The Many Faces of Hyperopia

You know the old clinical maxim: You may not see a certain type of case for awhile, and then several of them seem to show up in quick succession.  We feel that way with Jersey Shore weather patterns of late after having been spoiled by a mild and storm free winter until late January.  Just when the waters have receded and the beach is trying to return to normal following Winter Storm Jonas, the full moon strikes with high tide overnight, and coastal flooding is again of concern in the morning hours tomorrow – right about the same time that Governor Christie mops things up in the New Hampshire primary.

weather map

Well that’s the way it seems with appreciable latent hyperopia.  We can go for weeks without seeing a patient who has a significant difference between dry and wet conditions, and then have several within days of each other who unleash a torrent of plus power on cycloplegia, prompting the search for a full moon.

The many faces of hyperopia are revealed in the AOA CPG on the subject about which we blogged last week.  Sure enough, the very next day, Brayden came in to my office, a young hyperactive 5 year-old with accommodative esophoria and high bilateral latent hyperopia.  This afternoon I saw Megan an 8 year-old whose mother reported to be capable of grade level reading, but shied away from books.

Megan had failed her school screening.  Nothing on the school nurse’s form indicated why, and when I looked at the open view autorefractor data from diagnostic testing she appeared to near emmetropia in the right eye (+0.50) but close to +3.00 in the left eye.  Keystone Visual Skills testing showed a clear convergence insufficiency pattern with orthophoria and good fusion at distance but an exo shift and exo diplopia at near — what some might refer to as pseudo convergence insufficiency based on accommodative problems.

Naturally when I put up the standard VA chart I wasn’t surprised to see Megan cruise down to the 20/20 line with her right eye, and when covering the right eye seeing her squint on the 20/40 and 20/30 lines through the left eye and really struggle with 20/25.   Better than you’d expect with 2.50D of hyperopic aniso, isn’t it?  But wait … there’s more.  When I switched the paddle back to the left eye and asked her to read the 20/25 line with the right eye, casually mentioning that it should look a lot better than through her left eye, she replied “Hmm … not really.  It’s fuzzy now too.”

The vectographic acuity slide clarified what was happening when Megan used both eyes together.   The top row can only be seen by the right eye, bottom row only by the left eye, and middle row by either eye.

Vecto Slide

Megan began to read the chart: H,R.O,N,C haltingly.  Then the next line quite easily, reading N,C,K,Z,O, and stopped. There was no bottom line.  I covered the right eye and she could now read all but the last letter of the bottom line.   Megan’s mother, sitting in the room, was taken aback at how completely Megan was suppressing the left eye.  On cycloplegia, Megan refracted +2.75 with the right eye and +3.25 with the left eye.  As in Brayden’s case, there is wiggle room on how to Rx for her hyperopia.  I can only think of one approach that is wrong, and that would be discouraging the use of an Rx because she’s not yet struggling enough.

10 thoughts on “The Many Faces of Hyperopia

  1. In reading your final sentence, I was reminded of my days in California where most school districts required a student be greater than two years behind before additional assistance was sought. Luckily, we’re not bound by those same ridiculous (and borderline unethical) principles. Wishing Megan the best! 🙂

  2. Just a few days ago I was approached by an OT who had a two-day online program in vision rehab and was now given a complicated sheet to fill in for each child. The sheet represented elements in a reasonably complete vision function assessment, but was missing one obvious key element: Refractive status. She said the ophthalmologists say (all) the kids’s eyes are fine.

  3. Wonderfull that some are using the telebinocular keystone and the vectograph AO charts. And amazing that the others at possible corporate optometry are not using the same. I do believe the digital charts are available with stereo options.
    I just like the mirror system better even though I need to change the slides a couple of times with patients.
    Still amazing is when they suppress one side of the vectograph slide, then when they remove the stereo glasses the say “oh now I can see both sides so I am fine”. Another reason they report “why did the last eye exam not include the stereo glasses or the red green glasses or the bichrome (red-green) test.
    I have given your blog address to the O.D.’s who are interested in V.T. And are still patching eyes like the OMD’s
    Hope to see you Len in Cleveland. August

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