1. Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA
The objectives of this section are: Determine the prescription criteria in cases of subjects with hypermetropia.
This section is structured for:
5 hours of theory
1 job outside of the classroom
It does not provide directly associated practice. Simultaneously, we recommend that the students continue exercising clinical refraction techniques.
The methodology of the classes will be different according to the concrete objectives of the distinct sections and it will be commented upon in each of them.

2. HYPERMETROPIA: PROGRAM
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: PROGRAM

3. Hypermetropia: program I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: program I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Generalities:
Definition
Etiology and epidemiology
Signs and symptoms
Classification:
According to magnitude
According to refraction
According to the accomodative capacity
In the Generalities section the objective is to refresh previous knowledge that the students have about these aspects, explained in previous modules. Consequently there is no reason that class needs to me attended in person. Students can count on between 2 and 4 hours of personal work to refresh the previous knowledge.
We recommend working in groups of 3-4 students and the following procedure:
Turn in a summary of the section similar to the one in the slide for the section of Generalities.
Recommend a first step that consists of refreshing knowledge from previous modules that dealt with ametropias.
Professor’s interview with each of the groups in which strong and weak points in the summary realized up to that point will be detected. Elaboration along with any necesasry amplification for each group.
With the recommended books in this theme’s bibiography and with the webpages listed the students can improve their knowledge.
A definitive work handed in to the professor who can decide what will form part of the system of evaluation.
A later, corrected work handed in and indicating the quality of the work and assessing the capacity for synthesis.
The section of classification deserves greater relevance because it will be done partially as masterly exposition by the professor as well as through resolution of exercises by the students. We recommend individual work at this point.

4. Hypermetropia: program II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: program II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Clinical exam:
VA: hypermetropia and age
Characteristics of the retinoscopy
Characteristics of the subjective exam
Low refraction cycloplegia
Binocularity: effect of the optical compensation
In the clinical exam section we hope to determine the concrete peculiarities that clinical exploration of patients with hypermetropia can present. Students may have previous knowledge of some aspects from other modules, which is why we recommend the following course of action:
Exercise: in the corresponding section a proposal will be put forth.
Individual resolution in the classroom
Self-evaluation: the professor develops answers to different questions in tight collaboration with the students.
Detection by the students of their strong and weak points followed by open class comparison and discussion.
When a major lack of knowledge is detected: add the theme to the contents of the theoretical classes.
When a lack of concrete knowledge is detected: resolve it using tutorials

5. Hypermetropia: program III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: program III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Prescription criteria:
Hypermetropes from age 0 to 6
Hypermetropes from age 6 to 20
Hypermetropes between 20 and 45
Hypermetropes between 45 and 65
Hypermetropes older than 65
Resolution of clinical cases
The prescription criteria section is the most important of the module. It is necessary to dedicate sufficient time to this part. Among other possibilities we’ve chosen to display the prescription guidelines depending on age.
The teaching methodology is that of an attendance-based class of the magisterial type, respecting and stimulating student involvement.
It is important that the teaching introduce examples of patients. This will make the class more pleasant, but mainly will assure that the student see the direct application of the contents of the section.
The theme ends with a specific section on clinical cases that will allow the students to apply the knowledge acquired throughout the theme. In this section the teaching methodology requires the student’s active collaboration. The recommended steps are:
Work in groups of 4 students maximum
Give each of them the case breakdown and the corresponding questions
Have the students read and begin to think about and prepare the answers. During this time and in order to assure work on development of the following phases it is essential that the professor checks in with each and every group resolving doubts, posing questions, reflecting, etc.
After a reasonable period of time go on to class discussion, in which the professor has the role of moderator during the first two questions and helps to forment a reasonable critique.
Continue simimlarly for the rest of the questions regarding the case.

6. HYPERMETROPIA: GENERALITIES
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: GENERALITIES

7. Hypermetropia: Generalities I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Generalities I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
A condition in which the rays that come from a far away object, the eye being accomodatively relaxed, form their image behind the retina.
The structural causes of hypermetropia can be:
Small axial length of the eye
Weak eye
An error in the relation between the axial longitude and the power
We hope to use the slide to refresh student’s previously acquired and worked-on knowledge of concepts dealing with hypermetropia.

8. Hypermetropia: Generalities II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Generalities II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Epidemiology:
66% of the population has a refractive error in the range of +0,50D a +2,37D
Etiology:
Genetic influence
Environment and visual demands
Little is known about the factors related with the etiology of hypermetropia. We only can say:
Small levels of hypermetropia are considered normal as the final result of the process of emmetropization. This is what epidemiological studies show.
An important genetic influence has been found in moderate hypermetropia and, mainly, in elevated cases.
Various studies address the influence of environmental factors on ametropias, but the focus of attention has always been on myopia and on occasions astigmatism. We can only say that populations in which schooling is less common have a greater prevalence of hypermetropia than societies in which schooling is more common.

