CLE 162.3 Optometric Procedures
Notetaker: Kyle Reuter
Date: 4/3/12 1st Hour
Page 1
Hyperopia
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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
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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
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Total hyperopia
o Total hyperopia = manifest + latent hyperopia
 Recall: talking about distance vision ONLY – doesn’t include
near requirements
CLE 162.3 Optometric Procedures
Notetaker: Kyle Reuter
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Date: 4/3/12 1st Hour
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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
Notetaker: Kyle Reuter
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Date: 4/3/12 1st Hour
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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
 Net Manifest: +2.00 (OU) BCVA = 20/20
 Facultative = +2.00D
 Absolute = zero
o Patient could see clearly at distance without the +2.00D
CLE 162.3 Optometric Procedures
Notetaker: Kyle Reuter
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Date: 4/3/12 1st Hour
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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
 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
CLE 162.3 Optometric Procedures
Notetaker: Kyle Reuter
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Date: 4/3/12 1st Hour
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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