Hyperopia in Adolescents/Adults - Diagnosis and Management of Common Ocular Conditions Spring 2026

Children are usually born _____

hyperopic

Children who stay hyperopic throughout life fail to _____ after birth

emmetropize

Around 9mo of age, how much hyperopia do you want to see in a child?

+1.00-+2.00

What is axial hyperopia d/t?

short axial length

What is reflective hyperopia d/t?

low power cornea

Can absolute hyperopia be overcome with accommodation?

No -- a patient’s farsightedness that cannot be overcome by maximum accommodative effort, resulting in persistently blurred vision

What is facultative hyperopia?

the eye can voluntarily compensate for using its own accommodative power (ciliary muscle effort) to see clearly -- within the range of accommodation

What is latent hyperopia?

concealed by a spasm of accommodation -- the amount of hyperopia found on dry refraction is much different that amount found on wet

How is manifest hyperopia revealed?

by routine dry refraction

What is wet refraction?

cycloplegic drop used before refraction to minimize accommodation

Is hyperopia genetic?

yes there is a genetic component for all individuals

+1.00-+3.00 is _____ in infants through children in grade school

normal

When is >+3.00 concerning?

if seen after infancy

Are low amounts of hyperopia usually symptomatic in children?

Often not symptomatic

Are low amounts of hyperopia usually correlated to esotropia?

No

How does hyperopia present in adulthood?

chronic, slow presentation of blur in adults

Can hyperopia be induced acutely? How?

Yes -- corresponding to an increased visual demand

What are the symptoms of acute presentation of hyperopia?

blur, HAs, strain, symptoms worse with near work

What are the key features of low amounts of uncorrected hyperopia?

good VA at distance and near if in low amounts (<+3.00)

What are the key features of higher amounts of uncorrected hyperopia? (>+3.00)

Reduced and/or variable VA if in higher amounts

Individuals with uncorrected hyperopia are often (exophoric/esophoric)? At what distance?

Esophoric at distance and near

There may be a (lead/lag) of accommodation in individuals with uncorrected hyperopia

lag -- puts excessive work on the accommodative system

A lag of accommodation can result in (increased/decreased) eso posture

decrease

Decrease accommodation --> Decrease Accommodative Convergence --> Decrease Esophoria

Hyperopia can be very _____ during retinoscopy

unstable

During the monocular subjective refraction, patients will usually take the (most/least) amount of plus correction

least

During the binocular sphere check during refraction, patients will usually take (more/less) plus than during monocular testing

more -- the accommodation is more stable during binocular viewing

What are the indications that the dry refraction may not have revealed the full amount of hyperopia?

-symptoms not explained by the findings

-HIGH NRA (>+2.75)

Why would a HIGH NRA be indicative of a hyperopic refractive error?

Patients can take more plus because they have more accommodation to relax. Demand of the target is usually +2.50. Hyperopes are accommodating MORE than normal to see this target clearly. Adding plus of NRA will RELAX this accommodation.

What is the accommodative demand of a 4D hyperope wearing +3.00 specs at 40cm?

+3.50

What is the accommodative demand of a 4D hyperope wearing +3.00 specs w/ +2.50 lenses over it at 40cm?

+1.00D

+3.50-+2.50 = +1.00

What is the accommodative demand of a 4D hyperope wearing +3.00 specs w/ +3.50 lenses over it at 40cm?

0D

+3.50-+3.50 = +1.00

What is the accommodative demand of a 4D hyperope wearing +3.00 specs w/ +3.75 lenses over it at 40cm?

0D accommodative demand , BUT there will be 0.25D blur

+3.50-+3.75 = -0.25D

You have a 4D hyperope who refracts to +3.00D. You now do NRA. At +2.50 how much would the patient still be accommodating?

-1D of hyperopia uncorrected

-Patient's accommodative demand at 40cm is +3.50

-Patient would be accommodating +1.00 with +2.50 lenses in on NRA

When would a 4D hyperope who refracts to +3.00D likely report blur during NRA?

+3.50-+3.75

An NRA of >+2.75 is HIGHLY indicative of what?

refraction is under plussed or OVER minused

When determining binocularity and doing cover test on individuals with hyperopia, you have to be vigilent to ensure what?

that the patient is accurately accommodating during the testing (Esp at near)

REVIEW: Patients with hyperopia are likely to have a ____ of accommodation

lag

You may miss a significant amount of ____ if you allow the patient to not accommodate accurately

esophoria

How to ensure the patient is accommodating accurately during cover test?

use a small accommodative target (20/30 letter) and remind the patient to keep it clear

What should you do BEFORE retinoscopy?

blur the target (over plus the patient)

You must ensure what before starting the blur balance of refraction?

Must ensure that both eyes are over plussed and blurry

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +0.75DOU and putting in dissociating prisms (BD OD sees top chart).

