Hyperopia

Authors
Soumyadeep Majumdar; Koushik Tripathy.

Last Update: August 16, 2020.

Introduction
The most common refractive error in childhood is hyperopia.[1] The term hyperopia refers to
the refractive condition of the eye where parallel light rays coming from the infinity are
focussed behind the neurosensory retina (after refraction through the ocular media ) when
accommodation is at rest. The spontaneous accommodative effort of the human eye, by
increasing the anterior curvature and converging power of the crystalline lens, usually tries to
overcome this situation. So, accommodative rest is mandatory to elicit total hyperopia,
specifically in young individuals.[2] 
By birth, human beings are predominantly hyperopic, and as the age progresses, hyperopic
eyeballs grow to become emmetropic or even myopic.[3][4] Positive family history plays a
crucial role in the development of hyperopia in the next generations.[5] If left untreated after
diagnosis, sequelae such as amblyopia and tropia may develop.[6][7][6] 

Etiology
Conventionally the hyperopia is etiologically classified into:
Axial hyperopia (most common - simple hyperopia): It is due to anterior-posterior axial
shortening of the eyeball. Genetic predisposition plays an important role. Retinal edema can
cause a hyperopic shift. 1 mm decrease in axial length leads to 3 diopters of hyperopia.[8]
Curvature hyperopia: It is due to flattening of the cornea or the lens or both. A radius of
curvature increase in 1 mm leads to 6 diopters of hyperopia.
Index hyperopia: It is due to the change in the refractive index of the crystalline lens, which
occurs in old age or diabetics. The refractory index gradually increases from the center to the
periphery.
Positional hyperopia or absence of the lens (aphakia) or ocular pathologic conditions:
This condition occurs due to malposition or absence of the crystalline lens (congenital or
acquired) or intraocular lens owing to the creation of an aphakic zone in refractive media.
Post-traumatic or post-surgical aphakia is not an uncommon cause of hyperopia.
Few ocular pathologies, e.g., nanophthalmos, microphthalmos, aniridia, may cause
hyperopia. 
No unanimous causative factor is identified to date. Though sporadic, few genetic factors
have been identified in association with hyperopia. Apart from genetic and environmental
factors, few acquired conditions are also responsible, specifically in aged persons.[9] The
following are a few identified conditions leading to hyperopia:
 16p11.2 microdeletion[10]
 Myelin regulatory factor gene (MYRF) mutation[11]
  Family history of squint, and a history of maternal smoking during pregnancy[12]
 Cortical cataract (index hyperopia) 
 Aphakia (congenital or acquired)[13] 
 Hyperglycemia[14] 
 Diabetes mellitus and after prompt control of hyperglycemia in diabetes mellitus[15]
[16]
 Prolonged space mission due to retina and optic nerve head edema[17]
 Peripapillary pachychoroid syndrome (PPS)[18] 
 Heimler syndrome[19]
 Kenny syndrome[20]
 Accommodation loss due to complete CN III nerve palsy or internal ophthalmoplegia
or paralysis by cycloplegic drops, lorazepam (functional hyperopia)[21][22][21]
 After silicone oil injection in phakic and pseudophakic eyes. In aphakic eyes, the
amount of hyperopia reduces, but the eye remains hyperopic
 Loeys-Dietz syndrome, Larsen syndrome.[23]
 Leber congenital amaurosis
 X-linked retinoschisis and senile retinoschisis

