1. Childhood Hyperopia NEIL SINCLAIR RVEEH MOTILITY JNL CLUB EDITED BY LIONEL KOWAL

2. Slide 1 Epidemiology Prevalence Prevalence Definition varies between studies ie some use spherical equivalent and others most hyperopic meridian. Definition varies between studies ie some use spherical equivalent and others most hyperopic meridian. Some use cycloplegia, some not. Some use cycloplegia, some not.

3. Slide 2 Epidemiology Atkinson J et al (Cambridge infant screening program ) Study 1 Children 6-9 m invited for exam (71% attended) 1096 screened hyperopia without anisometropia 4.6%. Cycloplegic photorefraction 3.5D and hyperopia confirmed with retinoscopy hyperopia without anisometropia 4.6%. Cycloplegic photorefraction 3.5D and hyperopia confirmed with retinoscopy Study 2 Children 7-9 m invited for exam (74% attended) 3166 screened hyperopia without aniso 5.7% hyperopia without aniso 5.7% Study 3 Children 8 m invited for exam (84%attended) 5091 screened hyperopia without aniso 4.5%. Noncycloplegic photo refraction with a criterion for hyperopic focus: accommodative lag > 1.5D hyperopia without aniso 4.5%. Noncycloplegic photo refraction with a criterion for hyperopic focus: accommodative lag > 1.5D

4. Slide 3 Epidemiology UK: typical state of the infant eye at 8-9 m is modest hyperopia (+1.5 D) UK: typical state of the infant eye at 8-9 m is modest hyperopia (+1.5 D) long ‘tail’ of significant hyperopia in 5% long ‘tail’ of significant hyperopia in 5% This refraction identifies a group at increased risk of strabismus and poor acuity by age 4. This refraction identifies a group at increased risk of strabismus and poor acuity by age 4.

5. Slide 4 Epidemiology Other estimates of hyperopia prevalence come from smaller studies which are not population based and can over estimate the prevalence due to participation bias. Other estimates of hyperopia prevalence come from smaller studies which are not population based and can over estimate the prevalence due to participation bias. Cook et al (1951) found ≥ +3D SE hyperopia in 30% of newborns. 1000 cycloplegic refractions. Cook et al (1951) found ≥ +3D SE hyperopia in 30% of newborns. 1000 cycloplegic refractions. Mutti et al (2005) found +3D of hyperopia in 23.5% of 221 infants at 3m, reduced to 5.4% by 9 m Mutti et al (2005) found +3D of hyperopia in 23.5% of 221 infants at 3m, reduced to 5.4% by 9 m Ingram et al (2000) screened 6700 infants at 6 m, 9.2% with +3.5 of meridional hyperopia. Ingram et al (2000) screened 6700 infants at 6 m, 9.2% with +3.5 of meridional hyperopia. Ingram et al also (1979) studied 1648 infants at 1 year. 3.7% with +3.5D of meridional hyperopia. Ingram et al also (1979) studied 1648 infants at 1 year. 3.7% with +3.5D of meridional hyperopia.

6. Slide 5 Natural History and Emmetropization Corneal curvature, lens power and position and axial length are quite variable in the newborn. Corneal curvature, lens power and position and axial length are quite variable in the newborn. The range of refractive error is from –2 to +4 (Brown 1938). The range of refractive error is from –2 to +4 (Brown 1938). most children are born hyperopic and become less so. most children are born hyperopic and become less so.

7. Slide 6 Natural History and Emmetropization Mutti (2005): comparing hyperopia at 3m (23.5%) with 9m (5.4%) suggested emmetropization in 1st 12 m. Mutti (2005): comparing hyperopia at 3m (23.5%) with 9m (5.4%) suggested emmetropization in 1st 12 m. Ingram (1979) followed patients at 12m and compare the rates of hyperopia at 3.5y and found little change (10.8% vs. 11.8%) Ingram (1979) followed patients at 12m and compare the rates of hyperopia at 3.5y and found little change (10.8% vs. 11.8%) So this process mostly occurs in the first year of life. So this process mostly occurs in the first year of life.

8. Slide 7 Natural History and Emmetropization Other studies have shown that there is a split in eyes that emmetropize with those eyes with lesser degrees of hyperopia emmetropizing normally. Other studies have shown that there is a split in eyes that emmetropize with those eyes with lesser degrees of hyperopia emmetropizing normally. Mutti (2005) showed a split a 4D - patients above this level failed to emmetropize Mutti (2005) showed a split a 4D - patients above this level failed to emmetropize Confirmed in smaller studies by Pennie (2001) and Dobson & Sebris (1989). Confirmed in smaller studies by Pennie (2001) and Dobson & Sebris (1989).

