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Farsightedness is the common term for a vision condition when children cannot see near object well. In a way, this is a very simplistic explanation of an eye refraction error. Let’s explore it better.
Refraction is a name of a process explaining how the light reflected from the objects around us end up on the photosensitive layer of the inner eye – retina. As a matter of fact, the best man-made technology that resembles an eye system is a photo camera. Here’s what happens when you take a phone and shoot a picture:
The light rays reflected from an object are caught by a lens that is covered with a protective layer – same as lens in our eye that is covered by cornea.
Now the object needs to come in focus. The tiny diaphragm opens/closes just enough to get a better view of the object – that is our iris that constricts or relaxes while the lens actually moves to get a better curvature.
The whole idea is to get the best reflection of the image on a photosensitive cell of the camera – it is the way the image would focus on the retina in a human eye.
Let’s say that the camera has a defect, and the photoelement in too far – the image is too blurry, and you cannot focus on it even if you move the focus x10. But if you position your phone to get a picture of the bug that is very close to you – it gets a perfect detailed shot! That is an explanation of farsightedness in children.
Why hyperopia in children can be missed?
We all can adapt to the defects. For example, if a person is born with no hearing in one ear, another ear will double-compensate for that. The same with vision. Children who have focus of the objects from the far falling behind the retina will compensate with the mechanism called accommodation.
Visual accommodation involves tiny muscles of the inner eye that change the curvature of the crystalline lens and the size of the iris hole. It normally works for us to switch from near vision to far. Only in children who have a problem with farsightedness, the accommodation works overtime and returns their vision to normal!
Amazing! You might never know your child has a farsightedness until you visit an ophthalmologist who uses special eye drops to knock down accommodation. Then suddenly a child cannot see far. A real question then if you need to correct that problem or let it go. An expert child eye doctor will be able to answer this question right away.
Factors Contributing to Farsightedness in Children
So, what exactly causes farsightedness in children. Mechanically, this problem is divided according to the eye part that is problematic:
Axial hyperopia (most common – simple hyperopia): It is due to anterior-posterior axial shortening of the eyeball. Genetic predisposition plays an important role. Retinal edema can cause a hyperopic shift. 1 mm decrease in axial length leads to 3 diopters of hyperopia.
Curvature hyperopia: It is due to flattening of the cornea or the lens or both. A radius of curvature increase in 1 mm leads to 6 diopters of hyperopia.
Index hyperopia: It is due to the change in the refractive index of the crystalline lens, which occurs in old age or diabetics. The refractory index gradually increases from the center to the periphery.
Positional hyperopia or absence of the lens (aphakia) or ocular pathologic conditions: This condition occurs due to malposition or absence of the crystalline lens (congenital or acquired) or intraocular lens owing to the creation of an aphakic zone in refractive media. Post-traumatic or post-surgical aphakia is not an uncommon cause of hyperopia.
Farsightedness can run in families, but most of the situations are not explained. Certain genetic diseases can cause farsightedness, as certain eye structures might be affected in quality or growth (nanophthalmos, microphthalmos, aniridia). The following are a various conditions causing or leading to farsightedness:
16p11.2 microdeletion
Myelin regulatory factor gene (MYRF) mutation
Family history of squint, and a history of maternal smoking during pregnancy
Hyperglycemia (too much sugar in the blood)
Diabetes mellitus and after prompt control of hyperglycemia in diabetes mellitus
Prolonged space mission due to retina and optic nerve head edema
Peripapillary pachychoroid syndrome (PPS)
Heimler syndrome
Kenny syndrome
Accommodation loss due to complete CN III nerve palsy or internal ophthalmoplegia or paralysis by cycloplegic drops, lorazepam (functional hyperopia)
After silicone oil injection in phakic and pseudophakic eyes. In aphakic eyes, the amount of hyperopia reduces, but the eye remains hyperopic
Loeys-Dietz syndrome, Larsen syndrome.
Leber congenital amaurosis
X-linked retinoschisis and senile retinoschisis
Is hyperopia normal among children?
While children are growing fast, their vision also undergoing changes. At a certain point of development, the farsightedness can be a normal phenomenon which is compensated by the accommodation. In such situation the hyperopia is called facultative. Whenever the child has a poor vision even with a good accommodation, the hyperopia is symptomatic (absolute) – not normal.
Symptoms of hyperopia in children
In a significant (absolute) hyperopia the symptoms are: Squinting
Running into walls and objects
Reading and learning delay
Deviation of the eye (one or another eye moves usually toward the nose when the child is trying to focus)
Complains of tiredness of eyes with localized frontal/frontotemporal headache (amblyopia)
Episodes of sudden blurring of vision, often termed as pseudomyopia – more common in teens with missed farsightedness
Sensation of crossed eye – described by older kids
It is important to pay attention to your children’s complaints. Yes, kids can make up symptoms when they do not want to do something, like learning an alphabet. But it should be very alarming if your child stops a favorite activity due to inability to concentrate or a headache. It is also hard to catch a problem if you child spends most of the time in a child care. But attentive and professional caregivers will alert you about child’s vision problem.
