CLE 162.

3 Optometric Procedures Date: 4/3/12 1st Hour

Notetaker: Kyle Reuter Page 1

Hyperopia
- Prescribing for Hyperopes is completely different from prescribing for
Myopes!!
o Hyperopes may have a visual fluctuation secondary to
accommodation
o Myopes have constant symptoms – normally constant blur at
distance
 Hyperopes symptoms can fluctuate
 i.e. Symptoms come and go, intermittent blur at
distance after reading up close, worse at near vs.
distance, worse at the end of the day etc.
- The reason that hyperopes are more difficult to prescribe for is because
of their accommodative system
o Accommodation may provide clear vision at distance AND near
 If refractive error is low/moderate and accommodative
amplitude/reserve is adequate
- Entering VA’s cannot be correlated to the amount of uncorrected
refractive error – like in myopia
o Amplitude of accommodation varies among patients, so they may
be able to accommodate beyond the expected refractive error
- Amplitude of accommodation – max amount of accommodation the
patient can draw upon
o Average accommodative amplitude at any age = 18.5 – 1/3(age)
o Minimum accommodative amplitude expected = 15 – ¼(age)
Pseudo-myopia
- Condition of hyperopia compounded by inability to quickly/easily relax
their accommodative levels
o Results in “myopic” refractive error when refracted
- Accommodating up close and there is too much plus from the
accommodative system – creates a myope
o Symptoms are consistent with mild myopia
o Refraction reveals mild myopia, but retinoscopy reveals mild
hyperopia
- Don’t want to give them the myopic Rx – want to prescribe them reading
glasses
o Relax accommodation and relieve distance vision complaints
 By not triggering accommodative system up close, we will
be able to retain their clear vision at distance
 Lose myopic complaint because their accommodative
system will be able to relax
Types of Hyperopia
- Total hyperopia
o Total hyperopia = manifest + latent hyperopia
CLE 162.3 Optometric Procedures Date: 4/3/12 1st Hour
Notetaker: Kyle Reuter Page 2

 Recall: talking about distance vision ONLY – doesn’t include

near requirements
o To identify latent hyperopia – need cycoplegic drops
o To be defined as “latent” the amount of hyperopia needs to be >
+1.00D
 Everyone has a certain degree of “tonic” hyperopia
 < +1.00D
- Manifest hyperopia
o The amount of hyperopia that can be seen during a manifest
refraction
o Manifest hyperopia = facultative + absolute
 Absolute – the amount of hyperopia that you absolutely
need to see clearly at distance
 Amount of hyperopic refractive error unable to be
compensated for by their accommodative system
o i.e. minimum amount of plus power needed
to bring the patient to 20/20
 More often seen in adults vs. children
 Ex. If you have a +1.00D absolute hyperope and a +1.00D
facultative hyperope - the absolute will need the +1.00D to
see clearly at distance, whereas the facultative hyperope
will be able to get by without the +1.00D because their
accommodative system will compensate
 It is possible for a person to be both facultative and
absolute
- Absolute Hyperopia
o Amount of absolute hyperopia will increase with age as the
amplitude of accommodation decreases
o The MINIMUM PLUS Rx that is needed to bring the patient to BCVA
 Any additional plus lenses that are accepted may not
additionally clear up the visual acuity
 With myopes, we want to prescribe the max plus that will
allow them to see clearly at distance
 The opposite is true for hyperopes
- Why to do we want to give the minimum amount of plus to hyperopes?
o Uncorrected hyperopes are naturally over-minused
 They simply use their accommodation to see clearly
o The goal with hyperopes is to reduce the amount of over-minusing
until the patient is no longer symptomatic
o If you give a hyperope more plus that is needed, they will not see
an increase in clarity
 Sometimes they may see a decrease in clarity with too
much plus power because their system prefers to
accommodate at that distance
CLE 162.3 Optometric Procedures Date: 4/3/12 1st Hour
Notetaker: Kyle Reuter Page 3

- Absolute hyperopia example:

o 37 y/o patient with asthenopia-type symptoms (headache after
near work, blur with near work, eye fatigue worse at the end of the
day)
 Entering VA’s OU sc: 20/30 D 20/50 N
 We know the patient will be hyperopic because their
complaints at near are worse than their complaints
at distance
 During refraction: +1.25D (OU) brings the patient to 20/20
 Continuing to add plus finally blurs the patient past
20/20 at +2.75 OU
o The +1.25D would be their absolute
hyperopia and the +2.75D would be their
max plus BCVA
 Any more plus than +2.75D would
worsen their vision
o The difference between the min plus to BCVA
and max plus to BCVA = facultative hyperopia
 We would only want to give the patient the +1.25D because
it is the LEAST PLUS that is needed to achieve BCVA
- Facultative Hyperopia
o Amount of hyperopic refractive error that is found in manifest
refraction
 Accommodative system has enough magnification for
compensation
o Does NOT require spectacle correction because the
accommodative system can do the work on its own
o If you are prescribing the facultative Rx for a patient, it is most
often needed for NEAR VISION ONLY
o Common complaints for hyperopes falling into “facultative”
category:
 Near blur, fatigue after near work, distance blur after near
work of “x” length, headaches after near work
 Most often seen in children
o Children have the highest level of amplitude
of accommodation – leading to the least
amount of visual complaints
- Facultative Hyperopia Example
o 23 y/o patient without visual complaints
 Entering VA’s OU sc: 20/20 D 20/20 N
 Net Ret: +2.00D OD, OS
CLE 162.3 Optometric Procedures Date: 4/3/12 1st Hour
Notetaker: Kyle Reuter Page 4

 Net Manifest: +2.00 (OU) BCVA = 20/20

 Facultative = +2.00D
 Absolute = zero
o Patient could see clearly at distance without the +2.00D
o As the patient ages, some of the facultative will transition to
absolute because their accommodative reserve will decrease with
age
- Latent Hyperopia
o “Hidden” hyperopia
o Only way to uncover it is to use a cycloplegic agent
 Review table in slides to review the effects/timing duration
of varying cycloplegic agents
o More commonly seen in children with high amounts of hyperopia
o Not present in every hyperope!
o Cycloplegic retinoscopy or refraction = “wet”
 Mild cycloplegic (tropicamide) ret/ref = “damp”
- Prescribing for Hyperopes: Adults
o Rx absolute hyperopia for distance only OR Rx absolute hyperopia
for distance with portion of facultative hyperopia power as ADD if
distance and near complaints
 Can’t accept the total hyperopia at distance, but can accept
it at near
- Prescribing for Hyperopes: Children
o Do not typically provide reliable visual complaints
o Rely on objective testing:
 Retinoscopy, cover test, NPC, etc.
- Special Topics: Child hyperopes and strabismus
o High amounts of uncorrected hyperopia can cause strabismus
 Specifically esotropia
o Strabismus can cause AMBLYOPIA
 Caused by the accommodative system trying to compensate
for refractive error
 Near Triad: accommodation, convergence, and miosis
o If accommodative esotropia is caught early enough, add some plus
lenses and the eye will swing out
o Isoametropic Amblyopia
 Amblyopia that develops as a result of high uncorrected
refractive error in BOTH EYES
 Can develop if each eye has greater than 5.00D of
uncorrected hyperopia
 Age 8 is considered the cut-off point for amblyopia
 If the condition is not corrected before the patient is
8 years old, they will become amblyopic
o Anisometropic amblyopia
CLE 162.3 Optometric Procedures Date: 4/3/12 1st Hour
Notetaker: Kyle Reuter Page 5

 Amblyopia that develops as a result of asymmetric

uncorrected hyperopic refractive error
 Greater than 1.00D between the 2 eyes
 Amblyopia forms in the eye with the most uncorrected
refractive error
 Accommodative system is lazy and wants to work
the least amount possible to make images clear
o If you have a patient (<7 y/o) with greater than +1.50D that does
not have reduced VA’s, asthenopia, or eso posture (tropia/phoria)
 Monitor the patient closely
 Have them come back for follow-up about every 3-4
months
o If the patient is >+1.50D WITH reduced VA’s, or asthenopia, or eso
posture…
 Prescribe FULL amount of hyperopia uncovered for FTW if
less than school age (~7 y/o)
 FTW = Full Time Wear
o If the patient is older than 7 years old:
 If decreased VA or asthenopia is present – treat them as
adults
 SRx minimum amount of plus to relieve symptoms
 May only need to wear spectacles for NVO
o NVO = Near Vision Only
 If eso posture exists:
 Push as much plus power as you can to relieve the
posture
 Options: bifocals, donder’s rule, or cyclotherapy
- Donder’s Rule
o Correction = Manifest + ¼ (latent component)
 Applicable for hyperopic esotropes too IF the amount of
refractive error prescribed is ENOUGH to correct
strabismic posture
o If the patient can’t accept the mad plus Rx, bifocal specs, or
Donder’s rule correction – Consider cyclotherapy to help relax the
accommodative system and push plus
 Not appropriate for hyperopic adults
- NEVER FORGET!!
o Let symptoms guide the spectacle Rx
o Treat accommodative esotropia aggressively with plus power
o Don’t be afraid to prescribe cyclotherapy and full plus Rx for child
patients with amblyogenic factors