Hypermetropia, or farsightedness, is the most common refractive error in children. The document discusses the epidemiology, management strategies, and guidelines for prescribing corrections for childhood hypermetropia. It notes that significant uncorrected hyperopia can cause visual issues and disrupt visual development. The appropriate prescription depends on factors like the degree of hyperopia, symptoms, age, and binocular vision status, with more hyperopic correction typically prescribed for children with amblyopia or strabismus. The goal of treatment is to relieve symptoms while not interfering with normal eye growth.
2. Introduction
• Hypermetropia is the most common type of refractive error, but
there are many appearance of its development and subsequent
effects on its management in childhood that are poorly
understood.
Wisse RPL, Muijzer MB, Cassano F, Godefrooij DA, Prevoo YFDM, Soeters N .Validation of an Independent Web-Based Tool for Measuring Visual Acuity and Refractive Error (the
Manifest versus Online Refractive Evaluation Trial): Prospective Open-Label Noninferiority Clinical Trial. J Med Internet Res 2019;21(11):e1480
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3. Epidemiology
• The Mutli-Ethnic Pediatric Eye Disease Study Group reports
hyperopia prevalence of children in each ethnic group of the
sample population*
Asian
Americans;
13%
African
Americans;
20.80%
White
Americans;
25%
Hispanics;
26.90%
*Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of myopia and hyperopia in 6- to 72-month-***old african american and Hispanic
children: the multi-ethnic pediatric eye disease study. Ophthalmology. 2010;117(1):140‐147.e3. doi:10.1016/j.ophtha.2009.06.009
4. O'Connor in 2008 reported that the prevalence of childhood
hyperopia ranges from 0.9% to 12.8%, depending on the age at
test and definition of hypermetropia .
O'Connor, Anna. (2008). Hypermetropia in childhood: a review of research relating to clinical management. British and Irish Orthoptic Journal. 5.
15-21.
5. • the prevalence in young urban school children
in Sydney was 38.5 % in in an unselected
population*.
• Overall prevalence of hyperopia is around 10%,
approximately 14 million people, in the United
States**.
*B.M. Junghans, S.G. Crewther, P.M. Kiely, D.P. Crewther; The Prevalence of Hypermetropia and Myopia in a
Large Unselected, Multicultural Population of School Children in Eastern Sydney . Invest. Ophthalmol. Vis.
Sci. 2003;44(13):4775. doi: https://doi.org/.
**Trobe JD. The Physician’s Guide to Eye Care. San Francisco, CA: American Academy of Ophthalmology;
2006:145-149.
6. • Children with hyperopia >3.50 D of spherical equivalent are at
high risk for development of refractive amblyopia*
• Many factors affect RX:
• Eye's alignment
• Social factors, as children wearing glasses can be victimized by their
friends **.
• Accommodation condition.
• Optimum visual function (encompassing both visual acuity and binocular
vision) while not impeding emmetropization.
*Colburn JD, Morrison DG, Estes RL, Li C, Lu P, Donahue SP. Longitudinal follow-up of hypermetropic children identified during preschool
vision screening. J AAPOS. 2010;14:211–15.
**Horwood J, Waylen A, Herrick D, Williams C, Wolke D. Common visual defects and peer victimization in children. Invest Ophthalmol Vis Sci
2005; 46: 1177–1181.
The pattern of RX in childhood hypermetropia
7. • There are a number of published guidelines regarding what levels
of hyperopia should be considered for correction in children.
• Significant hyperopia, if uncorrected, can produce:
• Visual discomfort
• Blurred vision
• Amblyopia.
• Binocular dysfunction, including strabismus, and contribute to learning
problems.
• Treatment should be initiated both to relief symptoms and to
reduce the future risk of vision problems resulting from the
hyperopia *.
