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PERSPECTIVE

Management of Childhood Hyperopia:A Pediatric Optometrist’s PerspectiveSUSAN A. COTTER, OD, MS, FAAO

Southern California College of Optometry, Fullerton, California

ABSTRACTPurpose. To provide an optometric perspective on the management of hyperopia in children without strabismus or

amblyopia.Methods. Factors that have potentially shaped optometry’s viewpoint and influenced its prescribing philosophy forchildhood hyperopia, such as optometry school and residency training, professional association clinical guidelines,conferences and continuing education courses, textbooks, scientific studies, opinions of professional leaders, and clinicalexperiences are discussed.Results. Variations in prescribing patterns for childhood hyperopia occur within optometry and within ophthalmology.There are also differences in prescribing philosophies between the two professions. These differences are probably dueto a greater level of concern, more so among optometrists, about associated vision functions such as accommodation,vergence, and stereopsis, as well as concerns about the potential impact of uncorrected hyperopia on reading and schoolperformance.Conclusions. If indications for prescribing spectacles for children with hyperopia are to be validated, randomizedcontrolled trials need to be performed.(Optom Vis Sci 2007;84:103–109)

Key Words: hyperopia, hypermetropia, refractive error, spectacles, glasses, children

The clinical management of childhood hyperopia varies con-siderably among eye care practitioners, more from traditionthan research. In 1971 Grosvenor commented in a paper

titled, The Neglected Hyperope , that “. . . perhaps hyperopia war-rants more study and emphasis than it has been given in the past.”1

Thirty-three years later (2004), in the editorial titledThe Still Neglected Hyperope , Rosner lamented that, “Things haven’tchanged much . . .”2 I am sure that Drs. Grosvenor and Rosner arepleased that childhood hyperopia is the topic of this 2005 Monroe J. Hirsch Memorial Research Symposium.

My charge for this symposium is to provide an optometric per-spective on the management of childhood hyperopia. As a pediat-ric optometrist, I was asked to address factors such as traditions,teachings, and influential literature that have shaped optometry’sviewpoint. I plan to execute this charge largely in terms of factorsthat have shaped my own clinical perspective.

Differences in prescribing patterns for childhood hyperopia oc-cur within optometry and within ophthalmology. There are alsodifferences in prescribing between the two professions. In a survey on prescribing for bilateral asymptomatic hyperopia in young chil-dren,3 65% of pediatric optometrists usedϩ 3.00 D of bilateral

hyperopia as their prescribing threshold for 2-year-olds, but 28%used a higher threshold—with most of them (25%) using ϩ 5.00D as their threshold (Table 1). This variability in optometry is worth noting. Among pediatric ophthalmologists, 66% usedϩ 5.00 D as their threshold, with 25% using a ϩ 3.00 D threshold.Clearly, there is variability in the hyperopic prescribing thresholdfor 2-year olds within both professions, with optometrists having an average threshold somewhat lower than ophthalmologists. Theprescribing thresholds among optometrists and ophthalmologistsforchildren6 monthsand 4 years of age are shownin Table 1.Heretoo, there is variability in prescribing thresholds within each pro-fession, with the average threshold being lower for optometrists.

Using the same ages of 6 months to 4 years, another survey queried members of the College of Optometrists in Vision Devel-opment (COVD) and members of the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) regarding what magnitude of hyperopia in asymptomatic children should bereferred in a vision screening because it is “worrisome.”4 The me-dian worrisome level of hyperopia for the pediatric ophthalmolo-gists wasϩ 5.00 D from birth to 6 months and ϩ 4.00 D thereafterto 48 months. The COVD respondents, however, were concerned

