a detailed informative compilation on everything related to hypermetropia or hyperopia required in ophthalmic or optometric clinical practice and education

1. Hyperopia
Suraj shil
B. Optom 2nd year
Ridley college of optometry, Jorhat

2. Layout
1. Introduction 8. Visual acuity
2. Etiology 9. Correction of Hyperopia
3. Hereditary role 10. Prescription
4. Classification 11. Uncorrected hyperopia
5. Progression
6. Symptoms
7. Signs

3. Introduction
• Hyperopia (hypermetropia) is the condition in which rays of light
converge to a focus behind the retina with accommodation at rest
• Can occur in two scenarios; either the axial length is too small for
the eye’s normal refractive power or the refractive power is too low
for its normal axial length
Note: Short axial length more common etiology

5. Etiology
• Etiologically hypermetropia may be
• Axial
• Curvatural
• Index
• Positional
• Absence of crystalline lens(Aphakia)

6. Axial hypermetropia
• In this condition the total refractive power of the eye is normal but
there is an axial shortening of eyeball
• About 1mm shortening of the anteroposterior diameter of the eye
results in 3.00 D of hypermetropia

7. • Example: let a patient have axial length of 22mm and 21mm in right
eye and left eye respectively. Calculate refractive error in both
eyes.

8. • Soln: OD= (24-22)mm = 2mm
Refractive error = 2x3 = +6.00 D
OS= (24-21)mm = 3mm
Refractive error = 3x3 = +9.00 D

9. Curvatural hypermetropia
• It is the condition in which the curvature of the cornea or the lens or
both are flatter than the normal, resulting in a decreased refractive
power of the eye
• About 1mm increase in radius of curvature results in 6.00 D of
hypermetropia

10. • Example: If a patient has +12.00 D of refractive error in his right
eye, with no abnormal changes in his crystalline lens and the
anteroposterior diameter then calculate the radius of curvature of
his cornea

11. • Soln: 1mm increase in radius causes +6.00 D of error, then,
+12.00 D will be caused due to increase of 2mm of radius
Therefore,
radius= (7.5+2)mm = 9.5mm

13. Index hypermetropia
• It occurs due to change in refractive index of the lens in old age
• It may also occur in diabetics under treatment
Note: The Beaver Dam Study found that diabetes was associated
with a hyperopic shift over a 10-year period. Long term refractive
error has been studied among diabetic patients

14. Positional hypermetropia
• It results from posteriorly placed crystalline lens
Note: In a study done by Omar A. AlShehri and his colleagues from King Saud Bin
Abdulaziz University of Health Sciences, Saudi Arabia, the abstract read as: ectopia
lentis is defined as a crystalline lens diaplacement either partially or completely,
anteriorly or posteriorly due to zonular abnormalities. It can be a result of trauma,
hereditary ocular disease, or part of systemic diseases like Marfan syndrome and
homocystinuria

15. Connective tissue
disorder associated with
long narrow limbs,
skeletal abnormalities,
ocular abnormalities
Genetics:
Autosomal Dominant
mutation in fibrillin-1 (FBN1)
gene
located on chromosome 15
multiple mutations identified

16. Absence of crystalline lens
• It is either congenital or acquired (following surgical removal or
dislocation)
• It is a condition of high hyperopia
A case report done by G. Trabucchi, A. Piantanida and their collegues of Department
of Ophthalmology and Visual Sciences, University of Milan, Italy reported that:
Corneal defects and iridocorneal adhesion were found, but aphakia was the major
pathologic ocular finding. The clinical picture and pathology study indicated this case
as a Peter’s anomaly presenting congenital aphakia

17. Peters’ anomaly affects the iris,
corneal endothelium and
Descemet’s membrane leading to
Peters’ type I. Peters’ type II in
addition will have lens abnormalities
and tend to be bilateral
Genetics:
Reported chromosomal
abnormalities in chromosome 20,
trisomy 13 and chromosome 11
have been reported to contribute to
Peters’ anomaly

