good morning and welcome to the insight clinic lectures this is dr amrit and i welcome you to the series on hypermetropia today's video is on treatment of hypermetropia now let us begin as we already know that in hypermetropia the rays of light which are coming from infinity they get focused behind the retina because the eyeball is smaller the cornea is flatter or we can say that this eyeball is not very strong that is it is weaker so obviously the treatment would be to make this weaker eyeball a little bit stronger and how do we do that we do that by prescribing these patients convex lenses so what happens when we give these patients convex lenses so when we add a convex lens in front of the eye a convex lens as we know is a converging type of lens the rays of light now which are passing through this convex lens will start converging much before and because of this extra converging ability the image will now be formed on the retina and the patient will be happy and this is how we treat hypermetropia so if someone asks you what is the treatment of hypermetropia the answer is convex lenses or converging lenses so this convex lenses we can prescribe either in the form of spectacles or we can give patients these convex lenses as contact lenses okay yeah so the next question is how do you actually identify a particular lens how do you know that whether it is a convex lens or it is a concave lens so let me tell you what are the identifying features of a convex lens number one is a convex lens is thicker in the center and thinner at the periphery okay second whenever we look through a convex lens it tends to magnify an object and therefore most of our magnifying glasses also are made up of convex lenses okay coming to the third point is whenever we take a convex lens okay and we move we look at an object through the convex lens okay and we try to move the uh convex lens to and fro this object at which we are looking through the lens will be moving in a direction opposite to the direction of the lens so what i mean to say is if we take a convex lens and we move it towards the right side the image will shift towards the left side so that is what happens and that is also one way of identifying a convex lens so when we talk about the concave lens everything will be totally opposite of that of the convex lens okay so remember in a convex lens it is thicker at the center it will magnify the object whatever we are seeing and the movement of the image will be opposite to the direction of the movement of the lens all right next next whenever we are treating hypermetropia with the convex lenses there are certain principles about six principles that i want you to know and what are these let's see the first principle of treatment of hypermetropia is the importance of a complete cycloplegic examination now what is meant by a cycloplegic and why do we need a psychopathy examination in case of hypermetropic patient for this i would advise you to refer to my previous videos on latent hypermetropia facultative and manifest hypermetropia as you already know there is a role of our ciliary muscle okay in accommodation and hypermetrops usually they have this reserve and they are always using the ciliary muscle to accommodate and when they are accommodating part of the hypermetropic correction is getting corrected so whenever we want to assess the total hypermetropic error in such patients we need to paralyze the ciliary muscle and therefore what examination we are doing is a cycloplegic examination so how do you paralyze the serial muscles you paralyze these ciliary muscles by giving these patients cycloplegic agents and what are the cycloplegic agents they will be like cyclopentylate pentylate then one more common agent is atropine okay so these are the commonest agents which we use for cycloplegic examination to find out the total hypermetropic correction so whenever we are using these cyclopentylated nitrogen we are also bringing out the latent hypermetropia apart from that we are also uh unmasking the effect of accommodation and therefore we get to know what is the facultative hypometropia also in this patient so as such total hyperbotropic error could can be found out in such patients now the second principle is regarding the prescription of hypermetropic error so the question is like do you prescribe when the error is about one diopter or less than that the answer is only the patient is symptomatic that means the patient is telling that he has lots of asymptotic symptoms and only then we will prescribe less than one day after it is very rare to prescribe such a small hypermetropic error because we know that much is already being taken care by the ciliary muscle tone okay and that much latent hypermetropia is usually present so we usually do not prescribe such a small error okay next is what do you do in cases of children okay so there are certain uh principles and guidelines which are given by the american academy of ophthalmology regarding when to prescribe the glasses in case of children however generally speaking if a child is less than say four years of age who will require hypermetropic correction such a child usually will accept the full amount of cycloplegic hypermetropic error okay so whatever error you find out after cycloplegic examination say we found that the child has about plus five diopter or maybe plus six diopter or maybe plus seven doctor whatever it is this child who is less than four years of age meaning he's not going to school okay his visual demands are not much for the distance and also maybe for the near such a child will accept full error whatever we give them so we can give them five diopters we can give them six diopters we can give them seven diopters this child will accept but what happens to a child who starts going to school that means about more than four years of age now such a child will not be happy accepting this much amount of correction okay the reason is that for distance they will start having problem because some amount of accommodation about 2.5 diopter is also needed for distance so when we are supplementing them with such high powers they will not be able to use this accommodation for far and therefore these school going children's will have problem looking at the far