Susan J. Leat, Andrea Mittelstaedt, Stephen McIntosh, Carolyn M. Machan, Patricia K. Hrynchak, Elizabeth L. Prescribing for hyperopia in childhood
and teenage by academic optometrists. Irving Optom Vis Sci. 2011 Nov; 88(11): 1333–1342. doi: 10.1097/OPX.0b013e31822f4b9c.
8. Is the refractive error within the normal range for the child’s age?
Will this particular child’s refractive error emmetropise?
Will this level of refractive error disrupt normal visual development or functional
vision?
Will prescribing spectacles improve visual function or functional vision?
Will prescribing glasses interfere with the normal process of
emmetropisation?
When considering prescribing glasses for a young child, the
following questions must be considered:
Susan J. To prescribe or not to prescribe? Guidelines for spectacle prescribing in infants and children. Clin Exp Optom 2011; 94: 6: 514–527.
9. Management Strategies for Hyperopic Correction
There is no universal approach to the treatment of hyperopia.
Each patient should be considered in terms of:
• Age
• Degree of symptoms
• Amount of hyperopia
• Amplitude of accommodation
• VA
• Profession of the patient.
11. From birth to 10 years:
• Young children (birth-10 years of age) with low to moderate
hyperopia, but without strabismus, amblyopia, or other
significant vision problems, usually not require treatment.
• Decreased visual acuity, binocular anomalies, or functional
vision problems may signal the need for treatment.
A survey of prescribing patterns suggests that for 2-year-olds many
practitioners use a threshold of +3.0 D of bilateral asymptomatic hyperopia,
while some use a threshold of +5.0 D (7).
Susan J. To prescribe or not to prescribe? Guidelines for spectacle prescribing in infants and children. Clin Exp Optom 2011; 94: 6: 514–527.
12. • Hyperopic correction should also be prescribed along with
other interventions like occlusion or active vision therapy for
all young patients with actual or suspected amblyopia or
strabismus.
13. • Optical correction should be based on:
• Static retinoscopy (Dry and wet)
• Accommodative assessment
• Binocular assessment
• AC/A ratio
• Modification as needed to facilitate binocularity and
compliance.
14. • Careful follow-up is important, and frequent lens changes may
be needed.
• When compliance proves difficult, the optometrist may
encourage acceptance of the prescribed treatment by using
cycloplegic agents to blur uncorrected vision .
Ciner EB. Management of refractive error in infants, toddlers and preschool children. Probl Optom 1990; 2:(3)394-419.
15. From 10 to 15 years:
• Children between the ages of 10 and 15 years who have low
hyperopia require no correction, because the hyperopia is
asymptomatic.
• Amplitude of accommodative reserves compensates the visual
problems related to their hyperopia.
• Under increased visual stress and symptoms the child requires
correction.
Patients with moderate degrees of hyperopia are more likely to require at
least part-time correction, especially those who have significant near
demands or have accommodative or binocular anomalies*.
Susan J. Leat, Andrea Mittelstaedt, Stephen McIntosh, Carolyn M. Machan, Patricia K. Hrynchak, Elizabeth L. Prescribing for hyperopia in childhood
and teenage by academic optometrists. Irving Optom Vis Sci. 2011 Nov; 88(11): 1333–1342. doi: 10.1097/OPX.0b013e31822f4b9c.
16. Binocular vision approach
• Along with assessment of refractive error, patients
with hyperopia should undergo evaluation of:
• Ocular motility
• Binocular vision
• Accommodation assessment
• Anomalies of any of these visual functions may result
in visual acuity and visual performance deficits.
17. The following guidelines
come from the American
Academy of
Ophthalmology's preferred
practice patterns for
hyperopic child:
• <1 year: > +6 D
• 1-2 years: > +5 D
• 2-3 years: > +4.5 D
• >4 years: > +4 D or if
symptomatic
Summers CG, et al. Preferred practice pattern guidelines. Pediatric Eye Evaluations. San Francisco, CA: American Academy of Ophthalmology, 2012.
