractive keratectomy using combined topographic and refractive data for myopia and astigmatism in eyes with forme fruste and mild keratoconus". Journal of cataract and refractive surgery. 33 (4): 591–602. doi:10.1016/j.jcrs.2006.12.014. PMID 17397730.
  24. ^ Lyle, WM (1971). "Changes in corneal astigmatism with age". American Journal of Optometry and Archives of the American Academy of Optometry. 48 (6): 467–78. PMID 5281065.
  25. ^ Qian, YS; Huang, J; Liu, R; Chu, RY; Xu, Y; Zhou, XT; Hoffman, MR (2011). "Influence of internal optical astigmatism on the correction of myopic astigmatism by LASIK". Journal of Refractive Surgery. 37 (12): 863–8. doi:10.3928/1081597X-20110629-01. PMID 21739930.
  26. ^ Kugler, L; Cohen, L; Haddad, W; Wang, MX (2010). "Efficacy of laser in situ keratomileusis in correcting anterior and non-anterior corneal astigmatism: comparative study". Journal of Cataract and Refractive Surgery. 36 (10): 1745–52. doi:10.1016/j.jcrs.2010.05.014. PMID 20870122.
  27. ^ "Report a problem". US Food and Drug Administration website. 26 October 2012. Retrieved 23 July 2013.

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