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• The term hypermetropia is derived from
hyper meaning “In excess” met meaning
“measure” & opia meaning “of the eye”.
• Also called hyperopia / longsightedness
• First suggested in 1755 by KASTNER
DEFINITION
• It is the refractive state of eye where in
parallel rays of light coming from infinity
are focused behind the sentient layer of
retina with accommodation being at rest
• The posterior focal point is behind the
retina which receives a blurred image
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 curvatureRESULTS 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 which maximum visual
acuity
MANIFEST HYPERMETROPIA
CONT…
• Manifest HM – absolute HM = Facultative HM
(Strongest lens) – (weakest lens)
• Total HM – Manifest HM = Latent HM
NORMAL AGE VARIATION
 At birth +2+3D HM
• Slightly increase in one year of life,
• Gradually diminished untill by the age 5-10
years
 In old age after 50 year again tendency to HM





Ton of ciliary muscle decreases
Accommodative power decreases
Some amount of latent HM become manifest
More amount of facultative HM become absolute
Practically after 65 year all of it become absolute
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, large positive angle alpha,
apparent divergent squint
C) BLOOD VESSELS: Show undue
tortuosity & abnormal branchings
D) BACKGROUND: SHOT- SILK RETINA
COMPLICATION
• Recurrent styes m blepharitis or chalazia
• Accommodative convergent squint
• Amblyopia
– Anisometropic
– Stravismic
– Uncorrective bilateral high hypermetropia
• Predisposition to develop primary narrow
angle glaucomas
Care should be taken while instilling
mydriatics
TREATMENT
BASIS FOR TREATMENT
• No Treatment
Error is small
Asymptomatic
Visual acuity normal
No muscular imbalance
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
REFRACTIVE SURGERY
• Refractive surgery is not as effective as in
myopia
TYPES:
(1)HEXAGONAL KERATOTOMY(HK)
• Low to moderate degrees of hypermetropia
• Its risk /benefit ratio is not low enough to warrant
its continued use
LASER THERMAL
KERATOPLASTY(LTK)
• Procedure done using laser energy to heat
the cornea (contraction of collagen) and
increase its curvature
• Central heating of cornea results in central
corneal flattening thereby resulting in
hyperopic shift
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
PHAKIC IOL AND CLEAR LENS
EXTRACTION
• Done by Phaco technique
• Clear lens extraction with the implantation of an
IOL-----Preferably foldable IOL or a Piggyback
IOL is implanted
VISUAL HYGIENE
• While reading or doing intensive near work take
a break about every 30 min
• When reading maintain proper distance that is
the book should be at least as far from your eyes
as your elbow when you make a fist and hold it
against your nose
• Sufficient Illumination
• Place a limit spent watching television &
watching videogames
• Sit 5-6 feet away from the television
• Appropriate optical correction almost
always leads to clear and comfortable
single binocular vision
• Younger children who have significant
hyperopia associated with amblyopia,
strabismus,or
anisometropia
require
treatment, starting as early as 3-6 months
of age
CONCLUSION
• Hyperopia is a common refractive disorder that
has been overshadowed by myopia in public
perception,vision research & the scientific
literature
• Although uncorrected myopia has a greater
adverse effect on visual acuity than uncorrected
hyperopia,the close association between
hyperopia,amblyopia & strabismus,especially in
children,makes hyperopia a greater risk factor
for more permanent vision loss than myopia
• The early diagnosis & treatment of
significant hyperopia & its consequences
can prevent a significant amount of visual
disability in the general population
For Further Queries Contact :
Ms. Priyanka Singh
Head – Optometry Service
Email – [email protected]