HYPERMETROPIA. HYPERMETROPIA: PROGRAM Hypermetropia: program I Generalities: –Definition –Etiology and epidemiology –Signs and symptoms Classification:

HYPERMETROPIA

HYPERMETROPIA: PROGRAM

Hypermetropia: program I

• Generalities:– Definition– Etiology and epidemiology– Signs and symptoms

• Classification:– According to magnitude– According to refraction– According to the accomodative capacity

Hypermetropia: program II

• Clinical exam:– VA: hypermetropia and age– Characteristics of the retinoscopy– Characteristics of the subjective exam– Low refraction cycloplegia– Binocularity: effect of the optical

compensation

Hypermetropia: program III

• Prescription criteria:– Hypermetropes from age 0 to 6– Hypermetropes from age 6 to 20 – Hypermetropes between 20 and 45– Hypermetropes between 45 and 65– Hypermetropes older than 65

• Resolution of clinical cases

HYPERMETROPIA: GENERALITIES

Hypermetropia: Generalities I

• A condition in which the rays that come from a far away object, the eye being accomodatively relaxed, form their image behind the retina.

• The structural causes of hypermetropia can be:– Small axial length of the eye– Weak eye– An error in the relation between the axial

longitude and the power

Hypermetropia: Generalities II

• Epidemiology:– 66% of the population has a refractive error

in the range of +0,50D a +2,37D

• Etiology:– Genetic influence– Environment and visual demands

HYPERMETROPIA: CLASSIFICATION

Hypermetropia: Classification I

• According to the magnitude of the total hypermetropia:– Low hypermetropias: between +0,25 and

+2,00 D– Moderate hypermetropias: between +2,25

and +5,00 D– Elevated hypermetropias: above +5,00 D

Hypermetropia: Classification II

• According to refraction:– H. Total (HT): Total magnitude of the hypermetropia. It is

the value of the retinoscopy, using an appropriate accomodation control. In some cases the cycloplegic refraction can be necessary.

– H. Manifest (HM): that which the patient shows through the subjective refraction. It is the part of the HT that, in some patients, allows compensation through the lenses + (without diminishing VA in DV)

– H. Latent (HL): that which does not appear in the realization of the subjective exam. It is the part of the HT that, in some patients, does not allow compensation (secondary to the excessive tone or spasm of the ciliary muscle)

Hypermetropia: Classification III

• Example 1:– Youth of 16; no previous Rx– VAsc in DV: 20/20 in RE and LE– Retinoscopy: +3,50– Subjective: +1,00 (if the positive is augmented, the

VA and visual comfort from distances will be lost)

H TOTAL = H MANIFEST + H LATENT

NOTE: Rx: refraction; sc: without correction; for the VA, the notation of Snellen has been used in feet

Hypermetropia: Classification IV

• According to the accomodative capacity:– H. Total (HT): Total magnitude of the hypermetropia.

It is the value of the retinoscopy, utilizing an appropriate accomodation control. In some cases cycloplegic refraction can be necessary.

– H. Absolute (HA): that which cannot be compensated for by the accomodative capacity of the patient. It is responsible for the fact that a hypermetrope cannot achieve a normal VA in DV.

– H. Facultative (HF): that which can be compensated for by the accomodative capacity of the patient.

Hypermetropia: Classification V

• Example 1:– Patient, 52-years-old ; no previous Rx– VAsc in DV: 20/40 en RE– Retinoscopy: +2,25– Positive minimum necessary in order to achieve an

VA of 20/20: +1,50– Subjective: +2,25

H TOTAL = H FACULTATIVE + H ABSOLUTE

NOTE: Rx: refraction; sc: without correction; for the VA, we have used Snellen’s notation in feet

HYPERMETROPIA: CLINICAL EXAM

Hypermetropia: Clinical exam I

• Case history– Symptoms in NV– Symptoms of anticipated presbyopia– Lack of concentration– Elimination of task in NV– Occasional diplopia

Hypermetropia: Clinical exam II

• Visual acuity: The VA will be determined by:– The grade of hypermetropia– Age of the patient and accomodative capacity– General state of health of the patient

• Previous concepts:– Amplitude of monocular accomodation– Methods to determine the amplitude of

accomodation– Amplitude of the comfortable accomodation

Hypermetropia, VA and age

Condition AgeAm Accom.

totalAm. Accom.