How common is farsightedness (hyperopia)?
According to a large study, the prevalence of hyperopia >= 2.00 D decreases from 6 months of age to a low point around 24 months of age. This is consistent with previous reports describing early emmetropization. The drop is more prominent in Hispanic compared to African American children, perhaps because of higher initial levels of hyperopic refractive error in Hispanic children, since previous studies have shown that the rate of emmetropization is greater with larger initial refractive errors.
After approximately 24 months of age, however, the prevalence of hyperopia does not decrease further. In fact, it increases, and remains higher than at 24 months at all ages thereafter. The overall pattern of persistent hyperopia between 24 and 72 months of age is robust to the threshold definition of hyperopia employed, and is reflected also in the relative stability of the mean spherical equivalent refractive error over this same age range.
This finding is in marked contrast to the popularly held belief that hyperopia declines continuously with increasing age from infancy through adolescence, exemplified by an often-cited paper by Mayer et al.
The authors studied a non-population-based sample of children 1 to 48 months of age, and compiled the results together with those from other non-population-based studies in a graph that suggested continuous loss of hyperopia throughout childhood. In fact, the authors’ own data showed relative stability of mean spherical equivalent refractive error after 12 months of age. The findings of the present study echo other lesser-known observations in the literature showing relative stability of hyperopia prevalence in young children after infancy.
This has important implications for the follow-up of early childhood hyperopia, since it cannot be assumed that all children will “grow out of” their hyperopia, with its associated risk of complications such as accommodative esotropia. Indeed, it is tempting to speculate whether the increase in hyperopia prevalence beginning around 24 months of age is somehow related to the frequent onset of accommodative esotropia in children 2 to 3 years of age.
Diagnosing Childhood Farsightedness
It is important to have a good report with a pediatrician to ensure that everything in your child is developing well and healthy, including eyes. It is hard for new parents to realize if the child is just clumsy, or it is a vision problem. A smart pediatrician will watch your child crawl and run around, and do simple vision check. If there is any concern, usually you will be told to watch and wait – some problems just go away as the child grows so fast.
On the other hand, you may want to pay more attention to your child’s activities involving vision. Dependent on the age, babies develop abilities called milestones. Some of them depend a lot on the visual acuity:
Recognize familiar face
Follow and track objects and people (gaze fixation)
Pick up pellet-size objects
Fit cubes and rounds into the wholes
Stack the blocks
Walk independently
Learn to read and count
Most likely, you already have an ophthalmologist if the vision problem is running in the family. You can ask a recommendation of a pediatric ophthalmologist if you are concerned your child might not be seeing well.
The axial shortening of the eyeball or decreased converging potential of the cornea or crystalline lens due to flattening are common responsible factors for simple hyperopia. Congenital or acquired absence of the crystalline lens resulting in loss of converging capacity leads to the pathological hyperopia. This type of farsightedness is common with premature babies and congenital syndromes.
Risks
There are so many developmental risks you child may face if the vision is not corrected:
Developmental delay
Reading disability
Low self-esteem
Headaches and fatigue
Trauma from falls
Amblyopia: Stimulus deprivation or anisometropic amblyopia may take place if there is no timely correction. Proper refractive correction, orthoptic exercises are needed to treat this amblyopia.
Squint: Convergent strabismus is not very uncommon in developing children with uncorrected hyperopia. The squinted eye becomes more stimulus deprived gradually.
Angle-closure disease: Hyperopia is a predisposing condition to develop angle-closure disease.
Can it be corrected?
Yes! Yes! Farsightedness, just like nearsightedness is just a refractive error of the eye. glasses and contact lenses are an easy and inexpensive way to fix the issue. Be assured, it is not easy to keep those glasses on a 3-year-old… but modern technology has so many great solutions. You just need to find the right eye professional who is passionate about kids.
SMILE in hyperopia is a promising surgical correction option. Compared to LASIK, LASEK, CK, and PRK, SMILE can be a better option for high hyperopic cases with stable postoperative refraction. Newer technologies of wavefront analysis and correction of aberrations and treatment of associated astigmatism will give better optical satisfaction to the patient. Preparation and correction of aberrations in a customized manner with C-LASIK is also an upcoming procedure to deal with aberrations.
Refractive lens exchange and phakic intraocular lenses are other options for the management of hyperopia.
How can it be prevented?
Farsightedness cannot be prevented as we do not know what is causing it. But it is important to prevent the development and learning delays that may come from your child’s inability to see clear. A pediatric ophthalmologist your best adviser if an accommodation error was diagnosed. Make sure your got the right glasses or contact lens, as this is an affordable way to help your children see well.
When to see an eye care professional
As we discussed before, the first sign of your child not seeing well should prompt you to schedule a visit with a pediatrician. If the refractive error is confirmed – it is time to see an eye care professional.
Another alarming call is a failed vision screening at school or kindergarden. Sometimes it can happen because the child is not following directions or is bilingual. Then a visit to an optometrist can relieve a concern – a standard vision test administered by a child specialist will tell you for sure if you need to worry.
