HYPERMETROPIA

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HYPERMETROPIA
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HYPERMETROPIA PROGRAM
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Hypermetropia program I

• Generalities
• Definition
• Etiology and epidemiology
• Signs and symptoms
• Classification
• According to magnitude
• According to refraction
• According to the accomodative capacity

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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

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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

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HYPERMETROPIA GENERALITIES
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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

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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

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HYPERMETROPIA CLASSIFICATION
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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

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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)

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Hypermetropia Classification III
H TOTAL H MANIFEST H LATENT

• 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)

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

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Hypermetropia Classification V
H TOTAL H FACULTATIVE H ABSOLUTE

• 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

NOTE Rx refraction sc without correction for
the VA, we have used Snellens notation in feet
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HYPERMETROPIA CLINICAL EXAM
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Hypermetropia Clinical exam I

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

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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

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Hypermetropia, VA and age
Condition Age Am Accom. total Am. Accom. Comfort Necessary Accom. DV ExpectedVA DV Necessary Accom. 40cm ExpectedVA 40cm
EMMETROPE 20
EMMETROPE 40
EMMETROPE 60
HYPERMETROPE 2,50 sc 20
HYPERMETROPE 2,50 sc 40
HYPERMETROPE 2,50 sc 60
MYOPE -2,50 sc 20
MYOPE -2,50 sc 40
MYOPE -2,50 sc 60
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Hypermetropia, VA and age
Condition Age Am Accom. total Am comfort. Accom. NecessaryAccom. DV ExpectedVA DV Necessary Accom. 40cm ExpectedVA 40cm
EMMETROPE 20 12,5 6,25 0 1 (20/20) 2,5 20/20
EMMETROPE 40 6,5 3,25 0 1 (20/20) 2,5 20/20
EMMETROPE 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
HYPERMETROPE 2,50 sc 40 6,5 3,25 2,50 1 (20/20) 5,0 20/40
HYPERMETROPE 2,50 sc 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
MYOPE -2,50 sc 40 6,5 3,25 0 0,1 (20/200) 0 20/20
MYOPE -2,50 sc 60 0,5 0,25 0 0,1 (20/200) 0 20/20
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Hypermetropia Clinical exam III

• Retinoscopy without cycloplegia
• Good fogging
• Look for fluctuations in the reflex
• Assess variations of the pupils diameter
• Confirm astigmatisms

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Hypermetropia Clinical exam IV
IMPORTANT Do not confuse mydriatic effect with
cycloplegic effect

• 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

MEDICATION OPTIMAL CYCLE DURATION EFFECT RESIDUAL ACCOM.
Atropina 24 48 h 12 18 días
Ciclopentolate 30 45 8 10 h
Tropicamide 20 2 5 h
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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

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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

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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

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HYPERMETROPIA PRESCRIPTION CRITERIA
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Hypermetropia Prescription criteria I

• Patients age
• Grade of hypermetropia
• Symptoms
• Binocular dysfunction associated

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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.

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Hpermetropia Prescription criteria III

• From 0 to 6 years of age
• Hypermetropia lt 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 gt3 D. Generally prescribed (totally
  or partially), since it can be associated with or
  induce
• ? VA.
• ? development of binocular vision.

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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.

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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 gt 1 D
  or 1,50 D.

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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.

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Hypermetropia Prescription criteria VII

• From 6 to 20 years of age
• Hypermetropia lt 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 gt1,50D. Generally prescribed for,
  totally or partially, and especially if it is
  associated with an astigmatism gt 0,75D.

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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)

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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 gt 1 D.

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Hypermetropia Prescription criteria X

• From 20 to 45 years of age
• Small hypermetropias give symptomology in NV.
• According to the grade of the hypermetropia, gt 35
  years of age show signs of presbyopia.
• Reasons for consultation
• Visual fatigue in NV.
• Conjunctival hyperaemia.
• Importance of latent hypermetropias.

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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

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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.

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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).

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Hypermetropia Prescription criteria XIV

• From 45 to 65 years of age
• Hypermetropia exodeviations
• Hypermetropia and anisometropia

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Hypermetropia Prescription criteria XV

• Older than 65 years of age
• At ages gt 65-years-old there can be a
  diminishment of the hypermetropia (nuclear
  cataracts).
• Relationship between elevated hypermetropia and
  narrow anterior chamber.

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HYPERMETROPIA CASES
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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.

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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

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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 16cm6D
• LE 16cm6D
• Ocular health exams within normal limits

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Hypermetropia case 1-IV

• Complete diagnostic of the case
• Proposed treatment and plan of check-ups
• Possible evolution of the condition

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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

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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.

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Hypermetropia case 1-VIII

• Possible evolution of the condition
• Stability of the graduation until the appearance
  of presbyopia.

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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.

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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

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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

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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

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Hypermetropia case 2-V

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

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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

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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

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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

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HYPERMETROPIA BIBLIOGRPHHY
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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

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Hypermetropia bibliography

• http//www.wrongdiagnosis.com/h/hyperopia/intro.ht
  m
• http//www.healthatoz.com/healthatoz/Atoz/ency/hyp
  eropia.jsp
• http//www.eyemdlink.com/Condition.asp?ConditionID
  229
• http//en.wikipedia.org/wiki/Hyperopia
• http//www.nlm.nih.gov/medlineplus/ency/article/00
  1020.htm
• http//www.tarso.com/Hiper.html