Hypermetropia, also known as hyperopia or longsightedness, is a refractive error where the eye focuses images behind the retina. It has various causes including a short axial length of the eye or flattened cornea. Symptoms include blurry near vision and asthenopia. Treatment involves prescribing convex lenses to correct refractive errors or refractive surgery for more severe cases. Early treatment of hypermetropia in children is important to prevent amblyopia and strabismus.

1. HYPERMETROPIA
Dr. Siddharth Gautam

2.  The term hypermetropia is derived from HYPER
meaning “In excess” MET meaning “measure” &
OPIA meaning “of the eye”.
 Also called hyperopia / longsightedness as the
distant objects are seen clearly but the close objects
do not come into proper focus.
 First suggested in 1755 by KASTNER
( Mathematician)

3. DEFINITION
•It is the refractive state
of eye where in parallel
rays of light coming from
infinity are focused
behind the sensitive layer
of retina with
accommodation being at
rest.
•The posterior focal point
is behind the retina
which receives a blurred
image

4. ETIOLOGY
1) AXIAL
 Most common
 Axial length is short
 1mm shorting of AP dia  3 D of HM
 At birth +2.5 – 3 D of HM (physiologically)
 Phyiologically more than 6D HM are uncommon

5. 2) CURVATURAL
 Flattening of cornea, lens or both
 1mm increase in Radius of curvature 6D of HM
 Never exceed 6D HM physiologically
 Congenitally flattened is c/a cornea plana
 Result (trauma and disease )
3) INDEX
 Change in refractive index with age
 Physiologically in old age
 Pathologically in diabetics under treatment

6. 4)POSITIONAL
 Posteriorly placed crystalline lens
 Occurs as congenital anomaly
 Result of trauma or disease
5)ABSENCE OF LENS
 Seen in aphakia

7. PHYSIOLOGICAL HYPERMETROPIA
 Many children are born with hyperopia, and some of
them "outgrow" it as the eyeball lengthens with normal
growth.
 The prevalence of hyperopia-unlike that of myopia
changes very slowly with the years, and because once
hyperopia is present, it progresses slowly or not at all.
So, the conventional wisdom is that hyperopia occurs as a
result of genetic influences.

8. CLINICAL BACKGROUND
 Most newborn infants have mild hyperopia, with
only a small number of cases falling within the
moderate to high range.
 Infants with moderate to high hyperopia ( +3.50D)
are up to 13 times more likely to develop
strabismus by 4 years of age, and they are 6 times
more likely to have reduced visual acuity than
infants with low hyperopia or emmetropia.

9. CLINICAL TYPES
 SIMPLE HYPERMETROPIA,
 PATHOLOGICAL
 FUNCTIONAL HYPEROPIA

10. SIMPLE HYPERMETROPIA
 Commonest form
 Results from normal biological variations in the
development of eyeball
 Include axial and curvatural HM
 May be hereditary

11. PATHOLOGICAL HYPERMETROPIA
 Pathologic hyperopia may be due to maldevelopment of
the eye during the prenatal or early postnatal period, a
variety of corneal or lenticular changes, chorioretinal or
orbital inflammation or neoplasms, or to neurologic- or
pharmacologic-based etiologies.
• It is rare in comparison with physiologic hyperopia.
• Because of the relationship of pathologic hyperopia to
potentially serious ocular and systemic disorders,
proper diagnosis and treatment of the underlying cause
may prove critical to the patient's overall health.

12.  Microphthalmia (with or without congenital or early
acquired cataracts and persistent hyperplastic primary
vitreous) and this condition's often hereditary form,
nanophthalmia, may produce hyperopia in excess of
+20D.
• Anterior segment malformations such as corneal plana,
sclerocornea, anterior chamber cleavage syndrome, and
limbal dermoids are associated with high hyperopia.
• Acquired disorders that can cause a hyperopic shift
result from corneal distortion or trauma, chalazion,
chemical or thermal burn, retinal vascular problems,
diabetes mellitus, developing or transient cataract or
contact lens wear.

13.  Conditions that cause the photoreceptor layer of
the retina to project anteriorly (idiopathic central
serous choroidopathy and choroidal hemangioma
from Sturge-Weber disease) also induce hyperopia.
 Orbital tumors, idiopathic choroidal folds, and
edema can mechanically distort the globe and press
the retina anteriorly, thereby causing hyperopia.
 Cycloplegic agents may induce hyperopia by
affecting accommodation, and a variety of other
drugs can produce transient hyperopia.