Epidemiology
Axial hyperopia, being the commonest, is usually present from birth.[3] The prevalence of
moderate hyperopia, i.e., ≥ +2 diopter at 6 and 12 years of age, is 13.2% and 5.0%,
respectively, and it is more in White race individuals than in other ethnic groups.[24] The
prevalence of hyperopia ≥+4 diopter was 3.2% in the worse eye, with both eyes involved in
64.4% of cases in a study.[12] For United States participants, non-Hispanic, and Hispanic
White races have a significantly higher risk of hyperopia in 6 to 72 months of age group.[12] 
In 15 years or less age group, and ≥30 years age group, hyperopia prevalence was higher in
females.[25] A systematic review of refractive error revealed that the prevalence of hyperopia
is 4% (less than myopia) in the population with more prevalence in school going boys than
girls.[26] In the United States, for the ≥20 years age group, hyperopia is the least common
refractive error while it was the most common refractive error with astigmatism in the ≥60
years age group.[27] In Polish immigrants in Chicago, a study found that hyperopia is a more
common refractive error overall and in the >45 years age group.[28] 
In the 6 to 15 years age group in Cameroon, hyperopia is the most common refractive error.
[29] Hyperopia is unrelated to posterior subcapsular cataracts but is related to incident
nuclear and cortical cataract.[30] The intelligence quotient score in hyperopic patients was
lower than that of myopic in a study conducted in the United Kingdom.[31] A higher
prevalence of hyperopia is seen in people living in rural areas compared to urban areas.
[32] Hyperopia is more prevalent in families with a history of accommodative esotropia and
hyperopia, and 20% of the hyperopic individuals in infancy develop strabismus.[5] 
Pathophysiology
The axial shortening of the eyeball or decreased converging potential of the cornea or
crystalline lens due to flattening are common responsible factors for simple hyperopia.
Congenital or acquired absence of the crystalline lens resulting in loss of converging capacity
leads to the pathological hyperopia. Senile changes in cortical lens fibers lead to change in
the refractive index causing index hyperopia. Paralysis of accommodation (by cycloplegic
drugs) and loss of accommodation due to complete third nerve palsy or internal
ophthalmoplegia cause functional hyperopia.[22][21]
Accommodation is a dynamic factor in controlling the state of refraction, specifically in
hyperopia. Depending on the accommodation, manifest hyperopia may subdivide into:
 Absolute hyperopia, which can not be overcome by accommodative effort
o When a patient can not see 20/20 without glasses, absolute hyperopia is
denoted by the weakest plus lens with which the patient can see 20/20.
 Facultative hyperopia which can be overcome by accommodation
The manifest hyperopia is the sum of absolute and facultative hyperopia. Clinically, it is
measured by the strongest plus (or convex) lens with which the patient can still maintain the
maximum vision (20/20).
Latent hyperopia is due to the inherent ciliary muscle tone. Usually, the magnitude of latent
hyperopia is 1D, but it is higher at an early age and gradually decreases as age progresses.
Cycloplegic agents like atropine unmask this condition. This latent hyperopia causes
asthenopic symptoms without dimness of distant vision. Cycloplegia is a must to elicit the
amount of latent hyperopia in children.    
 Total hyperopia = Latent hyperopia + manifest hyperopia
 Manifest hyperopia = Absolute hyperopia + facultative hyperopia