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Optometry and Vision Science , Vol. 84, No. 2, February 2007



at lower levels of hyperopia:ϩ 3.50 D at birth to 6 months, ϩ 3.00D from 6 to 24 months, ϩ 2.50 D from 24 to 30 months, andϩ 2.00 D thereafter to 48 monthsof age. Although these latter results were generated froma small subgroupofspecializedpracticingoptom-

etrists, the average threshold was found to be lower for these optom-etry practitioners than for the pediatric ophthalmologists.The different prescribing approaches between many optometrists

and ophthalmologists is, in my opinion, less a matter of profes-sional difference than a difference in concern about associatedvision functions such as accommodation, vergence, and stereopsis,as well as a concern about the potential impact of uncorrectedhyperopia on reading and school performance. Some optometristsand ophthalmologists pay little attention to these associated visionfunctions, more so among ophthalmologists. Others, in both pro-fessions, routinely take these functions into account when pre-scribing for hyperopia in children, more so among optometrists.

Shaping a Prescribing Philosophy What is it about optometry’s heritage, background, traditions,

and teachings that shape optometrists’ approach to prescribing lenses for hyperopia in children? What forms the basis for what wedo? I have been asked, as a “middle-of-the-road” pediatric op-tometrist, to speak for the optometric profession. I am reluctantto do this. Rather, I offer mainly the opinion of one pediatricoptometrist – myself. Although I will endeavor to explain whatinfluences optometrists when they manage childhood hyperopia, what follows is largely my personal perspective and does not rep-resent that of the optometric profession or the American Academy of Optometry.

Furthermore, what follows herein is not meant to provide a literature review on childhood hyperopia, nor is it meant to assessthe strengths and weaknesses of literature cited. Instead, it high-lights factors that have influenced and shaped my clinical decision-making process of whether to prescribe a refractive correction for a child with hyperopia.

Numerous sources have influenced my clinical philosophy of when to prescribe an optical correction for a child with hyperopia.These include optometry school and my residency training, pro-fessional association clinical guidelines, conferences and continu-ing education courses, opinions of professional leaders, discussion with mentors and peers, patient feedback, clinical experiences,

textbooks, and scientific studies. I will comment on those factorsthat have had the greatest impact on me personally and those Ibelieve have influenced the profession of optometry.

Prescribing for hyperopic children who have strabismus and/oramblyopia dates back to Donders (1864)5 and Worth (1903). 6

Their views are used similarly within both professions. Most eyecare practitioners tend to prescribe maximum plus in an effort toproducealignment in cases of esotropia, full amounts of correction

for anisometropia and astigmatism to provide equal retinal imageclarity between the eyes, and symmetrically reduced hyperopicprescriptions when needed to ensure or promote acceptance of spectacles. For this symposium, I will mainly address the areas of greatest prescribing variability: children 12 years and younger whohave approximately equal hyperopia in the two eyes and who haveneither strabismus nor amblyopia.

Optometry School and Residency Training A person’s training and mentors influence one’s clinical man-

agement philosophy. The clinical preceptors I worked with at the

Illinois College of Optometry(inparticular, Barbara Schorr, KevinRoe, and Steven Greenspan) had a great deal of impact on my initial prescribing philosophy for children. My pediatric optometry residency mentors (Mike Rouse, Betty Caloroso, Lou Hoffman, and Julie Ryan) had a further and even greater effect in shaping my clinical management philosophy. And of course, my prescribing philosophy for children has evolved over the years with influencesfrom others, such as leaders in pediatric optometry—Elise Ciner, Wendy Marsh-Tootle, and Rowan Candy.

Physician Thomas Eames’ description of a child with hyperopia is very much in line with what I was taught in optometry school(Illinois College of Optometry, 1979–1983). Eames wrote, “The

farsighted child typically dislikes school and teachers and turnsfrom books. He prefers sport and rough, out-of-doors activities notrequiring closeapplication. This is because he has to usehis accom-modative mechanism to overcome his visual defect, and the excesseffort produces rapid fatigue and sometimes discomfort . . .”7

During both optometry school and my residency program, Ideveloped the impression that children who have a significantaccommodative demand may develop asthenopia (particularly as-sociated with near work), regardless of whether their age wouldpredict they possess a sufficient amplitude of accommodation. Weknow that a normal amplitude of accommodation is not guaran-teed in children. In fact, Helveston reported that of 1910 first-,second-, and third-grade children tested in a single school district,7 to 10%had subnormal accommodative ability. Moreover, I havelearned that even among children who have normal amplitudes of accommodation, some cannot comfortably and consistently sus-tain the required accommodation when doing near work for long periods of time.

