Definition

Astigmatism usually occurs when the front surface of the eye, the cornea, has an
irregular curvature. The cornea, instead of being shaped like a sphere, is ellipsoidal (like
an egg) and reduces the cornea's ability to focus light. Astigmatism is a refractive error of
the eye in which there is a difference in degree of refraction in different meridians (i.e.,
the eye has different focal points in different planes.) For eample, the image may be
clearly focused on the retina in the hori!ontal (sagittal) plane, but not in front of the retina
in the vertical (tangential) plane. T Astigmatism causes difficulties in seeing fine detail,
and in some cases vertical lines (e.g., walls) may appear to the patient to be leaning over
like the tower of "isa. Astigmatism often occurs with nearsightedness and farsightedness,
conditions also resulting from refractive errors.
#n astigmatism, the eye produces an image with multiple focal points or lines. #n
regular astigmatism, there are two principal meridians, with constant power and
orientation across the pupillary aperture, resulting in two focal lines. The astigmatism is
then further defined according to the position of these focal lines with respect to the
retina. $hen the principal meridians are at right angles and their aes lie within %&
degrees of the hori!ontal and vertical, the astigmatism is subdivided into astigmatism
with the rule, in which the greater refractive power is in the vertical meridian' and
astigmatism against the rule, in which the greater refractive power is in the hori!ontal
meridian. (bli)ue astigmatism is regular astigmatism in which the principal meridians do
not lie within %& degrees of the hori!ontal and vertical. #n irregular astigmatism, the
power or orientation of the principal meridians changes across the pupillary aperture.
#n contact lens terminology, lenticular astigmatism is called residual astigmatism
because it is not corrected by a spherical hard contact lens, which does correct corneal
astigmatism. Astigmatic errors can be corrected with cylindrical lenses, fre)uently in
combination with spherical lenses. *ecause the brain is capable of adapting to the visual
distortion of an uncorrected astigmatic error, new glasses that do correct the error may
cause temporary disorientation, particularly an apparent slanting of images.
Prevalence
According to an American study published in Archives of (phthalmology, nearly
+ in ,& children between the ages of - and ,. have astigmatism [1]. A recent *ra!ilian
study found that +/0 of the students in one city were astigmatic [2]. 1egarding the
prevalence in adults, a recent study in *angladesh found that nearly , in + (+%./0) of
those over the age of +& had astigmatism[3]. Astigmatism with the rule is more
commonly found in younger patients and astigmatism against the rule more commonly in
older patients
.
Pathophysiology
$hen either the cornea or the crystalline lens is not perfectly spherical, an image
will not be sharply focused in one plane. 2chematically, there will be two planes of focus.
*oth of the planes can be either in front of or behind the retina, or one of the planes can
be in front of the retina and the other behind it. This refractive state is described as
astigmatism. 3arge amounts of astigmatism not corrected at an early age can cause
decreased vision from amblyopia, but proper refractive correction can prevent this.
Symptoms and Signs
#f you have only a small amount of astigmatism, you may not notice it or have
4ust slightly blurred vision. *ut sometimes uncorrected astigmatism can give you
headaches or eyestrain, and distort or blur your vision at all distances. This abnormality
may result in vision that is much like looking into a distorted, wavy mirror. The distortion
results because of an inability of the eye to focus light rays to a point.
Types of astigmatism
Based on Axis of the Principal eridians
1egular astigmatism 5 principal meridians are perpendicular
$ith5the5rule astigmatism 5 ais lies between & and +& or ,-& and ,6&
degrees
Against5the5rule astigmatism 5 ais lies between 7& and ,%& degrees
(bli)ue astigmatism 5 ais lies between +& and 7& or ,%& and ,-& degrees
#rregular astigmatism 5 principal meridians are not perpendicular
Also known as 8urdoch 2yndrome (1ef9 glastonbury 8edics)
Ais is always recorded as an angle in degrees, between & and ,6& degrees in a
counter5clockwise direction. & and ,6& lie on a hori!ontal line at the level of the centre of
the pupil, and as seen by an observer & lies on the right of both eyes. Although it is
unproven, there remain proponents of the theory that astigmatism allows a greater pallette
of colors to reach the brain.
Based on !oc"s of the Principal eridians
2imple astigmatism
o 2imple hyperopic astigmatism 5 retina coincides with first focal line
o 2imple myopic astigmatism 5 retina coincides with second focal line
:ompound astigmatism
o :ompound hyperopic astigmatism 5 both focal lines are in front of the
retina
o :ompound myopic astigmatism 5 both focal lines are behind the retina
8ied astigmatism 5 focal lines are on both sides of the retina (straddling the
retina)
Tests
There are a number of tests used by ophthalmologists and optometrists during eye
eaminations to determine the presence of astigmatism and to )uantify the amount and
ais of the astigmatism. A 2nellen 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.