18. • To determine the best spectacle RX for maintaining ocular
alignment and comfortable accommodative demand, the
optometrist should assess the effect of plus lens power on any
dysfunctions prior to cycloplegia.
• Full hyperopic refractive correction is warranted in patients with
amblyopia and/or esotropia*.
Ann Webber. Paediatric hyperopia, accommodative esotropia and refractive amblyopia. Clin Exp Optom 2011; 94: 1: 108–111.
19. According to cover test result:
• Esotropia, give the maximum plus correction which does not severely affect
vision.
• Esophoria, the maximum plus correction which does not blur vision is given.
• Exophoria exists; the plus correction is usually less than the full correction. If
it is the maximum correction, it is accompanied by prism base in or by
orthoptic exercise.
• Also Full correction should be made when there is Constant or intermittent
esotropia, pseudo myopia and much near work required marked eye
strain.
21. • Children with high hyperopia and exotropia are likely to have
developmental delay or other systemic diseases, amblyopia, and
poor stereopsis.
• Children with high hyperopia and exotropia are likely to have
developmental delay or other systemic diseases, amblyopia, and
poor stereopsis.
22. Conclusion
• RX for hypermetropia is essential when a risk factor is present
would appear to be logical to avoid the development of amblyopia.
• A recent study found that prescribing the smallest amount of
hyperopic correction needed to allow near-focusing does not
impede emmetropization.
• The close link between hyperopia, amblyopia, and strabismus,
especially in children, makes hyperopia a greater risk factor than
myopia for a greater degree of permanent vision loss.
23. References
1. O'Connor, Anna. (2008). Hypermetropia in childhood: a review of research relating to clinical management. British
and Irish Orthoptic Journal. 5. 15-21.
2. Colburn JD, Morrison DG, Estes RL, Li C, Lu P, Donahue SP. Longitudinal follow-up of hypermetropic children
identified during preschool vision screening. J AAPOS. 2010;14:211–15.
3. Horwood J, Waylen A, Herrick D, Williams C, Wolke D. Common visual defects and peer victimization in children.
Invest Ophthalmol Vis Sci 2005; 46: 1177–1181.
4. Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. Association between accommodative accuracy, hypermetropia,
and strabismus in children with Down’s syndrome. Optom Vis Sci 2007; 84: 149– 155.
5. Susan J. Leat, Andrea Mittelstaedt, Stephen McIntosh, Carolyn M. Machan, Patricia K. Hrynchak, Elizabeth L.
Prescribing for hyperopia in childhood and teenage by academic optometrists. Irving Optom Vis Sci. 2011
Nov; 88(11): 1333–1342. doi: 10.1097/OPX.0b013e31822f4b9c.
6. American Optometric Association. Optometric Clinical Practice Guideline: Care of the Patient with Hyperopia.
Available at: http:// www.aoa.org/documents/CPG-16.pdf. Accessed July 14, 2010.
7. Susan J. To prescribe or not to prescribe? Guidelines for spectacle prescribing in infants and children. Clin Exp Optom
2011; 94: 6: 514–527.
8. Ciner EB. Management of refractive error in infants, toddlers and preschool children. Probl Optom 1990; 2:(3)394-
419.
9. Rosner J, Gruber J. Differences in the perceptual skills development of young myopes and hyperopes. Am J Optom
Physiol Opt 1985; 62:501-4.
10. Ann Webber. Paediatric hyperopia, accommodative esotropia and refractive amblyopia. Clin Exp Optom 2011; 94: 1:
108–111.
11. Summers CG, et al. Preferred practice pattern guidelines. Pediatric Eye Evaluations. San Francisco, CA: American
Academy of Ophthalmology, 2012.
12. B.M. Junghans, S.G. Crewther, P.M. Kiely, D.P. Crewther; The Prevalence of Hypermetropia and Myopia in
a Large Unselected, Multicultural Population of School Children in Eastern Sydney . Invest. Ophthalmol.
Vis. Sci. 2003;44(13):4775. doi: https://doi.org/.
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