A case report published during my residency by one of my mentors8 was influential in shaping my initial perspective on thistopic. The report described a 4-year-old girl with frequent intenseheadaches, who recently had been evaluated by a neurologist whofound no cause for the headaches. Uncorrected visual acuity was20/20 at distance and 20/40 at near. No strabismus was found;however, an esophoria of 3⌬ was present at near, stereoacuity atnear was 143 sec arc, and an excessive lag of accommodation of

TABLE 1.Pediatric optometry and pediatric ophthalmology: pre-scribing thresholds for hyperopia

Amount of bilateral

hyperopia

6 mo old 2 yr old 4 yr old

OD(%)

MD(%)

OD(%)

MD(%)

OD(%)

MD(%)

Ͼ 1.00 D 2.5 0 7.0 0 22.1 0Ͼ 3.00 D 30.4 3.6 64.6 25.0 67.1 42.1Ͼ 5.00 D 53.1 62.5 25.3 66.1 9.5 54.4Ͼ 7.00 D 10.8 26.8 2.5 5.4 0 1.8Ͼ 9.00 D 3.2 7.1 0.6 3.6 1.3 1.8

OD, optometrist; MD, ophthalmologist; D, diopter.Modified from Lyons SA et al.3

104 Childhood Hyperopia: A Pediatric Optometrist’s Perspective—Cotter




ϩ 2.00 D was found. Cycloplegic refraction revealed ODϩ 1.50Dand OS ϩ 1.75D and the eye health evaluation was unremarkable.She was givenϩ 1.50D for both eyes in spectacles for full-time wear because of the abnormally high lag of accommodation andsevere symptoms. After receiving the spectacles, the child’s visualprofile changed quite dramatically. When wearing the spectaclecorrection, the lag of accommodation decreased fromϩ 2.00 D toa normal lag of ϩ 0.50 D, the 3⌬ esophoria at near converted to a

4⌬ exophoria, and the stereoacuity at near improved from 143 to45 sec arc. More importantly, the parents reported that after re-ceiving the spectacles the child’s headaches ceased and her atten-tion and performance in preschool improved as well. I have seensimilar patients (albeit, usually with less severe symptoms) whohave reinforced my opinion that moderate and sometimes evensmall (e.g.,ϩ 1.00 or ϩ 1.25D) amounts of uncorrected hyperopia can cause symptoms, particularly in school-age children.

A subsequent influential patient encounter I had during my residency concerned a 6-year-old child named Diane who was infirst grade. The child’s mother reported that Diane had a shortattention span when reading and copying and had difficulty com-

pleting her assignments in class. In fact, Diane’s teacher reportedthat the child often left her seat during class assignments; thus,interrupting her classmates nearby and disrupting the class. Dianedid not report any symptoms. She had unaided distance visualacuities of 20/20 in both eyes, orthophoria at distance, 4⌬ of exophoria at near, and near stereoacuity of 30 sec arc. Her cyclo-plegic refraction was ODϩ 3.75 Ϫ 0.50 ϫ 180 and OS ϩ 4.00 Ϫ0.50 ϫ 180. Based on the possibility that her avoidance of neartasks might be associated with her uncorrected hyperopia, I pre-scribed a hyperopic correction of ODϩ 2.75 Ϫ 0.50 ϫ 180 andOS ϩ 3.00 to 0.50 ϫ 180. Several weeks later I received a phonecall from Diane’s teacher inquiring, “Whatever did you put into

Diane’s glasses? Whatever it was, it worked like magic! Diane nolonger leaves her seat during class; she now stays on task and com-pletes her assignments.” This particular experience had a signifi-cant influence on my perspective regarding the potential effect of moderate amounts of uncorrected hyperopia on reading and neartasks.

