Farsightedness

In this article:

• Treatment
• Prescription lenses
• Surgical treatment
• Thermal laser keratoplasty
• Hyperopic photorefractive keratectomy (PRK)
• Hyperopic LASIK
• Argon-fluoride (193 nanometers) excimer laser
• Monofocal and varifocal LASIK
• Hyperopic laser subepithelial keratomileusis (LASEK)
• Hyperopic epiploic LASIK (EPI-LASIK)
• Hyperopic customized-LASIK (C-LASIK)
• Conductive keratoplasty (CK)
• Small incision lenticule extraction (SMILE)
• Lifestyle and home remedies
• Does Farsightedness (Hyperopia) Get Better Over Time?
• References

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Treatment

Prescription lenses

Optical correction:Biconvex lenses (plus) are recommended to converge the light rays on the neurosensory retina. Basic principles of prescribing glasses are:

• The amount of total hyperopia should always be elicited by cycloplegic retinoscopy, especially in children.
• Symptomatic patients and young children should always be treated with proper refractive correction.
• Young children should be prescribed full hyperopic correction gradual tapering during school age. 
• The maximum accepted plus power with a clear vision (20/20) should be prescribed.
• A gradual increase in hyperopic correction from the comfortably accepted power in school-aged children may be necessary as full correction may produce blurring at distant. A short course of cycloplegic agents may improve the acceptance of hyperopic correction.
• Accommodative convergence should be treated with full hyperopic correction. Developing/developed amblyopia should undergo a thorough evaluation, and full hyperopic correction with occlusion therapy should be prescribed.
• Hyperopic children should have a reevaluation every 3 to 6 months.

American Academy of Ophthalmology (AAO) released guidelines when to prescribe glasses in hyperopia in young children. 

• Isometropia (similar eyesight in both eyes)
• Anisometropia (different eyesight in both eyes)
• Presence/absence of strabismus.

Acuity measurements should be considered: 

• Children under 1-year: +6D
• 1-year to less than 2 years: +5D
• 2-year to less than 3 years: +4.50D
• 3-year to less than 4 years: +3.50D

For children with hyperopic isometropia and esotropia:

• Less than 2 years: +2D
• 2-year to less than 4 years: +1.50D

Hyperopic anisometropia without strabismus: 

• Age under 1-year: +2.50D
• 1-year to less than 2 years: +2D
• 2-years to less than 4 years: +1.50D

Glasses and contact lenses are the best and safe method to ensure children have normal vision. Contact lenses are usually prescribed in cases of unilateral hyperopia or a large difference in hyperopia between eyes.

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Surgical treatment

There are significant advances to the surgical eyesight correction for adults and children when the glasses and contact lens are not an option. Expert ophthalmologists are trained to perform different procedures and use different technology.

 It is important that you understand the differences of the eye surgeries, so you can find the expert surgeon who will be able to use a certain procedure you like, not all techniques can be used interchangeably, so we recommend to arrange the consultations to receive a professional opinion first.

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Thermal laser keratoplasty

Thallium-holmium-chromium (THC): yttrium aluminum garnet (YAG) laser is used to create a contraction of the collagen matrix of the stroma of the cornea in eight areas of the optical zone with pulse energies of 159-199 milli-joule. This makes a mechanical constriction which steepens the cornea. 

The diode laser is also used in associated presbyopia cases. It is a good option in cases of iatrogenic hyperopia after LASIK in myopia and photorefractive keratectomy in myopia. Compared to LASIK, it is slow in achieving stable refraction with less predictability to correct astigmatism. Overcorrection may be present in the early postoperative period, but no significant surprise is noted in long term followups.

Currently, this procedure has approval for a temporary reduction of hyperopia of +0.75 to +2.50 diopters with  ≤ +/- 0.75 diopters of astigmatism by the United States Food and Drug Administration (USFDA). The patients should be of at least 40 years of age. The refraction should be documented to be stable for the prior six months (change of  ≤ 0.50D in spherical and cylindrical components of the manifest refraction).