9. HYPERMETROPIA: CLASSIFICATION
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: CLASSIFICATION

10. Hypermetropia: Classification I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Classification I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
According to the magnitude of the total hypermetropia:
Low hypermetropias: between +0,25 and +2,00 D
Moderate hypermetropias: between +2,25 and +5,00 D
Elevated hypermetropias: above +5,00 D
A simple way of classifying hypermetropia is by paying attention to its magnitude. Various authors agree that:
Low hypermetropias: between +0,25 until +2,75D. Evidently, the affectation of the VA and the presence or lack thereof of symptomology is very influenced by age, but in general we can say that in cases of low hypermetropias the patient does not tend to show symptoms until years of age; the VA in DV does not tend to be affected until the arrival of the presbyopia or even afterwards; and the VA in NV tends to be normal until a few years before the appearance of presbyopia. These patients frequently recount a history of use of glasses exclusively for NV and it is not until the arrival of the presbyopia that they begin to use glasses for all distances.
Moderate hypermetropias: from +3,00 to +5,00D. There are few hipermetropes that, in reality, pass the limit of 5,00 dioptres. In these cases the signs appear during infancy and a previous infantile endotropia (deviation shows in a visual axis towards the nose). At the beginning of school attendance the symptoms appear or the rejection of visual tasks of reading and writing. Despite the symptomolgy, the VA in DV can be normal even in youths, but in adults it diminishes.
High hypermetropias: above +5,00D. Signs: starting from the first few years and rapidly thereafter the VA without correction results diminished, even in young patients.

11. Hypermetropia: Classification II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Classification II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
According to refraction:
H. Total (HT): Total magnitude of the hypermetropia. It is the value of the retinoscopy, using an appropriate accomodation control. In some cases the cycloplegic refraction can be necessary.
H. Manifest (HM): that which the patient shows through the subjective refraction. It is the part of the HT that, in some patients, allows compensation through the lenses + (without diminishing VA in DV)
H. Latent (HL): that which does not appear in the realization of the subjective exam. It is the part of the HT that, in some patients, does not allow compensation (secondary to the excessive tone or spasm of the ciliary muscle)
A traditional way of classifying the hypermetropia is by paying attention to a patient’s answers in the subjective exam. In some cases the value, or the near value, of the hypermetropia determined through the realization of a good retinoscopy is going to coincide with the result of the subjective exam. But on other occasions an excessive tone/spasm of the ciliary muscle is not going to permit the subjective acceptance of the totality of the hypermetropia and marked differences between the objective and subjective values of the refraction will be found.

12. Hypermetropia: Classification III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Classification III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
H TOTAL = H MANIFEST + H LATENT
Example 1:
Youth of 16; no previous Rx
VAsc in DV: 20/20 in RE and LE
Retinoscopy: +3,50
Subjective: +1,00 (if the positive is augmented, the VA and visual comfort from distances will be lost)
Latent hypermetropia is considered clinically significant if it is  1,00D
At this point it is very important to provide some examples similar to the one described in the slide.
Solution example 1:
H total= +3,50D
H manifest= +1,00D
Consequently an H latent exists = +2,50D
NOTE: Rx: refraction; sc: without correction; for the VA, the notation of Snellen has been used in feet

13. Hypermetropia: Classification IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Classification IV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
According to the accomodative capacity:
H. Total (HT): Total magnitude of the hypermetropia. It is the value of the retinoscopy, utilizing an appropriate accomodation control. In some cases cycloplegic refraction can be necessary.
H. Absolute (HA): that which cannot be compensated for by the accomodative capacity of the patient. It is responsible for the fact that a hypermetrope cannot achieve a normal VA in DV.
H. Facultative (HF): that which can be compensated for by the accomodative capacity of the patient.
Another traditional way of classifying hypermetropia is by paying attention to the patient’s possibility of compensating for the hypermetropia through his/her accomodative capacity.
We can find that:
A subject can compensate for all of his/her hypermetropia through his/her accomodative capacity. This is to say, he/she is a hypermetrope without correctiong, but his/her VA is at 1. The totality of the hypermetropia is facultative.
A subject cannot compensate for any part of his/her hypermetropia through accomodation. This is to say, he/she is a hypermetrope that, without correction, has low VA; in addition, until the patient puts on the trial frames the totality of his/her hypermetropia does not reach an VA of 1. The totality of the hypermetropia is absolute.
Intermediate cases: without hypermetropic correction the patient does not achieve a good VA, but it is not necessary to compensate for the totality of his/her hypermetropia for an VA of 1. Part of his/her hypermetropia can accommodate and the other part cannot.
Before the same magnitude of the total hypermetropia the age of the patient is going to be a decisive factor in determining which part of his/her hypermetropia is facultative and part absolute.

14. Hypermetropia: Classification V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Classification V
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
H TOTAL = H FACULTATIVE + H ABSOLUTE
Example 1:
Patient, 52-years-old ; no previous Rx
VAsc in DV: 20/40 en RE
Retinoscopy: +2,25
Positive minimum necessary in order to achieve an VA of 20/20: +1,50
Subjective: +2,25
In this case it is also necessary to work with examples like the one in the slide:
H total (the value of the retinoscopy)= +2,25
H absolute (that which cannot be compensated for through accomodation)= +1,50
H facultative the difference)=+0,75. It is the quantity of hypermetropia that CAN be compensated for through accomodation and, although not neutralized through use of lenses, the patient shows a good VA.
REFLECTION: having a good VA is not a synonym for the absence of symptoms. For example:
A 20-year-old hypermetrope (+ 3,50) subject shows, without correction, good VA from a distance and even from close up. Nonetheless, the symptoms of fatigue will be very marked if he/she realizes prolonged visual activity without the appropriate optical correction.
NOTE: Rx: refraction; sc: without correction; for the VA, we have used Snellen’s notation in feet

15. HYPERMETROPIA: CLINICAL EXAM
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: CLINICAL EXAM

16. Hypermetropia: Clinical exam I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Case history
Symptoms in NV
Symptoms of anticipated presbyopia
Lack of concentration
Elimination of task in NV
Occasional diplopia
The symptoms of hypermetropia without compensation were already discussed in the general section describing ametropia, and could have been included in the work linked to the second slide in this theme.
The slide that shows a summary of the symptoms that will be easily identifiable by the students.

