Hypermetropia, also known as farsightedness or hyperopia, is a refractive error where the eye focuses light behind the retina. It occurs when the eyeball is too short or the cornea is too flat. Hypermetropia can be classified as physiological, pathological, or functional. It is commonly diagnosed using a retinoscope or autorefractor. Symptoms include blurry vision and eye strain. Treatment options include corrective lenses, refractive surgery such as LASIK, or intraocular lens implantation.

1. HYPERMETROPIA

2. OPTICS OF HYPERMETROPIA
• HYPERMETROPIA also known as long-sightedness, Far-sightedness or hyperopia.
• In this refractive state of eye where parallel rays of light coming from infinity are
focused behind the retina with accommodation being at rest.
• Is a TYPE OF AMETROPIA condition of the eye where distant objects can seen (BY
USING ACCOMODATION) but near objects appear blurred.
• Thus the posterior focal point (LONG FOCAL LENGTH) is behind the retina instead of
on, the retina wall therefore receives a blurred image.
• Minor hypermetropia (UPTO +1d ) in young patients is usually corrected by their
accommodation, without any defects in vision.
• But, due to this accommodative effort for distant vision, people may complain of
asthenopic symptoms during prolonged reading.

3. • FAR …Can see up to 1 Diopter error…With
accommodation (hence used the term FAR-
SIGHTEDNESS)
• NEAR… Not seen
• WHEN ACCOMMODATION AT REST CANNOT SEE
EITHER

4. AGE AND HYPERMETROPIA
• At birth, the eyeball is relatively short, having +2 to +3
hypermetropia.
• This is gradually reduced until by the age of 5-7 years, the eye is
emmetropic and remains so till age of about 50years.
• After this there is a tendency to develop hypermetropia again, which
gradually inceases until the extreme of life by which the eye has the
same =2 to +3 with which it started-SENILE HYPERMETROPIA is due
to changed in the crystalline lens.
• Far-sightedness is often present from birth, but children have a very
flexible eye lens, which helps to compensate.

5. AETIOLOGICALLY, CAUSES OF HYPERMETROPIA CAN BE CLASSIFIED AS:
1.AXIAL HYPERMETROPIA:
--COMMON
-- WHEN THE AXIAL LENGTH OF EYEBALL IS TOO SHORT.
--ABOUT 1 MM DECREASE IN AXIAL LENGTH(AP DIAMETER) A BOUT 3D OF
HYPERMETROPIA
--MICROPHTHALMOS AND NANOPHTHALMOS
2.CURVATURAL HYPERMETROPIA:
--OCCUR WHEN CURVATURE OF LENS OR CORNEA IS FLATTER THAN NORMAL.
--ABOUT 1 MM INCREASE IN RADIUS OF CURVATURE RESULTS IN 6 DIOPTERS
OF HYPERMETROPIA.
--CORNEA IS FLATTER IN MICROCORNEA AND CORNEA PLANA.
--CONSECUTIVE HYPERMETROPIA-DUE TO SURGICALLY OVER CORRECTED
MYOPIA
AETIOLOGICAL CLASSIFICATION / CAUSES

6. 3.INDEX HYPERMETROPIA:
--AGE RELATED CHANGES IN REFRACTIVE INDEX (CORTICAL SCLEROSIS,
DIABETES).
-- OCCASIONALLY, MILD HYPERMETROPIC SHIFT MAY BE SEEN IN
ASSOCIATION WITH CORTICAL OR SUBCAPSULAR CATARACT ALSO.
4.POSITIONAL HYPERMETROPIA:
--OCCUR DUE TO POSTERIOR DISLOCATION OF LENS OR I OL.
--IT MAY OCCUR DUE TO TRAUMA.
7.ABSENCE OF CRYSTRALLINE LENS: CONGENITAL OR ACQUIRED APHAKIA CAUSE
HIGH DEGREE HYPERMETROPIA*(+10 TO +12).
IN RARE INSTANCES HYPEROPIA CAN BE DUE TO DIABETES, AND PROBLEMS WITH
THE BLOOD VESSELS IN THE RETINA.

7. CLINICAL CLASSIFICATION
Hyperopia is typically classified according to clinical appearance, its SEVERITY, OR HOW IT RELATES TO THE
EYE'S ACCOMMODATIVE STATUS.There are three clinical categories of hyperopia.
1. PHYSIOLOGICAL / SIMPLE / DEVELOPMENTAL
• The most common form of hypermetropia
• Is caused by normal biological variations in the development of eyeball
• Occurs naturally due to biological diversity
2. PATHOLOGICAL /NON-PHYSIOLOGICAL HYPEROPIA
CONGENITAL-
• Micropthalmos
• Nanopthalmos
• Microcornea
• Congenital posterior dislocation of lens
• Congenital aphakia

8. ACQUIRED-
• Senile (index, Curvature),
• positional,
• aphakia,
• CONSECUTIVE HYPERMETROPIA: occur due to surgical over correction of
myopia or surgical under correction in cataract surgery.
• Acquired axial (retinal detachment,CSR, orbital tumor)
• Acquired curvature( inflammation,trauma)
• Pseudophakic hypermetropia
3.FUNCTIONAL HYPEROPIA:
• Caused by paralysis that interferes eye's ability to accommodate as seen in
internal ophthalmoplegia
• CN III palsy etc.