9. Slide 8 Natural History and Emmetropization Wood et al (1995) showed that even though the trend is towards emmetropia there is a large amount of scatter. Wood et al (1995) showed that even though the trend is towards emmetropia there is a large amount of scatter. Some children who are hyperopic can become worse Some children who are hyperopic can become worse The scatter is so marked that that you are unable to predict how hyperopic individuals will end up The scatter is so marked that that you are unable to predict how hyperopic individuals will end up

10. Slide 09 Risk Indicator for Hyperopia and Ethnic Variation A Twin study by Hammond et al (2001) demonstrated a high concordance of hyperopia in monozygotic twins compared to dizygotic twins. A Twin study by Hammond et al (2001) demonstrated a high concordance of hyperopia in monozygotic twins compared to dizygotic twins. In a population of 34 newborns to parents/ siblings with accommodative ET, hyperopia of 4D was found in 38% of infants at 6m. In a population of 34 newborns to parents/ siblings with accommodative ET, hyperopia of 4D was found in 38% of infants at 6m.

11. Slide 10 Risk Indicator for Hyperopia and Ethnic Variation There is no ethnic based data on infants. The Refractive error studies in children compared refractive error in children as young as 5 There is no ethnic based data on infants. The Refractive error studies in children compared refractive error in children as young as 5 Chile 2D hyperopia in 24.5% of right eyes (myopia 3.4%) Chile 2D hyperopia in 24.5% of right eyes (myopia 3.4%) Nepal 2D hyperopia in 1.9% of right eyes (myopia 0.4%) Nepal 2D hyperopia in 1.9% of right eyes (myopia 0.4%) Separate study Finnish 2D hyperopia 12.5% Separate study Finnish 2D hyperopia 12.5%

12. Slide 11 Risk Indicator for Hyperopia and Ethnic Variation Robaei et al. Recent Australian paper gave prevalence of 4.6% in whites and 2.4% in non whites Robaei et al. Recent Australian paper gave prevalence of 4.6% in whites and 2.4% in non whites Cleere (refractive error and ethnicity in children) demonstrated racial differences in rates of hyperopia (1.25D) in children from 5 to 17 years of age. Whites 19.3%, Hispanics 12.7% Asians and blacks 7%. Cleere (refractive error and ethnicity in children) demonstrated racial differences in rates of hyperopia (1.25D) in children from 5 to 17 years of age. Whites 19.3%, Hispanics 12.7% Asians and blacks 7%.

13. Slide 12 Risk Indicator for accommodative ET Ingram et al Ingram et al 285 patients at 6m with 4D of hyperopia followed for 3.5 years 285 patients at 6m with 4D of hyperopia followed for 3.5 years 24% became esotropic 24% became esotropic patients at 12m with 3.5D of hyperopia patients at 12m with 3.5D of hyperopia 45% became esotropic 45% became esotropic Atkinson et al Atkinson et al 124 patients at 6-8, with 3.5D hyperopia 124 patients at 6-8, with 3.5D hyperopia 15% became esotropic 15% became esotropic 1.6% of emmetropes became esotropic 1.6% of emmetropes became esotropic

14. Slide 13 Risk Indicator for accommodative ET In a population of 34 newborns to parents/ siblings with accommodative ET In a population of 34 newborns to parents/ siblings with accommodative ET 6 children (18%) all of which were hyperopic were found to have accommodative esotropia. 6 children (18%) all of which were hyperopic were found to have accommodative esotropia. Abrahamsson et al (1999) hyperopia and family history were more predicative of esotropia if found together. Abrahamsson et al (1999) hyperopia and family history were more predicative of esotropia if found together.

15. Slide 14 Risk Indicator for accommodative ET Persistence of hyperopia is also a factor Persistence of hyperopia is also a factor Reduced binocular vision and anisometropia may also influence the outcome of hyperopia. (these factors are very difficult to separate) Reduced binocular vision and anisometropia may also influence the outcome of hyperopia. (these factors are very difficult to separate) Ethnicity Ethnicity

16. Slide 16 Why do some patients with high hyperopia escape strabismus Why do some patients with high hyperopia escape strabismus Von Noorden suggested subnormal stimulus ACA ratios Von Noorden suggested subnormal stimulus ACA ratios

17. Slide 17 Preventing accommodative ET in hyperopes Ingram et al (1990) 6m with hyperopia Ingram et al (1990) 6m with hyperopia 152 treatment (specs) 13% ET 152 treatment (specs) 13% ET 154 no treatment 18% ET 154 no treatment 18% ET Not significant even when corrected for poor wear Not significant even when corrected for poor wear Ingram et al (1990) 12m with hyperopia Ingram et al (1990) 12m with hyperopia 144 treatment 24% ET 144 treatment 24% ET 141 No treatment 26% ET 141 No treatment 26% ET

18. Slide 18 Preventing accommodative ET in hyperopes Atkinson et al Atkinson et al 68 treatment 8.8% strabismic 68 treatment 8.8% strabismic 56 no treatment 23.2% strabismic 56 no treatment 23.2% strabismic This was not confirmed by a second study This was not confirmed by a second study The value of early spectacles in early hyperopia is still unclear The value of early spectacles in early hyperopia is still unclear

19. Slide 19 Can dynamic retinoscopy help? Can dynamic retinoscopy help? An objective assessment of an infants accommodation. An objective assessment of an infants accommodation. Can we pick those individuals who may develop accommodative ET? Can we pick those individuals who may develop accommodative ET?