Comfort

Necessary

Accom. DV

ExpectedVA DV

NecessaryAccom. 40cm

ExpectedVA

40cm

EMMETROPE

20

40

60

HYPERMETROPE

+2,50 sc

20

40

60

MYOPE-2,50 sc

20

40

60

Hypermetropia, VA and age

Condition AgeAm Accom.

total

Am comfort

. Accom.

NecessaryAccom. DV

ExpectedVA DV

NecessaryAccom. 40cm

ExpectedVA

40cm

EMMETROPE

20 12,5 6,25 0 1 (20/20)

2,5 20/20

40 6,5 3,25 0 1 (20/20)

2,5 20/20

60 0,5 0,25 0 1 (20/20)

2,5 ≤20/100

HYPERMETROPE

+2,50 sc

20 12,5 6,25 2,50 1 (20/20)

5,0 20/20

40 6,5 3,25 2,50 1(20/20)

5,0 ≈20/40

60 0,5 0,25 2,50 ≤20/100 5,0 ≤20/200

MYOPE-2,50 sc

20 12,5 6,25 0 0,1 (20/200)

0 20/20

40 6,5 3,25 0 0,1 (20/200)

0 20/20

60 0,5 0,25 0 0,1 (20/200)

0 20/20

Hypermetropia: Clinical exam III

• Retinoscopy without cycloplegia– Good fogging– Look for fluctuations in the reflex– Assess variations of the pupil’s diameter– Confirm astigmatisms

Hypermetropia: Clinical exam IV

• Retinoscopy with cycloplegia– When there is suspicion of a greater

hypermetropia than discovered in the retinoscopy

– When endotropias exist– When there is very low collaboration– Commonly used medications:

IMPORTANT: Do not confuse mydriatic effect with cycloplegic effect

MEDICATIONOPTIMAL CYCLE

DURATIONEFFECT

RESIDUAL ACCOM.

Atropina 24 – 48 h12 – 18

días+

Ciclopentolate 30’ – 45’ 8 – 10 h ++

Tropicamide 20’ 2 – 5 h +++

Hypermetropia: Clinical exam V

• Subjective exam in hypermetropes:– Begin the exam with the brute value of the

retinoscopy– When the H. Total H. Manifest special

considerations are not necessary– When a significant grade of H. Latent exists

the subjective exam is an art

Hypermetropia: Clinical exam VI

– Subjective exam in cases of latent hypermetropia:• Essential to maintain the fogging at all times• The dioptric variations necessary to get a line VA are

not logical• It is not always necessary to arrive at VA 1 the

monocular way• The patient tends to reject or diminish retinoscopic

astigmatisms in the subjective exam (back yourself up with keratometria)

• In anisometropias: guide yourself by the retinoscopy

Hypermetropia: clinical exam VII

• Binocularity and accomodation– An uncorrected or partially corrected

hypermetropia can:• Associate itself with more or less pronounced

myosis• Associate itself to endodeviations, mainly in

NV• Simulate a fatigue or an accomodative

insufficiency

HYPERMETROPIA: PRESCRIPTION CRITERIA

Hypermetropia: Prescription criteria I

• Patient’s age• Grade of hypermetropia• Symptoms• Binocular dysfunction associated

Hypermetropia: Prescription criteria II

• From 0 to 6 years of age– Reason for the consultation:

• School check-up.• It seems that one eye deviates.• Family history.• There do not tend to be subjective

complaints.

Hpermetropia: Prescription criteria III

• From 0 to 6 years of age– Hypermetropia < 3 D: does not tens to be

prescribed,as long as it is not found to be associated with a binocular dysfunction, a low VA, or an astigmatism 1,50D.

– Hypermetropia >3 D. Generally prescribed (totally or partially), since it can be associated with or induce: VA. development of binocular vision.

Hypermetropia: Prescription criteria IV

• From 0 to 6 years of age– Hypermetropia + endotropia:

• A cycloplegia tends to be necessary.• Evaluate deviation in DV and NV.• Evaluate the effect of positive lenses in NV.• Always prescribe the maximum positive

power.– Hypermetropia + exodeviations:

• Do not prescribe or PARCIALIZAR the prescription.