9. CLINICAL GRADING / CLASSIFICATION ACCORDING
TO SEVERITY
AMERICAN OPTOMETRIC ASSOCIATION (AOA) has defined
three grades categories according to severity:
• LOW: Refractive error less than or equal to +2.00 diopters (D).
• MODERATE: Refractive error between +2.00 D up to +5.00 D.
• HIGH: Refractive error greater than +5.00 D.

10. COMPONENTS OF HYPERMETROPIA
Accommodation has significant role in hyperopia. Considering accommodative status, hyperopia can be
classified as:
• LATENT HYPEROPIA: It is the amount of hyperopia normally corrected by inherent tone of ciliary
muscle (approximately +1 diopter).
• MANIFEST HYPEROPIA: It is the amount of hyperopia not corrected by ciliary tone. Manifest hyperopia
is further classified into two, facultative and absolute.
• Facultative hyperopia: It is the part of hyperopia corrected by patient's accommodation.
• Absolute hyperopia: It is the residual part of hyperopia which causes blurring of vision for distance.
• TOTAL HYPERMETROPIA: It is the total amount of hyperopia which is obtained after complete
relaxation of accommodation using cycloplegics like atropine.
• So, TOTAL HYPEROPIA= LATENT HYPEROPIA + MANIFEST HYPEROPIA (FACULTATIVE + ABSOLUTE)

11. CLINICAL FEATURES-SYMPTOMS
• In young patients, mild hypermetropia may not produce any
symptoms.
• The signs and symptoms of far-sightedness include blurry vision,
frontal or fronto temporal headaches, eye strain, tiredness of eyes
etc.
• The common symptom is eye strain. Difficulty seeing with both
eyes (binocular vision) may occur, as well as difficulty with depth
perception.
• The asthenopic symptoms and near blur are usually seen after
close work, especially in the evening or night.

12. CLINICAL FEATURES- SIGNS
1. Size of eyeball may appear small as a whole especially in high
hypermetropia
2. Cornea may be slightly smaller than the normal
3. Anterior chamber is comparitvely shallow
4. Retinoscopy and Auto refractrometry reveals hypermetropic
refractive errors
5. A- Scan Ultrasonography(biometry) may reveal a short antero
posterior length of the eyeball in Axial hypermetropia

13. 6. Fundus Examination reveals a
small optic disc which may
look more vascular with ill-
defined margins and even
may look more vascular with
ill-defined margins and even
may stimulate PAPILLITIS
(though there is no swelling
of the disc and so it is called
PSEUDOPAPILLITIS). The
retina as whole may shine
due to greater brilliance of
light reflections( SHOT SILK
APPEARANCE-because retina
is nearer to examiner).

14. DIAGNOSIS
• A diagnosis of far-sightedness is made by utilizing either a RETINOSCOPE or an
AUTOMATED REFRACTOR-objective refraction; or trial lenses in a trial frame or a
PHOROPTER to obtain a subjective examination.
• Ancillary tests for abnormal structures and physiology can be made via a SLIT
LAMP TEST, which examines the CORNEA, CONJUNCTIVA, ANTERIOR CHAMBER,
AND IRIS.
• In severe cases of hyperopia from birth, the brain has difficulty in merging the images
that each individual eye sees. This is because the images the brain receives from each
eye are always blurred. A child with severe hyperopia can never see objects in detail. If
the brain never learns to see objects in detail, then there is a high chance of one eye
becoming dominant. The result is that the brain will block the impulses of the non-
dominant eye. In contrast, the child with myopia can see objects close to the eye in
detail and does learn at an early age to see objects in detail.

15. COMPLICATIONS
• Recurrent Styes, Blephritis and chalazions.
• Esodeviation a/k/a accommodative convergent squint.
• Amblyopia -Anisotropic Amblyopia-due to unilateral refractive errors
-Strabismic Amblyopia-due to squint
-Ametropic Amblyopia-due to bilateral high hypermetropia
• At young age, severe far-sightedness can cause the child to have double
vision as a result of "over-focusing".
• Primary angle closure glaucoma-hypermetropic patients with short axial
length are at higher risk of dedeveloping so, routine gonioscopy and
glaucoma evaluation is recommended for all hypermetropic adults.