17. Hypermetropia: Clinical exam II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Visual acuity: The VA will be determined by:
The grade of hypermetropia
Age of the patient and accomodative capacity
General state of health of the patient
Previous concepts:
Amplitude of monocular accomodation
Methods to determine the amplitude of accomodation
Amplitude of the comfortable accomodation
Just as we commented in the slide, we share some of the student’s previous knowledge:
Concept of amplitude of accomodation: maximum accomodative capacity of the patient. Depends directly on age. It has small changes depending on the geographic latitude of distinct countries.
Methods to determine the amplitude of accomodation. In the section in which we deal with amplitude of accomodation we have already explained the two main methods to the students:
Method of nearing movement or Donders’ method. Remember that some tables exist with common values determined in 1864 by Donders and an approximation through Hofstetter’s formulas.
Method of negative lenses or Sheard’s method. There also exist some tables with normal values for distinct ages with this method.
Concept of amplitude of comfortable accomodation. It is evident that an individual cannot employ, in a prolonged way, his/her capacity for accomodation because the fatigue would be nearly immediate. There is no real agreement between authors regarding the value of amplitude that can be considered comfortable. We suppose that it is ½ of the total accomodative capacity
Given that the accomodative capacity diminishes with the passing years it is logical to think that a moment will arrive when the patient will not be able to work comfortably at his/her habitual work distance. This is the moment in which presbyopia appears.

18. Hypermetropia, VA and age
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia, VA and age
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Condition
Age
Am Accom.
total
Am. Accom.
Comfort
Necessary Accom. DV
ExpectedVA DV
Necessary
Accom.
40cm
ExpectedVA 40cm
EMMETROPE 20 40 60
HYPERMETROPE
+2,50 sc
MYOPE
-2,50 sc
In order to fill in the chart it is a good idea to:
Explain what each of the columns represents to the students:
Am Accom total: to determine the average amplitude of accomodation through Hofstetter’s formula, for example, the capacity of accomodation that we expect from this individual. We must remember the formula:
AA = 18,5 – agex0,3
Am Accom comfort: the level of accomodation the person can realize in a prolonged way without loss of VA or appearance of stenopaic symptoms. There are various criteria, but one of the most commonly used is that which supposes that:
Am Accom comfort = ½ Am Accom total
Necessary Accom in DV: The accomodation that the individual needs to realize in order to see objects at a distance.
Expected VA in DV: keeping th previous column in mind and the accomodative capacity of the person, try to give an approximation of the Expected VA in DV.
Necessary Accom at 40cm: the accomodation that the individual needs to realize in order to be able to see object clearly using near vision, keeping in mind the distance of observation (in this case 40cm) and the refractive error.
Expected VA at 40cm: depending on the previous column and the capacity of comfortable accomodation of the person, evaluate the possible VA what will be present in NV.
Allow the students a period of time for reflection, individual or in groups.

19. Hypermetropia, VA and age
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia, VA and age
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Condition
Age
Am Accom.
total
Am comfort. Accom.
NecessaryAccom. DV
ExpectedVA DV
Necessary
Accom.
40cm
ExpectedVA 40cm
EMMETROPE 20
12,5
6,25 1
(20/20)
2,5
20/20 40
6,5
3,25 60
0,5
0,25
≤20/100
HYPERMETROPE
+2,50 sc
2,50
5,0
≈20/40
≤20/200
MYOPE
-2,50 sc
0,1 (20/200)
Anterior slide resolution. Proceed by resolving each of the cases between the professor and the students. It is normal that at the beginning the procurement of the results will be very guided by the professor, but as the students get used to hypothesizing let them search for the solutions by themselves.

20. Hypermetropia: Clinical exam III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Retinoscopy without cycloplegia
Good fogging
Look for fluctuations in the reflex
Assess variations of the pupil’s diameter
Confirm astigmatisms
Remind of the importance of controlling the individual’s accomodation when realizing the retinoscopy. This is progressively more important the younger a person is.

21. Hypermetropia: Clinical exam IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam IV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
IMPORTANT: Do not confuse mydriatic effect with cycloplegic effect
Retinoscopy with cycloplegia
When there is suspicion of a greater hypermetropia than discovered in the retinoscopy
When endotropias exist
When there is very low collaboration
Commonly used medications:
To briefly explain the principle of cycloplegic medications. Assess with the students whether or not the medication described in the slide appears to them to be the most adequate in each case. As a summary:
Atropina: specifically for children with endotropias
Ciclopentolate: medication of choice, in general
Tropicamide: not recommendable due to its low cycloplegic effect
As a general rule for hypermetropes we can say that from the value of the retinoscopy under cycloplegia we must discount 1,00D in order to determine the maximum value of the prescription (by the tone of the ciliary muscle)
MEDICATION
OPTIMAL CYCLE
DURATION
EFFECT
RESIDUAL ACCOM.
Atropina
24 – 48 h
12 – 18 días +
Ciclopentolate
30’ – 45’
8 – 10 h ++
Tropicamide
20’
2 – 5 h
+++

22. Hypermetropia: Clinical exam V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam V
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Subjective exam in hypermetropes:
Begin the exam with the brute value of the retinoscopy
When the H. Total  H. Manifest special considerations are not necessary
When a significant grade of H. Latent exists the subjective exam is an art
The realzation of the subjective exam has already been dealt with in the corresponding slide.

