HYPERMETROPIA

What is Hypermetropia?
• Also known as hyperopia or long
sightedness.
• Parallel rays of light coming from infinity are
focused behind the retina with
accommodation being at rest.
• There for posterior focal point is behind the
retina which receives a blurred image.
 ETIOLOGICAL CLASSIFICATION

►Axial hypermetropia
►Curvatural hypermetropia
►Index hypermetropia
►Positional hypermetropia
►Absence of crystalline lens
• 1. Axial HM:
• short length of the eyeball
• Ex. About 1mm of shortening of anteroposterior diameter of
eye results in 3 Diopter of hypermetropia.
• May be pathological / developmental.
2. Curvatural HM:
• Curvature of cornea and lens or both is flatter than normal.
• Results in decreased in the refractive power of eye.
• Ex. 1 mm increase in radius of curvature results in 6
dioptre of Hypermetropia.
• May be developmental /Rarely pathological
3. Index HM:
• Decrease in refractive index of the lens in old age
• Due to Cortical Sclerosis.
• May also occurs in Diabetics under treatment.

4. Positional HM:
• Posteriorly placed Crystalline lens.

5. Absence of Crystalline Lens:

• Congenitally / Acquired leads to aphakia ( a condition of High
Hypermetropia)
CLINICAL TYPES
 Age & HM :
• At birth, eyeball is relatively short, having +2 to +3 hypermetropia
• Which gradually reduced until by the age of 5-7 years, then the eye
is emmetropic and remain till the age of about 50 yrs.
• After this there is a tendency to develop hypermetropia again which
gradually increases until the extreme of life by which the eye has
same +2 to +3 with which it started. This senile hypermetropia is
due to changes in the crystalline lens.
 CLINICAL PICTURES
• Symptoms:
It vary depending upon the age of patients and the degree of refractive
error.
1. Asymptomatic: No symptoms, usually <1 D, corrected with mild
accommodation
2. Asthenopic : Usually about 1-2 D refractive error is fully corrected
by accommodative effort, thus vision is normal
– Sustained accommodation produces asthenopic symptoms like:
• Tiredness of eyes
• Frontal / Frontotemporal headache
• Watering
• Mild photophobia
3.Defective vision with asthenopic symptoms:
• HM of about +2 to+4 D
• Not fully corrected by accommodation
• Thus, patient complains of defective vision more for near than
distance associated with asthenopic symptoms

4. Defective vision only:

• When the amount of HM is more than +4D, the patient do not
accommodate and there occurs marked defective vision for near
and distance.
 Effect of aging on vision:
• Patient with low hypermetropia have good vision in young
age.
• However, with the aging, due to decrease in
accommodative power, the HM becomes manifest and
patients complain of progressive decrease in vision.
• To begin with blurring occurs for near vision and then for
distance vision also
Signs:
• VA: Defective, varies with the degree of HM
• Eye ball : Small/ Normal size
• Cornea : Smaller
May be cornea Plana
• AC: shallower
• Lens : could be dislocated Backwards
• Retinoscopy & Autorefractometry reveals hypermetropia
• Fundus examination:
✓ Optic Disc: Small may look more vascular with ill- defined
margins
✓ May simulate papillitis(though there is no swelling of the disc,
and so it is called pseudo papillitis)
✓ Retina as a whole may shine (shot silk appearance)
• A- scan ultrasonography:
short anterior-posterior diameter in axial HM.
 GRADING

• Low HM : when error is <= 2D

• Moderate HM: when error is +2 to +5D.
• High HM: when error is >= +5D.
 COMPLICATIONS

• Recurrent styes, blepharitis or chalazion may occur.

• Accommodative convergent squint
• Amblyopia
• Predistortion to develop primary narrow angel glaucoma.
 TREATMENT
• Optical Treatment –
Appropriate convex lenses
➢ Method of prescription of convex lenses:
1. Spectacles:
Most comfortable, safe and easy
1. Contact lenses :
Indicated in unilateral HM
cosmetic reason
only prescribed when the prescription has stabilised
• Surgical Treatment :
• Thermal laser keratoplasty(TLK)
• Photorefractive keratectomy(PRK)
• Conductive keratoplasty(CK)
• LASIK
• IOL Implantation
MYOPIA
 EMMETROPIA
• When parallel rays of light coming from infinity are focused in
sensitive layer of retina with accommodation being at rest.
 AMETROPIA
• Condition of refractive error
• It is a problem with focusing light accurately on the retina
• Parralel rays of light coming from infinity are focused either infront
or behind retina