18. Hereditary role
• The assessment of the role of heredity in the determination of the
refractive state of the eye is complicated, because the refractive
state is the result of a number of interrelated refractive components
• Francois(1961) pointed out that it is likely that several genetic
factors contribute to the refraction of the eye - each of the
components being inherited independently of the others and
possibly transmitted according to different patterns of heredity

19. Contd…
• Francois cited that low hyperopia can be considered as variations
within the normal limits of the binomial distribution and refers to
additional studies indicating that these conditions are inherited as
dominant characteristics
• However, hyperopia of +6.00 D and over are inherited either as
dominant or recessive characteristics

20. Classification
1) On the basis of degree of Hyperopia
2) On the basis of clinical appearance
3) By accommodative stages

21. Degree of Hyperopia
• Low Hyperopia: +2.00 D or less
• Moderate Hyperopia: +2.25 D to +5.00 D
• High Hyperopia: +5.25 D or more

22. Clinical appearance
• Simple Hyperopia
• Pathological Hyperopia
• Functional Hyperopia

23. Simple hyperopia
• It is the commonest form and results from normal biological
variations in the development of the eyeball
• It includes axial and curvatural hyperopia
• Simple hyperopia may be hereditary, where inheritance is usually
dominant which may be irregular

24. Pathological hyperopia
• It results due to either congenital or acquired conditions of the eye
which are outside the normal biological variations of the
development
• It includes:
• Senile hypermetropia
• Positional hypermetropia
• Aphakia
• Consecutive hypermetropia

25. Contd…
• Senile hyperopia/Acquired hyperopia
• Curvatural hyperopia: due to decreased curvature of the outer lens fibres developing
later in life
• Index hyperopia: due to acquired cortical sclerosis
In youth the index of refraction of the cortex is considerably less than that of the
nucleus, and this inequality results in the formation of combination of a central
lens surrounded by two converging menisci
This results in an increase in the refracting power of the lens as a whole
In old age refractive index of the cortex increases. As a result the lens becomes
more homogenous and acts as a single lens. Consequently the converging
power of the lens as a whole decreases, resulting in index hyperopia

26. Contd…
• Positional hyperopia may occur due to posterior subluxation of the
lens
• Aphakia is the congenital or acquired absence of the lens
• Consecutive hyperopia occurs due to surgically overcorrected
myopia or pseudophakia with undercorrection

27. Functional hyperopia
• It results from paralysis of accommodation as seen in patients with
third nerve paralysis and internal ophthalmoplegia
Internal ophthalmoplegia is often associated with the Miller Fisher
syndrome, which constitutes of weak eye muscles, with blurred
vision and often drooping eyelids with facial weakness

28. The exact cause of Miller Fisher (Guillain-Barre) syndrome is
unknown. However in about 70% cases, a recent infection or surgery
serves as a trigger to an autoimmune response. This autoimmune
response attacks the peripheral nerves, leading to weakness and a
loss of sensation.

29. Accommodative stages
• Manifested Hyperopia
• Absolute Hyperopia
• Facultative Hyperopia
• Latent Hyperopia

31. Latent v/s Manifest Hyperopia
• The condition in which all or part of a patient’s hyperopia is
compensated for by the tonicity of the ciliary muscle, is known as
latent hyperopia
• The hyperopia which can be revealed in a subjective refraction
represents the patient’s manifest hyperopia
• Total hyperopia = Latent + Manifest
Latent Hyperopia can only be revealed in a cycloplegic refraction

32. Contd…
• As people age and their amplitude of accommodation decreases,
latent hyperopia tends to become manifest
• For this reason some low hyperopes not requiring glasses (and not
having enough latent hyperopia to cause symptoms of eyestrain)
find that, as amplitude of accommodation decreases with age,
glasses are eventually required for clear and comfortable vision

33. Absolute v/s Facultative Hyperopia
• Absolute Hyperopia is that hyperopia that cannot be compensated
for by accommodation
• The additional dioptres of Hyperopia that can be overcome by
accommodation is Facultative Hyperopia
• Absolute + Facultative = Manifest hyperopia

