Childhood Hyperopia

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Childhood Hyperopia

• NEIL SINCLAIR
• RVEEH MOTILITY JNL CLUB
• EDITED BY LIONEL KOWAL

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Slide 1 Epidemiology

• Prevalence
• Definition varies between studies ie some use
  spherical equivalent and others most hyperopic
  meridian.
• Some use cycloplegia, some not.

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Slide 2 EpidemiologyAtkinson J et al (Cambridge
infant screening program)

• Study 1 Children 6-9 m invited for exam (71
  attended) 1096 screened
• hyperopia without anisometropia 4.6. Cycloplegic
  photorefraction 3.5D and hyperopia confirmed with
  retinoscopy
• Study 2 Children 7-9 m invited for exam (74
  attended) 3166 screened
• hyperopia without aniso 5.7
• Study 3 Children 8 m invited for exam
  (84attended) 5091 screened
• hyperopia without aniso 4.5. Noncycloplegic
  photo refraction with a criterion for hyperopic
  focus accommodative lag gt 1.5D

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Slide 3 Epidemiology

• UK typical state of the infant eye at 8-9 m is
  modest hyperopia (1.5 D)
• long tail of significant hyperopia in 5
• This refraction identifies a group at increased
  risk of strabismus and poor acuity by age 4.

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Slide 4 Epidemiology

• Other estimates of hyperopia prevalence come from
  smaller studies which are not population based
  and can over estimate the prevalence due to
  participation bias.
• Cook et al (1951) found 3D SE hyperopia in 30
  of newborns. 1000 cycloplegic refractions.
• Mutti et al (2005) found 3D of hyperopia in
  23.5 of 221 infants at 3m, reduced to 5.4 by 9
  m
• Ingram et al (2000) screened 6700 infants at 6 m,
  9.2 with 3.5 of meridional hyperopia.
• Ingram et al also (1979) studied 1648 infants at
  1 year. 3.7 with 3.5D of meridional hyperopia.

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Slide 5 Natural History and Emmetropization

• Corneal curvature, lens power and position and
  axial length are quite variable in the newborn.
• The range of refractive error is from 2 to 4
  (Brown 1938).
• most children are born hyperopic and become less
  so.

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Slide 6 Natural History and Emmetropization

• Mutti (2005) comparing hyperopia at 3m (23.5)
  with 9m (5.4) suggested emmetropization in 1st
  12 m.
• Ingram (1979) followed patients at 12m and
  compare the rates of hyperopia at 3.5y and found
  little change (10.8 vs. 11.8)
• So this process mostly occurs in the first year
  of life.

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Slide 7 Natural History and Emmetropization

• Other studies have shown that there is a split in
  eyes that emmetropize with those eyes with lesser
  degrees of hyperopia emmetropizing normally.
• Mutti (2005) showed a split a 4D - patients above
  this level failed to emmetropize
• Confirmed in smaller studies by Pennie (2001) and
  Dobson Sebris (1989).

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Slide 8 Natural History and Emmetropization

• Wood et al (1995) showed that even though the
  trend is towards emmetropia there is a large
  amount of scatter.
• Some children who are hyperopic can become worse
• The scatter is so marked that that you are unable
  to predict how hyperopic individuals will end up

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Slide 09 Risk Indicator for Hyperopia and Ethnic
Variation

• A Twin study by Hammond et al (2001) demonstrated
  a high concordance of hyperopia in monozygotic
  twins compared to dizygotic twins.
• In a population of 34 newborns to parents/
  siblings with accommodative ET, hyperopia of 4D
  was found in 38 of infants at 6m.

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Slide 10 Risk Indicator for Hyperopia and Ethnic
Variation

• There is no ethnic based data on infants. The
  Refractive error studies in children compared
  refractive error in children as young as 5
• Chile 2D hyperopia in 24.5 of right eyes (myopia
  3.4)
• Nepal 2D hyperopia in 1.9 of right eyes (myopia
  0.4)
• Separate study Finnish 2D hyperopia 12.5

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Slide 11 Risk Indicator for Hyperopia and Ethnic
Variation

• Robaei et al. Recent Australian paper gave
  prevalence of 4.6 in whites and 2.4 in non
  whites
• Cleere (refractive error and ethnicity in
  children) demonstrated racial differences in
  rates of hyperopia (1.25D) in children from 5 to
  17 years of age. Whites 19.3, Hispanics 12.7
  Asians and blacks 7.

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Slide 12 Risk Indicator for accommodative ET

• Ingram et al
• 285 patients at 6m with 4D of hyperopia followed
  for 3.5 years
• 24 became esotropic
• patients at 12m with 3.5D of hyperopia
• 45 became esotropic
• Atkinson et al
• 124 patients at 6-8, with 3.5D hyperopia
• 15 became esotropic
• 1.6 of emmetropes became esotropic

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Slide 13 Risk Indicator for accommodative ET

• In a population of 34 newborns to parents/
  siblings with accommodative ET
• 6 children (18) all of which were hyperopic were
  found to have accommodative esotropia.
• Abrahamsson et al (1999) hyperopia and family
  history were more predicative of esotropia if
  found together.

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Slide 14 Risk Indicator for accommodative ET

• Persistence of hyperopia is also a factor
• Reduced binocular vision and anisometropia may
  also influence the outcome of hyperopia. (these
  factors are very difficult to separate)
• Ethnicity

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Slide 16

• Why do some patients with high hyperopia escape
  strabismus
• Von Noorden suggested subnormal stimulus ACA
  ratios

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Slide 17 Preventing accommodative ET in hyperopes

• Ingram et al (1990) 6m with hyperopia
• 152 treatment (specs) 13 ET
• 154 no treatment 18 ET
• Not significant even when corrected for poor wear
• Ingram et al (1990) 12m with hyperopia
• 144 treatment 24 ET
• 141 No treatment 26 ET

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Slide 18 Preventing accommodative ET in hyperopes

• Atkinson et al
• 68 treatment 8.8 strabismic
• 56 no treatment 23.2 strabismic
• This was not confirmed by a second study
• The value of early spectacles in early hyperopia
  is still unclear

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Slide 19

• Can dynamic retinoscopy help?
• An objective assessment of an infants
  accommodation.
• Can we pick those individuals who may develop
  accommodative ET?