Hypermetropia: Prescription criteria V

• From 0 to 6 years of age– Low bilateral vision (pathological cause):

Total prescription to reserve the accomodation for NV.

– Hypermetropia and anisometropia: – Hypermetropia + external ocular infections:

Evaluate the necessity to prescribe in Hp > 1 D or 1,50 D.

Hypermetropia: Prescription criteria VI

• From 6 to 20 years of age– Up until puberty hypermetropia tends to

diminish.– At these ages demands on NV.– Diverse reasons for consultation.– Importance of latent hypermetropias.

Hypermetropia : Prescription criteria VII

• From 6 to 20 years of age– Hypermetropia < 1,50D: does not tend to

be prescribed, as long as it is not found to be associated with a binocular dysfunction or visual fatigue in NV.

– Hypermetropia >1,50D. Generally prescribed for, totally or partially, and especially if it is associated with an astigmatism > 0,75D.

Hypermetropia : Prescription criteria VIII

• From 6 to 20 years of age– Hypermetropia + endodeviation: total

prescription. Constant use or principally for NV

– Hypermetropia + exodeviations: bias the prescription (without affecting the visual comfort in NV)

Hypermetropia : Prescription criteria IX

• From 6 to 20 years of age– Low bilateral vision (pathological cause): total

prescription in order to reserve the accomodation for NV.

– Hypermetropia and anisometropia:• Up until 8-10 years of age we can prescribe for

the total anisometropia 10 years of age: prudence with anisometropias

if they have never before been prescribed for– Hypermetropia + external ocular infections:

• Evaluate the necessity of prescribing in hypermetropias > 1 D.

Hypermetropia : Prescription criteria X

• From 20 to 45 years of age– Small hypermetropias give symptomology in NV.

– According to the grade of the hypermetropia, > 35 years of age show signs of presbyopia.

– Reasons for consultation:• Visual fatigue in NV.• Conjunctival hyperaemia.• Importance of latent hypermetropias.

Hypermetropia : Prescription criteria XI

• From 20 to 45 years of age– Generally totally prescribed, as much when

associated with an astigmatism as when not. Emphasizing its use for NV.

– Hypermetropia + exodeviations

– Hypermetropia and anisometropia

Hypermetropia : Prescription criteria XII

• From 45 to 65 years of age– Age of appearance of presbyopia– Glasses that were for near vision are now

used for distance vision.– Latent hypermetropias become manifest. – Facultative hypermetropias become

absolute.

– Reasons for the consultation:• Loss of VA in NV.

Hypermetropia : Prescription criteria XIII

• From 45 to 65 years of age– Prescribe totally as much for DV as for the

corresponding addition for NV (it will permit intermediate vision).

Hypermetropia : Prescription criteria XIV

• From 45 to 65 years of age– Hypermetropia + exodeviations:

– Hypermetropia and anisometropia:

Hypermetropia : Prescription criteria XV

• Older than 65 years of age– At ages > 65-years-old there can be a

diminishment of the hypermetropia (nuclear cataracts).

– Relationship between elevated hypermetropia and narrow anterior chamber.

HYPERMETROPIA: CASES

Hypermetropia: case 1-I

• QG, 39 years of age. Salesman.• MC: Occasionally notes that he/she does

not see well in NV. Asthenopic symptoms when reading.

• PH: Never worn glasses. Does not remember previous visual revisions. No illnesses or ingestion of medication.

• FH: Unimportant.

Hypermetropia : case 1-II

• Habitual VA in DV and NV:– RE: 20/20; NV: 20/20– LE: 20/20; NV: 20/25

• Binocularity in habitual conditions:– Cover test:

• DV: ortho• NV: low endophoria

– Proximal convergence: 10/12cm

Hypermetropia : case 1-III

• Retinoscopy:– RE: +1,00– LE: +1,50

• Subjective DV and VA:– RE: +0,75; VA: 20/20– LE: +1,25; VA: 20/20– NV with the subjective: VA 20/20 in both eyes. Good

comfort

• Amplitude of accomodation with the subjective:– RE: 16cm≈6D– LE: 16cm≈6D

• Ocular health exams: within normal limits

Hypermetropia : case 1-IV

• Complete diagnostic of the case• Proposed treatment and plan of check-

ups• Possible evolution of the condition

Hypermetropia : case 1-V

• Complete diagnostic of the case– Low hypermetropia manifests itself in both

eyes– The hypermetropia is facultative since the

habitual VA in DV is 20/20– Endophoric tendency in NV without

correction– The rest of the test results within normal

limits

Hypermetropia : case 1-VI

• Proposed treatment:– Glasses with the value of the subjective:

• RE: +0,75• LE: +1,25

– Use mainly for tasks involving NV. – Can be worn for general use.– Revision in two years or before if new

symtomology appears.– Explain the condition to the patient.

Hypermetropia : case 1-VIII

• Possible evolution of the condition:– Stability of the graduation until the

appearance of presbyopia.

Hypermetropia : case 2-I

• NP, 21-years-old. Student.• MC: Visual fatigue in NV. To study the

patient uses glasses but symptoms continue

• PH: 2 years ago he/she wore glasses for NV of +0,50 in both eyes. No illnesses or ingestion of medication.

• FH: Irrelevant.

Hypermetropia : case 2-II

• Rx and habitual VA in DV and NV:– REDV: 0,00; VADV: 20/20+; RENV: +0,50; VANV:

20/20– LEDV: 0,00; VADV: 20/20+; LENV: +0,50; VANV:

20/20 Binocularity in habitual conditions:– Cover test:

• DV: ortho

• NVcc: orthophoria

– Proximal convergence: 8/10cm

Hypermetropia : case 2-III

• Retinoscopy:– RE: +2,75-0,50x180º– LE: +3,50-0,50x180º

• Subjective DV and VA:– RE: +0,50; VA: 20/20+

– LE: +0,75; VA: 20/20+

• Retinoscopy in NV (with the subjective):– RE: +1,25 (fluctuates)– LE: +1,50 (fluctuates)

• Ocular health tests: within normal limits

Hypermetropia : case 2-IV

• Are other tests necessary for a correct diagnosis and treatment?

• Complete diagnostic of the case• Proposed treatment and a plan of

check-ups• Possible evolution of the condition

Hypermetropia : case 2-V

• Are other tests necessary for a correct diagnosis and treatment?– Cycloplegia?– Amplitude of accomodation?

Hypermetropia : case 2-VI

• Complete diagnostic of the case– Moderate hypermetropia in AO. Significant

latent hypermetropia. Small manifest hypermetropia

– Low, direct astigmatism in both eyes in the retinoscopy that is not accepted in the subjective

– The rest of the tests return result within normal limits

Hypermetropia : case 2-VII

• Proposed treatment:– Prescribe new glasses:

• RE: +1,75• LE: +2,25

– Main use in NV. Use in DV is also recommended.

– Explain the condition to the patient– New check-up in 3-4 months

Hypermetropia : case 2-VIII

• Possible evolution of the condition:– It is hoped that with the passage of time the

latent hypermetropia will manifest itself– The hypermetropic graduation in the glasses

will continue increasing up to the current value of the retinoscopy or even a slightly superior value

– Greater dependence on the glasses with the passage of time

HYPERMETROPIA : BIBLIOGRPHHY

Hypermetropia : bibliography

• Amos JF. Diagnosis and management in vision care. Butterworth-Heinemann, 1987

• Milder B, Rubin ML. The fine art of prescribing glasses. (2nd edition), Triad Publishing company, 1991.

• Brookman KE. Refractive management of ametropia. Butterworth-Heinemann, 1996

• Werner DL, Press LJ. Clinical pearls in refractive care. Butterworth-Heinemann, 2002

Hypermetropia: bibliography

• http://www.wrongdiagnosis.com/h/hyperopia/intro.htm

• http://www.healthatoz.com/healthatoz/Atoz/ency/hyperopia.jsp

• http://www.eyemdlink.com/Condition.asp?ConditionID=229

• http://en.wikipedia.org/wiki/Hyperopia• http://www.nlm.nih.gov/medlineplus/ency/

article/001020.htm• http://www.tarso.com/Hiper.html