14. FUNCTIONAL HYPERMETROPIA
 Results from paralysis of accommodation
 Seen in patients with 3rd nerve paralysis & internal
ophthalmoplegia

15. CATEGORISED BY DEGREE OF
REFRACTIVE ERROR
• Low hyperopia consists of an error of +2.00diopters
(D) or less.
• Moderate hyperopia includes a range of error from
+2.25 to +5.00 D.
• High hyperopia consists of an error over +5.00 D.

16. NOMENCLATURE
 TOTAL HYPERMETROPIA= LATENT +
MANIFEST (facultative +
absolute)

17. TOTAL HYPERMETROPIA
 It is the total amount of refractive error,estimated
after complete cycloplegia with atropine
 Divided into latent & manifest

18. LATENT HYPERMETROPIA (Hl)
 Amount of hyeropia corrected by inherent tone of
ciliary muscle (Usually about 1D)
 Degree of Hl High in children
 Decreases with age
 Revealed after abolishing tone of ciliary muscle
with atropine

19. MANIFEST HYPERMETROPIA
 Remaining part of total hypermetropia
 Correct by accommodation and convex lens
 Consists of facultative & absolute
FACULTATIVE HYPERMETROPIA
 Corrected by patients accommodative effort
ABSOLUTE HYPERMETROPIA
 Residual part not corrected by patients
accommodative effort

20.  Manifest HM – absolute HM = Facultative HM
(Strongest lens) – (weakest lens)
 Total HM – Manifest HM = Latent HM

21. NORMAL AGE VARIATION
 At birth +2+3D HM
 Slightly increase in one year of life,
 Gradually diminished until by the age 5-10 years
 In old age after 50 year again tendency to HM
 Tone of ciliary muscle decreases
 Accommodative power decreases
 Some amount of latent HM become manifest
 More amount of facultative HM become absolute
 Practically after 65 year all of it become absolute

22. SYMPTOMS
 Principal symptom is blurring of vision for close
work
 Symptoms vary depending upon age of patient &
degree of refractive error
1.ASYMPTOMATIC
 small error produces no symptoms
 Corrected by accommodation of patient

23. 2.ASTHENOPIA
 Refractive error are fully corrected by
accommodative effort
 Thus vision is normal
 Sustained accommodation produces symptoms
 Asthenopia increases as day progresses
 Increased after prolonged near work
SYMPTOMS
Tiredness
Frontal or fronto temporal headache
Watering
Mild photophobia

24.  To keep the image focused on retina an excessive
amount of accomodation is required in uncorrected
hyperopia, the visual system has three choices:
1. The visual system can let the letters go out of focus,
making reading impossible.
2. One eye may turn inward, toward the nose, relieving the
eyestrain but causing double vision.
3. Single vision may be maintained, but at the cost of large
amount of stress due to the continual unconscious effort
to keep the eye from overconverging, and thus avoid
double vision.

25. 3.DEFECTIVE VISION WITH ASTHENOPIA
 Not fully corrected by accommodation
 Defective vision for near more than distance
 Asthenopia due to sustained accommodation
 Refractive error more(>4D)
4.DEFECTIVE VISION ONLY
 Refractive vision more than 4D
 Adults who usually do not accommodate
 Marked defective vision for near and distance

26. 5. The effect of aging on vision :
 Progressive loss of accomodative power with
ageing  progressive loss of vision.
6. Intermittent sudden blurring of vision:
 May occur due to spasm of accomodation inducing
pseudomyopia
 Cycloplagic refraction reveals the underlying
hyperopia

27. SIGNS
 VISUAL ACUITY : Defective
 EYEBALL: small or normal in size
 CORNEA : may be smaller than normal. There can
be CORNEA PLANA
 ANTERIOR CHAMBER : may be shallow
 LENS: could be dislocated backwards
 A Scan ultrasonography (biometry) reveal short
axial length

28. FUNDUS:
A) DISC: Dark reddish color, irregular margins
,confused with Papillitis so termed as PSEUDO-
PAPILLITIS
B) MACULA: Situated farther from the disc than
usual, large positive angle alpha, apparent
divergent squint
C) BLOOD VESSELS: Show undue tortuosity &
abnormal branchings
D) BACKGROUND: SHOT- SILK RETINA (shiney)

29. COMPLICATION
 Recurrent styes blepharitis or chalazia
 Accommodative convergent squint
 Amblyopia
 Anisometropic
 Strabismic
 Uncorrective bilateral high hypermetropia
 Predisposition to develop primary narrow angle
glaucomas.
(small eye ball , shallow AC)

