Syed Barkat Islam

A.P. DOVS
DEFINITION (Long Sightedness)
 derived from hyper meaning “In excess”
met meaning “measure” & opia meaning
“of the eye”.
 It is the refractive state of eye where in
parallel rays of light coming from infinity
are focused behind the retina with
accommodation being at rest
 The posterior focal point is behind the retina
which receives a blurred image
Classification
 Borish listed a number of systems for
classifying hyperopia:
 • Anatomical features
 • Degree of hyperopia
 • Physiological and pathological
hyperopias
 • Action of accommodation
 Axial, in which the axial length is too short for the
refractive power of the eye.
 • Refractive, in which the refractive system is
underpowered with respect to the axial length of the eye.
 • Index hyperopia, in which one or more of the
refractive indices of the media are anomalous.
 • Curvature hyperopia, in which the increased radius
of curvature of one or more refractive surfaces produces
a decrease in refractive power.
 • Anterior chamber hyperopia, in which decreased
anterior chamber depth decreases the refractive power of
the eye.
 Classification by Degree of
Hyperopia
 Hyperopia may be classified as:
 Low : 0 - +3.0 DS
 Moderate : +3.12 - +5.0 DS
 High : >+5.0D S
 However, this method of classification
provides little information unless
accompanied by knowledge of the patient's
accommodative ability
 Classification by the Action of
Accommodation
 Because hyperopia results from a relatively
underpowered eye with respect to its axial length,
an increase in accommodation may serve to
compensate, at least partially, for this refractive
error.
 For example, if a young, healthy patient with +2.0
of hyperopia wishes to view a distant object of
regard, accommodating, that is, increasing the
refractive power of the lens by+2.00 D, will allow
the distant object to be imaged upon the retina
 Latent hyperopia-Hyperopia that is
masked by accommodation and is not
revealed by noncycloplegic refraction. A
cycloplegic agent is necessary to uncover
the full amount.
 Manifest hyperopia-Hyperopia indicated
by the maximum plus lens that provides the
optimum distance visual acuity.
 Total hyperopia-The sum of latent and
manifest hyperopia. Total hyperopia may
be further divided into facultative and
absolute hyperopia
 Facultative hyperopia-Hyperopia that is
masked by accommodation but can be
revealed by noncycloplegic refraction.
 • Absolute hyperopia-Hyperopia that cannot
be compensated for by accommodation, that
is, the portion of the refractive error that
exceeds the amplitude of accommodation. For
example, a +8.00 hyperope with an amplitude
of accommodation of 5.00 0 has 3.00 0 of
absolute hyperopia
ETIOLOGY
1) AXIAL
 Most common
 Total refractive power of eye is normal
 Axial shortening of eyeball
 1mm short- 3 D of HM
 Physiologically more than 6D HM are
uncommon
 At birth +2.5 – 3 D of HM (physiologically)
 Pathologically seen in cases like orbital
tumour, inflammatory mass , oedema,
coloboma and microphthalmos.
2) CURVATURAL
 Flattening of cornea, lens or both
 1mm increase in Radius of curvature-
RESULTS IN 6D of HM
 Never exceed 6D HM physiologically
 Congenitally flattened (cornea plana)
 Result (trauma and disease )

3) INDEX
 Change in refractive index with age
 Physiologically in old age
 Pathologically in diabetics under treatment
4)POSITIONAL
 Posteriorly placed crystalline lens
 Occurs as congenital anomaly
 Result of trauma or disease

5)ABSENCE OF LENS
 Seen in aphakia
CLINICAL TYPES

 SIMPLE HYPERMETROPIA,
 PATHOLOGICAL
 FUNCTIONAL HYPEROPIA
SIMPLE HYPERMETROPIA
 Commonest form
 Results from normal biological variations
in the development of eyeball
 Include axial and curvatural HM
 May be hereditary
PATHOLOGICAL HYPERMETROPIA
 Anomalies lie outside the limits of biological
variation
 Acquired hypermetropia
Decrease curvature of outer lens fibers in old age
 Cortical sclerosis

 Positional hypermetropia
 Aphakia
 Consecutive hypermetropia
FUNCTIONAL HYPERMETROPIA
 Results from paralysis of
accommodation

 Seen in patients with 3rd nerve paralysis

& internal ophthalmoplegia
OPTICAL CONDITION
 Parallel rays focus behind retina
 Diffusion circles produce blurred &
indistinct images
 Retina is nearer to nodal point
 Image is smaller than in emmetropic
 Rays diverge from retina
 Formation of clear image is possible only
when converging power of eye is increased
NOMENCLATURE

TOTAL HYPERMETROPIA=
LATENT + MANIFEST
(Facultative + Absolute)
TOTAL HYPERMETROPIA
 It is the total amount of refractive error,
estimated after complete cycloplegia
with atropine