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Hyperopic photorefractive keratectomy (PRK)

It is a safe procedure to correct mild to moderate degree of hyperopia. It’s a lengthy procedure by which a large burn is created with an excited dimer (excimer) laser. The cornea becomes dry and dehydrated, and epithelial healing is delayed. Decentration is another significant problem. After initial encouraging results, regression may take place. It may be combined with phototherapeutic keratectomy (PTK) to counter hyperopic shift. It is equally efficacious compared to LASIK for hyperopia.

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Hyperopic LASIK

The procedure is performed under topical anesthesia, and it can also be performed with pilocarpine-induced miosis on same day cycloplegia. It can correct up to 6 diopters of hyperopia. The creation of the flap can be by microkeratome or femtosecond laser (Femto laser). Femto laser is an infrared laser of 1053 nm wavelength. Femto laser has better predictability of flap thickness with the advantages of fewer postoperative higher-order aberrations, better contrast sensitivity, longer tear film breakup time. 

Different LASIK machines can correct different ranges of hyperopia. 

Argon-fluoride (193 nanometers) excimer laser

This procedure is used to ablate the corneal bed after the elevation of the flap by microkeratome. Intraocular pressure is raised artificially to maintain the hold during the elevation of the epithelial flap. After ablation, the epithelial flap is repositioned. It is safe and also effective in all degrees of hyperopia, especially in high hyperopia. 

Monofocal and varifocal LASIK

LASIK can be safely used in presbyopia. Epithelial remodeling is suspected to be responsible for masking the extra advantages of the varifocal laser. Better predictability and lower regression are making the use of Mitomycin C 0.02% (MMC) essential though further long term followup studies are needed. Femtosecond laser-assisted surgeries with MMC 0.02% give better refractive outcomes and less number of re-treatments. 

Contraindications: chronic eye or corneal diseases, systemic illness, unstable refraction, dry eyes, contact lens intolerance, chronic pain syndromes, pregnancy, and lactation.

Postoperative patching or dark glass, along with topical broadspectrum antibiotics are prescribed. 

Possible complications of LASIK include: 

• Regression
• Dry eyes 
• Night vision problems 
• Diminished corneal sensations. 
• Flap striae 
• Epithelial ingrowth especially in enhancement procedures, 
• Infectious (pseudomonas, mycobacterium chelonae) keratitis, noninfectious (diffuse lamellar) keratitis
• In high hyperopia cases: astigmatism, spherical aberrations, coma, and trefoil. 

Hyperopic laser subepithelial keratomileusis (LASEK)

The epithelium of the cornea is loosened and separated, then stromal ablation is performed by the excimer laser. Sometimes it is augmented by 0.02% mitomycin c after corneal ablation. 

It may be helpful in children to correct hyperopia with or without amblyopia (off label use).Though postoperative refraction status, contrast sensitivity, topography data shows better outcomes in lasek along with complications such as aberrations, ectasia, flap related complications are less than LASIK, but more postoperative pain, slow recovery keep it a little bit behind from PRK and epiploic LASIK.     

Hyperopic epiploic LASIK (EPI-LASIK)

It is similar to LASEK, but here epikeratome is used to raise the epithelial flap, not alcohol. So, alcohol-related toxicities are negated.  

Hyperopic customized-LASIK (C-LASIK)

It is either topography or wavefront-guided ablation procedure to correct associated astigmatism and aberrations, with wavefront-guided procedures having better contrast sensitivity and less glare. Quality of vision is improved compared to other procedures, but Snellen’s visual acuity, the refractive status remain comparable.

Conductive keratoplasty (CK)

It is a radiofrequency energy-based procedure to create shrinkage of collagen, which increases the converging power of the cornea. It is an excellent surgical option for hyperopia and presbyopia:

1.  Predictable and stable refractive status is achievable in low to moderate hyperopia. 
2. Minimally invasive and safe procedure 
3. Not effective in high hyperopia. 

Possible complications: 

• Recurrent corneal erosions
• Mild iritis
• Iris burn
• Endothelial cell loss
• Partial or full-thickness corneal injury (rare). 

Small incision lenticule extraction (SMILE)

It is a safe procedure for hyperopia, even in higher degrees. It is comparable to LASIK for hyperopia in effectiveness and safety with the induction of similar spherical aberration. 