Which chart will be clearer?

-Current lens in front of OD: +3.75

-Current lens in front of OS: +2.75

-OD is underplussed by +0.25D

-OS is underplussed by +1.25D

-Accommodative demand OD at distance: +0.25

-Accommodative demand OS at distance: +1.25

-The chart that is clearer depends on the amount that the patient accommodates

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +0.75DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates 0D, which chart would be clearer?

-OD Blur at distance: 0.25

-OS Blur at distance: 1.25

-Top (OD) will be clearer

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +0.75DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates +0.25D, which chart would be clearer?

-OD Blur at distance: 0 (clear)

-OS Blur at distance: 1.00D

-Top (OD) will be clearer

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +0.75DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates 1.25D, which chart would be clearer?

-OD Blur at distance: 1.00D

-OS Blur at distance: 0 (clear)

-Bottom (OS) will be clearer

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +0.75DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates 0.75D, which chart would be clearer?

-OD Blur at distance: 0.50

-OS Blur at distance: 0.50

-Both charts are equally blurry

What is the consequence of NOT over-plussing the patient during the blur balance?

Which chart is clearer will depend on how much the patient accommodates and THIS IS NOT GOOD. Results are not likely to be valid.

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +2.25DOU and putting in dissociating prisms (BD OD sees top chart).

Which chart will be clearer?

-Current lens in front of OD: +5.25

-Current lens in front of OS: +4.25

-OD is overplussed by +1.25D

-OS is overplussed by +0.25D

-Accommodative demand OD at distance: 0, 1.25D blur

-Accommodative demand OS at distance: 0, 0.25D of blur

-OS will be clearer

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +2.25DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates 0D, which chart would be clearer?

-OD Blur at distance: 1.25

-OS Blur at distance: 0.25

-Bottom (OS) wil be clearer

True RE: +4.00OU

Monocular Subjective: +3.00OD; +2.00OS

You begin blur balance by adding +2.25DOU and putting in dissociating prisms (BD OD sees top chart).

If the patient accommodates 0.50D, which chart would be clearer?

-OD Blur at distance: 1.75

-OS Blur at distance: 0.75

-Bottom (OS) will be clearer

True or False:

When the patient is properly overplussed before blur balance, the same eye will always be clearer no matter the amount of accommodation

True

We should always wait for what during blur balance?

Wait to see if the letters clear, pause

Once the first detectable 20/20 has been established, you should reduce plus by no more than ____D

0.75

True or False:

It is important to control vertex distance during refraction in patients who are high plus

true

What is the standard of care for a cycloplegic refraction in children?

1 drop cyclopentolate

What is the standard of care for a cycloplegic refraction in adults?

2 drops 1% Tropicamide

What are the objective ways to measure cycloplegic refraction?

-Wet retinoscopy

-Wet autorefraction

What are the subjective ways to measure cycloplegic refraction?

-Binocular Sphere Check only (performed same way as dry)

-Monocular Sphere Checks

-Cyl is not typically rechecked

It is common to lose _____ plus during a wet refraction compared to a MR in hyperopes

>+0.50

If MORE PLUS is found on wet refraction, what are possible reasons for this?

-latent hyperopia (larger amounts)

-loss of tonic accommodation (+0.25 to +0.50)

It is common to lose _____ plus during a wet refraction compared to a MR in myopes

+0.25-+0.50 d/t loss of tonic accommodation

It is common to lose _____ plus during a wet refraction compared to a MR in emmetropes

+0.25-+0.50 d/t loss of tonic accommodation

What is the formula for determining what to prescribe for hyperopes?

There is not one!

What do patients want from their prescription?

Single, clear, comfortable, non-distorted vision

In general, a new RX should _____ or _____ the accommodative response at distance that the patient currently has

maintain; decrease

Does a partial correction of hyperopia still decrease the amount of accommodation needed at distance compared to uncorrected?

Yes

**uncorrected hyperope will have an increased accommodative demand from an emmetrope but correcting some of the prescription will be better than nothing.

Does fully correcting a myope change accommodation at distance?

No -- just makes it clearer.

Why do we NOT want to over-minus a myope?

will make the patient accommodate more at distance

Does changing the current rx of a happy, asymptomatic patient risk causing problems?

Yes -- if it ain't broke don't fix it

According to some random study, _____% of spec checks were preventable by not changing anything about a patient's glasses when they were happy with their current set up

32

Why is the maxim "If it ain't broke don't fix it" hard to follow?

You tried really hard to do a perfect refraction for the patient and now have to abandon the data you worked hard to obtain.

In a hyperope, you will want to avoid rxing more (plus/minus) to an asymptomatic patient currently wearing no correction that perceives no benefit to it at distance or near

plus

Why do you want to avoid RXing more plus to an asymptomatic patient that perceives no benefit to it at distance or near?