History and Physical

Depending on the age of presentation and the degree of hyperopia, clinical presentation varies
from no symptom to a wide range of complaints. Age is an important factor not only due to
the ability to express but also the accommodative effort of the patient.
Asymptomatic: The patient's inherent ciliary muscle tone and accommodative effort can
overcome some degree of hyperopia without creating any difficulty.
Symptomatic:
Deviation of eyes (noted by the parents)[33][34]: Parents sometimes note deviation of
either or both eyes (simultaneous or alternative) in very young children with hyperopia. The
commonest type is an inward deviation (esotropia).  
Asthenopia: With total accommodative effort, the patient's hyperopia is corrected here. In
these cases, asthenopia (i.e., varied amount of tiredness of eyes with localized
frontal/frontotemporal headache) is a very common symptom due to prolonged
accommodative effort. Sometimes it may be associated with photophobia and watering.
Usually, asthenopia increases after near activity of long-duration.
Dimness of vision: There will be dimness of vision if existing hyperopia is not
corrected with total accommodative effort. In hyperopia, infinity focuses beyond the
neurosensory retina. So, nearer objects focus behind the retina. Characteristically the
defective vision affects near vision more than distant vision. Thus, the objects appear more
blurred as they come closer. This dimness may (small amount of hyperopia) or may not (a
large amount of hyperopia or after 40 years of age when accommodation is lost) be
associated with asthenopia. A significant difference in uncorrected hyperopia may predispose
the worse eye to develop amblyopia. Uncorrected hyperopia of both the eyes may develop
ametropic amblyopia bilaterally.   
Sudden blurring of vision (intermittent)[35]: Due to prolonged accommodative effort (e.g.,
during reading), there may be an episode of accommodative spasm leading to a sudden
blurring of vision, often termed as pseudomyopia. It is commonly found in teenagers with
uncorrected hyperopia. 
Recurrent Internal/External Hordeolum or Conjunctivitis: The exact mechanism of the
recurrent eyelid or conjunctival inflammation is unrevealed. The proposed theory is the
frequent rubbing of the eyes with unhygienic hands, which leads to recurrent inflammatory
episodes. Proper treatment of recurrent inflammation helps to get good best-corrected visual
acuity in the future and vice-versa.[36]    
A sensation of Crossed Eye: Prolonged sustained accommodation is sometimes felt as a
crossed eye. The patient may complain that the eyes are crossing each other (due to
convergence) without any diplopia. Ignorance towards this symptom in the pre-school age
group may lead to amblyopia in the future.[37]   
Premature Presbyopia: As the age progresses, obvious receding of the near point becomes
apparent. It occurs earlier (earlier than the 40s) in hyperope than emmetrope. The
progressive accommodation loss with age is more frustrating to the patient as the near vision
was already compromised earlier due to hyperopia.

Evaluation
A thorough clinical evaluation not only helps to diagnose hyperopia but also points out
significant related events. 
Visual Acuity: It depends on the age at presentation, degree of accommodation, and status of
the crystalline lens and posterior segment. In children, the vision may not be affected due to a
full accommodative effort to focus the image on the retina. As the status of the eye is usually
not complicated by cataract and retinal diseases in children, distant vision may be
affected with high hyperopia, which can not be corrected by the full range of accommodation.
There may be a gross reduction of vision if amblyopia develops in unilateral or bilateral high
hyperopia cases. Near vision may also be diminished in children with high hyperopia or in
aged where accommodation is partially or fully lost. An age-related hyperopic shift can make
near vision more difficult.
Diffuse light examination: Eyeball and cornea may appear smaller, especially in high
hyperopia and in unilateral cases. Sometimes it may simulate enophthalmos. Anterior
chamber (both central and peripheral) appears shallow, and the angle of the anterior chamber
may appear narrow with a small pupil. Gonioscopy is indicated in all cases to rule out
possible angle closure. Cortical cataracts may also be present in aged persons or young
individuals with diabetes.
Fundoscopy: Fundoscopy reveals a small optic disc with a very small cup. Disc margins
become blurred with overcrowding of blood vessels, sometimes termed as "pseudopapillitis"
or "pseudo-papilledema" if bilateral. Choroidal folds may be present.[38][39] An increased
reflex of retina named as "shot-silk appearance" is seen along with crowding of the nerve
fiber layer.[40]
Examination of Latent / Manifest strabismus: In children having uncorrected hyperopia
for a long duration, strabismus may be present: latent (-phoria) or manifest (-
tropia). Extraocular movement is usually full in all directions of gazes. 
Breaking the fusion by Alternate Cover-Uncover test with occluder and asking the patient to
focus at a point light source may reveal latent strabismus, mainly in children and young.
Alternate and sequential shifting of the occluder to cover either eye is done. The presence of
latent strabismus is confirmed if the covered eye deviates, which is noted during refixation
when uncovered.
In manifest strabismus, the deviated eye takes fixation after occlusion of the fellow
orthophoric eye. Manifest strabismus must be examined by Hirschberg corneal reflex test
(HCRT) and with a prism bar to note the degree of deviation. HCRT reveals the approximate
degree of deviation i.e., corneal light reflex on the pupillary border and the corneal border
corresponds to approximately 15 degrees and 45 degrees of deviation, respectively. Prisms
can also serve to keep the apex towards the deviation to bring the corneal light reflex at the
center and note that deviation in prism-diopter. 
Retinoscopy/Refraction: In the modern era of automated refraction, retinoscopy has its
importance while examining young children and bed-ridden patients. It's a good practice to
evaluate a child with suspected any refractive error with cycloplegic retinoscopy[41] from a
1-meter distance as routine. Cycloplegia abolishes ciliary muscle tone and accommodation to
reveal the actual status of refraction. With a streak retinoscope, under cycloplegia, different
powered-spherical lenses are used to reach a neutralization point (full illumination of the
fundus with no movement)  both in the horizontal and vertical axis. 
Existing refractive error (in horizontal/vertical axis) = Retinoscopic findings (in both
axis) - the value of distance in meter (1 for 1 meter, 1.5 for 2/3rd meter) - tonus
allowance for the particular cycloplegic drug (For atropine ointment 1% it is 1,
cyclopentolate drops 1% it is 0.75, and for homatropine drops 2% it is 0.5) 
If both the axis and the power (after deduction) are equal, then that is considered as the
spherical refractive power of the eye. If it is unequal, then the extra power (in one axis) is
denoted as the astigmatic power in the other axis.