Professional Association Guidelines, Conferences,and Continuing Education

Continuing education programs also influence clinical practice.Courses on examining and managing eye conditions of youngstershave been popular at optometry conferences and meetings, particu-larly in the last several years. For example, the American Optometric Association (AOA) programson Children’s Vision and InfantSEE™have each provided some prescribing recommendations.

Evidence-based guidelines would be expected to be the mostinfluential in affecting practice-prescribing patterns. Unfortu-nately, scientifically rigorous studies conductedspecifically to pro-vide prescribing guidelines have not been conducted.

However, consensus-based guidelines have been provided by the American Academy of Ophthalmology.9,10 Threshold values forchildren with bilateral hyperopia and no strabismus are:ϩ 6.00 Dfor ages up to 1 year,ϩ 5.00 D for ages 1 to 2 years, andϩ 4.50 Dfor ages 2 to 3 years. No guidelines are givenforchildren older than3 years. A footnote reminds us that the guidelines “were generated

by consensus and are based solely on professional experience andclinical impressions.”

Similar prescribing thresholds were found in a survey of mem-bers of the AAPOS regarding the dioptric value for which they

routinely prescribed glassesforchildren with hyperopia (Table2).11

For childrenϽ 2 years old, the average threshold wasϩ 4.82 D, forthose 2 to 4 years it wasϩ 4.35 D, and for those 4 to 7 years it wasϩ 4.00 D. However, 25% of the pediatric ophthalmologists indi-cated they used lower thresholds, reporting ϩ 4.00 D for childrenup to 4 years of age andϩ 3.00 D for those 4 to 7 years old.

Optometrydoesnot have similar consensus-based guidelines onprescribing for childhood hyperopia. In fact, the AOA ClinicalPractice Guideline on Hyperopia 12 states that there is no universalapproach to treating hyperopia. Rather, the patient’s age, degreeof symptoms, visual acuity, magnitude of hyperopia, accommodativeabilities, and efficiency with visual tasks should all be considered.

The Guideline notes that childrenϽ

10 years of age who have “low to moderate” hyperopia, but no strabismus, amblyopia, or othersignificant visionproblems,do notusually require treatment; how-ever, the presence of decreased visual acuity, binocular anomalies,functional vision problems, or learning or academic difficultiesmay indicate treatment is needed.

Optometry has consensus-based guidelines for the amount of hyperopic refractive error considered to be amblyogenic.TheAOA Clinical Practice Guideline on Amblyopia 13 indicates the amountof bilateral hyperopia thought to be amblyogenic is greater thanϩ 5.00D, which is veryclose to theϩ 4.50 D value in ophthalmol-ogy’s Preferred Practice Pattern for Amblyopia.10

Textbooks and Research PapersThrough their separate book chapters, Elise Ciner14,15 and

Wendy Marsh-Tootle 16 have been influential in shaping the pre-scribing philosophies of many optometrists. I know of severalyoung faculty members in schools and colleges of optometry whouse these chapters in their pediatric eye care courses to teach op-tometry students how to manage childhood refractive error.Marsh-Tootle provides the following uppernormal limits of hy-peropia for nonesotropic children:ϩ 3.50 D in infants, ϩ 2.00 Din the young child, and ϩ 1.50 D in adolescents.16 These values arein line with those found in the aforementioned survey of optome-trists by Miller.4

TABLE 2.When to prescribe spectacles for hyperopic children: anopinion survey of AAPOSa

Age Mean Ϯ SD

Proportion of those prescribingglasses (D)

25% 50% 75%

Ͻ 2 yr ϩ 4.82 Ϯ 1.20 ϩ 4.00 ϩ 5.00 ϩ 5.502–4 yr ϩ 4.35 Ϯ 1.02 ϩ 4.00 ϩ 4.00 ϩ 5.004–7 yr ϩ 3.99 Ϯ 0.98 ϩ 3.00 ϩ 4.00 ϩ 4.50

a American Academy of Pediatric Ophthalmology and Strabis-mus Members.