34. Note: Facultative Hyperopia and Latent Hyperopia must not be
confused with. Both apply to a relatively young individual with a
reasonable amount of accommodation, but whereas facultative
hyperopia can (at will) be compensated for by accommodation, latent
hyperopia is the hyperopia that the patient cannot help but
compensate for by accommodation as a result of increased tonicity
of the ciliary muscle

35. • Example: Visual acuity of a patient is 6/18 (OU) unaided, dry
retinoscopy values are +4.50 D (OD) and +4.50 D (OS),
acceptance is +2.00 D (OD)-6/9 and +2.00 (OS)-6/9, wet
retinoscopy using atropine is +6.00 D (OD) and +6.00 D (OS). Find
manifest hyperopia, latent hyperopia, absolute hyperopia,
facultative hyperopia and total hyperopia

36. • Soln : manifest= +4.50 D
latent = +5.00 D – (+4.50 D) = +0.50 D
absolute = +2.00 D
facultative = +4.50 D –(+2.00 D) = +2.50 D
Total = +4.50 D + (+0.50 D) = +5.00 D

37. Progression of Hyperopia
• Hyperopia does not progress with age (only the AOA reduces which manifests
the hyperopia)
• A child who is born hyperopic shows reduction in hyperopia in early years of age
• In later stages of life, it is the latent hyperopia that progresses to manifest
• Later the hyperopic correction acceptance increases in adulthood due to
accommodative effort
• As the age progresses the lens nuclear sclerosis or changes in the lens may
further show shift from hyperopia to lesser hyperopia or lesser hyperopia to
myopia

38. 0
10
20
30
40
50
60
70
80
90
Age in years
6-11 yrs
12-17 yrs
18-24 yrs
25-34 yrs
35-44 yrs
45-54 yrs
55-64 yrs
65-74 yrs
Figure: Percentages of individuals wearing plus lenses (Redrawn from
Refractive status and Motility Defects of Persons 4-74 years, U.S.
Department of Health, Education, and welfare, 1978)

39. Note: In their longitudinal study of 300 patients, Grosvenor and
Skaetes found that, among patients with 20/20 vision, emmetropic
and hyperopic eyes tended to have a hyperopic shift with age as
compared with the myopic eyes in their study

40. Symptoms of Hyperopia
• In hyperopic patients, the symptoms vary depending upon the age of the patient
and the degree of refractive error. These can be grouped as under:
 Asymptomatic: A small amount of refractive error in young patients is usually
corrected by mild accommodative effort without producing any symptoms
 Asthenopic symptoms: These include:
 Tiredness of eyes
 Frontal or frontotemporal headache
 Watering
 Mild photophobia

41. Contd…
Defective vision with asthenopic symptoms
Defective vision only
The effect of ageing on vision
Intermittent sudden blurring of vision
Crossed eye symptoms
Squinting of eyes

42. Signs of hyperopia
Size of the eyeball maybe normal or may appear small as a whole
Anterior chamber is comparatively shallow and the angle is narrow
Reduced amplitude of accommodation
Visual acuity varies with the degree of hyperopia and power of accommodation. In
patients with low degree of hyperopia, visual acuity maybe normal
Fundus examination reveals a small optic disc which may look more vascular with ill
defined margins and even simulate papillitis (pseudopapillitis)
A-scan ultrasonography may reveal a short anteroposterior length of the eyeball

43. Note: In a study done by Jonas JB of Department of Ophthalmology,
University of Heidelberg, Mannheim, Germany on the topic “optic disc
size correlated with refractive error”, a conclusion was found that the
optic disc size depends on the refractive error with an increase in
highly myopic eyes beyond -8.00 D and a decrease in highly
hyperopic eyes beyond +4.00 D