Treatment / Management
Aim:
 Provide good rehabilitation with proper refractive correction
 Prevention of amblyopia
 Prevention of development of strabismus
 Prevention of recurrent eyelid infection and conjunctivitis
1. Optical correction: Biconvex lenses (plus) are recommended to converge the light rays on
the neurosensory retina. Basic principles of prescribing glasses are:
 The amount of total hyperopia should always be elicited by cycloplegic retinoscopy,
especially in children.
 Symptomatic patients and young children should always be treated with proper
refractive correction.
 Young children should be prescribed full hyperopic correction gradual tapering during
school age. 
 The maximum accepted plus power with a clear vision (20/20) should be prescribed.
 A gradual increase in hyperopic correction from the comfortably accepted power
in school-aged children may be necessary as full correction may produce blurring at
distant. A short course of cycloplegic agents may improve the acceptance of
hyperopic correction.
 Accommodative convergence should be treated with full hyperopic correction.
Developing/developed amblyopia should undergo a thorough evaluation, and full
hyperopic correction with occlusion therapy should be prescribed.
 Hyperopic children should have a reevaluation every 3 to 6 months.
American Academy of Ophthalmology (AAO) has given a guideline about when to
prescribe glasses in hyperopia in young children.[42]
Dependent factors are
 Iso-metropia (similar refractive error in both eyes)
 Anisometropia (dis-similar errors of refraction between eyes)
 Presence/absence of strabismus.
Isoametropic eyes without tropia should be prescribed glasses if the hyperopia is at least:[42]
 Age under 1-year: +6D
 Age of 1-year to less than 2 years: +5D
 Age of 2-year to less than 3 years: +4.50D
 Age of 3-year to less than 4 years: +3.50D
Cases having hyperopic iso-metropia with esotropia need to be prescribed glasses when the
minimum refraction is at least:
 Age less than 2 years: +2D
 Age of 2-year to less than 4 years: +1.50D
Hyperopic anisometropia without strabismus should be corrected if it is at least:[42]
 Age under 1-year: +2.50D
 Age of 1-year to less than 2 years: +2D
  Age of 2-year to less than 4 years: +1.50D
Glasses and contact lenses can be used as rehabilitation devices. Contact lenses are usually
prescribed in cases of unilateral hyperopia or a large difference in hyperopia between eyes.
2. Surgical treatment: Preoperative stable refraction (cycloplegic and manifest)[43] is must
at least in three successive checkups one year apart. Counseling and discussion about possible
outcomes and side effects are very important. Before any surgical intervention, every patient
should undergo 
 Slit-lamp biomicroscopy: to rule out allergic blepharoconjunctivitis and dry eye
syndromes[44]
 Refraction testing (cycloplegic and manual) both distant and near vision
 Corneal thickness and topography, wavefront analysis[45]
 Intraocular pressure
 Pupil size estimation in dark and mesopic conditions
 Fundoscopy
So, all the investigations are of utmost importance before any sort of kerato-refractive
surgery.
 Incisional refractive procedure;
o Hexagonal keratotomy: It was done in the past to treat low to moderate
degrees of hyperopia previously.[46] Now it is obsolete. 
o Lamellar refractive procedure: hyperopic keratomileusis of Barraquer: It
is of historical importance and basis of modern laser in-situ keratomileusis
(LASIK) procedure.
 Laser-based refractive procedures: 
o Thermal laser keratoplasty: Thallium-holmium-chromium (THC): yttrium
aluminum garnet (YAG) laser is used to create a contraction of the collagen
matrix of the stroma of the cornea in eight areas of the optical zone with pulse
energies of 159-199 milli-joule.[47] This makes a mechanical constriction
which steepens the cornea. This can also be done by creating 12 pairs of
coagulation spots by Diode laser, which is also a safe procedure.[48] The
diode laser is also used in associated presbyopia cases.[48] It is a good option
in cases of iatrogenic hyperopia after LASIK in myopia and photorefractive
keratectomy in myopia.[49][50] Compared to LASIK, it is slow in achieving
stable refraction with less predictability to correct astigmatism.
[51] Overcorrection may be present in the early postoperative period, but no
significant surprise is noted in long term followups.[50]
Currently, this procedure has approval for a temporary reduction of hyperopia of +0.75 to