23. Hypermetropia: Clinical exam VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Clinical exam VI
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Subjective exam in cases of latent hypermetropia:
Essential to maintain the fogging at all times
The dioptric variations necessary to get a line VA are not logical
It is not always necessary to arrive at VA 1 the monocular way
The patient tends to reject or diminish retinoscopic astigmatisms in the subjective exam (back yourself up with keratometria)
In anisometropias: guide yourself by the retinoscopy
Just like we commented in the previous slide, realizing the subjective exam in cases of latent hypermetropia is not easy. Some recommendations are provided in the slide: We emphasize that when realizing the subjective exam with young subjects and/or with latent hypermetropia:
It is important to differentiate when a patient is fogged (patient has more positive than corresponds to him/her) or demonstrates a latent hypermetropia that does not allow itself to be neutralized with positive lenses. In the first case, diminishing the of the sphere by 0,25 will provoke, almost automatically, an improvement of the visual acuity in a line. When dealing with a latent hypermetropia a much greater dioptric change can be necessary in order to improve the line visual acuity.
Relaxing the accomodation in cases of latent hypermetropia is more easily achieved in binocular conditions than monocular. This is why in these cases it is advisble to finalize the monocular subjective with an VA near to 0,8 and to dedicate more attention to the binocular exam, where greater acceptance of the hypermetropia is possible.

24. Hypermetropia: clinical exam VII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: clinical exam VII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Binocularity and accomodation
An uncorrected or partially corrected hypermetropia can:
Associate itself with more or less pronounced myosis
Associate itself to endodeviations, mainly in NV
Simulate a fatigue or an accomodative insufficiency
In this section it is necessary to remind the students ahead of time of the shared innervation of the “proximal triad”:
Accomodation
Pupil’s diameter
Convergence
When a subject with accomodative capacity presents an uncompensated hypermetropia, or just partially compensated, he/she is going to require greater accomodation. The innervation necessary for this additional exertion of accomodation will provoke, in a secondary and inevitable way:
An excessive innervation to the sphincter muscle in the iris: will provoke myosis
An excessive innervation of the convergence: will provoke latent endodeviations (endophoria) or manifest endodeviations (endotropia)
In these cases, in addition, the symptomology of the patient can be confused with accomodative fatigue, with accomodative insufficiency, or even with an early presbyopia. Whichever of these three diagnoses would be erroneous, since the only visual disfunction that the individual would present would be a hypercorrected hypermetropia.

25. HYPERMETROPIA: PRESCRIPTION CRITERIA
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: PRESCRIPTION CRITERIA

26. Hypermetropia: Prescription criteria I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Prescription criteria I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Patient’s age
Grade of hypermetropia
Symptoms
Binocular dysfunction associated
In the following section we are going to display some indicative prescription critieria for hypermetropes. Students must take into account the factors shown in the slide:
Age of the patient. A magnitude of the hypermetropia of the same size can have a very different clinical treatment in a youth than in an elderly patient.
The magnitude of the hypermetropia . It is logical to think that the clinical significance for person presenting a hypermetropia of +0,50D or of +2,50D is not the same.
Symptoms that the patient experiences
The possible existence of a binocular disfunction. Hypermetropias of may have different treatments in subjects of the same age, one having endodeviation and the other having exodeviation.

27. Hypermetropia: Prescription criteria II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Prescription criteria II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 0 to 6 years of age
Reason for the consultation:
School check-up.
It seems that one eye deviates.
Family history.
There do not tend to be subjective complaints.
Reason for the consultation:
Children at these ages do not tend to make complaints regarding their vision
Revision
Family history
It seems that one eye averts/turns away
The child winks or rubs at the eyes frequently

28. Hpermetropia: Prescription criteria III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hpermetropia: Prescription criteria III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 0 to 6 years of age
Hypermetropia < 3 D: does not tens to be prescribed,as long as it is not found to be associated with a binocular dysfunction, a low VA, or an astigmatism 1,50D.
Hypermetropia >3 D. Generally prescribed (totally or partially), since it can be associated with or induce:
 VA.
 development of binocular vision.
Prescription guidelines according to the value of the hypermetropia:
Hypermetropia inferior to 3 D: does not tend to be prescribed as long as it is not found to be associated with a strabismus or low visual acuity. Realize periodical check-ups.
Hypermetropia superior to 3 D. Generally prescribed, totally or partially, since it can be associated with or induce:
Low visual acuity
Problems in the development of binocular vision
In children, if thinking of prescribing glasses and an astigmatism exists, prescribe for the astigmatism totally in order to facilitate the development of vision. Do frequent check-ups, given that at these ages even the astigmatism can go through important changes.

29. Hypermetropia: Prescription criteria IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Prescription criteria IV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 0 to 6 years of age
Hypermetropia + endotropia:
A cycloplegia tends to be necessary.
Evaluate deviation in DV and NV.
Evaluate the effect of positive lenses in NV.
Always prescribe the maximum positive power.
Hypermetropia + exodeviations:
Do not prescribe or PARCIALIZAR the prescription.
Prescription guidelines according to the binocular vision:
With frequency, elevated hypermetropias in children (superior to 3 D) come associated with endotropias (totally or partially secondary to the refraction)
If we observe an endotropia: realize a careful refractive study and reevaluate the binocularity with the value of the refraction:
If with the refraction (objective) the strabismus is eliminated as much from distances as from close up: prescribe glasses for everyday use. Schedule check-ups for every 6 months.
If with the refraction (objective) the strabismus is not eliminated it is necessary to realize an exam under cycloplegia
In all cases of association between hypermetropia and endotropias prescribe the maximum positive power
If an exotropia is observed (it is infrequent) it is recommended not to prescribe or to PARCIALIZAR the prescription.