SMILE in hyperopia is a promising area to explore. 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. 

Possible complications:

• Opaque bubble formation
• Postoperative keratitis
• Ectasia
• Dry eyes
• Phakic intraocular lenses

New lens is implanted anterior to the crystalline lens, or refractive lens exchange is a good option for a high degree of hyperopia or where corneal procedures are contraindicated or may lead to cataracts. 

Possible complications:

• Corneal decompensation
• Rhegmatogenous retinal detachment 
• Hyphema
• Uveitis

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Lifestyle and home remedies

While there are multiple genetic factors involved in the development of farsightedness, it is important to ensure the best development of the child who was vision problems. As we know, the accommodation is an important compensatory mechanism helping a child with anatomical eye problems. As accommodation is dependent on a small eye muscle, it is crucial to provide the right nutrition and development conditions:

• Vit. E and antioxidant rich diet
• Good lighting of the paly or study area
• More outdoor sports and activity, especially sports with changing eye focus, such as tennis, soccer, table ping-pong
• Breaks during work associated with eye strain
• Neck massage and exercise

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Does Farsightedness (Hyperopia) Get Better Over Time?

The answer is different for various types of farsightedness. For children who are able to compensate hyperopia with other mechanisms of accommodation, the prognosis is very good. If the hyperopia is significant, there is a good chance it needs to be corrected with glasses, lens or surgery. It is best to have a consultation with a refraction expert ophthalmologist, who can give you the best answer for prognosis and treatment options.

The prognosis of hyperopia is good if early diagnosis and treatment are started. It is of utmost importance in the pre-school age group. In suspected amblyopia, proper management gives a good prognosis. But if correction is not done early, it may lead to amblyopia and permanent visual decline. 

Negative prognostic factor predicting that farsightedness will not go away:

• Farsightedness that is a part of systemic and genetic diseases
• Surgical intervention
• Other eye diseases
• Family history of squint and amblyopia  

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References

Soler V, Benito A, Soler P, Triozon C, Arné JL, Madariaga V, Artal P, Malecaze F. A randomized comparison of pupil-centered versus vertex-centered ablation in LASIK correction of hyperopia. Am J Ophthalmol. 2011 Oct;152(4):591-599.e2. [PubMed]

Wilkinson JM, Cozine EW, Kahn AR. Refractive Eye Surgery: Helping Patients Make Informed Decisions About LASIK. Am Fam Physician. 2017 May 15;95(10):637-644. [PubMed]

Yan MK, Chang JS, Chan TC. Refractive regression after laser in situ keratomileusis. Clin Exp Ophthalmol. 2018 Nov;46(8):934-944. [PubMed]

Biscevic A, Pidro A, Pjano MA, Grisevic S, Ziga N, Bohac M. Lasik as a Solution for High Hypermetropia. Med Arch. 2019 Jun;73(3):191-194. [PMC free article] [PubMed]

Mohamed TA, Hoffman RS, Fine IH, Packer M. Post-laser assisted in situ keratomileusis epithelial ingrowth and its relation to pretreatment refractive error. Cornea. 2011 May;30(5):550-2. [PubMed]

Wallerstein A, Gauvin M, Adiguzel E, Singh H, Gupta V, Harissi-Dagher M, Cohen M. Clinically significant laser in situ keratomileusis flap striae. J Cataract Refract Surg. 2017 Dec;43(12):1523-1533. [PubMed]

Hyperopia. Majumdar S, Tripathy K.2021 Aug 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 32809551 Free Books & Documents. Review.

Photorefractive Keratectomy. Somani SN, Moshirfar M, Patel BC.2021 Jul 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 31751077 Free Books & Documents. Review.

Laser In Situ Keratomileusis. Moshirfar M, Bennett P, Ronquillo Y.2021 Jul 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 32310430 Free Books & Documents. Review.

Laser Eye Surgery for the Correction of Refractive Errors. Swedish Council on Health Technology Assessment.Stockholm: Swedish Council on Health Technology Assessment (SBU); 2007 Dec 4. SBU Alert Report No. 2007-04.PMID: 28876757 Free Books & Documents. Review.