+2.50 diopters with  ≤ +/- 0.75 diopters of astigmatism by the United States Food and Drug
Administration (USFDA). The patients should be of at least 40 years of age. The refraction
should be documented to be stable for the prior six months (change of  ≤ 0.50D in spherical
and cylindrical components of the manifest refraction).
  Hyperopic photorefractive keratectomy (PRK): It's a lengthy procedure by which a
large burn is created with an excited dimer (excimer) laser. The cornea becomes dry
and dehydrated, and epithelial healing is delayed.[52] Decentration is another
significant problem. After initial encouraging results, regression may take place. It
may be combined with phototherapeutic keratectomy(PTK) to counter hyperopic
shift.[53] It has shown initial instability but no significant change in refractive power
thereafter, with peripheral haze and Salzman-like changes without any ectatic
changes.[54] It is equally efficacious compared to LASIK for hyperopia.[55] It is a
safe procedure to correct mild to moderate degree of hyperopia.[56] It can give a
reasonably good result in the treatment of presbyopia.[57] USFDA approved excimer
(excited dimer) laser systems for this procedure.      
 Hyperopic LASIK: Patient selection depends on stable preoperative refractions,
corneal thickness, intraocular pressure, pupil size, fundoscopy, and corneal
topography. It can correct up to 6 diopters of hyperopia. The procedure is performed
under topical anesthesia, and it can also be performed with pilocarpine-induced miosis
on same day cycloplegia.[58] Before the flap elevation by microkeratome, the cornea
can be marked. This marking may have a risk of development of marker-pen induced
chemical diffuse lamellar keratitis (DLK).[59] The creation of the flap can be by
microkeratome or femtosecond laser (Femto laser). Femto laser is an infrared laser of
1053 nm wavelength. Femto laser has better predictability of flap thickness with the
advantages of fewer postoperative higher-order aberrations, better contrast sensitivity,
longer tear film breakup time.[60] Different USFDA approved machines for LASIK
in hyperopia work with an excimer laser system. Manifest refraction spherical
equivalent (MRSE) is calculated following the preoperative refraction of the patient.
A large number of them are used to correct associated astigmatism also. Most
importantly, hyperopia with myopic astigmatism is also taken care of by a few of the
systems. Different LASIK machines can correct different ranges of hyperopia. Few of
the machines are dedicated to those eyes with spherical power, less than cylindrical
power. Argon-fluoride (193 nanometers) excimer laser is used to ablate the corneal
bed after the elevation of the flap by microkeratome. Intraocular pressure is raised
artificially to maintain the hold during the elevation of the epithelial flap. After
ablation, the epithelial flap is repositioned. It is safe and also effective in all degrees
of hyperopia, especially in high hyperopia.[61] Monofocal and varifocal LASIK: both
can be safely used in presbyopia.[62] Epithelial remodeling is suspected to be
responsible for masking the extra advantages of the varifocal laser.[62] Better
predictability and lower regression are making the use of Mitomycin C 0.02% (MMC)
essential though further long term followup studies are needed.[63] Femtosecond
laser-assisted surgeries with MMC 0.02% gives better refractive outcomes and less
number of re-treatments.[64] Compared to the pupil-centered procedure, vertex-
centered gives better visual outcomes in temporally decentred pupil cases, though in
other cases, it is equivalent.[57][65] Postoperative patching or dark glass, along with
topical broadspectrum antibiotics are prescribed. 
Contraindications include chronic eye or corneal diseases, systemic illness, unstable
refraction, dry eyes, contact lens intolerance, chronic pain syndromes, pregnancy, and
lactation.[66]
Complications of LASIK include refractive regression, postoperative dry eyes, halos during
night driving, and diminished corneal sensations.[67][66] In high hyperopia cases and those
with associated astigmatism, spherical aberrations, coma, and trefoil are significantly
increased.[68] Flap striae, epithelial ingrowth especially in enhancement procedures,
infectious (Pseudomonas, Mycobacterium chelonae) keratitis, noninfectious (diffuse
lamellar) keratitis, and interface fluid are not uncommon.[69][70][71][72][59][73] DLK is