Adapted from Miller JM and Harvey EM.10

Childhood Hyperopia: A Pediatric Optometrist’s Perspective—Cotter 105




Clinicians tend to view small amounts of accommodation asbeing more important in myopes than hyperopes. Rosner demon-strated this point in a survey of about 200 Texas optometrists.2 Hepresented cases for two 7-year-olds, both symptom-freebut having “some difficulty in school.” Thefirst patient wasa Ϫ 0.50D myope who was wearing Ϫ 1.50 D and the second was a ϩ 1.00 hyperope who never wore glasses. Ninety-six percent of the optometristsrecommended the over-minused myopic prescription be reduced

in power by 1.00 D to the correct prescription of Ϫ 0.50 D, whereas only 73% stated they would provide a refractive correctionfor the hyperopic child. When asked their opinion if neither childhad any difficulty in school, nearly all would still reduce the minuspower for the myopic child, and only about half would stillprescribe lenses for the hyperopic child. Thus, despite the accom-modative demand being exactly the same for both children, thepresence of learning difficulties did not materially impact whetherthe optometrists reduced the power of the lenses for the myopicchild who was overminused, whereas school performance strongly influenced whether the hyperopic child was given a prescription.

Throughout the years there have been numerous studies sug-

gesting a link between childhood hyperopia and reading ability,visual perceptual skills, or academic achievement. The most influ-ential forme are papers that were published early in my optometriccareer. Those that come to mind are a literature review on refrac-tive error andreading by Grisham andSimons,17 a meta-analysis of the literature on vision anomalies and reading skills by Simons andGassler,18 and several papers by Rosner and Rosner.19–22 The tworeview papers concluded that most studies found a positive rela-tionship between poor reading and uncorrected hyperopia. Thepapers by Rosner and Rosner have suggested that there is a rela-tionship between hyperopia and academic achievement or visualperceptual skills. Although none of these studies are randomized

controlled clinical trials and unequivocal evidence is lacking, theaforementioned literature, as well numerous other studies from asfar back as the 1930s, have suggested that children with moderateamounts of hyperopia, or at least some of them, may experiencereading or academic problems. This gives me reason to think thatfor some hyperopicchildren, there is a connection. Therefore, I ammuch more likely to prescribe a refractive correction for a school-aged child with borderline hyperopia if the child is experiencing academic difficulties than for a child who is doing well in school.My intention is to eliminate any potential influence the uncor-rected hyperopia might have on reading comfort or efficiency.

Another influential paper is one by Dwyer and Wick 23 whoreported on spectacle correction of small to moderate refractiveerrors in 143 nonstrabismic patients with accommodative and/orvergence anomalies. After about a month’s wearing of low to mod-erate power lenses, improvement in binocular function occurred in79% of the hyperopes and only 20% of the myopes. Thus, forpatients with accommodative or binocular dysfunctions, I may prescribe lenses for lesser amounts of hyperopia than I would nor-mally prescribe in order to determine if the lenses will favorably impact the oculomotor dysfunction. This approach is especially valuable when there is associated anisometropia or astigmatism.

Studies presenting refractive error distributions such as the oft-shown onefor infants from Cook andGlascock (1951),24 as well ascomparison distributions for school-aged children such as thatfrom the Orinda Longitudinal Study of Myopia (Fig. 1)25 have

been influential in that they have provided data illustrating normalrefractive error distributions based on a child’s age. Fig. 1 showsthat between infancy and childhood, the distribution narrows andshifts towards emmetropia, with most school-age children ending up with either emmetropia or low hyperopia.

