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Sau21 (2)


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Sau21 (2)

  1. 1. HYPERMETROPIA (farsighted) By, Saurabh D.Patel
  2. 2. Topics of DisscussionEtiologyClinical typesClinical presentationDiagnosisManagementComplication
  3. 3. DefinationHypermetropia ( long sightedness ) is a refractive state of eye where in parellel rays of light coming from infinity are focus behind the retina with accomodation being at rest
  4. 4. EtiologyAxial hypermetropia – 1 mm shortening - 3D of hyperopiaCurvature hypermetropia – flat corneaIndex hypermeropia – old age & DM on tretmentPositional hypermetropia – Dislocation of lensAbsence of crystalline lens - AphakiaLoss of accomodation – d/t age & medication
  5. 5. Clinical typesSimple hypermetropia – axial or curvatural typePathological hypermetropia – Maldevelopment of eye - k & lens changes - chorioretinal & orbital inflamation / neoplasmaFunctional hypermetropia – 3rd nerve palsy / internal ophthalmoplegia
  9. 9. Components of hypermetropiaTotal hypermetropiaLatent hypermetropia – corrected by inherent tone of cilliary muscleManifest hypermetropia – Facultative hypermetropia ( corrected by accommodation) - Absolute hypermetropia (does not corrected by
  10. 10. Normal Age VariationAt birth - 2 to 3 diopter of hypermetropiaAt adolesence - it becomes emmetropicB/C in youth – cortex refractive index is less than that of nucleus – formation of combination of a central lens surrounded by two menisci - refractive power increase
  11. 11. Age The mean refractive error is +2.00D in newborns The mean refractive error is +1.00 to +0.50D in children at age 6 The mean refractive error is plano in children at age 10 The mean refractive error is skewed toward myopia in children after age 10
  12. 12. Compensating AccommodationFactors Fatigue – general and ocular  Due to continuous focusing of images in and out on the retina Illness (e.g., cold, fever) Mental state (e.g., stress) Alcohol Drugs and medications (e.g., antihistamines)  Antihistamines may relax accommodation and dilate the pupils
  13. 13. Clinical featuresSymtoms-AsymptomaticAsthenopic symtomsDefective vision with asthenopic symoptomDefective vision onlyThe effect of ageing on visionIntermittent sudden blurring of vision
  14. 14. SIGNSSize of eye ball – smallCornea - smallerA/C - shallow & narrow angle Pupil Enables accommodation and increased depth of focusEsophoria Inward deviation of the eyes With accommodation, eyes tend to converge Visual acuity – depend upon degree of hypermetropia & power of accomodation -Decreased visual acuities at distance and near,
  15. 15. Fundus examination : retina- whole may shine due to greater brillince of light reflection(Shot silk appearance) Optic disc - small , more vascular with ill defined margins resembles optic neuritis (pseudopapillitis)
  16. 16. Diagnosis of hypermetropia(1) Patients history - watering of eye - eyeache / frontal headache - actual / suspected crossing of eyes - difficulty with clarity / comfortability - presbyopic pt c/o difficulty in near vision - family history
  17. 17. 2) Occular examinationa) Visual acuity- In young pt- In presbyopic pt- In older age- In pt with never corrected high deree of hyperopia
  18. 18. b) Refraction# retinoscopy – useful in children , accomodative esotropia, latent hyperopia - atropine has max. cycloplagia# Autorefraction- validity & reliability lower
  19. 19. c)Occular motility , binocular vision &accomodation- anomalies in any of them detected by- cover uncover test- near point of convergence- accomodative amplitude
  20. 20. (d) Occular health assurance & systemicheath screening- colour vision- pupillary response- confrontation visual fied test- IOP- occular media & post. Segment evalution
  21. 21. Management of hypermetropia(1) Basis of treatment – depends on following - magnitude of hypermetropia - presence of astigmatism / anisoconia - patient ‘ age - presence of associated esotropia / amblyopia - status of accomodation & convergence - demands placed on the visual symtoms
  22. 22. (2) Available treatmentA) Optical correction-spectacles & contact lens most wildly used - Plus power / spherocylindrical lens prescribed - absolute hyperopia to accept nearly full correction - young patient with accomodative esotropia & hyperopia require short period of adaptation to tolerate full correction
  24. 24. Contact lens beneficial in case of - resist to wear spectacles - improve cosmosis - reduce aniseikonia & anisophoria in persons with anisometropia - accomodative esotropia beneficial - Unilateral high hypermetropia
  25. 25. (3)Management strategies hyperopiccorrection# Older children & pre – presbyopic adults (10 -40 yrs)Low degree of hypermetropia – optical correction with foggingHypermetropia of moderate degree with / without associated astigmatism – optical correction with fogging after cycloplegic retinoscopy
