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A-Z Glossary

Table of Contents

Refractive Error

Courtney Dryer, OD
Written byCourtney Dryer, OD
Courtney Dryer, OD
Courtney Dryer, ODOptometristCharlotte, NC

Bio

Dr. Courtney Dryer earned her doctorate from Southern College of Optometry, Memphis, Tennessee in 2011. She opened her own practice Autarchic Spec Shop in 2013 in Charlotte, NC. She has had the privilege of writing for numerous optometric publications and serving in various industry capacities. In 2015, Vision Monday named her a rising star and one of the most influential women in optometry. Her optometric passions include practice management, specialty contact lenses, and dry eye management.

  • Last updated November 16, 2022

What is Refractive Error?

Worldwide, refractive error is the leading cause of correctable vision impairment. Estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of those 670 million people are considered visually impaired because they do not have access to corrective lens treatment. Refractive errors, if left uncorrected, result in an impaired quality of life for millions.  

Refractive errors are the result of a mismatch between the eye’s focal power and axial length. Refractive error can change throughout life. Most newborns start out with hyperopia and against-the-rule astigmatism and shift towards with-the-rule astigmatism by 4 years of age. Adults tend to be less hyperopic but have a broad variance of refractive error. There is an increase in myopia with age over time.

Key Takeaways

  • Uncorrected refractive error is the leading cause of correctable visual impairment.
  • There are 3 types of refractive error: myopia, hyperopia, and astigmatism
  • Refractive error is due to a combination of genetic and environmental factors.
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Understanding Refractive Error

Myopia, hyperopia, and astigmatism are the 3 types of refractive error. Presbyopia is not traditionally considered a refractive error by researchers though it is diagnosed and treated similar to other refractive errors. Prebyopia is due to aging.

Myopia

Myopia, also known as near-sightedness, is a very common condition that typically begins in childhood. Severe forms of myopia (pathologic myopia) are associated with an increased risk of retinal detachments, glaucoma, and cataracts. Myopia affects all populations but is reaching epidemic proportions in East Asia. 

Myopia occurs when the axial length of the eye is longer than normal. When the light enters the myopic eye, it falls in front of the retina resulting in blurry distance vision.

Hyperopia

Children typically have a small amount of hyperopia in infancy and childhood. It is extremely important that all children undergo an eye exam. Uncorrected amounts of hyperopia can lead to reading and learning difficulties and an incorrect diagnosis like ADHD and dyslexia. 

Hyperopia occurs when the length of the eye is short. When the light enters the hyperopic eye, it falls behind the retina.  Depending upon the amount of hyperopia, the patient may be able to focus the light onto the retina resulting in good visual acuity.  If the amount of hyperopia is too great, the individual may experience blurry vision at distance and at near, eye fatigue, headaches, and eye strain. Hyperopia can also result in strabismus (crossed eyes).

Astigmatism

 Astigmatism is a common refractive error and accounts for 13% of the refractive errors of the human eye. Ocular astigmatism can occur because of unequal curvature along the two principal meridians of the anterior cornea, posterior cornea, unequal curvatures of the front and back surfaces of the crystalline lens or unequal refractive indices across the crystalline lens (internal astigmatism). 

Astigmatism is often described as the eye being shaped like a football or egg.  When the light hits the oblong shape of the eye, it results in a blur or halo effect around letters or numbers. Uncorrected astigmatism can lead to headaches, eye fatigue, and blurry vision. 

Presbyopia

Presbyopia is not traditionally considered a refractive error.  Presbyopia is the loss of near vision with age due to changes in the crystalline lens inside the eye. Individuals over the age of 40 experience presbyopia when the lens begins to harden and is unable to bend and flex to focus on near images.

Risk Factors for Refractive Error

Refractive error varies across geographic, racial, age, and ethnic boundaries. Myopia is caused by both genetic and environmental risk factors. Myopia occurs in more than 50% of the population in many industrialized countries and is expected to increase with digital device use. The prevalence of myopia is higher in individuals whose parents are myopic, suggesting that genetic factors are involved. Population studies suggest that myopia development is associated with education, and the amount of time spent doing near work.

A greater risk of astigmatism is associated with Hispanic, African American, and Asian race, and myopic and hyperopic refractive errors. It is unknown why astigmatism develops although theories include genetics, extraocular muscle tension, visual feedback, and eyelid pressure.