1) may result in distance blur d/t no wearing glasses before

2) If the patient perceives no benefit, they will not wear them & lose trust in you.

When is it OK to ignore the maxim, "if it ain't broke don't fix it"?

When the patient just does not know what they are missing & improvement is noted when the new rx is demo'ed.

When a patient notes improved clarity at near by rxing a plus, it is important to _____ the patient.

Educate -- the purpose of the glasses is to help with long term fatigue & a drastic improvement in vision probably will not be noticed.

When a hyperope is symptomatic you will want to prescribe ____ to ____ less than the full manifest RX

+0.25 to +1.00

If you prescribe a symptomatic hyperope +0.25-+1.00 less than the manifest RX, what should you do?

trial frame the RX and make sure you are not creating distance blur. Demo at a distance longer than the exam room.

What are some conditions that suggest you should prescribe more plus to a symptomatic hyperope?

-higher symptoms

-binocular vision/accommodative problems (esophoria, poor NFV, reduced PRA, accommodative insufficiency

-high latency (significantly more plus found on wet refraction)

In a hyperope, you will want to check ____ through the final RX

phorias

True or False:

The full rx may not be acceptable in one step. Several prescriptions over several years may be necessary for more complete acceptance.

true

True or False:

Acceptance of an RX will always be the same at distance and near

false -- acceptance of rx can be different at these 2 distances

Can you likely give the FULL PLUS RX as reading glasses?

Yes

Is distance blur as significant if we are just prescribing a patient reading glasses?

No

True or False:

Low amounts of hyperopia with no symptoms or performance problems can often remain uncorrected

true

If a patient is experiencing mild asthenopia and/or HA which may result in poor school or work performance, OR losing interest in near work, what should you do?

Prescribe an RX

With a hyperopic patient, is it important to explain the purpose and appropriate use of the RX you are prescribing?

Yes -- you should DEMO RX to these patients

What should you warn the patient of when prescribing for a hyperope?

distance vision may blur for a period of time when the RX is first put on. You have to let your eyes relax and then your vision will clear.

Should hyperopes wear their RX part time or switch back and forth to prior RX during the adaptation period?

No

Hyperopia Considerations

25YO

Entering VAs Sc: 20/20 OD, OS, OU

MR: +2.00

What will the VA of this patient be after dilation?

~20/200 or worse if there is more latent hyperopia present.

Hyperopia Considerations

25YO

Entering VAs Sc: 20/20 OD, OS, OU

MR: +2.00

If there a problem that presents if you chose to dilate this patient? How to avoid this?

This WILL NOT be good if the patient needs to drive home or has work that needs accomplished. May consider RXing glasses and then have the patient return for dilation after picking up glasses, but will be more challenging because we do not have a WET refraction to aid in our RX

Hyperopia Considerations

In general, a new RX should ____ or _____ the accommodative response at distance than the patient currently has

maintain; decrease

Hyperopia Considerations

For an uncorrected hyperope, should you prescribe minus lenses ever? Why?

NO -- you will be increasing the accommodative response

Hyperopia Considerations

It is important to think in terms of _____ when determining how much "plus to cut"

SE

Hyperopia Considerations

20YO with mild complaints of distance and near blur

DVA sc: 20/25 OD, OS, OU

NVA sc: 20/25 OD, OS, OU

D CT sc: Ortho; N CT sc: Ortho

MR: +1.00-1.00x090 20/20 OU

What should be prescribed for this patient?

-Decreased VA from uncorrected astigmatism

-SE: +0.50

-You should NOT cut more than 0.50D from this RX

-Prescribe: +0.50-1.00x090

Hyperopia Considerations

20YO with mild complaints of distance and near blur

DVA sc: 20/25 OD, OS, OU

NVA sc: 20/25 OD, OS, OU

D CT sc: Ortho; N CT sc: Ortho

MR: +1.00-1.00x090 20/20 OU

Why would you never want to cut more than +0.50D from this patient's MR?

Then you would be prescribing minus for a hyperope & this is NOT a good plan.

What is the cosmetic appearance of PLUS LENSES?

-eyes appear larger

-side of face is imaged outward

What are the RX considerations we want to make knowing the cosmetic appearance of plus lenses?

-consider a small eye size with will result in lighter lenses & a better cosmetic appearance

-fit the vertex distance as close as possible

-adjust RX for a comfortable fit which does not drop

If a hyperopic RX slides down a patient's nose, this will change the vertex distance, and the patient will have (more/less) effective power

less

You should consider an _____ lens design for higher RX

aspheric

For better optics and improved cosmetic appearance, patient's with a high hyperopic RX ma prefer _____

CLs