A Farsighted Approach To Hyperopia

Hyperopia is not currently receiving the level of attention that myopia attracts. However, it is an important facet of clinical practise that needs to be focussed on.

When consulting patients, the first step is to properly explain hyperopia.

Simply telling a patient that it means ‘farsighted’ will raise more questions and does not explain the implications or mechanisms at work. A newly diagnosed, older hyperopic patient may say they can’t be farsighted, as they cannot see near or far. Younger patients may have rather good visual acuity but their visual system may be under significant stress. Accommodative-convergence issues, resultant asthenopia, esotropia, learning problems, reduced depth perception and amblyopia may be some of the issues.

High-index, aspheric plastic lenses in the right frame can lead to exceptionally good cosmetic and functional outcomes

All too often patients are left with a limited understanding of this condition. Google ‘hyperopia’ and you’ll see what a poor job most explanations and videos do; so it’s usually not good enough to simply give a patient a brochure or link and think the job is done.

The use of simple diagrams, animated computer or tablet based explanations or videos may help. The trick is finding resources that satisfy you.

In essence, we need to show that the eyeball is effectively ‘too short’ or the optics ‘too weak’, which leads to the focus falling behind the retina. We then need to show how accommodation can ‘pull’ the focus back onto the retina and explain how ageing reduces accommodation. This is also a good time to explain presbyopia.

It’s a vicious circle of life.

VARIOUS FORMS

Hyperopia has various forms, from ‘normal’ levels or low degrees of hyperopia (that some see as a buffer against later myopia development, or an indicator of likely future myopia), to significant levels that can lead to accommodative esotropia. Significantly, anisometropia and esotropia can both lead to amblyopia and reduced or absent stereopsis, limiting employment opportunities and affecting everyday function and performance.

Uncorrected, undiagnosed or cases of latent hyperopia may be at the heart of learning or behavioural issues. It can be linked to attention deficit and hyperactivity disorder (ADHD), leading to unnecessary medical costs, prescription drugs such as Ritalin etc.

In some cases, prescribing low powered spectacles, in the order of +0.50D to +1.00D, can ‘unlock’ the visual system and dramatically improve the function of struggling children.

It’s a complex condition and needs careful management.

A good practice builder may be to run school screening clinics in your local area. Many practices have cyclical quiet times. Running an approved screening programme can provide important detection of potentially significant problems, grow your practice and fill some appointments during these quiet times.

Another one of those mutually beneficial scenarios we love.

Without going into great detail, screening that includes retinoscopy (or an autorefractor), cover testing, visual acuity, fogging lenses and stereopsis will detect most hyperopes and many other visual conditions.

PRESCRIBING FOR HYPEROPIA

Back in the ‘old days’, prescribing for significant degrees of hyperopia was a challenge. Thick, low index glass lenses were heavy and potentially dangerous should they suffer an impact. These spectacles were also unsightly and caused discomfort and indents on the nose. They would often fly off the faces of active children and be damaged. In some cases they would simply not be worn.

Today, as you will see in the accompanying product section, we can obtain amazing cosmetic and functional results. High-index, aspheric plastic lenses in the right frame can lead to exceptionally good cosmetic and functional outcomes. For higher degrees of hyperopia, a modern 1.74 index lens can look superb. Multicoating provides further cosmetic improvements, reducing annoying reflections and improving function. We can also provide very high levels of impact resistance and improved safety.

For infants, special frames with wide nose bridges and head bands may help the spectacles stay put. In other cases curl-side or wrapped, library-style temples may do the trick.

Getting children into frames that feature their favourite sporting or fashion logo, or provide the ‘Harry Potter’ look, can also help get them onside.

With adults – who may be first time, undiagnosed hyperopes suffering the ravages of advancing age and reduced accommodation – we need to deal with different issues. These patients are often rather unhappy as they get a double whammy of middle-age issues and are ‘suddenly’ not able to see near or far. They may frustratedly exclaim, “But I’ve always been able to see 20/20”. This is when chair side manner and the art of diplomacy are most important. You may also need to explain that spectacle wear may be a legal requirement for driving.

For early cases, single vision spectacles may suffice for near vision related problems and mild asthenopia, but as time goes by, it’s worth upgrading patients into occupational lenses that cover a greater range of near and intermediate tasks. Eventually, progressive lenses will usually be indicated, allowing clear vision at all distances.

There are many aspects to hyperopia. We could fill this entire edition of mivision on the subject. Fortunately, we can cater very well to our hyperopic patients of all ages. We can certainly make a difference in their lives and function. For some, our diagnosis and intervention can be life changing.

It’s so rewarding to be able to make a difference.