  26. 26. Uncorrected hypermetropia lead to near vision problem in early age (30 to 35 yr) as accomodation reserve approaches to presbyopiaNeeeds subjective correction after cycloplegic retinoscopy & require higher near addition than age
  27. 27. Presbyopic correction depends on - patients age - patient ‘ s job - habit of patientUnilateral high hypermetropia > 3 D then contact lens advice> 2.5 D difference in both eyes then undercorrection is given to eye having more hypermetropia
  28. 28. In high hypermetropia if not accepting high / strongest lens - in that case it is well to undercorrect at first then strengthen the lens at interval of few months ( in which weaker lens for distant & full correction for near is given ) -untill the full correction is comfertably borne
  29. 29. # Younger children (birth to 10 yrs of age)Treatment not require in case of –Treatment needed in case of – binocular anomalies - decrease visual acuity - learning difficulties< 5 yrs of age - >3 D of hyperopia - early optical correction on basis of full atropinized retinoscopy with other intervention like occlusion / active vision therapy if require & follow up periodically
  30. 30. Partial hyperopic correction in infants given b/c that does not interfere with emmetropization of infantsConcurrent amblyopia – patching & active vision therapy & full time spectacle wearB/L high hyperopia – if uncorrected may lead to isometropic amblyopia without esotropia - - full correctionn require & careful follow up made as previously nonexisting esotropia may present after correction
  31. 31. Occlusion therapy is given in which 6 hrly alternate use of both eyes advice & initial follow up after 15 days to 1 monthSmall children always prescribe plastic frame & plastic glasses with full frame & 3 monthly follow up require
  32. 32. # Presbyopic patient- optical correction to distant correction with near addition# Pathological hyperopia- underlying cause is chief concern – limited to need to correct hyperopia in best manner possible - reffer to eye care provider for special services
  33. 33. (d) Refractive surgeryAutomated lameller keratoplastyHolmium – YAG laser thermal keratoplastyExcimer laserSpiral hexagonal keratotomyConductive keratoplasty
  34. 34. The basic idea is to reshape the cornea using the laser to remove a very thin layer. The reshaped cornea allows the refraction of the eye to be corrected. LASIK® LASIK stands for Laser-Assisted In situ Keratomileusis. This is the most popular form of laser eye surgery. The laser is used to lift and remove a very thin layer of the cornea. The shape of the cornea is altered to be more curved, so that the light rays can be focused further forward, and on to the retina.
  35. 35. Epi-LASIKSimilar to LASEK, Epi-LASIK is a newer type of refractive surgery in which an epithelial flap is created with a super-fine blade, instead of an alcohol solution. With Epi-LASIK, the chance of the cells becoming too unstable to be replaced is reduced.This hyperopia treatment is suitable for people with thin corneas as well as those who have a relatively high degree of farsightedness.
  36. 36. PRK® PRK stands for Photo-Refractive Keratectomy. It is an older surgical operation, that has mostly been replaced by newer techniques.LASEK® LASEK stands for LAser Sub-Epithelial Keratomileusis. It is an improved form of PRK with some similarities to LASIK. Most of the outer layer of the cornea (the epithelium) is left intact. The LASEK procedure tends to be more painful, and discomfort can last longer than with LASIK.
  38. 38. Conductive keratoplasty The CK radio waves , guided by rinse – away dye - it change the shape of the cornea by shrinking targeted areas of collagen in the eye. Quick (about 3 minutes per eye) and painless & both eyes will be treated the same day.Do not have side effects such as dry eyes, “halos” and light sensitivity Also used to correct presbyopia - reduces dependence on reading glasses
  39. 39. (b) Vision therapyEffective in accomodative & binocular dysfunction resulting from hyperopia (c) Modifications of patient ‘ s habit & environment - improving light / reduces glare - using better quality of printed material - decreasing visual demands - ergonomic condition at computer terminal
  40. 40. (4) Patient education - Avoid stress or eye strain - Use appropriate lens - Use good light at work - Avoid prolong period of short distant approach - Maintain proper diet(5)Prognosis & follow upPhysiological hyperopia - not progressiveChildren with hyperopia – 3 to 6 monthly follow upFor adults (asymtometic) 1 to 2 yr follow upFrequent follow up require in –
  41. 41. ComplicationsRecurrent stye , blepharitis or chalazionAccomodative convergent squintAmblyopiaPrimary narrow angle glaucoma
  42. 42. Thank you