 Divided into latent & manifest

LATENT HYPERMETROPIA
 Corrected by inherent tone of ciliary muscle
 Usually about 1D
 High in children
 Decreases with age
 Revealed after abolishing tone of ciliary
muscle with atropine
 MANIFEST HYPERMETROPIA
 Remaining part of total hypermetropia
 Correct by accommodation and convex lens
 Measure by add strongest lens with max. vision
 Consists of facultative & absolute
FACULTATIVE HYPERMETROPIA
 Corrected by patients accommodative effort
ABSOLUTE HYPERMETROPIA
 Residual part not corrected by patients
accommodative effort
Absolute hypermetropia can be measured by the
weakest convex lens with maximum visual acuity
MANIFEST HYPERMETROPIA
CONT…
 Manifest HM – absolute HM = Facultative HM
(Strongest lens) – (weakest lens)
 Total HM – Manifest HM = Latent HM
 SYMPTOMS
 Principal symptom is blurring of vision for close
work
 Symptoms vary depending upon age of patient
& degree of refractive error
ASYMPTOMATIC
 small error produces no symptoms
 Corrected by accommodation of patient
ASTHENOPIA
 Refractive error are fully corrected by
accommodative effort
 Thus vision is normal
 Sustained accommodation produces
symptoms
 Asthenopia increases as day progresses
 Increased after prolonged near work
SYMPTOMS
Tiredness
Frontal or fronto temporal headache
Watering
Mild photophobia
DEFECTIVE VISION WITH ASTHENOPIA

 Not corrected by accommodation

 Defective vision for near more than
distance
 Asthenopia due to sustained
accommodation
 Refractive error more(>4D)
DEFECTIVE VISION ONLY
 Refractive vision more than 4D
 Adults usually do not accommodate
 Marked defective vision for near and
distance
SIGNS
 VISUAL ACUITY : Defective
 EYEBALL: small or normal in size
 CORNEA : may be smaller than normal.
There can be CORNEA PLANA
 ANTERIOR CHAMBER : may be
shallow
 LENS: could be dislocated backwards
 A Scan ultrasonography (biometry)
reveal short axial length
FUNDUS:
A) DISC: Dark reddish color, irregular
margins ,confused with Papillitis so
termed as PSEUDO-PAPILLITIS
B) MACULA: Situated further from the disc
than usual
C) BLOOD VESSELS: Show undue twists &
abnormal branchings
TREATMENT

BASIS FOR TREATMENT

 No Treatment
 Error is small
 Asymptomatic
 Visual acuity normal
 No muscular imbalance
COMPLICATION
 Recurrent styes ,blepharitis or chalazia
 Accommodative convergent squint
 Amblyopia
Anisometropic
Strabismic
Uncorrective bilateral high hypermetropia
 Predisposition to develop primary narrow
angle glaucomas
Care should be taken while instilling
mydriatics
Young children(<6 or 7yrs)
 Some degree of hypermetropia is physiological so
no correction
 Treatment required if error is high or strabismus is
present
 working in school small error may require
correction
 In children error tends normally to diminish with
growth so refraction should be carried out every
six month and if necessary the correction should
be reduced, ortherwise a lens which is
overcorrecting their error may induce an artificial
myopia
 No deduction of tonus allowance in strabismus
 ADULTS
 If symptoms of eye-strain are marked,we
correct as much of the total hypermetropia
as possible,trying as far as we can to relieve
the accommodation
 When there is spasm of accommodation we
correct the whole of the error
 Some patients with hypermetropia do not
initially tolerate the full correction indicated
by manifest refraction so we undercorrect
them
 Exophoria hyperopia should be under
correct by 1 to 2D
 Patients with absolute hypermetropia
are more likely to accept nearly the full
correction because they typically
experience immediate improvement in
visual acuity
 In pathological hypermetropia the
underlying cause rather than the
hypermetropia is chief concern
MODE OF TREATMENT
 SPECTACLES
OPTICAL TREATMENT
 CONTACT LENS

 SURGICAL
SPECTACLES
Basic principle
Prescribe convex lenses(Plus lenses)
so that rays are brought to focus on the
retina
Advantages
 Comfortable
 Easier method
 Less expensive
 Safe idea
CONTACT LENS
ADVANTAGES
Cosmetically good

Increased field of view

Less magnification

Elimination of aberrations & prismatic

effect
PHOTOREFRACTIVE
KERATECTOMY(PRK)
 Direct laser ablation of corneal stroma
after removal of corneal epithelium
mechanically
 Done using EXCIMER LASER
LASER IN SITU
KERATOMILEUSIS(LASIK)
 Anterior flap of cornea lifted with
keratome and excimer laser is used to
sculpt the stromal bed to change the
refractive error of eye

 It can correct up to 4D of hypermetropia

and 8D of astigmatism