distance so what do we do now in such cases in such cases and children who are going to school we are going to reduce this to one third that means suppose a child has an error of about plus three plus six diopters we are going to reduce it by one third that means six diopters one third is two diopters so what we will give them will give them about four diopters correction we will not give them full diopters of correction so a younger child is able to so principle that i want you to remember is a younger child can accept full correction whereas a child who has started going to school will not be able to accept for them we have to reduce it by one third okay so what basically even if an older child comes okay what i advise is that always under correct such kids okay don't start giving them full correction always under correct these kids and once they start becoming comfortable with their prescription gradually every six months every three months you check them and gradually you start increasing their power till they can actually accept this full power okay yeah next coming to situations uh in which there's a squint which is present so what do what are we going to do if a child is there and that child has say exophoria so what is meant by exophoria or exodaviation exophoria exodus is nothing but it is the outward deviation of the i so in a case of exophoria or xo deviation what happens is we need these kids to actually accommodate so that there is little bit of convergence and the eyes will be somewhat in the center because the eyes are actually outside deviated outside so but what happens when we give them plus lenses always whenever we are giving a kid plus lenses we are actually relaxing their accommodation because we are already making their eyes stronger by giving them plus lenses which is similar to our crystalline lens they do not need to do extra work they don't need accommodation so that it will lead to relaxation of accommodation and therefore it can cause worsening of the exophoria so therefore whenever a child has exophoria also plus he has an hypermetropia the advice which is given is to under correct okay so what do we do whenever a patient has exudation and plus hypermetropia we will under correct these patients about one to two day after so the if they have plus six diopters we will give them plus four diopters okay quite opposite to that if a person is actually having accommodative convergent squint now we have seen this in the complications of hypermetropia that one complication of untreated hyperemetropia is accommodative convergent squint convergence quint is nothing but isotropia right so here the eye is already deviated inside and why is the i treated inside because the patient is accommodating more so in this case if we give them plus lenses what will happen if we give them plus lenses their accommodation will be relaxed and the eyes will be straight therefore in such patients what do we do we will give them full correction okay so with respect to squint we have to remember that in exophoria we will undercorrect and in esotropia or a cognitive convergence quint the treatment is to give them full hypermetropic correction okay now what happens if a child is having associated amblyopia in such cases also we have to give them full correction because amblyopia is dangerous we should give them full correction okay and every patient that you prescribe you have to follow up every six months why because we know that hypermetropia is because of the smaller eyeball and as the child grows the eyeball will definitely increase in size so as the eyeball might increase in size hypermetropic error might decrease with age so we have to follow up such patients every six months and see if the hypermetropic error is getting reduced or not okay okay now next one more thing that i want you to know is regarding the american academy of ophthalmology guidelines which talks about when should we actually prescribe in a child okay so this american academy guidelines is for the pediatric population because uh you know the complications are more in pediatric population and therefore uh they talk about whether to prescribe hypermetropic correction in kids or not so these are the basic guidelines it's so let us go through it one at a time so if a child is having isometropia isometropia means the refractive error is same in both the eyes okay so it could be plus 2 plus 2 plus 3 plus 3 plus 4 plus 4 but in both eyes it is same so if the american academy of ophthalmology has divided the age group as zero to one years one to two years and two to three years so if a child has isometropia of that means if it has hypermetropia but there is no squint which is present the cutoff which is taken in zero to one years of age is about plus six okay and then for one to two it is plus five for two to three it is plus four point five so you can remember as six five and four point five okay but if the same child develops isotropia the cut off will be much low that means we have to treat these kids even earlier so from six it becomes plus two and even for 1 to 2 years it is plus 2 and then 2 to 3 it is plus 1.5 all right now what about an isometropia an isometropia is when the difference in refractive error is present between two eyes that means one eye might only be hypermetropic and the other eye might be normal so in such cases also the cutoff is less why is the cutoff less because such patients also can land up into amblyopia and isometropic amblyopia so the cutoff here is 2.5 and then again 2 and 1.5 okay so you can remember this table but also what i want you to remember is when there is no squint present you can maybe wait for some time and then prescribe the child with glasses but whenever the error is present in one eye there is a risk of amblyopia or when there is already strabismus present isotropia present the risk of amblyopia is more now because of this risk of amblyopia we need to intervene earlier so the cutoff will become much more smaller about plus two or plus 2.5 and gradually with the increasing h the cut off is less okay but when there's no complications you can start with plus 6 plus 5 and plus 4.5 i hope it is clear any doubts you can comment in the comment section kindly subscribe and hit the bell