30. Hypermetropia: Prescription criteria V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Prescription criteria V
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 0 to 6 years of age
Low bilateral vision (pathological cause): Total prescription to reserve the accomodation for NV.
Hypermetropia and anisometropia:
Hypermetropia + external ocular infections: Evaluate the necessity to prescribe in Hp > 1 D or 1,50 D.
Prescription guidelines according to anisometropia: pay attention to the previous recommendations on the necessity of the prescription (depending on the grade of hypermetropia and on the state of binocular vision). Nonetheless, if glasses are prescribed, it is recommendable to maintain the anisometropia in the prescription.
Hypermetropia in cases of children with external ocular infections: with frequency the children rub their eyes with dirty hands and this can provoke or aggravate, in a recurring way, external ocular infections. In these cases, the prescription of glasses with a protection barrier is recommended.

31. Hypermetropia: Prescription criteria VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: Prescription criteria VI
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 6 to 20 years of age
Up until puberty hypermetropia tends to diminish.
At these ages  demands on NV.
Diverse reasons for consultation.
Importance of latent hypermetropias.
Until years of age, hypermetropia tends to diminish. After these ages the value remains stable with small variations. This is true if we refer to the refractive exam through the retinoscopy.
In the age groups we are dealing with it is easy to find latend hypermetropias or partially latent ones: there is an important hypermetropia that can be seen through the retinoscopic exam, but the patient does not accept the total prescription of the refractive error in glasses.
At these ages, due to schooling, visual demands increase, which is why it is possible that symptoms of visual tiredness appear at this time, mainly when studying.
Reason for consultation:
Check-up
Lack of concentration and efficiency in studies. There are various scientific studies that show that children with moderate, uncorrected hypermetropias demonstrate poorer academic efficiency and less concentration
“Ocular reddening” (conjunctival hyperaemia) after long periods of study, due to the ocular exertion it involved.
Ocular/visual tiredness referred to by the child or youth

32. Hypermetropia : Prescription criteria VII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria VII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 6 to 20 years of age
Hypermetropia < 1,50D: does not tend to be prescribed, as long as it is not found to be associated with a binocular dysfunction or visual fatigue in NV.
Hypermetropia >1,50D. Generally prescribed for, totally or partially, and especially if it is associated with an astigmatism > 0,75D.
Prescription guidelines according to the value of the hypermetropia:
Hypermetropia inferior to 1,50D: does not tend to be prescribed, as long as it is not found to be associated with a binocular dysfunction, of the endodeviation type, or visual fatigue in near vision. It is essential to inform the subject of his/her refractive error and to make a clear argument for our decision not to prescribe for the time being.
Hypermetropia superior to or equal to 1,50D: generally prescribed, totally or partially. Mainly recommend the use of glasses for near vision. You have to keep in mind that children wear the glasses all the time in order to insure their use and to minimize loss and breakage.
Prescribe for low hypermetropias (even of 0,75D) if they are accompanied by astigmatisms superior to or equal to 1D. Recommend, again, the use of glasses mainly for near vision.

33. Hypermetropia : Prescription criteria VIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria VIII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 6 to 20 years of age
Hypermetropia + endodeviation: total prescription. Constant use or principally for NV
Hypermetropia + exodeviations: bias the prescription (without affecting the visual comfort in NV)
Prescription guidelines according to binocular vision:
In cases with endodeviation:
If the hypermetropia from the retinoscopy is similar to that from the subjective (there is hardly latent hypermetropia): prescribe the totality of the hypermetropia for general use. The patient may accept or deny the use of glasses, for aesthetic or comfort reasons, but we are sure that their vision with the glasses is good at all distances. In the case of very responsible children or older children it may be necessary to emphasize their use for near vision during reading and writing tasks.
If the hypermetropia determined through the retinoscopy is markedly greater than that obtained through the subjective exam: we are facing a case of latent hypermetropia. The prescription of glasses is necessary, but with them the child does not see well from far away, which will make their use more difficult. We can begin use of the glasses with a PARCIAL prescription and recommend a check-up within a few months with the final goal of prescribing the totality of the hypermetropia. Obviously, emphasize the use of the glasses for near vision paying attention to, nevertheless, recommendations from previous points.
In the case of existence of an exodeviation: Do not prescribe or PARCIALIZAR the prescription.

34. Hypermetropia : Prescription criteria IX
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria IX
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 6 to 20 years of age
Low bilateral vision (pathological cause): total prescription in order to reserve the accomodation for NV.
Hypermetropia and anisometropia:
Up until 8-10 years of age we can prescribe for the total anisometropia
 10 years of age: prudence with anisometropias if they have never before been prescribed for
Hypermetropia + external ocular infections:
Evaluate the necessity of prescribing in hypermetropias > 1 D.
Prescription guidelines according to the anisometropia: pay attention to the previous recommendations on the necessity of prescription (depending on the grade of the hypermetropia and the state of binocular vision). Nonetheless, if prescribing glasses it is advisable to maintain the anisometropia in the prescription for the youngest patients. From 8-10 years of age and onward, if the child has never worn glasses or a prescription for anisometropia, it is going to be more difficult to get him/her to carry out the complete prescription in a comfortable way. Evaluate, firstly, the comfort since it is a way of guaranteeing use of the glasses which, in the end, is what is important. Realize a test with trial frames.
Hypermetropia in cases with children with external ocular infections: with frequency, children rub their eyes with dirty hands and this can provoke and/or aggravate, in a recurring way, said external ocular infections. In these cases it is a good idea to prescribe glasses with a protection barrier.