16. TREATMENT
• CORRECTIVE LENSES
Eyeglasses or contact lenses.
Eyeglasses used to correct far-
sightedness have convex lenses
(Converging lense)
• How to identify a convex lens?
1. Thick at centre
2. Magnifies the object
3. Movement of image opposite
direction to Movement of lense

17. PRINCIPLES OF HYPERMETROPIA CORRECTION
1. GENERAL RULES
• --IMPORTANCE OF COMPLETE CYCLOPLEGIC EXAMINATION
• --DO YOU PRESCRIBED ERROR < 1D only if patient is symptomatic
• --SPERICAL CORRECTION should be given comfortably acceptable
• --ASTIGMATISM should be fully corrected
2. FOR CHILDREN
• -- <4yrs OF AGE- usually accept full cyclopegic measurements,school age reduce 1/3
• -- >4 yes of age (school Going) undercorrect and prescribe then gradually increase at interval of 6
months till accepts manifest hypermetropia.
• -- IN EXOTROPHIA should be undercorrected by 1-2 Diopter
• -- IN ACCOMMODATIVE CONVERGENT SQUINT– Full correction– muscle relaxed– eyes straight
• --IN AMBLYOPIA—Full correction
• --FOLLOW UP EVERY 6 MONTHS

18. AMERICAN ASSOCIATION OF OPHTHALMOLOGY --
IN CHILDREN
ISOMETROPIA 0 – 1 years 1- 2 years 2 -3 years
HYPERMETROPIA > Or = + 6.00 > Or = +5.00 > Or = +4.50
HYPERMETROPIA +
ESOTROPIA
> Or = +2.00 > Or = +2.00 > Or = +1.50
ANISOMETROPIA 0 – 1 years 1- 2 years 2 -3 years
HYPERMETROPIA > Or = +2.50 > Or = +2.00 > Or = +1.50

19. • SURGERY
There are also surgical treatments for far-sightedness as explained
LASER PROCEDURES IOL IMPLANTATION NON LASER PROCEDURES
PHOTOREFRACTIVE
KERATECTOMY
APHAKIA CORRECTION CONDUCTIVE
KERATOPLASTY(CK)
LASER ASSISTED IN SITU
KERATOMILEUSIS
(LASIK)
REFRACTIVE LENS
EXCHANGE(RLE)
AUTOMATED LAMELLAR
KERATOPLASTY(AKL)
Epi-LASIK PHAKIC IOL KERATOPHAKIA
LASER THERMAL
KERATOPLASTY (LTK)
EPIKERATOPHAKIA

20. LASER PROCEDURES
1.PHOTOREFRACTIVE KERATECTOMY (PRK): This is a refractive technique
that is done by removal of a minimal amount of the corneal
surface. Hyperopic PRK has many complications like regression effect,
astigmatism due to epithelial healing, and corneal haze.Post operative
epithelial healing time is also more for PRK.
.

21. • 2.LASER ASSISTED IN SITU
KERATOMILEUSIS (LASIK):
Laser eye surgery to
reshape the cornea, so
that glasses or
contactlenses are no
longer needed. Excimer
laser LASIK can correct
hypermetropia up to +6
diopters. LASIK is
contraindicated in patients
with lupus and rheumatoid
arthritis

22. 3.LASER EPITHELIAL KERATOMILEUSIS (LASEK): Resembles PRK, but
uses alcohol to loosen the corneal surface.
4.EPI-LASIK : is also used to correct hyperopia. In this procedure,
use of epikeratome eliminates the use of alcohol.

23. • 5.LASER THERMAL KERATOPLASTY (LTK): is a laser based
non-destructive refractive procedure used to correct
hyperopia and presbyopia. It uses Thallium-Holmium-
Chromium (THC): YAG laser.

24. IOL IMPLANTATION
1.APHAKIA CORRECTION:
High degree hypermetropia due to absence of lens (aphakia) is best
corrected using intraocular lens implantation.
2.REFRACTIVE LENS EXCHANGE (RLE):
A variation of cataract surgery where the natural crystalline lens is
replaced with an artificial intraocular lens; the difference is the
existence of abnormal ocular anatomy which causes a high refractive
error.
3.PHAKIC INTRAOCULAR LENS:
Phakic IOL are lenses that implanted inside eye without removing the
the normal crystalline lens. Phakic IOLs can be used to correct
hypermetropia up to +20 diopters.

25. NON LASER PROCEDURES
1.CONDUCTIVE KERATOPLASTY (CK):
is a non laser refractive procedure used to correct presbyopia and low hypermetropia
(+0.75D to +3.25D) with or without astigmatism (up to 0.75D). It uses radiofrequency
energy to heat and shrink corneal collagen tissue. CK is contraindicated in
pregnant/breastfeeding women, central corneal dystrophies and scarring, history
of herpetic keratitis, type 1 diabetes etc.
2.AUTOMATED LAMELLAR KERATOPLASTY (ALK):
Hyperopic automated lamellar keratoplasty (H-ALK) and Homoplastic ALK are ALK
procedures that corrects low to moderate hyperopia. Poor predictability and the risk of
complications limits usefulness of these procedures.
3.KERATOPHAKIA AND EPI-KERATOPHAKIA:
are another two non laser surgical procedures used to correct
hypermetropia. Keratophakia is a surgical technique developed by Barraquer for
treating high hypermetropia and aphakia. Poor predictability and induced
irregular astigmatism are complications of these procedures.