treated with intensive topical steroids with successful results.[59] Diminished corneal
sensations can have treatment with cyclosporine (0.05%) drops for 3-months.[74]     
 Hyperopic laser subepithelial keratomileusis (LASEK): Here, with the help of
20% ethyl alcohol for 60 seconds, the epithelium of the cornea is loosened and
separated. Then stromal ablation is performed by the excimer laser. Sometimes it is
augmented by 0.02% mitomycin c after corneal ablation.[75] It may be helpful in
children to correct hyperopia with or without amblyopia (off label use).[76] Though
postoperative refraction status, contrast sensitivity, topography data shows better
outcomes in lasek[77] along with complications such as aberrations, ectasia, flap
related complications are less than LASIK, but more postoperative pain, slow
recovery keep it a little bit behind from PRK and epiploic LASIK.[78]      
 Hyperopic epiploic LASIK (EPI-LASIK): It is similar to LASEK, but here
epikeratome is used to raise the epithelial flap, not alcohol. So, alcohol-related
toxicities are negated.  
 Hyperopic customized-LASIK (C-LASIK): It is either topography or wavefront-
guided ablation procedure to correct associated astigmatism and aberrations, with
wavefront-guided procedures having better contrast sensitivity and less glare.
[79] Quality of vision is improved compared to other procedures, but Snellen's visual
acuity, the refractive status remain comparable.[80] 
 Other refractive procedures:
o Conductive keratoplasty (CK): USFDA approved this for the treatment of
mild-moderate hyperopia with minimal astigmatism for a temporary basis.
After two years, it was approved for presbyopia with an endpoint of -1.00 to
-2.00 diopters for the nondominant eye. It is a radiofrequency energy-based
procedure to create shrinkage of stromal collagen. It increases the converging
power of the cornea.[81] It is an excellent surgical option for hyperopia[82]
[83] and presbyopia[84]. A keratoplasty of 90-um diameter and 450-um length
is used to produce ablation.[81] A variable number of ablations for 0.6-
seconds each in 6-mm, 7-mm, and 8-mm circular zone in the cornea is done
depending on the refractive error. It is a minimally invasive and safe
procedure but not effective in high hyperopia. Recurrent corneal erosions,
mild iritis, iris burn, endothelial cell loss[85], and rarely partial or full-
thickness corneal injury can take place. Predictable and stable refractive status
is achievable in low to moderate hyperopia.[86] 
o Small incision lenticule extraction (SMILE): It is the recent advancement in
the management of hyperopia. It was first performed in donor eyes where
concave lenticule extraction was performed, and interlamellar concave gap air
bubbles were noted.[87] It is a safe procedure for hyperopia, even in higher
degrees.[88] It is comparable to LASIK for hyperopia in effectiveness and
safety[89] with the induction of similar spherical aberration[90].
Intraoperative complications such as opaque bubble formation, suction loss are
mainly related to less experience of the surgeon. Postoperative keratitis,
ectasia, dry eye are not uncommon after SMILE.[91] 
  Intraocular Procedures: Phakic intraocular lenses[92], where a new intraocular lens
is implanted anterior to the crystalline lens, is a good option. Due to the shallowness
of intraocular spaces in hyperopia, pupillary block, oval pupil, and cataract formation
is not uncommon.[93] The refractive lens exchange is another option for a high
degree of hyperopia or where corneal procedures are contraindicated and associated
with cataract cases.[94] Intraocular surgery has its own complications e.g., corneal
decompensation, rhegmatogenous retinal detachment, hyphema, and uveitis.[95] 
 Management of angle-closure related to hyperopia: Hyperopia is one of the risk
factors of angle-closure disease.[96] Patients with symptomatic or suspected angle-
closure or patients with a positive family history should undergo tonometry,
gonioscopy, perimetry along with newer diagnostic modalities like Anterior Segment
Optical Coherence Tomography (AS-OCT), Ultrasound Biomicroscopy, and OCT
scan of optic nerve/retinal nerve fiber layer.[97] Laser peripheral iridotomy (LPI) is a
safe procedure in every stage of the angle-closure disease.[98] Cataract surgery or
clear lens extraction is also a very effective procedure and showed superiority to LPI
in a study.[98]     