35. Hypermetropia : Prescription criteria X
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria X
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 20 to 45 years of age
Small hypermetropias give symptomology in NV.
According to the grade of the hypermetropia, > 35 years of age show signs of presbyopia.
Reasons for consultation:
Visual fatigue in NV.
Conjunctival hyperaemia.
Importance of latent hypermetropias.
At these ages the refractive defects tend to remain stable, without large changes. Nonetheless, they can present changes in the symptoms of hypermetropes:
Small hypermetropias that the patient could accommodate when younger now provoke visual fatigue
Partially compensated hypermetropias require a more precise prescription
Symptomology tends to be greater in near vision
Must not be confused with presbyopia
Slowly, latent hypermetropias disappear and, around years of age the majority of hypermetropias are manifest.
Reasons for the consultation:
The main reason for consultation is visual fatigue in near vision.
On occasion the patient feels like his/her “vision is failing”, since the glasses that were prescribed years ago for near vision are also used from distance away. They also feel that from close up, their vision is not as comfortable as it was years ago, very probably because their glasses lack potency.

36. Hypermetropia : Prescription criteria XI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria XI
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 20 to 45 years of age
Generally totally prescribed, as much when associated with an astigmatism as when not. Emphasizing its use for NV.
Hypermetropia + exodeviations
Hypermetropia and anisometropia
Prescription guidelines according to the value of the hypermetropia:
As a general rule almost totally prescribe for the value of the hypermetropia. The prescription can be diminished by 0,50 in order to insure the patient’s comfort and his/her use of the glasses; mainly in those cases in which the value of the subjective exam is equal to the value of the retinoscopic exam.
Also prescribe for the astigmatism that can be associated. Nevertheless, we need to be prudent with the prescriptions for astigmatisms superior to 1 or 1,50 dioptres if the person has never worn glasses or other compensation. More attention will be paid to this in the Astigmatism theme.
Prescription guidelines according to binocular vision:
In the cases when endodeviations exist: prescribe the totality of the hypermetropia and recommend glasses for general use.
In the csaes when exodeviations exist: the choice is difficult.
The prescription for the hypermetropia will augment the exodeviation
If we do not prescribe for the hypermetropia, according to the age of the patient, he/she will suffer from marked discomfort from visual fatigue.
Perhaps the best recommendation is to begin solving the simplest problem first: the hypermetropia. That is to say, prescribe the glasses the person needs (evaluate if it allows for a small reduction!) and wait to see if the discomfort is eliminated or if it continues.
Prescription guidelines according to anisometropia: adult patients find it difficult to get used to the compensation of an anisometropia if they have never before worn glasses. This is why we recommend:
Be prudent in cases of anisometropia superior to 1D
Evaluate the patient’s previous prescription and realize the changes gradually with small changes.

37. Hypermetropia : Prescription criteria XII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria XII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 45 to 65 years of age
Age of appearance of presbyopia
Glasses that were for near vision are now used for distance vision.
Latent hypermetropias become manifest.
Facultative hypermetropias become absolute.
Reasons for the consultation:
Loss of VA in NV.
At this age the hypermetrope subject, in addition, enters into the age of presbyopia. In this section we will comment on the relevant aspects of graduation and later on we will deal with presbyopia.
The subject now begins to note the lack of vision, without correction, from distances. Up until these ages, the hypermetrope subject of 1, 2 or even 3 dioptres could see reasonably well from a distance without glasses (thanks to an accomodative force that he/she could realize). From 40 years of age and onwards the amplitude of accomodation diminishes and they can experience loss of vision even from distances.
Prescription guidelines:
Prescribe for all of the hypermetropia from distances plus the necessary near addition
Binocularity does not tend to be a determining factor. Nonetheless, certain peculiarities are dealt with in the section on presbyopia
When an anisometropia exists the best advice is to maintain the level of anisometropia that the patient was used to in the new prescription. Let’s think that in these moments the plasticity of the visual system is very reduced because:
If sensory adaptations and/or aged motors with years of evolution exist, the patient coexists definitively with them.
As people age we are less capable of tolerating important changes to the prescription.
In ages over 60 cataracts can appear (about which we will speak more later in the section dedicated to Geriatric Optometry). The appearance of cataracts on the refractive level can provoke:
Diminishment of the hypermetropia by senile nuclear cataracts.

38. Hypermetropia : Prescription criteria XIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria XIII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 45 to 65 years of age
Prescribe totally as much for DV as for the corresponding addition for NV (it will permit intermediate vision).
It is necessary to emphasize that at these ages it is appropriate to prescribe for the totality of the patient’s hypermetropia. This will permit them to use their remaining accomodative capacity to focus on intermediate distances. This capacity is also lost with the passing years.

39. Hypermetropia : Prescription criteria XIV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria XIV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
From 45 to 65 years of age
Hypermetropia + exodeviations:
Hypermetropia and anisometropia:
During the age of presbyopia, exodeviations can appear for two main reasons:
Marked loss of muscle tone in the adductors (rectus medialis). This can result in growth of exodeviations or can cause conditions that had remained in a more or less latent state to appear in the form of exotropias (indicators at the beginning).
The necessary near addition for the presbyope patient can provoke a certain near exodeviation.
In these cases, variations in the graduation in the hopes of reducing the binocular problem are not possible since the prescription at these ages must be total, due to the marked loss of the accomodative capacity.
Just like we commented with the previous age group, in cases of previously unprescribed anisometropia it is better not to initiate a prescription for it at this time.