30. BASIS FOR TREATMENT
 No Treatment
Error is small
Asymptomatic
Visual acuity normal
No muscular imbalance
TREATMENT

31. Young children(<6 or 7yrs)
Some degree of hypermetropia is physiological so no
correction
Treatment is required if error is high or strabismus is
present
 working in school small error may require correction
In children error tends normally to diminish with
growth so refraction should be carried out every six
month and if necessary the correction should be
reduced, ortherwise a lens which is overcorrecting
their error may induce an artificial myopia.
No deduction of tonus allowance in strabismus

32. ADULTS
If symptoms of eye-strain are marked , correct as
much of the total hypermetropia as possible , trying as
far as we can to relieve the accommodation
When there is spasm of accommodation we correct
the whole of the error
Some patients with hypermetropia do not initially
tolerate the full correction indicated by manifest
refraction so we undercorrect them
Exophoria hyperopia should be under correct by 1 to
2D

33. Patients with absolute hypermetropia are more
likely to accept nearly the full correction because
they typically experience immediate
improvement in visual acuity
In pathological hypermetropia the underlying
cause rather than the hypermetropia is chief
concern

34. MODE OF TREATMENT
 SPECTACLES
 CONTACT LENS
 SURGICAL
OPTICAL TREATMENT

35. SPECTACLES
Basic principle
Prescribe convex lenses (Plus lenses) so that
rays are brought to focus on the retina
Advantages
 Comfortable
 Easier method
 Less expensive
 Safe

36. CONTACT LENS
ADVANTAGES:
 Cosmetically good
 Increased field of view
 Less magnification
 Elimination of aberrations & prismatic effect

37. REFRACTIVE SURGERY
 Refractive surgery is not as effective as in myopia
TYPES:
(1)HEXAGONAL KERATOTOMY(HK)
 Low to moderate degrees of hypermetropia
 Its risk /benefit ratio is not low enough to warrant
its continued use

39. LASER THERMAL
KERATOPLASTY(LTK)
 Procedure done using Thallium-Holmium-Chromium
(THC:YAG) laser energy to heat the cornea (contraction
of collagen) and increase its curvature
 Central heating of cornea results in central corneal
flattening thereby resulting in hyperopic shift

40. PHOTOREFRACTIVE
KERATECTOMY(PRK)
 Direct laser ablation of corneal stroma after removal of
corneal epithelium mechanically
 Done using EXCIMER
LASER

41. LASER IN SITU
KERATOMILEUSIS(LASIK)
 Anterior flap of cornea lifted with keratome and excimer
laser is used to sculpt the stromal bed to change the
refractive error of eye
 It can correct up to 4D of hypermetropia and 8D of
astigmatism

42. CONDUCTIVE KERATOPLASTY
 Discovered by Mendez
 Uses radiofrequency to gently heat and shrink
corneal collagen tissue at specific sites to create
bands of tightening.
 The band reshapes and steepens cornea to correct
hyperopia.
 INDICATIONS:
1. Patients >40yrs having stable refraction
2. Hyperopia from +0.75 to +3.25D with -0.75 or
less astigmatism.

43. ADVANTAGES
 Minimally safe and effective for hyperopia upto +4 D
 Depth perception is maintained
 Contrast sensitivity is not lost from preoperative levels
DISADVANTAGES
 Not affective in hyperopia of >+4.0 D and 0.75D
astigmatism
 Non reversible
 Recurrent corneal erosions, perforation, mild iritis are
rare but do occur

44. PHAKIC IOL AND CLEAR LENS
EXTRACTION
 Done by Phaco technique
 Clear lens extraction with the implantation of an
IOL-----Preferably foldable IOL or a Piggyback IOL is
implanted. (>+10D)

45. VISUAL HYGIENE
 While reading or doing intensive near work take
a break about every 30 min
 When reading maintain proper distance that is
the book should be at least as far from your eyes
as your elbow when you make a fist and hold it
against your nose
 Sufficient Illumination
 Place a limit spent watching television &
watching videogames
 Sit 5-6 feet away from the television

46.  Appropriate optical correction almost always leads
to clear and comfortable single binocular vision
 Younger children who have significant hyperopia
associated with amblyopia, strabismus,or
anisometropia require treatment, starting as early
as 3-6 months of age

47. CONCLUSION
 Hyperopia is a common refractive disorder that
has been overshadowed by myopia in public
perception,vision research & the scientific
literature
 Although uncorrected myopia has a greater
adverse effect on visual acuity than uncorrected
hyperopia,the close association between
hyperopia,amblyopia & strabismus,especially in
children,makes hyperopia a greater risk factor
for more permanent vision loss than myopia

48.  The early diagnosis & treatment of significant
hyperopia & its consequences can prevent a
significant amount of visual disability in the general
population