Differential Diagnosis
Differential diagnosis of hyperopia includes:
 Nanophthalmos - Structurally normal, but the eye is smaller in size.[99]
 Microphthalmos - Smaller in size with structurally abnormal eye and sometimes
associated with systemic involvement.[99]
 Posterior microphthalmos: Microphthalmos involves the posterior segment only. The
dimensions of the anterior segment are normal.
 Micro-cornea, enophthalmos
 Partial ptosis simulating a small eyeball 
 Papilledema
 Retinal edema or serous or exudative elevation of the retina
 Orbital tumors causing anterior displacement of the posterior part of the eyeball
 Hypoglycemia
 Presbyopia

Pertinent Studies and Ongoing Trials

SMILE in hyperopia is a promising area to explore. Compared to LASIK, LASEK, CK, and
PRK, SMILE can be a better option for high hyperopic cases with stable postoperative
refraction. Newer technologies of wavefront analysis and correction of aberrations and
treatment of associated astigmatism will give better optical satisfaction to the patient.
Preparation and correction of aberrations in a customized manner with C-LASIK is also an
upcoming procedure to deal with aberrations. Refractive lens exchange and phakic
intraocular lenses are other options for the management of hyperopia. 
Staging
AR Augsburger, in his book, classified hyperopia into three stages or degrees, which the
convention followed to date and also by the American Optometric Association (AOA). 
 Low hyperopia i.e. +2.00 diopters (D) or less.
 Moderate hyperopia i.e.+2.25 to +5.00 D.
 High hyperopia i.e., +5.00 D.

Prognosis
Good Prognostic factors:
 The prognosis of hyperopia is good if early diagnosis and treatment are started. It is of
utmost importance in the pre-school age group. Cycloplegic refraction, followed by
post-cycloplegic refraction, is mandatory for them. In suspected amblyopia, proper
amblyopia management carries a good prognosis. If not done early, it may lead to
amblyopia and permanent visual decline.[100]
 Proper preoperative preparation and timely intervention carry a good prognosis. 
Bad prognostic factor:
 Associated other ocular abnormalities[18]  
 Surgical intervention in unstable refraction cases[66]
 Co-existing systemic syndromes[19][20]
 Family history of squint and amblyopia  