40. Hypermetropia : Prescription criteria XV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : Prescription criteria XV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Older than 65 years of age
At ages > 65-years-old there can be a diminishment of the hypermetropia (nuclear cataracts).
Relationship between elevated hypermetropia and narrow anterior chamber.
The visual issues in the population over the age of 65 tends to be dealt with in Geriatric Optometry. Here we refer to just a couple of central points:
The appearance of senile cataracts is frequent in this age group. The cataracts provoke a greater affectation of the vision depending on its type. The most frequent are:
Subcapsular cataracts: large diminishment of VA. They do not provoke significant refractive changes.
Cortical cataracts: scarce deterioration of the visual function.
Nuclear cataracts: gradual loss of VA. The crystalline increases the index of refraction which induces a change towards myopia, or diminishment of hypermetropia.
Eyes with moderate or elevated hypermetropia have short axial longitude. This provokes a certain proximity of the ocular structures and, with the passage of time, can diminish the drainage of the aqueous humour by the trabecular meshwork of the iridocorneal angle. An undesired increase in the intraocular pressure is provoked which can, in extreme cases, become a closed-angle glaucoma.

41. Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA: CASES
In the coming slides we display two cases of hypermetrope patients. The objective is to present the cases to the students and allow them a period of 15 minutes so that they can try to solve the questions shown at the end. It may be more appropriate to work in groups.

42. Hypermetropia: case 1-I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: case 1-I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
QG, 39 years of age. Salesman.
MC: Occasionally notes that he/she does not see well in NV. Asthenopic symptoms when reading.
PH: Never worn glasses. Does not remember previous visual revisions. No illnesses or ingestion of medication.
FH: Unimportant.
Some clarifications about the slide:
QG are the initials of the patient’s name. Laws exist to protect the personal information of patients that prohibit putting the patient’s name.
MC: Motive for the consultation
PH: Personal history
FH: Family history

43. Hypermetropia : case 1-II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Habitual VA in DV and NV:
RE: 20/20; NV: 20/20
LE: 20/20; NV: 20/25
Binocularity in habitual conditions:
Cover test:
DV: ortho
NV: low endophoria
Proximal convergence: 10/12cm
Results of the first clinical exams realized. We observe:
The monocular VA in DV is appropriate and in NV manifests a slight decrease with the LE. This information orients us towards the possible existence of a low hypermetropia, mainly in the left eye. We have doubts about whether it may be a case of early presbyopia.
Habitually, when the VA is not very reduced, we tend to realize an exam that will provide information on the efficiency of the visual system under normal conditions. In this case it is a good idea to point out a low endophoria in NV (latent deviation that manifests a greater tendency for near point convergence than the habitual)

44. Hypermetropia : case 1-III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Retinoscopy:
RE: +1,00
LE: +1,50
Subjective DV and VA:
RE: +0,75; VA: 20/20
LE: +1,25; VA: 20/20
NV with the subjective: VA 20/20 in both eyes. Good comfort
Amplitude of accomodation with the subjective:
RE: 16cm≈6D
LE: 16cm≈6D
Ocular health exams: within normal limits
Some comments on the contents of the slide:
The values of the retinoscopy and the subjective are similar. In addition the VA and the visual comfort in NV improve with the value of the subjective.
The amplitude of accomodation test has also been done. It has been done with the value of the subjective. It could have been done without glasses, but for its determination the refractive error needed to be taken into account. The value is normal for the patient’s age.

45. Hypermetropia : case 1-IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-IV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Complete diagnostic of the case
Proposed treatment and plan of check-ups
Possible evolution of the condition
There are the issues that the students must try to resolve.

46. Hypermetropia : case 1-V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-V
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Complete diagnostic of the case
Low hypermetropia manifests itself in both eyes
The hypermetropia is facultative since the habitual VA in DV is 20/20
Endophoric tendency in NV without correction
The rest of the test results within normal limits
The diagnostic is shown in the slide. Perhaps indicate that there has been no special mention of the anisometropia since a difference of graduation between both eyes of 0,50D is irrelevant.
It is important to point out in this case that we are not dealing with a presbyope patient but a low hypermetrope without correction that manifests his/her symptomology in NV, where the accomodative exertion he/she makes is great. The fact is that with the prescription for DV he/she achieves good VA and comfort in NV is shown.
The tests of binocularity with the graduation found could have been done again. The expected result is that the endophoria decreases or even disappears since the use of positive lenses diminishes the accomodation and the accomodative convergence.

47. Hypermetropia : case 1-VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-VI
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Proposed treatment:
Glasses with the value of the subjective:
RE: +0,75
LE: +1,25
Use mainly for tasks involving NV.
Can be worn for general use.
Revision in two years or before if new symtomology appears.
Explain the condition to the patient.
The proposed course of action is shown in the slide. Point out that the glasses are needed mainly for NV, but that their use in DV can also be acceptable.

48. Hypermetropia : case 1-VIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 1-VIII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Possible evolution of the condition:
Stability of the graduation until the appearance of presbyopia.
It is hoped that the refractive defect found in DV will remain stable for several years.