For comparison reasons, Hirsch and Weymouth26 reanalyzedthe Cook and Glascock data 24 for Caucasian newborns, finding theaverage refractive error to be aboutϩ 2.00D of hyperopia, witha standard deviation of 2.73 D. The more recent report by Mayeretal.27 found a similar mean spherical equivalent refractive error of ϩ 2.20 D at 1 month of age, with a smaller standard deviation of 1.60 D. As can be seen in Table 3, the mean refractive error forchildren aged 1 to 4 years decreases slightly and the standard devi-

FIGURE 1.Comparison of refractive error distribution from newborns 24 to that from

children (Orinda Longitudinal Study of Myopia, vertical meridian cyclo-plegic autorefraction, unpublished data, 1993). (Reprinted with permis-sion from Mutti and Zadnik 25 .)

TABLE 3.Refractive error in children ages 1 to 48 months

Age (mo) Spherical equivalent (D)a

95% predictionlimits (D)

Upper Lower

1 ϩ 2.20 Ϯ 1.60 ϩ 5.51 Ϫ 1.121.5 ϩ 2.08 Ϯ 1.12 ϩ 4.36 Ϫ 0.202.5 ϩ 2.44 Ϯ 1.32 ϩ 5.13 Ϫ 0.264 ϩ 2.03 Ϯ 1.56 ϩ 5.21 Ϫ 1.166 ϩ 1.79 Ϯ 1.27 ϩ 4.39 Ϫ 0.819 ϩ 1.32 Ϯ 1.13 ϩ 3.63 Ϫ 0.99

12 ϩ 1.57 Ϯ 0.78 ϩ 3.16 Ϫ 0.0118 ϩ 1.23 Ϯ 0.91 ϩ 3.09 Ϫ 0.6424 ϩ 1.19 Ϯ 0.83 ϩ 2.89 Ϫ 0.5030 ϩ 1.25 Ϯ 0.89 ϩ 3.07 Ϫ 0.5736 ϩ 1.00 Ϯ 0.76 ϩ 2.56 Ϫ 0.5648 ϩ 1.13 Ϯ 0.85 ϩ 2.89 Ϫ 0.62

a Values are expressed as mean Ϯ SD.Modified from: Mayer et al.27





ation remains approximately the same. These and other studies tellus that normal children start at birth with an average refractiveerror of about ϩ 2.00 D and that by 4 years it reduces to aboutϩ 1.25 D. Mayer at al found that 95% of the cycloplegic refrac-tions for children at 4.0 years of age wereՅ ϩ 2.83 D, suggesting that the upper limits for normal childhood hyperopia at this age isabout ϩ 3.00 D. These upper limits are lower than the magnitudeof hyperopia considered amblyogenic (i.e.,ϩ 4.50 to ϩ 5.00 D)and closer to the aforementioned prescribing thresholds for many optometrists.4

Also influential is the randomized controlled trial reported by Atkinson and colleagues.28 They had three groups of 6- to8-month-old children: hyperopia greater thanϩ 3.50 D (in any meridian), hyperopia less thanϩ 3.50 D, and children with nohyperopia. Children havingmore thanϩ 3.50 D of hyperopia wererandomized to receive either partial-correction spectacles or nocorrection. At age 4 years, those with the initially higher hyperopia in infancy were 13 times more likely to become strabismic and 6times more likely to become amblyopic than the children withlesser amounts of hyperopia. However, the wearing of partial-correction spectacles reduced the risk ratios to 4:1 and 2.5:1,respectively.

These results have been discussed at more conferences and con-tinuing education courses than any other study on childhood hy-peropia. Indeed, I routinely think of these results when I examinean infant with hyperopic refractive error of greater thanϩ 3.50 D. Although I may not prescribe spectacles for a nonesotropic infant with hyperopia in excess of ϩ 3.50 D, I always think to myself thatthis child may be atrisk for the development of esotropia andamblyopia, and that if I prescribe spectacles the risk may be less.Unfortunately, the Atkinson group’s later study 29 and one by

Ingram et al.30

reported that spectacle wear in infancy and early childhood for hyperopia did not reduce the incidence of esotropia.Thus, we must wait for further research to determine thedefinitiveanswer. However, when I donot prescribe a refractive correctionfor infants with more thanϩ 3.50 D of hyperopia, I advise theparents that the child may be at a higher risk for the developmentof strabismus and amblyopia. Also, I instruct them to call meimmediately if they note the emergence of an estropia or othervisually-related signs or symptoms. In addition, I see the childmore frequently in my follow-up schedule.