44. PAPILLITIS PSEUDOPAPILLITIS

45. Visual acuity in Hyperopia
• As compared to an uncorrected Myope-whose distance visual acuity cannot be
improved by accommodation-distance visual acuity of an uncorrected Hyperope
can be significantly improved by accommodation
• The extent to which a Hyperope’s distance visual acuity can be improved by
accommodation is limited only by the Amplitude of Accommodation
• A young person having 3.00 D of hyperopia and 10.00 D of accommodation will
have no difficulty accommodating enough to compensate for the hyperopia and
achieve clear vision. However an old person with the same amount of Hyperopia
and 2.00 D of accommodation would not be able to compensate fully for the
hyperopia and would therefore not have clear distance vision

46. Visual acuity in Hyperopia
• Near visual acuity in Hyperopia depends on the amount of hyperopia, the
amplitude of accommodation and the distance at which reading is
attempted
• Suppose an uncorrected 2.00 D hyperope with 3.00 D of accommodation
attempts to read at a distance of 40cm. Because 2.00 D of
accommodation will be needed to see clearly at infinity, only 1.00 D is
available to focus at a distance of 40cm
• However, 2.50 D of accommodation is necessary to focus at 40cm the
patient lacks 1.50 D of accommodation to accomplish the task, and near
vision will be blurred
Amplitude of Accommodation = Reciprocal of Near Point of Accommodation

47. Absolute hyperopia (D) Snellen’s visual acuity
+0.5 6/9
+0.75 6/12
+1.00 6/12 - 6/18
+1.50 6/24
+2.00 6/24(partial)
+2.50 6/36 – 6/60
+3.50 4/60
+4.50 3/60
Table: Estimate of visual acuity in absolute hypermetropia

48. Correction of Hyperopia
• Correction of hyperopia includes:
• Optical correction using spectacles
• Contact lenses
• Vision therapy
• Surgical treatment

49. Spectacles
• Plus (convex) lenses are used to correct hyperopia
• Spectacles are most comfortable, safe and easy method of
correcting hypermetropia
• Newer high index lenses and aspheric lens designs have reduced
the thickness and weight of high plus powered lenses increasing
their acceptance

50. Contact lenses
• Soft or rigid contact lenses are an excellent alternative for some
patients who resist wearing spectacles
• Contact lenses reduce aniseikonia in persons with anisometropia,
improving binocularity
• In patients with accommodative esotropia, contact lenses decrease
the accommodative and convergence demands, reducing or
eliminating esotropia at near to a greater extent than spectacles

51. Note: In case of Aphakia, a spectacle correction usually results in
approximately a 25% image magnification, which can be reduced to about
7% using a contact lens correction. Thus a resultant decrease in field of
view occurs with the wear of high plus spectacles. There is another 20%
loss of the visual field due to the ring scotoma effect of the high-plus
spectacle lens. Magnification also produces a pincushion distortion;
patients may complain of difficulty with depth perception, navigating stairs
becomes challenging, and vertical edges such as door frames may appear
curved and actually appear to change curvature while walking through them

52. Vision therapy
• High hyperopia and especially accommodative esotropia reduces
binocular functions which need to be improved by vision therapy
along with optical correction. These may include advices on
improving lighting or glare reduction, better postures and visual
hygiene should be emphasized on computer terminals
• Children should be under the supervision of an orthoptist for
improvement of binocular functions

53. Refractive surgery
• In general, refractive surgery for hyperopia is not as effective or
reliable as for myopia. However, following procedures are used:
• Cornea based procedures:
• Thermal laser keratoplasty (TLK) has been used for low degree of hyperopia.
In this technique, 8 laser spots are applied in a ring at the periphery to
produce central steepening with mid infrared energy from Thallium-Holmium-
Chromium (THC): YAG laser. Regression effect and induced astigmatism are
the main problems
• Hyperopic LASIK is effective in correcting hyperopia upto +4.00 D

54. Refractive surgery
• Hyperopic PRK using excimer laser has also been tried.
Regression effect and prolonged epithelial healing are the main
problems encountered
• Conductive Keratoplasty (CK) is nonablative and nonincisional
procedure in which cornea is steepened by collagen shrinkage
through the radiofrequency energy applied through a fine tip
inserted into the peripheral corneal stroma in a ring pattern. This
technique is effective for correcting hyperopia of upto 3.00 D