49. Hypermetropia : case 2-I
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-I
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
NP, 21-years-old. Student.
MC: Visual fatigue in NV. To study the patient uses glasses but symptoms continue
PH: 2 years ago he/she wore glasses for NV of +0,50 in both eyes. No illnesses or ingestion of medication.
FH: Irrelevant.
Some clarifications about the slide:
NP are the initials of the patient’s name. The laws in existence regarding protection of a patient’s personal information prohibit putting the patient’s name.
MC: Main reason for the consultation
PH: Personal history
FH: Family history

50. Hypermetropia : case 2-II
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-II
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Rx and habitual VA in DV and NV:
REDV: 0,00; VADV: 20/20+; RENV: +0,50; VANV: 20/20
LEDV: 0,00; VADV: 20/20+; LENV: +0,50; VANV: 20/20 Binocularity in habitual conditions:
Cover test:
DV: ortho
NVcc: orthophoria
Proximal convergence: 8/10cm
Results of the first clinical tests realized. We observe:
The VA in DV without glasses (habitual conditions) is very good in both eyes.
The VA in NV with glasses of +0,50 (habitual near use) is also good.
The cover test has been done without prescription in DV and with the patient’s habitual glasses in NV. The result is found within the normal limits.
The proximal convergence is normal. Emphasize that this exam can be realized, in this case, as much with correction as without since few changes are expected between the two conditions.

51. Hypermetropia : case 2-III
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-III
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Retinoscopy:
RE: +2,75-0,50x180º
LE: +3,50-0,50x180º
Subjective DV and VA:
RE: +0,50; VA: 20/20+
LE: +0,75; VA: 20/20+
Retinoscopy in NV (with the subjective):
RE: +1,25 (fluctuates)
LE: +1,50 (fluctuates)
Ocular health tests: within normal limits
Some comments on the contents of the slide:
The retinoscopy shows a moderate to elevated hypermetropia and a low direct astigmatism in both eyes.
In the subjective the patient accepts very little hypermetropia and does not accept the astigmatism. It is important to remember that in this case it is essential to have well refined the subjective in binocular conditions.
In this case the retinoscopy has been done in NV. These results provide information on the maximum acceptance of positives for this distance. Given that neither the patient’s uncompensated hypermetropia nor the elevated result of this exam (normally with young patients a result near +0,50 is expected)or the fact of the fluctuation detected were surprising.

52. Hypermetropia : case 2-IV
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-IV
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Are other tests necessary for a correct diagnosis and treatment?
Complete diagnostic of the case
Proposed treatment and a plan of check-ups
Possible evolution of the condition
These are the isues that the students must resolve.

53. Hypermetropia : case 2-V
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-V
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Are other tests necessary for a correct diagnosis and treatment?
Cycloplegia?
Amplitude of accomodation?
In this case it seems interesting to ask the students this question. Basically, the slide has made reference to two sections:
Is a refraction under cycloplegia considered necessary? There is not one answer. Just some reflections:
We know that a latent hypermetropia exists
We believe that we know the origin of the symptomology that the patient refers to
There is no associated endotropia
Will the fact that a refraction under cycloplegia shows a greater hypermetropia vary the diagnostic and treatment of the condition?
The other point of reflection is the necessity to measure the amplitude of accomodation. It is evident that while the patient does not accept the value of the hypermetropia the near point of accomodation will result further off. Inarguably, if the refractive error were taken into account, its determination would have been appropriate.

54. Hypermetropia : case 2-VI
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-VI
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Complete diagnostic of the case
Moderate hypermetropia in AO. Significant latent hypermetropia. Small manifest hypermetropia
Low, direct astigmatism in both eyes in the retinoscopy that is not accepted in the subjective
The rest of the tests return result within normal limits
The diagnostic is shown in the slide. Perhaps indicate that in this case we have not made special mention of the anisometropia because it wasn’t significant.

55. Hypermetropia : case 2-VII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-VII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Proposed treatment:
Prescribe new glasses:
RE: +1,75
LE: +2,25
Main use in NV. Use in DV is also recommended.
Explain the condition to the patient
New check-up in 3-4 months
Different professionals could propose slightly different treatments, but in all cases they aim at trying to increase the prescription in the glasses for hypermetropia. One possibility is displayed in the slide.
Explaining the condition to the patient is as essential as recommending the next check-up in order to further evaluate:
The symptomology
A new refractive exam: retinoscopy and subjective
Possible change to the graduation of the glasses.

56. Hypermetropia : case 2-VIII
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : case 2-VIII
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Possible evolution of the condition:
It is hoped that with the passage of time the latent hypermetropia will manifest itself
The hypermetropic graduation in the glasses will continue increasing up to the current value of the retinoscopy or even a slightly superior value
Greater dependence on the glasses with the passage of time
In the slide the evolution of the condition that can be logically expected with the passage of time is shown.

57. HYPERMETROPIA : BIBLIOGRPHHY
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
HYPERMETROPIA : BIBLIOGRPHHY

58. Hypermetropia : bibliography
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia : bibliography
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)
Amos JF. Diagnosis and management in vision care. Butterworth-Heinemann, 1987
Milder B, Rubin ML. The fine art of prescribing glasses. (2nd edition), Triad Publishing company, 1991.
Brookman KE. Refractive management of ametropia. Butterworth-Heinemann, 1996
Werner DL, Press LJ. Clinical pearls in refractive care. Butterworth-Heinemann, 2002

59. Hypermetropia: bibliography
Óptico de Atención Primaria (Tahoma 10 negrita y alineado izquierda)
Hypermetropia: bibliography
Asignatura
Número y Título del tel tema (Tahoma 10 negrita y alineado derecha)