Age is the primary risk factor for presbyopia.

Refractive Error Symptoms

  • Decreased vision
  • Headaches
  • Blur

Diagnosing Refractive Error

A comprehensive eye exam including a refraction is used to determine refractive error. Refraction is the test when you view the letters and the doctor asks you which appears better, choice one or choice two. The refraction process has not changed in over 200 years. 

Refractive Error Treatment

An individual is unable to cure refractive error naturally. A refractive error can be diagnosed, measured, and corrected with the aid of optical correction such as spectacles and contact lenses or by refractive surgical procedures. 

Bibliography

  1. Baird PN, Saw SM, Lanca C, Guggenheim JA, Smith Iii EL, Zhou X, Matsui KO, Wu PC, Sankaridurg P, Chia A, Rosman M, Lamoureux EL, Man R, He M. Myopia. Nat Rev Dis Primers. 2020 Dec 17;6(1):99. doi: 10.1038/s41572-020-00231-4. PMID: 33328468.
  2. Clarke-Farr, Peter. (2004). Presbyopia: refractive error or the result of the normal ageing process of the eye. 63.
  3. Cooper J, Tkatchenko AV. A Review of Current Concepts of the Etiology and Treatment of Myopia. Eye Contact Lens. 2018 Jul;44(4):231-247. doi: 10.1097/ICL.0000000000000499. PMID: 29901472; PMCID: PMC6023584.
  4. Irving EL, Machan CM, Lam S, Hrynchak PK, Lillakas L. Refractive error magnitude and variability: Relation to age. J Optom. 2019 Jan-Mar;12(1):55-63. doi: 10.1016/j.optom.2018.02.002. Epub 2018 Mar 19. PMID: 29567041; PMCID: PMC6318544.
  5. Kulp MT, Ciner E, Ying GS, Candy TR, Moore BD, Orel-Bixler D; VIP Study Group, and the VIP-HIP Study Group. Vision Screening, Vision Disorders, and Impacts of Hyperopia in Young Children: Outcomes of the Vision in Preschoolers (VIP) and Vision in Preschoolers – Hyperopia in Preschoolers (VIP-HIP) Studies. Asia Pac J Ophthalmol (Phila). 2022 Jan 18;11(1):52-58. doi: 10.1097/APO.0000000000000483. PMID: 35044337; PMCID: PMC8813881.
  6. Naidoo KS, Jaggernath J. Uncorrected refractive errors. Indian J Ophthalmol. 2012 Sep-Oct;60(5):432-7. doi: 10.4103/0301-4738.100543. PMID: 22944755; PMCID: PMC3491271.
  7. Read SA, Collins MJ, Carney LG. A review of astigmatism and its possible genesis. Clin Exp Optom. 2007 Jan;90(1):5-19. doi: 10.1111/j.1444-0938.2007.00112.x. PMID: 17177660.
  8. Rodriguez-Lopez V, Dorronsoro C. Beyond traditional subjective refraction. Curr Opin Ophthalmol. 2022 May 1;33(3):228-234. doi: 10.1097/ICU.0000000000000834. Epub 2022 Jan 31. PMID: 35102097.
  9. Van der Sande E, Haarman AEG, Quint WH, Tadema KCD, Meester-Smoor MA, Kamermans M, De Zeeuw CI, Klaver CCW, Winkelman BHJ, Iglesias AI. The Role of GJD2(Cx36) in Refractive Error Development. Invest Ophthalmol Vis Sci. 2022 Mar 2;63(3):5. doi: 10.1167/iovs.63.3.5. PMID: 35262731; PMCID: PMC8934558.

Related Terms

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Contrast Sensitivity

is the ability to distinguish between an object and the background

Blepharochalasis

Occurs when the eyelids suddenly become inflamed and swell

Exotropia

is an eye misalignment (strabismus) where one eye is turned outward. The turn may be constant or intermittent

Trichiasis

is a lid margin disorder in which the eyelashes that arise from their normal position are misdirected toward the ocular surface

Anterior Chamber

is located between the iris and the innermost corneal surface. It is filled with fluid called aqueous humor

Spatial Frequency

describes the rate that a stimulus changes across space. It is usually measured with black and white line gratings

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