1. HYPERMETROPIA (farsighted)
By, Saurabh D. Patel

2. Topics of Disscussion
 Etiology
 Clinical types
 Clinical presentation
 Diagnosis
 Management
 Complication

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

5. 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

6. 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

7. PATHOLOGICAL CAUSES
OF HYPEROPIA
1 mm = 3D
RETINAL FLUID

8. DISLOCATED LENS

9. RETINAL DETACHMENT CHOROIDAL TUMOR

10. 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
accommodation)

11. 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

12.  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

13. 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

14. 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

15.  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,
especially the latter

16.  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)

17. 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

18. 2) Occular examination
a) Visual acuity
- In young pt
- In presbyopic pt
- In older age
- In pt with never corrected high deree of hyperopia

19. b) Refraction
# retinoscopy – useful in children , accomodative
esotropia, latent hyperopia
- atropine has max. cycloplagia
# Autorefraction- validity & reliability lower

20. c)Occular motility , binocular vision &
accomodation
- anomalies in any of them detected by
- cover uncover test
- near point of convergence
- accomodative amplitude

21. (d) Occular health assurance & systemic
heath screening
- colour vision
- pupillary response
- confrontation visual fied test
- IOP
- occular media & post. Segment evalution

22. 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

23. (2) Available treatment
A) 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. NORMAL VISION
UNCORRECTED
HYPEROPIA
LENS CORRECTED
HYPEROPIA

25. 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

26. (3)Management strategies hyperopic
correction
# 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

27.  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

28.  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

29.  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

30. # 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

31.  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

32.  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

33. # 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

34. (d) Refractive surgery
 Automated lameller keratoplasty
 Holmium – YAG laser thermal keratoplasty
 Excimer laser
 Spiral hexagonal keratotomy
 Conductive keratoplasty

35.  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.

36. 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.

37.  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. HYPEROPIC -LASIK

39. 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

40. (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

41. (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 –

42. Complications
 Recurrent stye , blepharitis or chalazion
 Accomodative convergent squint
 Amblyopia
 Primary narrow angle glaucoma

43. Thank you