An important series of studies on refractive error and develop-ment of the eye by Smith, Hung, and colleagues showed that

wearing spectacle lenses can alter the ocular growth and refractivestatus of infant monkeys.31–33 Some optometrists are reluctant toprescribe refractive corrections to infants and young children be-cause of these studies. Recently, Smith summarized his group’s work and discussed why the possible effects of refractive correc-tions on human emmetropization are equivocal.31 More recently,Mutti and coworkers have shown that through emmetropizationmost refractive changes inchildrenhave taken place by the end of the first year of life.34 This result as well as the report by Atkinsonet al.35 that hyperopic spectacle correction during infancy did notimpair emmetropization in their hyperopic children has alleviatedsome optometrists’ concerns regarding spectacles interfering withthe normal emmetropization process after infancy.

How I Prescribe for Hyperopia in ChildrenThe clinical profile of the child is extremely important in deter-

mining whether spectacles for childhood hyperopia might be ben-eficial. When hyperopia coexists with esotropia or amblyopia, Iand virtually all practitioners prescribe spectacles. In cases of borderline amounts of hyperopia in young children without stra-bismus or amblyopia, other factors become important to me: de-ficient accommodation, vergence dysfunctions, signs or symptomssuch as frequent blinking or headaches, avoidance of near work,reduced visual acuity, and poor school performance.

If I am on the fence about prescribing hyperopic lenses for a school-aged child with an otherwise normal eye examination, Itypically consider the child’s academic performance. For example,if the parents report that their child is not performing up to his orher potential in school and I find no vision problems other thanhyperopia (say approximately ϩ 1.25 D orso), I mayoffera hyper-opic prescription as an option that might benefit the child whenreading and doing close work, particularly if I am worried that thechild may be having difficulty sustaining consistent and comfort-able accommodation at near. Similarly, I am more apt to prescribehyperopic corrections for children with neurodevelopmental de-lays, particularly children with Down syndrome or cerebral palsy,many of whom are known to possess poor accommodative abili-ties36,37 and whom are less likely to compensate for ocular prob-lems. The same is true if I suspect that a medication the child istaking is impairing accommodation.

In terms of the clinical examination, reduced visual acuity thatresponds to a hyperopic refractive correction is an indication forprescribing for childhood hyperopia. In my clinical experience notmany young children with low to moderate hyperopiapresent witha chief complaint of reduced visualacuity. Hence, I am always alertto the possibility of malingering by some children who want to wear glasses. When hyperopic children have associated anisome-tropia or astigmatism that requires correction, I am more likely toalso prescribe for the hyperopia component.

Oculomotor functioning, part of the patient’s clinical profile, isan important determinant in deciding whether a nonstrabismicchild might benefit from a hyperopic correction. The presence orprevention of future accommodative or vergence disorders is a key consideration. Symptomatic patients with decreased accommoda-tive abilities or high lags of accommodation often benefit from thecorrection of fairly small amounts of hyperopia (say,ϩ 1.00 toϩ 1.25 D). Beyond accommodation, I routinely consider the rela-tionship between accommodation and vergence (the AC/A ratio),the child’s near phoria, and negative fusional vergence ability. Un-corrected hyperopia of ϩ 3.00 D by itself may not be a problem fora young child if the child has a normal amplitude of accommoda-tion. However, assuming a near working distance of approximately 33 cm, the first concern is whether the child can comfortably sustain an accommodative stimulus at near of approximately 6 D(in this case). Second, if this child is esophoric and has a moderateor high AC/A ratio, every time the child accommodates to seeclearly at near, a significant esophoria will be present for which thechild will need to have sufficientcompensating fusional divergenceso as to maintain clear and comfortable binocular vision. Childrensuch as these are likely to benefit from a hyperopic correction whenreading and doing close work. Reduced stereoacuity at near that





improves with a hyperopic correction is also an indication that a hyperopic correction may be helpful.