A corneal topographer may also be used to
obtain a more accurate representation of the cornea's shape. An autorefractor or
retinoscopy may provide an ob4ective estimate of the eye's refractive error and the use of
;ackson cross cylinders in a phoropter may be used to sub4ectively refine those
measurements. An alternative techni)ue with the phoropter re)uires the use of a <clock
dial< or <sunburst< chart to determine the astigmatic ais and power.
Another refraction techni)ue that is rarely used involves the use of a stenopaic slit
(a thin slit aperture) where the refraction is determined in specific meridians 5 this
techni)ue is particularly useful in cases where the patient has a high degree of
astigmatism or in refracting patients with irregular astigmatism.
Treatment
#f the degree of astigmatism is slight and no other problems of refraction, such as
nearsightedness or farsightedness, are present, corrective lenses may not be needed. #f the
degree of astigmatism is great enough to cause eyestrain, headache, or distortion of
vision, prescription lenses will be needed for clear and comfortable vision. #f your
eyeglass or contact lens prescription contains three parts rather than one, your eye care
practitioner has found some astigmatism in one or both of your eyes. A prescription with
three parts looks like this9 5%..- 5,.%- =&.
The first part indicates your main spherical correction, meaning the amount of
power (in diopters) re)uired in a lens to sharpen your visual acuity to an
acceptable level, usually %&>%&. #n this eample, the person has myopia and
re)uires a negative (concave) lens to correct it.
"art two shows the etent of the astigmatism in diopters. Again, the minus sign
means a concave lens is needed.
"art three is the ais (in degrees) of the cylinder re)uired to bend certain light rays
to compensate for the cornea's oval shape.
#ontact $enses
The first contact lenses were glass fluid5filled scleral lenses. These were difficult
to wear for etended periods and caused corneal edema and much ocular discomfort.
?ard corneal lenses, made of polymethylmethacrylate, were the first really successful
contact lenses and gained wide acceptance for cosmetic replacement of glasses.
2ubse)uent developments include gas5permeable rigid lenses, made of cellulose acetate
butyrate, silicone, or various silicone and plastic polymers, and soft contact lenses, made
of various hydrogel plastics, all of which provide increased comfort but greater risk of
serious complications.
?ard and gas5permeable lenses correct refractive errors by changing the curvature
of the anterior surface of the eye. The total refractive power consists of the power
induced by the back curvature of the lens, the base curve, together with the actual power
of the lens due to the difference between its front and back curvatures. (nly the second is
dependent on the refractive inde of the contact lens material. ?ard and gas5permeable
lenses overcome corneal astigmatism by modifying the anterior surface of the eye into a
truly spherical shape.
2oft contact lenses, particularly the more fleible forms, adopt the shape of the
patient's cornea. Thus, their refractive power resides only in the difference between their
front and back curvature, and they correct little corneal astigmatism unless a cylindrical
correction is incorporated to make a toric lens.
:ontact lens base curves are selected according to corneal curvature, as
determined by keratometry or trial fittings. The front curvature is then calculated from the
results of overrefraction with a trial contact lens, or from the patient's spectacle refraction
as corrected for the corneal plane.
?ard contact lenses are specifically indicated for the correction of irregular
astigmatism, such as in keratoconus. 2oft contact lenses are used for the treatment of
corneal surface disorders, but for control of symptoms rather than for refractive reasons.
All forms of contact lenses are used in the refractive correction of aphakia, particularly in
overcoming the aniseikonia of monocular aphakia, and the correction of high myopia, in
which they produce a much better visual image than spectacles. *ut the vast ma4ority of
contact lenses worn are for cosmetic correction of low refractive errors. This has
important implications for the risks that can be reasonably accepted in the use of contact
lenses.
"rocedures to :orrect Astigmatism
The corrective lenses needed when astigmatism is present are called Toric lenses
and have an additional power element called a cylinder. They have greater light5bending
power in one ais than in others.
@arious patterns of keratotomy have been described to correct corneal
astigmatism. #rregular astigmatism continues to be a serious problem following most
corneal operations, including radial keratotomy and penetrating keratoplasty, and after
cataract surgery. Troutman and others have described relaing incisions, compression
sutures, and wedge resections for postkeratoplasty astigmatism, utili!ing a surgical
keratometer. @arious techni)ues for cataract incision, such as scleral tunnel incisions and
clear corneal incisions as well as altering incision location, have been reported as useful
in preventing postoperative astigmatism after cataract surgery.
$asers
A further approach to refractive corneal surgery involves the use of lasers. The
ecimer laser has received the most publicity, but other machines such as the solid5state
neodymium9AAB laser and <minilasers< have been shown to be effective also. 3aser
photorefractive keratectomy ("1C) produces precisely controlled flattening of the
anterior cornea to reduce myopia. The procedure also is done for astigmatism and
hyperopia. Anterior stromal ha!e, irregular astigmatism, and regression have been
observed after "1C. #n the Dnited 2tates, the FEA has given approval to two laser
companies for "1C' the procedure has been done in many other countries for years.
3A2FC (laser epithelial keratectomy) is a form of "1C in which the corneal epithelium
is preserved.
%eferensi
en.wikipedia.org
www.accessmedicine.com
www.allaboutvision.com