The prevalence of hyperopia (farsightedness) in the United States is approximately 10% (33 million), and the most common refractive error in children.¹ While eye care professionals have understandably pivoted much of their clinical focus to the detection and intervention toward the global myopia epidemic, it is also important to identify the “silent sufferers” of hyperopia. When not properly diagnosed and managed, those folks can experience unnecessary strain on their visual system, regardless of their age.

In this article, I will discuss how to best approach hyperopia treatment for both children and adults, so optometrists can go about creating happier hyperopic patients.

Child hyperopia patients

Hyperopia is such an intriguing refractive error, especially when referencing the timeline for normal eye size from infancy to adulthood. Clinically, we know that eyes are naturally smaller (measured in millimeters as axial length) in newborns and, thus, higher levels of hyperopia are expected at infancy. As the eye grows from toddler, to childhood, to the teen years, the normal elongation diminishes the amount of hyperopia, ideally toward emmetropization.

Surprisingly, there is still no consensus on what levels of bilateral hyperopia are appropriate to prescribe due to a lack of evidence-based clinical guidelines. Kulp, et al, looked at the prescribing habits of pediatric eye care providers (both OD and MD) and found there was widely varying opinions on the topic among the providers.²

When it comes to creating a happy, young hyperope, we have found this clinical protocol to be the most productive approach. Always:

1. Obtain a baseline cycloplegic examination on record to help with clinical judgement on the most optimal final prescription. Remember, the definition of hyperopia is based on when accommodation is at rest. In the pediatric population, we can never be certain if accommodation is truly at rest unless we take the patient’s ability to compensate away.
2. Always stress the importance of visual efficiency and comfort vs. clarity. Because most young hyperopes can easily accommodate to see clearly, there is a common misconception by the patient and parents that “everything is fine.” I like to use a pertinent analogy to visual performance depending on the young patient’s hobbies or interests. For example, the conversation sounds like this: “We see you like to play basketball; you can play basketball with sandals on, but isn’t it easier and aren’t you at your best when you play wearing your nice gym shoes? This is exactly what we want to do for your vision; you can see without glasses, but we want to give you the right lenses, so that you can perform at your very best!”
3. Always discuss the future option of utilizing contact lenses. There are many patients and parents who prefer them to wearing glasses. In the hyperopic population, the magnification and weight of spectacle lenses can lead to potential issues with comfort and cosmesis, especially with higher levels of refractive error. Contact lenses have sometimes been controversial in the pediatric population due to worries with poor compliance and hygiene. With the advent of single use, daily disposable lenses, though, it has never been easier to prescribe contact lenses that are comfortable, healthy, and convenient for the neophyte wearer. Also, visual freedom from eye glass frames can be very important for the young athlete, especially with helmet sports, such as football, lacrosse, and hockey. If a patient doesn’t feel motivated by the idea of wearing glasses, it’s important to plant the seed that contact lenses are an option.

Projections for the U.S. population with hyperopia

 

 

Adult hyperopia patients

We know as patients age there is an inherent, refractive, hyperopic shift due to natural changes in crystalline lens thickness and flexibility. The undiagnosed adult hyperope will be plagued with near-vision blur sooner than the emmetropic adult who is approaching presbyopic years. Adult hyperopes who have never been correctly identified and treated usually hit the proverbial “wall” of sudden near blur rapidly and unexpectantly; this usually happens around age 50.

When it comes to satisfying the adult hyperope, we have found that the following protocol works nicely:

1. Always be prepared to address the emotions surrounding the loss of effortless near vision. We approach every refractive error by looking at the upside of the patient’s diagnosis. For hyperopes the conversation sounds like this: “How fortunate you are to be able to see well at a distance, our nearsighted patient’s do not have that luxury. Due to the eye’s naturally occurring changes, we all lose the ability to readily focus from distance to near; actually, it would be strange if this didn’t happen!” Being sensitive to how the patient is feeling about the hyperopic diagnosis is as important as educating them on treatment options.
2. Offer the latest spectacle lens technologies. This helps to enhance the patient’s vision and also reduces the magnification associated with hyperopic lenses. Doctors and opticians who are proficient at explaining the benefits of improved lens technology to reduce lens thickness, weight, and distortions make a great impression on easing any patient angst surrounding choosing the right pair of glasses. I prescribe high-index digital or polycarbonate lenses that have AR coatings to meet this need. Also, if there are any team members in the practice who are hyperopes, it’s a nice touch to share their visual correction success stories with the patient.
3. Ask whether the patient is interested in contact lenses. If so, present the technologies available to the patient. At my practice, I assume every spectacle lens patient is a contact lens patient until I prove or they say otherwise. I stress the importance of a healthy contact lens fit for optimal comfort and vision; to this end, I start the conversation by pointing out how daily disposable lenses have changed the contact lens experience by eliminating the burden of cleaning lenses and proper storage. I stress there is nothing healthier than putting on a fresh contact lens everyday. Of course, depending on the patient’s wants and lifestyle needs, ODs can be confident in pivoting to reusable lenses if need be. Surprisingly, many patients interested in contact lenses have the perception that wearing contact lenses is an automatic commitment to full-time wear. When discussing the benefits of contact lens wear, optometrists should be certain to point out that being fit with contact lenses is not an “all or nothing” proposition. I love to brag about my many patients who are happy, successful part-time wearers as well.
4. Keep surgical procedures as a viable option. Some patients will feel spectacles and contact lens corrections are too cumbersome, or are simply not their “cup of tea.” These discussions have certainly changed over time due to advances in hyperopic laser vision correction and clear cataract extraction. Prior to these advances, we didn’t mention surgical options to this group unless they inquired about them. We used to proactively recommend laser vision correction and refractive lens exchanges, almost exclusively, to the high myope or the high myopic presbyope who was nearing the “cataract years.” Now, we do not pigeon hole these procedures based on the type or magnitude of refractive error. These surgical procedures can be life-changing for a good many of those who are proper candidates.

Helping hyperopes

With the many challenges of modern daily life — such as navigating cell phones, tablets, computers, and car dashboards that look like flight deck cockpits — near and intermediate visual demands have never been greater among our patients. Couple this with an ever-increasing aging population, and the number of those who are needing and seeking eye care services continues to grow rapidly year after year.

With timely diagnosis and early treatment, hyperopes of all ages can experience the visual performance and satisfaction they deserve. If we hold true to the foundations of what we do best, it is a win for patients and ODs. OM

References

1. Majumdar S, Tripathy K. Hyperopia. StatPearls [Internet]. Jan. 2023. Updated Feb. 23, 2023. Acccessed Aug. 10, 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560716/
2. Kulp TM, Ciner EB, Mitchell GL, at al. Prescribing Patterns for Hyperopia. Invest Ophthalmol Vis Sci. 2021;62(8):137.

DR. LOWE is owner/director of Professional Eye Care Center, a full-scope primary care office she founded in 1992 on the northwest side of Chicago. She is a Fellow with the American Academy of Optometry, a Diplomate of the American Board of Optometry, and current chair of the American Optometric Association Strategic Communications Committee. Dr. Lowe is also an administrator/medical director for Vision Source Chicagoland.