Finally, I sometimes prescribe for asymptomatic children whodo not demonstrate a vergence or accommodative dysfunction, donot have a high AC/A ratio, and are not experiencing academicdifficulties. In these cases, I prescribe because the child’s refractiveerror is outside of what is considered to be the normal range of hyperopia for his or her age. I prescribe because I am concerned

that the accommodative demand, particularly at near, will becomeburdensometo thechild. I often prescribethespectacles to be wornmainly for school and near work and explain my prescribing ratio-nal to the parents.

CONCLUSIONSHyperopia has received increased clinical and research attention

in recent years, but perhaps not enough, nor soon enough. A big problem is the large variation in prescribing approaches among practitioners. Within optometry, some clinicians prescribe only if there is a large degree of hyperopia, while others prescribe for

smaller amounts of hyperopia after considering associated abnor-malities in accommodation and vergence, stereopsis, and schoolachievement. Ophthalmologists also have a range of prescribing approaches, with a minority who consider the more subtle func-tional abnormalities. The different prescribing approaches be-tween many optometrists and ophthalmologists is, in my opinion,less a matter of professional difference than a difference in concernabout associated factors such as accommodation, vergence, stere-opsis, and school achievement. The prescribing patterns of many pediatric ophthalmologists appear to be heavily influenced by the American Academy of Ophthalmology consensus-based guide-lines,9,10 which are primarily related to whether the childhood

hyperopia represents an amblyogenic factor. Optometrists tend toplace considerable weight on the patient’s age and magnitude of hyperopia, symptoms, visual acuity, phoria, AC/A ratio, accom-modation, and school performance—to predict whether a refrac-tive correction might be beneficial for a hyperopic child. Recentstudies indicate that some pediatric ophthalmologists are showing interest in evaluating factors such as accommodative ampli-tudes38,39 and accommodative response.40

Jerry Rosner summed it up nicely when he said, “Our treatmentdecisions regarding the management of hyperopia (regardless of the degree of the ametropia) should not be based on . . . philoso-phies that have no scientific basis. It is time for serious investiga-

tion.”2

So, my call to action to the eye care community is todevelop evidence-based rather than consensus-based guidelines. If indications for prescribing spectacles for children with hyperopia are to be validated, randomized controlled trials need to be per-formed. As additional solid research is brought to bear on child-hood hyperopia, I am sure that prescribing differences within eachprofession, and between them, will shrink.

ACKNOWLEDGMENTSI thank Don Mutti for the invitation to present at the Hirsch Memorial Research Symposium and for his encouragement and support. I thank SeanDonahue for co-presenting and providing his perspective as a pediatric oph-thalmologist. I gratefully acknowledge Mike Rouse, Susan Shin, and Julie Yu

for their helpful comments and suggestions on the first draft of this paFinally, I am indebted to Mert Flom for his thoughtful review and expecontent and editorial advice.

This manuscript is based on a presentation given at the 2005 Monroe Hirsch Memorial Research Symposium, Hyperopia: A Prescription for Chdren’s Vision Research, AmericanAcademy of OptometryMeeting, SanDieCA, December 11, 2005.

Received September 12, 2006; accepted November 6, 2006.

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223–4.3. Lyons SA, Jones LA, Walline JJ, Bartolone AG, Carlson NB, Kattouf

V, Harris M, Moore B, Mutti DO, Twelker JD. A survey of clinicalprescribing philosophies for hyperopia. Optom Vis Sci 2004;81:233–7.

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Susan A. CotterSouthern California College of Optometry

2575 Yorba Linda Blvd.Fullerton, CA 92831

e-mail: [email protected]



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