• Classified into:
▪ Myopia
▪ Hypermetropia
▪ astigmatism
 MYOPIA
• Short sightedness
• Parralel rays of light coming from infinity are focused infront of
the retina
 ETIOLOGICAL CLASSIFICATION

• Axial myopia
• Curvatural myopia
• Positional Myopia
• Index Myopia
• Myopia due to excessive accommodation
 CLINICAL TYPES
• Congenital Myopia
• Simple or Developmental Myopia
• Pathological or Degenerative Myopia
• Acquired Myopia: post traumatic
post keratitic
drug induced
pseudomyopia
space myopia
night myopia
consecutive myopia
 GRADING
• By AOA
❑Mild - < -3D
❑Moderate -3D to -6D
❑High - >-6D
 CONGENITAL MYOPIA

• Frequently seen in:

❑Premature babies
❑Increase in axial length
❑Increase in overall globe size
❑Since birth, diagnosed at age 2-3 year
❑Mostly unilateral
❑Usually 8-10 D, remains constant
❑May develop squint
 Cont.
• May associated with:
❑Catract
❑Micropthalmus
❑Aniridia
❑Megalocornea
❑Congenital separation of retina

➢ Early correction is desirable

 SIMPLE MYOPIA
• Commonest variety
• Physiological error not associated with any disease of the eye
• School myopia

• Etiology:
▪ Normal biological variation in development of eye
▪ inheritance
• Associated Factors:
▪ Axial type
▪ Curvatural type
▪ Role of diet
▪ Role of genetics
▪ Theory of excessive near work
 CLINICAL PICTURES

• Symptoms:

▪ Poor vision for distance

▪ Asthenopic symptoms develop due to dissociation between
accommodation and convergence
▪ Half shuting of the eye
• Signs:
▪ Large and prominent eyeball
▪ Deep AC
▪ Large, sluggishly reacting pupil
▪ Normal fundus, rarely crescent
▪ Usually occur between 5-10 year age and keep increasing till
18-20 year
▪ Usually dose not exceeds 6-8 D

➢ Diagnosis is confirmed by Retinoscopy

 PATHOLOGICAL MYOPIA
• Rapidly progressive error associated with degenerative changes in eye

• Etiology:
❑ Rapid axial growth of the eyeball outside the normal biological
variations of development
❑ Role of heridetry- familial
more common in female

❑ Role of general growth process: nutritional deficiency

debilitating disorders
 ETIOLOGICAL HYPOTHESIS

Genetic factors General growth process

More growth of retina

Streching of sclera

Increased axial length

Degenration of choroid

Degeneration of retina

Degeneration of vitreous
 CLINICAL PICTURE
• Symptoms:
❑ Defective vision
❑ Muscae volitantes/floating black opacities
❑ Night blindness

➢Signs:
❑ Prominent eyeball
❑ Cornea large
❑ Deep AC
❑ Pupil slightly large and react sluggishly
 Cont…
• Fundus examination:
A. Optic Disc:
▪ Large and pale
▪ Myopic crescent on the temporal side of disc
▪ Sometimes peripapilary crescent
▪ Super traction crescent on nasal side

B. Macula:
▪ White atrophic patches at the macula
▪ Foster Fuch’s spot
▪ Cystoid degeneration at periphery
C. Posterior Staphyloma(sclera thining)
D. Degenerative changes in vitreous:
▪ Vitreous liquification
▪ Vitreous degeneration
▪ PVD

E. Visual fields contraction

F. ERG reveals subnormal electroretinogram due to choreoretinal atrophy
 COMPLICATIONS

• Retinal detachment
• Complicated cataract
• Vitreous haemmorhage
• Choroidal haemmorhage
 TREATMENT
• Optical Treatment –
❑ appropriate concave lenses

• Surgical Treatment –
❑ epikeratophakia, RK, PRK, Phakik IOL’S ,LASIK

• General measures -
❑ Balanced diet
❑ Early management of associated debilating disease
 Cont…..
• Visual Hygiene
❑ To avoid asthenopic symptoms
❑ Adequate illumination during close work
❑ Clarity of print should begood to avoid undue ocular fatigue

• Low vision Aids

❑ Indicated in patient of progressive myopia with advanced degenerative
changes

❑ Prophylaxis
❑ Genetic counciling for people having pathological myopia