Complications
 Amblyopia: Stimulus deprivation or anisometropic amblyopia may take place if there
is no timely correction.[100] Proper refractive correction, orthoptic exercises are
needed to treat this amblyopia.   
 Squint: Convergent strabismus[101] is not very uncommon in developing children
with uncorrected hyperopia. The squinted eye becomes more stimulus deprived
gradually.
 Angle-closure disease: Hyperopia is a predisposing condition to develop angle-
closure disease.[96]
 Anterior ischaemic optic neuropathy (AION): Hyperopia is a risk factor of the
development of AION (non-arteritic).[102]
 Retinal vein occlusion: Though few studies denied its association with hyperopia,
branch retinal vein occlusion might be more likely to be associated with hyperopia
than central vein occlusion.[103] 
 Age-related macular degeneration (ARMD): ARMD may be associated with
hyperopia.
  Central serous chorioretinopathy (CSCR): Hyperopic eyes may be more prone to
develop CSCR.[104] 
 Uveal effusion syndrome: Posterior microphthalmos with hyperopia predisposes the
eye to develop uveal effusion.[105]
 Nanophthalmos/posterior microphthalmos: Serous retinal detachment, pre-retinal
folds with macular cysts, macular folds, and thickening of the fovea and retinal
pigment epithelium are common retinal features of nanophthalmos or posterior
microphthalmos.[106]

Postoperative and Rehabilitation Care

Rehabilitation in the form of glasses or contact lenses is the most effective and cost-effective
care for hyperopia. Constant use of glasses, along with amblyopia therapy
(occlusion/orthoptic exercises), is the mainstay of management of developing refractive
amblyopia. It can also prevent strabismus development.
Keratorefractive surgeries are one of the most important solutions for hyperopia. After laser
or radiofrequency ablation based surgical procedures, 
 Dark glasses (LASIK) or eye patching (CK) are given.
 Topical broad-spectrum antibiotics for 5 to 7 days or more if needed, along with
artificial tear substitutes[107].
 Immediate postoperative rubbing to be avoided.
 Topical cyclosporine A after surgery can treat dry eyes.[108]
 Follow up at regular intervals to evaluate refraction, flap condition, and diagnose
complications.  

Consultations
A very good optometrist/ophthalmic assistant should be on the team for proper refractive
rehabilitation and amblyopia therapy. For the assessment and treatment of associated anterior
chamber and posterior segment complications, specialists should be consulted.  

Deterrence and Patient Education

Patient and parental health education is most important to prevent complications.[109]
 Maternal smoking during pregnancy positively correlates with hyperopia in the child.
[12]
 Parental education and counseling are very important, not only to early diagnosis and
treatment of hyperopia but also to prevent strabismus and amblyopia development.
 Proper use of glasses, along with patching and exercises for amblyopia treatment,
requires the active involvement of the parents.
 Regular follow-ups with an eye examination and refraction testing are essential.

Pearls and Other Issues

No definite cause of hyperopia is identified to date. Genetic predisposition, along with family
history, plays an important role. Asthenopic symptoms must be emphasized and evaluated in
children. Hyperopic children are usually less intelligent compared to myopic. Their social,
mental, and educational development depends upon their vision.
The commonest treatment option is rehabilitation with glasses. Regular follow-ups with
cycloplegic refraction are mandatory. Adult hyperopic should be treated with glasses or
cataract surgery if the cataract is the cause. Unilateral/bilateral aphakia should be treated with
amblyopia therapy with glasses or contact lenses immediately followed by intraocular lens
implantation.     

Enhancing Healthcare Team Outcomes

Our main aim is to give good vision and optimal binocular vision to the patients. For children
with refractive error only, proper refractive correction is indicated. If amblyopia development
is suspected, orthoptic exercises and patching of eyes are used. Good interdepartmental
coordination is necessary for regular followups and proper rehabilitation.
The development of the visual system is often affected by strabismus and amblyopia, which
needs cycloplegic refraction and followups. After proper preparation and counseling, it can
be corrected with refractive surgery. Adult with hyperopia needs refractive support along
with complication evaluation by gonioscopy and fundoscopy.  

Questions
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