55. Refractive surgery
• Lens based procedures:
• Phakic refractive lens (PRL) or implantable contact lens (ICL) is being
considered a surgical option for hyperopia of more than +4.00 D
• Refractive lens exchange (RLE) is a good option for high hyperopia
especially in presbyopic age

56. PRESCRIPTION GUIDELINES
Consideration Prescription
Age 3-6 years Due to cycloplegic refraction or non
cycloplegic (Mohindra) refraction, give a
partial prescription, if the power is >/= +3.25
D of spherical equivalent then subtract 0.75
D from the gross retinoscopy
>/= +3.50 D in one or more meridian at 1
year of age upwards
Sphere: prescribe 1.00 D less than the least
hyperopic meridian
Cylinder: prescribe half of the astigmatism, if
>+2.50 D
>+2.50 D at 4 yrs upwards Still give a partial correction for hyperopia;
undercorrecting by approx. 1.00 D to 1.50 D,
which is the mean hyperopia at this age
>/= +1.50 D in the school years without
symptoms
A full or near full correction maybe given at
this age, as emmetropisation has essentially
ended

57. PRESCRIPTION GUIDELINES
INDICATION PRESCRIPTION
Bilateral refractive amblyopia Cycloplegic refraction of
+5.00 D or more, full amount
or reduce 1.00 D to 2.00 D
Accommodative esotropia Give full cycloplegic
refraction
Accommodative esotropia
with amblyopia
Cycloplegic refraction of
+3.00 D or more, reduce
1.00 D to 2.00 D

58. PRESCRIPTION GUIDELINES
Consideration Management
Birth to 6 years No compensation, except for strabismus,
suppressions, or poor school performance
6 to 20 years No compensations, except for strabismus,
suppressions, poor school performance, near
asthenopia or acuity loss, prescribe
cautiously with liberal cut in plus power
20 to 40 years Compensate for complaints, with moderate
cut in plus power for distance, yet full plus
compensation for near activity
40 years and up Usually compensate with full plus power with
near add for presbyopic compensation
Esotropes Fully correct, with a possible near addition
Exotropes Partially correct to minimize secondary exo
problems;

59. UNCORRECTED HYPEROPIA AND ESOTROPIA
• When an excessive amount of accommodation is required in
uncorrected hyperopia, the visual system has three choices:
• The visual system may let the letters go out of focus, making reading
impossible
• One eye may turn inward, towards the nose, relieving the eyestrain but
causing double vision
• Single vision may be maintained, but at the cost of a large amount of stress
due to the continual unconscious effort to keep the eyes from overconverging
and thus avoid diplopia

60. Contd...
• If the hyperopia has gone uncorrected for a long time, the convex lenses
may fail to straighten the eyes: Because the brain receives conflicting
information from the eye that is turning inward, resulting in the following:
• SUPPRESSION of the retinal image of the deviating eye
• AMBLYOPIA or “dull vision”. If the child’s esotropia is allowed to continue
indefinitely, the visual acuity of the turning eye may fail to develop normally
Once suppression and amblyopia has occurred, the mere correction of
the hyperopia does not necessarily straighten the eyes. However, it is
usually possible to improve their coordination by a series of vision
therapy sessions

61. References
• Theodore Grosvenor, Primary Care Optometry, Fifth Edition, Page no. 16, 17, 35, 193
• AK Khurana, Theory and practice of Optics and Refraction, Second Edition, Page no. 62-71
• Monica Chaudhry, Refraction and Lens Prescription, page no. 42-45, 150-151
• Borish’s Clinical Refraction, Page no. 1518, 1652
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC565977/#__ffn_sectitle
• https://www.ncbi.nlm.nih.gov/m/pubmed/9469564/
• https://www.ncbi.nlm.nih.gov/m/pubmed/15734000/
• https://www.orthobullets.com/pediatrics/4089/marfan-syndrome
• http://eyewiki.aao.org/Peters%27_Anomaly

62. THANK YOU